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t THE
THEORY  AND  PRACTICE
MEDICINE
PREPARED FOR
STUDENTS AND PRACTITIONERS
          JAMES T. WHITTAKER, M.D., LL.D.
Professor of the Theory and Practice of Medicine in the Medical College of Ohio; Lecturer on
   Clinical Medicine at the Good Samaritan Hospital; Fellow of the College of Physicians
      of Philadelphia; Member of the Association of American Physicians, of
          the American Academy of Medicine, and of the American ——»^_
                                             III tS^*"V.
                      Medical Association      ..-, \ \l.  1L J fix
(*/*£££

   &BRA&,
WITH A CHROMO-LITHOGRAPHIC PLATE AND THREE HUNDRED ENGRAVINGS
          NEW YORK
WILLIAM WOOD  &  COMPANY
               1803 

         Copyright by
WILLIAM  WOOD  &  COMPANY
               18! 3
       PRESS OF
5TETTINER,  LAMBERT  A CO..
  22, 24 & 26 READE ST.,
      NEW YORK, 
THIS BOOK  IS  DEDICATED
            (by permission)
               ROBERT  KOCH,
          MEDICAL PRIVY COUNCILLOR OF PRUSSIA:
FOUNDER OF BACTERIOLOGY: WHOSE WORK IS MAKING A SCIENCE
                OF THE ART OF MEDICINE ;

                          BY

               HIS FIRST AMERICAN STUDENT ;
       GEORGE  M.  STERNBERG,
      SURGEON-GENERAL OF THE UNITED STATES ARMY:
THE PIONEER IN THE STUDY OF PARASITISM IN THIS COUNTRY
    BY

HIS FRIEND,
THE AUTHOR. 
  "As for the truth, it endureth and  is

always strong;  it  Uveth  and  conquereth

for ever more."
                       —Esdras I. iv. 3*.



  "Pilate saith unto him, What is truth ?"
                       —John xviii. 38.




  " Appie del vero il dubbio."
                        —Dante, Del Par ad i so, iv. 131. 
PREFACE.
   In the preparation of this book the most work has been put upon
the infections, as the most frequent and dangerous, at the same time
the most preventable, of all diseases ; and in the study of the infec-
tions the most  space has been devoted to cause and diagnosis, for
the reason that a knowledge of the cause establishes prevention, and
with the diagnosis  develops  treatment, except in so far as treatment
must still remain wholly symptomatic.   Morbid anatomy meets here
with but little consideration, and post-mortem revelations are men-
tioned only when they may throw a clear light upon the nature and
treatment of disease.  The practitioner who looks up from the signs
and lesions to the  cause will entertain more hope of treatment; for
the  practice of  medicine is now not so empirical as the symptoma-
tologists clairrij or so barren as the pathologists deplore.
   From  this standpoint this book is prepared for the student and
practitioner of medicine, but especially for the young physician who,
with microscope and  test tube, would fit himself  for the  higher
places in his profession.
   With  the most highly appreciated generosity, the Messrs. Wm.
Wood & Co., Lea Bros. & Co., and W.  B. Saunders have per-
mitted the author  to select, condense,  or make use of  contributions
prepared by  him for works recently or just issued by them.  These
chapters (selections from which constitute perhaps one-twelfth  of
the  present  volume), in Wood's  " Reference Handbook," Pepper's
"System of Medicine," Hare's "Therapeutics,"  Pepper's "Ameri-
can  Text Book," contain accounts more full than may be found  in
an ordinary  text book,  whose chief  merit must consist in the suc-
cinct presentation of the latest  facts.   The fact that the proof was
corrected at a watering place distant from a library will excuse the
absence of proper  credit from  any figures  or statements where it
may have been lost in press.
   A text book must necessarily be full of shortcomings.  No one  so
fully appreciates the vast wealth of knowledge in internal pathology,
accumulated through the ages, as  he who attempts to encompass it
in a  book, or so  keenly realizes his own  poverty as he who attempts
to add to the general sum the most inconsiderable mite.
                                                    J. T. W.
  Cincinnati, Ohio, September 1st,  1893. 
         PATHOGENIC  MICRO-ORGANISMS.

              Chiefly from  Original Drawings by Koch and Ldffler.

                        EXPLANATION  OF PLATE.

Fig. 1.  Lepra.—Fluid expressed from a nodule, stained with carbol-fuchsin, display-
    ing bacilli, free and enclosed in large, non-nucleated cells.
Fig. 2.  Materia.—Plasmodium Malarias.  Protozoa from drop of blood from finger
    pulp after a chill, stained with methylene blue, displaying large, nucleated white
    blood corpuscles, smaller non-nucleated red blood corpuscles, free and filled with
    protozoa; also free protozoa.
Figs. 3, 4.  Pyemia.— Streptococcus pyogenes and Staphylococcus pyogenes aureus.
Fig. 5.  Gonorrhoea.—Gonococcus,  cover-glass preparation, stained with methylene
    blue;  pus cells filled with gonococci.
Fig. 6.  Pneumonia.—Diplococcus  of  pneumonia  (Frankel-Weichselbaum), stained
    by Gram's method;  section of  alveolus, displaying exudation of cells with diplo-
    cocci, alone and in chains, in and between the cells.
Fig. 7.  Charbon.—Milzbrand bacilli, gelatin  stick culture; upper stratum fluidified,
    bacilli as whitish mass at  bottom of fluid; displaying two  large  colonies  with
    numerous radiating outshoots  into the substance of the still solid gelatin.
Fig. 8.  Cholera.—Stick culture of cholera spirillum in gelatin,  four days old ; upper
    stratum  exposed to air, fluidified to characteristic funnel shape; spirilla in
    mass at bottom and in neck of funnel.
Fig. 9.  Typhoid Fever.—Gelatin stick  culture of typhoid bacillus, displaying opales-
    cent, translucent surface.
Fig. 10. Tuberculosis.—Pure culture  of tubercle bacillus on  surface  of gelatin in
    inclined  test tube, displaying dry,  white scales, natural size.
Fig. 11. Cholera.—Gelatin surface culture of cholera spirillum, x 80, displaying irregu-
    lar  border and irregular " broken-glass" surface.   The larger colonies, with  more
    sunken border, lie nearer the surface of the gelatin.
Fig. 12. Typhoid Fever.—Gelatin surface culture of typhoid bacillus, x 80, displaying
    dark-brown, sharply-defined  border with finely  granulated  surface; sometimes
    showing concentric zones.
Fig. 13. danders.— Bacillus mallei from spleen of field mouse, cover-glass prepa-
    ration, stained  with methylene blue, displaying  uncolored  regions resembling
    spores.
Fig. 14. Cliolera.—Pure culture of cholera spirillum in bouillon, stained with  f uch-
    sin, displaying "comma" bacilli, alone and  united in spirals.
Fig. 15. Typhoid Fever.—Pure culture of typhoid bacillus in gelatin, displaying short,
    thick rods as in tissues, and elongated structures in culture.
Fig. 16. Tuberculosis.—Tubercle bacillus from sputum, double-stained with aniline-
    gentian-violet and Bismarck brown.
Fig. 17. Dysentery.—Amoeba? coli. 
TABLE  OF CONTENTS.
                               PART  I.


                        GENERAL  DISEASES.

                       INFECTIONS—PARASITES.

                               CHAPTER I.

 Ectozoa...............3
    Animal: Scabies—Pediculi, capitis, pubis, vestimenti—Acarus folliculo-
    rum—Pulex—Pulex  penetrans—Cimex—Mosquito, etc.   Vegetable:  Fa-
    vus—Herpes tonsurans, Eczema marginatum, Onychomycosis—Pityriasis
    versicolor, Madura Disease,  Muscardine,  Fly Fungus—Thrush—Lepto-
    thrix buccalis—Actinomycosis.

                               CHAPTER II.

 Entozoa,..............23
    Cysticercus cellulosae—Taenia armata, saginata, lata—Taenia  echinococ-
    cus—Multilocular  Cysts—Round   Worm—Threadworm—Whipworm—
    Anchylostoma—Trichina  spiralis—Filaria, medinensis,  sanguinis—Ele-
    phantiasis—Liver Fluke—Distoma Haematobium.

                               CHAPTER III.

 Bacteria,..............56
    Bacteria — Microprotein — Micrococci — Bacilli—Spirilla—Spores—Sapro-
    phytes—Parasites—Aerobes—Anaerobes—Coloration—Cultivation—Inocu-
    lation — Ptomaines—Toxines—Phagocytes—Antitoxiues—Protozoa—Rhi-
    zopods—Sporozoa—Infusoria—Plasmodium malariae.

                               CHAPTER IV.

Infectious Diseases,...........68
    Diseases caused by Micrococci, Bacilli,  Spirilla: Septicaemia—Pyaemia—
    Septico-pyaemia.  Staphylococcus pyogenes aureus, albus, citreus,  Micro-
    coccus  pyogenes  tenuis,  Staphylococcus  pyogenes:  Erysipelas—An-
    thrax—Foot  and  Mouth  Disease—Glanders—Hydrophobia—Tetanus—
    Pertussis—Influenza—Hay Fever—Pneumonia—Tuberculosis—Lepra—Sy-
    philis —Chancroid—Gonorrhoea. 
vm
TABLE  OF  CONTENTS.
                              CHAPTER V.
                                                                      18fi
Infectious Diseases—Continued,.......•   #  *
    Mumps—Measles—Rubella—Scarlatina-Variola,  Varioloid,  Vaccination
    —Varicella-Diphtheria—Croup-Quinsy—Typhus, Relapsing,  Typhoid
    Fever—Malaria—Yellow Fever—Cerebro-spinal Meningitis—Rheumatism
    —Dysentery—Asiatic Cholera—Cholera Morbus.
                             PART  II.

                     DISEASES OF ORGANS.

            DISEASES OF THE  ORGANS OF DIGESTION.

                              CHAPTER I.

Diseases of the Mouth, Fauces, and Pharynx,......349
    Syphilis—Stomatitis,  catarrhalis,  ulcerosa—Aphtha—Noma—Glossitis-
    Angina—Tonsillitis—Globus hystericus—Cancer of the Oesophagus—An-
    gina Ludovici—Retropharyngeal Abscess.

                             CHAPTER II.

Diseases of the Stomach,   .    .    ........363
    Gastric Catarrh — Ulcer—Cancer — Gastrectasia —Gastralgia—Diagnosis,
    Diet, Treatment.

                             CHAPTER III.

Diseases of the Intestine,..........397
    Intestinal Catarrh—Ulcer—Haemorrhage of the Bowels—Typhlitis, Peri-
    typhlitis, Paratyphlitis, Appendicitis—Occlusion—Cancer—Peritonitis.

                             CHAPTER IV.

Diseases of the Liver,...........439
    Icterus — Cholelithiasis — Abscess—Cirrhosis— Hypertrophic Cirrhosis—
    Simple Atrophy—Acute Yellow Atrophy—Weil's  Disease—Hyperemia—
    Fatty Liver—Amyloid Liver—Cancer.


         DISEASES OF THE  ORGANS OF  RESPIRATION.

                             CHAPTER V.

Diseases of the Nose and Throat.........473
    Acute and Chronic Catarrh—Syphilitic Catarrh—Neoplasms.
Diseases of the Larynx,..........4^
    Catarrhal Laryngitis—CEdema of the Glottis—Perichondritis—Tuberculo-
    sis—Syphilis—Paralysis of the Larynx—Tumors. 
TABLE OF CONTENTS.
IX
                              CHAPTER VI.
Diseases of the Lungs............489
    Bronchitis, Acute, Capillary, Chronic—Bronchorrhcea—Putrid  Bronchi-
    tis—Fibrinous Bronchitis—Bronchiectasis—Asthma—Emphysema—Pneu-
    monia,   Catarrhal,  Hypostatic—03dema of  the   Lungs — Atelectasis—
    Drowning—Embolism, Hemorrhagic  Infarction—Abscess—Gangrene—
    Syphilis — Cancer,  Sarcoma,  Echinococcus — Pneumonoconiosis—Pleu-
    risy—Empyema — Pneumothorax — Hydrothorax—Haematothorax—Peri-
    pleuritic Abscess—Subphrenic Abscess.

         DISEASES  OF THE  ORGANS  OF  CIRCULATION.
                              CHAPTER VII.
Diseases of the Heart,..........554
    Pericarditis — Tuberculosis,  Syphilis  of  the Pericardium—Hydroperi-
    cardium — Endocarditis — Sclerotic Endocarditis — Myocarditis — Heart
    Failure — Tuberculosis —Syphilis—Neoplasms—Neuroses—Palpitation—
    Angina Pectoris—Exophthalmic Goitre—Myxcedema.
Diseases of  the Blood  Vessels,.........590
    Arterio-sclerosis—Aneurism of the Aorta—Phlebitis.

                             CHAPTER VIII.
Diseases of  the Blood............597
    Plethora—Hydraemia—Lipaemia—Uraemia—Cholaemia—Blood Parasites—
    Anaemia—Pernicious  Anaemia—Chlorosis—Leukaemia—Pseudo-leukaemia
    —The Haemorrhagic Diathesis—Haemoglobinaemia—Purpura—Haemophi-
    lia—Scorbutus—Morbus Addisonii—Gout—Arthritis Deformans—Rachitis
    —Osteomalacia—Obesity.

         DISEASES  OF  THE  GENITO-URINARY  SYSTEM.
                              CHAPTER IX.
Diseases of the Kidney,     .    .        .......637
    History—Albuminuria—Casts—Dropsy—Uraemia — Hypertrophy  of  the
    Heart — Hyperaemia — Anaemia — Acute Parenchymatous  Nephritis —
    Chronic Parenchymatous Nephritis—Renal Cirrhosis—Amyloid Degenera-
    tion—Tuberculosis—Syphilis—Floating Kidney.

                              CHAPTER X.
Diseases of the Pelvis  of the Kidney, Bladder, etc,  ....   663
    Nephrolithiasis—Pyelitis—Hydronephrosis— Cystitis—Enuresis—Sperma-
    torrhoea—Impotence—Diabetes Mellitus—Diabetes  Insipidus.

              DISEASES  OF THE  NERVOUS SYSTEM.
                              CHAPTER XI.
Diseases of the Nerves and Membranes,.......685
    Neuralgia, Trigeminal,  Occipital,  Intercostal—Sciatica—Coccyodynia—
    Headache—Migraine—Gastralgia—Enteralgia—Neuralgia of  the Sperm-
    atic Cord—Neuralgia of the Joints—Neuritis—Multiple Neuritis—Spasm—
    Myotony—Torticollis—Lumbago—Paralysis—Facial Paralysis—Meningitis
    —Pachymeningitis—Hypertrophic Cervical Pachymeningitis—Leptomenin-
    gitis. 
X
TABLE OF CONTENTS.
                              CHAPTER XII.

Diseases of the Spinal Cord,.........~°"
    Myelitis—Locomotor Ataxia—Hereditary Ataxia—Lateral Sclerosis—Pro
    gressive Muscular Atrophy—Infantile Paralysis—Bulbar Paralysis—Acute
    Ascending  Paralysis—Spinal Haemorrhage—Syringomyelia—Acromegaly
    —Morvan's Disease—Raynaud's Disease—Brown-Sequard's Paralysis-
    Progressive Dystrophy—Pseudo-hypertrophy—Juvenile  Dystrophy—He-
    reditary Atrophy—Facial Atrophy—Tetany.

                             CHAPTER XIII.

Diseases of the Brain,...........736
    Apoplexy—Epilepsy—Tumor—Abscess—Localization of Lesions—Hyste-
    ria—Hypochondriasis—Neurasthenia—Chorea—Paralysis Agitans—Multi-
    ple  Sclerosis—Dementia Paralytica—Avocation  Neuroses—Insolation—
    Congelation—Saturnism—Alcoholism—Delirium   Tremens—Cocainism—
    Poisoning by Opium—Poisoning by Nicotine—Poisoning by Gases.
Notes,..............799
Index,..............S07 
LIST   OF   ILLUSTRATIONS.
FIG.                                                                      PAGE
     Chromo lithograph of pathogenic micro-organisms,.....vi
  1.  Female Acarus scabiei,  dorsal surface,........4
  2.  Acarus burrow, with ova,..........5
  3.  Pediculus capitis, male,...........6
  4.  Hair with agglutinated eggs and nits.........6
  5.  Pediculus pubis,............7
  6.  Pediculus vestimenti,...........8
  7.  Acarus folliculorum,...........8
  8.  Achorion Schonleinii from favus cup,........   9
  9.  Favus scutulum,............10
10.  Hair and root sheaths in favus, infiltrated with conidia and mycelia,  .     .11
11.  Epidermis scale in herpes tonsurans, showing more mycelia than conidia,   .  12
12.  Hair in herpes tonsurans,..........13
13.  Onychomycosis,............13
14.  Microsporon furfur,...........14
15.  Pityriasis; mycelia and conidia..........15
16.  Mycoderma albicans............15
17.  Transverse section of flake of coat of tongue  after  death in typhoid state,
        covered with mycoderma,.........16
18.  Thrush fui.gus,............17
19.  Leptothrix buccalis.............18
20.  Actinomyces,.............19
21.  Actinomyces of the tongue,..........19
22.  Taenia saginata.............24
23.  Segments of taenia in motion,.........25
24.  Ova containing embryos of Taenia saginata,.......25
25.  Calf's heart with  measles of Taenia saginata,.......25
26.  Cysticerci,.............25
27.  Measles in pork,............27
28.  Pork tapeworm,............27
29.  Head and neck of Taenia saginata,.........28
30.  Head of Taenia solium within that of Taenia saginata, to show differences,  .  28
31.  Head and neck of Taenia lata,.........29
32.  Ova of fish tapeworm,...........29
33.  Segments of taenia,...........31
34.  Taenia echinococcus,...........35
35.  Extended echinococcus with hooklets.........35
36.  Echinococcus sacs in the liver of man,........35
37.  Echinococcus membrane with hooks.........35
38.  Echinococcus multilocularis,..........37 
Xll
LIST OF ILLUSTRATIONS.
FIG.
 39.
 40.
 41.
 42.
 43.
 44.
 45.
 46,
 48.
 49.
 50.
 51.
 52.
 53.
 54.
 55.
 56.
 57.
 58.
 59.
 60.
 61.
 62.
 63.
 64.
 65.
 66.
 67.
70.
71.
72.
73.
74.
75.
76.
77.

78.
79.
80.
81.
82.
83.
84.
85.
86.
87.
  Ascaris lumbricoides,   .
  Round worm.....
  Oxyuris vermicularis,   ...
  Oxyuris vermicularis,   ....
  Whipworm, female and male,
  tggs of  entozoa,  ....
  Anchylostomum duodenale, .
47.   Mature trichinae,    ....
  Young trichinae in muscle,  .
  Trichina encapsulated in muscle, .
  Calcified relics,.....
  Young trichina liberated from capsule,
  Encapsulated trichina.....
  Trichina in muscle,     ....
  Guinea worm......
  Filaria sanguinis,.....
  Filariae in blood vessels,
  Elephantiasis cruris lymphangiectatica,
  Liver fluke,......
  Distoma haematobium with ova,  .
  Bacilli stained to show vibratile cilia and flagella
  Streptococcus,
  Spirochaetes of relapsing fever,
  Sarcinae,.....
  Yeast plant,.....
 Bacillus  pneumoniae with gelatinous envelope,
 Bacilli tuberculosis, showing spores,
 Bacillus  Havaniensis,  .
 Scale surface culture (serum) of tubercle bacillus
 Nail stick culture (gelatin) of pneumococcus,
 Trichomonas intestinalis,
 Naked "amoebae  coli,    ....
 Cercomonas intestinalis,
 Plasmodium malariae,  ....
 Coccidia  from the human liver,  .
 Scirrhus  of the  breast,  ....
 Pus from an acute abscess,  .
 Septic infection of pectoral muscle after a
   hand,......
 Temperature in a fatal case of sepsis,  .
 Erysipelas cocci in the cutis,
 Streptococcus erysipelatis,  .
 Temperature in severe facial erysipelas,
 Anthrax  bacillus, with and without spores,
 The anthrax bacillus in the blood,
 The bacillus of glanders,
 Farcy buds in the skin,
 Tubercular glanders in the nose,
 Discharging cicatrices in the nose,
 Bacillus of tetanus,
 Pneumococcus of Friedliinder ; oval cells with gelatinous envelope-
' post
from
pleen,
mortem
wound of
the
  .  69
   .  70
  .  73
  .  74
  .  77
  .  82
  .  85
  .  91
  .   92
  .   93
  .   91
  .  107
  . 126 
LIST OF ILLUSTRATIONS.
xiii
six weeks
on vertical section,
FIG.
 90.   Pneumococcus of Friedl&nder ; stick culture in gelatin,
 91.   Diplococcus pneumoniae,........
 92.   Diplococci from sputum, acute pneumonia, early stage,
 93.   Diplococcus of pneumonia in sputum, much more highly magnified,
 94.   Temperature chart ;  fibrinous pneumonia, adult,
 95.   Temperature chart;  fibrinous pneumonia in child,
 96.   Section  of alveolus of lung  in croupous  pneumonia, filled with exudate
          consisting of fibrin, with desquamated epithelium and  red  and white
          blood corpuscles (Delafield and Prudden),
 97.   Diplococcus of pneumonia in sputum,
 98.   Tubercle bacilli—sputum,   ....
 99.   Tubercle bacilli with spores, in sputum,
100.   Tubercle bacilli  in sputum,  ....
101.   Tubercle bacilli  in sputum,  ....
102.   Tubercle bacilli  in sputum,  ....
103.   Colonies of tubercle  bacillus in scales on surface of blood serum
          old,     .     .    .    .     .
104.   Hectic (i.e., septic) fever in tuberculosis,
105.   Phthisical thorax in  a girl eighteen years old,
106.   Tubercular ulcer of ileum,  ....
107.   Tubercular ulcers in the larynx and trachea, seen
108.  Shred of elastic tissue in sputum,
109.   Elastic tissue with epithelium and bacteria,
110.   Bacillus tuberculosis in urine,
111.   Tuberculous caries (stiffness) of cervical vertebrae
112.   Tuberculous caries (gibbus) of dorsal vertebrae,
113.  Leontiasis leprosa,.....
114.   Mutilating leprosy,.....
115.   Lustgarten's bacillus of syphilis,
116,  117, 118.  Teeth in hereditary syphilis,
119.  Syphilitic roseola with malformation of teeth,
120.   Syphilis of the larynx with great deformity,
121.  Tubercular syphiloderm of face,
122.   Syphilitic necrosis of cranium,
123.   Syphilitic endarteritis,  .
124.  Gonococcus, ....
125.  Gonococcus in pus cells,
126.  Non-specific bacteria, streptococcu
127.  Cystin plates, gonorrhceal thread, spermatozoids,
128.  Temperature in  simple measles,  ....
129.   Contrast between the fever of scarlatina and that of measles,
130.   Mild scarlatina,
131.   Protracted scarlatina,   .
132.   Fatal scarlatina,   .
133.  Pock of small-pox,
134.  Temperature chart in variola, showing secondary fever,
135.  Mortality from small-pox in Boston,   .
136.  Deaths from small-pox in Berlin  and Vienna,
137.   Strokes and cross-strokes for vaccination,  .
138.   Bone point for vaccine virus,
139.   Bacillus diphtheriae from blood serum,
PAGE
 126
 127
 128
 128
 129
 129
s and staphylococcus, found in urine, 
XIV
LIST OF ILLUSTRATIONS.
 FIG.
 140.
 141.
 142.
 143.
 144.
 145.
 146.
 147.
 148.
 149.
 150.
 151.
 152.
 153a.
 153ft.
 154.
 155.

 156.
 157.
 158.
 159.
 160.
 161.
162.
163.

164.
165.
166.
167.
168.
169.
170.
171.
172.
173.
174.

175.
176.
177.
178.

179.
180.
181.
182.
183.
184.
185.
 Streptococcus and staphylococcus from exudate,
 Temperature chart in adynamic petechial typhus fever,
 Temperature chart in ordinary typhus,
 Temperature chart in typhus fever,
 Temperature chart in typhus fever,
 Temperature chart in typhus fever,
 Spirilla of relapsing fever in the blood,
 Temperature chart, relapsing fever,
 Typhoid bacillus.  Pure culture,
 Typhoid bacilli in the wall of the intestine,
 Typhoid bacilli from section of spleen,
 Typhoid bacilli in mucous membrane of small intestine (child),
 Typical temperature  curve in severe typhoid fever,
 Typhoid fever with recrudescence.  Primary fever,
 Typhoid fever with relapse after twenty-four days' interval.  Relapse,
 Typhoid fever with recrudescence,
 Temperature curve in man  after injection of blood from patient affected
  with malarial (quartan) fever,  .
 Plasmodium malariae.....
 Quotidian fever,.....
 Tertian fever,.....
 Quartan fever,.....
 Temperature chart, yellow fever; mild case,
 Temperature chart, yellow fever; typical severe case,
 Temperature chart, yellow fever; protracted  case,
 Liver cells in yellow  fever with  necrotic masses in and between  the
  cells,.........
 Streptococcus from vomit (not black) of yellow fever
 Extreme opisthotonos,.....
 Hyperpyrexia of acute rheumatism,  .
 Torticollis,........
 Descending colon with sloughing pseudo-membrane,
 Descending colon with oval ulcers,
 Cicatrices of diphtheritic ulcers in the colon,
 Comma bacillus of cholera, pure culture,
 Mould fungi, etc.,  from mouth.....
The tongue coated  white, moist.  Section from case of granular kidney,
 The tongue denuded, red, and  dry (raw beef tongue).
  of peritonitis,.....
 Pharyngo-nasal catarrh.  Physiognomy before removal of adenoid tissue
 Pharyngo-nasal catarrh.  Physiognomy after removal of adenoid tissue '
 Action of the digestive juices,
 The soft stomach tube with openings at the end  and  side, and  with re'
   ceiving glass funnel,
 Partially digested matter from the stomach,    .    '
 Irrigation of the stomach,  .
Discharge by siphonage,
Microscopic appearance of section of scirrhu's carcinoma
 Haemin crystals obtained by Teichmann's test,
Protozoa in the faeces, .
Faeces under the microscope,
liver
355
357
357
366

367
367
370
370
381
382
400
400 
LIST OF ILLUSTRATIONS.
XV
FIG.
PAGE
186.   Tubercular ulcer of ileum,..........405
187.   Typhlitis.   Ulceration of the vermiform appendix,.....419
188.   Distended ductus choledochus,.........444
189.   Dilated bile ducts with thickened walls under pressure from cancer of pan-
        creas,     .............444
190.   Two large gall stones from the gall bladder articulated by smooth surfaces,  447
191.   Faceted gall stones, natural size,.........447
192.   Section of compound gall  stone with concentric laminae and with nucleus
        formed  by a smaller gall stone,........448
193.   Section of  gall stone with concentric nucleus; concentric laminae  only at
        one end..............448
194.   Section of cholesterin stone after removal of cbolesterin.....449
195.   Cirrhosis hepatis (hobnail liver),.........463
196.   Apparent enlargement of the liver, the result of tight lacing,        .     . 472
197.   Cancer of  the liver............477
198.   Nasal mucus,............478
199.   Adenoid tissue at vault of pharynx.........479
200.   Posterior  nares in  the rhinoscope,........479
201.   Normal larynx and trachea to bifurcation of bronchi,     .     .    .     .482
202.   CEdema of the glottis,...........485
203.   Advanced tuberculosis of the larynx,........486
204.   Papilloma of the larynx,..........486
205.   Fibroid tumor of the larynx,.........486
206.   Cancer of the larynx,...........486
207.   Normal larynx.  Position of cords in deep inspiration,    .     .         .487
208.   Normal larynx.  Position of cords in phonation......487
209.   Paralysis of the arytenoid in phonation........487
210.   Paralysis of both thyro-arytenoids in phonation,.....487
211.   Paralysis of the arytenoid and both thyroarytenoids in phonation,  .     .487
212.   Paralysis  of left recurrent in respiration,.......487
213.   Paralysis of left recurrent in phonation,.......487
214.   Paralysis of right posterior crico-arytenoid in respiration,      .    .     .487
215.   Paralysis of both posterior crico-arytenoids in respiration,      .    .     .487
216.   Paralysis of both recurrents—cadaver,.......487
217.   Koch's syringe,............4^1
218.   Fibrinous bronchitis,...........498
219.   Casts of the bronchial tubes expectorated in fibrinous bronchitis,    .     .498
220.   Asthma crystals.............510
      Curschmann's spirals in the sputum of asthma,......510
      Spirals with crystals in sputum of asthma........511
223.  Emphysema pulmonum,..........^19
224.  Cellular pneumonia,...........0<w3
225   ffidema  pulmonum.   Desquamated epithelium  enclosing  particles of
           ,                                        .....- 528
        coal,........                             .qo
226.  Marshall Hall's method of artificial respiration,......oaa
227.  Sylvester's method,...........5j3
228.  Sylvester's method,...........
229.  Howard's method,.........         '
230   Mould fungi from sputum of abscess of lungs.......odx>
231   Sputum from abscess of lungs, showing elastic tissue, fat crystals, phos-
        phates, epithelium, pigment matter,  pus cells, and bacteria,  .    .     .537
221
222 
xvi
LIST OF ILLUSTRATIONS.
FIG.
                                                                           PAGE
232..  Micrococcus pneumoniae crouposae,  showing capsule  from  exudate in
        pleural cavity of inoculated rabbit, .    .     •    •    •     ■           \aa
233.  Limited expansion of chest on left side,    .     •    •    •     •     •
234.  Tyrosin in  needle-shaped  crystals  arranged  in bundles and  stellate
        groups,   .     .    .    .     .    .     •     •    •    •     •     ' .    ' 555
235.  Corvillosum.   Fibrinous pericarditis,     .     •    •    •     •     •
236.  Pericardial effusion with displacement downward of the liver,  .     .     • 5b0
237.  Endocarditis at and about the aortic valves, with ulceration, perforation of
        valves, and thrombi,..........
238.  Sphygmographic tracing of normal pulse curve,      .    -^    •     •        n
239.  Pulse curve of mitral regurgitation with perfect compensation, .     .     .570
240.  Mitral regurgitation with systolic murmur at the apex,   .... 571
241.  Mitral stenosis with diastolic—i.e., presystolic—bruit at the apex,   .     .571
242.  Aortic regurgitation with diastolic bruit at second right interspace,  .     . 572
243.  Aortic stenosis with systolic bruit at second right interspace,   .     .     . 572
244.  Pulse curve in mitral stenosis with broken compensation ; feeble ascent,
        feeble force,............^"3
245.  Hypertrophy of the left ventricle from insufficiency and stenosis of the
        aortic valves,............ 574
246.  Pulse curve in aortic regurgitation,   .    .     .     .    .    .     •     • 574
247.  Pulse curve in aortic stenosis,    ......••• 575
248.  Topography of the heart.   Mechanical relation  of the heart and abdo-
        minal aorta to the stomach and contiguous viscera,     .... 583
249.  Exophthalmic goitre,...........587
250.  Exophthalmic goitre;  enlarged  thyroid and prominent eyes,   .     .     . 588
251.  Exophthalmic goitre.   Defective descent of upper lid in looking down,   .588
252.  Aneurism of femoral artery,......    .     .     . 593
253.  Aneurisms of (he hypogastric artery,........593
254.  Aneurism of the aorta,......     .    .    .     .     . 594
255.  Section of aneurism filled with clot, surrounded by dense layers of  con-
        nective (fibrous) tissue,..........595
256.  Obliteration of right femoral vein, showing remains of a thrombosis three
        years before death,...........596
257.  Poikilocytbaemia,...........600
258.  Pernicious anaemia,...........605
259.  The blood in leukaemia, showing the disproportion of the white and red
        corpuscles,............609
260.  Hypertrophy of spleen in lienal lymphatic leukaemia,      ....  610
261.  Gouty fingers,............620
262.  Tophi in the joints and  tendons,.........621
263.  Arthritis deformans.  Section of cartilage of head of femur,   .    .    .626
264.  Deformities of rickets,........              _  630
265.  Casts of the urinary tubules in nephritis,.......645
266.  Retinitis albuminurica with irregularly scattered white patches.   .    . 648
267.  Epithelium in urine of nephritis,.......         .649
268.  Chronic nephritis; epithelial and mixed casts,......650
269.  Topography of the kidney from behind, in  relation to thoracic and ab-
        dominal viscera,.........          egi
270.  Crystals of oxalate of lime,..........gg4
271.  Mulberry-shaped red blood corpuscles in urinary sediment in hae'maturia, . 665
272.  Epithelial cells from mucous membrane of renal pelvis,    .     .    .    .668 
                         LIST  OF ILLUSTRATIONS.                      Xvii

FIG.                                                                        PAGE
273.  Urinary sediment in acute pyelitis,........668
274.  Stone causing hydronephrosis,.........670
275.  Cystitis with gangrene and separation of the mucous membrane and part
        of the muscular coat,..........671
276.  Multiple (alcoholic) neuritis...........691
277.  Spasm of the trapezius,..........692
278.  Facial paralysis,............694
279.  Facial paralysis,............695
280.  Beginning sclerotic patches,..........712
281.  Knee jerk after tap on patellar tendon,.......714
282.  Tabes: perforating ulcer of the foot.........715
283.  Scleroses on cross-section of the lateral columns of the cord.    .     .    . 717
284.  Posture of healthy child,..........724
285.  Posture of infantile paralysis,.........724
286.  Bulbar paralysis,............726
287.  Pseudo-hypertrophic paralysis ;  big calves of legs,.....732
288.  Pseudo-hypertrophic paralysis ;  attempt to rise from  floor,    .     .    . 733
289.  Pseudo-hypertrophic paralysis ; patient "climbing  up his thighs."  .    . 733
290.  Forms of hemiplegia,...........740
291.  Epilepsy..............746
292.  Tubercular  tumor of middle lobe of cerebellum,.....750
293.  Gliomataof left hemisphere,.........751
294.  Cerebral localizations.  Outside view,.......755
295.  Localizations in the cerebrum.  Inside view (Dana)......756
 296.  Chorea magna,............?59
297.  Hysterical contracture of right leg and foot,......760
298.  Position of  the hand  in paralysis agitans,.......770
299.  Attitude and gait in paralysis agitans,.......771
300.  Duchenne's apparatus for relief of writer's cramp,.....780 
 
       PART I.




GEXERAL DISEASES. 
   ".  .  . For it is also thus  in nature,
the greatest balsams do  lie  enveloped in
the body of most potverful  corrosives; I
say  moreover, and  I  ground upon  expe-
rience,  that  poisons contain  within them-
selves  their  own antidote and that  which
preserves them from the venom  of them-
selves, irithout  which they  were  not dele-
terious  to others only,  but  to themselves
also.''
               —Thomas Brown, M.D., Religio Medici. 
IXFEGTIOXS-PARASITES.
                         CHAPTER  I

    Most of the diseases of plants  are  produced by parasites.   This
 fact, like the discovery of the cell  structure  in  histology, has finally
 been brought to bear upon the diseases of man (pathology) and other
 animals, with the discovery in most cases of the same cause.  Thus,
 it has been ascertained that  diseases come,  for the most part, from
 without, and not from within.
    The  parasites of man are both animal  and vegetable.  Larger
 parasites lodge  upon the  surface—Ectozoa;  or  through the  food  or
 drink reach the interior of the body—Entozoa.  The ectozoa produce
 many of the diseases of the skin ; entozoa are worms in the intestinal
 canal.
    Most of the vegetable parasites are so minute as to be microscopic.
 They are known as microbes or micro-organisms.  They reach the
 recesses of the body by way of the mucous  membranes or by inocu-
 lation of the skin.  They multiply in the interior of the body to pro-
 duce symptoms, both by their presence and  their products (toxines),
 and cause the group of diseases distinguished as the infections.
    Pathogenic micro-organisms are known, 1, by their morphology—
 that is, their size, shape, and general appearance ; 2, by their chemical
 affinities, as shown in  their reactions to coloring matter; 3, by their
 preference of soil  in  cultivation  experiments,  and  the manner in
 which they grow in the soil ;  4, by  the effect  produced by their intro-
 duction into the bodies of various animals.
    The mass of micro-organisms belongs to  the vegetable  kingdom,
 to  the  subdivision cryptogamia, which forms  neither flowers nor
 seed, but reproduces itself by spores.   Pathogenic micro-organisms
 may be divided  into :
       1. Fungi, or moulds.
       2. Ferments, or yeast plants.
       o. Bacteria, or schizomycetes.
       4. Protozoa.
    The fungi include  the various vegetable  growths, often of such
magnitude as to be visible to the naked eye, which cause many 
4
ECTOZOA—ANIMAL.
skin diseases, and sometimes, by  metastasis, as  in  the  case  of the
actinomvces. affection of the internal organs.  Yeast plants produce
the various, chiefly the alcoholic,  fermentations.  Bacteria  cause
most  infectious  diseases.   Protozoa certainly  produce malaria and
probably cause cancer.

                           ECTOZOA.
                            ANIMAL.

   Scabies (scurf: itch).—An  eczema produced partly by the itch
insect (Acarus scabiei) itself, but chiefly by scratching in relief of the
itch the insect causes.
   The disease has been always known, is alluded to  in the Bible,
and was formerly regarded as a constitutional (blood) malady, the
cure of which might entail worse evils.
   The Acarus scabiei has a hard, crab-like body with thorny exterior;
stiff  hairs protrude from  its  borders.   The head has strong jaws,
which work like  scissors  and are fixed with teeth.  Respiration is
wholly cutaneous.  The  animal is  bisexual.  The female is oval-
shaped, broader than long, <>.35x0.23 mm., white or gray ; the male
                         smaller, 0."25 X 0.15  mm., brown  or yel-
                         low.   Each has two pairs of extremities in
                         front  and  behind,  the first pair provided
                         with suckers, a  hinder pair  in the male
                         with fasteners.
                           The male lives in slight excavations
                         which he makes in the surface of the skin;
                         the female bores for herself lightly curved
                         burrows or canals, three centimetres long,
                         in the course of which, as she advances.
                         she  deposits  eggs, one or two per  day.
                         The  young acari shed the  skin three or
                         four times at intervals of six  days ; first
                         in fourteen to seventeen  days, to appear
                         after the first moult with eight legs—hav-
ing had but six  hitherto—and  after the  third with mature sexual
organs.
   The insect seeks naturally regions where the epidermis is thin
and  the  deeper layers succulent, as  the front of the wrist, sides of
the fingers, space between the fingers, front of the axilla, flexure of
the elbow, penis, nipple, etc.  The face is spared except in bad cases,
and in sucklings who  may be infected by nurses.   So, too, the dis-
ease  may be carried, by scratching, to  unwonted seats, even to the
hairy scalp.
 Fig. 1.—Female Acarus scabiei,
dorsal surface. 
ECTOZOA—ANIMAL.
5
   Scratching develops eczema,  which  is sometimes obstinate and
extensive, and may require treatment after destruction of the cause
of the disease.
   The lesion is that form of superficial  irritation which shows itself
in itching, and which may vary in every degree of  intensity from
annoyance to torture, according to the extent of the disease and sen-
sitiveness of the individual.   It is usually worse at night and may
exhaust the strength through insomnia.
   The diagnosis rests upon, 1, the itch—the situation of the lesion;
2. the character and course of the canals—curved lines colored with
fseces and studded with salient points ineffaceable on washing ; 3, the
demonstration of the insect  itself—a white  granule at the end of a
canal, which, with a little practice, may be lifted out under a lens on
the point of a knife or a pin.
Fig. 2.—Acarus burrow, with ova.
   Treatment calls  for  the  destruction  of the parasite and all its
progeny—usually  an easy task—and  in aggravated cases applica-
tions in relief of the eczema.
   There is much  choice of  remedy: as  a  rule, mild means are the
best.   (hie of the following ointments  should be thoroughly rubbed
into the skin :
   1  ]J Balsami Peruviani,
       Styracis liquidse.
    M.

   2 IJ  Florum sulphuris,
       Olei rusci........
       Cretae preparatse.
       Saponis viridis,
       Axungiae—---
    M.
   3 1*  /3 naphthol......
       Saponis viridis...
       Cretae preparatae
       Axungiae.......
    M.
afi3ij.
,  gr. xv.

aa 1 ii.
3 SS.
3iss.


3»j- 
ECTOZOA—ANIMAL.
Fig.
   4. A more elegant but more expensive preparation :
     1} Lactis sulphuris.......................  ..................1 ij-
       Potassii carbonatis......................................3 vi.
       Olei lavandulae,
       Olei caryophylli..........'............................aa gtt. x.
       Axungiee................................................. ll- s-
     Ft. unguentum.
    Recipes No. 2 and 3 are better than No. 1.   No. 3 is the best, be-
cause it irritates  less and  soils  least.   In all cases a good quantity
must be thoroughly rubbed into the affected parts.  Woollen cloth-
ing should be worn, that the surface be not robbed by absorption.   If
there is still itching the inunction must be repeated on the following
day.   Bath after several days.  The cure of the scabies is now com-
plete.  Any eczema left will disappear under diachylon ointment.
    Bathing, as it aggravates  eczema,  should be avoided for four or
               five days, or until the skin under the ointments dries
               and desquamates.  Finally,  after bathing, the skin
               may be anointed with vaseline or cocoa butter.
                  Pediculus Capitis (head louse).—An elongated,
               hard body, 2 x 1 mm., which  cracks between  the fin-
               ger nails,  with six feet provided  with claws for climb-
               ing and clutching hairs.  The female, which greatly
  3itis!'niaieedlCUlUS outn"mbers the  male,  glues  her eggs  to hairs by a
               layer of chitin, commencing at  the head end of the
hair and depositing eggs upward, as many as fifty in successive layers,
so that the duration of infection may be determined,
on  inspection with a lens, by the situation of the eggs
or young (nits).   The  young  escape in three to eight
days, and become mature in eighteen  to twenty days.
A single female  may give birth within six weeks  to
five thousand young.
    The irritation caused  by  pediculi  causes eczema
through scratching; and  as such regions are avoided
in combing the head, they offer quiet retreat for multi-
plication of the parasite and aggravation of the eczema
Continued neglect  may thus  lead to suppuration and
agglutination of the hair into  a foul, offensive mass or
cap, the pi/ ca polonica.
   The insect is  strictly  confined  to  the hair  of  the
head, but the resultant eczema may extend to the neck
or face or m bad  cases lead to lymphangitis and swell-
ing of the neighboring glands
   Cases of light  infection are best treated by frequent -S^1
use of the fine-tooth comb and thorough ablution with andnits-
soap.   More extensive infection  calls for a parasiticide, as a .M;xture
 
ECTOZOA—ANIMAL.
7
of equal parts of petroleum and balsam of Peru, which may be most
thoroughly  applied  after cutting the hair short.  The worst cases
require more thorough saturation, as by the application and wear-
ing, after inunction, of a flannel  cap soaked in the same mixture
made thinner by  the addition  of one-fourth part olive or cod-liver
oil.  Any fixed  or volatile oil kills all kinds of lice (Leidy).  The
eggs  and nits are afterward dislodged with saturated solutions of
soda.  Crusts are best softened with cod-liver oil.  The eczema dis-
appears with destruction of its cause.
   Pediculus Pubis (morpio; crab louse) finds its  habitat on any
hairy surface except the head, but is especially at home at the pubes,
whence it is derived in sexual congress, and where it may be seen on
close inspection  as a small brown speck near
the skin.   It has the same general construc-
tion as the  Pediculus  capitis, and  the eggs
are fastened to the hair, only close to the root,
by the same chitin.   The insect is effectually
destroyed by mercury, best in the form of the
white  precipitate ointment.  Two  applica-
tions of the size of the end of the little finger
will alwavs suffice to relieve the itching, ec-
zema, or other effect, with the eradication of    FlG' 5-Pedlculu* p**-
the cause.  When mercury itself produces eczema or is contra-indi-
cated from  any cause, it  may be substituted  by naphthol with  olive
oil 1:10, or creolin 1: 50.   The remedy should be applied with cotton
at night, and the application should be repeated on the following
night, whereupon on the next  morning it may be washed off with
soap.  To destroy the young of subsequent growth, the application
should be repeated at the end of one and two weeks.
    The most potent  preparation for permanent cure—i.e., to destroy
nits and eggs—is  (Saalfeld) :

     Pp Hydrargyri bichloridi  ....................................gr. x.
       Aceti communis.....,...................................1 viii.
    M.  S. Apply morning and evening for three days.

   Pediculus Vestimenti  (body louse; clothes louse).—The largest
of all the lice, 3-5  X1-2 mm.   It has the same general construction as
the species above described,  but lives in the clothes, and leaves  the
folds and creases, in  which it lies secreted, to suck blood from the body
as food.  The irritation thus produced is intensely aggravated by
scratching,  so that the skin is torn by the nails  and the surface is
literally lacerated in every  direction.  Urticaria, excoriations, ec-
zemata, pustules,  furuncles,  and actual ulcers may form in  these
regions.   Parts  of the body which suffer most are surfaces of closest 
8
ECTOZOA—ANIMAL.
 Fig. 6.—Pediculus
vestimenti.
 contact with the clothes, as at the back of the neck and shoulders,
 sacrum, nates, hips,  etc.; or regions  of  friction, as at the  waist,
 wrist, line of the garter,  etc.   Continued irritation at these places
               leads to deposit of pigment, so that the affected sur-
               face may be deeply discolored.  Infection is most ex-
               tensive in the class of peripatetic pilgrims commonly
               known  as tramps, but is not infrequently seen in the
               higher  classes  as accidentally contracted in  hotels,
               sleeping cars,  ship cabins, etc.   Moreover, exterior
               and interior do not always correspond.  Undercloth-
               ing may be  worn  so long as to become a good breed-
               ing place after the slightest infection ; the clothing
               may be clean and the bed foul, etc.
                 Treatment, to be effective, must be radical.  The
               clothes, bedding, etc., must be burned, boiled, steamed,
or subjected to dry heat at 212°  F.  for twenty-four  to  forty-eight
hours, or, when this is not practicable, saturated for hours in a solu-
tion of sublimate 1: 1000, or in crude petroleum.  The surface irri-
tation disappears with  destruction of the cause.
   Acarus Folliculorum,  an elongated,  0.08x0.02 mm., worm-
like body, with mandibles and four pairs of extremities on the upper
third of  the body, is found in the secretion of the oil
and hair glands, especially  of the nose, temples, cheeks,
external  ear, etc., and rendered visible under the lens
after expression of the  contents of the gland by the fin-
ger nails.  These contents, of cheesy  consistence, often
with  a top  of black coal dust, flattened out under an
object glass are seen to include, for the most part none
at all, but at times one, or exceptionally more—in re-
corded cases as many as twenty—acari.  The animal
always lies head downward, and seems to be perfectly
innocuous to man, though  allied species do damage to
the skin in lower animals.
   Pulex  (the common  flea)   in its bite  produces
petechias with hyperaemic areola, which fades on pres-
sure and soon disappears altogether, while the petechias
persist for several days.  The flea bites usually covered
surfaces  in light contact with the clothes, as the  back
chest, thighs, etc.  Confusion with petechial eruption 'is avoided by
observance  of the  region affected—the legs  in purpura, the lower
abdomen in variola, the upper abdomen in typhoid fever, etc   Th
central blood point of the fresh flea bite, and the dark-brown or black
specks which mark the deposit of faeces, suffice for diagnosis
   Pulex  penetrans (the sand flea) is found  alon
m
 Fig. 7.—Acarus
folliculorum.
the
coast 
ECTOZOA—VEGETABLE.
0
regions.  The female penetrates the surface to suck  blood and leave,
in the course of three or four days, more severe inflammation of the
skin.  Erysipelas, lymphangitis, ulceration, gangrene, even tetanus.
have been thus introduced.
   Cimex  lectularius  (the  bedbug) makes distinctions, in that
it selects certain individuals and spares others.  It produces in sen-
sitive subjects, especially  infants, itching urticaria, eczema, and, in
consequence of scratching, more or less extensive incrustation.  The
insect makes its excursions in  search of food at  night  only, and
attacks more  especially  exposed  surfaces—face,  neck, and  arms.
These points suffice for diagnosis.
   Mosquitoes, Wasps,  Bees,  Hornets,  or  other Flies, and
other insects, may produce lesions of the skin by  bites, by the de-
posit of  eggs  (maggots)  in wounds, and, in the  case of wasps and
bees, by the insertion  of poisonous matter.   The  history makes the
diagnosis.   The writer once failed to get a diagnosis from a class of
students in the case of a patient semi-comatose with typhoid fever.
one-half of whose face was thickly studded  with  papules  while the
other half was wholly free, the studded half having become exposed
in the night from under the mosquito bar.
   The application   of dilute  liquor ammonias  1  :10, alcohol,  or
water with the addition of a few drops of carbolic acid  or  of creolin
(one or two per cent), allays the irritation and neutralizes the poison
of the bite.
                  VEGETABLE—DERMATOMYCOSES.

    Favus (honeycomb) ;  tinea favosa.—An affection, chiefly of the
 hairy scalp, produced by the growth of a mould
 fungus named by Remak in honor of Schonlein,
 its discoverer (1839), the Achorion Schonleinii.
 The disease begins as a papule penetrated by a
 hair.  The papules grow  gradually to the size
 of a ten-cent piece, flattening and sinking in the
 centre to form the characteristic saucer-shaped
 masses, scales, or cusps of sulphur-yellow color,
 the  so-called  scutula (dish).  Crushed between
 the fingers the scales crumble, to emit a peculiar
 musty odor.   Particles placed under the micro-
 scope show,  with epidermis scales, hair  frag-
 ments,  detritus,  etc., a wilderness of threads
 (mycelia) and  spores (conidia),  the cause of the
disease.
   In the course of time the favus crusts  co-
alesce to form a more uniform  mass; the invaded hairs lose  their
 Fig 8.— Achorion Schon-
leinii from favus cup (Ka-
posi). 
10
ECTOZOA—VEGETABLE.
lustre  appear as if powdered, become fragile, and are easily broken
off or  detached ; in bad cases, where the papilla is attacked, they
mar be permanently destroyed.   The surface, which is now con-
verted into a mortar-like, dirty yellow mass (honeycomb), presents an
appearance offensive to both  sight and smell.   Crusts, which were
before so  adherent as  to be detached with haemorrhage, now des-
quamate continuously  and the color  gradually changes to gray or
brown.
   The disease may in exceptional cases attack uncovered surfaces,
and in still rarer cases invade the nails (onychomycosis favosa), which
then show the same sulphur-yellow deposits with degeneration and
detachment of nail  substance.  The  characteristic  elements  of  the
  Fig. 9.—Favus scutulum : a, free border ;  6, corneal layer ; c, d, mycelia ; e, conidia; /, epithe-
lium: g, papilla; h, cell infiltrate at base of scutulum; i, cutis (Neumann).
growth have been observed once (Kundrat,  Kaposi) in matter voided
from the stomach.
   The disease is common to many domestic animals,  especially to
mice,  rats,  and cats, from the  last of which it  may be contracted,
though infection usually comes from an affected bedfellow or from
use of the same comb.   It is not eminently contagious  and may re-
main  confined to one child in a family in  close contact with others
for years.
   The diagnosis rests upon the form of the favus crusts, the net-
low color,  the odor like that of mice,  the destruction of the hair;
more  positively upon the presence of the parasite, which is best dis-
played by the addition of a few drops of liquor potassse and examina-
tion with glycerin.  The diagnosis has been made easy  since the dis-
covery by Neisser that a favus crust touched icith alcohol is stained 
ECTOZOA—VEGETABLE.
11
a deep yellow, a change which does not occur in crusts of eczema'or
other simulating affections.
   Treatment.—The crusts must be softened with oils, that a parasi-
ticide may be brought to bear directly upon the cause of the disease..
                                              b
Fjg. 10 —Hair and root sheaths in favus, infiltrated with conidia and mycelia.
In uncovered places saturation with cod-liver oil over night, and the
subsequent application of carbolic acid, naphthol, resorcin, thymol,
or sublimate, according to the following formulas, suffice  to control
the disease.   The disease is much more obstinate on hairy surfaces,
and successful treatment demands epilation.   After  softening by 
12                    ECTOZOA—VEGETABLE.

saturation over night with cod-liver oil under a flanm  cap, the head
should be thoroughly washed with soap liniment, dried, and all loose
hairs extracted.   Thereupon  one of the following preparations must
be rubbed into the  scalp with a stiff  brush, whereby it is not neces-
sary to give pain :

   1  li Acidi carbolici.............................................3 ss.
      Olei olivse.................................................3 1 v-
    M.
   2  R Resorcin.................................  ............  31.
      Unguenti petrolati.........................................11V-
    M.
   3  R Thymol..................................................3 i.
      Chloroform..............................................§ ij.
      Olei olivse..................___...........................1 iv.
    M.
   4  B Unguenti hydrargyri ammoniati...........................3 ij.
      Unguenti petrolati........................................§ ij.
    M.
  Fig. ll.-Epidermis scale in herpes tonsurans, showing more mycelia than conidia (Kaposi).

   The most  powerful parasiticides, when well borne, are pyrogal-
hc acid ten per cent, or chrysarobin ten per cent,  or alcoholic subli-
mate s jlution 1 : 100.

   Herpes tonsurans (kpnV,, creeping eruption; tondeo, to shear);
herpes  circmatus :  rmgworm.-A  disease  of both hairy and free
 hakSeHo"    *    1 ^^ °n **** the^°f the trichophyton
SI      w   7' narr°W thPeads Which di^ bu?httle,
form no masses, but much more readily invade the hair.
   The parasite is common to domestic animals, dogs,  eats  cattle
between which and man the disease is  transferable.   ItmaybeCul-
tn uted  in beef infusions, on agar, potato, etc.               * 
ECTOZOA—VEGETABLE.
13
   On the scalp it attacks and bends or breaks off the hairs, to leave
partly bared, as if badly cut, or later bald, spots, smooth, scaly, or cov-
ered with pustules or crusts  with more or less reddened edge.  The
hairs look  dull and dusty, and the skin of the scalp is lightly infil-
trated with serum and is slightly sensitive to pressure.
   On a free surface the disease
appears in  small  vesicles upon a
reddened base. The vesicles rup-
ture, to leave the red points  cov-
ered with  small  scales.  In the
progress of the disease new ve-
sicles  develop  in the form  of a
ring  about the  first  set, while
the original centre fades to leave
no  trace.  The  process  repeats
itself  in this way with an  ad-
vancing circular or  serpentine
wall of  vesicles, or contiguous
rings  break  into each  other  to
aggravate  the inflammation and
show pustules, crusts,  or  more
extensive eczema.  Desquamation finally sheds the parasite, and the
disease ceases spontaneously in six weeks to six months.
   A good illustration of this process is often seen on delicate surfaces
Hair in herpes tonsurans.
Fig. 13.—Onychomycosis.
kept warm and moist by apposition, as where the skin of the scrotum
rests upon the inner face of the thigh.  Maceration with abrasion of
the epidermis forms here a good nidus for  the  parasite, which ad-
vances with an outlying marginal ring of papules to constitute the
affection known as eczema marginatum.  The finer forms of myce- 
11
KCTOZOA—VEGETABLE.
 lia sometimes found in this  affection have  received  the  name mi-
 crosporon minutissimum.
    The nails invaded by the  parasite (onychomycosis  tonsurans) be-
 come opaque, scaly, and brittle.
    More extensive inflammation results  at  times from invasion  of
 the hairs of the beard, with the formation of papules and pustules,
 which may coalesce to form ulcers with wide infiltration of the skin,
 constituting the  condition known  as  the parasitic sycosis menti.
 The disease is contracted in barber shops. The common acne  men-
 tagra  is also parasitic, but is produced  by  the  Staphylococcus au-
 reus.
    Treatment.—During the stage of vesiculation or  abrasion on a
 free surface, no  other treatment is necessary than  the use of some
 inert powder, as  of  starch,  to prevent contact with air or with op-
 posed  surfaces.  Later stages call for :

   1 R  /S-naphthol....................................3 ss.
       Saponis viridis..................  ... ................  3 ii.
     M.
   2 R  Acidi pyrogallici.....................................3 i.
       Unguenti petrolati...............   ............ .........  -x,
     M.

   3 R  Hydrargyri chloridi corrosivi, Aquas destillatse, 1:1000.
     M. S.:  Wash the surface three times a day.

    (hi the hairy scalp successful treatment requires, in addition to
 softening of crusts with  olive,  almond, or cod-liver oil,  removal of
 dead or diseased hairs, with subsequent destruction of the fungus by
 one of  the parasiticides mentioned.   Penn  applies sublimate with elec-
 tricity. The sp;,nge of the positive pole is dipped into a three- to five-
                                   per-cent  sublimate solution and
   ^s_   . (f2^» (0~~ir__'?      aPplied to the  affected  region
 c7^^7-w  ^M^<r^f^T9    ten minutes with  a current not

  ^^^^m^;A3~c     t0°strong-
    ^^C|/tgp^r^^yi         Pityriasis  versicolor  is
   3  ~|g|g^v- r^^^__    that  discoloration of  the sur-
     ^88b&  %  ^-^l^y-^     face'  Pretty uniformly  yellow
     ^wSP'-—■_-!^;« ,            or In-own.  not so variegated as
  Fig 14.-Microsporon furfur: a, mycelium    the name implies, which results
threads;  b, conidia; c. epithelium.             f ,.^1V1  +i_ A    -^   ,
                                   tiom  the deposit and growth of
, n       .   n.  .                 the microsporon furfur  a ve^e-
table parage .Languished  only from those hitherto d-s.-'rite  1 y
it> smaller  s,ze and more superficial  growth.   It develops l,v urefe
ren-e upon warm, moist surfaces of  the trunk, neck, flexures of the 
ECTOZOA—VEGETABLE.
15
 joints, etc., and is most commonly seen  on the skin  over the pit of
 the stomach, especially in the uncleanly or phthisical, patients  who
 sweat much.  The discolorations vary in size from minute spots to
 tracts which may by spread or coalescence cover large regions of the
 body.
    Treatment.—Friction with  carbolic acid,  sulphur, or naphthol
 soaps usually suffices to reach this parasite.  The following is an eli-
 gible preparation :
    R /^.-naphthol...........................................gr. x.
       Spiritus lavandula?....................................3 j,
       Saponis  viridis.....................................= i
    M.

   Other forms of pityriasis—viz.. rosacea, maculata,  circinata—and
various dermatomycoses—erythrasma, etc.—are produced by allied
hyphomycetes.  Carter considers the Madura disease, in which tumors
Fig. 15.—Pityriasis ; mycelia and conidia.          Fig. 16.—Mycoderma albicans.
 and ulcers form on  the hands and feet, the so-called fungus disease
 of India, as a  mycetoma.  Certain diseases of invertebrate anim Is
 are  found to be  due to fungi.   The  silkworm is destroyed by  the
 muscardine, Botrytis Bassiana ;  the crab by penetration of its flesh
 by the Achy la prolifera; and the  common house fly is killed b}' pene-
 tration of the mycelia of a species of empusa.

   A'transition from  the external to the internal parasites is offered
 in thrush and actinomycosis—affections of the mucous membrane
 and  deeper structures of the mouth.
   Thrush (thrush ;  curd; German, Soar;  French, muguet).—A su
 perficial disease of the mucous membrane, mostly of the mouth, caused
 by the deposit and  development  of the thrush fungus (Mycoderma
 albicans), and characterized by the formation of white spots and sur-
 faces non-adherent  or but loosely adherent to the epithelial  layer,
clinically by sore mouth and dysphagia.
   The thrush  fungus was formerly regarded as the Oidium albicans,
but snu'O  it has been  observed to grow by  the budding process it is 
1G
ECTOZOA—VEGETABLE.
person
especially in cases
classed among the ferment fungi and called the Mycoderma albicans.
It is readily recognized by its mycelia and conidia, and may be  cul-
tivated on various soils.  It has a wide distribution in nature, but not
much affinity for the soils offered in the body of man.  as it develops
on  the mucous  membranes only of the weak and debilitated or in
        of unclean habits.  It is  found in the mouths of  sucklings,
                  of gastro-intestinal catarrh or  in cases of  use of
                                 unclean utensils for food, espe-
                                 cially unclean nursing bottles and
                                 nipples.  It is seen also upon the
                                 breast nipples of nursing women
                                 careless as to  cleanliness ;  and
                                 these two sources, the  natural
                                 and  artificial  nipple,  introduce
                                 the disease to  the  mouth of the
                                 child.
                                    Typical cases are also encoun-
                                 tered in the adult where the body
                                 has become debilitated by long-
                                 standing disease, typhoid  fever,
                                 tuberculosis, diabetes, or any ma-
                                 rasmus.  In the last stages of tu-
                                 berculosis  the  whole  interior of
                                 the mouth and pharynx, as far
                                 as may be seen, may be  lined with
                                 thrush.
                                    The fungus is also found upon
                                 other  mucosae—larynx,  oesopha-
                                 gus, stomach, vagina, glans penis.
                                 and rectum.  It lies at first under
                                 and in the epidermic layer of the
                                 mucosa, but is speedily exposed
                                 by desquamation  and  is  found
                                 mingled with  epidermic scales.
                                 detritus, and the myriad bacteria
                                 of the  mouth.   Occasionally, as
a great exception, it is carried by metastasis to distant organs  Thus
Sehmorl found it in the kidney, and Zenker (sole observation) in mul-
tiple abscesses in the brain.   Such transfer is exceedingly rare, but
the possibility of it has  been  proven in animals by Klemperer, who
produced a general  mycosis by injection of it into the blood of the
rabbit   Asperated into  the lungs of man, it helps to produce the
catarrhal (Srhluck)  pneumonia  of  paralyzed,  reduced, dphilir*^
 Fig. 17.—Transverse section of flake of coat
of tongue after death in typhoid state, covered
with mycoderma (Dickinson).
(senile) patients. 
ECTOZOA—VEGETABLE.
17
   Symptoms.— Thrush may be latent.   In fact,  most cases of light
deposit hitherto unsuspected are recognized only by inspection—as of
the process of dentition,  for  sore  throat, etc.  The disease shows
itself at first as small pinhead deposits of white cheesy matter, bor-
dered with a red ring,  upon the surface.   The points coalesce to form
large surfaces, which may coat extensive areas or absolutely line the
whole cavity.   The deposits may be detached without much break of
surface—i. e., without haemorrhage—to leave a lightly reddened, hard,
slightly abraded base,  which is tender to the  touch.  The secretions
of the mouth are always acid, not,  however,  in a necessary relation
to growth of the fungus, as Kehrer showed that it will thrive in solu-
tions of the lactate of soda and potash.
Fig. 18.—Thrush fungus : a, mycelia with polar granules; b, conidia; c, epithelium; d, leucocytes.

    When present in any quantity it causes soreness of the mouth,
with consequent aversion to food and at times even difficulty of deg-
lutition.
    Diagnosis.—The disease is usually recognized at a glance, even
though the color may be changed, by admixture with food or foreign
matter, to a dirty gray or brown.   The  deposit is confined  to the
surface of the tongue, cheeks, lips, or only later involves the throat,
and then without the  adenopathies which distinguish  sore  throat
from other causes.  In case of doubt the microscope reveals the true
character of the deposit.   The specimen,  best examined  in glycerin,
shows leucocytes, detritus, conidia (spores),  and threads with clear
contents, each section of which contains two polar granules.
    Treatment.—Prophylaxis is  a main element.   The disease may
be avoided by care of the mouth and  scrupulous attention to utensils,
nursing bottles, nipples, etc., which  should be boiled, steamed, and
washed in soda.  In fact, bottles and nipples should be dispensed
        2 
jS                   ECTOZOA—VEGETABLE.

with as soon as possible.  All expenditures of  patienee in feeding
with the spoon and from a glass (not a cup. even though ot silver
or gold) will be thus amply rewarded.  The oral cavity of patients
with prostratim-'maladies (the tuberculous, etc.)  must  be  cared for
evervdav   The child's mouth may be best washed out with clean
linen rags dipped in five-to ten-per-cent solutions of soda  or borax.
^.posits of thrush mav be thus mechanically washed away, and the
parasite itself dislodged and  destroyed.   The base may be touched
with nitrate of silver (two-per-cent) or with—
                      .•                               °T V.
    R  Potassu permanganatis.....................................°   .
       Aqua- destillatae............................................3
    M.  Apply with camel's-hair brush.
   A very mild. safe, and efficacious remedy is methylene  blue, two-
or three-per-cent solution, applied with a brush.
   Syrups, because they favor the development  of fungi,  should be
alwavs avoided in the preparation of any remedy for thrush.
   The general  health must  be fortified  by the  tincture of  iron,
malt, cod-liver oil. fresh food,  and open-air exercise.
   The Leptothkix buccalis is the common fungus  which abun-
                         dantly infests the mouth.  It is found on
                         the coat of the tongue ; on the teeth, to the
                         caries of which it is said to contribute; and
                         in the crypts, cheesy contents, of the ton-
                         sils, where it produces  a form of tonsillitis
                         which simulates in its deposits and symp-
                         toms a beginning diphtheria.  The lepto-
                         thrix  may  be  always recognized by its
     i9.-LeptothriX buccalis.  mycelia.   Under the  iodine-potassium-io-
From tartar of teeth.           dide solution it takes on a purple color.
   Actinomycosis (axri?, axrivos, ray,  /xvh?/?,  fungus)  ; big jaw,
swelled head, bone tumor; German, Kinnl)enle,  Holzzunge, Kuoch-
eitkrebs.—A peculiar infection of cattle as well as man,  caused by the
ray fungus, actinomyces, characterized by development of the fungus
in mass, with excessive overgrowth of the soil in which it grows, at-
tended by metastases  to  different  organs,  marked by  symptoms of
pyaemia and marasmus, and distinguished always by the detection of
particles of the fungus itself in the  mass, in its metastases, and in its
discharges.
   History.— Bollinger (1877) first  saw the fungus as the cause of
the disease known as the big jaw in cattle.   Israel, of Berlin, saw the
para-ite in  man in the same year of  its discovery in cattle, and de-
scribed it as a new mycosis of man.   Ponfick (1879) established the
identity of the disease it  caused in man with  the actinomycosis of
cattle.  Belfield, of Chicago,  first recognized the parasite in cattle in
Fig 
ACTINOMYCOSIS.
19
our own country as the cause of the disease known as swelled head,
technically as a jaw sarcoma.
   Pathology.—Actinomyces constitutes a mass so large as to be
visible to the naked  eye.   It consists of a conglomeration of innu-
merable threads of mycelia about a central mass of the same struc-
ture, from which the threads radiate in every direction to construct
the ray shape.  The mycelia  can be  always  recognized by their
clubbed extremities, and the  mass, on an average about one-fortieth
of an inch, is as large at times as one-tenth of an inch in diameter.
Agglomerated masses may be as big as a fist.  Fragments detached
and discharged have a tallowy consistence and a distinctly greasy
feel.  Peripheral  protrusions divide  dichotomously,  and show, as
stated, distinctly clubbed- or pear-shaped extremities, to resemble in
certain  fragments the appearance  of a  hand or glove  with out-
stretched fingers.  The peripheral radiation  from a central mass
gives, under the microscope, something of the  appearance of an aster
            Fig. 20.                               Fig. 21.
   Fig. 20.—Actinomyces.
   Fig. 21.—Actinomycosis of the tongue: a, actinomyces mass; b, cell masses; c, pus corpuscles;
 d, muscle tissue, cross-section; e, ditto, longitudinal section; /, blood vessel (Ziegler).

 or sunflower.  Many deviations,  however, may occur from this clas-
 sical type.  The size of the individual mass may vary from barely
 visible granules up to masses of measurable diameter.
    Besides the typical  yellow color, particles may be seen colorless,
 transparent, greenish,  or brown.   The young granules are whitish-
 gray, the  very j^oungest gelatinous, almost diffluent; the other colo-
 nies are opaque, and the oldest yellowish-brown and yellowish-green.
 The surface  may be granulated,  mulberry  form.  Harz and Johne
 tried in vain to cultivate it.  Israel finally succeeded with coagulated
 blood serum,  but with such  different appearance from  the normal
 structure as to make it impossible  to decide upon the exact botanic
 relations of the microprryte.  Bostrom succeeded best with granules
 floating  free  in pus or lying loose in granulation  tissue.   Wolff
finally inoculated the  disease with pure  cultures  of  actinomyces.
The mass is colored Avith difficulty, though the mycelia at the peri-
phery absorb the aniline  d}*es. especially gentian violet, and retain 
oo                      ACTINOMYCOSIS,

them.  Fine  pictures are made with double colorations, as by  the
method of Gram, and subsequent stain with eosine.
   The pathology of the affection differs in man from that ot  tne
lower animals, in that the process in the animal is a local swelling, a
so-called  granulation tumor, while in  man the tendency is toward
a suppurative process with metastatic dissemination.   So  that  the
di^ea^e in man runs its course with the formation of multiple ab-
scesses, under the picture  of a  chronic pyemia.   The difference is
explained bv the belief that the process is not pure in man, but is
attended with mixed infections, especially with  the penetration of
the pyogenic micro-organisms.  Of the nine cases reported by Baracz,
in only <>ne was there a pure actinomycosis; in all the others there
was subsequent infection  with the micro-organisms of pus.  The
suppurative process in man is attended also with a distinct tendency
to extensive fatty degeneration.   Preparations of the granulation tis-
sue show great accumulations of fatty degenerated cells.
    Etiology.— The most frequent avenue of entrance in man is, as
stated, the cavity of the mouth,  and especially the teeth whose  sur-
face is broken with caries ;  next the bones of the jaw ; less frequently
solutions of continuity in the pharynx  and tonsils.  More than half
of  all the cases hitherto observed in man have arisen in this way.
The origin of the disease is ascribed to the ingestion of vegetable food,
especially certain cereals (barley).   The avenue of entrance in man
bespeaks the same origin, that is, some vegetable source.
    Symptoms.—The disease demonstrates itself as a torpid and but
 slightly painful growth, which finally perforates the skin with  sin-
 uous  tracts and various  fistulous orifices.   Some, if not most, of
 the great tumors or masses in the region of the lower jaw, formerly
 diagnosticated as cases of angina Ludovici, which constituted in an-
 cient times a much-dreaded malady, were  certainly cases of actino-
 mycosis of the lower jaw.   Besides  the penetration of  the teeth, the
 parasite finds entrance  into the body  of man by way of the bronchi
 and also by way of the intestinal canal.  Thus there is an actinomy-
 cosis of the jaw. of the  lungs, and of the intestine.  The disease dis-
 tinguishes itself by its gradual encroachment upon tissues, hard  and
 soft, in its vicinity.  It expands bone,  enlarges the natural outlines of
 the neck, converting the skin into a  mass of cicatricial tissue, finds
 its way  at times into the anterior mediastinum,  and finally, after a
 lapse of months or years, causes the death of the individual by a slow
 process of suppuration or by a quicker suffocation or occlusion of
 larger vessels.
    It may be distinguished upon the surface by the mass of cicatri-
 cial tissue, by the formation of  abscesses with subsequent discharge
 without  offensive  odor, often through fistulse of sinuous tracts, and 
ACTINOMYCOSIS.
21
absolutely by its yellowish granules,  of  the  size of grains of sand,
visible to the naked eye, greasy to the feel, which, when placed under
the microscope, reveal the distinctive characteristics of the growth.
   Entering  the bronchial tubes,  it produces  a peculiar  form of
bronchitis, most closely allied to putrid bronchitis, save that the of-
fensive discharge which is expectorated separates into two instead of
three la}Ters—an upper supernatant, and a lower, turbid fluid con-
taining the actinomyces.   In the lungs proper the disease gives  rise
to the symptoms of tuberculosis, and has been not  infrequently mis-
taken for this disease.  The gradual decline of health and strength,
the progressive emaciation,  cough, suppuration,  night siveats,
make it closely resemble tuberculosis.   In cases of  more rapid prog-
ress the  disease may simulate pneumonia with its  glutinous, mu-
co-purulent,  or  rusty sputa,  dulness  to  percussion, and bronchial
respiration.   Metastatic  processes  from  these  centres  disseminate
the parasite  to  distant organs, most frequently to the subcutaneous
and intermuscular connective tissue, and also to the various viscera
—liver, kidneys, intestine,  heart, and brain.  The eruption  into the
various serous cavities—pleura, pericardium, peritoneum, meninges—
quickly causes fatal inflammations.   Cases which escape these calam-
ities survive to  succumb to amyloid degeneration with anasarca,
and more protracted marasmus, whereby  the disease may last two or
three years.
   In the intestine the mucous membrane shows  whitish patches
covered with yellowish granules, firmly adherent to the membrane
upon which  they rest.  Various swellings appear, therefore, in its
course, some of which suppurate and discharge their contents at
times into the peritoneal sac,  or by successive agglutination to the
surface of the abdomen with subsequent free discharge.   Metastases,
which are rare on account of the size of the growth, carry fragments
to the liver, where they may attain considerable magnitude.   So me-
tastases through the jugulars have  developed into masses in the lung
and heart.
   Diagnosis.— The disease may be distinguished from ordinary af-
fections of the jaw by its  long duration,  its tedious suppuration, its
recurrence after incomplete exsection, its periods of quiescence, and
defiance  of all ordinary treatment,  In the lungs it affects the pos-
terior and lateral portions, rarely the apices, and in  the  intestine it
reveals nodular  masses which may at times be felt beneath the sur-
face.   But neither the enlargement, suppuration, nor general symp-
toms absolutely declare the disease, whose nature  is only definitely
established by  the recognition  of fragments of the parasite with
the eye and its characteristic  elements under the microscope.  Cer-
tain apparently inscrutable cases  of  cryptogenetic  infection  have 
•»
ACTINOMYCOSIS.
been unveiled as actinomycoses.  ()ne of the most remarkable of these
cases was that mentioned by Bollinger of an apparently primary ac-
tinomycosis of the brain.  Fischer remarks that the presence of vege-
table fibres in  the purulent discharges should excite suspicion of
the etiology of the disease.
   Prophylaxis includes the supervision of the food of animals ;  the
avoidance of thorny and prickly twigs and plants, as well as of moist
or wet food ; the absolute destruction, as by fire, of all aetino-
iin/ces  in diseased organs of slaughtered animals; and enjoins, above
all things, the most scrupulous care of the teeth and mouth.
    Treatment.— The treatment is almost entirely surgical.  It con-
sists in the  complete exsection and enucleation  of the entire mass
with the knife,  or its thorough eradication  and  destruction with
caustic.  The parasite seems to be singularly susceptible to the ni-
trate of silver.  Kottnitz cured four cases with  the solid  stick,  ap-
plied and inserted freely in every direction.   Favorable results—i.e.,
destruction  of  the growth  and rescue  of the patient—have been
secured in individual cases by  injection of the ferric sulphate, tinc-
ture of iodine, carbolic acid,  or sublimate, as also by cauterization
with the  zinc  chloride  and the internal use of potassium  iodide.
Gautier reports the cure of a case by the  electro-chemical treatment
—i.e., by the hypodermatic  injection of a ten-per-cent solution of
potassium iodide  into the dead tissue, followed  by the insertion of
needle electrodes through which was passed a current of fifty milam-
peres for twenty minutes.   Billroth cured a refractory  case with
fifteen injections of tuberculin. 
CHAPTEB II.
                           ENTOZOA.

    Of the whole number of the grosser parasites of man, now in the
 neighborhood of sixty, twenty-one occupy the interior of the body as
 the so-called entozoa.   Most of these forms are so rarely found as to
 constitute clinical  curiosities, and many of them have never been
 observed in our country.  In fact, but four varieties—the tapeworm,
 the round worm, the threadworm, and the trichina—are so commonly
 encountered as to demand especial study by the practitioner of medi-
 cine.
    Tapeworms (Latin, taenia; Greek,  raivia,  a  band;  cestodes,
 HEffToZ, belt, eidoS, like).—Of the three hundred species of taeniae in
 the whole animal kingdom, but four are  found in  the body of man,
 viz., in the order of frequency in our country, the Taenia  saginata,
 armata,  echinococcus, and lata,  or Bothriocephalus latus, derived
 respectively from the ox, pig, dog, and fish.
    History.—The  first recognition of a difference in the varieties of
 tapeworm was made by Felix Plater (1602) with the discovery of the
 Bothriocephalus {fiodpos, a pit) latus, thus named hy Rudolphi (1810).
 The Taenia mediocanellata or saginata was separated from the armata
 by Kiichenmeister (1852).  The Taenia echinococcus {exivos, hedge-
 hog) was first distinguished as a living thing by Pallas (1760), and its
 scolices (ffuolios, crooked) recognized as tapeworm heads by Pastor
 Goze (1782).  Except in the case  of the bothriocephalus, the larva of
 which has recently been discovered by Braun, of Dorpat, the devel-
 opment of the larval  into the mature form, in all the varieties of
 taenia in man, was  demonstrated  by the feeding experiments of  Ben-
 eden, Siebold,  Leuckart, and more  especially Kiichenmeister, who
 verified his observations on animals in the bodies of criminals which
 he was permitted to use.
   Anatomy, etc.—The whole  animal in its maturity consists of a
 head (scolex), a  slender neck which at some distance from the head
shows transverse folds or wrinkles, deepening later or  lower  down
into furrows, which indicate the  separate segments (proglottides) of
the body.   The  head of  the tapeworm is oval, about the  size of a 
21
ENTOZOA.
9
B
pin's head, and is provided with from two to four equidistant suckers
about its upper surface.   The segments, from four to twelve hundred
in number, are at first longer than broad, then in some cases quadrate,
and  finally broader than long or extremely oblong.  Upper are let
into lower segments, and the union, firm at first, becomes  more lax
                          toward the end  of the worm, where de-
                          tachment readily occurs.  New segments
                          are always produced from the  neck, so
                          that the last segment is always  the last
                          so long as it remains united to  the rest.
                          Hence the  necessity of securing the ex-
                          trusion of the head in the total extirpa-
                          tion of the worm.   Each  segment con-
                          tains or is filled with the generative appa-
                          ratus of both sexes; hence the animal is
                          hermaphrodite.  It is  also  self-impreg-
                          nating.  The bulk of the segment is taken
   P S   ar^rm^     llli    UP ^3' the uterus, which forms an  elon-
                          gated central  cavity  with  radiating
                          branches stuffed with  eggs.  The  male
                          element  is comprised in a bunch of semi-
                          nal vesicles which  empty into a seminal
                          duct terminating at a pore in the lateral
                          margin of the segment, common to the
                          uterine opening or vagina.  These genital
                          pores are disposed alternately, or on op-
                          posite sides of the different segments.
                             The tapeworm  fastens  itself  by  its
                          suckers to the mucous membrane  of the
                          small intestine, the body floating free in
                          loose folds or elongated along the course
                          of the canal, from  the  contents of which
                          it  imbibes nutrition  by osmosis.  The
                          contents of the large intestine  will not
                          support it.  Robin found one extending
                          into the large intestine, the head fastened
                          at the pylorus,  the  anterior end being
                          rolled up into a coil as large as an apple.
 Portions found in the large intestine are in process of expulsion.  It
 is feebly endowed with motion, so that detached  segments voided
 with faeces may migrate by slow vermicular action a few feet from
     eat of  deposit.   More extensive change  of place is effected by
         agencies—running water, processes of  manuring,  wander-
 ing  animals,  etc.   Each segment may contain as many as  53,000
w
 Fig. 22.-Taenia
ments natural size
the
outside
saginata; seg- 
ENTOZOA.
25
•eggs, so that a tapeworm producing 800 ripe  segments a  year may
furnish an annual contribution of 42,000,000 eggs.  Fortunately, in
ihe struggle for existence myriads  fail to find the necessary condi-
tions for development;  thus Leuckart calculates the chances of de-
velopment of an egg to a cysticercus as 1 to 1,340, and to a mature
worm as 1 to  85,000,000.  The tapeworm may live  in an  intestinal
canal from ten to fifteen  years.   Segments may retain vitality out
•of the body for ten years.
Fig. 23.—Segments in motion.
 Fig. 24.—Ova containing embryos
of Taenia saginata.  X 350.
   The egg of a tapeworm is a rounded or ovoid body provided with
a thick envelope containing an embryo endowed with hooklets.  Re-
ceived into the body of an appropriate host, it is freed of its envelope
by the action of the gastric juice, protrudes its head, and  appears in
the form of a larva.  The larva is, of course, an undeveloped tape-
•worm.  It has the same head and  neck,  much reduced in size, but
                Fig. 25.                           Fig. 26.
                Fig. 25.—Call's heart with measles of Taenia saginata
                Fig. 26.—Cysticerci: a and b, of pig ;  c, of ox.

the body remains a vesicle.  It is always  provided with hooklets, by
means of which it bores its way through the walls of the stomach or
intestine, to be lodged in adjacent structures, or to be carried off by
the lymph or blood current to distant organs, where it may excite
a destructive inflammation, or, encysted, remain  innocuous.  The
muscular structure of the body is the soil of predilection, and muscle
thus  affected is said to be " measly," from measle,  a spot.  In the
-course of three or four months the vesicle attains  its full develop- 
26
ENTOZOA.
ment  to the size of  a large  pea; the larva becomes a cysticercus.
(hv?ti?. bladder, HepnoS, tail).
   Ci/sticercus cell ulosa—The pork tapeworm infests the body of
man both  in its mature form as the developed  tapeworm,  and  the
immature form  as the cysticercus; but, as the liberation and  de-
velopment of the eggs of the segments  may occur only accidentally
in man, the presence of cysticerci is a rarity.  Thus Karenski found
them but nine times in eight thousand five hundred autopsies.  Pigs
which have access to the faeces of man are the natural hosts of cysti-
cerci, and pigs thus infested show signs of disease, according to  the
location of the cysticerci.  When present  in  great numbers (one
pound of  meat lias  been  known to contain five hundred and forty
cvsticerci) the animal shows signs of general distress in progressive
emaciation, oedema, falling of the bristles, etc. ; stupor and convul-
sive attacks indicate  infection of the brain ; alterations in the sounds
emitted, infection of  the larynx ; paresis and paralysis,  invasion of
the muscles of locomotion ; dyspnoea, invasion of  the  diaphragm,
etc.   Cysticerci select by preference  the  psoas  and iliacus muscles,
the diaphragm, and the tongue—parts of the animal most prized as
food.  They may be seen  on drawing out the tongue, studding its
under surface like tubercles, which they were formerly considered to
he.  They show  also  in man the same predilection  for  muscular
tissue, being found  most frequently in  the diaphragm, costal and
cervical  muscles,  lying embedded in the intermuscular  connective
tissue, or floating in the  pus of abscesses which they cause.   Yet
they  are  occasionally  caught in the lymph and blood currents and
carried to viscera, as to the brain (seventy-two times in five  thou-
sand  three hundred examinations),  eye, lungs, liver, kidneys, etc.
They usually give rise to but little distress, being, as a rule, solitary,
and,  becoming soon encysted or calcified,  they remain as foreign
bodies during the life of their host.   They have been seen in the  eye
with  the  ophthalmoscope, in the vitreous humor and under the con-
junctiva or retina, which they detach and perforate.  The pain and
inflammation  which they  cause in  this organ necessitate their  ex-
tirpation,  or, after failure of this operation, enucleation of the globe.
    The cysticercus lives, as a rule, from  three to six years, when it  ,
perishes and undergoes calcareous degeneration ; but, ingested dur-
ing its  life into the stomach  of man, it attaches itself to the  small
intestine,  and reproduces segments  which become sexually mature
in the course of three or four months.   Periods of quiescence may
occur.  Bettelheim records a case in  which no segments were given
off in the space  of  three  years.  Ordinarily but one tapeworm is
found in the body of man, yet there are abundant  instances of  the
presence  of two or  more of the same or different varieties  at  the; 
ENTOZOA.
same time, or of their coincidence with other  forms of intestinal
worms.  Of  three hundred cases examined by Krabbe, Taenia sa-
ginata occurred one hundred  and ninety times,  always  solitary;
Taenia solium seventy-seven times, multiple  in thirteen cases up to
ten worms.   Beranger-Feraud once found twelve in the body of one
individual, and Kleefer, of Gorlitz, records a case in which forty-one
taeniae were  discharged  with heads.  Roux saw ninety Bothrioce-
phali lati, half filling a vessel, voided at once from a  healthy child ;
and Lister and Botticher each report cases where one  hundred  were
discharged, all, of course, small and young.
   The different varieties of tapeworm may be readily distinguished.
I.  The Tcenia armata (armed), or pork  tapeworm ; Tcenia solium,
from Syriac  schuschl-e (chain), Arabic corruption susl or  sosl (not
from solus,  alone,  because less  frequently found alone than any
other form),  is known by its coronet  of from twenty-two to thirty-
two hooklets—whence the name armata—on  the circular rostel-
Fig. 27.—Measles in pork.        Fig. 28.—Pork tapeworm. Head with hooklets.
lum of its head, which is likewise provided with four small circular
suckers.   Its  segments number from  seven hundred and  fifty to
eight hundred and twenty-five, and  become sexually mature  at the
four hundred  and fiftieth member, as recognized by the presence of
the genital pore, so that the worm may reach a length of from seven
to ten feet.  They are at first longer than broad, then quadrate, and
finally extremely oblong, whence the synonym cucurbitina.  They
are rarely discharged except  at stool.   The  uterus  consists of a
median cavity, never quite reaching the upper or lower margins,
with  from seven  to twelve lateral  branches,  radiating irregularly
like  the  branches of a tree—hence dentritic.  Its larva, the Cysti-
cercus cellulosa, provided with four  suckers and six hooks, is found
in the tissues of the pig, dog, deer, rat, sheep, ape,  and bear,  as well
as in man in the liver, subcutaneous connective tissue, muscle, eye,
and brain.  Its circular  ova contain also six hooklets.  The  Taenia
armata is found wherever raw or half-cooked pork is used as food.
   II. The Taenia saginata (fat),  or beef tapeworm—erroneously
called mediocanellata by its discoverer, the narrow, cylindrical ute- 
2S                          ENTOZOA.

rus having been mistaken for a  median canal; sometimes still called
lata because  of its  breadth—is known  by its greater thickness
and breadth, whence  its name.   Its head is larger and more square.
and, being devoid of a rostellum and hooklets. more flat on the top.
It has likewise four suckers (though there is of this species,  as well
as of the armata, a variety which has six).  The whole  worm, espe-
cially the head, is darker, from the presence of more pigment matter
than the Taenia armata;  the neck is shorter and broader.  It is larger
than the Taenia armata. its twelve hundred and more segments mea-
suring from ten  to fourteen feet.  Each segment is broad and long,
often one-half  bjr one inch.  The  body of the uterus quite reaches the
upper and lower margins of the segments; but it is more narrow than
in the armata, and all its branches are finer.   These lateral branches.
more numerous than in the Taenia armata, fifteen to twent}7'-seven on
the side of the genital pore, thirty-one on the opposite side, are always
given off dichotomouslv.  The segments are voided not only at stool,
                   Fig- 29.                        Fig. 30.
   Fig. 29.—Head and neck of Taenia saginata.
   Fig. 30.—Head of Taenia solium within that of Taenia saginata, to show differences (Heller).

1 »ut often also spontaneously.   Acetic acid renders the segments trans-
lucent, and displays the uterus with many branches in the Taenia
saginata. few in the Taenia armata.  Patients who are continually or
occasionally discovering detached fragments in their clothes are nearly
always hosts of the Taenia saginata.   Its larva is found in cattle and
various other ruminants, but not  in man.   Its eggs, of which each
segment may contain thirty-five thousand, are oval, larger than those
of the Taenia armata, and devoid of hooklets.  The Taenia sa-inata is
found wherever rare or raw beef is used for  food; consequently much
more frequently in our country than the  Taenia armata.   The Taenia
saginata is now the common  tapeworm.  Leidy states that the tape-
worms from Philadelphia and its vicinity, which he had occasion to
examine in the last twenty years,  -perhaps in all about fifty " were
specimens of the Taenia saginata.   The  condition assumes epidemic
proportions in Abyssinia, where the  flesh of cattle is eaten while still 
ENTOZOA.
20
quivering with life.  Knox reports the  existence of the condition in
epidemic proportions in the English army during the Kaffir war.  A
mature worm was raised from a beef " measle," purposely swallowed
by a student, in fifty-four days.
   III. The Taenia lata, or Bothriocephalus latus, differs in marked
degree from the preceding varieties.  It is the largest of all the tape-
worms, its  four  thousand segments attaining a length at times of
twenty-five feet.   The head is long and narrow, and is  slit  at the
sides to form the bilateral elliptical suckers which give the worm its
name.  The segments, not sharply separated, are from two to four
times as broad as they are long.   The central uterus has the appear-
ance of coils of intestine.  The genital pore is situated on the ventral
surface.  The cysticercus is  provided with  spiculae  and a ciliated
envelope, by means of which  it swims in water.  The eggs are oval,
and  are furnished with a lid (operculum) at one end to  afford  escape
for the embryo.   This species  of tapeworm is found wherever raw or
partially  cooked fish is used  as  food;  consequently  in Russia and
Sweden, East  Prussia, Poland, and parts of Switzerland—not in our
      Fig. 31.—Head and neck of Taenia lata.          Fig. 33.—Ova of fish tapeworm.

country.  The sole specimen  thus far reported in our country was
found by Leidy in  the body of a recently immigrated Swede.   The
mature  Taenia lata is found in the intestine of the dog as well as in
man.
   Symptoms.—Mature  tapeworms are seldom dangerous to  man.
In many cases  they produce  no symptoms of any kind, and  their
presence is recognized for the first  time upon  the post-mortem table,
or in the discharge of segments with the stools ;  the appearance of
them in clothes at other times is the first indication of their presence.
Individuals who use water  closets may thus  entertain  these guests
unawares, until on some occasion the faeces are voided visibly, as
upon the ground in the open air, or in a night vessel.  As no mature
worm penetrates the intestinal canal or evolves  noxious products,
what symptoms do occur are  due to mechanical irritation of the in-
testinal  walls  or are reflex manifestations.  Thus, anorexia, nausea,
vomiting, colic, diarrhoea,  alternating perhaps  with  constipation,
heartburn,  pyrosis,  flatulence, the group of symptoms characteristic
of gastric catarrh, summed up under the vague term dyspepsia, and,
as effects, lassitude with malaise and depression  of  spirits, are  not
infrequently present.  A ravenous or  insatiable  appetite is excep-
 
3("
ENTOZOA.
tional, and when present is due. not to the consumption by the para-
site of nourishment, which is insignificant in amount, but to reflex
irritation  or  defective assimilation, the result of  irritation.   More
importance may be attached to  morning vomiting, which,  in  the
absence of more common causes—pregnancy, gastric catarrh,  cirrho-
sis, tuberculosis. Bright's  disease, etc.—may be an index to the con-
dition.  Young children or highly sensitive adults may exhibit more
pronounced disturbances of the nervous system.   Thus dilatation
of the pupils, itching  of the nose and anus, palpitation of the heart,
choreic manifestations, even veritable convulsions and epilepsy, have
been observed in these cases.  But the symptoms caused by intestinal
parasites are exaggerated as a rule.  All the symptoms mentioned
may be produced by any cause that will excite the same irritation,
and grave accidents are to be attributed to tapeworms only in cases
where symptoms subside  with the expulsion  of  the worms.   Rare
instances of  this kind are recorded.  Thus Williams describes  the
case of a young girl who was (aired of a periodically recurring blind-
ness and deafness of  several  hours' duration by the extirpation of a
tapeworm ; and Homolle  reports a case of epilepsy relieved  in  the
same way.  Commini cured  a  case  of  epilepsy by causing the dis-
charge of a tapeworm, which had been voiding segments spontane-
ously.  The disease returned with the  reappearance of eggs  in  the
stools.
   In a few cases grave symptoms admit of a  different explanation ;
for especial danger  attaches to the pork tapeworm, in that the  deglu-
tition of its eggs or their premature discharge into  the intestinal
canal may lead to the development of  cysticerci in the same host.
This accident may  take  place  in sleep, when the hand is used to
relieve itching or irritation at the anus, or the moist segments  escap-
ing at the anus and crawling about on the skin are grasped in order
to relieve the unpleasant sensations.  Kiichenmeister  often  found
fingers contaminated in this way.   Cases of self-infection have also
happened  from  careless handling of worms  after their expulsion.
Moreover, the  act  of vomiting may introduce segments into  the
stomach, where eggs may be  liberated to develop into cysticerci.
Se.-ger mentions six  cases of ejection of tapeworms  by the  act of
vomiting,  and Rebsamen reported the  case of a  woman who with-
drew a Taenia lata from her mouth with her fingers.   Frankenhausen
related a case of cysticercus in a patient  who had previously vomited
a tapeworm, and Lewis collected a number of such cases.  In  two of
Graefes cases of  cysticercus  of the eye, the patients, while hosts of
the worms, had suffered from the vomiting of pregnancy  ; and in  the
case  of cysticercus  of the brain reported by Moller the patient had
had  a tapeworm expelled twenty  years before death   Thus  the 
ENTOZOA.
31
 existence of severe nervous symptoms might awaken the suspicion
 of  the presence of cysticerci.  But examples of  this kind are very
 rare.  In the vast majority of cases grave nervous symptoms, which
 are not pure psychoses, are due to other and more obvious causes.
 As curiosities  may be mentioned the escape  of tapeworms through
 previous openings at the umbilicus, into the bladder, etc.
    The diagnosis of tapeworm  is sometimes quite  obscure.  The
 only positive proof of the existence of tapeworm in the body is the
 pi'esence of segments in the stools or clothes.  As in most cases
 eggs are not discharged in the intestines, it is very rare to find them
 in the stools.   AVhere reason-
 able doubt exists,  the adminis-
 tration of a cathartic, or of an
 anthelmintic to be followed by
 a cathartic, may  secure the
 proofs. Foreign bodies, shreds
 of inspissated mucus, most fre-
 quently shown, are generally
 recognized  by naked-e}Te in-
 spection.  Differentiation of the
 form  of  tapeworm is easily
 made.  The segments are flat-
 tened  by pressure  upon the
 object glass and examined with
 a power of 'five hundred diameters, when the characteristic features
 of each form become apparent at a glance.  Dried specimens  should
 be  first  softened  in  water.   Acetic acid,  as stated,  clears  up an
 opaque field to make  the  uterus visible.  The occasional evacuation
 of segments independently of stools, or the discovery of them in the
 clothes, speaks in favor of the Taenia saginata.
   Prophylaxis.—The subjection of meat to a boiling temperature
 throughout its  bulk effectually destroys all cysticerci, and thus posi-
 tively  prevents the development of tapeworm.  The  recognition of
 this fact  with  regard to  the  Trichina spiralis has already  dimin-
 ished the number  of cases of pork tapeworm.   Cleanliness is the
 factor of next importance. The Oriental custom of ablutions before
 each meal may be commended in this regard.  Individuals affected
 with the disease should be enlightened as to  the fact that they are
 possible sources of infection of others.   Bettelheim speaks of having
 seen in  a house  of  poverty and squalor segments  of tapeworm
 deposited  upon and crawling about the floor,  furniture,  and beds.
 Butchers, cooks, all persons employed in the preparation and  distri-
 bution  of meats, should  be cautioned as to the necessity  of cleanli-
ness of hands, instruments, vessels, and clothing.   To prevent infec-
Taenia saginata.   Taenia armata.
         Fig. 33.—Segments.
Taenia lata. 
32
ENTOZOA.
tion of animals with eggs, habits of decency in regard to the deposit
of fceces should be enforced, and check should be put upon the bar-
barous custom  of promiscuous  defecation.  A Texas physician in-
formed Leidy, of Philadelphia, to whom he had sent a piece  of measly
pork  for examination, that all the pigs in the place were  thus
affected,  and that there  was not a privy in the whole village.  In
the administration  of  anthelmintics to the subjects of tapeworm
selection  should be made of such remedies  as will not cause vomit-
ing.   Especial attention is to be paid in this regard  to the relief of
the vomiting of pregnancy.   Physicians as  well as patients  need
repeated  injunction against the  careless handling of  tapeworms in
their  examinations.   Specialists who have  devoted  a large part of
their  lives  to the study  of intestinal  parasites become exceedingly
careful in  their manipulations.  Kiichenmeister states that he al-
ways handles tapeworms with two pairs of  long forceps, seizing
them as  near the points  as will secure firm purchase ; and Cobbold
warns against the danger of leaving specimens about, or  carelessly
throwing them  away, with the emphatic injunction to destroy  them
by fire.
   Treatment.—The Greek and Roman physicians possessed  sixty
remedies for  the cure of tapeworm, and the number has been greatly
increased in our day.   But few of these agents, however, have stood
the test of time.  Such uncertainty has attended the  use of most of
them as  to  have left the treatment of the condition a fertile field for
quacks.  This  uncertainty depends, however, upon the  failure to
observe  a few  precautions, the chief of which  is the use  only of
fresh, and the avoidance  of old or stale, drugs.   A  second precau-
tion  demands the evacuation  of other contents  of  the bowels as
effectually  as may be. that the remedy used may come in direct con-
tact -with the worm.   Elaborate preparatory or supplementary  treat-
ment is  now, in the main, superfluous, but a light  diet during the
day.  or,  better, a fast, broken only by a cup of coffee or a  glass
of milk,  should precede  the administration of the remedy selected.
These remedies may be ranked in efficacy as follows :
  1.  The bark of the pomegranate root, of which three ounces should
lie  macerated  in twelve  ounces  of  water  for  from twelve to
twenty-four  hours,  to be then  reduced one-half under gentle  heat.
The whole quantity is to be taken in divided doses in the course
of an hour.  Pomegranate root, when fresh, remains the most effec-
tive  of all anthelmintics, and would long since have  excluded all
others, did it  not at times produce 'nausea,  vomiting, and colicky
pains. To avoid the first of  these evils Bettelheim suggests the
introduction of the infusion  into  the stomach by means of the
stomach pump;  and  to obviate all  of  them Feraud recommends 
ENTOZOA.
33
pelletierine. an  active alkaloid of the root, named in honor of the
discoverer of quinine.  One to two drachms of the infusion of senna
are to be  taken on the morning following a day of fasting, and in
the course of an hour fully as much as five grains of the tannate
of pelletierine suspended in water.   The tannate is preferred because
of its slow  absorption.  Half an  hour later the dose is repeated,
to be followed in  another half-hour with a tablespoonful of castor oil,
the patient remaining meanwhile  quiet in bed to avoid disturbance
of the stomach.  In  one  instance twelve  tapeworms  were expelled
at once in this way.
   2. Turpentine is a powerful  taeniacide, but the use of  it is liable
to cause  headache,  pain  in the  stomach,  fever,  and  strangury.
These effects are, however, much  less frequent after large than after
small doses.  Hence the dose for an adult should be never less than
one or two ounces, for a child from one drachm to one ounce,  accord-
ing to age.  It may be administered in emulsion with white  of egg,
or be briskly stirred in half  a glass of milk and swallowed rapidly;
should it  fail to act as a cathartic, it should be followed with a dose
of castor oil.
   3. Male  fern, the  ethereal extract, two drachms in four or five
gelatin capsules,  of which one may be swallowed every five minutes
with the  aid of a  cup of  coffee.  A dose of calomel with  brandy
should follow the capsules in the course of half an hour.   Since the
poisonous principle of male fern  is  soluble in oils and is thus rendered
absorbable, calomel and not castor oil should be given as a purgative
to secure the extrusion of the parasite.
   4. Thymol (which is both a taeniacide and a taeniafuge), two
drachms in twelve doses, one every quarter of an hour, preceded the
evening  before, and  followed one half-hour after the last dose, by
half an ounce of castor oil.  Alcohol in some form should be given
with it or after it to counteract its depressant effects.
   5. Kousso, koussin, pumpkin  seeds, santonin,  kamala, carbolic
acid, and zinc are other parasiticides of less value.
   The discharges should be passed  for  several days in a vessel
of warm water,  and all fragments be brought to the physician, that
he may  positively recognize the  head  of the  worm.  In no  case
should traction be made during  the passage of the worm.  Full dis-
charge can be readily effected during the evacuation by the injection
of warm water.
   Every attempt at treatment  being a forcible intervention, only
such individuals should be subjected to it as are known to be  affect-
ed.  The  mere statement  of a  patient is  not sufficient  proof, and
cases of  taeniaphobia  do  not justify  it, on  so-called  psychological
grounds,  because failures  only  aggravate the  condition as a rule.
        3 
34
ENTOZOA.
Pregnancy,  advanced age, debility  from any cause, are  contra-
indications to all treatment.
   Finally,  the physician must be  awake  to cases of deception.
Everything  found in a vessel does not necessarily escape from  the
bowels, and the same vessel is sometimes used by others.  Bremsen
savs he once found in a vessel a pair of snuffers.  Heller reports the
case of a child finally debilitated by repeated treatment because
of the continued exhibition of real segments of tapeworm, when upon
closer  examination it turned  out  that the fragments did not come
from the child at all, but from a lazy nurse who made a convenience
of the child's stool-chair.
   IAr.  The  Tenia echinococcus, dog  tapeworm—hydatid tape-
worm, bladder worm—is the smallest of all the tapeworms, measur-
ing but one-fourth of an  inch in length.  It lives in the mature state
in the  dog,  wolf, and jackal, but not in man.   The  head resembles
that of a diminutive Taenia armata, in that it is furnished with four
suckers, a rostellum,  and a double row of hooklets.   The  segments,
in number but four,  progressively increase in size to  the last, which
is as large as all the rest, and which  is alone  mature.  This taenia
exists at times in such numbers in the  intestine of the dog as to have
been mistaken for  intestinal villi.
   The larva (echinococcus) of this  taenia, which infests man and
many of the herbivora,  horse, ox, sheep, etc.,  differs from that of
all other tapeworms in that it is endowed with the property of self-
multiplication  to a  degree limited only by the restraint of outside
pressure.  The eggs, issuing from the anus of the dog and brought
often in contact with the nose  and mouth of this animal,  may be
thence received into the  mouth and stomach of man, where  the six-
hooked embryo is liberated  to  penetrate the walls  of the intestine
and emigrate to various parts of the body.  Infection of man usually
occurs  from drinking  water,  raw  vegetables,  etc., contaminated
with dogs' faeces, or from  the hair licked by the animal and stroked
by man.  From  the fact  that  the  liver is  found  infested more
frequently than all  the  other organs together,  sixty-nine per cent
of cases, the inference is natural that the embryo is  carried thither
by the portal vein.  Measly liver fed  to dogs  reproduces the Taenia
echinococcus in the intestine of the dog.  Having reached its destina-
tion, in whatever organ, including the bones, preferably viscera, the
echinococcus develops the hydatid tumor, which may consist of a
single cyst or, by  proliferation from its  inner wall, of multiple
daughter cysts, or from them, in turn, of granddaughter  cysts to
the number of many hundreds.
    The fluid of hydatid cysts is naturally clear and limpid,  though
it may  be  rendered  turbid, opaque,  or sanguineous  by accidental 
C.«*j
ENTOZOA.
35
admixture of pus and blood.   It is distinguished, when clear, by the
presence of common salt and the absence of albumin.   The echinococ-
cus is rare in our country.  But it is safe to say that the  majority
of cases in our country do  not find  their way into print.   For in-
               z  3
Fig. 35.
               Fig. 31.                           Fig. 36.
   Fig. 34.—Taenia echinococcus :  1, natural size ; 2, head ; 3, neck ; 4, 5, immature segments ; 6,
mature segments; 7, genital pore; 8, ova, 9, containing larvae.
   Fig. 35. —Extended echinococcus with hooklets.
   Fig. 36.—Echinococcus sacs in the liver of man.
stance, a pathologist at  the Cincinnati  Hospital, a thoroughly com-
petent  observer,  informed  the writer, on the occasion of reporting
the only case which  had occurred in his practice of twenty-six years,
that he had himself seen three cases since the beginning  of his ser-
vice, less  than two years, none of which had been  reported.   It is
common in countries where the dog is a most intimate companion of
man.  In Iceland, where the dog shares
with man both bed and board, the disease
is epidemic, one-fifth of all sheep and one-
seventh of mankind being thus affected,
females, from their  indoor life, oftener
than males.  Victoria, Australia, vies
with Iceland in the frequency of the dis-
ease.  Krabbe, of Copenhagen,  found
twenty-eight per cent of five  hundred
dogs affected with Taenia echinococcus.
   The echinococcus is  enveloped in a dense, impermeable,  elastic
capsule, which, upon section,  rolls up at its edges to furnish a diag-
nostic point  of great value.   From the inner surface of this capsule
new echinococci develop with characteristic scolices and hooklets.
 Fig. 37.—Echinococcus membrane
with hooks. 
3G
ENTOZOA.
   Diagnosis.— The microscope reveals those structures, shreds of
membrane, scolices. or hooklets, in the fluid of about half the cases.
The  recognition of them makes the diagnosis infallible.  The other
half  of all  cases  must be  diagnosticated by  chemical analysis,  a
means of examination which applies to nearly all cases.   Suspicion
may be excited in the first place by  the  situation of the  tumor.
Echinococci, unlike cysticerci, avoid muscular tissue, and come to be
lodged as a rule in certain viscera, preferably in the liver, lungs,
spleen, brain,  eye  (orbit, but  not in the ball),  and kidneys.  The
anatomical elements mentioned have been discovered  in the faeces,
vomited  matter, urine,  sputum,  or in surface fluid from sponta-
neously ruptured  sacs, most commonly in the fluid withdrawn  by
aspiration.   The growth  of the tumor  is slow,  extending at times
over periods of from ten to fifteen, exceptionally to  fifty-five, years.
Years of latency may follow the infection.  It is not malignant, and
is  seldom painful: its symptoms  being produced  mainly by pres-
sure upon, and dislocation of, natural structures.  The tumor, when
it  may be  percussed,  palpated, or grasped, is found to be  elastic,
with  a sense  of semi-fluctuation.   It develops on  palpation also a
peculiar fremitus, the so-called hydatid purring—a sensation similar
to that felt in stroking a cat, or striking the  spiral spring of a sofa
or a bass chord of  the pianoforte, r- Opinions differ as to the value of
this so-called hydatid fremitus, which was first remarked by Brian-
con  in 1828.   Skoda  claims that  the same sensation is yielded
by every  sac  with fluid contents and  elastic walls.  Cobbold does
not think it different from the impulse communicated by fluid matter
in any other kind of tumor.  Bamberger, finding it  in ascites  and
ovarian tumors, does  not consider  it characteristic.  On the other
hand, Heller and most French authors regard it as almost pathog-
nomonic.   Frerichs found it in but half his examinations.  Tillaux
maintains that  it  is caused by the impulse of daughter sacs upon
each  other in the absence of liquid in the parent  sac.  When the
parent sac contains fluid in which the daughter sacs swim, there
is no tremor.
   As already stated, chemistry furnishes the surest means of diag-
nosis.  The fluid is colorless, opalescent, neutral, and has a  specific
gravity of 1.005 to 1.015.  Albumin is wanting, or is  present in but
very  slight amount, although it  begins to abound after frequent
tappings.   The  test is satisfactorily made by  heat  or nitric acid.
Common  salt  is  abundant,  A  solution  of  the silver nitrate  dis-
tinctly precipitates the insoluble  chloride.  In doubtful cases there
remain two other tests of  almost equal value, viz.,  the detection  of
succinic acid and inosite or muscle sugar.  Both of  these agents are
found naturally in other organs of the body, but not in the liver; 
ENTOZOA.
37
 hence the value of the evidence furnished by  their presence in this
 organ.
    It need scarcely be stated that while the absence of succinic acid
 and inosite does not exclude echinococcus, the presence of them is
 strong evidence of its existence.   In general, it may be said that the
 chemical tests are more valuable than the microscopic, though the
 latter are more positive when present.
    With all these means of recognition, the echinococcus cyst often
 escapes detection.  Echinococcus of the brain  may simulate typhoid
 fever ; in long bones it develops spontaneous fracture rather than
 tumor.  Thierfelder  states that  but seven of  thirteen cases  were
 recognized during life at Rostock; Briicke declares that but thirteen
 of twenty-two cases were discovered at the Berlin  Charite; and
 Madelung maintains that, as a rule, but one-third of all the cases are
 diagnosticated.  Most of these observations,  however,  antedate the
 days of aspiration, which has immensely simplified the examination.
    Echinococcus  cysts are not amenable to relief by  internal medi-
 cation.  If further evidence than the failure of  every kind of  drug
 were necessary to prove this fact, it may be found in an observation
 of Leidy, who discovered in the body of an English sailor sent to
 him for dissection, the tissues having been thoroughly bleached by
 an injection of zinc chloride several days after death,  a hydatid tu-
 mor of the size of the fist in  the  right iliac region, full of daughter
 cysts containing still living scolices.
    The most simple method of treatment of echinococcus cysts is by
 aspiration of their contents.   Murchison reported, of  forty-six cases
 thus treated, thirty-five successful results.   In ten cases subsequent
 suppuration necessitated incision, whereby eight cases recovered and
 two died.  The remaining case died  of acute  peritonitis in twenty-
 four hours.  Fagg, Hilton, Durham, and Hand-
 field report  nine cases cured by electrolysis.
 Jansen, of Iceland, still adheres to the plan of
 opening  by the  caustic method  of  Recamier.
 Loreta (1886) first successfully resected a  large
 part of the left lobe of  the liver stuffed  with
 echinococci.   Radical treatment demands  lapa-
 rotomy incision and drainage  under asepsis.
 Mudd  successfully cut out an  echinococcus cyst   muitii0cuiaris.
 protruding as a tumor from the brain.
   The rare form of  degeneration known  as  the multilocular cyst
 was first differentiated from colloid cancer in 185G by  Virchow, who
showed its parasitic nature.  Vierordt, who has been  able to collect
in all seventy-nine cases, some  of them antedating Virchow's dis-
closures,  makes the curious discovery that the  disease is limited to a
 
38
ENTOZOA.
very circumscribed geographical  area.  Of the seventy-nine cases.
               sixty-eight occurred in  Wurtemberg. Bavaria, and
               Switzerland, the rest in Baden, Austria, and Russia,
               and one in the United States.  Strange to relate, no
               case has  ever been reported from the classic centres
               of Echinococcus hydatinosus, Iceland and Australia.
               All the victims were adults.  The duration of the
               disease averages from one to two years, in one excep-
               tion eleven years.   It is recognized by the anatomi-
               cal  elements of the parasites, as in the other form of
               the disease.   From its exogenous  character there is
               no tendenoy to capsulation  and no hope of securing
               its  total extirpation ; hence the prognosis is, as yet
               at  least, always fatal.   Multilocular echinococcus is
               by no means to be confounded with exogenous hy-
               datid cysts, in  which projections of brood capsules
               occur external  to the parent membrane, penetrating
               the liver or  other viscus at times in every direction.
               Such cysts are known as compound cysts, in distinc-
               tion from the multilocular cysts, which give to the
               organ invaded a honeycomb appearance.  The prog-
               nosis of  the compound or exogenous  cyst is much
               more grave than that of the simple or endogenous
               cyst, on  account  of the inaccessibility of many, or
               most, of the growths.

                   Round Worms.—Nematoid  (vrjpa,  a thread)
               worms are represented as pathogenic entozoa of the
               human body in the round worm, the threadworm,
               the anchylostoma,  and the  trichina spiralis.   The
               order, higher in the scale of life than the cestodes, is
               characterized by an  elongated, filiform body without
               circulatory  or respiratory  apparatus,  but generally
               provided with an intestine open at both ends.   The
               sexes are separate.
                   The Round Worm, Ascaris lumbricoides—a slug-
               gish worm, inappropriately designated ascaris, as it
               is much less active than the threadworm ;  surnamed
               lumbricoid, a lubricitate (Hooper), from its slipperi-
               ness; coarsely  resembling the  common earthworm,
                which seems to have been named for it—is the most
              i  common, as it is  the most prolific, of all intestinal
 lumbricoides.      parasites.   It  is  also  found everywhere over the
 globe.  It  is  cylindrical in shape, with  pointed ends, pale red in 
ENTOZOA.
39
color during life, paler than the common earthworm, pinkish gray
after death, averaging  the  diameter of a goose quill; the female,
measuring in  length fifteen inches with  a  capacity of extension to
twenty-four inches, is twice  as long as the male.  The head tapers to
a point more gradually than the tail, which, in the male, is distin-
guished by its direct incurvation to a hook-like process for grasping
the female.  A pair of white, delicate hairs,  the protruding penis, are
often visible on the ventral  aspect near the tail; the vulvar opening
is situated at the  junction of the first and middle thirds of the body.
The head is further characterized by three semicircular, knob-like
projections about the triangular opening of the mouth, whereby it
is readily distinguished from  the earthworm, sometimes shown in
attempted deception, which has a rounded  head with  the mouth
under it in the form of  a transverse slit.  Vacuoles in the muscular
mesh work of the  skin give issue to a pale-red, oily,               _
irritating matter  of a peculiar  odor, which is so    /aCfr
persistent as to remain with the worm after thor-    SF-*l[   £Jbk
ough washing, and communicate itself in time to    |;   1   \^?
alcohol in which these worms have been preserved.     i   '1
The bulk of the  body is taken up  by the genital
apparatus, one female developing sixty-two million
eggs.  The ova, ^^o to t\q of an inch in diameter,
provided  with a  thick, firm albuminous shell or
envelope, of nodular surface, usually stained with
bile, offer extraordinary resistance to destructive
agents.  Thus they may withstand  desiccation for  fig.40—Round worm:
months, or remain a long time  without injury to  *' hefd f™m.1sl,de;,2,
       '               °               .     .    from top; 3, tail of male.
the embryo in alcohol, turpentine, chromic acid,
etc., agents which quickly  kill the mature worm.  They are voided
in quantity with  the faeces,  and may be counted by hundreds with a
low power under  the microscope in  a small mass of faeces.
   Although Hippocrates was familiar with and described this para-
site, the mode of  development of the egg to the worm has been but
recently determined.  Impure drinking water has alwaj^s been sup-
posed to convey  the parasite  or its ova  to the body of  man; and
recent observations by Grassi, Lutz,  and  Leuckart confirm this
view.  Aside  from impure  water, the  disease is conveyed by  dirt,
mud, sand contaminated with faeces, and but rarely and accidentally
by food, as fruits and salads.   Infection begins in childhood with
the first attempts at walking, infants being comparatively exempt.
It never prevails extensively, nor  are numerous ascarides  ever en-
countered, in denizens of cities with good water supply.   It is much
more frequent  in the country and small towns, and if most prevalent
in the tropics,  which seems to be the case, it is because of the greater
 
40
ENTOZOA.
neglect  of the water supply.  The insane, whose habits are notori-
ously unclean (coprophagi), are infected as a rule.
   The round worm dwells in the small intestine, usually about the
middle of it, lying stretched  out in its course.  But a  single worm
may be present, more commonly from four to six, more rarely great
numbers.  Cruveilhier once counted a thousand.  They cannot  live
in the stomach or  colon, and,  when  found  in  either place,  are in
process of extrusion.  They have no power of effecting perforation,
but may migrate into natural openings in the intestinal canal, as  into
the gali ducts, pancreatic  ducts, vermiform appendix, or, during the
act of vomiting, into the laiynx—where they have caused fatal suffo-
cation—bronchi, nares, and thence into the  tear ducts and into the
Eustachian tubes, whence they may  escape, through  a previous
perforation of the drum  membrane,  into the external  ear.  Thus
Kartulis found, in a fatal case, one hundred  and twenty in the small
intestine, twenty in the large  intestine, twenty in the stomach, three
in the common bile ducts, three  in the hepatic duct, five in the  gall
bladder, and sixty in the liver—all in the liver the seat of abscesses.
Most of the migrations occur, however, after  the death of their host.
Such massive accumulations as  to cause more or less  complete occlu-
sion of the intestine are also for the most part, though not always,
post-mortem phenomena.  Escape into the peritoneal cavity presup-
poses a perforation of the intestine, as from  typhoid fever, tubercu-
losis, etc.  So, also, worm abscesses, accumulations of pus containing
worms,  occur at the site of herniae, at the umbilicus in childhood, in.
the groin in adults.  Incarcerated with other contents of the bowel,
the worm escapes through some perforation in its wall, the result of
an inflammation to the cause of which the worm may possibly con-
tribute chemically; as Huber noticed in himself, after handling these
worms,  itching of the head and neck, wheal-like formations on the
skin, swelling of the ear, conjunctivitis, and chemosis.  It is observed
also that worm abscesses speedily heal after evacuation of the  pus
and discharge of the worm.
    Symptoms.—Round worms  frequently exist in the body without
symptoms.  In Grassi's case a boy aged  seven voided,  two months
after taking a pill containing one hundred and fifty ova, one hundred
and forty-three mature worms, showing meanwhile no  symptoms
whatever.  The discharge of the ivorm is thus often  the first  and
only sign of its presence.  It is often an independent catarrh of the
intestine which sickens and discharges the worm, so that, as  Kiich-
enmeister remarks, " host and guest agree very well together"  as a
rule. On the other hand, there may be due to the worm dyspeptic
manifestations, anorexia, heartburn, colic,  constipation or diar-
rheal, with puffiness of the eyelids, discolored ion about the eyes, 
ENTOZOA.
41
 itching of the nose and anus, etc.  The symptoms are wholly due
 to local irritations,  which display the same  symptoms from any
 cause.  Various nervous disorders, paraesthesiae,  chorea, epilepsj^,
 have been attributed to these worms,  but, as in the case of tape-
 worms, without foundation as a rule.  Disappearance of the symp-
 toms with extrusion of the worm would be the only  proof  of such
 •dependence.
    The diagnosis rests, as has been said, presumptively upon the
 discharge of one worm, when others may be supposed to exist; or
 upon the discovery of ova in the faeces, which infallibly indicates the
 continued presence of the worm in the  bowel.  All other symptoms
 are fallacious.
    Prophylaxis.—A supply of  pure water is the best preventive.
 I So long as doubt pertains to drinking water the precaution should be
 taken to filter it properly.   The ova of no intestinal parasite will pass
 through a filter of porous clay.   Children should be kept out of the
 •dirt, or at least some care should be exercised  regarding  the source
 of the sand and dirt in which they play.  They should be taught not
 to taste the " mud pies " they make.
    Treatment.—Santonin is the best parasiticide.  It is best admin-
 istered in doses of from two to five grains suspended in castor oil,
p.as it kills, but does not expel, the worm; or in capsule, compressed
 disc, troche, or powder with sugar of milk, equal  quantity, fol-
 lowed by a dose of castor oil 3  i.- 3  i., or calomel gr. ij.-v.   It
 : should be given at night,  every night  or every other night,  three
 times, that the patient be not disturbed by the blue or yellow vision
 which it sometimes occasions.  Transitory dysuria, incontinence  of
 urine, and, in very nervous subjects, even light delirium, rarely en-
 rsue.  Where this remedy would seem to be contra-indicated it may
 be best substituted by thymol, one to two drachms, in divided doses
 , given in quick succession, and followed by wine, whiskey, or brandy
 to counteract any depressing effects.
    Threadworm.—Oxyuris (oB,vs, sharp, ovpa,  tail, characteristic
 only of the female)  vermicularis, from its  size and shape ; the
 thread, pin, from its situation, seat; or from its activity, spring
 worm, is found only in the lower part of the large intestine of man,
 in which it spends its whole existence.   The female, two-fifths of an
 inch in length, is  readily recognized  by its long, awl-like,  slightly
 wavy tail and  chalky-white color, the color of  the eggs with which
 the  body is stuffed appearing through its translucent envelope  or
-skin.  The orifice of the vulva is near the middle of the body.  The
 male measures but one-tenth of an inch, is blunt at both ends, and
.incurvated at the tail for grasp of the female.   The penis  consists  of
.a single spiculum, often seen projecting near  the tail.  Males, rare 
42
ENTOZOA.
in number and small in size, were for a long time overlooked, and
are best discovered in scrapings of the intestinal mucus.  The hab-
itat of the threadworm is the caecum, and not the rectum  as is com-
monly believed.  Ignorance of this fact  accounts  for  the frequent
                    failure of treatment.   Threadworms are  ubi-
                    quitous, occur  at all ages, but are more fre-
                    quent among the poor and unclean,  and  espe-
                    cially among children.   Young worms begin to
                    pass  from the  rectum  in fourteen  days after
                    ingestion of  the ova  ; and -as  each female may
                    give issue to successive crops, though the dura-
                    tion of individual life is short, the  progeny is
                    maintained of ten throughout the life of the host.
                       The eggs, -^ X y^nr in°h in diameter, are
                    oval and  plano-convex.  The embryo develops
                    rapidly, in from four to six hours, so that the-
                    whole  process may be easily followed up with
                    the microscope.  The myriad ova and rapid de-
                    velopment render self-infection almost unavoid-
                    able.   In fact, ova are always to be found in-
                    sinuated  (by scratching) under the finger nails.
                    of infected  individuals.   Helminthologists be-
                    come infected in handling the worms.
                       Threadworms, though active in movement,
                    have little power of  migration  over  a dry sur-
 face, perishing rapidly after leaving the bowel; hence infection from
 contact, as from a bedfellow who happens to be the host of  worms,
 cannot occur.  The introduction  of ripe  ova from an infected indi-
 vidual into the stomach is an essential factor  in etio-
 logy.  Infected mothers, nurses, cooks, waiters, etc.,
 generally convey the ova.   Biting the nails is a not
 uncommon  mode of reinfection.   Orphan and in-
 sane asylums furnish all the prerequisites for rapid
 dissemination.
    Sympjtoms.—So  long as  the parasite remains
 above the rectum it gives rise to no symptoms.   De-
 scent of  the  mature female into the rectum to dis-
 charge its ova and escape at the anus—which occurs
 most frequently at night, on account of the quiet of the body  at night
 and the greater warmth of the bed—is attended with  itching, bor-
 ing, burning sensations,  which may become so intolerable as to
 prevent sleep and lead thereby to nervous distress.  Migration into
 the vagina extends the surface of irritation,  and may induce pruri-
 tus, masturbation,  and nymphomania.   It  is  questionable if the-
Mature
female.
 Fig 41
cularis.
-Oxyuris vermi-
 Fig. 42. — Oxyuris;
vermicularis, natural
size; one female, two
males. 
ENTOZOA.
43
worm ever  finds its way beneath  the prepuce or into  the male
urethra, though it may be  carried thither by the fingers.  The in-
tense irritation about the perineum, with manipulations for its reliefr
may of themselves excite the genital apparatus  and thus lead to' a
train of nervous disorders.
   Diagnosis.—Direct inspection of the anus, more especially after
the use of an enema, discloses oxyurides in numbers, so that a search
for the ova is generally superfluous.  The ova may, however, always
be found,  in the absence of visible worms, in scrapings of  the upper
parts of the anus, as everted in defecation, upon  paper used in wip-
mg, or in  its uppermost parts accessible to the handle of a scalpel or
the eye of a catheter.  Vix declares that  he never found a single
case where  the  eggs  were not visible in countless numbers in the
first field of vision.  The detection of the worm or its ova,  it is need-
less to state, affords the only positive diagnosis.
    Prophylaxis.—Scrupulous cleanliness on  the  part  of those af-
fected, regular ablutions before meals,  and the frequent use of the
nail brush, are preventive measures of importance.  Children cannot
be  prevented from putting their own fingers in  their mouths, but
surely the filthy habit might be stopped of inserting those of their
attendants.   The bad habit of biting  the  nails can be broken up.
After all,  the only real prophylaxis is the speedy evacuation of every
member of the colony in affected individuals.
    Treatment.—Though some degree of moisture is necessary to the
growth and reproduction of the threadworm, it cannot live in water,
which causes it  to swell up and burst.   Hence the  administration of
anthelmintics is unnecessary and,  because of the  distance of the
worms from the mouth, inefficacious.   Heller saw oxyurides creeping
about "quite lively"' under  strong solutions of carbolic acid applied
as  a dressing  to  condylomata  of  the perineum.   Inundation and
maceration with water, if practised effectively, suffice to destro}^ and
remove them.   Simple as it may seem to accomplish it, the treat-
ment is nevertheless seldom successful.  Failure is due to  the fact
that the applications are limited to the  rectum.   Irrigation with soap
and water, because less irritant to the  bowels than simple water, by
means of  a long rectal tube or catheter in the knee-elbow posture,
best dislodges  and discharges these worms.  Irrigation  with luke-
warm water, two to four  quarts, should precede the injection of the
same quantity of soap water, and the operation should be repeated  at
intervals of one or two weeks, at least three times, that subsequent
broods, previously secreted in the sacculi of the intestine or vermi-
form appendix, may be successively attacked.  Ammoniated mercu-
rial ointment best relieves subsequent itching and irritation about the
perineum. 
44
ENTOZOA.
   Whipworm.— Trickocephalus dispar (#/>/£, rpixo?, hair, necpaXy,
head; disjxtr, unequal), male one and a quarter, female two inches m
length ; is readily recognized by the inequality of  its thickness, the
head extremity constituting a long, spirally turned thread, the lash ;
the body  a much stouter, shorter mass, the  handle of the whip;
habitat, the  caecum and its vicinity.  The brownish-colored eggs,
                        0.05 X 0.0-2 mm., which are not infrequently
                        voided in the stools, are differentiated from
                        those of other nematoids by their double
                        contour, strongly granulated yolk, and  dis-
                        tinct lemon shape, which is  more  closely
                        simulated at both (flattened) poles by pro-
                        jecting  (shining)  coverlets.   The eggs  are
                        developed into mature worms in the body
of man.   The whipworm, which may furnish one and a half million
eggs in twenty-four hours, indicating the presence of nine hundred to
fifteen hundred parasites, is, according to Moosbriigger and Leich-
tenstern,  a frequent  cause of  anaemia and blood-stained diarrhoea
in children.
   Anchylostoma  (a'yKvXo? aropa, fixed  mouth)  DUODENALIS ;
Gothard worm, from the number of cases (over one thousand reported)
among the workmen in the excavation of this tunnel.—A thick, red,
 Fig. 43.
and male
Whipworm, female
   Fig. 44.—Eggs of entozoa: 1, Distoma hepaticum; 2, Distoma lanceolatum; 3, Taenia solium;
l.Taeniasaginata; 5, Taenia lata; 6, Oxyuris vermicularis; 7, Trichocephalusdispar; 8, Ascaris lum-
bricoides.

round worm, female one-half to three-quarters of  an inch long, male
half as long; it is distinguished  by an open, oval stoma, lined with
teeth, by means of which it attaches itself by hundreds and thousands
to the duodenum and jejunum, penetrating even to the submucous
tissue, where it  sucks itself, like  a leech, full of  blood.   It is found
in Egypt, parts of Europe, South America, and Africa, whence it
was imported by slaves into  our own  Southern States, Louisiana,
Alabama, and Georgia.  The oval ova. 0.05 mm.  long, are voided in 
ENTOZOA.
45
1, male: 2, female.
 % natural size.
3, magnified head,.
 showing teeth.
Fig. 45.—Anchylostomum duodenale.
the intestines to be discharged with the faeces  and continue their
growth in stagnant water, whence they are received into the intes-
tine of man, in which development is completed.
   The symptoms, which  show  themselves  in acute and chronic
forms of anchylostomiasis, depend mainly upon loss of blood.  The
disease is announced in both  forms with pxiin  in  the stomach and
intestines, to be followed by anaania and clilorosis.  The lips and
finger nails become pale, the pulse is increased in frequency, and in
chronic forms there is either marked hypertrophy and dilatation of
the heart or disturbance of  valvular ac-
tion.   In the  last stages  of the disease
ancemia becomes profound and axle ma
begins  to show itself about the ankles
and legs.  Fatty  degeneration  of the
heart,  with   stasis,  cyanosis,  and
dropsy, gradually supervenes  in the
cases of more protracted  course.
    The symptoms may  simulate, and
have been mistaken for,  catarrh, ulcer,
and cancer of  the stomach, clilorosis,
anaemia, pernicious anaemia, leukaemia,
valvular disease of the heart, and malarial cachexia.  The diagnosis
rests upon the fact of multitudinous attack, by preference  of  the
working classes, masons,  and miners, without regard to age and sex,
but with especial regard to a hot climate  and bad drinking water.
Malaria is differentiated by  enlargement  of the  spleen  and liver,
melanaemia, and characteristic corpuscles in the blood; leukaemia,
by affection  of the spleen and lymph glands,  with specific  altera-
tions in the blood.  Certain cases  of pernicious anaemia are cases of
this disease.   In doubtful cases the  diagnosis is established by the
detection of  ova in the  stools, generally intimately intermixed with
the contents of the bowel on account of the high habitat of the worm.
They are best disclosed by dilution of the faeces in water,  and exami-
nation of the sediment which falls over night in a conical glass.
   Treatment.—Thymol  has proven, in  the hands of Bozzolo, Grazi-
adei, and Lutz, a specific  in the treatment of this hitherto intractable
disease.  The treatment  should be prefaced with a dose of calomel,
gr. x., and the drug should  be given in  repeated moderate doses, 3 i.
pro die in capsule or compressed tablet, for several days.   Large doses
of the fluid extract of male fern, 3 ij.-vi-, if fresh and of good quality,
are almost equally effective.
   Trichina (dpiS, rpixos, hair) spiralis (a  name applied by Owen,
1835,  to the  immature  parasite encapsulated in  muscle, where  it
was  first observed) is present  in  man  in  both the developed and 
4<i
ENTOZOA.
undeveloped states: developed, mature in the intestinal canal;  un-
developed, immature in the muscles.   The trichina also infests the
hog, rat, cat. rabbit, fox,  and guinea-pig.   It is  a pure parasite, the
sole  example among the  entozoa, having lost all relation  with  the
external world.
   The history of the trichina is wholly modern.  Calcified  remnants
of this parasite in muscle were looked upon as dissecting-room curi-
osities up to 1835, when Paget  took a specimen  to Owen, who gave
it the very appropriate name it bears.   Leidy,  in  1840, discovered
in a piece of ham upon his  plate the  same immature form,  which
was still  regarded  as  an innocent wandering nematoid worm until
1S«I0. when Zenker discovered it in myriads in the muscles of a
patient who had died of-a disease diagnosticated as  typhoid  fever,
but  marked by extreme  pain in the muscles,  with oedema of the
surface, which  symptoms he correctly attributed  to the presence
of the parasites.  Virchow, Leuckart, and Zenker then demonstrated
their migration from  the intestines to  the  muscles ; and two years
Fig. 46.                       Fig. 47.
      Figs. 46 and 47.—Mature trichinae.
later, in 1862, Friedreich made the first diagnosis of  the disease in
life, with the detection of the parasite in a piece of exsected muscle.
   Anatomy, etc.—The mature intestinal trichina is round, elon-
gated, white, and, as its name implies, extremely filiform, on which
account it  is barely visible  to the naked  eye as a fine wool hair or
silvery thread.   The head,  formerly regarded as the  tail, is drawn
c >ut alm< >st  to a line, while the caudal extremity is somewhat rounded
off and is  not much thinner than the body.   The alimentary canal
begins with a muscular  mouth, is continued  into an elongated oeso-
phagus,  expanding into a  flask-shaped stomach,  to  be again con-
tinued into the intestinal canal, which at its extremity receives in the
male the opening of the seminal duct, arising from a  single testicle,
a  thick  cul-de-sac  which  runs along the side of the body.  The
female, one-eighth of an inch in length, is twice as long as the male
to accommodate the  ova with which it is  stuffed,  and which are
hatched within the body and born alive.  The orifice of the vagina
is situated at the junction of the first and  second quarters of the
body.   Each female may give birth,  in  the  course of a month,  to
over a thousand young.  The parent trichinae are short-lived.  The 
ENTOZOA.
47
■are probably, for the most part, digested and absorbed after repro-
duction, as they disappear from the intestine in five to eight weeks,
and are, unfortunately, not often to be found in the stools.
   The new-born immature trichinae, one two-hundredth of a line in
length, having  escaped from the body of the parent,  penetrate the
intestinal wall,  probably by
means  of  chemical irritation,
to migrate, chiefly along the
meshes of the connective tissue,
to  contiguous muscles, more
especially  to  the diaphragm,
abdominal, intercostal, laryn-
geal,  cervical,  ocular,   and
proximal muscles  of  the ex-
tremities, in  which latter re-
gion  they are crowded,  as  if
arrested, at the tendinous ex-
tremities.  Here they continue
to grow for fourteen days to a
length  of half a  line, when
they coil up to assume the well-
known  spiral  form,   disinte-
grating the muscular tissue.
expanding and thickening the
sarcolemma,  and,  as  a result
of  the  inflammatory  process
thus  produced,  leading to the
formation of  a lemon-shaped       Fm 48_Young trichinae in muscle.
capsule  one-fifth of a  line in
length, in which they lie for the most part singly, or more rarely in
groups of two, three, or even four. Thus they remain encysted alive
for a year or more, exceptionally as long as  tAventy-five years, or
become  subsequently  calcified—after calcification of the containing
capsule—a process which begins at the poles of the cyst, but is not of
necessity fatal to its contents, even when complete.
    Muscular tissue thus infested, when taken as food (one ounce con-
taining  at times fifty  to  one hundred  thousand  parasites), is dis-
solved  in the process  of. digestion,  liberating from their capsules,
in from three hours to three  days, the muscle trichinae, which attain
sexual  maturity in  the intestinal canal in five days, and then  re-
produce their species  with the rapidity described.  Trichinae have
also been found in the blood, mesenteric glands,  and peritoneal cavity.
   Thus the  Trichina  spiralis, which was  formerly regarded as an
accidental and innocent inhabitant of the muscular tissue, has been
 
48
ENTOZOA.
unmasked, since the first observation of Zenker in 1800 on a servant
girl in the  hospital at Dresden, as  one of the  most widely dissemi-
nated and deadly of all known parasites.
   The symptoms of trichinosis, as the disease  is  called, vary ac-
cording to the quantity ingested and the irritation produced.  Small
numbers produce no  symptoms,  calcified  remnants having  been
often found in autopsies with a history of absence of any symptoms
Fig. 19.—Trichina encapsulated in muscle.           Fig. 50.—Calcified relics.
in life.   A certain  stage of development  and capsulation is also re-
quisite to infection.  Too  young or insufficiently protected trichinae
are killed in the stomach.  Calcified capsules may not liberate their
contents.  The irritation, with the consequent rapid increase of peri-
stalsis in childhood, often causes the expulsion of trichinae unlibe-
rated from their capsules in the stools.  The ingestion of alcohol in
large quantities with the meal may destroy them as rapidly as they
are liberated.
Fig. 51.—Young trichina liberated from capsule.         Fig. 52.—Encapsulated trichina.
   The stage of invasion, which shows itself in from three hours to
three days or longer, as successive quantities may be ingested, is cha-
racterized by irritation on the part of the stomach and intestines, viz.,
by anorexia, nausea, vomiting, tenderness to pjressure, pain in the
bowels, and diarrhoea.   These symptoms may be absent altogether,
or may vary greatly in  intensity, to assume at times  such severity
as to be mistaken  for  cholera, as in the epidemic of Hedersleben in
ISO5. a city of  two thousand inhabitants, where three hundred and
thirty-seven persons were attacked, and one hundred and one died, 
ENTOZOA.
49
 three on the sixth day.  Animals fed  with trichinotic  flesh often
 succumb on the fourth day.   The fever, thirst, headache, and gene-
 ral prostration which may accompany the local signs belong equally
 to  other causes of intestinal irritation and are not peculiar to trichi-
 nosis.
    Characteristic symptoms  announce  the  advent of the stage of
 migration and colonization  in the muscles, which begins as a rule
 on the seventh day with, oedema, functional disturbance, and pain
 in the muscles.  CEdema shows itself  first, or is noticed first as a
 rule, in the eyelids,  disappearing  in a few days and returning later
 in the course of  the disease.   This oedema  is often coincident with
 pain, tension, and restriction of movement in the muscles of the
 eyes, as evidence of early invasion of these muscles ; though the pre-
 sence of oedema here as elsewhere, in the absence of muscular signs,
 has also been  ascribed to the action of some toxic principle acting
 upon the vaso-motor system.   GCdema of the face is often, that of
 the hands  and feet more rarely, associated with  that of the eyelids.
 Pronounced oedema of the skin over the  affected muscles occurs
 even more constantly than about the face—is absent, in fact, in only
 ten per  cent of cases.  This  cutaneous oedema  also  disappears for
 a few days, to return later.   It  is distinguished from the oedema
 of  heart and kidney disease  by its  association  with the muscular
 signs, as well as by the  fact  that it spares the genital organs, the
 scrotum and labia majora.
    Muscle symptoms appear on the ninth  or tenth day as a rule, de-
 layed at times to the fourteenth, varying in  every grade of intensity
 from lassitude, stiffness,  or tension, to board-like  indurations and
 most atrocious pains.  The flexors of the extremities, the biceps and
 muscles  of the calf especially, become  swollen,  tense, and tender,
 the extremities being held in  semi-flexion to simulate the postures
 of acute articular rheumatism.  Invasion of the diaphragm, abdo-
 minal  and  intercostal muscles, gives rise to dyspnoea ; invasion of
 the masseters, which may excite trismus,  renders mastication pain-
 ful or impossible ; while invasion of  the tongue  and pharyngeal
 muscles may restrict or prevent deglutition,  accounting thus for the
 rapid emaciation.  Invasion of the larynx  is shown by hoarseness of
 voice or aphonia in twenty per cent of cases, and of the ocular mus-
 cles by fixation of the eyeball, chemosis, and occasionally by mydri-
 asis and nystagmus.   Impairment of  hearing follows invasion of
 the stapedius muscle.
   Sweating is another common  symptom of trichinosis.  It occurs
early, always in connection with  the  muscular pains, and is profuse
and distressing in correspondence with  their severity.   It is often
attended with miliaria, occasionally with herpes.   Pustular erup-
        4 
50
ENTOZOA.
tions—Friedreich once found a free trichina in a pustule —acne, furun-
culosis.  may follow the disappearing oedema of the face.
   Still another quite common as well as obstinate symptom is in-
somnia, which often rapidly exhausts the patient.  With this excep-
tion the nervous system shows no symptoms.  Though most cases
are characterized by apathy or depression, the brain remains clear,
except in the last stages of the  severe attacks, when  somnolence,
stupor, or delirium may for a short time precede the end.
   Fever does not belong of necessity to trichinosis.  Average cases
show slight elevations of temperature,  up to 104° F. in the severe
forms, which at times present the course of remittent, or more fre-
quently of typhoid, curves.   Bronchitis, even catarrhal  pneumonia,
may result from the impeded respiration, while extensive, even fatal
hypostatic pneumonia from  prolonged decubitus is not uncommon in
protracted cases.
   Duration.—The disease lasts  from two weeks  in  the lightest
cases to eight weeks in pronounced cases, and with sequelae, for the
greater part of a year, in the severest forms.   Kunze  heard com-
plaints of rheumatic pains  in bad weather four years after the He-
                           dersleben  epidemic,  and Kratz found
                           weakness  of the muscles in  one  case
                           eight years after the attack.  The mor-
                           tality  ranges   from  one  to  seventy,
                           averaging thirty per  cent.  Death oc-
                           curs usually from exhaustion or blood
                           poisoning in from four to six weeks, ex-
ceptionally  earlier  from  gastro-intestinal irritation,  and later from
hypostatic pneumonia and marasmus.
   The prognosis  depends largely upon the number ingested and
the lapse of time.   Children almost never succumb, because most of
the trichinae are ejected by diarrhoea.   Patients who survive the
eighth week recover. Severe myositis or dyspnoea,  profound pros-
tration and nervous symptoms, aggravate the prognosis.  Recovery
is, as a  rule,  much more tedious  and protracted than after other
acute infections of corresponding severity.
   The diagnosis  is illuminated often by the fact  that others are
simultaneously  affected,  or by the inspection of suspected pork ;
possibly by the  detection of mature or  encapsulated trichinae, more
especially after a brisk cathartic, in the mucous but  not in the  fluid
contents of the voided stools ; positively by the  discovery  of imma-
ture trichinae  in the muscles, extracted preferably after linear inci-
sion under  antisepsis, from the  deltoid or lower part of the biceps
muscles—for the most part  an unnecessary procedure.   A history of
gastro-intestinal irritation,  followed  by constipation, oedema of the
 
ENTOZOA.
51
 face on the eighth day, and muscle signs by the tenth  day, with
 sweating,  insomnia, headache, thirst, and  fever, sufficiently charac-
 terizes the disease.
    Articular rheumatism, which has pain and sweating in common
 with trichinosis, is distinguished by the affection of the joints proper,
 more especially of the smaller joints, by the absence of gastro-intes-
 tinal irritation, dyspnoea, insomnia, and affection of  the muscles of
 the jaws and eyes.
    Muscular  rheumatism selects by preference other muscles than
 those affected in trichinosis,  and is unattended with gastro-intes-
 tinal irritation, oedema, fever, and  sweats.   Grawitz, Virchow's as-
 sistant,  declares that trichinae were found, on autopsy,  in one-third
 of the cases of so-called muscular rheumatism.
    Typhoid fever is differentiated by the mental disturbance, a char-
 acteristic temperature curve,  diarrhoea generally throughout  the dis-
 ease, meteorism, and is not attended with oedema, asthma, and mus-
 cular signs.
    Meningitis shows herpes as a rule,  hyperaesthesia, opisthotonos,
 a contracted abdomen, and has a  different history.  Finally, poly-
 myositis, which shows pain in the muscles, tension, deformity, pros-
 tration, oedema, sweats, and  insomnia—in  short, most of  the signs
 of trichinosis—is distinguished by isolated attack, by the absence  of
 hiskay and gastro-intestinal signs, preference of the extensor mus-
 cles, and exemption of the diaphragm, larynx, tongue, and pharynx.
 Excised  portions of muscle  show hyaline or waxy degeneration, but
 no trichinae.
   Prophylaxis.—Naked-eye inspection of meat does  not disclose
 the Trichina spiralis except in cases of calcification, and  calcification
 is not necessarily fatal to  the trichinae.  Putrefaction does not de-
 stroy them.  Copious libations of alcohol with meals is a preventive
 as unreliable as unadvisable.  Smoking and pickling, as ordinarily
 practised, kill only the surface trichinae.   A temperature of 160° F.
 is fatal to the trichina, so  that  thorough cooking of meat offers a
 sure prevention of infection.   A long subjection to high temperature
 is requisite to secure penetration to the interior of  a large mass  of
 meat of the necessary grade of heat.
   Therapy.—Successful therapy depends upon an early diagnosis,
 which is  often unattainable.   A brisk cathartic,  calomel gr.  x.-xx.,
 castor-oil § i., or infusion of senna, followed by irrigation of the
 colon, offers a hope of discharging many of the  worms  before they
 have  been  liberated from  their  capsules; and inasmuch  as  Kratz
and  Cohnheim found  trichinae in the stools as late  as  the twelfth
week, it may be said that it is never too early or too late, for pur-
 poses either of diagnosis or  of therapy, to give this method trial. 
o2
ENTOZOA.
Recently liberated trichinae may be benumbed and more readily dis-
charged by the administration of thymol.  3 i.-iss., divided in two or
three doses ; or extract of male fern, 3i.-iv.  After colonization in
the muscles the treatment becomes purely  symptomatic.   The hope
of  radical extermination  by rapidly diffusible  agents,  picric acid
and benzin, or  water-extracting  agents, glycerin and alcohol, has
proven illusory.   Applications of  hot water, salicylic acid gr. vij.,
salol gr. x., more especially phenacetin  gr. x., or antipyrin gr. v.,
every hour, may be tried in relief  of pain not so great as to indicate
morphine,  which becomes a  necessity in  severer  cases.  Sodium
bromide  gr. xl., antipyrin gr. x., chloral gr. xv., may suffice to  se-
cure sleep,  which is, however, in bad cases forced only by morphine.
As the safety of the patient depends upon speedy encystment of the
trichinae—a process which is hindered by motion  of every kind—re-
pose and quiet as absolute as possible should be enjoined and se-
cured.  The strength is  to be sustained by alcohol and food until
the force of the disease is spent.
Fig. 54.—Guinea worm.
   Filaria Medinensis (Guinea worm).—Found frequently in Asia
and Africa.  A very long—sixty to one hundred centimetres—slender
worm with  rounded head and hooked tail; female  only known as
yet, which finds some median host in minute Crustacea, with which,
in drinking water, the embryo gets entrance into the body of man.
It is carried by the blood vessels  to the periphery, where it  develops
to maturity, forming furuncles and abscesses in the subcutaneous
tissue, most frequently in the lower extremity near the heel.  In this
process  it may develop  gangrene  or  general  rigors, fever, convul-
sions, etc.   Care must be taken in its extraction not  to break it off,
as it may protrude from an open wound in  the skin.  To avoid this
accident it should be gently wound around a stick and very slowly
withdrawn in the course, if necessary,  of several hours.
   Filaria Sanguinis.—A  dangerous nematoid worm found in the
body  is the Filaria sanguinis, first described  by Bancroft, hence
Filaria  Bancrofti, and  first  recognized as  a cause  of chyluria by
Wucherer, of Bahia (1809).
   The  Filaria sanguinis, like the Trichina spiralis, is found in  both
mature  and immature  states in the body of man.  The mature form 
ENTOZOA.
53
lives viviparous in the lymph vessels of  the scrotum and the lower
extremities, and is a parasite of  the respectable length of eight to ten
centimetres.  The young filariae find their way from the lymph ves-
sels to the blood, where they are encountered in great        ^^>
numbers, each worm  measuring  0.35 mm. in length,       NT'
with a breadth about  the diameter of a red blood cor-       II
puscle.   A protruding sheath often envelops one end of       \\
it.  The  worm shows  active sinuous motion.  Manson       J J
made the curious discovery that the filariae of the blood     /f
are to be seen only at  night, whence the failure which     //
has marked many attempts at  their discovery during    j F
the day.   Fluids must also be examined fresh.   Some    U
intermediate stage of  development must exist between     \\
the mature  filaria in the lymph vessels and the imma-     I j
ture filaria in the blood, outside the body, else various    JJ
transition forms would be seen.   There is reason to be-  /j
lieve that the animal or insect which officiates in secur-  ^==^^
ing this transition state is the mosquito.  The mosquito  fig. 55.-Fiiaria
sucks itself full of blood containing the filaria and carries Sansuims-
Fig. 56.—Filariae in blood vessels.           Fig. 57.—Elephantiasis cruris lym-
                                    phangiectatica (Ziegler).
   The Filaria sanguinis is a  dangerous parasite, in that it produces
symptoms  in  both stages of development.  In  the skin it  causes 
54
ENTOZOA.
sclerosis, elephantiasis, occlusions of the lymph vessels,  lymphan-
gitis, lymphangiectasis, and ruptures.  In the  blood and lymph ves-
sels it may lead to occlusions, dilatations, and ruptures, with escape
of lymph, sometimes of blood.
   The curious condition known as chyluria, from rupture of lymph
vessels into the bladder or  renal pelvis, is found to depend in many
cases upon the Filaria sanguinis.  The urine in these cases looks like
milk, and may contain as much as three per cent  of fat.  Haematuria
also, but more infrequently, arises from the same cause.
   Prophylaxis is simple.  It consists  in  thorough boiling  of all
drinking water, from whatever source.  Perfect filtration would be
equally effective.
   No known remedy may reach this parasite in  the tissues or in the
blood.   It has  been suggested  that the picro-nitrate of  potash, on
account of its highly diffusible properties, might be of benefit.  Treat-
ment is really wholly symptomatic.   The tincture of iron is indicated,
gtt. xxx. ter in die.  Lewis recommended gallic acid.
Fig. 58.—Liver fluke.
   Liver Fluke.—Of  the trematoid (rpr/pa, foramen) worms, the
only example of particular interest to the practitioner of medicine is
the Distoma  (double mouth) hepaticum, or liver fluke.  The liver
fluke is, as the name implies, a flat, somewhat triangular worm about
an inch long and  half an inch wide.  The somewhat elongated head
terminates, or begins, in an oval sucker, below which on the ventral
aspect is another sucker, which  orifices have given the worm its
place.   Between the two suckers is  the  genital orifice.  The yellow-
ish, oval eggs are among the largest found in the faeces.
   The liver fluke is encountered rarely in man, more frequently in
the ox, deer,  occasionally in  the horse and hog, by far most fre-
quently of  all in the sheep, where it causes the disease commonly
known as the rot, which kills annually thousands of sheep.
   The development of  the liver fluke is a strange story.  The eggs
escape with the bile into the intestine, whence they eventually reach 
ENTOZOA.                         55
water, and, being provided with a ciliated envelope, swim about freely
until they come in contact with the body of a snail, which they pene-
trate to become lodged in  its  interior.  Here the embryo, losing its
ciliated envelope, becomes converted into  a  cyst, which produces on
its interior elongated bodies called nurses.   The nurses penetrate to
the liver of the snail, where are developed new forms somewhat of the
shape of the parent fluke, called cercarias.  The cercarias escape from
the nurse and the body of the snail  into the water, and, being pro-
vided with a long tail like a tadpole, swim about actively for a time
until they become attached to subaqueous grasses, when they lose
the tail and become quiescent.  Thence, in the grazing of sheep,  they
may be reconvened to  their bodies to find a way to the liver and
develop to sexual maturity.
      Fig. 59.—Distoma haematobium with ova. Male in gynaecophoric canal of female.

   The liver fluke is rarely found in the body of man in such num-
bers as to cause occlusion, dilatation of the  bile ducts, and reabsorp-
tion of the bile, with the serious complications which result from this
condition.  The paucity of their number in man protects him against
disastrous consequences.  Prevention is the avoidance of subaqueous
vegetables, such as watercresses, to which  the bodies of snails are
attached, and of impure drinking water.
   The Distoma Haematobium  is found in the portal vein, in its
trunk and derivative branches, in the body of men and apes.  The ova,
deposited in the mucosa of the  ureters,  bladder,  etc.,  develop em-
bryos which produce ulceration in these structures.  This parasite
is frequent in Egypt and Abyssinia, but has  not been seen elsewhere. 
                       CIIAPTEE  III.

                            BACTERIA.

    The  term bacteria (ftanrpov, a rod)  applies collectively to a
large class of micro-organisms, the  study  of  which is known as
bacteriology.   These bodies constitute the simplest and lowest forms
of  all living  things.  From  their mode of propagation—by fission
—they fall in botanical classification under the  division of schizo-
mycetes (<?xi&iv, to split).   Bacteria are  collections of  protoplasm
made up of an albuminose body, microprotein, fat, salts, and water.
They have no chlorophyll, and may not,  therefore,  appropriate  for
their nutrition carbonic  acid.  Hence they must live as parasites
on  preformed combinations, but the smallest traces of nutritious
matter—that  which may be  found,  for instance, in the purest dis-
tilled water—may abundantly suffice  for their nutrition.  They flour-
ish best, as a rule,  on feebly alkaline soils.  With all other forms
of life, they originate only from themselves, and  never by spontane-
ous generation.
    The  body  of  the bacterium  consists of the protoplasm (mostly
colorless), enclosed in a delicate  but resistant membrane,  like cel-
lulose, insoluble in acids and  alkalies.  This membrane  may, under
certain circumstances, swell to form a sheath or capsule, or exude a
mucoid-like substance in which masses of bacteria may be agglome-
rated to constitute the so-called zooglcea.  Such zooglcea, in masses or
lines, show definite shapes in definite soils, and furnish  distinguish-
ing characteristics.
    Bacteria are  divided,  from  their shape, into  micrococci, bacilli,
and spirilla—i.e., spherules and cylinders, straight or curved.
    Micrococci occur alone as monococci, in pairs as diplococci, in
fours in  a single plane as merista,  and in eights as sarcinae, which
multiply in the three dimensions of space, to appear like dice.  Mi-
crococci multiplying in a line  are known as streptococci {arpenroi, a
chain) ; multiplying in a mass,  as staphylococci (ffracpvXy, a bunch
of grapes).  A coccus or  bacterium  whose length is greater than its
diameter—i.e., an oval  micrococcus—is  a bacillus.   Spirilla  are
curved bacteria—with one curve, like a comma, the vibrio ; or with 
BACTERIA.
D<
Fig. 60.— Bacilli stained to show vibratile cilia and flagella (after Zettnow) 
5s
BACTERIA.
successive curves, like a corkscrew,  the spirochaete.   Bacteria vary
greatly in both length  and  breadth,  but are, for the most part, so
small as to be on the confines of the visible, even with the micro-
scope.
   The mass of micro-organisms are innocent to man.  The bacteria
Fig. 61.—Streptococcus.             Fig. 62.—Spirochaetes of relapsing fever.
of putrefaction return to earth and air everything that has ceased to
live, so that life would soon become impossible without them.   It is
only under certain circumstances that the bacteria of putrefaction
may prove injurious.  Innocent micro-organisms injected into the
body, even in mass, do no harm.  They fail to find necessary condi-
tions for development, and perish.
Fig. 63.—Sarcinae.     Fig. 64.—Yeast plant.   Fig. 65.—Bacillus pneumoniae (Fried-
                                     liinder) with gelatinous envelope.
   Pathogenic micro-organisms vary in length from  one to forty
(1-40 p) micromillimetres, and in breadth from 0.5 to 7 p.1  Many
micrococci are too minute to admit of accurate  measurement.  The
largest micro-organism is the spirillum, which may reach a length of
1 An M (mikron) = j-^ millimetre. 
BACTERIA.
59
0.2 of a millimetre.   Perhaps a better idea of size  can be conveyed
by comparison with a  similar  object.   The  bacillus tuberculosis,
which occupies in respect to size a median place, varies in length
from t^Vo" to -gVoir of  an inch, the smaller measurement being the
average diameter of a corpuscle of human blood.   Many species are
endowed with motion, gyration, sometimes with address and agility,
rotation and oscillation, flexion, extension, and locomotion.  The ba-
cilli of tuberculosis  and milzbrand,  together with  all  micrococci,
have  no  motion  at any time.   That tremulous, molecular motion—
the so-called Brown's motion—in the same  place, observed  also in
inorganic matter, is to be  distinguished, of  course, from individual
motion.  Motion is often secured to micro-organisms by means of
vibratile cilia, though most bacteriologists believe it to be a property
innate or inherent to the protoplasm.
   Bacteria  multiply  by  division
(fission)—that is, by increase in size
and separation into two (the cholera
vibrio splits in two in  fifteen to
forty minutes)—or by the formation
of spores, spherical  bodies which
elongate to form bacteria.   Micro-
cocci  multiply only by division,  and
spores have not yet been distinctly
demonstrated in  spirilla.   Bacilli
form  spores in two ways : by devel-
opment in their  interior, with sub-
sequent liberation on rupture of the
,  .,,       ^            t    t   ^     Fig. 66. — Bacilli tuberculosis,  showing
bacillus—endospores ;  or by devel-   spores.
opment at an extremity, which falls
away to  constitute a new individual—arthrospores (apdpov, a joint).
Endospores are much more tenacious of life than the bacillus, or than
the arthrospore,  which  is  endowed with no particular resistance.
Hence endospores constitute what are known as  permanent forms.
In either case the protoplasm of the bacillus clears up at the point of
formation of the spore, to assume  the  shape of a minute drop of
greater diameter, at times, than the bacterium itself.  Bacilli filled
with spores, which may exist to the  number of three or four, show a
checkered or beaded surface.   The activity of formation of spores is
an index to the degree of nutrition.   The liberated spore soon breaks
the spherical surface with a  point, which gradually elongates to
form,  in turn, the perfect  bacillus.   Spores may be recognized by
their glistening, highly refracting contour.
   According to the mode of nutrition bacteria are divided into sap-
rophytes  {aanpos, rotten), which live  on dead soils, and parasites
 
GO
BACTERIA.
(napaajiToS, feeding with or on), which live on living matter.  Pa-
rasites are also divided into obligates—that is, pure  parasites—and
facultatives. which may live both as parasites and saprophytes.
   Bacteria are again  divided, according-as they may live with or
without oxygen, into aerobes and anaerobes. Here, too, there are ob-
ligate aerobes, which can  live only in the presence of oxygen, and
obligate  anaerobes, which  can live only in the absence of  oxygen.
And here, too, there are facultative anaerobes,  which  may live in
the presence of oxygen.
   Saprophytes thrive best  at a temperature of 20° to  25° C, para-
sites best at 35° to 40° C.   Every  micro-organism has its  own pe-
culiarities regarding temperature.  Sunlight  destroys all micro-or-
ganisms  ; even the most tenacious spores or permanent forms perish
under the direct rays of the sun in the course of a  few days.
   Bacteria are invisible not only because of their size, but also be-
cause of  their lack of color,  and are rendered visible by various stains
or dyes.   For this purpose  the best materials are the acid and basic
aniline dyes,  especially methylene blue and violet,  gentian violet,
Bismarck brown,  fuchsin,  and, of the acid anilines, eosin and acid
fuchsin.   They are usually  prepared as follows :
   Alkaline methylene blue solution (Loftier) : Concentrated alco-
holic methylene blue solution,  thirty cubic centimetres ; liquor po-
tassae (1  :10),  one hundred cubic centimetres.
   Aqueous aniline dyes (Ehrlich): Aniline oil, four cubic centimetres,
thoroughly agitated with water, one hundred  cubic  centimetres, fil-
tered after deposit; whereupon  is added concentrated alcoholic solu-
tion of fuchsin or methylene violet up to distinct opalescence.
   Carbolic-acid-fuchsin (Ziehl-Xeelsen)  : Distilled  water, one hun-
dred ; crystallized carbolic acid, five ;  alcohol,  ten ; fuchsin, one.
   Iodine-potassium-iodide solution :   Iodine, one gramme ; potassi-
um iodide, two grammes; distilled water,  three  hundred grammes.
For use the solution is diluted to a Madeira color.
   The most generally employed is the carbol-fuchsin solution.   The
various micrococci, staphylococci, streptococci, FrankePs diplococci,
cholera vibrios, recurrent fever spirilla, and nearly all the pathogenic
micro-organisms of man, as well as most of the saprophytic bacteria,
are quickly and distinctly stained in this way.   A large drop of this
solution,  let fall upon the object glass from a pipette and heated a few
seconds to half a minute, suffices to color all bacteria distinctly.  A
few forms with dense membranes must be heated a whole minute.
   Bacteria are prepared for color, if  in water or bouillon free of fat,
by simply washing in water;  but, if in an albuminose fluid (blood,
pus, or oedematous fluid of pneumonia) the cover  glass should be
dipped in absolute  alcohol; if in fat  (milk or oedema of connective 
BACTERIA.
61
tissue), the cover glass,  after drying and before heating,  should be
placed a  short  time in absolute alcohol and ether.  In this way are
colored not only the bacteria but also all protoplasm in the field.
   A valuable solution, especially in differential diagnosis, is that of
Gram, which is prepared as follows :  To ten parts of aniline water
(i.e., the milky fluid which  results  from the agitation of  four parts
of aniline oil with one hundred parts distilled  water)  is  added one
part concentrated alcoholic  gentian violet solution.  The mixture is
then passed through a filter moistened with water. The object glass,
after drying and heating, is  floated upon  this stain five to fifteen
minutes, sometimes under heat, and is then, without washing, ex-
posed at  least five  minutes to the iodine-potassium-iodide solution.
The blue-black color thus imparted is decolorized in first weak, then
stronger, but not absolute, alcohol  to a pale gray  or yellow.  Here-
upon the specimen is  dried in the air and examined under the oil of
cedar or conserved in balsam.   By  the method of Gram all cell ele-
ments are  decolorized, while  the bacteria maintain their dark-blue
stain.  Thus are colored the pneumococcus of Frankel, the strepto-
coccus of erysipelas  and acute suppuration, the  staphylococcus of
pus, the bacilli of anthrax, the mycelia of actinomyces, and the bacilli
of tuberculosis.  But the method of Gram will not color Friedlanderis
pneumonia bacillus, the  typhus bacillus, the gonococcus, or the chol-
era vibrio.
   As they are  but indistinctly colored in  this way, tubercle bacilli
require special  treatment.   A particle of sputum compressed between
two coloring glasses  is  spread out by the separation of the glasses.
The specimen is then dried by the passage of the glass, held with
forceps, about as fast as cutting bread, three times through a flame,
specimen side up.   The cover glasses are then dropped upon the ani-
line water solution  with fuchsin or gentian violet, or heated in this
solution until vapor arises, then decolorized in a solution of nitric
acid (1:4) and alcohol (sixty per cent).  An aqueous solution of methy-
lene blue or Bismarck  brown furnishes the after-stain;  or,  by a
shorter method, the cover glasses or sections are colored in carbol-
fuchsin, and then brought  for one minute  into a solution of water
fifty, alcohol thirty,  nitric acid twenty.
   Spores may not  be colored after these methods, as their firm en-
velopes prevent penetration.  This resistance is overcome by subjec-
tion to heated steam for an hour, or by  passage  seven to ten  times
through a flame.
   Bacteria are isolated and are further and much more positively
distinguished by cultivation in certain soils.   The first experiments in
cultivating bacteria were made in  fluids, solutions of meat, beef tea,
chicken soup, malt extracts, infusion of hay, etc.; but fluids are open 
H2
BACTERIA.
to the objection that they  admit  other germs to coalesce with, and
     '-s ..-->.,„-.,   render  impure, the special  variety to be studied.
             -Jl"v  Pure cultivations  became possible only with the
                   use  of  the solid culture soil  first  employed by
                   Koch.  Germs falling upon a solid surface remain



 Fig. 68.—Scale surface culture
(serum) of tubercle bacillus.
1
iilii
 Fig. 69.—Nail  stick
culture (gelatin)  of
pneumococcus.
                   fixed in the same place.  The solid  culture soil
                   made practicable the absolute isolation of germs,
                   without which accurate investigation is impos-
                   sible.  Koch made his first studies with the com-
                   mon potato.  The potato was the key to the whole
                   subject of solid cultures.  What the apple was to
Newton the potato was to Koch.   Subsequently gelatin was employed,
 Fig. 67.—Bacillus Hava-
niensis (Sternberg). 
BACTERIA.
63
 then aqueous humor, then gelatinized meat preparations, peptonized
 gelatins, etc., and, as a  climax, gelatinized blood.   Thus has been
 determined the peculiar soil in which the varieties of pathogenic bac-
 teria thrive best.  Moreover, it  is seen that the colonies  in their
 growth assume different forms or shapes, or exercise different effects
 upon  the  soil.  Different bacteria vary also in the  degree in which
 they fluidify the semi-solid substance of their soil.
    Lastly, pathogenic bacteria are distinguished by their physiologi-
 cal  effects.  From any special  successive  generation  of  a special
 variety of bacteria, material may be selected for introduction into the
 body or blood  of various animals.   Bacteria, or their products in
 culture soils, are introduced  into animals  by ingestion with food or
 by means of the oesophageal  sound; by inhalation or insufflation of
 atomized matter; by intraperitoneal, intraocular, or  intravenous in-
 jection, as into the external jugular or (in rabbits) posterior auricular
 veins ;  lastly, by subcutaneous injection with the disinfected syringe,
 or by subcutaneous insertion with the pla,tinum needle, usually into
 slight  wounds of the skin, under thorough asepsis.
    Pathogenic micro-organisms act in two ways: by intoxication and
 by infection.  Intoxication is a poisoning  by products of micro-or-
 ganisms produced outside of the body; infection is  poisoning by
 products produced by bacteria inside the body.  These sources are
 sometimes distinguished as ectogenic and endogenic—terms destined
 soon to substitute miasmatic and contagious as applied to infectious
 disease.  Intoxication is caused by the saprophytes,  which may pro-
 duce ferments in food, as in meat, fish, sausage, milk, and  cheese.
 The ferments may be infective even after destruction of the micro-
 organisms which caused them; so food, even though cooked, may
 produce disease.  The causes of infection are the pathogenic micro-
 organisms  which multiply inside the  body and evolve  chemical
 products.   The  fact  that  pathogenic micro-organisms are not ab-
 sorbed proves that they produce disease by some chemical change.
 Moreover,  the character  of  the symptoms—sopor, stupor,  coma,
 delirium—which supervene in cases of grave acute infection speaks in
 favor of this view and against the belief that bacteria act mechanically
 or by the mere  abstraction of  oxygen.  The only hitherto  known
 poisons which may, in minute quantities,  induce such grave toxic
 signs are the poisons resulting from  the action  of  the bacteria  of
 decomposition upon organic  matter.   As  these  intensely virulent
 poisons were first observed only in dead organic matter, they were
 called ptomaines (izrobpa,  the fallen, a corpse ; hence more properly
 ptomatines).   As many ptomaines are perfectly innocent, the term
has been better substituted by Toxines.  The toxines are nitrogenous,
basic compounds, like  the vegetable  alkaloids,  of  complex com- 
64
BACTERIA.
position.  Among  the non-poisonous  ptomaines  there  have been
extracted, in  all cases from  decomposing  dead  bodies, neuridin,
cadaverin, putrescin,  and  cholin.   Poisonous—i.e.,  toxines—are:
peptotoxin,  present in many peptones;  neurin,  in  decomposing
meat; muscarin, the poison of the fly fungus, found also in decom-
posing fish.   From pure cultures  of  pathogenic  bacteria have been
extracted a  toxine  from the  typhoid bacillus—typhotoxine; from
cultures of the  tetanus bacillus  and  the amputated extremity of a
man  dead of tetanus, tetanin and tetanotoxin.   Besides  the  pto-
maines or toxines there are to be found certain albuminoid bodies,
products of micro-organisms, with similar poisonous but very differ-
ent chemical  properties, which are  known as toxalbumins.  Such
toxalbumins  have been separated from cultures of the  diphtheria,
typhoid, and  tetanus bacillus.
   Animals, including man, vary in susceptibility to the action  of
micro-organisms and  toxines.  Certain animals are  more, certain
animals are less, liable or susceptible to contract or be inoculated with
a disease.  These animals are  said  to be,  one predisposed to, the
other endowed with, immunity to these diseases.
   The disposition to a disease may be natural—i.e., inherent—or
acquired.
   Natural immunity may be overcome in various ways.  Starvation
makes pigeons susceptible  to anthrax.  The  injection of papayotin
leads to the  appearance  of hitherto  lament  micro-organisms to such
degree, according to Ribbert, that the heart's blood will be thick with
them in two hours;  that is, the introduction of a vegetable ferment so
profoundly alters the condition of  the blood as to make of a hitherto
sterile a fertile soil.  So, also, certain ptomaines will reduce all en-
ergy to such an extent that bacteria hitherto innocuous become infec-
tious.   According to Rogers, the immunity of rabbits to rauschbrand
is overcome by the introduction of the innocent Bacillus prodigiosus.
Guinea-pigs immune to chicken cholera are rendered susceptible  by
the injection of hydracetin or pyrogallol, substances which  dissolve
red blood corpuscles; and the addition of phloridzin, which causes a
toxic diabetes, discharges the immunity of white mice to glanders.
   Hunger makes pigeons, naturally immune, susceptible to milz-
brand.  Fatigue acts in the  same way with  other animals.  Thus
white rats made to walk a wheel continuously for seven days lose
their immunity.  Temperature plays  a similar role.   Frogs kept
at a  temperature below 28° C. will not contract the disease, but will
inevitably succumb to it at higher grades.  Hydraemia  lessens  the
susceptibility of rabbits to the staphylococcus by eliminating toxines
through the  kidney.   Here is a  hint regarding the  value of free
libations of water in the treatment of typhoid  fever and  other infec- 
BACTERIA.
65
tions of man.  Staphylococci injected into the peritoneal sac are re-
sorbed without damage, unless the peritoneal endothelium be injured
or diseased.  Lipari  found that the intratracheal injection  of the
sputum of pneumonia did no damage unless the animals were  ex-
posed to cold, which probably acted  by producing catarrhal swelling
and paralyzing ciliary motion,  to permit the retention of bacteria.
The so-called " mixed infection" occurs  in this connection.  Tuber-
culosis admits the organisms of  sepsis, as does also diphtheria.  The
organisms of measles and pertussis prepare the soil for tuberculosis,
etc.
   The problem of medicine in  the prevention and cure of disease is
the reverse of this process, to wit, to confer immunity in lieu of lia-
bility.
   Artificial immunity is conferred in various ways : 1. By increas-
ing cell energy  to resist the invasion of disease.   Phagocytosis is an
exemplification  of this process.  Healthy cells incorporate, digest,
 Fig. 70.—Trichomonas intestinalis.  Fig. 71.—Naked amoebae coli.     Fig. 72. — Cercomonas
                                               intestinalis.

and destroy micro-organisms; feebler cells yield before them.  2. By
previous attack of a disease, as in  inoculation of variola.   3.  By
inoculation of a milder form of the disease with attenuated micro-
organisms  or  matter, as in the case of vaccinia and  hydrophobia.
4. By inoculation of substances extracted from the blood (serum) of
animals which  enjoy natural  immunity, or to which immunity  has
been conferred.   These principles may  be also extracted from the
milk (Ehrlich).  5. By inoculation of matters extracted from culture
soils in which specific micro-organisms have been developed.
   Substances extracted in this way from the  blood, milk,  or from
culture soils are known as antitoxines.  Such antitoxines have been
already found in  tuberculosis (tuberculin), pneumonia, diphtheria,
glanders, hydrophobia,  tetanus, and  typhoid fever.  Future specific
therapy lies in the direction of the discovery and perfection of anti-
toxines.
   Protozoa are the very lowest forms of animal life.  They are mi-
nute masses of protoplasm of various shape ; sometimes naked, gene-
        5
[rn 
66
BACTERIA.
rally invested with a membrane ;  sometimes enclosing pigment mat-
ter and vacuoles, and sometimes ciliated, flagellated,  etc.   How
protozoa find entrance into the body of man is as 3Tet unknown, but
they are certainly encountered in the blood, in various juices, or-
                               b.
   Fig. 73.—Plasmodium malariae : a, b, c, intracorpuscular bodies; g, crescent; h, flagella.
gans, and  tissues of the body, epithelium, and, in  some cases, defi-
nitely in connection with certain diseases.
   Protozoa are divided, according  to  their modes  of motion, nutri-
tion, etc., into  three groups—the  rhizopods, sporozoa, and infusoria.
Rhizopods are, for the most part, naked—i. e., membraneless—masses
of protoplasm, with digital  or filiform protrusions (pseudopods) to
surround and incorporate  food or foreign bodies, as in the amoebae,
which belong to this group.
                               Infusoria possess  permanent cilia,
    a               B       by which they secure motion and ingest
                            food into  an oval  orifice.  Both infu-
                            soria  and  rhizopods live  on  solid  or
                            semi-solid  food.  Sporozoa are covered
                            by a cuticle having neither pseudopodia
                            nor cilia,  and are nourished wholly by
                            osmosis.  Sporozoa  multiply by  hard-
                            shelled spores produced in the interior
                            of the  body.
                               Perhaps the best-studied  example of
                            disease produced by  protozoa is mal-
                            aria.   Blood withdrawn from any part
                            of the body, especially from the spleen,
                            but  most conveniently and safely from
the end of the finger, shows in this disease such masses of protoplasm,
sometimes granular, sometimes crescentic, very often irregular, as to
enable the practitioner in a doubtful case to declare the existence of
the disease and differentiate it from simulating maladies.   As these
 Fig. 74.—Coccidia from the human
liver: A X 330, B and C X 1.C00 (Leuck-
art). 
BACTERIA.
67
bodies are  to be found in all cases of malaria, and not in any other
disease, increasing during fever, disappearing after the administra-
tion of quinine or  other antiperiodic, and as the  inoculation of
blood containing them conveys  the disease,  they are regarded as the
specific cause of malaria, notwithstanding  the  fact that  they have
not yet been cultivated outside of the  body.  Protozoa belonging to
the group  coccidia have  been  recognized by Nisser in the nodules
of molluscum  contagiosum,  a  disease of the  skin.  The failure to
   Fig. 75.—Scirrhus of the breast: epithelium enclosing protozoa, black stellate bodies, large
and small (Foa).

discover micro organisms of other nature, and the recognition of pro-
tozoa in these affections, have awakened the suspicion  that  certain
exanthemata, also dysentery, abscess of the liver, cancer, etc., may
depend upon, or be associated with, this cause.
   Pfeiffer depicts sporules found in  the  interior of the vesicles of
herpes zoster, which is  now regarded as an infection,  also  similar
structures in varicella and variola vera ; and Van der Loof finds cell
forms—plasmodia—in the vesicles of vaccinia. 
CHAPTER  IV.
                    INFECTIOUS DISEASES.

   Up to the" present time it is definitely known that micrococci pro-
duce pyaemia, septicaemia, furunculosis, acne, erysipelas, gonorrhoea,
trachoma, pneumonia ; bacilli cause anthrax, diphtheria including
croup, typhoid fever, tetanus, tuberculosis, lepra, glanders, measles,
and  typhus fever ;  spirilla produce  cholera  and relapsing  fever;
sporozoa cause malaria.
   Regarding other infections the evidence is not so positive ; in some
cases it is probable, in others as yet only presumptive.

            SEPTICEMIA,  PYAEMIA,  SEPTICO-PY-EMIA.
   Septicaemia (aij-nto?, poisonous); Pyaemia; Septico-pyaemia.—In-
fection  (intoxication) of the blood and  body by ferments, toxines,
products of the various pus-producing micro-organisms, characterized
by chills,  high fever, profuse sweats,  joint affections, metastatic de-
posits, haemorrhages, diarrhoea,  and nervous symptoms.
   These  affections, which  were formerly considered separate, are
now known to be due to the same cause and belong properl}^ together.
Predominance of  general signs of  blood poisoning—i.e., nervous
signs, high fever, etc.—in the absence of  metastatic deposits,  consti-
tutes  septicaemia ; predominance of  metastatic processes, haemor-
rhage, abscesses, etc.,  constitutes pyaemia;  conjunction of the two
sets of signs constitutes septico-pyaemia.
   Numerous micro-organisms produce pus and act as causes of this
condition.  1.  One of the most frequent is the Staphylococcus pyo-
genes aureus,  which, cultivated on gelatin or  agar, shows, after ex-
posure to light, gold-yellow colonies.   Smaller  numbers localized pro ■
duce in the skin acne, furunculosis, and subcutaneous abscesses; in the
interior of the body, suppurations of bones and joints, of the lungs,
pleura, liver, heart (endocarditis), and kidneys.  The staphylococcus
abounds in the air of crowded rooms.  2. The Staphylococcus pyo-
genes albus, which forms white colonies.  3. The Staphylococcus pyo-
genes citreus, which forms lemon-yellow colonies.  4. The Micrococcus
pyogenes tenuis, which forms perfectly clear colonies.  5. The Strep- 
              SEPTICEMIA, PYAEMIA,  SEPTICO-PYAEMIA.            00

tococcus pyogenes, which grows in chains of four, ten, or more mem-
bers.   The streptococcus has a much greater tendency to spread and
to give rise to extensive phlegmonous processes.
   The various micro-organisms or their products, sometimes both,
   Fig. 76.— Pus from an acute abscess: a, pus corpuscles; b, diplococcus; c, streptococci; d, set
of four, tetrads (Woodhead and Hare).


are introduced through breaks of the surface, wounds (parturient or
puerperal uterus, etc.), or upon the heels of other micro-organisms in
   Fig. 77.—Septic infection of pectoral muscle after a " post-mortem " wound of the hand : a,
perimysium with streptococci; b, cross section of unaffected muscle fibre ; c, cross section of af-
fected fibre ; d, fibre penetrated by streptococci.


the course of specific disease, tuberculosis, variola, dysentery, to cause

a mixed infection or constitute the terminal link in the chain of disease

process. 
TO           SEPTICAEMIA, PYEMIA,  SEPTICO-PYEMIA.

   Sometimes the avenue of entrance may not be seen or discovered.
Poisonous matter may be introduced from the lungs,  intestine, or
other recess,  to give rise, in light cases, to the symptoms of a  " bad
cold," dyspepsia, or rheumatism, or in bad cases to a pleuritis, ulce-
rative endocarditis, etc.  A searching investigation  will sometimes
discover the source of such infection at the  prostatic urethra, ileo-
cecal valve, interior  or  adnexa of  the uterus  (salpingitis), etc.
Certain cases defy detection.  These cases of  concealed  origin are
very  appropriately called cryptogenetic sepsis—a term much more
conducive to inquiry than "idiopathic" or  "spontaneous," which
rest upon entirely false conceptions.
   Symptoms.—The disease, considered as a septico-pyaemia, is ush-
ered in  suddenly in the course of puerperium,  after a traumatism,
                             operation, or in  the midst of appa-
                             rent health, with a chill or series of
                             chills, followed by  high fever,  head-
                             ache,  vertigo, perhaps vomiting, and
                             usually with well-marked nervous de-
                             pression.  The patient soon complains
                             of pain in  the region of the joints,
                             which are sometimes swollen and ten-
                             der.  The spleen  swells early.  Some-
                             times there is icterus in light form from
                             duodenal catarrh, in rarer (hematoge-
                             nic) form from dissolutio sanguinis.
    FiG.78.-Temperatureinafatal    Tne  fever  ig continuOUS, Subject  to
         case of sepsis.              .                    '   .
                             remissions, usually with evening exa-
cerbation, with  no distinct periodicity,  but  with periods of great
elevation (106° F.)  followed by profuse sweats.  The surface is cold
and clammy.  The hectic and night sweats of tuberculosis are really
septic.  The pulse  is enormously quickened, is soon irregular and
reduced in force.   The patient falls  into a typhoid state, with low,
muttering delirium.  Metastatic affection  shows  itself—in the skin
as scarlatiniform rashes,  herpes, pustules,  pemphigus, petechiae, or
larger haemorrhage, abscesses; in the eyes as haemorrhage of the
retina,  irido-choroiditis, panophthalmia;  in  the heart in irregular
action, bruits mostly mitral, friction sounds of pericarditis, dyspnoea ;
in the kidneys as  albuminuria, haematuria,  casts; in the brain as
embolic deposits, abscess,  and haemorrhage.
   Diagnosis.—The disease must be differentiated from : 1. Typhoid
fever, which has in common with it fever, diarrhoea, spleen tumor, and
petechiae.   Typhoid fever begins more  slowly,  is  attended  with
mental dulness from the start; the fever  is more typical.  Herpes,
joint affections, mitral lesions, retinal haemorrhage, do not belong to
 
SEPTICEMIA, PYEMIA, SEPTICO-PYEMIA.          71
 typhoid fever.   2. Miliary tuberculosis, in  which may be often dis-
 covered a local  depot of tuberculosis in the lungs, lymph glands,
 spine, hip, etc.   Meningeal tuberculosis  is usually preceded by evi-
 dence of local infection in the way of bronchial and intestinal catarrh.
 3. From rheumatism, which has in common sweats and affection of the
 joints, but which has not successive chills, metastatic abscesses, affec-
 tions of the skin, eye complication, etc.  4. Cerebro-spinal meningitis
 also occurs suddenly, but prefers winter, soldiers, children, and shows
 with no, or much less, or more irregular fever, hyperaesthesia, opisthot-
 onos, constipation, etc.  5. Malaria shows more distinct fever,  with
 quotidian or tertian periodicity, and is jugulated by quinine, which has
 no real control over pyaemia.   The discovery of the plasmodium  in
 the blood of malaria, as well as of the typhoid bacillus in the spleen
 of typhoid fever, has already cleared up doubtful cases.   Ulcerative
 endocarditis is itself evidence of septico-pyaemia.
   The prognosis is always  grave, though it varies according to the
 range of the disease.   Light cases readily recover.   High fever, pro-
 fuse  sweats,  severe  nervous signs  are  always grave.   Metastatic
 deposits are ominous, though not  of necessity fatal.  Recovery has
 occurred even after affection of the eye.   In every severe case recov-
 ery is tedious and protracted.
   Treatment.—Prevention  is easier than cure.  Modern methods of
 asepsis shut out entrance of pus micro-organisms to large extent and
 thus  at least  prevent the epidemics  of former times.  Prophylaxis
 pays scrupulous regard  to  dressings, instruments,  personnel, etc.
 Depots of infection are excised  or laid open  and washed out.  Mem-
 bers  may require amputation, the interior of the  uterus curetting.
 Wounds are  dressed with antiseptics—sublimate  solutions one per
 cent, carbolic acid five per cent.  Rutter recommends:
     B Iodoform................................................1 part.
       Ether.............................................2 parts.
       Alcohol  ...................................... ........8 parts.
    M.
 as a  disinfectant wash, to be applied thoroughly  into every crevice
 and  recess of  a wound.   The  actual cautery,  Paquelin's  thermo-
 cautery, galvano-cautery, furnish  at times  the finest results.  In
cryptogenetic  cases everything  depends upon the  discovery of  and
destruction of the cause. A  slow sepsis of months' duration has
been stopped at once by the deep urethral injection with the Ultzmann
catheter of a  strong  solution of nitrate of silver,  gr. xx.-§i.;  and
dangerous  signs  have disappeared  after extirpation of a  diseased
ovary, after a laparotomy, trephining a mastoid process, etc.
   Drugs can  do but little.  Quinine in round dose, gr. v. every two
to four hours, may help a simple case.   The  antipyretics are not 
72
ERYSIPELAS.
much indicated in  the treatment of a long fever whose cause is un-
discoverable or ineradicable.  The body may be saturated with sub-
limate, small doses frequently repeated, one thirty-second grain every
hour  or two, or with creosote thirty or forty drops a day, as in the
treatment of tuberculosis.  It may become necessary to  give opium
to relieve pain or secure sleep.   The only real address to the cause of
the disease is in the exhibition of  alcohol in the form of whiskey or
brandy in large and frequently repeated doses.   It  is difficult to get
the toxic effect of alcohol in a case of septicaemia.  Alcohol feeds the
body, lowers the temperature, and, to what extent it may, neutralizes
the ferments and toxines of  septicaemia.  When the patient can no
longer take alcohol the outlook is bad.

                          ERYSIPELAS.

    Erysipelas   (epvoo,  to draw;   synonym,  eXuco,  e'XnoS,  wound;
Latin, ulcus, ulcer; 7r£XaS, near;  Latin, prope ab  aliquo loco, i.e.,
to spread; also, ipvdponeXaS, epvffoi, epvdpoS; Latin,  ruber, red;
neXXa, pellicle,' skin, vide  Stephanus, " Thesaurus  linguae Graecae";
whence in the  sixteenth century the German Rothlauf, Rose, Miaid-
rose).—A specific acute infection of the surface of  the body, always
of local origin, and implying always a present or previous break of
the surface, caused by the Streptococcus erysipelatis, marked  by in-
tense inflammation (pain,  heat, redness,  and swelling), high fever,
gastric and nervous distress,  a  tendency to spread,  and a liability to
mixed infection (suppuration, phlegmon,  gangrene), short duration,
and in uncomplicated cases a restitutio ad integrum.
    History.—Erysipelas  received  its  name  in the  most remote an-
tiquity, and was, in the earliest history of medicine, associated with
wounds of the surface.  Yet this association was  not considered a
necessity in ancient times.  Hippocrates recognized an idiopathic as
well  as a traumatic erysipelas—a  distinction which found advocates
up to the  most recent times.  This  so-called  erysipelas verum, s.
spontaneum,  the medical, as distinguished from the erysipelas spu-
rium, s.  traumaticum, or surgical form, was in the humoral pathol-
ogy an inflammation of the skin  excited  by the escape of -' peccant
matter" in the  blood.   Although Hippocrates and his followers
included under the term many processes,  suppurative, phlegmonous,
gangrenous, etc., which we now consider  complications, he had,
nevertheless, a clear idea of the character of the disease.   '' In many
cases," he  says ("Epidemics," book hi., 4),  "erysipelas, from some
obvious  cause,  such  as an  accident, and sometimes  from  a very
small wound,  broke out all over  the body . .  . great inflammation
took  place, and the inflammation quickly spread all over .  . .  but 
                          ERYSIPELAS.                         73

these things were more formidable in appearance than dangerous, for
when the concoction turned to a suppuration most of them recovered."
   The first vague  intimation of the true  cause of erysipelas is due
to the penetrating insight of Henle (184.0), the real pioneer of para-
sitism, who maintained that it was introduced by the invasion of the
lowest forms of vegetable growth, which were invisible because they
could not be distinguished from tissue cells; but the first distinct
clinical exposition of the mode of origin  of the  disease belongs to
Trousseau (1848), who insisted that even the medical, so-called non-
traumatic cases '' have almost always a starting point, which, though
it cannot, strictly speaking, be called a wound, is at least a lesion, a
small lesion of the integument at some point on the face [or else-
where], such as the corner of the eye, the nose, the lips, behind the
Fig. 79.—E^j -M' las cocci in the cutis (Eichhorst).
ear, or on  the hairy scalp."  Specific micro-organisms had  been
claimed as the cause of erysipelas by Nepveu (1870), Hueter, Billroth
and Ehrlich, Klebs, Orth, Tillmans and Wolff (1880), for the  most
part in the blood, but were first definitely discovered in the skin  by
Koch (1881), who observed them as chain-forming cocci, streptococci,
exclusively  in  the lymph vessels and  adjoining lymph spaces, but
never in the blood vessels.  Fehleisen (1881), independently of Koch,
made the same discovery, and by isolating, cultivating, and inocu-
lating the micro-organism in man for  therapeutic  purposes, as well
as in the lower animals, confirmed  his conclusions and established
for all time the nature of the disease.
   Etiology.—The erysipelas coccus develops in serpentine form, as
a  bead or  chain coccus, whose individual members, though  very
small, vary somewhat in size.  It thrives in all kinds of culture  soils,
gelatin, agar, blood serum, milk bouillon, as well as upon the surface
of the potato ; with and without oxygen equally well; best at a tern- 
74
ERYSIPELAS.
 perature of 30° to 37° C but also at room temperature if not too low.
 It differs in no visible way from the pus streptococcus (Streptococcus
 P3Togenes).   Whether or not it is the same organism remains as yet
 an open question.  Should it prove  to be so,  the suppurative and
 phlegmonous processes  so  often observed in erysipelas  would be ex-
 plained by invasion of structures—viz., the loose subcutaneous tissue
 —which offer less resistance than the  skin.  It is  found in greatest
 abundance in  the zone  of tissue just beyond the  region of  deepest
 redness, still uncolored by the inflammatory process.  The lymph
 vessels and spaces of the skin, and later of the subcutaneous connec-
 tive  and fatty tissues,  are crowded  to occlusion  and distention by
 quickly  multiplying streptococci,  which have  disappeared already
 from the visible zone of inflammation,  either by reason  of  the  short
 life of the organism or of consumption (incorporation) by the tissue
 cells and phagocytes, and not on account of  the high fever they ex-
                                   cite, as they continue to develop
                                   at 40°  C, but with  difficulty at
                                   43°  C, to perish in  twenty-four
                                   hours at 48°  C.  (118° F.).  'They
   ^^^^g^s^^^^i^-^si.---"     seem  to  perish rapidly  in  the
                            ~~-    blood, as they  are not  found in
  Fig. 80._Streptococcus erysipelatis : colony in   the blood vegsels  though the pos-
 a lymph vessel, ear of rabbit, two days after in-                     .  .
 ocuiation(Ziegier).                      sibility of metastasis in this way
                                   is  proven by exceptional cases of
 intra-uterine (fetal)  infection.   Lebemeff  found them in a section of
 skin of a child dead of the disease ten minutes  after birth.  Though
 Eiselsberg and Emmerich collected them from the air of surgical
 wards and operating rooms, as disseminated from particles of des-
 quamated skin, there is reason to rank the erysipelas coccus with the
 class of saprophytes, as similar cocci are discovered  in various decom-
 posing matters, so that the parasitism of man is an accidental inva-
 sion.   Hajek claims that the body of man is not  a very favorable soil
 for the growth of the erysipelas coccus, inasmuch as it is carried only
 by the lymph vessels, whereas the coccus of pus (phlegmon) develops,
 independently of lymph vessels, in every direction.  Brieger and Was-
 herman dialyzed from the urine of a patient affected with consecutive
 nephritis a toxalbumin fatal to mice and guinea pigs.  With resolu-
 tion of the erysipelas and nephritis the urine ceased to be poisonous.
   Age,  sex, season, soil, have no influence in the  production of the
disease,  which owes its origin exclusively to a specific cause, and
which, once established in a house  or institution, may develop upon
the surface of any, even the most trivial, break of the surface—mere
abrasions, leech bites, old granulations,  slight fissures, etc.—in a sus-
ceptible individual.   Vaccination had to be suspended in Boston in
1851  on account of the frequency of erysipelas infection—an accident 
ERYSIPELAS.
75
 put beyond  the suspicion of a mere sequence in the experience of
 Doepp, who infected every one of nine children by the use of lymph
 from a child that showed erysipelas on the following day.
    The erysipelas streptococcus has no power of attacking or dissolv-
 ing sound skin, but may easily penetrate the delicate connective tis-
 sue which constitutes a new cicatrix.   Konig  found in  nineteen of
 thirty-six cases of  " spontaneous " erysipelas a sligh't injury, which
 could not be recognized in the  rest on account of the great swelling
 of the affected tissues ;  and Volkmann declares that scarcely an ex-
 ception can  be found where " idiopathic " erysipelas does not start
 from a wound, as  from a scratched pustule or some such break.
 Auto-infection with the  finger nails is an interesting illustration of
 this point.  A medical student, under the observation of  the author,
 affected with erysipelas of the face, reinfected himself in the leg by
 scratching, and quickly  succumbed to the double infection.  Here,
 too, it must not be forgotten that light lesions, visible points of pre-
 vious infection, may be healed to leave no trace in twenty-four hours.
    The disease  spreads for the most  part by direct contagion {i.e.,
 from bed to  bed in a hospital ward), and remains thus  confined to
 closed apartments—hospitals,  prisons,  ships, etc.  In St. Bartholo-
 mew's it spread by attacking the nearest  patient with an open wound.
 In the Berlin  Charite erysipelas was confined, on one occasion, to the
 various occupants of certain beds directly over a defective privy pipe,
 the repair of which put  a stop to the disease.   Radcliffe discovered
 and removed a similar  cause of erysipelas in Oxford,  in 1874, in
 choked sewer pipes.   A still more instructive case occurred in  the
 Middlesex Hospital, where erysipelas was strictly  confined to two
 beds, successive occupants being invariably attacked ;  with the re-
 pair of a flaw in a privy pipe,  finally  discovered in the adjoining
 wall, the disease disappeared for a  time, to return in the same way
 after the lapse of ten years.  Mindful of former experience, the pipe
 was again examined and again found defective ; on mending it no
 new case occurred (Zuelzer).   Goodfellow reports a successive attack
 of every patient in  a ward of thirteen beds, the disease  going regu-
 larly down one side and  up the other.
   Erysipelas thus rarely assumes epidemic proportions and seldom
 spreads over an entire community.  Yet the germ may be conveyed
 by  third persons or things,  as by clothing, bedding, instruments,
 utensils, and  cases of apparently spontaneous origin find explanation
 in this way.   Thus, in a light epidemic  at Rostock, Konig observed
that the disease was confined to patients operated on in the amphi-
theatre, and the cause was finally located in  some blood-saturated
pillows, the substitution  of which by clean pillows ended the cases.
A rabbit  inoculated with an aqueous infusion of these pillows was
affected with a diffuse dermatitis whichjasted twelve days. 
70
ERYSIPELAS.
   Overcrowding in hospitals, as during the existence  of other epi-
demics  or  during  war,  furnishes  the conditions which favor the
spread of the  disease.  This was so often the case in our civil war
"that it was frequently deemed desirable to establish 'erysipelas
wards' for  the isolation and better  treatment of those affected"
(Woodward).   Yet in all cases the specific cause must be first intro-
duced.  Thus, Calmeil relates that the Paris hospitals were  crowded
with  patients affected with  erysipelas in 1828 ; Schonlein observed
an extensive epidemic in the hospital at Zurich in 1836 ;  Gintrac de-
scribed a similar occurrence at Bordeaux in 1844, where every inci-
sion, cauterization,  vesication, or venesection served as  the  starting
point for an attack ;  Trousseau remarked  upon the coincidence of
puerperal fever in  the Paris  Maternite in 1858 with grave erysipe-
las in the surgical division.  In this connection it may be mentioned
that Doyen (Rheims) declares  that he was not able to discover a
streptococcus among  the micro-organisms of the vagina, so that it
must be always  carried to the uterus by hands, instruments, etc.
But while pyaemia  and gangrene were very  frequent,  erysipelas was
almost unknown during the  Crimean  war, and Volkmann did not
see  a single  well-marked case in Tratenau and other hospitals in 186(5,
where about one thousand wounded  were quartered.   And  while
the disease was very  infrequent  in quickly established and necessa-
rily badly kept lazarettos in France, it attacked fully two per cent of
the wounded in the "  well-situated" hospitals of Berlin.
   The period of incubation is very short—but one or  two days as a
rule; exceptionally, according to Heiberg,  the temperature rose in
the Rostock epidemic in two hours after a surgical incision.   One
invasion is said to rather predispose to  than prevent  subsequent at-
tacks, though most cases of  so-called habitual  erysipelas are mere
erythemas, simple dermatitis,  carbuncles, drug eruptions, etc.
   Symptoms.—Erysipelas is usually introduced by a chill  or series
of chills,  with  malaise, anorexia, nausea,  sometimes vomiting,
headache, sometimes  delirium, scanty urine, hot, dry skin, and fever
in vaiying degrees  of intensity.  The  temperature  rises rapidly to
102° to 105° F., to fall in three to five days, or reascend later with
each new extension of the disease.   The general symptoms are due
to the development  of a  chemical poison, toxine, since the strepto-
coccus does  not enter  the blood.
   The eruption or local manifestation shows itself most commonly
about the face (in  twenty-eight  of forty-two cases—Heyf elder), on
account of its greater exposure.   The  region of the nose is the most
frequent starting point; nose twelve, ear six, eyelids five, scalp five,
etc.   And this predilection for the  face is observed  even  though 
ERYSIPELAS.
77
L=S=I
 wounds of the extremities  are  twice as frequent (Billroth)—a fact
 which of itself demonstrates outside infection.
    The eruption appears as  a rose-red flush, which rapidly spreads
 from the part affected like red  ink over blotting paper.  The skin is
 swollen, glazed, and oedematous; pits hence on pressure, and burns
 as if scorched by fire.
    If the nose be the starting  point, the disease spreads toward the
 lips, ear, forehead, scalp, nucha, but not downward over the chin.
 Commencing elsewhere, as  at the back  of the neck or scalp, it pur-
 sues a reverse course, but  still respects the chin.   From the breasts
 it extends toward the axilla and over the  chest,  but  does not pass
 down over the xyphoid cartilage.  The germ follows the rhombic
 meshwork of the skin (as indicated by the lines of tension or elonga-
 tion after a circular punch), along which the lymph vessels course,
 and meets with obstacles where these lines cross,
 as at the chin and ensiform cartilage, or where
 the skin is bound down to bone or subcutaneous HJQ3BBQJBJ Iflj
 tendons.   Visible tongue-like  or dendritic pro- |
 longations may reveal its progress in this way
 up to adjoining lymph  glands, which show in-
 vasion by tenderness and swelling ;  or wall-like
 indurations may indicate its advance en masse,
 erysipelas  marginatum.  Vesicles,   always
 visible with a lens, and blebs frequently form
 on the affected  surface.  Barring  exceptional   Fro.  si. — Temperature
 cases (erysipelas fixum),  the  disease  does not if^lmcZ^1^'
 last longer than four days in  one locality, though
 previously affected regions may be revisited as a result of  reinfec-
 tion. More widely or rapidly advancing cases constitute erysipelas
 migrans, s.  ambulans, s.  serpens.  Vaccinal erysipelas in a feeble
 child may thus spread over the whole body in less than a week.
   The deep discoloration,  more  especially the great swelling, oede-
 matous infiltration, of the parts affected, produce deformities quite
 characteristic of the disease.  The  eyelids are puffed to complete
 closure, the nares blocked, the  ears bloated, the lips protuberant, the
 face seems a shapeless mass or  repulsive mask like that shown in
 small-pox.  Drops of sticky  serum ooze out upon the glazed  surface
 from ruptured blebs, to add to  the picture of distress.   Infiltration
 of the scalp gives it a doughy  sensation to the touch, lifts  it from
 the cranium, or  interferes  to such extent with the nutrition of the
 hair as to cause it to fall—defluvium capillitii—to  be restored, how-
 ever, in all cases with the  subsidence  of the disease.   The back  of
 the neck  may present the appearance and give the discomfort of a
huge carbuncle.
 
IS;
i o
ERVSIPELAS.
   At this time, during the height of the disease, there is  always
more or less delirium, muttering, insomnia,  or more  frequently
somnolence and coma, more rarelj^ mania, especially at night.  The
tongue is heaviby coated, fuliginous ; the spleen is swollen; the bow-
els constipated ; the urine scanty, and albuminous from fever ; and
complications of various kinds, some of great gravity, are liable to
ensue.   But just at this time, as  a rule about the fourth  or fifth day
of the disease, when the gravest apprehensions are being entertained,
resolution sets in, occasionally with epistaxis or herpes, more rarely
with suppuration,  with fall of temperature, subsidence of swelling,
frequently with desquamation of  the skin, and in an incredibly short
time there is restitutio ad integrum—i.e., to leave no trace of pre-
vious affection.   And so, ''as if by magic, a hideous monster  was
metamorphosed into a comely damsel" (Watson).   The disease lasts
usually three to ten days.
   Erysipelas is not confined to the outside skin.   It may originate
in or subsequently invade also the various mucosae, to produce the
same changes as in the skin.  Gerhardt thinks it questionable  that
we should regard all internal affections occurring during the  course
of erysipelas as directly caused by the disease, though he admits the
possibility of an intimate connection with pericarditis.   Diseases of
the mucosae by extension from the skin  or from border lines would
seem to admit of no other explanation.   So also subsequent exten-
sion from the mucosae to the skin, with typical manifestations in the
skin, furnish evidence satisfactory to diagnosis.   Thus, to quote one
case from a now crowded literature, Wells reports an erysipelas fau-
cium, characterized by fever, thirst, headache, swollen glands in the
neck, pharyngeal oedema and redness, with phlyctenular, subsequent
invasion of the nose, and in forty-eight hours of the face, with typi-
cal signs,  and final recovery.  Pozzi speaks of erysipelas of the nose,
ear  ducts, external auditory canal, drum cavity, and  Eustachian
tube.  Cordone remarks  that hitherto pharyngeal erysipelas has been
considered secondary because of the absence of proof of primary af-
fection by bacterioscopic  examination.   This proof he claims to have
furnished in four  cases  of what  he calls "unconditional" erysipe-
las.  In all these cases  fluid withdrawn from phlyctenular in the
throat by a  sterilized syringe furnished, among other micro-organ-
isms, Fehleisen's streptococcus, as demonstrated by subsequent culti-
vation and inoculation experiments.   The pharynx offers a favorable
nidus for  erysipelas, he  says, because of the richness of its lymph
plexus.   Thus in  the throat erysipelas may simulate diphtheria or
scarlet fever, the deeply  reddened surface becoming swollen, tense,
and  oedematous ; in the larynx it may assume the sudden gravity of
oedema of the glottis.  The vagina is less frequently  involved, but 
ERYSIPELAS.
79
 the coincidence of erysipelas with puerperal fever, already noticed,
 shows involvement also of the uterine mucosa.
    Complications.—Abscess of the skin, gangrene, bronchitis, pneu-
 monia ; more rarely, oedema of the glottis ;  more frequently,  endo-
 carditis,  pericarditis, meningitis; icterus, dysentery ; more rarely,
 enterorrhagia, ulcer of the duodenum, peritonitis; according to Hart-
 mann certain cases of " spontaneous peritonitis are caused by the
 erysipelas coccus " ; nephritis ;  Cerne claims to have found the strep-
 tococcus in the urine ;  affections of the joints ;  exceptionally paroti-
 tis, keratitis, amaurosis, panophthalmitis ; paralysis.
    Diagnosis.—Erysipelas is written upon the surface in its intense
 redness and swelling, origin about a wound, characteristic deform-
 ity, f'ifjuvity, and restitutio ad integrum, together with the con-
 stitutional  distress  and  complications.   It is distinguished from
 erythema  by the more tense, glazed, and oedematous condition of
 the skin, arising about a  broken surface, by  its more strict locali-
 zation, blebs, indurated  margins,  fever, with other signs of  toxae-
 mia which do not belong to erythema.  Erythema nodosum, though
 associated with fever and often with gastric distress, is recognized
 by its nodosities, especially about the joints.  Drug eruptions after
 the antipyretics, copaiba, etc., have a history, less severe local, and
 no constitutional signs.   Malignant pustule (milzbrand) and malig-
 nant oedema, rare affections, show characteristic bacilli; erysipelas,
 characteristic micrococci.
    Prognosis.—The prognosis is favorable as a rule, for, as observed
 by Hippocrates, the disease is more " formidable in appearance than
 reality."  The occurrence  of suppuration, which is comparatively
 rare, and is certainly indicative of mixed infection, does not aggra-
 vate it greatly.   '' Verum  ac legitimum erysipelas raro terminatur
 suppuratione, sed magna ex parte insensibili transpiratione seu reso-
 lutione" (Vidus).  Previous  debility reduces the rate of recovery,
 and symptoms  on the part  of  the nervous system are especially
 threatening.   Rapid spread, undue  protraction, reinfection, relapses,
 complications, gravely affect the natural  tendency to resolution.
   Prophylaxis is difficult on account of the extreme tenacity of the
 streptococcus, which  fixes itself to walls, carpets, curtains, bedding,
 almost  ineradicably.   Ferraro propagated erysipelas from strepto-
 cocci  kept dried  on  a silk thread fifty-two days.  Walls should be
 rubbed down with bread; furniture disinfected by long ventilation in
 the open air ; rooms flushed with  fresh air day and night ; floors
 scrubbed with corrosive sublimate ;  bedding, clothing, etc., subjected
 to steam heat or destroyed by  fire;  patients isolated  as much as
may be.  Attendants should  not wear woollen clothes.  Above all
things,  instruments, best wrapped  in towels, should be placed in 
80
ERYSIPELAS.
boiling water for five to ten minutes, and utensils thoroughly scalded
out.
   Treatment.—The treatment of erysipelas is  based upon attempts
to destroy or limit the extension of the  streptococcus, and to support
the patient during the progress  of  the  disease.    Fehleisen found
that thin layers of the streptococcus perished in a one-per-cent  solu-
tion of carbolic acid  in forty-five seconds.   Gartner  and Plagge de-
clare that cocci cultivated in bouillon  feel the  deleterious  influence
of a three-per-cent solution of carbolic acid  in eight to eleven sec-
onds.  Hartmann observed all streptococci, wet or dry, perish under
five to ten minutes' exposure to undiluted  liquor ferri sesquichloridi,
which absolutely destroys those on the surface, but only  limits or
checks the development of those deeper in the tissues.  These  facts
furnished by the bacteriologist  give  the clue to the scientific treat-
ment of the disease,  as well as explain the failure of specific treat-
ment hitherto.
   Mild cases require no treatment beyond wet  compresses  or inunc-
tions to relieve the heat and tension of  the surface.   More severe or
rapidly spreading invasions may be attacked  by aiitimycotic agents,
at the head of which stand  the agents mentioned.   External appli-
cations are obviously useless.  The fact that so many practitioners
of the " school of experience " possess specific applications, each dif-
ferent from the rest, is patent proof of the inefficiency of all of them.
Scientific  disproof of such  specificness  is offered  in the  report of
Polotebrow (1888), of St. Petersburg, who made parallel observa-
tions  in  sixty cases, thirty of which were treated  with cold-water
compresses alone and thirty with energetic applications of  nitrate of
silver—4:30—over the affected surface  and two  or three fingers*
breadth beyond it, without influence  on  the temperature, nervous
symptoms, albuminuria, or  other complications, and without appre-
ciable difference in the duration or mortality, which was one in each
set of cases.   Hueter first employed carbolic acid  subcutaneously,
introducing the  agent beyond the limit  of  invasion.   This  treat-
ment, which is admirably adapted to the trunk or extremities, is
impracticable about  the  face or  scalp.   Bogusch  recommends the
subcutaneous injection of resorcin 1.5:30 aqua destillata; Cattani,
the application  of the same agent, two-  or three-per-cent solution,
every  two hours, externally by  means of a brush or saturated cot-
ton, together with its internal administration (4 : 6)  in water, barley
water, or red  wine.  Hiicker advises the painting of  the  surface
with  cocaine  in  relief  of pain.   Hofmokl applies  compresses of  a
three- to  five-per-cent  solution of carbolic acid, and covers  them
with some material impervious to water.  Lovanz paints the surface
repeatedly with  a mixture  of ichthyol twenty, glycerin and ether 
ANTHRAX.
81
 each ten.  Duckworth uses  an ointment of equal parts of chalk and
 melted fat.   Barwell applies white lead as quickly and as thickly as
 possible.  The Berlin Charite paints  the surface with a concentrated
 solution of carbonate of lead in glycerin, and covers it all  in with
 cotton.   Popoff applies with  a brush  trichlorphenol, five-per-cent
 solution, in glycerin.  Winiwarter claims to check the spread of ery-
 sipelas migrans as follows :  The affected surface is washed, or, if the
 extremities,  bathed, in a three-per-cent solution of  corrosive subli-
 mate.   Next is applied to it. and to two fingers' breadth beyond it, a
 thick  layer of tar, which is now covered in.   The  covered  surface
 becomes macerated  in a few days, and is next redressed with subli-
 mate water in but one-per-cent solution, which thus checks the fur-
 ther advance of the disease.  Much more radical treatment is  prac-
 tised by  Kraske, who makes  multiple punctate  scarifications and
 small incisions one centimetre long through the corium, and in places
 through the whole  skin, washes  over and rubs into  the surface a
 five-per-cent  solution, and covers  it all in with compresses saturated
 with a two-and-one-half-per-cent solution of carbolic acid.
    A recent remedy, highly lauded, is :
    B.  Iodoformi,
       Creolini...............................  ..............aa gr. xv,
       Unguenti petrolati ........................................z ss-
       Lanolini..................................................§ iss.
    M.  Apply with a brush.
    The use of this preparation is said to check fever and stop  the
 spread of the  disease after three applications.   Wolfler claims to
 have cut short fifty-eight of sixty cases by strapping the  surface
 with adhesive plaster.
    The real value of any or all of these remedies remains to be tested
 by  time.  They seem at present to  show  the direction of modern
 therapy as determined by etiological discovery.
    Few practitioners will now maintain  a specific action for  any in-
 ternal  remedy, though none will deny the necessity of sustentation of
 the patient by alcohol, if necessary, until the disease shall have run
 its  course.
    The natural tendency of the disease to resolution in the course of
 a few days makes it difficult to decide whether  any " cure" be due
 to Nature or  to art.
   It is wise  to keep  the bowels open with calomel  and  Carlsbad
salts, to  allay nausea and vomiting with small doses of chloral, gr.
ii.-v.  in  peppermint water.   Here, as everywhere,  "ubi  pus,  ibi
 iucisio."
                            ANTHRAX.
   Anthrax (civdpaS,  coal)  ; carbuncle ; malignant pustule ;  splenic
        6 
8'2
ANTHRAX.
fever;  German, ]\[ilzl>rand;  French,  charbon.—An  exquisitely
acute, often fatal infection, caused by the Bacillus anthracis ; charac-
terized by the formation of a boil  with a black centre (anthrax), ex-
tensive circumjacent infiltration, and subsequent sepsis ; in internal
form by rapid toxaemia and the development of metastatic carbun-
cles in the skin.
   History.—Anthrax existed in  the most remote antiquity.  It is
recognized that most of  the fatal  plagues which chiefly affected ani-
mals, and not infrequently men, correspond to the  symptomatology
of anthrax.   The plague  of murrain with boils and blains, on man
and  beast, mentioned  in Genesis, is believed to have been anthrax
(Blanc).
   The  Bacillus  anthracis (Pollender, 1855)  is  famous  as the first
                               micro-organism discovered as  the
                               actual cause  of an  infectious dis-
                               ease.  It is the longest known and
                               best studied of all  the micro-organ-
                               isms.
                                   Etiology.—The milzbrand  ba-
                               cillus is a motionless rod of elon-
                               gated, jointed cells, 0.005  to 0.0125
                               mm.  in length—i.e.,  two  to  ten
                               times as long  as  a  red blood cor-
                               puscle—0.001 to 0.0015  mm. broad.
                                Under proper conditions it forms in
                               the culture soil, but never inside of
                               the body or tissues of the living ani-
  Fig. 82.—Anthrax bacillus, with and without     ■,     -,                   -,->,
spores, from spleen (Woodhead and Hare).  maL endogenous  spores.    Decom-
                               position, the action  of the gastric ■
juice, quickly destroy  the  bacilli,  but fail to attack the spores.  The
ingestion of meat free of  spores produces no  infection.   The inges-
tion of  meat with  spores  infects  infallibly.  In San Domingo (1770)
fifteen thousand persons perished  in six weeks from eating  the bodies
of animals  dead  of the disease.  Freezing affects neither  the bacilli
nor the spores.
   Anthrax infects chiefly herbivora, next omnivora, least  carnivora,
man as an omnivorous animal.  The disease is therefore not quite so
dangerous in man as in some other animals.  The Bacillus anthracis
is a saprophyte.  It goes through with all its phases of development
outside,  and makes only accidental  incursion into, the body of man.
Martin  succeeded in extracting from cultures certain chemical  pro-
ducts :   first,  proto- and  deutero-albumose ;  second,  an alkaloid;
third, small quantities of leucin and tyrosin.   Mice injected with the
proto- and deutero-albumose were affected with oedema at the place
 
ANTHRAX.
83
of injection, and with a sufficient quantity (0.3 gramme for a mouse
weighing 22 grammes) they were killed.  Similar symptoms were
produced with the alkaloid (0.1 gramme fatal to a  mouse weigh-
ing  15  grammes).   Hankin also found  an albumose which he in-
jected in prophylaxis against the disease.   Anthrax is  peculiarly
malignant in small animals.   It is so surely and quickl}' fatal to
mice, guinea-pigs, and rabbits  as to make their bodies the best phy-
siological tests in cases of doubt as to the nature of a micro-organ-
ism.
   Anthrax is usually conveyed  to man  by contact with a diseased
animal  or by the ingestion of its flesh as food.   Individuals most
closely  connected with cattle are chiefly affected—butchers, stable
boys, shepherds, veterinary physicians, etc.  On account of the great
tenacity of the spores, people who come in contact at any time with the
skins, hairs, bristles, cloths, horns, hoofs—as tanners, brushmakers,
upholsterers (horse-hair),  wool  sorters, rag sorters,  glue makers, etc.
—may be affected through open wounds in the skin or through in-
halation of dust.
   Since  Bollinger demonstrated the bacillus in the stomach of car-
nivorous flies, and with Raimbert and Davaine produced the disease
by inoculation with the stomach, legs, and feelers of these insects, it
must be admitted that malignant pustule may be conveyed by in-
sects.  It had long been remarked that  malignant pustule occurs
more especially on the  exposed parts of the body—face,  hands.
Bell, of Brooklyn, found  fifty-six of sixty cases on the face, two on
the hands, one on the wrist, and one on the forearm.  It was avident
that the bite of a  fly or  mosquito had often originated the disease.
Extensive epidemics have been caused, as stated, by the ingestion of
raw or insufficiently cooked flesh.  Animals rarely contract the dis-
ease from each other ; they get it  from the soil.   It has often been
observed that certain regions are centres of infection where  the dis-
ease shows itself year after year.   The superficial burial of carcases
leads to infection of the soil, which, once produced, is seldom eradi-
cated.   The disease is spread chiefly in the warm months of summer,
when the soil is softer, by grazing upon its surface, and is trans-
ported by streams of water which convey infected soil to a distance.
Floods may disseminate the disease to places previously free.  Stable
utensils, fodder, hay from anthrax fields, litter,  harness, surgical
instruments, have been known to convey the disease.   The foetus is
not infected as a rule.  The placenta, when  sound, acts as a filter.
Exceptional cases have been accounted for by lesion of the placenta.
Immunity is not secured by a single attack.
   Symptoms.—The  disease presents  itself  in two distinct forms,
one  as it originates externally, the  other internally.   The external 
S4
ANTHRAX.
disease is the anthrax, malignant pustule, or charbon, Avitb its  le-
sions in the skin and subjacent tissues.  The internal is the intestinal
or thoracic mycosis, which is  recognized by the general signs of
toxaemia, the nature of which  may be, if unsuspected, overlooked.
The external disease is confined to individuals ; the internal may as-
sume, as stated, endemic and epidemic proportions.
   The period of incubation varies from one to several days.   Symp-
toms may show themselves in a few hours  after inoculation.   They
may be delayed as late as four days.   A slight itching, pricl'ling,
or burning sensation is first perceived on the face or neck at the
site of inoculation.   Sometimes  the patient feels as if he had been
just stung b}^an insect.   Very soon appears a  papule with a central
vesicle, the rupture of which discharges bloody contents, to be con-
verted into a dark red-brown or black crust—the anthrax.  Smaller
vesicles may appear about  it.  The  parent  nucleus, as Virchow
called the first eruption, rapidly extends ;  the skin swells about it. be-
comes indurated, livid, and hard.   The subcutaneous tissues are ex-
tensively infiltrated  with serum.   The appearance is  characterized
as a " brawny oedema," which rapidl}T spreads to  involve a mass of
tissue, the whole of one arm or of one side of  the neck, in the course
of a few days.   Lymphangitis and swelling of the lymph glands,
with phlebitis,  are frequent complications.  For the first day or two
there may be no disturbance  of the general health, the patient may
even continue at work ; but toxic signs set in, as a rule,  by the end of
the second day, with delirium.diavrJuea, sweating, vomiting, and
collapse, and so the patient may die of heart failure in five to eight
days.  This result, however, is not so frequent as was formerly sup-
posed.  In the  majority of cases  the local inflammation begins to
abate in the course of a few days.   The anthrax sloughs off and the
subjacent ulcer closes over by granulation.
    A sub-variety  of this condition was first  described by Bollinger
as anthrax oedema.   In this form the local lesion is  absent.  The
poison seems to be introduced more  deeply  into  the tissues, and
chemical products produce an oedematous state of wide range.   This
variety is most  often noticed in the region of the eyelids.
   The internal mycosis announces itself more distinctly as an infec-
tion.  The disease begins suddenly with chill, pain in  the head and
joints, vomiting, and diarrhoea.   The case looks like a poisoning,
which it is.  Free hiemorrhage may occur  from the mouth, nose,
and kidneys.   Nearly always (exceptions by Bonisson)  there is  an
outbreak upon  the skin of small, phlegmonous, carbuncular inflam-
mations, the so-called metastatic carbuncles.  There is usually but
little fever.  There may be much delirium, convulsions, sometimes
opisthotonos.   There is  often precordial  anxiety  and  intense. 
ANTHRAX.
85
dyspnoea.   Cyanosis and heart failure usually precede the termina-
tion, which may occur in the course of a very few days.
   Where  the disease originates  in  the chest  respiration soon be-
comes difficult, though auscultation reveals, as a rule, only the signs
of a light  bronchitis.  Diarrhoea  is usually  absent.  The  nervous
system may be depressed, or so little affected  as to lead patients to
decline  medical advice,  even a few hours before death.  The case
bears the aspect of a rapidly spreading pneumonia with heart fail-
ure.   Most of these cases succumb in  three to five days.  Bell de-
clares that they who survive for a week recover.  This form of the
disease has been observed more especially among the sorters of wool.
Most of the  fatal cases have  been  hitherto  unrecognized.  Bell
thinks that many of the cases diagnosticated  as pneumonia, bron-
chitis, congestion of  the lungs, etc., occurring in factories of carpets,
blankets, furs, etc., are really cases of thoracic anthrax.  It is not
improbable that some of the cases ascribed to poisoning by mush-
rooms, meat ptomaines, etc., are really cases of intestinal anthrax.
   Diagnosis.—Anthrax is  distinguished by its
origin as a red papule with a  dark centre—     NsDf ^Jf] \
"gran   nero''—and its rapid  extension  with   ^|ra/£!#\^\
brawny  oedema.  The black central crust is  ab-  A ,  fa'/jy^JZ'
sent,  and any extensive surrounding inflamma-  \ *^ys " ^ JL  )
tion  is absent, in a common boil or furuncle.   •  "*ir ?■'^->C^
There is a furunculosis of the upper lip which is     ^ \"*''%$
more fatal  than anthrax (Konig).  Carbuncles   FlG-  8-?.-The  anthrax
 .     j,      ,        .       „       ,      ,    bacillus in the blood.
show themselves much  more frequently on the
back of the neck, trunk,  and extremities ; anthrax occurs on  uncov-
ered surfaces.  Anthrax spreads  from one  central point or parent
nucleus; carbuncle  results  from the coalescence of  a  number of
points.   Anthrax oedema, in the absence of a central papule, is dis-
tinguished  by its sudden appearance, its yellow-greenish hue, and
septic symptoms.  Erysipelas is more superficial, has no anthrax or
parent nucleus, and  shows no bacteria in the blood.
   The  diagnosis of intestinal and thoracic  anthrax  is sometimes
reached only by exclusion.  The nature of the avocation, the exposure
to the cause, is the most  common index to the condition.  The sud-
den occurrence, in the midst  of health, of the intense signs of a grave
infection—headache, nausea and vomiting,  dyspnoea, cyanosis, con-
vulsions, free haemorrhages, especially of skin carbuncles—in connec-
tion with the history of exposure, should lead to the recognition of
the disease.  In any  case of doubt the  diagnosis may be established
by the examination of the blood under  the microscope, or by a  phy-
siological test.  A rabbit, guinea-pig, or a mouse shows dyspnoea,
dilatation of the pupils, and convulsions, with death in the course of 
86
ANTHRAX.
two or three days after inoculation.  The  blood of these  animals
then swarms with bacilli.
   The prognosis is  always grave ; that of malignant pustule de-
pends upon the stage of its recognition.  The disease can be always
eradicated at first.   In  places where its  picture  is familiar,  and
where the disease is attacked  at  once, the  mortality is reduced to
five to nine per cent, and even this  mortality is ascribed to delay in
treatment.  Under neglect the mortality may reach fifty to sixty per
cent.   Intestinal and thoracic anthrax, recognized only after general
infection, have always, at least at present, a fatal prognosis.
   Prophylaxis  consists in the proper disposition of the  bodies of
dead  animals by deeper  burial  or  by cremation ; by the  avoidance
of the use of the hides  or  other products of these animals ; by the
destruction of their discharges, as by fire ;  by shutting off  affected
pasture fields, damming  up  streams of water, etc. ; by the abundant
use of disinfectants—carbolic acid, chloride  of  lime, corrosive sub-
limate—in handling suspected wools,  horns, and other products ;  and
by protective inoculation of cattle and sheep with attenuated cultures
or antitoxines—a procedure  the value of which is yet sub jud ice.
   Treatment.—The successful treatment of anthrax depends upon
the energy of  the local  attack.  Deep  crucial  incisions should be
made through the substance of the  mass, and the gaping cuts stuffed
with  carbolic acid fluidified  by heat.  They should be  afterward
dressed with the more dilute solution 1 : 10.  Individual carbuncles
may be excised en masse or excavated with a sharp spoon, where-
upon the base must be treated with powerful caustics—carbolic acid
as stated, corrosive  sublimate, caustic  potash,  etc.  Camera  best
expresses the principle of treatment with the most successful practice
in countries where the condition is most frequently encountered, as
follows : The mass is to be circumscribed  by a deep incision  and
penetrated by  numerous crucial incisions.  Into the bottom of all
these cuts is  to be strewn corrosive sublimate itself, in powder,  0.04
to 0.15.  The liquefaction of the sublimate produces extensive, thor-
oughly penetrating destruction of the entire mass.   Where the  sur-
face is so great as to lead to the fear of poisoning by the sublimate
itself, its action may be modified  and poisoning prevented  by ad-
mixture  with a proportion  of calomel.  Weil first  anaesthetizes the
mass with cocaine, scoops it out, and applies to the wound  dressings
saturated with a  one-per-cent solution of corrosive sublimate.  Con-
tento injects into, under, and about the mass subcutaneously three-
per-cent solutions of carbolic acid.   In the oedematous  form the
whole  infiltrate  must be abundantly scarified  and cut deep down
to the  healthy tissue in  the same  way, and  dressed in solutions  of
iodine and carbolic acid. 
FOOT  AND MOUTH DISEASE.
87
    In the cases of general infection metastatic carbuncles are to be
 treated in the same way,  and the patient supported with brandy or
 subcutaneous injections of ether, camphor, or other analeptic.
    The therapy of internal anthrax is well-nigh hopeless.  Where it
 is known that poisoned meat has been ingested, the stomach should
 be immediately washed out, or a powerful emetic  administered, fol-
 lowed by a purgative dose of castor oil.  For an internal mycosis it
 has been recommended to administer carbolic  acid in dose of three
 to five drops  three  or four times a  day.   It might  be  better to
 saturate the blood with creosote, as in the treatment  of  the sepsis of
 tuberculosis ;  and with alcohol, as in poisoning by  snake bites.   Not
 much hope is to be entertained from either plan.  The hope which
 seemed justified  by the experiments of Fodor regarding protection
 by saturation of the blood with an alkali, has proven futile accord-
 ing to the  subsequent investigations of Chor.  Future success must
 be obtained by means of sozines or antitoxines.  Hankin,  of Cam-
 bridge, finds certain defensive proteids in the serum of the  blood of
 certain  animals.  There is a  protective albuminoid, a non-dialyzable
 globulin insoluble in alcohol and water, in the blood and spleen of
 a rat, which  renders  a  mouse immune against the most virulent
 anthrax.  Kostjurin and  Krainsky reached the conclusion that cer-
 tain toxines from decomposition, introduced at the  proper time into
 the bodies of rabbits affected with anthrax, totally prevent  the  de-
 velopment  of the disease.  Ogata and Jasuhara claim that the blood
 of  animals, dogs, fowl contains a ferment  which, injected  subcu-
 taneously in  but one- or two-drop doses, acts as  a preventive and
 curative remedy.   These  disclosures  of  much  promise have not yet
 been utilized in the treatment of anthrax in man.

                   FOOT AND MOUTH  DISEASE
 Latin,  aphthae  (otTtroo,  to  fasten)  epizooticoe;■ German,  JIaul
 klauenseuche ; French, stomatite aphtliense; Italian, febbre  af-
 tosa.—A mild, acute infection of  the lower animals, especially of
 cattle, sheep, pigs, less frequently of the goat and horse, much more
 rarely of fowl, dogs, cats, evidently caused by a peculiar  micro-
 organism not yet  exactly  defined ; characterized by the formation of
 vesicles  and ulcers in the mucous membrane of the mouth,  with the
 development of eruptions and ulcers in crevices about the feet, some-
 times about the  udder; communicable  to  man for the most part
 through the milk of diseased animals, to appear, with malaise and
 light fever, as vesicles and ulcers in the mouth, of benign course and
 short duration.
   History.—The disease was recognized in animals in antiquity,
but was, in the early history of veterinary medicine, evident!y con- 
8S
FOOT AND  MOUTH DISEASE.
founded with anthrax and actinomycosis.  Hertwig (1S34) established
the contagiousness of the disease by experimenting upon himself and
two other medical men.   They drank daily for four days a quart  of
fresh milk from diseased cows.   Symptoms of fever, headache, dry-
ness and heat in the mouth, and itching in the  hands and fingers
began in  two and lasted  for  five days, at  the end of which time
vesicles appeared in the mouth.  The disease has now, therefore, a
recognized place  in human pathology.  Though benign in its mani-
festation and  course, it is  nevertheless a serious  affection from the
fact that  so many young animals, sucklings, succumb on account
of degradation of the milk.   It is stated that in  many epizootics
as many as seventy-five per cent of  sucking calves perished.  The
disease, once  developed, is  exceedingly  persistent.  Stables remain
infectious for  a long time.  It is  gradually transported along the
lines  of travel, hence along the course of rivers, and with a general
tendency westward, to assume at times very wide range.   Thus  in
the year 1871 seven hundred thousand animals were  attacked  in
England alone, entailing in the same year in France a loss  of thirty
million  francs.  In  1 sc>i»  the  disease  ranged  over nearly  all Eu-
rope.  It makes up for its mildness by its range, and costs a country
more than the malignant  diseases, anthrax, glanders,  and rinder-
pest.
   Etiology.—The infectious  principle, evidently  a micro-organism,
has  not yet been  distinctly isolated.   It is certainly distinctly com-
municable by inoculation.   Nesswitzky (1891)  conveyed it with the
contents of  vesicles and secretions of  ulcers, as well as with milk.
Inoculation failed in the experiments of the  Berlin Health  Office  in
30.3 per cent of cases.  Klein, Siegel, and Schottelius isolated micro-
organisms, but with no other proof of pathogenesis.
   The disease shows itself in the lower animals as  a  mild fever
attended with a catarrhal inflammation of the mucosa of the mouth
and the formation of vesicles and pustules about the feet. The m ilk
of the affected animal is  altered,  in quantity and quality.  It is
reduced often as much as  one-half  in man,  assumes  a yellowish
colostrum-like appearance, and coagulates prematurely.  It has
a  bitter,  nauseating taste and deposits a dark-yellow sediment.
The disease terminates usually in twelve to fourteen days.
   Man is usually affected  through diseased  milk, which retains its
infection even when added to coffee  or when diluted with normal
milk in the proportion of one to ten.  Boiling absolutely  destrojTs the
poison in the milk and renders it perfectly harmless.  It is  doubtful
if the disease may be conveyed by the meat of  diseased animals, but
instances of infection have  been reported from the  ingestion of butter
and  cheese  made from the milk  of  diseased cows.   Infection by 
FOOT  AND MOUTH DISEASE.
89
 direct inoculation, as in milking, is not uncommon in those who have
 the care of diseased animals.
   The chief  interest  in connection with foot and  mouth disease
 occurs in relation  to aphtha, which is declared to be the expression
 of the disease in man.   It has been observed that aphtha prevails in
 children coincidently with outbreaks of the foot and mouth disease in
 cattle.   What lends also especial support to this view is the fact that
 the appearance of the  disease is much the same in man as in the
 animals.
   Symptoms.—The period of incubation in man ranges from three
 to five days.   The disease may begin with chills, or chilly sensations,
 followed by fever, anorexia, and malaise.   Vesides now appear
 upon the inner surface of the lips and tongue.  Along with the
 sense of heat and dryness there  is  difficulty in speaking, cheic-
 ing.  and, swallowing.   The mucous membrane is very much red-
 dened and swollen,  and saliva floivs abundantly.  There is often
 noticed also at this time a vesicular eruption  on  the fingers and
 hands,  sometimes in association with intestinal disturbance.  The
 vesicles upon the fingers are at first small and transparent.  They
 soon increase in size and change in color to show purulent  contents,
 and sometimes closely simulate the eruptions of small-pox.  Cases
 have been reported where the eruption was so extensive as  to cover
 the entire body (Biercher).  Holm saw vesicles on the nipple of the
 breast in a woman who drank daily large quantities  of milk  from
 cows affected with the disease.
   The catarrhal  inflammation  may assume such proportions as to
 constitute an  extensive stomatitis.   Briscoe saw a case in which the
 tongue was so much swollen as  to project more than  an inch  from
 the mouth.
   Prophylaxis includes proper care of the animal regarding pas-
 turage and stables.  Man is  best protected by the ingestion of milk
 from healthy cows, or, if that be impossible, by the thorough boiling
 of milk from diseased cows.
   The  diagnosis is usually easy.   It may be known that the disease
 exists at the time in animals.  The peculiar coincidence of  eruption
 in the mouth and extremities, sparing the  rest of the body, is unlike
 any other eruptive disease.  Thus the mycoses of the mouth are un-
 attended with affections of the feet, and eczemata, etc., of the feet are
 unassociated with  eruptions of the  mouth.
   The prognosis is favorable.   The disease runs a mild course, and
terminates, as  a rule, in from five to eight days.  Extensive affection
of the hands, with the difficulty of  proper protection, may extend the
disease to several  weeks.  Fatal cases have been reported in  very
delicate children. 
90
OLANDEKS,
    Therapy.—Stomatitis is best treated with weak solutions of borax
as mouth washes.  Erosions and ulcers should be cauterized with the
nitrate of silver, which not only protects an  abraded surface from
irritating contact, but also by its antimycotic  properties directly ad-
dresses the cause of the disease.  The superficial lesions of the ex-
tremities may be best treated by lead washes, diachylon ointment,
light bandages, etc.   The fever and general distress of infection may
call for mild or repeated doses of  salicylates, phenacetin, chloral.
or Dover's powder.

                            GLANDERS.

    Glanders (from gland) ; farcy (from farcio. to stuff);  Greek, pa-
Xi;;  Latin, malleus, maliasmus; German, Rotz,  Wurm ; French,
morve.—An infection, acute or chronic, of the horse  and allied soli-
peds. ass and bastards, communicable by inoculation to many domes-
ticated animals  (but  not  to  cattle)  and to man ;  produced by  the
Bacillus mallei; characterized by the formation of nodules (granulo-
mata) and ulcers in the mucous membrane of the  nose, with dis-
charge of fetid pus,  as from glands (whence glanders), and also by
deposits in the skin and subcutaneous lymph  structures  (whence
farcy), and subsequent general infection.
    History.—Apsyrtus, a veterinary surgeon  in the  army of Con-
stantine the Great, is credited with having made the first  mention of
glanders, under the  name malis, a term which included, however,
many other maladies.  Vegetius also spoke of it, and Aristotle  de-
scribed it in asses.   The disease had in former  times a much more
intense interest, in that to it, at various periods, was  credited  the
origin of syphilis, tuberculosis, scrofula,  diphtheria, and pyaemia.
The chief interest of glanders at the present day is in connection with
diseases of the horse.
    Schilling of Berlin,  and Muscroft of  England, recorded  accu-
rately studied cases  in 1821.  Raver published the first monograph
in 1837.   Arirchow contributed exhaustively to the  pathology of  the
disease in 1S55-63.
   Etiology.—The question as to the possibility of spontaneous origin
was definitely denied with the discovery by  Loffler and Schutz (1SS2)
of a  specific  bacillus—the Bacillus mallei—which these observers
isolated, cultivated,  and inoculated to reproduce the  disease  in  the
horse.
   The bacillus of glanders much resembles in form and size that of
tuberculosis and leprosy, though it is shorter and more slender than
either.  It is immobile ;  maintains its virulence desiccated for three
months; is readily colored with alkaline aniline dyes.   It forms  a
characteristic colony on the surface of a potato, as a delicate yellowish, 
GLANDERS.
91
transparent coat, like a thin layer of honey, as early as the second
day.  Acting upon the method of Koch with  tuberculin, Kalning,
of Dorpat  (1891), succeeded in extracting  from cultures a  product
which he proposed to use in prevention and treatment.   Most unfor-
tunately Kalning fell a victim to the disease ; but his  studies were
taken up  by Preusse of Dantzic,  and Pearson  of Berlin, who also
succeeded in extracting a dark-yellow, rather  opaque, oily fluid of
peculiar odor and neutral reaction, which  they called mall em, and
with which they obtained characteristic reactions  in horses affected
with the disease.
   The  original seat of the disease in  the majority of cases is the
nasal mucous membrane, whence it may be disseminated through
the body, to  show itself more especially in the skin.   The disease
may be  always recognized unmistakably by the examination of tissue
exsected from the masses in the nose or in the skin.            .^
It is not readily recognized in fluid secretions,  as           -^✓"^
it is  easily destroyed by other bacteria.  Field    ^ ^/*£>~oc"=fT
mice may not be used for the physiological test,  as   /    **     Si
they are so exquisitely susceptible to the bacteria   ^ *  /  JSr^
of septicaemia.   The guinea-pig is to be preferred,  < v-^  "^T"   '.
as offering a  much more exclusive soil.                  4^
   The  disease is disseminated, as stated, through   Fl°- 84 -The bacillus
the lymph vessels and also through the blood ves-
sels, and is communicated to man either through  a broken integu-
ment, especially in the nose, during the  process of currying or feed-
ing, or other  contact with diseased horses, especially in slaughtering,
skinning, tanning.  It is sometimes, but  much more rarely, conveyed
by the ingestion of infected meat—a mode of infection much more
common in animals  fed upon horse  flesh,  as  in menageries.  The
most  unsuspected and unavoidable  source  of infection, fortunately
of most rare  occurrence, is that which  occurs  in inhaling into the
nose or  open mouth the discharges from a horse's nose  or mouth, as
after the act of sneezing, snorting, coughing, etc.  Exceptional cases
have been recorded from drinking from  the same pail used in water-
ing horses, or from the common use of a handkerchief.   The bacillus
may also be lifted into the air and disseminated in the vicinity of the
animal,  especially in close apartments, stables,  etc., whence it may
be  inhaled into the  respiratory tract of man.   The disease has at-
tacked and exterminated an entire family, man, wife, and four chil-
dren, from the use of the same dish.  Glanders occurs in the great
majority of cases among hostlers,  coachmen, drivers, stock-farmers,
veterinary  surgeons,  butchers—that is,  individuals who  come  in
closest contact with the horse—and is, of course, much more common
in the male sex.  Bollinger found but  six  females in  one hundred 
92
GLANDERS.
and twenty cases, and then in the case of women compelled to sub-
stitute men  in the care of horses.  For the same reason children are
almost exempt from the disease.  Man is much less susceptible to
glanders than the soliped.
   The period of incubation after inoculation  or inspiration varies
from three to five days.  It may extend to three weeks.
   Symptoms.—The disease manifests itself at the point of inocula-
tion with redness, swelling, and pain, with speedy affection of the
neighboring lymphatics.   Constitutional signs occur  in the course
of a few days.  They may even precede apparent changes  in the
wound.   Chilly sensations icith fever are attended with  headache
and prostration.   Vague rheumatic pains, more especially in the
neighborhood  of the joints, with local  symptoms in the skin, may
more distinctly announce the infection.  Where or while the  local
symptoms or the cutaneous signs are still  absent, the disease simu-
lates typhoid fever, for which it  has  often been  mistaken.  The
character of the  disease  is,  however, soon made  manifest  by the
appearance  of hard, red nodules, varying in  size from a pea to a
walnut, much resembling the eruption of small-pox.  These nodules
soon show softening of the centre and become converted into pustules.
which burst,  to give vent to thick, fetid  pus.  The nodules may
increase  to  such magnitude as to form tumors—the so-called farcy
buds—or, in the process of suppuration, constitute abscesses, the rup-
ture of which leaves ulcers.   These ulcers may destroy tissue  to such
depth as to expose tendons  and  bones.   The process  may  extend 
GLANDERS.
93
rapidly in twenty-four to forty-eight hours, or more slowly, to persist
for three or four weeks.
   It is a fact, to be explained, perhaps, by the difference in the role
of the nose in respiration, that while  the  manifestations in the skin
are much  less frequent  and severe in the horse, symptoms on the
part of the nose assuming in this animal so much greater prominence,
the converse is true of man.  Glanders  in the nose is less frequent
and severe in man than in the horse.   Hauff declares that in more
than half the cases in man the nose is not at all affected.  Occurring
in man, it shows the same symptoms as in the horse.   The secretions,
which may come only from the affected side, soon become changed,
and the discharge from the  nose shows the same thick, purulent,
fetid matter  as  in the case of the horse.   There may be usually seen
at a glance, on inspection, such swelling and redness of the nose and
Fig. 86.—Tubercular glanders in the nose.
face as at times to simulate erysipelas.  Sometimes tubercles may
be discovered upon the alae of the nose.  As in the horse, the affec-
tion of the nose may show itself later in the course of the  disease,
often  in the second  or  third week.  The  mucous  membrane of the
eye, mouth, fauces, and of the whole respiratory tract may subse-
quently become involved.   The appearance  of  the  membrane, with
the tendency to  haemorrhage, fetor oris, and dysphagia, may  much
resemble scurvy.  There may be always observed in these cases the
same involvement of  the glands.  The submaxillary and sublingual
glands may suppurate to discharge externally.
   Affection of  the  bronchial  mucous membrane is evidenced by
harassing  congh, with the profuse expectoration of. the same fetid
matter and  the  subsequent development of dyspnaxi.  Fever may
be entirely absent, or may, in an individual case, assume prominence, 
94
GLANDERS.
with a temperature at 106°, and a feeble, irregular pulse like that of
pyaemia.
   The chronic distinguishes itself from the acute form by its  less
intense manifestations and more protracted  course.  The affection
of the nose, when present, does  not vary in any essential from that
already described.   It  is. however, less frequently present in man
than  in the  acute  form of  the  disease.  There is the same puru-
lent  discharge with its excessive fcetor, the same swelling of  the
whole structure,   while the .nares  are  blocked  with  offensive
crusts.  Peculiar repulsiveness is added to individual cases in gan-
grenous changes which ma}* occur at  the root of the nose.  The
manifestations in the skin are much more common, and upon these
the diagnosis is, for the most  part,  established.   Nodular masses
may  form anywhere over the body,  more especially upon the  ex-
tremities,  to discharge sanguineous serum and pus.  Sometimes the
Fig. 87.—Discharging cicatrices in the nose.
affection is more superficial and shows itself in the form of blebs,
which may simulate small-pox, chicken-pox, or pemphigus.
   The various complications of pyaemia may subsequently ensue.
Arthritis, serous or suppurative  inflammations of the various serous
membranes,  with exudations, suppurating nodules,  and  masses in
the muscles and bones, followed  by extensive destruction of muscle
and necrosis of bone, with  deep erosions in the mucosae and subcu-
taneous tissues, are common phenomena of marked cases.
   These  various  complications  may  follow each other  rapidly in
acute cases.  The blood is quickly poisoned and the patient succumbs
in the course of a week ; in the  more  subacute cases, in two to four
weeks, with  delirium and coma.  The  disease  is much  more pro-
tracted in chronic cases.   It may  last for several  weeks, months,
even years, and finally cause death  by marasmus.  There is  during
all this time constant liability to  the development of  the acute form
with its more rapidly fatal consequences. 
GLANDERS.
95
   The diagnosis is made to rest upon the nature of the avocation
and the possibility of exposure.  It is further determined by the two
signs which have given names to the disease—to wit, the glanders.
which finds its  analogue in man in the term  ozaena.  It  is to be
remembered, however,  that  ozaena applies also to fetid discharges
from the nose from various other  causes,  notably  from  syphilis.
The  second factor is the farcy, the nodular eruptions, abscesses, and
ulcers found in  the skin.  The disease is recognized in its  constitu-
tional form by the signs of pyaemia—that is, by the chills, fever, and
sweats, hebetude, delirium,  and  coma, together with  the various
metastatic depots.
   Syphilis may be separated in a doubtful case,  ex juvantibus. as
iodine and mercury have no effect upon glanders.
   Tuberculosis shows,  as a  rule, predominating  signs  on  the  part
of the lungs ;  and  while it  may  affect the  bones, as in a case of
glanders,  tuberculosis  distinguishes itself  by sparing the  nose and
skin, organs of selection in  glanders.   Small-pox is more uniform.
The  pustules  of glanders  appear in successive crops  and rapidly
ulcerate (Liveing).   Pyaemia usually results from a single centre or
depot, which may be recognized or discovered.  Cryptogenetic cases
may be distinguished at times only by the discovery of the specific
micro-organism of glanders.
   The diagnosis of glanders really  rests absolutely upon the re-
cognition of the Bacillus mallei.  Travers, long before the discovery
of the specific micro-organism, established the diagnosis in  doubtful
cases by inoculation of goats and rabbits with matter discharged
from some of the ulcers.  Bollinger recognized the disease in the
same way b}~  the inoculation of a horse.  The inoculated animals
showTed the special  lesions and succumbed in the course of two or
three months.   Cornil succeeded  in  inoculating two  of fifteen  gui-
nea-pigs by rubbing cultures into the intact skin of guinea-pigs.
Washbourn and Schwartznecker established  a diagnosis of human
glanders by the isolation of the micro-organism, its cultivation, and
the inoculation of animals.   Jakowski  called attention  to the affec-
tion of the testicle  that occurs in these cases, and Strauss adopted
the method of intraperitoneal injection as the quickest means of ab-
solutely identifying  the disease by  implication of this  organ.  He
was led to adopt this method on account of the difficulties attending
the inoculation of animals with the products of the disease.   Subcu-
taneous injections in dogs do not always give definite  results, and
the inoculation  of  less  susceptible  animals—e.g.,  guinea-pigs—is
unsatisfactory because of the length of time before death, twenty-
five to thirty days.   Field mice and marmots succumb in two to five
days, but these animals are often difficult of access. 
96
HYDROPHOBIA.
   After the intraperitoneal injection of the discharges of glanders
into the bodies of male guinea-pigs, there is observed first, as a pro-
minent lesion, affection of the testicle as early as the second to the
third day.   The scrotum  becomes tense, red, and shining, the epi-
dermis desquamates.   Suppuration speedily occurs, to perforate the
integument, and in the pus is to be found the Bacillus mallei.   The
animal succumbs  somewhere between  four and fifteen days.   The
complication results also under subcutaneous injection, but much
later—ten to twelve days.  Loffler showed that it was not only the
tunica vaginalis but also the parenchyma itself which showed nod-
ules of the disease.  The tunica vaginalis is covered with granula-
tions, and by the third to the fourth day its laj^ers are agglomerated
by an exudation of pus rich with bacilli.   A means of diagnosis  is
also offered with the injection of mallein  (Preusse), which, as in the
case of tuberculin in tuberculosis, produces  a  peculiar febrile reac-
tion in glanders.
   The prognosis in a case of acute glanders is absolutely unfavor-
able.  The only possible rescue  may result from the speedy destruc-
tion and thorough annihilation of  the first infection.  Nearly all the
acute and more than half of the chronic cases succumb to the disease.
   Prophylaxis.—Animals affected with glanders are to be isolated
and  killed.  According to the  report of the Berlin Health Office,
1890, there were reported as affected with glanders thirteen hundred
and  thirty-seven  horses.   Eighty died ;  ninety-three were killed at
the request of their owners; fifteen hundred and ninety-eight ani-
mals were destroyed by the police—in all seventeen hundred and
seventy-one horses perished.  For rhose killed by the police  there
was paid by the State 459,834.08 marks indemnity.
   The cadaver is  to be cremated or buried deep.  Litter and fodder
are to be likewise burned and  stables thoroughly disinfected.  All
persons who have come in contact with infected horses should be
warned of their danger.
   Treatment.—Local  depots  are to  be treated thoroughly and
promptly by the application of  the actual cautery, strong carbolic
acid, mineral acids, and corrosive  sublimate, as in the treatment of
anthrax.   Chronic cases are to be supported with  quinine, arsenic
(Gamgee),  and alcohol.

                         HYDROPHOBIA.
   Hydrophobia {vdoop, water,  cpofio?,  fear) ; Greek, Xvaaa,  rage;
Latin, rabies; French,   la  rage;  German,  Wuth,  TollwutJi,
Hundsiruth ; Italian, rabbi a ; Swedish, Huudsjuka.—An intensely
virulent infection of lower animals—dog, fox, wolf, cat, and skunk—
in the order of  decreasing  frequency, communicable also to any ani- 
HYDROPHOBIA.
97'
mal (herbivora, fowl) and to man ; with the most variable, often the
longest known period of incubation ; distinguished by melancholia,
terror, intense hyperaesthesia of the medulla ;  evinced as a spasm of
the pharynx and larynx excited by attempts to swallow, or the pre-
sence or the mere thought of  liquids, a subsequent very short stage
of paralysis, and almost inevitable death.
   The name is appropriate as expressing the most prominent symp-
tom of the disease in man, but is inappropriate  for the lower animals,
as precisely this symptom, the fear of water, so obtrusive in man,
is in them entirely absent.
   History.—It is strange  that  while the  disease appears to have
been known to the ancient  Indians, Egyptians, and Israelites, Hip-
pocrates makes no mention of it.  Aristotle (322 B.C.) recognized it
unmistakably in dogs :  " Dogs suffer from  rabies.   This induces a
state  of madness, and all animals who are  then bitten by them are
likewise attacked  by rabies." Democritus considered  it an inflam-
mation of the nerves allied  to tetanus.   It is mentioned by Virgil,
Horace, Ovid, Plutarch.  Celsus, who first uses  the word, speaks of
it as the disease which vSoopyofiiav  Groeci appellant.
   The thorough elaboration of symptomatology in the lower animals
as well as in  man is chiefly due to English observers, especially
to Youatt.  Pasteur has connected his name  with  hydrophobia for
all time, with  his studies of  prophylaxis—studies which established
the nature of the disease as an infection whose symptoms are  due to
toxines from some as yet undiscovered micro-organism, and which
fixed the fact of the first importance that rabies may in no case arise
spontaneously, but always and only from itself.
   Etiology.—Hydrophobia, like syphilis,  is  communicated by in-
oculation through a broken skin ;  and while it may be transmitted by
any animal, it is actually communicated to man, in the great majority
of cases (ninety per cent), by the bites of rabid dogs.
   The period of incubation in the dog varies usually from twenty to
fifty days. It may vary from six to two hundred and  forty days.
It is certain that the animal may  communicate the  disease dur-
ing the ichole of the period of incubation.
   Escape may be due to accident.  A bite after a recent bite is less
dangerous.  Saliva may have been  wiped off in the first bite or on
the garments.  The danger is illustrated by the part of the body bit-
ten.   In some American statistics quoted by Watson, of seventy-five
cases  the  wound was in the hand forty times,  on the face fifteen, in
the leg eleven, and the arm nine times.   Of four hundred and ninety-
five cases collected by Bollinger, fifty-three per cent were bitten on the
upper extremities, twenty-two per cent on the head and face, twenty-
two per cent on the feet, and three per cent on  the bod}* and scrotum. 
98
HYDROPHOBIA.
The cures of the charlatans by so-called madstones. etc.. often of
great virtue in psychical cases, get their reputation from use in cases
which have escaped real infection.
   Incubation.—The  period of incubation of hydrophobia covers a
point of the most  intense and anxious interest.  How long after a
bite may an individual be considered safe ?  This  is the point in
which hydrophobia differs from all  known  diseases, in  that  the
period of incubation is so indefinite.   In the majority of cases it is
unusually long.  Thus in sixty per cent the period of  incubation va-
ries from eighteen to sixty days, but in thirty-four per cent—that is.
in a little over one-third of all the cases—the period is longer than
two months.   Cases are abundantly upon record of outbreak of the
disease only after the lapse of three  to six months, and there  are
cases upon authentic record where the only  exposure which could
have accounted for the disease occurred one or even more than two
years  before  the attack.   In  a  very small ratio of  cases  (six  to
eighteen per cent) the period of incubation is short, from three to
eighteen  days.   Sometimes these  alleged long  periods, as well as
cases without apparent cause,  find explanation in a more recent in-
fection which has been overlooked or forgotten.
   A^ariation in the time of outbreak has been distinctly observed in
dogs.  On one occasion six dogs bitten by one rabid animal showed
signs of the disease respectively in twenty-three, fifty -six, sixty-seven,
eighty-eight, one hundred and fifty-five, and one hundred and eighty-
three days.
   From almost the first recognition of the disease in man  attempts
have been made from  time to time to deny its existence  altogether,
and to consider hydrophobia a fright or a form of hysteria or of  tet-
anus.  The fact,  however, to say nothing of  inoculation experiments
in animals, that  so many children under the age of five  (nine per
cent), and so many idiots  and imbeciles, in whom  the imagination
could play no role, have succumbed to the  disease,  sufficiently dis-
proves this view.  The symptoms, as will be seen,  distinctly differ
from tetanus ; and the most that may be said of the hysterical origin is
the fact that hysteria may simulate hydrophobia or any cither disease.
   Notwithstanding the searching investigations at the hands of the
best observers, especially  in connection with the study  of prophy-
laxis, the cause of hydrophobia remains unknown.  The  analyses of
chemistry have failed to disclose it.  No specific  micro-organism has
been detected in the saliva or  other fluid, and no distinct toxine has
been eliminated from  any of the secretions or tissues of  the body.
The poison is in  all cases  fixed, never volatile.  It is produced only
within the body,  never outside of it.   It acts in  every respect like a
chemical poison which is evolved  from micro-organisms, but differs 
HYDROPHOBIA.
99
from all the known poisons by the length of time in which it may
remain innocuous in the body.   Other secretions than the saliva, as
well as the flesh of animals, as a rule fail to convey the disease.
   A'arious theories have  been proposed  to account for the long
latency  of the disease.   The latest assumes that the poison lies latent
at the wound, and from it  chemical products are occasionally intro-
duced into the blood, but  are neutralized from time to  time by the
serum of the healthy blood, by the so-called protective proteids which
act as antitoxines or antidotes, until  finally  they fail, to permit in-
toxication.  This view  has now the  best support.  It accounts for
the  escape  of so  many cases with  the simultaneous infection of
others.   It furnishes an explanation of the fact that the bite of a dog
in the stage of incubation may be, but is not always, infectious.   It
accounts also for the favorable influence  even to the prevention of
the disease by the  destruction of it  at its origin.  It allies it with
other poisons, as in a case of septicaemia, where the removal of a
local depot may  put a stop  to a long train of septic signs.
   Morbid Anatomy.—The only changes which can be said to be at
all characteristic are microscopic, and they are, with the  rest, some-
times entirely absent.   The  small vessels  are dilated, and invested
upon their exterior  with leucocytes, which invade also the  circum-
jacent tissues.  These  changes are  most marked  in the  medulla
and the upper part of the spinal cord, as well as in the cerebral cor-
tex, whence the symptoms of hydrophobia arise.  Gowers observed
this condition in seven of nine cases.   Emigration or accumulation
of leucocytes is at times so  great as to fill up the whole space within
the lymphatic sheath.   These escaped and accumulated  cells consti-
tute what may be called miliary abscesses.  In association with them
are observed at times small haemorrhages, seldom large enough to be
visible to the naked eye.  This perivascular  accumulation of leuco-
cytes, especially in  connection with the vessels of the medulla and
cortex, constitutes  the  most constant  and characteristic lesion  of
hydrophobia.  Unfortunately, as stated, this sign, with all the rest, is
sometimes entirely absent.
   Symptoms.—Hydrophobia is divided into three stages :  the psy-
chical, spasmodic, and  paralytic.   The disease is exceptionally  an-
nounced by changes at the seat of the wound, which, as a rule, has long
since healed.  The wound may open anew or become the seat  of pain,
itching,  numbness, or other paraesthesia.  Sometimes pain irradiates
from it in various directions.  Sometimes the first feeling is in  the
nose or throat—a sneezing,  a dryness or rawness, which  is con-
sidered "a cold."
   A peculiar state of depression and irritability soon  sets in,
sometimes suddenly with headache, anorexia,  insomnia, anxiety. 
100                      HYDROPHOBIA.
 Mental symptoms assume prominence according to the temperament
 of the individual.  A man may deny the fact that he ever was bitten
 by a dog, while he is unable to divert his mind from the actual
 occurrence and the terrible consequences which are liable to ensue.
 The inquiry or suggestion of a thoughtless, meddlesome, or inqui-
 sitive  neighbor will plunge the strongest  man into melancholy or
 mania.   The  mental  distress is, however, always an exaggeration
 of a state of apprehension, of a sense of  impending danger or im-
 minent death ; and though a man may show, under the stress of this
 suffering, signs of  insanity, there is no  time when he may not be
 recalled to himself  by  a right address.  A patient affected with the
 first stage of hydrophobia presents a pitiful  picture.   He sits quiet,
 apparently listless,  his whole  mind intensely concentrated upon the
 one thought from which no appeal or address may really divert him.
 It is only in the very first hours of the attack that he may find relief
 in walking about or in change of scene.  He soon becomes exhausted,
 and sits with an expression of intense anxiety to which he makes
 total surrender.  At the same time the special  senses are keenly
 alert, so that a flare of light, a draught of  air, a noise, may produce
 intense excitement.   The very first day shows the characteristic sign
 of the disease—the fear of water.   The patient suffers with thirst,
 but is unable to allay it.  He may make the attempt, may succeed
 at first in swallowing  a mouthful  or two,  but  soon abandons it,
 either on account of the intense suffering which ensues, or from the
 fear of its certain following.  An unmistakable sign of the  disease
 is the occurrence of burning, more especially a sense of tightness or
 constriction, of the larynx.  The fear of water is the fear of exciting
 spasm  of  the larynx,  and the reflex excitability of the larynx be-
 comes  so intense that  spasm is later precipitated by the sight, the
 sound, or the  mere thought  of water, even by  the mere sight or
 touch of a smooth  or  cold surface.  A  coachman under Watson's
 observation had to  desist from sponging himself, according to his
 habit, with cold water, though he said he  " could not think how he
 could be so  silly."  Frequent  sighing is a common sign at the in-
 ception of the disease.
   The first stage usually lasts about twenty-four hours, when the
second stage, the spasmodic  or  true hydrojdiobic stage,  sets in.
 This stage is characterized by an exaggeration or an intensification
of the  spasmodic contraction of  the larynx.  Every attempt to
 swallow is attended with frightful anxiety.   The contraction  is so
 powerful as to  lead to dyspnoea with maniacal  excitement.  The
 patient may strike  about in every direction,  roll his head from side
to side, while the mouth opens and closes convulsively, sometimes
 with snapping sounds, whereby  wounds are occasionally inflicted 
HYDROPHOBIA.
101
upon ministering hands ; and the disease has actually been conveyed
in this way.  These convulsive seizures gave rise to the stories that
hydrophobic patients bite and snap like dogs, and led, through the
fear which they excited, to the cowardly assassination of patients by
shooting them  down—a  practice still in vogue on the confines of
Austria—or by smothering them between feather beds. The parox-
ysms seem all the more dreadful because they are attended with the
escape of glutinous, foaming saliva, which is sometimes ejected with
great  force in every direction.   Inspiration is  also attended with
gaping and sighing and various sounds, sometimes simulating the
bark and howl of dogs.  These things occur in paroxysms,  in the
interval  of which the mind is clear, though  sometimes,  in highly
nervous  temperaments, it may be excited to show more  persistent
hallucination.  The pulse is quickened  and rendered irregular, but
with all  the struggle there is, as a rule, but little elevation of tem-
perature.  The  employment of  any forcible  measures of restraint
aggravates the explosion.
   The second stage lasts, as a rule, from one to three days, rarely as
long as four days.  The patient now becomes gradually exhausted.
Paroxysms occur, but they are less intense.  The extreme anxiety of
mind is diminished; there are intervals  of nearly complete  tranquil-
lity.  It  is plain  to see, however, that while the breathing is easier
and the explosions less severe—there may be even ability to swallow
—the patient becomes more and  more prostrated and reduced.  The
strong man is broken.   The heart's action is weak, the  pulse flutters,
the surface is covered with a cold sweat.  The movements of the
body are so much enfeebled as to present the appearance of para-
lysis ; hence this third  stage has been characterized  as the stadium
paralyticum.  Death, which  may occur suddenly in  a convulsion
or from  asphyxia,  usually does  occur  quietly from failure of the
heart.
   Hydrophobia is an exquisitely acute infection.  However long the
period of incubation, the whole  duration of the disease  proper is
measured in a few days.  Eighty-two per cent of cases perish in from
two to four days.  Individual cases may succumb  in two or may
last as long as five or six days.
   The diagnosis is generally easy, and rests chiefly upon the height-
ened reflex of the medulla, as manifested in spasm of the muscles of
deglutition and respiration.
   The disease is differentiated  from tetanus by its  much longer
period of incubation.  Tetanus occurs in from three to ten days after
the wound  or injury.   Tetanus usually begins with  trismus, and is
often attended with opisthotonos.  It lacks the laryngeal symptoms
and spasms of hydrophobia.   It lacks also the psychical exaltation 
102
HYDROPHOBIA.
and  mental anguish of hydrophobia.  Tetanus may also be distin-
guished by its special micro-organism.
   The disease is  often distinguished with great difficulty from the
imaginary condition known as LYSSOPHOBIA, or fear of hydrophobia.
These cases have a common origin, though in the one case the wound
comes from a non-affected animal.  It might be imagined that lysso-
phobia occurred more frequently in nervous subjects  or in women.
This is not the case.  The strongest men have  suffered, and not
infrequently actually succumbed to fright or fear of  hydrophobia.
Some of these cases have been rescued by knowledge of the fact that
the animal was not rabid ; hence the advisability, when  possible, of
secluding the animal, that the existence or course of its disease may be
observed.  The fact that the animal recovers at all almost necessarily
excludes hydrophobia.   Abundant cases are recorded where informa-
tion of the recovery of the animal, or the  sight of the  animal itself,
has allayed the most intense nervous symptoms.
   The p)rognosis is fatal.  It is commonly said that  the physician
that cures is death.  Bollinger goes so far as to say that the cases of
alleged recovery may be invariably found  to be  due to  some  other
disease, or to the fact that the animal was not rabid.  Yet it must be
admitted that dogs have recovered from the disease.  Law mentions
eight such cases, two of which were attested by successful inoculation
of other animals.   The possibility of spontaneous recovery may there-
fore be entertained in  man.   Wounds on the  face are, as stated, al-
ways the  most serious.  Bouley declares that ninety per cent of these
cases are followed by hydrophobia, whereas the  mortality  from
wounds of the hands is sixty-three per cent, of the lower extremities
twenty-eight,  and  of the upper extremities twenty per cent.  Many
cases are certainly rescued by prompt treatment.  Bollinger quotes
in proof the following  statistics in France :  Of two hundred human
beings bitten by rabid animals, one hundred and thirty-four were cau-
terized.   Of these, ninety-two (that is, sixty-nine per cent) remained
healthy, while forty-two (that is, thirty-one per cent) died of hydro-
phobia.   Of those not cauterized, eighty-three per cent succumbed to
the disease.  In one case sixteen persons and one ass were bitten by
the same  animal.  The human beings were cauterized and  rescued
without exception;  the ass,  which received  no treatment,  died of
the disease.
   The only true prophylaxis is the muzzle, which renders all other
prophylaxis superfluous.  But for various reasons, including a kind
of sentimentality, the process of muzzling had never been rigidly en-
forced outside of a military country like Prussia.  The  disease, which
was formerly common in Prussia,was actually extinguished, as stated,
for nine years by the rigid enforcement of universal muzzling.  Hoi- 
HYDROPHOBIA.
103
land secured nearly the same exemption in the same way.  The num-
ber of dogs  may be limited by being subject to higher  taxation.
Every dog should have a known master.  Suspected dogs must be
carefully confined, and for as long a period as six months.   Dogs im-
ported from countries of lax laws in this regard should be quaran-
tined for  six months.  Actually rabid dogs or other animals that
need not be preserved to determine the condition of human beings or
other animals attacked, should be killed at  once.  Filing the teeth,
or attachment  of blocks of wood, about the  neck, confinement by
chains, attempted prophylaxis by injection of virus, are all means too
unreliable for practice.
   Treatment consists in the destruction or elimination of the poison
in the wound.   Absorption should be first  prevented where practi-
cable, as on the extremities, by a ligature above the wound.  A piece
of cord or handkerchief should be firmly twisted about the limb with
a piece of wood.  Where it may be done, the patient should with-
draw the  poison  from the wound  by suction.   With  proper precau-
tions  this act may  be substituted by another person.   The act of
suction is, however, dangerous in cases of carious teeth, or wounds in
the gum, cheek, or other parts of the mouth.  The operation may be
done, nevertheless, if the individual take the precaution to rinse the
mouth thoroughly, after every suction, with carbolic acid.  Hertwig
found that the virus of hydrophobia applied to the  mucous  mem-
brane of the mouth and digestive tract was entirely innocuous.   This
process, which has been resorted to from the most ancient times, has
never yet proven infectious.  In the first decades of the present cen-
tury,  in Lyons, certain women—Hiindsaugnerinnen—pursued this
business as an avocation.  They received ten francs for the first, and
five for each  succeeding suck.   On the surface of the trunk and some
parts  of the  face the poison may be exhausted by cups.  Immedi-
ately after suction the wound should be cauterized.  Youatt relied
entirely upon such a superficial caustic as the nitrate of silver.  As
he was himself  bitten seven times, and operated  on four hundred
persons, only one of whom died,  and that one, as  he  declared, from
fright, this caustic may be  considered sufficiently strong if applied
immediately.  Caustic potash burns deeper.   The actual cautery, as
from  a poker, a nail, the galvano-cautery, brought to a white heat,
would certainly destroy the poison more effectually.  Where wounds
are very extensive or numerous the effect may be best accomplished
with stronger solutions, 1 :500 or 1:1000, of corrosive sublimate.
Extensive laceration of extremities may require amputation.
   Psychical treatment is of  supreme importance.   Romberg first
advised the necessity, on the part of the attendants and friends,  "' to
preserve a calm demeanor, to avoid all allusion to the  previous in- 
104
HYDROPHOBIA.
jury, and to appear cheerful."  To secure diversion without effort or
remark is an essential factor in the relief of suffering, at least.   The
intense reflex excitability of  the medulla  is best met by seclusion
in a quiet and rather dark room.  The exhibition of  cases as curiosi-
ties, or as objects of morbid sympathy, is a cruelty, if not a crime.
Frequent warm baths, where at all permissible, as at the very start,
tend to allay excitability and spasm.  Very soon,  however,  resort
must be had to anodynes and anaesthetics.  Violent cases may require
the use of chloroform.   The same object may be at  first obtained
with chloral.  The various remedies recommended  as  specifics—
curare, calabar bean,  pilocarpine—have proven useless, except in al-
laying spasms.  The use of animal poisons has proven equally futile.
Watson speaks of cases treated with the virus of  snake bites.   One
man was bitten by nine vipers  without effect.   Opium is the  best
shield.  Sooner or later resort must be had to  morphia in the later
course of the disease, preferably subcutaneously, with a view at least
to secure euthanasia.
    With this history hitherto, it may be appreciated with what accla-
mation was hailed the claim by Pasteur of the discovery of a means
of preventing the disease  by  the use  of attenuated virus.  It had
been always known that the disease expends its main force upon the
medulla.   Whatever lesions are encountered in the disease are  seen
here.
    So soon as Pasteur had determined that the virus of hydrophobia
comes to be located in the central nervous  system, especially in the
spinal cord, he began his experiments with this substance to secure
attenuated matter.  He found that a continued inoculation of the
virus from rabbit to rabbit increased its virulence to such degree that
after about twenty-five generations he got a virus which showed its
effect after an incubation of but eight  days.  In twenty-five genera-
tions further the period of incubation was limited to seven days.  This
virus was taken as a so-called  virus fixe, as a  basis substance for
protective inoculation.   Pasteur discovered that desiccation of the
medulla from such an animal in sterilized glass vessels in which had
been put pieces of caustic potash brought about a gradual reduction
of virulence.  The medulla became  less and  less  poisonous.  The
drying process was continued, until, after two weeks' desiccation,  it
was entirely innocuous.  Injections were now made with an emul-
sion of the non-virulent medulla, and  were followed up  with emul-
sions of medullae of increasing violence up to those which had  been
dried but one or two days.  Dogs so treated were immune to infection
with fresh hydrophobic matter.
    In the treatment of the hydrophobia of man,  Pasteur began with
weaker preparations—to wit,  with the medulla of the rabbit  after 
TETANUS.
105
fourteen days' desiccation, and increased on the following days up to
that of the fifth day, whereby immunity or protection was secured.
The attempt to use stronger preparations in a  shorter time, in pro-
tection against the more dangerous and extensive laceration of wolf
bites, had to be discontinued.  This treatment has been used now in
thousands of cases ; and while it cannot be said to have furnished
perfect  results, as a number of cases thus treated have nevertheless
succumbed to the  disease, it must be admitted that  the majority of
cases thus treated have been rescued  from the horrors  of hydro-
phobia.   The statistics of the Pasteur Institute from 1886 to 1891 show
a continued decrease of deaths from 0.94 per cent in 1886  to 0.25 per
cent in 1891.   In 1891 as many as 1,464 patients passed under treat-
ment.
    These results, brilliant as  they are,  are eclipsed  by the report of
Tizzoni and Centanni, who make the extraordinary  claim to be able
not only to  confer  immunity,  but to actually cure hydrophobia,
even after  the disease has developed, by the injection of the blood
serum of animals rendered immune to the disease.  The immunity is
conferred by the inoculation of an emulsion of spinal cords (rabbits)
attenuated by partial digestion in artificial  gastric juice  (peptones).
Poppi finds that the matter  used by Pasteur may be further attenu-
ated, by dilution and heat, to act not only like a veritable vaccine in
protection against the disease, but also to cure it.  These claims have
not yet  been conclusively established.

                            TETANUS.
    Tetanus (teravo?, reiroj, to stretch) ; trismus, lockjaw,  opistho-
tonos (o7tiad£, backward, reivco, to stretch) ; German,  Wundstarr-
krampf.—A grave, often exquisitely acute infection, caused by  the
tetanus bacillus, introduced through a wound or some break of the sur-
face ; characterized by excessively heightened reflex under the action
of toxines which induce spasmodic contraction  of the voluntary mus-
cles, first and especially, of the jaw (trismus, lockjaw), face, and neck,
and extensors of the spine (opisthotonos); of short duration, often of
rapidly  fatal termination.   Among  the larger animals  the horse,
sheep, and goat are especially liable to the disease.
    History.—The clinical features of tetanus are so coarse  and ob-
trusive as to  have been remarked in the most ancient times.  Some
of the finest descriptions of  Aretaeus were based upon observations
of tetanus.   " In all the varieties," he says, " there is pain and ten-
sion of the tendons and  spine, and of the muscles connected with the
jaws and cheek, so that the jaws could not easily be separated, even
with levers or a wedge." Hippocrates devoted a whole  section to
its treatment,  and certainly  appreciated the gravity of the disease. 
106
TETANUS.
"" Such persons," he says, " as are seized with tetanus die within four
days, or if they pass these they recover."
   Most of the contributions of later times have been presented by the
surgeons,  Laurent, Larrey, etc.  Curling wrote his famous ''• Treatise1
on Tetanus" (Jacksonian prize essay) in  1834; Rose (E.) made the1
most valuable clinical  contribution of  modern times to the '" Hand-
buch der allgemeinen und speciellen  Chirurgie " (Pitha und Billroth,
Bd. i., Abtheil. A, 1870).   Nicolaier discovered the bacillus of tetanus
in the soil in 1885.  Rosenbach demonstrated it in man in 1886.  Ga-
gliardi reported the first cure of  tetanus in man by the subcutaneous
injection of the antitoxine of Tizzoni-Centanni in 1892.
   Etiology.—Tetanus may occur in  consequence of any kind  of
wound, but does occur much more frequently after contused wounds
with penetration  of foreign bodies.  It is,  therefore, frequent after
gunshot wounds, and is especially frequent in wounds of the extremi-
ties. Wounds of nerves are also attended with special liability.  Tet-
anus may follow a lesion as trivial as the extraction of a tooth, a vene-
section, the  sting of  an insect, a simple scratch  of the surface, the
application of a blister, a slight wound of the foot, as from a nail  in
a shoe.   It  occurs not infrequently in  the new-born from lesions  of
the umbilical cord, and has been repeatedly observed after a wound
of the cervix uteri, as after parturition.  The intrusion of a splinter
of wood, the lodgment of a fish bone in the throat, have broken the
surface sufficiently to introduce or give entrance to the cause of the
disease ; and as the cause comes from without, tetanus occurs, in the
great majority of cases, in wounds of the extremities.  Curling found
one hundred and eleven of one hundred and twenty-eight cases  on
the extremities, and Thamhaym,  in three hundred and ninety-five
cases, found the  locality of the injury in the hand and  finger one
hundred and nineteen times.
   Tetanus is a rare disease.  Rose states that the mortality of teta-
nus  in Berlin was but  0.04 per cent, and this  included two hundred
and sixty-six cases in new-born infants.
   The disease is most frequent in hot countries.  Aside from attack
of the new-born, the period of greatest liability is between ten and
thirty.
   The tetanus bacillus is a delicate  rod,  a little longer  than the
bacillus of mouse septicaemia.   It occurs  in irregular masses in the
affected tissue, and is  recognized  by the characteristic development
of  its  spores.  One end  of the  bacillus swells to show an oval,
sharply defined, shining spore, and present the appearance of  clock-
bell strikers, drumsticks, or, better,  pins.  This  spore formation  oc-
curs in great abundance in the body of the animal, as well as in
artificial cultures.  The bacilli are  easily colored  with  methyl blue 
TETANUS.                         107
 and fuchsin.  Artificial culture is difficult.  The bacillus is  strictly,
 i.e., an obligate anaerobe,  so  that in artificial culture particles of
 infected matter must be introduced into the deeper layers  of blood
 serum to secure growth.  The culture is so commonly contaminated
 as to require often subsequent separation to obtain it pure.
    Brieger  (1887) obtained from  sterilized  cultures of the tetanus
 bacillus a toxine, which  in mice,  in  the  smallest  doses, produced
 the typical symptoms of trismus and tetanus, with fatal termination.
 Besides this body, Brieger eliminated  various toxalbumins with spe-
 cific properties.
    The bacilli and spores of tetanus are so widely disseminated in
 soil and dust as to be almost  ubiquitous.  They abound  most on
 the surface of inhabited soil, and  are  not  entirely absent in uncon-
 taminated virgin soil.   The rub-
 bish and dust of streets and houses
 are  soils  of predilection.   The
 wide dissemination of the parasite
 accounts for the cases of apparent
 spontaneous or  idiopathic teta-
 nus, while the fact that the free
 access  of  oxygen prevents  its
 growth furnishes explanation of
 4he comparative rarity of the dis-
 ease and the greater liability of
 penetrating wounds.
    The period of incubation varies
 from one to two weeks.
   Symptoms.—The  disease be-         fig. 88.-Baciiius of tetanus.
 gins, as a rule, with spasm of the
 muscles of mastication.  Contraction of the masseters locks the
 jaws, to produce the condition known as trismus, lockjaw.  Con-
 traction of the muscles of the neck occurs at the same time, or may
 precede the contraction of the jaws.  Rose declares that the contrac-
 tion of the masseters may be felt by the insertion of the finger within
 the mouth, and that the stiffness of the muscles of the back of the neck
 is best recognized, as in cerebro-spinal  meningitis, by attempts to lift
 the body by the head.   The affection of the muscles of the face soon
 produces a peculiar physiognomy.   The lips are usually stretched
 over  the  closed  teeth,  to  produce the  characteristic  smile,  the
 risus sardonicus, so graphically described by Hippocrates.  Fagge
 speaks of the case of a girl who  was reprimanded by her mother on
 account of a singular grinning  expression of the face,  over which
 she had, of course, no  control.   This alteration of the physiognomy
gives to the patient the appearance of age.  Farr says a man aged
 
108
TETANUS.
twenty-six was taken for sixty.  The disease begins usually mildly,
and increases  gradually and progressively.  There is in association
with the stiffness of the neck or diminished mobility of the jaw some
difficulty of deglutition.  The  muscles are affected from  abort-
downward.
   The spasm extends to involve the muscles of the back.  Implica-
tion of  the groups of great muscles in the spine soon distorts the
body.   The whole trunk  is stiffened like a statue (orthotonos), or is
more frequently arched, with its convexity upward, so that the body
may rest upon the back of the  head and  the heel*—opisthotonos.
The forearms and hands are spared for a long time.  Motion, either
active or passive, is soon inhibited or lost altogether under the board-
like indurations  of  the muscles.   During  these states of  rigidity
convulsive  attacks  occur with shocks like strokes of lightning.
They show themselves in consequence of effort, even  of involuntary
effort, or as the  result  of  any outside irritation,  and  express the in-
tense reflex excitability of the spinal cord.   In the interval the body
assumes the position of rigidity from which it has been distorted by
the violence of the spasm.  The  suffering of the patient at this time
is indescribable.  The spasms are attended with excruciating pain.
The mind is perfectly clear, but is weak from loss of  sleep and anx-
iety.   The patient may not satisfy either hunger or thirst, on account
of locking of the jaws.  The opisthotonos prevents a proper decubi-
tus.   Individual muscles, especially the  recti abdominis,  have actu-
ally  ruptured under  the powerful contraction, to discharge masses of
blood at their  divided ends.   Difficulty of breathing,  cyanosis, a
sense of distress and danger, with lancinating  pains at the bottom
of the chest, indicate the spasmodic contraction of the diaphragm.
Fever may be entirely absent.  There is generally some elevation of
temperature,  which is  liable to sudden  exaggeration, often without
discoverable cause, probably due to the influence of the nervous sys-
tem.   Extreme elevations of temperature to 110°  or 112° are pre-ago-
nal.   Sometimes there  is an elevation of temperature post mortem.
The skin is  usually  covered with sweat—a point often of diagnostic
value.  The bowels  are constipated.  There is often suppression and
more frequently retention of urine.
   The diagnosis largely rests upon the  early appearance of trismus.
Lockjaw  from sore  throat,  mumps, synovitis,  rheumatism at  the
temporo-maxillary articulation, should be easily distinguished by the
most superficial examination. The feel of the rigid masseters inside
the mouth, and the associate stiffness at the back of the neck, speedily
dissipate doubts.  Hysteria and hystero-epilepsy may show the typi-
cal opisthotonos of  tetanus, but hysteria is, as a rule, unattended
with trismus ;  and when  trismus is simulated by the fixation of the; 
TETANUS.
109
 jaws, hysteria  is recognized by the fact that the intervals of attack
 are irregular and always entirely free from spasm or pain.
    The regular invasion of tetanus from above downward, first of
 the muscles of  the face and neck, later of the trunk, distinguishes the
 disease from the spasmodic contractions of spastic myelitis.  Cerebro-
 spinal and basilar meningitis, which have, in common with tetanus,
 stiffness of the neck and opisthotonos, almost never  show trismus.
 They have also a different origin and history—i.e., epidemic, tubercu-
 lous—with associated symptoms, vomiting, headache, hyperaesthesia,
 herpes, etc., not seen in tetanus.
    Tetany is distinguished by its typical  spasms of days' and some-
 times weeks' duration, and absolute intermissions ; by the peculiar
 contraction or position of the hand, which may be called out by long
 pressure upon the nerves or arteries of the arm—the so-called Trous-
 seau phenomenon ; by the  frequent laryngo-spasm ;  and by the in-
 creased mechanical and galvanic excitability of the motor nerves.
    Hydrophobia, which has, in common with tetanus, spasm  of the
 muscles of deglutition, is  distinguished by the much shorter  period
 of incubation, by the trismus and opisthotonos of tetanus, and by the
 psychical exaltation and anxiety of hydrophobia.
    By far the  most important question in differential diagnosis
 concerns the recognition of poisoning by  strychnia, which is most
 closely simulated by the effects of the  toxines  of tetanus.  This
 diagnosis rests upon the following points :   1.  The history of origin,
 where it may be obtained.   2.  The existence of a wound.  3.  The
 period of incubation.  Signs of  strychnia poison supervene at once.
 Tetanus  begins with trismus and  gradually descends,  sparing, as
 a  rule, except  in children, the arms and hands ;  strychnia often
 shows its first signs in irritation of  the stomach  and in the affection
 of the muscles, seizes by preference upon the extremities.   In tetanus
 there is persistent rigidity; in strychnia poisoning there are intervals
 of absolute relaxation.  Thus, in the interval between the paroxysms
 the mouth  remains  closed in tetanus, but may be  freely opened in
 strychnia.  The reflex spasms of tetanus occur later in the course of
 the disease and  increase in  intensity, while those of strychnia occur
 at  once,  intense from the  start.   Strychnia poisoning  is quickly
 terminated by death  or recovery.   Tetanus may be protracted  into
 days and weeks. Golding-Bird reported the case of a boy affected
 with tetanus, with spasms for fifty-one days, with subsequent  per-
 sistent rigidity, and death on the one hundred and seventh day.
   Eiselsberg establishes, as a  difference between tetanus and other
 wound infections, the fact that in tetanus  local wound reactions are
entirely absent.   So-called cases of rheumatic tetanus are, therefore,
really of traumatic origin. 
110
TETANUS.
   The 2iro9>iOSiS is exceedingly grave.   Death may occur in any
attack of convulsions.  The heart has actually, under observation,
suddenly ceased to beat.  Death occurs, as a rule,  before the end of
the first week, so that, as Hippocrates said, '' patients die within four
days, or if they pass  these they recover."  In exceptional cases.
however, the fatal termination may not occur for three weeks.  The
disease rarely lasts longer in childhood than two or three days.  The
prognosis is so grave in the new-born that, as Bauer declares, the
occasional cases of recovery have been looked upon as being probably
errors in diagnosis.  According to Richter six hundred and  thirty-
one of seven hundred and seventeen military cases—i.e., eighty-eight
per cent—were fatal.
   According to Rose sixty-three per cent of all cases die within the
first five, and eighty-eight per cent within the first ten days.  The re-
lief of the later periods  is probably to be explained by elimination of
the toxines.   Rigidity may persist for some time, even for months,
after  recovery.  The ability to sleep is always a favorable sign.
   Prophylaxis.—In prevention  of tetanus it is to be emphasized
that the  minutest wounds soiled with earth, dust,  or foreign bodies,
as splinters, are to be scrupulously cleaned and disinfected.  Patients
themselves are to be isolated from other surgical cases.
   In prophylaxis  of the new-born it  must be observed that the
wound at the navel is attended  with the utmost care.  The aseptic
treatment already recommended by various authors meets thus with
scientific  justification.  For all the investigations concerning the
origin of the tetanus bacillus demonstrate that  it has an unusually
wide ectogonous dissemination.  Unclean hands, the use  of  ban-
dages not sufficiently aseptic, and the raising of dust in the cleaning
of the puerperal room, sufficed, in the  observations of Beumer, to
convey the infecting agent.
    Treatment.—As in hydrophobia or  other disease characterized
by excessive hyperaesthesia of  nerve centres, the  patient should be
kept perfectly quiet.  He should be put in  a dark room and isolated
from curiosity  or officious or meddlesome ministration.   The  most
absolute silence should  be enjoined, on the part of the patient as well
as the attendants.   On account of the locked jaw the food should be
fluid, but should be as nutritious as possible.  Milk, soft-boiled egg
diluted with hot water, nutrient soups, stimulants, wine, whiskey,
brandy,  should be regularly administered.  Where the act of deglu-
tition excites spasm, the patient may be anaesthetized and, according
to the suggestion of Rose, fed through a tube, which may be.  as in
the case of insane or refractory patients, inserted through the  nose.
Foreign bodies should certainly be immediately extracted, irritated
nerve trunks excised.  Angry  wounds, "festering  sores,"  may be 
TETANUS.
Ill
treated  with the  powerful  antimycotics.  carbolic acid,  corrosive
sublimate, or with the actual cautery.   More  extensive exsections,
more especially amputations, are surgical  barbarities of  the  past.
Spasmodic contractions  are  best relieved by the administration  of
anodynes.  Opium,  on account  of   its  associate discomfort  and
distress,  is better  substituted in  our day by chloral.   A large dose
—one drachm at first—may be followed by smaller doses, fifteen  to
thirty grains, every hour or two, or as often as necessary to subdue
spasm.   Calabar  bean  and curare  have been administered  with
success in individual cases, sometimes of questionable diagnosis ; but
these remedies have failed, as a rule, to secure other than temporary
relief.
   Bacelli recommended the injection of one  centigramme of car-
bolic acid every  hour or two until the spasms entirely  ceased.
Caliari claims to have cured a case in this way.
   The hope of successful treatment lies in the use of the antitoxines
derived from the blood serum of animals—dogs—rendered immune
to the disease,  or from the bodies of  the  bacteria themselves.
Taruffi  has already recorded  a sixth case rescued  in  this  way.
The  treatment  consists in the injection  of the tetanus  antitoxine
obtained from the  blood of a dog rendered  immune to the disease.
Twenty-five centigrammes are injected twice a day.  Such improve-
ment occurs in the course of a week as to render the further use  of
the  remedy unnecessary,  and the treatment is  usually  concluded
with the hydrate of chloral.
   Unfortunately  some of the best  observers do not confirm  these
conclusions.  Kitasato was not able to  get immunity by  tolerance,
nor  by the use  of filtrates attenuated by heat.  Rabbits were ren-
dered immune  in  forty  per  cent of  cases  with  the  trichloride  of
iodine, but the immunity was lost in the course of two months.   Im-
munity is conferred  upon mice by the injection of the serum of im-
munized rabbits, but this immunity is  lost in forty to  fifty  days.
The  fowl is by nature immune to tetanus, but the blood of the fowl
does not  confer immunity upon other animals.
   By the second method Ehrlich, Brieger, and  Wassermann utilize
the antitoxines developed by the bodies of the bacteria themselves,
after the manner  of Koch with tuberculin.  These antitoxines  or
protective bodies are to be obtained in the milk of parturient animals
previously rendered immune  in pregnancy  by  inoculation of an
attenuated culture which is gradually increased in virulence.   The
protective principle remains in the whey after coagulation  and  sepa-
ration of the casein, so that it may be preserved indefinitely.   Some
of the most sensitive of the lower animals—mice, goats,  etc.—have
already been protected in this way, but up to the  time of the pre- 
112
WHOOPING COUGH.
sent writing  the accounts published of work with man have  not
been satisfactory.

                       WHOOPING  COUGH.

    Pertussis (per, intensive, tussis, cough) ; tussis convulsiva : Ger-
man, Keudihusten ; French, coquetuche  [used also for influenza]
{from  coqueluchon, a cape worn by patients).—An acute infection
of childhood,  distinguished by paroxysms of cough in rapid series,
threatening suffocation, terminated by along-drawn, audible (whoop)
inspiration.
    The name is derived from the fact that the cough is distinguished
by  a prolonged, forcible, and audible inspiration through a spasmod-
ically contracted glottis.   But many cases of  whooping cough  are
without  this characteristic sound, and, where different stages of the
affection may be recognized, the sound is absent during the whole of
the first and most of the last stage.   The cough consists of a series
of short, sharp explosions,  spasmodic in their character ;  a series of
expiratory efforts without stop to catch the breath, until finally, after
the lapse of from fifteen to sixty seconds, at the point of exhaustion
occurs this prolonged, audible inspiration.   It is the series of explo-
sive coughs in quick and uninterrupted sequence, the short,  sudden
cough, the staccato cough, which marks whooping cough.
    History.—The origin and home  of whooping cough are involved
in obscurity.  According to Mason Good the disease was known to
the Greeks ; but  their descriptions, as well as  those of  subsequent
writers, do not distinguish it,  strange to say, from  other  spasmodic
or catarrhal affections.  All authors agree that the disease was cer-
tainly definitely described  by Baillou (Paris, 1578), who  spoke of it
as a well-known malady.
    Etiology.—Whooping cough is an infectious disease, because it is
contagious and prevails as  an endemic and epidemic ;  because, also,
of the absolute immunity which one attack  confers.  Rare  as  are
second attacks of scarlet fever, measles, or small-pox, still more rare
are second attacks of whooping cough.   With  the other infections it
attacks preferably the age of  childhood.  Facts which have been
taken to militate against the views of its infectious nature  are  ab-
sence of fever and indefiniteness  of  duration.   Facts  which refute
the idea  that pertussis is a neurosis  are, first, origin and dissemina-
tion by contagion ; second, appearance  as  an  epidemic ;  third,  im-
munity conferred by single attack.  Neuroses belong to  individuals
and not to numbers.  They show no relation to others and have con-
stant tendency to recur.  Proof of contagion is furnished by the at-
tack of wet-nurses and nurses  generally, instances of which are no-
ticed in every epidemic. 
WHOOPING COUGH.
113
   The period of preference as regards age is from six months to six
years.  Sucklings, because of natural immunity, are rarely attacked.
Susceptibility diminishes at six and is nearly annulled at ten years.
Yet cases are on record where the  disease has occurred in infancy
and advanced life.   From some inexplicable reason the female sex
suffers most, in the proportion, according to nearly all authors, of
five to four.  The disease is not only more frequent but  also more
severe in girls.   Measles, pregnancy, and the puerperium predispose
to pertussis.  The contagion is conveyed directly.
   The contagious principle exists in the sputum, hardly possibly in
expired air which contains no sputum.  It is  a contagium halituo-
sum.  The great botanist Linnaeus, nearly two  centuries ago, ex-
pressed the belief that whooping cough was due to a contagium ani-
matum, which he thought would be found to be the eggs of insects.
The principle is thoroughly accepted in our day.
   Afanassieff succeeded in isolating from the  sputum  of whoop-
ing-cough patients a short, thick bacillus, which  he cultivated upon
beef peptone and agar.   The bacillus differs in important particulars
from forms hitherto  described, and gives rise, when introduced into
the trachea or  lungs of dogs and rabbits, to  symptoms simulating
whooping cough and to lobular pneumonia.  Ssemtchenko,  after
considerable experimentation, reached the conclusion that the bacillus
of Afanassieff  is specific.  It may be found in the sputum as early
as the fourth day of  the disease.  It multiplies in the body, and as it
increases, the disease diminishes in severity.  It disappears with the
resolution of the disease, or when the paroxysms are  reduced to two
to four daily.   In the presence of complications, especially catarrhal
pneumonia, it  increases in  the sputum.  Thus this  bacillus is  of
value not only in etiology  and diagnosis,  but also in  prognosis.
These conclusions have, however, not yet met with universal ac-
ceptance, as the observations  have not been  sufficiently verified.
Renewed interest  attaches to  this bacillus of Afanassieff with the
discovery by Griffiths of a ptomaine or toxine  in  the urine  of
whooping-cough patients.  Griffiths  claims to have  established the
fact experimentally  that  an absolutely identical  toxine is developed
by this bacillus.  The toxine  is not found in any case  of  normal
urine, nor in that of  any other disease than pertussis.
   There is now scarcely room for doubt that pertussis is a mycosis
whose toxines  have a special action upon that part of the nervous
system which presides over cough—to wit, the centres of the superior
laryngeal and vagus nerves.  In this way, in our  day, the mycotic
has displaced the neurotic theory.
   The contagious principle is not  often disseminated without direct
         8 
114
WHOOPING COU(ill.
exposure to the  disease.   Very slight  isolation  secures exemption
from the attack.  The bacillus has no great tenacity of life.
   Whooping  cough occurs  with special frequency during con-
valescence from  measles.   The disease shows  itself also in close
relation to tuberculosis.   It has long been noticed that tuberculosis
often follows close upon the heels of whooping cough.  It is impos-
sible to say in a given case whether the whooping  cough made the
soil fertile or merely aroused the latent disease.
   It is  an error to consider whooping cough as a trivial malady.
There  occurred in  England in one year, of 500.341  deaths,  10,318
deaths from whooping cough.   In New York in  one decade, wherein
4,0(52 deaths occurred from typhoid fever, there were 4,094 deaths
from whooping cough.  Hagenbach says that whooping cough had
more victims in Basel in fifty years than any disease  except typhoid
fever and diphtheria.  The general mortality  is  estimated at three
to seven per cent.  It has  reached as high as forty-eight per cent
in the second year of life.
   Symptoms.—The disease begins with  the signs of an ordinary
catarrh of the exposed mucous membranes.
   Whooping cough occurs, as stated, in paroxysms or explosions.
It would appear as if the nerve centres suddenly discharged them-
selves of accumulated irritation, as in a case of  epilepsy.   Close ob-
servation of  a case gives rise  to the impression  that the poison ac-
cumulates gradually up to a certain point,  when it may be no longer
stored and is discharged with the explosion that characterizes a par-
oxysm of the disease.
   Whooping cough is  usually divided into three stages : the stage
of catarrh, of spasm, and of resolution.  The first stage lasts about
one week.  Sometimes this catarrhal stage  is very short, and the spas
modic element manifests itself at the end of the second or third day.
Very soon the cough assumes the convulsive character, and  sooner
or later  occurs the typical staccato cough,  with the long-drawn, aud-
ible inspiration.   The  second stage has  now  set in.  In these at-
tacks the seizure  is sudden.  Sometimes, though not as a rule, there
is a kind of premonition or aura which previous  experience has
taught  the child to recognize.  It is usually a sense  of impending
distress or danger, which leads it to  leave its play and run to its
parents, or grasp a chair for support.   The aura may be in the form
of a dyspnoea, a precordial distress, a nausea, sometimes an actual
vomiting, whereupon ensues the series of expiratory coughs which
 distinguish the disease. The breath is lost.   The face flushes or be-
 comes  livid.   The  eyes  protrude.   Saliva  flows  from the  mouth.
 The look is wild, bewildered.  There is for a few moments the ap-
pearance of imminent danger. 
WHOOPING COUGH.
115
   The discharge of the contents of the stomach and a mass of glassy,
glutinous mucus from the throat closes the attack.  But the scene
may be repeated  once or twice before the last spasm yields.   Inspi-
ration then becomes quieter, and the child, pale, covered with sweat,
exhausted, sometimes almost  in collapse, is released until the next
attack.  Meanwhile it recovers itself entirely, resumes its play, un-
mindful of the disease, until it is suddenly  seized again.
   Paroxysms occur  in every grade of severity.   They  are  some-
times so mild as to make the diagnosis difficult;  in other cases so se-
vere as to lead to rupture of vessels.  Haemorrhages may occur from
the nose and mouth.   Subconjunctival haemorrhage is not uncommon.
The membrana tympani ruptures at times,  and free blood  appears at
the external meatus.  Ectatic vessels burst in the skin in the face, in
the cheeks, to show, visible at a distance, subcutaneous extravasated
blood.  Haemorrhage from the stomach or  intestine, or from the  kid-
neys or bladder, is much more rare.  Haemorrhage in the brain,  which
sometimes occurs, is fortunately very  much more rare.  Hernia is
not uncommon.   Convulsions are possible.  The duration of an at-
tack is usually from a half to two minutes, though it seems to anxious,
sympathetic relatives four or five times as long.
   As the severity stands in quite close relation with the frequency
of attacks, it is important that the number be counted, as by a stroke
on a piece of paper or a slate,  according to the suggestion of Trous-
seau.  Diminution  in the  number of  attacks  is the  first sign of
approaching relief.  Barman  attributes the frequency of attack at
night to the diminished vigilance of the respiratory centres, retarded
and more superficial  respiration, and greater accumulation of  car-
bonic acid gas.
   About the fourth decade of the present century attention  began
to be directed to the more or less constant appearance of an ulcer on
the frcenum lingure,  due to friction of the  protruded tongue against
the inferior incisors.   It is absent altogether where  the attacks are
very light, or where the fraenum is short, or the tongue may not be
protruded, or where  the incisors  are  dull.  It  has been seen  also
independently of whooping cough, in cases of cough from ordinary
catarrh, where the lower teeth have been unusually incisive.
   The spasmodic stage lasts,  as a rule, two to four weeks, when the
interval between the paroxysms becomes  gradually longer and the
explosions themselves less severe.
   Whooping cough is liable  to many complications, especially on
the part of the respiratory organs.  Bronchitis belongs to the disease,
and  usually drowns all  other sounds in  the lungs with its  rales.
Any disease attended with  bronchitis is liable also to broncho-pneu-
monia, and broncho-pneumonia is the most frequent of the serious 
116
WHOOPING COUGH.
 complications of whooping cough.   The spasmodic  closure  of  the
 glottis and the powerful efforts of the expiratory muscles sometimes
 develop  oedema of the  glottis, more frequently emphysema  of  the
 lungs.  The wonder is that emphysema is not more universal.  The
 occurrence of it is. in fact, an exception.  It is usually slight, mar-
 ginal or peripheral, and is marked by dilatation only of the air cells,
 whose walls  are so resilient as to  recover themselves entirely with
 the relief of the strain on cessation of the disease.   Sometimes, how-
 ever, especially in cases  of  failing nutrition, tuberculosis, syphilis,
 and rickets, the dividing walls are broken and air cells are ruptured.
 Still more rarely air  may escape into the pleural sac  to constitute a
 pneumothorax, or break the lung at its hilus, reach the mediastinum,
 or escape into the subcutaneous connective tissue and inflate, literally
 blow up, the upper half of the body.  There is no better proof of the
 strength of the heart  than the fact that it escapes damage under the
 spasm and stasis of whooping cough.
   Complications on the  part of the nervous system  are very rare.
 At the height of the attack there is experienced extreme anxiety, a
 sense of suffocation, a vertiginous bewilderment, approaching loss of
 consciousness, which  disappears entirely with  the recovery  of  the
 breath.   The momentary apncea may be prolonged to the point of
 danger, and very young children may actually  succumb  to suffoca-
 tion.  Vomiting, which is usually hailed with pleasure as indicating
 the end of the attack, may be excessive.   It may continue into the
 interval.  It may even produce collapse, or in more protracted form
 lead to marasmus.  More frequently a more or  less decided convul-
 sion ensues, and the case may be marked by a series of convulsions,
 any one of which  may prove  fatal.   Sometimes cerebral symptoms
 continue during the interval, and the case  may bear the aspect of a
 meningitis.   Stupor, coma, and hemiplegia would indicate the occur-
 rence of cerebral haemorrhage.
   Diagnosis.—The recognition of  whooping cough in the convul-
 sive  stage is an easy matter.   The series  of rapid, sudden,  explo-
 sive, breath-taking coughs, attended by the evidence of venous stasis,
 cyanosis (whence the old name blue cough), which ceases only when
 a quantity of mucus, under the combined efforts of cough, retching,
 and vomiting, is expelled ; the prolonged expiratory efforts, followed
 by a  long-drawn, audible  inspiration, which  has been  not inaptly
 likened to the bray of  an ass; and the  gradual cessation of the dis-
 ease, sufficiently characterize it.
   The prognosis is for the most part entirely favorable.  Notwith-
 standing the  threatened suffocation and tremendous strain upon the
heart, recovery is the  rule, and that without a trace of lesion.  But
complications and bad surroundings may intensely exaggerate  the 
WHOOPING COUGH.
117
natural benign prognosis.  The prognosis is determined to consider-
able extent by the age and sex.  The disease is, as stated, from some
inexplicable cause, not only more frequent but  more severe in the
female  sex.  It becomes less and less  grave with advancing life.
Majer declares that ninety-seven per cent of all the fatal cases occur
under the age of five ; fifty-eight per cent in the first year.  Biermer
made a grand average of the  established mortality rate, based upon
the statistics of many authors, at 7.6 per cent, a figure that certainly
entitles the disease to respect.  The most frequent causes of  death
are: 1, suffocation from  spasm of  the glottis;  2, broncho-pneumonia;
3, haemorrhage; 4,  marasmus.
   The prognosis is grave where the attacks reach fifty in the course
of twenty-four hours; at sixty it assumes special gravity.  Individual
attacks may do damage also by their  intensity; thus haemorrhage
may be copious from mucous surfaces.  Blindness occurs occasionally,
probably from oedema of the brain.
   Prophylaxis.—As the disease  has, at least at times, such  grav-
ity,  prophylaxis assumes importance.  The only  prophylaxis worthy
of the name is isolation.  The patient must be  separated, not  only
from children, but from adults who  come  in  contact with  unaf-
fected members of the family.   As this  isolation, in a disease which
is usually considered so mild, is  practically impossible, attention
should  be  directed rather to the protection of delicate members of
the  family;  they should  be  isolated.   It is advisable that tuber-
culous,  rachitic, syphilitic, or otherwise diseased  or debilitated  chil-
dren should be removed from the house as early as possible.
   The most essential element in prophylaxis at all times is  the de-
struction of the sputum.  Though  the individual is attacked with
the suddenness of an explosion, mucus,  at least in quantities, is  not
expelled until the attack has  spent  itself, so that there is, for the
most part, time for the collection of sputum in water.  As in tuber-
culosis,  the handkerchief should never be used for  the reception of
sputum.
   Treatment.—The  older writers used the anodynes early.  Opium,
in some form  or other,  was the shield  which was soon interposed.
In more modern times the active principle of opium, morphia, was,
and  is  still,  extensively employed.  With the  morphia are  often
combined five- to ten-grain doses of the bromide of  sodium or potas-
sium, or there may be added the hydrochlorate of apomorphia.   The
remedies commonly employed in the treatment of bronchitis are also
frequently resorted to.  The syrup, simple or compound, of ipecac,
one-half to one teaspoonful; the wine of ipecac in half  these doses ;
minute doses of antimony, one-sixty-fourth to one-thirty-second of a
grain; belladonna,  one drop of the  tincture for each year  of life; 
US
INFLUENZA.
  or atropine, one grain to one ounce of water, given in doses of from
  one to two drops two or three times a day.  The iodide of potassium
  is a remedy of value.  It may be given as follows :
    5 Potassii iodidi..................................................§ ss.
      Aquae menthae piperita?......................................fl. 3 ss.
    M.   Sig. Two to five drops in a dessertspoonful of milk three or four times a day.
  Excessive vomiting may be relieved by chloral, gr. ii.-v.   Mild cases
  are best let alone.  Bad cases call for control by opium.   Change of
  climate is  the only remedy which does really sometimes "act like
  magic."
                            INFLUENZA.

    Influenza; la grippe;  the grip.—An  acute infection  caused by
  a specific bacillus and characterized by catarrhal,  gastric, and nerv-
  ous signs.
    Influenza has the same origin as catarrh, rheumatism, etc.—dis-
  eases  derived from the Greek word  meaning a flow or flux—but
  differs from these diseases in the fact  that its origin came not from
  within  but  from without.   It was  derived,  in the most ancient
  times,  from extraneous influence.  It was the "influence" of the
 stars or of the weather, mysterious telluric influence, that constituted     •
 influenza—an Italian word.
    Influenza takes  the front rank among the acute infections on ac-
 count of its extent.   It  surpasses all  other diseases in its range, in
 that it often covers  the entire globe.   It is the type of the pandemic
 diseases.  It never attacks solely individuals, but always  communi-
 ties, peoples, hemispheres.
   History.—Accounts of  it date from the earliest times,  and when
 first seen its  universal distribution was  appreciated.  It was cer-
 tainly recognized as early as 1173  in Italy, Germany,  and England.
 It prevailed as a true pandemic from  1510 on, at  different periods,.
 with intervals ranging from forty to one hundred years.  It showed
 itself in our own country first in  1627 in Massachusetts and Con-
 necticut, and extended to the West Indies  and South America as far
 as Chili, and it reappeared again and again with us, at varying inter-
 vals of five to fifty years, without any distinct periodicity,  up to the
 present time.   It is established of influenza, in a general way, that
 it originates in the East and extends over the West.  Thus the most
 recent epidemic that has visited our country was first recognized in
 Bokhara in May, 189o.   It  reached St. Petersburg in October, Ber-
 lin in November, London in December, and by the middle of Decem-
 ber showed itself in individual  cases in Philadelphia and New York,
 whence it gradually extended  over the United States, to appear in
Mexico in the following spring. 
INFLUENZA.
119
   Etiology.—The first cases of influenza are usually unrecognized.
The individuals affected are said to be attacked with a bad cold, or
nervous phenomena are interpreted as signs of other diseases, typhoid
fever, etc.  It is only when individual cases multiply that the poison
accumulates to sufficient extent to strike the masses, and this fact has
led to the belief in the  sudden  appearance of epidemics.   Influenza
is spread by human intercourse.  It follows  the line of travel, and
extends with the transportation of individuals by river and rail, with
the velocity in our day that corresponds to the rapidity of modern
transit.   Having traversed a country and gone beyond it, it is liable
to return and reappear,  especially among  individuals  previously
spared,  and thus the disease hovers about a country for  a period of
months, sometimes years, before it entirely disappears.
   The  cause is in the air.  Crews of ships have been seized in
the open sea.  The fleet under Admiral Kempenfeld had to put into
harbor in the  second week  at sea,  having had in the meantime no
connection with the  land; and this observation has been repeatedly
made.   Hermits are said to have been attacked in the woods,  or in
the caves of their isolated homes.
   Influenza travels against  the  wind as well as with  it, and is
totally independent of  climate, season, or  soil.  It is difficult to fix
the place amongst  the  acute infections  where influenza belongs.
Whether it shall be considered a miasmatic or a contagious disease
will depend altogether  upon what is meant by these terms.  Advo-
cates of miasm contend that the disease originates de novo, or that it
is carried by the wind,  and meet the objection that it is often carried
against the wind by the assumption that the wind at greater altitudes
moves in a different direction.  We are,  however, little concerned
with the direction of the upper strata of the air.  The wind at high
altitudes is more liable  to blow down the castles we build  in the air
than to  affect the habitations in which we live.
   It is  observed of influenza that it shows itself first along the lines
of river and rail, and that it appears first in towns about railroad sta-
tions, later in places removed from the lines of travel. Pfeiffer (1892)
discovered the micro-organisms of influenza as bacilli in the pus cells
of tracheal mucus.   They are minute structures,  about the breadth
and half the length of the bacilli of mouse septicaemia.  They are best
displayed with the dilute Ziehl or in the hot Loftier  methylene solu-
tion.   They are immobile in hanging drops.  The bacilli of  influ-
enza form  colonies on one  and a  half  per cent  sugar agar, visible
only  with a lens, in drops as clear as water.  An absolutely dis-
tinctive  feature, according  to Kitasato, is the fact that these  drops
always  remain apart; they never coalesce.  The bacilli penetrate
the peribronchial tissue to reach the surface of the pleura.  Canon, in 
120
INFLUENZA.
the same year, demonstrated the bacillus in the blood itself.  Toxines
from these micro-organisms develop the complications and sequelae—
endocarditis, nephritis, etc.—of the disease.
   No period of life is exempt, though infancy is comparatively rarely
attacked.  The greatest liability ranges from twenty to thirty.   The
period of danger is in advanced life.  The incubation  is short, two
to three days.  In most cases the onset is sudden.
   Symptoms.—Prodromata, when they exist in the exceptional cases,
consist of malaise, languor, headache, light catarrh.  The disease sets
in, as a rule, suddenly—a fact of value in a diagnostic way—and dis-
tinguishes itself in its course by three sets of symptoms, to wit, the
catarrhal, gastric, and nervous.   Epidemics vary greatly with re-
ference to the intensity or predominance of individual  symptoms.
Individual cases vary in still greater degree.  It is, however, the co-
incidence of symptoms on the part of these various organs which estab-
lishes the nature  of influenza and distinguishes it from other catar-
rhal affections.  The catarrhal symptoms may affect any part of the
respiratory tract;  i.e., there may be coryza, irritation, burning, dry-
ness,  or discharge from  the  nose, sneezing, hyperaesthesia of the
conjunctiva, photophobia, or catarrhal affection of the throat which
may not be  distinguished  from a  simple angina.  There is much
more  commonly  catarrh of the bronchial mucous membrane.   The
bronchitis of influenza distinguishes itself by its universality.  It
is a bilateral affection.  It shows great disposition to  extend to and
involve the  capillary bronchi, whence the liability to, and danger
of, catarrhal pneumonia. There is corresponding oppression about
the chest, difficulty of breathing, precordial anxiety.
   The gastric symptoms are more marked in childhood.  The disease
is often announced  in children by vomiting, and cases have  been
reported in which the severity of the vomiting has excited the suspi-
cion of the development of scarlet fever, cerebro-spinal meningitis, or
pneumonia.  As  a  rule,  however, gastric symptoms are  marked
rather by anorexia,  sometimes nausea, dyspepsia, more especially
duodenal catarrh with a light  icterus  manifest in the tint of the
conjunctiva.  Exceptional cases show diarrhoea, or even bloody dis-
charges.
   It is the  third set of symptoms—the nervous symptoms—which
more  especially distinguish influenza from other catarrhal affections
and give it its specific place as distinct  from  common catarrh.
There is headache, some of which may be accounted for by catarrh
in the frontal  sinuses, most of which, however, is toxic.  There  is
supra-orbital  neuralgia. The headache is frontal, more rarely oc-
cipital.   Neuralgic  pains wander about the  body.   Patients  com-
plain especially,  often bitterly, of  deep-seated muscle and  bone 
INFLUENZA.
121
pains.   There is with these pains  great depression of spirits,
something more than the mere hebetude of the inception of typhoid
fever.   These sinking sensations, which take the interest out  of
and create a  disgust for life, characterize well-marked cases of in-
fluenza.   In exceptional  cases nervous symptoms of graver charac-
ter occur.  The disease may be announced in a child in epileptiform
convulsions.   Various paralyses, chorea, tetanus, psychoses have
been noticed  in different cases.  A patient may be affected with in-
;Somnia for a week.  Roger reported the case of  a lady who slept
for over a week.   Da Costa mentioned the case of a woman, of great
delicacy and refinement, who greeted  the appearance of the physician
with blasphemy.
    Influenza calls out latent diseases.  This  is especially true of tu-
berculosis.   Many cases  date the origin of their various diseases to
an attack of grippe.  " I was all right until I had the grippe," is a
common observation ;  and while it is possible here to confound with
influenza the  symptoms of individual diseases, as of tuberculosis or
pneumonia, it remains true  that influenza is a common exciting
cause of these affections.
    Diagnosis.—The three sets of  symptoms—catarrhal, gastric,
nervous—distinguish the disease.   Influenza  is overlooked or misin-
terpreted only in  the beginning of an  epidemic when  the cases are
few. The predominance of nervous distress, more especially nervous
depression and dejection, is a characteristic feature of the disease.
    Prophylaxis.—According to observations Goldschmidt, of Ma-
deira, made in the presence of both diseases as epidemics, re vaccina-
tion with vaccine virus  protects not only against variola, but also
against influenza.  This statement needs verification.
    The prognosis of influenza itself is good ; the mortality is almost
nil, but the fraction of one per cent—Lynrote says 0.25.   Lee reports
1,120,000 cases in Pennsylvania  in  the  last  epidemic,  with 7,780
deaths, or 1  in 142 cases.   Nevertheless,  the occurrence of influenza
is a serious thing.   It calls out, as has been stated, latent diseases.  It
aggravates the progress  of all diseases  in course and terminates
many fatally.  The disease assumes special  gravity in  age.   It is
difficult  for an aged person to escape an attack of influenza with
good health.   It  is the  indirect cause of death in  many of these
cases—indirect through  catarrhal pneumonia or heart failure.   So
the death list is  duplicated through the prevalence of pneumonia ;
and while it is true  that the mortality list at the end of  the year is
not sensibly increased by the occurrence of an epidemic of influenza,
,it makes a great difference in  a community whether these deaths be
diluted through a period of months or years or be concentrated upon
•a few weeks. 
122
HAY FEVER.
   The treatment is now nearly specific.  To meet individual symp-
toms and sustain the patient for three to five days constitutes the
rational therapy of influenza.  A most essential factor is  rest.   All
patients  affected with influenza should observe  quiet and repose of
mind and body in a properly ventilated and warm room.
   Fever seldom calls for treatment.  The  temperature rarely rises
above 101° or 102°,  and when excessive is best met by sponge baths.
   The pain  is best relieved by broken doses of Dover's powder, or,
in the presence of much nausea, by phenacetin.   Phenacetin may be
given in a single dose of ten grains to an adult  to secure a peaceful
sleep.  Caution  must be entered against the abuse of  any antipy-
retic.  Where there is  much debility from  age or  heart weakness,
quinine may take its place.  The salicylates have  something of a
specific influence in relief of the symptoms of  influenza.  Choice
may be had  as  between  salicin, salol, and  salicylate of soda.   All
these agents, however,  have a  sensible  though  slight effect  in de-
pressing the  circulation, and should be administered in  conjunction
with a stimulant, a glass of wine or a dessertspoonful or tablespoon-
ful of whiskey.   A good salicylate in the treatment of influenza is
the salicylate of  cinchonidia.   Support of the Peruvian bark principle
counteracts the  depression of the salicylic acid.  It is bitter and in-
soluble, and hence should be given in capsule or pill in  dose of two
to five grains every two to  four hours.   The best single  remedy is
salipyrin, which may be given in powder or wafer in  the dose of
grs. x.-xv. every two to four hours.   Salipyrin  is almost  a specific
in the treatment of influenza.   During the attack all patients should
remain at home  at  rest, and in convalescence should expose them-
selves with caution.

                          HAY FEVER.
   Hay fever; hay asthma: catarrh us cestivus, summer catarrh;
June cold.—Catarrh of the  mucous membrane of the eyes and air
passages, produced only in sensitive subjects, by pollen, hence periodic
in recurrence and protracted in duration.
   History.—The disease is modern not only in recognition, but actu-
ally in origin.  It was first announced by Bostock (1819) as a " period-
ical affection of the eyes and chest," based  on personal experience.
Elliotson (1839) pointed to pollen as the probable cause of the disease.
Helmholtz, also  a sufferer, ascribed it to vibrios and lauded quinine
by insufflation in its relief.  Blackley (1S73), another victim, proved
pollen to be the true materies morbi.   Beard (1*70) laid stress upon
the neurotic temperament which constitutes the  susceptibility to the
disease.  The condition of the nasal passages themselves, as consti-
tuting susceptibility, is  a contribution of the last decade. 
HAY FEVER.
123
   Etiology.—Hay fever is a rare disease.   It  demands a peculiar
susceptibility or  idiosyncrasy, as. of the  millions exposed, but  very
few are attacked.  It is  almost  confined to the  Anglo-Saxon race,
and follows it in foreign lands, as in Asia and Africa, where the dis-
ease is unknown to the natives.  It spares  foreigners for the most
part in  England and America,   It shows predilection for males in
the ratio  of  2:1,  probably because of their -greater out-door ex-
posure.   It shows preference also for the upper classes, especially
for the clerical avocations.  It attacks maturity up  to  forty,  only
very exceptionally youth or age.  The  liability is  transmitted by
heredity ; and whether inherited  or acquired,  once  developed the
disease  recurs with  great regularity or  periodicity about the same
time every year.  Certain cases have anatomical foundation in the
condition  of the nose, in occlusions, hypertrophies, polypi, sensitive
areas, etc.
   Pollen is the chief if not the only cause.  Blackley proved by ex-
perimentation upon himself and others that the  disease was  caused
by pollen, aggravated by greater exposure and limited by less, as by
active movements out-doors or quiet within.  The pollen of many
plants will produce it.  That of the graminaceae causes ninety-five
per cent of cases.  Wyman ascribed most of the  cases in America to
the wormwood, which blooms in August and September.  The pollen
of plants  in blossom often fills the air, is wafted at times to great
distances, many miles, to be deposited, sometimes visibly, on roads
and streets, where it  may appear like sulphur.
   Symptoms.—Hay fever begins,  as a rule, suddenly, at or about
the day it is due—wherein it may be helped by a lively imagination—
as a coryza or an asthma.  The disease shows itself in two forms, ca-
tarrhal and asthmatic.   These forms may follow each other or co-
exist.   In the catarrhal form there  is coryza. The conjunctivae are
inflamed,  the  eyes  burn, and  hot tears run over upon the face.
There ispjhotophobia and headache.  The nose itches and  burns.
There is sneezing,  sometimes  violent and  persistent,   The whole
tract of the nose is blocked by oedematous  swelling, often of rapid
onset, of the entire mucosa.  The voice is nasal.   The inflammation
extends to the throat, which is also red and dry, with sensations of
rawness and  actual pain.
   In the asthmatic form there is sudden, oppressive, and persistent
dyspnaxi.  Wheezing sounds pervade the entire chest.  With this
distress there is the depression of  spirits and  disinclination or ac-
tual incapacity for effort which belongs to true asthma.
   The diagnosis depends upon the  recurrence—periodic—in sum-
mer, and persistence  throughout the exposure.
   The prognosis is  good, quoad vitam ; bad, quoad valetudinem. 
124
PNEUMONIA.
The disease subsides to leave no trace, but  recurs every year and
lasts for weeks or months.
   The treatment is addressed to the temperament or tendency, with
the administration of, especially, arsenic, which, in the form of the
liquor potassae arsenitis, is given in closes of gtt, ii.-v. tor in die to
tolerance.  The remedy should be begun  before the attack.  Qui-
nine ranks next in  dose of gr. v. twice a day, morning and eve-
ning.  During the attack some relief may be obtained with solutions
of cocaine, four to ten per cent, applied with a brush or by insuffla-
tion.   Unfdrtunately such  relief is too temporary to be of much
value.   The insufflation of  an ointment of  boric acid and vaseline,.
gr. xv. to 3 ss., soothes the  irritated  nasal  membrane.   Intense
conjunctivitis may  be  relieved by the instillation  of  a solution
of cocaine,  four per cent, or of morphia  gr. iv. to  aqua destillata
 1 ss.   Gargles of potassii  chloras,  or  internal exhibition  of the
solutio  saturata, 3 i. every two hours, help the throat.   Chloral
in small  doses, gr. v., may  relieve  the  asthma.   It is  common
practice  to  administer the iodides in  this as  in  other asthmas,
being careful to avoid iodism.  Belladonna generally does more harm
than good.  Morphine in small dose,  gr  ?-%, is sometimes  indis-
pensable.   Phenacetin  or  the salicylates relieve the headache and
the fever.  Patients should  stay in-doors and keep quiet.   The only
radical relief is change  of climate—i.e., sojourn in  some place dis-
tant from the cause, as at  the White  Mountains, Fire Island, etc.
But individual cases yield  to surgical treatment, the application of
the galvano-cautery, chromic acid,  trichloracetic acid,  etc., after
cocaine.
                           PNEUMONIA.

   Pneumonia (itvEvpovia, nvevpoov, the  lungs) ; fibrinous, lobar,
genuine pneumonia.—An ubiquitous, non-contagious, acute, general
infection, with its main  local expression in the lungs ; caused by a dip-
lococcus ; characterized by high fever, pain in the side, cough with
expectoration of a glutinous, rusty-colored sputum,  consolidation of
the lungs with coagulated blood, and resolution in five to nine days
with restitutio ad integrum.
   History.—Pneumonia was known as such and as peripneumonia
by Hippocrates, though not separably, in antiquity, from pleurisy and
other painful affections  of the lungs.   Even Sydenham (1670) failed
to distinguish between pneumonia and pleurisy.  The gross anatomy
was first described by Morgagni (1761).  Pneumonia was separated
into the three well-known stages, congestion, hepatization, and sup-
puration or  resolution,  by Laennec (1819), by whom the disease was
first recognized in  life  ; the lesion  (croupous exudation) was first 
PNEUMONIA.
125
 accurately described by Rokitansky (1841) ; the physical signs  and
 diagnosis were definitely  established by his contemporary and  col-
 league,  Skoda.  Acute croupous or fibrinous is so-called from its
 exudation ; lobar, from its extent; genuine, in distinction from catar-
 rhal, hypostatic, metastatic, etc., forms of pneumonia.
    Etiology.—Pneumonia, in all time limited  as a local  disease,
 "the type of  the acute inflammations." was finally evolved as an
 acute, general infection, with main local expression in the lungs, by
 Jiirgensen (1872); a pathogenic micro-organism discovered by Fried-
 lander  (1883), and more  conclusively demonstrated by  A. Frankel
 (1886).   The frequency of pneumonia is evidenced by the fact that it
 constitutes three per cent of all diseases and six per cent of all internal
 diseases; its gravity by the fact that it  causes  6.6 per cent of  the
 total mortality and 12.7 of the mortality of internal diseases, ranking
 thus in  frequency and gravity  next  to  tuberculosis.   The  disease
 occurs at all ages—three-fifths of the cases before the age of  fifteen ;
 and at all seasons—two-thirds of cases in spring and winter (minimum,
 September to November), with predilection for  feeble constitutions
 and in-door life.  Sinking subsoil water releases soil bacteria ; rain-
 fall by precipitation frees the air.  The history of seven hundred  and
 fifty cases examined by Dietl showed previous perfect health in but
 eighteen per  cent.  Contrary to common  belief, pneumonia is  not
 contracted by trauma or by taking  cold.   Trauma  may produce an
 inflammation  of the lungs,  but not  a  croupous pneumonia.   Under
 trauma  are included inhalations  of dust.   Thus the  percentage of
 cases among coal merchants not  especially exposed  to dust is 14.4 ;
 among coal miners, working in almost suffocating dust, but 4.7.   Ex-
 cessive use or straining of the lungs, as in playing wind instruments,
 crying  vocations, etc., do not  predispose  to attack.   Regarding
 " cold " it may be said that over eighty per cent of individuals at-
 tacked can recall no exposure in explanation of the  origin of the  dis-
 ease.  Soldiers are attacked in  garrison  life, seldom  during field
 service;  sailors  ashore or when near the coast, seldom upon  the
 open sea.   Deaths  from  pneumonia  among the  nuns of  Paris
 amounted to  7.02 per one  thousand ; among washerwomen, 3.05.
 Among six hundred and seventy laborers constantly exposed  to cold
 and wet, engaged in loading vessels,  Parent-du-Chatelet found  but
 one  case of " congestion of the lungs " Prisoners and factory girls
 furnish a large contingent of cases.  The ratio of  deaths among deni-
 zens of cities and the country is as 5 : 2.  Cold and trauma may, how-
 ever, act exceptionally as exciting or localizing causes in cases where
the real cause pre-exists in the body, just as injuries to the skull and
spine may localize abscess  of the brain and caries of the spine, or
measles excite tuberculosis. 
126
PNEUMONIA.
  it.

®  >
/
'\\

 Fig. 89.—Pneumococcus
of Friedlander; oval cells
■with gelatinous envelope.
   It was the recognition of these facts, together with the observations
that the disease (1) has different temporal and spatial relations from
affections commonly ascribed to taking cold :  (2) that other organs
                    besides the lungs—notably the heart, brain, kid-
                    neys, and  spleen—are often also  involved ; (3)
                    that the  general symptoms, fever, prostration,
                    gastro-intestinal signs,  etc., do  not,  by any
                    means, of necessity correspond with  the  extent
                    of invasion of the lungs, which should be the
                    case in a local disease (i.e., slight invasion of ten
                    shows grave symptoms,  and vice versa) ; fin-
                    ally, (4) that the disease  runs a specific course,
terminating at a definite period, after the manner of most of the acute
infections—which led Jiirgensen, a close, keen, and critical observer,
to anticipate  the  disclosures  by the bacteriologists
of the real cause of the disease in certain  definite
micro-organisms.
   Bacteriology.—Of the various micro-organisms
found in pneumonia,  two have been finally elimi-
nated as pathogenic—viz., the  pneumococcus  of
Friedlander and the diplococcus of Frankel. Fried-
lander and Frobenius described as " pneumococcus "
certain micro-organisms discovered in sections  of
hepatized lung tissue, in the alveolar exudation, and
later in the rusty sputum.  These micro-organisms
could be cultivated and inoculated to produce the
disease.
   Inspected  in hanging drops they are seen to  be
thicker in one diameter, hence to constitute really
very short bacilli.  As found in the body they are
enveloped in  a distinct capsule which encloses,  as
a rule, but one, exceptionally two or more elements.
They belong to the  class of facultative anaerobes ;
thrive, hence, without  oxygen.  They are  motion-
less.   In staining, the capsule remains  uncolored.
They do not fluidify gelatin, and develop in the test
tube in  the form of a nail  with  a thick  head.
They thrive  upon  agar  and  luxuriate upon the
potato.  They are found in but 5.5 per  cent  of
cases.
   It is now  established that the true pathogenic micro-organism of
pneumonia, found almost universally in typical cases—ninety-two per
cent of cases (Weichselbaum)—is the " diplococcus " of Frankel (first
seen and described by Sternberg), which is closely allied to the pneu-
 Fig. 90. — Pneumo-
coccus of Friedliinder;
stick culture in gela-
tin, nail shape. 
PNEUMONIA.
12?
mococcus of Friedlander.   This coccus is also, strictly speaking, a ba-
cillus, with one end pointed—" lancet-shaped " (see Frontispiece, Fig.
6).  It is found in pairs, whence the name; sometimes in rows or beads
of five or six or more elements ; is also encapsulated in  the body, but
never out of  it as in cultures.   It differs from the pneumococcus in
admitting of double coloration, and in not being decolorized by Gram's
method.  It grows with difficulty upon gelatin,  thrives upon agar
and in bouillon.  Injected into the blood of rabbits  and guinea-
pigs, it produces septicaemia, which is fatal in twenty-four to forty-
eight hours.  Introduced  directly into  the lungs of rabbits, mice.
guinea-pigs, and dogs, it produces intense inflammation of the pleura
with condensation of the lung tissue, identical with the lobar pneu-
monia of man.  A peculiarity of this micro-organism is the rapidity
with which it loses its  virulence in four to  five days.  Successive
cultivations with every precaution show loss of infecting properties,
which can be maintained only by return to
the animal body every  ten days.  Heat at-         t
tenuates and finally abstracts the infectious   f.   ^
principle, and thus the diplococcus becomes
attenuated in a few days at 41° C. and in-   %   y^
nocuous in twenty-four  hours at  42° C.   ^0  £ e
These diplococci have  been  found in  the   °  <^
dust Of the floors Of houses, as also ill the   Fig. 91.-Diplococcus pneumo-
saliva of healthy individuals, as have, how-  Dise <F™kel weichselbaum): a.
                                           lancet shape  ; 6, in gelatinous
ever, other  pathogenic  micro-organisms,  envelope^, d, m rows and beads.
Staphylococcus aureus, actinomyces, etc.
   The avenue  of  entrance into  the body is not definitely  estab-
lished.  It has wide distribution in the body : throat, ear, meninges,
joints, kidneys,  pleura, peritoneum, etc.  Inhalation experiments do
not furnish uniform results.   Entering the lungs, it excites in these
organs  specific inflammation, attended by hyperaemia and  hepatiza-
tion, to be followed by fatty and mucous degeneration  and the stage
of resolution.   From the lungs or other portal  it enters the blood,
in which  it has been occasionally detected,  to lodge by preference,
in individual  cases, in  the  spleen, kidneys,  endocardium,  and
membranes of the brain, etc.   AVhether the  inflammation in these
organs  depends in all cases upon  the  diplococcus of pneumonia or
upon other secondary invasions, as of streptococci, staphylococci,
etc., remains as yet  undetermined.  The differentiation of the diplo-
coccus from the pathogenic streptococcus is often very  difficult.
   The short duration of the disease corresponds with the short life
or infectiousness of the diplococci.   They evolve products, antitox-
ines,  fatal to their  growth.   Phagocytic processes not yet  dem-
onstrated  of  these  micro-organisms  do not need to be invoked to
 
128
PNEUMONIA.
account for the duration or the recovery from the disease.  Irregular,
secondary, and complicated cases of pneumonia may be  produced
or explained by invasion of other bacteria, as by the streptococcus,
staphylococcus, other diplococcus, typhoid bacillus, etc., all of which
may undoubtedly produce inflammation of the lungs.
   Symp)toms.—Pneumonia begins, as a rule, suddenly, without pre-
monition  or  prodromata, which may, however,  occur in less than
one-fourth of cases.   Thus malaise, wandering  pains, and  distur-
bance of digestion may precede an attack of the disease one or two
days.  Pneumonia is generally announced by a violent chill, often
at night,  the severity  of which is equalled  only by a sharp attack of
malaria or small-pox.   The chill is especially pronounced in adoles-
cence or adult life.  In infants the onset is marked by  coldness of
              Fig. 92.                            Fig 93.
   Fig. 92.—Diplococci from sputum, acute pneumonia, early stage: a, pus cells, c, diplococci
with capsules (Woodhead and Hare).
   Fig. 93.—Diplococcus of pneumonia in sputum, much more highly magnified.
the surface, vomiting, convulsions, or even coma; in the aged and
cachectic the onset of the disease is much more insidious.
   Fever rises rapidly, reaching its greatest elevation about the
third day.   The chill and fever are accompanied or quickly followed
by sharp pain in the side, due to accompanying  pleurisy, for  lung
tissue itself is not sensitive to pain.  Pain is, as a rule, wanting in
old people, in whom the disease usually begins more centrally, t< > ex-
tend outward much more  gradually.  By  the  second day the fever
is high, especially in young patients.   In children it not infrequently
reaches 105°.   In adults 104°  represents an average case.  The  tem-
perature is often out of all proportion to the amount of invasion of
the lung.  It may stand at 105° when the lesion of  the lung may be
difficult to fix,  or may scarcely show itself until the half or whole of 
PNEUMONIA.
129
the lung  is blocked with  blood.   After the  third  day  the  fever
begins to  show daily remissions, and by the fifth to the seventh day
it falls suddenly, especially in the young, reaching the normal degree
within thirty-six hours—i.e.,  by'crisis.  The "crises" (xpivoo,  to
decide) of the older writers were mostly based upon  studies of fever
in pneumonia.   In the majority of cases, however, fever ends rather
by a rapid lysis (Xveiv, to dissolve).   Fluctuations occur throughout
the disease.   Such uniform  or sustained elevations as are  charac-
teristic of typhoid  fever are unknown in pneumonia.  Crisis is pre-
ceded  or  caused by leucocytosis,  which liberates  antitoxines.   The
ratio  of white  to red corpuscles may be at this time  1: 60 or 1:40—
a valuable prognostic point.   The fall of temperature, with general
Fig. 91.                             Fig. 95.
   Fig. 94.— Temperature chart; fibrinous pneumonia; adult; crisis on sixth day.
   Fig. 95.—Temperature chart; fibrinous pneumonia in child; pseudo-crisis on seventh, real
crisis on tenth day Q3ichhorst).

subsidence of symptoms and resolution of the  disease,  occurs  in
twenty-three per cent of cases before  the seventh day,  in seventy-
six per cent before the ninth  day.   In  advanced  age,  or cachexia
at  any age,  the fever frequently  runs  quite  a  different course,
the ascent  and  decline being much more gradual and the  course
more protracted.  The typical  curve is also altered by  complica-
tions.  This rapid rise of temperature at the start distinguishes  a
typical pneumonia from a typical typhoid fever.
    Cough commences within the first two days, often with the pain.
It is due either to associate bronchitis or pleuritis, usually to both.
Since some degree of bronchitis is  always  present,  expectoration
consists at first of frothy mucus, to assume  later a more significant
        U
005900 
130
PNEUMONIA.
 appearance.   The sputum becomes thick,  viscid, tenacious, adher-
 ing  to the  receptacle like  glue, even when inverted.  About  the
 second or third day, in a large proportion of cases, it has imparted to
 it a peculiar rusty or brick-dust color, due to admixture of blood
 corpuscles.  This color is not usually present in pneumonia in  old
 age.   Pure blood may show itself  in streaks, or be itself the sole
 constituent of sputum.  Liquid, black or dark "prune-juice spu-
 tum," often accompanied by fcetor  due  to mixed infection, is  of
 grave import  as indicating decomposition of the blood.  Purulent
 sputum, which is more common, also  proves mixed infection with
 pyogenic bacteria, but is not of necessity so grave.
   Respiration is soon increased to 30 to  40 per minute.  It is hur-
 ried, shallow, superficial,  and painful—painful because of pleu-
 risy.   It is, as a rule, more  rapid in  children than in adults ; it may
 remain unaffected in age.   The pulse, 100  to 120, full and  bounding
 at first, becomes later  soft  and feeble.  It is not increased in  the
 same ratio  with  the respiration.   Very early  in the  progress  of
 the disease the pulse-respi rat ion  ratio  is disturbed, respiration
 being  hurried out of  all proportion to the pulse.  Thus   the nor-
 mal ratio, two to nine, or one to four and  a half, may become two
 to four, two to three,  or  even one to one.   The  majority  of cases
 show temporary albuminuria, due to retarded circulation during
 the height of  the  disease.   The  chlorides diminisii and may  be
 entirely absent from the urine, as is  readily shown by the  nitrate of
 silver test.  They reappear about or  at the  time of crisis.   This sign
 has lost much of its  former diagnostic and prognostic  value since
 the observation that  the same change occurs in the  urine in other
 fevers.   The presence or absence of  chlorides is largely a  matter of
 refusal or lack of digestion of food.
   Herpes occurs in about fifty per cent of cases.  The vesicles  ap-
 pear iqjon the  face or  exceptionally over  the body.   Herpes is of
 prognostic as well as diagnostic significance.   It does not show itself
 in typhoid fever.   In  a large majority of cases in which it occurs in
 pneumonia in  well-developed form it foretells recovery.  The appear-
 ance of herpes is more welcome because it shows itself early, usually
 about the third day of the disease.   Unfortunately it  does  not occur
 so often in age.
   Physical Signs.—Pneumonia picks by preference upon  the right
lung, the base rather than the apex.   It is bilateral  only in excep-
tional cases, and then more  especially in drunkards.   Pneumonia at
the apex is  often confounded with tuberculosis.   Inspection shows
 limited expansion.   The difference  in the  excursion of the two sides
is best seen when viewed from behind.  It is perhaps better  appre-
ciated by palpation than by inspection, the hands being placed flat 
                           PNEUMONIA.                        131

upon the postero-lateral parts of the chest.  Percussion may disclose
an alteration of  the note,  even  early  in the stage of hyperaemia,
The  sound may become tympanitic and thus deceptive.  This sign is
wont to recur after resolution, and may persist for several weeks.  A
little later, in a few hours to  two or three days, percussion shows
dulness over a sharply defined area.  It may  be observed only upon
the posterior aspect of the chest.   When doubt arises as to the  char-
   Fig. 98.—Section of alveolus of lung in croupous pneumonia, filled with exudate consisting'of
fibrin, with desquamated epithelium and red and white blood corpuscles.

acter of  the pneumonia, whether croupous  or catarrhal, unilateral
dulness  speaks  for croupous,  bilateral  for catarrhal pneumonia.
Vocal  fremitus  and  resonance  are both increased.   Auscultation
furnishes the most valuable  evidence in pneumonia, as it reveals
something characteristic in the first as well as in the second stage of
the disease.   During the stage of hyperaemia the bronchioles as well
as the air cells  become more moistened from exudation into their 
132
PNEUMONIA.
interior, so that the act of inspiration separates them, and the pene-
tration of air is attended with a fine crackling sound, the crej>itant
rale.  This sound, which is often likened to that which is heard when
salt is thrown on the  fire, and is closely simulated  by rubbing the
hair between the fingers near  the ears,  is heard only at the  end of
full inspiration.  Heard in this stage at  this time, it is known as the
crepitans indux.  It is soon obliterated.  The air cells  and bronchi-
oles are filled with blood, which coagulates to form a cast of their in-
terior.  The lung has become solidified.  A piece of it exsected sinks
in water.  There is no longer question of the penetration of  air be-
yond the larger bronchial tubes.
    The second stage of the disease has  now set in, and the natural
vesicular rale, the crepitant rale, disappears entirely, to be substituted
by bronchial  respiration.  Sometimes nothing is heard in the act of
respiration.  This silence is often more eloquent than sound, as indi-
cating the effusion of fluid in the pleural sac.   The crepitant rale is
of value in establishing the nature of the disease, because it is heard
at the base of tluj lungs, where other diseases which might produce
it do not naturally exist.   A  crepitant  rale may  be heard  also in
tuberculosis, bronchitis, and is often closely simulated by the friction
sound of pleurisy.   The location of the sound under  the  clavicles in
tuberculosis, everywhere over the chest in bronchitis, and  in  both
cases with other associate sounds; the location of the sound in the re-
gion of the nipple in pleurisy, helps to distinguish these affections.
With the bronchial respiration there  is  often bronchophony, heard,
as a rule, most distinctly about the angle of the  scapula, or, in  apex
pneumonia, under the  clavicle. After the absorption of blood in the
process of resolution the crepitant sound returns.  It is then heard
in connection with both inspiration and expiration, and is known as
the crepitans  redux.   It is now, 'as a rule, accompanied by coarse
and fine mucous and submucous rales.
   Pneumonia resolves itself,  as stated, in seventy-five per cent of
cases, in from five to nine days. Most of the blood is absorbed, some
of it is converted into mucus and expectorated.   In certain cases the
process of resolution does not occur.   Suppuration takes place.  The
air cells and bronchial tubes  are filled up with pus.  The disease is
said to have passed into the  stage of suppuration.  This process of
suppuration does not belong to pure pneumonia.  It follows mixed or
subsequent infection with the micro-organisms of pus.  It occurs in
connection with the pneumonias produced by these micro-organisms,
by that of the typhoid bacillus, etc.  This event  may not be  known
by any special change in the signs elicited by percussion and  auscul-
tation.  It is recognized rather by general symptoms, by the prostra-
tion, weakening of the pulse, chilly sensations, rise and fall  of  tern- 
PNEUMONIA.
133
 perature, resulting from pyaemia ;  sometimes by sweats, by the ap-
 pearance of pure pus in the sputum ;  sometimes by the appearance
 of disorganized blood to constitute the " prune-juice " sputum.
    The pleura is  almost always involved.  The disease is essentially
 a pleuro-pneumonia.  Sometimes pleurisy predominates throughout
 the history of the disease.   Not infrequently it overshadows the
 pneumonia during the first few days.   Ordinarily it subsides, so that
 pleurisy with perceptible effusion is  present in but  five per cent of
 cases.
    As already stated, pneumonia is  a general infection.  Its chief
 local manifestation is in the lungs.  It involves, however, other or-
 gans, in which it sometimes shows its main symptoms.  In two hun-
 dred and thirty cases of pneumonia treated by Liebermeister in the
 hospital at Basel, occurred as  complications :  pleuritis with abun-
 dant exudation, forty-one times;  well-marked acute nephritis, but
 once ; diarrhoea, twenty-five times ; meningitis, probably on account
 of the prevailing epidemic of cerebro-spinal meningitis, twice ; peri-
 carditis, nine  times ; endocarditis, twice ; icterus, sixty-five times ;
 decubitus, five times.
    The frequency with which the  brain  is affected  is indicated in
 the  old names, cerebral or  meningeal pneumonia.  Many cases are
 marked  by nervous  symptoms, especially in childhood  and  age.  A
 temperature of 103°  in childhood or 102° in old age  is not  uncom-
 monly attended with delirium.  The micro-organisms of pneumonia
 show a predilection for the meninges of the brain.  Victims of  alco-
 holism attacked with pneumonia show brain symptoms, as a  rule.
 Slight albuminuria is  often  found  in  pneumonia, as in any febrile
 disease, due to high  temperature and blood stasis.   In a certain pro-
 portion of cases true Bright's disease ensues.  The spleen is enlarged
 in about one-half  the cases.  Sometimes the disease seems to spend
 its force  upon the digestive system with all the signs of  gastro-intes-
 tinal catarrh.   Icterus is a very frequent sign.
   Though pneumonia is of  short duration, it is frequently attended
 with serious parenchymatous change.  In all cases the  chief danger
 is on the part of  the heart.   The interference with the circulation
 throws extra  work upon the heart, since it must force the same
 amount of blood through a smaller  amount  of lung  tissue.  The
 heart is also directly damaged by the toxic products of the  disease.
 It becomes thus incompetent to do the extra work thrown  upon it.
 Heart failure results.   The majority of deaths in pneumonia is due,
not to high fever, nor to sepsis in its ordinary sense, nor to any of the
previously mentioned complications, but to paralysis of the heart.
The  condition of  the heart is, therefore,  the index to the situation.
Heart failure  may be indicated by general prostration, increase in 
134
PNEUMONIA.
the dyspnoea, cyanosis.  Above all other signs, the pulse in pneumo-
nia is to be closely and continuously watched  throughout tin1 course
of the disease.  An irregular, compressible, fluttering pulse, fading
when the arm is elevated,  is a sign of a flagging heart.  Nine-tenths
of the deaths from pneumonia are due to heart failure, which shows
itself, in the majority of cases, by the fifth or sixth day of the disease.
Every effort is, therefore,  made  to conserve the  strength of  the
heart, and under  no circumstances is a patient allowed to rise in or
from  the  bed.  The mere elevation of the  body for the purpose of
examination has proven fatal.   Bad cases should be simply turned
over in bed.
   Many forms of pneumonia were formerly described, based chiefly
upon  symptoms, not upon causes or  lesions.   True  pneumonia runs
a course so typical as to be explicable only by a uniform typical cause.
But abortive, protracted, and irregular forms do undoubtedly occur,
as do also rapid, migrating, asthenic, etc., forms.  The pneumonia
potatorum is a dangerous form.  "Congestion of the lungs" is  a
common term for a pneumonia  aborted in one or two days.   After
exudation there can be no  abortion.   Resolution, once begun, usually
proceeds rapidly to completion, with restitutio ad integrum  in. the
great majority of  cases.   Cachectic cases may be protracted even in
the absence of complication.  Cirrhosis, abscess, and gangrene of
the lungs as sequelae imply mixed infection.   The same may  be
said of tuberculosis as  a sequel.  The diseases sometimes coexist,
and certain cases of apparent pneumonia pass gradually into tuber-
culosis ;  especially is this  the  tendency when the pneumonia  is
apicial.   This sequence is of course not a transformation, but is, in
the majority of cases, an awakening of a  hitherto latent tubercu-
losis.   It must be understood,  however, that a pneumonia, pur et
simple, may run a typical course at  the  apex  of the lungs.  Catar-
rhal pneumonia may also coincide or supervene.
   The differential diagnosis practically concerns, 1, Typhoid fever.
Sometimes such a minor event as an epistaxis, which does not occur
in pneumonia, or the appearance of herpes, which does not occur in
typhoid fever,  may turn the diagnosis in the early stage.  Most
cases of typhoid  show diarrhoea early, whereas constipation  is the
rule in pneumonia. The temperature of pneumonia runs up rapidly,
to reach its greatest elevation, as a rule, by the second or third day,
while that of typhoid ascends  gradually during a period of one or
two weeks.   The cloud about the brain, which so soon establishes
the nature of typhoid fever, is  absent  in pneumonia, or present  in
only the last stages of the disease.  In the course of a few days the
physical  signs in  the chest in the one case, in the abdomen in the
other, will usually clear up any doubt.   A little later the roseola  of 
PNEUMONIA.
135
typhoid fever is distinctive.   It must be appreciated that pneumonia
and  typhoid fever may coexist, and that the typhoid bacillus may
produce pneumonia.
   2. Meningitis is  sometimes confounded with pneumonia.  Cere-
bro spinal meningitis is often announced in the same way, suddenly,
with a violent chill, and both diseases  may show herpes and consti-
pation.   In meningitis, however, early vomiting, opisthotonos, and
hyperaesthesia develop rapidly, while physical signs  on the part of
the lungs are wanting.  In doubtful cases  the diagnosis may be es-
tablished by the discovery of the diplococcus in the sputum.   The
preparation, colored with fuchsin, decolorized with dilute alcohol, re-
colored with methylene blue, shows the diplococcus blue in a red cap-
sule.  In seventy successive cases thus examined by Wolff the dip-
lococcus was discovered sixty-six times, the pneumococcus  three
times, the result being negative in but one case.
Inoculation experiments succeeded  in twenty-
two  of twenty-four  cases.  It must not be  for-
gotten that these micro-organisms  have been
found in the nasal mucus and saliva in health.
   Thus also is the disease differentiated from,
3, Tuberculosis.  The failure to make a correct
diagnosis is due, in  the majority of instances,
,         ■,    i            i  '   n n               Fig. 97.—Diplococcus of
here as elsewhere, to neglect of the proper ex-  pneumonia in sputum.
amination of the lungs.  This is especially true
regarding the debilitated and aged, and the remark is worthy of re-
petition  that pneumonia is  a disease of age.   The greatest number
of old people succumb to this disease.
   The prognosis of pneumonia depends upon three factors—the age,
habits, and condition of the heart.   In children the prognosis is good,
the disease having almost no mortality at this period of life.   In ad-
vanced age the mortality is estimated as high as sixty per cent.  The
disease is most fatal of all in drunkards.  The existence of a chronic
valvular disease of the heart intensely aggravates the prognosis.  A
pulse over  120 is grave.   High fever is an index of gravity.   Fen-
wick (London Hospital, one thousand cases from 1880 to 1890) found
the mortality in direct ratio  to the fever.  Albuminuria is grave in
proportion  to its amount.  Taking cases as  they come, the mortality
averages about  ten  per  cent.   The disease is,  therefore, fully as
fatal as typhoid fever with all its complications.
   It is  impossible to speak intelligently of prophylaxis without
more definite  knowledge of the mode of ingress and action of the
cause of the  disease.   To inure the body by  exposure to fresh air
and  by cold baths,  with well-ventilated sleeping apartments,  the
avoidance of defective hygiene in every way that concerns the habi- 
136
PNEUMONIA.
tation and the ventilation of the lungs, to protect the heart by avoid-
ance of stimulants or mental anxieties, nearly covers the ground.
   In treatment  a case of pneumonia calls for a large, well-venti-
lated room.   The temperature of  the room should  not be allowed to
rise above 68°, as recorded by a thermometer at the head of the bed.
Here it is important to remember and repeat the fact that the disease
is not due to taking cold, and that there need be no fear in securing
free ventilation.   An abundance of pure air is of supreme import-
ance in the treatment of this disease of the lungs.   The respiratory
centres are best stimulated,  in the presence of  high fever, with cold
baths,  or with baths which may begin  at moderate temperatures
and be gradually reduced.   Where for any reason baths are imprac-
ticable, they may be substituted with an occasional  dose of quinine
or phenacetin.  There is seldom call for the treatment of fever in
pneumonia.   Cough does not often demand special treatment.  Any
excess of cough  may be best relieved  by Dover's powder gr. ij. or
iij., or apomorphia gr. tV~tV or the syrup of senega 1 drachm every
two to four or six  hours.  Small doses of  morphia, gr.  ^ in cherry-
laurel  water  or  peppermint water,  are most efficacious.  Morphia
also  best relieves  pain, and, by permitting deeper respiration, best
prevents oedema  of the lungs  and protects the brain.  Poultices or
other external applications to the chest are of no value  except in re-
lief of  pleuritic pain.  Dry cups will drain  an inflamed pleura, an
ice bag sometimes gives intense relief, but morphia subcutaneously
is the sovereign anodyne.  Sleeplessness may be met by sulphonal or
trional, gr. xv. in hot milk or tea, or by  small doses of chloral, the
latter always to be preceded by the administration of gtt. x.-xx. of
dilute hydrochloric acid, or to be taken in connection with a wineglass-
ful of sherry wine or a dessert-  or tablespoonf ul of whiskey.   Where
the heart is feeble, as in the  aged  or drunkards, chloral must be ad-
ministered with caution and  in minimum dose, gr. ij.  or iij.  In these
cases it is often better substituted by morphine, gr. T^ - \.  Any un-
due intolerance of the stomach may be brought  into subjection by
small doses of chloral in peppermint water,  or a  drop  or  two of
creosote, with the tincture of nux vomica ;  or, after failure of these
remedies, by rectal injection of the bromide of sodium gr. xxx. or xl.,
chloral gr. v.-xv., or morphia subcutaneously gr. ■$--■$■.
   The real danger, as stated, lies with the heart.   The best support
in ordinary cases  is alcohol  in  the form of whiskey, which may be
given to an adult in dessert- to tablespoonf ul doses every two to four
hours.   A call for a stronger stimulant may be  met with brandy,
with coffee, or both.  Cold sponge baths always fortify  the heart.
   Among the drugs the most valuable are caffeine, the soda ben-
zoate, two or three grains every two or three hours ; strophanthin, 
TUBERCULOSIS.
137
 sparteine, and digitalis.  Sparteine and strophanthin may substitute
 digitalis for a short time in case of great irritability of  the  stomach.
 Digitalis is always best when it may be borne.  The infusion,  fresh,
 made from the leaves, may be given in the dose of 3 i. to  3 i. every
 two to four hours, or the tincture, five to ten drops at the same inter-
 val.  The danger of the drug is in tetanizing the heart, which may be
 avoided by withdrawing the remedy so soon as the hard, wiry, digi-
 talis pulse begins to be felt.   It is wise in all cases to administer some
 form of alcohol as the patient approaches the crisis, and it is not un-
 wise to stimulate moderately from the start.
    Behring,  Kitasato,  and the Klemperers utilized the antitoxine
 derived from the blood of immunized animals  in prophylaxis and
 cure of the  disease.  The antitoxines in the blood serum of man
 rendered "' immune by crisis "—i.e., withdrawn just after the crisis—
 proved equally effective in the experiments of Neisser in aborting
 the  disease.   Such  serum, withdrawn two or three days after the
 crisis, and  injected,  one hundred and thirty, seventy, and fifty cubic
 centimetres respectively, into the arms of patients in the height of the
 disease, cut it short within twenty-four hours.

                         TUBERCULOSIS.
   Tuberculosis is the specific infection produced by tubercles, which
 are in turn special products of a distinct micro-organism known as
 the Bacillus tuberculosis, or,  from its discoverer,  Bacillus Kochii.
   Tubercle is the diminutive of tuber, a nodule,  induration, projec-
 tion mass.  Though  the word tubercle is as old as anatomy, the term
 tuberculosis,  in designation  of  a  definite  disease, is modern.   Vir-
 chow has shown conclusively that tubercle, in  its modern specific
 sense, cannot be found in the works of ancient writers, who used it
 only to  express a  morphological meaning.  It is difficult to fix the
 time when  the term began, by common consent, to be limited and
 confined to the special disease, for the reason that the distinct isola-
 tion of the affection is an acquisition of such recent date.   But it is
 safe to say that the day begins with Bayle and Laennec (1810 to
 1819) when they  declared, with proof, that " tubercle is the  cause
 and constitutes the proper anatomical  character of pulmonary phthi-
 sis."  As both Bayle and Laennec literally consecrated  their lives to
 the study of this disease, they may be  said to have earned the right
 to make, or rather to  fix, its name.  The word " tuberculosis " itself
 was first employed by Schonlein (1839), a disbeliever in the specific
 character of the disease.
   Phthisis—literally wasting, consumption—was the  Greek name,
as an expression of  the  most prominent symptom of the disease.
Phthisis was the term for the wasting disease attended or caused by 
138
TUBERCULOSIS.
suppurations of the lungs ; it included abscess, gangrene, suppura-
tive pneumonias, empyemas, etc.—in short, all varieties of suppura-
tive processes.   As each of these affections was gradually eliminated
and set upon an independent footing,  phthisis came to be limited to
the condition which, since  the days of Laennec. is  more properly
known as pulmonary tuberculosis.
    The existence of tubercles in the beginning  or course  of the dis-
ease, at some period or place in the body, justifies the adoption of the
general name tuberculosis, while the localizations in the lungs, intes-
tine, testis, etc.. are sufficiently defined as tuberculosis pulmonalis,
intestinalis. testis, etc.
    The history of tuberculosis falls naturally into five periods, three
Fig. 98.—Tubercle bacilli—sputum.
of which, at least, are quite distinct, in that they date from the dis-
coveries of  distinct individuals—Bavle and Laennec, Villemin, and
Koch.
   The first is the period of ancient history.   During all this period
the disease was  observed only  from a clinical standpoint.  The
second period, beginning with the birth of anatomy in the sixteenth
century, furnishes the first definite knowledge regarding changes or
lesions  of structure.   The  third  period  followed the publication of
the discoveries of  Bayle and Laennec in the first quarter of the nine-
teenth century, declaring tuberculosis a separate affection, due to the
deposit of tubercle,  a specific product independent of  ordinary in-
flammation.  This period is made more distinctly memorable by the 
TUBERCULOSIS.
139
discovery of auscultation as a means of diagnosis.  It was the genius
of Laennec in the discovery of auscultation which first rendered pos-
sible a diagnosis of the disease in life.   The fourth period was intro-
duced late in the last half of the nineteenth century with the inocu-
lation experiments of Villemin (1865)  ; and the fifth was announced
with the discovery by Koch (1882) of the tubercle bacillus as the de-
finite cause of the disease.
   The discovery of the tubercle bacillus gave the final death-blow
to the doctrine  that tuberculosis was ever in any sense secondary.
The spectre of inflammation, which perpetually stalked to  the  front
to obscure the  true  nature  of  the  disease, was quieted  forever.
Fig. 99.—Tubercle bacilli with spores, in sputum.
 Instead of producing the disease, inflammation is itself relegated to a
secondary place in pathology as a mere result of infection.
   We may epitomize the history of tuberculosis with the statement
 that it was regarded first as a process of suppuration (pus) ; then  as
consisting of nodules, which in the third period are seen to be dis-
tinct tubercles ;  fourthly, these tubercles contain a virus ; and in the
final period the virus takes shape in the tubercle bacillus.
   The tubercle bacillus invades the body through the lungs,  in
 which it produces the disease commonly called  consumption ; or,
reaching the bronchial glands, is thence disseminated at some future
time to the brain (meninges), bones (vertebrae, hip joint, etc.), and
other organs and  tissues  (larynx, testis,  serosae,  etc.), to lead  to
sepsis and slow marasmus.  Introduced into the intestinal canal with 
140
TUBERCULOSIS.
food (milk), it ulcerates the mucous membrane, to produce diarrhoea,
marasmus, or fatal peritonitis.
   Tuberculosis in its various forms destroys two-sevenths  of man-
kind.  Tuberculosis of the lungs alone carries  off one-sixth  of man-
kind and nearly one-third of the working class.
   Etiology.—The tubercle bacillus is a slender rod whose length is
about one third of the diameter of a red blood corpuscle.  It is about
five times as long as broad.  It varies somewhat in size, but presents
such nearly uniform appearance as to be used as a standard of com-
parison for other bacilli.   It lies usually slightly curved, but is often
perfectly straight and uniform throughout its  length, except where
it  is apparently  broken  by intervening highly refracting  spherical
spaces, four to eight in number, which are regarded as spores.  Bacilli
of rapidly developing disease show these spores in greater number.
Fig. 101.— Tubercle bacilli in sputum.
In retrograde or quiescent processes they are usually entirely absent.
The figures show various common pictures of  the bacillus, with and
without spores, in the sputum ; also frontispiece, Figs. 10 and 16.
A point of singular interest is the fact that the bacillus is quite as
resistant to heat and  destructive agents  as the spores themselves.
The Bacillus tuberculosis is distinguished  by its extreme tenacity of
life.  It is invested by a membrane so dense as to be almost impene-
trable  by dyes  in long  saturation, or by the aid of heat.  This very
fact, however, which made the bacillus  so difficult of detection, led
later to its easier recognition ; for the membrane, having once become
permeated, retains the color in subsequent attempts at displacement,
so that while an original color may be displaced in surrounding ob-
jects by a new dye, the bacillus retains its own color, whereby its
presence may be recognized  by difference  or contrast of color ; color


"'"ISI?--.-;!:.- >
Fig. 100.—Tubercle bacilli in sputum. 
TUBERCULOSIS.
141
All that
^X\
/>A   • J.
V
\
4

w',
Fig. 102.—Tubercle bacilli in sputum.
 being more obtrusive than shape.  Colonies cultivated with difficulty
 appear as scales upon the surface of the soil selected, usually gelatin-
 ized blood, and do not invade the substance of the soil.
    What is the original source of the Bacillus tuberculosis
 is known is that it has come down to
 us from the older civilizations.  The
 Indians of  our own country, the ne-
 groes of Central  Africa, the inhabi-
 tants of islands of Australasia, never
 knew tuberculosis until it was brought
 to them by Europeans.  So. too, tuber-
 culosis was unknown  in the North,
 among the Esquimaux, Laplanders,
 etc., until they received it by impor-
 tation.   Once  received it  is  propa-
 gated by direct  descent.   Resistant
 as is the bacillus,  so tenacious of life as to  be able to live for months
                 outside of the body, it is nevertheless a strict para-
                 site.   It may live, but not grow and multiply, out-
                 side of the body.  Man, with many other mammals,
                 especially the cow, offers the best soil for the growth
                 and maintenance of the tubercle bacillus, and  the
                 disease is spread chiefly by the desiccation and dis-
                 semination of sputum.  The sputum is nearly a pure
                 culture of the Bacillus tuberculosis. Diluted 1 :400,-
                 000 times, it will still propagate the  disease in the
                 bodies of rabbits and  guinea-pigs, animals most of
                 all susceptible  to the  disease.  Inoculation is  the
                 final test in a doubtful case.
                   The discovery of the fact, made by Koch, that the
                 disease is chiefly conveyed by the dried and disse-
                minated sputum, met  with remarkable confirmation
                in the investigations of  Cornet.   Inasmuch as it
                had been impossible to discover the tubercle bacillus
                in the dust-laden atmosphere, or in the dust deposits
                upon  walls, ceilings,  furniture, etc.,  of rooms in-
                habited by tuberculous patients. Cornet undertook
                to collect it under every precaution, and to establish
                its infectiveness by inoculation of guinea-pigs, rab-
                bits, and other sensitive animals.  This  experiment
                succeeded in two-thirds of the cases.
   It  had long been noticed that relatives in close association con-
tracted the disease from each other—husbands from wives, wives more
especially from husbands because of the closer contact and confine-
 Fig. 103.—Colonies of
tubercle  bacillus in
scales on  surface of
blood serum, six weeks
old. 
142
TUBERCULOSIS.
ment in the house.  So  the  disease1 had been observed to extend
through factories and prisons, showing a mortality equal to fifty per
cent after a long confinement.  It had been remarked, indeed, that
confinement to prison  for life is condemnation to death  by tubercu-
losis.  Flick called  attention to  the fact that so many cases occur in
individual  houses that  a  house  remains a centre of infection for an
indefinite time.  Seventeen of twenty-two deaths from marasmus and
meningitis in children occurred in houses which had boon infected by
tuberculosis of the lungs and bowels in adults.   Niven. observed (hat
twenty-six of forty-five cases were contracted in a house where death
occurred; sixteen in houses previously occupied by tuberculous  pa-
tients.  McMullen called attention to the danger of sea voyages with
consumptive companions in confined cabins, and the same danger has
been remarked, though in less degree, with the discovery of tubercle
bacilli in sleeping cars.   Individuals who make the beds, dust and
sweep rooms of patients  are the most exposed.   Seventy-three per
cent of nurses up to the age of fifty die of tuberculosis.
   The tenacity of life of the bacillus was demonstrated in  one  re-
markable experiment, where a feather bed upon which  a consump-
tive lay was sent to five different cleaners in Berlin, and  an infusion
made of the feathers after its return the last time proved infective
to guinea-pigs.  The disease, therefore, is chiefly  conveyed through
the avenue of the  lungs.  Tuberculosis  pulmonum is the common
expression.  The bacilli,  inhaled  and  inspired everywhere in the
bronchial tubes, come to lodge more  especially at the apices of the
lungs.  Received anywhere in  the  bronchial tubes, they  are  more
readily expelled from the middle and lower regions of the lungs, or
are coughed up into the apices—parts furthest  removed  from the
blood supply, regions also more quiet for growth and multiplication.
There is no proof that the disease is  ever  inherited  in man, though
inheritance is assumed as a potent factor in the transmission of the
disease.  Thus it is said that of one hundred patients affected with
phthisis, twenty-five will  have had  tuberculous parents ; but if we
recall the fact that these one hundred patients had two hundred pa-
rents, it will be seen that twenty-five represents heredity in but one-
eighth of the cases, whereas  we know already that tuberculosis is
fatal, in the lungs alone, to one-sixth of all mankind.   If the disease
were  produced by  heredity it should  appear  first in the internal
organs—the liver, spleen, the kidneys, etc.  It should be discoverable
also in the foetus.  It is known, however, that tuberculosis  appears
first in the lungs, and in children only at the end of one or two  years
of life.  Advocates  of heredity maintain, to account for the absence
of the disease  in the  new-born child,  that the micro-organism is
transmitted in the form of spores.  The burden of proof rests with 
TUBERCULOSIS.
143
them.   In the meantime  it is observed  that the disease  appears
nearly always in the lungs, whence it is evident that  the  cause  of it
is inhaled from the outside air.   But when, in the more  exceptional
case,  tuberculosis affects  other, even  distant  organs,  an  autopsy
reveals the existence, or the evidence of pre-existence, of caseous bron-
chial or mesenteric glands as  depots  or centres  of infection.  The
theory of heredity is dangerous, in that it removes attention from the
avoidable sources  of the disease.   It is unsatisfactory, in  that it does •
not prove enough.  It is  also undemonstrable :  experiments made
to prove it are all  open to objection.   Finally, it is superfluous.
   Certain individuals are said to be predisposed to tuberculosis.
This predisposition  is stated to be  announced  by  an  elongated,
flattened thorax,  a long,  narrow neck, a  thin skin  with apparent
blue veins, an enfeebled musculature, etc.  This condition is  de-
clared to  constitute the phthisical habitus.   The truth is, these indi-
viduals are already the hosts of the tubercle bacillus and  the victims
of the disease.  Deutsch has  shown that there is no predisposition in
the configuration of the thorax, and that broad-chested men  contract
the disease as  readily as  those with  narrow chests.  It is claimed
that certain catarrhal conditions of the mucous  membrane predis-
pose to the disease.  This may  be, but the fact has not been demon-
strated.  Predisposition is  probably largely a matter of  quantity or
number of  bacilli inhaled.  Conditions which markedly  interfere
with the nutrition of the lungs  may be admitted to favor the reten-
tion and growth of micro-organisms.   Thus it has been noticed that
individuals in whom the pulmonary  artery is small easily become
victims to this disease.  Congenital stenosis of the pulmonary artery
is nearly always attended with or followed by tuberculosis.
   On the other hand, certain anatomical conditions render  an  indi-
vidual less liable to be attacked.  Such conditions as favor venous
stasis or hyperaemia offer  obstacle to the  development  of tubercu-
losis.   Thus tuberculosis does not occur, as a  rule, in cases of val-
vular  disease of  the heart,  asthma,  or  emphysema. Exceptional
cases sometimes admit of explanation.  Thus clinicians  differ as to
the effect of aneurism of the aorta.  Aneurism of  the aorta, so long
as it causes a venous stasis,  interferes with  the  development of
tuberculosis.   When it, however, attains such size or disposition as
to encroach upon the pulmonary artery, it  will favor tuberculosis.
There is probably  no such  thing as  an individual predisposition to
tuberculosis.  A man may  have weak lungs, as he may have a weak
stomach, weak eyes, or a weak brain.  This weakness may  be said
to constitute a predisposition to disease of any kind, and in this way
only may  be admitted a predisposition to  tuberculosis.   Degraded
surroundings constitute  the  chief predisposition to  the  disease. 
144                      TUBERCULOSIS.

Trudeau showed that infected rabbits confined in dark, damp holes
speedily succumb, but allowed to run about in the open air recover
from the disease.
   The chief source of infection—by the alimentary canal—occurs
through the milk of tuberculous cows.  Bollinger showed that milk
may be infectious even though the udder show no signs of disease.
Ernst and Hirschberger confirmed this fact.   Dilution of the milk,
which diminishes the relative proportion of bacilli, renders it  much
less  infectious, so that it may be said, as a rule, that milk from a
large dairy is not so dangerous as milk from a single tuberculous cow.
   Cases  of  infection through mucous membranes or the broken
skin are much more rare.
   Symptoms.—Tuberculosis of  the lungs begins,  as a  rule, insi-
diously, and usually  in one of  three ways: first, as a  bronchial
catarrh;  second, with general fa ilure of health ;  third, as a dys-
pepsia.   Other individual  cases begin  with disturbances of men-
struation,  with  metrorrhagia,  more  especially with  chlorosis or
amenorrlaea.   Other  cases follow in  the  wake of a tuberculosis
localized elsewhere, as in the bones of the spinal column or  the  hip.
In ot infrequently the disease of the lungs lies latent  for a  time until
brought into prominence by some  intercurrent affection.  Measles
and pertussis very frequently awaken tuberculosis.  In a more ex-
ceptional case the disease appears suddenly as an acute pneumonia,
acute pleurisy, a sharp haemorrhage, etc.
   The majority of cases begin with a bronchial catarrh.  These in-
dividuals are said to have taken '' cold."   They are subject to taking
cold.  On every slight exposure they take cold, and the cold  distin-
guishes itself by its persistence.  They take cold with  every change
of weather, with every change of clothing, often without  any kind
of  exposure.  The  cold becomes more suspicious when  the  cough
which marks it occurs with greater frequency just after retiring, or
just after arising in the morning.   The change in the blood current
is invoked to account for this occurrence.
    A gradual  deterioration of strength,  vigor, color,  appearance is
noticed by relatives and friends.   The  individual is said to be "fall-
ing  into a decline." The general degradation of strength and health
very often overshadows the cold.
    Certain poisons are evolved from the soil in which the tubercle
bacillus grows  to affect the nutrition, to produce dyspepsia.  The
menses are withheld, delayed, more especially in young girls about
the  time of puberty.  In all these cases the physician entertains first
the  suspicion  of  tuberculosis.  Pneumonias  which are situated at
the  apex should more especially excite the suspicion of a tuberculous
basis or origin.   The pleurisies which are "insidious in their develop- 
TUBERCULOSIS.                       145
 ment, which are not attended with much  pain, but are marked by
 more profuse effusions, belong to tuberculosis.
    Bronchial  catarrh  becomes more significant when  associated
 with.physical signs.   It must be remembered, however, that there
 is a pre-pliysical stage of tuberculosis, often of months' duration.
 Sooner or later  characteristic  signs  develop in the  chest.    These
 changes can be recognized first by auscultation.  The hyperaemia of
 the bronchial walls under the first irritations of tuberculosis roughens
 the inspiratory sound.  The inspiration  is  said to be  rude,  like
 that of a child, puerile.  Soon the elasticity of the lung tissue is
 impaired.   It takes the lung a longer time to contract.   Hence expi-
 ration is prolonged.  This rudeness of inspiration  and prolonga-
 tion of expiration is observed in its finer shades only  by comparison
 with the  sound side.   Moist  rales develop  later,  and these moist
 rales of bronchial catarrh  have peculiar  significance  in their locali-
 zation.  All these signs point  to tuberculosis when  they are fixed
 about the region of the clavicles.
    -As the  disease advances  these symptoms  show  themselves in
 greater intensity.  The cough becomes more  continuous, it prevents
 sleep at night, and so harasses  the patient during the day as  to lead
 in its violent efforts to vomiting and  the  loss of food.   The cough
 shows itself  in all grades of intensity in different cases, and  in  the
 same case at different  times.   It must be remembered that cough
 which is  attended with expectoration is really salutary.   Cough
 literally expectorates  the disease, and  it is only when it becomes so
 severe as  to lead to the ejection of food, or so harassing as  to pre-
 vent sleep, that it calls for alleviation.
    The expectoration becomes now more  characteristic. There is
 ejected along with the frothy mucus more or less solid matter, parti-
 cles or pellets which are often pure cultures of the tubercle bacillus.
 The whole mass of the  sputum becomes more solid.  Expectorated
 in water, it assumes a more or less globular or coin  shape and sinks
 to the bottom of the vessel.  This is the sputum rotundum funclum
 petendum of the old writers.   The quantity of the sputum  varies
 in every degree in different cases, and in the same case at different
 times.  At times  violent efforts secure nothing.  Again the sputum
 is so profuse as to constitute a bronchorrhcea.   Many individuals
 empty cavities  in the lungs in the morning  upon rising, and then
 cough no more for hours or even during the day.  This is the his-
 tory of certain cases for months or for  years.  For the most part  the
 cough varies.   In states of fever, along with general dryness of  the
 mucosae, there is little or no expectoration.  In  apyretic  states it is
 apt to be more profuse.   With the  extrusion of sputum the true
character of the disease is  disclosed.  Whatever doubt existed  be-
        10 
146
TUBERCULOSIS.
fore is cleared up with the discovery of  ttie tubercle bacillus or of
elastic tissue.
   Certain cases, as stated, begin with haemorrhage   Many cases
show no haemorrhage from  beginning to end.  Haemorrhage occurs
in about half the cases.   It alarms the patient at first ; it produces a
condition of anxiety and trepidation.  This apprehension, however,
ceases with  its repeated occurrence, so that later it may not excite
sufficient alarm to secure the rest requisite for its relief.  The haem-
orrhage does a good turn at times in beginning cases by impressing
upon the individual the nature of his case and enforcing the neces-
sity of treatment.   Haemorrhage  is rarely profuse.  It shows itself,
as a rule, after or in association with a light degree of fever.  Cer-
tain cases become conscious of it only on awakening.  The pillow
or clothing is stained with  blood : the taste in the mouth attracts
attention.  For the most part it is  accidentally discovered as it is
received in a vessel.  In exceptional cases the patient is suffocated
in his own blood ; the haemorrhage is so profuse as to inundate the
trachea.   Other exceptional cases where the haemorrhage is abun-
dant but not so inundating in character literally die of  loss of blood ;
but, as a rule, haemorrhage ceases under the rest and light diet of a
few days, or is cut short by appropriate  treatment, to return or to
recur again and again in the history of the case.  Haemorrhage is not
more common in tuberculosis because the blood vessels are blocked
by the advance of the disease. Cases marked by haemorrhage live,
as a rule, as long as those in which there is no haemorrhage.
   Pain in  the chest  is a common expression of the disease.  Infra-
clavicular pain is always suspicious ; it is, as a rule, pleuritic.  The
pain of intercostal  neuralgia  from  the toxic effect of  the disease is
common throughout its course.
   As the disease advances and the lung tissue is encroached upon,
the patient becomes more and more short of  breath.  Dyspjiaea be-
longs to all more  advanced  cases,  from  mechanical reasons, also
from marasmus  of the  heart and  muscular failures.   There is  a
dyspnoea which  belongs to  the earlier history of the  disease, when
there is no  marked consumption  of the lung tissue.  It is  a toxic
effect.  It belongs,  along with the excitability of the heart—erethis-
mus cordis—in the earlier stages of the disease.
   The fever continues and becomes absolutely characteristic.  Sus-
picion of the nature of  the  disease in  its inception is confirmed for
the most  part by the presence of  the fever in the evening.  The
temperature rises from one-half to two  degrees every evening, to
subside again toward midnight, to show a normal or even subnormal
grade in the morning.   High temperatures are preceded by chills
and followed by  sweats.  Increase in fever marks new invasion by 
TUBERCULOSIS.
147
the organisms  of  pus.   The chill, fever,  and sweat belong to sep-
ticaemia.  Sometimes the fever is high only at noon.
   The prognosis is  largely determined  by the fever.  In a con-
firmed case the fever rises from the normal grade in the morning to
Fig. 104.—Hectic (i.e., septic) fever in tuberculosis.
104° or 105° in the evening, to fall again the same night, and to
show thus such abrupt elevations and descents as to  constitute that
         Fig. 105.—Phthisical thorax in a girl eighteen years old (Eichhorst).

see-saw record characteristic of sepsis.   The fever  depends not so
much upon the extent of the disease as upon secondary infection by
the streptococcus of pus.  It does not, therefore, necessarily stand
in any connection with the amount or  degree  of consolidation or 
148
TUBERCULOSIS.
destruction of  lung tissue, though, as a rule, high fever and rapid
destruction coincide.   The  tubercle  bacillus grows slowly.  The
streptococcus may rapidly flood the lungs.
   Phthisis, as stated, is derived from the Greek word  c/iHiM. to
waste.  It has  its Latin equivalent in consumptio,  and emaciation,
is the most characteristic feature of the disease.   The people speak
of an individual who is losing  flesh rapidly as going into a decline,
meaning thereby a subject of  tuberculosis of the lungs.   A loss of
weight, along  with  pallor, chlorosis,  ameiiorrliaea, erethism of the
heart, dyspnoea upon exercise, slight fever in the evening—these are
the symptoms which announce  the inception of  the disease ; but no
one of these symptoms is so obtrusive in its further course as the
progressive loss of weight.  An individual may lose one-third, even
one-half, his weight.  The fat entirely disappears.  The muscular
tissue, the glands, even the bones, the nervous tissue least and last,
all suffer loss of weight.   Yet during the quiescent periods of tuber-
                                  culosis  the weight  may  be  re-
                                  gained.   Patients may thus  in-
                                  crease in weight ten, twenty, or
                                  even thirty pounds.  An acces-
                                  sible scales is a valuable adjunct
                                  in the treatment of tuberculosis-
                                     Along with the fever  or  fol-
                                  lowing the fever there is, as a
                                  rule, more or less of a sweating
                                  stage.  It is noticed in the early
                                  history of a case of  tuberculosis
                                  that the skin is unnaturally moist.
                                  The hands are either dry and hot
or moist and hot, clammy.   Tuberculous patients are very prone to
show discolorations  upon the skin, and especially in the region of
the sternum, from pityriasis versicolor, fungi which grow in the skin
on account of its increased moisture.  When sweating becomes pro-
fuse it constitutes a feature of the disease, and, inasmuch as it occurs
after the fever, it is known as night sweat.  Night sweats may be so
profuse as to saturate the  clothing and  bed linen to such an extent
that the patient suffers actual cold, and the clothing must be changed
in the night.  Such sweating is sometimes colliquative.
   It is a curious fact that these night sweats  come and go in the
history of a case of tuberculosis under circumstances which do not
admit of explanation—that is, they disappear of themselves at times
under the  same conditions as existed during their appearance.   Ap-
peal is made in explanation to the action of the sympathetic nervous
system, to  the  effect of septic toxines on sweat-producing centres.
   Dyspepsia belongs to tuberculosis.  Many cases, as remarked, are
 Fig. 106.—Tubercular ulcer of ileum (Med. and
Surg. Hist. War of Rebellion). 
TUBERCULOSIS.
149
preceded or announced by an obstinate dyspepsia.   It is at first due
to the poisoning of the blood, later, to some extent, to deglutition of
the sputum.  It is the history of most cases to show, during the first
stage of fever, constipation.  Later on, far along, nearly all cases of
tuberculosis show diarrhoea.  The diarrhcea is due to  the direct in-
vasion of the mucous membrane by the tubercle bacillus as conveyed
to the intestines by the sputum.  It is also due to sepsis.
    The ulcers of tuberculosis are found in great-
est abundance in the lowest part of the ileum
about the ileo-caecal valve, in the same region as
the ulcers in typhoid fever, and  for the same
reason—that is, that  the bacillus'received into
the upper  part is hurried along the alimentary
canal  under a more rapid peristalsis until it
reaches the lower part of the ileum, where move-
ment is checked that  absorption may take place,
and where time and rest are offered for  the  ac-
tion of poisonous matter  or  poisonous micro-
organisms.  Ulcers are  found in the intestines
of tuberculous  patients  in ninety per cent of
cases,  and along with these ulcers, in correspon-
dence  largely with their abundance, diarrhoea,
which becomes finally colliquative.
    Invasion  of the larynx is probably  always
secondary to invasion of the lungs.   It is  pos-
sible to conceive of a primary laryngeal tuber-
culosis, and cases have been recorded in which
a post-mortem  examination has  failed  to dis-
close centres in the lung.   We may look, how-
ever, with suspicion upon all these cases.  Tu-
berculosis  reaches the body through  the lungs,
and finds  lodgment, if not in the lungs, in the
bronchial glands.   Recent investigations show
more and  more the frequency of involvement
of the bronchial glands.  It is here that tuber-
culosis sleeps during the quiescent stages of the disease, and  hence
it irradiates as from  a lair.   Tuberculosis  of  the larynx  shows  no
sign at first  different from an ordinary catarrh.  Later,  however,
the hyperaemia becomes more pronounced, the swelling more intense.
Pure cultures are to be seen at times upon the surface,  and with the
erosion of tissue occur the well-known tuberculous ulcers and deform-
ities of the disease.   Tuberculous patients very commonly become
hoarse  of  voice ;  at times, and not infrequently, aphonic.   These
conditions are explained by the hyperaemia of the mucous membrane
 Fig. 107.—Tubercular ul-
cers in the larynx and tra-
chea, seen on vertical sec-
tion: a, deep ulcer over the
arytenoid cartilage;  b, su-
perficial ulcers of trachea
(Ziegler). 
150
TUBERCULOSIS.
and the paretic states of the subjacent muscles.   Later on the total
loss of voice, together with the difficulty in deglutition, is accounted
for by the gross destructive change.  The tubercle bacilli seem to
find a favorable nidus  for development  in the regions about the
larynx, and perhaps there is no place in the body in which they revel
in such luxuriant growth.
   In correspondence with the progress of the disease, with the loss
of substance, and the fever, the  colliquative night sweats, and diar-
rhoea,  the patient's strength becomes more and more reduced, the
movements of the body more and more confined to the house, to the
room, the  chair, the sofa, and the bed.  This progress may extend
over months or years, or over the greater part of a  lifetime, with ex-
acerbations and remissions, with quiescent stages of months' or of
years' duration.
   During the first stage of the disease the physical signs are few.
There  is  no  perceptible limitation to the excursion  of  the  chest.
Some degree of emaciation may be  remarked.  There is no  differ-
ence in mensuration, and no, or very slight, difference in percussion.
But auscultation reveals the rudeness of inspiration and prolongation
of expiration  in the early history of the disease.   A little later the
movements of the chest become more limited and in advanced cases
almost annulled.  The breathing in these cases is chiefly diaphragm-
atic, abdominal.
   Differences in  expansion may be more readily recognized  by
mensuration.  All cases of pronounced tuberculosis show a diminu-
tion of so-called vital capacity.  For practical purposes it may be said
that the difference between inspiration and expiration in a man of
the stature of five feet eight inches should  be  three  full inches.  In
tuberculosis this difference is lessened.   A  difference of but two and
a half inches should excite suspicion.  A difference below two  inches
points  strongly to  the  character of the disease.   Percussion now
shows dulness under the clavicles.  Slight shades of difference are
recognized best by comparison of one side with the other.  Auscul-
tation furnishes the evidence of  consolidation.  There is  bronchial
respiration, bronchophony, or evidence of pleuritic effusion, or great
thickening of the layer  of  the pleura itself.  Inspection shows now
marked change in the contours of the chest.   The thorax is flattened,
the intercostal spaces sunken.   The clavicles and scapulae stand out
in bold prominence.  It is the picture described by Aretaeus. The
absorption of  fat from the body  changes the physiognomy. The
features are sunken.  A curious condition  is noticed in the fingers.
The hands themselves become so thin as  to be diaphanous, and the
absorption of the fat at the ends  of-the fingers gives rise to that pecu-
liar condition called "clubbed." 
TUBERCULOSIS.
151
Fig. 108. — Shred
    The diagnosis rests upon the discovery of the bacillus in the spu-
 tum.  When first revealed the disclosure of the bacillus took the time
 of twenty-four hours to secure saturation with color.   Many subse-
 quent improvements have been made in this original process, so that
 at the present time the examination occupies scarcely
 more than fifteen minutes.  The most  effective means
 in general use at present is the so-called carbol-f uchsin
 test:  Aquae  destillatae one  hundred, acidi carbolici
 crystal, five, alcohol ten, fuchsin one.   A particle  (of
 sputum)  is placed  upon  a  cover glass,  covered and
 pressed over  the whole   surface by a similar  glass,
 which is then drawn away.   The glass is dried in the
 air, then drawn  thrice, specimen side up, through a
 flame, whereupon it is covered by the coloring fluid of elastic tissue in
 hot, then immersed one  minute in the  decolorizing spu um'
 fluid—viz., water fifty, alcohol thirty, nitric acid twenty—and finally
 stained with  methylene blue.  Tubercle  bacilli stand out red in a
 blue field.  Masses of sputum should be first boiled with liquor sodae
 and allowed to deposit sediment over night.  While the presence of
 a single or distinct bacillus  would establish the disease, absence of
                              the bacillus does not necessarily ex-
                              clude it,  as the specimen  examined
                              might not include any bacilli.  Re-
                              peated  examination may  thus  be-
                              come necessary.
                                  The diagnosis may be established,
                              in a case at all advanced, by the dis-
                              covery in the sputum of elastic tissue.
                              For this examination  no particular
                              skill  or apparatus is demanded.   A
                              morsel of sputum, preferably a gray-
                              ish  or  reddish-yellow  particle,  is
                              pressed upon the slide by the cover
                              glass, to reveal at once, best after the
                              addition of a drop of a thirty-per-cent
                              solution of caustic potash, the curled
 fibre of elastic tissue, usually, on account of its incompressibility,
 near the edge  of the glass.
   In all other cases of tuberculosis, of the skin, glands, bones, testis,
etc., as well as in all concealed, latent, or quiescent cases, the diag-
 nosis may be declared in the course of a few days  by the subcuta-
neous injection of tuberculin—one milligramme of the diluted 1 :100
solution—which will  produce fever in tuberculosis, but will have  no
effect in other diseases or in health.            »
 Fig. 109 —Elastic tissue with epithelium
and bacteria. 
152
TUBERCULOSIS.
   The prognosis is determined  by various factors, chief among
which  are the habits of the  patient with regard to personal cleanli-
ness,  especially with regard to destruction of the sputum.   Many
patients, by neglect  of  these precautions, live in  an  atmosphere of
tuberculosis of their  own creation, so that  there is more or less con-
tinuous auto-infection.  The actual extent of invasion is a factor of
importance, but,  strange as it may appear, of  rather secondary im-
portance.  A  pure atmosphere  free from the streptococcus of pus
gives the best prognosis.
   The continued progress of the disease is indicated best by fever, hec-
tic.  Night sweats furnish signs of more value in a prognostic way
than the amount of lung tissue invaded.   It must  always be remem-
bered that at any time periods of quiescence may occur, that the dis-
ease may be brought to a standstill, that even in conditions of des-
perate outlook improvement may take place for a time.
   The condition of the heart is a factor of value, as indicated by the
strength of the pulse.  A feeble pulse is a bad omen.   The degree of
dyspnoea furnishes striking evidence.  Superficial, shallow respira-
tion indicates rapid advance.   Implication of the larynx  is a bad
sign.  Well-marked laryngeal tuberculosis gives the patient not much
longer than three to six months to live.
   Diarrhoea, especially if profuse or obstinate, indicative of more or
less  extensive ulceration,  occurs toward the close  of nearly all cases.
The signs of marasmus in general, oedema of the  feet, vertigo, more
or less complete syncope,  are ominous signs.
   Prophylaxis.—From what has been  said already, the prevention
of tuberculosis resolves itself into  a  simple problem,  to  wit, the de-
struction of the sputum.  True, cases are acquired in other ways, as
by the food, milk from tuberculous cows.  Tuberculosis may be in-
troduced through the skin,  but all these other ways are exceptions.
The mass of tuberculosis  comes through the lungs.  It  is no longer
a question of inheritance.  The  theory of heredity  is, as  has been
shown, superfluous and injurious.  The prevention of the disease, as
we know it, in the lungs follows as a matter of course from destruc-
tion of the sputum.   Cuspidors should stand in every room and  hall
of houses inhabited by tuberculous patients.  The cloths used as
handkerchiefs should be burnt before any drying may occur.  Pa-
tients should  expectorate in water, and cuspidors  or spit cups should
be emptied twice a  day.  Houses inhabited by tuberculous patients
should be subject to sanitary inspection when absolute reliance may
not be placed upon the cleanliness of attendants.   It  is not necessary
to isolate tuberculous patients.  It is absolutely necessary to remove
a child from the breast of a tuberculous mother.   It  is not necessary
to prevent the marriage of tuberculous patients. 
TUBERCULOSIS.
153
   The prevention of tuberculosis depends upon the destruction of
the sputum and the thorough boiling—i. e., sterilization—of milk.  All
else is trivial.   With these two precautions tuberculosis will practi-
cally cease to exist.
   The radical treatment of tuberculosis implies some address to the
destruction of the cause of the disease, or to the rendering of the soil
of the body infertile for its growth.  Search has been  made for a
specific ever since  the time  the disease  was known  to be a specific
affection.   So long as it was  believed that tuberculosis was only a
secondary affection consequent upon other diseases, it was irrational
to look for a specific treatment.  Chlorine was introduced  as a specific
in the time of Louis, who found it valueless : and one substance after
another in materia medica, recommended as a specific, weighed in the
balance, has been found wanting.   All these remedies were empirical.
   The treatment of tuberculosis up to the present time consisted in
climate  and cod-liver oil, with address to symptoms  in individual
cases.  There is unanimity of opinion regarding the  value of climate
in the therapy  of  phthisis.   Any climate which permits outdoor
exercise is of value ; but the value increases with  altitude, and in
still more marked degree if  the altitude be dry.   A high, dry air is
best suited for phthisical patients.  Climatic considerations are  best
fulfilled in  our  country in  Colorado, at the altitude  of about five
thousand  feet above the  sea.  Wyoming, Nevada, Montana,  New
Mexico, all offer points of greater or less elevation, together with
the comforts of  life—a sine qua non.   There is no contra-indication
to climate except that which experience may furnish  in an individual
case.  It has been found that  cases are less liable  to haemorrhage in
the altitudes.   Cases in which  fevers  are less  marked do the best
here as everywhere,  and here as everywhere quiescent cases all im-
prove.  Many,  perhaps most, recover absolutely.   Latent depots
are often  left, to be  awakened  into renewed  activity upon return
home.  Advanced cases  secure  the best  advantage in milder cli-
mates.  The islands in the ocean, the Sandwich Islands, the  Baha-
mas, especially  Nassau, the Bermudas, are sojourns at sea without
the disadvantages of a ship, which is to  most  people, as  it was to
Johnson,  '' a prison with the  additional disadvantage  of danger of
death by drowning."  Gestation at sea was recommended by Galen.
Many cases recover in the longer trips of sailing vessels  or in the re-
peated voyages of  officers, ship surgeons, etc.  Mild  cases, as stated,
are benefited by any change of climate which permits life in the open
air.  The house climate in which the disease is begotten is inimical
to recovery.  A high, dry climate acts by increasing the respirations
as well as the  activity of the heart.   The lungs are thus better fed
with air and with  blood.  The air of altitudes  is more pure ; it is 
154
TUBERCULOSIS.
also more  dry.   There is less  self-infection  and less infection by
sepsis.  The products of the disease are more rapidly dissipated.
   Of all the internal remedies used in the treatment of tuberculosis,
but one holds its place as having any real virtue.  This remedy is
creosote.   Testimony increases  as to the value of creosote.   To be
effective the remedy must be pure.   Impure preparations contain car-
bolic acid, which injures the stomach.   The patient must be saturated
with the drug.   Guttmann has shown that the tubercle bacillus will
not grow in solutions of creosote 1 : 4000.  Such saturation is impos-
sible, but large doses are  given  with  the best effect.   It is adminis-
tered best in mixture with equal parts of tincture of gentian or tinc-
ture of nux vomica.   The patient may take five drops of this mixture
three times a day in an equal number of  teaspoonfuls of whiskey and
water, equal parts.  The creosote mixture is to be increased a drop a
day, the whiskey and water a teaspoon a day up to  ten, whereupon
intermediate doses between meals and bedtime should be commenced
and increased likewise up  to ten, so that the patient  takes finally ten
drops in ten teaspoonfuls of whiskey and water six times a day.   At
this time the body is saturated.  Creosote is perceived in the breath,
in the exhalations from the skin, etc., and by this time the patient
begins to improve.  It is astonishing what change  takes place in cer-
tain cases.   It may be said, as a rule, that the afebrile cases do the
best, but fever is no contra-indication.  In many cases the fever sub-
sides ; night sweats cease ; cough disappears ; the patient gains in
weight, strength, and spirits.  But not in all cases.   There are many
disappointments.  There  are cases which gain temporarily, to lose
later under continued administration, and there are cases which are
not benefited from the start.   Harm  the remedy cannot do.  Cornet
believes creosote acts only by improving digestion.   Another expla-
nation is offered in the neutralization of certain tuberculous toxines,
or in the aseptic  properties of the drug, as its name implies.  It is
now known that most  of the symptoms of  tuberculosis are due  to
sepsis from mixed infection.  Cases  in  which the  remedy  irritates
the  stomach are  very  few.   Exceptional cases may suffer nausea
and aversion.  In these  cases  the creosote  may be  administered
mixed with the balsam of tolu  in capsules, and gradually increased
as before ;  or the creosote may be suspended in milk.  It is claimed
that good effects are obtained by subcutaneous injection of pure creo-
sote with pure olive oil,  the oil having been  rendered aseptic by
boiling, in the proportion  of one part  creosote  to three  or four parts
oil.  The first injection may be five drops creosote and fifteen drops
oil.   The quantity is to be increased to ten or fifteen drops of creosote,
with oil in proportion.   The  injection should be  made in the back,
twice daily, at  a different place  each  time.  It is attended with very 
TUBERCULOSIS.
155
 little pain.  Arsenic is the next remedy, because it improves diges-
 tion and absorption.
    Tuberculous patients should be fed.  Where the stomach is ex-
 cessively sensitive, milk with equal parts of Selters water, in wine-
 glassful doses every hour  or two, may still be retained.   A  gentle
 stimulation may be offered with  a light extract of malt, wine whey,
 Rhine wine, etc.  Debove  proposed to  introduce food in large quan-
 tities through the  stomach tube in the process of suralimentation,
 and remarkable results were reported from this method.  It is as a
 rule, however, unnecessary, as the appetite may be stimulated and
 digestion increased by diluted hydrochloric acid,  tincture  of nux
 vomica, or  liquor potassii arsenitis, so that patients may be made to
 eat.  Buttermilk, sweet-breads, fish, beef—these are the staple arti-
 cles of  diet.  Cod-liver oil is now made so pure as to be almost pal-
 atable.   It  should be given pure, not in emulsion or mixture, immedi-
 ately after meals, when the taste is blunted by satiety, in conjunction
 with or followed  by an equal  quantity—that is, a  teaspoonful to a
 tablespoonful—of good cognac, rum, or other form of alcohol.
    The result of treatment by cod-liver oil and alcohol shows how
 much good  can be accomplished  by food alone.   For with the previ-
 ous administration of an acid, and the  after-administration of a bit-
 ter, especially strychnia, along with the cod-liver oil, the duration of
 the life of the consumptive has been fully trebled.
    In combating the special  symptoms the treatment of fever merits
 the first consideration.  We  encounter here at  once the problem of
 therapy.  A successful treatment of  the fever means a successful
 treatment of the whole disease, and nothing convinces the physician
 more thoroughly of the futility of radical therapy than the attempt
 to subdue or keep subdued the fever.
    The hectic of a day can be held in control by antipyretics, and the
 fever of the disease may be  subdued for several days, or even for a
 week or two, by the judicious use of the milder remedies of this class.
 Where  there is, along with the fever, irritability of  the nervous sys-
 tem, anxiety, and exhaustion, it is best to use phenacetin in two- to
 five-grain doses three or four times a day, in combination with alco-
 hol, sherry  wine,  etc.   The  excessive fever of  the  evening may be
 prevented or  subdued by a large dose of quinine, ten grains, three
 to five  hours  before the period of maximum temperature, but this
 remedy gives such distress  that it  is sooner  or later abandoned.
 Salicylate of soda, salicin, or salol may substitute  it in equal dose,
or in divided  doses, five to ten grains every three to six hours, with
 perceptible but less marked effect.  The salicylates have also their
discomforts, which sooner  or later more than compensate for their
virtues; so that the treatment of the fever of tuberculosis in the long 
156
TUBERCULOSIS.
run resolves itself into the general treatment of the disease, ('spe-
cially by creosote.
   Night sweats, if moderate, may be let alone.   They require treat-
ment only when profuse enough to require change of clothing in the
night or  to exhaust the patient.  Remedies to control night sweats
should be used in the following order :  Sponge baths with hot. boil-
ing, water.   A hot general bath.   A solution of atropia, one grain
to the ounce ; begin with a dose of three drops ;  increase on the fol-
lowing nights to four, five, or six drops, or until there is brought
about dilation of the pupils or dryness of the throat.  Camphoric
acid, twenty to thirty grains in capsules at bedtime.   Agaric acid or
agaricin, one-eighth to  one-quarter grain two or three times a day.
Chloral,  five grains, with a tablespoon of whiskey or a dessertspoon
of brandy to counteract its depressing  effect.  The end will be ac-
complished with some one of these remedies.
   Haemorrhage, if slight,  or especially if frequently repeated in the
history of the patient, calls for no treatment by drugs.  In all cases
the patient should go to bed.   Haemorrhage demands absolute rest.
More continuous or profuse haemorrhage calls for the use of atropia,
one grain to the ounce,  in dose of two to four drops every two to six
hours up to toxic effects.  Quinine, in five-grain  dose at intervals of
two to four hours, subdues the fever upon which the hyperaemia and
haemoptysis seem at times to depend.   An  ice bag may be put over
the region of the heart  to slow down its action.   Tincture of aconite
in drop dose every hour has been recommended for the same purpose.
A persistent  haemorrhage calls for the  subcutaneous injection of
ergotin or sclerotinic acid in  half-syringeful doses every half to two
hours.  Certain individuals learn to check haemorrhage by swallow-
ing a teaspoonful of salt, through reflex contraction.
   Cough in some degree is salutary, for patients literally expectorate
the disease with the sputum.   Some cough should, therefore, rather
be encouraged than checked.  The cough  upon rising is of especial
value in  this regard.  The  cough which is  so excessive as to lead to
the evacuation of the stomach, or so harassing as to prevent sleep at
night, calls  for treatment.  The  same remark  applies here as to
fever, that the radical relief of cough is the cure of the disease.  Pa-
tients often  say. feeling their improvement, if they  " could only get
rid of the cough " they  would be well ; and so they would, but the
cure of the cough implies, of course, the cure of the disease.  Hence
the best  remedies for cough are creosote and tuberculin.
   Cough which begins to be excessive may be relieved by apomor-
phia,  to  which there may be  added very small doses of morphia.
The bromides, in  dose of  ten to fifteen grains, may alleviate the
cough, as  a  rule, however, at too much  expense to the  stomach.. 
TUBERCULOSIS.
157
■Chloral in dose of five grains, especially if associated with alcohol, is
a safe and pretty sure remedy for the night cough of tuberculosis.
It counteracts also  night sweats and  insomnia.   Later it loses its
effect.  It should never be given in dose sufficient to bewilder the
patient or weaken the heart.
   In the effort to keep away as  long as  possible from opium, resort
may be had to codeia, which may be given, with cherry-laurel water
or bitter-almond water, in doses of one-sixteenth to one-eighth or
one-quarter of a  grain.  Sooner or later  we must  come to morphia.
Opium in combination with benzoic acid  and camphor, as we  find it
in paregoric,  in fifteen- to  thirty-drop  doses, may be used at first.
Some of the evil of opium is obviated by the use  of the deodorized
tincture.  An intelligent patient in the practice of the author labelled
his bottle of laudanum the tincture of hope, on account of the long
(years) relief  it gave.   The fear  of  the opium habit is not to be con-
sidered in this disease.  No evil is so great as tuberculosis.  The evil
is not the fear of the habit, but the  disturbance of the digestive
system.  Opium seems to foster tuberculosis, hence  resort is had to
the use of it about the time when all hope of recovery is being aban-
doned.   At the same time it must be admitted that opium with its
shield may be called into use earlier since the day of creosote and
tuberculin.  Opium alone is bad practice.  Judiciously employed in
connection with attempts at radical relief, it is not  bad practice.
   In gastric catarrh dyspepsia is best avoided or relieved  by regula-
tion of the diet.  Dyspepsia, which  precedes the disease for months,
is brought under control  by diluted hydrochloric acid, ten to fifteen
drops in a wineglass of water before  meals.   A  powder  of pepsin
after meals helps it.   A large wineglass of good malt, bitter or sweet
according to taste, preferably bitter  for most people, also  assists it.
Let medicated malts be avoided, and let  all medicaments be admin-
istered separately.  The stomach tube should be used early and often.
   In acute miliary tuberculosis, or phthisis florida, the stomach must
be handled with great care.  The  patient may take at first equal
parts of sweet milk and some alkaline  mineral water, at the very
first perhaps preferably the German Sellers water.  In spring and
summer  buttermilk is a most excellent  drink ; it is never so good in
winter.  Sips  of water excessively hot  relieve nausea and vomiting
of most  acute infections.   Milk  may at  times  be  taken boiling hot
when ungratefully rejected in  any other  way.  Per contra, certain
cases  are relieved by cracked ice, lime water  and milk, or a pinch of
soda in milk.  Selters water may be  had  fresh from siphon bottles ;
most of it as we get  it is unfit  for drink.   The diet  may be brought
up gradually through the soups without fat, and fresh oyster juice, to
the white meat of sweat-bread, fish, or fowl.   Rare beef  should be 
158                      TUBERCULOSIS.
introduced as early as possible in the dietary of phthisis.  Rare is as
good  as raw beef,  and is infinitely more  palatable.  It  may  be
chopped fine  and made into patties, browned upon the outside.  To
get the nourishment of beef  the  meat  must be swallowed.   Eggs
may be used at  first  only when  diluted, as in soups or with  hot
water or hot milk.  Though nutritious, egg in substance is not easily
digestible.  Vomiting due  to  indigestible  matter is best relieved by
washing out the stomach  with hot water, preferably with the sto-
mach tube.   Creosote with  tincture of nux  vomica is a most valuable
remedy in the vomiting of phthisis. Patients under the creosote
treatment improve as  to the stomach at once.   Cherry-laurel water
or bitter-almond water, with or without a half-grain or a grain of
sulphate of  zinc,  succeeds in  some obstinate  cases.  Bismuth  or
powdered charcoal sometimes suffices.  A very potent  remedy is
chloral in three- to five-grain dose largely diluted.  A mustard plas-
ter over the epigastrium is  not to be despised.
   A light diarrhoea may be  allowed to run, and may be regulated
by the diet.   In such a case milk is an important element, especially
in connection with lime water, one-quarter; animal food.  A  more
obstinate  case would  call  for bismuth,  ten or twenty grains at a
dose after meals.   It  is helped at times by the addition of salol,
five grains to each dose ;  or ipecac, half to one grain to  each dose ;
or Dover's powder, one or two grains to each dose.   A suppository
containing a grain of opium at bedtime  relieves  the case  for  the
night.   A time-hallowed remedy  is  the  tincture of  opium five to
seven drops,  diluted hydrochloric  acid five drops, camphor water a
tablespoonful, every two to six hours.  Patients under creosote do
not suffer so much as others from diarrhoea.
   Pain seldom calls for treatment.   Intercostal neuralgia is com-
bated best by quinine,  salol, phenacetin, or  salipyrin.  Pleuritic
pain is often relieved by dry cups, hot fomentations, a hot-water bag,
preferably a large flannel wrung out of boiling water and put about
the whole chest.  Counter-irritation with tincture of iodine  or with
croton oil is of some use. Belladonna plasters  give some relief.
They are  always unsightly, sometimes uncomfortable.  They accu-
mulate dirt and interfere with the examination of the chest.
   The discovery of  tuberculin established the first real epoch in
the treatment of tuberculosis, as  it constituted the first actual  ad-
dress to its cause.  In beginning cases it dislodges hidden depots of
the disease and makes manifest secreted centres.  Thus it frequently
makes a diagnosis which could not be established without it.  As a
therapeutic agent tuberculin has  stood the fire of trial, so that  its
value may now be definitely stated.  The use of it is contra-indicated
in hectic and haemorrhage, and in serious  affection  of the intestinal 
TUBERCULOSIS.
159
canal—conditions due to sepsis, and best controlled, if controllable at
all, by creosote and cognac.  Tuberculin cures only pure tuberculo-
sis.  It is therefore  of especial value in incipient cases of lung dis-
ease, before sepsis has set in, and in  deep-seated or secreted, latent
cases of gland and bone affection.  In these cases it  soon puts a new
phase upon the disease.  Cases of anaemia, amenorrhcea, dyspepsia,
cryptogenetic fevers,  "colds,"  bronchial catarrh, so-called rheuma-
tism—in reality beginning bone caries—recurrent or obstinate laryngi-
tis, or  other of the multiform manifestations of tuberculosis, whose
real nature was only disclosed perhaps by tuberculin, gradually yield
under its continued and judicious use. The beginning dose should
be  small—one-twentieth to one-tenth milligramme—and  gradually
increased, avoiding fever,  slowly at  first, more rapidly later, up to
ten centigrammes.  The  remedy should be introduced subcutane-
ously about the back of the trunk, not oftener than every other day,
and always  in the morning, that the effect upon  the temperature
may be studied during the day.

    Tubercle bacilli are distributed from the lungs and  intestines uni-
versally over the body, but find fertile soil only in certain organs or
tissues, as in the lymph glands (scrofula);  serous membranes (tuber-
cular peritonitis, pleuritis) ;  brain, meninges (tumor,  basilar meningi-
tis) ; bones and joints, vertebrae, knee and hip (Pott's disease, white
swelling,  bone caries, morbus  coxarius) ; testicles  (orchitis);  skin
(lupus), etc.   The recognition of the fact that all these different dis-
eases depend upon the same cause is  one of the great acquisitions of
the discovery of the tubercle bacillus.  The muscles, mucous mem-
brane of the stomach, duodenum, bile ducts, and urethra are sterile
soils.
    Inundation of  the blood and body after erosion into blood  and
lymph vessels (thoracic duct) leads to acute attacks  or  exacerbations
(miliary tuberculosis, phthisis florida) ; arrest of development, gene-
rally after destruction of tissue, to overgrowth of connective tissue
with cicatrization and shrinkage (cirrhosis), or to caseous  degenera-
tion with subsequent softening and formation of cavities  (vomicae).
The lesions of tuberculosis outside of the lungs, larynx, brain, serosae,
and intestine belong  to the domain of surgery.
    Tubercular Meningitis.—Guerin and Guersant in 1827 first
set apart and distinguished tubercular from simple meningitis.   Be-
cause of the eruption of tubercles in nodular form they called it the
granular meningitis ; and because it was found localized at the base
of the brain it soon came to be known as basilar meningitis, in distinc-
tion again from the simple form which affects the covering of the
whole brain and is seen in greatest intensity at  the  convexity.   The 
160
TUBERCULOSIS.
knowledge that basilar meningitis is a part of the general process of
tuberculosis is an acquisition of much more recent times, but the dis-
ease was  recognized  as distinctly tubercular (1839) long before the
direct cause of tuberculosis, the bacillus (18.82), had been disclosed.
   Etiology.—Tubercular meningitis is never a primary disease, nor
are tubercles ever first deposited at the base of the brain.  Meningitis
is a part process, a localization, a migration, a colonization of an over-
flow from elsewhere.   Post-mortem examination reveals the primary
seat of the affection in some other part of the body, in one of the ave-
nues of entrance to the body.  Tuberculosis has its seat first in the
lungs.  The expression of the disease in  the lungs may be  slight,
transitory.  It may have disappeared altogether at the time of the
examination.  The lungs may show little or no lesion.  Meanwhile
the cause of the disease, the Bacillus tuberculosis, will have penetrated
the lung substance and become lodged in the bronchial glands  at the
root of the lungs.   Many of the victims of tubercular meningitis
show the  presence  of tubercular glands in the neck.   It is not un-
common to have observed a  chain of  enlarged lymphatics above
the clavicles and in front of the sterno-cleido-mastoid muscle.   These
glands are only outposts of more  extensive  internal affection.  Ex-
sections of these glands would not remove the  disease or the liability
of subsequent  extension.  It may be assumed, though the connection
has  never been  so distinctly traced, that in some cases the affection
arises from the  mesenteric glands—that is, from intestinal tubercu-
losis.  Somewhere or other there must have been in the body a depot
of tuberculous matter.  Sometimes there is to be found tuberculosis
of the lungs, sometimes affection of the vertebrae, Pott's disease, in-
testinal tuberculosis, orchitis, hip-joint affection, so that the menin-
gitis, when it occurs, though it may seem to supervene suddenly, is
only an episode  in the course of tuberculosis and in the life of a tu-
berculous patient.  Most of the children affected come of tuberculous
stock, or live  in  an atmosphere contaminated by the  disease.   The
evidence of local infection may be so well concealed as to have been
overlooked, so that the outbreak in  the brain is often an ugly sur-
prise.
   Symptoms.—There may usually be elicited in the study of a case
a history of a preceding bronchial catarrh, marked by a  cough, distin-
guished by its  obstinacy to treatment, its aggravation and remission,
its frequent recurrence.   Instead of a bronchial there is  sometimes an
intestinal catarrh with the same history.   The child is hence often
more or less emaciated,  easily fatigued.  There is thus usually a long
train of prodromata preceding distinct evidence of the disease.
   Cases distinguish themselves as cerebral from the start, or as gas-
tric  from the start.   In  the  cerebral form there  maybe  oliserved 
TUBERCULOSIS.
161
 more or less psychical change.  The disposition of the child is al-
 tered.   It is easily affected, becomes peevish, fretful, irritable,
 soon loses interest in its play, may no longer be  so readily diverted,
 seems to be seized in the midst of its occupation with a kind of ab-
 straction, loses itself, as it were, for a time, gazes into vacancy, re-
 sumes its occupation  with indifference or  listlessness.  Perhaps at
 this early period it  may complain occasionally of headache.   It is
 seen to put its hands to its head.   It sleeps heavily,  falls into sopor
 with a tendency to stupor, is longer in awakening, or is suddenly
 aroused, sometimes with a cry, a peculiar  sharp cry.  It grinds its
 teeth in sleep.  These symptoms may pass unrecognized.  The physi-
 cian is summoned because the child is suddenly stricken with  con-
 vulsions or strabismus, falls into a state of  coma as after a stroke
 of apoplexy, from which it recovers consciousness paralyzed, usually
 after some more or less marked psychical disturbance.
    The  scene proper opens with  vomiting.  The vomiting is cere-
 bral.  It distinguishes itself by occurring  suddenly, without cause,
 without nausea  or  retching.  It  is  copious.  Cerebral  vomiting
 always excites alarm.   One of the first questions that a physician
 asks is : " Has the  child vomited ? "  The  pulse offers strong evi-
 dence.   The rhythm of the pulse becomes soon disturbed.  There
 is a sensation as if the pulsation  was to be withheld, a  retarda-
 tion, whereupon  follow several strokes in  quicker succession.  In
 the further course of the disease the pulse  becomes more and more
 retarded, though there is about this symptom no regularity.   The
 rhythmic acts of respiration are likewise  soon disturbed.   In  the
 very earliest stages of the disease the child  stops to sigh.  There is
 gaping, yawning, sighing.  Later in the course of the disease the
 respiration becomes  more  and more disturbed, retarded or quick-
 ened.  In the last stages it ceases altogether for a time, to reappear
 with a series of quicker  inspirations—the  so-called Cheyne-Stokes
 phenomena.
   The temperature shows the same irregularity.  It is sometimes
 subnormal throughout  the course of the disease.  The rule is  that
 there is slight elevation of temperature at first. This sign is among
 the most valuable of the earlier symptoms of the disease.  It is dis-
 covered, however, only by  painstaking  observations.  To be  ac-
 curate the temperature must be taken in the rectum.
   Early in the disease there  are  also vaso-motor disturbances.
 The cheeks are  flushed, often  of  a deep  crimson,  or  blanched.
 Sometimes one side of  the face is  suffused, the  other pallid.   The
color comes and goes quickly without emotional excitement.  A line
drawn down the surface of  the body with the  flat of the finger,
across the forehead, down the cheek, a long diagonal over the breast,
         11 
162
TUBERCULOSIS.
stomach, or thighs, blanches at first, to. in the course of a few min-
utes, fill  with blood and  show itself as a crimson trace—the /ache-
rouge of Bouchut.  This sign is also of value in a doubtful case.   It
indicates the spasto-paretic condition of the vaso-motors, and is seen
also in other grave infections, as in scarlet fever.
   If the pupils be observed closely, inequalities may be detected.
One may be found larger than  the other.   One is often found more
or less  contracted.  In the later course  of the disease the  pupils
become irresponsive to light.  Under a powerful  irritation they
may both be contracted, as in opium poisoning.  Last of all, when
effusion has taken place in the brain the pupils are dilated.
   The symptoms which indicate the direct onset of the disease  are
vomiting, headache, constipation.  The child puts its hands to its
head.  It tosses about in bed with pain.   It  has been mentioned
already that there is often preliminary diarrhoea from intestinal tu-
berculosis.   With the onset of the disease proper there is, as a rule,
constipation which amounts to obstipation.  Sharp purgatives  fail
to move the bowels, but  with this constipation there is also, as a
rule, collapse  of  the abdomen,  so  that  the  abdomen  presents a
sunken appearance, to assume a characteristic boat shape.
   The disease is often divided into stages, and while there  can be
no systematic division of symptoms, as the symptoms of the various
stages so closely intermingle, no objection can be urged  against this
division if this fact be held in view.
   Thus the first stage—that of irritation—is marked by hyperaemia
of the  pia  mater.  During this stage occur the  psychical  symp-
toms and the vomiting, the early headache, the constipation.
   Next ensues the  stage of eruption of tubercles in clusters about
the blood vessels or pia, with intervening  opacity of the membrane
itself, with, also, the accumulation of some exudation, which appears
as a milky serum about the  optic chiasm and the various sulci and
spaces at the base of the brain.  In this stage the headache becomes
more severe, intense.  There are  convulsions, profound vaso-motor
disturbances, sweatings, beginning paralyses.  These paralyses af-
fect often  individual  muscles—the  oculo-motor,  abducent, facial
groups.  There  is ptosis,  strabismus, facial paralysis, sometimes
hemiplegia.
   In the third stage there is free effusion.  The blood vessels are
occluded, the brain  is compressed by fluid within  and without the
ventricles.   The  picture is now  rather  that of encephalitis than
meningitis.  The child lies in more or  less  constant stupor or coma.
The eyes, insensitive to light or  to touch, are partly filled with pus.
The surface is cold and  clammy, the pulse and respiration  feeble,
slow, and irregular.  Convulsions sometimes occur, to, shake with 
TUBERCULOSIS.
163
violence this almost inanimate  mass ;  in one  of them the  heart
ceases to beat, and death comes to the relief of the relatives and at-
tendants as well as the patient.
   The diagnosis rests upon the fact  that the child is tubercu-
lous, comes of tuberculous stock, or is brought up in a tuberculous
atmosphere;  that  the outbreak in the brain is preceded by a long
train  of symptoms, whereupon  ensue the  psychical change, the
vomiting, the headache, the constipation.   Later  on the twitching of
muscles, strabismus, convulsions, comatose  state, leave no doubt.
The duration is short, the whole  course  of the  disease extending
over a period not longer, as a rule, than three to six weeks.
   The question of diagnosis seldom concerns a separation of the form
of meningitis.  The difficulty lies with the distinction of meningitis
from  typhoid fever or malaria, each of which  shows more or less
irregularity in a child.   In this separation the most reliance is to be
placed upon  the thermometer. Malaria  shows always a more dis-
tinct periodicity, a more distinct enlargement of the spleen.  It  alone
is really influenced by quinia.   Should doubt continue, resort should.
be had to examination of a drop of blood.   The regular elevation or
step-ladder ascent of the first week of typhoid fever, and the constant
plane  of the later weeks, should distinguish this disease from the ir-
regular temperatures of meningitis.  The hebetude of typhoid  fever
is  very different from the more or less periodical and paroxysmal
mental disturbance of the first stage of meningitis.  There are not in
typhoid fever the same vaso-motor suffusions and sweatings.   Men-
ingitis is marked by constipation, typhoid fever  by diarrhoea.  The
muttering delirium of typhoid fever differs from the excitements and
convulsions of meningitis.   The ophthalmoscope has revealed in very
exceptional cases tubercles in the retina (choroid).
   The prognosis  is fatal.  It is assumed of a case that recovers that
there has been an error in diagnosis.   Yet there is good authority for
the recovery  of exceptional cases.   It is claimed  that post-mortems
made  upon individuals  who  have died of intercurrent maladies or
by accident have revealed lesions indicative of a pre-existent menin-
gitis.
   The hope is in prevention.   When the health officers take charge
of houses  inhabited by tuberculous patients and  secure the destruc-
tion of all tuberculous  sputum, there will be less or no tuberculous
meningitis.  Meantime much more may be done than is done in this
direction by education of the people by the physician.
   The therapy is wholly symptomatic and palliative.   There can be
no question of the radical treatment of meningitis without address to
the whole process of miliary tuberculosis,  of which the meningitis is
a part. 
164
TUBERCULOSIS.
   The treatment of the condition therefore implies a treatment of
tuberculosis in general.  The ice bag is put to the head more in de-
ference to authority than from any possible use it might be.   Nilsson
claimed to have had success with the  application of iodoform oint-
ment 1 :10, rubbed into the scalp three times a day. and brought into
more constant application by the  use of a  cap.  The bromides and
chloral will relieve to some extent pains and convulsions.  Resort
may  be had to chloroform  or  ether to cut the convulsions short.
Morphia, internally by the rectum or subcutaneously, may give relief,
will at least furnish euthanasia.
   Acute Miliary  Tuberculosis is distinguished  by  the dis-
semination of minute tubercles throughout a great part or the entire
substance of both lungs, as  well as by its  general distribution over
the whole body.  It represents an inundation by auto-infection from
some local depot, lymph gland, serous sheet, or bone deposit.
   Miliary tuberculosis  is distinguished by its  continuous fever,
sustained  at high degree ; by the increased frequency in respiration,
which amounts to dyspnoea; by pallor,  cyanosis, and rapid col-
lapse.   The dyspnea and  cyanosis are main factors in differentia-
tion from typhoid fever, especially in the presence of a roseola and
spleen tumor, which are common to both.
   Tuberculosis of the Lymph  Glands is common to all cases,
but is so  called only when the glands  are affected visibly or show
affection in  signs of disease.  In this regard the cervical glands are
the most  obtrusive.   These  glands  appear as visible  prominences,
tumors, or actual deformities, to contribute to the affection commonly
called scrofula.  The tendency is toward latency with induration.
Under stimulus—measles, pertussis, sore throat, or other unknown
cause—the glands  show signs of  inflammation, usually of passive
or subacute form.  Thus they may undergo caseation or sup] jura-
tion, and  discharge their contents under a slow process of months'
or years' duration, to leave finally disfiguring scars.
   Affection of other glands (bronchial, mesenteric, retroperitoneal),
     ,,                  „,     equally common  but less  obtrusive,
   J&       UK7"   ' ^     shows itself in signs of disease  of the
, fl&   %  ~&       "?"  "Vj     lungs,   intestine,  and  peritoneum.
    *'    "  W  '***   *J'    Scrofula is usually attended also with
  ^-  "^ii  "s   iS$   **>^     conjunctivitis,   blepharitis,    otitis,
 1  ., W »;=^L\ fi&  /gfflki     ozaena, and various diseases  of  the
~^*/«.-^  '-\ z-'      -J&m       skin
  fv^fC'i i* "      f**   '-        Tuberculosis  op the Genito-
 Fig. ilO.-Bacillus tuberculosis in urine  URINARY APPARATUS.— Tubercle ba-
(Vonjakscb).                     cilli  come to  lodge in various  parts
of the genito-urinary  tract, in the kidneys,  including  the pelvis, 
TUBERCULOSIS.
165
the ureters, bladder, and, very rarely, the prostate gland, but not in
the urethra.   The  disease shows itself in  dysuria and pain, and
the urine may contain pus and blood.  The diagnosis really  rests,
however, upon the detection  of bacilli in the urine.  The urine is
to be filtered and the sediment tested in the usual way.
   Cases of salpingitis and peritoneal tuberculosis have been found
to depend upon a deposit in the Fallopian tubes.  A much more com-
mon localization  is in the testicles, to constitute an orchitis, which
distinguishes itself from orchitis  from  other  cause by its painless-
ness and protraction.   Such tumors may, however,  undergo at any
time rapid caseation and  destruction.  The disease begins  in one
      Fig. 111.                      Fig. 112.
Fig. 111.—Tuberculous caries (stiffness) of cervical vertebrae.
Fig. 112.—Tuberculous caries (gibbus) of dorsal vertebrae (Bradford).
organ at any period of life, including infancy, and usually involves
the other in the course of time.   Other deposits may be usually dis-
covered in these cases, especially in the lungs, and this deposit, as
well as that in any other organ, may in turn serve as a distributing
centre for disease of other organs or for general dissemination.
   Tuberculosis  of the Bones and Joints.—According to the
observations of Alfer—1,752 cases in six years—affection of the bones
and  joints shows itself  in the following frequency : knee joint, hip
joint, vertebral column, tarsal and  metatarsal bones, elbow joint,
carpal and metacarpal bones.  The disease (caries) is  distinguished 
166
tuberculosis.
in all cases by its sluggish character, long duration,  deformity,  and
obstinacy to treatment.
   Tuberculosis of other organs will be discussed under  appropriate
heads.
   The diagnosis in all these cases  rests ultimately upon the  detec-
tion of the tubercle bacillus, which is the  central point about  which
everything else connected with the subject must revolve.
   It is only fair to say, however, that while the presence of the ba-
cillus  declares the character of the disease, absence of  it does not
exclude it, as dead bacilli dwindle and  disappear.   In any case the
diagnosis may be established by the injection of a milligramme of
tuberculin, which sets up a reaction in a case of tuberculosis.
   Prophylaxis includes removal from the air of infection, or,  where
that is impossible, purification of the air  by ventilation,  destruction
of sputum,  general cleanliness, etc.  A  scrofulous child should be
bathed regularly and fed substantially  with nutritious  diet—milk,
eggs,  meats,  and  all  kinds  of  fruits and vegetables.   The milk
should not come from a tuberculous mother, nurse,  nor  from a tu-
berculous cow.   Here, again, the condition  may be determined at
times  only  by  an  injection  of  tuberculin, which discloses  tuber-
culosis  at times in people, especially in  milk cows,  apparently per-
fectly healthy.
   The treatment  in every case is  the  treatment of tuberculosis in
general, by roborant diet, fresh air, altitude, cod-liver oil, tubercu-
lin, creosote, iodine, etc., with especial address to the  especial form of
the disease.   Iodine is best administered to a child in the  form  of the
syrup of the iodide,  gtt.  x.-xxx. in double the quantity of  simple
syrup, three times a day.  Where the iron may be contra-indicated
on account of constipation the iodide of potassium or sodium may
be preferred.  Five drops of the ounce-to-ounce solution—i.e., the
iodide with  peppermint water—may be administered before meals in
a wineglass of milk.  Swollen glands often disappear entirely  under
this  treatment.   Hueter recommends extirpation by means of a long
excision along  the  posterior border of  the sterno-mastoid muscle,
enucleation with a blunt instrument, and dressing with the iodoform
tampon.  It is certain that the glands, though a constant menace,
remain innocuous in many cases.
   Bone and joint affections may be sometimes  reached by injections
of iodoform.  The remedy is  best brought to bear upon the disease in
the form of iodoformol—i.e., iodoform with twenty per cent of olive
oil.  Boiling sterilizes as well as makes a fine emulsion  of this mix-
ture, which  when injected releases  the  iodoform to be distributed
over and about the seat of the disease.    The  oil is not more painful
injected hot than cold.  The  injection, containing iodoform 3 i. each 
LEPRA.
167
time, should  be made about once  a week.  Trendelenberg reports
forty per cent of cures, or approximate cures, with this method.
   Systematic trial should be made, in all obstinate cases, of the in-
unction treatment with massage.   Green soap (sapo viridis) should
be rubbed into the  trunk and extremities twice a day for one week,
then once a day for three days, after  which, not before, the body
may be washed clean.  Remarkable results may follow this simple
procedure.   After failure with these means,  or in connection with
them, resort may be had to tuberculin in very small dose, and finally
to the  surgeon's  knife.  Speedy extirpation of an  affected testicle
may save the sound side, and may prevent a general dissemination
of the disease.
   Lastly, perfectly quiescent cases should be let alone, on the prin-
ciple •' quieta non  movere ! "  On this principle the surgeon some-
times compromises with an abscess about the hip, and always splints
the spine in vertebral caries by a plaster jacket or other fixed sup-
port.  But here, as everywhere, cases must be individualized.   Gland
and bone tuberculosis is more  apt to be a pure process than lung
tuberculosis, which is, as  a rule, complicated with subsequent septic
infection.  The apyretic  is the best period for radical address by tu-
berculin, and cases  which show paroxysmal or continually recurrent
attack  of fever should be subjected to this  treatment.   The dose
should be increased from one-twentieth of one milligramme, the mini-
mum, to ten centigrammes, the  maximum quantity.   The remedy
should be injected not oftener than every other day, and with strict
regard to the temperature,  i.e.,  to the keeping  this side of fever.
The tone and vigor of the body  rapidly improve under the  use of
tuberculin, and the uncontrollable evils of septic invasion and  the
long,  slow-  tortures  of  marasmus from   later  dissemination  are
averted in this way.
                             LEPRA.

   Lepra; leprosy (Xt7tpos, scaly): elephantiasisGraecorum; German,
Aussatz (set apart, isolate).—A chronic infection,  chiefly of the skin
and nerves ; produced by a special bacillus ; characterized by infil-
tration and destruction of tissue, disturbance and destruction of sen-
sation (anaesthesia), and slow, progressive marasmus.
   History.—Lepra, the famous plague of the Old  Testament, was
the most dreaded disease of antiquity and the most formidable foe of
mankind.  On account of its deformity,  infectiousness, and incurabil-
ity, victims of the disease were shunned and set  apart.  The term
" leper " is still a contumely.  With the advent of syphilis in the fif-
teenth  century  leprosy began to recede, to  occupy finally a subordi-
nate role, so that the disease is now seen in Europe  only in Norway 
168
LEPRA.
and Sweden. Turkey, along the borders of the Mediterranean:  and, in
America, in the Sandwich Islands and in the southern part of our
own country (Florida and Louisiana), though it still prevails in epi-
demic proportions in the East.  The luminous period in the  history
of the disease was the discovery of the Bacillus leprae by Hansen and
Neisser in 18TO.
   Bacteriology.—The Bacillus leprae is a slender, delicate rod, about
half as long as the diameter of a red blood corpuscle.  It resembles
closely the Bacillus tuberculosis, and is usually disclosed in the same
way, but differs from it in that it may be stained in acids, eosin, and
Fig. 113.—Leontiasis leprosa (Munch).
acid fuchsin—a fact which led to its earlier recognition.   The Bacillus
leprae has been cultivated on gelatinized blood serum and cooked egg.
Authorities differ regarding the possibility of inoculation of animals
and the mode of ingress into the human body.  The best bacteriolo-
gists deny any hereditary transmission.  Lepers live for years in inti-
mate (family)  relation  with others without ever conveying the dis-
ease.   It is certain that the bacillus or its spores may lie latent in the
body for a long time, for months  or  years.  It is usually dissemi-
nated through  lymph channels, more rarely by the blood (vide Fron-
tispiece, Fig. 1).
   Symptoms.—-The  soils of selection in the body are the skin and 
SYPHILIS.
169
 nerves, but  other organs, the liver, spleen,  and testicle, are often
 visited en masse.
    In the skin, especially of the face, knees, elbows, and backs of the
 hands, lepra forms masses or tuberosities, which slowly increase in
 size, to produce  characteristic deformity (leontiasis) or  ulceration
 with destruction.  The destructive process slowly extends, to invade
 deeper tissues and organs.   In fact, lepra may attack any part of the
 body; the hairy scalp and glans penis alone
 escape.
    Nerve tissue is irritated, thickened, and
 finally destroyed, with  symptoms at first  of
 hyperesthesia and pain, especially in the do-
 main of the ulnar,  median,  and  peroneal
 nerves, and later anesthesia, not infrequent-
 ly paralysis.  Trophic change, discolorations,
 morphea nigra et alba, and pemphigus are
 common expressions of the disease.  Every in-
 vasion is attended with that rapid multiplica-
 tion of cell  elements which constitutes the
 " granulation tumor."
   The incubation runs from three to five
 years (Hansen).   The course lasts  for  life,
 which  it usually abbreviates with deformities
 to which the patient grows indifferent.
   Prophylaxis  and  Treatment. — As the
 mode or avenue of invasion is unknown, and
 as the disease is general or constitutional when
 first seen or recognized, the only prevention consists in destroying ex-
 creted matter, and isolation of patients, whose lot should certainly be
 made as comfortable  as  isolation admits.   Periods of  latency or
 quiescence, even of years' duration, must not be mistaken for cure of
 the disease.   Treatment is as yet symptomatic and empirical.  Unna
 claims  to  have cured  cases with the internal administration of  the
 ichthyo-sulphate of soda and local  applications of ichthyol and pyro-
 gallic acid.
                           SYPHILIS.
   Syphilis,  sive morbus Gallicus (Fracastorius, 1530) ; pudenda-
 gra, lues venerea, pox; etymology unknown (possibly gvs cpiXeiv,
 mutual love).—An exclusively human infection,  of venereal origin,
 inherited or acquired, distinguished by a long period of incubation,
 two to  four weeks, a  primary sore at the point of inoculation, with
 subsequent glandular enlargement; a second stage  marked by sore
throat, cutaneous eruptions, and condylomata; a third stage with
fall of the hair, disease of bone, and finally of internal organs.
Fig
-Mutilating leprosy. 
iro
SYPHILIS.
   Syphilis formerly included  other venereal  diseases—gonorrhoea
and chancroid.  Knowledge of true syphilis dates from J 493 a.p.
Definite information and differentiation from  gonorrhoea was  fur-
nished by Ricord, 1838.   The contest between the unicists. who
maintained that the  varieties of venereal disease were but different
expressions of the same malady, and the dualists, who maintained
that each disease was separate, was decided by Ricord, who, with
overwhelming proof, established the fact that syphilis is a constitu-
tional, chancroid a strictly local disease.  No other venereal disease
than syphilis is or becomes constitutional.  Chancroid may involve
the lymphatics and produce buboes,  the sore itself may  become gan-
grenous, but chancroid is never systemic.   So,  also, gonorrhoea may
affect the lymphatics of the groin, may extend to the bladder, in
women also to the uterus, tubes,  ovaries, and even to the  perito-
neum, it may invade the joints,  but it never  causes late constitu-
tional disease.
   History.—Gonorrhoea  and chancroid  have been known from
time immemorial.  Syphilis, as stated, entered Europe  and was  first
described as a form of venereal disease about 1493.  It appeared be-
fore Naples  and spread through  Italy  with the invading  French
army.   During the following years it raged violently throughout all
Southern Europe.  The primeval origin is unknown.  The period of
its appearance was a period of adventure and exploration.  America
was discovered and  Africa explored.  Certain medical historians de-
rived the disease from America, but there  was  no history of syph-
ilis among the indigines until it was introduced from Europe.  With
more reason it  is supposed to  have been imported from Africa by
Portuguese explorers.  With its first recognition it was certainly a
new disease,  but within ten years it spread over the whole civilized
world.  The filthy personal habits and the peculiar social customs of
the time explain its rapid diffusion.  Ricord believed it to be a trans-
formation of glanders ; Simon considered it a form of leprosy.  It is
now known  to be specific, sui generis.   The  confusion  which so
long prevailed regarding the identity of venereal diseases was partly
due to the fact that  two or more affections may be conveyed at the
same time.   It is possible at one impure intercourse to contract syph-
ilis, chancroid, and gonorrhoea, with scabies or pediculi.
   Syphilis is distinguished by its long period  of incubation.  The
first manifestation appears in two to four weeks,  usually not later
than the twenty-first day after infection.  Any lesion which appears
before the lapse of two weeks is almost certainly not syphilitic.
   Etiology.—The disease may be conveyed, aside from sexual in-
tercourse, through the medium of utensils, drinking vessels,  towels,
by contact of other parts of the body, as of the lips in kissing.  Phy- 
SYPHILIS.
171
sicians have become infected in the  manipulation and treatment of
a case, more especially in obstetric service.
   Syphilis is introduced only by inoculation, whereby is  required a
break of the surface.  Slight lacerations, abrasions, or other lesions
of the genital mucosa suffice to give it entrance.
   Bacteriology.—Lustgarten ascribes  pathogenic properties to a
bacillus  much like  that of  tuberculosis.  It is 3 to 7 p long and
somewhat enlarged at the ends.   It is demonstrated with difficulty,
best, according to Muschalk, in the hot Lof-
tier solution with subsequent stain with vesu-    ,,   a - *
vin, when the bacilli  stand out blue on a
brown field.  Cultivation has not  yet been    '<jf   ^) -    f^r,, '■
successful.  The pathogenetic relation of  this  ",■ ^C^ ..&§ts::•.'-.%
organism is not yet  definitely  established;     '^ ,,^ ' v-5    „„
for it speaks the  facts  that  it may be found   || k^ „   A'  *w
in all kinds of syphilitic lesions, and that it          l^-.^'f '""
may be  now distinguished  by the carbol-  FlG. n5.-Lustgarten-s ba-
fuchsin test from smegma bacilli, from which ciiius of syphilis.
it could not hitherto be separated.
   Hereditary Syphilis.-—Either  parent  affected  with  syphilis,
manifest or latent, may communicate the disease to the foetus.  The
child may be affected during birth by disease of the soft parts of the
mother (congenital  syphilis), at conception by diseased ova or sper-
matozoids, or during gestation through  the blood (hereditary  syphi-
lis).  Further, a  father may communicate the  disease to the  child
      Fig. 116.                Fig. lit.                   Fig. 118.
                   Teeth in hereditary syphilis (Hutchinson).

through the spermatozoids. while the mother escapes altogether or is
subsequently affected by the child.
   The foetus thus affected  may perish in utero and be discharged.
Habitual abortus is frequently due to this cause or  to  placental
syphilis.  More frequently the  child  is carried longer  and birth is
premature.  The child then, or  later, shows evidence of the disease
in feeble constitution, stunted growth (arrested development), notched
teeth, etc., or in actual eruption of papules, vesicles, and scales upon
the palms of the hands and soles  of the  feet (pemphigus and psori-
asis).   Coryza, caries of bone, periostitis, keratitis, are other evidences 
172
SYPHILIS.
of infection.  In the vast majority of cases of hereditary syphilis the
disease  shows itself within three months after birth.  In a small
proportion, ten per cent, it may be delayed up to six months—syphi-
lis hereditaria tarda.
   As  the disease expires in  the parents,  subsequent conceptions
show less and less infection, until finally children are born healthy
and at term.
   Symptoms.—The first sign  of syphilis appears at the site of in-
oculation in  the form  of  a chancre (from cancer), ulcus durum, a
papule,  upon the summit of which is formed a small vesicle whose
rupture leaves a cup-shaped depression.  The chancre is peculiar in
having  an indurated base.  This induration, which is best detected
           Fig. 119.—Syphilitic roseola with malformation of teeth (Keyes).

by pinching up the papule between the fingers, is almost pathogno-
monic.  It constitutes what is called the initial sclerosis.   The sore
lasts, as a rule, at least three or  four weeks, often as many months.
It may reappear  after having subsided, and this process may be
repeated.
   In the female the  initial lesion is usually located upon the inner
surface of  the labia  or on the vaginal portion of  the cervix.   In
these situations it appears  as a flat or slightly elevated sore without
the distinct papular character.  On account of its location and char-
acter it is frequently overlooked.
   By the time the induration of the chancre is well developed there
is enlargement of the inguinal glands,  usually more marked in one- 
SYPHILIS.
173
gland, forming the so-called indolent  bubo.   The  common  seat of
bubo is in the groin.   If the hand is the site of the primary sore, the
glands back of the elbow, the cubital or post-cubital glands, first en-
large.  The situation of the chancre determines the site of the bubo,
in that the nearest glands are the earliest affected.
   A month may now elapse without further manifestations, after
which time lesions show themselves in the skin.  The eruption upon
the skin is  often preceded  by malaise,  chill, fever,  and other evi-
dences of systemic affection.  It appears as a roseola over the fore-
head, chest, shoulders, abdomen, and may be distributed as  an
efflorescence over the whole body.
   The syphilitic roseola is to be distinguished from  measles by the
fact of its occurrence in an adult,  by its  brighter color, the  broader
basis of  the eruption, and by the history of the case.  The initial
sore may usually still be found at  this time.   The eruption has fre-
quently a coppery hue, a pigmentation,
the result of prolonged  irritation of the
skin.  It is not always  seen in syphilis,
and does not belong especially to this
disease.
   Following  the early eruption of sec-
ondary  syphilis occur others  represent-
ing nearly all the various forms of dermal
disease—e.g.,  small and large papular
eruptions, acne;  small and large pustu-
lar eruptions, ecthyma, etc.   Destruc-
tive pustular, tubercular, and gumma-
tous lesions belong to the later (tertiary)
stage.   Syphilis in the  skin is distinguished by its  polymorphism.
Several different varieties of eruption may frequently be found at the
same time.
   By the time of the first eruption there is generally enlargement of
the lymphatic glands.   All the glands may become affected, and the
disease is distinguished by the involvement of glands which in other
diseases  usually  escape, as the glands behind the sterno-mastoid
muscle and  those behind the elbow.
   About the same time lesions appear upon  the mucous membrane
of the throat.  The throat becomes hyperaemic, especially the arch
of the palate and the  pillars of the fauces.  There is usually some
angina.   The nose is similarly affected.  Later in  the course of  the
disease  destructive lesions  develop in  the throat  and nose.  They
may not remain  confined to the soft palate, but may extend to  the
larynx, beginning, as a rule, upon the lingual surface of the epiglot-
tis.  Laryngeal  tuberculosis,  on the other hand, usually begins  on
 Fig. 120.—Syphilis of the larynx with
great deformity. 
174
SYPHILIS.
the posterior surface.   No disease deforms the nose and throat more
than syphilis.   The sunken bridge of the nose is a  characteristic
lesion.
   Among the  most prominent of the lesions of secondary syphilis
are the condylomata.  These patches or plaques are the most com-
mon sources of infection, since they last much  longer than the pri-
mary sore.  They occur  not only upon the mucous membranes, but
Fig. 121.—Tubercular syphiloderm of face (Hyde).
upon  the skin where it is moist and subject to intertrigo, as about
the vulva, nates,  and  under the breasts.   They differ from gon-
orrhoeal condylomata, which have a drier surface and a more raised,
warty, or cauliflower appearance.
   The eye is involved.  There is wont to appear an affection of the
iris during the secondary stage of syphilis, which demands immedi-
ate dilatation of the pupil to prevent adhesion to the lens.   Keratitis
is common later.   The  choroid,  the retina, the optic nerve may be 
SYPHILIS.
175
affected at any time.  Paresis  and paralysis of the eye muscles are
not infrequent.
   During succeeding  years  symptoms may appear and disappear
repeatedly.
   The tertiary  lesions upon the skin are  chiefly pustular, ecthy-
matous in character.   Syphilitic rupia is characteristic.  It consists
of pustules  which  scale over,  break down,  and form  scales again.
The crust is therefore laminated in structure and appearance, like an
oyster shell.  Large pustular  lesions not covered in this way are
called  tubercular.  They  occur most frequently upon the  back
about the sacrum.   All these lesions of syphilis  destroy tissue and
leave scars.   They are sometimes attended  by itching, which does
Fig. 122.—Syphilitic necrosis of cranium QSichhorst).
not occur in the secondary eruptions.   These late manifestations are
not infectious or contagious.
   The  affection of the bones is characterized by a peculiar noc-
turnal  exacerbation, ascribed to pressure  from distended  veins.
Subcutaneous nodes develop, especially upon the sternum, clavicle,
and spine of the tibia.   Changes in the structure of the bones may
occur in any part of the body, either in the direction  of necrosis or
eburnation.
   Syphilitic disease of the internal organs belongs to  the tertiary
period.  It occurs,  as a rule, very late—ten,  twenty, or more years
after the primary lesion.  It  is  often recognized by  the fact that
syphilitic  manifestations  have  occurred at  intervals  during  this
period.
   On  the part of the nervous  system  pressure  symptoms, more 
176
SYPHILIS.
especially incomplete paralysis, may arise as the result of exostosis
from the cranial bones or spine.  Tumors of the brain and cord may
have this origin, or may consist  of gummata, more distinctively
characteristic of the disease.
   A certain change  affects the  blood  vessels, as an endarteritis
obliterans, which gives rise to regions of softening in the brain  and
cord.  Syphilis attacks the nerves themselves, especially the third,
fifth, and seventh.   The muscles,  though rarely, are sometimes in-
vaded.   There is a syphilitic myositis, most frequent in  the deltoid
muscle.
   The lungs are attacked more frequently in hereditary  than ac-
quired syphilis.  It is  often difficult to distinguish the disease from
\n*s
.A:v.\«y
   Fig. 123.—Syphilitic endarteritis Qlaumgarten):  1, endarteritic growth ; 2, new tunica fenes.
trata ; 3, old tunic; 4, gummata in the adventitial av, adventitia; ms, muscular coat.
ordinary phthisis due  to  tuberculosis.  It  is  said  to attack the
middle portion of the lung rather than the apices.   It does not give
rise to  cavities,  and  is more amenable to treatment  than  tuber-
culosis.
    In the liver syphilis causes a form of cirrhosis, a proliferation of
the connective tissue (diffuse hepatitis),  compressing the vessels, and
followed by all the signs of ordinary cirrhosis.  Gummata frequently
appear in the liver, sometimes to produce a nodular condition  which
may simulate carcinoma. With these lesions some external evidence
of the disease can usually be found.
    Syphilis causes a peculiar sarcocele,  which may be of large size,
involving the whole testicle.   It is usually of  slow  growth and not 
SYPHILIS.
177
 painful.   It is distinguished from the tubercular disease by the fact
 that the latter affects the structure proper of the testicle, and is,
 moreover, usually accompanied by tuberculosis elsewhere.   It differs
 from gonorrhceal epididymitis in  the absence of fluid within the
 tunic.
    The diagnosis of syphilis can usually be made by observing the
 polymorphism  but symmetrical  distribution of  its eruptions, the
 glandular enlargements, and the changes in the bones.  Suspicion is
 often aroused during inspection of the patient by the condition of the
 eyes, nasal bones, the presence of cicatrices or pigmentations in cer-
 tain localities—shins—or the detection  of an ozaena.  The diagnosis
 is sometimes only definitely established by the results of treatment.
    The prognosis is for the most  part favorable.  The manifesta-
 tions can usually be controlled.   Deep-seated lesions due to syphilis
 are, as  a rule,  more amenable to treatment than when dependent
 upon other cause.
    Treatment.—The initial lesion is best treated upon an expectant
 plan.  It is sufficient to make soma local application, as dry calomel,
 iodoform, or bismuth.  Excision is no longer practised.
    Those patients have, as a rule, the best prospects in  whom gene-
 ral, specific treatment is begun latest.   It is not best to endeavor  to
 prevent the secondary lesions, which are harmless.  When, however,
 destructive changes threaten (palate, nose) it is necessary  to inter-
 fere.
    Specific treatment may be postponed till  the  disease has reached
 full efflorescence.  This can rarely be done in practice.  So great  is
 the popular fear of the disease that it is usually necessary  to begin
 treatment at once.  The treatment,  then, should be mild at the start,
 a syrup of sarsaparilla or mild Zittmann's decoction.  Unfortunately,
 both physician and patient are impatient for results.
    Mercury is specific for syphilis.   This fact was known  long ago
 (manna metallorum), but the drug  was given so recklessly and for
 all the venereal diseases that some of the late lesions were often erro-
 neously ascribed to the treatment.
   The best  form in which to administer mercury internally is calo-
 mel.  The method of the Vienna school is as follows : One grain  is
 given three times daily for  five days ; the dose is increased one grain
 every five days for twenty days.  One to- three-grain doses are then
 continued for twenty days longer.
   If the bowels are too much affected they may  be  confined by
 opium.  Ptyalism is to be met by the use of potassium chlorate, satu-
rated solution, a teaspoonful every  two hours.   The evils of ptyal-
ism have been much exaggerated.   They are as nothing compared
with the late lesions of syphilis, against which  thorough treatment
         12 
178
CHANCROID.
 offers the best protection.  The best effects are to be obtained by the
 inunction method.  A small mass of mercurial ointment, a piece as
 big as the end of the little finger, is rubbed between the hands,  as a
 barber rubs hair oil before applying it, and is then applied at bedtime
 with friction for five  minutes to  the body in the following order :
 Forearms, arms, chest, abdomen,  thighs, legs—one part each night,
 to avoid eczema.  The body should be bathed but once a week.
   The treatment should be continued for weeks or months, or up to
 slight ptyalism.  Thereupon mercury should be given in small dose,
 as  the   biniodide gr.  ^ in  pill,  one  to three times  a day for a
 year or  two, that the remote evils of the disease may be avoided.
 The iodides of potassium and sodium furnish quicker results  in ter-
 tiary forms (gummata).  They should  be administered in  milk  in
 doses of ten to thirty grains before meals,  and  be  kept in circu-
 lation by free libations of water (mineral waters).   Iodine and mer-
 cury may alternate as remedies in the treatment of syphilis,  which
 should be  continued,  with  intervals of rest,  for  fully two  years.
 Thus only may the  patient certainly escape the terrible remote se-
 quelae of syphilis—amyloid change, locomotor  ataxia, brain soften-
 ing, etc.

                           CHANCROID.

   Chancroid  (like chancre); ulcus molle, "soft  sore."—A  specific
 (venereal) sore which appears, in twelve to twenty-four hours after
 infection or inoculation, about the frenum or other  portion  of  the
 glans penis, as a red spot, which  is elevated into a papule and  con-
 verted into a vesicle in the course of another day or two.  The vesicle
 ruptures to leave an ulcer with sharply defined, often overhanging
 borders, and a ragged,  profusely suppurating base.  The chancroid
 is always inoculable,  in the ape as well as in man, to reproduce  it-
 self on any broken surface of skin  or mucous membrane.   Hence, by
 auto- or reinoculation, chancroid is often multiple.  It often  infects
 neighboring lymph glands,  and is a common cause of the  rapidly
 suppurating bubo.  Under bad surroundings and  in depraved  con-
 stitutions it may  spread to  form  more  extensive and destructive
 lesions, phagedenic (serpiginous) or gangrenous in  character ; yet it
 is always a local process, and is never followed by signs of infection
 of the blood.  These two features,  the rapidity of onset and local con-
 finement, distinguish the chancroid from the true chancre (syphilis).
   The  treatment is  simple.  If  seen  early it should be destroyed,
 best  by fire—galvano-cautery, Paquelin's thermo-cautery,  ferrum
 candens ; or where from any reason this procedure is impracticable, by
 strong caustics—caustic potash or  the zinc chloride in stick.   Nitrate
of silver is too superficial; it does more harm than good, in  that it 
GONORRHCEA.
179
 only adds to  the irritation and  favors the development of buboes.
 Fuming  nitric  acid, applied with wood (match), is very  effective.
 After  the first few days the treatment must be mild.   The surface
 should be thoroughly cleansed and dusted with iodoform as the best
 remedy, or, next, with dermatol, or calomel or bismuth.  Sometimes
 it is best to use these remedies in the form of  an ointment rubbed up
 with vaseline or lanoline, sometimes as a wash (black wash), or sub-
 limate solutions 1 :1000-5000.
    Buboes at the  start may sometimes be aborted with an ice  bag ;
 later they must be poulticed and freely incised.   Rest in bed is the
 best remedy.
                          GONORRHCEA.
   Gonorrhoea (yovy, seed, semen) ; blennorrhcea (fiXevva, mucus,
 peao, to flow), from ancient erroneous views of the nature of the dis-
 charge ;  urethritis specifica ; clap; German,  Tripper.—A venereal
 infection  of the urethra, caused by a special micro-organism, the
 Gonococcus,  and  characterized by dysuria with discharge of pus,
 adenitis (bubo), condylomata, sometimes by affection of the prostate,
 testicle, bladder, kidneys (pyelitis), Fallopian tubes (salpingitis), and
 occasionally followed by inflammation of the joints (gonorrhceal rheu-
 matism).
   History.—Gonorrhoea  dates  from  the most remote antiquity.
 The Jews were very well acquainted with the disease, and they, with
 older nations, practised circumcision in prevention of it and in pro-
 tection  against it  and  other evils  (balanitis).   The  museum  at
 Naples exhibits catheters and dilators (bougies) exhumed from Pom-
 peii.  Syphilis on its appearance was known to be distinct from gon-
 orrhoea, but was later, after Hunter's unfortunate double inoculation
 of himself, confounded  with it, to be only finally dissociated by the
 more extensive observations of Ricord (1838).  The Micrococcus gon-
 orrhoeae was discovered by Neisser in 1879.
   Etiology.—Gonorrhoea  is  contracted in impure sexual inter-
 course by the introduction into the urethra of a specific cause, a par-
 ticular micro-organism, which may be thence disseminated to any
 part of the genito-urinary tract.   The  disease has therefore a  very
 wide range, and is wont to secrete itself in some recess or lacuna of the
 posterior urethra, prostate gland, Fallopian tube, as a malady often
 of years'duration  (gleet, oophoritis, etc.).  Intense or protracted in-
 flammation, heroic treatment, as with concentrated injections,  may
 develop stricture of the urethra with its attendant evils.  Lack of
 cleanliness, or careless manipulations, may convey the discharge to
other mucosae, as to the anus (condylomata)  or  eye (conjunctivitis).
 The  eye, more rarely the vagina, of the new-born child may be in-
fected during birth (conjunctivitis, blennorrhcea neonatorum). 
180
GONORRHCEA.
   The disease is most readily contracted  with filthy habits, and is
favored  by conditions  which retain  secretions—phimosis, hypo-
spadias, balanitis, etc.  The tougher mucosa of the vagina is more
resistant, so that  females are less affected, or,  while actually  con-
taining the virus to convey the disease, may  themselves escape all
infection.
   One attack predisposes to others, which are, however, aside from
complications, successively milder as a rule.
   Bacteriology.—The Gonococcus is a diplococcus, apparently com-
posed of hemispheres separated by an equatorial  zone.  It  is found
in gonorrhceal  pus in association with other  pyogenic cocci, from
some of which it is differentiated with difficulty.  It grows on blood
serum as a thin, yellowish-gray coat  with smooth surface, only at
high temperatures, and speedily perishes.   It takes the color of the
       Fig. 124.                            Fig. 125.
Fig. 124.—Gonococcus (Sternberg) : a, pure culture ; b, in pus, and c, in epithelial cells.
Fig. 1^5.—Gonococcus in pus cells.
aniline  dyes, and gives it  up under the Gram method.   It is found
incorporated in pus  cells, as well as free in the matter discharged
(vide Frontispiece, Fig. 5).   It is found in the tissue of the urethra,
incorporated in as well as between the epithelial cells and leucocytes.
It has been traced, throughout the whole range of the disease, in the
prostate, testicle,  Fallopian tubes, perimetritic processes, and joints.
and in the  eye as the  cause of a specific acute  conjunctivitis and of
a specific chronic trachoma.
   Symptoms.—The  incubation is two or three days, at the end of
which time tingling, then  burning,  and later scalding sensations
are felt  in the urethra on passing water.  The under surface of the
penis (urethra) is tender ; the lips of  the meatus become tumid, red,
and dry, or stick together with glutinous mucus.   Erections assert 
GONORRHCEA.
181
themselves, especially at night, to produce  excruciating pain and
distress with  deformity  (chordee).   In the course of  a day or two
muco-purulent matter, and later pus itself, is voided, at first with the
urine, later more or less continuously, or may be at any time more
freely expressed.   In the  height of  the average case there are fever
and general distress.  Bad cases  may be marked by destruction of
tissue, erosion of  the capillaries,  with discharge  colored  by blood
(Russian clap).
    In certain cases infection travels along the  lymphatics to reach
and inflame  the nearest  glands  in the groin, a chain  of which
constitutes a  painful, indurated mass, filling the groin on one or
both sides, and putting a  stop to locomotion.  In  other  cases the
disease extends to involve the posterior urethra, pars prostatica, vas
deferens, and epididymus, which swells with great pain and  effu-
sion into  the tunica vaginalis  (acute  hydrops).   Moist surfaces of
mucous membrane or skin suffer maceration  and irritation,  with
hyperplasia of papillae, to produce the warty or cauliflower condylo-
mata so common on the glans penis and not uncommon in the  peri-
neum.  A more acute inflammation of  the  prepuce,  as  produced
especially  by  lack of cleanliness, retained secretions,  or by fissures
from retraction, may result in phimosis or paraphimosis.
    In  certain cases  the  clap involves  the  posterior urethra in due
sequence,  usually in the course  of the second or third week, to pro-
duce posterior  urethritis and prostatitis.   In certain other  cases
the posterior  urethra and  prostate are seemingly involved first, the
disease having been latent at the fossa navicularis and  pars pendula.
In  either  case, whether with evident or absent discharge, there is
dysuria, with more  or less constant desire to micturate, often with
sudden stoppage of the flow from spasmodic contraction of the  bulb.
Perturbations in the psychic sphere, irritability, dejection, emotional
disturbance,  hysteria  virilis,  along  with  insomnia, headache,
priapism, occur with this  complication, which is very much  more
frequent than is commonly known.
   Involvement of the glands of Cowper, usually not before the third
week, is revealed by  a sense of weight and  pain  in the  perineum,
with the formation of a  tumor in the line of the raphe under the
skin, which is movable above it.  The tumor may recede by resolu-
tion, or continue to  enlarge to involve  the  skin  in a suppurative
process, and discharge itself externally with  relief of  previous dis-
tress, or internally with the bad signs of infiltration of  urine and the
formation of fistulae.
   Peri-urethral and prostatic  abscess,  purulent  cystitis,  pyelitis,
subsequent stricture of the urethra, are not uncommon complications.
Women are  affected  with vulvo-vaginitis, vaginitis  (leucorrhcea), 
182
GONORRHCEA.
metritis,  oophoritis,  salpingitis, sometimes with  peritonitis, as  the
result of  gonorrhceal infection, much more frequently than is com-
monly believed.   In this way gonorrhoea is  a frequent  cans*1 of
sterility.
    Gonorrhceal rheumatism attacks most frequently the knee joint,
one or both, and  one joint rather than a number, usually late in the
history of the disease, and distinguishes itself by its sluggish, passive-
character (hydrarthrosis) and exceeding obstinacy.  The heart is not,
or is only very rarely, affected.
    Duration.  Prognosis.—Gonorrhoea  usually  lasts,  aside  from
complications, two to four weeks.  It may be terminated earlier by
felicitous  treatment,  or  may by bad treatment or by complications
(prostatitis, salpingitis,  etc.)  be protracted to constitute a lifetime
malady.   The prognosis of urethritis is favorable; that of  the com-
plication depends upon its nature.   The disease  is often very obsti-
nate and  shows constant tendency to recur.   On the whole, though
apparently a simple local affection, gonorrhoea is, on account of its
complications, more  destructive of  comfort, more defiant  of treat-
ment, and absolutely, in the long run, more dangerous  to  life than
syphilis.   But it is not so insidious and treacherous as syphilis, and
hence is not so much feared or loathed.
    The prophylaxis is purity  and cleanliness.  The eye affection of
infancy is best prevented by vaginal irrigations with  a  weak subli-
mate solution 1 :10,000 before  labor, and washing out the  eyes  im-
mediately after birth with a solution of nitrate of silver in distilled
water two per cent.
    The diagnosis is in most cases easy.   The history is sometimes a
help ; often, on account of misrepresentation, a hindrance.   The ure-
thritis with dysuria and discharge, subsequent adenitis or epididy-
mitis, distinguish gonorrhoea.   Urethritis from other cause, so-called
simple urethritis, supervenes  at  once  and shows very slight   dis-
charge of very short duration.  Adenitis from other infection (strain,
muscular  fatigue ?) has  different association—i.e., has no discharge
or dysuria.
    The diagnosis rests absolutely on the discovery of the  gonococcus,
which is recognized (1) by its form as a diplococcus, twin bodies with
the straight or concave edges  apposed like the halves of a grain of
coffee ; (2) by appearance in numbers, never as a single pair ;  (3) by
their incorporation or enclosure in the protoplasm of the  pus cells, as
well as by occurrence free, i.e., between the cells ; (4) by the affinity
for the basic aniline dyes ; (5) by decolorization under absolute alcohol
and under the method of Gram ; (6) by difficulty of  culture,  which
really succeeds only  with human blood serum.  The decolorization
by  the Gram method especially differentiates the gonococcus from 
GONORRHCEA.
183
other simulating diplococci.  The gonococcus is best displayed by
spreading a thin layer of the discharge upon an object glass, which is
then drawn through the flame of  an alcohol lamp to fix the  object,
dipped for two minutes in the solution of methylene blue (Loftier),
washed with distilled water, well dried with blotting paper and exam-
ined with the oil immersion, whereby the oil may be dropped directly
upon the object.  The gonococci  are thus colored deep blue, the nuclei
lighter blue, the cell protoplasm gray-blue (Finger).   The micro-or-
ganism has  been thus demonstrated in endometritis, conjunctivitis,
and all kinds of gonorrhceal processes.   It is scarce and often absent
in old chronic discharge.  Sexual intercourse is prohibited so long as
it is present even  in the single, so-called "bonjour" drop or sticky
mucus seen  in the morning.
    The gonococcus may now be relied  upon as furnishing the very
strongest corroborative evidence in cases of rape,
etc., though Nissen claims to have found a simi-
lar structure in the eyes of a child born with mem-
branes intact.
    The diagnosis of posterior urethritis, in the
absence of history of gonorrhoea, is usually led up
to on the basis of signs of infection not otherwise
explicable, and rests chiefly upon  examination of
the urine, which must be always  made in every
case of dysuria.   The  urine (morning) in  these   FlG 126 _ Non.speCinc
cases shows fine, long filaments of mucus floating bacteria,   streptococcus
in  its mass and sinking to the bottom of the ves- and staphylococcus, found
sel. These clap fibres or threads (Tripperfdden)
come from the prostate gland and its vicinity, and are very charac-
teristic.  The first and last  parts of the morning urine should be
caught in separate vessels, that it may be determined whether the
threads come first from the urethra or later from the bladder.
    The swollen prostate may be felt with the finger as a tumid, tender
mass protruding into the rectum, or offering obstacle to the  passage
of the catheter, which should not be introduced until all acute inflam-
mation shall have subsided.
    Treatment.—During the stage of acute urethritis the treatment
should be simply expectant.  The testicles should be suspended in a
light bandage, the bowels should be kept open with a saline laxative
—Rochelle salts, Carlsbad salts—and fluids (water, milk, lemonade,
flaxseed  tea, etc.) should be drunk freely; every form of alcohol
must be abjured.   The diet should be light.   The patient should take
every  opportunity to rest recumbent.  Sexual indulgence  should
cease entirely.  Priapism may be prevented  at night by sponging of
the organ from a basin of  cold water at the bedside, and excitement
 
184
GONORRHCEA.
allayed by a dose of the bromide of sodium or potassium, gr. xxx.-l.
in a full  glass of water at bedtime; or by camphor  gr. iij.-v., or
lupulin gr. iij., or both together, every two or three hours during the
day.
   The pain of micturition may be relieved by salol, gr. v.-x. every
two or three hours, or by the salicylate of soda, bicarbonate of  soda,
aa gr. x.-xv. every two or three hours during the day.  Phenacetin,
gr. v.-x. every four hours, has also a soothing effect.   More severe
pain with  priapism, or dysuria with  frequent desire of micturition,
   Fig. 127.—1, hexagonal plates of cystin ; 2, gonorrhceal thread composed of pus and desqua-
mated epithelial cells ; 3, spermatozoids.

calls for opium, gr. i. with  cocoa butter in  suppository, or with ex-
tract  of belladonna gr. -J-4;.  No attempt  should  be made at any
direct  medication of the urethra at this  time.   Upon subsidence of
the most acute stage the urethra may be addressed  at first internally
through the urine with the oil of copaiba or sandal wood, best in the
form  of capsules, each gtt. v.,  of which one may be  administered
every two to four hours.  Hereupon, or later when all acute inflam-
mation shall have entirely  disappeared, but not until then, the urethra
maybe medicated directly with weak injections, as of plumbi acetatis
gr. ss.-ij. to 3 i., or zinci acetatis gr. i.- 3 i., or argenti nitratis gr. i.-ij. 
GONORRHCEA.
185
to 1 iv. aquae destillatae, at first twice a day.   Alumnol in the one- to
two-per-cent solution is a  bland, mild  remedy ;  the chloride of zinc,
gr. i.-ij. to the ounce, is a much more powerful antimycotic and
styptic.  Injections must be continued for several days or a week,
at least once a day, after all sign of discharge has disappeared.
   Posterior urethritis will not be reached by any ordinary syringe.
The remedy, to be effective, must be introduced  with a  catheter,
preferably  with  the  Ultzmann  capillary injector,  which reaches
only to the bulb and prostatic portion.  By far the best remedy in
these cases is the nitrate of silver, whose strength  may be gradually
increased from 1 : 500 to solutions of one, two, up to five  per cent,
prepared always,  of course, with distilled water, and  used in gradu-
ally increasing quantities, at first daily, later once or twice a week.
Toxic headaches  of extreme severity, defiant neuralgias,  obstinate
anorexias,  fits of depression bordering  on melancholy, often yield
like magic to this method of treatment, which in  a short time con-
stringes  the prostatic urethra, prevents  the absorption  of septic
matter, and  literally  gives new tone  and zest  to  life.   Precaution
must be taken to boil the  instrument thoroughly before each intro-
duction, to anoint it  with glycerin, and to have the solution warm.
Excessive sensitiveness of the  urethra may sometimes be quickly al-
layed by the passage of cold water through the psychrophore for a
few minutes once a day.
   Cystitis is best treated by washing  out the bladder with weak
solutions of boric acid and later of nitrate of silver.  Treatment must
be continued for months.   Refractory cases call for use of the endo-
scope.
   Here, more than anywhere,  is to be emphasized a maxim of Hip-
pocrates : " Primum  non nocere!"  Here, as  much as anywhere,
some of the finest triumphs of medicine have been achieved. 
CHAPTER  V.
               INFECTIOUS  DISEASES—Continued.

                             MUMPS.

   Mumps (Danish, Mompen, whence  our word  mum, mumble);
parotitis epidemica ;   French, oreillons;   German,  Schafskopf,
Ziegenpeter.— An acute, contagious infection, of short duration and
little gravity, distinguished by painful inflammation of the parotid
gland and vicinity, sometimes also by orchitis.
   History.—Mumps  was  known from  the  remotest- antiquity.
Hippocrates mentions it, and the  older physicians associated it with
measles, scarlet fever, whooping cough, etc., as an affection of child-
hood.  It was observed then, as frequently since, that the disease
prevails in epidemic form, and that epidemics are wont to precede or
follow outbreaks  of some of the  exanthemata or other affection of
childhood.
   Metastatic Mumps.—A  special affection  or  infection  of  the
parotid gland, which occurs at any age, in the course  of, or a sequel
to, many  of  the graver  infections—septicaemia, the  typhus  fevers,
puerperal fever, etc.—is set apart  and distinguished  from the  epi-
demic parotitis as a metastatic inflammation.  A sub-variety of  this
form may follow intestinal or pelvic  lesions.  Canstatt speaks of
metastasis of mumps  to the pancreas in the  same sense as to the
testes,  ovaries, and   mammae.  Schmackpfeffer  reported  a  case
wherein an autopsy revealed a pancreatitis in explanation of a paro-
titis, and, after a full review of this subject, Friedrich  is not willing
to dismiss the possibility of such  metastasis, a question which must
be decided in some future extensive epidemic of mumps or fortunate
opportunity at autopsies.  A so-called  reflex parotitis is sometimes
observed  after catheterization of  the  urethra.  Baginsky reported
three cases which occurred in his  own practice after operations for
the relief of genital affections in  women.
   Etiology.—Parotitis epidemica, our common mumps, prefers the
colder seasons of the year.  Of one hundred and seventeen epidemics
tabulated by Hirsch fifty-one occurred in winter, and  of ninety-nine 
MUMPS.
187
 studied by Leichtenstern forty-two were in the first quarter of the
 year.  The disease show's also a preference for certain localities, in
 which it may prevail continuously, or recur with every accumula-
 tion of fresh material.  Great variation is shown also in its extent or
 range.   It remains confined to certain institutions, boarding schools,
 orphan asylums, barracks, etc., or again extends over, or is circum-
 scribed to, a certain quarter of a city, or ranges over the entire  city
 and surrounding country.   Epidemics may be extinguished in the
 course of a few weeks, or prevail throughout the greater part of a
 year.  The disease shows some predilection for soldiers, probably on
 account  of close association in barrack life. Some of the best reports
 are  furnished  by the military  surgeons (Bruns).   It attacks males
 always more  frequently than  females, and  is at times  limited to
 children ; or,  again, spares no individual unprotected by previous
 attack,  except sucklings and old  people, who almost universally
 escape.   The age of preference is from two to  ten.  In a house full
 of children mumps usually begins with the  youngest, successively
 seizes the older children, and may afterward attack  adults.   Liabil-
 ity of males is nearly universal.  The disease has often been  known
 to attack ninety per cent of the residents or inhabitants of public in-
 stitutions, schools, barracks, etc.
   Mumps is undoubtedly contagious, and probably, as no other ex-
 planation seems  possible,  through matter expectorated  from  the
 mouth to contaminate the  atmosphere in the vicinity of the patient.
 It may attack animals (dogs) with active salivary glands.   Roth de-
 clares that third parties may carry the disease.
   Mumps is probably at first an entirely local process.  From the
 nature of the disease there can be little doubt that the cause  is a micro-
 organism which  infects  the blood,  or which,  from  its nidus in the
 parotid gland, evolves toxines to produce fever and the  other general
 symptoms of the  disease.  The evidence actually in possession goes
 to show that mumps  originates in the mouth, and not  in  the blood ;
 that the poison of the disease is conveyed to the parotid gland through
 the duct of Steno, and not through the blood vessels.   This fact seems
 to have been proven of metastatic parotitis, where a priori  reason-
 ing would certainly derive the poison from the blood.   What lends
 special support  to this view in  epidemic parotitis is the fact  that the
 disease is found associated  almost  universally with  stomatitis or
 some form of sore mouth or  sore throat.   Soltmann attributes the
exemption from mumps of infancy  and old age to the fact that the
duct of Steno is too small in infancy and too atrophied in age to per-
mit the entrance of noxious matter.  One attack secures  future im-
munity as a rule. .
   The period of incubation  ranges  from ten to fourteen days.  It 
188
MUMPS.
may be as short as seven or as long as twenty-one days.  English
writers generally put it at a fortnight.
    Symptoms.—The disease sets in with chill or shivering fits, fol-
lowed by fever of 102° to 105°, and may often be preceded for a few-
days by malaise, anorexia, headache,  and neuralgic pains.  Coinci-
dent with the elevation of temperature is the pain, the  localization of
which distinguishes the  disease.   Shoots and stabs of pain are felt
at the angle of the jaw, radiating  to the temple and the ear.  The
parotid gland swells.  It fills up the space between the mastoid pro-
cess and the angle of the jaw, mounting over  the side  of the fact1.
and extending over the cheek and down the neck with  such a degree
of tumefaction as at times to obliterate natural outlines.   By this time
there is such interference with the action of muscles and the excur-
sions of  the jaw as to close it, so that often the handle of a spoon
may not be inserted between the teeth.   The pain, on account of the
tumefaction, tension, and interference  with the circulation,  always
severe, is sometimes  excruciating,  and  is  of course greatly aggra-
vated by every  attempt at  motion of the jaw and deglutition, or
even at times by the sigJit  or odor of food, which may stimulate
the salivary glands.   The  inflammation extends also  through  all
the tissues  of the throat, and is manifest  often  in the throat and
mouth by marked  redness  and swelling, sometimes  by actual dis-
placement or partial occlusion of the palate, pharynx,  and larynx.
The lobe of the ear is lifted  and carried forward; the whole head
may be pushed over to one side.  The swelling reaches its height, as
a rule, by the fourth day, when with the fall of temperature it begins
to subside, and subsides so rapidly as to  have almost entirely disap-
peared by the sixth to the eighth day,  unless,  which is not infre-
quently  the case,  the opposite side takes on the same  swelling to
repeat the same process.   Much more rarely the affection is bilateral
from the start.  In such a case deformity is most  pronounced.  The
cheeks, the  jaws, the neck form a vast tumefied, (edematous, indu-
rated mass, and the suffering from distention becomes correspond-
ingly great.  A peculiar characteristic, and not the less striking be-
cause somewhat comical picture, is thus presented by an individual
affected with mumps.
   The contagious principle  or cause of mumps finds nidus  also, in
certain cases, in the other salivary glands, and in an organ as remote
as the testicle.
   The inflammation or infection of tlte testicle is  the most inte-
resting complication of mumps.  The  organ is usually affected after
the process in the parotid has subsided,  sometimes coincidentlv, still
more  rarely alone as the sole  sign of the  infection.   It is the tes-
ticle itself which  is invaded—orchitis—very rarely the  epididymus 
MUMPS.
189
 or the cord, and  only after puberty.  In  double mumps the right
 testicle, in single the organ  on the side of the affected parotid, is
 most frequently affected.  Double orchitis is rare.  Affection of the
 testicle is  revealed by a sensation  of weight  and pain in the gland
 and along the cord, by fever, and  sometimes by vomiting.  The tes-
 ticle soon becomes swollen  and  tender, and the  scrotum is often
 reddened and oedematous.
    Liability is not increased by the severity of the mumps.  Orchitis
 may occur in the lightest cases.  Urethritis with  blennorrheea has
 been also  noticed with oedema of  the  scrotum, and in women,  very
 exceptionally, oophoritis with leucorrhcea and swelling of the exter-
 nal labia and the  mammary glands.
    Mumps, though  considered  a light infection, is liable to certain
 grave complications.  Sudden deafness  may set in from labyrinth-
 ine disease, and serious affection  of the brain  ensue from interfe-
 rence with the  circulation or poisoning  by toxines.   Mental aliena-
 tion, mania, and melancholia have been reported in  consequence of
 mumps.
    Other complications  recorded are hyperaemia of  the brain from
 pressure on the jugulars, meningitis, amblyopia and color blindness,
 conjunctivitis, laryngeal stenosis, albuminuria, haematuria, nephritis,
 etc.  But it must not be  inferred that  mumps is  a grave disease.
 The author, in the practice of a quarter of a century, has never  seen
 any other complication than a trivial and transitory orchitis.
    The diagnosis is usually easy, and is  helped, in any doubt, by the
 existence of the disease  elsewhere.  The extraordinary swelling and
 pain, with closure of the mouth, lifting of the lobe of  the  ear, and
 torsion of the head,  distinguish the affection.  Lesser swelling with
 less pain may necessitate  inspection  of the throat  in elimination of
 scarlet fever, diphtheria, or quinsy.  Digital  examination would de-
 tect a retropharyngeal abscess, which might extend to  involve the
 connective tissue  about the jaw.  A lymphangitis,  or simple adeno-
 pathy from infection of the throat—a very common affection—may be
 nearly as extensive and  painful as mumps.  It is usually seated or
 arises lower on the neck, has no definite duration, and is much more
 prone to suppuration.  Resolution almost never occurs in metastatic
 parotitis, and suppuration shows itself in the course of a few days.
   Mumps requires but little  treatment.   Confinement to the house,
 if  not  to bed, applies of course to every case attended with  fever.
 Light diet from necessity, thin milk, soups, soft-boiled egg, custard,
 suffices to  secure  nourishment without  strain  upon the inflamed
 tissue or disturbance of the stomach.   Hot emollient applications—
hot oils,  olive oil, cod-liver oil,  cocoa butter, vaseline, etc.; flannels
wrung out of hot water; hot, not too  heavy, poultices of flaxseed or 
190
MEASLES.
slippery elm ;  the lead and opium wash bound on witii oiled silk, best
relieve the tension and pain.   Gargles of hot water with  salt, re-
peated every half-hour or hour, are  poultices  applied nearer to the
seat of the disease.   A saline laxative, a dose of calomel,  an anti-
pyretic, quinine gr. ij.-v., phenacetin gr. iij.—x.,  broken  doses  of
Dover's powder gr.  ij.-iij.,  every  two to six  hours,  best meet  the
indications and protect the patient during the short duration of the
disease.  Some mode of light suspension, especially in  the recumbent
posture,  gives great  relief to  a developing orchitis.   Faradization
later  will often prevent atrophy.   Affections  of the ear and  brain
call for special treatment, though little hope may be harbored of re-
lief of a deafness which sets in  over night.
   Metastatic parotitis is treated in  the same way. with address to
the remote  origin  of the complication and  speedy  evacuation  of
accumulated pus.

                            MEASLES.

   Measles (Sanscrit, ma sura j German,  Maseru) spots; rubeola
(Sauvages).  ruber (French,  rougeole, red); morbilli (diminutive of
morbus).—An intensely contagious, acute infection, characterized by
coryza and bronchitis, a red-spotted eruption with branny desquama-
tion, fever of typical course subsiding at efflorescence, with liability,
mostly as sequel, to catarrhal pneumonia, sometimes to tuberculosis.
   Synonyms and History.—Though  existent from time immemo-
rial, measles was first described by Rhazes, 900 A.D., in an attempt to
separate it from small-pox.   Rhazes noticed among the symptoms of
measles '' redness of the eyes with a great flow of tears, nausea, and
anxiety," remarking also that the measles " that are green or violet
colored are of a bad kind, especially if they sink in suddenly,  for then
a swooning will come on and  the patient will soon die."  The dis-
ease was described under the name hhasbah.   Nearly  all subsequent
writers adopted the Italian  term morbilli  up to the  middle of  the
eighteenth century, when Sauvages substituted for it or re-established
the term rubeola, which the French accepted in their own equivalent
of rougeole.   Rubeola  means  something  definite.  It  expresses a
characteristic  feature of the  disease,  in .fact the most characteristic
feature—the redness of the eruption.   It is unfortunate that this term
rubeola has been adopted by  certain German writers to express that
particular sub-variety, special or hybrid form of the disease known as
German or French measles ;  popularly, in Germany, as rotheln.  So
long as scarlatina would seem by universal acceptance  to be the most
appropriate name for scarlet  fever, rubeola must be the most appro-
priate for measles.
   Foreest  (1565), the Dutch Hippocrates, first pointed out certain 
MEASLES.
191
 distinctions between measles and scarlet fever, though the separation
 of the affections is usually credited to Sydenham, the English Hippo-
 crates.
    General Remarks.—The primeval home of  measles is unknown.
 From its earliest recognition it  has  prevailed  in epidemic  form in
 Asia,  Europe, and South America.   It was  imported to  the United
 States with the  first settlers, to gradually spread over it with the
 inarch of the pioneers.  It reached Oregon in  1829, California and
 Hudson's Bay in 1846, the Sandwich Islands in 1848, whence it was
 carried to Australia in 1854 and  to Greenland in 1864.  Though the
 disease has now become indigenous  everywhere,  and individual
 cases  are of continual occurrence in large cities,  measles usually
 prevails as  an  epidemic over a wide extent of country,  with inter-
 vening periods of absence.  Epidemics die out in two to three months
 from lack of material.  Measles does not hold over in sporadic cases,
 like scarlatina, but disappears completely, to reappear with reaccu-
 mulation of material every three or four years.
    Etiology.—Susceptibility to the disease is  almost universal, so
 that it has been said if measles had the mortality of  scarlet fever the
 human race would have  long since  become extinct.   The  eminent
 contagiousness of the disease is  shown in the attack of whole com-
 munities previously entirely or for a long time exempt, as in  the
 Faroe Islands,  where six thousand people were seized at once.   In
 1886 the disease overran nearly the whole of Russia.  Thus  measles
 makes up for its mildness  by its range.
    Measles  prevails more distinctly in  the colder months.  Of  the
 epidemics tabulated by Hirsch, bhree hundred and thirty-nine occurred
 in the colder and one hundred  and ninety-one in the warmer months.
 The frequency of epidemics in winter has  usually been ascribed to
 the closer contact of people at this season.   It  is certainly observed
 in cities that the disease assumes epidemic proportions with the open-
 ing of schools and kindergartens.   These institutions disseminate the
 disease because measles is a children's disease, and a children's dis-
 ease because it attacks at the earliest exposure.  Escape in child-
 hood by no means secures exemption, as is evidenced by  the attack
 of people of all ages in isolated regions.
   Measles occurs at all ages, preferably from one to five, the period
 of earliest exposure ; rarely among sucklings, the age of  least expo-
 sure, as well as of protection by protective elements  in the mother's
 milk.   It is certain that even pregnancy is no defence.  The organ-
 ism of measles may be conveyed  by third parties and by things (fo-
 mites).
   Measles may certainly coexist with other  infections, with scarlet
fever, with rotheln, with  typhoid fever, etc., and  most especially 
192
MEASLES.
and frequently with pertussis.  An unmistakable coincidence is men-
tioned by Panum,  who vaccinated  a child  in the incubative stage
of the disease, both vaccinia and measles running a typical course.
With the exception of pertussis, the existence of an acute disease.
as a  rule, postpones an attack of measles until after its subsidence.
Coincidence is therefore an exception to the rule.
   The micro-organism of measles escapes from the body through
the nasal mucus,  which, dried and infinitely subdivided, floats in
and contaminates the atmosphere about—that is, in the vicinity of—
the patient.  Mayr certainly succeeded in propagating the disease
with mucus from the nose.   Canon  and Pielicke found in the blood
during life in fourteen cases, and in the nasal mucus, a bacillus of
great difference of  length, usually in groups or clusters, during  the
whole course of the disease.   It was demonstrated by a stain of eosin-
methylene-blue  (concentrated aqueous solution of methylene blue,
eighty; one-fourth per cent eosin solution [in seventy-per-cent alco-
hol],  twenty ; two to three hours' stain in the incubator).  Doehle
depicts protozoa as the cause of the disease.
   The period of incubation, as determined by inoculation experi-
ments and  observations by  conveyance of single cases to isolated
places, is  quite definitely established at ten  days—that is, fourteen
days before the eruption.  The most indisputable observations were
furnished by Panum  in the  Faroe Islands.   It was easy  in  these
cases to trace up the source  of infection, which  corresponded to  the
landing of a case  from a ship.  In all these cases thirteen to four-
teen days elapsed  from the day of exposure  to the beginning of  the
eruption.
   Symptoms.—The period of incubation is,  in the vast majority of
cases,  wholly free of symptoms. Very exceptional cases show malaise
or ephemeral fever, which may arise from toxines.  The stage of in-
vasion may be marked by a distinct chill, or, more  commonly, by a
series of shiverings, to be attended or followed by a rise in tempera-
ture to 100° to 104°, with gastric irritation  and nervous symptoms
in correspondence with the temperature.  The fever  is in many cases
so slight as  to be overlooked, when  the  disease may announce itself
with more distinctive  signs.  After the first remission the tempera-
ture again rises with the appearance of the eruption, to reach its
acme  at the period of full  efflorescence, and to decline  as it fades
away.  In an average case  the fever falls by crisis—that is, within
thirty-six hours after the first decisive fall.   During the stage of in-
vasion characteristic catarrhal symptoms  show themselves in the
mucous membrane of the nose, eyes, throat, and bronchial tubes.
These symptoms  are summed under  the term coryza.  The eyes
grow  intolerant to light; the conjunctiva  is hyperaemic ; the nose 
MEASLES.
193
''runs"; the eyes, nose, and throat itch and  burn—sensations but
partially relieved by more or less sneezing and cough.   The uvula
and  soft palate now show dark-red spots and  later diffuse redness,
the so-called enanthem, the first appearance of the eruption.  Bron-
chitis, the result of the  direct invasion of the bronchial tubes, be-
longs to measles as definitely as the eruption.
   The eruption proper is seen first, as a rule,  on the morning of the
fourth day, exceptionally as early as the end of the third or as late as
the fifth day.  The eruption shows itself in " spots " (measles), usually
somewhat elevated, dark-red, " raspberry" red, or tinged with blue,
first upon the forehead and sides of the face.   It  distinguishes itself
especially upon the face by coalescence and aggregation into irregu-
lar or crescentic patches with in-
tervening islets  of unaffected tis-
sue.   During  full  efflorescence
the face seems puffed and swollen.
The eruption  gradually spreads
downward over  the neck, chest,
trunk, and  extremities,  to cover
the whole surface by  the  eighth
day. More  or less confluent  on
the  face and  neck, it gradually
grows more and more discrete
over the trunk,  legs, and feet.
Reaching the lower extremities,
it begins to fade from the face.
Desquamation, which is  absent
in light cases, is  furfuraceous  as
a rule.
   The eruption reaches its height   FlQ ]28 _Temperature in simple measles.
in thirty-six to forty-eight  hours,
the period of efflorescence, and the height of  the fever corresponds
with its duration.   So soon as the fever  has reached its height it be-
gins to fall, and falls rapidly, to terminate, as stated, by crisis within
thirty-six to forty eight hours.   This  fall of the temperature  with
the appearance of the  eruption is so characteristic as to enable the
observer often to  differentiate measles in cases of doubtful eruption
from simulating maladies.   There is the appearance  that  the  body
struggled with the disease, and finally succeeded, as the old writers
believed, in throwing it off in  an eruption.  But the disease is not
really in the eruption.  The eruption is really only a  toxic reflex,
like herpes, urticaria, etc.  The fact is, the fall of temperature is ob-
served, as a rule, before the eruption  has reached its  full height.
When it is on the eve of  efflorescence, as if a poison had been voided
        13
 
194
MEASLES.
from the blood the temperature falls rapidly.  So the crisis occurs
often within forty-eight hours  after the appearance of the eruption,
and hence measles (barring complications) is a mild disease.   Hence
measles is a little (short) disease.   At the end of  forty-eight hours
after the appearance of the eruption there is  in most cases no fever
at all, and in many cases actually a subnormal temperature, at least
in the morning.  So well established is this fact in measles  that the
persistence  of temperature,  or the existence of an elevation of
even one or  two degrees on the third or fourth day after the appear-
ance of the eruption, betokens a complication,  which will announce
itself with  its distinctive  signs in the  course of a day  or two.
Day of
Disease
xaxm
1
toy
s
1
m
I

5*
H
ts.
el
5
s:
«
«
u
55
k;
1;
98'
Fig.
  Scarlatina                    Measles.
129.— Contrast between the fever of scarlatina and that of measles (Moore).
Where  records of temperature are faithfully kept  complications are
thus often announced before they may assume distinct proportions.
   Duration and Desquamation.—The clinical history of an ave-
rage uncomplicated case of measles implies thus ten to fourteen days'
incubation, three days' invasion, three days' progress, and three days'
decline.
   Abnormities, complications, and sequelae are of frequent occur-
rence.   The eruption or the catarrhal symptoms may either be ab-
sent, morbilli sine catarrho,  sine eruptione, though some eruption
may be seen or found somewhere  under  scrutiny close enough.
Blood poisoning in the stage of invasion may be so  intense as to take
life at the start—rubeola s id era ns.  Haemorrhage may show itself in
two forms.  In the more frequent but less grave form a few or many 
MEASLES.
195
of the spots become petechiae.  In the true haemorrhagic or black
measles,  rubeola nigra, observed  only in cachectic cases and de-
graded surroundings, free haemorrhage occurs—that is, blood flows
from the nose, mouth, kidneys, vagina, or intestines, and vibices and
ecchymoses appear upon the surface.
   Nervous symptoms may assume prominence.   Headache is com-
mon,  and at times severe.  Invasion, especially in young children,
may be marked by delirium, coma, or convulsions.   True meningitis
is rare.  Transitory albuminuria is common, but nephritis  is very
rare.  Very sharp attack is ushered in by anorexia, nausea, vomit-
ing—symptoms which may extend over the period of invasion.  Paro-
titis is very rare, but laryngismus, due at times to laryngeal enanthem,
is not at all infrequent.  The picture of laryngeal stenosis—some-
times as the result of a true croup (diphtheria), more frequently of a
false croup (laryngismus stridulus), sometimes as evoked by a  spot
of hyperaemia on an exquisitely sensitive surface, which may be  seen
and treated under the laryngoscope—presents itself occasionally in
the course of  the  disease.   Noma, a gangrenous affection of the
mouth or vulva, is an ugly complication in cachectic cases or under
exceptionally  degraded hygienic surroundings ; it is fortunately a
rare complication, but  measles  (Woronichin)  is its most frequent
cause.
   Catarrhal pneumonia  is the  complication most frequent and
most feared.  It is recognized by rise of temperature, frequency of
breathing,  increase of cough,  dyspnoea, with the physical  signs of
this disease.  Latent  tuberculosis  is brought to the surface by an
attack of measles, as a rule.  Hyperaemia of the bronchial tubes and
glands excites quiescent bacilli to quick and active growth, or renders
fruitful a soil previously sterile to this disease.   Above all other dis-
eases, as stated already, measles liberates  tubercle bacilli from bron-
chial glands.  This is probably the true  relation of these diseases.
The  primary infection is a thing of  the past.  Penetration to the
bronchial glands has been favored by coddling, by the house climate,
by various medications, by the administration of cough mixtures,
opiates, under the cover  of which the disease has secreted itself in the
recesses of the lungs—to wit, the bronchial glands.   Measles,  with its
hyperaemia, its bronchial and pulmonary congestions, irrigates the
soil, swells the glands, and  arouses dormant or quiescent  seed  into
active life.   Ziemssen long ago called attention  to the revelations of
the laboratory with reference to cervical glands, in that they  so often
contain  tubercle bacilli  hitherto quiescent;  and the same condition
has been revealed of the bronchial glands, which may be called nur-
ture soils of the tubercle bacillus.
   The eruption of measles may prematurely disappear, "strike in," 
190
MEASLES.
at any time, not as the cause but the effect of complications.  This
disappearance of the eruption with the development of a complication
is, however, the exception, and not, as commonly believed, the rule.
The eruption runs its course, as a rule, in  spite of  the complication.
Complications are due to the nature of the  poison, to the constitution
of the individual, not, as commonly believed, to "catching cold," the
fear of which interferes with one of the chief  means  of successful
treatment—free ventilation of the sick-room.
   The diagnosis  is easy, as a rule.   The  prevalence of an epidemic
or existence of other  cases, escape  of  attack hitherto,  are points  in
circumstantial  evidence.  Measles is differentiated from a simple
catarrh or coryza by its higher temperature,  by the enanthem on the
second or third day, and by the exanthem on the  fourth day; from
hay fever  by the period of occurrence  and  the history of  repeated
attacks  of  bay fever, as well  as  by  the eruptions  of measles; from
simulating drug eruptions—copaiba, quinia, and  the various anti-
pyretics—by the history of the case, and the  immediate supervention
of these eruptions  without previous coryza ;  from roseola by the
more uniform redness,  of lighter color,  more limited range but
shorter  duration, with the absence  of fever,  characteristic of this
affection—if this affection may, indeed,  be  specialized.   Papular ery-
thema, which may coarsely resemble measles in the face, is distin-
guished by its localizations elsewhere, upon the forearms and backs
of the hands and feet, as well as by the absence  of fever, catarrh,
and bronchitis.
    Scarlatina, rubeola, variola, typhus are  differentiated in the study
of these affections.
    Prophylaxis is almost impossible.   Sickly, debilitated, more espe-
cially tuberculous  children should be removed from infected houses.
The liability of infection by third persons  and things is by no means
so great as in scarlatina, hence the  necessity is  not so  imperative of
withholding other members of the family such a length of time from
attendance at school.
    The prognosis in general is favorable.  The mortality of measles
per se is almost nil.  Death seldom or never occurs directly from the
disease, but  from  complications, previous debilities,  and  bad sur-
roundings.  Thus,  Pott found as the cause of death pneumonia and
capillary bronchitis in twenty-one, and croup in three, of twenty-four
cases.   The mortality of  the disease in hospital and tenement-house
practice is  quite different from that of private practice.  It is not
uncommon to observe a mortality of thirty  per cent under bad sur-
roundings, and the range would  be still higher if  it included all the
incident cases of pneumonia and the subsequent cases of tuberculosis
which have come to light in consequence of  measles.   The mortality 
                            MEASLES.                         197
                              t
stands also in quite direct relationship  to  the age of a  child, and
diminishes from fifty per cent under two, to fifteen above this period.
The ravages of  the disease among savages, as among our  own In-
dians, were due  wholly to lack of sanitation.
   The treatment is purely expectant and symptomatic.  Full and
free ventilation at a temperature of 70°, a night gown without under-
wear, light but sufficient bed covers, absolute cleanliness,  water and
milk ad libitum, supply the requisites of  treatment for an  average
case.
   Any  case of fever above  103° is best controlled  by warm baths,
which may be gradually cooled, or by the occasional administration
of phenacetin, gr. iij.-v., more especially in relief of associate nervous
distress.   Dover's powder, gr.  ij., which is now made into  a palat-
able syrup (gr.  v.-3i.),  is just as good,  is often  better than any
antipyretic or any other anodyne.   Burning or itching of  the skin is
best relieved by  warm baths with subsequent  anointment with  vase-
line or cocoa butter.  Photophobia calls for smoked glasses,  or shad-
ing of the eyes in the disposition of the bed or screens, rather than
for darkening of the room—an objectionable procedure.
   A drop or two of a solution of morphia gr. iv.- § ss., or of atropia
gr.  i.-§i., allays any extreme irritation of the eyes; smearing the
edges of the lids with an ointment of hydrargyri oxidi flavi gr. v.- § ss.
unguenti petrolati  will prevent or cure blepharitis marginalis and
keratitis.  The same ointment, or simple pure vaseline or boric acid
ointment, gr. xv.- % ss., snuffed into the nose, will  generally relieve
the  sense of dryness and  irritation in  the nose and  throat.  The in-
stillation of hot  water or of a drop or two of the solution of  atropia,
gr.  i.-f i., will  often quiet earache.   Evaporation  from  a  piece of
cotton saturated with chloroform, held close to the meatus,  is  often
equally effective.  Gastric distress and vomiting may require cracked
ice ;  sips of  hot water, lime water,  and milk one-third  ;  bismuth
 3ss.-3h, or chloral gr. ij.-v.; rectal injections of sodium  bromide
gr.  x.-xxx. to water § ij., or of chloral gr.  v.-x. to  water § i.   Few
cases of vomiting from any cause will  resist chloral, if its  absorption
can  be secured.
   Nervous  symptoms  may  call  for  sodium bromide gr. x.-xxx.,
trional gr. x , or chloral gr. v.-x.  Phenacetin, gr. v.-x., may suffice
for a lighter case. Haemorrhage and prostration demand alcohol—best
in the form of  brandy—black coffee, turpentine gtt. v.-xv. briskly
stirred, in a- wineglass of milk ; or nitroglycerin, one per cent, gtt. i.
in whiskey and water ;  possibly opium, best in the  form of the  cam-
phorated tincture, gtt. v.-xl. ;  codeia, gr.  ■£-£, may substitute  mor-
phia for more protracted use ; carbonate  of  ammonia grs. v.-x. in
milk; ergotin, preferably sclerotinic acid,  one-fourth to  one-half a 
198
RUBELLA.
 syringeful.  The syrup or wine of ipecac, to which may be added, if
 necessary, a small quantity of Dover's  powder, preferably in the
 form of  a syrup, suffices to restrain any excess  of cough.   The
 following is a good prescription for a child :
    R Apomorphinae hydrochloratis.............................gr. ss.
      Acidi hydrochlorici diluti.............................   . gtt. x.
      Syrupi...................................................1 ss.
      Aquae menthae piperitae  .................................§ iss.
    M. S. Teaspoonful every two or three hours.

    Diarrhoea requires at first no control.   Later, as  the discharges
 become more abundant or colliquative, it may be restrained by bis-
 muth, to  which may be added, if necessary, a drop or two of tincture
 of  opium.   An improvement  on  a time-honored  remedy may be
 written as follows:
    B Tincturae opii.........................................gtt.  xl-3l
      Acidi hydrochlorici diluti...............................gtt.  xl.
      Aquae camphoree..................................ad f iv.
    M. S. A tea- to a dessertspoonful every two to four hours.
    Broncho-pneumonia  calls  for  stimulation  of  the  respiratory
 centres as well as  of the heart.  These centres are best reached by
 baths, warm baths, with cold affusions to the head.  A rapid respira-
 tion, a quick pulse, cold  surface, somnolence, and delirium call for
 baths and baths, repeated baths with cold affusions, together with
 the use of the analeptics, camphor, benzoic acid, ether, musk, nitro-
 glycerin,  caffeine, and brandy.
    Gangrene of the skin, noma, ulcerative processes, caries of bone,
 are best treated with caustics, carbolic acid, solutions of  corrosive
 sublimate, or the actual  cautery, later with iodoform.  In all these
 cases alcohol must be administered abundantly.
    Cod-liver oil, pure  or with  malt extract, iron,  arsenic, out-door
 air, fresh air, for  the inlander especially sea-side and mountain air,
 with good food, are the best reconstructives during  and after conva-
 lescence.
                             RCBELLA.
    Rubella (dim. of rubeola, from ruber, red) ; rotheln (dim. of Roth,
 red) ; German measles, French measles, because described by Ger-
man and  French observers, really first isolated by an  English phy-
 sician ; hybrid measles, false measles, etc.—A specific, feebly conta-
gious, acute infection of short duration, characterized by  the absence
 of prodromata, the presence of an  eruption simulating that of  true
measles, faucial catarrh, and enlargement of the lymphatic glands.
    The word rubella, first suggested by Veale (1860), soon met with
 general acceptance.  The universal use of the term varicella, which 
RUBELLA.
199
 has a similar relation to variola, establishes a perfect precedent for
 rubella and rubeola.
    History and Nature.—Bergen (1752), who described it among
 the roseolae, first maintained the view that it should be separated
 from measles and scarlet fever ; but it was reserved for an  English
 physician, Maton (1815), to establish the individuality of the disease,
 as based chiefly upon the observation that though self-protective, in
 that one attack confers future immunity, it does not protect against
 either measles  or scarlatina, nor do these diseases protect against
 rubella.
    Rubella stands in relation to rubeola, not as varioloid, but as vari-
 cella to variola.  It certainly differs from both measles and scarlet
 fever in its contagiousness, mode of invasion, symptomatology, du-
 ration, and decline.   Though much less contagious than measles, and
 hence much less frequent, the disease  is decidedly more prevalent
 than is commonly believed.   Many cases are mistaken for measles,
 and most of the so-called successive or repeated  attacks of measles
 are really rubellae.
    Etiology.—The disease is propagated by contact, also by  third
 persons and by things.   The bedding of steerage passengers has been
 known to conceal and convey contagion for a long time.  From the
 nature of the disease the cause of rubella must be a micro-organism,
 but the specific structure has not yet been isolated.  Micrococci have
 been observed in the blood, but without any other  evidence of posi-
 tive relationship.  Griffiths  found a highly toxic  ptomaine in the
 urine peculiar to rubella.
    Rubella  occurs at all ages, rarely in  infancy;  seventy-five per
 cent of cases before fifteen, the period of greatest liability.  But sus-
 ceptibility to it is so much less than to measles that the majority of
 people escape it throughout life.   Attack in  adult life is much more
 frequent than attacks of measles, first, because the susceptibility is
 not so universal, so that childhood often escapes  it;  and, secondly,
 because epidemics prevail at  much longer intervals.  Adults have,
 however, immunity in high degree.   Kassowitz  observed  but five
 cases in adult life.  Seitz recorded a case  in a woman aged seventy-
 three.
   Symptoms.—The period of incubation,  two  to three weeks, is
 uncommonly long, while the stage of invasion, or prodromal stage,
 one-half to one day, is uncommonly short.  An initial chill is an ex-
 ception ; malaise, pain in the head, back, or joints, anorexia, rarely
 vertigo, very rarely more pronounced distress on the part of the ner-
 vous system, more  or less immediately usher in  the eruption  and
affection of the  mucosae and glands.  Not infrequently the  appear-
ance of the eruption, totally unprefaced  by any fever, is the first sign 
200
RUBELLA.
of disease.  The eruption appears as minute rose-red maculae, dis-
crete  or confluent, "like dark-red ink pen points in white blotting
paper," on the forehead and temples, spreading quickly over the rest
of the face, neck, and trunk, to reach full efflorescence and begin to
fade in twenty-four to thirty-six hours.  By the third day, as a rule,
all signs of  eruption  disappear without desquamation.   Coincident
with the eruption  is a rise of temperature to 99° to 101° F., very ex-
ceptionally to 102° to  103°.
   Hyperaemia of  the conjunctiva with photophobia and epijliora,
of the nasal mucous membrane with a sense of dryness  and irritation,
with sneezing  or with increased discharge, more especially  hyper-
aemia or visible enanthem of the fauces and pharynx, may precede
the eruption during the stage of invasion, when it occurs, to co-exist
with the eruption, and remain  after it as late as the fourth day of
the disease.
   Affection of  the glands constitutes a much more distinctive feature
of rubella.  The cervical,  submaxillary, and occipital glands, more
rarely also the  glands of the axilla, elbow, and groin, become swollen
and tender, limiting  the movements of  the head  at times  in  the
swelling and stiffness of the neck. These adenopathies, which exist
in fifty to seventy-five per cent of cases, disappear entirely in two or
three days.  Abnormal cases show only an eruption  or only affection
of the glands.
   As a rule, the physician is summoned to distinguish the eruption,
which, as stated, appears earlier, often without any previous disor-
der ; is lighter  in color—a rose, not a raspberry red ;  more frequently
discrete,  or, when  confluent, more  diffuse, not  aggregated into
patches ;  disappears completely, without, or with but slight, desqua-
mation, in one  to three days.  These features, in connection with the
more pronounced implication of the throat and the  glandular affec-
tions, sufficiently distinguish the disease.
   Rubella  is distinguished from measles, the only  affection with
which it is likely to be confounded, by the history or  absence of a pre-
vious attack of measles ; by the existence of other cases; by its feebler
contagiousness, longer incubation,  shorter invasion,  hence  earlier
appearance  of  the eruption, absent or but light or limited affection of
the mucosae, more frequent and extensive adenopathies, more trivial
fever, and shorter duration.
   Rubella  is  distinguished  from scarlatina by the  history  of the
individual, as  stated  above; by the longer incubation, two to three
weeks in rubella, one day  to one week in scarlet fever ; by the char-
acteristic intense sore throat of scarlet fever in contrast with the triv-
ial catarrh of rubella ;  by the violence of the invasion of scarlatina ;
vomiting, hyperpyrexia, often delirium and convulsions, in scarlet 
SCARLATINA.                       201
 fever,  all absent in  rubella ;  by the  more  universal  affection  of
 glands in rubella, more intense inflammation and tumefaction of the
 submaxillary glands  only in scarlet fever ; by the appearance of the
 eruption first upon the face  or universally in rubella,  first on the
 chest and neck with  slower spread in scarlet fever ; by the disap-
 pearance  of the eruption in one to four days in rubella, in four to six
 days in scarlet fever  ; by the disappearance  of  symptoms with ap-
 pearance  of the eruption in rubella, by the persistence of symptoms
 during the eruption of scarlet  fewer ; by the strawberry tongue  of
 scarlet fever, absent in rubella ; by the albuminuria and affections  of
 the kidney in scarlet fever, absent in rubella ; by the desquamation,
 membranous in scarlet fever, absent or furfuraceous in rubella.
   The roseola, adenopathies, and sore throat of syphilis could not,
 on account of their  persistence, be long mistaken for rubella, even  in
 the absence of all history of a primary infection.
   The diffuse erythemata of a drug eruption, antipyretics, copaiba,
 chloral, etc., have a history of  their use, are unattended with fever,
 sore throat, or affections of the glands.
   Inasmuch as most people escape rubella,  isolation  of cases  in a
 separate room or  story of the house is, when practicable, advisable.
   The mortality is almost nil.   In this regard the disease has, how-
 ever, the same history as measles.  Bad surroundings may impart
 great gravity.  Hospital and tenement-house practice furnishes  a
 mortality of three to  ten per cent, due  almost wholly to complica-
 tions, chief  among  which are capillary bronchitis and broncho-pneu-
 monia.
   Treatment, which  is for the most  part superfluous, does  not dif-
 fer, when necessary, from that of measles.

                          SCARLATINA.
   Scarlatina ; scarlet fever ; German, Scharlach; Italian, scarlatto,
 red.—A treacherous,  acute, contagious infection, characterized  by a
 more or less typical fever and inflammation of the throat, a diffuse
 scarlet exanthem  followed by membranous  exfoliation  of the skin,
 occasionally by otitis,  exceptionally by arthritis,  and not infre-
 quently by nephritis.
   History.—The first use of the term febris scarlatina  is found  in
 a comment by Lancelotti, of Italy (1527), but it was  not distinctly
applied to the affection as we know  it until by Sydenham (1661),
 who first separated  it from measles, with which it had hitherto been
confounded.  Sydenham saw only mild cases.  He considered the
disease " only an  ailment; we can hardly call it more," but was able
to recognize it without the help of throat symptoms, which  he  does
not mention in his brief description.   It was, however,  a full  cen- 
202
SCARLATINA.
 fury after Sydenham before the ability to separate scarlatina became
 common property, and no sooner was it firmly set upon its tripod of
 symptoms,  to wit, fever, exanthem, angina—that is, no sooner were
 the throat symptoms established as an integral factor of the disease
 —than it became confounded with diphtheria as much as it had ever
 been with measles.  Irregular cases of either are not yet easily dis-
 entangled.
   Etiology.—Whence it was originally imported or when it first
 appeared in Europe is unknown, but it was first recognized in  Eng-
 land in 1661, Scotland in 1716, Germany and Italy in 1717, Denmark
 in 1740; North America, Kingston and Boston  in 1735, New  York
 and Philadelphia in 1746, Ohio and Kentucky in 1791, Toronto in
 1843, New Orleans in 1847, California in 1851.
   The disease is rare in Asia and Africa, and is said  to  be (Wer-
 nich, 1871) entirely unknown in  Japan.   Scarlatina  is  therefore
 much less widely disseminated than  measles and small-pox, both of
 which have repeatedly ravaged Asia and Africa.
   A pronounced peculiarity of scarlatina,  in distinction from  mea-
 sles and small-pox, is the variation  in  the  intensity of epidemics,
 which are sometimes so mild,  as in the time of Sydenham, that the
 affection vix uomen morbi merebatur (scarcely deserved the name
 of a disease), and again virulent and malignant, more  especially in
 villages and small towns, with a mortality as great as that of  chol-
 era and the plague.   " Malum hoc grave," said Sennert almost sim-
 ultaneously with Sydenham,  " periculosum et saepe  lethale  est."
 Bretonneau never saw a single fatal case of scarlet fever in all  his
 practice during twenty-four years—1799-1823—but in  1825 he en-
 countered an epidemic so virulent as to cause him to entirely change
 his opinion  regarding the benignity of the  disease.  Lewis Smith
 relates that a  distinguished physician of  New  York treated  more
 than fifty cases of scarlet fever in one of the hospitals,  without a
 single death.  A few months later his own son died of  the disease.
 That this virulence  is not due to the accumulation of susceptible
 material in long intervals of  absence is proven by the experience
 of Kostlin, of Stuttgart, who observed an epidemic in 1846 so  mild
 as to be without a single death, following  an interval  free of  scar-
latina for a  period of sixteen years.
   Soil, season,  climate offer no explanation  of this peculiarity ;  we
 remain as yet,  in the language of Drake,  "entirely ignorant of the
causes or conditions  which determine these remarkable  diversities of
phenomena  and danger."
   Thus it may be said that since small-pox has been  shorn of  its
terrors, scarlatina takes rank, next to diphtheria, as the most dreaded
of all the infections which now prevail.   It is estimated  to cause one- 
SCARLATINA.
203
 twenty-fifth to one-twentieth of the whole mortality in England and
 America.
    Susceptibility to scarlatina  is much less  than to measles, one
 member of a large family being often alone attacked.   Hence the
 majority of individuals escape it  throughout life.  Individual fami-
 lies seem predisposed to or exempt from the disease.  Ziemssen says
 he saw cases which annihilated  posterity, and practitioners  every-
 where  have become demoralized by the loss of one member after
 another of a family to literally extinguish it.   Geil attributes suscep-
 tibility to the condition of the throat.  The disease, to take hold, must
 have a denuded surface.  While  epidemics of scarlatina are much
 less frequent than measles,  decades often intervening, individual
 cases are much  more common.   It  is said that children have been
 born at various stages of the disease, but it must be remembered that
 hyperaemia and desquamation occur frequently in  the new-born in
 health.  Sucklings certainly enjoy comparative immunity.  The age
 of predilection ranges from two  to seven.   Sixty per cent of cases
 occur  before the age of five, ninety per cent under ten.  Attacks
 later in life are rare  and are  usually mild.  Here too, however, are
 observed the  same differences in  epidemics.  Thus, in  Ziemssen's
 report,  the mortality among adults in  1865-1875 was 11.5 per cent,
 and in 1876-1887 it  was but 1.3 per cent.
    One attack confers immunity, as a rule, for life.   With an obser-
 vation  of two thousand cases Willan  never saw a second  attack.
 A second attack is  possible, but rare, and occurs more especially in
 cases of exposure in more advanced life in taking care of a younger
 member of a family affected with  the disease.  These second attacks
 are, as a rule, so abortive or rudimentary as  to be easily overlooked,
 and are recognized at times, as are first attacks in the mildest cases,
 only by sequelae.  Hence the suspicion may be entertained that some
 of the insusceptibility of certain individuals may be immunities con-
 ferred  by attack so  mild as to  have  been considered  ephemeral
 affections.   Most so-called second attacks are erythemata, rubellae,
 septic rashes, etc.
   Pregnancy certainly protects against it, but puerperium and open
 wounds of any kind invite it.
   Regarding puerperal  scarlatina, caution must be entered against
 confounding it with septicaemia, which  often shows fever and erup-
 tions simulating scarlatina.  There is  no doubt, however, that  the
 puerperal state  confers  additional susceptibility  to  scarlatina.  In
 these cases the eruption occurs more quickly, almost suddenly.  The
throat symptoms are  much milder or are absent altogether,  while
local lesions  about the vulva and uterus predominate.
   In  proof of  the  increased  susceptibility  of  the  puerperal  state, 
204
SCARLATINA.
Boxall declared of his cases that ten had had scarlatina before, and
one had had it twice.
   With reference to surgical scarlatina, so-called, the same precau-
tion must be  entertained  to  prevent confusion with erysipelatous,
erythematous, or other eruptions of septicaemia.
   Etiology.—The disease is conveyed by contact, direct or indirect,
as  by clothing eminently, by washing, bedding, furniture, letters,
books (as from a library or  school), toys, etc.  A not infrequent
source of infection is milk, sometimes  from an infected dairy.   Per-
haps the most instructive example of  this source of contagium was
furnished by Miller, who reported twenty-four cases of infection in
this way.
   The disease may be conveyed also by third persons, who may
carry the poison in their  hands, hair, or clothing, but may them-
selves remain  exempt.  Convalescents from the disease carry  it to
school, church, theatre, train, etc., and disseminate it throughout a
community.
   The cause  of the  disease is  said to be disseminated from the skin
or the secretions,  and given  off during incubation and desquama-
tion, as well as during the stage of  eruption.  There  is as yet no
direct proof that the poison of scarlatina lies in the skin.  It is sin-
gularly tenacious,  adhering to clothing after  months of disuse, and
to rooms after months of vacation and seemingly thorough disinfec-
tion and ventilation.   The poison of scarlatina literally lurks in long-
discarded clothes.  Cold does not affect it.   It is destroyed, however,
by heat, especially by steam, and quickly by steam in motion—so-
called "live steam."   Henry,  after subjecting the flannel garments
of scarlatinous patients to a dry heat of 212° F., had them  worn  by
unaffected children from  six to thirteen years  of age,  no  infection
following.
   Bacteriology.—The cause of scarlatina,  presumptively a micro-
organism, has not yet been definitely determined.  Klebs (1880) pic-
tured and described a structure  found  in  the blood as the monas
scarlatinosum.  Eklund, Stockholm  (1881), Power, Cameron and
Klein (1885-86), Jamison  and  Eddington  (1887), Marr (1891),  all
ascribed  to  various  micro-organisms  pathogenic properties, but  all
these various micro-organisms are now believed to be varieties of the
ordinary pyogenic bacteria.  It cannot as yet be maintained of any
of them  that  they are found uniformly or only in scarlatina, nor
that the disease produced by them is really scarlatina.   It is not yet
established that any of the lower animals are  susceptible to the dis-
ease.   It would be more natural to look for the  poison in the throat
and in the blood in the earliest stage of the disease, rather than in
the secretions  from the kidneys or the substance or exfoliations of the 
SCARLATINA.
205
lotr-se+p —'  1 •■ 1—'—L-
skin.   The kidney affection is doubtless the result of a chemical poi-
son in its escape from the body,  and  the exanthem must also  be
regarded as toxic, like that produced
by  certain  drugs.   Luff  has suc-
ceeded in eliminating a hitherto un-
known alkaloid from the  urine  of         2J"»5£EEb«ESES5£E^
scarlatina, and Leyden declares it to   |H|H-"""""»S3S3SlSi
be useless to look for the poison  of   IB9|Q|SSiiS."nSSSBSSSSSS
scarlatina in the skin.                  IHMSSSSiSTfiSfilBSSSSSl
   Regarding the relation of  diph-   IgSl&BSSBSiSttSSSKSSS!
theria, it is  admitted  that  one may
follow the other, and that they may
even coincide, but only as exceptions.
The rule is that the diseases prevail         Fm 130._Mild scarlatilia
in communities and exist in individ-
uals independently of  each other.  Tangl's culture  studies  never
lanaour.'iJHiBHBKaiiaBitoMaHOBaBMHBi
            JKnBBBBMUgqDUBHBHaBHBDigni
InClVBTjBtT.BBBBMBBBBBBraaiBBBBBaflKBBaBBBH__
(■■•JBBiBiBiB^^BABBianaiTafiBMvnBasBDHBunaBHiiaiiHsasnati
iBBBBBBBBBnVaBriBIIKirjaSBBBrilBBBBBBBBaHaitnaiajBJllSElBH
ICBBJBDBOBBB.'iB^'ABIia'BBlBBB:^'; nBBBa&BIBaaaillBDHHBBBI
       jaBBBBBi'.Bi^BV«i&iut<'^*i^rr«!r?'7}ffCa;-.j^nni=Biti»siranci»Bii
       ESBBBBpjUBL'aiViBBK^^.'aPiiTieLKEV^ait^^tgKCailSBUaniillllBI
       IIBBBBBaaBBBUBB«;''it)Bi«QrvNr.<^ia.UT:I^BBIBBir.ISBnE!HBe
       • ■maaHBMCBiBBMiwauwiais.'j'at'Rij. Li^snataauwEsjEBu
       iBBaBaHBBRBSBMUVBMaiiriciiaeaaiBmiifflaRnianEiiiHE
]BBBDBBBBRBBBBBKIIBH»BBaeiH1^TiaC>:'iirinGII!;niFlLISni!IBm
iHBIUBBn«inMBBKIBBMHIRBP"KtUT^i<faiWi'BniJ<nriSlliinCBBn
            ~~iaBBBaaanaEaaaBH%]Ha^ciitiiiu'iii8it3aBBMBBai
             IBHBBBBBiKIBlKaiBniBBBBttMeaBIBIBtBaaiHaiBBlatBiBlBII
          ■ ■■■BBBBBBBBBBBBUCBBWCiaBr.l.rBWBaBltaBByi
        __IBBBBBBBBBBIDBBBBBaBCmBnBailBtf«iaiBI';BaBBBJ1
|BBOBBBJBBUilBBHaBBBBaBBlBBC;Kt«9B:SIP3BiaiBG)!IBMa!HBtlB>B'AlBJI
             IBBBBBBBBBBBBBBBBJaiiJMBiaBiaBBgBBIIBIVaVMr
            __aiMBBIMBBiraEIIBBBaBIBBIHHBBBBBBfl
    iJBBBJilBBi      IBIBlBBBBBBHlBBBBBfa  IBBl'l
                         Fig. 131.—Protracted scarlatina.
once developed from the angina of  scarlatina  a specimen  of the
bacillus of diphtheria.
                               Symptoms.—The period of incuba-
                            tion is short, ranging from one to seven
                            days.  Ziemssen declares that the few
                            unimpeachable observations that we pos-
                            sess put it at  seven  days.   English
                            writers make it generally less, and de-
                            clare that  from  the second day after
                            exposure liability  of attack grows pro-
                            gressively less.
                               The invasion is usually sudden and
                            violent;  grave,  dangerous, and  some-
    Fig. 232.—Fatal searlatina.     ,.      „  , ,  ...      -,   -,        .,-, .
                            times fatal  illness developing withm a
few hours.  An initial chill or series of shiver ings is attended with
 
206
SCARLATINA.
 a quick and high rise of temperature.  It is more frequently the case
 that the disease is ushered in without any chill at all.  A child presents
 evidence of attack in a shock, manifest by extreme pallor and prostra-
 tion.   A highly susceptible, sensitive child may be seized with a con-
 vulsion.   Usually the scene opens with vom iting.  Early vomiting
 belongs to all the grave, acute infections.  It occurs with especial fre-
 quency in scarlatina because of the gravity of the disease.  After the
 vomiting it is noticed that the patient has fevev.  Inspection thus
 early reveals angina, or the child complains at once of sore throat.
 Vomiting, sore throat,  and fever at the start  should excite the sus-
 picion of scarlatina,  or,  in the presence of an epidemic or proximity
 of another case, establish the existence of the disease.  The tempera-
 ture distinguishes itself by the rapidity of its ascent.  The ascent of
 the temperature in  scarlet fever  is more rapid than  in almost any
 other disease, reaching often within twenty-four to forty-eight  hours
 104° to 107°.   Calor mordax was the  term applied by the older pre-
 thermometric writers to express the biting heat of the skin.  The
 temperature reaches its height with the efflorescence of the eruption,
 and terminates by lysis, barring complications, in one to two weeks.
   In  correspondence with the height  of  this fever, especially  in
 young children, nervous signs, as stated, show themselves—delirium
 and convulsions.  The delirium may  deepen rapidly into coma.
 There is  in every marked  case profound prostration.   It  is seen on
 the iik >st  superficial inspection  that the  child  is seriously ill.  This
 stage of invasion  lasts  from one to two days.   Comment has been
 made  upon the irregularity  or variety  in  severity of epidemics  of
 scarlatina.  The same variety is noticed  of individual cases in the
 same epidemic.  In the same family, side by side with a malignant
 case, occurs an attack so mild  that it may be scarcely recognized.
 Lightly affected brothers and sisters may be playing about the house
 where one member  lies fatally ill or has just  fallen a victim to the
 disease.   So there may be every grade of intensity in the onset, but,
 as a rule,  the  disease is  announced by a  sudden attack of fever at-
 tended by vomiting, which assumes more and more importance when
 it may not be accounted for  by a  sufficient provocation,  as by indi-
 gestion, or by other  infection, croupous pneumonia,  cerebro-spinal
 meningitis, small-pox, etc.
   In  the absence of these symptoms the diagnosis  must be held  in
 abeyance  until the appearance of the eruption.  The eruption shows
itself in twelve to twenty-four hours after the  initial symptom, chill
or vomiting or shock, on the face, over the  forehead, cheeks, the
chin, and  often at the same  time, as a rule in fact, at the clavicles.
Here, at least, it is first seen.  When  search is made it may usually
be discovered soonest on the neck, breast, and  back.  It usually 
SCARLATINA.                       207
spares or skips the region  of the mouth, which is left blanched by
contracted capillaries, in striking contrast with the scarlet flush of the
rest of  the face.  The  white line about the mouth, the apparent
bleaching of the chin, make the diagnosis easy as between this dis-
ease and measles or small-pox.  Seen at some distance the eruption
appears uniform, but close  inspection shows it punctate, with conflu-
ent halo; yet, though  confluent, there are lines or spaces here and
there of unaffected surface. This marbled appearance of the skin is
very characteristic, and is  due to the intense irritability of the vaso-
motors, which show paralytic dilatations and spasmodic contractions
in the same sets of capillaries.  The deeply colored skin is bleached
out by pressure in lines or surfaces, so  that  figures or letters may
be inscribed upon  the surface with a vividness equalled in no  other
disease.
   The color is scarlet, that bright red which is designated by this
hue, in striking contrast to the duskier red of measles.   The Germans
speak of the crushed-raspberry color of scarlatina, as distinct from the
mulberry hue of measles.   The shade becomes darker, however, in
bad cases, or especially under defective hygiene, when it may be sub-
stituted by haemorrhagic eruptions.  In  a pronounced case the af-
fected skin is more or less oedematous.   The eruption lasts from four
to six days, extending meantime over the body, but with less uni-
formity over the extremities, where it may show itself only in blotches
or patches.  It begins to fade in the order of its appearance, first from
the face, neck, and chest, later over the body, and disappears with a
desquamation or exfoliation  of the skin, which constitutes one of
the peculiar  features  of the disease.  From  regions covered  by a
thick epidermis, the hands  and feet, more or less perfect casts, epi-
dermic gloves and stockings, may be detached.  More or less perfect
specimens of this kind are to be found in the museums.   The desqua-
mation begins usually on the sixth day.   It may be, in a mild case,
furfuraceous.  It may, indeed, be absent altogether, but it is usually,
as stated, membranous or lamellar, the skin peeling off in strips and
flakes.  The process may be repeated several times during the course
of the disease, to form  at times an interesting diversion or an annoy-
ing occupation of  convalescence.   It is impossible to  overrate  the
value of this process of  desquamation.  It confirms the diagnosis in
a doubtful  case.  It establishes the pre-existence of the disease.  It
reveals the nature of a meningitis, rheumatism, an ear disease, a
nephritis, which have suddenly or insidiously developed.
   The sore throat is one  of the cardinal symptoms of the disease.
It precedes the eruption, as  has been said, and constitutes at times an
overshadowing  symptom.  Suspicion is  excited of the existence of
scarlatina by the fact that the child complains of the throat, and it is 
208
SCARLATINA.
seen that there is some hesitation or difficulty with deglutition.  The
act of  swallowing is marked by an expression of pain ; by the appli-
cation of the hands to the neck; sometimes, as a rule later in the
course of the disease, by regurgitation of fluids through the nose.  In
many  cases  an inspection of the throat discloses at a glance  the
character of the disease.  As a rule, the sore throat of scarlatina dif-
fers in no way, at first, from that of a simple catarrh.  There is red-
ness, dryness, and swelling.  The mucosa is puffed or glazed, espe-
cially  about the soft palate and uvula.  The  glands of the neck
become swollen and tender.  Diphtheritic patches, often gangrenous
sores, may appear later, while an extensive inter glandular cellulitis
may swell the neck to such degree as to obliterate its natural out-
lines.  It is therefore not at all strange that scarlatina is often con-
founded with diphtheria.  It is to be remarked, however, that no
individual symptom shows such variation of intensity as the angina.
Throat symptoms may be so mild as to be detected only on close inspec-
tion—scarlatina simplex  or sine angina ; or so severe, as said, as to
overshadow all other signs—scarlatina anginosa, of the older writers.
It is now no longer an unsettled question whether the diphtheritic
exudations which occur in grave cases belong intrinsically to scarla-
tina or to a complicating diphtheria.   The view now prevails that
the affection is primary.  It is produced by the micro-organisms of
pus.  It belongs to scarlatina,  and it may, in the vast majority of
cases, by culture be differentiated from diphtheria.
   Among the disturbances of  the digestive organs common to all
the infections, the condition of the tongue is peculiar in scarlatina.
The tongue is coated white and studded with red spots, the protrud-
ing swollen papillae, to constitute what is known as the strawberry
or mulberry tongue.  While this condition is not absolutely peculiar
to scarlatina, it occurs in it more frequently than any other infection,
and from its obtrusiveness is regarded as a sign of much value. It
is unfortunately not always  present, but when present it should ex-
cite at once suspicion of the existence of this disease.
   Scarlet fever shows predilection for three organs besides the skin
and throat—namely, the ear, the joints, and the kidneys.  The way
is open to invasion of the ear from the throat through the Eustachian
tube.   So scarlatina is the most fertile source of earache, otitis media,
and otorrhcea.  The membrane of the drum is seen  to be intensely
reddened on  inspection, or it may be paler and pushed outward by
fluid pent up within the drum cavity.
   Suppurative processes  may intervene, to extend to or directly in-
volve the fold of dura mater which  in the young  pushes into the
cavity of the drum.  Scarlatina is thus the most frequent cause of
an immediate or ultimate lepto-meningitis. 
SCARLATINA.
209
    Affection of the joints is much more uncommon, but there occurs
 in certain cases or  certain epidemics a peculiar scarlatinal rheuma-
 tism affecting chiefly the larger joints—ankle, wrist, elbow, and knee.
 The affection runs  usually a mild and short course, but may, unlike
 true rheumatism, result in suppuration or leave permanent deformity.
 The joint affection is to be referred in these cases to a mixed septic or
 secondary pyogenic infection.
    Of all the signs, complications, or sequelae connected with scarla-
 tina, no one assumes such prominence and importance as the affec-
 tion of the kidneys.  Scarlatina  is said to be the mother of acute
 nephritis.  Aside from the transitory albuminuria which may attend
 any high fever, disease of the kidneys is comparatively frequent.
 Epidemics are distinguished from each other in this regard with en-
 tire or comparative absence  and frequency of this complication.  The
 severity of the individual case or of the epidemic does not necessarily
 indicate the probability of nephritis.  It cannot be said that early ex-
 posure, as to cold, predisposes to it.   It may not be ascribed to affec-
 tion of the skin ; small-pox,  with its destructive lesions, does not show
 it.   Every case marked by high temperature shows, as stated, some
 albuminuria, but the albuminuria which excites apprehension is that
 which appears, not at the height, but in the later course of the disease,
 at the end of the third week  after the disease proper, during convales-
 cence.  Strictly speaking, the process is, therefore, a post-scarlatinal
 nephritis.  It sets in on the  tenth to the thirty-first day—on the ave-
 rage in twenty days after the  first show of the rash.   It is an acute
 parenchymatous process, from which the  patient recovers or  suc-
 cumbs quickly, very rarely developing into  chronic Bright's disease.
 It is  announced  often by  nervous  symptoms—headache, neural-
 gia, vertigo,  insomnia, restlessness,  blindness,  convulsion, or coma.
 Puffiness of  the eyes, any local oedema or dropsy, should excite
 suspicion of its presence.
   Scarlatinal nephritis may be divided into two periods,  in the first
 of which there is a diminution in  the quantity of urine, albuminuria,
 and some of the general symptoms mentioned.  The second period is
 distinguished by haematuria with the discharge of formed elements,
 granular and epithelial casts, also with an increase in the quantity of
 urine and diminution of the  general signs.   So  that should the urine
 become more abundant, contain more blood, and exhibit formed ele-
 ments,  though grave  symptoms may still  show themselves for a
 time, the worst is over, and, as Sorensen puts it, " the kidneys are
 beginning to free themselves of the disease."  Perhaps the most grave
 single symptom  of  nephritis  is  anuria, but  even  long-continued
anuria is not incompatible with recovery.  While it may be said that
 the gravity of the case corresponds in a general way with  the degree
        14 
210
SCARLATINA.
of oliguria or the duration of anuria, there need never be despair as
to the possibility of recovery, as Whitelaw reported a case of recov-
ery after a  total absence of  urine for twenty-five days.  As a rule,
it may be  said that the blood and albumin disappear in mild cases,
and the patient recovers from the nephritis entirely in two to  three
weeks.
   Forms.—Besides the typical form described,  scarlatina  shows
itself in variation as follows : 1. Abortive, in which the eruption dis-
appears after a short duration,  without, or with very mild, throat
symptoms, but usually with lamellar desquamation, and sometimes
with  subsequent nephritis.   2. Fulminant, in which the  patient is
killed by the poison of the disease  before the period of eruption.
3. Anginose,  in which throat  symptoms  predominate.   4. Malig-
nant, with the status typhosus, in which all symptoms are intense
and haemorrhage may occur  free from the various mucosae or into
the skin, or with rapid collapse after the signs  of a cholera morbus.
In some very exceptional instances of undoubted scarlatina the  erup-
tion is entirely wanting, throat symptoms only presenting.   In these
cases careful inspection will usually  disclose some eruption on cov-
ered parts, especially on the posterior  aspect of the body.  It may be
seen at times on or over any part of the body immediately after death
from fulminant forms.
   True diphtheria  may coincide with or  follow scarlatina ;  much
more frequently the membrane which  forms in the throat is sui
generis.  The membranous angina or pseudo-diphtheria of scarlatina
is much less amenable to treatment than true diphtheria.
   The diagnosis rests upon : 1. The absence of  previous attack.
2. The  existence of other cases.  3. The short period of incubation—
one to seven days as a rule.  4. The  violence of the invasion, espe-
cially the occurrence  of  unprovoked vomiting (eighty per cent of
cases), and the nervous symptoms.   5. The early  appearance (sec-
ond day) of the eruption, which shows itself first usually about  the
clavicles, is scarlet-colored, diffuse, but punctate upon close inspec-
tion ; in its disposition about  the  face commonly sparing the mouth,
showing in vivid contrast the blanched lips  and the blazing cheeks.
6. The  strawberry  tongue.   7.  The  early  appearance  of throat
symptoms with glandular enlargements in the neck.  8. The lamel-
lar desquamation.   9.  The ear complications.  10.  Nephritis.
   In very mild, sporadic, or anomalous cases the diagnosis may be
determined  only by desquamation, complications, or sequelae.
   Scarlatina is differentiated from measles by  knowledge  of pre-
vious attacks of either, existence of other cases of either,  especially
in the same family, neighborhood, or  school; by the longer incuba-
tion of measles, when the period of exposure may be (exceptionally) 
SCARLATINA.
211
 known; by the coryza which precedes the eruption of measles, and
 the angina that of scarlatina ; by the shorter or more intense  inva-
 sion of scarlatina with vomiting, and sharp nervous symptoms not
 so common  in  measles ; by the time of appearance of the eruption
 (twenty-four to forty-eight  hours  after initial chill or vomiting in
 scarlatina, four days  in  measles) ; by the color, character, disposi-
 tion, and duration of  the eruption (dark red, aggregated in patches,
 and  disappearing in two to four  days in measles ; scarlet-colored,
 punctate, diffuse over the chest and face, sparing the mouth, disap-
 pearing in eight days plus in scarlatina); by the complications or
 sequelae (bronchitis, catarrhal pneumonia, in measles ; joint and ear
 affections, nephritis, in scarlatina) ; by the desquamation (usually
 branny in measles, membranous in scarlatina).
    Scarlatina is differentiated from rubella (rotheln) by the longer
 incubation or shorter or absent stage of invasion ; by the darker col-
 ored and shorter  duration  of  the  eruption of rubella; by the as-
 sociate catarrh of  the nose and eyes in rubella, absent in scarlatina ;
 by the  much more severe faucial inflammation and gland implica-
 tion in scarlatina ; by  the much milder character and shorter dura-
 tion of rubella.
    Septicaemia and pyaemia show,  with the history of a cause, suc-
 cessive chills, irregular temperatures, efflorescences, quite different
 in appearance and order of distribution from the eruption of  scar-
 latina ; more marked enlargement of the liver and spleen;  more
 common  general  affections, metastatic  processes,  longer   duration.
 Erythema, a diffuse,  rather dark redness, without  points or  des-
 quamation, though sometimes with  a light furfuraceous desquama-
 tion, with absent or but very slight fever up to 100° F., has neither
 the throat symptoms nor complications of scarlatina, and disappears
 in a few days.  Drug eruptions—copaiba, cubebs, antipyretics—have
 a history of administration, no fever, no complications.
    Scarlatina differs from diphtheria in its cause.  It may be de-
 clared that the  cause  of diphtheria has been now definitely deter-
 mined.   While the  same cause is  not to be found in unmistakable
 cases of scarlatina, it  must be held in mind that the diseases may,
 as stated, coincide, and that either  may be a sequel to the other.
 These things, however, are exceptional;  the rule is that the diseases
 exist  alone, and that,  as stated, the exudation of scarlatina is not
 that of diphtheria,  but  is sui generis.
   Clinically  the affections differ as follows : The false membrane
 appears at once in diphtheria, later in the course, three to five days,
of  scarlatina.   It shows itself in nearly all cases of diphtheria, but in
only severe cases of scarlatina—namely, such as are marked by  high
fever, delirium, etc., at the start.  It shows a  preference,  after the 
212
SCARLATINA.
pharynx, for the larynx in diphtheria, and for the upper respiratory
passages in scarlatina.   In connection  with it  suppuration of the
cervical glands and affections of the ear are  frequent in scarlatina,
rare  in  diphtheria.  The interglandular connective tissue  is  in-
durated in scarlatina, and only oedematous in diphtheria.  Paralysis.
which is frequent in or after diphtheria, is almost unknown in scar-
latina.  On the other hand, nephritis, a frequent sequel of scarla-
tina, is very rare after diphtheria.  Lastly, as stated, treatment has
much less  effect on  the membrane of scarlatina.   For  all  these
reasons it is proposed by good  clinicians to abandon the use  of the
term " diphtheritic " in scarlet fever, and to  designate such cases as
 " membranous scarlatinal anginas."
    Besides the affections of the organs mentioned, grave complica 1 ion
is not infrequently presented by the intense inflammation about the
neck.  The glands, the lymph  vessels, the interglandular tissues are
swollen  and  amalgamated  into a  mass of board-like induration,
which fixes the head  to the body, compresses the great vessels, and
results  not infrequently in extensive  suppurations.  Phlegmonous
processes,  gangrenous destructions, occur frequently in connection
with diphtheritic or pseudo-diphtheritic deposits in the throat.  The
pressure may compress the trachea or suffocate by edema of the glot-
 tis.  Pus may burrow down into the chest, to  erode  in  its  course
large vessels and to lead  to fatal haemorrhage or destroy important
nerves or other structure.  The inflammation of the throat may ex-
tend to involve the larynx and bronchial tubes.  Pneumonia, both
bronchial  and croupous,  occurs not infrequently in  grave cases.
 Haemorrhage of the  lungs, gangrene, more especially oedema, hy-
postases, take life directly or indirectly by overstrain of the heart.
    The most frequent and fatal so-called end or terminal  complica-
tions are the affections of the serous membranes.   Meningitis heads
 the list, in that it is not only the most severe but most early  mem-
 brane involved.  It occurs at times almost with the onset  of the dis-
 ease, so that the separation of this affection  from toxic effects of the
 blood poison upon the brain itself may be difficult.  In meningitis
 the headache becomes more intense, or recurs  if it shall  have sub-
 sided.  The special senses suffer extreme hyperaesthesia.   There is
 usually evidence of affection of the membranes  of the spine, opistho-
 tonos, vomiting, convulsions.  The pleura  is next  most  frequently
 affected.   Scarlatinalpleuritis distinguishes itself, strange to say,
 by its unilateral  character, and differs from  pleuritis from other
 causes in the fact that it  so easily becomes purulent.   Pericarditis
 is usually  so much more rare as to be generally overlooked, while
 endocarditis  is readily recognized by its  valve lesions, hypertro-
 phies, and embolic products. 
SCARLATINA.
213
   All these various complications are now known to be due  to the
 micro-organisms of pus, which,  strictly speaking, have nothing
 really to do with the cause  of  scarlatina.  The cause of scarlatina
 opens the way  for their invasion,  and these micro-organisms, or the
 evidence of their invasion, have been traced directly from the throat
 as the avenue of entrance.
   The prognosis  of  scarlatina varies  greatly, perhaps  as in no
 other disease.   On account, however, of the severity of certain epi-
 demics, and of the suddenness with which the disease may assume
 gravity in any individual case by  reason  of its own poison  or by
 reason of  complications, the prognosis  is always grave.   Reimer,
 who studied the subject from this standpoint most thoroughly, says
 that the prognosis of a simple complicated case which has no mortal-
 ity advances through the complicated cases of medium gravity with
 a mortality of 25 per cent  up to the severest cases whose  mortality
 reaches 83.75 per cent.
   In estimating the prognosis it may be said that  the  pulse, as a
 rule,  corresponds to the temperature.  Arhythmia is usually a fore-
 runner of complications. Grave nervous symptoms are always omi-
 nous, as are also extensive  suppurative processes.  It is not good to
 seethe eruption " sink in."  The complications  on the part of the
 kidneys,  however severe the signs, though grave, are never  neces-
 sarily fatal.  From the gravest accidents recovery is still possible.
   Pneumonia, more often of such insidious onset as to have escaped
 detection at first, pleurisy with its  wonted suppurative  course, and
 peritonitis, intensely aggravate the prognosis.  Peri- and endocardi-
 tis are almost necessarily fatal.   An undue protraction of the disease
 by reason of reabsorption of products to constitute a relapse, or by
 reason of complications, makes the prognosis grave in correspondence
 with  the intensity of the signs, duration of the disease, or character
 of the complication.  Some of these cases  succumb finally to atelec-
 tasis, heart failure, decubitus, marasmus.
   Prophylaxis.—Isolation is the only prophylaxis ; and inasmuch
 as the area of infection is so closely circumscribed, isolation is much
 more effective in scarlatina than in measles or small-pox.  But as the
 disease may undoubtedly be carried by third persons, the attendants
 upon the sick should not come in contact with unaffected  members
 of the family.   The best protection  is offered by removal  from the
 house of all children liable to—that is, unprotected by previous attack
 of—the disease.   Unaffected children remaining at home  may not
 attend school or other  assembly for several weeks  after perfect re-
 covery of a member of the family.   It is believed, whether it may be
 proven or not, that contagium emanates from the body so long as des-
quamation continues, and the child should not be allowed to associate 
214
SCARLATINA.
with its fellows until the last scale of skin has been removed.  Des-
quamation continues longest on the soles of the feet, and inspection
of these parts gives the best answer as to the time  when all desqua-
mation shall have ceased.  Such desquamation has been observed as
late as forty days after the disappearance of the eruption, though it
usually ceases entirely in less than half that time.
    Prophylaxis implies also the destruction or thorough disinfection
of all articles which have come in contact, direct or indirect, with the
patient.   The room should  be disinfected, ceilings whitened, walls
rubbed down with  bread, floors scrubbed with corrosive sublimate
solutions, carpets or rugs beaten and suspended in the open air for a
long time, bedding and clothing boiled if not buried or burned, or, if
preserved, subjected to live steam.  It is a sad comment upon our san-
itation that  public disinfecting  stations are not yet  established in all
our cities and towns. Prophylaxis involves attention to detail. The
disease has  been  conveyed by  letters sent out from a sick-room, by
cushions  of  chairs,  curtains, piano  covers, etc.   Special attention
must be  paid to the discharges, to sponges, cloths, towels used in
ablutions.  The  fact is that sponges, handkerchiefs,  etc., are best
substituted by rags, which may be immediately destroyed by fire.   It
must not  be forgotten that the hair of the head retains and conveys
contagium.   Thorough ablution with soap and  water or with  the
carbolized soaps  will disinfect the hair.   The hair of the boy patient
should be cut short.  It must  be  remembered even that the shoes
require disinfection.   They may be painted inside and out with car-
bolic acid and glycerin,  equal  parts.  Ventilation  of the sick-room
throughout  the whole period of the disease is not only a necessity of
treatment but also of disinfection.   The frequent bathing of the body,
with the  subsequent application of some unctuous material—cocoa
butter, lanoline, vaseline, etc.—not only gives great comfort to the pa-
tient, but confines the poison to a narrower field.  After the recovery
of a patient, more especially after a death, outside  windows should
be thrown open and  the room  ventilated for a week.  Here, too,  at-
tention must be paid to  detail.   Closet doors must be opened and  the
inside of closets with their contents disinfected and ventilated as be-
fore.  The fact is, the city government should take charge of all such
apartments.   They should  be  disinfected and ventilated under the
inspection of health authorities.  The inside doors to halls and other
rooms should be closed by the seal of authority, and the same precau-
tions taken as in  the prevention of entrance or interference in cases
of crime.   Scarlet fever is for the most part spread by ignorance,
by  carelessness,  by  blunders which are worse than crimes.   Refe-
rence is made here to the premature return of children  to schools or
the constant attendance at school of unaffected members of a family, 
SCARLATINA.
215
to contact which is effected in street cars, railroad trains, steamers, etc.
Parents, nurses, even physicians, are all too careless in this  regard.
   In the way of a drug there is no preventive of scarlet fever.  The
claim that a drug may protect against the disease, because when ad-
ministered it produces a symptom which resembles that of the dis-
ease, is, in the light of  our present knowledge regarding the infec-
tions, worse than mediaeval gibberish—worse because it may beget a
sense of  false security in exposure.   This claim has been made for
belladonna because it flushes the face.  It has no more foundation in
fact than protection by a blush, which has the same effect.   Bella-
donna, by making a child sick, rather predisposes to, than protects
against, scarlatina.   The hope that has been cherished regarding pro-
tection by vaccination has proven equally vain.   Attempts have been
made to inoculate certain disease products of animals—horses, dogs,
rabbits—with a view of producing a milder or more modified form of
scarlatina.   Claim has been set up in  this direction, as by Strickler,
who introduced the nasal mucus of horses supposed to have been af-
fected with  the disease into the bodies of twelve children, in all of
whom it produced sores at the point of introduction, with circumja-
cent inflammation of the skin and  lymph glands.  It was stated that
these children thus inoculated failed to contract the disease after ex-
posure to scarlatina.   These experiments were made  in imitation of
the first experiments of Jenner with reference to small-pox, but the
objections to accepting such conclusion  are numerous  and obvious.
In the first place, it is not known that any of the lower animals really
suffer scarlatina or any allied disease.  Secondly, it has not been es-
tablished by experiment that the disease which results  from  the in-
troduction of scarlatinal matter of man into animals is really scarla-
tina.  Third, it  could  not,  therefore,  be known that matter taken
from animals was the product of this disease.  Fourth, susceptibility
is so much less in scarlatina that failure to contract  the disease after
exposure has not the same weight  as in small-pox.
   Treatment is wholly symptomatic.  The sick-room  requires con-
stant, thorough  ventilation from the outside air.  The temperature
should be held at 65° to 70°, as registered by a thermometer, not at
the door, window, or fire, but at the head of the bed.  An open fire
in winter is preferable to any other method of heating.  The  patient
should wear a long muslin night dress, without other clothing.  The
bed covering must be as light as is consistent with comfort.
   Milk and meat soups make the best diet.   Water, carbonated
water, Selters,  Apollinaris, lemonade, toast  water, barley  water,
should be given freely to  relieve thirst and to keep the kidneys
flushed.   Drink  should be proffered in  fever  once an  hour  during
the day. 
210
SCARLATINA.
   The utmost cleanliness is to be maintained by frequent sponging
and bathing of the surface.   Daily tepid baths  (full length) give the
greatest  comfort throughout the  disease.   Fever above 103° is best
combated with cold sponges, cold packs, cold baths.  Cold baths are
most effective, but are seldom practicable as yet.  It is not essential
that the temperature be brought down to the normal degree.  A re-
duction of a few degrees suffices to give the patient comfort and re-
lieves all danger  attendant upon high temperatures.  A warm or
tepid bath will reduce the  temperature one or two degrees, and pa-
tients solicit such bathing when a cold bath may excite terror.  While
it is true that  the temperature reaches the highest  grades  in scarla-
tina and the patient suffers  corresponding discomfort and  danger, it
is not true that the danger is caused by the fever.   The danger, the
discomfort, and the fever are produced by a  common cause—namely,
the poisoning  of the blood—and there can be no question  of radical
therapy until  after the  discovery of  some agent, some antitoxine,
which will neutralize the chemical  poison  circulating  in  the blood.
It is, indeed, "a question if  some fever be not salutary.  We  combat
the fever in our day more especially with regard to the comfort of
the patient.  A difference of two degrees makes a great difference in
the feelings of the patient.   The reduction of high temperatures by
cold bathing is attended, as a rule,  with the diminution of  discom-
forts and dangers.  The bath addresses the  cause indirectly through
its effects.  The real virtue of the cold bath lies in the fortification of
the heart.  Frequent bathing is the best therapy in the treatment of
scarlatina, as  of any other infection.  There may  be reasons which
render a bath  impossible.   In these  cases resort must be had to fre-
quent ablutions.  It may become necessary to  substitute a bath by
drugs, especially in the presence of other indications.  Resort  may
then be had to the antipyretics.  Phenacetin is the least  injurious.
It may be given to a child in a  dose of gr. ijss.-v., to an adult in
double this dose, once or twice in the course of a day.  It  is of espe-
cial value in headache or other nervous distress.  It is best adminis-
tered in capsule or in powder taken directly upon the tongue, stirred
—that is, suspended—in milk, or, in  case of high fever with dry
tongue, floated upon the surface of a  teaspoon of water.  Only in
case of failure with phenacetin should  resort be had to antipyrin or
antifebrin, either of which  must be given in half the dose of phena-
cetin.  Burning and itching of the skin are best allayed by applica-
tion, after tepid baths, of vaseline, cocoa butter, lanoline, goose grease,
bacon, or fresh lard.  Quiet, peaceful,  and more or less restorative
sleep is wont to occur after a bath and inunction in this way.
   Nervous distress, jactitation, convulsions, insomnia, headache, are
best combated by bromide of sodium, gr. v.-x. to a  child, gr. xxx.-x'l. 
SCARLATINA.
217
 to an adult, largely diluted ;  or, if  more obstinate, by sulphonal or
 trional,  gr.  v. to a child,  gr.  xv.  to an adult,  dissolved in a cup
 of hot milk or tea, or chloral, gr. v. to a child, gr. xv.  to an adult.
 No other single  remedy gives the  comfort of chloral in  small,
 two or three grain, repeated dose.   Broken doses of Dover's pow-
 der, gr.  i. to a child, gr. iij.-vi. to an adult, may substitute it in
 suitable case.  Ice bags should be applied to the head for meningeal
 symptoms.   The vomiting which occurs in the inception of the dis-
 ease is often sufficiently relieved by  carbonated drinks, the best of
 which is the German  Selters water  with milk  equal parts, or by
 lime water and milk  one to  three, by small doses  of bismuth  gr.
 v.-x., by the bicarbonate of soda in equal dose, by sips of water ex-
 cessively hot.  The most powerful drug we possess is chloral.  The
 most refractory vomiting, of whatever cause, will yield to the admin-
 istration of a few two- to five-grain doses of chloral diluted  in a des-
 sert- to  a tablespoonful of peppermint water.  Should the remedy
 be rejected before it can be absorbed, it may be introduced into the
 bowel in double dose.   It must be a remarkable case to resist chloral
 in one or other of these modes of use,  or to justify resort at last to a
 subcutaneous injection of morphia.
    Throat symptoms call for inhalations of steam,  best  from the
 steam vaporizer, simple or medicated with bicarbonate of soda, satu-
 rated solution, or boric acid 3 ij.- § iv., or carbolic acid 3 i.- 3 iv., or
 thymol gr. v.- \ i. alcohol, water \ iii.;  or gargles  of hot  water,
 of carbolic acid gtt. xv.-xxx.- § iv.,  perchloride of iron 3 i.-1 iv.;
 or direct applications  of  carbolic acid with glycerin  equal parts,
 bichloride solutions from 1 :1000 to 1 :100, or intraparenchymatous
 injections (tonsillar) of  a few drops of the same solution by means of
 a hypodermatic syringe with  a fine, long aspirator needle.   Nothing
 keeps the throat so clean inside, whatever be its disinfecting proper-
 ties, as  sprays of  the  peroxide of hydrogen as procured  from the
 shops.   Cloths wrung out of boiling water, applied about the throat
 and covered in by thick dry cloths, relieve the pains of extreme disten-
 tion.
   Affections of the ear  are  best treated by a douche of hot water
 and a Politzer inflation with  air. Tension in the membrane of the
 tympanum may require puncture; and suppuration in the mastoid
 cells,  trephining.  Earache is best relieved  by instillation  of hot
 water, or solutions of atropia gr.  i.- § i.  Otorrhcea is best treated by
 washing the  external canal with a solution of boric  acid after thor-
 ough cleansing with a cotton-wrapped sound, or direct application to
accessible granulations of chromic acid, London paste, or the galvanic
cautery.   Nephritis calls imperatively  for hot baths, under which all
the symptoms of this complication, including vomiting, are wont to 
218
SMALL-POX.
speedily subside.   The bath must be hot (100° to 110°), the patient
rolled in blankets after it and be allowed to sweat for an hour.
   Rheumatism calls for the salicylates in saturating dose.  Alc< >hol,
digitalis, nitroglycerin, may become necessities in the later course of
all grave cases, and may be urged in over-dosage together with other
analeptics—camphor, ether, musk—in the way of a  " forlorn hope"
in fulminant forms.
                           SMALL-POX.

   Small-pox, or pocks  (pock, a bag or sac) ; variola,  diminutive of
varus, a pimple (a term applied in ancient times to many eruptions,
first limited  to small-pox  in the epidemics of  France and Italy, 570
a.d. [Hirsch]); German,  Pocken, Blatter (blister).—A highly con-
tagious, extremely dangerous disease, characterized  by violent onset
with severe chill, excruciating pain in the back and head, by an erup-
tion of papules, subsequently converted into vesicles and pustules,
Avhich leave disfiguring pits or scars, and by a fever which remits at
the period of  papular efflorescence, to increase in the stage of suppura-
tion.
   History.—Small-pox has existed from time immemorial in India,
where temples were built and a goddess worshipped, and where, more
to the purpose,  the Brahmins practised  inoculation  in protection
against it.  Accounts of it in Africa date also from  the most remote
antiquity, and the great susceptibility of the negro race lends color to
the view that the disease may have originated in  these lands.  It
was imported into China probably about 200 a.d.  Rhazes wrote his
famous work concerning it in 900 a.d.
   Small-pox entered England in 1241 and Iceland  in 1306, but did
not reach Germany and  Sweden until toward the  close of the fif-
teenth century.   It was imported to America first in the West In-
dies in 1507,  exterminating whole races of natives ;  next by Spanish
troops into Mexico in 1520, where it carried off  three  and one-half
millions of people.  In the United States  it reached  Boston from
Europe in 1649, and, though decimating the Indians in every direc-
tion, made but slow progress  and  limited ravage among the white
races, because of  the introduction of vaccination in  1799, the period
of commencing AVestern  migration.  Thus it did not reach Kansas
until 1837, and California until  1850.  Epidemics in South America,
first in 1554, corresponded  with the introduction of slaves from Africa.
Certain islands of Polynesia remain as yet exempt.
   Small-pox has now only historic  interest.  It is on the  road to
extinction, and may occur in  epidemic proportion  only  in  uncivil-
ized lands.   As now seen it occurs in the  modified  form known as 
SMALL-POX.
219
 varioloid.  Since the general introduction of vaccination, small-pox
 has lost all its terrors for those who recognize its absolute protection.
 In many parts of Europe small-pox patients  are no longer isolated
 in pest houses, but are received into the general wards  of hospitals,
 other inmates being protected by, if necessary, fresh vaccination.  It
 is computed of the century preceding vaccination that fifty millions
 of people died in Europe of small-pox.  Macaulay called it the  most
 terrible of all the ministers of death.
   Etiology.—Susceptibility  to  small-pox is  almost,  though not
 quite, universal.   The extent of immunity it is difficult to establish in
 our day  because  of the protection of vaccination.
   Age.—Though it spares no age, small-pox is essentially a disease
 of childhood, "interrupted and postponed by vaccination."  Of the
 new-born, one-third die before their first, one-half  before their fifth
 year of life (Werner).   Old synonyms of the disease, Kinderpocken,
 Barnkoppen, attest this fact.
   Exemption of maturity and age is due, in some degree at least, to
 immunity secured by former attack.  Accurate statistics disclose the
 fact that the  disease occurs at all periods of life, even up to the ad-
 vanced age of sixty and seventy.
   Sucklings enjoy some immunity.  Liability grows intense at the
 end of the first year and continues  up to forty, when it becomes less
 marked.   Pregnancy and puerperium  rather invite than  repel the
 disease.  Small-pox may  certainly attack the foetus  in utero  after
 the fourth month, and children have been born in every stage of the
 ■disease.
   The disease is severe with the colored race.  This fact has  been
 noticed not only in their own country, but in all lands to which they
 have been carried.  The more frequent disfiguration of the  colored
 race seen upon the streets is due partly  to this cause,  but chiefly to
 neglect of vaccination.
   One attack, however light, confers immunity for life, with  occa-
 sional rare exceptions.  Louis XV. of France survived an attack
 at the age of fourteen and died of the disease at sixty-four.  One
 successful vaccinationlikewise protects, but with more frequent ex-
 ceptions.
   Epidemics  occur more frequently in the colder seasons, partly
 because of the closer contact of people at this time, chiefly because of
 the concentration of the contagium in less ventilated rooms.
   The contagious principle of small-pox certainly exists in  the skin,
 whence it is disseminated about the body of  the patient.  Inocula-
tion was formerly  practised wholly by the matter of the disease in
the skin.   It was the custom in China in the  most ancient times to
introduce the crusts of small-pox matter into the nose in the  process 
220
SMALL-POX.
of inoculation, and in India to rub the matter on an abraded  skin.
The fact of infection of the foetus, which  is undeniable, proves that
the poison exists  in the blood.  There is, however, no proof of the
existence of the poison in any of the various secretions or excretions
of the body.  Doubt was thrown upon even the infectiousness of the
blood,  until Ziilzer succeeded  in communicating the disease  to a
monkey with the blood of a variolous patient.
   The contagious principle has singular  tenacity of life.  Jt sticks
especially to bedding  and clothing,  which,  if  kept  secluded  at a
warm  temperature,  may  remain  infectious for  months,  and  even
years.   It  is certain  that the pox  has  been contracted  by an  in-
dividual who has approached a patient  no  nearer than three feet,
and it is  well established that the disease may be conveyed by third
persons and by things.  The contagion is given off from the bod}' at
all periods of the  disease.  Proof of the transmissibility of the dis-
ease during incubation was offered by Schaper in the case of an  in-
dividual  who had some particles of skin engrafted upon an ulcer.
The particles were taken from an amputated arm of a person during
the period of incubation of small-pox. The patient was attacked by
variola on the sixth day after the operation.
   Bacteriology.—The contagious principle or cause of  the  disease
has not  yet been isolated, the  micro-organisms discovered being
those only of pus.  V. Loff claims to have  developed in sterilized
tubes,  from fresh matter, amoebae or proteids.  Pfeiffer claims to-
have discovered  as  constantly present in the exanthem of variola a
parasite of the species protozoa, which runs its whole  course of  de-
velopment in the body of man  or  other mammal.   According to
Koch and Schulze our present methods will not suffice  to  unveil the
virus of variola.
   Symptoms.—The period of incubation varies from ten to  four-
teen days.  Invasion is ushered in  by a  chill, which is, as  a  rule,
violent,  with rise of temperature to 103° to 104° on the first day.
Prostration  is pronounced from the start.  Anorexia,  vomiting,
jactitation, insomnia, and severe headache set in at once.  Above
all other signs pain in the loins assumes prominence.   It  accom-
panies the fever from the  start,  and subsides only with its fall with
the appearance of the eruption on the third day.
   Inasmuch as the eruption proper does not appear until the  third
day, especial value attaches  to two rashes of earlier occurrence in
certain cases or  in certain epidemics.  One is petechial, the  other
erythematous.   Petechiae appear on the second day in the form of  a
fine macular or spotted eruption in the space known as "  Simon's
triangle," whose base is at the umbilicus, apex at the knees.  It may
occur elsewhere, especially in the space under the axillae. The ery- 
SMALL-POX.
221
thematous eruption has its favorite  seat on the sides  and inner sur-
faces of the legs from the ankles up, sometimes, in women, about the
nipples.  This eruption indicates a mild case of the  disease, whereas
petechiae have no such prognostic  value.
   Petechiae  should never be  mistaken for the  true haemorrhagic
eruption, which may stamp the disease  from the start  or occur at any
later period.  Both these eruptions disappear, as a rule, in twelve to
twenty-four hours.   They may last longer, and they may, especially
the petechiae, leave behind them slight brownish colorations.
   The true eruption in its very first appearance is  purely macular.
In the course of the very first day, however, the macule is  thickened
  Fig. 133— Pock of small-pox ; a, outer layer of epidermis; b, middle layer; c, rete Malpighi;
d, reticulated cavity of pock containing pus corpuscles, with the epithelial framework; e, purulent
infiltration of epidermis (Curschmann).
to become a papule.  It shows itself first on the face and scalp,
where it  is unfortunately always worst, over  the forehead and tem-
ples, then upon the sides of the nose, about the lips, over the  chin,
and spreads thence  downward in quite regular progression  over the
body.  Surfaces rendered  hyperaemic, as by  poultices or  mustard
plasters,  show more profuse  eruption.  The hands and fingers fur-
nish the  next most favored surfaces.   The eruption disappears upon
pressure, yielding to palpation a sense of hardness, as of  shot under
the skin.   It is always discrete at first.  By the sixth day the papules
contain fluid.  They become vesicles and protrude like half-peas.
These vesicles are peculiar in showing later a central depression or 
222
SMALL-POX.
 umbilicus, which is most marked just before the vesicles change
 into pustules.   The depression is explained in this way :   The vesicle
 is not a single sac.   It is reticulated—i.e., many-celled—in structure,
 so that puncture evacuates only part of its contents, and the bands
 which form the reticula  hold down the surface more firmly at one
 point, perhaps the site of a hair follicle, sweat gland, or  firmer strip
 of connective  tissue.   Effusion  takes place between the upper and
 lower layers of the epidermis with  the dissolution of these bands.
 In three days  more the umbilicus disappears, the vesicle becomes a
pustule  which is full, round, and large; the half becomes a whole
 pea.  With the coalescence of pustules walls are broken down, dis-
 solved, and eroded.   The eruption becomes confluent.
                                      The eruption  of small-pox
                                   appears also on the  inside  skin,
                                   the mucous  membrane of the
                                   mouth, pharynx,   and some-
                                   times deeper structures. It may
                                   be nearly always discovered in
                                   the fauces, over the palate and
                                   tonsils, and  sometimes on the
                                   inner  surfaces of the lips and
                                   cheeks. Occasionally it invades
                                   the larynx.  Ulcers  may  form
                                   in the  larynx, with affection of
                                   the cartilage, perichondritis, and
                                   oedema of the glottis.  In a bad
                                   case  the tongue, which seldom
                                   shows  any sign of eruption, is
   Fig. 134-Temperature chart in variola, showing swoUen to such an extent  as to
 secondary fever (Moore).
                                   protrude from  the mouth, and
salivation may be profuse.  The affection may also extend from the
throat to the nose, which it may block from  behind, and subsequently
involve the Eustachian tubes and middle ear.  Mucosae of other
parts of the body are rarely attacked.
   The course of the temperature in variola is characteristic.  The
fever reaches  its height, as stated, with the period of eruption.  So
soon as the eruption has covered  the  body the  temperature begins
to subside, and falls often nearly  to the normal grade within thirty-
six hours.   With the subsidence of the temperature the  pain in the
back, the nausea and vomiting,  disappear, and the patient seems on
the road to recovery.   So soon, however, as the vesicles become con-
verted into pustules, about the sixth to the  ninth day of the disease,
fever is renewed, sometimes with shivering fits, always with a rise of
temperature to 102° or 103°, but rarely to the elevations reached dur-
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SMALL-POX.
223
ing the stage of invasion.   This is the secondary fever, the fever of
suppuration, caused entirely by the micro-organisms of pus.  Strictly
speaking, it does not belong to the small-pox process.   It is a secon-
dary effect, but is none the less characteristic of the course of the dis-
ease.  With the stage of  desiccation the fever again gradually sub-
sides, to terminate by lysis in the  course of the subsequent week.   In
the height of confluent  small-pox the stage of vesiculation is repre-
sented by an accumulation of a more or less milky fluid over flat sur-
faces, often in irregular  or zigzag  shapes.  The swelling is greater, as
is also the corresponding deformity at the period of suppuration.
The eyes and the ears  are blocked, the face is enormously bloated,
the scalp  is lifted from the head,  and the face has the appearance as
if covered with a mask or heavily coated with  coarse sand.  With
the rupture of this parchment-like coat masses of  decomposing fluid
ooze out,  to stream down over the face and make of  the patient an
object so loathsome to sight and smell as to be repulsive.
   Chief  among  the  varieties of small-pox are the abortive  and
haemorrhagic forms.  The  abortive is that variety in which  the
course of the disease is altered from the start.  The period of incuba-
tion is sometimes shortened, the invasion may be  brief, the eruption
changed in various ways, or the duration cut short.   This form is
best described under  the  rather unfortunate  denomination,  vario-
loid.
   Haemorrhage may occur in the course of small-pox in no less than
four distinct varieties:  1.  Blood  is  not infrequently  effused  in the
vesicles or pustules of patients who do not  remain recumbent, who
leave the bed and get  up too soon in the period of convalescence.   In
these cases the haemorrhage is  confined almost  exclusively  to the
lower extremities, and shows  itself  as petechiae or purpura, not  un-
like the common form of this affection.  Such haemorrhage is purely
local, due to escape of  blood  through  paretic vessels.  It speedily
subsides by absorption with rest in bed; it has no prognostic gravity.
   2. Reference has already been made to  that petechial eruption
which occurs as an initial  rash on the lower surfaces of the abdomen
and  inner  aspect of  the thighs.  This eruption has also a haemor-
rhagic foundation.  It is  of diagnostic value, but has no prognostic
significance.
   Aside from these eruptions, 3, blood may  be  poured out into  the
true  eruptions of small-pox at any part of the course of the disease.
This accident occurs most  frequently in cases debilitated by previous
disease or bad surroundings, but  sometimes, fortunately exception-
ally, under totally unaccountable  circumstances.  The blood  is
effused at times into the papules, more frequently into vesicles at the
period of full maturation—i. e., at the height of  the  disease.  The 
224
SMALL-POX.
clear serum becomes turbid, sero-sanguinolent, and finally the  vesi-
cle is filled with blood.   Sheets of blood, diffuse and black, fill the in-
terior of confluent vesicles and pustules, and blood appears under the
skin as livid patches, vibices, and ecchymoses,  in various parts of the
body, to constitute what is called hemorrhagic  small-pox. black
small-pox, " variola nigra."  With this effusion of blood there is cor-
responding collapse.  Free haemorrhages  may occur also from the
various mucous surfaces, under which the  patient rapidly succumbs.
Should the patient survive the prostration caused by the haemorrhage
itself, he may have to face  other and worse dangers.   Diphtheritic
deposits form in the pharynx, a scorbutic  condition of the  gums, or
nephritis ensues and the patient may perish from  uraemia.  Recov-
ery from this condition is rare; convalescence is slow and tedious.
    Last among the haemorrhagic eruptions  remains to be described, 4,
that particular variety in which the haemorrhage assumes prominence
over  all other signs.  This variety presents such distinctive features
as to have led competent observers  to consider it a special malady.
The fact that the disease, in any of its forms, may be communicated
from this form, and that  the body remains infectious also after death,
establishes its true nature.  That this haemorrhagic form may be
distinguished from those just  described, especially from the variola
haemorrhagica pustulosa, it has been given the separate name of
"purpura variolosa"—a term which fixes in the foreground the
haemorrhagic character which literally dominates the disease.   In this
variety of small-pox the initial rash  and the true eruption are alike
wanting.  Although this is the fulminant  form of small-pox, it  does
not necessarily commence with violent signs. It attacks, by preference,
the young, healthy, and  strong, but does not spare  the weak and de-
bilitated.   Drinkers and pregnant and parturient women are among
its especial victims.
    The disease begins in the ordinary way, with chill, vomiting, and
rapid prostration.   The  stage of invasion (if it differ  in  any  way
from ordinary cases  of  small-pox)  is distinguished by  the severity
of pain in the back.  In the experience of  the  author, patients have
complained of  excruciating pains in the  back  when there was no
other symptom, not even fever.   Another distinctive feature is the
rapidity of  appearance  of haemorrhage.   Should the disease occur
during menstruation, metrorrhagia ensues and the  nature of the dis-
ease may be thus overlooked, as the pain  and  the haemorrhage  may
be both connected with menstruation. Haemorrhage now shows itself
under the skin, first upon the trunk, later upon the extremities, but
never upon the face.  The surface assumes a blood-red hue, like  that
of scarlet fever, and in this redness points and patches  of blood ap-
pear.   The eruption is usually petechial upon  the extremities, and 
SMALL-POX.                        225
 confluent as irregular ecchymotic patches on the chest and trunk.
 The face is  swollen, the eyes suffused and sunken and  surrounded
 with black rings.  The tongue  is thick and heavily coated.   The
 breath is exceedingly fetid.  There may be elevation of temperature ;
 sometimes there is no fever, and  often the temperature is subnormal.
 The tendency is steadily downward, and  death  occurs by the end of
 the first week.   Fortunately this form occurs in but five per cent of
 cases.
   A peculiar variety or disposition of eruption is that described by
 Marson as " corymbose."  In these cases the  eruption shows itself in
 patches or  clusters the size of the hand, as  thickly set as possible,
 while the surrounding skin remains often entirely free.   The patches
 are often symmetrically distributed upon the  extremities.  The vari-
 ety is very  rare, but,  contrary to what might be expected, is very
 dangerous.  Other  singularities are verrucose,  pemphigose, or mili-
 ary eruptions.  They are, however, more commonly encountered in
 varioloid.
    Varioloid is a misnomer, for  the affection is not like variola, it is
 variola itself.   Varioloid does not stand in the same relation to  vari-
 ola as typhoid to typhus fever; varioloid is variola in modified form.
 Varioloid is the lightest form of small-pox.  The disease occurs in
 this form on account of natural insusceptibility,  or on account of pre-
 vious attack, formerly on account of inoculation.  The great major-
 ity of cases seen in  our day are due to incomplete protection by
 vaccination.  The immunity secured by vaccination has run out, and
 the severity of the attack will, to a certain extent, depend upon the
 remaining degree of protection.   A case of unmodified variola in our
 day is a rarity; that modified or mitigated variola known as vario-
 loid  is still frequently seen.   A knowledge of  the nature of  varioloid
 and  its differences  from other simulating affections  is necessary,
 that the disease be recognized at once, in protection of others.  From
 what has been stated, it is needless to add that varioloid, mild as it
 may be in itself,  may transmit  true  variola, in any, even its most
 fulminant forms.   Most of the cases  encountered in our day are so
 mild that the question of diagnosis concerns differentiation of vario-
 loid from varicella as much as the recognition of variola itself.   Va-
 rioloid distinguishes itself by abnormities in every phase of the dis-
 ease.  As most of  the cases are due to incomplete  protection by
 vaccination, the various  irregularities are mentioned by Morrow
 when he says that  "vaccination  denaturalizes small-pox, deranges
 the original order of the disease, and effaces its most distinctive fea-
 tures."
   It is generally assumed that the modification of symptoms is ap-
parent in the initial stage of the disease ;  this view, however, is by
        15 
226
SMALL-POX.
no means correct.  The disease begins with its usual train of symp-
toms, and, as a rule, with its original violence.  The difference con-
cerns duration rather than  degree.  The initial stage is often cut
short a day or two, so that the eruption may appear by the end of
the first or second day.   The various initial  eruptions occur also in
varioloid ; the petechial as an exception, the erythematous as a rule.
It is a common observation  that  a pronounced erythematous erup-
tion or scarlatiniform rash betokens varioloid rather than  variola.
Curschmann declares that we may predict, in spite of the severe
depression of the general system, that the  form of the disease, if
erythematous, will be mild,  while petechiae will nearly always  be
followed by variola vera, which is not  infrequently confluent.  For
what comfort it may bring, the author  may  state that the cases of
petechial eruptions in Simon's  triangle  which  have occurred in his
experience have preceded, without exception, a mild, abortive attack
of the disease.
   With regard to the real eruption, varioloid  presents the greatest
variations.  It may begin on the  scalp, forehead, and temples, as in
an ordinary case, and progress in  irregular course.   It  may, on the
other hand, show itself first on the neck and chest, or elsewhere over
the trunk, to appear later on the extremities or face.  As a rule it is
much less abundant, so that it is nearly always discrete.  There are,
however,  exceptions to this rule,  and marked cases may show iso-
lated patches of  confluence on the face and hands.   On  its first
appearance the eruption differs in no  way from that of the more
pronounced form of the disease.   It comes out in spots, which  are
elevated into papules  in the  course of the  first day.   The papules
slowly show fluid at their  acuminated apices,  and become thus
entirely converted into vesicles as  before.  Here, now, the change is
usually observed ; the eruption usually stops  at this stage, and  the
vesicles, which may have become umbilicated,  begin  to  dry  up and
disappear.   They  may fill out, as in the course of severer forms ;
their contents may become turbid  and opaque,  and the vesicle may
be transformed into a pustule ; but it is plain to see that the force of
the disease is spent.  Certain pustules may rupture, but the process
is limited and the secondary fever of suppuration is reduced or is
entirely absent.   In consequence  of the  fact that pustulation does
occur in places, with erosion  and destruction  of tissue, pits may be
left, but they are  few and far between as compared with the  lesions
of ordinary small-pox.
   The disturbance of the general progress of the disease is  marked
also by irregularity.   It  is more  common to find pustules and vesi-
cles, or vesicles and papules,  in closer  proximity in varioloid than
in variola.  Moreover, the  eruption does not last so long.  Desicca- 
                          SMALL-POX.                         227

tion begins on the fifth or seventh day, and most  of the papules  dry
up into crusts without rupture.  These crusts, as a  rule, leave only
pigmented traces without scars.  There  is  often also disproportion
between the severity of the fever and the eruption.   There may be
high fever in the presence of  but ten or twenty vesicles  or pustules
over the body,  or, per contra, the eruption may be almost or, in
places, even confluent with but little elevation of temperature.  It is
plain to see that vaccination has at every point  put a muzzle upon
the disease.
   The various transformations of vesicles and papules  which may
occur during the process of  modification or abortion may convert
vesicles or pustules into warty masses, or bullae ;  or ruptured vesicles
may fill with air, to  constitute varieties known as variola  verru-
cosa,  pemphigosa,  miliaris,  ventosa, or cellulosa, etc.   So  of  the
various affections  of  the mucous  membrane.  While they may be
present, or in individual cases  more or less pronounced in  initial
stages, they rarely assume prominence or give rise to serious compli-
cations.
   Complications which occur in the  course of small-pox  do  not
differ much from those of equally grave acute infections.   Sufficient
mention has already been made of the lighter affections of the pha-
rynx and larynx.  It remains to be said  that gangrenous processes,
oedema  of the  glottis, perichondritis  occur  in   exceptional  cases.
Stenosis from either of  these causes may necessitate intubation or
tracheotomy.
   Bronchitis belongs to variola, as to most of the exanthemata.  It is
very liable to extend in childhood, to infect the finer bronchial tubes
and result in broncho-pneumonia.  Pleurisy is by no means so com-
mon, but is by no means rare.  Pericarditis, endocarditis, endome-
tritis, meningitis, are  not uncommon complications  in grave cases.
Affections of the joints, arthritis,  pyaemia, septicaemia, are much
more frequent.
   Small-pox occasionally affects the eye ;  conjunctivitis, keratitis,
affections  of the lids, are the most common lesions.   Disease  of  the
choroid and retina occurs in exceptional cases.  Panophthalmitis with
destruction of the globe was not uncommon  in ancient times.  Eye
complications in our day are  neither frequent nor severe.   In  all his
remarkable experience Hebra saw eye complications in only one  per
cent of five thousand cases of small-pox.
   By extension of the inflammation of the fauces and pharynx  the
middle ear may be attacked,  to result in  otitis or  otorrhcea with sub-
sequent anchylosis  of bones  and deafness.   Phlegmonous inflam-
mations, gangrene  of the skin, furunculosis, occur frequently in con-
fluent cases, and local and diffused inflammation of the brain  and 
228
SMALL-POX.
cord, paralysis, bed sores may nearly complete the possible1 compli-
cations.
   The diagnosis of the disease rests upon the following points :  the
possible existence of other cases, the history of sufficiently recent
protection by vaccination.   The  mere existence of a scar is no  evi-
dence of protection.  The worst case of purpura variolosa encountered
in the experience of the author had three well-marked cicatrices upon
the arm as evidence of previous vaccination.  Then it is observed
that the illness sets in suddenly and is usually severe from the start.
Strong men stagger as if  drunk.  The temperature rises rapidly.
Pain in the back is peculiar in its intensity ;  initial eruptio)is may
be characteristic.  The true eruption appears upon the tliird day
after the initial chill.   It is maculated, not punctate like that of scar-
latina, but darker than the scarlet of scarlatina and lighter than the
dusky hue of measles.  It is seen first upon the scalp and  upper
part of the face, spreading downward regularly and rapidly ,' it does
not spare the nose or region of  the mouth.  It yields a peculiar feel-
ing of hardness, as of shot under the skin.   Elevation into papules
occurs during the first day.  The diagnosis becomes  nearly certain
when  the papules by  the  third  day change  into  vesicles, some of
which subsequently become umbilicated.
   Small-pox is one of the most grave of the acute infections which
survive from the pre-sanatory period of civilization.   We see it for
the most part as a mere relic or rudiment of its former self.  There is
lacking with us that element of multitudinous infection which gives
volume and virulence to a disease.  Nevertheless even in its  modi-
fied  form it preserves its character as a grave infection, and it may
hence  be confounded with any of the infections of equal gravity, es-
pecially with any attended with an eruption.
   Disregarding  the eruption for the present, because not manifest at
the start, mistakes have thus arisen in  connection with meningitis,
pneumonia, and  typhus fever.  Meningitis, especially the cerebro-
spinal form,pneumonia and typhoid fever, begin, like small-pox, in
the midst of health, with violent chill, rise of temperature, and rapid
prostration.  Gastric symptoms,  vomiting or nervous shock, espe-
cially, in children, convulsions, may announce the onset of any of these
infections.  In the absence  of an epidemic or the history of exposure,
in the absence also of adequate protection by vaccination, the diag-
nosis must sometimes be held in abeyance for twenty-four or forty-
eight hours until distinctive signs of one or the other of these diseases
are manifest.   Meningitis distinguishes itself  by hyperesthesia, opis-
thotonos, and herpes, as well as by its irregular temperature  curve.
Pneumonia is early characterized by pain in the side, cough with
glutinous and rusty sputum, and increase of respiration  out of  pro- 
SMALL-POX.                        229
 portion to the pulse.  But  the diseases which are most  frequently
 confounded with small-pox are those which are attended with an
 eruption,  and chief among these is typhus fever.  But typhus fever
 has a history of importation which may be traced, or  prevalence
 which may be known.   It begins often like small-pox, suddenly, with
 a severe chill, in the midst of health, and shows an  eruption on the
 third day.  The eruption of typhus, however, appears first upon the
 body, chest, and abdomen in the form of maculae, which soon become
 petechial.   The eruption of small-pox appears first upon the scalp and
 forehead,  and progresses over the  face before it appears upon the
 body.   It shows itself in the form of  maculae, which soon become
 papular, vesicular, etc.  The petechiae which may occur in small-pox
 occur on the legs or thighs, or in the course of a haemorrhagic form.
 Vesicles,  especially umbilicated vesicles, are never  seen  in typhus
 fever.   There is also characteristic  difference in  temperature, which
 subsides with  the appearance of the eruption in  small-pox, but  per-
 sists unaffected for  several days  or as long as a  week in typhus
 fever.
    Confusion with typhoid fever is less pardonable.   Typhoid fever
 begins insidiously, requiring the time of a week to reach the eleva-
 tion of temperature of small-pox in  a day or  two.  The cloud about
 the brain, which belongs both to typhoid and typhus fever from the
 start, is not present in small-pox until  the last stages of the disease.
 Typhoid fever shows abdominal symptoms,  roseola on the seventh
 to tenth days, meteorism,  gurgling, diarrhoea, etc., absent in small-
 pox.
    A light case of small-pox may be regarded  as  measles, and a
 bad case  of measles as small-pox.   Consequently the separation of
 small-pox  from measles is the most frequent problem submitted to
 the practitioner.  The future of the case, the safety of the  commu-
 nity, the reputation of the physician, depend upon  the proper solu-
 tion of this problem.   Here, too, help may be had by a knowledge of
 the history of the case as to the existence  or absence of an attack of
 measles or small-pox, the period of the last successful vaccination,
 the prevalence of either  disease in the community.   As for measles,
 it is always present in cities.  Thanks to the  popular fear of small-
 pox, knowledge  of its existence is early promulgated by the health
 authorities.  Nevertheless sporadic cases steal  in  at times  unan-
 nounced.  In the experience of the  author with the management of
 a large dispensary practice, small-pox was twice introduced into Cin-
 cinnati by the  peripatetic philosophers  commonly called  "tramps."
 These cases formed centres  of infection.  Knowledge of  the period
of exposure—i e., the period of incubation—is of little value.   The
stage of invasion is much milder in measles than in even modified 
230
SMALL-POX.
forms of small-pox, for, as  has been stated, varioloid  may be an-
nounced with symptoms as  severe as  those which distinguish the
onset of variola vera.  The chill is less severe, the fever  is less high,
the prostration is less profound in measles as a rule.   There are, of
course,  exceptions on both sides.  The eruption appears  on the third
day of  small-pox, on the fourth day of  measles.  The  maculae of
measles are bigger than those of small-pox.  They appear also upon
the back almost at the same time as upon the face, whereas the erup-
tion of  small-pox much more uniformly appears upon the face  and
reaches the back only later in its advance over the body.  The  ma-
culae  of measles  are softer than those  of small-pox.  Rhazes said,
nearly  a thousand years ago,  the difference  between  the two he
found to be " that measles are red and appear only on the surface of
the skin without rising above it, while the small-pox consists of round
eminences.   AVhen these eminences appear,  fix your attention on
them, and, if you are in doubt as to the disease,  do not  express any
opinion  about it for a day or two ; but when there are  no eminences
you must  not give as your opinion that  the disease is  small-pox."
And Collie, a recent writer, observes : "A case of  small-pox  severe
enough to simulate measles imparts to the hand, in passing it over
the surface, a hardness and furrowed roughness, as that  produced in
passing the hand over a  piece of corduroy ; whereas in  raised, con-
fluent measles it is that of passing the hand over  a piece of velvet."
The catarrhal symptoms, more especially the coryza, which may ex-
ist in both affections, are wont to be more prominent  in measles at
the start, but persist longer in small-pox.   The course  of the tem-
perature is characteristic in  the two diseases.   The  appearance of
papules or  vesicles soon dissipates all idea of measles.
   The  severity of  the sore throat, the backache, and the scarlet
color  of the rash, which  appears as minute points as early as the
second  day after the initial  chill,  distinguish scarlet fever.  The
grave haemorrhagic form, " purpura variolosa," is recognized  by the
extreme severity  of pain in the back, as well as by the petechial char-
acter of the eruption, free haemorrhages, etc.
   Papular eczema is irregular in  its distribution, unattended with
fever or involvement of the  mucous membranes.   The  same excep-
tions  apply to erythema, acne, and herpes.  Only the  most  super-
ficial  observer could consider these eruptions variolous.
   Syphilis may show pustules to  closely resemble discrete variola,
including even the process of umbilication; but the absence of  the in-
itial signs—chill,  fever, pain in the  back, etc.—the history of syphilis,
or associated evidence elsewhere, render the diagnosis easy as  a rule.
   The  separation of variola and varicella will  be discussed under
" Varicella." 
SMALL-POX.
231
   All cases concerning which there is any doubt should  at least  be
isolated for a time until sufficient protection can be offered to oth-
ers by vaccination.  Marson says of his experience in the London
small-pox hospital : " Upward  of twenty  diseases have been mis-
taken within the last few years, in the early stage of the disease, for
small-pox, and the patients have been sent, as having small-pox,  to
the small-pox hospital."
   The prognosis is largely determined by the last successful vacci-
nation.   The next most important factor is the determination of the
form of the disease.  The third is the age of the patient.   Small-pox
in infancy has a mortality which  is put at ninety per cent.  Almost
equally grave are the cases which occur in pregnancy and the puer-
perium.  The greater danger which is thus  imparted  to the female
sex is counterbalanced in the male sex by the mortality of the disease
among drinkers.  The percentage runs high, again, in advanced age ;
nearly seventy-five per  cent of old people, unprotected by vaccination
or previous attack, succumb to the disease.
   Severe symptoms on the part of the nervous  system are of evil
omen, but to a less degree in children than adults.  Trousseau laid
great stress upon  tumefaction of  the extremities, what he calls "red
oedema," which should set in at the end of the ninth day with acute
pain; with Sydenham, Morton, Van  Swieten, Borsieri,  he attaches
great importance  to it in a prognostic way.  He says:  " Swelling of
the hands and feet is such  a  necessary phenomenon in confluent
small-pox that  patients almost invariably succumb where it  is ab-
sent, unless  there be a great critical  discharge by the  kidneys or
bowels."  Profuse  suppuration  in the skin  is a  sign  of danger.
Haemorrhagic  small-pox is very serious; less than one-half the cases
recover.  But  the prognosis  is not unfavorable because of  initial
petechiae, which may show later upon the legs of patients who try to
get about too  soon.  Purpura variolosa is always fatal.   The mor-
tality of the unvaccinated ranges, even in our day, at twenty to forty
per cent.
   Prophylaxis.—Vaccination, if it could be enforced, would render
superfluous all  other prophylaxis, including  isolation.   Inoculation,
which it substitutes, has only historic interest.  Vaccination and re.
vaccination,  if it could be made compulsory, would eventually eradi-
cate the disease; thus but a single fatal case of small-pox has occurred
in the German army during the past twenty years.  Unfortunately,
however, vaccination cannot be  made  compulsory in  our country,
'' where the cry of infringement of  personal liberty is the shibboleth
of the demagogue" (Foster), so that patients must still be isolated
and sick-rooms  disinfected.  A temperature of 400° F.  is fatal to
small-pox.  The organisms of the disease are destroyed by sulphur 
232
SMALL-POX.
in sufficient  concentration.  That  this  process  may  be properly
brought about, it must  be done by health authorities.   All combus-
tible material should be consumed, if it may not  be subjected to the
antimycotic action of live steam; walls should be rubbed down with
bread; floors  scrubbed with a solution of corrosive sublimate 1 :1000;
doors and windows should be closed, and sulphur, four  pounds to
every 1000 cubic feet of air, should be burnt  to  bring about perfect
fumigation; at the end of two days the chamber may be thrown
open and thoroughly ventilated for two weeks.   Bedding, clothing,
curtains, etc., after subjection to superheated steam, should be sus-
pended in the open air, day and night, for a week.
   The dead body should be  subjected to immediate  interment, as
infection is disseminated from its surface up to the period of decom-
position.  In the interval between death and burial the body should
be enveloped in a sheet  saturated in the solution of corrosive subli-
mate 1 : 1000.  Transportation should  be permitted only when  a
body is put in an air-tight metal  case.  In the experience of the
author an epidemic was once developed at a distance  in a country
town by neglect of this precaution.
   Treatment.—If seen early the  patient should be vaccinated at
once.   Vaccination modifies variola in the early stage of the disease.
After the fourth day vaccination  is  useless.  Marson  puts it posi-
tively: " Suppose an unvaccinated person  to be exposed to small-pox
on Monday; if he be vaccinated as late as Wednesday the vaccination
will be in time to prevent  small-pox being developed; if it be put off
until Thursday small-pox will appear, but will be modified; if the
vaccination be deferred until Friday it will be useless—it will not
have had  time to reach the stage of areola, the index of safety before
the illness, and indications of small-pox begin."   Curschmann does
not subscribe to these points.   He declares that he has seen, in cases
in which vaccination was  practised, that infection with vaccinia and
small-pox pustules developed side by side.  He doubts whether vac-
cination can render the  disease even milder in its  course.  Neverthe-
less so long as there is  doubt the patient should have the possible
benefit of  early vaccination.
   Treatment, in the absence of a specific, is wholly symptomatic:
Rest in bed in a thoroughly ventilated room at a temperature of 65°
F., as determined by a thermometer at the head of the bed; light but
sufficient  covering; cool drinks—water, lemonade, Selters water, in
sufficient quantities; fever diet—milk, soups, gruels.  Thus much we
owe to Sydenham.  What it must have effected  may be  learned by
what it substituted.   The contrast  is shown in a chapter from the
practice of Diemerbroeck:  " Keep the patient," says Diemerbroeck,
"in a chamber close shut; if it be winter, let the  air be corrected by 
VACCINATION.
233
 large fires; take care that no cold air gets to the patient's bed ; cover
 him over with blankets.  Never shift the patient's linen till after
 the fourteenth day, for fear of striking in the pock to the irrecover-
 able ruin of the patient.  Far better it is to let the patient bear with
 the stench than thus be the cause of his own death."   Trousseau is
 right when he says: " If the second epoch in small-pox was introduced
 with inoculation, and the third with vaccination, the first was intro-
•duced with the treatment of Sydenham."
   Fever above 163° can best be combated by frequent baths, or by phe-
 nacetin or salipyrin gr.  x., or antipyrin  gr. v.,  or in  half  of these
 doses in childhood.  For throat complications, steam from an atomizer,
 simple or medicated with boric  acid  gr. xv.-| iv., thymol gr. xv.,
 alcohol and water aa § ij., or carbolic acid or creosote  3 ss.- 3 i. alco-
 hol to 3 iij. water, or, with less efficacy, gargles of the same strength.
 Inhalations may substitute all local applications in very young or
 refractory children.  Chloral, gr. ii.-x., becomes  a necessity in peri-
 ods  of unrest, nervousness, insomnia.  It has no equal in the relief
 of nausea and vomiting.   For jactitation or extreme nervous distress
 it may have to be substituted by Dover's powder gr. ii.-v. Frequent
 ablutions of tepid water, ointments, diachylon ointment, plasters, mer-
 curial plaster, or opening pustules  after the  manner  of  the Arabs
 and touching them with nitrate of silver, or, better, with equal parts
 of carbolic acid and glycerin, or touching the tops of beginning pus-
 tules—i. e., mature vesicles—with a camel's-hair brush  dipped in car-
 bolic acid, best prevent or limit pitting.  Xylol internally is said
 by Ziilzer to have the power of coagulating the contents of pustules,
 but the claim was not at all substantiated by subsequent trial.
   Where tissue is destroyed cicatrization must  result, and, in con-
 sequence of it, pits and scars.  Means to  prevent deformity, to be
 effectual, must therefore be  brought  into  use before the  stage of
 suppuration is complete.  Nothing can prevent pitting in an estab-
 lished confluent small-pox.  The best clinicians are content with fre-
 quently renewed water dressings, made antiseptic as much as may be
 with sublimate solutions 1 :5,000-10,000 or with one-per-cent solu-
 tions of creolin.   The whole question, with all the other horrible evils
 of small-pox, sinks into insignificance and slinks away, like the devil
 at sight of the cross, when brought face to face with vaccination.

                         VACCINATION.
   Vaccination (vacca, a cow); vaccinia; cow-pox.—The inoculation
of man with cow-pox in prevention of small-pox.   The  promulgation
of vaccination by Edward Jenner in  1798 constitutes one of the great
epochs in the history of mankind, in that from this period the tropi-
cal plague variola, which overran and literally decimated Europe and 
234
VACCINATION.
the rest of the world, was reduced to the trivial malady varioloid,
which is. uncomplicated, never fatal.
   History.—Jenner was a medical apprentice at Sodlmry when he
became acquainted with the popular belief in the protective influence
of cow-pox, a subject which he was unable to dismiss from his mind.
He visited Gloucestershire, and made observations and prosecuted
the investigations for himself.  He found that there existed a wide-
spread belief amongst the dairymen that certain individuals who
had contracted sores upon their hands from contact with sores on the
bags of cows were never attacked with small-pox.   Much contradic-
tory testimony presented itself at first,  and many  disheartening ex-
ceptions were found.
   May  14th,  1796,  is the memorable  day when Edward  Jenner
transferred cow-pox  from vesicles on the hands of Sarah Nelmes, a
dairymaid, by  means of two superficial  incisions,  into the arms of
James Phipps, a healthy boy eight years of  age.   The cow-pox ran
its ordinary course, and a subsequent inoculation  with small-pox on
the 1st of the following July  failed to  produce  the disease.  This
was the first attempt of a simple practice which has within less than
a century, and without radical correction  or real improvement, af-
forded to all mankind protection from the ravages of small-pox.  A
number of children subsequently vaccinated in  succession, "one
from the other," were, after several months, exposed to the infection
of small-pox, "some by inoculation, others by variolous effluvia, and
some in both ways, but they all resisted it."  There is evidence that
Jenner worked with this  subject, encountering and overcoming ob-
stacles and opposition on every hand, for over twenty years before he
announced it  to  the  world,  and it is known  that fully two years
elapsed between the first vaccination and the  publication of his paper.
It was entitled an '' Inquiry into the Causes  and Effects of the Vari-
olae A'accinae, a Disease discovered in some of the  western counties of
England, particularly Gloucestershire, and  known by the name of
Cow-Pox."1   Jenner lived to see all opposition, overcome, while the
procedure was at once adopted all over the world, and to  receive
universal honors  and emoluments as the  greatest benefactor of his
kind.
   Cow-pox is an infectious  disease which  appears in dairies from
time to time, often at wide intervals  of both time and space, and
shows itself first in  some particular cow, usually a  young  cow, a
heifer in her first milk.   It never appears first in other cattle than
milk cows, and never shows itself elsewhere than on  the teats or at
adjoining parts of the bag, as they may be infected by direct pressure.
It appears in the form of scattered papules, which in the course of a
            1 London, 1798, quarto; 1800, octavo; 1801, octavo. 
VACCINATION.
235
few days show fluid at their apices, to become transformed into dis-
tinct vesicles.  These vesicles are broken by the hands of the milkers,
and the disease  is thus disseminated in the course of a few weeks,
sometimes months, throughout the entire dairy.
    It is a matter of secondary importance, so far as the protective
efficacy of the virus is concerned, whether so-called animal or human
lymph be employed in  vaccinating, for it  is the same virus in every
case.   Animal lymph  "takes" slower and harder, but compensates
for these objections by  freedom from any possible  infection with
tuberculosis, syphilis, or other disease, excepting possibly erysipelas.
    Bacteriology.—Vaccinia alone would  seem to offer all the condi-
tions  essential to easy  separation of characteristic elements, but the
numerous attempts in this direction have not yet been rewarded with
success.  The efforts of  Schulz resulted rather in the conversion of
active into useless matter.  Garre was not able to  induce vaccinia
with  the micrococcus  he considered peculiar  to the affection, and
the efforts  of Tenholdt and Dougall were not more successful with
the micrococci isolated  and cultivated from lymph of proven po-
tency.
    The proof of the degree of protection is seen at a glance  by ob-
servation of statistics in countries and cities where they are most ac-
curately kept.   Thus in Sweden the mortality from small-pox in the
twenty-four years before the introduction of vaccinia (1801)  was
2,050  per million annually; after vaccination, 158 per million.  Drys-
dale says of Berlin that the mortality in that city during the epidemic
of 1872-73 rose to 243 and 262 respectively per one hundred thousand
inhabitants.  Thereupon vaccination in the first year of life  was
made compulsory, and revaccination in the twelfth year of life, with
the result that in the first year of enforcement (1875) the mortality
fell to 3.6 per one hundred thousand, to 3.1 in the year 1876, to 0.3 in
1877,  and so on for succeeding years  down to 1883 with an average
of 1.7 per one hundred thousand.  The nearly absolute protection of
vaccination is shown again by comparison of cities in which vaccina-
tion and revaccination are obligatory and optional.  Thus, according
to the Berlin Health Office, the mortality of small-pox per one hun-'
dred thousand inhabitants in  1888 was in Dresden 0, in Berlin 0.07,
in London 0.6, in Munich 0.75, in Hamburg 3.58, in Paris 9 0, in St.
Petersburg 15.30, in Vienna 26.15, in  Prague 55.49.   Corbally re-
ports that the vaccinated children of  Sheffield, 1887-88, had, as com-
pared with  the unvaccinated children, a twenty-fold immunity from
attack, and a four hundred and eighty fold security against death by
small-pox.   These facts render further statements superfluous, but a
few points  may be  added from  army life.  Army statistics, on ac-
count  of accuracy, are especially valuable.  Schulz shows that since 
236
VACCINATION.
the operation of the German law the annual average cases of small-
pox per one hundred thousand was, in the army of Germany, 4.91; of
France, 169.72; of Austria, 374.   During the Franco-Gorman war
(1870-71) the mortality of small-pox in the  unvaccinated  French
army was 23,469, while that of the vaccinated German army was but
261.   As stated elsewhere, there has been reported but a single case
of death from small-pox in the German army since 1874.
   The immunity conferred  by vaccination  does  not, as  Jenner
                              Fig. 135.

hoped, last for life.   Therefore revaccination becomes a necessity
after a lapse of years.  The best proof of this necessity is furnished
in the fact that revaccination "takes" as a rule; thus among the
soldiers of Prussia, Russia, and Denmark in 50 to 70 per cent of cases.
Heim found in five years but one case of  varioloid among 14,384 re-
vaccinated soldiers and but one case among 3,000 civilians, small-pox
meanwhile prevailing in three hundred and forty-four places in which
these people lived. 
VACCINATION.
237
   Moreover, the number  of  extensive  epidemics have  diminished
from 71.4 per century previous to vaccination, increased to 84 during
inoculation, to 24 since vaccination.
   Protection begins on the fourth day after the introduction of the
virus, and is perfect on the ninth day.  The degree of protection, in-
dependent of  revaccination, is determined to considerable extent by
the success of the operation and by the  quantity of matter  intro-
duced—i.e., by the number of places vaccinated.  Thus, according
to Marson, the average  mortality of small-pox among all vaccinated
persons is 5.24 per cent, while  that of individuals showing perfect
cicatrices is about one-half  of one percent.  In 6,000 cases of small-
                              FlG. 136.

pox after -vaccination observed by Simon in twenty-five years, the
percentage of death among individuals without cicatrices was 21.75
per cent;  with one indefinite  cicatrix, 12 per cent; with one typical
cicatrix, 4.25 per cent; with  two cicatrices, 4 percent; with three
cicatrices, 3.25 per cent; with four or more cicatrices, 3  per cent.
This fact finds additional  proof in the observation that the pro-
tection  of vaccination, however great, is  not so thorough and sus-
tained  as that offered by an attack of small-pox itself, whether con-
tracted  by  ordinary exposure  or by inoculation.  Vaccination, and
revaccination once or twice in later life, as at puberty and maturity,
protect  for life  absolutely.   The exact protection by single vaccina-
tion cannot be definitely established.  It varies in  different cases.
If revaccination "takes," the  individual was certainly liable to take
small-pox.  The operation is so simple and inexpensive as  to justify
its practice at stated intervals,  and inasmuch as no  case  of small- 
238
VACCINATION*.
pox contracted within seven years—twelve in (Jermanv, according to
the report of the Health Office—after a successful vaccination stands
upon authentic  record, this period may be put down as the proper
interval for absolute  protection, with the injunction in all cases that
revaccination be performed with every exposure seven years after the
last successful vaccination.
   Objections.—As  already  stated,  it is a matter of indifference
whether use be made of human  or  bovine  lymph.  Objection was
raised against  human lymph  on  the ground that it had undergone
degradation.  Hebra  declared, however, that the  lymph  used in
Vienna produced the same effect as when first introduced.   Chapin,
of Rhode Island, made the same observation of matter that had been
employed  for  twenty-six years upon  nearly forty-seven thousand
persons.   With proper care in the  selection and preservation  of
lymph, it undergoes no diminution in potency and protection.
   But a valid objection to the use of human lymph is the possibility
-of the conveyance of other disease.   Thus it has been  asserted that
tuberculosis, syphilis,  and erysipelas  have been transmitted  in
this  way.   The possibility of  introducing these  diseases  with vac-
cination  is unquestioned, though,  as  a matter of fact, tuberculosis
has never  been transmitted in this  way.   The few apparent cases
recorded meet  with truer interpretation as localizations of bacilli
tuberculosis previously latent in lymphatic glands (scrofula). As to
syphilis there is no doubt.  It is admitted that the disease has  been
introduced  in this way by the use of virus from syphilitic infants.
It was for  a long time maintained that this disease could not be thus
conveyed unless blood,  pus, or matter other than the pure lymph
had  been introduced with the lymph itself.  It is, however,  now
determined that the virus of  syphilis may be conveyed with the
pure  lymph of  vaccinia virus. Robert Cory, chief of the  Natural
Vaccine  Establishment, England, settled this question with a self-
sacrifice  that finds but too frequent following in other fields.  He
selected only clear, pure lymph from children who showed unmis-
takable evidence of the disease in the stage of active eruption.  With
this  lymph he vaccinated himself on  several occasions.  After re-
peated failures  he succeeded in producing  in the course  of three
weeks, after a last inoculation, a distinct eruption, followed in irre-
gular  course by sore throat and other  unmistakable  evidences of
syphilis (Plant).   The difficulty as well as the possibility of trans-
mitting  syphilis in  this  way  is  proven in this  experiment.  The
smallest  precaution as to the selection of subjects suffices to procure
protection  against this disaster.  The  transmission  of syphilis is
easily avoidable by  taking matter only from healthy children at
least  six months old, the ultimate limit of " tardy" inherited syph- 
VACCINATION.
239
ilis, and  all possibility is absolutely excluded  by the use of animal
matter, as syphilis is an  exclusively human disease.
   Erysipelas (streptococcus) may be introduced with vaccination,
or may fall later upon the broken  surface.  The accident is rare in
any event, occurring  in the practice of the author  but twice  in
twenty-five years, but has been sufficiently frequent during the pre-
valence of an epidemic of erysipelas—as in Boston, 1854—to justify
the suspension or postponement of vaccination.
   Time  and Technique.—Vaccination should be done at the age of
three to six months, or, in the presence of an  epidemic, at any time,
even at birth.   In case of failure the operation should be repeated at
intervals  until it is crowned  with complete success.   Revaccination
at stated  intervals—at puberty, maturity, or at  any time during an
epidemic—robs the question of the value of  the kind of virus, or  the
number of vaccinations at one time, of practical interest.
   Points of selection for the  operation are about the insertion of  the
deltoid or the junction of the heads  of  the gastrocnemius muscles.
In protection against future carelessness regarding revaccination the
             Fig. 137.                         Fig. 138.
                Fig. 137.—Strokes and cross-strokes for vaccination.
                Fig. 138.—Bone point for vaccine virus.

 matter may be introduced at three places,  at the angles of a triangle
 (horizontal insertions at the shoulders permit concealment by a nar-
 row sleeve), at least half an inch distant from each other.  Six or
 eight parallel tracings or strokes, with  as many cross-strokes, with
 the point of a knife, so light as to expose  the superficial  lymphatics
 and draw little or no blood, afford the best wound, upon which the
 moistened bone surfaces may be gently rubbed.
   Susceptibility is universal.   There is no such thing as insuscep-
 tibility  to  vaccination.  Seaton never  saw  it  in  more than nine
 thousand cases at the Black Briars National Vaccine Station.  Cory
 confirms this statement  with reference later to bovine lymph, and
 Robertson declares that  so-called constitutional insusceptibility is
 usually  a confession on the part of the  operator that  he has  not
 ascertained the cause of his failures.
   Pathology.—The true vaccination shows all the characteristics of
 a single typical small-pox pustule.  At the  end  of forty-eight  hours
the surface of insertion is marked by slight redness and swelling to
 the size of a large papule, upon the  summit of which develops, by 
240
VARICELLA.
the third or fourth day, a small" vesicle filled  with a  clear fluid.
This vesicle is  a reticulated sac. the puncture of which, as for the
collection of lymph, discharges by slow oozing its fluid contents.   It
reaches its maximum size by the seventh or eighth day, at which
time it is umbilicated and surrounded by a ring of inflamed tissue—
the areola—which continues to enlarge for two days, to attain in full
development a  diameter of one to three inches.   The contents of the
vesicle now begin  to grow somewhat opaque (pus), to present the
appearance  on  its inflamed base quaintly described by Jenner as
"the pearl on the rose."   The areola is the evidence of a successful
vaccination.  By the tenth day the serum is changed into pus ; the
vesicle has become opaque and yellow ; its centre shows  inspissation
in the form  of a crust, which, by the fourteenth day, extends to
convert the whole pustule  into a hard, dry mass.  The crust falls
spontaneously by the twentieth to twenty-fifth  day, to  leave, as a
result of  tissue destruction, a characteristic scar.  The cicatrix of
vaccinia is a more or less circular depression markfed by  minute  pits
and radiating  lines.  It should measure in its diameter fully one-
third of an inch.   Red or pink at  first, its color  gradually fades to
the bleached appearance of cicatricial tissue, to remain as a mark for
life, or to gradually disappear, in the course of adolescence, to the
faintest trace.   However pronounced, a  cicatrix, it is  needless to
state, is evidence only of destruction of tissue, not of permanent
protection against small-pox.  The writer recalls a malignant case of
purpura variolosa in a young  woman whose arms were marked by
typical cicatrices, relics of successful vaccination in early childhood.
Slight fever, fretfulness,  headache,  insomnia, restlessness, disturb-
ances of digestion, lymphangitis (as marked by swelling of the axillary
glands), may be present for a few days about the time of maturation
of the vesicle, to subside  rapidly during  the period  of incrustation.
More extensive inflammation, dermatitis, or ulceration indicate mixed
infection.  The constitutional  signs are mildest in infancy, and in-
crease in severity with advancing years.
   Delay in the appearance of the vesicle, even to the end of a week,
does  not preclude success,  provided  the subsequent  phenomena
appear in course.   Accelerated, abortive, so-called " spurious " vac-
cinations differ in various ways, and furnish only partial, limited, or
no protection.
                           VARICELLA.

   Varicella, or varicellae, diminutive of varus, pimple, pock;  chicken
(French,  chiche;  Latin,  cicer, insignificant)  pocks or  pox; water
pock, wind pox; variola notha, spuria, false pox.—A trivial, acute in-
fection of childhood, distinguished by a  long  period of incubation, 
VARICELLA.                        241
absence of prodromata, slight fever, a vesicular eruption varied in
size  and short  in  duration,  as a  rule  without  complications  or
sequelae.
   History.—Chicken-pox met its first description under the term
crystalli by the Italian anatomists, Ignassias (1575), Guido Guidi
(Latin, Vidus Vidius, as in the Vidian canal) (1585), and received its
present unfortunate name from Vogel (1764).
   Fuller  (1730) and Heberden (1767) made the  first attempts to
separate it from variola (varioloid), with which it had been hitherto
confounded, and has been since by many authors (Hebra, Thompson)
"with inconceivable persistence" (Thomas)—a  mistake which re-
sulted in complete confusion regarding the nature of both affections,
and in reproach and disrepute of vaccination in its early history.
   The recognition of the fact that  an attack of  one secures future
immunity from itself, but does not protect against the other, finally
led to a distinct separation of the two diseases.  Confirmation of this
view was also obtained  in  the fact, as  stated,  that vaccinia does
not  prevent varicella, nor varicella vaccinia.  Czakert, after three
failures in the ordinary way, succeeded  in vaccinating  a boy, aet.
four, by introducing lymph  into the interior of vesicles during an
attack of varicella.
   Etiology.—Varicella  appears in sporadic  and endemic, rarely
epidemic, form, but  epidemics never assume the range nor show the
intervals of measles and small-pox.  The  disease does not die  out
entirely in large cities, but assumes somewhat of epidemic proportion
once or twice a year on the opening of schools and kindergarten.  It is
confined exclusively to childhood (exceptions by Heberden, Gregory,
and Seitz) up to the age of twelve, and is rare after ten.   The short-
lived contagious principle, probably  from the vesicles, is believed to
be inhaled (contagium halituosum).   Infants are never born with
chicken-pox.
   Bacteriology.—Inoculation experiments fail oftener than they
succeed.   Thus Hesse failed in eighty-seven, succeeded in  causing
a local eruption in seventeen and  a general eruption in nine cases.
Steiner claims to have succeeded eight times in ten trials, but was
unable to propagate the  disease from any case.   Tenholdt found in
the contents of vesicles  a micrococcus which, inoculated in man,
produced light redness and swelling like  that of spurious vaccinia,
and  in one  case a vesicle smaller  than  a sudamen, the  affection
remaining local.  Pfeiffer found in fresh  vesicles of  thirty cases,
without exception, a parasite  (proteid) showing an amoeboid stage, a
cystic stage, spore formation, and, after the development of numer-
ous spores, a return to the amoeboid stage.  Inoculation  with con-
tents of vesicles showed, three times in five days,  a localized, circum-
        16 
242
VARICELLA.
 scribed varicellar exanthem, recurring scattered up to the eighth day.
 The parasite could not be cultivated upon any culture soil.
    Incubation varies from eight to seventeen days.
    Symptoms.—Prodromata, in some form of light malaise, occur
 only  very exceptionally.   In these rare cases they  may assume
 prominence,  and thus there may be headache, vomiting, high fever.
 Henoch once saw a case begin with convulsions.
    The disease is announced, as a rule, by the eruption, which shows
 itself in the form of spots of  hyperaemia, in the centre of which
 appear, in the course of a few  hours, distinct but slightly elevated
 vesicles, which attain their greatest circumference in the course of
 three to  twenty-four hours.   The vesicles  contain  a  clear, sticky
 serum of neutral  or  alkaline, never acid (as in sudamina) reaction,
 which fully  distends the vesicle, and which exudes slowly, but not
 wholly, on puncture of the  sac.  The serum shows under the micro-
 scope a few  pus cells, which, when exceptionally present  in greater
 quantity, may make the vesicles appear like drops of wax.  In lighter
 cases, without halo, the patient  looks as if sprinkled with  " drops of
 Water" (Fagge).
    The eruption shows itself first upon the neck and  cliest (face,
 according to Thomas), to spread  subsequently  over the face and
 scalp, trunk  and extremities, and shows itself always in successive
 crops, to the  number  of ten to fifty, or  as many as two hundred to
 eight hundred, over the  whole body, irregularly, never uniformly or
 at once.
    Vesicles vary also in size, usually from a  pinhead  to  a pea, ex-
 ceptionally from a dime even to a dollar.  These large vesicles are,
 however, always lax, never  full, as is the case in the blebs of burns,
 blisters, and  pemphigus.  Distinct, isolate, and irregular elsewhere,
 they may show aggregation, like  zoster, upon the extremities, but
 are very  rarely confluent anywhere.  They are very  superficial,
 lifting only the  upper layers  of the epidermis, and penetrate to the
 rete Malpighi in only exceptional cases.   Hence they but rarely show
 an umbilicus, and seldom leave a  scar.  Yet  one or two  scars are
 sometimes to be seen on the forehead,  eyelid, or other part of the
 face, and a few such scars may produce as much  deformity as a case
 of varioloid.  In fact, the isolated  chalk-white scars of the face in
 children are nearly always relics of varicella.
   The eruption may also show itself on various mucosa', as in the
 eyes, to produce conjunctivitis, keratitis;  in the mouth and palate,
to cause stomatitis; in the pharynx, to lead to more orless dysphagia,
and induce, at times, swelling of the cervical glands; on the vulva and
prepuce, where it may show itself  as a string of vesicles on the inner
aspect of the  labia majora, or at the fraenum, to give rise to pain in 
VARICELLA.
243
micturition.  Vesicles which appear in the mouth, especially on the
tongue,  are readily  broken, to  show  irregular, ragged  abrasions,
sometimes with aphtha-like surfaces.
   A slight rise of temperature, maximum 102° (exceptionally 106°,
Heberden), with associate symptoms of fever, headache, insomnia,
anorexia, nausea, etc., attends or may attend the eruption, to con-
tinue with it two  or three  or, exceptionally, as long  as  five days.
Defervescence is  by crisis,  without subsequent elevation or inter-
ruption.  Very light cases may  show no fever at all.   Relapse and
recurrence are possible but not probable.
   Hutchinson described a  grave form of varicella which occurred
most commonly in weakly,  ill-nourished children.  The vesicles, in-
stead of drying up in the ordinary way, grow blacker and larger, to
present the appearance of round, black spots, of the diameter  of an
inch or more, scattered  over the body.  These crusts cover under-
lying ulcers, which sometimes extend through the skin and subjacent
muscular tissue.  These cases are said to be very fatal.   They may
be attended with  eye complications,  irido-choroiditis and loss  of
sight.  This variety must be exceedingly rare, as it is not mentioned
by other authors, except Eustace  Smith, who  connects it with  the
curious tendency to gangrene seen in certain children.   It is probably
the result of a mixed infection, and has no more to do with genuine
varicella than a coincident erysipelas or other  dermatitis.  Haemor-
rhagic varicella has  been observed (Andrew) as a special complica-
tion in  cachectic  cases.  Varicella may occur in connection with
other  infections, with measles,  scarlet fever,  diphtheria, pertussis,
and even with variola (Sharkey).
   Diagnosis.—Inasmuch as varicella was so long, and is often yet,
mistaken for variola (varioloid),  the question of differential diagnosis
assumes supreme importance. The diagnosis demands: 1. A knowl-
edge of the existence of either disease in the vicinity or community,
and a definite history of the pre-existence or absence of either in the
individual, together  with the period of the last successful vaccina-
tion.  2. The age of the patient, as variola occurs at all ages, and
varicella is almost confined to childhood.   3. Variola  is preceded by
prodromata—malaise, fever, headache, backache, sometimes by ini-
tial rashes—and is attended  by a characteristic eruption on the third
day; varicella announces itself with its eruption, without prodromata.
The most anxious mothers seldom notice illness of any kind until the
eruption appears.  The  physician  is called to decipher the eruption.
4. Varicella appears, as a rule, first upon the back, neck, and chest,
or, if upon the face, irregularly over it, and irregularly over the body.
A'ariola appears, as a rule,  first upon the face, forehead, to extend
over it regularly from above downward, thence to spread uniformly 
244
DIPHTHERIA.
over the neck, chest, etc.   5. The superficial vesicles of variola con-
tain only serum;  the deeper-seated  vesicles of variola, serum and,
later, pus.   6. The eruption of variola is much  move  uniform  in
size; that of varicella varies greatly.   7. Varicella is rarely conflu-
ent anywhere, and its vesicles are only exceptionally umbilicated.
By the  end of the third  day spots  of hyperaemia, fully developed
vesicles, and crusts may be perceived simultaneously and side by side
in varicella, whereas the variations in the age of the eruption would
be observed only at points distant from each other in variola.  S.
The eruption of varicella may be abundant anyivliere over the body,
the face, trunk, or extremities;  the eruption of variola is most abun-
dant upon the face and fingers.  A thick eruption upon the fingers
has often established  the presence of variola.  9. Fever precedes by
several  days  the  eruption of variola, to fall with its appearance ;
whereas fever occurs  only with the eruption of varicella, to increase;
with its development.  Variola  shows in  further course marked sec-
ondary  fever,  absent in varicella.
   There are exceptions to all these rules, but they form in their en-
semble almost unimpeachable evidence.  The cases about which may
still hover any doubt  or uncertainty  should  be considered as variola
to secure proper protection of others by vaccination.
   Prophylaxis and  Treatment.—The mortality  of varicella is prac-
tically nil.  Trousseau says no physician has ever seen a patient die
of  chicken-pox alone; yet, inasmuch as complications, fatal haemor-
rhages,  catarrhal pneumonia (Meigs and Pepper), nephritis  (Hutch-
inson and Henoch), have been  recorded as coincidences or complica-
tions, delicate children may  be  protected by removal from  the area
of  infection, or isolation of patients in  separate rooms.   Patients
should remain indoors, if  not in bed, during the existence of the erup-
tion, and should not be permitted to return to school until all signs of
it have  disappeared.   Vesicles, more especially extensive vesicles or
pustules on exposed surfaces, should be treated with consideration to
prevent or limit subsequent lesions.   It is advisable to touch the sur-
face of  such vesicles with equal parts of carbolic  acid  and glycerin,
to secure, if possible, speedy coagulation of  their  contents and de-
struction of pus-producing micro-organisms.  Where the eruption  is
unusually abundant,  as on the face, the whole surface may be bathed
in  sublimate  solutions 1 :1000-5000,  or washed with one-per-cent
solutions of creolin.
   Other treatment is superfluous,  or does not differ, if called for by
complications, from that discussed with varioloid.

                          DIPHTHERIA.
   Diphtheria (Sicpdepa,  leather,  membrane), term diphtheritis first 
DIPHTHERIA.
245
applied by Bretonneau (1821);  angina maligna; German,  Brdune,
from prima, glowing coal ;  Spanish, garrotillo.—A grave, acute
infection of the exposed mucosae, especially the fauces, pharynx, la-
rynx, nose, exceptionally the vulva, vagina, uterus,  palpebrae,  pre-
puce, anus, occasionally of any wound of the skin; characterized by
the formation upon  and in the tissues of the affected surface of a
grayish-white  membrane, tumefaction and  pain in the throat, dys-
phagia, enlargement of the lymphatic glands, general prostration,
comparatively short though  indefinite duration; complicated often
with septic infection; and followed at times by a paralysis peculiar to
this disease.  Diphtheria of the throat, which is alone discussed here,
has a mortality equal to that of scarlet fever, measles, and typhoid
fever combined.
   History.—The history of diphtheria is  involved  in inextricable
confusion, from the fact that all kinds of sore throat, simple and  ma-
lignant, catarrhal and croupous, gangrenous, individual and epidem-
ic,  were differently styled by different authors up  to  the time of
Bretonneau, who succeeded in disentangling diphtheria  proper  as a
disease distinguished by the formation of a false membrane in the
throat.  That the ancient writers were familiar with  the affection is
recognized  in  a passage  from  Aretaeus,  who speaks of ulcers  cov-
ered with a quod am concreto humor e albo.
   Disregarding now the frequent allusions made to the anginas by
the early writers, because always confounded with secondary or other
affections, we read the first clear and certain  account of the disease as
it prevailed under the name garrotillo, in Seville, in 1583, to extend
throughout Spain in 1583-1618, the year 1613 being characterized,
from the frightful mortality,  as the " anno de los garrotillos."  The
disease appears next unmistakably in Italy in 1610, while Portugal
was visited but  slightly in 1626.  The first  definite account of  it in
Holland and France occurs in 1745, in England  in 1748,  in Switzer-
land and Germany  in 1752; and in  our own country,  in  New York
in 1771, in our northern colonies in 1755, in Virginia in 1799.  Diph-
theria now nearly disappears from medical history from 1810  to 1840,
with the exception of France, where it again showed itself  in Lyons
in is 10 and in Tours in 1818 to 1821, to fall  under the  observation
of the eccentric but  always original Bretonneau, who dissociated it,
as stated, from other affections of the throat and distinguished  it as
a special disease.  Bretonneau stoutly maintained that it was always
a local process at first, with subsequent general infection.  Later, in
1825, he recommended  alum  in its treatment, made tracheotomy in
grave cases of invasion of the larynx, and invented the double canula
for this purpose. Trousseau, the pupil of Bretonneau, declared:  "In
diphtheria it is as in malignant pustule, in which malady, by  making 
246
DIPHTHERIA.
a direct attack upon the local affection,  we  stop the progress of the
general disease. ... So also it is in diphtheria: by  energetically
treating the local affection as soon as it shows itself, we arrest  its
progress and prevent the occurrence of ulterior symptoms."
   The new era of general  dissemination or  pandemic occurrence
dates, according to Hirsch, from 1X57-58, when the disease appeared
in, or was  carried  to,  remote  parts  of  the  earth, as India, China,
Australia, Polynesia, Africa.  It showed itself almost simultaneously
in California and New York  in 1856, next in  the Eastern States, then
in the Middle,  Southern, and  Western States, reaching Oregon in
1867.  Our  first accounts of it date from  Mexico  in  18(14;  New-
foundland  in 1867; South Russia in 1872  to 1879, when it raged
in villages to such extent that Kupffer says " the children disap-
peared."
   Etiology.—Neither  season, soil, nor  social caste  is directly con-
                            cerned in the production or tin; spread
                            of  true  diphtheria.   The  disease pre-
                            vails in the  most  salubrious  villages
                            at  times, sparing  the marsh, passes the
                            crowded tenements of the city  to visit
                            the palaces of  the suburb,  and shows
                            itself at  every season of the year.
                               False membrane  may be formed in
                            the throat by various micro-organisms,
                            especially by the Streptococcus pyoge-
                            nes, but the true diphtheria is produced
                            by a special bacillus  discovered by Lof-
                            tier  in  1883.  Klebs  had previously
seen the same structure among others in the false membrane of this
disease, and had  recognized it  as one  among other causes of the
disease, so that the micro-organism is now known as the Klebs-Lofner
bacillus.  To Loftier is  due  the credit of having first isolated it and
experimented with it upon lower animals.
   Bacteriology.—The Bacillus diphtheriae  is about  as long but
is twice as thick as that of  tuberculosis.   It  is  always rounded
at both ends, and  is frequently knobbed, to present the appearance
of dumbbells, by which name it is commonly  known.  It is im-
mobile, shows no spores, has its optimum temperature at body heat,
and  stains  perfectly with alkaline  methylene blue.  It  thrives in
most of the culture soils, best  in blood serum, lives desiccated over
one  hundred days, and produces, when injected into the bodies of
certain animals, definite symptoms  and speedy death.   Thus  it de-
velops in guinea-pigs,  rabbits,  chickens, and  pigeons, at the seat of
inoculation,  a  pseudo-membrane, in which  it  rapidly  multiplies.
 Fig. 139 —Bacillus diphtheriae from
blood serum (Sternberg). 
DIPHTHERIA.
247
 Frosch  declares that  he found  it in the blood, brain, lungs, liver,
 spleen, kidneys, cervical and bronchial glands in man, and Abbott
 claims to have demonstrated it in the  omentum after inoculation of
 the testicle  of  lower  animals.   Most  of  these  animals  succumb
 within a few days after its introduction into the tissues.  Injected
 into the trachea of these animals, or engrafted upon a scratched con-
 junctiva or  vagina,  it develops the  pseudo-membrane found in
 human croup.  Paralysis follows in certain cases.
    Culture soils, filtered free of bacilli, produce, when injected, the
 same  effect  as  soil  containing  bacilli (Kitasato).   Diphtheria is
 therefore a local infection, by a bacillus whose toxalbumin  produces
 the general  effects (Welch and Abbott).  This toxalbumin is very
 sensitive to heat.  It perishes in a few minutes at 65 C.°  All ob-
 servers  encountered  also  other  bacteria,  especially  strepto- and
 staphylococci, which penetrate the depths of the tissues and induce
 general  infection.  Thus develop varieties—mild, or secondary, or
 malignant, or gangrenous  diphtherias.  Cultures  distinguish  the
 various  bacteria and  establish the diagnosis in
 a doubtful case (Baginsky).                         •.••.../•"    .It..
    Animals may be rendered immune to diph-   - ••-.  -  '/••.."'.'...
 theria by previous treatment with the  peroxide   •'"N '"•:'  •' '••«;•
 of hydrogen ; by inoculation with cultures sub-    '•  '.";  '■."/"' .;,  '*■>
 jected to heat,  with the trichloride of iodine,    "••.£'   -.""' ..•'"'
 with certain products of the bacillus itself,  or   FlG 140.-streptococcus
 with the fluid of pleural effusions which always and staphylococcus from
, form in inoculated guinea-pigs.
    Symptoms.—After  a period of incubation of  three to five days
 an  average typical case of  diphtheria  begins with a chill, or  chilly
 sensations, attended with  malaise,  rise of temperature, more or
 less nervous unrest, and, in the course  of the same day, distress in
 the throat.   In  lighter cases throat  symptoms  may  alone  direct
 attention to the character of the disease, while in more pronounced
 cases the general distress assumes such prominence that the practi-
 tioner is led to look into the throat only because he may find for it
 no  adequate explanation elsewhere.   Thus  it may happen that the
 disease is not recognized until the third or fourth  day, by  which
 period valuable time for therapy is lost.
    It is  characteristic of diphtheria to show objective signs in the
 throat very early in the history of the disease.  Along with the com-
 plaints of  dryness, burning and constriction, evident  dysphagia
 and tenderness,  there  may be  merely a more or less pronounced
 hyperaemia about the tonsils, veil of the palate, or pharyngeal  wall,
to constitute the so-called catarrhal stage, in which the false  mem-
brane may be entirely absent.  Such cases are readily mistaken for a 
24X
DIPHTHERIA.
 simple  catarrh, tonsillitis, or quinsy until complications or sequela1
 betray the true character of the disease.
    For the  most part, however, there is little room for mistake.
 The false membrane  shows itself early as  flakes, spots, or streaks,
 not easily distinguished from pure mucus, upon the mucous surface ;
 white, filmy, or fleecy, easily detachable at first with the finger or
 handle of the spoon, to become in the course of a few days thicker,
 tougher, and darker in color, and to involve  the mucous coat to such
 extent as to leave  a raw, bleeding  surface after forcible removal.
 The false membrane may remain localized, or may spread gradually
 or rapidly over the whole interior of  the throat, to extend  thence to
 the nose, Eustachian  tube,  larynx and bronchi, oesophagus, or,
 being detached by cough or processes of sloughing, may renew itself
 in former sites to indefinitely prolong the disease.
    Still later in the course of the disease, as a result of mixed infec-
 tion, the membrane may  grow darker, grayish-black or  absolutely
 black, become more friable and be  detached in places to hang in
 festoons, or be insufflated  with acts  of  respiration  to excite violent
 cough or interfere directly with respiration.  The peculiar  and fetid
 odor of decomposition is now usually present;  the face is pallid, the
 pulse feeble  or easily  excited, and blood poisoning  is marked by
 apathy and profound adynamia.
    AVith the extension of  the disease deep into the tissues  of the
 mucous membrane  there is invasion of the submucous connective
 tissues,  lymph  ducts and glands, and interglandular connective tis-
 sue, so  that  individual glands, tender  to pressure, may  stand out
 prominently  above  the  general surface  of the  neck, or the natural
 outlines of the neck be  obliterated in  a universal tumefaction.
    As in all the grave  infections,  parenchymatous changes may
 occur in the  heart, liver, spleen, and kidneys, so that heart failures
 in the course of the disease, peri- and endocarditis with subsequent
 valve lesions, albuminuria, with subsequent Blight's disease, may
 attend the course, complicate the progress, or  protract the convales-
 cence, if they do not directly take life.
    The paralysis which occurs during, or  much  more frequently
 after, diphtheria is, as stated, in its course and character peculiar to
 this disease.  It shows itself in  about one-fourth of all cases which
 do  not  succumb to the attack.  Rare in infancy, liability to it in-
 creases with  years.   It  occurs alike in the strong and  feeble, in mild
 as well as in  severe cases, in diphtheria of other  mucosae, or of
 wounds as well as of the throat.  It  has been observed in the throat
 as early as the  second,  more frequently at the fifth to the tenth day
 of the disease, but as a rule not until the second or third week after
the disease has run its course.  It is  regarded, hence, as a post-diph- 
DIPHTHERIA.
249
 theritic  process, due in all  probability  to the delayed action of
 toxines upon peripheral nervous organs.   Its mode of invasion  and
 progress constitute peculiarities distinctive of diphtheritic paralysis.
 In the first place, it is ushered in at once without prodromata, usually
 in the midst of  health,  or that degree of it which is left in convales-
 cence from the attack proper.   With very few exceptions it shows
 itself first in the palate, in  difficulty of deglutition, and often of
 phonation.   Fluids regurgitate through the  nose, and  the voice is
 altered.   On inspection it is seen that the palate drops or is not lifted
 in pronouncing  "ah," or the  uvula  is deflected.  Gargling is impos-
 sible.  The paralysis may extend to involve also the epiglottis, which
 ceases then to protect the larynx during deglutition, or more rarely
 to the  pharynx to increase  the dysphagia.  There is often  also
 paralysis of  sensation,  so that the veil of the palate may be manipu-
 lated without reflex  action, or the  pharynx may form  a pouch in
 which food accumulates.
    The paralysis next affects  the intrinsic  muscles of the eye.   Far
 sight remains, but accommodation for near objects, as in reading, is
 decidedly interfered with.   Yet the  light reflex persists unaffected.
 Here the paralysis  may cease, or in  about one-half of cases  the ex-
 tremities, the  lower first, are  affected  with tingling, numbness,
 formication.  More frequently motion alone is impaired, the legs are
 weak, there  is   early fatigue with  a sense of heaviness or weight,
 the patient staggers occasionally or  constantly, the gait limps.  As
 in the throat and eye,  the  affection  is usually bilateral, though one
 side may suffer sooner or more.   Electric action, unimpaired at first,
 becomes feeble  or  absent  to  faradization.   Knee jerk is always di-
 minished, then  lost,  from  and even before  any sign  of paralysis
 proper—a  phenomenon of  very  great diagnostic  significance,  and
 " part of a wider fact that the knee jerk is often lost after diphtheria
 (two-thirds  of  cases) in which no   paralysis occurs" (Bernhardt).
 Paralysis of  the  intercostal muscles, diaphragm, and heart is fortu-
 nately very much more rare.  Dyspnoea, vertigo, heart failures, with
 retarded, irregular, and intermittent pulse and fatal syncope, result
 from attack of  these  muscles.  Impotence from  affection  of  the
 sexual centres is not quite so  rare in adult males.  The  bladder  and
 rectum are very rarely involved.   It is in this order that diphtheritic
 paralysis shows  itself as a rule, though the natural sequence is often
 disturbed and "irregular waves of palsy seem to  flow  through  the
 body" (Gowers).
   Still another  peculiarity  of diphtheritic paralysis is its incomplete-
ness.  The paralysis is rarely absolute.  It is,  as a rule, more  a
weakness than a total loss of power.   It is regarded as a  polyneuritis
and not as a central lesion. 
250
DIPHTHERIA.
   Diagnosis.—The points upon which the diagnosis of diphtheria
rests are: 1.  The prevalence  of  the  disease.  2.  The absence  of  a
previous attack ; for the belief gains ground, contrary to previous
opinion, that one attack secures future, at least temporary, immunity.
Thoresen claims that in six hundred patients he never knew a, second
attack.   He  had the hardihood to quarter diphtheria patients in
houses where children had suffered previously,  and never saw  a
second attack.   Contrary opinion is due to  confusion with follicular
angina.  3.  Affection of  both tonsils, with  extension to the palate,
etc.  4. Albuminuria.  5. Discharge of a thin, serous fluid from, or
presence of false membrane in, the nose.  6.  Contagiousness.   7. The
bacillus,  which is easiest  cultivated to colonies (twenty-four hours)
upon cooked white of egg.   Tumefaction,  lymphadenitis, and fever
are not essential; typical  cases may show none of these signs.
   Diphtheria is distinguished from simple  tonsillitis by its attack
of others (en- or epidemic), false membrane,  lymphadenitis, and gene-
ral tumefaction, not present in tonsillitis; by the more profound pros-
tration, adynamia, loss of knee jerk,  and  subsequent paralysis in
diphtheria; from quinsy,  which is epidemic tonsillitis,  by the more
pronounced inflammation and acute distress,  greater swelling  and
dysphagia, with at times oedema of the uvula, palate, and glottis, ab-
sence of false membrane, presence of knee jerk,  and, notwithstanding
the severity of the symptoms,  more favorable course of quinsy.
   That a scarlatinal differs  from true diphtheria is now determined
by the researches of bacteriology.   Clinically the affections differ as
follows:  The false membrane  appears at once in  diphtheria, later in
the course, three to five days, of scarlatina; it shows itself in nearly all
cases of diphtheria, but only in severe cases of  scarlatina—viz., such
as are  marked by high fever,  delirium, etc., at the start;  it shows a
preference, after the  pharynx, for the larynx in  diphtheria, and for
the upper respiratory passages in  scarlatina.   In  connection with  it
suppuration of the  cervical glands and affections of the ear are fre-
quent in scarlatina, rare  in diphtheria.  The interglandular connec-
tive tissue is indurated in scarlatina and only oedematous in diphthe-
ria.  Paralysis,  which is frequent in or after diphtheria, is almost
unknown in scarlatina.  On  the other hand,  nephritis,  a frequent
sequel  of scarlatina, is very rare after diphtheria.   Lastly, treatment
has much less effect upon the membrane of scarlatina.  Hence it is
proposed by clinicians (Henock,  Filatow) to abandon the use of the
term diphtheritic in scarlet fever, and to designate such cases as ma-
lignant scarlatinal anginas.
   The prognosis of diphtheria is always grave on account of liabil-
ity to heart failure, to sepsis (from mixed infection), and to extension
to the larynx (croup). All these dangers are lessened or prevented by
jugulation of the disease by  energetic local treatment at the  start. 
DIPHTHERIA.
251
 Statistics, which date from the time when the disease was believed to
 be constitutional with a local expression, are valueless in determina-
 tion of its gravity.  Practitioners, thoroughly convinced of  the local
 origin of diphtheria, do not fear it as they do scarlatina.  It must be
 stated, however, that the amount or extent of  the false membrane is
 no gauge of the gravity of the disease.   Cases with throats covered
 as if with a layer of thick white paint often run a mild, short course,
 while  the gravest  symptoms—adynamia, heart failure, syncope—
 may occur in cases in which the membrane is so scant as to embarrass
 diagnosis.  The character of the cause,  whether the Loftier bacillus
 or the streptococcus, may make  the difference.  The gravity of the
 disease is rather a question of absorption than deposit, and  the dan-
 ger is determined by the penetrability of the barrier which the tissues
 interpose.  This is a condition which  may not be discovered by sim-
 ple inspection.  It reveals itself only in its effects.   Profound adyna-
 mia, a feeble pulse, m ixed infection, extension into the nose where it
 cannot be reached, suppuration,  gangrene, make the prognosis very
 grave. The paralyses of diphtheria generally  subside spontaneously
 in from three weeks to three  months, and may  be much abridged
 with appropriate treatment.
   Prophylaxis consists in isolation of the patient, thorough ventila-
 tion of the sick-room, and utmost cleanliness.   The weaker antimy-
 cotic  gargles mentioned in treatment may be used by others in  the
 house.  A child should not return to school for forty days.
   Treatment.—From what has been  stated it is  obvious that the
 true treatment of diphtheria must secure or attempt  the eradication
 of the membrane  which  contains the germs of the disease.  This
 treatment must be introduced at once, or  so soon as the diagnosis is
 made. A dubious diagnosis justifies it,  inasmuch as under no  cir-
 cumstances can it do harm.   AAmat particular agent is employed is
 probably a matter of indifference,  so  that it be  powerful enough to
 accomplish the object.   Bretonneau used fuming hydrochloric acid.
 Carbolic acid,corrosive sublimate,creosote, andcreolin each have their
 advocates.  The author prefers above every other  agent the subsul-
 phate of iron, as it not only destroys all micro-organisms which it may
 reach, but by its powerful  astringent action interposes a barrier be-
 tween them or their products and the blood, and thus prevents the
 absorption which produces the so-called constitutional signs.   The
 subsulphate is preferable to the tersulphate, on account of its greater
astringency; and to the perchloride, which is much  more astringent
because it is much less irritant.
   The remedy is applied best by means of a cotton-wrapped sound,
the end of which is immersed in the undiluted solution and pressed
on withdrawal against the neck of the bottle, that the  fluid  may not 
252
DIPHTHERIA.
drop into the larynx, and the false membrane is touched or the sur-
face painted, under a good light, with the deftness and dexterity of
an  artist in  touching a canvas.  One application a day will suffice
in an average,  two in an  aggravated  case.  It is generally well
borne, exciting but little cough  and expectoration,  both  of which
are, however,  favorable for the dislodgment of  the  membrane.
Retching and vomiting sometimes follow—processes which also facil-
itate the discharge of the membrane and stimulate the patient out
of the apathy and adynamia characteristic of grave cases.
    Inhalations of steam  from a steam atomizer,  as hot as can be
borne, are also of great value, if practised repeatedly throughout the
day and night.   They accomplish more  in  the dissolution of mem-
brane and disinfection  of  the  throat  than any chemical solvents,
lime water, lactic acid, pepsin, papayotin, etc., and the various dis-
infecting gargles, etc.,  all of which are useless  unless inhaled or
applied more or  less  continuously, which is  almost impracticable.
The insufflation  of yellow oxide ointment gr. v.- 3 ss.  vaseline into
the nose, two or  three  times a day, keeps the nasal passages moist
and free, and adds much to the comfort of the patient.  Sprays of
fresh, pure peroxide of hydrogen are more efficacious in this regard
than  any other agents.  Loftier recommended  very deep gargling
with  sublimate  solution 1 :1,000, or  carbolic acid  three  per cent
dissolved in alcohol thirty per cent, or carbol five per  cent, or bro-
mine two per  cent, or chlorine one per  cent solutions.   In the first
stage of the disease, when the membrane is very thin, or  in prophy-
laxis, Loftier prefers weaker solutions, as of sublimate 1 :10,000 or
15,000,  or, for its more agreeable taste, the  cyanide  1 : 8,000-10,000,
with  introduction into the  nose of toluol, which  will  diffuse  itself
throughout the nasal tract.
    The general symptoms are  best met with alcohol, which, in its
direct effects upon the heart as a cardiac stimulant, best obviates the
danger of heart failure.  Digitalis, preferably in infusion, 3 i.- § ss.
every two to four hours,  may become  a  necessity in protracted
cases.  Nitroglycerin  acts  quickly  and  does not  at all irritate the
stomach.  A cup of strong, black coffee, with a tea- to  a tablespoon-
ful of cognac, is a quick though more  temporary restorative.  Sub-
cutaneous injections  of alcohol, ether,  camphor,  musk,  may be
necessary to bridge a case over an impending or actual  collapse.  In
most cases a bold local  treatment, by putting a stop to  further in-
fection, will often rescue a case from the  profoundest prostration,
and put a new  and more favorable phase upon the  disease in the
course  of a few hours.
    Paralysis is best treated by faradization and nitrate of strychnia
gr. y^ subcutaneously. 
CROUP.
253
                            CROUP.

   Croup (old Scotch, croops ; Danish, hrop ; old Dutch, hrof and
geroef; German, Geruf, cry, crow).—The crowing, stridulous sound
of inspiration through an occluded glottis, as by spasm, false croup,
laryngismus stridulus, or  by false membrane, true croup, membra-
nous croup.
   True croup, in the majority of cases, is diphtheria of  the larynx.
What features of difference it may show depend upon its localization
and the rapidity with which it ends life by suffocation.   Croup is,
therefore, a disease which adds to the dangers of diphtheria a me-
chanical obstacle to  respiration.  Croup may also exceptionally de-
velop in connection with, or as a sequel to, other infections—measles,
scarlatina, pertussis,  rotheln, variola, typhoid fever, etc.—or in still
more exceptional cases from mere  catarrhal inflammation, or most
exceptionally from chemical or mechanical irritation.
   History.—Dyspnoea and dysphagia from throat disease were all
included under the term cynanche (angina) by the old Greek writers,
and laryngotomy (first by Asclepiades, 100 A. C.) was not infrequently
resorted to in relief of suffocation.  Galen  certainly refers to a case
of croup in  an adolescent " qui tussicando tunicam  crassam visco-
samque exspuerat."  Baillou, Paris (1576),  describes cases secondary
to measles  and pertussis, and Van Hilden (1641), Ettmuller (1685),
Patrick Blair (1718),  who is credited with  the  first adoption of the
popular word "croops" into medicine, mention cases under the term
" catarrhus suffocativus," which included also all kinds of diseases of
the pharynx and larynx.   It is, however, to Francis Home, of Edin-
burgh (1765), that we are by universal consent indebted for the first
distinct identification and isolation of true croup.   Home  published
his conclusions, based upon  a wide  and keen observation, in a short
tract of sixty pages  entitled "An  Inquiry into the Nature, Cause,
and Cure of the Croup."  Home looked upon the disease as primary
in the larynx, and ascribed its symptoms to the presence of a mem-
brane which he  found in the trachea in all his post-mortem obser-
vations.  Cheyne (1801), in an essay on " Cynanche Trachealis,  or
Croup," confirmed these views, which now prevailed undisturbed up
to the time of Bretonneau (1821), who first advocated the identity of
croup with diphtheria.
   Etiology.—Croup occurs occasionally  also as a complication,
sometimes a fatal complication, of measles.  It is more rarely seen in
the course of, or as  a sequel to, scarlatina; still  more  rarely after
typhoid fever.  Croup may occur entirely independent of any infec-
tious disease.  Bretonneau himself recognized the possibility of the
production of croup by the application of irritants,  as by cantharides. 
254
CROUP.
Oertel, Trendelenberg. Schwenninger were able to produce false mem-
brane in animals by various mechanical and chemical irritants.   It
has long been  known that false  membrane may be  formed in  the
larynx in consequence  of the inhalation of hot steam.  Heubncr pro-
duced  false membrane in the larynx by interruptions of the circula-
tion.  Most interesting are the observations of Kreissig, who saw
false membrane formed in the larynx of animals subjected to high
temperature.  Heat and dryness  are  at times sufficient causes  for
the formation  of false membrane.  Inhalation of  irritant  gases—
ammonia, chlorine,  bromine, fuming mineral acids—will also produce
false membrane in the throat.
   These constitute the cases of so-called primary croup.  It is  un-
deniable that such cases do occur.  They constitute, however,  the
small minority  of cases of croup.   In these cases the cause is demon-
strable, and  the  lesion of  tissue  or false  membrane which forms
distinguishes itself by remaining circumscribed.  These are the cases
in which the disease remains more strictly confined to the  larynx.
They differ, therefore, radically from  the  cases produced by infec-
tious matter, whose nature it is  to spread.  It remains, therefore,
true that  croup, in the vast majority of cases, is  diphtheria  of  the
larynx.
   The disease attacks by preference  children between the  ages of
two and seven.   Cases of attack  in infancy, as by Bouchut at  the
age of eight days,  Monti fourteen days, are very great  exceptions.
Liability begins to  diminish at five and becomes almost annulled at
seven.   Exceptionally  cases have  been reported even late  in life.
Diphtheritic croup does not  remain confined to the larynx, as a rule,
but extends in most cases to involve the trachea and bronchial tubes.
Steinert saw four cases of croup  ascend  from the trachea to  the
larynx; and of  fifty-five cases, five only were confined to  the larynx,
nineteen involved also the  trachea, and thirty-one  extended to  the
bronchial  tubes. In  the epidemic at Konigsberg, Bohn found in
twenty autopsies the trachea affected sixteen times,  the bronchi only
three times.  Bretonneau  in  thirty-two cases found the bronchial
tubes unaffected only once.  In one hundred and forty-four autopsies
after croup,  Peter  found in the bronchial tubes  catarrh forty-four
times, croup thirty-two times, in eleven no lesion at  all.
   Symptoms.—Croup sets in very insidiously, and may not be  dis-
tinguished at the start from  an ordinary  catarrh  localized in  the
larynx.   There may or may not be more or less malaise, fretfulness,
irritability, irritation about the throat, but in the course of a day or
two the inflammation  of the throat takes  on  that specific character
which distinguishes itself by the alteration of the voice,  the charac-
ter of the cough, and the difficulty of breathing.   The voice becomes 
CROUP.
255
husky, the cough more (guttural, the breathing more difficult.   As
a rule the child wakens in the night with the symptoms  of marked
croup.   Probably at the very start the voice is lost.   The child can-
not speak above a whisper.   It tosses about the bed, exhausted,  agi-
tated, moves its head about first on one side, then on the other, seek-
ing by  change of posture to obtain relief.   The breath is longer
drawn,  occasionally sighing; the auxiliary  muscles of respiration
are called into play.  The mouth is open; there is play of the nostrils,
evident straining to force a full breath.  Under all  these efforts, in
the course of time, the  breathing  becomes somewhat easier.   The
child, exhausted, sinks to sleep, to be awakened often in the course of
the night with a repetition of the same scene.   The patient is no, or
but little, better in  the  morning.  There are more  or  less distinct
remissions, but there is no real relief.   The attack repeats itself seve-
ral times  during the day, and by the following night becomes dis-
tinctly intensified.   The  child is now  wholly unable to sleep.   The
efforts at breathing become more strained and  more painful to see.
The face is flushed, the eyes glisten with a wild anxiety.  The child
clutches its throat, as if to tear an opening into the larynx, seizes the
bedclothes, frantically tears the paper from the  wall, shows mania,
and finally sinks back exhausted, sometimes actually to suffocate in
the attack, oftener  to secure a  comparative rest after the final  en-
trance of a small quantity of air.  Soon now ensues the stage of  car-
bonic-acid poisoning.   The face becomes pallid, cold,  and blue, the
surface is covered with  a clammy sweat, the hot maniacal  struggle
ceases, the spirit is broken, the child lies apathetic, seemingly indiffer-
ent.  Respiration is more shallow  and superficial.  The intercostal
spaces, the jugulum, epigastrium, supraclavicular regions, no longer
retract or sink in with each act of inspiration.   Sopor  sets in, which
deepens into stupor, coma, death.  But in a minority of cases, at the
height of the stage of struggle, quantities of false membrane may be
ejected, casts of the larynx or the trachea, or even of  the bronchial
tubes, with  such temporary relief at times as to give rise to the illu-
sory belief in  recovery.   The membrane  forms again, however, in
the course of a few hours.  An entire cast  may  reform in five or
seven hours, to renew the same picture of distress.
    As a rule not much is to be  seen in  the throat—hyperaemia,
swelling, occasional flakes or films or masses of false membrane about
the fauces or glottis, or in the larynx itself.   What is especially to be
remarked in the larynx  is the swelling and occlusion  of its orifice.
Pieniazek finds the cause of the dyspnoea  to be not so much the de-
posit of false membrane as the  fixation of the vocal cords or bands
by reason of the exudation of intense inflammation.  The arytenoid
cartilages lose their play of  motion, becoming, as  it were, solid,  an- 
256
CROUP.
chylotic.  Hence the dyspnoea; hence also the character of the cough
and the alteration of the voice.
   Duration.—Croup is sometimes divided into  stages of catarrh,
stenosis, and collapse.   The first stage lasts from  one to ten,  on  the
average three, days; the second one-half to  seven, on the average
three,  days ; the  third one-half to two, on the  average  one, day.
Thus the disease may run its whole course in two days, or protract
itself over  two  weeks, but most cases  scarcely occupy more than
one week.
   Diagnosis.—Croup is diagnosticated by the catarrh of the larynx;
by the  laryngismus and loss of voice; by the peculiar character of the
cough  (Trousseau likens it, happily,  to  the sound of the  bark of a
puppy  dog  at a distance); by the dyspnoea with its long-drawn, aud-
ible, stridulous inspiration; by the play  of  the  auxiliary muscles of
respiration; by the retractions of the intercostal spaces ; and  by the
false membrane.
   True must be separated from false croup, laryngismus  stridulus,
which  attacks for the most part infants  brought up in close, hot,  ill-
ventilated apartments, hence  children of the wealthy, coddled, pam-
pered,  over-protected  rich  oftener than the children of  the more
exposed poor.   False  croup may  rest  at  times also upon a light
catarrh. The child goes to bed, however, comparatively well, and is
awakened  suddenly in the night with the same terrible struggle for
air.  It shows the same distress as true croup,  even  more  intense at
the start, but subsides more quickly and completely, with, if  it is to
recur,  much more distinct intermissions, and yields readily to  simple
treatment.   It occurs  again and again in the history of  the child,
whereas true croup occurs but once.  There is, of course, no mem-
brane in false croup.
   (Edema of the glottis occurs, in the great majority of cases, in
adolescence or maturity, and in the course of laryngitis or some out-
side disease, as of the heart or kidney.   It is often associated with
oedema,visible oedema, of the palate and fauces.   The uvula itself is
often affected.   The condition may be seen at times  with  the naked
eye, and felt frequently with the finger.
   Retropharyngeal abscess occurs, in  a great majority of cases, in
children in early infancy.  It develops  more insidiously than croup,
and reveals itself sometimes to inspection, more frequently to palpa-
tion, as a soft, fluctuating tumor on  the posterior pharyngeal wall.
Abscesses, after infancy, occur  next most frequently in youth, in
consequence of caries of the spine, with the history of exposure to in-
fection by tuberculosis or with evident depots elsewhere.
   The prognosis of croup is intensely  grave.   The  child succumbs
for the most part to direct suffocation, carbonic-acid poisoning, as- 
CROUP.
257
phyxiation, or,  surviving this danger,  perishes  later  from blood
poisoning in consequence of absorption, as in other cases of diphthe-
ria.   Operations for the relief of stenosis have, however,  considerably
ameliorated the mortality statistics.   Cases left to themselves have a
mortality, as a rule, of sixty to seventy per cent.   Recoveries are the
exceptions.  Death is the rule.
   Treatment.—Internal medication has over the false membrane of
croup no control.  Emetics may  dislodge  loose fragments, or more
especially relax spasm to give temporary relief, but for the  most part
they add their own depression to that of the disease  and are not to
be recommended.   Where for any reason they may be administered,
selection should be made of the milder drugs, as of the subsulphate of
mercury gr. iij.-v.. or ipecac gr. xv., or apomorphia gr. y1^, which
has the double advantage that it does not depress and may be ad-
ministered subcutaneously.  These are  emetics and expectorants to
be selected, but in no case to be continuously administered.   Local
applications, gargles,  etc., are useless, because they may not reach
the disease, or under any circumstances remain longer than a few
seconds in contact with it.
   Benefit  is always  to  be derived  from  the inhalation of steam,
which may be conveyed to the bed under a tent improvised from the
bedclothing, from a kettle on the  fire, or, better, by means of a steam
atomizer, to which additional solvent properties may be  given by the
use of bicarbonate of soda, lime water,  lactic acid, etc.  Papayotin
may be applied in  solution with a  brush.  Nothing radical may,
however, be expected of any such treatment.  Nor may drugs fur-
nish any substantial relief until they may  be applied in concentrated
form  to the interior  of  the larynx itself  after  tracheotomy.   The
application of  carbolic acid, corrosive sublimate,  solution of the sub-
sulphate of iron, directed  to the interior of the larynx after laying it
open,  is a question of the near future.  At the present time the only
relief  to be  expected  in  a case of croup  comes from  surgery.   The
obstacle in the  throat is  to  be  overcome either by intubation or
tracheotomy.  Intubation  is a simple operation, which  proves effec-
tual in nearly forty per cent of all cases;  most effectual,  of course, in
cases  more  circumscribed or more  strictly confined  to  the larynx.
The operation  requires but little  practice or skill, and does no harm
should it fail to do any good.   Moreover, it in no  way interferes
with  the  more  radical   operation of tracheotomy.  Tracheotomy
itself  has been recently much simplified. •  It  is an operation per se
devoid of danger.  It is performed now for the most part bloodlessly.
Tracheotomy rescues about thirty-five per  cent of all  cases, thirteen
per cent of diphtheritic, and sixty per cent of non-diphtheritic croup
  a percentage  which would be increased if the  operation  could be
        17 
258
QUINSY.
 done as soon as the first signs of  stenosis sot  in.  Both  operations
 have saved children who  have actually ceased to breathe, so that
 it is never too late to try either or both.

                             QUINSY.
    Quinsy is an anglicization of the Greek cynanche : Latin,  an-
 gina (sore throat); limited  in our  day to  epidemic tonsillitis.   It is
 an acute, probably contagious infection of the fauces, pharynx, and
 tonsils.
    Etiology.—The disease  prevails most frequently during the sea-
 sons of fall and winter.  It spares the extremes of life, to show itself
 between the ages of fifteen and thirty.  There is a marked difference
 in different people in susceptibility to this affection, in  that certain
 individuals suffer  repeated  attacks.  Yet a single sharp attack con-
 fers immunity for at least a year.
    Symptoms.—Quinsy distinguishes itself by the severity of its
 symptoms, which  are out of all proportion to the  gravity of the dis-
 ease.   It announces itself after an indefinite and unestablished period
 of  incubation, with more  or less  sharp  chill, attended  by ferer,
 anorexia, at times even nausea, pain in the back and limbs, head-
 ache, and pretty profound prostration.   Gastric distress  is more or
 less pronounced.  There is a heavy coat upon  the  tongue, at times
 distinct nausea, and in younger individuals occasionally  vomiting.
 The fever is high; the temperature advances, on an average, to 103°,
 and it may run up to 105° at the onset or at any time in the course
 of the disease.   It is plain  to see  that an individual affected with
 quinsy is a  sick man.  The local manifestations are pronounced.
 The patient complains at once of a sore throat,  which shows itself
 also in difficulty of  deglutition.  The veil of the palate, the uvula,
 both tonsils,  the wall of the pharynx, are  markedly hyperaemic and
 swollen.  The tonsils project as globular, shining  masses into the
 throat, to such an extent often as to touch, sometimes to make such
 contact as to be flattened by mutual compression.  Deglutition has
 now become not only difficult but painful, and in extreme cases well-
 nigh impossible.  Drinks or fluid food  may regurgitate through the
 nose.   Coughing and strangling efforts attend the ingestion of food.
 The patient finds no rest in a recumbent posture.   He sits up in bed
 or out of bed, nursing his head in his hands, or walks about the floor,
 a picture of  suffering and  distress.  By this time  the tonsils have
 assumed such magnitude as to be manifest on  the outside of  the
neck, visibly or palpably.  Any pressure upon them elicits or aggra-
vates pain.
   Quinsy is naturally a suppurative disease.  It was  known for-
merly as angina phlegmonosa.  Sendtner  found in a case the Strep- 
THE TYPHUS FEVERS.
259
tococcus  pyogenes, which could not  be distinguished from that of
common  pus.  It becomes,  therefore, a necessity  to recognize  the
presence of pus and evacuate it as soon as possible.   The protruding
point of suppuration may at times be seen as a grayish-white dis-
coloration of the surface, more often  felt  in posterior  and inferior
portions of the tonsillar mass.  If the finger  be  passed over  the
surface of the tonsil and swept around its circumference, while pres-
sure from the outside pushes it into the throat, the point of tender-
ness may be elicited, or, indeed,  fluctuation felt.   Masses  of this
magnitude block the Eustachian tube to produce more or less deaf-
ness, and  occlude the nares to interrupt respiration and alter  the
voice, stop the pharynx  to  cause more or less profound dysphagia.
There is also the possibility that rupture of the abscess in the tonsil
may inundate  the larynx.  Fatal cases of this  occurrence at night
have been reported.  In  the natural  course  of  events  the abscess
ruptures itself, to the indescribable relief of the patient.   Quite fre-
quently the disease stops short of suppuration, to undergo favonable
resolution.  The physician evacuates  the pus, so soon as discovered,
by a simple plunge of  the  bistoury, taking care to keep  the knife
parallel with the sides  of the throat, or, if  he finds it  necessary to
make a longer incision, to  cut from  without inward, that he may
avoid the carotid artery.  Outside pressure will  help to fix the tonsil
in the desired position to secure proper penetration by the knife.
   The prognosis is not grave,  notwithstanding the apparent sever-
ity of  the disease.   Patients recover  entirely, sometimes,  however,
with hypertrophied tonsils,  which, in fact, most  of these patients
will have had before the attack.  There are no  means  by which
quinsy may be cut short, and still less prevented.
   Treatment consists  in the application of moist heat—hot-water
bandages, soft,  hot poultices,  hot^water   gargles, inhalations of
steam, whose efficacy may be increased by the addition of  carbonate
of soda—and especially in the speedy recognition and early evacua-
tion of the abscess.  Scarification  and  incision are not only useless
but dangerous before suppuration.  Sometimes  the presence  of  pus
may be recognized by means of a  subcutaneous syringe—a safe and
innocent procedure.  Evacuation of the abscess ends the case.  The
salicylates, especially salipyrin, with Dover's powder, control any
fever, light sepsis, or pain.
                      THE  TYPHUS FEVERS.

   Hippocrates used the  term typhus  (rixpo?, smoke) to  describe  a
benumbed condition of the  sensorium, as  if produced by a cloud
about the brain ; and the term was used for ages to indicate this in-
tellectual obscurity, without reference  to the name or character of 
260
THE TYPHUS FEVERS.
the disease in which it occurred.  So, meaning nothing more definite1,
it fell into complete  disuse until the time of Sauvages (K<i(>), who
revived it with special application to  particular forms,  which  we
now recognize  more  distinctly as three varieties of typhus fever—
first,  the oldest, typhus fever; second, a form separated in the
fourth decade  of  the present century,  typhoid—i.e..  like typhus
fever; and  the third, isolated distinctly by  Obermeier in 1X73 as
typhus recurrens,  or relapsing fever.  All  these forms were for-
merly inextricably confounded, and  the graver  varieties  were
studied under the common terms of spotted fever, fleck-typhus, hos-
pital, ship, and jail fever, hunger typhus,  etc., as indicating  a dis-
ease produced  by crowd-poisoning and following upon the heels of
famine and  want.   Starvation, crowd-poisoning, filth, bad hygiene,
these were the  factors supposed  to produce typhus  fever spontane-
ously—factors now recognized as important elements in the spread,
but not in the development, of the disease.
   True Typhus,   Typhus  Exanthematicus.—Typhus  fever
prevails still in  countries which represent the  presanatory period of
civilization,  raging with great virulence in Ireland and Russia, and
occurring, only in  much more modified form, at longer intervals, in
seaport towns of our own country.  Congregations of men in armies
and  upon pilgrimages have often since  disseminated  typhus  fever.
It causes, in fact, or has caused, more death in military life than all
the battles and perhaps all other diseases put  together.  Typhus
fever was one of the plagues of old times.
   History.—Typhus fever made its first appearance in our country
in 1812 in New England, at which time it spread over the New Eng-
land States,  to  thereupon disappear, and reappear only in  1X36, on
which occasion it visited Philadelphia in  great virulence.  Here, for-
tunately, it  fell under  the  observation of Gerhard,  who drew the
first distinctive lines  between typhus  and typhoid fever.  As these
points were subsequently presented to the profession, more especially
by Jenner, of London,  they soon obtained general recognition.  A
few cases have  been imported since from time to time, last in 1XH2
with one hundred and eighty-five cases, fifteen deaths.  The disease
has not spread  beyond our seaport towns.
   Etiology.—Typhus  fever  is pre-eminently a  contagious disease,
its infectious matter radiating  from every surface  and secretion.
Susceptibility is almost, if not quite, universal, as the disease is  ex-
quisitely diffusible.  The  child of seven  days, the old man of sev-
enty years, are alike attacked.  The poison may also be conveyed by
third persons and  by things.  Physicians  and nurses in direct con-
tact with patients in hospitals fall frequent victims  to this disease.
The  exact  cause  of the  infection has  not as yet been  isolated. 
the  typhus fevers.
261
Opportunity for study in centres where the etiology of the disease
is most diligently investigated has not occurred in recent times.
Lewaschew, of Kasan, finds a peculiar spirillum, endowed with active
motion, in the blood of the spleen, less constantly in blood from the
finger, which he was able to cultivate apart; and Cheeseman found
in the blood of six patients a short, thick bacillus which he could cul-
tivate upon agar and ox-blood serum, and which showed pathogenic
properties, but not typhus fever, in rabbits, guinea-pigs,  and mice.
Typhus fever in its nature closely resembles a bad case of measles,
in that the disease is so contagious, the liability is universal, in that
the eruptions are much alike, and in that haemorrhage may occur in
either.
   Symptoms.—The disease begins with a chill, or series  of shiver-
ing fits, attended by rise of temperature to 103° to 104°  or 105° in
the course of twelve to twenty-four hours.   The onset of  the disease
is sudden, often in the  midst of perfect health.   Exceptional cases
show prodromata for two  or  three  days in the way of malaise, de-
pression, headache, pains in the loins and limbs.   There is from the
start profound prostration, and, with the very inception of the dis-
ease,  overshadowing  symptoms  of mental dulness, drowsiness,
sopor, deepening into stupor which  readily passes over  into coma.
This is the cloud about the brain.   In the first few days of the  dis-
ease, and throughout the whole course  of the malady, however light
the case, the symptoms on the part of the  nervous system are ob-
trusively distinct.
   By the third day the eruption appears upon the body, over the
chest, to extend thence over the entire body, but to  spare always, or
nearly always, the face.  The eruption shows itself  in the form of
macule, crimson  red,  which soon become darker,  and  often co-
alesce, to give the body a spotted appearance, from which  it derives
a popular name.   So the body is more or less equally studded  with
points of intense hyperaemia, maculae, which  may, as  stated, co-
alesce and form larger surface ecchymoses or vibices, especially in
debilitated cases or bad surroundings.  A peculiarity in the eruption
of typhus fever is the fact that by the  third or fourth  day these
maculae aggregate themselves  into points of  pinhead size filled with
black blood—the  so-called petechia;.  Another  very distinct pecu-
liarity is the fact that the  temperature does not fall with a full
appearance of the eruption.  In most of the eruptive diseases the
temperature at its height represents the period of efflorescence, after
which all the symptoms, as a rule, decline and disappear.  But in
typhus fever the appearance of the eruption  has no  effect  upon the
temperature, which remains, with diurnal variations and  accidental
complications, much at the level at which it began, up to the twelfth 
262
the typhus fevers.
to the fifteenth day,  whereupon it  falls more or less suddenly, to
reach the normal grade within twenty-four hours, to constitute the
so-called decline by crisis.   Figs. 141-145,  from Moore on  Fevers,
show the temperature in typhus  fever.  The crises of the ancient
writers, marked by profuse sweat and diuresis, were based, for the
most part, upon observations  of cases of typhus  fever  and pneu-
monia.   The spleen is enlarged, as a rule,  but not to the degree  or
with the uniformity that marks cases of typhoid fever.
   All this time the  symptoms on the part of the nervous system
continue or increase.  The patient is  at first preoccupied, abstracted,
           Fig. 141.—Temperature chart in adynamic petechial typhus fever.

pays little or no attention to his surroundings, lies in a state of sopor
which lapses into stupor; responds at first to sharp address rationally,
later irrelevantly, and later still not at all;  lies in muttering deliri-
um, slips down in bed like a leaden  image, and may be pushed or
pinched without a sign of feeling.
   Parenchymatous change affects the muscles;  the voluntary mus-
cles, and more,especially  the heart muscle,  suffer degeneration.
This parenchymatous change is not the  effect of the fever.   Neither
the delirium nor the degeneration is caused  by the fever.  They are
both, with the fever, effects of a common cause.   They do, as a rule,
correspond.  But cases of low fever may show great delirium.   The
converse is also true.  Throughout the  whole course of the disease 
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THE  typhus fevers.
265
 there is great  disturbance and  distress  on the  part of the digestive
 system: the tongue  is heavily coated,  fuliginous;  sordes accumu-
 lates about the teeth; later the tongue becomes dry, is fissured, and
 bleeds.  By this time it may be no longer protruded from the mouth,
 or, if protruded under great effort, remains, and is not withdrawn un-
 til after repeated request.
    There is from the start  anorexia, nausea, frequently vomiting,
 which is at times excessively defiant of control.   As in all  the grave
 acute affections where the  intestinal  wall is  itself not affected, the
 bowels remain constipated throughout.
    The diagnosis is based first upon the  existence of the  disease in
 the land.  In our country there is a history of direct importation and
 transportation to the individual case.   Ireland, Russia, some parts of
 India, are the homes and haunts of typhus fever, and cases, to reach
 us, must follow  the  lines of travel.  The disease begins suddenly,
 often without prodromata, and violently.  The eruption appears
 on the third day as maculae  over the  bod}-, to become after three
 days petechial.  The eruption spares  the face.  The appearance
 of the eruption  is  not attended with any fall of temperature.  The
 symptoms on the part of the nervous system show themselves from
 the start, and  prevail and  predominate  throughout the whole course
 of  the disease.  Abdominal symptoms are wanting.  The  fever
 falls on the twelfth to the  fifteenth day, and the disease terminates
 by crisis.
    Typhus is distinguished from typhoid fever by the sudden onset
 of  typhus, or more  protracted,  insidious onset of typhoid.   One
 attack of typhus secures  but  temporary exemption; one attack of
 typhoid confers  immunity, as  a rule, for  the rest of life.  The ner-
 vous symptoms show themselves in the incubative and prodromatous
 stage of typhoid, and but for  a few days, if at all, before the out-
 break of typhus.  Typhoid fever is frequently announced by nose
 bleed, absent in typhus.   It is  the upper respiratory tract which is
 attacked in typhus, along  with the rest of it.   In typhoid  fever the
 bronchial tubes only are involved.  Thus  there is bronchitis  in both
 diseases, but there is also coryza in typhus fever, with irritation in the
 nose, sneezing, which almost never occurs in typhoid.  Constipation
 is the rule throughout the whole course of typhus fever.  There may
 be constipation during the first week in typhoid, but,  as a rule, there
 is more or less diarrhoea from the start.  The spleen is more distinct-
 ly  and more constantly enlarged in typhoid fever.  The eruption ap-
pears on the third day of typhus fever, more or less universally over
the body.   The eruption appears in typhoid fever on the chest about
the seventh to the tenth day.  It is much more scanty and much more
distinctly  isolated.   Typhus fever often shows herpes on the face, 
266
recurrent fever.
typhoid almost never.  The duration of typhus fever is two, typhoid
fever four weeks.
   Typhus fever is distinguished from measles, which it more closely
simulates, by the fact that  typhus attacks  all ages, measles chiefly
children.  This fact is not due to the greater liability to measles, but
to the fact  that measles prevails always, and typhus only at inter-
vals.   Measles is preceded  for three days by coryza;  typhus shows
coryza at the  onset of the disease  proper.  Measles has a period of
invasion of three or four days; typhus begins at once.  The eruption
in typhus fever appears on the third day on the body; of measles
on the fourth day on the face.  The eruption of measles  occurs in
patches or individual spots in spreading over the body, including the
face where  it begins; the  eruption of typhus is more universally
distributed over the body, sparing the face.  The eruption of measles
remains  macular  and disappears  by  branny  desquamation ; the
eruption of  typhus becomes petechial and disappears by absorption
without desquamation.
   The prognosis of  typhus fever is always grave, yet its gravity
has been reduced in our period by sanitation, relief from crowd and
sewage poison, to  twenty per cent.  The therapy of the disease is
wholly  symptomatic  and will be  discussed with  that of typhoid
fever.
                       REFURRENT FEVER.

   Recurrent (relapsing) fever has  been distinctly recognized in the
history of the graver infections since the beginning of the eighteenth
century, though its differentiation from other forms  of typhus, more
especially true typhus, is an acquisition, as  stated, of very recent
times.   Recurrent fever has its home  in Ireland  and the east of
Europe, whence it has been  carried, often in epidemic proportions, to
various parts of the earth.
   Etiology.—Recurrent fever arises only from itself.  It  is rapidly
disseminated in unsanitary conditions.  It has in  this regard the
same history as true typhus.  The disease is declared to be con-
tagious.   There is no individual immunity.   Immunity is not con-
ferred even by a single attack, which seems rather  to predispose to
other attacks.   Recurrent fever is now known to be caused  distinctly
by the invasion of a special micro-organism, the spirillum or spiro-
chetes of Obermeier (1873).
   Bacteriology.—-These spirilla,  interesting  as  the first  micro-or-
ganism actually seen in the  blood or body of man, exist in the blood
only during the period of fever.   They disappear entirely from the
blood of the dead  body.  They are long (16 to 40 p), spiral threads,
curled like a corkscrew, and endowed with active motion, both spiral 
RECURRENT FEVER.
267
 and undulatory.  Though attempts at outside cultivation have not
 yet been successful, the introduction of blood containing the parasite
 conveys the disease to other animals (apes) and to man.
   Pathology.—The changes in the body do not differ much from
 those of typhus.  There  is rather more  predominating evidence of
 parenchymatous degeneration of the liver, and at times such disten-
 tion of the spleen as to lead to rupture of  its capsule.  The disease is
 more fatal in the ape after exsection of the spleen.   Thus antimycotic
 action is ascribed  to the  spleen.  While the mesenteric glands are
 enlarged, the plaques of Peyer  and solitary follicles  remain  un-
 affected.  Haemorrhages, petechiae,  etc., occur  occasionally, and
 icterus  so frequently as  to sustain the view of "bilious  typhoid."
 This is one of the diseases included under the old " bilious typhus."
   The period of incubation is five
 to seven days.   The disease begins
 generally with a sharp chill, rap-
 idly rising fever, severe pains  in
 the  joints, with  rapid  prostra-
 tion and  gastric  distress.  Icte-
 rus  occurs as early  as the fourth
 day.  Enlargement of the spleen
 may be  soon  detected.   Mental
 distress and delirium may  show
 themselves at once.
   What  distinguishes the disease
 in any doubtful case is  the  dis-
 appear llCe of all these SVlliptomS,   FlG-  146.-Spirilla of relapsing fever in the
 /r                   '   '         blood.
 however severe, so soon as they
 reach their height.   At the end of the first week, when the patient
 shows such prostration and grave symptoms  as to  excite intense
 solicitude, the symptoms all speedily subside, the temperature reaches
 its natural limits sometimes  in  the course of a few hours, and the
 patient seems  to have perfectly recovered.  Somewhere between the
 fourth and the fourteenth day the same symj)toms show themselves
 anew.   They may be equally severe in their recurrence, but  are, as
 a rule, much shorter in their -duration, lasting from two to four days,
 when the temperature again falls and  the  symptoms subside as
 before.  In most cases this is the end of the disease.  In exceptional
 cases the patient may experience a third or fourth relapse.
   Diagnosis.—Relapsing distinguishes  itself from typhoid fever
 by the suddenness of its onset, or  violence of the pains in the bones,
 muscles, and joints, and  the  secondary and  subordinate  character
 of the brain symptoms.   Hebetude and headache are not so marked
in the course of  relapsing fever.   Enlargement of the spleen occurs
 
268                     TYPHOID  FEVER.

early and is equally marked, but symptoms on the part of the liver
assume much greater prominence than in typhoid fever.  There is
usually more or less icterus.  Herpes, which is almost never seen in
typhoid,  is not infrequent  in relapsing fever.   The  diagnosis rests
further upon the apparent termination of the disease at tin1 end of the
first week, and its recurrence once or twice.   It really rests upon the
discovery of the spirillum in the blood.  Examination is made in  the
same way as for malaria.
   The treatment is wholly symptomatic.  It differs in no way from
that of typhoid fever.
Fig, 117.—Temperature chart, relapsing fever (Seguin).
TYPHOID FEVER.
   Typhoid fever (rvcpos, smoke; eidos, like—i.e., like typhus fever);.
typhus abdominalis,  ileo-typhus,  enteric fever; German,  Nerven-
fieber; Iceland, landsfarsot, sickness of the country.—An acute in-
fection, caused by a special bacillus, characterized by slow,  insidious
onset,  hebetude, headache, typical fever, roseola, enlargement of the
spleen and mesenteric glands, swelling and sloughing of intestinal
glands (Peyer's patches),  diarrhoea, meteorism, liability to peritoni-
tis and intestinal haemorrhage, and termination at about the twenty-
first day.
   History.—Typhoid  fever  is a disease of comparatively modern
recognition.  Although the term typhoide was proposed by Louis in
1829, the disease was distinctly separated from typhus in the fourth
decade, and from recurrent fever in the seventh decade of the present
01575104578061 
TYPHOID FEVER.
269
century.  The  first attempt  at  separation of typhoid  from typhus
fever arose from the recognition of anatomical lesions in  typhoid as
distinct from typhus fever, first made by Prout  in 1804; but the dis-
ease, then and  for a long time after regarded  as a milder variety
of typhus, was clinically distinguished only in 1840 to 1850 by the
observations of Gerhard and Pennock, of Philadelphia;  Shattuck, of
Boston; and Barlow  and Jenner, of London.   The Bacillus typhosus
was discovered by Eberth and verified by Koch in 1880.   Very fine
illustrations of  the lesions of the intestines are to be found  in the
"Medical  and Surgical History of the  War  of  the Rebellion,''
1888, by Charles Smart. Surgeon U. S. A.
   Etiology.—Typhoid fever is the most frequent of all the acute,
grave,  infectious diseases.   It attacks  all ages, but spares the ex-
tremes of life.  One-half of all cases occur between the ages of fifteen
and  twenty-five; one-fourth under fifteen; one-tenth between twenty-
five  and thirty.  Liability begins to cease at thirty-five, and is almost
null at fifty.  Yet cases do occur in the most extreme age,  as verified
by autopsy.  So, too, cases have been recognized in early childhood.
One should be  slow in  childhood, and extremely loath in  advanced
age, to accept the diagnosis of typhoid fever.  Most of the cases of so-
called typhoid fever in infancy and age are typhoid states of other dis-
eases—pneumonia, tuberculosis (marasmus), etc.  The disease may
occur at any time of the year, but prevails especially during the fall
and  winter.  It coincides with  stages of low water.  Typhoid fever
is now known to arise only from itself, and to be chiefly conveyed by
drinking water (including diluted milk) contaminated with the faeces
of typhoid-fever patients.
   Bacteriology.—The typhoid bacillus—Koch-Eberth bacillus—is
a short, thick rod with rounded  ends, three times as long  as  broad,
rendered easily visible by saturated alcoholic solutions of methylene
blue.  Vacuoles in the ends of the vessels are        (/.^, w,Cn
taken for spores.  The bacilli are recognized en     Y*?~ / ^i^'tY^,
masse in the intestinal wall; in the plaques and     v*. A^.^Si^S
follicles; in  the  mesenteric glands, spleen,      'j-K*' '*?r\)L&
whence  they  have  been  withdrawn in life;     ^l^'^A^S'
much less abundantly in the liver, lungs, brain      ■^■'^S'/,-^' *'
(meninges), and kidneys.(urine).  They have   fig.i48.-TyPhoidbacillus.
,             -,      •   n    i   •   xt   r       Pure culture.
been recovered occasionally also m  the  tseces,
and  have been absolutely  recognized in the spots of roseola which
belong to the disease.   They may pass the placenta, presumptively
only after some lesion of its structure,  for they have been found in
the blood of the foetus.  This bacillus is endowed with motion, grows
rapidly upon various culture soils, especially upon the cut  surface of
a sterilized potato, where it forms yellowish, circumscribed colonies 
270
TYPHOID FEVER.
so characteristic as  to distinguish it in doubtful cases.   The typhoid
bacillus  continues to grow in the presence of acid of  high degree.
It will show all its  characteristics in an  acidified gelatin highly
 Fig. 149—Typhoid bacilli .in (he wall of the
intestine.
 Fig. 150.—Typhoid bacilli from section of
spleen (Flugge).
 colored  with  methylene blue, which  simulating bacilli  will not
 (Uffelmann).   Other  bacilli  of the colon  decompose  glucose with
 the  evolution of gas; the typhoid bacilli do not  (Theobald Smith).
 (Vide Frontispiece, Figs. 9 and 15.)
    It was difficult to  fulfil  the three postulates  required to establish
 the  pathogenetic  nature of the  typhoid  bacillus, because  animals
                                    seem naturally immune  to the
                                    disease,  and because an  active
                                    gastric juice destroys the bacillus.
                                    But when the  acidity of the gas-
                                    tric juice is neutralized with soda,
                                    and the peristaltic motion  of the
                                    intestine is  checked by the use
                                    of  opium,  or if the culture soil
                                    containing the bacillus be intro-
                                    duced directly into  the  duode-
                                    num, certain characteristic symp-
                                    toms  supervene, as alteration  of
                                    Peyer's plaques and  swelling  of
                                    the mesenteric glands, etc.
                                       Sirotinin,   Beumer,  Peiper,
                                    and  others  made the important
                                    discovery that the  culture soil,
sterilized by heat enough to destroy the typhoid bacillus, produced?
when injected, the same symptoms; so that the  poison of typhoid
 Fig. 153.—Typhoid bacilli iti mucous mem-
brane of small intestine (child):  a, epithe-
lium of crypts, 6, small round cells like adenoid
bodies; c, typhoid bacilli in colonies. 
TYPHOID FEVER.
271
fever is known to be a chemical agent, the  so-called  typhotoxine,
since extracted (Brieger), which produces the  fever, the nervous
symptoms, and other conditions which distinguish the disease.   The
micro-organism finds its way from the discharges into the drinking
water, and is thence conveyed into the body of man to produce the
disease.  The bacillus of typhoid fever  does  not live  very long  in
drinking water, perishing,  as a rule,  in from seven to fourteen
days, so that the  spread of  typhoid fever to endemic or epidemic
proportions  implies  a  continued contamination of  the drinking
water.  Under favorable conditions, as in  dung heaps,  sewage, etc.,
the bacillus may live as long as three months,  the outside limit of life
(Karlinski).   Boiling water  thoroughly destroys this  bacillus  and
purifies it for drinking purposes.
   Symjitoms.—The period of incubation of typhoid fever varies
from two to three weeks, during  which time the individual affected
Fig. 152—Typical temperature curve in severe typhoid fever (Eichhorst).
 may present few or no alterations from health.   In most cases, how-
 ever, there is, during this whole period, more or less malaise, languor,.
 debility, headache,  neuralgic  pain,  anorexia,  and  constipation or
 diarrhoea.   The disease sets in with a chill, or series of shivering fits,
 and, as a rule, a prostration, to such a degree as to early put the
 strongest men to bed.  In about one-fifth of the  cases  the  disease is
 announced by an epistaxis, and, in the absence of free haemorrhage,
 scales or stains of blood  about the  nose and the  fingers,  which have
 been used to relieve irritation, are suggestive signs to  the observant
 practitioner.   The  typhoid state early assumes prominence.  As
 stated, at times during the whole period of  incubation—in nearly all
 cases with the earliest inception of the disease—there is drowsiness,
 dulness, languor, headache, inability of concentration, apathy,  and
depression of spirits.  This condition exists  from the start in greater
3293
2 
272
TYPHOID FEVER.
or less severity, and prevails throughout the disease, to deepen often
later  in its course into states of muttering delirium, mania,  and
coma.
   The  factors which assume prominence at once are those which
have given the name to the  disease—namely, the typhoid state -and
the fever.  The fever of typhoid  fever is peculiar.   The disease dis-
tinguishes itself in all its symptoms  by insidious  development,  and
the slow onset  is manifest also in  the  fever.  The fever rises, as a
rule, a degree a day for seven days.  It is one degree higher in the
evening than in the morning of the  same day, and one degree higher
in the morning than the  morning  of the previous day, so that the
typhoid-fever curve is often said  to show a stepladder ascent.  The
height which the fever attains by the end of the first week is some-
thing of an index of the gravity of  the case.  By the end of the first
week the  fever becomes more  or less continuous.  It shows the
diurnal variations, but, barring complications, it holds itself  on an
elevated line, four to six degrees, above the normal for two weeks.
Then, by the end of the twenty-first day, the fever falls.  It may
reach the level of the previous  night  for two or three successive
evenings, but it falls lower  every  morning, until in the course of
another week, by the twenty-eighth  day, it reaches finally the normal
grade.  Thus typhoid fever is often divided into weeks: first  a week
of ascent, second the two weeks  of continuous elevation,  third the
week of marked remission up to the conclusion of the disease.   These
weeks correspond quite closely to the anatomical lesions in the intes-
tinal  canal.  During the  first week the glands and follicles  are in
a state of hyperaemia; during the second week there is  associated
tumefaction; during the third week  the glands slough; during the
fourth week they cicatrize.
   Typhoid fever shows  early a  symptom of  importance  in  an
enlargement of the spleen.  The  spleen  begins to  swell in the first
days of the disease, and by the end of  the first week may be recog-
nized as substituting its dulness for the tympanitic resonance of the
fundus of the stomach, as it begins to encroach upon the abdominal
cavity.
   Typhoid fever is often  distinguished as ileo-typhus because of the
localization of its lesions about the lower region of  the ileum.  The
bacillus passes the stomach, upon which it can produce no effect.  It
is hurried on by the more rapid  peristalsis of  the duodenum, jeju-
num, and upper  to  the lower part of  the ileum, where obstacle is
offered to rapid escape of the fluid contents of the stomach by the
ileo-caecal  valve.  Here, at this  comparatively stagnant  reservoir,
the bacillus makes its attack upon, or  is incorporated in, the intestinal
wall, to be carried thence through the blood  and lymph vessels to 
TYPHOID FEVER.
273
the mesenteric glands and spleen.   Symptoms  on the part of the
intestinal canal present themselves therefore early, assuming promi-
nence later in the course of the disease.
   Some few exceptional cases are marked by  constipation during
the first week, but  as  a  rule  diarrhoea exists,  often  early, always
later, sometimes profuse in  the  later period of the  disease.  The
abdominal wall soon becomes distended.  There is meteorism.  Per-
cussion is tympanitic.   There is  tenderness to  pressure.  There is
gurgling in the region of the right iliac fossa.
   The disease is called ileo-typhus,  typhus abdominalis, as distinct
from typhus exanthematicus, fleck-typhus, spotted typhus or fever,
because  of the prominence of the eruption  in  typhus fever.  But
typhoid fever is not without an eruption.   Typhoid  fever has a quite
characteristic eruption, which appears upon the surface of the chest
or abdomen, about the region of the diaphragm,  in the form of small
red spots, "rose-colored, lenticular spots" (Louis), which appear to
the number of five to fifteen distinctly macular, subsequently slightly
elevated spots, like flea-bites,  which disappear upon pressure, to re-
appear with  its relief.   These rose-colored spots, scattered usually
over the chest and abdomen, have at times a more profuse and wider
distribution.  They may appear  first in the loins, and may be ob-
served only  on inspection of the back.  They  may extend over the
chest, over the whole abdomen and upper part of the lower extremi-
ties, and be even crowded over  upon the  neck to the  number of
several hundred.  They may appear, disappear,  and reappear in the
further course of the disease.   They are present in the majority of
cases, and form, while not  pathognomonic, certainly strong corrobo-
rative evidence of the nature of the disease.  Cases sometimes show
no spots. Chomel  speaks  of  an  epidemic at Turenne where  spots
appeared in no case.  They do appear in the great majority of cases,
and  at about  the period of the  disease mentioned, and are strong
points in the recognition and diagnosis of typhoid fever.
   The discharges of typhoid fever are more or less  distinctive.
They consist at first of the natural contents of  the intestinal canal.
Later they become  more fluid, assuming  a  distinct consistence and
color.  The old  writers spoke of  the "pea-soup, ochre-colored" dis-
charges of typhoid fever.  This  character  is sometimes markedly
changed by the  appearance of blood.  Some  blood appears in the
discharges of nearly all cases of typhoid fever, but, as a rule, in
minute quantity.   Discharges are called bloody only when the blood
may be recognized with the naked eye.  The discharges  in typhoid
fever are frequently stained with blood,  or  contain blood in quanti-
ties,  or consist wholly of blood.   Individuals have  succumbed to
haemorrhage  in this way.  The rule is,  that  the discharges are
         18 
274
TYPHOID FEVER.
bloody for a time, several days, that haemorrhages occur during this
period, that the bleeding ceases probably with the block of the vessel.
to recur with dissolution of the clot, or with  the reopening of an
ulcer, or from a new ulcer.
   All this time the typhoid state deepens.   The  patient complains
at first only of headache, of drowsiness, or his sleep deepens into
states of stupor.  After a while the condition continues more perma-
nently ; the patient is in a more or less constant state1 of  vacancy or
stupor. If spoken to or sharply addressed he may answer rationally
at first, or later make some unintelligible or irrelevant response.  If
asked to protrude the tongue he may fail at first to comprehend, but
if the  request be made manifest  by pressure of the finger upon
the chin, the tongue is  with effort  protruded,  as  a heavily coated,
fuliginous, tremulous mass, which remains  protruded until the pa-
tient is admonished by injunction or touch to withdraw it.  The pa-
tient falls into a state of mild delirium.  He seems constantly and
incessantly occupied.   The mind is busy, in the  strict sense1  of the
term—so busy as to prevent sleep.  There is low, muttering delirium,
a state of stupor with vigilance—a condition which is well described
under  the  term coma-vigil.   The body becomes more  and more
an inert mass.  There is no effort on  the part  of  the  patient.  The
most imperative wants  of the  body pass unrecognized. ■ The dis-
charges are  voided  unconsciously and involuntarily.  The patient
slips down in bed, and  must be continually lifted toward the head
of the bed.   Flies crawl unnoticed over the  face.  There  is no per-
ception of heat or cold.   All the while the mind seems intently pre-
occupied.  Soon there is subsultus tendinum.  The patient picks at
the bedclothes.  The face is dusky.   The  prostration is profound.
Heart failure or thrombus may close the scene.
   Fortunately such cases are rare in our day.   The old  pictures of
cloud and collapse  are seen only in neglected cases, especially in
cases which  remain as long as possible out of  bed, whereby the
strength which should be saved  for resistance is wasted  away,
whereby also tendency to haemorrhage or peritonitis is increased.
   Hemorrhage and  perforation are the accidents most to be
feared.  Slight haemorrhage may show at any time in the course of
the disease,  but such  an amount of blood  as to be visible  to the
naked eye, or to constitute most or all of the discharge, occurs, as a
rule, in the third and fourth weeks of the disease,  and is  due  to the
erosion of a blood vessel or  the reopening of  a cicatrization.  A
haemorrhage is recognized at  once by the  presence of blood, or, if
the blood be concealed—that is, retained in  the intestinal canal—by
the collapse into which the patient sinks ; by the fall of the tempera-
ture suddenly from  104° or 105° to 100°, to the normal, or even to 
TYPHOID FEVER.
275
 subnormal  grades.  There is, after such copious haemorrhage, an
 illusory improvement in the mental  state.  The patient  awakens
 from coma, or appears more rational and bright.  The temperature,
 however, speedily reaches its former, or often higher,  level, and the
 strength and the mental state are reduced more than before.  While
 it is a  rule that haemorrhage occurs  more  especially in bad cases,
 there are many  exceptions.  Fatal  haemorrhage has taken place in
 cases so light as not to have confined the patient to bed, and patients
 have even bled  to  death from a single ulcer.  But the haemorrhage
 is by  no means necessarily fatal.  The usual history of a haemor-
 rhage is its occurrence in quantity, disappearance for several days,
 and recurrence perhaps on several subsequent occasions.  The stools
 of a single day,  or of twenty-four hours, are bloody or  all blood.   On
 the  following day the  condition is more normal.  On a subsequent
 day the haemorrhage returns.
   Of all the accidents that befall a patient with typhoid  fever none
 is so grave as perforation.  This accident, as a rule, occurs in close
 proximity to the ileo-caecal valve, where the  ulcers are most abun-
 dant and deep.   The condition is  announced, for the most part, by
 sudden, profound collapse.  The face is pinched,  the  eyes sunken;
 the surface is cold,  often clammy ; the pulse is feeble  or  almost im-
 perceptible, thready.  The patient often  lies  in  bed with the knees
 flexed to relax the abdominal wall.  The abdomen  itself is distended,
 tympanitic.  The  dulness  of  the liver and spleen is substituted by
 tympanitic resonance.  A mistake may here readily arise  from a dis-
 tended colon, which may itself  substitute the  hepatic  and splenic
 dulness.  In perforation the temperature usually falls suddenly,  and
 often to a subnormal degree.  The  patient  may become  rational.
 There is an illusory appearance of resolution of the disease.  These
 hopes  are, however, speedily  abandoned, as  the collapse continues,
 to end in death in twelve to twenty-four hours.
   Peritonitis by no means of necessity  implies a perforation.   An
 ulcer may affect the peritoneum without perforating it.  In  this
 case, for the most  part, the peritonitis is circumscribed, and points
 or surfaces of tenderness may be elicited by gentle pressure over  the
 abdominal wall.  A circumscribed peritonitis may become  diffuse
 when no perforation exists.
   Typhoid fever presents two sets of complications—one which
 applies to the disease proper, and  one common to other infections.
 The  lesions peculiar to the disease include  the swelling and ulcer-
ation of the glands in the intestine, and affection of the  spleen  and
other  lymphatics.  The second  set of  lesions are the  parenchy-
matous  degenerations,  that have been usually ascribed to  the
height and duration of the fever, but are considered in  our day to be 
276
TYPHOID FEVER.
due to the poisoning  of  the  blood.  These states affect chiefly  the
muscles, which undergo  granular, fatty, and waxy degenerations, to
such a degree at times as to lead to paralysis, ruptures, and failures.
Thus the heart may become feeble or cease  to beat,  the diaphragm
enfeebled or paralyzed,  and voluntary muscles may rupture.   The
author has seen rupture of the rectus abdominis.
   Typhoid fever is a treacherous disease, and no disease is attended
with  so  many pitfalls in the way  of  complications  and sequelae.
Haemorrhage, perforation,  peritonitis, may occur in  any case unex-
pectedly.   Among the more uncommon sequelce  may  be mentioned
laryngitis, which may assume a diphtheritic character and neces-
sitate tracheotomy.  Parotitis on  one or both sides  sometimes  pro-
ceeds to suppuration,  probably as the result of a mixed infection.
About once in a  hundred  cases there occurs thrombosis of the fem-
oral vein—phlegmasia alba  dolens.  Although albuminuria occurs
in perhaps every case at  the height  of  the fever,  typhoid  fever is
very rarely followed by Bright's disease.  Pyaemia occurs as a rare
exception.  Bronchitis belongs to the disease, and lobular pneumonia
may result from it.   Pleurisy, pericarditis,  endocarditis, are  among
the rarer complications.   So certain cases  of valve disease of the
heart owe their origin to typhoid fever. Bed sores are common, and
show themselves in aggravated form in protracted cases, defiant of
all relief at times until the period  of natural resolution, when they
are wont to take on a  new aspect and heal up.
   Typhoid fever shows  itself in  various forms.  There is : 1.  The
abortive  form, in  which the disease,  while commencing violently
and showing all its signs, terminates at the  end of the second week.
These cases are not so uncommonly rare.   Protracted forms, where
the disease extends into the fifth or sixth week  and beyond, are by
no  means  rare, and must  not  be  confounded with relapses, which
imply a  previous  return to  the  normal  temperature.   2. The ful-
minant form, where life is taken in the course  of a few days, as
under the action of  a  virulent poison.   3. The disease differs some-
what in children, in that the eruption is by no means so abundant or
distinct.   The onset of the disease is more abrupt, the pulse and
heart's action are not so much enfeebled.  4.  In the aged the  fever is
not so high, diarrhoea is not so severe or persistent, eruption is not
so abundant or distinct.  There is more apt to be earlier and longer-
continued muttering  delirium.  Prostration comes  on quickly and
continues after  the subsidence of  the fever, while  other  nervous
symptoms of alow character—tremors, subsultus tendinum, etc.—are
more constant.
   Such  cases are only to  be considered relapses  wherein, as
stated, the temperature reaches the normal  grade.  Testimony dif- 
TYPHOID FEVER.
 fers as to the frequency of this accident, and  confusion has arisen
 in  regarding or not as relapses those recrudescences of  fever which
 may be provoked  by errors of  diet,  exciting causes, emotional anx-
 iety,  premature  physical
 effort, etc.   In these cases
 the fever subsides  in the
 course of  a  few   days,
 whereas in the true relapse
 the whole scene is repeated
 in at least a great part of
 its role.  Relapses usually
 begin more abruptly, the
 temperature sooner reaches
 its maximum grade.  The
 rose-colored eruption  ap-
 pears  earlier,  even on the
 second or third day; the
 disease subsides more rap-
 idly.   Thus the  duration
 of  the case may extend
 to  include   two  or  even
 three  distinct  attacks  of
 the disease.  An  abortive
 case may be followed by
 distinct attack, or the case
 may  consist of a distinct
 attack  followed  by  two
 abortive relapses.
    Typhoid  fever,   as  a
 rule, lasts twenty-one days
 or thereabout—that is, the
 fever begins to break on
 the  twenty-first  day,  to
 terminate by the twenty-
 eighth  day, so that the
 average duration   of the
 disease may be regarded
 as about one month.  Com-
 plications  may vastly pro-
 long its duration.  Death
            .        .  ,  j.  Fig. 153r»
 may occur at any period of fever
 the disease,  rarely before
the end of the first week.
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    Typhoid fever with recrudescence. Primary
(Vide p. 278 )
                           Death may occur, again, several  weeks
after the disease has run its course, as the result of some sequel. 
27S
TYPHOID  FEVER.
   The diagnosis rests  upon:  1. The typhoid  state—i.e., the dul-
ness. headache, insomnia, etc.  2. The  fever with its gradual ascent
and  sustentation at a plane much above the normal for three weeks.
3.  The abdominal symptoms, the diarrhoea, the  stools,  meteorism,
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   Fig. 1536.—Typhoid fever with relapse after twenty-four days' interval. Relapse (Moore).

enlarged spleen.  4.  The  roseola.  5.  The  complications, especially
the haemorrhage, heart failure, peritonitis.   6. The bacillus extracted
from the spleen.
   Prognosis.—From what has been said regarding complications of
Fig. 154.—Typhoid fever with recrudescence.
typhoid fever, it must be regarded always as a very grave disease.
The prognosis must be guarded.  In childhood the prognosis is by
no means so  grave.  Accidents and complications are much less 
TYPHOID FEVER.                     279
 frequent.  Nearly all children recover.  At puberty the disease begins
 to assume gravity, and the  gravity increases with advancing years.
 We base the prognosis, 1,  upon the degree of fever.  Fiedler says
 that all cases die when the fever once touches a temperature of 107°;
 one-half die at 106°, one-fourth at 105°.   Murchison reported a recov-
 ery after a temperature of 108°.  Hutchinson states  that the highest
 temperature reached in any of his cases was 106°.  In this fatal case
 the temperature reached 105° five times.  So single elevations of tem-
 perature to extreme degrees indicate  gravity in  this more than in
 any other febrile disease.  Unusually protracted temperatures, though
 far less high, into the fourth week and  beyond, give great gravity.
    The prognosis is based, 2, upon the character of the complication.
 A  new gravity is  imparted to the case by  haemorrhage.  Cases in
 which  haemorrhage is profuse or repeated furnish  a mortality of
 thirty to  forty per cent.  Peritonitis is very grave.   Perforation is
 not quite, but  is almost, necessarily fatal.  Rare cases are rescued
 by agglutinative inflammation.  3.  The condition of the heart is a
 criterion  of  the danger.  The pulse seldom  rises above 100 to 120
 throughout the course of typhoid fever.   The more frequent pulse
 betokens gravity.   The strength of the heart's action, independent of
 its frequency, is an index of the  gravity.   4. The time wdien a pa-
 tient is put to bed determines to a great degree the future of the case.
 Hospital cases which go to  bed late have, notwithstanding care and
 skill, a greater mortality than cases in private practice which are put
 to bed at once.   An early decubitus economizes force as well as pre-
 vents complication.
    Lastly, the outlook of the case is determined by its surroundings.
 The prognosis of typhoid fever depends  largely upon the  attention
 which it may receive.   Under the improved  methods of treatment of
 the present day the mortality of typhoid fever is reduced to seven to
 ten per cent.
    Prophylaxis.—Typhoid  fever is a preventable disease.   With our
 knowledge of the nature of its cause, it is necessary to secure pure
 drinking water to prevent typhoid fever.   To avoid contamination of
 drinking water by human excrement rescues a community from the
 dangers of this disease.  Where this condition  cannot  be complied
 with, thorough boiling of the water destroys the parasite which pro-
 duces it, and renders  the water  safe.   So, also, perfect  filtration
 through porcelain or asbestos prevents the passage of the germs.  Un-
 fortunately the disease occurs, at times, where these precautions are
 taken, by neglect of the mi Ik, which is often diluted with contaminated
 water.  The disease may be contracted, where even this precaution is
observed, by the ingestion of drinking water elsewhere than at home.
    Prophylaxis includes cleanliness  about the sick-room, especially 
280
TYPHOID FEVER.
with regard to the bed linen  and the utensils employed in the treat-
ment of the disease.   AVasherwomen, by careless handling of linens.
often contract the disease by direct infection.
   The treatment  of typhoid fever is wholly symptomatic.  The
hopes entertained regarding  the jugulation, mitigation, or abbrevia-
tion of the disease with specifics  have proven groundless.   The pre-
parations of iodine,  carbolic acid, calomel, hydronaphthol, etc., have
been recommended  as antimycotic agents, but without evidence of
real value.  When it is remembered that typhoid fever is a disease
of long incubation, that the poison is received into the body at least
two weeks before the manifestation of symptoms, by which time micro-
organisms have  penetrated into the recesses of tissues out of the reach
of remedies introduced into the intestinal canal, it may be understood
why hopes of parasiticidal agents may not be entertained.  More is to
be expected of some  protective proteid or  antitoxine, and hope is en-
tertained that available antitoxines may be extracted from the blood
of patients who have just survived or recovered from the disease.
   As stated, the success of treatment is based  largely upon the sur-
roundings of the patient.   After the diagnosis is established, treat-
ment of an ordinary case, aside from complications, is more  a matter
of good nursing than of scientific skill.  The temperature of the room
should be maintained at 68°,  as established by a thermometer at the
head of the bed.   Ventilation must be secured from outside air.  The
bedroom should be  faultless in its cleanliness,  and,  with the linen
of the patient, should be changed, where  it is  possible, every day.
An additional bed, sofa, or lounge,  to which the patient can be trans-
ferred absolutely without effort on his part, best secures this object.
   A typhoid-fever  patient must go to bed at once,  and remain in
bed, without rising under any pretext, throughout the whole period of
the disease.   Haemorrhage and  perforation, the evils most dreaded
in this disease, occur much more frequently in patients who change
posture than in those who lie recumbent and at rest.
   The diet must be fluid. Milk is the food par excellence when not
especially contra-indicated, as by natural aversion, too much con-
stipation, etc.   Under such  circumstances, or even when the milk
is well borne, it  may be substituted or supplemented by beef tea,
chicken soup,  mutton broth,  oyster soup, and later, in beginning con-
valescence, diluted eggs  and thin custards.  Fermented milk,  sour
milk, buttermilk, koumyss, may be taken when other preparations
pall.  Solid food is on no account to be administered to a typhoid-
fever patient until the temperature shall have remained in convales-
cence for three days at the normal grade.   Fluids must be given to a
typhoid-fever  patient regularly.   Cold water must  be accessible,
fresh, pure cold water, at all times; and in the states of pre-occupation, 
TYPHOID FEVER.
281
 delirium, coma, cold water must be not so much offered as adminis-
 tered at regular times.  A grateful drink, in the absence of diarrhoea,
 is the prescription of Cheyne as improved by Graves :
    B Sodii carbonatis.........................................3 i.
      Succi limonis............................................§ i 3 vi.
    M. et adde,
      Tincturse aurantii recentis................................ 3 ij.
      Syrupi aurantii........................................... § ss.
      Aquse............................. ................ ... ad § vi.
    M.   S. A wineglassful every three or four hours.
 Graves says nothing is more agreeable to a fever patient than  this
 mixture.  The citrate of  sodium  thus formed "tends  to  keep up a
 soluble state of the bowels and forms a most grateful and refreshing
 beverage."  The mouth should be washed out two or three times a
 day with solutions of borax.  Vaseline, or, better, borated vaseline,
    B Acidi borici.................................................gr. xv.
      Unguenti petrolati,
      Lanolini...................................... .........aa 3 ij.
 is to be introduced at the nostrils, not deeply inserted, to liquefy  and
 disseminate itself through the nasal fossae and the pharynx.   The
 face, neck, and  chest should  be sponged with fresh water  or with
 Cologne water two or three times a day.
    The conditions which may call for special treatment are, first, the
 typhoid state and  the fever.  Some hebetude,  headache, drowsiness
 belong to every case and call for no treatment.  Headache in excess
 may be controlled  by moderate doses,  gr. x.-xv.,  of the bromide
 of sodium, largely diluted, every three or four hours.  Light deliri-
 um may be met in the same way.   Vigilant states may be combated
 by sulphonal, gr.' x.-xv., in a bowl of warm milk or a cup of hot  tea;
 trional, gr. xv., or, in the earlier periods of the disease, by chloral, gr.
 v.-xv.,  in half  an  ounce  of peppermint or  orange-flower  water.
 Nervous distress is best controlled by small gr. ij.-v. doses of pure
 chloral.   When these hypnotics fail resort must be had to morphia,
 gr. 1;-^, administered, where the tongue is dry or in the presence of
 nausea, preferably subcutaneously.  Morphia may become in certain
 cases indispensable,  but should be used only after  failure  of milder
 means,  and always  with judgment.  In  the rarer cases of maniacal
 excitement necessary supervision must be secured.
   Some fever belongs  to the disease and may be  allowed to run.
 Fever above 103° in  the rectum becomes  excessive.   The dangers of
typhoid fever are no longer attributed  to the fever.  The  fever is
looked upon, not as  the cause, but as the effect of the poison of the
disease, as a coeffect with other symptoms; and while it is true that
the range of the fever is a gauge of the gravity of  the disease,  it is 

TYPHOID FEVER.
not true that the control of the fever subdues the disease1 or controls
the condition.   The fact is that in our day treatment of  the fever is
more an address to the comfort than the safety of the patient.
   The best antipyretic is  the  cold bath.   To be effective the patient
must be lowered by sheets, held at the four corners, into a full-length
cold bath, where he is to remain  at first five, then ten. later fifteen
minutes or more, when he is  to be removed to bed with  the same
care, gently wiped off, covered  with blankets, and allowed, if he
may, to sleep.  The bath is  cold when the temperature is 08° F.  It
is sometimes advisable to commence with a warmer bath, 75° to 80°,
even 90°, and  gradually cool it down with lumps or masses of ice.
The bath should be administered whenever the  temperature reaches
103° in the rectum, where alone reliable records can be  read, every
hour if necessary, precaution being taken to secure the advantage of
the bath  between midnight  and morning hours, as well as at other
periods of  the day.  The cold bath strengthens the heart and in-
creases  the excretion by the  kidneys of  typhotoxines (Roque  and
Weill).
   Where reaction is slow to establish itself, a tablespoon  or two of
whiskey diluted should be given to the patient both  before and after
the bath.  The cold bath  reduces the temperature two or three de-
grees, as a rule, and brings it down  often to the normal, sometimes to
subnormal grades, where it  will likely remain for an  hour or two.
To be effective it must, as  stated,  be  repeated  throughout the day
and night.   Cold baths and alcohol make now almost routine prac-
tice.  Both  give comfort and safety.  There  must  be care  with
chloral in late stages of the  disease.
   Peritonitis, whether from  perforation  or  not,  haemorrhage,  con-
stitute about the only contra-indications.  So far from increasing, it
has been proven that  the cold bath actually lessens the liability to
haemorrhage of  the bowels.   No  remedy that we possess secures the
advantages and avoids the disadvantages of antipyresis so effectually
as the cold bath.  The cold  bath is  sometimes impracticable and
impossible, whether from prejudice, absence of  apparatus, or  condi-
tion of body, and in these cases resort must be had  to other agents.
Sponge baths and wet sheets  are poor substitutes for the bath.   The
safest of the modern antipyretics is phenacetin, which is best given
in a large dose, three grains  to  a  child, five grains in adolescence,
ten  grains to an adult, at the height of the temperature, which it
will reduce, in the  course of  fifteen or twenty  minutes, a degree or
two, with some slight  sweating, which in turn aids in sustaining the
antipyresis.  Antipyrin or  antifebrin in half the dose of phenacetin
secures the same advantages, but with a more depressing effect upon
the heart.   These depressions may be counteracted by alcohol,  whis- 
TYPHOID FEVER.
283
key, a teaspoonful to  a tablespoonful diluted, in which case there is
not much choice between the remedies.  Aconite and veratrum, on
account of damage to the heart, are no longer given in typhoid fever
except in infinitesimal doses, ut aliquid faciat, in which case  they
may be better substituted by dilute hydrochloric acid, gtt. ij.-v., di-
luted in a tablespoon or wineglass of water.   The modern antipy-
retics have the additional advantage that they possess some anodyne
properties and thus allay insomnia, headache,  neuralgic pains, while
they reduce fever.  A dose of phenacetin used with judgment at the
proper time will give  comfort in the course of typhoid fever.
   The time  for stimulation arrives  in  the course of nearly every
case of typhoid fever.  This time is indicated,  first, by the character
of the pulse, which begins to flag in its force.  Perhaps the first
signal of its weakness is shown in the condition known as dicrotism,
or reduplication at the radial pulse.   The  force  of the heart is
estimated readily also  by the degree of compression necessary to
obliterate the pulse with the finger.  The degree of weakening or
faintness of  the pulse, which follows the lifting of the right arm at
right angles to the body, indicates its strength.
   Alcohol is the best whip for a  flagging heart—in a mild case in
the form  of wine, especially sherry or Madeira; in  a severe  case in
the form of whiskey,  which may be given as milk punch or as a cold
drink with ice water, or, as it  may be made  more  palatable by the
addition  of sugar and lemon juice or  some  bitter (tincture of nux
vomica), as a cocktail.  In the  most prostrated cases  the  alcohol
should be in the form of brandy. A  threatened  collapse may be
bridged over  by a cup of black coffee with a teaspoonful of cognac,
or resort in the extreme cases must be had to the analeptics, as the
oil of camphor 1 :10, or tincture  of camphor or  musk.   Whiskey
may be injected into the bowel  or administered subcutaneously.
Nitroglycerin 1 :100, in dose of  gtt. i.-iij. in whiskey, is one of the
most powerful agents we possess.   It  may be administered also in
the same dose under the skin.   It is especially indicated when the
urine is scant.
   Diarrhoea seldom  calls for treatment.  A moderate diarrhoea be-
longs to typhoid fever and should be let alone.   It carries off noxious
matter.  Excessive diarrhoea is best restrained by bismuth gr. x.-xx.,
lime water with milk, or by a small dose of the camphorated or
simple tincture of opium; or,
   B Acidi hydrochlorici diluti........................... ... gtt. xl.
     Tincturae opii...........................................gtt. xl.-lx.
     Aquae camphora?.....................................ad § iv.
  M.  S.  Tablespoonful every two to six hours.
A dry tongue with sordes and muttering delirium is an indication 
2S1
MALARIA.
for turpentine gtt. x.-xx. in milk, or hydronaphthol gr. v. every two
to four hours.
   Constipation belongs often to the first week  of  the disease, and
disappears of  itself  later  without treatment.  Should it become
troublesome it  may be relieved  by enemata rather than  by drugs.
Protracted constipation is due, as a rule, to error in diet, more  espe-
cially to too long-continued or  exclusive  use of milk, and may be
often counteracted by the substitution of other fluid food.   Calomel,
gr. i.-iij., is never harmful in the first week, when it sometimes
clears up comatose states.
   Complications  call for treatment according  to  their  character.
Haemorrhage demands more absolute rest and the avoidance1 of all
food.  Ice dissolved in the mouth may relieve or lessen thirst.   Ice
bags may be put over the belly at the region of the  ileo-oaval valve.
Peristalsis should be arrested by  opium.   No form is better  here
than the  simple tincture gtt. x.-xx., or camphorated  tincture 3i.,
repeated as may be deemed necessary.   Ergotin, or preferably scle-
rotinic acid, in syringeful doses, may be injected under  the skin of
the abdomen every fifteen  to thirty minutes.  Rescue may be had
at times by  transfusion of warm salt  water, one drachm to the
pint, the water having been previously boiled.  Subcutaneous injec-
tion sometimes suffices as well as  intravenous, without its dangers.
Perforation  calls for  opium almost up to  narcosis. In the light of
present evidence it is quite justifiable to cut down upon the intestine
in the hope of finding the seat of perforation or source of excessive
haemorrhage.   But let medicine be not brought into disrepute by
surgery in articulo mortis !  The  convalescence is long.   It is  often
pleasant,  sometimes tedious, and always  subject to relapse.   It is
impossible to exercise too much  restraint  in the matter of  diet and
muscular effort in the earlier period of convalescence.   Patients in
typhoid fever should only very gradually get upon their feet.
   The dilute hydrochloric acid, five to ten drops in a wineglass of
water before meals, best  aids the digestion of food taken, with, as a
rule, an appetite increased to voracity, whereby  the  patient  often
gains a pound a day.   It  is common observation that patients have
a  more robust health and  vigorous intellect,  possibly from the de-
struction of some  previous  poison, probably on account  of  the long
rest of mind and body, after typhoid fever than ever before.


                            MALARIA.

   Malaria  (mal-aria, bad air); ague;  German, Wechseljieber.—A
disease caused by infection  of the blood, especially the red blood cor-
puscles, by certain animal organisms (protozoa); marked in typical 
MALARIA.
285
cases by attacks of chill, fever, and sweat, in irregular cases by neu-
ralgias and various nervous phenomena, and in more protracted cases
by marasmus and enlargement of the spleen.  The  predominating
element in symptomatology  of  whatever  character is periodicity.
with intervals of more or less complete absence of symptoms.   The
pathogenic micro-organisms disappear from the blood and the symp-
toms of the disease subside under the influence of quinia.
   History.—Forms of malaria  were known in the most ancient
times.  Protagoras described the drowsiness and coma  of pernicious
fever.  Celsus recognized the quotidian, tertian,  and quartan types.
Archigenes observed various masked forms, and Rhazes put  upon
record cases in which one attack followed so close upon another  as to
constitute the subintrant form.
   Rome was early the seat of malarious disease.  The waters which
poured down   from the Palatine,  Aventine, and  Tarpeian  hills
formed marshes, emanations from which developed the disease.  The
elder Tarquin drained Rome with subterranean sewers—which, from
their extent, Pliny likened to subterranean streets—with the effect of
freeing the city from malaria to such an  extent that, by the time of
the Caesars, Rome contained more people than any city before or for
centuries  after.  With the invasion of the Goths the sewers  were
blocked and Rome again became a centre of malaria.  The country
about Rome, the Pontine marshes, have long been famous as hotbeds
of malaria.  Appius Claudius drained the marshes into the Tiber,
built bridges and the celebrated  Way, which still remains, so  that
the  country became the seat of  an extensive  population.  Under
Theodoric the drains were broken up, plains were converted  into
marshes,  and the Maremma became malarious to such degree  as to
render it, as it yet remains, practically uninhabitable.  The cause
(Plasmodium) of malaria was  discovered by Laveran (1881).
   Etiology.—From all time it  has been  recognized that marshes
breed malaria.  Ever since the days of Hippocrates it was remarked
that  while the average mortality is one in thirty-four, that in marshy
countries  is one in  twenty.   Marshes  are to  be  found  in nearly
every country.  In India, one hundred and eighty-four square miles
south of  Calcutta, lies the vast  marsh of  the Sunderbund, twenty
thousand square miles in extent,  a breeding place for malaria as well
as cholera. The deltas and embouchures of rivers spread with  their
detritus marshes over vast areas;  thus in China at the mouths of the
Blue and Yellow Rivers; in Africa, of the Orange, Zais,  and Zam-
besi; in South America, the Amazon,  Orinoco, Rio del Norte;  Eng-
land  has its fens of Lincolnshire  and Norfolk.  In our own country
the swamps and bayous overflowed and bared annually by the large
Western and Southern rivers are perpetual  homes of  malaria.   Per- 
2SG
MALARIA.
haps nowhere upon earth do the  conditions exist that produce1 the
disease  in  such  virulence  and constancy  as in Central America,
where workmen upon the great canals have to be substituted every
few months.
   Heat,, moisture, and vegetable  decomposition are the factors rec-
ognized as essential to the production of malaria, so that the disease
finds its limit, on account of temperature alone, at G3° North and 5?°
South latitude.   The cause of the disease is heavy and hugs the
ground.  It may be transported by winds, but, as a rule,  altitude
exempts from malaria.   This altitude must be greater in proportion
as the malarial infection is most intense.  It must  be  greater and
greater  toward the equator.  Near Rome is the elevation of Tivoli,
one hundred and sixty-five yards  perpendicular height, where mal-
aria still exists,  but  in  much less intense degree; beyond is Monte
Mario, two hundred and thirty yards, where fewer and fewer cases
are found; while further off is Serre, three hundred and twenty yards,
absolutely free of malaria.
   It is  estimated, as a rule,  that the necessary altitude to secure
exemption is,  in Italy, ten or eleven  hundred feet; in the Pyrenees,
five thousand feet; in Ceylon, sixty-five hundred feet ; and in Peru,
ten thousand feet.  The limit to which the disease can be transported
by the wind is estimated best at  sea.  The crews of ships off the
coast of Africa secure exemption at a distance  of about three thou-
sand feet, and about the same distance is observed, in malarious sea-
sons, off the rocks of Gibraltar.   So well recognized is the fact of
altitudinal exemption that  the inhabitants  of intensely  malarious
countries build their houses above the level of  the ground.   Thus at
Demerara  the natives build their huts  on corn stalks to  lift them
above the surface.  Soldiers in these countries  are not permitted to
sleep on the ground floor of barracks.
   It is the relative rather than the absolute humidity which deter-
mines in certain  places the production of the disease.  Thus in the
perfectly dry island of Barbadoes malaria prevails  only when the
rain falls, a greater part of  the year; while  in  Trinidad, unless the
rain falls a greater part  of the year,  malaria is developed.   In Bar-
badoes any diminution of the rainfall is drunk up and disposed of  by
the soil, while in Trinidad a diminution of rainfall lays bare vast
tracts of marsh otherwise covered with water.  The rocks of Gib-
raltar and  the rocks about the Orinoco, considerable elevations, are
nevertheless hotbeds of malaria, because  the springs which prevail
in these places feed the vegetation which forms in fissures and cre-
vices, and, with  the abundant moisture and great heat, furnish the
requisites for  malaria.   Malaria has developed also an  intensity in
sandy plains,  as in the English army at Rosendaal.   In these cases 
                            MALARIA.                        287

water may be found at any place a foot or so beneath the excessively
dry  surface.  The  subsoil is really detritus,  vegetation originally
brought  down by the  Rhine and Waal, and covered by the winds
with find sand, the  silt of the sea.   These  are, therefore, apparent
and not real exceptions.
   On the other  hand,  there are places upon the earth where all the
necessary conditions seem to exist and  yet malaria is absent.  Before
the gates of Mexico lies the great lake of Tescudo, twenty-five square
miles in extent, stagnant, brackish, with abundant decomposing vege-
tation, subject to the heat of a tropical sun, and yet developing little
or no malaria.  The same thing has been seen in certain islands of the
Pacific, in  swamp lands of Australia,  Asia, and  notably, curious as
it may seem, in the well-known marshes of the Emerald Isle.  Here
are heat, moisture, and vegetable decomposition, but, for some unex-
plained reason as yet, no malaria.  Liebermeister ventures an expla-
nation to the effect that the cause has not yet  been carried there.
Perhaps there may be discovered other conditions which prevent its
growth.
   Obstacle is sometimes offered to the transmission of the infection
by interposing trees.  Malaria prevailed at Villatri until it was in-
tercepted by the growth of a grove of trees, which Pope Benedict
XIV. afterward cut down to expose the place to new infection.  The
ancient temples of medicine, which were sanatoria, were situated on
islands and surrounded by trees.  The indigo planters  are not afraid
to dump the refuse of the plant  after  the extraction of  its coloring
matter, hotbeds  of malaria, in close  proximity to their houses, pro-
vided there intervene a grove of trees.
   As marshes become drained,  more  especially  as cities are built,
streets paved, sewers constructed, places and towns previously un-
healthy become habitable.  Hippocrates says of Abydos  that it was
freed from  malaria in this way.  Sydenham declares that in his time
one to two  thousand people died every  year in London.  At the pre-
sent  time it is  difficult to find  a case.  So it is noticed in our own
country that cases seldom or never develop in the city proper, but in
the suburbs and  outlying districts, more especially in the valleys of
rivers after the recession of overflows.
   Malaria has for a long time been supposed to be caused  by a con-
tagium vivum,  with  no other  positive proof, however,  than the
isolated experiments of  Gerhardt, of  Berlin, who succeeded in pro-
ducing, the  disease by injecting blood from the spleen of  an affected
individual into the veins of a healthy man.   All  efforts  to discover
any  demonstrable and acceptable  cause   of  the disease  remained
futile up to the time  of the investigations  of  Laveran  (1881),  a
French military surgeon of Algiers, who succeeded in  discovering. 
288
MALARIA.
in the red blood corpuscles peculiar amoeboid bodies endowed with
characteristic protoplasmic motion  and containing granules <>f  pig-
ment matter (vide Frontispiece, Fig. 2). Certain smaller bodies of ir-
regular,  semilunar, crescentic outline are  also found  in the blood
plasma, connected together often by fine threads.   These bodies are
present in the blood of malaria in greatest abundance during a chill,
and disappear to a great extent after  the attack.   Many of them are
rHHHHHHHHH
  ~mammmmmmmi
mmmfflmmmmmmm
liliill
Iliiil
  Fig 155 —Temperature curve in man after injection of blood from patient affected with mal-
arial (quartan) fever : x 19, noon, injection of four cubic centimetres blood ; + injection of two
grammes of muriate of quinia (Bacelli),

clear, more or less spherical, sometimes flagellated, hyaline masses.
undiscoverable without the use of dyes.  They gradually increase in
size until they fill the body of the corpuscle,  during which process they
undergo peculiar segmentation.   The intracorpuscular body receives
the name plasmodium.   Besides the plasmodium, flagellate structures
with three to eight long, active cilia may be seen floating free in the
blood of more acute cases,  or may  be  discovered more especially in
blood withdrawn from the spleen, which is regarded as the hotbed
   Fig. 156.—Plasmodium malariae : a, b, c, intracorpuscular bodies ; g, crescent; h, flagella.

of malaria in the body.  Golgi claims that the various types of fever,
anomalies, etc., depend upon peculiarities or differences in these pa-
rasites, and Laveran maintains that the crescentic forms are found
only in inveterate and cachectic cases.   So, too, it is said that qui-
nine destroys only the plasmodium, and that arsenic has more  effect
upon the crescentic form. Concentrated aqueous solutions of fuchsin 
MALARIA.
289
and methylene blue are the  best staining agents for ordinary diag-
nosis.  Fine double colorings are made with eosin concentrated solu-
tion in glycerin, with two to  five per cent absolute alcohol, and sub-
sequent stain with methylene blue.  The specimen, after five  to ten
minutes  in each staining, is washed off and preserved in balsam.
After this method the red corpuscles are colored pale red, the nuclei of
the white blood corpuscles pale blue, and the parasites a deep blue.
The blood is best examined as taken fresh, at the height of fever, from
a drop after puncture of the end of a finger, upon a cover glass which
is at once covered by another glass, put under the microscope and
stained, when the amoeboid bodies  show themselves in abundance.
These bodies  disappear after the  administration  of  quinine  and
arsenic, hence they may not be found in subjects under  treatment.
Variations in the type of the disease—quotidian, tertian, and quar-
tan—are believed to correspond to varieties in the  life  history of
these structures.   As they are found always in malaria, and only in
malaria, and disappear from  the blood with the cure of the disease
spontaneously or artificially,  they are believed to be the cause  of the
disease ; but  as  they have not been discovered out of the body, and
as they may not be cultivated in special soils, the mode of ingress  is
not known.   It is probable that these bodies, as  such,  or  in prelimi-
nary stage of development, originate in  water ; that they are then
taken up by the air and inhaled into the  body of man.  It is known
that the disease  has resulted  distinctly from drinking-water, as well
as from air.   An instructive  illustration  of this fact is found  in the
statement of  Baudin, who  reported  the infection of a  number of
soldiers by the  use of  drinking-water.  The soldiers were being
transported  from Algiers to Marseilles. From some oversight the
water supply was neglected  and had  to be taken in at  a  swampy
place known as Bona.   The crew had their  own water, and nine of
the soldiers used only the water of the crew.  The crew remained
entirely unaffected, as did also the  nine  soldiers, while all the rest,
without  exception, were taken sick  with the disease.   Probably
malaqua is a name as  appropriate as  malaria.   But in the vast
majority of cases the disease is inhaled.   Abundant proof of this
fact  is  established by direct observation.   Experimenters have ex-
posed themselves for hours, have gone to sleep or spent the night in
proximity or in the midst of a marsh, to  be taken, in the course of  a
few hours, with characteristic symptoms of the disease.
   Malaria presents itself in a varied picture of forms so different as
to seem to belong to different affections,  but all  resolvable into mal-
aria by the periodicity of symptoms  or  by the success of treatment.
   The forms which are now recognized  are :
   1.  Intermittent fever with distinct interval.
         19 
290
MALARIA.
   2.  Remittent or continuous fever, where the  interval is  short  or
nearly absent.
   3.  Masked malaria, with an infinitely varied  symptomatology.
   1.  Pernicious malaria, with grave symptoms  of blood poisoning.
   5.  Malarial cachexia.
   Intermittent fever begins with a eh ill, which distinguishes itself
by its severity, in which regard it is  equalled  only by that which
announces croupous pneumonia and cerebro-spinal meningitis.  The
cold is so severe as to make the teeth chatter and agitate the body in
those violent shivering movements which  constitute a chill.  The
temperature  rises during  the  chill to 101°. even to 105°. and is not
increased more than half to one degree during the subsequent fever.
Yet the surface of the body  remains distinctly cold.  The nose is
pinched, the  eyes are sunken, the cheeks,  the  tip of the nose, the
lobes of the ear are cold, the  surface is tinged blue.   There is cutis
anserina.   Cold sensations shoot out from the spinal column through
the trunk to the extremities, and may not be overcome or subdued at
first by approach to the fire or  by any amount of clothing.   In bad
cases there are, at this  stage, signs of distinct collapse : the  heart's
action becomes feeble, the pulse flutters, there  is profound  prostra-
tion of strength  and almost  entire abolition of the voice.   In the
course of half an hour to two hours the chill gives place to a second
stage, the fever.  Sensations of heat now shoot out  from the spine,
at first as agreeable  substitutes  for the extreme cold.  For a time
flashes of heat and  shivering fits may alternate.   Soon  the heat
assumes the mastery; the surface is  supplied  with blood, the face
becomes flushed, the  eyes are reddened,  the vessels  throb, the pulse
bounds.   The heart's action  visibly agitates the chest.  The heat
becomes now so excessive as to be far from agreeable, and associated
with it is more or  less violent, beating headache.   The skin is dry
and hot, the  mouth is parched, there is great thirst.   The secretions
seem all dried up.  In this condition of extreme distress the patient
remains from two to  four hours, when the heat  begins gradually to
subside.  The attack is passing  over now into the third stage, the
sweat.
    Perspiration presents itself at first about the chest, but extends
gradually over the body.  It is especially abundant about  the neck
and flexures  of  the  joints ;  it stands out  in beads at last, and,  ac-
cumulating,  trickles  down upon  the face.  Gradually the extreme
heat begins to  abate.  Under the  evaporation of the  excessive
amount of fluid the surface cools, the  head  ceases to ache, the ves-
sels to throb, the heart to bound.  The sweating stage lasts again
from half an hour to two hours.   It is, as a rule, the shortest of  the
three stages  of the disease.  The patient now falls  into comfortable 
MALARIA.
291
slumber, or is able, feeling somewhat languid  or relaxed, to resume
his occupation.
    The scene repeats  itself in twenty-four, forty-eight, or seventy-

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two hours, to constitute quotidian, tertian, and quartan types of the
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292
MALARIA.
and  extremities may even become blue, but there is no convulsive-
agitation.  In the majority  of  cases the attack is announced with
the onset of the fever.   The picture does not vary in fever from that
of an  adult, save that, 2, children easily suffer delirium  and may
become more or less comatose.  3.  The sweating stage may be want-
ing entirely, or, if present, is never so abundant or long continued.
   As the intermissions become less and less marked  the  disease
finally  presents the  form  of a  remittent fever.   Fever now never
entirely abates  throughout  the whole course of  the  twenty-four
hours, but there may be noticed during the early hours of the morn-
ing a more or less distinct remission of  symptoms  and fall of tem-
perature of one to three degrees, with corresponding improvement in
the subjective condition.  In  remittent fever the attack distinguishes
itself by prominence  of symptoms on the  part  of the digestive sys.
tern.   There is  gastro-intestinal, more especially  duodenal  ca-
tarrh.   The tongue is  more or less heavily coated  ; there is more
marked anorexia and  nausea ;  vomiting  is  more  persistent and
troublesome.  Many cases are marked by jaundice; the conjunctiva
is tinted.  The skin assumes  a distinct yellowish hue.  There is also
pronounced constipation.  These are the attacks that the old writers
called bilious fever.  As the disease becomes more and more con-
tinuous  it comes to finally  assume the picture of  typhoid  fever.
There is, along with the gastric, more and more nervous depression,
more and more stupor or headache, so  that at times the  diagnosis
is not easily distinguished from that of typhoid fever.  IPematuria
is a complication which  occasionally occurs in these cases.  This
accident is much more frequent in the more intensely  malarious
countries, but occurs occasionally everywhere.  In  the  temperate
zone  haematuria  should first excite the  suspicion of malarial fever.
As a rule it yields readily to  quinia.
   Masked malaria shows itself under a multitude of forms, the chief
of which is neuralgia.  Under whatever form, masked malaria is
usually quotidian in type.  The affection  sets in in the earlier hours
of the morning  and ceases toward the  close of the afternoon.  The
supra-orbital nerves are picked upon by special preference.  Supra-
orbital neuralgia is of  malarial origin in the majority of cases.  This
is the brow ague, or, from its occurrence during the day and absence
at night, the " sun pain" of  old people.   The occipital nerves rank
second in the order of attack—pain in the back of the head, with  the
dull depression  that  distinguishes malarial poisonings.  It sets in
about 10 o'clock in the morning, to remain with the patient through-
out the day.  The intercostal nerves are attacked in the same way,
to be  distinguished  at times from other  intercostal neuralgia, or
affection of deeper seated organs, only by the therapeutic test. 
MALARIA.
293
   Sciatica has malarial origin rather as an exception, neuralgia of
this nerve arising generally from other causes.   Various paraesthesise,
more rarely anaesthesias, may likewise depend upon malarial cause,
and be recognized by periodicity of occurrence and rapid relief under
the use of quinia.  Malaria may also simulate pneumonia and pleu-
risy, affection of the kidney and bladder.   There are malarial dysen-
teries and diarrhoeas, malarial coryzas and catarrhs.  There are cases
of malarial hydrophobia and tetanus, night blindness, etc.   Curiosi-
ties of all kinds may be found in the case books, dependent upon
malaria as proven in the same way.   It may be said that as the
malarial poison becomes less and less intense,  in cities, for instance,
as distinguished from  country places, the  masked  forms of malaria,
which are the milder  forms, predominate.  The general rule holds
good for all diseases or for any affection which shows more or less
distinct periodicity of occurrence.  It probably depends upon  mal-
arial  cause.  Thus dyspepsias and dysenteries  which  have defied
all kinds of local treatment for months or years have yielded quickly
and permanently to specific treatment.   At the same time it must be
admitted that the element  of periodicity is not so distinct in our day
as formerly.   In the first place, the  disease itself is milder.   It may
be assumed that less of the cause has been ingested or inhaled, or
that in most cases the course of the  disease has been interrupted or
disturbed by treatment, so that the typical periodicity is not so easily
elicited.   But doubt alone justifies  a trial of the therapeutic test.
Of these cases it is said that the diagnosis is made ex  juvantibus.
Thus also it is made plain that many  affections, especially neuralgias,
of periodic occurrence  or recurrence,  are not necessarily malarial, are
rather rheumatic in that they yield sooner to the salicylates than to
quinine.
   Pernicious malaria  is that form in which either an enormous
amount of the poison  has  been received into  the  body, or the body
itself has been greatly debilitated in  the course of the disease or by
other maladies.   Pernicious malaria  shows itself,  therefore, most in
the unacclimatized, who are always peculiarly susceptible.   It never
occurs with the first, but shows itself in the  second or  third attack.
It is announced with a  chill, or with the second  or third attack of
quotidian, tertian, or quartan form; and presents itself also in variety
of form.   The most common is the comatose form, in which, under
the chill, the patient falls into fever, stupor, and  coma.  The face is
deeply flushed, the conjunctivae congested  ; the pupils, dilated or con-
tracted, are irresponsive to light; the cheeks flap in respiration ; there
is stertorous breathing, general  abolition of all sense, sensation, and
motion, as in the picture of cerebral haemorrhage.
   A marked contrast to  it is  the  so-called  algid form, in which 
291
MALARIA.
there is  profound  collapse, feeble,  fluttering  pulse, cold surface
covered with a clammy sweat,  as in the picture of a  protracted
syncope.
   Pernicious malaria is sometimes manifested also in the convulsive
form.   Fits, which closely resemble  attacks of eclampsia, agitate
the body,  or assume at times the aspect of hydrophobia  with its
dread of water and terrible anxiety; or of tetanus, with fixation of
the jaw, rigid contraction of the muscles of the  body,  sometimes
with complete opisthotonos.
   Malarial cachexia shows itself in individuals, long residents of a
malarial climate, who have become  to a degree acclimatized.   In
these cases the blood may be said to be saturated with malarial  poi-
son, to the degradation of the strength, physical and mental.   These
individuals show the picture, more or less pronounced, of marasmus.
There is emaciation with the prostration ; the complexion is sallow,
the eyes  sunken, the expression listless, apathetic.  Perhaps  the
most marked bodily change to be discovered in these cases is distinct
enlargement of the spleen, which, in the form of " ague cake," may
be increased from five to fifteen times its natural size, to  largely, or
apparently entirely, fill  up  the  abdominal cavity.  These  subjects
are continual sufferers from irregular chills  and fever, with head-
ache, neuralgias,  and the various masked forms of the disease.   The
poison which  accumulates in the blood  and spleen  may manifest
itself in almost any organ at any time.
   The diagnosis rests upon the periodicity of attack, the intermis-
sions or remissions (as determined by the thermometer in the hours
of early morning), the  enlargement of the spleen, and,  in doubtful
cases,  the examination of the blood.  Laveran found the parasite
four hundred  and thirty-two  times in four hundred and eighty ob-
servations.
   The prognosis has entirely changed for the better since the  dis-
covery of quinia—in fact, since  the  discovery of cinchona, in 1640,
when the  first specimen  was brought to Spain from  Peru by the
Count of Cinchon, the  Spanish Viceroy, and his body physician,
Juan del Vego.   Not much  distinct progress  was made, however, in
the treatment of the  disease until  the time  of  Sydenham, who
adopted the practice suggested by a druggist's clerk,  Robert Talbor,
of Cambridge, to dissolve the bark in alcohol (making a tincture, in
other words), and administering the remedy  close upon the heels of
the previous, to prevent a future, attack. This treatment was per-
fected by the discovery of quinia by Pelletier, since which time the
bark itself has been only rarely employed.  All question of discus-
sion regarding the treatment of malaria revolves now about dosage
and time of administration.   It is now common and the best prac- 
MALARIA.
295
tice to administer the  remedy before the attack, and, as quinine has
its maximum effect five  hours after administration, it is given so
that this effect shall coincide with the onset of the attack.   An adult
requires twenty-five to thirty grains, a child five to fifteen grains, to
prevent attack.   It is  best given in pill,  capsule, or wafer, and to
children in powder with milk, in broken doses, taken in the course of
half to one hour.  Quinine is one of the remedies which may be
given with nearly equal efficacy in the same doses per rectum.  But
quinine may fail, for two reasons—one, that the remedy may not be
absorbed ; another, that after long use tolerance is begotten.  These
evils may be avoided by the administration of the  remedy per  rec-
tum or subcutaneously.  For such use the  neutral bromide is to be
preferred, as all acids irritate the skin.  Care must  be taken to keep
the solution hot.   The  test tube, the spoon, and the syringe must all
be kept warm, and the drug, in the ordinary dose of five grains to
the maximum dose of ten grains, must be injected under the skin of
the back deep into the subcutaneous tissues.   Quinine may be used
in this way in only the most exceptional cases, as,  for instance, in
pernicious malaria, where no  time  may be lost in  addressing the
cause of the disease.
   The use  of arsenic in malaria  dates from the last century.  It
was first employed by charlatans under the name of  " ague drops,"
and came into general  use only when Fowler prepared  a solution by
which the  quantity of the drug could be easily graduated and ad-
ministered without danger.   Arsenic is adapted especially to the
cases of chronic malaria, malarial  cachexia, and masked forms ob-
stinate to quinia.  The remedy is best given in the form of Fowler's
solution, gtt. ij.-v. after  each meal, to be  increased daily to tole-
rance, as manifest in puffiness of the eyelids, pain in the  bowels, or
diarrhoea.  Upon the occurrence of either of these signs the remedy
is to be discontinued at once.  Should it be deemed necessary to con-
tinue the dose in larger quantity, the pain and the diarrhoea may be
prevented by the simultaneous use of a few drops of the tincture of
opium.
   Under the use of quinia and arsenic the protozoa which cause the
disease disappear  from the blood,  but  to secure permanent  disap-
pearance it is necessary that the remedy shall be continued in grad-
ually diminished doses  for at least a week after the subsidence of all
symptoms.
   As  methylene  blue has been observed to have the same effect
upon the plasmodium malarias,  this remedy has been tried  success-
fully by Guttman and  Ehrlich.  Doses of one  to one  and  one-half
grains of pure medicinal methylene blue, administered in  capsule to
prevent staining the mouth,  every two hours for one or  two  days, 
29G
YELLOW FEVER.
rid the blood of protozoa and  break up the attacks of the disease.
The remedy sometimes causes severe dysuria and has no advantage
over quinia.  Obstinate cases demand change of climate.
                        YELLOW FEVER.

   Yellow fever ; Spanish, vomito negro (black vomit).—An acute
infection of tropical coast towns, characterized by fewer, which shows
itself in stages  of access, subsidence (stage of calm), and  renewal
(stage of reaction), icterus, albuminuria, haematemesis  (black vomit),
and rapid and profound prostration.
   History,  Geography, etc.—Yellow fever is indigenous in  cer-
										Day		c	f	D	He a^e													
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              Fig. 160.—Temperature chart, yellow fever; mild case

tain parts of the tropics—West  Africa, where it is believed to have
originated ;  West  Indies (Antilles), first in 161? ; Mexico in 1099—
and is thence disseminated along lines  of  travel by sea to seaport
towns or towns in  direct (river) communication with the sea.
   It is nowhere indigenous ki our country, and *m&s out every win-
ter on the advent  of frost.  Hence it must be freshly imported, un-
less infected matter be held over under favoring circumstances, as at
Memphis, 1879. where it had hibernated from the previous year.
   It reached the United States first at Boston in 1(593, and has since
occurred and prevailed at various places and periods—sometimes as a
mild endemic, sometimes as a devastating epidemic—up to the present 
YELLOW FEVER.
297
time.  Thus in Philadelphia in 1793, of 11,000 cases, 1,010 fell victims
to the disease; in the epidemic of  1853 at New Orleans the mortal-
ity was 7,970, and in that of Memphis in 1873 the deaths numbered
2,000.   The disease  has been carried as far  north as Portsmouth,
New Hampshire (1798), and has penetrated to the interior by refugees
as far as Cincinnati and Gallipolis  (1887).  The highest altitude
(seven hundred and forty-five feet above the level of the sea) was
reached at Chattanooga, Tennessee (1878).  The famous College of
Physicians of Philadelphia first (1797) promulgated the view that the
disease is always of foreign origin and should be barred out by quar-
antine.  The finest description of yellow fever was furnished by La
										L	a	Y	°	f	D	■sea _?e												
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           Fig. 161.—Temperature chart, yellow fever; typical severe case.

Roche, Philadelphia (1793) ; the most thorough studies of etiology by
Sternberg, Surgeon U. S. A., Washington (1890).
   Etiology.—Y_.elJ.ow fever comes only from without, and is pre-
sumptively caused by a micro-organism which, despite claims to the
contrary, has not yet been isolated.   The disease requires for develop-
ment a certain temperature (75° F.) and moisture.   It is not directly
contagious, and is chiefly conveyed by things (fomites), especially
by baggage and bedding of patients, and bilge water of ships carry-
ing cases of the disease.   The acclimatized have a degree of immu-
nity which is lost by change of residence to regions  never visited  by 
298
YELLOW FEVER.
the disease.   The colored races, Africans, Creoles, have a certain im-
munity and lessened mortality.  One attack confers immunity, as a
rule.
   Symj-)toms.—The incubation is short,  from one  to  five days.
This period is  usually wholly free of  symptoms.  In  exceptional
cases malaise, anorexia, headache, vertigo, pain in the back, fatigue
with tendency to sweat, may show themselves as prodromata.
   As  a rule the onset is sudden, with a chill,  attended and followed
by fever, frontal headache, and heavy rheumatic pains.  Pains in
the loins and  legs may be excruciating in severity.  The face is
flushed,  the eyes shine and are  intolerant to light.   " The dusky
Tfr,p ' /Of"	I	J	<l	Da-y of D<sea se. S~ 6 7 8 <? 'o // tz, /J /v
				
/or'---				
				
/«<•'.	r---H~			
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101'----				#-=§§--E-------
ic.'-----	-----			
99'— 9f- —				1 II
	1			
Fig. 162.—Temperature chart, yellow fever ; protracted case.
face with the deep suffusion of the eyes in severe cases is quite char-
acteristic " (Sternberg).   The pulse, full and strong at first, is reduced
in frequency and force, often during the height of the fever, and
always in the stage of calm, when it may fall from 100-120 to 10-30
in the minute.
   The cardinal symptoms of yellow fever are three—viz., the fever,
the icterus, the vomit.  These symptoms have given the name to the
disease.
   The fever is peculiar, in that it consists of  but a single paroxysm 
YELLOW FEVER.
299
with a break in its gradual fall.  The temperature is highest at the
start and falls at once, and to such degree that the first few days only
are considered febrile.
   Hereupon ensues the stage of calm, a period nearly or quite free
of fever, but marked by profound  prostration.   The stage of calm,
like the stage of fever, lasts from a few hours to a few days, and is
followed by the reaction  with  fever of remittent type.  The accom-
panying charts (Figs. 160-162) from Sternberg's account  record the
run of the temperature in a mild, a protracted, and a severe case.
   The  icterus, which may be  entirely absent, usually shows  itself
about the third day, and varies in degree from a faint yellowish
tinge to a deep mahogany hue.  When absent from  the skin it may
be still seen in the conjunctivae, where it often makes striking con-
  Fig. 163. -Liver cells in yellow fever with    Fig. 164.—Streptococcus from vomit (not black)
necrotic masses in and between the liver  of yellow fever (Sternberg).
cells (Sternberg).
trasts in the colored race; in  a fatal  case  it may show itself only
post mortem.   The icterus is due to rapid disorganization of the liver
and reabsorption of bile.  The symptoms largely revolve about  the
condition of the liver, which  is found on autopsy to have suffered
acute parenchymatous with fatty change  without sensible atrophy.
Products of this degeneration,  as well as of the kidney, which shows
the same process, poison the blood and produce  in the last stages of
the disease symptoms of urcemia, the cholera typhoid with coma.
   Gastric distress, vomiting,  as  a sign of  toxaemia, belongs to all
the grave infections, but is especially frequent and severe in yellow
fever.  The black vomit  is blood from haemorrhage by diapedesis 
300
YELLOW FEVER.
through paretic vessel walls.  It shows itself in the graver case^ in
the course of the first days, but is often entirely absent  even in fatal
cases of the disease.  Haemorrhage  may occur also from other mu-
cosae, as from the mouth and nose (epistaxis), more rarely from the
stomach, intestine, bladder, uterus, etc.
   The urine is scanty and dark, in bad cases suppressed, and al-
ways contains albumin as one of the main features of the disease.
The mind is usually clear but indifferent.   Consciousness  is main-
tained with  apathy.   Delirium is not common, though the  scene
usually closes with coma.
   The diagnosis rests upon, 1, the existence of the disease in the
community,  or  knowledge of  its importation; 2, the  albuminuria,
which in its presence or abundance helps to  distinguish yellow from
remittent (malarial) fever; 3,  the character of  the fever  with its
stages; 1, the icterus; 5, the coffee-ground or black vomit.   Yellow
fever is distinguished from dengue  by the fever (stages), as well as
by the predominant or persistent  pains of dengue, and  from typhoid
by the mental state, fever, and abdominal signs of typhoid fever.
   The prognosis is always grave, and is based upon the intensity of
individual signs,  the amount of albuminuria, the degree of fever and
of jaundice,  etc.  Black vomit is ominous, but is by  no means of
necessity fatal.   The mortality ranges from ten  per cent with  the
acclimatized, to eighty per cent with those not thus protected. Three-
fourths of the deaths  occur in the first week of the disease.
   Prophylaxis  consists in the quarantine  of ships carrying cases
of the disease.  Land quarantine is useless.  Camp life in healthy
places is  the best protection during prevalence of epidemics.
   The treatment is symptomatic.  It is considered good practice to
open the bowels freely at the start with calomel or castor oil, but bad
practice  to continue  purgation.   Fever is  best  allayed by sponge
baths and phenacetin gr. v.-x.; irritability of the stomach by cracked
ice, bicarbonate of soda gr. x.-xx., best in soda or Selters water, or
by chloral gr. ij.-v. in peppermint water.
   To counteract the  excessive  acidity of  the  various secretions,
Sternberg suggested  the use of sublimate with the bicarbonate of
soda as an alkaline antiseptic.  After favorable reports from exten-
sive trial, the combination was improved as follows:
   B Sodii bicarbonatis.............................................3 iv.
     Hydrargyri bichloridis....................................gr. ss.
     Aquae puree...................................................O ij.
   M.
For a severe case two  tablespoonfuls every hour, day and  night;
for a mild case, every hour by day and every two hours by night;
administer always ice-cold. 
CEREBRO-SPINAL MENINGITIS.
301
                  CEREBRO-SPINAL MENINGITIS.

   Cerebro-spinal meningitis (epidemic as distinct from simple and
tubercular  meningitis, prjviy^, a membrane).—An  acute infection,
caused probably by various bacteria, commonly by a diplococcus,
characterized  by  sudden  onset,  headache,  opisthotonos,  herpes,
hyperaesthesia, and constipation.
   History,  Geography, etc.—Cerebro-spinal meningitis is a dis-
ease of modern origin or of modern recognition, for previous to the
present century there was no possible differentiation of this  disease
and forms of typhus fever,  pernicious  malarial fever,  tetanus, and
the various inflammations of the brain and cord, diseases known  to
be as old as the history of medicine.
   It is  now conceded that it was first remarked as a  separate dis-
ease in Geneva, February,  1805, by Vieusseux, who called the mal-
ady a fie v re cerebrate ataxique. and admitted that neither he nor
his colleagues had ever seen a similar disease.
   The next outbreak of the disease, with unmistakable signs,  oc-
curred in our oAvn country, with the first cases at Medfield, Mass.,
in 1806.  These cases formed the preface to a  long chapter in the
history of the disease, known then as " sinking typhus," ten  years
in duration, during which time it extended over, but remained con-
fined to. the New England States.
   Though doubtful cases prevailed before this time,  cerebro-spinal
meningitis belongs to the nineteenth century,  and its history  natu-
rally falls into three periods, quite distinct, the first embracing  the
first cases of "ataxic cerebral fever," observed at Geneva in  1805,
and of " spotted fever," in  Massachusetts, in 1806 ; the second com-
mencing with the outbreak at Bayonne  in 1837, and extending over
various parts of Europe and America  up to the year 1866, gradu-
ally merging into the third or present period, when the disease has
become nearly universal.
   Cerebro-spinal meningitis belongs among the rarest of epidemic
diseases.  Since the establishment of the disease as a pandemic af-
fection sporadic cases are of continual  recurrence, but these cases re-
main isolated as a rule.   The practitioner is often surprised at  being
confronted with a pronounced case of  this disease in a crowded ten-
ement  house, in a palatial suburban residence, in a barrack or jail,
in the ward of a hospital, in  a distant farmhouse, when no similar
case may have been reported, and probably no  other case may show
itself for years.  Widespread epidemics  constitute the great excep-
tion in the history of this disease, the  outbreak at Dantzic in  1864-
65 being the only notable example.  So that  individual cases, not
distinctly marked, are apt to be overlooked for a time or erroneously 
302
CEREBRO-SPINAL MENINGITIS.
diagnosticated, and numerous  instances are recorded in which  the
diagnosis has been fully established only upon autopsy.
   Etiology.—Every attempt  to connect cerebro-spinal meningitis
with any special  climate has turned out a signal failure.  Equally
futile has been the endeavor to  fix the disease in connection with any
special soil.  But the season of the year has more to do with  the
development of this disease.  Perhaps  the most striking fact appa-
rent in the study of  the etiology of this affection  is the frequency
of its occurrence during the colder months of the year.  Thus, of
fifty-two epidemics in France and Switzerland, twenty-three occurred
in winter, thirteen in winter and spring, and but two in the midst
of summer;  while of sixteen epidemics in our own country, six oc-
curred in winter anel five in winter and  spring.
   While it  is acknowledged  of  cerebro-spinal meningitis  that an
almost freakish variation has occurred in its attack of individuals, it
is generally  conceded that it shows predilection for  the period of
youth.   Thus it is stated by  Hirsch  that of  1,267 fatal cases in
Sweden  in the years 1855-60,  where the  age  was  stated, 889 were
under fifteen years of age, 328 from sixteen to forty years, and 50
over forty years of age.  Emminghaus makes the collective state-
ment, from  over fifty extensive observers, that of  1,435 cases 1,133
were  under fifteen years of age.  Smith,  New York, found that of
975 cases 771 occurred in persons under  fifteen years of age,  and  336
in children  under five years of age.  In  some epidemics children
have been the only victims of the disease.
   Individual epidemics have been frequently noticed to have been
distinctly connected with  different  social  states.   The  selection of
soldiers as exclusive victims has made this disease a familiar guest
in army life.  The recent conscripts  and new recruits have been
often the sole victims of the disease.   Pfeiffer says the disease " pre-
fers winter,  soldiers, and children."
   A strict localization of the disease to certain houses, flats, or sto-
ries has often been observed.  Prisons, workhouses, orphan asylums,
constitute at times breeding places of cerebro-spinal meningitis. The
epidemic  in Ireland in 1846 was strictly confined to the prisons, and
the disease broke out with  the same  seclusion in the orphan asylums
in Philadelphia and Vienna in  1863, Washington in 1S69, and Jeru-
salem in 1872.
   One attack of cerebro-spinal meningitis confers future immunity.
   Symptoms.—The disease begins with the aspect of a grave, acute
infection.  As a  rule the onset is sudden, with the impress of pro-
found toxaemia.   A chill comes on in the  midst of apparent health,
with  vomiting,  excruciating  headache, and rapid  prostration.
Tenderness  and stiffness in the back of the neck supervene in  the 
                  CEREBRO-SPINAL MENINGITIS.                303

course of a few hours.  The face is pale, the expression anxious and
strange, the extremities stiff and tremulous.   The slightest motion
intensifies the pain in the whole body ; the act of vomiting makes it
atrocious.  A sense of formication with  hyperesthesia is felt first,
as a rule, in the lower extremities, to which it may remain confined,
or it may extend over the whole  body.   The special  senses of sight
and hearing  become likewise supersensitive.   A flare of light, the
slam of a door, the  rumble of wheels in the  street, a touch of the
bed, produce  a condition  of agony.  Even the approach of an at-
tendant with the gentlest  ministrations is watched with apprehen-
sion.  Temporary relief of  this distress  is secured during a  state of
sopor or stupor which may occur, from  which the patient awakens
or is aroused—children often with a cri hydrocephaly que—with a
renewal of the same symptoms in greater or less degree.
   In the course of  a few days, often during the same day of attack,
   Fig. 165.—Extreme opisthotonos.  From the original painting by Sir Charles Bell (Spence).

the stiffness of the neck increases to rigidity, or extends to constitute
the characteristic opisthotonos.
   Opisthotonos stands in the foreground in the semeiology of this
disease.  It is rare that some degree of rigidity in  the back of the
neck is not present, though Burdon Sanderson declares that in the
Prussian epidemic, 1864-65, there were  many cases  in  which there
was no stiffness  or retraction of  the muscles.   In the lightest cases
there is simply a sense of increased resistance on attempts at flexion
of the head upon the chest—a valuable point in differential  diagnosis
—or a slight degree of tenderness to pressure upon the  cervical ver-
tebras.   In most severe  cases rigidity is marked, with  retraction of
the entire head, to such degree at times as  to  give  rise to extreme
mechanical d}Tsphagia.   Leyden speaks of cases  in  which the  head
was bent back at a right angle to the spine, and Gordon mentions an
instance in which, in addition to this deformity, the  spine presented 
304
CEREBROSPINAL MENINGITIS.
"a most wonderful  uniform curve concave backward."  The most
striking illustration of the degree to which this extension may occur
was reported by Neville Hart in a case in which the pressure of the
occiput caused a slough between  the  scapulae.   In the experience of
this author the degree of opisthotonos corresponded with the  gravity
of the disease.   Not infrequently the rigidity extends  lower in the
vertebral column, as in Gordon's case just mentioned.  Thus Jan-
sen mentions an instance where the whole body could be lifted rigid
with the hand behind the occiput, and Ziemssen and Merkel report
cases of '' orthotonos" in which attempts to flex  the  head pushed
the body like a statue to the  foot of the bed.  With the other symp-
toms mentioned this condition may disappear, to reappear in greater
or less  degree,  undergo fluctuations throughout the disease, con-
tinue to the fatal end—as long in  one case as forty-nine days—or re-
main in some degree until full recovery.  Ziemssen speaks of conva-
lescents going  about with rigid  spines,  and cases are reported in
which the condition  lasted  throughout life.   Usually the retraction
is  symmetrical, as pleurosthotonos is very rare.   The rigidity is due
to tonic contraction of the deep muscles of the neck, the splenii; the
superficial  muscles, the trapezii, remain unaffected.   Convulsive
twitchings of the face, or clonic spasms  in the  muscles of  the ex-
tremities,  may  now occur, with  delirium or outbursts of maniacal
excitement under the slightest provocation.   In the case of a young
lady,  under the observation of the author, clonic convulsions of the
upper extremities existed continuously for three days and nights, and
were  only stilled finally by narcotic  doses of opium.   This patient
escaped with life, but with lesions that left it of little value.
   The skin shows the greatest variety of eruption  of any one of
the acute infections,  with nothing peculiar or pathognomonic in any.
A scarlatinous blush, more especially of the face, is very frequent in
the first days of the disease, and a roseolar exanthem, more espe-
cially upon the  trunk and  extremities, frequently follows later.
Hirsch speaks of spots resembling measles, Ziemssen  mentions urti-
caria,  Kamph   erysipelatous maculae, Grimshaw pemphigus,  and
Jenks bullae, in individual  cases.  As to  the petechiae which  have
falsely named the disease, they are most frequently distinguished by
their absence.  Yet bloody eruptions  or extravasations  do occur in
this disease as frequently as in any acute  infectious malady of equal
gravity.
   The only eruption which  has  any real significance in  meningitis
is  herpes.  It begins usually as early as the third day of the disease,
and may continue in renewed eruption throughout its course, or, as
Hirsch remarks, weeks after full recovery.  It shows itself first, as a
rule, about the face, on the lips, nose, forehead,  and neck,  or may 
CEREBRO-SPINAL MENINGITIS.
305
extend to the chest, abdomen, back, nates, and even the extremities.
Pneumonia is, perhaps, the only disease which shows herpes in equal
frequency, but the herpes of meningitis differs from that of pneumo-
nia in having no prognostic value.  In fact,  a renewed outbreak
rather signifies an exacerbation of the elisease.
   The temperature curve of the  disease distinguishes itself by its
irregularity.   As a rule it rises quickly at first to  102° F., or even
104° F.,  to fall in the  course of a few days, or to  undergo fluctua-
tions in extreme degree, sinking at times below the normal.  An ex-
treme hyperpyrexia  not infrequently precedes a fatal termination,
which is usually attended, however, with a reduction  to correspond
with the marble coldness of the skin.
   The pulse increases out of all proportion to the temperature, to
experience, later on in the attack, greater fluctuation  in frequency,
volume,  and tone than in almost any other disease.   The same  va-
riations are noticed also in the acts of respiration,  which  are often
quick and slow in the course of the same hour of the day.
   The  tongue is usually dry and  red, in bad cases fissured and fu-
liginous, and sordes in these cases cover the teeth and  gums.
   The  abdomen is sunken and retracted, often to  such a  degree as
to show the outlines of the bodies of the vertebras, or make distinctly
apparent the crests  and  prominences of the iliac bones.   Constipa-
tion is present, as a rule.  The urine flows scantily and slowly from
a paretic bladder, or in the worst  cases is  voided  unconsciously in
bed.  Trismus, singultus, delirium, and coma,  with ecchymoses and
meteorism of the abdomen, mark the speedy advent of the close of
the disease ; or relaxation of the opisthotonos, relief  of the pain in
the head, with critical sweats or enuresis, indicate a favorable reso-
lution.
   Of the symptoms produced by the local lesions, pain in the head
is among the most prominent.  Headache—crushing as if produced
by a vise, or boring as from the penetration  of nails or screws—is, as
has been stated, one of the initial signs, and it constitutes always one
of the most obstinate and distressing features of the disease.   Fortu-
nately it is subject to intermissions or remissions in the course of the
disease, and not infrequently it  disappears  altogether.  The other
signs of the disease may then still remain in force, though cessation
of headache may be  usually regarded as one of the most  favorable
signs in prognosis.   Warning  should be entered  here,  however,
against  that  ominous arrest of headache,  along with  a general
euphora, which  sometimes immediately precedes the end.   Vertigo
may be  associated with the headache, to  greatly aggravate the suf-
ferings of the patient  by compelling the continued observance of the
recumbent posture.
        20 
306
CEREBRO-SPINAL MENINGITIS.
   Pain of a similar character, indescribable in its intensity, is also
feltin other parts of the body, in the spinal column—rhaehiidgia—in
the extremities, or anywhere upon the  surface in  the course of the
spinal nerves.  Usually such pain is paroxysmal, fulgurant, agoniz-
ing.   It shoots out from the posterior nerve roots of the spinal cord.
where the local lesion, as determined by gravity, is most intense, and
carries with it sickening sensations of precordial depression.
   A more characteristic, though less frequent, sign of cerebro-spinal
meningitis is hyjwirestJiesia of the surface.   It is commonly absent
altogether in the lighter or  abortive forms, and may not show itself
throughout  the short course of the foudroyant forms, but it is quite
constant, at least in the earlier days of the disease, in cases of average
intensity.   It is first seen, as a rule, in the lower extremities, to which
it may remain  confined, next in  the upper extremities, and lastly in
the face and head.  Like  the pain, it may undergo remissions and
exacerbations,  may disappear to recur  later,  or may last over,  in
regions, to the  period  of convalescence.  When present it adds a
peculiar poignancy to the suffering of the patient, who watches with
anxious eyes every movement about the  room.   In aggravated cases
it is manifest also during sleep, and even the stupor of coma does not
entirely annul it.  In such cases it interferes with, or even entirely
prevents, an examination of the patient, wdiich, however, may be un-
necessary, as, with the history and superficial inspection, it frequently
declares the disease.  It is often absent throughout the whole course
of the malady.
   The symptoms on the part of the digestive system belong among
the cardinal manifestations of the disease, as vom iting ranks in signi-
ficance along with the chill, headache, and opisthotonos.  It  is only
the mildest  cases which show no disturbance of the stomach.  It
ceases frequently in a few days, to reappear in bad cases, and to re-
main at times a more or less constant attendant of the disease.
   Complications.—Cerebro-spinal meningitis is particularly prone
to a number of grave complications and sequelae, prominent among
which may be mentioned  paralysis and paresis of various  organs
and members, and profound, often permanent lesions of the eye and
ear.
   Among the most frequent and serious of  the complications are
catarrhal and croupous pneumonia.   Of these affections catarrhal
pneumonia, or broncho-pneumonia, is most frequently encountered in
children, and, if developed  as a  secondary affection,  readily under-
goes favorable  resolution.  But  croupous  pneumonia  has a much
more serious prognosis.  It occurs more frequently  in certain epi-
demics—fif teen times in the Erlangen epidemic of 18'iO to  1872—and
develops by predilection in the later periods of the outbreak of the dis- 
CEREBRO-SPINAL MENINGITIS.
307
ease.   Hyperaesthesia  may eventuate in anaesthesia to such  degree
as to permit the penetration of a pin.
   Of  the special senses, besides that of touch, the senses of vision
and hearing suffer most.  Corresponding to the hyperaesthesia or hy-
peralgesia of the surface of the body is photophobia, to such degree,
as a rule, as to necessitate the darkening of  the chamber and the
avoidance of artificial light.  Graver lesions than this functional dis-
turbance, conjunctivitis, iritis, irido-choroiditis, neuritis, atrophy of
the optic nerve, even panophthalmitis, may occur in the course of the
disease.   The same exaltation of sensibility affects the ear with even
greater distress, because  offence in this regard is less preventable.
Suppurative  processes in  the middle and internal ear, perforation of
the membranes, atrophic changes, are among the graver affections
of this organ as complications and sequelae of this disease.  So  cere-
bro-spinal meningitis is one of the most common causes of  deafness,
perhaps the most common cause of all diseases affecting the internal
ear.   For in the vast majority of  cases the affection is  bilateral and
permanent.  Deaf-mutism most frequently results from this disease.
   Forms.—Although different epidemics exhibit great variations in
the degree and number of the symptoms  cited, cerebro-spinal  men-
ingitis usually shows itself besides, in  the typical  cases  mentioned,
in one of three distinct forms or types—namely, the abortive,  the in-
termittent, and the siderant or foudroyant.
   The abort iveioTm  exhibits all its symptoms in the lightest grade.
The headache is slight, the stiffness of the neck trivial or temporary,
and vomiting may not occur, or may not recur after the first  attack.
Such cases often entirely escape recognition, or are diagnosticated
only because of the prevalence of an epidemic of the disease.
   The intermittent form is noticed more especially in certain epi-
demics, though such cases are wont to occur in any extensive out-
break  of the  disease.  Not  infrequently  isolated  sporadic  cases
assume this form, to the great  embarrassment  of the practitioner.
Quotidian and  tertian intermissions  or remissions occur  in all the
symptoms of the disease,  leading often for a time to erroneous prog-
nostications.   The  intermissions are by no means as distinct, as a
rule, as the periodicities of malarial disease, yet they prove exceed-
ingly deceptive to superficial observation.  The exacerbations corre-
spond  undoubtedly  to the irregular invasions or  advances  of the
cause of the disease.
   The foudroyant is  the fulminant  form, in which  the  patient is
often killed by the force of the poison before permanent local  lesions
have time to  develop.  These are the cases which destroy life in the
course of from six  to thirty-six hours.  The patients  in these  cases
are often  suddenly stricken with  unconsciousness  and convulsions, 
3(>8               CEREBRO-SPINAL MENINGITIS.

sometimes preceded for an hour or two with vomiting and pain  in
the head, in which condition they are  carried home, pallid, cold,  or
slightly cyanotic, showing no  reaction to the most powerful  stimu-
lants, to sink into coma and speedily succumb.
   Morbid  Anatomy.—The external appearance of  the  body  in
cerebro-spinal meningitis  varies with  the duration of the disease.
Rapid or  foudroyant cases exhibit no change,  but cases  of  longer
duration show an emaciation which in protracted illness  simulates
that of cancer and tuberculosis.  No trace of eruption is discover-
able, as a rule, though occasionally the surface remains covered with
petechiae.  Suggillations form quickly  and in quantity over the body,
and post-mortem rigidity  sets in soon.   Moreover,  decomposition
begins unusually early  in rapid cases, as in other acute infections.
In  the most chronic  forms, with  extreme emaciation, bed sores are
common and extensive.
   The muscular tissue  is  in the foudroyant cases brown and fragile,
in cases of  average duration more pale from  loss of blood.  The
molecular change  of  fatty degeneration  invades its structure, and
gives it the appearance, which is especially remarked of the heart,  of
being strewn with sand.
   The condition of the  spleen varies greatly.   It is usually found
swollen in fulminant forms, with deeply darkened pulp, but not in-
frequently it is shrunk to such degree  as to show a wrinkled cap-
sule.  In average  cases it is rather the rule to  find this organ  of
diminished size.  As  might have been  expected, the intermittent
forms show no enlargement of the spleen. The cloudy swelling,
fatty and granular degeneration of the kidney and liver, ecchymotic
state of the mucosae, oedema of the lungs, effusions  in the  serous
sacs, post-mortem softening of the stomach, swollen condition of the
mesenteric glands, dark color  and altered consistence of the blood,
are changes which belong to all the acute infections  and are espe-
cially marked in this disease.
   The characteristic  lesions are encountered at  the anatomical seat
of the disease, in the membranes of the brain and cord.
   On opening the skull the membranes of the brain are revealed  in
a state of intense hyperaemia.   The sinus longitudinalis is distended
to tension of its walls, and ail visible vessels are  filled to their utmo.-t
capacity.  In fulminant cases there may be no trace of  exudation,
but the pia mater is already opaque and lustreless, sometimes  ecchy-
motic, from infiltration  into its texture.  The substance of the brain
and cord is oedematous and softened in the most superficial layers.
   In cases of longer duration the dura mater  is stretched tense by
the effusion beneath it, punctate haemorrhages  are diffused over its
surface, and the hyperaemia involves the porous substance  of the 
CEREBRO-SPINAL MENINGITIS.               309
 bones of the spinal column, whose spongy structure appears saturated
 with blood.  The  pia mater is  reddened with  distended vessels, is
 opaque in some places, eccbymotic in others, and is softened in spots
 or more  extensive surfaces.  The first  exudation is a light serum,
 which  soon becomes  an opaque milky fluid of  semi-gelatinous or
 mucilaginous consistence, sticky, "drawing to a thread," which later
 becomes greenish, " leek-green," or yellowish with pus.  It is effused
 first in the subarachnoid spaces and along the course of the vessels of
 the pia mater at the base and sides of the cerebrum, in the fissure of
 Sylvius and between the cerebrum and cerebellum, or extends over the
 whole surface of the brain to form a veritable cap.   Or the exudation,
 more limited to the base, surrounds the emerging nerves, dissecting up
 their investing sheaths and  following them out in their course.   In
 the spinal column the exudation  is deposited first along the posterior
 aspect of the cord, as determined by gravity, but soon extends to its
 lateral surface  to affect or  to follow out the spinal  nerves in the
 same manner as in the brain.  The thickest masses of exudation are
 found in the cervical and lumbar regions of the cord, though effusion
 in spots, bands, or islands occurs  irregularly throughout its course.
 In its advance  the suppurative  process invades the  sheath of  the
 optic nerve, to  travel along its  course, infiltrate the orbital fat, to
 account in life for an iritis, choroiditis, or an all-destructive  panoph-
 thalmitis   So, also, implication  of and transit along  the  facial  and
 auditory nerves lead to destructive changes in the ear.
    A microscopic examination reveals the fact that the inflammation
 affects  the tissues through the  blood vessels.   Numberless round
 cells infiltrate the intima and adventitia, to collect on the external
 surface and form the lines and layers of pus cells along their course.
    Duration.—Cerebro-spinal meningitis has no definite duration.
 Hirsch says of it that it may last  from a few hours to several months.
 The first period  applies to the foudroyant cases, in which patients are
 killed  as  by a stroke; the last to the cases with complications or
 sequelae, which may, indeed, prolong the disease indefinitely.  Gor-
 don's shortest case was five hours, and Jewell records a case of death
 in three hours and a half after seizure.  These are, of course, most
 extreme and exceptional cases.   Clymer states that more than one-
 half the deaths happen as early as from the second to the fifth day.
 This author quotes also from Parkes, who found the duration of the
 disease in sixty-six of ninety-five cases, five days or less; in one, eight
 days; in twenty-eight, eight days or over.  Abortive forms termi-
 nate in resolution in from three to five days; foudroyant forms, with
 rare exceptions, in death within  three days; and intermittent  and
average forms in  one or the other way, barring complications  and
sequelae, in from one to three weeks. 
310
CEREBRO-SPINAL MENINGITIS.
   Diagnosis.—In the presence of an epidemic of the disease1 the
diagnosis of cerebro-spinal meningitis is sufficiently easy.  The1 exist-
ence of cases in the vicinity prepares the practitioner for new attacks.
Cases which are affected with, or more especially quickly succumb
to, any disease with predominant nervous symptoms  should excite
the suspicion of the physician in this direction.  Sporadic cases, how-
ever isolated in space or time, are likewise readily recognized in the
presence, in sufficient number, of  the symptoms peculiar to tin1 dis-
ease.   The sudden seizure, often in the midst of health, with chill,
vomiting, and prostration, followed by  opisthotonos, hyperesthesia,
herpes, irregular pulse, constipation, constitute an array of symptoms
that belong to no other  disease.   Unfortunately for the1 diagnosis,
many cases deviate from the regular type in essential particulars,
more especially in the absence of characteristic signs, to such degree
as to make the diagnosis difficult or at times impossible.  Foudroyant
cases differ most  widely  by the predominance of the symptoms of
blood poisoning which are common to all the grave acute affections.
Light is  sometimes thrown upon these  cases by the consieleration of
the season of the year, the age of the patient, the existence  of other
cases more  pronounced, or,  if  equally obscure,  by the exclusion of
simulating maladies or accidents.   Thus a meningitis from trauma,
syphilis,  or otitis should be discovered by the history and inspection
of a case ; or occurring  in the course of scarlatina, pneumonia, sep-
ticaemia, it should be eliminated by the presence of signs character-
istic of these affections.
   Typhoid fever distinguishes itself by the fact that it usually spares
the period of earliest  youth, that its onset  is insidious, that it is at-
tended with diarrhoea and distention of the  abdomen, that it often
shows a rose-color eruption, has a constant high pulse, a typical tem-
perature curve,  and  a definite  duration.  Moreover, typhoid fever
almost never shows herpes, and almost always shows enlargement of
the spleen.  Malarial fever  is marked by its preference  for certain
regions and certain seasons of the year.  Periodicity is the criterion
of malaria, and, though  this factor is  simulated in the intermittent
cases of meningitis, it is never so precise.  Reeve says the early vom-
iting was the key to the diagnosis of his  first cases of meningitis.
Whatever doubt may exist at first is quickly dissipated by the admin-
istration of quinine in sufficient dose.   Tetanus is eliminated by its
trismus,  and hydrophobia by its characteristic paroxysms of inspira-
tory spasm.  Tubercular  meningitis  rarely shows symptoms on the
part of the spinal cord,  though opisthotonos and hyperaesthesia are
not uncommon in this disease.  Tubercular meningitis is nearly con-
fined to childhood.  In the great majority of cases its victims are e>f
tuberculous parentage or  stock.  It is not affected by the  season of 
CEREBRO-SPINAL MENINGITIS.
311
 the year.  It distinguishes  itself  especially by its long prodromal
 stage, by its periods of reduction of temperature and retardation of
 pulse, by the occasional  signs of tuberculosis elsewhere, in the lungs
 or intestines, externally  (scrofula)  upon the skin, or possibly in the
 bottom of the eye.
    Prognosis and Mortality.—The prognosis of  this  disease is al-
 ways grave.  The factor of most importance in its determination, is
 the type of the disease.   Foudroyant  cases perish with very rare
 exceptions, abortive  forms  recover with but few exceptions, and
 average cases  survive and succumb in about equal number.  The
 character  of the epidemic  is the next consideration.   Certain out-
 breaks are distinguished by their mildness, as are others by malig-
 nancy.  Between these extremes is every grade of gravity in different
 attacks.  It is also true of this, as of most of the acute affections, that
 the first cases  are most  severe.  The epidemic grows  feebler, as a
 rule, with the gradual exhaustion of its most fertile soil.  Individual
 considerations follow next.   The prognosis is more grave in infancy
 and childhood than in adolescence and  maturity.   The ratio of mor-
 tality falls from 75 per cent in children under one year of age to 53.5
 per cent in later childhood and 35 per cent in adolescence.  Of 15,632
 cases analyzed by Hirsch, 5,731 terminated fatally.  Thus the ave-
 rage ratio of mortality of this disease, under all conditions, is given at
 37 per cent.  The influence of "bad hygiene" in aggravating the
 prognosis is too patent to require mention.   Of more importance are
 the signs which prognosticate the result in individual cases.  It may
 be stated as a rule of this, as of all the acute infections, that a severe
 onset indicates a grave case.   Thus a high fever  at the start, obsti-
 nate vomiting, marked opisthotonos, early convulsions,  are signs of
 ominous import.   As one-half the deaths happen before  the fifth day
 (Clymer), a case which survives the first week has a more favorable
 outlook.'  The first three or  four days are attended with the greatest
 anxiety.  '' Every day passed after the seventh day renders recovery
 more and more  probable"  (Loomis).  Typhoid symptoms at any
 stage of the disease imprint upon it an unfavorable prognosis.  Arch-
 ing of the great fontanelle,  as indicative of intracranial oedema and
 exudation, is a very  bad sign.  Almost all such  cases end  fatally
 (Maurer).  A return of headache and vertigo which has disappeared,
 especially if associated with vomiting and convulsions,  evidences of
 consecutive hydrocephalus,  is  likewise ominous  (Ziemssen).  Yet
 secondary hydrocephalus is  not absolutely hopeless, as Ziemssen saw
 " some cases in which a complete, and others in which an incomplete,
recovery took place."   Profuse sweats, with cold surface, are charac-
teristic; of  a  fatal issue  (Hirsch).   The persistence, after recovery
from the disease,  of anorexia, debility, and emaciation, perhaps with 
312               CEREBRO-SPINAL MENINGITIS.

diarrhoea, gives a poor outlook, especially for children (Emminghaus).
A sudden high elevation of temperature, or hyperpyrexia, after a chill
in a previously apyretic case, means a complication and  not a fatal
issue; but a hyperpyrexia without chill, and with a profuse sweat, is
pre-agonic (Immermann).
    Treatment.—A patient affected with this disease should lie upon
a comfortable bed, not too hot,  in a spacious, continuously ventilated
room, whose windows  can be darkened,  if necessary, while they
still admit the  air, as remote from the  street wnth  its offensive
sounds as may be.  The temperature of the room should be regu-
lated, with a thermometer near the head of the bed, at  65° F., by an
open fire, preferably in a grate.   The physician and the necessary at-
tendants should be the  sole visitors.  Quiet should reign supreme.
In  no other disease is continuous or officious ministration so meddle-
some and mischievous.  Even  cleanliness or apparent discomfort in
posture must be sacrificed  at times to peace of mind.   The diet is to
be simple and light at first, but as nutritious as possible with return-
ing health.  Beef tea palatably made, soups of any kind, milk if it
do not  increase constipation,  scraped raw meat  with a little salt.
gruels if not distasteful, with water, Selters water, Apollinaris,  any
simple carbonated drink,  should  be proffered  at  proper intervals.
without over-solicitation  or any  anxiety  should  everything be re-
fused.   With the beginning subsidence of the disease an egg may be
dropped into the soup, or sweetbreads, fish, the white meat of fowl,
may for a few days preface the more solid meats.
    Especial attention is to be paid to the bladder.  The  soft catheter,
thoroughly cleansed,  warmed above the heat of the  body  and
greased with pure vaseline, brings this organ,  when refractory,  un-
der  control.   Constipation is  overcome with  calomel, two to  ten
grains,  or castor oil, in preference to an enema,  which  causes  too
much disturbance.
    The treatment proper is purely symptomatic and has reference to
both sets of symptoms, general  and local.  Of these the symptoms
produced by the local  lesions—pain, opisthotonos, hyperaesthesia—
assume prominence in  the great  majority of cases.  For the relief
of these symptoms no remedy equals in value opium.   Opium is  the
•"sheet anchor "in the treatment of cerebro-spinal meningitis.   It
acts solely by its anodyne influence.  It protects, by  obtunding.  the
nervous system until the force of the  poison  is  spent.  Surprising
amounts of the drug may be given in  this disease without narcotic
effects.   Thus Steiner often gave ten grains at a dose in cases of se-
vere convulsions, without producing stupor ; Chauffard,  three to fif-
teen grains : and Boudin, seven to fifteen grains  at  first, and later
one to two grains every hour, before soporific effects were produced. 
RHEUMATISM.
313
 Stifle was in the habit of prescribing one grain  every hour in  very
 severe, and every two hours in moderately severe, cases, without in-
 ducing even an approach to  narcotism in any case.   " Under the in-
 fluence of the medicine the pain and spasms subsided, the skin grew
 warmer and the pulse fuller, and the  entire condition of  the patient
 more hopeful."  When quick effects are to be had, or when the  drug
 is rejected by the  stomach, resort will be had, of course, to the hy-
 podermatic use of morphia.   Ziemssen gives expression to  an expe-
 rience made by every practitioner  with this disease when he  says
 that morphia is, without doubt, " indispensable " in its treatment.
    Cold, in the form of bags of ice to the  head  or along the spine, is
 of great value when the period of excitability, hyperaesthesia, and
 jactitation may have given place to the state of sopor and indiffer-
 ence.  Radcliffe claims that " the application of cold to the  head
 and spine, either by means of ice or a freezing mixture in Esmarch's
 (or Chapman's) india-rubber bags, has furnished by far the most sat-
 isfactory results of all direct treatment."
    Vomiting is best relieved by ice, champagne, effervescent drinks,
 milk and lime water, bismuth, soda, creosote, and chloral.  No drug
 equals in efficacy, at times, sips of water excessively hot.
    Hiccough is often brought under control by  the same  means pre-
 scribed for vomiting, by  the administration of a few drops of the
 oil of cajuput, or by clysters of sodium bromide or chloral.   More
 obstinate cases of either vomiting  or singultus call for the subcuta-
 neous use of morphine.

                          RHEUMATISM.

    Rheumatism (pavpa,  peco, to flow), with the same derivation as
 catarrh ; from the old Greek idea  of a peccant humor circulating in
 the blood and instilled into the joints.—A  term  applied subsequently
 to all kinds of maladies thought to be due to exposure to cold, limited
 about the  time of Ballonius (1600) to pains about the  bones, joints,
 and other  structures than mucous membranes, to  which alone the
 term catarrh was confined.  In our day catarrh is further limited to
 express those  inflammations of mucous membranes  which are not to
 be attributed to any special or specific cause, while  rheumatism has
 yet much of the vague and diffuse  meaning of ancient times.   Thus
 the older writers  spoke  of visceral, gastric, cerebral,  cardiac, vesi-
 cal, etc., rheumatism ;  certain modern writers  continue  to describe
 cases of rheumatic pleurisy, peritonitis, etc., and  the oculists still
 speak of rheumatic iritis in describing affections which are not to be
 attributed to a specific cause.
   Pathology.—Rheumatism is, therefore, still a sort of refuge for
maladies, especially affecting the bones  or joints, whose real nature 
311
RHEUMATISM.
is  unknown.  Sydenham separated gout, Senator arthritis. Zenker
trichinosis.  No less than five maladies are still considered under the
head of rheumatism, but definite ideas cannot be had concerning any
of them until each is distinctly isolated, if not as to its cause, at least
as to its symptomatology.  There is thus, first, acute articular rheu-
matism ;  second,  chronic articular rheumatism ;  third, museular
rheumatism ; fourth, gonorrhceal  rheumatism ; fifth, nodular rheu-
matism.   These various  affections must  be separated  from  each
other and from  gout, syphilis, tuberculosis, rickets, or other  affec-
tions  of  the bones and joints, before any clear understanding may
be had of any one.  It is probable that  in the near future the  term
rheumatism will be  confined to  that acute articular  variety which
distinguishes itself by a more or  less sudden onset with fever  after
the manner of an infection, inflammation of a number of joints with
sweating, and liability to affection of the heart.  This  disease is
commonly known  as  inflammatory  rheumatism because  of  the
acuteness and intensity of the inflammatory signs.   The other dis-
eases, until better defined, may be known as rheumatoid affections
of the muscles, bones, or joints.
   Acute Rheumatism occurs  at all seasons of  the year, but with
preference for the fall and  winter  months, and thus more  espe-
cially in  connection with changing temperatures.  It attacks par-
ticularly  or almost exclusively the period of adolescence, from fifteen
to thirty or thirty-five.  Acute  rheumatism in infancy or  early
childhood is  almost unknown.  Individuals with the widest oppor-
tunity for observation  record isolated cases  of  rheumatism in the
earlier weeks of life.  Liability begins  at four, begins to cease at
forty, and is almost nil at fifty.   Cases at or over fifty are survivals
from earlier periods.  It seizes by preference the  poorer or working
class, that most exposed to changes of weather,  but picks  espe-
cially upon certain individuals who seem to possess for it a natural
predisposition.   What  constitutes this  susceptibility is unknown.
These individuals  suffer, not one, but repeated attacks, for rheuma-
tism is a  disease to which the individual, originally so to some extent,
becomes  more susceptible after each attack.
   Rheumatism is commonly ascribed to taking  cold, though there
is no more satisfactory explanation of the relation between cause and
effect in  this than in any other disease said to be due  to the same
cause.  The older writers spoke of  rheumatism  as a neurosis.  Im-
pressions made upon the skin were conveyed through the nerves to
be reflected to the joints.  The impression of cold was said to seize
upon the joint as a locus minoris resisteutice—an explanation which
is only a paraphrase.
   Froriep and Canstatt invoked a toxic theory in ascribing rheuma- 
RHEUMATISM.
315
 tism to the accumulation or to the excess of lactic acid in the blood,
 and some  support  seemed to be lent to this view through the fact
 that the administration of lactic acid in  large doses, as in the treat-
 ment of diabetes, produced in some cases inflammation of the joints.
 This view, however, lacks the important support of the discovery or
 detection of any excess of lactic acid in the blood.  The tendency in
 our day is to regard rheumatism as an infection or mycosis, based
 upon the facts (1)  of the nature of its onset and course; (2) of the
 occurrence of the  disease undeniably in the course of certain infec-
 tions,  as  scarlet fever, dysentery, puerperal fever;  (3)  that  the
 remedy which has  over it almost specific control—salicylic acid—is a
 powerful antimycotic remedy.  But this view lacks also the all-im-
 portant evidence,  or at least sufficient evidence, of the discovery
 of any particular micro-organism in the blood or organs affected by
 the disease.  Buday (1892) found that the injection of the Strepto-
 coccus pyogenes into the jugular vein of the rabbit was followed by
 inflammation of the joints.   In six fatal cases of acute rheumatism
 in man pyogenic micro-organisms were found in the joints, as they
 are in the fluid of all cases examined.  They are discharged into the
 joint by the rupture of metastatic (capillary) emboli.
    Symptoms.—Rheumatism begins with a chill, or series of shiver-
 ing fits, attended and followed by rise of temperature to 102°-105°
 F., in the course of the first twelve to twenty-four hours.  There is
 at this time the  malaise and distress which belong to fever, though
 there is not. as a  rule, the  same anorexia, nausea, or nervous dis-
 turbance that belong to most of the acute  infections.  Rheumatism,
 in fact, distinguishes itself rather by the absence of these signs in its
 inception.  The nature of the disease is proclaimed in the course  of
 the first twelve to twenty-four hours by the affection of  the joints.
 The rule is that the medium-sized joints are affected first:  thus the
 knee and the ankle and the wrist, and afterward the shoulder and
 elbow, then, some time after, in the order of frequency, the  fingers
 and the joints of the vertebrae.
   In bad cases  unusual joints are affected, as  the joints of the jaw,
 of the larynx, of the symphyses, of the ribs, so that in an extreme
 case,the patient lies paralyzed as to motion, on account of pain, which
 is  perceived all the more acutely because of the clearness of the sen-
 sorium.  The affection  of the joints announces itself also by the in-
 hibition of  motion.   The limbs  are held in the semi-flexed position
 to  avoid tension, and as absolutely immobile as may be.   Every agi-
 tation of the room, more especially of the bed, increases the pain,
which shoots through the joints like the stab of a knife and dies
away only  gradually under perfect rest.
   The  medium-sized and smaller  joints  show inflammation  by 
316
RHEUMATISM.
swelling or redness as the synovial fluid  is increased to cause disten-
tion of the capsule of the joint.  Sometimes the skin over tlu1 joint
pits upon pressure from a subcutaneous eedema.  Spots or strips of
redness are to be seen over the larger joints.  Sometimes a  sheet of
crimson  red  announces  the intensity of the inflammation beneath.
In cases of the largest joints, as the hip or the shoulder, there may
be no external discoloration, on account of the depth of the disease.
    What especially characterizes this form of rheumatism is  the
fugacity of  the affection.   It  attacks  a  joint severely,  so that it
remains inflamed intensely for a few days, whereupon it disappears
to attack another joint or  joints.  Rheumatism is said to fly from
joint to joint.  Sometimes it returns to the joint first affected, and
thus projects itself over a long  period of time.   But, notwithstand-
ing the intensity of the inflammation, as manifested by the swelling,
redness,  and pain, the disease disappears when  it subsides, to leave
no  trace.  There is in  rheumatism a  restitutio  ad  integrum.
Should suppuration occur, or should  the joint be left ancbylosed, it
is a case of mixed infection.  Pure rheumatism shows no pus and
leaves no deformity in the joints.
    A prominent symptom in the course of rheumatism is sweating.
which is ordinarily so profuse as to saturate the garments and  the
bed linen.  The perspiration has an acid  reaction and an intensely
sour odor.  But the evaporation of this large amount of fluid has
little or  no effect upon the temperature.  Where ablutions are  not
frequently practised sudamina form, and may be seen  as  glistening
vesicles, sometimes over the whole surface of the body.
    The grave complication of rheumatism occurs in the heart.  In
a certain percentage of  cases  either pericarditis, endocarditis,  or
myocarditis occurs in the course of rheumatism.  This complication
does not occur always in  correspondence with the  severity of  the
fever or the number of joints affected ; involvement of joints near
the heart has nothing to do with its production.  Thus an affection
of the foot would be as likely to be attended by heart disease as an
affection of the costo-chondral  joints.   The heart is affected  more
especially in  the young.   The patient between fifteen and  twenty-
five is most liable to suffer heart complication.   Attacks in later  life
are generally free from heart disease.
    Authorities differ as to the frequency of this  complication. Boul-
laud  believed that all cases had heart  disease—regarded rheuma-
tism, in fact, as the effect of the heart  disease,  or described  the
heart  disease as one of  the  joints affected.   Wells believed that
heart complications occurred in about one-third of the cases.   Sib-
son and Fagge put their estimate at about fifty per cent—a ratio
which represents the modern belief. 
RHEUMATISM.
317
    Heart disease reveals  itself  most  frequently  by a precordial
 pain, palpitcdion, and dyspnea ; often, however, by none of these
 signs, so that the condition is discovered  only by careful examina-
 tion of the  heart, whereby a  bruit is elicited or enlargement of the
 diameters recognized.   Many cases recover from heart disease, but
 in more, permanent lesion is left. The heart is crippled for life.
    Rheumatism is sometimes marked by excessively high tempera-
 tures—hyperperexia,  110° to 118° F.  These sudden elevations oc-
 cur in the course of  the rheumatism.   The disease does not begin in
 this way.  This  complication is recognized also by grave  cerebral
 signs—delirium, convulsions, and coma.   Most of these cases termi-
 nate fatally.
    Diagnosis.—Acute rheumatism is to be separated from pyemia,
 if it be not itself a mild pyaemia.  There is in pyaemia usually a his-
 tory  of  an abscess or  of a trauma.   There
 is recurrence of chills and a more regular
 temperature curve, evidences of emboli else-
 where as well as in the joints, a protrac-
 tion of the disease over a longer time when
 not cut  short by some grave complication,
 and an inamenability to treatment.   Rheu-
 matism has  in itself no  special mortality,
 except in the few cases of hyperpyrexia.
    * • j  £     i          v   i-      i       Fig. 166.—Hyperpyrexia of acute
    Aside from heart  complications,   rheu-  rheumatism
 matism  has a mortality of about three per
 cent, so that the disease is more dreaded from its complications than
 from its own character.
    The treatment of  rheumatism has been resolved in our day to
 the administration of  salicin or  the salicylates, which are looked
 upon as specifics.  The treatment by alkalies, by  acids, by blisters
 has fallen  into disrepute in  the presence of the salicylates.  Clini-
 cal observation has shown  that when  a certain number of cases in a
 ward are treated by each of these methods, there is no appreciable
 difference between them and cases treated without any remedies, as
 to duration, complication, or mortality.
   Strieker, in  1876, called attention  to  the virtues of salicylic  acid
 in the treatment of this disease, and Maclagan,  of  Dundee,  an-
 nounced in this year that he had employed salicin as a specific since
 1871.   The fact  has  since been  unearthed that the Boers of South
 Africa were accustomed to administer to patients affected with rheu-
matism teas made from the willow bark. Scepticism and incredulity
have completely disappeared under the  test of observation and ex-
periment.  It was soon seen that the remedy possessed the virtues
ascribed  to it by the discoverers or first observers—that the salicy- 
318
RHEUMATISM.
lates cut the disease short, and, by abbreviating it, lessoned in this
way, and only in this way, complications on the part of the heart
and acute pyrexias.   The form of the remedy most in use in our day
is the salicylate of soda.   The following  is a convenient recipe for
quick effects :
    R Sodii salicylatis...............................................3ij.
      Glycerinae.....................................................3 i.
      Aquae menthae piperitse........................................1 iij.
    M.  S. Dessertspoonful to a tablespoonful every two to four hours.
Equally efficacious is salicylic acid or salol, in powder or capsule,
gr. v.-x. every hour or  two.  Obstinate cases  require change of
form.
    In a pronounced  case with much  suffering it is justifiable to ad-
minister a dose of morphia subcutaneously, to be followed up imme-
diately  with salicylates, gr. vijss.-x. every hour at first, later every
two hours.  So soon as the pains lessen or the remedy produces any
toxic effects, as nausea, ringing  of the ears, vertigo,  headache, the
interval  is to be  increased or the dose diminished or the  remedy
stopped.  Salol is contra-indicated in the  presence of any suspicion
of kidney disease.
    Pain  usually yields in the course of five  hours, and swelling be-
gins to subside on the following day.  The average duration of the
disease under this treatment is about five days—a great gain over the
six weeks at the time of Cullen.
    The best external treatment is fixation of the joint by pillows or
bags of sand and  the application to the surface of cloths wrung out
of hot water.   Cases marked by hyperpyrexia call imperatively for
the cold  bath.  Apparently desperate cases have  been thus rescued,
as by Da Costa from a temperature of 106° F., by Draper and May-
nard from 107.1° F., and by Fox  from 108.4° F.   Masses of ice were
applied freely to the chest and abdomen in these cases, and brandy
was given in abundance.
    Chronic  Rheumatism.—Chronic rheumatism is a different af-
fection.   It is true that occasionally chronic results from acute rheu-
matism,  more especially in those  cases in which acute rheumatism
repeats  itself often in the same  joint, until there is at last  left an
irritation which remains.   It is, however, only the exceptional  case
of acute rheumatism which  becomes chronic.  In the rule  chronic
rheumatism begins as such, and distinguishes itself by remaining a
local affection.  Chronic  rheumatism belongs  to the  last half of
life, whereas acute rheumatism begins in adolescence and begins to
diminish at maturity.  Chronic rheumatism  begins at  maturity and
increases with advancing age.  Chronic rheumatism is also, for the
most part, a disease of the poorer class; when occurring among the 
RHEUMATISM.
319
 better class it may be attributed  to local and, for the most part, dis-
 coverable conditions.  Chronic rheumatism confines itself to one or
 a few joints, where  it remains  for months, for years, or for life.
 Chronic rheumatism  is monarticular or oligarticular in distinction
 from acute rheumatism,  which is polyarticular.  Acute rheumatism
 is said to fly from joint to joint.  Chronic rheumatism rema ins fixed
 in one or a few joints.
    Pathology.—Continued exposure to cold is cited as the most fre-
 quent cause of this affection, and the exposed joints are the joints af-
 fected. Thus washerwomen  are affected in the wrists, maid servants
 in the  ankles, scrubwomen  in the knees, coachmen  in the  wrists,
 porters in the feet, etc.   The continued exposure of a side of the
 body, as by the apposition of the bed to a damp wall, or of the knees
 in writing at a desk,  or feet  as in riding, are frequent causes of this
 affection, which may disappear  with removal of the  cause.  The
 pain in  chronic rheumatism is not so acute or intense; it is rather
 subacute, and distinguishes  itself by its protraction rather than in-
 tensity.  Dull, boring, grinding, aching pains are the characteristics
 of chronic rheumatism,, subject at times to more or less acute exacer-
 bation.  Chronic rheumatism shows itself in a more or less fluctuating
 course, with  relief of pain  in warm or  dry weather, increase or
 aggravation in raw or damp weather.  Acute pains  supervening in
 the course of chronic rheumatism show complication with the acute
 form of the disease.   Chronic rheumatism, pure and simple, is un-
 attended with any sweating or complication on the part of the heart.
    Long-standing cases,  especially under bad hygiene, show more or
 less permanent change.   The effusion, which may be very extensive,
 persists.  The tendons about and membranes  in the  joint become
 more or less thickened and opaque.  Various anchyloses show them-
 selves, but in the vast majority of cases there is no alteration of bone
 or cartilage to such degree  as to produce organic deformity.   De-
 formities of chronic rheumatism disappear or may be dissipated by
 massage, forcible extension,  etc., especially under chloroform.  The
 disease affects chiefly the larger joints, hip and shoulder and knee,
 wrist and ankle.  Affection of the smaller joints  implies  for the
 most part a different disease—gout,  nodular rheumatism, etc.
   Diagnosis.—Chronic  distinguishes itself from acute rheumatism
 by the fact that it occurs in  the  latter half of life, mostly in old
 people; that it affects a  single or  a few joints, to which it remains
 confined; that it persists in spite of medication;  that it is unattended
 by sweating, heart complication,  or high fever.
   The prognosis quoad vitam is good; quoad valetudinem  is bad.
 Few diseases which are  not  in themselves fatal or involve organic
change are so obstinate  to treatment.   Chronic rheumatism is for 
320
RHEUMATISM.
 the  most part a disease of life.  The hopelessness of  any radical
 therapy is evidenced by the number of remedies recommended in its
 relief.  Chronic  rheumatism is,  in  fact, a  fertile field  for quacks,
 and every age abounds in  plasters, liniments, and oils, in appeal to
 the credulity of the people, and in such profuseness of advertisement
 with us as to deform the face of nature.
    Treatment.—For the acute  attacks of pain or exacerbations of
 inflammation the best remedy is salicylic acid,  the salicylates,  salol.
 For the chronic  states the best remedy is the  iodide of potassium.
 Most patients are more or less debilitated by age  if not by  the disease1,
 so that alcohol, cod-liver oil, iron, quinine, hypophosphites are indi-
 cated in different cases.   The  virtues of local application  depend
 upon heat and friction.  Heat in  the acute exacerbations is best
 applied with cloths wrung out  of hot water, with poultices, hot water
 bags, etc.   Fixation of the  joint in these cases is of value, as by sand
 bags, pillows, splints, bandages.   Such fixation,  however, is not to be
 retained long enough to allow of anchylosis  or atrophy from disuse.
 Hot-water  baths at home or, better, at watering places,  sand baths,
 peat  baths, mud baths, are various applications of heat.  Blisters in
 the neighborhood of the joints are the best derivatives, especially
 flying blisters—i.e., repeated in  the vicinity of the joint—after the
 manner of the former treatment of acute rheumatism.   Blisters de-
 rive materials which, reabsorbed into the blood,  officiate as protective
 albumens, so  that there is something more in blisters  than  mere
 counter-irritation.  Liniments, sal-volatile  liniment, opodeldoc,  com-
 pound soap liniment, more  especially applications containing chloro-
 form, opium, aconite,  are stimulating embrocations.
   R Tincturae opii,
     Tincturae aconiti
     Chloroformi.....
     Olei olivae......
 Or
   B Olei gaultberiae,
     Olei olivae sive morrhuae.....................................ful § i.

 applied with friction,  are  good combinations.   Arnica should  be
 avoided, because it produces at times an obstinate eczema.
   A victim of chronic rheumatism, when able, should travel, should
 find a suitable climate in Georgia, the Carolinas, Florida, Nassau,
 the Bermudas, California, etc.
   Gonorrhceal  Rheumatism.—Gonorrhceal rheumatism  is a
 separate form which  has points in common with both acute and
 chronic, and points by which it may be separated from either.  Thus
it  attacks  for  the  most part  the age of adolescence  or maturity,
 
RHEUMATISM.
321
 males four times more frequently than females, and is confined to  a
 single or a few joints.   The disease distinguishes itself by its sub-
 acute character.  It  occurs for the  most part six to twelve weeks
 after the original infection,  and persists for months, sometimes for
 years. AVhen first observed it was thought to be a mere coincidence;
 but the frequency of  its occurrence,  more  especially the continued
 recurrence in certain individuals, establishes it as a complication.
    It is as yet undecided whether gonorrhceal rheumatism depends
 upon the gonococcus or upon pyogenic organisms of subsequent, i.e.,
 secondary, infection or invasion.
    The disease fixes itself for the most part upon the knee, ankle.
 or  joints of the foot.  These joints become swollen, sometimes im-
 mensely swollen, without any acute pain because  of the tolerance
 which is established under a slow  development.  Gonorrhoeal  rheu-
 matism, like chronic rheumatism, shows no  sweating, has no cardiac
 complication,  and  leaves no deformity.  Unlike  chronic rheuma-
 tism, when finally  cured it ceases, never to return, unless through
 new infection.
    The treatment does  not differ radically from  that already de-
 tailed.  The constant current of electricity furnishes better results
 in  gonorrhceal than in  other  chronic rheumatism.  The sluggish
 character of the ailment calls for this stimulus, as well as that fur-
 nished by friction, massage, etc.  The chronic gonorrhoea, gleet, or
 posterior urethritis, which may persist  as a cause of continuous in-
 fection, should be treated until every  trace of it disappears.
    Muscular Rheumatism.  Pathology.—Muscular rheumatism
 is another of  the  varied forms of affection included under the term
 "rheumatism"  as  evidence of the vagueness and elasticity of the
 term itself.  For muscular rheumatism confined to  the muscles has
 nothing to do with the  bones or with the  joints, and "the disease is
 called rheumatism  only because it  is marked by  pain.   Muscular
 rheumatism occurs at any  time of life,  but is  noticed  in certain
 forms, or particularly at certain periods of life.   Thus affection of
 the cervical muscles belongs more particularly to youth ;  of the in-
 tercostal muscles, to maturity ; of the lumbar muscles, to age.  In
 many cases muscular rheumatism is simply the effect of trauma.
 whereby muscular fibres are ruptured.  This is the case especially in
 the sudden attacks of lumbago commonly known as stitches in the-
 loins or back (Hexenschuss). The same thing is true also of many
 cases of intercostal muscular  rheumatism,  so-called  pleurodynias.
 Sudden tensions,  sudden wrenches,  rupture individual fibrils and
fibres.  Other  forms of the  disease seem more directly attributable
to exposure to cold.   Thus torticollis, or rheumatism of deeper-seated
muscles of the neck, may arise from sleeping opposite an open window
        21 
322                       rheumatism.

in a draught or sitting at an  open car window in travelling.  In
many  cases  it may be assumed that poisons in the blood, micro-
organisms or their products, hitherto innocuous, have become local-
ized in individual muscles or their nerve centres by irritation or ex-
posure.  Such cases therefore may be said to be of infectious origin.
   A fine example  of  this  muscular  rheumatism  is  offered  in
trichinosis,  which  was formerly regarded as a kind  of malignant
rheumatism.  Grawitz declares that in ninety per cent of cases of
aggravated muscular rheumatism, so considered, he found on autopsy
trichinae in the structure of the muscle.
   It may be readily understood that trichinae may be ingested in
sufficient  number to produce light  or more or less severe muscular
Fig. 167.—Torticollis (Gowers).
rheumatism without previous or subsequent sign of their presence,
and this origin may he assumed to exist all the more  for  the reason
that the  muscles affected—to  wit. of the neck,  of the chest, of the
loins—are precisely the muscles most frequently invaded by trichina?.
    Morbid anatomy  shows'at  times hyperaemia, opacities of the
sarcolemma. coagulations in muscular protoplasm, etc.; but in most
cases no lesion is to be found under the most careful inspection, and,
inasmuch as the disease disappears to leave no trace,  it must be be-
lieved that in most cases no real lesion exists.
    Symptoms.—Muscular rheumatism  manifests  itself  chiefly  in
pain,  spasm, in interference  or abolition of motion, sometimes in dis-
tortion.
    Occipito-frouted rheumatism is felt on motion of the scalp, and
is distinguished from occipital and frontal neuralgia by the fact that 
DYSENTERY.
323
in neuralgia tender points can be located in the course  of the occipi-
tal and trigeminal nerves.
   Torticollis (cervical rheumatism) shows itself in twisting of the
head to one or the other side.  It must be distinguished from affec-
tion  of the vertebrae or deep-seated neuralgias due to lesions in the
spinal  cord, from which affections it is, as a rule, readily separated
by its  more  or less sudden origin, acute pain, short  duration, and
entire disappearance.
   Pleurodynia is distinguished from intercostal neuralgia by the
absence of the tender points near the spine, in  the axillary line, and
near the sternum, to be discovered by pressure in neuralgia.
   Lumbago  is the most common form of all.   There is pain on mo-
tion, especially aggravated in rising from a sitting posture or  from
bed after a night's rest.  In a bad case  the whole body is literally
paralyzed by pain, and patients,  more especially  obese patients, lie
helpless on the bed.
   The diagnosis  must be established at the  start.   An acute in-
fection must be eliminated.  Thus, small-pox distinguishes itself by
the severity of its pain  in  the  loins and sometimes the back of the
head.  Tuberculosis, aneurism, caries of bone, tumors, need  only
be mentioned to be separated.  A protracted lumbago in a young
person should always excite suspicion of  caries of the spine, Pott's
disease, which may reveal itself in a gibbus or in rigidity of the mus-
cles of the spine.  A very early diagnosis  may be made with tuber-
culin.
   The prognosis  is good not only as regards the general health,
but also the condition of the muscle, which is usually restored to the
status in quo.
   The treatment is simple.  Applications of heat and friction are
the essential  elements.  Dry is better than moist heat.  Hot-water
bags, hot flannels, cloths over which a hot iron is passed, are domes-
tic remedies.  Dry cups often give quick relief.  Excruciating pains,
pains which prevent all motion, are best counteracted  by deep injec-
tions of morphia, gr. £-£.   Sometimes  a  subcutaneous injection, or
the internal administration of phenacetin or antipyrin, gr. v., suffices.
Friction with  liniments, massage with alcohol, ointments of vaselin
or lanolin,  incorporating perhaps opium  or  aconite,   according  to
formulae suggested, relieve the pain in most cases.  More permanent
relief is often afforded by faradization with a wire brush, with a roller,
or with simple sponges, or by galvanization when the former fails.

                           DYSENTERY.
   Dysentery  (Sv? evrepoi, xlifficultas intestinorum) ; flux ;  Ger-
man, Ruhr.—An infection  of the large intestine, of specific and non- 
321
DYSENTERY.
specific (catarrhal) origin and form ;  characterized by  hyperaemia.
infiltration, and necrosis (ulceration) of its mucous membrane ; dis-
tinguished by discharges of mucus, blood, pus, and tissue debris ; and
attended with griping and expulsive pains (tormina and tenesmus).
   History.—Dysentery is one  of  the oldest known diseases.  The
Ayur-Veda of  India  mentions forms of  it, Hippocrates described it.
and Herodotus relates how this disease and the plague1 decimated the
army of Xerxes on the desert plains of Thessaly.  Galen derived the
discharges from  the  bile, Aretaeus  wrote graphic accounts  of the
symptoms.  The  disease  assumes epidemic  proportion  only  in hot
climates, and rages as a  pestilence in army life, where it numbers
more victims than the bullets of the foe.  The accounts of this and
allied disease,  and the illustrations of  its  lesions, in the '* Medical
and Surgical History of  the War of the Rebellion," vol. ii., make a
lasting monument to  the labor and learning of the editor, Joseph J.
Woodward, of the United States Army.
   Etiology.—Dysentery is only a clinical  expression, and the dis-
ease is due  to many causes.  The most fruitful  cause is drinking
water contaminated by the discharges  of  dysenteric patients or per-
haps  by any  decomposing  matter.  Exposure to cold, bad  food,
through nervous  influence and  by direct irritation of the mucous
membrane, may produce individual cases of the catarrhal form.   The
disease is certainly intensified by crowd-poisoning, as in army life,
pilgrimages, etc.
   Bacteriology.—Many micro-organisms  are found  in  the dis-
charges of dysentery.  Two have been isolated as probable causes of
the disease.   One is the Amoeba dysenteriae, the other a bacillus.
Kartulis (L892) especially makes emphatic  claim for an amoeboid
body  which he finds constantly in the discharges, and  which has
been found also in the contents of hepatic  abscess.  Kartulis culti-
vated the amoeba in decoctions of straw, and inoculated it to produce
certain symptoms of  the  disease.   Lambl and Losch  had remarked
this  structure  previously, but had not ascribed  to it pathogenetic
property.  Councilman and  Lafleur  of Baltimore, and Musser of
Philadelphia,  confirm in  part the  claim of Kartulis; and Lutz of
Honolulu probably defined the exact position of the amoeba  as the
cause of only certain individual (catarrhal) cases, but not of the epi-
demic disease, which is  more  probably produced  by  a vegetable
structure  (vide Frontispiece, Fig.  17).  The other is  the bacillus
described more especially by Ogata as the definite cause of an epi-
demic in  Japan.   This bacillus, isolated and cultivated, produces,
when introduced  with the food or injected into the bowel of various
animals,  ulcers  and haemorrhages in  the colon,  swelling  of the
mesenteric glands, and nodular masses in the liver and spleen. 
DYSENTERY.
325
   Symptoms.—Dysentery is a disease of the large intestine only,
but it is usually gradually ushered in from a lighter form of gastro-
intestinal catarrh.  After a stage of incubation, which lasts from a
few hours to a few days, symptoms of dyspepsia and diarrhea set
in or increase, attended with anorexia, heartburn, nausea, eructation
or borborygmi, pain in the abdomen, and copious fluid discharges.
Hereupon ensue the pains and discharges characteristic of the dis-
ease.   Violent griping and  colicky pains (tormina)  traverse the
abdomen, with  sickening  sensations of  depression.   The desire  of
evacuation of the bowels  (tenesmus) becomes  intense and  more or
less constant, and the discharge itself  is attended with little or no
relief.   At the same time the region of the rectum, intensely inflamed,
is the seat of intolerable, burning pain, which becomes excruciating
with the introduction of a speculum or the finger.
   Ordinarily the peculiar pains  of  dysentery first proclaim the
character of the disease.   The  severe grinding, twisting pains (tor-
mina) are more or less localized in the course of  the colon, and hence
surround or traverse the entire abdomen, the pains at the epigastrium
being due to  spasmodic contractions of  the transverse colon.  The
patient in vain adopts various postures in relief, or sits  with  his
hands  firmly compressing the  abdominal walls.   The tormina are
more or less intermittent or remittent, and are usually experienced in
greater severity toward evening.  During their  acme the face wears
the aspect of the intense  suffering, which is expressed in  outcries
and groans.   At the same time there is, upon pressure over the whole
abdomen, more or less tenderness, which  soon comes to be especially
localized at the caecum or sigmoid flexure
   The tenesmus (cupiditas egerendi) is a  more distressing, and
certainly more distinctive, sign of dysentery.  It is the feeling  of
heavy weight or oppression,  of  the presence of a foreign body in the
rectum, which demands instant relief.   At the same time intense
heat is felt in the rectum, which the patient likens sometimes to the
passage of a red-hot  iron.  The desire of evacuation becomes as fre-
quent as urgent.   In well-marked cases the patient sits at stool half
an hour or an hour at a time, straining until faint and exhausted,
leaving the commode with reluctance, only immediately or very soon
to use it again.
   Great depression is felt at the stomach at the same time, with
nausea, occasionally with  vomiting; and strangury, with  the dis-
charge of only a few drops of scalding urine or  blood from the blad-
der,  adds additional  suffering  to  the  disease.  Retraction of the
testicle and  prolapsus ani, especially in  children, are prone  to occur
in severe cases.
   The  discharges may be  copious, dark brown, thin, and highly 
326
DYSENTERY.
offensive  (bilious dysentery),  may contain occasional hard, round
fecal casts of intestinal sacculi  (scybala), or may become more1 and
more scant until with the most  violent efforts only the  minutesl
quantity  is extruded  of mucus, generally streaked or tinged  with
blood (rose mucus), like the rusty sputum of pneumonia..  Later all
effort  at  emptying  the alimentary canal may be futile  (dysenteria
sicca), or  the mucus may be pure or commingled with pus to remain
perfectly  colorless (dysenteria alba), or with blood in larger quantity
(dysenteria rubra).   In other cases, or at other periods in the same
case, the  discharges consist of  fleshy masses composed of inspissated
mucus or pus, blood, and tissue  debris (lotura carnea).  Sometimes,
though rarely, the discharges  consist of  pure blood, but oftener of a
copious turbid fluid which, on standing,  separates into a clear upper
layer of serum and  a  sediment of disintegrated lotura carnea.  Or,
lastly, the sediment is composed  of small,  round vitreous  masses,
evidently swollen by maceration to look like sago grains, which have
been erroneously supposed to represent the liberated  contents of the
intestinal  follicles.
   Neither the pain  nor the  prostration is so characteristic  of
dysentery as  the stools, which, though  of  very varied nature, are
nevertheless  distinctive.  After  the discharge of the intestinal  con-
tents the  first evacuation consists of mucus in the form  of glairy,
stringy matter, like  the white  of an  egg, expressed as the result of
the violent efforts at straining.  The mucus may be pure or tinged
with blood, but it is usually very scant  in  quantity, and stands in
this  regard in marked contrast  with the violence of  the efforts  to
secure its  extrusion.   It is the frequency of its discharge which  con-
stitutes an especial  distress.  Twenty to forty,  even  two hundred,
times in the twenty-four hours the patient must go to stool.   In the
worst cases the patient sits at stool or  lies upon the bed-pan the most
of the day.
   The mucus is sooner  or later mingled with  pus or stained with
blood.   The presence of blood  is equally  characteristic of dysenteric
stools.  Usually it is intimately commingled with the mucus or  pus.
or forms the chief element of the copious so-called bilious discharge.
The  evacuation of pure blood indicates erosion  of vessels low in the
colon, often in the rectum itself, though enormous quantities of blood
are sometimes voided from unbroken surfaces.
   Besides the mucus, pus, and blood, the  dysenteric stool contains the
sloughs which have  been torn off by violent peristalsis in cases of the
diphtheritic form.  Usually they are separated in shreds and frag-
ments, but occasionally large sheets,  even casts of a section of the
colon, are voided en masse.  These fragments consist for the most
part of inspissated mucus, pus, blood, and tissue debris, but there is 
DYSENTERY.                        327
  no doubt that in some cases partially necrosed mucosa also enters into
  their construction.  One enormous tubular cast fourteen inches long,
  preserved in our Army Medical Museum, was found to be "composed
  of pseudo-membranous lymph,  in which no trace of the structure of
  the mucous  membrane  could
  be detected" (Woodward).
     There still remains to be
  mentioned  the  boiled-sago or
  frog's-spawn matter,   whose
  origin has given rise to such a
  curious  mistake.  Not infre-
  quently these vitreous-looking
  bodies compose the bulk of the
  sediment in the  stools of  dys-
  entery, and even some of our
  modern authors,  unacquainted
  with the more searching inves-
  tigations of Virchow, have re-
  garded them as expressed  con-
  tents  of  intestinal  follicles.
  Virchow found that under the
  application  of iodine they al-
  ways assumed  a blue  color.
  They are simply granules of
  starch  ingested as food, to re-
  main partially or wholly undi-
  gested.
    The general   condition  of
 the patient suffers correspond-
 ingly.   There may be  fever
 or there may be none through-
 out the whole course of  the
 disease, but  the pain and dis-
 charges quickly  exhaust  the
 strength of the patient, and in
 severe or long-continued cases
 lead  to emaciation  and pro-
 found prostration.
    The skin is hot and dry;
 the tongue is heavily coated;
 the face wears an anxious expression.  The abdomen is tumid with
 gases, or  in  more advanced cases sunken,  discolored, and  tender,
especially in the course of the colon, whose thickened walls may be
often felt beneath the emaciated surface.   The anus is spasmodically
  Fig.  16tf.— Descending colon with sloughing
pseudo-membrane (Medical History of the War
of the Rebellion). 
328                        DYSENTERY.

constricted, or in the worst cases paralyzed, patulous, and livid or
blue.  Prolapse of the rectum is common in children, and excoriation
of the perineum by the acrid discharge is not infrequent.
   Finally a typhoid state may set  in  or a pynnnia occur, when the
discharges may become involuntary or unconscious, and brain symp-
toms—insomnia,  stupor, delirium,  and  coma—supervene ;  or the
patient may linger long  enough to perish by simple exhaustion or
marasmus.
   Under favorable hygiene the great majority of cases of catarrhal
dysentery recover without special treatment in the course of from
three to ten days, but specific dysentery has no definite duration and
but  little tendency to spontaneous cure.  The worst cases are  often
quickly controlled by appropriate interference, and the most surpris-
ing results may be sometimes obtained in cases of even years' dura-
tion.  On the other hand, a certain  percentage of cases is character-
ized by a  defiance  to  every  kind of treatment, including the last
resort, a change of climate.
   An acute case of catarrhal dysentery generally subsides without
lesions, and the natural duration of the attack may be much abbre-
viated by proper treatment.  Epidemic dysentery lasts from two to
four weeks, or. becoming chronic, continues for years or for life, with
exacerbations and remissions.
   Various complications are liable to occur in the course of the dis-
ease.  Three deserve especial mention—viz., affection of  the  joints
(rheumatism), paralysis, and abscess of the liver.  Perforation and
peritonitis  are always possibilities,  and deformities of  the  colon,
thickenings, and constrictions are not infrequently left.
   Morbid  Anatomy.—Catarrhal dysentery shows hyperaemia  of
the mucous surface, limited, in a large majority of cases, to the large
intestine.   The hyperaemia is most marked in the lowest parts  of the
intestine, the rectum, or descending  colon.   The whole process may
be arrested at this stage, or  it may  increase to lead to softening of
the cells and desquamation, the fundamental, anatomical  character-
istic of dysentery, by which process the submucous connective tissue
is  laid bare  and ulceration results.   In  other cases a pseudo-mem-
branous or  diphtheritic process is developed.  This condition may
vary in intensity from a mere frosting  of the surface to dense infil-
tration of the entire thickness.  Subsequent sloughing may ensue.
The fall of the slough leaves the dysenteric ulcer.   Its edges are ir-
regular and ragged, its base uneven like a crater, and its surface is
more or less covered with pultaceous debris.   Perforation  from such
an ulcer is fortunately rare, but is the most frequent cause of perito-
nitis in chronic dysentery.  In rarer cases perityphlitis may ensue,
or periproctitis with perineal abscess,  or, finally,  fistulae  may form 
DYSENTERY.
329
 to burrow about and discharge themselves anywhere in or  upon the
 surface of the abdomen, the lumbar region, or the thigh.  The  au-
 thor once saw in consultation  a case of fistula which extended from
 the descending colon to  the vagina.  Through the opening made to
 discharge the pus from a fluctuating abscess pointing into the vagi-
 nal vault, an india-rubber tube was passed for  six  or  eight inches.
 The patient died finally from marasmus.  Ulceration shows itself in
 chronic dysentery in every grade and stage, from superficial denuda-
 tions  to old cicatrizations.  In bad cases the whole  course of  the
 colon  from the ileo-caecal valve to the rectum may constitute  one
 vast tract of suppuration.  Chronic dysentery is marked by atrophy
 of glandular structure and hy-
 pertrophy of the wrall  of  the
 bowel.
    Complications   and  Se-
 quelce. — Pyaemia  announces
 itself  with  a series of  chills,
 followed by irregular tempera-
 ture, by the speedy  occurrence
 of multiple abscesses in distant
 organs, venous  thromboses,
 affections of the serous mem-
 branes, pleuritis, pericarditis,
 and embolic pneumonia.   Gan-
 grene  of  the intestine,  which
 may occur as early as the third
 day of the disease, is evidenced
 by the signs of  general col-
 lapse.
   Arthritis, when  it occurs,
 shows itself, as a rule,  in  the
 second week of the disease, or after the disease has run its course,
 during the period of convalescence.  All authors who admit it de-
 scribe  the knee joint as being the most  frequent seat of the affection,
 but acknowledge that it  is mostly polyarticular; while there is much
 difference of opinion whether it ever presents the general signs of
 true rheumatism—pyrexia, diaphoresis, or its complications on  the
 part of the heart.  It usually lasts four to six weeks, but neither its
 occurrence nor its severity stands in any relation to the intensity of
 the attack of dysentery.  It is probably to be regarded as a manifes-
 tation  of a light pyaemia or septicaemia, as  it is a  frequent  manifes-
tation  of this condition  in  or  after scarlatina, puerperal fever, and
the septic fevers of surgery, where it is a streptococcus infection.
   Paralysis  has been observed to  occur after dysentery ever since
 Fig. 169.—^Descending colon with oval ulcers
(Army Medical Museum). 
330
DYSENTERY.
the days of Galen.   It is usually confined to the lower extremities,
but may extend to and involve the upper extremities, by preference
in the form of paralysis transversa (opposite arm and leg).
   Abscess of the liver gives rise to few distinctive symptoms, and is
mostly recognized or suspected, in  the absence of positive signs, by
the persistence or obstinacy of dysentery.  The ease and impunity
with  which aspiration may be performed in its  recognition justify
the use of it in every doubtful case.
   Dysentery may be further complicated  by parotitis;  by venous
thrombosis (phlegmasia dolens); by  diphtheritic  deposits on other
mucous surfaces, which Virchow  declares to be exceedingly rare;  and
by hydrops, which is oftener a concomitant of the period  of  conval-
escence.
   Besides the deformities of the colon which may ensue as a conse-
quence of ulceration or peritonitis, a long attack of dysentery is apt
to leave  a hyperaesthetic or non-resistant state of the mucous sur-
faces, so that  every imprudence in exposure or in  diet begets an in-
testinal catarrh or a relapse of the disease.
   Diagnosis.—The tormina and tenesmus, the peculiar discharges,
the rapid reduction of strength, leave no doubt as to the nature of the
affection.  The prevalence of an epidemic of the disease  will often
establish the character of a case  even  when all the signs are not pre-
sent or when anomalies occur.  Embarrassment in diagnosis only at-
tends the recognition of catarrhal or isolated cases, and in these cases
there may be a doubt as between dysentery and diarrhoea—if such a
symptom can be called a disease—or typhoid fever, cholera, or some
purely local affection of the rectum,  cancer, haemorrhoids, etc.   In
children  difficulty of diagnosis may arise as between dysentery and
intussusception.
   Dysentery is differentiated from that lighter form of intestinal ca-
tarrh whose main symptom is diarrhoea by the presence of tenesmus
in dysentery, as well as by  its mucous, muco-purulent, diphtheritic,
and bloody discharges.  Dysentery lasts longer than diarrhoea, as a
rule, and does not yield so readily to treatment.
   Typhoid fever shows from the start brain symptoms,  which are
absent from dysentery ; has  a typical temperature curve, whereas
there  may  be  no fever  in dysentery,  or,  if any, it is of  irregu-
lar, remittent type; is often prefaced by epistaxis and attended with
bronchitis, both  of which are absent in dysentery ; and  exhibits
ochre-colored,  pea-soup stools altogether different from those of dys-
entery.
   Cholera morbus distinguishes itself from dysentery by its  sudden
onset, its profuse vomiting and discharges, its violent cramps and
speedy collapse. 
DYSENTERY.
331
    Cancer of the rectum can be usually felt, and haemorrhoids can be
 always seen, so that no difficulty should be experienced in the recog-
 nition of these cases.
    Intussusception occurs mostly  in  children, and has, in  common
 with dysentery, vomiting, mucous or bloody stools, colic, tenesmus,
 nervous unrest, and prostration, so that a differential diagnosis may
 be impossible for a few days.  The more strict localization of an in-
 tussusception, which may sometimes be felt as a sausage-like mass,
 most frequently in the right ileum and hypochondrium, the greater
 frequency and persistency of the vomiting and pain, the presence,
 visibly or palpably, of the  invaginated gut at the anus or rectum,
 soon enable the careful examiner to recognize the case.
    Prognosis.—The prognosis of dysentery varies between extremes.
 Catarrhal cases are mostly so mild as to terminate of themselves, un-
 der favorable hygiene, without special treatment.   On the  other
 hand, no known disease has a more frightful mortality than  dysen-
 tery in some of its epidemics, especially in army life.   It was this
 class of cases which Trousseau had in mind when he called dysentery
 the most murderous of all diseases.  Sixty  to eighty may be the ap-
 palling percentage of death in these cases.
   Complications on the part of the nervous system, the status ty-
 phosus, pyaemia, and  great prostration necessarily render the prog-
 nosis grave, yet even these cases are not necessarily fatal.  Cases have
 recovered after complete paralysis of the sphincter ani.  The recogni-
 tion and discharge of  an hepatic abscess relieve the patient from the
 dangers of this complication.  Peritonitis alarmingly aggravates the
 prognosis, and perforation is almost of necessity fatal.
    Prophylaxis.—The improved sanitation of modern times has al-
 ready diminished  the frequency and mitigated the severity of epi-
 demics of dysentery; and this fact, which is only an accidental ob-
 servation, as it were, gives the clue to the means of its further pre-
 vention.
    The selection of proper sites for camping grounds, barracks, and
 hospitals, the prevention of overcrowding in tenement houses, ships,
 and jails, the regulation of sewage, care for  the food and drink, the
 observation of  the  strictest cleanliness by  authoritative control—all
 these are general measures which suggest themselves in the prophy-
 laxis of this or any disease.
   In the management of individual cases the  first precaution is to
 prevent the dissemination of the disease, as this protection of others
 secures  also for the individual patient the most favorable hygiene.
   The  bedding must be frequently changed ; the windows kept open
 to secure free ventilation, which, in the light of existing knowledge,
is the only true disinfectant;  and all the  furniture of the sick-room, 
332
DYSENTERY.
especially including the receptacles for the discharges, must be kept
perfectly clean.   For this purpose the best purifier is boiling water.
   The drinking-water should be secured, during an epidemic, from
the purest possible source ; and if good drinking-water cannot be had,
what there is should be thoroughly boiled.
   The discharges should be  properly mixed with  sawdust or some
combustible substance and burned ; or, if this be impracticable, should
be buried in the  soil  a  few feet below the surface, and not emptied
into water closets or privy vaults used by others.
   Such  articles  of food should be  abjured as have a tendency to
produce  intestinal  catarrh.   So unripe  fruits, vegetables  which
readily undergo fermentation—in short, all indigestible substances—
should stand under ban.   But no prohibition should be put upon ripe
fruits or simple, nutritious food of any kind.  Lastly, liable individu-
als should protect themselves from catching cold.
    Treatment.—The  first requisite in the  treatment of an individual
case is perfect rest.  Patients with even the lighter forms of catarrhal
dysentery should observe the recumbent posture, and cases of more
serious illness  should  be put to bed.  Rest in bed, an exclusive diet
of milk—which should always have been boiled—and the time of a
few days is  sufficient treatment  for the mildest case.  Where there
is objection to milk,  meat soups, with  or without  farinaceous mat-
ters, rice, barley, etc., may take its place.
    A case which is somewhat more severe  will require perhaps a light
saline laxative—a Seidlitz powder, a dose  of Rochelle or Epsom salts
in broken doses—or a tablespoonful of castor oil or five to ten grains
of calomel, to  effect a cure.  For the relief of the pain of the lighter
cases nothing is equal to tincture  of opium, of which five to ten drops
every three or four hours, in a tablespoonful of camphor water acidu-
lated with a few drops  of hydrochloric acid, will generally suffice;
Dover's powder  in broken  doses, one to three grains, with five to
fifteen grains of bismuth or soda, or both, is a  good substitute  for a
change.   Salol in tablet gr.  v., or hydronaphthol  in keratin-coated
pill gr. v., every  hour or two, sometimes cures  the disease.
   The successful treatment of dysentery in any form depends upon
a recognition of the fact that the disease is local as  to its seat and is
probably specific  as to its cause.   Anodynes relieve effects, but laxa-
tives must remove the cause.  Consequently the most rational treat-
ment of the severer cases is the irrigation of the large intestine and
the thorough flushing out of its  contents.   Since Hegar has recently
shown how the whole tract of the large intestine can be thoroughly
inundated and flushed with  a common  funnel  and rubber tube, the
practice  has continually gained ground, until it is now.admitted as
the most valuable method  of treatment.  Wood of Philadelphia, 
DYSENTERY.
333
 and later Mackenzie of London, reported a number of cases in which
 irrigation of the bowel with large injections medicated with nitrate
 of silver, 3 i.-Oi., was attended with the most surprising  results,
 sometimes but a single injection effecting a cure ; and the author has
 reported a case, almost in articulo mortis, where complete cure fol-
 lowed the irrigation of the bowel—on three occasions  with three
 pints of water containing  three drachms of common alum.   This
 case  was all the more instructive from the fact that  a relapse had
 occurred after very striking but only temporary relief had been ob-
 tained with the nitrate of silver, the alum having been  substituted
 simply on the ground of expense.  Usually half a drachm to the pint
 will suffice for either drug.  Tannin in one-per-cent solution is a good
 substitute.
    The object is to introduce as much cold water as possible without
 producing too much pain.  The large intestine of an adult holds, on
 an average, six imperial pints, but  in the  author's experience not
 more than three  or  four  pints can be, as a  rule, safely introduced.
 The patient should lie upon the back or left side, with the hips ele-
 vated and the head low, while the  injection is slowly  introduced
 from  a funnel, fountain, or a bulb syringe whose nozzle is  thoroughly
 anointed with vaselin.  In  the absence of a thoroughly competent
 assistant the operation should be performed by the physician him-
 self, for the proper use of an irrigating enema is a practice which re-
 quires both judgment and skill.   When pain is experienced the further
 influx of the fluid should  cease for  a few minutes, when it may be
 resumed again and again until the largest possible quantity is intro-
 duced.  It is impossible to  overestimate the value of this treatment
 in cleansing, disinfecting, and  constringing the foul and flabby sur-
 face of the whole seat of the disease.  As was said by  Hare: " It
 changes a huge internal into an external abscess, and enables us to
 cleanse the bowel of its putrid contents."
   Of all the remedies which have been recommended in the relief of
 dysentery, besides the  irrigation method, but one—ipecacuanha—de-
 serves the name of a specific.
   The remedy is best administered  in large doses, gr. xx.-xl., and
 should be repeated every four to twelve hours until permanent good
 effects are secured.  A dose of fifteen to thirty drops of  tincture of
 opium, or morphia one-fourth grain hypodermatically, will best pro-
 tect the patient from too great exhaustion.  The beneficial results are
 mostly obtained in the acute cases, though surprising results sometimes
 follow in cases of very long standing.  Should the remedy fail to be of
service in the course of twenty-four hours,  it should be discontinued.
   Suppositories of opium and  belladonna with cocoa butter quickly
relieve severe tenesmus.  Clysters of nitrate  of silver gr.  iv. and 
331                         DYSENTERY.

water 3 v. (Duchs), or with a few drops of tincture of opium (Ber-
ger); of ipecacuanha (Begbie and  Duckworth); of laudanum and
starch (Sydenham, Abercrombie);  of the various astringents, espe-
cially acetate of  lead gr. viij. and water  3 iv., may be tried in obsti-
nate, more especially chronic, cases.
   Local  inspection  of  the rectum by means of  the speculum  may
possibly reveal an ulcer, which is the chief or sole cause1 of the tenes-
mus and bloody discharge.  Maury reports such a case1, in which the
   Fig. 170.—Cicatrices of diphtheritic ulcers in the colon (Medical History of the War of the Re-
bellion).

ulcer was deep enough to hide a small sponge.  In such cases topical
treatment may effect a cure.
   Dilatation may suffice to overcome a stricture in the rectum, the
result  of cicatricial contraction, or colotomy may  be necessary in
cases more refractory  or situated higher in the bowel.  Post reported
a successful colotomy, with the formation of an artificial anus in the
left lumbar region, in  such a case.   Perforation calls for immediate
laparotomy.
   In all cases of  pronounced prostration stimulants are to be freely 
CHOLERA.
335
used; and of all stimulants alcohol is the best, as it has also nutritive
and  antiseptic  properties.  Alcohol  is thus trebly indicated in  the
treatment of dysentery, but the choice of the form and  strength will
be a matter of judgment in the individual case.
   Where life is imperilled by haemorrhage  or anaemia  from any
cause, a forlorn  hope is offered in subcutaneous  transfusion of salt
water (boiled), one drachm to the pint.
   Abscess of the liver is best treated by aspiration or hepatotomy,
rheumatism by the salicylates, and paralysis  by the constant cur-
rent of electricity.
   Obstinate cases of chronic or continually recurring dysentery are
thoroughly cured only by a sea voyage, a sojourn at the sea shore, a
mountain excursion, or a permanent change of climate.

                           CHOLERA.
   Cholera {x°^V, bile, ptoo, to flow, from ancient erroneous concep-
tion, as it is precisely the bile which does not flow); Indian or Asiatic
cholera, as distinct from cholera nostras, cholera morbus.—An exqui-
sitely acute infection of the intestines, caused by a spirillum ingested
with the  drink, characterized by profuse discharges like  rice water
from the  bowels and stomach, congelation of  the blood, suppression
of urine, huskiness of  voice, cyanosis,  cramps and collapse ;  or re-
action and recovery ; or at times, later,  a typhoid state.
   History,  Geography, etc.—Asiatic cholera was unknown to the
old Greek writers.  They applied the term to our cholera morbus or
cholera infantum.  Yet the disease has had its home and haunt from
time immemorial on the banks and swamps of the Ganges and Bra-
maputra,  where it finds the necessary heat, moisture, and decompo-
sition to  perpetuate its cause.  But  it never broke its leash until
1817, when it appeared in Jessora, and later Bagdad, 1819,  and tra-
velled thence across Persia to the Trans-Caucasus (Tiflis), whence it
was carried to Astrakhan, September, 1S23,  and was here  effectually
killed by the extreme cold of October of that year.  The next out-
break made  itself  memorable as the first real pandemic  of the dis-
ease. It  started from the Ganges in 1826, reached China in 1828,
whence it was shipped to Orenburg and Astrakhan, 1830.  Thence it
reached Russia  in 1831, and in the same year invaded Prussia, ap-
pearing for the first time in  Berlin and  Hamburg.  From Hamburg
it was carried to England, and thence by Irish emigrants  to Canada
(Quebec) and the whole of North America in  J 832.   This attack did
not cease  until  1837.  The third  pandemic started in India in 1818,
reached China, Persia, European Turkey and Russia, Siberia, Ger-
many (Hamburg),  Hull,  and thence in the same year New York
and  New Orleans and the whole of  the United States.  This epi- 
336
CHOLERA.
demic visited  Norway, Sweden, and Denmark for the first time in
1853.  The disease did not die out in Europe until 1861.  The fourth
pandemic, 1863-75, was  carried from the Ganges to Bombay, by
pilgrims also to Mecca, Suez, Egypt, by ship to Constantinople and
Marseilles.  It reached the United States in 1866.   In 1S81 cholera
appeared in Toulon, an importation from Egypt, and traversed Hun-
gary. Spain, and Italy, reaching South America from  Genoa.  The
epidemic of 1890-02 followed both northern  and southern  courses.
reaching the west of Europe in 1892.  This outbreak, highly fatal at
Hamburg, was successfully  quarantined  at  New York Harbor in
1S93.  The Cholera Bacillus was discovered by Koch in India in 1S81.
   Etiology.—Cholera is a purely " water-borne disease" (E. Hart).
Certain places  are always visited,  others often spared by visitations
of cholera.  Porous soils, sinking  subsoil water  by opening access
to oxygen,  more  especially by contaminating  wells and drinking-
water, favor  the  development  of cholera.   Cities of valleys and
plains are oftener  or  more severely attacked than those of eleva-
tions or  mountainous  regions.  Assemblages of  multitudes in pil-
grimages,  camps,  etc.,  especially under  bad  hygiene,  favor the
spread of the disease.  Cold weather inhibits and checks the growth
of the spirillum and puts a stop to an epidemic.   Of individual con-
siderations age is important.   The young are likely to escape  alto-
gether or suffer a mild  attack, largely on account of active (acid)
gastric juice and rapid peristalsis, which destroy and expel the cause
of the disease.  The old and enfeebled suffer most.   Imprudence in
diet  and drink (alcohol), bad habits of any kind, catarrh of the sto-
mach or intestines, dyspepsia and diarrhoea, predispose  to the dis-
ease. That amount of fear which  leads to prudence in diet, care of
the  drinking-water, including milk and all  other drinks,  protects
against the disease.  Excessive or abject fear  increases the liability.
   Bacteriology.—The cholera spirillum is a curved rod like a comma,
the " comma bacillus," flagellated,  endowed with motion, 1-2 p long
(vide Frontispiece, Fig. 14).   It is an aerobe, though it may still de-
velop in the absence of oxygen, with optimum temperature at 85°-
106° F.   It ceases to  grow at 60°  F., but perishes only after thor-
ough freezing.  It is  very sensitive to  acids, is  speedily killed by
sublimate, carbolic acid,  etc., and quickly dies under desiccation.
It grows in all kinds  of  culture soils, luxuriates in fresh milk, but
perishes  at once so soon as the milk becomes sour.   It lives on bread
(rye) one day, on bread wrapped in paper three days, on bread under
a glass cover seven days,  on the surface of feebly acid butter four to
six days, in beer twenty-four hours, in acid (0.7 per cent) wine but
fifteen minutes.   It perishes at once in lemonade (Uffelmann), which
is therefore a better drink than even dilute muriatic acid during the 
                             CHOLERA.                         337

  prevalence of cholera.   The spirillum freshly discharged is feeble.
  It gains in tenacity out of the body, so that it resists the action of the
  gastric juice.  It lives longer  in contaminated than in pure water.
  It has been  demonstrated in  well water after thirty  days (Koch),
  and in harbor (sea)  water  eighty-one days  (Nicati and Rietsch).
  Koch found it in India in streams contaminated
  by the washing of cholera linen and in tanks      y1^ ~
  used for drinking water.  Fresh  aerobe  cul-     u^1  ** \ *
  tures  of the cholera spirilla develop  a special   K )  iT^   -?"*>■
  poison of  extraordinary  intensity.   Thymol,   ^  -i\*v    *-*-
  chloroform, desiccation, which destroy the  spi-     '"1^   V„>V n V,
  rilla, do not attenuate the virulence of this  poi-
  son.  Most of the symptoms of  cholera are attri-  FlG- ""t.-comma bacillus
               ..„,...,       .         of cholera, pure culture.
  buted to the action of this cholera toxine.
    The cholera spirillum is usually easily demonstrated in the dis-
  charges by  fuchsin or methylene blue.  A rice-water flocculus is
  often almost a pure culture.  Cases of doubt may be determined by
  cultures.  A quantity of the discharge is added to a double quantity
  of alkaline bouillon and kept at a temperature of 100° F.   Colonies
  which quickly show on the surface  may be transferred to plate cul-
  tures.   On gelatin plates the colony grows  as flat,  yellow  discs,
  which in one day fluidify the soil and show under the  lens a granu-
  lated appearance, as if the surface had been strewn with small pieces
  of glass (Koch) (vide Frontispiece, Fig. 11).   Stick cultures show a
  line  of  fluidified gelatin, expanding at the  top to a small funnel, a
  point of distinction  from simulating bacteria  (vide  Frontispiece,
  Fig. 8). The addition to bouillon  cultures of  five to ten per cent
  common nitric  acid develops a violet  color.   The addition of sul-
 phuric acid, with  subsequent neutralization with soda, develops a
 Burgundy red, the so-called " cholera red."
    Symptoms.—Cholera begins suddenly, often in  the night, with
 diarrhea, which voids first the contents of the bowels stained with
 bile;  later, in the course of an hour or two, the characteristic alkaline
 rice-water discharges.  The discharges are voided without  effort,
 pain, or tenesmus.   They gush  from the body in such  quantity,  fif-
 teen  to  twenty during the day, as  to drain the blood.  Vomiting
 now sets in—at first of the contents of the stomach, with bile regurgi-
 tated from the duodenum; later, through an incontinent pylorus, of
 the same rice-w~ater contents of  the small intestine.   The vomiting is
 also without effort or strain.   It gushes from the mouth and is some-
 times projected  several feet from the  body. The patient soon falls
 into collapse,  with precordial constriction, intense  anxiety, unap-
peasable thirst, heart failure, and faintness.   During the attack
 cramps  develop  in the calves of  the legs, later in the arms and 
338
CHOLERA.
abdomen, not suddenly or universally at a stroke, as in tetanus, but
more gradually, successively,  one after another, to the indescribable
torture of the patient while they last.
   The  disease is now at its  height.  The surface  is cold, tinged
with blue on a gray ground.  A  wide black halo  lies about the
deep-sunken eyes.  The nose is pinched,  the lips livid, the tears dried
up, the cornea grows opaque.   The breathing is oppressed and diffi-
cult; the very breath  is  cold.  The voice is husky, reduced to a
whisper, and lost.  The  urine is reduced more and more.   Finally
the kidneys fail entirely.   There is  often complete anuria, generally
for a period not longer than a  day or two, in fatal cast's often for the
greater  part of  a week.  The  discharges continue profuse. The
anxiety gives way to apathy.   The mind, clear from the start, be-
comes clouded.  The heart's action grows feebler and feebler, cya-
nosis increases, and the patient dies of asphyxia.
   This scene represents the  first stage, or the stage of asjdiyxia.
It lasts from three to thirty six hours, and is followed, in cases which
recover, by the second stage, the stage of reaction.  The discharges
now cease in frequency, cease  altogether, or become natural and are
again tinged  with  bile.   The  pulse  grows  stronger, the  surface
warmer or bathed in sweat, the secretion of urine is re-established,
is sometimes  increased beyond the normal amount (polyuria), the
appetite returns, the patient gains  strength; convalescence is estab-
lished.
   Unfortunately, in a certain percentage of cases the reaction does
not stop at  the standard.  It goes beyond;  it becomes excessive.
Fever increases, the mind becomes  clouded, the tongue is coated, the
lips are covered with sordes, the voice is again reduced to a whisper,
the kidneys fail, and the patient, under  the signs of uraemia or tox-
aemia from chemical products of the bacillus, sinks into the danger-
ous state known as the cholera typhoid.
   Eruptions of  various  kinds  may now occur:  erythema, roseola,
urticaria, first on the forearms and wrists, later on the face and body,
rarely widely scattered anywhere;  or various more dangerous com-
plications or sequelae may develop.  Thus croupous or catarrhal
pneumonia, meningitis,  decubitus,  gangrene,  erysipelatous inflam-
mation,  diphtheritic,  ulcerative,  and destructive processes  some-
where in the course of the alimentary canal, may occur to threaten
or take life which has survived the disease itself.
    Forms.—During the  prevalence of an epidemic a great many
cases develop nothing more than a  more or less sharp diarrhoea with
dyspeptic signs lasting over the greater  part of a week.  These  are
the cases of so-called cholerine—little, m ild, or light  cholera—most
dangerous cases in the dissemination of the disease.  These patients 
CHOLERA.
339
 go about soiling linen, and through defective sewerage contaminating
 drinking-water with their dejections, until cases multiply to constitute
 an epidemic.  In other cases the attack is foudroyant.  Such at-
 tacks may take life in the short space of two hours.  Between these
 extremes are attacks of every grade of intensity.   More rare are the
 cases in which no discharge at all appears—cases of so-called cholera
 sicca, dry cholera.   Many of these  cases succumb rapidly.  The
 paralyzed  bowel is  found  filled to distention, unable to expel its
 contents.
    Morbid Anatomy.—Post-mortem rigidity sets in soon; decompo-
 sition is delayed.  The body is  cold and blue.  Emaciation may be
 pronounced.   The skin is shrunken.   The muscles  may show post-
 mortem tremor (fibrillation), whereby members of the  body or the
 whole body  may be moved.   The  intestine,  more 'especially  the
 ileum, is distended with  the rice-water fluid, which is grayish white,
 odorless, and full of flocculi.  The mucous membrane is hyperaemic
 and swollen, or oedematous, macerated, and denuded of epithelium.
 Ecchymoses are abundant;  diphtheritic deposits, ulcerations are not
 infrequent.  The internal organs are drained of blood and dry.  The
 blood in the right heart is often thick like tar.  The spleen is small,
 its surface wrinkled.  In protracted cases the kidneys show evidence
 of profound lesion in degeneration of  the epithelium of the urinary
 tubules, as a result,  not of stasis, but of poisoning by the cholera tox-
 ine (Aufrecht).
   The diagnosis is  easy in the presence of an epidemic, though
 cases of poisoning by the metals, especially by arsenic, and cases of
 heat stroke, have been included in cholera times.  First cases are dif-
 ficult, though these cases are not so dubious under the present rapid
 dissemination of  news.  The true physician, who hesitates to alarm
 a community unnecessarily, will not be deterred  by fear of  adverse
 criticism from declaring  a  diagnosis.  The  safety of a community
 depends upon the recognition of the  first cases.  The peculiar rice-
 water discharges, cramps, heart failure, cyanosis, and rapid collapse
 distinguish the  clinical history.   Cholera nostras occurs more espe-
 cially in late  summer and fall, in the absence of an epidemic or news
 of the advent or approach of true cholera.   It begins with vomiting,
 as a rule; purging follows later.   The discharges  of  cholera morbus
 are not like rice water, as a rule, though such discharges may occur.
   The diagnosis really rests  upon the recognition of the cholera
 spirillum in the  discharges or upon linen.  The best demonstrations
 are made with the carbol-fuchsin solution.   Caution must be  used
 with alcohol in withdrawing the water, as the comma bacillus very
 readily gives up its color (Neelsen),   It is not colored by the method
•of Gram.   For practical purpose the inoculation of gelatin in a clean 
310
CHOLKRA.
saucer will suffice ; for the appearance of the dotted or stippled sur-
face, the "broken glass " surface, from irregular fluidification of the
gelatin in the short space of twenty-four hours, is absolutely pecu-
liar to the comma bacillus of  cholera  (Pfeiffer).  The tube tests.
which take a longer time, are thus rendered superfluous.  But super-
flu a non nocent.  The cholera spirillum is differentiated from simu-
lating structures, those of Finkler-Prior, Deneke,  Escherich, etc.. In-
different action on culture soils.
   To confirm the diagnosis of cholera a flocculus is picked  from
the faeces or from the linen with  a platinum  needle previously steril-
ized at a white  heat.   This flocculus is introduced  into a test tube
partly filled with warm, 86° F., agar-agar, previously sterilized by
boiling.   The particle  is distributed throughout the gelatin.   Three
or four drops are now taken from this tube and inserted into a sec-
ond tube, and from this second tube in like manner into a third  tube.
The contents of  these three tubes are now poured out upon the sur-
face of three glass plates which have been previously sterilized by
washing  in a sublimate  solution and thorough heating for a long
time.  Here the gelatin  is allowed to set.  The three plates are now
banked one above the other, and covered  in  by a bell glass cover—
three  soup plates will suffice—whose interior is kept moist and pure
by being lined with a  layer of filtering paper moistened in a subli-
mate solution.   Colonies which  form on the third day are now ex-
amined under the microscope, and suspicious bodies are proved with
the stick  cultures in  tubes filled with solid  gelatin (agar).   Studies
of motion are also made in hanging drops.   Information  furnished
by all these methods establishes  the diagnosis.
    Poisoning by the  metals, corrosive sublimate,  more  especially
arsenic, is eliminated  by the detection of these substances by chemi-
cal tests.   Heat strokes show no comma bacilli in the stools.
    The absolute  diagnosis of cholera is  determined at Koch's  Insti-
tute, Berlin,  in  six ways : 1,  by microscopic examination  ;  2, by
peptone culture ;  3, by gelatin culture ;  4,  by agar culture  ;  5, by
the cholera-red (indol) reaction ; 6,  by inoculation of guinea-pigs.
    1.  The microscopic examination  alone declares the diagnosis in
half of all cases.   A  rice-water floccule on  the cover glass  stained
with diluted Ziehl's fuchsin solution is seen, in the case of true cholera,
to show numbers of comma bacilli, all disposed in the same direction,
that is, apparently following each other like a school of fish in a slug-
gish stream.  This appearance is itself characteristic.
    2.  The peptone culture is  prepared  by adding to a sterilized
watery solution of peptone and common salt, each one per  cent, as
much soda as will make the solution strongly alkaline.   Examina-
tion for bacilli is made in twelve hours after inoculation of the soil. 
CHOLERA.
311
   3. The gelatin plate culture—i.e., twenty per cent gelatin in oven
at 22° C.—shows the characteristic appearance in fifteen to twenty-
two hours.
   1. The agar plate culture displays colonies in eight to ten hours.
   5. The cholera-red (indol) reaction is obtained by adding a nitrate
to the peptone culture soil containing pure cultures of cholera bacilli.
Sulphuric acid (pure) develops the peculiar color.
   6. The inoculation test consists in  the introduction of  a platinose
of 1.5 milligrammes agar culture with 1 cubic centimetre sterilized
bouillon into the peritoneal  cavity of a guinea-pig of three hundred
to three hundred and fifty grammes weight.  The animal perishes
in a short time with typical symptoms of poisoning and fall of tem-
perature.   No other curved or  spiral bacteria have yet been found
which will in a dose  so small produce  anything like  the  same
symptoms.
   Finally, the drinking-water should be tested with the peptone cul-
ture soil, and the numerous bacteria thence derived examined and
tested as  before.  Cholera  bacilli were  thus disclosed in the river
Elbe and in wells, etc., in the epidemic of 1892 in Hamburg and
Altona.
   The prognosis   is  always  grave.   The  mortality,  excluding
cholerine and the lighter forms of diarrhoea, ranges about fifty per
cent.  It is always highest in  the beginning of an epidemic, and
greatest among the aged and enfeebled.
   Prophylaxis consists in quarantine at  sea.  There  is no excuse
for cholera in lands separated by oceans.  A sea blockade as effec-
tive as that of the  South in the late war would  suffice to bar out
cholera, and the expense entailed would be a trifle compared with the
cost of an epidemic.  Land quarantine is useless because necessarily
ineffective.   Detention of passengers from infected ports in quaran-
tine, especially of all individuals affected with diarrhoea, and  disin-
fection  of all soiled linen under  dry heat, 250° F., constitute the
best prophylaxis.  The  thorough cleansing of  cities, with house-to-
house inspection by intelligent  sanitary  officers armed with author-
ity and, if necessary,  provided  with means of indemnification for
destruction  of dangerous property  (clothing,  bedding,  etc.), with
care for pure drinking-water and discharge of  sewage, has much  to
do with the  prevention of  the  disease.  During the actual preva-
lence of an  epidemic people best protect themselves  by prudent
habits,  personal cleanliness, and  the use of pure  drinking-water.
They who can afford it  may partake  only of the mineral or carbon-
ated waters or light wines; all other waters should be  thorough ly
boiled.  The milk should be boiled.  The digestion should be kept
sound by  care as to diet, if necessary by the use of dilute hydro- 
312
CHOLERA.
chloric acid gtt. x-xx. in a w-ineglassof cold water before meals.  The
slightest  diarrJuea demands prompt  attention.   The discharges
of patients should be buried, or mixed with  sawdust and burned.
Soiled linen as it accumulates must be kept in a five-per-cent solution
of carbolic acid and  later subjected to  dry heat.   Utensils, bed-
pans, etc., should be washed out with carbolic acid solution.
   Immunity.—Brieger,  Wassermann, and  Kitasato injected into
guinea-pigs cholera cultures in a soil of thymus-gland tissue heated
to 65°  C. fifteen minutes and  cooled  in an ice chest twenty-four
hours.  The animals were thus rendered absolutely immune to viru-
lent  cholera  cultures, surviving  the introduction of three times the
quantity fatal to control animals.
   Klemperer induced immunity with cultures attenuated by heat,
also  by the galvanic current.  Blood serum from animals immunized
in this way produced immunity in other animals.  Haffkine secured
from pure cultures of cholera bacilli a so-called anti-cholera vaccine,
with which he inoculated himself and other men, securing protection
against the virulent disease.   All these methods are now under trial.
   Treatment.—The most important element  in treatment is the
arrest at once of diarrhoea by an opiate, which is made more effi-
cacious by the addition of an acid.

    R  Tinctune opii...............................................3 i.
       Acidi hydrochlorici  diluti................................gtt. xl.
       Aquae camphorae...........................................§ iv.
   M.  S. A tablespoonful every hour or two.

Rest in bed must be  absolute.  A mild case may be controlled by
a suppository of opium, one grain, especially at night.  A more se-
vere case calls for morphia  subcutaneously, in dose of one-fourth
grain to an adult.   To children the tincture of opium must be given
with caution.   One drop is the dose for the first year.  A child over
two  years of age may take  a teaspoonful of the mixture just pre-
scribed.  The algid state  must  be counteracted by  heat.  The pa-
tient may be wrapped in blankets, with bags, jugs, and bottles of hot
water along the spine,  sides of the body,  and at the feet.   Hot sand
bags retain heat a long  time.   The intolerable thirst may be ap-
peased with cracked ice,  and the patient may drink freely of  pure
carbonated waters.  Vomiting is best  controlled  by chloral.  Mus-
tard plasters to some extent allay epigastric pain.  Friction helps the
cramps somewhat.  Quicker relief is offered in very bad cases by
injections of chloral, gr.  v., deep into the substance of the  muscle.
Persistent diarrhoea, vomiting,  and cramp may be  stilled by a re-
peated hypodermatic injection of morphia.   Irrigation of the whole
 bowel with a hot one-per-cent solution of  tannic acid (entero-clyster) 
CHOLERA.
313
 or with very weak sublimate  solutions 1 :100,000 is  all the more
 indicated because the rice-water discharges contain so little albumen
 to weaken the  parasiticidal effect.  In the absence of any specific
 address to the  toxine in  the blood, attempt is made  to counteract
 the drain by transfusion with salt water, which is best practised sub-
 cutaneously.  Samuel recommends a solution of the strength of one-
 half  drachm to the pint of sterilized, warm, 105°  F., water injected
 continuously at the infraclavicular  fossa.   Cantani  prefers a solu-
 tion of common salt  3i.,  carbonate of soda gr. xlv., distilled water
 one quart, introduced at the sides of the body (loins), behind the ribs,
 by means  of a fountain syringe.  The skin is punctured with a fine
 canula, the trocar withdrawn,  the tube adjusted,  and the fluid al-
 lowed to flow, absorption being hastened by massage.   Cantani calls
 the process, which may be repeated on the other side, a hypoderma-
 tic clyster. There is no doubt of the great value of these injections,
 whereby patients  recover  at times even from states of asphyxia and
 unconsciousness.   The salt solutions not only fluidify the blood, but
 also neutralize, to some extent, the poisonous action of the cholera
 toxines upon the nervous system.  Unfortunately, the  restoration
 does  not hold.
    Collapse is met with alcohol (brandy) by the mouth, also by sub-
 cutaneous  injection.   Keppler recommends for this purpose :
    R  Sodii bicarbonatis................................ ..........  7.0
       Alcohol absoluti............................................  10.0
       Aquae destillatae.............................................1000.0

 injected anywhere under the skin, warm, 37° C. (100° F.), fifty cubic
 centimetres, at first every minute, later, so soon as the  pulse is per-
 ceptible, every five minutes, then every half hour.   Camphor is also
 a good excitant:
    R  Camphor rasurarum......................................,.. 3 ss.
       Ether, sulphuric............................................3 iiss.
    M.
 Inject ten  drops at a dose.  During the stage of  reaction the at-
 tempt is made to secure  free  action of the kidneys, especially by
 copious draughts  of  warm water, hot  baths,  diuretics,  etc.  The
 treatment  of the cholera-typhoid stage  is wholly  symptomatic and
 does not differ from that of typhoid fever itself.   During convales-
 cence the  diet  should be  fluid—milk, soups, diluted egg, thin cus-
 tards, gruels, etc.—for a week or more.

                       CHOLERA MORBUS.
   Cholera morbus, nostras; European, sporadic cholera (joA^, bile,
pica, to flow, because the discharges are stained with bile); in infants, 
;;n
CHOLERA.
 cholera  infantum.—An acute infection of the stomach and  intes-
 tine, sporadic, occasionally endemic, characterized by vomiting and
 diarrhoea, cramps, heart failure,  and rapid collapse.
    Cholera morbus has been known from the most remote antiquity.
 It was this affection which  received the name cholera.   The cause
 of the disease has been ascribed to excessive heat, to exposure to cold,
 to bad diet, to unripe fruit, fermenting and  decomposing food and
 drink, artificial feeding of infants, to contaminated drinking-water,
 etc.  The disease is evidently due to the  absorption of some toxine
 from the intestinal canal, though no particular micro-organism has
 yet been distinctly isolated  from the myriad bacteria of the  intes-
 tinal canal as its  cause.
    Symptoms.—The disease begins with pains in the stomach and
 bowels, severe colic with  flatulence and rumbling, and is announce1*!
 in the course of an hour or two with vomiting at first of the contents
 of  the stomach stained with bile (bilious  vomiting), and later dis-
 charges  from the bowels, copious, offensive, also stained with bile,
 which are hurried along under  rapid  peristalsis.  It usually ceases
 with these signs in the course of the same day, but may persist in the
 enfeebled or aged, more especially in childhood, to show the alarm-
 ing signs of true  cholera, rice-water discharges, cramps, hoarseness
 of  voice, heart failure, anuria, cyanosis, and asphyxia  or collapse.
 Convulsions and comatose states  are common  in children.
    Diagnosis.—In severe form  the disease  may be differentiated
 from true cholera only by the detection of the cholera spirillum  as
 established by its conduct on culture soils.
    The prognosis is favorable.  Most patients recover quickly under
 appropriate treatment.  On account of damage to the heart an attack
 is dangerous in advanced life, and aged people occasionally succumb
 to the disease.  The outlook is very grave in childhood under arti-
 ficial feeding, where the form of the disease  is more subacute, but
 becomes  immediately favorable under recourse to a good w-et-nurse.
    The treatment consists in the prompt use of opium, as indicated
 under Asiatic cholera.  Where the suffering  is not too extreme for
 delay with this drug, recovery is hastened by first washing out the
 stomach  with  copious  draughts of  hot water, or preferably with the
 stomach  tube.  Irrigation of the bowel with solutions of alum water.
 four or five pints,  half a drachm to the pint, assist in the same way.
 Where pain is severe an adult should receive  at once a subcutaneous
injection of  morphia gr. £-}.   Caution  must be used with repetition
 of this use of morphia, as absorption is powerful  under the drain  of
 the discharges, and patients  are easily narcotized.  Cracked ice, and
chloral gr. ij.-v.  in  peppermint  water, will usually allay vomiting.
The body must be kept warm with external heat, the heart's action 
CHOLERA.
315
supported with alcohol, brandy, and analeptics, as already described.
More protracted, obstinate (subacute) cases are best brought under
control by astringent irrigations.  The whole  bowel is washed out
with solutions of alum, tannin one per cent, or other astringent, as
described  in the treatment  of dysentery.  The stomach  should be
drenched with hot water. 
 
        PART II.




DISEASES  OF ORGANS. 
 
         DISEASES OF  THE
OPiGAXS  OF  DIGESTION.
                       CHAPTER  I.

    DISEASES  OF  THE MOUTH, FAUCES,  AND PHARYNX.
   Diseases of the mouth for the most part reveal themselves
 readily to inspection.  Daylight is the best.  Evidence is sometimes
 shown in the condition  of the lips, which may be swollen and fis-
 sured, as in cases of eczema, scrofula (tuberculosis).  Herpes about
 the lips may signify merely ephemeral catarrhal infections, or may
 indicate pneumonia, cerebro-spinal meningitis, etc.,  so  that herpes
 has both diagnostic and prognostic significance.
   Cyanosis reveals itself usually first about  the lips.  A light-blu-
 ish tint catches the eye of the physician as an index of heart disease
 or impeded respiration  (pneumonia).  The same discolorations are
 evident on the inside of the mouth, especially about the region of the
 palate, where at times the light-yellowish tinge of icterus is first or
 is corroboratively observed.  Certain drugs (antipyretics) give rise to
 a bluish coloration of the lips.
   Tumefactions which  may be visible upon the outside of  the face
 are best examined by palpation with one finger inside, the other out-
 side the mouth, whereby often inflammations  of  the  gums, whether
 mere indurations or containing serum, blood, or pus, often in connec-
 tion with carious teeth, are observed.  The mucous membrane may
 be hyperaemic,  indented by the teeth, ulcerated, or covered more or
 less extensively with membrane or sloughs as indicative of various
 forms of stomatitis.
   The tongue may be swollen and indented by the teeth, or cut, ul-
 cerated, showing bleeding wounds along its edge or scars indicative
 of epileptic attacks.   The enlargement of the  tongue is  often  a ve-
 nous engorgement due  to glossitis or to an extralingual infection.
 The most common cause of glossitis (stomatitis) is mercurial poi-
 soning.  In this condition the gums also become swollen, tender, as
 the first evidence of the condition. Effort  is  made in treatment of
 various conditions by mercury to avoid stomatitis, so that the admin-
istration of the  drug should cease upon the  first evidence of tender-
ness, as the patient closes the jaws more forcibly, or with the first ap- 
350     diseases of the mouth, fauces, and pharynx.

pearance of increased saliva.   The drug is  most efficacious when the
administration of it is  continued up to the time when it (barely)
touches the gums.   It may still be administered (see treatment) with
the simultaneous exhibition of chlorate of potash and frequent cleans-
ing of the mouth.   This continued administration is a great deside-
ratum in many cases, notably in the treatment of dropsy of  heart dis-
ease,  where no remedy can take the place of calomel.
   The recognition and treatment of affections of the teeth constitute
the special department of dentistry, which  has  reached great perfec-
tion in our day.  It falls within the province of tin1 physician to em-
phasize the necessity of cleanliness and care of  the teeth, which care1
should be extended also  to the first set in a child, that the permanent
set may be perfect.  Notches in the incisors are  recognized as an evi-
dence of impaired nutrition.  Late appearance, imperfect  develop-
ment, go along with rickets and syphilis.  Semilunar excavation of
the upper middle incisor, taken in connection with catarrh of the mid-
dle ear and keratitis, constitute the triad (not so infallible as Hutch-
inson claimed) in evidence of hereditary syphilis.
   Occlusions, retention cysts, calculi, are sometimes, though rarely,
discovered in connection with the salivary ducts.  The hard and soft
palate present distinctive evidence of disease.  The physician has here
to differentiate between simple, catarrhal,  diphtheritic, and  specific
processes.  The palate is a  favorite site of syphilis.   There is ob-
served at first intense hyperaemia with swelling, which may not be
separated from a simple catarrhal process.  Later, however, distinct
erosion of tissue occurs, whereby the soft palate is slit up often by
the side of the uvula, or perforated to permit regurgitation of fluids
through the nose—conditions often found associated with destructive
lesion in the nose itself.  The alas nasi may be alone or simultaneously
invaded, with gradual progressive erosion and subsequent marked
deformity.  The septum of the nose is perforated or the bridge broken
down.  The sunken bridge of the nose  constitutes almost  infallible
evidence of lues.  The lesions in the throat distinguish themselves
by their painless  but progressively destructive character.  They dis-
tinguish themselves also by the rapidity of their disappearance  and
complete cure under appropriate treatment.  In  any case of doubt the
patient should be subjected to this treatment,  that the diagnosis may
be established before irreparable deformity ensues.
   The mucous membrane which lines  the mouth and covers the
tongue  is dense, resistant, and relatively impermeable, so that, not-
withstanding the exposure of these organs to insult and injury, dis-
ease of the mouth and  tongue is rare.  It is   otherwise  with the
throat.   The stomata of the tonsils, which permit the migration of
leucocytes at  all times (Stohr),  readily admit pathogenic micro- 
STOMATITIS.
351
-organisms.  The absorptive (lymphatic) system  of  vessels is pecu-
liarly rich in the throat.

                           STOMATITIS.
   Stomatitis {6t6pa, the mouth) shows itself in a number of forms,
catarrhal, ulcerative, gangrenous,  and special affections have been
set apart, as aphtha, thrush, and noma.
   Micro-organisms have been found in all forms of sore mouth.  In
certain  cases—thrush, actinomycosis—genetic  relationship has been
established.  In  other  cases—forms of  stomatitis,  aphtha—micro-
organisms find entrance only when normal resistance has been  over-
come or epithelial barrier broken by lack of nutrition, long macera-
tion, chemical irritation (mercury), etc.
   Stomatitis  catarrhalis is
produced by mechanical, chemi-
cal, or thermic irritant, as in in-
fants by maceration  from  long
suckling of empty breasts, or by
an even worse  habit,  the use of
sugar teats or bags,  etc.; in adults
more especially by strong tobacco
and alcohol, hot, highly spiced or
acid food or drink, caries of teeth,
by certain  infectious diseases,
measles, scarlet fever, small-pox,
typhoid fever, diphtheria ; in con-
nection especially with syphilis, sometimes with cancer, much more
rarely with  tuberculosis.
   Symptoms.—Patients complain of  dryness, burning, and posi-
tive pain.   Infants at the breast whimper and cry with distress, and
suffer actual inanition from inability to  take or retain the  breast.
The taste is lost  in  adults, sometimes the breath is  foul, more
rarely salivation is  profuse.
   The mouth shows on inspection spots and surfaces of redness and
swelling.  The  tongue,  more  or  less heavily  coated,  is swollen,
its edges often  indented by the teeth.   The gums may be swollen,
spongy, tender,  bleeding, or blue.
   Stomatitis  ulcerosa is distinguished  by deeper lesions—viz.,
by necrosis and  destruction of tissue, especially in the  vicinity of
the incisor and  canine teeth of the lower jaw.   The swollen, spongy
gums bleed  spontaneously or on the  slightest touch, and epithelium
breaks  down  later to leave an ulcer covered with a gray  slough.
The  process may  involve  also other  parts—the mouth,  the  lips,
cheeks,  border of the tongue, etc.   The disease was more frequent in
^ »w
  Fig. 172.—Mould fungi, etc., from mouth:
a, flat epithelium; b, granules of saliva; c.fat;
rf, leucocytes; e, spirochaetes buccalis;/, com-
ma bacilli of mouth ; g, leptorhrix buccalis;
h, i, k, various fungi. 
 35'2                           APHTHA.

 old times under  the  abuse of mercury, but is now  more frequent
 with disuse of the drug in connection with the lesions  of syphilis.
 Bad cases may  be associated with inflammation of neighboring
 lymph glands, may show oedema, gangrene, and sepsis, or, after ex-
 tensive sloughing of the gums, result in  periostitis, caries,  and se-
 questration of bone.
    The disease is most frequent in childhood, and sometimes assumes,
 under  conditions of crowd-poisoning in camps, jails, ships, the pro-
 portions of an epidemic.
    Ulcerative stomatitis begins almost suddenly with pain, fetor,
 and salivation.   The excessive fetor  is characteristic.  The gums
 about the ulcer grow tender and bleed.  These symptoms, with the
 appearance and situation of the lesion, make the diagnosis plain.
 The prognosis is  for the most  part favorable.  Abstention from to-
 bacco,  alcohol, or other bad habits, from  mercury or other  drugs,
 quickly stops a toxic stomatitis.
    Thrush and actinomycosis have been already described.

                             APHTHA.
    Aphtha {aq)dai, anxgo, to inflame).—An  acute  infection  of the
 mucous membrane of the mouth in children, attended or preceded by
 fever  and general  distress, caused  probably by a staphylococcus
 (citreus and flavus, E. Frankel;  vide Foot and Mouth Disease),
 characterized by the formation of small pin-head or larger scattered
 superficial grayish sjiots bordered with  a bright-red  line.  The
 disease occurs most frequently in the second year of life,  and  is rare
 after the age of six.   It is especially frequent in  orphan asylums,
 tenement  houses, etc., where  it may assume in its successive, not
 simultaneous, attack of the inmates something of the proportions of
 an endemic.   It is  entirely independent of,  though  often  coincident
 with, dentition.
    The prodromal fever is sometimes  high, and the  cause of it is dis-
 covered often only by that general inspection which leads to the ex-
 amination of the whole body, including the  throat.
    The mucosa of the mouth shows more or less diffuse redness ; the
 glands about the neck may be swollen.  The eruption—ten to twenty
 spots in all—appears in the course of a day or two anywhere  in the
 mouth,  but with especial predilection for the tip and borders  of the
 tongue, sides of the frenum linguae,  gums, cheeks, lips, and palate.
 More rarely the characteristic spots may be seen upon the posterior
wall of  the pharynx and tonsils.  The eruption is a fibrinous exuda-
tion with subsequent necrosis of epithelium.  Denudation  of the epi-
thelium makes the mouth sensitive and  sore; salivation may be
profuse, and nutrition may be impaired through difficulty (pain) in 
                            APHTHA.                          353

 nursing.  Individual spots heal from the  periphery by gradual  con-
 traction of the red border to the  centre.  Each spot lasts five to six
 days, the whole eruption with its successive crops ten to twelve days,
 leaving at first slight depressions of lighter color,  never any real
 cicatrices, with final complete restoration of tissue.
    Diagnosis.—Aphtha is distinguished  from traumatic lesions  of
 the mouth, as from sharp teeth, pertussis,  erosions, etc., from burns,
 tuberculous, syphilitic processes, etc., besides by the site of aphtha,
 by the fact that the eruption is scattered, isolated, circumscribed, and
 bordered  with a  bright-red  line.  So also are separated forms  of
 stomatitis.  Aphtha  never shows real ulcers and is not of itself at-
 tended with fetor oris—facts which distinguish it  from ulcerative
 stomatitis.  Thrush is a separable curd or deposit, often of great ex-
 tent, on the surface, and hence easily separable from aphtha.  Since
 the special form of aphtha known as Bednaris aphtha, which consists
 of erosions or ulceration on each side of the raphe of the hard palate
 close to the  alveolar border,  has been demonstrated to be due to in-
 jury inflicted by the fingers and cloths in the  act of cleaning the
 mouth  (Baumm, Epstein), and not to sucking lesions or to syphilis
 as formerly believed, the condition has lost all pathological interest.
 The same remark applies also to the miliary eruption, '' epithelial
 pearls " (Epstein), which shows itself directly and only in the  line
 of the raphe, as yellowish,  round, prominent bodies of the size of a
 pin's head, and which has been demonstrated to be normal growths
 in congenital clefts.   The slight ulcers which result from accidental
 breaks of the surface speedily heal.
    Bednar's aphtha is obviated by avoiding  the roof of  the mouth
 altogether in washing out the mouth.
    Treatment.—Most cases of sore mouth in infancy can  be pre-
 vented  by cleanliness of breasts,  artificial nipples, feeding  bottles,
 etc. Inspection of dairies  and occasional testing of milk itself by
 competent sanitary officers  best  secure purity  for this staple food.
 Attention to the first  teeth, especially to carious teeth, the early use
 of  the  brush—these  are points of  the first  order  in  prophylaxis.
 Mouth washes of  borax, a teaspoonful to a glass of water, or boric
 acid with glycerin and water, secure asepsis as well as  antisepsis.
 Spongy gums are best treated with daily brushing or pencilling with
 tincture of myrrh or of rhubarb, the root of which chewed is also an
 effective and, to many, pleasant astringent.   The standard remedies
 in the treatment of all forms of sore mouth are nitrate of silver and
 chlorate  of  potash.   Ulcers  or abrasions of stomatitis are lightly
 touched with the stick  once  a day or every  other day.   The albu-
minate of silver which thus coats the surface protects it from further
insult or injury, and the healing process goes  on beneath.   The chlo-
        23 
354
APHTHA.
rate of potash is best given internally, that it may come in more con-
stant contact with the parts in its continuous elimination by the saliva.
A teaspoonful of a saturated solution in peppermint water every two
hours is maximum dosage.  The dose of the chlorate1 should not ex-
ceed one or two drachms per  day to  an adult.   The permanganate
of potash  ranks high as a mouth  wash or local  application with a
cameFs-hair brush in the proportion  of 1 :100.   It is especially use-
ful in ulcerative forms with excessive fetor.  Thymol gr.  xv., alco-
hol, aqua aa § ij., makes a good purifying mouth wash.  Mercurial
stomatitis  is  best  treated  by thorough  cleansing  with a  cotton-
wrapped sound.  The cotton is to be carried along the edge of  the
gums and inserted between the teeth, especially the back teeth, where
the  process, as  determined  by  gravity in  the night, commences.
Hereupon the gums and spaces between  the teeth are to be treated
with a concentrated solution  of chromic acid!   In sensitive subjects
the treatment may be preceded by an application of  cocaine, ten per
cent.   Feibes, who first used this treatment, recommends also a tooth
powder, especially under mercurial treatment:
   R Calcii carbonatis praecipitati,
     Lapidis pumicis subtile pulveris,
     Potassii chloratis,
     Cinchona? rubra? corticis pulveris............................... fifi 16.0
     Rhei radicis pulveris........................................     10.0
     Saponis puri..................................................    23.0
     Olei menthae piperitae..................................    3.0
   M.   Ft. pulveres subfiles terendo.

As a gargle :
   R Solutionis alumini acetatis.....   ...................... 10.0:200.0
     Aquai florium aurantii ....    ..................  ...       200.0'
   M.   S. One tablespoonful in a glass of water as a gargle every half-hour.

   Noma,  a gangrene of the cheek, attended with the most profound
destruction and horrible deformity, is fortunately a very rare (22 cases
in 8,286 patients, Woronichin) condition.   It occurs  mostly between
the ages of two and seven, next among soldiers.  It is found, as a rule,
only under the most degraded surroundings, usually in the course of
one of the infections, chiefly measles, typhoid fever, small-pox, some-
times  whooping cough,  and  syphilis and rickets, and in connec-
tion with thrombotic  occlusion ,of  vessels.   It  is fatal by sepsis in
three-fourths of  all cases.   It must be attacked with  carbolic acid,
concentrated solutions, with corrosive sublimate, or with actual fire,
Paquelihs thermo-cautery, ferrum candens,  galvano-caustic wire.
   The coat of the tongue has  less significance in  our  day.  A
healthy tongue is always more or less coated in its posterior third.
The coat is, with epithelial debris, a mass  of micro-organisms, of 
                              APHTHA.                            355

which the mouth is a reservoir.   A perfectly clean condition from
front to rear is not a sign of health.   The coat of the tongue is an evi-
  Fig. 173.—The tongue coated white, moist.  Section from case of granular kidney CDickinson).
dence rather of the condition of its mucous membrane, with reference
more particularly  to  exfoliation and detachment of foreign matter.
   Fig. 174.—The tongue denuded, red, and dry (raw-beef tongue).  Section from case of peri.
tonitis (Dickinson).

A healthy tongue sheds its coat so continuously as to prevent accu-
mulation.   Interruptions of the  circulation which impair its nutri- 
35G
angina.
tion, in infectious diseases, for instance, or in any cachexia, interfere
with this process and lead to a coated tongue.  The coat of the tongue
is therefore not so  much an indication of the condition of  the sto-
mach as is commonly believed.   Nevertheless the condition of the
tongue is an index of disease.
   The tongue shows a difference also  in dryness.  Ordinarily it is
moist.   The extraordinary pliability of the tongue is due largely to
its humidity.  Where the nose is occluded, as by catarrh, polypi, etc.,
and breathing takes place by the mouth, the tongue becomes dry, its
movements inhibited, even its protrusion from the mouth difficult  or
impossible.  When  the  uncoated tongue becomes dry it assumes a
glazed and horny appearance.   The coated tongue,  dry,  shows a
brown or blackish crust, which leads to the formation of crusts and
fissures, whence blood may exude to become inspissated, to make of
the organ an indurated, immobile mass.   A peculiar " black tongue"
is caused by certain  fungi.

                            ANGINA.
   Angina {ayxGo, to choke).—A term applied to all kinds of affections
of the  fauces, pharynx,  and throat attended  with pain,  dysphagia,
and dyspnoea, but more  strictly limited at the present time to affec-
tions of the fauces and tonsils.  Aside from the sore throat produced
by specific diseases—scarlet fever,  diphtheria, syphilis, tuberculosis,
scurvy, etc. —forms of angina are described of the fauces as catarrhal,
rheumatic, herpetic;  of the tonsils as lacunar, follicular, phlegmonous;
of the whole throat as septic, gangrenous, erysipelatous,  etc.  A spe-
cial form which emanates from the mouth, salivary ducts and glands,
and involves the whole  mass  of tissue composing the  floor of the
mouth and upper throat, is set  apart  and distinguished as angina
Ludovici.   Retropharyngeal abscess is also  often erroneously in-
cluded under the term angina.
   The  tonsils are  the seat of frequent disease.   Simple catarrhal
inflammation expends itself upon the surface of the tonsils or extends
to involve the soft  parts in their  immediate vicinity.   Pain in the
pharynx, tenderness to pressure, more or less  difficulty with degluti-
tion, are signs of this affection, which shows itself by increased swell-
ing and redness on inspection.  A special variety of tonsillitis is shown
in the so-called follicular form,  whereby the natural crypts or follicles
are enlarged and contain caseous  masses which, when removed, as by
the finger nail, spoon handle, or point of the knife, emit upon pres-
sure of the caseous mass an excessively fetid odor.   In situ they often
cause inflammation about them.  They sometimes stick like a pin or
a knife, unpleasant  sensations which disappear with their removal.
More extensive or deep-seated  inflammation involving the structure 
                             ANGINA.                          357

of the tonsil is shown in the suppurative or phlegmonous form.   In
these cases the tonsil enlarges to twice or thrice its natural size.  It
protrudes to partially block the throat, and shows itself as a hard
swelling upon the outside of the neck.  Inspection reveals this glo-
bular mass, which is more distinctly outlined by palpation between
two fingers, one external, the other internal; and points of suppura-
tion may be seen upon the surface of the tonsil, more especially in its
posterior inferior region, or may be felt as a deep-seated fluctuation.
Rupture which occurs naturally to discharge its contents, or incision
which is made as soon as the condition is detected, cures the disease.
   More protracted are the cases of hypertrophy of the tonsils.   Re-
peated attacks of tonsillitis themselves leave the tonsils large.  Life
in a contaminated atmosphere, with its continual insults and more or
less continual absorption of infected matter, eventually leads to perma-
nent enlargement of the tonsils.   Many children are born with large
                 Fig. 175.                       Fig. 176.
  Fins 175.—Pharyngo-nasal catarrh.  Physiognomy before removal of adeuoid tissue (Buck).
  Fig. 176.—Pharyngo-nasal catarrh.  Physiognomy after removal of adenoid tissue (Buck).

tonsils, or  seem to acquire  the condition early—not the result neces-
sarily of scrofula (tuberculosis), but as the result of the absorption of
other or any poisons in the  mouth into these first outlying lymphatic
glands (Hodenpyl).  In these cases the tonsils are  often found  so
large as to nearly or even quite touch  each other,  so that a slight
additional  inflammation brings them together or largely  occludes
the fauces.   Children who  live in an atmosphere of  infection, more
especially by the streptococcus, or of tuberculosis or  of the various
exanthemata, for any length of time, become subjects of enlarged
tonsils.
   The condition seems in all cases to result from an absorption from
the mouth and throat, and not from blood poisoning.
   Chronic hypertrophy may oppress the circumjacent structures in
the same way as in a case of quinsy.  Thus there is often disturb-
 
358
ANGINA.
ance of hearing from compression  of the Eustachian tube's, or more
especially from invasion of these tubes from  the1  same infectious
process.   So, too, the nares may be blocked.   The sense of smell is
abolished; the  child becomes a mouth-breather.  The physiognomy
then changes.  The countenance is listless, the expression drooping
and vacant, the special senses lose their keenness of perception.  In
adults the condition is wont to be associated with more1 or less melan-
choly.  This hypochondriasis leads to frequent change of physicians,
to the use of various nostrums, proprietary and patent medicines.
In fact, pharyngeal or pharyngo-nasal catarrh, with which this con-
dition is associated, is a special field for quackery, and from its mental
associations has developed a specialty even in regular medicine.  Ex-
cessive refinement has been  reached in the study of these cases of
pharyngeal catarrh.   Surfaces from which the upper layer  of the
mucous membrane have been denuded  appear glazed, shining, and
dry.  Thicker mucosae show a more granulated or gelatinous appear-
ance.  Follicular affections show pinhead granules,  sometimes pain-
ful, in the pharyngeal wall, on the  palate, especially on the surface of
the tonsils, where they may be  seen as whitish masses from the size
of a pinhead to a pea, which  may be  expressed by the finger nail
or the handle or point of the scalpel, to liberate caseous particles of
excessively offensive odor.
   Another cause of occlusion, especially at the vault of the pharynx,
is the formation of adenoid tissue, succulent masses of low vitality
rich in lymph cells, rapid in growth, which  spring from the posterior
wall of the palate or vault of the pharynx, to  at times occlude the
posterior nares, alter the voice, and interfere with respiration.   These
are the cases in which are noticed the alterations of voice which pro-
duce the nasal  twang.   The change is  noticed  more especially with
the articulation of certain letters, m, n, ng, to which are given a dead
expression characteristic of the condition, on  account of  occlusion
of the resonating cavities in and about the nose.
   The diagnosis of  the various forms of  angina is made by simple
inspection, by examination with the laryngoscopic  and pharyngeal
(rhinoscope) mirror.  Palpation recognizes enlargement of lymphatic
glands in the neck.
   The treatment of  acute angina consists in rest in  a pure, warm
atmosphere, and relief of pain by external application of heat, hot
water, flannels, gargles of hot water, applications of cocaine four per-
cent solutions, and the internal use of salicylic acid or salipyrin:
   3 Salipyrin......................    .....................3 i.-ij.
     Glycerinse............................................\ i.
     Syrupi aurantii corticis....................................§ ss.
       quae.....     ......  .....    ............  ..........% iiss.
   M.   S.  Dessertspoonful to tablespoonful every three or four hours. 
ANGINA.                         359
 One whole dose  gr. x., or several broken doses of Dover's powder
 gr. iij., quickly relieve tension and pain.  Inhalations of steam im-
 pregnated with  carbonate of  soda help also  to relax tension and
 relieve pain.  The lapse of a little time  must be awaited with some
 patience in the resolution of an acute  angina.
    The ciironic hypertrophies and catarrhs are treated best by as-
 tringent applications of alum and iron, ferric alum, gargles or sprays
 of  the same materials, especially  by  the nitrate of silver of varying
 strength; more obstinate cases by parenchymatous injections into
 the tonsil, as of iodine, etc , applications to the surface of stronger
 caustics of London and Vienna paste  and caustic potash.  By far the
 most effective remedy in the treatment of  these conditions, whether
 of  hypertrophied tonsils,  exuberant  mucosae,  or adenoid tissue, is
 the galvano-caustic wire.   Either the  hypertrophied tonsil is sur-
 rounded by a loop, which is gradually tightened, or by means of the
 knife,  more particularly the  guillotine, a slice of the tonsil is ab-
 stracted, whereupon the mass will usually undergo atrophy.  The
 loop is also introduced into the interior meatus to destroy hyperplas-
 tic tissue in the nose, or, by means of the  finger in the mouth, may
 be  carried up about any adenoid tissue  in the vault of the pharynx
 to successfully remove it.  Or the galvano-caustic platinum spatula
 or plate may be brought to bear  upon the  mass in situ  to effect, in
 the course of several sessions, its entire destruction.
    The (Esophagus is seldom the seat of  disease.  Constituting, as
 it does, the avenue of entrance of all food and drink, and subjected to
 every possible variety of insult, it is surprising that it is not more often
 affected.  The reason of the exemption  lies probably in the rapidity
 of transit through the tube.   The diseased condition most commonly
 encountered is the nervous contraction known as globus hystericus.
 This condition is supposed to result from an approximation by circu-
 lar contraction of the oesophageal walls, and is one of the common
 expressions of hysteria.   It is found, therefore, more frequently in
 hysterical  patients, young  females  especially, in connection  with
 emotional disturbance.  It reveals itself often by the fact that more
 obstacle is offered to the deglutition of fluids than solids.   Solids are,
 swallowed easily, fluids are regurgitated.   The condition  is usually
 readily recognized by the passage of the stomach tube.  Gentle and
 persistent effort will always overcome a  spasmodic constriction.
   Contraction of the lumen of the tube from other cause is the con-
 dition next most  frequent.   This contraction may be due  to outside
cause, as a goitre, an aneurism, a tumor of the  neck or chest;  or it
may be due to intrinsic cause, as to the cicatrization of an ulcer.  It
is most frequently due  to carcinoma.  Inasmuch as the oesophagus
cannot be inspected or subjected to palpation, and inasmuch as ceso- 
300
ANGINA.
phagoscopy is  as  yet entirely unsatisfactory, examination may be
aided by auscultation.  Auscultation along the left side1 of the ver-
tebral column  reveals in the act of deglutition a peculiar gurgling
sound, which has  been likened to that which is emitted by the fluid
ejected from a syringe ; while auscultation in the region of the ster-
num discloses a peculiar pressure sound several  minutes later than
the first sound.  This second  sound in the presence of obstruction
may be absent altogether.  Much more reliance is to be placed upon
examination of the oesophagus with the stomach  tube or oesophageal
sound.  In all cases examination should be made with the ordinary
soft  stomach tube first.  It is impossible to do damage with this
tube.   The  instrument is anointed with glycerin rather than with
olive  oil or vaselin, seized with the finger and thumb of the right
hand, after  the  manner of holding a pen, while  the left hand is in-
troduced into the  mouth of the patient seated in front of the physi-
cian, and as the end of the  tube reaches  the posterior pharyngeal
wall the fingers of the left hand are depressed to turn the tube into
the oesophagus.  Once past the larynx, the tube glides readily to the
stomach.  The obstruction which  is encountered opposite the larynx
is natural.   There should be encountered no obstruction in the fur-
ther course of the  tube.   Should this soft tube fail to pass, recourse
may then be had to the English sound of solid rubber or waxed silk,
a thick, continuous rod, smaller at the end, which  terminates in a
bulbous enlargement.  This tube may be rendered slightly softer by
immersion in hot  water, and is with much  more ease introduced to
the stomach   Finally, the whalebone sound, with its series of olive-
shaped metal tips,  may be substituted to push down the foreign body
or to dilate a commencing stricture.  Stricture from an ulcer usually
results from an  ingestion of  an acrid poison, mineral acid, etc., and
is encountered  in  the upper part of the oesophagus.  Peptic ulcers
are excessively rare in the oesophagus.
   Cancer  of the  oesophagus is  a not infrequent disease; it is the
most frequent organic disease of the  oesophagus. It is encountered
for the most part after the middle period of life, in individuals who
show more or less cancerous cachexia and  complain of pain ivith
difficulty of deglutition or  regurgitation of solid  food, which ac-
cumulates in the pouch above the stricture.
   The seat of cancer is in the  lower half of the oesophagus, more
espeeaally about the region of the  cardiac orifice.  It shows itself at
first, as a rule, as a girdle-like stricture, to permit often the passage
of the smaller sounds ; often as an impermeable mass with a pouch
above  it, in which the softer tube rolls  itself up to give the impres-
sion at times of penetration into the stomach.  The treatment of can- 
ANGINA.
361
 cer of the oesophagus impenetrable by the tube or sound does not
 differ from that of cancer of the pylorus.
    Angina Ludovici starts from the submaxillary  gland,  whose
 tissue is invaded through its ducts by pyogenic micro-organisms.  It
 occurs in connection with the infections, but arises oftener of itself.
 It distinguishes itself  by the  extent of  its range and the severity of
 its inflammation.   The region of  the floor of the mouth, the whole
 lower jaw, sometimes  the whole throat, forms a vast mass of board-
 like hardness.   All the functions of the mouth are crippled.  Com-
 pression of the great vessels in the neck may develop cyanosis of the
 face, insomnia, sometimes confusion  of ideas  and extreme general
 distress.  With  suppuration,  which is often  prefaced by surface
 cedema, sepsis may ensue, with chills, sweats, icterus,  diarrhoea,
 petechiae, joint affection, and other signs of streptococcus infection.
    The treatment consists in applications of heat and moisture, free
 incision, with subsequent irrigation and  disinfection  of  the  cavity
 left.
    Retropharyngeal  abscess results from caries of  the cervical
 vertebrae (tuberculosis), or, oftener, infection of lymph glands at the
 back of the throat.  Infection is carried to the glands in front of the
 second and third cervical vertebrae from  the nose and throat in the
 natural course of the circulation ;  hence the connection between this
 abscess and diphtheria, scarlet fever, and erysipelas is easily under-
 stood.  The abscess arises, however, for the most part independently
 of these diseases, as it occurs chiefly in  childhood in the first year of
 life.  It is rare after the age of five; in fact,  the condition itself is
 quite rare, but is of importance from the fact that it is often overlooked,
 a negligence which has been punished with fatal results.  A swelling
 in the back wall of the small throat of an infant blocks the throat, the
 posterior  nose, the Eustachian tubes, and may infringe upon or pro-
 duce cedema of the larynx.   Rupture of the abscess, especially spon-
 taneous rupture, may  inundate the larynx,  and, more likely in the
 night, drown the patient, or pus may burrow to the mediastinum and
 break its way into the  pleura or  pericardium.   More rare are the
 cases in which the discharge finds vent in the parotid gland or  on the
 surface at the angle of the jaw.
    The abscess may develop rapidly in the course of a few days,  or
 slowly in the course of  weeks or months.  Acute cases are attended
 with  pain, dysphagia with  regurgitation, and dyspnoea with snoring
 respiration.   Hoarseness of voice  (cry), signs  of stenosis, cyanosis,
 swelling of the cervical veins, retraction of  the chest, give proof  of
 pressure upon the larynx.   All the signs are easier under  decubitus
 with  the  head retracted upon the spine, and  are aggravated with
flexion of the head upon the body.   Inspection reveals a tumor, tough, 
362
ANGINA.
elastic, or fluctuating to touch.  Aspiration may disclose the contents
and character of the growth.
   The prognosis is favorable if the disease be recognized early, and
the abscess may be evacuated without danger to the larynx.
   The treatment consists in the evacuation of the abscess, gradu-
ally if necessary in protection  of the larynx, by means of an aspira-
tor.  The knife, wrapped  nearly  to the  edge, must be  used with
caution to avoid wounding important vessels. 
CHAPTER  II.
                 DISEASES OF THE  STOMACH.

                       GASTRIC CATARRH.

   An affection of the mucous membrane and musculature of the
 stomach, acute and chronic, characterized  by indigestion,  defective
 secretion of gastric juice, excessive secretion of mucus, pain, nausea,
 vomiting, constipation, depression of  spirits, atrophy of the mucosa,
 and marasmus.
   Gastric catarrh was formerly known  and  described under the
 term  gastritis.  Gastritis is objectionable.  It fails to localize the
 affection.   Gastritis is used in our day to express a more intense or
 extensive  inflammation of the stomach, that which results, for in-
 stance,  from  the  ingestion of poisons, mineral  acids, etc., which
 corrode and perforate the various coats of the stomach.   Catarrh
 limits the disease to the mucous membrane.   This term is also not
 unobjectionable, for it is especially a gastric catarrh which does not
 remain  confined to the mucous membrane, but extends to and in-
 volves, at least produces paresis in, the muscular coat.  On the other
 hand, as an  advantage, the term catarrh  implies an inflammation
 likewise of  the various glands, mucous and peptic,  of the stomach ;
 for the stomach mucosa is not  to be  regarded as  a mere surface
 membrane, but as  an organ made up of closely apposed, deeply in-
 voluted glands.   Ewald appropriately  calls the disease  a gastritis
 glandularis.   Dyspepsia is only  a  symptom.   Catarrh  is every-
 where a provisional term.   Under catarrh is embraced that group of
 affections  which  cannot be accounted  for by  any specific  process,
 ulcer, cancer, etc.
   Etiology.— Gastric catarrh may  be  the  expression  of irritant
ingesta, of an insult offered to the  stomach in the food or drink.  It
results often from  faulty habits  of life, particularly with regard to
food, quality, quantity, preparation, time of taking,  etc.   The action
of the stomach is also  strongly under nervous influence, so  that
catarrh  may result from neuroses.  A  fruitful  source of catarrh in
our country is worry, business worry.  Gastric catarrh is  the result
of causes both intrinsic and extrinsic.  No mucous membrane is more 
364
GASTRIC CATARRH.
sensitive than that of the stomach.   Many of the worst cases of gas-
tric catarrh result from  diseases of other organs, and the physician
in the presence of gastric  catarrh, more  especially chronic gastric
catarrh, must first of all eliminate disease of other organs.  Accord-
ing to the intensity of the symptoms, or more especially the duration,
catarrh is divided into the two forms, acute and chronic.
   Acute catarrh finds its most frequent expression in infancy, and is
the direct result of an offence, irritation, of the mucous membrane l>y
improper  food.  The human race would long  since  have been re-
duced to very limited numbers were it not for the fact that the food
of infancy is for the most part furnished fresh.   Infants fed at the
breast of healthy mothers seldom suffer acute catarrh.  Overfeeding
is attended with overflow; easy, natural vomiting, more in the way of
regurgitation, relieves a distended stomach.  How slight an effort is
required to secure this relief is observed in the  frequent vomiting
which occurs  in a well-fed  child after the lightest pressure upon the
stomach.
   Gastric catarrh,  more properly  gastro-intestinal catarrh, is the
most frequent and most  fatal disease in childhood, especially in hot
weather.  The food of childhood, milk, from any outside source, is
most prone to undergo decomposition.  The poor  have no  ice chests
and no provision  for  the preservation of milk.  Consequently the
poor not  fed at the fountain of nature succumb in the heat of sum-
mer.
   Acute gastric catarrh in adults is  the result more frequently of
insult to the stomach by improper or injudicious drinks.  Not at all
infrequently the fault lies with the drinking-water itself, which  is
contaminated by the discharges of disease, typhoid fever, dysentery,
etc.   Gastric and  gastro-intestinal  catarrh  may  be  the  means in
these cases of  eliminating  causes  of disease, which otherwise find
lodgment to reproduce the disease itself.   Individuals have been
rescued from trichinosis by the copious  vomiting which  has dis-
charged the infected food.   Crude beer, sophisticated wines, drugged
whiskey and brandy, etc., inflame the stomach to produce acute gas-
tric catarrh.  Improperly cooked foods may act at any time in this
way.
   Gastric catarrh belongs to all the acute infectious  diseases.  An-
orexia, nausea, sometimes vomiting, announce the onset of these affec-
tions.  An acute indigestion results at times from exposure to cold,
as also from nervous emotions.
   Chronic catarrh is for the most  part an expression of an outside
disease.  At the head of this list of diseases  stands tuberculosis.
Many cases of tuberculosis are marked by a long-continued and
obstinate dyspepsia.   Gastric catarrh may exist in  these  cases for 
GASTRIC CATARRH.
365
months without suspicion of the existence of tuberculosis.  It is plain
to see that treatment addressed in this case to the stomach itself may
bring little or no  relief, whereas the condition may be made to dis-
appear often promptly, sometimes permanently, by  the  recognition
of its cause.   Bright's disease is a fruitful factor of  gastric catarrh.
The lack of appetite and digestion contributes largely to the progres-
sive degradation  of physical  and mental tone in  these cases.   The
gastric catarrh is the direct effect  of some toxic matter circulating in
the blood, which  matter the  kidneys fail to eliminate.  These cases
are singularly obstinate, and yield only, if at all, by  reference or ad-
dress to the cause of the condition.   Disturbance in the portal circu-
lation, disease  of the liver (cirrhosis), soon  brings  about a gastric
catarrh.   Constant reflux of bile, by neutralizing  the acidity of the
gastric juice, begets the changes  of catarrh.   Disease of the uterus
or ovaries is a not infrequent cause of gastric  catarrh.   Dyspepsia
may be the first sign of carcinoma or salpingitis.  Prostatitis is the
analogue in the other sex.
   Gastric catarrh  must be always  carefully dissociated from  ulcer
and cancer of the  stomach  itself.   This  differentiation is often a
nice problem in diagnosis.  The fact is, both ulcer  and cancer are,
as a rule,  associated with gastric catarrh.
   Pathology.—Chronic gastric catarrh is in its  essence a parenchy-
matous inflammation which results in a transformation of the proto-
plasm of the gland cells into mucus, with final  atrophy of the cells
and glands.
   Symptoms.—Acute  gastric catarrh announces  itself  with pain,
more or less severe, in the region of  the epigastrium.  The pain is
attended at times  with sinking  sensations, with  actual  vertigo.
There is a vertigo  a stomacho leso, which is often quickly relieved
by the administration of a few grains of chloral to obtund the sensi-
tiveness of the  stomach nerves.  Vomiting finally  removes the acrid
ingesta, to relieve  the  condition, at least for a  time; and  the true
treatment of this condition  is to quickly empty the stomach of its
contents by the use of hot water or by the administration  of a laxa-
tive, which may discharge the contents of the stomach into the intes-
tine.
   Chronic gastric catarrh has an extensive symptomatology.   The
pain of the chronic  condition is not so acute, but it is more constant,
and not so strictly dependent  upon the taking of food, though it is
always aggravated in this way.   There is  more or less  tenderness
to pressure over the region of the stomach in these cases.   The sto-
mach is frequently distended with gas, to show  its enlarged outlines
upon the  surface  to   inspection or palpation.    The distention is
often so great as to impede respiration, or more frequently to inter- 
366
GASTRIC CATARRH.
fere with the action of the heart.   Most attacks of simple indenta-
tion of the heart are the expressions of an indigestion.  Reflected
acrid, burning pain in the course of the  oesophagus is  known as
heartburn.  Gas from the stomach escapes in eructations, which
have often excessively fetid odor.
   The disease  is associated  for the most part with constipation,
and, in  consequence of the  constipation,  with haemorrhoids.   In
consequence also of the defect in digestion and absorption of gases
into the blood there is poisoning of the nervous system.  The energy
is reduced.  The victim of gastric catarrh has a disgust for life.  He
can accomplish nothing.   Many patients are melancholic.   ^\Iore arc
hypochondriacal.  Nearly all hypochondriacs are dyspeptics, and
   Fig. 177. —Action of the digestive juices: A, muscle fibre from the stomach; B, starch gran-
ules from the stomach; C, muscle fibre from the faeces (Wesener).

this often notwithstanding the fact that they may be great eaters.
Vomiting is a frequent symptom, of the contents of the stomach, of
large quantities of tough, glairy mucus, of foul, acid, and other pro-
ducts of fermentation, and of bile, along with masses of undigested
food.  Where the condition has existed for a long time, so that the
submucous  connective  tissue has become hypertrophied, especially
in the region of the pylorus, the stomach suffers distention to such
extent as to simulate at times the gastrectasias of cancer, and to
discharge thus by vomiting enormous quantities of accumulated
matter.
   The diagnosis,  which  is discussed later in connection with or-
ganic disease, is best established by means of the stomach tube.  The 
GASTRIC CATARRH.
367
stomach tube gives information which surpasses in the exactness of
its value that furnished by  all other signs.   The patient whose con-
dition is to be investigated receives in the morn-
ing a meal consisting of a plate of soup, a bis-
cuit,  and a piece of beef.   This food should dis-
appear  from the stomach in six or seven hours,
so that  the tube, introduced into the stomach at
this time, should  withdraw nothing more than a
little  mucus.   In gastric  catarrh, however,  resi-
due,  sometimes in large  amount, of undigested
food  escapes through the tube and may be  sub-
mitted  to  further examination.   It  is observed
then  to what  extent the muscular tissue is disin-
tegrated  and   digested,  how  much the starch
granules are eroded  and  destroyed, to what de-
gree  the  fat  globules are floated  free.  It is ob-
served if fungi or bacteria be present in the mass,
and the ejected matter is  then subjected to chem-
ical test.
    The information of most value in the study
of diseases of the  stomach is  the  recognition of
the presence,  amount, or absence  of free hydro-
chloric acid.   The presence or amount of pepsin is
secondary.  It corresponds for the most part to the hydrochloric acid.
It will be remembered that hydrochloric acid  is not secreted in any
 Fig. 178.—The softstom-
ach tube with openings at
the end and side, and with
receiving glass funnel.
^11  dt^f /•"
   Fig. 179 —Partially digested matter from the stomach: a, muscle fibre; b, white blood cor-
puscje; c, c, c, flat and cylindrical epithelium; d, starch corpuscles; e, fat globules; /, sarcina
ventriculi; gr, yeast ferment; h, i, cocci and bacilli (those near h were once found by Von Jaksch
in a case of ileus, hence arising from the intestine) ; fc, fat needles, connective tissue ; I, vege-
table cells (Von Jaksch).
appreciable amount in an empty stomach.  It begins to be secreted
with the process of digestion, but is at first combined with the alka- 
368
GASTRIC CATARRH.
 lies in the food, and does not appear free  until at  the end of half or
 three-quarters  of an hour.  Now it shows itself in increasing abun-
 dance, to be present in greatest amount at the height of digestion at
 the end of four or five hours.   In catarrh of the stomach the amount
 of hydrochloric  acid is limited.  Hydrochloric acid is limited (sub-
 acidity)  when  present in less than  0.06  per cent; it is increased
 (superacidity) when present in more than 0  24 per cent.  The1 acid
 maybe discovered free or in connection with other acids, lactic acid,
 acetic acid, butyric acid, etc.,  which hinder rather than  help diges-
 tion.   The  excessively  acid   odor of  vomited  matter of  gastric
 catarrh is no  index of the amount of hydrochloric acid.  ()dor in
 these cases is due to acid fermentations, acetic, butyric, etc.—condi-
 tions which markedly interfere with digestion or are the expressions
 of impaired digestion.
    The detection of  free hydrochloric acid becomes a matter of su-
 preme value when it is known that, as a rule, free hydrochloric acid
 is  absent altogether  in  cancer, and present,  though reduced in
 amount, in gastric catarrh.   Free hydrochloric acid is  absent or re-
 duced,  not on  account of any neutralization by products of cancer,
 but on  account of disease of the mucous membrane.  It is absent or
 reduced also in amyloid degeneration, atrophy from any cause, debi-
 litating disease,  tuberculosis, Addison's disease, pernicious anaemia,
 all kinds  of fever, etc.                                     •
    Numerous  tests have been  devised  for the recognition  of the
 presence  and amount of free  hydrochloric acid.  A common test is
 made with methyl violet.  Two test tubes  are half-filled with trans-
 lucent solutions of methyl violet.  To one  are added a few drops of
 the filtered solution  which  escapes from  the  stomach tube.  Free
 hydrochloric acid changes the violet to blue, and, if present in great
 amount, to green.  Contrast is offered in the two tubes.  The test is
 very simple,  but is unfortunately not very reliable.   The same dis-
 coloration results in the presence of much  common salt, or the color
 may be concealed by products of digested albuminates, etc.
    A very convenient  method is offered  with a piece of filter paper
 soaked in a saturated solution of OO-tropaeolin.   A drop of the filtrate
 is let fall upon the paper, which is then heated in a watch glass   In
 the presence of free hydrochloric acid the paper becomes brown and,
 as it dries, lilac.   The value of this test consists in the fact that lactic
 acid does  not produce this result.
   The best  test is made with  phloroglucin-vanillin—phloroglucin
 two parts, vanillin one part, absolute alcohol thirty parts (Gunzburg).
 To two or three drops of this fluid is added an equal amount  of the
filtrate in  a watch glass or porcelain dish, which is then heated.  In
the presence of free hydrochloric acid the  fluid assumes a deep red 
GASTRIC CATARRH.                    369
 hue, in the absence of it a brown-red or brown.   As the glass is
 heated and the acid fluid dries, streaks of crimson show themselves
 about the edge.  The  only fallacy that can occur in this test is that
 which will result after the ingestion  of bad eggs, as it is invalidated
 by sulphuretted hydrogen.  The phloroglucin-vanillin test will  de-
 tect free hydrochloric  acid in as small amount as 0.005 per 1,000.   It
 is thus by far the most  delicate and valuable test that can be em-
 ployed, and its execution  requires  but  a few minutes.   This test
 fluid,  fresh, has an odor of vanilla  and a golden-yellow color.   It
 must be kept from the light, which turns it brown.
    Lactic  acid is  best disclosed by the test of Uffelmann.  One or
 two drops of the solution of the chloride  of iron added to about one
 hundred grammes of a two-per-cent  solution  of carbolic acid make a
 steel-blue mixture.  To this fluid is added some of the filtered sto-
 mach juice.  In  the  presence of lactic acid the solution  becomes
 yellow, a yellowish-green.   In the presence  of hydrochloric acid it
 becomes clear like water.  Uffelmann's test will detect 0.01 per 1,000
 of lactic acid.
    Acetic  and butyric acids are readily recognized by their  odor,
 which may be additionally developed by mixing the  stomach fluid
 with ether and evaporating the ether.  Despite the searching inves-
 tigations of modern times (Boas, Sjoqvist), the physiological remains
 the best quantitative test for free hydrochloric  acid.  Cubes of albu-
 men (boiled egg) are digested in test tubes in an oven  and compared
 with the results of healthy digestion.
    It  is important to estimate the movement of  the stomach,  as
 movement constitutes  an important factor in the digestive process.
    An ingenious attempt to discover the activity of the stomach was
 suggested by  Ewald, who administered salol in capsule and noted the
 time when the products of its decomposition should be discovered in
 the urine.  Salol does not  decompose in the stomach, but splits up
 into salicylic and carbolic acid in the intestine.   Salicylic acid is rec-
 ognized in  the urine by the violet color which results after the addi-
 tion of the chloride of  iron.   Ewald found the  first positive reaction
 in health in a half to one hour after the  drug had  been taken ; but
 there was so much irregularity about the period of its recognition  in
 disease as to  make it  practically of little value.   Pills of iodide of
 potash coated with keratin were then substituted, with the additional
 advantage that the absorption of the iodine could be determined by
 its appearance in the  saliva.   The patient expectorates upon starch
 paper  every five  minutes.   The  blue color  is struck in  health  in
 fifteen to thirty minutes.  A delay of one hour is evidence of disease.
 But this method also proved valueless in estimating motion, from the
fact that the pills were sometimes dissolved in the stomach.
        24 
:j;()                     GASTRIC  CATARRH.

   Sufficient information for all practical purposes  can be obtained
with the use of the stomach tube.   Introduction of the stomach tube
is for the most part an easy matter.   It implies a certain degree of
confidence which the physician may be able to inspire  so that suc-
cess may attend the first efforts.  As a rule, strange to say,  women
succeed better than men.  It not  infrequently happens that  the  pa-
tient may succeed in the first effort where the physician fails.   All
patients  succeed after repeated effort, so  that the introduction  be-
comes simple and easy.
Fig. 180.—Irrigation of the stomach.           Fig. 1S1.—Discharge by siphonage.
   Treatment.—An acute indigestion is treated, as stated, by empty-
ing the stomach of its contents.   The most effective as  well as the
safest way to treat poisoning is to wash out the stomach.   Patients
who would have survived poisons are  sometimes  killed  by so-called
antidotes.  Where the patient is conscious this relief may be secured
by the ingestion of large quantities of hot water.  The water should
be drunk until it is rejected, without reference to  quantity, and the
operation should be repeated, having due regard  to the exhaustion
of the patient, until the fluid escapes clear.   Resort must  be had at
times to the  stomach tube in the presence of unconsciousness, un-
willingness, etc., but great care must be exercised with all hard tubes 
CASTRIC CATARRH.
371
 to avoid perforation or inflammation of soft tissue.  It is  best in all
 cases to use the soft tube, which may be forced into the stomach, if
 necessary, by the aid of a gag and a catheter introduced into the eye
 of the stomach tube with a blind end, and withdrawn after the oeso-
 phagus has been fairly entered.  Warm  water is then to be poured
 into the funnel until the stomach is full, when the tube is quickly de-
 pressed  and the stomach emptied by siphonage.  Where there  is
 any delay in the flow it may be facilitated by squeezing the tube be-
 tween the thumb and fingers.  The outside end of the  tube may be
 inserted into a basin  of water  and slowly withdrawn toward the
 surface of the water, when the contents of the stomach soon begin  to
 flow.  Sometimes orifices in the tube become blocked by mixed par-
 ticles of food, etc., to require some manipulation.  Patients soon learn
 to handle the tube themselves.  Where the tube is used as a remedial
 measure the stomach should be washed out once a day, preferably at
 night, whereby often substantial sleep of a whole night is secured.
 Ordinary gastric catarrh, even though chronic, may be successfully
 treated without the tube by regulation of the  diet and by drugs.
   The diet should  commence with  milk diluted one-half with im-
 ported Selters water.   The milk may then be increased in strength,
 or it may be  substituted by kumyss or egg  largely diluted at  first
 with hot water.  In a  day or two  there  may be added scraped or
 chopped beef with warm water and a little pepper and salt, mixed to
 the consistence of a thin mush; a tablespoonful of the meat mixture
 to be taken once or twice a day.  In a few days more the patient may
 take the white meat of fish, sweetbreads, raw oysters, white meat of
 fowls,  chopped steak, roast beef,  and later bread, potatoes, and so on
 up to full diet, as described in detail later.
   Of drugs, far and away the best is hydrochloric acid, gtt. v.-x. in
 a wineglass of water before meals.  Next in value ranks  arsenic,
 gtt. ii.-v. in a tablespoon of water after meals.   The salicylates are
 especially adapted  to  cases in  connection  with gastralgia.   The
tincture of nux vomica gtt. x.-xx.,  solutions of strychnine gr. Vo~tV>
bitter tonics, Peruvian  bark, the  simple  or compound tincture, give
the  stomach  tone.  The following formulae  from  Ewald are  fine
bitters  :

  R  Corticis condurango..................................... 2o.0-30.0
     Macera per horas xii. cum aqua.............................300.0
     Digere lento calore ad colaturam.......................... 150.0

  Adde
     Acidi hydrochlorici diluti................................  5.0
     Syrupi zingiberis.....................................ad 200.0
  M. S. Tablespoonful every three hours. 
372
ULCER.
   R Tincturae nucis vomicae........................................  5.0
     Resorcin resublimati.........---. ......................... 10.0
     Tincturae gentianae........................................2~>.()
     Syrupi simplicis...........................................ad 200.0
   M.  S. Tablespoonful every two or three hours.

    Laxatives—Carlsbad  salts, a teaspoonful in a wineglass  of hot
water before breakfast ; a compound rhubarb pill, one  after each
meal; a pill of podophyllin, gr. {-?,, at bedtime ; a tablet of cascara
sagrada;  a teaspoonful of a cascara mixture—suffice to relieve consti-
pation.  The  antifermentative virtue of  creosote has been remarked
under tuberculosis.
                              ULCER.

    Ulcus  pepticum, rotundum,  perforans,  etc.—A disease  whose
lesion is  a small, round ulcer with tendency to haemorrhage  and
perforation; characterized  by pain, dyspepsia, hyperacidity  of the
gastric juice,  vomiting,  hsematemesis,  peritonitis,  and  liability of
relapse.
    Ulcer of the stomach is a specific disease, quite different from an
ulcer or a process of ulceration elsewhere.  Ordinary ulceration may
also affect the stomach, as the result, for instance, of the ingestion of
irritants, mineral acids, or other poisons.  Gastric ulcer distinguishes
itself by its definite shape, size, location.   It entails also certain com-
plications and distinguishes itself by its tendency to relapse.  Gastric
ulcer is a frequent affection.  It is a matter of surprise to those who
are not familiar with the subject to learn that ulcer occurs or is found
in five per cent of autopsies.  The discovery of  this condition so  fre-
quently is not so much a proof of  the fact that the disease is  some-
times latent, as of the fact that it is commonly confounded with gas-
tric catarrh or is included under  that vague,  indefinite, and elastic
symptom—dyspepsia.
    History.—The lesion of the stomach in gastric ulcer is so gross
that it could not fail to have been recognized by the  earliest ob-
servers.   Galen  mentions it and  prescribes the  diet which is  still
maintained as the main element  of treatment.  He says the food
should be glutinous.  Acid and acrid substances must be avoided.
Wine may be taken, but not too hot  or too cold.  Gratius (1695)  saw
an ulcer which perforated the stomach.  There was adhesion to the
spleen, which prevented the escape  of the  contents of the  stomach
into the peritoneal cavity.  Littre  (1704) discovered the source of a
fatal haemorrhage in  a round ulcer of the stomach.   Baillie (1793)
spoke of the clean-cut edges, as if exsected by a knife.   Abercrombie
(1832) made important contributions to symptomatology.   Cruveil-
hier (1830) first distinguished the disease from  cancer.  Rokitansky 
ULCER.

pointed out the frequency of its occurrence.  Virchow (1865) found
the cause of certain ulcers in blocks in the circulation.  From the in-
vestigation of several hundred cases Brinton was able to draw con-
clusions as to the location and to illuminate many of the  signs of  the
disease.  Finally, Leube (1875) found valuable evidence regarding
the diagnosis  from the use of the stomach  tube, and furnished  the
best instructions in the way of feeding these cases.
   Pathology.—Gastric  ulcer is commonly known as the ulcus ro-
tundum  from its  shape, and perforans from its tendency  to  erode
the stomach  walls.   It is usually round or more or less  elliptical
and distinctly funnel-shaped,  the  orifice of the funnel being eccen-
trically situated at the site of a gastric vessel.  Ulcers vary greatly
in size, from a ten-cent piece up to the largest ulcers, of more irregu-
lar shape, resulting from the coalescence of two or more.   Haber-
shon  described  a case in which  the  ulcers or ulcerations  reached
from  the pylorus nearly to the fundus.   The ulcer is usually single.
There may be a number in a single  case.  Wollmann once found
eight. Lange  found so  many that "he gave up trying  to  count
them."   Ulcer of the stomach rarely coincides  with  ulcer of  the
duodenum or oesophagus.   The edges of the ulcer, as stated,  are
clean-cut, as  if  removed  by  a  punch  (Rokitansky).   Old ulcers,
however, show indurations about their edges, to such extent at times
as to  have been  taken for carcinomatous masses.  It is  the tendency
of the gastric ulcer to perforate so that the base of the ulcer may
involve only the mucosa, or the submucous connective tissue, or  the
muscular coat, or the peritoneal coat, which in turn may be perfo-
rated to permit the escape of the contents of  the stomach.   Not in-
frequently such  accident is prevented by agglutinative inflammation
with  adhesion  between  the stomach  and contiguous viscus,  liver,
spleen, pancreas, etc.
   Gastric ulcers are situated, in the vast majority of cases, on  the
posterior wall—i.e., on  the lowest part  of  the  stomach when  the
posture is erect.   According to the statistics of Brinton and  Roki-
tansky four-fifths of all cases are  situated on the  posterior wall,  the
lesser curvature, and  the pylorus,  so that the vast surface of the  an-
terior wall, the great curvature, the fundus, and the cardiac orifice
are comparatively rarely seats of  the disease.  The comparative  ex-
emption of the anterior wall is most fortunate, in that there is here
no viscus to which the stomach can be tied or glued in  case of per-
foration.   The adhesions which do occur between the stomach and
the abdominal wall are few and fragile, and are easily broken down.
Ulcers, disclosed on autopsies, are found,  of course, in every stage of
ulceration or cicatrization.   In fact,  scars the results of ulcer  are
found in  about  half  of all cases of gastric ulcer.  The base of  the 
374
ULCER.
ulcer is  usually covered with a gray slough.  It may, however, bo
perfectly clean, as if dissected out.   Sometimes the ulcerative process
continues in the body of the viscus to which the stomach has become
attached, and excavations, abscess formations, are thus found in the
liver, spleen, pancreas,  etc.  More frequently fistulous communica-
tions with the colon, duodenum, or small intestine result.  Adventi-
tious sacs may be formed, subphrenic abscess, or perforations may
occur externally or by burrowing sinuses  at  some distance from the
seat of the disease.
   Deformity of  the stomach may result also from the process of
cicatrization.  The situation at the pylorus is thus peculiarly unfor-
tunate, in that a cicatrix may contract the pylorus, to lead to more
or less complete occlusion and gastrectasia,  to simulate at time's the
condition produced by carcinoma.  Hour-glass contractions about the
centre of the stomach from girdled ulcers are curiosities occasionally
encountered.  The liability of haemorrhage is another accident which
gives gravity to this disease.   The ulcer may open vessels of some
size, most frequently the splenic artery, or blood may ooze in quan-
tity from distended or varicose  veins in the vicinity of or about the
edges of the ulcer.
   Etiology.—Ulcer of the stomach is a disease of adolescence rather
than maturity and age.  It is almost unknown before the age of ten.
Among  the cases collected by Brinton, but  0.08 per cent occurred
under the age of  ten.   The disease begins to show itself about  the
period of puberty, and  is  encountered with  especial  frequency be-
tween the ages of fifteen and thirty.  Sex has an important influence.
According to all  statisticians the  disease is more frequent in  the
female sex; 2 :1, 3 :1  are the proportions usually observed.  Ulcer
of the stomach is noticed especially in connection with chlorosis, with
anaemia, menstrual  disturbance, hysterical  states.  In  one-fifth of
the cases the condition is found in connection  with tuberculosis of the
lungs; in two-thirds of  the cases, according to Steiner, with diseases
of the heart and vessels, endocarditis, endarteritis.  Ulcer of  the
stomach, in consequence  of  thrombotic occlusion  with  destroyed
blood corpuscles,  is also found to occur as the result of burns of  the
skin, though not so frequently as ulcer of the duodenum.
   The  true cause of the  condition  is still obscure.  It is generally
attributed to the erosive action of the gastric juice, which does not
attack the stomach wall in health, because the acid juice is neutral-
ized by  the alkaline   blood.   An interruption in the  circulation
which diminishes or withholds the blood supply permits the erosion.
Cases have been  observed in which embolus or thrombus,  in  con-
nection  with heart disease, atheroma, lues, has been observed,  but
in the majority of cases the cause eludes detection. 
ULCER.
   The revelations of the stomach tube have made it plain that in
the majority of cases of ulcer  the gastric juice is excessively acid.
This hyperacidity is one of the  points of differentiation between this
disease and cancer.   The ulcer has been attributed to  the erosive
power of this excessive acidity.   It is difficult to understand why the
ulcer should assume its particular shape under such action.  Yet the
situation of the ulcer at the surface of longest and closest contact
with  the stomach wall  points  to  a development  under destructive
action.  Panum found that he could produce haemorrhagic erosion
and ulcers  of  the stomach in animals by the injection into the arte-
ries of insoluble particles.   Ebstein and Schiff remarked that inju-
ries of the nervous system, brain, and  cord were attended with the
same lesions.  These accidents  are due  here, as in the case of burns,
to thrombotic occlusions by dead blood corpuscles.  Klebs calls in a
spastic contraction of the arteries to account for  certain cases, and
Boettcher invokes the action  of  unknown micro-organisms.   Vir-
chow assumes that ulcer of the stomach may result from numerous
causes.   One  may be, however, loath to accept such a view.  The
picture is so typical, the character of the ulcer so uniform, as to stamp
the affection as an individual disease produced by a definite cause.
   Symptoms.—Ulcer of the stomach is sometimes latent.  Ulcers
have  been  found upon autopsy without sign of existence in  life.
More frequently an ulcer has turned up to satisfactorily  account for
a long-continued and obstinate dyspepsia  or gastric catarrh.  As a
rule  the disease is announced with a  distinct train of symptoms.
Pain is almost universally present.  It varies in character, is some-
times sharp, lancinating, sometimes dull, gnawing.  A more charac-
teristic feature is its more exact circumscription.  The pain is located
about the ensiform cartilage, at the umbilicus, in the back,  at the
middle  of  the dorsal vertebrae,  or at the angle  of the  scapula.
Wherever  felt, it is  more or less localized in this region in an in-
dividual  case.  Pressure upon  the stomach rather  intensifies than
relieves pain.   On the  other hand,  the pain is usually modified or
abolished  by change of posture.   Individuals who feel pain  only
in lying  upon  the back or  upon  the left side, and who may be re-
lieved by lying upon the face or the right side, are probably subjects
of gastric ulcer.  The situation of the ulcer may  not be defined by
the interval between the ingestion of food and the perception of pain.
The pain does stand in  relation to  the taking of  food—no food, no
pain.   It sometimes  occurs quickly, sometimes after the  lapse of
time.   In a case recorded by Busch pain occurred  in twelve minutes
after  the taking  of food ; the  ulcer was found in  the  duodenum;
while in the case of Pinel the pain was felt immediately, and the ulcer
was found at the pylorus. 
o. 0
ULCER.
    Vomiting is the next most frequent sign.  It is present in three-
fourths of the cases, and when absent is thought to be due to the loca-
tion of the ulcer in exceptional places, as at the fundus, anterior wall,
etc.  Vomiting, which discharges the contents of the stomach, relieves
the pain.   It stands more directly in  relation to the character of the
food.   Irritant foods inevitably produce pain  and vomiting.  The
presence of both pain and vomiting does not distinguish gastric ulcer
from gastric catarrh; but the vomited matter in gastric ulcer some-
times contains a distinctive feature  in blood.  Hematemesis is  a
valuable sign.  It distinguishes itself in gastric ulcer, as a rule, by the
quantity of the blood which  is ejected.  The physician  is shown  a
basin or a bowl  or a vessel filled with blood, and the patient is found
exsanguine.   Individuals have  died  of concealed  haemorrhage in
cases which have thereby assumed juridical  importance.  The sto-
mach has been found full of blood and the intestinal canal distended
through its entire length.  In many  cases  the blood is not vomited,
but is discharged by the bowels.  Haemorrhage would be discovered
more  frequently if the stools were more closely inspected.   Black,
tarry matter is found in the discharges in these cases.  In the expe-
rience of the author a mass of inspissated blood had to be  removed at
one time from  the  rectum with instruments several days after  a
haematemesis.   Haemorrhage is the most  obtrusive sign of  gastric
ulcer.  Unfortunately for the diagnostician, it is not present in even
the majority of cases.  It occurs in not quite one-half of the cases,
and may be recognized when it  occurs, in  the  absence  of apparent
blood, by faintness, nausea, vertigo, collapse, sometimes convulsions.
Haemorrhage is peculiarly liable to recur with the  detachment  of  a
clot which  blocks the vessel.
   Along with ulcer of the stomach is associated always that train
of symptoms known under the term dyspepsia.  There is anorexia,
distaste for food, eructation of gas and fluids, heartburn, depression
of spirits, and, in chronic or protracted cases, impairment of nutrition.
On the other hand, many cases  show  a bien-etre.   The author had
under observation the case of a man whose  weight varied little from
two hundred and fifty pounds.   In this case signs of ulcer  showed
themselves with every dissipation.  The signs included haemorrhage,
which at last proved fatal.  Constipation  is marked, as  a rule, and
is frequently obstinate.  .
   The  excess of hydrochloric acid  in the gastric juice consumes the
chlorides, so that the urine is distinguished by absence of chlorides
and increase of alkalinity.  The test made by a solution of silver ni-
trate is very easy and very valuable.
   The duration of the disease is indefinite.  Brinton recorded a case
which  lasted thirty-five years.   The usual history is one  of recovery 
CANCER.
37?
 with cicatrization, reopening of the cicatrix after some insult to the
 stomach, and a repetition of the symptoms.  It is, however, true that
 the majority of cases recover permanently after a single attack. The
 prognosis, on  account  of  the possibility of perforation, is always
 grave.
    The diagnosis rests upon the age, sex, history of previous attack,
 dyspepsia, pain, vomiting, hsematemesis.  The diagnosis is often very
 easy, especially in the presence of  copious haemorrhage.  The only
 disease which simulates ulcer in this regard is cirrhosis of the liver,
 in which  haemorrhage  is frequently profuse and not  infrequently
 fatal.   Cirrhosis hepatis is rare.   It is a disease of  the male sex in
 the vast majority of cases.  It results from alcohol and is associated
 with other signs, dropsy, enlarged veins, marasmus, etc.   The dif-
 ferentiation of diseases of  the stomach from each other is discussed
 later.   It  is in this connection that the diagnosis is difficult, some-
 times actually impossible.
    Treatment.—The best food is milk when it can be borne, later
 beef or beef-pancreas emulsion.   Starchy food must be avoided, as,
 while meat is well digested, starch is  not attacked.   Hsematemesis
 is an absolute contra-indication of all  food by the mouth.  Support
 for a few days may be  had by the rectum (see Food).   In  the pre-
 sence of copious haemorrhage  an ice bag is  put at the epigastrium.
 Ergotin may  be injected subcutaneously or sclerotinic acid  in sy-
 ringeful doses.  Pain may be controlled by bismuth gr.  x.-xx. every
 two hours, or nitrate of  silver gr. ^Hb or chloroform gtt. v. in  a
 tablespoonful  of water, or cherry-laurel water 3 i., or morphia gr. ^—fc.
 Constipation is best relieved  by Carlsbad salts, a teaspoonful in a
 glass of hot water before breakfast, or more safely in recent cases by
 enemata.   Perforation calls for laparotomy, already successfully per-
 formed by Parsons.  The most essential factors in treatment are
 rest, abstinence from food, and time.   As Jiirgensen says, for ulcer
 of the stomach " hunger is the best cook and cure."

                             CANCER.
   Carcinoma  {uapHivos, cancer, crab).—An epithelial  overgrowth,
 probably caused by  protozoa, in the region  chiefly  of the pylorus,
 which  orifice  becomes  blocked; characterized by pain, dyspepsia,
 diminution of  secretion of hydrochloric acid and pepsin, vomiting of
 food, mucus, disorganized blood (coffee grounds), tumor, with pro-
 gressive emaciation, and death by inanition.
   History.—Up to  the time of Morgagni (1760) cancer was called
scirrhus {6mpoi, induration), and only that  form of it which  broke
the surface to  cause or show  ulceration was  known as  cancer.
The term scirrhus had reference only to hardness of structure.  The 
378
CANCER.
fact that cancer  shows itself in  various forms in the body  is an
acquisition of later date.  Laennec (1812) first sot apart the brain-like,
encepbaloid form.   Otto (1816) recognized a peculiar gelatiniform
degeneration that takes place in other forms, which he distinguished
as colloid cancer.  Rheinhardt (1851) discovered the form commonly
known in other places as  epithelioma.  The  absence of free hydro-
chloric acid in cancer was first utilized in diagnosis by R. v. d. Velden
(1871), though the fact was really first observed by Golding Bird (1842).
   Pathology and, Etiology. —Up to  this time it was belie1 ved that
cancer might develop in  any kind of tissue, but Thiersch (1861) and
Waldeyer (1867) demonstrated that cancer is  an epithelial growth,
and that the varieties in density are largely due to the amount of
connective tissue which  constitutes the stroma of the growth.   No-
thing more definite is known of the nature of  cancer of the stomach
than of cancer elsewhere.   The tendency at  the present  time is to
regard cancer as  an epithelial cell  containing corpuscular elements,
which are parasites  (protozoa) or degenerated protoplasm or gran-
ules.   These corpuscular elements transmit or disseminate the dis-
ease.   They take root and grow in the new soil, extending like a
living thing by continuity and contiguity of structure.
   It is universally recognized  that the stomach is one of  the most.
if not  the most frequent seat of primary cancer.  The uterus is the
only organ in the body which may dispute the field with the sto-
mach.  Tanchou found the uterus affected more frequently than the
stomach by about seven per cent.   Virchow gives the preference to
the stomach.  Welch, who makes his computation from 31,482 cases,
puts the percentage for the stomach at 21.4, for the uterus 29.5—that
is, rather more  than one-fifth of all primary cancers affect the sto-
mach, somewhat less than one-third the uterus.   Cancer of the sto-
mach is, therefore, a frequent disease, though it is by no  means as
frequent as ulcer.   Statistics  with regard to  the  frequency  with
which cancer is found on autopsy vary  from one-half to three and
one-half per cent.  It is claimed that  one one-hundredths of deaths
from twenty years up are  caused by cancer.   Sex shows no differ-
ence.   The predominance of males in  hospital practice is  due to
the fact that males predominate  at  hospitals.  Age  has a most
important  influence.  Steiner and  Neureutter failed to  discover a
single case in two  thousand  autopsies  of children.   What  cases
have been reported under the age of twenty must be regarded with
suspicion until the  nature of the affection has been verified by the
microscope. Some of these cases were undoubtedly sarcomata.  Can-
cer occurs with increasing  frequency in  advancing age.   According
to the statistics  of  Brinton  three-fourths of patients are between
forty and seventy, two-sevenths between fifty and sixty.  The re- 
CANCER.
379
 duction in frequency after sixty is apparent and not real, and is due
 to the fact that few survive this age.   In these statements  the fact
 must  not  be ignored that  cancer has been not infrequently found
 between the ages of twenty and thirty.
    It has been claimed that cancer of  the stomach is less frequent in
 tropical countries.  From lack of definite data these statements must
 be accepted with caution.   Welch declares that, from his analysis of
 7,518  deaths among negroes, he finds the proportion one-third less
 than among whites.  The role of heredity, formerly considered so
 important, has been reduced to insignificance in our day.  Cancer is
 found in the ancestry of but fourteen per cent of cases—an infre-
 quency which makes a coincidence rather than a cause.
   When cancer affects the stomach it  is situated, as a rule, at the
 pylorus.  Of the three hundred and sixty cases of Brinton, the py-
 lorus was  the  seat of the disease in sixty, the cardiac orifice in but
 ten  per cent.   Eisenhart reports eighty-one cases, forty-four at the
 pylorus.  Exceptional cases are found in other parts of the stomach.
 Cancer is seated at the orifices of the  stomach in seventy-five per
 cent of cases—a contrast with ulcer, which is located at the orifices in
 but  sixteen per cent of cases.  Usually the  disease is located as a
 mass or tumor which can  for the most part  be felt at  the  pylorus,
 whence it may extend to  involve other parts  of  the stomach.  In
 exceptional cases the cancer may diffuse itself more or less exten-
 sively over the anterior wall.  It is in the vast  majority  of  cases
 primary in the stomach.   Where the  disease has existed  for any
 length  of time it develops  secondary deposits,  first in frequency in
 the  liver, which is found  affected in one-fourth  of  all the cases;
 next in the peritoneum, then in  the lungs, retroperitoneal glands,
 intestines,  ovaries, etc.
   The most important questions  in etiology revolve about  the con-
 nection between cancer and catarrh.   It is certainly true that in
 most cases cancer is associated with gastric catarrh, that the symp-
 toms of gastric catarrh belong to the symptomatology of cancer.  It
 is, however, also true that in the majority of cases a diagnosis of
 cancer may be  established at the  start—that is, with the occurrence
 of dyspepsia.   It is  always impossible  to know just when a cancer
 commences.  The point of the utmost  practical importance is the
 establishment of the exact relationship between cancer and  catarrh.
 Cancer develops occasionally, but  only exceptionally, in the borders
 of an ulcer, probably, however, only as a mere coincidence.
   May cancer of the stomach be prevented by arrest of gastric ca-
 tarrh ?  It is impossible as yet to determine this question.  Cancer is
probably sui generis.   Certain it  is that cancer occurs among indi-
viduals, seemingly in perfect health, who have subjected the stomach 
380
CANCER.
to no abuse either with food or drink, whih1 individuals who abuse
the stomach in every way may remain exempt.  No circumstance in
the way of social  standing, avocation, mental distress, or other sur-
rounding  seems  to  show  any genetic relationship to the disease.
When it is stated by  the authorities that individuals  who  show
cancer have had a predisposition to the disease, it may be seen to
what extremity the pathologist is reduced in etiology.
   Symptoms.—Cancer of the stomach is often latent, and masses
as big  as the  fist  have been  disclosed upon  the post-mortem  table
whose existence  was unsuspected in life.   Siewecke collected one
hundred and  twelve cases without typical  signs.  It need scarcely
be stated that these masses were situated away from the orifice's of
the stomach.  Cancer shows signs early, as a rule, because  it affects
these orifices.   As a rule the  disease shows itself with a train of dis-
tinct symptoms.   Pain is present in nearly  all cases.  It is usually
a  dull, dragging sensation with epigastric  distress.  It may be felt
most intensely in the back, about the vertebrae or  the  scapula, or
lower down in front at  the umbilicus, or at the pubes in cases of dis-
located pylorus.  The pain of cancer is usually due to  indigestion,
and not infrequently to  gaseous distention.  It does not stand in such
intimate relation to the  taking of food as in gastric ulcer.  It may
occur only as a vague  distress as the stomach becomes more and
more full toward evening, and show itself in  intensity throughout
the night.  Proof of this lies  in the fact that it nearly always dis-
appears when the stomach is emptied, naturally or artificially.   The
pain is usually prevented and a night's sleep secured by washing out
the stomach in the evening.   It may, however,  be due to direct pres-
sure of the carcinomatous mass upon  nerve fibres, or exposure of
these fibres in ulcerative processes, as in the case of gastric  ulcer.
Pain may  be entirely  absent throughout the whole history of  the
disease; in fact, in eight per cent of all the cases.  It happens occa-
sionally, but very exceptionally, that a case  presents all the  other
symptoms of  cancer, including the tumor, but shows no pain.   The
aged especially feel no pain.   Along with the pain are usually asso-
ciated other symptoms of indigestion.
   Cancer  shows dyspepsia  early,  as a rule.  It literally  ruins the
appetite from  the start.   Cancer poisons the blood and brings  about
early degradation of the mind and body.  Feltz found the urine of
cancerous patients more toxic than that of  healthy patients.  Klem-
perer observed that the injection of blood serum of cancerous patients
into a dog  brought about  a quicker decomposition of the albumen,
and Gros saw a foudroyant septicsemia supervene after the breaking
down  (softening)  of a cancerous  gland.   Vomiting soon sets  in,
especially if the disease be situated at the pylorus.  It may be due to 
CANCER.
381
mechanical obstruction, which leads to gastrectasia and accumula-
tion  of food, mucus,  detritus, until its final  ejection en  masse  in
large quantity.  The  discharge  by vomiting of  immense quanti-
ties, basinfuls, of fluid once a day or once in two  or three days,
should excite the suspicion of dilatation of the stomach, the most
frequent  cause of which is cancer.  This  dilatation is discovered,
also, often by percussion, which reveals dulness over an  increased
area; not infrequently by palpation,  which, when  practised with
alternate hands, may  give rise to a  sense of succussion, a peculiar
fluctuation caused  by  the presence  of  fluid  and gas—what the
Germans call a Schwappen-gefuhl.   Vomiting  may  occur early,
Fig. ItO — Microscopic appearance of section of scirrhus carcinoma (Councilman).
though the deposit of cancer be small.   It may irritate the pylorus
and lead to spastic  contraction.  Carcinoma at the cardiac orifice
leads to vomiting  early by irritative process, or, when pronounced,
to regurgitation before the fluid has entered the  stomach.   Vomiting
may be entirely absent in cases where the cancer is seated elsewhere
than at the orifices—according to Lebert, in one-fifth; to Brinton, in
one-eighth; to Ewald, in but one-twelfth of all the cases.
   Vomited matter, aside from its quantity, may reveal the nature
of the disease by its character.  Thus Rosenbach was  able to diag-
nosticate cases from fragments withdrawn by the stomadi tube.
The vomited  matter at times contains blood.   Hsemorrhage from
the  stomach is  not so frequent or so copious in cancer as in ulcer.
The blood is, as a rule, poured out into the stomach more slowly in 
382
CANCER.
cancer.  Acted upon by the gastric juice, it is disintegrated to show
itself as coffee-ground matter.   Vomiting of coffee ground mailer
is regarded as valuable evidence of cancer.  Hsemorrhage is copious
in but twelve per cent of cases.  In these cases, however, it may  so
closely simulate ulcer as  to necessitate  appeal  to other signs  in
diagnosis.
   Blood may be recognized visibly, or  by the microscope,  or by
Teichmanhs chemical  test.  The  following is Teichmanhs test  as
given by Vierordt: Some of the coffee-ground material is filtered; a
little of this matter is evaporated in a watch glass.   Scrape off some
of the dried material, mix it with a trace of finely pulverized salt,
place the dried mixture upon an object glass, cover  it with a  glass
       Fig. 183.— Haemin crystals obtained by Teichmann's test, enlarged 300 times.

cover, and allow one or two drops of glacial acetic acid to flow under
it; then the acetic acid is again evaporated very slowly, and, after it
is thoroughly dry, one or two drops of distilled water are allowed
to flow under to dissolve any crystals of salt that may  be present.
Under the microscope there  can be  seen  crystals  of haemin (hydro-
chlorate  of hsematin) in coffee-brown or  reddish-brown  crystals in
rhombic plates, which must be considerably  magnified, as the crys-
tals are very small.
   The following method (an adaptation to the vomit of Heller's test
for blood-coloring material in the urine, which see) leads to a result
more quickly : Place some of the filtered  stomach fluid in a reagent
glass with a like quantity of normal  urine, make it strongly alkaline 
CANCER.
383
 with liquor potassse, and heat it.  The urine phosphates are precipi-
 tated and carry with them the coloring material of the blood, to show,
 when blood is present, a cloudy, flocculent, reddish-brown deposit.
    The most reliable evidence of cancer is furnished by the detection
 of a tumor.  Tumor, at least localized induration, occurs in all cases,
 but may not assume  sufficient magnitude to be detected  in every
 case.  In fact, taking the history of cases  from beginning to end,
 the tumor is actually found in but eighty per cent of cases.   In one-
 fifth of the cases of gastric cancer the diagnosis must be made with-
 out tumor.   When present it is found in the majority of cases at the
 pylorus, the situation of which, however, is  by no means always the
 same.  The pylorus is very  apt to be  dislocated by the weight or
 growth of a cancer.   Brinton calls attention to  the transverse line
 midway between the  ensiform cartilage  and the umbilicus.  The
 tumor  is found in the majority of cases above this  line in males,
 below it in females.   It is at times recognized below the umbilicus,
 and very exceptionally, as stated, as low as  the pubes.  It  is impor-
 tant not to mistake the lobe of the liver, the  head of the pancreas, a
 rigid rectus, a distended colon, or other mass for a carcinoma. These
 things  may be excluded only by careful  examination.   It  is of su-
 preme value to be able to  feel the tumor when present.  The patient
 must often be put in various positions, on the right or left side, in the
 knee-elbow  posture.  The pylorus has a way of hiding itself behind
 the ribs, behind the liver, whence it may be dislodged at times by dis-
 tention of the stomach.  Wagner has suggested and used the method
 of inflation by means of a seidlitz powder.  The bicarbonate of soda,
 twenty or thirty grains, is dissolved in  one glass of water, ten or fif-
 teen grains of tartaric acid in another glass, and the glasses are taken
 separately.  Or, better, the powders are swallowed dry with  sufficient
 water to dissolve them, whereupon the stomach becomes distended, to
 show at times peristaltic movements through an attenuated or ema-
 ciated abdomen, or to dislodge the mass at the pylorus that may be
 felt.  Runeberg accomplishes  the same object  by distending  the
 stomach with air  by means of a common air balloon or through the
 stomach tube.  Affections of the colon may be differentiated by dis-
 tention of the intestine with water or gas.
   Up to the last decade it was maintained  that the tumor formed
 the most valuable evidence of cancer.   It  is, however, by no means
 pathognomonic.  In the first place, the tumor may not concern the
 stomach; in the  second place, a tumor of the  stomach may be be-
 nign.  The  discovery by Van der Velden, 1874, of the  absence of
free hydrochloric acid in cases of gastric  cancer was hailed with
acclamation.  The discovery  was made with the claim that the acid
is  absent in cancer, present in  ulcer and catarrh.  The claim  has 
384
CANCER.
 since met with modification.  It  is known that exceptional cases of
 carcinoma show free hydrochloric acid, and that  free hydrochloric
 acid may be absent also in cases of  catarrh, or more especially de-
 generations other than cancer.  Nevertheless it is true that the acid
 is absent as a rule  in  cancer, but is present as a rule in ulcer in
 excess, in catarrh in reduceel  amount, so that at the present time it
 may be declared that the persistent absence of free hydrochloric acid
 speaks strongly for carcinoma.  Riegel considers the sign more1 valu-
 able than the tumor.  Probably few  clinicians will  coincide with
 him to this extent.  The tests for free hydrochloric acid have been de-
 scribed in connection with  catarrh of the  stomach.  There may or
 may not be much loss of nutrition.  As  a rule the  strength fails
 with the loss of flesh,  and the progressive emaciation and prostra-
 tion are to be attributed partly to anorexia, mainly to dyspepsia in
 its true sense, somewhat also to infection of  the blood.  Exceptional
 cases preserve weight up to the last days of  the disease.   As  a,  rule
 the degradation is marked by cachexia. With the progressive loss
 of weight there is  corresponding  depression of spirits.  The expres-
 sion becomes  listless, melancholic.  The face assumes a greenish-
 yellow tinge, the tongue is coated.   There is cedema of  the  ankles
 and progressive marasmus.
    The diagnosis, which is studied more closely later, rests upon the
 age, absence of hydrochloric acid  on account  of disease  of the
 mucous membrane, pain,  vomiting,  especially of large  quantities,
 or of coffee-ground  matter,  tumor, progressive course,  etc. The
 presence of sixty per cent haemoglobin  excludes cancer  (Haberlin),
 and thus distinguishes cancer from pernicious  anemia, which  shows
 absence  of HC1, but  increase of haemoglobin (Mouisset).  But the
 same blood changes  found  in cancer are  sometimes  seen in ulcer
 (Osterspey).
    It is impossible to fix the duration of cancer, because the date of
 origin may not be established.  An average case lasts from  six to
 fifteen months.  The  general duration ranges from  one  to three
 years.  Cancer may become quiescent.  The patient often succumbs
 to metastatic deposits, especially  in the liver.  Sudden coma may
 supervene, as in diabetes, from diminished alkalescence of the blood
 and development of oxybutyric acid, or from absorption of toxic pro-
 ducts (gases, etc.) in the stomach.   The prognosis is fatal.
   The treatment is wholly symptomatic.  The daily or nightly use
of the stomach tube gives the most relief.  An early diagnosis—i.e.,
 before implication of the liver or metastatic deposits—justifies the use
of the knife,  which is, of course, a confession of despair. Condu-
 rango prolongs life.  Opium secures  euthanasia.   Hope  lies  in eti-
ology and prophylaxis. 
GASTRECTASIA.
385
                          GASTRECTASIA.

    Gastrectasia {yaffxyp, stomach, i'nra6ii, dilatation).—Dilatation
 of the stomach results most frequently from occlusion of the pylorus,
 and occlusion of the pylorus is caused, in the majority of cases, by
 cancer.   The block is mechanical, but before the mass accumulates
 to such extent as to completely occlude the pyloric  orifice it is shut
 off by spastic contraction of its muscle under irritation of the altered
 contents of the stomach as well as of  the growth itself.   It is, how-
 ever, a serious and not uncommon mistake to assume that every case
 of dilatation depends upon cancer.  Certain cases are caused by the
 constriction of cicatrices from  ulcers.   The pylorus  is a favorite site
 of ulcer, and the coalescence of two or more  ulcers may make some-
 thing of a girdle, the cicatrization of which may close the gate.  So
 the pylorus may be blocked by outside cause, as by an impacted gall
 stone, tumor, aneurism, abscess, as of the vertebrae, etc.
    Independently of any occlusion of the  pylorus, dilatation of the
 stomach may be due to intrinsic cause, more especially to paresis of
 the stomach wall,  the result  most frequently of a  chronic gastric
 catarrh.  Affection of  a mucous membrane for any length of time
 involves, in the course of time, the submucous muscular coat.  It
 loses tone, it  fails  to  empty the stomach, and, even when hypertro-
 phied as the first result of an occlusion of  the pylorus, it must sub-
 sequently become weakened, degenerated, overcome.  Fatty degene-
 ration,  extensive atheroma, more especially amyloid degeneration,
 lead also  to dilatation.   In  undergoing  dilatation the  stomach in-
 creases in all its diameters.   The fundus fills the left hypochondrium,
 the great curvature extends to  and below the umbilicus, the  pylo-
 rus reaches over into the right hypochondrium.  There is frequently
 direct interference with the action of  the diaphragm and the heart.
 The increase in size of the stomach is recognized in emaciated sub-
 jects by inspection.  It may be brought  out more distinctly by in-
 flation of the stomach with air, or with carbonic  acid  gas in the
 manner already described.  So, too, the body of the stomach and its
 outlines become evident to percussion.  There is increased dulness,
 increased tympanites, as the stomach is more or less full of fluid or
 gas in every direction.  It seems often  as if the stomach  fills the
 upper half of the abdominal cavity, or  comes to lie diagonally across
 it in cases of downward dislocation of the pylorus.  Palpation dis-
 tinguishes often a kind of fluctuation,  due to the presence of water
and gas, and a sort of succussion—Klatschgerdusch—a very valuable
sign.  On introducing the stomach tube it  seems impossible to find
bottom, it extends so much further than in a healthy stomach.
   Suspicion is frequently excited as to the existence of  this condi-
        25 
386
GASTRECTASIA.
tion by the  character of the vomit.   Large quantities, more than a
normal stomach could hold, may be ejected at once, often with much
subsequent relief, and this accumulation  to distention and ejection
repeats itself in  the  course of  every few  days.  The Duke de
Chausnes, a  famous gourmand of Paris, was in the habit of vomit-
ing a gallon  at a time, and common washbowls are often filled with
the rancid discharges of gastric  catarrh and cancer.  The vomited
matter shows signs of decomposition.  The antiseptic action of  the
gastric  juice is  overcome by the acetic and butyric fermentations.
The matter  contains also  sarcinse  with  various  micro-organisms
which  are destroyed in the healthy stomach after the hydrochloric
acid becomes free.
   The absorption of gases from the stomach leads to various nervous
symptoms.   In most cases there is depression of spirits.   The condi-
tion is commonly encountered in the case of hypochondriacs.  Occa-
sionally symptoms of greater gravity show themselves.  These  are
the patients who sometimes fall  into states of coma  to be mistaken
at times for apoplexies.   Coma belongs to gastrectasia as well as to
diabetes, and results, as in diabetes, from a peculiar acid intoxication
of the  nervous  system  through  the blood.  There is in  these cases
the same peculiar alteration of respiration, the same deep, forcible
breathing, and the same fatality seen in diabetic coma.
   In diagnosis the condition must be distinguished from distention
of the colon. Doubt may be  cleared up  by filling  the  colon with
water or air. Dropsy,  as from cirrhosis or other ascites, cystic  tu-
mors of the pancreas,  ovary,  etc.,  may be, as  a  rule, readily  ex-
cluded.
   The prognosis takes color from the cause.   Gastrectasia due to
cancer has a fatal prognosis; due to stricture, has a prognosis favor-
able or fatal, as the stricture may be accessible to  the sound or  the
knife after laparotomy.  Gastrectasia due to catarrh or paretic con-
ditions of the muscular tissue may be entirely relieved.
   In treatment main reliance  is placed upon the use of the stomach
tube, whereby the stomach is thoroughly emptied, its irritating con-
tents removed, and the patient properly fed with appropriate food.
Even the irremediable cases secure great relief of  suffering in  this
way.  Pain, eructations,  heartburns, vomiting, insomnia, depres-
sion of  spirits, all disappear often after the first use  of the stomach
tube.  Under the continued use of it once  or twice a  day, as may be
necessary, the underlying condition is addressed, if it may be reached
at all,  with appropriate remedies.  Digestion may be stimulated by
hydrochloric acid gtt. x.-xv. in a wineglass of water before meals;
by bitter tonics, gentian, cinchona, condurango, more especially by
the tincture of nux vomica gtt. x.-xx. in a wineglass  of water before 
GASTRALGIA.
387
meals ;  strychnia itself ;  faradization.  The stomach may be flushed
and the associate constipation overcome by the use of Carlsbad salts
(artificial), a teaspoonful in a glass of hot water before breakfast;  or
tone may be imparted to a weak-walled stomach by rhubarb in the
form of the compound pill, cascara sagrada in tablet or cordial.   It
goes without saying that in these patients  the habits of life must be
regulated as regards exercise, food, surroundings.
    Operative procedure  in mechanical occlusion from cancer is re-
duced in our day to a resection and gastroenterostomy.

                          GASTRALGIA.
    Gastralgia {ya6xrjp, stomach, a\yol,  pain)—neuralgia of the
stomach—belongs among  the neuroses of the stomach.   Of these
neuroses it is about the only one whose nature we know.   The tro-
phic neuroses, the secretory neuroses, which  produce alterations  in
the structure and function of the cells,  and which preside  over the
formation and flow of the gastric juice, are mostly beyond our ken.
Attempt has been made to estimate the mechanical movements of
the stomach—that is, to know something of the motor neuroses—by
observing the length of stay of food in the stomach.  A  healthy
stomach should  empty itself  completely in seven hours after the in-
gestion of a certain meal.   Food found in the stomach at or after
this time indicates lack of tone in the muscular coat.  Ewald endeav-
ored to discover  the rapidity with which a substance was moved out
of the stomach into the intestine by the use of agents which, insolu-
ble in the stomach, were dissolved in the intestine to be absorbed by
the blood and show themselves in secretions.   Thus salol is insoluble
in the stomach, but soluble in the intestinal juice, where it is resolved
into carbolic and salicylic acids.   Salicylic acid is quickly eliminated
from  the kidneys, and recognized in the urine by the addition of a
few drops of the tincture of the chloride of iron, which imparts to the
fluid a deep-brown color.  Salol  may be recognized in the  urine  in
half an hour to one hour after its ingestion into the healthy stomach.
A failure to recognize it for two to  three hours indicates  disease.
The objections to estimates made by this method are that, first, there
is sometimes delay in physiological states; second, the method  re-
quires examination of urine and such an amount of time as to make
it impracticable.   Penzoldt next  administered pills of the  iodide  of
potassium, coated  with  keratin, which met both these objections,  in
that the iodine is recognized in the saliva in from six to twelve min-
utes after its ingestion into a healthy stomach.  It is only necessary
in these cases that the  patient  should expectorate upon a piece  of
filtering paper saturated in a solution of starch.   The iodine in the
saliva strikes a blue color at once.  In cancer at the  pylorus, with 
388
GASTRALGIA.
dilatation, absorption is delayed often one hour, at the fundus often
twenty  minutes.   Unfortunately the keratin envelope is sometimes
dissolved in the stomach to invalidate conclusions, so that up to the
present  time this testimony can be regarded only as corroborative,
and the most practical deductions  are  drawn from the presence or
character  of the contents of the stomach as withdrawn by the sto-
mach tube.
   Pathology and Symptomatology.—Gastralgia is  an affection of
the sensitive nerves.  The condition manifests itself in pain, which
is often excessively severe.   Gastralgia is,  as  the name  implies,  a
neuralgia of the stomach.  Strictly speaking, the condition as a sepa-
rate disease is a pure neurosis.  There is often, however, very great
difficulty in separating neuroses from organic affections. All the dis-
eases of the stomach  are marked by pain:  gastric catarrh,  gastric
ulcer, gastric cancer are all associated with pain. Attacks of gas-
tralgia occur in connection with all these diseases, but gastralgia is
considered as a separate disease only when dissociated from organic
affections.   True gastralgia occurs as the result of abnormal ingesta—
abnormal in themselves or abnormal to the individual on account of
idiosyncrasy—or is the result of  the altered condition of the stomach
nerves,  a kind of hyperesthesia.  Finally it may be reflex.  It is not
exactly true that what is one man's meat is another man's poison, but
it is true of some things in certain cases.  Shell fish not infrequently
excite attacks  of gastralgia.   There are  individuals who may not
partake of oysters, many more who may  not eat clams, without suf-
fering pain.  Ice water produces attacks in certain individuals, straw-
berries  in others.  There are not lacking individuals who suffer after
taking milk.   These abnormalities may develop when  they may not
have existed before, in or after attacks of illness of various kinds.
    In the majority of cases gastralgia is the result of an altered ner-
vous system.   A large number of cases occur in hysterical females,
especially in connection with menstrual disturbances, or with indi-
viduals who show other neuroses, asthma, migraine, or  other neu-
ralgias.  Gastralgia is often an outward sign of  an  underlying con-
dition,  an  unstable, mobile,  excitable state  of  the nervous system.
This condition is sometimes produced by excesses which lead to ex-
haustion, by alcohol, tobacco, tea, and coffee, more especially by dis-
eases which sap the nutrition or directly poison the nervous centres—
ansemia, diabetes, Bright's disease, malaria, rheumatism, etc.
    Under the head of reflex causes are diseases of the genito-urinary
system, various affections of  the uterus and ovaries.   Salpingitis and
prostatitis have been found to produce exquisite gastralgias.  In cases
where relationship has been established cure of the cause cures  the
consequence. 
GASTRALGIA.
389
   Gastralgia shows itself in acute and  subacute or chronic forms.
 In the acute attack the pain comes on suddenly, often without pre-
 monition, and distinguishes itself by its intensity.  The pain is located
 at the pit of the stomach, or irradiates thence to  the back or sides,
 and is frequently associated with a precordial pain and  anxiety. Cer-
 tain cases of pseudo-angina are cases of  gastralgia.  The attack is
 often associated also with the various symptoms of dyspepsia, and is
 relieved at times by the discharge of large quantities of gas, at times
 again by a profuse sweat.   In the more chronic cases the pain is less
 intense ; it is more continuous.  There are intervals of comparative
 relief, with attacks at times excruciating in severity, especially as
 the result of any imprudence in diet or exposure to cold.
   Diagnosis.—Gastralgia must be separated  from intercostal neu-
 ralgia,  enteralgia,  muscular  rheumatism, gall-stone colic, and the
 dyspepsias of organic diseases.  Location of the pain usually suffices
 to distinguish neuralgia of the stomach  from that of  the intestine.
 The discovery of painful points between the ribs, near  the sternum,
 in the axillary line, and in the vicinity of the  spinal column suffices
 to separate intercostal neuralgia.  Muscular  rheumatism,  pleuro-
 dynia, is more especially aggravated by  motion  and is unattended
 with dyspeptic phenomena.  Gall-stone colic affects more especially
 women past the middle  period of life.  The condition may be dis-
 tinguished by the existence or history of jaundice, by a distended gall
 bladder.  Hepatalgia  may be separated from gastralgia only by the
 fact that the pain is more strictly localized in the region of the liver.
 It is of much more importance to  be able to recognize the cause of
 the disease, whether due to food, bad habits, chlorosis, Bright's dis-
 ease,  etc., as the future of the case depends entirely upon its cause.
 In locomotor  ataxia  the  attacks  occur as " crises," caused by scle-
 rosis of the vagus at its origin and in its course (Landouzi).  The
 gastralgias of hysteria occur in connection with psychical disturb-
 ance  and alternate with other neuralgias.   Reflex gastralgias are
 most pronounced in pregnancy and the puerperium.
   Gastralgia is for the most part a .curable condition.   It is often a
 relief to the practitioner to be able to discover a pure neurosis as dis-
 tinct from an organic disease.
   Treatment.—Sometimes the pain is relieved at  once and the na-
 ture of the disease recognized by a single  application of the galvanic
 current, anode between the  shoulders,  cathode at the  pit of the
 stomach.   Electricity seems to have more direct control  over these
 than over any other forms of neuralgia.   The  daily application of a
 mild current for five minutes for several days suffices to cure simple
 cases.   The diet and habits  of life must be regulated.   Chlorosis
is  treated with iron ;  a tablespoonful of  the simple carbonate with 
390           DIAGNOSIS,  DIET,  AND  TREATMENT OF

about half a tablespoonful of sugar of  milk three or four times a day
makes an eligible preparation.   The compound  mixture of iron,
though an inelegant, is a very efficacious  form.   It may be  substi-
tuted later with a compound pill of iron.   It may be deemed advis-
able to give the iron in combination with hydrochloric acid, whereby
it  is preferable to administer the  drugs  separately.  The  value of
arsenic has always been recognized ; three to  five drops of  Fowler's
solution of arsenic in a tablespoonful of water after meals  is almost
routine practice.  Bismuth, in doses of ten to twenty grains after
meals, proves often of great value.  The salicylates, salol, especially
of soda,  gr.vij.-x. every two to three  hours, act often like  specifics.
Tincture of nux vomica gtt. x.-xx. in a tablespoonful of water, or
strychnia gr. tV-tV* are tonics to the nervous system.
   The immediate pain must be relieved by anodynes.  Two to five
grains of chloral in a dessertspoonful of peppermint water often give
quick relief.  A teaspoonful of bitter-almond water may suffice for a
milder case.  A severer case calls for opium, best in the form of mor-
phia ;  gr.  yV-j-j in  a teaspoonful of cherry-laurel water relieves
most cases.  In  the presence of  excruciating attacks resort must
be had to morphia subcutaneously, best combined with atropia  gr.
 10"  1

DIAGNOSIS,  DIET, AND TREATMENT OF THE VARIOUS DISEASES OF
                         THE STOMACH.
   The separation of the different forms of disease of  the stomach is
often easy, but is sometimes very difficult.   The differentiation of can-
cer from chronic catarrh and of gastralgia  from simple ulcer becomes
at times  a real problem in diagnosis.  There is  in no case any one
single symptom which may determine  the exact character of the dis-
ease.  Even the  tumor which  is  supposed to be pathognomonic of
cancer is often deceptive.  The diagnosis  is made by the considera-
tion of all the facts as elicited under patient investigation.  There is
to be considered  first, age.  An affection of the stomach past  the
middle period of life is  more probably cancer, or, if of long duration, a
protracted catarrh.  Affections of younger middle age are more likely
to be gastralgia and ulcer.  To these rules, however, there are many
exceptions.   Cancer is sometimes encountered between twenty and
thirty.  An ulcer may last over and prove  recurrent at a later period
in life, while gastralgia and catarrh  may occur at any time.  The
sex of the patient speaks rather  in favor  of ulcer and neuralgia as
against cancer and catarrh.  A large contingent of cases of gastral-
gia occur, as stated, in chlorotic and hysterical females.  Ulcer of the
stomach  is seen also  under like  conditions.   Catarrh occurs rather
more frequently in the male  sex, while cancer is no respecter of  sex 
DISEASES  OF THE STOMACH.                391
 at all.   Something may be learned at times by the appearance of the
 individual.   Neuralgias and ulcers do not, as a rule, disturb the gen-
 eral appearance;  though frequently attended with loss of flesh, they
 are not inconsistent with an appearance of health.   Chronic catarrh
 is commonly found in hypochondriacal  patients.  Cancer produces
 in the course of time that peculiar degradation which is called a ca-
 chexia.  The cachexia is, however, not peculiar to cancer.   It  may
 occur  in any long-standing, wasting disease—tuberculosis, Bright's
 disease, etc.—but shows itself, as a rule, rather earlier  in cancer be-
 cause  of the early attack upon nutrition.   Exceptional  cases of can-
 cer show, however, no cachexia and no marasmus until the very last
 days of the disease.
    The cause of the condition, in so far as it may be discovered, may
 be invoked in explanation.  Gastric  catarrh may be found associated
 with irregularities or imprudences in diet, or  as  an expression of
 tuberculosis or Bright's disease.  Gastric ulcer  may be found asso-
 ciated with heart  affections or with hyperacidities of the gastric juice.
 Gastralgia occurs in connection with or alternative  to  migraine,
 asthma, though  neuroses  may be found to  have  been caused by
 abuses of alcohol, tea and coffee, tobacco, bodily excesses, etc.  Cancer
 has no known cause.   Of the symptoms proper, pain is predominant.
 It occurs in all the varieties of stomach disease, but shows points of
 distinction in different forms.   The pain of catarrh is  more diffuse,
 more or less constant, with exacerbations, dependent more particu-
 larly upon distention.  It is relieved by eructations, more especially
 by emptying and irrigating the  stomach.   The pain of  ulcer is more
 strictly circumscribed.   It is certainly more dependent upon the tak-
 ing of food.  As a rule, no food, no pain.   It is brought out, intensi-
 fied, mitigated, or relieved by change  of posture.  The pain of cancer
 does not differ very much from that of chronic catarrh.  It is apt to
 be associated with more tenderness  to pressure in the right hypo-
 chondrium.  It disappears, like that of catarrh, with the emptying of
 the stomach.  Gastralgia is for the most part a paroxysmal pain.  It
 is frequently relieved by pressure, more frequently by the ingestion
 of food.  When not more or less continuous it is most assertive when
 the stomach  is  empty.   It is often much  more intense.  It is more
 amenable to relief.  It may disappear entirely under antiperiodics,
 antineuralgics,  or under the constant current of electricity.
   The appetite  is permanently ruined  in cancer, may be good in
 the intervals of attacks in ulcer, and is mostly  good in gastralgia.
 The tongue is  coated in cancer, but clean, as a rule,  in  ulcer and
gastralgia.
   Vomiting may occur in any form of stomach disease, but is less
apt to show itself  in gastralgia.  The vomiting of catarrh and cancer 
 392           DIAGNOSIS, DIET, AND TREATMENT OF

 is more prone to occur in states of  dilatation, when the stomach dis-
 charges  large  quantities  of  decomposing and  fermenting matter.
 Blood is vomited only in ulcer and cancer.  There may he excep-
 tional cases  of  violent retching in which the vomited  matter or the
 ropy mucus  discharged in catarrh may be streaked with blood, but
 the presence of  blood is an exception.   Blood may be vomited pure
 in both ulcer and cancer.  It is much more frequently  pure in ulcer,
 where it is  present also in greatest quantity.   It shows more fre-
 quently the coffee-ground appearance in cancer, as disintegrated by
 the action of the gastric juice.   Blood may, however,  assume either
 character in exceptional cases of either disease.
   The penetration of the stomach tube to unwonted depths speaks
 for dilatation of the stomach  which in younger individuals is found
 in connection with catarrh; in rarer cases as  the result of a cicatrized
 ulcer at the pylorus; in older individuals with cancer.  Tumor, when
 detected unmistakably, speaks  for cancer.  There is room here for
 error with  reference to  outside tumors,  as  of the  liver, pancreas,
 retroperitoneal glands, or intrinsic tumor, benign tumor, hyperplastic
 tissue from catarrh, or about an ulcer, etc.  The gastric juice shows,
 as a rule, a reduction of acidity in catarrh, absence altogether in can-
 cer,  an. increase in ulcer, an unaffected condition in gastralgia.  In
 this way the diagnosis is  reached as a rule.  Ulcer is the condition
 most frequently overlooked and confounded with or considered as a
 simple gastric catarrh.  Cancer remains often  unrecognized until it
 displays itself as a palpable mass at  the  pylorus.   But by the inter-
 rogation of a patient from these various  standpoints, the diagnosis,
 as stated, is reached as a rule.
   Diet.—The dietary is a most important question in the manage-
 ment of  stomach disease, and may be considered here in some detail
 and  in connection with the general subject.   In  the  treatment of
 diabetes, obesity, as well as in stomach disease itself, it assumes more
 importance than the materia medica.   During the existence of fever
 the body wastes more rapidly, and this waste must be compensated
 by the administration of food.   Food must  be administered, there-
 fore,  as much as may be handled and disposed of by  the stomach.
 Any fault in this regard of quantity or quality does damage, in that,
 undigested, it decomposes and remains as foreign matter, to be dis-
 charged by the  act of vomiting or to become decomposed and add
 noxious elements to the blood.   The most important food in all cases
 is water.  Sixty per cent of the body is water.  Water is necessary
 for the fluidification of  the food as well as for the circulation of the
blood and other juices.   All water contains salt, notably lime salts.
 One-half  of  bone tissue is made up  of the lime  phosphate; the
sodium and  potassium  phosphates make the  blood alkaline, and 
DISEASES OF THE STOMACH.
393
 alkalinity of the blood is a very necessity of  existence.   Water con-
 tains also the sodium chloride which enters into the composition of
 all the tissues.  Sodium chloride, however, exists in such an insuffi-
 cient quantity in water that it must be continually furnished by solid
 elements of the food and in the preparation of food.   The sodium
 chloride holds the globulin in solution; it regulates also the diffusion
 of fluids through  animal  membranes  in the  process  of osmosis.
 Necessary as water is in health, it is  even more necessary in disease.
 Water is constantly being given off from the body, from the  skin
 and the various secretions, but especially from the skin in fever to
 secure the reduction of temperature, and from the kidneys in  the
 elimination of toxines.  Water must  be,  therefore, administered
 freely to  all fever patients.   It should  stand always in reach or be
 periodically administered.   The water must be pure.  Cases of gas-
 tric and intestinal catarrh often fail to yield to treatment because the
 diseased  state is  kept up  by the administration of  contaminated
 drinking  water.  In all cases of doubt the  water must be filtered
 through asbestos or porcelain, or boiled.
    The stomach is spared much of its work by the administration of
 food in fluid form.   The best food is milk.  Milk is a complete food.
 It has the advantage,  in  the first place, of fluidity;  it has the great
 disadvantage that it will not keep.  Another disadvantage lies in the
 fact that, though administered in fluid form, it often becomes solid and
 is rejected as a coagulated mass.  To obviate this evil, milk is some-
 times  substituted  by buttermilk.  Buttermilk is a  good substitute
 in summer; buttermilk is  bad in  winter.  Artificial fermentations
 may substitute milk, as in the form of kumyss, the taste of which is
 objected to by many patients.  To obviate the evil of coagulation it
 is only necessary to dilute  milk.   This  dilution may be secured in
 cases of intestinal catarrh, or excessive sensitiveness of the stomach,
 with lime water i-f.   Coagulation is sometimes prevented by  the
 addition of a small quantity of bicarbonate of soda.  The best solu-
 tion is secured with soda water, Apollinaris or Selters  (imported)
 water, half and half.  In this  dilution the milk is never coagulated
 en masse, and is very rarely rejected by the most delicate stomach.
 In this exceptional case, or where it  is  deemed  advisable to change
 the form of the milk, the curd may be separated and the milk given
 in the form of whey.  A teaspoonful  of  lemon juice added to a pint
 of milk secures this separation, and the whey may be made richer if,
 during the process of straining, the  curd  be squeezed that only the
casein be  retained.   This whey may be  administered by itself or in
combination with various  other foods, with diluted eggs, with bread
crumbs, with a dash of rum or brandy, or  with wine.
   Egg is also a complete food, but too  concentrated for a diseased 
394           DIAGNOSIS,  DIET,  AND  TREATMENT OF

stomach or for the febrile condition.  To be  digested it must  be
diluted with hot water and administered thus pure or after strain-
ing through a linen cloth.   An egg in a glass of sherry  is concen-
trated nutrition.  Diluted egg  in wine win1}- in a cup of tea. with or
without a teaspoonful  of cognac, is strong food.   Custards of milk
and egg are delicate, palatable, and nutritious.
   Beef is best administered raw.  Scraped raw beef,  teaspoonful to
a tablespoonful—that is, the extract of the protoplasm without  the
fibre—mixed with a little  warm water, seasoned with pepper and.
salt, forms concentrated nutrition.  The taste is  repulsive to some
patients.  A piece of beefsteak may be then very lightly broiled, that
the aroma of cooking may  stimulate the  flow of the digestive juices.
According to the experiments of Fick the stomach digests raw three
times  as quickly as cooked meat.   Beef tea, chicken soup, mutton
broth, are valuable contributions to the dietary.  The best beef tea is
made by taking a  pound of lean beef, cut in  strips the  size of  the
finger, and a pint of cold water, to which is added a teaspoonful of
salt.   It is to be allowed to simmer fifteen minutes, but not to boil.
A stronger preparation, known as beef essence, is prepared by placing
the strips of cut meat or  chopped beef in a  wide-mouthed bottle,
which is inserted into a vessel of boiling water and allowed to remain
for half an hour.  Beef tea or bouillon may be used also as a basis,
to which may be added crumbs of bread, or strained egg,  or various
vegetables, whose juice and flavor may  be taken without the  sub-
stance. Carrots, turnips, parsnips,  celery, are vegetables used in this
way.   The juice of the fresh oyster is a  stimulating, nutritious food
which the most delicate stomach will rarely reject.  The soft part of
the oyster itself, the body without the  muscle, is, as a rule, easily di-
gested.  It must be taken fresh from the shell, with pepper and salt,
lemon juice,  and horseradish.   The white meat of fish, if properly
prepared—an art seldom understood in  inland places  ("forty  reli-
gions and but one sauce ")—is delicate food.  Sweetbreads stewed in
milk are very digestible.   The white meat of broiled chicken, phea-
sant,  quail, short-fibred meat, is  much more easily handled than
that of geese, ducks,  wild fowl, wild game.   There is often crav-
ing for farinaceous  food.   The  simplest forms are  the  gruels : a
glass of water with a piece of  toast inserted into it, cornmeal gruel,
oatmeal gruel, barley,  rice. Milk may be thickened with flour, with
arrowroot or tapioca as articles of light diet for fever  or for  gastric
catarrh.   Fine white bread of  wheat is  much  more easily digested
than that from any other  grain.  Starch may  be tried first in  the
form  of toast.   The "  zwieback " is a  good beginning.  Coffee and
tea are often necessary stimulants and adjuvants.  They  may  be
even fortified with rum or brandy, or the coffee may be made black, 
DISEASES  OF THE STOMACH.                395
 as in cases of heart failure, opium poison, etc.  As a rule these beve-
 rages are not contra-indicated in fevers.  The value of them in these
 states depends more upon the stimulation of heat which  is thus in-
 troduced into the stomach, and they are made more palatable by the
 flavor of tea and coffee.  They may be advantageously substituted
 often by chocolate, which imparts more solid nutrition; or, in cases of
 intestinal catarrh, by cocoa, a light form of which is found in the so-
 called acorn cocoa.   It may become a necessity at times in the treat-
 ment of disease of the stomach, especially in cases of ulcer or in the
 presence of hsemorrhage, to abstain from food altogether and support
 the  patient by nutrient enemata.  Enemata are poor substitutes at
 best.  Baumler has shown that only about one-fourth of the most nu-
 trient matter is absorbed from the rectum.  The beef-pancreas emul-
 sion  of Leube may be used in this way.   Foods which have  been
 partly predigested, as in the case of the peptonized preparations, may
 be tried by the rectum as well as by the stomach.
   In the treatment of chronic gastric catarrh Leube's series of four
 diet lists, graded from the lightest up, is as good as any:  1. Bouillon,
 Leube-Rosenthal meat solution (beef boiled twenty-four to thirty-six
 hours, with the addition of dilute hydrochloric acid), milk, raw egg,
 zwieback, crackers (without sugar), Apollinaris, Selters, Vichy water.
 2. Boiled calves' brains, thymus gland of  calf (sweetbread), boiled
 chicken (young without skin), boiled calves' feet, milk gruels  with
 tapioca, whipped egg.   3. Raw beef chopped fine, raw ham chopped
 fine,  beefsteak lightly broiled with fresh  butter, fine scraped beef
 (loin), white bread, potato puree, coffee and tea largely diluted with
 milk.  4. Roast chicken, roast pigeon, roast venison, roast beef (cold),
 veal  (choice), macaroni,  rice gruel, spinach (finely chopped), aspara-
 gus, steamed  apple, the  lightest white and  red wine.  Food should
 be taken every three  or four hours  in small quantities, never in a
 state of fatigue, and the patient must stop short of  satiety.  Small
 quantities of alcohol aid digestion ; champagne or other effervescent
 forms hinder it, still more so  do  fruit wines.  Beer may  be taken in
 small quantity some time after meals.   Caviare, sardelles, ham and
 smoked meats excite the appetite through  creosote;  with the devel-
 opment of much gas, vegetables, fresh bread, all fruit and milk must
 be avoided.  Bad breath is  obviated by avoiding fresh albumen.
 The meat in these cases should be smoked.
   Regular  habits of  rising  and going to  bed, exercise in the fresh
air, morning baths, cultivation of a  cheerful disposition, are adju-
vants.  The mineral waters,  especially at their sources, are most
valuable.  They may be  substituted at  home by artificial products,
common salt, Carlsbad  salts, the carbonated waters of the  soda
fountains, Vichy water, which in cities may be decanted into bottles 
396        TREATMENT OF DISEASES  OF THE STOMACH.

at the drug store and served at home  like beer.   As stated already,
no drug equals dilute hydrochloric acid, gtt. x.-xx. in a wineglass of
cold water before or after meals.  Pepsin may help; still  better is
pancreatin, gr. xv.-xxx. after meals.  The physician must  have the
help of an honest apothecary with these preparations.  Of bitters
choice may be made  of  quassia, gentian, calamus,  absinthe.  Two
excellent bitters are fluid extract  of  condurango bark  gtt. x.-xv.,
and the tincture of rhubarb 3 ss.-i. diluted.   Creosote is one of the
finest contributions of  modern  therapy.   It shows its virtue in that
most obstinate of all forms  connected with and based upon tubercu-
losis.  It may be  given in capsule gtt.  i.-ij., or, better, with equal
parts of tincture of nux vomica, rhubarb, or gentian ;  and the dose
may be of the mixture  gtt. v.-x. in wine (sherry),  or whiskey and
water  equal parts,  a  teaspoonful  to  each drop.  An  appetizer of
much promise in bad cases of  gastric catarrh, tuberculosis, Bright's
disease, etc., is  orexin.  Care  must be  taken  to secure the basic
orexin,  as  the acid form burns  the stomach.   It is given best in
capsules, gr.  v. twice a day with much fluid.  The appetite sets in
sometimes  after the first dose and continues, or again only after sev-
eral days, or only after each  dose.  It  acts by exciting the flow of
hydrochloric acid.   Sometimes  it produces a ravenous  appetite;
sometimes  it fails (Penzoldt).  Vomiting may be checked best by irri-
gation with the stomach tube, which is always the sovereign remedy,
by small doses of chloral  in peppermint  water gr. ij.-v., by tincture
of belladonna gtt. x., or chloroform gtt. v.-x.  on sugar, or cocaine or
morphia, or morphia with atropine.   Morning vomiting is  brought
under  control best by atropia  gr. i.- § i. solution, dose gtt.  ij.-v.  at
bedtime.   Vertigo is relieved by chloral  gr. v.-xv.
   Surgical measures are always called for in desperate cases.  Bill-
roth, in the  review of his one hundred  and twenty-four  cases of
operations  on the stomach  and intestine  in  the past  twelve years,
records a rescue of one-half of all the cases of all kinds.  Metastases
and recurrence  took place, of course, in  carcinoma, quickly in the
gelatinous  and cylindrical forms, more slowly in scirrhus, but surgi-
cal intervention gave relief in all cases,  showing striking contrast in
this regard with the cases left to  fate. 
CHAPTER  III.
                DISEASES OF THE INTESTINE.

                      INTESTINAL CATARRH.

   Catarrh of the intestine differs from that of the stomach  in
that, while it is in the acute form more frequent, it is in the chronic
form less frequent.   Catarrh of the  intestine when chronic depends,
as a ftile, upon some  outside disease.  Acute  intestinal catarrh is
perhaps the most frequent of all  diseases.  It constitutes  a large
contingent of cases of diseases of infancy, where it is encountered in
its most exquisite expression.
   Pathology and Etiology.—Catarrh of the intestine results first
from fault in the ingesta.   It is the fluid rather than the solid food
which is most at fault.   The  chief fault  lies with drinking-water.
Contamination of drinking-water by the discharges of other  cases of
intestinal catarrh, or of other diseases altogether, is the most fruitful
source of  this affection.   The  disease may in this way assume epi-
demic proportions.  When it shows itself in intense degree, affecting
also the stomach, it constitutes the affection commonly called cholera
morbus.   Any great fault with the ingesta affects the stomach as
well as the intestine, to produce the condition commonly called gastro-
intestinal catarrh.  That cholera morbus results often from contami-
nated drinking-water is proven by the fact that in so many cases the
discharges contain various micro-organisms.
   Cholera morbus,  or that intensely  acute expression of gastro-
intestinal catarrh, is, however, by no means always due to this cause.
It may result from the other causes of intestinal catarrh.  Bad food is
responsible for fewer cases.  Decomposing meats, spoiled fish, unripe
vegetables, decayed fruits, account for individual cases.  Where the
process of decomposition is not too far advanced it is arrested under
the antisepsis of free  hydrochloric  acid in the stomach—a process
which is continued for a short time in the intestinal canal.  The food
that causes the most  irritation is milk.   It is unfortunate that the
food upon which most reliance  is placed to substitute  the mother's
milk is the most prone  to  decomposition.  Intestinal catarrh  re-
sults also  from  toxic  cause, as from the  action of poisons, arsenic, 
398
INTESTINAL CATARRH.
corrosive sublimate, or too intense action of the various purgatives.
Herein is included also the action of specific diseases, typhoid fever,
tuberculosis, rickets,  cholera, dysentery, etc.  There may be abnor-
mal excitability of the sensory or secretory nerves.   Influence of the
nervous  system is  perceived in cases in which intestinal  catarrh re-
sults from exposure to cold, which, in certain individuals, will always
produce  diarrhoea.  Fright may have  the  same  effect.   Intestinal
catarrh results also from disturbances in the circulation.   It is found
in connection with  disease of the  heart and lungs, more especially in
association with disturbances in the portal circulation, in cirrhosis of
the liver,  etc.  The absorption  of  chemical products,  ptomaines,
toxines,  is  responsible for  certain  cases.  The intestinal  catarrh
which results from the mere presence  of micro-organisms  is  often
salutary, in that it  secures their expulsion, as in the case of trichino-
sis.  Where peristalsis is easily excited,  as in children, the individual
is protected  against disease in this  way.  Many  of us owe escape
from various infections to the fact that, in the first place, the poison
is destroyed  in the stomach by the gastric juice or is hurried out of
the intestinal canal by rapid peristalsis.
   Symptoms.—Catarrh of the intestine shows symptoms which dif-
fer according to the location of the affection.  The condition rarely
extends to involve  the whole length of the intestinal tract, but is
manifest more especially at one or the  other extremity.  The  most
common expression of  intestinal  catarrh  is diarrtioea.   Diarrhoea,
however, is only a  symptom.   Under the rapid peristalsis the con-
tents of  the intestine, for the most part  digestive juices, are  hurried
along the canal before there is time for their reabsorption.   Many
pounds of  these digestive juices are secreted during the day.   All of
it, or nearly all of it, is reabsorbed into the blood.  The stay in the in-
testine is just long enough to secure fluidification and absorption.  In
hypersensitive, irritable states of the mucous membrane the  muscu-
lar coat  propels the contents of the intestine along its course too rap-
idly to permit absorption.  The mass of the discharges, therefore, is
made up of digestive juices.   Catarrh located in  the duodenum,
which exists for the most part in connection with catarrh of the sto-
mach, manifests itself by the very opposite condition, to wit, consti-
pation.   More or less tenderness may usually be felt in the region
of the pylorus.  There is usually anorexia, frequently nausea, and not
infrequently icterus.   The catarrhal process, which thickens the mu-
cous membrane, occludes the orifice  of the bile ducts.   Sometimes it
invades  the bile ducts to lead to the same occlusion, and but very
slight swelling is necessary to block the bile ducts and necessitate the
reabsorption of bile into the blood.  Hence most of  these  cases  are
associated with jaundice.  Catarrh of the jejunum may not be dis- 
INTESTINAL CATARRH.
399
 sociated from catarrh of the ileum.   The known seats of the lesion
 of typhoid fever and tuberculosis in the ileum enable  us to  exclude
 the jejunum from participation in these affections.  In the rare cases
 in which dysentery invades the small intestine its lesions  are confined
 about the ileo-csecal valve.
   The point of greatest practical importance is to separate the affec-
 tions of the small from the large intestine in the effort to secure local
 therapy.  In a normal state the contents of the small intestine  are
 fluid, of the large intestine more or less solid.  Copious discharges
 of fluid  matter usually come from the small intestine ;  smaller dis-
 charges of more solid masses, scybala,  come from the  large intes-
 tine.   Ordinarily the bile is reabsorbed in  its passage  through  the
 small intestine, so that it does not  appear in the  large intestine.
 Quantities of bile with the  stools, which impart to them their green-
 ish color, indicate a discharge from the small intestine, provided al-
 ways the gall ducts be not blocked, in which case, however,  there is
 usually constipation.  A  better evidence of discharge from the large
 intestine is the presence of mucus, alone or coating the exterior of the
 mass.   The  character  of the blood or pus sometimes  discharged
 from the stools indicates also the seat of the disease.  Blood from the
 small intestine is usually  intimately intermingled with  the discharge;
 from the large intestine it is either voided pure or it streaks or coats
 the outside of the mass.  In some cases the stools are composed al-
 most entirely of water.   The stools  of  cholera  morbus and  cholera
 are ninety to ninety-five per cent of water.   In these cases water is
 not only voided from the intestinal canal, but is drained also by osmo-
 sis from the blood,  and with such rapid exudation as to macerate
 and  detach the epithelial  cells which appear to constitute the rice-
 water discharges of these diseases.  In these cases the stools have lost
 all natural to assume a peculiar odor.   Something may be  learned
 from the odor of the discharge.  An acid odor frequently observed
 in the discharges of childhood indicates for the most part  decom-
 position of vegetable food;  a putrid  odor, decomposition of animal
 food.   Naked-eye inspection, more especially as assisted by the mi-
 croscope, gives information as to the degree of digestion.  Particles
 of undigested fat indicate, for instance,  absence or defective action of
 the bile and pancreatic juice.   Undigested muscular fibre shows  de-
 fective action of the intestinal as well as of the gastric juice.   Parti-
 cles of starchy food, unaffected or but little affected, masses of detri-
 tus, unattached or undigested residue, constitute the condition known
 by the older writers as lientery.  Miller called attention  to  the fact
 that  where the catarrhal process is slight the lack of digestion first
concerns the fats ;  where extensive it  concerns all kinds of food.
Bacteria and protozoa abound in the faeces of intestinal catarrh. 
400
INTESTINAL CATARRH.
   Intestinal catarrh manifests itself also  by pain.  The pain is
more acute in accordance with the degree of distention of the intes-
tine  by gas—colic.  Colic  is often relieved by pressure.  Usually,
however, there is more or less tenderness over  the  whole region of
the abdomen.   The escape of gas  or  its wanderings constitute1 the
rumble or borborygmi and show  increased or irregular peristalsis
and paretic states.
   Fig. 181.—Protozoa in the faeces : a, Trichomonas intestinalis; b, Cercomonas intestinalis; c,
Amoeba coli: d, Paramecium coli; e, monadines, living; /, monadines, dead.

   Forms of intestinal  catarrh are divided usually into duodenitis,
ileitis, colitis.  A peculiar variety of  inflammation,  situated at or
about the  head of the large intestine at the  caecum, is commonly
known, from the  Greek equivalent of csecum, as typhlitis.  The dis-

        __■>,-... «..  ...*\
^^pE®pp? X^y   ^Mk*^
   Fig. 185.—Fapces under the microscope : a. muscle fibre ; 6, connective tissue ; c, epithelium;
d, white blood corpuscles ; e, spiral cells; f-i, various plant cells ; fc, triple phosphates. Inter-
spersed are various micro-organisms (Von Jaksch).

ease begins, as a rule, in the vermiform appendix and is often known
as appendicitis.  It is an especial variety of intestinal inflammation,
which from its frequency and gravity merits  especial consideration.
Colitis is usually described with dysentery.  Dysentery is some-
times a specific colitis, prevailing  often in epidemic form.  It, too,
merits especial consideration.  Inflammation in the rectum is known 
INTESTINAL CATARRH.
401
 as proctitis.  The rectum is also secondarily involved from inflamma-
 tions outside, in connection often with the uterus, or as a localization
 of a septic process, peri- and paraproctitis.  The rectum is also a final
 habitat of the tubercle bacillus, which erodes its tissue to form peri-
 neal abscesses and result in fistulse.
    Diagnosis.—The important point in the consideration of intestinal
 catarrh is the  recognition of its cause.   In acute intestinal catarrh
 this cause is usually obvious in fault with  the food.  In chronic in-
 testinal catarrh the cause, as stated, is most  frequently outside the
 canal.  In some cases the mucous  membrane  undergoes a degenera-
 tion as part process of a widespread affection.  This is particularly
 the case in amyloid change, which almost always occurs in connection
 with amyloid kidney and is recognized  by the signs of that disease.
 Bright's  disease not infrequently causes intestinal catarrh through
 mere cedema—a salutary process by which urea is eliminated.  Ulce-
 rative processes, as from typhoid fever, tuberculosis, dysentery,  carci-
 noma, syphilis, must  be  always carefully eliminated.   They consti-
 tute, as stated, the mass of cases of chronic intestinal catarrh.
    The prognosis depends  altogether upon the cause.  It is for the
 most part favorable in the  acute  forms of the disease, but  is often
 excessively grave in  childhood.   Infants succumb quickly  unless
 radical change can be made in the diet.  Summer diarrhoea, as it is
 called, is the most fruitful cause of death in infancy.  It occurs in the
 second summer, because it  is at this time that the child is put upon
 outside food.   The chronic diarrhoea which is so fatal  to childhood,
 constituting the mass of cases which are called  marasmus,  is an ex-
 pression for the most part of  tuberculosis.  All  tuberculous patients
 are affected with diarrhoea sooner or later from deglutition of the spu-
 tum.  Children never expectorate, so that they show affection of the
 intestine out of all proportion to that of the lungs.
    The treatment of acute intestinal catarrh in infancy is a matter
 wholly of diet.  It depends upon  fault  in diet and is remedied only
 by its correction.  The great contingent of  cases is  furnished  by
 children fed with artificial  food.  The  only real remedy is a wet-
 nurse.  All other remedies are of secondary  importance.   No arti-
 ficial food, milk  of no animal, will really substitute mother's  milk.
 The experiment is usually tried of substituting one form of food after
 another.  Sometimes it succeeds ; as a rule it fails, and if a wet-nurse
 may not be obtained, and that quickly, the result is frequently  fatal.
 The infants' foods in the market are numerous.  Resort must be had
 to them in certain cases.  Perhaps most use is  made  of  condensed
 milk, milk with wheat, peptonized milk.  The food that should be
 tried first in all cases where mother's milk may not be obtained is the
milk of the cow.   Failure is experienced often with cow's  milk be-
        2G 
402
INTESTINAL CATARRH.
 cause it is given in form too concentrated.   It  should be diluted al-
 ways.   In the case of a healthy child the mixture is made1, for the
 first three months, two parts water and one part milk : for the second
 three months, equal parts; from the sixth month on the water is grad-
 ually reduced until pure milk is given.  In intestinal catarrh at what-
 ever age, even in advanced life, milk, which still constitutes the  best
 food, must be diluted as if for infancy.  The dilution may be made1
 two-thirds, one-half, one-third, with lime water, with simple water,
 pure, preferably with soda,  Selters water, when it  may be  handled
 by the most delicate stomach.  In adults the milk maybe substituted
 with, or there  may  be given in addition,  malted milk, beef  tea,
 chicken soup, mutton broth, later rice  and barley, still later crumbs
 of  bread, or zwieback or egg at  first  diluted as before  directed.
 Aside from the  specific diseases which require special treatment, all
 irritating ingesta must be first removed.  The remedy which best
 secures this effect in either  childhood or age is calomel.  Calomel
 purifies as it evacuates.  It still merits all the praise which has been
 expended upon it in the treatment of these conditions, and has not yet
 found a substitute.  It is a remedy which  can  be  given with great
 impunity in childhood and age, though with  some reserve in contin-
 ued administration in adult life.   It may be given alone or combined
 with chalk.  Favorite prescriptions are calomel, bismuth, and soda ;
 calomel, ipecac,  and soda; calomel, salol, bismuth, etc. Luff declares
 that the biniodide of mercury, in a dose of  one milligramme every
 three to five hours, cures eighty per cent of cases of summer diarrhoea.
    Catarrh of the duodenum usually calls for laxatives, at the head
 of which, in this case, stands Carlsbad salts, of which there may be
 taken a teaspoonful in a glass of hot water two or three times a day
 before meals.   Frequent libations  of any  alkaline  mineral water,
 Congress water, Vichy water, are of value.
    In catarrh of the  small  intestine address must be made to the
 pain,  and in this regard no remedy equals opium.  Opium stops the
 peristalsis and obtunds the hypersesthesia of the sensitive nerves.   A
 fine old combination  is that which contains also diluted  nitric or
 hydrochloric acid with a little camphor:
   R Tincturae opii............................................gtt. xl.-lx.
     Acidi hydrochlorici diluti.................................gtt. xl.
     Aquae camphorae...................................ad \ iv.
  M\  y. A tea- to a tablespoonful every two to four hours.
    Broken doses of bismuth gr. v.-xv. alone, or in combination with
salol gr.  iij.-v.,  or salicylate  of soda gr. v.-x.,  or with a grain or a
fraction of a grain of ipecac, or with one to  three grains of  Dover's
powder,  make nice combinations for individual cases.   Infants and
individuals who are  extremely sensitive to  cold may  be protected 
INTESTINAL ULCER.
403
against attack by warmer clothing, by flannel bandages, or an extra
undergarment.  A tablespoonful of brandy for an adult, with a dose
of quinine  gr. v.-x., or Dover's powder gr. x.,  taken at night after
an exposure, to quicken the circulation and dissipate chemical poison,
will often prevent an attack.  Irrigation of the intestine is as effective
in the treatment of intestinal catarrh as in the  case of the stomach.
The fluid should be introduced in infants with a soft catheter, which,
warmed and oiled, may be carried into the bowel six to twelve inches.
The bowel  is thus thoroughly washed out once or twice a day under
careful injection, as in a case of dysentery, where the process is de-
scribed.  The fluid may be medicated, as by a few drops of creosote,
by the salicylate of soda 3 ij.-Oij., by alum 3 ss.-Oij.  Not a little
of the good accomplished with injections is due to the absorption of
water  by the drained-out bowel.  Warm  baths are especially bene-
ficial  in  the  intestinal catarrh  of infancy,  and obstinate cases of
chronic intestinal  catarrh are sometimes brought  under control by
small % i.-ij. rectal injections of acetate of lead gr. x.- 3 i.  An opium
suppository at bedtime, or a clyster of starch 3 ss., tincture of opium
gtt. x.-xv., gives comfort for the night, or repeated after each stool
checks diarrhoea.  A fraction of or a whole teaspoonful of brandy in
hot water with a little sugar is a valuable aid in childhood.  Cholera
morbus is usually cut short at once  in an adult by a subcutaneous
injection of a quarter of a grain of morphia.

                       INTESTINAL  ULCER.

   Intestinal ulcer—ulcus intestinorum, entero-helcosis {sXko?, ulcer)
—represents a solution of continuity in the wall of the intestine, affect-
ing first, as a rule, its mucous coat.   Ulcer of the intestine, like ulcer
of the stomach, its occasional congener and not infrequent associate,
is the expression of an insult  or  injury offered  to the intestinal coat
in its inner exposed surface, or the result  of a  local occlusion in the
general blood supply.  Hence ulcer of the  intestine may be a purely
local disease, or be the local  expression of a general, so-called consti-
tutional disease.   While in many cases the lines differentiating these
conditions  may not be distinctly drawn, as many so-called constitu-
tional conditions (tuberculosis, typhoid fever, etc.) are  discovered to
be, at first at least, local processes, the toxic ulcer (arsenic, mineral
acids)  may be taken as a type of the local process acting from within,
and the  syphilitic ulcer as a type of the  local process acting from
without.    At the same time it must be recognized of syphilis that an
ulcer may  result from the dissolution or breaking down of a gumma-
tous mass  anywhere in the course of the intestine, or may be the
effect of  infection by extension into the rectum  of syphilitic processes 
404
INTESTINAL ULCER.
about the genital organs, or, lastly, of direct introduction of the dis-
ease in perverted intercourse (paederasty, coitus heterotopicus).
    Ulcer of the intestine is occasionally, though  comparatively very
rarely, observed also as the result of pressure from within or without.
Such an ulcer is properly considered of traumatic or mechanical ori-
gin, as it is induced as  the direct effect of mechanical irritation or
arrest of blood supply.  Thus  dense masses  of inspissated faeces,
foreign bodies, indigestible  residue of food may fret  the  mucous
surface into a condition  of hyperaemia and later  absolute ulceration.
Undue retention, as behind a cicatricial contraction, or  an occlusion
from whatever cause  at places  where the intestinal tube normally
offers resistance  (at the ileo-csecal valve, sigmoid flexure, etc.), may
lead  to ulceration in the same way.  Schonlein has called attention
to the paralytic condition of the intestinal muscularis in age as a pre-
disposing cause of  mechanical  intestinal ulcer; and Virchow has
noticed the same condition among the insane,  whose  intense pre-
occupation leads to neglect of evacuation  of  the bowels.   Certain
intestinal parasites, more especially ascarides, are admitted as occa-
sional causes of ulceration,  and more superficial solutions of continu-
ity in the rectum have been noticed as the result of too frequent or
too careless use of enemata.
   Curling was the first to call  attention to the fact that extensive
burns of the skin are sometimes  followed by ulceration of the intes-
tines.  The ulcerative process is almost exclusively confined to the
duodenum, and is due to erosive action of the gastric juice, continued
in the intestine upon a tract or section of mucous membrane whose
blood vessels are blocked with dead blood corpuscles.  Whatever the
cause, the frequency of  its occurrence makes it  more than  a mere
coincidence.   According to  Meyer, it is observed most in women,
and shows its first symptoms in  seven to fourteen days after the ini-
tial burn.
   Aside from toxic and traumatic causes, ulcer of the intestine occurs
as the result of dysentery, typhoid  fever, and tuberculosis—diseases
mentioned in the order of frequency in the production of the process.
The ulcers of dysentery  in  the large  intestine, and  of typhoid fever
in the small intestine, assume such prominence in these affections—
having even been erroneously considered at one time as  the cause of
these maladies—that their  study belongs to the history  of these dis-
eases.  The ulcer of tuberculosis is rather an incident in the course of
this affection, and is now recognized as the occasional result of direct
infection by the  ingestion  of tuberculous milk, but, far  more fre-
quently, of the deglutition of tuberculous sputum.  As a rule the
tuberculous ulcer shows itself late in the course of pulmonary phthisis,
and is the cause of the obstinate and colliquative  diarrhoea which 
INTESTINAL ULCER.                    405
 speedily exhausts  the  patient.   Yet cases are occasionally met in
 which numerous or extensive  ulcers  occur in the intestinal  canal
 early in the history of  phthisis, before any serious damage has been
 inflicted upon the lungs.   The tuberculous ulcer affects, and for the
 most part is confined to, the same  structures which form the seat of
 disease in typhoid fever—viz., the  solitary and agminated glands of
 the ileum.  When the bacilli tuberculosis are conveyed to the intes-
 tine by means of the lymph and blood supply through the mesenteric
 vessels, the resulting ulcer takes the shape of the vascular arrange-
 ment ; that is, the long axis of  the ulcer  is at right angles  to the
 course of the tube.  Thus, if sufficiently extensive, the  ulcer may be
 circular or form a girdle or ring entirely around the tube.  With the
 tubercular ulcer or ulcers are usually found  tubercular nodules and
 plaques in the serous coat, which are visible to  the naked eye as opa-
 cities or milky deposits  beneath
 the peritoneal coat.   The  glands
 of the mesentery may be at the
 same time so much increased in
 size as to form visible or palpable
 tumors  in the  abdomen.  The
 frequency with which tuberculo-
 sis affects  the vermiform appen-
 dix calls for special notice in con-
 nection with typhlitis.  The ulcer
 of the intestine which is the re-
 sult Of a  catarrhal  process, SO- and Surgical History of War of Rebellion).
 called, belongs to the history of chronic diarrhoea and dysentery.
    The true intestinal  ulcer per se, which has its analogue in the
 stomach as the gastric ulcer, ulcus rotundum, is due to  the  same
 cause as in the stomach—viz., to arrest of circulation and erosion by
 the gastric juice.   It is a  well-established fact in physiology that
 gastric  digestion is continued—is,  indeed, mainly effected—in  the
 small intestine ; hence an arrest of circulation in the  small intestine
 is attended by the  same  result.  The  fact that this so-called peptic
 ulcer is found almost exclusively in the duodenum speaks  most em-
 phatically for this origin of the disease.   Arrest of the circulation in
 the intestinal wall may be due to embolus, which, according to the
 observations of Nothnagel and  Barenski, is  not  infrequently found
 in the branches of the duodenal artery ;  to infarction, the  condition
 so commonly encountered in pyaemia and septicsemia ; or to throm-
 botic occlusion, as seen  in amyloid  degeneration—a disease process
 which selects by preference the vessels of the  alimentary canal along
with those of the kidney and spleen.
   The duodenal resembles the gastric  ulcer in  form  as well as ori-
gin. It has the same appearance, in its recent stage at least, of hav-
Fig. 186.—Tubercular ulcer of ileum (Medical 
406
INTESTINAL ULCER.
ing been cut out with a punch, shows no inflammation, induration,
or thickening about its borders at first, and presents the same funnel
shape with terraced walls, its apex below eccentrically situated,  as
a rule, corresponding to the situation of the artery.   It is most fre-
quently found in the upper horizontal portion of the duodenum, but
is occasionally, though rarely,  seen  in the  descending portion.   In
the further course of the duodenum the  gastric juice becomes  grad-
ually neutralized, so that ulcers situated  below the orifice of the gall
ducts are very great exceptions.  In Krauss* collection of forty-
seven cases but two were found in the lower sections of the duode-
num.  The intestinal, like the gastric ulcer, is  usually found single
or alone, but occasionally two, three,  or even four ulcers  are encoun-
tered.   According to the  tables of Morot a single  ulcer is found  in
81.8 per cent of cases, two in 9.2 per cent, and three and four in 4.5
per cent each.
   Duodenal, like gastric ulcers, are attended with liability to haem-
orrhage and perforation in equal, if  not  greater,  degree.  There  is
also the same  tendency  to implication of contiguous  structures.
Stich records  a case  of perforation  of the aorta,  Eichenhorst men-
tions the formation of abnormal communication with the  gall  blad-
der, and Frerichs a thrombosis of the vena porta, in consequence  of
duodenal ulcer.   Lastly, the process of cicatrization may be followed
by the same  disasters as occur in pyloric ulcers  in consequence  of
contraction and constriction.  Thus the orifices of the pancreatic and
choledochus ducts may be narrowed or completely closed, or the
whole lumen of the duodenum obliterated, with consecutive dilata-
tion of the stomach and oesophagus, as in the case narrated  by Bier-
mer.  A very nice question in differential diagnosis, as between py-
loric carcinoma and pyloric or duodenal  ulcer, is sometimes raised in
this way.  In the vast majority of cases it is safe,  even in the ab-
sence of a palpable tumor  and without regard to the age of the pa-
tient, to decide this question in favor of  carcinoma.  Cases  of com-
plete occlusion constitute the rule in  carcinoma and the very great
exception in ulcer.
    It remains to be said that duodenal is much more rare than gas-
tric ulcer, in the ratio of one to thirty, and that, unlike gastric ulcer,
it chiefly affects males.  According to the  statistics of Krauss,  al-
ready cited, the ratio of males to females is nine to one ; according
to Trier, five to one.  It occurs in greatest frequency between the
ages of thirty and forty, diminishing with advancing age.
    Symptoms.—Ulcer of  the  intestines  announces itself by  symp-
toms which are, as a rule, much more vague and indefinite than the
same process in the stomach.  In a certain percentage  of cases the
symptoms may be entirely latent, and the cause  of a sudden death 
INTESTINAL ULCER.
407
be revealed as ulcer only on the post-mortem table.   In less severe
cases the entire symptomatology of intestinal ulcer is  grouped un-
der the term dyspepsia, no characteristic phenomena being manifest
throughout the course of the disease.
   On the other hand, a very small ulcer may give rise to the most
dangerous  symptoms—haemorrhage  and  perforative  peritonitis—
which may be even fatal in the course of a few days or hours.
   Among the symptoms  that appear with prominence in the course
of the disease is pain.  Although cases are abundantly on record
marked by the entire absence of pain, and although pain is by no
means so universally  present  as in  gastric ulcer, it occurs in  the
great majority of cases.  The pain of intestinal  ulcer  distinguishes
itself from that of gastric ulcer by being more independent of  the
character of the food or the time of taking it.  For the most part it
occurs in attacks of colic, which are  characterized at times by their
extreme severity,  long duration, and obstinacy to every means of
relief.  These attacks occur in paroxysms with complete or only in-
complete remissions, and are ascribed, as in gastric ulcer, to the ero-
sive action of the gastric juice upon exposed nerve fibres, the inter-
vals of relief corresponding to the periods of exhaustion of the nerve
centres.  At the same time, in exceptional cases, a long-continued,
localized tenderness to pressure may indicate the seat of the disease.
   Palpation may elicit, besides tenderness, points or regions of in-
duration or intumescence.   Such a condition is  more  especially en-
countered in cases of tuberculous disease,  the so-called  scrofula of
the intestine, the  tabes mesenterica of childhood.  More localized
enlargements are occasionally to be felt in the vicinity of the duode-
nal or other intestinal ulcer in consequence of  circumscribed peri-
tonitis with  its resultant  agglutinations  and adhesions.  In this
connection caution must be exercised not to confound masses of  im-
pacted faeces with tumefactions.  The history of constipation or the
administration of a light laxative will generally suffice  to  remove
this source of error.
   Anorexia is a symptom of  intestinal ulcer as a rule.  The loss of
appetite may amount to a complete  aversion  to all  food or only to
the more fatty articles  of  diet.  A curious exception  to this rule is
not infrequently seen  in  the unappeasable  hunger of children the
victims of  tuberculous ulceration.  The  contrast  offered in the ex-
treme emaciation  of these patients has  been made  the  subject of
frequent comment.
   With this loss or perversion of appetite and defective digestion of
the food the general condition soon begins to fail.  Though cases are
occasionally  met in  which a bien-etre  has  been  maintained for
years, or a  condition of obesity has been  retained, these cases form 
408
INTESTINAL ULCER.
the exception in the history of  intestinal ulcer.  More or less emaci-
ation gradually develops as a rule, and a reduction of the general
strength that is out of all proportion in its degree to the loss of flesh.
At the same time the mental condition of the patient suffers a degra-
dation to the level of the sufferer with chronic dyspepsia.
   The disturbances  of digestion which occur in intestinal ulcer pre-
sent many varieties in degree  and kind.  Some patients show none
or but few of the signs, while others run the gamut, so to speak, in
the semeiology of dyspepsia.  Heartburn, eructations, pyrosis, bor-
borygmi, flatulence, gastralgias, pseudo-anginas, nausea and vomit-
ing,  the  familiar phenomena of gastric or intestinal catarrh, attend,
at some time or other in the course of the disease, most of the cases
of intestinal ulcer.
   The condition of the discharges demands notice in  detail, more
especially as abnormalities in the evacuations belong among the few
of the more constant symptoms of the disease.
   Diarrhea is the rule in intestinal ulcer.   The discharges consist
at first of the undigested food  and the digestive juices, which have
been hurried along the alimentary canal and prematurely evacuated
on account of the increase  of peristalsis caused by the irritation in
the upper part of its tract.  The arrest of the digestive process leads
to early decomposition of the ingested matters, and thus imparts to
the discharges an exceedingly offensive odor.  While, in exceptional
cases, constipation may be present, or even obstipation of the bowels,
the discharges are usually so abundant as to constitute a diarrhoea,
which in some cases is so frequent  or  profuse as to become colliqua-
tive and  speedily exhaust the strength  of the patient.
   An ulceration situated in the  colon or rectum would furnish  the
discharges characteristic of  dysentery, while the same process in the
ileum would show the evacuations  characteristic of typhoid fever or
tuberculosis.
   The most characteristic  ingredient of the true duodenal ulcer is
blood.  Ulcer of the intestine constitutes the most frequent source of
hsemorrhage of the bowels, which is  sometimes so grave as to take
life in the course of a few days or hours.  The blood from an intesti-
nal ulcer may be evacuated both by the mouth and the anus, or may
be retained in the alimentary canal and not appear at all.  Such cases
constitute the condition known and described under the heading of
occult or concealed hemorrhage,  which is recognized  by the rapid
general collapse of  the patient.  When the blood  issues from a duo-
denal  ulcer it is intimately commingled  with the contents of  the
alimentary canal.   The discharges in such  cases are usually black.
tarry, and  more  or less fluid; whereas blood  from the colon or
rectum still preserves its fresh red color and is discharged separate 
INTESTINAL ULCER.
409
 from the faeces or simply coats the exterior.   Occasionally cases are
 met where the blood coagulates in the interior of the intestinal canal
 to form a cast of its lumen or to  accumulate in great mass in the
 sigmoid flexure  or  rectum.  In one case in the experience of the
 author such an  accumulation was the cause of a very severe tenes-
 mus, which was only relieved by the digital evacuation of large
 masses of inspissated, coagulated blood.
    The presence of pus would indicate lesion of the colon, as typically
 shown  in dysentery; for suppuration, at least with  any visible pro-
 ducts, does not occur in ulcer of the duodenum.
    Duration —Ulcer of the intestine has no definite duration.  As
 in the case of its  prototype, gastric ulcer, it may speedily be  covered
 with cicatricial tissue and never appear again in the course of a long
 life.  But such a course is as unusual as in gastric ulcer.  Frequent
 recurrence constitutes the rule in intestinal ulcer, or a partial recov-
 ery with frequent relapse, as in the course of ulcer of the stomach.
 So ulcer of the intestine is not infrequently a lifetime malady, with
 exacerbations and remissions dependent largely upon the prudence or
 imprudence of the patient with regard  to diet.  It need  hardly be
 stated that ulcer of  the intestine may terminate  fatally, even in the
 course  of a few days,  from  hsemorrhage, circumscribed and, later,
 diffuse  peritonitis, or may drag out a slow length of years to finally
 destroy the patient with the general symptoms of inanition, hydrops,
 and marasmus.
    Diagnosis.—From what has been said it is plain that ulcer of the
 intestine is often entirely overlooked or may be  readily confounded
 with other maladies of the  digestive tract.  Cases  of  traumatic or
 toxic origin are  generally readily recognized by the history of  the
 patient, and tuberculosis may reveal itself by the youth of the indi-
 vidual, the existence of the disease elsewhere, the gradual emaciation,
 the premature senescence—in short, the general signs of the phthisi-
 cal habitus, the  meteorism, and  perhaps  the  presence of nodular
 enlargements of the mesenteric glands.   A still  doubtful case may
 be cleared up with tuberculin.
   The most characteristic symptom of the peptic ulcer is, as stated,
 hsemorrhage.  But haemorrhage is present in only the minority of
 cases, is, as a rule, occasional and transitory, and is at all times dif-
 ficult of differentiation as to its source.   Blood from a gastric ulcer
 may also be voided per rectum as well as per os, and the blood from
 a  duodenal ulcer after regurgitation may be  wholly discharged by
 vomiting.  The absence of  vomiting, and the presence—more  es-
pecially the persistence—of tarry evacuations from the bowels, would
speak for ulcer of the intestine.  Dilatation of the duodenum, a con-
dition of ectasia, closure of  the bile duct with consecutive jaundice, 
410
INTESTINAL ULCER.
or the presence of fatty stools from occlusion of the pancreatic duct
(a sign not now regarded of the same value as in the days of Bright)
would also declare in favor of ulcer of the duodenum.  As between
intestinal ulcer and catarrh or intestinal ulcer and carcinoma, pre-
cisely the same rules would hold as in the case of the stomach.  A
simple enteralgia would be  recognized by its more frequent occur-
rence among females or individuals of neurotic temperament;  by its
connection with faults  of  diet,  malaria, or exposure to cold ;  by the
absence of hsemorrhage, diarrhoea, or peritonitis.
   Prognosis.—Too  much caution cannot be exercised in the prog-
nosis of ulcer of the intestine ; for in even the cases which run a per-
fectly mild course the gravest, even fatal, accidents are liable to occur.
The danger of perforation, in cases of typhoid fever, from a single or
from one of  the  few ulcers  that  may be present imparts one of the
chief elements of gravity in  this disease ;  and the same catastrophe1
may occur at any time in dysentery or tuberculosis.  The duodenal
ulcer may likewise have a sudden gravity imparted to a mild cast.1
by a  copious hsemorrhage or a  peritonitis; and even though the pa-
tient  escape  all possible complications, though he  recover with the
surface of the ulcer  healed  so  that the loss of  substance is filled in
with firm cicatricial tissue, the danger of contraction or stenosis still
remains.  The ulcers of dysentery in the  colon and of syphilis in the
rectum  are especially liable  to be followed  by deformities of this
kind, while the tuberculous ulcer in the ileum not  infrequently  re-
sults in a more or less complete  stenosis.   The ulcer of typhoid fever
in its cicatrization almost never reduces the size of the intestinal
canal.
   Treatment.—The most valuable therapeutic means of relieving
the pain and obviating  the dangers of ulcer of the intestine consist in
the regulation of the diet.  The food should be light, easily digesti-
ble, and during the acute stages of the disease as nearly fluid in  its
consistence as  may be.   Milk would be the staple article of diet in
all cases, were it not  for the fact that in some cases constipation  at-
tends its too exclusive use.  The various soups, without solids, malted
milk in hot water, starch (sago,  arrowroot,  tapioca, etc.), may suf-
ficiently nourish the patient until the healing  process  shall have
commenced.   Raw beef chopped up and made into an emulsion is
perhaps the most nutritious and least injurious of any kind of food.
Bread, potatoes and other vegetables, should be ruled out altogether,
because of their liability to produce masses of faeces whose inspissa-
tion may do mechanical damage to ulcers in process of cicatrization.
   Where there is failure in the general strength early resort should
be had to alcohol,  which may be administered in the form of red
wine (in preference to white, because of the tannin it contains), wine 
INTESTINAL ULCER.
411
 whey, or, in more serious prostration, of sherry wine, milk punch,
 egg-nog made with good whiskey or brandy.
    In the worst cases, where all food irritates, feeding at the mouth
 may be abandoned altogether for a time, and the strength of the
 patient sustained by nutritive enemata of  beef or  pancreatic emul-
 sion.  Ewald uses as an enema two eggs beaten  up with a table-
 spoonful of cold water, to which are added a little starch boiled with
 a half-teacupful of a twenty-per-cent solution of glucose, and a wine-
 glassful of claret wine.  All enemata should be introduced warm,
 and by means of a long, soft, well-oiled rectal tube, as high up in the
 bowel as may be.  Roberts nourished a patient with occluded oesopha-
 gus nine weeks  with pancreatized milk, and Donkin supported ten
 cases of gastric ulcer with enemata of plain milk occasionally varied
 by clysters of beef tea, three of them for nineteen days (Stewart).
    The diarrhoea should be controlled rather than entirely checked,
 for fear of the greater  evil of constipation.  A little bismuth with
 bicarbonate of sodium or oxide of  zinc gr. v. may suffice for the
 milder cases, while in the more aggravated cases resort must be had
 sooner or later to opium.
    Constipation is best relieved by careful  injections of warm water
 or by the  administration of the lighter laxatives—mineral  waters,
 seidlitz powders,  Carlsbad salts, citrate of magnesia, castor oil, etc.
    Vomiting is  combated by ice, soda water, cherry-laurel water,
 chloral with peppermint water, and, in graver  cases,  by morphia
 hypodermatically.
    Pain may be relieved by applications of hot water,  cataplasms,
 injections  of hot water,  and, when  necessary, by morphia  with  or
 without belladonna.
    Hsemorrhage  is checked by ice internally and.externally,  turpen-
 tine, ergot or preferably ergotin or sclerotinic acid by subcutaneous in-
 jection, and opium. Transfusion, or preferably the subcutaneous intro-
 duction of salt water (4-6  :1000, introduced by two needles under mas-
 sage), as in cholera, offers hope of rescue from death by loss of blood.
   Patients the victims of intestinal (or  gastric) ulcer must maintain
 a guarded  diet for months, often for  years, after all signs of  the dis-
 ease shall  have disappeared, as the best prophylaxis against recur-
 rence.  Constant vigilance is also required to avoid constipation, and
 the greatest temperance exercised with regard to the  use of  alcohol.
 Sometimes a course of mineral waters, a sea voyage, or other change
 of life or scene constitutes the best means of avoiding frequent  relapse.
   It need hardly be said that an ulcer in the rectum, which is readily
 recognized by its  attending tenesmus, calls for local treatment; and it
is  equally plain that  tuberculosis or  syphilis demands  appropriate
address. 
412              HEMORRHAGE OF  THE BOWELS.
                 HEMORRHAGE  OF THE BOWELS.
    General Remarks.—Hsemorrhage of the bowels occurs  in both
sexes, though more frequently in the male, and  at  all ages, though
more frequently at the middle period of life.   In the infant a form
of it is sometimes considered as a distinct affection under the head of
melsena neonatorum, and in age it sometimes shows itself as a distinct
sign of a disease characteristic of age—namely, cancer.   According
to the tables of Bamberger it is caused, in the order  of frequency, by
dysentery, typhus fever, cancer  (of the colon),  mechanical injury,
poisons and foreign bodies,  ulceration  (tubercular, follicular), the
round ulcer of the duodenum, and aneurism ; last and least frequent
is the so-called vicarious hsemorrhage.
    Etiology.—Haemorrhage from the intestinal canal arises from (1)
anomalies in the contents of  the bowel, (2) disease of the wall of the
bowel, and (3) from  general diseases.
    1. The inspissation of the natural contents  of the bowel during
long-standing or habitual  constipation may convert the faeces  into
dense masses,  which irritate and scratch  the mucous membrane, and
thus induce haemorrhage directly by simple solution of continuity, or
indirectly as the result of extreme hyperaemia.  Such hsemorrhage is
nearly always slight, streaking or coating the surf ace of the scybalous
mass, or being extruded from the anus  as  a small  deposit of blood
during the last act  of defecation ; in which latter  case it  is found
mostly associated with  haemorrhoids or fissure of the anus.  Inde-
pendent of these conditions, this haemorrhage usually has its origin in
the lowest region of the large intestine, where condensation of the
fa?ces is naturally greatest.
    Foreign bodies in the intestinal canal descended from the stomach
may also be the cause of hsemorrhage in the same way.  Thus, stones
of fruits, bones of fish, fragments of oyster shell, or other substances
in no way connected with aliment (false teeth,  buttons,  pins  and
needles,  etc.),  may  be swallowed accidentally or purposely (as by
children  or the insane) to  produce intestinal haemorrhage.   Drastic
cathartics (podophyllin, gamboge, etc.) and poisons (arsenic, mineral
acids) occasionally act in the same way.  Tardieu reports the case of
a servant to whom was administered, by a charlatan, veratrum with
coffee, with fatal effect in six days.  At the autopsy,  made by Amus-
sat and Reymond, the stomach and small intestine were found filled
with a dark-brown or black,  bloody fluid, but there  was no trace of
perforation, ulceration, or organic disease.
   Under this head mention should be made also of certain parasites
whose habitat is the  intestinal canal, the walls of which they perfo-
rate.  Two varieties, the Anchylostoma  duodenale and the Distoma
hepaticum, are frequent causes of haemorrhage—the former from the 
HEMORRHAGE  OF THE BOWELS.
413
 duodenum and jejunum, the latter from the rectum—in hot climates,
 more especially in India and Egypt.
   2. Anomalies in the intestinal walls produce haemorrhage as the
 result of intense hyperaemia (per diapedesin) or of actual loss of sub-
 stance (per rhexin).   Copious,  even fatal, hsemorrhage has thus en-
 sued from dysenteric and typhoid processes (and even without  dis-
 coverable cause) where no ulceration  or  loss of  substance could be
 discovered on autopsy ; and this accident is  so frequent as the result
 of ulceration in the disease mentioned as to constitute a characteristic
 sign or complication.   It must  be said, however, that cases of alarm-
 ing or fatal hsemorrhage,  without apparent cause  during life or lesion
 after death, were more frequently reported in the literature of the times
 preceding our more accurate knowledge of pathology and pathogeny.
 Few clinicians or pathologists would now be content with reports
 made without  full knowledge  of the history of  the case  or micro-
 scopic examination of the intestinal walls.   Thus, the report before
 the  Societe medicale d'Emulation, April 2d, 1834,  by Dubois, of a
 young man who quickly died of intestinal hsemorrhage five days after
 a severe headache, and on the same occasion, by Guillemot, of several
 similar cases, would awaken the suspicion of masked typhoid fever ;
 and the case of an old man aged seventy-four who died of intestinal
 hsemorrhage after four days' diarrhoea, reported by Husson, would call
 for a close examination of the vessels in the intestinal walls.   In fact,
 Bricheteau, who reported a case from the Hopital Neckar, was able
 on autopsy to discover a rupture in a small artery of the intestines.
   Embolic processes leading to the formation of ulceration (by pre-
 dilection in the duodenum) are often attended with intestinal  hsem-
 orrhage, which would be more constantly present were it not for the
 fact that, as in the stomach,  the speedy establishment of  collateral
 circulation prevents  the consequences of complete infarction.
   Besides dysentery and typhoid fever, tuberculosis and syphilis are
 occasional causes of  ulceration and necrosis of the intestinal walls
 which may be  attended with hsemorrhage.   Cancer of the  intestine
 most frequently affects the rectum, but wherever situated may show
 hsemorrhage as one of its signs.
   The local hyperplasia of  the mucous  tissue which constitutes a
 polypus,  and which in children^ in whom it most frequently occurs,
 is mostly situated in  the rectum, is suspected to exist or is recog-
 nized by the frequent discharge of blood from the bowels.  A far
 more grave affection  of the intestinal walls, likewise most  frequent
 in childhood, is the peculiar dislocation known as intussusception or
 invagination.   This  condition  is so commonly  attended  with dis-
 tressing evacuations of blood and mucus as to simulate dysentery.
 The strangulation of the intussuscepted mesentery  with its vessels
easily accounts for the hsemorrhage in such cases. 
414
HEMORRHAGE OF THE BOWELS.
    A more extensive compression is exercised at times by tumors in
the abdominal cavity, as by pregnancy,  ovarian growths, ote\; oc-
clusions in the course of the portal system (cirrhosis  hepatis); inter-
ference with the general circulation,  as  in disease1 of the heart or
lungs, with intestinal haemorrhage as a consequence.
    Diseases of the blood vessels themselves,  as amyloid degenera-
tion, aneurism, should not be omitted from the list of factors possi-
bly productive of this result.
    3.  The general diseases attended with hsemorrhage from the bowel
are characterized for the most part by more or less general disinte-
gration or dissolution of the blood, with  the  manifestation of hsem-
orrhage in various parts of the body, kidneys, uterus, subcutaneous
tissue, etc., the enterorrhagia being an accidental localization, so to
speak, of  the effusion.  The most prolific causes of this disorganiza-
tion are the micro-organisms, which "touch the life of the blood
corruptibly*'; and hence the various acute infectious diseases may
show in the severer forms hsemorrhage from the bowels.   Under this
head  may be  ranged variola, which boasts even of a haemorrhagic
form ; typhus, yellow,  and malarial fevers ; the forms  of  nephritis
marked by uraemia ; cholera, icterus gravis, erysipelas,  etc.  Disin-
tegration  of the  blood or  partial dissolution  of  its corpuscular ele-
ments occurs also in  those obscure affections which constitute the
group, or  are included in the description, of the haemorrhagic diathe-
ses, as haemophilia, leukaemia, pernicious anaemia,  scurvy, of any of
which enterorrhagia may be a distinct or dangerous sign.
   Melsena neonatorum is the distinct name given  to a hsemorrhage
from  the  bowels  which  occurs a few hours or  days after birth, and
which is often so profuse as to  cause death at once or  in a short
time.   In most cases  no anatomical lesions  can be discovered after
death, save an intense hyperaemia of the intestinal mucosa, so that
the etiology of this affection is involved  in obscurity.  The  various
causes assigned in its production—ulceration of the stomach or duo-
denum (Bohn), embolism (Landau),  fatty  degeneration (Steiner),
premature ligature of the umbilical cord (Kiwisch)—answer only for
individual cases.   Betz  reports a case in a family subject to haemo-
philia, and Trousseau once saw twins thus affected; but that hered-
ity cannot account for all cases  is shown by the  fact that it  occurs
mostly in healthy children from  healthy parentage.   Klebs  is in-
clined to attribute the affection to the  action of micro-organisms, in-
troduced  perhaps as the result of puerperal infection; but this cause
can be assumed in only a  small minority of  cases—at  least but a
small percentage of cases coincide with puerperal disease on the part
of the mother.
   The affection is fortunately rare.   Eichhorst states that Hecker 
                  HEMORRHAGE OF THE BOWELS.             415

 observed it but once in five hundred births and  Gemich but once in
 one thousand births. According to Rilliet the hsemorrhage is oftener
 (eight-fourteenths)  intestinal, rarer (four-fourteenths) gastric, and
 rarest (two-fourteenths) both.  It is almost always  abundant and
 quickly repeated, the blood being mostly pure, in clots or masses and
 fluid, though it is sometimes commingled with  meconium.  It usu-
 ally ceases within twenty-four hours,  though it may  continue for
 three, five, or more  days.  Of twenty-three cases reported by this
 author twelve recovered and eleven died.
    Morbid Anatomy.—Haemorrhage from  the bowels,  being only a
 symptom of very many different conditions, is marked  by lesions
 characteristic of the condition in an  individual  case.   These lesions
 are more appropriately  described in connection with the various dis-
 eases.  Not infrequently in these cases the intestine is distinguished
 by the absence of any lesion at all.   But, from whatever cause, haem-
 orrhage from the  bowels,  like haemorrhage from any other source,
 shows a more or less profound anaemia of all the  internal organs, and
 in more chronic and protracted cases leads to fatty degeneration,
 more especially of the heart.
    Symptomatology.—Hsemorrhage from  the  bowels is usually
 readily recognized by the discharge of  blood, either pure or mixed
 with the natural contents of  the alimentary canal.  The actual seat
 of the hsemorrhage  may, however, only rarely be recognized by the
 rectal speculum.   The colicky pains, borborygmi, or sensations of
 fluids in the abdomen which are occasionally experienced may not be
 relied upon in fixing the  seat of the effusion.  Should the haemor-
 rhage occur in quantity, or, more especially, should the seat of the
 effusion be low in the  intestinal canal, the blood which escapes is
 more or less pure.  When the haemorrhage is  higher, or when the
 stay of the blood in the bowel is  longer, it becomes more  or less in-
 corporated with the contents of  the bowels  or altered by the intesti-
 nal juices, to present a discharge of mushy or semi-fluid consistence,
 of dark-brown or black color.   So-called tarry stools are thus largely
 composed of blood.
   But  serious, even fatal, hsemorrhage sometimes occurs without
 the escape of any blood at  all.  Such are  the so-called cases of  con-
 cealed,  occult, or internal hemorrhage, in which the nature of the
 malady is  only  suspected  or  recognized by the general  symptoms
 attending the profuse loss of blood.  Should  the hsemorrhage be
 gradual, anaemia slowly supervenes, with  hydraemia and subcutane-
 ous dropsy.  Traube reported a  fatal  case of cedema of the glottis
 from such a cause.  Sudden hsemorrhage announces itself by pallor
 and prostration, dyspnea, vertigo, and syncope.  Amaurosis, tin-
nitus aurium, formication, emesis, and, if the disease be high up in 
416
HEMORRHAGE  OF THE  BOWELS.
 the intestinal  canal, hsematemesis. are1 the common attendants of
 serious hsemorrhage.   In the worst cases of sudden effusion the pa-
 tient may present the appearance of complete collapse, and the in-
 testinal canal be found on autopsy distended with blood throughout
 a great part of its course, while no blood whatever has escaped from
 the rectum.  In such a case, or with more gradual loss of  blood, the
 patient experiences a sense of increasing weakness; the skin becomes
 cold, is bedewed with a clammy sweat; the pulse grows feebler, and
 death from exhaustion more or less speedily ensues.
    Diagnosis.—The presence  of blood in any quantity in  the stools
 is readily recognized by its  coarser characteristics.  Ridiculous er-
 rors  have been made by mistaking the coloration produced by bis-
 muth, iron, logwood, etc.,  administered internally, or by coloring
 matters  introduced  into the discharges for purpose of  deception.
 The  microscope,  Teichmanhs test for blood crystals, and in  ex-
 tremely doubtful or medico-legal cases the spectroscope, furnish easy
 means of detecting blood in whatever quantity or character.
  ,  It is the cause and seat, rather than the existence, of the haemor-
 rhage that  mostly produce embarrassment in differential diagnosis.
 Haemorrhage from the lungs, nose, or  stomach is usually readily ex-
 cluded by the absence of any evidence  of disease of these organs, and
 the presence of  the other symptoms of any general disease attended
 with enterorrhagia makes a  diagnosis in most cases easy enough.
 Alterations in the contents  of the bowel, the  presence of  foreign
 bodies, are recognized by the history of the case and by careful local
examination, while a diagnosis of anomalies in the walls of  the bowel
 is usually reached by exclusion.   In no doubtful case should local
 inspection or digital examination of the anus and rectum be omitted.
    Treatment.—As in all cases of haemorrhage, the first requisite is
 absolute rest.  The  patient should at once be put to bed and kept
 perfectly  quiet.  Many a case of haemorrhage  in typhoid fever is
 produced  by arising from  bed to  go to stool. The  bedpan  is an ab-
 solute necessity in the management of a case of typhoid fever after
 the second week of the disease.  Rest is the chief element in prophy-
 laxis as well as therapy.
   The  most  effective  styptic  in  enterorrhagia  is  cold.  An  ice
bladder should be laid upon or suspended immediately above the
abdomen  during the whole  duration of the flow.   The injection of
ice water  into the bowel should be practised only in cases where the
hsemorrhage is believed  to  come from  the colon, otherwise the
peristalsis it awakens may only aggravate the danger.  Should rest
and cold fail to quickly check the hsemorrhage, resort should be  had
at once to ergot.  This remedy, in the form of  ergotin or sclero-
tinic acid, is most effective when introduced beneath the  skin.   In 
     TYPHLITIS, PERITYPHLITIS, PARATYPHLITIS, APPENDICITIS. 417

 cases of less imminent danger the practitioner may be content to give
 the remedy by the mouth.
    Small  doses of the simple or camphorated tincture of opium fre-
 quently repeated speedily arrest contractions of the bowel and at the
 same time feed the brain in threatening syncope.   The astringents
 proper—tannic acid or its preparations, acetate of lead, alum, the per-
 chloride of iron—are seldom necessary or advisable, but may be called
 for in obstinate or protracted cases.
    To turpentine have been ascribed from time immemorial specific
 virtues in relief of hsemorrhage of the bowels, and its administration
 is  still a  routine system with  many older practitioners.   It is most
 effective in large doses—one drachm, with milk or in emulsion, every
 hour or two until the haemorrhage ceases.
    In relief of collapse, alcohol, ether, camphor, and musk are im-
 peratively indicated, with the external application of heat; and in the
 treatment of the anaemia and hydraemia, the  preparations of iron,
 including  later the mineral waters which contain it.   In the worst
 cases of sudden, alarming haemorrhage the physician should not fail
 to practise the transfusion of blood,  or preferably hypodermato-clysis
 with solutions of salt water.
    Milk, including malted milk, is the best food and drink during the
 attack, and after it for some days or weeks.  Chopped or scraped raw
 beef may  substitute it  later, while all farinaceous foods are to  be
 strictly avoided for some time.

    TYPHLITIS, PERITYPHLITIS, PARATYPHLITIS, APPENDICITIS.
    History.—Typhlitis {xvtpXoZ, blind)—inflammation of or about
 the head of the colon, more especially the vermiform  process—is a
 disease of modern recognition.  Individual cases have been reported
 as  curiosities where foreign bodies  or faecal accumulations  had ex-
 cited inflammation in this part of  the intestine, but it is undoubtedly
 to Dupuytren that the credit is due of having first individualized this
 disease as a separate affection.  About the same time, 1827, Longer
 Villermay published his communications on the diseases of  the ver-
 miform process, to be followed in the same year by Melier and Hussar
 and Dance with observations on inflammation of the connective tis-
 sue in the region of the caecum.  These affections, which had been
 hitherto described as inflammatory tumors in the right iliac region,
 now received from Puchelt the distinct name perityphlitis.
   Perhaps the most remarkable events in the history of these affec-
 tions since this time are the contributions of  Stokes and Petrequin
 (1837)  on  the value of opium in the treatment of perforation of the
 vermiform  appendix;  of Albers, who first distinguished the special
form of typhlitis stercoralis; and of Oppolzer (1858-64),who set apart,
        27 
418 TYPHLITIS, PERITYPHLITIS, PARATYPHLITIS, APPENDICITIS.

perhaps  as  an unnecessary refinement in differential diagnosis,  a
paratyphlitis, an  inflammation of the post-caecal connective tissue.
Matterstock (1880) deserves especial mention for having given such
prominence to anomalies of the vermiform appendix in the etiology
of the affection ;  and Kraussold (1881) has connected  his name with
the therapy of  the disease  by the boldness with which he expresses
his convictions regarding the necessity of early evacuation, by inci-
sion, of inflammatory products, as first practised by Willard Parker
in 1843.  The affection is more common or has been more frequently
reported  in the United States than in foreign countries, and has boon
thoroughly treated by American authors, especially by Fitz (Trans-
actions of the Association of American Physicians, 1886).
   General Remarks.—Typhlitis, strictly speaking, is limited to af-
fections  of the csecum  and its appendix vermiformis ; perityphlitis
implies an extension of inflammation  to  the peritoneal envelope of
these organs ; while  paratyphlitis  signifies  an involvement of the
extraperitoneal and post-caecal  connective tissues.   Both perityph-
litis and  paratyphlitis are therefore secondary processes, though they
may, in  exceptional cases, arise from affections of organs other than
the caecum, as  from perinephritis,  psoitis, vertebral caries, or  as an
expression of metastatic processes in pyaemia, septicsemia  (puerpe-
ral fever), typhoid fever, etc.
   Etiology.—Typhlitis and its allied affections or complications
show especial predilection for the male sex and the period of adoles-
cence.  Nearly three-fourths (seven hundred and thirty-three)  of the
whole number (one thousand and thirty) of cases of perityphlitis col-
lected from the literature by Matterstock were males, and this pro-
portion holds good in infancy and early youth  as well as in adoles-
cence.  The greatest number of cases, thirty-three per cent,  occur at
the ages of twenty-one to thirty ; next, thirty per cent, at eleven to
twenty ;  while the ratio gradually decreases toward both extremes of
life.   So the opinion is expressed  with singular unanimity by all
authors that these diseases pre-eminently affect the bloom of life.
   The observation that typhlitis has so often been  found to arise
from disease of the vermiform process has led to a closer study of its
anatomical relations,  and developed the fact that this organ is sub-
ject to great variation in size, shape, and situation.
   Normally the  appendix  vermiformis arises from the posterior
interior aspect of the caecum as a tube  of  the diameter of a goose
quill and a length of three to six inches, with a general direction up-
ward and inward behind the csecum.  It is commonly provided with
a small mesentery, which retains it in its place.   Its cavity communi-
cates with the  cavity of the csecum by a small orifice which  is at
times guarded by a valvular fold of mucous membrane, while its free 
   TYPHLITIS, PERITYPHLITIS, PARATYPHLITIS, APPENDICITIS. 419

closed  end terminates abruptly in  a blunt point.  It is commonly
found filled with mucus throughout its entire length.   The existence
of this superfluous structure, which is found only in man and certain
of the  higher apes, has given rise  to much  speculation among the
anatomists and physiologists, especially of  the teleological school, as
to its possible use.   It is now, however, the generally acknowledged
opinion that the appendix vermiformis is a relic or rudiment of a sub-
sidiary stomach in lower forms of life.  The head of the large intes-
tine, which forms almost an additional stomach in the gramnivora, is
very much reduced in the  carnivora, whose food contains but little
indigestible matter, and is greatly reduced in the omnivora,  as in
man.   The vermiform appendix is the shrivelled remnant of the great
csecal receptaculum of the lower animals.  In the orang it is still a
        Fig. 187.—Typhlitis.  Ulceration of the vermiform appendix (Kraussold).

 long, convoluted tube, but in man it is reduced, as stated, to the size
 of a quill three or four inches in length, and is often entirely absent.
   Kraussold,  who  complains that the vermiform process  has  hith-
 erto received only stepmotherly treatment at the hands of anato-
 mists and clinicians, undertook a series of investigations which  went
 to show how often and what extreme  anomalies do occur.   In  some
 cases the appendix was disposed in an  exactly opposite to the normal
 direction,  its blind end being  turned upward along the  ascending
 colon.  In one case it was found wound about the ileum ; in an-
 other, spirally turned at its end and lightly adherent to a hernial sac.
 Sometimes it was abnormally long  or short, open or closed with a
 valve, cylindrical, saccular, or bulbed, fixed or free, curved or bent
 upon itself at a sharp angle, provided with a short  mesentery, and
sometimes, as stated, it was entirely absent. 
420  TYPHLITIS, PERITYPHLITIS, PARATYPHLITIS, APPENDICITIS.

   But by far the most interesting point connected with this organ
was the frequency with which it was found the seat of ulceration or
stricture from cicatrization  somewhere in its  course, the result of
dysentery, typhoid fever, syphilis, and more especially of tubercu-
losis.  Clinicians who  have  been struck  with the frequency with
which typhlitis has occurred in tuberculous subjects find in this dis-
covery a satisfactory explanation of this remarkable coincidence.
   Normally the vermiform appendix is found filled, as stated, with
a tough, vitreous mucus, but not infrequently masses of faeces, for-
eign bodies, intestinal worms, etc., find their way into it, where they
remain innocuous or may excite  a dangerous inflammation.  This
fact, in connection with  the general uselessness or superfluousness of
this structure, has led pathologists to distinguish the vermiform pro-
cess with the significant appellation of a death-trap.
   Two anatomical factors deserve especial emphasis  in explanation
of the frequent origin of disease in the vermiform appendix.   One is
the existence of the valvular fold of  mucous membrane,  already
mentioned, at or near the orifice of the tube  in the caecum, the clini-
cal importance of which was first pointed out by Gerlach.  This fold
is most marked between the ages of three and  twelve, and when
pronounced narrows  the orifice to one-half or one-third of the whole
calibre of the tube.   As a rule this fold and the consequent diminu-
tion in the size of  the orifice are but little marked in the first years
of life and in old age, which accounts for the relative infrequency of
typhlitis at these periods of life.
   The second mechanical factor is the deformity caused by the  ab-
normal anatomical position of the organ, either as a  congenital  de-
fect or as a pathological change.  Matterstock  quotes from  Zungel,
who observed, in fifty-nine cases in the Hamburg Hospital, whole or
partial obliteration thirty times, catarrh and old  fsecal concretions
forty-three times, abnormal adhesions twelve times, and actual ulce
ration (without perforation) eleven times.  Toft claims as the result
of three hundred personal investigations that every third person  be-
tween the ages of  twenty and seventy showed the traces of present
or past inflammation, and that  actual  ulceration existed in  five  per
cent of all bodies  examined.   Kraussold declares  that  this percent-
age is rather too  low than too high, and adds that  among his pa-
tients—who were, it  should be stated,  mostly  phthisical—it was re-
markable how extraordinarily often the whole  vermiform appendix
was the seat of an  encroaching  ulcer.  In a number of cases cica-
trices  or  cicatricial  alterations were found where typhoid fever or
dysentery had existed in the previous history.
   Attention should at  least be called  to a last anatomical factor in
explanation of the frequency of ulceration and  inflammation of this 
    TYPHLITIS, PERITYPHLITIS, PARATYPHLITIS, APPENDICITIS. 421

 structure, in that its walls are so  sparsely endowed with  muscular
 tissue as to render it unable to empty itself of bacteria or organisms
 of disease  which enter it from the comparatively stagnant  reser-
 voir, the csecum.
   Constipation is usually invoked as a cardinal factor in  the gene-
 sis of typhlitis  (typhlitis stercoralis).   Speck calls attention to the
 frequency  of the disease in East  Siberia, where the food,  mostly
 vegetable, contains a large amount of indigestible residue.  But that
 this condition  cannot sufficiently account for the disease in  most
 cases is proved by the fact that constipation is more frequent in ad-
 vanced life and among females, in whom  typhlitis with its associate
 lesions is more infrequent.  For the same reason a sedentary mode
 of life loses  force as an  argument in  its production.  Perhaps the
 most efficient cause of the condition is  a local paresis of  the muscu-
 lar tissue of the csecum,  produced by the irritation of intestinal ca-
 tarrh, of disease products, of  a fsecal  concretion or a foreign body
 —an irritation which  may induce first  a spasmodic action, and sub-
 sequently, as a result, a  partial paralysis or  a  paresis.  The  same
 condition may be brought about more  directly by the presence of a
 centre of irritation—viz.,  by reflex inhibition or innervation.  Accu-
 mulation and impaction of faeces must then necessarily ensue, and it
 is highly probable that this accumulation occurs in  this way as a
 result more  frequently than as a cause of the condition.  For the
 symptoms of a simple accumulation of faeces (coprostasis)  are never
 so severe, at  least at the start, as to mark the  onset of a genuine
 typhlitis.   Nor is  there  anything  in healthy fseces to  induce the
 signs of a severe blood poisoning, which so commonly announces the
 advent or course of typhlitis.
   The  role of pure mechanical causes cannot be ignored or  under-
 rated in true typhlitis, understanding by this  term processes which
 commence in the vermiform appendix.  For it is the rule to discover
 in the vermiform appendix in  these cases either fsecal concretions or
 foreign bodies.  Hackel and Buhl found concretions of meconium in
 a new-born child ;  and faecal concretions, intestinal  stones, are far
 more frequently encountered than foreign bodies.  In one hundred
 and  forty-six accurately  observed  adult  cases recorded  by Matter-
 stock, faecal  concretions were  met  with sixty-three  times, foreign
 bodies nine times, while in  the other cases nothing could be discov-
 ered ; and  in  forty-nine  cases among children fsecal  concretions
 were discovered twenty-seven times, foreign bodies three times, and
 nothing abnormal in the remaining cases.   Not infrequently a small
 foreign  body acts as a centre of crystallization for fseces, which be-
 come superimposed in successive layers.   Hairs, as of the  beard,
sometimes officiate in  this way. Among  other  foreign  bodies met 
422  TYPHLITIS. PERITYPHLITIS. PARATYPHLITIS, APPENDICITIS.

with in  fatal cases of perforation, independently of fares, may be
mentioned round worms  (Faber), cherry stones (Paterson), needles
(Payne), fish bones (Ziingel), gall stones (Hallete1), a mass of asea-
rides (Klebs), buttons (Gerhardt), etc., etc.   As  already intimated,
supposed foreign bodies are often found on examination to be nothing
else  than intestinal concretions.  As  to cherry stones, which are so
often accused of producing  typhlitis, Biermer and Bossard found it
difficult or impossible to force them into the vermiform process.
   Symptoms.—Typhlitis announces itself in two ways, suddenly
and  insidiously.  In adults the disease begins, as a rule, with violent
signs ; in children there is often a prodromatous stage, which may
last  for days or for months before a positive  diagnosis can be estab-
lished.   There are in these cases anorexia and vomiting, constipation
and  diarrhoea, colicky pains, mostly concentrated about the ileo-caecal
region.   There is  at this  time a disinclination  to stand or walk,
a stooped posture or  gait,  occasionally a  light icterus, a feeling
of formication or paresis  in the right thigh.
   In the adult the disease  is wont to begin with more tempestuous
signs.  Not infrequently it is ushered in with a well-marked  chill,
upon which immediately supervenes a sharp pain at the affected re-
gion.  A general collapse of strength soon follows, with fever, thirst,
a husky  voice, a coated tongue, vomiting, singultus, and  an expres-
sion  of anxiety.  The impression of serious illness becomes apparent
at once.  The case early bears the aspect of a grave infectious dis-
ease.  A constant, dull, boring, gnawing,  or lancinating pain in
the right iliac  region first  excites the suspicion of the physician as
to the real nature  of the disease.  In children the pain is sometimes
felt  first in the  epigastrium; in three cases mentioned by Buchner,
Herzfelder,  and Traube it was  first experienced  in the left ileum.
There may be at this time no tumor, but there is increased resistance
to pressure and exquisite tenderness to touch in the neighborhood of
the csecum.  A particular point of tenderness on a line toward the
umbilicus, two to two and a half inches from the anterior superior
spinous process, is known as McBurney's point, and is  considered
characteristic of true typhlitis, though with little reason, considering
the anomalies of the appendix.  The whole abdomen may  be more or
less  tender and often tumid.  If there should be also gurgling from
displacement of gas, doubt  is excited as to  the possible existence of
typhoid fever.   In the course of a few days the tumor takes shape.
A typhlitis stercoralis shows a distention  of the whole  ascending
colon, a  sausage-shaped tumor, smooth or nodulated, along the en-
tire  right side of the abdomen, with increased resistance also in the
transverse  colon.   More  frequently  in typhlitis, and as  a  rule in
peri- and paratyphlitis, the  tumor or tumefaction is more localized 
   TYPHLITIS, PERITYPHLITIS, PARATYPHLITIS, APPENDICITIS. 423

about the head of the colon.  Frequently the  swelling is so  great
as to be visible as a protrusion  or bulging of  the  affected region.
Percussion shows dulness, tanquam femoris, in  cases of pure typhli-
tis, whereas in paratyphlitis there is tympanites  on light and dulness
only on deep  percussion.   Palpation or palpatory auscultation occa-
sionally,  though very  rarely, reveals  a peritoneal friction sound
{Gerhard t).
   The third cardinal symptom of the disease is the disturbance of
digestion, which, as stated, often precedes  or attends the first mani-
festation  of the pain and the tumor.   Anorexia, nausea, and  vom-
iting—which is, in the last stage  of the disease,  often substituted by
singultus—present themselves as occasional or constant signs of the
disease.   Constipation remains, as a  rule, throughout  the whole
course of the disease with an obstinacy which sometimes  excites ap-
prehension of an intestinal occlusion ; or the constipation may alter-
nate ivith diarrhea or dysenteric phenomena, more especially in
the earlier stages.  The tongue is, as a rule, heavily coated,  or in
typhoid states is dry, glazed, or fissured, and sordes covers the teeth
and  gums.
   Fever is not a necessary factor in typhlitis, but when present dis-
tinguishes itself by its irregular range.  The pulse is usually accele-
rated, full, and hard ;  the skin is dry and harsh ; the urine is scanty
and  high-colored, and contains, "almost without exception, unusu-
ally  high quantities of indican" (Eichhorst).
   Perforation, when it occurs, is usually recognized at once by the
signs of more or less immediate  collapse, which  quickly  results in
death.  The abdomen becomes suddenly distended, meteoric over its
entire surface.   The normal hepatic dulness may give place to  tym-
panitic resonance.
   Not infrequently perforation  occurs as the result of an accident,
as after a push or blow  upon the abdomen (Volz), heavy lifting
(Volperling), riding in a wagon (Downs), after emesis (Urban), pur-
gation (Stokes), enema (Metier),  etc., etc.   That the slightest agita-
tion  may suffice  at times  to break down the last barrier of serous
tissue separating the intestinal and peritoneal cavity is shown in the
case recorded by With, where fatal perforative peritonitis occurred
after a fit of immoderate laughter.
   Paratyphlitis distinguishes itself from the other forms of the dis-
ease by its more insidious character.  There is  also in paratyphlitis,
as a  rule, less disturbance in the  alimentary canal.   The  cecum in
paratyphlitis is mostly empty, or is filled with gas whose pre-
sence is recognized  by tympanitic resonance on lighter percussion.
On the other hand, paratyphlitis  is characterized by the greater fre-
quency of pressure signs in  the  right lower extremity.  If the 
 424 TYPHLITIS, PERITYPHLITIS, PARATYPHLITIS, APPENDICITIS.

 subjacent  iliac  and psoas muscles be implicated the  thigh is flexed
 upon the  leg in  decubitus.   Various  paresthesie, formication,
 numbness, pain, and veritable paresis are experienced in the right
 leg.  Dysuria,  retraction of the testicle, and, priapism  may also
 occur in this form  of the disease.   Or pressure upon the iliac vein
 induces thrombosis, with edema, milk leg.   The long-continued
 process of suppuration in paratyphlitis  leads also at times to hectic
 fever or pyemia, with sloiv marasmus.
    In all cases relapses  are very frequent, and repeated recurrence
 of  the disease constitutes the rule.   Eichhorst records the case of a
 court officer who suffered five attacks of paratyphlitis in the short
 space of one and a half years.
    Morbid Anatomy.—The lesions revealed  upon the post-mortem
 table show for the most part the ordinary picture of perforative peri-
 tonitis, which is by far the most frequent cause of death.   The peri-
 toneum in the vicinity of the perforation is found hyperaemic, swollen,
 necrosed, covered with flakes  or soft fibrin, or partially agglutinated
 to  contiguous structures.  The  wall of the  bowel  is very much
 thickened by catarrhal swelling of its mucosa, proliferation of  its sub-
 mucous tissue in more chronic cases, oedema  of all its coats,  or sup-
 purative processes.   Not infrequently the mucous tissue is the seat
 of extensive ulceration, which may involve other structures of the gut
 or form an abscess, even as large as a man's  head, in its immediate
 vicinity.  The abscess may remain strictly localized, or may wander
 to discharge itself into the ileum, csecum, duodenum, and diaphragm
 (Bamberger) with resultant empyema (Duddenhausen) ; colon  (Prud-
 homme); bladder (Bossard), in which case the fecal concretion became
 the nucleus for  a vesical stone ; acetabulum  (Aubry) ; inferior vena
 cava (Demaux)  ; or peritoneal cavity, the most frequent eventuality.
 Duddenhausen saw in  one case  a pylephlebitis result; Von  Buhl a
 pylephlebitis and metastatic liver abscess, which condition, Matter-
 stock says, is noted eleven times in one hundred and forty-six autop-
 sies ; and older writers speak  of discharges into the pleural sac, into
 the lungs, pericardium, uterus, vagina, etc.   A curious case was ob-
 served by  Eichhorst in  Frerichs' clinic, where pus  found  escape
 through the umbilicus.   So cases of burrowing sinuses with abscesses
 at distant seats, as in the groin or lumbar region, fistulse with con-
 tinuous discharge,  and other curiosities, may be found  among the
 records by the curious.
   In  cases  of  more  acute  course the  lesions are found centred
 about the vermiform appendix.  The most various contortions, adhe-
 sions, or erosions are observed in this structure.  Occasionally a con-
 striction occludes the course of the tube, while the distal end is dilated
into a condition  of hydrops.   It may be found  perforated in one or 
    TYPHLITIS, PERITYPHLITIS, PARATYPHLITIS, APPENDICITIS. 425

 several places.  The cicatrices or agglutinations  of old attacks may
 be encountered ; it may be cut in two or three  pieces (Matterstock),
 or have been entirely absorbed.  Kraussold records  a case of this
 kind in a colleague who died of typhlitis.  Upon the post-mortem
 table no trace of the vermiform appendix could be encountered, except
 a dimple on the mucous surface of the csecum indicating the site of
 its former orifice.
    Diagnosis.—Though sometimes latent for a long time, the recog-
 nition of the disease is usually simple.   The age, the sex, the pain, the
 tenderness, the tumor, and the disturbances of  digestion sufficiently,
 and for the most part sufficiently early, distinguish the affection.
    Simple impaction of faeces is differentiated by the  history of con-
 stipation ; by the  feel of the hardened faeces, which form an  elon-
 gated, nodulated, sausage-shaped tumor  along the entire ascending
 colon, shifting later along the transverse colon ; by the comparative
 slight tenderness ;  and by the entire  relief which follows thorough
 irrigation of the bowel.   Perforation  from typhoid fever occurs late
 in the disease.
    Cancer may be eliminated by regard of the age of the patient, the
 slow development and  course  of  the symptoms, and the gradual
 manifestation of its cachexia.
    Invagination is an affection for the most part of early childhood,
 is marked by the sudden appearance of violent symptoms of disturb-
 ance of digestion,  vomiting,  often stercoraceous, occlusion,  diar-
 rhoea, or dysentery, with straining and discharges of blood.
    Gibney reported a case of confusion with hip-joint  disease.
    Duration.—Typhlitis  with  its various complications has  no
 definite duration.   A case may terminate fatally in the course of a
 few days, or may extend itself over months, or with its  effects over
 years or for life.  The disease is, as a rule, much shorter in child-
 hood than in adult  life.   According to Matterstock nearly one-half
 (forty-four per cent) of  children succumb to the  disease within the
 first three days.  Wood  records the case of a girl aged ten who died
 in nine hours.   The average  duration of  cases of typhlitis without
 suppuration ranges from fourteen  to  twenty-one days.   The  early
 evacuation of  inflammatory products  by incision and exsection may
 cut the disease  short at  any time, or exacerbations and remissions
 may manifest themselves for months or years—a condition especially
 liable to  occur when burrowing  sinuses or fistulae develop, or when
 passive encapsulated abscesses are aroused into activity by some ac-
 cident or indiscretion on  the part of the patient.
   Prognosis.—A case  of typhlitis stercoralis has no gravity, and
 should terminate or be terminated within twenty-four to forty-eight
hours after its recognition.  Neglected or unrecognized cases,  how- 
426  TYPHLITIS, PERITYPHLITIS, PARATYPHLITIS. APPENDICITIS.

ever, are not infrequently fatal from the circumscribed or more es-
pecially diffuse peritonitis which may ensue.
   Typhlitis independent of faecal impaction is always a grave infec-
tion, requiring in every instance a very guarded prognosis.
   Every form of typhlitis is more  fatal in  childhood than in adult
life,  and any case of the disease may present grave  complications or
assume a dangerous form at any time.   The greater danger of child-
hood lies in the  greater  liability to peritonitis.   Most  subsequent
writers confirm this statement, first made by Willard Parker, who
also  remarked that suppurative processes, abscess formation, is more
common in the adult.  The mortality of appendicitis alone in child-
hood is seventy per cent, in adult life thirty  per cent, so that the pro-
portion of recoveries is exactly the reverse of these figures at the dif-
ferent periods of life.
   The general adoption of the  opium treatment has, however, ren-
dered  the  prognosis  of  typhlitis far more  favorable—has, in fact,
reduced the mortality in adult life from eighty per cent, the appall-
ing figures of the older statistics (Volz), to fifteen per cent, the ratio
of modern times.
   The means of  earlier detection and readier  relief of appendicitis
or evacuation of accumulated pus have also contributed much to re-
duce the mortality of typhlitis.  In 1872 Bull, of New York, had to
report of sixty-seven cases of perityphlitic abscess collected by him,
mostly treated without operation,  a mortality of forty-seven  and
one-half per cent, while ten years  later Noyes, of Providence, was
able to report of one hundred cases treated by operation a mortality
of only fifteen per cent (Pepper).
   The development of fistulae or wandering abscess, the occurrence
of pyaemia and  peritonitis, necessarily aggravate the prognosis of a
simple case.  Perforation is fatal almost of necessity, yet cases are
not wanting where recovery has occurred even after this gravest of all
the accidents of the disease.  Thus, Patschkrowski reports from Fre-
richs' clinic a case of recovery after perforation; and Pepper men-
tions the results of an autopsy made upon an old man who  died of
vesical haemorrhage,  in whom he "found that there had, at some
unknown previous time, been perforation of the appendix."
   Prophylaxis.—The prevention of typhlitis has  reference more
especially to cases of habitual recurrence of the disease in adults or
to the earliest, prodromatous stage in childhood. The slightest mani-
festation of pain  in  the right iliac region should be looked upon
with suspicion in these cases and absolute rest enjoined at once.
Since in childhood perforation has occurred in insidious cases after
so slight an irritation as  a laxative or an enema, or even  after a
bath, every provocation of this kind should  be avoided.   Injunction 
    TYPHLITIS, PERITYPHLITIS, PARATYPHLITIS, APPENDICITIS. 427

 is to be put upon all solid food in all cases, in the inception as well
 as throughout the course of the affection, that the element of copro-
 stasis be not  superadded.   Adults subject to frequent recurrence or
 relapse may thus avoid the development or aggravation of an intes-
 tinal  catarrh, which in other  cases of trivial import  may  become
 dangerous  to them.  Many cases  of typhlitis are doubtless aborted
 at the start by the observance of  absolute rest and abstinence from
 food or rigid diet at the start.
    Treatment.—Perhaps no disease requires such careful considera-
 tion of its cause or form, inasmuch as  the different varieties call  for
 entirely different treatment.   A typhlitis stercoralis,  for instance,
 requires an  exclusive evacuant treatment, whereas  a peri- or para-
 typhlitis demands a laparotomy  or a  treatment that shall put the
 bowel at rest.
    The safest and most effective method of emptying the caecum of
 impacted faeces is by irrigation of the  bowels by means of the fun-
 nel syringe devised by  Hegar.   The patient is put in the knee-elbow
 or face-chest posture, "as  Arabs pray," and warm water—which is
 the best solvent for hardened  fseces—is allowed to  slowly inundate
 the whole  tract of the  colon.   Feeble or reduced patients should be
 supported in this posture until as much water as possible is slowly
 introduced.  As a rule a single thorough irrigation will suffice, or
 one or several additional operations may be  required to secure the
 desired effect.  At the same time broken  doses,  twenty grains, of
 sulphate of  magnesia may be administered every hour or two, not so
 much for the purpose of exciting additional peristalsis as of turning
 water into  the  intestinal  canal  from  above.  The indiscriminate
 habit of purging all cases with Epsom salts, recommended by the gy-
 naecologists, is to be deplored.   Very different conditions  prevail in
 peritonitis from typhlitis and uterine disease (salpingitis).  In the one
 case the bowel is, in the other the bowel is not, affected.  Purgation
 which secures osmosis is beneficial in  salpingitis, but injurious in
 typhlitis.  Where the  bowel is itself  inflamed purgation  is bad
 practice.
   The other varieties  of the affection call for opium at  the start,
 with the double view of preventing the irregular,  spasmodic, or te-
 tanic contraction of the muscular coat  and of obviating the danger
 of peritonitis.  Opium is not contra-indicated in these cases, even if
 the element of fsecal  impaction be  superadded, as all clinicians are
 familiar with  the fact  that the bowels will move of themselves at
 times even under its full narcotic effects.  The remedy is best given
 in fluid form, as in the  tincture, that the dose may be graduated in
its repetition to secure its full effect without  danger ; and it is to be
remembered  that opium, with  all its active  principles, is of more 
428 TYPHLITIS, PERITYPHLITIS, PARATYPHLITIS, APPENDICITIS.

value in the relief of peritonitis than morphia alone.  The idea that
opium does harm by  " masking the symptoms," as advanced by the
gynaecologists and surgeons, is unfounded in fact.  Opium masks no
symptom but pain.   A careful watch should be kept  upon all  pa-
tients treated with large or frequently repeated doses of opium, that
its toxic effects be avoided.   Not infrequently symptoms of poison-
ing have supervened  after a sudden  relief of pain, necessitating tin1
use of means to keep  the patient awake for a number of hours.
   Hot embrocations or poultices applied over large surfaces of the
abdomen give great comfort to the patient, though the very opposite
treatment by an ice  bag, occasionally shifted or suspended, is more
agreeable in some cases in the inception of the disease.
   So soon as a distinct doughy sensation or a more marked fluctu-
ation indicates the development of pus, steps  should  be taken at
once to secure its evacuation.  In  cases of doubt it is best to make a
tentative exploration with the needle of the aspirator,  a large-sized
needle being  preferred on account of the liability of occlusion with
tissue shreds  or other debris.   It is quite surprising how rapidly a
case clears up at times after the evacuation of  even only a drachm
or two of oedematous fluid.  More frequently,  however, a laparo-
tomy must be performed and  the abscess completely discharged.
An abscess of more superficial situation, of larger size, or  of con-
tinuous formation is best relieved by free incision.  As to the time of
the operation, the old rule, ubi pus ibi incisio, holds  good here as
elsewhere.  An  early evacuation  of the products of inflammation
prevents the supreme danger of  perforative peritonitis or the forma-
tion of burrowing sinuses, fistulse, amyloid degeneration, and maras-
mus.   Indurated tumors are sometimes made  to soften under  the
long-continued use of cataplasms, and chronic thickenings  of  the
walls of the intestine are relieved  by general tonics, mild laxatives,
mineral waters, and  gentle frictions with iodine or mercurial oint-
ments.
   Perforative peritonitis calls for immediate laparotomy, which is
most successful when not too long delayed, i.e., beyond the third day
(Fitz).  It is, however,  not true that  laparotomy is imperative in all
cases of typhlitis.  Judgment must be used here as elsewhere.  The
surgeon is too often and too directly followed in  certain cases by the
undertaker.  Literature abounds  in cases  where delay in operation
(laparotomy) has permitted natural resolution.   The frequently and
rapidly recurrent cases point most strongly  to the necessity of exsec-
tion,  though  even in these cases  it may be a question if it  be  not
wiser to suffer a week or two once a year  or once in several years.
Relapses occur also after laparotomy.
   Under no circumstances should a patient affected with typhlitis 
INTESTINAL OCCLUSION.                  429
leave his bed until the last trace of inflammation has subsided, as
there is always liability to recurrence or relapse.

                     INTESTINAL OCCLUSION.
    The writers of  antiquity used the  terms ileus and volvulus to
describe many and very varied diseases of the intestine.  Volvulus
has become limited in our day to that peculiar torsion upon its own
axis which the intestine sometimes undergoes, and which is the rar-
est form of intestinal occlusion ; while ileus has come to be used as a
generic term to express occlusion from whatever cause.   Miserere
was a term often used by the older  clinicians to  express the agony
caused  by this condition.  Occlusion of the intestine is naturally a
clinical expression based upon a gross anatomical state.  The  state
may arise from a multitude of causes,  but  the general result will be
the same.   Occlusion  of the intestine necessarily implies a state of
obstinate and prolonged constipation, usually in this condition termed
obstipation.  Constipation is in itself a relative condition.   Accord-
ing to the teachings of physiology the intestines should be evacuated
once in twenty-four hours, usually after the break of the fast in the
morning.  Peristalsis is started in the stomach with the ingestion of
food, to propagate itself along the entire course of the intestinal tract,
and thus to secure the evacuation of any matter in its lowest parts.
Evacuation once a day would  constitute with some individuals  an
abnormal state ;  once  every other day, twice a week, once a week,
are conditions often noticed.   Instances are upon record where the
bowels  have not been  evacuated  for a month, for two months, for
even three months, without danger.
    1.  The tendency of civilization is  more and more toward the  state
of constipation.   In the first place, life becomes more and more sed-
entary ;  women are constipated almost as a rule.
    In the second place, food is more and more completely digested by
the cuisine, so that the amount of indigestible residue which may
alone traverse the whole course of the intestinal canal becomes less
and less.  The life of  man becomes also more and more sedentary.
In-door avocations increase with the advance of civilization.   Animal
food prevails more and more.   All  these things tend to render the
bowels  sluggish and to produce states  of constipation.  Preoccupa-
tion of the mind is a notorious factor.  The concentration of business
and professional  avocations diverts  nerve force  from the intestinal
canal as well as from the stomach.   A fine  illustration of this effect
is noticed in the insane, whose intense preoccupation leads to neglect
of the natural functions. The  large intestine becomes enormously
dilated in these cases, and stretched so that the transverse colon  may
present a distinct M shape. 
430
INTESTINAL OCCLUSION.
    Hypochondriacs are nearly always constipated.  While constipa-
 tion is a relative condition, the state is absolute in an individual, and
 the condition produces distinct discomfort.   There is flatulence with
 borborygmi and  eructations of gas ;  colicky pain from distention :
 dyspepsia; at times, from the irritation of accumulated masses, dys-
 enteric  phenomena.  There is malaise,  depression  of spirits,  not
 infrequently evidence  of disturbed  circulation in  the  peripheral
 vessels, acne about the face, haemorrhoids, etc.
    Constipation is usually relieved by appropriate treatment of the
 cause, as by the regulation of exercise, a daily walk or ride on horse-
 back,  some kind  of  gymnastics, massage and  faradization of the
 abdomen, enemas ; by address to conditions of the blood,  as to chlo-
 rosis or ansemia,  by iron, belladonna,  strychnia; in amenorrhea
 by pills  which  contain aloes,  the official pill  of  aloes  and iron,
 arsenic, etc.  Sometimes a teaspoonful of Carlsbad salts in a glass of
 hot water before breakfast will suffice.  Then resort must often be
 had to vegetable matters; the simplest are fruits and oatmeal.  The
 compound pill of rhubarb, calomel,  cascara sagrada, a minute pill
 of  podophyllin  gr. 5-^  at bedtime, are effective  laxatives; lastly,
 the slow injection and retention until morning of a pint of pure olive
 oil every night.   When constipation becomes obstinate, whether of
 slow or sudden development, it is an obstipation and  constitutes  a
 marked factor in the history of occlusion of the intestine.   An occlu-
 sion may be caused simply by accumulation of faeces, the so-called
 coprostasis, or, when especially marked at the region of the caecum,
 as typhlitis stercoralis.  This condition may be usually recognized by
 palpation, which reveals a  sausage-like mass in the course of  the
 colon,  sometimes by touch of the finger introduced into the rectum.
 Occasionally the diagnosis may be established only ex juvantibus—
 that is,  by prolonged and  repeated irrigation of the bowels in  the
 knee-elbow posture.
    2.  The  occlusion may  result also from a foreign  body—coins,
 buttons, fruit stone, marbles, teeth, parts of the  insertions of teeth,
 hairs,  fragments of cotton,  dirt, all kinds of foreign matters taken
 purposely  or  accidentally, especially by children and the  insane.
 Most foreign bodies pass.  Fragments of oyster shell  pass, as a rule,
 in the course of time,  creating often much mischief by the way.
 More angular particles, pins or needles, may do destructive damage
 by perforations of the intestine, peritonitis, or the formation of sinu-
 ous tracts, burrowing fistulse, abscesses,  etc.  The insoluble drugs
in continuous administration, iron, bismuth, magnesia, may form
concretions in the intestinal canal.   All  these substances, however,
sink into insignificance, so far as foreign bodies are concerned, when
compared to gall stones, which constitute the most  frequent cause
of intestinal occlusion.   Gall stones from  one to three  inches in 
INTESTINAL OCCLUSION.                 431
 length and diameter  escape  from the  gall bladder  by process of
 direct ulceration into the transverse colon, and  are passed along fit-
 fully, locked up at times in the intestinal sacculse, dislodged under a
 more powerful peristalsis, as a rule to be entirely discharged, but not
 infrequently of themselves, or as  a centre for fsecal matter, to be-
 come direct causes of occlusion.
    3.  Confining the causes to  the  bowel itself, there is next to notice
 stricture, as a rule from ulcerative process.  Typhoid fever, tuber-
 culosis, and  dysentery are the diseases which most frequently pro-
 duce ulceration in the intestinal canal or cicatrization.   Typhoid and
 tuberculous ulcers seldom contract the lumen of the bowel.  On the
 other hand, dysenteric ulcers  frequently narrow the bowel, and al-
 most exclusively, of course, the large  intestine.  Syphilis and carci-
 noma are perhaps the most  frequent causes of stricture.   In both
 cases the diagnosis may be made, as a  rule, by the introduction of
 the finger.  In both cases the  lesion is usually situated in the rectum
 and within reach of touch.
    4. Passing  next to extrinsic causes, the first condition to be  no-
 ticed is that of internal strangulation.  In all cases of occlusion
 careful search  must be  made for the common  forms of hernia, in
 the elimination of which it may  be necessary to make rectal and
 vaginal examinations.   The intestine  is sometimes  strangulated by
 passing through natural or acquired perforations of the mesentery,
 as, for instance, the foramen  of Winslow, orifices in the mesentery,
 meso-colon, omentum.   Sometimes a loop of intestine slips under
 the lower edge of  the elongated mesentery, low in the pelvis, or in-
 sinuates itself  under the pedicle  of  an  ovarian or uterine tumor.
 The most frequent cause of strangulation is that which occurs as the
 result of inflammation, especially  of tuberculous character, whereby
 bands of false membrane  are formed  or abnormal adhesions.   A
 knuckle of intestine may slip under an  arch formed by adhesion in
 the tip of the vermiform appendix, or  parts of the intestine may be
 nipped or compressed by agglutinative inflammation.  Under this
 head belong  also  the  cases of obstruction from compression, as
 by tumor, uterine  or ovarian,  aneurism, retroperitoneal gland, etc.
    5. Volvulus, torsion of the bowel  upon itself, implies some  de-
 fect in innervation which disturbs the tonicity of  the gut.  Cases
 have been reported where a volvulus, after being untwisted, twisted
 back upon itself.
    6. The most frequent and strange of all the  accidents which oc-
cur to the intestine are the so-called invaginations or  intussuscep-
tions, a process which has been coarsely likened to a telescoping of
the gut.   This condition  implies also some defect in  nutrition or in-
nervation, whereby a  ring of  the  gut  becomes  paralyzed, to permit 
432
INTESTINAL OCCLUSION.
the  upper portion to  slip into its  interior.  Invagination  of  the
intestine is most frequently observed in childhood, one-half of all the
cases under the age of seven.  As a rule the small intestine1 slips
into the large, or the ileo-csecal valve leads the way, or the lips of the
valve glide into the ascending colon and in the extension of inva-
gination drag down successive portions of  the colon.   In adult life,
where the condition is much more  infrequent, the ileum may be in-
tussuscepted into itself, or more rarely the jejunum into the ileum ;
rarest of all, the ileum is intussuscepted through the ileo-caecal valve.
In the process of invagination two  peritoneal and two mucous coats
come in contact.  The part of the bowel which begins the intussus-
ception continues  always the lowest part, and the extension of the
process takes place at the expense of  the intussuscipient gut, so that
in the ordinary case the lips of the ileo-caecal valve advance through
the ascending colon, across the transverse colon at the expense  of the
ascending colon, down the descending colon at the expense of the
transverse colon, to finally protrude, sometimes in an elongated mass,
at the anus.  If the process were a simple telescoping, with apposi-
tion of  two serous  and two mucous  membranes and a maintenance
of the lumen of the bowel, it woukl not do so much damage.  Unfor-
tunately,  however, this is not all of  the process.  The mesentery is
dragged in with the descending gut, so that its lumen  comes to lie
against the wall of the receiving gut.  Moreover, the vessels in the
mesentery are blocked.  Necrosis sets in and the intussuscepted gut
sloughs.  This process may take  place quickly, so  that the invagi-
nated gut may be discharged in twenty to thirty days, sometimes by
the end of the first week ; or, again, it may be protracted for a year
or more, with the continuous danger of occlusion  or of pyaemia and
marasmus.   Recovery  occurs, however, in about  half the  cases.
According to the statistics of Brinton, of every hundred cases  of in-
testinal obstruction forty-three are cases of intussusception, twenty-
seven of internal strangulation, seventeen of stricture, five of impac-
tion of gall stones, eight of torsion or twisting.
   Symptoms.—Besides the constipjation  referred to,  occlusion at
the intestine  announces itself by severe pain.  The pain is usually
paroxysmal in  its severity, though more  or less continuous—par-
oxysmal because it exhausts the nerve centres for a time.  Violent
tormina characterize nearly all cases.  Tenesmus, with straining at
stool and  the  discharge of bloody mucus, is more especially charac-
teristic of intussusception.   Vomiting occurs in all cases.   It is usu-
ally excessive, often stercoraceous, and may with  its repetition so
harass the patient as to entirely prevent sleep.  It would seem as if
nature made the effort to  overcome the obstruction by the discharge
above of  a large quantity of fluid  matter.  The fluid, finding no 
INTESTINAL OCCLUSION.
433
egress,  must be  ejected from  the  mouth.   Vomiting grows in fre-
quency and severity as the occlusion approximates  the stomach.
iStercoraceous vomiting indicates occlusion  of  the large intestine.
Valuable information is furnished by the action of the kidneys.   The
urine is often  remarkably reduced, and the reduction stands in re-
lation to the situation of the block.   Occlusion high in the course  of
the canal most markedly  reduces  the quantity of urine.  Various
explanations have been offered to account for this fact.   Barlow
thought that the  scantiness of  urine was due to the fact that there
was left no surface for absorption.  Brinton  attributed it to the  pro-
fuse vomiting, which discharged the fluids of the body in this way;
Sedgwick to shock, which is most marked in cases of high occlusion.
Valuable information may be at times derived from the discovery of
indican in the urine.  In cases of  high occlusion the amount of in-
dican is increased—that is  to say, the  indican does not undergo the
subsequent changes which eliminate  it from  the bowel.  Indican
reveals itself sometimes by the blue color of indigo, which may  be
especially observed in decomposing  urine.   More frequently the color
of the urine is normal and the  indican must be disclosed by chemi-
cal test.  To a  quantity of urine  in  a test tube is added an equal
quantity of fuming nitro-muriatic acid, and to this  fluid three, or  at
the most four, drops of a concentrated  solution of chlorinated potash,
whereby the deep-blue  color of indigo is produced.  A few drops of
chloroform added to this  mixture, which is then gently agitated,
carry the blue color with a deposit  of  the chloroform to the bottom
of the tube.
   The condition of the abdomen itself furnishes the next infor-
mation.  Distended over its whole  course and  markedly tympanitic
everywhere means usually occlusion in the course of the large intes-
tine.  Distentions limited more particularly to  the upper region of
the abdomen, with  collapse of the lower region, indicate occlusion
of the small intestine.   The percussion note, the discovery  of
masses, solid  or gaseous, by palpation, indicate to some extent
the situation and character of the lesion.
   The diagnosis of the existence of an occlusion is, as a rule, suffi-
ciently easy.   Occlusion must be separated from typhlitis, coprosta-
sis, and peritonitis.  Typhlitis  shows  a  circumscribed mass in the
region of the  csecum, with at times  symptoms of pressure in the
right  lower  extremity.   Sooner or  later an abscess may be discov-
ered in the course of the disease.   Coprostasis  is relieved  by irriga-
tion or  by hydragogue  laxatives.  Peritonitis  shows fever, dulness
to percussion at the sides of the abdomen, pain in micturition, ab-
sence  of fsecal vomiting.  The  cause of peritonitis may often be dis-
covered.
        28 
434
CANCER OF THE  INTESTINES.
    The discovery of  the cause of occlusion is unfortunately more-
 difficult.  Age, gradual development, cachexia, may speak for can-
 cer, which may be recognized by the touch in the rectum or by pal-
 pation of the surface.  Previous attacks of jaundice in females past
 the meridian of life  speak for occlusion  from gall  stones.  A pre-
 vious attack of dysentery may lead to the discovery of stricture.
 The injection of water into the colon may locate the stricture. The
 depth to which a rectal bougie may be introduced may also furnish
 information.
    It is easy to multiply words in the differential diagnosis of occlu-
 sion of  the  intestine.  No field of medicine is more  obscure.  Diag-
 noses which are made by guess or which are  based upon statistics
 fail oftener than they succeed in an individual case.
    The prognosis is always grave and takes color wholly from the
 nature of the lesion.
    Treatment.—Laxatives in the early treatment of the condition
 may not be pushed too far.   " It is easier to untie a knot," Leichten-
 stern says,  "by gentle than  by forcible means.   Forcible  means
 often make it tighter."  Purgatives may lacerate the bowel and pro-
 duce fatal  peritonitis.  An  intussusception may at times be over-
 come by the injection of water or air.  A  stricture may be dilated
 with the bougie.  The contents of the stomach may always be dis-
 charged by the stomach tube.   This process prevents extreme ten-
 sion, lessens  peristalsis,  puts  the intestine  at  rest,  and  favors the
 chance of recovery where recovery is possible.    This method,  which
 is officially  known as Kussmaul's, was really first  used, practised,
 and published in  Cincinnati five years before the  report of  Kuss-
 mauPs cases.
    The  classical treatment  of occlusion  is the administration  of
 opium in  doses which put the  bowel at rest.   Opium is  given pre-
 ferably in the form of tincture, and close watch is kept upon  its ef-
 fects.  Hot applications are usually made  to the surface.
    Radical  treatment resolves  itself into a question of laparotomy, a
 question which may be decided only by a  consultation of  physicians
 in an individual case.

                   CANCER OF THE INTESTINES.
    The  intestine is one of the rarer seats of carcinoma.  It is af-
 fected, in fact, in but four to  eight  per  cent of all cases  of cancer.
 The disease is four times more  frequent in  the large than in the small
 intestine,  and is seated in the  rectum in eighty per cent of all cases.
 It is next most frequent at the flexures  of the colon.  The cancer is
 commonly primary, and subsequently invades the peritoneum, mesen-
tery, and retroperitoneal glands, or sends a metastatic deposit to the 
CANCER OF  THE INTESTINES.
435
 liver.   Sometimes this relation is reversed: the disease of the intes-
 tine is secondary to that of the liver.
    The form is usually scirrhus.  Colloid comes next, and colloid
 cancer has  been recognized in matter in the faeces before the devel-
 opment of  symptoms (Charon, Ledegank).   Sarcoma is  still more
 rare.  Lympho-sarcoma may extend to the rectum from neighboring
 lymph glands, and melano-sarcoma or carcinoma may develop in the
 intestine (only in the rectum) by metastasis from the eye or skin.
    Scirrhus of the rectum constitutes, as stated, the most common
 form.   The deposit is, as a rule, more or less circular.  It forms an
 encroaching ring which constricts, finally occludes, the lumen of the
 gut.   Peripheral extension gives rise to agglutinative inflammation,
 which finally converts contiguous structures into an indurated mass.
 Ulcerative processes,  degenerations, and dissolutions bring about the
 same destructive changes as at other seats.  Cancer  is rare before
 forty,  and occurs in both sexes with equal frequency.
    Symptoms.—The disease develops very insidiously, and frequently
 exists  for months  unrecognized.   Disturbances of digestion, more
 especially alternating constipation and  diarrhea, the dysenteric
 phenomena, tenesmus, bloody  mucus, etc., with gradual but pro-
 gressive degradation of vigor, announce its onset as a rule.  Pa-
 tients  are commonly treated for  chronic  intestinal catarrh, or for
 hsemorrhoids, or, especially in  women, for affections  of contiguous
 viscera, especially  the  uterus  and ovaries.   The  obstinacy  of the
 symptoms  to treatment leads finally to examination of the rectum,
 with, as a rule, the immediate  recognition of the nature of  the dis-
 ease.   This examination should be made early in cases of chronic in-
 testinal disease, for the reason  that cachexia develops later in carci-
 noma  of the  intestine than  elsewhere.   The same remark  applies
 also to pain.  The form of the feces is  often characteristic.  Fre-
 quently the  fseces  are compressed into bands or rods, which alone
 may pass the constricted  regions.   Tape-like,  lead-pencil,  sheep-
 balls, are terms applied to matter so compressed.  Naturally this
 alteration of form refers simply to anatomical  change, which may
 depend upon various other, often outside, causes.  Far more  charac-
 teristic is the discharge of decomposing, highly offensive  matter
 mixed with  blood  and pus, in which, in rare cases, cancer  masses
 themselves may be detected  and  disclosed.  A tumor may tell the
 story to the touch.
   Duodenal cancer would show the same symptoms  as  cancer of
 the pylorus—to wit,  dyspepsia,  vomiting, and dilatation, with
 icterus at times in addition.   Perforation produces the symptoms
 of more or less sudden collapse.  Perforation of  the bladder leads to
the discharge of faeces, intestinal gases, etc.,  with the urine. 
436
PERITONITIS.
   The diagnosis  really rests upon the recognition of the constric-
tion by the finger introduced  into the rectum, where the elisease is
accessible ; in higher regions of  the intestine, by the detection of a
tumor by palpation.  In  consequence of the peculiar attachment of
the intestine the tumor often changes place, may at time's disappear,
and, in upper regions of the intestine, may be, by pressure, consider-
ably displaced.  The presence of icterus with normal acidity of the
gastric juice  speaks for duodenal  rather than  for pylorie- cancer.
Faecal masses may be usually removed by copious irrigation.  Tumors
of the kidney and mesentery are situated behind the intestine.   Cir-
cumscribed or inspissated  peritoneal exudations, as after  typhlitis,
which most closely resemble  cancer, may be  often distinguished  by
the age of the patient and the previous history of the disease. Some-
times a diagnosis may be quickly reached after free irrigation and
under chloroform narcosis.  The use of chloroform  is especially of
value  in cases of rectal cancer, where examination is attended with
pain.   An obscure case may justify the  excision of  a fragment from
the rectum for microscopic examination.  The ratio of frequency
helps  the diagnosis.   In eighty per cent  of all  cases of intestinal
cancer the disease is in the rectum, in  fifteen per cent in the csecum
and colon, in five per cent  in the intestine.  The prognosis is fatal.
The treatment is wholly symptomatic and surgical.

                           PERITONITIS.
   Inflammation, usually infection, of the peritoneum.
   History.—Knowledge of  the existence of peritonitis  as an inde-
pendent  disease dates  from the beginning of the  present century,
and is due largely to contributions of Laennec, Corvisart, and Brous-
sais.   Louis, in the first quarter of  this century, recognized the fact
that  spontaneous or idiopathic inflammation of  the peritoneum is
very  rare.  Peritonitis is regarded at the  present time as a second-
ary malady.  Cases  of so-called primary peritonitis become rarer
every year,  and are accounted  for, in the absence  of  mechanical
cause or extension of inflammation from contained or contiguous
viscus, by the action of poisons, micro-organisms or their  products,
circulating with the blood and lymph.
   Etiology.—In the majority of cases  peritonitis may be accounted
for by obvious cause.   As commonly  encountered,  it is  most fre-
quently due to, or consequent upon, inflammation of  the uterus  and
its adnexa.  Thus, circumscribed peritonitis  is a frequent sequence
of salpingitis (gonorrhoea), and general peritonitis is a common and
grave complication of  the puerperium.   The  next most frequent
cause is  hernia.  Hereupon ensue, in the order of freepiency, ulcer
and cancer of the stomach ;  diseased processes of the intestine, es- 
PERITONITIS.
437
  pecially typhlitis, typhoid, dysenteric,  tuberculous, carcinomatous
  ulcers of the intestine; subsequently,  diseased processes of other
  organs  and viscera, liver, kidneys, spleen,  mesenteric glands, etc.
  Aside from the local processes, many of  the acute infections develop
  peritonitis.   Pyaemia and septicsemia, especially  septico-pyaemia,
  scarlet fever, small-pox, erysipelas, and  rheumatism may beget the
  disease, usually late in their course.  Scurvy, various haemorrhagic
  maladies, especially Bright's disease, make the peritoneum vulner-
  able.  Peritonitis is distinguished, according  to its extent,  as cir-
  cumscribed and diffused; according to its intensity, as acute and
  chronic.   Peritonitis marked by the rapid accumulation of gas from
  perforation of a hollow viscus  is distinguished as pneumo-peritonitis.
  Metastatic deposits from tuberculosis and cancer produce tuberculous
  and cancerous peritonitis.
    Symptoms.—Pain is the most prominent symptom.  It is local-
  ized or  diffuse, according  to the situation or extent of the diseased
  process.  It is usually acute and intense, and is associated with an
  expression  of extreme anxiety; the weight of the  bedclothes must
  be lifted from the body.   The pain is intensely aggravated by motion.
  The action of the diaphragm is hemmed in inspiration.   The act of
  urination, especially at its close, is attended with severe pain,
  due to traction  of the contracting bladder, paresis of which reduces
 the quantity of urine.  The abdomen soon becomes distended,
 meteoric, partly from accumulation of gases, partly from paresis of
 the abdominal w^alls.  The  natural dulness of  the liver and  spleen
 may besubstituted by tympanites.  This distention  of  the abdomi-
 nal cavity displaces the thoracic viscera;  the  lungs  may descend no
 lower  than the  fourth or fifth ribs; the heart  is dislocated upward
 and outward.   Whether from mechanical cause or toxic effect, there
 is vomiting and singultus, with obstipation of the  bowels.   Acute
 peritonitis is attended with fever, which  may or may not be present
 in chronic forms.  The pulse is small and frequent, the respiration is
 rapid, the features are pinched and anxious, and thus the patient falls
 into rapid collapse.
    The diagnosis rests upon the recognition of the cause.   The dis-
 ease must be distinguished from hysterical states with hypersesthesia
 of the abdominal walls.   The age and sex of the patient, the absence
 of perception of pain on diversion of the mind from the seat of the dis-
 ease, together with the signs of hysteria—to wit, globus, convulsions,
 absence of  pain on deep pressure—usually  suffice  to  separate the
 maladies.  The  pain of gall stones and kidney stones, cardialgias
 and colics, is  not  aggravated  by  motion  and  is  unattended by
 fever.  Pneumoperitonitis is recognized by the rapid distention with
gas, tympanites  on percussion,  high stand of the diaphragm, intense 
438
PERITONITIS.
pain, and rapid collapse.  The effusionoi peritonitis is distinguished
from that of common ascites, as  withdrawn in either case by aspira-
tion, by the higher specific gravity in peritonitis, above 1012, and by
the presence usually of flocculi, or by greater turbidity, etc.  Bloody,
purulent, or ichorous fluid betokens tuberculous or cancerous peri-
tonitis.   Aid  is furnished in the recognition of these forms  by the
discovery of outside evidence of tuberculosis  or cancer.   The diag-
nosis of tubercular affection, which most chronic cases are thus
shown to be, is quickly  made  with tuberculin after the manner
already described.  The author  has never  yet been deceived or dis-
appointed with  this method in this  disease.   In one  case the diag-
nosis thus established was verified by laparotomy.  The prognosis
is always grave, but takes color largely from the cause.
   The treatment consists in arrest of  the  spread of the disease.
This object is chiefly to  be accomplished  by rest,  with the use of
opium.   Opium with all its constituents is better than any one of its
active principles.  The drug is often given  in peritonitis in the form
of the tincture.   The dose may begin with twenty to thirty drops,
and  be repeated every hour or two until it produces its effects.
There is in peritonitis singular tolerance  to opium.   Nevertheless
caution must be exercised, and the pupils and the breathing watched,
that with the  subsidence of pain the patient  be  not left narcotized.
Cold, in  the form  of  ice bags, may be  applied only at the start.
Greater comfort is secured later with hot applications.  Perforative
and  tuberculous peritonitis justify laparotomy and drainage,  which
may be made  more or less continuous with the physiological salt so-
lution, one drachm to the quart, sterilized and warmed. 
CHAPTER  IV.
                   DISEASES  OF  THE LIVER.

                            ICTERUS.

    The liver is the largest gland in the body, and has perhaps the
 most numerous and most varied  functions to perform, yet it is sel-
 dom  the  seat  of disease.  It is  said that the liver is more sinned
 against than sinning.  Of the affections of the liver proper—abscess,
 cirrhosis,  cancer,  echinococcus,  amyloid and fatty degeneration—
 very  few belong to the liver  alone.  Abscess is generally a part of
 pyaemia or the  result of a deposit from  dysentery.  Cirrhosis occurs
 in  consequence of alcoholism and  is associated with other lesions
 produced by alcohol.  Echinococcus is a parasite ; it may lodge any-
 where in the body, and comes to affect the liver simply because of its
 proximity to the stomach.  Fatty and  amyloid changes are degene-
 rative processes in consequence  of suppuration, syphilis, tuberculo-
 sis, etc.
    Jaundice, which is commonly considered as the sign of disease of
 the liver, is not an indication of disease  of the liver at all.  Jaundice
 seldom or never occurs in any of  the diseases of  the liver just men-
 tioned.  When it  occurs in these diseases it is accidental.  It does
 not belong to them, and the presence of it rather excludes than ad-
 mits them.  Jaundice is simply  a  symptom of occlusion of the bile
 ducts from any one  of twenty or thirty causes.   The  worst kind of
 occlusion of the gall ducts may show a clear skin,  and disappearance
 of the tint of jaundice during the existence of this occlusion may be
 a most ominous sign. It may result from non-formation of bile, sup-
 pression and not retention—a condition  which speedily terminates in
 death.  Jaundice is therefore not  a disease; it  is only a symptom
 of many diseases.   The symptom is, however, entitled to special con-
 sideration, first, because  it is so  obtrusive as to  be recognizable by
everybody ; second, because it is in its most frequent form produced
 by a distinct cause—namely, catarrh of the bile ducts ; third, because
in its  graver forms it requires a nice study of a great number of dis-
eases  to discover the cause in an  individual case.  The light of a 
440
ICTERUS.
 great many diseases is focussed upon  jaundice:  hence jaundice has
 always been considered an interesting  symptom to study.
    The  question  of the production  of jaundice  outsiele the liver is
 largely a matter of definition.  It has long been claimed that the dis-
 coloration of the skin noticed in certain cachexias, or more especially
 in certain infections and pysemic processes, etc., constitutes a particu-
 lar form of jaundice whose cause was located in the blood.  It was
 assumed that  this  so-called  hsematogenous jaundice existed  inde-
 pendently of any affection of the liver, and lines were drawn by
 which distinction could be made between hiematogcnous and hepa-
 togenous  jaundice.  The conditions could never  have been brought
 in the same consideration, were it  not  for the fact that the coloring
 matter of the blood is nearly identical with that of  the bile.  For cases
 of hsematogenous jaundice are due to disintegration of blood corpus-
 cles and liberation of coloring matter.   In these cases there is no  ques-
 tion of decolorization of the fseces or colorization of the urine—condi-
 tions reejuisite to constitute a true jaundice.   Consequently the  sepa-
 ration of hsematogenous  from hepatogenous affections has little or
 no real practical interest.   When, in the course of  the infections or
 poisonings, the coloring matter of the bile is shut off from the intes-
 tine,  to  be reabsorbed and excreted by the urine, true icterus has
 occurred.
   Icterus neonatorum is always a true icterus.   It shows itself in
 nearly all cases of enfeebled children.  Plump,  healthy, robust in-
 fants at birth maintain a reddish hue  or have it substituted by the
 tints of healthy flesh.   Infants not so strong have the reddish hue of
 birth substituted often by yellowish  tints of the  skin and mucosae.
 The coloration  passes  off  in the  course of a few days or weeks.
 Should it, however, persist longer than two or  three weeks, it as-
 sumes a deeper hue, marasmus sets in, fever, with  grave nervous
 symptoms, and there is presented the picture of icterus gravis.   The
 light, canalicular  catarrh  or  occlusion by inspissated mucus, which
 causes the milder forms, has now been substituted by organic change
 which has led to complete atresia of the bile ducts—a condition which
 is sometimes congenital.
   History.—Jaundice comes from the French word jaune. yellow.
 The Germans call the disease, from their own word for yellow,  gelb,
 Gelbsucht, the yellow disease.   The  technical is the Greek term,
 icterus.   The Greeks called icterus  a disease.   Aretaeus derived
 the word from certain yellow-eyed,  four-footed  terrestrial animals
 called iktides.  Pliny derived it from a bird called icterus, the  sight
 of which cured  the patient but killed the bird.   This bird  is now
believed to have been the golden oriole.  Suidas takes it from ihxivo?,
a kite which has, according to De Haen, yellow eyes.   The Romans 
ICTERUS.
441
 called it morbus regius, from the yellow color of gold, the rex me-
 tallorum.
    The bile played a most important  part  in  ancient pathology.
 The Grecian fathers  had many  varieties of bile.   Aretaeus  spoke
 of white and black bile.   Icterus  albus, icterus ruber, icterus cceru-
 leus,  w^ere  names  for chlorosis, erythema, and cyanosis.  The bile
 flowed about the body curiously  in ancient  pathology, to account
 for many  diseases.  It  was especially  responsible  for mental dis-
 eases and depressions.   Melancholia means black bile ; hypochondri-
 asis refers to the liver "  under the cartilage."
    Symptoms.—The color of the skin varies in all degrees of in-
 tensity in jaundice, from a light, almost imperceptible tinge to  a
 deep-mahogany hue.  Once distinctly manifest, it varies in shade,
 but preserves its main color  throughout the disease.   In lighter de-
 posit it is most manifest about the forehead, the roots of the hair, so
 that it may escape recognition in a man with his hat on in the street.
 The tint is diffused over the body, but is most marked on the flexor
 surfaces.  The bile is deposited also in the various mucosae, but the
 tint is hidden by the deeper color of the blood, to become manifest
 only  under pressure which removes the  blood, or in thin mucous
 membranes.  It may be seen always in the conjunctiva, and, though
 invisible on the lips, shows itself  on the hard and soft palate.
    The cause of jaundice  is occlusion of  the bile ducts.  In conse-
 quence of this occlusion  the gall  bladder and liver  become at first
 distended, while the bile is absorbed by the blood  and lymph vessels
 to  be  distributed over the body.   It  is soon visibly present in the
 urine,  which, too, varies in every  shade  in correspondence  with the
 amount of coloring matter it may contain. A true icterus always
 stains the urine, and the diagnosis of the condition rests largely
 upon this fact.   The deeper color of the urine  becomes  apparent
 at  a glance.  Agitation  of the vessel containing it  shows a  foam,
 persistent and distinctly colored. Spread in a thin  layer over a porce-
 lain plate and stroked with a glass  rod dipped  in fuming  nitric
 acid, it shows a play of color, an iridescence from oxygenation.
 The test is usually  made by pouring a small  quantity of nitric acid
 into a test tube and adding to it one or  two drops of fuming nitric
 acid.   A layer of the urine is let fall upon the side of the glass
 from  a pipette.  When  there  is much bile pigment the surface of
 contact of the two fluids shows a  ring of green, violet, and red.  A
smaller amount of bile is detected  by filtering the urine and pouring
upon the filtrate a mixture of nitric and nitrous acids, whereby the
colored rings form as before.   There are finer tests, but these suffice
for all clinical purposes.  Pettenkofer's test  for bile  acid, which
consists in adding  a solution  of cane sugar 1 : 500  and a trace of 
442
ICTERUS.
 concentrated  sulphuric acid to the urine, whereby a violet-red color
 is shown, is of but  little value.  The color is clearly exhibited  only
 when the bile acids have been isolated.  The detection of bile acids
 in the urine has, anyhow, but little diagnostic value.  Small quanti-
 ties can be detected  in normal urine.
    Occlusion of the bile ducts shuts the bile off from the intestinal
 canal;  consequently the feces lose their  color, to become  lighter.
 Moreover, under the exclusion of bile the fats are no longer digested.
 They appear, therefore, pure or partially decomposed, to impart their
 own color to the stools;  hence in a  case of complete occlusion the
 stools assume a putty-like appearance and consistence.  Watery
 stools almost never  show any of the ingredients of bile.   The water
 of these stools comes from the blood.  True jaundice implies, there-
 fore, a coloration of the skin and  mucous membranes, also  dis-
 tinctly of the urine, and a decolorization of the stools.  This col-
 lection of signs protects against deceit and simulation.  Where the
 face has  been colored, as by saffron or a turmeric, the color may be
 removed with soap  or with a chlorine solution or chlorinated lime.
 The mucous membranes show no tint and the urine is not discolored.
 When the urine is discolored, as by rhubarb and  santonin, the color
 will be converted into a deep-red hue by an alkali, which will  only
 make browner the urine of jaundice.   Moreover, in  these cases the
 stools show no absence of color.  The real secretions of the  body—
 tears, saliva,  sweat, milk—are never colored, or only so  rarely as
 to constitute curious cases.  Peculiar yellowish deposits, which may
 assume something of tubercular aspect, show  at times on the  skin
 in protracted  cases, at first  in  the eyelids, later  over the face and
 the  rest of  the body, to constitute the condition known as xanthe-
 lasma.  Yellow vision, xanthopsia, is a much more infrequent curi-
 osity.
   The accumulation of bile in the blood, and  the effect of  its  con-
 tact with the nervous system, produce' a distinctive train of symp-
 toms aside  from the coloration  of the  skin.  In rather more than
 half the cases the  sensitive nerve fibres  in the skin are irritated
 to produce  itching.   Itching  occurs in jaundice  in  sixty-eight
per  cent  of cases, and exists in all  grades of intensity.  It  is at
 times so severe as to excessively harass the patient and exhaust the
strength from want of sleep.   It shows itself, as a rule, most in-
tense on the palms of the hands and soles of the feet and between
the toes, and may extend to involve  any surface of the body.   It is
usually worse at night, and is, as a  rule, when  it shows itself, so
severe as  to call  for special  treatment.  The spirits are depressed.
More or less  mental hebetude  and dulness  belong to  jaundice.
There is also  a train of dyspeptic symptoms,  in connection  more 
ICTERUS.
443
especially with flatulence and constipation, which belongs to the
condition.   The pulse is often reduced in frequency to fifty, forty,
thirty strokes. in  the minute.  Frerichs counted  twenty-eight in one
case and twenty-one in another.  The reduction is ascribed to the di-
rect action of the bile salts upon the ganglia in the heart.  There is,
along with the dulness and depression of spirits,  more or less drow-
siness,  a tendency to  sopor, which in a bad case deepens into coma.
The urine usually shows albumin as well as bile ; irritation of the
bile pigment and salts may excite nephritis.  There may be found
in the urine of  jaundice occasional hyaline casts.
    Where the  condition continues and the occlusion becomes per-
manent the symptoms show greater  gravity.  From lack of diges-
tion of fats and other foods there sets in a gradual marasmus, and
patients who have been  jaundiced for many months or years more
or less progressively emaciate.   There is with this emaciation corre-
sponding loss of strength, manifest in the force as well as in the fre-
quency  of the heart's action.   G3dema  of the ankles and dropsy
may later supervene.   The gravest symptoms show themselves on
the  part of  the  nervous system.   Stupor,  convulsions, delirium,
coma, occur toward the last.
   Diagnosis.—Jaundice being  only a symptom, the question arises
at once  as to its cause.   Jaundice  alone indicates, as stated, simply
occlusion of the bile  ducts.  What  causes the occlusion?  Recent
cases, more especially in the young, are accounted for by simple
catarrhal swelling of the mucous membrane.  The bile flows un-
der very light pressure;  gravity and the vis a tergo force suffice to
secure its discharge.  A  slight swelling of the mucous lining in the
bile ducts will shut off its escape.  The inflammation begins often in
the stomach, to extend into the duodenum and involve the orifice of
the bile  ducts.  Many cases are, therefore, expressions of simple gas-
tro-duodenal catarrh.   More frequently catarrhal inflammation af-
fects the bile ducts themselves/ and may  extend from the orifice of
the common duct in  the duodenum to the gall bladder on the one
hand and to the lobes  of the liver on the other.
   The bile ducts are  blocked by a swollen mucous membrane, and
more especially by plugs of inspissated mucus, which, in conse-
quence of bile, is dammed back in the liver or gall bladder.  The gall
bladder swells to present a palpable tumor at times, which  may
give rise occasionally to a deep-seated sense of fluctuation.  The liver
itself is enlarged, though, as a  rule, not  to  any very great degree.
With the absorption and distribution of bile over the body the liver
is wont to become subsequently reduced in size.  The bile in the gall
bladder  becomes wholly absorbed, to be substituted by pure mucus,
so that the contents of the gall bladder may assume something of a 
444
ICTERUS.
gelatinous consistence and water-like clarity.  This is the common
form of catarrhal jaundice, which presents itself frequently in the
young and disappears in the course of two to six weeks*
   The next most frequent cause of occlusion is impaction of a gall
                              stone.   The stone  may be wedged in
                              the common duct, or wedged in the
                              neck or duct  of the gall  bladder in
                              such a way as to make pressure  upon
                              the common duct.   Case's  are on re-
                              cord where the jaundice  has disap-
                              peared while the impaction and occlu-
                              sion remained—cases in which agglu-
                              tinative inflammation has taken place
                              between the gall bladder and the small
                              intestine, with subsequent  perforation
                              and  escape of bile.
                                 The gall ducts are occluded next
                              by outside pressure, as by carcinoma
                              of the  stomacli, liver, pancreas, omen-
                              tum ; sarcoma  or  other affection of
lymph glands; by the cicatrization of an ulcer in the duodenum, or in
the course of the bile ducts themselves; by all kinds of tumors in the
 Fig. 188. — Distended  ductus chole-
dochus : probe a passed from empty
gall bladder into distended duct; probe
b from ductus choledochus ioto hepatic
duct (Frerichs).
   Fig. 189.—Dilated bile ducts with thickened walls under pressure from cancer of pancreas;
smaller openings of hepatic veins, surrounded by cells deeply stained with bile (dark shading).

abdominal cavity; by abscess from caries of the vertebrae; by aneurism;
by various causes, which must be worked out  in an individual case. 
ICTERUS.
445
   The prognosis depends upon the cause.   It is favorable in catar-
rhal jaundice, not unfavorable in gall stones, which may at least be
exsected, comparatively unfavorable in ulcer, absolutely unfavorable
in cancer, and dependent in  cases of  abscess, echinococcus, syphilis,
cirrhosis, when it occurs in the course of these diseases, upon  the
direction or extension of these processes.  Occlusion from swollen
lymph glands  may be  entirely relieved with  absorption of  these
glands.
   The treatment of catarrhal jaundice consists in the administra-
tion of gentle  laxatives, whereby states  of  hyperaemia,  catarrh, at
least of the duodenum, may be largely relieved.  A sort of  routine
practice consists in the administration of Carlsbad water, or a tea-
spoonful of the Carlsbad salts in a glass of hot water, before break-
fast  Stadelman has lately shown that alkalies in small quantity
have no effect upon the flow of bile, and in large quantity hinder it,
so that the known virtue of  the alkalies must consist in the increased
alkalescence of the blood, whereby the bile is made more fluid.   Rhu-
barb, aloes, tamarind, are various laxatives recommended. The diet
must be simple.   There is naturally an aversion to fats, which should
be avoided altogether.  The food should be mainly vegetable—this
food is, indeed, chiefly  craved by the patient—with  abundance of
drinks, more especially carbonated  drinks,  Apollinaris, Vichy, Sel-
ters water, etc.  The treatment consists in the support of the patient
until the catarrhal element shall have subsided or the plug of mucus
which blocks the tubes shall have been  discharged.   Gerhardt pro-
posed  to discharge  this plug  by faradization of the gall bladder,
and successful cases have  been reported, as  exceptions, however,
to the rule.  It has been recommended  also to express  the obstacle
with the hands, to seize the gall  bladder and  literally squeeze  out
its contents.  This procedure is for  the  most part  impracticable, as
the gall bladder may not be seized in this way,  or dangerous when it
may be seized, because of friability and possibility of rupture.   Much
safer and more effective is the plan proposed by Krull.   This method
consists in the  injection into  the  bowel of one to two quarts of
cold water every morning before breakfast.  The temperature of the
water should be 59° or 60° F., and may be increased to 65° or 68° in
the course of subsequent treatment.   Usually the water is discharged
in five to ten minutes.  The rationale of  the  treatment is ascribed to
reflex  contraction, whereby the gall bladder extrudes the plug of
mucus which  blocks its calibre.  The  injection must be repeated
every day.  The  desired effect is sometimes accomplished after the
second or  third treatment, oftener not until after the sixth or eighth
treatment.   Whatever  the  explanation, the  treatment is certainly
successful in a very respectable contingent of  cases.  Sometimes it 
•146
CHOLELITHIASIS.
causes colicky pains, and in delicate or sensitive persons it may even
produce  a chill,  in  which case,  upon the subsequent  occasion, the
water should be warmer.   The treatment is so simple, and the natu-
ral course of the disease is so protracted, that  it should always be
given trial first.

                        CHOLELITHIASIS.
   Cholelithiasis  {x°^V> bile, A/f>o?, stone) ; gall stones.—The most
frequent, severe, and dangerous disease  connected with the  liver  is
that produced by the formation and discharge of gall stones.
   History.—A condition so gross as the presence of gall stones
could not escape the  observation of ,the earliest observers.   It is not
surprising, therefore, to learn that gall stones were discovered in the
human body as soon as dissections were made.   Folligno at Mantua,
Tornamira at Monfpellier (1586 to 1600 A.D.), are credited  as  having
been the first anatomists to have seen gall stones in the human body.
Fallopius and Vesalius certainly  described them, but they seem not
to have been matters of common recognition by all  physicians until
in the  course  of the seventeenth century, and the pathology of the
affection was not at all understood  until the  eighteenth century.
Morgagni, in his  famous work " De Sedibus et Causis Morborum,"
made full description of the  condition, but it could not be said that
any  definite knowledge existed  concerning  it until the chemists
Fourcroy and Thenard discovered cholesterin, the chief constituent
of gall stones.  In the earlier half of  the eighteenth  century An-
dral,  Budd, Trousseau,  Frerichs,  and  Murchison  illuminated the
clinical aspects of the subject, and in the year 1851 Fauconneau-
Dufresne published  an exhaustive  monograph with  reference  to
nearly all the cases published up to  that tim'e.
   General Properties.—Gall stones result not from mere thicken-
ing of the bile, as is commonly believed, rather from precipitation of
certain substances normally held  in solution in the bile.   They exist
for the most part to the number of five to ten in the gall bladder, and
remain often, in whatever number, entirely quiescent, to produce no
symptom whatever and to be discovered only upon autopsy.   In ex-
ceptional cases the number is very great—the  greater the number
the smaller the size.  Frerichs  counted once 1,950, Morgagni 3,000,
Otto 7,S<'>2, in one gall bladder.  However numerous, they are nearly
always of the same construction and vary but little in size and com-
position in the same gall bladder.  They differ in less than four and
one-half  per cent of cases.  The  largest is that reported by Meckel,
six by two and one-half inches.   Stones vary in size from a grain of
sand to a pea, hazelnut, walnut, or  a  cast of  a  dilated gall bladder.
One such  reported  by Fiedler  measured twelve centimetres and 
CHOLELITHIASIS.
447
weighed forty-six grammes  (one and one-half ounces).   There is
not so much variety in shape.  Gall stones are for the  most part
polyhedral, with numerous facets and rounded edges.  Gall stones
of very different  shape and thickness are much more rarely found
in the liver itself.   They appear here as granular masses, but not in-
frequently assume the shape of the elongated ducts in which  they
are found, to look like black and shining  slate pencils; or present the
appearance at times, more frequently in  the lower animals, much
 Fig. 190.—Two large gall stones from the gall bladder articulated by smooth surfaces (Frerichs).

more rarely in man, of branching coral.   Gall stones formed in the
liver easily escape from the tubes, which gradually increase in size
toward the hepatic  ducts.   Tubular  concretions with canals like
straws were discovered in a case reported by Briquet, following the
ramifications of the bile ducts  to their finest branches.   Gall stones
show also great variety in color, from grayish-white to nearly black.
Fig. 191.—Faceted gall stones, natural size (Ziegler).
The prevailing tint is some shade of brown, the color of the bile pig-
ment.   For the most part they feel greasy to the touch, being smooth
upon  their faceted surfaces; they  may, however,  be rough like a
mulberry or show various erosions like a carious tooth.  They may
often be crushed between the fingers and nearly always nicked with
the nails.  Containing  much lime, they may be as hard as stones.
The weight of a gall stone depends  largely upon its freshness.  Old
stones from which the fluid is evaporated float upon water.  Fresh 
448
CHOLELITHIASIS.
stones exceed in weight the specific gravity of the bile, so that they
seldom float upon its surface.   A  gall stone is usually constructed
of a nucleus,  body,  and crust or rind.   The nucleus may be> formed
of coloring matter with lime, or of a  foreign body—a fruit stone1, a
round worm  or  other parasite, a needle,  globule of mercury after
administration of this drug.  Nuclei of foreign bodies are very rare.
The nucleus is usually mucus, upon and in which cholesterin is  de-
posited.   Curiosities are reported where the nucleus has been doubled
or tripled.  The body of the stone is made up chiefly of cholesterin
with coloring  matter.   It is usually homogeneous or amorphous, with
a fracture like  soap, and has the  consistence of soap.   The crust
is, as stated, usually smooth.   It is sometimes studded with warty
projections.   It,  too, is made up of cholesterin in smooth  layers  de-
posited horizontally at an angle thus to the body of the stone.   Some-
times it contains lime salts.
   Gall stones are  formed nearly  entirely,  seventy to eighty  per
           Fig. 192.                               Fig. 193.
  Fig. 192.—Section of compound gall stone with concentric laminae and with nucleus formed by
a smaller gall stone (Frerichs).
  Fjg. 193.—Section of gall stone with concentric nucleus; concentric laminae only at one end
(Frerichs).

cent, of cholesterin.  Normally  the bile contains but little choles-
terin, 0.015 to 0.025 per cent.  This substance is very slightly solu-
ble, and is held in solution by the  alkaline salts of the bile.  Color-
ing matters, bile acids, fatty acids, and lime salts form, as stated,
the  chief  additional constituents of gall stones.  Stones  composed
wholly  of  cholesterin  are  rare.   They vary in size from a  pea  to a
cherry,  are  colorless  or show a grass-green  hue.  The surface is
usually  smooth and the fracture  glistening ;  they are very light.
Pure pigment stones are  rare.   They are  generally small and very
numerous, often mulberry-shaped,  with  shining fracture, and homo-
geneous like tar.  They sometimes contain copper.   Exclusive lime
stones are very  rare.   They are nearly always single, whitish-gray
in color, very heavy, and very  hard,  rough, and warty  upon  the
surface.
   Etiology.—Especial interest attaches to the formation of gall
 
CHOLELITHIASIS.
449
stones.  What causes the precipitation of the cholesterin ?  Upon
this subject there are various views.   1. Cholesterin accumulates in
abnormal quantity.  What lends support to this view is the fact that
cholesterin is a product of  retrograde change, a process which  in-
creases with  advancing  age, and gall stones are found more abun-
dantly after the middle  period  of life.  2. The natural solvents of
cholesterin are diminished.   Thenard finds the deposit due to dimi-
nution of the soda salts.  Bramson ascribes it to an excess of  lime,
which substitutes soda and thus diminishes the solvent power of the
cholate of  soda.  They support  this argument with the  statement
that  the  coloring matter of  the bile constitutes the nucleus of so
many stones.   3. The alkalinity of the bile is diminished by catarrh
of the gall bladder.  The bile has a tendency to become acid under
Fig. 191.—Section of cholesterin stone after removal of cholesterin.
 meat diet, and gall stones are found with greater frequency in high
 livers and in the upper classes  of society.   Support is lent to this
 view also by the fact that  catarrh  of the gall bladder is so fre-
 quently found in connection with gall stones.  The catarrh may, how-
 ever, be a result as well as a cause.  Ebstein declares that gall stones
 contain a skeleton work of mucus, in the interstices of which choles-
 terin plates come to be deposited.   This view of the genesis of gall
 stones, as the result of precipitation of the cholesterin from catarrh
 of the bladder, has at the present time the best support.
   The irregular appearance of  gall  stones,  the faceted surface,  is
 not  due to attrition, as  is commonly  believed, but to the special
 relations of numerous  stones  crowded together in  the same cavity.
 Cholesterin deposits itself in the interstices  between the originally
more or less globular casts,  so that the angular  or  polyhedral  form
        29 
450                      CHOLELITHIASIS.
 necessarily results.  It is undeniable  that gall stones undergo ero-
 sion and disintegration in the gall bladder.  Sometimes they split
 with radiating fractures, and these are processes in pathology which
 art attempts in vain to imitate.   Gall stones eroded in this way pre-
 sent the appearance of carious teeth, and the destruction is believed
 to be brought about in the same way, by the action of micro-organ-
 isms.  It is  not believed by any chemist that any solvent  may be
 brought to bear upon gali stones in the body.
   Gall stones have been discovered at every age, but are found in
 greatest abundance toward,  at, and after the period of  maturity.
 Of three hundred and  ninety-five cases collected by Hein. but fifteen
 were under twenty-five and but three of these under twenty—to wit,
 sixteen,  seventeen, and eighteen.  There  is universal testimony  to
 the effect that gall stones prevail among women, and the  propor-
 tion of prevalence in  the sexes is usually put as 3 :2.  Furbringer
 put it  as 4 : 1, Bollinger as 5 :2.  This disproportion is  usually  as-
 cribed to the sedentary life, and more particularly to  constriction of
 the region of the liver in the mode  of dress.  In one hundred  and
eleven cases thirty-seven had constricted liver (Bollinger).  It is well
 known that whatever interferes with the outflow of bile,  whatever
condition leads to stasis or stagnation, favors the precipitation of in-
soluble or  slightly soluble substances.   Hence gall stones  are more
 frequently observed in sedentary lives and in the upper classes.  Gall
 stones  are rarities in hospital practice.   Benneke has called attention
 to the  frequency with which gall stones are found in connection with
atheromatous change and excessive development of fat.  What  re-
 lation  these conditions may have  toward each other is unknown.
 They are probably coincidents of age, retardations of  the  activities.
 Glisten noticed that cows suffered with gall stones during the winter
 when confined and fed on hay, and passed them in the summer when
 let out to pasture on grass.
   In the majority of  cases gall stones remain  entirely quiescent
 during the whole of life.  Fortuitous circumstances may,  however,
at any time dislodge them and force them into the gall ducts.  Here
 they meet with obstacles at  once, as but the smallest stones, one-
 fifth to two-fifths of an inch in diameter, may ever pass through even
 a dilated duct.  Fiedler declares that stones only as large as a pea
 can pass.  Hyrtl says a stone as big as a finger, Budd as big as an
almond, may pass.   But modern observers maintain that the larger
stones  must either remain in the gall bladder, become  wedged in the
tubes to block them,  or be  discharged by  perforation  of the gall
ducts.   Individuals thus pass gall stones through abnormal openings
between  the gall bladder or ducts and the small or large  intestine
Large  stones pass always in  this way.  Individuals discharge gall 
CHOLELITHIASIS.
451
stones  often without a sign  of  occlusion.   These stones,  as stated
elsewhere, may alone,  or especially when cemented  en masse with
fsecal matter, subsequently occlude the intestinal canal.  Thus gall
stones may pass through fistulse into the stomach—a rare diversion ;
more frequently into the duodenum, more rarely into the colon.  As
curiosities they may meander, to be discharged into  any part of the
ileum,  into the bladder and be evacuated with urine, into the pelvis
of the kidney, through fistulse upon the outside of the abdomen, ac-
cidentally into the interior of the portal vein, much more frequently
into the peritoneal cavity of the abdomen, to be followed by the con-
tents of the gall bladder and to  produce death by perforation peri-
tonitis in the course of a few days.
   Symptoms.—However free from symptoms  wdien quiescent, gall
stones  produce in  their discharge a distinct train  of signs—first,
pain.  Gall stones may be discharged by unnatural routes, as stated,
without any or with but little pain.   As  a rule, however,  the pas-
sage of gall stones along  the course  of the ducts is attended with
most excruciating pain.  It sets in suddenly, as a  rule, and two or
three hours after a meal.  The pain irradiates from the region of the
gall bladder, especially upward toward the shoulder, sometimes down
the  arm, most frequently toward the angle of the right  scapula.
These pains, as stated, are atrocious in their severity.   Women, who
suffer so frequently from gall stones, declare that the pains  of labor
are not to be compared with the pain of gall stones.   As the stone
comes to rest the pain may  cease, to recur with its renewed advance.
The pain ceases suddenly when the  stone either drops back into the
gall bladder or secures its escape into the  duodenum.   Jaundice  is
by no  means so universally present.   It is never present at the start.
Stones which plug the common duct must necessarily show jaun-
dice.  The persistent cases  of jaundice with deep mahogany discol-
oration, with marasmus, and later with nervous signs, belong much
more distinctly to carcinoma than to gall stones.  In  fact,  of forty-
five cases  accurately  studied  by Wolff  jaundice  existed in  but
twenty, and in but thirty-one of forty-one cases recorded by Fiirbrin-
ger, so that the diagnosis of gall stones must be made without jaun-
dice in  rather more  than half the cases.   When  jaundice does
show itself in cholelithiasis, it develops rapidly, so that it may be
complete and intense in  twelve hours after the beginning of the
attack.  The coloring matter  of the bile may show itself  in the
urine—sometimes in the absence of recognizable  icterus—in less
than twelve hours (Naunyn).
    Dyspeptic symptoms, eructation, anorexia, nausea and vomit-
ing, constipation (eighty per cent of cases), belong to the usual his-
tory of gall stones.  As  a rule the  liver is enlarged.   It may  be 
452
CHOLELITHIASIS.
 felt below  the  edge of the ribs.   It is sensitive to pressure, and tlu?
 gall bladder  may be recognized as a fluctuating tumor or a large,
 pyriform mass.   Sometimes, but rarely, gall stones crepitate.
    The diagnosis of gall stone is for the most part easy.   The sex,
 more particularly the age, of the individual are most important fac-
 tors.   Supreme in symptomatology is gall-stone colic.  A history of
 repeated attack often declares the nature of the disease.  Jaundice1
 may or may not be present ; in the majority of  cases the  diagnosis,
 as  stated, must be made without it.  Cholelithiasis may be some-
 times disclosed in the history of intestinal occlusion, or as the cause
 of  fatal peritonitis or of complications of various kinds produced by
 meandering stones.  The sex, the age, the  pain, the jaundice when
 it exists,  and with the  jaundice  the putty-like stools, deep-colored
 urine, itching,  insomnia-, slow pulse,  nervous symptoms when pre-
 sent, make  the  diagnosis sufficiently easy.   The pathognomonic evi-
 dence is the discovery of gall stones in the  stools, and the diagnosis
 is indeed sometimes established in this way in the absence of all other
 signs.   So the condition has been recognized by accidental discovery,
 or more particularly after a course at a watering place where  irriga-
 tion of the blood and inundation  of the gall bladder have dislodged
 and discharged smaller stones.   In  all  cases  the stools must be
passed through a sieve, and every discbarge must  be examined for
 a week after an attack.
    In  differential  diagnosis  gastralgia must be distinguished  and
 excluded.   Gastralgia occurs for  the most part in younger females,
 or in individuals of either sex affected with other neuroses, migraine,
 intercostal neuralgia, etc.  The pain in gastralgia  is more strictly
 epigastric, that of cholelithiasis hypochondriac.   The attacks may
 be nearly equally severe and attended with the same precordial dis-
 tress and anxiety.   There is, as a rule, a longer interval between the1
 attacks of gall-stone colic ; gastralgia is more or less persistent.  At-
 tacks of gall-stone colic are aggregated in time in connection with a
 discharge of individual stones.  The other symptoms of gall  stones
 —jaundice, presence  of  stones in the fseces, etc.—are of course ab-
 sent in gastralgia.  It is questionable if the liver be affected with a
 special neurosis.   Budd and Frerichs  maintained that the liver  suf-
fered the same neuralgias as the stomach, intestine, or other viscera.
 Hepatalgia, if it exists, would be separated with more difficulty than
gastralgia, because the pain in neuralgia of the liver would express
itself in the right hypochondrium.   Where the diagnosis rests upon
this single symptom it must  often be  held in abeyance.  Considera-
tion of the other symptoms, when present, separates the affections.
    Ulcer of  the stomach shows  pain more continuous, as a  rule
more circumscribed, and more directly connected with the taking of 
CHOLELITHIASIS.                   453
food.   In ulcer there is hyperacidity of the gastric juice.   Icterus
speaks for gall stones.
   Very difficult  at times is  the distinction between gall stone and
cancer.  Primary cancer of the gall bladder or of the liver in such
situation as to compress the bile duct is rare.   Cancer secondary to
affection of the stomach is the rule.  A previous history of cancer of
the stomach, more especially the  discovery or the recognition of a
tumor distinctly palpable and separable from an enlarged or dropsi-
cal gall bladder, is a sign of great importance.   Blood in the stools
may occur in  either or neither  affection.   It is more wont to occur
in affection of the liver than in gall stone.  The discovery of secon-
dary deposits of cancer  rarely assists in the diagnosis. Colic,  if pre-
sent at all, is not  so severe in cancer.  Aspiration of the gall bladder
and withdrawal of bile indicate only compression or occlusion with-
out regard to cause.   The author made the first diagnosis by means
of a needle used as a sound.  The long, fine needle of the aspirator
of Dieulafoy's apparatus was pushed into the  neck of the bladder,
and the stone was found distinctly palpable to  the touch.   A surgi-
cal confrere subsequently exsected a large mass completely blocking
the tube.  The introduction of a  clean needle in this way is unat-
tended with any  particular pain or danger, though objections have
been  urged by inexperienced  litterateurs.  Age  is comparatively
insensible to pain.  The introduction of  the exploratory needle causes
really no more pain at most than a hypodermatic injection.  Danger
has been incurred by the use of soiled sounds.   Gall stones are, how-
ever, sometimes so soft  as to escape detection in this  way, and carci-
noma  may be so  hard as to nearly simulate a  gall  stone.  It must
not be forgotten that  gall  stone  and carcinoma not infrequently
coincide in the same subject.   Long-continued occlusion with per-
sistent jaundice, marasmus, etc., in an  individual in advanced life,
speaks stronger for cancer than gall stone.
   Lead colic—saturnism—has a history of  exposure,  also of re-
peated attack, without icterus, may show the lead line on the gums,
or be associated  with the arthritis, palsies, wrist-drop, or encephalo-
pathies of this affection.  Kidney stone—nephrolithiasis—is marked
by pain lower, in  the course of the  ureters,  by alteration in the urine,
haematuria, etc.
   The prognosis should be made with  caution.  Gall stones  are
often  innocent.   They reveal themselves at times only by accident.
They may, however, at any time give rise  to a train of symptoms of
extreme severity,  and they not infrequently cause death.  The prog-
nosis is by no means so  grave as it was a quarter of a century ago.
Surgery scores triumphs in the exsection of gall stones.
   The treatment resolves itself into the treatment of  attack and 
454
CHOLELITHIASIS.
the treatment of the interval—that is, the relief of pain, assistance to
the discharge, and address to the concTitions which lead to the forma-
tion of the stone.   A light attack may be relieved by the external
application of  heat.  Flannel garments wrung out  of boiling water
and applied  over the whole  abdomen and  sides,  covered in with
thick, dry cloths, furnish the  body the sedative and relaxing influ-
ence of heat  and moisture.  This effect may be increased by the in-
gestion of quantities of hot water.  Contact with the seat of  disease1
is closer in this way.  Where practicable  it is advisable  to put the
patient in a  hot  bath, full  length.  Resort must be  usually had to
morphia, preferably subcutaneously, gr. i-$, a dose which must be
repeated as often as necessary.  Great caution  must be observed
that the patient be not left inundated with morphia  after the  sudden
relief of pain which  follows the discharge of the stone into the intes-
tine or its return to  the gall bladder.   Patients have been narcotized
in this way.   Pain, when present, neutralizes the  effect of  opium.
The virtue of opium may be  heightened by the addition of a small
quantity of atropia, gr. t» o~ffV  a^  a d°se-   The atropia  may not be
repeated as often as morphia.   Relaxing effects are better obtained
by  chloral.   It is customary to administer with the subcutaneous
injection of morphia a dose of chloral,  g. x.-xx. internally.  Chloro-
form itself, gtt. xv.  or xx., may be taken in  repeated doses in this
way.  It is not so good  as chloral.  Even these agents  fail  in bad
cases.   Resort must then be had to the inhalation  of chloroform or
ether, with the same precaution as is always observed in the admin-
istration of chloroform for the relief of pain elsewhere.   It is here not
a question of profound anaesthesia, as in the case of the capital opera
tions of surgery.   The object is to secure rather the  relief than the
abolition  of  pain. or, at  least,  of  consciousness.  Chloroform may
thus have to be given off  and  on for  several  hours  or  for  several
days.  The  administration of anaesthetics as antispasmodics is good
practice in the treatment of gall-stone colic.
    The real treatment of  the condition is address,  as far as possible,
to its cause.  This address is made first by regulation of the diet and
habits of the individual.  Fatty and  highly seasoned foods, spices.
sweets, dry or raw vegetables, cheese, heavy diet, must be eschewed.
Patients should live largely upon fresh-cooked vegetable food; meat
but once a day, lean meat at that.  Fluids should be taken in abun-
dance—soups,  milk, especially water;  mineral waters, especially al-
kaline mineral waters.  The virtue of medicated waters is  largely
due to the water itself.   It has been  shown  that  alkalies in  small
doses have no  effect upon the output  of the bile, and in large doses
hinder it.  There is acknowledged virtue, however, in the increased
alkalescence of the  blood and  the inundation of the bile ducts with 
ABSCESS  OF THE LIVER.
455
 fluid.  Gall stones whose very existence  has remained unsuspected
 have been discharged during, at, or after  a sojourn  at a watering
 place, and free libation of  alkaline mineral waters remains the best
 address  to the cause.  The Carlsbad water enjoys a deserved pre-
 eminence in this regard.   Artificial Carlsbad salts, taken in the same
 way as the water—that is, freely, a glassful  at a time, with  inter-
 vening promenades—have  the  same  effect.   Gall stones  may be
 dissolved very easily  out  of the  body.  They are soluble in ether,
 chloroform, or turpentine.  From time to time patent, proprietary,
 and secret remedies have been proposed  as solvents for gall stones.
 Durande's was a famous remedy for a time.   It consisted of a mix-
 ture of sulphuric ether and turpentine.  Whatever virtue it had was
 due wholly to  the antispasmodic action of the ether—an action which
 may be much  better obtained by the other means mentioned.  Ero-
 sion, crumbling, disintegration of gall stones takes place naturally.   It
 is supposed to be due  to the action of micro-organisms.  The discov-
 ery has not yet been made of any agent in chemistry which will bring
 about the same result.   The  salicylates undoubtedly make  the bile
 flow.   The best treatment of gall stones  consists in the  administra-
 tion of Carlsbad salts in doses of a teaspoonful in a glass of hot water
 once, twice, thrice, or more during the day, with the  continued ad-
 ministration of  the salicylates in divided dosage; regulation of the
 diet of the individual, and change from a sedentary to an active life.
 It is a good thing  to  keep the gall stones which  have been passed.
 Some idea may be had from their number and size, with what esti-
 mate  may be made of the size of  the gall bladder, as to the presence
 or absence of other stones.

                     ABSCESS OF THE LIVER.

   Abscess of  the liver ;  suppurative hepatitis.—Abscess of  the liver
 is a comparatively rare disease.  Modern methods of investigation
 have  shown,  however, that  it is more frequent than is commonly
 supposed.  The statistics  we possess  come from  the post-mortem
 table, and are consequently  fallacious, in that most abscesses as
 well as most other diseases do not come to autopsy.  Many unrecog-
 nized  cases do not succumb at all.   The most accurate records taken
 from  the Berlin Pathological Institute disclose abscess in 1.5 per
 cent of autopsies.   Abscess of the liver  is, therefore, while not a
frequent, by no means an uncommon  disease.   In no case is it per-
haps more true that the life of the individual is more dependent upon
the recognition of the disease.  For abscess of the liver left  alone
usually terminates fatally.
   History.—The lesion of the disease is so gross that it could not 
456
ABSCESS OF THE LIVER.
escape the observation of the oldest anatomists.  Hippocrates men-
tioned it and used the actual cautery in opening it.   Hy the time of
Celsus it had become a matter of dispute whether an abscess should
be  opened by fire or by the  knife.   The  necessity of agglutinative
inflammation previous to discharge was  appreciated by the oldest
savants.   Morgagni,  " De  Hypochondrorum  Tumore et Dolore,"
described the different  directions of discharge of  a liver abscess.
Subsequent contributions  to the history  of  the affection concern
wholly its etiology.  The aspirator introduced the new era in practice.
    Etiology.— Abscess of  the liver  is no  infrequent disease of the
tropics, where it  may be said to be indigenous.  The statistics men-
tioned refer to the temperate zone, where  the condition is the mani-
fest result of some embolic or metastatic process.  Liver abscesses as
seen here are always multiple, the single abscess resulting from the
coalescence of several or numerous smaller elepots.  The most nu-
merous abscesses are  found in connection with pyamiia, where the
liver divides the  honors  with other organs.  These  abscesses are so
numerous and so disseminated through the substance of the organ
as to be unable to unite into one or a few collections.  In these cases
the disease has, as a rule, a rapidly fatal termination.
    Abscess of the liver affects chiefly the period of  adolescence and
maturity.  It is  rare in infancy and extremely  rare in advanced
age.  A curious fact in the history of abscess of the liver is the com-
parative exemption of  the female sex.   Females are affected in but
four or five per  cent of the cases.  What makes this disproportion
strange is the fact that dysentery, a disease in which the question of
sex has no concern,  plays  such an important role in its  production.
The possible sources of infection of the liver  are  very numerous.
Abscess may result as  an  extension  by contiguity of structure :
thus, in connection with suppurative affections of the gall ducts or
vasa aberrantia; often  in connection with  intrahepatic gall stones ;
sometimes, much more  rarely, from parasites,  emigrated intestinal
worms, distoma, etc.  Foreign bodies which  have  penetrated from
the stomach may be cited in this connection  merely as curiosities.
The most frequent  cause of abscess of the liver  in this way is the
extension by erosion of  a gastric ulcer  after adhesion to the liver.
All these cases are, however, extremely rare.  As to trauma, it may
be practically discarded  as a cause of abscess of the liver.  Frerichs
reports a case of  a laborer crushed  between the  buffers of railway
carriages,  with evident  contusion of the liver and subsequent jaun-
dice, but without any hepatitis; and Thierfelder cites  a case of a
soldier shot through the liver, with discharge of bile from the open-
ing in the right  side for a long time, and with  complete recovery
without  suppuration.    Any ordinary  wound suppuration  in the 
ABSCESS  OF THE LIVER.                  457
 course of injury to the liver would not fall under the head of an
 hepatic abscess.
    The gateway to the liver is the portal vein, and  the portal vein is
 the main avenue of metastases in  the modern sense—to wit, embolic
 products.   The portal vein includes a vast  system of tributaries, in
 the domain of any one of which the original disease may lie.   Thus,
 in the infant,  disease products  may come  from the umbilical vein,
 in the adult from the gastric, splenic, pancreatic, and more especially
 from the mesenteric veins.  Disease of any part of the intestinal tract
 may furnish  morbid matter  for the liver.  The truth  is, however,
 that  but one disease  assumes prominence  in this regard, namely,
 dysentery.  Abscess of  the liver almost never arises in the course of
 typhoid fever,  tuberculosis,  or disease of  the  small intestine, but
 arises,  as a rule, in the course of that severe or protracted ulceration
 of the  large  intestine clinically known  as dysentery.  The associa-
 tion was observed in the earliest times.  Annesley thought that ab-
 scess of the liver caused the  dysentery, that the abscess altered the
 bile in  such a way as  to make it irritate and inflame the intestine.
 Budd (1842) first announced the true relations of the diseases, show-
 ing that products were conveyed from  the  ulcers in the intestine to
 the substance of the liver.  In two hundred and one cases of  abscess
 of the liver tabulated  by Waring, dysentery was found to have ex-
 isted in three-fourths of the cases.   The association is so frequent in
 the East that  the pathologists there attribute both to the same cause.
 The relation  first established by Budd is probably correct.   Dysen-
 tery is by no means the exclusive,  but is the most frequent, cause of
 abscess of the liver.  Other diseases of the  large intestine, typhlitis,
 proctitis, haemorrhoids, fistulse, or  operations for the relief of these
 conditions, have been followed by abscess.
    The pus-producing micro-organisms act  as the  direct causes of
 these abscesses of the liver.  In certain cases the amoebae found in
 dysentery (vide Frontispiece, Fig  17) have been discovered in the
 pus of hepatic abscess, but whether as cause or  mere coincidence  is
 not yet known, as  the exact role  of these  organisms in dysentery
 itself  is not yet determined.  The  amoebae  may be shown in fresh
 fseces, but are best seen  in mucus,  pus, and  blood.  They are some-
 times seen in the fseces in health.
   Disease products may be conveyed to the  liver also by the hepatic
 artery.   Cohen found abscess in the liver after the injection of crude
 pus into the thoracic aorta.   Putrid bronchitis,  ulcerative endocar-
ditis, suppurative processes  about  an aneurism,  have been attended
or followed by  abscesses of the liver, presumed to have been con-
veyed through the hepatic artery.  The older  surgeons—Desault,
Bichat—spoke of the frequency with which  suppurative processes in 
458
ABSCESS  OF THE LIVER.
bone, more especially in the skull, were  followed  by hepatic  ab-
scess ;  and  suppurative processes  anywhere in the  course  of  the
systemic veins have  been considered Satisfactory explanation  for
abscess of the liver.   It is well known of the veins of bone that they
remain patulous under all circumstances and are unable to collapse
upon their  contents ;  hence  the  avenue  of  transit is kept open.
More recent investigations, however, have  shown that abscess of
the liver is not more wont to  supervene from infection of  bone than
from infection of soft parts.  In all these case's the conveyance of
infectious matter to the liver would have to take place through the
lungs;  whose capillaries are excessively fine.  To explain  away this
obstacle it has been  assumed that secondary emboli are given off
from the thrombotic occlusions in the lungs.  Unfortunately  the
metastatic products are found in the liver and not in the lungs, and
metastatic abscess of the liver is much more frequent than the same
process in the lungs.   It is not  necessary  to appeal to speculation.
Bacteria may pass through derivative vessels without the interven-
tion of capillaries.  Streptococci may pass a primary to lodge in a
secondary set of vessels, especially in case of more sluggish circu-
lation.
   The last source of infection is by way of the hepatic vein,  which,
according to Meckel, is not very infrequent.  The older physiologists
—Magendie, Gaspard—found that mercury introduced into the1 jug-
ular vein  could be discovered in  the liver.   Cohen was not willing to
accept  this  analogy for emboli.  Heller experimented with particles
of flour enveloped in Canada balsam and found the same results.  He
caused these light particles, against which the objection  of  weight
could not be urged, to be sucked into the liver simply by  the move-
ments  of artificial respiration, so that the  theory of "refluent em-
bolus" found support in direct experimentation.  Heller also reported
a case where  a minute hepatic vein contained  cancerous  emboli
which  evidently originated from affected mediastinal glands.
   Symptoms.—The symptomatology of abscess of the liver is rather
indefinite.   Reliable signs are very few.  In certain cases the disease
is latent and is revealed only upon  autopsy,  sometimes without  the
existence  in life of  any symptom of disease, oftener with symptoms,
vague  and indefinite, that have been referred to the stomach or have
been diagnosticated under the elastic term  dyspepsia or the very
popular term biliousness.
   Usually  the liver  is swollen.  Abscess is most commonly found
in the right lobe and toward the convexity, so that the enlargement
in size is upward rather than  downward.  Dulness begins at the
level of the  fourth or fifth rather than at  that  of  the seventh  or
eighth  rib.  Sometimes the enlargement is  downward, sometimes the 
ABSCESS  OF THE LIVER.
459
weight of the liver causes a descent en masse.   Occasionally the tu-
mefaction may be felt, more rarely it extends to the level of the um-
bilicus or even to the crest of the ilium.  There is  often tenderness
to pressure.  Sometimes  the liver bulges in the  right hypochon-
drium, obliterating the intercostal spaces.  The infection may red-
den the surface,  or the abscess actually point between or under the
ribs or at the epigastrium.  A surface cedema sometimes  indicates
the best site for exploratory puncture. There is pain, as a rule ;  a
dull, heavy sense of weight, as of a stick of wood, across the trunk
—sensation de bar re.  More acute pain arises from perihepatitis.
Pain at the point of the shoulder is often more significant.   Shoul-
der-tip pain—i.e., at the point of the shoulder—or pain in the blade
or at the angle of the scapula, is,  when present,  a striking  sign.  It
is more marked when the abscess occupies the convexity of the liver,
and is absent, as a rule, when the seat is elsewhere.  Luschka inter-
preted it first as due to the inosculation of the phrenic,  whose fila-
ments  supply the suspensory ligament and convex  surface of the
liver, with the fourth cervical, whose  filaments supply the shoulder.
Twining called attention  to the rigidity of  the  right rectus as
indicative of abscess  of the liver.  The  sign has  some value,  and
is best estimated by comparative test—that is, by alternate palpa-
tion, with both hands, of  the right and  left rectus.  The truth is,
the rectus is rigid in any subjacent disease.  The rigidity is an in-
creased physiological  tonicity and reflex irritation in protection of
subjacent parts.
   All or some  of the  signs of dyspepsia are found in connection
with abscess of the liver.  The tongue is heavily coated.  There
is anorexia,  vomiting,  nausea, constipation,  and  the general
distress associated with these conditions.   Depression of spirits
assumes  prominence in abscess  of  the  liver.  The terms melan-
cholia and hypochondriasis indicate the connection  which  the
older writers  made between disease  of the liver and depression of
spirits.  Hammond reported cases in which he was led to explore
the liver several times, with successful results, on  account of these
symptoms alone.   The mental state could have reference to disease
of this kind only when  it  could not be accounted  for in other and
more obvious ways.  Jaundice occurs as an exception, or, it might
be said, as an accident, in  the history  of hepatitis suppurativa.   An
abscess might be  so situated as, by its weight, to block the common
duct.   The disease may produce a cachexia along with  marasmus,
but not jaundice, which is found in  but sixteen per cent  of cases.
Fever does not belong to  abscess of the liver.   Chills and fever
with sweats, sometimes so periodic  as to  closely simulate malaria,
indicate pyemia. 
460
ABSCESS OF THE LIVKR.
   The diagnosis rests upon the age and sex of the individual, par-
ticularly upon the history of previous disease—dysentery, etc.   The
disease may exist without reference to any of these conditions.   The
diagnosis then depends upon the tumefaction, the tenderness, protru-
sion of chest wall, and possible fluctuation ; the pain, especially the
shoulder-tip pain ; the fever, the dyspeptic symptoms and depression of
spirits.   The diagnosis rests absolutely upon the discovery of pus by
aspiration.   Aspiration is  practised in  any doubtful case, with the
needle of the aspirator, however, rather than  that of the hypoder-
matic  syringe, because  the abscess  is often deep and the pus is
always thick.  The point  of election, unless indicated elsewhere, is
somewhere  in the neighborhood of the axillary line, behind rather
than in front of the line, and above rather than below that diameter
which might be  called the equator of  the chest.  Where the first
effort  is a failure aspiration may be  repeated at different points.
The author failed once to find an abscess  after penetration  three
times  before a class of students  and once later.  On One occasion
further penetration of the needle was stopped by a hard body.   The
patient subsequently died of peritonitis from perforation  of an ab-
scess, and upon post-mortem examination it was  found that one in-
sertion had penetrated to within one-twelfth of an inch of the abscess,
where the needle was stopped by a dense pyogenic membrane.   The
puncture is usually painless.  In  the  experience of  the  writer it
became necessary upon one occasion to  use morphia  subcutaneously
to relieve excruciating, lancinating pain, probably caused by injury to
an intercostal nerve.
   The abscess may discharge itself favorably.  Most frequently it
empties  into the  right lung after agglutinative  inflammation with
the diaphragm and pleura, and discharges itself  through the bron-
chus, whereupon after the lapse of time  the abscess refills to repeat its
discharge.   These are the so-called cases of phthisis hepatica.  They
are separated from tuberculosis by the paroxysmal discharge of
large  quantities of  pus  after  intervals of quiescence, by the
dulness tamquam femoris of the whole posterior portion of the lungs,
as well as by the absence of the tubercle bacillus.
    Of  one  hundred and seventy  cases  tabulated  by Thierfelder
seventy-four emptied into the bronchi, twelve  into the  intestine,
twenty-six  into the right pleura,  twenty-three into  the abdominal
cavity, thirteen into the stomach,  four into the pericardium, and one
into the pelvis of the kidney.   No consideration was  made of open-
ings upon the surface, as it was impossible to  separate  the cases of
natural and artificial discharge.
    The prognosis of hepatic abscess has entirely changed since the
day of the discovery of aspiration.  The disease had  formerly the 
ABSCESS  OF THE LIVER.                 461
 appalling mortality of eighty per cent, due  chiefly to perforation,
 pyaemia, and marasmus.   Abscess of the liver has a  constant ten-
 dency to rupture.   It has no tendency  to heal.  Scars have been
 found in the liver as curiosities.  Neither absorption nor favorable
 discharge  can be counted upon.  The sword of  Damocles is sus-
 pended over the head of a patient affected with abscess of the liver.
 But recovery is absolute after evacuation  of the abscess, even though
 there  be  left but a shell  of liver tissue.  The liver reproduces itself
 both by hypertrophy and hyperplasia.  In rabbits,  dogs,  and cats
 a loss of three-fourths of the liver is completely restored in thirty-
 six days (Ponfick).
    Treatment.—Drugs are of no value in the treatment of abscess
 of the liver.  Indian and English physicians recommend ipecac as
 having the same virtue here as in dysentery.  It is difficult to under-
 stand how this may be.   Pain may require  relief by heat and  by
 morphia.   The true treatment is  the withdrawal of the pus and dis-
 charge of the abscess by  aspiration  or incision.  Sometimes, rather
 exceptionally, a single aspiration suffices, or the operation may be
 repeated once or twice.  It is safer not to wait  too long, but to cut
 down at once upon  the surface of the liver, unite it by suture to the
 abdominal wall, and plunge a knife—or better, to prevent bleeding,
 the blade of the thermo-cautery—into the abscess.   In this way a vast
 internal abscess with its manifold dangers is converted virtually into
 an external ulcer whose surface may be subjected to actual inspec-
 tion.   The contents  of the abscess are usually washed out and the
 cavity subjected to subsequent  irrigation with drainage.  A few
 weeks suffice, as a  rule, to bring the case to a happy termination.
 Progress in the method of operating is shown by comparison of sta-
 tistics.  Curtis (1782)  reports of  the first operations a recovery of
 two of ten  cases;  De Castro, thirty-four  of sixty-one; McConnel,
 twenty-two of thirty-four.  In one  case in  the experience  of the
 author pus  reaccumulated after  a second aspiration.   Joseph Ran-
 sohoff, a surgical colleague, practised hepatotomy.  The process of
 recovery at  the end of the second week was interrupted by a return
 of fever, anorexia, general distress, when it was found that certain
 masses in the anfractious walls had  become  necrotic and remained
 attached.   Under  illumination with headlights and laryngoscopic
 mirror these masses were separated with forceps  and the  bleeding
 bases cauterized.  This patient, a woman, finally made a perfect re-
 covery.  In the case of excessive pain after puncture, referred to, the
 first  incision, which was  superficial, discharged about one-half  an
 ounce of pus; the patient was extremely emaciated  and had suffered
 pain for six months.  It was  not believed that  this quantity could
account for  his condition.   A hypodermatic needle, plunged for two 
462                 CIRRHOSIS  OF THE LIVER.
 inches  below the bottom of this  abscess, discovered an additional
 depot, from which was discharged  over a pint of reddish hepatic pus.
 This patient also made a final recovery.   It is safe to say that eighty
 per cent of cases are rescued by timely operation.

                    CIRRHOSIS OF THE  LIVER.
   Cirrhosis of the liver  {xippo?, tawny, orange-yellow); hobnail
 liver, contracted  liver, gin-drinker's liver; interstitial hepatitis.—A
 disease  of the  liver chiefly caused by  alcohol; marked  by inter-
 stitial hyperplasia with subsequent contraction of the liver ; charac-
 terized  by dyspepsia, ascites, and marasmus.
   History.—The oldest anatomists had their attention attracted to
 the small size and hardness of the liver  in certain  states of disease.
 Aretaeus spoke of the  hepar durum, and  hepar  scirrhus was another
 appellation to indicate hepatic induration.   Bianchi  even spoke of
 the " jecus in minimam molem retractum," and Vesalius of a case,
 attended with the well-known  symptoms in life, where the liver on
 autopsy was found " totum candidum et  multis trabeculis asperum,"
 etc.   Morgagni reported from his own observation,  and from that of
 others,  undoubted cases of cirrhosis in which  the  liver was found
 after death "totum  granulosum."
   This was, however, the sum and substance  of knowledge of cir-
 rhosis up to  the time of Laennec (1819).  The disease was not yet
 known  as an  affection  distinct from others—from cancer, for in-
 stance—and  nothing was  known  at all  as yet either of  amyloid or
 syphilitic change, or of  the  change produced by organic disease of
 the heart.  So  all these affections were  confounded with  cirrhosis.
 Laennec came upon the disease quite accidentally in the  course of
 his examination of disease of the lungs.   He had under observation
 a fatal  case  of  pleurisy with hsemorrhage from the  lungs, and he
 noticed at the  autopsy the curious condition of the liver,  which he
 describes in a few words.   As this was  the first recognition of the
 disease  as a separate affection,  the  description is worthy of mention.
 He found the  liver, he says, "reduced  to one-third  of  its volume,
 concealed in the place  it occupies, and  seemingly composed of a mul-
 titude  of grains of  millet seed, of  a yellow or yellowish-red color."
 In a footnote he adds: "This is a species of production which has
 been called scirrhus.   I will designate it cirrhosis because of its color
 {nippoS, tawny  or orange color).   Its development in the liver is one
 of the most common causes of ascites.   The liver is always atrophied
 when it contains these cirrhoses."   Laennec, therefore, regarded the
 "cirrhoses" as new formations, and in accord with this  view Aber-
 crombie described the yellow matter of cirrhosis as '' in small nodules,
like peas, dispersed  through the substance of the liver."  Abercrom- 
CIRRHOSIS OF THE LIVER.                 463
bie says that the "French writers have a controversy whether the
cirrhosis or yellow degeneration of the liver be a new formation, or a
hypertrophia of the yellow substance which they suppose to constitute
a part of the structure of the liver in its healthy state.  No good can
arise from such discussions," he adds naively, '' as it is impossible to de-
cide them." In the same year of the recognition of this the common
form of cirrhosis (Laennec's  cirrhosis the French still call it) Bouil-
laud showed that  the nodular or  granular appearance was due to
atrophy of the red  substance of the liver, whence resulted a more
salient projection  of the yellow substance.    Kiernan (1836) first
clearly  pointed  out the  hyperplasia of  the  interstitial  connective
tissue which we now know to be the lesion  of cirrhosis, and Gubler
(1853) first called attention to the fact that the first stage of the dis-
ease may be characterized by hypertrophy, the second by atrophy of
Fig. 195.—Cirrhosis hepatis (hobnail liver).
 the liver.  Finally, Klebs (1868) first proclaimed phlebitis and peri-
 phlebitis of the radicles  of the portal vein as the initial anatomical
 factor in the pathology of the disease.   It is not the granules, there-
 fore, which constitute the disease.   The granules represent constric-
 tions of the liver substance.  The constricting agents, the connective
 tissue, constitute the  disease, which is  properly designated, as Bam-
 berger has shown, " chronic interstitial hepatitis."
   Etiology.—Almost  from the very first recognition of the disease
 the cause of it was known.  By all writers and clinicians cirrhosis is
 looked upon as an expression of chronic alcoholism.   " Gin-drinker's "
 liver is its  common name in England,  and the extent of the use of
 alcohol determines the geography of the disease.   Males are its most
frequent victims, because, as Hyrtl remarks, '' drinking is one of the
male accomplishments."  But typical cases are  encountered among
females under the same conditions.   Even  the apparent  exceptions 
464                 CIRRHOSIS  OF THE LIVER.
 support  the rule (Niemeyer).  " Thus Wunderlich found  typical
 cases of the disease in two sisters  aged eleven and twelve years;  and
 on careful inquiry it was learned  that  both of them were great
 schnapps drinkers."
    The liver has  singular affinity for alcohol in any form.  Percy
 found  that he could recover alcohol in the bodies of dogs poisoned
 with it, from the blood, the brain, and other organs, but in greatest
 quantity from the liver.   The researches of  Perrin, Lallemand,  and
 Duroy have shown that if we represent by 1 the quantity of alcohol
 found in the blood after the ingestion of a certain amount of it, that
 found  in the brain will be represented by 1.34 and that in the liver
 by 1.38.  This accumulation of alcohol in the liver, taken in connec-
 tion with the sluggishness of the circulation of the liver, the hepatic
 radicles being the second set of capillaries, furnishes sufficient explana-
 tion of the selection of the liver as the organ which shall suffer most
 from the toxic effects of alcohol.  Inasmuch, however, as all drinkers
 do not suffer alike, we must invoke, in addition to the alcoholism,
 some  special susceptibility which  renders the individual  liable to
 cirrhosis.  In this respect cirrhosis  does  not differ from nearly all
 affections.  The continuous reception and escape of alcohol  in  the
 organs of secretion finally induce in them at first irritative and then
 inflammatory change.
    First in order is chronic catarrh of the digestive tract, then  de-
 generation of the glandular organs, atheroma of  the vessels, pachy-
 meningitis, forms of Bright's  disease, and, among  the later pheno-
 mena, cirrhosis of the liver.  Thus epithelial cells and lining cells of
 vessels perish under long-continued irritation of alcohol, but the con-
 nective tissues before they perish are stimulated,  under irritation, to
 excessive growth.  Alcohol  reaches the liver through the radicles
 of the portal vein.   These radicles  at their ultimate termination are
 among the finest and thinnest, as well as among the richest, systems of
 vessels in the body.  The unoxidized alcohol—that is, that which is in
 excess of consumption—passes by easy osmosis through their delicate
 walls and bathes  the  equally delicate fibres and threads of connec-
 tive tissue which form the soft skeleton work of  the recesses of the
 liver.   The nuclei multiply, the threads become cords and bands.
 When the connective  tissue has attained its full maturity it begins
 to shrink.  The liver is so  shrunken by the retractile threads of con-
 nective tissue as to look, both upon its free surface and upon the sur-
 face of  section everywhere, like the bottom of an ironfounder's shoe.
 "Hobnail liver"  it is sometimes  called, and the hobs or  nodules
 may be sometimes felt in thin people  or after tapping beneath the
 skin of  the abdomen.   It  is not infrequent to find the whole of  the
left lobe shrivelled to a mere appendage to the right. 
                   CIRRHOSIS OF THE LIVER.                 465
                                                          (
   Alcohol does not, however, account for all the cases of cirrhosis.
The connection between alcoholism and cirrhosis is so close as to jus-
tify incredulity concerning any other cause, and alcoholism must be
eliminated  before the  idea of any other cause can be entertained.
Virchow declared  that interstitial  inflammation  may arise in the
course of syphilis, and Frerichs cited a number of cases followed by
cirrhosis.   The syphilitic hepatitis distinguishes itself, as a rule, by
its irregular development.  The  process is not so  uniformly diffused
through the substance  of the liver as in a true cirrhosis.   It is  more
apt to be accompanied by opacities of the surface and gummatous
masses,  and is found in association with evidence of  the disease else-
where.  Much interest attaches to the question if intermittent fever,
malaria, may be considered a cause of the disease.   Cantani, of Na-
ples, ascribes to malaria a potent influence in its production.  The
habits of life at this seaport town by no means exclude the possibility
of the more common cause.  Cirrhosis does not especially prevail in
malarial climates.   The  disease should be more common in Africa,
South America, and in the more intensely malarious regions of our
own country, if due to this cause.  There is no testimony to this ef-
fect.  Botkin declared  that he found cirrhosis frequently in connec-
tion  with cholera  and typhus fever,  but this  statement also  lacks
support.  Gintrac  and Ore found that they could produce cirrhosis
in dogs by closing the hepatic vein ; and Solowieff observed that
when the vena porta was ligated slowly and gradually the change in
the circulation  excited an interstitial  process in the  liver that  could
not be distinguished from that of true cirrhosis.
   The conclusions from these experiments leave at  least a loophole
for the evasion of alcohol as a universal cause, in that possibly some1
other irritant may act like  alcohol in producing the characteristic
changes in  and about the walls of the finer vessels.
   The symptoms of cirrhosis irradiate from the liyer as the central
point.  Most of them  are easy of explanation on mere mechanical
grounds.  A few of the last and worst of them call out a knowledge
of the physiology of the liver.
   It may never be known just  when the cirrhotic process begins in
the liver, for the first symptoms are  purely  gastric.  Gastric  ca-
tarrh with its well-known attendants precedes the more pronounced
and peculiar phenomena of the disease for months, or even years.
Gastric distress, nausea and  vomiting, especially  in the morning,
heartburn, constipation alternating with diarrhea, compose the
train of symptoms that march in the front or by the  side of  cirrhosis
of the liver, for months and years at  times, before the symptoms of
more  complete obstruction arrive.  Gradually, however, the hyper-
plasia of the connective tissue advances, or gradually it tightens up
        30 
466
CIRRHOSIS OF THE LIVF.R.
in its contraction upon intervening liver cells and vessels and ducts.
The skin grows sallow and dry. the conjunctiva' are yellow  from
the  start, emaciation sets  in, all from lack of formation, or  from
slight reabsorption of blocked-up bile ; then water is forced out of the
radicles of  the portal vein  into the abdominal cavity,  ascites de-
velops, and from  the distended  vessels blood may escape  into the
stomach  or intestine.  Collateral  circulation may to some extent
compensate for the occlusion of the portal vein, and thus obviate1 for
a time the worst phases  of mechanical hindrance.   In fact, it is the
establishment  of collateral circulation that chiefly protracts the life
of the individual affected with  the disease.   It is a  matter of real
surprise how many avenues  of collateral circulation are brought into
play in atrophy of the liver.   There are vessels in the gastro-hepatic
omentum from the lesser curvature of the  stomach, and in the con-
nective tissue between the folds of the omentum  there are twelve to
fifteen small vessels which pass from the gall bladder ; besides these,
the vasa vasorum, the vessels which run along the walls  of the por-
tal vein, hepatic artery, and bile ducts ; a fourth group descend from
the diaphragm in the suspensory ligament ;  a fifth, the largest of all,
the vessels which form the visible network on the surface of the ab-
domen communicating with the epigastric and internal mammary
veins ;  a sixth, the vessels which ramify upon the oesophagus and
•empty into  the diaphragmatic veins.   Fatal hainorrhage has  been
reported by Audibert and Fauvel from oesophageal varices formed
in this way.  Thiebaudet reported a case running a latent course up
to a  fatal haemorrhage, the cause of which on autopsy was found to
have come from oesophageal  veins.   Litten found a plexus of dilated
veins at the lower end of the oesophagus seven times.  He attributes
dilatation of these vessels to the overfilling of the azygos into which
they empty.  Gratia  declares that  the sclerosis  extends throughout
the whole portal system and helps to cause the ascites.   Reitmann
collected twenty-four cases of severe or a fatal haemorrhage into the
gastro-intestinal canal.  One of these  cases had been diagnosticated
"ulcer of the stomach," a  mistake corrected only upon  autopsy.
De-Bove and  Courtois-Suffit also  report a case  considered gastric
ulcer.   The author had a similar experience.  A man of middle age
was suddenly  prostrated by  haemorrhage of  the  stomach, upon the
street, and was brought into the hospital exsanguine and unconscious
There was continuous discharge in large quantity of fluid black blood
from the mouth.  The haemorrhage resisted all means of relief, and
the  patient  dieel within twenty-four hours, without  a  history, and
without a diagnosis other than the  assumption of  a possible gastric
ulcer.   Autopsy disclosed no  lesion of the  stomach, but  a typical
cirrhosis with  the peculiar and exceptional condition of an enlarged 
CIRRHOSIS  OF THE LIVER.
467
left lobe.  It was subsequently ascertained that this individual had
been  a  heavy drinker and  had suffered from  repeated attacks of
hsematemesis.  Next to ulcer of  the  stomach,  cirrhosis  of the
liver is the most frequent cause of  copious vomiting of blood.
Rollett reported a case in which haemorrhage repeated itself at inter-
vals of from four to five weeks for a period of two years.
   Rokitansky first  called attention to the circle of tortuous  and
distended vessels  about the umbilicus,  representing the so-called
" caput Medusae,"  present in cases of cirrhosis rather as an exception
than  as a rule.  After much discussion concerning these vessels the
appearance is now admitted to be due to the reopened umbilical vein
(Bamberger, Baumgartner,  and Klebs).  These various avenues of
collateral circulation  may become  enlarged to  such a degree as to
relieve the pressure  in the  portal vein  and thus allow to disappear
the ascites  already  formed, or,  if  preternaturally of  large  size, to
prevent its  appearance altogether.  It is only in  this way that we
may account for the fact that a certain percentage of  cases, accord-
ing to Frerichs one-third of the whole number, shows no ascites at all.
   Digestive disturbance, partly the  direct effect  of alcohol, partly
the effect of arrest of the hepatic function ; emaciation, and corre-
sponding reduction of strength from the same cause; ascites; enlarge-
ment of the spleen;  haemorrhoids,  and  haemorrhages from mechani-
cal occlusions ; enlargement and subsequent contraction of  the liver
itself—these are the chief and prominent symptoms of cirrhosis.
   Jaundice is seldom marked.   Some  slight  discoloration of the
skin belongs to every case,  but  genuine icterus betokens  rather an
accidental complication (gall stone, compression by a band of hyper-
plastic tissue, catarrh of the bile ducts, etc.).   Icterus is exceptional
in cirrhosis, for the  simple  reason  that the destruction of the liver
cells prevents the formation of bile.
   General dropsy or cedema of the lower  extremities does not be-
long to the  symptomatology of cirrhosis.  A great accumulation of
ascites may compress the vena cava, or a profound debility, the gen-
eral result of the suppression  or annihilation of the function of the
liver, may cause general dropsy ;  but these factors are not  peculiar
to cirrhosis.   So accumulations of fluid in the abdomen, or the heavy
weight of the liver,  may interfere with the action of the diaphragm
and thus induce dyspnoea ; but symptoms on the part of the respira-
tory system do not constitute an integral part of  the  history of the
disease.
   The brain is clear in cirrhosis throughout the course of  the dis-
ease,  but toward its close, when atrophy of the liver cells has be-
come more or less complete, there  supervene at times grave symp-
toms on the part  of the  nervous system—delirium, convulsions, or 
468
CIRRHOSIS OF THE LIVER.
coma—which indicate the toxic effects of elements that sliould be
excreted with the bile.  Pain, or even tenderness, is quite exceptional,
and  is due, when present, to perihepatitis.  The shoulder-tip pain,
which may be present in cirrhosis as well as in every other organic
disease of the liver, is satisfactorily explained by the anatomical de-
monstration by Luschkaof the anastomosis of the phrenic and fourth
cervical nerves.
   The urine in cirrhosis furnishes most  valuable evidence1.   It  is
scanty, dark, and turbid, loaded with urates and other products of
combustion,  the  result of the widespread havoc  in nutrition.    A
clear and limpid urine would  speak strongly against the existence of
the cirrhotic process.  It is now well known  that  the  liver  is the
chief organ in the body in the manufacture  of urea, but it is not
necessary to  appeal  to this fact, when the waste  is so universal, to
account, in cirrhosis, for the  accumulation of the urates (undecom-
posed urea) in the urine.
   Lepine called attention to the glycogenic function of the liver in
connection with cirrhosis.  The liver makes and  uses  up sugar in
greater abundance than any other organ  in the body.  Lepine found
that sugar appeared  in the  urine of cirrhotic patients who had been
fed with it—a result that might have been inferred from the destruc-
tion  of the liver cells.   In cancer this is not the case, because cancer
is  mostly localized in the liver and does not cause such  universal
abolition of function.
   It is impossible to fix  the duration of cirrhosis ;  first, because  it
can never be known exactly when  it commences ; secondly, because
the course of the  disease may be interrupted  fatally (by a haemor-
rhage, or  as  the  result  of pressure of ascites upon the heart  and
lungs, etc.), or conservatively by arrest of the process  in the  first
stage or in the beginning  of  the  second.  While it is safe to say
that the prognosis is bad,  it is dangerous to proclaim that the pa-
tient must die soon, or must die at all of the disease.   Cases are  now
abundantly on record, and  they may be recalled  in the experience
of every clinician, where the disease process  has been brought  to
a stand and the patient has survived for  years.
   Diagnosis.—The diagnosis of cirrhosis of the liver in the presence
of ascites,  shrinkage, and patent vessels upon the surface of the ab-
domen, even without the history, is an  easy  matter.   Most impor-
tance attaches to the ascites, which means always obstruction to the
portal circulation, as the most frequent  cause of this obstruction  is
cirrhosis of the  liver.  Obstruction in the course of the portal  vein
itself —pyelophlebitis—is  much  more rare  and the resulting ascites
much  more rapid.   In the  first stage of  cirrhosis of the liver, or  in
the  hypertrophic  form, the organ  is distinctly enlarged.  It   may 
CIRRHOSIS OF THE LIVER.
469
 extend to the level of the umbilicus or even to that of the crest of the
 ilium.  Usually, however, the process of enlargement is  more lim-
 ited.   The edge of the liver may be felt an  inch or two  below the
 level of the ribs.  It is also usually tender  to pressure.  Sometimes,
 rarely, the nodules may be recognized by touch.   Any slight dimi-
 nution in size easily escapes recognition, especially in the presence of
 much abdominal fat.  Under all circumstances the liver usually pre-
 serves its upper line of  dulness, as it is pushed up or held in place
 by the colon distended with gas.   Much value attaches also to the
 condition of the spleen, which is enlarged in three-fourths of cases.
 The spleen is a reservoir into which is dammed back the  blood which
 may not escape into the liver.   Gastric and  intestinal catarrh, con-
 stipation,  tympanites, haemorrhoids, and  haemorrhages have been
 sufficiently remarked.  The hsematemesis of cirrhosis is sudden, un-
 preceded  by nausea, and unattended  with pain—points which help to
 distinguish it from that of gastric ulcer.
   During the stage or form of enlargement the disease must be dif-
 ferentiated from fatty liver, the icterus  liver, amyloid liver,  the leu-
 kaemic liver, and that peculiar hyperplasia which is known as hyper-
 trophic cirrhosis, or elephantiasis of the liver.   Fatty liver is softer
 and amyloid liver is hairier than  cirrhosis in the first stage.  Both
 these  degenerations may be usually ruled out by  absence of their
 etiological conditions—syphilis, tuberculosis, suppuration of  bones
 and joints.  The distention due to obstruction of  the bile ducts is
 excluded  by the absence of any marked .jaundice, and leukemia is
 ruled out by an examination of the blood corpuscles.
   Elephantiasis of the  liver—hypertrophic cirrhosis—is attended
 with a pronounced jaundice from the start.  In this condition there
 is no stasis  of  the portal vein and  no ascites.   Hypertrophic dis-
 tinguishes itself from atrophic cirrhosis  by  the fact that  the  connec-
 tive  tissue swells, but does not  subsequently contract;  hence there
 is no  compression  of the radicles of  the portal vein, no hyperaemia
 in the course of the portal tract, no hemorrhoids, and no ascites.
 On the other hand, jaundice is pronounced and is almost  univer-
 sally present.  Neverttieless the stools are frequently colored with
 bile.   The presence of jaundice under these conditions  is explained
 by primary inflammation of the gall  ducts.   There'is in this  form of
 the disease great tendency to nose-bleed, frequent pulse, and frequent
 cholsemia (Ewald).  The liver may be very much  enlarged.  The
 surface is usually smooth.   The spleen is swollen.  The absence
 of the history of alcoholism in more than half the cases,  the enlarge-
 ment of the liver and spleen, the presence of jaundice with  colored
stools, and the absence of ascites, sufficiently distinguish  this affec-
tion. 
470
CIRRHOSIS OF THE LIVER.
   Fluxionary hyperemias cause no obstacle to the circulation and
no ascites.  The change  which  takes place in the course1  of heart
disease, the  venous stasis which constitutes the  so-called  nutmeg
liver, is attended with shrinkage in volume, from which true1 cirrho-
sis must be distinguished.  It is enough here  to recall the fact that
the cardiac cirrhosis, so-called, must  show the evidence of cardiac
disease in the state of the heart itself and the evidence1 of  disturb-
ance of the circulation.  In cardiac cirrhosis, also, anasarca precedes
the ascites.   It will be remembered always that enlargement of  the
liver due to cirrhosis is very rare.
   Syphilis  rarely shrinks the liver  to the same degree ; it rather
subdivides it into additional lobes and lobules, not into granules as
in the course of true cirrhosis.   Leube declares that syphilitic hepa-
titis is attended with more pain.
   Simple atrophy  is found in connection with the marasmus of
wasting disease,  more especially of old age.   The liver maintains in
this condition a smooth surface and edge,  shows no granulation,  no
form of icterus, and no sign of block in the portal tract.
   The fluid  of ascites must be at times distinguished from that of
an ovarian cyst.  A low specific gravity,  under 1015, speaks always
for ascites.
   Pyelophlebitis and pyelothrombosis  are distinguished by  the
rapid development of ascites and other  evidence of portal obstruc-
tion," enlargement of the spleen, hsematemesis, venous ectasise on the
surface of the abdomen.   The discovery of a cause for the condition
—some ulcerative process in the course of the portal vein or its tribu-
taries, gall  stones, etc.—lends  further  aid.   The  discharge  of a
murky  fluid  by  aspiration or through  the trocar, as evidence  of
chronic peritonitis, speaks in favor of affection of the portal vein.
   The indicatio causalis in the treatment of cirrhosis is total ab-
stention from alcohol.  The time may come  when the patient will
need  some support,  and when  the light Rhine wines,  or even a
little  beer, may  be allowed ; but  any  stronger  drink must  stand
absolutely under  ban.  The diet should be light and nutritious, on a
basis  of milk and other animal food.   A few drops of Fowler's solu-
tion after meals will help digestion, absorption, and more  especially
assimilation.
   As for drugs in general, they may meet  the symptoms  only.
With any knowledge of the anatomy of  the  disease, one may not
hope  to  cure it.   A stomachic tonic, nux vomica gtt. x.-xx. in a
wineglass of water, or dilute  hydrochloric acid  gtt. x.-xx., or tlu.1
tincture  of the chloride  of iron in the same dose, likewise diluted,
may be written id aliquid faciat and as real aids to digestion.
   In  hsematemesis or enterorrhagia the treatment  should be  the 
CIRRHOSIS OF THE LIVER.
471
 very opposite of that employed in gastric ulcer; thus, instead of ergo-
 tin to contract vessels, remedies should be used to dilate the arteries
 and diminish the pressure in the  veins.  On account of its almost
 immediate action in this regard, the amyl  nitrite is especially indi-
 cated.   More prolonged effects may be secured with  nitroglycerin
 or other less powerful nitrites.
    The only remedial agent that merits the  name is puncture of the
 abdominal wall and release from the abdominal dropsy.  Early and
 frequent puncture is the result of the testimony of those who have
 had most to do with cirrhosis.  Murchison, especially, is emphatic in
 its praise.   To wait until life is endangered  on the part of the heart
 and lungs and kidneys is to let slip the  only chance  of arresting the
 disease.   The release of the dropsy sets all the absorbents free.  The
 peritoneum cannot pick up fluids under great pressure.  Moreover,
 and this is the main  advantage, the relief  of the  pressure  renders
 possible  the establishment of  the collateral circulation—a process to
 be favored in every way.  The removal of the cause of the disease
 by abstention from alcohol, and the removal of its worst effect by
 relief  of the dropsy,  give the  patient the most scientific  benefit.
 Purgatives (like  the salines, Carlsbad salts), diaphoretics (like jabo-
 randi), diuretics  (like digitalis), temics (like  iron), may all meet indi-
 cations at  times in the earlier history of the disease ; hut paracen-
 tesis will substitute all of them when ascites is fully declared.  Not
 only are the lungs relieved in this way,  but,  by the  removal of pres-
 sure from  the  portal and renal veins,  the secretion of  urine is in-
 creased.  " I have known haemorrhage from the bowels," Murchison
 relates, "arrested by paracentesis in cirrhosis  ; and it is a  common
 observation that patients with much ascites,  who, notwithstanding
 the most powerful diuretics, have been passing only a small quan-
 tity of urine containing much albumin, will, after paracentesis, and
 independently of drugs, void large quantities of urine free from al-
 bumin."   The same author quotes the experience of  Lyons, of Dub-
 lin, in a case which he  tapped thirty-six times at intervals of three
 or four weeks,  withdrawing  fourteen  to sixteen  quarts on  each
 occasion, with the effect of bringing the disease to a stand at the end
 of one year after the last operation.
   Thus  it may  be  hoped to hold the disease in  check, so far as the
 mechanical evils are concerned.   Unfortunately,  over the physio-
 logical evils there is less control.  The body must have bile.  A suc-
 cessful biliary fistula which carries off all the bile inevitably leads
 to the death of the animal by inanition.  Should  the interstitial pro-
 cess continue, which it  does  in the  rule, the liver  cells  are finally
killed,  bile is  no longer formed, and death by starvation results.
This is the mode of death in  most cases of cirrhosis, and death in 
472
HYPERTROPHIC CIRRHOSIS.
this  way is lege art is.  But the liver is immense  in  its size, it has
superfluous cells in abundance, it has also remarkable regenerative1
powers, and the disease process may be arrested  before destruction
becomes universal.

                    HYPERTROPHIC CIRRHOSIS.
   Hypertrophic cirrhosis ;  biliary cirrhosis.—Disease's of the1  liver
are usually divided into those which shrink and those' which increase
the size of the organ.   Cirrhosis, simple and acute atrophy, are1 the
affections which shrink the  liver.   More numerous are1 the diseases
which cause its  enlargement.   In this regard must  be considered
simple hypertrophy, hyperaemia, cancer, amyloid  and fatty degene-
ration,  echinococcus,  and syphilis.  Hypertrophy of  the liver—the
so-called hypertrophic cirrhosis, or hepatic  elephantiasis—is a  disease
of most modern recognition.  The practical value of its  separation
                             depends upon the fact that it has hith-
                             erto been regarded as the first stage of
                             true cirrhosis.   It is very questionable
                             if true cirrhosis be ever attended with
                             a preliminary stage  of  enlargement.
                             It is probable that the disease begins
                             with atrophy.   Hypertrophic cirrhosis
                             —the so-called hyperplasia of the' liver
                             —differs  radically from  true cirrhosis
                             in the fact  that, while  the  elisease af-
                             fects chiefly the connective tissue, this
                             tissue does  not  shrink  as in the true
                             cirrhosis, and hence is not followed by
                             symptoms of obstruction—hyperaemia
                             of the stomach and intestine, haemor-
                             rhoids, hsemorrhage, and ascites. On
                             the  other hand, enlargement  of the
                             spleen from the same cause is univer-
                             sally present, as is also icterus of high
                              degree.  Icterus is  always present—
 a point of especial difference between this disease and true cirrho-
 sis.   Rosenstein, who met with  this  affection frequently in  Hol-
 land, has come to the conclusion  that it is  a disease sui  generis
 and that  it never represents the  first stage  of  atrophic cirrhosis.
 Hypertrophic  cirrhosis  occurs exclusively  between the ages  of
 twenty and forty, while atrophic cirrhosis occurs after forty. Al-
 coholism,  the most frequent cause of atrophic cirrhosis, does  not so
 often produce the hypertrophic form.  Malaria with enlargement of
 the spleen plays a more distinct role in its production.   The  absence
 Fig. 19o.—Apparent enlargement of
the iiver,  the result of  tight lacing
(Murchison).     • 
ACUTE ATROPHY OF THE LIVER.
473
 of icterus in atrophic cirrhosis depends upon degeneration of the liver
 cells.  In hypertrophic  cirrhosis, instead of acholia there is poly-
 cholia to such degree that the gall ducts are not able to carry it off,
 hence the jaundice.  The association of icterus ivith stools colored
 by the excess of bile distinguishes this disease.  The enlargement  of
 the liver is  usually marked, its consistence moderately hard, its bor-
 der lightly rounded, its surface smooth.
   Enlargement must not be mistaken for simple downward depres-
 sion,  as by effusion in  the  right pleura, subphrenic abscess, tight
 lacing, etc.
   Hypertrophic is related to atrophic cirrhosis as is the large  white
 kidney to the contracted kidney.  Though the diseases are indepen-
 dent, the same transition forms may be observed.  It is highly prob-
 able that the cases of atrophic cirrhosis characterized by enlarge-
 ment in the first  stage  are  really cases of hypertrophic  cirrhosis.
 The disease lasts from  a month to  three years.   Death usually
 occurs with the nervous symptoms of  cholsemia.
   The treatment is wholly symptomatic and does not differ from
 that of the atrophic form.

                SIMPLE ATROPHY  OF THE LIVER.

   Simple atrophy of the liver is not a disease, but is part  process  of
 the general  shrinkage which occurs in age and  marasmus.  Conse-
 quently, while the dimensions of the liver are markedly reduced  in
 every  direction, the symptoms  of disease of the liver—pain,  jaun-
 dice, hsemorrhage, ascites, etc.—are entirely lacking.   These points
 make simple and easy a separation of this condition from cirrhosis.

                 ACUTE ATROPHY OF THE LIVER.   .

   Acute atrophy constitutes the gravest, but fortunately the rarest,
of the  diseases of the liver.   It is, indeed, amongst  the  rarest  of  all
 diseases.  Many practitioners of large experience have  never seen a
 case, and not more than one case is  seen in a large hospital in the
course of three or four years.   As  indicative of the rarity of the dis-
ease, even under favoring conditions, it may be said that Spaeth saw
it but twice  in thirty-three thousand cases, and  Braun  but once   in
twenty-eight thousand cases of childbirth.  The majority of cases
occur from adolescence to maturity, and in females nearly twice as
often as in males, usually in them in the last half of gravidity.
   Acute atrophy has  been observed to follow cirrhosis of  the liver,
sometimes as a sequel  to an acute  infection (puerperal fever, typhoid
fever, etc.),  and is always seen to occur in the  last stages of  acute 
474
WEIL S DISEASE.
poisoning by phosphorus.  These  conditions  account, however, for
but exceptional cases of a most exceptional disease.
   The cause of the disease is unknown.   It  must be something in
the nature of a virulent  chemical poison,  the product, probably, of
some micro-organism, to produce  such rapid and profound disinte-
gration of the substance of the liver.
   Symptoms.—The  disease begins with  the symptoms of an  or-
dinary gastro-intestinal catarrh, associated from the start with a
light degree of jaundice.   There is nothing ominous in the onset of
the disease.   It soon reveals  itself, however, in  its true character,
sometimes after a lapse of but few days, sometimes a few weeks, with
a train of unmistakable symptoms, especially  on the part of the ner-
vous system.  These symptoms—delirium  and convulsions, sopor,
stupor, coma—belong to the  history of icterus  gravis, and distin-
guish themselves in  this disease  by the suddenness of their occur-
rence and rapidity of their progress.  In connection with them occur
also hemorrhages free  from the various mucosae,  or subcutane-
ous as in the more protracted forms of icterus gravis.  In all cases
the striking feature of the disease is the shrinkage of the liver.  Per-
cussion reveals dulness at times of but one or two inches. Some-
times,  again, hepatic  dulness  may  not  be  distinguished at all.
Occurring in pregnancy,  it produces  miscarriage  with subsequent
metrorrhagia.
   The disease is distinguished, again, by the absence of fever. Some
elevation of temperature is commonly present  in the inception during
the stage of gastro intestinal catarrh.  After the  shrinkage has com-
menced or may be recognized the temperature  is normal, or even
subnormal, another distinguishing feature.  The urine is reduced
in quantity.  It contains, as a rule, quantities of leucin and tyro-
sin, together with constituents of bile. Tyrosin often discloses itself,
after the evaporation of the urine, in the  form  of delicate needles,
grouped  in  colorless bundles or globular  masses tinged with bile.
The urea is often diminished to mere traces.  Casts are occasionally
encountered.
   The duration of  the elisease is very short.  Death occurs in the
course of two or three days, after the supervention of  the signs of
icterus gravis.  The prognosis is fatal.
   The treatment is wholly symptomatic.  Lebert is said to have
cured a case with benzoic acid and musk ; Teissier, another with aco-
nite.  The absence of details in the description of these cases throws
doubt upon the diagnosis.  Yet Wiesing reports  from the literature
sixteen cases of recovery.
   Weil's Disease.—Under this title is described as  sui generis a
grave,  infectious icterus  which begins suddenly with  chill and high 
FATTY LIVER.
475
 fever, headache, pain in the loins, bones, and  joints, soon  followed
 by bronchitis, albuminuria, icterus, and tumor of the spleen.   Among
 recent authorities Alfermann admits and  Frankel denies it a special
 place in nosology.
                           HYPEREMIA.
    The liver certainly changes its size within certain limits, according
 to its distention with blood or bile.   The icterus liver is always large.
 Overfilling of the blood vessels may also  precipitately increase  the
 size  of the liver.   In stasis of the  liver icterus may or may not be
 present, in correspondence with the pressure or lack of pressure upon
 the gall ducts.  So, too, ascites may be present or absent, according
 to the degree of venous stasis.  Swelling of the spleen is almost al-
 ways present.   The characteristic feature is the alteration in the size
 of the liver in correspondence with the increased or decreased tone of
 the heart.  Hyperaemia of the liver indicates fault in the circulation.
 Usually there is some obstruction  in the  heart.   Valvular disease
 of the  heart, weakness of the heart muscle, heart failures, obstruc-
 tions in the lungs, lead to insufficiency of the  tricuspid valves and
 regurgitation into the liver. The stasis of the sublobular veins, with
 the altered nutrition of  the hepatic cells, gives rise to  that change of
 color, seen on section, which is characterized as the nutmeg liver.
    Hyperaemia of  the liver may,  therefore, be diagnosticated only in
 the presence of some fault of the circulation, usually in connection
 with  disease of the heart  or lungs.  The "congestion of the liver,"
 so often remarked by the laity,  has reference to distention by bile.
 This  congestion, or " torpidity," as  it is also called, is usually an ex-
 pression of gastro-duodenal or biliary catarrh, and  is in no sense a
 true congestion or hyperaemia.  At the same time it must be recog-
 nized that the liver has certain definite antiseptic properties,  interfer-
 ence  with which leads to accumulation of toxic matter in the intes-
 tine.  When a section of liver tissue is destroyed or a large artery tied,
 the animal dies in the first instance in eight to fourteen hours and  in
 the second in four to eight hours.  But if injected with an  emulsion
 of liver  substance  it may be  kept alive for several days (Masini).
 The dulness and distress of " biliousness " may be thus a real expres-
 sion of torpor or inactivity of the liver.

                          FATTY LIVER.
   Fatty liver never reaches the excessive grades of enlargement of
amyloid degeneration.   In the most extensive case of fatty degenera-
tion the  liver does not reach  below the umbilicus.  Its surface is
perfectly smooth, its consistence remarkably soft.  Fatty liver occurs
more  especially in  connection with tuberculosis, cancer, phosphorus 
426
CANCER OF THE LIVER.
poisoning, where it meets  its main expression.  It is  seen also in
certain cases of obesity.
   It is, as a rule, unattended with symptoms of disea.se of the liver—
pain, jaundice, and ascites—and is of interest only from the point of
view of differential diagnosis.

                         AMYLOID  LIVER.
   Amyloid  liver is only a part process of a widespread  degenera-
tion.   Amyloid degeneration is a peculiar  retrograde change in the
hepatic tissue.   It is usually found in connection with  amyloid de-
generation of the kidney, of the spleen, often of  the mucous mem-
brane of  the  intestinal  canal.   The  recognition of the  affection
depends, therefore, upon  its association with lesion of other organs.
It is found  as the result  of chronic suppurative processes, more
particularly of bone caries  and necrosis of bone, especially of pro-
tracted course, or suppurative processes  of the skin, mucous mem-
branes; sometimes  in  serous  membranes.  Empyema  may precede
for months the development of an amyloid change.  Syphilis, cancer,
malaria, leukaemia, Bright's disease, pyaemia, rheumatism, exhaust-
ing discharge, may develop this change.
   In amyloid degeneration the liver reaches at times great magni-
tude.  It  may largely fill up the  abdominal cavity.  As  a rule it
reaches to the vicinity of  the umbilicus.  The surface is  perfectly
smooth,  the border round, and the  consistence  very hard.   In
exceptional  cases the enlargement may be but slight and the border
sometimes remains sharp.  There  is no icterus  and no ascites,  save
that which occurs in the last stages of the disease in connection  with
anasarca.   The dropsy is confined  to  the  lower extremities.   The
condition  is recognized in the size of the liver in every direction, by
its uniformly  smooth surface,  resistance,  and by the absence  of
icterus and ascites.
   The etiology of the affection—bone caries, tuberculosis, inveterate
syphilis, chronic  malaria, carcinoma—bespeaks  the character of the
disease.   Attention is usually directed to the liver by the  discovery
in the urine of evidence of amyloid degeneration of the kidney.

                     CANCER OF  THE  LIVER.
   Cancer of the liver is usually secondary.  It is primary in but
eighteen per cent of cases (Siegrist).   In  the vast majority of cases it
occurs in  the course of cancer of the stomach.  Sometimes the can-
cer is quiescent in  the stomach, while the  secondary deposit in the
liver  assumes  prominence  and overshadows  the  primary lesion.
Cancer of the stomach  may be secondary also  to cancer of the
breast, uterus,  rectum, or other organ.   Thus a digital  examination 
CANCER OF  THE LIVER.                  477
of the rectum or vagina has often  led  to a  true  interpretation of
the nature of a chronic or grave affection of the liver.  Cancer of
the liver is sometimes latent,  and has been recognized upon the post-
mortem table in the  absence of  signs in life.  It betrays  itself
usually,  however, with  unmistakable  signs.  The volume of the
liver, as determined  by palpation and percussion,  is early  in-
creased,  and, soon reaches enormous dimensions.  It may extend
from the  angle of the scapula to the ileum.   The surface is hard,
but not  smooth; it is  broken by protuberances and nodules.
Icterus is present in  about  half the cases, and depends in degree
upon  the site of  the deposit.  Ascites  is present, but  is not, as a
  Fig. 197.—Cancer of the liver, a; with multiple metastases, b, b, b; within the liver (Ziegler\

rule,  pronounced.  The body of the liver  may  be  usually felt
through it under  forcible, especially intermittent, palpation.   The
fluid may be clear, but it is usually turbid or bloody.   Pain may  be
present or absent, and, when present, is rather an expression of a
perihepatitis.  The stools vary  in  color and consistence, according
to the presence or absence of bile.   In the later course of the disease
they are often stained or tinged with blood.
   As in cancer elsewhere, cachexia gradually develops.   The dis-
ease advances rapidly in the liver, and usually  takes life in the
course of six months to a year.
   Treatment is wholly palliative.
   Echinococcus of the liver is discussed in connection with tape-
worms. 
            DISEASES OF  THE
ORGAXS   OF   INSPIRATION:
                       CHAPTER  T.

            DISEASES  OF  THE NOSE  AND THROAT.

                     DISEASES  OF THE  NOSE.
   Diseases of the organs of respiration begin with the affections
of the nose.   Acute catarrh of the nose  is distinguished as coryza.
It is often found in association with catarrh of the conjunctiva and
of the throat, especially in connection with various infections,  to the
effluvia of which these mucous membranes are exposed.  These sur-
faces constitute the avenues of invasion.   Or the affection begins in
 Fig. 198.—Nasal mucus: a, ciliated ceils: b. leucocytes; r, capsule cocci; d, bacilli; e micrococci.

the nose and extends through  the  throat  to the  bronchial  tubes.
More frequently the affection  remains confined to the nose, to con-
stitute an acute or chronic nasal catarrh.
   Acute nasal  catarrh is the  evident  expression of some outside
irritant.  But that the irritant may also come from within is proven
by the effects of iodine, which, in toxic dose  or in susceptible indi-
viduals, produces  exquisite nasal catarrh.  The disease announces
itself by dryness,  burning, and  irritation, which produces more  or
less constant  sneezing.  Very soon the surface is moistened with a 
DISEASES  OF THE NOSE.
479
discharge; watery mucus accumulates and escapes upon the  face,
requiring the constant use of a handkerchief.   The  mucous mem-
brane swells, often to occlude the nares.   The  spongy  structure of
the mucous membrane permits rapid swelling, so that mere gravity,
as in lying upon one side of the body, will block one side of the  nose,
and the block may be changed by changing posture.  Fever,  more
or less headache, hebetude, soreness and pain  in the frontal region
which may  be due  to extension of  inflammation  to  connecting
sinuses, are further signs of an acute nasal catarrh.
    Chronic catarrh of the nose is much more  frequent.   It results
at times from repeated attacks  of  acute  catarrh.  It  occurs  most
frequently in connection with scrofula  (tuberculosis) and syphilis,
where it leads to alteration of  structure, hyperplasia  and occlusion,
           Fig. 169.                           Fig. 200.
Fig. 199.—Adenoid tissue at vault of pharynx (Luschka1.
Fig. 200.—Posterior nares iu the rhiuoscope: a, uvula; b, b, orifices of the EustachiaD tubes.
or atrophic change.   The process extends also to the posterior nares,
and is liable to invade the Eustachian tubes; it is therefore a com-
mon cause of  deafness.   The secretion is altered; it becomes more
or less profuse and offensive (ozsena) ; the true gland structure  in
the mucous membrane is destroyed.   According to Schuchardt the
ciliated epithelium is destroyed, and substituted by squamous cells,
which much more readily suffer decomposition.   Subsequently the
bone substratum itself may be affected.   Thus chronic catarrh is,  as
a rule, a specific process.
   Syph ilitic catarrh is especially wont to be attended with destruc-
tive change, ulcers, and necroses.  Gummatous perichondritis breaks
down the cartilage and bony structure, with the formation of exces- 
4.s0
DISEASES OF THE NOSE.
sively offensive discbarge, which dries to form crusts, under which
the destructive change continues, to constitute tlu1 syphilitic ozama.
   Treatment.—Acute catarrh of the nose is  a common expression
of a '" bad cold."  It is usually of short duration, and is best relieved
by quiet and rest in the house.  Sometimes an attack may  be  cut
short with a dose of Dover's powder gr.  viij.-x., and hot baths and
hot drinks to excite prof use diaphoresis.   Of a solution of atropia. gr.
i.-3 i,  three drops, repeated two  or three times a  day, will often
quickly relieve the distress of acute catarrh.  See. also treatment of
angina and of acute laryngitis.
   Chronic catarrh of the nose is a malady of months', often  years',
duration.  Successful therapy  depends  upon  a recognition  of its
cause.   Syphilis calls  for the use of mercury,  especially by  inunc-
tion, and iodide of potassium, under which the most  obstinate and
destructive changes speedily yield ;  scrofula for tuberculin, cod-liver
oil, creosote,  and the iodide of iron.  Free ventilation of rooms with
pure, fresh air is in all cases a  sine qua non.  Local .treatment is of
great value.  The  nose must be  kept clean with douches of salt water.
Warm water, containing a drachm  each of common salt and carbon-
ate of soda to the  pint, may be snuffed up the nose or introduced by
means of a syringe,  care being taken,  by keeping the source low, to
avoid penetration  of the Eustachian tubes.
   Ointments keep the mucous  membrane soft and the fossae open:

   B Acidi borici..................................................gr. xv.
     Unguenti petrolati............................................§ ss.
   M. A mass the size of a bean or hazelnut to be snuffecl up the nose morning and
evening.
Or—
   B Hydrargyri oxidi flavi .......................................gr. v.
     Unguenti petrolati............................................§ ss.
   M. To be introduced the same way.

   Fetid atrophic  processes are  best treated with iodoform, creolin,
creosote, or that combination known as europhen, which is an iodide
of creosote, hence less noxious in its effects, as  well as to the sense
of smell, than iodoform.  The remedy is best introduced in the form
of an ointment:

   B Europhen....................................................gr. x.
     Olei olivfe....................................................3 i.
     Lanolini.....................................................3 iij.
   M.
   Solutions of pyoktanin,  1 :100, introduced with a saturated cot-
ton-wrapped sound, purify  all secretions and rapidly penetrate the 
DISEASES  OF THE LARYNX.
481
recesses of the nose.  A very effective treatment of ozsena consists
in the application of the creolin-ichthyol solution.   The nose is first
washed out with an alkaline solution and thoroughly cleansed with
a cotton-wrapped  sound.   The ichthyol is applied in a five-per-cent
solution of creolin.   The bad odor rapidly disappears.  Hypertrophic
processes and occlusions are best removed by concentrated solutions
of trichloracetic acid, which  is also  applied with cotton.   The pain
which  occurs a few minutes after the application slowly subsides.
It is not so  easily subdued by previous applications of cocaine as
with  the use of the galvano-cautery.  The mucous membrane  is
burned snow-white under this  acid.  The  process of healing takes
place without reaction or pain.   The  incrustation is desquamated
quicker than after burning (Killian).  Finally, the practitioner may
have  recourse to the use  of the galvano-cautery.  Batteries with
suitable end apparatus are now furnished at very  reasonable  price.
    Polypi (mucous)  which may undergo cystic degeneration, adeno-
matous, telangiectatic, or fibroid growths, more exceptionally  chon-
dromata, steomata, sarcomata, occur in the nose or connecting cavi-
ties.
    Polypi,  etc., must be extracted by surgical means.

                    DISEASES OF  THE LARYNX.
    The progress of medicine is scarcely anywhere better exemplified
than in the diseases of the larynx.   Less than half a century ago the
interior of  the larynx was an undiscovered country.  The physician
was able to recognize  laryngeal disease in general, but was in no
way able to distinguish the  character of the disease.  The deepest
recesses of the body were not more dark than the interior of the
larynx.
   History.—Bozzini (1804) made an attempt to illuminate the inte-
rior of the body, but, so far as the throat was concerned, the attempt
reached the pharynx but  not the larynx.   Cagnard de Latour in
1825 actually introduced a mirror into the throat, but failed in reach-
ing any conclusions for want of light.  Two years later Babington
invented a  glottiscope with  mirror  and tongue depressor, and ac-
tually used  reflected light, by means of which  he claimed to  have
been able on several occasions to see  the epiglottis, but nothing more.
Selligues (1832), a  victim  of tuberculosis, made the attempt to in-
spect his own larynx, in the hope of  being able to treat himself.  He
constructed a speculum out of a closed tube, and, as might have been
imagined, saw nothing.  Baumes introduced a mirror fastened to
the end  of a fish bone as a stem,  and claimed to have seen by the aid
of it ulceration in the larynx.  Liston and Warden, with the use of
mirrors  and handles,  declared that they were able to  distinguish
        31 
482
DISEASES OF THE LABYNX.
oedema and swelling of the  epiglottis.   Thus  far crude experiment
with barren result.   The real illumination was  made  by a singing
teacher,  the celebrated  Manuel Garcia, who introduced  a mirror
deep in the throat, heated it in warm water to prevent the cloud of
the breath which shut off all sight, and  fixed his patient so that the
sunlight fell directly  upon the glass in the throat, and  so by the ad-
justment of the mirror was able to study the interior of the larynx.
Garcia studied the larynx from the  standpoint of the  vocalist.  He
watched the play of  the vocal cords during phonation and respira-
tion, and described the process in a monograph entitled  '" Physio-
logical Observations on  the Human Voice," communicated to the
Royal Society in  1855.  With  the use of an outside mirror Garcia
introduced auto-laryngoscopy.  He  studied the process in his own
throat.  Strange to say, this remarkable observation excited no inte-
rest or attention, and it was not until two years later that Ttirck, an
assistant at the General Hospital in Vienna, made these observations
                            anew.  Tiirck  also used  sunlight,  and
                            hence was able to study the subject only
                            in propitious weather.  He did not re-
                            alize  the  extent of his  discovery.   It
                            was different with Czermak, who bor-
                            rowed  the mirror of  Tiirck and  de-
                            veloped laryngoscopy.  Tiirck  had al-
                            ready discovered the  ease with which
                            the throat might be inspected by with-
  Fig. 201,-NormaHarynxandtrachea drawal °f the tongue.   Czermak adopt-
 to bifurcation of bronchi.          ed this method.  He was the first  also
                            to use artificial light, which enabled him
 to study the subject day and night.  He  became  inspired  with it.
 He was like a man who first saw the light after  a long  blindness.
 He travelled about to the different universities of Europe, gave di-
 rections in every  direction,  and practically established,  or gave
 the incentive which resulted in the  establishment  of  laryngologieal
 clinics  everywhere   (Fleischer).   A few years later Bruns took a
 tumor out of the throat of his own brother ; and in less than a de-
 cade  a host of observers—Semeleder, Schrotter, Gerhardt, Ziemssen,
 Voltolini, Tobold, Levin, Fauvel, Mackenzie, B. Frankel—described
 every process of disease.  Artificial is now substituted in our day by
 the electric light, which gives natural  colors and  appearances : and
 these discoveries, with  the invention of much apparatus, including
 the galvano-caustic storage battery with suitable electrodes, have, so
 to speak, turned the larynx inside out and  rendered all its  diseases,
 if not curable, recognizable and amenable to treatment.
     The diseases of the  larynx which most commonly call for treat-
 
CATARRHAL LARYNGITIS.
483
ment are acute and chronic catarrh—i.e., acute and chronic laryn-
gitis, including laryngismus stridulus (spasmodic croup), true croup,
oedema, perichondritis, and  paralysis.  The general diseases which
affect the  larynx are tuberculosis,  syphilis, and cancer.  They are
none of them confined to the larynx, with the exception, perhaps, of
cancer, which is not infrequently primary in the throat.
   Catarbhal Laryngitis is  very frequent and  is one of the ex-
pressions of a common cold.  Just how catching cold produces laryn-
gitis is as difficult to explain as is the process elsewhere.  It is often
assumed that hyperaemia liberates toxic  matters  from micro-organ-
isms at other times latent or quiescent.  It is known, for instance, of
the tubercle bacillus, that it  abounds in the lymph spaces and vessels
of the larynx.  These bacilli are derived in all cases through lymph
tracts from the lungs.   They almost never penetrate from the sur-
face of the mucosae.  The subjects  of tuberculosis are particularly
prone to suffer laryngeal affections.  The  first stage of tuberculosis
is a stage of catarrh, which  differs in no way from catarrh from any
other  cause.   There are individuals who suffer laryngitis with every
exposure.  They are for  the most part individuals who lead indoor
lives,  in whom  the mucous membrane is sensitive by  long stay in
over-heated and ill-ventilated apartments.   Criers, public speakers,
singers, preachers, auctioneers, are  particularly prone to laryngitis.
The laryngoscope reveals the condition.  The mucous membrane is
swollen, reddened, tumefied. The vocal cords, which should glisten
white like dog's teeth, are  tinged with  red here  and  there, or are
more  or less uniformly red. The  inside of the throat looks like a
piece  of red flannel.  It is  seen that the cords may not so closely
approximate each other in phonation.  The slightest swelling, or the
slightest failure in muscular tonicity, or the  slightest accumulation
of mucus  changes the character of the  voice.  The voice  loses its
individuality ; it becomes altered, hoarse, husky; the individual may
make himself heard only by straining efforts.  Finally the voice is
lost altogether and the patient is  reduced to whispers.
   Acute catarrh distinguishes itself by hyperaemia, chronic catarrh
by hypertrophy.  In chronic catarrh  the throat is not so red.  The
hue is more dusky, slate-colored  in  places.   The membrane is thick.
ened.   The  arytenoid cartilages are hindered in  their free move-
ments.  The interarytenoid  band is more thick.   There is, however,
no break of the surface, no such hyperplasia of  tissue as to consti-
tute a tumor, and, other  than thickening of the mucous membrane,
no deformity.   Motion may be more sluggish, but there is no paraly-
sis.  Often there is a sensation of  burning and  dryness.   There is
frequent,  harassing, rasping cough, with the extrusion of tough,
glutinous  mucus, which  may be seen adhering to  the vocal cords or 
4S4
CATARRHAL LARYNOITIS.
other parts of the interior of the larynx.  There may be in an acute1
inflammation slight fever.  In chronic catarrh the symptoms are less
intense but more persistent.  The voice remains husky ; it Incomes
susceptible to changes in the weather.  Raw, damp weather aggra-
vates chronic catarrh ; mild, dry, warm weather benefits it.  Indi-
viduals secure exemption by spending the fall and winter in Florida.
Lower California, or other warm climate.
   The treatment demands above all things rest, and the difficulty
of obtaining  satisfactory result is due to the fact that the avocation
of the individual requires more or less  constant use' of  the voice.
Singers must sing and preachers must preach.   Many of the victims
of chronic catarrh of  the larynx have a  mania to talk.   In some of
the worst of these cases the long-continued catarrhal process has
actually  brought  about  usury  of  the vocal  cords.  Irrepressible
talkers affected with this disease have actually talked away parts of
the vocal cords.
   The general principle of treatment consists in the application of
astringents.  The best astringent is nitrate of silver, one- or two-per-
cent solution, applied always with the cotton-wrapped sound under
the laryngoscope.  The plan in present use is  to  saturate quite a
large mass of cotton  in solution and apply it with the laryngeal
forceps directly into the throat, if necessary after an application of
a  four-per-cent  solution  of cocaine,  which is  itself sometimes  used
alone in highly sensitive cases.  Practitioners  have preferences  in
the choice of astringents.   Tannin has advocates, as has also ferric
alum.  Others prefer the more antiseptic preparations—carbolic acid,
permanganate  of potash,  sublimate  solutions, thymol, pyoktanin,
aristol, dermatol, etc.  In  chronic catarrh with much hypertrophic
change no remedy equals  in value the galvano-cautery in light and
momentary touch.  Inhalations  are  of value,  best by steam from
the atomizer and medication with common salt, preferably with the
bicarbonate of soda, saturated solution, or an astringent, as specified.
Gargles  assist in controlling an associate pharyngitis.  They are of
no value in laryngitis  proper.  Sponges should be abolished,  as
should also brushes.  Applications should be made with fresh cotton
by means of the laryngeal forceps.
   Acute cases are often relieved by compresses, cloths saturated in
water, hot or cold, applied about the throat and enveloped in thick,
dry cloths.   Broken doses of  Dover's powder,  or  a round dose of
Dover's  powder, ten grains  at night, with a hot bath and free dia-
phoresis, may cut short an acute case.  A round dose of quinine with
an ounce of whiskey may have the same effect.  Treatment in gene-
ral is that of a common cold.  Chronic cases are especially defiant of
treatment.   They  try the patience  of the  practitioner.  They are 
(EDEMA OF THE GLOTTIS—PERICHONDRITIS.        485
 often associated with hypochondriasis.  They furnish the basis for
 the  specialist.  They are often entirely relieved, as stated, only by
 change of climate.
   CEdema of the  Glottis is a much more serious affection.  It
 occurs most frequently as the result of an  outside  cause, as from
 Bright's disease, disease of the lungs, emphysema, heart disease, etc.
 In only one-third of the cases does oedema arise from affection of the
 larynx  proper, and then more frequently in the  course of acute
 laryngitis.  CEdema  gives great gravity to an ordinary case of laryn-
 gitis, and, in association with oedema of the lungs, is often the termi-
 nal link  in the chain of disease process.  CEdema may extend above
 the  larynx to  involve the palate, and more especially the uvula,
 which sometimes has the appearance of
 a Malaga grape.  The rim of the  oede-
 matous  epiglottis may occasionally be
 seen on depressing the tongue.  For the
 most part the condition must be felt, not
 seen.  It may  be recognized, by the fin-
 ger  introduced deep in the throat, as a
 soft, semi-fluctuating mass about the
 base of the epiglottis.   It is  necessary
 to recognize oedema early, that the fluid
 may be  evacuated while it  will flow.
 Scarification is  the treatment, with a bis-
 toury wrapped close  to the end that it
 may not penetrate too  deeply.  Where
 incisions  are not  practised sufficiently
 early the  fluid sets—i.e., gelatinizes—
 and  subsequent scarification will not  evacuate it.
 be had to intubation  or tracheotomy.
   Perichondritis  depends  upon the graver diseases, tuberculosis,
 syphilis, and cancer.  It does sometimes occur, however, in the course
 of an excessively obstinate chronic catarrh.  In the majority of cases
 it shows itself as a more acute complication in the course of septic dis-
 eases or the infections.  Perichondritis may occur in consequence of
 variola, rubeola, more rarely scarlatina, still more rarely erysipelas.
 The  cricoid cartilage is chiefly the seat of the disease.  The thyroid
 is rarely involved, and the arytenoid only in the most exceptional case.
 It is  recognized by the  pain in the region of  the larynx, more espe-
 cially by  the tenderness.  Fluctuation, as detected by outside pal-
pation, may reveal the presence  of  phlegmonous  inflammation or
 abscess.
   The diagnosis  is usually disclosed by the laryngoscope, wdiich
shows at a glance more or less deformity.
the glottis
Resort must then 
4S(i
TUBERCULOSIS OF THE LABYNX.
   The prognosis will depend upon the original disease, as we'll as
upon the amount  of deformity.  It is always grave, because of the
gravity of its cause.  Immediate danger of stenosis may be obviated
                              by incision, by dilatation, by  intuba-
                  j£            tion, by tracheotomy.  The procedure
                              will be determined in the individual
                              case.
                                 Next to catarrhal laryngitis the
                              most  frequent affection  is  Ttbkb-
                              culosis,  caused,  as  stated,  by the
                              direct  invasion  of the  submucous
                              lymph spaces and vessels by the tu-
                              bercle bacillus derived from the lungs.
                              It produces at  first  only catarrhal
                              changes, present at times and absent
                              at times, but with more or less ten-
dency  to  continual recurrence, later more pronounced hyperaemia,
more limited localization of lesion, tumefaction,  ulceration, eventual
extreme deformity.   Cough, dysphagia, and dyspnoea, along with
 Fig. 203.—Advanced tuberculosis of the
larynx.
Fig. 201. —Papilloma of the larynx (Ingals).
Fig. 205.—Fibroid tumor of the larynx,
complete  aphonia,  distinguish  these  cases.  The aphonia assumes
prominence.  It is sometimes the only symptom to indicate disease of
the larynx, so far as outside symptoms go.  The laryngoscope clears
the diagnosis at a  glance.   Very often the in-
side of the larynx cannot  be  seen at all, but
is hidden under an immensely swollen, tume-
fied, oedematous, sometimes ulcerated epiglot-
tis.  It is  interesting to  observe  the  gradual
elevation  of this overhanging epiglottis under
applications  of  cocaine,  and more especially
under the use of tuberculin.   The same changes
are observed in the interior of the larynx, on
the lips of the  glottis, viz.. tumefied  cords, hyperaemic, oedematous.
distorted bands, obliterated sinuses, various deformities.
   The prognosis is exceedingly grave.   Laryngeal tuberculosis usu-
Cancer of the 
PABALYSIS  OF  THE  LARYNX.
487
  Fig. 207.—Normal larynx.  Position of cords
in deep inspiration.
  Fig. 208. —'Normal larynx.  Posi-
tion of cords in phonation.
  Fig. 209. — Paralysis  of  the   Fig. 210.—Paralysis of both thyro-   Fig. 211.—Paralysis of the aryte
arytenoid in phonation.         arytenoids in phonation.           noid and both  thyro-arytenoids in
                                                                 phonation.
  Fig. 212.—Paralysis of left recurrent
in respiration.
  Fig. 213.—Paralysis of left  re-
current in phonation.
  Fig. 214.—Paralysis of right pos-    Fig. 215.—Paralysis of  both pos-    Fig. 216.—Paralysis of both recur-
terior crico-arytenoid in respira-  terior crico-arytenoids in respira-  rents—cadaver,
tion.                             tion. 
488      SYPHILIS—PARALYSIS—TUMORS <»F THE LARYNX.

ally defies all kinds of treatment.  A patient with marked laryngeal
tuberculosis has without treatment, as a rule, at the outside not more
than six months to live.
   The treatment is that of tuberculosis in general, especially by tu-
berculin, creosote,  arsenic,  cod-liver  oil,  altitude, etc.   Local treat-
ment consists in the use of cocaine to allay extreme hyponesthesia and
dysphagia; the insufflation of iodoform; or, far better, the application,
with a brush, of lactic acid solutions,  twenty to eighty per cent.  The
last  stages demand morphia by insufflation.  Applications  do  not
reach  the larynx at all  unless  made  under the mirror in  a good
light.
   Curious lesions occur in  the mucous membrane in consequence of
typhoid fever.  Ecchymoses, erosions of  tissue, show themselves on
the under surface of the epiglottis, and especially on the  front wall
of the  larynx, produced by the  typhoid bacillus, or more probably
by bacteria of mixed infection.
   Syphilis shows itself in the larynx at first as an ordinary catarrh;
subsequently, with infiltration,  hyperplasia, and ulceration, most
frequently of the epiglottis, vocal  cords, and posterior wall of the
larynx.  Extensive necroses may denude large masses of cartilage.
Syphilis shows itself also in the form of gummatous deposit in the
epiglottis and vocal cords,  which  may result in ulceration and de-
struction, perichondritis and  necroses, with  great  deformity.  The
diagnosis rests upon the  recognition of the disease elsewhere in the
body, and upon the results of specific treatment by mercurial inunc-
tions, the iodides, which should always  be tried in questionable cases,
that the patient may have the benefit of a doubt.
   Paralysis of the Larynx occurs  in connection with lesions of
the brain and spinal cord (bulbar lesions), as the result of pressure
upon nerve trunks, as of the left recurrent in aneurism of  the aorta,
and in  consequence of accident  to or  disease of the larynx itself.
These various paralyses are shown in the figures on page 487, taken
from  Wesener's work on diagnosis.  Aphonia or dysphonia, some-
times dyspnoea and dysphagia, are the  principal signs of these para-
lyses, which are treated generally by address to the cause, and locally
by strychnia subcutaneously and electricity.
   Tumors of the larynx, polypi, etc., which are easily visible under
the laryngoscope, may be removed, under cocaine ten per cent, with
the forceps, or may be destroyed by caustics, or, better, by the gal-
vano-cautery.   Cancer, which shows  itself in more advanced  life
with pain, lymphadenitis, and deformity, justifies extensive exsection,
with, if necessary, substitution by an artificial larynx. 
OIIAPTEE  VI.
                    DISEASES OF THE LUNGS.

                            BRONCHITIS.

    Inflammation, for the most part infection, of  the bronchial
 tubes.
    Bronchitis  is the most  frequent of all  diseases.   It  constitutes
 three-tenths of all internal maladies.   It affects all ages, with es-
 pecial predilection for both ends of life.  It increases in frequency
 from the equator toward the poles.  It is recognized  in forms acute
 and chronic, circumscribed and diffuse, ascending and descending,
 with varieties according  to the character of the secretion and the
 condition of the bronchial walls ; but  the division which has chief
 interest  is into primary and secondary, the so-called  idiopathic and
 symptomatic forms.
    Etiology.—It is easy to understand the origin of cases of primary
 bronchitis caused  by the action of irritating or irrespirable gases or
 dusts.  Individuals employed in factories for the production of am-
 monia, chlorine, iodine, bromine, or  strong  mineral acids show oc-
 casional attacks of bronchitis until the mucous membranes become
 habituated  to the irritant.  So, too, it is  easy to understand bron-
 chitis or tracheo-bronchitis which results from the irritation of steam
 or  dusts.  Thus, engineers, bakers,  millers, stone masons, miners,
 brushmakers, polishers, housemaids  who  are engaged  much in
 sweeping, furnish another contingent of cases of bronchitis.  But the
 vast majority of cases of primary bronchitis arise independently of
 all  these conditions and are commonly  ascribed to the process of tak-
 ing cold.
    Secondary bronchitis develops in  consequence more especially of
 the infectious diseases.  Bronchitis belongs  to measles,  small-pox,
 hay fever,  typhoid fever, and  constitutes  an  integral symptom of
 these diseases.   Bronchitis is also frequently  found in connection
 with diphtheria, universally in connection with tuberculosis,  also
 almost universally, at least periodically, in association with asthma
 and emphysema. There is also more or less bronchitis in pneumonia
and pleurisy.  Inasmuch as bronchitis  shows itself in the infections 
490                         BRONCHITIS.
in the first part of the malady, it is fair  to assume that the cause of
the disease lodges in the bronchial tubes.   The acute exanthemata
arise from a contagium vivum, and bronchitis is  the first expression
of the irritation of micro-organisms, as a diarrhoea results from the
action of intestinal parasites.
   Secondary or symptomatic bronchitis occurs  also in connection
with mechanical disturbances of the circulation—that  is,  of nutri-
tion of the bronchial mucous membrane.  Bronchitis belongs to the
later stages of  heart disease, and shows  itself in  intensity in corre-
spondence with the  damage done to the heart.   Thus bronchitis is
more or less universal in tricuspid insufficiency.   For the same rea-
son bronchitis  occurs  in the course of cirrhosis of the liver or the
kidneys.  Every form of kidney disease which results ultimately in
heart failure is attended with bronchitis.   Bronchitis may  arise also
mechanically in the course of ascites or  tumors  of the abdomen of
rapid course, which interfere with the action of the diaphragm.
   The bronchitis which belongs especially to the chapter of bron-
chial catarrh is the malady which begins  in the bronchial tubes, and
which is ascribed to  taking cold.  " Catching cold " is really only a
synonym for contracting disease, for bronchitis does not result from
any change of  temperature.   Individuals plunge heated into a cold
bath and emerge without bronchitis.  Bronchitis is rare in the cold-
est regions; it is almost unknown in the Arctic zone.  So, also, bron-
chitis is almost unknown in the prairies,  in  the open sea, at the tops
of mountains—places where the air is rare and cold ; not because the
air is cold or rare, but because it is more pure.  Colds are caught in-
doors, not out-of-doors.  It is safe to say that most cases of bron-
chitis result from the  action of micro-organisms of very great vari-
ety.   Thus it is known that typical bronchitis occurs in connection
with tuberculosis and pneumonia.  But  that bronchitis may result
from  the action of micro-organisms indirectly, and be due rather to
their products than their presence, is shown  in the typical bronchitis
of typhoid fever, which is caused by a bacillus that is never found in
the bronchial tubes.  Individuals who live in the out-door air, and
who are subject to the greatest exposure, the most marked vicissi-
tudes of weather, seldom suffer from bronchitis.    Sailors have bron-
chitis on  shore, not  at sea ;  soldiers in barrack  life; inhabitants of
cities rather than the inhabitants of the country.
   Geigel states that more illegitimate than  legitimate children
suffer and die from diseases of the  alimentary canal, but that more
legitimate children die of diseases of the respiratory tract.  Illegiti-
mate children die from neglect, bad food, and legitimate from cod-
dling and confinement to the house, protection from every  exposure.
House air. as contaminated by closed windows, ill-ventilated com- 
ACUTE BRONCHITIS.
491
partments, more  especially  by crowds in tenement houses, public
assembly  rooms, concerts, theatres,  etc.,  schools and kindergarten,
court houses anel post offices, public buildings where men congregate
and where the products of men accumulate—these are the breeding-
places  of  bronchitis.  So  the  "cold"  which is manifest on return
from the theatre or ball room, if not present in latent form before,
was caught in the room and not on the way home.
   One of the most valuable acquisitions of our day in reference to
bronchitis is  the  frequency with which  it is  caused by, or is the
manifestation of, tuberculosis.   Many cases of tuberculosis neyer
go beyond the stage of bronchial catarrh, which may show itself in
exacerbations and remissions, the real nature  of which  is only dis-
covered by an examination of the sputum,  or more readily and surely
by the  use of tuberculin  with the Koch  syringe, after  the manner
specified in the chapter on  Tuberculosis.  Statistics, such as are
furnished  by  oculists  in  the examination of the eyes  of children,
when brought to  bear upon the  examination  of the sputum of the
school room, the work shop,  or the public  hall, may alone show how
          Fig. 217.—Koch's syringe : action of piston substituted by rubber ball.
 widespread is the catarrhal tuberculosis which is now known in most
 cases simply as an innocent bronchial catarrh.
    Acute bronchitis  shows  but few morbid changes, however dif-
 fuse the disease or distressing the symptoms.   The condition fades
 to leave no trace.  The morbid anatomy of  acute bronchitis is best
 studied during life, where it may be seen in the beginning of the
 bronchial tree.  It has  been abundantly observed  that  the  same
 hyperaemia and swelling of the bronchial mucous membrane extends
 into the bifurcation of the bronchial tubes and into the bodies of the
 tubes as far as can be seen.   It is seldom possible to see much further
 than the bifurcation of the bronchial tubes.   At this particular part
 the signs of inflammation are  pronounced.  There  is more or less
 diffuse  redness, distinct  swelling,  even  tenderness to  pressure from
 the outside, which pressure will at times beget  an exceedingly irri-
 tating, prolonged cough.  A tough, tenacious mucus  covers the sur-
 face.  In more chronic cases the mucous membrane is more distinctly
•hypertrophied, more  especially discolored to assume a slaty hue.
 Pigment deposits  are found more  or  less  abundantly distributed
 throughout the bronchial mucous membrane. Patches of atelectasis
occur in connection with the emphysematous process in the vicinity.
   Symptoms.—Scarcely any disease varies more in  intensity than 
492
ACUTE BRONCHITIS.
bronchial catarrh;  from the slightest grades  of inflammation, con-
fined  to  the  mucous membrane of the trachea and main branches
of the bronchial tree, which  hardly  show any symptoms at  all,
at least in adults, to more or less universal involvement of the finer
tubes, with more or less complete occlusion,  and  hence  dyspiuva,
suffocation, convulsions—the picture of capillary bronchitis, with all
intervening grades of intensity.  Thus the disease presents totally
different aspects.   Inflammation confined to the trachea  and large1
bronchi furnishes, as a rule, in adults  but few  symptoms.   Constrie-
tiqn, irritation, a sense of rawness, more especially a sense of tickling,
usually relieved by  a sharp cough  which literally scratches the
mucous membrane  in this region, slight expectoration of tough, tena-
cious mucus, few or no constitutional symptoms—this is the picture
of ordinary bronchial catarrh as seen in adults.   It does  not in any
way incapacitate the individual  for work, or, as a rule, call  for the
use of drugs.  In childhood  and advanced life the picture  may be
quite  different, even though the disease be limited to this  region.
The narrower calibre of the tubes in  childhood produces a greater
degree of stenosis, and the muscular failures of  senescence lead to
the accumulation  of mucus, epithelial  debris, etc., which may  be
aspirated in the deeper parts of  the lungs, to lead  here to symptoms
of capillary  bronchitis or catarrhal  pneumonia.   In  childhood  in
these cases the cough is much  more severe, the breathing more fre-
quent, the distress  from insufficient aeration of the blood more ap-
parent.   Duskiness of the face, cyanosis,  somnolence, convulsions,
coma, may occur in these cases, and are  especially wont to occur
where the individual is already debilitated by tuberculosis, syphilis,
or rickets. • The symptoms assume intensity in all cases  as the dis-
ease attacks the finer  bronchial  tubes, until finally, when it invades
the finest tubes to produce the so-called capillary bronchitis, the case
assumes the gravity of real catarrhal pneumonia.   In fact, the diag-
nosis between these diseases is well-nigh impossible.
   The lighter forms of bronchitis show no physical signs on  in-
spection.  The chest movements are  not  inhibited.   There is no-
where any consolidation.   The air still finds access to the  recesses of
the lung, so  that  auscultation  may disclose no sign of the disease.
This is especially the case in the tracheo-bronchitis of  adults, which
is revealed only by  subjective  signs, and  more  distinctly by the
laryngoscope, when  the  lining membrane  of  the  trachea  may
be seen to be inflamed, the disease concentrating itself more  espe-
cially at the point of  bifurcation.  Here, however, as elsewhere, the
tubes may be silent, so far as physical signs are concerned.  In the
middle-sized  tubes the diagnosis often  rests upon the physical signs.
This is more especially true of  the differential diagnosis.  There is
still no limitation  of  the excursions  of  the chest.   The chest walls 
CAPILLABY BRONCHITIS.
493
 still rise and fall to the same degree as in the normal state.  Men-
 suration shows no difference.   No  sign is  yielded to  percussion.
 Even  slight lobular consolidations, more especially if central, may
 escape detection by percussion.  All the more rich in signs is auscul-
 tation. As a result of  thickening of the walls of the tubes, an ob-
 stacle is offered to  the entrance of air,  and coarse groaning, hum-
 ming, sonorous rhonchi pervade the chest. What distinguishes them
 as  belonging to this disease is not so much their character as their
 distribution.  They are heard not only below the clavicles, but over
 the whole of the anterior surface of  the chest, in the lateral regions
 also,  posteriorly, behind the clavicles  and below.  The dry  rales
 are indicative of  the stages of  hyperaemia and occlusion  by the
 swollen mucous membrane.  They  give place, in  the  course of
 twenty-four to forty-eight hours, to moist sounds produced by the
 exudation of fluid.   Every variety of moist sounds may be heard in
 the chest, from  the coarse mucous rale to the finest crepitation.  It
 is here, again, not  so much  the  character of the sound as its wide
 distribution which is characteristic of bronchitis.  The rales are sym-
 metrical ; they occur in both lungs; they are  confined to no  parti-
 cular  region of the  chest.  What again distinguishes  them is the
 fact that they appear and disappear.   A more  profound inspiration
 or  expiration, more particularly a sharp cough, may  change the
 rales  from  moist to dry, or dissipate them altogether  for a time;
 then  they   recur.   The  universality  of the rales,  their fugacity.
 their change in character, distinguish bronchitis from diseases which
 may show the same signs at certain periods or at certain places.

                     CAPILLARY  BBONCHITIS.
    Capillary bronchitis  is recognized by the  frequency of breath-
 ing, the respiration increasing to from 40  to 80 in a  minute ; by
 the increase in the fever, which shows temperatures ranging  from
 102° to 105° ; by increase in the pulse rate, 160  to 180, in correspon-
 dence with the elevation of temperature.  Notwithstanding the in-
 creased frequency of breathing, dyspnoea becomes  more and more
 pronounced, the occlusion of the bronchial tubes leads to  atelectasis,
 and the lung can now no longer follow the excursions of the chest.
 This limitation of movement becomes apparent with every act of in-
 spiration.   The  supra-  and infraclavicular fossse,  the intercostal
 spaces, the  region  about the insertion  of the  diaphragm, and the
 whole  lower zone of the chest retract and sink with every act of in-
 spiration.   It is thus established that the lungs themselves, blocked
in their bronchial tubes, remain  more  or less immobile.   The defec-
tive expansion is shown more distinctly in defective aeration of the
blood.  Cyanosis, which reveals itself first to the practised eye about
the  lips, spreads gradually over the face; the finger  nails assume a 
494
CAPILLARY  BRONCHITIS.
bluish tint.   In the course of a few hours or a few days the extremi-
ties, then the whole body, become1 more or less distinctly dusky or
blue.  The anxiety of the patient becomes intense1.   Hereupon en-
sues the pitiable struggle for air, the silent, pain inflicting appeals to
relatives for relief.  As the cyanosis increases the sensitiveness of
the nervous  system becomes  gradually obtunded, the struggle for
air is less pronounced, the condition of excitement gives  place to
apathy, and there is at this  time an apparent but illusory improve-
ment.  Convulsions ensue at any time during this stage.   Comatose
states, sudden heart failures, put a merciful end to the scene.
   Capillary bronchitis is recognized for the most part by obtrusive
signs.  The frequency of breathing, the dyspnoea, the cyanosis, the
fever, the nervous  anxiety, above all things the retraction  of the
chest on inspiration,  distinguish capillary from coarser  forms of
bronchial catarrh.   In capillary  bronchitis, which  runs a  more
latent course, there is usually a history of catarrh which comes and
goes, which seems more directly dependent upon the weather, which
is present in the winter to  disappear in the spring, or whose pre-
sence or absence may be determined by change of residence.  There
is a cough, which  remains  unnoticed because of its long continu-
ance.  Old men have a " coughing spell " in the morning for  years,
and then are compelled to cough little or not at all during the rest of
the day.   They must expectorate the mucus which has accumulated
over-night.   The disease is more or less continuously present in these
cases, but is subject to exacerbations and remissions ; and it is only
when the exacerbation is attended by marked signs,  as  by increase
of fever,  violence of cough, pains in the limbs and joints, that the in-
dividual  will say he has caught a fresh cold and attention  is di-
rected to the disease.   Not infrequently the disease is recognized by
the conscientious physician,  who makes a thorough examination of
the body in the hope of discovering somewhere a latent  cause for
the symptoms of prostration.  In other words, a capillary bronchitis
in general has the same history as a catarrhal pneumonia.  There
may be in cases no dyspnoea, no anxiety, merely an increased weak-
ness which confines the individual to his room,  to his chair, to his
bed, and of which the cause is not apparent.  The physician ascer-
tains that the pulse is quick, that the skin is dry, that there is fever,
that the amount of urine is diminished, its specific gravity increased,
and its color  heightened, and he more or less suddenly comes upon
the bronchitis  in the course  of his examination.  The chest move-
ments  are feeble; respiration  is' more or less abdominal.   The tape
line reveals not more than an inch difference, if that, between  inspi-
ration and expiration.  There may have been made a diagnosis of
general debility from old age.  Percussion shows no  dulness, as a
rule, though there may be strips of dulness  along the spinal column 
CHE0NIC BBONCHITIS.
495
—proof that the disease has associated unto itself a catarrhal or a
hypostatic pneumonia.
   Auscultation tells the story.  A feeble, muffled, or absent vesicu-
lar rale, sibilant or sonorous rhonchi, scanty, tenacious expectoration
tinged with blood, make the diagnosis.  We look for the disease in
childhood in connection with measles, small-pox, and typhoid fever.
It is not infrequently a  sequel of diphtheria ; it belongs  to tubercu-
losis in all parts of its course.   It assumes gravity in childhood for
the reason,  as  stated, that the  tubes  are finer and the  amount of
swelling that would offer no appreciable occlusion in the adult lung
produces stenosis in a child's lung.  Then the  tubes are shorter in a
child's lung, so that diseased  particles  which would lodge some-
where along the surface of the  big  tubes  of the adult penetrate
to the recesses  of the child's  lung.   Both childhood  and old age
are more  liable to bronchitis from the fact that the  power of ex-
piration and expectoration  is less marked.  There  is not the same
resilience  in the lung  substance itself, and there  is not the same
muscle force outside the lung,  so  that  in both these cases  infec-
tions are liable to be introduced by aspiration from the mouth,  from
the throat, and  from the larger bronchi.  Mucus accumulates in the
mouth and throat, mucus from the nose, epithelial debris,- decompos-
ing food,  vomited  matter, micro-organisms for which  the mouth is
a reservoir—all these materials may be aspirated into the recesses of
the lungs, to produce first a bronchial catarrh, later  even a putrid
bronchitis or gangrene of the lung itself.

                      CHRONIC  BRONCHITIS.
   Chronic  bronchitis occurs frequently as a result of the  acute
form of the disease, especially  as the result of repeated attacks of
acute bronchial catarrh, but much more frequently as  a  result of
other affections of the lungs.  Thus chronic bronchitis is a more or
less  constant companion of emphysema, tuberculosis, and chronic
pleurisy,  especially in its purulent  form, empyema, and still  more
frequently it results from diseases of other organs which  interfere
with  the  circulation in the lungs.  Thus heart  disease,  kidney dis-
ease, and  diseases of the liver are attended at some time or other in
their course by bronchitis, subacute or chronic.
   Chronic bronchitis distinguishes  itself by its  subacute character,
not only as regards duration, but intensity of symptoms.   Violent
symptoms in its course betoken  acute complications, to which pa-
tients affected  with chronic bronchitis are especially liable.    The
cough is not so frequent or  severe, but continues over a longer time.
Expectoration,  on the other hand, may be much more abundant and
different in many particulars.   Dyspnoea is not, as a rule, so pro-
nounced.  It is  a disease, however, which is by no means  a trivial 
496                     BRONCHORRH(KA.
affection.  It may  be, and often is, followed by complications of
gravity.   Nearly all cases of long standing show some1 emphysema.
The chief damage, however, is done to the heart as a result of long-
continued cough and strain.   There occurs hypertrophy of the right
ventricle, which in time must result in degeneration, dilatation, and
incompetency.   There are present then cyanosis, cedema, dyspnoea,
syncope attendant upon heart failure, with, in more protracted cases,
oliguria, with the consequence  of stasis of the  kidney, somnolence
or insomnia, headache,  dropsies, and coma.  So, while,  as  a rule,
chronic bronchitis is not a disease of  gravity quoad  vitam, it has a
more or less grave prognosis quoad valetudinem, and may in special
cases, more especially cases  debilitated  by other disease, still more
frequently in age, be attended, through  its consequences, with fatal
results.  The fact is continually to be emphasized that chronic bron-
chitis is  rarely a  consequence of acute bronchitis.  It is mostly a
secondary malady due to affections of other organs.
   Bronchitis is  often divided  into two  forms, according  to  the
abundance of its secretion.   Thus there is a dry bronchitis, the ca-
tarrhe sec of Laennec.   This form of inflammation attacks more
especially the finer bronchial tubes, where the same amount of swell-
ing  produces marked occlusion,  and is  characterized therefore by
dyspnoea which seems out of proportion to the physical signs.  There
is no expectoration,  there is  sharp dyspnoea,  more pronounced cya-
nosis, anxiety, nervous unrest, and distress.  This form of bronchi-
tis is found frequently as a consequence, or in the course, of measles,
whooping cough,  and tuberculosis, and, because developing  gradu-
ally, is discovered more or less suddenly, especially in cases of apa-
thetic, debilitated aged persons who have made no  complaint that
might call attention  to the lungs.

                        BRONCHORRHCEA.
   On the other hand, there is a form of bronchitis which is attended
by such  profuse expectoration as to merit the name bronchorrhoea.
The discharge  consists of thin, watery, frothy matter, which sepa-
rates itself into layers.  Pints  or quarts of  this fluid may  be dis-
charged  in twenty-four hours.  On rising from bed there is usually
profuse expectoration of mucus that has accumulated over-night,
more particularly in bronchiectatic cavities.   The signs are not so
distressing in this disease.   There is no fever, there is little or no
dyspnoea.  The cough is not so harassing, because  it  is less con-
tinuous and more paroxysmal, and relief follows the expectoration of
a quantity of fluid.  Patients affected with bronchorrhoea may main-
tain a bien-etre for years ;  the  condition of  health, however, in
many cases becomes impaired daily, not infrequently because of as-
sociated, if not causative, tuberculosis. 
BRONCHITIS PUTRIDA.
497
                      BRONCHITIS PUTRIDA.
   A particular alteration occurs in the sputum of some of these
cases, constituting what is known as a  bronchitis putrida, or fetid
bronchitis.  Putrid bronchitis seldom occurs as a primary malady
or in people in  perfect health.  It shows itself in the course of ordi-
nary  bronchitis,  usually  in  the  course  of bronchitis secondary to
other diseases.  The patient is more or less suddenly attacked by
chilly sensations followed by an  elevation of temperature, and then
in the course of a day the discharge assumes a peculiar and offensive
odor, a kind of sweet,  rotten odor, "that of the mayflower or apple
blossom, with a kind of arriere-gout of fseces" (Laycock). The mat-
ter separates itself distinctly into layers on standing—an upper lay-
er, muco-purulent, frothy, with masses of  more or less solid  mucus
from the coarser bronchi ; a middle, a  scanty, greenish, sero-albu-
minous  fluid ;  and a  lower, more or less  distinctly purulent sedi-
ment, yellowish-green, the  sediment consisting in large degree of
smaller, more solid, caseous-looking masses, which Dittrich has shown
to be expressions or casts of the finer bronchi,  " Dittrich's plugs"
—masses which crumble under  pressure to emit that unspeakably
offensive odor which makes the patient an object of disgust to him-
self and every one else. One such patient will contaminate the air of
a ward  in a hospital, of a large room in  a factory, or of a whole
house.  The odor may be recognized upon opening the  front door.
It is impossible to account for the sudden change which occurs in
the sputum in these cases.  It is easy to see that the sputum abounds
with micro-organisms, fungi—Leyden speaks of a particular form of
leptothrix—all the bacteria of decomposition, fat products, and crys-
tals ; in fact,  all the products of decomposition—sulphuretted  hy-
drogen, ammonia, fatty acids, leucin, tyrosin—may be  discovered
in this sputum.
   The disease is found in association at  times with gangrene of  the
lungs, which makes itself manifest by the same  offensive  odor.  But
Traube has shown that the diseases are different; while they may
coexist,  they are more  frequently independent.
   Prognosis.—This form of bronchitis does not cease suddenly,
as it began, but  gradually, if  it ceases  at all.   It is very obstinate
to treatment.   It shows  itself in exacerbations and remissions for
months, for years, sometimes for  life.  It might be supposed  that
putrid bronchitis resulted from the aspiration of products of decom-
position from the mouth and throat into the lungs.  Such an asser-
tion  may not be disproved,  but it is a curious fact that  individuals
who work most with decomposing products, as tanners, scavengers,
ragpickers,  show no predisposition to it.   It  is, fortunately,  the
rarest form of bronchitis.
        32 
498
FIBRINOUS BRONCHITIS.
                     FIBRINOUS BRONCHITIS.
   A peculiar variety of bronchitis is the so-called fibrinous bronchi-
tis, or bronchial croup.  This affection develops in  consequence of
tracheal croup or croupous pneumonia, only as a very groat excep-
tion.   As a rule the disease is secondary and  occurs in the course
of other affections of the lungs, chiefly in  consequence of ordinary
bronchial catarrh.   The  cause of  this peculiar transformation  is
entirely unknown.   The individual will have been, as a rule, in the
enjoyment of  his usual health, or that degree of it which belongs to
ordinary bronchitis,  when he is seized suddenly with chills  or chilly
sensations, to be followed by fever and symptoms of great distress on
Fig. 219.—Casts of the bronchial tubes expectorated in fibrinous bronchitis.
the part of the organs of respiration—that is, there is  more or less
dyspnoea, great constriction, profound anxiety, and feeling of im-
pending suffocation, which indeed threatens and at times actually
occurs.  There is during  the whole of  the  attack a most violent,
harassing cough, which is attended in some of  its explosive efforts
with the discharge of casts of the bronchial tree.  These casts  alone
establish the diagnosis.   They may be  recognized, often  with the
naked eye, as grayish-white masses of flesh-colored substances tinged
with extravasated blood.  They may  be more readily distinguished.
and are often only recognized at all, after immersion in water,  when
the branching of the bronchial cast is shown.  They  are  thus dis- 
FIBRINOUS BRONCHITIS.
499
 tinctly casts of the bronchial tubes, and consist, in the smaller tubes,
 of solid masses of fibrin which have undergone hyaline transforma-
 tion, enclosing a large number of white blood corpuscles with a few
 red.   The smaller casts are solid; the larger, hollow and composed of
 concentric layers.
    The sudden development of the disease with acute manifestations
 after  chill and fever has led to the belief that fibrinous bronchitis
 is an  acute infection, and analogy would place it  in  the same cate-
 gory  with  diphtheritic  croup and croupous  pneumonia, of  whose
 infectious character there is no doubt.
    The disease by no means always occurs in this acute form, though
 much more frequently acute.  The chronic form  occurs also in the
 course of ordinary bronchitis, as a rule, but is distinguished by the
 milder character of the symptoms.  It runs a course for  the most
 part without fever, and  is a malady consisting rather  of exacerba-
 tions and remissions than of continuous course.   It is distinguished
 in its exacerbations by the same signs of distress as the acute form,
 and is absolutely recognized only by the expectoration of casts of the
 bronchial tubes.  Both forms occur especially  in the young, between
 the ages of fifteen and thirty years, with exceptions, however, in the
 extremes of life.  Kisch, for instance, reports the case of an indi-
 vidual aged sixty-six years who suffered from repeated attacks of
 fibrinous bronchitis, and who expectorated at times, over a period of
 twenty-five years, masses which looked like collections of coral.  In-
 tervals of weeks or months, and  sometimes even of years, with free-
 dom from symptoms, distinguish some of these cases.   Bugge, who
 collected the statistics of ninety cases with special reference to cause,
 found  that the great majority followed  in the course of chronic bron-
 chitis and phthisis.
    The character of the casts frequently locates the affection.  Casts
 from the upper portions of the lungs subdivide more  rapidly as the
 bronchial tubes of this part of the lung rapidly grow shorter.   Ordi-
 narily, bronchial casts are in their thickest portions about the size of
 goose quills, and subdivide gradually to the size of threads.
    The acute form of the disease has a very grave  prognosis, inas-
 much as twenty-five to fifty per cent succumb within fourteen days.
 The mortality in chronic fibrinous bronchitis ranges about twelve per
 cent.   Chronic fibrinous bronchitis  distinguishes itself not so much
 by the intensity of its  symptoms and its  mortality as by its compli-
 cations.  Emphysema, atelectasis, and catarrhal pneumonia ensue in
 a certain number of cases.
   The cause  of this peculiar transformation of the secretion of the
bronchial tubes remains involved in obscurity, and, as Kisch declares,
the treatment, like the etiology, is as yet unexplored territory. 
')(){I
BRONCHIECTASIS.
                         BRONCHIECTASIS.

   The last variety of bronchitis is that pathological alteration in the
walls of the bronchial tubes which permits their dilatation, to consti-
tute what is  known as  bronchiectasis.   This  condition was not
known until the time of Laennec, for the reason, as he states, that
dilatations of smaller tubes were considered as normal tube's of larger
size, and great dilatations of larger tubes were looked upon as vomi-
cae or cavities of phthisis.  A closer inspection of the dilated tubes
readily distinguishes them from normal  tubes by their  size  at the
periphery, inasmuch as normal tubes grow smaller gradually, tubes
pathologically  dilated  terminate  abruptly.  Bronchiectasis  occurs
more frequently in the upper anterior portions.of the1 bronchial tree,
and concerns chiefly a few  tubes of  the third and  fourth  order.
Tubes of  the first order are never affected in this way.  The disease
is never primary, but occurs always in connection with other mala-
dies, chiefly with  long-standing chronic bronchitis, catarrhal pneu-
monia, and more  especially  tuberculosis.   Corrigan,  in  183S, fur-
nished the most  satisfactory  explanation of development of most
cases in his description of the fibroid condensations that occur in the
lung, which  were  subsequently called interstitial pneumonia, later
fibroid phthisis, and which we now consider to be relics, in all cases.
of tuberculosis.   The contraction  of this hyperplastic mass of con-
nective tissue, as in the process of cicatrization elsewhere, mechani-
cally drags upon the tubes to force the deformity; and this deformity
is aided all the more by the fact that the bronchial wall itself suffers
from lack of nutrition,  interruption of its circulation, and consequent
degeneration.   The deformity occurs in various forms : the uniform
enlargement with cylindrical dilatation,  with  fusiform  or spindle-
shaped dilatation, saccular dilatation, with such consecutive saccular
dilatations as to constitute the beaded appearance, or with such sepa-
ration of  the dilated portions, with retention of their contents, as  to
form cysts in the lung—a very rare condition.
    The diagnosis of bronchiectasis is by no means always easy, for
the clinical picture is  that  of the underlying condition of chronic
bronchitis or tuberculosis.  There are,  therefore, all the signs which
belong to chronic  bronchitis—cough,  expectoration, interference
with circulation, and dyspnoea, more or less pronounced.  Somewhat
more characteristic is  the paroxysmal character of the cough and
the  discharge  at intervals of large quantities of  pent-up Jin id.
The mouthful or more copious discharges, however, speak for bron-
chiectasis by no means positively, as abundant discharges, paroxysmal
in character, are often seen  in simple chronic bronchitis, and more
especially in tuberculosis.  Not infrequently, as is known, the (lis- 
TREATMENT OF BRONCHITIS.
501
 charge from an abscess below the diaphragm, as from the liver, takes
 place in this way.
    Physical signs are not  especially marked.   The  chest expands.
 There is no percussion dulness, except in  the presence of a very
 large cavity.  Auscultation reveals only the  signs  that  belong to
 chronic  bronchitis  or tuberculosis.   The differential diagnosis  of
 bronchiectasis from chronic bronchitis rests more upon the discharge
 of large quantities of fluid—as a rule exceedingly offensive from de-
 composition—at intervals.  These symptoms, which may  occur as
 episodes in the course of bronchitis, belong to the regular course of
 bronchiectasis.  Tuberculosis is  distinguished by  its more or less
 continuous   fever, its progressive emaciation, haemoptysis,  night
 sweats, etc., more particularly by the use of tuberculin, by the dis-
 covery of elastic tissue and the tubercle  bacillus.  Bronchiectasis has
 no definite duration.   A developed deformity cannot be cured.   The
 treatment is that of the underlying condition, upon the state or stage
 of which the prognosis rests.

    Treatment.—Acute  bronchitis is best treated by  rest in  the
 house,  preferably in  bed,  and  the  use of  diaphoretics.  Thus an
 acute cold may be often cut short by ten grains of Dover's powder
 at bedtime,  or by  a grain of opium in any other  form.   Diaphoresis
 is often pleasantly  and profusely excited simply by warm drinks,
 especially if preceded or followed by a warm bath.   Common green
 or black tea, taken hot and in quantity,  is a diaphoretic  as effective
 as any of the nauseating infusions of the old materia medica.
    In  the acute bronchitis of childhood the warm  bath plays the
 most important role, if  given three or  four times in the course of
 twenty-four hours.  It is nearly always  followed  by peaceful sleep.
 Should diaphoresis fail, the treatment becomes purely symptomatic.
   In relief of the cough appeal is made to the  expectorants.  Chief
 among  the expectorants  in our  day  ranks  apomorphine.   A  good
 prescription for a child is :
   I< Apomorpbinfe hydrocliloratis..........................gr. ss.  to gr. i.
     Acidi hydrochlorici diluti....................................    gtt. x.
     Syrupi............................'.......................fl. I ss.
     Aquae mentlue piperilse.....................................  fl. 1 iss.
  M.  Sig. A half to one teaspoonful every two  hours.
 Apomorphine is a very soothing expectorant, which acts like  an
anodyne, and, as has been proved by experiment,  has real  virtue as
an expectorant.  In bad cases of  cyanosis and dyspnoea  the remedy
is best used subcutaneously in  doses of one-twelfth of  a grain, in-
creasing the dose if necessary.  It should not be used in old age.
   Ipecac in wine  or syrup is a time-honored remedy, and, especially 
502
TREATMENT OF BRONCHITIS.
 in the form  of  the  compound mixture,  has a wide  range of use.
 One grain of tartar emetic  dissolved in a glass of cold  water,  of
 which a teaspoonful may be taken every hour, is an old and useful
 remedy.   When the cough becomes very severe, and especially if it
 be associated with much pain, the necessity  arises for the use  of
 morphine, which may be incorporated with the apomorphine in the
 prescription above cited : or the opium may be given in tincture, sim-
 ple or camphorated.  Under no circumstances,  however, sliould mor-
 phine be given to children.   For an adult a prescription might read :
   B Morphinae sulphatis.......................,....................gr. i.
      Aquoa lauro-cerasi...........................................fl  3 ij.
      Aquae...............................................q. s.  ad fl. § ij.
   M.  Sig.  A teaspoonful every two, three, or four hours.
    The same  relief, without risk, may be reached in children  by the
 substitution of belladonna, which may be given, in  the form of the
 tincture, in a  dose of one drop for every year of the child's age.   A
 few dry cups applied  to the surface of  the chest give' great relief
 from pain  at any age.  Wet cups succeed when dry cups fail.  Fly-
 ing sinapisms often suffice.  Where pain is very severe,  in exceptional
 cases, especially in childhood, a poultice may be1 put about the chest.
   For fever there is no remedy so good as quinine, which  supports
 the heart while it attacks the fever.   Many individuals learn to cut
 short  a cold by a single dose of  ten grains of  quinine fortified by
 a drink of  hot whiskey; and whiskey or  brandy is always a safe
 remedy to  give  to a child, with a smaller dose of quinine—never
 over five grains.   Relief from fever is also given by the other anti-
 pyretics—antipyrin, which may  be given  to an adult in the dose of
 from three to five grains, a child one to two  grains ; antifebrin in
 the same dose, or phenacetin in double the quantity.   Phenacetin  is
 the  safest  remedy.   None of these drugs act  so well in childhood
 as the warm bath; and where bronchitis has become  capillary, and
 dyspnoea  assumes  prominence or  actual  cyanosis  has occurred, no
 remedy ranks in value with the hot or warm bath, and cold affusions
 to the head and chest while in the bath. Jiirgensen  has shown that
 a  small stream of cold water directed to the nape of the neck will
 cause  deep inhalations.  A debilitated child will require additional
 stimulation in the form of  senega, carbonate  of  ammonium, caf-
 feine, or digitalis.  One drop  of the tincture of digitalis every hour
or two is at times invaluable.
   The treatment of chronic bronchitis varies more with the intensity
than with the character or form of the disease.   The remedies which
are of real  value  are  few.  Prophylaxis merits discussion first. As
 already remarked, bronchitis is the most frequent of all dise'ases, and
 the greatest contingent of cases occurs in childhood.  When we re- 
TREATMENT OF BRONCHITIS.
503
 gard the manner in which children are brought up, in closed apart-
 ments with defective ventilation, too warmly clad, for the most part
 not regularly bathed, in the  ill-heated, ill-ventilated habitations that
 constitute what is known as the house  climate, it cannot be wondered
 at that bronchitis, a disease which results from the inhalation of a
 contaminated atmosphere, is so frequent.  We  have also to regard
 here, as well as in the case of  adults,  the frequency of tuberculosis,
 which has bronchitis as its forerunner  for  months  and as  its com-
 panion for life.  Rickets, too, is a disease which belongs to childhood,
 and which has bronchitis as one  of its  prominent and more or less
 constant symptoms.  These three causes—vitiated house air, tuber-
 culosis, and rickets—account  for the large majority of cases  of
 chronic or  constantly recurring  bronchitis.  In children bronchitis
 belongs, therefore,  to those who are debilitated or diseased, and the
 factor of supreme importance in childhood is prophylaxis.
   It is needless to say at this  age that  a house can be well venti-
 lated, that sunlight and fresh air may  be  admitted, that the tempera-
 ture may be regulated, that  the house may be  kept dry. Children
 affected with tuberculosis, rickets, and syphilis  must be treated for
 these diseases.   Phosphorus, iodine, creosote, cod-liver oil, iron, qui-
 nine—these agents belong as much to prophylaxis as to treatment.
 Weak and debilitated children and adults are best inured by baths,
 which should be warm at  first—98° F.—then  tepid, cool, and even
 cold, with brisk friction to the  skin until the surface is brought to a
 glow, the perfection of the reaction being the indication of the grade
 of temperature for the next bath.   Fresh air, exercise, a shorter stay
 in school, a better ventilated school room, are essentials in  cure  as
 well as prevention.   The regulation of clothing, the  avoidance espe-
 cially of heavy underwear, of mufflers  and comforters about  the
 throat, the exposure of the  body until it becomes hardened like the
 face—these are means  which  must be adopted  gradually, that the
 body may  become finally inured and, as it were, insured  against
 bronchitis.  A  subject which  deserves  continued emphasis is the
 destruction of the sputum, which so often conceals the most danger-
 ous parasites.   Cuspidors, with water in them, should be in  every
 room.
   Old men are best protected by avoiding  vicissitudes of tempera-
 ture, especially as connected with moist  or  windy days.  On cold,
 wet days the old man should remain  at  home  in his room—in the
 chimney corner, if not in bed.  The circulation of the old man is  to
be sustained by another meal—if necessary, later in the night—by
wine, brandy,  or an extra cup of coffee or tea.  Senile bronchitis
may be avoided also  by change of climate.  Individuals whose cir-
cumstances will  permit should  seek the warm, moist climate  of 
504
TREATMENT OF  BRONCHITIS.
 Florida. Southern California, the Bermudas. Nassau, or the  dry,
 warm climate of Central Florida. Georgia. Aiken, Asheville. in the
 Carolinas.
    Chronic bronchitis requires more continuous treatment.   In the
 dry form of chronic bronchial catarrh  exudation may be furthered
 or forced by inhalations.  The agent  of most value in  these inhala-
 tions is steam, and it is best generateel by a steam atomizer.  Simple
 atomizers without heat are of no value.  The steam  is given some
 additional solvent powers by the use  of common salt, more particu-
 larly the bicarbonate of sodium in saturated solution, or disinfectant
 properties with carbolic  acid, thymol, or boric  acid.   In capillary
 bronchitis steam is a necessity.   Where the  discharge is excessive in
 bronchorrhoea the best remedy is turpentine, which should be given
 in  the form  of  capsules containing  from five to ten drops.  Cap-
 sules of turpentine are  swallowed  without taste with milk, or five
 to ten drops of turpentine may be dropped into a wineglass of milk.
 Finally, turpentine may be smoked for  a long time in a pipe ;  here,
 however, there may be evidences of idiosyncrasy, such as slight cere-
 bral disturbance and vertigo.   A good substitute in these cases, or in
 any case, is terpin hydrate, which may also  be given in capsule five
 to ten drops, or in pill one to  two grains, three or four tunes a day.
 The balsams of Peru, tolu, copaiba, and sandalwood have virtue in
 individual cases.   Cod-liver oil is food as well as medicine ; for chil-
 dren  it is  nicely compounded with malt.  Many cases yield  only to
 the prolonged use of iodine, which is best given in the form of iodide
 of potassium or sodium  in  peppermint water, in the ounce-to-ounce
 solution, beginning with  from five to ten drops three times daily,
 largely diluted with milk.  Its action  is  best  suited to the cases
 complicated with  asthma or  dyspnoea.  The best  prescriptions for
 chronic bronchitis owe their virtue chiefly to the iodine they contain.
   Putrid bronchitis requires antiseptics, which may be inhaled from
 the atomizer, as  suggested above.  Terpin  hydrate is here  also of
 value  internally.  A most  excellent  remedy recently recommended
 is myrtol, which should  be taken internally in doses of  five to six
 grains.  Myrtol acts through the blood; it may also be inhaled.  It
 lessens the excessive quantities of sputum in putrid bronchitis and
 bronchiectasis, diminishes the offensive odor or destroys it altogether,
 and often in the course  of  a  few days puts a new phase upon a dis-
 ease which has hitherto assumed alarming gravity.
   Bronchiectasis has no special therapy.  No drug can restore tone
to or  contract the dilated  bronchial  walls.  The treatment is the
same as  that  for chronic  bronchitis, and more especially for putrid
bronchitis, whereby disinfectant inhalations, more especially of ter-
pin hydrate, menthol, and myrtol, play important parts.   As has 
ASTHMA.
505
 been intimated, the diagnosis of bronchiectasis, or its differentiation
 from cavities in the lung from tuberculosis, is  by no means easy.
 Moreover, inasmuch as these cavities are scattered  throughout the
 lungs, there is none of that hope from surgical intervention which
 might be entertained where the affection is local.
    In all cases of chronic bronchitis, especially where chronic organic
 changes have occurred in the bronchial walls,  such as  excessive
 hypertrophies, atrophies, decomposition of  their contents, and ecta-
 sias, there is necessity for support with alcohol.   Senega and  serpen-
 taria are considered good substitutes for squill, ipecac, and antimony
 in the debility of age.   The carbonate of ammonium, best given in
 milk, is a remedy of value in advanced life or in  extremis.  The
 Germans have  an anisated solution  of  ammonia which is  a good
 preparation.  Apomorphine is quick and pleasant, but not safe in age-
 A remedy which is of signal virtue in the chronic bronchitis of the
 aged, in the capillary bronchitis which may not be separated from
 catarrhal  pneumonia  at either  end  of life, more especially in  the
 chronic bronchitis of old age associated with heart failure and kidney
 suppression, is nitroglycerin, of which one or two drops of a one-per-
 cent solution may be given every hour or two, or, to bridge  over a
 sudden collapse, subcutaneously in doses of one to five drops.  Ben-
 zoic acid is a fine stimulating  expectorant.  A failing heart calls for
 digitalis, tincture, gtt. v.-x. every two to four hours.
    To sum up the therapy of bronchitis, the best remedy in the treat-
 ment of the bronchitis of childhood is the warm bath; the best remedy
 in the  treatment  of the acute bronchitis  of maturity is diaphore-
 sis;  for chronic bronchitis  the remedy suggests itself with the dis-
 covery and treatment of its cause, whether tuberculosis, emphysema,
 heart disease, or disease of the kidney;  the best remedy for senile
 bronchitis is support of the heart and change of climate.

                             ASTHMA.
   Asthma {a6^paS,oo,  to breathe hard) ;  bronchial asthma;  ner-
 vous, essential asthma.—A paroxysmal dyspnoea caused by a peculiar
 catarrh with spasm of the bronchi.
   History.—The name of the disease dates from the period  of
 symptomatic medicine, and the difficulty of  breathing was a sign so
 obtrusive as to have fixed itself firmly in nosology.  Hence asthma
 was a synonym for dyspnoea, and every difficulty of breathing that
 seemed  due to obstruction in the chest was indiscriminately dubbed
 asthma.  So forms  of  the disease multiplied with the effort to  find
place for various affections of the lungs and heart under this symp-
tom.  By the time of Sauvages (1768)  there were no less than seven-
teen species of asthma, a number reduced to eleven by Richter  (1822)> 
506
ASTHMA.
and gradually to two, idiopathic and symptomatic, in our own day.
" Few terms have been so much  abused in medicine  or made1  to
designate such  different diseases" (Laennec).  Though Willis and
Cullen spoke of nervous asthma, it was not until the appearance of
the paper by Ramaelge (1835)  and the prize essays by Bergson and
Lefevre (1836) that asthma was really regarded  as a neurosis of the
respiratory organs—a  view which  seemed established by Romberg
(1841), who based his conception of the  disease, as a spasmus bron-
chialis, upon the discovery by Reiseissen (isos) of muscular tissue in
the finer bronchial tubes, and the contraction of these tubes under
galvanization of  the lungs  by Williams (1840). and irritation of the
vagus by Longet (1842).
   Whatever doubt still hung about the contraction of the bronchial
tubes  themselves would seem  to  have been finally dissipated by
Lazarus (1891),  who  devised  an ingenious apparatus wherewith he
could, with the aid of  curare and tracheotomy, experiment upon ani-
mals in life, and whereby he produced the characteristic dyspnoea of
the disease by irritation of  the vagus nerve.
   Wintrich (1854)  and  Bamberger (1N70)  attributed  asthma  to
spasm of the diaphragm;  Biermer (1870) reinstated the  disease  in
the bronchial  tubes; Lebert (1873)  believed in both  factors; Weber
(1X72) invoked dilatation of the blood vessels and tumefaction, vas-
cular turgescence with rapid  exudation,  a  bronchiolitis exudativa;
and Storck supported this view with laryngoscopic demonstrations of
hyperaemia of the larynx, trachea, and visible bronchi.
   Etiology.—Asthma has been  reduced to two forms—idiopathic
and symptomatic, or  primary (essential) and secondary.   But it is
doubtful if  there be such a thing as an idiopathic, essential asthma.
Every year narrows more  and'more the number of  idiopathic cases
with the discovery of some cause,  immediate or remote,  to account
for the attack of the disease.   These causes may be grossly divided
into mechanical, chemical, and reflex, whereby many cases may fall
under more than one head.   Thus, among the  mechanical causes
may be cited goitre, .the so-called thymic asthma, aneurism, trauma,
foreign bodies, dusts (pollen, etc., grinder's asthma), rickets, disease
of the vertebrae (Pott's disease), disease of the heart (cardiac asthma),
and certain diseases  of the  lungs, more especially bronchitis and
tuberculosis.  Under the chemical  or toxic causes are renal, gastric,
saturnine, mercurial, and malarial  asthma, and the asthma produced
by odors, also cases of arthritic and tuberculous  asthma.  Under the
reflex causes  are gastric, cardiac, sexual (especially uterine), intes-
tinal (verminous), traumatic, and nasal asthmas.   Finally, a small
category of cases is  to be attributed to  psychic causes  or ideas— 
ASTHMA.
507
 hysterical asthma.   Most of these cases, it is plain to  see, are cases
 of dyspnoea rather than asthma.
    The exact method by which asthma is produced by any of these
 causes remains as yet unknown.  It is assumed that  there is some
 irritation in the centre, in the course of, or at the periphery of the
 vagus, which excites the muscular tissue to contraction, so that the
 existence of an idiopathic form in our day implies a concealed cause.
 It is better to assume a cryptogenetic than an idiopathic origin in all
 cases, if only because one stimulates, the other stifles, inquiry. While,
 therefore, it may be doubted whether there is such a thing  as  an
 asthma as a pure neurosis—i.e., independent of an outside cause—it
 may be admitted that the sensitiveness of  the nervous system differs
 in different  people, and that  certain individuals are more liable than
 others to attacks of  asthma  from the same cause.  In other words,
 asthma implies  unstable nerve cells of easy explosion,  and takes its
 place in nosology by the side of epilepsy, insanity, migraine, etc.,
 with which, indeed,  it  sometimes alternates.   It  is more in accord
 with modern  medicine to look for the cause of the hypersesthesia of
 the vagus in  irritations caused  by micro-organisms—diplococci,  for
 instance, tubercle bacilli, etc., or  toxines—rather than in '' heredity."
    Heredity plays a very insignificant role  in the production  of
 asthma.   Age plays a more important role, in that, according  to the
 statistics of  Salter, of one hundred and fifty-three cases, one-fourth
 were  under the age of ten  and  four-fifths under forty years.   Sex,
 social position, and  vocation have less to do with it.  The disease
 occurs more frequently in males and in  the  luxurious upper class,
 but it is by no means rare  among the poor.   Teachers,  clergymen,
 attorneys, people who lead  sedentary  lives,  are rather  more fre-
 quently affected.
   Since  Cullen made the first observation of the development of
 asthma in an apothecary's wife whenever  ipecac  was powdered in
 the shop, similar cases have been reported by most observers.   There
 is, however, an endless  variety of  materials which may  evoke
 asthma in a patient born with the asthmatic tendency.   Thus the
 smell of  a sulphur match, pitch,  smoke, hay, tobacco ;  the rose, lily,
 and other flowers ; coffee and the odors of the kitchen ; odors of cer-
 tain animals (cats, rats, dogs, horses, rabbits, guinea-pigs, chickens);
 the odors of  wild animals  (as in  menageries), precipitate attacks.
 Literature is full of curiosities in  this regard.   The proprietor  of  an
 equestrian establishment suffered from asthma continuously until he
 retired from business, when  the disease ceased, to return,  however,
 whenever he returned to his  horses.   Fagge speaks of the case of a
lady who was affected whenever she came into a room  in which was
a cat, no matter where the animal was  hidden.   Ramadge tells the 
50X
ASTHMA.
story of an employee in the East India Company who had to give
up  a lucrative appointment because the smell of tea developed an
attack of asthma.   Austin Flint was unable to sleep on a feather
pillow.   In one case the odor of roses brought on an  attack, and  so
sensitive was this lady as to suffer a seizure on one occasion, though
the rose which was held before her was artificial (psychic asthma).
   The frequency with which an explosion of asthma has occurred
in consequence of real odors should have sooner led to the investiga-
tion of the nasal cavity  for sensitive areas.  Voltolini long ago made
the observation that asthma may be  produced by a polypus in the
nose.  In one of his cases removal of the polypus  relieved the asth-
ma, which returned with the recurrence of the growth, to disappear
again  with  its  extirpation.  These observations have  been abun-
dantly  confirmed by observers,  many in our own land, first by
Hanisch, and more lately by  Hack, Roe, Harrison Allen, and  Bos-
worth ; so that at the present time the tendency is to exaggerate the
importance of the naso-pharyngeal genesis of  asthma, or to consider
that the disease  results  exclusively from this cause.   According  to
Schmiegelow asthma has a nasal origin in thirty per cent of cases—
i.e., polypus  twenty-two, rhinitis eight.  Irritations  about the lar-
ynx,  especially of the interarytenoid folds, are much less frequent
causes.   Glasgow made an interesting confirmatory observation  of
such cause by the accidental application of a concentrated solution
of carbolic acid to the larynx for some local affection, when the asth-
ma with which the individual had suffered severely for years disap-
peared, never to return.
   Errors, more especially excesses, in diet frequently excite an ex-
plosion of asthma.  Attacks limited to certain days of the week can
generally be  traced to  this cause.  The peptic asthmas of the old
writers were reflected indigestions, better explained  in our  day by
gastric distentions and interferences with the circulation in suscept-
ible subjects.
   Colds account for the many cases associated with  bronchitis.
These are the cases in which attacks occur after every exposure.
   Locality is a  factor  of etiology which cannot be overlooked.  It
has long been remarked—and the point was especially emphasized
by Salter—that certain patients  from the country get absolute ex-
emption from an attack during  a stay in the city.  The immunity
seems to be more assured or absolute as the air of the city is vitiated
by soot and more especially by fog.   London excels  in this regard.
Thus patients have come from the country to consult physicians  in
London, waiting for the development of  an  attack which never
occurred, and have returned home in the belief that the disease was
cured, to be  attacked on  the  night of  their return.   And many 
ASTHMA.
509
patients  must make a regular habit of visiting the cities at stated
intervals, or must make a permanent change of residence.
   Symjjtoms.—As a rule asthma sets  in suddenly in the night,
and, in the majority of cases, without the slightest premonition.  In
exceptional cases prodromata, as a sense of oppression or uneasiness
about the chest, are felt on retiring.  Certain  individuals experience
unusual health, a  feeling of exaltation, the  meaning of which ex-
perience has taught them  to understand.  Usually the patient is
awakened between midnight and morning, as writh the nightmare,
with a sense of terrible weight and, constriction about the chest.
He is unable to breathe, and must at once arise in  bed  in efforts to
secure inspiration.  In bad cases the patient seizes the bedposts or
the side of the bed, to get points of support for the auxiliary mus-
cles of respiration : the face wears a wild, anxious look ;  the sur-
face becomes suffused  and dusky ; the  alse nasi play visibly;  the
vessels stand out distended in the neck.  The patient speaks as little
as possible ; the speech is broken into syllables in economy of volun-
tary effort.  There is no cough and no expectoration.   The patient
declares that if he could cough he could clear his lungs.   Later in the
course of the attack, when the patient can find time to cough, there is a
scanty sputum in clumps or masses which contain spirals, crystals,
and eosinophile cells.
    The  chest, notwithstanding the powerful action of the  muscles,
stands almost immobile at full  distention.  A superficial observa-
tion reveals the fact  that the main difficulty is  with expiration.
There is difficulty in getting air into  the lungs ; to get air out of the
lungs seems impossible.  In bad cases the patient must get out of
bed, fix himself in  the kneeling posture beside the bed. or find some
relative relief in standing, as at a mantelpiece with the elbows braced,
or at an open window with the hands fixed on the uplifted sash, after
methods found helpful in former experience.  The descent of the dia-
phragm protrudes  the abdomen ;  the powerful contraction of the ab-
dominal muscles makes it hard as a board.  During the attack the
distention of the lungs is recognized by the  universal tympanites on
percussion, which  often  develops, in consequence of the tension of
the alveoli, the band-box  tone.  The heart sounds are muffled or
suppressed by the covering lung.  Auscultation reveals abundant
sonorous and sibilant, later mucous or  submucous rales, which
drown all other signs.  Finally, after the lapse of several hours, the
breathing begins to grow easier,  the patient falls into a deep sleep,
and awakens in the morning weary, but nearly as well as before.
The attack repeats itself irregularly, sometimes on consecutive nights,
sometimes not for several nights or a fortnight or more, usually with
the occurrence of damp weather, and always with  the development 
510
ASTHMA.


@&w
i^'U^VvvSr

gw?
Fig. 220.—Asthma crystals.
of bronchitis, to which the patient is especially liable.  In the invete-
rate cases the slightest exposure or imprudence precipitates attack.
    Crystals and Spirals.—Leyden (1872) made a contribution to
differential diagnosis in the discovery in the sputum of certain crys-
tals, angular, elongated octahedrals, which might be supposed to be
                        the active irritative  cause of the  attack.
                        These crystals are found  in grayish masse-s
                        in the  sputum, varying greatly in size,  col-
                        orless  or  of a bluish tint, surrounded by
                        masses of epithelium, and embedded often
                        in certain peculiar structures known as spi-
                        rals.  Some of them are distinctly visible
                        with the simplest lenses, but  they vary so
                        much  in size  as to be  manifest, some of
                        them,  only with higher powers, as  with a
Hartnack No. X.  The  crystals are insoluble in cold water, alcohol,
ether,  and chloroform,  but are easily soluble in alkalies, mineral
acid, warm water, ammonia, and  acetic acid—which  plainly allies
them to mucin, a form of which Salkowski declares  them to be.
They are  identical with the  crystals  discovered by Charcot  in
semen ; which Klemperer has shown to be a phosphate of diethylen-
diamin ; and by  Neumann in the blood and mar-
row of cases of leukaemia.  They are most abun-
dant during and after  the attack of  asthma.
Friedreich and Zenker  found them also in the
fibrinous plugs of bronchitis, and Bizzozero and
Von Jaksch  saw them  in bronchial catarrh
without asthma.  They have been observed also
as  confirmations in the fseces  in cases of hel-
minthiasis.   Most interesting is the fact  that
Lewy  found  them  in  nasal polypi, but more
especially in the pale-grayish, gelatinous masses
in patients not affected with asthma.   He could
not  find them  in the   hyperplastic  tissues or
tumors encountered in certain cases of asthma.
   Leyden in the same  year made the discov-
ery in the sputum of asthmatic patients of the
certain  peculiar spiral  structures  alluded to
above, which Curschmann  later more fully described and advanced
as characteristic of bronchial asthma.   These spirals, the so-called
Curschmann spirals, exist also  in the grayish masses found in the
sputum, often in connection, as  stated, with  the Charcot-Leyden
crystals, in most frequent abundance at the beginning of an attack
and in sharp, acute cases.   They may be recognized even with the
  Fig. 221.—Ourschmann's
spirals in the sputum of asth-
ma. 
ASTHMA.
511
 naked eye in their largest size, but are better defined with the micro-
 scope of low power as elongated, spiral fibres grouped about a series
 of central and more open fibres, which present  the  appearance of a
 central canal.  They exhibit, according to Vierordt, the finest forms
 of bronchial products, and hence correspond probably to catarrh of
 the smallest bronchial tubes (bronchiolitis exudativa).  They are not
 exclusively present in asthma, but have been remarked also in croup-
 ous pneumonia and tuberculosis.  These spirals also represent forms
 of inspissated  mucus.   They are, like  the crystals, products, not
 causes, of a peculiar bronchial catarrh.
   It has been remarked that the spirals exist in greatest abundance
 at the beginning of  the attack, when the crystals may be entirely
 absent, to  present themselves in greater abun-
 dance later in  the history  of the disease.   In-
 deed, crystals  have been made  to  develop di-
 rectly from or in  the spirals in sputum  pro-
 tected for several days from evaporation.  From
 the fact that both crystals and spirals have been
 found in other affections,  they cannot  be re-
 garded as  pathognomonic evidence of asthma;
 but there is no doubt of the supreme value of
 these structures in  differential diagnosis, for in
 any case of dyspnoea  the  existence  of  either
 crystals or spirals in the  sputum  speaks em-
 phatically for bronchial asthma.  Revealed, as
 they  are, by a glance  under the microscope,
 search for them  in  a doubtful  case should not
 be neglected.
   Further corroborative evidence is  furnished
 by cell elements in the sputum.   Muller demonstrated in the sputum
 of asthma numerous large lymphoid bodies,  with pale-yellow pigment
 granules, which showed affinity or avidity for eosin—the  eosinophile
 cells of Ehrlich.  Lewy found these same cells in nasal polypi, espe-
 cially in the gelatinous masses with but little gland structure.
   Diagnosis.—True asthma is, as a rule, sufficiently easily recog-
 nized.   The age of the individual, the time of  its occurrence—i. e.,
 during  the  night—the suddenness of  its onset, the intensity of the
 dyspnoea, above all  things the difficult expiration,  the sibilant and
 sonorous rhonchi, the great  anxiety,  the struggle  for air—" Luft-
 hunger "—with the gradual cessation to complete relief and the free
interval, the crystals and spirals and eosinophile cells, unmistakably
stamp the disease.
   The  diseases which simulate asthma are, first,  affections of the
larynx, spasm of the larynx, false  membrane,  and cedema of the
  Fig. 222.—Spirals with
crystals  in sputum  of
asthma. 
512
ASTHMA.
larynx, to  which  may be  added tracheal stenosis.  But in all these
cases the difficulty is with inspiration, not expiration.  Inspira-
tion is a long, powerful, stridulous struggle ; expiration follows easily.
There are no wheezing sounds in .the chest.   The condition is often
recognized with the laryngoscope.  Spasmodic contraction of the ad-
ductors or paralysis  of the abductors  shows  the  same inspiratory
dyspnoea.  Laryngismus  stridulus is closely allied  to asthma.   It
is also a neurosis with little or no associated catarrh.  Paralysis of
the posterior crico-arytenoid muscles is easily recognized  with  the
laryngoscope.  The vocal cords are found approximated, or separated
by  only a  narrow chink.  GMema of the larynx occurs in conse-
quence of  acute laryngitis or of  disease of  the kidneys or lungs.
Tracheal stenoses, unless  due to  foreign bodies, where the history is
plain, are caused by  neoplasms, syphilitic or carcinomatous, or by
aneurisms, or by goitre—conditions readily recognizee! by simple in-
spection or by evidences elsewhere in the body.
    Certain diseases of the lungs, more especially bronchitis and em-
physema, resemble asthma in  the fact that expiratory dyspnoea pre-
dominates.  It is often difficult  to distinguish between asthma and
emphysema because of their coexistence.  Asthma produces emphy-
sema, yet either may exist without the other.   The emphysematous
patient has the configuration and habitus of  the chronic asthmatic.
The dyspnoea is more or  less  continuous;  it  is aggravated  by ex-
ercise,  excitement,  emotions.    Its exacerbations,  which  simulate
asthma, attack the patient more, therefore, when he is awake.   True
asthma occurs for the most part in sleep.  Crystals and spirals, eosin-
ophile cells, rare in emphysema,  occur as a rule in asthma.  Inter-
mission  is  the rule of the dyspnoea in asthma, remission  in emphy-
sema.
    Bronchitis distinguishes itself by its more gradual, never sudden,
onset; by its more abundant cough and expectoration, which, at first
mucous, may become purulent—a change which never shows itself
in asthma.   In bronchitis the wheezing sounds, although sometimes
universal, are confined more especially to the posterior inferior lobes
of the lungs.   They  are  never  so intense as in asthma.  There is
more or less fever—absent in  asthma—in  acute diffuse  bronchitis,
which form alone resembles asthma.
   Dyspnoea from heart disease closely simulates  asthma at times.
Here too, however, the dyspnoea is more strictly dependent upon ex-
ercise or cardiac activity.   In cardiac dyspnoea there is evidence of
heart disease.  There are valvular murmurs, accentuations,  hyper-
trophies, especially dilatations,  and other evidence of incompetence,
irregularities in rhythm,  general dropsies, scleroses of vessels, etc.
The dyspnoea may become profound in cardiac disease, more espe- 
ASTHMA.                         513
cially in the later stages, in consequence of cedema of the lungs.
CEdema of the lungs does not, however, show the same degree or the
same kind of dyspnoea.  Respiration in it is more shallow and super-
ficial.  It is not so much a question of obstruction as of infiltration.
The expectoration is more profuse, watery, and is often tinged with
blood.
   Spasm of the diaphragm shows quite a different picture.  There
is a sudden, abrupt inspiration, often attended with hiccough and
forcible fixation for a few seconds, then a quick, violent, expulsive
effort.   Spasm of the diaphragm is best seen in tetanus.
   Intercostal neuralgia, which restricts the action of the respiratory
muscles, may be distinguished by its painful points and by its pain in
general.   There is no wheezing, no cough, no expectoration.
   Embolism  of  some of  the  branches of  the  pulmonary artery
sometimes resembles asthma.  Embolus is found in connection with
heart disease.  Respiration becomes  suddenly irregular.   There is
intense anxiety, often expectoration of blood, profound dyspnoea—
which differs from asthma in affecting both  inspiration and expira-
tion—marked prostration, and not infrequently sudden death. Often
there is evidence of embolus elsewhere.
   Renal asthma  is found in connection with Bright's disease with
its distinctive signs.
   The  treatment of asthma resolves itself into two problems: to
cure or cut  short the attack and to prevent  its recurrence—i.e., to
treat the paroxysms, and to treat the patient in the intervals between
the paroxysms.
   1. The patient should be placed first  in a comfortable position,
which, in  fact, he finds himself.  There should be allowed the same
latitude of disposition of the body in the paroxysm of  asthma as in
the pains of parturition.   Tight  clothing should  be  loosened, free
ventilation secured, officious ministrations  avoided.   To sit up in
bed  with  the elbows  on the knees  elevates the shoulders from  the
chest and  gives additional points of support to the auxiliary muscles
of respiration.  This posture is usually taken at once.   Many pa-
tients get this relief sitting in a chair with the elbows supported upon
its arms ;  others kneel, with the elbows upon the chair or side of the
bed, or seize the  framework of the bed, or  stand with the hands
grasping the mantel or the elevated sash of  the window.   Individ-
uals have found  some comfort  by  supporting the  shoulders on
short crutches by the side of a chair, and various apparatus have
been devised,  armchairs with  special supports, or head bands and
shoulder supports swung  from the  ceiling—different postures for
different individuals.
   Should the  attack be clearly  due to indigestion,  stomachic  or
33 
514
ASTHMA.
intestinal, the quickest means of relief is by an emetic or an enema.
A cardiac or a renal asthma is often quickest relieved by a hot bath.
Offensive odors, animals, flowers, feathers, drugs, should be removed
at once,  or  the patient may be removed from their vicinity.  The
mere lighting up of  a dark room at night suffices at times to  relieve
an attack, as was the case with Trousseau.
   Inhalations.—The fumes of saltpetre have been used for  half
a century, and probably no single remedy has so wide a range  of
utility.   It  is, as Salter remarked, always a matter  of surprise  to
learn that an individual has not tried this drug. Often it fails from
improper use.  The patient may make the solution  himself, or buy it
prepared, alone (chartse potassii nitratis), or with other drugs.  Or-
dinary blotting paper, not too thin or too thick, is  dipped in a warm
saturated solution of saltpetre, dried, cut in squares or strips, and
ignited,  the patient breathing the  fumes as they rise.  The room
should be small—a closet with a partly opened door, a seat under  an
umbrella, or a tent of bedclothes over a  chair to substitute the cur-
tains of  the  old four-posters.  It may be inhaled in any desired
strength from under  a funnel.  If it is to act  at all it acts quickly,
usually  exciting some  cough at first; breathing becomes easier  in
a few minutes.  Patients use it also as  a preventive, inhaling the
fumes for a few minutes before retiring or just after retiring, or they
leave the strips  in easy reach to be ignited with the first manifesta-
tion of symptoms.   There are patients who prefer not to go to bed
at all than to have to dispense with the fumes of nitre.  It should  be
used at  the very beginning of  the attack.  Sometimes it gives but
partial relief; sometimes it succeeds at first and fails later; sometimes
it fails utterly.   The potassium nitrate parts with oxygen readily,
and it is believed that its virtue in asthma is due to the nitrite which
is left.   The older practitioners used it also freely internally in doses
of twenty  grains,  with twenty or  thirty grains  of the  potassium
carbonate, in a tumbler of water three or four times a day.
    Stramonium is a still older remedy, having been introduced  from
India in 1802.   The stramonium  most  used  in our country is the
leaves of the common Jamestown weed dried and  ignited, or prefer-
ably rolled  in the form of a cigarette.  Stramonium may reach cases
in which nitre fails.   The  converse is more frequently true.  Stra-
monium is  a more dangerous remedy.  The danger is obviated by a
 cessation with the first confusion  of sight  or intellect.   Both nitre
 and stramonium sometimes  fail completely.   They are more likely
 to succeed in toxic or purely bronchial cases, and fail in  every way
 in nasal or naso-pharyngeal cases.
    Confine, hyoscyamine, and  hyoscine are remedies which  have
 been used  as substitutes  for stramonium, but they succeed only in 
ASTHMA.
515
the most exceptional cases and in the face of greater dangers.   More
may be claimed for atropine.   Belladonna was the favored remedy
of Trousseau, who recommended that it be used for a long time with
occasional intermissions.   Belladonna relaxes  spasm.  Lenhossek,
Harley, Salter, each advocate it strongly.  Its best effects are  ob-
tained when used in a  grain-to-the-ounce solution, beginning with
from two to five drops and pushed gradually to tolerance.  It should
be given at bedtime, to anticipate the onset of the disease in the early
morning.
   The remedy which has the most sovereign control over  the great-
est number  of cases is morphine subcutaneously.   Morphine rarely
fails to abort an attack  of asthma.  It  should be given in doses of
gr. i~i.   Some of its evils may be counteracted by admixture with
atropine gr. i^—Tib'-  Morphine would be used universally, were it
not for its unpleasant after-effects.  It nauseates  some  patients and
disturbs the digestion of  nearly  all patients.  It produces discomfort
for the whole of the following day.   Most  patients prefer rather to
suffer an attack of asthma during the night than to endure the dis-
comforts of  morphine and disqualification for work for the whole of
the following day.  Then, too, morphine has  the disadvantage that
it soon begets tolerance.  The  dose must be  gradually  increased.
There  are authors who maintain that it is better to suffer the evils of
morphine than the damage which protracted paroxysms of asthma
produce.  There are individuals who learn to use the remedy only in
the worst attacks, and  thus are not  obliged to increase  the  dose.
Stevenson in five years never increased the initial dose over one-sixth
of a grain, with uniform success.  It is  not good practice to resort
regularly to morphine; morphine is to be used as a dernier ressort.
   Next to  morphine—in the estimation of many practitioners,  far
above it—stands chloral, which often, indeed, "acts like  a charm."
Chloral is given in  large doses—gr.  xv.-xl. largely diluted—at once
rather  than in small doses frequently repeated.  It acts quickly, re-
laxes the spasm, and gives the indescribable relief of a full breath in
the course of five or ten  minutes.   No remedy has received higher
praise; no remedy is more satisfactory in most cases; no remedy fails
so utterly in  many others, for when it fails it  aggravates the  case.
It acts best in those cases which seem to be more  strictly idiopathic.
It acts worst in heart disease,  where it is even dangerous.   It is
certainly not good practice to resort indiscriminately to chloral.   The
drug does not deserve the praise lavished upon it a decade ago.   It
falls short, if only because it fails to address the cause.  It  leaves the
nervous system weaker than before.   Yet both morphine and chloral
are indispensable in certain cases.  The practitioner must  decide for
the individual case. 
516
ASTHMA.
   To most patients relief, sometimes absolute, more frequently par-
tial, but relief enough for sleep, is furnished by some one of the antipy-
retics—antipyrin, antifebrin, phenacetin, or quinine.   For an  adult
there is usually required at a dose of antipyrin gr. x., of antifebrin
gr. v., of phenacetin gr. xv., of quinine gr. x.; and one such dose at
bedtime or at the beginning of the attack will, as stated, usually
suffice at least to modify the attack.   Quinine gr. v.-x. at bedtime
is, as a rule, the better remedy.
   Chloroform acts more quickly than chloral, and then1 is no case
that will resist inhalations cf this drug.   Unfortunately the good
effects of chloroform do  not persist.   The symptoms return after the
cessation of its use.  Where patients are compelled to use it for them-
selves, four or five drops should be let fall upon and inhaled from a
handkerchief.   Other anaesthetics of equal or nearly equal value are
ether, iodide and bromide of ethyl, nitrite of amyl,  and pyridin.   All
these remedies are to be inhaled in the same way from a handkerchief,
except that pyridin is better administered by being poured—a dozen
drops—upon a hot plate and inhaled in a small room or closet.  It
may be said of all these  succedanea that they are of value only in
the milder cases  and that they will  fail entirely in the  majority of
cases.   And it may be said of chloroform that, while it  may be in-
haled in small quantities without danger, it becomes so dangerous in
large quantities, often  in sufficient quantity, and of such temporary
value in all quantities, as practically to  exclude its use.
   In the case of fatty heart, where there  is decided contra-indica-
tion to chloral, paraldehyde has been used as a substitute, best ad-
ministered with the tincture of orange peel.
   Tobacco is a drug that has no superior in persons not accustomed
to its use.  The profound nausea caused by the smoking of tobacco
stops asthma like the wave of a magician's wand ; and this may be
said of any agent that  has the same effect, as of antimony and lobe-
lia.  Nausea is the enemy of asthma, as of any other spasm.   Un-
fortunately the remedy cannot  be used by most  males  because of
tolerance,  and by  most people because of  the extreme distress of
intense nausea.   There are individuals, however, who have learned
to smoke to protect themselves against asthma, and who have re-
mained free from the attacks so long as they have used tobacco.
But it is true of the majority of cases that the asthma will assert
itself so soon as tolerance is  established.   Most patients prefer the
distress  of severe asthma to intense nausea, and are driven to eme-
tics—ipecac by preference—only because experience has taught them
the futility of everything else.
   Mental emotions, a shock, a sudden surprise, excessive joy, grief,
fright, a cry of fire, may cut short an attack at once.  Knight tells 
ASTHMA.
517
 the story of an asthmatic who was relieved at once, in playing cards,
 so soon as the stakes grew high.
    2. The success of the treatment of the interval, the prevention of
 the recurrence of the attacks, depends on the cause.  In a  certain
 percentage of cases the cause may be discovered in the nose,  and re-
 moved by the use of astringents, emollients, boric-acid ointments,
 more especially caustics,  chromic acid, trichloracetic acid, above all
 the galvano-cautery.  The extirpation of  polypi, the reduction of
 hyperplastic tissue, the destruction of sensitive  areas, as localized
 often by ten- to  fifteen-per-cent  solutions of cocaine, have been fol-
 lowed by results as satisfactory as could be desired ; this, too, in cases
 where other treatment has been tried for years.   Adenoid growths
 in the naso-pharynx, affections of the tonsils, cicatrices, ulcers, vari-
 ous affections of the pharynx, more rarely of the larynx,  tra-
 chea, and bronchi, have all served as excitants of the explosions of
 asthma.
    The remedy which enjoys the highest repute in the treatment of
 asthma  in general, without reference to discoverable cause, is the
 sodium iodide, or, preferably, the potassium iodide,  in gradually in-
 creasing doses.   The patient may begin with ten drops of the ounce-
 to-ounce solution (peppermint water), and increase it to intolerance
 as manifested by coryza, with,  in most cases, the  most beneficial
 results.   Of  all the remedies  which have been used in asthma
 none deserves so much praise as the iodides, probably because they
 address a hidden cause, which  may be enlarged  glands, cervical or
 bronchial, irritating the  vagus nerve.  Every practitioner may re-
 call individuals who remain free of attacks of asthma so long  as they
 are under the influence of an iodide.   It is the remedy which is to be
 tried the first and longest.  Large doses are best administered in milk.
 It is a rare case of pure nervous  asthma which is not at least bene-
 fited,  and many cases are actually cured,  by the persistent use of the
 drug.
    Next is arsenic, which should also be given in gradually increas-
 ing doses up to the point  of tolerance ; then reduced, and continued
 in smaller dosage over long periods of time.  Arsenic has manifold
 testimony as to its virtue.  It was the remedy most relied upon by
 the older  practitioners.  Quinine  is  of  signal value in individual
 cases.   It is best  adapted to those varieties of the disease which show
 some periodicity or recurrence.
    Leyden, finding that the crystals found in the  sputum of asthma
 were soluble in the  chloride of  sodium and carbonate of sodium,
 recommended the inhalation  of  one part of each of these agents in
 one hundred parts of water, twice daily, in the form of spray.  Fauth
 says that the carbonate of ammonia liquefies the  spirals.   He finds
it  of value, therefore, in the therapy of asthma.   Little could be 
5IX
EMPHYSEMA.
expected from the use of this remedy with our  present knowledge
of the relation to asthma of these structure's. ,
   Salter speaks highly of the use  of  alcohol in certain cases.   It
must be given hot and strong to be  of  any effect.  Saturation with
the bromides, as in the treatment of  epilepsy, is an efficacious treat-
ment in aggravated cases.
   It has already been intimated that many patients are relieved ab-
solutely by change of climate.   In this regard also asthma has its
freaks   Patients in the country are relieved in the city, and vice
versa; patients in valleys by mountain air, and patients in the moun-
tains by descending to the valleys.   A moist,  humid air will relieve
most patients.   Asthmatics are more often benefited at the seaside
than in the mountains.   So capricious is asthma that change of sleep-
ing  apartments  from  the ground floor to the upper story, or vice
versa, may have the same preventive effect.   The truth is, the
patient must find his own climate, must  sometimes make changes,
and must remain as long as he may in the climate which is best for
him.   Florida, Southern California,  the Bermudas, Nassau, the sea
or its coast, and the inland lakes are points of selection.
   Oxygen and compressed air are other resorts in the treatment of
this disease.  Patients are made  to  inhale compressed air in apart-
ments  or portable apparatus for  hours  at  a time—sometimes  to
effect a cure, offerer to give temporary relief, often to fail entirely.
As a general rule it  is best to inhale compressed air and exhale into
rarefied air.  Those cases are most benefited which are most depen-
dent upon bronchial catarrh.  Asthma per se is little or but tempo-
rarily affected by pneumatic therapy.
   The induced current of electricity—electrodes at the inner border of
the sterno-cleido muscle, and sessions of from ten to fifteen minutes
—has  met with  renewed advocacy  by  Schmitz,  and has proven of
value in exceptional cases.

                          EMPHYSEMA.
   Emphysema {ep.q)v6rjpa, inflation) of  the lungs.—Inflation, dila-
tation  of the air cells, with characteristic  deformity and dyspnoea.
   History.—Definite knowledge begins with Laennec (1x19), who
gave the disease a name and  distinguished two  forms, the alveolar
and interlobular, according as the air was found  in the air cells or
between them in the interlobular tissue.   Laennec ascribed the dis-
ease to bronchitis, which permitted the  ingress but prevented the
egress of air, and thus dilated the air  cells—the inspiration theory.
Mendelssohn  derived  the pressure from expiration, basing his view
upon the fact that efforts, as in labor, at stool,  blowing instruments.
especially with  cough, distend the air cells.  Gairdner  developed 
EMPHYSEMA.
519
the condition from the extra work thrown upon certain parts of the
lung on account of occlusion of other parts—compensatory  emphy-
sema.   Rokitansky attributed the disease to nutritive changes, espe-
cially  weakness of the elastic tissue, which permitted  dilatation.
Modern authors select one, especially the last,  or unite  several, of
these views to account for the lesions of the disease.
   Etiology.—Hard work, heavy straining, long labors, especially
frequent and protracted paroxysms of coughing,  furnish the condi-
tions which  develop emphysema.
whooping cough, more frequently
from bronchitis, and more espe-
cially  from  capillary bronchitis
with asthma.
   Compensatory  or  vicarious
emphysema  develops in connec-
tion with, or as a  result of, dis-
eases  which  interfere with  the
expansion of the lungs—occlusion
of the bronchi, adhesions of the
pleura, pneumothorax, ascites, de-
formities of the spinal column.
   Interlobular emphysema  re-
sults from rupture of air cells and
escape of air into  the interstitial
tissue.   Such  rupture  implies
natural defect and violent effort,
as in whooping cough, capillary
bronchitis, dyspnoea.
   From the nature of the avoca-
tion, males are affected more fre-
quently than females;  and, on account of the changes in nutrition,
middle and advanced life more than youth.
   Symptoms.—The disease is subacute and chronic, and is an-
nounced insidiously with a growing sense of constriction, dyspnea,
palpitation  of the heart, which shows itself at first only after effort
or cough, and gradually increases in degree to be, with exacerbations
and remissions, more or less continuous.
   Changes of climate, exposure to cold, errors in diet, any impru-
dence  or extra  effort, aggravate the disease.  Asthmatic attacks
soon supervene; the heart's  action  grows feebler, the extremities
cool, the veins stand out in the neck, the muscles of the neck are
hypertrophied;  the chest  is dilated  in all directions, it begins  to
hide the neck so that the head comes to rest upon the shoulders, and
the chest assumes  a distinct barrel shape.  Defective  inspiration
So emphysema may result from
 Fig. 223.—Emphysema pulmonum: a, dilated
intercapillary space with epithelial cell ; b,
empty spaces in alveolar wall; c, obliterating
vessel; d, great defect in alveolar wall with
still greater defect of capillaries (Ziegler). 
520
EMPHYSEMA.
 leads to defective  circulation, which shows itself in the signs of
 stasis—to wit, oedema about the ankles; oliguria, albuminuria, later
 parenchymatous nephritis with casts ; hypertrophy and dilatation
 of the right ventricle, announced by accentuation of the pulmonary
 valve  sound and pulsation in the epigastrium;  later, duskiness of
 the face and cyanosis.  Catarrh of the stomach, constipation, icterus.
 belong among the symptoms of digestive disturbance.  Aggravated
 cases are marked by accumulation of fluid in the serous sacs,  and
 anasarca.
   Inspection  reveals the external conditions—cyanosis, especially
 of the lips, ears, finger  nails ; ectasias of the finer vessels of the
 face ;  pulsation of  the  jugular, the  bulb  of  which protrudes, in
 coughing, a sac as big as a thumb (Fleischer).   The skin  is mottled
 and shining.  The  auxiliary muscles of respiration are hypertro-
 phied.  The  distention of the lungs in every direction elongates  and
 dilates the thorax to the cylindrical or barrel  shape.  The  heart is
 depressed and  often concealed by the overlapping lung, so that its
 impact may be no longer felt.   The  diaphragm, with the abdominal
 viscera, is pushed upward.  The dulness of  the liver reaches to the
 umbilicus.
   The conditions revealed by inspection are still more manifest to
palpation, which may better appreciate the  defective excursions
 of the chest, diminished or absent impact of the  heart, and dimin-
 ished vocal and pjectoral fremitus.   Mensuration more accurately
 marks the diminished expansion.  The difference between inspira-
 tion and expiration, which  should amount to three or four inches,
 is diminished to two  inches  or less.   Sometimes,  under the most
 powerful effort, the chest is not expanded at all.
   Percussion yields a peculiar resonance on account of the disten-
 tion of the alveoli and tension of the chest—the so-called band-box
 tone of Biermer.  Auscultation shows an enfeebled vesicular  rale.
 Inspiration is shortened.   Expiration is'scarcely  to be heard at all.
 Bronchitis, which is associated with  emphysema as a rule, espe-
 cially with exacerbations which bring the  patient to the physician,
 drowns everything else with its own peculiar sounds.
   The diagnosis  is determined by physical  examination.   The
 symptoms, which are closely simulated by asthma, are separated by
 the fact that asthma occurs in paroxysms, with intervals  of com-
 plete freedom.   Emphysema, though it varies in degree, is  more or
 less continuous.  Heart  disease, cardiac  dyspnoea,  is distinguished
 by the history of the case, especially by preceding rheumatism, and
 signs of valve lesion or muscle weakness.
   The prognosis is always serious.  The disease is organic, and,
 when chronic or pronounced, incurable.  The comfort of the patient 
CATARRHAL PNEUMONIA.
521
depends upon his surroundings.   The individual who is compelled to
work for a living has a hard  fate and a short life.  The patient in
position to secure exemption from effort and  change  of climate
longest postpones damage to the heart.  Complicating bronchitis,
asthma, especially pneumonia, intensely aggravate the prognosis.
   The prophylaxis is protection against attacks of bronchitis, asth-
ma, whooping cough, etc., regulation of the habits of life, especially
with  regard  to exercise  in the open  air, the  avoidance of errors in
diet, exposure to  cold, attention to the bowels, etc.
   The treatment resolves itself into the  treatment of the  accom-
panying bronchitis,  relief  of  strain upon the  lungs, and support of
the heart.
   The treatment of bronchitis and asthma  has been sufficiently re-
marked.  The heart is best supported  by small doses of digitalis,
which may be given in the form  of the tincture, five to ten drops
three or four times  a day ; or the infusion,  teaspoonful to a table-
spoonful every three or  four hours; or the  powder of the  leaves,
one or  two grains with  twice as  much white sugar.   The further
treatment of  heart disease and cardiac complications is discussed in
connection with these affections.  The only  treatment which may be
called specific is that of  pneumatotherapy.  Patients  are made to
inhale, with an appropriate apparatus (Heuck's, Williams', Walden-
burg's), compressed  air, and exhale  into  rarefied air.  Change of
climate accomplishes most.

             croupous pneumonia {see Infections).

                    CATARRHAL PNEUMONIA.

   Catarrhal pneumonia, broncho-pneumonia, lobular  pneumonia.—
Catarrhal inflammation of the capillary bronchi and air cells, charac-
terized by irregular  fever, cough, dyspnoea, increase  of respiration
and pulse, disturbance of pulse-respiration ratio, carbonic-acid poison-
ing, indefinite duration, grave prognosis.
   Neither the older anatomists nor the clinicians were able  to dis-
tinguish that form of pneumonia which occurs in consequence of the
extension of a bronchitis.  None of the older writers mentioned a
pneumonia in consequence of measles.  The recognition of catarrhal
pneumonia dates from the special studies of  diseases of children.  To
Barthez and Rilliet is generally  ascribed the  Credit  of having  first
recognized this  disease.   The term is not  very appropriate.   The
word  catarrhal is used in distinction from croupous,  with the under-
standing that the catarrhal process means an affection of the mucous
membrane with exudation of  mucus and, at the most, pus, whereas
the croupous  exudation is blood, fibrin, or transformed epithelium. 
522
CATARRHAL PNEUMONIA.
Neither term is likely to survive a definite understanding of the na-
ture of both processes.
   The distinction is often made between lobar and lobular pneumo-
nia,  understanding by lobular an inflammation which is  confined to
individual lobules but does not extend to involve an entire lobe.  In-
asmuch as the disease is always a  secondary process and occurs in
consequence of or as  a result of bronchitis, the  proper term for the
disease is broncho-pneumonia.  It should  be understood from the
start that a broncho-pneumonia does not exclude a croupous  pneu-
monia. The processes not infrequently coincide, and the question is
often one of predominance.  Cases which are considered catarrhal
resolve themselves not infrequently as croupous pneumonias,  and,
more rarely, cases which bear the aspect of croupous  pneumonia
turn out to be catarrhal.   As a rule, however, the diseases may be
distinctly set apart.
   Some of the best pathologists and clinicians already subdivide
cases of lobular pneumonia.   Thus Fiedler distinguishes a broncho-
pneumonia and a cellular pneumonia.  The cellular pneumonia is
not secondary to bronchitis, but springs up of itself in the air cells.
The pneumonia of influenza is the typical cellular pneumonia.  These
various pneumonias are best distinguished by their etiology, the study
of which explains also their relation to each other.  Thus in Fiedler's
fifty-five cases, in which the examinations were made by puncture of
the lungs in life, the cause was found to be as follows :
Dipiococcus pneumoniae Frankel's
Bacillus pneumoniae, Friedlander.
Staphylococcus.................
Streptococcus..................
 Fibrinous  Broncho-   Cellular
pneumonia, pneumonia, pneumonia,
15
 2
 2
 4
 2
 1
12
27
In five cases no bacteria were found.  These findings coincide in
the main with those of Weichselbaum.
   Etiology.—Croupous pueumonia begins as such.   It occurs sud-
denly in the midst of health, or that degree of  it which goes with
modern civilization.   Broncho-pneumonia is always a secondary pro-
cess.   It occurs  in consequence of bronchitis, and as  a result, in  the
rule, of infections in which bronchitis is a prominent symptom.  Thus
broncho-pneumonia occurs most frequently in the course of,  or as a
sequel to,  measles,  next pertussis, then diphtheria.   It may  occur
also in connection with variola, typhoid fever, scarlet fever, rubella.
The role of " cold " may not be ignored entirely in the production of
the pneumonias.  Lipari found that animals which had remained
healthy after the endotracheal injection of pneumonia sputum were 
CATARRHAL PNEUMONIA.
523
attacked with pneumonia  immediately upon exposure to cold either
before or after the injection.  The cold weakened ciliary action and
produced  swelling of the mucosa, both processes which favored the
growth of micro-organisms.
   Broncho-pneumonia is a disease of the extremes of life.   It occurs
most frequently in childhood, next in old age, and  shows itself in
adult life  only in individuals who have been debilitated by previous
disease.  Ziemssen found that sixty-seven of ninety-eight cases, and
Stephen  that fifty-two of seventy-two  cases, occurred  in patients
under three years of age.  Jiirgensen ascribes it chiefly  to the poi-
soned atmosphere of ill-ventilated apartments.
   After tuberculosis and croupous pneumonia, it is  the  most com-
mon cause of death in  old  age.   Most of the cases  of  death from
senile debility and " old age," and many of the cases of "heart fail-
ure," are really due to the pneumonias.  The disease process extends
   Fig. 224.—Cellular pneumonia.  Alveolar epithelium from the sputum : a, a', a", alveolar epi-
 thelium ; b, myelin forms ; c, ciliated cells ; d, crystals of lime phosphate ; e, crystals of hsema-
 toidin; /, white blood corpuscles; g, red blood corpuscles; h, squamous epithelium.

 to the air cells from the bronchial tubes by continuity of structure, or
 is inspired from upper  into lower bronchi under the defective ciliary
 action of catarrhal inflammation and the muscular failures of  pro-
 tracted disease or senescence.  Thus decomposing  foods  from the
 mouth or throat, and unexpectorated mucus, are inhaled or inspired
 into the bronchial tubes and bronchioles, to produce infection at the
 seat of final arrest.  The disease is  therefore a diffuse  process.  It
 occurs throughout the substance of  both lungs,  but is  observed
 chiefly in the lower lobes  and along the spine, where gravity assists
 its deposit.
   Symptoms.—Broncho-pneumonia sets in, as a  rule, insidiously.
 It is often  impossible to  draw the line between capillary bronchitis
and catarrhal pneumonia.  It is impossible to conceive of  a marked
case of capillary bronchitis without  some catarrhal pneumonia, and
it is safe to assume the  existence of  the pneumonic process  in all 
524
CATARRHAL PNEUMONIA.
cases of capillary bronchitis.  The  process  is assumed to develop
itself, because the bronchitis does not yield to treatment or to time.
On the contrary, the signs of bronchitis which have previously ex-
isted become more pronounced.   The  temperature runs higher.
Fever, which may have been absent, or present in but light degree be-
fore, now begins  to assume prominence  and persistence1.   The tem-
perature runs up in the evening to 102° or 103°, sometimes to 104° or
105°.  The parents call attention to the heat of the skin, which is
felt  by  the  hand, or more especially by the face  as applied to the
chest in the act of auscultation.  With this fever there is correspond-
ing  loss of strength, anorexia, and emaciation.  The child is more  ,
and more peevish and fretful and restless at night as the fever be-
comes  more marked.   If  there is  anything characteristic about the
fever it is its irregularity.  The temperature fluctuates as the dis-
ease process changes in the lungs.   The pulse is increased, and later
on  it becomes  feeble and fluttering.  Respirations are  markedly
increased from 20 to 30, 40, 50, 60, and more.  They become corre-
spondingly shallow and superficial.  The older clinicians, in watch-
ing  the acts of respiration, said "the breath flies."  The most re-
markable peculiarity is, however, the disproportion between  the
pulse and the respiration.  Instead of the relation of 2 : 9 or 1 : 44,
the ratio becomes 1 : 3, 1 : 2, or 2 : 3.  This disturbance in the judse-
respiration ratio is  a  sign of great value  in the recognition
of the pneumonias.  So  a child with a pneumonia, or even with
an  extensive diffuse  bronchitis,  is  not able to make a  sustained
effort with the  respiratory organs.   It  cannot hold  a  long breath
in  crying.   It must frequently release  its  hold  from  the  nip-
ple in nursing.   Henoch  thinks so much of this sign that he has a
child put to the breast to make this observation.  The physician, in
auscultating, may be well content to await the inspiration that  fol-
lows a long  cry, because the act itself excludes a pneumonia.   Later
on the picture  of carbonic-acid poisoning supervenes.   The sen-
sorium becomes obtunded.  There is  cyanosis  and  coma; finally
heart failure and death.
   The  physical signs furnish information of but comparatively
little value.   As  a rule percussion shows no dulness, except in the
most advanced cases where numerous condensed lobules have coal-
esced, or where in old people islets of condensation have extended to
involve a large  part of the lobe of the lung.   Dulness in strips  along
the spine  on both sides of the chest signifies catarrhal pneumonia.
The auscultatory signs distinguish themselves by their number and
abundance.   They  do  not, however, especially distinguish the  dis-
ease. The  signs which are present are those of  an acute diffuse
bronchitis.   There is  every  variety  of  dry  and  moist sound. 
CATARRHAL PNEUMONIA.
525
These sounds maybe heard universally over the chest.   They are
usually heard in intensity in the back between the scapulae and spine.
   The diagnosis rests upon the existence of bronchitis,  commonly
in connection with measles, influenza, or some other acute affection ;
later in life, in connection with senile bronchitis or tuberculosis.  The
disease develops with fever, increase in  the frequency of respiration
and of the  pulse, disturbance of the pulse-respiration ratio.  The
course of the affection is irregular, subject to remissions and exacer-
bations.  It has  no definite duration.  The natural tendency of the
disease is to extend.
   Catarrhal differs, therefore, from croupous pneumonia in the fact
that croupous is a primary and catarrhal a secondary disease process.
Catarrhal pneumonia attacks especially the extremes of life, infancy
and old age; croupous pneumonia is more frequent in childhood, but
is not infrequent in all periods of life.  Croupous pneumonia begins
suddenly, catarrhal pneumonia so insidiously as to make it impossi-
ble to fix the  time of its  inception.  There is seldom in catarrhal
pneumonia pain, which is often acute in the beginning of croupous
pneumonia.  The brick-dust, glutinous sputum is peculiar to croup-
ous, mucous and purulent  sputum to catarrhal, pneumonia.  Micro-
scopic examination of the  sputum reveals in croupous  pneumonia
the  diplococcus,  which  is  only  exceptionally present in catarrhal
pneumonias.   Croupous pneumonia terminates, as a rule, in from five
to nine days; catarrhal pneumonia has  no definite duration, but ex-
tends over weeks.
   Catarrhal pneumonia is separated from  tuberculosis by the local-
ization of tuberculosis, more especially at the apices, by the action
of tuberculin, and by the detection of the tubercle bacillus.
   The prognosis is always grave, even in infants where the future
of croupous pneumonia is favorable.   The bronchial tubes in infancy
are so small as to be more or  less completely occluded by a degree of
inflammation which would have no effect upon adult tubes.  In age
the advantage in the size of the tubes is counterbalanced by the  mus-
cular failures  of senescence.  Taking cases as we find  them, with
what improvements in environment we  are able  to surround them,
the mortality reaches  forty per cent.  The danger in catarrhal pneu-
monia is double: first, on the part of the lungs, in that so much lung
tissue is blocked off as to lead to death by suffocation, by carbonic-
acid poisoning; and, secondly, catarrhal has the danger of croupous
pneumonia of weakening the  action  of the heart,  and, though the
toxic effect of the disease  is  not so  immediately pronounced, long
duration of it  finally breaks  down the heart.  The right ventricle
becomes dilated and flabby; heart failure develops.
   Treatment has  therefore the double object  of stimulating the 
526
HYPOSTATIC  PNEUMONIA.
 respiratory centres and  sustaining the heart.   Expectorants cannot
 accomplish much.  Choice may be  had of ipecac in the wine or
 syrup, or the compound syrup of squills, or apomorphia, which has
 the  advantage that it may be given, in advanced cases, subcutane-
 ously.  The older practitioners still administer antimony up to eme-
 sis—a practice that must not be pushed too far.  Opiates are always
 dangerous.  They merely mask the disease.  They are better substi-
 tuted by chloral, or may be admitted  only in the form  of  Dover's
 powder.  The best stimulant  to the respiratory centre is the bath.
 A child should be put in a bath whenever the temperature  reaches
 103° in the rectum, and the  temperature of  the water must be so
 regulated as to reduce this temperature two degrees within half an
 hour after  the bath.  The warm, the lukewarm, or the cool bath,
 with cold affusions  upon  the head, constitute the most powerful
 respiratory stimulus we  possess.   A  child in the height of broncho-
 pneumonia should be put in the bath perhaps half a dozen times in
 the twenty-four hours.  Antipyretics are of little value.   A dose of
 phenacetin may secure  sleep at night.  It should be given always
 with a little whiskey  or wine.   In the presence of pain hot applica-
 tions may be made to the  chest.  One may not speak derisively of
 the value of mustard plasters in the more protracted cases.  The
 mustard may be made less irritating by admixture with flour or with
 the white of egg.  In age the strength must be sustained with alco-
 hol.   The  more stimulating expectorants—senega, ammonia, cam-
 phor, benzoic  acid—must  substitute emetics.  A drop  or  two  of
 nitroglycerin two or three times a  day will make a quick appeal to
 the heart, especially in  the presence of sclerotic  vessels.  Digitalis
 sustains it best in the long run.  Creosote and  iodine are remedies of
 great value in more protracted cases.  Cod-liver oil, good food, fresh
 air above all things, change of climate in more chronic cases, best
 meet the indications of treatment.   Further details of treatment may
 be found in connection with Bronchitis.

                    HYPOSTATIC  PNEUMONIA.
   What knowledge  we have regarding the  process  of hypostatic
 congestion we owe to Piorry, who showed that the congestion of  the
 lungs which is found on the  postero-inferior aspect in dead  bodies
 was not a post-mortem phenomenon.  He placed bodies after  death
 on the side or on  the  stomach, and  observed that the  blood did not
 leave the region of its first deposit.   On opening the body the hypo-
 stasis was  still found on the  posterior surface.  Piorry had  distin-
 guished the condition during  life.  Hypostatic congestion occurs in
 all cases of profound prostration or  long  debility.  It is, therefore,
seen most frequently in old people, whose lives  are often curtailed by 
CEDEMA OF THE LUNGS.
527
this process, but is observed also at any period of life as the result of
prolonged decubitus, more especially of failures on the part of the
heart.  So victims of protracted  tuberculosis, carcinoma,  chronic
infections, typhoid fever,  rheumatism, paralyses, fractures of bone,
etc.,  furnish  the large contingent of cases.   The condition occurs
also  not  infrequently in  the  course  of heart disease and catarrhal
pneumonia, and displays itself by the signs of impeded circulation.
   Symptoms.—Piorry called attention to the fact that old people at
the commencement of the disease begin to  sleep ivith  the  mouth
open, in order to secure the entrance of more air.   A light cyanosis
about the face  often betrays the first  hypostasis.  Later the face is
seen to grow  more dusky and edema of  the  lower extremities sets
in.   There is now dulness to percussion  at  the base of the lung,
ascending upward from below.   Respirations become more shallow.
   The treatment consists in the frequent change of  posture—i.e.,
in turning the  patient upon one side or the other, or upon the face,
or especially to bring him to a  semi-recumbent posture.  Caffeine,
the soda  benzoate gr. iij.  every  two or three hours, camphor, nitro-
glycerin, digitalis, best stimulate the heart.   The patient must be
taken out of bed as soon as possible.

   Embolic pneumonia is a complication of heart disease, and sep-
tic pneumonia of pyaemia.

                     OEDEMA OF THE LUNGS.
   CEdema {oidioo, to swell) of the lungs.—The passive escape of
serum, containing red blood corpuscles, through paretic vessels into
the interstitial tissue, alveoli,  and bronchi; characterized by universal
rales, cyanosis, dyspnoea, and  asphyxia.  The  condition was for-
merly considered a result of hydraemia, a view which was disproved
by Cohnheim and Lichtheim, who showed that oedema did not re-
sult  from the  inundation of the blood with large quantities of the
physiological salt solution (0.07 per cent).  Welch developed  cedema
in some experiments in which he weakened the action of the left ven-
tricle, leaving the right intact.  Interference with the escape of blood
from the left ventricle leads to the same result.  The frequency with
which the condition is found in connection with Bright's disease,
tuberculosis,  cancer, leukaemia, bespeaks the influence of disease of
the vessels.   CEdema of  the lungs sometimes occurs suddenly in
health, after  copious cold drinks, hot  baths, after paracentesis.  A
satisfactory explanation of these cases is wanting.   The affection is
bilateral, begins in the lower lobes, and gradually ascends.
   Symptoms.—Sometimes the condition develops insidiously, some-
times suddenly.  The symptoms result from defective aeration of the 
528                       ATELECTASIS.

blood, and are the same whatever the seat of the occlusion.  (Edema
of the lungs is  usually announced  by interference with  respiration,
by rapid respiration, appeal to  all the auxiliary muscles, increas-
ing cyanosis, sense of  suffocation, and anxiety.  The face wears
the look of desperation.   The  sputum is  thin, foamy, tinged ivith
                        blood.  In disease of the kidneys it contains
                        urea.  Inspection shows the limited excur-
                        sion of the chest.  Percussion gives dulness
                        below, increased resonance, even tympani-
                        tes, above the infusion.   Auscultation dis-
                        closes universal mucous and  submucous
                        rales, which drown all other sounds, which
                        may be felt in palpation, may be heard  by
 fig  aai.-cEiema  puimo-    the patient himself, and  often by others in
num. Desquamated epithelium     ,    . .  .
enclosing particles  of coal.    fhe Vicinity.
x 30°-                       The prognosis is always  grave, but
                        depends upon the underlying cause.  Where
the disease is not irremediable, and the heart can be forced to  extra
work, the patient may recover.  Death is by heart  failure and car-
bonic-acid poisoning.
   The treatment consists wholly in appeal to the heart  by caffeine,
the soda benzoate, which may be  administered internally or injected
subcutaneously in doses of two or three grains every hour or  two ;
digitalis infusion, dessert- to tablespoonful every two or three hours ;
alcohol.   The hot bath, hot pack, may, by derivation to the surface,
unload the congested vessels in the lungs.   For the same purpose a
venesection is justifiable in florid cases.

                          ATELECTASIS.
   Atelectasis {arsXy?,  ineffectual, £Hxa6i?, expansion) ;  hepatiza-
tion ; splenization.—A collapse of  the lung, congenital or acquired,
which results from defective expansion, or from occlusion of bronchi,
with reabsorption of gases' first of oxygen, then of carbonic acid, last
of nitrogen.
   Etio logy.—Congenital atelectasis results from lack of expansion,
on account of injury  to, or death  of, the respiratory centre,  as in
compression of  the umbilical cord, protracted  labor,   premature
birth, etc.
   Acquired atelectasis occurs in consequence chiefly of occlusion of
bronchi  with mucus,  false  membrane  (croup),  meconium, blood,
foreign bodies, or of processes which interfere with expansion, effu-
sions  into  the pleura,  pneumothorax, deformities of  the vertebrse
(tuberculosis and rickets), ascites, protracted tympanites, etc.  The
condition may be limited, localized,  in individual bronchi;  or exten- 
DROWNING.
529
 sive, involving numerous lobules, lobes, or the  greater part of the
 lungs.
    Symptoms.—Atelectasis  limited to a lobule or a few lobules may
 show no signs.  Unaffected parts  of the  lungs supply the defect.
 Compensation may be excessive  and result in emphysema.   Where
 one-sixth to one-eighth of a lung is involved the symptoms  are dis-
 tinct.  The new-born  child is born  asphytic; the surface is blue
 and cold.  The child may be born  dead or dying,  so  that efforts at
 artificial  respiration, particularly swinging by the feet  (Schultze's
 method), must be resorted to ;  or the respiration is feeble, the chest
 fails  to expand, the intercostal  muscles sink in as in inspiratory
 dyspnoea; there is no cry, or the  voice  is feeble and whimpering.
 The  patient slowly  recovers, or death  occurs from  heart  failure,
 thrombus of a  brain  sinus.   Inspection reveals  immobility of the
 chest, with collapse  of the intercostal spaces.  There is lessened re-
 sonance to percussion, enfeebled vesicular rale, diminished fremitus,
 and,  with extensive  consolidation, bronchial respiration.   Capillary
 bronchitis and bronchial pneumonia easily supervene.  -
    Diagnosis.—The condition is to be  separated from haemorrhagic
 infarction, which shows  bloody sputum, pain, and pleuritic frictions.
 Croupous pneumonia distinguishes itself by fever, crepitus, and short
 duration ; pleurisy by pain and friction sound, change of  the line of
 dulness with  change  of position, and  absence of  retraction of the
 chest on inspiration.    Slight  atelectases may be suspected on account
 of  the superficial respiration, reduction of  temperature, changes in
 circulation, which cannot be  accounted for in other ways.
    The  prognosis varies. Asphytic children may be recovered by
 artificial respiration,  baths, douches of cold water, faradization.  The
 outlook is worse with premature births.  In the acquired form the
 prognosis depends upon  the  cause.  Associate pneumonia or tuber-
 culosis,  stenosis of the pulmonary valves, permanence of the fora-
 men ovale, make the prognosis grave. •
    Treatment consists in stimulation of the respiratory centre by the
 methods referred to.   The asphytic child is to be  kept warm,  and,
 with established respiration, laid upon its right side.   Stimulants, a
 few drops of brandy  in hot water, may be administered from time to
 time.  In the acquired cases the  treatment is the same as that of
 broncho-pneumonia.

                          DROWNING.
   Drowning is the asphyxia  produced by submersion in fluid media.
Death by drowning  occurs by accident, suicide,  and homicide.  In
the reign of Charles V.  drowning was inflicted  as a  death  penalty
for  child murder ; and as late as the end of the seventeenth century,:
        34 
530
DRO'WXING.
in certain countries—Styria and Tyrol—the body of the suicide which
was refused consecrated burial was put on a boat and sent adrift.
   Accidental drowning is  not so common  since the rail has so
largely substituted the river.  Nevertheless it occurs not infrequently
among pleasure seekers, yachting parties, etc.  Boys are  drowned
more  frequently than girls.   Girls  remain at home and are more
frequently burned.  Drowning  sometimes occurs in the bath tub in
sudden syncope, alcoholism, epilepsy, apoplexy, etc.
   Homicide by drowning is rare.  In a thousand cases collected by
Belohradsky homicide by drowning occurred in  but  twenty-three*
and then, as a rule, under peculiar circumstances. Thus. Henle re-
corded a case where a laborer, driven to desperation through want,
drowned  his four  children ;   Casper-Liman, a  lithographer who
drowned his four children ; Maschke, an insane woman who pushed
her two daughters into  the water.  But drowning of  the  new-born
is frequent.   Nearly one-third of the violent deaths of the new born
occur in this way.  The new-born may have  drowned in the liquor
amnii by premature respiration  (breech  presentation) during as well
as after birth.
   Suicide numbers the  most victims, and chiefly in the female sex.
Ever  since  Sappho plunged from the  cliff, unhappy women have
found relief in death by drowning.   But statistics differ.   Thus sui-
cide by drowning occurs in Vienna in but 5 per cent of cases, in Paris
in 21.5,  in Italy in 38  per cent.   The little piece of the Seine which
runs through Paris numbers more victims than  all the rest of the
river,  or than any other  part of a river of the same length.  Drown-
ing is naturally more  frequent where opportunity is more abundant.
It is rare in inland cities away from  rivers,  lakes, reservoirs, etc.
Locus aggravat crimen.   But a very small amount of water is
necessary to drown.  Devergie relates  a case where a mother took
her four children to a canal in which  the water was but  two feet
deep,  prayed with them, and plunged  with them into the water.
The mother and youngest child were rescued alive.   Smith reports
the case of a woman who cut a hole in the ice and held her head in
it until  she  drowned.  Drunkards and epileptics have drowned in
water insufficient to cover  the entire  head.   If the face can be held
in water for half a minute, or until asphyxia occurs, the individual
loses the power to rescue himself and his fate passes out of his own
hands.
   The specific  gravity of the body  is greater than that of water,
hence there  is a natural tendency to sink;  but the tendency is not
great, and but slight effort is required to keep the face above water.
The greatest weight is in that part of the body out of the water and
unsupported by water ; hence struggle in the effort  to escape, as in 
DROWNING.
531
throwing the hands out of the water, increases the weight  of the
body.  Fat is lighter than water, hence fat people, women, and chil-
dren float  more  easily.   The head, from its  weight,  sinks most
readily.  The body generally rises to the surface during drowning
until the air from the lungs escapes in bubbles, and always after it
in the course of two or three days, unless restrained by weight or
entanglement.   The gases of decomposition suffice to lift the body to
the surface.
   The immediate sensations of drowning are really agonizing. They
attend the struggle  for air, which is always  powerful and painful.
But the struggle  is of very short duration, and dyspnea is quickly
succeeded by loss  of consciousness and convulsions.   An indescrib-
able delirium, with ringing of the  ears, is quickly followed by
loss of consciousness,  and  the period immediately preceding the
loss is attended with sensations at times pleasurable.  Marryatt said
the feeling was not one of pain, but "of sinking into sleep in the long,
soft grass of a cool  meadow."  Sometimes drowning is  entirely un-
attended with struggle, as after injury to the  head, in epilepsy, apo-
plexy,  syncope, alcoholism, etc., when  the body sinks at once like
a mass of lead,  to rise no more.
   The duration  of submersion necessary to  produce  death varies.
Children, especially the new-born, withstand asphyxia longer than
adults, in whom two minutes usually suffice to  take life.  Johnson,
the champion swimmer of England, could remain under  water three
minutes and ten seconds.  Dogs die in four minutes.
   Recovery from asphyxia by drowning is more difficult than from
other cause.   Water exercises an injurious effect upon the lungs.  A
dog with his windpipe plugged to prevent the ingress of  water may
be recovered from asphyxia after four minutes' submersion, while a
dog not so protected succumbs.
   The various signs of death by drowning are, for the  most part,
deceptive.  The blood is usually dark and thin ; the internal organs
often,  but not always, hyperaemic.   The skin  is covered  with goose
flesh from contraction of the cutaneous muscular tissue.   Mertzdorf
called attention to the extreme cold of the drowned body.  This  is
especially observable in bodies drowned in fresh water and after par-
tial removal of the water.  The coldness is due  to rapid  evaporation
from the saturated epidermis.  The epidermis itself  shows  signs of
maceration,  most marked where thickest, as in the  palms  of the
hands and soles of the feet, and most marked on the hands  of the
laborer.  The degree of maceration is an index also of the duration
of submersion.  Signs of maceration show themselves in the pulps
of the fingers and eminences of the hand in two to three hours, in the
palms  which assume a sodden appearance in  two to  three days. 
5 3 2
DROWNING.
The whole hand becomes chalk-white in five to six days.   Decompo-
sition shows itself from above downward, and depends in degree and
time of occurrence upon the exposure, season, temperature, fluid, etc.
Thus it occurs earlier in summer and in sewage.  It becomes often
a nice question in forensic medicine  to determine whether a body
was drowned, or was thrown into the water after death from other
cause.  The question depends largely upon the evidence of breathing
in water.   In the convulsions and  terminal  struggles of drowning
water may be swallowed and its presence recognized  in the stomach.
Unfortunately the  stomach generally contains  fluid.  The discov-
ery of fluid of particular character, liquor anmii, sewage, etc., fur-
nishes evidence of more  value.  Fluid, or  more particularly fine
foam, in the lungs—i.e., issuing from the bronchial tubes and trachea
like foam from  a beer bottle—may likewise  indicate aspiration  of
Fig. 226.—Marshall Hall's method.
water.  Here too, however, is room for doubt, as the same condition
may be encountered in other states, as in cedema of the  lungs, etc.
Of  most value is the  sign  furnished by Hofmann—the detection of
fluid in the middle ear.  Fluids, even chemical test fluids,  as  the
ferrocyanide of  potassium, do not penetrate to  the middle ear in
bodies submerged after death.   The discovery of fluid in the cavity
of the drum is therefore evidence of great value, especially in  the
case of the new-born,  in whom the observation is easily made by cut-
ting out the roof of the drum with a pair of scissors after removal of
the brain in this region.  Any  fluid present is withdrawn by a pi-
pette and examined under  the  microscope.   The operation is more
difficult in the adult and requires the use of the chisel.  Penetration
to the tympanum does not occur in cases  where death takes place
without struggle.  The finding of fluid in the cavity of the drum is
therefore not universal in cases of drowning. 
DROWNING.
533
   Although death usually results from submersion of a few minutes,
cases have  been rescued after much longer  periods.   Sometimes in
these cases the submersion has not  been  complete or  the body  has
come to the surface repeatedly and some air has been inhaled.   New-
born children have been rescued after submersion for ten  minutes.
A most remarkable case is reported in the Annates d'Hygiene Pub-
lique, vol. xliv., page 306, of the rescue of a boy aged fifteen after sub-
Fig. 227.—Sylvester's method.
mersion for nearly an hour.  Efforts at resuscitation should not be
abandoned after submersion short of one hour.   In all cases attempts
should be made to empty the air passages of water.  The older methods
of suspension by the feet or rolling the body over a barrel are bad.  The
body should  simply be inclined downward, as on  the bank of a
stream or in a boat, the chest raised with the clothing, and com-
pression exercised from below upward by the hand over the stomach.
The diaphragm may be thus  forced upward and the water extruded
B'ig. 228.—Sylvester's method.
through the open mouth.  Wet clothing should be immediately re-
moved, the body quickly dried and warmed with hot-water bottles.
Fires may be made in the vicinity and stones heated as substitutes.
Remarkable results have been reported from  the application of hot
water alone.   The clothes saturated with hot water, 110° to 140° F.,
and applied about the surface, stimulate the  centres of respiration
through the skin, as does exposure of the  skin in  the first acts  of
breathing in the new-born. 
534
EMBOLISM OF THE LUNGS.
   Various  methods  of rescue have been proposed.   They depend
entirely upon securing artificial respiration.
   The first method  devised  was that of Marshall Hall.  It con-
sisted in turning the body over on the side to  secure expiration and
turning it back to secure inspiration.
   The method of  Sylvester was  an  improvement.   Sylvester's
method consists in raising the arms  above the body by the side of
the head to  secure expansion of the chest and inspiration, and then
depressing them again by the side of  the  body, with some compres-
sion, [to secure expiration.  Satterthwaite suggests  also  the  with-
drawal of the tongue to keep the larynx open.
   Howard's method is a further improvement.  The operator be-
strides the body, places his hands upon  the front and sides of the
chest,  with  the thumbs  by the side  of  the  sternum, throws his
Fig. 229.—Howard's method (Satterthwaite).
weight  forward upon the body, making at the same time lateral
compression, while he counts one, two, three, or up to five ; and
then, with a final push, in which the hands are assisted with the
knees, throws himself back, that the chest  may recover  from the
compression with a spring.  These various acts of compression are
made first slowly, and gradually more rapidly until some signs of life
appear.
   Bad  signs are drooping, half-closed eyes, rigid, incurved fingers,
extreme and persistent coldness of the surface.  The first signs of
respiration are twitching of the muscles  of the face, slight flushing,
and  gasping respiration.   Bodies submerged for but a short time
soon begin to gasp and speedily recover.

                   EMBOLISM OF THE LUNGS.
   Embolism  of the lungs ;  hsemorrhagic  infarction.—Infarction
results from the occlusion of pulmonary arteries by thrombus or em- 
EMBOLISM OF THE LUNGS.
535
bolus.   It may result only when the circulation of neighboring capil-
laries is insufficient to counteract the stasis, which condition may
occur in connection with affections of the lung or insufficiency or
stenosis of the mitral valve.   Blood vessels may  be blocked also by
accumulation of  white blood corpuscles  in  leukaemia.  A simple
mechanical  plug produces the  infarction.  Infected matter breaks
down the tissue in its vicinity, to constitute the  metastatic abscess.
Infarction is usually peripheral, cone-shaped, with  the base at  the
pleura.   The tissue is brown or black, firm, and  elistinctly separated
from the sound tissue.  The pleura maintains its lustre at first,  but
later becomes cloudy and  covered with fibrin.  Emboli usually
come from the systemic veins, especially from the iliac and its
branches, from the  prostate  and uterus,  sometimes from lesions of
valves in the right heart.  The process is  favored by retardation of
circulation or heart disease.  On account  of paresis of the vessels
from lack of nutrition the vessels  become  permeable, and blood
fills  the alveoli and bronchioles of the whole domain  supplied by  the
occluded vessel—that  is, the stasis leads to diapedesis.  Conditions
which produce sudden changes in the circulation may dislodge  par-
tially developed  thrombi.   Thus the accident has  occurred  after
violent effort, the application or release of pressure, as chest corsets,
bandages of varicose veins, laparotomy, emptying of cysts,   etc.
Metastatic abscess is  found in connection with pyaemia,  especially
puerperal fever, ulcerative endocarditis, gangrene, furunculosis,  etc.
   Symptoms.—A small infarction may show no signs.   Occlusion
of a large branch of  the pulmonary artery usually takes life at once.
If the occlusion is not complete or the branch not so large, severe
symptoms ensue—extreme   dyspnea,  syncope, convulsions,  or
coma.  Stress is to  be laid  upon the  loss of consciousness, espe-
cially if associated  with  convulsions or preceded  by dyspnoea or
haemoptysis.   The dyspnea is the most distressing sign ; it becomes
extreme, and is  attended with the efforts  and  anxiety of despair ;
the  heart's action becomes feeble,  the pulse thready, the  surface
clammy with a cold  sweat.   The pleurisy gives rise  to severe pain ;
there is harassing cough and expectoration of dark, gelatinous,
bloody  mucus.   The  sputum  contains also  peculiar  large lymph
cells, resembling  alveolar cells, embodying blood corpuscles, some-
times as many as five or even more.   These giant cells transform the
blood corpuscles  into pigment matter.   They are seen especially in
cases of heart disease, and are known as the cells of heart  failure.
Metastatic abscesses are  accompanied  by chills and the fever  that
belongs to pyaemia (puerperal, etc.).  Physical examination reveals,
as a  rule, moist rales, dulness  to percussion, increased fremitus
and  resonance,  bronchicd  respiration.   Partial occlusion of  the 
530
ABSCESS OF THE LUNGS.
pulmonary artery develops a  systolic  murmur, with fivmissement
at the second left costal cartilage.
   The diagnosis rests upon the sudden supervention of loss of con-
sciousness, convulsions, dyspnoea, pain in the side', cough, bloody
sputum, with the signs revealed by physical examination, in connec-
tion with the condition which might develop a thrombus or embolus.
   The prognosis is always grave, but recovery is possible with the
dissolution of the thrombus.   Metastatic abscesses give the ominous
outlook of pyaemia, but recovery is not impossible in these cases.
   Treatment.—Inasmuch as the detachment or dissolution of the
thrombus or embolus by artificial  means is out of  the  question,
treatment resolves itself into  such disposition of the  body as will
favor the natural occurrence of these processes.  Prophylaxis  is of
most importance.   To discover the concealed disease, especially in
connection with maladies  of the uterus and  prostate gland; to pre-
vent,  so  far as may  be,  the formation  of  thrombi by  antiseptic
treatment of infectious disease ; to secure the greatest possible  rest,
with immobilization of affected extremities, varicose veins, etc., ex-
haust the resources of therapy.   Dyspnoea and pain demand the use
of morphia subcutaneously.
                     ABSCESS OF THE LUNGS.
   Abscess of the lungs is not an independent  malady.  Abscess de-
                             velops in connection with tuberculosis
                             as a vomica full of pus, detritus, micro-
                             organisms, mould fungi, etc., or from
                             the  coalescence  of smaller metastatic
                             abscesses  in  the course  of  pyaemia.
                             Abscess may result  from pneumonia,
                             especially catarrhal pneumonia, mixed
                             infection, or trauma, including lesions
                             of bronchi (foreign bodies).
                               The symptoms are those of the ori-
                             ginating malady.  The sputum is pur-
                             ulent, generally  greenish, sometimes
                             brownish as tinged with blood.  It is
                             made up chiefly of pus corpuscles with
                             alveolar epithelium,  elastic fibres and
                             masses of lung  tissue, detritus, crys-
                             tals of margarin, cholesterin,  hsemato-
                             idin with blood pigment matter, phos-
 fig. 230.—Mould fungi from sputum    phates, and various  mould fungi and
of abscess of lungs.                bacteria.  The diagnosis may be estab-
lished, with the aid of physical  signs—dulness to percussion, in con- 
                   GANGRENE OF THE LUNGS.                 o')7

nection with  fever, usually remittent—by aspiration, a perfectly safe
procedure with a perfectly clean instrument.   When the diagnosis is
established the abscess may be discharged by aspiration or incision.
As most cases depend upon tuberculosis, the evacuation of the abscess
does not cure the disease; in fact, an operation sometimes quickens
its course.  Where address is made at the same time to the cause of
the disease by creosote, tuberculin, etc., the operation is justifiable.
Abscesses from other cause (pneumonia, pyaemia) sometimes dis-
charge themselves into the bronchi  or pleural  sac.  Operation  in all
these cases may rescue the patient from the dangers of discharge into
thelium, pigment matter, pus cells, and bacteria.
the pleura, pericardium, peritoneum, etc., as well as from the remoter
evils of amyloid change and marasmus.

                    GANGRENE OF THE LUNGS.
   Gangrene of the lungs is a rare condition.   Primary gangrene, in
consequence of trauma, with penetration  from without of the organ-
isms of decomposition, is very rare.  The disease results rather more
frequently from croupous  and  catarrhal pneumonia,  infarction,
neoplasms, cancer, echinococcus, actinomyces, abscess, and most in-
frequently from tuberculosis.  Decomposing matter may be aspirated
from the bronchial tubes into the air cells, especially in cases of sub- 
538                GANGRENE OF  THE LUNGS.

jects suffering with coma or paralysis, alcoholism, old age, etc Tin1
condition is twice as frequent in males,  and occurs especially be-
tween the ages of twenty and fifty,  the period of greatest exposure,
and among the poorer classes.
   Symj^toms.—The  gangrene may  be  circumscribed or diffuse,
central  or peripheral ; it may reach and  destroy  the pleura and
lead to pyopneumothorax.  The disease is usually announced with
fever from the absorption of putrid matter.  The fever is attended
with chills and profuse sweats, as in the case of pysemia.  The pa-
tient falls into a typhoid state, with delirium and coma.  Pain in
the side indicates a developing pleurisy.   The cough is  usually dry,
continuous, and harassing.  The characteristic sign  is the expec-
toration of putrid sputum.   The  sputum is generally abundant, is
often  mixed with  blood whose corpuscles are usually disintegrated.
The odor is excessively fetid and penetrating; it fills the room
or the large ward of a hospital, and may  be  perceived  in adjoining
rooms ; it  contaminates everything in contact with the  patient.  On
standing it settles into three layers—an upper,  frothy,  greenish,
purulent;  a middle, greenish  opaque ; a lower,  purulent, greasy,
greenish mass, in which are  found the  characteristic grayish par-
ticles, plugs  of the small bronchial tubes  (the so-calleel  Dittrich
plugs),  with detritus, fat globules, pus  cells, and bacteria, mould
fungi (leptothrix).   The disease is  distinguished from  putrid bron-
chitis by the presence of particles of disintegrated  lung  tissue,
grayish-black  matter of irregular  surface,  containing little  or no
elastic tissue, which is supposed to be destroyed by a ferment some-
thing like trypsin.   Sputum in general is sometimes so tough as to
be teased thin with difficulty.   In such case it should be diluted on
the object glass with a solution of common salt 0.75  per cent, not
with pure water.   The following two solutions are used in the study
of sputum : (1) dilute acetic  acid 1 : 100 distilled water ; (2) soda
lye 3 :100 distilled water. The one-per-cent solution best clears up
fibrin and displays nuclei;  the three-per-cent solution destroys the
protoplasm, gradually also the nuclei, but distinctly displays elastic
tissue and micro-organisms (Graber).
   The  decubitus  in  gangrene is usually on the affected side ; re-
cumbent when the disease is  situated in the upper lobes,  semi-re-
cumbent when in the  lower lobes.
   Circumscribed  gangrene  reveals  no  signs on physical examina-
tion.  More extensive change shows the  symptoms  of  consolidation
—dulness  to  percussion,  bronchial or  amphoric  respiration.
cracked-pot sound, etc. Pleurisy,  pneumothorax, and pyopneumo-
thorax  reveal themselves  with their distinctive  signs.  Pysemia
with metastatic abscesses may ensue.  The course is chronic. The 
      CARCINOMA, SARCOMA,  ECHINOCOCCUS OF THE LUNGS.   539

disease lasts, with remissions and exacerbations, from several months
to several years.
   The  diagnosis depends chiefly upon  the fetid sputum.   Fetor
from  the mouth or nose is excluded by absence of disease of these
organs ;  putrid bronchitis, by the presence of lung tissue.   Simple
abscess  shows purulent sputum without offensive odor, containing
abundant elastic fibres.
   The prognosis is always grave, but depends upon the extent of
the disease and the strength of the patient.  Recovery is announced
by the substitution of purulent sputum without offensive odor.   Pa-
tients usually succumb to marasmus.
   Treatment.—The condition may be prevented often by attention
to the mouth  in cases of paralysis, protracted infections, etc.   The
mouth is to be kept clean with borax,  myrrh, thymol.  Creolin, one
per cent, makes a good mouth wash.  The same  attention is to be
paid to the nose, into which boric-acid ointment gr. xv.- 3 i. unguen-
ti petrolati may be  insufflated.   Traube  recommended the  acetate
of lead, half a grain every two hours, especially in relief of hsemor-
rhage.  The sputum should always be received in  water strongly
impregnated ivith carbolic acid or lysol.  The best treatment con-
sists in the administration of stimulants  and expectorants, with the
use of disinfectants, as  already  fully  discussed in connection with
putrid bronchitis.  As expectorants, the  best  remedies are senega,
benzoic  acid, apomorphia; and as disinfectants, turpentine, thymol,
pyridin, and myrtol.  A good preparation of creosote in capsule, or
with  the tincture of nux vomica equal parts, administered with
whiskey and water in equal parts, five drops of the creosote mixture
to a tablespoonful  or  two of  the whiskey and water, constitutes a
fine expectorant, stimulant, and disinfectant, as well as a  good sto-
machic tonic.
                    SYPHILIS OF THE LUNGS.
   Syphilis of  the lungs is rare and is usually congenital.   It  pre-
sents itself in the form of gummatous  deposits of the size of a pea to
a hazelnut, which subsequently undergo softening. A more common
form, especially in the new-born, is the syphilitic pneumonia, which
consists in a hyperplasia of the  connective  tissue, and  leads to exu-
beration and desquamation of the epithelium.   Nearly all the cases
of so-called syphilis of the lungs in adults  are cases of tuberculosis
in syphilitic subjects.

      CARCINOMA, SARCOMA,  ECHINOCOCCUS OF THE LUNGS.
   Carcinoma of the lungs is secondary, and depends upon metas-
tases conveyed from some distant seat,  usually by the lymph, or 
540
PNEUMONOCOXIOSIS.
results from extension by contiguity, as from the oesophagus, vertebra,
mediastinum, pleura,  etc.   The  right  lung is  affected more fre-
quently than the left, the upper than the lower lobes.   Cancer of the
lung is more common in men. and occurs usually at  an age earlier
than cancer elsewhere.   Primary cancer is very rare.   It develops
in these cases from the epithelium of the bronchial tubes.  It has
been most frequently observed in the Schneeberg cobalt mines, where
it  is attributed to the inhalation of arsenic  in association with the
cobalt, and  where it is said to cause three-fourths of all deaths.  It
is usually medullary, and in metastatic  form is commonly found in
association with metastases elsewhere.
   The signs of cancer of the lungs are  for a time those of bronchi-
tis.  Sooner or later the sputum begins to be tinged with blood, not
continuously but irregularly, and  occasionally it assumes a peculiar
raspberry-jelly appearance which is very characteristic.  Rusty spu-
tum occurs also, and sometimes a sharp hsemorrhage.   The diagnosis
can be definitely declared, however, only by the discovery of cancer
tissue in masses accidentally dislodged.
   Sarcoma of the lungs is even more rare than carcinoma.  It has
been observed in connection with lympho-sarcoma of the cervical
glands, more frequently  as  a metastatic deposit  in connection with
osteo-sarcoma.
   Echinococcus is usually found in connection with echinococcus
of the liver, and may be suspected when cough, pain, dyspnoea, with
the physical signs of consolidation, are found in cases  of echinococ-
cus of the liver.  The diagnosis can  be absolutely established only
with the recognition of scolices, hooklets, etc., in the sputum.
   The treatment of these  conditions is  wholly symptomatic or sur-
gical.

                       PNEUMONOCONIOSIS.
   Pneumonoconiosis  {nvevpoov,  lung,  xovia,  dust), the disease
produced by inhalation of dusts in various avocations, used as a gen-
eral term to include anthracosis, inhalation of coal dust; chalicosis,
inhalation of lime and stone dust; siderosis,  inhalation of iron dust,'
etc.
   History.—The character of the coloring  matter found in and on
the surface  of the lungs was long a matter of dispute.   Pearson and
Laennec expressed the suspicion  that it was coal dust.  Virchow
considered it  an organic pigment of internal formation.  Traube
(1860) first demonstrated the actual presence of coal dust in a miner's
lungs,  and Zenker showed the difference between this dust and or-
ganic pigment.  Hirt, in his thorough studies, reached  the conclusion
that vegetable dust and mixed dust are  much more intense irritants 
PNEUMONOCONIOSIS.                    541
to the mucous membrane of the respiratory tract than metallic, mine-
ral, or animal dust.
   Considerable accumulation of dust may occur in the lungs with-
out damage.  The body is  protected against exposure by outside
guards—hairs, moist surfaces which retain deposits, ciliae—by cough,
etc.   A  sound mucous membrane with perfect ciliary action gradu-
ally extrudes foreign particles.   It is only when the quantity is in ex-
cess or is directly injurious, as in the case of gases, micro-organisms,
etc., or, more especially, when the mucous membrane is affected with
catarrh or  other process which weakens ciliary action, that dust in-
halations produce disease.  Hence the mass of individuals exposed
to the inhalation of dust escape disease.  Disease produced by micro-
organisms  do not enter into consideration here.   Occasional  cases
of disease  from coal and stone dust occur among miners, chimney
sweeps, foundrymen, stone and brick masons, plasterers, mill work-
ers, glass and china factors, ivory grinders, lithographers; cases from
inhalation  of metallic dust, among  the various iron smiths, copper
smiths, etc.;  cases from the inhalation  of vegetable  dust, among
grain shovellers, cotton spinners, wood workers, millers, cigar mak-
ers, etc.
   Symptoms.—The irritation produced  by the inhalation of these
dusts causes in certain cases  at first acute and subsequently chronic
bronchitis,  which does not differ in any way, save  by the presence of
the various dusts, from bronchitis from other cause.  Protracted bron-
chitis  results in bronchiectasis, emphysema,  hypertrophy and dila-
tation of the right ventricle, as in cases from other cause.   The pene-
tration of  the bronchial tubes by foreign particles  excites inflam-
mation in  the interstitial tissue, which results in the formation of
small, hard nodules, constituting interstitial pneumonia.  This affec-
tion is, however, rather suspected than recognized, on account of the
obstinacy of symptoms.  Inhalation  of  coal  dust rather protects
against than invites tuberculosis; vegetable dust favors the develop-
ment of the disease.
   The diagnosis is the recognition of bronchitis, more  especially
chronic bronchitis, which disappears with removal to a purer at-
mosphere, but recurs with renewed exposure.  The various dusts dis-
appear from the  bronchial tubes, as a rule, in the course of ten to
twelve days' stay in a purer atmosphere.  Persistence in the sputum
after  this period  indicates organic change in the bronchial mucous
membrane.  The nature of the dust may be known from the charac-
ter of the avocation, or may be recognized in the sputum under the
microscope.  The addition of the  ferrocyanide of  potash to sputum
boiled with hydrochloric acid, demonstrates the presence of iron by
the formation of Prussian blue. 
542
PLEURISY.
   The prognosis is favorable under a proper hygiene1.   Factors in
dusty atmospheres should be allowed hours of exercise' in the fresh
air.   Better ventilation may  be  secured in  the workrooms them-
selves.
   The treatment does not differ from that of bronchitis from other
cause.
                            PLEURISY.
   Pleurisy {nlevpa, the side).—Infection of the pleura by the diplo-
coccus. streptococcus, tubercle bacillus, etc.
   History.—Paracentesis was performed even  before the days of
Hippocrates.  Euryphon of Cnidos is said to  have saved the  life of
Cinesias by opening the chest with the actual  cautery.  Hippocrates
was thoroughly familiar with  the operation.   He even advised the
very latest suggestion in therapy, to close the wound, after part of
the pus was discharged, with a roll of linen  to which a thread was
attached, and to let off some of the matter every day.  Hippocrates
made use also of a zinc drainage tube.  " If the  pus is clean, white,
or tinged with blood,  the patient will recover.  If it is thick, green,
or ichorous, he will die."
   Pleurisy was not  separated from  pneumonia  in  ancient times.
There is reason for this failure in  the fact  that the diseases  now
are so often found associated.  Sydenham, Morgagni, and Haller,
with  Boerhave  and Van  Swieten, all believed that the lungs were
affected in  this disease as much as  the  pleura itself.   Pinel first
gave  pleurisy its distinct place, and Laennec, with the discovery of
the friction  sound, furnished the ability to distinguish the disease in
life.  The turning point in  the treatment  of pleurisy was reached
in the discovery of the aspirator  by Bowditch,  of Boston, in 1852.
The fact that pleurisy is  never,  strictly speaking, a primary  mal-
ady, but occurs as the result of an infection which shows itself in
some other organ, or  is, at least, due to micro-organisms which pro-
duce diseases of other organs, is a matter of recent acquisition.
   Etiology.—Pleurisy is  looked  upon in our day as an expression
or localization of  one of  the infections.  The pleura is the serous
membrane most frequently invaded in the course of infectious dis-
eases.  The cause of pleurisy was formerly ascribed to trauma or
taking cold; a penetrating wound from without, as a stab, or  from
within, as a rupture from a broken rib, or invasion from caries of the
vertebrae, foreign  body in the oesophagus, aneurism, etc.  Any in-
flammation as the result  of disease in a contiguous structure will
produce inflammation of  the  pleura, but not that distinct  form of
disease which is set apart as  a  simple or distinct  pleurisy.  The diffi-
culty of discovering the cause of pleurisy, the cause of inflammation
in a structure so deep-seated  and apparently secluded from all avenue 
PLEURISY.
543
 of ingress, led pathologists to adopt the view that pleurisy was an
 expression of tuberculosis.  This view was fortified by the fact that
 the diseases were so often found associated, and that the subjects of
 pleurisy  become  not  infrequently subsequently victims of tubercu-
 losis.   Further study has shown, however, that this cause  applies
 only to the minority of cases, that most cases of pleurisy depend upon
 the invasion of other micro-organisms than the  bacillus tuberculosis.
 Bacteriological studies of recent years, as by Netter and Levy, reveal
 the fact that most cases of pleurisy are due to  the micro-organisms
 which produce  pneumonia—the  diplococcus of Frankel and the
 pneumococcus of Friedlander.   Netter shows that all forms of pleu-
 risy are of microbic origin, but that the microbes producing them are
 of many  different kinds.  In one hundred and  nine examinations of
 purulent pleurisy he found, in different cases, pneumococci, pyogenic
 streptococci,  staphylococci, the bacillus tuberculosis, Friedlander's
 encapsulated bacillus,  the pseudo-typhoid
 bacillus,  Micrococcus  tetragenus,  spirilla,
 filaments of leptrothrix, and saprogenic bac-
 teria.
    The cases of simple serous effusion dis-
 tinguish  themselves often by  negative evi-
 dence. These  cases  are  called rheumatic
 and are attributed to the cause of rheuma-
 tism (Fiedler).   In some of these  cases,
 however, the diplococcus has been discov-  _   no,  „.
               .                     .        Fig. 232.—Micrococcus pneumo-
 ered as the evident cause of the disease,  niae crouposse, showiDg  capsule*
 Cases  secondary to Bright's disease are be- f,om exudate in pleural cavitr of
               ,   .    .  .          .         inoculated   rabbit  (Sternberg,
 lieved to  owe their  origin to chemical pro-  after saivioii).
 ducts, toxines,  rather than  to  the direct
 presence  of a micro-organism itself.   Attempt  has  been made  to
 declare the future of  a case,  whether it will remain serous or be-
 come purulent,  by the character of the micro-organism encountered
 in fluid withdrawn for examination.  Decisive results have not yet
 been reached.  It is certain that the diplococcus of Frankel is often
 found  in cases which remain serous, and that the exclusive presence
 of this organism justifies a favorable prognosis.   The pyogenic micro-
 organisms do not necessarily determine suppuration.
    The role of exposure to cold in pleurisy is the same as that of the
 other infections.   It may awaken a dormant process or  localize an
 existing infection.  As a rule "taking cold" expresses merely the
 onset and outbreak of a disease.  In pysemic processes the pleura is
involved with the  other serosse; so pleurisy may occur in  the course
of puerperal fever, scarlatina, dysentery, rheumatism, etc., as  a sec-
ondary process, sometimes as  a terminal link in the chain of disease.
 
544
PLEURISY.
   The pleurisy which apparently develops first  is found to be pro-
duced, as stated, most frequently by the diplococcus or other micro-
organisms of pneumonia, so that pleurisy and pneumonia  are asso-
ciated as a rule.  The pain in pneumonia belongs to pleurisy.   It is
a (piestion rather which disease process predominates.  It is possible
to have a central pneumonia without a pleurisy, as it is possible to
have  a pleurisy  without  pneumonia.   The rule is  that  pneumonia
involves the pleura covering the affected lobe, and that pleurisy affects
a peripheric zone of lung  tissue.  The secondary process subsides to
leave  the main inflammation  dominant.  Actual  pleuritic effusion
occurs  in about five per  cent  of cases of pneumonia.   When  the
pleurisy and pneumonia occur  simultaneously  the  pleurisy is  said
to be  parapneumonic; when the pleurisy follows the pneumonia  it is
said to be metapneumonic.
                           Forms of pleurisy are  distinguished by
                       the amount and character of the effusion.
                       Cases in which the effusion  is slight or ab-
                       sent are known as pleuritis sicca; cases with
                       perceptible effusion as pleuritis humida, or
                       pleurisy with effusion.   The effusion is dis-
                       tinguished as serous or sero-fibrinous, puru-
                       lent, sanguineous, or ichorous, according as
                       it contains pure  serum,  fibrin, blood, or
                       ichor.   Forms are also separated into acute
                       and chronic, and subvarieties of these forms
                       into those which develop with the  most in-
                       tense  symptoms,  pleuritis  acutissima,  and
^„Tw,L:rdeed"PaDS'0n0' those  which develop so  insidiously ns  to
                       have remained latent for a long time.  Most
of these last cases belong to tuberculosis.
   Symptoms.—Pleuritis begins as an acute infection—i.e., with a
chill  or a series of shivering fits attended with rise of temperature.
The fever is quickly  followed by pain.  The pain  is usually pretty
strictly circumscribed and is localized in the region of the left nipple.
The pain is manifest in places where the layers of the pleura are sub-
ject to most friction.  The base and apices of the lungs remain at
comparative rest. The sides are subject to most motion.  The  pain
is present in every degree of intensity.  The distinctive pain of pleu-
risy is usually acute.   It stops the movements of the chest and checks
the act of respiration.  Respiration becomes chiefly abdominal.  The
patient learns to spare the chest, sometimes to limit the excursion
of the affected side.   There is, however, along with the pain of pleu-
risy,  no increase in the frequency of respiration, so characteristic
of pneumonia.   The  patient can take a long breath.  It is plain to
 
PLEURISY.
545
  see that the inhibition of respiration is not a matter of inability or in-
  capacity, but of pain.  The patient lies on the sound side in relief of
  pressure on the affected side.  Later, when  effusion takes place, the
  patient changes posture  to lie on the affected side, that -the sound
  side may expand to secure more full inspiration.  With the pain
  there is cough, dependent upon irritation of  the pleura.   That cough
  may  result from direct irritation of the  pleura is a fact with which
  clinicians may become familiar in the treatment of this  disease.  It
  may become  necessary to remove a drainage tube in relief of a cough
  so harassing  as to prevent sleep.  Expectoration is absent, scanty,
  or purely bronchial.  The disease is said to exist now in its first
  stage.  At this time inspection reveals only limitation in the move-
  ments of the  chest.  Percussion gives no sign.  Auscultation reveals
  the friction  sound, a fine subcrepitant rale, striking on account of
  its superficiality, and circumscribed about the region affected.  In a
  simple pleurisy the friction sound  is transitory.   It may be present
  for but  a few hours or a day.   It disappears under adhesion, effu-
  sion, or resolution.  It may  return with the reabsorption of fluid,
  which renews contact of inflamed and roughened surfaces.
    With the second stage of the disease,  the stage  of effusion, the
  physical signs change. When the effusion is very rapid, inspection
  will show more distinct interference with respiration.  The breathing
  is increased in frequency.  The pulse becomes irregular from in-
 terference with the  circulation  by pressure  upon the great vessels.
 Some  cyanosis may show itself.  Where the effusion is great  the
 affected side  of the chest may bulge, the  intercostal spaces become
 more prominent.  The abdomen itself protrudes from depression of
 the diaphragm by the weight of the effused fluid.  It is observed
 that the apex of the heart is displaced toward the right if the effu-
 sion be on the left side, toward the left if on the right side.   Slight
 displacement of the apex of the heart to the  right is observed before
 the accumulation is so great as  to account for it by mechanical dis-
 placement.  It is attributed to the altered resiliency of the lung on
 the affected side.  The accumulation of fluid may be followed up by
 percussion.  Change of posture reveals the fact that the fluid is free.
 It floats about as determined, by gravity.  The  dulness in the back
 becomes resonance by placing the patient on the  face, etc.  Finally,
 the lung is compressed as an airless cake against the spinal column.
   Auscultation reveals nothing.   But muffling or entire absence
 of sound is testimony more valuable than sound itself.   In the  re-
gion of the compressed lung, particularly between the scapula and the
spine,  bronchial respiration is audible  and bronchophony  is dis-
tinct.   Finally, fremitus and resonance are both either diminished
or absent over the affected lung.  A peculiar tremulous note, known
35 
546                        PLEURISY.
as egophony, may be heard just above the loved of the fluid.  It is pro-
duced, not by the fluid itself, but by laxity of the lung tissue1.  Bae-
celli claimed that a whisper could be heard through a clear fluid, but
not through a fluid rendered turbid by pus.  Rumino believers this sign
to be reliable—an opinion to which most clinicians fail to subscribe.
   Usually the fluid is serous or sero-fibriuous.   It is not uncom-
monly purulent.  It is a question if the effusion is purulent from the
start.  It may certainly become purulent in the course of a very few-
days.  The  change is usually indicated by increase of the fever.
The temperature, which may have been before but 100° to 102 , now
rises to  103° or 104°, especially  in  the  evening.   The patient loses
appetite and strength, becomes restless and sleepless.  These symp-
toms often signify the change to pus.  Very frequently the change
is so gradual as to be unannounced.   The clearest  serum contains a
corpuscular element.   Aspiration observations reveal the fact that a
fluid clear at first becomes often milky toward the close.   Corpuscles
sink by their weight to occupy the lower strata.   In most cases the
character of the fluid can be determined only by withdrawal through
an aspirator or a clean hypodermatic syringe.  Cases due to advanced
tuberculosis, as to irruption of a vomica into the pleural sac to con-
stitute pneumothorax, often show ichor.  Where  the effusion con-
tains blood the disease is usually either tuberculosis or cancer.  There
is in these cases corresponding cachexia and degradation.  It  is by
no means always easy to distinguish the kind of fluid in the chest by
the physical signs.  Aspiration makes the diagnosis easy.  Punc-
ture with a perfectly clean instrument under  aseptic precautions,
which consist merely in washing the skin with soap and a sublimate
solution  1 :1000, is always justifiable in an obscure case.  Failure to
withdraw fluid does  not necessarily exclude pleurisy.  The case may
be a pleuritis sicca, or effusion may have been absorbed to leave thick
membranes.  The needle sometimes becomes plugged with a flake of
fibrin ; hence the aspirator, with its great suction force, is to be pre-
ferred to the hypodermatic syringe.
    The diagnosis is determined by the  pain  in the side, the fever,
decubitus, limited respiration, friction sound, and  signs of  effusion.
The effusion is itself diagnosticated absolutely only by puncture with
the hypodermatic needle or aspirator.
    Pneumonia is distinguished by higher fever, cough, expectoration
of rusty  sputum, crepitation, dulness to  percussion unvaried by pos-
ture, bronchial respiration, etc.
    Hydrothorax is separated by its cause, heart disease, kidney dis-
ease,  etc.  It is bilateral, painless, free of fever, and  furnishes to
puncture a clear, light-yellow fluid, free of flocculi, of light specific
gravity,  less than 1018. 
EMPYEMA.
54i
    The prognosis  depends upon the cause.  Simple  pleurisy has a
 favorable prognosis.   Tubercular pleurisy is always grave, yet cases
 do recover absolutely.
    It is essential to distinguish the form of the disease, as the treat-
 ment  depends upon it.  Simple cases  are let  alone.   The  case is
 treated on  the expectant plan, or, with  the doctrine of  rheumatic
 origin, by the salicylates, precisely as in acute rheumatism.  Fiedler
 stoutly claims  that early treatment with the salicylates aborts the
 disease.   Pain  is  relieved  by hot applications—i.e., hot water—
 investing the whole side of the chest.   More severe pains may re-
 quire  broken doses of Dover's powder gr. ij.-vj., or  morphia itself
 gr. ^-|.  Under rest and relief of pain the fluid is absorbed sponta-
 neously.  Cases  of pneumonic  or  tuberculous  origin, unduly pro-
 tracted cases of any kind, and all cases of pleuritis acutissima, de-
 mand  aspiration of the effusion.  Nature should  be first  allowed a
 chance for two or three weeks.  Persistent fever, progressive failure
 in health and strength, weight and color and appetite,  command the
 operation.   The  puncture should be made in the fourth left, fifth
 right intercostal  space, and the  fluid slowly but never wholly with-
 drawn.

                            EMPYEMA.

    Empyema {spnvypa, an internal suppuration) ; suppurative pleu-
 risy.—The fluid  effused in pleurisy, though it may seem perfectly
 clear, always contains corpuscular elements.  These  elements  may
 be  so  few as to escape observation altogether.  As  the case pro-
 gresses, more especially after frequent paracentesis, the corpuscles
 accumulate, until finally the fluid becomes  milky and the serum is
 said to be converted into pus.   It is a  frequent observation that,
 though the fluid may be clear at first, it  later becomes more opaque.
 The first syringefuls may be clear serum, the last  purulent.   This
 change may take place rapidly or slowly ; sometimes the fluid is puru-
 lent from the start.   This condition occurs more frequently than is
 commonly believed.  Most of the cases of secondary pleurisy, as in
 the course of pysemia, after violent dysentery, etc., are  purulent from
 the start.  This form of pleurisy is known by a different name—em-
pyema.  It  has a different prognosis and requires a different treat-
 ment.  The character of the fluid is determined by the primary or
 superadded  cause of the  disease.   The organisms most  frequently
 encountered are  the streptococcus,  staphylococcus, pneumococcus,
 diplococcus,  and tubercle bacillus.
   Certain  symptoms  may indicate the period of accumulation or
formation of pus.  Fever shows itself, or increases if present before.
It is especially wont to assume a remittent type with  exacerba- 
548
EMPYEMA.
tions  at  night.  The patient loses what appetite  he bad.  becomes
restless,  sleepless,  suffers pain.  It is plain to see that he is losing
ground.   Frequently the change  takes  place  so  insidiously as to
escape notice.   Sometimes  the disease is perfectly latent, or. if de-
cline  be noticed, the diagnosis is  dubbed tuberculosis and dumped
into the  heap of so-called incurable diseases.  Empyema is in gene-
ral much  more common in childhood.   Empyema  is an internal
abscess.   Pus  may not remain with  impunity  within the  cavity
of the chest.   The  pus of  empyema has special  erosive properties
and may cut its  way to the surface.   In  these  cases it  genera Im-
perforates at  the  thinnest place, near the  sternum.  It  perforates
the parietal layer, insinuates itself between fibres of the intercostal
muscles, and appears as a subcutaneous abscess, where it shows it-
self in surface redness and  oedema.  When the track of perforation
                            is straight the outside  abscess  is seen
                            to expand  and contract  under  move-
                            ments of  expiration and inspiration.
                            Sometimes it conveys the impulse of the
                            action of the  heart.   Ordinarily  the
                            track is more oblique and irregular, to
                            form a kind of valve which permits only
                            the escape of fluid accumulated within;
                            or the surface may be more directly per-
                            forated, sometimes by a number of ori-
                            fices,  to permit rapid escape, or, more
                            frequently,  the long-continued  oozing
                            out, of pus.   Such a case is  an " em-
                            pyema necessitatis."
                               In other  cases the pus penetrates in-
wardly ; it attacks  and erodes the visceral pleura.   The lung may
now  take  it up and like a  sponge become saturated with pus. or.
more frequently,  the  bronchus  is invaded  and the  contents of the
pleural sac are poured into the bronchial tubes to issue in quantities
from the mouth.  An empyema may empty itself  in this way. The
pleural sac may thus become obliterated, or reaccumulation occurs
with  renewed  discharge.  Such patients who discharge with bron-
chial cough, at intervals, large quantities of pus, are often regarded
as tuberculous.                 *
    The sputum in  these cases  is distinguished by  the presence of
crystals of leucin and tyrosin.  Leucin  occurs as globular masses.
tyrosin as  needle-shaped crystals peculiarly arranged in  bundles.
These bodies are  degenerated  products of albuminoid bodies de-
veloped in pus under exclusion of air.   Hence they may be regularly
encountered in  a perforating empyema.   But they  are usually pre-
 Fig. 234.—Tyrosin in needle-shaped
crystals arranged in bundles and stel-
late groups. 
EMPYEMA.
549
sent in solution, and may be seen, therefore, only when the sputum
dries, as they are deposited in characteristic form about the border of
the object glass.  Leucin looks like fat globules, but is distinguished
by its insolubility in ether (Graber).
   The discharge through the bronchial tubes  is  the most favorable
event which  may occur spontaneously in the history of  empyema.
In rarer cases pus may penetrate  the diaphragm and insinuate itself
along the spine behind the peritoneum, to appear as an abscess at the
groin on the inner aspect of the thigh, where it may be mistaken for
a sinking abscess  from vertebral  caries.  As curiosities  may  be
mentioned cases in which pus breaks directly into the pericardium or
peritoneum, or by fistulse into the perineum, etc.
   Treatment.—Cases of pleuritis acutissima call for immediate re-
lief to prevent suffocation.  In these cases pain is intense, dyspnoea
is  pronounced,  the pulse is excessively weak, collapse is  imminent.
Weil collected seventy-five cases of  sudden death in the course of
acute pleurisy, due to compression of  blood vessels, pulmonary throm-
bosis, and heart failure.
   How long fluid may be permitted  to remain in the chest is a ques-
tion that must be decided in the individual case.  Where the patient
is doing well, as determined  by the  pulse, respiration, and general
appearance, the case may be let alone.  Spontaneous absorption, even
of pus, is the rule in childhood.  Should,  however, great change
be noticed  in any way, the fluid should  be withdrawn,  and in  no
case should it remain longer than two to three weeks for fear of com-
pression of the lung.  Paracentesis  is best performed by aspiration
with a needle, whose  cleanliness is  secured  by having been  boiled
five minutes.  The  surface is rendered aseptic with a 1 :  1000 subli-
mate solution, having been first cleaned with soap and water.  The
needle is then plunged between the ribs  in  the axillary  line at the
fifth,  sixth,  or  seventh intercostal space, near the upper border of
the lower rib,  to  prevent wounding  an  artery  or nerve.  Where
the fluid is known  to be a pure serum the finest needle may be em-
ployed. When a previous aspiration has revealed the fact that the
fluid is thick or contains flakes, a larger needle must  be used.  The
presence of fluid is usually discovered at once with the first attempt,
but accumulation or thick membranes may require repeated  punc-
ture.  The  fluid is  in no case to be withdrawn wholly.   The opera-
tion should be checked at once upon  the supervention  of any irregu-
larity in the action of  the heart, pulse, respiration, or severe cough.
The face should be as closely watched for any sign of syncope and
the chest for any evidence of  dyspnoea as in the inhalation of chloro-
form.  Sudden death has occurred from heart failure, from throm-
bosis, or from sudden obstruction  of the air cells.  The fluid  is 
550                     PNEUMOTHORAX.

withdrawn slowly, that the lung may follow it in expansion, or that,
where this is. impossible, the chest may undergo retraction.   With
these precautions  the operation is simple and safe.  A large accu-
mulation of fluid  may necessitate rapid operation.  Empyema in a
child may terminate,  as stated, of itself, and hence should bo allowed
to run a little longer.   In adults the operation is made  at once. The
patient is put in a semi-recumbent posture, inclined toward  the op-
posite sound  side to separate  as  much as possible the imbricated
ribs.   A piece of skin is pinched up between the fingers, transfixed,
and  severed by  a  bistoury from below  upward.   A  subcutaneous
injection of the solution of cocaine may substitute an anaesthetic.
The  rib may or may not require resection—always a simple, but for
the most part a  superfluous, procedure.  The knife is  then plunged
into  the pleural sac.   Pus  usually spurts out in quantity with much
gurgling and sound of insufflation, which speedily subsides  to give
place to a profuse discharge.  A perforated tube is  now inserted,
or, better, a roll of iodoform gauze, and the case, with cleanliness,
may be left to itself.  Irrigation is no longer considered necessary.

                        PNEUMOTHORAX.
   Air may penetrate to the pleural sac from without, as through
penetrating  wounds,  or  from within after  rupture  of the visceral
pleura, to constitute pneumothorax.   In more than three-fourths of
cases the condition is caused by tuberculosis of the lungs and repre-
sents irruption from a cavity.   In  exceptional  cases pneumothorax
may result from empyema  or from abscess or gangrene of the lungs ;
still  more rarely from disease of  the  oesophagus, stomach (gastric
ulcer), or intestine.  As  a rule  the connection with the lungs subse-
quently closes and the enclosed matter, air, serum, blood, or pus, be-
comes encapsulated.   Sometimes it remains open or is closed by a
valve.
   In consequence of  the connection with phthisis, pneumothorax oc-
curs  twice as frequently  on the left side, and is found oftenest in the
acute or subacute cases with rapid advance.  Double pneumothorax
is extremely  rare.
   Symptoms.—The condition is usually announced suddenly ; some-
times after effort,  muscular strain, or cough ;  with intense pain,
anxiety, and extreme dyspnea,  cyanosis, and  heart failure, to
constitute a picture of deep distress.   Collapse of the lung, with dis-
placement downward of  the diaphragm and abdominal organs, are
direct results of pressure.  The heart's action is barely perceptible.
the pulse is reduced to a thread.   CEdema of the hand of the affected
side is a striking symptom which stamps  the character of  the af-
fection in  certain cases ;  when  it occurs it shows itself early, and, as 
HYDR0TH0RAX.                      551
a rule, rapidly disappears (Weil).  After empyema pus may be  ex-
pectorated.  Inspection  reveals distention, sometimes  surface em-
physema. The heart's apex is displaced downward, and to the right
in left-side affections, to the left in right-side affections.  Resonance
and fremitus are diminished or lost.   Percussion shows tympan-
ites, which is diminished under extreme distention, with low dulness
over the displaced liver and spleen.  Nothing  is to be heard under
auscultation.  The vesicular rale is suppressed.  Various cavernous,
amphoric, metallic sounds  are  sometimes to be heard somewhere or
over various parts of the chest.  Auscultation during percussion ap-
preciates metallic sounds.  The presence of fluid in the cavity of the
chest substitutes dulness  for resonance or tympanites.  The dropping
of fluid may be recognized  sometimes as metallic tinkling, or the
play of air through valve openings and fistulae,  " water-pipe" sounds,
are  more or  less distinctly  audible.  Agitation of  the body  may
furnish splashing sounds—succussion.
   The prognosis is always grave, but depends upon the cause,
more especially upon the extent or advance of the phthisis.  While
the patient may sink into a fatal collapse in the attack, he may never-
theless recover from aggravated forms.  According to West seventy-
five per cent of cases succumb within fourteen days, ninety per cent
within a month.
   Treatment.—Pain must be relieved by morphia and  hot applica-
tions ; large  flannels wrung  out of excessively hot water may sur-
round and envelop the whole of the affected chest.  The pain, dysp-
noea, and anxiety of extreme distention may necessitate paracentesis
with an aspirator needle or a fine trocar.  The strength must be sus-
tained  with  stimulants—alcohol;  soda benzoate  of  caffeine three
grains every hour, internally or subcutaneously;  digitalis.  Witzel
recommends the displacement of the noxious matters  in the chest by
the injection of the sterilized  physiological solution of common salt.

                        HYDROTHORAX.
   Fluid, serum, is effused into the cavity of the chest in conse-
quence chiefly of heart and kidney disease, and the condition is an ex-
pression of general dropsy.   Effusion takes place in slighter amount
in consequence of marasmus, compression of the great lymph or
blood  vessels, thoracic duct, intrathoracic veins, as by aneurism,
tumors of the mediastinum, etc.  The effusion is usually passive and
bilateral,  and is found in connection with anasarca, ascites, some-
times with oedema of the lungs,* etc.  The fluid is clear,  yellowish,
often with a greenish tinge, alkaline, free  of  flocculi.  The  specific
gravity is light, 1010-1012.
   The diagnosis  rests upon the  recognition of the  cause, more 
552
PERIPLEURITIC ABSCESS.
 especially upon the physical signs, which do not differ from those of
 pleurisy with effusion, save that the effusion in hydrothorax  is bi-
 lateral.   In all cases of doubt the diagnosis is determined by
 aspiration.
    The prognosis and treatment depend upon the cause.  Exces-
 sive  dropsy, with the danger of asphyxia, is relieved  by caffeine,
 digitalis, diuretin, especially by calomel, as in the treatment of heart
 disease.   It is sometimes necessary to drain the legs.

                         HJ1MATOTHORAX,
    Hsematothorax, as the name indicates, is the presence of blood in
 the pleural sac,  as the result sometimes of penetrating wounds, or of
 fracture of a rib with rupture of an intercostal artery ;  much  more
 frequently of discharge from a cavity with eroded blood  vessels, in
 tuberculosis.  The blood in these cases is  usually mixed with pus,
 sometimes also with air or gases, to constitute a pyohsematothorax or
 a pneumopyohsematothorax.   The condition is not to be confounded
 with the bloody effusions of tuberculous or cancerous pleurisy.
    Prognosis.—The blood from a penetrating  wound  may be ab-
 sorbed and the  patient may recover.  The  prognosis after rupture
 of  an aneurism is fatal; the patient succumbs to internal hsemor-
 rhage.  The prognosis in cases of tuberculosis, where the condition
 is associated  with pyothorax  or  pneumothorax,  is  exceedingly
 grave.
    The treatment does not differ from that of pneumo- or hydrotho-
 rax.  It must have reference to the cause—tuberculosis, aneurism,
 etc.
                    PERIPLEURITIC ABSCESS.
    Peripleuritic  abscess is a rare condition, first recognized by Wun-
 derlich, afterward  more  thoroughly described  by  Bartels, which
 results most frequently from the invasion  of actinomyces, but may
 arise independently from unknown cause.  Peripleuritic abscess gives
 rise to symptoms which have led to confusion with pleuritic effusions,
 empyema, in that both affections distend the chest.  A point of dif-
 ferentiation is the fact that the ribs are separated, in abscess, at the
 seat of the greatest accumulation of pus, while they are crowded
 together in other regions, whereas  in empyema the  distention and
 separation  are uniform.  The intercostal  spaces, or abscess wall,
 retract or  become lax  on  inspiration and tense on  expiration,
whereas they remain unaffected in empyema.   There may be fluctu-
ation  in  abscess, absent  in empyema.  The abdominal  organs are
displaced in  abscess; the pus itself has a lighter specific gravity,
maximum 1032 in empyema, minimum 1040 in abscess.
   Treatment consists in the discharge of the abscess. 
SUBPHRENIC  ABSCESS.
553
                     SUBPHRENIC ABSCESS.
   Abscess below the diaphragm, the result of ulcer of the stomach,
disease of the liver, upward  wandering  paranephritic or peri-  or
paratyphlitic abscess, or the result of empyemata  whose products
have been carried by lymph vessels through the diaphragm,  etc.,
forms collections above the liver or spleen, sometimes of considerable
magnitude.  The diagnosis is established, in connection with the pre-
vious history, by means of the aspirator.  Treatment is the discharge
of the pus or other surgical intervention. 
               DISEASES  OF THE
'   ORGANS  OF CIRCULATION.
                      CHAPTER VII.

                  DISEASES OF THE HEART.

                         PERICARDITIS.

   Pericarditis.—Infection of the pericardium in the course of some
mycosis or  inflammation by extension of disease from some con-
tiguous viscus.
   History.—The ancients considered hairy hearts (fibrinous de-
posits) evidence of courage.   The earlier anatomists could not fail to
find the evidence of pericarditis in effusion.  Galen saw it in animals
and suspected it in men.  Rondelet recognized it under the symptoms
of pain, difficulty of breathing, and fever, with attacks of fainting.
Riolan went  so far as to suggest withdrawal of the fluid in cases of
effusion, and described the symptoms as being more dangerous than
those of pleurisy or pneumonia.  Vieussens relates that he often
encountered adhesion of the two layers of the pericardium.  There
was as yet, however, not sufficient knowledge to enable a diagnosis
to be clearly established in life.  Morgagni  declared that the day
was  distant when  the  ability to recognize the disease would justify
the operation of puncture of the pericardium.  Avenbrugger noticed
bulging of the prsecordium and increase of percussion dulness.  How
little these discoveries  contributed to a diagnosis may be learned by
the fact that even Laennec (1819) doubted the possibility of making
an accurate diagnosis.  Collin (1824) discovered the friction  sound.
which at once made the recognition of the disease general property.
Later contributions have  more to do with the etiology of the affec-
tion.
   The frequency of occurrence of pericarditis is best shown by sta-
tistics from hospital practice, where accurate records are kept and
full autopsies are held in all fatal cases.  According to the report
of one year,  23,249 cases of  disease of  all kinds were treated in 
PERICARDITIS.
555
 the General  Hospital in  Vienna.  Of  this  number 551, about one-
 fortieth of the whole number, were cases of rheumatism.   However,
 but 390, about one-sixtieth, were cases of rheumatism of the joints.
 Pericarditis occurred 32 times,  or once in every 720 cases of disease
 of all kinds.  The point of especial interest is the fact that the peri-
 carditis was a sequel or consequence of  rheumatism in but 6 cases,
 while in 26 cases—that is, five times as often—the disease depended
 upon other causes.  Endocarditis on this  occasion  occurred but 15
 times.   Pericarditis was, therefore, in that year twice as frequent as
 endocarditis.  This ratio  may  have been an accident, or  it may be
 that endocarditis only seems more fre-
 quent because it leaves valvular lesions.
 Patients recover or die of  pericarditis
 quickly, as a rule.   Cases do not accu-
 mulate  as  in endocarditis.   The older
 statistics, based simply upon  clinical ob-
 servation,  speak for the  greater fre-
 quency of  endocarditis.  Thus  Sibson's
 record shows three times as many cases
 of endocarditis.   But  clinical  observa-
 tions can give no precise information
 regarding the frequency of pericarditis,
 for the very reason that the  disease, so
 often latent, is overlooked.
    Exact information in this  respect can
 come only from the dead-room.  Duchek
 claims to have found evidences of peri-
 carditis  89  times  in 590 post-mortem
 examinations—that is, in a fraction over
 fifteen per cent of all the autopsies made
 —but this ratio must be regarded as an
 overestimate, for the reason  that Duchek included  in  his diagnosis
 the cases of so-called milk spots, which are  now no longer regarded
 as pericarditis.   But, with due allowance  for the tendinous spots,
 which are especially frequent in age, when true pericarditis is espe-
 cially infrequent, it is seen that pericarditis is a comparatively fre-
 quent disease.  Perhaps the statement of Willigk that pericarditis is
 encountered in four per cent  of autopsies is nearer the truth, in that
 this statement is based upon observations  made during the earlier
 periods of life.  Later observations only serve  to confirm the state-
 ment of Bauer to the effect  that "formerly, and up to the close of
 the last century, pericarditis was considered a rare disease; since then
it has been proved to be of quite frequent occurrence."
   Etiology.—It is universally conceded  that pericarditis  occurs
 Fig. 235.—Cor villosum. Fibrinous
pericarditis. 
55(i
PERICARDITIS.
oftener among males than  females.   Of the thirty-two cases cited
from the Vienna hospital, twenty-three were males.   Louis says of
his one hundred and six cases that only  one-fourth wore females, a
ratio which  agrees with the observation of Hache.  Bamberger's
ratio was thirty-eight males, twenty-five females.  Sibson, who saw
the largest proportion of females of  any author, observed neverthe-
less the preponderance of males; of his sixty-three cases, thirty-five'
were males, twenty-eight females.  This  ratio points  to  the greater
liability of males to the diseases which cause pericarditis.
   Excluding the cases of so-called tendinous spots, which are now
regarded as simple friction scleroses or hyperplasias of senescence, it
is as generally admitted  that pericarditis is a disease of youth and
maturity.  Grisolle and  Bamberger unite in  the statement that the
maximum frequency of the disease occurs between the ages of twenty
and  thirty.
   The relation of occupation to pericarditis has been  best shown  by
Sibson, who observes that " servants formed fully two-thirds of the
whole of the female patients affected with pericarditis." It is inte-
resting to note of  Sibson's cases that  pericarditis occurred in none of
his females of sedentary occupation, needlewomen, etc.  The influ-
ence of hard work is still further proven in the study of  his male
cases.
   Pericarditis is described as primary and secondary in its nature,
and  much confusion exists  as to what is meant by primary pericar-
ditis.  If by primary is  meant a  spontaneous or  autochthonous  in-
flammation, the term should be discarded altogether, for it may be
said that pericarditis never arises in this way.  Pericarditis is, strictly
speaking, always a secondary or deuteropathic malady.  There are
met, it is true, occasional cases where the cause has not  been or can-
not  be discovered, but these cases should be labelled  inexplicable or
cryptogenetic rather than primary.  All modern writers agree as to
the great rarity of so-called primary pericarditis.  Duchek  saw only
one case in eighty-nine, Bamberger but four in sixty-three.  Fried-
reich,  with his wide experience,  met but two cases in which he
could discover no cause for the  disease.  Since the field of "catch-
ing cold " is being daily more and more contracted in  the etiology
of disease, it is wiser to be agnostic regarding inexplicable cases than
to appeal to doctrines incapable of demonstration and hence bound
to become obsolete.
   An etiological division  of cases  more  in accord with  existing
knowledge would be into consecutive (or mechanical)  and infectious
(or mycotic).   Under the head of consecutive origin  would fall the
cases of insult or injury to the pericardium  from  without, as by
traumata, by  perforation from a gastric ulcer, from  the oesophagus. 
PERICARDITIS.
557
 from  an abscess of the spleen, from pulmonary and pleuritic pro-
 cesses, echinococci, aneurisms, caries of  the vertebrae, sternum, and
 ribs, mediastinal affections, inflammations of the mammae, skin dis-
 eases—in short,  all involvements of the pericardium by contiguity or
 continuity of structure, including under  this head also extensions of
 inflammation from the heart itself.
    While these  cases of so-called mechanical origin form a respect-
 able contingent of all the cases,  they nevertheless remain in the mi-
 nority, all combined, when compared with the inflammations or pro-
 cesses secondary to the infectious diseases.
    The pericardium is  not alike affected by all infections.  Certain
 forms of them show distinct predilection for this structure, and  so
 notoriously is this true of acute articular rheumatism as to lead
 many practitioners to exclude pericarditis in its absence.   It is un-
 doubtedly true that acute joint rheumatism remains the most promi-
 nent factor in the etiology of  pericarditis, that it causes, or  is at-
 tended with, more cases than  any other one factor—Bamberger
 claims that thirty per cent, Chambers and Thompson sixteen and
 twenty per cent, of cases arise from rheumatism—but it is equally
 true that there is no other acute infection which may not be followed
 by pericarditis.
    If  pericarditis is to occur in rheumatism it shows itself by pre-
 ference between the fourth and fourteenth days of the disease.
    While it is always  a possibility in  mild,  brief,  or  protracted
 cases, the  rheumatisms marked by severity or fugacity  are rather
 more liable to entail pericarditis.   With endocarditis it  occurs  far
 more frequently  in the young.
    Next in frequency in the pathogeny  of pericarditis comes pleu-
 risy.  Morgagni and Corvisart  remarked this complication in their
 day.  Duchek claims to have seen in forty-three cases  of  fresh peri-
 carditis an associate pleurisy twenty-two times; but, inasmuch  as
 the freshness or age of the pleurisy is not remarked, it is fair to infer
 that the order  of sequence, in some  of the cases at least, may have
 been reversed.   In Bamberger's cases of pericarditis  10.5 per cent
 arose from pleurisy and pneumonia.
    Tuberculosis  affects the pericardium in both ways.  That is, the
 process may by  contiguity inflame, or  a vomica open up, the peri-
 cardiunij to produce the disease in a mechanical way.   Or the micro-
 organisms of  tuberculosis may  lodge and multiply upon the serous
 surface, just as upon the cerebral meninges or tunica vaginalis,  as
 conveyed thither in the lymph and blood supply.  Bamberger's sta-
 tistics  show pericarditis in fourteen  per cent of cases of pulmonary
 phthisis, but it is impossible to eliminate  the role of pleurisy in any
of these cases. 
55s
PERICARDITIS.
    Statistics  are wanting declaring the relative1 frequency of peri-
 carditis in the various acute infections, yet it is known  of nearly all
 of them that this complication does occur.
    In pysemia and septicsemia, as typically represented in traumata,
 puerperal fever, and prostatitis, pericarditis  with  its frequent as-
 sociate, endocarditis, is the complication which directly or indirectly
 is the most frequent immediate cause of death.   It occurs in all
 three forms of typhus—the exanthematic, recurrent, but most rarely
 in the abdominal form.   Measles, scarlet fever,  and small-pox are
 attended with pericarditis occasionally only in the less  severe, as a
 rule in the malignant, forms of these diseases.   It is not very rare
 in cholera, and is quite common in epidemic dysentery,  along  with,
 or independent of, the rheumatism which  sometimes follows dysen-
 tery.  In erysipelas, diphtheria,  cerebro-spinal meningitis, pericar-
 ditis not infrequently constitutes the last link in the chain of disease
 process.  These are all diseases of mycotic origin.
   But pericarditis  may ensue  upon even the lightest infections.
 Perhaps the most interesting illustrations of  this fact are  those of
 Bednar, who several times observed pericarditis after vaccination.
 In one case an acute dermatitis developed in twenty-four hours after
 vaccination, with a simultaneous pericarditis.   In a second case—a
 sharp diarrhoea—subcutaneous abscesses and pericarditis proved the
 order of sequence.   In a third case the pericarditis developed on the
 thirteenth day after vaccination, without intervening disease.
   In Bednar's thirty-six cases of pericarditis the  disease was found
 independent of other demonstrable lesions only four times.  Thirty
 of these cases occurred within  the  first  month  of life, four in the
 second, and one in the third and fourth months.  In all cases the
 disease was attributable to puerperal processes in the mother, which,
 in the author's words, " extended their injurious effects to the child,
 and, in consequence of acute decomposition of the  blood, developed
 fibrinous  or purulent exudations in  various organs and frequently
 in the pericardium.   The disease proved fatal, as a rule, within the
 first sixteen days of life."
   Pericarditis shows itself informs distinguished  as primary and
 secondary, and acute and chronic ;  but  the forms  of  practical in-
 terest are those attended or not with effusion.
   Symptoms.—Few of the signs upon which the recognition of the
 disease is based  are  local.  The disease is generally recognized by
general signs.  Pain is not a prominent factor in the history of peri-
carditis.   It may be present as a more or less  diffuse distress, but is
manifest rather upon pressure than spontaneously.
   On account of disturbance in the action of the heart itself there is 
PERICARDITIS.                       559
 often precordial anxiety, as manifest in the physiognomy  of the
 patient.   Pericarditis sicca runs, as a rule, a latent and unsuspected
 course, and the diagnosis is only established by  auscultation.  The
 friction sound may often be heard anywhere over the  heart, most
 intensely  over the body of the heart at the left border of the ster-
 num.  In simple pericarditis from rheumatic cause  it is often very
 transitory and may exist during the space of but a few hours.  The
 earlier writers described it as a to-and-fro sound,  corresponding with
 the contraction  and dilatation of the ventricles.   While it is there-
 fore a double sound, it is not strictly synchronous with the sounds
 of the heart.   It may change or disappear by change of posture, by
 pressure of the stethoscope, and is often intensified  by the act of
 holding the breath.  It varies in every degree of intensity from a
 whisper to the  creaking of new leather, and seems to be, as compared
 with heart murmurs, exceedingly superficial, as if just under the
 ear.   It disappears naturally (1) in the process of resolution, (2) with
 the separation of the membrane by effusion, and (3) with adhesion
 of apposed surfaces.
   In pericarditis from tuberculosis or from mechanical cause the
 surface is wont to be much more roughened and the  sound coarser
 and  more persistent.  Having disappeared under  effusion, it may re-
 turn as a  " redux rub " after absorption of the fluid.
   Pericarditis with effusion is  much more  readily recognized.  In
 slight amount up to a few ounces the effusion may escape detection.
 Not  infrequently the first sign of effusion is interruption of  the fric-
 tion  sound.  As a rule effusion reveals itself by the general disturb-
 ance in  circulation and respiration.  Where  the process is  slow,
 tolerance  is established and effusion is  arrested in the  course of a
 few  hours or a few days at a point which does not materially inter-
 fere  with  the action of the heart.  The  fluid may now be  absorbed
 and  the disease disappear  without having even  been recognized in
 life.   The effusion is, however,  more wont to become persistent or
 permanent in  the pericardium than in the  pleura, and under any
 greater accumulation  signs of general distress more or less rapidly
 supervene.  The heart's action becomes weaker, the pulse is feebler.
 There is pallor, with prostration, dyspnea, sometimes  cyanosis
 and  syncope.
   A case strikingly illustrative of these points occurred in the expe-
 rience of the author.   The patient had been the victim of unsuspected
 pericarditis with effusion for fifteen years—at least the same  symp-
 toms had  been  present in  greater or less degree all that time.  The
prominent symptoms were pallor, dyspnoea, such  vertigo as  to com-
pel the recumbent position, occasional cough, and a pulse  so  feeble
as to fade away when the arm was held at right angles to the  body. 
5G0
PERICARDITIS.
Digitalis and alcohol administered from time to time obviated immi-
nent collapse.   There was  undoubted  increase of dulness over the
region of the heart, which had been taken for dilatation.  By aspira-
tion one pound of serum, at first clear, later brownish and floceulent,
was withdrawn  from the pericardium.  The symptoms of immediate
danger soon disappeared.   But the long pressure and maceration had
weakened the walls of the heart to such an extent as to prevent per-
fect recovery.
                                  The diagnosis  in these  cases is
                               established for the most part by the
                               physical signs.   Inspection shows,
                               in the  chest of the young, bulging,
                               and  palpation reveals muffling  or
                               absence of the impulse of the heart.
                               The  to-and-fro  friction  sound  is
                               characteristic.   The most valuable
                               signs  are disclosed to percussion.
                               There  is dulness  over  the entire
                               prsecordium,  corresponding to the
                               distended pericardial  sac.   When
                               this dulness is outlined upon the sur-
                               face  of the chest it  is seen to consti-
                               tute  a truncated  cone, whose base
                               is at the diaphragm and whose trun-
                               cated  apex  corresponds to the at-
                               tachment of  the pericardium about
                               the great vessels.   Fluid  accumu-
                               lates usually to  the extent of a pint
                               or more, and  such  accumulation
                               gives  rise to  distinct dulness  over
                               the whole left front of the chest.  In
                               the absence of tuberculosis  or  apex
                               pneumonia, dulness under the clav-
                               icles, beginning at the  second  or
third rib and extending downward and outward, should always ex-
cite suspicion of pericardial effusion.  Occasionally the accumulation
is so great as to conceal a great part or the whole of the lung which
it oppresses by its weight.
   Andral  once  discovered two  pounds of blood,  Corvisart  once
found eight pounds of  serum, and Alonzo Clark  reported the history
of a case where the  pericardium contained one gallon of sero-puru-
lent fluid.  The distention which the sac  must undergo to accommo-
date such quantities becomes evident with the statement of  the nor-
mal capacity, fourteen to twenty-two ounces in the adult male.
  Fig. 236.—Pericardial effusion with dis
placement downward of the liver. 
PERICARDITIS.
561
   The mental disturbances which have  been described in connec-
tion with pericarditis  are due either  to interference with the circula-
tion of the blood in the  brain, or are toxic effects in connection with
the original and originating maladies.   With the history of a myco-
sis, the previous occurrence of the friction  sound, and the presence
of dulness, the diagnosis  is very simple, and failures in recognition
of the diseases are due  here, as  well as elsewhere, to lack of exami-
nation.
   Diagnosis.—The  disease  must be  differentiated  at times from
pleurisy.  Pleuritic friction sound corresponds to the acts of respira-
tion, and is arrested when the patient holds his breath.   In rare cases
the pleura may be rubbed by the action of the heart.   The diagnosis
must be established, if the diseases are not associated, by a considera-
tion of the other signs.  Endocardial murmurs distinguish themselves
from pericarditic friction sound by the fact that they are more strictly
synchronous with the sounds of the heart.   They are more uniform
in intensity and are not affected by change of posture or pressure.
They may be  rendered  more intense by exercise.   Doubt regarding
the nature of the effusion may be  dispelled by puncture with the
hypodermatic  syringe.    The needle  should be introduced  at the
fourth, fifth, or sixth intercostal space, half an  inch or an inch to
the left of the sternum.   Failure to  secure  fluid does not necessarily
exclude its presence.  The tube may be blocked by a flake of fibrin,
or the fluid may be too thick to flow, so that subsequent puncture
may be tried with the larger  needle and greater force of the aspira-
tor.   It is needless to say that  all  needles  used in this way should
be previously  rendered aseptic by boiling  five minutes, best  with
sodium bicarbonate five per cent. Otherwise it is best to use no needle
twice, but to  employ a new needle  for each occasion.   Should the
fluid show blood or consist largely of blood, the pericarditis is prob-
ably tubercular or  cancerous.   Tuberculosis, however, by no means
always shows a bloody fluid.   It may be as clear as the product of
a more innocent mycosis.  It is a common observation that  a  fluid
which is serous on  the  first withdrawal may become purulent later,
or the fluid may be purulent from the start.
   A chronic  adhesive  pericarditis  cannot  be distinctly recognized
by any special train of symptoms.  The retraction at the apex of the
walls of the chest by no means  always occurs in this condition, and
when it occurs does  not  necessarily indicate the  adhesive change.
The same may be said of  the pulsus paradoxus—i.e., the decrease in
the force of the heart which attends an  act of inspiration.  It is
found also in many other  conditions.
   The prognosis is always much more grave than inflammation of
the pleura.  Pericarditis  sicca usually runs a favorable course, and
        36 
502                       PERICARDITIS.

though the membrane may be thickened by many layers and more1
or less adhesion produce a partial or complete obliteration of the
pericardial sac, there need be no serious disturbance in after-life.
   The conditions are not so favorable for rapid or complete absorp-
tion in pericarditis as in pleuritis.   The fluid  is more apt to remain.
and lead in the course of time to maceration of the  heart as well as
interference with its action.
   Simple  pericarditis without effusion requires little  or no treat-
ment.  Rest in  bed or out of it in the recumbent posture, the appli-
cation of dry  cups, an ice bag, or of moist  heat, according to the
sensations of the patient, with the time of a few days to a week, usu-
ally dissipate the disease.   The salicylates, in addressing the cause,
are as valuable  as in pleuritis.  Any unusual pain  may be  relieved
by broken doses of Dover's powder gr. iij.-v., or an extreme case by
the use of morphia.   Sleeplessness may be controlled by trional gr.
xv., or chloral gr. v., and  nervousness by the bromides gr. xx.-xl.
largely diluted.   Effusion not too rapid or extensive may be allowed
to remain, with the hope that it will disappear by absorption in the
course of a few weeks.  Should it  persist longer, or accumulate so
rapidly as to threaten suffocation, pericarditis acutissima, it must be
withdrawn at once, under the same or even greater precaution as in
pleurisy.
   The relief which follows the discharge of  even  a portion of this
fluid is indescribable. The author has seen patients who have been
confined  to bed for a  week, unable  to  lift the head without  vertigo,
recover to show a  strong  pulse, cheerful mien, appetite, and such
increase of bodily strength in the course of a few hours as to enable
them to sit up and  actually leave the house in the course of the fol-
lowing day.
   Delay in absorption may often be hastened by the administration
of a laxative, preferably calomel in all affections of the heart.  The
remedy may be given, as in the  treatment  of dropsy, in doses of
three grains three times a day, when benefit may be expected in the
course of the  third day.  Purgation favors osmosis.   Any sudden
collapse of the heart would call for the analeptics, alcohol, camphor,
digitalis, and, more especially for immediate effects, nitroglycerin.
   Protracted cases with  slight effusion may have absorption  has-
tened by the use of blisters, which are much more efficacious in peri-
carditis than in pleuritis, or by painting the surface with  iodine,  and
friction with mercurial ointment.

   Tuberculosis  of the pericardium is not infrequent.  Bacilli
may be carried directly by the blood vessels, or the  disease may ex-
tend by contiguity of structure from the lungs to  the  pleura.  The 
\
                          endocarditis.                       563

 effusion  may remain  perfectly clear;  it is more frequently tinged
 with blood, and is sometimes, after caseation, purulent.

    Syphilis of the pericardium is very rare.   It may occur in con-
 nection with disease of the heart  muscle.

    Hydropericardium, pneumopericardium, hsematopericardium,
 pyocardium (water,  air,  blood, pus in  the cavity of  the sac), occur
 under the same  conditions and require the same treatment  as in the
 pleural sac.
                          ENDOCARDITIS.
     •
    Endocarditis.—Infection of the endocardium.
    History.—Definite knowledge of  disease  of  the endocardium
 could date only from the discovery  of the circulation by Harvey
 (1G28), following the accurate description of the construction  of  the
 heart by Vesalius.   Nevertheless these discoveries  were not  at-
 tended with immediate  results, and it was almost a century later
 that Vieussens made mention of the first case of stenosis and insuffi-
 ciency  of the mitral valve.  Vieussens  recognized also the  enlarge-
 ment of the ventricle and alteration of the pulse, the result of  this
 condition.  Lancisi drew attention to the dilatation of the right ven-
 tricle and visible changes in the cervical veins.   Albertini reinstated
 palpation in estimating disease of the heart,  and Morgagni  ascribed
 cyanosis  to interruption of the circulation.  Senac was the first to
 devote himself to the systematic study  of disease of the heart.   He
 noticed especially the influence of age and the occurrence of  cerebral
 complications in heart disease.   Corvisart reintroduced percussion,
 which had been neglected since the days of Avenbrugger, in  the
 diagnosis of heart disease, and was the  first,  according to Laennec,
 to recognize fremitus  as a  symptom of valvular disease.   Laennec
 illuminated the whole field by means of auscultation, and  made it
 possible to  distinguish the various forms of valve disease in life.
 Rosenstein gives to Kreisig the credit of basing these  diseases upon
 inflammation of  the endocardium. Bouillaud baptized the disease
 with the  name endocarditis,  which still remains, and  to him is  due
 the credit of having especially emphasized the relation of  this affec-
 tion to rheumatism.
   The  work of subsequent investigators is more especially that of
 elaboration and refinement, up to the time of Virchow, who for  the
 first time  gave a satisfactory explanation of the  distant effects of
 heart disease, through  embolism, in the brain, eye, lungs, kidneys,
 etc.  Traube pointed out  the  mutual interdependence of  the heart
and kidneys.  Subsequent studies have dealt  more exclusively with
the etiology of endocarditis. 
564
ENDOCARDITIS.
   Etiology.—Endocarditis is said to  be primary and secondary.
Regarding the primary disease, the same restrictions apply as in
pericarditis.  Cases become fewer every year where no outside cause
can be discovered.  It is safer, in the light of existing knowledge, to
consider all cases secondary and as expressions, with the inflamma-
tions of other serous membranes,  of infection.  Endocarditis,  like
pericarditis, may occur in the  course or as a sequence  of any disease
that is produced by micro-organisms. The micro-organisms actually
encountered in the study of  lesions in the heart are chiefly those of
pus and of pneumonia.  During its prevalence as an epidemic, influ-
-enza may leave lesions in the  heart.
   The disease presents itself under three distinct forms: simple.
malignant, and sclerotic.  The simple and malignant are acute forms,
which result in the  sclerotic as the chronic form.   It was hoped
that the simple  might be distinguished from the malignant by the
diseases with which these forms respectively  were found associated.
It is, however, admitted that these forms are variations rather of
degree than kind, and that  the simple may pass into  the malignant
form.   It has always been admitted that the sclerotic is only a later
stage of either of the acute forms.  The  hope  thus entertained proved
fallacious,  as the same micro-organisms have been  found in both
forms.  The simple  form distinguishes  itself more  frequently by
failure to show micro-organisms of any kind, the malignant form by
the frequency of  the  micro-organisms of pus.  Weichselbaum made
bacteriological examinations of  twenty-nine  fatal cases of  endocar-
ditis.  In eight cases  of the simple form there were no micro-organ-
isms in the deposits on the valves; seven showed the  diplococcus of
pneumonia, six  the streptococcus, and  two  the staphylococcus; six
showed other rare  micro-organisms, the nature of all of which was
not  definitely established.  One case showed three varieties.   The
relation of these bacteria to the disease was proven by the production
of the disease in rabbits in all cases if the membrane had been pre-
viously subjected to  some  mechanical injury.   If the valves were
healthy it was impossible to excite  endocarditis; hence it is inferred
that the disease is brought to the valves by the blood in the heart, as
well as by the blood vessels of the heart.
   Morbid Anatomy.—Simple  endocarditis  is distinguished by the
formation upon the valves of  excrescences.   The smooth, glistening
serous membrane becomes opaque, thickened, and roughened, on ac-
count of changes in  nutrition and infiltration of small round cells.
These roughened surfaces in their  motion whip out from the blood
fibrin, which comes to be deposited in the form of warty growths, to
constitute the form commonly  known  as the verrucose.   Particles
from this cauliflower mass,  dislodged from the surface of the valve, 
ENDOCARDITIS.
565
are swept  onward by the current  of blood  to block vessels  in  the
brain, lungs (infarction), spleen, kidneys,  and the  intestinal  canal,
with the development of characteristic signs.   In certain cases  de-
structive changes occur in the fibrinous masses.   Necrosis takes place.
The tissue  crumbles away to leave an ulcer whose  surface is some-
times covered with detritus or disorganized blood in the form of a
membrane, to  constitute  the variety known  as the  ulcerative  or
diphtheritic form.  These particles washed into the circulation  ex-
cite inflammation at their points of deposit, break down  tissue  in
their vicinity, and form  metastatic abscesses.   The simple form is
found in connection more especially with rheumatism (that is, rheu-
matic polyarthritis) ; the malignant with  septic diseases  (puerperal
fever, dysentery, scarlet fever, diphtheria,  small-pox, the graver in-
fections).   Pneumonia may precede  or develop either form.  The
   Fig. 237.— Endocarditis at and about the aortic valves, with ulceration, perforation of valves,
 and thrombi: a, aorta ; b, pulmonary artery ; c, valve covered with vegetations ; d, perforation of
 a diseased valve ; e, ulceration of septum of the ventricles ; /, ulceration of ventricular surface of
 mitral valve.

 truth is, it is impossible to distinguish the form by the disease which
 causes the complication.  The simplest rheumatism is at times  at-
 tended  or followed by the gravest endocarditis, so that, while it is
 true that in a general way the gravity of the infection determines
 the  gravity  of the complication, exceptions are frequent on  both
 sides.
   Endocarditis  of any form is most infrequent in connection with
 diphtheria and typhoid fever among the grave infections, but  such
 simple diseases as mumps  and quinsy may  produce it.   The endo-
 cardium may be  affected in  any part, but inflammation of the  mem-
 brane which  lines the body of the heart, unless  ulcerative, is not
likely to produce signs.   The  disease rarely exists  upon the mural
 membrane alone, so that the term itself has  come to indicate acute 
560
ENDOCARDITIS.
 inflammation of the valves.   According to  all observation the left
 side of the heart is much more frequently affected.  Statistics  from
 the Berlin Pathological Department. 300 cases, show the lesion in
 207  on the left side; in 32 on  the  right; confined to the leftside
 alone, 268 : and to the right side alone, but 3.  The very reverse con-
 ditions prevail in the foetus and new-born child.  Rauchfuss found
 192  cases of foetal endocarditis in the right side and but 15 in the
 left.   The proportion may not be disputed ; the cases  were derived
 from  many  sources.  The mitral  valve suffers most.   Of the 30o
 cases  just mentioned, tabulated by Sperling, the disease was found
 255  times on the mitral, 129 on the aortic, 29 on the tricuspid, and
 3 on  the pulmonary  valves.  The  mitral valve was affected alone
 157 times ; the aortic valves alone 40 ; the tricuspid alone 3 times ;
 the valves of the pulmonary artery alone in not a single  case.   Em-
 boli  occurred in one-fourth of the whole  number  of  cases, and of
 these  84 cases deposits were  found in  the  kidneys 57 times, the
 spleen 39 times, the brain 15 times, the liver and alimentary canal 5
 times each, and the skin 14 times.
   Either form of endocarditis may be accompanied by pericarditis,
 and is often associated also with affection  of the  substance of the
 heart  itself (myocarditis). The simple form  is  most commonly
 found in  connection with rheumatism.  The relation  of these dis-
 eases has been already discussed, with  the frequency of complica-
 tion—ten to forty per cent, as given by various authors.  As already
 stated, it is endocarditis which gives gravity to acute articular rheu-
 matism ; so that the patient, especially if the  disease be very acute,
 is watched with solicitude throughout the course of  the  disease for
 the development of this affection.
   Symptoms.—Endocarditis sets in, as a rule, so insidiously that
 the period of its origin may escape notice.   The fact that the patient
 experiences  sensations of  distress  about the  heart or shows irregu-
 larity of the-pulse in the course of rheumatism  does not necessarily
 indicate the development of the disease ; for any affection attended
 with  fever, or more  especially with  pain, may show  these signs.
 More continuous and persistent complaint of this kind, especially in
 the absence of much fever or pain, becomes more suspicious.   Any
 interference ivith respiration, any cyanosis however  slight, any
 visible pulsation of the veins of the neck, should call attention to the
 possibility of endocarditis. For the most  part these  signs are ab-
sent.   Careful observations of the temperature furnish reliable indi-
cations.  As a rule the temperature varies  in correspondence with
the affection of the joints, so that the existence of fever, in the ab-
sence of sufficient joint affection to  account for it, should lead to an
examination  of  the heart.  In  the treatment of rheumatism the 
ENDOCARDITIS.
567
 temperature should  be taken four times a day.  With the devel-
 opment  of  endocarditis the  heart  becomes  easily excitable.   The
 lightest motion, sitting up in bed, any psychical emotion, excites
 the pulse.  The hands and  feet,  the whole body,  easily  become
 cold on  the slightest exposure.  The patient complains of chilly
 sensations, shows goose flesh, tremor, and tendency to sweat.  Ex-
 amination of the heart discloses excited action,  increased  area of
 impulse, dislocation of the apex, murmurs which substitute the  nor-
 mal heart sounds.  Diastolic murmurs are especially significant.
 With this association of symptoms the diagnosis is plain, and the oc-
 currence of these signs in the course of a simple rheumatism, light
 pneumonia, or other infection  speaks for  the  existence of simple
 endocarditis.
   The  septic form is more frequently announced with a chill or
 series  of shivering fits, and with severe pains in the bones  and
 joints, which latter sometimes swell to present the appearance of
 rheumatism independently of the general  existence of this disease.
 With the chill and fever, which is irregular, is anorexia, mental
 hebetude, prostration.  The disease now shows itself in one of  two
 distinct forms, the septic or the ttyphoid.   The septic form distin-
 guishes itself especially by the occurrence of repeated chills, at such
 intervals at times as to simulate and be mistaken for malarial fever,
 and more especially by profuse sweats.  The chill,  fever, and sweat,
 are supposed to be due to metastases, which  sometimes reveal them-
 selves  by characteristic signs.  The typhoid form  shows benumbed
 sensorium, sopor, stupor, muttering delirium, along with a  dry-
 coated tongue, sordes about the  teeth, enlargement of the  spleen,
 roseola, and  diarrhea.   The disease is most  frequently mistaken
 for typhoid fever.  The temperature curve is not typical, as in a  case
 of typhoid fever, but the fever is  sustained at a  high  level for a
 period as long, so that the case, even  if closely studied, may be re-
 garded as an anomalous typhoid.  Endocarditis may be distinguished
 by examination  of the heart, but then only when  the  heart shows
 distinctive signs, which is by no means always the case.   Irregu-
 larities,  palpitations, dyspnoea,  more particularly more  profound
 prostration, point to ulcerative endocarditis, especially when these
 signs  occur in the course of a grave infection.   Typhoid fever is
 a primary disease, ulcerative endocarditis is secondary, and the se-
 quence must often determine the character of the affection.
   Nothing constant  may, therefore,  be observed about the heart
itself, so  far as concerns its increase in size, disturbance of seiund, or
alteration of circulation.   One thing only is constant, the iveakness
of its action.  The pulse is more  feeble,  often  more frequent, al-
ways, as stated, more easily excited.   Much of this alteration is due 
568                      ENDOCARDITIS.
 to  affection  of the myocardium, which is usually  involved  in the
 malignant form of the disease.  It must be recognized that septic en-
 docarditis can run its entire  course  without  the  development  of
 metastases.   When  they occur they  develop in the order of fre-
 quency mentioned above.  The brain may be affected directly by the
 deposit of emboli, or functional disturbances of great gravity, but
 without demonstrable tissue lesions, may show themselves as in the
 course of grave acute infections. Suppurative meningitis may occur
 in connection with thrombus of brain sinuses.
    The field of vision may be contracted  to absolute blindness by
 hsemorrhage in the retina or  embolic occlusion of the central artery.
 A septic embolus  may develop  panophthalmitis with  destruction  of
 the globe. Affection of one eye is soon followed by affection of the
 other, as  a rule.   Haemorrhages and emboli may also affect or de-
 stroy the hearing.
    The most characteristic changes take place in the skin.   Minute
 haemorrhages, usually petechial, often excessively profuse, occur in
 the skin,  with eruptions which simulate  those of measles and scar-
 let fever, herpes  and  pemphigus, with sero-sanguineous contents.
 The same hemorrhages may occur also in the conjunctiva and cav-
 ity of the mouth.  Swelling and pain in the joints have already been
 noticed.  These accidents  occur sometimes in consequence  of tox-
 aemia, often  as the result  of embolism.  The spleen  is nearly al-
 ways swollen.  It is this enlargement of the spleen which especially
 leads to confusion with typhoid fever.  Infarctions in the kidneys
 develop albuminuria  and bloody  urine, which distinguishes itself
 more especially by its disappearance and recurrence.  Occlusion of
 intestinal vessels reveals itself in colic, diarrhea, and peritonitis.
 In the lungs there is bronchial catarrh, hsemorrhage, pleurisy, cede-
 ma, and hypostasis sub finem vitse.
    The  diagnosis rests upon the pre-existence of a primary cause.
 The disease must be distinguished, as stated, from typhoid fever and
 malaria, from tuberculosis and pneumonia, from the exanthemata
 and rheumatism.
    The  prognosis is  always grave.  Nearly all cases of  malignant
 endocarditis  perish.   The  pericarditis is often the terminal link in
 the chain of  disease process.   Occasionally  recovery occurs even
 from  a case of ulcerative endocarditis,  though there is in these
 cases  always  room for doubt as to the accuracy of the  diagnosis.
 The prognosis of simple endocarditis is grave, for the reason that  a
 benign course is sometimes suddenly interrupted by an embolus in
the brain, which may take life at once or  more often produce a sud-
den hemiplegia.   Most of the  hemiplegias in the  young are due to
this cause. Recovery with restitutio ad integrum is always possible 
SCLEROTIC ENDOCARDITIS.
569
 in a case of benign endocarditis.  All the signs, including the physi-
 cal signs, may have  existed in marked  degree and may disappear
 entirely.   This happy conclusion is, however,  the exception and not
 the rule.   In the rule the lesion is organic.  It persists, and the case
 is changed from the acute into the  subacute or chronic sclerotic
 form.

                     SCLEROTIC ENDOCARDITIS.

    It is estimated that about one-half of the cases of acute endocarditis
 become chronic, but sclerotic endocarditis begins often in such subacute
 form as to pass unrecognized, so that the disease develops insidiously.
 It is in these cases  often  only accidentally discovered.   In the ma-
 jority of  cases patients consult the physician  in relief of symptoms
 which they themselves  refer rather to disease of the lungs.   In  a
 respectable proportion of cases  the intercurrence of some  other affec-
 tion,  especially of the lungs, bronchitis, pleurisy, pneumonia, etc.,
 makes  manifest a heart disease which has  hitherto run  a latent
 course.
    Chronic endocarditis  is in its anatomy a sclerotic  process.  The
 smooth, pliable, semi-elastic tissue  of the valves becomes indurated?
 stiffened, thickened;  nodules form  in beads along the free edge of
 the valves just within the border, at the point  of closest  contact, on
 the auriculo-ventricular  valves, and about the corpora Arantise on
 the semilunar valves, or  chronic  thickening  of  the endocardium
 which lines the walls of the heart binds down  the chordae tendinese.
 Segments of valves  are sometimes  agglutinated or  fastened  to the
 sides  of  the heart or vessels into  which  they open.  The  tissue is
 thickened  and stiffened  by deposits of atheromatous  matter.  The
 valves are split  or  perforated  by destruction  of substance.  From
 whatever cause, the lesion interferes sooner or later with the circula-
 tion of the blood, and in such a way as either to prevent  the perfect
 closure of the valves and thus permit regurgitation,  or to offer
 obstacle to the passage of blood and thus lead to obstruction.
   Lesions of the valves are thus divided into insufficiencies (regur-
 gitations) and stenoses (obstructions).  While the final event is in all
 cases the same, the condition which immediately results varies greatly
 according to the nature of the lesions, and the prognosis  of an indi-
 vidual case, other things being  equal, rests largely upon the form of
the disease.  The difficulty, whatever be its nature, is overcome and
counteracted for a time by increase  in the force of the heart,  due to
hypertrophy of its muscular substance.   In this regard the  tissue of
the ventricle  has great advantage  over that of the auricle.   Most
fortunate  are  those  lesions whose  difficulties  can be  overcome by
hypertrophy of  the  ventricles.   Such  a hypertrophy  is  said  to be 
570
SCLEROTIC ENDOCARDITIS.
compensatory.   The condition is best illustrated by a comparison of
the normal pulse curve with that of mitral regurgitation with per-
fect compensation.  It occurs rapidly in young people and remains in
force long, so that the  damage which is done to the heart becomes
manifest only, as a rule, under extraordinary demands, as from great
exertion, or more particularly from disease of the lungs.  Sooner or
later in all cases the hypertrophy must give way.   Any case may be
put, but no case can be kept, under ideal surroundings.  Some acci-
   Fig. 238.—Sphygmographic tracing of normal pulse curve : e, elevation; r, recoil; e, elevation
of resilience.

dent supervenes.  Rheumatism recurs, some other infection develops,
an atheromatous process extends to spread the disease over the valve
affected or to implicate other valves.   The muscular tissue suffers
fatty change.   The heart undergoes dilatation, and the general signs
of heart failure soon appear.
   Diagnosis.—The  recognition  of  the valve affected,  and the
nature of its  lesion,  is usually easily made.   A knowledge of the
Fig. 239.—Pulse curve of mitral regurgitation with perfect compensation: r, recoil.
course of the circulation of the blood in  the  heart and the cause of
its sounds furnishes the basis of diagnosis.
   As already stated, the disease process, from whatever cause, endo-
carditis  or  atheroma, confines itself largely to  the  left heart.  It
becomes necessary practically to distinguish between lesions of the
mitral and  aortic valves.   With the retrograde  changes  that take
place in heart failure under dilatation of the heart, signs of failure of
the tricuspid valve  are  of the main importance.  Heart  failure is
often first announced by insufficiency of the tricuspid valve.  In de-
termining the nature of a valvular lesion it is necessary t< > ascertain 
SCLEROTIC ENDOCARDITIS.
571
(1) the diameters of the  heart, (2) the alterations in its sounds.  Of
these two factors, by far the most  important is the increase of size.
Unfortunately this sign is the most difficult of detection.   The size
of the heart, as determined by percussion, depends so much upon its
situation with  reference to the overlying  lung  that considerable
hypertrophy may remain unrecognized in life, to be revealed only on
autopsy.  Any marked enlargement of the  heart may, however, as
a rule,  be readily recognized.  Alterations in sounds are more decep-
tive.  Failure to close valves, or the presentation of obstacles, neces-
sarily changes the natural sounds of the heart.  But these sounds are
            s    d     s     d     s    d     s
Fig. 240.—Mitral regurgitation with systolic murmur at the apex.  S, systole ; D, diastole.
 altered by so many other factors, irregular vibrations, roughnesses in
 the walls of vessels, alterations in the composition of the blood, etc.,
 as to make the so-called murmurs comparatively insignificant.   The
 adventitious murmurs usually occur in  connection with the contrac-
 tion of the ventricle, so that murmurs  synchronous with  the  first
 sound of the heart do not mean as much as those which occur with
 the second sound, with the diastole.   The sounds connected with the
 lesions of the auriculo-ventricular orifices are heard most distinctly
 at the apex.   Sounds  connected with the lesions of  the semilunar
 valves of the  aorta  and pulmonary artery are most distinct at the
 base.  It is not a question as to where the sounds may be heard, for


                         uS        mm
                S    D     S    D     S     D    S
        Fig. 241.—Mitral stenosis with diastolic—i.e., presystolic—bruit at the apex.

 they may be heard all  over the chest and sometimes in the back.
 The question is, where are the sounds  heard  in greatest intensity?
 Practically the valves of the heart which demand study are, as stated,
 the mitral, the aortic, and the tricuspid, which in frequency of af-
 fection at the inception  of the disease stand to each other in the rela-
 tion of twenty, ten, and one.
   Vierordt represents the various murmurs graphically as shown in
 Figs. 240-243.
   Mitral  Regurgitation.—Lesions  of the  mitral valve are by far
the most frequent, and  the particular form  of lesion is that which
prevents closure and permits regurgitation.   In  this accident the 
572
SCLEROTIC ENDOCARDITIS.
blood,  which  should be propelled from the ventricle  through the
aorta, finds its way, some of it. back  into the left auricle, which  is
thus kept in a state of distention.  The auricle undergoes what hyper-
trophy it may.   It is, however, thin  and  distensible, and  speedily
undergoes dilatation, so that it is never perfectly emptied.  In conse-
quence of this distention the pulmonary veins are overloaded.  Blood
is dammed back  into the lungs, wdiose capillaries are kept in a state
of ectasia.  The pulmonary artery is, therefore, overfilled to  such
degree as to cause in its rebound  a sharp accentuation of the j>uf-
monary valve sound.  To overcome this distention in the pulmonary



               S    D      S     D     S    D     S
       Fig. 212.—Aortic regurgitation with diastolic bruit at second right interspace.

artery'Me right ventricle  undergoes hypertrophy.  It increases in
size to such extent that the right border of the  heart  in  a marked
case reaches over to and beyond the right border of the sternum.
    The recognition of mitral regurgitation rests,  therefore, upon the
following  facts : 1. Dilatation of the left auricle, which may some-
times be recognized by percussion dulness to the left of the sternum
at the second rib.  2.  Ectasise of the capillaries in the lungs, with
overdistention of the pulmonary artery and accentuation of the pul-
monary valve sound, manifest to auscultation at the left of  the ster-
num  at the second interspace.  3.^Increase in the transverse dia-
meter of the heart, as  determined by percussion dulness extending


              D                   IS        II
               S     D      S     D     S    D     S
         Fig. 243.—Aortic stenosis with systolic bruit at second right interspace.

often to the right border of the sternum.   4. Bruit, heard in greatest
intensity at the apex and synchronous with the first sound of the heart.
5. As a result of the hypertrophy of the right ventricle,  dislocation of
the apex to the  left.  The  apex beat  may be perceived in the mam-
mary line  or between it and the  axillary line.  The hypertrophy of
the right ventricle compensates for the regurgitation for a long time,
so  that this lesion is  looked upon as the most favorable  of all the
valvular affections.  Patients with proper surroundings may live  to
die of old age.
    Mitral Stenosis.—The  mitral valve is now  so affected  as to offer
obstacle to the passage of blood from  the left auricle to the left ven- 
SCLEROTIC ENDOCARDITIS.                 573
tricle.  In  mitral stenosis the blood received  from the  pulmonary
veins accumulates in the left auricle.  Much  of it falls by gravity
through the auriculo-ventricular orifice into the left ventricle.   Ob-
stacle is offered, as a rule, to the emptying of the auricle in its firmer
final contraction.  The bru it is therefore presystolic.   The ventricle
receives less than the normal amount of blood.   The  left  auricle
is distended  earlier and  more completely.  There is consequently
quicker and greater distention in the lungs and in the pulmonary
artery.  The resistance  to the column of blood in the pulmonary
artery is so great as to  intensify and often  delay tlie closure of
the pulmonary -valves.  This sound is therefore accentuated early.
The delay  is at times so great as to separate its sound from that of
the aortic valve and thus to split the second sound.   In a marked
case, at the height of the disease there is thus heard over the base
a double click.  The hypertrophy which takes place in the right
ventricle produces the same changes in the heart as in  the  case of
mitral regurgitation.  Under the still greater pressure which exists
in this instance, the heart muscle more speedily gives way and signs
  Fig. 214.—Pulse curve in mitral stenosis with broken compensation; feeble ascent, feeble force:
e, elevation; r, recoil.

of general stagnation more quickly supervene.   The  lesion of mi-
tral  stenosis  is therefore much more grave.   The average duration
of life ranges about  five years.  The condition is aggravated by the
fact that mitral stenosis almost never exists alone.  The lesion which
causes the stenosis is so disposed as to prevent closure.  Regurgita-
tion exists alone, as a rule.  Stenosis alone is an exception.
   Aortic Insufficiency  is usually due,  as stated,  to atheroma, a
process which begins at the arch of the aorta and extends down to
involve the valve at its base.   This disease is  therefore found much
more frequently in age, though successive attacks of rheumatism or
other infection may subsequently implicate also the aortic valve.   In-
sufficient closure of the aortic valve permits the reflux of blood from
the aorta into the left ventricle.   This reflux is immediately propelled
under  the powerful  contraction  of  the  ventricle, and the ventricle
thereby undergoes a degree of hypertrophy which is not approach-
ed in  any other  form of heart disease.  These  are the cases of 
574
SCLEROTIC  ENDOCARDITIS.
cor bovinum, where the heart is often quadrupled in its si/.*1 and
may weigh as  much as  three pounds.   This extraordinary hyper-
trophy  of the  left  ventricle  compensates for a time  for  a defi-
ciency in  the blood  supply.  The condition  is  recognized  by  in-
crease  in the size of  the  heart, more particularly in  the vertical
  Fig. 245.—Hypertrophy of the left ventricle from insufficiency and stenosis of the aortic valves:
a, left, b, right ventricle; cross section (Ziegler).

diameter, by a bruit  which is heard in greatest intensity at the
base and  synchronous ivith  the dilatation of the ventricle—that
is, with the second sound of the heart.   The force of the ventricular
contraction propels the blood with violence into the branches  of the
aorta,  so that the pulsations of the carotids are visible in the neck.
    Fig. 246.—Pulse curve in aortic regurgitation. High, perpendicular ascent; sudden descent.
» Cannon-ball pulse.
 In consequence of the regurgitation, the  blood in the suddenly  dis-
 tended arteries escapes rapidly in both  directions,  forward into th«-
 capillaries, backward into the heart, so that the vessels undergo a
 collapse as sudden as the distention.  The rapid relaxation of the
 vessels  gives  rise to what  is  known as  the cannon-ball or water- 
SCLEROTIC ENDOCARDITIS.
575
hammer pulse—the " pouls du Corrigan" it was named in France,
in honor of the Irish clinician who first described it.   The sudden
distention and collapse develops also tones in the  great  vessels, and
bruits may be heard in the femoral, brachial, and carotid arteries.
Pulsation is also propagated into the arterioles.  The  undulations
are visible in the retina.  The beds of  the nails flush and blanch.
Cerebral symptoms—vertigo or syncope—are not infrequent.
   Aortic Stenosis is more rare.   Obstacle is offered  at times by
agglutinations of segments of the valves, more frequently by such
thickenings or adhesions as to prevent apposition of the valve with
the wall of  the vessel.  The ventricle is kept  overdistended with
blood, and in  its contraction forces the blood through the narrowed
orifice.  The  hypertrophy leads  to increase in  the diameters of
the heart, more  especially  in the  vertical  direction.  Auscul-
tation reveals a bruit heard  in greatest intensity at the base in  the
second right  interspace and  synchronous with  the first sound of
the heart.  The pulse  in these cases is  hard and  wiry.   The
     Fig 247.—Pulse curve in aortic stenosis : short ascent, great resistance. Wire pulse.

 condition is usually associated with atheroma, which implicates also
 the vessels of the brain, and headache and cerebral haemorrhages are
 frequent complications.  Aortic stenosis also seldom exists alone.  It
 is usually associated with aortic regurgitation.  Lesions of the aortic
 valve are, as a rule, more grave than corresponding affections of the
 mitral valve, chiefly because they more distinctly interfere with the
 blood  supply of the brain and body, but largely on account of the
 conditions which create them—alcoholism, Bright's disease, age, etc.
 —which also cause disease elsewhere.
   Tricuspid Insufficiency.—So  long  as compensation continues
 the patient may suffer no special distress.   In consequence of over-
 exertion or intercurrent disease, sooner or later this compensation
 must give way.   Dilatation supervenes and  shows itself generally
first in the right ventricle, which dilates to such degree  that the
tricuspid valve may no longer close the auriculo-ventricular  orifice.
This valve is said then to show relative insufficiency.   The condi-
tion is revealed by regurgitation into the right auricle, into the vense
cavse and jugular veins.  So long as  the distention of the jugulars 
576
SCLEROTIC ENDOCARDITIS.
is not too great the pulsation is seen only in the bulbs, which pro-
trude at times like the small end of eggs at the  root  of the neck.
Sooner or later the valves of the veins themselves become relatively
incompetent and the undulation is transmitted along  the whole
course of the vessels in the neck.  The  same regurgitant wave is
transmitted downward into the inferior vense cavse,  and may be felt
as pulsations of the liver by the  hands apposed upon its surface
and inserted under the edge of the ribs.  Pulsation becomes distinctly
palpable  and visible  also at the epigastrium, where a loud, blowing
murmur, synchronous with the systole, may now be heard.   Signs
of general stasis now soon supervene.  Dropsy begins to show itself
about the feet as  oedema of the ankles.  It disappears  during the
night, to recur during the following day.   The dropsy accumulates
to mount up the lower extremities, invade the abdomen and serous
sacs or subcutaneous connective tissue over the body, to constitute a
general anasarca or sometimes to terminate life by cedema of the lungs.
   Interference  with the circulation in the  lungs is  revealed by
cough; more especially by  shortness  of breath, which is  one of
the first  signs of a  flagging heart; sometimes, more exceptionally,
by hemorrhage.
   The prognosis is grave in all cases.   The lesion is organic and
irremediable.  The future of the case depends largely upon its sur-
roundings.  The life must be remodelled upon a new basis which
would include  peace of mind as  well  as  rest of  body.  Attention
must be paid to details, as to diet,  clothing, exposure, habits of life,
whereby idleness is to be avoided as much as excess.
   Tricuspid stenosis is congenital and is very rare.   It is marked
by presystolic murmur, most intense at the ensiform cartilage, ex-
treme dilatation of the right auricle, and extreme stasis in the whole
venous system.
   Pulmonary regurgitation, also congenital and rare, is marked
by hypertrophy  and dilatation of  the right ventricle, with diastolic
bruit at the base, second left interspace.
   Pulmonary stenosis, the most  common congenital  lesion of the
heart, coincides  often with  a patulous  foramen ovale, defects in the
ventricular septum,  and other malformations.  It is marked by cya-
nosis—" blue births "—the face and fingers are livid, the ends of the
fingers clubbed; development is arrested; attacks of  dyspnoea, ver-
tigo, syncope are more or less continuous.   Nevertheless life may be
prolonged at times up to five, ten/or at the outside limit fifteen years.
It is often cut short  by tuberculosis.
   The physical signs are  : an intense bruit, most audible at the
second left interspace, synchronous with the systole, and extreme hy-
pertrophy or dilatation of the right ventricle. 
SCLEROTIC ENDOCARDITIS.                 577
   Treatment.—So long as compensation exists the case calls for no
treatment.  Compensation may be, in the young, at times excessive,
when it  may be subdued by occasional  doses  of  the  bromides, gr.
xx.-xxx.  in half a glass  of water every two  to four hours.   The
same remedy or a small dose of chloral gr. v. at bedtime, or tri-
onal gr. xv. in  a cup of hot milk after supper, may secure  sleep
and  allay nervousness.   The salicylates should be prescribed at first
in acute cases or exacerbations, in address to the cause.  The mildest
of the antipyretics, phenacetin, may relieve an obstinate headache.
Violent action of more continuous  character is best subdued by the
application of an ice bag to the chest.  Hollow tin vessels filled with
cold water, in the form of shields, may be worn during the day.
   With the first sign of failure—shortness of breath, dropsy, or cya-
nosis—resort must be had at once to the cardiac  stimulants.   The
evil day may be postponed for a time by  the judicious use of alcohol;
a dessert- to a tablespoonful or two of good whiskey once or twice in
the twenty-four  hours may suffice.   Sooner or later recourse must
be had  to digitalis.   Mild effects may be had with the use of the
tincture in doses of five to fifteen drops every three to six hours.
More prompt and powerful effect may be secured by the use of the
infusion made fresh from the leaves, a teaspoonful, a dessertspoon-
ful, or a  tablespoonful every two to four or six hours.  Digitalis re-
mains the most powerful cardiac stimulant.  It has the advantage
that its action may be sustained.   It has the disadvantage that it acts
slowly and that in large doses it irritates  the stomach.  It should
never be given uninterruptedly.  Its administration should cease so
soon as its  effect upon the pulse is made manifest, for fear of pro-
ducing tetanic contraction.  Unfortunately digitalis not only stimu-
lates the ventricle but also raises  the tension of the capillaries, which
therefore, to some degree, resist  the action  of the heart.   A  great
desideratum was a remedy which would increase the tension of the
ventricle and lessen that of the arteries.  Such a remedy was found
in nitroglycerin.  This remedy has the additional advantage that it
acts at once.  It may be used, to bridge a collapse, in dose of one to two
drops in whiskey and water every two  to six  hours.   In imminent
danger  the  drug may be used subcutaneously.  It shows  its best
effects in arterio-capillary sclerosis and  defective action of the kid-
neys.  Stasis of the blood in the kidney leads to most disastrous con-
sequences; the secretion of the kidney maybe released at once under
the action of nitroglycerin.  Strychnia, one-per-cent solution, begin-
ning with one drop and gradually increasing, is the remedy par excel-
lence for continuous sustentation of the heart.  Dropsy is best relieved
by calomel.  No remedy in the materia medica has the efficacy of calo-
mel in  the dropsy of heart  disease.  It  must  be given in  doses  of
        37 
578
MYOCARDITIS.
 three grains three times a day, and no effect must be looked for be-
 fore the administration of the seventh to the ninth dose1.   Any irri-
 tant effect upon the bowels may be restrained by opium, and ptyal-
 ism avoided by the use of chlorate of potash, cleansing the mouth
 and touching ulcers with caustic (chromic acid).   Excessive dropsy
 may demand puncture of the legs, best with two or four clean silver
 canulas, rendered aseptic by boiling five  minutes with the carbonate1
 of  soda, five per cent.  Further details of treatment  under Heart
 Failure.
                          MYOCARDITIS.

    Myocarditis {pvf, muscle).—Inflammation (infection) of the sub-
 stance (muscle) of the heart.
    Etiology.—Myocarditis results from the same causes as peri- and
 endocarditis and presents itself in the same forms, acute and chronic.
 Infection is conveyed to the myocardium directly through the coro-
 nary arteries or indirectly through the endocardium or pericardium.
 Myocarditis may occur, therefore, in the course of any of the infec-
 tions, and  is always present in some degree in connection with both
 pericarditis and endocarditis.   The micro-organisms which most fre-
 quently produce myocarditis are the streptococci  and staphylococci
 of pus.   When these organisms are introduced directly into the cir-
 culation, as in the experiments of Ribbert with fragments of potato
 containing pure cultures, myocarditis occurred more frequently than
 inflammation of the membranes  of  the heart.  So myocarditis oc-
 curs, as a rule, in the course of septico-pyaemia.   Rheumatism shows
 preference for the membranes, diphtheria for the walls, of the heart.
 Interstitial  myocarditis—i.e., round-cell  infiltration—always occurs
 in the course of diphtheria, scarlet fever,  and typhoid fever.
    Morbid Anatomy.—The  infection may result  in  the disintegra-
 tion of  muscular tissue and the formation of abscesses, or  in inter-
 stitial inflammation with the development of scleroses, scars, or, in
 consequence of weakening, aneurismal dilatation and rupture.
    Symptoms.—The disease is rarely found alone.  It occurs in con-
nection  with endocarditis  and pericarditis, whose symptoms over-
shadow the lesion of the heart.   Myocarditis may be suspected in
the presence of the general symptoms of  heart  disease—palpitation,
 dyspnoea, dilatation, heart failure, and syncope—in  the absence of
unmistakable signs of endo- and pericarditis.  The dyspneea of myo-
carditis  is often peculiar.   It commonly occurs suddenly in the first
hours of the night, and announces itself with the anxiety and distress
of asthma.  It is known, therefore,  as cardiac asthma, and is distin-
guished from true asthma by the fact that it occurs in later life in
connection with other signs of heart disease. 
HEART FAILURE.
579
   The diagnosis, independent  of affections of the membranes,  is
often difficult, sometimes impossible.  Myocarditis is commonly an-
nounced by a preliminary period of arhythmia marked by periodical
acceleration due to direct change in the muscular tissue.
   The treatment is symptomatic and  does not differ from that of
affection of the membranes.

                        HEART FAILURE.
   Heart failure from diffuse degeneration (myocarditis)  occurs ulti-
mately in all kinds of  organic heart  disease, and is the immediate
cause of death in all the chronic processes.  The degeneration is pa-
renchymatous and is chiefly fatty.   The striae grow dim on account
of transformation into  fat, which appears in granules ; more rarely
the degeneration is into waxy and amyloid matter.  The  heart mus-
cle loses color, becomes yellowish,-greenish, or mottled, loses firm-
ness, becomes friable and fragile.
   Etiology.—The process is usually secondary to valvular disease,
in the course of wdiich occurs, first, hypertrophy, then dilatation with
degeneration, along with disturbance of compensation.   It sets in
also in all cases  marked by the  same sequence, as in the course of
emphysema, long-continued, frequent asthma, chronic bronchitis, in
obstruction  to the circulation outside  of the heart.  It occurs also in
the left ventricle in Bright's disease, aneurism of the aorta, arterio-
sclerosis, processes which lead  to heart  failure through hypertro-
phy,  dilatation,  and  degeneration.   Affection  of  the membranes
which cover and line the heart involves zones of subjacent tissue by
direct contiguity of structure. Diffuse degeneration sets in also in
consequence of insufficient nutrition, from impoverished blood—as in
continued hsemorrhage, the various forms of anaemia—from disease
of the coronary arteries, and from general chronic disease, tubercu-
losis, cancer, marked  by marasmus.  Acute failures  are observed
most frequently  in consequence  of the infections, as the result of the
direct effect of toxines.   Gradual and sudden failures occur in alco-
holism.   Alcohol is a whip to the heart, which responds as long as
may be, but finally breaks down.   The  heart is always weak  in
drinkers.  It becomes too weak  to perform the  extra work imposed
by disease or effort, or to respond finally even  to extra stimulus.
Hence the great mortality of drunkards.   Depressing mental emo-
tions, anxiety, finally weaken the heart, until it may actually break
under a sudden strain—an accident which never happens in sound
muscle.  Severe or prolonged physical effort, heavy labor, as that of
porters, smiths, etc., exhausting discharges, have eventually the same
effect.   There is no lack of causes to explain the insidious process.
   The  symptoms are  almost wholly subjective and depend upon 
580
HEART FAILURE.
the retardation of circulation and stasis.   There is a feeling of grow-
ing weakness, loss of general energy.  The lightest effort excites the1
heart and quickens the breath—conditions which may be noticed first
in climbing stairs  or in sudden emotional disturbance.   (Edema oc-
curs about the ankles at night, disappears in the recumbent posture,
and gradually increases in amount during the day.  A sense of ful-
ness is felt in the region of the liver.  The patient takes cold upon
the slightest exposure ; begins to cough ; the face becomes florid or
pale ; the mind is  more sluggish or anxious ; there is loss of energy,
of the power of concentration, and of clearness.   Later dropsy be-
comes  marked, cyanosis develops with orthopncea, cardiac asthma,
delirium cordis.
  The  physical signs, aside from the  evidence of  valvular disease.
are not distinct.   Dulness may be appreciated beyond  the  natural
boundaries, especially to the right of the sternum.   The apex may
be displaced, especially to  the left, in consequence of dilatation of the
left ventricle.  Aside from the irregular and tumultuous actions that
betoken exhaustion,  the heart sounds  are muffled.  Aside from the
sounds of valve disease, murmurs may be heard, usually systolic, in
consequence of relative insufficiency of the mitral or tricuspid valves.
   The diagnosis is not difficult.  The important question concerns
the cause, whether  disease of the heart,  toxaemia,  anaemia, aleo-
holism, obesity, etc.   The neuroses of the heart  are separated by
the absence of physical signs and evidences of general stasis.
    Treatment must address itself  to the cause, in relief of rheuma-
tism, arterio-sclerosis,  anaemia,  haemorrhage, obesity,  alcoholism,
overwork, etc.  Patients affected  with  emphysema, asthma, and
chronic bronchitis may learn to spare the heart extra effort, avoid-
ing at  the same time that extreme inactivity which conduces to de-
generation and hypertrophy from disuse.  Every  imprudence in diet
is quickly punished.  The meals must  be regular and the patient
must be abstemious.  The food  should  consist chiefly  of fruit and
fish and  the white meat  of fowl.  All  vegetables, except potatoes
baked  whole, should be avoided.   A glass of warm water, at most  a
cup of very weak tea,  is a sufficient supper.  An exclusive milk diet
will itself sometimes cause cedema and dropsy to disappear.   Any
overfeeding is hurtful.  The exercise must  be graded to the in-
dividual case.  Nothing is worse than actual indolence,  except over-
work.   Climbing  stairs is always  hurtful, but climbing hills in the
open air is helpful if practised aright.  Fresh air feeds, and exercise
tones,  the muscle of  the heart.   Much can  be accomplished by  a
change of  climate, especially by sojourn  at watering  places—in
Germany. Marienbad, Nauheim  ; in our own country, the Virginia
Springs—with exact regulation of  the diet and exercise.  Damage  is 
NEUROSES OF THE  HEART.
581
often done by incautious exercise, as with the Oertel method (Schott).
For steady support no remedy equals strychnia.  Sooner or later the
necessity arises for the administration of the various  stimulants, at
the head of which is digitalis.  Many cases recover absolutely under
the judicious Use of digitalis, which may be  administered in tinc-
ture, gtt. v.-x. two or three times a day ; fresh infusion, a teaspoon-
ful or two; or powder of the leaves, gr. i.-iij. with sugar of milk at
the same interval.  Strophanthus, tincture, gtt. xv.-xl., makes a good
temporary  substitute.  Sudden heart failure calls for more powerful
stimulants—alcohol, ether,  camphor.   Thus camphor may be dis-
solved in ether 1 :10, and of the mixture ten drops may be adminis-
tered every fifteen minutes or half-hour, or for still quicker effect be
injected  subcutaneously.  Further details are described under  the
treatment of valve lesions.

                  TUBERCULOSIS OF THE HEART.
   Tuberculosis of the  heart is  very  rare.   Deposit  is  sometimes
found  in miliary  tuberculosis under the  endocardium of the  right
ventricle.   Tuberculosis is more frequent in connection with chronic
pericarditis.
                    SYPHILIS OF THE HEART.
   Syphilis of the heart is  extremely  rare.  Most of  the  lesions so
interpreted are cicatrices of  arterio-sclerosis.   Specific  indurations of
muscle are  sometimes found in connection with inherited or acquired
syphilis,  and gummatous  deposits, sometimes caseous,  have been
found  in the walls of the heart and have broken through into its
cavities.  Occasional cases of arhythmia, palpitation, etc., otherwise
defiant, are cured by appeal to antisyphilitic treatment, as suggested
by some accidental finding elsewhere in the body.

                          CYSTICERCUS.
   Cysticercus, echinococcus, may come to lodge in the heart muscle,
and, after  rupture into its  interior, have been disseminated to  the
lungs or elsewhere over the  body.
   All these conditions are suspected or recognized  by coexistent
evidence of disease elsewhere outside of the heart.

                    NEUROSES OF THE HEART.
   The heart muscle may contract  and expand—that  is, perform its
work—entirely independently  of the nervous system.   The heart
muscle may  not  only contract and expand,  but it may  do these
things  rhythmically without nerves.  What is muscular tissue, any-
how, but the terminal expansion of nerve fibre ?   In the body, how- 
5s2
PALPITATION.
ever, the heart muscle moves in obedience to nerve stimulus, which
excites it or retards it,  as  Lauder Brunton  says, as the whip, the
reins, and the brake regulate the movements of the horse and cart.
   The  mechanism of the nerve supply to the heart, notwithstand-
ing the study which has  been expended  upon  it, is not yet definitely
established.  Three  sets  of  nerves, the vagus, the sympathetic, and
the vaso-motors, have to do with the motions and sensations of the
heart,  to say nothing of  the  ganglionic masses embedded in its
substance.   Recent studies prove that the ganglia belong exclusively
to the auricles—i.e., the  receiving chambers—and that they are con-
nected exclusively with  the sensitive  sphere.  The ventricles have
no ganglia.
    The  pathology  of the nervous affections is  even less satisfac-
tory than the physiology, and the neuroses of the heart are stuelied
wholly from the  standpoint of symptomatology.   It  is observed
that the heart, so far as motor nerves are concerned,  is increased
or decreased  in  the frequency and  force of its action, or has its
rhythm interrupted, and that regarding the sensory nerves there is
distress,  anxiety, and positive pain.  Disturbances of the motor sys-
tem are generally summed  under  the  most obtrusive symptom, pal-
pitation, as disturbances  of  the stomach are summed under the term
dyspepsia.   Neither of these affections is in any  sense a disease, but
a  symptom of many diseases inside and outside the heart.  Con-
tinued acceleration and protracted retardation  are often characterized
as Tachycardia {xaxvi, quick) and Bradycardia {ftpadv?, slow).

                          PALPITATION.
   Palpitation arises, first,  in connection with disease of the heart
itself.  Affections of the valves, of the  substance  of the heart, of
the pericardium, are all sooner or later attended with  palpitation.
These conditions  are excluded from consideration with the neuroses.
The causes of motor disturbances are summed  under the  heads or di-
visions, mechanical, chemical, and reflex.
   1.  That overloading of the whole vascular system which occurs
immediately after a full  meal is often attended by palpitation.  Any
affection of contiguous viscera, as by accumulation of  fluid in the
pleural sac; affections of the lung substance itself which  may disturb
the position of the heart  or interfere with the egress of blood from
the heart; more especially from distention of  the stomach, as from
gas, act  in  a  mechanical way.  Palpitation  of the heart has been
noticed among the frequent symptoms of gastric catarrh and dys-
pepsia.   These conditions present often coldness of  the  surface and
extremities, pallor, precordial pain, attacks of  syncope, as the result
of pressure partly, and partly of absorption of toxic  gases.  A mode 
PALPITATION.
5S3
 of taking life in old  times consisted in the deglutition of large quan-
 tities of  fresh blood, the coagulation of which made a solid mass in
. the distended stomach to interfere with or absolutely arrest  the ac-
 tion of the heart.  Gaseous distentions of the intestines, especially of
 the transverse colon, act in the same way.  The shock which shows
 itself early  in  those enormous accumulations  which occur  in the
 course of obstruction of  the intestine and after perforations is partly
 due to this cause.
    2. The most frequent causes of palpitation  of  the heart  are the
 chemical causes, at the head of which stands poisoning by nicotine.
 Tobacco  smokers form a large contin-
 gent of cases of heart neuroses.   When
 the  disturbance  shall have once oc-
 curred as a  result of the excessive use
 of tobacco,  even a moderate use will
 suffice to keep it up, so  that a cure may
 follow only entire abandonment of use.
 Tea, coffee,  alcohol in excess, or espe-
 cially in impure forms, act in the same
 way.  Mention has been made already
 of the effects of toxic  gases in the ali-
 mentary  canal.
    3.  Reflex  causes  are numerous.
 They  include  also  dyspeptic  states,
 disease of the kidney, of the uterus and
 its adnexa,  and any outside irritant.
 A patient  in  the experience   of  the
 author was  often  awakened  in  the
 night with chilly sensations, extreme
 anxiety,  cold sweat, and violent,  tu-
 multuous palpitation.  The cause was
 finally discovered in a subacute prosta-
 titis with posterior urethritis, and the  symptoms all subsided under
 injections, by means  of the Ultzmann catheter, of strong solutions of
 nitrate of silver.
    Besides all these things,  the heart  may be excited by  causes  of
emotional nature and by alterations of the blood, as in chlorosis,
ansemia, and exhaustions.  So it may be seen that most of the cases
of disturbance arise from causes outside the heart.  Sometimes the
relation between cause and effect may be distinctly traced, as after
smoking,  the use of alcohol, heavy meals, tea drinking, etc.  Often
it must be searched for in some disease of remoter organ.  Tachycar-
dia and bradycardia may be due to irritation of  the abdominal sym-
pathetic (Eccles,  Riegel).  The practitioner may  not overlook the
possibility of epileptic basis (Talamon).
 Fig. 218.—Topography of the heart.
Mechanical relation of the heart and
abdominal aorta to the stomach and
contiguous viscera. 
5S4
PALPITATION.
   Symjrtoms.—Palpitation  is  defined as pulsations that  are1 per-
ceived by the patient.  It comes on in paroxysms with intervals of
more or less complete freedom from attack.  The paroxysms may oc-
cur at any hour of the day or night.  The attacks which occur at night
in bed and arouse the individual from sleep are mostly due to disease
of the heart itself.  The heart  begins to beat violently.  It pounds
against the walls of the chest.  The vessels may throb in the  neck.
The  eyes become suffused and the head aches.  As a rule the  palpi-
tations of the heart are more frequent than  the pulsations.   All the
actions of the heart do not affect the pulse.  The heart beats with
the foetal gallop ; or, on the other hand, it may be very rapid and very
feeble, so that the pulse may consist of a series of rapid,  almost im-
palpable waves.   As Jimenez puts it, it has the rapid vibrations  of
a loose string.  On the other hand,  the beatings of the heart may
be so feeble as to be scarcely felt by the patient, and these cases cre-
ate the most alarm.  Patients  say so long as the  heart beats they
have no fear; it is only when it seems to stop beating  that they be-
come frightened.   The pulse in these cases is very feeble, sometimes
hardly perceptible.   The surface is  cold, the  expression  anxious.
Sometimes there is actual syncope.   The attack passes off, as a rule,
in from half an hour to an hour or more.   The more protracted cases
are found especially in neurotic or hysterical subjects.  The precor-
dial distress and  anxiety disappear, the  surface becomes warm and
the mind tranquil.   These attacks may recur several times in the
course of the day or at indefinite intervals, with or without connec-
tion with distinct exciting cause.
   The prognosis depends entirely upon the  cause.   Organic disease
must be eliminated, affections of remote organs discovered.
   The treatment will address itself wholly to the  cause.   In im-
mediate relief of  attack nothing is so good, as a rule, as the applica-
tion of cold, which may be applied with an ice-water bag, or, better,
with the light Leiter's coil.   A small dose of chloral gr.  v.-x.. with
a teaspoonful or two of whiskey, is justifiable in a bad case.  A bro-
mide, gr. xxx. largely  diluted,  will often suffice.  Dyspeptic  cases
may be often cured  by hydrochloric acid  gtt. x. before meals,  or by
arsenic gtt. iij. after  meals.  Nervous patients are relieved with the
use of valerian,  one drachm of the tincture in a tablespoonful  of
water every fifteen minutes or half an hour.  A teaspoonful or two
of the tincture of camphor diluted,  a pill of asafcetida, the  natro-
benzoate of caffeine gr. iij. every three hours, the more continuous
use of small doses, gtt. ij.-v., of the  tincture of digitalis or the tinc-
ture of strophanthus, with regulation of the habits and removal  of the
cause,  may cure the condition.   Too rapid action (tachycardia) may
necessitate the use of morphia; too slow action (bradycardia), of atro- 
ANGINA PECTORIS.
585
 pia to allay irritation of the vagus from constriction at the aortic
 valves (Rummo).

                         ANGINA PECTORIS.
    Much more serious are the cases of sensory disturbance, because
 they depend, as a rule, upon organic disease.  In these cases a sense
 of constriction of the chest assumes prominence over all other symp-
 toms ; hence the disease is  called angina pectoris.  Angina pectoris
 is not, however, strictly speaking, a neurosis of the heart.   A  true
 case of angina depends upon disease about the aortic valres, and the
 disease is of such a nature as to offer obstacle to the escape of blood
 (stenocardia) ; hence angina pectoris occurs more especially in indi-
 viduals of advanced life, from  forty to seventy, and  in connection
 with  atheroma  and arterio-sclerosis.   Obstacle  offered to the es-
 cape of fluid from other hollow viscus—e.g., the bladder—as well as
 the heart, causes pain.   Distention of the left ventricle is attended
 also with a sense of anxiety and danger like that of impending death.
 Fortunately angina pectoris is a very rare disease.  Pseudo-anginas,
 neuralgias of the heart which simulate the genuine affection, are very
 common and are very often mistaken for angina pectoris.
    Symptoms.—Angina pectoris distinguishes  itself  especially by
 pain, and by pain which is  best described as agonizing.   The pain
 seizes the patient suddenly during the day or night.  It arises in the
 prsecordium and radiates thence to the left shoulder and down
 the left arm.   It may shoot back  toward the spine or scapula, in
 rare cases downward, but  the  tract described is its usual course.
 The pain literally transfixes the patient. He lies motionless as if
 paralyzed.  The face shows the  picture of terror;  it is deathly white
 or livid; cold  sweat beads the surface.  The patient may  succumb
 at once in individual attack.  Usually the pain subsides in the course
 of a few minutes, to leave the patient in a state of profound prostra-
 tion with intense apprehension of subsequent attack.
    Diagnosis.—Pseudo-anginas are much less severe.   The patient
 in these cases is able to move about and may adopt various positions
 or resort to pressure in the attempt to secure relief.  Pseudo-anginas
 occur  more particularly in  neurotic and hysterical patients, conse-
 quently much  more frequently in the young and  in the female sex.
 They are found in connection with other neuroses, with anomalies of
 menstruation, etc.  Pseudo-angina is a simple  neuralgia, in connec-
 tion commonly with ansemia, neurasthenia, hysteria, or hyperchon-
 driasis.  The individual paroxysm may in these cases last for hours.
 The diagnosis of true angina rests upon  the age  of the patient and
the sex—the great majority of cases  occur in males—as well as upon
the recognition of the heart lesion by physical signs. 
586
EXOPHTHALMIC GOITRE.
    The prognosis is extremely grave.  Any attack may be fatal.
 Yet patients may survive many years.
    In treatment the most effective remedy is the nitrite  of amyl,
 which, in the smallest dose, has remarkable effect upon involuntary
 muscle fibre, especially that of the heart.  It is used by inhalation of
 three  to five  drops from a handkerchief.   Victims of this disease
 learn to carry with them "pearls" containing drops of this drug, which
 they may crush between the fingers upon a handkerchief and use im-
 mediately.  With the flushing of the face, which occurs at once from
 relaxation of  the capillaries and emptying of  the  heart, the patient
 usually gets relief.   Sometimes it fails, when resort must be had at
 once to  ether or chloroform.   Nitroglycerin,  gtt.  i.-iij.  every four
 hours, may later sustain the action of the nitrites.  A milder attack,
 especially if attended by some  signs which the patient from his own
 experience may consider premonitory, may be cut off or cut short
 by a dose of morphia or chloral.  Arsenic and iodine (Fowler's solu-
 tion and the iodides) are mainly relied upon in the treatment of the
 intervals.  It  goes without saying that the victims of this disease
 must in every way lead model lives.

                     EXOPHTHALMIC GOITRE.
   The curious association of symptoms on the part of  organs as re-
 mote from each other as the heart, the thyroid gland, and the eye,
 was first pointed out by Basedow (1840), and  was described a few
 years  later by Graves, of Dublin, and hence is called in Germany
 Basedow's,  and in English-speaking countries Graves', disease.  The
 connection of goitre and palpitation had really been first observed by
 Flajani,  of  Rome, in  1802 ; the Italians still call it  the morbo di
 Flajani.   Parry (1825) first noticed also the exophthalmos.
   The affection  is not common,  but is  noticed  much more fre-
 quently in women, especially in states of exhaustion, as after rapid
 child-bearing, prolonged  lactation, exhausting discharges, domestic
 infelicities,  etc.  Typical cases occur in men, usually without dis-
 coverable  cause.   The  disease  shows  itself,  as  a  rule,  between
 puberty and maturity.  It  is  seldom seen in adYanced life, if only
 because the disease, while not exactly  fatal, cuts short the duration
 "of life.
   Symptoms.—Usually the  first symptom to attract attention is
palpitation of the heart, frequently in the form of tachycardia.  As
 the disease is often associated with altered conditions of the blood or
 nervous  distress, the palpitation is attributed  to these causes, and,
 being but paroxysmal, is overlooked.   A little later the attacks be-
 come more common  and  more continuous.  The heart  becomes
 excitable;  the slightest  emotional disturbance or  physical effort 
EXOPHTHALMIC  GOITRE.
587
precipitates palpitation ; the patient becomes more and more emo-
tional.  At this time is noticed also—it may have been  remarked
before—flue tremor of the  muscles, especially of the hands.  The
symptom is not obstrusive,  and is  usually brought out only upon
interrogation.   The patient  recalls the fact that the condition has
existed for many months.  The tremor and palpitation may continue
for months or for the greater part of a year before the occurrence of
other signs.  Next there is  usually observed some enlargement of
the thyroid gland.  The mode of dress makes a woman sensitive to
deformity or alterations about the neck, so that this condition is soon
remarked.  One or the other lobe of the thyroid swells ;  very soon
Fig. 249.—Exophthalmic goitre.
in the course of the disease both  lobes become enlarged.  Pulsa-
tion of the cervical vessels  may be seen or felt in the mass.  The
size of the goitre varies from time to time.   It comes to a standstill
often for months at a time, and increases  in size fitfully and irreg-
ularly.   The nature of  the disease is best recognized by the protru-^
sion of the eyeballs, or exophthalmos. . At first there is  but slight
increase or pressure against the lids.   The  aperture of the palpebrse
is increased, the eyes appear more  full and large.  The movements
of the upper eyelid and globe fail to correspond.  The globe fol-
lows the lid so slowly in looking upward  as to show a line  of con-
junctiva, and in looking down the pupil is slow to appear (Grafe).
As the protrusion becomes greater it amounts to a positive deformity 
5ss
EXOPHTHALMIC GOITRE.
and attracts attention at a glance.  The lids may so far fail to cover
the globe as to develop a condition of dryness and xerophthnhnos. in
which the eye, if unprotected by mechanical  means, may actually
slough away.
   Etiology.—It  has been found very difficult to account for this
singular association of symptoms—palpitation of  the heart, enlarge-
ment of the thyroid, and exophthalmos.  The  lesion would seem to
lie with the nervous system, which  is  the  only means of  intercom-
munication.   But the revelations of autopsies have not disclosed as
yet definite lesions.   It is usually considered an affection of the sym-
pathetic nervous  system.   Injury or  irritation of any part of the
   Fig. 230.                             Fig. 251.
Fig. 250.—Exophthalmic goitre. Enlarged thyroid and prominent eyes.
Fig. 251 .—Exophthalmic goitre. Defective descent of upper lid in looking down (Willis).
sympathetic  may produce the condition.  The symptoms may be
worked out by lesions of the medulla, and the tendency in our day is
to consider the  disease as an  affection of the medulla through the
vaso-motor nerves.  The toxic or chemical theory attributes the dis-
ease to the affection of the thyroid gland, disease of which is said to
produce exophthalmic goitre, while destruction of it  produces myx-
cedema.   Support for this view is found in the improvement  which
sometimes occurs after operation, thyroidectomy, and after adminis-
tration of thyroid extract.
   The diagnosis rests upon the tripod of symptoms, the association 
MYXCEDEMA.
589
of palpitation, goitre, and exophthalmos, preceded often by tremor
and attended by great nervousness, i. e., neurasthenia.
   The prognosis, so far as life  is concerned, is not unfavorable.
The   disease  is  obstinate.   Absolute  recoveries are  exceptional.
Periods of quiescence occur, and the most that may be promised, as
a rule, is arrest at the present stage.   Cures have occurred under
hygienic  means, change of climate,  sea air, mountain  resort, etc.
All cases are benefited in this way.  Death from heart  failure is
sometimes sudden.
   Treatment.—The agent most potent in  relief of  the condition is
electricity.   One pole, the anode, is put at the nape of the neck, the
other, the cathode, is applied in front of the sterno-cleido muscle, and
the constant current is allowed to run from five to ten minutes.   The
tumultuous action of the heart is often stilled in this way.   The ice
bag may be applied at night over the heart, with intervening towels.
Arsenic is the remedy in most general use.  Its virtue is empirical.
Atropine, ergot, and iodine  are  agents which  may seem to be
adapted to an individual case, and may be tried in succession with the
hope, usually vain, of securing relief.   Tremor  may  be  stilled with
hyoscyamine gr. j-^.  The irregularities of the heart may be checked,
if tumultuous, with the bromides,  gr.  xxx.-xl.  largely diluted.
Sleep may  be  secured  with small doses (gr. v.-x.) of chloral with
a glass of wine, or sulphonal gr.  x.-xv.  in hot milk, two hours be-
fore bedtime.  Sometimes the  heart requires stimulus.  Digitalis is
the first  resort.   It  is given in small dose, five to ten drops, three
times a day.  To relieve the arterial tension digitalis is substituted,
often with great benefit, by the tincture of strophanthus  gtt. v.-x.
three times a day.   The natro-benzoate of caffeine, two or  three
grains every two or three hours, may give comfort for the  day.
   The author has seen  sometimes immediate benefit, but as yet no
cure,  from the use  of the fresh thyroid extract subcutaneously and
from  the administration of the desiccated extract  in powder, gr.
v.-xv. in  capsule, three  or four times  a day.  Wette  reported  of
thirty cases of  thyroidectomy collected  in  the literature twenty-six
improvements or cures, two deaths.  Trendelenberg declares that the
cures are not permanent.
   Excitement and imprudence are quickly punished.  The habits of
life must be nicely regulated.

                           MYXCEDEMA.

   Disease or destruction (extirpation) of the thyroid gland begets
or is  followed by three sets of symptoms—nervous, vascular, and
metabolic.   The mind becomes melancholy, morose, apathetic, and
imbecile.  Palpitations  set in, tachycardia, as in Basedow's disease, 
590
ARTERIO-SCLEROSIS.
with pallor and ansemia.  The number of blood corpuscles is sensibly
reduced, and the hsemoglobin is correspondingly lessened.  The most
curious change occurs in the tissues, which show a mucoid degenera-
tion with cedema.  This so-called myxcedema is most visible in the
face and hands, which swell to assume a gross  and revolting look.
The cheeks are puffed out, the lips protrude like sausages, the chin
bulges, and the neck grows so big as to make it difficult to turn the
head.  The hairs  fall, the eyebrows are scant,  the crines axilla res
absent altogether.  The eyelids swell to such extent as to produce
ptosis.  The  cornea is  often barely visible through a narrow slit.
The face  is a repulsive mask.   At  the same time the strength is
greatly reduced, the patient pants on walking or must actually ob-
serve the recumbent posture.
   Schiff  observed that  the dangers of  thyroidectomy could be ob-
viated by the insertion into the abdominal cavity of the thyroid gland
of another animal of the same species.  Horsley suggested the prin-
ciple in man, and Bircher (1890) actually put it in practice with good
results.  Lannelongue, Walter, Macpherson, Geraud followed quick-
ly with cases.  Howitz, Mackenzie, and Fox fed the gland of the sheep
to patients thus affected.  Murray and Beatty injected the  extract
of the gland  subcutaneously, and White administered  it internally.
The dose of the desiccated gland extract is five to fifteen grains three
times a day.   All patients are improved, many are  actually cured,
under this treatment.
   Acute goitre, which  is now believed to  be an infectious disease
whose cause is introduced with the drinking-water, is sometimes
quickly and completely cured by large doses of quinine.

              DISEASES OF THE BLOOD  VESSELS.

                       ARTERIO-SCLEROSIS.
   Arterio-sclerosis; atheroma {aSrjpy, porridge—i.e., grumous).—
Degeneration of the  arteries,  fatty and atheromatous, usually at-
tended with thickening of  the intima, later also the media.   Arte-
rio-sclerosis is a natural process in age, where it  is found associated
with  other evidence of senescence,  arcus senilis,  atrophy of the kid-
neys, and general atrophy, and the degeneration is  an expression of
involution.
   The condition is precipitated in maturity and youth especially by
alcohol, syphilis, and gout;  hence it  is that " a man is as old as his
arteries."  It may occur in any condition which raises the pressure
in the arterial  system—hard work, luxury,  sedentary life—and is
found usually in association with hypertrophy of the left ventricle.
It arises also in connection with retention of toxic elements, diabetes. 
ARTERIO-SCLEROSIS.
591
 ursemia, gout.   Men  are affected more  frequently than women, old
 people than young.   The vessels under greatest strain suffer first—
 to wit,  in  the order  of descending frequency, the ascending aorta,
 the arch of the aorta, the  descending aorta, the splenic, iliac, and
 crural arteries, coronary arteries, cerebral arteries, uterine arteries,
 brachial, ulnar, radial artery, etc.  The disease process shows itself
 as a simple thickening of the intima from hyperplasia of the connec-
 tive tissue, and is followed by fatty degeneration with the deposit of
 calcareous  matter, often by subsequent ulceration and cicatrization.
 The vessel loses its resilience, becomes thick and rough.   Deposits
 of chalky matter, which aggregate  to  form plates,  substitute the
 natural  tissue.  With the disintegration of this matter, detritus, fatty
 matter,  cholesterin, fibrin from the blood are deposited upon the sur-
 face to constitute the atheromatous—i.e., gruel-like—ulcer.  In con-
 sequence of the increased resistance offered to the action of the heart
 the vessel becomes elongated, serpentine, dilated into aneurisms, and
 so friable as to suffer rupture.  The thickening of the intima is often
 so great as  to lead  to  thrombosis with more or less perfect occlusion
 (endarteritis obliterans).
    Symptoms.—The condition is sometimes easily recognized.  Athe-
 romatous vessels may be seen or felt in the radial and temporal  re-
 gions  as tortuous, pulsating tubes, unyielding, rigid  to the touch.
 Sometimes the artery  at the wrist feels like a chain of  beads.  More
 frequently these vessels escape  while  internal arteries are affected.
 Hypertrophy of the heart without other explanation  (valve lesion,
 Bright's disease),  in association with  disease which might produce
 the condition,  may lead to  diagnosis.  Attacks of  angina pectoris
 and cardiac asthma may  indicate sclerosis of the coronary  arteries.
 The diameters of the  heart are increased on account of hypertrophy
 or dilatation.   The impact is more violent and extensive,  the apex
 somewhat dislocated.  The pulse is full, strong, and unyielding ;  it
 may be retarded.  The aortic valve sound, heard best at the base at
 the second  right interspace, is accentuated.  Hsemorrhage or evi-
 dence  of softening may  indicate rupture,  aneurismal dilatation,
 thrombosis or embolism of the brain arteries.   Sooner or later super-
 vene the signs of dilatation  and degeneration of the heart, with
 oedema, stasis, sometimes with ursemia in connection  with Bright's
 disease and  with gangrene in connection with diabetes.
    The diagnosis rests upon the hypertrophy of the left ventricle in
 association with increased tension in the vessels, independent of phy-
siological overgrowth,  valvular disease, Bright's disease, etc.
   The prognosis is always grave.   The patient stands in constant
danger of cerebral hsemorrhage, thrombosis, and embolism.  Through
affection of the coronary  arteries he is  menaced also with angina 
592
ANEURISM  OF THE AORTA.
 pectoris and cardiac asthma.  AVith the perfection of proper appara-
 tus it  must soon be the case that estimate of the duration of life, as
 for annuities, life insurance, etc., will be based largely upon the pros-
 sure of the blood in the arteries.
    The treatment must address itself to the  cause, and may be effi
 cacious only when the cause—alcoholism, gout, diabetes—may be re-
 moved.  The diet and the mode of life must be regulated to the new
 or developing conditions.   Exercise in the open air (horseback), the
 free libation of mineral waters, simple,  wholesome  food,  regular
 sleep,  good habits, and cheerful surroundings longest postpone  or
 best protect the patient against the remoter evils  of this disease.
    Alanus advises the exhibition of a mixed diet, especially of meat,
 basing the recommendation upon the observation that the Hindoos,
 who feed exclusively upon rice, and  certain  quite young monks in
 cloisters,  with other^vegetarians, suffer premature arterio-sclerosis
 (atheroma) from deposit of the excess of mineral salts.

                    ANEURISM  OF THE  AORTA.
    The lack of resilience imparted to an artery by arterio-sclerosis
 causes it to yield before the impact of blood and leads to dilatation
 of its walls.  The dilatation may be saccular,  cylindrical, or spindle-
 shaped.  Because subjected to greatest pressure it occurs most fre-
 quently in the ascending aorta and in the arch of the aorta. Such
 a dilatation constitutes an aneurism {avevpvvGo, to widen), which
 may vary from a scarcely perceptible enlargement to  the  size of a
 man's head.  The sac  of  the aneurism is filled with  blood, which
 coagulates in layers, and from which fragments  may be detached to
 constitute emboli.  Men are affected more frequently  than women,
 because men are  the more frequent subjects of the cause of arterio-
 sclerosis—to wit, syphilis, alcohol, hard work, and gout.  The great
 majority of cases occur, therefore, between the  ages of thirty and fifty.
    The symptoms depend chiefly upon pressure, and occur in num-
 ber and severity according to the direction of the growth and the
 structures implicated.  Aneurism remains for a long time latent.
 Symptoms are absent altogether in one-fifth  of  cases.   Among the
 subjective symptoms may  be mentioned sensations of fulness, pul-
 sation and oppression, pains in tie chest or back, vertigo, head-
 ache, hoarseness, etc.  As these symptoms may be all due to many
 causes, the objective symptoms assume prominence. Inspection may
 reveal distention, bulging of the chest, or the actual  presence of a
pulsating tumor.  Usually the pulsation is felt on the right or left
 of the sternum, or between the spinal column and the  scapula, ac-
 cording as the aneurism is situated in the ascending  aorta, arch of
 the aorta, or descending aorta.  Sometimes it is  first appreciated by 
ANEURISM  OF THE AORTA.
593
the finger introduced behind the sternum in the neck, when the head
is retracted and the larynx lifted up.   The aneurismal bruit may
be heard  in these situations or along the line of the carotids.   As
the disease advances, a tumor, most frequently at the second right
interspace, becomes more and more visible, or dulness in this region
indicates its presence.  Soft, blowing sounds are heard on ausculta-
tion in both systole and diastole.  The sounds are intensified with
insufficiency or stenosis at  the aortic valves.  The heart is often dis-
placed toward the left in  aneurism of the ascending aorta, and to-
ward the right in aneurism of the descending aorta.  Sometimes the
blood wave is unequally  distributed to the two  sides, so that the
left radial and carotid pmlse may be feebler or retarded.  The
sphygmograph shows reduction in the line of ascent, absence of sec-
       Fig. 252.                              Fig- 253.
  Fig. 252.—Aneurism of femoral artery : a, adventitia ; b, intima ; c, muscularis, present only at
entrance of sac (Weber).
  Fig. 253.—Aneurisms, a, a, of the hypogastric artery.
 ondary vibrations.   The veins of the thorax and the upper extremi-
 ties, on account of interference with the  return  current from com-
 pression of the right auricle, may become  tortuous, and oedema may
 develop upon  the  side  of the  chest—conditions more frequently
 encountered  in mediastinal tumors than aneurisms.   Dyspnea and
 cyanosis  may develop from direct compression of the trachea and
 bronchi, and  dysphagia  from  compression  of the (esophagus.
 Hoarseness  of voice, aphonia from paresis and paralysis of the left
 vocal cord, is often an early symptom of  pressure on the left recur-
 rent nerve.   Double paralysis occurs more  frequently in  tumors.
 Pressure upon the brachial plexus develops pain, pmresthesice, and
paresis in the upper  extremities.  The gradual development of the
        38 
594
ANEURISM OF THE AORTA.
aneurism leads to consumption, usury, of everything before it. in-
cluding bones, sternum, vertebral column, etc.
   Aneurism of the Abdominal Aorta reveals itself as a pulsating
tumor in front of  the vertebrae, at first above the umbilicus.  Aneu-
rism at this seat remains for a long time latent, and is usually sus-
pected on account of obstinate pains (gastralgia, enteralgia) and
  Fig. 251.—Aneurism of the aorta : a, aorta ; c, a fusiform aneurism of ascending aorta commu-
nicating at b with the dilated aorta ; d, rib adherent to sac of aneurism ; e, shrunken aortic valves,

paresis in the abdomen or  lower extremities.  The condition is often
mistaken for neuralgia or rheumatism  for  months, sometimes for
years, until the tumor makes itself manifest.  Sometimes the diagno-
sis is  only made by the collapse which follows rupture.  The aneu-
rism  may thus discharge  itself suddenby with  sudden death,  or
gradually with the symptoms of chronic anaemia.
   Aneurism of the aorta  may at any time terminate suddenly, or 
PHLEBITIS.
595
may last for years with slight or severe symptoms.  Aneurism of the
thoracic aorta may discharge itself into  the oesophagus or stomach
to be attended with hsematemesis, or into  the trachea or bronchi to
produce suffocation, into the pericardium to cause sudden death. On
account of defective nutrition it is often attended with tuberculosis.
Aneurism of the abdominal aorta may discharge itself  into the peri-
toneal sac, left pleura,  intestine, and stomach.  Sometimes the  blood
in coagula fills the  aneurism and  the patient makes a perfect recov-
ery.
   The diagnosis rests upon the recognition of a cause—alcoholism,
syphilis,  gout, trauma  with the signs of pressure,
aphonia, cedema,  dysphagia—and the discovery
of a fluctuating, pulsating tumor with  bruits at
the second right interspace and in the jugulum.
Abscess  is distinguished by its greater extent,
tenser walls, points or surfaces indicating suppu-
ration.  Malignant growths  show no fluctuation
or pulsation.  Doubt  which may not be settled
by careful  examination may be dispelled by the
introduction of the finest needle of the aspirator—
a procedure, according to Fiirbringer, unattended
with any danger.
   The prognosis  is always grave.   The danger
is from  rupture  and  compression of important
structures.
   The  treatment should address  itself to the
        ,1        p i  i  v       -i •!•    j         Fig. 255.— Section  of
cause in the cure of alcoholism, syphilis, and gout. aneurism fllled with clot>
The  best outlook is offered in syphilitic arterio- surrounded by dense iay-
sclerosis, where systematic use of mercurial oint- tZueTwTg^e™™^
ment and iodide  of potassium may be  followed
with the best results.  Repeated  subcutaneous injection of ergotin
or sclerotinic acid sometimes leads to contraction of the sac.   Acu-
puncture and galvano- puncture, the introduction of fluids,  the intro-
duction of solids (wire) to  bring about coagulation of  the blood, are
procedures, not unattended with danger (embolism), sometimes re-
sorted to in protection  against the  greater evils of aneurism.
PHLEBITIS.
   The veins show the same  changes as  the  arteries, but less fre-
quently and in a less pronounced  form.   Fatty degeneration, athe-
roma, sclerosis, are changes which begin in the intima of the veins as
well as in the arteries, and lead likewise to dilatation, phlebectasis,
varices, rupture.  The most common lesion is the formation, in con- 
596
PHLEBITIS.
nection with the infections (typhoid fever, pneumonia, septicemia,
dysentery), of a thrombus, which occurs especially in the veins of the
lower extremities (milk leg)  and the  pelvis, not infrequently in the
sinuses of the dura mater, more rarely in the  portal  veins—pylephle-
bitis.  Cicatrization may occur in the region of the thrombus,  with
   Fig. 256.—Obliteration of right femoral vein, showing remains of a thrombosis three years before
death: a, site of obliteration ; b, c, d, connective tissue in interior Lof vein and its branches; e,
recent thrombus.  Natural size (Ziegler).

contraction  and obliteration, so  that  the vein  may be converted
into a fibrous  cord.   Circulation must now be  conducted  by col-
lateral veins.   Calcification may  occur, with the formation  of phle-
boliths,  or toxic processes may result in suppuration. 
CHAPTER  Till.
                    DISEASES  OF  THE BLOOD.

    Affections or anomalies of the blood concern both quantity and
 quality, and in either case are felt  from the nature and distribution
 of this circulating fluid in every organ of the body.
    To get reliable data blood must  be examined fresh.  Fortunately,
 a drop or two, as taken with a fine lance  (not with a needle) from
 the finger  or from the lobe of the ear, suffice for all clinical pur-
 poses.  Blood thus collected, as it exudes, is studied  without pres-
 sure from the cover glass, that first the process of nummulation may
 be observed.  This process occurs in all healthy blood.  Absence of
 it or imperfect performance of  it indicates at once the existence of a
 grave disease.   Second, the fresh  drop is studied as  to its corpus-
 cular elements—their number, size, color, shape, nucleation, relative
 proportions, etc.  A solution of common salt, 0.75 per cent, will keep
 the corpuscles unaltered for longer study.
    Excesses  in  quantity  are distinguished as plethora (nXi/Sos,
 fulness), which  is recognized by fulness of vessels, flushing of the
 face, headache, tension of  the pulse, increased impact of the heart,
 palpitation, etc.   Such plethora is noticed after suppression  of hab-
 itual haemorrhages, haemorrhoids, epistaxis, menorrhagia, and after
 transfusion.   Flushing  of the face, with dilatation of vessels, may
 mean  not general but local plethora  in paretic and  dilated blood
 vessels.   The plethora of the drinker, in association with acne, may
 be thus wholly paretic and local.  Plethora is called serous when the
 proportion of water is above eighty per cent.   Serous plethora, which
 gives rise to local oedema  and general anasarca, is observed more
 especially in disease of the kidneys.   The blood is diminished in
 amount after heavy losses, haemoptysis, hsematemesis, or other hsem-
 orrhage, to  constitute the condition called  oligsemia or, more com-
 monly but improperly, ansemia.
   Anomalies of composition exist in  hydrsemia {vdoop, water), a
relative increase of water,  observed especially in Bright's disease;
and  anhydrsemia, a relative decrease of water,  observed after pro-
fuse watery  discharges, diarrhoea,  dysentery, cholera morbus, and
Asiatic cholera. 
508
DISEASES OF THE BLOOD.
   Slight inspissations of the  blood occur in  the  course  of  fevers.
after  the thirst  cure, etc.   Changes in the haemoglobin are best
estimated by means of Gowers' hsemoglobinometer.  The normal
per cent of haemoglobin is, in  the male, 13.77; in the female, 12.59.
Information sufficiently accurate for practical purposes is obtained by
the colorimetric test.   The  color imparted by dissolving  a drop of
blood in distilled water is compared with a previously prepared nor-
mally colored glass.   The glass devised by Fleischl gives a scale of
percentage.   It is highest in the new-born, is reduced to one-half in
the first years of life, increases from the age of twenty-one to forty-
five, and is  later  again  reduced.   The  haemoglobin  corresponds
closely, but not absolutely, to the number  of red  blood  corpuscles.
It may be increased 120 per cent above the normal.   It is reduced
in ansemia in all its forms, in malnutrition from  any cause, tuber-
culosis, cancer, or  other cachexias.   It is  especially diminished in
amount in chlorosis, pernicious ansemia, and leukaemia.   The reduc-
tion in leukaemia runs parallel with the reduction in red blood cor-
puscles, while in chlorosis,  notwithstanding the  reduction of  haemo-
globin, the corpuscles may be  normal in number.  Haemoglobin
may be reduced 10 per cent below the normal.  In  marked reduction
the blood is visibly pale.
   The albuminates exist  in  the blood  in combination  with the
haemoglobin and in solution in  the  plasma (8 to  10 per cent).  In-
crease (hyperalbuminosis) occurs in association with inspissation of
the blood; decrease (hypalbuminosis) with hydraemia and marasmus.
   Fibrin, which exists  normally in  the proportion of 0.1 to 0.4 per
cent, may be increased  (hyperinosis) to 1  per cent, as in croupous
pneumonia, acute rheumatism, etc.; or decreased (hypinosis)  in the
acute infections and  various  poisonings (prussic acid, sulphuretted
hydrogen, alcohol, etc.).
    Salt should exist  in the blood in the proportion of 0.85 per cent.
Reduction is especially noticed  in the sputum  of pneumonia, and
reappearance is  recognized evidence of resolution.  The sign has
lost much of its value since it has been learned that the variations
are largely  due to food.  Reductions are  in all cases speedily regu-
lated.
   Increase of fat, which exists  normally in the proportion of 0.1 to
0.2 per  cent,  shows itself in  increased,  or milky, opacity  of the
plasma.   It is observed after excessive indulgence in fat, obesity,
any disease attended by albuminoid  degenerations, affections of the
liver, alcoholism, and marasmus.  Globules of fat may escape from
the bone marrow after injuries  to bone, to block capillaries in the
lungs and to produce the dangerous affection  known as fatty em-
bolism. 
DISEASES  OF THE BLOOD.
599
    Increase of grape sugar, which exists normally in the proportion
 of 0.1 to 0.15 per cent of the plasma, is observed  after hsemorrhage
 and in the course of diabetes.  Any excess above 0.9 per cent is ex-
 creted with the urine.
    Urea, which may exist in normal blood in the proportion of 0.016
 per cent, and urates (traces), accumulate in consequence of disease
 of the  kidneys and  failure of elimination, to produce the condition
 known  as  ursemia {oipov, urine).  Increase of uric acid occurs in
 gout.
    Increase of bile pigment, cholsemia (^oln, bile), shows itself in
 icterus.   Small quantities are  detected in the blood by filtration of
 the serum,  withdrawn by cupping and separated  from the clot, and
 coagulation at 70° to 80° C.   After repeated heating to 50° to 60° C,
 serum assumes, in the  presence of bile, a grass-green color.  Disso-
 lution of the red blood corpuscles, with liberation of coloring matter,
 constitutes  hsemoglobinsemia and  hsemoglobinuria.  These  condi-
 tions occur in  consequence of the infections, freezing,  extensive
 burns, after transfusion of heterogeneous blood, in poisoning by chlo-
 rate of potash, tincture of iodine, arsenic, etc. (Stintzing).   Melanse-
 mia results from  dissolution of the red blood corpuscles and libera-
 tion of black pigment  granules  in the  course of malaria.   Small
 quantities of air may make the round of the circulation and  be ab-
 sorbed without damage.  Larger  quantities make the blood foamy,
 block the right heart or pulmonary vessels, and thus produce sudden
 death.
    Alterations of  the corpuscular elements  concern number, color,
 form, and composition.
    Healthy male  blood should contain 5,000,000 red corpuscles, fe-
 male  4,000,000,  to the cubic  millimetre.   Plethora of  corpuscles
 (polycythsemia) {7to\v?P uvxos, many cell) may increase the number
 to 7,000,000, with increase of haemoglobin from  13 to  16  per cent.
 Conditions  which lead to  inspissation  of  the blood,  watery dis-
 charges, etc., produce this effect.  Blood corpuscles may be increased
 in high degrees of heart failure to 8,800,000 in one cubic millimetre.
    Decrease (oligocythsemia) is  a constant attendant of ansemia,
 chronic diseases marked by malnutrition, and marasmus.  The blood
 corpuscles may be decreased in  pernicious ansemia  to 1,000,000 or
 500,000 to the cubic millimetre.
   Blood corpuscles  increased in size  to  a diameter of 9.5-10.0 p
 and over are called giant blood  cells—macrocytes.   They are seen in
certain ansemias, chlorosis, cholsemia, lead poisoning, especially after
haemorrhages, and often in connection with microcytes.  Corpuscles
decreased to 6.5  p  are called dwarf corpuscles.  Microcytes are
small, globular bodies which are found in high fever, severe chronic 
600
BLOOD PARASITES.
ansemia, extensive burns, poisoning by morphia, carbolic  acid, and
especially in septicsemia.  Megaloblasts are giant cells with nuclei.
   Changes of form are distinguished as poikilocytosis  (jto^/Ao?,
varied).   Such alterations are seen  in light  degree in chlorosis, leu-
kaemia, and secondary ansemia; in high  degree in progressive per-
nicious anaemia.
   The number of white blood corpuscles is  more variable  than that
of the  red.  A cubic millimetre  of blood  contains, on the average,
5,000 to 10,000 white corpuscles.   The proportion of white to red
ranges  between  1 :400 and 1 :1000.   Amoeboid motion  continues,
under heat and moisture, two to three hours.   The  leucocytes, as
they may be stained, are divided (Ehrlich) into (1) basophile,  which
may be colored with basic  aniline dyes (methylene violet, fuchsin),
found  in  connective tissue  ("mast" cells) but not in normal blood ;
(2) eosinophile, whose granules take  up  the acid dyes, especially
                            eosin, rarely  found  in normal blood ;
     • a- ^K   ^  \l      (3)  neutrophile, colored with neutral
          O    •   J J      dyes (methylene blue, acid  fuchsin),
   m^1, J *»   C*£ } %      which  form the bulk of the white cor-
    ^ ^   # ^V  (T  I      puscles of the blood.   All the pus cor-
                            puscles belong  to this group.
mT'b^^^h^^r^Z]     White blood corpuscles  are further
c different forms of degenerated red  divided into  mononuclear and polynu-
blood corpuscles (poikilocytes). X 500.   j      R   Th mononuclear cells con.
(Ziegler.)
                            stitute 25 per cent (varying between 15
and 35 per cent) and the polynuclear 75 per cent of the whole number.
Transition forms are not infrequent.
   Absolute increase in number indicates  either  leukocytosis or leu-
kaemia.  Leukocytosis is a  relative increase  from 1 : 400 to 1 :50.  It
occurs, as a rule, in the course of the  acute infections and chronic
wasting diseases.  The proportion may be reduced in the death ago-
ny to 1 : 5 (Litten).  The reduction reaches in leukaemia its highest
grade; it may  fall to 1 :1.  Increase in the eosinophile cells indicates
leukaemia.  The  sign is of  not so  much  value  in children,  where
these cells may be increased to 15 to 20 per cent of the whole  num-
ber of leukocytes, independent of affections of the spleen or bones.
                        BLOOD PARASITES.

   The parasites found in the blood are both animal and vegetable.
The animal  parasites, Distoma, Filaria, and Plasmodium  malaria'.
have been already described.
   In examining for vegetable parasites (bacteria), the end of the
finger punctured for blood must be first thoroughly washed with soap 
BLOOD PARASITES.
601
 and  sublimate  solution 1:1000,  and  this  solution  subsequently
 washed off with, first, alcohol, then ether.  The lancet, cooled after
 having been heated to redness, makes the slight cut necessary to se-
 cure the blood.   The slide and cover glass must be cleaned and dis-
 infected like the finger.   The drop of blood should be dried under a
 bell-glass  cover and then heated,  or should  be  three  times drawn
 through the  flame of an  alcohol lamp to fix it.  The preparation is
 stained with the aniline or other coloring matters, as already specified.
 A good microscope is required, provided with a condenser, best with
 the Abbe illuminating apparatus.
    Of the  bacteria found in the blood, the Bacillus anthracis and the
 recurrens spirillum are sufficiently distinguished, so far as the diseases
 of man are concerned, by their morphology alone.   The bacillus of
 glanders is readily recognized by inoculation, and the typhoid bacil-
 lus demands culture to confirm a diagnosis.
    The tubercle bacillus may be disclosed after the manner speci-
 fied in the study of the sputum, but  is more readily shown by the
 method of Gabett.  The  preparation of blood is immersed two min-
 utes in the solution of carbol fuchsin specified, in a watch  glass.   It
 is then washed off with distilled water, and thereupon immersed for
 about one  minute in a methylene-blue and sulphuric-acid  solution
 (methylene blue  one to two parts ; sulphuric  acid, twenty-five per
 cent solution, one hundred parts ; both solutions to be filtered).  The
 methylene-blue solution is to be decolorized immediately and stained
 as specified in the study of  the sputum.   A power of four  hundred
 diameters  displays the deep-red  tubercle bacilli  on a delicate blue
 ground without other tone of red.  These solutions of Gabett have the
 advantage that they keep for months.  The examination of the blood
 is made only in acute miliary tuberculosis, in which all sputum  is
 absent; and as the bacilli are in all cases so few and far apart, the
 blood,  a venesection-cupful, should be  allowed to stand  several
 hours and the  sediment  and clot  broken up fine with a glass rod.
 After this procedure an  unmistakable specimen or two is  usually
 found.  But while a positive discovery declares the diagnosis, nega-
 tive evidence does not exclude the disease.
   Lepra bacilli have been found in the blood in the beginning of
a new eruption.   The diagnosis is  usually made, however, from the
 masses in the skin.  The bacilli  of lepra closely resemble  those of
tuberculosis, but  differ from them and all other bacteria in the fact
that they are colored red by immersion six minutes in a concentrated
alcoholic solution of fuchsin and subsequent washing of the super-
fluous color in a mixture of nitric acid one part,  alcohol  ten parts.
All other bacteria are colorless—i.e., are decolorized by  this method. 
602
ANEMIA.
                            A N.EM I A.
   Anemia {av, without, aipa,  blood), more properly oligsemia
{oXiyoS, little), acute and  chronic, is called  primary  or  essential
when its cause is concealed, and secondary when it occurs in  the
course,  or in consequence, of various discoverable diseases.
   Anaemia is most acute after  direct loss of  blood, from whatever
cause, whether the hsemorrhage be manifest or concealed—ulcer of
the stomach, rupture of aneurism, tubal pregnancy, etc.  Tolerance
to hsemorrhage varies.  Infants and aged people  fall into  collapse
with losses which might be safely endured at maturity.  Women en-
dure haemorrhage better than men, the thin better than the obese.
The loss of a third of the whole  amount of blood is necessarily fatal;
the loss of a less amount, whereby the  blood corpuscles are reduced
one-half—from 5,000,000 to 2,500,000 to 2,000,000 in one cubic milli-
metre, in disproportion  thus to the amount of the  blood  itself—is
often fatal.   Blood corpuscles are rapidly restored in convalescence
at the rate  of  150,000 to  170,000  per day (Laache).   The haemo-
globin is not so quickly restored; hence the more persistent  pallor of
the skin.
   Symptoms.—Acute ansemia, as from haemorrhage, is attended by
pallor, cyanosis, and collapse; the skin is cold and clammy;  the
heart's  action is weak and fluttering.   Ringing in the ears, vertigo,
dyspnoea, precordial anxiety, retching and vomiting, faintness, con-
vulsions, and loss of consciousness are the common signs of rapid
loss of blood.
    Chronic  anemia  results  from  repeated hsemorrhage  or other
losses, prolonged lactation, onanism,  suppuration, or other profuse
discharge,  diarrhoea, albuminuria, leucorrhcea, fever, melancholia,
protracted insomnia, chronic infections, tuberculosis, malaria, scurvy,
syphilis, cancer,  certain intestinal parasites, especially those which
draw blood, anchylostomum, etc.
   Chronic ansemia shows itself in reduction of the red corpuscles.
It is most  frequently seen in  connection with cachexia, cancer,
amyloid degeneration, tuberculosis, malaria, syphilis, poisoning by
arsenic, lead, mercury.  In aggravated cases  there is also poikilo-
cytosis.  In  these cases the albuminates  may fall from 8 to 4 per
cent and the specific gravity from 1030 to 1013.  Cachexia develops
gradually; the face is gray, or greenish gray, from deposit of pigment
matter from disintegrated blood  cells.  On account of the lack of nutri-
tion emaciation gradually develops, the fat disappears, later the mus-
cular tissue; the patient falls into marasmus; the action of the heart
is enfeebled; the valves show  relative insufficiency, and,  in  conse-
quence of irregular vibration, yield to auscultation  a systolic mur-
mur.  Anaemic murmurs are heard also in the course of the arteries 
ANJEMIA.
603
and veins, especially at the root of the neck.  The heart is excitable
through  weakness and without apparent  provocation.  The symp-
toms of stasis supervene sooner or later—edema about the ankles, in
the serous sacs, cyanosis, diminution of urine, albuminuria, bron-
chial catarrh, and edema of the lungs.  In consequence of nutritive
change in the endothelium, marantic thrombosis is wont to occur in
various veins, including the sinuses of the brain.  Epistaxis, retinal
hsemorrhage, metrorrhagia, are haemorrhages which may occur by
diapedesis in cases of  aggravated ansemia.  Insomnia, disturbances
of special sense,  parsesthesia, hypersesthesia, mental affections,  hal-
lucinations, vary the scene.  All anaemic  patients are more  or  less
dyspeptic,  partly from diminution  of secretion, partly from atony.
Menstruation is disturbed in every way.
   The diagnosis of ansemia is usually easy, and the prognosis de-
pends  upon  the  cause.  Loss of  blood  up to one  per  cent  of  the
weight of the body is made up in two to  five days ; up to three per
cent, in five to fourteen days ; in larger amounts, in fourteen to thirty
days (Lyon).  The haemoglobin, as stated, is restored less rapidly than
the corpuscles.
   In the treatment of ansemia it must be remembered that the  con-
dition  is usually  only secondary.   Address  must  be made to the
cause.   The treatment of ansemia may resolve itself into  the treat-
ment of tuberculosis,  Bright's disease, diabetes, affections of  the
uterus, gastric catarrh, intestinal  parasites,  etc.   Acute  cases, as
after hsemorrhage (gastric ulcer),  are  sometimes rescued  by  the
transfusion of the physiological salt solution of one to one and a  half
pints, one-half drachm to the pint.   Transfusion may be made  into
the veins of the  arm  or upper thigh,  or, more safely, under the
skin as in  the treatment of cholera.  In cases of  extreme collapse
the intravenous method is to be preferred.  Patients apparently in
articulo mortis have been rescued in this way.   Alcohol may be in-
troduced also subcutaneously, or, better, camphor dissolved  in  sul-
phuric ether, in the proportion of 1 :10,  introduced in syringeful
doses under the skin.  In subacute or chronic cases the best remedy
is iron.  What form of iron is given matters but little.  Many prac-
titioners still prefer the old Blaud pill.  The following is the original
formula of Blaud (1831) :
   $ Ferri sulphatis................. .............................gr. xv.
     Potassii subcarbonatis.......  ...............................gr- xv.
   Reduce separately to a very fine powder.  Mix very slowly, little by little,
       and add—
     Mucilaginis adragantis......................................... q. s.
   Rub thoroughly and forcibly to a mass, and divide into forty-eight pills.

The more  modern preparations,  albuminated  or  peptonized,  owe 
604
PERNICIOUS ANEMIA.
their superiority  only to  the power of  suggestion.   Probably the
same explanation will account for the virtues of the  artificial hemo-
globin, as  we do not understand as yet the iron combination in the
complex molecule haemoglobin.   The tincture of the chloride of iron in
sweetened water  is indicated with any tendency to diarrho'a.  Gene-
rally the  tendency  is toward constipation.  The  saccharated car-
bonate may be given in teaspoonful doses three times a day. The1
compound mixture  of iron  is  an unpleasant  but  very efficacious
form ; dose, one tablespoonful three times a day.  A pill of reduced
iron, one  to two grains at a dose, in connection with one or two
drops of  Fowler's  solution  of  arsenic,  makes a fine blood tonic.
Roncegno  water  contains more arsenic than iron.  Food and fresh
air are even more  essential  agents in the successful treatment of
ansemia.
                      PERNICIOUS  ANJEMIA.
   Progressive, essential, idiopathic ansemia.
   Etiology.—The disease occurs more frequently in maturity, ex-
ceptionally in children.  Women are attacked more  frequently than
men, on account of the liabilities of pregnancy.  The disease is more
common in Europe, especially in Switzerland, and is rare with us.
Like all  diseases whose cause is obscure, it has been attributed to
accidents or conditions which preceded it (thus, to defective  nutri-
tion,  exhausting  discharges, frequent pregnancies,  haemorrhages,
ulcers of the stomach and intestine, malaria,  syphilis,  cancer,  alco-
holism, intestinal parasites, anchylostomum, bothriocephalus), some-
times without other foundation than sequence.   Von Jacksch claims
a parasitic origin ; Petrone and Holtz consider the disease infectious.
   Symptoms.—The  most obtrusive symptom is the pallor of the
skin and exposed mucous membranes.  The face is white  and the
mucous membranes blanched. On account of the extreme poverty of
the blood,  edema occurs about the ankles and face, with effusions
later into the serous sacs.  Nevertheless nutrition is preserred and
the adipose tissue is not lost.  The temperature is subject to great
fluctuation.  The disease is usually attended with fever, hence the
synonym "febrile ansemia."  It  is usually of more or less remittent
type.  The temperature rises  and falls without discoverable cause,
and the subjective condition is often better during fever (Van Xoor-
den).  Disturbances on the part of the digestive system  are fre-
quent.  Thirst, fcetor of the breath, nausea and vomiting, obstinate
diarrhoea, belong to the condition.   On the other hand, the  appetite
is  sometimes voracious and constipation prevails.  The epigastrium
is  always tender  to pressure.  The urine is  sometimes increased,
sometimes  diminished; it  may show increase of indican, uric acid,
and peptones.  The brain suffers for want of  healthy blood.   Some 
PERNICIOUS ANAEMIA.
605
patients are excitable, others indifferent.  Insomnia may alternate
with sopor.  Neuralgias, paresthesie,pareses, apoplectiform at-
tacks,  and delirium,  even outbreaks of mania, may occur in  the
course of the  disease.   Patients complain of weakness,  which is
manifest from  the beginning.
   The blood  is  thin and pale, more the  color of amber than
blood (Weiss), exceptionally dark (Gusserow), poor in  iron (Roki-
tansky).   The  blood corpuscles suffer  enormous diminution, be-
low a million down to half a million—in  a case recorded  by Quincke
143,000 in one cubic millimetre.   The  hemoglobin is  reduced  to
one-tenth of the normal, less in degree than the red blood corpuscles
—a disproportion considered characteristic of pernicious ansemia.
   Fig. 238.—Pernicious anaemia: A, poikilocytes ; B, microcytes "and granules ; C, eosinophile
cells (Wesener).

Deformity of corpuscles  {poikilocytosis) is more  marked than  in
any  other affection.  Elliptical, biscuit-shaped, bottle-shaped, reni-
form, acuminate  shapes  appear in  connection with very small and
very large cells—microcytes, megalocytes.   The  microscope shows
in the pernicious form nothing that may not be seen in other forms
of ansemia ;  but the fact that everything is so much more magnified
and distinct is of  itself characteristic.  The  red corpuscles no  longer
aggregate themselves like piled-up  coin, but remain apart, scattered
over the field.  The white blood corpuscles are really reduced, but in
so much less degree than the red as to appear to be increased—rela-
tive leucocytosis.
   On account of imperfect  nutrition,  the  heart's action becomes 
606
CHLOROSIS.
weak ; attacks of palpitation occur often in the night.  Dilatation
of the right ventricle sets in, dulness extends beyond the right border
of the sternum, the heart's apex is displaced to the left.  Auscul-
tation  reveals a systolic  murmur at  the base.  Anaemic murmurs
are also audible over all the superficial  vessels,  which show visible
pulsations.  Hemorrhages are frequent from the  various mucous
membranes.   Effusions in the brain  may be fatal.  Characteristic
ophthalmoscopic pictures are furnished by effusions of blood into
the retina.
   Though insidious in its onset, as the name indicates, the disease
is progressive.  The blood is robbed more and more  of its essential
constituents,  the body suffers from lack of nutrition, the patient
sinks from apathy into stupor, and death occurs suddenly as the
result  of  hsemorrhage,  or  more frequently in the course of a slowly
progressive marasmus.
   Since  the  other signs  are common  to the  various  forms of
ansemia, the diagnosis can be determined only by the condition of
the blood.  The important factor in diagnosis is the determination
of the cause  upon which  the condition rests.  Though occasional
glands are swollen, the lymphatic system is not affected.
   The prognosis  is  exceedingly grave.  The  disease is usually,
though not of necessity, fatal.
   The treatment is symptomatic, and,  aside from discovery and
treatment of the cause, does not differ  from that of  other forms of
anaemia.  In all cases of ansemia appeal  should be made  to the di-
gestive apparatus to secure the absorption of wholesome food.   It is
sometimes wise to abandon all address to the blood and resort to the
stomach tube, with daily irrigations, and to administration of dilute
hydrochloric  acid,  gtt.  x.-xv. largely   diluted, before  meals ; of
tinctura nucis vomicae gtt. x.-xx., or tinctura rhei aromatica, tea-
spoonful,  diluted, after meals.  The desperate case of Quincke re-
ferred to, with a reduction of corpuscles to 143,000, recovered after
the practice of transfusion.

                           CHLOROSIS.
   Chlorosis  {xXoopos,  yellow-green).—A  disease  which  occurs
chiefly  in girls  at puberty,  marked by anaemia  which usually
disappears under the use of iron.
   Etiology.—Chlorosis is almost limited to the female sex at the
period of puberty.   It has been exceptionally encountered in child-
hood and  maturity. A role of some importance in the causation of the
disease is played by heredity, which Virchow explains as a congeni-
tal hyperplasia of the vascular system.   Other causative  influences
are emotional disturbances, home sickness, love sickness, bad habits, 
CHLOROSIS.                         607
night work, loss of sleep, onanism,  premature pregnancy, lactation,
certain infections, malaria, typhoid fever, etc.   The chief cause of
chlorosis is  connected with some as yet inexplicable  disturbance
with ovulation.
   Symptoms.—The disease begins with a sense of growing weak-
ness and easy  fatigue.   In fact,  the  feeling of fatigue is  much
greater in chlorosis, because of the  great reduction of haemoglobin,
than in  any other  form of ansemia.  The tendency to sleep is irre-
sistible.  Some patients would, if permitted, remain in bed all day.
Soon there is indifference; loss of interest; caprice regarding food,
craving  for indigestible, sometimes repulsive  things  (chalk,  sand,
slate  pencils,  mortar), which is secretly gratified ;  constipation,
flatulence, anorexia, dyspepsia,palpitation of the heart, headache,
ringing in the ears,  wandering pains.   The skin and mucous  mem-
branes show  a peculiar pallor, tinted with green, though the di-
lated blood vessels of the  cheeks often leave a  red incarnation, the
so-called chlorosis rubra, which may confuse the diagnosis (Weiss).
Fluctuations of temperature, apparently without cause, dyspnoea,
transitory oedema about the  ankles and eyelids, occur, as in cases
of other ansemia.
   The blood is pale, and, while the corpuscles  are but  little re-
duced, the hemoglobin is reduced one-half, a disproportion char-
acteristic of chlorotic blood.   Alterations of form (poikilocytosis) oc-
cur in but slight degree.  In consequence of defective  nutrition the
action of the heart becomes weak, the dulness is increased to be per-
ceived beyond the  right border  of the sternum.  Auscultation re-
veals systolic murmurs,  in  the order  of decreasing frequency, at
the pulmonary,  mitral, tricuspid, and aortic valves.   Menstruation
is disturbed in various ways.   There is often amenorrhea for months
or years, sometimes metrorrhagia.
   Bleeding from the nose is not infrequent, is sometimes obstinate.
Haemorrhage  from the stomach depends upon ulcer,  to which  chlo-
rotic patients are especially liable.
   The temperature  is variously affected.   Occasionally there is fe-
ver without apparent cause.   Sometimes the temperature is subnor-
mal.  Palpitation is frequent and is easily excited.  The carotids
throb in the neck, and murmurs {bruits de diable) are to be  heard
over the bulb of the jugular vein.  Thrombosis may occur,  espe-
cially in the graver forms or after muscular strain.  Rendu reported
a fatal case from spontaneous thrombosis of the pulmonary artery.
The respiratory organs are  normal, but the respirations are in-
creased in  frequency, even during rest and sleep, because of the
extra demand for blood, hsematogenous insufficiency (Eichhorst).
Nervous disturbances, infinite in variety, characterize  chlorosis: 
608
LEUKAEMIA.
 headache, insomnia, parsesthesise, hyperaesthesiae,  psychical  altera-
 tions, caprice, incapacity, apathy, sometimes erotomania, kleptoma-
 nia, vary the scene.
    The diagnosis is often difficult at the start, for the gastro-intes-
 tinal catarrh, headache, psychical alterations may precede the altera-
 tions in the blood and conceal the condition for a long time.  The
 blood changes, when they appear, distinguish the disease from ordi-
 nary ansemia.  Chlorosis is distinguished from pernicious anaemia bv
 the prompt effect of treatment, and from the oedema of nephritis by
 the examination  of the urine.  Tuberculosis must always  be elimi-
 nated by careful  observation of temperature, the use of tuberculin,
 examination of the sputum and of the chest.  Ulcer of  the stomach,
 in  the  absence of haemorrhage, may be diagnosticated by  hyper-
 acidity, as revealed by the  stomach tube, which is often used in the
 treatment of the gastro-intestinal complications of chlorosis.
    The treatment consists in the use of iron.  The materia medica
 is rich in preparations.   The saccharated carbonate may be admin-
 istered in doses of gr.  xxx.-xl. a day, or  the ferrum redactum, in
 pills, gr. x.-xv. a day.  The  compound mixture is an efficacious
 preparation,  which may be substituted by the compound pill of iron.
 A combination of  iron with a few drops of Fowler's solution of arse-
 nic is often advantageous.   The pill of aloes and iron obviates  consti-
 pation.   The stomach  may be  toned and stimulated by hydrochloric
 acid. gtt. x.-xx. in a wineglass of cold water, before meals, and some
 bitter infusion, condurango, calumbo, absinth, or tinctura  rhei aro-
 matica, 3 ss.- 3 i.  in a dessert- to a tablespoonful  of  water, after
 meals.  Constipation may be relieved by tamarinds or by cascara
 in  cordial or tablet form.  Sometimes it is wise, on account of the
 condition  of  the  stomach, to abandon all specific treatment for a
 time and address the stomach directly by irrigation with the stomach
 tube.
                           LEUKAEMIA.
    Leukaemia {Xevno?, pale, aipa, blood); leucocythaemia.—A dis-
 ease characterized by reduction of both red and white blood corpus-
 cles, with the general signs of anaemia.  Virchow (1845) first  distin-
 guished the  affection  as a separate disease  dependent upon  the
 relative increase of the white blood corpuscles.  The normal propor-
 tion of white to red corpuscles is 1 : 300 or 1 : 400.   Leukaemia may
 show in a light case a ratio of 1 : 40 or 1 : 30 ;  in a marked case, 1 :10
 or 1 : 5 ; in the worst cases,  1 : 2 or even 1:1.
   Leukaemia leads always to enlargement of the blood-making or-
gans, especially to the organs which stand in close connection with
the white blood corpuscles, the spleen, the lymph  glands, and  the
marrow of bones.   The increase in  size depends  upon hyperplasia. 
LEUKAEMIA.
609
 It is sometimes very extensive.  The spleen may reach to the umbili-
 cus; the lymph glands form tumors in the neck, axilla, and groins,
 as large as an egg; the medulla  may actually distend and disrupt
 bones.  The attempt has been made to distinguish forms as lienal,
 lymphatic, and medullary, according as affection of one or the other
 organ or tissue assumed prominence.  But mixed forms are so com-
 mon as to invalidate conclusions.  Other  organs  besides those men-
 tioned,  the liver,  kidneys, skin,  mucous and serous membranes,
 undergo hyperplasia or contain secondary deposits.
   Etiology.—The cause of the condition is unknown.   The disease
 is more frequent  in men. and  between the ages of thirty and fifty,
 though it has been observed in children.   Leuksemia has been found
 to develop after malaria, syphilis, tuberculosis, rickets, under depress-
 ing mental emotions—anxiety,  ap-
 prehension,  grief—and  in  the
 course of exhausting discharges.
 Sometimes  it  develops without
 discoverable cause.  The disease
 is regarded as a chronic infec-
 tion from unknown cause.
   Symptoms. — The  symptoms
 are the same as those already  de-
 scribed in connection with  other
 forms of ansemia.  There arep)al-
 lor of the skin and mucous mem-
 branes, palpitation of the heart
 with  the  development of  mur-
 murs, shortness of breath upon the slightest exercise, early fatigue,
 alterations of disposition, disturbances of vision, fever without ap-
parent cause, epistaxis and other haemorrhages.  In the course of
 time  the disease, which has expended its main force in one or the
 other of the various organs—the spleen, the lymph glands, and the
 bone  marrow—extends to involve other organs, so that leuksemia is
 progressive.
   The diagnosis is not difficult.  The signs of anaemia are attended
 with distinct enlargement of the spleen and lymph glands.   In ad-
 vanced  cases the most superficial observation shows the disproportion
between the white and red blood corpuscles.   The Charcot crystals,
described with the  sputum  of asthma, are found free in the  serum
and incorporated in the  white blood corpuscles.   They are most
abundant in the  bone marrow, and may be  seen  in  blood freshly
drawn from the  spleen.  Leukaemia  is  distinguished from  leuco-
cytosis by the progressive character of leuksemia.   The  presence of
eosinophile cells speaks in favor of  leuksemia.
        39
 Fig. 259.—The blood in leukaemia, showing the
disproportion of the white and red corpuscles.
Nummulation perfect. 
610
PSEUDO-LEUKEMIA.
   The prognosis is very grave.   The  tendency is progressively
downward.
   Treatment is almost hopeless.  Quinine in large doses sometimes
arrests the progress of the disease, more especially in the beginning.
Arsenic  has no effect upon it.   Local treatment of the spleen  is of
no value.  Extirpation of the spleen only aggravates the condition.
Mosler, who had a large experience with leukaemia, recommended
quinine, piperin, and the oil of eucalyptus in its treatment.   Thus :
   R- Quinise hydrochloratis......................................   ^.0
     Piperini......................................................   °-^
     Olei eucalypti e foliis..........................................  ^ ^
     Ceraealbae....................................................   60
   M. Fiat piluloe No. 100.  S. Three pills two or three times a day.
Hoffmann saw  no good  from  inhalations of oxygen,  but found
T  Fig. 260.-Hypertrophy of spleen in lienal lymphatic leukaemia : a, white lymph nodules; b,
yellow ischaemic infarct.  Natural size, child.

virtue in douches and cold frictions over the spleen.   Mosler recom-
mends transfusion.   Surgical intervention is  absolutely to be con-
demned,  as of  twenty cases  of  extirpation of the  spleen but  one
escaped with life.
   Pseudo-leukemia,  ansemia splenica. Hodgkin's disease, is a
sub-variety of leukaemia, distinguished by enlargement of the spleen
and lymph glands, without, or with but slight, increase of the white
blood corpuscles.  The disease is essentially the same, save that the
progress is much less rapid, arrest with temporary improvement, and
actually recovery, more frequent.
   The'  treatment does  not differ  from  that of leuksemia.  It is
claimed that the injection of arsenic into the substance of the spleen
and lymph glands is sometimes of value. 
THE HEMORRHAGIC DIATHESIS.
611
                 THE HEMORRHAGIC DIATHESIS.

   The haemorrhagic diathesis is a disposition to haemorrhage from
capillaries (per diapedesin) or from larger vessels (per rhexin).  The
haemorrhage occurs  in  consequence of  trivial  accident,  break of
vessel, or spontaneously without any trauma whatever.  The blood
escapes with all its  elements through rupture of vessels or paretic
vessel  walls, or by  reason of the  disintegration of  the blood ; or
haemoglobin, liberated from the corpuscles and held in solution in the
serum, escapes from the blood vessels, especially in the kidneys, to
constitute hsemoglobinuria.  The diathesis is, as the term applies,
general, so that haemorrhage may occur from any surface.   Bleeding
from the nose, epistaxis, is most frequent.  It occurs spontaneously
— i.e., without apparent pro vocation—is  profuse, intractable, occa-
sionally fatal.  Sometimes the disposition is  local,  in which case  it
shows itself usually only in the nose; next most frequently in the
intestine.   Bleeding may  likewise  occur from  any  mucous mem-
brane, from the mouth, nose, lungs, from  the intestine,  bladder,
uterus.   Hsemorrhage may take place  also into the various  serous
membranes and internal organs, including the brain.  It shows itself
frequently  upon the surface in the form of petechiae,  ecchymoses,
vibices.
   Here belong also the cases of  hsemathidrosis, or  sweating of
blood—a condition which may not be denied, since blood corpuscles
have been found in the ducts of sweat glands with an unbroken skin
(Tittel), and the celebrated cases of stigmatism, or bleeding from a
sound skin, which Lefebvre alone has actually seen.
   The haemorrhagic diathesis is sometimes inherited, but is usually
acquired.   When  inherited  it must be  distinguished  from haemo-
philia, which is transmitted only in certain directions.  More  fre-
quently the condition is acquired.  It shows itself as a sequel to some
infection, especially  to typhoid fever and small-pox,  more infre-
quently to yellow fever, septicaemia, diphtheria. It belongs to the
graver forms of ansemia.
   The prognosis is serious.  Life is  usually cut short by haemor-
rhage from or in some inaccessible region.
   The treatment consists in the administration  of iron, the tincture
of the chloride gtt. xx.-xl., largely  diluted;  acids, hydrochloric acid
gtt.  xij.-xv., largely diluted; the tincture of cinchona 3 i.-ij. four
times a day; the syrup of the hypophosphites  in like quantity.  The
nutrition is to be improved, especially by  food and fresh air.   Haem-
orrhage is controlled  by rest, the application of  ice, the use of tam-
pons.  As haemorrhage  from the nose usually occurs from the  sep-
tum, it may be often stilled by the  deep  insertion of a roll of cotton 
612
PURPURA.
upon a small sound.  Aggravated cases necessitate the use of the
tampon, introduced by a canula.  Internal haemorrhage1 calls for the
use of opium, atropine, acetate  of lead, digitalis, the subcutaneous
injection of ergotin or sclerotinic acid.
   Hemoglobinemia  occurs in the form of  (1)  Paroxysmal
Hemoglobinuria of adults, characterized by periodical attacks of
fever, with nervous disturbance and the appearance of urine stained
red with the coloring matter, but free, or almost free1, of the corpus-
cular elements of the blood : and (■>) Congenital IPemoglobinuria.
which shows itself in the new-born  child, usually about the fourth
day, with vomiting and diarrhcea, icterus, cyanosis, and urine stained
with the coloring matter of the blood.  Some of the cases undoubt-
edly belong to the disease generally described as icterus neonatorum.

                           PURPURA.

   Purpura; morbus maculosis (Werlhof).—The  condition appears in
two forms, as purpura simplex and purpura hsemorrhagica.
   Purpura simplex is a haemorrhagic diathesis limited to certain
parts of the body, especially to the lower extremities, of little or no
gravity.   It shows itself most frequently on  the legs as petechia?,
which sometimes unite to form larger exudations, ecchymoses.  Pur-
pura is observed occasionally in  the course of the graver infections,
especially in patients who get about too  soon.  More commonly the
disease is  spontaneous, occurring often without known cause in the
midst of apparent health.   It shows itself  more frequently in the
young, and  rather more frequently  in women.   Subjects  of  it are
liable to frequent attacks.  The outbreak is sometimes preceded by
light fever.  The spots  usually fade away gradually and disappear
in the course of a week or ten days.
   Purpura hemorrhagica is the graver form, found in connec-
tion with haemorrhage elsewhere, as  with  epistaxis, hsematemesis.
haematuria, sometimes with evidences of hsemorrhage of serous mem-
branes and internal organs.  Both forms may be attended with pain
in the joints—purpura  rheumatica.   Where the joint  affection as-
sumes prominence the disease is sometimes  distinguished as peliosis
rheumatica {neXio?, black  and blue).  The  possible existence  of en-
docarditis (embolus) must not be overlooked in these cases.   Certain
snake bites produce a typical purpura.
   The  prognosis of purpura  simplex  is  favorable, of purpura
hsemorrhagica exceedingly grave.  Purpura hsemorrhagica occurs in
a fatal form of variola,  the so-called purpura variolosa.
   The treatment does not differ from that of general haemorrhagic
diathesis. 
hemophilia.
613
                         HEMOPHILIA.

   Haemophilia is a haemorrhagic diathesis which is transmitted by
heredity.
   History.—The condition was first described by an Arabian phy-
sician, Alsaharavi, Cordova (a.d. 1100), who recognized  it as a dis-
position to obstinate and uncontrollable  haemorrhage in the males of
certain families.  With the exception of isolated cases by Benedic-
tus (1525), Hoerchstetter  (1635), published by Virchow, and a third
by Banyer (1743), the disease is not  further mentioned  in medical
history until by Otto, of New York, in the record of a bleeder family
in which the disease could be traced back for nearly a hundred years.
Other cases of families similarly affected were  soon reported in this
country.   Xasse published the first monograph in 1820.   Grandidier
succeeded in collecting six hundred and fifty authenticated cases in
two hundred and nineteen families up to 1872.
   Etiology.—The disease is transmitted chiefly by mothers to sons,
in whom  the fully developed form is twelve times more frequent
than  in daughters.  Males who are thus bleeders do not, as a rule,
transmit the disease ; but females, the offspring of bleeder families,
without  being  themselves bleeders, beget children some of whom
suffer or show pronounced haemophilia.  Various causes have been
assigned for this condition—lack of fibrin or of fibrinogenous elements,
superficial and vulnerable course of blood vessels, thin walls of ves-
sels, etc.  Nothing definite is known.
   Symptoms.—The condition  is usually accidentally discovered :  a
trivial lesion is followed by profuse, protracted, sometimes uncon-
trollable  haemorrhage.  The scratch of a pin, the extraction of  a
tooth, the operation of circumcision, the application of a leech, vac-
cination, excite a dangerous haemorrhage.
   Diagnosis.—Haemophilia is distinguished from the haemorrhagic
diathesis by the fact that it is hereditary,  that  it  occurs in the male
child, or that in either sex it has been observed in the earlier years
of life.   Spontaneous  haemorrhage  is much more frequent in the
haemorrhagic diathesis.
   The prognosis is grave.  In most cases  life is  cut short by un-
controllable haemorrhage.
   The treatment consists, essentially, in  prophylaxis, in the avoid-
ance  of  accidents, operations,  etc.   Surface haemorrhage may  be
controlled by compression, which must be unusually long sustained.
Haemorrhage from the nose may be checked by the tampon; haemor-
rhage from the lungs by the  subcutaneous injection of ergotin or
sclerotinic acid; hsemorrhage from the bowels by the acetate of lead,
half a grain to  a grain every two hours  ; haemorrhage from the ute- 
614
SCORBUTUS.
rus is best controlled by the insertion of tampons of iodoform gauze;
haemorrhage from the mucous membranes and internal organs by the
use of cold and styptics, ice, iron,  iodoform.  Manteuffel dee-lares
that the parenchymatous injection of a solution of cocaine. 0.5 per
cent, into the gums will always temporarily arrest haemorrhage from
this source by contracting blood vessels, and that  the application of
what he calls zymoplastic matter, a substance derived from the blood
itself, will arrest it more permanently.   The nutrition is  to be  im-
proved  in every way with cod-liver oil and iron, food and fresh  air.

                           SCORBUTUS.
   Scorbutus (low Latin) ; scurvy (from scurf).—A general disease,
characterized by cachexia, characteristic affection of the gums, haem-
orrhagic diathesis, and marasmus.  Scurvy is a disease which stands
in close relation to the character of the food, especially with the ab-
sence of fresh and  vegetable  food.   Improvement in the conserva-
tion and transportation  of  foods has led largely to its  extinction.
The disease prevailed in epidemic form  from the fifteenth to  the
eighteenth centuries and  in special severity in prisons, workhouses,
and barracks.   Scurvy  was a constant  disease of sea life ; a very
long voyage was attended with  the loss of a number of men.   The
disease still prevails under similar conditions, as in Paris during the
siege of 1870 and 1871, where  scurvy assumed epidemic proportions.
   Etiology.—Scurvy is distinctly connected with defective nutri-
tion, whether  in quantity or quality,  though the  exact relationship
of this factor  has not yet been  established.  Crowd poisoning,  ex-
haustion,  anxiety,  nostalgia, cold,  lack of sunlight, haemorrhage,
chronic disease, malaria,  tuberculosis,  gastric catarrh, anything
which tends toward inanition, predisposes to the disease.  Scurvy
is probably an infection,  but there is as yet no other proof  for  this
statement than the character of the symptoms.
   Symptoms.—Scurvy begins with debility, which manifests itself
in early fatigue, rheumatic pains in the loins  and legs, and is soon
associated with the pallor and depression of spirits which  belong to
a cachexia.  Scurvy may not be distinguished in this regard from
other cachexias until a characteristic  appearance shows itself in  the
mouth.  The gums are swollen by infiltration with serum  and blood.
The color changes from  red to dark blue ;  the spongy tissue easily
bleeds, and the loss of substance shows ulceration and necrosis, some-
times with deep destruction of tissue.  The surface is covered with
debris and detritus of excessively fetid odor.  The breath is defiled.
The swelling  of the gum confines itself  to  the region  of  the teeth.
Toothless places remain  unaffected.   Scurvy soon shows the imprint
of the general hsemorrhagic  diathesis.   Spots of hemorrhage, pe- 
SCORBUTUS.
615
 techise, purpura, appear upon the skin, sometimes as papules, lichen
 scorbuticus,  vesicles, bullae, pemphigus  or linear streaks,  vibices.
 Extravasations occur also in the deeper structures, especially in the
 lower extremities at seats of pressure or injury.  Free haemorrhage
 occurs from the various mucosae, from the nose,  bronchi, stomach,
 intestines, bladder, etc.  The  serous  membranes are likewise at-
 tacked.  Extravasation occurs in the pleura, pericardium, into the
 joints, and the various inflammations which may occur show a haem-
 orrhagic character.  Tissues thus infiltrated are easily broken down
 to suffer extensive  ulceration and destruction.   As the general weak-
 ness increases  the action of the heart is weakened, its diameters are
 increased, and systolic murmurs may be  heard  at  the base.  The
 pulse becomes  frequent and feeble.  CEdema develops at the ankles.
 Attacks of syncope are common.
    The diagnosis rests  upon the history of a cause, upon the cachexia
 and haemorrhagic  diathesis, but is  really  determined by the pecu-
 liar condition of the gums.
    The prognosis  is always serious, and depends largely upon the
 strength of the individual, the surroundings of the patient,  and the
 stage of  the disease.  It is  more favorable at sea because of the
 fresh air,  at least.
    Treatment.—The better means of food supply shows its effect in
 the diminution of scurvy, which is on the road to extinction.  The
 treatment is a  continuance of the means of prophylaxis—viz., the
 administration of an abundance of fresh food, and especially vegeta-
 ble food : fruits—oranges, lemons,  apples, etc.; vegetables—onions,
 lettuce, radishes, cabbage, sauerkraut, spinach ; greens—dandelions,
 etc.  Fresh meat itself may be  transported packed in ice or  may be
 substituted  by the various  extracts of beef.   The mouth must be
 disinfected with washes of peroxide of hydrogen, creolin, one-half of
 one per cent solution, and the spongy gums directly treated  with so-
 lutions of nitrate of silver one per cent, tannin in some form, as
 in the tincture of kino, catechu, preferably the tincture of  myrrh.
 A fine remedy for protection and  preservation of  the teeth is the
 preparation of thymol  devised  by Thomas.  The mouth should be
 first thoroughly washed  with  soap, with care  that the brush pene-
 trate to all crevices of the teeth, and thereupon with the following
 solution :
   3 Thymol..............................................   0.25
     Acidi benzoici................................................   3.00
     Tincturae eucalypti.. .........................................  15.00
     Alcohol ..................................................  100.00
     Spiritus menthae piperitae.-.............................. —   0.75
  M.  Add a sufficient quantity to a glass of water to make it milky. S.  Use twice
a day. 
616
MORBUS  ADDISONII.
This preparation kills all bacteria of the mouth within one minute.
The mouth should also be rinsed  out  with a  three-per-cent boric-
acid solution after each meal.
   Thymol is the best remedy in the treatment of a sensitive pulp
cavity from any cause,  or in any kind of caries, and is destined soon
to substitute the dangerous arsenical pastes.
   The aniline preparations, methylene blue 1 :100, penetrate deeply
and purify.  The strength must be supported by the judicious  use
of stimulants, the appetite increased by dilute hydrochloric acid gtt.
xij.-xv. in a wineglass of water, dilute phosphoric acid gtt. xv.-xxx.,
nux vomica gtt. x.-xx. in a tablespoonful of water.  The maras-
mus is met by malt extracts, especially incorporating  cod-liver oil ten
to forty per cent.

                       MORBUS ADDISONII.
   Addison's disease ;  Bronze  Skin  disease.—An affection of  the
suprarenal capsules, distinguished by a peculiar discoloration of  the
skin, progressive cachexia, and marasmus.
   History.—Schotte (1823) and Bright (1831) reported cases of this
affection,  which were, however, only distinctly separated by Addi-
son (1855).   Ranking and  Taylor (1856) reported the first cases in
this country.
   Etiology.—The disease is rare.  Males are twice as  frequent
subjects.   The majority of cases occur between the ages of twenty
and forty.   It has been noticed to follow injuries.   The cause is
assumed to  be a  degeneration  of the suprarenal capsules, which
may be independent  as a fibroid change,  but  is  more  frequently
dependent upon tuberculosis as  a caseous change.  The condition of
the suprarenal capsules has been  also considered as an effect  of
disease of  nerve ganglia, especially the  plexus coeliacus.  In certain
cases the  suprarenal  capsules have been found to be affected with
carcinoma.
   Symptoms.—The disease is said to stand upon a tripod of  symp-
toms—to wit, discoloration of  the skin, progressive anemia, and
degeneration  of the suprarenal capsules.  Any one of these con-
ditions may be present  or absent in certain cases.  Addison associ-
ated with these symptoms general languor and debility, feebleness of
the heart's action, and irritability of the stomach.  The discoloration
assumes a bronze, that is, a greenish-brown, tint, but varies in shade
from light yellow to dark brown or black.   The pigment is deposited
in the deeper layers of  the rete  Malpighi.   Sometimes it is diffused,
but is  usually most marked on the surfaces naturally most deeply
pigmented—nipples, scrotum,  penis.  For  obvious reasons it is first
seen in the face.  The various mucosae are  also discolored; spots are 
MORBUS ADDISONII.
617
seen upon the lips and cheeks.  The vagina is often deeply tinged. The
serous membranes have been found bronzed.  The sclera usually es-
capes.  The bed of the nails remains white.   The discoloration usually
comes on later in the history of the disease,  and is preceded by a
period of debility.  Anaemia and cachexia gradually develop, usually
without much loss of flesh, and in association with them anasarca,
dyspepsia,  gastro-intestinal catarrh.   Rheumatoid pains are fre-
quent.  Symptoms on the part of the nervous system are prominent.
Languor  increases to depression; in the later period of the disease
there are sopor, delirium, convulsions, and coma. Patients succumb
slowly to marasmus, sometimes suddenly to heart failure.
   The pathogeny is obscure.  All attempts to locate the origin of
the disease in the suprarenal capsules would seem to have been nul-
lified by the experiments of Nothnagel, who found no changes in one
hundred and fifty-three  animals after  total  extirpation of these
bodies.  On  the other hand. Lewin  found actual tuberculosis of the
adrenals in  two hundred  and eighty-five of  three  hundred  and
seventy cases, and in the remaining eighty-five cases no disease of
these organs   It is  therefore not improbable that  other affections
have been included under  the term  Addison's disease, and  that the
malady pur et simple is, as Addison declared, a degeneration of
these bodies.  Brown-Sequard long ago ascribed to the suprarenal
bodies  the function of converting  pigment into colorless matter.
The failure of the symptoms after extirpation of the adrenals may
be  explained  by the  fact  that  the animals  were not  kept long
enough, as Tizzoni found that in rabbits kept alive two and  three-
quarter years after crushing of the adrenals  similar pathological
pigmentation  developed with multiple degenerations  in  the  spinal
cord.
   The diagnosis rests upon the train of symptoms mentioned: the
asthenia, discoloration, gastro-intestinal catarrh, progressive cachex-
ia, ansemia, and marasmus.   The presence of no single factor, not
even  the discoloration of the skin, is necessary to a diagnosis.   The
disease must  be  distinguished from the discolorations caused by
tumors in the abdomen, pregnancy, disease of the uterus and liver,
chloasmata, as well as from that deposit of pigment which occurs in
connection with pediculosis and from the peculiar  discoloration of
nitrate of silver.  The lack of associate symptoms suffices to make a
diagnosis.
   The prognosis is  fatal.  The disease lasts from a few weeks to
several  years.  The average duration  of life  is a year and a half.
The course is longer, and to this extent the aspect more favorable, in
cases where the bronze discoloration is  most pronounced.   Recov-
eries are considered proofs of mistake in diagnosis. 
618
GOUT.
   The treatment  does not differ in any way from that of anaemia
and cachexia from  other cause.  Rest of body and peace of mind,
with favorable hygienic surroundings, may materially prolong life.

                              GOUT.
   Gout {gutta, a drop).—A disease caused by the instillation into
the joints of uric acid ; characterized by pain in paroxysms—first in
the  big toe, later in other joints—later by deformities of the joints,
affection of the heart and kidneys (atheroma), and marasmus.
   History.—Gout is a disease of ancient recognition, though the
term itself is comparatively modern.  It was known at the time of
Hippocrates  as " podagra," and prevailed with such frequency in
the  opulent  days of  Rome as  to have  attacked  women as well as
men.  Lucien  named one  of  his  characters Podagra.  The  term
gout dates from the days of humoral pathology.  It has an  origin
of the same significance as rheumatism and catarrh,  in that the
peccant humors which float  about in the  blood come to be distilled,
drop by drop (guttatirn, gutta. a drop), into  the joints.
   However  much our views  of disease processes have changed
since the days of humoral pathology, gout still holds its place as the
distillation of an acrid humor from the blood.  While all the other
diatheses have failed and fallen to the ground,  the  gouty diathesis
remains.  An increase of uric acid in the blood, a deposit of uric
acid in the joints,  from kidney fault (Garrod),  from  local cause
(Ebstein), constitutes the pathology of gout.   This discovery, due to
Wollaston (1798), constitutes the keystone of our knowledge regard-
ing gout.   All other theories must conform  to this central fact.  It
was  Sydenham who first separated gout from the rheumatisms. The
graphic descriptions of Sydenham were founded upon not only per-
sonal observation, but personal experience ; and the fact was noticed
by him as a matter of comfort that individuals of the upper rather
than the lower class are the victims of this disease.   " Great kings,
emperors, generals, admirals,  and  philosophers have  all  died  of
gout," which, "unlike any other disease, kills more rich men  than
poor, more wise men than simple."  In  our day this fact is a poor
consolation, for it  is, as Fagge says, robbed of its virtue, because
life-insurance examiners put a higher premium  upon, or absolutely
refuse insurance on, the* lives of gouty patients.
   Etiology.—Gout occurs for the most  part in the latter period of
life,  with increasing  frequency from forty to sixty;  exceptional
cases at sixteen and eighteen have been put upon record, such cases
also  at eighty, but the disease rarely  originates after sixty-five.
Cases in advanced life are survivals.  Gout is a hereditary disease.
Statistics of the most competent observers—Garrod, Scudamore—put 
GOUT.
619
the proportion at from one-third to one-half.   It has  been remarked
that the eldest  members of the family suffer more uniformly and
more severely, as the younger members, observers of the  sufferings
of the disease, refrain from excitants to some extent.
   Gout is a disease of high livers, of  rich animal food with abun-
dant libations of alcohol, of  food more  especially which is highly
seasoned, of wines with rich aroma. So gout may attack the young.
It may  also attack  those who  are more  advanced in age, even
though of  abstemious habit, through heredity—sometimes as  the
only inheritance, the fortune  having  been  spent  in  its acquisition.
Workers in lead, more especially  plumbers, painters, and printers,
are predisposed to gout.
   Uric  acid injected into the blood in health is speedily converted
into urea and eliminated.  The excretion of uric acid varies in health
between three and fifteen grains per  day, and is subject to much
greater variation with changes in diet, exercise, etc.   It is therefore
difficult to establish estimates of  quantities which will produce dis-
ease.   Nevertheless Pfeiffer  ascertained  by careful  measurements,
taken with every possible precaution, that  patients with acute gout
excrete more, and patients with chronic gout less, uric acid than in
health.   Rich foods, especially the albuminates, in excess, overload
the blood with acids and diminish its alkalescence, a condition which
favors the  conversion of the urates into urea.
   Symptoms.—The attack occurs for the most part  suddenly.  The
patient retires in his usual health, sometimes  with exaltation of
spirits, more frequently with  more  or  less  depression, the result of
dyspepsia with its train of distress, and is  awakened in the night,
between midnight and morning,  with  pain localized, as a  rule, in
the big toe joint.  The pain  is at first an uneasiness, soreness ;  the
patient moves his foot about, extends it, withdraws it, protrudes it,
in the vain effort  of seeking a  comfortable position.   Sometimes
there is  a feeling as if tepid water  were  poured over the joint.
There is no finding  a comfortable position.   The pain increases, be-
comes excruciating ;  the patient feels as if the joint were penetrated
with hot irons, were  twisted,  crushed  in a vise.   The  slightest agi-
tation of the room or of the bed, the rumble in the streets, exaggerates
it  and  irritates the  patient beyond expression.  In the course of half
an hour  to two  hours the pain begins to diminish, sometimes with
diaphoresis, sometimes with  diuresis.    The  patient begins to feel
that he has at last found a comfortable position, the pain dies away,
the patient falls asleep, to be awakened in the morning, after rather
protracted  sleep, entirely, or almost entirely, free of pain.   On in-
spection of the joint it is seen now to be reddened, swollen, tender,
limited in its movements. The skin pits upon pressure.  The patient 
62n
GOUT.
is able to  resume his avocation.  On the following night tlu1 whole
condition  may reappear, or not for several nights, or a fortnight,
sometimes not for months or a year.   The. interval will  depend
largely upon the habits, especially regarding self-denial.   As a rule
the first interval is the longer.  The  patient profits by the first les-
son for a time until indulgence renews the attack.  The disease now
extends to involve other toes, to affect also the joints of the fingers,
to extend  afterward to the ankles  and wrists ;  but in however great
extent or severity, it never, or almost never, affects the largest joints,
the hip and shoulder.  As the disease repeats itself more frequently,
the attacks become comparatively milder.   The  interval  grows
shorter, but the individual attacks are longer.  Finally the inflam-
mation about the joints never does entirely subside.   (Characteristic
deformities supervene, and with these  deformities are associated
chronic gastric catarrh with its  attendant evils, affections  of the
kidneys,  atheromatous changes, functional  and organic heart
Fig. 261.—Gouty fingers.
affections.  The patient now becomes more or less emaciated, irri-
table, morose.  On the other hand, in some cases the bien-etre re-
mains.  The florid  face from paretic capillaries or acne rosacea, the
sluggish circulation,  the dull expression, indicate the adeliction  to
high living with its corresponding degradations.
   Cases of chronic gout present characteristic deformities about
the joints.   The  swelling  of the acute attacks subsides often  to
leave no trace, but as the disease becomes more  and more chronic
the swelling does not entirely subside ; it  abates, but does not dis-
appear.  The  fluctuation gives place to a doughy sensation, the
matter instilled into the joint becomes thicker and thicker as its fluid
elements are absorbed.   It becomes also more irritating, breaks the
skin, at times to show an ulcer or an abscess from whose surface or
interior oozes a substance  of mortar-like consistence, composed
almost exclusively of the urate of sodium.   These ulcers are exceed-
ingly refractory.   They continue to discharge, with quiescent inter-
vals at times, for months or years  or for the life of the patient. 
GOUT.
621
As a result of the depositions of this salt into  the  joint the articu-
lating surfaces are deformed, the joint becomes dislocated; various
anomalous positions are thus assumed.   A common habitus is that
of forcible flexion of the fingers at the second or third joint, with
exception of  the first.   The first knuckle is represented by a depres-
sion.  Sydenham says the fingers look like a bunch of parsnips.  The
same alterations occur about the feet, about the  toes, and deformities
of the wrist and ankles may incapacitate the individual for the needs
of life.   These tophi, erroneously called chalk stones, occur also, as
stated, in any joint distant from the
circulation, about the  ear, and va-
rious portions  of  the  skin,  at  any
one of which an ulcer may form.
    Diagnosis. — The   tendency to
gout is indicated by dyspeptic states,
pressure at the praecordium, palpi-
tation, numbness of the extremities,
with itching and eczema of the skin,
neuralgias or pains  anywhere,  mi-
graine, insomnia, asthmatic attacks.
The sudden  occurrence of conjunc-
tivitis,  iritis, or corneal ulcer be-
tokens attack in some people,  and
hitherto  inexplicable cases of any of
these affections become not only in-
telligible hut  curable when inter-
preted as  premonitions or  prodro-
mata of gout.
    Gout is distinguished from arti-
cular rheumatism by the fact  that
it attacks age rather  than  youth.
The history of heredity and high
living gives  some help. The char-
acter of the  onset in  one joint,  especially the big toe  joint, is very
different from that of implication of multiple joints, more especially
medium-sized joints, of acute rheumatism.  Gout remains fixed; rheu-
matism flies  from joint to joint.   Rheumatism is a disease of inde-
finite but of  shorter duration ;  gout is for the  most part a lifetime
malady.   Gout shows much  less fever, and the  fever in gout is more
directly proportionate to the extent of the local inflammation ; where-
as there may be in rheumatism  much fever with little inflammation,
or much  inflammation with but  little fever.  Gout is more especially
attended by gastric disturbance; in rheumatism there may not even
be anorexia.  Gout affects the  kidneys and heart with cirrhotic and
Fig.
Tophi in the joints and tendons. 
622
GOUT.
atheromatous change;  rheumatism affects the serous membranes.
Rheumatism yields more readily to treatment, gout more readily to
diet and regimen.
   Gout distinguishes itself from  chronic  rheumatism by the fact
that gout  affects small  joints,  chronic rheumatism  large  joints.
Chronic rheumatism shows no  fever  and is  unattended with any
cardiac or renal changes.  Chronic rheumatism is more unamenable
than gout to treatment.
   The disease  which is most frequently confounded with gout is
arthritis deformans.   The following points draw the lines of distinc-
tion: Gout affects most frequently males, arthritis females.  Gout
chiefly affects the upper, arthritis the lower classes.  Gout begins in
the toes, arthritis in the fingers.  Gout swells and  dislocates  the
joints of the big toe and afterward of the other toes.  Arthritis com-
mences by preference in  the fingers, which it  also swells and dislo-
cates, as a rule in a  more regular way, so as to imbricate the joints
of the  first  three fingers,  pointing  the fingers  toward the ulna.
Gout, when  it affects the hand, does  not to the  degree of arthritis
spare the thumb.  The  deformities of arthritis are produced by out-
growths of bone; of gout by deposits of sodium urate.   So-called
cases of rheumatic gout  are supposed to represent mixed forms or
coincident  attacks.   The possibility of such a  condition may not be
denied, but an autopsy  decides always in favor of one or the other.
In a doubtful case the blood may be examined for urate of sodium.
If two drachms of blood serum be slightly acidulated with acetic acid
in a watch glass and a linen thread be suspended  or laid across the
glass, the thread will be found after twenty-four hours covered with
crystals of uric acid.  Uric acid  may also be crystallized out of the
fluid of a blister not too near the joint.  It is needless to say that this
excess of uric acid cannot be detected in rheumatism in any form or
in arthritis deformans.   It belongs exclusively  to gout.
   Prognosis.—Gout is  in itself not especially dangerous.  It is
dangerous only in the remote  consequences  which its  persistence
may entail.  All cases  of acute gout recover,  and the future of the
case depends largely upon the habits of the individual.  On the other
hand, where the hereditary taint is strong or  the conditions of life
exclude proper hygiene, where gout becomes chronic, the duration of
life is abbreviated by disease of the kidneys, heart, or brain.   It may
be said, therefore, that the prognosis of acute gout is good, of chronic
gout is bad.
   The treatment depends, first, upon the regulation  of life.  The
sedentary  avocation  must  be changed; the  gouty patient  should
walk,  or, better, should ride horseback.  Conditions which tend to
obesity, sluggishness of circulation, constipation,  must be overcome. 
ARTHRITIS DEFORMANS.
623
 The diet should be simple, plain, and homely food.  Meat should be
 taken but once a day, vegetables without rich sauces.   Alcohol must
 be put under ban.  The time may come in chronic gout when a glass
 of Rhine wine  or claret may be necessary, but as a  rule the best
 drinks are water and milk.  Sydenham lamented that he might not
 live to witness the discovery of a specific for gout.   Not many years
 after his death a remedy was sold, under the name of Eau  Medicinal,
 which proved of  such virtue as to seem almost specific.   The active
 principle of this  remedy  was discovered  to be colchicum. meadow
 saffron; and colchicum in its alcoholic  preparations soon came into
 general use in the treatment of gout.  Watson vaunted  its virtue.
 The remedy was given as the wine of colchicum,  gtt.  x.-xl. two or
 three times a day, in association with or followed by a saline laxative.
    Mineral  waters—the alkaline  mineral  waters—largely  aid the
 treatment,  and sometimes suffice to make a cure without colchicum.
 The waters of Vichy and Carlsbad, and waters containing lithia, are
 of especial value.  The ordinary Carlsbad salts,  containing large
 quantities of the sodium  phosphate,  are a remedy justly in general
 use.   A glass of  cold water containing a teaspoonful of  this salt is
 taken three or four times a day.  After the discovery of the salicy-
 lates it was soon  found that these preparations had all the virtues
 without the vices of colchicum.   Colchicum in a dose too large, or
 in a stomach too irritable, produces nausea, vomiting,  diarrhoea.
 The salicylates are not attended with  these evils, and choice may be
 had, with reference to the condition of the stomach, of the salicylate
 of soda, salicin, or salol.   Piperazin  is a powerful  solvent.  It dis-
 solves twelve to fifteen times as much uric acid as lithia. It is given
 best in tablets, fifteen grains per day,  or in large quantities of water
 (soda water, Vichy, etc.), always in itself a valuable adjuvant.  It
 is especially indicated  in  cases complicated with gravel or kidney
 stone.  A good fluid preparation is:
   B  Piperazini puri........................................ .....gr. xv.
      Syrupi aurantii corticis.......................................3  v.
     Aquae destillatae.................................  ..........§  v.
   M.  S. The whole quantity to be taken during the day.
 The remedy is not injurious in any way in twice or thrice the dose.
   Envelop the joints in cotton.  All other local treatment is useless.
 Energetic patients cut an  attack short by getting out of bed and
going about as soon as possible.

                     ARTHRITIS DEFORMANS.
   Arthritis deformans ; rheumatic gout; nodular rheumatism ; ar-
thritis sicca ; arthritis pauperum;  poly panarthritis.—A disease char-
acterized by progressive, symmetrical deformity of the joints. 
624
ARTHRITIS DEFORMANS.
   History.—Arthritis deformans existed from the most remote an-
tiquity.  Chiaje, of Naples, saw the deformities  in bones  exhumed
from Pompeii.  Lebert described the same changes in skeletons found
in the catacombs of Rome, and Virchow in the joints of bodies  dug
up in an ancient monastery of Pomerania.  The  old writers consid-
ered it simply a form of rheumatism, and Sydenham, who sepa-
rated gout, was content to relegate this form of arthritis to the rheu-
matisms.   Hay garth, who suffered from  it, wrote the first classical
description, and the Irish surgeons, Smith, Colles, and Adams, dis-
tinguished it  from surgical affections of the joints and gave it a sepa-
rate place.
   Etiology.—The disease distinguishes itself by peculiar alterations
of the joints, by an affection of all  parts of the joint, and also by
gradual implication of  all the joints.   Hence the propriety of the
synonym of Hueter—polypanarthritis.   Arthritis deformans is a dis-
ease of age rather than maturity, though it may occur earlier in  peo-
ple in whom  age is precipitated, as by alcoholism, atheroma,  etc.
Women are the greatest sufferers, and the poorer class, with many
exceptions, is oftener affected.  The disease  sets in in two ways.
First, and more commonly, it attacks the smaller joints, with a  spe-
cal predilection for the joints about the hand, the metacarpophalan-
geal joints ; next, it affects the largest points, the joints of the verte-
brae and the hip joint.
   In the great majority of cases it commences in the smaller joints :
but,  whether  it commences in the smaller or in the larger joints, the
natural tendency of the disease is to  extend symmetrically until  it
involves them all. Various theories have been propounded to account
for its origin.  1. The mechanical theory is that the alterations about
the joints are due to trophic changes, because of mechanical pressure
at the escape  of  the nerves from  the  intervertebral  foramina.   In
this  explanation it is implied that the bones of the  vertebrae suffer
first, which is by no means the case, even as a rule.   2.  The chemi-
cal theory, that there  circulates  some  poison in the blood which
expends itself upon the joints after the manner of rickets  and lues.
3. The neurotic theory, which implies some affection of the spinal cord,
whereby the bones and joints suffer trophic change.   Support is lent
to this view from the well-known alterations in the bones and joints
which occur in certain cases of locomotor  ataxia.  Charcot, Bene-
dikt, and  Remak favor this view.  But the changes  which  occur  in
locomotor ataxia are more especially absorptive changes affecting
particularly certain joints, the hip and the knee, and then in only a
very small minority of cases.  The evidence in favor of the neurotic
theory of the disease is based mainly upon the fact that the disease
occurs about  the period of degenerative change and that it is distri- 
ARTHRITIS DEFORMANS.
625
 buted over the body symmetrically.  The real cause remains  as  yet
 unknown.
    Symptoms.—Arthritis deformans declares itself for the most part
 insidiously.   Cases have been reported in which, after depressing
 mental emotion, more especially prolonged sorrow or grief, dejection
 from financial  strain, domestic infelicity, etc., arthritis deformans
 has developed in the course of a few weeks, but for the most part  the
 disease sets in very gradually.  There is  noticed, first, a want of
 deftness and dexterity of the movements of the joints,  remarked
 more especially in artisans and mechanics, fine lace and needle work-
 ers, piano players,  etc.   The fingers do not respond ;  the fine, edu-
 cated  movements,  which have become more or less automatic,  lag
 behind.   There is stiffness, more especially noticed in the morning
 upon rising from bed, to pass away with exercise of the  body ; later
 it becomes more marked and more  permanent.   Soon—that is, in  the
 course of months rather than weeks—characteristic deformity shows
 itself, in that the metacarpo-phalangeal joints become swollen, ten-
 der, stiff.  Partial luxation occurs later  from the  changes in the
 bones.  The  fingers are  extended and  flexed upon the hand, and
 come to lie over each other, to assume an  imbricated  arrangement,
 pointing  usually toward the ulna, more exceptionally toward the
 radius.  The position of the hand is now quite peculiar : it assumes
 something of the position of a bii'd's claw when first lifted from the
 perch.  As the deformity advances more or less complete dislocation
 of the joints ensues.  Other joints of the fingers swell,  rendering ex-
 tension even more pronounced, so that at times the hand has the ap-
 pearance  of being turned over. Atrophy sets in in the  muscles. The
 hand is crippled ; it is also wasted.   All the while, however, as a
 rule, the  thumb remains unaffected,  and  by its range and  power
 makes up in great degree for the loss of movement of  the hand,  so
 that the patient is still able to perform many,  even delicate,  move-
 ments.
   Strange to say, when the foot  becomes involved,  which  is the
 case often  simultaneously, oftener subsequently to  the hand, the
 big toe is  the joint  first affected.   The metatarso-phalangeal joints
 become dislocated in the  same way as in the hand.  The  big toe
 joint is swollen,  tender, and stiff—a deformity noticed  but little, be-
 cause the foot is limited by its dress, but noticed on  account of the
 pain from pressure.  The shoe pinches, bunions form, the disease
 then involves other toes, and the nature of the affection is unmistak-
 able.  Thereupon it extends to involve the wrist,  the elbow, the
 shoulder,  and gradually,  in the course  of years, more distant articu-
 lations.   Finally the joints of the ribs,  the clavicle, the jaw may  be
affected, but the disease advances rather by exacerbation and abate-
        40 
626
ARTHRITIS  DEFORMANS.
me lit than continuously.   There are periods of acute inflammation,
short in duration, followed by long periods of arrest  or  quiescence,
each exacerbation leaving, as a rule, some, perhaps almost impercep-
tible, additional lesion.  The individual finally becomes hopelessly
crippled.   He may no longer dress himself, feed himself ; the body
takes the position of the chair in which it  rests.   For a time after
the individual has lost the power of motion he may help himself with
canes, with crutches, with wheeled chairs, to which he finally  be-
   Fig. 263.—Arthritis deformans. Section of cartilage of head of femur, X 40. a, hyaline'car-
tilage ; b, hyaline cartilage with exuberant cartilage cells; c, c, abraded cartilage ; d, clefts in
cartilage ; e, spots of softening ; /, cartilage calls ; g, new marrow spaces ; h, new, i, old bone tis-
sue ; k, old marrow spaces ; I, osteoclasts CZiegler).

comes locked, and must be lifted from the  chair to the  bed, and at
last must even have assistance to be turned in bed.
   The characteristic feature of the disease is the deform it y.  Irreg-
ular changes of all kinds occur in the bones and the joints.  Bony
outgrowths, exostoses, protrude about the joint to cause dislocations,
to swell the heads of bones,  to obliterate  cavities.   Exacerbations
make new cavities.  Striations occur from friction ; sometimes such
stimulation as to harden the bone to produce eburnations.  Harden- 
ARTHRITIS DEFORMANS.
627
ing and  softening go side by side, eburnations and porosities, until
at last the natural outlines of the bone are almost wholly destroyed.
   The cartilages suffer in the same way, now in certain places, now
in others.   The  capsules, the  tendons, finally  the muscles  which
move the joints,  become atrophied from disuse, so  that in extreme
cases the individual presents a characteristic  appearance : the body
is more  or  less emaciated, the joints are locked.   Atrophic condi-
tions occur  also in the skin, and sclerodermatous patches, more par-
ticularly surfaces of glossy skin, are not uncommon.  All the while
the sensorium is unaffected, the digestive system may remain unim-
paired, the  respiratory apparatus unattacked, the heart's action un-
affected.  For the most part, however,  patients  become, on account
of their  sufferings, irritable; there is a tendency  to  hypochondri-
asis;  there is  constipation : there is  more or less impairment of
the appetite and digestion, yet appetite and digestion continue to
suffice for the reduced wants (motions)  of the body.
   Diagnosis.—The disease is  distinguished from acute rheuma-
tism by  the fact that it  attacks  the aged, and  more  especially the
female sex ; that it remains fixed in the joints which it attacks, and
produces permanent deformities ; that it is unattended with sweating,
with fever,  except in the acute complications, and with cardiac dis-
ease.   It is  distinguished from chronic rheumatism by the affection
of so many  joints, chronic rheumatism being confined to one or a
few ; by the attack of the smaller joints; by the  peculiar deformity it
produces in  the smaller joints; by its universality.  Distinction from
gout, which it most closely simulates, has been described under gout.
   The prognosis quoad vitam is good ; most patients  die of old age.
Haygarth wrote his description of his own case at eighty.  The prog-
nosis quoad valetudinem  is bad, in that in  the great majority of
cases the disease is permanent.  It may be controlled, but not cured.
   Treatment  must  be  general  rather  than local :  warm  baths,
travel, sojourn in the South in winter, in the North in summer—
i.e.,  ability to pick the climate in which the individual suffers least,
as in the pine regions (Georgia, the Carolinas), on islands (Nassau),
in the mountains, Virginia, Maryland rather than Colorado, or some-
where in the varied  climate of California.   Locally the progress of
the disease  may be stayed  by  gentle  friction, massage.  Flying
blisters in the more chronic cases are  often of  value.  Electricity,
the galvanic current more especially, is  of occasional service.  As to
drugs,  the most good is accomplished by arsenic.   Small doses are
to be given  over a long  time, that the  action of the remedy  may be
sustained.   Iodine has long had  a reputation, more, really,  than it
deserves.  It was first  used by  Lasegue, Trousseau's assistant, in
the form of the  tincture, ten drops three times a day, but is best 
628
RACHITIS.
administered in the form of iodide of potassium or sodium with milk,
in small  doses long continued.   Salol, the salicylates,   salipyrin,
have over the acute exacerbations the quickest control.  Phenacetin
may suffice to control pain.

                            RACHITIS.
   Rachitis;  rickets.—A disease of childhood, seven months to seven
years, characterized by disturbance of digestion, bronchial catarrh,
with characteristic  changes in the skull, chest, and bones of the ex-
tremities.
   History.—Glisson, a distinguished anatomist and physician of
the seventeenth century in England, called this disease rachitis partly
because of the popular name rickets for a disease marked by deform-
ity of  bone,  and partly in deference to the Greek word racJiis
{paxi?), the spine, because of the distortions produced in the dorsal
chest.  The disease had long been known by the people and had at-
tracted the attention of physicians, more especially of the counties of
Devon and Somerset, in England.  A prominent English physician,
Whistler, described it as a disease of  English  children, and Conti-
nental writers took  it up  as an English disease,  though the changes
characteristic of  it had been  recognized in bones almost from  time
immemorial, and are perpetuated in one notable statue, that of the
famous .^Csop.
   Etiology.—It is difficult to assign rickets to its proper place in
nosology.   On account of  the prominence of the bone deformities,
especially in the neighborhood of the  joints, the disease is generally
discussed along with the  rheumatisms.  Because of the general dis-
turbances which precede and accompany it, it is sometimes given a
place by the side of tuberculosis and lues.  The  tendency in our day
is to put it among the chronic infections of the  blood by the side of
tuberculosis and syphilis.
   Inasmuch as most of  the main deformities of  the disease can be
accounted for by the softening of the bones, it was early supposed
that rickets resulted from  an insufficiency or a reabsorption of the
lime salts.   Chossat and  Milne-Edwards withheld the lime salts from
young animals and observed marked  deformities in the build of the
bones;  but Friedleben, who repeated all these experiments, observed
that while these  deformities do occur, they are evidence rather of
malnutrition and are not  the  characteristic deformities  of rickets.
Guerin advocated the theory of malnutrition, and he, too, proved it
by withdrawing young  animals, puppies, from their mothers and
feeding them with  meats.   Here too, however, the  changes which
occurred are to be ascribed, according to Tripier, to malnutrition and
not to rickets.  Wegleben  declares that if phosphorus in small quan- 
RACHITIS.
629
 tities be administered to animals from whose diet the lime phosphates
 are withheld, changes occur exactly like those of rickets.
    Bone Changes.—These changes affect chiefly the  ends of the
 bones.   They grow larger to such degree as to overlap the joints as if
 by condyles.  This development gives the appearance of the double
 joint which the disease is sometimes called.   The enlargement  is
 most observed where bone unites with cartilage, and is  seen in  most
 distinctive form at  the junction of  the ribs with their cartilages.
 Thus a line of nodules may be traced downward and outward from
 the first through the successive ribs to constitute what is known as
 "the rosary,"  or the beads of the  ribs.  Elsasser (1843) contri-
 buted an important fact to our knowledge of rickets in  the observa-
 tion that the bones  of the skull, especially the occipital bones, be-
 come softened in places.  The condition is recognized  by palpation
 of the  head with the whole  hand, with alternate pressure of the
 fingers,  whereby spots of softening, the so-called craniotabes, are
 recognized, especially about the lambdoidal suture.  Rickets shows
 characteristic deformities in the shape of the skull.  The fontanelles
 close late, sometimes not until the end of  the second or third years.
 The head fails,  therefore, to assume its natural ovoid shape.   It  is
 flat on  top, the  frontal eminences  protrude, the eyes seem  sunken.
 It is claimed that the precocity of rickety children is due to the easier
 expansion of the skull.  Fagge says this fact, if it be a fact, is  more
 readily explained by the confinement to the house  of these children,
 their closer association with adults, and, we might add, more con-
 stant resort  to  books.  The skeleton of rickety children is always
 short, hence the stature  is diminished.  Most dwarfs are victims
 of rickets.  Of  all the  specimens examined by Ritterhein,  but one
 came up to the normal standard.   The bones of the face are also ar-
 rested in development.   The face  seems a mere  appendage to the
 enlarged head.  The jaw  is narrow.  Dentition is late ;  the teeth,
 stunted, imperfectly covered by enamel, decay early.   On  account
 of the softening  and elasticity of the bones of the ribs the anteropos-
 terior diameter  of the  chest is increased.  The sides are flattened,
 the sternum  protrudes  to constitute what is known as  '' the pigeon
 breast."  The great glands, the liver and spleen, sink or are pushed
 below the level of the ribs to give undue prominence to the abdomen.
 The pelvis is deformed so that its  conjugate diameter is shortened ;
 or other deformity ensues from pressure, as in support of the  child
 upon the arm of the nurse, or even from long-continued decubitus.
 The bones of the arm yield outward, as do also  the bones of the legs,
to such  a degree as to constitute what is known as bowlegs.   Most
of the aggravated cases of bowlegs in  children are due to rickets.
Rickety bones also are apt to break, especially with a vitreous or 
630
RACHITIS.
green stick fracture.  Serious changes take place also in other organs
of the body.
   Symptoms.—Rickets announces itself for the most part by symp-
toms  which  may antedate  the  deformities  of bone  by weeks or
months, to such degree often that the early recognition of the disease
may prevent or limit subsequent changes.  Thus disturbances of di-
gestion, anorexia, diarrhea, constipation,  or disturbances of the
respiratory  tract, catarrhal affections  and cough,  may  precede
more distinctive symptoms for several weeks or months.  The symp-
toms  may simulate the  advent of tuberculosis, basilar meningitis,
and all the more from the fact that the ages affected are about the
same.  It is soon noticed that the rickety child is restless at night,
                      1                        2
   Fig. 264.—Deformities of rickets.  1, thigh of adult with rachitic deformity of diaphysis ; 2,
thigh of adult with rachitic deformity of lower epiphysis.

kicks off the covers, tosses about the bed uneasily, in marked contrast
with its former quiet state.
   A symptom  of more  value  is  sweating, which occurs without
provocation, which is not  to be accounted for by the  heat of the
weather or by bedcovers.  The sweating is  all  the  more readily
recognized because it  attacks more especially the head and neck—
exposed parts of the body.  It is observecLalso that rickety children
are sensitive to pressure and to manipulation.  They do not relish
being fondled, dandled on the knee, or  tossed.   It is plain to see that
any rough manipulation gives pain.  The observance of any of  these
conditions—restlessness at night, sweating of the head, sensitiveness 
RACHITIS.
631
—should excite the suspicion of rickets, which may be confirmed or
refuted by examination of the bones.  Rickets often announces itself
so insidiously as to be  preceded  by no observable change, so that
the disease becomes manifest only with the deformity of bone.
   On the other  hand,  the existence of  the disease in  even ad-
vanced or rapidly advancing, and still  unsuspected form, is made
manifest at times by a violent spasm,  more  especially  a  larynyo-
spasm.  Spasm of  the  larynx  belongs in nine-tenths  of  cases to
rickets.  The spasm occurs suddenly, in the day or night,  as the child
awakens from sleep, as it is moved, lifted, as it is carried,  as the light
is admitted to the room, as it is fed, on the approach of the spoon, as
it is being examined, in some contact with the throat.  Suddenly the
glottis closes, and is held closed  so that no air whatever enters the
chest.  The spasm may extend from the glottis to involve the mus-
cles of the neck and jaws, or, indeed, of the whole body to present the
appearance of tetanus.  Such spasm is well to be distinguished from
the spasmodic closure of the larynx in laryngismus stridulus, or false
croup, where air may still enter with a long-drawn, stridulous, or
crowing sound like that of true croup.   In the croup case the closure
is partial; in spasm, complete.  False croup yields to a  hot bath, to
bromides, or to an emetic—remedies which cannot even be brought
to bear in the treatment of spasm of the larynx in rickets.
   The diagnosis is easy if the existence of the disease be suspected,
but is confirmed only by the presence of the  characteristic changes
in the bones.
   Prognosis. —Rickets  is a disease which, undisturbed,  runs a ldhg
course.   It terminates spontaneously usually about the end of the
second, sometimes not until the  sixth or seventh year,  but may be
cut short, as a rule,  in a few months by proper treatment.  It has in
itself no mortality.  Fatalities are from complications—spasm of the
larynx, true croup, bronchitis, pneumonia, etc.
    Treatment.—While it  may not be said that malnutrition is the
essence of rickets,  it is certainly true that in most cases errors of diet
can be discovered.   Sometimes the child is weaned too  soon, some-
times it is nursed too long, more  frequently it is fed  prematurely
upon starchy food or meats, eggs, etc.  That these dietary errors are
insufficient to cause the disease is proven by the fact that many chil-
dren of the poor, under the grossest errors of diet, escape it.  Rickets
is almost unknown in high altitudes and  in the polar regions, places
where children  are fed  in the coarsest way.  It is, however, true
that the error of diet acts as an excitant to the cause of  the disease,
whatever it may be, and that correction of this error plays an impor-
tant role in treatment.
   Where the child may not be  nursed by its mother,  a wet-nurse 
632
RACHITIS.
 should be obtained ; but where this is not possible, as it is not pos-
 sible in the rule, a child should be fed with cow's  milk properly di-
 luted, or, if older, the diet must be regulated with  a proper selec-
 tion  of meats, vegetables, and fruits, especially  orange's, lemons.
 and  grapes, later  apples and cherries.  Green things are essential
 in the treatment of rickets.   Erroneous  postures  must be relieved.
 Nurses are to be enjoined to change the decubitus from side to side,
 and not to permit too long repose upon the back of the head.  Mat-
 tresses and pillows should be soft.   So,  also, injunction should be
 entered as to  the mode of carrying children,  that the bones  of the
 pelvis be not  too  much compressed.   Rickety children are to be
 restrained in  efforts  at  early walking, or traction with the hands,
 that bone deformities be limited  or prevented.   After the  bones be-
 come hard in the further course of the disease, these methods are of
 no avail.   Resort must be had in extreme cases to exsections, more
 especially wedge-shaped exsection of bones, in the  correction  of ex-
 treme deformity.   Cod-liver oil holds a place between a food and a
 drug.   It is administered best pure in tea-  to  tablespoon dose after
 each meal.   It certainly contributes largely to  the  relief of rickets.
 Iron  may be a valuable remedy, as also arsenic, in selected cases;
 but the agent upon which most reliance is placed, which acts  nearly
 as a specific in the  treatment  of rickets, is phosphorus.  To Kasso-
 witz is due the debt of this discovery.   Lime  phosphates and other
 phosphates had been administered for years in the hope of relieving
 rickets, but without avail. Phosphorus is  of value only when it may
 mtke  its own  compounds or select its own basis in the body.  It is
 best given, therefore,  pure, in the form of an emulsion with almond
 oil, olive oil, or preferably cod-liver oil.

   B Phosphorus..................................................  gr. \.
     Olei morrh uae..............................................§ ij.
   M.   Fiat emulsio.  S.  Teaspoonful three times a day after meals.

   Laryngo-spasm  is  most efficaciously treated by cold affusions.
 There is no possibility of the administration of an anaesthetic, as the
child cannot breathe until the spasm is  over.   Cases liable  to  laryn-
go-spasm should be treated with the consideration of cases of tetanus
and hydrophobia, with reference to outside irritation.  The  dress
should be open.  The child should rest upon an oil-cloth or rubber
cover, that the garments may be  quickly removed, and  the face,
chest, and neck douched with cold water.  Muth says he recovers his
worst cases by  inflating the lungs through a catheter—a process that
might be better accomplished  in our day by intubation.  Such inter-
vention is, however,  really superfluous.  Nearly  all cases recover
with time under the general treatment of the disease. 
OBESITY.
633
    Osteomalacia is  a disease of  adult bones, characterized by ab-
 sorption of  already deposited lime salts with corresponding soften-
 ing and deformity.  It occurs especially in  fertile women in preg-
 nancy, hence at the age of twenty to fifty, and is announced by pain
 in  the bones,  early  fatigue,  nervousness,  muscular  tremor,  and
 twitching.  Treatment is  the  avoiding of pregnancy,  securing the
 most favorable hygiene, and administering  lime salts, phosphorus,
 and cod-liver oil.
                            obesity.
    Obesity  (polysarcia, corpulence) is an  abnormal increase of fat.
 The condition may be acute or chronic, but usually develops slowly.
 The amount of fat  which may be consistent with health varies in
 different individuals, and in the same individual at different periods
 of life.  People gain and lose weight, which is largely a  matter of
 the amount of  fat, within certain but indefinite limits, without inter-
 ference with comfort or health.  The increase becomes pathological
 when it interferes with any of the natural processes.  Obesity may
 be hereditary or acquired.   The condition certainly runs in families.
 It  is also more marked in  certain races  and places.  It may be
 acquired  by excess in nutrition and defects in exercise.   Of foods,
 starch, sugar, and alcohol  especially contribute to the formation of
 fat. A  sedentary life, indolent habits,  prolonged sleep,  have the
 same result by diminishing consumption.  The accumulation of fat
 is physiological after the meridian of life,  especially at the period
 of the grand  climacteric  in women.  '" Fair, fat,  and forty "  is a
 proverb.  Most of the monstrous cases have  been females.   Benzen-
 berg's  four-year-old girl  weighed one  hundred  and thirty-seven
 pounds, Kischs ten-year-old girl one hundred and sixty-two pounds,
 and Regnelle's  eleven-year-old girl weighed  four hundred and fifty
 pounds.   The  bulging  face, big body, and waddling gait of these
 unfortunates always excite amusement, sometimes ridicule.
   Obesity  shows itself in two forms,  the plethoric  and anaemic
 (Kisch).   The plethoric form is more common in men.  It is distin-
 guished by fulness of vessels with  stagnant  circulation, redness of
 the face, distended pulse, hyperaemia of the liver and lungs, haemor-
 rhoids, increase of the haemoglobin and of the number of  red blood
 corpuscles.   The anemic form occurs  especially  in  women  and
 shows itself  in opposite  conditions—in pallor of the surface and of
the visible mucosae, in  weakness, languor, neurasthenia, palpitation,
dyspnoea, oedema.  The pulse is quick and feeble.  The blood shows
diminution  of  haemoglobin and reduction in the number  of blood
corpuscles.  Transition forms occurs in both  sexes.
   The accumulation of fat shows itself first by an increase at the
sites of normal deposit, as in the subcutaneous tissue (panniculus 
• 134
OBESITY
adiposus).   The natural contours of the body are  increased.  There
is visible fulness in the cheeks ; under the jaw, which may present
the aspect of a double chin ; in the breasts,  on the abdomen, at the
buttocks, etc.   The breasts may assume monstrous dimensions, and
the abdomen become pendulous upon the thighs.   Fat accumulates
also in regions where it is normally absent, as between the muscle
fibres, under the endocardium, in the glands, etc.
   Of the internal organs the heart suffers most,  and in two ways :
by simple accumulation of fat under the pericardium and between
the muscle fibres, and by degeneration of the fibres themselves.  The
subserous accumulation may be so great as to form a distinct en- .
velope—lipoma cordis capsulare (Virchow).  Under this condition the
action of the heart becomes enfeebled.  The impulse may be barely
perceptible to the touch or ear.  The pulse is correspondingly weak,
and is  often  retarded (bradycardia).   In  fatty degeneration the
changes are more grave.  Fatty degeneration occurs much more fre-
quently independent of obesity, and rather in connection with the op-
posite state, with emaciation, and is the consequence of the action of
toxines  from infectious processes, malaria,  typhoid fever,  pyaemia,
Bright's disease, cachexia,  cancer, or of exhaustion by hsemorrhage,
diarrhoea, and is the evidence of chronic myocarditis.   Fatty degene-
ration occurs  more  especially in acute polysarcia and results from
nutritive change.
   The lungs are likewise impeded in their action.  The excursions
of the chest are limited.  Hyperaemia supervenes.   Attacks of bron-
chitis are common.   Asthma is wont to occur, more especially in con-
nection  with enfeebled  action of the heart,  and severe, even  fatal,
dyspnoea may result from stasis or oedema of the lungs.
   The increase in size of the liver is detected by percussion and palpa-
tion.  This increase is not attended with tenderness—a point of value
in differential diagnosis from organic disease.   Gall stones are of not
infrequent occurrence in  these  cases, and  they sometimes, though
rarely, develop icterus.  The stasis in the liver leads to hyperaemia in
the radicles of the portal vein, and thus develops catarrh of the stom-
ach with dyspepsia and  constipation.   The kidneys are embedded in
a mass of fat and often  show signs of stasis in oliguria, albuminuria,
and cedema of the  extremities.  Glycosuria is also frequent, and
diabetes  mellitus  develops in  more  than  half  the  cases.  These
altered metabolic and nutritive changes which lead to obesity predis-
pose also to  the development of arterio-sclerosis, with disturbances in
the circulation  and liability to hsemorrhage.  The obese  are  gene-
rally  sluggish and dull;  they suffer  with  a feeling  of fulness in
the head, with vertigo, tinnitus aurium, muscse volitantes, and sensa-
tions  of formication. 
OBESITY.
635
   The sexual functions are likewise interfered with.  Amenorrhoea
is common.  There is leucorrhcea from catarrh; chronic metritis is
not  infrequent.   Displacements are common, and sterility is rather
the rule.  The genital organs are atrophied.
   The treatment, which is wholly a matter of exercise and diet, de-
mands often great self-denial and always much patience.  Exercise
is best taken on horseback.  Children  may substitute it with a bi-
cycle ; adults with pedestrian  excursions, especially with mountain
climbing.  Oertel justly lays much stress on withdrawal or limitation
of water.  On the other hand, Tarnier, Karell got good results on an
exclusive milk diet, and the quickest results are obtained at  Marien-
bad, Austria, with regulation of exercise, hot  baths, and massage,
and free libation of the  alkaline mineral waters.
   The importance of regulation of food was shown in  the Banting
method—a dietary on which Mr. Banting reduced himself in  one year
from two hundred and two to one hundred and fifty-six pounds.
Improvements in this method were suggested by Ebstein and Oertel,
whose formulae, according to  Burney  Yeo in Hare's "' System of
Practical Therapeutics," are published below.
   Ebstein recommends the use of fat because it satisfies with less
food—a fact which seems  to have been recognized even by Hippo-
crates.
   The Ebstein  dietary  is as follows : Breakfast (6 a.m. in summer,
7:30 a.m. in winter) :  White bread well  toasted (rather less than two
ounces)  and well covered with butter;  tea, without milk or sugar,
eight or nine ounces.   Dinner (2 p.m.)  : Soup  made with beef mar-
row; fat meat with fat sauce, four to five ounces; a moderate quan-
tity of certain vegetables,  asparagus, spinach,  cabbage, peas, beans  ;
two or three glasses of light white wine ;  after the meal,  a large cup
of tea without milk or sugar.   Supper (7:30 p.m.) : An egg ; a little
roast meat  with fat ; about an ounce of bread, well covered with
butter ; a large  cup of tea without milk or sugar.
   Oertel's  formula  differs in  allowing more  albumen and starch
and less fat, with a view especially of strengthening the muscle of
the heart.   This dietary is as follows : Morning: One cup of coffee
or tea with  a little milk,  altogether about six ounces ; bread, about
three ounces.  Noon: Three to four ounces of soup ; seven to eight
ounces of roast  or boiled  beef, veal, game, or  not too fat poultry  ;
salad or a  light vegetable; a  little  fish  (cooked without fat, if de-
sired); one ounce of bread or farinaceous pudding (never more than
three ounces); three  to  six ounces of fruit, fresh preferred, for des-
sert.  It is desirable at this meal to avoid taking fluids, but in hot
weather, or in the absence of fruit, six to eight ounces of light wine
may be taken.   Afternoon : The same amount of coffee or tea as in 
636
OBESITY.
the morning, with, at most, six ounces of water; an ounce of bread
as  an exceptional indulgence.  Evening:  One or  two soft-boiled
eggs, an ounce of bread, perhaps a small slice of cheese ;  salad and
fruit; six to eight ounces of wine with four or five ounces  of water.
   Weir Mitchell advises massage, with skimmed-milk diet, to effect
a safe and quick reduction in weight.  The milk is to be given in
just such quantity as to permit a loss of half a pound a day. 
           DISEASES  OF  THE

GENITO-URIXARY SYSTEM.
                    OHAPTEE IX.

                 DISEASES OF THE KIDNEY.
   Definite knowledge of the diseases of the kidney during life
dates from the discovery by Richard Bright (1827) that certain forms
of dropsy are distinguished as due to kidney disease by the pre-
sence of albumin in the urine.  Dropsy, which  had hitherto been
considered a disease, was  now  degraded  to a mere symptom of dis-
ease, and the ability to distinguish one cause of the dropsy was thus
established.  Bright followed his cases  to the post-mortem  room.
He observed that certain diseased conditions of the kidney were
found in cases characterized by albuminuria during life.  It seems
strange that so much knowledge should flow from a test so simple.
It had  been occasionally  remarked before, especially by Cotugno,
that the urine  of dropsical patients sometimes contained albumin,
but no one before Bright had ever appreciated the full value or the
clinical significance of this observation.   Bright's paper  was enti-
tled " Cases Illustrative of some of the Appearances on the Exami-
nation of Diseases terminating in Dropsical Effusion," and the cases
themselves are  described  under the title " Diseased Kidney in
Dropsy."
   Bright believed that the disease  originated in the stomach or
skin,  and attributed it mainly to  cold  and  bad living,  including
abuse of alcohol.  Two years  later Christison, of Edinburgh, pub-
lished  a paper  entitled "Observations on  the Variety of  Dropsy
which depends on  Diseased Kidney," and two years later again
Gregory issued  a treatise on " Diseased  States of the Kidneys con-
nected during Life with Albuminous Urine."  In 1834  Osborn, of
Dublin, wrote a work on " The Nature  and Treatment of Dropsies
accompanied by  Coagulative Urine and Suppressed Perspiration."
So that the relation between dropsy, albuminuria, and disease of the 
I53S
DISEASES OF THE KIDNEY
kidney  received  ready recognition.  Raver,  of  Paris  (1840), pub-
lished an exhaustive treatise on diseases of the kidneys, which he
treated  under the title "Albuminous Nephritis."   Frerichs  (1S51)
distinguished three stages: hyperaemia, fatty degeneration with exu-
dation,  and hyperplasia with  atrophy.   By  this time  already  all
forms of kidney disease were grouped under the general title Bright's
disease.  Rokitansky (1842) was the first to describe a special form of
kidney disease, known as amyloid degeneration, which does not really
belong to the  category of Bright's disease.  The study of  the rela-
tion between  the heart and the kidney, first developed by Bright,
but especially elaborated  by Traube (1865), constituted a luminous
epoch in the history of the disease.
   These  affections of the  kidney distinguish themselves  by their
distribution.   The process in Bright's disease is diffuse, not  localized
or circumscribed, and  various  forms admit of more or less distinct
recognition.  These forms may be found associated, or one form may
pass into another.  There are combined forms and transition stages,
but as a rule  there may be distinguished in life a form which  pre-
dominates and gives character to the  disease in symptomatology,
prognosis, and termination.   Such forms only as may be recognized
in life merit practical consideration.
   While the  pathology  of kidney disease  has undergone much
change  since the time of Bright, and every pathologist multiplies di-
visions or establishes new forms, there  may be  set  apart as  distin-
guishable in life three  special forms.
   Of these forms two affect the structure proper, the parenchyma
of the  kidney, understanding  by this  term the epithelium  which
lines the tubules and covers  the glomeruli.  Parenchymatous nephri-
tis is separable, again, into acute and  chronic forms,  for the most
part of  easy distinction during life by symptoms which stand apart.
In the third form the inflammation affects chiefly the connective tis-
sue, which undergoes hyperplasia with subsequent shrinkage,  to pro-
duce the condition known here as elsewhere as cirrhosis.  A fourth
variety, which, as stated, does  not belong to Bright's disease, of later
recognition, affects  first and chiefly the blood vessels, whose tissue
it alters and destroys  to constitute  what is known as the amyloid
change.
   A disease which unfits  the kidney  for its function reveals itself
(1) in the secretion of the kidney, the urine ; (2) in the effect of reten-
tion of toxic elements (ursemia);  (3) in the disturbance of the circu-
lation (dropsy).   In the separation  of kidney disease a case  should
be approached from the standpoint of the information furnished by
the urine, the nervous  system,  and the dropsy.   Distinctions maybe
drawn by differences more or less pronounced in  these respects. 
ALBUMINURIA.
63!)
                           ALBUMINURIA.

    The urine is especially distinguished by the presence of albumin
 (albuminuria), which is recognized by the simple test of coagulation
 under heat to the boiling point and under nitric acid.  These two
 tests correct each other of any fallacy pertaining to one alone.  Phos-
 phates precipitated by heat with the  escape of carbonic acid,  which
 helps to hold them in solution, are dissolved by the addition of nitric
 acid,  and urates precipitated by nitric acid are dissolved under heat.
 When the urine is alkaline the nitric acid should be added in amount
 equal to one-fifth of the volume of urine.  These simple tests suffice
 for all clinical purposes.  Mistakes in diagnosis result, not from fail-
 ure to resort to more delicate, but  from neglect of use of these simple,
 tests.
    The quantity of the albumin is roughly estimated by volume, by
 the size and density of the coagulum.  Urine  rendered cloudy or
 opaque by the  presence of blood or pus, detritus, etc., must be  first
 filtered.   If it still remains cloudy, usually on account of abundance
 of bacteria, it will be rendered clear by shaking in a test tube  with
 magnesia usta.  Albumin from sources outside of the kidney  struc-
 ture, as from the pelvis of the kidneys, ureters, bladder, etc., belongs
 to the blood, pus, or other exudation  which makes the urine opaque.
 Outside diseases are also recognized by other signs of these affections.
 Albumin  from the kidney always indicates affection of the epithelial
 cells ;  it is, therefore, always pathological.  There is transitory  and
 intermittent, but there is no physiological, albuminuria.  Any inter-
 ruption  to the circulation  of blood through the  glomeruli,  any
 interference with the nutrition of the epithelial cells, permits the pas-
 sage of albumin.  Kidneys rapidly exsected under these  circum-
 stances show a layer of albumin, under the microscope, surrounding
 the glomeruli.  They also show alteration, cloudiness, multiplication
 of nuclei, etc., in the epithelial cells.
    Albumin in quantity up to one-tenth of one per cent is said to be
 slight.   Such a quantity may be transitory and may indicate no or-
 ganic disease.  One-half of one per cent is a medium grade; one to
 two per  cent a high grade of albuminuria.  The presence of albumin
 alone does not necessarily indicate disease of the kidney, as albumin-
 uria occurs  in all the infections, in blood anomalies, ansemia, etc.,
 icterus, certain nervous diseases (paralysis, epilepsy), certain poison-
 ings (arsenic, opium, chloroform, etc.).  It is  the constant  presence
 of albumin in association with some of the other signs (casts, urae-
 mia, dropsy) that establishes the diagnosis.
   True  albuminuria distinguishes itself also by its  quantity, which
in  false albuminuria is small.   True is further  separated  from false 
<540
DROPSY.
—i.e.. outside albuminuria (from the bladder, urethra, etc.)—mainly
by the microscope.
                              CASTS.
   Of even more importance than albuminuria is the presence in the
urine  of casts, or moulds, of the urinary tubules.  These casts are
made up of coagulated albumin, and may contain in addition epithe-
lial cells, blood corpuscles, fat globules, detritus, etc.  They some-
times  undergo subsequent  degeneration into waxy matter.  Casts
which consist wholly of  coagulated albumin are known as hyalines
casts.   They  are  clear and colorless, and, though they have linear
contours, are often overlooked.  Hyaline casts are rendered more
distinctly visible  for the beginner  by the addition of a drop of a
dilute watery solution of methyl violet.  In this way, also, true casts or
true cylinders are distinguished from the " cylindroid" bodies, mere
mucous casts, very long masses of mucus, extending through several
fields, sometimes split like a fork or  teased into threads, with lines of
granules along the surface, which  are made visible or more visible
by dilute acetic acid.  Casts which contain, or are composed of, blood
corpuscles, red or white, epithelium, fat globules, granules, etc., are
known as blood, epithelial, fatty, granular, and waxy casts.
   Epithelial  casts  occur as actual linings of the urinary tubules
desquamated  in continuo, or  as  epithelial deposits upon a hyaline
basis.   The  epithelium  may  be  intact  or  degenerated into fatty,
granular, or waxy matter.  Epithelial casts indicate  actual disease
of the kidney structure.   They are found especially in  acute nephri-
tis or in the acute  complications of chronic nephritis.
   Granular casts are recognized by the dark color  of  the granules,
which are particles of albumin or fat. They are broader and shorter
than hyaline casts, and uniformly granulated.   They  represent de-
generations of epithelium, and occur in the course of all  kinds of
nephritis.
   Waxy casts are  also broad and short.   They are homogeneous,
faintly lustrous,  yellowish, with  straight or  often  irregular con-
tours.   They represent a stage of degeneration later than the gran-
ular, and occur in the more chronic forms of nephritis.  The  pre-
sence  of  a number of  waxy  casts in  the  sediment  makes  the
prognosis very grave.
                             DROPSY.
   Dropsy is due to  retention of water on account of defective elimi-
nation.  It shows itself as oedema of the loose connective tissue, and
is usually observed first in the morning in the lower eyelids;  later, at
the ankles, in the  legs.   Still later it invades the body, including the
serous  sacs, to produce  anasarca.  It is sometimes  limited to the 
UREMIA.
641
mucous membranes, and may take life in the form of cedema of the
glottis, lungs, or bronchi.   The fluid of dropsy is distinguished by its
abundance of salt and minimum amount of albumin.

                            UREMIA."

   Uraemia results from the accumulation in the blood of  urea and
the various salts which should be excreted by the urine.  It usually
corresponds to the  reduction in the quantity of urine, but  stands in
necessary relation only to  the solid matters voided.   Uraemia may
occur when large quantities of urine are voided, as in renal cirrhosis,
in which the  bulk of the urine is simple water.  It is observed not in-
frequently after the disappearance of dropsy, with the absorption of
solid matters accumulated in the dropsical fluid.  Uraemia shows
itself in  its  effects upon the  nervous system,  in headache, hebe-
tude, somnolence  or  insomnia, and  anxiety.   It  is a frequent
cause of obstinate  dyspepsia with  corresponding degradation of
health and strength.   Uraemia distinguishes itself especially by ir-
ritative signs, tic itch ings of the muscles of the face and extremities,
spasmodic contractions, convulsions rather than  comatose states.
Epileptiform convulsions and  comatose states in adult life,  in the ab-
sence of a history of epilepsy or syphilis, should excite the  suspicion
of uraemia.   These attacks distinguish themselves  from epilepsy by
their frequent repetition in a  short time, as in the course  of a sin-
gle day,  and  long  interval,  often  of several  months.  Epilepsy
may show the same interval, but not the same immediate recur-
rence.   Sudden blindness,  amaurosis  of central origin, results from
the action of the poison on the occipital cortex.   It  usually disap-
pears in the  course of twenty-four to forty-eight hours.  Vomiting
and diarrhea, direct  effects of irritation  of the nervous system,
often discharge urea vicariously and recover the patient from  con-
ditions of danger.   More  rarely the urea is discharged by the  skin.
The poison sometimes attacks the  respiratory centre, when the pa-
tient is seized with attacks of dyspnea simulating asthma, to  con-
stitute  the  so-called  renal  asthma,  which  is  recognized by its
connection with the other signs of uraemia or of  nephritis.
   During attacks  of ursemia the pulse is  usually retarded, but is
always  full and  hard.  This  condition  of  the pulse  depends  upon
hypertrophy of the  left  ventricle,  which always occurs in the
course of  chronic nephritis, and is due to the increased work thrown
upon  the  heart to overcome  the obstruction in the kidneys.   The
hypertrophy  of the  heart is  recognized,  besides,  first by the in-
creased tension of the pulse ;  second, by the increased area of im-
pact ; third, increased cardiac dulness ;  and fourth, accentuation of
        41 
642
HYPEREMIA.
the aortic valve sound—all in the absence of evidence of valvular
disease.
   The quantity of urea is reached roughly, but sufficiently accurately
for all practical purposes, by estimate of the whole amount of solid mat-
ter.  The healthy adult  voids in twenty-four  hours 1,500 cubic cen-
timetres, containing 25 to  40  grammes—i.e.. 2-3.5 per cent—urea.
Recent investigations show that in health but S4 to 90 per cent, average
87 per  cent, of the nitrogenous matter is urea, while in disease 82 tost;
per cent, average 84 per  cent,  is urea.   The rest is made up of other
compounds  of nitrogen, uric  acid, xanthin,  kreatinin, chromogen,
ammonia.   The amount of urea does not always correspond with
that of the other solids.   Thus  in high  fever,  notwithstanding the
increase of nitrogenous matters, there is a relative decrease of urea.
Ammonia is increased in fever, and in high degree in diabetes, while
the other extractives are diminished in amount.   But knowledge' of
these points is not yet sufficiently precise  to be utilized in diagnosis.
We  do not yet  know which of these bodies produce uraemia.  The
amount of  urea itself is very variable.  It varies in different layers
of urine in  the same bladder (Edelfsen), and estimates are still made
from the solids.   Clinical experience has shown  that the multiplica-
tion  of the two last figures of  the specific gravity by 2 furnishes
the quantity of solids for 1,000 grammes,  whence the whole quantity
is easily computed.  Thus in health  the specific gravity of  a  sample
from the whole quantity, twenty-four hours, 1,500 cubic centimetres,
is 1020, and 20x2 = 40 for 1,000 cubic centimetres, in all 60 grammes
solids.   Again,  the specific gravity from a  whole quantity, 1,875
cubic centimetres, is 1012, and 12x2=24 for 1,000 cubic centimetres,
for 875 is Vcmjo- =  21, which added to 24 = in all 45 grammes solids.
The estimate is of especial value in the inception of chronic nephritis
and  for diagnostic purpose in renal cirrhosis.

                          HYPERAEMIA.

   Hyperaemia of the kidney (stasis) occurs in consequence of inter-
ference with the general circulation, as in diseases of the lungs  and
heart.   Stasis of  short  duration interferes with the action of the
epithelial cells; permits the escape  of  albumin,  which may form
a transparent, colorless exudation in the urinary tubules, to appear
in the  urine as the so-called hyaline casts.   In the long-continued
stasis which occurs in the course of chronic heart failures, the  kid-
ney  becomes  hard, the  color fades from the cortical  substance, to
constitute  the  condition known  as cyanotic induration.  Infarction
is attended with the accumulation of blood in  the affected  domain
and haemorrhage into the capsule and urinary tubules.  Destruction 
ACUTE PARENCHYMATOUS NEPHRITIS.
643
of the kidney substance ensues,  with the formation of extensive
cicatrices.
                            ANAEMIA.
   Ansemia of the  kidney occurs in the course of general anaemia,
reduces the size of the kidney, and diminishes  the quantity of urine.
In chronic states it  is best observed in the course of  senile atrophy
and arterio-sclerosis, when the urinary tubules in the affected regions
are found collapsed, empty, and filled with atrophied epithelial cells.
The  arteries are  bent and tortuous, in places obliterated; the con-
nective tissue hyperplastic; the substance of  the  kidney is  often
permeated with cysts.

              ACUTE PARENCHYMATOUS NEPHRITIS.
   Acute inflammation of the kidney was recognized before the days
of Bright.   It was  not  known, however,  that the disease was a dif-
fuse process.  It was simply assumed that disease of  the kidney ex-
isted, on account of the change in the condition of the urine.  Wells
had actually called attention to the fact  that the urine after scarlet
fever might contain albumin, even in the absence of blood.  Bright
himself did not appreciate the relation  between scarlet fever and
disease of the kidney, and probably had  no occasion to observe the
changes of acute nephritis.  It is interesting to note  that Hamilton
as early as 1833 declared  that he had found the scarlet-fever kidney
in a case without dropsy.  All nephritis  is caused by the passage
through the kidney of  toxic matter.  It  was assumed that a  ready
explanation of the frequency of Bright's disease would be found in
the passage through  the kidneys of micro-organisms on their way
out of the body.  It was, however, soon observed that micro-organ-
isms do not escape  from the kidney unless the kidney be diseased,
and  are even then to be discovered with difficulty.   The abandon-
ment of this view,  that micro-organisms  produced Bright's disease,
seemed to disturb the dependence  of these diseases upon infectious
processes.  With the discovery later of toxines and toxalbumins in
the urine the relation of the infections was re-established.   It was
recognized that kidney disease could be produced  by the injection of
chemical irritants.  A typical example of chemical irritant derived
from life is offered in cantharidin, which may produce  a typical acute
nephritis.  So this condition has been seen to occur after an extensive
vesication, or  more  especially after  the internal administration  of the
tincture of cantharides.  Acute nephritis  may occur in the course of
any infectious process.  Scarlet fever heads the list.   Scarlet fever is
the cause of more than half the cases of acute nephritis.  The kidney
complication occurs more especially in  certain epidemics and  is ab-
sent  in others.  Thus of one hundred and eighty cases in 1853-54 
644
ACUTE PARENCHYMATOUS NEPHRITIS.
treated  by Bartels, twenty-two were followed by nephritis; and e>f
eighty-four  cases in 1863, thirteen showed the same complication,
fatal, strange to say, in every case.  Bartels declares that in other
epidemics he had met scarcely a single instance in a hundred cases.
   Nephritis in these cases was formerly attributed to early exposure
to cold.  It  was observed, however,  that the accident occurred with
equal frequency in  cases long confined to the house  and  to bed.
Nephritis was evidently not  due to  affection of the skin or suppres-
sion of its secretions, as it is almost never seen  after small-pox or
extensive burns—conditions attended with the most marked destruc-
tive lesions of the skin.  The complication sets in, not in the course
of, but  as a sequel to,  scarlatina proper.  Nephritis develops some-
where between the second and  fifth weeks, in the average at the end
of three weeks, after the disappearance of the eruption.  It is, there-
fore,  a post-scarlatinal  process.  Though it appears at this  late
period,  it begins earlier and  assumes  proportions  to make itself
manifest by this time.   It is  needless to state that nephritis gravely
complicates a case of scarlatina.
    After  scarlet fever, diphtheria, among the infections, takes  the
second  place in the production of this disease.  The remaining in-
fections—measles, rotheln,  small-pox, pneumonia, etc.—only rarely
show this complication; typhoid  fever,  for instance, not  once in  a
hundred times.  The diseases  cited account for more than half the
cases.  Most of the rest are  attributed to "taking cold."   A certain
contingent of cases  is  caused by pregnancy.   These two factors act
by liberating  chemical poisons whose  exact nature  is  unknown.
Acute  parenchymatous nephritis is, therefore, always a  secondary
process.
    Symptoms.—After scarlet fever  and in the course of pregnancy
the elisease  sets in suddenly, as a rule ; after  taking cold the onset is
more insidious.  The  attack may begin with a series of chills  and
light rise of temperature.  There is  noticed an increased frequency
 of micturition.  The urine is reduced in quantity to  one-half to
 one-quarter of the normal amount.   The secretion is sometimes en-
 tirely suppressed.   With the  diminution in  quantity there is  cor-
 responding increase in specific  gravity to  1025-1030.  Where  the
 quantity is not markedly diminished the specific gravity may not be
 materially  lessened.  The color may be darker  from admixture  of
 blood, and will show variations from  a  light tinge to almost black,
 corresponding to the amount of blood.   Tested by heat or nitric acid,
 it shows  albumin in quantity varying from a fraction  of  one to  two
 per cent.   Tube casts, epithelial and blood casts, are usually pre-
 sent.   Dropsy occurs as a rule.   It is usually first seen about the
 eyelids, which are puffed ; the  face is swollen later.  The face has 
              ACUTE PARENCHYMATOUS NEPHRITIS.           645

a bloated, pallid, unwholesome look.   Dropsy appears later in the
subcutaneous tissue everywhere, and, in the course of the disease, in
the serous cavities.   It may take life by suffocation, from cedema  of
the glottis, or more especially from cedema of the lungs.
   Nervous symptoms  are also prominent.   Individual  cases are
ushered in with headache, severe neuralgic pain, vertigo, nausea,
and vomiting.  Occasionally the first intimation of the existence  of
the disease is a convulsion.   The nephritis of pregnancy is wont  to
announce itself by sudden blindness and convulsions.   Sopor, stupor,
and coma belong to this state.
   The diagnosis is easy, as a rule.  The preceding infection, when
it shall have existed, the time, the  occurrence, the peculiar train  of
symptoms, the state of the urine, the dropsy, and the nervous phe-
nomena, unmistakably stamp the disease.
    Fig. 265.—Casts of the urinary tubules in nephritis : A, blood casts; B, hyaline casts.

   The prognosis is always  grave, though the future is mainly de-
termined by the early  recognition and speedy  treatment.  A case
assumes gravity in correspondence  with the diminution of urine.
Anuria is an ominous sign.  Yet children have recovered after total
anuria of three weeks;  in these cases the poisonous elements have
found escape through other emunctories—intestinal  canal, the skin,
lungs,  etc.   The presence of  blood is not so grave as might appear.
Haematuria is  common in acute nephritis.   Yet  the  prognosis re-
mains grave in the presence of bloody urine.  The amount of albu-
min may have its weight in determining the future of a case.  Dropsy
is  not  so dangerous as nervous symptoms, especially convulsions.
Comatose states are always grave.  Patients may succumb in any
paroxysm of convulsion or in  any attack of coma.  The immediate
effect of treatment has its bearing upon the prognosis. 
64'i           ACUTE PARENCHYMATOUS NEPHRITIS.

   Treatment.—Any knowledge of the nature of the disease process
will carry with it the dangers of diuresis.   The routine administra-
tion of digitalis or other diuretic is dangerous.  The kidneys a.re
already clogged, the blood vessels are ectatic,  the  tubules blocked
with epithelial debris, blood casts, and detritus.  The true treatment
is to flush out the kidneys with frequent libations of water, preferably
warm drinks.  Mucilaginous  drinks, toast  water, have the advan-
tage that they may be taken sweetened without aversion by a child.
Adults take more kindly to acidulated drinks, lemonade, and soda
waters.   Milk is the best food, drink, and drug at any age.
   The scientific treatment of the dropsy consists  in  appeal to the
skin whereby the kidneys are unloaded.  Derivation of blood to the
skin is best effected by the hot bath, which is, in the treatment of all
forms of Bright's disease, almost a sine qua non.  Patients, especially
in acute nephritis, should be treated to the hot bath two or three times
in the course of every twenty-four hours.  The patient should be
immersed in the bath, except  the  head, which should be enveloped
in a towel wet with cold water.  The temperature of the bath should
be kept at 100° F., and there should be a supply of hot water to con-
tinue this temperature during the bath, which may  last from five to
fifteen minutes.   The patient is then rolled in blankets, put into bed
previously warmed, and allowed to sweat for an hour or more.  The
process of sweating unloads the kidney.  It happens not infrequently
that the patient falls asleep after the bath,  as the first restful sleep
during the attack.  A quantity of  more normal, clear urine may
pass immediately upon awakening.  All clinical experience  abun-
dantly justifies this resort to  the hot bath  as the true treatment of
acute nephritis.  The bath, as stated, must be  repeated again and
again, and continued in the treatment of a case until all signs of the
disease shall have disappeared.
   Where a bath is totally impracticable a substitute may be found in
the hot pack.  A child may be enveloped in blankets which are cov-
ered in with a rubber cloth, and the body heated by hot bricks and
hot-water bottles in the bed.   The process is much more discomfort-
ing than the hot bath and is much less efficacious.  It  has about the
same  relative virtue as the cold pack to the  cold bath in the  treat-
ment of fever.  The hot pack may be itself impracticable. Hot packs
and hot baths alike at times affect the heart.  In these cases  resort
may be had to the use of drugs, the most efficacious of which is pi-
locarpine, which should be used with caution subcutaneously in doses
of gr. tV-s-t.   Sweating  usually occurs rapidly, often within a few
seconds, after the hypodermatic use  of pilocarpine.  It may also be
profuse and may be  sustained by repetition of the remedy.   Pilo-
carpine is a  dangerous drug and  should  not  be indiscriminately 
              CHRONIC PARENCHYMATOUSrNEPHRITIS.          647

 employed.  The physician may have to choose this remedy as the
 lesser evil.  Sometimes it acts admirably.
    Convulsive attacks  must be cut short at once by chloroform or
 ether, and frequently repeated attacks may be prevented with the use
 of chloral in doses of ten  to fifteen grains, more or less frequently re-
 peated.   As a shield to the nervous system resort may be had also to
 the  subcutaneous use of  morphia.  With chloral and morphia the
 brain may be protected until the poison of the disease is eliminated.
 As a rule the  poison  seems to inundate the nervous tissue in waves,
 so that vigilance and active treatment are demanded for several
 days or for a week or more.   A light diet—milk—a warm tempera-
 ture, confinement to bed,  later to the house, restraint of exercise and
 excitement, fulfil the remaining indications.

             CHRONIC  PARENCHYMATOUS NEPHRITIS.
   This form  constitutes the bulk of the cases of Bright's disease.  It
 occurs less  frequently alone ; it is often combined with other forms,
 especially with renal cirrhosis and amyloid degeneration.  Yet dur-
 ing the greater part of its course it is independent,  and becomes in
 its further progress  associated  with other forms.   The  view that
 Bright's disease presented itself as a single affection with three stages
 —acute and chronic nephritis and  renal cirrhosis—proved so simple
 as to be seductive.  It is,  however, unfounded in fact.  Chronic very
 rarely develops from  the acute  parenchymatous form.  The acute
 nephritis which occurs in consequence of the infections, except scar-
 let fever,  terminates life or terminates itself in resolution.  It almost
 never  becomes chronic.   Occasionally the form that occurs  in con-
 nection  with   scarlatina  and  pregnancy assumes  a more  chronic
 course.  Rather  more  frequently the acute nephritis which is, for
 want  of  a  better explanation,  ascribed to cold becomes chronic.
 Those cases which  result from suppurative processes, inveterate
 syphilis, and tuberculosis are more wont to become  chronic  because
 of persistence  of the cause.  All these causes  combined  constitute
 only the  small minority of cases of chronic parenchymatous ne-
 phritis.
   The disease arises for the most part without discoverable cause,
 and develops itself so insidiously as to be recognized, as a rule, only
 after a duration of several  months.  Chronic nephritis  develops in
 consequence of the existence of a concealed cause.  The disease is
 for the most part as yet  cryptogenetic.   It is assumed  that  some
chemical poison, a toxine in the process of slow elimination from the
 body through the kidneys, causes the disease.  In connection with
 suppurative processes Fischer found the acid butyrate of  soda, the
escape of which through the kidneys might have caused the disease. 
648           CHRONIC PARENCHYMATOUS NEPHRITIS.

The question has interest, aside from the explanation of chronic kid-
ney disease, as a demonstration of the existence of latent poisons.
   Symptoms.—Chronic parenchymatous nephritis distinguishes it-
self, as  a rule, by its insidious onset.  The  patient complains  of  no
signs which distinctly refer to the kidney.  Sometimes there is pain,
more often dull, dragging sensations in the region of the kidneys,
to be attributed sometimes to distention of the capsule (hyperemia),
but rather to  lumbago than disease of the  kidney.   The disease
shows itself usually first in depression of spirits and degradation
of energy.  Life loses its zest;  avocation, before a pleasure, becomes
a drag.   Effort brings on  early fatigue.   There is loss of appetite,
     Fig. 266.—Retinitis albuminuria with irregularly scattered white patches (Magnus).

 listlessness, drowsiness or the  opposite  state,  insomnia.  Sleep
 fails to refresh.   The color changes, the hue of health is lost to be
 substituted by pallor, which becomes an ashy-gray.  There is loss
 of weight, which progresses gradually and indicates with the gene-
 ral failure of health what the people call a decline.   But there is or
 need be no cough and no other sign of disease of the lungs.  Patients
 consult the physician for repair of broken health and relief of broken
 spirits.   Sometimes there may be noticed early pruffiness about  the
face, bloating of the eyelids,  swelling of the ankles.  After the
 work of the day the shoes are tight.  The swelling subsides in  the
 night.
   The disease sets in less frequently with nervous signs.  There is,
 with the hebetude, headache, neuralgic pains—trigeminal, sciatic, 
             CHRONIC PARENCHYMATOUS NEPHRITIS.           649
much more frequently occipital and intercostal.   There may be pal-
pitation and shortness of breath to simulate the onset of tuberculosis
or heart disease.  The diagnosis is sometimes first established by the
oculist, who discovers in  a retinitis albuminurica an explanation of
the disease.
   The urine is diminished in amount to two pints, to a pint, to a
half-pint or less, in twenty-four  hours.  There  is seldom  that  ex-
treme  oliguria, and  never the absolute anuria, which is sometimes
seen in acute nephritis.  The occurrence of anuria would indicate
a complication, more especially the supervention  of acute nephritis.
In accord with the reduction in quantity is an increase  in specific
gravity  to 1025-1030-1040, weights  which excite  the suspicion of
diabetes, which is readily excluded  by observation of the diminu-
   Fig. 267.—Epithelium in urine of nephritis : A, desquamated cells, many in fatty degeneration;
 B, epithelium from pelvis of kidney; C, epithelium from female (above) and male (below) urethra
 (Wesener).

 tion  in quantity.  The urine is also  correspondingly  turbid.   On
 standing  a heavy  sediment falls to the bottom  of the vessel.  Al-
 bumin is always present.   Albumin distinguishes itself  not only
 by its presence, but by its amount.   It may exist  in the urine in an
 amount which is not equalled in any  other  form  of kidney disease.
 All the fluid seems  to set solid on  boiling or on addition of nitric
 acid.   The albumin  may amount  to as much as five per cent.  It
 usually ranges about one or two per cent.  The sediment consists of
 epithelial detritus,  fat bodies, white blood corpuscles, and tube casts.
 White corpuscles are present in large amount.  Nearly all forms of
 tube  casts may be observed in different cases—hyaline casts;  epi-
thelial casts which show fatty change ; desquamated epithelial cells,
also in a state of fatty degeneration ; granular casts, more strictly
indicative of chronic nephritis;  and  broad, waxy casts, which are 
650          CHRONIC PARENCHYMATOUS NEPHRITIS.

found exclusively in chronic nephritis and in advanced forms of the
disease.  They distinguish themselves by their  size as well  as by
their color.  They represent advanced changes in the epithelium of
the larger and  of the largest tubules.  They  contribute more than
any other element in the urine to make the diagnosis and  to  estab-
lish the prognosis.
    The dropsy distinguishes  itself  also by its  amount.  It is or be-
comes universal.  It varies of course in degree, but may be discov-
ered somewhere in the body in  nearly every case.   In one hundred
Fig. 268.—Chronic nephritis : epithelial and mixed casts (Peyer).
consecutive cases Johnson  found it absent only twice.  It is noticed
first, as a rule, about the face, but soon shows  itself in the lower ex-
tremities and accumulates  in  the subcutaneous connective tissue to
constitute anasarca.  It mounts up the legs,  the  skin of which it
may distend to the utmost  degree.  The surface  then becomes tense
and shiny as if glazed.  Finally rupture may occur with the escape
of fluid in  continuous quantity, and sometimes with subsequent ex-
tensive sloughing and gangrene. The  serous  cavities  are subse-
quently  invaded.   Fluid accumulates in the  peritoneum, in the 
CHRONIC PARENCHYMATOUS NEPHRITIS.
651
 pleura, and most dangerously in the pericardium.  CEdema of the
 glottis is not quite  so frequent as in the  acute form of the disease ;
 but cedema  of the lungs, especially in connection with subsequent
 heart failure, often terminates the disease with the life of the patient.
 CEdematous states  of the mucous  membrane of the intestinal canal
 are not infrequent.  Obstinate vomiting and diarrhoea, sometimes
 with sloughing and the formation of ulcers, distinguish certain cases.
 Inflammations of the  various serous membranes, pleuritis, peritoni-
 tis, pericarditis, inflammation of  the  lungs, pneumonia, as excited
 by the presence of toxic  matters,  constitute terminal links in the
 chain of disease process.
    The nervous symptoms in this form  of kidney disease are  com-
 paratively insignificant.   They may assume prominence in an indi-
 vidual case.   The disease, as stated, may be announced by headache,
 vertigo, the neuralgias, etc., or convulsions and comatose states may
 occur in the progress of the disease ; but these ursemic symptoms are
 infrequent.  They are noticed also to occur less frequently in cases
 of most extensive  dropsy.  It is assumed that the dropsy is a kind
 of reservoir for the accumulation of toxic matters, which  are thus
 held in solution away from the blood and nervous system.  All kinds
 of nervous symptoms may occur in exceptional cases, marked even
 by dropsy, and ugly pictures are sometimes shown of  convulsions in
 a body distended and distorted by  dropsy.   Any predominance of
 nervous symptoms would indicate a case complicated  with acute
 nephritis or renal cirrhosis.
    The  diagnosis  rests upon  the general failure of  health  and
 strength, upon the bad color, loss of appetite, progressive emaciation.
 The emaciation may be masked  by dropsy, but is manifest in ex-
 treme degree with the subsidence of the dropsy.   The diminution of
 the quantity of urine, the  high specific gravity, the turbidity, exist-
 ence of albumin in  quantity, presence of  a heavy  sediment of white
 blood corpuscles, tube casts, and detritus, the dropsy which distin-
 guishes itself by its range and amount, the few, scattered, and for
 the most part insignificant nervous symptoms, distinguish this form
 of Bright's disease.
    The prognosis  is always grave, mainly for  the reason that the
 disease is not recognized until damage is done.   But chronic paren-
 chymatous nephritis is by no means of necessity fatal.  Other things
 being equal, it may be  said that the future is determined by the
 duration of the disease.  A case which has lasted not  over a year
 may recover.   The character of the  tube casts, more than any
 other single element in  the urine, determines the prognosis.  The
 presence of broad, waxy  casts especially indicates an advanced stage
of the disease.  Dropsy  is not dangerous.  The largest accumula- 
652          CHRONIC PARENCHYMATOUS NEPHRITIS.

tions  may be  speedily removed and  reaccumulations may be held
belowthe line of danger.  Nervous symptoms are always grave in
correspondence with their own gravity.   Convulsions and coma are
ominous signs.
   The treatment does not differ materially from that of the acute
form  of the disease.  The true principle of therapy is the flushing of
the kidney of its epithelial debris and exudation, and elimination of
the toxic elements through the skin.  The patient should drink freely
of water, pure water,  alkaline mineral waters.  Milk is  both food
and drink, and cases have been cured by milk  diet alone.   Unfortu-
nately in chronic nephritis life may not be sustained indefinitely on
this diet.  Buttermilk  is an aid and  substitute, as is also kumyss.
The most scrupulous  attention must be paid to  the  skin, which
should be protected from every exposure.  Patients with this form
of Bright's disease should remain in doors in all bad weather.  Blus-
tering,  raw winds should  be  shunned.  Wet weather is dangerous.
In  any kind of acute exacerbation or advanced form of the  disease
the patient should  stay in bed, where alone may  be secured  an
equable, warm temperature.  Underclothing must be warm and clean.
The same dress may not be worn day and night.  The diet should
be simple, plain, and nutritious.  It should consist mainly of vege-
table  food.  Baths must be given as directed in  the treatment of
acute  nephritis.  They are especially indicated in the presence of
nervous signs.   There is not the same objection to the use of cardiac
diuretics in chronic as in acute  nephritis.  To strengthen the force
pump while the sluice gates are opened is  to  attack the disease in
flank as well as in front.  The most  effective diuretic is digitalis,
which may be given at first, in the  form of the effusion, in teaspoon-
ful, dessertspoonful, or tablespoonful dose.   The infusion should be
made fresh from the leaves, and the use of it should be discontinued
so soon  as the pulse under its full action becomes  firm and hard.
Too prolonged administration may  tetanize the heart.  After several
days  the remedy may be  resumed in the same or less  dose, or in
another form, as the tincture five to fifteen drops.  As the infusion
does  not keep long, a small quantity, six to eight ounces, should be
prescribed at a time.   The preparation is made much more efficacious
in the treatment of kidney disease by the addition  of ten to fifteen
grains of the  acetate of potash to each dose.  Digitalis may be for
various  reasons  contra-indicated.  It may be substituted by stro-
phanthus, gtt. v.-xv., diluted, three times a day.  For quicker action
resort may be had  to the natro-benzoate of caffeine in two- or three-
grain powders every two or three hours.  The powder, dry upon the
tongue, is usually washed  down with soda water.   Still better is diu-
retin  in solution: 
RENAL CIRRHOSIS.
653
   R Diuretin...................................................3 i.- 3 ij.
     Aquae menthse piperitse...................................§ iv.
   M.  S. Tablespoonfuf every two to four hours.

For immediate results in cases complicated with cirrhosis no remedy
equals nitroglycerin, which not  only tones  the heart, but  has  the
additional advantage that it relaxes any spastic contraction of  the
arterioles, especially  in  the kidney, to permit an  easier release of
accumulated matter.  Where the distention of the skin threatens to
produce rupture with its associated dangers, this accident may be pre-
vented by the introduction of fine silver canulse, Southey's tubes, or
by puncture  in several places, as on the dorsum of the  foot  or the
most distended part  of  the leg.  Great caution must be exercised
with  these punctures that the skin be washed clean with soap and
water and rendered aseptic with the  solution of sublimate 1  :1000.
The physician may not use the knife which the surgeon employs for
other purposes.   The most minute puncture  suffices to permit the
escape of a drop, which  oozes down in a fine stream to discharge in
the course of time surprising quantities of fluid.  Dyspnoea,  so great
as to cause orthopnoea, may be relieved in this  way in a single  night.
There must  be  dyspnoea or other  great discomfort, or threatened
rupture of the skin, to justify the procedure.   Sometimes a dose or
two of elaterin, or of calomel after the mode  specified in heart dis-
ease, may postpone the necessity of puncture.   In subsequent treat-
ment resort is usually had to the iodides, which are best given with
milk.  The tincture of iron gtt.  xv.-xxx. in sweetened water, bitter
tonics, tinctura rhei aromatica 3 ss.- 3 i., strychnia, as in the tincture
of nux vomica gtt. x.-xx., may  be demanded  in an individual case.
A change of residence to a warm, dry climate is worth all the drugs
in the materia medica.

                        RENAL  CIRRHOSIS.
    Interstitial nephritis  rarely occurs  in the  course of,  or  as a se-
quence to, other forms  of kidney disease.   The transition  of acute
into chronic parenchymatous  nephritis  is  more frequent  than the
occurrence of the cirrhotic kidney in consequence of parenchymatous
inflammation. The  processes may be combined, but they  may not
be said to originate the one from the other.   There is certainly a re-
lation between renal cirrhosis and gout.   English and French writers
describe the gouty kidney.  This relation is rarely observed  in our
country, because of the infrequency of gout.
    Morbid Anatomy.—Though the obvious  anatomical lesion is  a
hyperplasia of the connective tissue to such  degree as to strangulate
vessels, tubules, and epithelial cells, the disease does not begin in the
connective but in all cases in the parenchymatous structure.  Renal 
654
RENAL CIRRHOSIS.
cirrhosis shows on section the small granular kidney with adherent
capsule, atrophied cortex, retention cysts, and apoplexies in the sub-
stance of the kidney.
   Etiology.—Renal cirrhosis arises for the most part from unknown
cause.   Luxurious habits,  alcohol, heavy meals, more especially of
meat, have been accused of causing this form of nephritis, but with-
out proof.  Renal cirrhosis occurs  in all  classes—among domestics,
artisans, merchants, professional men.   It  occurs  without  regard
to avocation. It is  unknown in infancy and is rare in  age.  The1
majority of cases are discovered between adolescence and maturity.
The great number of apparent cases in age are considered as scleroses
of advanced life.  The disease is four times as frequent in men as in
women.
   Symptoms.—Renal cirrhosis is the most insidious of all forms of
kidney disease.  It may reveal its presence suddenly, as by a stroke
of apoplexy,  but  even in these cases, as a rule, only after  a long,
more or less  latent  existence.  During  this latent stage there is the
same general degradation  of  health  and sjiirits noticed in the
other forms  of  chronic  nephritis.   The  color changes, the  hue of
health is substituted by pallor.  Fatigue follows slight effort.  Ner-
vous signs  predominate.   Headache is frequent  and  obstinate.
The condition may be first disclosed by an attack of asthma.  Palpi-
tation of the heart is a frequent precursor and attendant of  the dis-
ease.  Certain cases consult the oculist  for blindness or disturbance
of vision.  The first symptom to excite suspicion at times is hem-
orrhage, frequent and severe—nose-bleed, or hsemorrhage from'the
stomach or bowels.   Not infrequently the physician is  led up to the
diagnosis by an examination of the urine, made in the absence of
any other signs adequate  to  explain the condition.   The urine is
abundant.   It is usually clear,  limpid,  with a greenish tinge.  Pa-
tients must  pass water  several  times  during the night; they are
hence easily misled to believe that the kidneys are perfectly free from
disease.  The quantity may be  doubled or trebled.   Urine is dis-
charged more frequently at night because it is secreted more abun-
dantly at night.  At times there is associate thirst, which, with the
greater discharge of urine, may bring  the patient  to the physician
with a  suspicion of diabetes.   The specific  gravity is  light, 1010
and under.   The urine is clear, deposits on standing but little sedi-
ment, and shows but few isolated hyaline casts.   So scant is the de-
posit of sediment that the urine should stand in a conical glass over
night to collect it, or, better, be precipitated in the centrifuge  appa-
ratus, which causes immediate or quick deposit by rapid rotation.
Permanent preparations are kept by being bedded in glycerin-gelatin:
gelatin one  part, water six  parts, glycerin nine parts, with a few 
RENAL CIRRHOSIS.
655
drops of carbolic acid.   Albumin may  be entirely  absent in  the
specimen examined, hence the necessity of collecting the urine of the
twenty-four hours; a sample  from the whole quantity will nearly
always reveal albumin, but usually in very slight amount.  It forms
on boiling, or on the addition  of acid, a slight cloud,  which reveals
itself best by contrast with the fluid in an unheated test tube.  It is
a good plan to boil simply the upper strata.  When the tube is held
against  a dark background, the mantelpiece or coat  sleeve, a very
slight opacity is perceptible.  The urea is correspondingly diminished.
   Dropsy is usually absent.   It may show itself at some time or other
during the course of the disease, and always accumulates at the close
when the heart begins to flag in its force, but it  is absent, as a rule,
during the progress of  the  disease.   Yet  the disease is sometimes
announced by puffiness of the  eyelids and cedema of the ankles, and
in the last stages, for the reason  stated, there may be anasarca or
oedema of the lungs.  As a. substitute for the absence  of dropsy, and
as a cause for its absence, there is enlargement of the heart.  The
left  ventricle undergoes hypertrophy.  Bright noticed this  change,
and attributed it to extra work thrown upon the heart by the occlu-
sion in the kidneys, and to chemical change in the blood which irri-
tates the heart.  Thus symptoms on the part of the urine and symp-
toms connected with dropsy are few  and far between in  renal
cirrhosis.   On the  other hand, the nervous symptoms distinguish
themselves by their prominence.  Individual cases are announced, as
stated, by attacks of apoplexy,which may result from  simple uraemia
or from actual break of  a vessel in the brain.  Apoplexy or coma in
adolescence or maturity, without other obvious cause, should excite
the suspicion of Bright's disease.   The same thing may be said of
epilepsy.  Where this disease has not existed in the previous history
attention  should be at once directed to the kidney.  Headache, neu-
ralgia, vertigo, disturbances of vision, occur throughout the course of
the disease.   Asthmatic attacks are not  infrequent.  They occur in
the night with  the  same dyspnoea and distress as  in true  asthma.
Patients succumb to some expression of uraemia more frequently in
this than in other  forms of  chronic nephritis.  Explanation of the
frequency of uraemia with free, copious urine is found  in the fact that
the  urine, though  free, contains  but little solid matter.   Ursemia
results from the retention of toxic matter whose exact nature is
unknown.  Exemption from ursemia is due to the fact that  the urea
is eliminated through other avenues—the lungs, skin, the intestinal
canal.   Crystals of urea are  sometimes, though very rarely, seen
upon the face, to  present the  appearance of hoarfrost or a surface
freshly lathered for shaving.   The odor about the body is sometimes
marked. 
656
RENAL CIRRHOSIS.
   The diagnosis of renal cirrhosis is not difficult.   The voidance of
excessive quantities of clear urine of light specific gravity, nearly
free of albumin, detritus, and tube casts, stands in marked contrast
to the reduced quantity of turbid, highly albuminous urine of paren-
chymatous nephritis.  The  absence of dropsy is a striking feature
Dropsy is absent, as stated, so long as the hypertrophied heart may
force fluids  through the kidney.  The great frequency and severity
of nervous  symptoms speak also  for renal cirrhosis.   Hypertrophy
of the heart may occur also in parenchymatous  nephritis.  It occurs
always in renal cirrhosis.  It is  recognized by displacement of  the
apex to the  left, increase  in dulness to the left, accentuation of the
aortic valve sound, heard best at the second interspace on the right,
increase in the tension of  the radial pulse.
   The differentiation of renal cirrhosis from renal arterio-sclerosis,
always difficult, is sometimes impossible.  Arterio-sclerosis is more
distinctly a disease  of age  or of  alcoholism.   Patients are  usually
males who have suffered no previous disease of the kidney, who begin
to show light uraemic signs, with slight dropsies  (oedemas)  which
come and go.  Attacks of palpitation point to hypertrophy of  the
heart, which  is readily recognized.   The urine shows albumin in
traces or transitorily, sometimes also hyaline casts, but, instead of
being increased, is, as a rule, decreased in quantity.   The diagnosis
really rests more upon the evidence of age or of  arterio-sclerosis else-
where, especially in  the brain.
   The prognosis is always grave.  The natural tendency of the dis-
ease is to continued destruction of the kidney substance.   The conse-
quences of this evil are averted for a time by hypertrophy of  the
heart, so that the affection of the heart, as revealed especially by  the
state of the pulse, is a gauge of the gravity of the disease.  Uraemic
symptoms are  always grave.  Convulsions and coma are  ominous
signs. Attacks of asthma occur late in the history  of the disease.
   The treatment differs in no respect from that of parenchymatous
nephritis.  There  must  be made the same appeal to the skin  in
substitution of the kidneys as before, and treatment must be continu-
ally  directed to sustain the heart and reduce the tension in the distant
vessels.  The hot bath is practised with the same precaution as be-
fore.  The temperature  should be kept at 100° to 110°, and  the
patient should remain in the bath from five to fifteen minutes or
more. Sweating is  to be  encouraged  by blankets and hot teas.
When the heart begins to flag it  must be stimulated with digitalis,
strophanthus, or caffeine.  To relieve the resistance offered by tension
of the arterioles no remedy is so good as nitroglycerin, which may be
administered in doses of  one to three drops every four to six hours.
Administration of the remedy maybe continued in varying doses for 
AMYLOID DEGENERATION.
657
 several weeks.  The diet should be simple, chiefly vegetable, largely
 fluid.   Milk is the best animal food.  It  may be  agreeably substi-
 tuted,  especially  in summer,  by buttermilk,  or  at any time by
 kumyss.  The skin must be protected by warm underclothing at all
 times, and  by stay in the house in bad weather.   During any exa-
 cerbation the patient should remain  in bed.   Other evils are  coun-
 teracted after methods already discussed.

                     AMYLOID DEGENERATION.
    The amyloid kidney  is not one of the forms of Bright's disease.
 The process is diffuse and is part of a widespread degeneration.  The
 condition is recognized,  as a rule,  only when it attacks  the kidney,
 and may hence be best studied  in this connection,  especially in that
 it so frequently complicates or  results  from other forms  of kidney
 disease,  notoriously from chronic  parenchymatous nephritis, which
 is itself a suppurative process.
    History.—Amyloid degeneration  was first  seen on the post-mor-
 tem table, as might have been anticipated, in the liver.
    Budd says of  Laennec, who noticed everything, that he noticed
 also the " waxy " liver,  which  he, however, considered to be  a va-
 riety of fatty  liver.   The first mention of the condition with  a dis-
 tinct description was made by Antoine Portal in 1813,  who says
 that he "found the liver excessively voluminous, reduced  to a sub-
 stance like lard, both in  color and  consistence, in the body of an old
 woman who had various exostoses and ulcerations about the genital
 organs."  Nothing but unimportant and isolated observations,  as by
 Budd, Andral, Graves, were then made in the history  of amyloid
 degeneration until  1842, when  Rokitansky cleared up the field by
 showing that amyloid degeneration was a general process with local
 expressions in different  organs, and  that it stood in close genetic
 relations to certain cachexiae.   Rokitansky was the first to describe
 amyloid degeneration of the kidney.   Gairdner and Sanders next
 (1854)  demonstrated that the waxy condition of the liver and kidney
 also showed itself in the spleen, while  Virchow and  Meckel almost
 at the same time (1853) had already discovered the iodine and sul-
 phuric-acid  reaction which enables the pathologist to distinguish amy-
 loid matter in any organ at any time.   It was this reaction  which
 gave it its name.  Starch is colored blue by free iodine.   The  color-
 ation of amyloid matter  is not blue, but violet,  deepening to mahog-
 any.  Virchow called it matter like  starch—i.e.,  amyloid.   Fried-
 reich and Kekule (1860) demonstrated that it is neither starch nor
 fat, but a pure albuminous principle.
   After the nature of amyloid  matter had been decided, the next
point of  interest was to determine whether it was a material circu-
42 
658
AMYLOID  DEGENERATION.
 lating in the blood and deposited in the tissues where it was found,
 or whether it was a result of disintegration or retrograde1 metamor-
 phosis of the tissue itself; in other  words, whether it was a mere
 infiltration or a true degeneration.
    What seemed  to lend  special support  to the  infiltration  theory
 was the place of its first deposit.  Virchow and Recklinghausen more
 especially  emphasized the  point that  amyloid matter is first found in
 the  walls of the blood vessels.  Moreover, it  was noticed that  the
 most vascular organs—the spleen, the liver, and the kidneys, organs
 which stand in the most intimate relations with the blood—are  the
 most frequently and extensively affected.   But, it was maintained
 on the other hand, amyloid  matter has  never been found  in  the
 blood.  Moreover, amyloid matter is not infrequently  found   in
 strictly circumscribed  or isolated deposits,  as a purely local  change,
 and not as a local expression  of a constitutional condition.  Thus
 Billroth observed two cases in  which individual lymph glands had
 taken on amyloid  change ; Hirschfeld reported  an amyloid  degene-
 ration in a  single  mesenteric gland after  a case  of  typhoid fever ;
 Kyber described cases  of amyloid degeneration in inflammatory neo-
 plasms ;  Oettinger, Samisch,  and Leber,  amyloid degeneration  of
 the sclerotic, producing hypertrophic  exuberations similar to those of
 trachoma ; Burow, a case of amyloid  degeneration of a fibroid tumor
 of the larynx.  Friedreich states that he  got  the amyloid reaction
 from the interior of old blood  clots ; Juergens  had the same results
 in thrombi of the  endocardium ; Virchow  from the intervertebral,
 tracheal, and symphyseal cartilages of old  people ; lastly, Ziegler de-
 scribes amyloid tumors of the tongue  and larynx that had  developed
 in  the  immediate vicinity of old gummata which had run their
 course.
   Amyloid matter has four distinguishing characteristics—viz., a
peculiar consistence  (like dough or  caoutchouc), a waxy lustre, a
 vitreous translucency, and a lack of color.   But neither the ma-
 croscopic nor microscopic appearances enable us to pronounce upon
 it unmistakably.  The true test of amyloid matter  is its reaction
 with iodine and sulphuric acid.  The surface to be tested must be
 first washed free of blood, else a mistake is very easy,  and then
 painted over with a brush dipped in  an  aqueous solution of free
 iodine.  In a few  minutes the amyloid matter is colored violet  or
 brownish-red like the color of mahogany.  On  the superaddition  of
 sulphuric acid the  mahogany color changes to blue.   The iodide and
 chloride of zinc show the same reactions, as do also  the  iodide and
chloride  of  lime;  and  methylanilin  distinguishes itself  in this  re •
action by coloring the amyloid parts a beautiful red, while the un-
affected parts assume a bluish or violet tint. 
AMYLOID DEGENERATION.
659
    Regarding age, sex,  and social state, amyloid  degeneration oc-
 curs at all ages, and even congenitally  as  the result of hereditary
 syphilis.  Frerichs found among his sixty-eight cases three under
 the age of ten years and nineteen between the ages of ten and
 twenty ; and from Wagner's forty-eight cases it is  seen to occur in
 five cases under ten and in five between  ten and twenty.  The male
 sex is two or three times more frequently affected—a singular fact, as
 Frerichs justly  remarks, because the diseases which induce this de-
 generation by no means especially affect the male  sex.  Tuberculo-
 sis and syphilis have no regard for social caste, hence this affection
 is no respecter of persons.
    Amyloid degeneration follows, in the  rule,  some  disease  at-
 tended with protracted suppuration.  Dickinson proposed an in-
 genious theory to account for it, based upon this fact,  to wit : Pus is
 alkaline, and the long drain of pus dealkalizes the blood ; dealkalized
 fibrin  is amyloid matter; the scientific treatment of  the  condition,
 therefore, is the administration of the alkalies.   Unfortunately for
 this beautiful theory, typical cases of amyloid degeneration may  be
 unattended or unpreceded by suppuration.
    Tuberculosis is the most prolific cause of amyloid degeneration.
 Wagner gives the percentage of cases at  56.25, Weber at 40.55, Hoff-
 man at  67.5.    Bone caries  is followed by amyloid degeneration,
 according to Wagner, in 23 per cent of  cases; Weber, 38 per cent;
 Hoffman, but 7.5 per cent of cases.
    Symptoms.—The urine  is  increased  in quantity, as a rule,
 though never to the degree characteristic of renal cirrhosis.  It is
 usually clear and shows light specific gravity,  contains albumin
 in varying amount,  sometimes scant,  sometimes abundant, a few
 clear casts and ivhite corpuscles.  Dropsy is rare.  What there
 is shows itself in the lower extremities rather than in the face,
 and is  due not  so much to  the  kidney disease  as to the general
 hydraemia  of the  cachexia.  Many cases of amyloid kidney show
 no dropsy from  beginning to end.  Grainger Stewart saw general
 dropsy only six times in one hundred cases. With  the  cedema of
 the legs there is often ascites, due to obstruction in the portal vein
 from simultaneous affection of the liver.  The process implicates also
 the mucous membrane of the alimentary  canal.  Vomiting and
 diarrhea  may  be  profuse  and defiant of control.  With  much
 affection of the liver the stools are excessively offensive from lack
 of bile, and with much affection of the bowel they may show under
 the microscope, along with leucin,  tyrosin,  and  fat,  actual masses
of amyloid matter, recognizable by the chemical test.
   Symptoms  on  the part of the nervous  system, so frequent  in
Bright's disease proper, are distinguished by their  absence in amyloid 
660
TUBERCULOSIS.
kidney.  Bartels declares  that he knew but one case of amyloid
kidney to die of apoplexy.  Hypertrophy of the heart does not occur.
   The diagnosis rests upon the fact that amyloid disease is a gene-
ral process, and that affection of the kidneys coincides with affection
of the spleen, liver, and often of the alimentary canal.   Besides  the
history of the case, the connection with some suppurative process,
and the kidney symptoms mentioned, affection of the liver and spleen,
recognized by enlargement of these organs, and  of the alimentary
canal by profuse and  obstinate discharges, make the diagnosis clear.
The diagnosis has been established in doubtful cases by harpoonage
of liver or spleen substance under antiseptic precaution—a procedure
which is justifiable only in the most exceptional case.
   The prognosis in all cases of amyloid disease is bad.   It is most
favorable when dependent  upon syphilis.  Prevention by free evacu-
ation of pus, and destruction or obliteration of pus-secreting surfaces,
is the true treatment.   Amputation, exsection, drainage, aspiration,
are methods of prophylaxis and treatment of amyloid disease.  The
treatment of syphilis continued long after the subsidence of manifest
signs,  the thorough neutralization  of  chronic  malarial poisoning,
resort to  change of climate in phthisis pulmonalis, prevent the devel-
opment of amyloid disease.  As to drugs, iodine alone is  worthy of
trial, because cases may depend upon concealed syphilis :
   R Sodii iodidi.......................................................§ i.
    Aquae menthae piperitae.........................................§ i.
   M.  S.  Ten drops in a wineglass of milk three times a day.
Where iodine injures  digestion, as  it does sometimes, it should be
discontinued until appeal may be made .to the stomach with hydro-
chloric acid and bitters, condurango, nux vomica, tinctura rhei aro-
matica, etc.
                          TUBERCULOSIS.
   Tuberculosis of the kidney is not common.  It ajDpears in the form
of miliary tuberculosis, as  part of the universal dissemination, some-
times  confined  to a single  branch of  the  renal  artery, sometimes
widely diffused, and as a chronic local deposit in the substance of the
kidney or in its pelvis. As is the case elsewhere, tuberculosis forms
granules and nodules,  which undergo caseous degeneration, or break
down  to produce necroses,  ulcerations, and extensive  infiltrations.
The disease is sometimes recognized by the evidence of tuberculosis
elsewhere, more accurately by the discovery of the tubercle bacillus
in the urine.  But  tubercle bacilli  must not be confounded with
smegma bacilli, which look just like them.  In  case  of doubt the
prepared specimen should be  immersed a few minutes in absolute
alcohol,  which decolorizes the smegma bacilli but  not the  tubercle
bacilli. 
FLOATING  KIDNEY.                     661
                            SYPHILIS.
   Syphilis of the kidney is even  more rare.  It shows itself in the
hereditary form  by intra-uterine arrest  of development, and, after
birth,  with induration and shrinking.  Now and then  caseating
gummata and cicatricial connective tissue are  encountered in  the
kidneys of adults as the result of the acquired disease.
                        FLOATING KIDNEY.
    Wandering kidney ; ren mobile.—The kidney is usually fixed  in
 its position by the layer of  fat in which it lies  embedded, and is re-
 strained within light latitude of move-
 ment by the vessels of the hilus, which,
 with the connective tissue  that  binds
 them together,  constitute  something
 of a  pedicle.   An unusual laxity of
 this tissue and of the abdominal walls,
 more  especially' compression   from
 above, as by  corsets, belts, etc., dis-
 locates the kidney and allows it more
 or less wide range of  movement.  On
 account of the strain of hard work the
 condition is more common in  the la-
 boring classes ; and, on account of the
 mode of  dress, more  frequent  in wo-
 men than men.   Sometimes both kid-
 neys are thus dislocated and rendered
 movable; when   but  one,  the  right
 more frequently than the left.
    Symptoms.—In many  cases the
 condition is entirely latent and is dis-
 covered only upon autopsy.  There are
 no symptoms upon the part  of the kid-
 ney itself, so far as concerns its func-
 tion.  The secretion remains the same.
 Attacks of  dyspepsia,  colic, icterus
 have been  observed,  and  have been
 attributed to incarceration,  which has, however, never been discov-
 ered  upon the post-mortem table. They  are better  interpreted as
 neuralgias or as  the  result of  a circumscribed peritonitis.   More
reliance may be placed upon pain,  dragging  sensations, or sen-
sations of  displacement, which are  experienced as  a rule.   Some-
times a tumor may be felt, by bimanual examination, in the region
of the kidney.   In thin persons, in whom the kidney may be often
  Fig. 269.—Topography of
from behind, in relation to thoracic and
abdominal viscera. Outlines of oesopha-
gus, stomach, and large intestine in heavy
dotted lines; of liver and spleen in fine
dotted lines ; of other organs in continu-
ous lines.  Crosses at seventh cervical,
fourth and ninth dorsal, and first, third,
and  fifth lumbar vertebrae  (Stedman).
Compare with front view, page 583. 
662
FLOATING KIDNEY.
grasped in the hand, it may be recognized by its shape.   It is felt to
be mobile; is movable, especially upward, but may be seldom carried
beyond the median line.  It is usually extremely sensitive.
   Diagnosis.—A  floating kidney  must be  differentiated from a
dislocated spleen or a small ovarian tumor.   Aside  from the fact
that the left kidney is less movable, the  spleen is larger,  firmer, and
much more superficial.  The ovary  differs in shape,  moves down-
ward rather than upward, may be recognized at times by a vaginal
examination, or may be absolutely distinguished, in  case of  cystic
growth, by aspiration.
   The prognosis is favorable so far as  life is concerned.   Any radi-
cal correction of the displacement, except by surgical means, is diffi-
cult.  The enforced idleness which results from aggravation of the
pain by work sometimes conduces to melancholy.
    Treatment.— Corsets, belts, must be abjured. Pads,  compresses,
and bandages may give mental, but rarely any real bodily, relief.
 Extirpation of the kidney, notwithstanding the fact that one is usu-
 ally large enough for all the wants of  the body, is justifiable only
 in 'extreme cases, or really only in cases of disease of the kidneys.
 Harris reported sixteen  nephrectomies, with ten  recoveries.   The
 kidneys were found diseased in three of the six fatal cases. Kronlein
 lost a case on the fourth day after nephrectomy from insufficiency
 of the remaining kidney.  Attempt has also been made to transfix
 the kidney with a ligature passed into  the abdominal walls through
 the kidney and out again, without permanent benefit.  Halm simpli-
 fied this operation  by cutting down upon the kidney and stitching
 its  capsule into the wound.  Angerer  cured seven of nine cases by
 fixation with catgut ligature.  Such nephrorrhaphy is the proper pro-
 cedure. 
OHAPTEE X.
DISEASES OF THE  PELVIS OP THE KIDNEY, BLADDER, ETC.

                KIDNEY STONE—NEPHROLITHIASIS.

   Renal sand; gravel; calculus.—The old idea of a diathesis has
been entirely abandoned, but stone in the pelvis of the kidney is  still
distinguished as nephrolithiasis.  Nothing definite could possibly be
known of the nature of stone in the kidneys until the  discovery by
Scheele (1776) of uric acid as a normal ingredient of  urine.  Scheele
considered it  the  exclusive constituent  of kidney stones.   The dis-
covery later of cystin, xanthin, oxalic  acid, and the  phosphates put
the subject on solid ground.
   Nearly all the stones found in the urinary apparatus originate in
the kidney.  The proportion  of  original renal to vesical stones is
100 :1.   There is great variation in size and number.  A single stone
may fill and form a cast  of  the  pelvis of the kidney, or  multiple
stones—as many as one thousand  have been counted—may distend
the pelvis and ureter.  Larger stones, as of the size of  a  goose egg,
imply usury of the kidney substance.   Gee described a case in which
one thousand stones were found in  the pelvis of the right kidney,
one weighing 1,080 grammes, while the pelvis of the left kidney  was
taken up by a  stone  which  weighed  100 grammes.  The largest
of these stones is the largest yet found.  Kidney  stones  may be
round, oval, angular, or irregular; they vary  also in surface, color,
and consistence.
   Seven special forms have been described—stones of uric acid  and
urates, of oxalate of lime,  of the phosphates, of the carbonate of
lime, of cystin, xanthin, and indigo.   Stones of the urates are hard,
smooth  as if varnished upon  the surface, or granulated.  They are
usually small, varying in size from a poppy seed to a pea or bean.
They are recognized by the  murexide  test.   Scrape  powder from
the stone into  a watch glass, or, better, a porcelain cover, add a
drop of  nitric  acid, and  heat  to dryness. If  now the brown spots
of residue be touched with a drop of ammonia, there is developed in
the presence of  uric acid a brilliant  carmine-red,  the so-called
murexide color.  A drop of liquor potassae changes the carmine  to a 
664
KIDNEY STONE—NEPHROLITHIASIS.
dark  violet-blue.   Oxalic-acid stones  are distinguished by  then-
extra hardness, as if varnished, dark  color, and rough, warty sur-
face; they form the  so-called mulberry stones.   Heated to  redness
they turn white and effervesce  with acids.   Phosphatic stones  are
usually combinations of the phosphate  of lime and the triple (am-
monio-magnesia)  phosphates.  They are  small  and light,  gray in
color, and "sandy or granular upon the surface.   Soaked in potash
lye and heated to redness they develop the  odor of ammonia.  Cys-
tin, xanthin, and indigo stones are very rare.
   Cystinuria has now a new significance as a sign of infectious pro-
cess.   Recent investigations (Stadthagen, Brieger) go to show that
   Fig. 270.—Crystals of oxalate of lime. In the middle the ordinary octahedra ; at the sides,
disc, hour-glass, and dumb-bell shapes,  x 275. (Eichhorst.)

cystin is itself, or is the product of, a ptomaine in the intestinal
canal, due to the action of certain micro-organisms.  Cystin is found
in the fseces and in the urine in connection with diamin.  The acid
urine decomposes the combination, the soluble diamin is discharged,
and the  insoluble cystin precipitated to possibly form a stone.   Cys-
tin is recognized by the fact that it occurs in small, colorless, hexago-
nal tablets (see  page 184), which are easily dissolved in ammonia to
be precipitated again on evaporation of the ammonia.
   The  etiology of kidney  stone is obscure.  Stones are  found ten
times  more  frequently in the male than in the female sex, and at
both extremes of life rather  than at maturity.   Of 5,900 cases col- 
KIDNEY STONE —NEPHROLITHIASIS.
665
lected by Civiale forty-five per cent occurred in children.   The abso-
lutely greatest number of  cases occur between the ages of two and
twelve.   Sedentary and luxurious habits, conditions connected with
climate, food, and drink, have been accused, without proof, of pro-
ducing kidney stones.  Uric  acid and urates are frequently found
deposited as yellowish-red stripes in the pyramids of the kidneys of
new-born children, to present the appearance erroneously called in-
farction.  It was believed  that these deposits of the urates, as they
occur only in consequence of tissue change, would be found only in
children whose lungs had  been expanded most abundantly, at two
to twelve  days after birth, and  not, therefore, in the still-born.  As
   Fig. 271—Mulberry-shaped red blood corpuscles in urinary sediment in haematuria (Eich-
horst).

Hodann was able to demonstrate  the condition in a decomposed kid-
ney at the end of forty-five  days, the finding assumed forensic im-
portance.  But as exceptional cases have been since reported, it may
be said that the presence of this " infarction " constitutes not absolute
but strong corroborative evidence of  live birth.  Concretions of uric
acid may occur on  account of  excess of this  substance in the blood
or diminution of the salt which holds it in solution.  Both conditions
exist in certain cases.   Individuals affected with gout may also suf-
fer from kidney stones.  Erasmus wrote to a friend: " I have gravel,
37x>u have gout.  We have married twins." 
666
KIDNEY STONE—NEPHROLITHIASIS.
   The biphosphate of soda is the salt chiefly concerned in holding
uric acid in solution.  Diminution of  this salt, the  result of catar-
rhal inflammation of the pelvis of the kidney,  may lead to the pre-
cipitation of uric acid.   The phosphates  fall  in an alkaline urine, so
that nephrolithiasis, so  far as uric acid  and phosphatic stones are
concerned—and they form the great bulk of cases—is always a local
condition.
   Symptoms.—The presence of kidney sand  may  give rise to  no
symptoms, but  even minute  concretions  may cause excruciating
pain.   Stones  passed from the bladder are often much larger than
stones in the kidney or ureter.
   Kidney stones  usually reveal themselves  by pain, which is  ex-
cessive in its  severity.  The pain is located in the region  of  the
kidney, and radiates  thence downward  and in ward  toward  the
bladder.  It is so excruciating as to require  the use of  an  anaes-
thetic,  or  large  doses  of opium, to  secure relief.  It is usually
fitful, and  irregular  as the stone advances  on release of spastic
contraction, and often subsides suddenly with  escape into the blad-
der, sometimes to leave the patient narcotized.  The  urine may
appear perfectly natural, as it may  issue  only from the unaffected
kidney, or it may be tinged with blood or  contain pus  from the
affected kidney.   Hematuria and pyuria may thus alternate
with  perfectly normal urine.   Accordingly, sediment may  be
scant or abundant, and examination  of the deposit  under the mi-
croscope may disclose  the presence and  character of kidney stones.
Sometimes, in consequence of complete occlusion,  the kidney is con-
verted into a  retention cyst, to constitute a hydronephrosis.  The
kidney substance itself  may be consumed and  the capsule  distended
to such degree as to constitute a  tumor in the abdomen.  Pyelitis
is a more frequent complication.   Perinephritic abscesses may  re-
sult.   Under these conditions sepsis may set in.
    The prognosis is always serious.  The  stone may rupture the
ureter, whence peritonitis will  develop.  Abscesses with burrowing
sinuses and fistulae may lead to slow marasmus and amyloid change.
Nevertheless most cases recover.  Patients pass the stones once for
all; more frequently a  number of stones are passed in the course of
a week or month, and the  condition recurs  once or twice  in the
course of a year.   Sometimes the interval  lasts several years.
    The treatment consists in the flushing of the kidney with abun-
dance of drink, especially water,  mineral waters, alkaline  waters.
The waters of Saratoga and  Bethesda, any of  the pure simple alka-
line waters of our own country, may  suffice.   Better results are se-
cured by Carlsbad water, natural, or  preferably, with us, the artifi-
cial salts.   Lithia has long  been used.   Of late  one of the coal-oil 
PYELITIS.
667
products, piperazin,  has been highly  recommended.  It is given
in doses of gr. v.-xv. three to five times a day in a glass of soda or
Selters  water.   It is said to have the  power to  dissolve uric-acid
stones.
   The treatment of  the attack is the  relief of  pain  by the  inhala-
tion of  chloroform or ether, by the subcutaneous injection of mor-
phia gr. \, preferably with atropia gr.  y-J-g-, and by the administra-
tion especially of chloral gr. xv.-xxx. to secure relaxation of spastic
contraction and thus further the progress and final discharge of the
stone or stones per vias naturates.   Large flannels wrung  out of
boiling  water and made to envelop the whole of the affected side
assist in securing relaxation and relieving pain.

                           PYELITIS.
   Pyelitis is an inflammation of the kidney produced by some irri-
tating cause which develops in situ, or which  escapes with the se-
cretion  of the kidney.  The local cause  is most frequently a stone—
pyelitis calculosa—which may fret and irritate the  pelvis and pro-
duce hsemorrhage, suppuration, and ulceration.   The cause may
come from below, as from the bladder,  cystitis; or from gonorrhoea,
the use of unclean catheters, etc.   It is commonly a mycosis, and is
typically illustrated in the pyelitis which occurs in connection with
tuberculosis.  Pyogenic micro-organisms may find their way from
the ureter to the kidney.  More commonly the mycosis comes from
above.  Thus pyelitis occurs in the course of the graver infections
—typhoid fever, small-pox, scarlet fever, diphtheria, cholera, etc.
The micro-organisms themselves may not escape, but may do their
damage by their products, the toxines and toxalbumins.   A proof of
this process is found in the pyelitis which sometimes results from irri-
tating drugs, cantharides, turpentine, copaiba, etc.  Extension of dis-
ease from the pelvis to the substance of the kidney produces pyelo-
nephritis, which may terminate in the formation  of abscesses and
finally convert the kidney into a sac of pus, pyonephrosis, or extend
to envelop the adjacent tissue as a peri- and para-nephritis, often with
the formation of abscesses.  A stone may increase in size to form a
cast of the pelvis or of the whole kidney.  Much more frequently it
remains small and produces pyelitis.   The process is almost always
unilateral.   Stone is more frequent in the left kidney.
   Symptoms.—Pyelitis is announced by pain, more dull than acute,
and  more  often manifest by  sensations of  tension and weight.
The pain usually radiates from the kidneys along the course  of the
ureters to the bladder.  Pain is sometimes entirely absent.  The best
information is furnished by the urine, which contains pus or blood,
or both, therefore  albumin, and  sometimes  characteristic  epithe- 
668
PYELITIS.
lial cells.  In a case of pure pyelitis the urine remains acid.   Under
retention from  whatever  cause, ammoniacal decomposition  takes
place with alkaline reaction.  The cells  are from  the flattened cau-
   Fig. 272.—Epithelial cells from mucous membrane of renal pelvis, with prolongations and a
shingled arrangement, from intact mucous membrane in man.  x 275.

date epithelium of the renal pelvis, and when present are pathogno-
monic.   Unfortunately they are absent in many cases, as  they are
   Fig. 273.—Urinary sediment in acute pyelitis, containing epithelium, round cells, and red blood
corpuscles. X 275.

destroyed in ammoniacal urine.   The presence of fever, with chills,
diarrhoea, dehrium,  nervous signs, and the  status  typhosus,  indi-
cates pyelonephrosis or pyaemia. 
HYDRONEPHROSIS.
669
   The diagnosis rests upon the pain, if  present;  the  presence of
albumin, blood, or pus in the urine ; more  especially the  characteris-
tic epithelial cells ; and, in connection with pyelonephrosis, the chills,
fever, hebetude, and status typhosus.   Pyonephrosis may form an
abdominal tumor.
   The prognosis is always grave, but in the individual case de-
pends upon the cause.   It may disappear entirely after the discharge
of a kidney stone or cure of a cystitis.   The prognosis in the course
of infection is always  grave.  It is more favorable after typhoid
fever, in which disease it usually disappears with convalescence, than
after pyaemia, where it  is often fatal.  So long as the urine remains
acid the outlook is good ; with ammoniacal decomposition the course
of the disease is usually downward.
   Treatment  consists  in  the removal  of the cause, in  the cure of
gonorrhoea, the use of perfectly clean catheters, the removal  of  kid-
ney stones.   The administration of the salicylate of soda may pre-
vent or postpone ammoniacal degeneration of the urine.  The blad-
der  may  be washed  out with  disinfecting solutions  of creolin,
one-quarter of one per cent.  When  there is no obstruction fluids
must be administered freely to keep  the kidneys flushed.  Bad cases
may require nephrotomy or nephrectomy.  Guyon reported the cure
of six cases of pyonephrosis by nephrotomy.  The opening into the
kidney must be wide and deep.

                        HYDRONEPHROSIS.
   Cysts occur in the kidney in consequence  of dilatation of the uri-
nary tubules.   The dilatation is  most  frequently observed in  conse-
quence of hyperplasia  of the connective tissue, which causes com-
pression and accumulation.  Such cysts vary in size from a pea  to a
hen's  egg, and are  filled with colorless or yellowish fluid, more or
less gelatinous, from which the true elements of the urine have been
usually absorbed.  A peculiar degeneration, wherein the whole  sub-
stance  of the kidney is transformed into  cysts which may assume
magnitude  by  coalescence, is sometimes  observed as a congenital
malformation, to constitute the so-called cystic kidney.   The same
degeneration is sometimes observed in maturity and age, not infre-
quently accompanied by a  corresponding cystic degeneration of the
liver.  Occlusions in the pelvis  of  the kidney or the ureter, which
block the escape of urine, lead to h ydroneplirosis.  Shch occlusions
are most frequently formed by kidney stones, more  rarely by cica-
trices, strictures, compression of outside organs, tumors of the ute-
rus and ovaries, enlargement  of the prostate,  etc.   The kidney
substance suffers usury under the pressure of accumulating fluid ;
the capsule is distended to  a sac which may contain from five to ten 
670
CYSTITIS.
pints of fluid.   With the gradual disappearance of the kidney sub-
stance the elements of the urine are absorbed and substituted by
mucus wdiich  contains  albumin,  colloid matter,  and  sometimes
blood, which imparts to  the fluid a brown color.  The condition is
sometimes congenital, and in the experience of  the  author  once
formed, in labor, an obstacle which could be overcome only by punc-
ture of the abdominal wall. The child was still-born.
   Treatment depends upon the cause, which must, as in the case of
kidney stone, outside compression, etc., be discovered and removed.
Surgical intervention may become a necessity.
Fig. 274.—Stone causing hydronephrosis (Roosevelt).
                             CYSTITIS.
   Cystitis  {hv6xis,  the bladder) ;  inflammation of  the  bladder;
catarrh of the bladder.—A disease distinguished by the presence of
three symptoms,  pain, frequency of micturition, and  pyuria.  Albu-
min  is present only in small quantity in correspondence with the
amount of pus.
   Etiology.-—Cystitis may develop by  extension of  disease from
above or from below—that is, from the kidneys and ureters (pyelitis,
calculus), and from the urethra (gonorrhoea, stricture, disease of the
prostate gland).  Cystitis may be also the local expression of tuber-
culosis and cancer,  in which processes the disease may extend to the
bladder from contiguous structures (uterus, rectum,  etc.) or  be car- 
CYSTITIS.
671
 ried to it by the blood and lymph vessels.   So, too, cystitis may
 develop in connection with an infection of the blood—pyaemia, sep-
 ticaemia—when the cause of the disease may be discoverable, or the
 affection may be cryptogenetic.  Paralysis of the bladder, from dis-
 ease of  the  brain or  spinal cord, trauma, tabes, etc., may produce
 cystitis from retention and decomposition of urine.  A peculiar and
 rare form is attended with the formation of a false membrane, the
 pseudo-membranous cystitis.
    Gonorrhoea is the  most frequent  cause.   Cystitis  occurs  in the
 later course of gonorrhoea, often when the discharge is reduced to a
 gleet or to a single drop  in the morning.   The gonorrhoea is some-
 times overlooked or unrecognized, as  a posterior  urethritis may de-
 velop without visible discharge.  Posterior urethritis is detected by
 the presence of gonorrhoea! threads in the
 urine first passed in the morning, and by the
 presence of the gonococcus in the mucus.
    Symptoms.—The disease is distinguish-
 ed, as  stated, by the  association  of  three
 symptoms,  pain, dysuria (frequency  of
 micturition), and pyuria. Any one of these
 symptoms may occur  in other  affections;
 all three only in  cystitis.  The pain varies
 in every degree of intensity, from light dis-
 tress to the  most  intolerable  anguish. In
 acute  cases  it  radiates  from the  bladder
 along  the course of the urethra, involves
 the testicle and rectum, and is felt in inten-
 sity at the head of the penis.  In these cases
 it is associated with  intolerable tenesmus
 and dysuria.   The desire to pass  urine recurs every  few minutes ;
 but a small quantity, a drachm or  two, is voided  under the most in-
 tense effort; finally but a few drops of blood.  The presence of pus
 is best observed in the urine which is passed first and last.  With the
 development of cystitis the discharge of gonorrhoea usually ceases.
 The discharge should  be examined repeatedly for the gonococcus of
 Neisser.
   Tuberculosis is, as a rule, primary in the bladder; that is, the dis-
 ease is  derived from latent depots and not from the lungs.  Tubercu-
 lar cystitis is especially distinguished by the presence in  the urine of
 blood,  which  shows itself suddenly and apparently spontaneously,
without much pain or dysuria.  Tuberculous cystitis is often  associ-
ated with polyuria.   The diagnosis is difficult because of the diffi-
culty or impossibility of discovering the tubercle bacillus in the urine.
In  the absence of tuberculosis of the lungs, some expression of the
 Fig. 275.—Cystitis with gan-
grene and separation of the mu-
cous membrane and part of the
muscular coat (Gardner). 
072
ENURESIS.
disease may be found elsewhere, as in  the glands, joints, bones, epi-
didymis, etc.
   Calculus produces intense pain, frequent haemorrhage, and tenes-
mus, which are all increased by exercise of the body and relieved by
rest.   The stone may be felt by the sound.   Stricture is discovered
by the passage of a sound or bougie.  In  the membranous form
flakes or masses of exudation containing epithelial cells, or consisting
of actual exfoliations from  the  bladder  itself, are voided with the
urine or withdrawn by the catheter.
   Treatment.—Cystitis maybe prevented by the prompt and proper
treatment of gonorrhoea, with the avoidance of strong injections at
the start, by the use of clean catheters in retention, by the dilatation
of strictures, withdrawal of stones, etc.   Rest in  bed is an essential
factor.   Hot drinks, tea, milk,  mucilaginous drinks, are the best.
The diet should be light  and the bowels should be moved every day.
Copious  draughts of  warm fluids flush the bladder.  Pain  may be
relieved  by hyoscyamine gr. i.— 3 i., gtt.  iij.-v. every  three  or four
hours,  or atropia in  the  same solution and dose.   Warm baths con-
stitute the best remedy for dysuria. The injection of hot water into
the rectum during the  bath heightens the effect.  More obstinate
cases yield only to opium (gr. i.) suppositories, or opium with extract
of belladonna gr. ss., or  rectal injection of tincture of opium  gtt. x.-
xv. with starch  water.   Dysuria  which amounts to strangury re-
quires  a suprapubic subcutaneous injection of morphia.
   Gonorrhceal cystitis  is often cut short by the administration of
copaiba or  the  oil of sandalwood  in capsules containing gtt. v.-x.
every two to four hours, or by the use of  salicylate of soda:
   B  Sodii salicylates................................................  3 ij.
      Glycerin*......................................................  3 i.
      Aquae menthae piperitae.........................................  3 iij.
   M.  S. Tablespoonful every three hours.
   Chronic cystitis calls  for  irrigation of the bladder with solutions
of boric acid  three  to  five per  cent, of  sublimate  1 :20,000 to
1 :10,000, creolin one-quarter of one per cent, nitrate of silver one
per cent, etc.  Astringent effects are best secured by the use of solu-
tions of alumnol one per cent, sulphate of zinc one-tenth of  one per
cent, tannin one-tenth to one-half of one per cent.

              ENURESIS (INCONTINENCE OP  URINE).
   Incontinence {in, negative, continere, to hold) of urine occurs es-
pecially  at the extremes of life, in age and childhood, and depends,
aside from organic disease, upon overdistention from paresis of the
detrusor with continuous discharge, or defective closure from paresis
of the sphincter. 
SPERMATORRHOEA.                     673
   Incontinence is frequent in women from dilatation of the urethra
with relaxation of the sphincter  in  consequence of the strain and
trauma of parturition.  Involuntary dribbling  or  discharge occurs
readily in such cases  with coughing, sneezing, any exercise of the
body.  Masturbation may produce the  same effect.  Incontinence is
frequent, too, in old men  on account of atrophy or affection of the
prostate gland (Peyer).  Great care must be taken in all these cases
not  to mistake an overflowing for an empty  bladder.  The urine
dribbles from a distended as well as from a paralyzed bladder.  The
most disastrous, even fatal, accidents have resulted from this mis-
take.  The use of a clean catheter will at once clear up any doubt.
   Enuresis {ev, in, ovpy6i$, passing water) is the involuntary, and
usually unconscious, discharge of  normal urine from a normal blad-
der.  Enuresis is a neurosis of the sphincter, and is for the most part
a persistence of the infantile state, where the resistance of the sphinc-
ter is very slight.  So enuresis  is most frequent at night, when the
influence of the will is withdrawn by sleep and the innervation of the
sphincter is defective.   The condition shows itself especially between
the ages of three and ten, sometimes not until  puberty, and then at
times in connection with onanism.
   Treatment.—Inspection occasionally reveals verrucosities or poly-
poid excrescences at the orifice  of  the urethra in girls, the exsection
or cauterization of which relieves the condition.  Debilitated children
must be built up with quinine, iron, cod-liver oil, and especially with
exercise in the fresh  air.   Cold baths contribute to fortify the body
in this regard.  Atropia gr. i.- 3 i.. gtt. iij. at bedtime, is the remedy
of most value.  It must be given with great caution to delicate chil-
dren, and gradually increased to tolerance, not beyond  dilatation of
the pupil.   The  most effective  treatment is  the  use  of electricity,
which is  safely brought  into  indirect contact with  the sphincter
through the rectum.   The current  should be feeble, scarcely percep-
tible, and may be gradually increased  to tolerance with sessions of
five  to ten minutes every other day.  Treatment usually requires a
period of four to five weeks. Exceptional cases are very obstinate.

                        SPERMATORRHOEA.
   Spermatorrhoea {67teppa, sperm, peoo, to flow), an abnormal dis-
charge of  semen.  An overflow which may occur once or  twice a
month is not disease.   The condition  becomes pathological when the
discharge is more frequent. In this regard individuals differ, and
each man is,  in a manner, a law unto himself.  The abnormity con-
sists not so much in the frequency as the effect.  The  physiological
overflow is followed by a sense of relief; an excess,  by exhaustion.
   Spermatorrhoea is  for the most  part a misnomer.  In many cases
        43 
674
SPERM ATORRHCEA.
the discharge is not semen, but secretion from  the prostate and ac-
cessor}' glands.   Prostatorrhcea is often a more appropriate  name.
The secretion, with few exceptions, may be  declared to be  semen
when the fluid contains spermatozoids (vide page 184, Fig. I'i7, 3).
In the few exceptions these structures are absent (vide Impotence).
   The loss occurs chiefly with the discharge of urine and with  the
act of  defecation.  In the  urine it is seen more  especially at or just
after the end of micturition.  The patient may be unaware of its es-
cape, and  recognize it or  suspect it only from  the turbidity of  the
urine,  or the physician may come upon it in the examination of  the
urine or its sediment.
   With the discharge of  fseces it is always visible, as the seminal
fluid is expressed by the mass of faeces itself.  In more aggravated
cases the patient is able to express the fluid, or comes to the physician
with the statement that he feels its passage or presence, sees it at the
orifice, and knows it to be semen by its greasy or " soapy " feel.
   Etiology. —Masturbation is the most frequent cause of sperma-
torrhoea.  Sexual excess  also  finally  renders the nervous system
irritable.  Posterior urethritis, inflammation of  the prostatic portion
of the urethra, involving especially the caput gallinaginis, due chiefly
to gonorrhoea, constitutes a constant  irritation.   An  elongated pre-
puce, a natural or acquired phimosis, which retains secretion;  ab-
normal states  of  the rectum and anus, constipation, ascarides, ecze-
matous eruptions, haemorrhoids, are outside irritants which may
much more exceptionally excite the genital centres.
   SympAoms.—Besides the presence of the discharge, the nature of
which  may be demonstrated by the microscope, a real spermatorrhoea
is attended with a sense of weakness, languor, and depression, with
various paresthesie and  vaso-motor disturbances, flashes of
heat, vertigo, and headache.   Most persons are affected with hypo-
chondriasis and melancholia, conditions which are produced  rather
by degrading habits—onanism, sexual  excesses, and  perversion—
which  cause the  spermatorrhoea, or are intensified by the perusal of
popular literature regarding the disease.  Dyspepsia, palpitation,
and dyspnea, dependent upon anaemic conditions of the blood, occur
later in the course of the affection.
   Diagnosis.—True  spermatorrhoea shows  spermatozoids in  the
discharge.  Prostatorrhcea furnishes a thin, milky fluid of character-
istic spermatic odor, containing numerous lecithin granules and crys-
tals  of the phosphates (sperm crystals), which fall in abundance
on the addition of a one-per-cent solution of ammonium phosphate.
Prostatorrhcea furnishes no spermatozoids.
   Phosphaturia, a secretory neurosis, or a deposit from local cause,
a condition without any real clinical significance, sometimes imparts 
IMPOTENCE.
675
 to the urine a turbidity or a milky color which is cleared up at once
 on the addition of a few drops of acetic acid.
    Treatment consists in regulation of the  habits, abstention from
 masturbation  and sexual excesses, relief of dyspepsia and  gastric
 catarrh, the education of the mind to a better tone.  Matrimony is
 the most effective remedy;  as a rule it renders all others superfluous.
 Hydrotherapy—a cold  bath every morning, especially a cold douche
 —invigorates the nerve centres.  A  dose of the bromide of potas-
 sium, gr. xx.-xl. in a glass of  water at  bedtime, may subdue the
 excitability of  the nerve  centres  and prevent nocturnal pollution.
 Posterior urethritis is best treated by injections of nitrate of silver,
 one to three per cent, with the catheter, after the manner already
 described.  Electricity in both  forms, faradization and galvaniza-
 tion, short sessions and feeble currents, often furnishes good results.
    Spermatorrhoea  is usually  found in  connection with  onanism,
 sexual excess, often with sexual perversion, in victims weakened by
 self-indulgence.  The treatment calls for the exercise of much pa-
 tience and tact.  The physician may accomplish more by elevating
 the standard of morals than by prescribing drugs.  The condition of
 many of these patients is pitiful.  They have been led to believe that
 their lives  are  wrecked.  They are finally frightened at  shadows.
 They may be led out of these delusions only  by kindness and encou-
 ragement.  Ridicule or contempt  drives  them back to the  charla-
 tans, vampires who feed on the miseries of their fellow-men.


                           IMPOTENCE.

    Impotence {impotens, powerless) is a relative or absolute incapa-
 city for natural coitus.  It depends upon physical, toxic, and psychi-
 cal causes.  Sexual potency, which is wholly relative  and varies in
 degree in the same individual, depends on the integrity of a reflex
 loop to and from a special centre in the lumbar cord, but the activity
 of this centre depends, in turn, on cerebral and reflex influences.
 Cerebral centres normally exercise over the spinal  centre inhibitory
 or controlling effects.  In  the absence or alteration of this influence
 the spinal centre acts to excess to  produce priapism.  Thus  section
 or destruction of the cord above the lumbar region is often followed
 by powerful and continuous priapism, because the inhibition from
 the brain is cut off.  Sometimes  the inhibition is too strong and
 psychical influences prevent erections altogether (impotentia psy-
 chica).  This control, or lack of control, is partly a matter of original
endowment, and partly of habit.  It is, at first at least,  largely  a
 matter of self-denial or self-indulgence.  The originating or rein-
forcing centres  in the cerebrum may be  cultivated to such  degree 
,;-,;                        IMPOTENCE.

as to entirely overcome the inhibiting centres and make a man " a
slave to his passions."                                     .w,.,.^
   Etiology.-Yhysical  causes include  malformation and (h t    •
atrophy, tumors, etc., which belong to the domain of sm^ij.  C M^
orchism  {upvnr6s, concealed-*, e.,  ^^f^T^l^^
causes impotence only when both glands are atrophied.  M u  ret
tion in the abdomen or in the inguinal canal is not mcompablewth
potency.  Among physical causes are to be included also  the effect
of certain disease! of the brain and cord,  the degenerations and of^al
diseases which produce marasmus.  Maladies which shw impof nee
as an early sign are diabetes, diphtheria, and tabes dorsahs, an   all
Uases should be studied first with reference to the -stenceo  these
affections.  Tuberculosis pulmonum  is  an interesting  e,;ug  to
the rule  that diseases marked by marasmus are  *^^ ™f ™*£
fence  By far the most common physical cause is excessive vene }
o abuse, onanism.  Regarding excess the rule of  Luther may be
remembered: "In der Woche zweier macht im  Jahreiu hundnt
rier " (twice a week is one hundred and four times a year).
    The  most common  cause of  sterility in  the male is gonorrhoea.
 which blocks the efferent vessels and shuts off the spermatozoids.
    Toxic influences are  the  effects  of certain drugs  alcohol,  the
 bromides, the iodides, opium, camphor,  salicylic acid, lupulm.
    Psychical causes are fear  of failure,  despair, dislike aveisio.
 Sexual perverts are often impotent with virtuous wives.   The condi-
 tion shows itself, as an impotentia coeundi,  in  absence of desire,
 absence or incompleteness of erection, premature  discharge ; and, as
 an  impotentia  generandi, in absence (aspermatism), diminution or
 alteration  of the seminal fluid, which when present may be  scanty,
 watery, purulent, or bloody, and may contain  motionless (azoosper-
 mia) few, or no  spermatozoids.  Gonorrhoea with  epididymitis and
 occlusion of the vas deferens is,  as stated, the most common cause of
 the last-mentioned condition.                              .
     Th* prognosis is much more favorable in cases of psychical and
  toxic impotence than in the presence of defects or paralysis.
     Treatment.-Feav  of failure is  generally relieved by resolution
  with efforts at complete abstention.   Excesses are usually cured b}
  continence.  In all cases the most essential element in the treatment
  of impotence is rest.  Defective innervation, including anaesthesia at
  the sensorv surface, is best stimulated by  strychnia gr.  &-^,  and
  electricity; faradization and galvanization, with  the negative pole at
  the spinal centre and the positive, urethral electrode introduced into
  the prostatic portion to the sensory (sexual) surface at and about the
  orifices of the  seminal  ducts.  Aphrodisiacs, including  cantharides
  act only by irritation and suggestion.  Suspension with extension ot 
DIABETES MELLITUS.
677
 the spinal column, not longer than five minutes a day, often relieves
 the impotence of locomotor ataxia.  The deep injection of a strong
 solution, three  to five per cent,  of nitrate of silver is a  powerful
 stimulant.
    The treatment of the psychical features or effects of impotence is
 the same as that of spermatorrhoea.

                       DIABETES MELLITUS.
    Diabetes {dia, through, ftaivoo, to go)  mellitus {peXi, Latin mel,
 honey).—A disease characterized by increase in the quantity of urine,
 and the continued  presence of sugar in  the  urine, with disturbed
 nutrition,  marasmus, liability to sudden coma, and a tendency to tu-
 berculosis.  The disease receives its name, diabetes, from the first of
 these signs, the increased flow of urine.  It is,  however, often recog-
 nized in  the absence of this sign, and the quantity of urine may vary
 to fall even below the  natural amount in the course of, especially at
 the close of, the disease.   The presence of sugar in the urine does not
 necessarily imply diabetes.  Transitory glycosuria is common.  It is
 only when present in a certain amount, or  more especially when per-
 sistent,  that sugar  in the  urine indicates the  disease diabetes.  A
 variety distinguished by an increase  in quantity, without sugar, is
 known as a special form—diabetes insipidus.
    History.—Celsus recognized the disease as a dangerous affec-
 tion, marked by increase of urine and emaciation.   Aretaeus named
 the disease " diabetes" and considered  it  a disease of the stomach.
 Galen located it in the kidneys, Sylvius in the blood.  All this time
 the disease was  known only  by its main  symptom, diabetes;  and,
 though the Indian physicians were familiar with  the fact that the
 urine contained sugar, which  they  recognized by the taste, this
 fact was not known elsewhere until  it was discovered by Thomas
 Willis (1674).  Dobson (1775)  seems to have been the first to obtain
 sugar  from the urine, and with  Pole, Home, and Cowley (1778-
 17ss) to thus really distinguish the disease.  Rollo  (1797) now made
 the discovery, of inestimable value, of the relation to diabetes of vege-
 table food, which he banished  from the dietary of patients in the
 treatment of the disease.  Ambrosiani (1835) first demonstrated the
 presence of sugar in the blood, which Mialhe attributed to the dimin-
ished alkalescence of the blood, recommending the administration
of alkalies to substitute the deficit.  Bernard (1850)  produced sugar
in the urine by a puncture  of the floor of  the fourth ventricle, and
seemed to have established a nervous origin of the disease.  Frerichs
and Yon  Recklinghausen (1866) remarked upon the frequency in dia-
betes of  disease of the pancreas,  which later writers bring in close
connection with the origin of the disease. 
678
DIABETES MELLITUS.
   Etiology.—Diabetes has been attributed to disease of the stomach,
kidneys, blood, nervous system, and pancreas.  It has certainly been
observed in connection with alterations of these various organs, but
also without discoverable lesions in any.  The real pathogeny of dia-
betes is unknown.  The  disease is three times as frequent in men
as in women, and occurs with especial frequency from  twenty to
fifty.  Yet cases are occasionally observed in childhood, even as early
as the first year of life ; and in age, even over seventy. Hereditary
influence is sometimes pronounced.  The disease is more frequent in
the upper classes.  The obese are especially predisposed ;  according
to Pfeiffer thirty-three per cent of  the obese become diabetic.   Dia-
betes has  been observed  to occur after traumata, especially  after
violent contusions or concussions involving the nervous system ; in
the course of or after nervous diseases, insanity, epilepsy, tumors,
aneurisms, etc. ; after emotional disturbances, fright, grief, anxiety ;
and in the course of convalescence from infectious diseases, especially
malaria.  The disease in these cases is said to be symptomatic.
   Pathogeny.—The sugar which appears in the urine  is derived
from  two sources : 1, from the food  directly, or indirectly through
the glycogenic  function of the liver ;  2, from the blood, from  trans-
formation of the fats and albuminoids.  In the first  case the sugar
disappears entirely upon absolute withdrawal of sugar and starch from
the food; in the second case the sugar, though diminished in amount,
still remains.  Thus are to be distinguished two forms of diabetes.
   Morbid Anatomy.—No constant  lesion is found in connection
with diabetes.  In the majority of cases nothing abnormal is  found
in the nervous  system, including  the vagus  and the sympathetic.
The liver is usually enlarged, but solely on account of hyperaemia.
Statements concerning hyperplasia of liver cells and connective tissue
are to be received with reserve.  The kidneys are usually increased
in size, also  on account of hyperaemia.  The  epithelium of the uri-
nary tubules shows  sometimes diffused  inflammatory, more  rarely
fatty, change.  The pancreas is affected more frequently.   In nearly
one-half of the cases it is found in a state of atrophy or degeneration.
The disease of the pancreas has been  attributed to affection of the
cceliac plexus, which has also been considered a common cause of the
disease of the pancreas and the diabetes.
   Symptoms.—Diabetes sets in  insidiously, and, though usually
preceded by  dyspepsia and nervous signs—anorexia, nausea, head-
ache, insomnia—is commonly recognized only when the patient no-
tices an'Tncrease in the quantity of  urine and thirst.  Increased
frequency of discharge is usually first observed at night, on account
of the preoccupations of the day ;  the quantity may vary from  four
pints to four quarts in twenty-four hours. 
DIABETES MELLITUS.
679
    The urine is clear, light in color, and free of sediment.  It foams
 readily on shaking, and the foam persists.   The reaction is always
 acid.  The distinctive feature is the increase in its specific gravity
 up to 1030-1040,  or even 1060.  The specific gravity corresponds in a
 general way to the quantity of sugar and other solids present.  A
 great excess of water may show a light specific gravity, 1008-1010,
 even in the presence of sugar.   The quantity of sugar usually ranges
 at two to five per cent, but varies from the minimum, one-half of
 one per cent, to the maximum, ten per cent.
    For clinical purposes sugar is recognized by one of the following
 tests :
    1. Moore's Test.—To the urine in a test tube is added one-fourth
 of its volume of liquor potassae ; the upper part of the fluid is  thor-
 oughly boiled.  The presence of sugar  is revealed by a  brown color.
 The addition of an acid develops the odor of burnt sugar (caramel).
 The absence of  coloration after thorough boiling is reliable nega-
 tive—?', e., exclusive—evidence.
    2. Trommer's Test.—A ten-per-cent solution of sulphate of cop-
 per is let fall into the test tube containing the urine, drop by drop, so
 long as the copper dissolves.  Liquor  potassae is  added in amount
 equal to  the whole amount of fluid.   The mixture is then slowly
 heated.   The alkali, in the presence of sugar, deoxidizes the copper
 and precipitates the salmon-colored suboxide.   The coloration should
 show before the boiling point is reached.  It continues after cooling.
 When the quantity of sugar is small the test is rendered uncertain
 by the fact that uric acid and kreatinin show the same reaction.
    3. Nylander's Test.—Dissolve four grammes of Seignette salt in
 one hundred cubic centimetres of eight-per-cent potash solution,  heat
 (but not to the boiling point), and add as much subnitrate of bismuth
 as will  dissolve (about two grammes).   Let cool; filter.  The clear
 solution is ready for use.
   Add one part of the Xylander solution thus prepared to ten parts
 urine.  Boil for a few minutes.  In the presence of  sugar the mix-
 ture becomes first brown, then brownish-black or black from diffusion
 of the bismuth, which gradually sinks as a sediment.   Minimal quan-
 tities require long boiling, five minutes, to precipitate a  grayish sedi-
 ment, a mixture of earthy phosphates and bismuth.
   The test of Nylander is among the  most delicate and reliable  of
 all.  It discovers  sugar in an amount  as small as one-tenth of one
 per cent, and nothing natural to the body but sugar will give the re-
 action.  Moreover, it is easily prepared  and keeps almost indefinitely
 (Graber).   It must be remembered, however, that certain drugs, the
various modern antipyretics,  with salol, senna, turpentine, will give
the same result. 
(iSO
DIABETES MELLITUS.
   4. Fermentation Test.—Three test  tubes  are filled  two-thirds
full of mercury.  To the first are added the suspected urine and pure
yeast; to the second, normal urine with yeast ; to the third, a dilute
solution  of  sugar in yeast; and to  each tube  a drop of  solution of
tartaric acid.   All three tubes are now inverted,  under cover of the
thumb, into a vessel of mercury.  The  accumulation of carbonic
acid gas  at the top of the first and third tubes shows the  presence of
sugar.  The second tube shows no  displacement of its fluid.  The
quantity is  roughly estimated by the specific gravity, provided the
quantity of  urine is increased ; more accurately from the difference
in the specific gravity before and after the fermentation test.
   1. The rule runs :  Divide the last two  figures of the specific
gravity by 4, and subtract from  the quotient 1 or 2, according to the
quantity of  urine, the lesser number for a large  quantity.  Thus  a
specific gravity 1032 would give 32 -f-  4 = 8 — 1 or 2 = 6 or 7 per cent.
   2. Multiply the difference of  fermentation by 0.22 ; the sum is
the percentage of quantity.  Thus, specific gravity before fermenta-
tion 1032, after 1004, difference 28 ; and 28 X 0.22 = 6.16  per cent.
   The sugar commonly present is the variety known as grape sugar.
Sometimes the urine contains other forms of sugar—inosite and levu-
lose.  Sometimes the urine contains  products of  fermentation, alco-
hol,  diacetic acid, and acetone, which is recognized by the Burgundy-
red color struck on the addition  of the chloride of iron.   The urine
may also contain albumin.   The quantity  of urea is markedly in-
creased.   The  discharge of urine may be so frequent as to harass
the patient.   This is especially the case in childhood, where the sleep
may be disturbed.   Enuresis  nocturna should always excite  suspi-
cion of diabetes.
   The thirst stands in correspondence with  the quantity discharged.
It is sometimes associated with  a feeling of dryness, and is often
insatiable.   Suspicion of the existence of the disease may be excited
by the constant endeavor of the patient to moisten the lips with the
tongue.  The gums are sometimes swollen ;  they may bleed easily ;
the teeth may become carious.   The appetite is usually disturbed;
it may be voracious and yet fail to satisfy.  The bowels are con-
stipated.   Nervous  symptoms may  assume  prominence.  There is
usually progressive degradation of health and strength;  it is
remarked in loss of energy, headache,  disturbances of  sensation,
formication, other parsesthesise, severe neuralgia.   The expression is
usually nervous,  anxious, troubled.   A prominent symptom is im-
potence ; patients frequently present themselves for treatment  of
this symptom, which is found to rest upon diabetes.  The knee jerk
is diminished or lost.  Impotence,  in association with  absence of
knee jerk, often leads up to the recognition of diabetes.  On accoimt 
DIABETES MELLITUS.
681
of the excessive excretion of water the skin is dry and scaly.  Pru-
ritus, especially pruritus vulvae, is  often distressing and obstinate,
and scratching in its relief easily breaks the surface.  A tendency to
furunculosis is common, and the frequent occurrence of boils should
always lead to examination  of  the urine.  More extensive phleg-
monous inflammations, even gangrene, occur  in individual cases.
The surgeon hesitates  to operate upon the diabetic patient.  Cata-
ract occurs in five to ten per cent  of  cases, more especially in ad-
vanced stages.  The  opacity  of the lens is not due to loss of water,
as was formerly believed, but to disturbance of nutrition.
    A peculiar coma is liable to supervene in the course of  diabetes.
It is the  gravest of the nervous complications—in  fact, is usually
fatal.   The patient, in the midst of his usual  health, or that con-
dition of  it which belongs to diabetes, falls into somnolence and
stupor, finally into coma.  The coma supervenes  sometimes sud-
denly, and is  attended with heart  failure  and  collapse.   In  other
cases  it is  preceded by nervous disturbances, headache,  unrest,
anxiety.  It is commonly marked by a characteristic deep-sighing
respiration,  often by cyanosis.   Occasionally the breath has a pe-
culiar odor, sometimes fruity, sometimes suggestive of chloroform.
The coma is attributed to an acid fermentation of the blood with the
development of acetone, because it has been observed that the urine
strikes the  Burgundy-red  color with the  chloride of iron.  But
neither acetone nor other product of decomposition has yet been dis-
covered in the blood.  This  complication may put an end to  life
in twenty-four hours, more frequently in the course of three to five
days.
   Along with the general degradation of tissue connected with the
formation of carbuncles, necroses, and gangrene, is a tendency to
tuberculosis.   Diabetes fertilizes the  soil for the growth of  the
tubercle bacillus.   One-half of  all  cases of diabetes succumb  to
tuberculosis.
    Course.—Diabetes is a chronic disease of  varying  duration.
Cases are distinguished as diabetes acuta and even acutissima, which
may  run  their course in a  few weeks or months.  The disease
usually lasts from  three to fifteen  years ; the  average duration of
life ranges about five years.  Forms are differentiated as light and
severe, according as the symptoms may be controlled or not  by diet.
After the study of one thousand cases Seegen still insists upon this
classification of cases.  In the lighter  form sugar disappears from
the urine with  abstinence from  starch  and sugar in the food,  while
in the severer form  the sugar still persists.   There are, he still main-
tains,  no  mixed or other  forms.  The disease advances  rather in
stages than continuously, with periods of remission and exacerbation. 
682
DIABETES MELLITUS.
   The prognosis is  always grave.  Diabetes is  not yet a curable
disease.  But the  immediate outlook depends upon  the form of the
disease.  Patients may in the lighter form live to die of old age, while
life is always cut short in the graver forms.  Diabetic coma is always
an ominous sign, and tuberculosis has far greater gravity when  it
develops in the course of diabetes.
   The diagnosis depends upon  the  increased urine and the pre-
sence of sugar.  Sugar  exists naturally  in  the blood in very small
amount (0.1 to 0.3 per cent), and has been found in health in very
minute quantities even  in the urine.   The existence of 0.3 per cent
of sugar in the urine suffices to produce all the signs of grave dia-
betes (Abels).  It is the persistence of sugar in the urine in distinct
quantity that distinguishes diabetes.  The general  degradation of
strength, dyspeptic   signs, pains  and parsesthesiae,  furunculosis,
pruritus, disturbances of vision, excite suspicion of the existence of
diabetes, which can only be declared positively by the  discovery of
sugar in the urine.
   Treatment is mainly  a  matter  of diet. Sugar and  starch must
be withheld.   The food  should consist largely of milk and  meat,
every form of which,  in fish, flesh,  and fowl, may be allowed.  Vege-
tables which contain much starch  must be taken sparingly or put
under ban.  Certain vegetables may be given freely—lettuce, cress,
made into salad;  cucumbers, tomatoes (raw), spinach, asparagus,
string (green)  beans, cabbage,  and cauliflower.  But  beets, peas,
beans  (butter beans  and dried beans), potatoes, corn,  rice, cereals,
are prohibited foods.   Coffee and tea may be sweetened with a pinch
of saccharin, which is three hundred times as sweet as sugar and
does no damage.  Levulose is said to be a sugar which  acts without
injury as a  food.  The denial of bread  and potatoes becomes  a
punishment.   Patients crave bread.  The so-called  health foods—
flour  from which  the starch has  been removed, almond flour, etc.
—are poor substitutes.   It is  better  to  allow  small quantities of
bread regularly or occasionally.  The object in the treatment of dia-
betes is not so much to secure urine free from sugar as to maintain
the patient in a state of health, as near as may be.   It  is better to
maintain the health with a certain  glycosuria than to lose it without
glycosuria.  Of forty-nine cases treated by  Liebermeister  under
withdrawal of all carbohydrates, the sugar disappeared entirely in
twenty.  In  seven of these cases it reappeared  with return  of the
patient to the use of starchy food ;  in two, only when the food was
taken in excess ; in five,  only when white bread was  taken in quan-
tities exceeding four ounces per day.
   Drugs can accomplish little.  Opium distinctly reduces the quan-
tity of sugar and diminishes the quantity  of  urine ;  but it also dis- 
DIABETES INSIPIDUS.                    683
turbs digestion, and may therefore be resorted to only temporarily
in extreme cases.  In prolonged use its evils counterbalance its good.
Pavy preferred codeine  in dosage increased from three  to  thirty
grains a day.   But the same objections as to opium apply eventually.
Rational therapy is out of the question until the nature of the disease
is understood.   On account of  the acid condition of the urine and
the assumed reduced alkalinity of the  blood, alkalies, especially in
the form of mineral waters—Vichy and  Carlsbad—may be adminis-
tered freely.  The salicylate  of soda or salol, ten  to fifteen grains
four times a day, may be given with much temporary benefit.  Ar-
senic, Fowler's  solution, gtt. iij--v. three times a day,  best supports
the general nutrition.  Dyspeptic signs are relieved by regulation of
the diet.   Nux vomica, tincture, gtt. x.-xx., is  indicated in failing
appetite.   Thirst may be relieved by drinking less water at a time,
frequent washing of the  mouth, the use of ice pills, and chloroform
gtt. ij.-iij.  In diabetic coma  the blood may be saturated with alka-
lies, especially the  bicarbonate of soda.  The salt solution (common
salt  one drachm,  bicarbonate  of  soda  gr.  xlv., water one  pint),
sterilized by heat and  cooled to 100° F.,  may be  introduced into the
veins.   Diabetic patients should dress warmly, guard against expo-
sure, and avoid both  inactivity and excess.   Travel aggravates the
disease.

                      DIABETES INSIPIDUS.

   Diabetes insipidus is an increase in the quantity of urine without
the presence of sugar—a polyuria without  glycosuria.  But  every
polyuria does not constitute this form of diabetes, for  polyuria is  a
necessary result of the ingestion of  large quantities of fluid.  Ex-
cesses of fluid—water, milk, beer—are discharged in  this way.  Poly-
uria occurs also in connection  with certain forms of kidney dis-
ease—renal cirrhosis,  where it is due to disease of the  glomeruli,  as
well as to increased forcing power of the heart.   Bernard found that
irritation of a point in the floor of the fourth  ventricle a little  above
the diabetic point produces polyuria without glycosuria.  On this ac-
count the disease has been referred to nervous origin and considered
a subvariety of pure diabetes.   But diabetes  insipidus has nothing in
common with diabetes mellitus, except increased quantity of urine ;
for diabetes insipidus is not attended with the general signs—dys-
pepsia, neuroses, pruritus, cataract, marasmus—of diabetes mellitus.
   In the present stage of knowledge diabetes insipidus is considered
a vaso-motor neurosis, probably of central origin.
   Etiology.—Notwithstanding the essential difference in the na-
ture of the affections, the same obscurity surrounds  the origin of dia-
betes insipidus.  The  condition  has been noticed to occur in  the 
684
DIABETES INSIPIDUS.
course of organic brain disease after trauma and ('motional distress.
It has also been attributed to exhaustion and exposure to cold.  The
influence of heredity is sometimes marked.   Weil reported twenty-
three cases of diabetes insipidus in a family whose various branches
numbered ninety-one persons.   The disease is more frequent in the
male sex and about the period of maturity.
   Synqitoms.—The symptom is the increase  in  the quantity of
urine, which may be slight or great.  The quantity may vary from
four pints to four quarts, and not infrequently exceeds this amount.
The urine  is clear and light, 1005 and less.  Thirst increases in cor-
respondence with the loss of water, though it  is not so intense and
insatiable as in diabetes mellitus.  The secretion of sweat, including
the insensible perspiration, is reduced  or arrested—a point of great
value in differential diagnosis,  for the action  of  the skin is  unaf-
fected in the polyuria of health, hysteria, etc.  The general  health
may be sustained throughout.   The disease is chronic and runs its
course with remissions and exacerbations.  It is often arrested for
months at a time and is not infrequently absolutely cured.  Treat-
ment consists in regulation of life.   Water must be taken frequently
rather than abundantly.  Opium has the same effect as in true dia-
betes in producing immediate effect with the same remote evil.  Er-
got  sometimes controls the condition.  Antipyrin, antifebrin, and
agents of this class quickly reduce the secretion.  The preparations
of zinc, the lactate and valerianate, sometimes exercise more per-
manent effects.  Arsenic in the form of the common potash solution,
gtt.  iij. ter die, or with bromide, as the solution  of the arsenite  of
bromine, in the same dose, should  be given faithful  trial in every
case. 
    DISEASES OE THE

NERVOUS SYSTEM.
                        CHAPTER  XI.

         DISEASES OF  THE NEEVES AND MEMBEANES.

    Diseases of the nervous system  are  distinguished  as  organic
 with discoverable, and functional with undiscoverable,  lesions, and
 make themselves manifest by alteration  of sensation, as abnormi-
 ties, paraesthesia ; loss,  anaesthesia ; increase,  hypersesthesia ; pain,
 neuralgia ;  disturbance  of  nutrition,  trophic change ; alteration of
 motion; spasm, contraction, paralysis,  abnormity of reflex ; affec-
 tion of special sense, intellectual faculties,  and of consciousness.

                           NEURALGIA.
    Neuralgia {vsvpor, nerve, ixXyo?, pain), pain of nervous origin.—
 A symptom, not a disease, due to affection of the nerve at its centre,
 in its course, or at its distribution. The lesion may be gross  and dis-
 coverable {i.e., organic)  or merely molecular {i.e., functional).
    Etiology.—Neuralgia may depend upon irritation of the nerve by
 trauma, exposure of the nerve (toothache), or pressure.   Wounds of
 all kinds, aneurism, hernia, exostoses,  cicatrices, etc., may be the
 exciting cause.  More frequently neuralgia is due to poisoning of the
 blood  by infection  (malaria),  products  of inanition, exhaustion as
 from anaemia, chlorosis, loss of  blood.   Neuralgia is rare in child-
 hood, and is much more frequent in women than men.
    Symptoms.—As the name indicates, neuralgia is distinguished by
 pain, which varies  in every degree of variety from a dull headache
 to the excruciating  paroxysms of tic douloureux.  The pain is con-
 fined to the nerve  affected, trigeminus,  sciatic, etc., or irradiates
'from its origin in various directions, as in angina pectoris.  It  is some-
 times reflected or projected to a distant point, as  in pain of the knee
 from coxalgia.  Severe paroxysms are attended by general  distress,
 nausea and  vomiting, sinking signs, sometimes by muscular spasm. 
686
NEURALGIA.
Severe pain is paroxysmal for the reason that sensation becomes
exhausted for a time.
   Neuralgia of the Trigeminus occurs in  its various branches as
supra- and infra-orbital and as supra- and infra-maxillary neuralgia.
Painful points may be detected on pressure at the orifice  of exit
of these various branches.  Infra-orbital neuralgia occurring in par-
oxysms causes the excruciating pain in the side of the face known as
tic douloureux.   Supra-orbital neuralgia is  most frequently due to
malarious  or rheumatic cause.  The other  forms  may  be  caused
by affection of the teeth, pressure upon nerve trunks, degenerative
lesions of ganglia or nerve  cells at their deep  origin.
   Occipital Neuralgia, manifested by pain in  the back of the
head, is also a common expression of malaria or  other toxaemia.
Typical cases have been observed in connection with the absorption
of toxic substances from the uterus and prostate gland or posterior
urethra.
   Intercostal is a common form of neuralgia.  It is usually felt
in the neighborhood of the nipple, and more frequently upon the left
side.  It is a common  expression of Bright's disease, but may  be
due also to malaria, where it must  be distinguished  from rheuma-
tism, and to tuberculosis, where it must be distinguished from pleu-
risy.  Intercostal neuralgia distinguishes itself by its three painful
pioints: (1) near the spine,  where the nerve issues from the interver-
tebral  foramen; (2) near the axillary line, where the nerve becomes
subcutaneous;  (3) near the sternum, where  the terminal branches
become subcutaneous.  An eruption (herpes) in the course of these
nerves is not uncommon.
   Sciatica.—Pain in the course of the sciatic nerve is so frequent
as to be considered as a separate affection.  It is sometimes evidence
of organic disease, especially of  caries of the vertebra, and the sim-
ple neuralgic affection must be distinguished from the pain  of pres-
sure, as from coprostasis,  tumor, aneurism, etc. The cause of  sci-
atica is often obscure.   It is more frequent in men than women, and
in the lower classes where the  condition is  often confounded  with
rheumatism.  Sciatica  is  much more frequently excited by local
cause, cold and damp, and is much less  frequently due  to general
cause,  malaria, Bright's disease, etc.  Painful points may be some-
times discovered, especially in the neighborhood of  the tuberosity of
the ischium; in the course of the trunk of the nerve; lower, in the
ham, behind the head of the fibula, over the foot.  It is  sometimes
attended with cramp, and  is more  frequently than  any other form
associated with atrophy of  muscle.   The pains of sciatica are, as a
rule, more  continuous than acute, and stand in closer relation than
other forms to climatic change. 
NEURALGIA.
687
    Coccyodynia is an obstinate neuralgia of the coccygeal  plexus,
 which occurs especially as a traumatic lesion in connection with par-
 turition, less frequently from unknown cause, exposure to cold, etc.
 It may be so severe as to require resection of the nerve or even extir-
 pation of the coccyx.
    Headache (cephalalgia) is the most common of all the forms  of
 neuralgia, and may be an expression of all the multitude of  causes
 which may produce neuralgia in any form.   Headache announces
 the advent of the acute infections.  Persistent headache in an indi-
 vidual previously free from it should excite suspicion of Bright's dis-
 ease.  A localized, circumscribed point of pain (clavus) is a frequent
 expression of hysteria.
    A special form, of periodic occurrence, found usually in connection
 with disturbance of the stomach, constitutes the variety known  as
 sick-headache (migraine), which is variously interpreted as  a vaso-
 motor (sympathetic)  disturbance, or neuralgia  of  the  intracranial
 branch of the trigeminus. Migraine is transmitted by heredity di-
 rectly, or is an expression of  an allied neurosis—hysteria, epilepsy,
 insanity—and consists, with them, of an underlying state and explo-
 sion from exciting cause.   It runs in families, and appears in women,
 in whom it is  by far most frequent, especially in connection with
 menstrual disturbance.
    It occurs in paroxysms without distinct periodicity, though some-
 times quite regularly with menstruation, sometimes again twice a
 month, or several times only in the course  of the year.  It is espe-
 cially wont to occur in connection with emotional disturbances.
    The attack begins usually in the morning, upon awakening after
 a night  of restlessness or heavy sleep, with  malaise, depression,
 irritability, and the headache supervenes at once as a dull distress,
 sometimes diffuse, usually localized in one  or the other, more fre-
 quently the left,  side of the head.  The pain is sometimes confined
 to the region of individual nerves, especially in connection with pa-
 rietal and supra-orbital branches, and varies in every degree of inten-
sity.  The special senses are hyperesthetic:  light pains the eyes ;
 scotoma is common ; crenellated outlines more rare ; noises otherwise
 unnoticed inflict punishment; odors excite nausea.   Disturbance  of
the stomach assumes such prominence as to have given the common
name to the disease, sick-headache.  It is not the cause of the head-
ache or neuralgia, but is a coeffect of a common cause.  Vomiting
occurs frequently, with discharge of the contents of the stomach, or,
as the stomach is usually empty, of  accumulated mucus and  regur-
gitated bile.  The face on the affected side  is usually flushed, and
branches of the temporal artery throb visibly in their tortuous course.
   Diagnosis.—Migraine  is distinguished from  epileptic forebod- 
688
NEURALGIA.
ings by the stomach distress and preservation of consciousness, and
from Bright's disease, renal cirrhosis, by the absence of albuminuria.
   The treatment is usually successful at first, but fails later with
the same remedy.  Rest in bed, with perfect quiet of mind and body,
is the first essential.  Every case requires study for the discovery,
and if possible removal, of some distinct cause, as anaemia, dyspepsia.
irregular habit, insufficient sleep, mental strain, excess in social life,
domestic trial, etc.  The attack proper is relieved or curtailed by the
bromides in  large doses,  gr. xxx.-xl.  in a glass of water, caffeine
gr. ij.-iij., guarana gr.  xxx.,  the  powder  of coca  leaves gr.  xv.,
cocaine gr.  ss.,  antipyrin gr.  v.-x.  Any of these  remedies may
succeed at first, but with increasing tolerance fail  in later attacks.
The only real success is accomplished  by address to the underlying
state.  Increase in the  general health prolongs the interval and re-
duces the severity of the attacks.  Change of climate often gives re-
lief.  Change of occupation may have the same effect.  The attacks
cease sometimes  with the grand climacteric in women and at the
corresponding period of  life in men.   Sometimes  they remain in
greater or less severity, defiant of all medication, as a life-long evil.
    Gastralgia, neuralgia of the stomach, has already been described
in  connection with disease of the stomach, and neuralgias of the
heart, palpitation, angina pectoris, etc., in connection with disease of
the heart.
    Enteralgia, neuralgia of the  intestine, nervous colic, depends
upon the same causes as gastralgia. It occurs especially in nervous
individuals, and alternates with other forms of neuralgia.  It shows
itself also in other cases independent of other neuroses or of a neuro-
pathic temperament, as the result of a toxaemia. A typical example
of this enteralgia is furnished in lead colic, where the disease is due
to the direct effect of lead upon the ganglionic  centres.   As in gas-
tralgia, the  pain  may be very  severe and may be attended  with
sinking sensations, vomiting, heart failure, and collapse.  Hot appli-
cations, including copious injections of hot water, with the admin-
istration of anodynes, morphia subcutaneously, relieve the attack.
The cause, when rheumatic, is most effectively addressed by salicylic
acid in doses of gr. x.  every hour or  two until the ears ring.  The
remedy must be administered  continuously at longer intervals for a
week.  Lead poisoning calls for appropriate treatment.
    Neuralgia of the  Spermatic Nerve  occurs more especially
in the young, and shows  itself in shooting pain which radiates  from
the testicle along the course  of the spermatic cord.  It  may be also
associated with  nausea,  vomiting, and  sinking  sensations.  The
treatment is the same as  that of the neuralgias  just mentioned.
    Neuralgia of the Joints occurs especially in connection with 
NEURALGIA.
680
 hysteria, and is sometimes one of the most obstinate manifestations
 of that disease.  It is usually confined to a  single joint, the hip or
 knee, and may show itself with all the signs of acute rheumatism,
 including at  times  redness  of the skin.  It is  sometimes a.ttended
 with deformity and atrophy from disuse.  The diagnosis is often
 difficult, but is assisted by consideration of the age, sex, and history.
 The hysterical joint occurs in connection with  other signs of hyste-
 ria.   The sensations of .pain and distress are  out of all proportion to
 the objective signs,  etc.
   The treatment of neuralgia consists in the discovery and removal,
 if possible, of the cause.   This  cause is often, as stated, an infection
 of the blood, and treatment  consists in the neutralization of the pro-
 ducts of infection.   Thus  quinine and arsenic quickly cure the most
 obstinate cases of malarial neuralgia, and  mercury and iodide of
 potassium cure or control the pains of syphilis.  Neuralgias of the
 stomach  and bowels,  gastralgia and enteralgia, are usually relieved
 by salicylic acid or salol; the neuralgic pains of Bright's disease are
 best controlled by hot baths  and remedies which produce sweating—
 jaborandi, pilocarpine.  More permanent effects are obtained by the
 use  of mineral waters, sojourn at watering  places, etc.   Neuralgias
 which depend upon  alterations of the blood—anaemia, chlorosis, etc.
 —are treated with some of the various preparations of iron, as men-
 tioned under Chlorosis, etc.  The various antipyretics—phenacetin
 gr. x., antipyrin gr. v., antifebrin gr. v.—give sometimes immediate
 effects.  Counter-irritation, especially in the form  of linear cauteri-
 zation, may control  obstinate cases of neuralgia in the neighborhood
 of the spine.  The remedy of most value for general use is electri-
 city, which  may be used in the form of the  induced or constant
 current.   The negative pole is  applied usually to the  spine in the
 neighborhood  of the  origin of  the nerve; the positive  is stroked
 gently along the course of the nerve, or is held fixed for five minutes
 at the seat of pain.  Gentle  currents which  produce only redness of
 the surface are attended with the best effects.
   Atropine (gr. i.-|i.) gtt. iij.-v., hyoscyamine  gr. Tfa,  are effec-
 tive  anodynes.  Sometimes a severe neuralgia  is relieved at once by
 injection  into the  substance of the nerve,  with  the subcutaneous
 needle, of chloroform  or ether  gtt.  v.-x.  This procedure proves of
 most value in cases of sciatica.   Morphia should be used only as the
 last resort in extreme cases.   The evils of the opium habit are mostly
 engendered by resort to morphia in relief of neuralgia.
   The treatment of neurosis of the joints  is  that of the general
 rather than the local condition, whereby it is often best to ignore the
joint  affection as much as  may be, for concentration  of attention
 upon it  often aggravates the malady.   Isolation of the patient, or,
        44 
690
NEURITIS.
better still, occupation of a  bed in a hospital ward by the side1 of
cases of real maladies—other than joint diseases, of course—accom-
plishes more than local treatment.  Nevertheless massage, manipu-
lation, hydrotherapy, electricity, salol, are sometimes of value.

                            NEURITIS.
   Neuritis.—Inflammation of nerves, attended by hyperaemia, infil-
tration,  and degeneration.  Neuritis may be acute or chronic, fixed
or wandering, ascending or descending in the course of the nerve.
   It is usually due to trauma, though it may result from extension
of inflammation  from contiguous  structures.   Thus an ascending
neuritis is sometimes seen to develop in  consequence of an infection
of the genito-urinary organs.   A good example of a descending neu-
ritis is found in connection with changes in the spinal nerves issuing
from a cord affected with locomotor ataxia.  The  neuritis produced
by the  action of toxines—diphtheria, typhoid fever, etc.—is a pro-
cess better known in its effects than its lesions.  The peculiar infec-
tion of the tropics known as beriberi and kakke (Japan) is regarded
as a panneuritis.   This disease is associated with heart failure, with
paresthesias, numbness and burning, and paralysis.  Neuritis some-
times follows exposure to cold.  This form is known as rheumatic.
It occurs  also in  connection with  syphilis, lepra, cancer, and gout.
Multiple neuritis is often distinctly caused by alcohol.  The pains of
neuritis differ from those of neuralgia, in that they are more contin-
uous and are aggravated rather  than lessened by pressure.  They
are  also associated  with more  or less anaesthesia.  Muscles in the
domain of the affected nerve lose their electric excitability and show
later the reaction of degeneration.   Trophic changes sometimes de-
velop ; herpes zoster is common.   A much more rare trophic change
is the perforating ulcer of the foot, malum perforans pedis, which
develops as a progressive ulcer, uncontrollable in its progress, on the
sole of the foot.
    Multiple Necritis distinguishes itself  by the affection of  a
number  of  nerves, usually  consecutively.  It  results, as  stated,
chiefly from  alcoholism,  and is the common cause of alcoholic para-
lysis.  It occurs, however,  in connection with exposure  to cold,
rheumatism, and  exhaustion ; sometimes as  the result of toxaemia.
The musculo-spiral and anterior tibial nerves are usually first af-
fected.   The wrist drops, the feet are extended to lie on a line with
the legs.  The disease begins, as a rule,  with fever and sensations of
numbness and tingling in the fingers and toes, with more or less rheu-
matic pain.  The nerve trunks are sensitive to pressure.   The power
of extension  of the hand is impaired in both arms.   The same weak-
ness soon shows itself in the legs.  Electric  excitability is  lost and 
SPASM.
691
the muscles show the  reaction of  degeneration; reflex action is also
lost;  the  knee jerk  disappears  early in the  history of  the  disease.
Trophic  changes, oedema,  and joint  effusion  are common;  the
sphincters are unaffected.   The disease is chronic, and advances, as
a rule, more or less  continuously  for a period of four to six weeks,
when it slowly subsides.  Complete restitution requires a period of
many months.   In the alcoholic form of the disease relapses are fre-
quent.
   Treatment.—The asepsis of modern surgery prevents many cases
of neuritis.   Prompt  and  more persistent treatment of gout and
syphilis has  the same effect.   The pains of acute neuritis  may be
relieved by the methods used in the treatment of neuralgia.   Coun-
ter-irritants are of more decided value.  Hot applications, dry cups,
tincture of iodine, cauterization,  vesicants, may be used in  individ-
ual cases. The preparations of salicylic acid are of especial value
in rheumatic, febrile,  and alcoholic forms of the disease.   Alcohol
 Fig. 276.—Multiple (alcoholic) neuritis; palsy of extensors of wrist and flexors of ankle CGowers).

 itself must be put under ban.  The body must  be built up with
 quinine, cod-liver oil, tonics, fresh air, and good food ; the affected
 nerves with electricity and strychnia.

                              SPASM.
   Spasm may be of central or peripheric origin.  It occurs as more
 or less continuous (so-called tonic) and as interrupted (so-called clo-
 nic)  convulsions.   Examples  of tonic convulsions are furnished in
 tetanus, tetany, cramp (cholera), contractures (post-hemiplegic, etc.).
   Myotony, a peculiar form of contraction, was first described by
 Thomsen (1876), as experienced in  his own  person.  It is, hence,
 often known as Thomsen's disease.   In this affection the muscle, in-
 stead of  being relaxed after effort, remains in a state of tonic con-
 traction for some length of time.  The disease may even involve the
muscles  of the tongue.   In a curious case recorded by Ballet and
 Marie the eyes became fixed, and were only changed with  difficulty
from the direction which they were made to assume.
   Torticollis  (caput  obstipum) is the  most common example of 
692
PARALYSIS.
tonic spasm.  The muscles usually affected in this condition are the
sterno-cleido-mastoid, the splenius, and the trapezius.  The head is
rotated to one side and the face is turned up.  Distinction must be
drawn between cases which originate from simple exposure1 to cold,
so-called rheumatic affection of the muscles, and  conditions due to
diseases of the spinal cord or vertebrae, as caries of the spine.  The
rheumatic affection  may give rise to much pain and distress, but is
of short duration.   It disappears  readily under  faradization, hot ap-
plications, anodynes, stimulating liniments, etc.
    g Tincturae opii, tincturae aconiti, olei olivae....................aa p. ve.
    M. S. Lir/iment.

Pain may be relieved  by the use  of  atropia gr.  T£¥,  or hyoscya-
           Fig. 277.—Spasm of the trapezius (Duehenns).  See also page 323.

mine gr. Tfo> subcutaneously.   Cases due  to organic disease are ex-
ceedingly obstinate, sometimes irremediable.   Section and exsection
of the nerve  afford  only temporary relief.  Better  results may be
reached by exsection of  a series, as of the first three cervical nerves,
after the method suggested by Keen.
   Lumbago, which is  interpreted as a rheumatism of the muscles
of the loins or lumbar region oftener than  as a peripheral nerve af-
fection, may be so severe as to demand the injection of morphia gr. £
deep into the substance of the muscles.

                           PARALYSIS.
   Paralysis {napaXvoo, to loosen) may be central  or peripheral.   It
shows  itself as  impairment or abolition of  motion.  Partial  para-
lysis  is  sometimes  distinguished  as  paresis.   Paralyzed  nerves 
      PARALYSIS OF  THE FACIAL NERVE—BELL'S PARALYSIS.   693

degenerate.  This degeneration is marked by certain changes in elec-
trical  irritability.  In the normal nerve the application of  the
negative pole,  cathode, produces contraction at the moment of  clos-
ing, and of the positive pole,  anode, at the moment of opening the
circuit.  Healthy muscle, independent of the nerves, cannot be ex-
cited to contraction by the induced (faradic)  current, but may be
excited  to slow contraction by  the constant (galvanic)  current.
When the nerves are degenerated the induced current fails to excite
contraction when brought to bear either upon the nerves or upon the
muscles : and the constant current will not act upon the nerves, but
will nevertheless produce a slow contraction in the muscle so long as
the muscle itself has not suffered degeneration.  For a  certain pe-
riod muscles supplied by degenerated nerves are more easily excited
than muscles supplied by healthy nerves.  Contraction occurs  ear-
lier and stronger, and the order of contraction is reversed.  That is,
the positive pole produces the strongest contraction with closing, and
the negative with  opening, the circuit.   This  change, which  indi-
cates a certain period of degeneration, is known as the reaction of
degeneration.  It  is a  valuable  sign in  both diagnosis and prog-
nosis.
   Muscles supplied by degenerating nerve fibres are more sensitive
also to mechanical irritation.  A stroke upon the muscle, or exposure
to cold air, excites contraction.  Such idio-muscular contraction is
seen in the muscles of patients  suffering from marasmus from  any
cause, tuberculosis, carcinoma,  etc., and  is typically shown in the
fibrillar contractions of progressive muscular atrophy.

      PARALYSIS OF  THE FACIAL NERVE—BELL'S PARALYSIS.
   Paralysis of the  facial nerve  arises in  consequence of  disease or
injury to the nerve at its origin,  course, or distribution.   The para-
lysis  is central or peripheral.   Central  paralysis occurs in con-
nection with hemiplegia (haemorrhage, embolus),  and is nuclear, su-
pra- and intranuclear, according as the lesion is  situated in, above,
or below the  pons.  In supranuclear lesion, the  nerves  about  the
mouth  suffer most,  and voluntary are  more  impaired  than  emo-
tional movements, while electrical reaction remains normal.   In nu-
clear and intranuclear paralysis all parts  of the face are paralyzed
and secondary changes set in with reaction of degeneration.  Injury
in the intracranial course of the nerve is usually inflicted by menin-
geal exudation  and tumors.  The condition is recognized by impli-
cation of the auditory nerve.   Disease of the ear, caries  of bone, is
the most common cause of damage in the Fallopian canal.
   Etiology.—In the great majority of cases the lesion is peripheral,
and is a form of neuritis, the result of exposure to cold.  Paralysis 
694   PARALYSIS OF THE FACIAL NERVE—BELL'S  PARALYSIS.

is especially wont to set in after sitting in a draught, as at an  open
railroad car  window, where the rest of the body is  superheated.
Syphilis affects  the eye  (oculo-motor,  abducent) much  more fre-
quently than the  face.  Peripheral  facial paralysis is  sometimes
observed in  consequence of suppurative parotitis, and is  not infre-
quently produced in the new-born by the pressure of the forceps.
   Certain families, certain individuals (neurotic), are predisposed to
the disease.
   Fig. 278.—Facial paralysis, left side, under attempt at contraction of all the muscles of the
face (Putzel).

   Paralysis is limited to one side, but is exceptionally bilateral, in
consequence more particularly of disease of the  pons,  sometimes of
diphtheria.
   Symptoms.—In complete paralysis of the facial nerve one  whole
side of the face becomes immobile.  The muscles  hang without ex-
pression, so that the affected side looks like  a mask.  The contrast,
which is marked even  at rest,  becomes more marked with the at-
tempt to express an emotion.   The contraction of  the  sound distorts 
     PARALYSIS OF THE  FACIAL  NERVE—BELL'S PARALYSIS.   695

the affected side.   The eye is open and cannot be perfectly closed.
The ball is rolled upward in protection against the light.   The pa-
tient is unable to lift the eyebrows,  corrugate  the forehead, move
the side of the lips, show the teeth, wdiistle, or blow.   On account of
affection of the buccinator, food accumulates  between the teeth and
cheeks.  With lesion at or above the geniculate ganglion one side of
the palate is paralyzed ;  it hangs  lower than the other side, and  is
not lifted in articulation.  The uvula deviates (is drawn) toward the
sound side. Paralysis of the stapedius is taken advantage of by the
tensor tympani to render the hearing more acute.  In  pure peripheral
paralysis  affection of the hearing is  rare and the  palate shows no
deviation.   Sensations of pain, sometimes experienced, are attributed
to implication of sensitive fibres which run back in the course of the
chorda tympani from the trigeminus.
   The important point in diagnosis is the differentiation of central
   Fig. 279.—Facial paralysis, patient set. 65 ; showing loss of tone in inelastic skin. Figure on
right represents attempt to close both eyes (Gowers).

from peripheral lesion.   Central lesion occurs, as  stated, in connec-
tion with hemiplegia of the same or opposite  side,  and the paralysis
of the face is only partial.   The patient can open and close the eyes.
In central lesion reflex and  associated  movements remain and  the
muscles respond to  the  faradic current at any period.   Peripheral
lesion is more  complete.  The patient cannot  open and close  the
eyes, and electrical irritability is diminished  or  lost.   In peripheral
affection the lesion is assumed to be intracranial when the  auditory
or other cerebral nerves are affected, or when the opposite side of the
body is paralyzed.   Paralysis of the  palate  speaks for lesion  at or
above the geniculate ganglion.  The lesion is assumed to  be  in the
Fallopian canal when it is  found in association  with otitis media,
caries of the petrous portion of the temporal  bone, and  affection of
the hearing.   The lesion is superficial in the absence of these signs.
   The  prognosis  depends  upon  the  cause.  In  the  superficial
 
696
MENINGITIS,  SIMPLE CEREBRAL.
(rheumatic),  which  is the most frequent form of the disease,  the
prognosis is good, and is chiefly determined by the electrical reac-
tion.  Any response to the induced current is a favorable indication.
Such cases terminate with complete restoration  in the course of a
few  weeks.   In the absence of all response to  the induced current.
and of signs of the reaction of degeneration with the constant current,
the course is  more  chronic; recovery requires a period of  several
months.  A few cases never recover.
   The treatment is the application of electricity in the form of  the
constant current, the negative pole behind the jaw under the ear,
the positive stroked gently along  the course of the facial muscles.
The  session, daily or tri-weekly, should not continue longer than five
minutes.  All other treatment is superfluous.   The physician should
never despair of relief  so  long as there  is any kind  of reaction to
electricity.   In the experience of the author, a young lady deformed
by attack in childhood had the deformity  greatly relieved by galvan-
ization,  though fourteen years had elapsed without any treatment at
all.
                 MENINGITIS, SIMPLE CEREBRAL.

   Pachymeningitis  {naxvl, thick); leptomeningitis {Xs7rxo?, thin);
simple,  as  distinguished from cerebro-spinal and tubercular, menin-
gitis ; meningitis of  the  convexity, as  distinguished  from   basilar
meningitis.—Meningitis, in general, was first recognized as an affec-
tion  separate from disease of the brain by Morgagni (1760).   Epide-
mic cerebro-spinal meningitis first attracted the attention of Yieusseux,
of Geneva (1805), and  of  Strong,  North,  Fish,  Hale, Miner, and
Williams, of  our own  country (1806-1814), and  had  been  at  that
early period easily differentiated from affections limited to the mem-
branes of the brain.  Parent-Duchatelet  and  Martinet (1821)  first
distinguished inflammation of the  dura and pia mater, and Guerin
and  Guersant (1836-1839)  first  distinctly recognized and set apart
the tubercular, granular, or basilar form  of the  disease.  The first
clear descriptions of the  exclusively "simple" meningitis, from a
pathological standpoint, are to be found in the works of Cruveilhier
(1830); and from a clinical standpoint, in  those of Andral (1834) and
of Rilliet and Barthez (1843).   The recognition of the fact that simple
meningitis is always a secondary affection is the  result of the more
accurate post-mortem observations of the last ten years, in the light
of the recent investigations concerning infections, and the contribu-
tions from otology.
   Pachymeningitis, inflammation of the dura mater, presents itself
in two  forms, external and  internal, purulent  and  haemorrhagic,
representing  entirely different disease processes.  The first of these 
MENINGITIS, SIMPLE CEREBRAL.
697
 forms alone deserves the title or termination of the name, as it alone
 shows  the signs  and lesions of an  inflammation, pachymeningitis
 externa, the haemorrhagic form, being really the result of a degene-
 ration rather than an inflammation; but in the absence of definite
 knowledge regarding the genesis of this disease, the two forms may
 be best studied together.
    Pachymeningitis Externa.—Accidents or injuries which  di-
 rectly expose the dura, or effect its separation from the bones of  the
 skull, with consequent extravasation of blood, whereby is implied, at
 least, a " hidden crevice" or some  communication  of  the dura with
 the air, lead at once to inflammation of the outer lamella, which may
 extend to  involve all  the  rest of  the  membranes  of  the brain.
 Carious processes of the ear constitute an even more frequent cause
 of this condition.  A mere  microscopic breach in  the thin wall of
 bone that forms the upper covering of the tympanic cavity will bring
 pus from the tympanum to the dura.   So, also, caries of the ethmoid
 bone (ozaena), or other bones of the cranium (syphilis, carbuncle),
 may  excite this form of  meningitis; and, even without caries,  puru-
 lent inflammation of the mucosae in the ethmoid and frontal sinuses
 may  extend to the dura through natural openings of communicating
 vessels.  This complication has been noticed more especially in ery-
 sipelas  after "mixed infection," whose nature it is to spread.  As
 purulent pachymeningitis rarely remains confined  to  the  dura, but
 extends, as a rule, to involve the  pia mater, the  symptoms, patho-
 logy, and treatment of this condition will be further discussed with
 leptomeningitis.
    Pachymeningitis Interna.—The disease of  the dura  which
 merits most consideration, from its,frequency, limitation, and recog-
 nizability in life, is that  affection of the inner layer characterized by
 the extravasation of blood and subsequent development of an adven-
 titious membrane, commonly known as hsematoma durse matris, and
 technically  described  as pachymeningitis  interna hsemorrhagica.
 With these characteristics it is plain that internal pachymeningitis
 does not supply the requisite  conditions nor rise to the nosological
 dignity of an inflammation in the modern sense of the term.  It  de-
 velops oftenest independently of all  infection, and should properly be
 discussed as a subvariety of cerebral haemorrhage.
   The  pathology  of this affection  remains as  yet obscure.  The
 early  anatomists and clinicians were fain content with descriptions
 of the condition, without venturing to express opinions concerning
the nature  of the disease.  It was commonly held  and taught that
the disease  consisted in the  extravasation of blood,  and the only
question discussed  regarded its situation.  Thus Abercrombie and
Andral  (1807) maintained that the blood was  effused  between the 
ij9H
MENINGITIS, SIMPLE CEREBRAL.
dura and the parietal layer of the arachnoid, so-called;  while Hous-
sard (1817) located the extravasation in what was  then, and for the
sake of convenience  is still, known as the cavity of the arachnoid.
The haemorrhagic nature of the affection was  nearly lost sight of
when Bayle (1843) considered the haematoma as an inflammatory pro-
duct of the dura, but was again restored by Durand-Fardel (1854), who
believed in the development and  organization of a flat blood  clot.
Heschl  (1855) regarded the membrane as a highly vascular connec-
tive tissue, a view which Virchow, with his predilections for cellular
pathology, elaborated into a haemorrhagic inflammation of the  dura
as the first process, and a subsequent infiltration of the blood as the
second.   The authority of  these pioneers carried  these views  with
almost undisputed conviction up to our own times, when the studies
concerning the nature and processes of inflammation and infection
naturally diverted attention to the  condition of the blood and its ves-
sels as prime factors  in the production of the disease.
   That haemorrhagic  pachymeningitis  is not the expression of an
ordinary inflammation is shown by the fact  that no amount of irri-
tation of the  dura will produce it.  Injections of ordinary irritants
into and beneath the membranes of the  brain of lower animals  may
be followed by purulent, but never by haemorrhagic, pachymeningi-
tis.  On the other hand, the injection of blood with all  its constitu-
ents sufficed, in the experiments of Sperling, to  produce the typical
signs and lesions of the disease.  The role of the fibrin in these cases
is evidenced by the fact that a membrane was not developed after
injections of defibrinated  blood.
   Internal pachymeningitis  consists, then, in the extravasation of
blood, the formation  of a blood clot which, when the effusion is not
too great or rapid, is flattened by pressure, to become subsequently
organized into a  membrane.   In  the first  stage of the disease  pro-
cess the thin layer of coagulated blood  soon  begins to show, in the
separation of  its fibrin, a meshwork which  contains multitudinous
blood corpuscles.  At this time there is no apparent connection  with
the dura, whose  epithelium remains intact.  In the consolidation
which continues, the clot assumes  the appearance and density of a
membrane, which now in reality  develops  from the transformation
of white blood corpuscles into spindle-shaped  connective-tissue cells,
whence the synonym pachymeningitis fibrinosa.  The red corpuscles
now gradually lose their  coloring matter, which collects in spots on
the surface and in the texture of the membrane  (pachymeningitis
pigmentosa), lose their regular contours, and  finally become trans-
formed  into masses of protoplasm.  Young vessels now connect the
dura with the  membrane, which becomes  gradually more dense,
thick, and adherent.  In the meantime new layers of blood may be 
MENINGITIS, SIMPLE CEREBRAL.
699
effused into  the  membrane already in process of formation, which
consists thus of superimposed lamellae—Virchow has seen as many
as twenty—for a time separable from each other.  The effusion takes
place chiefly upon the convexity of the brain, limited, in fifty-four of
sixty-five cases collected by Kremiansky, quite precisely to the region
covered by the parietal bones.   It is rather more frequently bilate-
ral than unilateral, being confined to one hemisphere in but forty-
four per cent of cases.
   The source of  the haemorrhage still remains  a matter of dispute
and doubt.  Kremiansky thought it came from the middle menin-
geal artery, an origin which comports well with the situation of the
clot; but Huguenin declares that he has never seen this vessel af-
fected in any of his observations.  This author is inclined to find the
lesion in the veins which run from the cortex to the longitudinal sinus
along the falx cerebri ; and Pacchionian vessels have likewise been
accused, but all alike without as yet satisfactory anatomical proof.
   The chief danger of these effusions is pressure upon  the brain,
which shows itself in proportion to the amount of the extravasation.
Huguenin  has seen a  hemisphere flattened by a large unilateral
haematoma, which may be as large as a hen's egg—Eichhorst men-
tions effusions of five hundred grammes—and in some cases a lateral
ventricle has been reduced by pressure to half  its size.   The great
evil of pressure is obviated in many cases by the latitude allowed by
atrophy of the brain substance, a condition rather, as a  rule, coin-
cident with haematoma of the dura.  In fact, the greatest contingent
of cases is  found in connection with paralytic dementia, and cases
independent of some degree of atrophy are comparatively rare.
   When,  from any cause, a real inflammation is engrafted upon
this haemorrhagic  degeneration, serum or pus may be found in con-
nection with the blood which forms  the haematoma.  As curiosities
in this direction, Virchow describes a hydrocephalus externus pachy-
meningiticus, and Weber saw, in a  lamellated haematoma, blood in
one cavity and yellow-green pus in another.
   Various changes in the skull membranes  and  brain  have  been
observed in connection with pachymeningitis, but none so frequently
as to belong to it of necessity.   Thus  the bones have been found
thickened or thinned,  with an agglutinated dura at times, the pia
anaemic, hyperaemic, and swollen, or cloudy and  opaque, separable
or adherent to the dura, etc.  The  frequency with  which general
atheroma  of the cerebral vessels is  seen, with  thromboses, soften-
ings, apoplexies, scleroses, etc., of the brain, bespeaks the intimate
relation of  these processes to the development of the disease, in con-
nection more  especially with general paralysis, alcoholism, insanity,
senile atrophy, etc. 
700
MENINGITIS,  SIMPLE CEREBRAL.
   Pachymeningitis is a much more frequent affection than is com-
monly believed.  Savage records its presence in three per cent of
the autopsies made at the asylum at Bethlehem ; and when it is re-
membered that there are more cases of dementia and insanity, not
to mention alcoholism, out of than in asylums, it is seen that this
percentage is far too low.  It is safe to say that most of the cases
remain undiagnosticated  during  life;  and death, when it occurs,
though perhaps caused by this affection, is ascribed to the disease in
the course of which this accident develops.   All authors agree in
noting three-fourths of all the cases in the male sex, a proportion
which corresponds to the relation of the sexes to the affections which
produce the disease.   For the same reason haemorrhagic pachymen-
ingitis is  a disease  of advanced life.  Exceptional cases  at  early
periods of life—six months to eight  years—have been recorded by
Weber, Moses, Steffen, and others, mostly in connection  with the
venous stases from  the strain of asthma,  pertussis, etc., or  the im-
poverished nutrition of blood vessels from scurvy, leukaemia, and
more especially pernicious  ansemia;  and cases have been  more
abundantly reported during adolescence and maturity in connection
with tuberculosis, empyema, valvular  lesions of the heart,  the vari-
ous forms of Bright's disease, the various infections (variola, scarla-
tina, acute articular rheumatism, and typhoid fever), and  more es-
pecially local injuries of the dura (seventeen of seventy-four cases
described  by Schneider); but, aside from these accidents, pachymen-
ingitis  remains  a disease of age.   The  largest  number  of cases,
twenty-two per cent,  in  the  collection of Huguenin,  occurred be-
tween the ages of seventy and eighty.
   Symptomatology.—Internal pachymeningitis exists at times with-
out a symptom to mark its presence.   Moses reports such a case in
a child, aged seven months, who died of catarrhal pneumonia.  At
the autopsy there was found a pachymeningitic cyst which covered
the anterior half of the right hemisphere, though no sign  of brain
disease had ever been manifest in life.  Slight  extravasations often
show no sign because of absence of pressure, or, if slowly effused,
because of tolerance, which the brain acquires often in astonishing
degree.  In other cases the accident is overshadowed by symptoms
pertaining to the original disease.   These are, however, all exceptional
cases.   As a rule the disease may be diagnosticated during life by
signs which are not so valuable in themselves  as in their etiological
relations.
   In the majority of cases the disease announces itself suddenly and
violently.   The patient is stricken with apoplexy.  The haemorrhage
may be so great as to cause death  by compression of the brain with-
in forty-eight hours.  The nature of the disease, or, more strictly, 
MENINGITIS, SIMPLE CEREBRAL.
701
 the localization  of  the haemorrhage, is,  as a rule,  in such cases
 impossible to determine.  The  first attack is not, however, usually
 fatal.   In exceptional cases the patient may recover fully, but as a
 rule a train of symptoms ensue  which more or less distinctly charac-
 terize the disease. These symptoms vary greatly in individual cases,
 vary according to the locality and extent of the effusion, as well as
 according to the  nature of the original disease ; but they do not dif-
 fer in  essential  characters from the symptoms of meningitis from
 any cause.   Headache, stupor, which may at any time deepen to
 coma; monoplegias, hemiplegias, or, in the irritant stage, unilate-
 ral twitchings and  convulsions, limited at times to one extremity,
 or confined to the area of distribution of  the facial nerve ; aphasia,
 when the region  of the language centre is compressed—these symp-
 toms,  together with an irregular or retarded pulse,  vomiting,  and
 more especially  contracted or  dilated pupils  irresponsive to light,
 with little or no  disturbance of  general sensation, make up a group
 which, as a rule, distinguishes the disease.
    But, as already intimated, it is not so  much the symptomatology
 of the affection as its etiological relations which strictly define the
 disease.  The general signs of  meningitis refer especially to haema-
 toma only when they occur in the course of general paralysis, chronic
 psychoses, alcoholism, chronic Bright's disease, pernicious anaemia,
 traumata, the affections mentioned  in the discussion of  the etiology
 of the disease.
   Another distinguishing, but  by no means so  distinctive, feature
 to indicate the nature of the affection is the recurrence of the symp-
 toms.   Total or partial recovery from all  the general manifestations
 of meningitis is followed in pachymeningitis, as a rule, by repeated
 attacks; and though the special symptoms may show great variety in
 relapses or recurrent attacks, the general  character of the new signs
 is definitely sustained.
   The diagnosis of pachymeningitis is based upon these two cardi-
 nal points:  the existence of an underlying condition or causative
 disease, and the more or less rapid recurrence of the attacks - Cases
 are further characterized  by suddenness of onset and  rapidity of
 recovery.   The author had under observation an individual affected
 with chronic alcoholism, who was suddenly stricken with apoplexy
 on  the  street.  The patient  was carried  comatose to the hospital.
 The coma subsided in the course of a few hours, to leave a complete
 right-sided hemiplegia,  which  entirely disappeared  in three days,
leaving the individual in better physical  and mental condition than
for ten years.  Many  of the  cases  of so-called  '' serous" apoplexy
characterized by  sudden onset,  and more especially by speedy re-
covery,  are really, cases of pachymeningitis. 
702
MENINGITIS, SIMPLE CEREBRAL.
   The predominance of symptoms indicating cortical lesion  is
another feature of diagnostic importance.  Thus localized convulsions
and contractions, monoplegias, contracted pupils, following an apo-
plectic attack in an individual predisposed to the disease by the fac-
tors already emphasized, point almost certainly to pachymeningitis.
   The age and sex of the patient must not be overlooked.
   Basilar meningitis is differentiated by the youth of the patient,
the family history, the presence of tuberculosis elsewhere, by its long
prodromes, its insidious approach, its general and special hyper-
aesthesia, opisthotonos, boat-shaped abdomen,  etc.
   Cerebro spinal meningitis prefers winter, soldiers, and children,
occurs at times in endemic proportions, shows opisthotonos, herpes^
and sometimes petechiae, extreme hyperaesthesia, spinal lesions, and
does not recur.
   The prognosis is always grave.  Recovery without recurrence is
possible, but not probable.   The patient succumbs, as a rule, in a
subsequent attack, if he does not fall a victim in the meantime to the
original disease.  The immediate prognosis  is best established, as
after  any  cerebral  haemorrhage, by frequent observations of the
temperature, whereby the degree of the rise after the initial depres-
sion  incident to the shock would  receive proper interpretation.  A
sudden or gradual elevation to a high grade (105°) at anytime there-
after, independent of the original disease, is a sign of most ominous
significance.
   Treatment.—The treatment of pachymeningitis does not differ
materially from  that of any form  of meningitis or cerebral haemor-
rhage.  The application of an ice bag to the head, the local abstrac-
tion of blood by leeches or cups behind the ears or over the temples,
"derivation" by purgatives (calomel, senna, croton oil), constitute
the routine plan, which is sanctioned more by time and use than by
benefit based upon demonstrable  proof.  Tranquillity of surround-
ings, with all the measures which  make up a more or less perfect
hygiene, are the most effective agents in prophylaxis in the chronic
psychoses; while abstention from alcohol addresses the " causa indi-
cationis " in cases dependent upon its abuse.   Bright's disease, heart
disease, pernicious anaemia, etc.—in short, the underlying condition
calls for appropriate treatment, and paralyses, convulsive manifes-
tations, persistent headaches, whatever symptoms  may be left, are
to be met with symptomatic treatment.
   Pachymeningitis  cervicalis  hypertrophica is  a  peculiar
subvariety of meningitis, produced by great thickening of the menin-
ges in  the cervical cord, and marked by severe pains in the back of
the neck and both arms, with atrophy of the muscles of the neck and
flexors of the hands, and final spastic paraparesis. 
LEPTOMENINGITIS.
703
                        LEPTOMENINGITIS.

   It is possible, as already stated,  that  a real  inflammation may
limit itself to the dura mater alone, but such a distinct circumscrip-
tion is very  rare.  Inflammation of the dura extends,  as. a rule,
to involve the pia mater.   The  same  qualification applies to  the
pia mater, though a strict limitation to the pia mater is more fre-
quently observed.  The subsequent  remarks apply  more especially
to inflammation of the pia mater, with which the dura is,  or may be,
secondarily affected in greater or less degree.  It is taken for granted
that cerebro-spinal  meningitis and tubercular meningitis,  diseases
due to special causes, are not included under  the title leptomenin-
gitis, which  embraces all other kinds of simple meningitis of known
or unknown cause.
   Leptomeningitis is always a secondary affection.   The cases con-
sidered idiopathic become, under closer observation, so much fewer
every year that it is more safe to appeal to unknown primary affec-
tions than to subscribe to the possibility of a spontaneous  or idio-
pathic meningitis of any kind. A thorough conviction in this regard
will alone lead to the searching investigation necessary in many cases
to discover the original disease.
   Affections of the ear constitute by far the most fruitful cause of
leptomeningitis.   Of these affections, chronic suppurative inflamma-
tions of the tympanic cavity, which constitute over twenty per cent
of all diseases of the ear, most frequently lead to meningitis through
caries  of the osseous roof of the tympanum.  The roof of the tym-
panum is  composed of  an excessively thin plate of bone, which is
indeed at times congenitally defective, so that the way lies  open to
invasion of the cranial contents.
   A more or less open avenue  is also offered in the course of, or
along the sheaths of, the facial and auditory nerves and  the vessels
which penetrate the petrosal fissure.  Communication by caries may
be also directly established between the cavity of the cranium and the
mastoid cells ; while indirect involvement of the meninges may  fol-
low phlebitis and thrombosis of the cavernous, transverse, and supe-
rior petrosal  sinuses, as revealed by dilatation of the veins and local
oedema in the region of the mastoid  process.   Tuberculosis  plays  a
prominent role as a special cause in the  production of all these pro-
cesses, while syphilis furnishes a small contingent of cases through
caries of the upper meatus of the nose.
   Every meningitis whose cause is not  obvious  should  excite sus-
picion of ear disease, which may reveal itself to the sense of smell in an
offensive odor, before or in the absence of visible discharge.  So, also,
every case of otorrhcea should excite the  fear of possible meningitis. 
704
LEPTOMENINGITIS.
    Trauma or injury to the  cranial bones constitutes a  not  infre-
 quent cause of simple meningitis.  Where compound fracture  has
 occurred, or direct penetration has, been effected, the sequence is suf-
 ficiently simple.   In other cases  the meninges, though not directly
 exposed, become affected through phlebitis, thrombosis, or suppura-
 tions occurring in the patulous veins  of the  diploe, whereby is  im-
 plied, as previously intimated, some  hidden crevice or pre-existent
 communication with the air.  A far more infrequent involvement of
 the meninges  occurs at times, when an abscess in the interior of the
 brain reaches its periphery, or bursts into a lateral ventricle to come
 in contact with inflections of the pia mater at the base of  the brain.
 So-called brain " softenings," which consist simply of brain and  tis-
 sue debris,  and simple hypersemias, the so-called "congestions" of
 the brain, including sunstroke, could not, with our  present knowl-
 edge  of the nature of infections, produce a leptomeningitis.
    Next in  frequency to the direct invasion of the meninges from
 disease of the  ear are the metastatic processes from distant depots of
 infection.  Any one of the acute  infectious diseases may  be thus
 attended or followed by  meningitis, which is justly regarded as  the
 most  serious complication which can occur—which,  indeed,  imparts
 a sudden gravity  to an otherwise mild case of  disease.  Of all  the
 acute infections, pneumonia is the disease in which this complication
 most frequently occurs.   The intimate relations of  tuberculosis of
 the lung and brain in the frequent sequence of basilar meningitis
 upon tuberculosis pulmonum, prepare  us in a measure for the fre-
 quent supervention  of meningitis in the course of croupous pneu-
 monia.  The  same connection or relation has been observed also in
 cerebro-spinal  meningitis, and bacteriologists  have pointed out  the
 striking resemblance of the micro-organisms found in these two af-
 fections.  Pyaemia and septicaemia may be said to vie with pneumo-
 nia in the production of  metastatic meningitis, while endocarditis,
 empyema, acute articular rheumatism, the exanthematous  diseases
 —more especially variola and scarlet fever (aside from ear disease),
 and very rarely typhoid  fever—diseases mentioned in the order of
 frequency, furnish exceptional cases.  As curiosities, equally illus-
 trative, however, of the nature of the process, may be mentioned the
 cases  of meningitis which have followed such  trivial infections as
 vaccinia and mumps.
   The morbid anatomy and symptomatology  of this form  of
meningitis do not differ,  except in the preference of the convexity to
the base in the case of inflammation from metastatic and  traumatic
causes, from the cerebral signs and lesions of cerebro-spinal menin-
gitis,  which have been fully described elsewhere.
   The diagnosis of meningitis in connection with  disease of  the 
LEPTOMENINGITIS.                     705
ear, or trauma of the bones of the cranium, is very easy, as a rule,
but the diagnosis of metastatic meningitis is often very  difficult.
High fever and blood  poisoning show symptoms which so closely
simulate the signs of meningitis  as to render an absolute diagnosis
impossible, at least for a time.   The persistence of these signs after
subsidence of hyperpyrexia sometimes declares the disease.  Tuber-
culosis, pyaemia,  scarlatina,  variola,  erysipelas, and typhoid fever
are the affections which  oftenest create doubts as to the diagnosis.
But if close scrutiny be made of the etiological factors, and  close at-
tention be paid to the course of the disease, the diagnosis, as a rule,
soon becomes clear.  In distinction from tuberculosis  and typhoid
fever, it may be said that meningitis  develops quickly, almost sud-
denly, with violent pain in the head, active delirium, and often with
stiffness of the muscles of the neck or retraction of the head.
   Tuberculosis and typhoid fever show also typical temperature
curves, with lung  symptoms in tuberculosis,  and abdominal symp-
toms  in typhoid fever.  In scarlatina, variola, and erysipelas it is
rather a question of  detecting a complication, as each disease shows
characteristic eruptions upon the surface.  Here, too, the persistence
of cerebral signs  after  subsidence  of the high temperature is  of
value.  Septic and  pysemic diseases  follow  wounds,  are  attended
with  chills, show joint  affections  and internal metastases.   Ulce-
rative endocarditis, a septic process, has the same history.  Uraemia
is recognized by the  dropsy, the condition of the urine, and, so far as
the nervous symptoms are concerned, by the predominance of con-
vulsions.
   Cerebro-spinal  meningitis is differentiated by the more prominent
disturbances of sensation, by herpes, and by the occurrence of other
cases.  Basilar meningitis occurs more especially in children affected
with tuberculosis elsewhere, or who come of  tuberculous stock.  It
has long prodromata and a longer duration.   Its symptoms are less
acute and intense.   It more frequently implicates the membranes of
the spinal cord.  Pachymeningitis is a disease of age.  It occurs in
drunkards, dementia paralytica,  chronic  insanity,  etc.   It shows a
more  fluctuating course.   It must be repeated again and  again that
the various forms  of meningitis are to  be  separated and recognized
more  by the etiological relations of  the  disease than by any dif-
ference in symptomatology.
   The prognosis is far  more grave than that of cerebro-spinal, but
not so absolutely fatal as that of basilar, meningitis.  The great ma-
jority  of cases terminate fatally, in coma or convulsions, in  the
course of from two to ten days.
   The treatment of leptomeningitis does not differ  in any  way
from  that of any  other form of  meningitis ; what little may  be
45 
706                     LEPTOMENINGITIS.

accomplished in the relief of symptoms has been mentioned under the
title Cerebro-spinal Meningitis.  The physician  who is thoroughly
indoctrinated  as to the dangers of  disease of the ear, and who is
thoroughly familiar with the recent researches regarding the nature
of infection, will prevent many cases of meningitis by timely treat-
ment of the ear and by scrupulous antisepsis in all wounds of the
skull. 
CHAPTER XII.
               DISEASES OF THE SPINAL COED.

                            MYELITIS.
    Myelitis {pvsXoS, marrow).—Inflammation of the spinal cord, at-
 tended by paraplegia  with anaesthesia, interference with the action
 of the bladder and bowels in the chronic form, and degeneration of
 the  affected nerve cells, fibres, and muscles.  The disease is distin-
 guished, according to its  distribution, as central, transverse, peri-
 pheral,  focal, and disseminate.   Central myelitis, which  affects
 chiefly the gray  matter,  is known as poliomyelitis  {noXios, gray).
 Transverse myelitis affects a whole section ;  peripheral myelitis,  the
 outer layer ;  focal is a local depot;  disseminate  are scattered depots
 throughout the cord.
   History.—Inflammation of the cord was separated from that of
 its membranes at the  beginning of the present century.  It was at
 this time that the term  myelitis  was appropriately substituted  for
 spinitis.   The first extensive description was furnished by D'Angers
 (1821).  Hereupon ensued the discussion as to whether or not  the
 softening observed in the cord was of an inflammatory nature.  Vir-
 chow decided this question affirmatively.   The modern studies of  the
 histology of  the  cord  and of its physiology, as determined by  ex-
 periments, furnish the data for the localizations  effected in recent
 times.
   The etiology of myelitis remains obscure.  Individual cases cer-
 tainly ensue upon exposure to cold, but experiments in this direction
 furnish contradictory  results.  The same statement may be made
 regarding the action of other causes—fatigue ; excesses, especially
 sexual excesses ;  suppression of menses or other discharges, as from
 haemorrhoids, fistula ;  sweating, as of the feet.
   The development of cases under the influence of mental emotions
 —anger, fright,  etc.—is an  assumption  difficult  of  demonstration.
 The tendency of the present time is to ascribe all cases to the action
of some toxic agent developed in the course of  an  infection and pos-
sibly latent for some length of time.  The affection of the cord which
occurs in cerebro-spinal meningitis, and which may occur in septic 
708
MYELITIS.
(puerperal) affections, small-pox, typhoid  fever, etc., lends support
to this view.   Certain chronic cases are attributed to the  influence
of alcohol  and syphilis.   The disease has certainly followed after
haemorrhage  in the cord,  and has occurred in  consequence of  all
kinds of  injuries ; hence myelitis is more common in males, and in
the younger—that is, the more exposed—periods  of life.  The mye-
litis of childhood  is the affection, localized in the  anterior c< >rnua,
which constitutes infantile paralysis.
   Morbid Anatomy.—Myelitis is divided into stages of hyperaemia,
fatty degeneration, and cicatrization.   In  the stage of  hyperaemia
the cord is swollen,  reddened, and softened ; the vessels are sur-
rounded with corpuscles and a gelatinous exudation.  Nuclei multi-
ply in the  cells of the neuroglia.   The axis cylinder in the nerve
fibres is swollen, beaded, and granular.   Ganglion cells are enlarged,
apparently softened,  separated,  and robbed   of  their  nerve fibres.
In  the second stage fatty degeneration brings about the yellow and
white softening visible to the  naked eye.  A granulo-fatty degene-
ration affects the vessels of the connective tissue and nerve elements
in every direction.  In the third stage the  cord begins to shrink, its
consistence increases, and fat accumulates in  its tissues and cavities.
The connective tissue proliferates, shows abundant spider cells and
corpora ani} lacea.
    Symptoms.—The  mode  of onset is various.  Sometimes symp-
toms of weakness set in at once, or the weakness may be preceded
by pains or paresthesice for several days.   Convulsive movements
are not so common.   After  the first feeling of weakness paralysis
develops rapidly ;  the patient soon finds himself unable to walk or
stand ; rest does not relieve him.   Control of the legs is lost, and the
patient is put to bed, sometimes in the course of a few hours, para-
lyzed in his lower  extremities.   The disease sometimes sets in in the
night, so that the patient, who goes to bed apparently well, is unable
to get up in the morning.  There is also loss of sensation ; it is,
however, not so complete and does not show  itself so soon.   The re-
flexes may be increased or diminished, according as the seat of the
disease interrupts the course of the nerve  fibres  or breaks up  the
centre itself.  The bladder is affected at first with paralysis of the
detrusor, later of  the sphincter.   There is, therefore, first retention
and afterward  incontinence from overflow.  The bowels are af-
fected in the  same  way.  There  is at first obstruction, but later
paralysis of the rectum.  Trophic  changes assume prominence.   It
is almost impossible to avoid the  production of bed  sores of gan-
grenous character.  The slightest pressure causes destructive change,
which shows itself usually first in  the formation  of blebs or bullae
with bloody contents.  The blister breaks to leave a slough ; some- 
MYELITIS.
709
times the slough forms without pressure.  The same trophic changes
favor the development of cystitis from retention.   Ulcers may form
in the bladder, or cellulitis may develop in the perineum or lower
abdomen.  Myelitis  usually begins below and extends upward, pro-
gressively or interruptedly.  More rarely it begins above in the cer-
vical or dorsal region and descends to the lumbar region.
   The onset of  the disease is usually attended  with elevation of
temperature to 102° to 104°.   The temperature then subsides to the
normal, and  usually falls below normal in the paralyzed members.
Complications, cystitis, septicaemia from bed sores, marasmus, may
subsequently develop fever.
   Variation from these symptoms is shown  in the  more diffuse or
disseminated forms of  the  disease.  Thus a diffused myelitis  is
distinguished by  the rapidity of its spread and the intensity of its
symptoms.  The disease may  seem to show itself in both extremities
simultaneously.   Trophic disturbance is also  more extensive, and
death may ensue in the course of a few days.   In disseminated mye-
litis symptoms develop from different centres ;  individual muscles or
groups of  muscles may be affected in one arm and the  leg of the
same or opposite side.  Irregular distribution should always ex-
cite suspicion of syphilitic origin.
   The prognosis must  be made with  caution.   Cases which pro-
gress rapidly often terminate  fatally by involvement of the respira-
tory centre.  As  a rule the disease comes to a stand in the course of
a week, and the patient  recovers wuth more  or less paralysis, which
may or may not yield to subsequent treatment.  Any neglect in the
management of a case may be attended by cystitis or sepsis.
   Treatment.—During the acute stage the  inflammation is best
treated by application of  cold, in  the  form of ice  bags, along the
spine.   Absolute rest, with  attention  to the secretions,  is a sine
qua non.  The salicylates may be given at the start.
   Chronic  Myelitis differs from the acute only in the more pro-
tracted onset and development of the symptoms.   Like the acute, it
may be localized or diffused.   The disease rests largely on a clinical
basis,  and is hence often confounded  with the  degenerations or
scleroses.  The transverse myelitis, where the thickness of the cord
is involved at a definite region, presents  the most typical form.  The
disease occurs more frequently in  adolescence and maturity ; is un-
known in infancy, and is very rare in age.
   Etiology.—With the exception  of  the cases  that  may be ac-
counted for by a direct injury, or exposure to cold, especially during
fatigue or after over-exertion, the etiology of the  disease is obscure.
From the fact that alcohol produces a peculiar affection of the peri-
pheral nerves, which affects nerve tissue as in myelitis, certain cases 
710
myelitis.
may be attributed to this cause.  Gout is invoked as a  cause in the
old country.  Syphilis has more to support it.
   Morbid Anatomy.—The cord may present no visible change to
inspection, though some difference  in color and consistence is often
observed at the affected regions.  The color becomes more gray or
yellow and the consistence more hard.  Changes are distinctly mani-
fest  under the microscope.   There is alteration of the neuroglia,
which becomes amorphous and fibrillated.  Nerve  fibres waste, the
axis cylinder is beaded and  narrowed, and the myeline takes on a
deeper stain.   The blood vessels are varicose ; granules accumulate
with corpora amylacea.  Nerve fibres, cells, and ganglionic masses
waste and disappear.
   The symptoms set in very slowly, but vary little, notwithstanding
the different localization of the disease.  The affection is usually an-
nounced  by disturbance of sensation.   Various paresthesias come
and go; there are numbness and formication; the legs go to sleep; a
girdle sensation is felt at the level of the lesion.   Disturbance in the
motor function is soon established.  The slightest exertion produces
fatigue; the legs feel weak and heavy ; the bladder and bowels are
early affected ; there is constipation, and  the action of the bladder
is slow.  Impotence is soon established.  Except in the cases where
the centres are affected in the cord,  the reflexes are increased.  As
the disease progresses, evidences of irritation—twitchings  and con-
tractions—disappear, and paralysis advances continuously.   Muscles
waste ; there is paraplegia.   Two features distinguish the disease :
first, the slow onset and gradual development, and, second, the pre-
dominance of motor signs; the motor system is affected so  much
more than the sensory.  In both cases the direction  is toward de-
struction.  The  evidence of weakness exceeds that of irritation.
The anomalies of sensation are  in the direction of anesthesia.  The
disease lasts for years, and terminates  life usually by complications,
especially by decubitus and cystitis.   Recovery is  possible, but ex-
ceptional ; hence the prognosis is bad.
    Treatment.—With the exception of the few cases which may be
due to syphilis, there is no radical  address in therapy.   Antisypbi-
litic treatment, if pushed too far, aggravates the disease.   Iodide of
mercury,  in minute doses, gr.  -gz—£z, is  the best form.  Arsenic is
often an  admirable tonic.  Phosphorus, silver, strychnia, are  reme-
dies that may be tried, with but little hope of benefit.   More is to be
accomplished by hygiene.  Warm  baths are of value always.  Hot
peat and  mud baths sometimes do  good.  Counter-irritation,  as by
stripes with the actual cautery, on each side of the spine, at the seat
of the disease, sometimes produces remarkable results.  The strokes
may be repeated at intervals.  Absolute rest is of great advantage at 
LOCOMOTOR ATAXIA.
711
 first, but, maintained too long, favors degenerative change.  Galvan-
 ism, with short sessions and gentle currents, may arrest the advance
 of the disease.   Faradization may support  the  muscles  for a time.
 Constant attention must be paid to the bladder and the bowels, and
 especially to the prevention of bed sores.

                       LOCOMOTOR  ATAXIA.
    Locomotor ataxia {a, without, xagi>, order).—The most frequent
 and one of  the most grave affections of the spinal cord, caused by
 sclerosis of its posterior columns ; characterized by peculiar pains and
 paraesthesise, diminution  and loss of the  reflexes,  disturbance  of
 vision, impotence, inco-ordination of muscles, especially of the lower
 extremities, and very slowly progressive paralysis.
    History.—The term tabes dorsal is, wasting of the back, was used
 by Hippocrates to express certain symptoms  attributed  to venereal
 excess, and was limited to this tabes by Romberg (1851), who first
 distinctly isolated the affection with  a classical description in his text
 book on nervous diseases.   Duchenne (1858) named  the disease pro-
 gressive locomotor ataxia.  The main clinical symptom, the lack  of
 co-ordination of muscles with retention of voluntary power, was actu-
 ally first recognized and differentiated from ordinary paralysis  or
 paraplegia by the English physiologist, Todd (1847), who is the real
 pioneer in this disease.   From  the seat and character of  its lesion it
 has been named posterior spinal sclerosis.   Though Todd had, from
 the nature of  its symptoms, located  the disease in the posterior col-
 umns  of the  spinal cord, it was reserved for Rokitansky (1856)  to
 demonstrate and define the  lesion as a chronic, diffuse inflammatory
 process,  which converted the portion of the cord affected into a mass
 of indurated connective tissue.   During the following decade French
 observers,  more especially Charcot, Vulpian, Luys, connected the
 various complex symptoms with the  functions of the cord, and Fried-
 reich separated the hereditary form.   A most important contribution
 was made by Westphal (1878) with the discovery of an  early and
 almost pathognomonic symptom in  the loss or absence of the knee
 jerk.   Charcot  and Raynaud observed  the various crises, gastric,
 laryngeal, and nephritic crises, alterations of bone,  etc.
   Etiology.—The  disease  occurs more  frequently  in  males than
 females, in  the proportion of ten to  one, and ranges close about the
middle period of life.   One-half of  the cases occur between thirty
and forty,  one-fourth between forty and fifty, and less than one-
fourth between twenty and thirty;  it begins  but  rarely  after fifty,
and still more rarely under twenty.   Any influence of heredity can
be traced only very exceptionally—in fact, in  but ten  per cent  of
cases. 
T2
LOCOMOTOR ATAXIA.
   Syphilis is  the overshadowing  cause.   Statistics  of different
authors vary as to the  frequency of this cause.   Fournier puts it
as high as 75 per cent.   The disease usually occurs in the remoter
course of syphilis, and is rare in the early history of the disease.  It
may follow any of the acute infections, especially diphtheria, and has
been attributed to excesses, especially sexual excess, and, with all ob-
scure maladies, in the absence of other cause, to taking cold.
   Morbid Anatomy.—The disease is distinguished by sclerosis and
atrophy of the posterior columns of the spinal cord, which assume
a grayish-yellow color,  and show  the  granulo-fatty changes,  with
hyperplasia of  the connective tissue, characteristic of this degenera-
                            tion.   The dorsal and lumbar portions
                            of the cord are most affected.  At these
                            portions  the  membranes  are  usually
                            found adherent.  In the cervical region
                            the degeneration is usually found lim-
                            ited to the  columns of Gold.   In the
                            dorsal region it affects all parts of the
                            posterior  columns, while in the lumbar
                            region the anterior portion of the pos-
                            terior columns remains usually unaf-
                            fected. The degenerative process gen-
                            erally stops at the  level of the  striae
                            acousticae.  Certain cerebral  nerves,
                            the trunk of the optic, the nerves which
                            innervate the ocular muscles,  espe-
                            cially the oculo-motor, are picked upon
                            by preference.  Both halves  of  the
                            cord suffer alike; the process is always
                            symmetrical, and is usually strictly so.
                            The degeneration of nerve tissue pre-
                            cedes  the hyperplasia of the connec-
tive tissue.   The process is a pure degeneration and is in no sense an
inflammation.
    Symptoms.—The symptoms of locomotor  ataxia fall naturally
into three groups,  the sensory,  atactic, and paralytic, which pre-
sent themselves in predominance in succeeding stages of the disease.
But these symptoms  show no necessary sequence; they may occur at
any period of the disease.  Individual cases begin with atactic symp-
toms, and sensory phenomena show themselves throughout the whole
history of  the  disease.   Paralyses  are  commonly limited  to the last
stage.  Locomotor ataxia is usually announced by peculiar pains,
which are distinguished by their suddenness of occurrence, inten-
sity, and  shortness of duration.  Lancinating pains, like lightning
 Fig. 280.—Beginning sclerotic patches,
a,a, in the posterior columns of the cord. 
LOCOMOTOR ATAXIA.
713
 strokes, shoot through the body, the pelvis, and lower extremities,
 more rarely the upper extremities.  The attacks of pain usually occur
 in paroxysms of one or several days' duration, with subsequent inter-
 vals of days, weeks, or  months.  Sometimes the pains are more or
 less constant; in very rare cases they may be entirely absent.  An
 equally early symptom is some anomaly  of sensation, especially in
 the  lower extremities.  The anomaly may be appreciated first as a
 diminished sensitiveness to the  faradic current.  The surface  may
 become almost insensitive  to severe, but  abnormally sensitive to
 slight,  irritation.  Thus the touch of a pin may be experienced as
 pain, while penetration through  the skin is scarcely felt at all.  The
 perception of pain may be also very much delayed.
    Paresthesie are much more common.   Sensations or anomalies
 of sensation in the soles of the feet are very frequent.   Patients speak
 of walking on cushions, on wool, on ovals, girdle sensations, etc.
 The parsesthesia is usually in the direction of an anaesthesia, and the
 loss of  sensitiveness concerns  also the deeper tissues as well as the
 skin.  So a disease of an internal organ may give rise to no distress;
 a pleurisy may be painless.
    The loss of the power of co-ordination constitutes a symptom
 so striking as to have given the name to the disease.   It shows itself
 first in  the legs, and gives to the patient a characteristic gait.  The
 regulation of nerve force to muscular contraction  is so nicely ad-
 justed as to be unconscious and automatic.   In locomotor ataxia the
 course of the impressions through the  cord to the brain is broken into
 and interrupted, so that the patient must aid his estimate of effort
 with the sight.  Many  of  these patients stumble and  fall on rais-
 ing  their eyes from the ground  at their  feet.   So, too, the legs are
 lifted with unnecessary force, and  the feet are planted flat in a kind
 of mechanical way.  To broaden  the base of support, the patient
 must stand with the feet more widely separated, and in the further
 course of the disease he  must invoke the  aid of a cane that he may
 get  the firmer support of a tripod.   So the diagnosis of locomotor
 ataxia may often be made upon the streets.
   All the symptoms of inco-ordination  become  much more mani-
 fest  when the patient withdraws his sight, and one of the early signs
 of the disease is the inability to stand still with the eyes closed ;
 in all cases swaying is much increased, and in marked cases the pa-
 tient, unless supported, would fall.   The ability or inability to stand
 upon one foot or walk backward, or  make  special motions with the
 foot  while the leg is supported by the hand in the sitting posture, are
 signs of value, but of less value.  In  the course  of  time the inco-or-
 dination affects also the upper extremities.  It  is* noticed, of course,
in the finer movements first.   The deftness and dexterity of the hand 
714
LOCOMOTOR ATAXIA.
are lost.  This loss is  observed more  especially  in  the automatic
movements  of the trades, in writing, piano playing, in dressing and
undressing,  especially in buttoning and  unbuttoning garments.
   The single symptom of supreme value is the diminution or loss of
reflex, as manifest more especially in the  absence of the patellar reflex,
"loss  of knee jerk."  The patellar reflex is first diminished and,
then  lost.   In the earlier history of the disease this diminution and
loss is more  marked on one side than the other.  Total loss of  knee
jerk in a patient affected with a nervous disease should always sug-
gest locomotor ataxia first.  The symptom is universally present, and
is  best elicited by a stroke upon the patellar tendon as  the patient
sits upon a table with the legs hanging over  the side.   In people of
ordinary build it  is sufficiently distinctly brought out in the sitting
                             posture with the legs crossed, and in
                             patients  in bed  it may be estimated
                             by support of  the thigh with the left
                             hand while the right is used to give
                             the blow.  What reflex there is may
                             be always reinforced by simultaneous
                             use of other muscles, as by a  firm
                             grasp of the  hand, tight  closure of
                             the eyes, etc.  The ankle clonus is
                             diminished and lost in the same  way.
                             The skin reflexes suffer likewise, so
                             that in an advanced case even  tick-
                             ling of the foot may provoke no with-
                             drawal of the leg. In this connection
may be mentioned also the loss of sexual power, which may even
precede for months the atactic signs.  In exceptional cases the sexual
power may  be preserved up to the period when the patient  may  no
longer walk alone.
   Symptoms on the part of the eye occur in the large proportion of
cases.  The reflex of the iris is lost in five-sixths of all cases, while at
the same time the power of accommodation  remains.  This loss of
response to light, with preservation of accommodation, first dis-
covered by  Argyll-Robertson  and commonly known by his name, is
a characteristic sign of the disease.  Irritation of the skin at the back
of the neck  no  longer  produces dilatation of the pupils.  In  these
cases  of loss of reflex dilatation the pupils are commonly contracted,
and "pinhead" pupils  (spinal  myosis) should suggest locomotor
ataxia.  It is needless  to state that this condition is not necessary.
The pupils are sometimes dilated, more  frequently normal.   The eye
muscles are affected in every degree, from slight transitory paresis
to total palsy.  Atrophy of the optic  nerve is the most distressing
 Fig. 281.—Knee jerk after tap on patellar
tendon; dotted line represents response. 
LOCOMOTOR ATAXIA.
715
complication of locomotor ataxia.   It sometimes begins very early in
the history of the disease, and may itself suffice, without the exist-
ence of other signs, to foretell the disease.  The atrophy is at first
peripheral, but with the slow progress of the disease may become
total.  The only consolation connected with these apparently uncon-
solable cases is the evident arrest of the progress of the disease in
the cord;  for, in the presence  of optic atrophy, the degenerative pro-
cess in the cord is usually brought to a standstill.   The other cere-
bral nerves are rarely affected in this disease.
   The mind remains  unaffected and becomes quickly resigned to
the ravages of the disease.   A kind of jocund indifference  has been
remarked of  most cases.  The vegetative functions are usually nor-
mal, the appetite is good, the bowels are sluggish and must often be
aided by cathartics and injections.  Sooner or later the bladder be-
Fig. 282.—Tabes; perforating ulcer of the foot (Gowers).
 comes involved, at first the detrusor, later the sphincter, so that in-
 continence or retention of urine may occur.   Close attention must be
 paid to the bladder in  these cases to prevent  overdistention and
 cystitis.  Atrophic changes, especially eczematous eruptions  in  the
 skin ; softening of  bones  and alterations  of  joints; excruciating,
 paroxysmal pains in the internal organs, larynx, stomach, kidneys,
 etc.; so-called  "crises"; perforating ulcers, especially of  the feet,
 are more uncommon signs.
   Locomotor  ataxia is a  disease of long duration, often of many
 years, and, though it may undergo arrest at various stages  of  the
 disease, it remains entitled to the term  progressive  given to it with
 its name.  Recovery occurs only in the most exceptional cases.
   In pronounced forms  the  diagnosis  is easy.  The lancinating
pains, loss of the knee jerk, immobility of the pupils, are the cardinal
signs.   The reduction of sensibility, especially of deep sensibility, the
various paraesthesise, the amblyopia and amaurosis, the affections of 
716
HEREDITARY ATAXIA.
the bladder, impotence, and ataxia, with  at  first preservation  of
power, unmistakably stamp the character of the disease1.
   Treatment, so far as cure is concerned, offers but little promise,
but treatment may alleviate the symptoms and possibly arrest the1
progress of the  disease.  As locomotor ataxia is a sequel to, rather
than an effect of, syphilis, antisyphilitic treatment has over it little
or no control.   Nevertheless the treatment should be faithfully tried.
Mercury sliould be administered by inunction, and iodine should  be
pushed to tolerance.   The  hope in this connection lies in a longer
treatment of the syphilis itself, whereby the poisons it leaves may  be
in the course of  time thoroughly destroyed.  The  patient should  be
protected against cold and fatigue; attention is to be paid to the diet
and  digestion.   Excess of  any  kind, especially sexual excess, must
be avoided. Warm baths are of great value.  Of  the host of drugs
recommended arsenic is the best, and Fowler's solution is the best
form of it.  Many cases  improve  under it  rapidly for a time.  It
should be given in small  doses, gtt. ij.-v., over a long  time.  Pains
may be controlled by phenacetin gr. v.-x.  Quick relief is sometimes
obtained by the  application of excessively hot water, or better by the
injection of cocaine gr.  \ subcutaneously at the site of pain.  Severe
pains are controlled only by morphia subcutaneously.  Visceral pains
may be addressed in the same way.   Laryngeal spasms may be  re-
lieved by the nitrite of amyl or nitroglycerin.  Paresis of the bladder
is best overcome by strychnia, which is best given subcutaneously in
small commencing and progressively increasing,  gr. t^o-jV> doses.
Impotence is often quickly relieved by extension—that is, by sus-
pension—which has in nearly all cases good effects in every direction.
Unfortunately,  however,  suspension in no  way  really controls  or
cures the disease.
                      HEREDITARY ATAXIA.

   Hereditary  ataxia  {axaB,ia,  disorder)  was  first  described  by
Friedreich (1861).  It is, as the  name  implies, transmitted by hered-
ity, and shows itself in  several members of the same family, though
individual cases are  sometimes observed.  The lesion is in the poste-
rior lateral columns, and  the effect is  observed in the legs in inco-
ordination and frequent falling.   The disease extends to involve  the
upper extremities, the trunk, finally the tongue.   Pains are dull and
localized.  Sensation is not disturbed.   The disease is distinguished
from locomotor ataxia by the fact  that it  occurs in  childhood,
progresses even more slowly, and is unattended with shooting pains,
affection of the bladder or of vision; it has no  crises and no arthro-
pathies. 
LATERAL SCLEROSIS.
717
LATERAL SCLEROSIS.
   Lateral sclerosis; spastic paraplegia; spastic spinal paralysis.—A
degeneration of the  pyramidal  tracts, characterized by paresis or
paralysis  of  the lower extremities, with spastic contraction of the
affected muscles;  exaggeration of the tendon reflexes with  slight
reduction  of  electric excitability; without affection of the bladder or
bowels, and without trophic change.
   History.—This degeneration was first observed by Tiirck (1856),
afterward by Charcot (1865), but was more distinctly isolated by Erb
(1875).  The disease  may occur at any period  of life, but is  most
common at from twenty to forty years of age, decades which include
three-fourths of all the cases.  Very exceptional
cases may occur as early as  infancy and as late
as the age of sixty.
   Etiology. — The cause remains involved  in
obscurity.  The congenital form is always due
to injury  of the brain in birth.   Syphilis could
be considered a cause as rarely as it is frequent
in posterior sclerosis (locomotor ataxia).  A cer-
tain percentage of cases could be attributed  to
trauma, fall, blow, or concussion, after which,
with the  lapse of a long interval, sometimes  of
several years, the  disease has been known to de-
velop.  In the absence of other discoverable cause
it has been ascribed to exposure to  cold, to  chro-
nic rheumatism or other protracted or exhausting
disease.   The symptoms of spastic  paralysis may
show themselves  in  connection with  the other
symptoms of chronic hydrocephalus,  transverse myelitis,  multiple
sclerosis, and other diseases  of the brain and cord of more distinct
anatomical lesion ; for the view  that this spinal paralysis depends
upon a sclerosis of  the pyramidal tracts or  lateral columns is rather
an inference  than a demonstration, as the cases reported to  rest upon
an  anatomical  basis  by actual demonstration  are not entirely free
from objection.
    Symptoms.—The disease begins with iveakness of the legs, early
fatigue, and unsteadiness, and progresses so slowly as to make itself
distinctly  manifest only in the course of  several months.  In many
cases some kind of locomotion is preserved for years.  The progres-
sive paresis is unattended with atrophy, but is distinguished by an
excessively  heightened  reflex,  excitability.   A stroke upon the
patellar tendon calls out powerful extension with subsequent convul-
sive movements.   Rectus  clonus and foot clonus are also easily
 Fig. 2«3. — Scleroses on
cross section of the lateral
columns of the cord: a, b,
c, sclerotic patches. 
7ls
LATERAL SCLEROSIS.
excited.  This excitability is manifest with every action of the muscle,
and is noticed first as stiffness of the legs upon rising in the morning.
It varies in every degree from slight muscular twitchings to totanu-
rigidity, and is so constant as to be absent only in cases of complete1
flexion and relaxation.   With the first attempt at extension the spas-
modic condition renews itself at  once, and so powerfully as  often to
spring the leg into a state of complete extension, the condition known
as " clasp-knife " rigidity.  In advanced cases the reflex shows itself
also in  sleep, when the legs may be suddenly  jerked up in lied.
The surface  shows also more or less  intensely heightened reflex.
But with all this disturbance on the part of the motor system, the
sensitive and  secretory  centres are unaffected,  there is  never  the
slightest ataxia, there is no impotence, no affection of the bladder
or bowels, and no disturbance of the brain or organs of special sense.
The development of any of these symptoms, or symptoms on the part
of these organs in exceptional cases, belongs to complications.
   The  gait is characteristic.   The spastic  contraction neutralizes
the action of the joints and fixes the partially flexed leg as if by anky-
losis.   The patient steps upon his toes, and advances with a series
of short hops, the whole body leaning forward, with a constant ten-
dency to stumble and fall; the legs are closely pressed together and
are only separated with difficulty, as if being pulled apart in progres-
sion.  This habitus of the body in  locomotion is  so distinctive as to
establish the nature of  the disease at a  glance.   The upper extremi-
ties remain, as a rule, unaffected, but may show  in the course of
years the same spastic  contractions.  The muscles of the trunk may
also become  involved,  and a tap  on  the chin  may evoke sudden
closure  of the lower jaw.  When the disease  occurs in infancy it is
recognized in the same way, by the  sudden extension of the leg,
which may shoot out to a straight line as the child is seated upon the
lap or a chair.
   Diagnosis.—This sclerosis is distinguished by gradual onset, a
fact which at  once eliminates cases  in which symptoms suddenly
develop; by the growing weakness, with spasmodic contractions and
heightened reflexes, while at the same time the muscles do not waste
and the bladder and bowels remain unaffected.   The disease is dis-
tinguished from the paraplegia of hysteria, aside from considerations
of history, age, and sex, by the remarkably strict confinement of  the
spasm to acts of extension  ; the spasm  ceases in relaxation.  Rectus
clonus and ankle clonus are almost unknown in hysteria.  The dura
tion is indefinite.
   Prognosis.—The disease  is persistent, yet it  may not much cur-
tail life.  Recovery, which is the rule in infantile forms, may occur
only in  very exceptional cases in adult life. 
PROGRESSIVE MUSCULAR  ATROPHY.
719
    Treatment.—Rest is the most valuable agent.  Exercise should
be rather passive than active ;  riding is better than walking.  Mas-
sage, especially by upward rubbing, with warm baths, especially
Turkish baths,  are remedies of  value.  Recoveries  have been re-
ported under the long-continued, systematic use of massage,  hot
baths which excite sweating, and gentle exercise.   The only drug
worthy of mentioning in connection with the disease  is  arsenic,
which at least aids digestion and supports nutrition.  Electricity in
any form is useless, if not injurious.  The muscles are already over-
stimulated .
    Ataxic Paraplegia is a  combination of posterior and lateral
sclerosis,  which begins with the signs of lateral sclerosis—i. e., with
spastic excitability—and soon shows the ataxia but not the pains or
loss of reflex of posterior sclerosis.  Thus the knee jerk persists or is
increased.  The cause is probably a  chronic toxaemia.  Foundation
for  this view is furnished in  the disease known as pellagra,  an
Italian  endemic,  which shows symptoms of  ataxic  paraplegia, is
attended by degeneration of the posterior and  chiefly of  the lateral
columns of the cord, and is clearly caused by a toxine ingested with
diseased maize.  Ataxic paraplegia is not caused by  syphilis.  The
prognosis and treatment are the same as for lateral sclerosis.

               PROGRESSIVE MUSCULAR ATROPHY.
    Wasting  palsy ;  amyotrophic lateral sclerosis.—Characterized by
atrophy of certain muscles without  paralysis, or with but that de-
gree of paralysis which corresponds to loss of substance, with fibrillar
twitchings, with the reaction of degeneration, with reduction of the
reflexes, with preservation  of  sensation, and  normal action of  the
bladder and bowels.
    History.—Hippocrates noticed this atrophy,  but Van  Swieten
was the first to separate it from simple  emaciation.   Bell (1830)  dis-
tinguished it from  a  paralysis.   Cruveilhier considered it a spinal
disease.   Aran (1850), who first named it progressive muscular atro-
phy, located the disease in  the muscles, as did also  later Duchenne
(1849),  and still later Friedreich (1873).  Lockhard Clarke (1862)
located the disease  in the  spinal cord,  and  Charcot (1874) distin-
guished it as an atrophy of ganglion cells and thus definitely deter-
mined the lesion of the disease.
   Etiology.—An important role  is played by heredity ;  the disease
is sometimes transmitted through  many generations.  It may occur
occasionally at any period of life, but is most frequent between thirty
and fifty years of age.  Cases have been recorded  of inception at
twelve and seventy, but such cases must be regarded with suspicion,
as age secures almost  absolute exemption.  Men  are affected more 
720
PROGRESSIVE MUSCULAR ATROPHY.
 frequently than women, in the proportion of five to one.  But thirty-
 three  of  the  one hundred and seventy-six cases collected by Fried-
 reich were females—a disproportion evidently due to the greater use
 of the muscles in men.   The working class, especially hand workers,
 furnish  the majority of cases.   The influence of  mental distress,
 sexual excess, syphilis, trauma, exposure to cold and wet, has been
 distinctly noticed in individual  cases.  The disease has followed in
 the  course  of typhoid fever and diphtheria, and has occurred more
 frequently in  connection with, or as a consequence of, other  organic
 neuroses, as bulbar paralysis, infantile paralysis, in the history of
 the individual, arrested since infancy.
   Symptoms.—The onset is insidious and  imperceptible.  The dis-
 ease begins in the muscles of the upper extremities,  in  the  right
 oftener than in the left, and shows itself  as a feeling of weakness,
 sometimes preceded by pains or sensations of coldness, with loss of
 substance.  The weakness and wasting come and go together—that
 is, the weakness is due  to  the  wasting.  The  disease  is distin-
 guished by the particular muscles or group of muscles which it first
 selects.  The  weakness is  first noticed  in the shoulder, the wasting
 in the  hand.   The process begins in nine-tenths of cases either in the
 shoulder or in the hand, and is about  equally frequent in each.  Of
 the muscles of the hand the first attacked are the interossei and the
 muscles that constitute the ball of the thumb, the opponens and ad-
 ductor, muscles which constitute  the thenar and  hypothenar emi-
 nences.  The  wasting of these muscles impairs the power of the
 hand,  at first for  delicate movements  (writing), later for all move-
 ments.  At the shoulder the deltoid suffers first and most.  The loss
 of substance flattens  the  shoulder and thins the hand, to make
 conspicuous the bony prominences of  the acromion, and in  the  hand
 to make manifest first the ends and later  the whole  shaft of the
 metacarpal bones, which, with the grooves between them, present the
 appearance of a skeleton  hand. In exceptional cases the disease may
 begin in other muscles of the arm or leg, if  invited  thereto by par-
 ticular strain.   Wherever it begins, it gradually extends, generally
 centrifugally—thus, from  the  hand to the  forearm, arm,  and
 shoulder,  and  from the foot to the leg and thigh.  The disease pro-
 gresses symmetrically, though not absolutely uniformly, as fibres and
 groups of normal tissue may always be seen in the midst of degene-
 rated masses.   In all  uncomplicated cases  the muscles of the face
 and  neck, the diaphragm, and  rectus abdominis are the last,  if at
 all, attacked.
   Where the muscles of  the back,  especially  of  the  back of the
neck, are affected, as may  sometimes happen first, the patient has
difficulty in sustaining the haad upon  the vertebral  column, and  in 
PROGRESSIVE MUSCULAR ATROPHY.
721
 the effort must  tip the head somewhat backward.  So soon as the
 balance is lost the whole head falls forward, with the chin upon the
 chest, and is with difficulty restored.   In advanced cases the muscle
 substance is completely wasted and  seems to entirely disappear, to
 reveal distinctly the subjacent  outlines of  bones.   Over all  the af-
 fected muscles may be seen fibrillary tivitchings—slight contrac-
 tions which show  themselves spontaneously, or,  upon exposure of
 the surface,  under the slightest irritation.   They may  be  always
 called out by drawing the wet finger  over  the  surface and blowing
 upon it.  It is nothing in the nature  of a  contraction  which moves
 the limb.  Functional or spasmodic  contractions  are  almost never
 seen.  It is merely a superficial, flickering movement, and is of value
 in that it sometimes shows itself in muscles not yet, but about to be,
 involved in the  disease.  Though there is  no loss of  sensation, the
 reflex is lost with the advancing waste of muscle and loss  of motion.
 The reaction of degeneration sets in very slowly and corresponds
 to the  degree of  destruction.  Peculiar deformities are caused by
 the wasting of individual muscles or groups of  muscles, while their
 antagonists are  spared.  The most characteristic of these  changes is
 seen  in the claw  hand.  Vaso-motor and trophic disturbances are
 frequent.  The  atrophied members are cold, often cyanotic, more
 rarely covered with sweat.  The  skin is often the  seat of eruptions,
 and the bones and joints may show trophic change.
    Morbid  Anatomy.—The disease consists, in essence, of a degene-
 ration of motor ganglia in the  pyramidal tracts.  The motor cells
 seem on inspection to have  almost entirely disappeared ;  sometimes
 not a single large cell may be seen.  The affected  muscles show the
 signs of fatty degeneration.   The striae are separated,  absent, or
 substituted  by granules, and fat globules accumulate throughout the
 structure.   The preservation of bundles of normal tissue  in the
 midst of this waste is characteristic of the disease.
   In  diagnosis  the  disease  is  to be separated from  traumatic
 lesions of the ulnar nerve,  which show the same deformity in the
 hand, but always,  of course, in but one hand;  from rheumatic affec-
 tion, which  may  show  it  in  both,  but  would not involve other
 muscles in  the  order of frequency,  and would  be distinguished by
 the presence of pain.   The slow development, order of  progression,
 and limitation to the motor system define the disease.
   The prognosis  is bad.  Arrest may occur, with  recovery and
restoration by hyperplasia of unaffected fibres  ; but recovery is rare.
The disease  is, as its name indicates, progressive, and is in its later
course usually complicated  with  bulbar paralysis  with its necessa-
rily fatal prognosis.
   Treatment.—The  body is to be supported with food  and fresh
        46 
722
INFANTILE PARALYSIS.
air.  Anxiety and fatigue must be avoided.  Gentle massage is of
value, as is also the use of electricity, which, in the mildest constant
currents, sometimes suffices to arrest the disease.  The only drug
worthy of mention is strychnia, which should be used subcutane-
ously in the form  of the nitrate, in small doses at  first, gr. T£T,
increased to gr. T\, once a  day.  The dose  must be kept down to
avoid overstimulation, and every intervention must  be mild, per-
suasive, rather than forcible.
                      INFANTILE PARALYSIS.
   Poliomyelitis {7Z0X10S, gray) ;  essential paralysis of  childhood ;
acute anterior poliomyelitis.—A rapid paralysis with atrophy, chiefly
of one or both lower extremities, more  rarely of an upper extremity
or of one side of the body, with loss of the reflexes, but preservation
of the  action of the  bladder and bowels ; with the reaction of de-
generation ;  with intact sensation ; sometimes with deformities from
contractures of  unaffected muscles.   The  disease, which is certainly
an infection, may begin with fever or convulsions.
   History. —Heine (1840)  wrote the first monograph in which the
symptoms were associated  to constitute a separate disease.  Cornil
(1863)  first saw lesions in the spinal cord.   Prevost  and Vulpian
(1865) located the lesion in the anterior cornua—a localization subse-
quently confirmed by Lockhard Clarke (1868) and Charcot and  Jof-
froy (1870)  as  the true seat of the disease.  Duchenne (1872) ob-
served  the affection also in  adults.
   Etiology.—Age is the  most important  factor ; six-sevenths  of
cases occur within the first three years.  The disease  is rare before
four months, but has been observed as early as the twelfth day.   It
is rare  in after-childhood, and is very rare in adults.   It is more fre-
quent in summer than in  winter, and has thus been  attributed to
cold, as after exposure at  night in bed.   It has been  noticed to oc-
cur  in  a few cases within a few days after exposure to cold,  as from
a draught, from sitting upon damp ground, etc. Attacks after fatigue,
trauma, and during dentition are probably coincidences.  More close
is the relation of the infections, which more distinctly liberate some
toxic element to produce the disease.
    Morbid  Anatomy.—-The process is closely limited to the gray
matter in the anterior cells, where it attacks and destroys the multi-
 polar ganglion  cells.  The cells lose  their poles,  shrivel, and are
 filled with  pigment and granular matter.  The disease may extend
 to involve the  lateral columns.   There is an increase in the connec-
 tive tissue,  with strangulation and destruction of nerve elements.
 Whole bodies of cells seem to  have disappeared or be substituted by
 corpora amylacea.   The paralysis and wasting are  to  be  directly 
INFANTILE PARALYSIS.                  723
attributed to the  destruction of the multipolar ganglion cells in the
anterior cornua.   The process shows  its main expression in  the
lumbar enlargement, next in the cervical, and last in the dorsal por-
tions of the cord.   It is  not, as a rule, symmetrical.  It is usually
focal, but may be for a short distance funicular.
   Symptoms.—The disease begins as  an infection, with toxic signs
—i.e., with fever, headache, restlessness, sometimes with stupor,
delirium,  and  convulsions.   Individual cases  are  announced with
anxiety and pain.  Vomiting is common, sometimes with diarrhea,
so that the case may be interpreted as a mere  gastro-intestinal ca-
tarrh.  These  symptoms may be slight or pronounced.  They may
last  for several days, and some time in  the course of them the char-
acteristic  symptoms develop.  It not infrequently happens that the
child is put  to bed indisposed or ill, and wakes  up paralyzed.   It is
observed  that the child  has lost the power of  motion from one or
both legs.  Sensation is unaffected.  The paralysis develops rap-
idly, but  is always worse at first ; not infrequently the paralysis ex-
tends from one to other members.  There  may be incontinence of
urine from affection of the bladder.  But the advance of the disease
is soon checked.  It is a characteristic of this spinal paralysis that
it soon  comes to a standstill and recedes to some extent.  Power
over the  bladder is quickly  regained ;  the paralysis may disappear
entirely in the course of a few weeks or  months.  As a rule, how-
ever, the improvement is only partial, and enduring paralysis is left.
   The changes of  atrophy now intervene.  The  wasting process
is marked, the skin is cold and purple, the surface is often mottled,
and  all the reflexes are  lost from disruption of the muscle reflex
centre in  the gray matter of the  cord.  The atrophy is more  rapid
than after section of the nerves, and is associated with the develop-
ment of the reaction of degeneration.   Development is arrested
in all parts of the affected  member.  Bones cease  to  grow, in fact
they actually diminish and  show deformity in comparison with  the
sound limb, which continues in normal development.   The varieties
of talipes, with  various scolioses, may form  for  life.   Under all
this  wasting process the brain remains unaffected, and  with the sub-
sidence of the acute signs at the start all the functions of the body
remain normal.  In adults the symptoms of the onset are less pro-
nounced and the distribution is more irregular.   Sometimes the para-
lysis is crossed, or one side of the body is affected, or nerves usually
spared are involved ; thus  the facial may  be  attacked, and  char-
acteristic changes show themselves in the face.   In children the dis-
ease  affects the legs three times as often as the arms, the left leg
twice as often  as  the right.  Irregular distributions are more  un-
common. 
724
INFANTILE PARALYSIS.
   Diagnosis.—The rapid paralysis and atrophy in close association
distinguish  the  disease.  It is  especially to be remarked that the
symptoms are always worse at the start; that afterward the disease
subsides to  some extent.  The disease is  non-progressive, though it
finally leaves permanent lesions.   In two-thirds of cases the lesion is
confined to  one  member, and in even the worst cases there may be
usually discovered fibres or bundles of unaffected, or but slightly
affected, muscles.
   The association of paralysis and atrophy, both rapid in onset and
marked, often extreme, in degree, whether preceded or not by gene-
ral signs, sufficiently distinguishes the disease.
   The prognosis is  good so far as life Lis concerned, but bad con-
cerning recovery.  The amount of lesion to be left may be  deter-
Fro. 284.—Posture of healthy child.
 Fig. 285.—Posture of infantile paralysis;
supported by the arms.
mined only after the  subsidence  of the acute  signs at  the onset.
Muscles which at that time still respond to faradization will probably
recover; muscles which fail to respond, or  respond but very feebly,
will recover in part or. not at all.  The degree of atrophy will deter-
mine  the  prognosis  l^ter on.  Loss of power  after three  months
indicates destruction of nerve cells.  Response to faradization at any
time leaves possible a certain degree of recovery.
   The treatment of the first stage is wholly symptomatic.  AY arm
baths, broken doses of  Dover's powder, the salicylates, salicin or salol,
may to some extent counteract the fever, the toxines, and their associ-
ate signs.   AYith the subsidence of  the acute stage after the lapse of
three or four weeks, treatment is directed to the paralysis with strych-
nia and electricity.   Strychnia should be given  in small doses, one-
one-hundredth of a grain, at first,  and gradually increased but not 
BULBAR  PARALYSIS.
725
pushed, and by the mouth rather than subcutaneously.  Electricity
acts with more direct relief by support of the muscle.   It should be
used in the  form of the galvanic current, and applied both  to the
spine and the muscle, negative pole at the spine.   The central effect
is best obtained by the application of electrodes  above and  at the
level of the  disease in the cord.  The peripheral is applied best in the
form of the labile current, with one sponge at the entrance of the
nerves and the other stroked over the body of the muscle, the sponge
being  lifted from the  skin with each stroke.  The current should
be feeble, that from but a few cells, at first, and gradually increased
to many cells, as many as may be borne.   Occasional reversal of the
current assists in the process.  The treatment requires great patience,
but should be persisted in under the very slightest encouragement, as
it offers the only hope of relief from deformity and restoration to use.
Frictions, massage, and stimulating applications  help to sustain the
circulation.   Cod-liver oil and phosphorus are indicated in debilitated,
more especially in rachitic, cases.   Orthopaedic devices may relieve
deformities  in helpless cases and enable the patient to get about, and
thus sustain the general health.

                       BULBAR PARALYSIS.

   Glosso-labio-laryngeal paralysis (Trousseau).—A sclerosis  of the
medulla, distinguished by progressive paralysis and atrophy of the
muscles of  the tongue, lips, larynx, and  pharynx, with increased
mechanical  and reduced electric excitability, with the reaction of
degeneration and reduction of reflex.
   AAAth the other scleroses,  the etiology of this affection is involved
in obscurity.  The disease occurs more frequently in advanced life,
is rare before thirty, and attacks men more than women.  Bulbar
paralysis has also been ascribed to  exposure to  cold, excesses, and
fatigue, without other proof of cause than sequence.  The disease is
a degenerative  atrophy which successively involves the centres of
various cerebral nerves; hence it has been called a progressive para-
lysis of the cerebral nerves (Benedikt).  The centres  attacked are,
in the order of frequency  and severity,  the hypoglossus,  facial,
spinal accessory, pneumogastric, glossopharyngeal, more rarely the
abducent, and the motor part of the trigeminus.  The auditory nerve
is never affected.
   Morbid Anatomy.—-The atrophic process leads to  a destruction
of the  contents  of the great ganglion cells.  Nuclei and protoplasm
actually disappear to  leave  only granules  and  pigment  matter.
There  is hyperplasia of the  connective tissue, thickening and athe-
roma of the vessels.  The degenerative process extends  into the axis 
726
BULBAR  PARALVSIS.
cylinder  of  the nerves, and the muscles supplied by them suffer
granulo-fatty atrophy.
   Though this atrophic process may not be regarded as the primary
affection, it  is  impossible as yet  to  discover its cause1.  It has been
found  by Benedikt in connection with basilar meningitis,  and is
frequently associated, often as the terminal process, with progressive
muscular atrophy, lateral sclerosis, paralytic dementia, etc.
   Symptoms.—-The disease begins very insidiously, and  is marked
at first with the  difficulties of speech which arise from affection
of the hypoglossus.  Sounds which require the use of the tongue suf-
fer first: to  wit, of vowels, i; of consonants, first r, later s, I, k. g, t,
and lastly d and n.   Affection of the facial produces difficulty with the
pronunciation of, first, u, later a, and of the consonants p, f, further
with b, m, and v.   Paralysis of  the palate  gives  rise  to  the nasal
                      voice, and affection of the accessory produces
                      paresis of the vocal cords and muscles of the
                      larynx.  The lips lose power to whistle or to
                      blow  out a  light; the face loses  expression.
                      The difficulty with mastication from paresis of
                      the tongue and lips leads to accumulation of
                      food and lets it drop from the mouth.  Saliva
                      is freely discharged, or must be continuously
                      wiped away.   The paralysis of the vocal cords
                      interferes  with respiration and leads to diffi-
                      culties of expiration and to dyspnea.  The
                      affected muscles show the same  reactions of
                      degeneration and fibrillar twitellings as in
                      progressive atrophy.
   A rare variety of bulbar paralysis, which shows itself in acute
form, occurs in connection with haemorrhages in the medulla and
 pons, from thrombus and embolus in the domain of the vertebral, ante-
 rior spinal,  and basilar arteries.   This acute bulbar paralysis shows,
in connection with the signs of involvement of the  cerebral nerves,
 hemiplegia with  opposite facial paralysis,  hemiplegia  alternates ;
 or crossed paralysis of the upper and lower extremities,  hemiplegia
 cruciata, with bilateral paralysis.   The signs  of an acute paralysis
 may occur  also in connection with, though  as a very rare complica-
 tion of,  disseminated myelitis.  The disease is then  announced with
 the same irritative signs—headache, vertigo, etc.—followed by para-
 lysis of the various nerves that issue from the medulla, with rapidly
 fatal termination.
    The diagnosis rests upon the successive involvement, in  regular
 progression, of various cerebral nerves,  beginning with the  hypo-
 glossus and ending with  the  trigeminus,  or extending further to
 Fig. 286.—Bulbar paralysis;
maximum  protrusion of
tongue (Gowers). 
ACUTE ASCENDING PARALYSIS.
727
   involve the anterior cornua in the spinal column, in association with
   symptoms of progressive muscular atrophy.  The relation is usually
   the other way.  The muscular atrophy precedes the bulbar paralysis.
      Bulbar is  distinguished from multiple sclerosis, or tumor with
   pressure  upon the medulla, by the different advent of these affec-
   tions, and the involvement  of  other nerves than those  affected  in
   bulbar paralysis.   Headache, vertigo, vomiting, convulsions, with
   affections of the auditory nerve and sensitive portions of the trige-
   minus, paralysis and contractions without muscular atrophy, belong
   to these diseases, but not to bulbar paralysis.
      The prognosis is absolutely bad.   The disease extends over a period
   of two to five years, with a constant tendency to progression, though
   it may come to a standstill and seem to be arrested for several months
   at the beginning of the disease.
      The treatment  consists in a  use of the galvanic current and the
   subcutaneous injection of strychnia, after  the manner already speci-
   fied in connection with other  scleroses.

                   ACUTE ASCENDINO PARALYSIS.

      A paralysis which  begins in the lower extremities and  ascends
   rapidly to involve the body  and  upper extremities, in the  absence
   of  all discoverable lesion in the  spinal cord.    This paralysis was
   first  specialized by Landry  (1859), and  is often  called Landry's
   paralysis.
      Etiology.—The disease is assumed to be an infection,  the nature
   of which  is unknown.   Support of  this view is  furnished  in  the fre-
   quent presence of  enlargement of the  spleen common  to most infec-
   tions, and occasional attacks of fever and sweating.  It is more com-
   mon  in males and in the period between adolescence and maturity.
      Symptoms.—The paralysis begins as a  iveakness of the legs, and
   extends so rapidly as to take the patient off his feet in the course of
   twenty-four to forty-eight hours.  The weakness is noticed  next  in
   the pelvis, and rapidly ascends to involve the whole trunk and upper
   extremities.  In all cases the paralysis is pronounced ; in the lower
   extremities it is usually absolute.   The process may stop at the cer-
   vical  cord, but extends often to involve the medulla with  the centres
   of articulation, deglutition,  and respiration.   The unfortunate pa-
   tient, with full consciousness, may no longer express his wants; he is
   unable to swallow  and suffers attacks of  dyspnoea or succumbs  to
   suffocation.  Sensation is affected  in  much less degree.  The para-
   lysis  may be preceded by parsesthesia, especially by numbness and
   tingling in the extremities, but the sensation of touch  is usually pre-
•  served.  The reflexes  disappear and remain  lost in cases rapidly
   fatal, but return gradually with recovery.  The  sphincters usually 
728 SPINAL  HEMORRHAGE—HEMATORRHACHIS; HEM ATOM YEL1 A.

escape.  Notwithstanding the intensity of the signs, there is little or
no trophic change ;  the  muscles do not waste, electric  excitability
is not lost, and bed sores  do not develop.
   The prognosis is very grave.  The paralysis may extend to in-
volve respiratory or cardiac centres, and  thus prove fatal in the
course of  two days.  The duration on the average is  less than a
week.  Recovery, when it occurs, is rapid only in exceptional cases.
As a rule it is exceedingly slow and extends over a period of several
months.
   Treatment is of little avail, as the course of the disease is deter-
mined by the nature or amount of the infection, and may be but  lit-
tle influenced by drugs.   It is advisable to push the salicylate of soda
and  to  administer  warm baths.  The bichloride  has been recom-
mended in small and frequently repeated doses, or,  where mercury is
contra-indicated,  the perchloride of iron.

   SPINAL HEMORRHAGE—HEMATORRHACHIS; HEMATOMYELIA.

   Haemorrhage  may occur in any part  of the cord substance  or
membranes, where  it may be extra- or intrameningeal.   Meningeal
hemorrhage,  haematorrhachis, is chiefly  due  to injury, fractures,
falls, etc., but sometimes occurs after the straining efforts of violent
convulsions.   As miliary aneurisms do not develop in  the course of
the vessels, haemorrhage into the substance of the cord—haemato-
myelia—is rare.  But it may occur at any age from infancy to ad-
vanced life,  most  frequently  in adolescence  and early maturity.
Trauma is  the most frequent  cause.  In exceptional cases haemor-
rhage has been observed  after excesses in venery.
   The symptoms depend upon the seat and extent  of  the effusion.
Haemorrhage is usually announced by sudden and violent pain in
the back  and along the  course of the nerves which issue from the
seat of the lesion. Spasm, rigidity, convulsions, may immediately
supervene and be followed by rapid paralysis, paraplegia.  In ex-
ceptional  cases the  brain may be  affected indirectly from upward
displacement of the cerebro-spinal fluid.  Symptoms occur, as stated,
suddenly, and develop rapidly, to reach their height in a few hours or
days with fatal lesions, or, in favorable cases,  with gradual recovery
in the course of a few weeks.
    Diagnosis.—Meningeal haemorrhage  is  distinguished by  the
prominence of pain and irritation.  In hsemorrhage into the cord
paralysis is the  most prominent sign; fever, which develops early,
speaks rather in  favor of myelitis.
    The prognosis  is always  grave, and is determined  early in the
 history of the case.   Effusion into the cervical region is especially 
ACROMEGALY.
729
 grave.   The return of sensation is a favorable sign;  evidence of tro-
 phic change is unfavorable.
    The treatment is absolute rest, recumbent, with an ice bag to the
 spine, and attention to the secretions.   A subcutaneous injection of
 ergotin or sclerotinic acid may secure contraction of the vessels and
 check the hsemorrhage.

                        SYRINGOMYELIA.
    Syringomyelia  {6vpiyS,, pipe) ; gliomatosis of the cord.—A dis-
 ease marked by anaesthesia and muscular atrophy, and distinguished
 by the presence of  cavities in the spinal cord.  These cavities have
 been  variously interpreted as arrest of development, defective closure,
 Olivier (1827) ; the  results of sclerosis, Hallopeau ; neoplasm, glioma,
 Grimm  (186'.)) ; in  Brittany as the  result of leprosy.  The  disease
 was associated with distinct symptomatology by Kahler and Schultze
 (1882).
    Morbid Anatomy.—The cavities are usually found in the poste-
 rior parts of the cord, and result clearly from a glioma or gliosarcoma
 which has broken  down and disappeared.   The cavity is generally
 lined with a delicate covering layer containing glia cells, and not in-
 frequently communicates with the central canal of the cord.
    Symptoms.—Syringomyelia  is usually  announced  with  parses-
 thesia,  especially with diminution or loss of sensation to pain
 and heat.  Thus burns are not felt, and are discovered only by the
 destruction of  tissue.  Asmus reported a  handsomely  illustrated
 case (Bibliotheca Medica C. Heft 1), marked also by anaesthesia of
 the conjunctiva and cornea.  The sense of touch and the muscular
 sense are commonly  unaffected.  The atrophy of muscle occurs
 later  ; it  shows itself  in the hand and shoulder, and advances in
 the order of progressive  muscular atrophy.  Trophic changes are
 common.  Surfaces of the body may be cold and cyanotic ;  the joints
 may swell.   The patient succumbs to bed sores, cystitis, and maras-
 mus.
    The diagnosis rests upon the loss of sensation of heat  and pain,
 with  preservation of the sensation of touch, and the characteristic
 muscular atrophy.  The arthropathies, in distinction from tabes, are
 chiefly confined to the upper extremities (Sokoloff).
    Treatment is wholly symptomatic.

                          ACROMEGALY.
    Acromegaly {aupos, end,  peyaXrj, great).—A  disease distin-
guished  by hypertrophy of the bones and tissues of  the hands, feet,
and face, with headache, drowsiness, melancholy, sweating,  and
thirst.  The  alterations were  first  described by Pierre Marie  and 
730
Raynaud's  disease.
 Souza-Leite  (1891) with  a record of forty-eight cases.   Osborne
 (1892) reported the eighth  case observed in this country.   Acrome-
 galy usually occurs between fifteen and thirty-five, and may be oli-
 served in several members of the same family.  The  enlargement of
 its bones imparts to  the face a peculiar  expression.  The chin is
 prominent; the whole lower jaw protrudes.  The trunk and the long
 bones are unaffected, though there is usually anterior dorsal curva-
 ture with compensatory lumbar lordosis.  The stature is heightened,
 the abdomen projects.  The hands are very much  broadened, the
 fingers are uniformly enlarged ; the nails, broad and short, scarcely
 reach the ends of the  fingers.  Among the curious  anomalies of
 this condition are enlargement of the tongue, polyuria,  sweating,
 and disturbances  of special  senses.   The  condition  is ascribed to
 lesions of the spinal cord allied to those of syringomyelia.

                       morvan's disease.
    A trophic disease, distinguished by destruction and deformity of
 the ends of the fingers.  The affection was first described by Morvan
 (1883), later by Charcot.  The disease shows all the signs of inflam-
 mation except pain.  There are heat, redness, and swelling, but, as a
 rule, entire absence of pain, analgesia.  The ends of  the fingers suf-
 fer necrosis, the nails  fall out, the  hands may become blue.  Anaes-
 thesia and atrophy occur subsequently.  The  course is very slow;
 months, even years, may lapse while  the disease extends from one
 finger to another.
   The pathology is obscure.  The affection is considered a sclerosis
 of trophic centres in the spinal cord.
   Diagnosis.—Morvan's disease is distinguished from the destruc-
 tive dactylitis of syphilis by the signs of syphilis elsewhere and by
 the absence of analgesia in syphilis ; from  leprosy—if it be not lep-
 rosy itself—by the signs of leprosy elsewhere, the patches and nod-
 ules over the body, and by the affection of  the lower extremities in
 lepra; from  syringomyelia by the absence of  necrosis of bone, the
 presence of sensation, and the progressive muscular  atrophy of this
 disease.
   The prognosis is unfavorable.
   The treatment is wholly symptomatic.

                      RAYNAUD'S DISEASE.
   A gangrene of the extremities, sometimes of  other parts of the
body, distinguished by symmetrical distribution.  The affection was
first described  by Raynaud  (1862).   It is  considered a vaso-motor
neurosis.  The disease begins with pallor and parsesthesia in the first
phalanges of the fingers or toes, sometimes  also in the tip  of the 
                   PROGRESSIVE DYSTROPHY.                 731

nose and upper parts  of the  ears, which soon become cyanotic and
oedematous.  Gangrene and sloughing may supervene.
   Diagnosis.—The effects  of frost  bite,  which may simulate the
condition, disappear with  warm weather; the symptoms of Ray-
naud's disease, though aggravated by cold, persist.
   The prognosis  varies  according  to  the  extent and rapidity of
spread of the disease.   Recovery is possible in even the worst cases.
   Treatment is wholly symptomatic.  Vascular spasm may be re-
laxed by belladonna and the  bromides, the action of  the heart sus-
tained by digitalis.  Pain may be  so severe as to require the use of
morphia.  The nervous system may be supported by strychnia.  The
general health must be held up by tonics.

                 brown-sequard's  paralysis.
   Brown-Sequard's paralysis is  a paralysis  of motion on the same
side  and of sensation on the  opposite side  of a lesion  in the cord—
i.e.,  a hemiparaplegia  with  crossed  anaesthesia.  The condition is
attributed to a lesion in the lateral half of the cord, and is  explained
by damage to the motor fibres in  their downward course and to sen-
sory fibres before decussation in  their upward course.  Crossed sen-
sory and motor paralysis occurs  only in injury or disease of the cord
as low as, and below, the middle dorsal region.  Motion, by trans-
fer of nerve force through decussating fibres  from the opposite side
of the body, usually returps,  while sensation  remains lost.
   Horsley accepts  the  symptomatology, but doubts the interpreta-
tion.
   The prognosis is grave, yet cases of recovery have been reported.

                   progressive dytstrophy.
   Dystrophy {dvZ, mis-, xpocpeia, nourishment) of muscle is  a term
employed to distinguish disease dependent upon affection of the mus-
cle independent  of  nerves, that is, of myopathic as  distinguished
from neuropathic origin—a distinction that is by no means actually
established as yet.  The visible distinction lies in the fact that atro-
phy is attended  with distinct reduction in volume, while dystrophy
may be attended with an apparent increase in volume.  Atrophy is
distinguished by the occurrence of fibrillary twitchings and the pre-
sence of the reaction of degeneration  in  at least part of the affected
muscles.  Dystrophy is distinguished by  the fact that the electric,
faradic, and galvanic  irritability is reduced or lost without a show
of the reaction of degeneration.  The chief types of dystrophy are :
(1) pseudo-hypertrophy, (2) juvenile dystrophy, (3)  hereditary atro-
phy, (4) facial atrophy.
   1.  Pseudo-hypertrophy of  muscle is, as the name implies, 
73-2
progressive  dystrophy.
only an apparent increase of volume, as the muscular structure itself
is  reduced in amount and substituted by the abundant development
of interstitial fat.  The condition is commonly associated with pro-
gressive muscular atrophy, and shows itself in the lower half of the
body, while the atrophy advances in the upper  half.  The disease
always shows itself in early life—four times as frequently in boys—
during the period of development, and  is most frequently first ob-
served in the first attempts to walk.   The muscles of the calf of the
leg are earliest and most affected.  The enlargement may be  very
                                 great, so that the leg of the boy
                                 is as big as a man's and is out
                                 of all proportion to the rest of the
                                 body.   The infraspinatus is next
                                 most frequently affected, and is
                                 at times so much enlarged as to
                                 be mistaken  for the  scapula it-
                                 self.  The difficulty of locomotion
                                 is especially  marked in the at-
                                 tempt to climb stairs—the child
                                 must  pull itself up by the banis-
                                 ters—and  is very manifest in at-
                                 tempts to lift itself from the floor,
                                 an act  which  is accomplished
                                 only  by the  use of all four ex-
                                 tremities.
                                    Especial stress is laid, in di-
                                 agnosis,  upon  the  great size of
                                 the infraspinatus with atrophy of
                                 the  latissimus dorsi; next upon
                                 the  enlargement of the muscles
                                 of the calf and loss of knee jerk.
                                 The  disease  shares  the  grave
                                 prognosis  of  other  forms of
                                 muscular  atrophy.   It  is  pro-
                                 gressive.   After loss of the power
of standing, seven years is about the longest duration of life.
   The treatment is the same as that of progressive muscular  atro-
phy.
   2. Juvenile Dystrophy occurs in adolescence and begins in the
muscles of the upper extremity.  It shows itself  with  the  same in-
crease in volume and  diminution in force.  The muscles especially
affected are  the deltoid, supra- and infraspinatus,  teres major and
minor,  triceps,  tensor facise latse, sartorius,  gastrocnemius.   With
the exception of the supinator longus,  the muscles of the forearm
  Fig. 287.— Pseudo-hypertrophic paralysis:
big calves of legs (Putzel). 
tetany.
733
usually escape.  Lipomatosis is not so pronounced  as in pseudo-
hypertrophy, but sclerosis is more common.
   3.  Hereditary Atrophy is a subvariety which  occurs in later
childhood and  adolescence,  is  hereditary and affects a number of
members of  the same  family,  but otherwise is not  different from
forms already described.
   4.  Facial  Atrophy—Duchenne (1872)—attacks chiefly the or-
bicularis oris ;  later the  orbicularis  palpebrarum, frontalis,  levator
nasi, zygomatici, and risorius, and may extend to involve the mus-
cles of the shoulder and arm and even of the lower extremity.  It is
unilateral.   The alteration thus effected in the face changes the phy-
 Fig. 288.—Pseudohypertrophic paralysis;    Fia. 289.—Pseudo-hypertrophic paralysis;
attempt to rise from floor (Putzel).         patient " climbing up his thighs " (Putzel).
siognomy and gives the face the appearance of a mask.  The fact
that the atrophy occurs in youth, is hereditary, and coincides  with
sclerosis, lipomatosis, and hypertrophy, allies it to, or makes of it but
a subvariety of, the dystrophies already described, from which it dif-
fers only in the fact that it first affects the face.

                             tetany.
   Tetany {xeivao, to  stretch).—A  disease characterized by painful
cramp or spasm in the extremities, especially in the flexors, with ex-
cessive excitability of  the  motor nerves to mechanical or electrical
irritants. 
734
TETANY.
   History.—Though described a half-century ago. the distinctive
features were first distinctly emphasized by Trousseau, who gave it
the name tetanilla, diminutive of tetanus.  Corvisart (Lucien, 1852)
first called it tetany.
   Etiology.—Tetany is a disease of early life.  It shows itself in
infancy, and occurs with especial frequency in  the  first and  second
decades of life.  At this period the disease is more frequent in males.
After the age of twenty the ratio is reversed.   Tetany appears to be
a toxaemia, the result of exhausting discharge, though there is no
proof for this view.  It supervenes most frequently upon diarrhoea
and lactation.   In children it is connected with rickets ; sometimes
it follows attacks of typhoid fever, measles, small-pox,  rheumatism,
pneumonia.   A curious  sequence, too frequently observed to be a
mere  coincidence, is the occurrence of tetany after excision  of  the
thyroid gland.  Tetany is liable to develop within ten days after re-
moval of the whole thyroid gland.
   Symptoms.—The disease  is usually announced suddenly, with
spasms in the hands and feet.  The hand  is cramped to assume a
posture so distinctive as to be called the position of tetanus.  The fin-
gers,  extended upon their own joints, are flexed upon the meta-
carpus.  The thumb is fixed against  them; the wrist  is slightly
flexed.  Thus the hand is brought into the so-called obstetrical hab-
itus,  as  for introduction into the uterus to perform flexion.  The
feet are  extended and  inverted, to assume the position of  talipes
equino-varus.   The toes are flexed, the knees  extended.  The spasm
may extend to involve the  muscles of the trunk; in severe cases, of
the face ; and in extreme cases, of the eyes  and tongue.   Sensations
of numbness and tingling may precede  the  spasm, which, when
fully developed, is always attended by pain.  The attacks  are par-
oxysmal and apparently spontaneous.   They may occur in sleep.
The heightened excitability is especially observed in response to a
blow.  A tap upon a muscle is followed by muscular contraction.
This quick response constitutes the so-called Trousseau phenomenon.
The compression of a nerve, in the act of compressing an artery, pro-
duces spasmodic contraction in the course of a few minutes.  Some-
times this phenomenon  is absent.  Electric excitability is  so much
heightened that a current  from a single cell produces contraction.
The disease is intermittent, remittent, or more or  less continuous ; it
may last but a few days or continue for several weeks, in exceptional
cases for several months.  Recurrence is not infrequent.
   The prognosis is favorable.  Tetany is distinguished from tetanus
by the cause of tetany—diarrhoea, lactation, and exposure to cold ; by
the occurrence of  spasm first in the hands and feet.   Tetanus begins'
in the jaws.   The obstetrical posture of  the  hand is  peculiar to 
TETANY.
735
tetany.   Hysteria is unilateral; tetany is always bilateral.  Epilepsy
is attended with loss of consciousness and clonic convulsions.
   Treatment is the relief of the cause.   Diarrhoea is  arrested by
appropriate means; lactation  is stopped;  rickets is  relieved with
phosphorus and  cod-liver oil.  Severe  spasms may call for chloral,
or even subcutaneous injections of morphia; milder  cases yield to
the bromides, half a drachm in a glass of water three times a day.
In nocturnal tetany no remedy is so useful as a dose  of digitalis at
bedtime (Gowers). 
CHAPTER XIII.
                  DISEASES OF THE  BRAIN.

                           APOPLEXY.

   Apoplexy {anonXi]66oo, I strike down).—Sudden loss of conscious-
ness from  brain disease, with abolition of  motion, sensation, and of
special sense.  The  term as originally employed was  wholly symp-
tomatic ; but as in the course of time  so many cases were found to
be due to hsemorrhage in the brain, it got  gradually a wider range,
in that it was applied to rupture of blood vessels in other organs ; so
the older writers spoke of apoplexy in  the  lungs,  kidneys, retina,
etc.
   Brain apoplexy does not necessarily result from hsemorrhage, as
the same  stroke may follow embolus or  thrombus of the cerebral
arteries.   Hence apoplexy may occur in consequence of rheumatism,
alcoholism, and syphilis.   An apoplectiform stroke may be the result
of trauma,  uraemia,  poisoning by alcohol, chloral, opium, prussic
acid,  etc.,  so that a differential diagnosis becomes a necessity in
every case.
   Etiology.—True apoplexy in the  majority of  cases means  cere-
brat haemorrhage.  ^Haemorrhage implies a weak vessel and an in-
creased force behind it,  one  or both.   The first  is by far the  most
important factor.  The action of the heart, however strong, cannot
break a sound vessel; it might weaken it in  the  course of time and
then finally break it.  Frequently the increase in the force of the
heart is a struggle  against  resistance from disease of the vessel,
which prepares it for rupture.
   The most important factor in connection with ordinary cerebral
haemorrhage is age.   Four-fifths of cases occur after  the age of
forty, males preponderating over females in the proportion of  three
to two.  If haemorrhage from all sources be considered, the propor-
tion is greatest in  early life, infancy and about birth.  The rupture
here,  however,  concerns the meningeal  vessels,  as  the result of
strains connected with parturition.
   Heredity plays  a role of some importance, in that apoplexy oc-
curs in certain families and is absent in others. Weak arteries may 
APOPLEXY.
737
be inherited as well as weak eyes, weak stomachs, and weak brains.
Weak arteries  bulge and break  quicker under  the same strain.
Short, thick-necked, square-set, red-faced, heavily built men, the so-
called homines quadrati, are  popularly believed to have a special
liability to apoplexy.  They are said to have the apoplectic habit.
The  reverse is true.   More often thin men of  spare  habit have
weaker vessels in  the brain.  No outside condition, as accumulation
of fat,  atheromatous  degeneration of radial  or temporal arteries,
arcus senilis, etc., indicates any greater tendency to apoplexy.   Out-
side may coincide with inside atheroma  and aneurism ; the brain
vessels  may still not rupture.  More frequently the  conditions are
independent of each other.
   True apoplexy in the brain substance  remains a disease of age.
When it  occurs earlier,  in adolescence or  maturity, it  is the re-
sult of conditions  which precipitate the arterial changes of age—
chiefly alcoholism, syphilis, gout, and Bright's disease—so that the
common expression, quoted elsewhere, '' a man is as old as his ar-
teries," has  foundation in  fact.  The  walls  of the vessels suffer
particular change in age.   It is a  question whether the  change be-
gins in the intima  or the adventitia.   In either case it is  expressive
of failing nutrition, which is  felt in the  blood  vessels first.   This
failing nutrition may manifest itself in the blood vessels generally
over the body, to constitute the condition known as arterio-capillary
sclerosis, whereby, owing to the resistance and lack of resilience of
the walls in  the finer vessels, extra work is  thrown upon  the heart.
The solution of the cause of the failing  nutrition of age  is the solu-
tion of the problem of life itself.
   Fatty and atheromatous change occurs in the great blood vessels,
first and most markedly in the aorta. This chalky, fatty degenera-
tion may affect also the cerebral arteries and  lead to( final rupture.
More frequently a peculiar change  is noticed in  the finer blood ves-
sels given off in the substance of the brain.  The wall of the vessels
weakens in spots and bulges under  pressure, to form minute, so-
called miliary aneurisms.
   Charcot  and Bouchard demonstrated in the  brain  of apoplexy
almost universally the presence of  these miliary  aneurisms, the rup-
ture of which caused cerebral haemorrhage.  There are reasons why
the vessels in the brain soonest suffer this change.  In the first place,
they  are surrounded  by semi-solid,  almost diffluent substance, so
that they lack external support.  In  the second place, fine arterioles
are given off  directly from large trunks,  so  that delicate-walled
vessels must sustain the pressure of thicker trunks or tubes.  Mili-
ary aneurisms  are  detected  on the walls of the smaller  vessels by
placing the brain substance with its clot in water, and gently agitat-
        47 
738
APOPLEXY.
ing the water to wash away everything else.  The twigs vvith their
aneurism, like grains of red sand or minute drops of  blood, float out
to become manifest.  As many as two hundred aneurisms have been
counted in a  single brain, rupture of any of which produces  apo-
plexy.  The tendency  of  the condition to recurrence is thus ex-
plained.  The break is sudden, but the process which leads to it is
slow, requiring months and years for its full development.
   Any vessel in the brain,  the great vessels  at the  base  of  the
brain, arteries of the circle of Willis, or their immediate  branches,
may  break.   The rupture occurs most  frequently  in  branches of
these last-mentioned branches in the substance of the brain.   Hem-
orrhage may occur in any part of the brain substance.  It does oc-
cur most frequently about the great ganglia  and the island of Roil.
A branch of the middle cerebral artery breaks  so often as to have
been  called by Charcot the  artery of haemorrhage.  Haemorrhage
may occur in the cortical substance, in the pons, medulla, most rarely
in the cerebellum.  The quantity of blood which may escape varies:
a drop or two may exude, or  such a mass be  poured out as to tear
up the brain substance, break into the ventricles, and form a pool in
the brain.  Blood may pour out  en masse at  once, or may ooze  out
gradually ; or haemorrhage may  cease, to recur again and again.
   Should the patient survive the shock and pressure, the clot under-
goes the same subsequent changes as in other parts of the body.   It
may become encysted and  shut off from the  rest of  the brain.   Its
contents may be transformed into a clear fluid.  Such cysts are fre-
quently seen upon  autopsy.   The blood may be entirely absorbed,
when  connective tissue may fill up the breach to leave a scar, dis-
coverable also on autopsy.  Slight losses of  brain substance may be
substituted by other  cells and little or no damage may be left,   The
slightest loss is usually appreciated by the patient  as loss of energy
—so many battery cells have been cut out.
   Sometimes irritative changes set in ;  sometimes secondary  de-
generation takes place about the clot; and the process may extend
to the pons, medulla, and cord, with consequent  impairment or loss
of function.   It is rare that a lesion may disappear to leave no trace.
A severe lesion may take life  at  once, or  the patient may be para-
lyzed and recover to suffer subsequent attacks.
   Symptoms.— An  attack of hsemorrhage announces itself, as a
rule,  without symptoms.   The  patient is pursuing his ordinary
avocation when he is suddenly, without warning, stricken down.
In a few  cases there may be premonitions—headache, vertigo, neu-
ralgic  pains.  Premonitions  occur  more  frequently in connection
with kidney disease, and have been, in the history of  the individual,
frequently present before.  Sometimes the  attack occurs in sleep. 
APOPLEXY.
739
 It occurs frequently in the bath.  It may be directly provoked by
 emotion, or a strain, as at stool.  In  certain cases  there is felt  a
 sensation of numbness, lameness, in an arm or leg.   Sometimes the
 patient rises  to  fall unconscious ; or is able to go about, to reach
 home and go to bed, and send  for a physician before  the lapse into
 coma.  These cases have  been denominated "ingravescent" apo-
 plexy.   Certain  cases  are  preceded by violent pain in the  head.
 The first signs may precede the coma by several days   These vary-
 ing conditions may be explained by the quantity and rapidity of the
 haemorrhage.  More frequently the  patient is found unconscious,
 totally paralyzed, bereft of sensation, in whatever position he may
 have fallen, in a state of profound coma.   The face may be flushed,
 dark or pallid, or cyanotic ; sometimes it is covered with  sweat,
 which must be constantly mopped away.  The surface may be cold
 or hot.   The pulse may be full and bounding—this is  especially the
 case in kidney disease ; or feeble and fluttering, as after a profound
 shock.   The pupils may be  dilated or contracted ; they are most fre-
 quently  dilated,  especially in profuse or ventricular haemorrhage ;
 they  may be contracted to the size of a pin's head, especially in
 haemorrhage  in the pons;  they may be unequal—but whether di-
 lated, contracted, or unequal, they are always irresponsive to light.
    Respiration is stertorous; the patient  snores.  The cheeks flap.
 The alae nasi may be sucked in by inspiration.  The lips are blown
 out with expiration.  Respiration is usually retarded ; its rhythm
 is often irregular; it sometimes stops and is resumed  with a  series
 of more  rapid acts, preceded by one longer-drawn inspiration—the
 Cheyne-Stokes respiration.  The limbs, lifted from  the body, fall
 like dead weights.  The discharges may be voided involuntarily and
 unconsciously ; more  often they are retained  and must be voided
 artificially.
   The coma and paralysis may last for several hours, the greater part
 of a day, or several days.  During this period the patient is uncon-
 scious of everything about him.   The sound of a familiar voice, as of
 a wife or child, may excite a responsive groan or mutter.  The patient
 may be able to swallow.  Deglutition is usually impossible at first, and
 imperfect for some time.  Gradually there is dawn of consciousness.
 The sound side moves.  Deglutition is less difficult.   Speech is, if
 possible,  thick. Now it is seen that one side of the body—the side op-
 posite the lesion—is paralyzed.  There is hem iplegia.  The paralyzed
 side is to all appearance normal ; it is usually somewhat cooler, may
 sweat more easily and profusely, but  it is totally bereft of motion
and sensation.  Sensation returns in the course of a few  hours or
days,  but motion is lost.  During  the existence  of coma, and in the
presence  of universal paralysis, it may have been impossible to local- 
740
APOPLEXY.
ize the lesion.  Sometimes, however, the eyes are turned in the same
direction.  They both look  to  the right or left as far as may be, but
always, or very nearly always, toward the  lesion in the  brain  and
away from the paralyzed side of the body.  This "conjugated devia-
tion of the eyes " indicates lesion of the gyrus angularis  with silas-
tic contraction, which is itself  a bad sign.  Sometimes the head  also
is twisted over in the direction toward which the eyes look.  It may
be brought back to the median line with some degree of force, some-
times with manifest expression of  pain ; but, left alone, it returns
   Fig. 260.—Forms of hemiplegia: 1, common type of hemiplegia, from haemorrhage in the
neighborhood of the corpus striatum—the shaded parts indicate the distribution of the paralysis;
2, hemiplegia in lesions of the crus cerebri;  3, hemiplegia in lesions low down in pons Varolii
(Shaw).

as before.  So the eyes may be made to follow a light to the median
line, but not beyond, when they, too, assume the former direction.
The paralyzed side may show, instead of less, more motion, to con-
stitute actual rigidity.   The  hand  is  found clenched and  flexed
upon the forearm, the forearm upon the arm.   Less  frequently the
foot is extended and inverted.   This rigidity may  come  on early
during the  coma,  or within a few days  after the  stroke, or later
after the lapse of two or three weeks.   Whether the rigidity be early 
APOPLEXY.                        741
or late, it  constitutes always a bad  sign.  Early  rigidity speaks
against recovery with life, late rigidity against  recovery of use of
the limb.
   Diagnosis.—Haemorrhage may at times be differentiated from
embolus by the  fact that embolus  occurs more  particularly  in
adolescence and  maturity, and in consequence of rheumatism  or
some infection which has produced a lesion of the heart.  The  heart
may be found enlarged in its diameters, and changes may be audible
in  its sounds.   Otherwise haemorrhage  and embolus may not  be
separated.  Thrombus occurs more particularly in gout, renal cir-
rhosis, and syphilis, which conditions  may be recognized by evi-
dences of these diseases elsewhere.  Uraemia  occurs in connection
with kidney disease, which may have been plain in the previous his-
tory.   Albuminuria may be recognized  by the withdrawal of  urine
at the time of examination.   Uraemia distinguishes  itself by  the
predominance of convulsions over comatose states.   Alcoholism may
be recognized by the history  of  the individual, by the odor of  the
breath, by  the proximity of vomited matter.   Great caution must be
exercised concerning these things.   Mortifying  reflections have been
cast upon medical men who have carelessly permitted  patients with
organic lesion of the brain to be carried  to station houses  as " dead-
drunk."  It must be remembered that  drunkards are  especially
liable to cerebral haemorrhage and uraemic attacks.  A man in coma
should always be sent to a hospital until his true condition may  be
ascertained.  Trauma may be discovered by  examination of  the
skull, or may reveal itself later in the  history of the case.
   Time alone may  accurately determine the  prognosis.  Most
patients succumb to the first stroke.   Coma  which lasts longer than
forty-eight hours is usually fatal.  The immediate danger is best
recognized  by means of the  thermometer.  There  is  time to  make
observations, as death, though it may occur quickly, is never imme-
diate as in  heart disease.  In the initial shock the temperature falls
one or two degrees.  The lower it falls the worse is the outlook.
It should begin to  rise in the reaction in the course of a few hours,
and remain about 100° or 101° for a few days.  The more rapidly it
approaches the normal  grade the better is the outlook.   The dura-
tion of life in these cases may be most accurately determined by the
thermometer.   Temperature  which rises from  a level of  100°-1(>2°,
where it has stayed for several days, to  105°  or  100°, is pre-agonal.
   What damage will be  left may  be determined only  by time.
After a single  stroke individuals have remained  free for twenty
years, long enough to have died of extreme old  age.  There is, how-
ever, constant liability to another stroke  The sword of Damocles
literally hangs over the head of  an individual who has once suffered 
74:2
EPILEPSY.
a cerebral haemorrhage.  When the patient recovers, the leg recovers
first, but long after the patient may go about on foot the arm still
swings helpless  at  the  side.   In  general, left-sided hemiplegias are
worse than right.
   Treatment.—A  patient affected with apoplexy should be placed
in a recumbent  posture, the  clothes loosened about the neck and
body, the body kept warm, and the head cool by cold water or an ice
bag.  Stertor, which often depends upon prolapse of the tongue and
occlusion of the glottis  with reflux of saliva, may be usually largely
relieved by placing  the patient upon the right side, in such a position
that the saliva may drain away (Bowles).
   To bleed, or not  to bleed—that is the question.  Venesection was
formerly unanimously employed in case of high arterial tension.   A
flushed face and bounding pulse were said to call imperatively for the
letting of blood.  This  condition meets its explanation in our day
better by the  state  of the kidneys, which causes the whole mischief
in the heart and brain.  It is questionable if blood-letting be ever
justifiable in  a  case of haemorrhage  in the brain. A  meningeal
haemorrhage may  be relieved by surgery.   No  drug  can dissolve
blood clots in the brain.
   After  the  subsidence of acute symptoms, muscles  may be kept
from wasting by massage and faradization, which best substitute
absent or failing nerve  force.   Warm  baths always give great com-
fort.  States of irritation may be allayed by the bromides, gr. xxx. in
half a glass of water.   Sleep  is best secured  by trional, gr. xv.-xx.
in a cup of hot tea  at bedtime.  Still later  on some benefit may be
derived  by the  subcutaneous injection of strychnia, preferably the
nitrate,  given in dose  of  one-one-hundredth of a  grain,  with the
dosage gradually increased to tolerance.  Phosphorus, the compound
syrup of the hypophosphites, may be given  with it.  Peace of mind,
when possible, is a great help.  The panorama of travel may divert
the mind from its own organ.

                           EPILEPSY.
   Epilepsy (inikappavGo, to seize).—A fine  cortical lesion, charac-
terized by paroxysms of loss of consciousness and convulsions (mo-
mentary tonic and subsequent  clonic convulsions) of the whole  body,
with, as a rule,  dilatation of  the  pupils, which  are irresponsive to
light, and general  loss of the reflexes.  A subvariety marked  by
localized convulsions, unattended  with loss of consciousness,  is dis-
tinguished as Jacksonian epilepsy.  Other states  simulating,  but
differing in essential particulars,  are called epileptoid, in distinction
from the true  disease.   Explosions due to organic disease are  called
symptomatic;  they  do not fall under the head of true epilepsy. 
EPILEPSY.
743
    History.—Epilepsy was known  in  the most remote antiquity,
 when it was distinguished, on account of its dreadful aspect, as the
 sacred  disease of supernatural origin.   Hippocrates wrote an entire
 book " De Morbo Sacro," and described it, on account of its frequency
 in youth, as a child's  disease.  The term epilepsy was not used by
 Hippocrates or Galen, but was first employed in the tenth century
 by Avicenna.  Aretaeus and Coelius Aurelianus vividly described its
 symptomatology.  Morgagni made the  first  attempt to  discover its
 anatomical basis.  Tissot (1770) wrote the first elaborate monograph.
 Esquirol,  Calmeil, thoroughly described the disease.   Delasiauve
 (1852) and Schroder van der Kolk (1858) again studied its pathologi-
 cal anatomy.   Brown-Sequard, in his experiments in  the production
 of the disease in animals,  produced the disease by traumata.  Jack-
 son eliminated a special form.  Ferrier and Horsley recommended
 and practised  the exsection of  cortical  substance  of the brain in
 treatment.
    Etiology.—Epilepsy is  a chronic  affection which consists of an
 underlying condition  and characteristic  paroxysmal explosions of
 very short duration,  with  varying intervals  of  complete absence.
 The underlying condition is induced by various causes: 1. Heredity
 in one-third of the cases, Avherein the disease may alternate with other
 neuroses.  Thus insanity,  hysteria, alcoholism,  migraine, may ap-
 pear in the posterity as epilepsy.  In one case recorded  by Gowers
 fourteen members of  a family were epileptic in the  course of four
 generations.  Hereditary forms occur before twenty.   2. A ge; three-
 fourths of all cases begin before twenty, one-half between ten and
 twenty, one-eighth under three years of age.  3. Sex; females are
 rather more frequently affected, in the proportion of six to five.  4.
 Trauma.  Epilepsy may be acquired by injury of peripheral nerves,
 by disease of internal  organs, especially the brain.  Proof of the ac-
 quisition of the disease by injury was furnished in the experiments
 of  Brown-Sequard, especially  with guinea-pigs.  In  these animals
 blows upon the head produce convulsions, which subside to leave the
 animal  in  apparent health.  Certain  regions of the  surface of the
 body now  become so sensitive as, when irritated, to produce epilepti-
 form convulsions.  The cheek and front  of the neck—region of dis-
 tribution of the  trigeminus and occipital nerves—constitute these
 so-called epileptogenous zones.  The  curious fact was now observed
 that the progeny of these artificially epileptic animals  inherit the
 disease.  When both parents had been made epileptic, no one of the
young escaped.   5. Epilepsy may also be excited directly by disease
of the brain and spinal cord, in which are situated certain centres,
the excitation of which produces  convulsions,  and, through the vaso-
motors, spasmodic occlusion of the arteries, especially of the brain. 
744
EPILEPSY.
G.  Epilepsy may be excited by  gross  irritation of the cortical
substance.  These  cases  are distinguished by forcible movement of
a particular member innervated from the seat of irritation.  A more
extensive irritation involves  also the opposite side, or more extensive
groups of muscles, or the  whole body.   7.  Chemical poisons, alcohol,
especially absinthe, urea,  toxines (eclampsia), etc., produce epileptic
or epileptiform attacks.
   True epilepsy, however, requires the exclusion of all discoverable
organic disease or chemical poison.   Epilepsy, as a neurosis,  so-
called, i.e., a disease without discoverable lesion,  is assumed to de-
pend upon  discharging lesions from cortical centres rendered instable
of nerve force by heredity or acquisition.   This instability or irrita-
bility of nerve cells or centres constitutes the underlying condition,
which may be definitely determined in about one-third of cases.
   The immediate explosion is produced by  some  exciting  cause.
Infantile  cases  are generally due to rickets.   They are usually
ascribed to dentition, defect  or  delay in which  is  chiefly  caused by
rickets.  In very early life fright is a frequent cause, but the fright
is  often overlooked or forgotten because of the long interval which
may  follow.  Where  the fit follows the fright immediately it is
hysterical  rather than  epileptic.  The first  outbreak may be caused
by some infectious disease,  especially by scarlet fever  with and
without  nephritis,  more  rarely measles,  and still more rarely by
typhoid fever.  Cases which develop later in life may  owe their ori-
gin to poisoning by alcohol, tobacco, or other excess  or dissipation.
Syphilis is a frequent cause of symptomatic epilepsy.  Any one of
these exciting causes may suffice to produce epilepsy in the presence
of the underlying state.
   Epilepsy shows itself in two distinct forms, as major and minor
attacks,  the so-called grand and petit m al.  In the  major,  which
constitutes the common  form of the disease, the attack is usually
preceded by a distinct sensation known as the aura.   The aura was
described by Galen  as a  cool breath or breeze which started  in  the
extremity  and  travelled to the brain, where it  produced  the  loss of
consciousness and convulsions.  Such an aura is present in only the
minority of cases.   But  some  peculiar sensation or  impression, as
affecting the sensitive, vaso-motor, or motor nerves, the special senses,
or the mind itself,  is observed in at least half of all the cases.  The
sensitive aura  may show itself as a parsesthesia, pain, or anaesthe-
sia in some part of the body, especially the  extremities, the toe, the
thumb, the epigastrium, whence it travels rapidly to the head or
heart.  The vaso-motor  aura is distinguished as a flushing or pallor
or mottling of the face or other part of the surface.  The motor anra
shows itself in twitching motions of individual muscles or groups of 
EPILEPSY.
745
 muscles, grimaces, sudden spasms of the extremities,  contortions
 of  the head, trunk, circular movements,  stoppages of  speech, etc.
 The aura  of specicd sense concerns especially sight and hearing,
 as flashes,  sparks of light, sudden  darkness, display of colors, espe-
 cially  of red, or noises, a roll of thunder, rumble of wagons, tin-
 nitus,  sounds of voices, etc.  Hallucinations may be thus produced.
 Sauvages saw a woman to whom everything was magnified ; a phy-
 sician's watch was a cartwheel, etc.  Per  contra,  Hammond saw a
 case in which for  a certain period everything  was reduced in size.
 Aurae  of smell and taste are much more infrequent, as is also psychi-
 cal aura, which shows itself as a sudden confusion, incapacity, or
 excitement.
   Neither the absence nor the presence of the aura absolutely indi-
 cates an attack.  In at least half the cases all aura is absent.   The
 absence of aura in these cases may be attributed to the sudden-
 ness of the stroke.  There is no time for the perception of an aura,
 which would require at least the fraction of a second.   Interesting
 are those cases in which an aura may be intercepted or cut off and
 an explosion  prevented.   Thus a boy carried a string in his pocket,
 with which, by quickly winding it about his thumb, he could often
 prevent an attack.  The swallowing of  a handful of salt may inter-
 cept a stomach aura in the same way.  Firm pressure upon a particu-
 lar part of the body, as against a mantelpiece or piece of furniture,
 may have  the same result.  Subsequent attack after such interrup-
 tion is wont to be more severe.
   Symptoms.—The  attack proper occurs  like a seizure, suddenly.
 The patient, in whatever situation  or position,  sinks unconscious to
 the ground.  The fall may be attended or preceded by a cry, a pecu-
 liar, indescribable groan, of which the patient is unaware, though it
 is said that he sometimes hears and remembers  it.  The epileptic cry
 is a mechanical expression of air from the chest through a spasmodi-
 cally contracted glottis; but, with or without the cry, the patient falls
 as if stricken by lightning, falls precipitately,  and, from preponder-
 ance of  weight, usually forward upon the face.  There is total
 abolition of every sense and sensation, hence damage is often in-
 flicted  by the fall itself.  Patients  have been drowned in a tub of
 water,  or more frequently burned by fall into a fire, until the face,
 feet, or other part of the body have become charred.  At the moment
 of the stroke the face is blanched from spasmodic closure of the arte-
 ries.  Delasiauve had  the opportunity to see during an  ophthalmo-
 scopic examination the same blanching of the retina at  the moment
of attack.  In this moment of pallor the whole body is rigid.  There
is for  a  few seconds a complete tonic, tetanic spasm.   The breath
stops, the heart's action is arrested. 
74(1
EPILEPSY.
   Almost at once the scene changes.  The face  flushes, the color
deepens sometimes to the deepest cyanosis, the vessels stand out in
the neck, the eyes protrude, as Aretaeus said, like those of a strangu-
lated bull, and  convulsions, more or less violent,  agitate the entire
body.  The convulsions distinguish themselves  by their tumultuous
character.  The head is tossed from side to side, the eyes roll in their
orbits; the tongue is protruded and withdrawn; it is often caught and
cut between the teeth, so that the saliva, churned into foam, is tinged
with blood and oozes out, thus colored, upon the face.  The discharges
may be voided unconsciously.  The pupils are usually dilated, some-
times  contracted ;  they are always irresponsive;  with returning
consciousness they may show for several minutes alternate contrac-
tion and dilatation every few seconds.  As the convulsions progress
Fig. 291.—Epilepsy ; period of tonic convulsion (Mercier).
the body becomes covered with sweat.  Gradually, in the course of a
few minutes, though the time seems much longer to spectators, the
convulsions grow weaker, while the loss of consciousness still per-
sists.   With the entire subsidence of the convulsions some degree of
consciousness returns.   The  patient,  dull and exhausted, may fall
into deep sleep, from which he awakens without the slightest recol-
lection of the attack.
   There is every variety in the frequency of recurrence.  Attacks
may occur  only at intervals of years.  The first attacks are, as a
rule, the furthest apart; subsequent  attacks have shorter intervals.
Attacks may occur daily or may be  repeated  several times a day.
Such frequency of attack is usually due to organic disease.
   Epilepsia minor, petit mal, shows itself in much greater variety
of  form.   A common  expression  is a very  temporary  arrest or 
EPILEPSY.
747
 obscurity of consciousness  with preservation of automatic  control.
 The attack may consist of a staggering step or two upon the street;
 of a fall of the hand in writing, to  leave a scrawl upon the page; of
 a momentary vacant stare or gaze into vacancy ; of a sudden falling
 asleep with the eyes open  (narcolepsy) ; of a sensation of faintness
 or vertigo, with twitchings or convulsions of individual muscles or
 groups of muscles in the face, trunk, or extremities ;  or  the various
 disturbances which have been described among the  aurae.   Among
 these  conditions  are  curious psychical disturbances.   A  patient
 under the observation of the author left his bed in the hospital, ran
 up the track of an inclined plane in  the vicinity, jumped from  a
 great height to the street below, and was brought back in a mangled
 state.  In  these states of minor epilepsy crimes may be committed—
 suicide,  homicide—without  motive and without  remorse.   Strange
 dual mental states occur.  Patients have left home and have been
 found in distant cities or  countries, travelling meanwhile  without
 mishap.   Eccentricities are not infrequent.  Incongruities, even in-
 decencies,  may be  committed.  The patient may pass water or pre-
 pare in public for the  act of defecation, etc.  Between epilepsy and
 insanity, between neurosis and psychosis, it  may be impossible to
 draw the line.  The disease of the brain may be the cause of  both.
 Especially characteristic of epilepsy are dulness with  poverty of
 speech, defects of memory,  acts of cruelty.   These states may occur
 also after  the major attacks in the condition of stupor, where the
 mind is  still hazy; and  periods of maniacal excitement in which
 patients  become dangerous  are not  infrequent,  so that proof of the
 existence of epilepsy often suffices in a court of  law to secure ex-
 emption  from  punishment for crime, on the ground of irresponsi-
 bility.   The door is open here for much miscarriage of justice.   The
 performance of definite acts with the loss of regard of consequences
 is ascribed to the fact that the intellectual centres are held in  abey-
 ance, while the lower  automatic centres continue to  act.  Thus an
 architect has been known to walk  a scaffolding or gutter at  great
 height without losing balance ; a cabman to drive his vehicle through
 crowded streets without accident.  Mishaps may occur in these pro-
 cedures.   Patients thus affected are liable to pocket things which do
 not belong  to them.  Gowers speaks of a patient who mistook  a
 dinner table, on another occasion the shelves of a cupboard, for  a
 staircase.
   Mental  degeneration occurs also in certain cases in the  inter-
 paroxysmal state,  sometimes as loss of memory or control, restless-
 ness, irritability,  and perverted morale.  The intellect is usually
unaffected  at first, but becomes dull and blunted with successive
attacks, and with rapidity of degradation in correspondence with the 
748
EPILEPSY.
frequency and severity of attacks, so that, while in exceptional cases
epileptics have been  distinguished for mental vigor, they drift often
into dulness and end in imbecility.   It may be  offered as a consola-
tion to patients that  epilepsy may exist for years or for life, with at-
tacks frequent and  severe, and yet leave  the  intellect unimpaired.
It may be  repeated that epilepsy and  psychosis may have indepen-
dent as well as common origin, and that the psychosis  need not be a
necessary effect of the epilepsy.   Most of the cases of  genius said to
have  been  affected  with epilepsy (Mahomet, Napoleon, etc.) were
probably only cases of aggravated hysteria.
   Diagnosis.—In marked forms •epilepsy may  not  be mistaken.
The aura; the cry; the stroke with its loss of consciousness and total
abolition of motion and sensation; the subsequent convulsions, which
cease in the course of a few minutes, to leave the patient drowsy and
dull; with  the complete interval, sufficiently distinguish the disease.
Enuresis nocturna, ecchymoses of the conjunctivae, morning head-
ache or heaviness, may indicate nocturnal attacks.   Lighter cases of
petit mal are often  overlooked.  They may be  usually recognized
by the arrest of  consciousness with the subsequent mental dulness,
by the existence in certain cases of an aura, and  by the condition of
the interval.  The diagnosis may be difficult in childhood,  where re-
flex convulsions are frequent.   Time only may clear up certain cases.
Hysteria may closely simulate epilepsy.   The age and sex  of  the
patient may be distinguishing  points.  Epilepsy occurs first most
frequently in childhood; hysteria, first at  puberty.  The  attack of
epilepsy occurs without apparent cause, while hysteria supervenes
upon  some  emotional disturbance.   The  various aurse of epilepsy
all differ materially from the mental disturbances, palpitation, chok-
ing sensations, which announce the  advent of an attack of hysteria.
Epilepsy begins suddenly, hysteria gradually.   The attack in epi-
lepsy is often preceded by a cry, which occurs but once ; hysterical
patients may cry out more or less  continuously  during an attack.
The spasms of epilepsy differ from  the struggles of hysteria ; they
are wholly involuntary, irregular, and of very short duration.  The
movements of hysteria are more purposive, more careful  of injury
or exposure.  Opisthotonos may be  more or less  persistent in  hys-
teria, and the convulsions in general are of much  longer duration.
Involuntary  discharges, frequent in epilepsy, never  occur in  hys-
teria.  Loss of the  reflexes in the  height of the attack is proof of
epilepsy, but presence of the reflexes  does not entirely exclude it.
Organic disease  of the brain  (syphilis), uraemia, etc.,  are  separated
by other signs of these conditions.
   The prognosis regarding life is favorable, regarding recovery is
unfavorable.  The patient may die in a fit.   Death  occurs more fre- 
EPILEPSY.
74!)
quently from accident.   The disease has no tendency to spontaneous
termination.  Individual cases may recover.  The chances of recov-
ery become less with advancing age.   Recovery is not uncommon in
childhood, but is rare after puberty.
   Treatment.—Every case of epilepsy must be studied.  Sources
of reflex origin are to be removed.  Attention here must be directed
especially to affections of the stomach and uterus.  Irritating cica-
trices  may be excised.  Scrupulous  attention must be paid to  the
habits of life.   Excesses with food, alcohol, must be corrected.  Ad-
dress must be had to the  underlying state.  Treatment is directed
to the relief of the attack  and prevention of the convulsions.  Dur-
ing the convulsions  the patient should be  let alone.  Only so  much
restraint should be used as to prevent accident from fracture of bone
or dislocation of joints.  A cork, knife handle,  may be inserted  be-
tween the  teeth  to prevent  mutilation of  the tongue.  Clothing
should be  loosened about the body.   Attempts  to cut the  attack
short  with anaesthetics  are useless.   The subsequent condition of
the patient is better after a full explosion of the  disease.
   In the treatment of the disease  proper two remedies assume pro-
minence, the bromides and atropia.  The bromides are best admin-
istered largely diluted, and in dose and frequency of repetition  ac-
cording to the age of the patient and frequency and severity of  the
disease.  Of the various preparations the  bromide of potassium is
the most effective.  The remedy is  administered in dose varying
from  fifteen to forty grains  once  or twice a day, preferably in a
glass of soda water night  and morning, increasing up to tolerance.
Its efficacy may be heightened by administration with some  bitter
infusion, as the infusion of absinthe 3 ij.-iv. per dose.  Acne is best
avoided by the use of  arsenic, liquor potassae  arsenitis, gtt.  ij.-v.
with each  dose of the bromide,  and by frequent washing with soap.
As a rule  the  patients  do the best who show the least acne.  The
general rule in treatment  is to ascertain the  smallest dose neces-
sary to prevent the attacks,  and cut the  quantity down.   The  ad-
ministration of such quantities as produce mental dulness and  drow-
siness is unjustifiable except in the most extreme  cases.  Each case
must  be  studied also in this regard.   Attacks which are  persistent
under  small, have yielded under large, doses.  The remedy must
be used with regularity for months, sometimes  for years.  Atropia,
solution gr. i.- 3 i., is given in dose of gtt.  ij.-v. three or four times
a day  or up to tolerance;  then the  quantity is to be reduced and
kept within these limits.  Atropia addresses itself to the underlying
state.  Borax may be tried next, beginning with  a small dose, gr.
v.-xv., and increasing, in the absence of gastro-intestinal  irritation, 
750
TUMOR  OP THE BRAIN.
to 3i.-iss.   Borax is best administered with glycerin and syrup of
orange peel; thus :
    R Sodii boracis .:................................................3 ij-
     Gljcerinse.....................................................3 rj.
     Syrupi amantii corticis........................................I1-
     Salep  .......................................................Siij-
    M.  S. Begin with tablespoonfut doses.
   Should these remedies fail, resort may be had next to zinc, which
is best given in the form of the lactate in dose of ten to fifteen
grains three times a  day.   With the failure of all these means the
practitioner may experiment with a host of  remedies recommended
in the materia medica.  Cases uncontrolled by the bromides or atro-
pia are usually unamenable to relief.   The knife of the surgeon  is a
dernier ressort, justified  only in cases of threatening degradation of
the mind.  Thus far the results  are discouraging.
                     TUMOR  OP THE BRAIN.
   Tumor of the brain is a growth which, springing from the enve-
lopes or  arising in the substance of the brain, produces a train of
                               symptoms according to its situation,
                               character, and extent;  most fre-
                               quently intense headache, ambly-
                               opia or amaurosis, choked disc, ver-
                               tigo,  vomiting, convulsions,  para-
                               lysis  of  various  cerebral  nerves
                               successively, with or  without dis-
                               turbance of  the intellect.
                                  The  construction and  composi-
                               tion of  tumors vary greatly.  Tu-
                               berculosis and sypihilis are most
                               frequent  causes.  These  growths
spring from  the bones  or  membranes, or develop in the substance
of the brain.  Next ranks glioma {yXia, glue), a whitish or more
or less vascular growth, hard  or soft in consistence, according to the
amount of connective tissue, varying in size from a cherry to  a fist,
and situated most frequently in the cerebral hemispheres.  Gliomata
are distinguished, from their composition or combination, as angiec-
tatic, myxomatous, and sarcomatous, composed respectively of highly
vascular tissue with tortuous vessels, or of  mucous tissue, or abun-
dant  cells and sparse  connective tissue.  Gliomata are also distin-
guished  by  slow growth,  liability to haemorrhage, with occasional
tendency to fatty degeneration and atrophy.  Next  in the order of
frequency is  the sarcoma,  which is again distinguished as the angio-
sarcoma and  myxoma  or angio-myxo-sarcoma.  Primary carci-
 Fig. 292.—Tubercular tumor of middle lobe
of cerebellum (Gowers). 
TUMOR OF THE  BRAIN.
751
noma is rare ;  secondary (metastatic) is more frequent,  Peculiar
growths, which result from the aggregation of  numerous minute, ir-
regular, shining masses like mother-of-pearl, constitute the choles-
teatoma,  which arises from degenerated epidermic cells arranged
concentrically about  a nucleus.   More infrequent is  the  angioma,
composed almost entirely of vessels.  Still rarer are the fibroma,
enchondroma,  lipoma, and osteoma,  terms  which  indicate the
character of the growths.   Inasmuch  as the symptoms of brain
tumor are wholly due to pressure, distention of vessels and aneurism
of the cerebral  arteries must be included under this head.   The arte-
ries most frequently affected are the basilar and middle cerebral, the
left more frequently than the right.  Among the parasites which
form growths in the brain are the cysticercus and the echinococcus.
   Etiology.—Certain  tumors, the angioma,  cholesteatoma,  and
glioma, possibly also fibroma, enchondroma,  and lipoma, may be
   Fia. 293.—Gliomata of left hemisphere; asterisk marks site of subcortical growth (Gowers).

congenital, or at least arise at birth and develop later.  Cohnheim
believed that many cases are  survivals from  foetal life.  Childhood
offers the largest contingent of cases ; after childhood, the age from
thirty to sixty; males more frequently than females, in the proportion
of 3 : 2.  This  disproportion exists not only with reference to syph-
ilis, but to all  tumors.   Blows upon the head may develop changes
which are  not confined  to  the bones and membranes, but concern
also the interior of  the  brain.  This  fact, with the more frequent
abuse of alcohol, accounts  for the  more frequent affection  of  the
male sex.
   Symptoms.—The symptoms  of  brain tumor are  general  and
local.  They vary according to the seat rather than the character of
the lesion, rapidity of  growth, etc.  Symptoms are immediate and
remote, according  as  they result from direct or indirect pressure.
Tumors in silent regions, as in the hemisphere of either cerebrum 
75'i
TUMOR OF THE BRAIN.
 or cerebellum, may  show no  symptoms.   So tumors, unsuspected
 in life, have been discovered on autopsy.  Small size, slow growth,
 may account for lack of symptoms.  Increase in size naturally dis-
 places fluids or blocks vessels, to lead to the accumulation of fluids
 which constitute hydrops  in the ventricle, and to lead  to  the ac-
 cumulation of  cerebro-spinal fluid in the sheath of the optic  nerve.
 Softening about the  tumor  develops symptoms of irritation.  The
 most frequent of the general symptoms are early fatigue, associateel
 often with  depression or  melancholy, in use of the brain, whether
 for mental or physical labor.  The most constant sign is  headache,
 intense and persistent.  It  is felt especially in the region of the fore-
 head, temples,  and occiput, though the situation of the pain  does
 not necessarily localize the  tumor.   The headache is often associated
 with vertigo and vomiting—cerebral vomiting, which occurs with-
 out nausea and without reference to food. In the midst of symptoms
 of apparently trivial character convulsions may suddenly  supervene.
 They are epileptiform in type, from anaemia the result of reflex spasm
 of the cerebral arteries.  Dulness, stupor, retardation of pulse and
 respiration, are evidences of direct pressure upon the brain.  Along
 with these symptoms there shows itself, as a rule,  the choked  disc
 on both  sides; its early occurrence makes it a symptom of much
 value.   In these cases the swollen papilla becomes  opaque ; its  sur-
 face is traversed with dilated  arterioles and tortuous veins.   It is,
 however, not pathognomonic ; neither the presence  nor absence of it
 defines or excludes the disease.
   The tumor  acts directly or indirectly in pressure upon indi-
 vidual nerves, or a  mass of brain substance to cause hemiplegia.
 The situation  of the  growth  determines  the affection  of the par-
 ticular nerves.  The  most  frequently  affected are the  olfactory,
 optic, abducens, and oculo-motor.   The facial is usually involved in
 all its branches—a point of  value in differential  diagnosis.  The tri-
 geminal  is  affected,  as a rule, only,  or  most, in the sensitive
 branches.  The hypoglossus, in its narrow  bed,  is involved on both
 sides.  Hemiplegia is sometimes crossed.   Electric excitability in
 the affected  muscles is usually at first increased and later reduced.
 The reaction of  degeneration  is rare.  Paresis and paralysis  are
 much more  common  than  pains and paraesthesise,  as pressure de-
 stroys  rather than  irritates.  Tumors in the anterior fossa affect
 especially the olfactory and optic, the first branch of the trigeminus,
and the oculo-motor nerves.  Tumors in the middle fossa affect the
optic, oculo-motor, and oblique, the abducens and  trigeminus.  By
indirect pressure they may  produce  hemiplegia.  Tumors  in the pos-
 terior fossa affect the trigeminus,  facial,  auditory, glosso-pharyn-
geal, pneumogastric, and spinal accessory.   There may be  in these 
ABSCESS  OF THE  BRAIN.
753
cases tinnitus aurium  from irritation of the auditory nerve ; vomit-
ing and retardation of the pulse from irritation of the pneumogastric
nerve ;  amblyopia from pressure of fluid  accumulated in the ven-
tricles.  Tumors in the hem (spheres of the cerebrum show local con-
vulsions,  monoplegias or hemiplegias, with anaesthesia  and con-
tractions, amblyopia, aphasia, etc.  Tumors  of the cerebellum are
recognized  chiefly  by  the  reeling gait,  amblyopia, affection of
hearing and smell,  occipital headache, etc.
   The diagnosis rests chiefly upon the  tripod, headache, convul-
sions, and  choked disc.  It is further established by vertigo  and
vomiting, retardation  of pulse and circulation, successive involve-
ment of cerebral nerves, hemiplegia, etc.
   Treatment.—Therapy has reference only to tumors of  syphilitic
origin.  Every case should  have the benefit of doubt and be sub-
jected to radical treatment with mercury and  iodine.  The most in-
tense and  dangerous symptoms sometimes disappear as by magic
under the use of the  iodides.   Large doses  are best  administered in
milk, and are most thoroughly conveyed through the body with the
additional use of mineral waters in  quantity.   The effect of mercury
is best secured by inunction.  Most  frequently the relief which is
secured is partial and not complete.  It must be remembered that,
though  the tumor be dissolved away to leave no trace, irreparable
damage to the brain has often been done. Other treatment is wholly
symptomatic.  The  bromides sometimes suffice  to  hold headaches
under entire control.  Chloral may relieve insomnia or convulsive
manifestations,  etc.   Surgery  scores triumphs  in this field  of
medicine.

                    ABSCESS OF THE BRAIN.

   Suppuration may occur in any part of the brain substance.  It is
most frequent in the cerebrum, next in the cerebellum,  and  is rare
in the basal ganglia,  the pons and medulla.  The temporo-sphenoidal
lobe  suffers most, because of proximity to the ear, disease of which is
the most frequent cause of abscess.  The abscess is single in four-
fifths of cases.
   Etiology.—The cause of brain abscess may be local or general.
Nearly three-fourths of cases of abscess of the brain are  produced
by local causes : nearly one-half by diseases of the ear, one-fourth
by injury.   Other local  causes are  diseases of the nose and caries of
bones of the skull.  The general causes are for the most part metas-
tases of pyaemia of distant origin.  Abscess of the brain occurs at all
periods of life, but is most frequent in males, in the proportion of
three to one.
   Morbid Anatomy.—Brain abscesses vary in size from  a  walnut
        48 
754
ABSCESS  OF THE  BRAIN.
to a fist.  They are encapsulated in about one-half of the cases.  The
pus is often greenish, and is  sometimes fetid.  Metastatic abscesses
are minute and multiple.   Abscesses  from ear disease and injury
may occupy a  large part of a hemisphere.   An abscess may burst
into the ventricles, or may discharge upon the surface  of the brain
to produce meningitis.
    The symptoms may be latent.   Cases have been reported where
abscesses as large as a fist, without sign of disease in life, have been
discovered upon autopsy.   Abscesses in the frontal and temporo-
sphenoidal lobes seldom  show signs at first.  This is true also  of
abscesses in the great ganglia at the base.   Tolerance is established
in  abscesses of  slow growth.  Again, the disease  may be over-
shadowed by the symptoms of its  cause—e.g., disease of the ear,
trauma, pyaemia.  Pyaemia often shows itself with such periodicity
of fever and sweat as to be mistaken for malaria.  The typhoid form
of pyaemia masks the evidence  of brain abscess.   Of local signs the
most common is headache, the situation of which corresponds to the
seat of the disease more frequently than in tumor.  Epileptiform con-
vulsions are not infrequent.   Paralysis develops in correspondence
with the site of the abscess, but shows itself usually in the form of a
hemiplegia.  Paralysis in the course of, or in connection with, con-
vulsions indicates abscess more frequently than  any other condition.
Monoplegias are not common.   The most frequent monoplegia  is
ptosis.  The facial and auditory nerves are affected through the caries
of ear disease.  Optic neuritis, choked disc, occurs, but is not so fre-
quent as  in tumor.   Vertigo and vomiting, with staggering gait,
indicate localization in the cerebellum.   Dulness, drowsiness, stupor,
with progressive wreck of the mental  faculties, belong among the
later symptoms.  Patients usually succumb to coma.
    The diagnosis  rests especially  upon the  connection with the
cause.   Evidences of ear disease, trauma, or pyaemia may be found
in three-fourths of cases.   It must be remembered that abscess of the
brain occurs in the distant course of chronic ear disease.   Tumor, a
far more  frequent  disease of the brain, develops more  slowly and
advances  by progressive paralysis of cranial nerves, and with more
frequent and intense optic neuritis.
    The prognosis is always grave, but  the danger is less immediate
in cases where the abscess develops slowly and becomes encapsulated.
Gowers reports cases of abscesses, with calcified walls and inspissated
contents,  latent or quiescent for twenty years.
    Treatment.—The main consideration  is  prophylaxis, which in-
cludes especially patient and persistent treatment of ear disease, with
general asepsis  in all cases of trauma, etc.   The treatment proper is
the evacuation of the abscess under  the trephine, which the modern 
                    LOCALIZATION  QF LESIONS.                 755

methods of localization enable the surgeon to accomplish.  Unfortu-
nately final recovery is rare, even with the help of the knife.

                    LOCALIZATION OF LESIONS.
   Lesions  are localized in  the brain by  the parts of  the body
affected  with symptoms.   Though  the conclusions are still  indefi-
nite, and the facts of most value to  the  physiologist and the sur-
geon, the discovery of motor centres  in the brain marks an epoch
in the history of nervous diseases.  The pioneers in this field were
Hughlings  Jackson,  who  contributed his observations  from  the
standpoint of clinical  medicine, and Broca, who based his observa-
tions upon autopsies.  Experimental investigations followed later by
Fritsch and Hitzig, and Ferrier and Horsley.
Fig. 294.-Cerebral localizations. Outside view.
    Lesions are divided  into irritative and destructive.  Irritative
lesions  produce spasm and parsesthesia;  destructive lesions produce
paralysis and anaesthesia.   The field of localization in the brain lies
in the central convolutions and the paracentral lobule.  The cortical
centres  of  the hypoglossal and facial nerves, where the coarse motor
impulses are multiplied or reduced  to finer movements,  lie  in the
lower third of the anterior central convolution.  The centre for the
arm lies in the middle third of the anterior and part of the posterior
central  convolution.  The centre for the leg lies in the upper two-
thirds of the posterior, upper third of the anterior  convolution, and
the paracentral lobule.   The centres of  speech are situated in  the
frontal  lobes, chiefly of the left hemisphere, lesions  of which  pro- 
75( i
LOCALIZATION OF LESIONS.
duce aphasia  {<r. priv., <pa6ii. speech).   Lesion of the third  frontal
convolution produces ataxic {a, priv., rdf,i?, order), lesion of the first
temporal convolution produces amnesic {a, priv., pvyan, memory),
aphasia.  More extensive lesions of these centres produce agraphia,
inability to write, and alexia, inability to read.   But anarthria, a
condition in which the patient is not aphasic at all, but is unable to
form words or forms them badly, depends upon, and is a most valu-
able sign of, lesion of the pons.   Lesion of the parietal lobe affects the
muscular sense, so  that the patient without the aid of vision loses
equilibrium.   Lesion of the lower portion of the parietal lobe affects
the conjugated  movement  of the eyes—that is, irritation intensifies
the movement and directs the eyes to the seat of lesion,  while destruc-
tion paralyzes it and permits the eyes  to rotate in the opposite  direc-
tion.   Lesion of the  occipital cortex produces hemianopsia,   Disease
or injury of the internal capsule in its middle portion affects the mus-
Fig. 235.— Localizations in the cerebrum. Inside view.
cles of the face and extremities; disease of the posterior portion af-
fects sensation and produces complete hemianaesthesia.  Disease of
the crura cerebelli produces irritation or  paralysis, that is,  spastic
contraction  or hemiplegia  upon the opposite side, and affects the
oculo-motor upon  the  same side, of the body.  Disease of the pons
usually produces crossed paralysis of the body and face—that is, of
the opposite side of the body and same side of  the face.  When the
disease is exceptionally situated in  the  upper (cerebral) half of the
pons, above the decussation of the facial fibres, the face is paralyzed
on the same side as the body.  Disease of the corpora quadrigemina
produces irritation or  paralysis of the muscles of the eye.  Affection
of the anterior pair is distinguished by loss of sight and paralysis
of the pupils; of the posterior pair, by  paralysis of the oculo-motor
nerves, and often by ataxia.   Disease of the crura cerebelli may be 
HYSTERIA.
757
 attended  by compulsory movements, especially of rotary character.
 Disease of the cerebellum  is marked by vertigo and a staggering
 gait—conditions which have been observed, however, in other lesions
 of the brain.  Progressive implication of cranial nerves indicates an
 encroaching lesion, tumor, abscess, etc.

                            HYSTERIA.
   Hysteria {vaxkpa, the womb).—A neurosis with symptoms on the
 part of the whole nervous system, distinguished especially by unstable
 nerve centres and loss of control of the will.  The term dates from
 ancient times, and had its origin in the belief that the affection was
 due to disease of the uterus.  What diseases of this organ occur in
 connection with hysteria are n6w known to be coincidences or conse-
 quences and not causes.   One of the finest chapters  in the history of
 medicine  was written by Sydenham (Epistolary Dissertation 58) of
 this disease.
   In etiology the most important role is played by sex.  Ninety-five
 per cent of the cases are females.  When it occurs in males it is most
 frequent  in boys.  The disease may show itself at any period of  life
 from childhood to old age, but occurs with especial  frequency about
 the period of puberty.   The supreme factors in the production of the
 disease are heredity and training.   The disease may be transmitted
 directly, or the hysteria may be the expression of an allied neurosis,
 insanity,  epilepsy,  migraine, in  the ancestry.  In  our  country  the
 majority  of cases are  acquired through defects in education.  The
 fault  begins with childhood, and rests largely upon the failure to de-
 velop self-control; hence the disease is especially frequent among the
 upper classes, whose luxurious habits lead to indulgence and neglect.
 Diseases of organs, impoverishment of the blood, chlorosis, ansemia,
 indoor life, overstimulation  at school, aggravate and  precipitate at-
 tacks.  Outbreaks in  later  life are generally due to  disappointments
 in love  affairs or domestic infelicities.
   The disease shows no demonstrable lesion, for, as Sydenham said,
 the case may be considered  hysteria only when, after the most care-
 ful examination, all  evidence of disease can be excluded.  So  the
 pathology of the disease rests upon a disturbance of action or func-
 tion  which is supposed to be caused by imperceptible, as yet undis-
 coverable, molecular change.
   Symptoms.—The underlying condition is the weak nervous sys-
 tem and the lack of self-control.   The disease, as stated, shows symp-
 toms in the whole domain of the nervous system, in which regard it
is distinguished from hypochondriasis, which confines its manifesta-
tions  to the psychical sphere.  Disturbances in this sphere play a
most  important role in hysteria.   Hysterical patients are so highly 
758
HYSTERIA.
irritable as to be sensitive to circumstances and influences unnoticed
in health.   Trifles  are  exaggerated.   The patient yields more and
more easily, until finally all resistance is surrendered.  So the action
of the higher centres is  inhibited.   The faculties of the mind revert
to the uncontrolled, undeveloped, and emotional state of childhood.
As Sydenham said, "all is caprice."
   Affections of the motor system  show themselves especially in the
form of convulsions and paralyses.   The convulsions occur for the
most part  in paroxysms, preceded  by some  emotional disturbance.
The immediate outbreak is often preceded or attended  by aurse, usu-
ally on the part of the digestive system, as a sense of oppression or
distress in the region of  the stomach, singultus, eructations.   The
patient  suffers an attack of convulsions which more or less closely
simulates an epileptic attack.   There is  rigidity which is often ex-
treme.  Opisthotonos is common and persistent.  Spasmodic convul-
sions supervene, become universal, and are attended with the asso-
ciate disturbance in  circulation and breathing.    The difference
between the epileptic and the hysterical attack rests mainly upon the
maintenance of consciousness through hysteria.  The fall is not pre-
cipitate as in epilepsy.  The patient is careful to select a chair or sofa
in protection of the body.  The tonic and clonic convulsions are more
violent and much more sustained.   The spasms themselves are more
directly in  the line of voluntary movements, and the whole  attack
is protracted into hours  or fractions of an hour, far beyond the limits
of ordinary epilepsy.    During all  this period, though the eyes are
wholly  or  partly closed, the pupils are perfectly natural.  Excep-
tional cases show a closer approximation to epilepsy, sometimes as
complications—for the diseases do not concur, not even as transition
stages.  As the exact diagnosis is in these cases sometimes difficult
or impossible,  they are often  grouped under the term hystero-epi-
lepsy.  They  are, however,  not epilepsies.   They  are aggravated
hysterias.   A subvariety of  hysteria is offered also in the exagge-
rated choreic manifestations which  constitute chorea magna.  These
cases of wildest  gymnastic  contortions  and half-purposive  move-
ments, with the other vagaries of hysteria, trances, cataleptic states,
apparent death, make of the victims objects of curiosity and wonder
with the illiterate, and  excite that  kind of false sympathy and sen-
timentality which is fatal to cure.
   While the  convulsions of  hysteria may involve any of the mus-
cles of  the body, they are wont to affect more  especially certain
muscles, as the  muscles of the glottis to  produce  spasm  of the
glottis, of  the  pharynx to give rise to the impression of  a  foreign
body in the throat, the so-called globus hystericus; and regions thus
affected have  often the  reflex  sensibility so  much diminished as  to 
HYSTERIA.
759
show more or less anaesthesia.   So, too, any of the muscles of the
body, voluntary or involuntary, may be affected  with paresis or
paralysis.  But here, too, certain muscles are selected by preference.
Paralysis of the muscles of the larynx  leads to aphonia, of the
throat to dysphagia, of the intestine to  meteor ism and constipa-
tion.  The  whole limb  or  half  of the body may suffer the same
paralysis.  The  paralysis usually affects  the leg, and paraplegia is
much more common than hemiplegia.  In all cases  the affection is
rather a paresis than a paralysis.   But  long-continued paralyses,
Fig. 296.—Chorea magna. Rhythmical, half-purposive movements of hysteria (Dana).
often of years' duration, may finally bring about permanent lesions,
atrophic changes, which show themselves in the nerve centres as well
as in the muscles.   A  patient in the experience of the author re-
mained confined to her chair  for nineteen years, and finally made
what recovery was jDOSsible  under the  atrophic changes which had
supervened.   She became able  to go about with a  stick and crutch.
Up to the development of serious atrophic change, the  reaction of
degeneration is always absent in hysteria.
   Some form of disturbance of sensation is present in every case.
Hyperaesthesia is more  frequent than anaesthesia, and certain sensi- 
;go                        hysteria.
tive  points assume  prominence  in  the course of  hysteria.   Such
"hysterogenic" spots are points about the head,  as if pressed upon
by some hard, pointed object, as  a key, and constitute the  so-called
clavus hystericus ;  or in the course of the vertebral column, espe-
cially the region of the ovaries, pressure upon which sometimes calls
out an  explosion,  or, per contra, cuts it  short in its course.  Irra-
diations from the tender points  in the vertebral  column constitute
the so-called cases of "spinal irritation."  Anaesthesia may be also
irregular and slight, or diffuse and extreme.   The sensation may be
diminished or abolished in localized surfaces of the  skin or mucous
                            membranes, not infrequently in an entire
                            half of the body, to constitute the  hemi-
                            anesthesia which is almost peculiar to
                            hysteria.
                              The  contractures usually  occur in
                            connection with,  or immediately sub-
                            sequent  to, a convulsive attack or ex-
                            plosion, and are most frequently located
                            in  that  member  or  part of the body
                            which may be the seat  of pain or other
                            distress.   Concentration  of  attention
                            fixes the seat  of disease.  Once fixed in
                            a member, the contracture persists;  and
                            though the symptoms of the disease are
                            distinguished by  their protean charac-
                            ter, the  deformity assumed in an indi-
                            vidual case usually remains with it for
                            months, for years, sometimes for  life.
                            Thus  the arm may be contracted in
                            fixed flexion, and the contraction of the
                            fingers with the  included thumb simu-
                            lates the late  rigidity of hemiplegia.  In
more exceptional  cases the  fingers are extended to assume the posi-
tion of  tetany.  Any attempt to release the spasm intensifies it, and
increased flexion of the wrist, which loosens to some extent the rigid-
ity of hemiplegia, only exaggerates that  of hysteria.  The leg, on
the other hand, is fixed in extension with the heel, drawn up to bring
the foot with its inverted sole and flexed toes in a straight line with
the leg.  In any case hysterical contractures,  though of years' dura-
tion, may disappear under the influence of powerful emotion.   These
are the cases upon which miracles are worked, and the triumphs of
the faith cure are recorded in this field.   A.similar  spasm of the dia-
phragm, with relaxation of  the muscles of the abdominal  wall, pro-
duces,  with the accumulation of gas in the intestine, that  distention
 Fig. 29?.—Hysterical contracture of
right leg and foot (Charcot), 
HYSTERIA.
701
of the abdomen which is  known as the phantom  tumor.  Hence
this tumor disappears entirely under anaesthesia.
   Among vaso-motor disturbances may be noticed increase in the
secretion  of tears, saliva, sweat, which may be localized or unilate-
ral.   Even the flow of milk may be increased.   The secretion of
urine is often enormous.   Such urine is, Sydenham says, " clear as
water from a rock."  More peculiar is the discharge of blood which
may  take place  from  the mucous  membranes—that is,  from the
mouth, the intestine, the lungs.  More incredible are the  subcuta-
neous haemorrhages and free discharges of blood upon  the surface
which constitute  stigmata.  Localization of these  stigmata in the
hands and at  the  ankles in states of  religious ecstasy has been  cred-
ibly reported.   These cases, however, are usually regarded with sus-
picion, as most of the  haemorrhages are aided by voluntary breaks
of the surface.  The exact stigmata of  crucifixion  are always arti-
ficial, and real haemorrhage of the lungs belongs to disease, especially
to tuberculosis, which intensifies, if it does not  develop, the hysteria.
Pretty much all the cases of so-called vicarious menstruation belong
to tuberculosis, the disease par excellence which disturbs the menses.
Many cases of haemorrhage, " bleeding  from  the lungs," are really
bleedings from the gums, and blood shown in vessels has been found
to have been  derived  from an outside source.  See also chapter on
Haemorrhagic Diathesis.
   Hysteria is in its nature full of freaks,  some of which—catalep-
tic, clairvoyant, lethargic states, transfer of sensation from one limb
to another by  the application of a piece  of metal—remain as yet in-
capable of explanation.  It must be  remembered that hysteria is a
near neighbor to insanity,  and that the explosions of the disease are
states of temporary insanity.  A grave complication is that excessive
derangement  of  digestion which is shown in obstinate  vomiting
and anorexia.  " Fasting girls " are nearly all hysterical.   In many
of these cases  there may be detected an  element of  fraud.   Hidden
food is  swallowed on the  sly.  Individual cases are real,  and these
cases  may be always distinguished by the progressive loss of weight
which necessarily  ensues upon the deprivation of food.  In the expe-
rience of  the  author a case of this kind, attended with vomiting of
blood, was presented to the class as a gastric ulcer.  The patient ac-
tually died of  starvation, and the most  careful post-mortem exami-
nation failed to disclose any lesion whatever.
   Affections of the bladder are not at all infrequent, sometimes as
dysuria with  frequent  desire of micturition, more  frequently as
anuria,  which may last a  long time, a  week  or  ten days, without
evidence of uraemia—an  important  point in  differential diagnosis.
When catheterization is actually necessary in  these cases it should
be done by the nurse. 
762
HYSTERIA.
   The diagnosis rests  upon the sex. age. and  history of  the indi-
vidual, though negative testimony in any of these  particulars  does
not necessarily exclude the disease.   The train of symptoms is too
.irregular to be associated with organic disease.  The  influence
of the emotions  may be distinctly observed.  Examination by the
physician intensifies the symptoms.   The convulsive seizure is  elis-
tinguished by the preservation of consciousness, the rhythmical, half-
purposive  movements, the condition of the pupil, which responds to
light, the long duration of the attack.  The  contracture and paraly-
sis are differentiated by their associations.  Paraplegia, for  instance,
is almost never hysterical.  Affection of one vocal cord is unknown
in hysteria.  Hysterical  paralysis of the  larynx  is double.   It is as
easy to recite rules in diagnosis as to multiply words in the descrip-
tion of symptoms.   They are often alike vain.   The  most experi-
enced practitioner, in the face of  lessons which may be still fresh in
the memory, is liable to be deceived  by the freaks of hysteria.
   Prognosis.—Hysteria is always a chronic affection.  The under-
lying condition is born  with the individual and remains lifelong.
The disease may, as  stated, actually take  life.   Death has occurred
in an attack of convulsions, more frequently in cases on the border
lines of epilepsy.  Exceptional cases  succumb to spasm of the glot-
tis, more frequent cases to  vomiting and marasmus.   Individual
cases recover, sometimes absolutely,  more frequently  incompletely
with liability to relapse.   Bad cases may terminate  in insanity, es-
pecially in melancholia,  religious  fanaticism, finally  in dementia.
Psychoses, which supervene at the  grand climacteric, have a  bad
prognosis.
    Treatment is difficult.  It is usually a matter of morale.  In no
field of medicine is interference so often meddlesome and injurious.
This is especially true in the domain of gynaecology.   The manage-
ment of a case of hysteria calls out the tact of  the  physician.   He
must steer between sympathy and indifference.   In the treatment of
exaggerated  cases  isolation,  especially with a  reliable, preferably
a stolid or phlegmatic nurse, is a sine qua non.   The patient is to
be fed,  and the food is to be digested and absorbed.   The way out is
through food and sleep— i.e., nutrition and rest.  It is well to re-
member a French  proverb, " Qui  dort, dine"—who  sleeps, dines.
Regarding drugs, the less the better. Opiates  should certainly be
avoided.   The convulsions of hysteria are so quickly allayed by
chloral as to make the  use of it a  constant temptation; here,  too,
the less the better.  Convulsions  usually subside  so soon as the phy-
sician is left alone in the room with the patient,  who quickly learns
that he understands the case.  Nervous states may be relieved by
the bromides,  asafoetida, and valerian, but here, too,  the less the 
HYPOCHONDRIASIS.
763
better.  To treat the individual rather than the disease is the sum of
therapy.

                       HYPOCHONDRIASIS.

   Hypochondriasis {vno, under, joKtfpoV, cartilage).—A psychosis
characterized  by a concentration of the  mind  upon the internal or-
gans.  With hysteria, it is an almost wholly psychical condition, but
with an entirely different expression.  Hysteria is largely a loss of
control of the will ; the hypochondriac  may be a person of strong
will.   Males predominate, but there are hypochondriac females as
well as hysterical  males.  The conditions may be  associate.  Hypo-
chondriasis usually rests upon some slight  disturbance in the  sen-
sory sphere, a hyperaesthesia or parsesthesia,  which  passes unno-
ticed in health, but forms the basis of an imaginary malady in this
disease.  The affection is located, in the great majority of cases, as
the name  implies, under the cartilages  of the ribs, in the liver or
other organ of the abdomen, and is the exaggeration of sensations
caused by dyspepsia, flatulence, haemorrhoids, etc.  A slight lesion
of the mucous membrane is mistaken for syphilis, and the  patient
is often a  lifelong victim of syphilophobia.  Impotence, which the
patient may really induce by the fear of it, is considered  a sign of
organic disease of the  spinal cord, locomotor  ataxia,  etc.   Palpita-
tion of the heart, a common expression of gastric catarrh, is re-
garded as a sign of heart disease which may cause sudden death at
any time.  Flatulence indicates the existence of a tapeworm which
is consuming  the  vitality of the body.   The fear  of cholera, in the
presence of an epidemic, may be so great as  to  make the patient
sweat with  anxiety and actually produce a  diarrhoea.  The suffer-
ings of the hypochondriac are intensified and  prolonged by perusal
of medical works, or more especially of popular medical literature,
which can convey only erroneous  ideas.  The hypochondriac de-
lights  to dwell  upon his symptoms with a fellow-sufferer or with
any one whose attention he can secure.  He  gloats over details with
downcast eyes, and is finally shunned like a plague by those who
know him.  The confirmed hypochondriac, with his constant fear of
death, and  extraordinary care of  himself at  the expense of every
one else, will wear out and  survive  every  member of his  family.
   The treatment is an arduous task, for the disease, as in hysteria,
depends often upon inherited states.   The physician must not ignore
and must not emphasize individual symptoms.  Especial  attention
must be paid to the constipation which is almost always present.  A
course at a watering place best relieves all the symptoms.   As a rule
the bitter are better than the saline laxatives.  Among  them the phy-
sician may select the aromatic tincture of rhubarb, 3  i. ter die ; the 
764
NEURASTHENIA.
compound pill of  rhubarb,  one or two  after each  meal; a pill of
podophyllin,  gr. 4-£ at bedtime ;  a pill of aloes, belladonna,  and
strychnia ; or the  compound licorice powder, one or two teaspoon-
fuls once  or twice  a day.  Sedatives and hypnotics, bromides, chlo-
ral, etc., do more harm than good, but acids, especially hydrochloric
acid gtt.  xx.  well diluted  ter die; tonics, tinctura nucis vomicae
gtt. xx. ;  or strychnine nitrate gr. j\-^ ter die, brace the stomach
and the nervous system.  Alcohol is bad as a rule.   It disturbs di-
gestion.   In the subsequent reaction it  leads to melancholy.   The
management of hypochondriasis is a matter of tact, of savoir-faire,
of knowledge of the race and of the individual man.

                       NEURASTHENIA.
   Neurasthenia {veupov,  nerve, affSevsia, weakness) is an exhaus-
tion of the nerve centres, especially observed among individuals who
have inherited weakness from some weak, perhaps remote, ancestor,
or whose lives of  continuous occupation,  strain, and competition
leave no time for  rest.  Neurasthenia is a  disease of the railroad,
telegraph, and telephone life of our modern civilization.   The condi-
tion is aggravated by the use of remedies to stimulate strength and
enforce sleep—alcohol and morphia—and by sexual abuse  and ex-
cess.  Forms  are  distinguished as cerebral,  spinal, and universal
(Beard), and in these distinctions the transition  lines between  this
affection and hysteria, hypochondriasis, and melancholia cannot al-
ways be strictly drawn.   Spinal  neurasthenia is very apt to include
organic disease of the spinal  cord, myelitis, tabes,  or other scleroses.
   Symptoms.—Neurasthenia expresses  itself especially in early
fatigue, lack of concentration, loss of originality, incapacity of
effort, headache,  pain in  the  back of the neck,  irritability of
disposition,  more or less  constant anxiety and appjrehension.
Favorite  expressions  of fear are agoraphobia, fear in open places ;
claustrophobia, fear in closed place's;  monophobia, fear of being
alone ; anthropophobia, fear of human beings ; siderophobia, fear of
lightning ; mysophobia, fear  of  dirt; pantophobia, fear of every-
thing.   These conditions  may be the expression of other diseases or
of mere  nervousness, and may be  entirely  absent in cases of  pure
neurasthenia.   Most cases show disturbances of digestion,  with
dyspepsia and vertigo, sometimes with gastralgia.   Insomnia  is a
prominent symptom.  The  patient tosses about in bed sleepless for
hours, and awakens in the morning unrefreshed.   Finally he forces
sleep with hypnotics and thus further undermines the nerve cen-
tres.  Various paraesthesise, hyperaesthesise, and hyperalgesiae occur
in the course  of  these cases.  Localized  sensations in  the spinal
column constitute  the obstinate  symptom known as spnnal irrita- 
CHOREA.
765
tion.  The heart's action is disturbed in various ways.  Palpitation
is common, with arhythmia and precordial anxiety.   Onanism and
impotence occur as  both cause and effect in cases of neurasthenia.
Sensations of coldness, numbness, formication, flushing of the face
or pallor,  cyanosis, tachycardia, sweatings, spermatorrhoea, vary the
scene in the symptomatology of neurasthenia.
   Prophylaxis is the adoption of the rule laid down by the great
philosopher Kant:  Eight  hours work, eight hours recreation, eight
hours  sleep.   Unfortunately modern civilization does not  accept
these rules, and "' success " in life can rarely be reached in this way.
   Treatment is rest; all other remedies are  secondary and subor-
dinate. The difficulty is to secure rest.  Idleness, stagnation, is not
always rest.   In stagnation  set in at once the intensely active pro-
cesses of  decomposition.   In certain cases  isolation is a necessity.
Travelling is  always a diversion.   A sea voyage, with its inanities,
secures at least absolute rest.  The moving panorama observed from
the window of a railroad car furnishes diversion as well as rest.  A
stay of a few weeks at a watering place, with its ghange of scene and
association, may secure the desired effect.  Hydrotherapy,  in the
form of frequent warm baths with gentle friction, is often of value.
General electrization according to the method of Beard, the negative
pole at the feet and the positive stroked over the body with the roller,
refreshes, strengthens, and tranquillizes in the course of time.  Drugs
are to be  avoided as much as possible, yet  occasional doses  of sul-
phonal, paraldehyde, or even of  chloral may be  required.  Food
should be administered regularly, and remedies—hydrochloric acid,
nux vomica, orexin—may  be given to secure its digestion.
   Babes, of  Bucharest,  injected nerve  substance itself  subcuta-
neously, fifteen  to seventy-five grains per day in bouillon, into seve-
ral patients affected with neurasthenia, with satisfactory results.
Similar experiments  have also been made with  epilepsy and tabes.
The operation must be done with every precaution of antisepsis.
The good results, like those obtained after the injection of the juice
of the testicle of young dogs, are chiefly, if  not wholly, due to sug-
gestion, a remedy of more  value  in nervous  diseases than  in any
other affection.

                            CHOREA.

   Chorea {xopeia, dance), St. Vitus' dance, is a neurosis of child-
hood, characterized by more or less continuous  spasmodic  move-
ments, with  inco-ordination ; aggravated  by  voluntary motion, ar-
rested only in profound sleep ; associated usually with some, if only
slight, impairment of the mind and more or less paresis.
   The disease  exists in two forms, chorea major and minor, and 
766
CHOREA.
prevailed as an epidemic, as chorea major—the "dancing mania"—
in the middle ages.   Chorea major, from which the disease is named,
is a subvariety of hysteria, and, with other forms of that disease, is
rapidly spread by imitation.  The victims of  this affection wore sup-
posed to be cured at the  chapel dedicated to  St. Vitus, hence  St,
Vitus' disease.  Chorea minor, the true chorea, Sydenham's chorea,
here described, though it  rests upon no discoverable constant lesion,
stands in no direct relation with hysteria.
   Etiology.—Chorea is three times as frequent in girls  as in boys.
Nearly half the cases occur between  the ages of ten  and fifteen,
four-fifths between five and fifteen years.  The disease grows more
rare with advancing age, and cases which occur in extreme age are
usually symptoms of some definite disease of  the  brain.  Pregnancy
sometimes  causes chorea, which  distinguishes itself from that of
other cause by its  liability to recurrence  with subsequent preg-
nancies.  It is most frequent during the first  pregnancy, and almost
never occurs for the first time after the age of twenty-five years.   It
may show itself at any time in pregnancy, but is most  frequent in
the third month.  Recurrent attacks in subsequent pregnancies occur
at any time.
   Chorea  is sometimes precipitated or caused by  fright, in which
case it supervenes rapidly—as a rule in less  than a week.  Cases of
long interval have a different origin.  The relation to rheumatism is
more distinct, as fully one-fourth  of all  cases occur in the course
of, or subsequent to, rheumatism.  In a majority of these cases the
chorea is evidently due to heart disease of  rheumatic  origin,  and
the sequence runs :  acute  rheumatism, valvular disease of the heart,
chorea.  In this  connection the  chorea may depend  upon organic
lesion  of the  brain —- e. g., emboli  in  the capillaries of the brain,
a condition which has actually been demonstrated in certain cases.
The actual existence of valvular disease does not necessarily imply
this  condition, as the chorea  may be,  and is  in the vast majority
of cases, due to the same cause which produced the rheumatism and
heart disease.  In other words, chorea is probably  the  expression
of an infection, of defective innervation  due  to  the  action of a
toxine.  The more  or less definite duration  of the disease, and  the
exemption  secured  by single  attack, speak  in favor of this view.
The preference of  youth, and  the occurrence  during pregnancy,
which often liberates toxines, are additional points in support of  the
infection theory.  The fact, however, that chorea supervenes in con-
sequence of mental  emotions  or impressions, especially fright,  imi-
tation, after trauma, proves  that not all cases have  this origin.
Various organic diseases of the brain  (tumors, degenerative lesions
left by apoplexy, epilepsy, etc.) may be followed by chorea.  These 
CHOREA.
767
cases of traumatic post-apoplectic or post-epileptic attacks constitute
the cases of so-called symptomatic chorea.
   Chorea is, therefore, no single process ;  it may be a pure neurosis,
it may be symptomatic, or it may be an infection.   The pure chorea
of childhood, whether or not it occurs  in the course of rheumatism,
is probably, in the vast majority of cases, due to the same infection.
   The disease may or may not have a morbid anatomy.  Even the
cases dependent upon organic diseases show no constant lesion.  The
conditions actually discovered  are  the expressions of defective nu-
trition, as badly nourished arteries,  dilated vessels,  exudations  in
lymph spaces, along  with degenerative lesions.  Many cases show
no lesion whatever.
   Symptoms.—The disease usually develops insidiously.   There is
noticed at first some disturbance in the disposition : the child be-
comes  melancholy, irritable, or morose ; it loses the capacity of men-
tal effort,  and is  often punished at  school for lack  of attention,
stupidity, or forget fulness.   It soon becomes restless ; it cannot
sit still, loses appetite, becomes constipated, and finds it difficult  to
fall asleep.  The inco-ordinate  movement of muscle is usually first
shown in the face as a qnick grimace, a  sudden twitching  of the
mouth or wink of the eye.   The voluntary movements  show  soon
a certain awkwardness : water is spilled from a glass in the act  of
drinking, or food  from the spoon  or  fork  in the act of eating ; the
arm is suddenly jerked at the side,  sometimes with some contortion
of the body, to give the appearance of sulkiness.  Soon the move-
ments become more continuous and more universal; the leg jerks
as well as the arm, the face twitches more or less continuously, and
the whole body  moves irregularly.   This condition, which  shows
itself at  rest, is very much intensified by voluntary motion, oris
especially marked as  the child becomes  conscious of observation.
The disease continues to spread over the body, until  finally all the
voluntary muscles are involved,  including  the tongue, larynx, and
diaphragm.  Except  in the worse  cases, the involuntary muscles
are unaffected.   There is no difficulty in swallowing.  The bowels
and  bladder are perfectly normal.  The muscles first affected are
usually worse affected.  The disease always shows its main expres-
sion in the face, and, inasmuch as it is associated with some mental
impairment, it shows a peculiar physiognomy.  At perfect rest the
expression is listless, sullen, and dull, but the rapid play of indi-
vidual muscles distorts the expression in every way.   The face has
the appearance of a mask, whose monotony is played  upon by elec-
tric  shocks, and changed from melancholy to mockery,  from sur-
prise to a sardonic grin.  The voice, too, is broken, and changes in
its tones in the same sentence.  In bad cases the patient is unable to 
CHOREA.
walk, being tripped by his own legs.  In extreme cases be may find
no rest in a chair, or even in bed, out of  which he may  be con-
vulsively thrown.  In all cases the  disease is more marked on  one
side, usually the left.   Where the predominance is extreme the case
is known as hemichorea.
   Electric irritability is unaffected or but slightly increased.   The
disease is unattended with pains or parcesthesiie ; the sensitive
nerves are  unaffected, or, if  affected at all, are somewhat hyper-
aesthetic :  the reflexes are normal.  Notwithstanding the incessant
working of the muscles, there is  no feeling of fatigue.   Choreic
patients are, however, never  so strong as in health.  The  appetite
may  remain good, the bowels regular.  Nutrition suffers at  first
from loss of sleep ;  later there is pallor from anaemia, which may
lead to marasmus.   The  pupils are usually slightly dilated.   The
mental faculties in  mild cases are somewhat dulled; in marked
cases the dulness may increase to actual dementia, with involuntary
discharges from mental apathy.   In nervous women, in connection
with puberty or pregnancy, the nervous affection may take the form of
excitement with delusions or mania.  This so-called maniacal chorea
gives place in the course of a few weeks to dulness and  listlessness.
   Course and Complications.—The disease lasts for weeks,  on an
average from  six  to twelve weeks.   It may terminate in three
weeks or continue for six to twelve months.  Usually in  these  pro-
tracted cases there are remissions of longer or shorter duration.  Re-
lapse and recurrence  are frequent.  A second attack occurs in  one-
third of cases.   Instances are recorded of nine separate attacks.  The
occurrence of fever belongs to complications, especially to  rheuma-
tism or endocarditis.   The pulse is usually frequent, and is often ir-
regular in correspondence with the action of the heart, auscultation
of which  may  disclose a systolic murmur at the base or actual val-
vular lesion.   Embolus, hemiplegia, or softening of the brain  may
occur in consequence of the lesion  of the valves.  Ulcerative endo-
carditis in connection with chorea is almost  unknown.
   The prognosis  is favorable, especially in children, but assumes
some gravity with advancing age.  Pregnancy aggravates the  mor-
tality, at times to twenty-five  per cent.   Patients usually recover ab-
 solutely ; exceptional cases are followed by psychoses or paralysis.
    The diagnosis is usually easy.   The irregular, spasmodic,  bizarre
 movements of recent and rapid  onset, with the peculiar  physiog-
 nomy, readily  distinguish the disease.
    Forms.—Chorea  is sometimes closely connected with  hysteria.
    Hysterical chorea is often the result of imitation; the movements
 are  more regular and rhythmic.  They are also less violent  than
 cases of true chorea. 
CHOREA.
769
    Adult chorea occurs at any period of life, even up to advanced
 age, and more distinctly in connection with heredity.  Peretti re-
 cords a case where twelve descendants of a choreic woman were
 attacked with the disease in the second  half of life.   Adult or here-
 ditary chorea is unassociated with heart disease.   It is more common
 in men than women, and is especially distinguished by the fact that
 the movements are more distinctly under the control of the will.
    Electrical chorea  (Bergeron) is distinguished by the  sudden,
 shock-like twitchings of muscles, like those under electricity.  They
 are aggravated by emotion or efforts at control.  Electrical  chorea
 shows no other symptom, and these almost invariably disappear.  A
 peculiar variety of  this affection is seen in Lombardy, where  it is
 known as  Dubini's disease.  The  attacks leave, in  the  course  of
 months, paresis and paralysis, and are sometimes attended with uni-
 lateral epileptiform convulsions.  The disease is supposed  to have
 its seat in the cerebral cortex.
    Chorea major is really, as stated, a subvariety of hysteria.  The
 movements are more co-ordinate  and are  much more distinctly pur-
' posive.   The conscious convulsions and the exaggerated freaks  of
 hysteria, circular movements,  dancing manias, gymnastics, climbing
 of bedposts, etc., belong to this form of disease (see page 758).
    Treatment.—The mode of life is to  be regulated.  The patient
 should be kept quiet, must be removed from school.  Evidence  of
 caprice, apparent wilfulness, or obstinacy  should be allowed to pass
 unobserved.  Peace of  mind  is  best secured by quiet.   The most
 valuable  remedy is sleep, under  which the convulsive movements
 cease and the nervous system rests.   Sleep is best secured by warm
 baths at bedtime or frequently during the  day.   They may be re-
 peated as often as  every hour.  Aggravated cases require the use of
 chloral, which in small doses, gr.  ijss.-v.-x., with peppermint water
 3i.-Iss., usually  suffices.  Chloral is better than  any other hyp-
 notic, though sulphonal, trional, and paraldehyde  have individual
 advocates.  Arsenic may be regarded as a specific in a case of pure
 chorea—evidence again of the infectious origin or nature of the dis-
 ease.  The remedy should be given in small dose and  gradually
 pushed to tolerance.  No form is better than Fowler's solution, which
 may be increased from the dose of one or two to ten or fifteen drops
 three times a day after meals.   Irritant effects, pain, diarrhoea, may
 be avoided by the administration at the same time of a few drops of
 tincture of opium.   The disease is in this way usually cut short one-
 half or one-third its natural duration.  Rheumatic complications call
 for the use of the salicylates.  Faradization and  massage assist in
 supporting the nutrition of the muscles.   Iron, strychnia, and hypo-
 phosphites are the  best  general tonics in the way of  drugs.  Food
         49 
770
PARALYSIS AGITANS.
and fresh air are absolute essentials throughout the whole course of
the disease.
                       PARALYSIS AGITANS.
   Paralysis agitans; shaking palsy.—A peculiar paresis, attended by
tremors of individual members or of the whole body, which tremors
may be suppressed for a time by act of the will, ceasing altogether
or becoming feebler  in sleep;  normal  electro-motor and reflex ex-
citability ; inclination of the body forward.
   History.—Paralysis agitans was first described as a separate dis-
ease by Parkinson (1817), who distinguished it from chorea and other
tremors.   Parkinson's brief but  graphic  account excited, however,
but little attention, and the  character  of  the disease was only fully
appreciated  after the descriptions of Marshall Hall, Stokes, and Todd
in England, Romberg in Germany, and Trousseau in France (1840-
1800).  Charcot (1867)  separated the disease  from multiple or dis-
seminated sclerosis.
   Etiology.—In comparison with other neuroses  the disease is rare
       Fig. 298.—Position of the hand (pill-rolling) in paralysis agitans (Charcot).

and belongs to advanced life.  Males are affected more frequently
than females, in the proportion of five to three.   It is more common
in the lower walks of life.  The  role of heredity is insignificant.   It
has followed in the course of acute infections, more distinctly af-
ter trauma, and more frequently after psychical distress, as after
fright.
   Pure paralysis agitans is no longer a neurosis.  It has now a dis-
tinct  morbid  anatomy.   Ketscher  found abundant  degenerative
changes  in the brain and  cord  in three  cases,  and identified them
with the  changes in ten  cases which occur in  old age.  Paralysis
agitans is, therefore, in reality a premature senescence.
   Symptoms.—-The disease develops slowly.   The onset may  be
more rapid when the affection  follows fright.   The symptoms are
noticed first in the upper extremity, more frequently in the right
than in the left.  The hand loses its cunning.   The first loss is no-
ticed in the finer movements, as  in writing,  drawing, etc.  Associ-
ated with the weakness, preceding it in the majority of  cases, is the 
PARALYSIS AGITANS.
771
tremor.   It begins in  the  hand, in the thumb and index finger,
sometimes in the shoulder, and gradually extends, most frequently
in the order of hemiplegia—that is, from arm to leg on the same side.
In exceptional case this course may be interrupted.   Thus, it is not
so regular when the disease begins in  the  lower  extremity.  A
common beginning is that agitation of the thumb and forefinger as
if rolling a small body, a pill.  In the leg the tremor is most marked
in the foot.  In sitting the heel may beat a tattoo upon  the floor.
Though the muscles of the back  may be affected, the muscles of the
abdomen escape.   The head is not affected, though it may be indi-
rectly agitated by movements of the trunk. The face is very rarely
involved.   The tremor is distinguished from that of other or allied
affections by its persistence during rest.  The motion is continu-
Fig. 299.—Attitude and gait in paralysis agitans (Dana).
 ous; the  hands move upon the knees.  It is arrested for a time
 by volitional effort, but renews itself and attends its continuance.
 Efforts to control it, at first successful, intensify it later.  It is first
 recognized in the handwriting.  The letters are distinct,  but  the
 lines are  zigzag.  Fine variations  may be recognized by the lens.
 Stiffness sets in  later to limit  movements of various members.  So
 the head may be fixed upon the breast, the arms flexed, the fingers
 deformed as in arthritis deformans,  the feet brought to the condition
 of varo-equinus.   The whole body  is bent forward as  in running.
 The step is short, quick, and tumbling.   The expression is impas-
sive.  Extreme  cases may be  reduced to forced movements forward
or backward.  Sleep stops the tremors at first.  Electric reaction is
normal.  The reflexes are undisturbed.  There  is usually more or
less emotional disturbance, melancholy, from loss of power.  Tactile 
77*
MULTIPLE  SCLEROSIS.
sensation  remains unaffected, that of temperature is disturbed, in
three-fourths of the cases.  Victims  of  shaking palsy suffer with.
heat.  They cannot bear cover even  in  cold weather.  Aside from
the melancholy mentioned, the intellect is undisturbed.  Exceptional
cases show mental failures, convulsions, cramps in the legs, etc.—
symptoms probably due to organic complication.
   The disease is  as slow in  progress as in onset.   It may last for
decades,  but usually cuts  life short  through its remoter effects, as
want of exercise, bed sores, with sepsis, gradual marasmus, etc.
   The diagnosis is established by  the age  of the  patient, by the
peculiar  habitus,  continual rhythmical movements arrested only
in sleep,  with the  persistence  of  the  reflexes and electric reactions.
Paralysis agitans is differentiated from multiple sclerosis by the facts
that (1) sclerosis occurs before forty ;  (2) the movements, in paralysis
agitans arrested or reduced, are in sclerosis intensified by volitional
efforts ; (3) paralysis precedes the tremor in sclerosis, and, as a rule,
follows it in paralysis agitans ; (4) sclerosis affects the head and shows
nystagmus, conditions which do not occur  in paralysis agitans ;
(5) the words are disarticulated in sclerosis, and are rather  run to-
gether in  paralysis agitans,  which  shows also the  piping voice
(Shakspere's childish treble)  commonly, but very erroneously, as-
cribed to  age; (6) paralysis agitans usually shows itself  first in the
upper, sclerosis in the lower, extremity.
    The tremor of  age  is  distinguished by its more universal dis-
semination and early implication of the face.   Toxic tremor, as after
mercury, lead, etc.,  is distinguished by the presence of toxic signs.
    Prognosis.—Paralysis agitans is  incurable.  It may be  relieved
or temporarily retarded.   It is unattended with immediate danger to
life.
    The treatment calls for rest, relief of anxiety and fatigue.  Elec-
tricity is of little or no value.   Nerve stretching is dangerous.  The
only remedy which  merits the name is arsenic, which produces its
best effect when used subcutaneously.   The liquor potassse arsenitis
is diluted with twice as  much water and injected under  the skin of
the back.  The dose, small at first,  should  be gradually increased
to tolerance.  Anodynes, which may be demanded in extreme cases,
should be used with caution  and selected with care.  Indian hemp
more especially hyoscyamine gr.  Th~ih, is to be preferred to opium.


                      MULTIPLE SCLEROSIS.

    A disease caused by  the development of scleroses throughout the
brain and cord, characterized by tremor, evoked or exaggerated by
effort,  scanning  speech, nystagmus, pareses in various  muscles; 
MULTIPLE SCLEROSIS.
■vrvo
I i O
often with contractures, increased reflexes, preservation of sensation;
occasionally by amaurosis, apoplectiform attacks, and delirium.
   History.—The  disease is of modern recognition, and, though
oliserved by Cars well and Cruveilhier and described by Frerichs, was
especially set apart and distinguished by Vulpian and Charcot, who
isolated cerebral, spinal, and cerebro-spinal cases according to the
seat of the disease.   In most cases the process is disseminated, and
consists of islets of sclerotic tissue scattered through  the substance
of the brain and cord.
   Etiology.—Heredity is insignificant;  sexes show no difference;
age is of most moment.   The majority of cases occur between twenty
and thirty-five; exceptional cases have been recorded as early as
seven and as  late as sixty years. The disease has followed appa-
rently in consequence of trauma,  the  infections—typhoid  fever,
small-pox, diphtheria, and erysipelas—and  in  the  course of preg-
nancy after exposure to cold, after severe mental and bodily strains,
etc.   It has developed in the course of a year after recovery from
myelitis or other acute affection.  In a case under observation of the
author at the time of this writing, the sequence ran: haemorrhage in
the cord after violent effort; myelitis with paralysis of the bladder
and bowels; at the end of a year volitional tremor,  scanning speech,
nystagmus, and spastic contraction of the lower extremities.
   Morbid Anatomy.—The disease  consists, in essence, of depots of
condensed tissue, varying in size from the barely visible to masses
of the diameter of ten centimetres or more.   These masses are indu-
rated, sometimes elevated, sometimes sunken, gray or white, smooth
or  lustrous.   They are  seen  to consist,  under  the  microscope, of
hyperplastic connective tissue.   The nerve tissue proper is  shrunken
and wasted.   The vessel walls show hyaline degeneration with vari-
cosities.   The white substance is shrunken to a narrow ring about
the axis cylinder, which persists for  a time and finally disappears.
   Symptoms.—The symptoms of multiple sclerosis are said to be
kaleidoscopic; they vary according to the seat of the disease.  The
onset is  insidious, seldom sudden, and is distinguished, when it
begins in  the  brain, by headache, vertigo, and psychical distress.
Cases of  more sudden onset simulate attacks of apoplexy.  Begin-
ning in the cord, the disease shows itself  first in lack of co-ordina-
tion, early fatigue, tremor.  The  tremor is first noticed in the
arms; it extends to involve the lower extremities, and in the prog-
ress of the disease  does not spare the face.  The tremor is peculiar
and characteristic.   It is at first absent at rest, and shows itself only
on movement.  Later it is more continuous, but is always more in-
tense in efforts  of the will, or under observation or emotional dis-
turbance.  The  more the patient tries to  control the movements  the 
774
DEMENTIA PARALYTICA.
more uncontrollable they become.  The movements become wild and
irregular; the patient  spills water in an attempt  to  take a drink.
The disease is hereby distinguished from paralysis agitans, in which
tremor or movement is arrested or inhibited by efforts of the will.
As a modification of this tremor is the alteration of speech, which
consists in  the  disarticulation of words in syllables  expressed  in
monotones.   The effect is that of scanning.   Speech is often inter-
rupted also by sudden  inspiration, hiccough, etc.
   Spastic contractions are more frequent in the lower extremities.
Patients sometimes present the appearance of cases of lateral sclero-
sis.  The reflexes remain unaffected or are later intensified.  Various
paraesthesiae occur  in  individual cases.  Nystagmus  is often asso-
ciated with impairment of vision, as the tremor of the whole body is
later followed by paresis.  The disease  is slow in its progress, and is
more or less progressive, with periods of apparent  arrest  or sudden
aggravation.  Attacks of vertigo are frequent in  all  stages of the
disease.  Attacks of  apoplexy occur in  about twenty per  cent  of
cases.   A sudden coma,  with elevation of  temperature, is followed
by hemiplegia or by intensification of all the symptoms.
   The diagnosis  rests  upon the  tripod formed by the prominent
symptoms—volitional  tremor,  scanning  speech,  and nystagmus.
These  symptoms, in association with  the preservation of sensation
and escape of the bladder  and bowels, distinguish the disease in most
cases.   It must be remembered, as stated, that the picture varies
with the site of  the lesion.  The  disease lasts  two to twenty years,
on the average five to  ten years.  Death results from apoplexy, cys-
titis, decubitus, marasmus.
   Treatment is of little value.  Warm baths are beneficial in stay-
ing the progress of  the disease.  Cold of all kinds is injurious.  Re-
garding exercise, it is difficult to draw the lines to avoid the Scylla of
fatigue and the Charybdis of degeneration from disuse.  Electricity
in all forms seems to be useless.   Arsenic has recommendations.   It
is customary to prescribe arsenic in doses of three to five drops three
times a day.

                    DEMENTIA PARALYTICA.
   Dementia {de,  privative,  mens, mind) paralytica (a much finer
designation  than its synonyms, progressive paralysis of the insane
or general sclerosis) is  a wasting disease of  the brain, usually of in-
sidious onset  and slow course, marked by  alteration of the  dispo-
sition, signs of insanity,  delirium of grandeur, affection of speech,
tremor of the lip and tongue,  loss of light reflex in the iris with other
signs of tabes dorsalis, intercurrent apoplectic [and epileptiform at-
tacks, irregular— i.e., fitful—but progressive degradation, and death. 
DEMENTIA  PARALYTICA.
775
   Dementia paralytica is a frequent disease, but is often overlooked
for months or years, or diagnosticated under some of its advanced
or grosser signs as  "paralysis," "insanity," or "softening of the
brain."  The credit of the separation  of the disease as a definite
malady is due to the distinguished alienists of the old French school,
especially to Calmeil and Esquirol.
   Etiology.—The most common cause of  dementia is syphilis, but
the disease occurs, not as an immediate complication, but as a remote
sequel of syphilis.   With tabes dorsalis, many of whose symptoms it
shows, dementia paralytica is not a para- but a meta-syphilitic phe-
nomenon.  The relation of alcoholism is neither so strictly defined
nor so generally accepted.  Brain worry, especially from failure in
life, is often assigned as a cause, without other reason than sequence.
Real  brain work—i.e.,  intellectual work—produces no dementia.
On the contrary, brain work protects the brain from waste.   Hered-
ity plays the same role as in most nervous diseases—that is, epilepsy,
hysteria,  insanity, etc., in  the ancestry predispose to dementia in
posterity.  Dementia is a disease chiefly of the male sex, of maturity,
about forty, and age.
   Symptoms.—The mental faculties  suffer first, as  a rule, and the
disturbance begins in  the  sphere of the emotions.   The patient be-
comes irritable, more especially sensitive.  He is  easily excited,
angered, or hurt.  He flies into a passion or weeps without apparent
cause or from some imaginary  cause.  He may, exceptionally, ob-
serve the change himself; as a rule the friends notice it first.   What
pain is endured by silent sufferers (relatives and friends)  for months
or years is only learned as the cause is understood with the lapse of
time.
   Most patients  enjoy good health at the  start and often far into
the course of the disease.   Sometimes, with the appetite of a glutton
and the indolence of ease, there is unusual euphoria.
   Most patients are optimistic, or are for a time serenely, even inor-
dinately, happy.   They soon  begin to entertain  ideas of grandeur.
They  imagine themselves endowed  with  genius, wealth, power.
One patient, treated by the author, owned all the land in the State of
Ohio and had gigantic schemes  for the disposition of it.  Another
had  invented a machine of "oiled walnut and  steel wheels"—this
was all he knew of  the construction of it—which  he intended to fix
on top of the Mechanics'  Institute, whence he would regulate the
movements of the planets.
   In and bordering on this state of mind men have disposed of their
possessions, dissipated large fortunes,  and contracted heavy debts.
   In exceptional cases the opposite condition prevails.  The patient
falls  into melancholy, sits dejected and distrustful, still and silent, 
 776                 DEMENTIA PARALYTICA.

 the entire day.  Attacks of this kind occur also in the more common
 states of expansive delirium; but they are usually transitory, lasting
 a day or two, or even a week or two, to be substituted by the condi-
 tion more natural to the disease.
    These changes are light or  severe in individual cases, but are in
 either case appreciated by  intimate associates, and  soon, because
 permanent, come to be generally known.  In other words, the char-
 acter of the individual  is changed.
    At this time,  or  before  the  change  has been noticed—for the
 observance of change depends also upon  the observer—evidence of
 paralysis begins to appear.  It shows itself first in  the face  and
 tongue, and is noticed especially or obtrusively in the speech.   Articu-
 lation becomes difficult, syllables and words are dropped or confused.
 The change is noticed  first with unusual words, and  the speech is
 much like that of alcoholism, which indeed produces a dementia of its
 own in time.  Thus the patient will say "incalable" for "incalcula-
 ble," "artrerrilery" for "artillery," "eletrity" for "electricity,"etc.
 The attempt to pronounce the phrase " mathematical demonstration"
 excites a smile of compassion, at least.   A good test is such a demon-
 stration, whereby  it is seen that the  patient may still  perform sums
 in simple addition, but in multiplication he is at fault, and in division
 fails  entirely.  So much here  depends, however, upon the amount
 and direction  of previous training.  At this time—as a good test of
 the lapse of memory—it is difficult for the patient to  recall the  date
 of his birth, something that everybody knows.
    Soon—that is, sooner or later—the lower lip trembles.  The pa-
 tient looks as if about to burst into tears.  In more advanced cases
 the  lip falls away from the teeth.   The tongue is tremulous; so
 much so, often, that  the patient cannot protrude it, or, protruding
 it, cannot control  it.   Fibrillar twitchings and pareses  affect  also
 other muscles of the mouth and cheeks, so that food  may fall from
 the mouth, and the patient at an early stage may have to be  fed.
 Later there may be also difficulty with deglutition, so that the dis-
 ease may  resemble or  be associated with bulbar palsy.  These bad
 signs may, however,  all disappear again, and the patient survive a
 year, as in the case of  a colleague  of  the author, or  longer, as in
 recorded cases.
   Many  of the  symptoms of tabes are now wont to appear.  Thus
 there is, or may  be, paresis or paralysis  of  the bladder (a  very ugly
 complication, necessitating great care with the catheter), absence of
 knee jerk, loss of reflex in the pupils, impotence, ataxia, parsesthesia,
or pains,  though  the pains are never  as severe  as  in tabes.  Mi-
graine, supra-orbital neuralgia, scotoma, monoplegia of short dura-
tion, may  vary  the scene.   Charcot says  certain patients  present 
DEMENTIA  PARALYTICA.
777
themselves to the physician with sensations of distress in the tongue,
"apprehensive of cancer of the tongue," and will not be assured to
the  contrary, as prodromata  of paralytic  dementia.  If  these or
similar sensations, more especially formication and numbness of the
limbs, are felt in association with disturbance of speech and altera-
tion of disposition in a middle-aged man in previous  health, the  dis-
ease is probably dementia.
   It must be remembered, however, that no one of these symptoms
is essential to a diagnosis.  The knee jerk may persist in some cases ;
it may be increased and associated with spastic contractions.
   More characteristic events are the apoplectiform, more strictly
epileptiform, attacks which set in later in the course of the  dis-
ease, sometimes to cut it short fatally ; oftener to be recovered from
rapidly, but with life on a much lower plane.
   The patient  may now find it difficult to express himself in  any
direction.  He stops in the middle  of a  sentence, loses the word,
loses the thought, is vacant, as if a veil had fallen between.
   Morbid Anatomy.—The whole  brain is atrophied.  The pia is
thickened, opaque,  and adherent.  The vessels show signs of athero-
matous change.  The hyperplasia of the connective tissue is so great
as to have led to the view that the process was essentially  an inter-
stitial encephalitis.   In bad cases the surface of section, with its in-
durations  and vacuoles, looks like the surface  of a piece of Swiss
cheese.  The disease begins, however, always in the  nerve elements
themselves.   The convolutions are small.  The ganglion cells are de-
generated.  Prolongations, poles, are lost.   Nerve fibres are shriv-
elled.   The same degenerative, indurative changes are found in  the
cord  with the evidence of  more or less extensive tabes dorsalis.
The whole process  impresses the observer as the destruction  and
wreck of a general diffuse sclerosis, which, in  fact, the  disease is
declared to be.
   The diagnosis  is easy in a case with all the  symptoms set in
course.  It rests  chiefly upon the change of disposition, affection of
speech, fibrillar tremor, especially of the tongue, the delirium of gran-
deur, or, exceptionally, the melancholia, the epileptiform attacks,  etc.
   But the diagnosis  may be difficult  or impossible at the start.
Here must be taken into account the finer  changes of disposition or
temperament, attacks of migraine, double  vision, the altered hand-
writing, in association with one or more of the more distinctive signs.
   Dementia paralytica must  be differentiated  from  the  dementia
which may follow or occur in  the course of epilepsy and alcoholism,
as well as from the dementias secondary to mania, melancholia,  pa-
ranoia, or other pure psychoses. The preceding history helps to make
this diagnosis.  Senile dementia is the imbecility of old age. 
77S
AVOCATION NEUROSES.
   Prognosis and Course.—The disease is chronic, and, though
subject to remissions and periods of  quiescence of weeks', months',
even years' duration, it is, as the name  implies,  progressive.  Thus
dementia may last for  years with exacerbations or with such appa-
rent improvements as to make an absolute statement of the probable
duration of life  impossible.   Galloping cases may  take  life  in  a
month. Protracted cases last ten years.  Average cases extend from
one to three years.  Death is  by an apoplectic attack, by cystitis, de-
cubitus, intercurrent pneumonia, marasmus.
   Treatment.—As in the case of its allies and congeners, the other
scleroses, the treatment is wholly symptomatic.   States of irritation
are subdued by  the  bromides,  gr. xxx.-xl. largely diluted ; sleep-
lessness is allayed by trional,  gr. xv.  in a cup of  hot tea at bedtime.
All forms of alcohol are to be avoided.
   The judicious use of morphia in small daily dosage, by stimulat-
ing brain cells not yet attacked or entirely destroyed, will postpone
the wreck which is in  all cases  inevitable  at last.   Close attention
must be paid to the bladder and bowels.
   Life is best prolonged by peaceful surroundings.  When the pa-
tient  is gentle or childish he  may be kept  at home ; where violent
he should be sent to an asylum.

                     AVOCATION NEUROSES.
   Avocation  neurosis, the  most common  example of   which  is
writer's cramp, is an expression  of exhaustion of the nerve centres.
It is the result of the excessive use of the same  muscles in the  same
way.   The neurosis may show itself in other forms of nerve exhaus-
tion  than  cramp.  The act  of writing, including typewriting, fur-
nishes the largest contingent of cases ; but as other avocations may
produce the same result, the diseased state is better known  as an avo-
cation neurosis.   Thus typical  cases are encountered among piano
players.  Reuter recorded the case of a celebrated composer in whom
the right middle finger had refused service for ten years on account
of spasmodic  extension whenever he sat down to play.  Violinists
are not exempt.   Berger mentions the case of a hypochondriac vio-
linist who was seized with pain  in the left shoulder  and  spasmodic
cramp of the left hand, which he could  prevent only by holding the
instrument in an unusual way.   Tailors and fine-sewing women are
sometimes  attacked with a " stitch cramp.''  Duchenne described a
case attended with a spasmodic rotation of the arm inward.  Onimus
reported cases among telegraphers, and Hamilton mentions the let-
ters  most difficult  of  record in these  cases.    Cigarmakers, cow
milkers, watchmakers, shoemakers,  smiths, even pugilists, have all
been unfitted for their avocations by  like conditions. 
AVOCATION  NEUROSES.
779
   The disease does  not  confine itself to the upper extremities  and
trunk.  Men  who  have had to tread mills have been seized in the
sole of the foot.  Scissors grinders,  treadle operators, and sewing-
machine workers may be  affected in the  legs.  The danseuse on the
tiptoe is not  infrequently affected in the muscles supplied by the
tibial nerve.
   Etiology.—Aside from the avocation, the disease belongs to the
neuropathic temperament.  Individuals of irritable, sensitive ner-
vous systems, with multiform hypochondriac  or  other  functional
neurosis, are most frequently affected.  Thus the avocation neurosis
occurs most frequently in people affected with neuralgia, headache,
facial spasm,  strabismus,  stuttering, etc.  It has been noticed in con-
nection with  chorea, epilepsy,  paralysis agitans,  and  psychoses.
Alcoholism, onanism, sexual excesses, precipitate attacks.  Patients
themselves often  show other nervous  disturbances,  as  irritability,
sensations of  pressure about the head, vertigo, palpitation, nervous
dyspepsia, etc.  The condition is most apt to occur with the mechani-
cal writers, especially with those who take pains to write well and
attend more to the form than to the meaning of words.  Authors
seldom suffer.  Clerks,  secretaries,  amanuenses, bookkeepers, are
the  victims of this disease.   Cramped surroundings, bad postures,
wrong methods of writing and holding the pen, hard pens, are  pre-
disposing factors.
   Symptoms.—The disease begins with a sense of  weakness and
weariness ; the  hand and arm suffer early fatigue.   The sensations
disappear with cessation of writing, but with its resumption cramp
soon supervenes, the  fingers close about  the palm with the peculiar
pain  characteristic of cramp.   Effort of  the will, instead of subdu-
ing, aggravates the condition.   Rest restores tone to the overworked
muscles, and the cramp ceases.  But work after too  short an inter-
val is followed sooner and sooner by cramp more and more profound,
until finally the  spasm may extend up the arm to the forearm, neck,
and even the face.  The author had a case in which the spasm of the
arm, neck, and face  became epileptiform.  The individual, a clerk
in the auditor's office, had his head drawn down on his shoulder and
his hand twisted backward during the cramp.  The  pain he would
experience at this  time would cause him to cry out.  Thus enforced
work extends  the disease to induce finally organic lesion in the cord.
Palpitation of the heart, precordial anxiety, conditions bordering
on epilepsy, develop  in the history of the unfortunate  individuals
who must continue to work.
   But cramp does not constitute the  sole or even a necessary factor
in the symptomatology of the disease.  Many cases show no cramp
at all, and the disease expresses itself in other forms of muscular 
7 So
INSOLATION.
exhaustion—to wit, tremor and paralysis.  But cramp is the most
frequent symptom.  Thus in the sixty-four cases recorded by Berger
twenty-four were purely spastic, ten purely paralytic,  and eight
purely tremulous.  The  remaining  twenty-two cases were mixed;
cramp was present in all  in thirty-four cases.   The kind or form of
neurosis with which the  patient is afflicted is easily discovered.  In
the use of the pen the spastic variety makes zigzag lines, after the
manner of a man writing in a wagon jolting over a rough road ; the
tremulous is the chirography of  extreme age,  the letters are small
and wavy; the paralytic variety soon stops—it may form but a letter
or two.
   The prognosis is bad.  A few cases recover entirely.   Indi-
viduals unable to rest the hand or change the avocation seldom re-
cover entirely.
   The treatment is rest.  The  substitution  of other fingers or of
Fig. 300.—Duchenne's apparatus for relief of writer's cramp.
the left hand in writing changes the disease ultimately to them or to
that side.   The various mechanical devices of support may relieve at
first, but they all prove futile at last; tenotomy and nerve stretching
produce no permanent results.  The tone may  be  sustained for a
time by strychnia in  gradually increasing doses, but without rest
there is no  real relief.  Aside from rest, galvanization  is the  true
treatment of writer's cramp.  Duchenne was forced to admit  that
faradization was of avail only in the paralytic and anaesthetic forms
of the disease.   The negative pole should be  placed at the nape of
the neck, the positive stroked  over the affected muscles of the fore-
arm.   Galvanization should be gentle and the sessions brief.   Hydro-
therapy, manual gymnastics, massage, may assist treatment.

                    INSOLATION—SUNSTROKE.
   Sunstroke, heatstroke, occurs  most frequently in hot lands in
summer, but may be observed also at other times and places under
like  condition, as among firemen in the holds of ships, children in 
INSOLATION.
781
 overheated apartments.  Heatstroke has assumed epidemic propor-
 tions in army life.  In the passage of the Mincio 2,000  of  the 12,000
 soldiers  at Antemarres were attacked with heatstroke, and 26 died.
 Maclean relates that at the attack on Chiang-Kiang-Foo, in the first
 Chinese war, the men, still enveloped in rigid stocks, heavy clothing,
 and impedimenta, were charging  up a steep hill.   A great many
 were stricken down; fifteen died almost instantly after a few convul-
 sive gasps.  In army life the condition  is confined to the foot sol-
 diers ; the cavalry escapes. Heatstroke occurs especially among the
 working classes.  Most cases occur in hot, humid weather without
 wind or  breeze.   In  dry weather the evaporation of sweat  reduces
 the  temperature.  At  an artificial temperature  of 130°  to 140° F.
 even the most profuse  secretion of sweat will not suffice  to protect
 the  body  from overheating.   When the clothes become saturated
 with sweat, exhalations of the body are  prevented, evaporation
 almost ceases at the surface, the temperature continues to increase,
 carbonic acid  accumulates, and stupor,  coma, and convulsions su-
 pervene.   These conditions are precipitated all the more rapidly if
 the  individual at the same time suffers thirst and the quantity of
 water in the blood is reduced.
   Morbid Anatomy.—Autopsy reveals early rigidity  with dryness
 of the muscles.  The blood is thin  and dry, the brain and  lungs hy-
 peraemic; the left ventricle is empty, the right ventricle  is full.  Kos-
 ter found haemorrhages in various parts of the sympathetic.
   Etiology.—Antonini regarded sunstroke  as an acute neurosis of
 the vaso-motor system.  Senfleben, as the result of his observations
 on lower animals enclosed in hot boxes, ascribed the results to disor-
 ganization of the blood, disintegration of red blood corpuscles, accu-
 mulation of urea.  The temperature of a rabbit put into  a  hot box
 at 96° F. increases to 106° F.   The  pulse  and respiration increase
 rapidly ; the surface vessels are dilated.   At 104° F. the  body heat
 rises to 112° F., and the increase in respiration and pulsation is enor-
 mous.  The pupils are dilated,  the muscles relaxed, and death soon
 occurs from paralysis of the heart.   The protoplasm of the muscle of
 mammals coagulates  at 112° F., a fact alone sufficient to explain the
 cause of  death.  Animals perish under a  continuous stay in a  hot
 box, though the  body heat may not rise above 108°.  Under such
 conditions  fatty degeneration occurs in many tissues. Wood showed
 that heating the  brain of a mammal produces sudden  insensibility,
with or without convulsions, at a temperature of 108° F., and death at
 a temperature of 113° F., and that the life of the blood, as  evidenced
by the amoeboid movements of  the white blood cells and the absorp-
tive  power of the red blood cells, is not destroyed by any temperature
reached in  sunstroke; moreover, that if heat be withdrawn  before 
7S2
CONGELATION.
it has produced permanent injury, the convulsions and unconscious-
ness are immediately relieved and the animal recovers.  The damage
is not dependent, therefore, upon blood poisoning, but upon the heat
itself, and is due probably to direct effects upon heat-regulating cen-
tres in the pons and medulla.
   Diagnosis.—Heatstroke is differentiated from apoplexy by the
fact  that the fever  precedes the  stroke of heat  and follows  the
stroke of apoplexy.  The rapid pulse and respiration of heatstroke
are also points of distinction.
   Prophylaxis.—Heatstroke is prevented by avoidance of the heat
of the day, as in hot countries by a siesta at this time ; by temperate
habits, moderation  of  work  or inarching, regulation of clothing,
abundance of drinking-water,  which should be   taken  frequently
rather than in large quantities.
   The treatment is the application of cold, best in the bath, at first
at a  temperature of 80°-85°, and then rapidly reduced  with ice.
The patient, on withdrawal from the bath, should  be  quickly  dried
and  covered.  The  bath  may be  preceded  with  advantage  by a
moderate! dose  of whiskey with  gtt.  xx.-xxx.  tincture of digitalis
(Guiteras).  Where  this  treatment is not practicable the patient
should be  douched  at once  from the nearest water supply, and
masses of  ice may  be rubbed  over the  head and body.  Patients
once affected with heatstroke suffer for a long  time, sometimes for
life, under subsequent  exposure to heat.  Attacks of epilepsy may
ensue upon each occasion.   Strychnia gr. ¥V—2V  best obviates the
cardiac and cerebral depression following sunstroke.

                   CONGELATION—FREEZING.
   The human body can endure wide ranges of temperature.   If the
air be dry, life is possible at a temperature of 212° F., and at the low-
est grades, even below —50° F., or any temperature encountered any-
where on the sur/ace of the earth.   Consequently death by freezing-
is not common.  The various expeditions made to  the North Pole re-
cord no death by freezing.  When it occurs, it is met with, of course,
most frequently in the  colder climates, Russia, Siberia, etc., and in
the country rather than the city, as in long night rides or when trav-
ellers are lost in the snow.  But  statistics  differ.   Samson-Himmel-
stern, St. Petersburg, found  death by freezing  16 times  in 220 au-
topsies in seven years.  Dieberg  puts the proportion at ten per cent,
while Caspar-Liman, Prussia, in 100 cases  met  with but  2  which
were said to be deaths by freezing.   Here, with us, death by freezing
occurs but once in three or four years, and then usually in the case
of a street-car driver, who is sometimes found frozen at his post.
   But while death from freezing  is uncommon,  local congelations 
CONGELATION.
783
are very frequent.  In St. Petersburg, 1870, there were but 3 deaths
from freezing, but 700 cases required treatment.  In a single hospi-
tal there occurred in a decade 494 cases (456 males) with 42 deaths,
all from complications which occurred as sequelae—thus, 18 from
pysemia and septicsemia,
    There is no thermal or athermal death point.  Reincke once found,
in the case of a drunken laborer frozen on the street, a temperature
of 75°  F. in the rectum.  The patient nevertheless  recovered.   An
animal (rabbit) cooled down to 66° F.  cannot recover of itself, but it
may recover under heat and artificial  respiration, even after appa-
rent death for forty minutes.  Walther was able to recover animals
from a body temperature as low as 48° F., and Horwath young ani-
mals from a temperature as low as 40° F.
    The temperature at which a man will freeze depends upon  vari-
ous circumstances, as age : the old and the very young quickly suc-
cumb ; the aged lose  heat quickly on account of feeble circulation ;
the new-born part with it readily,  notwithstanding the active heart,
on account of the slight mass of  the  body.   Clothing, shelter, mo-
tion, wind, dryness and moisture of the atmosphere, make a differ-
ence.   Hunger makes ready victims.  Wounds, especially those  at-
tended with loss of  blood, greatly reduce resistance.  A powerful
influence is exerted by depressing  mental emotions.  In the retreat
from Moscow the  French suffered appalling mortality.   Larrey re-
lates that on January 2d, 1845, in the retreat toward Setif,  though
the temperature  was only 35° F.,  208 of 2,800 soldiers perished from
cold ;  and of the remainder, 525  had to be taken to the hospital,
where 21 subsequently died.  These men were hungry, wet, and cold.
 Under such conditions men have died from freezing at temperatures
 where other men were enjoying themselves skating upon ice.
    Alcoholism is the mpst frequent of all the  conjoined  influences.
 Two-thirds of all the cases of freezing in St. Petersburg occur among
 drunkards.  Liman declares that he never  saw an unmixed case of
 freezing.   Death results from the combined effect  of hunger, sick-
 ness, alcohol, and cold.
    There is no duration of exposure to cold which  is necessarily fa-
 tal.  Remarkable  experiences are related by the monks in the Swiss
 mountains.  Krajewski' reports that a Russian peasant  was found
 living under snow after twelve days' exposure.  This man recovered
 after two months' illness.
    The symptoms of freezing are general and local.  1.  There is
 first a sensation of chilliness and a feeling of intense cold, which
increases to actual suffering.  Drowsiness sets in and the tendency
 to sleep becomes irresistible; the |special senses  are obtunded,  the
               1 Schmidt's Jahrblicher, 1861, Bd. ex., p. 330. 
784
CONGELATION.
 sight is veiled, the hearing dulled, the touch blunted ; and though
 the  patient may resist sleep for a time, with the knowledge that to
 yield to it is fatal, he finally, if unsupported, falls senseless to the
 ground.   Death now occurs rapidly or slowly, according to circum-
 stances.   When death is rapid it is  usually preceded  by  bleeding
 from  the nose, often by involuntary and unconscious discharges.
 When it is more slow the pulse is gradually reduced to 40-50, res-
 pirations  to 8, per minute.  It may be days before death finally oc-
 curs.  When the patient recovers from a severe case he is apt to suf-
 fer violent headache or delirium ; sometimes paralysis ensues.
    2. The first effect of cold is contraction of the vessels, so that the
 surface becomes pale  or white.  The vessels subsequently dilate
 and the surface is reddened or rendered blue or  livid.  These lo-
 cal effects are seen on the exposed extremities, the ears,  the nose,
 fingers, and toes, where they  constitute  what  are known as chil-
 blains or frost erythemata—commonly, frost bites.
    Freezing occurs in three modes of severity :   1. The vessels are
 simply dilated  and are again restored and the parts recover their
 natural tone ; or the vessels remain dilated or more especially dilat-
 able, so that surfaces once frozen show hyperaemia upon every  new
 exposure  to cold.  Such surfaces are attended with sensations of
 burning or numbness,  or, more  particularly, intolerable  itching,
 especially at night, which is only partially relieved by scratching or
 other irritation.  Sometimes this susceptible condition,  which  rep-
 resents a  subparetic condition of the capillaries,  remains for many
 years.
   2. In the stage of vesiculation blisters are formed.   Entire resti-
 tution is also possible from this stage.
   3. Gangrene with destruction of tissue.
   Winiwarter  describes a peculiar thickening of the intima which
 occurs in  arterioles subject to  freezing as a cause of occlusion and
 gangrene.  Malum perforans pedis has been observed to occur after
 congelation.  Though  the patient may recover with life, with the
 loss  of gangrenous  parts, he may subsequently succumb to sepsis,
 tetanus, etc.
   Morbid Anatomy.—Congelation has a medico-legal aspect.   It
 is sometimes important to know if the freezing was a homicide.  The
 idea of suicide  cannot be entertained, as the suffering is. too great
 and  the victim would  necessarily seek shelter.   There is  no doubt
 that new-born babes have been killed by exposure  to cold.  There
 are,  however, no signs by which the fact could be determined that a
 body had  been frozen to death.  The  body is of course  rigid.  It is
 sometimes frozen through, so that the contents  of the  stomach are
found solidified  and blood is actually frozen in the heart.  The natu- 
CONGELATION.
785
ral post-mortem rigidity persists after the body has been thawed out.
Sometimes extremities, fingers, toes, nose, ears, etc., have been bro-
ken off; this is a very rare occurrence and is no proof of congela-
tion.   The cranial bones have been found separated—proof, however,
only of the fact that water expands and bursts the vessel that con-
tains it, exactly as it bursts an earthen jar.
    The internal  organs are found, as  a  rule, intensely  congested.
This is the case also in alcoholism, the condition especially to be dis-
tinguished, but often impossible of distinction because conjoined with
congelation.   One thing is certain, a frozen body does not decompose,
and the evidence of decomposition proves that the body was exposed
after death.   This point is often of value  in cases of  long absence,
as when an individual has disappeared  in  the summer  and the body
has been found in the  winter, frozen, and in a state of partial decom-
position.
    Rather more valuable evidence is furnished by the redness of the
skin and redness of the blood ; but both  states are not always present
in freezing, and are sometimes present in death from  other causes.
Redness of the skin, or red patches  on the skin, are more common
than redness  of the blood.   These conditions are due to the direct
effect of cold on the haemoglobin, and are always post-mortem  phe-
nomena.
    The cause of death from freezing has been variously attributed to
direct action on the corpuscles (Rollet), to influence on the nervous
system (Crecchio), to congelation of the muscular tissue (Horwath),
but, as Blumenstock remarks, the action is too complex to  attribute it
to any one cause.
    The prognosis depends upon the grade of freezing, the strength
of the individual,  and  various  surrounding circumstances.  Most
patients recover from frost bites in the  course of time,  and recovery
is always possible from septic states, and even after gangrene with
sloughing, though the prognosis  here is necessarily grave.
    The treatment in local frost bites  consists in the slowest possible
application of heat, as by means of friction with snow and later with
mild anodyne applications, as with equal parts of linseed oil and lime
water (Carron oil), or diachylon ointment.  The  indications are  to
restore heat gradually and to relieve stasis.   Stasis is best relieved
by vertical suspension.   The hands or  feet are put at right angles
to the body, or at least reposed upon  inclined planes.   All local hy-
peraemias disappear- at once  under this treatment.  Chilblains are
best treated  by strapping with  adhesive  plaster.  The  strapping
must  be close and firm,  and the straps should  be allowed to stick or
stay on for three days.   If the surface is broken the salicylated plas-
ters are the best.
        50 
786
SATURNISM.
   Frost bites of the second grade are treated exactly as are burns,
by mild emollient applications, as the Carron oil referred  to.  The
following is a fine dressing for burns :
    3 Europhen..................................................3.0
      Olei olivae...................................................... ?.0
      Vaselini...................................................6(>0
      Lanolini....................................................30.0
   M.  S. Apply to the surface.
   Care should be taken not to remove the cover of a blister, which
is itself the best natural protective.  Gangrenous processes fall in the
domain of surgery.

                 SATURNISM—LEAD POISONING.
   Saturnism, plumbism  {plumbum, lead), occurs in  two forms,
acute and chronic, entirely different from each other.  Acute Lead
Poisoning  is not common, as  very large quantities  of any salt of
lead are  necessary  to produce  dangerous effects.  As  much as  a
drachm of the sugar of lead is sometimes taken without evil effects.
Yet cases have occurred where lead poisoning has assumed  epidemic
proportions.  Bancks, of Stourbridge, reported such a case, where
thirty pounds of acetate of lead became  mixed by  accident with
eighty sacks of  flour, and  the whole mass was made by the bakers
into bread,  from the  eating of which five hundred people were
attacked with lead poisoning.  Poisoning sometimes occurs from the
glaze of crockery ware, solder of metallic kitchen vessels, white lead
used in confectionery,  red lead in  the  preparation of  lobsters.
Babies may be  poisoned  with  the lead  of rubber  nipples,  from
painted toys, glazed cards,  etc.
   Acute  lead poisoning runs its course with the symptoms of gas-
tritis, pain, vomiting,  and, in bad cases,  rapid  collapse.  The
diagnosis is established by the detection of  lead  in the  vomited
matters.   The ammonium  sulphide produces a black precipitate in
acid  solutions which contain less than the one-hundred-thousandth
part of a lead salt.
   Chronic Lead Poisoning is much more common, as any salt of
lead, even the most  insoluble, will produce  symptoms in the  course of
time.   The  condition was  known  in  the remotest antiquity.  Avi-
cenna described it.  The first exhaustive monograph was written by
Tanquerel des Planches (1830).
   Chronic lead poisoning is observed most frequently in workers in
lead, in painters, plumbers,  glaziers,  enamellers, etc.  Snuff  and
chewing tobacco take up two and one-half  to three per cent of lead
from lead foil envelopes.   Poisoning  occasionally results  from  the
use of water from lead pipes, though protection is here usually secured 
SATURNISM.

by the fact that the pipe becomes coated with  the insoluble sul-
phate.  Very small quantities of lead suffice  to produce symptoms.
The house of the king of France was poisoned in the course of seven
months by drinking-water  which contained 0.0002 per cent.   But
very  small quantities  are ever found in the body.  Thus Heubel
could detect in  his experiments upon dogs,  after long administra-
tion  of the acetate  of lead, in the bones but  0.025  per cent;  in
the kidneys, 0.012 per cent; liver,  0.01 per cent; spinal cord, 0.006
per cent ; brain, 0.004 per cent; muscles, 0.002 per  cent; intestines,
after  separation of contents, but a  mere trace.
   Symptoms.—Lead  poisoning shows itself in four sets of symp-
toms  : colic, affection of the joints (arthropathy), paralysis, and dis-
ease  of the brain (encephalopathy).   Colic  is by far the most fre-
quent symptom.  It may come on  gradually or suddenly.   It occurs
in attacks of intense griping pain in the region of the  umbilicus
or anywhere about  the abdomen.  The pain is  often attended by
nausea, retching and  vomiting, sometimes by excessive  tenesmus.
The pulse is retarded sometimes to thirty in the minute—a charac-
teristic feature.  The tongue is coated, the breath offensive.  A blue
line,  from deposit of lead, is often seen  on the gums.  The abdo-
men is retracted, the  bowels constipated.   The attack lasts,  with
exacerbations and remissions, several days  to a week, and termi-
nates gradually, sometimes suddenly.  The prognosis, aside from
other symptoms of lead poisoning, is favorable.
   Arthralgia manifests itself in pains in the joints, chiefly of the
lower extremities, especially the knee; and cramps of the muscles,
especially the flexors of the leg, which sometimes  also show tremor.
This  condition of tremor may be seen also in  other muscles, even fa-
cial muscles, which are never affected with any other expression  of
the disease.
   The paralysis, on the other hand, affects principally the exten-
sors, and of the upper  rather than the lower  extremities.  Paralysis
of the extensors of the hand, wrist-drop, with preservation of the
power of pronation and supination, is characteristic  of lead poison-
ing.   The triceps and deltoid are next most frequently affected.  Sen-
sation is not disturbed, but trophic change is always present and is
manifest by wasting,  which is equalled only by that which occurs
in progressive muscular atrophy.   The paralysis may disappear rap-
idly, or remain for years or for life.
   The brain  symptoms—encephalopathies—are distinguished  by
their gravity.  They occur usually late, but may supervene early in
the course of lead poisoning.   The most common form is eclampsia,
which is distinguished by the fact that it is never preceded by  an
aura  and is rarely attended  with complete loss of consciousness. 
78n
ALCOHOLISM.
The  patient may pass from one attack to another in  the course of
several days, and any attack may prove fatal.  Amaurosis, wholly
of brain origin, with perfectly normal conditions about the eye. is not
uncommon.   Attacks of mania, melancholia, and various psychoses
vary the scene.
   The  treatment of  acute poisoning consists in washing out the
stomach with the stomach tube or stomach pump, in the administra-
tion of the alkaline sulphates of sodium, potassium, and magnesium.
The patient  should be purged with Epsom salts.  In the absence of
antidotes, milk and  albumen (white of egg) should  be  administered
freely.
   Prophylaxis of chronic poisoning is best observed by cleanliness.
Painters should  not  put paint brushes  in  their mouths, and  all
workers  in  lead should practise  ablution before  eating.   Work-
ing rooms should be better ventilated, etc.
   The treatment of  chronic lead  poisoning consists also in the fre-
quent use of  the stomach tube.  Dilute sulphuric  acid should be
taken with  the  drink.  Iodide of potassium is administered inter-
nally with the view of making soluble  compounds which may be
eliminated by the kidneys.   Sulphur baths are recommended.  Sem-
mola reports some remarkable results with the electrolytic action of
the constant current.  The positive pole is put on  the tongue, the
negative at  the  pit of the stomach ; later the poles are changed to
the spine and abdomen, sessions daily, ten to fifteen minutes' dura-
tion, strong currents, one hundred to one hundred  and thirty milli-
amperes.  Obstinate, even grave, symptoms disappear entirely in
time.  Removal of the cause, change of work, is. unfortunately,
often a necessity.

                          ALCOHOLISM.
   Alcohol  (Arabic, kahala) may be disposed of as food in quanti-
ties of one pint of beer, or one-half pint of Rhine wine, or four ounces
of sherry wine, or two ounces of whiskey per day.  Beer contains four
per cent, Rhine wine eight per cent, sherry twenty per  cent, whiskey
forty per cent of alcohol.  Quantities above this amount constitute
excess which does damage to tissue and leaves lesions.
   Alcohol  whips up the heart, feeds the  brain,  and  thus forces
energy in states of exhaustion, but at the final expense of  the ma-
chine, which should recuperate through  rest.  " The  worker in the
use of alcohol consumes his capital instead of his interest, with the
inevitable result of bankruptcy in time" (Sippe).
   Drinkers have less working capacity, less endurance, and shorter
life  than the temperate or totally abstinent.   Thus  the  mortality
statisties of a leading  insurance company of London—which made 
ALCOHOLISM.
789
two classes, one of the totally abstinent and the other of all others—
showed for the abstinent seventy-one per cent and for the rest ninety-
seven per cent, a difference of twenty-six per cent in favor of the
abstinent.
   Billings makes this fact very plain by the following table, show-
ing the mortality of dealers in liquor (twenty-five to sixty years of
age) from various diseases, compared with that of men generally of
the same ages :
Alcoholism.................
Liver disease.................
Gout......................
Diseases of the nervous system
Suicide.....................
Diseases of the urinary system
Diseases of the circulatory system
Other diseases.................,
All causes
   Alcoholism as a disease  occurs in two forms, acute and chronic,
   Acute Alcoholism shows itself with loss of consciousness, as a
sudden intoxication.  The face is flushed and dusky, the eyes promi-
nent and staring, the pupils dilated, the surface is cool and insensible,
the pulse  retarded  and irregular, the  respiration  stertorous.  The
breath  smells of alcohol, as does  also the vomited matter which is of-
ten found upon the clothes or in the vicinity of the patient.   The tem-
perature may.fall as low as 75°  F.   The individual thus affected is
said to  be " dead-drunk."  The patient may succumb to heart failure
and collapse in this  attack of coma,  or may recover after  a stage of
long and heavy sleep.   Coma which lasts over twelve hours is usually
fatal.   The victim of intoxication by alcohol is especially liable to
suffer and succumb to epilepsy, pneumonia, oedema  of the lungs, and
failure  of the  heart.   Under exposure in cold weather such patients
easily freeze to death.
   Chronic Alcoholism reveals itself in organic disease and in vari-
ous neuroses,  including a special form known as delirium tremens.
Catarrh of the stomach, cirrhosis of the liver, chronic nephritis, fatty
degeneration  of  the heart, atheroma of vessels, are the  common
manifestations of continued abuse  of alcohol.   The nervous system
is affected in  all  its functions, in  every direction.   Disturbance of
motion shows itself in tremor, which especially affects the extremi-
ties and tongue, and occurs as fine rhythmic oscillations.   Muscular
force is  everywhere  reduced.   The tone of  the  face  is  lost, the 
790
DELIRIUM tremens.
patient staggers in his  gait, the grasp of the  hand is enfeebled.
More pronounced are the disturbances  of  sensation,  which occur
as paraesthesise, hypersesthesise. and neuralgias, an especial  form of
which is set apart as the alcoholic neuritis.  Disturbances of special
sense are manifold.  Flashes of light, derangements  of vision, ring-
ing in the ears, etc., are common signs.  Alcoholism shows nearly
every form of psychosis.  The memory is impaired,  comprehension
enfeebled, the power of  concentration lost.   Victims of alcohol are
full of bravado, often of brutality, but fail in real courage.   Alcohol
begets suspicion.  A common delusion is a suspicion  of marital infi-
delity, an act of which the patient may claim to see before his eyes.
Outbreaks of  mania are  not  infrequent,  and are often distinguished
with difficulty from the initial stage of paralytic dementia; or mania
alternates with melancholia.  The  psychoses take  sometimes  the
form  of paranoia  with sleeplessness and delusions.   The  patient is
persecuted with visions.   Distinctive features of the delusive vision
are the number, movement, and minuteness of surrounding objects.
   Treatment.—In  acute intoxication the excess of alcohol may be
allowed to eliminate itself in  sleep.  In recent ingestion the stomach
may be washed out with the tube and mouth gag or the stomach
pump.  Stimulation of the respiratory centre by cold affusion is the
most  effective restorative.  The  extremities should be kept warm.
The alcohol habit may be arrested and  aversion for liquor  excited
for a time by the subcutaneous injection of strychnia nitrate gr. 4^,
and atropia sulphate gr. T^, twice daily for two or three weeks.   Iso-
lation in an institution for the purpose is often  a necessity.   Perma-
nent cure may be effected only by strengthening the will, wherein
" the patient must minister unto himself."

              DELIRIUM TREMENS—MANIA A POTU.

   A special form of alcoholic intoxication distinguishes itself by the
prominence of two symptoms,  delirium  and tremor,  and has hence
received  the appropriate name,  delirium tremens.   The disease is
usually prefaced for  several days by excessive nervousness and sleep-
lessness, and insomnia is a third cardinal symptom of this disease.
The victims of alcoholism are haggard and worn from loss of sleep.
Delirium tremens  occurs only in  certain individuals, not in all cases
of alcoholism.   Victims of  this affection come of neuropathic stock,
or suffer  themselves some other  form of neurosis.  According to
Westphal thirty per  cent of cases are victims of epilepsy before  the
first manifestation of delirium tremens,  and thirty per cent of  the
remainder are seized with epilepsy during  attacks.   This fact has
more to do with the development of delirium tremens than/the quan-
tity of alcohol alone.  Delirium tremens is an expression also of  ex- 
DELIRIUM TREMENS.
791
 haustion of nerve centres.  So long as food is retained and digested
 delirium tremens does not occur.   The condition develops only in the
 presence or as the result of a subacute or chronic gastric catarrh,
 which may be itself in turn the effect or expression of  the abuse  of
 alcohol.   A trauma, a surgical operation, a severe intercurrent dis-
 ease, pneumonia, may precipitate an attack.
    The delirium is peculiar, and is distinguished  especially by ex-
 pressions of fear.  Most patients do not " see snakes," as is com-
 monly believed.  Patients surrounded  by animals are plagued by
 their number rather than their  size.  Bugs,  flies,  fleas, beetles,  in
 millions and myriads, crawl about  their beds, crowd the air of their
 rooms, fill the whole space.  More frequently patients make of objects
 in  their vicinity fantastic creatures, or  look upon attendants  as
 thieves and assassins, from whom they start  and shrink with fear.
 Chronic psychoses  may develop from these states.   Mendel says
 that Lasegue reported the case of a  patient who maintained that his
 family had cut off his penis and substituted for it  an organ of lead,
 which was not properly fastened and  greatly incommoded him  in
 getting about.  Such patients often report with circumstantial evi-
 dence crimes which they have  committed or seen committed, but
 which have no foundation in fact.   Suicide or attempted suicide oc-
 curs in six per cent of cases of delirium tremens.
    The tremor shows itself especially in  the hands, arms, tongue,
 and lips.   The double or disturbed vision, which leads to so many
 ludicrous mistakes in the drunkard, is a tremor or paresis of the mus-
 cles of  the eye.  The perception of sensation is  even more com-
 pletely annulled.   The subject of delirium tremens loses all sense  of
 pain.  He lies out over-night until his extremities are frozen, and
 the victim who has fallen in his flight from  imaginary danger will
 lift himself up on broken legs or hobble about on  a cracked  pelvis,
 oblivious of pain.
    The degree of insomnia is evidenced  by the quantity of  opium
 or  other anodyne necessary to secure sleep.   Thomas Sutton, who
 named the disease, gave  one of  his patients  forty-two grammes  of
 opium in all without securing the desired effect.   The stage of deli-
 rium lasts two to ten days, and terminates with a long, heavy sleep.
    The diagnosis rests upon the peculiar delirium, tremor, and insom-
 nia.  The disease is distinguished from the delirium of typhoid fever,
 septicaemia, etc.,  by the absence of fever in pure delirium tremens.
   The prognosis is grave, though most  patients  recover from the
individual attack.  The immediate outlook is determined more by
 the condition of the stomach than by any individual factor.  Patients
able to ingest and digest food speedily recover.   The condition  of
the heart establishes the final prognosis. 
792
COCAINISM.
   The treatment consists in restoring tone to the  nervous system
with food.   Attempt to force sleep with powerful anodynes is not
good practice.  The best results  are  accomplished with the use. as
soon as possible, of the stomach tube and the administration of dilute
hydrochloric acid.  Frenzied  patients should be  subjected only to
that degree of restraint necessary to prevent injury.  The bromides
are prescribed as sedatives in routine treatment,  but always with the
risk of damage to the stomach.  Chloral  is the  most powerful hyp-
notic, and may be given with safety at night in doses of ten or fifteen
grains to young, strong, and healthy subjects, but should not be ad-
ministered in the presence of  a feeble, fatty heart.  In  these cases
the best remedy is digitalis, which may be given in the form of infu-
sion, teaspoonful to a dessertspoonful  every two to four hours, or the
tincture gtt. x. at the same interval.  Digitalis also does damage to
the stomach.  Opium is the last resort.   It is better, when possible,.
to bear with the malady for a time than to destroy or injure the  pro-
cess of digestion.  The real  cure  of delirium tremens rests with the
patient rather than the physician.  The broken will must be built up
by the individual himself.
   The craving for alcohol, dipsomania, is a desire which asserts
itself periodically and leads to excessive indulgence for a period of a
week or two, or until  a gastric catarrh thus induced or a delirium
tremens puts a stop to further drinking.  Dipsomania is itself a neu-
rosis dependent upon unstable nerve cells.  The nervous symptoms, in-
somnia, dread, tremor, which ensue in the course of such indulgence,
though they are most severe at the close of a debauch,  are caused by
the alcohol itself and not by abstinence.  Hence they are best  con-
trolled by immediate and absolute abandonment of the use of alco-
hol—a sacrifice which can only be successfully made in an institution
under  supervision and restraint.  The  collapse which  may follow
such heroic treatment is obviated  to some extent by the use of atro-
pia gr. i.- 3 i., gtt. iij.-v. every three  or  four hours, or hyoscyamine
in the same dose.  The heart and the nervous system are best  sus-
tained subsequently by strychnia  gr. ^ ter die or by the tincture of
nux vomica gtt. x.-xx. ter die.  The  aromatic tincture  of  rhubarb,
 3 i. ter die,  diluted, is a good stomachic tonic  in these cases.

               COCAINISM—POISONING BY COCAINE.
   Cocaine  poisoning may be acute  or  chronic.   Acute poisoning
occurs in consequence of excessive use, in operations about the eye
and throat, and after subcutaneous injections to  secure  anaesthesia
for more extensive procedure (circumcision, etc.) ; sometimes after
injection of stronger  solutions into the bladder,  nasal  cavity, etc.
Reclus collected fifteen deaths, mostly from overdosage, ten to fifteen 
POISONING BY OPIUM.
793
 grains.  One to one and a half grains (one-half to one grain by in-
 jection)  is  maximum dosage.  For  anaesthesia, cocaine,  perfectly
 pure, should be  injected into and not under the skin or mucous
 membrane.   The object is  to reach  the nerve endings in the skin.
 The injection should be made slowly, drop by drop.  Acute cocainism
 is marked by collapse,  with pallor  of the face, vertigo, nausea,
precordial  anxiety, cyanosis, and syncope.  Poisoning in  less de-
 gree is attended with delirium marked by hilarity,  volubility,
 sometimes by hallucinations and mania.   Convulsions may occur
 in the course of  the intoxication.   Anomalous cases are marked by
 cardialgia. palpitation, insomnia, amblyopia.
   Chronic Cocainism produces cachexia ivith nervous debility,
 neurasthenia marked by anorexia, marasmus, insomnia.  Patients
 complain of dryness of the  throat, palpitation of the heart, and.
 suffer attacks of dyspnea and difficulty of articulation.  Chronic
 cocainism develops a peculiar paranoia, marked by hallucinations of
 sight and hearing, ideas  of persecution, and attacks of  melancholia.
   Tests.—Cocaine may be  recovered from the urine.  The addition
 of potassium permanganate produces  a violet-red precipitate, which
 soon becomes brown. A solution of cocaine  brought into  contact
 with white filtering paper saturated in a solution of the ferrocyanide
 of potash and chloride of iron develops a. blue spot in two minutes.
   Treatment.—Acute poisoning is treated by cold  douches, with
 artificial respiration  and massage.  Convulsions  are  controlled by
 chloroform or amyl nitrite.  Injections of ether or caffeine sustain the
 heart until the patient can swallow, when he may be fed with black
 coffee.  Morphia, gr. \ subcutaneously, is also antagonistic to cocaine.
   Victims of chronic cocainism must be treated as in  opiophagism.
 Real results are to be obtained as a rule only in an asylum, where the
 weak will of the patient is substituted by the strong will of authority.

                      POISONING  BY OPIUM.
   Poisoning by opium {0716?, juice) is acute and chronic.  The sus-
 ceptibility to opium differs, and the dose which may be injurious or
 fatal  varies  according to age  and still more according to habit.
 Children are particularly sensitive.  A single drop of laudanum has
produced dangerous  narcosis,  and two drops  have proven  fatal
through coma and  convulsions.  Three-fourths of all  the deaths
from opium occur in childhood under the age of five years.   On the
other hand,  opium eaters may secure such tolerance as  to be  able to
dispose of a drachm of morphia in a day.  In these cases the mass of
the morphia is unabsorbed.   Most cases of opium poisoning in adult
life occur among opiophagists who recommence the use of the drug,
after cessation or reduction, with too large a  dose. 
794
POISONING BY OPIUM.
   Acute  poisoning shows itself in sensations of warmth, stimula-
tion of the intellectual faculties ; later, sense of oppression,  drowsi-
ness, uncontrollable desire to sleep, and heavy slumber.  Sometimes
there is, instead of sleep, intoxication with headache, vertigo, tremor
of the hands, twitchings, and convulsions.  Itching of the nose and
of the face, and of the whole body {pruritus opii), is a common and
characteristic effect of opium.  Erythema may develop.  The patient
recovers with a sense of  languor, headache, anorexia, nausea, and
constipation.   In opium narcosis the pupils are contracted,  often to
the size of a  pin's head, and are irresponsive ; the eyes are fixed,
the pulse is irregular,  the patient is unable to swallow, respiration is
paralyzed, and death occurs with stertor and coma.
   Chronic poisoning is frequent.  The subjects of chronic poisoning
are the victims  of the opium habit,  which is, in places, as in the
East, a national  vice.   Chronic poisoning shows itself as a cachexia
with degradation of the intellectual and moral faculties, with impo-
tence in  men and sterility in  women.  The continued use of opium
begets a  condition of unrest, ill-defined anxiety, insomnia, with
gradual alienation, stupefaction, of the individual;  tremor develops,
with pallor, parsesthesia, sometimes with albuminuria.   Anorexia is
pronounced.   Chills occur, with sweats.   Constipation remains ob-
stinate, or is substituted in certain cases by diarrhoea and vomiting.
Conditions of  collapse sometimes supervene.   Many of these symp-
toms are intensified on withdrawal of the drug, and then constitute
what are known as "abstinence signs."  There is in this state unap-
peasable  craving for  morphia, which may eventuate in  maniacal
attacks.   In the experience of the author a patient at the hospital
wore out  two attendants,  who finally fell asleep.   The patient, a
young lady, arose from bed, made a rope of the bedclothes, let her-
self down from a second-story window to the ground one cold Decem-
ber night, and was found by a policeman standing at the door and
trying to effect an entrance into a drug store.   No less than nineteen
hypodermatic syringes were removed from  pockets, lining, seams of
the suit of clothes worn by another patient, a man, a confirmed vic-
tim of morphinism.
   Treatment.—The question is, shall the drug be withdrawn  sud-
denly or  gradually?  And  the answer may be determined by the
effects which supervene upon sudden  withdrawal.   Where  the pa-
tient is able to endure the suffering and survive the prostration, ab-
solute withdrawal is  best.  The amount of suffering is less in the
long run.   Otherwise  the drug may be withdrawn gradually.  The
patient must  be isolated  and guarded.   No victim of  morphinism
may be treated  successfully at home or at any ordinary hospital.
The patient must be  put where he absolutely cannot obtain opium. 
POISONING BY NICOTINE.
795
 The attempt to substitute morphia by other anodynes or hypnotics
 gives no real or permanent relief.  Temporary relief may be secured
 by cannabis indica, hyoscyamus, atropia, cocaine, the bromides, etc.
 Strychnia nitrate, especially when injected subcutaneously, gr. T1T7-
 yV? in combination with sulphate of atropia gr. -j^, best supports the
 nervous system.   Caffeine, strong coffee, support the heart.  Irriga-
 tion of the stomach,  warm baths and trional, with time, good feed-
 ing, and, as far as it may be secured, good cheer, carry the patient
 through.

                     POISONING BY NICOTINE.
    Nicotine, an active principle of tobacco, is one of the most  dan-
 gerous of all the alkaloids, ranking next in virulence to hydrocyanic
 acid.  The quantity of nicotine varies in different kinds of  tobacco.
 Common tobacco contains seven to eight per cent, finer Havana less
 than two per cent.   Animals vary also in resistance  to nicotine, in
 descending scale, according to  Berutti  and Vella:  centipedes,  flies,
 butterflies,  spiders, fish,  frogs,  dogs, rabbits,  and cats.  A dog is
 killed by one and a half to two drops, a rabbit by one-fourth of a drop,
 small birds by a touch on the  beak with  a  rod dipped in nicotine.
 Dangerous symptoms of  intoxication  have been observed in man at
 the dose of 0.003 gramme.  Tobacco contains also other substances—
 volatile  oils, pyridin, prussic acid, carbonic  oxide,  marsh gas, etc.
 —in varying quantities, usually  too minute to  produce much effect.
 Stronger tobacco can be smoked  from a cigar than from a pipe, as the
 volatile  and benumbing  pyridin is totally consumed in the cigar,
 and only imperfectly consumed in the bowl of a pipe.
   Symptoms.—Mammals poisoned with nicotine show unrest and ex-
 citement, tremor, discharges from the bowels and  bladder, stupor,
 clonic and tonic convulsions.  These symptoms have been observed
 after smoking, after the use of the infusion of tobacco in therapy, in
 poultices and clysters.
    Small doses of nicotine excite the vagus and thus reduce the fre-
 quency of the heart.   The blood pressure falls, with paralysis of the
 peripheric vessels.  The temperature is reduced.  In small quanti-
 ties, nicotine, by its effect on the nerve centres, allays nervousness,
 quiets discontent, subdues ambition, reconciles to idleness.  The per-
 centage of college students who use tobacco is, as a rule, less  than
 that of those who abstain.  In  seneitive subjects,  or in excess, to-
 bacco produces anorexia, nausea, catarrh of the stomach, catarrh of
 the throat,  palpitation, neuralgia of  the heart, angina (pseudo) pec-
toris, delirium cordis, tremor, nervous excitement, hypochondriasis,
 amblyopia—conditions which all disappear, to leave no lesion, on ces-
 sation of use. 
796
POISONING BY GASES.
                     POISONING BY GASES.

   Gases, as they affect the animal body, are divided into the indif-
ferent, irrespirable, and poisonous.
   The indifferent are the gases which have in themselves no injurious
effect,  but may  become injurious by accumulation, simply because
they diminish or dispel the natural air.   To this category belong ni-
trogen, hydrogen, and carburetted hydrogen (marsh gas).  Nitrogen
may occur in mines to diminish the proportion of oxygen (which
should be twenty-one) to fifteen per cent.   Such a diminution may
lead to emphysema ; still greater reductions may produce  asphyxia.
   The irrespirable are the gases which, in slight quantities, produce
certain injurious but not dangerous effects.  Among these may be
cited sulphurous acid, nitric acid, muriatic acid vapors, and the va-
pors of ammonia, chlorine, bromine, and iodine.   These  gases  are
present or accumulate in certain trades.  Sulphurous-acid gases are
developed in the bleaching of straw, manufacture of hats and bon-
nets, the bleaching of silk, woollen, and cotton goods, the manufacture
of brushes,  and in  coal, sulphur, and silver works, as well as in the
manufacture of sulphur acids themselves.   They occur also in  the
distillation of coal.   The accumulation may be but slight,  one, two,
or three per cent, according to the degree of ventilation;  or it may
increase, as in the manufacture of sulphur acids, to seven per cent.
Sulphurous-acid gases are absorbed into the blood and act directly
upon the nerve  centres.  The vaso-motor centre is at  first excited,
later paralyzed ; the respiratory  centre is affected in the same way.
The inhalation of the sulphur acids in slight quantities produces irri-
tation of the throat, cough,  angina, and  bronchitis.  The  strong
concentrations induce spasm of the glottis and, with a reduction of
oxygen,  asphyxia.
   The nitrates occur in the fabrication of nitric acid,  nitro-ben-
zine,  and  in certain copper, soda, and gold works.   The  vapors
are  usually present in  but very small  quantity; local effects are,
however, distinct.   There is irritation  and  burning  in  the nose,
constriction with a sense of suffocation  in  the  throat, cough, dysp-
noea, and general  symptoms of distress  on the part of the digestive
system and respiratory organs.  Muriatic-acid vapors occur in the
fabrication  of soda, the vulcanization of caoutchouc, in the glazing
of pottery,  manufacture of  glass, production of artificial manure,
always only in minute quantities.  Hydrofluoric-acid vapors, which
are  developed in the engraving of glass, crystal, etc.. produce irrita-
tion of the  eyelids and eyes, intense coryza, and spastic bronchitis.
Ammonia vapors are inhaled in the manufacture of ammonia, in the
 preparation of  mercury, in tanning, sewer cleaning, tobacco, sugar, 
POISONING BY GASES.
797
and artificial-ice factories.   In certain concentration ammonia pro-
duces constriction  of the chest, which may increase to suffocation,
increase of the blood pressure, with ischuria.   In such saturation the
odor of ammonia,  excreted by the sweat, emanates from the body.
Chlorine is developed in the manufacture of chlorine, nitric acid,
chloride of lime and  the alkalies, artificial soda, and in  the various
bleaching trades.  The first effect of inhalation of chlorine is  irrita-
tion of the mucous membrane of the respiratory organs.   The second,
reflex  actions, especially spasm of the glottis.  Epiphora, sneezing,
cough, pains  in the chest,  dyspnoea, occur at once in acute cases.
Chronic cases are characterized by blood spitting, spasm of the glot-
tis, and pneumonia of rapid course.  Workers with chlorine undergo
emaciation, show a bad color, and suffer from catarrh of the stomach
and chronic bronchitis.  Bromine and iodine exercise similar effects.
   The poisonous  gases are especially carbonic oxide (monoxide),
carbonic acid  (dioxide),  and sulphuretted hydrogen.  Ordinary
illuminating gas contains a large number of poisonous gases, along
with  carbonic acid and oxide, among which may be cited ammonia,
cyanogen, bisulphide of carbon, and sulphuretted hydrogen.  Car-
bonic oxide is a  colorless, odorless, and tasteless gas, which burns
with a blue flame.  It is exquisitely poisonous to the  animal organ-
ism.  Absorbed into the blood it displaces oxygen from the haemo-
globin, and forms new combinations with the coloring matter of the
blood, whereby the  corpuscles  are rendered incapable  of  further
absorbing oxygen.  This combination imparts the peculiar cherry-red
color to arterial as well as venous blood.  The gas  does not separate
from its combination in vacuo, but may be displaced by other gases
or by the air pump.
   Carbonic  oxide is developed also in iron smelting and in the
manufacture of coke, in which process coal is subjected in ovens to
dry distillation.  Carbonic-oxide gas occurs also in the usual heating
of houses, and may thus induce poisoning.   The imperfect combus-
tion of coal  develops carbonic oxide.  This imperfect combustion
occurs especially in arrangements for heating which do not admit of
sufficient ventilation.   Biefel  and Poleck give the following as the
average composition of numerous analyses of coal smoke: carbonic
acid,  6.75 per cent; carbonic oxide,  1.34  per cent; oxygen, 13.19 per
cent; nitrogen, 79.72 per cent.
   Carbonic oxide does not usually  accumulate in the air of a room,
because it escapes with the products of combustion; but it accumu-
lates in the room when the escape of gases through the chimney is
hindered  by the closure of the draught valves in the stove or furnace,
or when  the  chimney is  stopped by soot.   Any  hindrance to the
entrance of air leads to the accumulation of carbonic oxide.  The 
798
POISONING BY GASES.
quantity of  carbonic oxide necessary to make the air injurious is
variously given by different authors.   Fodor maintains that a pro-
portion of 0.5 per thousand continuously inhaled is decidedly delete-
rious.  Biefel and Poleck found a percentage of 0.19 fatal to rabbits.
   In poisoning  by carbonic oxide there is  dulness and drowsiness ;
the face is at first flushed, later pallid, and still later livid and
cyanotic.  The  stupor of the nervous  system may be so great as to
reduce to the minimum the difficulty of breathing.  Sometimes there
is  dyspnea with the convulsions of asphyxia.  Suffocation may set
in under stupor without much dyspnoea, and convulsions may occur
only at the close.  The  pulse  is at first full and rapid ; later, in the
state of coma, scarcely perceptible.  The temperature sinks two or
three degrees.   The urine may contain sugar and albumin.  There
is  at times  local, and at  times general, anaesthesia of the surface.
Paralysis of the bladder and intestine may occur.
   Carbonic-acid poisoning occurs not infrequently in certain trades.
The exhalation of carbonic acid from the body is in proportion to the
quantity of  gas in the air.  When this proportion reaches a certain
amount, the gas is not given off, but accumulates in the  organism,
produces dyspnoea, and finally paralysis of the sense of respiration.
Carbonic-acid gas is thus a narcotic, and belongs to those poisonous
gases to which the body becomes gradually accustomed.  Carbonic-
acid-gas poisoning in open air  occurs in places where the gas issues
from the earth in large amount, as in the Grotto of Puzzuoli, where it
is, from its weight, fatal to dogs;  at Pyrmont, in the poisonous valleys
of Java, and certain  places in the neighborhood of volcanoes; also in
mines, as well as  wine and beer  cellars, and apartments crowded
with people, etc.
   The treatment of poisoning by gases is the admission of fresh
air, the use of artificial  respiration, the administration of oxygen,
and, in the case  of the poisonous gases, the practice of transfusion.
   The operation of  transfusion of blood itself  is now done directly
from vein to vein with the apparatus of Aveling, a procedure which
requires some skill; or by the use of three different syringes, that one
may be kept always cleaned, i.e., sterilized and warmed,  ready for
use,  according to the method of Ziemssen, a perfectly safe procedure
in clean, i. e., aseptic, hands. Landois made use of the fact that blood
does not clot in the body of leeches in preparing a decoction of leech
heads with 0.6 per  cent of common salt, and Wright made use of the
fact that blood does not clot in the presence of certain  salts to receive
it as it flows in a solution of sodium oxalate to keep it thin.   By these
methods the troublesome  operation of  defibrination is avoided   In
no case may heterogeneous blood—i.e., blood from a different ani-
mal—be used in the body of man. 
NOTES.
    Sycosis (p. 14).  For every-day use :
    R Acidi tannici...............................................  2.0
      Sulphur prsecipitatis..........................................  4,0
      Zinci oxidi,
      Amy]i......................................................aa  7.0
      Vaselini....................................................20.0
    M.  S. Apply daily.
 To destroy the parasite :
    R  Sublimati...................................................  10
      Spiritus vini gallici.......................................... 99#0
    M.  S. Dab the surface with cotton morning and evening, after epilation.
    Bacteria, selective action of (p. 64) ; used as destructive agents.
 Loffler  exterminated the field mice, which multiplied to constitute
 a plague in Thessaly, by feeding them with the Bacillus typhi mu-
 rium, a micro-organism innocent to all other animals.

    Hydrophobia, treatment of  (p. 103).   Blasi  and Travati find
 that lemon juice most quickly neutralizes the poison of hydrophobia.
 Thus lemon juice destroys it within three minutes, creolin in one-per-
 cent  solution  in  three minutes,  etc.  Carbolic acid is one  of  the
 feeblest agents, as a ^five-per-cent solution requires  fifty minutes, a
 three-per-cent  solution one hour.

    Influenza.   Salipyrin (p. 122) is not a real specific, and there is
 no  specific.   Salipyrin acts only as an antineuralgic and antifebrile—
 i.e.,  as a  symptomatic remedy [(Furbringer).  Children are very
 rarely affected, and always later than adults (Baginsky).

    Tuberculosis (p.  147).  The hectic fever is not caused by the
tubercle bacillus, but by the streptococcus.   Koch calls the see-saw
hectic temperature record the " streptococcus curve."

    Agaricin  in  night sweats  of tuberculosis  (p. 156).  Agaricin
acts slowly, not before five  hours, but as long as for twenty-four
hours.   It should be given, therefore, early, at 5 p.m., in a pill or in
syrup. 
SOO
NOTES.
   Syphilis (p. 174).  Pigmented syphilides.
   IJ Corrosive sublimate,
     Salol................................................."A   1 P^-
     Alcohol .................................................. 10° Parts-
     Bergamot (or geranium) oil.....................enough to perfume.
Rub the spots with this solution daily, and let them dry without
wiping.  When they have become a little attenuated bathe them
lightly with the following lotion :
   R Glycerin,
     Rose water............................................«» 25 parts.
                                                       2   "
     Borax...................................................
     Corrosive sublimate solution 1 :1000........................ 10
Later on apply the following dusting powder :
   R Talc, powdered,
     Zinc oxide,
     Camphor, powdered,
     Salol.      ....................................... ^ eclual part8-
   Itching.—A fine preparation for relief of itching after  measles,
scarlet fever (p. 216), etc., is that of Klein:

    R Lanolini purissimi (Liebreich) anhydrici.......................  50.0
      Vaseliui puri................................................  20.0
      Aquas destillatae.............................................  25.0
    Misce terendo; fiat unguentum.  S. Apply every three hours.

The evaporation of the water cools  the surface and thus lessens the
hyperaemia of the cutis.

   Ear Furunculosis after scarlet  fever,  etc. (p. 217).   Cholewa
finds by far the best remedy is menthol, a ten-per-cent  solution in
oil.  Apply with cotton, which  is inserted and  allowed  to remain.
The pain is relieved  on the day of application, as the  vapor of men-
thol kills the micro-organisms.  Continue the treatment  for eight
days to prevent recurrence.
   Diphtheria.   A streptococcus  (p.  247), whose  virulence  was
tested in every way,  was found by Landmann in the well-water which
supplied five families in the suburbs of Frankfort.   Three of five
cases in these families died of diphtheria  which developed from a
streptococcus angina evidently introduced by the drinking-water.

   Diphtheria, Blood Serum Therapy  (p. -252).   Behring claims
to secure both immunity and cure of pure  diphtheria by inoculation
with the blood serum of animals—dogs and sheep—rendered immune
to diphtheria.  The animals are rendered immune by injection of
diphtheritic matter of gradually increasing virulence.   The serum is 
NOTES.
sOl
 prepared and preserved with 0.6 per cent carbolic acid ready for use.
 It is perfectly innocuous in the dose of 1 gramme per day for every
 kilogramme of body weight.  Experiments upon animals yield  per-
 fect results.   Diphtheria in man is, however, not a pure process.  It
 is usually complicated with sepsis—i.e., streptococcus infection, upon
 which the blood serum has no effect.   ^Nevertheless in all the cases
 thus  far reported the  mortality has been reduced from  sixty to
 twenty per cent.
    Typhoid Fever, perforation of intestine  (p. 284).  Of  12 cases
 thus far  operated upon but 1 recovered (Freyhaus).

    Gastro-intestinal Catarrh of Infants  (p. 364).  Of 1,000
 cases of death from summer diarrhoea Hope found but 30 that  had
 been fed exclusively at the breast, and Meinert found but 24 of  602.
 Meinert  and  Seibert showed that diarrhoea begins at 60° F., and be-
 comes epidemic when the mean daily temperature does not fall below
 this degree.
    Alimentation  per Rectum (p.  395). Maragliano  reported  a
 case where a patient was fed exclusively by the rectum for ninety-
four days  and ultimately recovered.  At the end of  that time she
 was found to have lost only 2.7 kilogrammes  (6 pounds avoirdupois)
 in weight.  The nutrient  enemata employed in  this case were pre-
 pared as follows : 300 grammes (10 ounces) of beef and 150 grammes
 (5 ounces) of pancreas  were pounded together in a mortar and the
 juice strained.  To this were added 5 grammes (75 grains) of sodium
 carbonate,  25 grammes  (6 fluidrachms) of fresh ox  bile, and water a
 sufficiency.   The enema was  administered in four portions in the
 course of the day, with a  sufficient quantity of warm water.  This
 formula  differs from that recommended  by Leube only in the addi-
 tion of ox bile—a modification  introduced by Sciolla for the purpose
 of stimulating absorption of the enema by the large intestine and of
 preventing putrefactive decomposition.
    Stomach Tube.  In the introduction of the stomach tube (p. 369)
always push it in the throat to the  left to follow the entrance  of the
oesophagus.
    Stomach.   Hyperacidity of  the gastric juice (p.  375) is  shown
whenever it requires more than 0.65  liquor potassse to neutralize 10
cubic centimetres of gastric juice.
   Occlusion of Intestine  (p. 433).   Spontaneous cure, accord-
ing to the latest reports, is more frequent than is commonly believed.
Thus Goldtdammer saw 15 recoveries in 50 cases treated wholly on
the expectant plan.
        51 
802                          NOTES.

   Biliousness (p. 475).   The liver protects the body against auto-
intoxication.   This antitoxic is one of the chief functions of the liver.
Poisons are introduced into the intestine with the foods (alkaloids,
potash salts, alcohol, etc)., or as products of the action of micro-or-
ganisms, ptomaines, toxines, toxalbumins.   Material is brought also
by the blood for the formation of bile, urea,  etc.   The liver in health
disinfects and purifies all these matters.   Slight interference with this
action of the liver produces the discomfort and distress of "bilious-
ness "; abolition  of  action produces the ominous  signs of icterus
gravis.
   Pleurisy (p.  543).  Serum free of bacteria is usually the result
of tuberculosis.  The effused serum may contain so  few bacilli that
a syringeful may  fail to  inoculate a healthy guinea-pig, but may
produce  in a  tuberculous guinea-pig the characteristic reaction  of
tuberculin.

   Myxcedema (p. 589).  Different  views have recently tended  to
unite  in the  belief  that  the three processes—strumous cachexia,
myxcedema, and cretinism—have the same original cause.  All cases
seem to be due to the absence of the thyroid  gland.   In the examina-
tions of 13 cretins at the Salkammergut, 10 were found in whom
more or less large tubercles of the thyroid were seen, and 3 in whom
no trace of a thyroid gland was found in the neck.
   Arterio-capillary Sclerosis (p. 590).  Alanus advances the
view that this condition is due to a too exclusive vegetable diet.  He
observed it in himself—a young man, not yet forty years of age, and
not  addicted to alcohol—in the temporal and radial  arteries.  Ray-
mond saw it in a  number  of young monks,  vegetarians, and  Treille
remarked it  of the inhabitants of Bombay and Calcutta, who live
largely on rice.  According to Gabler the mineral salts in the vege-
tables come  to  be deposited  in the walls  of the blood  vessels.
■'Vegetable  food injures  the blood vessels  and precipitates the
changes  of age."

   Larynx Tuberculosis (p. 489).  Siemen strongly recommends
the inhalation of iodoform according to a formula which masks the
evils (odor) but preserves the curative effects.   Thus :
   R Iodoformi.........................    .............    # „r xv
     Olei eucalypti  ...........................                ? vj
     Olei caryophilli ...........................................3 i>; gtt> xv
     Alcohol absoluti....................................       „^' ^
   M.  Pour ten to fifteen drops upon oil of turpentine and inhale three or four
times a day.

   Gonorrhcea  (p.  179).  The view that gonorrhoea is only a local 
NOTES.
803
process is much modified by the actual discovery by Leyden of the
gonococcus upon the valves as the cause of a verrucose endocarditis.
    Abbott recommends for  the purpose of obtaining a good double
staining of gonococci the following method : A drop of suspected
pus is smeared upon the surface of a cover glass, and after drying
is treated with a strong (twenty-per-cent) solution of tannic acid.  It
is then washed in alcohol, and after drying stained with Ziehfs solu-
tion of fuchsin.  It is next decolorized in acid alcohol (acetic acid 1,
alcohol 100 ; or hydrochloric acid 1, alcohol 500), and after drying
restained with methylene green, washed in water, dried, and mounted
in  balsam.   The  protoplasm of  the cells appears of a  light-green
color, the nuclei purple, and the diplococci a dark red.

    Bubo.   Wielander's abortive treatment : Inject into the bubo
fifteen drops of a one-per-cent solution of the benzoate of mercury in
two places.  As many as  seventy-three per cent of cases undergo
resolution   under  this treatment,  including  indolent  buboes six
months old, previously treated in  vain by incision and every other
way.  In some cases suppuration ceased even after it had begun.

    Chlorosis,  anaemia,  etc. (p.  603).   Iron in the form of haemo-
globin is ingested with the common, so-called blood sausage.
    Pernicious Anemia  (p.  604).  The view  gains  ground that
many  cases are due to helminthiasis—especially to the  fish tape-
worm.  Wiltschur reports the actual finding of tapeworms in 5 of 30
cases.

    Hydrops  (p. 653).  Puncture in relief of, should be done only in
the legs, never in the scrotum, with the aseptic precautions mentioned.
The leg should then be  enveloped in thick layers of  absorbent
cotton.   A  piece  of  three-per-cent carbolized,  or one-half-per-cent
sublimated, i.e.,  sterilized,  gauze  should  be  applied  over each
puncture.
   Hematuria (p.  066).   To determine  if blood comes from  the
kidney or bladder, Ultzmann washes out the bladder and injects into
it  a solution  of potassium iodide (1.5 per cent).  The saliva is now
tested  for iodine,  which, if  found, indicates a break in the bladder,
as the sound bladder  does not absorb it.

   Cystitis (p. 672).  Marsh highly recommends oxalic acid as a
sedative, which, he says, relieves the worst symptoms at once :
   R Acidi oxalici ...........................  .................    °-95
     Syrupi aurantii  corticis .....................................   80.0
     Aquae destillatae..........................................120.0
  M.  S. Coffeespoonful every four hours. 
804
NOTES.
   The  Cancer  Parasite (p.  67).  "The  cancer parasite  must
stand very near to the sporozoa.  It certainly does not belong to the
coccidia, nor to the sarco-, micro- or myxo-sporidia.  Most likely it
will be found among that variety of the sporozoa which Aime Schnei-
der long ago distinguished as the amoeba-sporidia" (LudwigPfeiffer,
Centralblatt fiir Bakteriologie, etc., August 1st, 1893).

   Creosote  in Tuberculosis (p. 154).  The virtue of creosote
depends chiefly upon the fact that it inhibits the growth of the micro-
organisms of  secondary  infection  without injuring the stomach.
Thus, while a saturated aqueous solution, it does not destroy  the
tubercle  bacillus in cultures in twelve hours (Sternberg) ; and while
rabbits inoculated with tuberculosis and  treated with creosote sub-
cutaneously presented the same  lesions as control animals not so
treated (Trudeau) ; further, that  in the proportion of 1  :100 it  fails,
after twenty hours' exposure, to destroy tubercle bacilli in the spu-
tum (Cornet), nevertheless  it is  fatal to  ordinary micro-organisms
in the proportion of  1 :500 or 1:1000  (Wernicke, Buchholtz), with-
out in the least interfering  with  the digestive action of the gastric
juice.  For, according to Brunton, while 1 part of chlorine in  8,540
parts of a saturated solution will arrest the digestive action of ptya-
lin upon starch paste, and corrosive sublimate  is so  enormously
destructive as to arrest its  action even in 1 part to 51,000, creosote
has no action on ptyalin, even in saturated solution, and has but a
very feeble action upon pepsin.   Creosote should  therefore be given
internally, after meals, and  not subcutaneously.

   Pertussis  Death Rate (p. 114). The following diagram, accu-
rately drawn to a scale by  the American Practitioner, shows  the
relative number of the deaths mentioned in the State of Kentucky
for the first year of this decade :

                  DEATHS  IN KENTUCKY, 1891.
                  -^^——^—»^———— Consumption.
                  ^—^ Typhoid Fever.
           ———- Diphtheria.
           —^— Cholera Infantum.
            —™ Measles.
           — Scarlet Fever.
           - Whooping Cough.

This record may be taken as a fair average, in the absence  of  any
prevailing epidemic, for other States and other years.

   Neuralgia  of the  Trigeminus (p.  686).  Seguin  strongly re-
commends acomtm in pill, each containing 0.0003 gramme, two  daily 
NOTES.
805
for women, three for men.  The number may be increased to twelve
daily, or up  to tolerance as evidenced by a feeling of coldness  and
numbness  in the whole  body.   Cumulative effects  do not occur.
From a rich experience the author declares that  but very few cases
are not benefited and many are cured—that is,  secure exemption for
one to three years.  In a dose of two pills per  day aconitin reduces
the pulse rate and arterial tension in  Basedow's disease.

    Migraine (p. 687).  After failure with every other means Weiss
found that pressure upon the abdominal aorta at  a point where  pul-
sation  may be felt, midway between the xiphoid cartilage  and the
umbilicus,  immediately arrested the most violent headache and hy-
peraesthesia in 23 cases.  Unfortunately the distress returns after
relief of the pressure, but all patients are grateful for the temporary
relief.

    Solutol—cresol made soluble in water by the addition of  an al-
kali—has the highest commendation as a disinfectant (p. 79).  One-
fourth of a pint  added to ten or fifteen pints of water (a watering-
canful) makes  the most penetrating, strongest, and quickest-acting
disinfectant for walls, floors, etc., which may be sprinkled  from the
can.

    Nocturnal  Incontinence of  Urine  (p.  673).  Gowers re-
commends  as the best remedy the perchloride of iron in  large doses,
gtt. xx.-xxx. three times a day.

   Singultus,  nervous or hysterical  (p.  762).  Stella controls it
with pilocarpine 0.10 in 10.0 water, of which ten drops three or four
times a day.  It is not to be used  in the acute  hiccough which is
such an ominous sign in many grave infections.

   Sulphonal in habitual use may produce a cherry-colored urine
(hsemato-porphyrin) as a warning sign of saturation. 
 
INDEX.
Abscess, actinomycotic, 20
    brain, 753
    liver, 455
    lungs, 535, 536
    peripleuritic, 552
    retropharyngeal, 231,  256
    subphrenic, 553
Acarus scabiei, 4
    folliculorum, 8
Acetone, test for, in diabetes, 68
Achorion Schonleinii, 9
Acne mentagra, 14
Aconitin in neuralgia of the trigeminus,
  804
Acromegaly, 729
Actinomycosis, 18, 19
Acute ascending paralysis, 727
    atrophy of the liver, 473
    bulbar paralysis, 726
    rheumatism, 314
Addison's disease, 616
Adenoid tissue, 479
    in pharynx, 358
Adrenals, disease of, 616
.Egophony,  546
Aerobes, 60
Agaricin in night sweats of phthisis, 799
Age and arteries, 737
    in diagnosis of stomach disease, 390
Agraphia, 756
Ague, 284
Air in blood, 599
    in pleural  sac, 550
Albumin in blood, 598
Albuminuria, 639, 655
Alcohol in the liver, 464
    in typhoid fever, 283
Alcoholic liver, 462
    neuritis, 690
Alcoholism,  788
    and apoplexy, diagnosis, 741
Alexia,  756
Alimentation by the rectum, 801
Alkalies in jaundice, 445
Altitude and malaria, 286
Amenorrhoea and tuberculosis, 144
Amnesia, 756
Amoebae coli, 400
Amyl nitrite in angina pectoris, 586
Amyloid degeneration, 657
Amyloid liver, 476
Amyotrophic lateral sclerosis, 719
Anaemia, 601
    blood-sausage iron in, 803
    pernicious, 603, 803
    splenic, 610
Anaerobes, 60
Anarthria, 765
Anchylostoma duodenale, 44, 412
Aneurism and tuberculosis,  143
    filled by clot, 595
    of abdominal aorta, 593
    of aorta, 592, 594
    of brain, 751
    of femoral artery, 593
    of hypogastric artery, 533
Aneurisms, miliary, in apoplexy, 737
Angina, 356
    Ludovici, 361
    pectoris, 585
Anhydraemia, 597
Aniline dyes, 60
Anthracosis pulmonum, 540
Anthrax, 81
    cedema, 84
Antitoxines, 21, 65
    of pneumonia, 137
    of tetanus, 111
Aorta, aneurism of, 592, 594
Aortic insufficiency, 573
    diagram of, 572
    tracing of, 574
Aortic obstruction, 575
    diagram of. 572
    tracing of, 575
Aphasia, 656
Aphonia, 149, 759
Aphtha, 87, 352
    Bednar's, 353
Apomorphia in measles, 148
Apoplexy, 736
Apparatus for relief of writer's cramp,
  780
Appendicitis, 417
Appendix vermiformis, 418
Argyll-Robertson sign in tabes, 714
Arsenic in chorea, 769
    in malaria, 295
Arteries and age, 737
Arterio-sclerosis, 590, 802 
8o8
INDEX.
Arthritis deformans, 623
    deformans and gout, diagnosis, 622
    pauperum, 623
Arthrospores, 59
Artificial respiration, modes of, 532
Ascaris lumbricoides, 38
Ascending paralysis, acute,  747
Asiatic cholera, 335
Aspermatism, 676
Asphyxia by drowning, 529
Aspiration in pleurisy, 546
Asthma, 505
    and tuberculosis, 143
    crystals, 510
    spirals, 510
Atactic paraplegia, 719
Ataxia, Friedreich's, 716
    hereditary, 716
    locomotor, 711
Atelectasis pulmonum, 528
Atrophy, facial, 733
    hereditary, 733
    of liver, 470, 473
    progressive muscular, 719
Atropia in epilepsy, 749
Aura, epileptic, 744
Avocation neuroses, 778
Azoospermia, 676

Bacilli, 56, 57
Bacillus,  anthrax, 82,  86
    diphtheria, 246
    glanders, 90
    Havaniensis, 62
    influenza, 119
    Kochii, 137,  140
    leprosy, 168
    leprosy, in blood,  601
    measles, 192
    pertussis, 113
    pneumonia, 58, 62, 126
    tetanus, 106
    tuberculosis, 62, 140, 164
    tuberculosis, in blood, 601
    typhosus, 269
 Bacteria. 3, 56, 799
 Bacteriology, abscess of lungs, 536
    anthrax, 82, 86
    bronchitis, 497
    chicken-pox, 241
    cholera, 336, 340
     diphtheria, 246, 247
     dysentery, 324
     glanders, 90
     influenza, 119
     intestinal catarrh, 399
     lepra,  168
     measles, 192
     myocarditis, 578
     pertussis, 113
     pleurisy, 543
     pneumonia,  58, 62, 126
     pneumonia,  catarrhal,  522
     pyelitis, 667
     relapsing fever, 265
Bacteriology, rheumatism, 315
    stomatitis, 351
    syphilis, 171
    tetanus, 106
    tuberculosis,  62, 140
    typhoid fever, 269
Band-box note in emphysema, 520
Basedow's disease, 586
Basilar meningitis,  159
Basophile cells, 600
Baths, cold, in typhoid fever, 282
    hot, in nephritis, 645
    warm, in intestinal catarrh, 402
Beard's method of  general electrization,
  765
Bedbug, 9
Bednar's aphtha, 353
Bed sores in myelitis, 708
    in typhoid fever, 276
Bee stings, 9
Beef, in dietary of stomach disease, 394
    tapeworm, 27
    tea, 394
Bell's palsy, 693
Beriberi, 690
Berlin,  small-pox in, 236
Beverage grateful in fever, 281
Big jaw,  18
Bile, in blood, 599
    pathology, 441
    test in urine, 441
Biliary  cirrhosis, 472
Bilious  fever, 292
Biliousness, action of liver in, 802
Black vomit, 296
Bladder affection in hysteria, 761
    inflammation, 670
Blennorrhcea, 179
Blood corpuscles, alterations of, 599
    corpuscles in urine, 665
    diseases of, 597
    examination of, 597, 600
    in leukaemia, 609
    in stools, 399, 408
    ingredients of, 598
    parasites, 600
    serum therapy in diphtheria, 800
    sweating of,  611
    Teichmann's test, 382
    transfusion of, 798
    vessels, disease of, 390
    vessels, filariae in, 53
Blue births, 576
    fingers in Morvan's disease,  730
Body lice. 7
Bone and joint tuberculosis, 165
     caries and amyloid degeneration, 659
     changes in rickets, 629, 630
Borax in epilepsy, 749
Boston, small-pox  in, 235
Bothriocephalus latus, 29
Bowels, haemorrhage from, 412
     obstruction  of, 429
Bradycardia, 582,  583, 584
Brain abscess, 753 
INDEX.
809
   Brain, localization of lesions, 755
       symptoms in lead poisoning, 787
       tumor, 750
   Breath, bad, 395
   Bright's disease, 643
       and gastric catarrh, 365
       in scarlatina, 209
   Bromides in epilepsy, 749
   Bronchial asthma, 505
       casts, 498
   Bronchiectasis, 500
   Bronchitis, 489
       capillary, 493
       chronic, 495
       croupous, 498
       putrid,  497
  Broncho-pneumonia, 521
  Bronchorrhoea, 496
  Bronze-skin disease,  616
  Brown-Sequard's paralysis, 731
  Bubo, 181
      abortive treatment of, 803
  Bulbar paralysis, 725, 726
  Burns, treatment of, 786

  Cachexia, in stomach disease, 391
      malarial, 294
  Caecum, inflammation of, 417
  Calcified trichinae, 47
  Calculus, renal, 663
  Calf, enlargement  of, in progressive at-
   rophy,  732
  Calomel in heart disease, 577
  Cancer, and  gall stones, 453
      of the brain, 750
      of the intestine, 434
      of the larynx. 486, 488
      of the liver,  476
      of the lung,  539
      of the oesophagus, 359
      of the stomach, 377
      protozoa of,  67, 804
 Capillary bronchitis,  493
 Caput medusee, 467
     obstipum, 691
 Carbol-fuchsin solution, 60
 Carbonic acid poisoning, 798
     acid poisoning in croup, 255
     oxide poisoning, 797
 Carbuncles, metastatic, 84
 Casts, bronchial, 498
     in the urine,  640, 645, 650
 Cataract in diabetes, 681
 Catarrh, and  rheumatism, 313
     gastric, 363
     intestinal, 397
     laryngeal, 483
     naso-pharyngeal,  357
 Catarrhal pneumonia,  161, 521
 Catarrhus aestivus. 122
 Cavities in the spinal cord, 729
 Cellular pneumonia, 522, 523
 Cercomonas intestinalis, 400
 Cerebral haemorrhage, 736
Cerebro-spinal meningitis, 301
  Cerebellum, localization in, 757
  Cerebrum, localization in,  756
  Chalicosis pulmonum, 540
  Chancre, 172
     soft, 178
  Chancroid,  178
  Charbon, 81
  Cherry stones in appendix vermiformis,
   422
  Chest expansion limited in pleurisy, 544
  Chicken-pox, 240
  Chilblains, 784
  Children, malaria in,  291
  Chlorides in urine absent in gastralgia,
       376
     in urine of pneumonia, 130
  Chlorine, poisoning by, 797
  Chloroform breath in diabetes, 631
  Chlorosis, 606
     iron in,  803
  Choked disc in brain tumor, 752
  Cholelithiasis, 446
  Cholera, Asiatic, 335
     infantum, 343
     morbus, 343, 397
     nostras, 343
     sicca, 339
     typhoid, 338
     typhoid, in yellow fever, 299
 Cholerine, 338
 Cholesteatoma of the brain, 751
 Cholesterin in gall stones, 448
 Chorea, 765
     adult, 769
     electrical, 769
     hysterical, 768
     magna, 758, 759, 769
     symptomatic, 767
 Chrysarobin  in favus,  10
 Chyluria, 54
 Cimex lectularius, 9
 Circulation, disease of organs of, 554
 Cirrhosis, hepatis, hypertrophic, 469, 472
     of the liver, 462
     renal, 653
 Clap,the, 179
 Clasp-knife rigidity in spinal disease, 718
 Clavus hystericus, 760
 Claw hand in progressive atrophy, 721
 Climate in tuberculosis, 153
 Clothes lice,  7
 Clubbed fingers in tuberculosis, 150
 Coal dust in the lungs. 540
     smoke, analysis of, 797
 Cocaine, in haemophilia, 614
     poisoning by, 792
 Coccidia,  66
 Coccyodynia, 687
 Coffee-ground vomit in cancer of   the
  stomach, 382
 Cold, extreme, effects of, 782
    bath in typhoid fever, 282
Colic, lead, 787
Colon, cancer of, 434
Coma in diabetes, 681 
810
INDEX.
Coma in gastrectasia, 386
    in yellow fever, 299
    malarial, 293
    vigil, 274
Comma bacillus of cholera. 336
Concealed haemorrhage, 415
Condurango in  diseases of  the stomach,
  370
Congelation, 782
Conjugated deviation  of  the eves, 740,
  756
Constipation, 429
Consumption, 137
Contractions in hysteria, 760
Convulsions, epileptic, 742, 746
Coprostasis, 429, 433
Coqueluche, 112
Cor bovinum, 574
Cord, spinal, diseases of ,707
    spinal, gliomatosis of, 729
    spinal, hsemorrhage of, 728
Corpulence, 633
Corpuscles, blood, alterations in, 599, 605
Corymbose eruption of variola, 225
 Coryza, 478
 Cow-pox, 234
 Cows, foot and mouth disease of, 88
 Crab lice, 7
 Cramp, writer's, 778
 Cranium, syphilitic necrosis of, 175
 Creolin, in erysipelas, 81
     -ichthyol solution,  481
 Creosote, action of,  804
     in tuberculosis, 154, 804
 Cretinism, 802
 Croup. 253
     false, 256
 Croupous bronchitis, 498
     pneumonia. 124
 Cry, epileptic, 745
 Cryptogenetic sepsis, 70
 Cryptorchism, 676
 Crystals, asthma, 510
 Culture soils, 61,  62
 Curschmann's crystals, 510
 Cyanosis, 349
 Cysticercus cellulosae, 25, 26, 27
     of the heart,  581
 Cystine kidney stones,  664
 Cystinuria, 664
 Cystitis, 670
     oxalic acid in, 803

 Dance, St. Vitus', 765
 Deafness, sudden, in mumps, 189
 Degeneration, amyloid, 657
      reaction of, 693
 Delirium tremens, 790
 Dementia paralytica, 774
 Dermatomycoses, 9
 Diabetes insipidus, 683
      mellitus, 677
 Diabetic coma, 681
 Diamine, 664
 Diaphragm,  spasm of, 513
Diarrhoea, 398
Diathesis, haemorrhagic, 611
Diet, in diabetes, 682
    in diseases of the stomach, 370, 392
    in tuberculosis, 155
Digitalis, in dropsy of nephritis, 652
    in heart disease, 577, 587
    in tetany, 735
Dilatation of stomach, 885
Diphtheria, 244
    and  scarlatina, diagnosis, 210,  211,
      250
    blood serum therapy in, 800
    streptococcus in drinking-water, 800
Diphtheritic paralysis. 248
Diplococcus pneumoniae, 127
    in sputum, examination of, 135
Dipsomania, 792
Disinfection of walls, etc., 79, 809
Disposition to disease, 64
    to tuberculosis, 143
Distoma haematobium, 55
    hepaticum, 54, 412
Dittrich's plugs, 497, 538
Diuretin in dropsy of nephritis, 652
Dog tapeworm, 34
Dogs and rabies, 97
Drinking-water, purity of, 393
Dropsy, in heart disease, 577
    in kidney disease, 640, 650, 653
    puncture in relief of, 803
 Drowning, 529
 Dwarf corpuscles in blood, 599
 Dysentery, 323
 Dysmenorrhoea and tuberculosis, 144
 Dyspepsia, 363, 376
     and tuberculosis, 144
     in helminthiasis, 29
 Dystrophy, juvenile,  732
     progressive, 731

 Ear affection in leptomeningitis, 703
     in scarlatina, 208
     disease in abscess of brain, 753
     furunculosis of, 800
 Echinococcus, 34
     multilocularis, 37
     of the lungs. 540
 Eclampsia from lead poisoning, 787
 Ectozoa, animal, 4
     vegetable, 9
 Eczema, 11
     marginatum, 13
     from  pediculi capitis, 6
     from  pediculi vestimenti, 7
     from  scabies, 4, 5
 Effusion, forms of, in pleurisy, 544
     in pericarditis, 559
 Egg in dietary of stomach disease,  393
 Ehrlich's solution, 60
 Elastic tissue in sputum,  151, 152
 Electricity in facial paralysis, 696
     in gastralgia, 389
 Elephantiasis from filaria sanguinis, 53
     Graecorum, 167 
INDEX.
811
 Emboli, pulmonary, and asthma, 513
 Embolism, fatty, 598
     of the lungs, 534
 Embolus and haemorrhage, 741
 Emphysema, and tuberculosis, 143
     of the lungs, 518
 Empyema, 547
 Endarteritis obliterans, 176
 Endocarditis, 563
     and pericarditis, 561
     produced by gonorrhoea, 802
     sclerotic, 569
     septic, 567
 Endospores, 59
 Enemata. nutrient. 395, 411
 English disease,  rickets, 628
 Enteralgia, 688
 Enteric fevers, 268
 Enteroclysters in cholera, 342
 Enterorrhagia, 408, 411
 Entozoa, 23
 Enuresis, 672
 Eosinophile cells, 600, 605, 609
 Epidemic cerebro-spinal meningitis, 301
 Epididymitis,  181
 Epilepsy, 742
     and hysteria, 748, 758
     and palpitation of the heart, 583
 Epithelium in urine of nephritis, 649
 Erysipelas, 72
     marginatum, 77
     migrans, 77
     and vaccination, 239
 Erythema in variola, 220
 Essential anaemia, 603
 Exophthalmic goitre, 586
 Extremities, gangrene in Raynaud's dis-
  ease, 730
 Eye affection, in Bright's disease,  648
     in endocarditis, 568
     in tabes dorsalis. 714
     in small-pox, 227
 Eyes, conjugated deviation of, 740, 756
     protrusion of, in Basedow's disease,
       587

 Facial atrophy, 733
     palsy, 693
 Faeces, bacteria of, 400
     under the microscope, 400
 Farcy, 90
     buds, 92
 Fasting girls, 761
 Fat, excessive, 633
     in blood, 598
     in undigested food,  399
 Fatty embolism,  598
 Fauces, diseases of, 349
 Favus, 9
     scutulum, 10
 Feet, paralysis of, in neuritis, 69
 Fermentation test for sugar, 679
Ferments, 3
Fern, male, in tapeworm, 33
Fetid bronchitis,  497
Fever and ague, 284
Fibrin in blood, 598
Fibrinous bronchitis, 498
Fibroid tumor of the larynx, 486
Filaria Bancrofti, 52
    Medinensis. 52
    sanguinis, 52
Fingers, deformity of,  in  Morvan's dis-
  ease, 730
Fish tapeworm, 29
Flea, the common,  9
    sand, 9
Flies and  anthrax, 83
Flux, 323
Fog in protection against asthma, 508
Foot and mouth disease, 87
    hysterical contraction of, 760
    perforating ulcer of, 690
Foreign bodies in appendix vermiformis,
  421
Fracture,  green-stick, in rickets, 630
Frankel's bacillus of pneumonia, 126
Freaks of hysteria,  761
Freezing,  782
Fremitus, hydatid, 36
Friedlander's pneumococcus, 126
Friedreich's ataxia, 716
Fright as  cause of epilepsy, 744
Frost bites, 784
    bites and Raynaud's disease, 731
Fungi, 3
    mould, from abscess of lungs, 536
Fungus, actinomyces, 18
    disease of India, 15
    thrush, 17
Furunculosis, in diabetes, 681
    of the ear, 800

Gabbett's  stain of tubercle bacillus, 601
Gait, in lateral sclerosis, 718
    in paralysis agitans, 771
Gall,  stones,  446
    as cause  of jaundice, 444
    as cause  of occlusion of intestine, 431
Gangrene, in diabetes, 681
    of extremities in Raynaud's disease,
      730
    of the lungs, 537
Gastralgia, 387, 688
    and gall  stones, diagnosis, 452
    and hysteria, 388
Gastrectasia,  385
Gastric catarrh, 363
    catarrh of infants, 801
    juice, hyperacidity of, 801
    ulcer, 372
Genito-urinary system, disease of, 637
Gin drinkers' liver, 462
Glanders,  90
Glioma of the brain, 750
Gliomatosis of the cord, 729
Globus hystericus, 359, 759
Glossitis, 349
Glosso-labio-laryngeal paralysis, 725
Glottis, oedema of, 485 
81"2                               INDEX.
Glottis, spasm of, 759
Glycosuria, 677
Goitre, acute, 590
    exophthalmic, 586
Gonococcus, 180, 182
    double stain for, 803
Gonorrhoea, 179, 802
    as cause of cystitis, 671
Gonorrhceal rheumatism, 320
    threads in urine, 184
Gothard worm, 44
Gout, 618
    and gravel, 665
    rheumatic, 623
Gouty fingers, 620
Gram's solution, 61
Grand mal in epilepsy, 744
Grandeur, ideas of, in dementia, 775
Gravel, and gout, 665
    renal, 663
Graves' disease, 5S6
Green sickness, 606
    soap in vertebral caries,  167
Grip, the, 118
Guinea worm, 52

Habitus, of lateral sclerosis,  718
    phthisical, 143
Haematemesis, 376
    in cirrhosis hepatis,  466
Haemathidrosis, 611
Haematoma of the dura mater, 696
Haematomyelia, 728
Hsematopericardium, 563
Haematorrhachis, 728
Haematothorax, 552
Haematuria, 54, 292
    in nephritis, 645
    red blood corpuscles in, 665
    source of, how to determine, 803
Haemin crystals,  382
Haemoglobin, 598
    in blood sausage, 803
    in chlorosis,  607
Haemoglobinaemia, 599, 612
Haemophilia, 613
Haemorrhage, cerebral, 736
    concealed, 408, 415
    from cirrhosis hepatis, 466
    from gastric ulcer, 376
    of the bowels,  408, 412
    in typhoid fever, 273, 274
    in variola, 223
    in yellow fever, 300
    spinal, 728
Haemorrhagic diathesis,  611
    infarction of the lungs, 534
Hair in favus, 11
    in herpes tonsurans, 13
Hairy hearts. 554
Hand, claw; in progressive atrophy, 721
    deformity in acromegaly, 729
    obstetric habitus in tetany, 734
    posture in paralysis agitans, 770
Hay asthma, 122
Hay fever, 122
Headache, (587
Heart, affection of, in typhus, 261
    cysticercus of, 581
    degeneration of, in typhoid fever, 276
    disease of, 554
    disease and asthma, 512
    disease and rheumatism, 317
    disease and tuberculosis, 143
    failure, 578
    failure in bronchitis, 496
    failure in pneumonia, 134
    hypertrophy in nephritis, 642, 655
    muscle, inflammation of, 577, 579
    neuralgia of, 585
    neuroses of, 581
    palpitation of, 582
    palpitation of, in Basedow's disease,
      586
    syphilis of, 581
    topography of, 583
    tuberculosis of, 581
Heatstroke, 780
Hegar's method of irrigation of the bowel,
  427
Heller's test  for blood-coloring matter,
  382
Hemianaesthesia, 756
Hemianopsia, 756
Hemiparaplegia, Brown-Sequards, 731
Hemiplegia alternans, 726
    cruciata, 726
    in apoplexy, 739, 740
Hepatalgia and gastralgia, 389, 452
Hepatitis, interstitial, 462
    suppurative, 455
Hepatotomy in abscess of the liver, 461
Hereditary ataxia,  716
    atrophy,  733
    syphilis,  171
Herpes circinatus,  12
    in cerebro-spinal meningitis, 304
    indications of,  349
    in pneumonia, 130
    tonsurans, 12.  13
Hiccough, pilocarpine in, 805
Hobnail liver, 462
Hodgkin's disease,  610
Homines quadrati in apoplexy, 737
Hooklets of echinococcus, 35
Hornet stings, 9
Howard's method of artificial respiration,
  Doo
Humidity and malaria, 286
Hunger and predisposition to disease, 64
Hydatid fremitus,  36
    tapeworm, 34
Hydraemia, 597
    and immunity, 64
Hydrochloric acid free in cancer of the
      stomach, 383
    acid in gastric juice,  368
Hydronephrosis, 669
Hydropericardium, 563
Hydrophobia, 96 
INDEX.
813
 Hydrophobia, lemon juice in, 799
 Hydrothorax, 546, 551
 Hyper- and Hypalbuminosis, 598
 Hyper- and Hypinosis,  598
 Hyperaesthesia in cerebro-spinal  menin-
   gitis, 303, 306
 Hyperpyrexia in rheumatism, 317
 Hypertrophic cirrhosis  of the liver, 469,
   472
 Hypertrophy, pseudo-, of muscle, 731
 Hypochondriasis, 763
 Hypodermatic clysters in cholera, 343
 Hypostatic pneumonia, 526
 Hysteria, 359, 757
     and epilepsy, diagnosis, 748, 758
     and gastralgia, 388
 Hysterogenic spots.  760

 Icterus, 439
     gravis, 802
     in intestinal catarrh, 398
     in remittent fever, 292
     in yellow fever,  299
     neonatorum, 440
 Ileo-typhus fever, 268
 Ileus, 427
 Immunity, 64, 65
 Impotence, 675
     in diabetes, 680
     in diphtheria, 249
     in tabes,  714
 Incontinence of urine, 672, 805
 India fungus, disease of, 15
 Indian cholera,  335
 Indican, in intestinal occlusion, 433
     in typhlitis, 423
     test for, 433
 Indigo kidney stone,  664
 Infantile paralysis, 722
 Infants, gastro-intestinal catarrh in, 801
 Infarct, uric-acid, in new-born, 665
 Infarction, haemorrhagic,of the lungs, 534
 Infections, 3, 63
 Infectious diseases, 68
 Influenza, 118
     action of salipyrin in,  799
 Infraspinatus, atrophy  of,   in  pseudo-
  hypertrophy, 732
 Infusoria, 66
 Ingravescent  apoplexy, 739
 Inosite in echinococcus cysts, 37
 Insane, progressive paralysis of, 774
 Insolation, 780
 Insomnia in delirium tremens, 791
    in trichinosis, 50
Intercostal neuralgia, 686
Intermittent cerebro-spinal meningitis, 307
    fever,  284, 289, 290
Intestine, neuralgia of, 688
    occlusion of, 801
Intestinal catarrh, 397
    haemorrhage, 44
    occlusion, 429
    protozoa, 400
    ulcer, 403
 Intestinal worms, 23
 Intoxication, 63
 Intubation in croup, 256
 Intussusception, of intestine, 431
     and dysentery, 331
 Invagination of the intestine, 431
 Iodine-potassium-iodide solution, 60
 Iodoform, in erysipelas, 81
     gauze in haemorrhage, 614
     in laryngeal tuberculosis, 802
     in sepsis, 71
 Iodoformol in bone tuberculosis, 166
 Ipecac in dysentery,  333
 Iron dust in the lungs, 541
     subsulphate in diphtheria, 251
 Irrigation of the bowel in dysentery, 332
     in jaundice, 445
     in treatment of threadworm, 43
 Itch, 4
 Itching, after measles, etc., treatment of,
       800
     in jaundice, 442

 Jaundice, 439
     in cirrhosis of the liver, 467
     in intestinal catarrh, 398
     in remittent fever, 292
     in yellow fever, 299
     simulation of, 442
     with gall stones,  451
 Jaw, big, actinomycosis, 18
 Jejunum, catarrh of, 399
 Joints, neuralgia of, 688
 June cold, 122
 Juvenile dystrophy, 732

 Kakke, 690
 Keratin pills in gastric digestion, 387
 Kidney,  acute inflammation of, 643
     affection in scarlatina, 209
     amyloid degeneration of, 657
     anaemia of. 643
     calculus, 663
     chronic inflammation of, 647
     cysts in, 669
     diseases of, 637
     epithelium, 649
     floating, 661
     gravel, 663
     hyperaemia of, 642
     interstitial inflammation of, 653
     pelvis, diseases of, 663
     sand, 663
     stone, 663, 670
     stone and gall stone, diagnosis, 453
     syphilis of, 661
     topography of, 661
     tuberculosis of, 155, 660
    uric-acid infarction in new-born, 665
    wandering, 661
Knee jerk in diabetes, 680
    in diphtheria, 249
    in tabes,  714
Krull's cold-water irrigation of jaundice,
  445 
814
INDEX.
Lactic acid, Uffelmann's test for, 369
Landry's paralysis, 727
Laparotomy,  in occlusion of  the  intes-
      tine, 434
    in typhlitis. 428
    in typhoid fever, 284, 801
Laryngeal glosso-labio paralysis, 725
Laryngismus stridulus, 256
Laryngitis, catarrhal, 483
    tuberculous, 146, 486
Larynx, cancer of, 486, 488
    catarrh of, 48o
    diseases of, 481
    irritation of, as cause of asthma, 508
    normal, and trachea, 482
    oedema of. 485
    paralysis of, 487, 488
    spasm of, in rickets, 631
    stenosis in measles, 195
    syphilis of, 488
    tuberculosis of, 486
    tumor of, 486, 488
Lateral sclerosis, 717, 719
    sclerosis, amyotrophic, 719
Lead poisoning, 786
    poisoning and gall stones, diagnosis,
      453
Leontiasis leprosa, 168
Lepra, 167
    bacilli in blood, 601
Leprosy, 167
Leptomeningitis, 703
Leptothrix buccalis, 18
Leube's four  diet lists, 395
Leucin in sputum of empyema, 548
Leucocytes, emigrated, in hydrophobia, 99
Leucocythaemia, 608
Leucocytosis,  600
Leukaemia, 608
Lice, body, 7
    crab, 7
    head, 6
Lime salts in rickets, 628
Lip, furunculosis of, 85
Lipomatosis in pseudo-hypertrophy, 733
Liquor dealers, mortality of, 789
Liver, abscess of, 455
    acute atrophy of, 473
    amyloid, 476
    antiseptic action of, 802
    atrophy of. 470
    cancer of, 476
    cells in yellow fever, 299
    cirrhosis of, 462, 469, 472
    diseases of, 439
    displaced by pericardial effusion, 560
    fatty, 475
    fluke, 54
    hyperaemia of, 475
    syphilis of, 176, 470
Lobular pneumonia, 521
Localizations in the brain, 755
Lockjaw, 105
Locomotor ataxia, 711
Loftier's  solution, 60
Lues venerea, 169
Lumbago, 332, 692
Lumbricoid worms, 88
Lungs, atelectasis of, 528
    cancer of, 539
    diseases of, 489
    echinococcus of, 540
    embolism of, 534
    emphysema of, 518
    gangrene of, 537
    inhalation of dust into, 540
    metastatic abscess of, 535
    cedema of, 527
    sarcoma of, 540
    syphilis of, 539
    test of expansion, uric acid, 665
Lustgarten's syphilis bacillus, 171

Macrocytes in blood,  599, 605
Madura disease, 15
Malaqua, 289
Malaria, 284
    and cerebro spinal meningitis, 310
    and meningitis, 163
    Plasmodium of,  66
Malarial cachexia, 294
    neuralgia,  292
Malignant  pustule, 81, 82
Malum perforans pedis, 690, 715
Mania a potu, 790
Marsh and malaria, 286
Marshall Hall's artificial respiration, 532
Masked malaria, 292
Masturbation, 674, 676
Measles, 190
    and variola, 229
    French,198
    German, 198
    noma in, 354
Measly pork, 25, 27
Meats in dietary. 394
Medulla, sclerosis of,  725
Megaloblasts, 600
Melanpemia, 599
Melaena neonatorum, 414
Membrane of echinococcus, 35
Meningeal haemorrhage, 728
Meningitis, and malaria, 163
    and pneumonia, diagnosis, 135
    and typhoid fever, 163
    cerebro-spinal, 301
    in scarlatina, 212
    in variola,  228
    simple cerebral,  696, 703
    tubercular, 159
Mercurial stomatitis. 349
Mercury, for pediculi, 7
    in favus, 12
    in herpes tonsurans, 14
Metal transfer  of sensations,  761
Metallic tinkling in pneumothorax, 551
Metastatic  abscess of lungs, 535
Methylene blue in thrush, 18
Micrococci, 56
    non-specific, in gonorrhoea, 183 
INDEX.
815
 Micrococcus gonorrhoeae, 180
     of pneumonia in pleurisy, 543
 Microcytes in blood, 599, 605
 Micro-organisms, 3, 56
 Microsporon furfur, 14
     minutissimum,  14
 Migraine, 687
     abdominal pressure in, 805
 Miliary aneurisms in apoplexy, 737
     tuberculosis, 164
 Milk, and tuberculosis, 144
     in dietary of stomach disease, 393
     in foot and mouth  disease, 88
     leg, 595
     spots, pericardial, 555
 Milzbrand, 81
 Mind, state of, in tabes, 715
 Mitral insufficiency, 571
     insufficiency, diagram of, 571
     insufficiency, tracing of, 570
     obstruction, 572
     obstruction, diagram of, 571
     obstruction, tracing of, 573
     valve, proportionate affection of, 566
 Molluscum contagiosum, 67
 Monadines. 400
 Moore's test for sugar,  679
 Morbilli,  190
 Morbus Addisonii, 616
 Morpio, 7
 Morvan's disease, 730
 Mosquitoes, 9
 Mould fungi from abscess of the lungs,
   536
 Moulds, 31
 Mouse odor of favus crusts, 10
 Mouth, disease of, 349
     breathers, 358
     wash. 615
 Mucus, nasal, 478
 Multilocular echinococcus cysts, 37
 Multiple neuritis, 690
     sclerosis, 772
     sclerosis and paralysis agitans, 771
 Mumps. 186
     metastatic,  186
 Murexide test, 663
 Muscle affection in dystrophy, 731
     fibre in faeces, 400
     septic infection of,  69
     trichina in, 47, 49
 Muscular  atrophy, progressive, 719
     rheumatism, 321
 Mycoderma albicans, 15
 Myelitis, 707
 Myocarditis, 577
 Myotony, 691
 Myrtol in  putrid bronchitis, 504
 Myxedema, 589, 802

Nails, biting, infection with round worms
  by, 42
Naphthol  in herpes tonsurans, 14
    in pityriasis, 15
    in scabies, 5
 Nasal catarrh, 478
 Nasopharyngeal catarrh, 357
 Nematoid worms, 38
 Nephritis, acute parenchymatous, 643
     ohronic parenchymatous, 647
     interstitial, 653
     scarlatinal, 209
 Nephrolithiasis, 663
 Nerves, diseases of,  685
     tissue, injection of, 765
 Nervous system,  diseases of, 685
 Neuralgia, 685
     malarial, 292
     occipital, 686
     of coccyx, 687
     of head, 687
     of heart, 585
     of intestine, 387, 688
     of joints, 688
     of spermatic nerve,  688
     of stomach, 688
     of sciatic nerve, 686
 Neurasthenia, 764
 Neuritis,  690
 Neuroses, of the heart, 581
     avocation, 778
 Neurosis,  vaso-motor,   Raynaud's  dis-
  ease, 730
 Neutrophile  blood cells,  600
 New-born, haemorrhage of the bowels of,
  414
 Nicotine poisoning, 795
 Nitrite of amyl in angina pectoris, 586
 Nitroglycerin in heart disease, 577
     in nephritis,  653
 Nodular rheumatism, 623
 Noma, 354
     in measles, 195
 Nose, catarrh of, 478
     diseases of, 478
     glanders in, 93, 94
     polypi in, 481
     relation of, to asthma, 508
     sunken bridge in syphilis. 174, 350
 Nummulation of blood corpuscles, 597
  609
 Nylander's test for sugar, 679
 Nystagmus in multiple sclerosis, 774

 Obesity, 633
 Obstetric  hand in tetany, 734
 Obstruction of the bowels, 429, 801
 Occipital neuralgia, 292,  686
 Occipito-frontal rheumatism, 322
 Occlusion of  intestine, 429, 801
 Odor, as cause of asthma, 507
    mouse-like, of favus  crusts, 10
    of stools  in diarrhoea, 399
 ffidema of anthrax, 84
    of the glottis, 485
    of the lungs, 527
Oesophagus, diseases of, 359
Oligeemia, 601
Oligocythaemia, 599
Onanism,  674, 676 
816
INDEX.
 Onychomycosis, 10, 13, 14
 Opisthotonos, 105, 107
     in cerebro spinal meningitis, 203
     in hysteria,  758
 Opium, in cerebro-spinal meningitis, 312
     poisoning by, 793
 Optic papilla in  brain tumor, 752
 Orchitis, in mumps, 188
     syphilitic, 17(5
     tuberculous, 165
 Orexin as an appetiser, 396
 Orthotonos, 304
 Osteomalacia, 638
 Otorrhcea and meningitis, 703
 Oxalate of sodium, property of  prevent-
   ing coagulation, 798
 Oxalic acid crystals, 664
     acid in cystitis, 803
     acid stones,  664
 Oxyuris vermicularis, 41

 Pachymeningitis, 696
 Palpitation of the heart, 582
     in Basedow's disease, 586
 Palsy, shaking, 770
     wasting, 719
 Papilloma of the larynx, 486
 Paracentesis abdominis in cirrhosis, 471
     thoracis, 542, 549
 Paralysis, 692
     acute ascending, 727
     agitans, 770
     bulbar, 725
     Brown-Sequard's, 731
     facial, 693, 694
     glosso-labio laryngeal, 725
     in abscess of the brain,754
     in diphtheria, 248
     in dysentery, 329
     infantile, 722, 724
     Landry's, 727
     lead, 787
     of the larynx, 487, 488
     progressive,  of the insane, 774
     spastic spinal, 717
 Paralytic dementia, 774
 Paraplegia,  ataxic, 719
     in spinal haemorrhage, 728
     spastic, 717
 Parasites, 31, 60
     blood, 600
 Paratyphlitis, 417
 Parenchymatous   degeneration  in   ty-
  phoid fever, 275
 Parkinson's  disease, 770
 Parotitis, 186
    in typhoid fever, 276
 Pasteur's treatment of hydrophobia,  104
 Pearl on the rose, 240
 Pearls, epithelial, 353
 Pediculus capitis, 6
    pubis, 7
    vestimenti, 7
 Pellagra, 719
Pelletierine in tapeworm, 33
 Pelvis, kidney, disease of, 663, 667
     kidney, inflammation of, 667
     renal, epithelial cells of, 668
 Peptic asthma^08
     ulcer, 372
 Perforation in typhlitis, 423
     in typhoid fever, 274, 284,  801
 Pericarditis, 554
     and endocarditis, diagnosis, 561
     and pleurisy, 557, 561
 Pericardium, syphilis of, 563
     tuberculous, 562
 Perichondritis, 479, 485
 Peripleuritic abscess, 552
 Peritonitis, 275, 436
 Perityphlitis, 417
 Permanganate of potash in thrush, 18
 Pernicious anaemia, 603, 605, 803
     malaria, 293
 Pertussis, 112
     mortality of,  804
 Petechiae in typhus fever,  260
     in variola, 220
 Petit mal of epilepsy, 746
 Pettenkofer's test for bile acids, 441
 Phagocytosis, 65
 Pharynx, diseases of, 349
 Pharyngo-nasal catarrh, 357
 Phlebitis, 595
 Phlegmasia dolens, 595
 Phlorglucin-vanillin test for hydrochlo-
       ric acid, 368
     test in typhoid fever, 276
 Phosphatic kidney stones,  664
 Phosphaturia, 674
 Phosphorus affection of the liver, 475
 Phosphorus in rickets, 632
 Phthisis, 137
 Physiognomy in tetanus, 107
 Pinworm, 4
 Piperazin, in gout, 623
    in kidney stones, 667
 Pityriasis versicolor, 14, 15
 Plasmodium of malaria, 66
 Plethora, 597
 Pleurisy, 542
    and pericarditis, 557, 561
    effusion of, 802
    suppurative, 547
Pleurodynia, 322
Plica polonica, 6
Plumbism, 786
Pneumococcus, 62, 540
Pneumonia, 124
    and variola, 228
    catarrhal, 521
    catarrhal, in measles, 195
    cellular, 522, 523
    deglutition, 16
    hypostatic, 526
    sputum, examination of, 135
Pneumopericardium, 563
Pneumothorax, 550
Podagra, 618
Poikilocytosis, 600, 605 
INDEX.
817
Poisoning bv cocaine, 792
    by gases, 796
    by lead, 786
    by nicotine, 795    „
    by opium,  793
Poliomyelitis, 722
Pollen and hay fever, 123
Poliomyositis, 51
Polypanarthritis, 624
Polypi, nasal, 481
    nasal, and asthma, 508
Polysarcia, 633
Polyuria, 683
Pomegranate bark in tapeworm, 32
Pork, measly, 25, 27
    tapewOrm, 27
Posture in infantile paralysis, 724
Potassium iodide in asthma, 517
Pott's disease, 165, 167
Pox, small-, 218
    syphilis, 169
Predisposition to disease, 64
    to tuberculosis,  143
Prescription for amyloid kidney, 660
    for anaemia, 603
    for angina, 358
    for bronchitis, 501
    for cholera, 342, 343
    for cystitis, 672, 803
    for epilepsy, 750
    for erysipelas, 81
    for favus, 12
    for gargle, 354
    for gastric catarrh, 371, 372
    for gout, 623
    for herpes tonsurans, 14
    for intestinal catarrh, 402
    for leukaemia, 610
    for mouth wash in scurvy, 615
    for nephritis, 653
    for neuralgia, 692
    for pertussis, 118
    for pityriasis, 15
    for rheumatism, 318, 320
    for rickets, 632
    for scabies, 5, 6
    for septicaemia,  71
    for thrush,  18
    for tooth powder, 354
    for typhoid fever, 281
    for typhoid fever, diarrhoea in, 283
    for typhoid fever drink, 281
    for yellow fever, 300
Proctitis, 401
Progressive muscular atrophy, 719
    paralysis of the  insane, 776
Prostatorrhcea, 674
Protozoa, 31, 65
    in cancer, 67, 804
    in dysentery, 324
    in faeces, 400
    in herpes zoster, 67
    in malaria, 287
    in molluscum contagiosum, 67
    in vaccinia and varicella, 67
Protozoa in variola, 67, 220
Pruritus, after measles, 800
    in diabetes, 681
    in jaundice, 442
    opii, 749
Pseudo-angina pectoris, 585
    -hypertrophic paralysis, 731, 733
    -leukaemia, 610
Ptomaines, 63
Puerperal scarlatina, 203
Pulex irritans, 8
    penetrans, 8
Pulmonary arteries, thrombus of, 534
    emboli and asthma, 513
    valves, regurgitation of, 576
    valves, stenosis of, 576
Pulse, sphygmographic tracing, 570
Purpura haemorrhagica,  612
    simplex, 612
    variolosa, 224
Pyaemia, 68
    in dysentery, 329
Pyelitis, 667
Pyelonephrosis, 677
    -phlebitis, 470
    -thrombosis, 470
Pylorectomy, 394
Pylorus, cancer of, 379
Pyocardium, 563
Pyrogallic acid, in favus, 12
    in herpes, i4

Quinine in malaria, 295
Quinsy, 257

Rabies, 96
Rachitis, 628
Ray fungus, 19
Raynaud's disease,  730
Reaction of degeneration, 657
Recrudescence in typhoid fever, 278
Rectal alimentation, 395, 801
Rectum, cancer of, 434
Rectus, rigidity of, in abscess of  liver,
   459
Recurrent fever, 266
Refluent embolus, 458
Relapses in typhoid fever, 277
Relapsing fever, 266
Relative insufficiency of tricuspid valve,
   575
Remittent fever, 292
Renal calculus,  663
    cirrhosis, 653
    gravel, 663
    sand, 663
    stone. 663, 670
Ren mobile,  661
Resorcin in favus, 12
Respiration,  artificial methods, 532
    diseases  of organs of, 478
Retinitis albuminuria, 648
Retropharyngeal abscess, 361
Rhachialgia  in cerebro-spinal meningitis,
   306
52 
8ls
INDEX.
Rheumatic gout, 623
Rheumatism, 313
    and endocarditis, 316, 565
    and gout, diagnosis, 622
    and pericarditis, 551
    and septicaemia, 71
    chronic, 318
    gonorrhceal, 182, 320
    in scarlatina, 209
    muscular, 321
    nodular, 623
Rhizopods, 66
Rickets. 628
Rigidity, in apoplexy, 740
    in epilepsy, 745
    in hysteria, 758
Ringworm, 12
Risus sardonicus, 107
Roseola syphilitica, 172
Rijtheln, 198
Round worm, 38
Rubella, 198

Saint Vitus' dance, 7G5
 Salicylic acid in rheumatism, 317
 Salipvriu in influenza, 622, 799
 Salofas test for stomach  digestion, 369,
   887
 Salpingitis, 165
 Salt, in the blood, 598
     necessity of, 393
 Sand, renal, 663
 Santonin in treatment of round worm, 41
 Saprophytes, 59
 Sarcinee, 58
 Sarcocele, 176
 Sarcoma of the lungs, 539
 Saturnism, 786
 Scabies, 4
 Scarlet fever, 201
     and diphtheria, 210, 211, 250
     and measles, diagnosis, 210
     in nephritis, 643
 Schizomycetes, 3
 Sciatica, 293, 686
 Sclerosis, arterio-,  590, 802
      general, 774
      lateral, 717
      multiple, 772
      of medulla, 725
      of tabes dorsalis, 712
 Sclerotic endocarditis, 569
 .Scorbutus, 614
 Scrofula, 165
 Scurvy, 614
 Segments of tapeworm, 25,  31
 Semen, abnormal discharge of, 673
 .Sepsis, 68
      cryptogenetic, 70
 Septic endocarditis, 567
 Septicaemia, 68
 Septico-pyaemia, 68
 Serum therapy, in diphtheria, 800
      in tetanus,  111
 Shaking palsy, 770
Shellfish and gastralgia, 388
Sick-headache, 687
    relief by pressure  upon abdomen,
      804
Siderosia pulmonum, 540
Simon's triangle in small-pox, 220
Simulation of jaundice, 442
Singultus, pilocarpine in, 805
Sinking typhus, 301
Skin, farcy  buds in, 92
    in herpes tonsurans, 12
Small-pox, 218
Smoke, coal, analysis of,  797
Snake bites  and purpura,  612
Sodium chloride, in blood, 598
    in echinococcus cysts, 36
    necessity of, 393
Softening of the bones,  633
Solutol as disinfectant, 805
Soor, 15
Spasm, 691
    in tetany, 733
    of the larynx, 631
Spastic paralysis,  717
    paraplegia. 717
Speech, in bulbar paralysis, 726
    in dementia, 776
Spermatic nerve, neuralgia of, 688
Spermatorrhoea, 673
Spermatozoids, 674
Sphygmographic  tracings, 570
Spinal cord, diseases of, 707
    sclerosis of, tabes, 712
    haemorrhage, 728
    irritation, 760
Spirals, asthma, 510
Spirilla, 56
     of cholera,  336
 Spirochetes, 58
     of relapsing fever,  265, 267
 Spleen, enlargement of, in typhoid fejier,
       292
     in anaemia, 610
     in leukaemia, 610
 Splenic fever, 81
 Spores, 59, 61
 Sporozoa, 66
 Spotted fever, 301
 Sputum, fluids for examination of, 538
     of abscess of  lungs. 537
     of pneumonia, diplococcus of, 127
     of pneumonia, examination of, 135
     of tuberculosis, examination  of, 61
 Staining fluids, 60
 Staphylococcus, 68
 Stenocardia, 585
 Stigmata, 611
     of hysteria, 769
 Stomach, catarrh of, 363
     cancer of, 359
     dilatation  of, 385
      diseases of, 363
      diseases of, diet and treatment,  390
      neuralgia of, 387
      tube, 366, 369, 801 
INDEX.                               819
Sternberg's diplococcus, 126
Stone in the kidney, 663
Strangulation, intestinal, 401
Strawberry tongue in scarlatina, 208
Streptococcus, 58
    curve, 799
    in diphtheria, 347, 850
    in erysipelas, 73
    in pyaemia, 69
    in quinsy, 258
    in tuberculosis, 147
Stricture of intestine, 431
Strychnia and tetanus, 109
Subphrenic abscess, 553
Subsulphate of iron in diphtheria, 251
Succinic acid  in echinococcus cysts, 37
Succussion in the stomach, 385
Sugar, in the  blood, 598
    in the urine, 678
    in the urine, tests for,  679
Sulphonal in urine, 805
Sulphur in scabies, 5, 6
Sulphuric acid, poisoning by, 796
Summer catarrh, 122
Sunstroke, 780
Suprarenal capsules, disease of, 616
Supra-orbital  neuralgia, 292
Sweating, as a sign of rickets, 680
    in rheumatism, 316
    in tuberculosis, 148
    of blood,  611
Sweden, small-pox in, 236
Sycosis, treatment of, 799
Sylvester's method of  artificial respira-
   tion, 532
Syphilis, 169
    and cirrhosis of the liver, 465
    and vaccination, 238
    of the heart, 5bl
    of the kidney, 661
    of the larynx,  488
    of the liver, 470
    of the lungs, 539
    of the nose, 479
    of the pericardium, 563
    of the throat, 350
Syphiloderm  174
Syphilides, pigmented,  treatment of, 800
Syringe, Koch's, for tuberculin, 491
Syringomyelia, 729

Tabes dorsalis, 711
Tachycardia,  582, 583, 584
    in Basedow's disease, 586
Taenia,  23
    armata, 27
    echinococcus, 34, 35
    lata. 29
    saginata,  24, 27
Taeniaphobia,  33
Tapeworm, 23       #          ,
    as cause of pernicious anaemia, 803
    treatment of, 32
Tarry stools, 415
Teeth in hereditary syphilis, 171
Teeth, notched, 350
    powder for, 854
    wash for preservation of, 615
Temperature charts, in malaria, 291
    in measles, 193
    in measles and scarlet fever, 194
    in pneumonia, 129
    in scarlet fever, 205
    in typhoid fever, 271, 277, 278
    in typhus fever, 262
    in variola, 222
    in yellow fever, 298
Test,  for acetone in diabetes, 681
    for cocaine. 793
    for sugar in the urine, 679
    Teichmann's, for  blood, 382, 416
    uric acid, murexide, 663
Testicle, in mumps, 188
    inoculated, as test for glanders, 96
    juice, injection of, 765
Tetanotoxine, 64, 107
Tetanus, 105
    and cerebro-spinal meningitis, 310
    and strychnia poisoning, 109
    and tetany, 109, 734
Tetany, 733
Thirst in diabetes, 680
Thomsen's disease, 691
Threadworm, 41
Throat, syphilis of, 350
Thrombus of pulmonary arteries, 534
Thrush, 15
Thymol, in favus, 12
    in preservation of teeth, 615
    in round worm, treatment of, 41
    in trichinosis, treatment of, 52
Thyroid  gland,  affection  of, in  Base-
       dow's disease, 587
    gland, disease of, 802
Tic douloureux, 686
Tinea favosa, 9
Tizzoni and  Centanni on hydrophobia,
  105
Tobacco, poisoning by, 795
    heart, 583
Toe,  big, affection of, in gout, 625
Tongue, black, 356
    condition of,  349, 354
    thrush of, 16
Tonsillitis, 257, 356
    and diphtheria, 250
Tonsils, hypertrophy  of, 357
    stomata of, 350
Tophi of gout, 621
Toxalbumins, 64
Toxine, of cholera, 337
    of diphtheria, 247
    of measles. 199
    of pertussis, 113
    of scarlatina, 205
    of tetanus, 107
    of typhoid fever,  64
Toxines, 63
Tracheotomy in croup, 256
Transfusion in dysentery, 335 
S-.20
INDEX.
Transfusion, in haemorrhage of the bow-
      els, 412
    of blood, 798
    of salt solution, 343
Tremor, of alcoholism, 789
    of delirium tremens, 790
    of dementia paralytica,  776
    of multiple sclerosis, 772
    of paralysis agitans, 772
Trematoid worms, 54
Trichina spiralis, 45, 322
Trichinosis, 45
Trichloracetic acid, 481
Trichomonas intestinalis, 400
Trichocephalus dispar, 44
Trichophyton tonsurans, 12
Tricuspid valve, insufficiency, 575
    obstruction, 576
Trigeminus,  neuralgia of, 686
Trismus, 105
Trommer's test for sugar, 679
Tubercle bacillus,  62
    culture,  62
    in blood, 601
    staining  fluid, 61
Tuberculin,  151, 158
Tuberculosis, 137
    acute miliary, 164
    and amyloid degeneration, 659
    and bronchiectasis, 501
    and diabetes, 681
    and glanders, 95
    and influenza, 120
    and measles, 195
    and pericarditis, 557, 562
    and pneumonia, diagnosis, 135
    and sepsis, 71
    and vaccination, 238
    as cause  of bronchitis, 491
    of the bladder, 671
    of the bones and joints, 165
    of the brain, 159, 750
    of the genito-urinary apparatus, 164
    of the heart, 581
    of the kidney, 660
    of the larynx, 149, 486, 802
    of the lymph glands, 164
Tuberculous  meningitis, 159
    tumor of the brain, 750
    ulcer of intestine, 405
Tumor, of the brain, 750
    in cancer of the stomach, 383
Turpentine in tapeworms, 33
Typhliiis. 417
Typhoid bacillus, 269
    cholera, 338
    fever, 268
    fever and cerebro-spinal meningitis,
      310
    fever and dysentery, 320
    fever and pneumonia, diagnosis, 134
    fever and septicaemia. 70
    fever and variola, 229
    fever, perforation of intestine in, 801
Typhotoxine, 64, 271
Typhus abdominalis, 268
    exanthematicus, 25!)
    fever, 258, 259, 268
    fever and variola, 229

Uffelmann's test for lactic acid, 369
Ulcer, dysenteric, 328, 334
    of the intestine, 403
    of the stomach, 372
    of the stomach  and gall stones, diag-
      nosis, 452
    perforating, of foot, 690
    tuberculous, of the larynx, 149
    tuberculous, of the intestine, 148
Uraemia, 641, 655
    in yellow fever, 299
Urea, estimate of quantity, 642
    in blood, 599
Urethra, epithelium of, in urine, 649
Urethritis, posterior, 181
Uric acid in  blood  in gout,  examination
       of, 622
    acid in gout, 618, 622
    acid in infarction in new-born, 665
    acid in kidney stones, 663
Urinary system, diseases of, 637
Urine, bacillus tuberculosis in, 164
    blood corpuscles in, 665
    gonorrhoeal threads in,  184
    in cirrhosis hepatis, 468
    in hysteria, 761
    incontinence of, 672, 805
    sugar in, 678
    sugar in, tests for.  679
    test for bile in, 441
Uvula, deviation of, in facial  paralysis,
  695

Vaccination, 233
    followed by pericarditis, 558
    in the treatment of variola, 232
    syphilis, 238
Valvular fold of appendix vermiformis,
  420
Varicella, 240
    and variola, diagnosis, 243
Variola, 218
Varioloid, 225
Vasomotor neurosis, Raynaud's disease,
  730
Vegetable parasites, ectozoa, 9
Vegetations,  verrucose,  on valves   of
  heart, 565
Vein, femoral, obliterated, 596
Veins, disease of, phlebitis, 595
Ventilation, defective,  cause of bronchi-
  tis, 503
Ventricle, heart, hypertrophy of, 574
    heart, hypertrophy of, in  nephritis,
      642, 655
Vertebral caries, 165, 167
Vicarious emphysema. 519
    menstruation, 761
Vienna, small-pox in, 236
Vision, affection of, in endocarditis, 568 
INDEX.
821
Voice, piping, of paralysis agitans, 771
Volvulus, 429, 431
Vomit, black, 296
Vomited matter in cancer of stomach, 386
Vomiting, in intestinal occlusion, 433
    in stomach disease, 392
    treatment of, 396
Vomito negro, 296

Wasp, sting of, 9
Wasting palsy, 719
Water, necessity of, in dietary, 392
    purification  in prophylaxis of ty-
       phoid fever, 279
Weil's disease. 474
Whipworm, 44
Whisper, audible, as test of effusion in
   pleurisy, 546
Whooping cough, 112
    mortality of, 804
White blood corpuscles, variations of, 600
Wine whey, preparation of, 393
Worms, intestinal, 23
Wrist drop,  in lead poisoning, 787
    in neuritis, 691
Writer's cramp, 778
Writing hand in paralysis agitans, 771

Yeast plant, 3,  58
Yellow  fever, 296

Ziehl-Neelsen solution, 60
Zinc lactate in epilepsy, 750
Zooglcea,  56
Zwieback in dietary, 394
Zymoplastic matter in haemophilia, 614 
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