A TREATISE 
 
 ON THE 
 
 PRINCIPLES AND PRACTICE 
 OF MEDICINE 
 
 BY 
 
 ARTHUR R EDWARDS, A.M., M.D. 
 
 PROFESSOR OF THE PRINCIPLES AND PRACTICE OF MEDICINE AND OF CLINICAL MEDICINE AND 
 
 DEAN OF THE FACULTY IN THE NORTHWESTERN UNIVERSITY MEDICAL SCHOOL, 
 
 CHICAGO J ATTENDING PHYSICIAN TO MERCY, WESLEY HOSPITALS, ETC. 
 
 SECOND AND THOROUGHLY REVISED EDITION 
 
 ■ffUustcateO wttb 100 ]£ngravtngs anD 21 plates 
 
 LEA &. FEBIGER 
 
 NEW YORK AND PHILADELPHIA 
 
 1909 
 
« 
 
 A 
 
 Entered according to Act of Congress, in the year 1909, by 
 
 LEA & FEBIGER 
 
 In the Office of the Librarian of Congress. All rights reserved. 
 
 @EP^ 1909 
 
 ci a : 
 SEP 4 1909 
 
PEEFACE TO THE SECOND EDITION 
 
 The demand for a new edition of a work in so highly developed a 
 field of medical literature is both a commendation and a summons 
 to improvement. The author has spared no effort in complying. The 
 real advances throughout this enormous and active domain have been 
 incorporated, and the whole work has moreover been virtually re- 
 written to secure increased brevity and clearness. The result is 
 indicated by the fact that a vastly greater amount of information is 
 furnished in a space decreased by seventy pages. 
 
 A few of the additions and changes may be mentioned. Particu- 
 lar attention has been given to therapeutic details in accordance 
 with the recent awakening of the profession to the importance of 
 logical treatment; numerous new preparations, and modified names 
 and dosages, particularly for children, are explicitly specified. 
 There are practically new chapters on the arrhythmias and other 
 cardiac neuroses, tropical splenomegaly and various other tropical 
 affections. Due consideration has been given to the meningitis serum 
 of Flexner and Jobling, Strong's work on amoebic dysentery, blood 
 cultures in typhoid and other bacterisemias, the " carriers of infec- 
 tion," the recent epidemics of meningitis and poliomyelitis, the 
 accumulating evidence in favor of the spirochete as the cause of 
 syphilis and the recent status of tuberculin in its therapeutic applica- 
 tion and in its various diagnostic uses, as the ophthalmo-reaction, and 
 von Pirquet's test. ISTew plates are introduced, illustrating the diph- 
 theria bacillus and its cultural appearance and also the spirochete 
 pallida and refringens. 
 
 The chapters on tuberculosis and syphilis are designedly amplified, 
 as these diseases touch every organ, enter every specialty, and attain 
 as great sociological as medical importance ; indeed, an understanding 
 of these maladies is almost an understanding of medicine. Recent 
 statistics of case reports have been incorporated. Attention has been 
 given to numerous criticisms and many minor alterations have been 
 made in the interest of logic, clarity and conciseness. 
 
 So wide is the range of Modern Practice that an author who would 
 cover it in a single volume, and a reader who would grasp it intelli- 
 gently, must approach their respective, tasks with the aid of thorough 
 system. An effort has been made to deal with the subject in this 
 manner, from its mam- divisions, which follow the most rational 
 classification, down to the... subordinate, paragraphs. Careful use has 
 been made of types of various prominence to facilitate the finding of a 
 topic and the appreciation of its importance. With the vast mass of 
 material, an attempt has been made so to arrange the facts that the 
 
iv PREFACE. 
 
 reader may grasp the process of reasoning. Causative pathology has 
 been blended with the consecutive clinical features of disease, reasons 
 have been given for facts, exceptions have been subordinated to what 
 is usually found at the bedside, and the allurements of typical 
 clinical pictures and dogmatic generalizations have been avoided be- 
 cause they hold neither in practice nor at the postmortem table. 
 
 The author also conceives that a book on Practice should be well- 
 directed, which implies that it should deal adequately with scientific 
 theories and principles, but that it should recognize that the final 
 object of its existence is the application of knowledge to the cure or 
 alleviation of disease. Accordingly, an unusual amount of space has 
 been devoted to treatment to the detailed consideration of drugs and 
 to numerous formula? and prescriptions ready for the student to use 
 or improve upon. The physiological action of drugs has been dwelt 
 upon carefully because, in the writer's experience, the symptoms of 
 disease may be confounded with those of the remedies exhibited for 
 its cure. The index embraces the chief references to the remedies 
 and the formulae for their exhibition. 
 
 The reader will also find a large number of tables giving the differ- 
 ential diagnosis of diseases likely to be confused, and in many in- 
 stances, of entire subjects, such as those of the liver and kidney, the 
 chief eruptive diseases and those of the typhoid group. They are 
 practical though necessarily schematic. Nowadays the border-lines 
 of surgery and medicine overlap, and the practitioner, internist and 
 surgeon must be familiar with the province of each other. For this 
 reason, as far as the scope of the treatise admits, surgical indications 
 and results are introduced. 
 
 Names and dates are employed to give credit, where it is possible, 
 to the great workers in the history of Medicine. 
 
 The writer wishes to acknowledge the extremely careful attention 
 bestowed by the Publishers upon every literary and typographical 
 detail, and the assistance of Dr. Milton Mandel in the proof reading, 
 and of Dr. G. B. Dyche in many valuable suggestions. 
 
 A. E. E. 
 
 Chicago, 1909. 
 
CONTENTS 
 
 Section 
 
 I. 
 
 Section II. 
 
 Section 
 
 III. 
 
 Section IV. 
 
 Section V. 
 
 Section 
 
 VI. 
 
 Section 
 
 VII. 
 
 Section 
 
 VIII, 
 
 Section 
 
 IX. 
 
 Section 
 
 X. 
 
 Section 
 
 XI. 
 
 Page 
 
 Specific Infections 17 
 
 Diseases of the Circulation 363 
 
 Diseases of the Respiratory Tract 469 
 
 Diseases of the Digestive Tract. ....... 553 
 
 Diseases of the Kidney 737 
 
 Diseases of the Blood 797 
 
 Diseases of the Ductless Glands 839 
 
 Constitutional Diseases . 863 
 
 Diseases of the Nervous System 899 
 
 Diseases Due to Animal Parasites 1175 
 
 Intoxications. Sunstroke 1191 
 
SECTION I. 
 
 THE SPECIFIC INFECTIONS 
 
 TYPHOID FEVER. 
 
 The name (Typlaos, Stupor) refers to the clouded mentality, and 
 dates from Hippocrates. Bright, Louis and others recognized that 
 ulceration of the bowels occurred in certain continuous fevers but 
 typhoid was first described as a disease separate from typhus by 
 Gerhard and Pennock (1837). 
 
 Definition. — Typhoid fever is a general infection, characterized — 
 
 1. Etiologically by the Bacillus typhosus. 
 
 2. Anatomically by hyperplasia and ulceration of the lymphatic 
 structures of the intestine, hyperplasia of the spleen and mesenteric 
 glands, and by parenchymatous change in other organs. 
 
 3. Clinically by a characteristic fever, roseolous eruption, enlarge- 
 ment of the spleen, slow pulse, a peculiar serum reaction, typhoid 
 bacilli in the blood, and often by intestinal symptoms. 
 
 Etiology, — The typhoid bacillus was first seen by Eberth and Koch 
 (1880), and first cultivated by Graffky (1884). 
 
 1. Characters. — It has short, thick, rounded ends, is three times 
 as long as wide, in length is one-third the diameter of a red blood- 
 corpuscle, and its numbers are usually, but not always, proportionate 
 to the degree of infection. It is polymorphous, sometimes thread- 
 like, varies in different media, contains no spores, is flagellated, and 
 actively motile. It grows best at body heat, and is a facultative 
 anaerobe growing on various solid and fluid media, especially on agar, 
 gelatin, and, characteristically, on the potato. It does not produce 
 acid, ferment lactose, produce indol, or coagulate milk. It stains 
 with aniline dyes, but not by Gram's method; it produces an endo- 
 toxin only by the disintegration of the bacillus itself. 
 
 Recently typical lesions have been produced in the chimpanzee. 
 
 Its tenacity of life is great, the germ persisting for years in bone 
 lesions and from three weeks to three months after death. It resists 
 drying, except in thin layers, for months, and lives some time in 
 water, seldom longer than three weeks, although its multiplication is 
 prevented by saprophytes. The germ may live for months in ice, 
 sour milk, faeces, or in the upper, but not in the deeper, layers of the 
 soil. It may live a year in soiled clothes, which explains contagion 
 2 17 
 
18 THE SPECIFIC INFECTIONS. 
 
 in washerwomen and nurses. It is killed in a few hours by direct 
 sunlight. 
 
 2. Location. — It is found in the typhoid ulcers, in the lymphatics 
 of the mesentery, in the spleen, in the intestines at autopsy (chiefly 
 in the upper small intestine), in the fceces, in the blood, in the gall 
 bladder, in the urine, in the roseolse, less frequently in the lungs, 
 muscles, oesophagus and tongue, and in various secondary foci, as in 
 pleurisy, pneumonia (sputum), endocarditis, meningitis, parotitis, 
 osteomyelitis, and abscesses. According to Lynch, it has also been 
 isolated sixteen times from the blood of the foetus in maternal typhoid 
 infections. In curious cases typhoid bacilli may occur in the stools 
 of individuals, particularly children, not suffering from typhoid 
 fever. 
 
 3. Exteaxce. — It resists gastric juice fairly well, yet its chief 
 and probably sole atrium is the digestive tract, the infection being 
 carried in water (its main medium), milk, butter, ice. vegetables, or 
 oysters. As shown in the Spanish- American and Boer wars, dried 
 faeces containing the bacilli may be carried by flies and sand. Alice 
 Hamilton found the bacilli in flies in the Hull House region of 
 Chicago. Cockroaches and other insects may also convey infection. 
 
 4. Exit. — The germ leaves the body chiefly in the faeces and urine, 
 which are dangerous even far into convalescence; they are the chief 
 means of dissemination, the disease being less often conveyed directly 
 from one individual to another, although direct infection occurs in 
 hospitals and camps. Lentz found that after a typhoid attack four 
 per cent, of persons become " chronic carriers of typhoid bacilli," the 
 germs remaining in their dejecta for one, fifteen or even forty-two 
 years. Soper describes a cook who. though perfectly well herself, 
 was a " bacillen-trager " and caused 26 cases of typhoid fever in 
 five years. 
 
 Predisposing Etiology. — 1. Reduced Physiological Resistaxce. 
 — Reduced physiological resistance, as from overwork or mental de- 
 pression, is a frequent predisposing cause : yet typhoid very often 
 occurs in the robust. It is claimed that the weak or emaciated are 
 immune. — e. g., those with syphilis, tuberculosis, cancer, endo- 
 carditis, anaemia, or convalescents from other diseases. Some im- 
 munity is claimed in pregnancy, lactation, and the puerperium. Ali- 
 mentary affections, according to Bouchard, such as decreased 
 hydrochloric acid formation, or dilated stomach, favor infection. 
 Most cases occur in time of war. or among the poorer classes, or 
 among recent residents in typhoid localities (Trousseau). 
 
 2. Seasox. — For unknown reasons most cases develop in the late 
 summer and fall (" autumnal fever "). 
 
 3. Age. — The years from fifteen to twenty-five include most cases 
 (56 per cent.), yet foetal cases are recorded, and a few cases occur in 
 the first year of life. Their number increases from the first to the 
 fifth year. Between the fifth and fifteenth years as many are affected 
 as after thirty-five. The disease is relatively rare after fifty. 
 
TYPHOID FEVER. 19 
 
 4. Geographical Distribution. — Typhoid is endemic rather 
 than epidemic. Although it is the most common continued fever 
 in temperate climates, it is a world-wide disease and sustains a 
 most intimate relation to the water • supply, the disposal of sewage, 
 the density of population, and personal hygiene. 
 
 Immunity, — Congenital immunity is not proved. Immunity has no 
 relation to the severity of the disease, though it is usually conferred 
 after one attack, but is not life-long nor as frequent as in the case of 
 scarlatina. In the Hamburg epidemic (1887), 2xo per cent, of the 
 cases were second attacks ; and in Eichhorst's series there were over 
 4 per cent, of such attacks. These second attacks equal or even 
 exceed the original in severity. 
 
 Symptoms. — The general clinical picture offers more variability 
 than that of any other infection. Typhoid is not an intestinal disease, 
 but a general infection. Its forms are : 
 
 1. The typical enteric, frequently with, diarrhoea, tympany, hemor- 
 rhage, and perforation. 
 
 2. The septicemic, without any, or with very slight, anatomical 
 intestinal lesions, though responding to the Widal test and accom- 
 panied by bacillsemia. 
 
 3. Other localizations than enteric ; e. g., in the lung, larynx, bone 
 or gall bladder. 
 
 4. Mixed infections — malaria, streptococcus, colon bacillus, etc. 
 
 5. Paratyphoid, with close clinical resemblance to typhoid but 
 with organisms differing culturally and in their agglutinating reac- 
 tions. (See Diagnosis.) 
 
 The incubation lasts one to two weeks, with symptoms more vague 
 than in other acute infections, — e. g., depression, pains in the head, 
 back, or limbs, dulness of hearing, disturbed sleep, or perhaps chilli- 
 ness, anorexia, epigastric oppression, constipation, or even diarrhoea. 
 The incubation lasted only three days in a girl who took a pure 
 typhoid culture with suicidal intent. 
 
 The first week corresponds anatomically to the intestinal catarrh 
 and the beginning of medullary infiltration of Peyer's plaques. The 
 disease dates from the fever, which each evening is from 1° to 1.5° 
 higher than on the previous day, until a temperature of 103° to 104° 
 is reached. The pulse is full, dicrotic, and rapid, but not high in 
 proportion to the fever. The tongue is coated white. Thirst, anorexia, 
 dry cough, enlarged spleen, eruption of rose spots, and typhoid ba- 
 cilli in the blood, are found. The abdomen shows slight distention 
 and pain or tenderness over the ileocsecal region or epigastrium. 
 Delirium is infrequent, and headache, constipation, dulness and 
 apathy are usually present. 
 
 The second iveek corresponds to the end of medullary infiltration 
 and the beginning of eschar-formation. The fever is higher and 
 usually continuous ; the morning remission is less. The pulse is full, 
 faster, and less dicrotic. The blood responds to the Widal test. 
 The tongue is dry and glazed, as are also the lips, pharynx, and 
 
20 TEE SPECIFIC INFECTIONS. 
 
 mouth, to which the mucus adheres. The voice is weak. The bron- 
 chitis increases, and the urine is febrile. Abdominal symptoms are 
 often aggravated. Meteorism appears. Yellow pea-soup dejecta, 
 which are involuntary in severe cases, occur. Roseolae usually de- 
 velop during this week. The face is apathetic, its lines obliterated, 
 the mouth half open, and the upper lip retracted, showing sordes, 
 Nervous symptoms increase with higher fever; delirium follows; 
 the patient becomes less querulous; and euphoria from narcosis by 
 the toxins is the rule, while pain suggests complications. The patient 
 may begin to recover, through the increased bactericidal powers of 
 the body fluids, or may die at this stage from hemorrhage, nervous 
 toxaemia, etc. 
 
 The third week is the stage of ulceration. The fever gradually de- 
 clines with marked morning remissions and unaccountable variations. 
 The pulse is smaller, and faster (100 to 120), and loses its dicrotism; 
 it is sometimes slower. The tongue clears and the roseolse disappear, 
 being replaced by miliaria from sweating. In exceptional cases diar- 
 rhoea may be seen for the first time in this week. Emaciation is 
 marked. When the fever falls, the patient complains of hunger, 
 weakness, and pain. Death may occur in the typhoid state from 
 heart weakness, pulmonary inflammation, paralysis of the nerve- 
 centers, hemorrhage, or perforation. 
 
 The fourth week (cicatrization) usually marks convalescence, as 
 the average duration of typhoid is from three to six weeks; in 
 severe cases the symptoms assigned to the third week may continue. 
 Convalescence may be uneventful, or marred by slight temperature, 
 rapid pulse, palpitation, nausea, vomiting, muscular weakness, etc. 
 
 Symptoms in Detail. — To avoid repetition, and to explain anatom- 
 ically the clinical signs and symptoms, the typhoid pathology will 
 be incorporated under the appropriate organs, and complications 
 and sequels will be classified with the more common typhoid mani- 
 festations. 
 
 1. Fever. — Fever is an expression of toxaemia, and is a cardinal 
 symptom of typhoid. It is subacute, averages three to four weeks in 
 duration, usually comes on without chill, and resolves by lysis. It 
 is the best studied chapter in the disease since the time of Wunder- 
 lich, who diagnosticated typhoid from the fever chart alone. In the 
 first week, corresponding to the catarrh and medullary infiltration, 
 the evening temperature is A° to 1° more than in the morning, and 
 the ascension is ladder-like. In the second week, corresponding to 
 the end of infiltration and to the formation of the slough, the fever 
 is continuous from one-half to three weeks. In the third week 
 (ulceration), the fever is remittent, the amphibolic stage of Wunder- 
 lich, and the stadium hecticum oi Traube. The cause of fever 
 variations is not known. The fourth week (cicatrization) is the stage 
 of " steep curves," lasting from three to eight days. When a sudden 
 drop occurs, recurrences and relapses are not infrequent. 
 
TYPHOID FEVEB. 
 
 21 
 
 Convalescence. — In its first week the fever-curve is usually sub- 
 normal; when not so, some irregularity must be looked for. Later 
 there is a gradual rise to normal. 
 
 Atypical Fever Course. — As to onset, two variations may be ob- 
 served, a sudden rise of the fever or its incidence with a chill. 
 Chomel (1834) described cases with sudden onset and De Mussy 
 (1884) spoke of an explosive onset; a sudden onset is observed in 
 10 per cent, of typhoid cases. The writer saw, with Dr. Korssell, a 
 child whose temperature rose suddenly to 106° on the second day. 
 When there is an initial chill every other possible disease should 
 first be excluded, yet Osier observed chills in 22 per cent, of his 
 cases; (a) at the onset, especially in children, and in light forms; 
 (b) throughout the course, and accompanied by sweats, the sudoral 
 
 Fig. 1. 
 
 Typical typhoid-fever curve. — The heavy line marks the temperature curve, and the 
 broken line the pulse curve. 
 
 type of the French; (c) in complications — pneumonia, pleurisy, 
 otitis media; (d) after antipyretics, tubbing, or (e) in defervescence 
 from secondary sepsis. 
 
 In the second week especially high temperature suggests complica- 
 tions; if the fever becomes very high, the course is apt to be severe. 
 Sometimes a pseudo-collapse may occur, particularly in subjects be- 
 tween twenty-five and thirty years of age. 
 
 In the third or fourth week, the fever exceptionally may decline 
 by crisis; Jaccoud observed a brusque defervescence in 29 per cent, 
 of his cases. 
 
 The fever may be intermittent or remittent throughout the dis- 
 ease, especially in children, the aged, and in severe cases. Irregu- 
 larity and variations, especially when protracted, cause difficulty in 
 diagnosis, suggesting, perhaps, miliary tuberculosis or sepsis. 
 
 In the typus inversus, seen chiefly in children and the aged, the 
 morning temperature is higher than the evening record. Afebrile 
 
22 
 
 TEE SPECIFIC INFECTIONS. 
 
 typhoid is exceptional. Modification of temperature may be caused 
 by visits from friends, excitement, entrance to the hospital, diet, 
 hemorrhage, abortion, peritonitis, and other complications, as well 
 as by relapse. 
 
 2. The Splenic Tumoe. — The splenic tumor is a cardinal symp- 
 tom occurring early and frequently, persisting in exacerbations and 
 relapses. In importance and size, it ranks second to the splenic 
 enlargement of malaria and sepsis. The cause of this tumor is the 
 bacillus or its toxin (not the fever) which produces splenic hyperemia 
 and hyperplasia — changes closely analogous to those in the intestinal 
 lymph-structures. Massive endothelial proliferation is said by 
 
 Fig. 2. 
 
 DAY 1 2 3 4 a 7 S 10 11 12 13 14 15 lfi 
 
 17 18 L-J 20 21 22 23 24 25 20 27 2S 29 :J0 31 32 
 
 TEMP. 
 
 
 104. 
 
 
 
 
 
 
 103 | 
 
 i 
 
 ft 
 
 I *-4Pj 4- -, 
 
 \ A a , TV ) 
 
 ft tit t i 
 
 102 f aa a a \ a y 
 
 ^ Alt. -A 4 
 
 \/ \ r iu m v 
 
 ^4 -\tB-3 A-4 
 
 a v V k \ \\\r 
 
 H £2 ?- it 
 
 ioi v \ A i , I If 
 
 Q_,Qt t . t± 
 
 V V V 
 
 S+\7 4 -- -,-tttl 
 
 
 I 4 -J jitti 
 
 100 
 
 tt 4 UJttfl 
 
 
 i '-tin 
 
 
 H 44 
 
 '.19 
 
 I 
 
 
 j 
 
 
 "1 
 
 98 
 
 
 
 
 
 
 
 
 Typhoid fever ; irregular fever curve throughout the course. 
 
 Mallory to occur in the splenic, lymphatic, and medullary vessels. In 
 the first week the spleen is hypersemic and swollen to two or three 
 times its normal size. Its markings are indistinct. In the second 
 week it is more pulpy and darker. By the fourth week it has 
 usually disappeared, but as long as we find the splenic tumor, the 
 disease has not ended. 
 
 Frequency. — (a) Anatomically the splenic tumor is present in 
 98.4 per cent, of the cases. Its rare absence is explained by thicken- 
 ing of the capsule, old induration or infarction of the organ, or 
 extreme emaciation, (b) Clinically, it is present in 75 per cent. 
 (Curschmann) or 90 per cent. (Leube). The percentage varies with 
 the skill of the observer, the method of examination, the epidemic, 
 and age of the subject (the sign being often absent in children, in 
 adults older than forty-five years, or after hemorrhage). It should 
 be palpated with the patient in the right diagonal position. The 
 examiner should stand or sit on the right side of the patient, pal- 
 pating with the right hand pressing evenly on the abdomen, and the 
 
TYPHOID FEVEB. 23 
 
 left hand hooked beneath and lifting up the lower left ribs. Tym- 
 pany may obscure the splenic tumor. The author has twice seen the 
 spleen ruptured by deep or rough palpation. Percussion of the spleen 
 is worthless. It should be remembered that the spleen may be ectopic. 
 Relatively rare splenic complications are abscess, infarct and rupture. 
 
 3. Dermal Symptoms. — (a) Rose Spots (roseola typhosa, tdche 
 rosee lenticulaire of Louis) constitute the third cardinal symptom. 
 They are round spots, varying from the size of a pin-head to that of a 
 lentil (lenticular), circumscribed, rose-colored, slightly elevated to 
 the touch, purely hypersemic, and therefore disappearing on pressure 
 and reappearing on its release, not often fusing, and later becoming 
 darker, but leaving no mark, with sometimes a vesicle at their apex, 
 and rarely desquamating, except in a few infantile or juvenile cases. 
 They are rarely hemorrhagic, and therefore the commonly used term, 
 petechia, is inappropriate. Being purely hypersemic, they are not 
 found at autopsy. They scarcely ever pustulate. They may be seen 
 as early as the fourth day, especially in women and children, but 
 usually appear from the seventh to the tenth day. They occur in 
 crops, during two weeks, each crop lasting from three to five days. 
 Occasionally, they outlive the fever. Their location is on the lower 
 chest and abdomen, though they sometimes appear twenty-four hours 
 earlier on the back, because of its warmth. They rarely occur on the 
 neck or face, and generally are more frequent on the proximal than 
 on the distal parts of the extremities. If there are many spots on the 
 lower parts of the limbs, they are probably not roseolse. They num- 
 ber five to ten, or even thirty. They are more abundant in women, 
 less so in children and the aged, and seldom so abundant as to re- 
 semble measles closely. Their frequency varies somewhat with the 
 epidemic. Eichhorst found them constantly in more than 1,200 
 cases, Leube in 80 per cent., Osier in 93 per cent., and Murchison in 
 33 per cent. 
 
 Typhoid bacilli in the roseolse may establish a doubtful diagnosis, 
 but rarely an early one; Polacco found bacilli in 100 per cent, and 
 Krause in 94 per cent, of their cases. In other diseases, as miliary 
 tuberculosis, meningitis, and pneumonia, roseolse are very rarely 
 encountered. 
 
 (b) Other Cutaneous Manifestations. — The typhoid odor is musty 
 or semi-cadaveric. Miliaria are frequent, though less than in sepsis. 
 They usually appear in the third or fourth week. Herpes is rare, 
 occurring in less than 1 per cent, of the cases. The author has ob- 
 served it only ten times in upwards of 1,800 cases. It is far less 
 frequent than in pneumonia, malaria, typhus, meningitis, and in- 
 fluenza. Decubitus occurs in 1 per cent., mostly in severe and hos- 
 pital cases. Noma is a rare complication. In 204 cases of gangrene 
 collected by Keen, 50 per cent, occurred in the leg, 25 per cent, in 
 the face, neck, and trunk, and the balance in other locations. Sweats 
 and chills occur in the " typhus sudoralis," especially in the latter 
 half of the fever course, described in Naples by Borelli and in Paris 
 
24 
 
 TEE SPECIFIC INFECTIONS. 
 
 by Jaccoud. (Edema is due most frequently to phlebitis, sometimes 
 to anaemia, and rarely to nephritis. The skin sometimes shows 
 atrophic striae like those of pregnancy. Desquamation may occur, 
 particularly in children. Other cutaneous manifestations are : Urti- 
 caria; erythema, even of the nodose or exudative forms; pelioma 
 typhosum, or the tdche bleudtre — pale blue spots measuring 4 to 10 
 millimeters, due to pediculosis, and therefore seen in parts nearest 
 the pubic or axillary hair, etc. ; erysipelas, phlegmon and furuncles 
 (increased by hydrotherapy) ; alopecia after the typhoid attack, 
 rarely followed by permanent baldness. 
 
 4. Circulation. — (a) The Slow Pulse. — The slow pulse is the 
 fourth cardinal symptom. In uncomplicated cases it follows the 
 temperature in the early stages, but is lower than the fever would 
 justify, especially in men under forty years; e. g., pulse 90 with 
 the fever 103°. It is rather faster in women, in children, and in the 
 nervous. Its slowness is due to an inhibitory action of the toxins 
 on the medulla or the heart, a fact not recognized either by the older 
 or by some modern writers. The author has seen four typhoid cases 
 in which the pulse ranged from fifty-six to sixty-four, with the 
 fever above 103° and the respirations above forty. Slowness is of 
 
 Fig. 3. 
 
 Pulse tracing in typhoid, showing dicrotism. 
 
 good import. At first a little tense in volume, it soon becomes 
 dicrotic, which, with slowness, suggests typhoid. Dicrotism, evi- 
 denced by a double shock, occurs in 80 per cent, of cases, but is not 
 prognostic. It is due to the shortened systole and to decreased 
 peripheral resistance. It is usual in adults, and is absent in children 
 and often in adults at the fastigium in very severe cases. Since it 
 indicates lack of arterial tone, it is also absent in arteriosclerosis, in 
 rigidity of the aorta or in vaso-motor paralysis. In Osier's Clinic, 
 the blood-pressure was found to be 115 to 125 millimeters of mercury 
 in the systole, and 85 to 100 millimeters in diastole. A fast pulse 
 early in the typhoid course is a poor prognostic, especially in men. 
 Irregularity or crossing of the pulse and temperature-curves, is also 
 ominous. The pulse may become faster from heart or lung inflam- 
 mation, perforative peritonitis, hemorrhage, and severe intoxication. 
 It may also run up on visiting days, in women, children, emaciated 
 and nervous individuals, or in the stage of great temperature varia- 
 tions. In the first stage of convalescence, when there is subnormal 
 
TYPHOID FEVEU. 25 
 
 temperature, the pulse is usually normal in rate, or slow, which is 
 explained by disturbed conductivity in the heart muscle or by myo- 
 carditis. In the second stage it is usually higher than normal, 
 especially after the patient gets out of bed, after eating, or a move- 
 ment of the bowels. On the whole, bradycardia in convalescence is 
 more common than tachycardia. 
 
 (b) Heart Muscle. — Early pathological changes are rare. Par- 
 enchymatous degeneration, evidenced by albuminous granules, nu- 
 clear swelling, and pigmentation, are found later, the heart as a 
 whole being flabby, soft, pale, and even waxy. Fatty and hyaline 
 degeneration, vacuole formation, and segmentary myocarditis are 
 the usual findings in fatal cases. Interstitial myocarditis, like that 
 of diphtheria or scarlatina, occurs in over 50 per cent, of typhoid 
 cases (Rhomberg). It usually regresses without functional or or- 
 ganic disturbance, and chronic myocarditis rarely develops. Its 
 clinical signs may appear at the end of the second week, lasting into 
 the fourth week, or may develop first in convalescence. The symp- 
 toms are gradual dilatation of the left ventricle, weak tones (espe- 
 cially the first tone at the apex), accentuation of the second pulmonic, 
 a systolic bruit, and a fast, irregular pulse with lessened tension but 
 without dicrotism. Tachycardia, without myocarditis, may result 
 from the toxins acting on the medulla oblongata. Recovery is usual, 
 even if the myocarditis lasts two or three months. 
 
 Dilatation of the right heart may be observed in severe cases. 
 Less frequent are the following complications: Cardiac thrombosis 
 and embolism; pericarditis ([once in 1,000 typhoid autopsies], 
 mostly fibrinous, and mostly in complicating sepsis) ; and endocar- 
 ditis ([once in 1,000], mostly mural over myocarditic patches), 
 sometimes due to Eberth's bacillus. Collapse, with its usual signs, 
 may cause death from heart degeneration, or from toxic vasomotor 
 paralysis (as in diphtheria, pneumonia, or pyocyaneus infections) ; 
 myocarditis is the most frequent cause, while pulmonary embolism, 
 uraemia, cerebral hemorrhage, etc., are far less common. Some- 
 times no clear cause is discovered at autopsy. Collapse develops 
 mostly in strong men (80 per cent, of Dewevre's 140 cases) and 
 most often during convalescence. (See Peognosis.) 
 
 (c) Vessels. — Phlebitis typhosa occurs in 1 per cent, of the cases, 
 being considered marantic, or infective due to Eberth's bacillus 
 or pus cocci, when pain and fever are present; it occurs chiefly in 
 males, is unilateral and is usually left-sided, since the left iliac vein 
 has a slower current, being crossed by the right iliac artery. The 
 symptoms are pain, coldness, oedema, and sometimes a tender, palpable 
 cord, which should be manipulated most carefully, if at all, lest 
 embolism be caused. Thrombosis usually occurs in the saphenous 
 vein where it empties into the femoral, sometimes in the popliteal 
 vein, and rarely in the arms. It may extend from the leg to the 
 cava, when the other leg may be involved. There is some danger 
 of detachment, pulmonary embolism, and sudden death ; but relative 
 
26 TME SPECIFIC INFECTIONS. 
 
 recovery is usual after two or three mouths. Arteritis typhosa, most 
 often found in the femoral artery, is rare, W. W. Keen collecting 
 only forty-four cases. It is a specific inflammation caused by the 
 typhoid bacillus. Spontaneous gangrene may result. Arterioscle- 
 rosis may be initiated by typhoid. 
 
 (d) The Blood.— The red blood-cells average 4,000,000. Their 
 reduction is always slow, and anaemia is especially frequent during 
 the third week or in relapses. An apparent increase of the red disks, 
 analogous to that observed in cholera, may result from loss of fluids, 
 as from diarrhoea (Hayem). The haemoglobin decreases propor- 
 tionately to, or slightly in excess of the oligocythaemia, especially in 
 convalescence. Marked post-febrile anaemia is not common. The 
 leukocytes decrease from 8,000 to 3,000, or even less, but average 
 5,000 per cubic millimeter. Leukopenia is more common in typhoid 
 than in any other febrile condition and helps to differentiate it from 
 pneumonia, sepsis, meningitis, etc. It is possibly due to destruc- 
 tion of the lymphatic elements by the endothelial phagocytes. In- 
 crease of the white cells occurs only in complicating inflammations 
 or in convalescence. The polymorphonuclear neutrophiles are abso- 
 lutely and relatively decreased to below 60 or 50 per cent., while 
 they are increased in other infections. The large mononuclear and 
 transitional forms are relatively increased. The eosinophiles are 
 greatly decreased; their return is a good prognostic (Tiirck). 
 
 Typhoid is a primary bacilloemia or septicaemia. Frankel and 
 Simmonds, in 1885 first found the bacilli in the blood. The bacilli 
 reach the blood from the lymphopoietic organs, and from the blood 
 reach the faeces secondarily by way of the bile or by ulceration of 
 Peyer's patches. A positive blood culture is the safest and surest 
 means of diagnosis in the first week of typhoid. Cultures are posi- 
 tive in 100 per cent, in the first week, in 71 per cent, in the second 
 and in 36 per cent, in the third week (Silverberg). Convalescence 
 is rapidly established as soon as the bacillaemia ceases. 
 
 The Gruber-Widal Serum Test. — The " agglutination " and " im- 
 mobilization " of typhoid bacilli brought in contact with a typhoid 
 serum, were found by Durham and Gruber, and also independently 
 by PfeifTer and Kolle. Gruber pointed out the value of the test in 
 proving the existence of a previous typhoid, while Widal applied the 
 laboratory facts at the bedside, and found the reaction during the 
 disease. The agglutinins are produced by the tissues reacting to the 
 bacilli. 
 
 Technique. — A bouillon culture, not more than twelve to eighteen 
 hours old, is used, taking forty parts of the bouillon and one of the 
 blood (dilution of 1 to 40). The test may be made macroscopically 
 in the test-tube, or on the microscope slide, where immobilization, 
 clumping, and agglutination of the bacilli, may be observed some- 
 times in a very short time — -an hour is the usual time-limit for the 
 test. Picker and Puediger have recently employed dead cultures 
 with equally accurate results, and this method is certainly more con- 
 
PLATE I 
 
 FIG. 
 
 .* -• / 
 
 - • 
 
 > 
 
 — • I 
 
 X / 
 
 > ' s» 
 
 
 /■■/ 
 
 ' 
 
 - 
 
 «/ 
 
 *i — , 
 
 _ 
 
 _ ' — 
 
 Bouillon Culture of Typhoid Bacilli before the Addition of Diluted 
 Typhoid Serum. X 500. (After Cabot. ) Serum diagnosis. 
 
 FIG. 2 
 
 The Same, Five Minutes after the Addition of Typhoid Serum 
 
 (dilution 1 to 10), showing Typical Clump Reaction. 
 
 X 400. (Cabot.) 
 
TYPHOID FEVER. 2? 
 
 venient, safe, and capable of wider use than the use of living bacilli, 
 especially in country practice. (Plate I.) 
 
 Significance. — The Gruber-Widal reaction may be found thirty 
 years after a typhoid attack. It is sometimes absent in typhoid, 
 particularly in severe cases and it often develops late, e. g., on the 
 seventeenth or the fortieth day. Cabot found the reaction in 97 
 per cent, of 5,978 collected typhoid cases. In Osier's series it ap- 
 peared in 93 per cent, before the eighth day. When it appears in 
 the first week, it is due to a " silently developing " infection (Widal) ; 
 i. e., the typhoid is more advanced than we appreciate. Leube 
 considers the test significant only when it is absent in the early 
 stages and develops later, care being necessary in all other cases 
 whether the reaction be positive or negative. Undue importance is 
 sometimes attached to this as well as to many other laboratory tests, 
 invaluable though they may be in connection with the physical 
 findings. Typhoid bacillsemia decreases as the Widal reaction de- 
 velops. Kasel and Mann believe the reaction is not one of infection, 
 but one of immunity, agglutination becoming most marked toward 
 the end of the disease. 
 
 5. Nervous Symptoms. — Typhoid was once called " nervous 
 fever" (febris nervosa, nervenfieber) . The nervous system may be 
 conspicuously involved even in the incubation stage. 
 
 (a) Headache. — Toxsemic headache is almost invariable, being 
 most often frontal or occipital, constricting, throbbing, or a pressure 
 sensation. It usually disappears in the second week, and, if it lasts 
 or develops late, it may indicate meningitis. Insomnia may be 
 both early and lasting. The early excitation passes into the later 
 euphoria of the typhoid state. 
 
 (b) The Typhoid State. — The typhoid state begins in the second 
 week (v. s.) with apathy and delirium, which is usually mild. The 
 patient may attempt to get out of bed, and, in alcoholics, delirium 
 tremens may be simulated or actually develop. In mild cases delir- 
 ium lasts into the third week. In very irritable subjects, as in 
 women and children, or in overwhelming intoxication, we may have 
 photophobia, stupor, coma, loud breathing with an open mouth, ab- 
 sence of the pharyngeal reflex, involuntaries, waving of the hands 
 (floctitation), leaping of the tendons (subsultus tendinum), picking 
 of the bedclothes (carphologia), trismus, contractures, grinding of the 
 teeth, rigid neck, and convulsions (in children especially), which 
 symptoms are not due to the fever, since they all may occur with 
 low temperature, but to toxsemia. In coma-vigil the patient is semi- 
 comatose subjectively, but the open, unseeing eyes give a " watchful ", 
 appearance objectively. Anatomically a " wet-brain " is found. 
 Murchison observed convulsions but six times in 2,960 cases. They 
 may develop in children, in severe intoxication, or from such cere- 
 bral complications as meningitis, encephalitis, thrombosis, or em- 
 bolism. 
 
 (c) Nervous Complications. — Typhoid may begin as mania. The 
 
28 THE SPECIFIC INFECTIONS. 
 
 author has seen five typhoid patients taken to the detention hospital 
 in the third week, or even in convalescence, under a mistaken diag- 
 nosis. Mania may be a later symptom. 
 
 Psychoses are due to the exhausting inanition of protracted toxae- 
 mia, or sometimes an hereditary predisposition. They are generally 
 post-febrile, are of the depressive variety such as melancholia, and 
 usually give a favorable prognosis, though alienists assert that one- 
 third to one-fifth do not recover. Edsall (1905) found that two 
 thirds of juvenile cases recover. Typhoid may cure a previous 
 insanity. 
 
 Meningitis occurs in 0.5 per cent, of cases, mostly in women and 
 children, generally as a complication and late in the typhoid course. 
 Meningitis may be due to the pneumococcus, the pyogenic cocci, or to 
 Eberth's bacilli, which have been found on lumbar puncture in over 
 twenty-six cases (Cole), of which half were serous and half suppura- 
 tive. There are four recorded cases of tuberculous meningitis com- 
 plicating typhoid. Actual meningitis must not be confounded with 
 pseudomeningitis or " meningismus," in which toxaemia . produces 
 irritative meningeal symptoms, as described under typhoid state 
 (v. s.). 
 
 In the brain, oedema, degenerated and pigmented ganglionic cells, 
 and nuclear multiplication, are the most common findings at the 
 autopsy. Hemorrhage, embolism, arterial and sinus thrombosis, and 
 abscess (sepsis), are rare pathological complications. Aphasia, mon- 
 oplegia, hemiplegia, and paralysis of the cerebral nerves, are rare 
 clinical complications. The author has twice noted hemiplegia devel- 
 oping suddenly in convalescence, probably embolic from detached 
 heartclots. In both cases the patients were allowed to leave the bed 
 too soon. Forty cases of hemiplegia in typhoid are on record. 
 
 In the spine, myelitis, multiple sclerosis, infantile paralysis, and 
 Landry's paralysis (Eberth's bacillus), are rare complications or 
 sequels. The knee-jerks are sometimes increased, especially in ema- 
 ciated subjects. 
 
 Neuroses may complicate convalescence, such as chorea, hysteria, 
 neurasthenia, Basedow's disease, tetany, paralysis agitans, etc. 
 
 In the nerves, neuritis in the single or multiple form (q. v.) 
 with anaesthesia, paralysis, and atrophy, may follow typhoid as it 
 does other infections. [Neuralgia occurs late. In the feet it con- 
 stitutes the " tender toes " of Hanford, and is seemingly increased 
 by bath treatment. It always results in recovery. 
 
 6. Digestive Tract. — The upper lip is retracted and bleeds 
 easily. Sordes of dried saliva, food, and epithelium, are observed 
 on the teeth and gums. Though the tongue shows nothing absolutely 
 characteristic, Leube attaches special importance to its appearance. 
 At first it is white on the dorsum, moist, flabby, and therefore in- 
 dented by the teeth, and its edges are red. It may be moist through- 
 out the disease. In the second week it becomes dry (from the fever, 
 lack of saliva, and mouth-breathing), small and fissured; it bleeds, 
 
TYPHOID FEVER. 29 
 
 and a brown or even black coating replaces the white. In the third 
 week or later, a triangular patch clears at its tip. Typhoid bacilli 
 are not uncommon on the tongue. Acute glossitis is a severe com- 
 plication. Aphthae are rare. 
 
 Angina may usher in the disease, or, occurring in the first week, 
 lead to a wrong diagnosis. The throat is swollen, granular, and 
 eroded. The angina, usually of the ordinary type, may be due to 
 the typhoid bacillus (Wagner and French). The phlegmonous type 
 is very dangerous. An angina cachectica of white plaques or epi- 
 thelium and bacteria is occasionally observed. Letulle has seen 60 
 cases with yellowish or pinkish gray ulcers on the uvula or anterior 
 pillars. 
 
 Parotitis, occurring in \ to 1 per cent, of the cases, has become 
 less frequent since special care of the mouth has lessened infection 
 ascending Steno's duct. It is usually one-sided, is due to the typhoid 
 bacillus, or pyogenic cocci, and is usually seen on the fifteenth day. 
 The prognosis is poor, especially when due to metastasis. Two per- 
 sonal cases, caused by the typhoid bacillus, recovered. 
 
 Ulceration of the oesophagus is very rare ; the cicatrized ulcer may 
 produce later stenosis (twelve cases were collected by J. E. Thomp- 
 son, 1904). 
 
 Specific typhoid lesions are rarely observed in the stomach, 
 although hsematemesis occurs (Leube and Schlesinger). Early and 
 severe epigastric pain rather contraindicates typhoid. Incipient 
 nausea and vomiting are unusual, occurring mostly in women or 
 children. If observed at the height of the disease these symptoms 
 suggest meningitis, overfeeding, or perforation, and (in convales- 
 cence) dietetic errors. 
 
 Anorexia is observed at the onset and during the fastigium, though 
 great hunger develops in convalescence. 
 
 Specific changes in the intestines: (a) Hypercemia, catarrh, and 
 beginning medullary infiltration in the lymphoid structures during 
 the first week, most changes being observed in the lower ileum, 
 whence the name ileo-typhoid. (b) Medullary infiltration or hyper- 
 plasia, during the second week, occurring first in Peyer's patches, 
 and then in the follicles. The patches are oval and parallel with the 
 long axis of the gut ; they lie opposite to the mesenteric attachment, 
 are 3 to 5 millimeters high, and are at first red, then paler from 
 compression of the bloodvessels. The infiltration is hard or soft. It 
 may be uneven and reach beyond the plaque. The solitary follicles, 
 even to the sigmoid flexure (colotyphoid), may be principally en- 
 larged. These changes are not absolutely distinctive of typhoid, but 
 are more significant in adults than in children, in whom they are 
 frequent in digestive diseases, the exanthemata, and diphtheria. 
 Mallory believes that the lymphoid swelling is wholly explained by 
 the proliferation of the endothelial cells of the vessels to act as phago- 
 cytes; when they degenerate, fibrinous thrombi develop. Medullary 
 infiltration need not advance to ulceration. Eegression may occur 
 
30 TEE SPECIFIC INFECTIONS. 
 
 and the lymph-cells degenerate and disappear. The lymphatic struc- 
 tures may then assume a reticulated, or " shaven beard," appearance, 
 (c) Ulceration occurs in the third week, from anaemic necrosis, 
 slough formation, and exfoliation of small particles. The ulcers thus 
 formed by the typhoid bacilli are usually easily seen without opening 
 the gut. They have an irregular, oval outline, sharp, steep, often 
 undermined edges, with a red floor generally composed of the muscu- 
 lar coat and often extending deeper than the eschar. The lower 
 ileum is most affected and may present almost no normal surface in 
 extreme cases. The solitary follicles, both in the large and small gut, 
 ulcerate at their apices. Baer has studied the localization of the 
 typhoid ulcer and states that it may occur in any part of the digestive 
 tract except the mouth. The pharynx is affected in 2 per cent, of 
 the cases, the oesophagus in 4 per cent., the stomach in 2 per cent. ; 97 
 per cent, of the ulcers develop in the small intestine, 89 per cent, in 
 the ileum, 2 per cent, in the appendix and 33 per cent, in the large 
 intestine, (d) Cicatrization occurs by granulation tissue and growth 
 inward of the epithelium. The patch is depressed and slightly pig- 
 mented. The typhoid cicatrix does not narrow the intestinal lumen. 
 
 There may be few or no anatomical changes in the intestine. 
 Slight bowel lesions are usually present in most of the cases reported 
 " without intestinal lesions." 
 
 The mesenteric glands are swollen in the second week, contain ty- 
 phoid bacilli, are altered like the intestinal lymphatics, and may be 
 palpable. The swollen glands usually regress, but may soften, be- 
 come tuberculous, or suppurate, sometimes causing peritonitis, or 
 simulating perforation. Only six cases are recorded of suppuration 
 in the mesenteric glands ; Le Conte reports a recovery after operation. 
 
 No parallelism exists between the frequency, constancy, or severity, 
 of the clinical symptoms, and the degree of anatomical involvement ; 
 e. g., in ambulant cases there may be perforation or hemorrhage, or 
 lethal cases may occur with little intestinal change. 
 
 Meteorism is rather less common than usually described. It occurs 
 mostly in the duodenum or jejunum above the ulceration, but some- 
 times involves the colon. It is less frequent and less intense with 
 early treatment and careful dieting. If much tympany develops 
 under these circumstances, the prognosis is poor, since meteorism is 
 due to toxcemic paresis of the intestinal musculature rather than to 
 local ulceration. The heart and lungs may be crowded upward and 
 dyspnoea result. It may occur with hemorrhage or perforation. 
 
 A thickened ileum may be palpated. Abdominal tenderness and 
 pain occurred in 60 per cent, of Osier's series and in 30 per cent, at 
 the onset, where particular attention was paid to these points. They 
 are due to: (a) Local bowel conditions, as gas, constipation, inflam- 
 mation in the ileocecal region, or perforative and peritonitic com- 
 plications; (&)'to splenic or hepatic tumefactions; (c) pleurisy, dis- 
 tended bladder, phlebitis, etc. ; (d) muscle changes or cutaneous 
 hyperesthesia, so frequently observed in fever of any variety. 
 
TYPHOID FEVER. 31 
 
 Typhoid appendicitis may simulate ordinary appendicitis, which is 
 differentiated only by the blood-count, sero-reaction, or, most surely, 
 by the clinical evolution; e. g., the fever, rose spots, etc., of typhoid, 
 precede local pain and tenderness. Gurgling has no diagnostic value 
 whatever in typhoid, although it occurs in most cases. 
 
 The stools present no pathognomonic chemical nor physical char- 
 acteristics ; the bacillus typhosus, present in 20 to 40 per cent, of cases, 
 reaches the bowel by the bile or through the ulcers. The dejecta are 
 thin, offensive, pea-soup-like, alkaline, and resemble the contents of 
 the small intestine (Addison) . Because the faeces are poor in mucus, 
 two layers form on standing, an upper cloudy, and a lower, yellow- 
 gray, granular and flocculent layer. The stools contain red corpuscles 
 and triple phosphates, the latter more abundantly than in any other 
 disease. Shreds or sloughs may also be found. 
 
 Diarrhoea in the febrile stage occurs in 25 to 33 per cent, of cases. 
 Three to six stools daily are the average. If this is exceeded, the 
 type of the disease is severe; prodromal diarrhoea rarely occurs. 
 Diarrhoea is a measure of the degree of toxcemia or of colonic involve- 
 ment, and is not a result of ulceration of the small intestine. 
 
 Hemorrhage is seen in 4 to 6 per cent, of the cases. In time it is 
 usually late, though some assert that in 30 per cent, it occurs in the 
 first two weeks. It is less frequent in relapses and in children (1 
 per cent.). Ulceration into the muscularis is its chief cause. Ooz- 
 ing, from simple hyperemia, bleeding in the hemorrhagic forms 
 (blood dissolution), and in patients inheriting the bleeding tendency, 
 are exceptional. Bleeding is more common in ambulatory, delirious, 
 and carelessly fed patients. There may be no symptoms if the hemor- 
 rhage is small (occult hemorrhage) ; but if it be large, acute anaemia 
 suddenly develops, with collapse, which is evidenced by a fast pulse, 
 lowered temperature, and pallid skin. The intellect often clears, 
 the spleen becomes smaller, and fresh blood, or, later, black, tar-like 
 movements, are voided (manifest hemorrhage). The abdomen is 
 often distended. There may be dulness on percussion from blood 
 retained in the bowel, if the peristalsis is weak and the hemorrhage 
 is very profuse. In two rapidly fatal cases the entire abdomen be- 
 came flat and one and two pints of blood were vomited. Confusion 
 with bleeding piles and bismuth stools is possible. The average num- 
 ber of hemorrhages is four. 
 
 Some patients improve at once after hemorrhage, as was remarked 
 at an early date by Graves and Trousseau; yet 20 to 50 per cent. die. 
 Large blood-clots are ominous, indicating erosion of a large artery. 
 Hemorrhage may cause death within an hour (Trousseau, Leymaire). 
 
 Perforation occurs mostly at the time of eschar-formation, at the 
 end of the second, or in the third week ; but it may also occur later, — 
 in the third to fifth week (Leube). Scott, found that 92 per cent, 
 occurred between the second and fifth weeks. It develops in 9 to 12 
 per cent, of fatal cases and in 3 per cent, of all cases, but it very 
 rarely occurs in children. Scott's figures, including 9,713 English 
 
32 
 
 TEE SPECIFIC INFECTIONS. 
 
 and American cases, show perforation in one-third of all fatal cases. 
 Perforation is usually low in the ileum (81 per cent.) ; or in the 
 colon or sigmoid (12 per cent.) ; in the appendix (3 per cent.) ; in 
 Meckel's diverticulum (2.4 per cent.) ; or in the jejunum (1.2 per 
 cent.), according to Fitz's figures. In 83 per cent, but one perfora- 
 tion is found; several may occur, twenty-five being observed in one 
 patient. It is promoted primarily by deep ulceration, and secon- 
 darily by severe infection, movement, strains, coughing, constipa- 
 tion, tympanites, or solid diet which increases peristalsis. It is 
 claimed that in 75 per cent, of cases perforation occurs in severe 
 infections. Three types are encountered: (1) Least frequently, un- 
 discovered latent perforation; the typhoid state masks the perfora- 
 tion, which affords an unpleasant postmortem surprise. (2) More 
 
 
 
 
 Fig. 4. 
 
 | 
 
 
 
 PU-SE TEMP. 
 
 104 
 
 
 
 
 
 
 
 ISO 
 
 103 
 
 A A/ 
 
 
 
 
 S\ 
 
 
 110 
 
 102 
 
 /v 
 
 
 
 / 
 
 \ 
 
 1 / 
 
 
 100 
 
 101 
 
 
 /■K 
 
 
 s 
 
 
 *\ — — ~ 
 
 90 
 
 100 
 
 -**\ *' 
 \,-*' 
 
 'N'" \ 
 
 -^'M 
 
 
 
 
 so 
 
 99 
 
 
 
 
 
 
 
 ro 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 2ND WEEK 
 
 FOUR CCFIOUS 
 
 1 HAEMORRHAGE 
 
 STC 
 
 S TR/ 
 
 )OLS WITHOUT 
 .CES OF BLOOD 
 
 Typhoid-fever curve, with fall of temperature (solid line) after hemorrhage and rise of 
 pulse (broken line). Note crossing of curves at A. 
 
 frequently, cases with gradual onset, and therefore ambiguous symp- 
 toms. (3) Most frequently, cases with sudden symptoms and more 
 or less clear diagnosis. The symptoms of perforation are : (a) Pain 
 (in 75 per cent.) due to the perforation itself, usually localized in 
 the hypogastrium or right lower quadrant of the abdomen and fol- 
 lowed later by the pains of peritonitis. In 70 per cent., the pain is 
 sudden and severe; in 20 per cent., gradual in onset; and in 10 per 
 cent., absent. (&) Tenderness on palpation (75 per cent.), evidenced 
 by the board-like rigidity of the abdominal muscles, (c) Limitation 
 of the respiratory movements of the abdomen, due to pain and tender- 
 ness, (d) Vomiting of gastric contents or fsecal matter, (e) In- 
 testinal obstruction. (/) Abdominal distention, appearing possibly 
 for the first time — in which event its significance is enhanced — or 
 increasing, if already present. There are cases in which the abdomen 
 is flat or even retracted ; in one typhoid patient, seen first in a dying 
 condition, the scaphoid abdomen contained three pints of pus. Ab- 
 dominal distention crowds upward the diaphragm, heart, and lungs, 
 
TYPHOID FEVER. 33 
 
 and causes hurried breathing, (g) Disappearance of the flatness of 
 the liver by reason of free gas in the peritoneum. This is most sig- 
 nificant if the abdomen was not previously distended. Perihepatitic 
 adhesions naturally prevent obliteration of the liver dulness, and it 
 must always be remembered that a gas-distended colon may overlie 
 the liver, and that in some cases the colon normally overlaps the liver. 
 (h) Other occasional abdominal findings are flatness in the flanks, 
 caused by fluid; the Beatty-Bright friction-rub; absence of peri- 
 stalsis; rectal or vesical pain or tenderness, (i) Marked leukocytosis 
 is not always found, and special emphasis on its absence is most mis- 
 leading, as the leukocytes are occasionally decreased, (j) Sudden 
 fall of temperature, rapid rise in pulse-rate, and other signs of shock, 
 may occur at the time of perforation, though less frequently than 
 the usual descriptions indicate. The writer has seen cases in which 
 the pulse-rate did not increase. Dieulafoy mentions a case, success- 
 fully operated upon, for perforation, in which two later perforations 
 resulted fatally. The sudden clearing of the patient's intellect may 
 deceive the inexperienced physician. In the advancing generalized 
 peritonitis, the fever, if it has fallen, rises ; the pulse becomes rapid, 
 small, and thready; the skin clammy and dusky, and the features 
 pinched (facies Hippocratica). Hiccough is common. The peri- 
 tonitis rarely remains local. In six of the author's cases, the local 
 abscess ruptured later. Ninety-eight per cent, of the unoperated 
 cases die. 
 
 Peritonitis occurs, frequently in ambulatory cases, from rupture of 
 the bowel, gall-bladder, spleen, or lymph-glands; occasionally from 
 post-typhoid appendicitis or without rupture of any organ or tissue. 
 It is found in 2 per cent, of fatal cases. 
 
 The liver in the early stages is anatomically hypersemic, large and 
 firm ; later its lobular markings become indistinct from cloudy swell- 
 ing and fatty change. The organ is softer, and Wagner's lympho- 
 mata (and some focal necrosis) occur. Clinically, some tenderness is 
 not unusual and at times may lead to an incorrect diagnosis of liver 
 abscess or cholecystitis. 
 
 Icterus is very rare (0.5 per cent.), and its absence is of diagnostic 
 value, as the duodenal catarrh common in other infections is usually 
 absent. Icterus may occur from gall-stones, cholecystitis, abscess, etc. 
 The author has but once seen icterus in typhoid fever. Single liver 
 abscess is rare, as are suppurative pylephlebitis and suppurative 
 cholangitis. Twenty-six cases of liver abscess are on record (Shel- 
 don, Swain, Sennert). 
 
 Typhoid favors the formation of gall-stones, which may develop 
 months, years, or decades later. 
 
 Cholecystitis has been reported by Chiari and others ; thirty cases 
 with perforation are on record. Tenderness, pain, muscular rigidity, 
 and enlarged gall-bladder, are found in most cases. Typhoid bacilli 
 are found in the gall-bladder in nearly all autopsies, although seldom 
 having produced symptoms, and probably occur from hematogenous 
 3 
 
34 THE SPECIFIC INFECTIONS. 
 
 infection. Dehler published a case in which the gall-bladder was 
 drained to rid a patient of the persistent bacilli. 
 
 1. The Respiratory Tract. — This is the seat of frequent and 
 manifold symptoms and complications. 
 
 (a) The Nose. — Epistaxis occurs in 20 per cent, of cases, usually 
 early, and in young subjects ; it is often profuse, sometimes danger- 
 ous, but rarely lethal. Croup and diphtheria are rare. The author 
 has seen but two cases begin with profuse coryza. 
 
 (b) Larynx. — Catarrh is common. Decubitus,, with erosions of 
 the swollen hyperplastic lymph-follicles (like the intestinal changes), 
 occur in the posterior wall, followed often by oedema glottidis. These 
 bed-sores are seen at the height of the fever ; occur rarely in children ; 
 and are found in 5 to 20 per cent, of the lethal cases. Perichondritis 
 and necrosis are attended by pain, aphonia, stenosis, mediastinitis ; 
 cervical cellulitis, and diffuse emphysema. Tracheotomy may be 
 indicated. The author has seen but three cases of perichondritis. 
 Dupuy (1903) collected 255 cases of perichondritis and submucous 
 laryngitis, and believes they explain 3 to 10 per cent, of typhoid 
 fatalities. Without operation, the mortality is 98 per cent. 
 
 (c) Air Tubes. — A dry catarrh of the trachea and bronchi is almost 
 invariable, while ulceration or fibrinous inflammation is rare. Rales, 
 retrosternal dryness, rawness, and pain, are present in the bronchitis 
 of typhoid. At autopsy the bronchial glands are often swollen, and 
 Eberth's bacillus is sometimes found. Bronchiolitis is regular and 
 specific. It is found everywhere in the lungs, but especially in the 
 lower lobes. Coughing is not invariable but its presence in early 
 typhoid is of value in differentiation from simple intestinal catarrh. 
 The outlook is less favorable when severe and early coughing occurs. 
 
 (d) Lungs. — Hypostasis, from a dorsal decubitus and weak heart, 
 is often relieved by change of posture. It is very common, and occurs 
 in the first half of the disease, or at its height, mostly in weak adults 
 and in cases of severe infection. Lesser degrees of hypostasis may be 
 overlooked. The percussion-note is tympanitic or dull; the fremitus 
 is increased, if the patient can talk, or decreased from stagnation of 
 secretion; the breathing, and especially the expiration, is distant 
 (or sometimes bronchial). Rales, moist, crepitant, and subcrepitant, 
 are heard. * 
 
 Lobar pneumonia may, in rare instances, dominate the early 
 clinical picture (pneumo-typhoid) and may be of two types. The 
 first type, (a) in which the pneumonia, usually seen at the height of 
 the disease, is a true complication, due to the pneumococcus, though 
 sometimes due to the colon bacillus and streptococcus, especially in 
 sepsis. The pneumonic symptoms are variable, atypical (as in most 
 secondary pneumonias), often without chill, with a slower course, and 
 often ending by lysis, or, less often, with such complications as 
 abscess or gangrene. More than one-half of these cases die. The 
 second type (b) is due to Eberth's bacillus. The course is that of an 
 initial pneumonia, which does not end typically, but shows later a 
 
TYPHOID FEVEE. 35 
 
 typhoid temperature, rose spots, Widal reaction, etc. These cases are 
 naturally confusing, especially in their incipiency, and the typhoid 
 is more apt to he overlooked than in the first type. Lobular pneu- 
 monia, from inhalation, pus cocci, and Eberth's bacillus, is a true 
 complication. Abscess follows pneumonia or sepsis; it occurs in 0.7 
 per cent, of the fatal cases. Infarct occurs in 6 per cent, of typhoid 
 fatalities. Marantic thrombi from the leg may reach the lungs by 
 way of the right heart. This is indicated by haemoptysis, chill, tem- 
 perature, pain, etc. Gangrene (1 to 2 per cent, of typhoid autopsies) 
 occurs more often than abscess, is seen late in the disease, and is 
 usually metapneumonic, but may be caused by perichondritis or 
 aspiration of food. 
 
 (e) Pleura. — Serofibrinous pleurisy is usually rare unless the lungs 
 are diseased. Sears observed 18 cases in 1,065 typhoid patients. 
 Postmortem statistics show it in 6 per cent. It is most common as 
 empyema in convalescence, and is due oftenest to Eberth's bacillus. 
 In 1903, fifty-five cases of pleurisy were collected in which the ty- 
 phoid bacillus was found. Pneumothorax and haemoptysis are very 
 uncommon. 
 
 (/) Tuberculosis. — Old latent tuberculosis may be aroused, usu- 
 ally late in the disease. Acute caseous pneumonia, subacute tuber- 
 culous peribronchitis with a few bacilli, fever, emphysema and ag- 
 gravation of the bronchial symptoms, and occasionally miliary 
 tuberculosis may occur. The sooner tuberculosis begins after typhoid 
 the more unfavorable is its course. 
 
 8. Gentto-Urinary Tract. — (a) The urine is febrile, i. e., de- 
 creased, acid, concentrated, with a specific gravity of 1,030 or more. 
 The amount of urine depends considerably upon the amount of 
 water ingested. Typhoid bacilli are present in 25 to 50 per cent, of 
 the cases. The bacilli may give the urine a glistening appearance. 
 Bacilli may persist from four months to several years after recovery, 
 probably multiplying; in the bladder. In convalescence, the urine is 
 increased, is neutral in reaction, and has a lower specific gravity. 
 Sometimes polyuria may occur during the fever, (b) Serum albu- 
 min, globulin, and rarely peptones, are found in febrile albuminuria. 
 Serum albumin is found in quantities varying from traces to con- 
 siderable amounts, in 20 per cent, of the cases ; cylindruria is approxi- 
 mately half as frequent. The prognosis is three times as unfavorable 
 when albumin is found. Albuminuria appears from the seventh to 
 the tenth day, and its average duration is twelve days. It corre- 
 sponds anatomically to parenchymatous and fatty degeneration of the 
 kidneys, (c) Nephritis in typhoid is of the acute parenchymatous 
 type, with the inter stitium of the organ but little involved. It is 
 often hemorrhagic, and occurs usually in the first three weeks but 
 occasionally in convalescence. It is found in 1 per cent, of cases, 
 mostly in men, rarely in children. Nephritis makes the prognosis 
 less favorable, as it indicates a more severe infection, from which 50 
 per cent, of the cases die. Uraemia and suppression of urine are rare, 
 
36 THE SPECIFIC INFECTIONS. 
 
 If not fatal, nephritis usually clears up entirely and rarely remains 
 in chronic form. Early and marked renal symptoms constitute the 
 nephrotyphoid of French writers. Miliary typhoid abscesses in the 
 kidney may keep up the bacilluria. Lymph-nodes are found in some 
 cases, as in the liver (Wagner), (d) The urine of typhoid exhibits 
 the diazo reaction of Ehrlich (1882), which is due to the incomplete 
 oxidation of the proteid metabolism of the aromatic sulphates. The 
 author has found it in 98 per cent, of his cases. It occurs in the 
 early stages of the disease, also at the acme and during relapses. It 
 is a valuable sign, though of secondary rank. Since it is found in 
 numerous other acute and chronic conditions, it has no differential or 
 pathognomonic value. It rather closely parallels the bacillsemia. Its 
 absence, together with the absence of other findings, contraindicates 
 a florid typhoid, (e) Cystitis and pyelitis occur, due chiefly to pus 
 organisms, or typhoid or colon bacilli. Simple retention of urine is 
 not uncommon. Hemoglobinuria is quite rare. Typhoid bacilli may 
 form the nuclei of renal stones. (/) The genitalia are more often 
 implicated in women than in men. Menstruation is disturbed. It 
 often appears early in the onset of typhoid, and is suppressed in 60 
 per cent, of the cases. Hematocele or hematometra may develop. 
 Endometritis, vaginal erosions, ulcers, inflammation, or gangrene 
 and mastitis, are rare complications. Pregnancy is of grave import, 
 the outlook being worse in its later stages than in the earlier (e. g., 
 eight to ten weeks). It is most dangerous at the acme of the fever, 
 abortion and premature delivery being very frequent (in 65 per 
 cent.). The maternal mortality is increased at least two fold. 
 Blumer and Dobbin have reported puerperal infection from the 
 typhoid bacillus. Orchitis usually develops late, or in convalescence, 
 with chills and fever. J. G. Beardsley, in 1907, collected 102 cases 
 which were chiefly due to the typhoid bacillus. The patient almost 
 always recovers in ten to fourteen days, although suppuration and 
 atrophy have occurred. It is frequently associated with urethritis. 
 Emissions are common in convalescence. 
 
 9. Special Senses. — The eye is rarely involved. Muscle paraly- 
 sis (neuritis) and various inflammations are very uncommon. In 
 convalescence, mydriasis and paralysis of accommodation often result 
 from exhaustion. Uhtoft, in 253 cases of optic neuritis, found 17 
 cases following typhoid. 
 
 Involvement of the ear includes functional toxemic disturbance 
 of hearing, abscess, and otitis media (2 per cent.). Mastoid disease 
 and meningitis are very exceptional. 
 
 10. Muscles, Thyeoid Gland, and Bones. — The muscles ana- 
 tomically are dry, of a smoked-meat appearance, and may be the seat 
 of hemorrhages, rupture, granulo-fatty and waxy degenerations, and 
 abscess, due to Eberth's bacilli and pus cocci. Myositis may explain 
 some cases of muscular tenderness with cramps. 
 
 In the thyroid gland, a strumitis typhosa, with suppuration or 
 regression, has been observed. It is due to the typhoid bacillus. Re- 
 covery is the rule. 
 
TYPHOID FEVEB. 37 
 
 Though bone disease was observed in 237 cases by Keen, it is much 
 more frequent than the figures indicate. Periostitis is more common 
 than bone disease proper. These complications are post-typhoid and 
 are due to the typhoid bacillus (75 per cent.), or pus cocci (25 per 
 cent.). They attack the tibia (38 per cent.), the ribs (13 per cent.), 
 femur, ulna, temporal bones, etc., and occur chiefly in young indi- 
 viduals. " Their most striking features are chronicity, indolence, and 
 a remarkable tendency to recurrence" (Osier). Osteomyelitis may 
 resemble syphilitic or tuberculous osteopathies. Typhoid bacilli have 
 been found seven and ten years after typhoid in osteomyelitic fistulse. 
 Longcope has found marrow changes which resemble lymphoid hyper- 
 plasia, and Frankel isolated typhoid bacilli in the vertebral marrow 
 in ordinary cases of typhoid. 
 
 Arthritis may be typhoid or gonorrheal, rheumatic, septic, etc. 
 Keen has noted eighty-four cases. It may be poly- or mono-articular, 
 serous or purulent. The hip is most frequently affected. The 
 " typhoid spine," of Gibney, is characterized by pain, tenderness, and 
 stiffness in the back; these seem to be root symptoms. Once classi- 
 fied as a neurosis, the x-tslj findings of McCrae seem to indicate an 
 actual spondylitis. 
 
 Anomalous Courses. — According to Curschmann, the following 
 aberrant courses are distinguished: 
 
 1. Malignant. — The malignant, hyperpyretic or fondroyant form 
 is rare. It is severe even in the earliest stages. The temperature 
 rises rapidly and there may be hyperpyrexia. The pulse is soft, 
 weak, and rapid. The status typhosus is profound. Meteorism, 
 diarrhoea, and albuminuria are present, and death from deep intoxi- 
 cation usually occurs. 
 
 2. The Slow Severe Form. — The slow severe form lasts from 
 four weeks to four months. The fever is often remittent with fre- 
 quent exacerbations. Defervescence may occur or death intervene, 
 marasmus alone being found at autopsy. The severe types of typhoid 
 have grown rare, even during the last decade. 
 
 3. Typhus Abortivus. — Typhus levissimus, typhulus, typhoid- 
 ette of Brouardel, exhibits a short and mild course, temperature with 
 a short initial stage, or often a crisis, lasting six to twenty days. 
 Bronchitis is frequent, the spleen enlargement is constant, and meteor- 
 ism, diarrhoea, roseolse, hemorrhage, and perforation, are rare. Re- 
 lapses are, however, more frequent. 
 
 4. Typhus Ambulatorius. — Typhus ambulatorius (of the Ger- 
 man, or latent typhoid of French writers — walking typhoid), occurs 
 in adults, especially in men, who often endure it by the help of 
 alcohol. Some malaise may exist. There are two types: (a) the 
 lighter and atypical, and (b) the usual course, very often ending in 
 hemorrhage, perforation, etc. The temperature is often not marked, 
 but is usually less at night than during the diurnal activity. The 
 pulse is faster because of exertion. The spleen is often enlarged and 
 the roseolse are frequent. 
 
38 TEE SPECIFIC INFECTIONS. 
 
 5. Typhus Afebrilis. — Typhus afebrilis (Liebermeister and 
 Gerhardt) is most often met with in family practice. It may assume 
 the ambulatory form, and is diagnosticated by exclusion and by the 
 pulse, spleen, roseolse, diazo reaction, Widal test, etc. Atypical 
 cases have apparently increased in recent years. 
 
 6. Hemorrhagic. — The hemorrhagic form is characterized by 
 nasal, subcutaneous, and particularly intestinal hemorrhage, con- 
 stituting the blood dissolution of the older writers. It occurs espe- 
 cially in children and alcoholics, and constitutes less than one-tenth 
 of 1 per cent, of typhoid cases. The prognosis is usually but not in- 
 variably bad. The four cases which the author has seen occurred in 
 1900, in St. Luke's Hospital, where a severe house-epidemic prevailed. 
 
 7. Visceral Forms. — The so-called visceral forms should seldom 
 cause confusion, if watched with care. They include, the gastric 
 or bilious types, nervous fever, meningo-typhoid, cerebro-typhoid 
 (mania, psychoses), laryngo- or tonsillo-typhoid, nephro-typhoid, 
 pneumo-typhoid with pneumococcus mixed infection or Eberth's ba- 
 cillus (Lepine, Chantemesse, Widal), which is pneumo-typhoid in 
 the narrowest sense. 
 
 8. In Children. — In children but few cases occur in hospitals. 
 The temperature course is shorter and milder than in adults. The 
 younger the patient, the less is the degree of fever. It may begin 
 with a chill. It is often remittent, the " infantile remittent fever " 
 of Abercrombie being really typhoid. Epistaxis is less common, 
 The pulse in children is faster, and more often irregular, than in 
 adults, though after the twelfth year, it is equally slow. A weak 
 and irregular pulse is very rare, and a fast, irregular pulse generally 
 indicates meningitis. Opinions differ as to the frequency of roseola?, 
 but it is probable that they occur as often in children as in adults, and 
 in some cases are abundant and confluent (in children between the 
 fifth and tenth year). Bedsores are very rare, but noma is more 
 frequent than in adults. The nervous system is generally less fre- 
 quently involved in children, though if the infection is severe, con- 
 vulsions, irregular pupils, rigidity of the neck, headache, etc., may 
 occur. (See Typhoid State.) Neuralgias and psychoses are rare. 
 The frequency of aphasia has not yet been explained. Bronchitis 
 occurs as often as in adults, but atelectasis, hypostasis, and lobular 
 pneumonia are more frequent. Children exhibit less meteorism and 
 hemorrhage (1 per cent.), and much less frequent perforation. 
 There are fewer anatomical changes. Splenic enlargement is less 
 frequently palpable (in 50 per cent.), and occurs somewhat later. 
 Initial vomiting, pain, and perhaps diarrhoea, are more frequent. 
 Albuminuria and nephritis are relatively rare. In infants. Griffith 
 and Ostheimer has assembled 394 cases in infants, of which 325 
 are beyond doubt. Of these, 139 occurred under one year, 187 in 
 the second, and 68 between two and two and one-half years. The 
 mortality under one year (v. i.) was 73 per cent., and of the entire 
 group, 50 per cent. Typhoid is rare in the first two years of life. 
 
TYPHOID FEVER. 
 
 39 
 
 It is sometimes overlooked, being very atypical. The course is 
 short. Bronchitis, splenic tumor, and roseolse are infrequent. If 
 the disease is severe, a very high temperature, meningeal symptoms, 
 and initial vomiting occur, and also 50 per cent, mortality caused 
 by toxaemia, pneumonia, perforation, or ulceration of the larynx. 
 
 9. In the Aged. — Typhoid is infrequent after the fortieth year. 
 The fever is lower, atypical, and often absent. The pulse is faster, 
 irregular, and without dicrotism. There is greater lung congestion 
 owing to weakness of the right heart, and lung complications are more 
 frequent. The nervous symptoms are dominant, often occurring 
 with great depression. Roseolae are fewer and bedsores are more fre- 
 quent. The spleen is less often enlarged because of old infarcts, indura- 
 tion, and a thicker capsule. Tympany and hemorrhage occur more 
 often. Convalescence is naturally slower. In 1903, the author had 
 under his care, in Wesley Hospital, a woman, aged fifty-seven, and her 
 mother, aged seventy-two, both with typhoid, ending in recovery. 
 
 Relapses and Exacerbations. — Relapses and exacerbations differ in 
 degree only. Their explanation is still obscure but is probably in- 
 
 Fig. 5. 
 
 HIGH FEVER REMISSION EXACERBATION LYSIS APYREXIA RELAPSE 
 
 Showing remission, exacerbation, lysis, and relapse. 
 
 volved in the immunity problem. In the relapse, the temperature 
 falls to normal, or nearly to normal, for five days on the average, 
 and then fever and other signs of typhoid reappear. It occurs in 
 9 per cent, and varies with the epidemic, sometimes occurring in as 
 much as 35 per cent. Relapses are more common in young (in one- 
 sixth of Henoch's cases) than in old subjects. They are more 
 likely to occur (a) in light or moderately severe cases (75 per cent.) 
 than in severe ones (25 per cent.) ; (b) when the splenic tumor does 
 not disappear (Gerhardt, but the question may arise whether the 
 spleen was enlarged from some previous disease, such as malaria) ; 
 (c) when the temperature in convalescence does not become subnor- 
 mal (Curschmann) ; or (d) when the pulse is variable and rapid 
 while the patient is quiet (Curschmann). 
 
 After an average defervescence of five days, the fever runs the 
 same course as in the first attack, though it is shorter by ten days 
 (Murchison). The pulse is faster (110 to 130 in women, children, 
 
40 THE SPECIFIC INFECTIONS. 
 
 and weak men), labile and less dicrotic. There are less roseolas, 
 nervous symptoms, respiratory symptoms, hemorrhage (4 per cent.), 
 and perforation (0.7 per cent.), whence, as a rule, the prognosis is 
 relatively good. The duration of the relapse is six to fifteen (even 
 twenty-one days), and there are seldom more than two, — three or 
 four being very rare. The author has seen five relapses, covering, 
 with the original attack, as many months. It is said that they may 
 be afebrile, with a return of the roseolse, spleen, etc. Relapses 
 should not be confused with Biermer's " after fever," due to inanition 
 or possibly, sepsis. Recrudescence is renewal of the fever after it has 
 lessened, but not entirely subsided. In 50 per cent, recrudescence 
 is followed by more severe symptoms. 
 
 Convalescence. — Convalescence requires fourteen to twenty-one 
 days, but its duration is variable, and it is not certainly established 
 till subnormal temperature, at least in moderate or severe infections, 
 is observed. The pulse tends to run high on exertion or excite- 
 ment. Anaemia, emaciation, oedema, phlebitis, tuberculosis, neu- 
 rasthenia, psychoses, bone, muscle, and other complications, may 
 intervene. If the appetite is poor in convalescence, complications 
 are to be expected. 
 
 Diagnosis. — General Rules. — 1. The bacteriological diagnosis is 
 not usually practicable for the inexperienced physician. Splenic 
 puncture is never permissible, though positive in 95 per cent, of 
 cases tested. The bacilli may be found in the blood in nearly all 
 cases, and practically always in the roseolas. 
 
 2. Observe long and carefully. Say that " a diagnosis is impos- 
 sible in the first few days." 
 
 3. ~No single sign is absolutely diagnostic, except bacilli in the 
 blood, etc., and the characteristic Widal reaction. 
 
 4. Diagnosticate (a) from positive findings, and (b) by careful 
 exclusion. 
 
 5. The " typhoid state " only indicates toxaemia, not necessarily 
 typhoid. 
 
 6. In doubtful cases remember the great statistical frequency of 
 typhoid. 
 
 7. Remember its manifold forms; e. g., pneumo-typhoid, etc. 
 
 8. Be on the safe side in light, ambulatory, or abortive cases as 
 to the diagnosis and the still more important matter of treatment. 
 
 The Cardinal Signs. — These are: (a) The Widal test; (b) 
 bacilli in the blood, urine, roseolse, etc.; (c) the roseolas; (d) the 
 slow pulse; (e) the fever-curve; and (/) the splenic tumor. 
 
 (a) The sero-test, successful in 95 to 97 per cent, of cases, is 
 important. As stated above, its absence does not exclude typhoid. 
 
 (b) The bacilli in the blood are found in practically all cases. 
 
 (c) The eruption has a diagnostic value in its location, occur- 
 rence in crops, time of appearance, and short duration. 
 
 (d) The slow pulse, and to a much less extent its dicrotism, are 
 suggestive. It is rarely to be confused with the slow pulse of 
 tuberculous meningitis. 
 
TYPHOID FEVER. 41 
 
 (e) The fever curve shows a gradual, step-like onset, continuous 
 fastigium, steep curves in the breaking stage, and subnormal register 
 in convalescence. 
 
 (/) While the splenic tumor occurs in many other infections, it is 
 per se suggestive after the first week. 
 
 Secondary Signs. — These are, in order of importance, the typhoid 
 tongue, the stools, bronchitis (especially after the first week), the 
 typhoid state, leukopenia, intestinal symptoms and complications, 
 and the diazo reaction. 
 
 Symptoms Contra-indicating Typhoid. — The symptoms contra- 
 indicating typhoid are, according to Leube, coryza, early vomiting 
 and sweating, herpes, endocarditis, retraction of the abdomen, per- 
 sistent constipation, and constantly negative diazo test. To these 
 may be added leukocytosis (unless some complication has occurred), 
 icterus and rigors. Any of the above symptoms may, exceptionally, 
 complicate typhoid. 
 
 Differential Diagnosis. — Differentiation from acute miliary tubercu- 
 losis may be most difficult. In both diseases protracted fever, splenic 
 tumor, brain symptoms, bronchitis and bronchopneumonia, rapid 
 pulse, etc., may be observed, and miliary tuberculosis may develop 
 from typhoid (Birsch-Hirschfeld, and in two personal observations). 
 Typhoid may be complicated with septicaemia, very rarely with mala- 
 ria in this climate, or with meningitis. The table on pages 42 and 
 43 illustrates the differential diagnosis of the diseases most likely to 
 be confused with typhoid. 
 
 Exanthematous typhns (q. v.) and recurrent fever (q. v.) are 
 easily distinguished. The exanthematous diseases, such as scarlatina 
 and measles are rarely confused, except, perhaps in the initial stage. 
 In 75 instances typhoid and scarlatina co-existed (Fournier). An 
 extensive eruption of roseolse resembling measles is easily distin- 
 guished by the course, temperature curve, and catarrhal symptoms. 
 
 Fibrinous pneumonia rarely resembles typhoid, and still more 
 rarely occurs with typhoid in its earliest stages by the localization 
 of typhoid bacilli in the lungs. Though typhoid may begin with 
 severe bronchitis or pneumonic symptoms, doubt usually exists only 
 during the first few days. The intestinal symptoms and cardinal 
 findings of typhoid usually appear after a few days when all doubt 
 is dispelled. Pneumonia undoubtedly may occur without local find- 
 ings, yet the diagnosis of central pneumonia is usually incorrect. 
 Sudden onset with chill, pain in the side, sudden rise of pulse and 
 temperature, rapid respiration, bloody, viscid sputum, herpes, leu- 
 kocytosis, and signs of local infiltration or a tympanitic note and a 
 few crepitant rales over one lobe, followed later by some typical 
 pneumonic infiltration as the disease advances from within toward 
 the periphery of the lung, establish the diagnosis of pneumonia on 
 the second or third day. 
 
 Intestinal anthrax is accompanied by fever, splenic tumor, and 
 nervous symptoms. Hemorrhagic vesicles in the mouth, vomiting, 
 colic, hemorrhage from the intestines and kidney, cyanosis and 
 
42 
 
 THE SPECIFIC INFECTIONS. 
 
 Pathognomonic Signs 
 
 Typhoid. 
 
 Pulse and 
 Circulation 
 
 Fever 
 
 Splenic 
 Enlarge- 
 ment 
 
 Blood 
 
 Typhoid bacilli Relatively slow di- Typical rise, acme, V 
 in the blood, erotic pulse early defervescence, 
 spleen (by in the disease, 
 puncture),! especially in men, 
 urine, rose- and in not too 
 olse, or stools, severe infections. 
 Widal test. . Endocarditis and 
 
 pericarditis very 
 
 rare. 
 
 and subnormal in 
 convalescence. 
 Remissions and 
 intermissions fol- 
 lowing continu- 
 ous fever speak 
 for typhoid. Re- 
 sponds to hydro-^ 
 tnerapy as a" rule, i 
 Sometimes chills 
 at onset or in 
 course. 
 
 ery fre- 
 q u e n t ; 
 1 a r g e r 
 than in 
 miliary 
 tubercu- 
 losis ; ap- 
 pears in 
 firstweek. 
 
 Bacilli in blood, 
 early ; Widal test 
 later. No leuko- 
 cytosis unless 
 complication s, 
 but leukopenia. 
 Polymorphonuc- 
 lears decreased. 
 Late anaemia. 
 
 Mi liar r Tubercle bacilli Rapid, 120 or more, No cycle : irregular Less f re- Sometimes tubercle 
 
 Tubercu- in the blood 
 
 LOSIS. 
 
 or splenic 
 pulp ; tuber- 
 cles in the 
 choroid. 
 
 high even dur- 
 ing remissions; 
 slowed in tuber- 
 culous meningitis 
 and in the aged. 
 Dicrotism uncom- 
 mon. Sometimes 
 pericardial rub. 
 
 or remittent. Sel- 
 dom long contin- 
 ued, and if so, 
 longer than in 
 typhoid. Exacer- 
 bations with re- 
 newed dissemin- 
 ation of tubercle 
 bacilli. Brain 
 involvement may 
 lower fever or 
 make it variable, 
 as inversed type. 
 
 q u e n t 
 smaller! 
 andusual-l 
 ly appears 
 later. 
 
 Malaria. Plasmodium in Pulse moderate in Intermittent 
 the blood (or rate; sometimes; 
 splenic pulp).: dicrotic; veryl 
 rarely endocard- 
 itis. 
 
 ginning very 
 often with chills ; 
 type varies (quo- 
 tidian, tertian, 
 etc.) ; often rises 
 high at once; if 
 continuous (sub-i 
 continuous), at 
 least made irregu- 
 lar by quinine or 
 usually wholly 
 abolished (for a 
 time at least). 
 
 bacilli in blood. 
 No Widal. Leuko- 
 cytosis not often, 
 but more than in 
 typhoid. 
 
 be- Much en- Plasmodium, mel- 
 
 1 ar ged ; 
 morethan 
 in t y - 
 p h o i "d ; 
 and per- 
 sists fre- 
 quently 
 as ague- 
 cake. 
 
 ansemia, no leuko- 
 cytosis save in 
 pernicious forms. 
 Great and early 
 anaemia. No 
 Widal. 
 
 Sepsis (in- 
 cluding En- 
 docarditis). 
 
 Cultivation of Usuallv fast and ir- 
 
 pyogenic or- 
 g"a n i s m s , 
 pneumococ- 
 cus , from 
 the blood or 
 various foci. 
 
 Meningitis. 
 
 regular ; cardiac 
 localizations 
 very frequent in 
 sepsis, puerperal 
 especially, and in 
 endocarditis (a 
 cardiac form of 
 sepsis). Cardiac 
 enlargement, 
 thrill, bruit, ac- 
 centuated p u 1 - 
 monic tone, etc. 
 
 Chills, sweats, Especially Various organisms, 
 
 steep elevations, enlarged Marked polymor- 
 
 and sudden de- from sep- phonuclear feuko- 
 
 pressions almost sis and in- cytosis very fre- 
 
 always at some f a r c t s . quent ; sometimes 
 
 time, and usually Also of- absent in en docar- 
 
 repeated with ten the ditis. No Widal. 
 
 each discharge lymph- 
 into the blood of nodes, 
 infective materi- 
 al. 
 
 Lumbar punc- 
 ture (a) men- 
 ingococci, 
 tubercle ba- 
 cilli, pyogen- 
 ic organisms. 
 etc.; (b) in- 
 creased, tur- 
 bid fluid, etc. 
 
 Rate differs with Differs with vari- Rare. 
 
 type ; variable. 
 
 ety, but seldom 
 as high as ty- 
 phoid ; no cycle. 
 
 Leukocytosis in ep- 
 idemic and puru- 
 lent types ; rarer 
 in tuberculous. 
 No Widal. 
 
TYPHOID FEVEH. 
 
 43 
 
 Skin 
 
 Roseolse, typical in 
 location, crops, 
 appearance, con- 
 taining typhoid 
 bacilli. Sweating 
 and miliaria less 
 often and later. 
 Icterus rare. 
 Herpes rare. 
 
 Roseolse absent or 
 extremely rare, 
 and then not in 
 crops. Drenching 
 sweats common. 
 Herpes more than 
 in typhoid. Skin 
 anaemic and very 
 often cyanotic. 
 
 In severe, eyes sub- 
 icteric or marked- 
 ly icteric. Herpes 
 very frequent 
 and urticaria the 
 next most fre- 
 quent exanthem. 
 
 Frequent sweating, 
 miliaria. Septic 
 (polymorphous) 
 rashes. S u b i c - 
 terus, frequently 
 purpuric skin 
 eruptions, herpes 
 not uncommon 
 
 Herpes in epidemic 
 cerebrospinal 
 form. Tache 
 cerebrale. 
 
 Lungs 
 
 Breathing somewhat 
 increased from tox- 
 aemia (cerebral 
 breathing), hypos- 
 tasis, or other com- 
 plications. Rales 
 below and behind. 
 Tympanitic note 
 never heard in ty- 
 phoid. 
 
 Breathing increased 
 even 40 to 60 ; cya- 
 nosis and dyspnoea 
 without adequate 
 physical findings. 
 Fine and localized 
 rales heard above 
 and in front. Tym 
 panitic percussion 
 note from lung re 
 laxation. Evidences 
 of pleural ad 
 hesions, apical 
 changes, fresh pleu 
 ral rub. 
 
 If lung congestion 
 (severe forms), it is 
 variable, recurrent 
 shifts from lobe to 
 lobe. 
 
 Bronchitis frequent. 
 Pulmonary infarcts 
 and pleurisy. 
 
 Variable breathing ; 
 Biot's breathing. 
 
 Nervous System 
 
 Early headache, re- 
 placed later by de- 
 lirium, typhoid 
 state, actual men- 
 ingitis very rare ; 
 intoxication may 
 closely simulate 
 meningitis. Very 
 rarely disk 
 changes. 
 
 Meningitis tubercu 
 losa very fre- 
 quent ; optic neu- 
 ritis ; choroidal 
 tubercles. 
 
 Headache at onset 
 is rare ; later is of- 
 ten pulsating or 
 neuralgic. Delir- 
 ium from begin- 
 ning in sestivo- 
 autumnal forms is 
 frequent. Rest- 
 lessness, anxious- 
 ness. In perni- 
 cious forms may 
 have convulsions, 
 coma, etc. 
 
 Dependent on 
 cause. Septic men 
 ingitis (with arth 
 ritis, pleurisy, 
 etc.), cerebral em- 
 bolism ; retinal 
 hemorrhages or 
 embolism. 
 
 Early triad, head- 
 ache, retracted 
 neck and hyper 
 eesthesia. Head- 
 ache violent 
 throughout the 
 disease, convul- 
 sions, paralysis, 
 Kernig's sign, etc. 
 Optic neuritis, ret- 
 inal hemorrhage 
 tubercles in cho- 
 roid. 
 
 Sputum, Urine 
 
 Typhoid bacilli in 
 urine. Diazo test 
 in nearly all cases. 
 
 Tubercle bacilli 
 sometimes found 
 in sputum, urine 
 and faeces, but are 
 indicative of old 
 tuberculous 1 e 
 sions, not of mil- 
 iary tuberculosis. 
 Diazo test fre- 
 quent. 
 
 Alimentary 
 Tract 
 
 Mouse-like breath, 
 semi-character- 
 istic tongue, 
 ochre-yellow 
 stools, tympany, 
 diarrhoea, bowel 
 hemorrhage, per- 
 foration, bacilli 
 in stools. Re- 
 tracted abdomen 
 or early vomiting 
 rare. 
 
 Diarrhoea not com- 
 mon, but may 
 rarely occur, as 
 indeed may hem- 
 orrhages ; both 
 may come from 
 tuberculous ulcer- 
 ation of bowels. 
 
 Heemoglobinuria in 
 pernicious ma- 
 laria. Diazo test 
 fairly frequent, 
 though much less 
 than in typhoid. 
 
 Acute embolic 
 nephritis. Pep- 
 tonuria. 
 
 Nauseating breath. 
 Sometimes abdo- 
 minal pain even in 
 mild types ; may 
 rarely have diar- 
 rhoea, even hemor- 
 rhage in aliment- 
 ary pernicious 
 types. Liver con- 
 gestion frequent, 
 also icterus. 
 
 Septic diarrhoea. 
 
 Early cerebral 
 vomiting. Re- 
 tracted scaphoid 
 abdomen. 
 
44 TEE SPECIFIC INFECTIONS. 
 
 dyspnoea, are suggestive, and the detection of the anthrax bacillus 
 in the blood, urine, stools, or sputum, and the results of inoculation, 
 establish the diagnosis. 
 
 Febrile gastritis may rarely simulate typhoid, but the fever is 
 usually low or irregular, and is more often absent than present. 
 Marked early gastric symptoms are not common in typhoid. Febrile 
 enteritis is usually characterized by much mucus in the stools. 
 Though typhoid may occur with an old enterocolitis, the typhoid stool 
 seldom contains much mucus. Splenic tumor is most uncommon in 
 enteritis. The fever in enteritis is lower or more irregular than in 
 typhoid; and the bronchitis, the slow pulse, and the other cardinal 
 signs of typhoid, are absent. Cases of typhoid developing suddenly 
 may be, at first, confused with grippe, diphtheria, or other diseases. 
 Febrile syphilis seldom causes diagnostic trouble but must be con- 
 sidered in dubious cases. 
 
 Paratyphoid is due to a bacillus differing from the bacillus of 
 typhoid and of dysentery, and from the Bacillus coli, and re- 
 sembling the Bacillus enteritidis, Bacillus psittacosis, etc. Two types 
 of organisms are recognized — one producing a permanent and the 
 other a transient reaction in milk. Infection may occur from milk, 
 water, and tainted meat. The bacilli are found in the stools, 
 blood, roseolse, and urine, and agglutinate in higher dilutions 
 (1 to 1,000 or 2,000) than the typhoid bacilli. The first cases were 
 reported by Schottmiiller, in 1900. In paratyphoid the tempera- 
 ture is more brusque in onset and more irregular than in typhoid, 
 shows greater remissions, and may end by crisis. The pulse is slow 
 and dicrotic. Roseolas are often present (80 per cent.), the spleen is 
 enlarged less often and later, and no leukocytosis is observed. Pro- 
 dromal catarrhs, diarrhoea, cervical adenitis, oedema of the lids, vom- 
 iting, rigors, epigastric pain, herpes, myositis, arthritis, pleurisy, 
 endocarditis, and meningitis, are more common than in typhoid and 
 enable the practitioner to differentiate paratyphoid, clinically. The 
 diazo reaction is positive in 30 to 60 per cent. The clinical course 
 covers two weeks. Relapses are common. The infection is usually 
 mild, sometimes severe, and rarely fatal (3.6 per cent.). Ulcera- 
 tion of the intestinal lymph-structures is absent in the fatal cases, 
 though other necroses occur, thus explaining the occasional hemor- 
 rhage (5 per cent.). Pneumonia and perforation are unknown. 
 Nervous symptoms are not prominent. The disease is comparatively 
 rare. The blood does not respond to the Widal test nor are typhoid 
 bacilli found. Grunberg and Roily hold that the Widal reaction is 
 less a specific than a group reaction, as they found agglutination in 
 the paratyphoid group by typhoid serum. This does not imply, how- 
 ever, that failure to respond to the Widal test excludes typhoid 
 (Johnstone). A mixed infection with typhoid may occur. 
 
 Trichinosis is differentiated from typhoid by the history, by muscu- 
 lar pain and oedema in the striped muscles, by trichinae in the stools 
 and muscles, and by eosinophilia. In typhoid these symptoms are ab- 
 
TYPHOID FEVEE. 45 
 
 sent, while the Widal reaction, rose spots, and enlargement of 
 spleen, are present. Three cases of double infections have been 
 reported (McCrae). 
 
 Prognosis. — The death-rate was formerly 20 per cent., based on 
 50,000 cases collected by Jaccoud. At present it is lower (5 to 12 
 per cent.) because of (a) more accurate diagnosis, thus including 
 lighter cases in our figures; (b) the virulence of typhoid becoming 
 less ; (c) better hygiene ; and (d) better treatment, Brand method, etc. 
 
 The prognostic factors are: 
 
 1. Age: The least mortality is between the second and the tenth 
 years ; the highest after the twenty-fifth. The very highest mortality 
 is in babes. 
 
 2. Constitution : Meagre and muscular patients are more likely to 
 recover than the plethoric, or adipose. 
 
 3. Sex is immaterial, aside from pregnancy. 
 
 4. Acute diseases modify the prognosis, — e. g. scarlatina, measles, 
 variola, diphtheria, malaria, erysipelas, etc. 
 
 5. Chronic diseases, such as gout, diabetes (low temperature, the 
 sugar often disappearing), cardiac, pulmonary, and renal disease; 
 alcoholism (34 per cent, mortality from weak heart or hemorrhagic dia- 
 thesis) ; convulsive affections, such as epilepsy or chorea, may cease. 
 
 The prognosis is better in relapses than in the original case. 
 Recrudescences are dangerous. In war times the prognosis is usually 
 less favorable; the Spanish- American war was an exception, the 
 death-rate being but 7 per cent., while in the Boer war the mortality 
 was 21 per cent. 
 
 Death usually occurs between the eighteenth and twenty-eighth 
 days, and is caused by — 
 
 1. Toxcemia, the most frequent cause of death (30 to 50 per cent.), 
 including: (a) Hyperpyrexia; (b) hemorrhagic types; (c) heart 
 weakness, vasomotor paralysis; and (d) brain paralysis. 
 
 2. Local typhoid lesions, as meteorism, diarrhoea, peritonitis (in 16 
 per cent, of fatal cases), or hemorrhage (in 20 per cent.). 
 
 3. Complications, as lung inflammations (in 15 per cent.), ne- 
 phritis (4.5 per cent.), etc. Septicaemia has been little studied except 
 by French writers ("forme septicemique generalisee"), the symp- 
 toms of which are high fever, chills, sweats, abscesses, enlarged glands 
 and spleen. Pyaemia may result from acute osteomyelitis, suppura- 
 tive parotitis, adenitis, phlebitis, or splenic infarction. 
 
 4. Collapse. Sudden death has been discussed under changes in 
 the heart muscle. Dieulafoy estimates that sudden death occurs 
 in 2 per cent, of typhoid cases. The pulse is always more important 
 than the fever, and early rapidity is unfavorable. Bradycardia and 
 marked agglutination are favorable prognostics. 
 
 5. We have already considered the ominous significance of pseudo- 
 collapse, the typhoid state, early delirium, diarrhoea, and meteorism ; 
 of the various severe complications, such as noma, gangrene, laryngeal 
 perichondritis, and pneumonia; and of the more severe types, such 
 
46 THE SPECIFIC INFECTIONS. 
 
 as the hyperpyretic and hemorrhagic; and of the ambulatory varie- 
 ties. Typhoid beginning suddenly entails a high mortality. 
 
 Treatment. — Dujardin-Beaumetz said: "The best treatment for 
 typhoid is a good physician." The treatment concerns (A) prophy- 
 laxis; (B) specific treatment; (C) hygiene and rest; (D) the ques- 
 tion of intestinal antisepsis; (E) antipyretic measures (hydro- 
 therapy); (F) diet; (G) symptomatic or expectant treatment; (H) 
 treatment during convalescence. 
 
 (A) Peophylaxis.- — Prophylaxis has as wide a scope in medicine 
 as asepsis and antisepsis in surgery. In Chicago, during the years 
 1889 to 1892, inclusive, there were 4,747 deaths from typhoid. In 
 the four years after the drainage-canal was opened there were 2,235 
 cases ; that is, per population, the mortality was reduced 75 per cent. 
 In 1905, typhoid cases were rare. General prevention is difficult, 
 because of the ubiquity of the germ and the carelessness of individu- 
 als. Systematic cooperation regarding sewage regulation and 
 water supply could efface typhoid. Koch has particularly empha- 
 sized this point lately and succeeded in wiping out certain 
 typhoid foci. One difficulty lies in the infrequent recognition of 
 light cases, which are particularly dangerous, another in the selfish 
 carelessness of many persons, and a third in the fact that some 
 individuals " carry bacilli " for years. Such persons should be 
 quarantined. It is easy to boil water for home use, and yet it 
 is done in but few families, even in those of physicians. The 
 traveler should avoid unboiled water and milk. In the treatment 
 of a case, everything with which the germ may come in con- 
 tact must be sterilized. ISText to the faeces, the urine is the 
 most important conveyer of the bacillus. They are the usual 
 means of dissemination, and their proper disinfection in every case 
 would surely obliterate typhoid. The bacilli may persist for 
 years in the faeces and urine. Hexamethylenamina (urotropin) 
 is recommended for such cases. Chloride of lime should be placed 
 in the bottom of the urinal, or bed-pan, before and after use. 
 Acidulated sublimate (1 to 500) or 10 per cent, crude carbolic 
 solution may also be used; but neither at once disinfects, for which 
 reason the dejections should stand an hour or two in about a quart 
 of the disinfectant. Both the pans and urinals must then be ster- 
 ilized. The same urgent disinfection is indicated in the case of 
 thermometers used in the rectum, and rectal syringes or tubes. The 
 perineum, after each movement, should be sponged with a l-to-2,000 
 bichloride solution, and also the back and thighs, when there are 
 involuntary evacuations. The rubber draw-sheets and linen should 
 be sterilized regularly with carbolic acid or bichloride of mercury, 
 sheets and linen should be sterilized regularly with carbolic acid or 
 bichloride of mercury, and the blankets, pillows, and mattresses, 
 steamed when taken off the bed. The bath-tub should be care- 
 fully cleaned with carbolic solution, as the patient's soiled skin and 
 the urine often voided during the bath are obvious sources of 
 
TYPHOID FEVEB. 47 
 
 danger. It seems superfluous to urge cleansing the hands of the 
 nurse or physician after examination or tubbing, but the not infre- 
 quent direct transmission of the disease to nurses, orderlies, and 
 doctors, is often forgotten. Rubber gloves are the safest protection. 
 Direct infection is growing in clinical importance. In the Spanish- 
 American war 20 per cent, of our soldiers were directly infected 
 by flies, and in the Boer war more died of typhoid than were killed 
 by bullets, infection being carried by flies and sand. The few cases 
 among the Japanese is one of the many lessons they taught us. 
 Flies should be carefully excluded from the house by screens. 
 
 In convalescence the room should be fumigated with formalde- 
 hyde, not by the useless sulphur method (see Smaeepox). 
 
 (B). Specific Treatment. — Specific treatment awaits the fur- 
 ther development of serotherapy initiated by Chantemesse, Widal, 
 Brieger, Wassermann, Wright, and others. Preventive inoculation in 
 India and South Africa reduced the percentages of typhoid morbidity 
 from 14 to 2 per cent., and the mortality from 3 to -| per cent. 
 
 (0). Hygienic Treatment. — Absolute physical and psychical 
 rest is imperative, and the best results are obtained in cases which 
 have been put to bed early. Cases of the ambulatory type never fare 
 as well. The invariable use of the bed-pan and urinal should be 
 insisted upon, as every patient can learn to use them. In all in- 
 fections, the furniture, carpets and hangings, should be removed 
 from the room, and it should have free ventilation, — fever patients 
 do not catch cold. The nurse should have written instructions. The 
 stools, baths, etc., should be watched or directed by the physician, 
 especially at the onset. The single bed should be low, should have a 
 firm mattress, rubber draw sheet, and perfectly smooth cotton or 
 linen sheets. A second bed is desirable for change and convenience. 
 
 (D). Antiseptic Therapy. — Antiseptic therapy is largely of 
 historical interest, as typhoid is not a local enteric disease but a septi- 
 caemia or bacillsemia. Calomel was given early in typhoid by von 
 Ziemssen and Liebermeister, who thought that it reduced the viru- 
 lence of the attack and lessened bowel symptoms and complications ; 
 it is unnecessary, and at the acme is actually harmful. Salol 
 (phenylis salicylas) is the least objectionable, since it is mild; it is 
 given in doses of grs. x., t. i. d. The urine should be closely watched 
 for signs of renal irritation. Dilute hydrochloric acid, 3ss after 
 each feeding, prevents diarrhoea and tympany. !No one of this group 
 of agents essentially influences the clinical course. They are effi- 
 cacious solely against the common organisms of fermentation. 
 
 (E). Antipyresis. — (1). Drug Antipyretics. — These are seldom 
 indicated, for they merely reduce fever and do not eliminate its 
 cause, the toxins. Quinine is recommended by Liebermeister and 
 Curschmann, in one or two doses of fifteen to twenty grains, given 
 before the fever reaches its highest point. !N"o cardiac depression 
 results, and its effects last from eight to twelve hours; the fever, 
 however, is but moderately influenced by quinine. Coal-tar products, 
 
48 
 
 TEE SPECIFIC INFECTIONS. 
 
 in full repeated doses, depress the brain, circulation, respiration, and 
 metabolism ; cause vomiting and eruptions ; increase the danger of col- 
 lapse; and are not indicated in typhoid as they are in the fugitive 
 fevers. In practically all cases, drug antipyresis is far inferior to — 
 (2). Hydrotherapy. — Hydrotherapy, which is the only logical 
 method of reducing temperature, since it alone eliminates the fever- 
 exciting toxins. Nature's method of reducing temperature by 
 sweating should not be ignored. Evaporation from the moist skin 
 should be helped by removal of the bed-clothing, (a) The full cold 
 bath of Currie (1787) and Brand is given with water at 64° to 68° ; 
 it lasts fifteen to twenty minutes and is repeated every three hours 
 
 Fig. 6. 
 
 Burr's bed. 
 
 for temperature of 102° or over. Chilling is averted by vigorous 
 friction, which must not abrade the skin; by cold affusions to the 
 head; or by administration of alcoholic stimulants. The apparent 
 brutality of the Brand method has excited considerable popular and 
 professional prejudice, but it is more valuable than any other measure 
 in typhoid. As Jtirgensen remarks, every deviation from the simple 
 principles above outlined gives less satisfactory results. Early resort 
 to hydrotherapy gives the best results. When the portable bath- 
 tub is not available, the method of A. H. Burr is equally good. 
 He uses a wooden frame, shaped like a large box ; the base fits over 
 any bed ; its upper part sustains a heavy rubber sheet, which passes 
 under the patient and constitutes the sides and bottom of the tub 
 (Eig. 6). Its use obviates the necessity of lifting the patient, and 
 saves excitement. Water is poured over the patient from pails and 
 is removed with a siphon. The advantages of Brand's method are : 
 (i) The mortality is lowered 6 to 8 per cent. ; (ii) toxaemia is less- 
 
TYPHOID FEVER. 49 
 
 ened, and therefore nervous and digestive symptoms, heart weakness, 
 and pulmonary complications, are relieved; fever is successfully 
 reduced, and there is less visceral degeneration ; (iii) the renal secre- 
 tion is stimulated, thereby washing the toxins out of the blood; (iv) 
 the skin becomes more active and bed-sores less frequent, although 
 furunculosis is seemingly increased ; (v) the clinical course is shorter, 
 and, on the whole, fewer complications occur, although the percentage 
 of hemorrhage and perforation is not lowered, and relapses seem 
 slightly more frequent. C ' ontra-indications to the use of Brand's 
 method are hemorrhage, perforation, great prostration, alcoholism, 
 advanced arteriosclerosis or cardiac disease, and marked phlebitis. 
 Pregnancy, nephritis, and pneumonia, are not contra-indications. 
 Various substitutes, for Brand's method, though less effectual, may 
 be indicated for special reasons: — (b) The gradually cooled bath 
 is identical with the Brand method, except that the temperature of 
 the water is gradually reduced from 90° to 75° or 65°. It is 
 adapted to cases coming under treatment late and to those with 
 great dyspnoea, or tendency to collapse, (c) The protracted tepid 
 bath. (d) Cold sponging, first with warm water to dilate the 
 skin-vessels and then with cold water to abstract heat. Equal parts 
 of alcohol and water should be mixed, to aid evaporation. One 
 part after another of the body is exposed and sponged. It is a re- 
 freshing and quieting placebo, but enormously inferior as an antipy- 
 retic, (e) The cold pack is also much less successful. In sthenic 
 cases, ice applications to the head, axilla, spine, etc., may be used, 
 or the body may even be ironed with ice. Ice-water enemas are 
 never used in typhoid, though sometimes employed in other fevers. 
 (F). Diet. — Fifty ounces of water should be given daily at defi- 
 nite intervals. It flushes the kidneys, lowers temperature by in- 
 creasing the sweat production, and lessens parenchymatous degenera- 
 tion of the viscera. Pure water is superior to barley- or albumin- 
 water, lemonade, etc., which dull the appetite and often derange 
 digestion. Care of the mouth may be considered here. The mouth 
 and pharynx should be carefully cleansed of sordes and food particles 
 lest infection travel to the ears, salivary or lymphatic glands. A 
 boric-acid solution, with tincture of myrrh or tincture of hydrastis, 
 meets every requirement. The liquor antisepticus, U. S. P., contains 
 2 per cent, boric acid and antiseptic oils. The cleansing must be 
 gentle lest fresh abrasions be inflicted. The diet must be fluid, since 
 there are intestinal lesions. It must also be easily digestible, since 
 fever lessens all the digestive juices. In the diet no reference is 
 made to individual symptoms, as there is no correspondence between 
 the clinical symptoms and the anatomical ulceration of the intes- 
 tines. Graves was the first to feed fever patients, who up to that 
 time had been starved, but there is, at the present time, almost equal 
 danger of overfeeding. Milk is the standard diet. Six to eight 
 ounces should be sipped at intervals of three hours, day and night, 
 as the patient, after being wakened, readily falls to sleep again. It 
 4 
 
50 THE SPECIFIC INFECTIONS. 
 
 is best given diluted with half an ounce of lime-water or with a 
 little carbonated water, which should not be cold, since the gas ex- 
 pands at body heat. Though milk alone is said to contain insuffi- 
 cient albumin to meet the tissue-waste, there is risk of overfeeding; 
 the physician himself should inspect the stools for curds, for milk, 
 curdling in the stomach, practically becomes solid food. As in 
 infant feeding, curds indicate skim-milk. Very few patients cannot 
 take milk. In other words, it can be forced upon unwilling patients. 
 Recalcitrant patients may be given some variation, such as koumyss, 
 matzoon, buttermilk, whey, or certain baby-foods. If the digestion 
 is peculiar or weak, peptonized milk, given with very thin, strained 
 gruels, or egg, may be tolerated. Carbohydrates are theoretically in- 
 dicated to lessen nitrogenous waste, and well-boiled cornstarch and 
 tapioca are allowed by some clinicians. They are permissible if no 
 tympany results, and the author agrees with Hare that taka-diastase 
 aids their assimilation. Meat-juice is obtained from freshly slaugh- 
 tered beef, by a meat-press. If its taste is disagreeable to the patient, 
 a few drops of peppermint oil may be given first. It may also be 
 given frozen (meat juice, 5 iij. ; sugar, 3 ij. ; lemon-juice, 3 j. ; yolk 
 of one egg; cognac, 3 j.). The following articles afford some va- 
 riety: ISTutrose, somatose, eukasin, yolk of egg in soup or wine, and 
 white of egg with twice its weight of water. Foods containing 
 gelatin conserve metabolism (Senator) but may irritate the bowels. 
 Beef -tea should be avoided, as it contains only stimulating sub- 
 stances, less than 1 per cent, albumin, and no fat or carbohydrates 
 and may irritate the kidneys and intestines. In stupid patients with 
 anaesthetic throats, food may enter the larynx and cause aspiration 
 pneumonia. The nasal catheter is then indicated. To its outer end 
 a funnel is attached, through which food, drink, and medicines, are 
 given. A safety-pin across its outer end prevents its escape down- 
 ward. The catheter should be long enough to pass into the oesopha- 
 gus beyond the larynx, and care should be exercised that it does not 
 enter the latter. Rectal feeding is sometimes indicated. 
 
 (G) Symptomatic or Expectant Treatment. — 1. Digestive 
 System, (a) Vomiting. — It must be ascertained that the patient has 
 been given no solid food by solicitous friends and that perforation has 
 not taken place. Rectal feeding, the use of warm carbonated water, 
 cocaine gr. J, or tincture iodine Til -J, for several doses, sinapisms or 
 an ice-bag to be placed on the epigastrium, are indicated. Bartho- 
 low's formula is very serviceable: 
 
 ]£ Phenolis gr. iv. 
 
 Bismuthi subnitratis 3iss. 
 
 Cerii oxalatis 3j. 
 
 Sodii bromidi 3ss. 
 
 Sacchari albi \ - - 
 
 Acacise j ^" * 
 
 Aquae menthse piperitee q.s. ad %ij. 
 
 M. et ft. emulsum. 
 
 S. — One teaspoonful, undiluted, every 15 to 30 minutes. 
 
TYPHOID FEVER. 51 
 
 (&) Constipation should be treated with enemas of water or sweet 
 oil every other day. Typhoid cases with constipation do better than 
 those with diarrhoea. Cathartics are never used, as they cause mete- 
 orism. (c) Diarrhoea is most frequently due to toxaemia and is, 
 therefore, most efficaciously treated with the cold bath; curds 
 (prevented by diluting or skimming the milk), beef -tea, impure 
 milk, or solid food, may be its cause. Treatment is indicated 
 when there are more than four movements daily, and when 
 there is colic, tenesmus, unrest or weakness. Cold tea with whiskey 
 and pulv. aromaticus gr. xv., or paregoric and bismuth each 5j., 
 after each movement, extr. opii. gr. i., or the starch-and-laudanum 
 enema usually give relief at once. Pepper considered silver nitrate 
 almost specific (gr. J to f). 
 
 ]£ Bismuthi subnitratis 3j- 
 
 Morphinae sulphatis gr. j. 
 
 M. et div. in pulv. xij. 
 
 S. — One to four a day. (Alonzo Clark.) 
 
 fy Acidi tannici gr. x. 
 
 Tincturse opii TTLvj. 
 
 Olei terebinthinae TTLv. 
 
 Mucilaginis 3ij. 
 
 Aqua? menthae piperita^ ad. Jj. 
 
 M. f . haust. 
 
 S. To be taken every two hours. (Mjirchison.) 
 
 ]£ Plumbi acetatis gr. iss ad iij. 
 
 Opii pulveris gr. i ad ijss. 
 
 Sacehari albi gr. lx. 
 
 M. et divide in pulv. vj. 
 
 S. — A powder every three hours. (Yeo.) 
 
 (d) Tympany. — This is sometimes an indication that the patient has 
 been given solid food. In severe cases albumin-water must be sub- 
 stituted for milk. The cold bath often gives relief, since most cases 
 of meteorism are due to toxaemia. Hydrochloric acid after feeding 
 may lessen the tympany. The turpentine stupe of Jenner should 
 be applied to the abdomen, flannel cloths being dipped in a mixture 
 of warm water and 3ss ol. terebinthinae and pressed hard together 
 to spread the oil evenly and thus avoid blistering. The ice-coil is also 
 beneficial. The old turpentine emulsion of Wood (emulsum olei 
 terebinthinae, 3j.) is excellent, though the urine must be watched care- 
 fully for signs of renal irritation : 
 
 ]£ 01. terebinthinae 3iss. 
 
 01. caryophylli gtt. vj. 
 
 Glycerin! # \ ^ ^ 
 
 Mucilaginis acacise J D 
 
 Syrupi et aquae aa, ^iss. 
 
 M. et ft. emulsum. 
 
 S. — A dessert spoonful every 3 or 4 hours. 
 
 Whiskey and spices are effective. Emulsum asafoetidae, Oj. ; spir- 
 itus chloroformi, 5ij.; and ol. terebinthinae, 3ss; as a warm enema, 
 often give relief, (e) Hemorrhage necessitates absolute quiet, men- 
 
52 THE SPECIFIC INFECTIONS. 
 
 tal, physical, and alimentary. The patient should not be moved for 
 any reason whatever. In severe cases he should lie in the blood 
 which has been passed, with cotton tucked around the hips and 
 between the legs to catch the urine and faeces, which should pass 
 into it without his being lifted on the bed-pan. ISTo food, no water, 
 no enema, no bath, should be given. Morphine is primarily indi- 
 cated. It quiets the excitement attending hemorrhage, lessens peri- 
 stalsis and enforces bodily quiet. It should be given in sufficiently 
 large amounts, gr. J being injected every half -hour for three doses, 
 then a quantity sufficiently large to produce its full physiological 
 effects, for the dose of a drug is not measured in grains but in its 
 effect; it should be repeated every two, four, or six hours in order 
 to sustain the primary indications above named. The author has 
 given even four to six grains in the first day, when the greatest 
 danger occurs, but in such cases the patient must be very closely 
 watched. The author considers that the sole valid objection to 
 morphine is that it may mask coincident perforation, which occurs 
 once in every -Qxe cases of hemorrhage; he believes, however, that 
 close circumspection invalidates this objection. Opium or styptics 
 by the mouth are dangerous and uncertain. The lead- or iron-salts 
 probably never reach the bowel. The ice-coil placed on the abdo- 
 men may be beneficial. Gelatin may be injected as in aneurysm 
 (q. v.). The question of stimulation is a difficult one. On the 
 one hand, there is the risk of forcing blood through the leak by 
 stimulation; on the other hand, the volume of blood must not sink 
 too low; but first the heart must be allowed to run down, — nature's 
 own and most certain method of hemostasis. At a later time only, 
 should strychnine or digitalis be administered hypodermatically, or 
 saline transfusions be given ; delay in their use is better than haste. 
 (/) Perforation necessitates an early diagnosis and immediate oper- 
 ation. Most reported recoveries were operated on in the first twenty- 
 four hours. Eecovery occurred in 30 per cent, of 358 operations 
 (Cazin). In twenty cases operated on at Johns Hopkins Hospital, 
 35 per cent, recovered. 
 
 2. Circulatory System. — Heart weakness is best prevented by abso- 
 lute rest, and hydrotherapy. An ice-bag placed over the heart tends 
 to regulate and calm its action. Strychnine, gr. ■£$, is the best heart 
 tonic, and may be given two or three times a day as a vasomotor 
 tonic in cases which do not show signs of heart-failure, but it is best 
 to await definite indications for stimulation. Digitalis is rarely 
 beneficial in fever cases, and may produce urgent signs of cumulative 
 action if the fever should fall. The author has seen one case in 
 which, with rather sudden defervescence, the pulse dropped from 
 140 to 40. Camphor, gr. ij., disagrees when given by the mouth and 
 should be given under the skin in 1 to 10 parts of sterilized olive 
 oil. Other cardiants are considered under valvular disease and 
 pneumonia. Sudden dilatation should be treated by venesection and 
 stimulation. Alcohol may be considered under this head. In ty- 
 
TYPHOID FEVES. 53 
 
 phoid it may be indicated (a) as a food, with milk and eggs, thus 
 aiding digestion: 5j. to iv. of whiskey may be given every two to 
 four hours in hot milk. Stokes' mixture contained cognac, ^ij* > 
 vitelli ovi., one ; syr. aurantii, 3v. ; water q. s. ad Jv. Eggnog 
 is valuable as a food which may be readily absorbed, (b) As a 
 cardiant (though pharmacologists hold that pure alcohol is not a 
 cardiant) ; Meltzer states that it equalizes the circulation. It is 
 indicated especially in young alcoholics, and in most cases over 
 forty years of age. Cognac may be given by the mouth, in coffee; 
 or by rectum, in peptonized milk with two drachms of tincture of 
 valerian, (c) As a nervine in debility or old age, as whiskey, 
 champagne (especially for vomiting), sherry, or port, (d) To a 
 less degree as an antipyretic, since it increases the sweat production. 
 Its use must be suspended when the pulse becomes bounding, the 
 respiration hurried, the skin or tongue dry, and when there is rest- 
 lessness, or the odor of alcohol appears on the breath. Like other 
 good things alcohol has been abused, and of late the reaction against 
 its use is in part sound and in part excessive. With care and dis- 
 cretion alcohol is invaluable in severe cases. 
 
 Thrombophlebitis is treated by quiet, elevation, warmth, and ban- 
 daging from the toes upward. 
 
 3. Respiratory System. — Epistaxis usually ceases spontaneously. 
 If the blood runs into the throat a tampon should be introduced. 
 Laryngeal complications may necessitate early tracheotomy. Only 
 2 per cent, of severe laryngeal complications recover without opera- 
 tion. Bronchitis is treated most efficaciously by hydrotherapy, or 
 rarely, by codeine. Expectorants are always avoided since they 
 produce gastric disorder. Hypostasis is best treated by hydro- 
 therapy, cardiants, and change of posture every two hours, for which 
 explicit written orders should be given. 
 
 4. Nervous System. — The initial headache may be relieved by hy- 
 drotherapy, the ice-cap, ergotin and acetphenetidinum (phenacetin) 
 each gr. v., for several doses. Depression is relieved by valerian 
 and whiskey. For delirium, and insomnia, hydrotherapy is the 
 most useful measure; veronal, gr. v.-vij. in warm water, produces a 
 very natural sleep ; alcohol ; morphia, gr. \ ; codeine, gr. J ; sodium 
 bromide, 3ss to j . ; and hyoscinse hydrobromidum, gr. yj-g- to -$-$ , 
 may be indicated. 
 
 ]£ Morphinae hydrochloridi gr- i. 
 
 Sodii bromidi gr. xxxxv. 
 
 Syrupi aurantii 3iij. 
 
 Aquae chlorof ormi ad ^ij. 
 
 M. f. mist. 
 
 S. — Half to be taken at bed-time, and the remainder in three hours, if 
 necessary. (Whitla.) 
 
 Typhoid patients should never be left alone, lest they leave the bed 
 or leap from the window. Restlessness may suggest a full bladder. 
 
 5. The Shin. — Massage with alcohol or olive oil is useful. The 
 
54 TME SPECIFIC INFECTIONS. 
 
 skin functions are helped by the full bath. In the formation of 
 bedsores, local heat, pressure, moisture, maceration, or filth are 
 factors. These are generally avoided by frequent changes of posture, 
 thick pads or rubber rings and cleanliness. In some cases great 
 debility may frustrate prophylaxis. The least erythema, papule, 
 abrasion, or pustule, on dependent parts is a matter of solicitude; 
 without great care, skin infections may cause ward-epidemics 
 (Edsall). If bed-sores have already developed, the simplest treat- 
 ment is the best, since antiseptics and powders may aggravate. The 
 balsam of Peru is excellent. Collodion and adhesive straps are al- 
 ways to be avoided as far as possible. 
 
 6. Bacilluria. — Bacilluria is met by phenylis salicylas and hexa- 
 methylenamina, each gr. x., t. i. d. Special care is necessary in 
 the use of catheters. 
 
 (H). Treatment in Convalescence. — The convalescence must 
 be actual, and the possibility of relapses must be excluded before 
 the patient can have substantial diet or be allowed to sit up. It is 
 best to err on the safe side, as embolism and collapse are not unknown 
 in convalescence. Eggs, toast, gruels, rice, etc., may be given after 
 one week of normal temperature. The patient should not leave his 
 bed for two weeks. Irregular fever lingers in some cases until solid 
 food is given and the patient sits up. In other cases, nitrogenous 
 food will cause a higher temperature (febris carnis). Vegetables 
 and fruits should be postponed for a few weeks. An excellent tonic 
 in convalescence is the following: 
 
 I£ Strychninse sulphatis gr. j. 
 
 Acidi nitrohydroehlorici 3j. 
 
 Tr. gentianas co $v. 
 
 M. et S. — One teaspoonful after meals in half a glass of water. 
 
 TYPHUS FEVER. 
 
 Synonyms. — Typhus fever; exanthematous typhus; war, prison, 
 ship or famine fever. 
 
 Definition. — An acute, highly contagious, specific infection of un- 
 known causation, mostly epidemic; with a sudden onset and a high 
 temperature, falling by crisis, and with a cyclic curve, a character- 
 istic eruption, and severe nervous symptoms. Typhus, first described 
 by Corradi (1083), was clearly distinguished by Fracostorius, in 
 Verona (1505). 
 
 Etiology. — All stages of the disease are highly contagious. The 
 unknown virus exists in the exhalations from the skin and lungs 
 (Murchison), and survives for a long time in clothing and furniture. 
 Infection is usually direct from person to person. The danger to 
 attending nurses and physicians is therefore great, especially in 
 severe epidemics. The more intimate the contact the greater is the 
 danger of direct infection. It is also communicable indirectly by a 
 third person, by means of fomites and fleas may convey infection. 
 
TYPHUS FEVEE. 55 
 
 The atrium is probably the lungs. Susceptibility to the disease is 
 general. Immunity is usually conferred by one attack. 
 
 Geography. — Ireland, Russia, Galatia, Hungary, Italy, and 
 Mexico, are its most frequent homes, and there are always cases in 
 China, Asia Minor, and Hungary. It is endemic in Berlin, occur- 
 ring among the lower classes, among vagabonds, and in the unclean, 
 poorly-fed, closely-packed and unhygienic population. Typhus was 
 one of the greatest scourges of the middle ages, with its wars and 
 famines, but it has decreased in the past century, the epidemics in 
 Ireland (1817 and 1846) and in the Turko-Russian war (1877-78) 
 being the last general outbreaks. Its most recent occurrence in this 
 country was in New York (1881-82 and 1893), in Philadelphia 
 (1883), and in Baltimore in 1901 (Osier). 
 
 Age. — Most cases occur between the fifteenth and twenty-fifth 
 years. It is rare in the young or aged. It may occur with other 
 epidemics. The bacteriology of typhus is undetermined. A strep- 
 tococcus was found by Hlava (1891) and a diplococcus by Dubieff 
 and Bruhl (1893). 
 
 General Clinical Picture. — 1. Incubation. — The incubation lasts 
 twelve days or less in children, and is usually unaccompanied by 
 symptoms. 
 
 2. The Stage of Invasion. — The invasion is sudden, exhibiting 
 one or more chills and a high temperature on the first day. Thirst 
 follows, with anorexia, coated tongue, vomiting, epigastric oppres- 
 sion, suffusion of the face, conjunctivae, nose, and pharynx, apathy, 
 delirium, epistaxis, backache, severe pains in the extremities, rapid 
 pulse, and early splenic intumescence. 
 
 . 3. The Exanthematous Stage. — On the third or fifth day a 
 roseolous eruption develops, at first pale-red and purely hypersemic. 
 It is seen first on the abdomen, and chest, extending rapidly to the 
 back and extremities. The eruption then develops a petechial char- 
 acter, with some serous infiltration in the centre or edge of the 
 flecks, which become dirty and copper-colored. It lasts seven to ten 
 days. In this stage there is no pain, but often apathy, prostration, 
 delirium or mania. The tongue and mouth are dry and dark. 
 Catarrhal inflammations of the pharynx, larynx and bronchi develop, 
 with hoarseness and cough. The fever is continuous. Coma-vigil, 
 rapid respiration and pulse, and hypostatic pneumonia may end the 
 course. 
 
 4. Defervescence. — A crisis usually occurs on the tenth to the 
 fourteenth day. The pulse becomes slower; the skin often desqua- 
 mates in dusky scales; profuse sweats are common; the tongue 
 clears, and convalescence is established in two weeks. Long defer- 
 vescence suggests complications. 
 
 Special Symptomatology. — 1. Fever. — After a rigor, the tempera- 
 ture rapidly rises to 103°, 105°, or even 107°. ~No other acute ex- 
 anthematous disease produces an equally high early temperature. 
 The maximum temperature is observed on the fifth day. On the 
 
56 TEE SPECIFIC INFECTIONS. 
 
 tenth day the temperature often remits, except in most severe cases. 
 The crisis occurs from the tenth to the fourteenth day. Curschmann 
 considers that lysis is as frequent as crisis. Death occurs with a 
 preagonal rise or with collapse-temperature. 
 
 2. The Skust. — The eruption consists of two elements: Roseolse 
 changing to petechia?, and a dusky-red mottling under the skin. 
 The roseolce are seen on the third or the fifth day; they increase 
 rapidly though never in recurrent crops. They are located chiefly 
 on the lower abdomen, chest, back or shoulders, are least abundant 
 on the thighs, and do not appear on the face except in women and 
 children whose skin is delicate. The palms of the hands and the 
 soles of the feet are generally exempt. The roseola? are pale-red, 
 washed in outline, round or oval, the size of a pin-head or a lentil. 
 They are hypersemic, and therefore disappear on pressure and after 
 death. They are easily overlooked at night. They last one, two, or 
 at the most three days, later becoming livid, copper-colored petechia 
 persisting on pressure and after death, became hemorrhagic. The 
 petechia? occur mostly on the back, or in the folds of the groin, and 
 may lie between the roseolse. The hemorrhage may extend more 
 widely into the skin or subcutaneous tissue. Typhus cases presenting 
 no rash are rare. A great multiplicity of petechia? is an ominous 
 feature, especially in cachectic and alcoholic subjects. A morbilli- 
 form eruption on the arms and legs is occasionally observed before 
 the usual typhus rash, especially in thin-skinned individuals. The 
 skin is usually dry, but miliaria may appear (in 10 per cent, of 
 cases), notably in the young. Icterus without decolorization of the 
 stools is frequent and is an unfavorable sign. Desquamation occurs 
 and is sometimes as profuse as in scarlatina; herpes occurs in 
 5 to 20 per cent., and bed-sores in 3 per cent, of the cases. The 
 skin has a peculiarly pungent offensive odor. 
 
 3. The Nervous System. — Toxaemia is profound. Headache is 
 constant until the exanthem appears; it is usually frontal and tem- 
 poral and radiates into the neck or shoulders. It is associated with 
 vertigo, backache, and hyperesthesia of the fingers and toes. The 
 sensorium first shows depression, characterized by apathy, insomnia, 
 incoherent speech, or disturbing dreams, which increase as the pains 
 disappear. In the second week coma-vigil, low delirium, mania and 
 hallucinations often develop. Suicidal tendencies may be noted. 
 Involuntary evacuations and noisy cerebral respiration also occur. 
 The earlier the nervous symptoms, the more ominous is their signifi- 
 cance. Neuralgia is occasional in defervescence. It is transient, 
 and occurs mostly in the lower extremities. Tremor of the forearms 
 and hands is almost constant. Convulsions are rare, but ominous. 
 They are observed chiefly in alcoholic or very irritable subjects and 
 in children. They are most often epileptiform. Paralysis occurs 
 from brain hemorrhage, embolism, etc. Cases of paraplegia and 
 aphasia are recorded. Meningitis is most rare. 
 
 Special Senses. — There is conjunctival catarrh and the " pin-head 
 
TYPHUS FEVEE. 57 
 
 pupil " of Graves. The ears are involved in 32 per cent, of cases. 
 
 4. Circulation. — The heart and vasomotor system suffer greatly 
 (Stokes). The pulse, which is of greatest prognostic value, is small 
 and reaches 100 to 120, or more in women and children. It is 
 slow only in light cases. It is labile and often slow in convalescence. 
 Acute myocarditis may occur with the highly dangerous acute dilata- 
 tion. Its symptoms are those described under Typhoid. In fatal 
 cases the heart muscle is granular and deep-red. The blood is dark 
 and fluid ; the red cells and haemoglobin are decreased, and the white 
 cells are increased. 
 
 5. Respiration. — Epistaxis is occasional. Hoarseness, erosions, 
 ulcerations, oedema, and perichondritis, may develop in the larynx 
 and may lead to secondary abscess of the lung or empyema. Bron- 
 chitis, and tracheitis are part of the disease and are present at the 
 onset, increase with the fever, and are evidenced by cough, and 
 slight expectoration. Catarrh with weak heart results in atelectasis, 
 hypostasis, and lobular pneumonia. 
 
 Pneumonia occurs in 15 per cent, of typhus cases, usually in the 
 second week, and is frequently atypical. 
 
 6. Gastrointestinal Tract. — The tongue, at first moist and 
 white, becomes dry and dark — the " parrot tongue." Thirst is com- 
 mon. Nausea and vomiting are fairly common, but meteorism is in- 
 frequent. The epigastrium only is tender. The liver is swollen, 
 soft, and grayish. There is usually constipation (90 per cent, of the 
 cases), although diarrhoea may appear at the crisis. Gastro-intes- 
 tinal hemorrhage, a hemorrhagic diathesis, diphtheritic ulcerations, 
 parotitis, ulceration of the oesophagus and pharynx, phlegmons, and 
 peritonitis, are infrequent. 
 
 7. Genito-Urinary Tract. — The urine is febrile. The urea is 
 decreased. Albumin frequently appears in the second week. Ne- 
 phritis (in 6 per cent.) is dangerous. Uraemia and haematuria are 
 rare. The urine will frequently show the diazo reaction. 
 
 8. Spleen and Glands. — An early splenic tumor is palpable in 
 33 to 66 per cent, and disappears in the second week. The splenic 
 pulp is fluid and degenerated. Rupture has been described. The 
 lymphatic glands are not usually enlarged, though adenitis was noted 
 during the Crimean and Turko-Russian epidemics. 
 
 Recurrence. — This happened only once in 5,000 cases (Buchanan). 
 
 Anomalous Courses.' — Light forms run a course of six to ten days, 
 with less fever, fewer nervous symptoms, and less rapid pulse than 
 in the more severe types. They include the abortive type without 
 eruption, and the ambulatory type. Very severe forms are the hy- 
 perpyretic (fatal in two to three days), or the adynamic (in which the 
 patient dies with low temperature, hemorrhages, etc.). 
 
 Differentiation.- — This is not difficult if the case is seen from begin- 
 ning to end, or during an epidemic. There are no absolute pathologi- 
 cal or bacteriological criteria. Mistakes in the diagnosis of sporadic 
 cases are often inevitable. In the initial stage only a probable diag- 
 nosis can be made. 
 
58 
 
 TBE SPECIFIC INFECTIONS. 
 
 In smallpox the chills, fever, prostration, severe aches, splenic tu- 
 mor, and backache, are not final, since they are less marked in mild 
 forms of variola. The initial scarlatiniform eruption in the angles 
 of the arms and groins is characteristic of smallpox. Morbilliform 
 eruptions occur in both. Smallpox invades the face more than 
 does typhus, and the relation of the eruption to the temperature re- 
 mission is not observed in typhus. Even at postmortem examina- 
 tions, differentiation between the hemorrhagic form of typhus and 
 purpura variolosa is frequently impossible. 
 
 Typhus. 
 Invasion; sudden; chill, coryza. 
 
 Eoseola; more numerous and earlier, 
 second day to fifth day. 
 
 Never in crops. 
 
 Distribution on body and extremities. 
 
 Sparingly on face. 
 
 Flat, pale, washed, hyperaemic, not 
 disappearing upon pressure when 
 they become petechial. 
 
 Course; more rapid. 
 
 Face and eyes injected. 
 
 Fever; abrupt rise, higher, less remis- 
 sion, if any; shorter; crisis, or short 
 lysis, on fourteenth day. 
 
 Soon bedridden. 
 
 Earlier and severer nervous symptoms. 
 
 Pulse; rapid and not dicrotic. 
 
 Spleen; early swelling, but less frequent. Later, but lasts longer; two or three 
 
 times more frequent. 
 
 Typhoid. 
 Slower and more gradual; no coryza. 
 
 Usually less points of eruption (are ex- 
 ceptions, — e. g., measles-like) ; on ex- 
 tremities, as in Franco-German war. 
 
 In successive crops. 
 
 On body; rarely on extremities. 
 
 Almost never on face. 
 
 Papular, pink, sharply outlined, always 
 hyperaamic, disappearing upon pres- 
 sure. 
 
 Slower. 
 
 Paler; conjunctivitis rare. 
 
 Slow rise and regular stages. 
 
 Oftener ambulatory. 
 
 Second week or later, and less severe. 
 
 Dicrotism of less importance than slow- 
 
 Less meteorism or none. 
 Stools; not characteristic. 
 Blood; leukocytosis. 
 
 Meteorism. 
 
 Ochre-stools. 
 
 Leukopenia, Widal reaction; bacteria 
 in blood, urine, roseolas. 
 
 Diazo reaction in both. 
 
 In recurrent fever, the fever-curve is important, but the diagnosis 
 may be difficult during the first attack. The history, the lack of in- 
 volvement of the sensorium, the generally favorable condition of the 
 patient, the absence of pain, the characteristic anaemic yellow-gray 
 skin, the spirilla and successive attacks, indicate recurrent fever. 
 
 In irregular epidemics, meningitis, with chills, fever, nervous 
 
BECU&RENT FEVfiR. 59 
 
 symptoms, coma, and headache (without rigid neck and with a 
 roseolous eruption), at first presents difficulties, though in the later 
 course, it may be distinguished after lumbar puncture and examina- 
 tion of the retinae. The eruption is at first roseolous but later is 
 petechial. If the petechise occur first, the disease is not typhus. 
 
 In measles the face is the first seat of eruption ; the rash is rarely 
 hemorrhagic; catarrhal symptoms precede the eruption, when the 
 fever again rises. Typhus is rare under five years of age. 
 
 Prognosis. — The prognosis depends upon the intensity of the tox- 
 aemia, the fever, the nervous symptoms, and on the complications — ■ 
 especially pneumonia. Death from toxaemia usually occurs in the 
 second week (twelfth day) ; from pneumonia in the third week. 
 The mortality varies between 6 and 20 per cent., but reaches 50 per 
 cent, in virulent epidemics and in patients over fifty years of age. 
 Children rarely die of typhus. 
 
 Treatmerit. — The treatment is that of typhoid, with the added in- 
 dication of strict isolation. Open-air treatment in tents is indicated, 
 with thorough disinfection of everything coming in contact with the 
 patient (see Small Pox). Cardiac stimulants are often required. 
 
 RECURRENT FEVER. 
 
 Synonyms. — Relapsing fever; febris recurrens; typhus recurrens; 
 seven-day fever; famine or prison fever; bilious typhoid. 
 
 Definition. — A specific infectious disease caused by Obermeier's 
 spirillum; acquired more often by direct personal contact than by 
 indirect infection; endemic in Ireland, Russian Poland, and India, 
 though sometimes epidemic; clinically characterized by a cyclic 
 course of febrile attacks lasting six or seven days, followed by an 
 equally long apyretic interval, which cycle may be repeated several 
 times. 
 
 Etiology. — Recurrent fever was first described by Rutty, of Dublin, 
 in 1739. It appeared in America in 1844, and was last seen in 
 1869. Obermeier in 1873 described a specific spirillum or spiro- 
 chseta (Spirillum Obermeieri) . Recurrent fever is transmitted not 
 by the spirillum itself, but by its spores, since the disease may recur 
 after the spirillum has been killed by quinine. The spores are 
 possibly the glistening bodies sometimes seen in the blood (q. v.). 
 The breath and exhalations are infectious. The secretions are ap- 
 parently not infectious. The disease has been inoculated in monkeys 
 and in man, from postmortem cuts. Bed-bugs may also convey it. 
 Infection is carried chiefly by vagabonds and emigrants. Males are 
 especially affected (90 per cent.). Most cases occur between the 
 twentieth and the fortieth years. 
 
 Symptoms. — Incubation. — After an incubation of from five to 
 seven days, the invasion occurs, usually, without prodromes. 
 
 The Invasion. — The invasion begins with a chill, a high tempera- 
 ture (reaching possibly 104° on the first day), a throbbing headache, 
 
60 TSE SPECIFIC INFECTIONS. 
 
 and, in the young, convulsions and vomiting. The vertigo and cere- 
 bral confusion may resemble acute alcoholism. Because of the 
 severe neuralgic pain in the back, legs, and calves, the patient lies 
 motionless. There is great depression, conjunctival suffusion, 
 slightly icteric sclerse, a pale (even cachectic) facial color, epigastric 
 oppression, with or without vomiting, and tenderness over the liver 
 and spleen. 
 
 Specific Findings. — The specific findings are in (1) the blood; 
 (2) the spleen; and (3) the bone-marrow. 
 
 1. The blood is dark and reveals the pathognomonic, motile, cork- 
 screw-shaped spirillum, which usually appears with the fever. 
 
 •It usually disappears before the fever falls, and appears again 
 with the next attack. The spirillum is found in the blood only. 
 The number is variable and not proportionate to the severity of the 
 disease; as, for instance one spirillum in ten to seventy fields at 
 first, and twelve to thirty spirilla in a field at the acme. Without 
 the immersion-lens, they may be located by the lashing about of the 
 red cells. They always lie between and never in them, and appear 
 as fine threads, sixteen to forty microns in length, with Rye to ten 
 waves in each, and move by undulation along their long axes. 
 They stain best with fuchsin, after the extraction of the haemoglobin 
 by acetic acid. Their life in the blood is usually thirty-seven days. 
 The white blood-cells are increased. Large, fatty, granular proto- 
 plasma-cells, probably from the spleen, may sometimes be seen. 
 
 2. The spleen is nearly always enlarged, painful, and palpable, 
 and varies in size directly with the temperature. According to 
 Leube, in no other infectious disease is the spleen so large, being in- 
 creased five- to sixfold and weighing even twenty pounds. The cap- 
 sule is tense, sometimes with perisplenic adhesions, and the pulp is 
 a fiuid-red. The Malpighian bodies are increased, and necrotic 
 areas and infarcts are common. Suppuration and rupture may 
 occur. Microscopically there are hyperemia, hyperplasia, spirilla, 
 and fatty desquamated endothelium from the veins, thus explaining 
 the spindle-cells found in the blood-stream. 
 
 3. The bone-marrow resembles the splenic follicles and contains 
 many granular cells, and, occasionally, aggregations of white blood- 
 cells. 
 
 Other Symptoms. — 1. ^Nervous System. — Headache is frequent. 
 The sensorium is usually free, delirium and insomnia being rare. 
 
 2. Temperature. — The temperature rises abruptly to 103° or 
 104°, and remains continuously high (105.8° to 107.6°), irom ^.ve 
 to seven days, when the crisis occurs. In no other disease is the 
 defervescence so precipitate (Leube). The fever falls 5° to 13° 
 (even 16°). In from five to seven days the patient is well, when 
 in 99 per cent, of cases the cycle is repeated. In the second attack 
 there may be no chill. There are usually but two or three relapses, 
 though as many as seven have been recorded, each successive one 
 being shorter by one to one and one-half-days. The temperature- 
 
RECURRENT FEVER. 
 
 61 
 
 curve is diagnostic. Lysis is rare (1 to 2 per cent.). The crisis is 
 followed by rapid convalescence, sweats, shrinkage of the spleen, 
 and disappearance of the spirillum; sometimes post-critical diar- 
 rhoea and collapse develop. 
 
 3. Circulatory System. — The pulse is rapid (120 to 140). 
 Compared with the temperature, it is full and hard, seldom dicrotic, 
 sometimes irregular, and often slow after the crisis. 
 
 4. Respiratory Tract. — Bronchitis (30 per cent.) and increased 
 respirations (thirty or more) have been observed. In fatal cases 
 atelectasis, hypostasis, pneumonia (40 per cent.), glottis oedema (31 
 per cent.), and pleurisy (2 per cent.), have been found. 
 
 
 
 
 
 
 
 
 
 
 Fig 
 
 . 7. 
 
 
 
 
 
 
 
 
 
 
 
 
 L):tj 
 
 4 
 
 5 ( 
 
 7 
 
 S 
 
 9 
 
 10 
 
 11 
 
 12 
 
 13 
 
 14 
 
 15 1 
 
 G 17 
 
 18 
 
 19 
 
 •20 
 
 •21 
 
 22 
 
 •23 
 
 •24 
 
 •2.", 
 
 •2$ 
 
 27 
 
 TEMP. 
 
 105 
 
 
 A 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 104 
 
 
 / 
 
 4 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 103 
 
 / 
 
 V 
 
 J 
 
 
 
 
 
 
 
 
 
 n 
 
 
 
 
 
 
 
 
 
 
 
 102 
 
 
 
 
 
 
 
 
 
 
 
 A 
 
 
 
 
 
 
 
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 101 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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 \ 
 
 
 100 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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 V 
 
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 99 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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 98 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 97 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 
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 90 
 
 
 
 
 \ 
 
 / 
 
 
 
 
 
 
 
 
 
 
 I 
 
 [1 
 
 
 
 
 
 
 
 95 
 
 
 
 
 
 J 
 
 
 
 
 
 
 
 
 
 
 
 V 
 
 
 
 
 
 
 
 94 
 
 
 
 
 
 V 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Fever chart in recurrent fever. 
 
 5. G astro-Intestinal Tract. — The tongue is white and later, 
 yellow-brown. Hsematemesis, a tender and swollen liver, icterus (8 
 to 25 per cent.), gall-bladder distention, bloody effusions in the ali- 
 mentary mucosa, and hyperplasia of the lymphatics, may be observed. 
 
 6. Genito-Urinary Tract. — The urinary findings resemble 
 those of typhoid. Nephritis is infrequent (2 per cent.), and abortion 
 occurs in 66 per cent. 
 
 7. Skin. — The skin is usually snbicteric, yet the stools remain 
 colored. Herpes, erythema, petechias, desquamation, and even roseo- 
 las, have been noted. The skin becomes drenched at the crisis. 
 
 Diagnosis. — The specific points are: A prevailing epidemic; onset 
 with chill and fever ; swelling and tenderness of the liver and spleen ; 
 
62 THE SPECIFIC INFECTIONS. 
 
 muscular pains; abrupt crisis; apyretic interval with recurrence 
 of the cycle, and spirilla found by blood examination. 
 
 Loventhal has found that the serum acts as a bactericide on the 
 spirochetal In the bilious type (bilious typhoid or septic recurrent 
 fever), there is severe icterus, destruction of the red corpuscles, and 
 pathological liver-findings which are suggestive of acute yellow 
 atrophy. Hemorrhages, involvement of the sensorium, and death 
 from collapse in the first attack are common. The colored stools, 
 rapid pulse, severe bronchitis, and enlarged spleen, are significant. 
 Malaria, typhoid, typhus, yellow fever, acute yellow atrophy of the 
 liver, and Weil's disease, are excluded by one examination of the 
 blood. 
 
 Convalescence. — Convalescence is rapid, after four or five weeks. 
 Death may occur from toxsemia, heart collapse, or from complications. 
 The prognosis is good, the mortality averaging 2 to 10 per cent., 
 although reaching 60 per cent, in the bilious type. One attack is not 
 certain to confer immunity. 
 
 Treatment. — The treatment is that of typhoid, and no drug has any 
 effect on the parasites. Pain often necessitates the use of opiates. 
 The heart weakness is treated as it is in typhoid. 
 
 SMALLPOX, VARIOLA. VACCINATION. 
 
 Definition. — Smallpox is an acute, highly infectious, specific dis- 
 ease. It begins suddenly with a chill, headache, vomiting, and 
 intense epigastric and lumbar pain, and is characterized by a typical 
 fever-curve and by an eruption on the skin and contiguous mucous 
 surfaces consisting of papules, vesicles, pustules, and crusts in suc- 
 cessive stages. 
 
 History. — Smallpox is said to have prevailed in China many cen- 
 turies and in India 1,000 years before the Christian era. Galen's 
 pesta magna of the second century is thought to have been variola. 
 Epidemics occurred in the sixth century, and during the crusades. 
 Rhazes (Arabia, ninth century) gave us the first accurate clinical 
 description of the disease. Smallpox was introduced into Mexico in 
 1520, by the Spaniards, and three and a half million persons con- 
 tracted the disease. Sydenham's classic of the seventeenth cen- 
 tury is most accurate and reliable. In 1718, Lady Montague intro- 
 duced into England preventative inoculation, which had been practiced 
 for centuries in Asia, and though she reduced the mortality by this 
 means to 1 per cent, or less, she only disseminated the disease in a 
 mitigated form. Jenner's discovery of vaccination, in 1796, has 
 greatly lessened the terrors of variola, which in Europe alone car- 
 ried off nearly half a million persons yearly, and in Iceland cost 
 the lives of 36 per cent, of the population. 
 
 Etiology. — The virus is still unknown. Weigert and others have 
 found pyogenic organisms, although suppuration is due to a later mixed 
 infection. Protozoa were first mentioned by Van der Loeff, in 1886. 
 
SMALLPOX. 
 
 63 
 
 The cytorrhyctes variolce of Guarnieri (1892) is an amoeba found in 
 the blood in the incipient stage, in that of vaccinated children and of 
 calves, and in the exanthem. PfeifTer, Roger, Weil, Funck, Cope- 
 man, Councilman, Mall ory, Calkins, Howard, and Perkins, have 
 found similar structures. Small bodies are found in the lower 
 epithelial layers. These bodies are structureless, measure one to four 
 microns, and lie in vacuoles in the cells. They enlarge and become 
 granular and segmented. 
 
 That the blood is infectious at an early stage was demonstrated by 
 the development of the disease in an individual on whom skin had 
 been transplanted from a person in the early stages of smallpox. 
 Variola without eruption is contagious, and it therefore seems that the 
 secretions, excretions, and exhalations, convey the virus. The virus 
 causes constitutional infection before the eruption appears. The 
 greatest infectiousness is noted during the eruption. Its chief 
 sources are the dried pustules in which the virus localizes. Infection 
 may be direct from person to person, or indirect by a third party or 
 by fomites. Cadavers of variola victims are dangerous. In short, 
 every new case comes directly or indirectly from a patient with 
 variola. The virus is very penetrative, and infection may exist 
 beyond the room, the building, or the area of the isolated case. The 
 disease persists in infected communities for years, becoming quiescent 
 and afterwards breaking out anew. The chief factor in dissemina- 
 tion is human intercourse. 
 
 Fig. 8. 
 
 TEMP. 
 
 10± 1 
 
 " " - - " ■ — T~ 
 
 103 M/i 
 
 A\ 
 
 [j n 
 
 -At-V 
 
 1" \ h 
 
 ___/ \w_ _ 
 
 100 / i a/ iA 
 
 lAf ^JKh^ 
 
 ■ --+^—4/^-^ 
 
 t _YT 
 
 , j r 
 
 1 
 
 
 INCUBATION PRODROMAL STAGE. ERUPTION OF MACULES ERUPTION OF SUPPURATION EXSICCATION & 
 12 DAYS .3J3AYS AND PAPULES 3 DAYS VESICLES 3 DAYS DECRUSTATION 
 
 2 DAYS 7 DAYS 
 
 Temperature chart and stages of smallpox. (Pfeiffer.) 
 
 Susceptibility to smallpox is almost universal ; only 1 per cent, of 
 people are immune. Individual immunity was noted by Mor- 
 gagni, Boerhaave, and Diemerbroeck. The author knows two persons 
 in whom vaccination has never been successful. Temporary 
 immunity is more frequent than congenital. Ordinarily and prac- 
 tically, immunity is only acquired by vaccination or a previous at- 
 tack. In prehistoric times, inoculation was practiced to afford immu- 
 nity. Second attacks are infrequent. Either sex and all ages may 
 be affected. Mothers with the disease may deliver babes with the 
 florid eruption or with scars. The virulence of the virus is great 
 in aboriginal and colored races (Indians and Mexicans), and in preg- 
 
64 TEE SPECIFIC INFECTIONS. 
 
 nant or menstruating women. Severe cases may follow mild infec- 
 tion, as shown in Osier's description of the Montreal epidemic, in 
 which 3,164 persons, infected by a mild case in a pnllman-car con- 
 ductor, died among the French Canadians, who oppose vaccination. 
 It is frequently conveyed by vagrants. 
 
 Point of Entrance. — Smallpox infection unquestionably occurs 
 through the respiratory tract, and perhaps also through the digestive 
 tract. Variola occurs sporadically, epidemically, or pandemically. 
 
 Symptoms. — Forms : 
 
 I. Variola Vera — 1. Discreta, discrete. 
 
 — 2. Confluens, confluent. 
 
 II. Variola — 3. Purpura variolosa (black smallpox"). 
 Hemorrhagica — 4. Variola hemorrhagica pustulosa. 
 
 III. Varioloid — 5. Smallpox modified by vaccination. 
 
 1. Variola Vera Discreta. — (A) The Incubation. — The incu- 
 bation averages twelve days (five to twenty). It usually presents no 
 symptoms, though there may be headache, anorexia, and pharvngitis. 
 
 (B) The Prodromal Stage. — The prodromal stage (initial stage, 
 or stage of invasion), dating from the first symptom to the cutaneous 
 eruption, is the same in all types, and its duration averages three 
 days. It is shorter in children and in the confluent type of the 
 disease ; the longer it is, the more severe is the infection (Trousseau). 
 Its intensity bears no invariable relation to prognosis, for varioloid 
 (mild smallpox), may present a severe onset; however, if the onset is 
 mild, the disease will not be confluent or hemorrhagic. Prodromal 
 symptoms are absent in rare instances. 
 
 The invasion begins acutely with chill, fever, rapid pulse and res- 
 piration, nervous toxemic symptoms, intense headache, backache and 
 vomiting, (a) The chill is usually severe, and frequently is repeated. 
 It may follow one or two days of fever (Jaccoud). In children it 
 is often absent, (b) The initial fever is almost invariably high, 
 rising suddenly to 103° or 104°, and reaching its maximum on the 
 second or third day. In rare instances there is no fever. The pulse 
 is rapid (120), full, and not often dicrotic except in severe cases. 
 The more frequent respiration (30 to 36) is somewhat characteristic, 
 constituting the so-called toxsemic or " cerebral respiration.'' The 
 skin is red, excessively hot {color mordax), and usually dry, but 
 there may be sweating in the discrete variety (Sydenham) and in 
 favorable cases (Trousseau). The face is flushed but the eyes are 
 clear, (c) Nervous toxcemia is evidenced by the benumbed sensorium, 
 depression, restlessness, insomnia, delirium (especially in alcoholics), 
 or convulsions and meningeal symptoms in children. Headache is 
 almost constant, usually appearing with or just before the chill. It 
 is frequently frontal or temporal, but may be generalized, occipital, 
 or neuralgic. When severe or agonizing in character, it may be sug- 
 gestive of meningitis, especially when accompanied by delirium, 
 hard vomiting, and neckache. (d) Backache appears with the chill, 
 and lasts one or two days. It occurs in nearly all cases though 
 
SMALLPOX. 65 
 
 rather less frequent than headache and vomiting. It is severe 
 like lumbago or actually agonizing. The " veritable paraplegia " 
 described by Trousseau is usually only immobility due to pain caused 
 by toxins or by intense congestion of the kidneys, spinal muscles, 
 or meninges (Jaccoud). It is rare in other fevers likely to be con- 
 fused with variola. Pain is sometimes observed in the pharynx, 
 larynx, or heart, and produces a sensation of constriction or actual 
 dyspnoea; it may occur in the intercostal nerves, sciatics, muscles, 
 and joints, (e) Vomiting and early epigastric pain are especially 
 constant in children. The spleen is not often enlarged in the initial 
 period. It is often tender, as are the liver and epigastrium. (/) 
 The initial or prodromal eruptions, studied especially by Sydenham, 
 Simon, Osier, Knecht, and Scheby-Busch, are present in 10 to 16 
 per cent, and have considerable diagnostic value. They are more 
 commonly limited to the lower abdomen, inside of the thighs, sides 
 of the thorax, axillae, and sometimes to the extensor surfaces of the 
 knees and elbows (Simon). There are two varieties: 
 
 1. The morbilliform variety (measles-like, roseola variolosa), 
 which appears during the second day on the face and body as small 
 maculae. These disappear upon pressure, are sometimes crescentic, 
 and usually last one day. They are due to hyperaemia but may be 
 purpuric. They are seen most often in varioloid, and therefore 
 have a favorable prognostic import. 
 
 2. The scarlatinal form (erythema variolosum) is more rare and 
 occurs earlier, either on the first day, or before any other symptoms. 
 It is less punctate, extensive, and bright, than it is in scarlet fever. 
 If it is purple in color and purpuric, it is almost always variolous. 
 It occurs on the lower abdomen, and on the thighs (forming a trian- 
 gle with base upwards when the legs are together), but may even 
 reach the knees. Sometimes it is found in the axilla or over the 
 shoulders, and is seen in women more frequently than in men. These 
 areas are rarely invaded by the pustular eruption. Some writers 
 speak of an erysipelas-like prodromal rash, and others have observed 
 prodromal urticaria. 
 
 (C). The Eruptive Stage. — The eruptive stage consists of several 
 serial sub-stages: 
 
 1. The stage of macules and papules (stadium maculosum et papu- 
 losum) occurs on the fourth day, and advances for three days. The 
 eruption begins on the forehead near the hair and on the cheek, with 
 itching and burning macules, resembling flea-bites, which, at first 
 purely hyperaemic, soon become papules. The papules are reddish, 
 discrete, circular, elevated, and hard or " shotty." A day after their 
 eruption on the face and head, they appear on the body, and on the 
 next day, on the extensor aspects of the extremities ; i. e., the papular 
 eruption advances for three days, and is descending. The papules 
 are thickest on the face and trunk. Sometimes they are very thick 
 on the neck. The eye-lids show collateral oedema. According to 
 Stokes, the amount of the eruption depends on the vascularity of the 
 5 
 
66 THE SPECIFIC INFECTIONS. 
 
 part. Trousseau and Sydenham maintained that if the eruption 
 appeared on the second day of the disease, the confluent type might 
 be expected ; if on the third day of the disease, the confluent type 
 might be anticipated. (If the eruption ceases at this point, the dis- 
 ease is called variola cornea, or verrucosa.) 
 
 Weigert holds that the first skin changes are not inflammatory but 
 necrobiotic or diphtheroid, and that inflammation begins later with 
 exudation into and about the necrotic areas in the rete Malpighii. 
 Other authorities consider inflammation the primary, and necrosis the 
 secondary process. 
 
 Unlike measles and scarlatina, the fever remits when the eruption 
 appears, and the backache and headache improve. In two or three 
 days the fever reaches normal by irregular steps. The lower the 
 fever falls in this remission, the lighter is the type of smallpox. 
 
 2. In the stage of vesiculation {stadium vesiculosum), lymph 
 gathers in many but not in all of the papules. This occurs on the 
 seventh day of the disease and lasts about two days. The vesicles 
 are multilocular, since they occur in the cells of the rete Malpighii. 
 Umbilication occurs in the centres of many vesicles, caused by eleva- 
 tion of their edges by infiltration and by the follicles in their centres. 
 It corresponds to the area of primary necrosis and is suggestive but 
 not pathognomonic of smallpox (Jaccoud, Eichhorst). On the soles 
 of the feet and the palms of the hands the fluid is situated deep in 
 the resistant tissues. (If the changes stop short of pustulation, the 
 disease is called variola crystallina.) The mucous membranes may 
 be the seat of simple inflammation, specific eruption, or pseudomem- 
 brane. 
 
 3. The stage of suppuration (stadium pustulosum) or maturation 
 begins on the ninth day with clouding of the vesicles and with inflam- 
 matory congestion (areola) about them. It advances for usually 
 three and rarely more than -five days. Increased mucous membrane 
 catarrh develops simultaneously with the cutaneous eruption. The 
 pustules become opaque, then yellow, and the thick pus obliterates the 
 umbilication and renders the eruption globular. The areola, or halo, 
 becomes more vivid and inflammatory oedema may result from fusion 
 of the areolae. This causes increased tension, deformity (especially 
 in the face and parts where the skin is most loose), closure of the 
 eyes, occlusion of the nose (of particular moment in children), and 
 great tenderness and pain. Pustulation follows the descending order 
 of the initial eruption and the pustules are less thick on the trunk 
 than on the extremities and head. On the volar and plantar sur- 
 faces they are less prominent and there is less oedema. The pus- 
 tules evacuate spontaneously, especially on the face, but may dry 
 without rupture. Various stages of the eruption may be observed 
 in different parts of the body at the same time; not all vesicles be- 
 come pustules. The skin exhales a peculiar, penetrating, offensive 
 odor, and bed-sores may develop. 
 
 (Anomalies are variola abortiva^ in which the pustular stage is not 
 
SMALLPOX. 67 
 
 reached; variola siliquosa, — air in the vesicles or pustules; and very 
 large eruptions three quarters of an inch in diameter.) 
 
 Pathologically, the pus originates from the vessels of the papillae 
 which may undergo much pressure-atrophy, or even necrosis. 
 
 The mucous membranes are involved in various ways, but the pock 
 eruption occurs mostly in the upper mucosse (mouth and naso- 
 pharynx), and therein resembles its cutaneous distribution; the 
 successive stages of papulation, vesiculation, pustulation, and crusta- 
 tion, may develop, but they are less typical than in the cutaneous 
 eruption ; erosions, diffuse catarrhal stomatitis, glossitis, phlegmonous 
 angina, etc., may result. The eruption has been found in very rare 
 instances in the external ear, Eustachian tube, eye, oesophagus, air 
 passages, alimentary and genito-urinary tracts. 
 
 With pustulation there is in most cases a gradual rise in tempera- 
 ture, secondary fever, the fever of suppuration. It is due to the 
 smallpox virus and mixed pyogenic infection. The duration of the 
 rise is proportionate to the degree of pustulation and of dermatitis. 
 In variola discreta the temperature does not remain high more than 
 twenty-four to thirty-six hours, with morning remissions. A 
 marked leukocytosis attends the secondary fever. It parallels the 
 degree of infection and may even attain 30,000 to 34,000 cells per 
 cubic millimeter. It ceases with involution unless complications 
 intervene. The lymphocytes are increased (to 50 or 66 per cent.), 
 the polymorphonuclears decreased (to 50 or 33 per cent.), and the 
 myelocytes may reach 10 to 12 per cent. 
 
 The red cells occur in clumps rather than in rouleaux, and some 
 deglobulization, even as low as 2,000,000, is observed. The fever 
 may show a pre-agonal increase or collapse. Hyperpyrexia may occur. 
 Eepeated rises in temperature are very dangerous. Cerebral symp- 
 toms occur, such as great excitement, or delirium with suicidal ten- 
 dencies. Albuminuria (33 per cent.), acute exhaustion, and heart 
 paralysis, may develop. 
 
 (D). The Stage of Involution. — The stage of involution (exsicca- 
 tion, decrustation) , begins on the twelfth day. It occurs in the same 
 descending order as the norition and suppuration, first on the head, 
 then on the body, etc., with decrease in the oedema, in the redness, and 
 in the pain. As the pain decreases, there is an intolerable itching and 
 some pigmentation. Crusts form, and remain longest on the soles of 
 the feet and palms of the hands where they may form complete casts 
 of the part. Mucous erosions heal more readily than crusts. The 
 hair falls out, and by the end of the second week the fever reaches 
 normal. There is no desiccation fever, as claimed by some writers, 
 and fever at this stage indicates some complication. Scars result 
 from the granulations, and the higher the granulating surface, the 
 deeper is the cicatrix. Scars occur when the true skin has been in- 
 volved, and are seen chiefly on the face, scalp, palms of the hands, and 
 soles of the feet. Sydenham's statement, that discrete smallpox rarely 
 leaves its mark, holds good in most cases, according to Osier. Others 
 
68 TEE SPECIFIC INFECTIONS. 
 
 hold that variola vera implies suppuration with fever and cicatrices 
 as necessary stigmata. Scar formation lasts three or four weeks. 
 Complete convalescence follows the disappearance of the last crust. 
 
 2. Variola Vera Confluens. — This is a malignant type, which 
 was more frequently observed in prevaccination days, and is now 
 seen largely in unvaccinated persons or in those vaccinated but once. 
 The initial stage is violent. The headache and backache are agon- 
 izing. The status typhosus and gastric symptoms are marked, the 
 fever remission is slight or absent, and there is little or no improve- 
 ment in the symptoms if a fall in temperature occurs. The exan- 
 them is precipitate both in its development (on the second or third 
 day), and in its extension. The earlier the exanthem in variola, the 
 greater is the probability of confluent smallpox. The patient usually 
 dies if the eruption does not appear. The eruption becomes confluent 
 especially on the face and head, and sometimes also upon the hands 
 and feet ; whereas on the body and limbs it is largely discrete. With 
 fusion of the eruption, great inflammatory oedema appears, the symp- 
 toms increase, swelling and erosion of the mucous membranes, 
 closure of the eyes, keratitis, and obstruction of the nose, develop. 
 The general aspect is desperate. High fever, high pulse, rapid, noisy, 
 even irregular or stertorous breathing, delirium, albuminuria, per- 
 sistent nausea and vomiting, great thirst, salivation in adults and 
 diarrhoea in children (Sydenham), husky voice, enlarged cervical 
 glands and often parotitis, are present. This type is severe from the 
 onset and the prognosis depends upon the number of pustules upon 
 the face. Sydenham says that " if upon the face they are as thick as 
 sand, it is no advantage to have them few and far between upon the 
 body." Death occurs from acute toxaemia (variola typhosa seu 
 adynamica), with hyperpyrexia and cardiac asthenia, or, if the pa- 
 tient lives longer, from septicopysemia, phlegmon, erysipelas, gan- 
 grene, pneumonia, pleurisy, and nephritis. Eecovery from variola 
 confluens is infrequent; in convalescent cases permanent deformity, 
 such as ectropion, is probable. These cases run a course of three or 
 more weeks. 
 
 3. Purpura Variolosa. — This is the black smallpox — smallpox 
 ivith primary hemorrhage in the initial stages. It is the worst type, 
 and results almost uniformly in early death. It was frequent in the 
 great pandemic of 1870-72. It is also important because of the diffi- 
 culty in its diagnosis. It is seen most frequently in the unvaccinated, 
 but may occur in the vaccinated, in women during the puerperium, in 
 the young, and in robust males. The incubation is short (six to eight 
 days), the invasion is stormy, with agonizing lumbar pain, great 
 prostration, a rapid, small, soft, and sometimes dicrotic or irregular 
 pulse, and disproportionately increased respiration. The initial 
 epigastric pain and vomiting may last until death. 
 
 On the second day (or even on the first), there appears a dark scar- 
 let or plum-colored eruption, with brick-red, purple, or inky ecchy- 
 moses, especially about the eyes. The aspect of the discolored and 
 
SMALLPOX. 69 
 
 swollen face, and ecchymotic, sunken and intelligent eyes, is des- 
 perate. Hematuria is the most common of internal or visceral 
 hemorrhages. Other forms are: Haematemesis, enterorrhagia, epis- 
 taxis, metrorrhagia, and hemorrhage from the gums, ears, and 
 bronchi, sometimes accompanied by gangrene of the pharynx. Tym- 
 panites and albuminuria may be noted. Miscarriage is frequent. 
 The spleen is not enlarged. The disease does not usually reach the 
 real eruption of variola, or, at the most, only the papules are observed, 
 because, as Phazes observed, the course is almost invariably fatal in 
 four or five days. The mind often remains lucid to the end. In the 
 majority of cases the fever is not high, but in the most fulminant 
 type it reaches 105° or 106°, with delirium, collapse, and coma. 
 Death results in a few hours, even before cutaneous hemorrhage is 
 seen, although internal hemorrhages are found at autopsy. Accord- 
 ing to Unna, the " blood dissolution " of the older writers is a mycotic 
 coagulation thrombosis. 
 
 4. Variola Pustulosa Hemorrhagica. — This is more common 
 than Purpura Variolosa (primary hemorrhage). In this type of 
 smallpox hemorrhage occurs after the eruption appears (secondary 
 hemorrhage). This form occurs in weakly or alcoholic subjects. 
 The initial stage is severe, and secondary hemorrhages occur into the 
 vesicles or pustules, or into the lower parts of the body if the delirious 
 patient has left his bed, or there may be " blood dissolution," epis- 
 taxis, hematuria, and metrorrhagia. Adynamic manifestations are 
 usual, and the outcome is almost always fatal, though in one type, 
 hemorrhage at the vesicular stage may be followed by rapid abortion 
 of the rash and speedy recovery (Osier). 
 
 5. Varioloid. — Varioloid (variola modificata s. mitigata, vario- 
 lois) is variola mitigated by vaccination. The more marked the 
 initial eruption, which is often morbilliform, the less the number of 
 pustules. Varioloid begins suddenly. The fever is atypical. It may 
 reach 103° and usually falls with the specific eruption, reaching 
 normal on the fourth day. Secondary suppuration fever is rare and 
 euphoria is common. The eruption is superficial, and, according to 
 French clinicians, there is no suppuration. The eruption varies in 
 amount, being present on the trunk only, or being typical chiefly on 
 the hands and feet. It may be absent entirely. It may not be um- 
 bilicated and may desiccate rapidly without rupture. The exanthem 
 is usually small and scars are rare. The mucous surfaces are little 
 involved, or are entirely unaffected. The entire course is shorter, 
 more irregular, and rudimentary, and more benign than in variola vera. 
 
 Complications and Sequelae. — The complications and sequelae of 
 variola are many, occurring chiefly in the more severe forms and 
 during the stage of suppuration. They embrace severe early tox- 
 aemia and later, secondary infections. 
 
 1. The Nervous System. — Nervous complications are very fre- 
 quent. Delirium is caused by brain hyperemia, which results from 
 swelling of the face and scalp, simple toxaemia, alcoholism, or hyper- 
 
70 THE SPECIFIC INFECTIONS. 
 
 pyrexia. Convulsions are frequent in children. Psychoses are usu- 
 ally asthenic and are not frequent. Meningitis suppurativa, encepha- 
 litis, hemiplegia, embolism, cerebral softening, phlebitis, and abscess, 
 are occasional complications. Paraplegia and monoplegia, both 
 caused by myelitis, Landry's paralysis and neuritis in the trunk, 
 extremities, or cranial nerves, are exceptional sequels. 
 
 2. The Vascular System. — Vascular changes are more rare. The 
 heart muscle may degenerate, becoming soft and relaxed, and 1 micro- 
 scopically revealing segmentation, and cloudy and fatty conditions. 
 Dilatation may occur. French writers speak of a coronary endar- 
 teritis and myocarditis. A systolic bruit may be heard at the apex, 
 with weak first tone, and tachycardia, as is the case in typhoid. 
 Aortitis, pericarditis, ulcerative endocarditis and marantic throm- 
 bosis are infrequent. 
 
 3. The Respiratory Tract. — (Edema of the larynx and peri- 
 chondritis are usually fatal, for laryngeal anaesthesia promotes inhala- 
 tion pneumonia. Obstruction of the larynx by submucous hemor- 
 rhage is uncommon. Bronchitis is invariable in severe cases. Pneu- 
 monia, usually lobular, occurs in 60 per cent, of fatal cases; lobar 
 pneumonia is rare. Lung abscess, embolism, and gangrene, are un- 
 common. Pleurisy is present in some epidemics, occurs chiefly in 
 the stage of suppuration, and is especially and rapidly fatal in 
 children (E. Smith). 
 
 4. The Digestive System. — Glossitis is rare, retropharyngeal 
 abscess, parotitis, noma, phlegmonous oesophagitis, and hemorrhage, 
 or membrane formation in the throat, are ominous though uncommon 
 complications. The early vomiting rarely persists. Diarrhoea is not 
 common, but a simple form is seen in children (Trousseau, Syden- 
 ham), and a dysenteric form is occasionally seen in adults. Peri- 
 tonitis, retroperitoneal cellulitis, mediastinitis and perineal abscess 
 are infrequent. The alimentary tract, with the exception of the 
 rectum, is usually considered exempt from the eruption. The liver 
 may suffer cloudy or fatty change, focal necrosis, or diffuse hepatitis. 
 The spleen is usually swollen and soft. 
 
 5. The Gentto-urinary Tract. — This is not often involved. Al- 
 buminuria occurs early in 25 per cent, of cases, during the eruption, 
 during suppuration, or in convalescence. Nephritis is not frequent, 
 but may develop during the fever or in convalescence; it is often 
 glomerular. Eocal necrosis may be noted. Pyelitis from cystitis or 
 myelitis, ovaritis, and vulvar gangrene, have been observed. Menor- 
 rhagia is common in the early stages of onset or in hemorrhagic 
 forms, and abortion from hemorrhagic endometritis is the rule in 
 pregnant women. Orchitis variolosa is very frequent, the inflam- 
 matory foci being multiple (Trousseau, Chiari, Velpeau). They lie 
 mostly in the connective tissue, but are rarely suppurative, or asso- 
 ciated with focal necrosis. 
 
 6. The Special Senses. — The eye is involved in 1 per cent. 
 (Hebra). Pox in the conjunctivae are rare, as are conjunctivitis, 
 
SMALLPOX. 71 
 
 keratitis, diphtheria of the conjunctiva, iridochoroiditis, neuro- 
 retinitis, metastatic panophthalmitis, and retinal hemorrhage. Otitis, 
 mastoid caries, and suppurative thrombophlebitis, may occur. 
 
 7. The Locomotor System. — Muscular abscess or hemorrhage 
 and arthritis, especially in the knee and shoulder, may occur during 
 desiccation. Arthritis is more often suppurative than serous, and is a 
 feature of the secondary sepsis. In the bones there are almost in- 
 variably hemorrhage into the marrow, hyperplasia of the marrow 
 cells, and multiple foci of necrosis or nonsuppurative osteomyelitis 
 (in 72 per cent., Chiari). 
 
 8. The Skin. — Decubitus, erysipelas, abscesses (local or pysemic), 
 post-variolous eruptions, erythema, pustules, bullae, great desqua- 
 mation, or acute gangrene may develop in severe cases. Hemorrhages 
 into existing exudates, and less often into the viscera, cellular tissues 
 or brain also occur. 
 
 Diagnosis. — The diagnosis of smallpox is usually easy when chill, 
 fever, headache, backache, and vomiting, occur in the presence of an 
 epidemic or after exposure to infection. Vaccination and revaccina- 
 tion are factors and their scars must be searched for. It is often- im- 
 possible to avoid mistakes in the diagnosis of the first cases of an 
 epidemic. In abortive or purpuric cases a diagnosis is also difficult or 
 impossible. Hemorrhagic scarlatina or measles sometimes cause 
 difficulty. In the former the mucous membrane hemorrhages are less 
 frequent than in smallpox. Differentiation between smallpox and 
 virulent hemorrhagic or fulminating purpura may be difficult. The 
 initial suggestive scarlatiniform eruption is important but has been 
 unduly emphasized ; the prodromal eruptions plus purpura are highly 
 suggestive. Exposure to infection, an acute onset and high tempera- 
 ture are significant, although acute onset and high fever may occur in 
 typhus (chill, macular and petechial rash, especially on the body, and 
 persistently high fever), in pneumonia (chill, vomiting, herpes, pain 
 in the chest, and rusty sputum), in scarlatina and influenza, with an 
 initial rash, and in meningitis (joint involvement, headache, or 
 vomiting). Lumbar and sacral pain is more common in smallpox 
 than in typhus, pneumonia, or scarlatina. Intense frontal headache, 
 severe backache, vomiting, chill, and fever, are sufficient grounds for 
 a tentative diagnosis, and isolation. Nevertheless, the diagnosis is 
 uncertain until the eruption is seen. In the variola sine exantJiemate 
 (the febris variolosa of Rhazes and Sydenham, the variola sine vari- 
 olois of de Haen, the varioles frustes of Costes) the diagnosis must 
 be made from the history of exposure, the presence of an epidemic, 
 fever, pain, delirium, possibly the initial rash, and the absence of 
 secondary fever because there is no suppuration. An eruption which 
 appears on the third day of the affection, accompanied by a fall of 
 the fever and euphoria, is most important. 
 
72 
 
 TEE SPECIFIC INFECTIONS. 
 
 Varicella vs. 
 
 Etiology different. Vaccination and 
 smallpox do not protect. 
 
 -Variola. 
 
 Age is not distinctively differential; 
 varicella usually occurs before pu- 
 berty; it may occur in adults. 
 
 An initial stage is practically absent. 
 
 Temperature; no remission with out- 
 break of rash. 
 
 Prodromal rash; very exceptional. 
 
 Vesicles and roseolas (maculae) occur in 
 crops and are simultaneous; very 
 rarely shotty. 
 
 Kash evolution; is much more rapid; 
 vesicles on the first or second day. 
 
 Eruption is universal, successive crops; 
 most abundant and characteristic on 
 back; begins on body; less on face, 
 hairy scalp, mucosas, hands, and feet. 
 
 The vesicle is superficial, and the trans- 
 parent fluid shines through. (Wyss 
 has observed confluent eruption and 
 umbilication) . 
 
 Areola (halo) is usually absent. 
 
 Involution is rapid. 
 
 Smallpox may closely resemble chicken- 
 pox (epidemic of Lee) ; very mild 
 cases are especially misleading. 
 
 Usually after puberty, with numerous 
 exceptions. 
 
 It is severe, even in mild cases. 
 
 Typical remission with secondary fever 
 (except in varioloid). 
 
 Frequent (10 to 16 per cent.). 
 
 Never in crops; first macules, then 
 hard, shotty papules, followed by 
 vesicles, etc. 
 
 Much slower; vesiculation on the sev- 
 enth day (see Pfeiffer's table). 
 
 Note place of first development; devel- 
 opment progresses downward — face 
 first, then hands and feet; less on 
 trunk. 
 
 The fluid is pearl-colored, not transpar- 
 ent, and has a thicker covering. 
 
 Marked. 
 Tardy. 
 
 Mistakes may occur among smallpox experts, but attention to the 
 history, somatic findings, and course, rather than to the eruption, pre- 
 vents many disastrous results. 
 
 Measles- 
 
 -vs. 
 
 -Variola. 
 
 Both present the same prodromal duration; in each the eruption begins on the 
 face; according to some observers, simultaneously on face and trunk. 
 
 Age; eminently a childhood affection. 
 Catarrhal stage characteristic. 
 
 Fever; present in catarrhal stage, but 
 low before exanthem, and rises with 
 its appearance. 
 
 Exanthem; Koplik's spots on buccal 
 and labial mucosa; bluish-white sur- 
 rounded by red. 
 
 Eruption later with rise of fever. 
 
 Papules ' ' grouped, ' ' crescentic. 
 
 Papules remain relatively flat, smooth, 
 velvety. 
 
 Grisolle's sign absent and the eruption 
 disappears under pressure. 
 
 Areola (halo) absent. 
 
 Chiefly in adults. 
 
 Catarrh present, if at all, in rudiment- 
 ary form. 
 
 High before eruption, and falls with 
 florition of the exanthem even in 
 severe cases. 
 
 Absent. Early papular eruption on 
 palate, etc. 
 
 Initial morbilliform eruption with the 
 primary fever. 
 
 Never so. 
 
 Change into vesicles, pustules, crusts, 
 scars; hard and shotty. 
 
 Grisolle's sign present; i. e., persistence 
 in smallpox of the papule on stretch- 
 ing the skin, which distinguishes its 
 eruption from scarlatina, varicella, 
 etc. 
 
 "Halo" present. 
 
SMALLPOX. 73 
 
 Scarlatina vs. Variola. 
 
 Hash on the second day, angina, straw- Kash later; slow evolution of different 
 berry tongue, desquamation, glands, phases. No angina (or late, at least), 
 
 nephritis, etc. (See cardinal symp- no glands, no strawberry tongue; 
 
 toms of scarlet fever.) the initial scarlatinal eruption is not 
 
 punctate, less extensive and bright, 
 and does not desquamate. 
 
 No double elevation of fever-curve. Double summit to curve. 
 
 In drug rashes (copaiba, etc.), the pustules occur largely on the 
 face, head, arms, and forearms, and much less frequently upon the 
 trunk or legs. In syphilis the initial lesion, the glands, the poly- 
 morphism of the rash, and the absence of fever, or its presence in 
 moderate form, are easily distinctive. 
 
 The lumbago form of acute nephritis (Eobin), acute myelitis or 
 rheumatism, erythema, menstrual rashes, septicemic rashes, acne 
 (cachectic and vulgar), and lichen, only superficially resemble 
 variola. 
 
 Glanders may cause more difficulty in diagnosis. Its features are 
 pyrexia, pains, papules, pustules, nasal discharge, considerable exu- 
 dation, and the proper bacteriological findings. Its general symptoms 
 are more severe than the degree of skin eruption would indicate. 
 
 Prognosis. — The prognosis depends on (a) previous vaccination, 
 the disease being very fatal (50 per cent, mortality) in those unpro- 
 tected by vaccination and revaccination. Smallpox is rarely fatal in 
 persons who have been vaccinated within five or six years; only 8 
 per cent, of those vaccinated once, die and only 4 per cent, of those 
 vaccinated twice, (&) On the genius epidemicus: In our last epi- 
 demic the death rate was but 3 per cent, (c) On the type, being (i) 
 practically 100 per cent, in purpura variolosa; (ii) nearly 100 per 
 cent, in variola pustulosa hemorrhagica ; (iii) 60 per cent, in variola 
 confluens — especially fatal in the first decade of life; (iv) 25 per 
 cent, in variola discreta, — particularly dangerous in those over fifty 
 or under ten years, in pregnancy, in the puerperium, in weakly and in 
 alcoholic subjects; (v) 1 per cent, in varioloid; (vi) recovery usual 
 in variola sine exanthemate. . 
 
 d. The prognosis also depends upon individual symptoms: 1. Incu- 
 bation is short in unfavorable forms, especially in purpura variolosa. 
 
 2. Initial symptoms are mild, chiefly in varioloid, but may be 
 severe in both the benignant and malignant forms. 
 
 3. The initial rash is usually a partial erythema in mild forms 
 of smallpox; in general, morbilliform eruptions occur in varioloid. 
 Scarlatiniform eruptions occur in rather severe forms, and a uni- 
 versal scarlatinal hemorrhagic eruption, especially in the groins, 
 occurs particularly in purpuric types. 
 
 4. The danger is proportionate to the amount of the eruption on 
 the face and hands (Sydenham). A slow typical exanthem indicates' 
 variola discreta, and a precipitate atypical eruption presages variola 
 confluens. 
 
74 TEE SPECIFIC INFECTIONS. 
 
 5. A prompt fall in temperature after the eruption is favorable. 
 A slow, complete fall occurs chiefly in the severe forms. Persistent 
 apyrexia, after norition and early desiccation indicate a mild type. 
 Accession of fever after pustulation is ominous (Ehazes). There 
 are fewer complications with an early fall of temperature. Hyper- 
 pyrexia or temperature collapse during suppuration is a sign of im- 
 minent death. 
 
 6. In the stage of suppuration the danger is parallel to the height 
 of the fever and the amount of cutaneous and mucous efflorescence. 
 Enlargement of the spleen is ominous. 
 
 Treatment. — 1. Prophylactic Vaccination. — Vaccinia. — Protec- 
 tion from smallpox by cowpox vaccination was discovered by Jenner, 
 who published his results in 1796, although he was certain of his 
 evidence twenty years earlier. The idea had been long prevalent 
 among farmers that cowpox afforded immunity to smallpox. Pro- 
 fessor Water house, of Harvard, in 1800, introduced vaccination into 
 this country, and, among others, President Jefferson was instru- 
 mental in disseminating its practice. 
 
 The nature of cowpox, or vaccinia, is still bitterly disputed. The 
 most probable view is that cowpox and horsepox are human smallpox 
 modified by transmission through animals. Copeman suggests that 
 vaccinia and variola have descended from a common stock. Variola 
 inoculated in the cow produces typical vaccinia. The other view, held 
 largely by the French, is based upon Chauveau's experiments, which 
 conclude that the two affections are distinct. The bacteriology of 
 vaccinia is also uncertain; micrococci, bacilli, and amoebae (Guar- 
 nieri's cytorrhyctes vaccinias) have been found. 
 
 Usual Symptoms. The incubation period is three days, during 
 which there may be slight traumatic local reaction. The eruption 
 occurs on the third day as a hard papule surrounded by a delicate 
 halo. The papule enlarges, and on the fifth (or sixth) day shows 
 Jenner's vesicle filled with clear serum, and umbilicated in the centre. 
 It merges peripherally into the already indurated and painful skin, 
 in which, by the eighth day, the magnifying lens shows many minute 
 vesicles. By the tenth day, the serum of the vesicle has become puru- 
 lent and the surrounding tissues are very hard and painful. By the 
 eleventh day, a small central crust appears, which, by the end of the 
 second week, covers the entire vesicle and is accompanied by a reces- 
 sion of the adjacent cellulitis. In one or two weeks, the ulceration, 
 decrustation, and granulation, are usually complete, and a scar or pit 
 remains, which pales with time. Constitutional reaction is greatest 
 in children. The fever in most cases appears on the fifth day, and 
 sometimes lasts four or Rve days, with leukocytosis, restlessness, 
 headache, or backache. A swelling, depending on the site of inocu- 
 lation, occurs in the axillary or inguinal glands. School physicians 
 should not accept certificates of recent vaccination but should watch 
 the evolution of the vaccination. 
 
 Unusual Symptoms. — The vesicles may develop early and run a 
 
SMALLPOX. 75 
 
 course which may be shorter by half than the usual one. Crusts may 
 form in a week. In other cases the eruption may be tardy and 
 atypical. In both instances revaccination is indicated. 
 
 Complications. — These are rarely fatal. In Germany, in 1895, 
 two deaths (from erysipelas) occurred in two and a half million 
 vaccinations. To offset this theoretical risk there is the almost uni- 
 versal susceptibility to smallpox in all unvaccinated individuals. (1) 
 Erythema, urticaria, roseolas, or erysipelas (third to eighth day). 
 (2) Accessory vaccinia near the original inoculation, or generalized 
 vaccinia, which develops about the eighth day on the trunk, extrem- 
 ities, and wrists; bullous or miliary vesicles sometimes continue to 
 develop for over a month, and in weakly subjects are very exception- 
 ally fatal. (3) Secondary infection in the first week or two, either 
 local (deep ulceration, gangrene, lymphangitis, or lymphadenitis), 
 or systemic (sepsis, pericarditis, meningitis, and parotitis). Very 
 few cases of tetanus have occurred; McFarland (1903) collected 68 
 certain cases, the majority of which occurred in Philadelphia. Album- 
 inuria is infrequent. (4) Later infections, such as tuberculosis or 
 syphilis. Tuberculosis is but seldom inoculated, because it is rare 
 in calves. Its inoculation can easily be prevented by the Belgian 
 method of not using the lymph until the animal has been killed and 
 found healthy. In some cases a latent tuberculosis in the patient 
 may be awakened by vaccination, which seems to act like tuberculin. 
 The danger of inoculating syphilis is far less now than when human 
 virus was used. Fifteen days are necessary for the development of 
 a chancre, and after about eight weeks more the secondaries appear. 
 Syphilis may be inocula'ted accidentally and also intentionally, as in 
 the oft-cited case of Dr. Cory. In exceptional cases syphilis already 
 in the system may be aroused by vaccination. There are no clear 
 cases of inoculation of leprosy. 
 
 Age. — Children should be vaccinated in the third or fourth month, 
 and it should never be delayed beyond the first year. 
 
 Technique. — The arm (or leg, in the case of girls), should be 
 washed, but no antiseptics should be employed, lest they neutralize 
 the virus. A fold of skin should be raised and either rubbed with a 
 piece of sterile gauze or scraped with a knife held almost parallel to 
 the skin, until the epidermis is removed and slight oozing of lymph 
 appears. The virus must reach the lymph stream, and therefore 
 blood should not be drawn, as coagulation somewhat inhibits "tak- 
 ing.' 7 The vaccine should be slowly rubbed over and into the abraded 
 skin. The spot should be covered with a sterile dressing or cloth held 
 in place by adhesive plaster, only after the virus has thoroughly 
 dried. Boric, carbolic, or bichloride gauze must not be used. 
 
 Lymph. — Vaccinia virus is harmless if it is pure and has been col- 
 lected in the vesicular and not in the pustular stage. It can best be 
 preserved in the fluid form, in sealed sterile tubes with three or four 
 parts of glycerin. This obviates pyogenic infection, preserves the 
 virus longer (four months), and is more economical than any other 
 
76 TEE SPECIFIC INFECTIONS. 
 
 method; twenty to twenty-five times as many vaccinations are pos- 
 sible with the same amount of virus when preserved by this method. 
 When human virus must be used it should be taken from a perfectly 
 sound child which has been carefully examined for tuberculosis and 
 syphilis. It should be taken from the clear and unbroken vaccinia 
 vesicle on the seventh or eighth day. No blood should be withdrawn, 
 and the vesicle must be free from pus. 
 
 Results. — The successful vaccination, accompanied by typical 
 papulation, vesiculation, pustulation, crustation, cicatrization, and 
 by local and often general reaction, confers immunity in almost all 
 cases, though there are isolated instances when variola has closely 
 followed successful vaccination. Although immunity is not abso- 
 lutely infallible, vaccination is the greatest triumph of prophylaxis 
 yet achieved. Immunity is not as a rule life-long, as Jenner thought. 
 In some few cases, the individual is permanently protected by one 
 vaccination, and revaccination is unsuccessful. Protection lasts on 
 an average ten years, after which 60 (or 90) per cent, can be suc- 
 cessfully revaccinated once or twice. Conversely, the child should be 
 revaccinated in his tenth to twelfth year, and if the vaccination does 
 not "take," it should be repeated. The reaction, fever, induration, 
 and size of the vesicle and scar, are less in revaccination. It is also 
 held that immunity is more certain and enduring when more than 
 one inoculation has been made ; the Germans vaccinate two areas or 
 even four or six. The nature of the immunity conferred is still dis- 
 puted, but, unlike the immunity of diphtheria, it is probably due to 
 actual tissue change. PfeifTer advances the idea that in smallpox 
 the germ endures in the tissues, and in this Way maintains permanent 
 immunity. Vaccination immediately after exposure is also thought 
 to prevent or modify an impending attack. Partial immunity is evi- 
 denced by mild varioloid (smallpox mitigated by vaccination). The 
 general beneficence of vaccination needs no multiplied statistics. In 
 general, epidemics prevail in communities which are least protected, 
 and conversely, they disappear with systematic compulsory vaccina- 
 tion. The lesson regarding the alleged immunity is that repeated, 
 careful vaccination nearly always produces vaccinia. 
 
 2. Other Methods of Prophylaxis. — Isolation hospitals and 
 stations are indispensable, because smallpox patients are infectious in 
 all stages of the disease. Isolation is necessary from the incipiency 
 until the disappearance of the last crust. The dead body is dangerous 
 and the funeral must not be public. The clothes used by the patient 
 must be steamed, and other articles must be washed with bichloride 
 of mercury and fumigated with formaldehyde vapor ; Schoch's method 
 has the advantages of not requiring any special form of apparatus, 
 of cheapness, and freedom from danger of fire. The following are 
 required: Good quicklime in lumps, commercial sulphuric acid, and 
 ordinary 40-per-cent. formaldehyde solution. Por every 1,000 cubic 
 feet of space, the size of the average room, one pound of commercial 
 formaldehyde (40 per cent.), one-half pound of sulphuric acid, and 
 
SMALLPOX. 77 
 
 three pounds of quicklime are required. The acid and the formalde- 
 hyde are first mixed in an earthenware vessel by pouring the acid 
 into the formaldehyde. Then the lime is placed in a shallow vessel 
 in the centre of the room. All openings to the room are carefully 
 closed, the mixture is poured on the quicklime, and the operator leaves 
 the room. The rooms should remain closed for from five to eight 
 hours. Disinfection of the face, hands, beard and hair of attendants 
 by bichloride solution is imperative. The family should be isolated 
 for sixteen to twenty days. 
 
 3. Actual Treatment. — As Jaccoud early announced, there is 
 no specific treatment for smallpox. Its hygiene and dietary are the 
 same as in typhoid. For headache, the ice-bag, opium, and hydro- 
 therapy are employed. Pain is relieved by opiates. 
 
 The initial vomiting is difficult to overcome, but its duration is 
 fortunately short. Ice-pills, lime-water, iodine, chloroform, morphia, 
 carbolic acid, and bismuth, may be used as they are in typhoid 
 (q. v.) ; mustard plasters may necrose the skin. 
 
 Early hydrotherapy is important in fever. It lessens the derma- 
 titis, though later, when the rash has developed, baths are contra- 
 indicated. 
 
 Delirium may be relieved by hydrotherapy, by chloral, bromides, 
 hyoscine, and morphia. The latter, in half -grain doses, is invaluable 
 as a routine treatment, since it lessens itching and pain and conserves 
 metabolism. There is great danger that the patient, if delirious, may 
 escape, injure himself, or commit suicide. Dr. Mc!N"amara, a class- 
 mate of the author, killed himself by jumping through a window 
 which had been carelessly left open near him. Patients should never 
 be confined by straps, for this may cause serious skin necrosis. It is 
 better to dress them, or even walk them up and down the room. 
 
 The eruption may be pricked and cauterized with silver nitrate 
 (Arabian method), treated with bichloride or boric compresses (He- 
 bra), covered with mercurial plaster, or with 1-per-cent. carbolic 
 vaseline. The latter is the best, because it counteracts the particu- 
 larly offensive odor. Carbolic salve should be used on the face only, 
 since general use over the body may cause carbolic-acid poisoning. 
 These measures are not specific nor do they prevent cicatrix forma- 
 tion, but they relieve dermatitis and itching. Protecting the face from 
 the light with wet compresses seems to lessen the pitting. The crusts 
 should be kept soft with olive oil. The hair should be cut short, and 
 the eyes should be closely watched, and douched frequently with 
 boric-acid solution. 
 
 The mouth, the larynx, the circulation, and diarrhoea, should be 
 treated as they are in typhoid fever. For bed-sores, a water-bag or 
 -ring should be used. Svdenham allowed his patients to leave bed 
 as soon as the fever declined. 
 
 For sepsis, quinine (v. sepsis') and alcohol (v. typhoid) are given 
 by the rectum, since dysphagia is always present. Eggnog properly 
 prepared will not injure the throat. During convalescence the crusts 
 
78 TEE SPECIFIC INFECTIONS. 
 
 should be carefully washed, and the patient may he considered safe 
 only when the skin is clear of the last scab. 
 
 CHICKENPOX (VARICELLA). 
 
 Definition. — An acute specific febrile contagious disease, chiefly one 
 of infancy and childhood, characterized by an exanthem of vesicles 
 which usually appear in crops. 
 
 History. — Varicella was recognized by Ingrassias in 1553, Heber- 
 den in 1767, and by Trousseau, as a disease distinct from smallpox. 
 
 Etiology. — It is transferable by direct inoculation, by personal con- 
 tact, by the air, or by a third person. It is infective while crusts re- 
 main. Epidemics of varicella may coincide with, precede, or follow, 
 smallpox. Smallpox does not prevent an attack of varicella nor is 
 the converse true. The disease occurs chiefly in epidemics. Season 
 has no influence upon the appearance of the disease. It occurs chiefly 
 in the first year of life, or, according to others, 66 per cent, of the 
 cases occur between the years of two and six. A second attack is rare. 
 
 The actual cause is not determined. Bareggi described a peculiar 
 coccus; Guttmann, a staphylococcus; and Pfeiffer and Guinon, a 
 protozoon. 
 
 Symptomatology. — 1. Incubation. — The stage of incubation, like 
 that of measles, lasts thirteen or fourteen days. 
 
 2. Stage of Prodromes. — Prodromal symptoms are rare. If 
 there are any prodromal symptoms, they last but twenty-four hours 
 (Trousseau). Severe intoxication is rare, but the following have 
 been observed : Delirium, convulsions, violent vomiting, hyperthermia, 
 dyspnoea, angina, conjunctivitis, dysphagia, muscle pains, lassitude, 
 intestinal irregularity, bloody vomiting and stools, and an initial 
 erythema (usually scarlatiniform, rarely morbilliform, in the fifteen 
 cases recorded). 
 
 3. Stage of Eruption. — The exanthem sometimes appears sud- 
 denly after a slight chill, usually in the first twenty-four hours, as 
 red macules or papules. They are comparable to the typhoid 
 roseolse, are slightly elevated, disappear on pressure, and are lenticu- 
 lar. Some regress, but most become vesicular in from six to twelve 
 hours. The vesicles mature within a day. They are very super- 
 ficial, and do not occupy the whole roseola, but leave a slight areola 
 about them, which is hypersemic and not inflammatory as in smallpox. 
 In some cases the areola may be absent, the eruption appearing like 
 drops of water sprinkled on the skin. Though usually discrete, Wyss 
 and Immermann describe confluent eruptions. The vesicles may be 
 few or numerous ; Thomas counted 800 in one case. The eruption is 
 mostly elliptical or circular. Pare forms are reported with jagged, 
 sinuous edges, when the vesicle overlaps the skin. The vesicles may 
 be very large, and, in exceptional cases, resemble pemphigus. 
 
 The eruption begins on the trunk, back, and chest (Osier, Guer- 
 
CHICKENPOX (VARICELLA) . 79 
 
 sant, Blache) ; on the face, temples, forehead (Eichhorst, Immer- 
 mann), and, according to Thomas, rarely fails to appear on the scalp. 
 Troussean held that there is no point of predilection for the eruption. 
 Henoch finds it often on the part on which the patient lies or where 
 irritation exists. RTo part can be considered exempt, though most 
 vesicles appear on the trunk, fewer on the face, arms and legs, and 
 the least number upon the hands and feet. The eruption is some- 
 times grouped, as it is in herpes zoster. 
 
 The contents of the vesicle is clear at first, becomes turbid in 
 thirty-six to forty-eight hours and is neutral or alkaline. Pustulation 
 and hemorrhage into the vesicle rarely occur. The vesicle may con- 
 tain air after rupture. Umbilication, though rare, may occur 
 (Wyss) ; Eichhorst denies the statement made by G-oruall that the 
 umbilication of variola exists from the beginning of the eruption, 
 while that of varicella occurs late. Crusts may simulate umbilica- 
 tion. The vesicles of varicella are not always unilocular. 
 
 Occurrence in crops is frequently observed; the skin then shows 
 simultaneously macules, vesicles, and crusts. Yellowish-brown crusts 
 form on the third and fourth days and gradually disappear, leaving 
 a somewhat flattened epidermis, which may desquamate slightly. 
 Distinct scars may result from scratching or infection, and a few 
 cicatrices are usual in every case of varicella, but they are smooth, 
 white, and some of them disappear with time. 
 
 Enanthems are not frequent ; vesicles seen on the palate may easily 
 be overlooked; breaking down, they resemble aphthae. On rare oc- 
 casions they are seen on the tongue, cheek, nose, larynx, external ear, 
 prepuce, or labia. 
 
 Fever. — The fever is slight, if indeed there be any. It is atypical 
 and is not parallel to the eruption. Eever as high as 106.8° is re- 
 corded by Thomas. It is very rarely present in the prodromal stage, 
 but may occur with profuse eruptions, or with successive crops ; its 
 persistence suggests complications. 
 
 General Symptoms. — These sometimes include dysphagia, cervical 
 and submaxillary swellings, tracheitis, bronchitis, or albuminuria. 
 
 The entire course of an uncomplicated case lasts one to two weeks. 
 
 Complications and Sequels. — These are usually dismissed with a few 
 words. Nephritis, first described by Henoch, is generally mild, 
 tubular, and occurs from three to fourteen days after the rash 
 declines. Though usually mild, fatal cases have been reported, as 
 well as some eventuating in chronic nephritis, cardiac hypertrophy, 
 and uraemia. Gangrene of the skin, seen in delicate or tuberculous 
 children, and first described by J. Hutchinson, may occur in the 
 extremities, scrotum, or eye-lids. -Pneumonia is rare. Infrequent 
 complications are abscess of the lung, pleurisy, acute miliary tuber- 
 culosis, erysipelas, sores in the skin, glandular swelling, pemphigus, 
 infantile hemiplegia, osteitis, polyarthritis, peritonitis, otitis media ? 
 neuritis, etc, 
 
80 TEE SPECIFIC INFECTIONS. 
 
 Diagnosis. — The diagnosis is very easy if the case is seen early. 
 Differentiation from smallpox has been considered. There is usually 
 no fever, the eruption is more vesicular, without halo, larger, but less 
 in number than in smallpox. In pemphigus the vesicles are larger 
 and run a slower course of weeks or months. Miliaria rubra are 
 preceded by sweats, occur chiefly on the covered parts, have acid 
 contents, are smaller than the varicelloid eruption and disappear 
 more rapidly. Sometimes consideration must be given to molluscum 
 contagiosum (soft, umbilicated tumors with white granular con- 
 tents) ; prurigo varicelliformis (with crop-like eruptions at longer 
 intervals) ; eczema vesiculosum, which always occurs with great itch- 
 ing; herpes, always appearing in groups and often along nerve- 
 trunks ; varicellse syphilitica?, and medicinal rashes from cantharides, 
 bromide, arsenic, and iodide. 
 
 Treatment. — Active treatment is rarely indicated. 
 
 SCARLET FEVER (SCARLATINA). 
 
 Definition. — A specific infective disease of unknown bacteriology, 
 characterized by sudden onset, fever, diffuse exanthem, and angina. 
 
 History. — It was recognized by Ingrassias and Coyttar in the six- 
 teenth century, but was first fully described by Sydenham (1660) ; 
 before this, it was known as measles. Scarlatina was introduced into 
 America in 1735. 
 
 Etiology. — The etiology is unknown. Babes, Babinsky, Pearce, 
 Wright, and others, have found a streptococcus in 58 per cent, of 
 fatal cases, and, while their results in no way prove that it is the 
 cause of scarlatina, it is probable that the streptococcus is the most 
 important factor in the production of complications and in their mor- 
 tality. Hektoen, Weaver, and Ruediger, in 100 cases, found it in the 
 blood in 12 per cent. Combining several statistics, the streptococcus 
 was found in about 70 per cent, of the fatalities; i. e., it is the cause 
 of the malignancy of the disease, but not of the disease itself. The 
 virus of scarlet fever produces severe necrosis, but no suppuration. 
 Mallory describes a protozoon, the cyclaster scarlatinalis. 
 
 Susceptibility is not universal and is inversely proportional to 
 the age ; only 38 per cent, of children and 5 per cent, of adults ex- 
 posed to infection acquire the disease. Ninety per cent, of cases 
 occur under ten years of age (Murchison). It is rare in the first 
 year of life. Susceptibility varies, also from time to time in the 
 same family. 
 
 So-called " surgical and puerperal scarlatina/' noted in 1864 by 
 Paget, are, in the vast majority of cases, sepsis, erythema conges- 
 tivum, erythema toxicum, or drug rashes. Alice Hamilton (1905) 
 collected 174 cases from the literature, and concluded that these 
 forms are mostly septic, or that scarlatina is a mere accident in a 
 surgical case. 
 
 The virus circulates in the blood, whence the possibility of foetal 
 
SCARLET FEVER (SCARLATINA). 81 
 
 infection. The mother may contract the disease and the child may 
 escape. It is usually held that the virus is especially active during 
 desquamation; Aaser holds, and justly, that the throat secretions are 
 also dangerous. The streptococci may be spread by coughing (Ham- 
 ilton). Infection is often spread even two months or more after 
 desquamation is complete. In no other disease is the virus so tena- 
 cious; it may persist as long as ten years in clothes, furniture, and 
 on the walls. Light forms are as contagious as severe ones. Inocu- 
 lations from the living subject have occurred and Leube acquired 
 the disease by a cut during an autopsy upon a scarlatina case. The 
 atrium is not known, but it is probably through the throat. 
 
 As to the degree of infectiousness, smallpox ranks first, measles 
 second and scarlatina. third. Infection may be spread by servants, 
 by physicians, by any third person, and by means of toys, books, 
 clothes, and milk, and in schools ; but the mode of infection is often 
 unknown. One attack usually confers immunity, but second, and 
 even third, attacks are known. In some individuals there appears 
 to be a temporary or permanent immunity. Scarlet fever occurs at 
 all seasons, but probably more often in the autumn and winter. 
 Scarlatina is observed more in the cities, and measles prevails more 
 diffusely through the country. Scarlatina is more permanent than 
 measles. When it becomes epidemic it is likely to spread widely 
 and usually with increased mortality. 
 
 Scarlatina sometimes occurs with other infections, such as diph- 
 theria or measles, and less often with variola, varicella, pertussis, 
 erysipelas, or typhoid. 
 
 General Symptomatology. — 1. The Stadium Incubationis. — The 
 incubation, with no noticeable symptoms except perhaps anorexia or 
 slight depression, lasts from two to four days ; McCollom places the 
 average at ten to fourteen days. 
 
 2. The Stadium Izstvasionts. — The invasion lasts one day. 
 Symptoms begin suddenly, with perhaps a chill. This is followed by 
 (a) vomiting, early, and characteristic, which occurs in scarlatina 
 more often (75 per cent.) than in other diseases of childhood except 
 pneumonia; (b) headache, dulness, convulsions, and delirium; (c) 
 sudden elevation of temperature, even to 105°, with disproportionate 
 pulse-rate, 120 to 150, with dry, burning skin, and febrile urine; (d) 
 dryness, redness, burning, pain in the throat, dysphagia, and intu- 
 mescence of the cervical glands. 
 
 3. The Stadium Exastthematioum. — The exanthem lasts four to 
 six days. It appears on" the second d ay, first below the clavicles, on 
 the upper trunk, and on the neck, then on the extremities, and 
 least on the face and scalp. The skin about the mouth is pale. 
 The exanthem pales on pressure. It consists first of small red 
 spots (swollen hair follicles), the size of a pin-head, which fuse as 
 the skin swells, and result in an intense diffuse lobster-colored ery- 
 thema. The tongue swells, becomes covered with a grayish-yellow 
 coating, is red on the tip and edges, and shows swollen red papillae 
 
 6 
 
82 THE SPECIFIC INFECTIONS. 
 
 — " cat's tongue," or " strawberry tongue." Later the whole tongue 
 becomes red and dry. On the tonsils and palate a grayish-yellow 
 coating and confluent spots appear. The nostrils become slightly 
 swollen, and redness of the conjunctivae develops with secretion. 
 Some rales over the larger bronchi, a slight cough, swelling of the 
 cervical and other glands, and sometimes albuminuria, may be noted. 
 
 4. The Stadium Desquamations. — The desquamation lasts sev- 
 eral weeks, though the rash itself lasts but three to six days. Des- 
 quamation begins first on the face, from the sixth to ninth day. The 
 glandular swelling disappears, the fever falls by lysis, and convales- 
 cence is established unless complications intervene. 
 
 Special Symptoms, Complications and Sequels. — These are given in 
 detail because of the extreme variability in the clinical symptoms: 
 
 1. The Fever. — The fever is less typical than in smallpox and 
 measles. In the invasion there is a rapid rise to 104° or 105°. 
 The fever is usually somewhat higher on the second day, with slight 
 morning remissions and gradual subsidence when the rash is mature. 
 
 In the most severe types there may be low fever or no fever at all, 
 or it may rise to 107°. We usually note a close parallelism between 
 the abundance of the exanthem and the height of the fever. The 
 temperature should be taken during one month after the rash disap- 
 pears, lest such complications as sloughing of the throat, pleuritis, 
 endocarditis, pericarditis, synovitis, or adenitis be overlooked. A 
 long course of fever may exceptionally occur without complications, 
 but it is rather ominous. 
 
 2. The Eruption. — The eruption is often atypical. Typically, 
 it begins in the form of light-red, pin-head-like points which become 
 darker as the skin swells and the eruption diffuses. It then appears 
 as an even red, and on close inspection is found beset with small 
 points. These are the first part of the exanthem to develop, and the 
 last to go. The eruption, then, first consists of red spots, especially 
 in the axilla and groin; second, of red spots in a diffuse erythema; 
 and lastly, of red spots again. This minute papulation is a very im- 
 portant aid to diagnosis in the second week. There may be minimal 
 white lines in the eruption, but rarely ever spaces as there are in 
 measles. The skin is sometimes vesiculated. Though it spreads 
 less regularly than in measles, the eruption appears first on the neck, 
 below the mastoid processes, and below the clavicles, then upon the 
 trunk, arms, and hands, and lastly upon the legs and feet. It is 
 most intense over the extensor surfaces of the joints and on the trunk, 
 and is least developed on the face and scalp. The palms of the 
 hands and soles of the feet are usually free. The pallor around the 
 mouth contrasts vividly with the scarlet cheeks and minutely papu- 
 lated forehead. This pale area is circular or triangular, bounded by 
 the nasolabial folds above and the chin below. Though not patho- 
 gnomonic, it is always valuable in differentiation, and is due pos- 
 sibly to vascular spasm. Herpes near the angles of the mouth is 
 very common. The eruption is occasionally roseolous about the 
 
SC ABLET FEVEE {SCARLATINA). 83 
 
 ankles and wrists. The skin is always swollen, and sometimes 
 itches, or is wet with sweat and vesicnlated. The eruption is hy- 
 persemic, and therefore pales on pressure and disappears after death, 
 unless there are punctate hemorrhages, which are not uncommon 
 in severe types of the disease. After twenty-four hours of the erup- 
 tion, the tension disappears, and the bright-red color becomes a yel- 
 lowish-red. Patho]ogical changes in the skin, according to Unna, 
 consist of hypersemia, especially in the papillse, but rarely oedema 
 or inflammation. After complete florition the skin becomes dry, and 
 desquamation begins. This is usually bran-like as it is in measles, 
 on the head, face, neck, and trunk, and it is more scale-like and 
 lamellar on the hands and feet, complete casts of which are some- 
 times shed. The scales are often large in proportion to the inten- 
 sity of the eruption. In severe cases even the hair and nails are 
 shed, and the nails become furrowed. Desquamation results from 
 a slight exudation of serum between the layers of the skin. It be- 
 gins on the cheek with the " rouge-and-powder " appearance, and 
 is usually first observed when the fever and angina decline. The 
 skin may present a " pin-hole" or "worm eaten" aspect before des- 
 quamation begins. Its duration is most variable, usually lasting 
 from one-half to three weeks. Anomalies of eruption: Scarlatina 
 Iwvigata is the typical rash described above. Other forms are 
 scarlatina Icnvis (rudimentary or localized eruption) ; scarlatina 
 sine exanthemate (the rash being absent) ; scarlatina papulosa 
 (marked papulation) ; scarlatina miliaris (from sweating, and exu- 
 dation between the rete Malpighii and the epidermis) ; scarlatina 
 variegata (like measles, though not equally elevated) ; scarlatina 
 hemorrhagica (usually ominous, and at times part of a general hemor- 
 rhagic diathesis). In general, irregular forms are dangerous. 
 
 3. The Throat. — The throat changes are the most constant lesions 
 in scarlet fever, and constitute the internal eruption (enanthem). 
 The disease begins in the throat with dryness, uniform redness, and 
 invariably with early swelling. The throat very soon becomes 
 speckled with fine red points like the skin papulation. Though 
 always present, it varies in intensity from simple angina to diphthe- 
 ritic or gangrenous inflammation: (a) In mild cases, a simple catarrh 
 with little swelling, a thick mucous coating, and more or less red- 
 dening of the palate and tonsils, develop, (b) In moderate cases 
 there is, in addition to the above, more swelling of the palate, and 
 tonsillitis, (c) In severe cases, membrane, small abscesses, gan- 
 grene, small hemorrhages, sloughing, and, perhaps, sudden hemor- 
 rhage, oedema, adenitis, periadenitis, or cellulitis, develop. Severe 
 inflammation in the throat occurs in 65 per cent, of cases (von 
 Ranke). 
 
 Clinical and anatomical diphtheria are often confused. " Necrotic 
 inflammation " in scarlatina is that caused by the virus of scarlatina 
 alone. Genuine diphtheria may accompany or follow scarlatina ; of 
 these, post-scarlatinal diphtheria is the more dangerous (Trousseau). 
 
84 TEE SPECIFIC INFECTIONS. 
 
 Diphtheritic Membrane vs. Scarlatinal Membrane. 
 
 Firm, adherent. Softer, loosened in fragments. 
 
 Yellow-gray. Brownish tint. 
 
 Deep ulceration rarer, in more severe More frequent and earlier (even in 
 cases only, and later. twenty-four hours). 
 
 Phlegmon rare. Not infrequent. 
 
 Laryngeal membrane (croup) frequent Rare, membrane thinner; lung compli- 
 and deeper. cations rare. 
 
 Bacteriologically, the Klebs-Loeffler Streptococcus (Klebs-Loeffler bacillus 
 
 bacillus. only as a complication). 
 
 Paralysis frequent. Eare, except local paralysis due to local 
 
 swelling of pharynx. 
 
 Recurrence frequent. Infrequent. 
 
 Since the bacteriological cause of scarlatina is undetermined, it is 
 doubtful whether the pyogenic cocci found in the throat are integral 
 or complicating. 
 
 4. The Respiratory Tract. — Though often unaffected, the res- 
 piratory tract may become secondarily involved by a descending pro- 
 cess. The nose is involved in direct ratio to the severity of the 
 throat developments, such as necrosis, diphtheria, and gangrene. 
 Acute oedema of the glottis is infrequent. The bronchial mucosa is 
 more often involved than is clinically recognized. Bronchopneu- 
 monia, acute lobar pneumonia (usually in the upper lobes and co-ex- 
 isting with nephritis), gangrene, infarcts, inflammatory oedema and 
 hypostasis, are not common. Pleurisy, described especially by R. P. 
 Howard, occurs in 5 per cent, of the cases. It is often overlooked, 
 is likely to be severe, is very frequently purulent, and often occurs 
 during convalescence. 
 
 5. The Circulation. — The heart is greatly damaged by the scar- 
 latinal virus in 35 per cent, of cases, not including the cases of sepsis 
 and nephritis (Schmatz). Endocarditis is frequently mural, whence 
 its frequent latency, but it may result in chronic valvular disease, es- 
 pecially of the mitral valves. " After rheumatism, scarlatina is the 
 most frequent cause of endocarditis " (Leube) . With increased arte- 
 rial tension due to kidney disease, the heart is slowed, and hypertrophy 
 may result, unless pancarditis (endo-, myo-, and pericarditis), exist. 
 Pericarditis is usually septic. Disquieting cardiac dilatation may 
 be seen in severe cases, accompanied by the usual evidences of acute 
 cardiac insufficiency; myocarditis may occur during the fever 
 (Rhomberg), or in convalescence (Schmaltz). Tachycardia may 
 often be observed from toxaemia or acute infective myocarditis. 
 Dilatation and hypertrophy are much more frequent in children than 
 in adults, and often complicate renal lesions. The pulse is irregular 
 in 90 per cent, of cases. Blood. Leukocytosis develops early and 
 may become extreme in fatal cases. The polymorphonuclears are 
 
SC ABLET FEVER (SCARLATINA). 85 
 
 absolutely and relatively increased two or three days after the erup- 
 tion. The eosinophils are also increased. The haemoglobin and 
 red cells suffer an early and increasing reduction. The red cells 
 average 4,000,000. Hemorrhagic diathesis seldom occurs except as a 
 result of sepsis. 
 
 6. The Digestive System. — The tongue is swollen, indented, 
 broad, and thick. Its papilla? become larger and separated from 
 each other. Its coating is first grayish, and only the edges and tip of 
 the tongue are reddish, but later the coating disappears, leaving the 
 tongue very red, dry, and glistening, on which the papilla? appear 
 granular and warty — the " strawberry," " raspberry," or " cat's 
 tongue." This appears from the third to the fifth day and lasts a 
 week. It is quite pathognomonic, according to Leube, and is only 
 second in importance to the angina. McCollom found it the only 
 constant sign in 1,000 cases of scarlatina. The breath may be 
 sweet and heavy. Diphtheritic ulcers and secondary necrosis in the 
 stomach, oesophagus, and intestines, have been found. Vomiting 
 may result from nephritis, brain toxaemia, or coughing. The liver 
 and spleen may be slightly swollen. There may be abdominal pain. 
 Constipation is usual. Diarrhoea, however, may result from (a) 
 simple transitory catarrhal enteritis; (b) dysentery, with tenesmus 
 and blood; (c) the so-called " scarlet-typhoid " of Thomas, which is 
 accompanied by tympany, hemorrhage, very rapid pulse, and lethal 
 outcome. Its resemblance to typhoid is heightened by the autopsy 
 findings of splenic intumescence, and hyperplasia and ulceration of 
 Peyer's patches. 
 
 7. The Kidxeys. — The urine is febrile. It often responds to Ger- 
 hardt's reaction and to the diazo test. Albuminuria occurs in 75 per 
 cent, of all cases. The " initial catarrhal nephritis " is accompanied 
 anatomically by hyperaemia, parenchymatous changes, some fluid in 
 the glomeruli, a few cylinders in the tubules, and little interstitial in- 
 volvement and runs a short course. 
 
 Nephritis usually develops in the third week. Its frequency 
 varies with the epidemic, between 5 and 70, or even 90 per cent. 
 !N"o apparent relation exists between its frequency and the severity 
 of the infection. Xo single anatomical form is invariable, but the 
 glomerulonephritis of Klebs is most frequent. It is characterized 
 anatomically by hyperaemia, increased consistence, and such glom- 
 erular changes as gray color, diffuse fatty granular degeneration, 
 increase of nuclei, and increase in the size of the tufts, which be- 
 come sausage-like solid masses. "We also note exudation of leukocytes 
 about the afferent vessels, multiplication of capsular epithelium 
 with occlusion of the lumen, hyaline alteration of the vessels, and 
 small and early interstitial changes, and later connective-tissue 
 growth. Friedlander observed septic interstitial nephritis and the 
 large variegated kidney, in cases accompanied by diphtheria, or phleg- 
 monous complications. 
 
 Clinically, hydrops in the vast majority of cases is renal and shows 
 
86 TEE SPECIFIC INFECTIONS. 
 
 the characters of renal dropsy. It appears first under the skin, as 
 the cutaneous blood- and lymph-vessels are altered by the virus. It 
 shifts its location, varies without cause, and may also produce hydro- 
 thorax, ascites, oedema of the larynx, lungs, or genitalia. The older 
 writers claimed that hydrops occurred without nephritis, and that 
 kidney inflammataion might exist without appropriate urinary altera- 
 tions. Such views can be proved by autopsy only. The temperature 
 is inconstant. There may be lumbar pain, vesical tenesmus, and 
 urcemic symptoms, such as headache, twitchings, convulsions, wide 
 pupils, amaurosis, disturbance in motility, sensation, and cerebration, 
 coma, involuntary evacuations, vomiting, diarrhoea, cardialgia ; rapid 
 pulse and breathing, and pale skin tinged with cyanosis. The 
 retinae are usually normal. Many convulsions usually imply a lethal 
 termination in coma. The prognosis is more favorable if the pupils 
 are not immobile. The urine is decreased or suppressed, is heavy 
 with sediment and albumin (averaging 0.5 per cent.), is poor in urea, 
 turbid (specific gravity 1030), and is full of casts of all types — 
 especially, long, flat, band-like, twisted, and frayed casts. Much ox- 
 alic and uric acid is found and, in many cases, blood. Uraemia, 
 hydrops, and intercurrent inflammation, are always dangerous. Con- 
 valescence is the rule after four to six weeks (eight to eighteen 
 months), and the nephritis rarely becomes chronic. 
 
 8. The Special Senses. — Decreased secretion in the eye is 
 common. Cerebral complications promote inflammation in that the 
 eyes close less frequently. Catarrhal conjunctivitis, diphtheritic 
 inflammation, involvement of the lachrymal sacs, herpes or necrosis 
 of the cornea ; panophthalmitis, muscular paralysis, and disturbance 
 in accommodation, are possible complications. Uraemic amaurosis, 
 neuroretinitis septica seu nephritica, and retinal hemorrhage, are 
 rare. Middle-ear inflammation (11 to 33 per cent.) usually begins 
 before desquamation, but may be observed later. It may easily be 
 overlooked, and is accompanied by fever alone or with pain, glandu- 
 lar swelling, difficult hearing, tinnitus, a reddened, glistening, sunken 
 membrane, and, in children, by some brain manifestations. It is 
 quite frequent in early life and rare after the fifteenth year ; 10 per 
 cent, (even 42.6 per cent.!) of cases of acquired deafness are said 
 to result from scarlatina. 
 
 9. The Lymphatic System. — The lymphatic system is generally 
 involved ; e. g., glands, spleen, follicles, and in severe cases, all the 
 lymphatic structures, are affected by the sepsis. McCollom found 
 the cervical glands enlarged in 50 per cent. ; they suppurated in 8 
 per cent. The " collar of brawn " results from cervical adenitis and 
 periadenitis. Gangrene, retrosternal abscess, and jugular phlebitis 
 with sepsis, occur in desperate cases. After recovery the neck may 
 remain swollen for a long time. 
 
 10. The Bones and Joints. — Scarlatinal arthritis ("rheuma- 
 tism ") is found in 6 per cent, of the cases, usually in the second or 
 third week, with desquamation and subsidence of the fever, and usu- 
 
SCARLET FEVER (SCARLATINA). 87 
 
 ally lasts three or four days. It attacks the smaller rather than the 
 larger joints, the wrists rather than the elbows or shoulders, and the 
 ankles rather than the knees. It develops with pain, and is not so 
 migratory as ordinary rheumatism. It may leave no autopsy find- 
 ings, or it may become purulent. Swelling of the joints does not 
 always occur. It occurs in old rather than in young subjects. The 
 prognosis is usually good. Bone involvement is rare. 
 
 Scarlatinal sequels are anaemia, hemorrhagic diathesis, retarded 
 development, and decreased physiological resistance. Tuberculosis 
 rarely follows scarlatina. Latent sepsis with brain foci, valvular 
 disease, chronic nephritis, chronic adenitis, otitis, mastoiditis, men- 
 ingitis, hemiplegia, cerebral venous thrombosis, facial paralysis, 
 ascending spinal paralysis, chorea, and exhaustion psychoses, are 
 fortunately rare complications and sequels. 
 
 Diagnosis. — Typical cases are easily determined when an epidemic 
 prevails, and when the eruption is not considered of chief diagnostic 
 value. The criteria are as follows : 
 
 1. Sudden onset and rapid development, with fever and vomiting. 
 
 2. Angina, pain, redness, punctate spots in vault of the mouth, 
 swelling and dysphagia, which are practically always present. 
 Severe symptoms in the throat, especially during an epidemic, are 
 suspicious. 
 
 3. Strawberry tongue, which is constant. 
 
 4. Exanthem, first about the clavicles, with characteristic progres- 
 sion, the face less involved, and the mouth free ; it is intense on body ; 
 papules then erythema develop ; there are no free spaces ; it results 
 in desquamation. 
 
 5. Lymphadenitis. In this, the cervical are less important than 
 the inguinal or other glands. 
 
 6. Fever, hydrops, albuminuria, and nephritis in atypical cases. 
 
 7. Scaling, tender joints, and albuminuria, are strong indications 
 of scarlatina if the initial symptoms were not observed or were not 
 clear; they help in making a retrospective diagnosis. 
 
 Diagnosis of Atypical Scarlatina. — 1. Severe scarlatina, (a) 
 The anginose form resembles septic diphtheria, with marked toxaemia, 
 necrosis, and adenitis, (b) Atactic form. Violent early intoxica- 
 tion; high fever and death even on the eleventh hour of the disease 
 (Trousseau), before the eruption appears; blood dissolution, vomit- 
 ing, diarrhoea, convulsions, coma, and an excessively rapid, weak 
 heart, are the chief symptoms, (c) Hemorrhagic scarlatina. This 
 is characterized by severe fever and brain symptoms at the onset; 
 incomplete exanthem, necrosing angina, marked glandular and splenic 
 swelling; subcutaneous, serous and mucous membrane hemorrhages 
 with exulceration. It is usually lethal after ten to twenty hours from 
 hyperpyrexia, exhausting vomiting, diarrhoea, stupor, delirium, con- 
 vulsions and dyspnoea. It is encountered especially in reduced 
 subjects under two years of age. 
 
 2. Very light cases may present (a) all the usual signs, though 
 
88 TEE SPECIFIC INFECTIONS. 
 
 but mildly developed; or (b) some symptoms may be absent (scar- 
 latina fragmentaria) , as in cases with no temperature (scarlatina 
 sine febre), no rash (scarlatina sine exanthemate) , or no angina (scar- 
 latina sine enanthemate) . In some atypical cases a definite diagnosis 
 is impossible, as in acute nephritis with uraemia, fever, sore throat, 
 and gastro-enteritis, without the characteristic rash. Kecurrent 
 forms are not frequent. They occur in the middle of the third 
 week, and result from incomplete elimination of the virus during 
 the first attack. Many of these cases are septic complications rather 
 than actual recurrences. According to Korner, only forty relapses 
 are on record. 
 
 Differentiation.. — The differentiation is as follows: 
 
 Scarlet Fever vs. Sepsis. 
 
 Bright-red erythema, with small red A very deep purple-red rash, sometimes 
 papules. spreading over entire body. 
 
 The eruption is much the same in both diseases, the same places being exempt. 
 
 Miliaria are rare. Frequent. 
 
 Eather typical desquamation. Desquamation also observed, but less 
 
 frequently. 
 
 Criteria (q. v.) ; angina, tongue, abrupt Etiology, chills, sweats, fever irregu- 
 onset, glands, etc. larity, polymorphous exanthems, etc. 
 
 Diphtheria is often differentiated with difficulty. A simple ery- 
 thema is sometimes observed in diphtheria, which is darker, more on 
 the trunk, and more transitory than in scarlatina (see Throat Com- 
 plications). 
 
 Drug rashes, from belladonna, iodoform, quinine, iodide, chloral, 
 or copaiba, may be easily differentiated, if the cardinal signs of scar- 
 latina rather than its rash alone, are considered. 
 
 Measles and German measles (q. v.). Acute exfoliating dermatitis 
 also begins with fever, with a spreading erythema, and very early 
 desquamation, but the other cardinal criteria of scarlatina are lacking. 
 Erythema is more transitory ; the points are absent ; it occurs with less 
 fever and without angina or adenitis. 
 
 Erysipelas presents a sharp border, oedematous swelling, marked 
 pain, and a slow advance. 
 
 Prognosis, — This should be guarded for at least one month. The 
 outcome often depends on the genius epidemicus, since the mortality 
 ranges between 2 and 40 per cent. The death-rate averages about 
 10 per cent. The prognosis is least favorable in hospital cases and 
 in children. Most deaths occur under six years ; in children under 
 ^.ye years, the mortality is 20 to 30 per cent. (Holt). In the first 
 year of life the disease is very fatal. 
 
 Uraemia accounts for 50 per cent., and respiratory complications 
 for 20 per cent, of scarlatinal fatalities. The social status, severity of 
 the infection, hemorrhagic forms, severe toxaemia, complicating sepsis, 
 
SCARLET FEVEE (SCARLATINA). 89 
 
 necrosis in the throat, otitis, and heart complications (high pulse- 
 rate being always unfavorable), are the other factors in prognosis. 
 
 Treatment. — There is no specific therapy and the disease runs its 
 self-limited course. 
 
 1. Prophylaxis. — Prophylaxis is equally imperative in severe 
 and light cases. Indeed, the light or ambulatory forms more often 
 convey infection. Isolation is important, because susceptibility is 
 not universal and the virus is less penetrative than in measles, and 
 it is therefore possible to circumscribe its diffusion. Care should 
 be taken to prevent transmission through schools and by means of 
 fomites and by third persons. The infected room should be kept 
 empty for oue month afterwards, and should be exposed to the wind 
 and sun for several weeks. JNo susceptible person should use the 
 room for several months. The physician should wear an operating 
 gown and carefully wash his face, beard, and hands, after leaving 
 the sickroom. Quarantine should be maintained from six to eight 
 weeks. Even this is probably too short a period. A sheet saturated 
 with carbolic acid or formaldehyde, and hung before the door, is of 
 no special value. Formaldehyde fumigation has been discussed un- 
 der smallpox. Care in surgical and puerperal cases is important, 
 but the danger has been overestimated. All discharges should be 
 disinfected. Bichloride wrappings should be placed about the dead 
 body, and the funeral should be private. 
 
 Schools should be closed during epidemics. In hospitals the cases 
 of scarlatina with streptococcus infection should be separated from 
 cases of simple scarlatina. Sound children should be sent away from 
 the house and isolated lest they spread the disease. If they remain at 
 home, about one-quarter of them will contract scarlatina (Chapin). 
 
 II. General Treatment. 1. Position. — The prone position in 
 bed is imperative in all cases, both during the disease and in the first 
 two weeks of apyrexia. 
 
 2. Room. — The room should be light, well ventilated, dry and 
 warm, especially in convalescence. A grate fire is advisable and the 
 windows should be open at the top. During the fever the skin should 
 be covered with linen, and in convalescence with wool. 
 
 3. Skin. — The eruption should be brought out, when necessary, 
 by mustard baths. During the fever, the patient should be washed 
 daily with warm water and soap, though unnecessary exposure should 
 be avoided. The tension of the skin is thus lessened, the fever de- 
 creased, and toxsemic symptoms, such as insomnia and restlessness, 
 are allayed. During desquamation, oil-rubs were once employed 
 to decrease the risk of infection by dissemination of dry scales but are 
 now considered deleterious, as they decrease the functions of the 
 skin, which are of great importance when the kidneys are involved. 
 Besides, infection is more probably carried by means of throat secre- 
 tions, than by desquamation. Soap and warm water serve equally 
 well. The author is opposed to antiseptic soaps because of the 
 chance of absorption which may result in renal injury. 
 
90 TME specific infections. 
 
 4r. Fever. — The following is a harmless fever mixture: 
 
 I£ Liquoris ammonii aeetatis §iss. 
 
 Tincturae aconiti TTLxxiv. 
 
 Aquas q.s. ad ^xj. 
 
 Misce et fac misturam. 
 
 S. — One to three teaspoonfuls every four or five hours, according to age. 
 
 This mixture tranquilizes, promotes the rash, and allays fever. 
 Hydrotherapy is useful, such as the warm sponge or full warm bath. 
 Special care is indicated (a) in adynamic cases, because of danger 
 of heart-failure ; therefore the full cold bath should always be avoided 
 and the moderately warm bath should be used; (b) in pericarditis; 
 (c) in stenosis of the air-passages, or dyspnoea; (d) in hemorrhagic 
 forms; (e) in arthritis; and (/) in nephritis. 
 
 5. Diet — Water should be given very freely. A fluid diet is indi- 
 cated by the fever, the percentage of renal complications, and the 
 dysphagia. This may consist of concentrated foods, milk, soups, 
 and jellies. In defervescence, milk-toast, custard, puddings, and 
 bread and butter, may be given. Eggs and meats may cause album- 
 inuria, and should therefore be avoided. Fruit and vegetables may 
 be given freely at all stages, if this can be done without irritating 
 the throat. In severe throat complications, rectal feeding is indi- 
 cated. (See Gastric Ulcer.) 
 
 6. Scarlet Arthritis. — The A.B.C. liniment (aconite, bella- 
 donna, and chloroform), warm wool and flannel bandages, are helpful. 
 
 ]£ Tr. opii 3iij. 
 
 Phenolis 3j. 
 
 Tr. belladonnas 3iij- 
 
 01. olivae 3iv. 
 
 M. et S. — Applied on muslin covered by cotton. 
 
 Salicylates are most beneficial, but unless given carefully, may in- 
 jure the kidneys. If the arthritis is obstinate or purulent, aspiration 
 with all surgical care and even drainage may be indicated. 
 
 7. Angina. — Ice in the mouth, ice-cravats, hot fomentations espec- 
 ially for the enlarged glands, and Dobell's solution as a nasal douche 
 should be given. Care should be exercised in the use of antiseptics 
 lest children swallow them. A 10-per-cent. peroxide of hydrogen, 2- 
 per-cent. chlorate of potash, or 2-per-cent. carbolic gargle, may be 
 used. Formalin gargles are too irritating. Caustics are contra-indi- 
 cated. 
 
 For the nose the following formula is excellent: 
 
 fy Phenolis 3ss. 
 
 Acidi borici 3ss. 
 
 Glycerini ^j. 
 
 Tr. myrrhae ^j. 
 
 Aquae q.s. ad gv. 
 
 M. et S. — Locally, in such dilution that no irritation is felt. 
 
 Heubner injects 3-per-cent. carbolic solution into the tonsils (5ss 
 b.i.d. on each side). A 10-per-cent. nitrate-of -silver solution is used 
 
SCAELET EEVEE {SCAELAT1NA). 
 
 91 
 
 with great advantage in the early stages of the angina. Coincident 
 diphtheria is treated by antitoxin (described under diphtheria), 
 and the antistreptococcic sernm may be exhibited in streptococcic 
 angina. 
 
 8. Heart. — Cardiac stimulation may be regulated according to 
 
 Rotch's dosage table 
 
 Age 
 
 Tr. Digitalis 
 
 Strychnine 
 
 1 i Sol. 
 Nitroglycerine 
 
 Atropine 
 
 3 months 
 
 T V- \ minim 
 
 3oVo _ ToVo 
 l _ l 
 
 15 Too 
 
 grain 
 
 T5—5S minim 
 
 soVo-ttoo g ra in 
 
 6 " 
 
 1 _ 3 « 
 
 10 4 
 
 i i_ a 
 
 ^5 15 
 
 2T0O~~To7F0 
 
 9 " 
 
 1-1 " 
 
 1 1 < i 
 
 F0 3 0(7 
 
 1 1 it 
 
 25 10 
 
 1 1 U 
 15 00 T~5~0 
 
 12 " 
 
 1-1* " 
 
 1 1 
 500 250 
 
 a 
 
 11 il\ 
 
 25~5 
 
 1 1 it 
 
 1000 500 
 
 2 years 
 
 ^—2 minims 
 
 1 -_ 1 
 500 150 
 
 a 
 
 1 1 a 
 15 3 
 
 1 1 a 
 T50 25~0 
 
 3 " 
 
 1-3 " 
 
 1 1 
 300 100 
 
 it 
 
 1 1 (I 
 
 TO" 2 
 
 1 1 U 
 5 0"0" 2 
 
 4-10 " 
 
 1-5 
 
 1 1 it 
 
 200 6 0" 
 
 1_3 it 
 2 4 
 
 2Fo _ tIo 
 
 10-12 " 
 
 3-8 
 
 1 1" " 
 100 40 
 
 11 H 
 
 2 L 
 
 1 1 a 
 
 200 100 
 
 9. Lymph Glands. — Secondary infection may occur, against which 
 prophylactic care of the mouth and throat is important. Ice should 
 be applied in the beginning only, and later hot boric-acid dressings 
 when the blood- and lymph-streams become stagnant. Iodine and 
 ichthyol salves and surgical intervention are indicated in the order 
 named. 
 
 10. Otitis.- — Otitis is treated by copious boric irrigation, given 
 quite hot and at a slight elevation, and followed by equal parts of 
 glycerine and laudanum, 5-per-cent. carbolic acid and 1-per-cent. 
 cocaine in olive oil. Leeches over the mastoid often relieve the pain. 
 Examination of the drum is rather impracticable in children with a 
 small sensitive meatus. Early puncture under cocaine is much safer 
 than awaiting spontaneous rupture. After rupture, a small amount 
 of cotton with iodoform or boric powder should be applied. 
 
 11. Nephritis. — Nephritis is treated (a) according to the old 
 prophylactic rule, by which all cases, severe or light, are confined to 
 bed for at least four weeks. The urine must be watched. According 
 to Jaccoud, the milk diet is valuable in the prevention of nephritis. 
 Irritants, Like cantharides, are always to be avoided. Tepid baths 
 lasting a quarter of an hour should be given daily, especially in con- 
 valescence. Watch the temperature and the urine in convalescence. 
 Wiodowitz in 102 cases used urotropin successfully as a prophylactic. 
 The number of his cases is too small for generalization, but his 
 results are at least suggestive, (b) Treatment of established ue- 
 phritis. Hot baths increase the sweat and the flow of urine. They 
 should be given twice daily, and may last for even an hour, but the 
 patient must be kept afterward between blankets. Alkaline diuretics, 
 
92 THE SPECIFIC INFECTIONS. 
 
 such as potas. acet, pot. bicarb., p. citrat., and infus. tritici repentis, 
 may be given ; pilocarpine for a child two years old, ^V t0 V S r -> W1 ^- 
 often relax the skin. (See Treatment of Nephritis.) Calomel 
 as a laxative and diuretic must be used with great care. Digitalis in 
 moderate doses aids diuresis. 
 
 ]£ Inf usi digitalis 3v. 
 
 Potassii acetatis 3ss. 
 
 Syrupi simplicis 3ij- 
 
 Aquae destillatae q.s. ad §ij. 
 
 M. et S. — One teaspoonful every two hours. 
 
 High arterial tension should be treated with nitroglycerine. For 
 convulsions, chloroform, chloral, and bromides are valuable. For 
 vomiting, iodine is efficacious (see Vomiting, Typhoid). Vene- 
 section and the administration of digitalis are necessary in severe 
 pulmonary oedema. For marked ursemia, two drops of croton oil in 
 milk or placed undiluted on the tongue, should produce free catharsis 
 in two hours. If not successful' by that time it should be repeated. 
 Pulvis jalapse compositus (gr. xv. to 3j.) will unload the bowels in 
 less urgent cases. Early evacuation is indicated in pleurisy, if chain 
 cocci are found by puncture. 
 
 12. Tonics. — Such tonics as iron, arsenic, and cod-liver oil, are 
 indicated in convalescence. The heart must be watched for weeks, 
 because the myocardium is often degenerated. 
 
 13. Serum. — Marmoreck's and other streptococcic sera have given 
 no definite results. Everything depends on whether streptococci are 
 the primary cause or only secondary symbiotic organisms. Again, 
 immunization against one variety of streptococcus does not produce 
 immunity against other varieties. In Vienna, Moser's serum has 
 apparently been efficacious. In the St. Anna Children's Hospital, 
 the mortality was 8 per cent., and in other institutions it amounted to 
 14.5 per cent, without serotherapy. 
 
 MEASLES (MORBILLI, RUBEOLA). 
 
 Definition. — An acute, highly infectious disease, characterized by 
 an initial coryza and inflammation of the air-passages, by a rapidly 
 spreading eruption, a fever-curve with a double summit, and by 
 toxaemia. 
 
 History. — Its first clear description dates from Rhazes (980-1037 
 A. D.). It is a very old disease and was widely epidemic in the 
 eighteenth century. 
 
 Etiology. — (a) Susceptibility is almost universal; few individuals 
 escape (14 per cent, only, Madsen), and one attack generally confers 
 immunity. Maiselis collected 106 cases with a second attack; third 
 and fourth attacks are known, (b) Age — It is rare during the first 
 five months of life, and occurs most frequently after the first year. 
 Twenty instances of placental transmission to the child are reported. 
 It is more common in adults than is scarlet fever. In Schwalbe's 
 
PLATE II 
 
 FIG. 1 
 
 FIG. 2 
 
 FIG. 3 
 
 FIG. 
 
 The Pathognomonic Sign of Measles (Koplik's Spots). 
 
 Fig. 1. — The discrete measles spots on the buccal or labial mucous membrane, showing the isolated 
 rose-red spot, with the minute bluish-white centre, on the normally colored mucous membrane. 
 
 Fig. 2. — Shows the partially diffuse eruption on the mucous membrane of the cheeks and lips; patches 
 of pale pink interspersed among rose-red patches, the latter showing numerous pale bluish-white spots. 
 
 Fig. 3. — The appearance of the buccal or labial mucous membrane when the measles spots completely 
 coalesce and give a diffuse redness, with the myriads of bluish-white specks. The exanthem on the skin 
 is at this time generally fully developed. 
 
 Fig. 4. — Aphthous stomatitis apt to be mistaken for measles spots. Mucous membrane normal in hue. 
 Minute yellow points are surrounded by a red area. Always discrete. 
 
MEASLES {MOEBILLI, EUBEOLA). 93 
 
 collection of 16,981 cases, 50.4 per cent, occurred in the first five 
 years; 42 per cent, between five and ten years; 5.2 per cent, between 
 ten and twenty years, and 2.4 per cent, after twenty years of age. 
 (c) Season — Measles occurs mostly in the winter and in the cooler 
 spring months, (d) The actual virus is unknown. The longevity of 
 the virus without the body is not great. It exists in the blood, tears, 
 skin, and in the bronchial and nasal secretions. Its activity is great- 
 est during the catarrhal stage, but it is also dangerous during the 
 eruption, and possibly even during incubation and desquamation. 
 Hektoen twice succeeded in inoculating the disease from the blood 
 of measles patients. 
 
 Propagation usually occurs by personal contact, and rarely through 
 a third person. Aerial transmission is frequent, whence in the home 
 the disease usually runs through the family. The most frequent 
 means of dissemination is the school-room. It is more often epidemic 
 than is scarlatina, especially through the country. After smallpox 
 in the unvaccinated, measles is the most infectious of diseases. 
 
 General Clinical Course. — The stages are: (1) Incubation of nine 
 or ten days; (2) initial, catarrhal, or prodromal stage of three or 
 four days, with fever, catarrhal symptoms in the eyes, nose, etc., and 
 an enanthem; (3) the eruptive stage, lasting four or five days, with 
 renewed fever, intoxication, eruption, and inflamed mucosae; (4) the 
 desquamative period of variable duration. 
 
 1. Incubation. — The incubation lasts nine or ten to fourteen days. 
 
 2. Catarrhal Symptoms. — Then the catarrhal symptoms appear. 
 Chilly sensations, malaise and frontal headache attend redness of 
 the eyes, lachrymation, photophobia, coryza, and sneezing; dryness, 
 redness, and pain in the nose, throat, and bronchi, and early cough, 
 which develops after one day. Vomiting may rarely occur. The 
 respiratory symptoms are due to a mucous-membrane enanthem 
 (Rehn). Examination of the throat reveals Koplih's spots (Plate 
 II) in 86 to 97 per cent, of cases, described by him in 1886, and by 
 Filatow in 1885. They are practically constant on the buccal mucosa 
 near the molars, and are found on the first day. They are round, of 
 a bluish-white color, and are surrounded by a reddish areola. Early 
 catarrhal symptoms are more common in measles than in any other 
 acute infection of childhood. The initial fever reaches 102° or 103°, 
 and declines gradually during the third and fourth days. Occa- 
 sionally there is a diffuse prodromal erythema which is mostly 
 hypersemic. 
 
 3. The Eruption. — The eruption begins on the fourth day with 
 papules on the temples, cheeks, forehead, then on the back, wrists, 
 forearms, and on the anterior surface of the body and legs, in order 
 of progression as named; with the appearance of the eruption, the 
 fever again rises. The eruption disappears on pressure or on lateral 
 stretching of the skin, and is palpable and superficial. There are 
 always islets of normal skin, even in the thickest eruption. The 
 glands are usually enlarged and there is more or less marked sweating. 
 
94 
 
 THE SPECIFIC INFECTIONS. 
 
 The general and local symptoms usually abate on the sixth day, 
 and the fever falls by crisis. In severe cases, epistaxis, diarrhoea, 
 cerebral intoxication, bronchiolitis, pneumonia, hypostasis, cyanosis, 
 and asphyxia, may be observed, and death may result from lung in- 
 volvement, mixed infection, or decreased physiological resistance. 
 
 4. Desquamation. — In the desquamative stage the skin pales, be- 
 comes slightly pigmented, and scales form. Convalescence is estab- 
 lished in eight or ten days. 
 
 Individual Symptoms in Detail. — 1. The Eruption. — It is essen- 
 tially the same on the skin and on the mucosae. In the mouth the 
 mucosa is red on the first day of fever, and Koplik's spots are found; 
 on the second day redness without swelling is especially noted on the 
 tonsils and palate. The enanthem may reach the larynx, intestines, 
 and genitalia. Though the enanthem tends to spread, the skin erup- 
 
 Fig. 9. 
 
 ll)ay 
 
 TEMP. 
 
 2 
 
 3 
 
 4 
 
 5 
 
 6 
 
 104 
 
 
 
 
 
 
 103 A 
 
 
 
 
 
 
 102 / \ 
 
 
 
 
 
 
 ioW 
 
 A 
 
 
 
 
 
 / 
 
 100 
 
 \ 
 
 
 
 
 
 99 
 
 V 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 INITIAL 
 RISE 
 
 FALL 
 
 
 RISE WITH 
 RASH 
 
 EXTENSION 
 OF RASH 
 
 
 Fever curve in measles. 
 
 Hon (exanthem) is circumscribed. The rash is due to hypersemia 
 rather than to actual exudation. It fades on pressure ; in some cases 
 the roseolse do not fade on pressure, but leave a brown-colored area, 
 especially in the nodular form of measles. The roseoloe usually are 
 discrete, are slightly elevated, especially in the centre, from spastic 
 contraction of the bloodvessels and oedema, are light to dark red in 
 color, are round or crescentic in shape, and average 2 to 6 millimeters 
 in diameter. They always leave islets of normal skin between the 
 independent spots of eruption, even in the most diffuse types. The 
 eruption follows a descending order and reaches the lower parts of 
 the body last. When the eruption develops on the body first, the 
 course is usually anomalous. Itching may be noted, and sweating 
 may be marked. Desquamation follows the same order as the erup- 
 
MEASLES (MORBILLI, RUBEOLA). 95 
 
 tion, and is usually fine. Scars never result. The eruption is rudi- 
 mentary in those who are debilitated by chronic diseases, and is 
 exuberant in the healthy. 
 
 The varieties are: (a) Morbilli Iceves, the usual form, with small 
 elevations, (b) M. vesiculosi seu miliar -es. (c) M. papulosi, nodular 
 measles ; the eruption may feel slightly " shotty," but such induration 
 is always superficial, (d) M. confluences seu conferti. (e) M. hem- 
 orrhagica, benign or malignant (black measles; typhoid, septic, 
 adynamic types) ; early hemorrhage into the eruption is almost al- 
 ways fatal. (/) M. sine exanthemate; sine enanthemate. " Reces- 
 sion" of the eruption (fading or " striking in") is usually a sign of 
 heart-failure. 
 
 2. The Fever. — The curve is not absolutely typical. It begins 
 suddenly without a chill, and falls on the second day, perhaps even to 
 normal, usually rises again with the eruption, and reaches its maxi- 
 mum in thirty-six hours, thus giving a curve with a double summit. 
 It usually falls by crisis before the eruption disappears. Fever, after 
 the eruption begins to fade, indicates complications. In rare cases 
 fever is absent. The temperature is normal, even subnormal during 
 desquamation. 
 
 3. The Respiratory Tract. — Nasal catarrh is of special moment 
 in sucklings. Catarrhal laryngitis may occur, accompanied by 
 hoarseness and false croup ; 50 per cent, of the cases suffer from ero- 
 sions or ulcerations of the larynx (Rillet and Barthez), 16 per cent, 
 from pseudomembranous laryngitis, and 15 per cent, from simple in- 
 flammation. Laryngeal complications are not necessarily febrile. 
 Bronchial catarrh cannot be excluded by the absence of rales. It may 
 reach the smaller tubules and usually, but not always, occurs late in 
 the disease. It produces a clear, stringy, viscid sputum which later 
 may become purulent and nummular. The bronchial glands are 
 always swollen. Simple atelectasis may occur, and may occasion 
 indeterminate breathing and dulness, which decrease with change 
 of posture or deep breathing. Bronchopneumonia occurs in 6 to 12 
 per cent, of cases and is the most frequent fatal complication; 
 Henoch and others affirm that patches of bronchopneumonia occur 
 in every fatal case. It differs from other lobular pneumonias in its 
 rapid development, and its greater tendency to pus formation, which 
 result from the fact that the measles-catarrh favors pneumococcic 
 and pyogenic infection. The temperature is often no higher than in 
 bronchitis. Bronchial breathing and other physical signs are not 
 always detected clinically. Toxsemia and carbon-dioxide narcosis 
 accentuate the patient's distress. Bronchopneumonia is rapid in de- 
 velopment, but slow or sometimes incomplete in resolution. It may 
 result in interstitial pneumonia, gangrene, or tuberculosis. The 
 latter is a dreaded sequel of measles and occurs (a) as a miliary in- 
 vasion, and in the brain more frequently than in the lungs. It is 
 caused by the bacilli, from old caseated bronchial glands, which are 
 released by solvent substances reaching them from the lungs by way 
 
96 THE SPECIFIC INFECTIONS. 
 
 of the lymph-vessels. It also occurs (&) as a fresh tuberculosis devel- 
 oping upon a bronchopneumonia. This variety may heal or appar- 
 ently recover, to break out anew at a later time. Croupous 
 pneumonia is as infrequent as pleurisy. Pleurisy is in most cases 
 secondary to lobular pneumonic foci and may cause, effusion. 
 
 4. Cardiac Symptoms. — These are rare. Accidental bruits may 
 be heard. Toxaemia may, in exceptional cases, cause myocardial 
 degeneration. 
 
 5. The Digestive Tract. — The tongue is coated. There is thirst 
 and aphthae and stomatitis may be observed. As a result of an intes- 
 tinal enanthem, diarrhoea, mucus in the stools, and, anatomically, 
 swelling of Peyer's patches, have been described. The liver is seldom 
 swollen. 
 
 6. The Nervous System. — Nervous symptoms, such as delirium, 
 stupor, coma, or convulsions, may, in rare cases, result from severe 
 toxaemia, even though the delicate nervous system of children is sel- 
 dom involved in measles. Nervous symptoms may occur in pro- 
 tracted pneumonia, and doubt may exist as to whether they are caused 
 by the measles, miliary tuberculosis, tuberculous meningitis, or car- 
 bon-dioxide narcosis. Paralyses, myelitis, muscular atrophy, poly- 
 neuritis, and polymyositis, are most infrequent. 
 
 7. Genito-Urinary Tract. — Acetonuria and albuminuria are 
 frequent. Ehrlich's diazo reaction occurs in 80 to 100 per cent, of 
 cases. Nephritis is very uncommon. It is most often due to com- 
 plicating diphtheria, or tuberculosis. Gangrene of the genitalia has 
 been observed. 
 
 8. Other Symptoms. — The spleen and lymph-nodes are but 
 slightly swollen; bone and joint complications are rare; keratitis is 
 infrequent ; otitis media occurs in a small percentage of cases. It is 
 said that streptococci in the conjunctivae are much more frequent in 
 severe than in mild cases. The red cells are little altered, while the 
 leukocytes show a relative lymphocytosis, with an absolute leukopenia. 
 
 Diagnosis. — The diagnosis depends upon the existence of an epi- 
 demic, and upon consideration of all the symptoms (coryza, cough, 
 fever, enanthem) rather than of the eruption alone. Differentiation 
 from typhus is made by the greater general disturbance in typhus, its 
 more sudden onset, higher fever, swelling of the spleen, and by the 
 roseolous eruption becoming petechial. 
 
 Sepsis with a morbilliform exanthem, the early stage of influenza, 
 syphilis (in which other secondary symptoms appear with the erup- 
 tion, and variola (q. v.), may sometimes delay the early diagnosis. 
 In the drug-eruptions of turpentine, iodides, quinine, chloral, cubebs, 
 copaiba, and antipyrin, the diagnosis may be most difficult. The 
 fever, Koplik's spots, catarrh, and central elevations in the eruption, 
 are indicative of measles. (See page 97.) 
 
 Prognosis. — The mortality is very great among aboriginal races. 
 In private practice 3 per cent, is the average death-rate. In the Fiji 
 Islands the death-rate was very high. In the Samoan Islands 4,000 
 
MEASLES (HORBILLI, RUBEOLA). 
 
 Differentiation from German Measles and Scarlatina. 
 
 97 
 
 German Measles 
 
 Incubation ; 14 to 21 days, 
 
 Prodromes ; absent, short) 
 or light. 
 
 Invasion ; very mild. 
 
 Exanthem ; the rash is the 
 first symptom, usually 
 appearing on the first or 
 second day on the face ; as 
 small red dots, rosy and 
 brighter than in measles ; 
 small, little elevated, and 
 thick about the mouth 
 They do not fuse. Less 
 crescentic than in meas- 
 les. 
 
 Enanthem, etc. ; may be 
 diffuse redness of throat 
 and conjunctivae. 
 
 Glands ; usually enlarged, 
 hard, tender, especially 
 posterior cervical, also 
 axillary and inguinal 
 Spleen somewhat en 
 larged. 
 
 Constitutional symptoms ; 
 few ; no depression ; no 
 leukocytosis ; little pulse 
 increase and fever. 
 
 Complications ; practically 
 
 Convalescence ; rapid ; des- 
 quamation rarely copious, 
 and always fine. 
 
 2 (1 to 7) days. 
 
 Scarlatina 
 
 Brief, a few hours to 1 or 
 1J days. 
 
 Sudden, stormy, vomiting, 
 convulsions, angina, and 
 adenitis. 
 
 Appears on first or second 
 day, reaching a maximum 
 on second to fourth day, 
 first below clavicles, in- 
 volving face later ; dusky- 
 red, diffuse, burning, leav- 
 ing mouth and eyes free. 
 
 Angina proportionate to 
 skin eruption ; dusky- 
 red ; tonsillar plugs ; con- 
 junctivae, bronchi, intes- 
 tines usually intact. 
 
 Proportionate to angina, 
 hence largely cervical. 
 Enlarged spleen. 
 
 Much depression with rash, 
 coated tongue with peel- 
 ing on the fourth day 
 (strawberry tongue) ; fe- 
 ver 105° to 106° ; pulse 
 increased more than fe- 
 ver ; lysis on seventh day ; 
 leukocytosis. 
 
 Nephritis, arthritis, endo- 
 carditis, sepsis, periaden- 
 itis. 
 
 Prolonged, tardy ; desqua- 
 mation copious and usu- 
 ally in shreds (hands and 
 feet). 
 
 Measles 
 
 9 to 10 days. 
 
 3 to 4 days, generally 
 markedly catarrhal. 
 
 Catarrhal symptoms. 
 
 Occurs on fourth day, 
 greatest on fifth or sixth 
 day on the face, forehead, 
 and about the mouth ; 
 brick-red, elevated pap- 
 ules or crescentic islets 
 of eruption, always with 
 areas of healthy skin be- 
 tween. 
 
 Koplik's spots ; patchy red- 
 ness of throat ; photo- 
 phobia ; conjunctivitis, 
 marked bronchitis, very 
 often bronchopneumon- 
 ia ; diarrhoea in some 
 cases. 
 
 Mostly at angle of jaw ; 
 rarely systematic enlarge- 
 ment. No enlargement of 
 spleen. 
 
 Depression, coated tongue, 
 anorexia ; fever-curve 
 
 with two elevations ; cri- 
 sis on seventh day ; no 
 leukocytosis. 
 
 Catarrhal pneumonia, pleu- 
 risv, tuberculosis. 
 
 Often prolonged ; desqua- 
 mation rarely copious and 
 always fine. 
 
 deaths followed the introduction of measles in 1893. The usual 
 important factors are: (a) The genius epidemicus: Henoch records 
 30 per cent, and Heubner 37 per cent, in certain epidemics. The 
 
 7 ; ,. 
 
98 TEE SPECIFIC INFECTIONS. 
 
 mortality in a German epidemic of 2,881 cases was only 1 per cent. 
 (Heissler). (b) Individual resistance: It is higher in institutional 
 practice and in the army. It is 16 per cent, in the children's hospitals 
 in Paris. Measles ranks third among the exanthemata in mortality. 
 (c) Age: The death-rate is highest at the second year; 55 per cent, of 
 fatal cases occur in the first two years of life (Henoch), (d) Com- 
 plications are more important than the disease itself, e. g., tubercu- 
 losis and bronchopneumonia, which is the worst complication, with a 
 mortality of 33 per cent. 
 
 Treatment. — 1. Prophylaxis. — Prevention is important, especially 
 in children under two years, in severe epidemics with pneumonia, 
 in the weakly, and in cases of pertussis. Though the mortality and 
 complications are greater in adults, it is of no advantage for the 
 young to contract measles, and the too prevalent practice of allowing 
 the disease to run through the family must be condemned. In all 
 cases, the secretions from the nose, throat, and bronchi, must be dis- 
 infected, and general sanitary care should be exercised as in smallpox 
 (q. v.) and scarlatina. * 
 
 2. Hygiene. — The patient should have fresh air, warm quarters, 
 rest in bed until after desquamation, and a liquid diet. A mustard 
 bath may be employed in order to bring out the rash. 
 
 3. Catarrhal Symptoms. — Photophobia does not necessitate a 
 dark room. Some sunlight should be admitted. A boric-acid solution 
 should be dropped frequently into the eyes and vaseline applied to 
 the lids. Prophylactic care of the mouth is necessary. To relieve 
 pain in the ears, belladonna, opium, and a 1-per-cent. cocaine solution 
 may be used; paracentesis is indicated for gathering. The nose 
 should be douched with Dobell's solution. Tr. belladonnas, TT\,i. — iii. 
 may be given every two hours for coryza until flushing of the face, 
 increase of pulse-rate, or a dry, red throat, develops. 
 
 4. Antipyresis. — Antipyretics are indicated in sudden high ele- 
 vation with severe cerebral toxsemia, and in high fever with diffuse 
 bronchitis or pneumonia. They are given most efficaciously in the 
 form of baths, with cold affusions to the head and neck. Wine, 
 leeches to the mastoids, mustard plasters, and laxatives, may also be 
 indicated in toxsemia. 
 
 5. The Circulation. — The heart rarely requires treatment, ex- 
 cept in septic types or in pulmonary complications, when camphor, 
 aromatic spirits of ammonia, strychnia, wine, or coffee, is indicated. 
 (See dosage table, page 91.) 
 
 6. Respiratory Symptoms. — Care of the mouth, a soft or liquid 
 diet, inhalations of steam, hot fomentations over the larynx, warm 
 baths, emetics (such as apomorphine or ipecac), and possibly intuba- 
 tion or tracheotomy, are indicated for laryngeal complications. 
 Bronchitis should be treated with ipecac, codeine (morphine), em- 
 etics, inhalations of steam, massive hot packs to the chest, and cold 
 affusions over the nape of the neck (see Acute Bronchitis) ; stimu- 
 lation for pneumonia (q. v.) may be indicated. 
 
RUBELLA. 99 
 
 7. Alimentary Tract. — Enemata relieve constipation. When 
 diarrhoea is excessive, opium, hot wine, or cognac, demulcents, hot 
 applications, and physiological salt-solution by rectum, are indicated. 
 
 8. The Skin. — The skin should be rubbed with olive oil ; a 2-per- 
 cent, menthol salve, or 1-per-cent. carbolic solution, relieves itching. 
 
 9. Complications. — The treatment of complications, such as 
 tuberculosis, pertussis, etc., will be described under these topics. 
 
 RUBELLA. 
 
 Synonyms. — Kubeola notha, German measles, Potheln. By the 
 Germans it is called rubeola, though we employ rubeola as synony- 
 mous with measles. 
 
 History. Definition.- — Eubella was first described by Bergen (1752) 
 in Germany, and its existence as an independent infection was estab- 
 lished by Maton (1815) in England. It is more often confused with 
 atypical scarlatina than with atypical measles. One attack confers 
 immunity. 
 
 Etiology. — Its etiology is not known. Most cases occur during the 
 first half of the year. The disease most frequently attacks children. 
 
 Symptoms. — 1. The Incubation. — The incubation lasts from ten 
 to twelve (perhaps fourteen to twenty-one) days. 
 
 2. Prodromes. — Prodromes are usually lacking; for a period of 
 two hours to a day, there may be cough, photophobia, sneezing, slight 
 temperature, chilliness or headache. 
 
 3. The Eruption. — The eruption occurs on the first day, usually 
 in the palate and throat. It resembles measles and consists of hyper- 
 semic punctate red spots (Eorchheimer's spots). The skin is red, and 
 the eruption disappears at first under pressure ; then the macules be- 
 come darker and more circumscribed; later, the eruption does not 
 entirely disappear under pressure. There are two forms, the cir- 
 cumscribed and the diffuse. The eruption becomes slightly elevated, 
 does not fuse as it does in measles, and erythema is not present about 
 the points of eruption as it is in scarlatina. Anatomically, it is a 
 capillary hyperemia of the papillary and upper layers of the corium, 
 accompanied by slight inflammation and exudation between the 
 corium and epidermis. It advances in "jumps," and fades in one 
 place while it blossoms in another. It appears first on the scalp and 
 face, and progresses downward to the neck, body, arms, and lastly to 
 the legs and feet. Unlike scarlatina, spots are aggregated about the 
 mouth. The eruption is greatest on the upper parts of the body, and 
 is increased by constriction or by pressure of the clothing. Its 
 average duration is from two to four days. The papillae of the 
 tongue show slightly through the fur. Desquamation is minimal and 
 fine. Tracheitis, or, rarely, bronchitis, may be observed. Almost 
 characteristic is the swelling of the posterior cervical and post- 
 auricular glands. There may be some angina, dysphagia, or anorexia. 
 
 4. The Constitutional Symptoms. — The constitutional symp- 
 toms are few. The fever is usually slight. Its duration averages 
 
100 THE SPECIFIC INFECTIONS. 
 
 three days, and it falls by crisis or lysis when the eruption has ma- 
 tured. Except in a few American epidemics, urgent nervous and 
 other complications, such as icterus, albuminuria, nephritis, or colitis, 
 have rarely been observed. 
 
 Diagnosis. — The diagnosis is often very difficult and the unity of 
 the disease is sometimes questioned (see Measles). The "fourth 
 disease/' described by Dukes, cannot be admitted to our nosology. 
 Erythema infectiosum, emphasized particularly by Escherich, is a 
 weakly contagious, maculo-papular erythema, prevalent particularly 
 in the spring and fall, and occurring chiefly on the extensor surface 
 of the extremities, and rarely on the trunk. 
 
 Prognosis. — The prognosis is good, and therapy is symptomatic. 
 Isolation is theoretically advisable. 
 
 ERYSIPELAS. 
 
 Synonym. — St. Anthony's Fire. 
 
 Definition. — An acute, febrile, contagious disease caused by Fehlei- 
 sen' s Streptococcus erysipelatos. It is characterized by a peculiar cir- 
 cumscribed inflammation of the skin and adjacent mucosae, which 
 tends to rapid and broad extension. It usually runs a self-limited 
 course, with slight, if any, visceral involvement. 
 
 History. — Erysipelas was known to Hippocrates and Galen. Trous- 
 seau (1848), in France, maintained that it was always a wound 
 infection. Werner, in England, maintained that it was an infectious 
 disease, and Koch (1880) found the streptococcus, which was more 
 fully described by Fehleisen (1881) and bears his name. 
 
 Etiology. — It is wide-spread, and sporadic cases are seen in almost 
 every centre of population. It occasionally breaks out epidemically. 
 It prevails largely in the early spring months ; 60 per cent, of cases 
 occur between January and May (Anders). In the preantiseptic 
 era it was the dread of hospital physicians, and even at this day it 
 occasionally visits the most sanitary institutions. It is conveyed by 
 a third person and by f omites ; and, infrequently, by unclean instru- 
 ments, and vaccine. Cases of placental transmission to the foetus are 
 known. The virus is not particularly penetrating but may adhere to 
 clothing and furniture with great tenacity. Individual predisposition 
 varies, but many persons have, apparently, a natural, or perhaps an 
 hereditary, susceptibility to the disease. It is like rheumatism or 
 acute angina, in that it often recurs repeatedly. It occurs mostly in 
 the female sex (73 per cent, of cases). Alcoholism, debility, and 
 chronic nephritis, are predisposing factors. Any distinction between 
 " idiopathic " and " wound " erysipelas is artificial, for in practically 
 every instance, some abrasion, though perhaps too small for the eye 
 to detect, occurs in the skin or mucosa?. 
 
 Bacteriology. — The Streptococcus erysipelatos (seu pyogenes 
 longus) was found in the lymph-vessels by Fehleisen, who first drew 
 the distinction between erysipelas and phlegmon. Its absolute differ- 
 
ERYSIPELAS. 101 
 
 entiation from the Streptococcus pyogenes is impracticable. Inocu- 
 lations from cases of erysipelas sometimes produce suppuration. Pus 
 from abscesses has caused erysipelas, and, in certain cases, erysipelas 
 and suppuration have developed simultaneously. This has given 
 some weight to the theory of the bacteriological unity of erysipelas 
 and suppuration. 
 
 Symptoms. — 1. Incubation. — Incubation lasts from three to seven 
 days (fifteen to seventy-two hours in direct inoculations). 
 
 2. The Eruptive Stage. — (a) Usually preceded by a few hours 
 of general discomfort, this stage begins with vomiting, fever, chill, 
 and the eruption. The fever rises rapidly to 103°. The chill occurs 
 in 75 per cent, of cases and is chiefly absent in erysipelas secondary 
 to other diseases, (&) The eruption first appears on the face (95 per 
 cent, of cases), near the inner canthus of the eye, near the nose, or 
 on the cheek. It consists of a hard, bright-red, slightly elevated, 
 burning, and painful area of inflammation, which pits but little on 
 pressure, though its color may disappear. Pathologically, erysipelas 
 is simple inflammation; in and under the skin are found oedema, 
 hypersemia, white- and red-cell extravasation, and streptococci which 
 advance in the lymph-clefts, and are most abundant in the spreading 
 edge, but also in the lymph-vessels beyond it. Its elevated red edge 
 is sharply marked, or " wall-like/' As the area spreads, the skin 
 becomes much swollen, oedematous, smooth, tense, red, and hot, 
 causing a shapeless swelling of the eyes, nose, lips, and ears, and ob- 
 literating the facial lines and expression. The extent of this area is 
 indicated by tenderness, and is therefore more accurately measured 
 with the finger than with the eye. The skin blisters and under the 
 lens, small vesicles are always found. The prong-like advance of the 
 eruption is similar to that of spilt alcohol, or, as Yolkmann puts it, 
 like burning paper ; i. e., it disappears behind as it advances forward. 
 Its extension is irregular, because the streptococci follow the lines 
 of least resistance. If obstructed by dense tissue, deep attachments, 
 or the so-called ligamenta cutis, its course becomes circuitous, asym- 
 metrical, and tardy in one area though rapid in another. It is 
 limited at the base of the skull, and rarely affects the chin, or passes 
 over it to the opposite side. The neck resists its advance, often suc- 
 cessfully, but erysipelas may course over the entire body. The 
 sternum, condyles, ilium, and Poupart's ligament, check or divert 
 its progress. When apparently obstructed, new islets of eruption 
 appear near by, which are nearly always consecutive, as may be seen 
 by the faint lymphatic involvement between the foci. The scalp is 
 often unaffected, but if invaded it becomes swollen, tense, and pale or 
 blue rather than red, and the hair falls out. The genitalia may swell 
 enormously. Necrosis of these tissues, and also of the elbow and 
 knee, may result from excessive tension. The first area pales, and a 
 coarse desquamation results, while the eruption at more remote points 
 advances. The lymph-glands are almost constantly swollen, tender, 
 and palpable, unless hidden by oedema. They enlarge proportionately 
 
102 TEE SPECIFIC INFECTIONS. 
 
 to the dermatitis. The eruption presents few variations : Erysipelas 
 miliare (yesiculosum) ; less frequently erysipelas bullosum; erysipe- 
 las squamosum, or, in old and cachectic subjects, erysipelas hemor- 
 rhagicum. (c) The fever rises suddenly, and is highest on the third 
 or fourth day (103° to 104° or higher). It is continuous, then be- 
 comes remittent or irregular, and finally, after seven to nine days, 
 resolves by crisis, or less often by lysis. Fever is almost always 
 present. In attenuated erysipelas there is little fever and there are 
 few general symptoms, though the rash may be well developed. In 
 general the intensity and the progress of the infection are marked by 
 the degree of fever. 
 
 Other General Symptoms. — The pulse is soft, and ranges between 
 100 and 120; albuminuria occurs in 38 to 67 per cent, of cases; 
 moderate leukocytosis is the rule, and there may be some pain and 
 swelling of the liver and spleen. Nervous toxsemia, with the excep- 
 tion of headache, is uncommon. 
 
 Course. — When limited to the face and head, eight to ten days is 
 the usual duration, and a course longer than two weeks is uncommon. 
 Erysipelas migrans may last weeks or months, travel from limb to 
 limb, and recur again and again. In one of the author's cases it 
 lasted six months. 
 
 Complications and Sequels. — 1. JSTervous. — Toxsemic symptoms are 
 infrequent except in aged, debilitated, or alcoholic subjects. De- 
 lirium is a toxsemic unfavorable development and occurs especially 
 when the scalp is invaded. A profound typhoid condition may 
 ensue in debilitated, or alcoholic patients. Meningitis, formerly con- 
 fused with toxaemia, infrequently follows orbital cellulitis or ex- 
 tension along the fifth nerve. Post-febrile psychoses, multiple neu- 
 ritis, degeneration of the cord, and eye inflammation are exceptional. 
 
 2. Circulatory. — Endocarditis, pericarditis, myocarditis, acute 
 dilatation, and arterial or venous thrombosis, are infrequent. Leu- 
 kocytosis is usually moderate, and is parallel with the fever. High 
 counts indicate concomitant suppuration. Streptococci in the blood 
 are usually ominous. 
 
 3. Respiratory. — Erysipelatous coryza, otitis, and stomatitis, are 
 infrequent and are difficult of recognition. Erysipelatous angina 
 is characterized by much pain, sharply marked redness or lividity, a 
 glazed varnished surface, marked oedema of the uvula and epiglottis, 
 and the formation of vesicles or bullae. Sometimes a wall-like mar- 
 gin is seen. Gangrene may develop in severe instances. The cervical 
 glands may be swollen. For the recognition of erysipelatous angina, 
 coincident facial erysipelas is necessary. Laryngeal erysipelas is 
 most often secondary to pharyngeal erysipelas. It is rare, severe, is 
 easily or necessarily confused with glottis oedema, and is marked 
 by great turgescence, rapid spreading and swelling, and high, early 
 fever. Without tracheotomy, fatal stenosis and extension to the lower 
 air-passages may occur. The rare so-called " erysipelas pneumonia " 
 is especially described by French writers. Though any infection 
 
ERYSIPELAS. 103 
 
 may travel downward from the throat, it is more probably a septic 
 localization than " internal " erysipelas. In streptococcus pneu- 
 monia, the spleen is enlarged (sepsis) more frequently than it is in 
 ordinary pneumonia. The advance is rapid, the extension is wide, 
 the gray hepatization is great, and fibrin formation is scant or lacking. 
 Nevertheless, in pneumococcus infection the same " wandering pneu- 
 monia " may be seen. Pleurisy is usually metastatic (septic). 
 
 4. Alimentary. — Vomiting is often cerebral. Exceptional com- 
 plications are parotitis, oesophagitis, gastritis, enteritis, intestinal 
 ulceration, hemorrhage, pain, icterus, and pylethrombosis. 
 
 5. Genito-ITrinary. — Albuminuria (67 per cent.) is the most 
 constant visceral finding. Nephritis (4 per cent.) is often of the 
 acute glomerular type. Streptococci have been found in the urine 
 and kidneys, especially in septic types. Typical erysipelas may 
 begin in the external genitalia, especially in puerperce, or may first 
 infect the internal mucosa which has been abraded during labor. 
 (See Septic Affections. ) 
 
 6. Septic. — Subcutaneous small abscesses which resemble cold 
 abscesses appear on the head or body in 6 per cent, of cases, espe- 
 cially in alcoholic, nephritic, diabetic, or debilitated patients. Phleg- 
 mons may develop, usually on the legs, and even without mixed 
 infection. Gangrene is fortunately rare (i of 1 per cent.). It may 
 develop early in the eye-lids, genitalia, or over the joints, or it may 
 develop later in the extremities. Herpes is not infrequent. Bald- 
 ness may also result. The joints may be painful or swollen ; suppura- 
 tion is metastatic. Suppurative adenitis may occur with or without 
 mixed infection. General fatal sepsis, aside from the puerperal 
 form, is infrequent. It bears the same relation to local erysipelas as 
 does miliary tuberculosis to a local tuberculous focus (Ponfick). 
 
 Diagnosis. — Diagnosis is easy, when the area is the size of a dollar, 
 (a) because of its very location; (b) because of the early involvement 
 of the lymphatics and of the lachrymal sac; (c) because in most 
 cases the point of entrance can be found ; it may have healed ; it may 
 be concealed by the swelling, or lie an inch or more away from the 
 first eruption ; (d) because of the redness, smoothness, swelling, and 
 oedema; (e) because of the elevated, wall-like margin; and (/) be- 
 cause of the prong-like, irregular progression. 
 
 In weeping eczema, the edges are not raised, the skin is not smooth, 
 there is less fever, the development is slower and itching is present. 
 Malignant pustule may cause redness and swelling, but anthrax 
 bacilli are found under the primary papule and crust. Dermatitis 
 venenata, or medicamentosa, and pemphigus, are unlike erysipelas. 
 Erythema nodosum is discrete, though diffuse, and does not spread. 
 Diffuse simple erythema is a febrile affection, and of short duration. 
 Dermatitis exfoliativa (Hitter) in the new-born is afebrile, develops 
 first about the mouth and chin, and reaches the body and limbs 
 later. Its diffuseness and redness are characteristic. In lymphan- 
 gitis the swelling of the lymphatics advances toward the centre and 
 
104 TBE SPECIFIC INFECTIONS. 
 
 presents cord-like or net-like areas, which are not confluent, vesicu- 
 lated, uniformly red, or evenly edged. In phlegmon and deep cellu- 
 litis, the process is deeper and harder, and the blisters and margin of 
 erysipelas are lacking. 
 
 Erysipelatous angina may not be diagnosed without coincident 
 facial erysipelas. The local findings are not pathognomonic ; neither 
 are the general findings, such as high fever, albuminuria, nephritis 
 and splenic tumor. 
 
 Erysipeloid, a zoonotic affection described first by Rosenbach, oc- 
 curs especially in persons who handle meat. It is recognized by the 
 " butterfly " eruption which develops on both cheeks or on the finger- 
 ends, and is unaccompanied by fever or general symptoms. The edge 
 of the eruption is clear-cut, its advancement slow, its color a dark 
 livid-red, and its course lasts one to three weeks with spontaneous 
 recovery. Gilchrist (1904) reported 329 cases, of which 323 were 
 caused by crab-bites. 
 
 Prognosis. — (a) In uncomplicated facial erysipelas the outlook is 
 good. In general the mortality is 3 to 4 per cent, in private practice, 
 and double that figure in hospitals, (b) In erysipelas migrans the 
 outlook is less favorable, (c) In erysipelas neonatorum (Trousseau, 
 Lorain) the outlook is almost invariably fatal on the fifth to seventh 
 day. It begins on the navel, and less often on the vulva, and on 
 circumcision-wounds. Vomiting, toxsemic diarrhoea, peritonitis, 
 icterus, pneumonia, necrosis, gangrene, suppuration, and sepsis, are 
 much more common than in adult forms. Fortunately, like puer- 
 peral fever, this form is now infrequent, (d) Erysipelas secondary 
 to other infections is serious, especially in chronic maladies, such as 
 alcoholism, diabetes, nephritis, and tuberculosis, and also in bed- 
 ridden, or senile subjects, in whom the asthenic, hemorrhagic, or gan- 
 grenous types are chiefly observed. In acute diseases such as ty- 
 phoid, diphtheria, and pneumonia, this complication is dreaded, (e) 
 Puerperal forms or involvement of the mucosa, especially that of the 
 larynx, are unfavorable (Hippocrates). (/) Recurrence is more fre- 
 quent than in any other infection, which shows' that no permanent 
 immunity is conferred. Relapses (10 to 15 per cent.) are attacks 
 recurring within a few days. Recurrences (20 to 50 per cent.), 
 properly speaking, return after months or years ; indeed, in some 
 individuals, erysipelas may be called habitual. It is observed most 
 frequently in the young and in women (75 per cent.), and mostly 
 on the face. It may result in elephantiasis. Five to fifteen attacks 
 are not uncommon, and Roger has seen forty in one person. 
 
 Treatment. — 1. Prophylaxis. — In this bacteriological era, the dis- 
 ease has been decreased by means of asepsis and isolation, though in 
 regard to the latter, many physicians are still remiss. Chronic 
 rhinitis, rhagades, decayed teeth, and neglected ulcers, must be con- 
 sidered in cases of habitual erysipelas. (See Smallpox; disin- 
 fection.) 
 
 2. Mechanical Means. — Mechanical efforts to limit extension of 
 
MALABIA. 105 
 
 the disease are still used, but unsuccessfully. These consist of bind- 
 ing with elastic strips, elastic constriction, or heavy applications of 
 collodion. 
 
 3. Local Applications. — Iodine, creolin, bichloride of mercury, 
 carbolic acid, alcohol, iodoform, boric acid, and numerous other topi- 
 cal applications, may be recommended but the water they contain is 
 the best ingredient, and was recommended by Hippocrates himself. 
 Mechanical and local applications cannot reach the deeply-situated 
 cocci. Cold compresses afford a sure relief for pain and tension. 
 Ichthyol ointment, 10 to 20 per cent., is soothing but in no sense 
 curative. 
 
 j£ Creolin 1 part. 
 
 Iodof ormi 4 parts. 
 
 Adipis lanae hydrosi (Lanolin) 10 parts. 
 
 M. f. ung. (Koch.) 
 
 4. Drugs. — Erysipelas is a self-limited disease, therapeutically 
 unapproachable. Tincture of the chloride of iron (Hamilton Bell, 
 1851) is well tolerated in large doses (nl x-xxx) but neither 
 shortens nor mitigates the disease. 
 
 I£ Tincturae f erri chloridi 3iiss. 
 
 Quininse sulphatis gr. xxiv. 
 
 Spiritus chloroformi 3ij- 
 
 Aquae q.s. ad ^vj. 
 
 M. f. mist. 
 
 S. — Two tablespoonfuls every three or four hours. (J. Burney Yeo.) 
 
 5. General Treatment. — The symptoms are managed expec- 
 tantly, — L e., as they arise. Headache, delirium, pain, vomiting, 
 and cardiac weakness, are treated as in typhoid. Best in bed and as 
 generous nourishment as the stomach will tolerate, are indicated. 
 
 6. Marmorek's Serum. — Chantemesse reduced the death-rate of 
 his cases to 2 \ per cent, by serum treatment, a figure often reached 
 by more simple measures (Eoger and Botognesi). 
 
 Erysipelas as a curative agent (erysipelas salutare) : Permanent 
 cure of lupus has followed a complicating erysipelas. Syphilis 
 quickly subsides after this infection, and its beneficial effects have 
 been observed in leukaemia, Hoclgkin's disease, carcinoma, sarcoma, 
 chronic arthritis, tuberculous adenitis, diphtheria, and tuberculosis. 
 
 MALARIA. 
 
 Definition. — An acute infection caused by the Plasmodium malarias, 
 inoculated in man by the mosquito and characterized clinically by 
 (1) paroxysms of intermittent, quartan, tertian, or quotidian fever, 
 or by ( 2) " remittent or subcontinuous fever, and sometimes by (3) 
 pernicious, or (4) chronic cachectic forms. 
 
 History. — Malaria, known to Hippocrates and Celsus, is the most 
 completely investigated of all diseases, in that (a) its cause is exactly 
 known; (b) its prophylaxis has become known since the discovery of 
 
106 THE SPECIFIC INFECTIONS. 
 
 infection by the mosquito ; (c) the disease can be watched in different 
 stages in the blood; and (d) there is a truly specific treatment. 
 
 Etiology. — All ages and both sexes are affected equally. Men are 
 more exposed to infection, and children are readily infected on ac- 
 count of their thin skin. Such occupations as sewer and railroad 
 building, ditching, and night work, especially, are predisposing 
 factors; 32 per cent, of the French soldiers in Madagascar in 1895 
 acquired malaria ; reduced physiological resistance, exposure, excesses, 
 and alcoholism, also predispose to the disease. Negroes have a rela- 
 tive immunity. Instances of familial or individual immunity have 
 been noted. Epidemics may occur, as happened during the building 
 of the Paris boulevards. Indirect causes, such as warmth of climate, 
 the warm season, moisture, rain, swampy localities, telluric influences, 
 bad air (mal-aria) , and impure drinking-water, are now proved to be 
 causes only in so far as they relate to the breeding of the m.osquito. 
 In Africa, severe forms of malaria are found everywhere except in its 
 lower part and in the Sahara. In the far East its chief seats are 
 India, Burma, Assam, Faral, and the East Asiatic coast; Asia 
 Minor, Japan, and the East Indies. In Europe, lower Russia, 
 Italy, Hungary, the Balkans, and Greece, are most affected. Malaria 
 also abounds in the northern three-fourths of South America. In 
 the West Indies, severe types prevail. In the United States, malaria 
 is slowly moving southward, and cases seldom develop on the Pacific 
 coast, in the Northwest, in the dry "West and in the Lake region. 
 Even in the South it is becoming less frequent. 
 
 Direct Cause. — The direct cause is the malarial parasite, described 
 by Laveran, in 1880, and also by Marchiafava and Celli, in 1885. 
 In this country Councilman, Abbott, Osier, James, Dock, Koplik, 
 Thayer, Hewetson, and others have studied the organism. It is a red- 
 cell parasite, a hsemocytozoon. The biology of the Plasmodium ma- 
 laria? concerns (A) its life in the human blood, and (B) its life in 
 the mosquito. The unity of all species was maintained by Laveran, 
 but various species must be recognized because (1) their morphology 
 varies; (2) their geography, seasonal prevalence, and malignancy 
 vary; (3) on inoculation, the species and fever type are main- 
 tained ; and (4) the type remains the same in the same individual. 
 
 (A ) . The Plasmodium in Man. — Special forms of the parasite : 
 
 1. The quartan parasite has a life-cycle of three days. In the 
 first twelve hours the young form is without pigment. A small amor- 
 phous bright hyaline spot lies in the red cell, whose form flattens the 
 parasite. There is some amoeboid movement upon warming the 
 slide. It gains little in size for one day, when some pigment or mel- 
 anin appears in the form of coarse dark rods and granules with 
 little movement. Melanin is the haemoglobin digested by the para- 
 site. It is usually dark or black and resembles the melanin of ma- 
 lignant growths. It is dissolved by alkalies and ammonium sulphide, 
 but not by acids. Movement of the parasite ceases as pigment in- 
 creases. The parasite occupies one-half to two-thirds of the red 
 
PLATE III 
 
 P ^ 
 
 W 
 
 
 
 ts # 
 
 & 
 
 t 
 
 C 
 
 Malarial Parasites. 
 
 A. Tertian parasite. 1, young form ; 2-4, stages of growth and pigmen- 
 tation ; 5-7, segmentation; 8, rupture of spores from corpuscle; 9. extra- 
 cellular form ; 10, flagellate form. 
 
 B. Quartan parasite. 1-6, development and pigmentation; 7, 8, central 
 grouping of pigment and spore formation; 9, rosette of spores with nuclei; 
 lO, extracellular form ; 11, flagellate form. 
 
 C ^Estivo-autumnal parasite. 1, ring-like body; 2, 3. amoeboid forms; 
 4, parasite in brassy degenerated red cell; 5, pigmentation; 6, segmentation; 
 7. 8, half-moon bodies; 9, flagellate forms. 
 
MALAEIA. 107 
 
 cell after forty-eight hours, and almost the entire cell after sixty 
 hours. There is rarely more than one parasite in each cell. Flagella 
 (v.i.) are not frequent. During growth the red cell on which the 
 Plasmodium feeds either undergoes no change in size or becomes 
 smaller and darker peripherally. As sporulation occurs, the pigment 
 gathers centrally and the spores, usually not numbering more than 
 ten, develop into the " daisy " form. Vacuoles are seen in some cases. 
 After sixty-nine hours, mature segments finally separate, each with 
 a bright spot or nucleolus ; i. e., segmentation occurs in the peripheral 
 blood three hours before the paroxysm, which corresponds with their 
 rupture from the red corpuscle into the plasma. Sporulation means 
 death of the adult parasite, or its " death in childbed.'' as VEanna- 
 berg well describes it. The spores rupture through the red cell. 
 and escape into the plasma, whence they attack and enter other red 
 cells, to repeat their life cycle. The pigment and fragments of red 
 cells are picked up by the leukocytes and are carried to the liver and 
 spleen. Some forms (gametocytes ) do not mature nor sporulate. 
 Thev are taken up bv the mosquito, to complete in it another cycle. 
 (Plate III.) 
 
 2. The tertian organism has a forty-eight-hour cycle. In its first 
 day it is small (1^ to 2/x), and appears as a bright, unpigmented, 
 disklike or annular spot in the red cell, thrusting out pseudopodia, 
 with most active amceboid movement, and possessing a relatively large 
 nucleus. — partly clear chromatin, and partly chromatin deeply 
 stained by the Eomanowsky method. It fills about one-third of the 
 cell. In its second day. pigment rapidly accumulates as fine granules 
 or rods, which are usually peripherally located, and have an actively 
 swarming movement, compared by Laveran to that of boiling water. 
 This is due to currents in the protoplasm of the parasite. The 
 amceboid movement decreases in twenty-four to thirty-six hours, as 
 the parasite grows and as the pigment increases, but some movement 
 remains for a long time. Vacuoles are frequent. The parasite oc- 
 cupies two-thirds to three-fourths of the red cell, which becomes dis- 
 tended and chlorotic. The most common form of the sporulation is 
 the concentric accumulation of pigment and the development of fifteen 
 to twenty rough, refractile spores, which form in two concentric cir- 
 cles r* sunflower '* arrangement), or are more frequently irregular, 
 like a bunch of grapes. The spores are small and round. Sporula- 
 tion occurs three hours before the chill and the rise of temperature, 
 and is completed in forty-eight hours, when the toxins secreted pro- 
 duce the rigor and fever. Most spores are seen at the time of the 
 chill, and even then few can be seen, because sporulation occurs 
 to a greater extent in the internal organs than in the peripheral 
 blood-stream. When spores are seen between paroxysms they repre- 
 sent the sporulation of another generation of parasites, too weak or 
 too few to induce a paroxysm. The generations are never absolute 
 as they are in the quartan type, and the parasites of the same gen- 
 eration vary six or eight hours in their cycle. This explains the 
 
108 TSE SPECIFIC INFECTIONS. 
 
 clinical variations in periodicity. Flagellated forms may be seen 
 a few minutes after withdrawal of the blood. The nodulated and 
 clubbed flagella lash about and indent the red cells. They may 
 break off and swim about. They occur in numerous parasites which 
 never sporulate in human blood, and remain as large bodies with 
 vibrating pigment. Formerly regarded as degenerated parasites, 
 they really represent gametocytes or the " sexual forms/' which de- 
 velop later in the mosquito (MacCallum, 1897). 
 
 3. The oBstivo-autumnal 'parasite has a life-cycle of from twenty- 
 four to forty-eight hours. It has a very small, unpigmented body, 
 and possesses most active amoeboid movement. It thus attracts 
 early attention but is easily overlooked, as it possesses almost the 
 same refraction as the red cell. It becomes quiet after drawing 
 the blood from the body, when it appears characteristically ring-like, 
 often with a central vacuole. The shape may be successively amoe- 
 boid, cliskoid, annular, cruciform, or often may have a slight protub- 
 erance at one side — the seal-ring form. Mature forms contain parti- 
 cles of haemoglobin. The pigment is extremely fine, powder-like, 
 dark, sometimes reddish, peripherally located, and has some move- 
 ment. When the parasite reaches one-third the size of the corpuscle, 
 it is usually motionless, and the pigment usually becomes concentrated 
 centrally. Motion in the parasite has been seen in the cadaver by 
 Ziemann. The spores number six to sixteen, are very small, round, 
 and without movement or vacuoles. Sporulation occurs as in the 
 other forms. Fever, pigment concentration, and sporulation, coincide 
 (Golgi). If large parasites with much* pigment are seen in the 
 peripheral blood, they denote the onset of a paroxysm, and after the 
 paroxysm, ring-forms without pigment may be observed. The young 
 forms circulate in the general blood-stream, though sporulation usu- 
 ally occurs in the viscera. The half-moon bodies, or crescents, 
 are delicate, highly refractile bodies, measuring eight to ten microns 
 by two to three microns, are developed in the bone-marrow or spleen, 
 and possess considerable pigment, which is usually mesial]y located 
 and has little, if any, motion. They have no amoeboid movement 
 but may slowly change form. In shape they are spindle, oval, or 
 spherical. They occur singly in the red cell. They do not multiply 
 in the human blood. The young crescents develop in the viscera 
 or bone, and their adult forms are seen in the peripheral blood, for 
 the periphery offers the best opportunity for leaving the body — through 
 the bites of mosquitos. The male form of the crescent has flagella 
 (microgametes) which penetrate the sexual elements of the female 
 crescents (macrogametes). This occurs outside of the body, either 
 on the slide or in the body of the mosquito (Ross). After several 
 days crescents, spherules, or spindles, appear. Crescents indicate 
 that the fever has just begun. Fever rarely occurs when crescents 
 alone are found in the blood. If fever develops with the presence of 
 crescents, amoeboid bodies, also, are nearly always found. The red 
 blood-cell becomes copper-colored or brassy. 
 
MALARIA. 109 
 
 The parasite may be stained with methylene blue or hematoxylin, 
 and counterstained with eosin. 1 For the beginner, at least, study of 
 the fresh blood under an oil-immersion is the best method. 
 
 (B). The Life of the Organism Without the Human Body. 
 — King (1883) first suggested that the mosquito was the intermediate 
 host and sole source of infection. It takes the plasmodium from 
 man and reinoculates him with it after the life-cycle within its body. 
 Other analogous infections are known, such as the hsemosporidia of 
 birds, frogs, bats, dogs, sheep, monkeys; e. g., Texas cattle-fever in- 
 oculated by the tick, and the African tsetse disease (trypanosoma) in 
 animals and man, which is inoculated by the tsetse-fly. Manson 
 (1894), especially, then Ross, Grassi, Bastianelli, Bignami, Daniels, 
 Stephens, Christopher, and others, have developed this most interest- 
 ing subject. The Plasmodium malaria? has not been found except 
 in man and in the mosquito. The mosquito is the primary and 
 higher host, since the sexual process of reproduction in its stomach 
 is biologically higher than the simple sporulation in man. The culex 
 and the anopheles are the two chief genera. The culex does not con- 
 tain nor convey the parasite. Its palpi are very short and its wings 
 generally have no mottling. When sitting, its hind legs are carried 
 above the body and its body lies parallel with the wall, or may sag 
 from the blood it has sucked. Its eggs are laid in tanks or pud- 
 dles. It is the ordinary house mosquito and is found chiefly in cities. 
 The anopheles conveys malaria. Its palpi are almost as long as the 
 proboscis; the wings are mottled; the rear legs usually depend, or 
 touch the wall. Its body makes an angle of 45° with the wall. The 
 eggs are laid in pools or sluggish streams with algse growth, and the 
 open country is its preferred habitat. In America, four species 
 exist : (1) The most important is the Anopheles maculipennis ; (2) A. 
 crucians; (3) A. punctipennis ; (4) A. argyrotarsis. When the ano- 
 pheles bites persons whose blood contains sexually mature forms 
 of the plasmodium (gametocytes), flagellation in the male form occurs 
 and the flagella enter the female cells. After fecundation in the 
 insect's stomach, the impregnated cell enters the muscular walls of 
 the middle intestine, and, after two days, small, round, refractile, pig- 
 mented bodies appear, which, after a week, grow to 60 or 70/* in 
 
 1 The Nocht-Bomanowsky staining fluid, according to Ewing, is made as fol- 
 lows: (1) Polychrome methylene blue solution: To 1 ounce of polychrome methy- 
 lene blue (Griibler) add 5 drops of 3-per-cent. solution of acetic acid (U. S. P. 33 
 per cent.), to neutralize the undue alkalinity. (2) Ordinary methylene blue solu- 
 tion: Make a 1-per-cent. (saturated) watery solution of methylene blue, preferably 
 Ehrlich's rectified, or Koch's, by aid of gentle heat. This solution improves with 
 age and should be at least a week old. (3) Eosin solution: A 1-per-cent. solution 
 in water of Griibler 's aqueous eosin. Then to 10 c.c. of water add 4 drops of (3), 
 6 drops of (1) and 2 drops of (2), mixing well. To use, the specimens, fixed by 
 alcohol or heat, should be immersed for two hours, specimen-side downward; they 
 will not overstain by twenty-four hours' immersion. They should then be washed 
 in distilled water, dried slowly over the flame, and mounted in Canada balsam. 
 The density of the blue may be varied to suit individual fancy, nor need the pro- 
 portions be rigidly followed, but the accurate neutralization of the polychrome 
 solution is most important. 
 
110 THE SPECIFIC INFECTIONS. 
 
 diameter. They develop into myriads of sporoblasts which reach 
 the salivary glands of the insect, whence they are again inoculated 
 into man by biting. The sporozoids thus resulting from sexual 
 conjugation in the mosquito, are equivalent to spores formed by asex- 
 ual sporulation in the human blood. Entering the red cells in man, 
 they follow the cycle of their type as above described, and produce 
 either sporulating forms or sterile forms. The sterile forms in the 
 human blood — i. e., the forms which do not sporulate — linger in the 
 peripheral blood with the teleologic purpose of preserving and con- 
 tinuing their life in the mosquito, and, on reaching its body, develop 
 again the agents of reinfection. This knowledge concerning the 
 mosquito explains many interesting and formerly incomprehensible 
 details. We now know why those living in the first story of houses 
 are more likely to be infected than those living in the upper floors, and 
 why those who slept in houses facing inland were infected while 
 those in houses exposed to the sea air escaped, etc. In Rome, the 
 fever prevailed just outside the Porta del Populo, while the Corso, 
 three hundred feet distant in the city, escaped. 
 
 Symptomatology. — 1. Fever. — Fever is, next to the finding of the 
 melanin and the plasmodium, the most constant symptom, though 
 malaria should not be divided into types by the fever alone. It comes 
 on after an incubation varying irregularly from one and a half to fif- 
 teen days. Fever hears a close relation to sporulation (Golgi, 1885). 
 The fever-curve is most variable, being irregular in some types or 
 almost mathematically regular in others. It is usually irregular at 
 first even in regular types. It may be remittent (subcontinuous), 
 intermittent (tertian, quartan, quotidian), or continuous for a few 
 days, when it ends by crisis or becomes remittent or intermittent be- 
 fore recovery. The paroxysm may be delayed beyond the time when 
 it is due (postponens) , or may anticipate this time (anteponens) . 
 In the algid variety there may be hyperpyrexia, or normal or subnor- 
 mal temperature. 
 
 The classical divisions of the paroxysm are (a) chill, (b) fever, 
 and (c) sweating, whose respective duration is in the proportion of 
 3-2-7 (Lorain). Any element of the paroxysm may be absent. Thus 
 the fever or the rigor is absent in some virulent varieties and in 
 persons partly immunized, and the sweating may be slight or absent. 
 The paroxysm lasts ten (four to forty-eight hours), and in 91 per cent, 
 of the cases occurs between 10 a. m. and 3 p. m. (a) The chill is sud- 
 den in its onset, often very severe, with headache, emesis, coldness, 
 contraction and lividity of the skin (cutis anserina) ; the temperature 
 by rectum is elevated, the pulse rapid, small, and hard ; the respira- 
 tion is rapid or even dyspnoeic, and the urine is increased. The 
 parasites are in the peripheral blood in the tertian and quartan 
 types but largely in the internal organs in the sestivo-autumnal type. 
 (b) The fever is high, perhaps not higher by rectum than during the 
 chill, but is more evidenced by the red skin, thirst, delirium, and 
 headache, soft, full, or dicrotic pulse, and other fever symptoms, 
 
MALARIA. 
 
 Ill 
 
 In this stage the young parasites are free in the blood and begin to 
 attack new red cells. After their entrance into these cells the fever 
 ceases, (c) In the sweating stage the young parasites are found in 
 the red^ cells, and phagocytes take up the detritus and pigment. The 
 sweat is usually profuse and somewhat characteristic, giving off 
 an odor like that of semen. The patient may be exhausted, but 
 postfebrile euphoria is usual. 
 
 Special Febrile Types of Malaria. — The quartan and tertian forms 
 are regular and intermittent, and the aBstivo-autumnal forms are 
 more irregular and remittent. 
 
 1. The quartan fever is the rarest of all types ( t 8 q of 1 per cent.), 
 is found in the temperate zones, and occupies a position geographi- 
 cally intermediate between the tertian and aestivo-autumnal varie- 
 ties. It is caused by the quartan parasite, is the most regular of all 
 types, and is called quartan because the simple form causes paroxysms 
 every fourth day. The parasitic cycles are readily followed in the 
 circulating blood, and the organisms do not accumulate in the internal 
 organs. The fever is rather obstinate and recurrence is frequent, but 
 
 Day 
 
 Fig. 10. 
 3 
 
 TEMP. 
 
 104 
 
 
 
 
 
 
 
 
 
 
 
 
 
 102 
 
 
 
 
 
 
 
 
 
 
 \ 
 
 
 
 100 
 
 
 
 
 
 >s ^AA 
 
 1 
 
 
 
 \y 
 
 / 
 
 
 
 
 
 
 
 
 
 
 V 
 
 
 Quartan malaria. (Silvestrini.) 
 
 quinine exerts its specific action in a relatively short time. The type 
 may be single, from one generation of parasites; double, from two 
 generations ; or triple, from three generations thus producing, respec- 
 tively, temperature, every fourth, every first and second, or finally, 
 every day of the cycle. 
 
 2. Tertian fever is most frequent in the temperate zones and is the 
 most widely distributed variety. It is found in all malarial coun- 
 tries and constitutes 50 to 65 per cent, of all malaria. The organisms 
 tend to accumulate in the internal organs. It is rarely pernicious. 
 The type may be single, or more frequently, double from two genera^ 
 
112 
 
 THE SPECIFIC INFECTIONS. 
 
 Day 1 
 
 2 
 
 3 
 
 Fig. 11. 
 4 
 
 
 5 
 
 6 
 
 7 
 
 
 TEMP. 
 
 104 
 
 
 
 
 
 
 
 
 
 103 
 
 ~J_ 
 
 
 
 
 h 
 
 
 
 
 102 
 
 
 
 
 
 h 
 
 
 A 
 
 
 101 
 
 
 
 
 
 \ 
 
 
 A 
 
 
 100 
 
 1 
 
 
 
 
 I \ 
 
 
 /\ 
 
 
 99 
 
 / 
 
 
 
 V 
 
 
 
 
 7 \ 
 
 
 
 _J 
 
 
 
 \ J* 
 
 ^ 
 
 
 , / 
 
 ^j v 
 
 v 
 
 98 
 
 
 
 
 W^^ 
 
 
 vA — / 
 
 
 \ 
 
 Tertian malaria. 
 
 tions of parasites. Almost continuous fever may be observed. It re- 
 sponds very readily to quinine or may recover spontaneously. 
 
 3. 2Estivo-autumnal fever, caused by the sestivo-autumnal parasite, 
 is often irregular, remittent, intermittent, or continuous (subcontin- 
 uous). It is characterized clinically by severe and recurrent fever, 
 marked ansemia, frequently by absence of paroxysms (chills occur- 
 ring in only 71 per cent.), and sometimes by pernicious symptoms. 
 It was first called sestivo-autumnal by Marchiafava and Bignami, in 
 contradistinction to the vernal or milder spring forms. Sub-types: 
 {a) Regular intermittent a3stivo-autumnal fever: — (i) The sestivo- 
 autumnal tertian, in which the temperature is apt to be high, 
 and the paroxysm doubly long. The typical curve may be mod- 
 
 Day 
 
 1 
 
 2 
 
 Fig. 12. 
 •6 4 
 
 5 
 
 6 
 
 7 
 
 8 
 
 TEMP. 
 
 106 
 
 
 
 
 
 
 
 
 
 105 
 
 
 
 
 
 
 
 
 
 104 
 
 
 A 
 
 i 
 
 
 
 
 
 
 103 
 
 A 
 
 / 
 
 \ 
 
 A 
 
 
 
 
 
 102 
 
 / 
 
 A/ 
 
 \ 
 
 A 
 
 
 
 
 
 101 
 
 / 
 
 V 
 
 ± 
 
 V 
 
 \ A 
 
 
 
 
 100 
 
 
 
 V 
 
 
 V 
 
 
 
 
 99 
 
 
 
 
 
 V 
 
 
 
 
 
 
 
 
 
 
 
 
 
 9S 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 iEstivo-autumnal malaria. 
 
 ified by the absence of a distinct initial elevation, by an exaggerated 
 pseudo-crisis, by a briefer or longer duration of the attack, by 
 anticipation or procrastination, by double attacks, and by marked 
 oscillations, (ii) The sestivo-autumnal quotidian, in which the 
 attack is usually short, but has an abrupt elevation of temperature. 
 
MALARIA. 1 1 3 
 
 This form often becomes irregular, has fewer symptoms than 
 the other variety, is often mild and the patient may recover 
 spontaneously. It is readily confused with typhoid. (&) The 
 irregular intermittent sestivo-autumnal fever, which has marked 
 irregular intermittency or remittency, or subcohtinuous fever, be- 
 cause the attacks are duplicated, anticipated, or prolonged. The 
 paroxysm may last twenty hours. The life-cycle of the parasite is 
 often difficult to follow. The symptoms may be mild or very severe. 
 2. Blood-Findings. — The blood-findings are pathognomonic; viz., 
 parasites, melansemia, anaemia and absence of leukocytosis are found. 
 
 (a) Bed Cells. — Ansemia is always present from direct deglobuli- 
 zation by the parasite, and possibly from liberated toxins. Acute 
 ancemia is naturally more marked and rapid than in any other acute 
 infection. The loss is greatest in the first attack, especially in per- 
 nicious cases, and sometimes reaches half a million cells. Reduction 
 to 500,000 red cells (Kelsch), thus giving the picture of pernicious 
 ansemia, has been observed especially in pregnancy, and in children 
 (Frayer and Ewart). 
 
 (b) White Cells. — The absolute and relative leukopenia is due to 
 the collection of the white cells in the liver and spleen, to the destruc- 
 tion of the phagocytes, and to lesions of the blood-making organs. 
 As in other anaemias caused by diseases of the bone-marrow and 
 spleen, an increase of lymphocytes or large, mononuclear cells, with 
 decrease of the polymorphonuclear cells, may be observed. Stevens 
 finds the large mononuclears increased to 20 per cent. Leukocytosis 
 in malaria denotes complications. An absolute increase is sometimes 
 observed in the " black-water fever," but even here the increase is 
 in the lymphocytes. 
 
 (c) Melancemia. — Melansemia (observed by Virchow and Heschl, 
 1847-50) is, next to the presence of the plasmodium, the most con- 
 stant change in malaria. It probably occurs in every malaria. 
 Melansemia is present during fresh infection and may occur shortly 
 after the fever has disappeared, as in the half-moon forms. After 
 infection it usually disappears within forty-eight hours. It is prac- 
 tically pathognomonic of malaria, though it is said to occur in recur- 
 rent fever, in melanotic new growths, and in Addison's disease. It 
 is found in the polymorphonuclears and sometimes in the lympho- 
 cytes. It is seen in the smaller capillary walls where their diameter 
 suddenly decreases (lung alveoli, intestinal villi, appendices 
 epiploicse, renal glomeruli, cerebral convolutions, spleen, liver, and 
 bone-marrow) ; the capillaries may be occluded by pigment. The 
 lymph-glands are usually free of pigment. Besides this pigment the 
 copper-colored hsemosiderin may be found not only in the vessels but 
 in the parenchyma of the liver. 
 
 3. Spleen. — Enlargement of the spleen (first described by Andou- 
 ard, 1803), is the third important finding. It is palpable in 88 per 
 cent, of the cases and anatomically is rarely absent. Its size, hard- 
 ness, and plumpness, are proportionate to the duration of the fever, 
 8 
 
114 TEE SPECIFIC INFECTIONS. 
 
 increase with its rise, and remit between attacks. In acnte infections 
 the spleen is increased three to five times its normal weight (five 
 ounces) ; it is soft and friable; the veins are dilated, and the paren- 
 chyma is flooded with infected red and macrophagic cells ; and there 
 are occasional areas of focal necrosis. The Malpighian bodies con- 
 trast strongly with the pnlp. A sticking pain over the organ, in- 
 creased by moving the diaphragm, is due to capsular tension, or 
 perisplenitis, and is often associated with pain and tenderness in 
 the bones. As the disease subsides the splenic intumescence disap- 
 pears. In chronic infections the spleen is permanently enlarged 
 (fever-cake), reaching even into the pelvis. It may weigh two to 
 ten pounds, the capsule is thickened, even calcified, perisplenic ad- 
 hesions occur and friction is frequent. Sometimes a systolic murmur 
 is heard (Griesinger). The organ is plump, and the acute hyper- 
 semia and focal necrosis lead to increase of the connective tissue. The 
 redundant pigment gradually decreases. Ultimately little remains 
 of the pulp, follicles, and splenic function. 
 
 Rare complications are pressure on the intestines, nerves, and ure- 
 ters, torsion of the pedicle of a wandering spleen, abscess, or rupture 
 (of which Choux has collated 147 cases). 
 
 4. Skix. — The vasomotor constriction during the chill gives way, 
 during the febrile rise, to hyperalgesia and vaso-dilatation. Miliaria 
 appear in the sweating stage. Herpes is very frequent, mostly nasal 
 or labial. Erythema is not common except from quinine ; erythema 
 nodosum has been observed in children. Koseolas are most rare. 
 (Edema and a cachectic hue occur chiefly in chronic cases. Slight 
 icterus is not infrequent (urobilin icterus), and sometimes it is 
 intense. Infrequent complications are urticaria, pemphigus, pe- 
 techias, pigmentation, a measles-like eruption, furuncles, noma, gan- 
 grene, or erysipelas. 
 
 5. Circulatory Symptoms. — The heart is little involved, though 
 myocardial degeneration with dilatation may occur. The pulse rises 
 parallel with the fever, small at first from vaso-constriction, later 
 dicrotic and full from vaso-dilatation. Endocarditis, angina pectoris, 
 aortitis, or phlebitis are rare developments. 
 
 6. Eespiratory Symptoms. — The rare dyspnoea and pulmonary 
 congestion during a paroxysm are due to parasites and phagocytes 
 accumulating in or even occluding the capillaries of the lung. 
 Chronic bronchitis, emphysema, and chronic interstitial pneumonia, 
 occur as complications. Plasmodia have been seen in the sputum. 
 Bronchopneumonia is frequent in malarial cachexia. Genuine lobar 
 pneumonia occurs only as a mixed infection. It is atypical, is often 
 present without rusty sputum and without chill, and, in malarial 
 cachexia, is especially fatal. Pulmonary tuberculosis and pleurisy 
 are rare. 
 
 7. Digestive Symptoms. — The oral mucous membrane is drv: 
 the tongue is heavily coated and the breath is foul. The parotid 
 gland is sometimes swollen. The stomach may be the seat of erosions, 
 
MALARIA. 1 1 5 
 
 catarrh, hyperemia, or of infarction with plasmodia. Anorexia, 
 pyrosis, vomiting, and gastralgia, are common symptoms. Ulcera- 
 tion from amyloid degeneration is observed only in a few chronic 
 cases. Hsematemesis from chronic splenic tumor has proved fatal. 
 
 The Intestines. — Swelling of the lymphatic structures, erosions, 
 catarrh, hyperemia, thrombosis from parasite aggregation, meteor- 
 ism, constipation, and rarely diarrhoea, are observed. Acute abdom- 
 inal pain is not uncommon, but occurs without obvious cause. Pain 
 may simulate peritonitis. Rarely the disease may resemble dysen- 
 tery, with ulcers in the large and small gut. 
 
 The Liver. — In acute infections the liver is swollen, hypersemic, 
 or the seat of focal necrosis. Its macrophagic endothelial cells are 
 swollen and its veins are full of pigment, though few parasites are 
 present. Icterus may develop from sepsis or red-cell destruction; it 
 is usually polycholic. Pigmentation from degenerated red cells is 
 more common than actual melanosis. In chronic infections the liver 
 may weigh eight or ten pounds, is hard and smooth, and has a thick 
 capsule. The changes, seriatim, are focal necrosis, atrophy or partial 
 regeneration, and pigmentation with hyperemia. As a result of 
 atrophy and regeneration, angioma, lymph-cysts, or abnormal lobules 
 develop ; hyperplasia of the perilobular connective tissue occurs with 
 ultimate cirrhosis. Atrophic and hypertrophic cirrhosis may follow 
 chronic malaria without necessarily being of malarial origin. Amy- 
 loid degeneration and simple atrophy from pylethrombosis are un- 
 common sequels. Acute ascites may result from pylethrombosis, from 
 plugging of the capillaries by melaniferous cells. 
 
 8. Geistto-Urixary Symptoms. — Polyuria is often observed dur- 
 ing the paroxysm, despite the severe sweating. The urine is usually 
 decreased in the estivo-autumnal type. The post-malarial polyuria 
 of convalescence is frequent. In one instance the author observed a 
 veritable diabetes insipidus as described by Sydenham and Mosse. 
 
 The urea, iron, chlorides, and specific gravity, of the urine are in- 
 creased. Phosphates are decreased during the paroxysm, and in- 
 creased afterwards. Albuminuria is present in 25 to 40 per cent, of 
 cases, and usually disappears with the paroxysm. Ehrlich's diazo re- 
 action was obtained in 5 per cent, of the cases of Thayer and Hewitson. 
 Nephritis occurs in 4.5 per cent, of cases, but is seldom fatal. Plas- 
 modia are rarely found in the glomeruli or veins but frequently 
 abound in the intenubular capillaries. Glomerular desquamation 
 and epithelial exfoliation, endocapsular exudation, necrosis, and cast 
 formation, develop in the convoluted tubules. Chronic parenchyma- 
 tous and interstitial nephritis may result from previous malarial in- 
 fection. The large white kidney, followed by secondary contraction, 
 is considered by some to be a frequent sequel. Hemoglobinuria, 
 anuria, and uremia, occur in blackwater fever (see Pernicious 
 Forms). Gangrene of the genitalia is an uncommon sequel. Metror- 
 rhagia and abortions occur frequently. 
 
116 TEE SPECIFIC INFECTIONS. 
 
 9. Xeevous Symptoms. — The parasite and its presumed toxin 
 especially affect the nervous system, whence van Swieten long ago 
 called malaria a neurosis. There is scarcely a nervous symptom 
 which is not occasionally observed in malaria. The sensorium, in- 
 volved slightly in mild cases, is more seriously affected in the more 
 severe types, the symptoms ranging from simple exaltation to coma 
 and paralysis. Headache is usual, and neuralgias are frequent, espe- 
 cially of the fifth nerve. Cerebral confusion was noted by the writer 
 in two ordinary tertian cases. In pernicious types it is not always 
 easy to determine whether nervous symptoms are due to simple tox- 
 aemia or to cerebral thrombosis. The central nervous tissues are dis- 
 tinctly hyperaemic, and are auaunic only in the algid or choleraic 
 types. The endothelial cells of the vessels are fatty, swollen, and 
 pigmented. Thrombosis in grave cases, though it is usually caused 
 by the rough infected red cells, may result from swelling of the 
 endothelium. Thrombosis may lead to multiple small extravasations 
 of blood. The infected erythrocytes never leave the vessels. 
 
 Symptoms of paralysis (hemiplegia, paraplegia, and monoplegia), 
 or of motor irritation (tremor, chorea, contractures, epileptic at- 
 tacks, or reflex spasms), may possibly occur in urgent types. Neu- 
 ritis, neuroses, psychoses, ascending spinal paralysis, bulbar symp- 
 toms, symptoms resembling multiple sclerosis (Spiller), tabes or 
 acute ataxia (Kahler and Pick), are rare sequences. 
 
 10. Muscles and Boxes. — The muscles are often painful. Rheu- 
 matism is infrequent except in India. The bone-marrow is at first 
 fatty and pigmented; the fat and pigment then disappear with 
 marked vascularization, and, finally, with proliferation of the mar- 
 row-cells and connective-tissue thickening. Bone tenderness is often 
 noted. 
 
 Relapses. — Eelapses. caused by the awakening of an old infection, 
 are almost invariable in all forms, but are most obstinate in the 
 sestivo-autumnal type; the blood-findings are almost always positive. 
 Reinfection is also frequent. 
 
 Chronic Malaria. — Untreated infection, or reinfection, persists for 
 months, notably in the aestivo-autumn al variety. It is accompanied 
 by irregular fever, marked anamiia, the parasite in the blood, and 
 splenic and hepatic swelling. In severe chronic cases, the malarial 
 cachexia develops, usually after years of infection. It is most 
 marked in intensely malarial regions, in the aestivo-autumnal infec- 
 tion, and in reduced subjects. The fever is slight, irregular or en- 
 tirely absent. The essential features of malarial cachexia are (1) 
 anaemia from defective blood regeneration, with its general symptoms, 
 such as oedema, rapid pulse, venous thrombosis, and hemorrhages in 
 the skin, retina?, stomach, etc.; (2) vascular changes, possibly due to 
 pigment occlusion; (3) enlarged spleen and liver; and (4) gangrene, 
 nervous symptoms, alimentary and respiratory catarrh, amyloid 
 disease, liver hypertrophy, and extreme malnutrition. 
 
 Kelation to the Other Diseases.- — Malaria and typhoid rarely co- 
 
MALARIA. 1 1 1 
 
 exist; Craig saw but 8 instances in 5,000 personal cases. The de- 
 tection of the plasmodia on the one hand, and typhoid bacillsemia or 
 the Widal test, on the other hand, are necessary for diagnosis. Sur- 
 gical operations may aronse a latent malaria. Sunstroke may initiate 
 a pernicious attack. Erysipelas, septicaemia, dysentery, cholera, 
 smallpox, tuberculosis, etc., very infrequently co-exist with malaria. 
 
 Pernicious Malaria. — Pernicious malaria, in the widest sense, is 
 malaria which threatens life. Pernicious malaria constitutes but a 
 small proportion of cases of sestivo-autumnal malaria. Very few per- 
 nicious cases have followed infection with the ordinary tertian para- 
 site (Ziemann, French, and one case observed by the author). It is 
 characterized by severe, obstinately recurring fever, pronounced in- 
 tractable anaemia, pernicious visceral symptoms, frequently by abor- 
 tive paroxysms without chills, by depression, tendency to recurrence, 
 and the presence in the blood of the sestivo-autumnal plasmodium. 
 The pathogenesis of perniciousness lies in the inelastic, irregular, in- 
 fected red cells which cannot pass the visceral capillaries, and there- 
 fore slow the blood current. The melanosis, phagocyte aggregations, 
 and endothelial swelling are of wholly secondary importance. In 
 cases of capillary hemorrhages, only the normal red cells, not the 
 parasite-laden red corpuscles, escape from the vessels. Pegressional 
 organic changes may occur in the cerebrum, gastro-intestinal mucosa, 
 spleen, liver, and kidney. Accessory factors are (a) arteriosclerosis, 
 renal disease, cardiac dilatation, alcoholism, sunstroke, overwork, 
 malnutrition, and lack of acclimatization; (b) the number of para- 
 sites and their abundance in internal organs. iEstivo-autumnal para- 
 sites, with large blocks of central pigment, usually indicate many 
 plasmodia in the viscera. The parasites are often few in the periph- 
 eral blood or in the blood of a splenic puncture, though they may 
 abound in the brain at autopsy (Bastianelli, Marchiafava, and Big- 
 nami) ; (c) great activity in multiplication may be observed even in 
 the peripheral blood where they are usually less abundant during 
 the sporulating stage. Several plasmodia are sometimes found in a 
 single corpuscle ; the spores may number ten, twenty, or even thirty ; 
 (d) increased toxicity of the malarial parasites is purely hypothetical, 
 as their toxin has not yet been isolated, but the necroses in the viscera 
 and the great morphologic alteration in the " brassy" red cells, are 
 suggestive. 
 
 1. The pernicious typhoid form (perniciosa typhosa), is inappro- 
 priately called typhomalaria. Its clinical picture is variable; chills 
 are often absent ; the sensorium is involved to a variable extent, and 
 depression, delirium, insomnia, headache, and backache, occur. The 
 fever is atypical, intermittent, or remittent (subcontinuous), resolves 
 by crisis or by lysis, and is sometimes hyperpyretic or subnormal in 
 register. Quinine generally disturbs or breaks the type. The pulse 
 and respiration are increased. Vomiting of bile or blood, epigastric 
 pain and tenderness, tympany, and thin, dark movements of the 
 bowels may be marked. The spleen and liver are usually tender and 
 
118 
 
 TEE SPECIFIC INFECTIONS. 
 
 swollen. An irregular bronchitis, hsenioglobinuria and albuminuria 
 are frequent. The mortality is 10 per cent., and, in adynamic forms, 
 25 per cent. Fatal cases usually terminate with nervous symptoms, 
 and especially with coma. The differential diagnosis was impossible 
 before the blood-findings were known, but was often made ex juvanti- 
 bus by administration of quinine. Without blood examination ma- 
 laria and typhoid may be confused ; they very rarely co-exist ; benign 
 or malign malaria may resemble typhoid closely, with slow, dicrotic 
 pulse, splenic tumor, headache, fever-curve, cerebral and abdominal 
 symptoms, and even roseolas and intestinal hemorrhage ; on the other 
 hand, erratic typhoid with remittent temperature, chills, and sweats, 
 or typhoid in the latter part of its normal course, may simulate 
 malaria. 
 
 Baccelli gives the following differentiation: 
 
 Malaria (Subccmtiiiua typhosa).- 
 
 -Ttphoid. 
 
 Begins intermittently. 
 E emissions very irregular. 
 
 Temperature may be high at first. 
 
 Headache in beginning is rare, variable 
 in site and intensity, pulsating and 
 neuralgic. 
 
 Eyes dull, subicteric from beginning. 
 
 Stupor, dry tongue, and sordes, less. 
 
 Breath nauseating. 
 
 Delirium from beginning; recurs. 
 
 Lung congestion begins suddenly; foci 
 change recurrently; dyspnoea from de- 
 ranged circulation. 
 
 Nervous restlessness, jactitation. 
 
 Meteorism not characteristic; stools 
 darker. 
 
 Liver congestion frequent; subicterus. 
 
 Herpes is frequent. 
 
 Cycle, none. 
 
 Blood; plasmodia and melanaemia. 
 
 Eecurrence. 
 
 Convalescence more rapid and easier. 
 
 In adynamic; icterus, hemoglobinuria, 
 leukocytosis, great anaemia. 
 
 Progressively remittent. 
 
 Very regular, and in the morning; step- 
 like. 
 
 Considerable fever, reached only on the 
 third or fourth day, or later. 
 
 Early, permanent, frontal, oppressive, 
 characteristic. 
 
 Glistening eyes; no icterus. 
 
 Marked. 
 
 Mouse-like. 
 
 In advanced stage; constant. 
 
 Slow development, hypostatic; dys- 
 pnoea rare (from tympany). 
 
 Stupor, prostration. 
 
 Meteorism and diarrhoea begin gradu- 
 ally; pronounced; ochre stools. 
 
 Less congestion, rarely icterus. 
 
 Eare. Eoseolae. 
 
 Very typical. 
 
 Widal reaction and typhoid bacillaemia. 
 
 Eelapses less frequent. 
 
 Tardy. 
 
 Does not respond to quinine, which 
 specifically reduces malarial symp- 
 toms. 
 
MALAE1A. 1 1 9 
 
 2. Of cerebral forms, the comatose (perniciosa comatosa) is the 
 most frequent. Melancholia, and impaired memory, may exist in 
 the preliminary stage ; later, contracted pupils, , involuntary evacu- 
 ations, lessened reflexes, or paralysis, may develop before coma inter- 
 venes. If the patient recovers, bradylalia, scanning speech, and in- 
 sufficient motility of the lips or tongue, may be observed. The pulse 
 at first is generally slow and regular, but as death approaches it be- 
 comes soft, thready and rapid. Death is usually cardiac. The res- 
 pirations vary, being quiet or noisy, hurried, or of the Cheyne-Stokes' 
 type. If fever is present it is irregular. The author has seen four 
 such cases in Chicago. Apoplexy, uraemia, and sunstroke must be 
 considered. The splenic tumor per se suggests a blood examination. 
 The " meningeal type " occurs especially in children, and in these 
 cases the slow pulse, headache, rigid and tender neck, stupor, con- 
 vulsions, involuntaries, hyperesthesia, and ultimate coma, can be 
 correctly interpreted only after a blood examination. Delirium may 
 be the main symptom, and may appear as a mania, as fixed ideas, 
 hallucinations, or as melancholia. The rare convulsive type may 
 be (a) generalized, and may simulate tetanus, hysteria, uraemia, or 
 epilepsy especially in children, or (b) localized, with such symp- 
 toms as contractures, trismus, or opisthotonos. The paralytic form 
 is the least frequent type. Hemiplegia with aphasia is more com- 
 mon than monoplegia, the bulbar form, etc. 
 
 3. The algid pernicious type occurs with cyanosis, collapse, Hippo- 
 cratic expression, marked alimentary symptoms, and usually, early 
 death. 
 
 4. After the cerebral type the pernicious gastro-intestinal variety 
 is most frequent and occurs with vomiting, pain, epigastric distress, 
 icterus, and dysenteric manifestations. In a soldier from Cuba, the 
 author observed profuse hemorrhages from the bowel. A prompt re- 
 sponse to quinine followed the detection of the aestivo-autumnal Plas- 
 modium. 
 
 6. The pernicious biliary fever ("jungle fever") occurs with 
 vomiting, polycholia, icterus, nervous symptoms, hemorrhages, ady- 
 namia, oedema, and dark albuminous urine. The course is usually 
 ten to twelve days, but even after the administration of quinine this 
 type may be lethal. 
 
 6. The hemorrhagic types resemble WerlhofPs disease, and scurvy. 
 
 1. The febris biliaris hcemoglobinurica (" black-water fever") 
 occurs in South America, in Africa, and in our Southern States. 
 The factors in its production are syphilis, alcoholism, repeated ma- 
 larial attacks, exposure to changes in climate, undue exertion, cold, 
 and in some instances the use of quinine. The etiological role of 
 quinine is questioned, and some other factor is apparently more po- 
 tent. The cardinal symptoms of this type are (a) hemoglobinuria ; 
 the urine is always albuminous, neutral, or alkaline, in reaction; 
 haemoglobin is detected only after the destruction of at least one-sixth 
 of the circulating red blood corpuscles; (b) icterus, invariable ex- 
 
120 THE SPECIFIC INFECTIONS. 
 
 cept in the mildest cases; (c) irregular fever; (d) the detection of 
 the plasmodia ; Stephens in 95 cases found the parasite in 96 per cent, 
 before, and in 62 per cent, at the onset of the attack. The mortality of 
 40 to 50 per cent, is due to syncope, hemorrhages, anuria, and coma. 
 Diagnosis. — 1. From Symptoms. — A probable diagnosis can often 
 be made, as, for instance, from typical intermittent fever which 
 occurs early in the day and is distinct from the vesperal hectic or 
 septic fever. The three elements of the paroxysm are most marked 
 in the benign malaria. In the aestivo-autumnal form the chills may 
 often be absent. Splenic enlargement, and herpes, are always sug- 
 gestive, but they also occur frequently in ephemeral fevers, pneu- 
 monia, meningitis, and influenza, and more rarely in typhoid or tuber- 
 culosis. Much emphasis was once placed on intermittent neuralgia, 
 vertigo, herpes zoster, and alimentary and respiratory catarrh but 
 intermittence is not synonymous with malaria. 
 
 2. The Diagnosis ex Juvantibus. — Laveran excluded malaria, 
 when, for more than four days the fever resisted the daily administra- 
 tion of 20 to 30 grains of quinine. In tropical forms more quinine 
 may be necessary for this purpose. However, other diseases than ma- 
 laria may subside under the administration of quinine. 
 
 3. The Plasmodium. — The plasmodium may be mistaken for 
 vacuoles resulting from mechanical injury to the red cells ; particles 
 of immersion oil; retraction of the haemoglobin of the corpuscle; 
 swarming particles from the red-blood-cells ; blood plates which are 
 sometimes mistaken for spores ; the differentiation from these is easily 
 made in the stained specimen; and for poikilocytosis. Possibly 
 fewer mistakes are made when the inexperienced observer examines 
 the fresh blood. Leukocytes containing pigment are distinguished 
 by their large nucleus and by their amoeboid movement, the latter of 
 which is lacking in plasmodia sufficiently large to cause confusion. 
 
 Positive Findings. — The malarial parasite is found in the blood 
 of malarial patients only. Osier found them in every instance, in 
 531 cases. It is usually stated that they occur in largest numbers 
 before or at the time of the paroxysm though it must be admitted 
 that the first examinations in early fever are often negative. Pre- 
 vious administration of quinine may render the findings ©bscure. 
 Melansemia is practically pathognomonic. Pigment lying free in 
 the plasma is of no importance, for even the greatest care will 
 not eliminate the possibility of contamination. 
 
 Negative Findings. — These are of relative value only, and depend 
 upon the skill of the observer, and the time of the examination. 
 The findings were negative in only 2 per cent, of Baccelli's series. 
 Puncture of the spleen is dangerous. 
 
 Differential Diagnosis. — 1. Prom typhoid fever (see Pernicious 
 Malaria and Typhoid). 
 
 2. In sepsis (see table under typhoid), pyaemia, septicopyemia, 
 ulcerative endocarditis, liver abscess, hectic pulmonary phthisis, and 
 suppuration in the intestinal and urinary tracts, may be confounded 
 
MALAEIA. 121 
 
 with malaria. However, we find in malaria the plasmodium, mel- 
 anaemia, response to quinine, and absence of leukocytosis ; whereas in 
 sepsis, leukocytosis, positive blood cultures and septic localizations 
 are very frequent. 
 
 3. Pneumonia with remittent fever; irregular grippal tempera- 
 ture ; recurrent fever ; miliary tuberculosis ; fever in malignancy, espe- 
 cially in sarcomatosis ; pernicious anaemia; splenic anaemia; leukae- 
 mia ; pseudoleukemia ; Weil's disease ; yellow fever and acute febrile 
 jaundice, may be confused with malaria, if careful and repeated 
 blood examinations are not made. Pernicious malaria (v. s.) may 
 superficially simulate apoplexy, sunstroke, meningitis, cholera, dys- 
 entery, or purpura. Among 1267 malaria patients, 25 per cent, were 
 " masked," simulating tuberculosis, pneumonia, dysentery, appen- 
 dicitis, etc. (Craig). 
 
 Prognosis. — The degree of infection, type of parasite, reinfection, 
 health and habits of the individual, and antecedent renal or cardiac 
 disease, are the most important considerations. The prognosis must 
 be conservative in pernicious and cachectic forms. In Italy the 
 yearly death-rate was 15,000, and the French lost 6,000 soldiers in 
 Madagascar in three months. On the other hand, fully 20 per 
 cent, recover when given rest in bed and a full diet, as is often shown 
 in cases which are treated with placebos and saved for clinical demon- 
 strations. Spontaneous recovery is not yet fully understood. The 
 factors are the phagocytes in the spleen, bone-marrow, and to a less 
 degree, the endothelium of the splenic, hepatic, and cerebral vessels, 
 Kupfer's cells in the liver, and possibly the leukocytes. 
 
 Treatment. — 1. Prophylaxis. — Prophylaxis embraces more than 
 personal prevention. In Italy and other countries it is a national 
 economic problem. Drainage, the filling in of stagnant pools and 
 swamps and the planting of pines, eucalyptus trees and sugar-cane, 
 have proved most successful, though sometimes accomplished at great 
 sacrifice of life. The drainage of the great Bordeaux swamp in 1805 
 cost 3,000 lives. In digging canals or building roads, immunes 
 should be employed, but whites may work successfully if they avoid 
 excessive labor in the hot sun, alcohol, and exposure to the night air. 
 Nocturnal infection by mosquitos may be minimized by using 
 nettings on the doors and windows. The pools where the insects 
 breed should be filled in, or covered with crude petroleum to kill the 
 larvae. The stocking of semistagnant streams with fish is also of 
 value. The prophylactic use of quinine in daily doses of 5 to 10 
 grains is effective. Sick malarial patients and also the considerable 
 number of those with malaria but without symptoms, should be pro- 
 tected from the bites of mosquitos which carry infection to others. 
 
 2. Specific Treatment. — Quinine is one of our few specifics. 
 Cinchona has been used for ages in Peru and was known as the 
 " tree of health " to Pizarro in the conquest of Peru. Introduced 
 over one hundred years later into Europe by del Yego (1640), 
 its alkaloid was discovered by Pelletier and Caventou in 1820. It 
 
122 TEE SPECIFIC INFECTIONS. 
 
 acts on the malarial organism while it is developing (Marchiafava 
 and Bignami) ; when the parasite has transformed all the haemoglo- 
 bin into melanin, and segmentation begins, quinine is ineffectual. 
 All such malarial manifestations as fever, acute splenic tumor, and 
 anaemia, are cured by quinine except in pernicious forms. It acts 
 as a direct protozoan poison. Binz thought it entered into such close 
 union with the haemoglobin that the parasite was suffocated. Just 
 as syphilitics tolerate much mercury and iodide, so malarial sub- 
 jects escape many or all of the symptoms of cinchonism, such as 
 tinnitus aurium, cephalic distention, and slight deafness resulting 
 from therapeutic doses (gr. x). (Deafness, disordered vision, flushed 
 face, and cerebral congestion, vomiting, staggering, tremor, and 
 twitchings, result from larger doses, and stupor, delirium, cardiac 
 oppression, complete deafness and amaurosis, dilated pupils, con- 
 vulsions, paralysis, hemoglobinuria, dyspnoea, coma, weak heart, or 
 hemorrhages result from toxic doses.) 
 
 Administration. — If idiosyncrasy exists, cinchonism is lessened 
 by fluidext. ergotse 3ss, or, better, by sodium bromide oss. Its anti- 
 periodic action is enhanced by combining it with opium gr. ss. Lax- 
 atives are unnecessary. Pills are often insoluble, and the drug is there- 
 fore given in powders involved in starch wafers, or with one drop of 
 sulphuric acid to each grain of the sulphate. Chloroform, coffee, 
 cognac, and extract of glycyrrhiza but poorly disguise its bitterness. 
 If the stomach rebels, a warm-water enema with equal parts of qui- 
 nine and tinct. opii deodorat. may be used. In severe cases the 
 hydrochloride (gr. vii) in 15 minims of water should be used hypo- 
 dermatically, but, though every care be taken, abscesses develop too 
 often. In pernicious types, Baccelli injects quinine intravenously 
 (sterilized solution of sodium chloride, quinine muriate, and water, 
 in the proportion of 1, 10, and 100, parts respectively). 
 
 Time of Exhibition. — If the fever recurs regularly, gr. xx. to xxx. 
 should be given as the fever falls, to act on the growing young forms 
 in the red cells, to be repeated before the next paroxysm, in order 
 to have the drug in the circulation when the spores are scattered 
 (Torti and Golgi). If the fever is continuous or sub-continuous, or 
 if the type is severe, gr. v. should be given every four hours. Large 
 doses are recommended because they are more effectual, and small 
 doses are quite useless and sometimes only serve to aggravate existing 
 malaria and develop quiescent forms (Steudel-Kuchel). In the treat- 
 ment of black-water fever, one view maintains that it is caused by the 
 parasite, and another that quinine is its cause. Quinine, however, 
 should be given only when plasmodia are found, and should be with- 
 held after they disappear. 
 
 3. Symptomatic Treatment of the Paeoxysm. — During the 
 vaso-constriction of the chill, morphia gr. \ and nitroglycerine gr. 3^, 
 hypodermatically, and spirits of chloroform oj., in hot whiskey and 
 water afford great relief. The fever is short-lived and requires little 
 interference other than the ice-cap, and cool sponging. The sweat- 
 
SEPTIC INFECTIONS. 123 
 
 ing requires no treatment. A weak heart should be supported by mor- 
 phine, and strychnine hypodermatically, and saline enemata. 
 
 In chronic malaria, iron and full increasing doses of arsenic should 
 be combined with quinine. Arsenic is said by Durham to act on 
 the gametocytes. Celli finds iron and arsenic useless. 
 
 SEPTIC INFECTIONS. 
 
 Synonyms. — Sapremia, septicemia (sepsis) , pyaemia, septicopyemia. 
 
 Definition. — Intoxications are the result of the absorption of sub- 
 stances elaborated for the most part by microorganisms, but possibly 
 also by living cells. Infections are always due to microorganisms. 
 Saprcemia is the absorption of putrescent substances but not of the 
 germs which develop them. Septicemia (sepsis) is the presence in 
 the blood of microorganisms (bacteriemia), — which are usually pyo- 
 genic, — without hematogenous suppuration or metastasis. Pyaemia 
 is infection, caused by microorganisms, which leads to hematogenous 
 suppuration or metastasis. Septicopyemia is co-existent septicemia 
 (bacteriemia) and pyemia (metastatic suppuration). 
 
 General Groups. — 1. Some infections — such as carbuncles, puerperal 
 parametritis, diphtheria, and tetanus — are wholly local so far as the 
 causal microbe is concerned, and their symptoms are due to absorbed 
 toxins (toxinemia, toxemia). 
 
 2. Other infections — such as typhoid, pneumonia, carbuncles, puer- 
 peral sepsis, anthrax, and gonorrhea which cause hactericemia or 
 septicaemia — at first local, may become general when their germs 
 enter the blood. Some of these infections, especially typhoid and 
 pneumonia, which were previously considered local, are always 
 general. 
 
 3. Still other infections, often resulting from the same germs, cause 
 metastatic suppuration (pycemia). Among these are multiple ab- 
 scesses from carbuncle, puerperal fever, typhoid osteomyelitis, pneu- 
 mococcic arthritis, and gonorrheal endocarditis. It is frequently 
 difficult or impossible to preserve clinically these types which 
 so often blend; what is seemingly toxemia may prove bacteriemia 
 on examination of the blood; apparently pure bacteriemia may 
 prove pyemia at necropsy; all three grades may occur successively; 
 the primary infection — -e. g., with scarlatina, tuberculosis, and 
 diphtheria — whether local or general, may be complicated by sec- 
 ondary, or mixed infection, especially by the streptococcus; again 
 the symptoms vary, first with the variety of microbe and its viru- 
 lence; second, with its localization (in the throat, lung, pelvis, 
 etc.) ; and third, with the physiological resistance. Subjects of 
 malignancy, cardiac, vascular, nephritic, cirrhotic, and other disease, 
 readily succumb to an ultimate sepsis to which the name of terminal 
 infection is applied. For these reasons we will discuss septic in- 
 fections as a whole, and indicate such special etiological and clinical 
 variations as seem necessary. 
 
124 THE SPECIFIC INFECTIONS. 
 
 Etiology of Septicopyemia. — The causal organisms of septic infec- 
 tions are numerous. The most common are the pyogenic cocci, the 
 pneumococcus and the colon bacillus; less frequent are the gono- 
 coccus, anthrax bacillus, typhoid or diphtheria bacillus, Friedlander's 
 pneumobacillus, meningococcus, bacillus pyocyaneus, influenza bacil- 
 lus, Frankel' s bacillus phlegmones emphysematosa, bacillus aerogenes 
 encapsulatus, and possibly the micrococcus tetragenus, the spirilli 
 and bacilli of Vincent, and the proteus group. Although puerperal 
 fever, primary wound fever and severe late pysemic infection were 
 known to Hippocrates, and also to Willis (1682), Semmelweiss 
 (1847), and others, it was reserved for the bacteriological era, build- 
 ing on Virchow's work, to clarify this group of affections. Though 
 Wunderlich (1847) spoke of spontaneous pyaemia, and Leube (1878) 
 of cryptogenetic (occult) septicopyemia, careful clinical and necropsy 
 investigations reveal the atrium of infection in 94 per cent, of cases ; 
 (1) shin lesions, such as furuncles, felons, and bites (staphylococcus 
 more frequent than streptococcus) ; (2) throat (streptococcus) ; (3) 
 nose (not frequent in sepsis, though in meningitis the atrium for the 
 meningococcus and pneumococcus) ; (4) . ear (pneumococcus and 
 streptococcus) ; (5) lungs (pneumococcus) ; (6) intestines and bile 
 tracts (colon bacillus ; typhoid bacillus, gall-stone infection, appen- 
 dicitis, dysenteric ulcers) ; (7) urinary tract (pyelitis from colon 
 bacillus ; vesical and urethral infections chiefly by the staphylococcus, 
 far less by the streptococcus and gonococcus) ; and (8) vagina and 
 uterus (chiefly streptococcus). 
 
 General Pathology and Symptomatology. — (A) General Toxemic 
 Symptoms. — 1. Fever. — Fever is usually the first clinical symptom 
 and most often occurs abruptly. The virulence of the germ and its 
 toxin (rather than its variety) governs the intensity of the toxcemic 
 symptoms. . In general the fever tends to be remittent or intermit- 
 tent. Lenhartz, in his work on septic infections, concludes that (a) 
 the streptococcus infections usually produce irregular intermittent 
 fever with moderate variations (sometimes remittent or in severe 
 cases, continuous fever) ; (b) the staphylococcus usually causes weakly 
 remittent or continuous fever; (c) the pneumococcus produces re- 
 mittent or continuous fever; (d) the colon bacillus and gonococcus 
 cause intermittent fever with great variations. Fever may be absent 
 in very severe forms, especially before death. 
 
 2. Chills. — Chills occur both in septicemic and in pysemic forms, 
 are usually irregular, but may occur daily or two or more times a 
 day. 
 
 3. Nervous Toxcemia. — Pronounced toxaemia may appear as un- 
 rest, delirium, stupor, dry tongue, and the status typhosus, or it may 
 resemble meningitis. The sensorium may be clear. 
 
 4. Vasomotor and cardiac weakness may be present, with increased, 
 often irregular, or hopping pulse. 5. Increased respiration and bron- 
 chitis may be noted. 6. Albuminuria and acute nephritis are com- 
 mon. 7. Septic diarrhoea, in which the dark movements number six 
 
SEPTIC INFECTIONS. 125 
 
 to ten daily, may be observed. 8. Acute splenic tumor is present. 
 
 9. Anatomically we find cloudy swelling of the heart, liver, and 
 kidneys ; a vascular, soft, moderately swollen spleen ; acute nephritis ; 
 hemorrhages into the skin, retina, and mucous and serous membranes, 
 with or without bacteria; lung oedema, and, where there is marked 
 anaemia, fatty heart, hemorrhage into the bone-marrow, and increased 
 iron deposit in the liver. 
 
 (B) Blood-Findings. — 1. Bactericemia is found in 50 per cent. 
 of the cases clinically, and in 95 per cent, at autopsy (Lenhartz). 
 Some circulating bacteria are apparently killed by the blood. In 
 most streptococcic and staphylococcic infections, these organisms are 
 found in the blood. 
 
 2. Polymorphonuclear leukocytosis is frequent, though not invari- 
 able. 
 
 3. Anaemia. — Marked anaemia is usual, and sometimes even re- 
 sembles the pernicious form. 
 
 (0) Metastases. — They are apparent clinically, or first found 
 at necropsy. Metastases occur through the veins or lymph-vessels. 
 Thrombo-phlebitis develops at the seat of primary infection, and dis- 
 integrated thrombi, containing bacteria, escape into the venous cir- 
 culation. They lodge in the lungs or, passing them, reach the left 
 heart and arterial system. Purulent lymphangitis may, in the same 
 way cause metastatic suppuration. If " end arteries " are plugged, 
 infarcts result; if the arteries are not terminal, small foci develop. 
 Not all infarcts suppurate. This difference is explained by the fact 
 that the germs found in them are less virulent, or that the embolic 
 material is bland or free of microbes. Suppurative foci occur in or- 
 gans in which there are end arteries and in which the circulation 
 is slow, especially, therefore, in the liver, kidney, and spleen. (1) 
 Cerebral metastasis may cause meningitis, brain abscess, or extensive 
 softening (encephalomalacia with aphasia and hemiplegia). (2) 
 Cardiac metastasis develops in 21 (even 63) per cent, of the meta- 
 static group; endocarditis is localized chiefly on the mitral (62 per 
 cent.) and aortic (22 per cent.) valves; it is attended by a heart mur- 
 mur in only 60 per cent., and often by pericarditis ; the heart muscle 
 is sometimes the seat of abscesses. (3) Lung localization may cause 
 multiple or single abscesses, and often sero-fibrinous or purulent 
 pleurisy. (4) Renal localization may result in nephritis or suppurat- 
 ing infarcts, with albuminuria, cylindruria, pyuria and bacteriuria. 
 (5) Splenic localization usually results in enlargement, frequently 
 in pain, and rarely in perisplenic friction. (6) Localization in the 
 bones, may cause early fugitive bone pain, or later, fixed osteomye- 
 litic tenderness over one or more bones, with inflammatory signs ; in 
 the joints (as in the post-febrile arthritides), it may cause simple 
 pain, or serous or purulent synovitis ; in the muscles it may produce 
 abscesses, purulent oedema, or Wagner's polymyositis. (7) Localiza- 
 tion in the shin. Ecchymoses occur in 50 per cent, of fatal cases; 
 they are usually late, often symmetrical, and sometimes occur on the 
 
126 THE SPECIFIC INFECTIONS. 
 
 nose, finger s, toes, or ears. Pustules and vesicles are less frequent; 
 herpes occasionally develops. Scarlatiniform, morbilliform, roseo- 
 lous or urticarial eruptions, are only toxemic rashes. (8) Localiza- 
 tion in the eyes produces retinal ecchymoses in 33 per cent, which 
 were first described by Litten. They are round, irregular, or develop 
 in streaks, with small white centers and appear late or before death; 
 the white spots of Roth (8 per cent.) were once considered inflamma- 
 tory, and are still unexplained. Least frequently eye localization 
 results in panophthalmitis, of which 33 per cent, is due to ulcerative 
 endocarditis. (9) The peritoneum is chiefly involved in puerperal 
 forms. (10) The slightly enlarged liver is more often due to toxic 
 parenchymatous degeneration and cardiac weakness than to abscess, 
 which occurs in only 1,5 per cent, of cases of surgical septicopyemia 
 (Barensprung). Intestinal infarction is rare. 
 
 Special Symptomatology. — This may be considered etiologically or 
 topographically. Only the leading characteristics are presented. 
 
 (A) Etiological. — 1. Streptococcic infection is the most frequent 
 primary and secondary septic infection. It constitutes 66 per cent, 
 of all forms (Man), the coccus entering the blood before death in 33 
 per cent, of all fatal diseases. Its atrium is most often the throat 
 and (in the female) the genitalia ; it enters the veins in puerperal 
 pyemia more often than the lymphatics (erysipelas and puerperal 
 sepsis) ; it more often produces septicaemia (65 per cent.) than pyae- 
 mia (35 per cent.) ; the lungs are usually unaffected; endocarditis 
 occurs in 7 per cent. ; its course is chiefly acute, though sometimes 
 subacute (ulcerative endocarditis). 
 
 2. Staphylococcic infection usually enters by the skin and the 
 furuncle is the typical primary local lesion. On the eye-lids, nose, 
 or lips, this lesion is dangerous because infection may reach the facial 
 vein, then the ophthalmic vein and the cavernous sinus. Furuncle 
 of the neck may reach the transverse sinus. Infections of the skin 
 are the most frequent cause of osteomyelitis. Meningitis is known 
 to have followed a felon. The infection enters through the throat, 
 with difficulty but then with increased malignancy (Kocher and 
 Tavel). It travels by the veins or lymphatics ; it produces metastasis 
 in 95 per cent, and endocarditis in 6 per cent, of cases. Abscesses 
 of the lung and kidneys are very frequent ; the coccus is found very 
 often in the blood and urine. Pustular skin eruptions are fre- 
 quent. Staphylococcic infection is 'usually acute. 
 
 3. Pneumococcic Infections. — In all cases of pneumonia (q. v.) 
 the pneumococcus appears in the blood (pneumohaemia). In actual 
 sepsis following pneumonia, it enters the blood through the pulmonary 
 veins. Infection through the ear or bile-tracts is less frequent ; metas- 
 tases occur in 25 per cent, and endocarditis in 6 per cent. Twenty- 
 nine cases of pneumococcic meningitis were first reported by ISTau- 
 werk (1881), but it is yet unknown why lung infections so frequently 
 cause brain metastases. The pneumococcus alone may produce pus 
 in the joints, skin, thyroid, and serous membranes, better's state- 
 
SEPTIC INFECTIONS. 127 
 
 ment that pneumococcic sepsis is less severe than other types may 
 be true in some cases, but it is often malignant. It may be associated 
 with the pyogenic cocci. 
 
 4. Colon sepsis, which is less frequent, may follow wounds, suppur- 
 ation in cholelithiasis, cystitis, pyelitis, or intestinal obstruction. 
 Endocarditis is exceptional, and sepsis (78 per cent.) is more com- 
 mon than metastasis (22 per cent.). 
 
 5. Gonococcic infection is rather more benign than the other types. 
 There may be gonorrhoea! endocarditis (Bordoni, UfTreduzzi), peri- 
 carditis, and pleuritis, or the more common gonorrheal arthritis. 
 
 Thayer found the gonococcus in the blood (v. Gonorrheal Infection). 
 
 Other forms are less frequent. These are typhoid suppuration 
 in the pleura, thyroid, bones, meninges, muscles, ear, and parotids, 
 sepsis from Friedlander's pneumobacillus, the meningococcus, etc. 
 Pyocyaneus sepsis is attended by irregular or continuous fever, rapid 
 pulse, vomiting, diarrhoea, and an hemorrhagic diathesis. 
 
 (J3) Topographical. — (1) Ulcerative endocarditis; (2) cliolan- 
 gitic sepsis; and (3) otogenous sepsis (v. Sinus Thrombosis, Menin- 
 gitis, Brain Abscess) will be considered elsewhere. The two follow- 
 ing surgical or obstetrical localizations are of importance to the 
 general practitioner and internalist. 
 
 (4) Osteomyelitis is either a solitary metastasis or part of a gen- 
 eralized sepsis. Even when a single bone is involved, the blood often 
 contains the causal microorganism. It is due to the staphylococcus 
 chiefly ; then to mixed infection with the streptococcus, which is found 
 in all fatal cases, or with the pneumococcus ; and but rarely to the 
 typhoid organism. Frankel has recently found that in most autop- 
 sies on typhoid and pneumonia cases, their causal bacteria are present 
 in the bone marrow. Acute forms of osteomyelitis are most frequent 
 in the growing bones of children. Trauma is a promoting element 
 and the onset occurs with chill, fever, vomiting, diarrhoea, headache, 
 and hone pain. It is usually first seen (and often mistaken) by the 
 general practitioner. Chronic forms are quite infrequent, but 
 Kocher, Jordan, and others, have described cases, which, lasting one 
 year or more (even thirty), may simulate sarcoma, or syphilis. 
 
 5. Puerperal fever is caused by the streptococcus (95 per cent.) 
 or rarely by other organisms. It is still disputed whether streptococci 
 normally reside in the healthy vagina. Its varieties are (a) toxcemia 
 or saprcemia. The symptoms are caused by toxins or putrid decom- 
 position products respectively. Even in cases apparently of this 
 group, bacterisemia may be found (colon bacillus, saprophytes, or 
 streptococcus). The rare puerperal tetanus is wholly toxsemic. (b) 
 Lymphangitic form — Lymphangitis, from infected vaginal or cervi- 
 cal wounds, may cause, (i) moderate, benign, localized parametritis. 
 (ii) General septicaemia, from vaginal or cervical wounds, which fol- 
 lows the lymph-vessels through the pelvic cellular tissue to the general 
 circulation. The symptoms usually appear within a day or so after 
 delivery. Death may result in two to fourteen days, or encapsulation 
 
128 TEE SPECIFIC INFECTIONS. 
 
 and massive cellulitis may develop, (iii) Lymphangitic peritonitis 
 is more frequent (20 per cent, of fatal cases). It begins three or four 
 days after delivery and is usually generalized and suppurative. 
 Infection may travel directly to the peritoneum or, more often, by re- 
 trograde lymphatic routes. This form includes Virchow's " erysipe- 
 las grave internum puerperale." It is more common in labor at 
 term than in abortion. The symptoms are chill, fever, tense pulse, 
 vomiting, abdominal pain and distention, and often effusion, and diar- 
 rhoea. In many apparently purely peritonitic cases baoterisemia is 
 found. Early death is the rule, commonly in five to six days, but 
 encapsulation is possible, (c) The thrombophlebitic (pysemic) type 
 occurs in 50 per cent, of fatal cases. It usually begins in endomet- 
 ritic ulceration, diphtheria, or ichorous inflammation, in contradis- 
 tinction to the lymphangitic form of vagino-cervical origin. Infective 
 thrombophlebitis travels (i) from the upper veins by way of the sper- 
 matic veins, of which the right empties into the inferior cava and 
 the left into the renal vein; the phlebitis may actually extend into 
 the vena cava; (ii) from the lower plexus, by way of the uterine 
 veins into the hypogastric veins, and thence to the inferior cava. Bilat- 
 eral venous thrombosis is common (25 to 66 per cent.). Metastases 
 are common, — 58 per cent, in the lungs, 25 per cent, in the kidneys, 
 20 per cent, in the joints and muscles, and 16 per cent, in the spleen. 
 Ulcerative endocarditis, meningitis, and peritonitis, may be present. 
 The course may be stormy from predominating toxaemia, or slower 
 with metastases. The fever is irregular, the pulse rapid, the chills 
 severe, the anaemia marked, and streptococcaemia is present in over 90 
 per cent. 
 
 Diagnosis. — The direct diagnosis rests upon the etiology, the symp- 
 toms of toxaemia and metastatic suppuration and the blood cultures. 
 The differentiation from typhoid, malaria, and miliary tuberculosis, 
 is fully considered in the table under typhoid fever. Solitary local 
 or visceral symptoms, as osteomyelitis, arthritis, endocarditis, etc., 
 may cause confusion if not viewed in their broad relations to a 
 possible sepsis. 
 
 Prognosis. — The prognosis depends upon the organism, its viru- 
 lence and dissemination, the patient's physiological resistance (whence 
 the obviously poor outlook in terminal infections), and finally on the 
 surgical accessibility of the primary lesion or metastatic foci. Only 
 17 per cent, of Lenhartz's cases with bacteremia recovered. A 
 stormy onset and chills are ominous. A case of Lenhartz with empy- 
 ema, lung abscess, panophthalmitis, diffuse venous thrombosis, and 
 multiple osteomyelitis, recovered. Puerperal infections, with the 
 large wound-surface and frequent hemorrhages, are severe, the mor- 
 tality of all forms being 55 per cent., and of severe forms 65 per 
 cent. (Curschmann). The streptococcus has been regarded with 
 particular dread; however, Bertelsmann (1904) states that the prog- 
 nosis is twice as favorable as in staphylococcic invasion. 
 
 Treatment. — Surgical prophylaxis, even in apparently insignificant 
 
PNEUMONIA. 129 
 
 wounds, and obstetrical asepsis, is important, especially in subjects 
 reduced by general diseases. Treatment of existing sepsis consists 
 in giving the largest possible amount of food which can be digested ; 
 in free administration of salt solution by rectum or transfusion, in 
 order to flush the toxins through the kidneys; and in the free use 
 of alcohol, given as in typhoid or pneumonia, but in its maximum 
 dosage because patients exhibit an exceptional tolerance to the 
 drug; unquestionable benefit results. The treatment of hypostasis, 
 diarrhoea, vomiting, and chills, is symptomatic. The temperature is 
 seldom influenced by drugs, though quinine (see Pneumonia) is 
 most safely given. The internal use of germicides is justly abandoned. 
 We have not observed, the slightest benefit from Crede's silver oint- 
 ment ; Crede's collargol has been used with benefit, intravenously, in 
 doses of one to two and a half drams. Nuclein and 3j to 3ij of 
 fresh brewers' yeast are also advised. The use of Marmoreck's anti- 
 streptococcic serum has given no essential reduction in the death- 
 rate, and its suggestive effects in isolated cases is easily misleading. 
 Lenhartz has used a serum from the blood of convalescents from sepsis 
 with some success. Surgical intervention is indicated whenever 
 definite accessible foci are localized. 
 
 PNEUMONIA. 
 
 Synonyms. — Fibrinous pneumonia, croupous pneumonia, lobar 
 pneumonia, pleuropneumonia, pneumonitis, lung fever. 
 
 Definition. — An acute specific infection caused by the pneumococcus, 
 self-limited in its course, characterized by lobar fibrinous inflamma- 
 tion of the lung, toxaemia, pneumococci in the blood, and solution of 
 the fever by crisis. It is not uncommonly complicated by secondary 
 infective processes. 
 
 Frequency. — Pneumonia constitutes 6.5 per cent, of all internal 
 diseases, 4 per cent, of all diseases, 6.6 per cent, of all medical deaths 
 (Liebermeister), and 8 per cent, of all deaths (E. F. Wells). 
 
 Bacteriology. — 1. The pneumococcus or Diplococcus pneumoniae 
 (Plate IV.), was recognized by Frankel (1884) and Weichselbaum 
 (1886), who first demonstrated its frequency and importance; the 
 diplococcus bears their name. It is an elliptical, lanceolate, encap- 
 sulated diplococcus ; it is easily seen in cover slips, it readily stains by 
 the Gram method, and presents many cultural variations. Its atrium 
 in pneumonia is by way of the respiratory tract, although in sepsis 
 (q. v.) it may enter the blood by other avenues. From the lung it 
 may spread diffusely, chiefly through the bloodvessels or possibly by 
 way of the lymphatics. It is found in dust, in saliva, and in 30 per 
 cent, of healthy noses and throats, though usually with attenuated 
 virulence. Again, the organism is virulent, and experimental inocu- 
 lation has produced pericarditis, endocarditis, and empyema. It 
 has been found in the blood, joints, brain, bone-marrow, etc., in otitis 
 media, endocarditis, peritonitis, cholangitis, and endometritis ; in the 
 d 
 
130 TEE SPECIFIC INFECTIONS. 
 
 urine and fasces ; and it may pass from the mother to the foetus. It 
 may be a terminal septic infection. Until recently it was thought 
 that typhoid and pneumonia were local infections with general symp- 
 toms, and that the presence of the microbes in the blood was a 
 serious and true complication. The typhoid bacillus is found in 
 the blood in 95 per cent, of typhoid cases, and Rosenow, of Chicago, 
 has found the pneumococcus in the blood in about 93 per cent, of 
 pneumonia patients (v. i.). Prochaska found the organism in all of 
 fifty cases. It is assumed that a pneumotoxin exists and produces 
 the toxsemic symptoms; when an antitoxin develops, the crisis oc- 
 curs. Immunity does not result from one attack; as in erysipelas, 
 recurrence is likely in 13 to 33 per cent. ; ten, or even twenty-eight 
 recurrences are known. The pneumococcus is probably the sole cause 
 of typical pneumonia, but other microorganisms are sometimes found : 
 
 2. The pneumobacillus (Friedlander, 1883) is l/i long, one-third 
 as wide as long, with a capsule ; it sometimes is found in the healthy 
 nose, is larger than the pneumococcus, and does not stain by Gram's 
 method. It has distinct biological and cultural characters, but its 
 relation to pneumonia is probably that of a mixed infection only. 
 
 3. Other bacteria, such as the typhoid, colon, diphtheria, proteus, 
 influenza, plague, and pyogenic organisms, have been found. 
 
 Indirect Causes. — (a) Age. — Pneumonia may be seen even in the 
 new born. Predisposition to infection is great up to the sixth year, 
 and then much less until the fifteenth year. After the fifteenth year 
 its frequency increases after each decade. Over half the cases of 
 pneumonia occur between the twentieth and fortieth years, and over 
 80 per cent, between the tenth and fiftieth years, (b) Sex. — Eighty 
 per cent, of cases are males. The relation to trauma is in doubt, 
 though contusions seem an occasional accessory factor. (c) Cold. 
 — Cold and wet are predisposing factors. Pneumonia prevails es- 
 pecially in February, March, and April, when the weather varies, 
 the temperature is low, the moisture is great, and the winds are high. 
 Three-quarters of all cases of pneumonia occur in cold months. It is 
 probable that dust disseminates the dried sputum. Pneumonia is 
 half again as frequent in the cities as in the country. In the win- 
 ter of 1903—4, when 4,000 persons died of pneumonia in Chicago, 
 the author knew of practitioners in many towns not one hundred miles 
 distant, who did not see a single case, (d) Individual predisposi- 
 tion is said to be a more important factor than in any other acute 
 injection. Susceptibility to pneumonia is increased by debility, over- 
 work, and alcoholism, though the disease also attacks the most robust 
 individuals. 
 
 General Clinical Course. — After a very short incubation of a few 
 hours to a day, the disease begins suddenly. In infants it often be- 
 gins with convulsions — in the young with vomiting, and in older sub- 
 jects with a severe chill, which often occurs in apparently perfect 
 health. On the first day there is a sudden rise of temperature; the 
 face becomes red, even livid; the eyes are injected; the pulse and res- 
 
PLATE IV 
 
 L. SCHMIDT. FEC 
 
 The Diploeoeeus Pneumoniae, Stained with Methylene Blue 
 and Fuehsin as a Ccunterstain. Taken from the Sputum of a 
 Case of Acute Croupous Pneumonia. (Simon.) 
 
PNEUMONIA. 131 
 
 piration are accelerated; the patient lies characteristically flat in 
 bed ; there is much depression ; thirst, headache, and a sudden, sharp 
 pain in the side develop, accompanied by cough and increased res- 
 piration. On the second day, the cough, pain, respiration-rate and 
 headache increase, with dilatation of the alee nasi ; the expiration is 
 short and grunting, and speaking is difficult; leukocytosis develops. 
 The sputum appears, or> if already present, becomes bloody; this, 
 with the sudden fever, chill, pain, and increased breathing, practically 
 establishes the diagnosis before signs of consolidation appear. On the 
 second or third day there are evidences of lung consolidation, such 
 as tympany which is soon followed by dulness, the crepitant rale, 
 and bronchial breathing ; high temperature develops with slight morn- 
 ing remissions ; the skin becomes dry and red ; there is increased 
 pulse and respiration; herpes, anorexia, coated tongue, constipation, 
 moderate delirium, febrile urine, and coughing attacks develop. 
 The coughing is frequent but short in duration, voids a viscid, red 
 sputum, and causes catching respiration, pain and broken sleep. 
 The prognosis cannot be made from the symptoms up to this time, 
 since the clinical course may be unfavorably modified (a) especially 
 by collapse due to myocardial or vasomotor paralysis, or to embolism 
 of the lung from right-heart dilatation; (&) by profound toxaemia; 
 (c) by delirium tremens; or (d) by death, though at this stage it is 
 rare. In favorable cases, when the toxaemia is spent, the crisis oc- 
 curs, usually on the uneven days (the fifth, seventh, or ninth) with 
 gradually decreasing dulness and disappearance of other local find- 
 ings. A " critical " fall of temperature, pulse, and respiration-rate, 
 and relief of nervous symptoms, and sweating, result. Lysis is less 
 frequent. As a general statement, the toxaemia is the dominant 
 feature of pneumonia, and the consolidation is decidedly secondary. 
 Furthermore, the degree of toxaemia has no necessary or constant 
 relation to the amount of consolidation, just as the toxaemia of ty- 
 phoid does not depend on the presence or degree of the intestinal 
 changes. 
 
 Analysis of Individual Symptoms. — 1. Onset. — In over 75 per cent. 
 the onset of pneumonia is sudden. Chill, convulsions, vomiting, and 
 fever, after a short incubation, usually mark the brusque onset. Re- 
 peated chilly sensations, occurring when the heart is weak, do not 
 as accurately designate the onset as does an initial rigor. A chill 
 is present in 75 per cent, of the cases, and in no other acute disease 
 except malaria is the chill so severe and constant ; it lasts from a quar- 
 ter to half an hour. The onset is atypical in senile pneumonia, and 
 in pneumonia secondary to other diseases — e. g., delirium tremens, 
 typhoid, variola, and psychoses — the chill, cough, dyspnoea, pain, 
 and sputum are often absent, so that the existence of pneumonia may 
 not be suspected. Prodromes occur in 25 per cent, of cases (Gri- 
 solle), mostly in men between thirty and forty years, and rarely last 
 more than five days ; anorexia, depression, headache, bronchitis, back- 
 ache, and low fever may be noticed. In one of the author's cases a 
 
132 
 
 TEE SPECIFIC INFECTIONS. 
 
 pneumococcus infection began in the throat, then invaded the larynx, 
 and only after three weeks invaded the lung. In four cases, low 
 fever and haemoptysis for several days suggested tuberculosis. 
 
 ^ 2. Fever. — The usual course of the fever is, first, a very sudden 
 rise, especially in menstruating women ; the fever is then continuous, 
 
 often with not more than 1° or 2° 
 variation; in three-quarters of the 
 cases the maximum fever is between 
 102° and 105°. It may then re- 
 mit, which is of good prognostic im- 
 port ; remittent fever throughout 
 the disease occurs in some cases. 
 Recrudescences occur when consoli- 
 dation passes from one lobe to an- 
 other. The fever is lower or even 
 absent in the aged, in alcoholics, 
 and in cases of secondary pneu- 
 monia. Fever produces a marked 
 loss of weight (twenty to thirty 
 pounds). The rise preceding the 
 crisis (perturbatio critica) may be 
 mistaken for an ante-mortem rise. 
 In both conditions there may be 
 delirium, convulsions, chill, or an 
 alarmingly irregular pulse. A 
 pseudocrisis may deceive the phy- 
 sician, the fever resuming its 
 original elevation. Crisis occurs in 
 80 per cent, of cases, usually on un- 
 even days, as noted by Hippocrates, 
 — the fifth, seventh, ninth, or eleventh days, — and usually between 
 evening and early morning. It very rarely occurs on or before the 
 third day. It marks the end of the toxaemia but not of the consolida- 
 tion which requires several days more. In six to ten hours the 
 temperature falls to or below normal, accompanied by sleep, euphoria, 
 lessened pulse and respiration, lateritious deposits and reappearance 
 of the chlorides in the more abundant, limpid urine, and " critical " 
 sweating or even diarrhoea. The fall may measure even 10° or 11° 
 (and the pulse may reach 30). Lysis occurs in 20 per cent, of cases. 
 It is likely to occur when the fever lasts more than ten days, but lin- 
 gering fever may indicate progression in other lobes and such compli- 
 cations as empyema or endocarditis. Lysis may be gradual and 
 continuous or slow and remittent. 
 
 3. Respiratory FiiromGs. — (1). Pain. — Pain in the side is gen- 
 erally pleural and its presence in 90 per cent, of cases makes it of 
 diagnostic value, since it is the most frequent respiratory symptom. 
 It appears early, is increased by coughing or motion, and is sharp 
 and sometimes agonizing. It is usually well localized over the con- 
 
 
 
 Fig. 
 
 13. 
 
 
 
 
 Day 
 
 1 
 
 2 
 
 3 
 
 4 
 
 5 
 
 
 
 7 
 
 TEMP. 
 . 105 
 
 
 
 
 
 
 
 
 104 
 
 
 U 
 
 
 ,/ 
 
 i/ 
 
 \A 
 
 103 
 
 
 v 
 
 
 
 V 
 
 V 
 
 
 102 
 
 
 V 
 
 
 
 
 
 
 101 
 
 
 
 
 
 
 
 
 100 
 
 
 
 
 Je 
 
 
 
 
 99 
 
 \ 
 
 
 
 
 
 
 C 
 
 
 1 
 
 
 
 
 
 
 98 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Fever-curve of typical case of pneumonia : 
 A, sudden rise ; B, pseudo- 
 crisis ; C, crisis. 
 
PNEUMONIA. 
 
 133 
 
 Pneumonia; remittent (subcontinuous) fever. 
 
 soliclated focus, but in 8 per cent, is referred along the lower intercos- 
 tal nerves to the abdomen, in children especially, and sometimes in 
 adults. Appendicitis or cholecystitis may be thus simulated. Some- 
 times the pain is located on the opposite side of the chest. Pain is 
 absent in central, secondary, and upper-lobe pneumonias ; in the aged, 
 and often in children; and in cases with great delirium. 
 
 (2). Dyspnoea. — Dyspnoea is frequent; it is caused by pain and 
 especially toxcemia, but also by cardiac weakness, diminished respira- 
 tory area, bronchitis, and complicating pulmonary oedema. 
 
 Fig. 15. 
 
 March 
 Days 28 1 2 3 
 
 105 
 
 4 15 C 7 8 9 llO Il|l2ll3 14 15 16|17 18ll9 2 
 
 OI21I22 23 24 25|26 27 
 
 28 29 30 
 
 103 
 
 102 
 
 
 rrh 
 
 1 
 
 1 
 
 
 100 I i\ 
 
 99 yvTV/ \f\ 
 
 -^T^fWryylw 
 
 m 
 
 f^jj^^ 
 
 ^n^- 
 
 97 / 
 
 hh — i i i ; ; i i i h - j 
 
 1 1 i i i i i 
 
 =Li — ^ 
 
 Pneumonia fever curve ; exceptionally protracted though uncomplicated fever. 
 
 (3). The Respiration-rate. — The respiration-rate is practically 
 always increased to 24 or 40 (or more in children) ; and in two-thirds 
 of all cases, it ranges between 30 and 50 ; it almost never rises to 60 
 or 80 except in the death agony, but such frequency is common in 
 miliary tuberculosis. The author once saw a rate of 96 with re- 
 covery; the pulse was 90. Dilatation of the nares is said to be omin- 
 ous, but to the author seems common in ordinary cases. Alteration 
 of the pulse and respiration ratio was first noted by von Jiirgensen ; 
 the normal ratio of 1 to 4 becomes 1 to 3 or 2. In one personal 
 instance with the entire right lung consolidated, respiration was 18. 
 
 (4). The Cough. — The cough always irritates, is sometimes dan- 
 
134 mn specific infections. 
 
 gerous, and seldom relieves the patient. It is usually present from 
 the beginning of the disease to the crisis, is due to the bronchitis and 
 almost invariably occurs in lower-lobe pneumonia, but is often absent 
 in upper-lobe consolidation, in terminal or secondary pneumonia, in 
 cases where there is much delirium, in the aged, and the young. 
 
 (5). The Sputum. — The sputum is at first transparent, mucous, 
 and very scanty. It soon becomes viscid, and is difficult to raise and 
 to expectorate, as it adheres to the mouth and lips. It is so viscid 
 that the sputum-cup may be inverted without any flow of the sputum. 
 In two days, it becomes red and rusty (80 per cent, of cases). Later, 
 the sputum becomes more abundant, averaging between one and 
 seven ounces daily. Increased fluidity may rarely result from weak 
 heart, or decreased coagulability of the blood. Rusty sputum is 
 often absent in children who swallow their sputum; in cases of 
 upper-lobe pneumonia, in which there is less hemorrhage, less con- 
 solidation, and less cough to dislodge exudation; and finally in the 
 
 Fig. 16. 
 
 Fibrinous coagulum from a case of croupous pneumonia (Bizzozero). 
 
 senile and secondary pneumonias, possibly because of an early gray 
 hepatization. The cause of unusual color in the sputum, such as 
 lemon- or brick-color, is unknown; it is sometimes observed in pul- 
 monary oedema, or in incipient gangrene and renders the prognosis 
 uncertain. Safranin color (sputum croceum) indicates resolution. 
 The rusty sputum is of great diagnostic value,— e. g., in the beginning 
 of the disease or in central pneumonia — and generally is of good 
 import. Fibrin threads or " casts " of the bronchioles are usually 
 
PNEUMONIA. 135 
 
 seen between the third and seventh days. On shaking the sputum 
 in water and catching the shreds on a slide they appear clubbed at 
 their alveolar ends. They are not wholly pathognomonic, since Laen- 
 nec found them in tuberculosis and fibrinous bronchitis. They 
 consist of fibrin, white cells, fatty cells and epithelium. Thinner 
 casts, analogous to the cylindroids of the urine, and spirals are 
 sometimes found. Microscopically the sputum contains blood cells, 
 various epithelia, and the pneumococci (found first by Wolff in 
 sputum and by Weichselbaum in the lung). 
 
 (6). Lung Pathology. — Laennec (1819) was the first to accurately 
 separate pneumonia from pleurisy. He described three stages. (1) 
 The stage of hyperemia is very exceptionally observed unless the sub- 
 ject dies in twenty-four to thirty-six hours, because hepatization 
 (v. i.) develops rapidly; hyperemia is most often seen at the edges 
 of the consolidated lung where the pneumonia is beginning to extend. 
 The lung crepitates less than normal and floats ; it is red, voluminous, 
 and tears readily, since it has lost its elasticity, and on section 
 exudes a sero-sanguineous fluid. Under the microscope, congestion, 
 serum, and diplococci in the alveoli are observed. The alveolar 
 epithelial cells swell and desquamate, which, according to some observ- 
 ers, are the primary changes. (2) In the stage of red hepatization, 
 the lung is evenly red, friable, airless (not wholly so in pneumonia 
 of an upper lobe), and sinks when put into water. Its weight is 
 increased ten to fifty ounces. The lung has marks of the ribs on its 
 fibrin-coated surface and is enlarged to the size of deepest inspiration 
 (Rokitansky, who developed the gross anatomy of pneumonia). On 
 scraping the cut surface, fibrinous casts or plugs of the bronchioles 
 are observed. The lung is granular on section (Laennec), which 
 results from fibrinous exudation into the alveoli. These granulations 
 are seen best by oblique illumination. Under the microscope, coag- 
 ulated blood and exudate, alveolar epithelium, injected bloodvessels, 
 emigration of leukocytes, diplococci, and meshes of fibrin, are noted. 
 (3) In the stage of gray hepatization, the granulations are grayish- 
 yellow — not red because the blood is absorbed; they are larger and 
 looser than in the second stage. The connective tissue is grayer than 
 the granulations, and is sharply defined by the lung pigment. It has 
 been claimed that death always occurs if this stage is reached. If the 
 patient lives, the granulations disappear; the lung exudate becomes 
 semi-fluid (purulent infiltration) and can be washed out ; there is a 
 fatty emulsion, and resorption occurs by the lymphatic vessels and 
 not by evacuation through the sputum. Proteolytic enzymes (fer- 
 ments), probably derived from the leukocytes, dissolve the exudate; 
 the products of this autolysis are excreted by the kidneys. 
 
 Seat of pneumonia: Lichtheim's claim that the process begins at 
 the hilum and extends to the pleura, has been proven by the x-tslj. 
 If it remains at the hilum it is called central pneumonia (1.7 per 
 cent. ) ; if the entire lung is involved, it is termed pneumonia totalis or 
 massiva ; the terms " double pneumonia " and " crossed pneumonia " 
 
136 TEE SPECIFIC INFECTIONS, 
 
 are self-explanatory. The lobes are involved in the following order 
 of frequency: (1) Eight lower lobe; (2) left lower; (3) right mid- 
 dle; (4) right upper; (5) left upper lobe. Jiirgensen's collation of 
 16,614 cases of pneumonia shows that the right lung is affected in 
 53 per cent., the left in 37 per cent., and both lungs in 10 per 
 cent. Frankel found the upper lobes involved in 16 per cent, 
 and the lower in 84 per cent. 
 
 (7). Physical Signs. — The physical signs develop in the lungs 
 only after twelve to twenty-four hours, or later. 
 
 a. Inspection. — The decubitus is variable. It is often dorsal in 
 lower-lobe, and erect in upper-lobe pneumonia; the patient at first 
 lies on the sound side to avoid pain; on the diseased side later, for 
 better expansion of the sound lung. The spinal column is concave 
 toward the diseased lung for its better immobilization. The ex- 
 cursion is less on the diseased side because of pleuritic pain, and 
 Litten's diaphragmatic sign is absent and the sound lung is vicari- 
 ously active. The diseased side is larger by one inch. The ac- 
 cessory muscles of respiration are active and dilatation of the nares 
 is seen. [Systolic pulsation of the lung occurs when the lingual 
 lobe is consolidated, or, in the first stage, when the heart beats against 
 semifluid exudation, Graves.] 
 
 b. Palpation. — This detects the lessened excursion more readily 
 than does inspection ; vocal fremitus is usually increased because of 
 better sound propagation, fremitus being normally greater on the right 
 than on the left side. It is decreased (i) by occlusion of the 
 bronchus by fibrinous plugs, which are, however, usually dislodged 
 by having the patient cough; (ii) by coincident pleural effusion; 
 (iii) by great consolidation (Gerhardt), in which the chest wall be- 
 comes tense. Pleural friction may be felt. 
 
 c. Percussion. — (i) A tympanitic note is obtained in the first 
 stage (Skoda's resonance), caused by decreased elasticity of the 
 lung and therefore decreased tension and amplitude of vibration 
 [due to the swelling of the alveolar epithelium and turgescent capil- 
 laries]. This condition may last as long as two days, and causes 
 doubt as to the side involved. Careful watching of the tympany 
 often leads to detection of extension, which is shown by relaxation of 
 the lung tissue contiguous to areas already consolidated. Tympany 
 in the later stages is not uncommon in upper-lobe pneumonia where 
 exudation is usually incomplete, or in moderate compression, — e. g., 
 of right upper lobe when right middle and lower are consolidated. It 
 is rare in lower-lobe pneumonias. Tympany may remain days 
 or weeks after the crisis. (ii) Dulness is usually found on 
 the second day and is the percussion sign of the second stage. When 
 complete, it corresponds to the lobe confines, which are outlined in 
 Fig. 33 under Pleurisy. The dulness is not absolute. It is usually 
 first detected in the posterior axillary line in lower-lobe pneumonia 
 and generally is more complete behind than in the front of the chest 
 and more in a lower- than in an upper-lobe involvement. Dulness 
 
PNEUMONIA. 137 
 
 is difficult to detect if the area is not at least 1 by 2 inches, or if it 
 is deeper than 2 inches from the surface. It is absent in central 
 pneumonia. It disappears with resolution to be replaced by tympany. 
 Wintrich's palpatory percussion is very valuable. [Wintrich's 
 change of pitch (on opening the mouth) is heard in upper-lobe pneu- 
 monia, where the percussion wave is conveyed to the bronchus more 
 often than in lower-lobe pneumonia. Cracked-pot resonance over the 
 edge of the consolidation bordering on sound tissue is due to irregular 
 tension.] 
 
 d. Auscultation. — Decreased breathing is often noticed at first 
 (Grisolle). Stokes diagnosticated the first stage by sudden local 
 puerile breathing with fever and disordered breathing. 
 
 First Stage. — The crepitant rale of Laennec remains the ausculta- 
 tory sign of the first stage ; but, as Laennec stated, it is not absolutely 
 specific, because it occurs also in tuberculosis, lung-oedema, infarct, 
 hypostasis and bronchiolitis. It probably has its origin in the viscid 
 exudate in the finest tubules and in the alveoli. It is coarser in the 
 aged and in the children because the large tubes are more involved. 
 It is heard at the height of inspiration as a succession or shower of 
 delicate crackles. When not heard, a coughing effort may elicit the 
 crepitant rale. It often disappears after a number of deep inspira- 
 tions ; e. g., when it is demonstrated to a class, only the first students 
 hear it. Dislodged plugs may occasion expiratory rales. The crep- 
 itant rale disappears during the second, and reappears in the third 
 stage. 
 
 Second Stage. — The distinct, intense bronchial breathing is due to 
 increased transmission of the breath sounds through the solidified 
 lung. It sounds as though nothing intervened between the lung and 
 the stethoscope and is especially clear and near when the ear is placed 
 directly on the chest. It is absent or partial in central pneumonia, 
 especially anteriorly, in coincident pleurisy, and in obstruction of the 
 bronchi by mucus or fibrinous casts. In the latter case, several coughs 
 usually loosen the obstruction and restore the bronchial breathing. 
 Bronchophony, due to the voice sounds being better transmitted 
 through the consolidated area, is heard when the patient counts or 
 speaks, but especially after each involuntary expiratory grunt. 
 2Egophony is occasionally heard, as well as Baccelli's phenomenon 
 (auscultatory whispering). The crepitant rale disappears in this 
 stage, except at the edges of the hepatization where extension occurs. 
 
 Third Stage. — The crepitant rale reappears, — the rale redux. 
 
 4. Circulation. — (a) The pulse rate is usually 100 to 120 or 
 higher in children. It is also rapid in the aged, and in severe tox- 
 cemia. In adults, a rate of 130 to 140 makes the prognosis less fav- 
 orable. If the rate is slow at the height of the disease, grave heart 
 or brain complications are indicated (Traube). Irregularity and 
 gallop-rhythm (one systolic tone and two diastolic tones) are of poor 
 prognostic import. Antecritical irregularity frequently occurs. The 
 pulse is usually deceptive and its fulness is of no value in prognosis. 
 
138 T2E SPECIFIC INFECTIONS. 
 
 It is not often dicrotic. Extensive pneumonias may compress the 
 subclavian artery, making the pulse smaller in one wrist than in the 
 other, (b) In the right heart, dilatation from toxaemia may occur; 
 the second pulmonic tone is accentuated but this is not observed when 
 the right heart becomes greatly weakened. There may be functional 
 bruits especially in children. In very rapid cardiac action, the two 
 heart tones sound alike, resembling the foetal heart tones (embryo- 
 cardia). (c) Collapse is usually due to myocardial or to central 
 vasomotor paralysis and may occur at the onset, acme, defervescence 
 or convalescence, (d) The blood shows anaemia, which may explain 
 some cases of collapse. The fibrin increase is readily noted in 
 fresh blood preparations. A polymorphonuclear leukocytosis of 15,- 
 000 to even 100,000 appears early, and lasts slightly longer than the 
 fever. The leukocytes ran between 15,000 and 30,000 in 75 per 
 cent, of Cabot's counts. The eosinophiles are decreased or absent 
 until the infection reaches its height whence the favorable signifi- 
 cance of their reappearance. The lymphocytes are decreased. Dur- 
 ing convalescence many myelocytes appear. The white count re- 
 mains high in delayed resolution or complications. A low count is 
 generally unfavorable. Pneumococccemia (pneumococci in the blood) 
 was, until recently, considered of bad prognostic import, but it is of 
 no great prognostic value. Posenow found pneumococci in blood 
 cultures in 93 per cent., and in smears in 42 per cent., most abun- 
 dantly on the fourth day, and few just before or at the crisis. Pro- 
 chaska found pneumococci in 100 per cent., when two or three drams 
 (10 c.c.) of blood were taken for cultivation and mixed with 98 or 99 
 parts of bouillon. Pneumococcaemia has been found before hepatiza- 
 tion. Posenow noted increased agglutinative power of the serum 
 until the crisis occurs. 
 
 5. The Digestive System. — There is the febrile tongue, thirst, 
 and anorexia. Vomiting occurs in 25 per cent, of cases and results 
 from cerebral toxaemia, coughing or pharyngitis. The distressing, 
 sometimes dangerous tympany and the occasional diarrhoea are toxae- 
 mic. Constipation is the rule. There is often intumescence of the 
 liver. Frankel found splenic tumor in 15 per cent, of all cases and 
 in 40 per cent, of fatal cases. 
 
 6. The Skin. — The red cheek on the affected side was known to 
 Aretaeus. The skin is usually dry, but miliaria and sweating may be 
 seen, especially in children. Herpes is found more often than in any 
 other disease (30 to 50 per cent.). It appears from the third to 
 fifth day, chiefly on the lips, nose, cheek or ear; Howard found 
 causal changes in the Gasserian ganglion. Herpes is of diagnostic 
 value, e. g., from typhoid, and is generally of favorable import. 
 Rarer eruptions are erythema, roseolae, purpura or pemphigus. 
 The lymph-glands are enlarged in 25 per cent, of cases. 
 
 7. The Urine. — Characteristic fever urine is found, and the urea 
 is increased threefold after the crisis from over-production and accu- 
 mulation during the fever and from the resolving exudate. The 
 
PNEUMONIA. 139 
 
 chlorides are decreased from 225 grains daily to 30 grains, or they 
 may be absent until the crisis or later, when they reappear in in- 
 creased quantities (Eottenbacher) ; no satisfactory explanation for the 
 decrease of the chlorides is known. Pick notes that the urine often 
 becomes neutral or alkaline two days after the crisis, due to the so- 
 dium deposit in the lungs. Albuminuria and cylindruria appear in 
 about 50 per cent, of cases ; peptonuria and acetonuria are not uncom- 
 mon, and the diazo reaction appears in 20 per cent. Hematuria is 
 found in 1.6 per cent. Nephritis seldom occurs (1 to 2 per cent.), 
 and uraemia is very uncommon. Pneumococci have been found in 
 the urine and glomeruli (Koch, Nauwerck). 
 
 8. The Nervous System. — Headache is constant. There may 
 be insomnia, restlessness, or stupor, and the latter is always ominous. 
 Delirium (22 per cent.) occurs in adults, with upper-lobe pneu- 
 monia, alcoholism, or marked toxaemia. Delirium and other nervous 
 symptoms resulting from exhaustion may occur even a week after the 
 crisis (2.5 per cent.). Venesection in former times greatly in- 
 creased the percentage of delirium. The patellar reflexes are often 
 absent and the pupils may be dilated or sluggish. Convulsions, 
 coma, and rigid neck, in children, result from toxaemia of the more 
 sensitive young brain, from complicating otitis, from brain oedema, 
 or from actual meningitis. Hemiplegia may result from brain 
 oedema or anaemia, or arteriosclerosis and weakened heart. 
 
 Mechanism of Death in Pneumonia. — Death is rare in the first three 
 days; within this time, its cause is usually some antecedent malady 
 such as nephritis or typhoid. (1) Toxaemia is all-important in its 
 action on the heart, brain, and vasomotor nerves. Death ensues with 
 a rapid pulse, rapid respiration, algid extremities, and obtunded sen- 
 sorium. (2) Pulmonary oedema is either mechanical (cardiac) or in- 
 flammatory — i. e., the first stages of a developing pneumonia. (3) 
 The extent of pneumonia is the least important factor. A massive 
 pneumonia in a robust person causes less disturbance than a very 
 small patch in a nephritic patient. There is no parallelism between 
 the area hepatized and the resulting toxaemia. (4) Pneumococci 
 in other tissues, e. g., pneumococcic meningitis, endocarditis, or 
 pericarditis. 
 
 Complications. — These are few but severe. 
 
 1. Pleurisy. — Dry pleurisy is so constant that the name of pleuro- 
 pneumonia is rather justified, the pleura being covered with a very 
 thick, tenacious, curdy exudate. It is usually due to the pneumo- 
 coccus ; if due to the streptococcus, it is a complication of great dan- 
 ger. Effusive pleurisy is said to occur in 5 to 15 per cent., though 
 Prankel saw serofibrinous pleurisy in but 1 per cent, in 1,000 cases. 
 Maragliano aspirated his pneumonic patients and found some fluid in 
 66 per cent. Pleuritis is para- or metapneumonic, serofibrinous 
 or purulent (2 per cent.). The presence of leukocytosis in a 
 pleurisy may indicate a previous unobserved or overlooked pneu- 
 monia. Pneumonia may exist on one side and pleurisy on the 
 
140 TEE SPECIFIC INFECTIONS. 
 
 other (Traube). The author has seen two such cases. The prog- 
 nosis is not necessarily unfavorable, even when operation for pneu- 
 mococcic empyema is refused. Interlobular empyema is most serious, 
 because it so often escapes detection. Pneumococcic empyema occurs 
 in 2 per cent, of cases of pneumonia and is notable since the pneu- 
 mococcus so seldom provokes suppuration in the lung. Its symptoms 
 are discussed under pleurisy. 
 
 2. Endocarditis. — Acute endocarditis complicates pneumonia in 
 1 per cent. (Chvostek) of all cases and in 5 per cent, of fatal cases; 
 autopsy figures are higher than figures in general practice. The 
 pneumococcus is found in the vegetations. The valvular exudate is 
 voluminous, though ulceration, valvular aneurysm and perforation are 
 less common than in staphylo- and streptococcic forms. Endocar- 
 ditis develops especially on old valvular lesions in the left heart and 
 most frequently on the aortic valves (Eetter, Heschl). The right 
 heart is involved three or four times as frequently as in endocarditis 
 due to other bacteria. Sixty per cent, of cases are associated with 
 meningitis. Middle-aged adults are more often affected than the 
 young, and women more often than men. Symptoms may be absent. 
 Endocarditis is probable when a murmur, systolic or particularly 
 diastolic, occurs with irregular and protracted fever, chills, sweats 
 and embolism (50 per cent.). Symptoms may directly follow the 
 pneumonia or develop after one-half to one week of normal tempera- 
 ture. The endocarditis is malignant in 80 per cent, of cases ; in the 
 balance, milder endocarditis occurs; 25 per cent, of all ulcerative 
 endocarditides are pneumococcic. Fever is sometimes, and leukocy- 
 tosis frequently, absent. (Vide Ulcerative Endocarditis and 
 Septic Infections.) 
 
 3. Pericarditis. — Some figures place its post-mortem frequency 
 at 5 to 15 per cent, but Erankel estimates it at seven-tenths of 1 
 per cent. About 60 per cent, of cases are latent because the peri- 
 cardial rub is frequently absent. Dry pericarditis occurs more 
 often in children than in adults and, in all cases, chiefly at the height 
 of the disease. Effusive pericarditis is less common than the fibrin- 
 ous form. It is more common when the left lung is involved. It 
 is dangerous though not necessarily fatal. 
 
 4. Arteritis and Thrombophlebitis. — These are far less fre- 
 quent than in typhoid, but nearly every clinician encounters a few 
 cases. Steiner collected forty-eight cases of venous thrombosis 
 (1903) ; it most often develops in convalescence and heals usually (75 
 per cent.) though early embolism or permanent venous obstruction 
 may develop. 
 
 5. Nervous Complications. — The chief nervous complications 
 are delirium tremens, meningitis, or, less frequently, Landry's paraly- 
 sis, cerebral embolism, encephalitis, neuritis, etc. Meningitis, first 
 observed by Immermann and Heller, occurs in 5 per cent, of autopsies, 
 and in three-tenths of 1 per cent, of clinical cases. It occurs in 
 asthenic patients, in upper-lobe pneumonia, and often accompanies 
 
PNEUMONIA. 141 
 
 endocarditis. One of the author's cases died at dinner a week after 
 apparently complete convalescence, and the autopsy showed a quarter 
 inch of pus over the convexity. The usual meningitic symptoms de- 
 velop if infection reaches the base of the brain, but this is not usual 
 [see Meningitis]. Lumbar puncture determines the diagnosis. > The 
 prognosis is considered absolutely unfavorable, yet Achard and the 
 author have seen recovery. 
 
 6. Alimentary Complications. — These are few. Croupous gas- 
 tritis and enteritis, parotitis or peritonitis, are not frequent. Dieula- 
 foy described an ulcerative gastritis, caused by pneumococcic embol- 
 ism and attended by gastrorrhagia. Icterus in frequency aver- 
 ages 1 per cent., though Chvostek saw it in 21 per cent. Its causes 
 are (a) lessened excursion of the diaphragm; (b) hepatic stasis; (c) 
 duodenal catarrh; (d) hematogenous jaundice resulting from absorp- 
 tion of the hemorrhagic exudate or toxemic solution of the red 
 blood-cells (hemolysis). (See Pneumococcic Peritonitis.) 
 
 1. Lung- Complications. — Suppurative mediastinitis was first ob- 
 served by Weichselbaum, who regards it as the connecting link be- 
 tween pneumonia, meningitis, and pericarditis. Pulmonary indura- 
 tion (cirrhosis of the lung) may follow incomplete resolution, espe- 
 cially after repeated attacks of pneumonia (Charcot) ; it is usually 
 febrile. Abscess is not frequent (5 per cent., Laennec, or once in 
 1,200 cases, Frankel). Skoda emphasized the uncertainty of its 
 signs and the difficulty in its diagnosis, for pus and elastic fibers in 
 the sputum, and less frequently cholesterin and hematoidin crystals 
 may be the sole signs, and continual coughing may be the chief symp- 
 tom. Suppuration may result from the pneumococcus or from the 
 pyogenic bacteria proper. Gangrene occurs in 1 to 2 per cent, of the 
 cases. Clinically it is recognized by the horribly fetid sputum. 
 Abscess and gangrene are more fully treated under Diseases of the 
 Lungs. 
 
 8. Joint Complications. — Genuine rheumatism may occur 
 with, before, or after a pneumonia. Ninety-two cases of pneumococ- 
 cic arthritis (pseudorheumatism) were reported by Howard (1903). 
 The arthritis may be serous or purulent. The knee is affected in 30 
 per cent. Arthritis is monarticular in 62 per cent, and fatal in 65 
 per cent, of cases (Herrick). The infection is hematogenous. 
 Frankel found the pneumococcus constantly in the bone-marrow. 
 
 Clinical Types and Variations. — These are as follows: 
 
 1. Abortive Pneumonia. — This type is recognized by the rusty 
 sputum, fever and respiratory disturbance, and produces no hepatiza- 
 tion. 
 
 2. Ephemeral Pneumonia. — This type is characterized by one 
 day of fever, and very rapid resolution. In this type, the onset is 
 brusque and a severe disease seems imminent but the symptoms abate 
 surprisingly soon. 
 
 3. Relapsing Type.' — After fall of the temperature, the entire 
 cycle recurs (in 0.3 per cent., Wagner). Recurrent type (v. s, 
 Immunity) , 
 
142 THE SPECIFIC INFECTIONS. 
 
 4. Local Variations. — Apex pneumonia is often more severe 
 and more atypical in symptoms and signs ; it is frequently adynamic, 
 and pulmonary and cerebral complications are rather more common. 
 Migratory pneumonia travels from one part to another (the so-called 
 erysipelas-pneumonia). Central and massive pneumonia (pneumonia 
 totalis, affecting an entire side) will be considered under diagnosis. 
 
 5. In Children. — An abrupt onset occurs without chill before 
 the seventh year, but with vomiting (50 per cent.) or convulsions 
 (7 per cent.) and other cerebral or meningeal symptoms. Cough 
 is often absent, no sputum appears, and the pain (third to fifth 
 year) is referred to the abdomen but commonly without abdominal 
 tenderness. Pain is a more important symptom than increased res- 
 piration, which occurs in any fever. The respirations may number 
 eighty in cases under two years of age; in older children, fifty. 
 Crepitant rales are usually absent because of the superficial breathing 
 caused by pain. Latency of physical signs, such as absence of bron- 
 chial breathing, bronchophony or dulness, is sometimes noted. Lo- 
 calization is more often central, apical, or migratory. The fever 
 may rise more slowly and lysis is more frequent than in adults. 
 Riviere found croupous pneumonia as frequently (or more fre- 
 quently) in children under two years as in those above two years. In 
 118 cases reported by Morse, 50 of them occurred in the first, and 68 
 in the second year of life. 
 
 6. In the Aged. — Pneumonia is frequently latent, insidious, and 
 asthenic, with ill-marked signs, without chill, even without fever, and 
 often without cough, pain, or sputum. It is strange that so severe an 
 infection can exist with so few of its usual evidences. In this and 
 the following type, pneumonia is declared by the physical findings 
 only. 
 
 7. In Alcoholics. — The same latency or lack of type may be 
 noted. In alcoholics the delirium tremens masks the lung lesion. 
 
 8. Asthenic Pneumonia. — In asthenic, "typhoid," or " toxic" 
 pneumonia, toxaemia is dominant, there are high fever, enlarged 
 spleen, albuminuria, icterus, mixed infections, severe complications, 
 such as meningitis or gangrene, and high mortality. These cases 
 contrast strongly with what we might call " walking pneumonia." 
 The author had two patients who worked throughout the disease. 
 
 9. Pneumonia Secondary to Other Diseases. — Pneumonia 
 may be secondary to emphysema, arteriosclerosis, hepatic cirrhosis, 
 nephritis, diabetes, tuberculosis, typhoid, or other conditions. Anaes- 
 thesia by ether is thought to predispose to pneumonia by irritation 
 of the respiratory tract. The nose and mouth should be cleansed 
 before anesthetization to remove native germs. The frequency of 
 ether-pneumonia in abdominal operations suggests the possibility 
 of embolism as a factor. 
 
 Various microorganisms are found — colon bacillus, streptococcus, 
 etc. This type is commonly misinterpreted because it is atypical, 
 ill developed, or masked by the primary disease. Pathologically, the 
 
PNEUMONIA. 143 
 
 hepatization is rarely typical and is more Lobular than lobar; the lung 
 
 ion is smooth and moist, and the exudation is more cellular than 
 fibrinous. 
 
 10. Delayed ob [mpebfeot Resolution. — Normal resolution is 
 chiefly effected by lymphatic absorption and not by the sputum, (a) 
 
 Resolution may require weeks or even months, especially in apical in- 
 volvement, and it more often follows lysis than crisis. The toxaemia 
 disappears but dulness and bronchial breathing persist, (b) Im- 
 perfect clearing up of the lung may be caused by abscess formation, 
 old pleuritic adhesions, fresh pericarditis, or inflammatory involve- 
 ment of the connective tissue and lymphatic vessels. Induration of 
 the lung by organization of the exudate is usually febrile (Frankel). 
 (c) The so-called pneumonia migrans is pneumonia which slowly 
 progresses from one part to another. 
 
 Diagnosis.. — Mistakes are rare in the diagnosis of primary, frank 
 pneumonia in adults — they occur mostly in cases of aged individuals, 
 alcoholics, children, and pneumonia secondary to cancer, nephritis, 
 diabetes, etc. Therefore, all cases with chronic disease, must be 
 
 jely examined and the back percussed — when the respiration, 
 pulse, and temperature rise, or when, without these or other symptoms 
 the subject is not doing well. 
 
 1. Onset Symptoms. — The chill in adults, or convulsions and 
 vomiting in children, suggest the possibility of pneumonia. Chill, 
 pain in the side, sudden high fever, and rusty sputum, are quite 
 final, because pneumonia is practically the only disease in which they 
 occur, except infarct of the lung — in which the same symptoms may 
 obtain, but in which the sputum is reddish, not viscid, usually darker, 
 and far more abundant. In 25 per cent, of cases the onset of pneu- 
 monia is not typically brusque and the physical findings of pneu- 
 monia are present without a suggestive history ; indeed it may rather 
 be suggestive of simple pleurisy, grippe, etc. The prodromes of 
 pneumonia are too often disregarded by physicians. The prodro- 
 mata may last two to seven days. 
 
 2. Diagnosis from the Physical Findings. — The physical find- 
 ings are usually detected in the typical case upon thorough examina- 
 tion, and as a rule usually appear within two days after the charac- 
 teristic symptoms of onset. They are the well known lessened ex- 
 pansion on the side of the lesion ; increased vocal fremitus ; distinct 
 dulness; bronchial breathing; the crepitant rale; the grunting, abbre- 
 viated, expiratory " huh " sound, and a bronchial tone to the whis- 
 pered or louder voice sounds. Typical as are these simple findings 
 in their usual grouping, and easily recognized as they are when the 
 
 lent or practitioner has once heard and learned them, neverthe- 
 less many conditions modify their classical appearance and character. 
 Thus the fremitus is decreased in massive consolidations which render 
 tense the chest wall, in coincident pleural effusions or in fibrinous 
 plugging of the bronchi. The latter may, however, usually be dis- 
 lodged by repeated coughing. The dulness is found only in hepa- 
 
144 TEE SPECIFIC INFECTIONS. 
 
 tization which is nearly complete and is both preceded and followed 
 by a tympanitic note. The crepitant rale is found only in the first 
 and third stages, but in almost every case can be fonnd in some part 
 of the affected lung. Bronchial breathing is rudimentary or absent 
 in incomplete hepatization, is often so in upper-lobe pneumonias, in 
 complicating effusive pleurisy, and in obstructed bronchi. These 
 physical signs are pathognomonic only in connection with the cyclic 
 course, onset, disturbed pulse and respiration ratio, pneumococcsemia, 
 diminished chlorides, herpes, leukocytosis and crisis. 
 
 3. Localization. — Massive pneumonia (total pneumonia of one 
 side) not infrequently simulates pleurisy, because fibrinous plug- 
 ging of the bronchi is not uncommon, and prevents bronchial breath- 
 ing, bronchophony, and the crepitant rale; and again, the fremitus 
 may be absent together with some slight luxation of neighboring 
 viscera. Consideration of the onset, the later cyclic course, and the 
 dislodging of the plugs by forcible coughing, almost invariably de- 
 termine the diagnosis. Too much is generally said about central 
 pneumonia. It exists beyond all doubt, but conservatism is necessary 
 in its diagnosis. All pneumonias are central in their incipiency but 
 rarely remain so. The author demonstrated two cases in which the 
 symptoms were pneumonic, but the local findings did not appear for 
 a week. 
 
 4. In Children. — Pneumonia in children may be mistaken for 
 abdominal disease, pleurisy, or brain affections. The " cerebral 
 pneumonia " of Billiet and Barthez may be (a) convulsive, occur- 
 ring under two years, with fever, vomiting, and convulsions ; but the 
 evenly high fever is very suggestive even if the cough and dyspnoea 
 are obscured by the brain symptoms; or (b) meningeal, occurring 
 between the second and sixth years; but the pulse is not slow, and 
 there is no deep breathing, nor other signs of meningitis. 
 
 5. Differentiation from Pleurisy. — The differentiation is usu- 
 ally easy, but confusion is unfortunately common. (See page 145.) 
 
 In lung tumors, bronchial breathing, bronchophony, dulness, red 
 (or green) sputum, are also noted, but the history and course differen- 
 tiate. In acute tuberculous infiltration, the course differentiates it 
 from upper-lobe pneumonia in which cough, sputum, and typical phy- 
 sical findings are absent. Many mistakes in both directions are made, 
 simply by forgetting that pneumonia may occur in the apices, in 
 which the incomplete exudation may impart a tympanitic note, and 
 that the breath sounds are not always typically bronchial, at least 
 anteriorly. In some cases tuberculous pneumonia may commence 
 like lobar pneumonia (see Acute Pneumonic Form, under Course 
 of Pulmonary Tuberculosis). 
 
 Prognosis. — Pneumonia is the most fatal acute disease and even 
 has a greater death-rate than tuberculosis. In 1903, 4,629 persons 
 died of pneumonia in Chicago, and, in 1904, 8,360 in ISTew York 
 City. From 1851 to 1860, the mortality, in Chicago, from tuber- 
 culosis, was 35 per cent, more than from pneumonia. From 1891 
 
PNEUMONIA. 
 
 145 
 
 to 1901, the pneumonia death-rate was 9 per cent, more than the 
 tuberculosis mortality. 
 
 Pneumonia- 
 
 -Pleuritic Effusion. 
 
 Onset sudden, with rigor, vomiting, Gradual; chilly sensations rather than 
 herpes. rigor. 
 
 Friction less common; may be present'. Usually, at some time in the clinical 
 
 course. 
 
 Cyclical short course; high fever, crisis. 
 
 Sputum rusty. 
 Leukocytosis. 
 
 Ectasia absent. 
 
 Fremitus increased (coughing usually 
 dislodging bronchial plugs). 
 
 Dulness, preceded and succeeded by 
 tympany (tympany or partial dul- 
 ness in upper-lobe pneumonia is not 
 uncommon). 
 
 Crepitant rales, bronchial breathing (un- 
 less bronchus is plugged), and bron- 
 chophony. 
 
 No essential luxation of heart, liver or 
 spleen. 
 
 Paracentesis negative. 
 
 Longer duration, lower fever, lysis. 
 Often tuberculous foci at apex, etc. 
 
 Mucous, if any. 
 
 Usually absent, unless purulent or com- 
 plicating a pneumonia. 
 
 Present. 
 
 Absent over effusion unless adhesions 
 bind the lung to the chest wall; in- 
 creased above over compressed lung 
 or in the interscapular region. 
 
 Flatness, increased downward; entering 
 Traube 's suace on the left side. Level 
 seldom shifts with change of position. 
 (See Fig. 33.) 
 
 Decreased or absent respiratory mur- 
 mur; bronchial breathing in inter- 
 scapular region from compression, or 
 even through the fluid; segophony. 
 
 Luxation of viscera named, is usual in 
 large effusions. 
 
 Tapping nearly alwavs decides doubtful 
 cases; fluid found beneath the flat 
 
 There are various prognostic factors: 1. The Virulence of the 
 pneumococcns, which varies from year to year (5 per cent, mortality 
 in one year, 31 per cent, in another, Brandes). The mortality of 
 85,000 cases in the German army was 3y% per cent., but these were 
 necessarily selected cases. In hospitals the mortality ranges between 
 20 and 40 per cent., from alcoholism, excesses, and overwork. In 
 465,400 collected cases, E. ~F. Wells found 20 per cent, the average 
 death-rate. 
 
 2. Age. — According to Frankel, the mortality is ; one to five 
 years, 30 per cent. ; five to ten years, 3 per cent. ; ten to twenty 
 years, 5 per cent. ; twenty to thirty years, 8 per cent. ; thirty to 
 forty years, 25 per cent. ; forty to fifty years, 39 per cent. ; fifty to 
 sixty years, 43 per cent. ; sixty to seventy years, 53 per cent. ; seventy 
 to eighty years, 87 per cent. The aged succumb readily; long ago 
 Cruveilhier spoke of pneumonia, in this connection, as the most for- 
 midable scourge of the aged, and Peter characterized pneumonia as 
 10 
 
146 THE SPECIFIC INFECTIONS. 
 
 the natural end of old people. Morse found the mortality in children 
 36 per cent, in the first year and 19 per cent, in the second; Beviere, 
 25 per cent, in the first, 15 per cent, in the second year, and 2 per 
 cent, in older children. 
 
 3. Sex. — The mortality is 50 to 100 per cent, higher in women; 
 in pregnancy the disease is always severe. 
 
 4. Location. — Eight-sided is more fatal than left-sided pneu- 
 monia, and upper- is more fatal than lower-lobe involvement. Exten- 
 sion from lobe to lobe is serious. 
 
 5. Unfavorable Conditions. — These are hepatic cirrhosis and 
 nephritis, in which the death-rate is almost 100 per cent, ; delirium 
 tremens and inveterate alcoholism, in which it is 45 to 50 per cent. ; 
 cardiovascular disease, scoliosis, and high altitude. 
 
 6. Unfavorable Symptoms. — These are long prodromata, hyper- 
 pyrexia, enteritis, marked jaundice, albuminuria, severe pain, 
 marked cyanosis, pulmonary oedema, diffuse bronchitis, and a white 
 cell-count under 10,000. Sears and Larabee found the mortality 
 9 per cent, with the respirations under 30, 15 per cent, under 40, 
 and 60 per cent, over 60 per minute ; and 50 per cent, with the pulse 
 over 130. Over 50 per cent, of delirious subjects die. 
 
 7. Unfavorable Complications. — Endocarditis and meningitis 
 are almost always fatal; abscess, gangrene, and arthritis are always 
 serious ; pericarditis is fatal in 50 to 75 per cent, of the cases. 
 
 Strictly speaking, death is due in almost all cases to cardiac tox- 
 cemia. Mechanical overwork of the heart or diminished respiratory 
 space are of small importance. 
 
 Treatment. — 1. Prophylaxis. — Prophylaxis concerns disinfection 
 of the sputum, cleansing of the room [See Smallpox], isolation, 
 and maintenance of the physiological resistance. Cleansing of the 
 nose may be of preventive importance. 
 
 2. Serotherapy. — Serotherapy has not proved successful, and 
 pneumonia remains a self-limited disease. 
 
 3. Hygiene. — The hygiene is the same as in typhoid. Quiet 
 should be maintained, the mouth, especially, should be cared for, and 
 the patient should be clothed with a light flannel jacket open down 
 the back. The fresh air treatment works wonders in pneumonia; the 
 bed should be placed out of doors or the windows widely opened and 
 the bed protected by screens ; mental and cardiac symptoms, particu- 
 larly, are greatly improved. 
 
 4. Diet. — The diet consists of milk, eggs, and cereals. 
 
 5. Symptomatic Therapy. — (a) The Chill. — The chill, which is 
 rarely seen by the physician, is managed as in malaria. 
 
 (b) Cough. — Expectorants are unnecessary, and codeine gr. J, and 
 carbonate of ammonium gr. iij, should be given every two to four 
 hours. If these are ineffectual, morphine is indicated (v. i.). 
 
 (c) Pain. — The chest should be firmly strapped with adhesive 
 plaster, applied in several oblique directions so that the pieces cross 
 each other. Morphine does not essentially depress respiration but 
 
PNEUMONIA. 147 
 
 rather lessens the irritability of the respiratory centre and relieves 
 pain. Poultices can be more easily endured than ice, but, like blis- 
 ters, leeches, and the Paquelin cautery, are superfluous. In pneu- 
 monia, general is far more important than local treatment. 
 
 (d) Heart. — Care of the heart is the main objective in treatment. 
 Constant watching is imperative lest the delirious patient leave his 
 bed, and it is a safe rule to consider all pneumonics delirious. Sitting 
 up to drink, defecate, or urinate is never permissible, as pneumonia 
 is a disease of sudden and alarming changes and there is constant 
 danger of sudden death. ~No therapeutic measure which depresses the 
 heart should be employed, and therefore acetanilide, antimony, acon- 
 ite, and pilocarpine are always to be avoided. 
 
 Cardiac Stimulation. — Strychnia. — Strychnia is the best heart 
 tonic, and should be given in every case because of the cardiac and 
 vasomotor instability which often develops without warning. Vaso- 
 motor paralysis and collapse are attended by accumulation of blood 
 in the abdominal vessels; thus, pallor of the retinal vessels follows 
 section of the splanchnic nerve. In the collapse caused by acute 
 toxaemia, the vasodilatation is general, but particularly concerns the 
 deep abdominal vessels. Strychnine is here indicated, not only be- 
 cause of its general effects but because of its powers of vasoconstric- 
 tion on the deep abdominal vessels ; the vascular tonus in the skin and 
 brain is not increased, whereby the brain vessels are flushed and the 
 bulbar vasomotor and other vital centres are stimulated. The drug 
 stimulates the central nervous system; the digestive tract, the secre- 
 tions, and peristalsis; the circulation, the heart-muscle, and chiefly 
 the vasomotor centre; and the respiratory centre. 
 
 Administration. — The dose is gr. ^ to ^V? every two to four hours. 
 (For dosage in children, see Scarlatina.) Some strychnine re- 
 mains in the system from three to eight days, though some is 
 destroyed at once by the liver, and some is quickly eliminated by 
 the kidneys. If the kidneys or liver are diseased or functionally 
 tardy, as in old age, the drug may accumulate. Full doses 
 sometimes produce nervousness, irregular heart, palpitation, or 
 renal-vessel spasm, as does digitalis. Hypodermic administration 
 gives less chance for the liver to destroy the drug than does adminis- 
 tration by mouth. 
 
 Ammonia. — The ammonia preparations are of great clinical im- 
 portance. It temporarily stimulates the heart-muscle, increases its 
 frequency, and constricts the vasomotor system, thereby raising arte- 
 rial tension. Its superficial effects are local flushing, subjective 
 warmth, tension in the temples, a sense of exhilaration, and increased 
 secretion of urine, sweat, and mucus. The prime indication for 
 ammonia is sudden and functional cardiac adynamia, which occurs at 
 the crisis. It is a local irritant to the skin, subcutaneous tissues, and 
 the respiratory and alimentary mucosae, and therein lie its therapeutic 
 value and its clinical disadvantages. Its application to the upper 
 respiratory passages or its ingestion by mouth causes a sudden reflex 
 
148 THE SPECIFIC INFECTIONS. 
 
 stimulation of the respiratory and circulatory centres and initiates 
 centripetal stimulation, which travels from the throat, oesophagus, 
 and stomach, to the brain, long before the drug is absorbed. Un- 
 toward action is frequently observed in gastric, intestinal, renal and 
 bronchial irritation resulting from overdoses, and also in undue irrita- 
 tion or necrosis following subcutaneous administration. The cor- 
 rosiveness and fugitive action of ammonium carbonate are both very 
 relative contra-indications, and are obviated by administration of 
 small and frequent doses, gr. iij every two hours. 
 
 Digitalis. — Digitalis, in doses of 75 to 150 ( !) grains, was recom- 
 mended by Traube and Petrescu. Such administration simply 
 proves, in the author's opinion, that the digitalis is not absorbed. It 
 is claimed that exudation is modified and that leukocytosis is 
 increased. Personally, the author has never seen digitalis produce 
 as good results as strychnine, but he has repeatedly noticed toxic 
 symptoms appear at the crisis when the repeated doses of digitalis 
 were absorbed together. Digitalis should be used only as a last resort ; 
 TlXij to v of fluidextract should be given hypodermatically. The 
 author believes digital in is almost inert (see Treatment of Valvu- 
 lar Heart Disease). 
 
 Alcohol. — Alcohol was first recommended by Todd for fevers. The 
 chief interest centres in its action upon the circulation. For years it 
 has been called a heart stimulant, though no pharmacologist now 
 holds that alcohol stimulates the heart as do digitalis, strychnine, and 
 camphor. Direct cardiac stimulation by alcohol per se is im- 
 possible, except by preparations like champagne which contain other 
 ingredients. The frequency of the heart's action is increased, but it is 
 known beyond all doubt that the drug acts as a vasodilator or as a 
 blood distributor. Some clinicians refuse to employ it because it is 
 narcotic to the nervous system and to the respiratory, circulatory, and 
 vasomotor centres in the lower brain, or because it is a vasodilator. 
 It must be admitted that alcohol has some good effects. It is effective 
 in all varieties of sepsis. It protects tissues from excessive waste and 
 is well tolerated in nearly all cases. There is no danger of cardiac 
 collapse when it is withdrawn in convalescence. Jiirgensen gives it in 
 all cases, using red Bordeaux wine as a routine procedure, especially 
 if cool baths are employed. If the heart becomes weaker, Bordeaux 
 is replaced by the stronger sherry or port; then by rum, cognac, 
 champagne, or whiskey in hot water, and tea or coffee, which can also 
 be given by rectum. Alcohol is invaluable, whatever its action ; it is 
 second only to strychnine and is indicated by collapse or cardiac tox- 
 aemia, in which hot whiskey and water unquestionably stimulate by 
 reflex action on the throat and stomach. 
 
 Opiates. — It is the author's belief that morphine is not sufficiently 
 valued as a cardio-vascular tonic. Many withhold opiates even 
 when the drug is indicated by maniacal outbursts, active delirium, 
 and harassing coughing or pain, because it depresses respiration, and 
 ill effects upon the circulation are feared. When used freely, it de- 
 
PNEUMONIA. 149 
 
 creases the irritability of the respiratory centres, lessens cough, 
 dyspnoea, the attendant headache and insomnia, and it almost inva- 
 riably acts as a cardiovascular tonic. Its effects on diseased kidneys 
 are not to be feared with ordinary care in administration, as little 
 morphine is eliminated by the urine. Morphine will of itself help to 
 sustain life, and in critical cases, where the author has watched its 
 effects for hours, its hypodermic use has strengthened and regulated 
 respiration, even when Cheyne-Stokes' respiration was marked. 
 When the heart weakens, its force will often be renewed by morphine. 
 It is a most valuable adjunct to the true cardiovascular stimulants, 
 either those which have continued action, as strychnine and digitalis, or 
 those whose action is more fugitive, such as camphor, ammonia, or 
 caffeine, which latter has an excellent effect, given by rectum, in 
 neutralizing the effects of opiates. 
 
 Camphor. — Camphor is an excellent diffusive stimulant for the 
 heart and brain (grain i hypodermatically in 10 parts of sterilized 
 oil, every two to four hours). 
 
 Saline Infusions. — These are indicated in profound toxaemia with 
 weak heart. Two drams of salt in one quart of water are the rough 
 proportions of the physiological salt solution. They are the " lavage 
 of the blood " of French writers, who combine them with venesection. 
 Although once abused, venesection, which has been employed since the 
 time of Hippocrates, has again come more into vogue. It is valuable 
 at the very onset in the robust for severe pain, active delirium, and 
 urgent dyspnoea, and later when great engorgement of the right heart 
 occurs. It rather promotes heart thrombosis and delays resolution. 
 Heart stimulants must be used with phlebotomy. Continuous use of 
 the salt solution by rectum is valuable. 
 
 Oxygen. — Oxygen is said to relieve dyspnoea, but recent studies 
 prove that it is often irritating and injurious. The mouth-piece 
 should not be held closely over the mouth, but merely near it. 
 
 Atropine. — Atropine is valuable in collapse with low temperature 
 and clammy skin. The daily dosage should not exceed one-fortieth 
 of a grain. 
 
 (e) Antipyretics. — A high temperature is not per se injurious. 
 Cantani proved that patients with fever between 103° and 105° pro- 
 gress most favorably and that those with temperature above or below 
 these limits have a more severe course. Yon Jiirgensen insists that 
 all measures or remedies which suddenly reduce the temperature must 
 be avoided. They are especially injurious at the crisis, when the 
 heart sometimes staggers under the sudden fall of the fever. 
 
 Hydrotherapy is opposed by many, though Liebermeister lessened 
 the mortality in his cases by 9 per cent. The tonic vasomotor effects 
 are thought to outweigh the element of shock. It is less indicated in 
 children and is contraindicated in the very obese, the weak, and the 
 aged. Cool sponging with water and alcohol is the safest method. 
 Quinine gives no antipyretic effect except in large doses; Aufrecht, 
 Jiirgensen and See give thirty grains at 6 p. m., thereby inducing a 
 slow reduction of temperature without cardiac depression. 
 
150 TEE SPECIFIC INFECTIONS. 
 
 (/) Nervous Symptoms. — These are toxaemic, but should be con- 
 sidered with regard to ; (i) fever ; the greater the temperature varia- 
 tion, the more marked are the nervous symptoms; febrile nervous 
 symptoms are most efficaciously treated by baths or cool affusions; 
 (ii) anaemia, the delirium of which is relieved by morphine, coffee, 
 alcoholic and saline infusions; (iii) deficient oxygenation, in which 
 cold baths, cardiants, and oxygen inhalations are indicated ; (iv) in- 
 somnia, which is treated by morphia, bromides, hyoscine hydrobro- 
 mide, sulphonal, and cool sponging, but never by chloral ; (v) delirium 
 tremens (q. v.), in which rest is absolutely necessary and is best 
 secured by the drugs named under (iv) and by alcohol. 
 
 (g) Iodides and Col-liver Oil. — These should be given in delayed 
 resolution. 
 
 DIPHTHERIA. 
 
 Definition. — An acute specific infective disease, which usually be- 
 gins in the throat or upper air-passages, and is characterized by a 
 local yellowish adherent membrane formed by the Klebs-Loefiler 
 bacillus, and by constitutional symptoms due to toxaemia. 
 
 History. — Diphtheria was known to Hippocrates. Asclepiades, 
 100 B. C, performed the first tracheotomy. The name diphtheria 
 literally means membrane and originated with Bretonneau (1821). 
 
 Terms and Restrictions! — True diphtheria implies a membrane 
 formed by the Klebs-Loefiler bacillus whose absorbed toxins usually 
 also produce toxaemia. There are, however, membranes not formed 
 by this bacillus but due to the scarlatinal virus, streptococci, pneumo- 
 cocci, staphylococci, etc. While these are diphtheritic membranes in 
 the old anatomical sense, they are not diphtheritic in the bacterio- 
 logical sense. We must then term them pseudodiphtheritic or necrotic 
 inflammation, or diphtheroid. Therefore, clinically, there are some 
 discrepancies ; (a) what seems diphtheria, anatomically, may prove 
 not due to the Klebs-Loefiler bacillus; (b) some apparently simple 
 throat inflammations, resembling angina or tonsillitis, may show no 
 membrane or an atypical membrane, but bacteriologically are found 
 due to the Klebs-Loefiler bacillus, — i. e., are true diphtheria; (c) the 
 diphtheria bacillus is found in 1 per cent, of perfectly healthy 
 throats; (d) there are bacilli which closely simulate the diphtheria 
 bacillus. The pseudodiphtheritic or diphtheroid membrane is most 
 often due to the streptococcus and is seen oftenest in scarlatina, 
 but also in typhoid, measles, Vincent's angina, syphilis and pertussis. 
 It develops not merely in the throat, but wherever the true diph- 
 theritic membrane may occur, — e. g., the larynx, bronchi, eyes, skin, 
 etc. As a working statement, most cases clinically resembling diph- 
 theria are proved diphtheria by close and repeated bacteriological 
 tests. G. Smith found the bacillus in 72 per cent, of 27,000 collected 
 cases. 
 
 Bacteriology. — The diphtheria bacillus (described by Klebs, 1883. 
 and cultivated by Loeffler, 1884) is 1.2 to 2fi long and 0.3 to 0.5/*. 
 
PLATE V 
 
 %->. 
 
 B 
 
 vs 
 
 s n.4f^\ 
 
 ' - >&'F 
 
 
 I \x 
 
 \/ 
 
 "/\ 
 
 \\ 
 
 NT 
 
 «V*- 
 
 MV 
 
 /M 
 
 X*** 
 
 A.. Culture of diphtheri 
 
 B. Same magnified. 
 
 C. Diphtheria bacilli. 
 
 bacillus. 
 
DIPHTHERIA. , 151 
 
 wide, with small round ends, or ends slightly enlarged. It stains 
 readily by Gram's method, by Loeffler's methylene bine, and by carbol 
 fuchsin. There are many irregular variations in form, such as 
 branching types, but the serum culture always reveals the wedge- or 
 mallet-like forms. Some are very long, others short and parallel. 
 Their grouping is characteristic, like Chinese letters, in lines set 
 asymmetrically at various irregular or slight angles. They are im- 
 motile and sporeless. Cultivated in all media, the diphtheria bacillus 
 overgrows other associated bacteria on blood serum. On blood serum 
 mixed with glucose bouillon, the culture is visible in eight to ten hours 
 as yellow streaks, whose surface is slightly granulated and whose 
 edges are somewhat thick. In twenty-four hours the growths have 
 spread everywhere, with a wavelike surface, high, undulating edges, 
 and a succulent, glistening appearance. The diphtheria bacillus is 
 very resistant, and though it usually disappears in two or three weeks 
 after the patient has shed the membrane, it may live for weeks or 
 months in the throat (even six to fifteen months) or for a long period 
 in clothing. It is found chiefly in the throat membrane, and is less 
 frequently detected in the submucosa, heart (endocarditis), blood, 
 lungs (bronchopneumonic foci), spleen, liver, brain, cord, kidney or 
 urine. In one report, it was found in the blood and viscera eleven 
 times in fourteen cases. Its presence in these parts has been ex- 
 plained by what we may call diphtherisemia, by post-mortem migra- 
 tion, or by association with other bacteria, of which the streptococcus 
 is the most important, being found in septic types, in bronchopneu- 
 monia, and in glandular suppuration. Symbiosis with the strepto- 
 coccus, which is the most common of all secondary infections and 
 enters by the throat mucosa, increases the virulence of the diphtheria 
 toxin (Roux and Yersin). Less important are the staphylococci — 
 which, rarely enter through the throat, but when they do, are ex- 
 tremely virulent — the proteus, colon bacillus, and pneumococcus. 
 
 The action of the bacillus is (a) local, altering tissue, producing 
 necrosis, and forming membrane; when inoculated in animals, local 
 necrosis develops, whereon fibrin exudes and forms a membrane in 
 which the bacillus is found; the contiguous tissues are oedematous; 
 and (b) general, forming toxins which are absorbed by the blood and 
 lymph-vessels. Roux and Yersin (1888) found that the toxins in- 
 jected alone, after killing the bacillus, produce no membrane or 
 necrosis, but toxsemia and even paralysis precisely similar to the post- 
 diphtheritic paralysis. According to Ehrlich there are two toxins; 
 one, the toxin, produces the ordinary acute phenomena of diphtheria ; 
 and the other, the toxon, produces the later anaemia and paralysis. 
 The chief receptors of the virus are the nervous and lymphatic 
 tissues. 
 
 The virulence of the germ varies. This is tested on the guinea-pig 
 by inoculating it with 200"°^ ^s body-weight of a forty-eight-hour 
 bouillon culture, and by noting the results : (a) Death in three days 
 or less results from fully virulent cultures; (b) death in three to five 
 
152 TUB SPECIFIC INFECTIONS. 
 
 days from one of medium virulence; (c) death after a longer time, or 
 only local changes, from weak cultures. 
 
 Some bacilli, known as the pseudodiphtheria bacillus, bacillus 
 xerosis, etc., microscopically resemble the Klebs-Loeffler bacillus. An 
 interesting and vital point is that pseudodiphtheria bacilli may be- 
 come virulent and may kill; they are not neutralized by the diph- 
 theria serum but only by the pseudodiphtheria serum (Alice Hamil- 
 ton, Spronek, Ruediger). 
 
 Dissemination. — Diphtheria is disseminated (1) by patients acutely 
 ill with the disease ; the nasal, throat and laryngeal secretion or mem- 
 brane may be coughed into the face or mouth of one of the family, 
 nurse, or attending physician. Infections in which the patient is not 
 kept in bed are especially dangerous, for children going to school may 
 impart to others a most virulent diphtheria, though the same bacilli 
 have produced in them little or no constitutional reaction; (2) by 
 healthy individuals, in 1 per cent, of whom the germ is found without 
 causing diphtheria, since individual predisposition is almost as 
 necessary to infection as virulence in the microbe; (3) by fomites, 
 especially damp cloths, in which the germ may live for months ; cul- 
 tures have been made from dry cloths after iive months; the germ 
 lives in gelatin from twelve to eighteen months; and (4) as the germ 
 may be cultivated in dust, it is probable that it may be spread by the 
 wind. Although the bacillus has been cultivated from cheese, milk, 
 and eating utensils, many question this mode of propagation. It is 
 not demonstrated that domestic animals convey the disease. Diph- 
 theria is endemic in all thickly populated districts, and from these, 
 epidemics develop from time to time. Unlike scarlatina, which is 
 growing milder, diphtheria epidemics are apparently increasing in 
 virulence, although far less malignant than in the middle ages and 
 earlier modern times. 
 
 Age. — Most cases occur between the second and fifteenth years, 
 and most deaths occur between the second and fourth years. Jacobi 
 has seen three cases in the new-born, but infants at the breast are far 
 less exposed than creeping children whose hands and mouths come 
 into close contact with dirt and dust (Jacobi). It develops more 
 frequently in girls than in boys. Adults are frequently affected. 
 
 Season. — Most cases occur in the cold months. Predisposition, 
 bad teeth, stomatitis, hypertrophied tonsils, nasopharyngeal and 
 bronchial catarrh, measles, and nervous affections, are predisposing 
 factors. Some individuals are temporarily, and some permanently, 
 immune. One attack confers no immunity, and in this respect diph- 
 theria resembles erysipelas, pneumonia and rheumatism. 
 
 Symptoms. — There are three major localizations of diphtheria, the 
 throat, the nose and the larynx. . 
 
 1. Pharyngeal Diphtheria. — The typical case is pharyngeal. 
 
 (a) The simple localized diphtheria begins after an incubation of 
 two to seven days with fatigue, pallor, coated tongue, anorexia, dys- 
 phagia, pain beneath the angle of the jaw and vomiting. Chilly 
 
D1PHTHEBIA. 153 
 
 sensations, fever and thirst, pharyngeal voice, and sometimes abdomi- 
 nal distention, ensue. Infants refuse the bottle on account of nasal 
 obstruction. 
 
 The pharynx is moist, glistening, and characteristically purple- 
 red, with later, areas of gray, yellowish, or dirty green color, 
 which vary in extent from small white bands to irregular, gelatinous 
 elevations or masses, located on the tonsils, epiglottis, palate, pillars, 
 arch, or pharynx. Except in the very incipiency of the disease, they 
 are adherent, and, on removal, leave red, bleeding spots which are 
 soon covered again with membrane. The pharyngeal tonsil alone may 
 be involved, but may easily be overlooked without systematic exami- 
 nation. The breath is septic in odor. The nose is not wholly free and 
 some discharge is the rule. The glands at the angle of the jaw are 
 tender, and fever reaches 102°, may be rather irregular, or may be 
 absent. In 90 per cent, of patients who recover, the fever does not 
 exceed 102°. The patient usually recovers in seven to ten days. 
 Otitis, suppurative adenitis, vomiting, and albuminuria are less 
 common than in the more severe forms. 
 
 Wagner, Weigert, and Oertel, have shown that the diphtheritic 
 membrane is composed: (i) Of necrobiotic tissue. The superficial 
 epithelium, and, later, the deeper structures, are necrosed ; the bacilli 
 are found in the superficial layers and streptococci and staphylococci 
 may be found more deeply situated; the necrobiosis may be also 
 noticed in the connected lymph-glands, and in the internal organs 
 ( Weigert's coagulation necrosis, or hyaline transformation of the dead 
 cells), (ii) Somewhat deeper, the membrane is composed of more or 
 less marked fibrin exudation, which is probably a conservative, 
 walling-off process, and also pervades the tissue initially necrosed, 
 (iii) In the deepest part of the membrane, emigration of leukocytes 
 occurs. In most adults the membrane is thrown off by the fourth or 
 fifth day ; in children by the seventh or eighth day. 
 
 The form described is the classical type of mild local infection. 
 Even though the bacilli may be virulent, the tissues and blood resist 
 the infection. Several deviations from this type are often clinically 
 misinterpreted: (1) In " catarrhal diphtheria" the membrane is 
 often absent or atypical and pultaceous. This type is especially com- 
 mon in families where the more severe forms are seen. The bacilli, 
 redness, oedema, and swelling, are present. (2) Diphtheria may 
 resemble follicular pharyngitis, and between them there is no abso- 
 lute distinction except bacteriologically ; in diphtheria the red is 
 brighter, the tendency to fuse is greater, and the spots are yellow, 
 gray, or green, while in angina, the color is duskier, the areas more 
 discrete, yellow, and pus-like. (3) Follicular tonsillitis may be very 
 closely simulated, and then is only distinguished bacteriologically. 
 (4) In chronic diphtheria, there is a variable deposit upon a red, 
 relaxed, oedematous pharynx. The glands may be swollen, but usu- 
 ally there are no toxemic symptoms. (5) The latent diphtheria of 
 Heubner, which occurs in marantic subjects, may easily escape 
 detection. 
 
154 TEtE SPECIFIC INFECTIONS. 
 
 (b) The diphtheritic general infection is difficult to describe in all 
 its variations. It begins with high fever and such febrile toxcemic 
 symptoms as headache, depression, insomnia, rapidly increasing 
 anaemia, anorexia, dysphagia, and vomiting. Albuminuria and ne- 
 phritis may appear later, with rapid respiration and the heart move- 
 ment following the fever, the tones being dull and often accompanied 
 by a systolic murmur. The pharynx is dark red, swollen, and glisten- 
 ing, and a membrane is seen on the tonsils or pharynx. This mem- 
 brane is thin and gray ; it begins in the form of streaks, or as a thin 
 veil over the pharynx ; it tends to spread very rapidly and sometimes 
 diffusely and with offensive secretion. The hard palate and the 
 superior part of the soft palate are usually normal. The neck is 
 tender from glandular intumescence. The nose is often closed by a 
 purulent secretion and diffuse membrane, and oral breathing results. 
 There is a type peculiar to young children who, with initial nasal 
 symptoms and without appreciable throat symptoms, suddenly de- 
 velop laryngeal stenosis, and, in the pre-antitoxin days, almost in- 
 variably died. In severe cases the heart is irregular, with gallop- 
 rhythm ; there are throat paralysis, infiltration of the neck, dyspnoea, 
 cyanosis, albuminous urine, tympany, swollen liver and spleen, ante- 
 mortem fall of temperature, and death resulting from pneumonia, 
 cardiac insufficiency, nervous symptoms or paralysis or nephritis. 
 
 (c) Septic diphtheria, according to Baginsky, is due to the diph- 
 theria toxins, and is therefore seldom observed since the introduction 
 of antitoxin. Other writers maintain that streptococcus and staphy- 
 lococcus infection determine this septic type. The yellow-gray exu- 
 date becomes a dirty green or brown from hemorrhage, is ichorous 
 and horribly fetid, and may reach the nose or larynx, causing ero- 
 sions, necroses, and stenosis. It often involves the lymph glands 
 (adenitis) and connective tissue (periadenitis). The tongue is dry; 
 respiration difficult; and nephritis, generalized hemorrhage or local 
 arterial ulceration, failing pulse, low temperature, swollen joints, and 
 intumescence of the abdomen, liver, and spleen, usually result fatally. 
 In 1881, 94 per cent, and, in 1884, 66 per cent, of cases of this type 
 died (Grlaeser). 
 
 The initial, atypical fever in diphtheria may be maintained by 
 otitis, pneumonia, adenitis, and other complications in the severer 
 types of diphtheria, or by concomitant diseases, such as measles, 
 scarlatina or tuberculosis. The temperature of sepsis may develop. 
 A pre-agonal perturbation may be observed, or there may be ante- 
 mortem collapse. As in perforative peritonitis, algidity is due to 
 febrifuge toxins. These statements apply chiefly to cases untreated 
 with antitoxin. 
 
 Leukocytosis of the polymorphonuclear type develops in 90 per 
 cent, of diphtheria cases. When absent, the infection is either very 
 severe or very slight. It does not correspond to the severity of the 
 disease nor to the fever curve. It disappears in favorable, and per- 
 sists in severe, cases. 
 
DIPHTBER1A. 155 
 
 2. Nasal Diphtheria. — Diphtheritic rhinitis, catarrhal or croup- 
 ous, due to the diphtheria bacillus, may usher in the disease or 
 accompany the benign or more usually, the severe forms. The serous 
 and often sanious or bloody nasal discharge excoriates the alee nasi, 
 lips and cheeks; membrane is often expelled; infection may travel 
 to the eyes, lachrymal sacs, antrum or ears. Cervical adenitis is 
 frequent, for the nasal lymph supply is most abundant and, as Jacobi 
 pointed out, enlargement of the angular glands is always suspicious. 
 The prognosis is nearly always grave, and convalescence very tardy. 
 In contrast with this severe form, usually diphtheritic, though some- 
 times diphtheroid (streptococcic), there is a fibrinous rhinitis usually 
 subacute or chronic and generally observed in children, which is due 
 to the Klebs-Loeffler bacillus (82 per cent.), or to the streptococcus 
 (18 per cent, of the cases) ; the membrane is abundant. This form 
 is obviously dangerous to other children, since the remarkable ab- 
 sence of constitutional reaction, despite the menacing discharge, does 
 not prevent play or school-going. It responds readily to antiseptic 
 douches. Cultures should be taken, before adenoid operation, in all 
 children with nasal discharge. 
 
 3. Laryngeal Diphtheria or Croup. — Most cases (85 per cent.) 
 of croup are diphtheritic, though some are streptococcic ; their symp- 
 toms are identical. Frequency : Diphtheria involves the throat in 84 
 per cent, and the larynx in 16 per cent, of the cases. Forms: (a) 
 Catarrhal laryngitis, due to the diphtheria bacillus, produces symp- 
 toms of short duration, usually two or three days ; they may be severe 
 or even stenotic, (b) Diphtheritic laryngitis (croup) is descending 
 in 97 per cent, of cases — i. e., secondary to pharyngeal or nasal diph- 
 theria ; even in the rare and seemingly primary cases there is usually 
 some pharyngeal involvement. The child is usually hoarse at night 
 or early in the morning, coughs the croupy cough, and then after 
 twelve to twenty-four hours is distinctly dyspnoeic. Aphonia is com- 
 mon but not invariable. The stridor becomes menacing and then we 
 know that the enduring croup is diphtheritic. The stenosis is due to 
 membrane in the epiglottis, true cords, trachea, or even in the bronchi. 
 The membrane is less adherent than in the pharynx, and sometimes 
 more pultaceous. The accessory muscles of respiration come into 
 play and there is inspiratory retraction of the thorax and epigastrium, 
 especially in rhachitic children. Excursion of the larynx up and 
 down, extreme restlessness, and temporary improvement after ex- 
 pectorating the membrane, may also be noted. The stenosis is accen- 
 tuated by the central, immovable position of the vocal cords, by swell- 
 ing in the subchordal tissue, and by muscular spasm. The cough is 
 usually rather hoarse than metallic, is often periodic, is increased 
 after tracheotomy or intubation, and often evacuates both the mem- 
 brane and tube. Cough may be wholly absent because of decreased 
 reflex bronchial excitability. Fever is usually absent. The pulse 
 rate increases with augmentation of the stenosis because the vessels 
 contract from central stimulation. The respite following the raising 
 
156 THE SPECIFIC INFECTIONS. 
 
 of the membrane is usually transient, exacerbations occur, and finally, 
 unless intubation or tracheotomy is performed, dyspnoea becomes con- 
 tinuous, with stagnation of secretion in the tubes, absence of the 
 vesicular murmur, stridor, extension downward of the membrane, loss 
 of strength, increasing rapidity and weakness of the pulse, cold 
 clammy skin — in short, the complete picture of carbon-dioxide 
 poisoning and total asphyxia develops. In some instances, perichon- 
 dritis, deep necroses, or gangrene may develop. (In reading older 
 medical works and pathologies, the student may be confused with the 
 use of the terms " croup " and " diphtheria." Anatomically it was 
 held that croupous and diphtheritic membranes differed chiefly in 
 degree — croupous being more superficial and benign, diphtheritic 
 being more deep and malign. In the present connection we use the 
 term " croup " as synonymous with laryngeal diphtheria. ) 
 
 4. Other Localizations. — (a) Diphtheria of Shin. — The/ diph- 
 theria bacillus may produce membrane on the eye, lips, nose, navel, 
 neck, genitalia, and extremities. It is usually associated with 
 pharyngeal localization. The skin is hard and infiltrated, the secre- 
 tion is corrosive, the contiguous lymphatics are involved, and some- 
 times cellulitis or phlegmon may result. Other instances of so-called 
 " wound diphtheria " are due to the streptococcus — the most common 
 cause of skin membranes. In tracheotomy, the membrane which 
 forms in the wound is mostly streptococcic. 
 
 (b) Diphtheritic Vulvo-vaginitis. — Genital involvement ranges 
 under 1 per cent., is dangerous, and usually follows severe pharyngeal 
 diphtheria ; it consists of diffuse membrane, painful rhagades, ulcers, 
 and foul secretion, with intumescence of the lymph glands. A diph- 
 theroid (usually streptococcic) form is also encountered. 
 
 (c) Diphtheritic Ophthalmia. — This localization is (a) false or 
 diphtheroid (due to pus cocci) or (b) genuine or diphtheritic. Diph- 
 theritic ophthalmia, chiefly in young children, occurs in 3 per cent, 
 of cases. It may be primary in the eye, or secondary to nasopharyn- 
 geal diphtheria. 
 
 (d) Diphtheritic Otitis. — This does not occur in over 5 or 6 per 
 cent, of the cases (as against 33 per cent, of otitis in scarlatina and 
 nearly 100 per cent, in measles). The orifice of the Eustachian 
 tube or the middle ear may be reached by the diphtheria bacillus 
 which usually travels from the throat. 
 
 Complications and Sequels. — The most important are heart paralysis, 
 nephritis, and diphtheritic paralysis. 
 
 1. Cardiac Complications (Diphtheritic Heart Paralysis). — 
 Anatomically, the heart muscle is the seat of early changes. It is 
 soft, thin, friable, light brown or yellow in color, and fatty ; it is the 
 occasional seat of endocardial and myocardial hemorrhages, acute 
 interstitial myocarditis and fragmentation or myolysis, which Ep- 
 pinger, in describing eighteen cases of sudden death, considers the 
 usual cause of death. Pericarditis, with septic or hemorrhagic effu- 
 sion, is not frequent. Permanent changes due to endocarditis (in 2 
 per cent, of fatal cases) or to myocarditis are uncommon. 
 
DIPHTHERIA. 157 
 
 Clinically, the tones are muffled. The first tone is impure or ob- 
 scured by a systolic murmur (90 per cent, of cases) ; the second pul- 
 monic is accentuated, the rhythm is disturbed (60 per cent.) and 
 sometimes there is gallop-rhythm and embryocardia. The pulse is 
 soft, dicrotic, increased from 80 to 120 (or 150), but it may be slow. 
 Heart-failure is more frequent than in any other acute infection, not 
 excepting pneumonia. Syncope on sitting up is fairly common. 
 Diphtheritic heart paralysis occurs (1) early in severe or gangrenous 
 types, or (2) late (in 10 to 20 per cent, of diphtheria cases) after 
 three to four or six weeks, when convalescence is apparently estab- 
 lished. It is marked by copious vomiting from vagus neuritis, pain 
 in the chest and epigastrium, cardiac dilatation, cold extremities, 
 pallor, dyspnoea, cyanosis and convulsions. The pulse is often irregu- 
 lar, fast, or with equally ominous significance, slow. Heart failure 
 is explained in various ways (a) acute interstitial myocarditis 
 (Khomberg) ; (b) myolysis (Eppinger) ; (c) sudden centric vaso- 
 motor paralysis (Hasse) ; (d) neuritis of the cardiac plexus or of the 
 vagus or phrenic nerves; (e) cardiac thrombosis causing cerebral 
 or pulmonary embolism; 33 per cent. die. 
 
 2. Diphtheritic Nephritis. — (a) Albuminuria, resulting from 
 renal degeneration, occurs in 50 per cent, of all cases and in 100 per 
 cent, of severe cases. ( b) In light forms of nephritis there is some 
 albumin; the specific gravity and quantity of the urine are about 
 normal, and there are leukocytes or epithelial cells with indistinct 
 nuclei, the cells being highly refractive and coarsely granular. Blood 
 is rarely found. There are some hyaline and granular casts. These 
 findings are caused by the toxins and correspond in time and degree 
 to the diphtheritic local process in the pharynx, (c) The severe forms 
 of nephritis almost always occur in the severe general infection or in 
 septic types and are characterized anatomically by diffuse paren- 
 chymatous changes, necrosis, hemorrhage, and exudation. Albumin, 
 epithelium, casts, and cylindroids, are abundant. Hematuria is rare, 
 although hemorrhage into the kidney substance is frequent anatom- 
 ically. Although nephritis influences the prognosis, diphtheritic 
 nephritis rarely produces hydrops or ursemia and " is not an inde- 
 pendent factor as in scarlatina." It very rarely becomes chronic. 
 
 3. Diphtheritic Paralysis. — The paralyses occur clinically and 
 experimentally from toxsemia in 3 to 10 per cent, of cases. The per- 
 centage, apparently, has not been reduced by the use of antitoxin 
 (v. i.). The frequency and intensity of the paralysis is usually di- 
 rectly proportional to the intensity of the diphtheria; the causal 
 diphtheria, in some cases, has apparently escaped detection. 
 
 (a) Early Diphtheritic Paralysis. — This occurs in septic cases at 
 the acme. Dysphagia is its most common form. There is danger of 
 inhalation pneumonia, especially in stupid cases. The patellar re- 
 flexes may disappear. Most cases die. 
 
 (b) Post-diphtheritic Paralysis. — This, the typical variety, occurs 
 after two or three weeks and usually follows throat lesions since laryn- 
 
158 THE SPECIFIC INFECTIONS. 
 
 geal cases are likely to die early; Baginsky saw it principally in 
 adults and Eolleston mostly between the years of three and six. 
 Growers claims that all throat troubles leading to paralysis are diph- 
 theritic, though Bourges and others cite cases of paralysis after simple 
 angina. The most common paralysis is that of the palate, which 
 causes dysphagia, anaesthesia of the throat and nasal speech. From 
 central or peripheral change the pupils become wide and react to 
 light but not to accommodation (Donders). The arms frequently 
 escape. Ataxia may be the first symptom. The reflexes disappear 
 early whether actual paralysis is reached or not. and the muscles react 
 slowly, if at all. to the faradic current, although the reaction of 
 degeneration by no means runs parallel to the degree of loss of volun- 
 tary motion. The muscles waste considerably. The palsied limbs 
 are sometimes painful and the muscles and nerve trunks are often 
 tender. The trunk, bladder and rectum are more commonly involved 
 than is usually admitted. The sensory nerves suffer less, sensation 
 being largely retained above the knees. Sensory disturbance may be 
 noted in the rectal, genital and vesical twigs. The cranial nerves 
 (strabismus, ptosis, diplopia), the phrenic nerve and the vagus (re- 
 current paralysis, superior laryngeal, cardiac branches), may be in- 
 volved : fearful abdominal pains with threatening collapse attributable 
 to sympathetic involvement, and sometimes psychical disturbance 
 may be noted. Anatomically, disintegration of the medullary sub- 
 stance, multiplication of nuclei in Schwann's sheath, granular degen- 
 eration, and even total loss of the axis cylinder and sometimes foci of 
 hemorrhage, are present, the changes being almost totally paren- 
 chymatous. Diphtheritic neuritis (actual nerve inflammation) is 
 seen almost wholly in the palate and is due to local invasion from the 
 inflamed throat. The patient recovers in two to three weeks if the 
 pharynx alone is involved, and in three to eight months if the limbs 
 are affected. Death results in 18 per cent, of the cases, chiefly from 
 vagus involvement. 
 
 (c) Organic Central Changes. — The brain is slightly congested 
 and oedematous. Degenerated areas may occur in the crura, medulla, 
 or pons. Accidental findings are cerebral hemorrhage, embolism 
 from heart thrombi, and acute encephalitis (possibly terminating in 
 focal sclerosis^. The literature contains 85 instances of hemiplegia 
 (Eolleston, 1905). In the spine, hemorrhage, exudation into the 
 nerve roots, meningitis, and degeneration of the motor cells and their 
 roots, have been noted. The degenerative cerebrospinal lesions not 
 infrequently occur with multiple neuritis. 
 
 4. Bespeeatoby Coalpeicatpoxs. — The bronchi and trachea may 
 remain free. There may be membrane formation (in 50 per cent, of 
 fatal cases) or purulent secretion. Lobar pneumonia is a genuine 
 complication, but bronchopneumonia is present in 50 to 80 per cent. 
 of the fatal cases and is caused by the Klebs-Loeffler bacillus alone, or 
 by the pus or pneumonia cocci, by the colon, proteus or pyocyaneus 
 bacilli. Anatomically, some cases are due to downward extension of 
 
DIPETHEEIA. 159 
 
 the bronchitis ; some are hematogenous infarcts or abscesses ; others 
 are due to inhalation, and still others, seen after intubation or trache- 
 otomy, rather resemble lobar pneumonia and are elevated and granu- 
 lar in appearance. Increase of pulse and respiration-rate, local con- 
 solidation, and accession of fever are observed. Pleurisy (serous, 
 hemorrhagic or purulent) is not often encountered. 
 
 5. Alimentary Tract. — Mouth. — Fissures, sordes, membrane or 
 ulcers on the lips, suppuration in the tonsils and in the retropharyn- 
 geal space, gangrene and deforming cicatrices sometimes occur. 
 The oesophagus is usually intact, but the diphtheritic process, in sep- 
 tic cases, may reach downward and produce stenosis. 
 
 Stomach. — Epigastric pain and vomiting are most often cardiac ; 
 death is usual in patients who develop vomiting late in the disease. 
 The rare hemorrhage and membrane formation usually escape clinical 
 recognition. 
 
 Intestines. — Constipation is usual; in septic forms, thick, foul or 
 even dysenteric evacuations may be exceptionally observed. Anatom- 
 ically, there may be membrane formation and swelling of Peyer's 
 patches. The liver is swollen from fatty or cloudy degeneration or 
 from congestion, in which latter case it also becomes painful. Icterus 
 is rare. Splenic tumor is found in septic types especially. 
 
 6. The Skix. — The skin is usually normal, except for the febrile 
 hyperemia, cardiac pallor, croup-cyanosis or septic grayness. The 
 following alterations may be observed: Herpes, sweats, petechia?, 
 symmetrical gangrene and septic dermatomyositis ; they usually occur 
 with adenitis, nephritis, pneumonia, ulcerative endocarditis and 
 scarlatiniform or morbilliform erythemata. Scarlatina or measles 
 may actually complicate diphtheria. 
 
 7. The Geaxds. — The anterior cervical glands are swollen, ten- 
 der and painful. In the most severe forms periadenitis follows with 
 diffuse involvement of the cellular tissue (angina Ludovici), section 
 of which evacuates serum, seldom pus. Glandular and articular 
 changes are less frequent than in scarlatina. Muscular degeneration, 
 interstitial infiltration, and tendency to separation of the muscle- 
 fibers (myolysis or fragmentation) are observed in the heart or even 
 more clearly in the diaphragm. 
 
 Diagnosis. — To the naked eye a thick, adherent membrane, which 
 is not removable without hemorrhage and which leaves ulceration 
 (Bretonneau), is sufficiently characteristic. The enlarged glands are 
 of diagnostic value. A positive bacteriological diagnosis is important, 
 in such cases as have actual membrane, diffuse reddening, and ton- 
 sillitis ; but three or four negative examinations are necessary before 
 negative conclusions can certainly be drawn. The statistics of 
 Heubner and of Baginsky show positive findings in from 92 to 98 
 per cent, of cases in which the climcal diagnosis of diphtheria has 
 been made. These figures are probably most nearly correct, although 
 others find the diphtheria bacillus in a notably lower percentage. 
 The nose, nasopharynx and pharynx must always be examined in 
 
160 TEE SPECIFIC INFECTIONS. 
 
 sick children and adults. In suspicious cases, particularly when 
 cultures cause considerable delay, antitoxin should be given at once. 
 
 The health departments in large cities provide cultures, stations at 
 which cultures and antitoxin may be obtained, and central and sub- 
 sidiary laboratories for diagnosis. The Chicago Health Department 
 has an able corps of physicians for free treatment, consultation and 
 intubation. It is easy to' obtain, on sterile cotton on a probe, a smear 
 from the membrane or suspicious focus, to rub it on the serum with- 
 out breaking its surface, and to put the tin box containing it in the 
 incubator or under the axilla until the brood oven can be reached. 
 In half a day characteristic cultures are obtained. Direct smears 
 from the throat on a slide very often show the bacillus. In small 
 places communal laboratories can be maintained easily, and com- 
 petent young practitioners found to do this, and other clinical mi- 
 croscopy. In laryngeal diphtheria the bacillus is usually found on 
 the pharynx, but not on the tonsils. Repeatedly negative findings 
 are of value in the pseudodiphtheritic or diphtheroid pharyngitis, 
 rhinitis, laryngitis, and bronchitis, — e. g. } membranes due to strepto-, 
 staphylo-, and pneumococci, aphthous growth, syphilis, and the colon 
 bacillus. The scarlatinal membrane has been considered. In Yin- 
 cent's angina {q. v.), angina diphtheroides or angina ulceromem- 
 branosa, described by Vincent (1898), there is a whitish-yellow or 
 grayish-brown membrane which may be confused with diphtheria 
 and syphilis and which is caused by the symbiosis of two otherwise 
 innocuous parasites; the bacillus fusiformis (6 to 12/*, staining 
 readily with methylene blue and fuchsin), and the spirochseta darti- 
 cola (twice as large, and not growing in cultures) . The infection is 
 usually mild. 
 
 Course and Prognosis. — Aside from complications, the average 
 course is one week, or possibly two. It is more favorable in diph- 
 theria of the tonsils and skin than in that of the nose. The prognosis 
 always must be guarded, (a) Without serotherapy the danger is 
 great, since light cases may become severe or extend to the larynx. 
 (b) Epidemics vary in virulence, 30 to 50 per cent, mortality having 
 been observed twelve to fifteen years ago. (c) According to Grlaeser, 
 in the first year the mortality is 77 per cent., and sinks with each 
 year until it is, at ten years, 20 to 25 per cent. ; after ten, 2 to 5-J per 
 cent. ; after thirty and forty, 1 to 3 per cent, (d) Other factors are 
 debility, wide extension of the infection from part to part, adenitis, 
 and croup; the general diphtheritic infection or septic forms with 
 hemorrhage or gangrene; heart and renal complications; rapid and 
 weak or slow pulse : ecchymoses and late vomiting ; or involvement of 
 the brain or nerves, (e) In 946 fatalities studied by White and 
 Smith, about 50 per cent, died of bronchopneumonia, -usually after 
 intubation or tracheotomy; 25 per cent, died of cardiac complications, 
 and 25 per cent, of early severe toxaemia, though some succumbed to 
 asphyxia or late paralysis. (/) Coincidence with other infections is 
 ominous, such as measles, in which the exanthem may become hemor- 
 
DIPHTHERIA. 161 
 
 rhagic, and a lethal respiratory catarrh usually results; coincidence 
 with typhoid, frequently with gangrene or laryngeal stenosis ; and 
 with scarlatina, summer diarrhoea, and tuberculosis. The disease is 
 less severe in conjunction with varicella and pertussis. Diphtheria 
 belongs to the recurrent infections. 
 
 Treatment. — 1. Prophylaxis. — For the physician, this begins with 
 the case in hand. Isolation must be absolute. In needy families the 
 isolation hospital offers the best solution. In Boston it has reduced 
 the mortality of diphtheria to one-third or one-sixth of its former 
 rate. All suspicious throat cases should be isolated pending their 
 immediate clinical and cultural evolution. Xot only should a sick 
 child be isolated, but other children in the family should be kept from 
 school and away from playmates. Of course, the sick one must be 
 isolated until the throat gives two negative cultures : three weeks is 
 the average isolation. The physician may protect himself by exam- 
 ining the throat through a piece of glass, and may avoid carrying 
 the germs by slipping on a surgical gown and washing both face and 
 hands with bichloride of mercury or similar solution. In fatal cases 
 the body should be wrapped in a sheet saturated with bichloride, and 
 buried privately in a tightly closed casket. Those exposed to infection 
 may receive antitoxin, and should gargle the throat once with J of 1-per- 
 cent, solution of silver nitrate, or often, with bichloride of mercury 
 ("5W5")' ^he clothing, blankets, rugs, etc., must be steamed. After 
 convalescence, the walls of the room should be rubbed with bread 
 which is then burned, the woodwork should be washed with 2-per-cent. 
 lysol solution or bichloride of mercury and the room should be 
 fumigated (see Smallpox). "Under prophylaxis may be included 
 the building up of the general physiological resistance and the treat- 
 ment of chronic catarrh of the nose, throat and bronchi. 
 
 2. Local Teeatatext. — Though local treatment of the throat is less 
 important than before the days of serotherapy, the antitoxin does not 
 always kill the bacilli, and does not affect the associated streptococci. 
 Caustics are never necessary. In children such mild antiseptics as 3- 
 per-cent. boric solution and 3- to 10-per-eent. potassium permanganate 
 solution, should be used lest they be swallowed. The child is held in 
 the nurse's arms with its arms and body firmly wrapped in a sheet. 
 The mouth is made to open by closing the nostrils, and a piece of wood 
 or cork is inserted between the teeth. The throat is then swabbed. 
 It is a harsh procedure and the effects are apparently more than 
 offset by the resultant exhaustion. In adults 1 to 1000 bichloride, 
 25-per-eent. hydrogen peroxide, or 1-per-cent. carbolic solutions, or 
 iodoform salve, may be used, or Loefflers solution, which is as 
 follows : 
 
 I£ Mentholis 10 parts. 
 
 Toluolis 30 parts. 
 
 Liq. ferri eliloridi -i parts. 
 
 Alcoholis absoluti , 60 pa*rts. 
 
 11 
 
162 THE SPECIFIC INFECTIONS. 
 
 Loeffler's solution should be kept well corked in a dark bottle. Local 
 injury, such as opening up new wound surfaces for infection, must be 
 avoided. In nasal irrigation the tube is held horizontally, so that 
 fluid may return by the other nostril. A kettle containing a weak 
 carbolic solution should be kept steaming in the room. 
 
 3. Serotherapy. — Behring (1890) borrowed Ehrlich's results 
 with ricin and abrin to establish the units of immunization, and 
 (1893) used the diphtheria antitoxin on diphtheria patients. The 
 method of action of an antitoxin is vital or active (Buchner, Roux, 
 Martin) though some (Behring and Kitasato) consider that it is 
 chemical or passive. 
 
 1. Technique. — A syringe with an asbestos plunger should be used. 
 The syringe need not be boiled each time, but should be cleaned after 
 each injection with water until the serum is washed out; it should 
 then be washed with carbolic acid or alcohol, which should be thor- 
 oughly removed each time lest it coagulate the antitoxin at the next 
 injection. Syringes are generally supplied with the serum. With 
 ordinary surgical antisepsis, inject the antitoxin into the subcutane- 
 ous tissue of the thigh in adults, and into the interscapular region in 
 children. In very severe infections, intravenous injections give re- 
 sults eight hours earlier. The unit is 1 c.c, which counteracts ten 
 times the minimum dose of diphtheria poison fatal to a 300 gm. 
 guinea-pig. 
 
 2. The dosage is rather empirical, depending on the localization, 
 age, and severity of the disease and the effects produced. After ad- 
 ministration the discharge should lessen, the membrane exfoliate, the 
 fever fall, and toxaemia decrease. At least twice as much antitoxin is 
 necessary for cure as for immunization. After eight hours, three 
 times as much is necessary as at the beginning; after twenty-four to 
 thirty-six hours, eight times as much. As we cannot measure the 
 toxins, so we cannot exactly specify regarding the antitoxin dose. 
 Personally, the author prefers an initial dosage of 3,000 to 5,000 
 units to insure results and to avoid delay and frequent repetition. 
 The decreased bulk of present preparations also allows a larger 
 dosage. In severe cases twice the above amount should be given. 
 McCallum, above all others, has emphasized the importance of full 
 doses, and he speaks of doses of 10,000, 30,000, or even 50,000 units 
 in desperate cases, because results must be produced. Sutherlin gave 
 a total of 498,000 units in one case! 
 
 3. Effects. — (a) The local changes are lessened, the mucosa be- 
 comes redder, and the membrane more yellow and it exfoliates in one- 
 half to three days, with decrease in glandular swelling. Extension 
 afterward is rare, (b) The fever falls by crisis or by lysis, unless 
 there are complications. A temporary rise in temperature sometimes 
 occurs. Antitoxin is given until the fever falls, (c) The pulse is 
 lessened, and hyperleukocytosis is decreased. Light cases rarely 
 become severe, and nonseptic rarely become septic, unless there is 
 co-existing tuberculosis, syphilis, etc. The kidneys are never injured. 
 
DIPHTHERIA. 163 
 
 The author believes that paralysis and heart failure are less frequent 
 when the administration of the antitoxin is prompt. Both of these 
 complications are thought to occur in the same proportion as in pre- 
 serum days. But even if their percentage is not absolutely reduced, 
 many patients now live who would previously have died before de- 
 veloping paralysis, (d) The mortality is reduced from 41 (46 per 
 cent.) to 15 per cent. (Siegert's collection 42,000 cases) ; to 10 per 
 cent. (Wenner, 9.8 per cent., 132,500 cases, American cities) ; or to 
 6.7 per cent. (Chicago Health Department Report). According to 
 Bayeux, the mortality in 230,000 diphtheria patients was 55 per cent, 
 before, and 16 per cent, after, the introduction of antitoxin. The 
 fatal cases and severe complications are lessened in direct ratio as the 
 antitoxin is given early; if on first day of disease, less than 1 per 
 cent ; second day, 2 per cent. ; third day, 8 to 10 per cent. ; fourth day, 
 14 per cent. Failure to use antitoxin is criminal neglect; 50 per 
 cent, of croup cases regress with the use of antitoxin, and heart 
 lesions are reduced 50 per cent, in fatal cases, (e) Antitoxin is a 
 prophylactic, and should be given in special instances ; e. g., to weak 
 or very young children (in smaller doses). It protected for two or 
 three weeks in all but 0.7 per cent, of 1,000 cases (Zuppinger). (/) 
 The sequels are: (i) Abscess formation; (ii) exanthemata, which are 
 local (on the fourth or fifth day) or general (in one to two weeks), 
 are due to individual peculiarity or some unknown element in the 
 antitoxin, and appear as urticaria, morbilliform, scarlatiniform, or 
 petechial eruptions; antitoxin rashes occur in 33 per cent, of the 
 cases, and are said to be decreased by calcium chloride, gr. xv, for 
 three days after the injection (better) ; (iii) nephritis, always due, 
 however, to the diphtheria itself; (iv) sudden death which results 
 from vomiting into the larynx, shock, lymphatic diathesis, and from 
 other disease ; sudden death is exceedingly rare ; (v) tetanus has been 
 inoculated. In a few cases where antitoxin was injected for prophy- 
 laxis, the author has seen extremely severe symptoms ; pallor alter- 
 nating with flushing, chills, fever, renal suppression, oedema of the 
 skin and pharynx and very severe cardiac weakness ; these cases to a 
 certainty had no diphtheria, for throat cultures were first taken ; the 
 statement, therefore, that antitoxin never injures does not hold for all 
 prophylactic doses. This " hypersusceptibility " or anaphylaxis, has 
 lately been studied by Rosenau and Anderson, who refer the reaction 
 merely to the foreign proteid introduced in the injection. 
 
 4. General and Symptomatic Treatment. — A rich fluid diet of 
 milk, eggs, etc., with tonics, cinchona, wine, etc., is given. In 
 marked dysphagia rectal feeding is indicated. Forced feeding by 
 the stomach tube or nasal catheter is likely to injure the throat. 
 
 Sepsis. — Concentrated diet by mouth and rectum, alcohol ad libi- 
 tum, oxygen, saline infusions or enemata, strychnine, iron, and anti- 
 streptococcic serum should be given; all measures are usually of no 
 avail if tens of thousands of units do not give relief. Crede's collar- 
 gol is given intravenously in severe cases ; better, in 586 cases, found 
 that it reduced the death rate by 8 (to 20) per cent. 
 
164 TEE SPECIFIC INFECTIONS. 
 
 Paralysis. — General stimulation and alimentation are indicated; 
 electricity is of little or no avail ; massage, baths and strychnine are 
 useful in the later stages. 
 
 Heart Failure. — The ice-bag is indicated for stormy heart action ; 
 strychnine, iron, oxygen, digitalis, coffee, alcohol, aromatic wines and 
 camphor should be given. (See Scarlatina, for dosage table.) 
 For severe abdominal pain and vomiting, usually an evidence of 
 cardiac failure, the above remedies, and champagne with menthol 
 and carbolic acid, are indicated. The heart must be watched far into 
 apparently complete convalescence. 
 
 Nephritis. — Nephritis cannot be prevented. Alcohol, tincture of 
 ferric chloride, beef tea and eggs are to be avoided ; vichy, cardiants, 
 milk diet, baths, laxatives, and care of the skin are indicated. 
 
 Local Diphtheria. — Two per cent, nitrate of silver in balsam of 
 Peru affords relief in vaginitis; ice applications, atropia, and silver 
 in ophthalmia ; over inflamed glands, a 10 per cent, ichthyol salve 
 may be applied; local diphtheria necessitates antitoxin, irrespective 
 of its location. 
 
 Croup. — Mercurial inunctions are given, together with steam 
 sprays or tents and ice locally applied ; for emergencies, the hot water 
 may be turned on in the bath-room, after closing the door ( Jacobi) ; 
 or the child may be held over a pail of water into which live coals are 
 thrown; emetics may be administered, with which wine is given 
 because emetics often fail in carbon-dioxide narcosis (Strieker) ; 
 retraction of the chest walls, suffocation, cyanosis, and cold extremi- 
 ties, necessitate intubation or tracheotomy. 
 
 O'Dwyers Intubation. — Advantages. — It is bloodless, easier, and 
 quicker than tracheotomy; there is less wound infection, and it is 
 less objectionable to the family. 
 
 Disadvantages. — Membrane may rise beneath the tube, and trach- 
 eotomy may therefore be necessary after intubation. The tube may 
 sometimes produce trauma, false passages, necrosis, ulcers, perichon- 
 dritis and stricture. The tube is usually replaced two, three, or 
 four times, and rarely need remain more than five or six days when 
 the serum is used. It is removed by the extubator, or by pressure. 
 Size of the tube : 5 to 6 millimeters, one to two years ; 6 to 7 milli- 
 meters, two to four years ; 7 to 8 millimeters, four to six years ; 8 to 
 9 millimeters, six to eight years. 
 
 Tracheotomy. — Tracheotomy is indicated when the heart is weak 
 or when great asphyxia, much secretion, or gangrenous, diffuse or 
 septic infiltration exist. In the after-treatment, the patient re- 
 quires a moist atmosphere, and cleaning of the tracheotomy tube every 
 second day, is important. The tube should not be permanently re- 
 moved until all stenotic symptoms and all plaques disappear. In 
 cases treated by serotherapy, this may be done on the fourth day as 
 against the sixth or seventh in cases treated before antitoxin was in- 
 troduced. The prognosis of tracheotomy depends upon possible coin- 
 cident wound-infection with erysipelas or diphtheria, phlegmon, 
 
CEREBROSPINAL FEVER. 165 
 
 thrombophlebitis, mediastinal suppuration, ulceration of trachea, in- 
 halation pneumonia, cardiac collapse, and nephritis. Rapid rise of 
 temperature is ominous. Antitoxin has reduced the mortality from 
 66 per cent, to 35 or 25 per cent. 
 
 CEREBROSPINAL FEVER. 
 
 Definition. — Cerebrospinal or " spotted " fever is an acute specific 
 infection, caused by the meningococcus, characterized anatomically 
 by a purulent or sero- or fibrino-purulent exudation in the cerebro- 
 spinal meninges and marked clinically by headache, rigidity of the 
 neck and spine, hyperesthesia, vomiting, Kernig's sign and often by 
 various paralyses. 
 
 In 1805, Vieusseux, of Geneva, first described epidemic menin- 
 gitis ; in 1806, it was seen by Danielson and Mann in New England, 
 and they performed the first autopsies (Osier). 
 
 Bacteriology. — The Diplococcus intracellularis meningitidis of 
 Weichselbaum or meningococcus resembles the pneumococcus and 
 gonococcus. It lies in pairs or even tetrads, its contiguous sides are 
 flattened, and it resembles two coffee grains with their flat sides ap- 
 posed. It is wider and less lanceolate than the pneumococcus. It 
 is usually intracellular, being enclosed in the polymorphonuclear 
 leukocytes. Unlike the pneumococcus, it usually has no capsule, 
 although one may develop in serum cultures. It decolorizes by 
 Gram's method. Cultures do not show very active growths; it 
 develops best on agar or blood serum as white, viscid, shining colonies 
 and it grows poorly on gelatin. Subcutaneous inoculations are usu- 
 ally negative, therein differing from the pneumococcus, but it pro- 
 duces inoculation-meningitis and peritonitis. The meningococcus 
 is found in the nose, from which it is thought to invade the brain. 
 Lord found it in the nose, in cases with and without meningitis. 
 Von Lingelstein found the meningococcus in the nasopharynx in 94 
 per cent, of cases in the Silesian epidemic (v. i.) and every time in 68 
 personal observations. He asserts that the disease is communicable 
 only by direct contact with the mucus from the nasopharynx of pa- 
 tients or of those in contact with them. Its presence has been 
 demonstrated in the blood in 25 per cent, of cases by Elser, kidneys, 
 joints, spleen, ear, tonsils, lymphatic nodes, pleura, lung, heart valves, 
 pericardium and more rarely in the sputum and urine; it probably 
 travels by way of the lymph vessels. 
 
 Predisposing Etiology. — Children and young adults are especially 
 predisposed; it occurs more often in males, is apparently more fre- 
 quent in the country, although it is often endemic or epidemic in 
 barracks, prisons, hospitals and tenements. The disease has close- 
 ly followed the movements of armies or regiments. Though not very 
 directly contagious, its contagiousness seems proven beyond question. 
 As many as seven members of a family have been successively stricken. 
 Most cases are seen in the late winter and early spring; the author 
 
166 THE SPECIFIC INFECTIONS. 
 
 has always seen some cases in these months. 2,594 deaths occurred 
 in New York in 1904 and 1905. In a Silesian epidemic in 1905 
 there was a mortality of 57.6 per cent, of 3102 cases. Trauma, 
 overwork and depression are but predisposing causes. Like pneu- 
 monia, it often attacks the robust and may recur; Councilman col- 
 lected five instances of recurrence. The disease is also seen in the 
 horse and goat. 
 
 Pathology. — The findings in the main are those of the suppurative 
 form, viz., those of an acute fibrinopurulent, or less often a sero- 
 purulent leptomeningitis. The cerebral dura is seldom, and the 
 spinal dura often, involved. The inflammation follows the lympha- 
 tics and vessels penetrating the brain and cord, resulting in encepha- 
 litic or myelitic foci, small abscesses, parenchymatous and interstitial 
 changes. The axis cylinders are sometimes lost. Flexuer and 
 Barker observed rows of cells " like miniature tubercles," of which 
 some were two to eight times the size of the leukocytes. The exudate 
 is rich along the fissures, fossa of Sylvius and at the base about the 
 chiasm or the surface of the pons and cerebellum. Hydrops ventricu- 
 lorum is fairly frequent, in cases of long standing. In other organs 
 the changes are those of acute infection, the muscles are brownish- 
 red, dry and degenerated, there is parenchymatous degeneration in 
 the heart and kidneys, and sometimes acute splenic tumor, arthritis, 
 pneumonic foci or swollen glands in which the coccus may be found. 
 
 Symptoms. — The period of incubation is not definitely known, but 
 lasts from a few hours to several days (three to eleven). Prodromes 
 are vague, as malaise, or headache. Strumpell and others observed 
 initial coryza. The onset may be gradual or sudden, sometimes with 
 a chill and usually with fever. In general, the course is febrile, at- 
 tended by brain irritation ; by an almost constant triad of symptoms, 
 headache, rigid neck and hyperesthesia; by vomiting, mental, motor 
 and sensory symptoms, and in fatal cases death results from paralysis, 
 convulsions or coma. 
 
 1. General Nervous Symptoms. — (a) Headache is almost invar- 
 iable, though rarely absent in very young children, or alcoholics. It 
 develops early, is most severe and is at first localized but soon be- 
 comes generalized. Though it varies somewhat in intensity, it is con- 
 stant, with exacerbations, and provokes the short plaintive, clear men- 
 ingeal cry, cri hydrencephalique which is largely heard in children 
 (Coindet, 1817). The headache is throbbing or lancinating, even 
 under narcotics, and persists after delirium and even coma have set in. 
 Its cause may be compression of the dura, changes in the brain, in- 
 flammation of the nerve trunks, or ventricular exudation, (b) 
 Hyperesthesia or hyperalgesia affects the special senses, causing 
 intolerance of light and noise, or general sensation — affecting the 
 arms most, the trunk less and the legs least. It is rarely absent, 
 always suggestive, and probably due to root neuritis, (c) Rigidity of 
 the neck and spine is caused by inflammation of the nerve-roots, 
 possibly from lesions in the pons or medulla. The head is retracted, 
 
CEBEBBOSPINAL FEVER. 167 
 
 sometimes so severely that the occiput lies between the shoulders, pro- 
 ducing dysphagia and decubitus. The entire body may be lifted by 
 the head. Marked opisthotonos may be present. The most common 
 attitude is the lateral, with the head retracted, the arms flexed and the 
 knees drawn up. Flexion and extension of the head are impossible. 
 Retraction is one of the cardinal triad. Closely associated and 
 caused in the same way, is severe spinal pain with tenderness, 
 chiefly in the neck and loins, which is felt rather to the side of the 
 spine than directly over it. It may radiate to the trunk and in 
 33 per cent, of cases to the extremities, (d) Contractures of the 
 limbs are caused by root inflammation, increased pressure, or lesions 
 in the pyramidal tracts. Kernigs sign (see Diagnosis) comes 
 under this head, (e) Mental symptoms often occur early, especially 
 in children, neurotics and alcoholics; they include unrest, insomnia, 
 delirium (sometimes with periods of normal intelligence), and mania 
 which is followed by stupor and incomplete coma. (/) Vomiting, 
 in the initial stage, is due to vagus irritation; later it results from 
 ventricular hydrops or increased cerebrospinal pressure. It is of the 
 cerebral type, i. e., it occurs without nausea, without relation to eat- 
 ing, is often projectile and is not amenable to gastric therapy. Vom- 
 iting is more typical and common in children. The tongue may 
 later become coated and foul, (g) The pulse at first is increased, and 
 is sometimes disproportionately rapid, considering the fever. Some- 
 times it slows later because of brain pressure but ultimately it is 
 fast again. It may be irregular in rhythm and oscillating in rate. 
 Friis noted variation from 84 to 144 within a minute, (h) Res- 
 piration is irregular in 20 per cent, of cases ; Cheyne-Stokes' breath- 
 ing is not common, save toward the end. Deep breathing with 
 apnoeic pauses (Biot's breathing) is quite common, though less so than 
 in the tuberculous type, (i) Convulsions are most common in the 
 young; they may occur at the onset or later. They are ambiguous 
 from their frequent occurrence in other diseases of childhood. 
 
 2. Focal Nervous Symptoms. — These are partly irritative and 
 partly paralytic, (a) Symptoms relating to the cranial nerves are as 
 follows: These nerves are most involved in basal localization, while 
 the limbs are most affected in that of the convexity. The optic nerve 
 is frequently inflamed, if the disease lasts over four days. The disk 
 is swollen and its margin is " washed " (see Plate VII, Fig. 4). Neu- 
 ritis is less frequent than in tumor ; hemorrhage and choking are un- 
 common. The ocular muscles may be involved. The pupils at first 
 are usually small, often unequal, and sometimes variable like the 
 pulse. Later they widen spontaneously or on movement of the rigid 
 neck, and irritation of the skin, but do not react to light. These as 
 well as the following changes, result from cortical or basal disease. 
 Ptosis, diplopia, nystagmus, and strabismus are frequent and often 
 vary from time to time. Complete paralysis of the third nerve is 
 not common. Involvement of the fifth nerve is unusual, although 
 trismus, grinding of the teeth and trigeminal neuralgia have been 
 
168 TSE SPECIFIC INFECTIONS. 
 
 noted. Involvement of the facial nerve is frequent, ranking next 
 to that of the third nerve. If diseased at the base, its paralysis 
 is usually total: if at the cortex it is of the cerebral type, and its 
 upper third escapes. The paralysis varies from time to time (v. s.). 
 The facial expression shows suffering, the brows are slightly elevated 
 and the forehead is corrugated. The risus sardonicus is not fre- 
 quent. The auditory uerve is often bathed in pus, and hemorrhagic 
 inflammation in the labyrinth results from extension. The tongue 
 on protrusion may deviate to one side; dysarthria or dysphagia are 
 sometimes seen. (b) Symptoms relating to the limbs occur as fol- 
 lows : Paralysis of the limbs is not very frequent, although noted in 
 some epidemics. Hemiplegia is rarely complete, occurs with or with- 
 out participation of the tongue and face, and is caused by involvement 
 of the cortex, changes in the pyramidal tracts, and sometimes appar- 
 ently by reflex inhibition. It is frequently accompanied by rigidity 
 of the limbs and aphasia. It is most frequent in children, occurs 
 early or late and may be temporary or permanent. Monoplegia 
 is not common and most often concerns the face or arm. Choreiform 
 or athetotic movements, twitchings and tremor are occasional. Con- 
 vulsions are frequently Jacksonian in type. Sometimes the paralyses 
 are spinal, as paraplegia, which also involves the functions of the 
 bladder and rectum. The tendon reflexes, as the patellars, may be 
 increased at first and are often decreased or abolished late in the dis- 
 ease. The reflexes of the skin are variable. 
 
 3. Gexebat axd Somatic Symptoms. — (a) There is almost 
 always fever. The temperature rises suddenly, is usually irregular 
 or remittent, follows no definite cycle, and lysis is usual in cases 
 which recover. A temperature of 107° may be registered before 
 death, (b) The blood shows leukocytosis, which is early, constant 
 and of no prognostic import; the white cells may number 25,000 to 
 40,000; the meningococcus is found in 25 per cent, of cases. 
 
 (c) The abdomen is often retracted, and is scaphoid, although less so 
 than in the tuberculous type. It may be due to retraction of the ab- 
 dominal walls or intestines from irritation of the vagus [Traube]. 
 
 (d) The spleen is often palpable, (e) The urine is febrile, albumin- 
 ous (33 per cent.) and may show peptonuria, hematuria in malig- 
 nant cases, and rarely glycosuria or polyuria (Traube). (/) The 
 nutrition suffers, which Leube explains by cerebral influences, (g) 
 Skin: The taclie cerebrate described by Trousseau has no differentiat- 
 ing value, for it occurs in many febrile and other conditions. Erup- 
 tions are more common in the epidemic than in the sporadic cases, and 
 vary with the individual epidemic. Herpes varies with the epidemic 
 (40 to even 90 per cent.) ; it is most frequent on the face, but may 
 develop anywhere ; it spreads more rapidly than in any other disease 
 (v. Ziemssen) ; in one case the author saw it extend from the lip to 
 the ear, neck, chest and shoulder. Purpura ["spotted fever"~\ 
 occurs in severe types. Erythema, roseola, urticaria and gangrene 
 are uncommon. 
 
CEREBROSPINAL FEVER, 169 
 
 Clinical Forms. — Hirsch distinguishes (a) the acute or subacute 
 type, the ordinary form in which the acute symptoms of onset are fol- 
 lowed by the general nervous symptoms enumerated, then by focal 
 nervous symptoms, somatic symptoms, death in coma, or slow recov- 
 ery; (b) the foudroyant form, with violent onset, rapid course and 
 death in a few hours (three to thirty-six) with apoplectic symptoms, 
 or purpura, high fever, irregular heart and early coma; (c) the 
 abortive form, with low fever and symptoms so mild that the disease 
 is recognized only by its association with an epidemic ; the ambulatory 
 type is included here; and (d) Heubners chronic form, which lasts 
 two to six months, with marasmus, and recurrent fever. 
 
 Complications. — These vary with the epidemic. Pneumonia, bron- 
 chitis, tonsillitis, pleurisy, parotitis, endo- and pericarditis, arthritis 
 and nephritis are the most common. Pneumonia usually is due to 
 the pneumococcus, but Councilman found the meningococcus in 
 small isolated foci in the lung. The arthritis is either poly- or mono- 
 articular, simple or suppurative, and may heal even when suppura- 
 tive; it occurred in 25 per cent, of Flexner's and Barker's series. 
 
 Sequels. — Mental alteration, paralysis, contractures, obstinate head- 
 ache, optic atrophy, deafness or Meniere's syndrome may remain 
 after recovery. Chronic hydrocephalus, paroxysmal headache, vom- 
 iting, pains, and convulsions may result (v. Ziemssen). In an Heid- 
 elberg epidemic, Moos found as sequels deaf -mutism in 60 per cent., 
 absolute deafness in 31 per cent, and an atactic gait in 50 per cent, 
 of the cases. 
 
 Prognosis. — The average mortality is 37 per cent. (Hirsch in 
 15,632 cases), but varies with the epidemic, and may reach 75 
 per cent. Fifty per cent, of the deaths occur in the first five days. 
 Recovery is exceptional after deep coma, repeated convulsions, high 
 fever or paralysis of the vagus. Obstinate vomiting, disturbed res- 
 piration, sudden drop of temperature and inanition are ominous 
 signs. 
 
 General Diagnosis. — The first step is the diagnosis of meningitis, 
 which in general has an acute or subacute onset, with signs at first 
 of general, then local inflammation of the surface of the brain. The 
 second step is determination of the variety (suppurative, epidemic, 
 tuberculous, primary or secondary), cause, and localization. 
 
 Cardinal Symptoms. — The important early triad of (a) head- 
 ache, (b) retracted rigid neck and (c) hyperesthesia, develops 
 early, (d) General symptoms, as vomiting, abdominal retraction, 
 pulse and respiratory changes, fever or convulsions, are important in 
 their grouping, (e) Lumbar puncture (Quincke, 1890) is of great 
 diagnostic value. Its technique is as follows: The patient lies on 
 the side with the knees drawn up and the body bent as far forward 
 as spinal rigidity allows; with or without chloroform, an aspirating 
 needle or small trocar is introduced in the median line in children, 
 and a quarter to half an inch to one side in adults, between the third 
 and fourth lumbar vertebras (Quincke) or between the last lumbar 
 
170 
 
 TME SPECIFIC INFECTIONS. 
 
 Fig. 17. 
 
 vertebra and sacrum, and is pushed forward toward the median line 
 and a little upward, one and a half inches deep in children and 1.5 
 to 2.5 inches in adults, until it passes into the canal. Fiirbringer 
 prefers to have the patient in the sitting posture. Not more than 
 4 to 5 drams (15 to 20 c.c.) should be withdrawn, lest fatal results 
 ensue. Negative taps result from needle occlusion by clots. Results: 
 (i) Normally, the pressure with the patient in the lateral position, 
 equals 100 to 150 mm. of water and the escaping fluid only trickles 
 out. In meningitis, the pressure is greatly increased (200 to 700 
 mm.) and the fluid often spurts out. (ii) The normal fluid is clear, 
 has a specific gravity of 1,007-09 and contains little albumin (-J- to 1 
 pro mille) . Though the fluid may be clear in all forms of meningitis, 
 it is usually clear in the serous form, but cloudy, flocculent or some- 
 times bloody in other forms ; in the tuberculous variety it is usually 
 clear or slightly yellow with a whitish clot forming on standing; 
 in the epidemic form, it may be turbid or clear, with a yellowish 
 clot; in the purulent type it is opaque, and in rare cases pure pus. 
 The specific gravity is about 1,010 in the serous, 1,011 in tuberculous, 
 
 and 1,015 in the purulent or 
 epidemic variety, although 
 these figures are not absolute. 
 The percentage of albumin 
 is small in the serous, 2 pro 
 mille in tuberculous, and 3 or 
 even 9 pro mille in the sup- 
 purative forms, (iii) Bacter- 
 iologically in the purulent 
 type the streptococcus, sta- 
 phylococcus, pneumococcus, 
 typhoid and colon bacilli are 
 found; in the epidemic va- 
 riety, the meningococcus 
 which was positive in 100 per 
 cent, in the last New York 
 epidemic, is present; in the 
 tuberculous type, tubercle ba- 
 cilli exist in 66 per cent, of 
 cases as an average (81 per 
 cent. Fiirbringer, and 100 per 
 
 Kernig's sign, showing retraction of head and , tt -, \ • 
 
 back and prominence of knees in the erect pos- Cent. ±lOltzmannj ; even m 
 
 <Dfeuik&y) he impossibility of extension ol knees this form, mixed infection 
 
 with the pus organisms and 
 meningococcus may be seen ; the tubercle bacilli are often found on 
 cover slip preparations, (iv) The cellular morphology (cyto-diag- 
 nosis) is a valuable aid. In the purulent and epidemic forms leu- 
 kocytes are largely polymorphonuclear ; in the tuberculous form the 
 lymphocytes predominate according to Widal, Sicard, and Eivault 
 (see Cytodiagnosis, Pleurisy). 
 
 (/) Kernig (St. Petersburg, 1882), described a sign known as 
 
CEREBROSPINAL FEVER. 
 
 171 
 
 Kernig's sign. When the patient sits or the thighs are at right angles 
 with the trunk, in 75 to 95 per cent, of all meningitis cases it is im- 
 possible to extend the knees, as shown in Fig. 17. The legs and 
 thighs are flexed (flexor contracture) and the knees cannot be pressed 
 down, i. e., cannot be extended when the patient is sitting but this is 
 possible when he is lying. It indicates involvement of the spinal 
 meninges, degeneration of the pyramidal tracts or irritation of the 
 posterior sensory roots. It lasts well into convalescence, whence, as 
 better states, " a retrospective diagnosis may be made." It occurs 
 at times in other conditions, but in infancy is almost invariably men- 
 ingitic. It is sometimes unilateral. 
 
 (g) Local signs usually follow the general signs, and are more 
 important. They include the pupillary changes, strabismus, facial 
 paralysis, and hemiplegia. Often their late development lessens their 
 value for early diagnosis. 
 
 Diagnosis of the Variety (v. s.). — This is more difficult. Cases 
 of tuberculous meningitis sometimes increase when the epidemic 
 form prevails, and the meningococcus may be found in these cases. 
 Sporadic cases, due to the meningococcus, may be indistinguishable 
 from primary pneumococcic meningitis, save by lumbar puncture. 
 
 Onset 
 
 Fever : 
 
 Eruptions: 
 
 Leukocytosis : 
 Kigiclity of neck : 
 
 Other symptoms: 
 Course : 
 
 Lumbar puncture 
 
 Epidemic Form. 
 
 Sudden, with few- 
 prodromes. 
 
 Fairly high ; pulse 
 more rapid than in 
 tuberculous type. 
 
 Herpes and purpura 
 very common. 
 
 Regular and marked. 
 
 Most frequent. 
 
 Peptonuria. 
 
 Rapid — more recov- 
 eries. 
 
 Meningococcus; 
 leukocytes poly- 
 morphonuclear. 
 
 Tuberculous. 
 
 Longer prodromes; 
 family history; 
 other evidences of 
 tuberculosis. 
 
 Less ; inversed type 
 frequently; some- 
 times absent. 
 
 Rare. 
 
 Exceptional. 
 
 Spinal symptoms 
 somewhat less fre- 
 quent. 
 
 Choroidal tubercles. 
 
 Subacute, slower, 
 fatal. 
 
 Tubercle bacilli; 
 mononuclear. 
 
 Suppurative. 
 
 Sometimes primary 
 but oftenest secon- 
 dary to ear dis- 
 ease, acute infec- 
 tions, trauma, 
 pneumonia. 
 
 Especially high, with 
 chills, perhaps 
 pysemic type. 
 
 Rare — polymorphous 
 septic rashes. 
 
 Frequent. 
 
 Sometimes absent 
 (pneumococcic 
 form) . 
 
 Peptonuria. 
 
 More acute, very 
 rarely recover. 
 
 Pyogenic cocci, 
 pneumococcus ; 
 polymorpho- 
 nuclear. 
 
 Diagnosis of Location. — (a) Localization on the convexity 
 is characterized by more frequent delirium, Jacksonian convulsions, 
 
172 THE SPECIFIC INFECTIONS. 
 
 mono- or hemiplegia, less cranial nerve paralysis and less optic neu- 
 ritis. (b) Localization at the hase is characterized by more frequent 
 cranial neuritis, and optic neuritis, (c) The ventricular form rarely 
 involves the cranial nerves. 
 
 Differentiation. — 1. From Nervous Toxemic Symptoms. — Jenner 
 pointed out that the headache ceases when delirium begins in acute 
 infections, e. g., the pseudo-meningeal symptoms of pneumonia, ty- 
 phoid (q. v.), sepsis, etc. Meningitis with focal symptoms may be 
 most confusing (see Uraemia), but the albuminuric retinitis, cardio- 
 vascular changes, albuminuria, casts, and deficient elimination are 
 usually distinctive. Acute inflammation of the labyrinth may resem- 
 ble meningitis, for it sometimes produces headache, vomiting, fever, 
 convulsions, stiff neck, and even optic neuritis. If labyrinthitis in- 
 volves the meninges, the facial nerve is likely to be affected. Such 
 conditions resembling meningitis Dupre called meningismus, and 
 Bouchut pseudomeningitis. 
 
 2. From Brain Disease. — See syphilitic meningitis, brain abscess, 
 cerebral hemorrhage, and encephalitis. Great difficulty is sometimes 
 experienced in differentiating between slow tuberculous meningitis 
 and tumors of the brain (q. v.), as tubercle of the pons, or rapidly 
 growing glioma. Moderately severe optic neuritis may suggest tumor 
 or meningitis; intense neuritis, with choking, swelling and hemor- 
 rhage is indicative of tumor. Paralysis is more sudden in meningi- 
 tis than in tumor. 
 
 3. From Hydrencephaeoid (see Brain" Anaemia). 
 
 4. From Hysteria. — Hysteria is marked by psychical alteration, 
 limitation of the field of vision, anaesthesia and other stigmata. 
 Hysterical strabismus is always spastic and convergent, and is often 
 associated with small pupils ; meningitic strabismus is often divergent 
 (always a sign of organic disease), and the pupils are unequal. 
 
 Treatment. — Prophylaxis ; the nose should be douched with a weak 
 resorcin solution. 
 
 Flexners Serum has given 75 per cent, of recoveries in 400 cases. 
 The mortality varied directly with the time of administration ; given 
 on first to third day, it was 15 per cent. ; fourth to seventh, 22 per 
 cent. ; after the seventh day, 36 per cent, mortality. The serum re- 
 sults are (a) the meningococci become more intracellular; (b) the 
 exudate becomes less turbid or purulent; (c) leukocytosis decreases 
 rapidly, even critically; and (d) complications are few and recovery 
 is usually complete. The patient should be kept quiet in a dark room, 
 the head elevated without flexion, an ice-bag applied to the head and 
 spine, or an ice-pillow used. Nutrition should be maintained by 
 feeding with the nasal tube or by nutrient enemata, if retraction of 
 the neck causes dysphagia. The bowels should be mildly relaxed, and 
 the bladder should be watched. Vomiting is treated as in acute 
 gastritis (q. v.), but therapy is usually unavailing, for the cause is 
 cerebral irritation; of drugs the bromides are in general most ser- 
 viceable. Feeding by the rectum, sucking of ice, and the remedies in- 
 
INFLUENZA (LA GRIPPE). 173 
 
 dicated for the headache give the greatest relief. Counterirritation 
 by blisters and the use of the cautery are dangerous because the skin 
 sloughs readily. Headache, restlessness and convulsions necessitate 
 the use of opiates. The hypodermic use of morphine, or the use 
 of the tincture of deodorized opium by mouth, is necessary, and free 
 from harm; no other analgesic is equally potent. Ergot, to relieve 
 congestion, never replaces the opiates. Atropine reinforces the anal- 
 gesic action of opium. Chloral is used chiefly for the convulsions and 
 for unrest. Warm baths were first recommended by Concetti and 
 Aufrecht, and are considered almost specific by Netter. Stimulation 
 is indicated when the heart weakens, and coma is imminent, until 
 which time alcohol should be withheld. Resorbents, as iodides, are 
 of little value. Mercurial inunctions are inefficacious although serous 
 meningitis seems apparently benefited by them. 
 
 Lumbar puncture can permanently relieve only the simple or serous 
 forms. Sudden death is much less likely to occur from repeated 
 punctures than in uraemia or brain tumor. 20—40 cc. are withdrawn. 
 
 INFLUENZA (LA GRIPPE). 
 
 Definition. — A specific infective disease, caused by the Bacillus 
 influenza?, propagated by direct human intercourse but also by means 
 of f omites ; endemic over the entire world and almost yearly epidemic 
 somewhere, characterized by its unparalleled rapidity in extension, 
 the large number of people attacked, its protean symptomatology and 
 its particular affinity for the respiratory tract. 
 
 Varieties. — (1) Influenza vera, (a) pandemic; (b) endemic or 
 epidemic; due to Pfeiffer's bacillus. (2) Influenza notha s. nostras, 
 pseudogrippe, catarrhal fever of unknown or variable bacteriology. 
 
 Pandemics originate in Asiatic Russia. ~No other pandemic has 
 ever been so widely distributed as influenza, which spreads very rap- 
 idly but not faster than the fastest trains and steamers. The rapidity 
 of its dissemination is due to the enormous virulence of the virus; 
 to the universal susceptibility ; and to the fact that many moderately 
 sick individuals frequent cars, conveyances, churches, schools, and 
 places of business. Epidemics develop gradually, usually follow- 
 ing pandemics; they occur every few years whereas pandemics are 
 separated by decades. According to Hirsch, the first epidemic oc- 
 curred in 1173. The first pandemic seems to have been in 1510. 
 
 Etiology. — Though no age confers immunity, most cases occur be- 
 tween the twentieth and fortieth years. Physicians are very often 
 attacked. The immunity usually conferred by one attack is less en- 
 during and absolute than in other infectious diseases. 
 
 Bacteriology. — The organism discovered by Pfeiffer (1891-2) is 
 the smallest bacillus cultivated. Its ends are rounded and it re- 
 sembles a diplococcus when two bacilli lie end to end. It has no 
 capsule, is non-motile, it lies free in the sputum in the early stages 
 and later is found in the leukocytes, but often disappears early 
 
174 TEE SPECIFIC INFECTIONS. 
 
 from the sputum. The bacilli lie in lines "like schools of fish" 
 (Finckler). Ten minutes are necessary for staining with carbol 
 fuchsin. The bacillus is aerobic, short-lived, and very susceptible to 
 drying. Culturally it grows characteristically on blood-serum as 
 closely compressed yet discrete colonies, clear as water, and almost 
 microscopic in size ; it grows at body temperature and is easily over- 
 grown by saprophytes. The germ has also been found in rare in- 
 stances in the blood, pneumonic and encephalitic foci, peritoneum, 
 and other parts, and possesses rather marked pyogenic characters. 
 Its atrium is probably through the upper respiratory tract. 
 
 Symptoms. — There is no uniform clinical picture of influenza and 
 certainly there is scarcely an acute infection with such varied group- 
 ing of symptoms and such varied sequels and complications. 
 
 After a short incubation, of one to three days, the grippe begins 
 suddenly with chill and fever, headache, anorexia and depression, 
 pains in the back and legs, respiratory catarrh, and intense nervous 
 and sometimes digestive symptoms. 
 
 Types. — The form of infection varies greatly. In the simple tox- 
 cemic type there are coryza, moderate soreness of the throat, possibly 
 some respiratory symptoms as cough and the toxaemia is evidenced 
 by fever, some depression, headache and pains in the back and limbs. 
 In the severer toxcemic form, the above named symptoms obtain but 
 the patient suffers more profound depression both with the fever, and 
 after it. Prostration, neuralgias and possibly cardiovascular atoni- 
 city mark the tardy convalescence. The intensely respiratory variety 
 is attended by fever and toxaemia but the bronchitis is severe, perhaps 
 intractable, and is not uncommonly followed by pneumonia: 75 per 
 cent, of all influenzas are characterized by respiratory inflammations. 
 The g astro-intestinal grippe is less a type per se than influenza at- 
 tended by gastric intolerance and diarrhoea. 
 
 The duration is one to three days and the diagnosis is usually easy 
 without the detection of the bacillus. Recurrences are frequent; 
 most frequently, an initial respiratory catarrh is seen with nervous 
 manifestations in the recrudescence but the order may be reversed. 
 In rare instances influenza may cause chronic symptoms. Convales- 
 cence is marked by great nervous depression, neuralgias, and tardy 
 return of vigor. 
 
 Special Symptoms. — 1. Fever. — The rise is usually sudden to 103° 
 or 104° ; exceptionally it rises gradually. It is entirely atypical. 
 Remittent fever is more common than continuous fever, which may 
 suggest typhoid. It is occasionally intermittent, resembling malaria. 
 Hyperpyrexia is observed particularly in encephalitis ; some of these 
 cases and certain nervous forms are afebrile (Eichhorst). The typus 
 inversus has been noted (Pribram). The fever averages one to three 
 or four days, and rarely lasts a week. Sometimes fever returns as 
 a recurrence or relapse. Fever may last longer as a result of com- 
 plications. Remarkable loss in weight may attend the fever. 
 
 2. Nervous System. — The nervous system is second in importance 
 
INFLUENZA {LA GBIPPE). 175 
 
 only to the respiratory tract. The most frequent disturbances are 
 functional and psychical but gross anatomical lesions are sometimes 
 found. Headache is observed in nearly 100 per cent, of cases, and 
 often is very severe. Influenza comatosa results from very acute in- 
 toxication, which may cause epileptiform seizures, tremors, or severe 
 delirium. The post-influenzal psychoses are due to cerebral toxaemia 
 or exhaustion and are observed five to eight times as frequently as 
 in any other acute disease. An hereditary tendency is observed in 
 62 per cent., and most cases are seen in the young. They may occur 
 from the initial intoxication but usually follow the attack. The 
 majority are of the hypochondriacal type (exhaustion psychoses). 
 Suicides were increased 25 per cent, in Paris during the last pan- 
 demic. In encephalitis grippalis, of which twelve cases are recorded, 
 there are acute foci of inflammation usually discrete and multiple; 
 they almost always occur in the gray substance of the cortex or gan- 
 glia and vary in size from the " flea-bite " spots of inflammatory hem- 
 orrhage with surrounding softening to the size of a cherry or pigeon's 
 egg. The inflammation is due to embolism by the Bacillus influenzae 
 (Pfuhl and ]N"anwerk) or to encephalitis, which in turn is either 
 primary, or secondary to foci in the nose, ear, and lung. Mono- and 
 hemiplegia or sudden apoplectiform onset may mark the process, or 
 there may be diffuse cerebral symptoms without definite focal locali- 
 zation. Encephalitis is usually fatal but recovery is recorded. Men- 
 ingitis grippalis generally develops early. The virus reaches the 
 brain by the blood stream or by contiguity through the basis cranii. 
 It is basal or cortical. Lumbar puncture may show the grippe bacil- 
 lus. My a (1904-) reported three cases of suppurative meningitis 
 in which recovery occurred ; the bacillus was found by lumbar punc- 
 ture. Spinal complications, such as transverse myelitis, and acute 
 poliomyelitis, have been observed. Neuritis, is usually post-influ- 
 enzal. Pains are frequent in the back, legs and joints; neuralgia 
 affects most often the fifth, sciatic, and intercostal nerves ; neurasthe- 
 nia, hypochondriasis, and hysteria may be observed as sequels. 
 
 3. The Respiratory Tract. — This is the atrium of the bacillus 
 and is involved in 75 per cent, of cases. 
 
 Epistaxis is uncommon, though coryza is seen in 70 per cent, of 
 cases. The bacillus may be found in the conjunctiva or the frontal 
 or other sinuses. Angina is seen in 33 per cent, and tonsillitis in 60 
 per cent, of cases. Laryngitis (10 per cent.) occurs with hoarseness. 
 Tracheitis (65 per cent.) causes pain, tenderness and severe paroxys- 
 mal cough, induced by irritation at the tracheal bifurcation. 
 
 Bronchitis is either diffuse, or more characteristically, occurs over 
 one lung or one lobe. At autopsy are found great congestion, ten- 
 dency to extension, hemorrhage, round-cell infiltration into the mu- 
 cosa, and exudation and thrombosis in the smaller vessels, which 
 causes necrosis of the mucosa. The sputum, according to Pfeiffer, is 
 characteristically nummular and greenish-yellow. It is often blood- 
 stained, contains the bacillus, is viscid and is often abundant. Eales 
 
176 TEE SPECIFIC INFECTIONS. 
 
 # 
 
 are most often found above the liver and near the lingual lobe. We 
 also ma j observe dyspnoea, which is nervous or congestive in origin, 
 without appropriate physical findings. Cyanosis is particularly 
 dangerous in the young, aged and decrepit. 
 
 Acute bronchiectasis is not uncommon, but usually escapes clini- 
 cal recognition. 
 
 Influenzal pneumonia occurs in 6 per cent, of the cases and is the 
 most important complication. Pfeiffer's bacillus is its most frequent 
 cause (Leichenstern and Wassermann). The pneumococcus, strep- 
 tococcus, and staphylococcus, alone or combined with the Bacillus 
 influenzae, are the cause of some cases. A grippe epidemic may 
 double the number of lobar pneumonia cases. When it complicates 
 grippe, it is less completely lobar and granular. 
 
 Influenzal pneumonia, strictly speaking, is exclusively catarrhal 
 and shows no fibrinous exudation or granulations, but merely infiltra- 
 tion of cells, which commences about the bronchi as multiple distinct 
 foci with normal lung between them. It often causes minute ab- 
 scesses. Mixed infection is of great importance in variations from 
 this type. Clinically, the pneumonia is usually atypical and begins 
 insidiously without a chill, but with increase of the prior cough and 
 dyspnoea. It usually develops during or after the influenzal attack, 
 although pneumonia may be the first sign of influenza. Its symp- 
 toms are more pronounced than its physical signs, and the dispropor- 
 tionate cyanosis and dyspnoea sometimes suggest miliary tuberculosis. 
 Foci of dulness may be found but distinct bronchial breathing is 
 rare ; bronchophony is a much more reliable symptom. The heart is 
 often weak and a peculiar redness of the face and head, profuse 
 sweats at the beginning, and characteristic paroxysmal coughing are 
 symptoms not seen in ordinary pneumonia. The foci are bilateral or 
 multiple in 60 per cent, of the cases and the apices are involved 
 very frequently. The symptoms and signs may intermit, or recur, 
 as the consolidation wanders from place to place. The sputum is 
 purulent or bloody. Issues: (1) In solution by lysis; (2) in death 
 from early oedema pulmonum ; the patient may die later, with early 
 gray hepatization; the mortality is 20 to 30 per cent. ; (3) in chronic 
 influenza pneumonia, with hectic fever and suppuration, simulating 
 tuberculosis ; during a grippal epidemic, an increased mortality from 
 tuberculosis is noticed ; (4) in abscess or gangrene of the lung. 
 
 Pleurisy may follow pulmonary lesions or even the bronchitis. 
 Primary pleurisy occurs in 27 per cent, of the fatal cases of influenza. 
 It may begin early and its symptoms are frequently severe and pro- 
 tracted. 
 
 4. Circulation. — The heart-muscle is directly injured, especially 
 its nervous apparatus. The lesser circulation is most involved. 
 Weakness of contraction, syncope, even death, may occur during con- 
 valescence, especially from preexisting fatty, valvular, or arterio- 
 sclerotic changes. The pulse is labile, often arrhythmic or dicrotic ; it 
 may be rapid, and out of proportion to the fever ; cyanosis, dyspnoea 
 
INFLUENZA {LA GEIPPE). 177 
 
 and bronchiolitis are frequent in such cases. A slow pulse occurs 
 in 50 per cent, of the severer types, from toxsemic stimulation of the 
 vagus. Acute endocarditis sometimes follows suppurating foci in the 
 lungs; three cases are recorded in which the influenza bacillus was 
 found. Acute phlebitis is seen mostly in severe cases with weakness 
 of the heart, most frequently in the upper extremities. Arteritis is 
 rare, occurs mostly in the popliteal vessels, and may end in gangrene. 
 Leukocytosis occurs in not more than a third of the cases. Hemor- 
 rhages into the skin, serous and mucous membranes indicate severe 
 intoxication. 
 
 5. Alimentary Tract. — Digestive symptoms are not important. 
 The coated tongue is rarely dry or typhoidal. Vomiting (34 per 
 cent.) which is sometimes bilious and persistent, and grippal hyper- 
 esthesia of the stomach may be observed. Constipation is more fre- 
 quent than diarrhoea. There are the usual febrile degenerative 
 changes in the liver. Icterus is rare (2 per cent.). The spleen 
 is enlarged clinically in but 15 per cent, of cases. 
 
 6. Genito-Urinary Tract. — Albuminuria may result from toxae- 
 mia or stasis (10 per cent.). Altered red blood-cells in the urine are 
 rather frequent. Acute glomerulonephritis occurs in 1 per cent, of 
 cases. Diabetes mellitus is said to have followed influenza; if in- 
 fluenza complicates an old diabetes, the prognosis is doubtful. Sen- 
 ator noted the frequent occurrence of the diazo reaction and of in- 
 dicanuria. Cystitis, hsematuria, menorrhagia, abortion and orchitis 
 are but occasional complications. 
 
 7. Skin, Muscees, Joints. — Urticaria, herpes (5 per cent.), 
 redness and hyperidrosis, miliaria, erythema nodosum or multiforme, 
 scarlatiniform or morbilliform eruptions on the face or chest, or pur- 
 pura, may be noted. Skin eruptions occur in 16 per cent, of the 
 cases. Polysynovitis (7 per cent.), py arthrosis and myositis are not 
 common ; bone involvement is infrequent. 
 
 Eye involvement (7 per cent.), conjunctivitis, keratitis, herpes, 
 swelling of the lids, and otitis media (35 per cent.), which is usu- 
 ally purulent, and often hemorrhagic, are due to the pyogenic cocci, 
 pneumococci and the influenza bacillus. 
 
 Diagnosis. — At the time of an epidemic the diagnosis is usually 
 easy. Respiratory catarrh, headache, pains in the joints and back, 
 nervous depression and tardy convalescence are significant. The 
 diagnosis of the toxic, nervous and alimentary forms is more difficult 
 and many errors may be made. The importance of bacteriological 
 diagnosis has been over-rated, but positive results are decisive. 
 
 Differentiation. — Typhoid Fever. — The diseases may be confused 
 when atypical severe influenza begins with gradual, or step-like rise of 
 the fever and typhoid symptoms, such as tympany, enteritis, in- 
 testinal hemorrhage, swelling of the spleen and roseolse. At autopsy, 
 swelling and even ulceration of the stomach mucosa and Peyer's 
 patches occur (Jiirgens). However, coryza, conjunctivitis, the ex- 
 istence of an epidemic and early catarrhal symptoms, indicate influ- 
 12 
 
178 THE SPECIFIC INFECTIONS. 
 
 enza, and the serum test and other cardinal typhoid findings (q. v.) 
 decide the diagnosis. 
 
 Simple Coryza, Bronchitis, etc. — These are distinguished from 
 true influenza by the sudden rise of fever in influenza, its nervous 
 manifestations, pains in the head, bacteriology, spleen and exan- 
 thems. Lord found the bacillus of Pfeiffer in 30 per cent, of bron- 
 chitis cases in Boston, in which there was no suspicion of influenza. 
 
 Measles. — The early diffuse respiratory catarrh in each disease 
 may cause confusion, and doubts may be increased by measles-like 
 eruptions in influenza, but the typical measles fever curve (the fever 
 rising again, after the prodromes, with the exanthem), and Koplik's 
 spots, determine the diagnosis on the third or fourth day. 
 
 Miliary Tuberculosis. — This is suggested only in severe respir- 
 atory types ; the history is usually distinctive. 
 
 Meningitis, apoplexy, the acute psychoses and acute poisoning are 
 rarely simulated by influenza. 
 
 Prognosis. — (1) The morbidity is enormous, reaching 50 or even 
 75 per cent, of the population (pandemic of 1889-1890). (2) The 
 mortality is to to 1 per cent., but statistics are unreliable since the 
 diagnosis of influenza is often carelessly made. It is certain that in- 
 fluenza increases the total number of deaths from pneumonia and 
 tuberculosis, especially in the weak and aged. In some cases the 
 course is chronic, the bacillus being found in the sputum for weeks or 
 months, especially in tuberculous subjects, who are remarkably sus- 
 ceptible. 
 
 Treatment. — There is scarcely any prophylaxis except that persons 
 should avoid crowds. Isolation should be practised in asylums, hos- 
 pitals and prisons. Quinine is very uncertain. Gargles and nasal 
 douches may possibly prevent infection and are distinctly indicated 
 in grippal patients. There is no specific treatment and symptoms 
 must be met as they arise. In every case, influenza should be treated 
 as a serious disease and complications should be avoided by means 
 of rest in bed and restricted diet. The treatment. is much like that 
 of a severe cold. 
 
 1. Pain. — At the onset, Dover's powder and acetphenetidin 
 (phenacetin) aa grains x, at once, are given for pain. Phenacetin 
 has been used to excess, but is superior to acetanilid and is less de- 
 pressing. If these measures do not relieve the pain, the salicylates 
 (or acetylsalicylic acid, aspirin) should be used as they are in rheu- 
 matism. Cold baths for high fever are poorly tolerated by the patient. 
 
 2. Catarrhal Symptoms. — For conjunctivitis, boric acid solution 
 is excellent; for coryza, douches with Dobelle's solution, tincture of 
 belladonna and of aconite in two- and one-drop doses, respectively, 
 should be used every half hour for about three hours, and the alka- 
 loid cocaine gr. j to albolene ^j should be used locally; for pharyn- 
 gitis, silver nitrate (20 per cent.) should be applied once or twice; 
 for tonsillitis, nitrate of silver should be introduced into the follicles 
 which are first opened and touched with Dobelle's solution ; for bron- 
 
PEETUSSIS (WHOOPING-COUGH). 179 
 
 chitis (q. v.), codeine or morphine is indicated; for enteritis, bismuth 
 and paregoric aa 3j should be given after each bowel movement. 
 
 3. Severe Nervous Symptoms. — These are somewhat relieved by 
 warm baths. Neuralgia necessitates the use of acetphenetidin, gelse- 
 mium, quinine, camphor, iron and arsenic. Headache is treated 
 as it is in typhoid ; it is increased by alcohol. 
 
 4. Heart. — The heart may require strychnine. 
 
 5. Convalescence. — Care in convalescence is important; cases 
 of chronic tuberculosis or bronchitis require high altitudes. 
 
 PERTUSSIS (WHOOPING-COUGH). 
 
 Definition. — A specific, frequently epidemic, infection of the upper 
 air-passages, occurring chiefly in children, and characterized by a 
 cyclic course and a severe convulsive cough, which ends in a long- 
 drawn, spasmodic inspiration or whoop. Cullen's definition was Mor- 
 bus contagiosus, tussis convulsiva strangulans cum inspiratione sonora 
 iterata, saepe vomitus." 
 
 History. — Pertussis was described by Ballonius (1578) and Willis 
 (1674). 
 
 Etiology. — (a) Age. — It usually occurs in children and is most 
 frequent at the fourth year. It is extremely infrequent after the 
 twentieth year, though cases occur in middle and advanced life, (b) 
 Sex. — Sixty-six per cent, of cases occur in girls, (c) Ancemia and 
 respiratory catarrh are predisposing factors, (d) Most cases occur 
 in March and April. 
 
 Koplik, Affanassiew and Hensel have described a facultatively 
 aerobic bacillus which has small rounded ends, is but little larger 
 than the influenza bacillus, and which occurs in clumps, but the micro- 
 organism has not been proven causative. One attack confers almost 
 absolute immunity. Incubation lasts from two to five to eight days. 
 
 Symptoms. — 1. Stage of Prodromes. — The stadium prodromorum 
 s. catarrhale is characterized by headache, backache, photophobia, 
 conjunctivitis, coryza, sneezing, angina, and by a cough which be- 
 comes dryer and harder toward the end of this stage. In a 
 few cases there is moderate fever. This stage averages one week 
 (one-half to two weeks), but is often shorter when marked epidemics 
 prevail. 
 
 2. Convulsive Stage. — The stadium convulsivum s. spasmodi- 
 cum dates from the first " whoop." The fever, aside from complica- 
 tions, ceases with the onset of this stage. The seizures are paroxys- 
 mal, convulsive, and are accompanied by dyspnoea and vomiting. As 
 a rule the child is well except for the paroxysm, which has for an 
 aura, tickling in the larynx or back of the sternum, thoracic constric- 
 tion, vertigo, or a creeping sensation, and then the child braces him- 
 self, and terrified, runs for support. Then the explosion comes in 
 the form of three to ten or more short expiratory coughs following 
 in rapid succession until the breath is lost, when the "whoop" is 
 
180 TEE SPECIFIC INFECTIONS. 
 
 heard as a long, rapid, deep, sharp, singing or whistling inspiration. 
 Then a thin, tenacious mucus is expectorated and vomiting consti- 
 tutes the crisis of the paroxysm. The laryngoscope sometimes re- 
 veals laryngeal or tracheal catarrh. In severe cases there may he 
 apnoea, great cyanosis, and usually diminution of the vesicular mur- 
 mur. One to two minutes elapse between expiration and inspiration, 
 and inspiratory and expiratory spasms or generalized convulsions 
 may develop. The eyes are injected, the nose runs, the jugular veins 
 are large and the skin is clammy. Involuntary evacuations occur; 
 the pulse is small; ecchymoses sometimes occur in the conjunctivas, 
 scleras, neck or face. After the attack, consciousness returns, respira- 
 tion is fast, and there is fatigue, stupor, sweating, and pain in the 
 abdominal or other muscles from the strain of coughing or occasion- 
 ally from actual muscle rupture. The attacks occur largely at night 
 but especially toward morning. In the free interval there may be 
 euphoria or great depression, stomach disturbance, inanition, or 
 diarrhoea. Leukocytosis is observed early in the disease, is unusually 
 marked, and the increase is chiefly in the lymphocytes (Frolich). 
 Frank S. Churchill states that lymphocytosis occurs in 85 per cent, of 
 cases, and in 90 per cent, during the catarrhal stage. The number of 
 the attacks averages about twenty daily. 
 
 3. Stage of Decline. — The stadium decrements follows after 
 three or four weeks, but may require months. The attacks become 
 less frequent, but this stage is longer in proportion as the case is 
 mild. From its complications (v. i.) it is the most dangerous stage. 
 
 Course. — The incubation lasts one week; the catarrhal stage one to 
 two weeks, the spasmodic, three to six weeks, and the decline, three 
 weeks. It is modified by the following complications: 
 
 Complications. — 1. Increase or Extension of the Usual Symp- 
 toms. — Catarrhal inflammation is common in the initial stage, — 
 stomatitis, laryngitis, catarrhal diarrhoea (10 per cent.), and otitis 
 media (10 per cent.). Bronchitis (bronchiolitis) is not common in 
 the spasmodic stage. It may occur with fever, a pulse of 120 to 150, 
 respirations of 30 to 50, irregularity of breathing, many rales, 
 cyanosis and atelectasis. Bronchopneumonia is the most frequent 
 and severe complication, occurring particularly in rhachitic children 
 between the third and fifth years ; it most often occurs in the con- 
 vulsive stage. The onset is gradual with fever of 100° to 102°, a 
 pulse of 130 to 160, respirations of 30 to 80, with cyanosis and 
 dyspnoea. The mortality may reach 25 per cent, and an almost abso- 
 lutely bad prognosis must be given in the very young. Sometimes 
 the pneumonia greatly lessens or entirely prevents the spasms (Trous- 
 seau). Lobar pneumonia is much rarer. Exudative pleurisy is a 
 rare but very severe complication, and is seen almost exclusively 
 in older children or adults. Endocarditis, pericarditis, meningitis 
 and nephritis are very infrequent. Spasm of the glottis in nervous 
 or scrofulous children rarely occurs before the fourth year. Its in- 
 cidence is largely nocturnal, and it may cause death from asphyxia 
 
PERTUSSIS (WHOOPING-COUGH). 181 
 
 even in the lightest cases. Convulsions of the carpopedal type, espe- 
 cially in nervous and hydrocephalic children, may occur at any time 
 but are most frequent at the height of the apncea, at the time of the 
 first teething, and in the second to fifth week of the disease. The eyes 
 are rolled upward and outward, the pupils are dilated, and coma 
 follows. 
 
 2. Mechanical Complications. — Hemorrhages may occur into 
 the skin, conjunctiva, nose, ears and throat. Hemorrhage in the 
 brain has produced paralyses, of which Valentine summarized 83 
 instances. Detachment of the retina and extravasation of blood into 
 the lungs, stomach, and intestine, are rare. There may be oedema of 
 the eye-lids, anasarca, rupture of the tympanum, or rupture of the 
 frenulum of the tongue, the ulceration of which is almost constant. 
 Vomiting occurs regularly at the end of the paroxysm as a mechanical 
 crisis to the attack. Other mechanical complications are cardiac 
 dilatation, pulmonary emphysema (less often interstitial than alveo- 
 lar), bronchiectasis, pneumothorax, involuntary evacuations, pro- 
 lapse of the rectum or uterus, aneurysm, muscular ruptures, hernias, 
 rib fracture, and spinal deformity. 
 
 3. Toxaemia. — Marked toxaemia is rare. Parenchymatous degen- 
 erations are found in the fatal cases. Nephritis is not common. 
 
 Sequels. — The hysterical coughing and spasm which sometimes fol- 
 low pertussis may very closely resemble it ; rhachitis is an incidental 
 sequel ; tuberculosis may involve the lungs or peritoneal or mediastinal 
 lymph glands, the latter signalized by retrosternal dulness ; it occurs 
 especially after pertussis with measles, both of which infections pre- 
 dispose to tuberculosis. Preexisting tuberculosis renders the prog- 
 nosis of whooping-cough very unfavorable. Tuberculosis, as a com- 
 plication, develops in the third stadium, in children between the sixth 
 and tenth years of age. The heart-muscle may suffer permanent 
 weakness. 
 
 Diagnosis. — Diagnosis is easily made (1) by the definite stages of 
 the disease; (2) by the presence of an epidemic; (3) by the abso- 
 lutely characteristic convulsive seizures ; (4) by stigmata, such as 
 sublingual ulceration, swollen upper eye-lids, oedema of the face, 
 petechia, and tender areas in the larynx; (5) pressing the tongue 
 down and back with a spoon often elicits a characteristic attack of 
 coughing. The stridor may be absent in nurslings and adults. The 
 diagnosis may be difficult in intervals between paroxysms in the early 
 or late stages. Intercurrent — especially febrile — diseases, like 
 pneumonia or measles, may render pertussis atypical. 
 
 Differentiation. — In croup there is fever, aphonia, metallic inspira- 
 tion, lividity and constancy of the symptoms, i. e., no interval. 
 
 False croup (laryngismus stridulus) beginning with acute catar- 
 rhal laryngotracheitis, occurs at night in healthy children. Spas- 
 modic cough from disease in the bronchial glands more closely resem- 
 bles pertussis than any other cough. 
 
 Barthez and Sannee give the following differentiation : 
 
182 TEE SPECIFIC INFECTIONS. 
 
 "Whooping Cough vs. Enlarged Glands. 
 
 1. Contagious, epidemic. 1. Isolated, not contagious. 
 
 2. Three periods, second paroxysmal. 2. No distinct periods. 
 
 3. Paroxysmal cough with whoop, vom- 3. Paroxysms, without the whoop, ex- 
 
 iting and viscid expectoration. pectoration or vomiting. 
 
 4. Eespiratory sounds normal. 4. Signs of enlarged glands sometimes 
 
 present. 
 
 5. Respiration normal in interval; apy- 5. Asthma in some cases alternating 
 
 rexia if simple. with paroxysms. Febrile movements 
 
 with recrudescence in the evening, 
 sweats, progressive wasting, etc. 
 
 6. Voice natural. 6. Sometimes a change in voice. 
 
 7. Acute. 7. Chronic. 
 
 Spasmus glottidis occurs in nervous children at dentition, in rhachi- 
 tis and tetany ; it is a sudden spasmodic closure of the glottis without 
 prodromes, but with dyspnoea, cyanosis and convulsions. Asthma 
 periodicum (Millar's asthma) may develop in healthy children from 
 the second to the sixth year with hoarseness, moderate fever, dyspnoea 
 on the second day, with convulsions, cyanosis, and repeated seizures. 
 Eecovery occurs, or death, within the first eight days of the disease. 
 Hysterical " after "-pertussis is characterized by the absence of 
 catarrhal symptoms, fever, vomiting, sublingual ulceration, oedema 
 of the face, petechias and a tender point in the larynx, irritation of 
 which induces an attack. Hysterical imitation is associated with the 
 stigmata of hysteria (q. v.), the influence of suggestion and a longer 
 course than that of pertussis proper. 
 
 Prognosis. — Whooping-cough, with its complications, ranks third 
 in the mortality of the English vital statistics of children. Hirsch 
 states that, in Prussia, 85,000 deaths occurred from pertussis from 
 1875 to 1880, and in England, from 1857 to 1867, 120,000 died 
 from the disease. The mortality averages 3 per cent., but varies 
 with the virulence of the epidemic, and may even reach 15 per cent. 
 The longer the time of development of the convulsive stage, the better 
 is the prognosis, and the clearer are the intervals between paroxysms. 
 The outlook is more unfavorable in girls, in the poor, in nurslings 
 and in children under five years, especially in colored children. The 
 mortality of cases in the first year is about 27 per cent. ; in the second 
 year, 11 per cent. ; from the second to the fifth year, 3 per cent. ; 
 from the fifth to fifteenth year, 1.8 per cent. (Hagenbach) ; Toplitz 
 found 41.7 per cent, of pertussis deaths in children under one year, 
 and 48 per cent, in children between one and two years of age. Ac- 
 cording to Trousseau, when more than forty attacks occur in one day, 
 a grave prognosis is indicated and when over 60 attacks occur a 
 fatal outcome is certain. The writer, however, has seen recovery in 
 cases with over 100 paroxysms daily. Coincident measles, pneu- 
 monia or bronchitis, especially if of early development, weak heart, 
 
PERTUSSIS (WHOOPING-COUGM). 183 
 
 purpura, continued emesis, glottis spasm, eclampsia, sinus thrombosis, 
 skin emphysema, encephalitis, brain hemorrhage, asphyxia, and the 
 sequels of scrofula and tuberculosis render the prognosis very un- 
 certain. 
 
 Treatment. — 1. Prophylaxis. — Isolation is difficult, but is indi- 
 cated, particularly in tuberculous children. It is never advisable to 
 expose a child to an epidemic. The greatest danger of infection 
 exists during the catarrhal stage. The sputum, and the washing of 
 clothes, etc., should be cared for on antiseptic principles. It was 
 thought that vaccination mitigated or aborted pertussis (Archer), but 
 in eleven personal unvaccinated cases, vaccinia had no prophylactic 
 effect. 
 
 2. Medication. — There is no specific, as proved by the multitude 
 of vaunted remedies. All drugs should be employed cautiously. 
 The following are of value: Quinine, the foremost remedy, was in- 
 troduced by Binz, who gave 1-J times as many grains per diem as the 
 child was years old ; to children under two years, he gave i grain for 
 each month. Children seldom object to the taste of quinine. 
 
 Widerhofer's formula runs as follows : 
 
 I£ Extr. belladonna gr. iss. 
 
 Quininae sulph gr. viij. 
 
 Sacchari albi gr. xxx. 
 
 M. et divide in pulv. no. X. 
 
 S. — One powder three times daily. 
 
 Camphor, recommended by Jacobi, may be indicated as a stimulant 
 in asthenia and in increasing bronchitis, f grain at a dose. Cold 
 tars should not be exhibited. Bromine should be administered as 
 bromide or bromoform (Stepp). It is not curative, but moderates 
 the course of the disease. Bromoform should be kept bottled in the 
 dark and administered fresh from the stock solution each time — one 
 to five minims in simple syrup. 
 
 The catarrh may be treated with expectorants and alkaline drinks. 
 A steaming kettle somewhat alleviates bronchitis, a tent being con- 
 structed over the bed. Intralaryngeal insufflations of resorcin (1 
 per cent, with starch) are recommended. Blenorrhoea should be 
 treated with benzoic and tannic acids (aa gr. ij, t. i. d.). 
 
 For the paroxysm there is no specific. Belladonna is given by 
 Jacobi in the form of the extract, one-sixth grain to a child of six 
 to eight months, until flushing is observed. Symptomatically it is 
 also useful for the clammy, cool skin and for collapse symptoms. 
 Though children tolerate belladonna well, great care must be exercised 
 in very young children. The same caution is necessary with ipecac, 
 chloral and Henoch's combination of belladonna and opium. 
 
 Chloroform inhalations are dangerous. Codeine is less effective 
 than morphia. Chloroform (Schilling) is given with advantage in 
 dry coughs, and twice as many drops may be administered as the child 
 is years old, in one dram of warm water. It is said that the paroxysm 
 
184 TEE SPECIFIC INFECTIONS. 
 
 may be averted by pulling the lower jaw downward and forward. 
 Yeo recommends the following formulas: 
 
 I£ Morphinse hydroehloridi gr. i. 
 
 Sodii bromidi 3ss. 
 
 Aquae laurocerasi 3ij- 
 
 Aquaa chlorof ormi ad 5J SS - 
 
 Misce, fiat mistura. 
 
 S. — One to three teaspoonfuls for a dose, according to the age of the child. 
 
 ]£ Chlorali hydrati gr. xvj. 
 
 Sodii bromidi gr. xxxij. 
 
 Aquse chlorof ormi ad ^ij. 
 
 Misce, fiat mistura. 
 
 S. — One to four teaspoonfuls for a dose, according to age. 
 
 fy Sodii benzoatis gr. lxxij. 
 
 Sodii bicarbonatis gr. xlviij. 
 
 Ammonii chloridi gr. xxiv. 
 
 Aquae chloroformi |j. 
 
 Aquae anisi ad ^iij. 
 
 Misce, fiat mistura. 
 
 S. — One to four teaspoonfuls, according to the age of the child, in a little 
 hot milk, every four hours. 
 
 Digitalis is used by Koplik and Knight for right-heart dilatation. 
 O'Dwyer recommends intubation for the spasm of the glottis. This 
 is open to the criticism that ulceration might occur from the long- 
 continued pressure in the larynx. Bronchopneumonia (q. v.). 
 
 3. Hygiene. — In warm climates pertussis is rare and runs a mild 
 course. A suitable climate is likewise prophylactic against tubercu- 
 losis. The attacks are often lessened, or the disease quickly ended, 
 by removal to the country. Such irritants as beef tea or stimulants, 
 dry bread, cookies, and overfeeding or drinking, provoke coughing 
 and vomiting in the convulsive stage. Food should be given at fre- 
 quent intervals in concentrated form — gruels, milk with lime-water, 
 zwieback in milk, eggs, malt, meat-juice, etc. Older patients tolerate 
 more solid food, Rectal feeding is sometimes advantageous. 
 
 EPIDEMIC PAROTITIS (MUMPS). 
 
 Definition. — An acute specific infection, contagions, febrile, often 
 epidemic, and characterized by a primary inflammation of the parotid 
 glands. 
 
 History. — Parotitis epidemica was known to Hippocrates, who de- 
 scribed every essential point, but later it was confused with other 
 swellings of the parotid gland. Its distribution is world-wide. 
 
 Etiology. — (a) Its precise cause is unknown, although various mi- 
 croorganisms have been described, (b) Most cases occur between 
 six and fifteen years of age; isolated cases are seen in adults, (c) 
 The sexes are equally involved, (d) Most cases occur in the cold, 
 moist, spring months, (e) Contagion is more frequently direct, from 
 person to person, than indirect by a third party or by fomites. (/) It 
 prevails largely in epidemics. (g) Immunity is conferred by one 
 attack. It rarely prevails with the exanthemata. 
 
EPIDEMIC PAROTITIS (MUMPS). 185 
 
 Symptoms. — After an incubation of two and a half to three weeks, 
 the disease begins with fever, followed in a few days by 'parotid 
 intumescence and fain. In some cases slight fever, chilliness, and 
 redness of the throat may exist before fever and parotitis develop. In 
 other instances the severity of the epidemic determines such severe 
 initial symptoms as vomiting, convulsions, or facial spasm in child- 
 ren; or delirium, prostration, diarrhoea, or a typhoidal condition in 
 adults. As a rule, the fever rises at the onset to 101° or even 104°, 
 the pulse averages 100, and in two days the characteristic parotitis 
 develops. Its signs are clearly inflammatory (swelling, pain, tem- 
 perature, and interference in function). The parotitis is bilateral, 
 for the inflammation of one gland is rapidly followed by parotitis in 
 the other. Indeed, Bouchoud said : " Mumps have no singular " ; in 
 rare epidemics the parotitis is unilateral (Laveran). Its degree 
 varies and sometimes there is partial swelling. We know little of its 
 pathology beyond what Yirchow described — hyperemia of the par- 
 enchyma, interstitial swelling, catarrhal secretion in the ducts and 
 inflammation of the contiguous lymph-glands. The swelling about 
 the gland may reach the eyelids, forehead, mastoid region, or even the 
 clavicle, making the features unrecognizable and even invading the 
 pharynx and larynx. The swelling is due less to periparotitis than 
 to pressure on the facial and other veins. It is soft and does not pit. 
 Compression of the masticatory muscles by the swollen glands makes 
 chewing or opening the mouth difficult ; chewing also elicits pain 
 because it excites salivary secretion which often cannot pass the 
 turgid ducts. Compression of the Eustachian tube or external meatus 
 may occasion tinnitus. In the early unilateral involvement, the 
 face inclines to the affected side in order to relax the swollen tissues ; 
 in the later bilateral parotitis, the head is often bent forward to the 
 same end. The salivary secretion may be normal, increased or de- 
 creased. Suppuration is due to mixed infection. Leukocytosis is 
 usually absent. 
 
 In severe cases the submaxillary and sublingual glands are swollen 
 (even in 50 per cent, of some epidemics) ; in atypical cases they may 
 be the sole seat of the disease. The parotitic swelling reaches its 
 acme in three or four days and an equal period is necessary for its 
 subsidence. The course is one week, perhaps two. The fever is 
 remittent or intermittent, and falls by lysis. One to two weeks are 
 necessary for convalescence. 
 
 Complications and Sequels. — 1. The most important are orchitis 
 and epididymitis, which were described by Hippocrates. On the 
 sixth to the ninth day fever returns (102° to 105°), sometimes with 
 chills and local redness. Swelling and pain in one testicle develop, 
 often accompanied by general symptoms. Orchitis usually follows 
 the parotitis, whence it was formerly considered metastatic, but in 
 some epidemics, orchitis precedes or even occurs without parotitis. 
 We must then explain mumps as a general infection, the blood car- 
 rying the virus first and most commonly to the parotid glands and 
 
186 TEE SPECIFIC INFECTIONS. 
 
 later to the testicle. A urethritis is sometimes observed, analogous 
 to the catarrh of the parotid duct. Testicular localization occurs 
 almost wholly in the sexually mature, active testis and therefore is 
 most rare in children or the aged. Orchitis or epididymitis is usu- 
 ally unilateral. Comby observed it in 30 per cent, of mumps among 
 French soldiers. Acute hydrocele is due to the epididymitis. Sup- 
 puration from mixed infection is very exceptional. Testicular atro- 
 phy occurs in 50 per cent, and if bilateral may occasion sterility. 
 In women, ovaritis and vulvovaginitis are infrequent. Mastitis is 
 rather more frequent, and may also be observed in men and boys. 
 
 2. Other glandular organs. Of these the lachrymal glands are 
 most often affected, then the thyroid, with symptoms of acute Graves' 
 disease, pancreas (1.5 per cent., Simonin), and the thymus. The 
 spleen is seldom swollen. 
 
 3. Other complications are very rare. These are delirium, menin- 
 gitis, paralysis of the cranial nerves; polyneuritis, or the neuroses; 
 middle-ear disease, eye inflammations, optic neuritis; endocarditis; 
 synovitis ; albuminuria or nephritis ; bronchitis or bronchopneumonia ; 
 necrosis, suppuration, or gangrene of the parotid or testis. 
 
 Diagnosis. — The diagnosis is usually easily made. Osteomyelitis of 
 the jaw, periostitis, lymphadenitis, thrombo-phlebitis of the external 
 jugular, and furuncle of the external ear, should be considered and 
 excluded. Epidemic parotitis must not be confused with secondary 
 parotitis, which results from trauma, or pus burrowing from the 
 middle ear, or with mercurial, iodide or lead parotitis, and purulent 
 metastasis in typhoid, pneumonia, and erysipelas, in which the pyo- 
 genic virus enters by the ducts or settles from the blood-current. 
 In post-operative parotitis, after laparotomy, trauma to the gland, 
 from holding up the jaw, may promote infection. 
 
 Prognosis. — The prognosis is good, for but 7 deaths occurred in 
 58,331 cases. The course is lighter in children than in adults. 
 Sterility may result from orchitis. 
 
 Treatment. — The patient should be isolated. The fever is con- 
 trolled as in other fevers, and diet and hygiene are the same. Com- 
 plications are treated symptomatically. The patient should be kept 
 in bed for one and a half weeks. Pain often necessitates the use of 
 opiates. The local parotid or testicular inflammation is self-limited, 
 and resists all attempts at abortion or mitigation. Local heat is 
 soothing and better tolerated than the ice-bag. 
 
 ACUTE ARTICULAR RHEUMATISM (RHEUMATIC FEVER). 
 
 Definition. — An acute, febrile, non-contagious disease, with multiple 
 articular involvement and with a tendency to heart complications. 
 
 Frequency. — McCrae's statistics, from Johns Hopkins Hospital, 
 show that rheumatism constitutes 2 per cent, of admissions, as 
 against 3.5 to 7 per cent, in London hospitals. 
 
 Etiology. — The evidence is strongly presumptive that rheumatism 
 
ACUTE ABTICVLAB BSEUMAT1SM. 187 
 
 is an acute infection. TKis is shown by its occasional epidemiology ; 
 its clinical picture ; its tendency to recur like pneumonia and erysipe- 
 las ; the autopsy findings of exudation, hemorrhage, cloudy swelling, 
 and acute splenic tumor; the frequency with which an atrium may 
 be observed, such as an angina, and its indubitable close affiliations 
 with endocarditis, pericarditis, and meningitis, whose mycotic origin 
 is clearly established. The rheumatism virus is unknown. Birsch- 
 Hirschfeld, Triboulet, Poynton, Paine and others, have found bac- 
 teria in the joints and blood, but the organisms are neither constant 
 nor uniform. 
 
 Singer likens rheumatism to septicopyemia in that common symp- 
 toms occur in each — temperature, anaemia, articular metastases, endo- 
 carditis, leukocytosis, and peptonuria. He places particular stress 
 upon the detection of pyogenic organisms in the rheumatic joints, 
 the initial angina, endocarditis, erythema multiforme, etc. Chvos- 
 tek and Egger explain the presence of organisms by bacterial inva- 
 sion during the death agony, since bacteria could not be obtained 
 from aspiration of the joints during life. The rheumatic arthritis is 
 sometimes explained by toxaemia rather than by bacteriaemia. 
 
 Some writers question the " unity " of acute articular rheumatism, 
 because the clinical picture is not always the same. Age modifies 
 the disease, as is shown by the predominance of chorea, pericarditis, 
 and endocarditis in childhood, with striking synovial subordination. 
 The " genius epidemicus " changes the symptomatology, and the fre- 
 quency of complications. However, no greater variations are noted 
 than in other diseases, — e.g., in typhoid. 
 
 Predisposing Factors. — (a) Cold; 75 per cent, of cases occur in 
 the first half of the year (McCrae) ; (&) heredity in 25 per cent.; 
 (c) male sex (70 per cent.); (d) age; the greatest susceptibility 
 exists between ten and thirty years (50 per cent.) ; M. Miller col- 
 lected nineteen cases in nurslings; (e) trauma, overexertion, ex- 
 posure, and occupation, occurring frequently in sailors, divers, bakers, 
 and day laborers. 
 
 General Clinical Picture and Course. — The onset is usually sudden, 
 with moderate fever, redness of the skin, considerable prostration, 
 drenching sweats and polyarthritis. The joints are involved in suc- 
 cession, the inflammation lasting a few days in one joint and then 
 passing to many others, with frequent heart localization and the 
 fever ending in solution by lysis. In adults and adolescents there is 
 febrile urine, constipation, conjunctival injection, coated, moist 
 tongue, some irritability, restlessness, and fever which is renewed 
 as fresh joints are involved. There is marked anaemia and loss of 
 weight. If endocarditis occurs valvular disease is the usual sequence. 
 The usual duration without therapy is three to four weeks. Recovery 
 is usual, but death- may result from hyperpyrexia and brain toxae- 
 mia. A tendency to recur and a family tendency to rheumatism 
 and valvular lesions are noted. The articular disease is directly in- 
 fluenced by the salicylates, but cardiac localizations are much less 
 directly affected. 
 
188 TSE SPECIFIC INFECTIONS. 
 
 Symptoms in Detail. — 1. Prodromal Symptoms. — These are an- 
 gina or tonsillitis (estimated at from 2 to 20 per cent.), regarding 
 which there are two conceptions ; (a) that the angina is primary and 
 rheumatic, and (b) that the rheumatism following angina is pseudo- 
 rheumatism (polyarthritis anginosa), characterized by exanthems, 
 occurring chiefly in the arms and reacting poorly to salicylates. 
 Other possible prodromes are laryngitis, chorea, erythema nodosum, 
 albuminuria or gastro-enteritis. Diagnostic doubts are settled by the 
 appearance of the polyarthritis. 
 
 2. Polyarthritis. — (a) Localization. — The joints most frequently 
 involved are those of the lower extremity, particularly the knee (53 
 to 84 per cent.) ; and usually one side is affected after the other. 
 The ankles, elbows and wrists are the next most frequent localiza- 
 tions. Though usually found in the large joints, it may early in- 
 volve the smaller articulations, such as the small bones of the carpus — 
 thought by Trousseau to promote endocarditis. Rheumatism may 
 invade the spine, jaw, sterno-clavicular joints, the synchondroses of 
 the ribs, the sacroiliac or pubic articulations, and the larynx. Occu- 
 pation has a bearing on the disease; for instance, rheumatism may 
 occur in the arms of washerwomen. If a joint of an upper ex- 
 tremity is first involved, the opposite arm is usually next inflamed. 
 (b) In general the arthritis is ascending, fleeting and almost invar- 
 iably polyarticular. The characteristic erratic character of the ar- 
 thritis was mentioned by the oldest writers as Van Swieten, who spoke 
 of it as " migratory inflammation " or " fleeting gout." Though usu- 
 ally fleeting in its nature, the virus may settle in one joint for a 
 period, but persistency in one joint always suggests pseudorheumatism 
 (symptomatic or secondary forms), (c) Signs and Symptoms. — 
 Polyarthritis is a better term than polysynovitis because the in- 
 flammation pervades all structures of the joint, the periarticular 
 bursse, cellular tissue, muscular insertions and tendons, — indeed, 
 the external oedema is usually greater than the synovial effusion. 
 The joints are swollen, red, tender and painful. Pain is the most 
 prominent and frequent joint finding. Lasegue attributes pain not 
 to the joint but to inflammation in the associated muscles and 
 tendons, affirming that if these be voluntarily relaxed or suitably 
 supported, the joint can be moved freely in all directions. Lasegue's 
 phenomenon is said to be absent in gonorrheal and surgical ar- 
 thritis. The contiguous tendon reflexes are lessened or abolished. 
 (d) Duration. — The inflammation remains in one joint from one 
 to eight days, seldom longer, and its involution is shorter than its 
 evolution, (e) Sequels. — The joints become normal, in fact anky- 
 losis usually reflects doubt upon a previous diagnosis of rheumatism. 
 Suppuration is extremely exceptional, and results only from mixed in- 
 fection. Spontaneous dislocations are rarities. 
 
 3. Temperature. — The fever is directly related to the intensity 
 of infection, the number of articulations involved, and to the develop- 
 ment and progression of visceral complications. As Wunderlich 
 
ACUTE ARTICULAR RHEUMATISM. 189 
 
 noted in his celebrated communication on fever, the temperature is 
 usually highest when the patient is first examined. The fever rises 
 with each new localization, be it arthritic, endocarditic, or pericar- 
 diac. The fever curve is in no wise cyclic, beyond undulation with 
 each new manifestation, and is rarely higher than 102° or 104°. 
 The temperature usually drops when the sweats occur. Prodromal 
 fever was early noted by Todd, Graves and Fuller. The fever 
 averages ten days, defervescence occurring spontaneously or with 
 the salicylate therapy. The fever is longer when treatment is com- 
 menced late. Kahler held that fever could occur independently of 
 joint inflammation (febris rheumatica). Pleuritis, renewed arth- 
 ritis, angina, erythemata, embolic and other complications, prolong 
 the pyrexia. Simple fixation of the joints reduces the fever, tachycar- 
 dia and tachypnoea (Pribram). Chills suggest septicopyemia 
 rather than rheumatism. Hyperpyrexia is exceptional. With Dr. 
 Lackner, the writer saw a patient with a fever of 112°, who recovered. 
 Severe nervous symptoms, coma, convulsions, rapid pulse, transitory 
 paralysis, stertorous breathing and hyperpyrexia constitute the " cere- 
 bral rheumatism " ; 50 to 60 per cent, of cases of hyperpyrexia occur 
 in the first attack of polyarthritis, with lesser frequency in later 
 seizures. It is less frequent since the introduction of the salicylates. 
 
 The pulse is usually said to exceed 100, although McCrae found 
 that its rate was not over 100 in 59 per cent, of his cases. Dicrot- 
 ism and arrhythmia may sometimes be noted before involvement of 
 the joints. The respiration follows the fever ; Pribram noted one case 
 with 80 to 100 per minute. 
 
 4. Heart Complications. — These are almost an integral part of 
 rheumatism and constitute visceral rheumatism as distinguished from 
 articular rheumatism. Heredity seems to be a factor in certain cases. 
 Heart lesions occur as frequently in light as in severe forms. They 
 vary somewhat with the epidemic, are most frequent and most dan- 
 gerous at the time of puberty and increase in frequency with repeated 
 attacks of rheumatism. Lasegue says : " Acute rheumatism licks the 
 joints, pleura, and even the meninges, but it bites the heart." 
 
 1. Endocarditis. — This, the most vital complication, was first 
 described by Pitcairn (1788), and Bouillaud, Pidoux, Besnier and 
 Homolle developed the subject. Bouillaud (1832) formulated 
 the statement that "in every severe case of acute rheumatism, endocar- 
 ditis was the rule." The frequency of endocarditis is about 20 per 
 cent. Mackenzie finds endocarditis in 58 per cent, of first attacks, 
 63 per cent, of second attacks, and 71 per cent, of third attacks. In 
 McCrae's series we might divide the cases into thirds; in one third 
 the heart is normal ; in another third, it is doubtful ; and in the last 
 third, it is diseased. Hospital statistics, however, represent the sever- 
 est cases. Clinically, endocarditis often escapes recognition, or is 
 latent; — i. e., it is found more frequently at the autopsy table than 
 at the bedside. It is usually verrucose, and rarely ulcerative even 
 in the fatal cases. Accidental or " functional " murmurs must not 
 
190 THE SPECIFIC INFECTIONS. 
 
 be called endocarditis. To be certain that an endocarditis exists, two 
 points are absolutely necessary: (a) Continued observation of the pa- 
 tient after convalescence ; and (b) attention to signs of valvular disease 
 (q. v.), other than the mere murmur, such as dilatation, hypertrophy, 
 pulmonic accentuation, etc. Trousseau called attention to the possi- 
 bility of the functional murmur, but Potain, almost alone among 
 the present French writers, properly estimates its importance. The 
 diagnosis of acute endocarditis, consequently, must long be uncertain, 
 yet therapeutically we must protect the patient, and ourselves, by 
 keeping him sufficiently long in bed. We may interpret the disap- 
 pearance of a murmur in two ways, — first, as the disappearance of a 
 functional murmur when the fever falls, the toxaemia disappears, the 
 heart slows, dilatation subsides, or the anaemia mends; or, second, as 
 the healing of a slight endocarditis, though this is always the less 
 probable issue. 
 
 Valves Affected. — McCrae finds the mitral valve involved in 95 
 per cent, of the cases, the aortic in 23 per cent., and both valves in 
 18 per cent. (Aortic lesions are usually estimated at 12 per cent.) 
 The fever may be continuous with that of the arthritis but is often 
 higher. Less often the fever is remittent with severe rigors and may 
 require differentiation from malaria, pyaemia, or gonorrhoeal endocar- 
 ditis. A low remittent fever may suggest pulmonary or serous mem- 
 brane tuberculosis. The endocarditis exceptionally antedates the 
 polyarthritis (Jaccoud, Trousseau). 
 
 Masked or atypical rheumatism embraces rheumatism masquerad- 
 ing under the guise of an endocarditis or trifacial neuralgia and yield- 
 ing to salicylate treatment (Immermann). Kahler's opinion of 
 rheumatic fever without arthritis has been mentioned. It is claimed 
 that rheumatic pericarditis or endocarditis occurs without articular 
 inflammation — " polyarthritis rheumatica sine arthritide." We may 
 call this the " rheumatic equivalent," borrowing from the nomen- 
 clature of epilepsy. 
 
 In old heart lesions with renewed rheumatism, lingering fever sug- 
 gests the possibility of an exacerbation of an old endocarditis aroused 
 by the last rheumatic attack. Various embolisms may occur. The 
 bacteriological findings are most varied, and not knowing the actual 
 cause of rheumatism, we cannot say exactly what is rheumatic and 
 what is mixed infection. 
 
 2. Pericarditis. — Osier states that rheumatism explains more cases 
 of pericarditis than all other causes combined. Its frequency is given 
 as 5 to 10 per cent. Pericarditis is very frequently latent. In 
 children, especially, a subacute or latent course is most common. 
 Baginsky found that adhesive pericarditis was the most common 
 autopsy finding in rheumatic children. 
 
 3. Myocarditis. — Disturbance of the heart in the acute stage is 
 almost certainly myocardial, and toxic or mycotic. Acute interstitial 
 myocarditis (in 28 per cent.), coronary disease, myocardial invasion 
 by contiguity from endocarditis in the later stages, and sometimes 
 
ACUTE ABTICULAB BEEUMATISM. 191 
 
 the use of salicylates, are possible causes. Recovery is usual, but 
 chronic fibrous myocarditis is a not uncommon sequel. Acute myo- 
 carditis may produce a systolic murmur, suggesting an early endo- 
 carditis. Myocarditis may cause sudden heart pain with weakness, 
 and possibly death, — the " heart rheumatism " of the laity. Trans- 
 ient palpitation, cardiac oppression, or tachycardia, may occur. 
 Bradycardia with vertigo and syncope is probably myocardial. 
 
 As a practical point, it must be remembered that the right heart 
 may be dilated as in other fevers and various abdominal affections ; 
 this dilatation disappears with convalescence. When accompanied by 
 a murmur it may lead to an incorrect diagnosis of endocarditis. The 
 bloodvessels are rarely inflamed, but French writers maintain that 
 acute arteritis is common ; severe pain over the artery is followed by 
 paresthesia and pain over its smaller branches in the extremities ; 
 pathologically only part of the vessel-wall is affected and healing 
 usually follows, but gangrene may develop after complete arterial oc- 
 clusion. Endophlebitis is somewhat more common. 
 
 5. SKiisr.-^Sweating is most profuse, constant and characteristic; 
 in odor it is sour or mouse-like (Schonlein) ; in reaction it is first 
 acid and later neutral or alkaline. The skin is frequently macerated 
 and sudamina alba are common (in 4 per cent., sudamina rubra). 
 Rheumatic nodes (first described by Hilliers, Meynert, Hirschsprung, 
 Barlow and Warner) are subcutaneous nodes, as large as buckshot, on 
 the fingers, hands, wrists, elbows and spine. They may appear 
 during or after an attack, or independently of acute seizures. They 
 occur especially in children, but are also observed in adults, particu- 
 larly in women. They are abundant, sometimes numbering even 
 sixty, are symmetrical, hard, and are usually tender. Sometimes 
 osseous or arterial endothelial proliferation is observed. Nodes occur 
 most often in chronic cases or in cases with severe endocarditis or 
 pericarditis. If very numerous or large they indicate an unfavorable 
 prognosis. In contradistinction to these more fixed nodosities, Fereol 
 has described more fugitive and less indurated nodes {nodosities 
 cutanees ephemeres). (Edema of the skin may be septic, rheumatic, 
 or angioneurotic. Erythema polymorphum is generally regarded as 
 an independent affection but in rheumatism the nodose form occurs. 
 Some cases are possibly septic or anginose eruptions. The salicylates 
 relieve some cases and fail to benefit others. Morbilliform or scar- 
 latiniform rashes are infrequent, and may be attributed to errors in 
 diagnosis, or to drug eruptions. Purpuric eruptions are not uncom- 
 mon. The intestinal hemorrhage, colic, and vomiting, with articular 
 intumescence, described by Henoch, are entirely distinct from gen- 
 uine rheumatism and will be considered under Purpura (q. v.). 
 
 6. Muscles astd Boistes. — Myositis is infrequent, though myalgia 
 is common. Muscular atrophy may follow inflammatory extension 
 from the joints to the muscles. "Muscle scars' 7 are not frequent, 
 and are much more often due to trauma, or other infections, than 
 to rheumatism. Periostitis may occur, and some cases of albuminous 
 periostitis are clearly rheumatic. 
 
192 THE SPECIFIC INFECTIONS. 
 
 7. Respiratory Tract. — Laryngitis may be prodromal and an 
 atrium for the rheumatic invasion, or may occur later as diffuse 
 catarrh or as local nodes. The rare acute oedema of the larynx is 
 most dangerous. Pleurisy may result from the rheumatic virus or 
 secondary infections. Its frequency is 2 to 3 per cent. A primary 
 pre-arthritic pleurisy is very rarely observed. Pleurisy and pneu- 
 monia are usually associated with heart disease. Pleurisy is found 
 in 54 per cent, of cases of endopericarditis (Pribram). The writer 
 believes that the so-called rheumatic pleurisy is almost always tuber- 
 culous (see Etiology of Pleurisy). Pneumonia occurs in but one- 
 tenth of 1 per cent, of cases of rheumatism not involving the heart, 
 and in 66 per cent, of cases with endopericarditis. Howard found 
 lung and pleural complications in only 10 per cent, of cases with rheu- 
 matic endocarditis, in 58 per cent, of those with pericarditis, and in 
 71 per cent, of those with endopericarditis. Many cases are called 
 pneumonia which are pulmonary infarction, stasis, or compression 
 from pleural or pericardial exudates. 
 
 8. Digestive Tract. — Angina or tonsillitis occurs as a prodrome 
 (v. s.) or as a later development. The tongue is coated and moist 
 except in the severest cases where it is dry. Gastric symptoms are 
 rare, though Dam ash considers them the most frequent prodrome. 
 Constipation is the rule. Diarrhoea occurs as prodromal enteritis or 
 as a rare complication. Peritonitis, icterus and liver enlargement are 
 most exceptional. 
 
 9. Genito-TTrinary Tract. — Albuminuria is mostly transitory. 
 It occurs late in the course or after several attacks, and mostly in 
 individuals over thirty years of age. The percentage ranges up to 34 
 (McCrae). Albumosuria is frequent, especially during resorption, 
 whence it has a slight diagnostic value. Cylindruria may occur with- 
 out albuminuria. Renal infarction usually occurs late in the course 
 of cardiac cases. Acute nephritis is seldom seen (to to 1 per cent.) ; 
 it occurs early, and chiefly in endopericarditis, and is usually benign 
 but may become chronic. But few of the author's cases in private 
 practice show nephritis, though it is present in 50 per cent, of hospital 
 patients ; it is probably latent until awakened by the fresh toxsemia 
 and is probably due to exposure and alcoholism. Haematoporphyrin 
 has been found and the characteristics of fever urine, and reduction of 
 the chlorides. Cystitis may result from cantharides blisters. Amen- 
 orrhoea is usual. Hemorrhagic endometritis and genital hemorrhage 
 are infrequent. 
 
 10. Blood. — The blood in low dilutions, is said to respond to the 
 Widal reaction. The red disks are reduced 25 to 30 per cent, and 
 chlorotic characteristics are noted. The fever, the anaemia and the 
 intensity of articular involvement run more or less parallel. The 
 white cells, in moderate cases, range between 10,000 and 15,000, 
 and higher figures (20,000) are only reached in extensive endocar- 
 ditis, pericarditis, pleurisy, pneumonia, or in septicaemic or suppura- 
 tive arthritis. The increase is in the polymorphonuclear neutrophils 
 
ACUTE ARTICULAR RHEUMATISM. 193 
 
 while other cells are normal or decreased. The eosinophiles are prac- 
 tically absent, but increase with betterment of the articular findings. 
 If they are increased in a florid case, the prognosis is good, since the 
 course will probably be mild. Bacteriological findings are negative. 
 
 11. Nervous System. — The relation of chorea to rheumatism is 
 an unsettled question. Chorea, rheumatism and endocarditis are 
 associated (in 50 per cent, of cases, Pribram), or coordinated, and 
 possibly a common, though unknown, infection is the essential cor- 
 relating cause. A constant anatomical cause of chorea, as arterial 
 change, encephalitis, or embolism, is not known. Cases with rheu- 
 matic or endocarditic association usually run a slow and often a 
 relapsing course; cases which react to the salicylates are probably 
 rheumatic. Cerebral rheumatism is very infrequent ; it may develop 
 acutely at the acme of the disease, with psychical alteration, often 
 with hyperpyrexia, sometimes with warnings, or again precipitately. 
 Delirium, unrest, convulsions, and coma, frequently result in death. 
 High fever may be solely a cerebral symptom, but cerebral symptoms 
 may occur without high temperature. The course is foudroyant or 
 lasts several days, and even a week. The author has seen two cases 
 of recovery after mania, convulsions, meningeal symptoms, and coma. 
 Chronic psychoses, hallucinations, mania, melancholia or convulsions, 
 may occur in convalescence. They are usually due to inanition and 
 the patient generally recovers. Brain embolism (from endocarditis), 
 hemorrhage and rheumatic meningitis, are infrequent. Spinal rheu- 
 matism may be confused with myelitis, septic or gonorrheal menin- 
 gitis, multiple neuritis, local myopathies adjacent to the joints in- 
 volved, or cerebral embolism. In Kraus' clinic the author saw one 
 fatal case characterized pathologically by meningomyelitis. Multiple 
 neuritis is often rheumatic; it may precede the polyarthritis, but 
 usually occurs in the first or second week of rheumatism and presents 
 the usual characteristics, such as pain and tenderness over the muscles 
 and nerve trunks, paralysis, muscle atrophy, reaction of degeneration, 
 anaesthesia and lost reflexes. The prognosis is good and the neuritis 
 reacts well to electrotherapy. Mononeuritis also occurs and usually 
 regresses entirely. 
 
 The Eye. — Rheumatism may result in benign episcleritis, iritis, 
 iridocyclitis, and possibly conjunctivitis. Optic neuritis, with or 
 without atrophy, and retinal embolism or thrombosis occur exception- 
 ally ; their prognosis is doubtful. 
 
 Acute thyroiditis is most uncommon. Lymphadenitis is not un- 
 common, but is rarely marked or extreme. It occurs with arthritis, 
 erythemata, endocarditis or pericarditis. 
 
 Prognosis. — The prognosis as to life is usually excellent and is 
 generally proportionate to the severity and duration of the infection 
 and to the number of joints involved. The percentage of deaths is 
 1.5 to 3 per cent, but these hospital figures are higher than in general 
 practice. In statistics other arthritides are not carefully excluded. 
 There are waves of increased mortality every three or four years. 
 13 
 
194 TEE SPECIFIC INFECTIONS. 
 
 In late years the death-rate has somewhat decreased. The causes of 
 death are (1) hyperpyrexia, the most important; (2) cerebral rheu- 
 matism, chorea; (3) peri-, endo- and myocarditis; (4) pneumonia 
 and lung infarcts. Recurrence occurs in 19 per cent, of cases or in a 
 larger percentage in general practice. They are more dangerous in 
 pregnancy or with complications such as influenza, etc. The prog- 
 nosis is less favorable in children than in adults. The salicylate 
 therapy influences the disease and also its relapses; but the heart 
 complications are only slightly relieved. At the onset it is impossible 
 to declare the case light or severe. According to Trousseau, the in- 
 volvement of the small joints of the hands and feet predict a severe 
 course. 
 
 Diagnosis. — 1. Rheumatism in Childhood. — In the very young 
 the disease is most rare (3 cases in 85,000 nurslings) but becomes 
 more common after the fifth year. The course is more rapid and 
 the urine is normal or less febrile. Generally speaking, the joints 
 are less susceptible and the arthritis less intense, while the skin, 
 nervous system, and heart, are more often involved. Heredity is 
 most potent in the young, and the sexes are equally involved. The 
 various phases of rheumatism occur separately, — first arthritis, then 
 endocarditis, later chorea, subcutaneous nodules, pericarditis, and so 
 on. The child rarely lies quietly, but tosses about ; the tendons and 
 fasciae are more often involved than the joints. The pain is less 
 and the arthritis may entirely escape recognition. The lower tem- 
 perature is particularly remarkable at this epoch of life, when high 
 fever is often excited by trivial lesions. There is much less sweating. 
 The anaemia in childhood is especially rapid and marked. In 
 children the differential possibilities are acute osteomyelitis, acute 
 pyaemia, monarticular arthritis, especially of the knee and hip in 
 nurslings, gonorrhoeal arthritis, Barlow's disease, syphilis, and hse- 
 mophilic joints; if the rheumatism occurs in the spine, meningitis or 
 torticollis are of differential importance. Endocarditis is usually 
 not so clearly nor so immediately connected with the polyarthritis as 
 in adults, but it develops more slowly, insidiously, later, and twice 
 as frequently as in adults (80 per cent. Vernay). Thomas Watson 
 knew but three instances of acute rheumatism, before puberty, which 
 escaped severe heart disease. This is due to the greater functional 
 demands on the child's heart and to the aorta being narrow at the 
 isthmus. Endocarditis occurs relatively early in what Cheadle 
 terms the " rheumatic progression," but pericarditis occurs later after 
 the valvular lesion, has developed. Pericarditis is almost always 
 found in necropsies on children with valvular disease (Sturges). 
 Rheumatic heart disease in general at this epoch, leads to greater 
 hypertrophy because of greater nutrition, to more marked dilatation 
 because of greater tissue elasticity, and to more frequent recurrence. 
 The prognosis is therefore much more unfavorable than in adults. In 
 the diagnosis, functional murmurs are not frequent in children. 
 The pulse is often irregular, the precordium more readily bulges; 
 
ACUTE ARTICULAR RHEUMATISM. 195 
 
 left-sided pleurisy is more frequent than in adults, and rheumatic 
 nodes are more common. Oppression over the heart is infrequent, 
 as are pain, cyanosis, dropsy, hepatic congestion, pulmonary infarc- 
 tion, dyspnoea and fever. Rheumatic children are more nervous. 
 More marginate, papular and urticarious erythemata and more pur- 
 pura develop in children. Large subcutaneous nodes (rheumatismus 
 nodosus) are serious prognostically and always suggest danger from 
 severe intercurrent valvulitis. Chorea is prone to develop with ar- 
 thritis, heart disease, nodes, or with the erythemata. 
 
 2. Rheumatoldes. — Rheumatoides (Gerhardt) or pseudorheuma- 
 tism (Bouchard) are symptomatic arthritides resembling rheu- 
 matism, in that fever, arthritis, or endocarditis, may occasionally de- 
 velop in their course. The nomenclature of Quincke, who speaks 
 polyarthritis gonorrhoica, scarlatinosa, etc., is the least objectionable. 
 (a) Polyarthritis gonorrhoica resembles rheumatism most closely and 
 most frequently. Konig holds that the most common of all joint 
 diseases is the gonorrheal (v. Gonorrhoeae Infection) . (b) Poly- 
 arthritis scarlatinosa often most closely resembles rheumatism, occurs 
 most frequently in the third to fourth week, and varies with the 
 epidemic. In 66 per cent, of patients it occurs in the hands, and 
 lasts four days, frequently with endocarditis or pericarditis (32 per 
 cent., Hodges), and sometimes with recurrence and serous or purulent 
 exudation. With it have been observed nodes, erythema and chorea. 
 (c) Polyarthritis may also complicate many other diseases, including 
 most of the infections; e. g., measles, smallpox, erysipelas, typhoid, 
 angina, appendicitis, diphtheria, syphilis, pneumonia, etc., etc. 
 
 3. Severe Types. — In grave types the visceral findings are least 
 confusing when secondary, both in development and degree, to the 
 arthritis. Jaccoud speaks of the primary visceral type, wherein the 
 findings (e. g., cardiac) antedate the arthritis, but the diagnosis re- 
 mains uncertain, until the joints are involved. 
 
 4. Gout (q. v.). 5. Arthritis Deformans (q. v.). 6. Tuber- 
 culous Polyarthritis (q. v.). 
 
 The number of joints involved is always highly suggestive, but 
 not finally diagnostic. True rheumatism and gonorrheal rheuma- 
 tism are often polyarticular. Diagnosis of gonorrheal rheumatism 
 in women is often difficult for notable reasons. In women, puer- 
 peral infections, and an acute monarticular osteoarthritis, beginning 
 acutely from exhaustion in pregnancy or lactation, may cause diffi- 
 culty. In growing children, acute osteomyelitis may cause articular 
 swelling, which, however, is monarticular. 
 
 Treatment. — 1. Diet. — The diet should be limited to fluids, arrow- 
 root, milk, gruels, etc. Biot's results, with a strict milk diet, were 
 extremely good. Antecedent tonsillitis indicates tonsillectomy. 
 
 2. Clothing.' — The patient should wear a flannel gown and lie 
 between blankets, which are more comfortable than sheets on account 
 of the sweating. Care must be taken lest the drenching sweats macer- 
 ate the skin. This can be avoided by dusting talcum powder in the 
 
196 THE SPECIFIC INFECTIONS. 
 
 axillae, between the toes, etc., and by sponging the body with warm 
 water and alcohol. 
 
 3. Local Treatment. — Fixation lessens pain, fever, pulse and 
 respiration-rate. Cold applications, boric fomentations, and salicylic 
 salve are useful (Acidi salicylici 3j, adipis lanse hydrosi gj). 
 Davies' cantharides blister and the actual cautery are indicated for 
 tardy involution. 
 
 4. Rest. — The patient should lie in the most comfortable position. 
 Splints afford relief to the muscles and joints, but muscular atrophy 
 may result from the use of plaster-of-Paris casts. The absolute dor- 
 sal decubitus, long into convalescence, or at least for two weeks, must 
 be enforced because of the weak condition of the heart. 
 
 5. Salicylate Treatment. — Buss (1875) remarked the antipy- 
 retic action of the salicylates, and Strickler (1876) first discovered 
 their remarkable action in rheumatism. — (a) Effect on the Arthritis. — 
 The pain and swelling are usually relieved after three to five full 
 doses or within twenty-four hours after taking the first dose. Sal- 
 icylates are the best analgesic in rheumatism. Hypodermics of mor- 
 phine are rarely necessary except, perhaps, in the first twelve hours. 
 Salicylates are thought to cause articular hypersemia. 
 
 (b) Effect on the Temperature. — The fever falls coincidently with 
 relief of the articular symptoms, and reaches normal in two days. 
 In the great majority of cases the acute stage is over within three 
 days. In hyperpyrexia less influence is noted, especially if the sali- 
 cylates are administered late. 
 
 c. Effect on the Endocarditis. — The weight of opinion is that en- 
 docarditis occurs as frequently with the use of salicylates, — i. e., 
 salicylates are analgesic and antipyretic but not strictly antirheu- 
 matic. Many, however, claim that the salicylates are in every sense 
 antirheumatic. The writer believes that the salicylates are practi- 
 cally specific and that heart complications are lessened by shortening 
 of the acute stage. 
 
 d. Relapses. — Relapses are said to be more frequent with the ad- 
 ministration of the salicylates than with the alkaline treatment, and 
 especially so when treatment is discontinued early. This claim seems 
 unfounded. Relapses are apparently less frequent with the con- 
 tinued use of salicylates for two weeks after the initial symptoms 
 are relieved. 
 
 Physiological Action of the Salicyl-preparations. — They 
 are absorbed from local applications. The smallest doses produce 
 symptoms of cinchonism, as fulness of the head or roaring in the 
 head and ears. After larger doses dulness, headache, giddiness, a 
 flushed dusky and moist skin, disturbed sight and hearing, and tre- 
 mor, develop. Toxic doses produce the above symptoms, plus eye- 
 muscle paralysis, pupil dilatation, deafness, increased reflexes, rest- 
 lessness, delirium, dyspnoea, disturbed circulation, skin eruptions, 
 sweating and also green urine (indican and pyocatechin). Post- 
 mortem, visceral congestion and serous ecchymoses are seen, 
 
ACUTE ABTICULAB BHEUMATISM. 197 
 
 Administration. — Sodium salicylate is the best preparation. Its 
 action is most prompt and certain; it is soluble and least irritating. 
 Where it fails, other preparations are usually unsuccessful. All 
 salicyl-preparations are absorbed as sodium salicylate produced by the 
 alkaline intestinal juices. Grains xv of the natural acid, which is 
 better than the synthetic, or grains xx of the sodium salt, are given 
 every two or three hours until salicylism, appears, i. e., until slight 
 dulness, dyspnoea and deafness develop. This action is maintained 
 for twelve hours, when the interval between doses is lengthened to four 
 or six hours. The effects are better in proportion as the disease is 
 more acute, the symptoms more pronounced, the inflammation greater, 
 the number of involved joints larger, and the fever higher. It is 
 well tolerated by children and usually can be given by mouth in fluid, 
 if the taste be disguised by wintergreen oil, syrup of ginger, and 
 syrup of orange. Even then, however, it is frequently nauseating. 
 
 fy Sodii salicylates 3vj. 
 
 Sodii bicarbonatis 3iv. 
 
 Syrupi zingiberis 5J. 
 
 Syrupi aurantii §j. 
 
 AquaB q.s. ad ^iv. 
 
 M. et S. — Shake. One teaspoonful every three hours. 
 
 Theoretically it should not be given in capsules, for in this form it 
 may irritate the stomach, but it may be given in powders which are 
 taken in starch wafers. As in cinchonism, bromide of potassium may 
 be given to lessen the ringing in the ears. In case the stomach is in- 
 tolerant, salicylates may be administered in pepsin, or given by rec- 
 tum in peptonized milk. When given as an inunction, it is soon 
 found in the urine, but absorption by the skin is uncertain. Aspirin 
 (acidum acetylsalicylicum) is much less irritating to the stomach 
 than salicylate of soda, less antipyretic and less analgesic but more 
 sudorific. It is given in doses of ten to twenty grains at the same in- 
 tervals. Salol (phenylis salicylas) is given in the same dose at the 
 same interval, but the kidneys must be carefully watched ; it is far less 
 efficacious. 
 
 The alkaline treatment is said to decrease the heart complications 
 and shorten the disease. Though these claims are not established, 
 the alkaline treatment may be used in conjunction with the salicy- 
 lates, using vichy salts with enough citrate of potassium or bicarbon- 
 ate of soda to make and keep the urine alkaline. Long ago Fuller 
 advised the following : — 
 
 Jfc Sodii bicarbonatis 5ss. 
 
 Potassii acetatis 5ss. 
 
 Liquoris ammonii acetatis 3iij. 
 
 Aquae ad ^ij- 
 
 M. f . haust. 
 
 S. — To be taken in effervescence with — 
 
 ]£ Acidi citrici 3ss. 
 
 Aquae §ij. 
 
198 TBE SPECIFIC INFECTIONS. 
 
 Baginsky thinks the administration of gr. xv to xl of potassium 
 iodide daily produces better results in children than do the salicylates. 
 Unusual Results. — Unusual results of salicylate treatment: 
 
 1. Nervous. — Salicylate delirium has been observed in anaemic 
 girls, neurotics, and in alcoholics. It may be violent and protracted. 
 Convulsions are quite infrequent ; they are centric. 
 
 2. Cardiac. — Small doses stimulate the heart, and cardiac depres- 
 sion is observed only when the largest dosage is given, when the pre- 
 parations are impure, or when the heart is already diseased. If the 
 heart becomes weak or irregular, acute myocarditis is probably devel- 
 oping and salicylate treatment must be suspended, the dose must be 
 decreased, or the heart muscle must be stimulated by coffee, strych- 
 nine or alcohol. Slight irregularity without weakness is not a con- 
 traindication. Cardiac depression may be noted in nervous subjects. 
 Thorne has observed collapse from aspirin. 
 
 3. Respiratory. — With antecedent or concomitant bronchitis, the 
 lungs should be explored for possible congestion which may result 
 from the remedy. Cardiac depression, sudden respiratory failure 
 and violent expiratory dyspnoea are observed in a few cases. Tuber- 
 culous patients should be carefully watched. 
 
 4. Renal. — Caution is necessary in old nephritics, because the sal- 
 icylates are excreted by the kidneys as salicylic, or salicyluric acids ; 
 however infective albuminuria, directly due to the rheumatic virus, in- 
 dicates, rather than contraindicates, the use of the salicylates. Binz 
 believes that the salicylates may induce abortion. 
 
 5. Alimentary. — Vomiting (v. s.) and diarrhoea may result from 
 salicylate treatment. Digestive disorders are partly due to inhibition 
 of the digestive ferments. Constipation is said to favor salicylism. 
 
 Diagnostic Therapy. — Senator claimed that sodium salicylate is 
 specific in true rheumatism and inert in pseudorheumatism. Though 
 the general truth of this statement is acknowledged, its application is 
 not absolute. Some rheumatic patients resist salicylates. Salicyl- 
 ates are of some value in the arthritic type of grippe. They usu- 
 ally are useless in other arthritides. 
 
 Convalescence. — Absolute rest must be enforced for two to four 
 weeks to save the heart. 
 
 DENGUE. 
 
 Definition. — An acute specific infection, occurring chiefly in trop- 
 ical and subtropical countries, extremely contagious, and characterized 
 by fever, an initial prodromal eruption, violent articular and muscu- 
 lar pains, and a secondary polymorphous eruption. 
 
 Etiology and Epidemiology. — The actual cause is uncertain. A 
 small diplococcus or bacillus resembling the Bacillus influenzae has 
 been described. Graham found, in the blood-cells, an organism re- 
 sembling the Plasmodium mal arise, but small and unpigmented. For 
 this reason infection has been connected with mosquito-bites. Eberle 
 
DENGVti. 199 
 
 describes a "plasmeba," The disease is very contagious and seems 
 disseminated less by direct than indirect infection, e. g., by fomites, 
 bites, etc. It is carried by pilgrims, sailors, and emigrants. The 
 disease spreads with remarkable rapidity and infects large numbers 
 of people. Its home is in the tropical and subtropical zones and it 
 prevails chiefly in the hot months. It has invaded Europe, Asiatic 
 Turkey, South America and the United States. It is remarkable 
 that the coast ports are alone invaded. It very seldom reaches in- 
 land, and even in regions where the disease prevails endemically, 
 closely contiguous inland towns and higher places are exempt. Un- 
 hygienic conditions promote its development. In the first Philadel- 
 phia epidemic it was called " Front Street Fever," on account of the 
 squalid condition of the houses along the river front. The first 
 epidemic, in 1779, in Java, was described by Brylon, and Benjamin 
 Rush wrote of the Philadelphia epidemic in 1780. The chief later 
 epidemics or pandemics occurred in 1818, 1824 to 1828 (reaching 
 Savannah and IsTew Orleans), 1830 to 1870 (again reaching America 
 and seen even as far north as Ohio), 1876 (Virginia), 1889, 1890, 
 1895 to 1897. The morbidity is enormous but the mortality is 
 strikingly inconspicuous. Epidemics last two to five months. ISTo 
 immunity is conferred by one attack and two, three or even four, 
 infections have been observed. 
 
 Symptoms. — After an incubation of one to two days, or sometimes 
 a little longer, the disease begins suddenly. 
 
 1. Febrile Stage. — The fever rises quickly to 102°, 104° or 
 even 107°, usually with a chill, severe frontal headache, and sudden 
 intense pains in the back and limbs, which incapacitate the patient 
 and involve especially the knees. The names a breakbone fever," 
 first mentioned in Rush's description, and " dandy fever," given be- 
 cause of the mincing gait which results, bring out this salient feature. 
 Many large and small joints are swollen (pseudorheumatism), one 
 after another. The muscles are painful and the skin is sometimes 
 hypersesthetic. The pulse averages 100. The face is suffused and 
 swollen, the conjunctivae are injected, the flow of tears is increased, 
 and in some cases there is coryza. Total anorexia, foul breath, coated 
 tongue, and great thirst, develop ; vomiting is occasional and constipa- 
 tion the rule. The premonitory hypercemic rash may last but one 
 to five hours, and is frequently absent. The urine is febrile. Pros- 
 tration may be marked, and, in some cases, severe delirium, convul- 
 sions, and coma may develop. This stage lasts three days (" three- 
 day fever") and ends with profuse sweating. Fever is absent in 
 the lightest cases. 
 
 2. Exakthemat.otjs Stage. — The eruption begins on the fourth 
 day chiefly on the face, hands, forearms and chest, and is decidedly 
 polymorphous. It is scarlatiniform, morbilliform, urticarial, ery- 
 sipeloid, lichen-like, vesicular, or even pustular. It is present in 
 60 to 100 per cent, of the cases. It lasts two to three days, and is 
 followed by fine desquamation, intense itching, sometimes by falling 
 
200 THE SPECIFIC INFECTIONS. 
 
 of the hair, and by cutaneous hyperesthesia. The throat is some- 
 times red or even inflamed, and occasionally lymph-gland enlarge- 
 ment, parotitis and orchitis occur. The fever in this stage may be 
 elevated, may be absent, or subnormal temperature be noted. The 
 pain often recurs. Herpes, splenic tumor, otitis, albuminuria and 
 leukocytosis are absent. 
 
 3. Convalescence. — Convalescence begins in five to seven days, 
 after a crisis or lysis, and is very tardy. There is great prostration, 
 gastric uneasiness, insomnia, emaciation, and anemia, all of which 
 are remarkable after such a short illness. In no other disease of 
 equal duration is such marked constitutional disturbance noted. 
 
 Complications and Sequels. — These are great rarities. Cutaneous or 
 gastric hemorrhage, neuralgia, endocarditis, pericarditis, nephritis, 
 pneumonia, pleurisy, oedema or ulcers, rarely develop. 
 
 Prognosis. — Death is rare, though the morbidity is enormous. The 
 highest recorded death-rate was J of 1 per cent. One death occurred 
 in 7,435 cases in the Anglo-Indian army (1872), and 10 deaths in 
 100,000 cases occurred in Smyrna. Relapse may occur in one to two 
 weeks. 
 
 Diagnosis. — The geography and the presence of an epidemic are 
 suggestive. The exanthemata, rheumatism, insolation, yellow fever 
 (q. v.) and epidemic erythema exudativum multiforme may be sug- 
 gested. Influenza is differentiated by its epidemic-pandemic inci- 
 dence, its occurrence in all climates, seasons and locations (inland 
 as well as on seaboard), its more frequent direct infection, the more 
 general immunity conferred, the higher coincident mortality (pneu- 
 monia and tuberculosis), its more frequent respiratory catarrh and 
 lung complications, its more severe nervous, intestinal and cardiac 
 symptoms, and the greater frequency of herpes, splenic tumor, otitis 
 media, and albuminuria. In the rare cases of acrodynia, observed 
 in France, Belgium, Turkey, Persia, and Mexico, Scheube gives the 
 following differential points: (1) Digestive disturbance; (2) facial 
 swelling; (3) pains in the extremities, sometimes with anesthesia of 
 the soles; (4) spastic symptoms; (5) afebrile course; (6) erythema 
 multiforme. 
 
 Treatment. — Isolation and quarantine are necessary. Pain is the 
 prominent indication, for which acetphenetidinum and salicylates 
 serve fairly well, though they are much inferior to opium. 
 
 CHOLERA ASIATICA 
 
 Definition. — A specific infection caused by Koch's comma bacillus. 
 It is chiefly disseminated by drinking-water, is characterized clini- 
 cally by vomiting, severe purging, and by such symptoms as cardiac 
 failure and suppression of urine which are due to loss of fluids and to 
 toxaemia. 
 
 History. — The name has been used since the time of Hippocrates, 
 Galen and Celsus, but apparently not for Asiatic cholera. Asiatic 
 
CHOLERA ASIAT1CA. 201 
 
 cholera is said to have existed before Christ, and travelers in India in 
 the sixteenth century spoke of it. Its first European invasion was in 
 1817, from which time our knowledge of cholera dates. Other epi- 
 demics have occurred in 1826, 1832, 1847-1855, 1865-1867, 1873, 
 1881-1884, and 1892-1894. Cholera visited America in 1832- 
 1835, 1836, 1848, 1849, 1854, 1865, 1867, and 1873. This was 
 the last epidemic, though isolated cases have occurred since. 
 
 Bacteriology. — Koch, while studying cholera in Egypt and India, 
 in 1883-1884, discovered the specific organism in the faeces during 
 life and in the bowel at autopsy. The comma bacillus is 1 to 1.5 /* 
 long and half as wide; it is smaller than the tubercle bacillus, but 
 more plump and curved and is motile and flagellated (Loeffler). 
 Gaffky (1887) first obtained pure growths on various media. In 
 cultures its form varies, being sometimes S-shaped, and thread- or 
 spirillum-like. The comma bacillus is found in the stools and in the 
 intestines, usually in pure cultures. After several days it may be 
 found in the bowel wall, though rarely in the stomach or vomitus. It 
 disappears from the movements after six to eleven days and rarely 
 reaches the blood or viscera. 
 
 Etiology. — In its dissemination and contagion, cholera resembles 
 typhoid rather than the exanthemata, i. e., infection is less direct than 
 indirect. Attendance on cholera patients is not dangerous if the 
 hands are kept clean. The germ is very susceptible to boiling, acids, 
 antiseptics, drying, and the presence of saprophytes in sewers and 
 water. There is little risk of aerial dissemination, though fiies may 
 carry infection. Koch early maintained that cholera was conveyed 
 by water contamination. He found the cholera vibrios in a water- 
 tank in Calcutta from which infection was clearly traced. Frankel, 
 von Ermingen, Biernacki, and others, found it in flowing and stag- 
 nant water. It is well known that cholera vibrios may be found in 
 the movements without cholera symptoms, just as diphtheria bacilli 
 may be found in healthy throats. The normal acid of the stomach 
 protects the individual, and animals are infected experimentally 
 only when the gastric acidity is neutralized and peristalsis is arrested 
 by opium. Pettenkofer vigorously objected to Koch's teaching and 
 insisted that individual and local disposition was more essential. 
 He even swallowed pure cultures, and luckily escaped infection. 
 Nevertheless, the terrible Hamburg epidemic (1892-1894) amounted, 
 as Koch said, to a demonstration of almost laboratory exactness. The 
 disease developed " explosively." On August 16 there was one case ; 
 by August 27 there were 1,000 deaths, and September 3, there were 
 lb,00cT cases and 4,300 deaths. The total mortality was over 8,300. 
 The Hamburg drinking water came unflltered from the Elbe Kiver, 
 which was then at a low level, the weather being hot. The germ 
 was found in this supply. Altona and Wandsbeck, which are parts 
 of Hamburg, had a supply of good water, and practically escaped. 
 That part of Hamburg which used Altona water was exempt. The 
 cholera germ is difficult to find in water because it is so easily over- 
 grown by saprophytes. 
 
202 TBE SPECIFIC INFECTIONS. 
 
 Infection by ice, by milk, by green lettuce, by flies, or in the labora- 
 tory, is less common. The washing of infected linen is particularly 
 dangerous to washerwomen. In India, hundreds of thousands of 
 pilgrims drink the " holy water " of the Ganges, in which they also 
 bathe and defecate. Similar infections occur in the pilgrimages to 
 Mecca. In former years the caravans carried infection from India 
 through Persia and xifghanistan to Russia, which was also the route 
 of dissemination in 1892. Ships from the Orient are extremely dan- 
 gerous. 
 
 Individual Predisposition. — Decrease of physiological resistance 
 increases the risk of infection. Alcoholism, strong purgatives, dys- 
 pepsia, overexertion, poor hygienic conditions, and debilitating dis- 
 eases are predisposing factors. Counting the mortality in a cholera- 
 stricken community for a few years, it is seen that the total death- 
 rate is not increased, which means that weakly persons succumb to 
 cholera and that later epidemics of other diseases have a diminished 
 prey. 
 
 Epidemics involve a smaller percentage of the people in large than 
 in small cities, but they last for months in large cities and usually 
 only for weeks in small towns. Epidemics end with a lessening mor- 
 tality, and both their ending and the lessened mortality are probably 
 best explained by the decreasing virulence of the germ. Warm 
 weather tends to increase epidemics and they are usually checked by 
 frost. Nevertheless, Russia's severest epidemic occurred in the winter. 
 
 Symptoms. — After an incubation of two or three days, the disease 
 develops with varying virulence. The bacilli are found in the stools 
 of some healthy persons. Several stages are usually described, which 
 also correspond to clinical types of different severity. 
 
 1. Prodromal Diarrhoea. — The stools contain the comma bacillus, 
 are thin and normal in color, are voided without pain or tenesmus, 
 and sometimes produce only moderate depression or malaise. The 
 trouble may cease here, when we speak of cholera diarrhoea, or it may 
 pass into the choleraic stage. 
 
 2. Choleraic Stage. — This may usher in the disease or follow 
 the first stage. The stools, at first yellow and voided frequently, 
 become colorless because the bile pigment is diluted and decreased, 
 and become thin, — the ominous " rice-water " stools. Diarrhoea usu- 
 ally comes on first at night. The stools may number twenty or thirty 
 and a pint to five quarts (500 to 5,000 c.c.) are voided daily. They 
 have a fetid, not a fecal odor, and contain 98 to 99 per cent, water. 
 In the evacuations are seen flocculi of comma bacilli, leukocytes, epi- 
 thelial cells or shreds, detritus, and a few red cells. There is often 
 gurgling, although little gas is voided. Much fluid is thus lost to 
 the circulation, and this causes some of the following symptoms : The 
 abdomen is flat, usually neither tender nor painful, and fluid may be 
 percussed in the bowels. Vomiting is frequent, painless, although ex- 
 hausting, and thin, and profuse, even to three quarts daily; some- 
 times Koch's bacillus is found. The skin early shows the lack of 
 
CHOLERA AS1AT1CA. 203 
 
 fluid ; it becomes shrunken, lax, wrinkled, and when pinched, its folds 
 disappear but slowly. The nose becomes small and pointed, the eyes 
 hollowed, and the malar bones jut out prominently; the extremities, 
 nose, and ears become cold and cyanotic, and grayish-blue rings de- 
 velop beneath the sunken eyes {fades cholerica). If pleurisy or 
 dropsy are present they are rapidly absorbed. The saliva and urine 
 diminish and disappear, though nursing mothers may continue to 
 secrete milk. The loss of fluid occasions distressing thirst and muscle 
 cramps, especially in the calves of the legs, but also in other muscles, 
 which are found dry at autopsy. The immense transudation into the 
 bowel has other effects ; it concentrates the blood, whose cells and hae- 
 moglobin rise; the red cells may total six to eight millions and the 
 serum has a specific gravity of 1,040 or even 1,070 (1,028 being the 
 normal). The heart tones become weah and the pulse rises to 100, 
 because the body cannot lose 10 per cent, of its fluid without injury. 
 The heart has not enough blood upon which to contract and the blood 
 is viscid ; the heart also suffers reflexly, as it does in intestinal incar- 
 ceration, and degenerates from absorption of toxins (soluble sub- 
 stances from the bacilli) . The difficulty in oxygenation increases the 
 respiration to thirty or forty, and occasions precordial and epigastric 
 anxiety. The vox cholerica is due to the dry larynx and weak mus- 
 cles. The reflexes are decreased or absent, the pupils tardy ; the sen- 
 sorium is normal, although exhaustion, apathy, and vertigo are usual. 
 The urine contains albumin and casts which are largely hyaline. 
 While the external parts are colder by 5° to 10° or more, the patient 
 feels hot, and the internal temperature may be 102° or higher. The 
 loss of weight is great (even 0.5 to 1 per cent, hourly!). In some 
 few cases the patient dies before diarrhoea develops (cholera sicca). 
 Recovery is possible, even with these ominous symptoms ; reaction 
 may set in, the diarrhoea and algidity may lessen, the heart may im- 
 prove, and erythematous, roseolous, urticarial and other rashes may 
 develop. Indican, which was previously absent from the urine, may 
 reappear ; the urea is increased two- or threefold and the ethereal sul- 
 phates are increased. The symptoms are then chiefly toxic, and 
 probably result from absorption of the cholera and other toxins from 
 the intestine (the so-called cholera typhoid, — i. e., cholera with a 
 pronounced typhoid state). 
 
 3. Stage of Collapse. — This stage is characterized by asphyxia 
 (literally meaning without pulse), paralysis or algidity. The heart 
 tones are inaudible, the radial pulse imperceptible, the arteries empty, 
 and the veins full. In the days of venesection the blood would not 
 drain from the incised veins, and at autopsy little or no blood escapes 
 from the vessels. The picture is that of collapse. The skin is. lead- 
 colored, cyanotic, even violet or purple, and will not vesicate after 
 blistering. There is dyspnoea, the expired air is cool, the voice gone, 
 the mouth dry, the conjunctivae dry or opaque, and the lids are parted, 
 yet the mind is clear. The evacuations cease. Pericardial or pleural 
 rubs may be heard, due to the great viscidity found in all the serosse 
 
204 TBE SPECIFIC INFECTIONS. 
 
 at necropsy. Very few cases with the symptoms of cholera-typhoid 
 react and recover, but most of them die within a few hours, or a day 
 or two. After death the muscles frequently contract, to the great 
 terror of observers. The face is distorted, the fingers flexed, and the 
 legs drawn up. Post-agonal rise in temperature may occur. At 
 autopsy the small intestines are injected, filled with rice-water con- 
 tents, their epithelium or villi are desquamated or necrosed, the lym- 
 phatic structures are sometimes swollen, reddened and reticulated. 
 Comma bacilli are found in the stools and intestinal wall, and occa- 
 sionally there is an agonal invagination of the gut. The muscles 
 are dry, the spleen small, and the kidneys show a pale cortex with 
 great cortical degeneration, especially in the convoluted tubules ; the 
 renal changes, once attributed to loss of water and disturbed cir- 
 culation, are probably toxemic. 
 
 Complications. — The so-called croupous or diphtheritic enteritis is 
 due to the pyogenic cocci. Diphtheroid changes may also be found 
 in the uterus, vagina and throat. Hemorrhages from mucous or 
 serous surfaces, though usually small, may occur. Pneumonia (20 
 per cent, of fatal cases), pleurisy or lung infarct; skin, parotid or 
 other suppurations; icterus, bronchitis, venous thrombosis or post- 
 febrile psychoses, are uncommon. Griesinger's "cholera-typhoid" 
 is the most frequent sequel (25 per cent, of cases) ; nervous complica- 
 tions and uraemia are far less common causes than the toxins absorbed 
 late from the intestine and operating intensely on the already ex- 
 hausted, slightly degenerated, and anaemic brain. 
 
 Diagnosis.^ — Diagnosis is usually easy in the presence of an epi- 
 demic. The first cases occasion the most difficulty, especially if they 
 are light. As already stated, robust individuals may not react to the 
 germs found in their stools; simple diarrhoea may result in other 
 cases, and only a mild depression may mark some cases known as 
 cholerine. On the other hand, aged, weakly, or tuberculous persons 
 may succumb to cholera before its characteristic stages develop. In 
 clinically suspicious cases, laboratory measures are necessary for 
 diagnosis. The pseudocholera vibrios in the Elbe, Seine, or Danube 
 Canal (Vienna) are differentiated with difficulty. The comma 
 bacillus is obtained (a) in nearly pure cultures from the stools, espe- 
 cially from their shreds; (&) in peptone cultures (1 per cent., with 
 1 per cent, salt) in which the germs are found on the surface in six 
 hours, because they rise to obtain oxygen; (c) in 10 per cent, gelatin 
 plates, in which they develop in fifteen to twenty hours; (d) the 
 nitrosoindol (cholera-red) reaction results on adding sulphuric or hy- 
 drochloric acid. It was thought that no other bacterium produced 
 both nitrates and indol, but the pseudocomma organisms may produce 
 the same reaction ; (e) in animals, in which the cholera germ produces 
 a sudden fall of temperature, but this is uncertain ; (/) Pfeiffers test 
 is the sole absolute criterion, according to which the blood of animals 
 immunized to cholera produces agglutination of the true cholera 
 bacillus. 
 
CHOLEEA ASIATICA. 205 
 
 Cholera nostras produces a similar picture. It is usually less 
 severe. In some few cases the Finckler-Prior bacillus is found, but 
 in the majority of cases other microbes are present, such as the colon 
 bacillus, and less often the streptococcus, staphylococcus, and a bacil- 
 lus like the Bacillus subtilis ; vibrios, proteus and pyocyaneus forms ; 
 an encapsulated bacillus; Gartner's Bacillus enteritidis; in meat, 
 anaerobic forms ; and in mollusks, Zieber's Bacillus piscicidus agilis. 
 It is possible that many of our domestic intestinal organisms may 
 become virulent. Liebermeister said cholera nostras bears the same 
 relation to cholera Asiatica as varicella does to variola, German 
 measles to measles, or epidemic icterus to yellow fever. It occurs at 
 the same season. Its symptoms differ chiefly in degree, and occasion- 
 ally, a large percentage (even 40) of deaths occur, chiefly in the ex- 
 tremes of life. 
 
 Arsenical poisoning, peritonitis, and intussusception without bacter- 
 iological confirmation may closely resemble cholera. 
 
 Prognosis. — The prognosis is always grave. Cholera ranks next 
 after the plague in death-rate, and averages over 50 to 60 per cent., 
 and sometimes 80 per cent. ; 100,000 to 700,000 die yearly in India. 
 In 1883, 28,000 died in Egypt, 8,605 died in Hamburg, and 800,- 
 000 in Russia (1892-1894). About 45 per cent, of the deaths in 
 Hamburg occurred in the first twenty-four hours and 17 per cent, 
 in forty-eight hours, whence the prognosis is more favorable after 
 the second day; 85 per cent, die when the stage of collapse is reached. 
 Light cases may become severe or the worst cases may recover. Un- 
 favorable factors are youth and old age; pregnancy; colorless stools, 
 early frequent movements, early vomiting, anuria and low peripheral 
 temperature. 
 
 Treatment.- — 1. Prophylaxis. — Quarantine of ships, isolation of 
 early cases, thorough disinfection of the stools, soiled linen, etc., and 
 special attention to light cases and to any suspicious diarrhoea, are 
 most important. In convalescence the stools may remain infective for 
 seven weeks (Kolle). Despite the sudden outbreaks in Germany in 
 1892-1894, sanitary measures kept the total of deaths at 10,000, 
 while in Russia 800,000 died in the same period. Individual pro- 
 phylaxis concerns the maintenance of physiological resistance ; moder- 
 ation in eating and drinking ; boiling of water for drinking and wash- 
 ing ; boiling of milk ; care in regard to ice ; avoidance of green fruits 
 or vegetables, and contamination of food by flies. In one series of 
 cases the use of the prophylactic serum of Ferran and Haffkine re- 
 duced the morbidity two-thirds and the mortality one-half. 
 
 2. Diarrhoea. — This should be treated by absolute rest in bed, and 
 by initial cleansing of the bowels with calomel and castor oil ; thin 
 gruels should be given as a diet ; red wine and aromatics, tea, and full 
 doses of bismuth and opium should be given. Intestinal antiseptics 
 are inert. The diarrhoea, except the early movements, is not easily 
 stopped, because absorption is arrested. Cantani advised that 1 or 
 2 quarts of 1 per cent, tannic acid solution be given slowly by rectum 
 
206 THE SPECIFIC INFECTIONS. 
 
 in the hope that it would reach the small intestine, and Griesinger 
 advised that larger quantities be given, and that expulsion by the rec- 
 tum be forcibly prevented. The fluid was given until it was vomited, 
 apparently with some benefit. 
 
 3. Vomiting. — Vomiting is intractable. Fluids should not be 
 withheld. The stomach may be washed with normal salt solution. 
 Hot wine, champagne, and hypodermics of morphia are also indicated. 
 
 4. Heart. — Failing heart action and renal secretion are sometimes 
 helped by a warm bath. Hypodermatoclysis was recommended by 
 Cantani (1865) and intravenous transfusions were employed by 
 Hermann and Latta (1830). Their use was studied during the 
 Hamburg epidemic and their employment often increased the heart's 
 force and benefited the general condition greatly, at least for a time. 
 The results are somewhat better than the mortality (65 to 77 per 
 cent.) would indicate, for they were used in the stage of profound 
 collapse (where the death-rate is as high as 85 per cent.). If used 
 earlier the results might have been better. The kidney secretion is 
 apparently little influenced by this treatment. 
 
 5. Musct.es. — Muscular cramps are helped by warm baths, sinap- 
 isms, friction, local heat, saline infusions, and morphine, which should 
 be given hypodermatically. 
 
 6. Convalescence. — In convalescence, great care is necessary lest 
 the diarrhoea return. 
 
 Other symptoms, complications and sequels are treated expectantly. 
 
 YELLOW FEVER. 
 
 Definition. — A specific infection of unknown etiology, which is 
 transmitted by the mosquito, is endemic in the American tropics and 
 subtropics, and is characterized pathologically by moderate degenera- 
 tion, especially of the liver and kidneys, and clinically by a rapidly 
 developing fever, by icterus, albuminuria, adynamia, hsematemesis, 
 and by other hemorrhages. 
 
 Etiology. — The cause is unknown, although two microorganisms 
 have been especially described: (1) Sanarelli's Bacillus icteroides, 
 which is said to be present in the blood, and viscera, but not in the 
 intestine; it is a facultative anaerobe, with rounded ends, 2 to 4 fi 
 loug and half as wide; positive agglutination tests are said to have 
 been made. Sanarelli's organism is generally considered as a con- 
 tamination. (2) Sternberg's bacillus, resembling the influenza germ. 
 While the cause is not known, it is certain that the disease is trans- 
 mitted by the mosquito (Stegomyia fasciata). This was first sus- 
 pected by Carlos Finlay, in 1881, and the mosquito was demonstrated 
 to be the intermediate host by the investigating board composed of 
 Walter Reed, James Carroll, A. Argamonte and J. W. Lazear. Dr. 
 Carroll recovered from a severe attack, but Dr. Lazear died from 
 inoculation. Dr. Myers, of the English Commission, also succumbed. 
 The Stegomyia breeds not only in stagnant street pools, but also in 
 
YELLOW FEVER. 207 
 
 cesspools and sewers, whence its special danger in unhygienic tropical 
 towns. Voluntary inoculations by mosquitos, which twelve days 
 previously had bitten yellow-fever patients in the first three days, 
 produced yellow fever in non-immunes. Einlay failed to prove his 
 correct suspicion because he allowed the mosquitos only three to 
 six days in which to develop the germs which they had absorbed, while 
 twelve days are necessary. The mosquito carries infection only 
 when it bites the patient in the first three days of the disease. As in 
 malaria, the tropical foci, the hot summer and autumn seasons, the in- 
 vasion of low altitudes, river courses and coast towns, humidity, and 
 exposure to night air, are only conditions which are suitable to the 
 mosquito. Frost stops infection because it kills the mosquito. 
 Direct contagion does not occur. ^Nurses and physicians are not in- 
 fected from contact with yellow-fever patients. Persons going from 
 the City of Mexico to Vera Cruz may acquire the disease, but on 
 coming home with it they do not cause its dissemination, because the 
 mosquito is not present. Postmortem wounds and direct voluntary 
 inoculations, however, have directly communicated the disease. The 
 yellow-fever virus is the only virus, infecting man, which passes 
 through fine- filters. Reed's committee experimentally exploded the 
 theory that fomites, clothing, etc., were infective. Volunteers re- 
 mained in rooms occupied by yellow-fever patients and slept in their 
 soiled linen without contracting the disease. 
 
 Predisposition.^ — The lighter races are more prone to infection. It 
 is thought that immunes are merely those who have had light and 
 unrecognized infections. Most cases occur in males between twenty 
 and forty years of age. Yellow fever is kept alive in endemic foci 
 by mild cases, especially among the Creole children. 
 
 Foci and Epidemiology. — The two prominent homes of yellow fever 
 are (1) Mexico, the Antilles, Mexican Gulf and Caribbean Sea; and 
 (2) Africa, from Senegal, through Sierra Leone, to the Gold Coast. 
 The first clear description of yellow fever, according to Sodre and 
 Couto, was in 1686, but certainly yellow fever was known before the 
 discovery of America. It reached this country possibly in the six- 
 teenth century and has extended as far north on the coast as Boston 
 and on the Mississippi Piver as far as St. Louis. It has reached 
 Quebec and Chicago. In Philadelphia (1793, 1797-1798), 4,041 
 died in a year; in E"ew York, 2,080 ; and in ~New Orleans, in 1853, 
 8,000 died. Epidemics occurred also in 1802, 1805, 1853, 1867, 
 1873, 1878, and to a slight degree in 1897-1899 ; New Orleans was 
 visited severely in 1905 ; there were about 9,000 cases and 1,000 
 deaths. Europe is seldom, but South America is frequently invaded. 
 General Clinical Description. — Incubation. — The incubation aver- 
 ages three or four days. Prodromal symptoms last less than a day ; 
 they are malaise, fatigue, headache, dyspepsia, colic, or other indis- 
 stinctive symptoms. The disease is often divided into stages, not 
 all of which are always present: 
 
208 TEE SPECIFIC INFECTIONS. 
 
 Stage I. — The stage of congestion begins (a) with some headache, 
 frontal, supraorbital or retroocular, the earliest and most prominent 
 symptom; (&) sometimes with a chill; (c) with flushed face; the con- 
 junctivae are injected and sometimes icteric even at this stage; the 
 eyes are sensitive to light, the lids somewhat puffed and the expres- 
 sion is a mixture of pain, restlessness and confusion, comparable 
 to the alcoholic facies ; (d) with backache, and pains radiating into 
 the calves of the legs; (e) with fever rising to 104° or more; and 
 (/) with a full, tense pulse of 100 to 110. 
 
 The tongue is usually clean or slightly coated dorsally, and its tip 
 and edges are red. The urine is febrile and very early albuminous. 
 The skin is intensely red and dry. The epigastrium is tender early 
 in the disease and there is marked gastric irritability and intolerance 
 of food, water and medicine. This stage averages two days. 
 
 Stage II. — The remission stage, or deceptive stage, occurs in some 
 cases and is so-called because of the subsequent severe symptoms. 
 The fever, pulse and the pain remit. Slight jaundice may appear. 
 
 Stage III. — The Reaction Stage. — Slight temperature, the " black 
 vomit" (vomito negro) of blood, hemorrhage into the nose, intestines, 
 uterus or skin, hiccough, epigastric pain and tenderness, liver enlarge- 
 ment, and icterus mark this period. The urine becomes scant and 
 laden with bile pigment, or its secretion is suppressed ; the pulse be- 
 comes weaker, and insomnia, prostration and restlessness may appear. 
 
 Various issues are possible: (a) Gradual amelioration; (b) fatal 
 •anuria; (c) profuse hemorrhages, which end in collapse, and rarely 
 in recovery; (d) profound icterus, which results in adynamic phe- 
 nomena and usually in death, and (e) death, from cardiac insuffi- 
 ciency. 
 
 Special forms of yellow fever are described by Soude and Couto : — 
 (A). Variations in intensity include (1) light, abortive, ambulatory, 
 atypical forms, especially in children; (2) the usual severe forms, 
 and (3) the foudroyant type, which is rapidly lethal in one to two 
 days. (B). Visceral forms: (1) The hepatic type, with two weeks 
 of the status typhosus, often with normal temperature and some- 
 times with hemorrhages; (2) the ursemic type, often with early 
 death; (3) the hemorrhagic; (4) the cardiac; and (5) nervous or 
 atactic type. 
 
 Special Symptomatology. — 1. Fever. — The fever is neither cyclic 
 nor diagnostic. Sternberg describes a single febrile paroxysm of 
 two to seven days. It is usually highest in the first stage, and 
 reaches an average of 104°. It may fall on the second or third day 
 to nearly normal in benign cases or in the ominous urgemic type. 
 High fever on or after the second day is a poor prognostic, and is 
 sometimes clue to secondary infection with the pyogenic cocci, or the 
 typhoid or colon bacillus. In the second stage fever is usually be- 
 tween 99° and 100°, and may rise in the third stage. A high post- 
 mortem rise is frequent. In convalescence, the temperature is sub- 
 normal, 
 
YELLOW FEVEE. 209 
 
 2. Nervous Symptoms. — Nervous symptoms are often absent in 
 both benign and malignant cases. Insomnia and headache are com- 
 mon in the congestive period. Delirium is infrequent, and in 80 
 per cent, of the cases, is ursemic rather than purely toxemic. Atac- 
 tic symptoms are most common in children, alcoholics and in the de- 
 bilitated. In children, the status typhosus or meningo-encephalitic 
 symptoms (convulsions, unequal pupils, Cheyne-Stokes' breathing, 
 and coma) are possible. Pathologically, few changes are found 
 except the slight degenerations common to the febrile state, punctate 
 hemorrhage (mostly agonal), or bile-tinging. 
 
 3. Circulatory Symptoms. — (a) The pulse in the congestive 
 stage is usually 100 to 130 and is tense from increased blood pres- 
 sure; on the third day, 90 to 100 (even 70 to SO) ; in the second 
 stage it is still lower in benign and more rapid in severe cases (110 
 to 140), is small, and the manometer shows lowered arterial tension; 
 in convalescence it is usually slow (50 to 60, or even 30). Paget, 
 of New Orleans, considers the slowing of the pulse with maintenance 
 of the fever, almost pathognomonic, (b) In severe forms the first 
 tone of the heart becomes weak and is finally lost. The same is 
 true of the second tone. The heart action is rarely irregular or 
 intermittent. Embryocardia is found in severe cardiac types. In 
 the second or third stage, cardiac dilatation is common (in 70 per 
 cent, of autopsies). Cardiac insufficiency is due to myocardial de- 
 generation; pericardial and endocardial ecchymoses are frequent. 
 Cardiac action is exaggerated when uraemia is present, (c) Often 
 there is no ansemia. The white cells are decreased in proportion to 
 the severity of infection. The polynuclears are relatively increased. 
 
 4. Respiratory Symptoms. — Respiratory symptoms may be due 
 to intercurrent, or more often to cardiac or renal complications. 
 
 5. Digestive Tract. — Severe hiccough is attributed to irritation 
 of the phrenic nerve. Epigastric pain, tenderness and anxiety may 
 be symptomatic of cardiac distress, premonitory of the black vomit, 
 or indicative of disturbed circulation in the medulla. 
 
 6. Icterus (Yeleow Fever, Typhus Icteroides). — Jaundice 
 usually develops on the third to the fifth day. It is frequently 
 absent in children, or in cases of early death from uraemia. It is 
 absent in 50 per cent, of cases which recover. The explanation of 
 the icterus is disputed: — Eeraud distinguishes (a) the early, lighter 
 jaundice, due to blood pigment, and (b) the later and more severe 
 type due to bile pigments. 
 
 7. Liver. — The liver is slightly enlarged and is tender. Patho- 
 logically, its color is light, and has a cooked appearance. The left 
 lobe may reach the spleen. On section, it is oily, fatty, and ansemic. 
 
 8. Urine. — The urine is early febrile. Albuminuria occurs in 88 
 per cent, of cases in the first three days. Leucin, casts and the bile 
 pigments are common. Indicanuria is very infrequent. The 
 kidneys, anatomically are normal in size, rather pale or yellowish, 
 and, microscopically, show great fatty degeneration of the tubules, 
 
 14 
 
210 TEE SPECIFIC INFECTIONS. 
 
 which in severe cases are actually choked by desquamated epithelium 
 and casts. The glomeruli show remarkably few changes. Anuria 
 is due to these changes and is fatal in 97 per cent, of cases. Urcemia 
 causes 33 per cent, of the fatalities; it is marked by delirium, ner- 
 vousness, twitching or convulsions, decreased or suppressed urine, by 
 rapid, forced, irregular, labored or Cheyne-Stokes' breathing, and by 
 a tense pulse. Death in coma may occur on the third day. Ursemia 
 is rare in children. 
 
 9. Hemorrhages. — They are most frequent in the alimentary 
 tract, nose, and uterus. They result from fatty degeneration, or 
 actual rupture of the bloodvessels, (a) Alimentary tract. Hemor- 
 rhages may occur from the mouth, tongue, lips, stomach or intestine. 
 The black vomit is gradually transuded blood altered by the gastric 
 acid ; it most often occurs on the fourth to the sixth day ; it is the or- 
 dinary " coffee grounds " vomit or is ink-like ; the stomach, at autopsy, 
 shows the black contents, congestion, or even dark discoloration, 
 epithelial desquamation and fatty change in the muscularis. Hemor- 
 rhage from the small intestine is equally frequent, (b) Epistaxis 
 is often profuse, and sometimes fatal, (c) Uterine hemorrhages are 
 severe, especially at the menses, and in pregnant women cause abor- 
 tion or premature delivery. Less frequent are (d) skin petechia?, 
 (e) muscular hemorrhages and (/) hemorrhage in other mucosae, 
 serosse or viscera. 
 
 Complications and Sequels. — These include (1) secondary infec- 
 tions such as endocarditis, pericarditis, pneumonia, erysipelas, paro- 
 titis, arthritis, suppuration, and gangrene. (2) Coincident typhoid, 
 malaria, influenza, and insolation. (3) Post-febrile psychoses. 
 
 Diagnosis. — The diagnosis is usually easy from (1)' the flushed, 
 semi-intoxicated facies; (2) icterus; (3) the almost invariable and 
 early albuminuria — the most valuable finding in doubtful cases ; (4) 
 black vomit, gastric intolerance, and marked epigastric tenderness; 
 (5) hemorrhages, and (6) the slow pulse, which is absent in some 
 severe, but therefore clear, cases. Dengue lacks these features. Per- 
 nicious malaria, with icterus, is distinguished by the blood findings, 
 enlarged spleen (always absent in yellow fever), the infrequency of 
 early icterus, albuminuria and hemorrhages (except hematuria). 
 This form of malaria is rare in the cities, whence the constant sug- 
 gestion of yellow fever, when more than sporadic cases are reported. 
 Weil's disease (infectious jaundice), and acute yellow atrophy of the 
 liver are usually readily distinguished. 
 
 Prognosis. — The mortality of epidemics varies from 10 to 85 per 
 cent. The average death-rate is about 30 per cent. The mean death- 
 rate, according to age, is 33 per cent, (one to three years), 14 per 
 cent, (four to eighteen years), and 37 per cent, (nineteen to forty 
 years). Unfavorable events are hepatic, renal, or cardiac insuffi- 
 ciency, the typhoid state, diffuse hemorrhages, combination of special 
 types (cardiac plus renal, or hepatic plus renal), high fever with 
 hepatic symptoms, and hemorrhages. 
 
THE PLAGUE. 211 
 
 Treatment. — 1. Prophylaxis. — Disinfection of the fomites is now 
 less important than the question of the mosquito. Probably no 
 greater triumph of hygiene exists than the stamping out of yellow 
 fever since the American occupation of Havana. It illustrates not 
 only the efficiency of the investigating scientific commission, but also 
 the possibilities of medicine in administrative capacity with unlim- 
 ited discretionary power. In Havana the average death-rate was 500 
 yearly, until Gorgas cut it down to nil. The patient should be iso- 
 lated, not to prevent direct personal contagion but to keep mosquitos 
 from the infected person. Healthy individuals should be kept from 
 infection by the mosquito by the same measures that are employed in 
 malaria, e. g., screens, and extermination of breeding foci. The 
 Stegomyia is found outside the habitual yellow-fever foci, and after 
 biting patients from abroad, may inoculate other persons. Infected 
 insects, too, may be carried by ships. 
 
 2. Symptomatic Treatment. — (a) In the first stage, fluidex- 
 tractum aconiti, TT\ iij, and sodium salicylat., gr. xx, may be given 
 every two to four hours for a few doses, until the congestion and 
 pains are relieved. Coal-tar products tend to depress. Fractional 
 doses of calomel, gr. ^ every hour for five doses, should be given and 
 followed by two ounces of castor oil. Overmedication is particularly 
 to be avoided because of the gastric irritability, and feeding by rec- 
 tum is often indicated. Early or violent cerebral, ursemic, or pul- 
 monary symptoms are sometimes treated by phlebotomy. (&) In the 
 last stage, the black vomit contraindicates any fluid, food, or medi- 
 cation by mouth; warm peptonized milk and normal salt solution 
 should be given by rectum; morphine by mouth is dangerous, (c) 
 In cardiac insufficiency, digitalis is especially good, and is beneficial 
 even when cardiac failure is absent; saline solution, by rectum or 
 subcutaneously, is better than intravenous transfusions. The patient 
 must be kept absolutely quiet, (d) Uramiic symptoms are treated 
 in much the same way. Much water should be given by the bowel, 
 (e) Nervous manifestations necessitate cool spongings, bromides, 
 morphine and hyoscine, as in Typhoid. (/) Vomiting is relieved 
 most efficaciously by chopped ice (see Typhoid). 
 
 THE PLAGUE. 
 
 Definition. — The pest, or bubonic plague, is a specific acute infec- 
 tion caused by the Bacillus pestis and characterized by a pronounced 
 typhoid state, fever, buboes and carbuncles, very frequently by sep- 
 ticaemia (pesticsemia), and by extremely high mortality. 
 
 History. — The first clear accounts date from the times of Trajan, 
 in the second century, and of Justinian, in the year 542. The plague 
 was important among the pestilences of the middle ages. In the 
 fourteenth century the " black death" swept over Europe with a 
 mortality of 25,000,000 (one-quarter of the world's population). It 
 reappeared in the sixteenth and seventeenth centuries, but in the 
 
212 TEE SPECIFIC INFECTIONS. 
 
 eighteenth century it withdrew southeast, and disappeared from 
 Europe until the small Eussian epidemic in 1878-1879. Egypt was 
 the early focus for African epidemics, and European epidemics 
 started from Turkey. Syria was the leading Asiatic focus for thir- 
 teen epidemics (1773 and 1843). The present Oriental focus is 
 Thibet, whence India and China have been invaded thirty times 
 between 1823 and 1.897. Uganda is considered a permanent plague 
 home by Koch; plague is endemic in Asia near Mecca, in Mesopo- 
 tamia and in Siberia. In 1899-1900, New York, San Francisco, 
 Cape Town, South America and Australia were visited. Epidemics 
 appear, reach their maximum, and decline at nearly the same time 
 each year. 
 
 Etiology. — The Bacillus pestis was found by Yersin, in 1894, and 
 at the same time Kitasato found a possibly identical bacillus. Its 
 ends are rounded and stain deeply; its sides are somewhat convex; 
 it measures H to If by -J to f ^ and is encapsulated. It is polymor- 
 phous, and appears as rods or diplo-bacilli. Atypical forms are oval, 
 ovoid, annular, chain-, thread-, or branch-like ; degenerative or in- 
 volution forms are the pyriform, biscuit, comma-shaped, or sperma- 
 tozoid. It is most often outside of the cells. It contains no spores 
 or flagella. It is found in all organs, in the sputum, the urine and 
 fseces, and in the bubo and carbuncles. Its cultures are typical, and 
 superficial, and have bulging, wall-like edges. It stains with or- 
 dinary stains, but not by Gram's method. It is readily killed by 
 sunlight, desiccation, antiseptics, and is often overgrown by secondary 
 infection. It lives three to four weeks in buried bodies, but per- 
 sists longer (v. i.) in excreta of convalescents. 
 
 Atrium. — It may enter (1) by the shin, through invisible wounds, 
 scratches, or the intact integument (Albrecht and Ghon). Post- 
 mortem and laboratory inoculation is possible, as in the unfortunate 
 case of Miiller, of Vienna, who was writing his well known mono- 
 graph. Flies, fleas, ants, bed-bugs, f etc, may inoculate* the disease. 
 (2) The mucosa?, conjunctivae, nose, tonsils, anus and external gen- 
 italia, may be primarily infected. The nose and throat are especially 
 frequent atria in children, for obvious reasons. (3) The alimentary 
 tract affords a possible atrium. (4) The bacillus may cause primary 
 plague pneumonia. 
 
 Contagion may be direct or indirect, (a) Direct. — Dissemination 
 of plague pneumonia by the sputum is most dangerous, for the bacilli 
 are scattered by coughing, as shown in Fliigge's experiments in tuber- 
 culosis (q. v.). The pest spreads rapidly only when it is of the 
 pneumonic type. The bacilli may penetrate from unruptured car- 
 buncles or buboes or scatter from them after their rupture. The 
 urine, the faeces, and the milk of nursing women are also dangerous. 
 Direct contagion may result from autopsies, from operations, or 
 from nasal or urinary hemorrhages, (b) Indirect. — This may re- 
 sult from fomites, or bites of animals or insects containing the germ. 
 Epidemics among rats precede human epidemics. In Canton, 35,- 
 
TUE PLAGUE. 213 
 
 000 dead rats were found in one district. The disease also exists 
 among apes, cats, mice, and ground-squirrels. Infection by rat-fleas 
 is clearly proven. Flies may convey infection from the urine or 
 faeces of infected rats. The bacillus produces virulent toxins. 
 
 Symptoms. — There are two factors in the clinical picture : (a) The 
 local changes, as those in the primary localization (bubo or pneu- 
 monia), and (b) the successive septicaemia (pesticaamia) and toxae- 
 mia. The average incubation is five days. Occasionally there is pro- 
 dromal depression, or glandular pain, but usually the onset is very 
 acute, with marked headache, intense vertigo, severe rigor, sudden 
 fever, and, in children, convulsions. Early vomiting is quite fre- 
 quent. There is early glandular pain, the prostration is profound, 
 and an early typhoid state develops. The fever reaches 104° on the 
 second day, is either continuous or remittent, in convalescing cases 
 falls by lysis (fifth to seventh day), or may remain high until death. 
 Crisis is seen in light cases only. The skin is hot and dry or may be 
 covered with sweat as death approaches. Herpes never develops. 
 Skin hemorrhages are frequent, due to embolism by the Bacillus 
 pestis ; they occur shortly before death, and are seen mostly in the 
 upper trunk, arms, head and neck. Abscesses, gangrene or bedsores, 
 are not common. 
 
 1. Chaeacteeistic Local Fi]n t di^"g. — This is the bubo, for the 
 lymph glands are more important than 'in any other infection. The 
 several clinical forms of the plague usually described are (a) the 
 bubonic type (77.7 per cent.) ; (b) the septiccemic type (14 per 
 cent.) ; (c) the pulmonary type (4.3 per cent.) ; (d) the carbuncle 
 type (2.5 per cent.) ; (e) mixed infection (1 per cent.), and (/) the 
 ambulatory type (pestis minor, 0.5 per cent.), which is considered 
 by Scheube as not plague but " climatic bubo." The figures are from 
 Choksey, of Bombay. In probably all except the pulmonary type, 
 the bubo is found very early (90 to 98 per cent.) and local pain, 
 tenderness and swelling are present. The primary bubo occurs in 
 the external lymph glands in the region of the atrium; it is large, 
 very painful and tender, and is attended by great periadenitis, oedema, 
 hemorrhage and vesicle formation in the skin. Its size and rapid 
 growth are due in part to medullary swelling of the lymph glands, 
 but chiefly to hemorrhage, which may spread along the nerves, arteries 
 or veins, into which it may break, thus disseminating the bacilli. 
 The glands may fuse, and a brawny mass, as large as an egg, or a 
 man's fist, results. The glands and surrounding tissues contain 
 enormous numbers of bacilli. The location is inguinal (70 per 
 cent.), axillary (20 per cent.), and cervical (10 per cent.). The in- 
 guinal and axillary adenitis is more common in males ; cervical adeni- 
 tis results in children from infection of nose and throat by dirty 
 fingers ; the popliteal and epitrochlear glands, curiously, are involved 
 in but 1 or 2 per cent. Strangely, too, the lymph-vessels are usually 
 unaffected, although they are sometimes inflamed around the buboes, 
 carbuncles, or atrium of infection. From the primary bubo the con- 
 
214 THE SPECIFIC INFECTIONS. 
 
 tiguous glands are involved; e. g., after the infection of the inguinal 
 glands, the iliac, aortic, mediastinal, subpectoral, infra- and supra- 
 clavicular or cervical glands may be involved ; i. e., infection usually 
 occurs in the direction of the lymph-current. On the fourth to the 
 sixth day necrosis occurs, and on the eighth or ninth day suppuration 
 develops, resulting more often (66 per cent.) from the Bacillus pestis 
 alone than from mixed infection (33 per cent.). Some glands may 
 resolve without suppuration. The primary bubo is often incon- 
 spicuous and its size has no bearing on the intensity of the disease, 
 although cases with marked periadenitis rarely recover. Besides 
 the primary bubo, Albrecht and Ghon described the secondary bubo 
 which is infected by the bacilli-laden blood current. The bacilli 
 have a remarkable affinity for lymphatic structures and settle in 
 them largely. These hcematogenous buboes are generally smaller 
 and less extensive, tender, painful, (Edematous, and hemorrhagic, than 
 the primary bubo. They contain bacilli in large numbers, as do 
 the mesenteric glands, the pharyngeal follicles, stomach, intestine, and 
 lung. Carbuncles result chiefly from pesticremia, although appar- 
 ently in some cases they are the atrium. They occur in 10 to 15 
 per cent, of the cases, often near the primary bubo. The crowning 
 serous vesicle is ruptured, discharges bacilli, and leaves an ulcer, 
 whose floor is bluish-red from hemorrhage, or yellow from swarms 
 of bacilli. A dark crust then forms. There is great peripheral in- 
 filtration, and the whole limb may become oedematous. These les- 
 ions indicate that the pesticsemic type is less a distinct type than an 
 almost regular part of the disease. Cases rarely recover which 
 show bacillsemia. The blood shows some anaemia and moderate 
 polymorphonuclear leukocytosis. The spleen is increased three to 
 four times, is reddish, and is somewhat less soft than in other in- 
 fections. Its cut surface is finely granular and is slightly glistening. 
 It is infiltrated with white cells and bacilli, which are found in the 
 innumerable foci of minute necrosis. It is usually palpable on the 
 first or second day. 
 
 2. Nervous System. — The nervous system suffers few anatomical 
 changes except meningeal hemorrhages and brain oedema. Clinically 
 the toxsemic "typhoid" symptoms are prominent. There is early 
 headache and marked prostration. Vertigo is especially notable, 
 causing a drunken, cerebellar gait, and vomiting. The delirium is 
 more often dull, dreamy and docile, than active or maniacal. 
 Twitching, spasms, rigidity of the neck and even bulbar symptoms, 
 such as increased pulse and respiration, polyphagia or polydipsia, may 
 suggest meningitis. Paralyses are uncommon. Ear symptoms are 
 unusual. Conjunctival hypersemia, sometimes with ecchymoses, is 
 so frequent that it is, together with the fever and buboes, "made one 
 of the cardinal symptoms by Yamagiwa. 
 
 3. Circulation. — The circulatory and the nervous changes meas- 
 ure the intensity of infection and forecast the prognosis. Possibly 
 there is no other cardiac poison as intense as the plague toxin which 
 
THE PLAGUE. 215 
 
 operates on the medulla and its vagus nucleus. Early in the attack 
 the pulse is full and dicrotic, with a rate of 80 to 90. Later, the 
 pulse increases to 120, 150, or even 200; the heart tones become 
 muffled ; tachypnoea, great dyspnoea, and all the signs of acute cardiac 
 insufficiency develop. In some virulent infections the pulse may 
 remain slow. At autopsy the heart is lax, the right ventricle dilated, 
 the myocardium cloudy, and the serous investment ecchymotic. En- 
 docarditis and pericarditis almost never occur. 
 
 4. Bespiratory Tract. — The lymph structures in the larynx, 
 trachea, or bronchi are infected by aspiration from tonsillar foci or 
 through the blood. Most important is the plague pneumonia, of 
 which there are two varieties, (a) the primary, in which the lung is 
 the atrium (or analogue of the primary bubo). It was clearly the 
 " black death " of the middle ages (Eorbes). It was seen in India, 
 in 1838, and became well known in the Indo-Chinese epidemic of 
 1896-1897, when Childe first found the Bacillus pestis in the lung. 
 The bacillus, if inhaled, causes typical confluent lobar pneumonia and 
 salient lymphatic involvement. The bacilli exist in hordes in the 
 lung and sputum, and may cause hematogenous buboes and car- 
 buncles. The diagnosis is positive only from the sputum, cyanosis, 
 dyspnoea, hsemoptysis, pleuritic pains, signs of consolidation, adyna- 
 mia, splenic tumor, and collapse. Death occurs in 97 per cent, of 
 cases, (b) Secondary pneumonia is (i) embolic, as multiple small 
 foci, difficult to diagnosticate, though bacilli in the sputum, dyspnoea, 
 and pleuritic pain are suggestive, (ii) Aspiration pneumonia usually 
 occurs in the lower lobes, its diagnosis is difficult, it follows bubonic 
 disease of the tonsil, pharynx or bronchi, and is almost invariably 
 fatal. 
 
 5. Digestive Tract. — A moist, then dry, tongue, hemorrhage 
 from the mouth, and involvement of the tonsils or pharynx, are com- 
 mon. There may be ecchymoses and erosions in the stomach and 
 intestines. Bubonic changes in the lymph structures, generally con- 
 sidered rare, were found by Wilm in 20 per cent, of his cases, and 
 mesenteric adenitis in 60 per cent. Vomiting is frequent, meteorism 
 and diarrhoea occasional. The liver is swollen from degeneration or 
 stasis. 
 
 6. The Gentto-uri:nary Tract. — The urine is decreased, and 
 moderate albuminuria is very common. Nephritis is quite frequent. 
 Anatomically, degeneration, minute areas of focal necrosis, and glom- 
 erular hemorrhage from capillary embolism of the bacilli, are com- 
 mon. Bacilluria occurs in about 30 per cent, of the cases. The 
 bacilli have been found in the aborted foetus. Genital complications, 
 except uterine bleeding, are rare. 
 
 Diagnosis. — The cardinal signs are fever, buboes, pesticsemia, and 
 the results of examinations by cultures, agglutination, and inocula- 
 tion. In the blood, the cultural results are reliable. The agglutina- 
 tion reaction is not well marked until the second week of infection, 
 but is best developed in convalescence. A positive test is final, 
 though negative results do not exclude plague. 
 
216 TEE SPECIFIC INFECTIONS. 
 
 Prognosis. — -A patient, stricken in the morning, may die before 
 night. The average duration of the disease is about a week. If the 
 patient outlives this time, the chances of recovery are good. Recur- 
 rences are not frequent, and the immunity conferred is only relative. 
 Ominous symptoms are marked nervous and cardiac toxaemia, diges- 
 tive disorder, hemorrhages, cervical buboes, tonsillar involvement, 
 and pneumonia. The death-rate is often 80 and sometimes 90 or 95 
 per cent. It is highest between the fiftieth and sixtieth years. In 
 Toulon (1721), 77 per cent, of the population had the plague and 
 62 per cent, died — higher percentages than in any other epidemic 
 disease. 430,500 died in Bombay, from 1896 to 1899. 
 
 Treatment. — 1. Prophylaxis. — The plague patient should be iso- 
 lated and carefully covered with netting. Infected houses should 
 be isolated, unroofed to admit the sun, fumigated to kill insects 
 and rats, and the walls should be washed with antiseptics. Vigor- 
 ous attacks should be made on rats. , Ships should be held in 
 quarantine until the rats in their holds are killed, the bilge-water 
 disinfected, and all clothing fumigated. The sputum may be infec- 
 tive for three months and the urine for one and a half months. Car- 
 buncles and buboes should be washed with bichloride of mercury and 
 dressed antiseptic ally. Prophylactic inoculation with dead cultures 
 and with serum from immunized animals and from convalescent 
 patients, is a measure assured of success (Haffkine, Yersin, Roux 
 and Lustig). 
 
 2. Symptomatic Treatment. — Buboes and carbuncles are most 
 efficaciously treated with weak sublimate dressings. Surgical extir- 
 pation disseminates infection, and injection, into the buboes, of car- 
 bolic acid, does not stay the septicaemia. Digitalis, alcohol, and hy- 
 drotherapy are employed as in other toxaemias. Bichloride of mer- 
 cury is well tolerated and was suggested by the observation that syph- 
 ilitics under mercurial treatment withstood infection. 
 
 DYSENTERY. 
 
 Definition. — An acute contagious disease, (a) with varying etiology, 
 but caused chiefly by the Amoeba dysenteriae and Shiga's Bacillus dys- 
 enteriae; (b) attended anatomically by bowel inflammation (catar- 
 rhal, necrotic, or ulcerative) and (c) characterized clinically by colic, 
 pain, tenesmus, and frequent muco-bloody passages. 
 
 History. — The name dysentery dates from Hippocrates (480 B. C), 
 and the affection is clearlv mentioned in the oldest medical .script, 
 the Papyrus Ebers (1550 B. C), and in the Veda. It has been the 
 scourge of armies from the times of the Greco-Persian wars. The 
 most severe and wide-spread epidemic occurred in 1847-1856. In 
 our civil war there were 287,522 cases among the Northern troops. 
 Among the English soldiers in India 30 per cent, of the deaths 
 were due to dysentery. It prevailed in the recent South African and 
 Spanish- American wars, but was practically absent among the Jap- 
 
DYSENTERY. 'Ill 
 
 anese forces (1904-1905). Though essentially a disease of the 
 tropics and subtropics, it is frequently observed in temperate zones, 
 especially in prisons and in asylums. Lack of hygiene, overcrowding, 
 eating of spoiled food or fruits, impure water, and alcoholic or other 
 excesses, are predisposing causes. For several decades the disease 
 has decreased in Europe and America. 
 
 Classification. — A classification and description of dysentery is most 
 difficult, because our knowledge of all its causes is as yet imperfect. 
 
 Shiga's Bacillary Form of Dysentery. —In 1897 Shiga, of Japan, 
 Two well known forms will be described first, and various indeter- 
 minate allied forms afterward. 
 
 described the Bacillus dysenteries as the sole cause of the Japanese 
 form. Shiga demonstrated that: (a) It is always found; (b) it 
 occurs in no other affection; (c) its numbers correspond to the in- 
 tensity of infection; (d) it is found in the intestinal wall; (e) the 
 bacillus and its toxins, when inoculated, produce intestinal hemor- 
 rhage; (/) there is a specific agglutination, increasing in intensity 
 under observation and most marked in convalescents ; (g) the serum 
 of the immunized cases is of prophylactic and therapeutic value ; (h) 
 actual inoculations of man produce dysentery, as in Strong's inocu- 
 lation of a criminal under sentence of death, and in Flexner's assist- 
 ant, as well as in accidental laboratory infections. The bacillus 
 resembles the colon and typhoid bacilli in form. It usually occurs 
 singly. It is less motile than the Bacillus typhosus but is flagellated ; 
 it is a facultative anaerobe, contains no spores, stains readily but not 
 by Gram's method, and grows on all media. In gelatin it grows 
 with deep, pin-point cultures, is brownish-yellow without liquefaction, 
 and has well marked borders ; it develops best in glucose agar (gray- 
 ish growth along the puncture, without fermentation), or in litmus 
 milk (some slight acidification, followed by alkalinization and a 
 brownish color). Inoculations by mouth succeed, even without first 
 disordering digestion. Inoculation intraperitoneally or subcutan- 
 eously is usually fatal, but sometimes causes colitis. Almost pure 
 cultures are obtained from the movements. The bacilli are most 
 abundant when the lower intestine is greatly involved, and are less 
 in the early stages from diarrhoeal stools than in the later stages from 
 muco-bloody stools. When the dejecta become purulent (latest stages) 
 the bacillus disappears. It is found in the mesenteric glands, but not 
 in the blood, spleen, or liver. Infection is probably carried by con- 
 taminated drinking water. Flexner, Barker, Strong, Musgrave and 
 Craig found this type in the Philippines ; Kruse found it in Germany, 
 Flexner, Goodliife and others in America (1901). It has been 
 found in Porto Kico. Duval, Bassett, Wollstein and other clinicians 
 have found it in infantile types. There are three strains of the bacil- 
 lus: (1) The Shiga type, which attacks glucose but not other sugars; 
 (2) Mexner-Harris type, which attacks glucose, mannite and dex- 
 trine but not lactose, and forms more acid; (3) Hiss-Russell type, 
 which attacks glucose and mannite but not lactose or dextrine. The 
 
218 THE SPECIFIC INFECTIONS. 
 
 blood of a dysentery subject will agglutinate all types, but particu- 
 larly the second. The bacillary form constituted 54 per cent, of 
 Strong's and Musgrave's series of 1,328 cases in the Philippines. 
 Epidemics have existed for centuries in Japan, chiefly between the 
 months of June and October. In the Philippines dysentery prevails 
 at the end of the rainy season. 
 
 Symptoms. — After an incubation of two to eight days, there is a 
 sudden onset with fever, reaching 100° to 102° (even 104°), colic, 
 and diarrhoea. Pain becomes marked and the simple diarrhoeal stools 
 soon show mucus, and then bloody mucus or pure blood, which is 
 voided with great frequency and severe rectal tenesmus. The pas- 
 sages are small, numbering twenty to sixty or even one hundred a 
 day, and contain Shiga's bacillus. • The rectum may prolapse. The 
 urine is scanty. In mild cases the symptoms abate in two to three 
 weeks, and the stools become purulent and contain fewer bacilli. 
 
 The symptoms arise from local inflammation and from systemic 
 reaction, not to toxins, according to Shiga, but to solution of the 
 bacilli themselves in the tissues. In the more severe cases the sys- 
 temic reaction is profound, especially when lesions occur in the lower 
 small intestine, the absorptive power of which is great. A typlwidal 
 condition results, with coated tongue, nervous toxaemia, and weak 
 pulse, and death frequently occurs as early as the fourth or seventh 
 day. Shiga names this form entero-dysentery. as distinguished from 
 the ordinary type, colo-dysentery. If the stools become putrid or 
 gangrenous, the outlook is hopeless. Ecchymoses on the chest, epi- 
 gastrium, and inner surface of the limbs are quite frequent. Some 
 choleriform cases occur. The disease sometimes lasts for weeks or 
 months. Emaciation is marked in acute and chronic forms, which is 
 due to diarrhoea, inanition, pain, and intoxication. 
 
 The symptoms are largely explained by the anatomical findings. 
 The bacilli lodge more in the small folds and large flexures of the 
 colon and sigmoid than in the small intestine. Their action is fur- 
 thered by constipation. The mucosa is intensely hyperaemic and 
 shows various grades of inflammation, according to the intensitv and 
 duration of the infection. It becomes catarrhal, hemorrhagic, "diph- 
 theritic, and finally necrotic with ulceration. The ruga? are wide 
 and swollen : the entire mucosa is swollen, cedematous, thickened, and 
 shows superficial coagulation necrosis, fibrinous exudation, and cellu- 
 lar infiltration; the submucosa is infiltrated and vascular; the rnus- 
 cularis is sometimes infiltrated and the serosa is ecchymotic and 
 freshly fibrinous. In marked cases the necrotic areas become ulcers, 
 in or between the follicles ; they have a flat base, occupy chieflv the 
 folds, usually reach only the niuscularis mucosae, and in intense 
 cases impart a sieve-like aspect. The swelling may obliterate the 
 lumen of the intestine. Cocci and colon bacilli are in the upper 
 layers but never in the lower ones, where we find the Bacillus dvsen- 
 teriae in and around the glands. In the virulent cases the gut be- 
 comes gangrenous. Stenosis may follow cicatrization of the "ulcers. 
 
DYSENTERY. 219 
 
 Diagnosis. — Local rectal disease (syphilis, cancer, or papilloma) 
 may possibly be confusing. In contradistinction to amoebic dysen- 
 tery, it is generally acute, with a course of two or three weeks; 
 toxsemic symptoms, such as fever, headache and delirium, and hem- 
 orrhages, are common, because involvement of the small intestine is 
 common ; anatomically the ulcers are flat, are on the folds of the in- 
 testine and are never undermined ; liver abscess never occurs. Amoe- 
 bic dysentery is characteristically subacute or chronic. The small 
 intestine less frequently suffers ; liver abscess is common (20 to 33 per 
 cent.), and anatomically necrosis begins in the submucosa and pro- 
 duces ulcers with undermined edges. Agglutination, similar to the 
 Widal reaction in typhoid, occurs in dilutions of 1 to 20 (even 1 to 
 50, 100, or 1,000). Shiga observed that it gradually increased as 
 the disease progressed, as Forster noted in typhoid fever. It is 
 usually seen in the second week and most clearly in convalescence, 
 and therefore late for diagnostic purposes. If it increases while 
 under observation and is marked, it is a good prognostic; the con- 
 verse is true. 
 
 Prognosis. — The prognosis is more favorable in involvement of the 
 rectum and sigmoid flexure than when the upper colon or caecum is 
 affected. The outlook is grave in patients under 5, or over 50 years 
 of age. Intoxication is a bad prognostic. The effect of serotherapy 
 (v. i.) is another factor. The mortality is high, particularly in 
 Japan, ranging from 20 to 25 per cent. No immunity is conferred. 
 A second attack was observed in 2.7 per cent, and a third in 0.3 per 
 cent, in Ogata's collection of 25,279 cases. 
 
 Amoebic Dysentery. — Lambl (1859) and Losch (1876) discov- 
 ered an amoeba in the bowel movements, but Kartulis, in Egypt, 
 found the amoeba in over 500 cases and found the secondary 
 liver abscess. Kartulis established his claims for the Amoeba dysen- 
 terise on the grounds that (a) it was constant in certain forms of 
 dysentery, in the ulcers, fseces and liver abscesses; (&) it was inocu- 
 lable in cats; (c) negative results were obtained with other organ- 
 isms and with the amoeba which is found in normal fseces. This 
 was confirmed by Koch, Hlava, Eenoglio, Quincke, Kovacs, and 
 others in Europe, and in America first by Osier (1890) ; the impor- 
 tant monographs of Councilman and Lafleur, Dock, Simon, Musser, 
 Stengel, and Harris soon followed. The home of amoebic dysen- 
 tery is in the tropics, especially in Egypt, India, Formosa, China, 
 Arabia and in Italy, where it is endemic and sometimes epidemic. 
 Sporadic cases occur everywhere, in the temperate zone, especially in 
 Germany and in America, where it is the most frequent form. The 
 author has seen six cases which were clearly acquired in Chicago. 
 In the Philippines it constituted 67 to 80 per cent, of Strong's 
 series. The amoeba is found in the pus, glairy mucus, or blood- 
 tinged mucus of the evacuations. It is round in the quiescent stage 
 or irregular from protrusion of pseudopodia, particularly when the 
 slide is slightly warmed. It is unicellular, measures 10 to 50 ft 
 
220 
 
 THE SPECIFIC INFECTIONS. 
 
 Fig. 18. 
 
 and consists of a hyaline ectoplasm and a finely granular endoplasm. 
 For diagnosis, it must be motile. The minutely granular nucleus 
 measures 5 to 7 /*. Besides the nucleus one or several vacuoles may 
 be seen in the cell. Its glistening appearance, size, movement, 
 swarming granules, vacuoles, and frequent red blood-cell inclusions, 
 readily differentiate it from swollen epithelia or leukocytes. It 
 stains readily by the Wright-Komanowsky method and in tissues 
 best with thionin. It has been cultivated in pure cultures (Wooley 
 and Musgrave). The amoeba probably enters in the food or drink. 
 Unhygienic conditions favor infection. Intestinal amoebiasis (Mus- 
 grave) occurs largely in males in the third or fourth decade. 
 
 Symptoms. — The symptoms of acute amoebic dysentery begin rather 
 abruptly with much the same picture as in Shiga's type, although, 
 the fever is generally lower and shorter, rarely lasts more than two 
 or three days, and is sometimes absent. The movements are alkaline, 
 
 pultaceous, fluid, and yellow, at 
 first, and later, mucous and bloody. 
 Sometimes in one movement fseces 
 are voided first, followed by mucus 
 and blood, or blood-tinged fluid 
 containing amoebae, slightly yel- 
 low, glairy clumps like swollen 
 sago or frog spawn, pus cells, detri- 
 tus, and sometimes the Charcot- 
 Leyden crystals. The stools may 
 be chocolate-colored. Sometimes 
 large masses of necrotic tissue are 
 voided. The stools number 5 to 20 
 or more daily; their odor is fetid 
 when fseces are present; they are 
 odorless when only blood or mucus 
 is present; and are stinking when gangrene occurs. The repeated 
 and painful movements cause straining, sweating, and sometimes 
 syncope. Colic and borborygmus are nearly always present; pain 
 is referred to the navel; tenderness is usually marked over the sig- 
 moid, colon and frequently over the caecum, and tenesmus and a 
 burning anal pain mark involvement of the lower bowel, though less 
 than in Shiga's type. The rectum may prolapse and vesical stran- 
 gury appear. The abdomen is sometimes distended. Very light 
 cases show only catarrhal movements, but blood, pus, membrane, or 
 shreds, indicate necrosis and ulceration. Strong men may be ill for 
 months or even die before the malady is suspected. Severe cases 
 may begin with chills, fever of 103° or 104°, vomiting, herpes, and 
 symptoms like those of cholera; e. g., 20 to 100 movements daily, 
 leg cramps, scanty urine, failing pulse, rapid emaciation from loss of 
 rest and fluid, and from pain. Early death may result. Peracute 
 cases, with chill, high fever, great abdominal pain, collapse, and even 
 sudden death, exceptionally result from rapid necrosis or gangrene. 
 
 Amoeba (Hallopeau). 
 
DYSENTEEY. 221 
 
 In the average acute case, the course of one and a half to three weeks, 
 varies with the individual resistance and the treatment. Perforative 
 peritonitis or profuse exhausting hemorrhages sometimes occur. 
 Light cases, if neglected, easily become severe or chronic ; spontaneous 
 recovery is quite uncommon. 
 
 Chronic amoebic dysentery results from the acute form or is sub- 
 chronic from the beginning. The symptoms are essentially the same 
 but less intense. There is marked, and sometimes extreme emacia- 
 tion, particularly in the tropics. A secondary anaemia develops. 
 On the other hand, some patients maintain their weight and suffer 
 only from recurrent diarrhoea every few weeks or months, or from 
 irregular moderate intestinal derangement. In the average case the 
 tongue is lacquered and red, the abdomen is somewhat distended and 
 tender, the lower colon and sigmoid are palpable as a thick cord, and 
 sometimes mental depression or hypochondriasis is observed. The 
 outcome is (1) recovery after two to four months; severe infections 
 generally leave intestinal cicatrices or chronic catarrh; recovery is 
 seldom complete after a year's illness; (2) recurrent attacks for 
 months or years, constipation alternating with diarrhoea; (3) com- 
 plications, such as liver abscess (20 to 33 per cent.), especially in 
 the tropics (peritonitis, empyema, or lung abscess). Strong reports 
 10 cases of profuse fatal enterorrhagia, coincident with liver abscess. 
 Perforative peritonitis, brain or splenic abscess, pseudorheumatism, 
 myelitis, neuritis, and less frequently, endocarditis, or chronic 
 nephritis, are other complications; (4) gradually increasing anaemia, 
 emaciation and death from exhaustion. 
 
 Pathology. — The early changes in the mucosa are catarrh, inflam- 
 matory injection, swelling, and hemorrhage, mostly in the large intes- 
 tine. The essential change is not superficial in the mucosa, but in the 
 submucosa, as John Hunter first noted, though Councilman and 
 Lafleur first brought out this point clearly. The amoebae enter by the 
 tubular glands and reach the submucosa where, by their action alone, 
 without bacterial cooperation, they cause cellular accumulations 
 which are not leukocytes, but chiefly fibrinous exudation and con- 
 nective-tissue cells. Sometimes the amoebae enter the blood-vessels 
 early and pass through them to the submucosa. These foci undergo 
 coagulation necrosis and slightly elevate the mucosa which at first 
 covers the small submucous cavities, but afterward sloughs, and 
 exposes the primary grayish-yellow necrosis in the submucosa. When 
 the necrotic tissue sloughs out, the dysenteric ulcers are more appar- 
 ent. They lie according to Kartulis, in the whole of the large intes- 
 tine (50 per cent, of cases) ; in the colon descendens and sigmoid 
 (25 per cent.) ; in the caecum, with ascending or descending colon, 
 or in the rectum (25 per cent.) ; in the rectum alone (20 per cent.) ; 
 in the caecum alone (5 per cent.), and only rarely in the small bowel 
 or in the appendix; Musgrave found the appendix involved in 7 
 per cent., the ileum in 3.5 per cent., and the entire bowel in 80 per 
 cent., of his series of 200 cases. The deep ulceration generally 
 
222 THE SPECIFIC INFECTIONS. 
 
 exceeds the superficial ulceration, and the ulcers in the early stage 
 may communicate with the intestinal lumen only by fistulous tracts 
 which undermine the apparently healthy mucous membrane. Even 
 when the ulcer's opening is large, its edges are generally undermined. 
 Ulceration of the solitary follicles is less frequent than submucous 
 necrosis. The ulcers may be round, or serpiginous and are usually 
 discrete. They may penetrate to the muscularis or to the serosa, 
 which is sometimes perforated, thus causing diffuse or localized peri- 
 tonitis. The lymphatic structures of the bowel are less affected 
 than in Shiga's type. Secondary changes include membranous diph- 
 theroid deposits (usually streptococcic), diffuse sloughing of entire 
 blocks of the intestinal wall, gangrene, and great hyperplasia of the 
 mucosa. In chronic cases the muscularis frequently thickens, which 
 may greatly narrow the lumen of the intestine. The small intestine 
 may atrophy or hypertrophy. Healing ulcers produce pigmented 
 stellate scars which sometimes cause stenosis. Amoebae have been 
 seen in the mesenteric bloodvessels, by which they reach the portal 
 circulation (pylephlebitis; liver abscess). The liver shows focal 
 necroses which are probablv toxaemic, and, in a large percentage, it 
 shows solitary or multiple abscesses. The single, large abscess gen- 
 erally develops in the right lobe near the diaphragm or colon. The 
 multiple small abscesses are also superficial. In both types there is 
 central necrosis and softening, the contents are yellow, green or choco- 
 late-colored, contain fat droplets, liver detritus, and the amoebae lie 
 on the abscess walls. In the older cases there is a firm connective 
 tissue capsule but round cell infiltration is as infrequent as it is. in 
 the intestine. Amoebae may be found in the sputum when the liver 
 abscess ruptures into the lung, or in the pus of secondary empyema. 
 The pseuclorheumatism and neuritis are probably toxaemic. The 
 mortality averages 6 per cent. ; 7 per cent, of the deaths in Cairo are 
 dysenteric. 
 
 Indeterminate Dysenteries. — The classification and cause of these 
 forms are not yet defined, but some are apparently primary and 
 others are secondary infections. The colon bacillus, proteus, pyo- 
 cyaneus, pneumococcus, streptococcus, and staphylococcus have been 
 found, but their action is still undetermined. Varieties: (a) 
 Catarrhal dysentery, in which the mucous membrane is injected, 
 cloudy, and infiltrated; the solitary follicles are swollen and often 
 ulcerated, — the " acute follicular colitis " seen especially in children ; 
 the ulcers are round, deep, and small. In some instances there is 
 also inflammation in the small intestine. The symptoms are usually 
 mild pain, and muco-bloody evacuations, (b) The croupous or diph- 
 theroid dysentery represents a severe stas^e or degree. The epithel- 
 ium necroses, the submucosa is considerably infiltrated, and there are 
 membranous deposits on the rugae over slight superficial ulcerations, 
 or there may be deeper, wider ulcers with great thickening of all the 
 intestinal layers. This may occur (i) as a primary infection, with 
 dysenteric symptoms, marked typhoidal symptoms, fever and chill. 
 
DYSENTEEY. 223 
 
 and frequently with a fatal outcome ; or (ii) as a secondary incident 
 in various infections, e. g., in pneumonia particularly, in typhoid, 
 scarlatina, diphtheria, cholera, syphilis, cardiac affections, cachectic 
 conditions, mercurial or other poisonings and in uraemia. This 
 secondary form may produce marked symptoms or clinically may be 
 latent, (c) The gangrenous dysentery is attended by the same 
 changes, but results in enormous swelling, softening, and sloughing 
 of dark, gangrenous shreds, and sometimes in tubular sloughs of the 
 larger part of the intestinal circumference. Perforation sometimes 
 occurs. In the Cochin China endemic form, enlarged glands, splenic 
 tumor and intumescence of the liver are found. Coprostasis, foreign 
 bodies and parasites are promoting factors in all these types. In 
 some cases the Cercomonas, Trichocephalus dispar, or Anguillula 
 stercoralis may be found. The Distoma haematobium (Bilharz) may 
 cause symptoms closely resembling those of dysentery; bloody urine, 
 and strangury result from invasion of the vesical venous plexus by 
 the Distoma; anatomically, hypertrophy of the mucosa, even to the 
 extent of small or large polypi, may result, as well as superficial 
 ulceration and infiltration of the submucosa. 
 
 Treatment of all Forms. — 1. Specific Treatment. — This is lim- 
 ited to the bacillary type. Shiga's bactericidal and antitoxic serum 
 reduces the mortality at least one-half and shortens the course; in 
 mild cases two and a half drams (10 c.c.) are injected once; in med- 
 ium cases two and a half drams (10 c.c.) twice, and in severe cases 
 20 c.c. daily for two or three days. The best results are obtained by 
 early injection. 
 
 2. Prophylaxis. — Drinking water should be boiled, and fruits 
 and vegetables should be cooked. In the tropics, sudden variations 
 of temperature are to be carefully avoided. 
 
 3. Diet. — Acute and chronic cases must be carefully dieted and 
 the patient must be kept in bed. Boiled milk, raw or slightly cooked 
 eggs, or the whites of eggs beaten with water should be given to 
 relieve colic and tenesmus. The nearest allowable approach to solid 
 food is well-cooked rice or sago. Broths and cold drinks irritate the 
 stomach and excite peristalsis. Some lemonade is permissible. In 
 convalescent acute or in chronic cases, solids should be given late, 
 commencing with well-cooked tender meat and starches, and avoiding 
 vegetables and fruit until convalescence is absolutely established. 
 
 4. Eliminative Treatment. — Sodium or magnesium sulphate is 
 given in early cases to cleanse the bowel and to minimize the danger 
 of ascent of the virus from the lower intestine (3j every two hours 
 until the bowel is thoroughly emptied). Aromatic sulphuric acid, 
 mxx p.c, is sometimes given after the saline treatment. Castor oil 
 is a mild laxative but is of little use except in the early stages. 
 Calomel is considered beneficial by some writers, by whom it is given 
 in frequent and small doses until slight mercurialization is noted. 
 
 5. Antisepsis. — Betanaphthol and salol (phenylis salicylas), aa 
 gr. x, t. i. d. or q. i. d., are sometimes helpful, although probably but 
 
224 THE SPECIFIC INFECTIONS. 
 
 small parts of the drugs reach the larger intestine. Bichloride of 
 mercury, gr. 3^ to 2V > i s efficient in some cases. 
 
 6. Ipecac. — This was introduced from Brazil, by Piso, in 1648. 
 It is considered almost specific in India and Brazil, but, like the 
 drugs above named, has little effect in the amoebic type. Frayer held 
 that it reduced the mortality from 11 per cent, to 5 per cent, in his 
 series. In India it is given as follows ; food is withheld for four or 
 five hours, and then a hypodermic of morphine, or opium by mouth, is 
 administered to quiet the stomach and lessen nausea; 15 grains of 
 powdered ipecac are administered every hour for two, three, or possi- 
 bly four,, doses. If the first dose is vomited, the opium and ipecac 
 are given again. A mustard plaster should be applied to the epigas- 
 trium or a turpentine stupe to the abdomen. In Brazil, a decoction 
 is preferred. The pulv. ipecac, et opii and salol may be given, aa gr. 
 x, for a few doses. 
 
 7. Pain. — Pain necessitates the use of opium, which also quiets the 
 patient, enforces rest and decreases tenesmus and peristalsis. It is 
 given most efficaciously by rectum in a suppository, or, if poorly 
 retained, by enema, mixing Tr. opii deodorat. TT\, xx with an ounce 
 of starch water. 
 
 8. Local Measures. — Under this caption the use of bismuth by 
 mouth may be mentioned, because its action is for the most part local ; 
 doses of 3j to ij are necessary, and even two ounces daily are given. 
 Musgrave dislikes the use of bismuth because it seems to cake in the 
 ulcers; if employed, an occasional enema should be given to cleanse 
 the bowel. Lavage is difficult because of the tenesmus, and is not 
 without danger, for perforation has resulted from copious irriga- 
 tions. The rectal tube must be introduced carefully as the rectum is 
 very sensitive. Tenesmus may be avoided by injection of a cocaine 
 or laudanum solution, or a cocaine, opium, or iodoform (five-grain) 
 suppository. 
 
 ]£ Ac. tannici gr. xv. 
 
 Extr. opii gr. iv. 
 
 Extr. belladonna? gr. j. 
 
 Olei theobromatis q.s. 
 
 M. et ft. suppos. no. iv. 
 
 Carbolic acid and bichloride of mercury solutions are seldom em- 
 ployed ; Bellei employs as an antiseptic and anaesthetic douche, car- 
 bolic acid nixx, tannin 3j, marshmallow root gij to a quart of warm 
 water. Among the other solutions of value are quinine, of which 
 Strong advises two quarts of a 1 to 3000 solution, the bag being 
 three to four feet higher than . the bed and the flow being slow. 
 A weak peroxide solution for the amoebic variety is recommended 
 by Harris; all enemata should be warm. Strong silver solutions 
 (1 to 500 or less) cause great pain, and weak dilutions are inert; 
 silver, however, is most suitable for chronic cases. In the author's 
 experience, Kartulis' method is the most valuable ;— e. g., -5- per cent, 
 solution of tannic acid, injecting as much as the bowel will tolerate 
 
MALTA FEVER. 225 
 
 and retain. It kills the amcebse and two or three injections are usu- 
 ally sufficient. Kartulis has " never been disappointed in hun- 
 dreds of cases. " It may be given in the genupectoral position as an 
 enteroclysis, as advocated by Cantani in cholera. 
 
 9. Turpentine Emulsion. — This may be used for tympanites, 
 and the ice-bag, or Leiter's coil with opium, may be used for hemor- 
 rhage or peritonitis. 
 
 10. Colostomy. — In chronic cases, colostomy has been advocated. 
 
 MALTA FEVER. 
 
 Definition. — A specific infection, which is endemic on the coast and 
 in the islands of the Mediterranean Sea, is caused by the Micrococcus 
 melitensis, somewhat resembles typhoid, but is characterized by a 
 much longer course, by recurrent, irregular, "undulant " fever, severe 
 sweats, splenic tumor, constipation, orchitis, and rheumatoid or neu- 
 ralgic pains. 
 
 History. — Observed about a century ago, it was first described by 
 Marston (1858) as a separate disease. Marston, Bruce and Hughes, 
 English army surgeons, have been the largest contributors to our 
 knowledge of Malta fever. Its distribution is fairly well covered by 
 its names, — Mediterranean, Rock or Gibraltar fever, Malta fever, 
 Neapolitan or Levant fever. It has also been seen on the Danube, 
 Red Sea, Bosphorus; in China, India, the Philippines; in the 
 Canaries, Azores, and Antilles; in Venezuela (Caracas fever), Brazil 
 and South Africa. Less than a dozen cases have come to this coun- 
 try. Musser and Sailer published an account of the first one. 
 
 Etiology. — The Micrococcus melitensis, which was discovered by 
 Bruce (1887), is round or oval, measures 0.3 fi, often occurs in chains, 
 is non-motile, and stains with methylene blue, or gentian violet, but 
 not by Gram's method. It grows best on slightly acid 1.5 per cent, 
 beef -water, with peptone and agar ; cultures grow characteristically in 
 the form of small pearl-like spots; these after a few weeks become 
 yellowish-brown. The bacillus is found in the blood, in the milk, 
 faeces and urine (even two years after recovery), and in the liver and 
 spleen. The apes inoculated by Bruce and Hughes showed a typi- 
 cal clinical course and postmortem findings. The disease prevails 
 chiefly between the sixth and thirtieth years, in the hot, dry weather 
 from May to mid-October, and in old unhygienic buildings. It is not 
 directly contagious. The atrium is the lungs (by dust, Hughes), 
 or the alimentary tract (by food or drinking-water, Bruce). In 
 Strong's laboratory infection, the conjunctiva was the point of en- 
 trance. It has been recently suggested that mosquitos and goats 
 convey infection; the organism is found in the blood of goats in 50 
 per cent, and in their milk in 10 per cent. 
 
 Symptoms. — Symptoms appear after an incubation of six to ten 
 days. Some symptoms so resemble those of typhoid and malaria that 
 the three diseases were formerly confounded. The fever rises grad- 
 15 
 
226 THE SPECIFIC INFECTIONS. 
 
 ually, reaching 104° to 105° after a few days. The face is red, 
 there are chilly sensations, frontal headache, insomnia, depression, 
 and pains in the back and legs. The tongue is coated, is at first moist, 
 then dry and fissured, and sometimes bleeds. The tonsils are fre- 
 quently swollen, and the pharynx is red or at times ulcerated. 
 Anorexia, nausea, epigastric pain and tenderness, and constipation, 
 are the rule, but vomiting, icterus, meteorism and diarrhoea,with dark, 
 malodorous, mucous, and even bloody stools, are sometimes seen. 
 Bruce denies that there are any anatomical findings in the intestines. 
 There is considerable bronchitis and the sputum is often streaked 
 with blood. Dyspnoea is quite frequent. The pulse-rate is at first 
 between 80 and 90 ; later it becomes faster, and is frequently at- 
 tended by palpitation. Severe sweats occur, usually after midnight, 
 and are accompanied by sudamina (febris sudoralis). An acute 
 splenic tumor and hepatic intumescence develop, which are due to de- 
 generation and infiltration by round-cells. 
 
 After one to three weeks, the fever, which at first is continuous, 
 remits, other symptoms abate, and convalescence is apparently es- 
 tablished; but the symptoms again return, frequently several 
 times. The fever curve shows waves accompanying each relapse 
 (literally " undulant fever "). The patient becomes weak, emaciated 
 and pallid. There is no leukocytosis and the micrococci are found in 
 the blood in 60 per cent, of cases. 
 
 Complications. — Complications, which are uncommon in typhoid, 
 are frequent. Pseudorheumatism occurs in 50 per cent, of cases and 
 is accompanied by redness, swelling, and pain in the shoulders, knees, 
 hips, and sacroiliac joints, and sometimes also in the bursse, perios- 
 teum and fibrous tissues. Neuralgias are common. Orchitis and 
 epididymitis are usually unilateral and ephemeral. Occasionally 
 polyneuritis develops from intoxication and exhaustion and is evi- 
 denced by partial anaesthesia, hyperesthesia, especially of the soles 
 of the feet, paresthesia and rarely paralysis. Psychoses may follow 
 Malta fever. 
 
 Erythematous or hemorrhagic shin eruptions occur in the relapses, 
 sometimes accompanied by hemorrhages from the nose, tongue, gums 
 or lungs ; desquamation and falling of the hair are common. In con- 
 valescence, tuberculosis not infrequently develops. 
 
 Course and Prognosis. — In the majority of cases relapses occur after 
 two or three weeks. The average duration of the disease is 120 
 days, but Bruce records a case which lasted over two years. Hughes 
 described three types: (a) The undulant, the most common type; (b) 
 the malignant, which ends in death in from one to three weeks from 
 weak heart, hyperpyrexia (110° or 111°), or possibly lobular pneu- 
 monia; and (c) the intermittent, which lasts for months. The 
 severity of the infection varies; Melland found that 50 per cent, of 
 cases in the Canary Islands lasted from two to three weeks, and in 
 only 10 per cent, did the protracted undulating type occur. The 
 cleath-rate is constantly decreasing, In the last century it was over 
 
BEBIBEBI. 227 
 
 3 per cent, but it is now under 1 per cent. Immunity after one 
 attack is usual. 
 
 Diagnosis. — The differentiation from typhoid is often difficult. In 
 Malta fever the roseola?, diazo reaction, Widal, and the bacillsemia are 
 absent. The course is longer, the sweats more severe, and the joints 
 inflamed ; orchitis, and neuralgias develop. A positive diagnosis can 
 be made by the use of Wright's serum reaction (1897). The blood 
 responds to this test after the fifth clay. Agglutination is obtained 
 equally well with the living or dead cultures; the dilution of the 
 blood is 1 to 50, and the time for the test is limited to one hour. The 
 severe bronchitis, fever, and sweats may cause confusion with tuber- 
 culosis. Indeed, the older writers spoke of Malta fever as " Mediter- 
 ranean phthisis." The bronchi in Malta fever are intensely hyperse- 
 mic and the sputum is frequently blood-tinged. Malaria, ulcerative 
 endocarditis, febrile pseudoleukemia, liver abscess, etc., are differ- 
 entiated by the agglutination test. 
 
 Treatment. — There is no specific treatment, though serum therapy 
 is likely to prove valuable (Aldridge, Fitzgerald, Ewart). Quinine 
 and arsenic are ineffectual. Headache and backache are relieved by 
 acetanilide and morphine; insomnia by bromides, chloral and hyo- 
 scine ; diarrhcea by tr. ferri chlor. ; pseudorheumatism by heat, wool 
 investment, tr. iodi, locally, and by salicylates, internally; orchitis, 
 by local heat and suspensory elevation. The general therapy is the 
 same as in typhoid. Milk diet lessens the chance of intestinal com- 
 plications, though Dalton advocates a solid diet. The milk of goats 
 should be discontinued. In convalescence a change of climate is 
 necessary. 
 
 BERIBERI. 
 
 Definition. — Beriberi, or polyneuritis endemica (Balz, Scheube), is 
 an endemic and epidemic affection of the tropics and subtropics, of 
 unknown etiology, characterized anatomically by degenerative inflam- 
 mation of the peripheral nerves, and clinically by motor and sensory 
 disturbances, anasarca, cardiac disturbance and by a subacute or 
 chronic course. Beri is said to signify a sheep's gait, and the term 
 kakke also means disturbance of the gait. 
 
 History. — Beriberi is mentioned in the oldest Chinese writings and 
 was observed in the Boman legions, 24 B. C, by Strabo and Cassius. 
 In the seventeenth century, beriberi was noted in Brazil and in the 
 Malay archipelago; in recent times (1835) it has been described by 
 Malcolmson in India; by Balz, Scheube, Grimm, and Miura in 
 Japan; by the physicians in the Dutch Oriental colonies; and by 
 Birge, Putnam, and Bonduret in this country. 
 
 Distribution. — The main foci of beriberi are (1) the Malay archi- 
 pelago, Sumatra, Borneo, and Java; also China, India (where it is de- 
 creasing), the Philippines, Japan, and even Australia. The mor- 
 tality has been very high among the Chinese coolies in the Dutch 
 possessions. (2) Africa, including the mainland and adjacent 
 
228 THE SPECIFIC INFECTIONS. 
 
 islands. (3) America and the West Indies. Brazil, Honduras, and 
 Cuba. Scheube doubts that the eases which developed in the United 
 States, in the epidemic at Tuscaloosa, Alabama, were beriberi, but 
 they are apparently identical with oriental beriberi. Cases have 
 appeared in Dublin (1894^-1898, with forty-two deaths), in England 
 and in Paris. 
 
 Etiology. — The etiology is greatly disputed and there are two dis- 
 tinct views: (1) That it is an acute infection (Balz. Scheube), be- 
 cause it occurs in certain localities as epidemics and endemics, it 
 occurs in the summer months, and in moist, alluvial land near the 
 sea, and near the river mouths, — i. e., the same telluric conditions pro- 
 mote berberi, which promote malaria. It is considered by some per- 
 sons to be contagious, though no constant microorganism has been 
 found. The fact that many cases develop in houses, barracks, and 
 ships favors the theory of contagion. In the 80,000 cases which de- 
 veloped among the Japanese troops in the Russo-Japanese War, 
 Kokubo frequently found a coccus. (2) The second view is that 
 beriberi results from food. Shelled rice is said to have caused 
 it in the Dutch East Indies, and raw fish is considered the cause of 
 the disease among the Japanese (Miura). The use of fish in the 
 navy was forbidden by Takaki, and the mortality fell from 25 per 
 cent, to almost nothing. ISTatives are more often affected than 
 Europeans, and males more frequently than females. Improper diet 
 may be a cause of beriberi or an indirect factor. In 1579 there 
 were 8,197 cases in Japan and in 1891 this number decreased to oue. 
 Poor food, overcrowding and lack of hygiene are important factors. 
 Symptoms. — The incubation is probably several months, and the 
 disease is due to repeated infections. The symptoms are threefold: 
 (1) those of neuritis. (2) dropsy, and (3) cardiac insufficiencv. 
 
 1. ^EFRtTic Symptoms. — A more detailed description of these 
 symptoms will be given under Multiple Xllritis. Anatomieallv 
 there is the same symmetrical degeneration (or inflammation') in the 
 distal parts of the peripheral nerves to which, however, it is not 
 limited; the phrenic and pneumogastric nerves and the cardiac, renal. 
 and solar plexuses, are often involved: the nuclei of the sheath 
 multiply: the axis cylinders degenerate; there is a lumpy degenera- 
 tion in the medullary sheath: and later, there is connective-tissue 
 hypertrophy. In eight cases there were degenerative changes in the 
 cord, anterior horns, and posterior ganglia. Clinically, the onset is 
 gradual and the course chronic. 
 
 (a) Motor Symptoms. — The muscles of the calves, the knee exten- 
 sors, and the abductors and flexors of the thigh are weakened, flaccid. 
 swollen and atrophied. The muscles are more frequently tender than 
 the nerve-trunks. In severe cases the trunk, arms and even the 
 face, are involved. The muscles are anatomically much degenerated. 
 Phrenic weakness and vagus symptoms, such as rapid heart, vomiting, 
 epigastric oppression, or digestive disorder are not infrequent : the 
 lungs are sometimes acutely emphysematous, from involvement of 
 
BMMBEBL 229 
 
 the pulmonary plexus. Symptoms of involvement of the larynx, 
 of glossopharyngeal, hypoglossal or ocular participation are more 
 rare. Cramps in the calves and fibrillary contractions are frequent, 
 but ataxia is uncommon, although the name beriberi refers specifi- 
 cally to disturbed locomotion. The gait is described as like that of 
 one walking in wet clothes or wading in water. 
 
 b. Sensory Symptoms. — Paresthesia is common. Hypesthesia is 
 most marked in the distal parts, though the sole of the foot is exempt ; 
 it is more frequent than anaesthesia, which is rarely complete. Hy- 
 peresthesia may occasionally occur over the spine and abdomen. 
 Pains over the joints and intercostal spaces are quite common. 
 
 c. Trophic Symptoms. — These are uncommon. They include joint 
 relaxation, herpes or skin atrophy. 
 
 d. Reflexes. — The skin reflexes are seldom abolished. Reduction 
 of the tendon reflexes develops equally with the paralysis. 
 
 e. Degeneration. — Slight reaction of degeneration is common and 
 may be marked in severe cases. It occurs particularly in the leg. 
 
 (2). Deopsy. — Dropsy to some degree occurs in 97 per cent, of 
 cases ; it may be marked in the legs, and face, and in all the serous 
 chambers. It is most severe in the pericardium, quite severe in the 
 pleura?, and least severe in the peritoneum. It is caused by cardiac 
 and perhaps also by vasomotor involvement. Dropsy invariably 
 occurs in fatal cases. 
 
 (3). Caedtac Ixsufficiexcy. — In the acute cases, death may 
 result in a day, and in 65 per cent, of cases acute forms terminate 
 fatally within two weeks. There is palpitation, cardiac or epigas- 
 tric oppression, or actual pain; tachycardia, dyspnoea, and cyanosis 
 develop; the right ventricle is hypertrophied and dilated, the first 
 apical tone is weak; there is splitting of the heart tones, gallop- 
 rhythm, and systolic or even diastolic functional bruits ; the urine 
 is decreased in amount; the liver is turgid. Anaemia is marked and 
 the leukocytes may be increased. Acute pulmonary oedema is usually 
 fatal. The heart muscle is pale, friable, colloid, or the seat of acute 
 myocarditis. 
 
 The types of beriberi only accentuate the above-named symptoms. 
 (1) The rudimentary form may begin with fever, and catarrh of 
 the air-passages, and alimentary tract. There is a slight oedema 
 of the ankles; muscular weakness, especially in the legs, indicates 
 neuritis; muscular tenderness, paresthesia, and palpitation are also 
 symptoms. (2) The atrophic form is marked by atrophy and paraly- 
 sis. If oedema does not develop, these types are called " dry forms." 
 (3) The dropsical form is characterized by much transudation and 
 pronounced insufficiency of the heart. (4) The acute cardiac or per- 
 nicious form (v. s.). 
 
 Diagnosis. — Diagnosis of beriberi is difficult when it occurs in the 
 temperate countries. The leading points are (a) the multiple neu- 
 ritis, which is most marked in the legs; (b) vagus neuritis and 
 cardiac insufficiency; and (c) dropsy. 
 
230 TEE SPECIFIC INFECTIONS. 
 
 Prognosis. — In Japan and the Dutch Indies the death-rate ranges 
 between 3 and 4 per cent. ; in Brazil it formerly varied from 50 to 
 75 per cent. ; and in the Malay archipelago it reached 40 to 50 per 
 cent. Death results primarily from heart failure, secondarily from 
 paralysis of respiration, less frequently from ursemia, embolism of 
 the lungs, aspiration pneumonia, dysentery, tuberculosis or marasmus. 
 Even in recovery, permanent residua are common, such as weakness, 
 obstinate contractures of the legs, absence of knee-jerk, and cardiac 
 instability and hypertrophy. In 43 per cent, of the fatalities, there 
 is a sudden death. Recurrences are common. 
 
 Treatment. — In the early stages of the disease purgation and salicy- 
 lates are beneficial. In the later stages, electrotherapy and other 
 measures employed in multiple neuritis (q. v.) are indicated. The 
 heart should receive stimulation. Venesection is advisable to re- 
 lieve the overladen right heart and dyspnoea, and promote action 
 of the kidneys. Digitalis is strongly recommended by some, whereas 
 others fail to find any benefit from its administration because the 
 vagus is degenerated. In dropsical forms it is helpful, as is caffeine. 
 The ice-bag over the heart, bromides and belladonna, may mitigate 
 cardiac unrest and palpitation. (See Treatment of Valvular 
 Disease of the Heart.) 
 
 ANTHRAX. 
 
 Anthrax is one of the zoonoses (diseases acquired from animals). 
 Glanders, foot-and-mouth disease, vaccinia and hydrophobia consti- 
 tute the remainder of this group. xVctinomycosis is less a zoonosis 
 than a disease acquired from a common cause by man and beast. 
 Anthrax is also called splenic fever, pustula maligna, and carbunculus 
 contagiosus. 
 
 Definition. — It is an acute infection caused by the Bacillus anthra- 
 cis, and is usually communicated to man from the herbivora. 
 
 History. — Over a century ago Morand and Fournier distinguished 
 between the simple carbuncle and that of anthrax, which could be 
 inoculated. The bacilli were seen by Pollander (1855) and Branell 
 (1858), but Davaine (1864-1873) noted that the organisms were 
 bacteria. It remained for Koch with his epoch-making technique to 
 find the spores and to absolutely differentiate the disease, which is 
 now one of the best known maladies. 
 
 Bacteriology. — The anthrax bacillus is the largest pathogenic mi- 
 crobe, and measures 3 to 10 by 1 to 1.5 f*. In growths it occurs 
 singly or in chains. The ends are slightly rounded, and the chains 
 resemble the phalanges of the finger, for the organisms lie end to end. 
 They are non-motile, and transparent, and may be stained by Gram's 
 method, and also with various dyes, especially Bismarck brown. 
 At high temperatures they grow in long, thread-like, winding, seg- 
 mented filaments. Spores are absent in the cadaver and in the living 
 tissue; in the living tissues the bacilli multiply by fission. In atten- 
 uated cultures, one spore develops for each bacillus; these become 
 
AttTEKAX. 231 
 
 bacilli which are extremely resistant to drying and to high* tem- 
 perature. 
 
 Cultukes. — The bacillus is an obligate aerobe which requires 
 oxygen and carbon-dioxide, and grows best on neutral or weakly 
 alkaline media and at a temperature between 95° and 102°. Stab 
 cultures of agar are characteristic. A white, milky yet transparent 
 and band-like growth appears in one or two days, which develops 
 horizontally in blood serum, and grows downward at an acute angle, 
 so that in three days it resembles a quill with a feathered upper end. 
 Growths on gelatin have a thick, wooly covering. The gelatin lique- 
 fies after a few days, and a white, granular sediment falls to the bot- 
 tom of the tube. The bacillus loses its virulence in blood which has 
 been rapidly dried, but in blood which has been slowly dried, it 
 develops spores. 
 
 Anthrax is endemic and epidemic in Europe and Asia. There 
 are persistent foci in Germany, especially in Saxony, parts of 
 Bavaria, and in Frankfort ; in France, in the provinces of Burgundy, 
 and Auvergne; in Hungary; in Russia, principally in Siberia (the 
 " Siberian plague ") ; in China, India, and in South America. An- 
 thrax is rare in America, though small epidemics have appeared in 
 Delaware and Pennsylvania. From Russia, infection may be dis- 
 seminated by horse's hair and from Asia by mohair (Angora goats). 
 Among animals, the herbivora are most often affected, especially 
 sheep and cattle, and in Russia, horses. Omnivora are more suscep- 
 tible than carnivora. Mice, guinea-pigs, rabbits, dogs, and fowl 
 rarely acquire the disease. Pasteur thought that earth-worms carried 
 the bacilli from buried bodies to the surface. Transmission of the 
 spores by means of snails, flies and fleas is possible. Spores reach- 
 ing water may be widely disseminated. The germ may have a facul- 
 tative saprophytic existence on vegetable media. 
 
 Infection may be carried to man from animals, and, on rare occa- 
 sions, from other human beings. Of Koranyi's cases, 65 per cent, 
 were attributed to sheep and 35 per cent, to cattle; Bourgois con- 
 siders that the greatest percentage comes from cattle, the second 
 largest from sheep, and the third largest from horses. 
 
 External Anthrax. — External anthrax is by far the most common 
 type. The atrium is an abrasion of the skin, possibly through in- 
 tact hair-follicles. Koch observed that sheep were infected by fly- 
 bites on the exposed skin of the neck. Shepherds, coachmen, and 
 all those who attend diseased animals ; butchers, tanners, wool-sorters 
 and persons who handle diseased hides or meat; and saddlers, tan- 
 ners, rag-pickers and gardeners are most likely to acquire the disease. 
 Jacobi records infection from a hypodermic needle, first used on a 
 patient with anthrax. The spores are more virulent than the bacilli. 
 
 Site of the Pustula Maligna. — In Koch's collection of 1,077 cases, 
 the exact distribution is noted in 966 ; 51 per cent, developed on the 
 head and face, 38 per cent, on the upper extremities, 2 per cent, on 
 the lower, 5 per cent, on the neck, and 4 per cent, on the trunk, 
 
232 TEE SPECIFIC INFECTIONS. 
 
 that is, the exposed parts are the usual seat of primary infection. 
 The lesion is usually single, but several pustules or carbuncles may 
 develop, possibly from inoculation by the finger-nails in scratching. 
 
 Symptoms. — The incubation lasts two or three days. A small red 
 prominence is first seen, which resembles an insect-bite. It itches, 
 burns, and in twelve hours develops a small vesicle. This is filled 
 with yellow or blood-stained serum, which becomes purulent if rup- 
 tured or scratched, and dries with scab formation. It develops a 
 dark, dry, central, necrotic, leathery slough, which is caused by 
 streptococcic infection, and is surrounded by dense round-cell, fibrin- 
 ous, and often hemorrhagic, infiltration. This in turn is surrounded 
 by oedema of the connective tissue, in the deeper lymph-vessels of 
 which the Bacillus anthracis abounds. If the carbuncle extends, a 
 circle or even concentric circles of new vesicles appear, which fuse 
 and increase the infiltration and oedema. The eyes may be closed 
 by swelling of the lids, or the lips may be so swollen that the jaws 
 cannot be opened. Demarcation now occurs, followed by sloughing ; 
 granulation tissue and cicatrization or general infection develop, and 
 the adjacent lymph-vessels and glands become infected, soft, and 
 hemorrhagic. This usually occurs on the fourth to sixth day, or 
 earlier in violent infection or reduced physiological resistance. It 
 is marked by depression, headache, backache, pain in the limbs, chilli- 
 ness, continuous or remittent fever, soft pulse, rapid breathing, vom- 
 iting of mucus or blood, vertigo, leukocytosis, colic, diarrhoea, and col- 
 lapse. Hemorrhages or even gangrene may develop around the car- 
 buncle. Anthrax bacillaemia is sometimes found. The mind is 
 usually clear, although delirium, convulsions or coma may develop, 
 and death may occur on the seventh to ninth day with an antemor- 
 tem fall of temperature. Toxaemia and septicaemia cause the symp- 
 toms given above. In fatal cases there is only slight rigor mortis 
 but rapid decomposition, dark fluid blood, hemorrhages into various 
 tissues, swelling of the lymph glands, and lymphadenoid tissue of 
 the intestine and sometimes of the spleen. In the liver, kidneys, 
 spleen, heart, lungs, brain and meninges, deposition of bacilli and 
 hemorrhages and swelling may be found ; the bacilli are seen less in 
 the large vessels than in the capillaries. Bourgois describes another 
 cutaneous form of the disease in which there is great oedema (char- 
 bon Mane, anthrax oedema), but no pustule or carbuncle. He con- 
 siders that it occurs more often on the body than does the carbuncle. 
 
 Diagnosis. — In most cases this is not difficult. The simple car- 
 buncle resembles that of anthrax, in that it is also hard, has a prom- 
 inent central necrosis, is surrounded by oedema and sometimes is 
 vesiculated. It usually causes great pain, has numerous openings 
 which discharge ordinary pus, and is often malodorous. The anthrax 
 carbuncle, however, may be differentiated by the presence of bacilli, 
 depression of the necrotic centre, the corona of vesicles, more rapid 
 evolution, greater oedema, remarkable freedom from pain, and lack of 
 odor. Glanders may be distinguished by involvement of the mucosae, 
 
ANTHRAX. 233 
 
 painful nodes without eschars, and ulcerations which discharge the 
 Bacillus mallei. It is often difficult to recognize Bourgois' cliar- 
 hon blanc. 
 
 Prognosis. — The prognosis is more favorable in children than in 
 adults, in cases with local than in those with general symptoms, and 
 in those with simple carbuncle than in those with oedema. In 
 Koch's collection of cases, 68 per cent, recovered. Xasarow's figures 
 show 26 per cent, mortality when anthrax occurs in the head and 
 face, 23 per cent, when it occurs in the trunk, 19 per cent, in the 
 neck, 14 per cent, in the upper, and 5 per cent, in lower extremity. 
 
 Treatment. — Prophylaxis. — Infected animals should be cremated 
 entire and their hides and wool destroyed. Toussaint (1880) and 
 later, Pasteur, Chauveau and Colbert, attenuated the virulence of 
 anthrax cultures by exposing them to sunlight or increased atmos- 
 pheric pressure, and used them to immunize animals. In France 
 (1882-1893), 1,788,677 sheep were thus inoculated, with a resulting 
 mortality of 0.9 per cent, and 200,962 cattle were also inoculated, and 
 a 0.3-per-cent. mortality occurred. 
 
 Active Teeatmext. — Wounds in those who have been exposed to 
 infection should be promptly washed with strong sublimate solution. 
 Cauterization with the live cautery, carbolic or nitric acids or caus- 
 tic potash; surgical excision through sound tissue; and injections of 
 iodine or corrosive sublimate have been recommended, but it is also 
 maintained that equally good results may be obtained by elevation, 
 the use of mercurial paste, and expectant treatment, which at least 
 avoid dissemination of the parasite through sound tissues. Ery- 
 sipelas serum has apparently been useful in anthrax infections. 
 Sclavo (1903) reported 164 cases which were treated by serotherapy; 
 the mortality was but 6 per cent. In 1,073 cases treated with Men- 
 dez's serum, the mortality was but 4 per cent. 
 
 II. Internal Anthrax. — Internal anthrax is less frequent than the 
 external type. It occurs in the alimentary and respiratory tracts. 
 
 1. Alimentary Form. — The alimentary form (mycosis intestinalis) 
 was first described by vVahl and Kecklinghausen, and was more fully 
 discussed by Waldeyer and Munch. Bacilli may enter the system 
 through cuts in the mouth and throat, but usually directly invade the 
 intestines and stomach, which are more frequently infected by spores 
 in milk or water than by diseased meat. The gastric juice kills the 
 bacilli but not the spores. Peasants often eat the pickled meat of 
 diseased animals without being infected. In Wurzen, Saxony, there 
 were 206 cases of intestinal anthrax in 1877. 
 
 Symptoms. — There may be prodromal chills, fever, epigastric or 
 lumbar pains, or depression. The onset is, however, usually abrupt, 
 with fever, coated tongue, thirst, and vomiting of mucus or of blood. 
 This is followed by sensitiveness or great pain over the bowels, by 
 serous and afterward bloody movements, meteorism, dyspnoea, weak 
 pulse, and by symptoms of collapse which resemble those seen in 
 the generalization of infection in the cutaneous form. Secondary 
 
234 T8E SPECIFIC WFECTlOttS. 
 
 carbuncles, or more often hemorrhages into the skin of the neck and of 
 the abdomen, may develop. The course is usually severe and, in 
 some instances, is peracute ; death usually results in five or six days 
 in well marked cases, although recovery is possible. 
 
 Diagnosis. — The history of the case, the finding of bacilli in the 
 stools and in the blood, or the findings at autopsy, determine the diag- 
 nosis. In the small intestine there are changes like those of the cuta- 
 neous carbuncle. These consist of localized induration with central 
 sloughing which usually occurs opposite the mesenteric attachment 
 and is accompanied by surrounding hemorrhage and oedema in the 
 mucosa, and of swelling of the solitary follicles, of Peyer's patches, 
 of the mesenteric glands and of the omental and retroperitoneal cel- 
 lular tissue. The bacillus is found in these lymphadenoid structures 
 in large numbers and sometimes also in the chylevessels and portal 
 bloodvessels. The greatest changes most frequently occur in the 
 upper small intestine, sometimes in the stomach or ileum, seldom in 
 the colon and most rarely in the rectum. More than thirty or forty 
 foci may be seen in the small gut, but the lesions in the stomach 
 or rectum are fewer in number and more discrete. Secondary em- 
 bolism of the intestinal arteries may result from anthrax of the skin, 
 in which event hemorrhagic stools are uncommon. Serohemorrhagic 
 fluid may be found in the peritoneal cavity. Treatment is without 
 effect, though ipecac, calomel and bichloride of mercury are often 
 recommended. 
 
 2. Respiratory Form. — The respiratory form was described by Bell 
 (1879), and Spear and Carpenter (1881) in England, as the " wool- 
 sorters' disease"; and by Eppinger (1894) in Steiermark, Austria, 
 as the " rag-sorters' disease." Infection may, on rare occasions, 
 occur in the nose, larynx, tonsils or bronchi. Particles of inhaled 
 chalk are thought to facilitate infection by producing minute trau- 
 mata, but the bacilli are apparently capable of entering the uninjured 
 bronchioles and alveoli. Wool-sorters' disease results especially from 
 infection by hides imported from Russia and Brazil, and, in 1897, 
 anthrax developed in this country from hides of Chinese origin. 
 
 Symptoms. — Prodromes are uncommon. The symptoms begin 
 suddenly with chill and high fever, tachypncea and dyspnoea; there 
 are bronchitic and irregular pneumonic findings ; the sputum, which 
 in some instances contains the pathognomonic bacilli, is viscid or 
 hemorrhagic. The later symptoms are cyanosis caused by diffuse med- 
 iastinal infiltration; serous pleurisy, weak heart, vomiting and the 
 terminal collapse and antemortem fall of temperature. Icterus, he- 
 maturia, glycosuria and anthrax endocarditis have been observed. 
 The sensorium is clear to the end in most of the fatal cases, though 
 convulsions and coma occur in some cases, due to meningeal hemor- 
 rhage. The patient may die on the second or third day. The mor- 
 tality in rag-sorters' disease is 50 to 87 per cent., and is rather lower 
 in wool-sorters' disease. At the autopsy the special findings are as 
 follows : The bacilli enter the alveoli, wherein they produce alveolar 
 
GLAXDEH8. 235 
 
 desquamation and cellulo-fibrinous exudation — the analogue of the 
 carbuncle — and much sero-hemorrhagic exudate, — comparable to the 
 skin oedema. Where there is much cellular exudate, the bacilli 
 decrease and recovery may result from demarcation; where there 
 is much serous infiltration the bacilli are abundant and extension of 
 the infection is likely along the lymphvessels in the direction of the 
 mediastinal cellular tissue, peribronchial lymph glands and pleurae, 
 which may hold as much as four quarts of anthrax-infected serous 
 blood-stained exudate. 
 
 Treatment. — The disease may, to a great extent, be prevented by 
 sterilization of the germ-laden hair, hides or hair used in the manu- 
 facture of paper. The actual therapy is wholly symptomatic and 
 supportive. 
 
 3. Anthrax Septicaemia. — Anthrax septicaemia is a rare form in 
 which the blood is charged with bacilli, though no point of entrance 
 can be found. It is almost always fatal. 
 
 GLANDERS. 
 
 Definition. — An acute or more often a chronic contagion, which is 
 caused by the Bacillus mallei. It is characterized by the formation of 
 nodules and ulcers, which occur chiefly in the nose and skin and less 
 often in other structures. It is observed largely in the horse, which 
 is the main source of human infection. 
 
 Etiology. — Glanders and farcy were known to Aristotle and Hip- 
 pocrates. The Bacillus mallei was discovered by Loefner and Schuetz 
 (1882), and independently by Bouchard, Capitau and Charrin. 
 By its discovery, glanders and farcy were identified as one disease. 
 Weichselbaum (1885) first found the bacillus in human infection. 
 It closely resembles the tubercle bacillus morphologically, but is 
 shorter and thicker and measures 2 to 5 by 0.4 to 1.5 p; it is 
 straight or slightly bent ; its ends are somewhat rounded ; it is usually 
 single, but may lie in pairs or groups ; and is not motile. It stains 
 with the alkaline anilines, easily in cultures but with more difficulty 
 in sections, and the bacillus tinges unevenly, showing lighter areas, 
 which are thought by some to be spores. It is a facultative aerobe 
 and its most characteristic culture is on potato, in which a thin light 
 yellow film develops in two days, soon becomes amber-colored and in 
 eight days assumes a weakly red tinge with somewhat greenish-blue 
 borders. The atrium is usually the skin, through which the bacil- 
 lus enters by some small, perhaps microscopic lesion. Babes con- 
 siders that infection may take place through the intact mucosa of the 
 nose and air-passages. Horse-bites may cause inoculation. Infection 
 may also occur through the conjunctiva, nose, respiratory tract or 
 very rarely, the digestive tract (xTocard). Man is usually infected 
 by chronically diseased horses ; man-to-man infection is far less fre- 
 quent. The bacillus is found in the nasal nodes (glanders) ; in the 
 skin nodes (farcy) ; in the lymphvessels and glands (in which its 
 
236 TEE SPECIFIC INFECTIONS. 
 
 virulence is greatest) ; in the saliva, urine, sweat, semen and in the 
 blood-current, where it occurs more frequently in man than in ani- 
 mals, in which it is found only in the most acute cases. 
 
 The vitality of the bacillus is not great. It is soon destroyed in 
 pus, but may endure for three or four weeks in the viscera of cadavers 
 or three or four months in cultures ; it is rapidly killed by sunlight, 
 but persists two or more weeks in damp protected places. It is 
 killed in two minutes at 212°, in fifteen minutes by 1 to 1,000 sub- 
 limate solution and in one hour by 5 per cent, carbolic solution. 
 Babes (1890) and Kalming (1891) isolated a toxin, and Kalming, 
 during his researches, succumbed to acute glanders. Hellmann 
 (1891) isolated mallein and Babes (1892) morvine, both of which 
 are successfully injected for diagnosis and for immunization. The 
 horse, ass and mule are the most susceptible animals and from them, 
 goats, sheep, cats, lions, rabbits and guinea-pigs may be inoculated. 
 Babes found that in some localities half the horses have latent 
 glanders. Cattle, mice, rats and fowl are practically immune. In- 
 fection is carried by the nasal or cutaneous discharge, whence glan- 
 ders and farcy are chiefly observed in stable-boys, coachmen, farmers 
 and veterinary surgeons. 
 
 Symptoms, Pathology and Course. — These are considered under two 
 topics: (A) Farcy, the cutaneous type; (1) acute or (2) chronic; 
 and (_£>) glanders, the nasal type; (1) acute or (2) chronic. In 
 most cases the types are not wholly distinct, though symptoms of one 
 localization may prevail. 
 
 (A) Fabcy. — 1. Acute Form. — The incubation is from three to 
 five days -and is attended by depression, nausea, headache and leg 
 pains. The infected skin shows infiltration, which may heal only to 
 break out anew. Lymphangitis and lymphadenitis are less marked 
 than in the horse and result in lymphangitic farcy-buds. Subcutan- 
 eous and cutaneous nodes or areas of diffuse infiltration develop. 
 These swellings are classed with the infective granulomata, are com- 
 posed of epithelioid, lymphoid and white blood cells, and contain 
 the bacilli, which are free, rarely intracellular and most abundant 
 in the centre of the node. Early sections are succulent and show 
 central necrosis, which is followed by suppuration and ulceration. 
 The ulcers are painful, deep and crater-like, with sharply cut, everted 
 borders and with speckled bases ; they have a thin, purif orm, hemor- 
 rhagic or ichorous discharge and they often fuse. Thrombophle- 
 bitis, diffuse phlegmons or gangrene may develop. The rise of the 
 fever may closely resemble the ladder-like ascent of the temperature 
 in typhoid. Chills are common. Polyarthritis and large muscular 
 abscesses are frequent. In some cases a skin eruption occurs which 
 is successively macular, papular and pustular and resembles that 
 of smallpox except that it is rarely umbilicated ; it may be scant and 
 scattered, or very diffuse and even confluent; and may affect the 
 mouth, throat and conjunctivae. The patient is often delirious and 
 has an offensive diarrhoea; the pulse becomes rapid and fresh skin 
 
GLANDERS. 237 
 
 nodes develop, which are accompanied by ulceration or perhaps gan- 
 grene. The pulse is fast, small and irregular; the urine contains 
 albumin or casts, or shows the diazo reaction, and death occurs in 
 about two weeks from exhaustion or from lung inflammation. In 
 the horse, acute farcy occurs with acute nasal localization. 
 
 2. Chronic Form. — Chronic farcy shows the same skin changes, 
 but they are gradual in onset, slow in progression and unaccom- 
 panied by essential inflammatory reaction or by lymphatic invasion. 
 For the first month or two there are pains in the limbs and joints, and 
 after a few weeks, indolent swellings appear in the extremities and 
 in the periarticular tissues. These are followed by ulceration. The 
 ulcers may cicatrize, but break out again after months and there- 
 fore somewhat resemble lupus, which heals on one side and develops 
 on another. Muscular abscesses may appear and are very often lo- 
 cated in the pectoralis, biceps, brachialis and gastrocnemius. The 
 course lasts for months or years (two to eleven) . Recovery occurs in 
 50 per cent, of the cases (Bollinger), or death results from exhaustion 
 and acute dissemination. In horses the lymphvessels and glands are 
 greatly swollen, and appear as sausage-shaped masses, on account 
 of which fact the term " farcy " was used by Vegetius. In horses 
 the skin eruptions and orchitis are more frequent than in man. 
 
 (B) Glanders. — 1. Acute Nasal Form. — The conjunctiva? are 
 sometimes swollen, but the process generally begins in the nose after 
 an incubation of three or four days. Miliary nodules develop. 
 These are elevated, are yellowish-white in the centre, grow to the 
 size of a pea, are surrounded by a pale red zone and become ulcerated. 
 New nodes form on the edges of the ulcers, which break down, fuse 
 with them, and discharge a thin, puriform, dirty, sanguinolent fluid. 
 Diphtheroid deposits or crusts form ; desiccation may also occur. Ul- 
 ceration may erode the bone or cartilage and cause perforation of the 
 septum. The nose is swollen and eroded externally, and the lesions 
 may resemble those of erysipelas. The process reaches the mouth 
 by the lymph channels or by thrombophlebitis. Perforation of the 
 palate may occur; the tongue, gums or tonsils are invaded; the 
 angular lymphatic, parotid and submaxillary glands are swollen, 
 and the larynx, and finally the lungs are infected. Beregin found 
 that microscopic nodes may develop in nearly all the parenchymatous 
 organs, the liver, kidney, spleen and brain. In the lungs the nodes 
 may resemble miliary tubercles, or actual hepatization (pneumonia 
 malleosa) may develop and is frequently accompanied by hemor- 
 rhage, abscess formation, gangrene, a distressing cough and rasp- 
 berry, mucopurulent or sometimes stinking sputum. Secondary sup- 
 puration in the bones, muscles, joints or skin may develop. The 
 course is that of acute farcy, though perhaps more rapid, and is at- 
 tended by drenching sweats, diarrhoea, clouded sensorium and con- 
 vulsions ; death occurs in one or two weeks. The leukocytes are 
 increased. 
 
 2. Chronic Nasal Form, — This is similar to acute glanders except 
 
238 TEE SPECIFIC INFECTIONS. 
 
 that it is chronic. It is less frequent, and in forms which are lim- 
 ited to the nose, confusion with other diseases is common. When 
 nasal involvement is slight it may resemble pulmonary tuberculosis, 
 chronic coryza, pyaemia or osteomyelitis. Healing by cicatrization is 
 infrequent. According to Babes, recovery may take place or, at 
 least, the malady may "slumber," possibly to be aroused later by 
 trauma or some other infection, notably symbiosis with the staphy- 
 lococcus. Death occurs from exhaustion or from generalization by 
 lymphangitis or thrombophlebitis. 
 
 Diagnosis of Glanders and Farcy. — Typhoid, pyaemia, rheumatism, 
 erysipelas, variola, syphilis, lupus, tuberculosis and anthrax may 
 cause confusion, but the surroundings, the history and the bacteriol- 
 ogy of the case determine the diagnosis. The cultural findings are 
 proven by intraperitoneal inoculation of a guinea-pig, in which 
 orchitis should develop rapidly. Injections of mallein differentiate 
 the disease in 90 to 95 per cent, of the cases for they produce a rise 
 of temperature of three degrees or more. The bacilli are agglutinated 
 by the serum of normal horses in a dilution of 1 to 200, and of those 
 subject to glanders in a dilution of 1 to 1,000. 
 
 Treatment. — The prophylaxis of glanders is like that of anthrax. 
 The principal measures indicated are isolation of diseased, and cre- 
 mation of dead animals, and the use of strong antiseptics in wounds 
 of persons exposed to infection. Skin ulcers should be curetted and 
 bandaged antiseptically ; if they are obstinate, the live cautery should 
 be applied. Infection of the nose ■ should be treated by carbolic 
 douches, zinc chloride paste, iodoLor iodoform. Arsenic, mercurial 
 inunctions, iodides, quinine and alcohol for the maintenance of 
 strength are recommended. Injections of mallein may prove of thera- 
 peutic as well as of diagnostic value (Babes, Pilavios). Large doses 
 of potassium iodide have been recently recommended. 
 
 TETANUS. 
 
 Definition. — Tetanus, or lock-jaw, is an acute infection caused by 
 the tetanus bacillus and is characterized clinically by greatly in- 
 creased reflexes, muscular rigidity and tonic spasms such as trismus 
 and opisthotonos. Tetanus is literally tension or stretching. The 
 disease is described in Hippocrates' aphorisms. 
 
 Etiology. — In 1884, Carle, Bosenbach and Battone produced the 
 disease by inoculations of pus, and in the same year, Nicholaier dis- 
 covered the tetanus bacillus, of which Kitasato (1889) first obtained 
 pure cultures from wounds and from earth, and found it an obligate 
 anaerobe. The Bacillus tetani measures 3 to 5 by i to \ n and is en- 
 larged at one end, in which there is a spore, thus having a pin-head 
 or drum-stick shape. It becomes thread-like in cultures. It stains 
 readily by Gram's method, and is delicately flagellated and motile. 
 It is anaerobic and cultures emit an onion-like smell. It is very diffi- 
 cult to isolate but grows well in sugar solutions. The bacillus is 
 
TETANUS. 239 
 
 very enduring and lives even if dried or frozen; the spores may 
 live eight years. It always exists in the primary wound and is 
 thought to exist only on rare occasions in the tissues of the brain and 
 cord, but recent figures show that it is present in 44 per cent, of the 
 severest infections, so that tetanus no longer seems to be a simple tox- 
 aemia. The bacillus has been found in the blood and sputum. 
 Tetanus is usually classified as traumatic or idiopathic (rheumatic) ; 
 the so-called idiopathic form is similar to idiopathic erysipelas, for the 
 atrium is either unseen, is microscopic, or is apparently through the 
 pharynx. The bacillus produces toxins which are 100 to 400 times 
 as toxic as strychnine and which in turn produce the symptoms. 
 They are tetano-spasmin and -lysin. The bacillus does not produce 
 inflammation, though mixed infections are usual. Tetanus symp- 
 toms result from the tetanus toxin alone, but both infection and viru- 
 lence are enhanced by association with various putrefactive micro- 
 organisms, and innocuous solutions of tetanus poison become lethal if 
 combined with sterilized cultures of these putrefactive bacteria. 
 Mice, guinea-pigs and rabbits are inoculable. In nature the bacillus 
 is found in the alimentary tract of herbivora, whence it occurs in 
 manure, garden earth, street or house dust, hay, putrefying fluids 
 and in splinters. Though it is spread over the world, the disease is 
 ten to twenty times as frequent in the tropics as in temperate zones, 
 because the bacillus thrives in heat. More cases exist in Prague than 
 in Berlin. It may lurk in certain districts, as it did formerly in the 
 eastern end of Long Island, or as it does in the West Indies where 
 negroes are more often and more seriously affected than whites. 
 
 Mode of Infection. — Incised wounds are obviously less dangerous 
 than punctured, gunshot or contused wounds or haematomata. Tet- 
 anus occurred less frequently in our Civil War than it did in the 
 Spanish- American conflict, in which many cases developed among the 
 Spaniards. It may result from minor operations, as circumcision, 
 hypodermic injections, the administration of antitoxin, tooth-extrac- 
 tion and vaccination (95 cases), and also from major operations. 
 Parturition, lack of attention to the navels of the new-born, the use 
 of imperfectly sterilized cat-gut, and leech-bites or pin-pricks may 
 also cause its development. ChaufTard (1903) collected 18 cases in 
 which infection occurred from injections of gelatin for various acute 
 hemorrhages, and Dieulafoy reports 11 cases after injections for 
 aneurysm. Preventive inoculations against the plague caused 19 
 deaths. The germ is very frequently found in gelatin, which should 
 therefore be sterilized three times in very small amounts, each 
 time for thirty to forty-five minutes at 212°. H. G. Wells has 
 placed emphasis on the danger resulting from the use of toy pistols 
 and blank cartridges for Fourth-of-July celebrations. He noted that 
 39 per cent, of tetanus mortality of 1903 occurred near that date; 
 415 deaths from tetanus are listed in the United States for that year 
 as against 89 in 1906; 75 per cent, of cases occur between the tenth 
 and fortieth year of life, 
 
240 THE SPECIFIC INFECTIONS. 
 
 Incubation. — This lasts from six to twelve hours in severe experi- 
 mental inoculations, from two to nine days in less intense inocula- 
 tions, and in man, the incubation in 66 per cent, of cases lasts from 
 live to fourteen days; Rose observed that in 33 per cent, of his cases 
 the symptoms appeared in one, and in 45 per cent, in two, weeks. 
 
 Symptoms. — These appear suddenly, without any or with only inde- 
 terminate prodromes, and are due to toxaemia. This is proven by 
 the fact that autopsies show no constant gross or minute alterations 
 except those common to all convulsive conditions — e. g., points of 
 congestion or punctate hemorrhage. Ehrlich's side-chain theory is 
 a fairly satisfactory explanation, for the anterior cells of the cord and 
 medulla combine with the toxins. Babes believed that some third 
 substance formed and produced the symptoms. These are, at first, 
 rigidity of the jaw (" lock-jaw," trismus) and stiffness of the neck. 
 In most animals the muscles become rigid near the seat of inoculation 
 first, and sometimes, in injuries received in war, the muscles of a 
 limb may be first involved. The probable explanation of this is that 
 the toxin travels along the nerve trunks (Marie, Morais, Ransom, 
 Meyer). The horse, like man, develops trismus first. The poison 
 incites the anterior cells of the cord and medulla to tonic contraction. 
 
 The fades tetanica results from a spasm of the zygomatic muscles, 
 which produces the risus sardonicus, and imparts a smiling expression 
 to the upper and a sad expression to the lower part of the face 
 (Konig) ; there are folds in the forehead ; the eyebrows are raised 
 and approximated, the eyeballs directed forward, the masseters prom- 
 inent, the teeth set and the nares dilated. The spinal extensors are 
 tonically contracted, arching the head backward and the trunk for- 
 ward (opisthotonos) ; the abdominal muscles are hard and retracted 
 and are occasionally even ruptured by their violent contraction; in 
 rare cases the contracture is lateral (pleurothotonos), or forward (em- 
 prosthotonos), or the body is straight and rigid (orthotonos). The 
 limbs are extended, the legs more so than the arms and the feet 
 and hands least. The spasms are chiefly tonic, but clonic exacerba- 
 tions for a few seconds may result from peripheral stimulation of the 
 sensory nerves or those of special sense, by the least touch, jar, breath 
 of air, bright light or sound. The reflexes are enormously increased, 
 particularly those of the skin. The spasms occasion violent muscu- 
 lar pain, oppression over the lower chest and epigastrium, speechless- 
 ness, insomnia and, from participation of the medulla, profuse sweats 
 and increased and irregular heart action. Fever may be present 
 (even 105° to 111°) or the temperature may be normal or subnormal. 
 After death a temperature of 114° has been observed. The sensorium 
 is usually clear. Evacuation of the bladder and rectum is difficult, 
 and erection or ejaculation may occur. The urine is decreased and 
 sometimes contains albumin, sugar, acetone or indican ; but increased 
 excretion of urea and creatin is not noted. In some cases the lymph 
 glands adjacent to the seat of infection are enlarged. In very rare 
 cases the toxins cause death without muscular spasm ; i. e., they com- 
 Ibine with other than the nervous tissues, 
 
TETANUS. 241 
 
 Death. — Sixty-six per cent, of the cases die in a paroxysm. The 
 usual fatal factor is a respiratory spasm, an oedema or spasm of the 
 larynx, hyperpyrexia, exhaustion or an increasing heart weakness. 
 
 Diagnosis. — The diagnosis is based on the nature of the wound, the 
 presence of the Bacillus tetarii, trismus (which is necessary for a 
 diagnosis), the facies, substernal oppression and opisthotonos. 
 Serum from cases of tetanus obtained by blistering, is fatal 
 to white mice in twelve to twenty-four hours. In strychnine poison- 
 ing the history, tests for the drug in the stomach washings and urine, 
 the more abrupt onset of the spasm and reflex excitability, the more 
 diffuse and violent clonic intermittence of the convulsions, their 
 greater involvement of the hands and feet, and the later appearance 
 of trismus and its inter paroxysmal relaxation, are entirely distinctive. 
 Hysteria, hydrophobia and tetany (q. v.) are wholly different from 
 tetanus. In meningitis the sensorium is affected. Trismus may be 
 due to other causes as dental caries or parotitis. Inflammation of 
 the temporo-maxillary joint usually results in a tender area in front 
 of the tragus, produces unilateral masticatory cramp and is easily dis- 
 tinguished by the clinical evolution alone. Escherich's pseudotetanus 
 is characterized by tonic contractures of the jaw, back and limbs, 
 which occur oftener after an acute infection than as an independent 
 disease, and by convalescence after a few weeks. 
 
 Prognosis. — The death-rate averages between 80 and 90 per cent., 
 and is modified by the following factors: 
 
 1. Incitbatiow. — The later after inoculation tetanus develops, the 
 better is the outlook. The mortality is 91 per cent, if it appears 
 in the first week, 81 per cent, if in the second, and 53 per cent, if 
 later (Rose). 
 
 2. Site of Intectiois". — Infection in the arms results in a 70 per 
 cent, mortality; in the legs, 90 per cent. (Morris) ; in cephalic tetanus 
 (the tetanus facialis or Jcopftetanus of Rose, first described by 
 Charles Bell, in 1830), the mortality is almost 100 per cent.; Ross 
 (1906) collected 129 cases of this type; J. H. Lloyd finds the prog- 
 nosis better than in the ordinary tetanus ; Lloyd found seven cases of 
 facial diplegia. In this type there is facial paralysis and involve- 
 ment of the pontine and medullary nuclei, which sometimes causes 
 dysphagia (hydrophobic type) or paralysis of the eye muscles. The 
 author observed these symptoms in a boy who had been kicked over 
 the ear by a horse. Tetanus or trismus neonatorum, especially de- 
 scribed by Beumer (1887), is an infection of the navel which occurs 
 in the second week of life. It prevents nursing and is fatal on the 
 third or fourth day in 83 per cent, of the cases. In the West Indies 
 50 per cent, of the children died of tetanus at one time, in the Western 
 Llebrides, 67 per cent, and in Iceland, 100 per cent. Anders and 
 Morgan collected 1307 cases (1850 to 1905). Tetanus puerperalis, 
 particularly described by Ileyse (1893), is a uterine infection, 
 usually follows difficult labor, abortions or ministration by mid- 
 wives and is generally fatal. In three years there were 232 cases 
 in Bombay (Growers). 
 
242 THE SPECIFIC INFECTIONS. 
 
 3. Course. — Hippocrates observed that patients who survive the 
 fourth day may recover; G8 per cent, die in the first four days. 
 According to Willard 88 per cent, of acute and 75 per cent, of chronic 
 cases die. 
 
 4. Trauma. — The death-rate in traumatic cases is over 80 per 
 cent. ; in the so-called idiopathic cases it is 50 per cent, or lower. 
 
 5. Sex. — More women recover than men. 
 
 6. Symptoms. — Slight trismus and response to antispasmodics are 
 favorable ; high fever and involvement of the pons or medulla, respir- 
 atory spasm, dysphagia and ocular paralysis are unfavorable. 
 
 Treatment. — 1. Prophylaxis. — This consists of general surgical 
 antisepsis and special care of punctured wounds, hcematomata and 
 injuries caused by blank cartridges. Iodine and silver nitrate are 
 very helpful, but wide incision to open the punctured wound, for 
 the bacillus is anaerobic, thorough lavage and packing are most es- 
 sential. Antiseptic conduct of labor, and care of the navel in the 
 new-born, need but little emphasis at the present day. 
 
 2. Antitoxic Therapy. — Behring and Kitasato (1880) dis- 
 covered an antitoxin and were able to immunize animals by cultures 
 which were heated from 122° to 140°, or treated with Lugol's solu- 
 tion, which changes the toxins to toxoids (Ehrlich). The antitoxin 
 was found in animals naturally immune to tetanus, such as crocodiles 
 and chickens, and it was found in the fluids (the blood, milk, and 
 bile) but not in the tissues. Tetanus antitoxin is not bactericidal, 
 — i. e., it does not act on the bacilli. It neutralizes the tetanus toxin 
 in the blood, but not after the toxin has become fixed in nervous tissue, 
 from which the antitoxin cannot dislodge it. Behring and Ehrlich 
 think that the antitoxin neutralizes the toxin chemically, while Babes 
 and others consider that cell metabolism is the most important factor. 
 From the above it is obvious that (a) serum prophylaxis may be suc- 
 cessful in suspected cases of earth infection or in dirty abortions, 
 although the term " successful " is presumptive, as it implies that tet- 
 anus would certainly have developed; it- has been successful in 
 cases of wounds received on the Fourth of July, and in the Prague 
 obstetrical clinic, in which latter instance every other measure failed ; 
 (b) if used early it may neutralize circulating toxins which have 
 not yet become attached to nervous structures; and (c) when the 
 toxins have combined with the motor cells, it must be ineffectual. 
 Babes estimates the mortality at 70 per cent, even when the serum 
 is used, which confutes the alleged lowering of the death-rate (34 
 per cent., Engleman; 43 per cent., Kohler; 16 per cent., Behring). 
 The first dose should be 20 to 30 c.c, and later 15 to 20 c.c. should 
 be given two to four times daily. It should be injected near the site 
 of inoculation, and especially into the nerve trunks near the injury, 
 in order to reach the toxins more readily. Subdural inoculations 
 saved a severe case of cephalic tetanus (Holub). The technique is 
 the same as in lumbar puncture (see page 169). 
 
 3. Clonic Convulsions. — These may be minimized by absolute 
 

 
 HYDEOPHOBIA (LYSSA; BABIES). 243 
 
 quiet and seclusion, by darkening the room and by careful handling 
 of the patient. Morphine may be given hypodermatically to relieve 
 pain, insomnia and cutaneous reflex irritability ; one-quarter grain 
 may be given every four to six hours for a day or two, but the pupils 
 and respiration rate must be carefully watched. Occasionally a cor- 
 rective hypodermic of atropine should be given. Chloral hydrate 
 depresses the motor elements of the cord ; twenty grains may be 
 given every two hours for three doses, but even this amount may 
 cause dangerous cardiac symptoms in alcoholics or in cases of arterio- 
 sclerosis. Digitalis may be given with chloral hydrate to steady the 
 heart, and morphine and potassium bromide to enhance its depresso- 
 motor action and to lessen the cutaneous irritability. The bromides 
 should be given, oiss every three hours, for six doses, after which the 
 interval should be lengthened. Inhalations of chloroform and amyl 
 nitrite may inhibit the onset of severe attacks. 
 
 4. Xeteitiox. — This must be carefully maintained by the nasal 
 catheter (see Typhoid") or by the rectum. In this way. the difficul- 
 ties offered by trismus or dysphagia are overcome. 
 
 5. Otiiee Measures. — (a) J. B. Murphy performs lumbar punc- 
 ture and injects a weak solution of eucaine and morphine, with ap- 
 parent results; (b) Baecelli, Ascoli and Babes secure better results 
 with hypodermics consisting of 10 drops of 3 per cent, carbolic solu- 
 tion, than they do with serotherapy ; no ill effects were observed from 
 long continued daily use; (c) Wassermann's proposal to inject sub- 
 durally an emulsion of sheep brains is endorsed by Babes and others. 
 (d) AEeltzer has recently been successful with intraspinal injections 
 of a dram of a 25 per cent, solution of magnesium sulphate. 
 
 HYDROPHOBIA (LYSSA; RABIES). 
 
 Definition. — An acute specific infection, of unknown causation, pe- 
 culiar to carnivora. the bites of which convey infection to other ani- 
 mals and to man. The disease is characterized by tonic and clonic 
 spasms of the oesophagus, respiratory and other muscles and by an 
 
 inevitably fatal evolution. It was described in ancient Jewish, 
 Egyptian and Indian writings and was discussed by Democritus in 
 the fourth and fifth centuries, B. C. The first adequate account was 
 by Youatt (1S2S, London). 
 
 Etiology. — In Germany it is infrequent, because of the strict laws : 
 from 1SST to 1594 only 16 cases occurred. In England. Eranee 
 and America it is far more common and in Russia many cases de- 
 velop. Australia alone is totally exempt. Dogs are most susceptible, 
 are most frequently arfected and are the chief cause of dissemination 
 (90 per cent.) ; next come wolves, cats and cattle: and finally skunks. 
 horses, deer. pigs, rabbits and even fowl may be inoculated. The 
 character of the virus is unknown. It is found in the nervous tissues 
 most abundantly, in the saliva and also in small quantities, in tears, 
 sputum, semen, urine and milk and in the adrenals. Its propaga- 
 
244 TEE SPECIFIC INFECTIONS. 
 
 tion has been held to occur along the nerve trunk but it must also 
 reach the blood current. It resists putrefaction for fourteen to 
 twenty-four days but, on drying, becomes attenuated in ten to fif- 
 teen days. The disease prevails chiefly in warm weather, particu- 
 larly in the " dog days" and most laws are based on this assump- 
 tion; but it is also fairly common in cool weather. In Paris most 
 cases occur in March and May. Sixty per cent, of cases occur in 
 males and 40 per cent, under fifteen years of age. Inoculation 
 occurs through the skin and nearly always results from bites of in- 
 fected animals, which may transmit the disease even during the 
 incubation period. Punctured or deep wounds and those in the 
 nerves or muscles are most dangerous ; 17 per cent, of those bitten 
 by mad dogs, 62 to 90 per cent, of those bitten by wolves and 60 
 per cent, of those bitten by cats die. In exceptional cases, rabies 
 results from being licked by an infected dog, from kissing an in- 
 fected person or from dissecting an infected body. 
 
 The incubation period varies greatly, averaging 40 days. It varies 
 with (a) the age, being shorter in children than in adults; and (b) 
 the site of the wound. If this is on the face or head, the incubation is 
 very short and the symptoms are very severe. The incubation is 
 longer and the symptoms less intense when the point of infection is on 
 the body, because the clothing tends to clean the virus off the teeth. 
 Symptoms. — Three somewhat arbitrary stages are described. 
 First oe Prodromal Stage. — The scar may become tender or 
 painful; the adjacent glands sometimes swell. Distinct psychical 
 alteration is usual, such as depression, irritability or extreme anxiety. 
 Headache, backache, insomnia, hyperesthesia to light, sound and 
 touch, anorexia and some elevation of the temperature and pulse rate 
 are usual. Sometimes speech is slightly disturbed, the voice is 
 hoarse, the pupils are somewhat dilated and premonitions of dyspha- 
 gia are experienced. This stage lasts from one to two days. 
 
 Second or Excitation Stage. — (a) The excitement is more motor 
 than psychical. The cutaneous and deep reflexes are increased. 
 There is such hyperesthesia that the least sound or light, the slight- 
 est breath of air, or food and water in the throat, induce violent 
 reflex spasms, whence the patient's dread of these excitants (photo- 
 phobia, aerophobia, hydrophobia). Tonic spasms, following attempts 
 at swallowing affect chiefly the muscles of the mouth, the hyoid ele- 
 vators and the laryngeal and respiratory muscles. Even without 
 involvement of the larynx, the respiration is labored, with irregular 
 jerky and often deep or sighing inspirations, during which the 
 shoulders are lifted and the epigastrium is protruded. The spasms 
 may extend to the trunk and limbs, (b) The excitement is also 
 'psychical and is marked at the time of the spasm by restlessness and 
 often late in the course by delirium, horror or even by violent 
 mania. Delirium tremens may be simulated. The mind is usually 
 clear between the spasms. The patient rarely attempts to injure at- 
 tendants, although such an impression may be made by the patient's 
 
HYDROPHOBIA (LYSSA; BABIES). 245 
 
 restlessness, the peculiar growling sounds occasioned by pharyngeal 
 and laryngeal spasm and the " frothing at the mouth/' which is due to 
 inability to swallow the increased flow of saliva. Other less constant 
 symptoms are elevation of temperature from 100° to 103° or 105°; 
 salivation and lachrymation ; thirst; tremors, erections and ejacula- 
 tions; increased pulse rate; scanty, albuminous urine (25 per cent.), 
 often with casts. The excitation stage lasts one and a half to three days. 
 
 Third, Paralytic or Terminal Stage. — This stage is less com- 
 mon in human than in animal rabies. In animals it may be marked 
 from the beginning and the other stages may be lacking or rudimen- 
 tary — the " dumb " rabies as contrasted with the furibund type. 
 The spasms and excitement cease, the pulse becomes fast, small and 
 irregular, the pupils are wide and irregular, sweating is profuse, 
 swallowing becomes impossible and paralyses develop, mono-, para-, 
 or hemiplegic, or of the acute ascending type of Landry. The sphinc- 
 ters are sometimes paralyzed. The patient dies, unconscious, of car- 
 diac collapse, rarely of asphyxia or convulsions. The third stage 
 seldom lasts more than eighteen hours. 
 
 Autopsy Findings. — Pathologists are not unanimous in regard to the 
 specific autopsy findings. Minute hemorrhages and special con- 
 gestion of the medulla and cord mark hydrophobia as they do other 
 convulsive states. Babes' tabic tubercles are aggregations of leuko- 
 cytes around the vessels and nerve cells. The latter may degenerate. 
 Rapid diagnosis of rabies may be made according to von Gehuchten 
 and Nelis, by examination of the sympathetic and cerebro-spinal gan- 
 glia, under the capsules of which are found accumulations of epithe- 
 lioid and lymphoid cells, in animals, only, which died of the disease. 
 The bodies described by Negri and Pavia (1903) in the cell processes 
 may be protozoal parasites or artefacts. 
 
 Course and Prognosis. — In twelve hours to ten days — on the average 
 two to four days — all untreated cases die, 10 per cent, in the first 
 day and 60 per cent, in the first three days. Hogyes' is the only 
 recovery verified by inoculations of the saliva. 
 
 Diagnosis. — The diagnosis is usually made with ease. After bites 
 from supposedly rabid animals, microscopic examination of the plex- 
 iform ganglion of the vagus can be made and also subdural inocula- 
 tions in rabbits, which die in two or three weeks with paralytic 
 symptoms. Tetanus of the cephalic and hydrophobic type is easily 
 distinguished by the invariable trismus. Hysteria (pseudohydro- 
 phobia, lyssophobia) in one bitten by a dog may at first cause sus- 
 picion but rarely any protracted doubt. The initial spasmodic dys- 
 phagia and irritability are not followed by the other symptoms and 
 stages of hydrophobia, and the clinical evolution alone is distinctive. 
 
 Treatment. — Prophylactic. — In Australia, where laws concerning 
 dogs are not only passed but are enforced, hydrophobia is extinct, 
 while in Roumania over 100 cases occur yearly. In human rabies 
 it must be remembered that the saliva is infective. 
 
 Preventive Inoculation. — Pasteur, in 1881, found the rabic virus 
 
246 THE SPECIFIC INFECTIOUS. 
 
 in the nervous tissues. ■" The virus of the street," as Pasteur called 
 it, varies in virulence and subdural inoculations from the brains of 
 rabid dogs, into rabbits, killed them in periods varying from fourteen 
 to twenty days. By inoculating a series of rabbits, the incubation 
 period is progressively shortened to a fixed period of seven days, this 
 virus being called the " fixed virus." Pasteur attenuated this virus 
 by suspending the spinal cord of the rabbit in a clean jar and desic- 
 cating it with caustic potash. Animals were inoculated with virus 
 which had been desiccated for two weeks, then with virus a little 
 stronger > — i. e., with virus desiccated for ten or twelve days, until 
 finally immunization was secured against inoculations which pre- 
 viously would have been fatal. In 1885, human beings bitten by 
 rabid beasts were thus treated by two inoculations daily, for fifteen 
 days and immunization was secured, for the slow rabic incubation 
 gives ample time for treatment. Early treatment secures the best 
 results. Statistics show that the former mortality of 80 per cent, in 
 untreated bites in the head or face has been reduced to 1.25 per cent. ; 
 the mortality of 60 per cent, in those bitten in the hands is reduced 
 to 0.75 per cent. ; the mortality of 80 per centi in those bitten in the 
 covered parts of the arm and trunk, and of 15 per cent, in those 
 bitten in the leg, is reduced to 0.25 per cent. The total mortality has 
 been reduced to 0.5 per cent. As sequences of Pasteur's treatment, 
 neuritis, bulbar or spinal and Landry's paralysis are very rarely 
 found (Babes, 1905). 
 
 2. Primary Wound Treatment. — The wound may be sucked by 
 the victim, but by no other person. It should be washed with strong 
 antiseptics, burned with caustic potash, pure carbolic acid or nitrate 
 of silver, and as soon as possible should be exposed surgically, 
 treated with the live cautery and packed with gauze, so that healing 
 may be delayed for over a month. 
 
 3. Late Treatment. — In developed cases the mortality is 100 per 
 cent., whence curative therapy is out of the question. The treatment 
 of the convulsions is similar to that of tetanus, and nutrition is main- 
 tained by nutritive rectal enemata. Morphine and inhalation of 
 chloroform are better than chloral and bromides and should be given 
 until they show their full physiological effects. Cocainization of the 
 mouth and pharynx may overcome the pharyngeal spasm incident to 
 swallowing milk and water and to medication. Tracheotomy is use- 
 less for the respiratory spasm, which reaches further than the larynx 
 and involves the muscles of the chest and diaphragm ; and besides, it 
 is maintained by many that the larynx itself is not closed. 
 
 ACTINOMYCOSIS. 
 
 Definition. — An infection caused by the actinomyces (literally 
 "ray-fungus") ; it is mostly sporadic in cattle and less frequently so 
 in swine, horses, deer or elephants ; it occurs occasionally in man ; it 
 is rarely endemic or epidemic ; it is marked by chronic inflammation 
 

 ACTINOMYCOSIS. 247 
 
 (a) in the month, head or neck, (b) in the lnngs or (c) in the intes- 
 tines or abdomen ; and it usually runs a chronic course. 
 
 History. — Von Langenbeck (1845), Davaine (1850), Laboulbene 
 and Robin (1853) and Lebert (1857), observed the peculiar sulphur 
 granules in the discharges of pus. Rivolta (1868) and Perroncito 
 (1875) described the fungus, Bollinger (1877) first scientifically 
 established its constant occurrence in cattle and Hartz named it 
 Actinomycosis bovis. J. Israel (1878) first found the parasite in 
 human cases, but to Ponfick (1879) is due the credit of identifying 
 the bovine and the human types. William T. Belfield, of Chicago, 
 first found actinomycosis in this country. The monographs by 
 Ponfick, Israel, Bostroem and Illich are the most important. 
 
 Etiology. — Its distribution varies. Statistics in Berlin, Breslau 
 and Vienna show large numbers of cases. There are more cases in 
 Scotland, Denmark, Italy and Russia than in America, where it is 
 less frequent in the United States than in Canada. Up to 1902, 
 100 cases were observed in America (Erving). Seventy per cent, 
 of the cases occur in males and most of them are in subjects between 
 twenty and forty years of age (33 per cent, between twenty and 
 thirty; 82 per cent, between ten and fifty). The fungus enters the 
 system chiefly by the mouth, in which ragged teeth, abrasions, etc., 
 favor its access. Though almost nothing is known of it outside of the 
 body, it probably exists in the intestines of herbivora. Most cases 
 occur in young cattle at dentition ; 89 per cent, in the last half of the 
 year, when the hair and the grain which are ingested are dry. The 
 drinking water may be the source of infection. 
 
 Bacteriology. — The parasite of actinomycosis is classed as a strepto- 
 thrix and is found in small granules which measure 0.15 to 0.75 milli- 
 meters, are usually ovoid in shape and show a " radiate " form when 
 squeezed under the cover glass. The younger forms are transparent, 
 sago-like, white-gray bodies which may be easily overlooked and 
 the older forms are more yellow. These sulphur-like granules, on 
 minute examination, consist of threads and coccoid bodies which some 
 consider spores. The older yellow forms become clubbed, which is 
 considered a degenerative change. The threads divide and branch. 
 The fungus is therefore phleomorphic. . It stains fairly well with the 
 usual stains and by Gram's method. Cultures are successfully grown 
 in 50 per cent, of the cases, and are best obtained by mixing the 
 granules thoroughly with softened gelatin and bouillon and then 
 by spreading or inoculating them as usual. The colonies are thick, 
 folded, membranous, resistant and at first have a mucoid or crystalline 
 appearance. Experimental inoculations may succeed but infection is 
 very rarely direct either from animals to man or from one person 
 to another. The virulence is, therefore, of low grade. 
 
 Forms. — Incubation averages four weeks. Clinically there are 
 three main forms: (1) That of the head and neck; (2) that of the 
 lower digestive tract ; and (3) that of the respiratory tract. 
 
 1. Head and ^Neck. — The forms localized in the head and neck 
 
248 THE SPECIFIC INFECTIONS. 
 
 constitute 50 per cent, of actinomycosis. The atrium is in the soft 
 tissues of the mouth and throat. Entering these, the fungus is sur- 
 rounded by a massive accumulation of round cells which soon de- 
 generate centrally. The reaction of the connective tissue is marked 
 and the proliferation shows numerous round or polygonal cells with 
 large nuclei, — the epithelioid cells. Giant cells also form. The 
 process is designated by Bostroem as a chronic inflammation, and by 
 Israel as an infective granuloma, resembling the tuberculous, syphil- 
 itic or leprous process. The further destiny of these granulations 
 in the tissue is modified by the resistance of the tissues and by the 
 animal diseased, (a) In man the granulation wall usually melts so 
 that the fungus is surrounded by a mucoid, creamy, cloudy fluid, 
 in which there are oil, fibrin, blood, pigment and actinomycotic 
 cocci and threads ; the " cold " abscess is formed by the fungus itself 
 which, unaided by pyogenic organisms, burrows and reaches the 
 surface by circuitous fistulce; it discharges a thin, puriform secretion 
 like that of scrofulous glands but contains the sulphur-like grains, 
 (b) In cattle and horses the granulation tissue is more effectually 
 obliterative and limitative and hard, board-like or ligneous tumors 
 develop (" lumpy jaw," " wooden tongue"); suppuration and 
 miliary dissemination are less frequent, and calcification is more 
 frequent than in man. In human subjects the infiltration may 
 involve the neck, face, tongue, pharynx, tonsils, larynx and thy- 
 roid gland. In general, the most frequent involvements are inflam- 
 mation of the soft tissues about the jaw, especially those under 
 the lower jaw, submaxillary or submental infiltration and superficial 
 invasion of the bones. In the tongue, actinomycosis may resemble 
 gummata or cancer but in cancer there is more pain and glandu- 
 lar invasion. In some few cases the maxillae may be primarily in- 
 vaded (Israel, Murphy). Sarcoma and caries may be simulated. 
 The process sometimes spreads regionally along the bones to the 
 base of the brain and results in meningitis; along the spine and 
 causes vertebral erosion; and behind the sternum with mediastinal 
 infiltration. 
 
 Symptoms. — These vary with the part invaded. The fever is ir- 
 regular, rarely continuous. Pain and tenderness are not marked, 
 for the process is indolent or chronic. Dysphagia accompanies 
 retropharyngeal involvement, oedema occurs in laryngeal localization 
 and other local interference such as venous obstruction is frequent. 
 The writer observed trismus and severe unilateral trifacial neuralgia 
 from a primary focus at the base of the skull; recovery followed 
 operation. Besides the regional invasion by contiguity, above named 
 hematogenous extension by metastasis may occur in this type as 
 well as in the others to be described later. Unlike tuberculosis ex- 
 tension to the lymphatics, or general dissemination by them, is un- 
 usual. Subacute hsematogenous, pyemic deposits may occur with 
 a very wide distribution. In the head-and-neck form the mortality 
 is 10 per cent. 
 
ACTINOMYCOSIS. 249 
 
 2. Digestive Tract. — The lower digestive tract ranks next in 
 frequency of infection (20 to 30 per cent.). Any tissue between the 
 oesophagus and rectum may be diseased but 50 per cent, of this group 
 occurs in the region of the ileum, caecum and appendix (perityphlitis 
 actinomycotic a) . Of 200 instances of inflamed caecum, 4 per cent, 
 were actinomycotic (Friedrich). Local pain, tenderness, indura- 
 tion and adhesions frequently follow the primary lesion of the intes- 
 tine. In rare instances this lesion is superficial (enteritis actinomy- 
 cotica superficialis, Chiari), but small nodes usually develop in the 
 submucosa, followed by central softening and the development of 
 small ulcers, the undermined edges and uneven bases of which resem- 
 ble tuberculous ulcers. Secondary pyogenic infections are frequent. 
 The ulcers may cicatrize or fuse into larger ulcerations. 
 
 Symptoms. — The signs are often those of appendicitis ; symptoms 
 may be absent, but colic and vomiting are often present and consti- 
 pation is more frequent than diarrhoea. Extension of the process is 
 usually downward; it involves the iliac bone and occasionally the 
 thigh, hip, bladder, ovaries, vagina or rectum; the ray fungus is 
 voided in the urine and faeces; and anteriorly, preperitoneal, supra- 
 pubic or muscular infiltrations occur, with external fistulse. The 
 process then extends backward into the retro-peritoneal cellular tissue, 
 in which it may burrow around the kidneys or even into the chest. 
 These varied localizations may simulate perinephritis, peripsoitis or 
 parametritis. In rare cases, freely movable, and therefore operable 
 tumors may develop. Vascular metastases may occur but suppura- 
 tion in the liver is the most frequent development, and is secondary 
 clinically and pathologically, though it is sometimes apparently 
 primary (forty cases are reported). In 71 per cent, death results 
 from exhaustion, mixed infection or amyloidosis. Diagnosis must 
 be made from the yellow granules or microscopic recognition of the 
 fungus. 
 
 3. Respiratory Tract. — Respiratory involvement is still less fre- 
 quent. It is (a) secondary to extension by contiguity from the neck 
 or abdomen, or to miliary or larger infarcts, or (b) primary in the 
 lungs, which is a less frequent form (14 per cent.). Primary pul- 
 monary actinomycosis is rarely of the superficial type (bronchitis ac- 
 tinomycotica superficialis). Canali described a case of seven years 
 duration. This form may easily escape recognition. A case of actino- 
 mycotic fibrinous 1 bronchitis is reported. More often it is deeper 
 and invades the alveoli. The lower lobes, its usual seat, show a gray 
 hepatization with the ordinary actinomycotic changes. Fusion of the 
 usually small foci may involve large portions of tissue, but demarca- 
 tion is usual in the lung. The clinical picture varies, (i) In some 
 instances cavity formation is obviously present. There are fever of 
 an hectic type, an harassing cough and malnutrition; the sputum is 
 puriform, sometimes foetid and stained with altered blood like rasp- 
 berry jelly and ofteu reveals the actinomycosis rays, (ii) Induration 
 may occur from cicatricial development, (iii) Pleurisy ; (iv) peri- 
 
250 THE SPECIFIC INFECTIONS. 
 
 pleuritis; (v.) pericarditis; or (vi) mediastinitis may be the domi- 
 nant finding. There may be much luxation of the intrathoracic con- 
 tents, and involvement of the heart is characterized by great dyspnoea, 
 dilatation and hydrops. Penetration may occur through the chest 
 wall with characteristic discharge from the sinuses which run along 
 the spine and iliopsoas muscle, or into the abdomen. Hematogenous 
 generalization occurs as in other forms. The examination of the 
 sputum is essential for diagnosis unless fistula? develop. In 25 per 
 cent, of, cases the ray fungus is seen and tuberculosis is excluded by 
 absence of tubercle bacilli and elastic fibers. Otherwise the resemb- 
 lance may be very close or differentiation impossible. The course is 
 usually subchronic (averaging under a year) , less often chronic (two to 
 three years) and very rarely acute. Only 6 recoveries are reported. 
 
 4. Other Localizations. — Other primary localizations are rare ; 
 23 primary skin cases are reported. They may resemble lupus or 
 tubercle. Primary brain lesions are infrequent ; they may simulate 
 brain tumor or cause cortical epilepsy. Primary genito-urinary in- 
 fection is possible, though very few cases are recorded (Stanton). 
 The lachrymal duct or middle ear is very rarely the primary focus. 
 
 Diagnosis. — Similar fungi may cause difficulty in diagnosis, but 
 their classification is -still a mooted question. Eppinger's cladothrix 
 asteroides may cause deposits in the cervical glands or brain, and 
 miliary nodes in the lung. Rosenbach noted a similar growth in 
 erysipeloid, and Vincent in Madura foot, which produces a red pig- 
 ment. The leptothrix. of the mouth is a possible cause of confusion. 
 
 Treatment. — 1. Prophylaxis. — Besides general measures employed 
 in any contagion, care is necessary in regard to the holding of straws 
 in the mouth or picking the teeth with them. Thorough cooking of 
 cereals before eating is essential. 
 
 2. Surgical Extirpation. — This is indicated, if possible; or a 
 sharp spoon should be used to clean accessible foci and fistula?, which 
 should then be packed with iodoform or sublimate gauze. Injections 
 of bichloride of mercury ( T V to 1 per cent.) are used especially by 
 Illich and Hochenegg. Recurrence is frequent in abdominal types. 
 
 3. Potassium Iodide. — In cases wholly inaccessible to the knife, 
 potassium iodide is excellent or even specific, according to some 
 writers. It is not parasiticidal, but softens the tissues, . prepares 
 operable cases for surgical measures, inhibits growth and minimizes 
 metastasis ; 53 per cent, of bovine cases recover under its use. Thom- 
 assen and ISTetter use six grams daily for a month and then decrease 
 the dosage. Rydygier injects large quantities of a 1 per cent, solu- 
 tion into the affected tissues. 
 
 4. Tuberculin iNJECTioisrs.-^These were advantageous when 
 used by Billroth, Kahler and Socin. Bevan has seen benefit result 
 from the internal use of copper sulphate, J to 1 grain. 
 
&ONO&RHCEAL INFECTION. 251 
 
 GONORRHEAL INFECTION. 
 
 Lightly spoken of as " the badge of virility," gonorrhoea is often 
 untreated and neglected. It frequently becomes chronic, and in its 
 so-called latent form may be conveyed after marriage to the wife, on 
 whom it usually entails suffering, frequently sterility, and some- 
 times permanent invalidism. Its other dangers are: 
 
 I. Regional Invasion. — The regional invasion of the genital tracts 
 (a) in the male, of the prostate, seminal vesicles and. testes; (b) 
 in the female, of the vagina, cervix, uterus, tubes, ovaries and peri- 
 toneum; in institutions, repeated epidemics of vaginitis in children 
 have occurred; (c) in both sexes, of the rectum, bladder, pelvis and 
 kidneys, in which extension, mixed infection is an important factor. 
 
 II. Gonococcal Septicopyemia. — Hematogenous generalization has 
 already been discussed under septic infections. The fever is toxemic 
 and septicemic. The fever is intermittent and is often marked by 
 great variations. Injection of sterilized cultures produces violent 
 reaction, which hitherto has baffled attempts at animal immunization. 
 Among the gonorrheal invasions of tissues other than the urethra, 
 Wertheim first found the organism in the bladder wall. The gonococ- 
 cus has been found in the blood 29 times (first by Thayer and 
 Blumer, 1895) ; in the myocardium (Councilman) ; in the pleura 
 (15 cases collected by Lemoine and Gallis, 1905) ; and in the joints 
 (v. i.), kidneys, spleen, muscular abscesses, lymph-glands and skin. 
 It has also been found in meningo-myelitic foci ; in myositis ( 7 cases 
 collected by Harris and Haskell, 1904) ; in arteritis and phlebitis (25 
 cases collected by Heller, 1904 ; the author saw one in 1905 with Dr. 
 Cuthbertson) ; in felons, osteomyelitis and periostitis. 49 cases of 
 ulcerative gonorrheal endocarditis were collected by Kulbs in 1904. 
 Septicopyemic lesions may be due to Neisser's diplococcus alone, or 
 to mixed infections. 
 
 Most cases of gonorrhoea! arthritis must be regarded as a form of 
 mild septicemia. Occasionally it is part of a severe septicopyemia. 
 It was described by Selle and Swediaur in 1781, but first clearly by 
 Brande, 1854; the gonococcus was first found by Petrone (1883) and 
 Kammerer (1884) and cultivated by Hoch (1893). According to 
 Damasch it develops in 2 to 3 per cent, of gonorrheal infections. 
 Konig asserts that it is the most common disease of the joints. 
 Eighty per cent, show an acute urethritis ; in the balance the ure- 
 thritis has subsided or become chronic. It has followed experimental 
 gonorrhea. In 18 cases reported by Lucas, the infection was pri- 
 marily gonorrheal conjunctivitis, especially in infantile cases ; the 
 coccus reaches the blood by way of the nose. ISTorthrup's series of 
 252 cases of gonorrheal arthritis gives 91 per cent, in males ; Brun 
 and Bennecke find 62 per cent, in women, which is contrary to com- 
 mon experience. About 50 per cent, of the cases occur between 
 twenty and fifty years of age. Too active treatment and sexual in- 
 dulgence during the florid stage of gonorrhea are held to be pre- 
 disposing causes. 
 
252 TEE SPECIFIC INFECTIONS. 
 
 Symptoms. — The symptoms are extremely variable. Fever rarely 
 exceeds 102°. The joints alone may be involved, or there may 
 be more severe evidences of blood invasion, such as endocarditis. 
 While the synovial membrane is most often inflamed, gonorrheal 
 " rheumatism " is more than synovitis. The accessory bursse, con- 
 tiguous tendon sheaths and the extracapsular structures are often 
 involved, whence the name of gonorrhoeal arthritis. It is often held 
 that it affects one joint (monarticular) or at least few joints (oligar- 
 ticular). Though fewer joints are usually involved than in genuine 
 rheumatism, in Jullien's collection the affection was polyarticular 
 in 60 per cent. ; in Northrup's series more than one joint was affected 
 in 78 per cent, of the cases, and three or more joints in 69 per cent. ; 
 and in Gerhardt's series two to nine or more joints were involved in 
 87 per cent., and one joint only in 13 per cent. Gonorrhoeal arthritis 
 frequently involves joints which are usually unaffected in acute artic- 
 ular rheumatism, e. g., the sacro-iliac synchondrosis, sternoclavicular, 
 temporo-maxillary and intervertebral joints. The knee is affected 
 in 70 per cent., the ankle in 27 per cent., fingers and toes in 19 per 
 cent., hip in 13 per cent., wrist in 12 per cent., shoulder in 10 
 per cent, and the elbow in 9 per cent., of the cases. Within the 
 joint a greenish serofibrin exudes, and without the joint there is 
 oedema and infiltration. Suppuration is not frequent but may occur 
 with or without coincident pyogenic infection, especially in the joints 
 and tendons of the hand. The gonococci are found with variable 
 frequency, the highest reported percentage being 75. 
 
 Konig's pathological classification includes (1) simple hydrops of 
 the joint; (2) catarrhal or serofibrinous hydrops; (3) py arthrosis, 
 and (4) gonorrhoeal phlegmon, affecting the soft parts. A clinical 
 classification may be made as follows: (1) Arthritic form, pain with 
 exudation; (2) acute or subacute polyarthritis, by itself, or with 
 septicaemia; (3) polytendosynovitis and polybursitis, often with peri- 
 ostitis, — this is the periarthritis form; (4) acute monarticular form, 
 with local reaction, sometimes with suppuration: and (5) the chronic 
 monarticular hydrarthrosis especially of the knee, a far less frequent 
 form. We might add (6) the forms in which simple arthralgia is 
 present or the process localizes in the heel. 
 
 Course. — The course is essentially chronic and is sometimes relaps- 
 ing, or marked by complications ; iritis is fairly frequent ; atrophy in 
 the contiguous muscles may occur as in rheumatism; ankylosis may 
 result, which is far oftener plastic than osseous. In exceptional in- 
 stances, sciatica, permanent arthritic changes resembling arthritis 
 deformans (q. v.), exhaustion psychoses or multiple neuritis develop. 
 
 Treatment. — Eecovery is a matter of time and nature, rather than 
 of therapy. The salicylates are almost wholly inert and the iodides 
 highly unsatisfactory. In the acute stage, immobilization by plaster 
 casts or splints, and in the chronic stage, blisters, Pacquelin^ cautery 
 massage, passive movements and extension, to overcome residual 
 exudation and contractures, are useful. Some cases are helped by 
 
SYPHILIS. 253 
 
 Roentgen rays and by superheated air (See Arthritis Deformans). 
 Injections into the joint of 1 per cent, formalin are advantageous. 
 Bier's passive congestion is frequently of great benefit. Surgical in- 
 cision and simple irrigation are indicated after a reasonable lapse 
 of time and after the failure of expectant treatment. In some in- 
 tractable cases, however, there is no fluid to drain. The vaccine 
 therapy promises results. 
 
 SYPHILIS (POX, VARIOLA MAGNA, LUES VENEREA). 
 
 Syphilis is evidently an ancient disease as is indicated by probably 
 syphilitic bones belonging to the stone age found in Japan, ^usi 
 King described syphilis in China 2600 B.C. The first clear outbreak 
 occurred in 1494 among the troops of Charles VIII, who was then 
 investing Naples. A full account of this disease will be given because 
 of its colossal importance. 
 
 Definition. — A specific chronic infection, found in man only, either 
 hereditary or acquired by inoculation, in the seat of which a primary 
 lesion, hard chancre, develops. This is followed in two or three 
 months by secondary lesions in the skin and mucosae. Later, after 
 months or years, tertiary lesions or gummata develop in the viscera, 
 bones and skin, and these are finally followed in some instances by 
 meta- or parasyphilitic manifestations, as tabes dorsalis, dementia 
 and aneurysm. This division of Ricord is most convenient but does 
 not invariably hold, — e. g., in hereditary syphilis and sometimes in 
 the malignant, acquired variety, where the stages overlap. Virchow 
 finds a very close histological resemblance between the primary, 
 secondary and tertiary lesions. 
 
 Stages According to Ricord. — The Primary Stage. — (1) Incuba- 
 tion lasts until the chancre appears, when syphilis is already a general 
 disease; (2) the chancre develops, the lymph-vessels and adjacent 
 glands enlarge, and there is a period of latency, sometimes called the 
 " second incubation." 
 
 The Secondary Stage. — (1) Symptoms prodromal to the erup- 
 tion, as fever or anaemia, develop and then (2) the eruption appears 
 on the skin and mucosae, with headache, " rheumatism," iritis, or 
 sometimes jaundice, albuminuria and splenic tumor. 
 
 The Tertiary Stage. — This may follow very closely upon the 
 secondaries or appear with them (syphilis maligna), but usually is 
 not manifest for three or four years (even fifty or sixty). Tumor- 
 like gummata occur in the skin and viscera, especially in the liver, 
 scrotum, brain and cord. Unlike secondary manifestations, they are 
 asymmetrical, persistent, recurrent, less contagious, and respond to 
 different therapeutic agents. 
 
 The Quaternary or Parasyphieitic Stage of Fournier, Sig- 
 mund, Lancereaux and Baiimler is not included in Ricord's division. 
 
 I. Acquired Syphilis — Etiology.. — 1. Transmission by Sexual 
 Intercourse. — This causes the great majority of cases, but the term 
 
254 TEE SPECIFIC INFECTIONS. 
 
 lues venerea is often incorrect and unjust since syphilis may occur 
 in the innocent (syphilis insontium) ; in certain districts m Enssia 
 70 per cent, of syphilis is innocent. In 1905 Schandinn and Hoff- 
 mann described a spirochete pallida, so named because of the diffi- 
 culty in staining it : It is long, delicate, thread-like, refractile, actively 
 motile, pointed at its ends and twisted like a corkscrew ; it measures 
 4 to 20/* in length; it lies free and not in the cells; it resembles the 
 spirochete of relapsing fever but is a flagellated protozoon. _ It is 
 present in all cases, stages, types and tissues, and probably is the 
 cause of syphilis. It is found in anthropoid apes which were suc- 
 cessfully inoculated by Metschnikoff and Mcolle. With Giemsa's 
 stain 1 the spirochetes stain a delicate violet and the leucocyte nuclei 
 deep red. The spirochete refrigens, found in the mouth, in ulcers, 
 smegma and venereal warts, is differentiated by its being more 
 quickly stained, its greater size and, particularly, by its broader and 
 more wave-like undulations. (See Plate VI.) 
 
 The sound skin and mucose resist infection, and hence a raw sur- 
 face, erosion, wound or hyperemia is necessary for infection. Syph- 
 ilis not only has a certain choice of place in its inoculation, but 
 persists with peculiar obstinacy in certain localities, notably in the 
 genitalia, under the breasts, in the axilla, in the navel, between the 
 toes, in the angles of the mouth, on the tongue, iris, palate or tonsils, 
 because of irritation by secretions, pressure by clothing, trauma or 
 irritation from smoking, etc. These foci are of great moment in the 
 awakening or reproduction of the disease. Syphilis is sometimes 
 called a disease of cities ; though more common in cities, syphilis very 
 frequently escapes recognition in the country. 
 
 2. Accidental Ixfectiox. — Accidental infection occurs in sur- 
 gical or obstetrical practice, in skin-grafting, by postmortem infection 
 (two cases of personal observation), in ritual circumcision, in nurs- 
 ing, vaccination, kissing, from use of pipes, in shaving, by scratches, 
 from instruments used in glass-blowing, or from catheters. 
 
 Symptoms. — 1. Primary Stage. — After an incubation of two to 
 three weeks, the initial lesion occurs (the ulcus durum, Hunterian 
 chancre or initial sclerosis). Multiple lesions occur in 25 per cent. 
 (Fournier records 26 simultaneous chancres.) The induration is 
 usually oval, is always sharply localized, of variable or even car- 
 tilaginous hardness, freely movable, and usually papular and copper- 
 colored. Hardness is the most constant characteristic of the chancre ; 
 it may last a long time, and heals only when the hardness disap- 
 
 1 Azure II (azure plus methylene blue aa) 3.0 
 
 Eosin (B. A.) 8 
 
 Glycerin (U. S. P.) 25o!o 
 
 Methyl alcohol (Kahlbaum I) 250.0 
 
 It is prepared by grinding up the dyes in the absolute alcohol and then adding 
 the glycerin. The blood films are fixed for a minute in absolute methyl alcohol and 
 then stained for five minutes in a mixture of 14 drops of the dye to 10 c.c. of dis- 
 tilled water, which is freshly prepared; a trace of sodium carbonate may be added 
 to the water to intensify the basic colors. After washing in water the films are 
 blotted. 
 
PLATE VI 
 
 Kb 
 
 r^ 
 
 \ 
 
 Spirochetes of Syphilis (Simon.) 
 
 a, S. refringens; b, S. pallida. (Stained with Giemsa's stain.) 
 
SYPHILIS. 255 
 
 pears. It cannot be diagnosticated before the sixteenth day, and is 
 most characteristic in the third or fourth week, when the adjacent 
 glands enlarge. Retrogressive changes as ulceration or necrosis are 
 frequent. The ulcer varies in size, is round, elliptical, slit-like or 
 irregular ; it is hard, painless, with even surface, seldom with eleva- 
 tions or excavations; it has no areola, but a smooth, glistening base 
 with thin secretion. On the skin the chancre may appear as an 
 erosion. Contact ulcers around the corona are hard. The sclerosis 
 may resemble herpes, but there is seldom itching. An herpetiform 
 chancre becomes indurated in about sixteen days, while simple herpes 
 lasts but three or four days ; herpes may be the atrium for syphilitic 
 inoculation. If the sclerosis occur on a mucous surface there is little 
 elevation; maceration and bleeding readily occur, (a) The genital 
 sclerosis in men occurs on the urethral orifice ; in the fossa navicularis, 
 possibly producing some stenosis or ulceration, with a thin, " meat 
 juice" secretion; on the glans, often as an erosion, usually not ex- 
 tensive, and difficult to diagnosticate because of the hardness of the 
 glans; on the corona, circular and hard; on the (broken) frenulum or 
 in the sulcus coronarius, usually with ulceration and much indura- 
 tion, giving the " split pea " appearance, one-half lying on the glans 
 and the other' half on the prepuce ; on the prepuce, often with phi- 
 mosis; or on the dorsum, (b) The genital sclerosis in women occurs 
 mostly on the labia ; on the labia majora, as large, readily ulcerating 
 contact ulcers with inflammatory oedema; on the labia minora as 
 small, hard and circumscribed nodes ; on the prepuce as hard fissures ; 
 in the urethral orifice with widening and induration which is felt 
 from the vagina ; on the posterior commissure, as erosions, which 
 are especially prone to infect during coitus ; on the hymen relics, as 
 fissures, or large hard ulcers reaching into the vagina ; rarely in the 
 vagina, because of its paucity in glands and its thick epithelium, 
 although chancre may develop on gonorrhoeal erosions ; in the vaginal 
 portion of the cervix, usually in women who have been pregnant, in 
 which location it produces chancres on the male meatus and is diffi- 
 cult to differentiate from simple and gonorrhoeal erosions, (c) The 
 perigenital sclerosis occurs on the scrotum, mons veneris or inner 
 thigh, (d) Extragenital scleroses (3 to 6 per cent, of chancres) are 
 especially dangerous in midwives, physicians and wet-nurses. They 
 occur on the scalp, conjunctiva, nose, eyelids, lips, tongue and tonsils 
 (from sexual perversion), cheeks, fingers, arms and mammae. In 
 rare cases of accidental syphilis the chancre may not be found. 
 Among 9,058 extragenital chancres, 1,863 occurred from vaccina- 
 tion, 745 from cupping or phlebotomy, 179 from circumcision and 
 82 from tattooing (Bulkley). Fenger demonstrated that sweat and 
 tears are infectious, if enough is inoculated. 
 
 The primary sclerosis is always inoculated from an individual with 
 a chancre or secondary syphilis, and, in very rare cases, from tertiary 
 syphilis; Williams (1906) reports 41 infections from gummata,. 
 When the sclerosis is recognized, the blood is already infected. 
 
256 
 
 THE SPECIFIC IXFECII 
 
 Histology of the Sclerosis. — The round cells increase the vessel- 
 walls ten- or nventyiold. and the vessel lumen is narrowed from ex- 
 ternal pressure and endothelial proliferation, even to obliteration, 
 when re" _ ssive ulceration ensues. The lymph vessels and glands 
 involved later. Epithelioid and giant cells, and proliferation of 
 the connective tissue in and about thr — -. are noted. The spiro- 
 cha?te pallida is invariably present. 
 
 ibsk. — I _ —ion usually occurs and induration disappears 
 in thirty to nine ~ generally with scar formation. In excep- 
 
 tional cases I the sclerosis lasts longer, especially on the corona or 
 prepuce, and relics may be found after years (even 50) due to per- 
 manent vascular injury: i acute or (3) phagedenic inflammation 
 sometimes intervenes. Chancre and chancroid are separate affecti 
 according to the dualistic doctrine developed by Bassereau and I 
 revenue in 1852 and Rieord in 1 S 60. - 
 
 Diagnosis (According to Nkumawtn). 
 
 Chancre or Sct.kr.: b : - — — Vskess&l Viz?. or Chancroid. 
 
 Incubation; tiro to three weeks. 
 
 Form; indurated erosion, ulcer, nodule. 
 
 Xumber; single in 75 per cent., rarely 
 sueeessivery inoculated. 
 
 Depth; erosion is superficial, flat, with 
 little elevation, rarely deep excava- 
 tions. 
 
 Pustule. iljtT. etc, without induration. 
 
 Often multiple at beginning of succes- 
 sively inoculated. 
 
 Through entire cutis or mucosa; 
 i£ punehed-out " appearance. 
 
 Border; gradual descent. 
 
 Abrupt, sharp, indented, undermined. 
 
 Surface ; red, livid, sometimes pseudo- White, gray, 
 membranous, thick, yellow-white cov- 
 ering or crusts. 
 
 Induration ; marked, cartilaginous, 
 sharply outlined, movable,, sometimes 
 thin, lasting weeks, perhaps months. 
 
 ion; scanty, serous, autoinoeula- 
 tion difficult; spirochetes. 
 
 Pain; little. 
 
 Destruction; rarely phagedenic (and 
 then circumscribed) . 
 
 Be-infection ; extremely rare. 
 
 Lymph-vessels; inflamed freque^Tlj. 
 hard and wide. 
 
 Xo basal induration; not sharply out- 
 lined ; merges gradually into adjacent 
 
 ns.5Y.-r : ; L . " .V:.r ;-.::: ::.. 
 
 Eich, purulent, autoinoeulation 
 
 Much. 
 
 More often phagedenic; diffuse. 
 
 ti:. 
 Painful; cylindrical. 
 
 Lymph-glands; regional, indolent, swell- Often absent or acute inflammatory 
 
 ing hard, painless, movable; rarely swelling; often pus formation, eapa- 
 
 pus formation. ble of automoculation. 
 
 Xature of the disease; constitutional A local infection, or involving at most 
 
 ptoms follow in eight weeks. contiguous lymph-glands. 
 
SYPHILIS. 257 
 
 Mixed infection may occur, whence the now abandoned idea of the 
 unity of all venereal ulcers. The real practical lesson from this doc- 
 trine is diagnostic rest for some time in doubtful cases. 
 
 Lymphangitis syphilitica is marked in 70 per cent, of cases. The 
 lymph vessels may become as thick as a lead pencil, bulging at the site 
 of the valves (" bubonulus ") : they become hard, are usually painless. 
 reddened, and are narrowed in their lumen from endothelial prolifer- 
 ation and from pressure inward of their infiltrated walls. The 
 inflammation is best seen on the dorsum penis, extending toward the 
 symphysis pubis ; it is usually not over 6 to S centimeters in length, 
 but may reach the glands. Resorption occurs in three to eight 
 months. Lymphangitic cedema is particularly suggestive in women 
 when the initial lesion cannot be found. Local lymphadenitis (indo- 
 lent buboes ) is present in 97.3 per cent, of cases, and appears in 
 three weeks if 'here be much, or in four weeks if little secretion from 
 the chancre: and in six weeks reaches the contralateral inguinal, the 
 iliac and lumbar groups, and in seven weeks, the cubital glands. Just 
 before the secondary eruption, the other glands are involved. 
 
 2. Secoxdaby Stage. — Secondary symptoms usually appear 
 toward the end of the eighth week (sixth to twelfth week), (a It, - 
 era 1 Infection occurs. Fever is spoken of by the oldest writers, but is 
 less frequent at the present time 20 _ : 33 per cent/). It is far less 
 common in primary or tertiary than in secondary syphilis (" fever of 
 syphilitic invasion"). It often just precedes the eruption, and 
 mostly in the pustular variety. It may be continuous, remittent or 
 intermittent. Solution by crisis has been observed by Gtinz. Four- 
 nier described a tvphoidal type. Janeway reports instances resem- 
 bling Tuberculosis ptilmonalis. It may occur with chills, suggesting 
 malaria. Other toxemic symptoms are anosmia, headache, nocturnal 
 hone-aches, vasomotor symptoms, psychical depression, vertigo, neu- 
 ralgias, palpitation, night-sweats, polydipsia, digestive disorders. 
 synoviTis. increased reflexes and ic-Terus : swollen Tonsils, spleen or 
 liver, and albuminuria may also occur as prodromata to The exanThem. 
 
 (&) The exanthem is polymorphous, sharply marked, frequently 
 grouped in a circular arrangement and is without pain or itching : it 
 is highly infective, is not reddish as in other eruptions but copper- 
 colored, a fact recognized in the fifth century: it appears where other 
 eruptions are rare, as on the forehead or nasolabial fold: crusts may 
 develop on an infiltrated basis. It is recurrent and responds to anti- 
 syphilitic treatment. The most frequent form is the 'macule or 
 roseola, next the papular syphilide. and then forms resembling pus- 
 tules, varicella, pemphigus or impetigo. In the folds or damp parr- 
 ot* the skin the so-called mucous patches appear, as at the angles of 
 the mouth, the groin or perineum. 
 
 (c) The enanthem on the mucous membranes is observed on the 
 tongue, lips and cheeks mueoi s patches), and is often accompanied 
 by pharyngitis 
 
 (d) The lymphatic enlargement becomes general, although it may 
 
258 THE SPECIFIC INFECTIONS. 
 
 remain localized. Syphilitic " rheumatism," bone-aches, iritis, etc., 
 are treated under special symptomatology. 
 
 Late Secondary Symptoms occurred after two to thirty years in 5.8 
 per cent, of Founder's 19,000 cases; they are best designated " re- 
 current syphilis." 
 
 3. The Tertiary Stage. — This is characterized by the gumma 
 which occurs in many tissues. It is not known what determines ter- 
 tiary development; in 2,396 tertiary lesions, 78 per cent, of the cases 
 were not treated at all, 19 per cent, moderately and only 3 per cent, 
 well treated ( Fournier ) . The specific symptomatology of gumma will 
 be described below. The gumma may be microscopic, or an inch or 
 more in diameter. On section it is usually hard, grayish-yellow, 
 homogeneous, centrally caseous and peripherally fibrous. Baiimler 
 first remarked that tertiary syphilis, particularly of the viscera, may 
 be attended by fever. In 20 to 40 per cent, of cases of tertiary 
 syphilis, no evidence of earlier lesions can be found, which, the au- 
 thor believes, explains many instances of the so-called mendacia 
 syphilitica. 
 
 Special Symptomatology of Syphilis. — 1. The Skin. — The macular 
 (roseolous) syphilide is the most frequent secondary eruption. It is 
 hypersemic at first and later the spots show some infiltration; it de- 
 velops rapidly, lasts eight to ten days, varies in size from that of a 
 lentil to that of a dime, is at first red, then livid, and pressure leaves 
 it yellow. It comes out more clearly by chilling the skin, and some- 
 times after administration of mercury. It occurs mostly on the 
 trunk. The face, hands and feet are usually free except in severe 
 cases. It is symmetrical, appears mostly on the flexor surfaces, is 
 circumscribed, recurs more frequently than does any other variety 
 and is prognostically favorable. It is recognized with difficulty when 
 sweat or other secretions cause maceration. On the scalp focal alo- 
 pecia results. Annular or gyrate forms may occur. Some pigmen- 
 tation is left. 
 
 The papular syphilide presents various forms: (a) The small mil- 
 iary papules (lichen syphiliticus), usually develops on the forehead, 
 chin, nose, shoulders, buttocks, back and flexor surfaces of the ex- 
 tremities and usually corresponds to the glands of the skin. Irregu- 
 larly distributed, it may appear in rings or circles. At first red, it 
 rapidly becomes brownish-red. Fine scales or crusts may form, 
 which, on falling, leave a lacquered appearance. Recurrences are 
 infrequent. It must be differentiated from psoriasis, the develop- 
 ment of which on the scalp, ear and extensor surfaces is not observed 
 in syphilis, where the scales are smaller, thinner and less glistening ; 
 the hemorrhage on their removal is parenchymatous and not punc- 
 tate ; the glands are swollen ; and the hair thinned. On the palms of 
 the hands and soles of the feet differentiation may be difficult, but in 
 syphilis the centre of the papule is likely to be sunken, (b) The 
 large papular syphilide is often associated with fever, constitutional 
 disturbance or synovitis, and may occur on all parts of the body, as 
 
SYPHILIS. 259 
 
 the corona veneris on the upper forehead, around the nose or in the 
 furrows of the chin and neck. Though infrequent on the palm, it is 
 often seen on the dorsum of the hand. This variety occurs most 
 frequently at the junction of the skin and mucosa and its polymorph- 
 ism is pronounced, as psoriasis palmaris, rhagades, onychia or 
 verrucose forms, (c) The condyloma latum or mucous patch is the 
 papule altered by secretions or excretions, and is found about the 
 genito-anal regions, axillae, etc. It is the most important syphilide 
 in the propagation of syphilis by its occurrence on the lips, breast 
 and genitalia; it is flat, elevated, dirty, ill-smelling, and secretes a 
 highly infective secretion, (d) The pustular syphilide includes the 
 acne form, the varioloid, varicelliform and impetiginous forms; a 
 brown pigmented scar usually results. 
 
 The broad general characters of secondary eruptions are : (i) Their 
 circular form; (ii) tendency to circular groupings; (iii) slow evolu- 
 tion; (iv) symmetry of distribution; (v) polymorphism of the erup- 
 tion or of its successive crops; (vi) induration; (vii) copper-color; 
 (viii) diffuseness; and (ix) their usual resolution. 
 
 Gummata of the skin are asymmetrically disposed; are cutaneous 
 or subcutaneous, involving deeper structures ; are non-infective com- 
 pared with the secondary eruptions ; are prone to develop at the site 
 of secondary involvements; occur in the skin more than in all other 
 localities combined ; follow incomplete mercurial treatment ; are pro- 
 moted by vicious habits and constitutional diseases ; and are seen in 
 6 to 13 per cent, of cases, most frequently in the third year after in- 
 fection. Small gummata may resorb by fatty degeneration, but the 
 larger ones caseate, ulcerate, suffer secondary infection and leave a 
 kidney-shaped scar with deformation. Gummata are differentiated 
 from malignant ulcerations by the absence of adenopathy, by their slow 
 growth, painlessness and multiplicity, and by the results of therapy. 
 In gumma, ulceration is more rapid than in lupus ; it is deeper, less 
 sharply marked, redder and less symmetrical; recurrence after cica- 
 trization is less frequent ; the scars are less flat and smooth, and the 
 bacteriological findings of lupus are absent. 
 
 Leukoderma syphiliticum is observed in recent, but rarely in late 
 syphilis — e. g. } after macular or lenticular syphilides — as white spots 
 with peripheral brown pigmentation, appearing mostly on the face 
 and neck. Leukoderma usually disappears in from two to twelve 
 years, is rarely seen in either extreme of life and occurs in 4 per 
 cent, of syphilitic men and 45 per cent, of syphilitic women (Neisser ) . 
 
 The hair falls out except from the crown of the head, most fre- 
 quently during the secondary stage, and is proportionate to the 
 intensity of the eruption. It is greater in poorly nourished cases, and 
 its regrowth is usually good. In the bald areas, there are no broken 
 hairs. 
 
 The nails are sometimes affected. Onychia syphilitica occurs par- 
 ticularly in women, in whom it may be the only secondary symptom. 
 The nails may hypertrophy, fall out or fail to grow. Peri- or paro- 
 
260 TEE SPECIFIC INFECTIONS. 
 
 nychia rarely occurs without other specific signs and rarely causes 
 pain, ulceration or suppuration. 
 
 2. Lymph Glaxds. — The inguinal glands are first enlarged be- 
 cause they are nearest to the most common genital chancre. Some 
 glands are more involved than others, yet adenopathy of any par- 
 ticular group, as the epitrochlear, is less pathognomonic than sug- 
 gestive, of secondary syphilis. The posterior cervical glands are 
 involved more than the anterior. Xext in frequency are the axillary, 
 epitrochlear and those along the pectoralis. It is well to recall 
 Dietrich's observation that 99 per cent, of healthy individuals have 
 palpable glands. Inflammation and pain are rare, and suppuration 
 occurs in but 3 per cent. ; these are due to secondary infection. In 
 extragenital sclerosis, other glands are enlarged first, — e. g., the an- 
 terior cervical, from chancre of the lip. The glands are freely mov- 
 able : may remain swollen for years ; and are not usually larger than 
 a hazelnut, but occasionally become massive from trauma, scrofula 
 or gumma formation, and then may resemble Hodgkin's disease. 
 
 3. Gastko-ixtestinax Teact. — On mucous membranes the erup- 
 tion (enanthem) is not necessarily characteristic, is less frequent and 
 is less polymorphous than the exanthem, with which it occurs syn- 
 chronously. 
 
 Mouth.. — This is more involved than any other part except the skin, 
 and may precede the skin eruption. Recurrence is very frequent. 
 (a) Erythema may occur as diffuse or circumscribed dark red mac- 
 ula?, especially on the cheek, pharynx, uvula, palate and swollen ton- 
 sils — the acute syphilitic angina; it ceases sharply at the border of 
 the soft and hard palate, and it often escapes recognition. Desquama- 
 tion, infiltration or fissures, with a slightly granulated and vesicular 
 appearance, may develop. Erosions may last long in users of tobacco 
 and of alcohol. 
 
 (b) Mucous patches, which are papules modified by moisture, de- 
 velop with the exanthem, and mostly on the tonsils, cheeks and lips. 
 They are single or multiple, disseminated, elliptical or irregular, flat 
 or slightly elevated patches which are circumscribed and of variable 
 color, white, milky or red. On the lips they may measure 6 to 17 
 millimeters. The course is usually chronic; the patches swell, be- 
 come granular, ecchymotic and often ulcerated. On the tonsils thev 
 may simulate diphtheritic patches, and in smokers a cure cannot be 
 effected until the habit is stopped. Cauterization leaves scars. Thev 
 are the most important syphil.ide because so highly contagious. 
 
 (c) Chronic angina is of a light red, granular appearance, and is 
 accompanied by hyperemia, some oedema and erosion, a o Ta v coating 
 on the swollen tonsils, and the general appearance of pharyngitis 
 granulosa. 
 
 (d) Pachydermia, ichthyosis and leidcoplalia occur on the mucosa 
 of the cheeks, and on the angles of the mouth, lips and tongue, and 
 are not always syphilitic. They are swellings with fissures, are gray 
 in color, irregular, they vary in shape and size and are thick 
 
SYPHILIS. 261 
 
 and scar-like. They occur especially in users of tobacco and alcohol. 
 They may become carcinomatous. Leukoplakia in tobacco users 
 usually occurs on the tongue, or under the lip or palate, while 
 in syphilis it is mostly on the cheek. Psoriasis linguae is usually 
 central, with round or elliptical, bright red, flat spots, with thread- 
 like coating; fissures are frequent on the edges of the tongue and 
 result especially from the use of tobacco and from bad teeth. 
 
 (e) Gummata of the oral cavity are tertiary. They appear on 
 the lips, when the face is involved. They are rare and without 
 glandular swelling, and occur chiefly in smokers. Gummata of 
 the tongue are most frequent, occurring (a) as a diffuse glossitis or 
 infiltration with a later cirrhotic shrinkage or (b) as circumscribed 
 gummata, with nodes or ulceration, and without pain or glandular 
 involvement. Gummata of the palate or pharynx are mostly multi- 
 ple, and ulceration may reach the nose, spine, base of the brain, etc. 
 They are dangerous because they are frequently diffuse, deep or 
 phagedenic; they destroy the uvula, produce adhesions, ob] iterate the 
 posterior nares or Eustachian tube, stenose the pharynx or draw 
 the tongue back, thus stenosing the respiratory passage. In the 
 tonsils they are very deep and may erode the carotid or palatine 
 artery. Differentiation is required from tuberculosis and epithe- 
 lioma, in which the glands are usually but not always involved. The 
 diagnosis ex juvantibus is important. 
 
 (Esophagus. — Strictures result from deep gummata, ulcerations 
 in the larynx, or extension from the bronchial glands. Differentia- 
 tion is required from tumors of the mediastinum, aneurysm, carci- 
 noma, round ulcer and nervous dysphagia. Diverticula may result. 
 
 Stomach. — (a) Acute catarrhal gastritis in the secondary stage 
 is usually toxsemic, — rarely organic. (b) Chronic gastritis is more 
 common, in part explaining the anaemia and malnutrition ; it differs 
 from the vulgar gastritis only in the influence of treatment. Amy- 
 loid and glandular wasting are infrequent, (c) Ulcers of the stom- 
 ach may result from syphilitic arteritis; Rosanow and Lafleur de- 
 scribe convincing instances. Elexner has collected 16 definite cases. 
 (d) Gummata are rare. They begin in the submucosa, are usually 
 multiple, leave radiate scars and differ from the ordinary round 
 ulcer in that they are not funnel-shaped, have undermined edges and 
 are broader at the base, (c) Hemorrhages from the stomach are most 
 rare and Hay em's case is almost unique. They may also result 
 from cardiac, splenic, hepatic or renal lesions. 
 
 Intestines. — Except for the rectal involvement, little is known of 
 intestinal syphilis in the adult, (a) Acute catarrhal enteritis may 
 induce icterus; it resists treatment other than specific, (b) Chronic 
 enteritis in the syphilitic new-born, is manifested by the viscid 
 meconium and disappears with antisyphilitic treatment. Obstinate 
 diarrhoea and stenosis may follow, (c) Ulcerations may result from 
 enteritis in secondary syphilis, from gummatous and diphtheroid 
 changes in the tertiary, and from amyloid disease in the tertiary or 
 
262 THE SPECIFIC INFECTIONS. 
 
 quaternary stages. Meschede collected 54 cases of ulcer in the 
 small intestines. They occur around the axis of the intestine and 
 are characterized by productive inflammation which prevents ^ per- 
 foration but leads to stenosis, (d) Intestinal amyloid disease is as- 
 sociated with amyloid liver, spleen and kidneys. The gut is pale, 
 smooth, waxy, thick and rigid and there are obstinate diarrhoea, 
 stinking stools and hydrops. It is most frequent in the small 
 intestine and is essentially a vascular change. Amyloidosis in gen- 
 eral occurs in 67 per cent, of tuberculosis and in 21 per cent, of 
 syphilis (Hoffmann). 
 
 Rectum. — Ulceration occurs in papules near the anus, or results 
 from fissures (Johnson). Eectal disease is usually secondary by 
 contiguity, (a) Irritative proctitis is most frequently chronic, at- 
 tended, by evacuations of pus, by itching, tenesmus and external 
 excoriations and by a long course, (b) Syphilitic ulcers of the 
 rectum are tertiary. They occur high up, extend to the colon and 
 often produce stenosis. Stricture without previous ulceration is 
 rare. Perforation is rare. The periproctic tissues are invaded. 
 Fistuhe may develop, but the symptoms are less marked than in : 
 cancer or tuberculosis. The fasces are covered with mucus and 
 blood. Diarrhoea from catarrh of the colon, myositis of the sphincter 
 with involuntary evacuations, burrowing of pus and sepsis necessi- 
 tate at best a long course. Tuberculous ulcers rarely occur in the 
 rectum alone, and are marked by the tubercle bacillus. In dysentery 
 the involvement is higher up, colic is more frequent, diarrhoea is more 
 profuse, and the resulting stenosis is higher in the intestine. In car- 
 cinoma, age, cachexia and local appearances are suggestive but not 
 positive criteria. Stricture is lower in syphilis than in carcinoma, 
 and adhesions are more commonly carcinomatous. 
 
 Pancreas. — Acute syphilitic pancreatitis was noted by Eokitan- 
 sky. The interstitial inflammation with sclerosis causing parenchy- 
 matous atrophy is rarer in acquired (2.2 per cent.,) than in hereditary 
 syphilis. Only 3 instances of gumma are recorded. The peritoneum 
 sometimes participates in syphilitic disease of the organs which it 
 envelops, e. g., perisplenitis, perihepatitis, perinephritis or perityph- 
 litis; it is extremely rare as an independent disease; Lancereaux, 
 Aufrecht and Laurenzi have observed gummatous peritonitis. 
 
 4. Spleen. — (a) Acute splenic tumor (Walter, 1821) occurs in 
 31 per cent, of acquired and 61 per cent, of congenital syphilis, (b) 
 Interstitial splenitis occurs chiefly with syphilitic liver" The oro-an 
 is increased in size, hard, tender and painful, from perisplenitis, (c) 
 Gummatous splenitis is very rare, (d) Amyloidosis occurs very fre- 
 quently as the "sago" spleen, which is not necessarily very much 
 enlarged ; or as the diffuse amyloid spleen, which causes" considerable 
 swelling. 
 
 5. Liver. — Syphilis of the liver occurs in two forms, interstitial 
 and gummatous, which are often associated with perihepatitis, amy- 
 loid or fatty change, and sometimes with parenchymatous changes 
 
SYPHILIS. 263 
 
 as acute yellow atrophy, (a) Interstitial hepatitis (syphilitic indura- 
 tion, syphilitic cirrhosis) is more frequent in congenital (in 65 per 
 cent.) than in acquired syphilis. The volume of the liver is in- 
 creased in children, and sometimes decreased in adults. The sur- 
 face is usually uneven, with furrows or nodules; the edge is thin, 
 indented and fairly sharp, whereas in other cirrhoses it is rounded. 
 Perihepatitic adhesions to the colon or abdominal wall are frequent, 
 and clinically evidenced by lessened respiratory excursion. The con- 
 nective tissue forms in Glisson's capsule, follows the branches of 
 the portal vein into the liver (peripylephlebitis), and shows as bands 
 of grayish tissue, the protruding granules representing normal tissue. 
 The liver cells are degenerated, even destroyed by the connective 
 tissue or by obliterating endarteritis of the small vessels. The 
 atrophy is most marked in the anterior border of the liver and in the 
 left lobe. The connective tissue is not only perilobular, but reaches 
 into the lobules more than it does in alcoholic cirrhosis. In acquired 
 syphilis the liver is not equally nor completely diseased, whence pro- 
 trusions of the sound tissue are noted. New bloodvessels from the 
 hepatic artery develop in the connective tissue and thrombosis may 
 occur in the portal vein and its radicles (pylephlebitis). 
 
 Symptoms. — The clinical development is latent or insidious, — 
 e. g., without pain, ascites or oedema. The abdominal veins may 
 be distended; the urine is often dark, possibly icteric ancl often 
 albuminuric. The concomitant splenic tumor results from hyper- 
 plasia, stasis or amyloid degeneration. Ascites is less frequent and 
 develops late and gradually, herein differing from alcoholic cirrhosis. 
 Icterus develops in 33 per cent. More bile is present in the stools 
 than in ordinary cirrhosis. Gastro-intestinal dyspepsia and vomiting 
 of blood are not infrequent. This form develops more often in men 
 than in women ; is promoted by alcoholism ; has a chronic course ; and 
 its prognosis is rather better than in non-syphilitic cirrhosis, since 
 relative recovery is possible. When the liver is small, recovery is 
 impossible and death results from intercurrent pneumonia, pleurisy, 
 cholsemia or hemorrhagic diathesis. 
 
 (b) Gummatous hepatitis (syphilitic hepatitis par excellence) is 
 more frequent than the first form, and occurs oftener in acquired 
 than in congenital syphilis. The gummata are either miliary or large 
 nodes which may fill the abdomen. The nodes vary from one to 
 over fifty, and may be superficial or deep. The surface of the liver 
 is smooth or warty, thickened, or adherent to the diaphragm or 
 colon. The liver is distorted, mammillated or lobulated (hepar loba- 
 tum). Deep, irregular, radiating furrows are frequent, resulting 
 from absorbed gummata, affecting either lobe and occurring mostly 
 on the anterior surface near the suspensory ligament (Virchow) or on 
 the edge. In congenital syphilis gummata are often observed at 
 the hilum, in the wall of the portal vein or near the bile vessels. 
 
 Symptoms. — Gummata are frequently latent — i. e., are discovered 
 only at postmortem. Considerable pain occurs in the shoulder, as well as 
 
264 IRE SPECIFIC INFECTIONS. 
 
 pain on motion or Tenderness on pressure in the epigastrium or hy- 
 pochondrium. Pain is due mostly to perihepatitis: a friction rub 
 is heard when the inflammation is fresh ; adhesions and loss of respira- 
 tory excursion result, in older cases. Icterus is infrequent and 
 results from accidental gummatous compression of the bile ducts, from 
 perihepatitis or from cicatrices. When icterus exists the affection 
 is often mistaken for cancer. The liver usually shows furrows and 
 nodules. Early enlargement is more frequent than in alcoholic- 
 cirrhosis but a final shrinkage has been observed. Ascites is rare 
 except from syphilitic cirrhosis, amyloid liver or cardiac instrfn- 
 eieney. When present, ascites is usually terminal, independent of the 
 size of the liver and often associated with albuminuria. Splenic 
 tumor is infrequent, except from gum m at a or amyloid degeneration 
 in the spleen, from coincident liver cirrhosis or gummata at the 
 porta hepatis. Dyspeptic disturbances, bronzed skin, hemorrhages 
 and inflammations of the serous membranes infrequently complicate 
 liver gummata. 
 
 Diagnosis. — This depends upon other evidence- of syphilis, and 
 while sometimes easy, it is often difficult or impossible. All forms 
 of syphilis of the liver may remain stationary for a time (Bam- 
 berger), and in general a longer course is expected than in alcoholic 
 cirrhosis. Oppolzer and Bachdalek mistook gummata for cancer, 
 and the* reported cases of cure of cancer by the earlier writers are 
 clearly confusions with syphilis : age is only a relative criterion, 
 yet most cases of syphilis of the liver occur under the fortieth 
 year : ascites, icterus, enlarged liver and cachexia may occur in 
 both diseases, occasioning donbt and confusion. The nodules of syph- 
 ilis are usually small but may be larger than those of cancer. Rapid 
 growth is an indication of cancer : more constant size, of syphilis. 
 Albuminuria and splenic tumor are more common in syphilitic liver. 
 The best clinicians have confused syphilis with cancer, and the safest 
 rule is always to think of syphilis when cancer seems the obvious 
 diagnosis. Coincident amyloid disease renders the diagnosis difficult. 
 The lungs are compressed in cancer more than they are in syphilis. 
 The smooth edge of the liver, signs of fresh hepatitis, and lack of respi- 
 ratory excursion, indicate syphilis I Lancereaux and Riedel). Eiedel 
 found similar symptoms in syphilis and gall-stones, such as pain, 
 fever and tenderness. Fever is not uncommon in hepatic syphilis, 
 which may then be easily confused with liver abscess I q. y.). Final 
 differentiation may be made ex juvantibus. I See TJfffeeextlal 
 Tabee of Diseases of the Liver.) 
 
 Prognosis. — This is more favorable than in the vulgar cirrhosis, 
 for the disease lasts several years. Spontaneous recovery from guni- 
 mata may result without specific treatment. Rupture into the peri- 
 toneal cavity is rare. Death from cachexia and amyloidosis may 
 occur. 
 
 Amyloid liver (q. v.) is most frequent in the tertiary or qua- 
 ternary stage of acquired syphilis. Amyloidosis rarely occurs in the 
 liver alone. 
 

 SYPHILIS. 265 
 
 Syphilitic pylethrombosis (see Pylephlebitis). 
 
 Icterus, especially investigated by French writers, has been attri- 
 buted to swelling of the portal lymphatics, early hepatitis, cholan- 
 gitis, injury to the liver cells or to gastroduodenal catarrh. 
 
 6. Kidneys. — (a) Albuminuria occurs in recent syphilis or in the 
 later ulceration. It is usually transitory and it is thought to result 
 from toxaemia or vascular changes. Its prognosis is usually good, 
 since nephritis rarely follows it, but the later in the disease that album- 
 inuria appears, the poorer is the prognosis. Mercury in moderate 
 dosage does not cause it though energetic mercurialization may pro- 
 duce albuminuria, cylindruria and even calcification of the convoluted 
 tubules, (b) Paroxysmal hoemoglobinuria occurs relatively often 
 after mercurial therapy. The prognosis is better than in non-syphili- 
 tic cases, (c) Acute parenchymatous nephritis is focal and cortical. 
 It occurs with the eruption, is toxaemic and is rare. When it de- 
 velops late, from ulceration, the prognosis is unfavorable. There 
 may be no symptoms; anaemia, vomiting or other symptoms of 
 acute nephritis may be present, but uraemia is rare, since it is 
 a focal disease (Bamberger), (d) Chronic parenchymatous neph- 
 ritis may follow syphilis. Its relation and its percentage are 
 difficult to estimate (0.5 per cent.). (e) Chronic interstitial 
 nephritis differs from the ordinary form in its disseminated focal in- 
 volvement, which leaves scars. Polyuria is rarely great, casts and 
 albumin are present in greater amount, and the course is more rapid 
 than the ordinary course of three to seven years, because of marantic, 
 amyloid and other visceral changes. It often occurs at an early age 
 when arteriosclerosis is rare. There is said to be no cardiac hyper- 
 trophy. Bamberger found a history of syphilis in 3 per cent, of 
 cases of ordinary contracted kidney. (/) Gummata are found in the 
 miliary or large forms in the cortex and sometimes in the medulla, 
 usually multiple and generally unilateral. The renal tissue is partly 
 destroyed. They coexist with liver gummata, amyloid kidney and 
 chronic parenchymatous nephritis. The symptoms are indeterminate. 
 (g) Amyloid kidney, q. v., under diseases of the kidney, (h) Accord- 
 ing to Frerichs, Cantani and others, syphilis is an etiological factor 
 in glycosuria. The suprarenale are rarely involved, except in con- 
 genital syphilis; swelling, hyperemia, fatty degeneration, gummata, 
 interstitial inflammation and amyloid changes in the Malpighian 
 bodies have been recorded. Gummata have been observed in Addi- 
 son's disease. 
 
 7. Circulation. — Heart. The heart was found involved but six 
 times in 100,000 autopsies (Mracek). 
 
 (a) Syphilitic myocarditis is coronary arteritis; foci of interstitial 
 involvement occur, as infiltration along the small vessels, especially 
 in congenital syphilis, into the intermuscular septa. Microscopically, 
 the general picture of myocarditis prevails. It involves the front or 
 apex of the left ventricle, or the intermuscular septum. In congen- 
 ital syphilis it occurs in the right more than in the left heart. Ee- 
 
266 TEE SPECIFIC INFECTIONS. 
 
 suiting changes are cardiac hypertrophy, aneurysm of the heart and 
 Dittrich's true heart stenosis (conus stenosis). Gummatous myocar- 
 ditis is usually observed with a diffuse myocarditis. Only 97 (62 
 perfectly clear) cases of myocardial gummata are recorded (Stock- 
 mann, Goldfrank). Gummata may attain great dimensions in the 
 interventricular septum. The disease is often latent until, in 50 
 per cent, of the cases sudden death results. Most fatalities occur in 
 persons between thirty and forty years of age. The heart action 
 may be incompetent or irregular, and there may be dyspnoea, asthma, 
 angina pectoris or cerebral embolism. Hydrops is rare. Amyloid 
 of the heart is occasionally associated with gummatous myocarditis. 
 Heart rupture is recorded. 
 
 (b) Independent syphilitic pericarditis is unknown; it is invariably 
 a complication of myocardial syphilis, occurring over the large vessels 
 or anterior surface of the heart, as serofibrinous pericarditis or com- 
 plete concretion. Gummatous pericarditis is always combined with 
 the serofibrinous form, and sometimes with aneurysms of the coro- 
 nary arteries. The symptoms are those of disordered compensation 
 or of myocarditis, its invariable associate. 
 
 (c) Syphilitic endocarditis rarely develops. The nodules on the 
 valves rarely retract or cause valvular disease. Mural plaques com- 
 plicate myocardial gummata. Endocardial gummata may occur. 
 
 Bloodvessels. — Endarteritis syphilitica. Syphilitic arterial disease, 
 known to Morgagni and Pare, causes wide-spread, of ten ■ irreparable 
 or fatal complications, (a) In the fibrous form, the wall is thick 
 and opaque, the intima and elastic tissue are hyperplastic and the. 
 lumen is eccentric. When the muscular coat is not involved, throm- 
 boses occur; when both the muscular and elastic coats are diseased, 
 aneurysms result ; this type is known as the obliterating endarteritis 
 of Heubner (see Syphilis of the Brain), (b) Gummatous arteri- 
 tis or periarteritis is very rare, (c) General arteriosclerosis involves 
 the vessels more widely than does the syphilitic arteritis which is, 
 largely localized in the aorta and brain-vessels and exceptionally in 
 the other vessels. Coronary involvement is held by some writers to 
 be more frequent than brain involvement. It may begin in the first 
 year after infection. 
 
 Aorta. — Syphilitic aortitis (Heiberg, 1877) is oftenest seen in 
 the ascending aorta, its arch and thoracic segment, and the lower 
 part of the abdominal aorta. It begins in the adventitia or intima and 
 ultimately involves all the walls in varying degrees. The early stages 
 show gray, transparent, gelatinous patches of productive cellular 
 inflammation and spirochetes in the intima ; older foci are gray-white 
 round or oval, elevated and stellate plaques. The process sometimes 
 becomes deep and calcification occurs in the intima with thrombosis. 
 It may extend down to the aortic valves. Its origin may be (a) 
 in the intima, (b) in the adventitia and media together (mesaortitis) 
 or (c) in the intima and adventitia (vasa vasorum). The resulting 
 loss of elasticity and resistance promotes aneurysm. Welsh held that 
 
SYPHILIS. 267 
 
 66 per cent, of aneurysms were syphilitic; personally, the author 
 believes 80 to 90 per cent, is a more accurate estimation. Syphilitic 
 aneurysms develop more rapidly than those due to other causes. 
 They may be single or multiple and usually occur in the arch of the 
 aorta, and sometimes also in the abdominal aorta or its branches 
 (see Aneurysm). Straub found this aortitis in 98 per cent, of 
 cases of paretic dementia, and Chiari in 50 per cent, of syphilitics. 
 Benda describes gummata, of which only six cases are on record. 
 
 Pulmonary Artery. — Valvular gumma is very rare, as are occlu- 
 sions of the pulmonary trunk or its compression by scars. Accord- 
 ing to Neumann, syphilitic dilatation or aneurysm of the pulmonary 
 artery has not yet been observed. 
 
 Vein Syphilis. — Thirty-three cases of phlebitis were collected by 
 Roussy in 1903. Schuppel has described a periphlebitis originating 
 in the adventitia and seen especially in hereditary syphilis. Gummata 
 exist in the veins or involve them secondarily. 
 
 Blood. — Oligocythemia and oligochromasia occur early and 
 most markedly when the glands are widely involved. The anaemia 
 disappears under administration of mercury, to reappear if too much 
 be given. A count as low as 1,700,000 may be observed. The 
 haemoglobin is reduced 15 to 30 per cent, and the loss may exceed 
 that of the red cells. The " Justus' test" is based on a 10 to 20 
 per cent, reduction in the haemoglobin after a large inunction or 
 injection of mercury, in the florid secondary stage; a positive test 
 is only suggestive of syphilis^-not pathognomonic. The white cells 
 are slightly increased, especially the lymphocytes; the eosinophiles, 
 as in other skin diseases, are increased but not constantly. Myelo- 
 cytosis may develop in the tertiary stage. The blood contains the 
 spirochetes and by way of the blood syphilis becomes a general dis- 
 ease. Pernicious anaemia and leukaemia are rare sequels. 
 
 8. Respiratory Tract.— Nose, (a) An initial nasal lesion is 
 most rare, only 95 cases being recorded, (b) Acute rhinitis is much 
 rarer in adults than in the new-born. It is characterized by its 
 persistence, erythematous papular foci, hemorrhagic erosions and 
 by fetor, (c) Rhinitis atrophicans is the result of hyperplastic 
 rhinitis, (d) Gummata usually develop late, though they have been 
 seen in the seventh month ( Mauri ac) ; they begin in the floor and 
 septum of the nose, the periosteum, bone and secondarily in the • 
 cartilage. They occur with diffuse necrosis and involve the carti- 
 laginous and membranous septum and cartilages of the alae ; sequestra 
 may be blown from the nose. Septal perforation may develop and 
 a long course is usual, with discharge of pus and crusts ; the bone is 
 often denuded. The deformed " saddle-bach " nose is due to loss of 
 the triangular cartilage and vomer, and sometimes to simple atrophy. 
 Differentiation from noma, tuberculosis, carcinoma and the ordinary 
 perforating ulcer of Zuckerkandl (beginning as a hemorrhage and due 
 to streptococcic and staphylococcic infection) must be considered. 
 The diagnosis ex juvantibus is the best test. 
 
268 THE SPECIFIC INFECTIONS. 
 
 Larynx. — (a) Catarrhal laryngitis occurs with the eruption. The 
 larynx is red and swollen, with a secretion, at first thin and later 
 purulent. Coughing and hoarseness are common, (b) In papular 
 laryngitis the papules often ulcerate and are associated with diffuse 
 infiltration and nodes. The epiglottis is also involved. Deforming 
 ulcers are neither acute nor inflammatory. Stenosis of the glottis 
 results if ulcers invade the submucous tissue, (c) Gummata of 
 the larynx are usually multiple, and vary from the miliary size 
 to that of a pigeon's egg; sometimes a diffuse infiltration occurs. 
 They may soften, ulcerate and produce dysphonia, dysphagia, dys- 
 pnoea, hemorrhage or suffocation. They always leave adhesions, 
 stenosis, scars or deformity. 
 
 Diagnosis. — In cancer the glands are usually enlarged, the growth 
 is harder than in syphilis and the microscopic examination may be 
 of value. Syphilis and tuberculosis may occur together. Though 
 the round form of syphilitic ulcer is not of absolute diagnostic 
 value, it usually begins near the epiglottis, is rounder and larger 
 and has sharper edges, a more reddened border, and a whitish-yellow 
 coating of its deeper base, while the tuberculous ulcer is less red, 
 less infiltrated, less deep and less insidious in its development. 
 
 (d) Perichondritis may affect any cartilage. The cartilage is 
 discolored, excoriated and surrounded by oedema; there may be 
 submucous necrosis, or difficulty in respiration and deglutition. 
 The prognosis is always grave. The lower the necrosis develops, the 
 worse is the prognosis, for deformity and stenosis occur. Syphilis 
 causes 13 per cent, of cases of glottis oedema; tuberculosis, 9 per 
 cent. 
 
 (e) Syphilitic vegetations, due to irritating secretions, are sessile or 
 pedunculated and cause dysphonia or even suffocation. 
 
 Trachea. — Only two instances of condylomata have been recog- 
 nized. The trachea is red, swollen and sometimes ulcerated and 
 distorted. Tracheal stenosis, resulting from healing gummata, is 
 usually angular (Mauriac) and involves mostly the middle third. 
 The symptoms are a burning sense of constriction; inspiratory 
 dyspnoea at night, on exertion or on lying down ; a cough resembling 
 that of pertussis, with sanguineo-purulent sputum, which may con- 
 tain fragments of cartilage; and cyanosis. The diagnosis is made 
 by the laryngoscope. 
 
 Bronchi. — (a) Acute bronchitis is observed, with the secondary 
 symptoms especially in tuberculous, cachectic and alcoholic subjects. 
 
 (b) Chronic bronchitis often accompanies laryngeal, tracheal or 
 bronchial affections. Phthisis may be suggested. The breathing 
 is disproportionately disturbed by irritation of the vagus from en- 
 larged bronchial glands (Morton), (c) Kidney-shaped ulcers may 
 cause stenosis and sometimes perforation into the pulmonary artery, 
 mediastinum or oesophagus. L. A. Conner, of New York, collected 
 128 cases of bronchial and tracheal syphilis; in 56 per cent, the 
 trachea alone was affected ; gummata occurred in 15 per cent. ; ulcers 
 
SYPHILIS. 269 
 
 in 44 per cent., frequently with severe hemorrhages; cicatrices and 
 stenoses in 40 per cent. ; and bronchiectasis in 20, fibrous peritra- 
 cheitis in 6, and pulmonary syphilis in 7 per cent. 
 
 Lungs. — Syphilis of the lungs, recognized by Morton (eighteenth 
 century), may cause symptoms like those of pulmonary tuberculosis. 
 Sims holds that every patient with tuberculous signs should be 
 searched for syphilis. 
 
 (a) The white pneumonia of hereditary syphilis may be described 
 here although it presents no clinical symptoms. The lung is firm, 
 heavy, airless and grayish-white, — called white hepatization by Vir- 
 chow, the chief change being in the thickened and infiltrated alveolar 
 walls. In the air cells, desquamated and swollen epithelium and 
 spirochetes are found, with scattered miliary foci about the arteries. 
 
 (b) Diffuse infiltration differs from tuberculosis in that it occurs 
 in the centre of the lung, and exceptionally in the apex (Fournier). 
 It usually travels downward rather than upward. In the beginning 
 the lung is red, hard, large, airless and smooth on section and 
 later becomes gray, uneven and nodulated; the alveoli are filled 
 with fibrin, epithelium and blood-cells. Infiltration of the con- 
 nective tissue occurs about the vessels impinging upon the air-cells. 
 The origin of this infiltration is disputed. It arises from desquama- 
 tive pneumonia, alveolar connective tissue, the bloodvessels, peribron- 
 chial connective tissue, or from the lymph-vessels. Necrosis, fatty 
 change and caseation may result from occlusion of the vessels, 
 which later may form cavities. Disproportionate dyspnoea is pres- 
 ent. Temperature may occur with or without ulceration. 
 
 (c) Gummatous pneumonia may occur alone or with diffuse infil- 
 tration. Gummata develop largely in the lower lobes near the 
 hilum. Differentiation from tuberculosis is often difficult; the two 
 lesions may occur together. Dulness and other signs of consolidation 
 or cavity formation often result. The sputum is mucous, purulent, 
 profuse, bloody, stinking, and contains masses of tissue but no tubercle 
 bacilli. The course is usually chronic, and advanced cases may heal 
 with appropriate treatment; Brambilla (1777) described a supposedly 
 phthisical patient, who, by mistake, took mercury and recovered. 
 Diagnosis is most difficult if the foci are small. Tuberculosis occurs 
 more often on the left and syphilis, on the right side. Tuberculosis 
 occurs more frequently in the upper, syphilis more often in the lower 
 or middle lobes. Rise of temperature is more frequent in tubercu- 
 losis. In syphilis, hemorrhage is rare, as the vessels are obliterated, 
 and night sweats are infrequent. In caseous tuberculous pneumonia, 
 localization is of no diagnostic value. 
 
 (d) Syphilitic interstitial pneumonia occurs with the above affec- 
 tions. The lung may be lobulated (pulmo lobatus) like the lobulated 
 liver; there is marked induration as irregular branching bands, 
 which dilate or distort the bronchi ; diagnosis is impossible. 
 
 (e) Syphilitic disease of the pleura is rare. It may occur with 
 lesions of the lung alone or with pleural gummata, 
 
270 THE SPECIFIC INFECTIONS. 
 
 9. Nervous System. — The changes are partly toxsemic, partly 
 anatomical. Syphilis of the nervous system occurs in men more 
 frequently than in women (8 to 1), mostly between the years of 
 twenty-five and forty, in neuropathic subjects and after trauma; in 
 brain workers or those debilitated by worry, excesses, lead or nicotine ; 
 and in children as perhaps the first symptom of parental disease. 
 
 The primary lesion often escapes recognition. In 20 per cent, of 
 cases, there is no history of chancre. It occurs where the secondaries 
 have been light and have had ineffectual or no treatment. Syphilis 
 •is said to occur in the brain in 16.5 per cent, of syphilitics, more, in- 
 deed, than in other viscera, excepting the liver. (Again, it has been 
 held that only 10 to 1 5 per cent, of syphilitics have visceral, and only 
 3 per cent, brain, complications.) 
 
 Fifty per cent, of brain syphilis occurs within three years after 
 infection. Formerly described as occurring many years after in- 
 fection, instances are recorded where cerebrospinal syphilis developed 
 even as early as 'Qxe weeks after infection. Nervous symptoms may 
 occur soon after an infection in those advanced in years (Kuh). 
 Nervous symptoms in the secondary stage as headache, neuralgia, 
 increased reflexes or fleeting paralyses, are probably chiefly toxgemic. 
 In general, the symptoms are marked by — (a) variability, undula- 
 tion and inconsistency, due to the characteristic growth and vessel 
 changes which regress and recur; (&) incompleteness, as partial 
 paralysis or disturbance of consciousness; (c) the symptoms are 
 partly tumor-like, partly vascular, or partly inflammatory; they are 
 partly meningeal, partly basal or cortical, and rarely occur in the 
 centre of the brain except from secondary vessel lesions and gummata. 
 The disease may begin with diffuse neurasthenic, meningeal, psycho- 
 pathic or focal symptoms. As Wunderlich stated, syphilis produces 
 no symptom not produced by other disease ; therefore, no typical pic- 
 ture obtains. 
 
 Types. — 1. Syphilitic arterial disease occurs alone or with the 
 other varieties of brain syphilis. It is the most frequent form and, 
 aside from neuritis paralysis, the most frequent cause of syphilitic 
 paralysis. There are prodromal disturbances ; headache is usual but' 
 less constant than in meningeal syphilis ; vomiting, vertigo, psychical 
 changes, dementia, convulsions, intermittent hemianopsia and 
 aphasia may occur; choked disk is rare; thrombosis and obliteration 
 of the vessels is gradual in onset and is intermittent, — e. g., it may 
 involve the leg and, in a few hours or days, the arm. These changes 
 are due to obliteration of the vessels and multiple softening which (in 
 95 per cent, of cases) occur in the Arteria fossse Sylvii; pseudo- 
 bulbar paralysis may rarely result from involvement of the bulbar 
 vessels. 
 
 Course. — The first attacks are mild and short; the later ones are 
 more severe, and occur with marked somnolence, very frequently with 
 bilateral, alternating, or crossed paralysis, with general, unilateral 
 or rarely Jacksonian convulsions, or with partial or mixed aphasia,' 
 
SYPHILIS. 271 
 
 mental changes and progressive bulbar phenomena, such as dys- 
 phagia. They result from arterial disease ; hemorrhage is most rare 
 except from ruptured cerebral aneurysm. 
 
 It may be difficult to diagnosticate primary syphilitic disease from 
 the ordinary arteriosclerosis; in over 90 per cent, of cases the latter 
 occurs in late life, its progress is slower, the changes are more dis- 
 seminated, all coats of the vessels are involved, its fatty and calcareous 
 changes lead more often to widening than to obliteration, psychical 
 changes and convulsions are less frequent and hemorrhage is more 
 characteristic than softening; whereas in syphilis the onset is more 
 acute and headache more conspicuous, encephalomalacia occurs at a 
 younger age (see Brain Embolism, Differential Table), the changes 
 affect chiefly the aorta and brain vessels, the intima is principally in- 
 volved, calcareous and fatty changes are rare and obliteration is 
 usual, and there are characteristic psychical changes as somnolence 
 or apathy; the hemiplegia occurs by "epochs" or " installments," 
 associated with meningitis, dementia or delirium; finally the symp- 
 toms are more diffuse than in senile arteriosclerosis. Without treat- 
 ment, the average duration is one to three months (Oppenheim). 
 
 Dieulafoy has described multiple aneurysms in the basilar, Sylvian 
 and carotid trunks ; they are generally tertiary, but may occur eight 
 months after infection. Their rupture produces symptoms of apo- 
 plexy or meningeal hemorrhage. Otherwise hemorrhage is rare in 
 brain syphilis. (See illustrations under Aneurysm.) 
 
 While softening is usually ischwmic and not inflammatory, we 
 sometimes encounter foci of encephalitis syphilitica as (a) dissemi- 
 nated foci in the brain and cord; (&) indurated sclerosis; and very 
 rarely (c) softening occurring apart from disease of the vessels. 
 
 2. Basal gummatous meningitis, the best known type, and, after 
 arterial disease, the most frequent form, begins in the dura, especially 
 along the chiasma opticum, in the interpeduncular spaces or along 
 the cavernous sinus; less frequently in the fossa of Sylvius and the 
 cortex; pathologically it consists of fibrinous exudate, granulation 
 tissue, cicatrices and gummata. 
 
 General Symptoms. — Headache is the most important, constant 
 and early symptom (in 75 per cent.). It is paroxysmal, or, if per- 
 sistent, is increased at night, is sharp, boring or dull, is deep-seated 
 (Fournier) and but rarely circumscribed. Other symptoms are neu- 
 ralgias, cerebral projectile vomiting, vertigo and changes in men- 
 tality, — somnolence, semi-intoxication, or motiveless activity and loss 
 of the aesthetic sense. Again, the brain may be normal, except during 
 the attacks, — e. g., coma may occur from which spontaneous recov- 
 ery is possible. Persistent sleep, lasting for weeks or months, is 
 usually ominous. The brain activity may be tardy or excited, while 
 nocturnal automatism (Wood) or dementia, may develop, alternating 
 with delirium, epileptic attacks or paralytic seizures. The brain 
 symptoms may. on rare occasions, resemble those of uraemia, menin- 
 gitis or typhoid. Epilepsy may be typical or unilateral, frequent or 
 
272 TEE SPECIFIC INFECTIONS. 
 
 violent. Polyuria or polydipsia (33 per cent, of cases), diabetes 
 insipidus, resulting from disease in the third ventricle, or diabetes 
 mellitus, of which Oppenheim has collected 20 cases, may occur. 
 Fever may be present, but usually accompanies the secondary mani- 
 festations. 
 
 The cerebral nerves are often affected, especially the second and 
 third. Involvement of the nerve branches successively is most char- 
 acteristic (85 per cent., Uhthoff) ; 80 to 90 per cent, of cases of nerve 
 involvement results from syphilis of the brain, tabes or less fre- 
 quently, from general paralysis and brain tumor, (a) The third 
 nerve is involved most frequently — 50 to 80 per cent, of the cases, 
 "the sign of syphilis" (Eicord). (b) Disease of the optic nerve 
 occurs anatomically in 82 per cent, and clinically in 40 per cent, of 
 cases. Choked disk (10 per cent.) is almost always bilateral. (See 
 Eetinal Plates under Miliary Tuberculosis.) Neuritis is uni- 
 lateral in 4.6 per cent. ; simple atrophy, with complete blindness (in 
 6.6 per cent.), is most frequent in tabes and next most frequent in 
 brain syphilis and general paralysis. Amaurosis is common and 
 often unilateral. Hemianopsia is homonymous. Temporal heterony- 
 mous hemianopsia is very often syphilitic while the nasal form is 
 rarely so. In 5 per cent, of cases the field of vision is contracted. 
 The eye changes, due to meningitis, bone disease or gumma are 
 susceptible to treatment, (c) The fourth nerve, (d) the sixth and 
 (e) the fifth nerve are next in frequency of involvement. The fifth 
 is unilaterally affected, and more in its sensory than in its motor 
 branches. The olfactory nerve is rarely involved. The facial nerve 
 may be paralyzed, nearly always unilaterally and peripherally. The 
 eighth nerve is sometimes involved, and the Meniere symptom- 
 complex results, which, according to Pournier, is ominous. The 
 vagus or hypoglossus may be affected. 
 
 Together with the above changes gummata may grow into the pons, 
 crus or medulla, and may cause hemiplegia and crossed paralyses, 
 as hemiplegia plus oculomotor paralysis (Weber's paralysis) ; plus 
 facial paralysis (Gubler's paralysis) or plus abducens and trigeminus 
 paralysis (Leyden's paralysis). In basal meningitis, arterial phe- 
 nomena are often noted; in the cortical region they are evidenced by 
 syncope or apoplectiform attacks from sudden variation in the blood 
 pressure ; toward the base they produce encephalomalacia, hemiplegia, 
 hemiangesthesia and hemianopsia. These, however, are usually later 
 symptoms than meningitis and neuritis. The course of syphilitic 
 meningitis is typically subacute with remissions and exacerbations, 
 and lasts rarely more than a half a year. To summarize : Headache, 
 convulsions, sopor, coma, delirium and neuritis are followed by irri- 
 tative and paralytic symptoms with remissions, then with renewal 
 of the old, or advent of new, symptoms. 
 
 Differential Diagnosis. — Carcinoma and sarcoma at the base of the 
 brain, involving the meninges, run a continuous progressive course, 
 with definite localization and with few changes in the vessels, while 
 
SYPHILIS. 273 
 
 in syphilis the course is intermittent or remittent, localization varies, 
 and changes in the vessels may be marked. Tuberculous meningitis 
 exceptionally may give identical symptoms, but there is less develop- 
 ment of connective tissue, vascular changes are rarer, the nerves less 
 frequently involved, the course more acute, febrile and progressive, 
 and remissions less frequent and less marked ; stiff neck and general 
 muscular rigidity occur, which are rare except in the congenital type 
 of syphilis. Mental obscurity is more marked and sudden, while it 
 intermits in syphilis. The irritation, in the initial stage, is followed 
 by paralysis later, while paralysis may occur at once in syphilis. 
 Tuberculous meningitis is a disease of the first, second or third 
 decennium, while syphilis usually occurs after twenty years of age. 
 Other syphilitic or tuberculous foci and the results of therapy deter- 
 mine the differentiation. Differentiation from Quincke's serous 
 meningitis may be difficult, but the syphilitic variations and the 
 therapy are the final tests. Differentiation must be made from pri- 
 mary syphilitic neuritis. It is questionable whether primary involve- 
 ment of the second and third nerves may occur in syphilis. It is 
 rare at the base of the brain and these cases are generally caused by 
 an anatomical meningitis with but few symptoms. The multiple 
 nerve root affections of Kahler, involving the seventh and third 
 cerebral and the cervical and dorsal nerve roots, were observed with- 
 out symptoms of meningitis or tumor, and caused neuralgia and 
 paralysis. Optic neuritis requires differentiation from similar 
 changes due to tumor, alcohol, nephritis, diabetes and acute infec- 
 tions. Periodic paralysis of the third nerve is rhythmic in its at- 
 tacks, usually involves the entire nerve, occurs in young children 
 especially, and with attacks of migraine. 
 
 3. Syphilis of the convexity may occur as circumscript or diffuse 
 meningitis or meningo-encephalitis, with symptoms like those of cor- 
 tical tumor or with diffuse manifestations. 
 
 General Symptoms. — Headache is usually the first and most com- 
 mon manifestation. Mental symptoms may occur independently of 
 the localization. Focal symptoms are the Jacksonian attacks of epi- 
 lepsy, which occur with mono- or hemiplegia, develop by starts or 
 " installments " and occur without an aura. Ninety per cent, of 
 convulsions in those over thirty years of age, not urcemic or alcoholic, 
 are syphilitic (Fournier). The symptoms are more diffuse than in 
 vulgar epilepsy. The convulsions may even number 400 in twenty- 
 four hours. Pain or paresthesia occurs but anaesthesia is uncommon. 
 Aphasia is frequent and is usually of the transitory motor type at 
 first, word deafness being relatively rare; aphasia occurs less often 
 from gumma than from vascular disease. Alexia and agraphia have 
 been observed. When the process is diffuse it may be manifested 
 clinically as an acute psychosis which answers only to antisyphilitic 
 therapy; dementia is the most frequent type. Both the diffuse and 
 gummatous forms recover more frequently than do other forms. 
 
 4. Gummata are the least frequent variety ; they occur in any part 
 18 
 
274 THE SPECIFIC INFECTIONS. 
 
 of the brain, usually in the meninges, sometimes in the medullary 
 substance, central ganglia, cerebellum, pons or crus. If they occur 
 alone, the symptoms are the same as in brain tumor, except that there 
 is often regression, which is either spontaneous or results from anti- 
 syphilitic treatment. Cortical gummata, producing cortical epilepsy 
 and monoplegia, require differentiation from other tumors (q.v.) 
 as tubercle or glioma; in cortical tumor the headache is duller and 
 deeper ; the pressure symptoms, mental depression and slow pulse are 
 more marked ; the disk changes follow focal symptoms and the process 
 advances less by epochs ; while in syphilis the headache is frequently 
 local and the pressure symptoms are more diffuse and rapidly exten- 
 sive ; the disk, as a rule^ is involved only when coincident basal men- 
 ingitis occurs. Cortical paralysis may develop, and is often asso- 
 ciated with Jacksonian epilepsy (v.s.). The symptoms are more 
 undulatory, and finally treatment is successful. 
 
 5. Cerebrospinal syphilis produces no characteristic spinal symp- 
 toms; suggestive, however, are (a) their asymmetry, (b) their less 
 pronounced character, (c) their variability, (d) meningeal and nerve 
 root symptoms and (e) response to mercury and iodides. Syphilis 
 is never a system-disease (Growers). Syphilis of the cord is five to 
 six times less frequent than brain syphilis. 
 
 The most frequent and characteristic form is cerebrospinal men- 
 ingoencephalitis, observed in both acquired and congenital syphilis. 
 While the symptoms may be strictly spinal, anatomically, cerebral 
 gummatous meningitis or meningoencephalitis is frequently found. 
 Of the three sets of spinal bloodvessels, the peripheral are most in- 
 volved and Heubner's arterial findings are not noted in them. Brain 
 changes usually occur first and may mask the spinal symptoms. The 
 meninges are most involved in the cervical and upper dorsal regions, 
 as evidenced by pain, stiffness or girdle sensation; while the cord 
 itself is mostly affected in the lower dorsal region, and therefore 
 involves chiefly the lower extremities, causing weakness in the legs, 
 paresthesia, sphincter disturbance and decubitus. Intercostal neu- 
 ralgia, pains in. the extremities (often most severe at night), spastic 
 paraparesis, hemiparaplegia, triplegia, Brown-Sequard's syndrome, 
 anterior poliomyelitis or amyotrophic lateral sclerosis, increased 
 (varying) reflexes, involvement of the bladder and rectum, and gen- 
 eral or selective sensory disturbances, are some of the symptoms of 
 cerebrospinal syphilis. Erb has laid special stress on the spastic 
 paraplegic type. It is now maintained that the so-called syphilitic 
 myelitis is only softening — i. e., myelomalacia. Gummata of the 
 cord are infrequent. Perineuritis gummosa of the sensory or motor 
 nerve roots is uncommon. 
 
 Differentiation from combined system-disease is often difficult. 
 Some cases of ascending paralysis have been helped by mercury. In 
 cerebrospinal syphilis and para syphilitic tabes or dementia, the 
 lymphocytes predominate in the fluid withdrawn by lumbar puncture. 
 
 Prognosis of Brain Syphilis. — According to Naunyn, only 48 per 
 
SYPHILIS. 275 
 
 cent, of the cases recover. The later the disease, the worse is the 
 prognosis. The prognosis is more favorable in meningeal (i. e., extra- 
 cerebral) involvement, when nerve symptoms are dominant, when 
 epilepsy and other symptoms of peripheral brain irritation occnr or 
 when early treatment is instituted. Eighty-two to 88 per cent, of 
 cases of syphilis receive insufficient mercnrialization (Hjelman). 
 The prognosis is less favorable in specific arterial disease (paralysis 
 from softening), in bulbar forms, in diffuse involvement, in great 
 psychic alteration, and in proportion as the primary and secondary 
 lesions were poorly developed; also in extragenital infections, in 
 hereditary syphilis, and in complicating trauma, tuberculosis or 
 alcoholism. Eecovery is rarely complete and recurrence may be 
 observed. The prognosis is relatively poor in spinal lesions. 
 
 6. Syphilis of the peripheral nerves may cause facial and trigemi- 
 nal paralysis, even in the secondary stage. The most frequently 
 affected spinal nerves are the occipital and auriculotemporal. Other 
 nerves are infrequently involved. Multiple neuritis is rare. 
 
 10. Eye and Ear. — Syphilis comprises 2 to 3 per cent, of all eye 
 diseases and at least 3 per cent, of all syphilitics have eye disease. 
 Any part may be involved, except the lens, which suffers only from 
 arterial disease in the uveal tract. The uveal tract is most involved; 
 next in frequency come the retina, optic nerve and eye-muscles. The 
 lids are not often involved; chancre, condyloma and gumma may 
 occur, and are easily confused with chalazion. 
 
 Conjunctiva. — Twenty-two scleroses (Guzeit) have been observed, 
 as well as a few gummata ; catarrh occurs in the secondary stage. 
 
 Cornea. — The cornea is frequently involved: (a) As parenchyma- 
 tous keratitis, which is mostly observed in congenital syphilis, and 
 occurs even in the third generation, while in acquired syphilis it 
 occurs in but 2 per cent, of cases. " Hutchinson s triad " in congeni- 
 tal syphilis consists of keratitis, notched teeth and congenital or 
 early acquired deafness. The cornea is diffusely clouded and milky, 
 and on close examination shows patches or streaks of inflammation 
 and sometimes new-formed vessels; (&) as keratitis parenchymatosa, 
 circumscribed or punctate; (c) as gumma, which is infrequent; (d) 
 as keratomalacia, which is observed in the congenital variety. 
 
 Iris. — Of all inflammations of the iris, 75 (Mauthner) or 90 per 
 cent. (Klein) are syphilitic. The symptoms are those of other va- 
 rieties of iritis — ciliary injection with discoloration, narrowed pupil, 
 slow reaction and synechia or occlusion of the pupil. It is usually 
 plastic, or exudative with tiny papules (Fuchs) ; iritis with nodules, 
 if it is not the result of trauma, is strongly indicative of syphilis. 
 Iritis is usually secondary and rarely tertiary. Without cyclitis it is 
 rare in congenital syphilis. As it rarely heals completely, atropine 
 should be administered early while mercury is being given, for ex- 
 pectant treatment results in severe lesions and inflammation tends to 
 recur. Ciliary involvement is usually secondary, rarely tertiary and 
 may be the sole symptom of syphilis. Injection and exquisite tender- 
 ness to touch are characteristic. Gummata usually heal. 
 
276 THE SPECIFIC INFECTIONS. 
 
 Choroid. — The choroid is involved late in the secondary period ; it 
 may be involved secondarily to iritis or cyclitis. The several forms 
 terminate with the same appearances — e. g., the exudative choroiditis 
 with bright yellowish, bluish' or even rose-colored spots, which are 
 small, oval or irregular, and are usually peripherally pigmented. The 
 pigmented type is" without spots. Both the spots and pigment lie be- 
 hind the retinal vessels, which branch over them in the ophthalmo- 
 scopic, picture. (See Retinal Plates under Miliary Tuberculosis.) 
 Disseminated choroiditis consisting of spots of pigment, especially in 
 the peripheral eye ground, usually indicates syphilis. When occur- 
 ring with inflammation of the retina and choroid (choroiditis totalis) 
 the prognosis is usually bad, as blindness may result from recurrent 
 attacks. Though no objective signs positively point to a syphilitic 
 origin, syphilis is always suspected. The vitreous humor is rarely 
 involved without other lesions, especially those of the uvea. It results 
 merely in opacities or dust-like bodies ; in the absence of myopia and 
 hemorrhage, it rather indicates syphilis. 
 
 Retina. — The retina is involved chiefly in its anterior layers, be- 
 coming cloudy about the disk, with opacity of the nerve and blurring 
 of the disk outlines. The course of the arteries is lost or broken and 
 the veins are tortuous and engorged. Hemorrhages are uncommon. 
 Most idiopathic cases of retinitis are syphilitic, although no unique 
 morphological characters exist. Modules, either papules or gummata, 
 constitute the specific retinitis. This is usually late or tertiary and 
 its prognosis is usually good. Central recurring retinitis (v. Graefe), 
 commencing at the macula, is of great importance. Retinitis with 
 pigment formation occurs mostly in congenital syphilis. The optic 
 nerve is usually involved with the retina. It may be involved any- 
 where from its central origin to the disk. Sometimes the change is 
 simple blue atrophy; again the appearance is nearly normal, or 
 again choked disk occurs. The causative lesions are gumma in the 
 brain, basal disease or independent syphilitic inflammation of the 
 intracranial portion of the tract. Neither its syphilitic nature nor 
 its location can be diagnosticated by the ophthalmoscope. Atrophy 
 may occur, as in tabes or progressive paralysis. Amblyopia or amau- 
 rosis may result from transitory circulatory, or permanent organic 
 changes. Hemianopsia is often central, results from lesion in the 
 ojDtic tract and, in most cases, is transitory. 
 
 Eye Muscles. — The eye muscles are involved as frequently as is the 
 iris. Syphilis explains many so-called rheumatic cases; more than 
 half the paralyses of the eye muscles are syphilitic. Ocular paralyses 
 may be (a) peripheral; (b) intracranial as at the base of the brain; 
 or (c) central, comprising nuclear, fascicular and cortical localiza- 
 tion. Anatomically the following lesions occur: Syphilitic menin- 
 gitis, basal gummata and periostitis, cellulitis of the orbit, diffuse 
 arterial disease, nuclear disease, poliencephalitis and gummata of the 
 hemispheres or cortex. Other causes, as tabes, general paralvsis 
 and tumor, must be considered. Thirty-six to 50 per cent, of nuclear 
 
, SYPHILIS. 277 
 
 paralyses are syphilitic. According to Gowers, syphilis frequently 
 produces progressive paralysis of all the muscles of both eyes. Total 
 paralysis of the oculomotor is rare ; if it occurs, the lesion is usually 
 at the base, is rarely orbital, or may be nuclear with localization in 
 the third ventricle, especially if one twig after another become in- 
 volved. If it is partial, it is usually nuclear, rarely neural or muscu- 
 lar. Ptosis occurs very frequently, and is highly suggestive of syph- 
 ilis. Abducens and trochlear paralysis may occur. Ophthalmoplegia 
 interna, involving the sphincter iridis and the ciliary muscle, pro- 
 duces mydriasis and paresis of accommodation. Thirty-six per cent, 
 of all mydriases are syphilitic (Alexander). Its origin is purely 
 nuclear (Mauthner). Ophthalmoplegia externa may occur with 
 facial paralysis, involving the orbicularis palpebrarum, or with tri- 
 geminal paralysis involving the sensory filaments of the eye (in 25 
 per cent, of brain syphilis, Uhthoff). 
 
 Orbit. — Cellulitis and periostitis occur frequently. Periostitis is 
 indicated by deep pain on pressure over the eyeball, or over the edge 
 of the orbit, which is sometimes prominent ; by pain on movement of 
 the eye; more rarely by blindness, exophthalmos and thrombosis. 
 Periosteal gummata may often be mistaken for tumors. 
 
 Ear. — Four instances of primary sclerosis on the external ear 
 have been noted (Politzer). The ear in general is involved in 0.6 per 
 cent, in acquired syphilis; 33 per cent, of children with hereditary 
 syphilis are deaf. Secondary maculae or condylomata, mastoid peri- 
 ostitis or gumma, sclerosis or gumma of the Eustachian tube, sup- 
 purative otitis media, sclerosing otitis media and labyrinthine dis- 
 ease (rapid deafness, vertigo and tinnitus), may be observed. 
 
 11. Genitalia. — Some primary lesions occur in the urethra. Sec- 
 ondary manifestations are infrequent; gummata have been occasion- 
 ally observed in the urethra and bladder. 
 
 Penis. — Gummata may occur at the site of the primary lesion or 
 elsewhere, and often have been confused with chancre, chancroids, 
 pustules or carcinoma. 
 
 Testes. — (a) The diffuse interstitial form (orchitis fibrosa syph- 
 ilitica) occurs with great enlargement ; the swelling is pyriform, with 
 flattening of the epididymis ; it is more often nodular than smooth, 
 due to periorchitis or sometimes to gummata. Serous effusion and 
 partial or total synechia occur. Recovery by absorption of this 
 sarcocele syphilitica may result. The connective tissue is increased 
 and the canals are compressed, separated, fatty and infiltrated with 
 round cells. (&) Gummatous orchitis is less frequent, and usually 
 involves one testis, and also the epididymis and cord. Great sym- 
 metrical or irregular swelling may occur, and frequently the entire 
 testis is elastic, firm and studded with gummata. It is often mis- 
 taken for sarcoma. The testes atrophy and sclerose. The symptoms 
 develop gradually or after strain or trauma. The anterior portion of 
 the testis is most involved, with single or multiple, hard, irregular 
 nodules, which are usually not painful. The veins are dilated and 
 
278 THE SPECIFIC INFECTIONS. 
 
 adhesions occur. The scrotum is infiltrated, nodular and red or 
 violet in color. Perforation is frequent, with a crater-like opening 
 and irregular edges. Oligospermia, azoospermia or impotentia do 
 not always follow, because islets of functionating tissue frequently 
 remain. Differentiation is required from gonorrheal orchitis, which 
 is more rapid, painful and involves the epididymis first; plastic 
 orchitis, resulting from stricture, traumatic orchitis and mumps 
 orchitis; also from tuberculous disease, which is often bilateral, or 
 which at least occurs in several foci, and frequently involves the cord, 
 vesicles, epididymis and often causes perforation with pain, fever 
 and prostration, in which case tubercle bacilli may be detected. Dif- 
 ferentiation is necessary from sarcoma, which is harder, develops 
 more rapidly, is more nodular, produces lancinating pains and fre- 
 quently affects the epididymis and cord, which are less often involved 
 in syphilis. Sarcoma also invades the glands and, when perforation 
 results, is more rapid and painful and occurs with fever, necrosis, 
 hemorrhage and cachexia. Carcinoma, which is often difficult to 
 differentiate from the interstitial form of syphilis, does not respond 
 to specific treatment. 
 
 Vas Deferens. — Gummata may rarely form. Syphilis of the 
 seminal vesicles may convey the disease to the mother and child. 
 Prostatic involvement is rare. 
 
 Vagina. — Chancres are relatively rare, because of the thick epi- 
 thelium and the paucity of glands; secondary eruptions are rarely 
 observed. Condylomata must disappear under mercury to make 
 certain the diagnosis. Gummata rarely occur. 
 
 Vulva. — The vulva is very frequently the seat of secondary lesions, 
 upon which tertiary lesions may develop. These may extend to the 
 urethra or bladder. Enormous swelling, sometimes resembling blis- 
 ters, is a common result of lymphatic involvement. Phagedenic 
 ulcerations or strictures may occur. Gummata are readily differen- 
 tiated from carcinoma and tuberculosis. 
 
 Cervix. — Chancre occurs in 5.5 per cent, of the cases (Fournier, 
 Mracek and Neumann). Scars may result, with stenosis and ster- 
 ility. Tertiary lesions may occur and recur. Diagnosis may be 
 difficult. 
 
 Uterus. — Syphilitic endometritis is frequent; its symptoms are 
 the same as those of the non-syphilitic type; metrorrhagia may re- 
 spond only to mercury. Yirchow describes a papular and a tuberous 
 variety. Endometritis may produce sterility. Metritis syphilitica 
 has been less studied, but clear cases are recorded, in which large 
 tumors disappeared on administration of iodide. Specific peri- 
 metritis or simple perimetritis is secondary to rectal disease. 
 
 Tubes and Ovaries. — Salpingitis and oophoritis syphilitica and 
 gummata have been described. 
 
 12. Bones, Joints and Muscles. — Secondary periostitis pro- 
 duces pain, tenderness and considerable swelling, which is hard at 
 first, and later is elastic even to fluctuation. It occurs especially on 
 
SYPHILIS. 279 
 
 parts subject to trauma, as the forehead, temporal bone, sternum, ribs, 
 tibia or clavicle. Osteophytes develop. Fugitive pain may occur 
 with the secondary eruption, but the pain of periostitis is fixed; it 
 may radiate but rarely migrates, is increased by pressure, is largely 
 boring in character, appears at night — the dolores nocturnce — and 
 disappears at one or two o'clock in the morning with sweating, but 
 otherwise resembles the common types of periostitis. In 28 per cent, 
 of cases it occurs in the frontal or temporal bones, and forms circum- 
 scribed, smooth, elastic and immovable tumors. On the ribs, it 
 occasions pain on coughing, neuralgia over the sternum or possibly 
 dyspnoea. Tibial nodes occur in 16 per cent, of cases. Periosteal 
 changes last for five or six weeks. Gummata of the bones were the 
 first well-studied form of gummata. They occur on the exposed parts 
 largely as: (a) Diffuse subperiosteal infiltration, which causes molec- 
 ular destruction of the bone, and possibly reaches the marrow or 
 meninges (perforating type). Osteophytes develop as an effort of 
 nature toward regeneration. The bone may rarefy or show foci of 
 sclerosis; multiple areas exist in the pernicious forms of gummata. 
 In large bones sequestra may form, especially in the femur; osteo- 
 phytes in the diaphysis sometimes resemble arthritis deformans. 
 (&) Circumscribed gummata, the more important form, develop 
 chiefly in the periosteum; they form elastic, immobile, not especially 
 tender tumors which afterward soften and, at a late stage, may 
 fibrose and calcify. 
 
 Symptoms. — Gummata of the cranium are attended by dull pain, 
 especially at night ; have a slow growth ; are at first soft, and later 
 have a wall-like, hard edge. They rarely ulcerate and often disap- 
 pear spontaneously, leaving a somewhat elevated periphery and a 
 deep centre. They are very often mistaken for supraorbital neu- 
 ralgia or migraine. Tuberculous ulcers rarely occur in this location. 
 Pyogenic infection may produce ulceration ; or meningeal symptoms 
 may develop. Gummata at the base, where periostitis is observed 
 infrequently, occur chiefly in the middle fossa and involve the nerves 
 or bloodvessels. Diffuse gummatous infiltration develops very slowly, 
 with little pain, possibly with ulcerative exposure of the bone and is 
 diagnosticated with difficulty. The spine is rarely the seat of gum- 
 mata ; but when involved, the affection is largely cervical, rarely dor- 
 sal, very rarely lumbar, and affects the bodies of the vertebrae less than 
 their processes and arches, in contradistinction to tuberculosis. Pain 
 and immobility are observed. The head is held in the hands, if the 
 atlas is involved ; recovery is possible, but death may result from ul- 
 ceration, pressure on the medulla or luxation. Paralysis of the upper 
 extremities has been observed. The humerus, radius and carpus 
 are less frequently involved. The phalanges may be involved, but 
 this usually affects one finger only, the spina ventosa, the parts being 
 swollen but soft, with periosteal thickening, shining appearance 
 and rarely pain or ulceration. The clavicle, from its slight protec- 
 tion and its exposure to trauma, is very frequently involved; the 
 
280 THE SPECIFIC INFECTIONS. 
 
 course is slow, often without pain. Ulceration of the sternum is 
 frequent ; of the ilium and sacrum rare. 
 
 Joints. — (a) Acute synovitis occurs alone or with bone changes at 
 the time of the eruption ; pain alone may be observed or the swelling 
 may be multiple, constituting the pseudorheumatism of Fournier, 
 with tenderness, nocturnal pain, immobility, temperature, fluctua- 
 tion and involvement of the periarticular structures, as the muscles 
 and tendons. The acute form is polyarticular, while the subacute va- 
 riety is oftener monarticular. The knees are most frequently involved 
 and, according to Fournier, more than three joints are never affected. 
 The affection may last for weeks or months, does not induce cardiac 
 complications, and responds to mercury and iodide and rarely to sali- 
 cylates. ( b ) Chronic synovitis or arthritis is usually monarticular, in- 
 dolent, with little or no pain or fever, and affects- chiefly the knee and 
 elbow, with fluctuation and slow loss of function. It responds to anti- 
 syphilitic treatment, (c) Joint disease of late syphilis originates in 
 the bone or cartilages (tumor albus syphilitique of Richet),and affects 
 chiefly the knee and elbow and next in frequency the ankle. The 
 central portion of the cartilage is involved, and not its edge, as is the 
 case in arthritis deformans. This is probably due to gummata origi- 
 nating in the bone and is most frequently seen in congenital syphilis. 
 The symptoms begin slowly with moderate pain, swelling and local- 
 ized tumors; no temperature is observed, the symptoms vary and 
 contracture may result. There may be a close resemblance to tuber- 
 culous lesions, diagnosis from which depends upon other stigmata 
 of syphilis or tuberculosis; while tuberculosis is usually inflamma- 
 tory, incipient syphilitic lesions are non-inflammatory; in syphilis, 
 sequestration and ulceration are infrequent ; therapy is the final test. 
 
 Muscles. — Early involvement may occur from toxaemia or myositis. 
 The latter is either a diffuse or circumscribed infiltration, which 
 possibly eventuates in muscular contractures, especially in the arm 
 and finger flexors, sphincter ani, masseters, deltoid and sternomas- 
 toid. The course is subacute or chronic, depending on treatment. 
 The affection is most often observed from two to twelve months after 
 infection. Differentiation from muscular rheumatism may be neces- 
 sary. Gummata of the muscles are important because of confusion 
 with neoplasms, especially in the arms and neck ; they may be as large 
 as the fist, single or multiple, usually with a firm connective-tissue 
 capsule; they involve the long muscles, especially at their attach- 
 ments. The course is long, and regression may occur with indura- 
 tion. Myositis ossificans is rare. Syphilitic atrophy of the muscles 
 may follow arterial disease and, less frequently, central nervous 
 lesions. The tendons may be involved, partly from changes in the 
 bones or muscles, (a) The irritative form, occurring early as acute 
 bursitis or tendosynovitis (Fournier), is sometimes confused with 
 rheumatism. There is more tension than pain. It occurs most fre- 
 quently in sewing women and washerwomen, and the exudate is usu- 
 ally absorbed. (6) The gummatous form, occurring in the flexor 
 
SYPHILIS. 281 
 
 tendons, is characterized by slow growth, little pain and usually a 
 favorable prognosis. 
 
 13. Mamma. — The mammae may be involved (a) by diffuse infil- 
 tration, syphilitic mastitis, with increased size, and even tumor for- 
 mation. The affection occurs largely in the secondary stage, and 
 often resorbs spontaneously, (b) Gummatous mastitis is deep-seated 
 and is not very sensitive. Rapid growth may be observed with cen- 
 tral necrosis, fluctuation, or even external ulceration. It requires 
 differentiation from adenoma, fibroma and carcinoma ; no glands are 
 involved, it occurs frequently on both sides, without cachexia, but 
 possibly with gummata elsewhere, and it responds to antisyphilitic 
 treatment, (c) 206 cases of mammary chancre are recorded 
 (Dimey). 
 
 Abnormal Course of Syphilis. — Of special importance is malignant 
 syphilis (syphilis prgecox, acute or galloping syphilis, synonymous 
 with early tertiary development). The cause may be increased viru- 
 lence of the spirochete, or decreased physiological resistance, as in 
 cases of tuberculosis, alcoholism and other cachexias Early ulcera- 
 tion, grave general symptoms and hemorrhage are noted. 
 
 Prognosis. — The mortality is great in congenital syphilis (v. i.) ; 
 tuberculosis, retarded development, idiocy and epilepsy may result 
 later. On pregnancy the disease has a bad influence and mercury is 
 less universally successful. Exanthematous diseases may cause syph- 
 ilis to disappear but their curative influence is short. The effect of 
 coincident measles and smallpox is unfavorable. Chronic diseases, 
 as tuberculosis, are unfavorable and often induce the ulcerative form 
 with early tertiary symptoms. Syphilitic cachexia may be compli- 
 cated by tuberculosis; glaucoma may become aggravated, and syph- 
 ilitic psoriasis may become carcinomatous. Trauma; in the treat- 
 ment of fractures in syphilis, mercury is indicated. Syphilis is im- 
 portant in plastic operations. Wounds may become the seat of 
 specific ulceration. 
 
 In life assurance, the outlook is uncertain; it has been estimated 
 that 11 per cent, die before their expectancy (Runeberg) ; the main 
 direct causes of premature death are cardiac disease, aneurysm, ne- 
 phritis and nervous localizations (dementia, tabes and arterial 
 thrombosis) ; the chief contributing causes are poverty, worry, over- 
 work, tuberculosis and alcoholism. 
 
 II. Hereditary Syphilis. — That syphilis descends only to the first 
 generation is the general belief. Eournier (1905) finds 115 cases 
 recorded in the second generation, of which many are very doubtful. 
 
 If both parents are diseased the child mortality is 75 per cent., but 
 this depends on treatment; 95 per cent, of living syphilitic children 
 die, if not treated, and only 10 per cent, if treated (Etienne) ; only 
 3 per cent, die, if the parents were properly treated (Fournier). In 
 330 syphilitic pregnancies, abortion or premature delivery occurred 
 in 40 per cent., and delivery at term in 60 per cent. 
 
 1. Syphilis of the Child Acquired from the Father at the Time of Con- 
 
282 TEE SPECIFIC INFECTIONS. 
 
 ception. — Purely spermatic (paternal) infection is the simplest and 
 most frequent variety, in that 97 per cent, of cases of syphilis occur 
 in men (Fournier), although a larger ratio occurs in women of the 
 lower classes. It rarely occurs after the second year of infection has 
 passed. This form of transmission is more probable, the more recent 
 the paternal disease. The effects are shown by abortion, premature 
 birth, less frequently by syphilitic children at full term, or all of the 
 above successively (the virulence of paternal syphilis decreasing 
 with time). The child mortality is 28 per cent, and the morbidity 
 37 per cent., this being the most favorable form. The mother, it 
 was once maintained, remained uninfected ; since the discovery of the 
 spirochetes, it would appear that the mother is always infected. 
 
 2. Syphilis of Child from Mother, Syphilitic at the Time of Conception. 
 — Infection is most dangerous in the first year of the disease and 
 generally persists longer than in man. Abortions occur first, then 
 premature deliveries, and finally, dead or diseased children at term. 
 The mortality is 60 per cent, and the morbidity 84 per cent. 
 
 3. Infection of the Mother and Conception Occurring Simultaneously. — 
 This form is dangerous to the child, though early treatment may 
 modify the result. According to Neumann, in 29 per cent, of cases, 
 the children are not viable, and 39 per cent, die soon after birth (i. e., 
 68 per cent. die). 
 
 4. Postconceptional Syphilis. — The child is less liable to contract the 
 disease, the later the infection of the mother ; it may even escape di- 
 rect infection and only suffer inanition. The virus may pass through 
 the placenta to the child, although there is a theory that the placenta, 
 if not diseased, may protect the child from infection. 
 
 Influence upon the Sound Mother of the Child Infected by the Father. — ■ 
 Colles' (or Beaume's) law is as follows: The child is held to make 
 the mother immune to infection; she cannot be infected from her in- 
 fected child; she can nurse her syphilitic child without danger. 
 Some exceptions exist and 30 cases are reported in which the mother 
 was infected after the birth of a syphilitic child. In such cases, 
 Fournier held that the mother is already syphilitic. Sound chil- 
 dren of syphilitic parents have apparently some immunity against 
 syphilis because of action of toxins (Prof eta's law, — i. e., the syphi- 
 litic mother is said not to infect the sound child, which theory has 
 many exceptions). If the children acquire syphilis, it is said to run 
 a mild course. It is, nevertheless, a fact that the sound child may 
 become infected intra partum (Grunfeld). 
 
 Influence on the Child. — Abortions and miscarriages have been 
 overestimated as evidences of syphilis. They are frequent in ani- 
 mals. Abortion, atrophy, maceration, retarded development, con- 
 genital syphilis or evidences of the disease after birth are frequent. 
 Many children, born first after infection, die, though those born 
 later may be sound. A difference exists between the congenital syph- 
 ilis with signs at birth, and the hereditary type, which develops later 
 (possibly very late, syphilis hereditaria tarda). Even when specific 
 
SYPHILIS. 283 
 
 lesions are absent, pathological cell degeneration, rhachitis, scrofu- 
 losis, slow intelligence, neuroses, psychoses and a high percentage 
 of mortality to all diseases may result. 
 
 Symptomatology. — The primary, secondary and tertiary stages are 
 not usually present and lymphatic infection does not precede that of 
 the entire organism. Secondary and tertiary manifestations may 
 occur in the most intimate and synchronous connection. The symp- 
 toms are usually recognizable at birth or soon afterward, usually 
 after a few days or weeks, and almost always within the first three 
 months. 
 
 Appearance.— The atrophic child presents a characteristic appear- 
 ance, with relaxed yellow-gray skin, poorly developed hair, bent or 
 undeveloped nails (onychia) and "the little old man" appearance 
 described by Trousseau. The palms and soles are lacquered, the 
 voice and muscles are weak and the child does not nurse well. Such 
 children, especially when several are born in succession, are sug- 
 gestive of syphilis, even when no lesions are found. Other suggestive 
 symptoms include the heavy placenta whose weight compared with 
 that of the syphilitic child is 1 to 5, 4 or 3 (normally 1 to 6) ; increas- 
 ing loss of weight for one to two weeks (normally three days), which 
 may amount to 13 ounces; and enlargement of the spleen. In the 
 placental villi end- and periarteritis occur, which may cause, by vas- 
 cular occlusion, placental necrosis and adherence. Similar changes 
 in the umbilical vessels may destroy the child. 
 
 Pathognomonic Symptoms. — The exanthem, as in adults, is poly- 
 morphous, but varieties occur which are absent or infrequent in the 
 adult, such as pemphigus, hemorrhages, furuncles and diffuse in- 
 filtration of, the skin. There is a general tendency to severe forms. 
 The maculae are dirty, brown-red and often confluent, and occur on 
 the face, body, extremities and in the genital region. The papules 
 occur principally in the folds of the joints, axillae, groins and gluteal 
 region and tend to recur; papules of various ages co-exist with de- 
 squamation, though never with condyloma, which is always a sign 
 of acquired syphilis. They tend to ulcerate. Psoriasis of the hands 
 and soles of the feet with desquamation is common. Pustular lesions 
 occur in severe syphilis and are prognostically unfavorable. They 
 occur not only in the new-born but also in the immature foetus; 
 pemphigus is a subtype of the pustule; gangrene and necrosis may 
 occur. The copper-colored syphilitic infiltration especially on the 
 nates and lower extremities, often may be mistaken for erysipelas. 
 Coryza ("snuffles") is very characteristic and almost invariable, the 
 secretion being bloody and purulent, with crust formation. Fissures 
 occur about the mouth, with an infiltrated base and cicatrix forma- 
 tion. Papular eruptions (erosions) occur in the mouth, especially 
 on the tongue and the palate, with a tendency to necrosis. Eruptions 
 and rhagades occur about the genital and anal regions. 
 
 Teeth. — Erosions, furrows and notches may develop. The teeth 
 are small, often irregular and poorly developed. Hutchinson held 
 
284 TEE SPECIFIC INFECTIONS. 
 
 f 
 that the semilunar curving on the free edge of the upper middle 
 permanent incisors was pathognomonic of tardy hereditary syphilis, 
 but Hutchinson's teeth occur in other affections, such as scrofula and 
 rickets, and are expressions of constitutional derangement and not 
 necessarily syphilitic. Later the lateral borders of the teeth become 
 curved ; the teeth may become peg-like or the notches grind off even. 
 
 Fig. 19. 
 
 "OQwO' 
 
 Notched teeth. Malformation of permanent teeth found in hereditary syphilis. 
 (Jonathan Hutchinson.) 
 
 Bones. — The bones, as in adults, may present characteristic find- 
 ings. There may be periostitis, tophi or perforated palate. Osteo- 
 chondritis occurs in various bones but especially in the lower end of 
 the femur; the diaphysis and epiphysis may be separated (Wagner). 
 There is (a) overgrowth of the cartilage of the diaphysis which pro- 
 duces the wavy line of white cartilage cells; (&) the line of cartilage 
 cells becomes thick and foci of decalcification occur; (c) the cartilage 
 is as prominent as it is in rickets, the part nearest the bone being 
 soft. The immobility of the leg may suggest paralysis (Parrot). 
 
 Viscera. — The changes are vascular or gummatous. There are 
 characteristic changes in certain organs which are rarely involved in 
 acquired syphilis; — e. g., in the thymus, umbilical cord, pancreas, 
 lungs, intestines and adrenals. The liver and spleen are greatly 
 enlarged. To avoid repetition and to conserve the classification, these 
 changes have been described under Special Symptomatology. Vas- 
 cular changes are especially marked, as in the umbilical vessels, with a 
 tendency to hemorrhage — syphilis hcemorrhagica neonatorum. Hem- 
 orrhages in the skin, mucous membranes and viscera, may be pro- 
 fuse, especially in the liver and the lungs, where the circulation is pre- 
 cipitately altered after birth. Some vessels may be thickened or 
 infiltrated (disease of the vasa vasorum). There is often deficient 
 brain development or meningitis in the posterior cerebral fossa. 
 
 Acquired Syphilis in Children vs. Hereditary. 
 
 Less mortality and less malnutrition. Marked. 
 
 After third month (are exceptions). Before third month. 
 
 A primary lesion occurs. Absent. 
 
 Secondary lesions, then tertiary. Secondary and tertiary together. 
 
 Lymph glands enlarged. Absent (except from accidental causes 
 
 or suppuration). 
 
 Usual sequence of primary, secondary Snuffles, anaemia, diffuse pigmentation, 
 and tertiary symptoms. pemphigus, involvement of soles and 
 
 palms, epiphyseal changes, etc. 
 
SYPHILIS. 285 
 
 Syphilis hereditaria tarda develops its first symptoms in later years, 
 as for instance, at puberty. This variety is recognized if (a) the 
 parents are syphilitic, and if (b) the individual has presented no 
 previous signs of syphilis. Most cases begin between the tenth and 
 eighteenth years (rarely before the tenth and even after the fortieth 
 year). Most cases are seen in private practice. The symptoms 
 are mostly those of infantilism, in regard to puberty, bone develop- 
 ment, teeth, hair and brain. 
 
 Immunity. — Syphilis usually confers immunity, but this is neither 
 absolute nor life-long, because (1) reinfection may occur (80 in- 
 stances, Stern, 1907) ; (2) in hereditary syphilis, a later infection 
 may be acquired (27 cases known) ; and (3) a sound child of syphi- 
 litic parentage may acquire syphilis (29 cases reported). 
 
 Treatment of Syphilis. — Prophylaxis. — The disease prevails in 
 spite of the numerous opportunities for free treatment, for the sexual 
 instinct is even stronger than that of self-preservation. Irregular 
 intercourse is possible because of class differences, lack of barriers 
 among the ignorant and destitute, and is promoted by the struggle 
 for existence which often makes early marriage impossible. Prosti- 
 tution, hidden or open, is the basis of syphilis. Sixty-nine per 
 cent, of women in open houses have the disease for months before 
 treatment is instituted, while hidden prostitution among waitresses, 
 for example, is much more dangerous. In prostitutes, condylomata 
 last as long as seven years and repeatedly recur about the genitalia. 
 Continence is the sole prophylactic measure. Enforced medical in- 
 spection is ineffectual. American sentiment is against licensed pros- 
 titution, which, besides, is incomplete because it does not regulate 
 men or unlicensed hidden prostitution. Licensing also teaches the 
 young that immorality is safe. Many infections are acquired under 
 the influence of liquor (Sine Baccho friget Venus). "Where ethical 
 considerations fail, an appeal to fear may be effectual. Metschnikoff 
 comments upon the remarkable fact that diseases conveyed by insects 
 are rapidly becoming preventable, whereas diseases like syphilis 
 and tuberculosis conveyed by rational human beings, are not. Efforts 
 to educate the public will doubtless avail much. 
 
 The importance of the disease lies in its long course, in the in- 
 volvement of vital viscera, in its transmission to the wife and offspring 
 whose mortality and morbidity are enormous, in its wide dissemina- 
 tion (13 per cent, of the population acquire the disease, and 1,650,000 
 persons are infected annually), and finally in our possession of specific 
 remedies. 
 
 Marriage should be forbidden for at least three or better, four or 
 five years. Coitus must be avoided when there are recurrences. In 
 cases of doubtful infection of the wife or husband, both should be 
 treated. Inunctions should be given the. pregnant mother, whether 
 she be infected in the first or second part of pregnancy. If the 
 child be diseased and the mother healthy, the facts should be laid 
 before her and some would then allow her to choose whether she 
 
286 TEE SPECIFIC INFECTIONS. 
 
 would nurse her child. Mercury should be given her. The physi- 
 cian should never countenance employing a healthy wet-nurse for 
 the syphilitic child. Circumcision is thought to lessen chances of 
 infection. Metschnikoff advises a prophylactic calomel ointment, to 
 be applied at once after intercourse. 
 
 1. Initial Lesion. — Extirpation is inefficient. The early use 
 of mercury does not prevent the secondaries or the recurrence of the 
 disease ; it may lessen secondary manifestations. Nevertheless, the 
 writer believes early treatment is indicated, but only when the diag- 
 nosis is certain, i. e., when there is a typical chancre and spiro- 
 chetes are found. The diagnosis must he positive, as syphilis en- 
 tails years of scrutiny and complicates the life of the wife and 
 offspring. Local treatment includes the use of antiseptics, iodoform, 
 aristol, mercurial plasters, iodoform in suppository in rectum or 
 vagina, bichloride washes for mouth and calomel for condylomata 
 (calomel 6 parts, boric acid 3, and salicylic acid 1 part). 
 
 2. Secondary Stage. — In the secondary stage mercury is a spe- 
 cific. It must always be used with care ; the teeth should be cleaned 
 first, and bad teeth filled. Calomel acts especially on the lesions of 
 the mouth and is prone to produce salivation. Mercury is indicated 
 for all of the irritative (i. e., secondary) phenomena of syphilis, and 
 Gowers always uses it with the iodides, even in the tertiary stage, 
 especially in nervous lesions. Mercury may produce bad effects 
 (v. i.) in tuberculous, cachectic, alcoholic, malarial or anaemic sub- 
 jects, in bleeders and in cases of galloping syphilis, in which latter 
 iodides are considered by some better than mercury. Mercury must 
 be used with great care in nephritic subjects. During and after a 
 course of mercury, tobacco must be interdicted because it perpetuates 
 syphilitic sores in the mouth for years, even decades. Moderation 
 in all matters of life is enjoined upon the patient. 
 
 Methods of Administration. — 1. By Mouth. — Ninety-five per cent, 
 of cases are treated by this method in this country: (a) Calomel 
 (Hydrargyri chloridum mite) is especially adapted to children with 
 hereditary syphilis, who are rarely salivated under three years of 
 age ; gr. J to \ t. i. d. plus opium p. r. n. It is insoluble, and is prob- 
 ably converted by the alkaline carbonates in the intestines into the 
 gray oxide which is absorbed with the fats, (b) Blue mass (Massa 
 hydrargyri), gr. -J to 1, is milder than calomel and less irritant to the 
 stomach, but produces salivation oftener than any other mercurial. 
 Women are less subject to ptyalism than men. (c) Hydrargyrum 
 tannicum oxydulatum (Lustgarten) contains 50 per cent, mercury, 
 is non-irritant, does not salivate, produces less diarrhoea and is easily 
 assimilated; gr. 1 to 1^ plus pulv. opii gr. -fo ; (d) The Hydrarg. 
 iodidum flavum or protiodide is mild, insoluble and analogous to 
 calomel. 
 
 ]£ Hydrargyri iodidi flavi gr. xv. 
 
 Extr. opii gr. v. 
 
 Extr. gentianse q.s. 
 
 M. et ft. pilulsB no. 60. 
 S. — One after meals. 
 
SYPHILIS. 287 
 
 (e) The bichloride of mercury is irritating (Hydrarg. chloridivm 
 corrosivum) ; it is not prone to salivate, is absorbed by the intestine 
 and stimulates the liver. Mercury, administered internally, produces 
 more irritation and is less likely to be absorbed. Patients are more 
 apt to persist in this form of treatment. Sublimate is readily soluble. 
 It is used especially in children and in lighter forms of the disease. 
 Mercury internally was first used by Benedictus (1525). 
 
 2. Inunctions. — These must be thorough and should be given 
 where the skin is soft (flexor surfaces). The mercury is rubbed into 
 the sebaceous or sweat-glands and is probably absorbed by the lymph- 
 vessels. The skin must be cared for by daily baths. A simple diet 
 and mild laxatives should be given, though, as a rule, mercury some- 
 what loosens the bowels. The rubbing should continue for twenty to 
 thirty minutes. Hairy regions, the axillae, navel, nipple and 
 areas of accidental eczema, abscess, psoriasis or furuncle, are to be 
 avoided. On the first day the inunction should be given on the 
 abdomen, on the second day on the chest, on the third on the calf, 
 then on the thigh, forearm, arm, etc. After inunction, the part is en- 
 veloped in cotton. If an attendant gives the rubbing, his hand 
 should be protected by a rubber glove. Written instructions should 
 always be given to the patient. 
 
 The number of inunctions necessarily varies with the case ; twenty 
 to thirty should be given for the macular and papular types ; more 
 than thirty, for all pustular or ulcerating eruptions, but not more 
 than thirty should be given continuously. Inunctions must be inter- 
 rupted for ulceration, diarrhoea or stomatitis. Salivation is not de- 
 sirable, nor is it a sign that enough mercury has been given. The 
 unguentum contains 50 per cent, of mercury, and the more elegant 
 oleatum but 20 per cent., which should be considered, as about 3ss 
 of mercury should be incorporated daily. 
 
 ]£ Unguent, hydrarg Jiv. 
 
 Div. in dos. sequal. no. xxx. 
 
 Dent, ad cartam cerat. 
 S. — One as directed daily. 
 
 In children, mercurial ointment may be applied on a binder and 
 allowed to remain for many days (Westlander). Children stand rela- 
 tively large doses but women usually endure only half the adult dose. 
 The advantages of inunctions are as follows: They cause almost no 
 digestive disturbance ; they are especially good in children ; they are 
 the most rapid method, and are attended by the least general bad 
 effects. The disadvantages are publicity, troublesomeness and dirti- 
 ness, all of which, however, are but relative objections. Inunctions 
 were first used by the Galenists. 
 
 3. Injections. — A great diversity of opinion exists as to the value 
 of injections. Their advantages are prompt action and exact dosage. 
 Intravenous injections may be imperative in cases with coma and 
 other urgent symptoms. The disadvantages are the risk of em- 
 
288 THE SPECIFIC INFECTIONS. 
 
 holism, suppuration, sloughing and pain; once given, their action 
 cannot be regulated or decreased. The soluble salts are best : 
 
 ]£ Hydrarg. chlorid. corrosivi 1-00 
 
 Sodii chloridi 10.00 
 
 Aquae dest 100.00 
 
 One c.c. daily equals 0.01 gm. or gr. £ of HgCl 2 ; forty injections 
 are usually necessary. 
 
 4. Baths. — 3ij to iij of HgCl 2 to a full bath are useful for skin 
 lesions, such as syphilitic psoriasis. 5. Fumigations are impractic- 
 able. As a working rule, mercury should first be given two months 
 and stopped one month, through the first year i. e., two thirds of 
 the time; in the second year, about half the time, with intervals; 
 in the third year, one third of the time. 
 
 Mercury is incompatible with nearly everything. Coincident anae- 
 mia is treated by iron, strychnia and arsenic. Syphilitics tolerate 
 mercury well, in large doses, and for a remarkable period. In- 
 deed, they sometimes seem to develop an immunity to its action. It 
 is not out of place to consider briefly the general action of the drug ; 
 in the smallest doses it is tonic, for it increases the number of red 
 cells. In small doses there develops a symptom-complex known as 
 salivation, of which peculiar foetor is first noted; then sore teeth, 
 red, swollen, spongy and bleeding gums, and increased saliva, follow. 
 The drug is never given beyond this point.' In larger doses the 
 tongue becomes swollen, the gums inflamed ; the teeth become loose ; 
 the saliva is increased greatly, is viscid and stringy; the salivary 
 glands become intumescent; there is low fever; fugaceous eruptions 
 appear, resembling eczema, scarlatina, measles and more rarely, 
 purpura and pemphigus. Severe salivation results in loss of teeth, 
 necrosis of jaw, ulceration of the mouth and contiguous parts, 
 marked changes in the blood and profound exhaustion. The treat- 
 ment consists of potassium chlorate as an antiseptic mouth wash, 
 and astringents, as tr. myrrh and tannic acid. 
 
 3. Tertiary Stage. — Iodides are specific in this stage and their 
 resolvent action is little short of miraculous. They were introduced 
 by Welch of Ireland and popularized by Hicord in France. They 
 are sometimes used in the secondary stage (v. s.) y especially in 
 febrile cases, secondary osseous and nervous manifestations, and 
 weakly persons with a marked macular eruption. They act more 
 slowly than mercury. They are especially indicated when the bones, 
 nervous system and viscera are the seat of gummata, and when the 
 general health is broken. Patients may acquire immunity to iodides 
 and their use should therefore be intermittent and should alternate 
 with mercury. Mercury is Conjointly employed when organs of great 
 importance are involved, such as the larynx, brain and eye. 
 
 The therapeutic tests for syphilis are (a) cure with mercury and 
 iodides ; (b) tolerance by the patient of very large doses. Eegarding 
 their diagnostic value, Gower's criteria are: (1) That the influence 
 
SYPHILIS. 289 
 
 of the drugs must be unequivocal and fairly immediate. (2) That 
 no other remedy be used. (3) That spontaneous remissions seen in 
 other diseases must be excluded. (4) That the remedies used must 
 not operate on any disease other than syphilis. (5) Before negative 
 conclusions are drawn regarding the syphilitic nature of the lesion, 
 it must be remembered that loss of tissue, e. g., in arterial occlusion 
 and paralysis from brain softening, cannot be restored. 
 
 The iodides contain the following percentages of iodine: KI, 
 75.5 per cent; E"al, 84.6 per cent.; Lil, 95.5 per cent; Ami, 87 
 per cent. 
 
 Sodium iodide is milder, produces less iodism, has a less bitter 
 taste, and has less effect on metabolism than potassium iodide, which 
 however, is better than other iodides (Schmiedeberg), though it irri- 
 tates the stomach and bowels, depresses the muscles, and depresses the 
 motor nerves. 
 
 The following proportions for a single ordinary dose may be em- 
 ployed ; the mercury becomes mercuric iodide : 
 
 ]£ Potassii iodidi gr. xv. (gm. 1.0) 
 
 Hydrargyri chloridi corrosivi gr. £% (gm. 0.002) 
 
 Tincturoe opii TTL 2 (gm. 0.13) 
 
 Syrupi aurantii eorticis 3ss (gm. 2.0) 
 
 M. et S. — After meals in a glass of water. 
 
 Large doses of iodide are sometimes given in urgent cases, 3j-ij 
 t.i.d., to break down more rapidly the new-formed granulation tissue. 
 The author believes that enormous doses are unnecessary and are 
 not without danger (v. i.). Lournier warns against their intemperate 
 use — "iodide debauches." Iodide dissolves in its own weight of 
 water; hence one minim of a saturated solution equals one grain of 
 iodide. It is best disguised by Syr. sarsaparillse co., dr. ss and Tr. 
 iodi, Tit 1. 
 
 Iodism is often produced by small doses, and usually ceases with 
 larger ones. It is obviated by intermittent administration, by daily 
 baths, by flushing out the kidneys, the inactivity of which is the 
 usual cause, by giving aromatic spirits of ammonia, or arsenic 
 and belladonna. Iodism is likely to occur in renal disease. Its 
 leading characters are : Increased secretion from the eyes, nose, mouth, 
 salivary glands, bronchi, stomach, bowels, skin and kidneys. The 
 eyes, throat, larynx and salivary glands swell. The writer once 
 nearly suffocated from oedema of the pharynx and uvula after inges- 
 tion of 10 grains of iodide for a cold. Laryngeal and pulmonary 
 oedema and albuminuria, or even nephritis, may develop. Gastric 
 irritation; and nervous depression, mental derangement or excite- 
 ment. Acne, hemorrhages, blebs and telangiectases in the skin. 
 Cachexia and ancemia, especially in goitrous subjects; emaciation, 
 wasting of mammse and testes ; fever, increased pulse and neuralgias. 
 
 The iodides are continued for two months and their use then 
 remitted for one month and so on. After several years, iodides 
 are given for one month twice a year e. c/. } in January and July. 
 
290 TEE SPECIFIC INFECTIONS. 
 
 A Syphilitic Should Never be Dismissed or be given any guar- 
 antee of the extinction of the disease (Ricord). 
 
 TUBERCULOSIS. 
 
 Definition. — A specific infection, characterized (a) etiologically by 
 the Bacillus tuberculosis, (b) pathologically by nodes or tubercles, or 
 diffuse tuberculous infiltration, and (c) clinically by symptomatology 
 varying with the tissues or organs invaded. Tuberculosis, by deriva- 
 tion, refers to tubercles, but in the light of our present knowledge, 
 only to tubercles caused by the Bacillus tuberculosis. 
 
 History. — The term phthisis (wasting) was first used by Hippoc- 
 rates. The history of tuberculosis includes several epochs : Epoch I. 
 The anatomical tubercle was recognized by Sylvius (1614—1672), 
 Morton (1689) whom some consider the real pioneer, Mangetus 
 (1700) and Bayle (1810), who specially described the miliary 
 tubercle. Laennec, the pupil of Bayle, in 1819, spoke for the unity 
 of phthisis. Virchow threw the weight of his influence for Laen- 
 nec's views, but in 1847, showed that caseation was only a retrogres- 
 sive change and not necessarily tuberculous. In 1857, Buhl de- 
 scribed a case of miliary tuberculosis arising from old foci of 
 caseation. Cruveilhier, Billet and Barthez identified scrofula and 
 tuberculosis. 
 
 Epoch II was opened by Vi]lemin (1865) who positively estab- 
 lished the inocul ability of tuberculosis by experiments on animals. 
 Klenkpe (1843) made some successful inoculations, but Villemin 
 absolutely proved his point. It is interesting to note that from 
 the time of Hippocrates, Aristotle, Aretauis and Galen, tubercu- 
 losis was feared as a contagion, and the older pathologists, as Mor- 
 gagni, dreaded to section phthisical subjects. Villemin's formula- 
 tions met great scepticism and opposition, but were supported by 
 Fox, Charcot, Grancher, Thaon, Cohnheim and Salamonson. The 
 histology of the tubercle was developed by Wagner, Schiippel and 
 Virchow; Langhaus fully described the giant cells previously seen 
 by Virchow and Bokitansky; tubercles were found in lupus (Fried- 
 lander, 1875), in lymph-glands (Schiippel, 1871) and in fungus 
 joints (Koster, 1876). The firm and ancient belief in its contag- 
 iousness led to the successful search for the cause. It seems strange 
 that Aufrecht, Baumgarten and von Ziemssen still practically deny 
 the infectivity of tuberculosis. 
 
 Epoch III began with Koch's announcement, in 1882, of the 
 tubercle bacillus. His report, as health officer in an obscure German 
 town, was so complete that scarcely a single essential point has since 
 been added to his initial communication. The bacillus was found 
 in all tuberculous lesions, such as chronic phthisis, miliary tubercu- 
 losis, intestinal ulcers, " scrofulous " lesions, bone and joint disease, 
 lupus and in the sputum, in cattle, ■ etc. ; it occurred in no other 
 disease; it was cultivated by him and inoculated into animals with 
 
TUBERCULOSIS. 291 
 
 reproduction of tuberculosis, thereby fulfilling what has become 
 known as " Koch's law." 
 
 Bacillus Tuberculosis. — 1. Morphology. — It is a thin, narrow rod, 
 measuring 1-J- to 4//, long and more often slightly curved than 
 straight; it contains no spores, the light unstained areas in its 
 body being vacuoles or degeneration; it is immotile; in young cul- 
 tures it is shorter than it is in the sputum; in old cultures and 
 in lung cavities it is longer and is frequently thread-like ; it occurs 
 singly or in groups and bundles. Pleomorphism ; variations in form 
 are often noted, as bulging sides or ends, thread-like or branching 
 forms and even forms said to resemble actinomyces. (See Plate 
 under Pulmonary Tuberculosis.) 
 
 2. Staining- Reaction. — Tt stains slowly, except at body-heat, 
 and once stained gives up the dye reluctantly. Ziehl's solution is 
 the best for clinical purposes (fuchsin 1, absolute alcohol 10 and 
 5 per cent, carbolic solution 100). The sputum is spread 
 out in a dish over a black background and the yellow-green areas 
 selected are thinly distributed on the slide which is held in the hand, 
 and heated until dry at some distance from the flame; it is then 
 stained by the carbol-fuchsin, being passed repeatedly but lightly 
 through the flame (without boiling) to deepen the stain; it is then 
 washed, treated with 33 per cent, nitric acid, washed well in water 
 and then alcohol and dried. If the sputum is thick or. if previous 
 examinations were negative, 15 c.c. of sputum with 30 c.c. of water 
 are treated with 8 drops of a 10 per cent, caustic potash solution, are 
 shaken and allowed to settle for some hours, after which the super- 
 natant fluid is decanted, and the sediment is examined directly or 
 after centrifugation. Spengler digests the sputum with pancreatin 
 instead of using potassium hydrate. The bacillus resists destaining 
 because of its fat, an almost pathognomonic feature. For clinical 
 purposes only (a) the bacilli found in bronchiectasis and gangrene of 
 the lung (q. v.), (b) the smegma bacillus and (c) the leprosy bacillus 
 need be considered; the leprosy germs are intracellular, cover the 
 nucleus of the containing cell, and are stained in six or seven min- 
 utes, with alcoholic fuchsin, while tubercle bacilli are extracellular 
 and stain slowly; the smegma bacillus causes many errors in genito- 
 urinary examinations ; it grows rapidly in twenty-four hours, does 
 not show the beaded appearance which is seen in the Bacillus tuber- 
 culosis, and when stained and counterstained in the usual way, be- 
 comes tinged with methylene blue (Weichselbaum). 
 
 3. Cultures. — These develop best at body heat in one or two 
 weeks; blood serum is the best medium, but growths are also suc- 
 cessful on bouillon, glycerine-agar and potato; they are dry, thin, 
 grayish and scale-like. The germ is a facultative aerobe and mul- 
 tiplies by transverse fission. It seemingly does not lead a sapro- 
 phytic life in nature, outside the bodies of animals and of man. 
 
 4. Chemistry, Metabolism, Resistance, Virulence, Etc. — 
 It contains 2 to 16 times as much fat as other bacteria. Aronson 
 
292 TEE SPECIFIC INFECTIONS. 
 
 holds that a waxy substance envelops the bacillus ; its other constitu- 
 ents are proteids, a glycogen-like substance, cellulose, nucleic acid, 
 water and ash; it also develops tuberculin whose chief components 
 are peptone, albumose and alkaloidal substances ; it is soluble in gly- 
 cerine. Its resisting powers are as a rule limited, (a) Drying is 
 endured by the bacillus strikingly well, for a few months (six or 
 even ten months). In decomposing media its average life is one to 
 one and a half weeks. (6) Heat (106°) kills it in a few minutes. 
 (c) It may survive 14° below zero for weeks, (d) Sunlight kills the 
 bacillus in a few minutes to a few hours. 
 
 Koch was inclined to assume that it had an equal virulence 
 independent of the source of the germ, while the Arloing school finds 
 that it has an attenuated virulence in glandular and osseous lesions, 
 and Theobald Smith holds that bovine cultures are more viru- 
 lent for rabbits than is human sputum. Large numbers are found 
 in fresh tubercles; few are found in chronic articular, osseous or 
 glandular lesions, and inoculations may be necessary to demonstrate 
 the nature of long-standing lesions. Arloing and Courmont (1898) 
 found that serum from inoculated rabbits or goats, agglutinized 
 tubercle bacilli in a dilution of 1 to 5 or 20, in two to twenty-four 
 hours; agglutination was noted in 95 per cent, of the cases of lung 
 tuberculosis and in 50 per cent, of the cases of surgical tuberculosis. 
 Its differential value has not, however, been generally conceded. 
 
 Associated or Mixed Infection. — Symbiosis has been noted with 
 the streptococcus, staphylococcus and pneumococcus, to a lesser degree 
 with the Bacillus pyocyaneus, influenzae, etc. This has been much 
 emphasized by Ortner, Weichselbaum, Striimpell, Roger, Dieulafoy, 
 Mosney, Marfan, Osier, Wolf, Spengler and King, though Straus, 
 Ley den, Baumgarten, Erankel and Troje lay but little stress upon it. 
 
 Prevalence in Man. — Tuberculosis is the greatest foe of man ; it 
 causes 14 per cent, of all deaths, and 33 per cent, of deaths between 
 fifteen and forty-five years of age; it causes more deaths than war, 
 famine, plague, cholera, yellow fever and smallpox combined; in 
 Germany, in 1894, the deaths from diphtheria, croup, measles, scar- 
 latina, pertussis and typhoid, together, were 7,000 less than those 
 from tuberculosis. Five million die yearly from this plague, one 
 million in Europe, 70,000 in England, 150,000 in France, 150,- 
 000 in the United States, and 170,000 in Germany. Postmortem 
 and hospital statistics do not exactly depict the tuberculosis situation ; 
 in Austria, the general death rate from tuberculosis is 11 per cent. ; 
 the hospital rate from the poorer classes is 25 per cent. 
 
 Quiescent (latent) and healed tuberculosis is found in many 
 postmortems upon those dying of other diseases ; Heitler, of Vienna, 
 found obsolete pulmonary tuberculosis in 4.8 per cent, among 16,- 
 562 autopsies. Latent tuberculosis occurs in 25 to 33 per cent, of 
 the population (Baumgarten, Birch-Hirschfeld and Bollinger), 39 
 per cent. (Harris) and 50 per cent. ( Cruveilhier, Eoger and 
 Dejerine), 91 per cent (Burkhardt) and in 97 per cent, of all ne- 
 cropsies (O, E"aegeli), 
 
TUBERCULOSIS. 293 
 
 Prevalence in Animals. — (a) Cattle. — In Germany, it is found in 
 from 4 to 20 or 30 per cent. ; in Leipsic, it even reached 20 per cent, 
 in bullocks and 48 per cent, in cows. In New York, the tuberculin 
 test was positive in 17 per cent. In 1898, Theobald Smith, and later 
 Koch, contended that bovine and human tuberculosis were separate 
 infections ; most writers incline to the view of Smith and Koch. In 
 cattle, tuberculosis is less often attended by softening of the tuber- 
 cle, and the serous membranes are more often involved; the lungs 
 and pleurse are involved in 40 per cent., the lungs alone in 20 per 
 cent., and the pleurae and peritoneum in 15 per cent, of tuberculous 
 cattle, (b) Swine are affected more often in Europe than in this 
 country; in Saxony tuberculosis occurs in 1 per cent, and in Copen- 
 hagen and Dantzig, in 11 per cent. ; because their infection commonly 
 results from eating tuberculous offal, the type is usually alimentary 
 (90 per cent.), (c) Other mammals. — Dogs, cats, horses, sheep and 
 goats, are rarely diseased. Monkeys in captivity die frequently 
 (43 per cent.) from tuberculosis, referred by Dieulafoy and Krisha- 
 ber to foul cages, (d) In reptiles, it is rarely seen, except in those 
 in captivity, (e) In most birds, tuberculous lesions are more fre- 
 quent in the liver, spleen, intestine, mesenteric glands, bones and 
 joints, than in the lungs, though parrots suffer from skin and lung 
 localization. Avian, bovine, reptilian and human tuberculosis are 
 closely related types. Tubercles are not uncommon in animals from 
 nematodes, protozoa and bacteria, and are designated pseudotuber- 
 culosis. In man, Flexner has described a streptothrix pseudotuber- 
 culosis causing caseous pneumonia and peritoneal nodes ; the 
 streptothrix differed both from the tubercle bacillus and the ray 
 fungus. An aspergillus tuberculosis has been described (v. diagnosis 
 Tuberculosis of Lungs). 
 
 Atrium. — The details will be especially considered under the dif- 
 ferent clinical localizations of the disease. 
 
 1. By the Respiratory Tract. — The bacillus enters the respira- 
 tory tract by inhalation. In the vast majority of cases the sputum 
 of diseased persons is causative both of the disease, and its gre*at fre- 
 quency of localization in the respiratory organs. It has been esti- 
 mated that a phthisical person voids 7,200 millions of tubercle bacilli 
 daily. As the expired air is proven germ-free, the sputum must be 
 the chief factor in dissemination. Cornet holds that the greatest 
 danger lies in the drying of the sputum in the room, on the hand- 
 kerchief, the lips, beard, hair, fingers and clothing. Fliigge con- 
 tends that dried sputum is less dangerous than the moist expectora- 
 tion, and demonstrated that in coughing, which seemingly voids no 
 secretion, in singing, in sneezing or talking, small and almost in- 
 visible drops of moisture containing the bacilli are voided; he has 
 cultivated bacilli from glass plates which were covered with solid 
 culture media and held near the patient; he believes that minute 
 particles remain in suspension in the air and thus infect other indi- 
 viduals. Drying of the sputum voided in the street or other open 
 
294 THE SPECIFIC INFECTIONS. 
 
 places is less significant than was formerly thought, since the sun 
 soon kills the bacilli. Hence the ubiquity of the tubercle bacillus is 
 generally exaggerated, though it is of great importance in poorly ven- 
 tilated, dark dwelling-rooms, hospitals, cloisters, hotels or prisons, 
 which are frequented by victims of tuberculosis. Cornet found the 
 bacilli in the dust of such rooms in large numbers, yet in about 10 
 per cent, of tuberculous wards no bacilli were f oimd ; he experiment- 
 ally demonstrated that animals confined in rooms with dried tuber- 
 culous sputum readily acquired tuberculosis. Straus, of Paris, col- 
 lected the germ from the nose in 31 per cent, of the attendants in 
 tuberculous wards. The closer the contact with tuberculous subjects, 
 the greater is the danger of infection, as tuberculosis is surely an 
 infection. In crowded prisons, the death-rate is three or four times 
 that of the general community; in Austria, for example, the gen- 
 eral mortality is 11 to 15 per cent., and the prison mortality is 40 to 
 60 per cent. In nursing sisterhoods, the death-rate exceeded 
 75 per cent. Six cases were observed by the writer, in two years, 
 in one small, closely cloistered community. In Philadelphia, Flick's 
 studies showed that 33 per cent, of infected houses contributed more 
 than one case. In Palkenstein, Germany, and Brompton Hospital, 
 London, acquisition of tuberculosis by attendants is infrequent, while 
 in Paris, Straus puts their mortality at a high figure. In our dis- 
 pensary service, seven rapidly fatal cases were observed in one family 
 which had no hereditary stigma or previous disease (Harpole). 
 Oral breathing, caused by adenoids, inhalation of coal-dust or stone- 
 dust, syphilis, cancer and leprosy are favoring factors. 
 
 _ Dusting, sweeping or shaking the bed clothes disseminates the 
 virus ; there is less danger of infection when the windows and doors 
 are open and when dusting is done with moist cloths rather than with 
 feather-dusters. In hospital wards there are more germs in the air 
 during the cleaning hour than during the other twenty-three hours. 
 However, if bacilli are in the dust, they are not necessarily in the 
 inhaled air. If inhaled, they do not necessarily reach the lungs. 
 for they may be caught in the upper air-passages whose secretions 
 antagonize their development, and are often waved back by the cili- 
 ated epithelium of the lower air-passages. Cornet holds that the 
 statement that " every man lives in the environment of tuberculosis " 
 is surely exaggeration. ."Married persons, because of their intimate 
 association, may contract the disease from each other, as was noted 
 by Ettmiiller and Morton, in the seventeenth centurv ; the husband 
 more often conveys infection to the wife than the wife to the husband ; 
 in Weber's series of cases, a husband lost four wives, another three 
 wives, and in four other cases two wives contracted tuberculosis. 
 TVhen bacilli are inhaled into the respiratory tract (a) no lesions 
 may result, (&) the lungs may become diseased, or (c) the ^erms 
 may pass the mucosa of the mouth or bronchi 'and cause cervical 
 or peribronchial tuberculous adenitis. 
 
 2. By the Digestive Teact.— Bacilli may pass the mucosa, espe- 
 
TUBERCULOSIS. 295 
 
 cially in children, and produce the first lesions in the mesenteric 
 glands. Milk is dangerous (Gerlach, Bollinger, Bang and others), 
 though lately attempts have been made to minimize the danger from 
 this source of infection. It was formerly thought that, in cows, 
 a tuberculous mastitis was necessary to milk infection, but Ernst and 
 others demonstrated that milk may be infective from cows with 
 tuberculosis which does not invade the udders. Pigs, fed on tuber- 
 culous milk, develop intestinal tuberculosis. Butter may contain 
 tubercle bacilli. Meat is less dangerous, as it is usually well cooked, 
 but tubercles in raw offal frequently infect swine. 
 
 3. Direct Inoculation. — Inoculation through the skin, eye, 
 genito-urinary tract, by trauma or operations, is far less significant 
 and will be considered under the various tissues occasionally involved. 
 
 Predisposing Factors. — These are important, but if practically con- 
 sidered, tuberculosis is best prevented and treated as an infection, 
 communicated and acquired by direct personal contact 
 
 1. Heredity. — (a) Hereditary Predisposition to Tuberculosis. — 
 A tuberculous family history is obtained in infected individuals 
 in 25 per cent. It is remarkable what statistics can be made to estab- 
 lish, and one might prove by figures a formidable hereditary influ- 
 ence in measles, pneumonia and other common diseases. Kuthri 
 found essentially the same percentage of family tuberculosis in non- 
 tuberculous as in tuberculous cases. Tuberculous parents may in- 
 fect their children (50 per cent.), as they may infect others, but 
 97 per cent, escape the disease when removed from their parents. 
 According to RiefTel, 3 per cent, of children acquire tuberculosis 
 when both parents are sound, 22 per cent, when both parents are 
 tuberculous, 10 per cent, when the mother and 7 per cent, when the 
 father is tuberculous. Hereditary predisposition is no obstacle to 
 prevention and treatment. 
 
 (b) Congenital Tuberculosis. — It is thought by Baumgarten that 
 children actually inherit the bacillus, vvhich remains latent for years, 
 and then develops an active tuberculosis. If his views are correct, 
 we are confronted with a difficult problem. Congenital tuberculosis 
 can be acquired only through (i) the spermatozoon, (ii) the ovum 
 or (iii) placenta. The spermatozoon and ovum can not carry bac- 
 teria. Placental tuberculosis has been observed clearly in about 22 
 human cases (according to Warthin and Cowie in only 5), and in 
 slightly over 100 cases in animals (Friedman, 1905). The first 
 indisputable case was that of Schmorl and Birch-Hirschfeld, which 
 was confirmed by inoculation and finding of the bacillus. Usually 
 there is a placental focus before the foetal blood is infected, but the 
 bacillus may sometimes pass directly to the foetus. Many experi- 
 enced observers, like Yirchow, have never seen a case. Schmorl 
 and Geipel recently found tuberculosis in nearly 50 per cent, of 
 placentae of tuberculous mothers. 
 
 The arguments against hereditary tuberculosis are (1) that child- 
 ren born with the disease die very early; (2) that tuberculosis in 
 
296 TEE SPECIFIC INFECTIONS. 
 
 the first months of life is extremely rare; (3) that the disease seldom 
 remains latent until adult life, as most cases of infantile tubercu- 
 losis develop during the period of special growth, namely frorn the 
 second to third year ; (4) in congenital infection, the liver is chiefly 
 diseased because of the nature of its vascular relations to the placenta ; 
 in tuberculosis of children, the lungs, glands and other organs are 
 more often diseased, — i. e., the infection is respiratory, and there- 
 fore extra-uterine. (5) When removed from their tuberculous par- 
 ents, children thrive well. 
 
 2. Environment. — This covers many points mentioned under 
 Ateium. Environment is but another name for exposure — or con- 
 tact-infection. Dampness and poor drainage, emphasized by Bow- 
 ditch and Buchannan, are factors which reduce the physiological 
 resistance. Trudeau's experiments show that inoculated animals, 
 kept in dark, damp cellars, die, while others, allowed to run at large, 
 outlive the infection. Density of population raises the proportion of 
 tuberculous cases. In recent years the large cities have shown an 
 apparent decrease of tuberculosis, as shown by Edward F. Wells, of 
 Chicago, and Jas. B. Bussel, of Grlascow. It has also decreased in 
 ISTew York and London. In Massachusetts the total is less by half 
 than it was fifty years ago. The decrease is attributed to more intelli- 
 gent hygiene. The figures show a decided decrease in Chicago (v. 
 Pneumonia) ; it is possible, in recent years at least, that this is ex- 
 plained by the fact that pneumonia carries off the less resistant of the 
 population, as in Munich the death-rate from tuberculosis was 12 
 per cent, at a time when typhoid was epidemic; when typhoid was 
 practically abolished, the tuberculosis rate increased to 16 per cent., 
 — i. e., 4 per cent, of those with tuberculosis had previously died 
 from typhoid. 
 
 3. Occupation. — Occupations involving work in close, damp 
 rooms, in dust, in crowded quarters, particularly when associated 
 with poor food, alcoholism, worry and over-exertion, lower resistance 
 and promote tuberculosis when exposure to infected individuals 
 exists. Clerks, stenographers or waiters are naturally more 
 easily infected than are those working in the fresh air, for example, 
 cab-drivers. It is rather surprising that miners do not suffer more 
 frequently, but the explanation is the dampness, which prevents 
 the drying of infected sputum. 
 
 4. Age. — Cornet's figures show the following death-rate per 10,- 
 000 of population: First year 2 to 3, the child being in close contact 
 with the mother. These figures grow smaller, until the lowest figure 
 is reached, namely ^, between the fifth to tenth years; fifteenth to 
 twentieth years, 17 to 19; twentieth to thirtieth years, 32 to 36; 
 thirtieth to fortieth years, 44; fortieth to fiftieth years, 55; fiftieth 
 to sixtieth years, 76 : sixtieth to seventieth years, 100 ; seventieth 
 to eightieth years, 70 ; over eightieth year, 20. In the first decade of 
 life, glandular, meningeal, osseous # and cutaneous tuberculosis are 
 more frequent. 
 
TUBERCULOSIS. 297 
 
 5. Sex. — Between five and twenty years of age, girls are more 
 prone to tuberculosis, because their life is more sedentary. After 
 twenty years males more often contract tuberculosis, because of their 
 greater exposure to infection. Repeated pregnancies and protracted 
 lactations may favor infection by lowering physiological resistance. 
 Skin lesions are more frequent in women; in 68 per cent, lupus oc- 
 curs in women. 
 
 6. Climate. — Warm, dry climates, high altitudes and lack of sud- 
 den variations in temperature, generally are inimical to tuberculosis. 
 The French Alps were long free of tuberculosis until crowded by 
 infected subjects, and the same seems true of other localities. Some 
 writers even hold that the chief advantages of many resorts is their 
 sparse population and inaccessibility. 
 
 7. Race. — In this country the Irish and negroes are most fre- 
 quently diseased. The Indians have justly come to dread the " cough- 
 ing white man," and they die in large numbers from consumption. 
 Infection among Jews is peculiarly infrequent. 
 
 8. Individual Predisposition. — This was considered important 
 by the oldest medical writers, who described the winged scapulas, 
 paralytic thorax and depressed sternum; but poor thoracic and gen- 
 eral development is very often an expression of already existing 
 tuberculosis; phthisis often occurs in splendidly developed chests, 
 exposure to infection being the most important factor. Tuberculosis 
 confers no immunity to relapses or to new localizations ; a lung lesion 
 may heal while a coincident intestinal lesion progresses. 
 
 9. Trauma. — This is a somewhat determining factor. Bacilli in 
 the blood may be localized in a bone or joint by trauma ; a blow on the 
 head or spine may initiate meningitis in a tuberculous subject; pleu- 
 risy or pulmonary tuberculosis may be initiated by injury to the 
 chest, which is thought to awaken latent lesions in the peribronchial 
 glands. 
 
 10. Other Factors. — These are diabetes, in which 23 to 50 per 
 cent, die of tuberculosis of the lung; psychoses, especially of the de- 
 pressive type, as melancholia ; ansemia, which, however, is more often 
 the result than the cause of tuberculosis ; inflammation of the mucous 
 membranes, acute processes, such as heavy colds, measles and per- 
 tussis, and less often scarlatina, influenza or diphtheria, may pre- 
 dispose to infection, or they probably more often awaken slumbering 
 glandular tuberculosis by the irritative action of products absorbed 
 from the bronchi or lungs. Enterocolitis in children, or typhoid in 
 adults, may in a similar way awaken or initiate abdominal tuber- 
 culosis. Contracted hidney, cirrhotic liver, sclerosed arteries, stenosis 
 of the pulmonary artery, aortic aneurysm and narrowed hypoplastic 
 aorta are predisposing factors. As Rokitansky first pointed out, 
 valvular disease of the left heart prevents or checks infection, be- 
 cause it congests the lungs ; Bier's treatment of surgical tubercu- 
 losis, by inducing congestion through constriction, is based on 
 this point; Birch-Hirschfeld, in 4,359 autopsies, found chronic pul- 
 
298 TEE SPECIFIC INFECTIONS. 
 
 monary tuberculosis in 21 per cent., and in 107 autopsies of valvular 
 heart disease, it was present in but 2.8 per cent. Potain, in 54 cases 
 of mitral stenosis, found pulmonary tuberculosis in 16.6 per cent, 
 (see Valvular Disease of the Heart). Syphilis, pleurisy (q. v.) 
 and haemoptysis (q. v.) are occasional predisposing factors. 
 ^General Histo-pathology of the Tubercle. — The only absolutely path- 
 ognomonic feature of the tubercle is Koch's bacillus, as similar infec- 
 tive granulomata are seen in strongylus in sheep, in actinomycosis 
 and in syphilis. Baumgarten described the changes following inocu- 
 lation of the anterior chamber of the eye : (a) On the first day the 
 bacilli increase and spread somewhat along the lymph-spaces. (&) 
 By the sixth day, the fixed connective-tissue cells proliferate under 
 the stimulus of the tubercle bacillus, which acts as a foreign body; 
 these cells, known as epithelioid cells, are large, rounded or polygonal 
 cells with distended nuclei, and sometimes contain tubercle bacilli; 
 in another day or two they show karyokinetic figures; the bacilli 
 multiply and the endothelial cells of the vessels proliferate. The 
 tubercle of this stage is sometimes called the epithelioid tubercle, 
 (c) On the tenth or eleventh day the leukocytes emigrate. This 
 inflammatory reaction results from the toxins secreted by the bacillus ; 
 at first most of the white cells are polymorphonuclear, many of which 
 degenerate ; later they are mononuclear, which do not suffer retrogres- 
 sive changes ; the mononuclears crowd the epithelioid cells and domi- 
 nate the histological picture, especially with complicating trauma 
 (lymphoid tubercle), (d) The reticulum of the tubercle consists of 
 the stretched fibers of the infected tissue or coagulation necrosis. 
 Tubercles contain no bloodvessels, (e) The epithelioid cells in- 
 crease in size and are often multinucleated. From them or from the 
 extravasated leukocytes, by growth or by fusion, giant cells develop ; 
 they contain many large, oval, vesicular nuclei and tubercle bacilli ; 
 the bacilli may number 50 to a cell in very active processes but are 
 few in chronic tuberculosis ; the giant cells are particularly abun- 
 dant or even may be the chief histological finding in chronic forms, 
 such as lupus, scrofulous glands or fungoid joint-disease; they are 
 few or absent in acute processes, as in miliary tuberculosis; there 
 seems to be a certain antagonism between the nuclei and bacilli, for 
 if the nuclei lie on the margin of the cell, the bacilli are centrally 
 grouped, and if the nuclei lie at one pole of the cell, the bacilli con- 
 centrate at the other pole. The cellular inclusion of the bacilli is con- 
 sidered a phagocytosis by Metschnikoff, which Baumgarten, however, 
 denies. The completed miliary tubercle is non-vascular, cellular, 
 millet-seed (miliary) in size, gray in color and translucent; opacity 
 marks the later caseation (v. i.). It is the invariable pathological 
 unit of all tuberculous lesions, however extensive, and, more or less, 
 is a continuous process. In the diffused inflammatory tubercle, the 
 diffuse areas result from the fusion of myriads of miliary tubercles 
 (see Caseous Pneumonia). 
 
 The tubercle then undergoes one of two degenerations, caseation or 
 
TUBERCULOSIS. 299 
 
 induration : ( 1 ) Caseation results from degeneration of the tubercle, 
 beginning at its centre, from ischsemia (vascular obliteration) and 
 from coagulation necrosis (action of the bacilli and its toxins). In- 
 oculations with dead bacilli may cause tubercles and even caseation. 
 The area of coagulation necrosis then gradually becomes more yellow 
 and granular, and finally results in an amorphous, homogeneous, 
 cheesy ' debris. Caseation is a dangerous, destructive degeneration. 
 (2) Induration, sclerosis or encapsulation, results from growth of 
 connective tissue around the tubercle or conglomeration of tubercles ; 
 it limits the tubercle, is the measure of the resisting power of the 
 surrounding tissue, of the process of bacteriolysis, and is a conserva- 
 tive change. It occurs most frequently in the peritoneum, but also 
 in the lungs and other tissues. Inflammation, varying with the tissue 
 involved, may cause other histological findings. Suppuration may 
 result from mixed infection with streptococci, though Koch held that 
 pus may be formed by the tubercle bacillus itself ; the ordinary tuber- 
 culous " cold abscess " is not really pus, but merely thick, amorphous, 
 granular debris. 
 
 Extension. — (1) Tubercles develop at the point of infection and 
 also in the nearest lymph-glands, which permanently or temporarily 
 arrest the process. (2) Infection may occur through the uninjured 
 mucosa or skin, but the process rarely passes beyond the tributary 
 lymph-glands. (3) The later advance of the process occurs inter- 
 ruptedly or gradually, so that it can be traced clearly at autopsy. (4) 
 Extension usually occurs along the lymph vessels and glands. 
 
 1. Tuberculosis Miliaris Acuta. — Definition. — An acute general, 
 sometimes almost universal, embolic dissemination of the tubercle 
 bacillus in great numbers, by the blood or lymph stream. It results 
 pathologically in the wide-spread formation of miliary tubercles in 
 various tissues, and it produces, clinically, acute toxemic (typhoid- 
 like), pulmonary, meningitic or other symptoms, and is invariably 
 and rapidly fatal. 
 
 Etiology. — 1. Development. — Acute miliary tuberculosis always 
 develops from a tuberculous focus. This is found in direct ratio to 
 the carefulness of dissection ; von Buhl, who first fully described the 
 affection (1856), recognized that miliary dissemination occurred by 
 absorption from old tuberculous foci, just as pygemia results from 
 local suppuration; and he found the primary focus in 90 per cent, of 
 cases. It may be small or even miscroscopic and may easily escape 
 detection but Simmonds found the initial lesion in 100 per cent. As 
 Cornet remarks, it is curious that miliary tuberculosis occurs from 
 foci so small as to be easily overlooked, and that large tuberculous 
 lesions so seldom result in miliary dissemination. A description of 
 all primary foci would be an enumeration of every possible localiza- 
 tion of tuberculosis. 
 
 2. Lesiox. — Pulmonary tuberculosis is the most frequent lesion 
 and causes over 50 per cent. (Ruble, Orth, Litten) of cases of acute 
 
300 THE SPECIFIC INFECTIONS. 
 
 miliary tuberculosis. Glandular lesions rank next, and articular, 
 osseous, genito-urinary and serous-membrane tuberculosis cause most 
 of the balance. The more the tubercle is indurated, the less is the 
 danger of local or general dissemination. Acute generalization only 
 follows the introduction into the circulation of large numbers of 
 bacilli, for they do not multiply in the blood. A few bacilli reaching 
 the circulation cause a solitary tubercle in some organ — for example, 
 in the brain. Repeated ruptures of moderate numbers of bacilli lead 
 to the so-called chronic miliary tuberculosis (v. i.). 
 
 3. Mode of Access of Bacilli into Blood Stream. — Sir Astley 
 Cooper, in 1798, found tubercles in the thoracic duct, and this was 
 later confirmed by Ponfick, Weigert, Koch and Meisels. In 1877, 
 Weigert demonstrated that tubercles invade the vessel walls, which 
 Rokitansky had declared immune. Tuberculosis reaching a vessel 
 usually causes its gradual obliteration and in this way localizes the 
 process, but in some cases bacilli reach the lumen of the vessel and 
 are distributed in the direction of its current. Two views are held 
 as to the nature of the involvement of the vessels: (a) That of Wei- 
 gert, who thought the most frequent process was periangitis, by 
 which a tubercle adhered to and emptied into a vein; and (b) that of 
 Benda, who contended that the common lesion was endangitis, by 
 which tubercle bacilli lodged in the intima, and, grouping there, 
 further disseminated the infection. One of the most common meth- 
 ods is periadenitis of a tuberculous bronchial gland, its adhesion to a 
 pulmonary vein and final rupture into it. Tuberculous lesions may 
 rupture into the vena azygos, pulmonary artery, aorta, thoracic duct, 
 jugular or other veins, into the cavse or into the brain sinuses. From 
 the pleurae and peritoneum infection may travel directly to the 
 thoracic duct. 
 
 4. Organs Involved. — (a) Rupture into a pulmonary vein floods 
 the arterial circulation with bacilli, whence miliary deposits occur in 
 the brain, choroid, liver, spleen, kidneys, myocardium near pulmo- 
 nary artery, bones, serous and mucous membranes and in the blood- 
 vessels themselves, (b) Rupture into a portal venous radicle affects 
 chiefly the liver, (c) Into the pulmonary artery, the lungs and (d) 
 into a peripheral artery, the tissue supplied by it. 
 
 5. Predisposing Factors. — Though miliary dissemination may 
 occur at any age, it is most frequent in children at the developmental 
 period, especially between one and four years of age, because the 
 circulation is faster, metabolism is quicker, thrombosis of the vessels 
 is less frequent, tissue reaction is less marked and the lymph-vessels 
 and spaces are wider. Depleting factors, pregnancy, the puerperium, 
 trauma, bone operations, measles, pertussis, mixed infections and the 
 spring and summer months, are somewhat predisposing causes. 
 
 Symptoms. — The clinical picture varies greatly, depending on (a) 
 the quality (virulence) and quantity of the bacilli; (b) the toxins 
 thrown into the circulation from the primary ruptured focus; (c) 
 the toxins developed elsewhere by the bacilli ; and (d) the localization 
 of the tubercles formed. Naturally toxcemic precede local symptoms. 
 
PLATE VII 
 
 Retinal Findings in the More Important Diseases. 
 
 1 Retinitis diabetica. 2. Atrophy (and pigmentation) of retina 
 and optic nerve. 3. Choked disk in brain tumor. 4. Optic 
 neuritis in meningitis. 5. Medullated nerve fibers (normal). 
 
TUBEBCULOSIS. 301 
 
 Types. — Waller (1845) distinguished the following forms: 
 
 1. Typhoid Type. — The febrile onset may be gradual or sudden, 
 with or without chills. The patient often exhibits little beyond a 
 marked toxaemia. The typhoid type is due to greater toxcemia with 
 less local reaction from the tubercle, and therefore with few local 
 findings. The status typhosus, delirium, headache, moderate con- 
 tinuous or weakly remittent fever, enlarged spleen and bronchitis sug- 
 gest typhoid but the fever is more variable and the pulse runs higher ; 
 less frequently roseolas, meteorism, diarrhoea and intestinal hemor- 
 rhage may cause even a closer resemblance to typhoid (q. v. for dif- 
 ferentiation). Unless the meninges or lungs are involved the diag- 
 nostic confusion may be insuperable. Epistaxis is less common; 
 hyperaesthesia and herpes are more common but all symptoms may 
 be deceptive except the typhoid bacillaemia and the Widal reaction 
 in typhoid, as opposed to the tubercle bacillaemia and choroidal tuber- 
 cles- in miliary tuberculosis. Rosenberger recently found tubercle 
 bacilli in the feces. Acute miliary bacillaemia is more common in 
 children than in adults, and runs a course of ten to twenty days, or 
 somewhat longer. Typhoid and miliary tuberculosis have rarely 
 occurred in the same subject (Birch-Hirschfeld, Burkart, Massini, 
 Schiitze, and two personal observations) . 
 
 2. Respiratory Type. — In the respiratory type the toxcemia is 
 rather subordinated by the local miliary eruption. Tachypnoea, 
 dyspnoea and cyanosis, without proportionate physical findings 
 are always suggestive. This variety is unmistakable; the respi- 
 ratory urgency and the rapid pulse, without heart lesion and with a 
 normal or tympanitic pulmonary resonance declare the diagnosis. 
 The following forms are less characteristic: Pneumonia may be 
 closely simulated by the fever, chills, pain, cough, rusty sputum, in- 
 creased breathing, dyspnoea, cyanosis, or even by tubular breathing 
 (in children). Capillary bronchitis (bronchopneumonia) should be 
 differentiated after recent measles, or after pertussis with patches of 
 atelectasis. Diagnosis should be made from senile bronchitis and 
 emphysema in the aged, in whom this type is particularly frequent 
 without fever. Tubercle bacilli in the sputum or urine may occur 
 accidentally. The course averages three to four weeks. 
 
 3. Meningeal Type. — In the typical meningeal form, tubercu- 
 lous meningitis appears as the only apparent trouble, whereas it is 
 but a part of a miliary dissemination. Its symptoms will be detailed 
 later under a separate topic (page 304). Meningitis occurs in 80 
 per cent, of cases of miliary tuberculosis. The increased respiration, 
 with occasional deep breathing and increased irregular heart action, 
 are suggestive (Riihle). The choroid findings, the results of lum- 
 bar puncture and Kernig's sign are corroborative. Lumbar punc- 
 ture often shows the presence of bacilli. The symptoms may be 
 clearly organic, and yet, in children who are especially prone to this 
 form of miliary tuberculosis, toxaemia may very closely simulate 
 actual inflammation, as in Henoch's cases, where only brain oedema, 
 was found instead of the anticipated meningitis, 
 
302 THE SPECIFIC INFECTIONS. 
 
 4. Other Types. — These are less frequent, but their mere mention 
 may show the great and almost necessary liability to diagnostic error 
 in atypical forms. They are: The latent type (Leudet), marked only 
 by catarrhal symptoms, and often called grippal ; the ambulant type, 
 as in Grawitz's case, where an apparently healthy soldier died after 
 four days of indisposition ; nephritic ; arthritic ; apoplectiform, de- 
 lirium tremens, pharyngeolaryngeal, suffocative or asthmatic type; 
 fulminant type, where the patient dies in a few hours, or in his sleep. 
 In some cases, sepsis, miliary carcinosis, ursemia or the cyanosis of 
 nitro-benzol poisoning may be suggested. 
 
 Individual Symptoms. — 1. Temperature. — Continuous fever may 
 be observed in very acute cases with wide-spread localization, but 
 as a rule it is lower than that of typhoid. Remittent or intermittent 
 fever is more common; miliary tuberculosis following pulmonary 
 phthisis may change neither the hectic fever of the latter nor its 
 euphoria. The typus inversus may occur, though it usually lasts but 
 a few days (Bruniche). In 17.5 per cent, of cases (Rheinhold) the 
 course is afebrile; involvement of the brain or meninges lowers the 
 temperature or renders it variable; hemorrhages, vomiting or diar- 
 rhoea may depress the fever (Litten) ; low temperatures are common 
 in the aged, in the ambulant and in bronchitic or cardiac types. 
 
 2. Circulation. — (a) The pulse is faster than is proportionate to 
 the degree of fever, being 120 in the early stages and 140 to 160 
 later ; the blood-pressure is low but dicrotism is infrequent ; a pulse 
 under 100 is very rare and nearly always occurs in old people or in 
 cases of meningitic localization, (b) The heart is somewhat dilated 
 and an apical systolic murmur, with accentuation of the second pul- 
 monic sound, is fairly frequent. A pericardial rub is heard on rare 
 occasions, due to roughening of the serosa by the miliary eruption 
 (Litten). (c) Tubercle bacilli were first found at autopsy in the 
 blood by Weichselbaum and "Meisels, and clinically by Lustig and 
 Riitimeyer, Sticker, Ulacacis and Doutrelepoint. In the death 
 agony from lung tuberculosis, bacilli may enter the blood, (d) The 
 leukocytes are usually not increased. 
 
 3. Respiration. — Early symptoms are frequent, (a) There is 
 very often a severe continuous cough, which is always a suspicious 
 symptom. It is due to the toxins or to irritation of the vagus twigs 
 by abundant miliary nodes in the lung ; it causes considerable muscu- 
 lar pain, but little voiding of sputum and ceases later if the brain 
 becomes involved, (b) The breathing is increased to 40 or 60 in 
 adults, and to 80 or 90 in children, (c) Dyspnoea and cyanosis de- 
 velop from irritation of the vagus (Riihle) or from diaphragmatic 
 involvement (Rheinhold). The tachypnea, dyspnoea and cyanosis 
 are peculiarly significant diagnostically in that they have no adequate 
 explanation in the physical findings. (d) The sputum is scant, 
 foamy white and mucous, in acute cases. It seldom contains dots 
 of blood, and is rarely rusty without the presence of complicating 
 pneumonia. It may be more abundant in subacute cases, (e) The 
 
TUBERCULOSIS. 303 
 
 physical findings are not as marked as the urgent respiratory symp- 
 toms would indicate. A tympanitic note is very frequent, resulting 
 from relaxation of the lung, or from acute emphysema from cough- 
 ing. Dulness only results from older tuberculous foci in the lung, 
 or from complicating atelectasis or consolidation. Auscultation often 
 reveals fine rales, which are especially suggestive when they occur 
 over the upper chest, where stasis is uncommon. Jiirgensen notes a 
 fine pleural rub, which is due, he thinks, to pleural tubercles. A 
 terminal pulmonary oedema is frequent. At autopsy innumerable 
 translucent nodes are scattered through the lung, and are most ap- 
 parent on oblique illumination. 
 
 4. Nervous System. — Nervous symptoms may predominate, and 
 may result from toxsemia (like the symptoms following tuberculin 
 injection), or from central organic changes, (a) The toxcemic symp- 
 toms are headache, dulness, vertigo and tinnitus; these are followed 
 by delirium, muscular adynamia and tremor, and result in stupor, 
 which is broken by fits of delirium, and finally in coma. In rare 
 instances coma may develop early in an apoplectiform fashion, or the 
 sensorium may be normal, (b) Meningitic symptoms may develop, 
 such as headache, variable pulse and respiration, retraction of head 
 and spinal tenderness and rigidity, narrow and then widened pupils, 
 strabismus, paralysis of other cranial nerves, Kernig's sign, clonic 
 contractions, convulsions and coma. The findings at autopsy are 
 those of tuberculous meningitis (q.v.). 
 
 5. Digestive System. — The tongue is coated and there is ano- 
 rexia. Nausea and vomiting are usually meningitic. There is usu- 
 ally constipation and the abdomen is normal. Diarrhoea is infre- 
 quent, but bloody stools may occur with tympany. Ascites is 
 infrequent in miliary tuberculosis of the peritoneum (as distin- 
 guished from tuberculous peritonitis). Litten once heard a friction 
 rub over the liver. Miliary tubercles may occur in the stomach and 
 bowels, most frequently in children. 
 
 6. Choroidal Tubercles. — These are said to occur in 16 (Rhein- 
 hold) to 75 per cent. (Litten) of the cases. They are most numerous 
 in very generalized tuberculosis. They occur singly or in large num- 
 bers, usually in both eyes as whitish-yellow protuberances with ir- 
 regular washed borders. They become quite large, for they cause 
 so much atrophy of the retinal pigment layer which covers them that 
 they can be seen through it. Daily examination for them is neces- 
 sary, as they frequently develop in half a day. They are seen only 
 after one or several weeks. (See Plate VIII, Fig. 6.) 
 
 7. Other Symptoms. — Emaciation is often pronounced; one of 
 Wunderlich's cases was reduced to one-quarter of his ordinary weight. 
 The spleen is enlarged in 70 per cent. (Litten), but is usually smaller 
 than it is in typhoid, except in children, where it may assume great 
 dimensions. Collin observed swelling of the lymphatic glands, which 
 in one instance became enormous. The urine is concentrated and 
 dark, from the fever and from sweating, may contain albumin or pep- 
 
304 THE SPECIFIC INFECTIONS. 
 
 tone, and quite often shows the diazo reaction. Eosenstein observed 
 anuria, especially in children. Hemorrhages into the gums, nose, 
 retinae and intestines are infrequent and possibly result from mixed 
 infections. The skin is pale and cyanotic ; profuse sweats, and there- 
 fore sudamina, are frequent. Herpes may be observed, as well as 
 rose spots, miliary tubercles in the skin, petechia?, erythema nodosum 
 and terminal oedema. 
 
 Remissions may occur for a time, even for a month or two, as the 
 toxaemia may subside, while the tubercles continue to develop. The 
 fall of the fever resulting from brain implication may be deceptive. 
 As a rule the course is acute, even stormy or peracute, and death 
 intervenes from exhaustion, meningitis, heart weakness, dyspnoea 
 or pulmonary oedema. Severe infection is fatal in two or three 
 weeks, moderate infection in one to two months. Chronic miliary 
 tuberculosis is rare. Recovery is almost impossible, but Waller, 
 TTunderlich. Burkart and Spengler believed that it exceptionally oc- 
 curred, and Strieker saw recovery of a case in which the diagnosis 
 seemed incontestable, as he found bacilli in the blood. Therapy is 
 useless. The symptoms should be treated expectantly, as in typhoid, 
 pneumonia and meningitis. 
 
 II. Tuberculous Meningitis. — Etiology. — Most cases occur between 
 the second and tenth years, some cases develop in adolescence and 
 few late in life ; at least three times as many cases occur in children 
 as in adults. Tuberculosis in children is usually generalized, and 
 miliary tuberculosis is in 80 per cent, associated with meningeal 
 disease. Tuberculous meningitis is almost always secondary, and 
 follows pulmonary or glandular tuberculosis, less frequently joint 
 disease, genito-urinary, brain and other localizations. Extension by 
 contiguity from the nose, eye or spinal cord is possible. Striimpell 
 and Leube believe that infection may creep from the pleura, along 
 the nerve sheaths to the spinal cord, whence it reaches the brain. 
 Measles, whooping-cough^ typhoid or pneumonia may seemingly 
 arouse latent glandular or other tuberculous foci. Trauma is not a 
 frequent cause but is of distinct clinical and medico-legal import- 
 ance. In the case of a baggage man thrown upon his occiput by the 
 sudden stopping of the train, an acute tuberculous meningitis de- 
 veloped, which resulted in death in three weeks. The autopsy dis- 
 closed an apical focus, from which the bacilli infected the -injured 
 brain. In one instance, meningitis followed an anaesthetic, given to 
 examine a tender spine, and was fatal within a week. 
 
 Pathology. — The diagnosis is made macroscopically in the majority 
 of cases, although in some instances the changes are slight. The 
 exudate is gray, yellow or green, gelatinous, sticky, purulent or serous 
 and covers the base (basilar meningitis) from the chiasm to the 
 medulla. Tiny tubercles are found on the basal nerves and deep in 
 the fissure along the Sylvian artery where " they look like lice eggs 
 on a hair." Careful search is sometimes necessary for their detec- 
 
TUBERCULOSIS. 305 
 
 tion. They are most clearly seen in the translucent arachnoid, and 
 on superficial examination look like minute air bubbles. They are 
 seen quite frequently over the convexity and may cause adhesions 
 between the two hemispheres. The ventricular fluid is increased in 
 80 per cent, of cases, and usually measures a few ounces; tubercles 
 and inflammation of the ependyma are not uncommon ; the external 
 and internal communications of the ventricles may be obliterated. 
 The substance of the brain shows ischemic or encephalitic softening. 
 The cerebrospinal fluid is usually increased and is clear or cloudy. 
 In the cord the exudate may be a quarter of an inch in thickness, and 
 is largely disposed over the posterior part of cord because of the 
 patient's dorsal decubitus. The cord membranes are almost regularly 
 affected, and sometimes appear granular, as " though sown with fine 
 sand." Tubercles in the substance of the cord are not considered 
 common, but Wartmann found them in 87 per cent, of his cases. 
 The cranial and spinal nerve sheaths are bulging. Microscopically , 
 exudation is found. The nodes are proven to be tubercles; bacilli 
 are found in them and in the cerebrospinal fluids The microscope 
 differentiates between tuberculous inflammation and tuberculosis of 
 the meninges (without inflammation), and again in some cases proves 
 the existence of tuberculous meningitis not visible to the naked eye. 
 Neuritis of the cranial and spinal nerves is constant. The optic, 
 oculomotor and facial nerves are the most often affected. In the 
 cortex, base and ependyma of the brain, the usual histopathology of 
 tubercle is seen, with tuberculous endarteritis and periarteritis, small 
 encephalitic and myelitic foci in practically every case, swelling of 
 the neuroglia and degeneration of the nerve cells and especially of the 
 axis cylinders. 
 
 Symptoms. — Prodromes are more prominent in children than in 
 adults ; fever, emaciation and ansemia are due to preexisting lung or 
 glandular tuberculosis. Irritability, change in disposition, tendency 
 to cry, inability in children to play or in adults to work, unrest, 
 insomnia, headache, nausea and constipation may develop in a week 
 or two or in one to three months. Trauma, measles or pertussis 
 may be the apparent cause. The outbreak develops with much the 
 same symptoms as those described under the epidemic form, but in 
 86 per cent. (Koplik) they appear more gradually, so that the clas- 
 sical description comprises three stages: (a) The stage of irritation, 
 with headache, vomiting, remittent fever reaching 102° in the even- 
 ing, the cri hydrencephalique of Coindet, night terrors, pain and 
 rigidity in the neck and spine, small irregular pupils, delirium, grind- 
 ing of the teeth, hyperesthesia, rigidity of the limbs and Kernig's 
 sign (in 22 of Koplik's 82 cases) ; (&) the stage of brain pressure, 
 with paralytic and irritative conditions in the eye muscles, as ptosis 
 or strabismus; with paralysis of other cranial nerves or of the ex- 
 tremities, as monoplegia or hemiplegia from involvement of the 
 cortex, and very frequently aphasia and dulness; with general or 
 Jacksonian convulsions, slow, irregular and quite variable pulse; 
 20 
 
306 TEE SPECIFIC INFECTIONS. 
 
 retracted abdomen, constipation, continued vomiting; sighing respi- 
 ration; and very frequently with optic neuritis; and (c) the stage of 
 paralysis, in which the vomiting and often the headache cease, the 
 sensorium is dulled, absolute coma develops, the pulse becomes rapid 
 and vacillates in rate and rhythm. Biot's alternating apncea and 
 hyperpnoea or Cheyne-Stokes' breathing appears, emaciation is ex- 
 treme, the pupils are wide and immobile, the eyeballs roll upward, 
 and a typhoid state with dry tongue or abdominal distention exists. 
 Temporary remissions of days, weeks, or even a year are occasional, 
 in which the pulse remains irregular, but the patient lapses again 
 into coma, the fever rises very high (107°) or falls low (even to 
 93°), and death occurs in several weeks from cardiac or respiratory 
 failure, dysphagia, inanition or hypostasis. This division into stages 
 is not wholly satisfactory, because the. symptoms of one stage may 
 merge into those of another but the progression of symptoms is some- 
 what as described. 
 
 Tubercles in the choroid are rare clinically, being found by Gar- 
 lick in 4 and Kramer in 13.6 per cent, of cases. Heinzell did not find 
 them in 41 cases. At postmortem examination Litten found them 
 in about 75 per cent. (See Plate VIII.) Leukocytosis is absent 
 except during the agony or from mixed infection. The spleen is 
 enlarged in 33 per cent. 
 
 Many variations exist. The process may be wholly latent, being 
 masked by miliary tuberculosis (or meningeal symptoms may domi- 
 nate when the greatest pathological changes are in the lungs). Coma 
 may be sudden and the disease may run a short course, resembling 
 apoplexy, especially in adults ; in these cases the hemiplegia probably 
 results from changes in the arteries. It may appear to be a psychosis. 
 In adults the course is more rapid, the headache and delirium more 
 marked and the convexity more frequently involved than in children. 
 
 Death is usual, but rare recoveries, numbering about twenty, are 
 recorded, even after bacilli were found by lumbar puncture or after 
 choroidal tubercles were demonstrated. (See Cerebrospinal Fever 
 for Differentiation and Treatment. ) 
 
 III. Tuberculosis of the Lungs (Phthisis, Consumption). — The 
 
 lungs are involved with great frequency, not because they are pe- 
 culiarly susceptible, but because infection by inhalation is the most 
 frequent cause of tuberculosis. Besides this aerogenous infection, 
 secondary infection by the bloodvessels, as in miliary tuberculosis 
 (hematogenous infection), and by the lymph vessels (lymphogenous 
 infection), is possible. 
 
 Pathology. — The tubercle bacillus localizes in the bronchi (tuber- 
 culous lymphangitis), bronchioles or alveoli (tuberculous pneumonia), 
 and causes a tubercle as described in the general pathology. There 
 is cellular hyperplasia of the alveolar, epithelial and endothelial 
 cells, and fibrinous inflammation develops. Isolated tubercles by 
 fusion cause the conglomerate tubercle. 
 
PLATE VIII 
 
 6. Tubercles in choroid. 7. Syphilitic ehoroidoretinitis. 
 8. Albuminuric retinitis. 9. Hemorrhages in pernicious 
 anaemia. (Figures 1 to 3 are from Jaeger and the balance 
 are from Sahli.) 
 
TUBEECULOSIS. 307 
 
 Extension. — (a) Lymphatic extension is the most common form. 
 In young individuals the lymph paths are wider and absorption gen- 
 erally is greater, so that intoxication and bacillary migration are 
 more active. Those who have lost weight, as convalescing typhoids, 
 show greater absorbing powers; absorption is also greater after 
 trauma, pneumonia, etc. Bacilli may pass the bronchi and reach 
 the glands at the hilum, which in turn may infect the blood or break 
 into the lung. Extension is usually along the lymph vessels in the 
 bronchial walls (lymphangitis tuberculosa), (b) Extension by the 
 air passages is quite common; when a tubercle ruptures into the 
 bronchi, its contents may be coughed up or waved upward by the cili- 
 ated epithelia if they are intact; on the other hand, a deep breath 
 may aspirate, or coughing may impel, infected particles into sound 
 areas, where they develop into new foci; much depends on whether 
 the bacilli are living or dead; if living, an active tuberculosis de- 
 velops ; if dead, a pneumonia (lobar or lobular) is more common, 
 (c) Extension by the bloodvessels may cause a local miliary dissemi- 
 nation in the lungs or in the entire body. Preliminary to the 
 clinical description in which special pathological features will be 
 fully described, it may be said that some caseated areas fuse into 
 large infiltrations; some may encapsulate or calcify and thus effect 
 a temporary arrest or a permanent recovery; other caseated areas 
 soften, forming ulcers and cavities. 
 
 Symptoms. — A clinical description covering all types is impossible, 
 as the course may be galloping or extremely chronic; one form is 
 marked pathologically by caseation, another by ulceration ; one symp- 
 tom, such as haemoptysis, may indicate the type and may be the 
 first and chief symptom ; in some persons the symptoms suggest other 
 diseases and the physical findings are indeterminate or lacking; 
 in others the physical findings are remarkably dissociated from the 
 usual symptoms. In the following description, the symptoms and 
 signs usually found will be covered first and the special types will be 
 dealt with afterward : 
 
 1. Local Respiratory Symptoms. — These are usually the first 
 noted, and may only appear months after the primary focus has begun 
 to spread ; they are due to the local tubercle and its toxins. 
 
 (a) Cough. — Cough is one of the first symptoms and is the most 
 constant symptom; it is usually present from the incipiency to the 
 close of phthisis. It is due to toxins irritating the vagus twigs, 
 which irritation is referred to the medulla, from which issue mus- 
 cular contractions, with the glottis closed in order to evacuate the 
 slight secretion; as shown by ISTothnagel, Stark, Kohts and Reyher, 
 the sensitive inter arytenoid space and tracheal bifurcation initiate 
 this reflex. Less often coughing is due to pleurisy, catarrh of the 
 pharynx, enlarged bronchial glands or laryngitis. It is slight at first, 
 and has no peculiar characteristics, other than being dry, difficult 
 and paroxysmal. Later it becomes more frequent but less difficult 
 as the secretion increases. In some cases it is most severe in the 
 
308 TEE SPECIFIC INFECTIONS. 
 
 morning, the secretion having accumulated over night, while in others 
 it is most severe at night, for the lungs become congested by the dor- 
 sal decubitus; saliva reaching the larynx during the night, may 
 cause a sudden explosive cough. It may be provoked by dust, smoke, 
 variations in temperature, opening windows or getting into the cool 
 bed, by exertion, laughing or taking alcohol. It varies with the indi- 
 vidual, being more marked in neurotics and less conspicuous in the 
 phlegmatic, the aged or the insane. When quite obstinate it may 
 constantly invoke vomiting and lead to great emaciation. 
 
 (b) Sputum. — The sputum is first caused by the toxins, and later 
 by the secretion from the tuberculous focus. At first it is glairy and 
 contains sago-like bodies composed of alveolar cells transformed into 
 a myelin substance. It later becomes yellow from admixture of pus, 
 yellow, green or red from saprophytic organisms, and blood may 
 give it a red. rusty, flesh-like or chocolate hue. Other bacteria and 
 saprophytes are frequent (v. Bacteriology). It tastes sweet and 
 smells slightly foetid. Its amount varies from a few globules to over 
 a pint. It is most abundant in cavities; it stagnates before death, 
 because of the patient's muscular weakness ; women and children are 
 prone to swallow the sputum. Nummular sputum from cavities is 
 flat, " coin-like," greenish-gray, extremely abundant and sinks in 
 water, as it is airless ; it occurs in other than tuberculous cavities, as 
 in bronchiectasis. The only characteristic of the sputum is the 
 tubercle bacillus (v. s.), which is found only in tuberculosis; it 
 may be seen before the advent of any physical finding, but in other 
 cases it must be sought repeatedly, as it appears only when ulcerar 
 tion communicating with a bronchus, develops. The tubercle ba- 
 cillus is found in only one-third of the cases of incipient tuberculosis. 
 If the patient expectorates into water a crumbling precipitate, rich 
 in bacilli, is obtained (Virchow). Elastic fibers are found in 70 to 
 90 per cent, and originate from the vessels or parenchyma of the 
 lung. The elastic fibers from the vessels are elongated and twisted, 
 and sometimes considerable shreds of the vessel-wall are seen ; elastic 
 fibers from the bronchi are also long and twining; those from the 
 lung substance often show its alveolar arrangement. Elastic fibers 
 can often be located by flattening the sputum between two plates of 
 glass and picking out the yellowish areas for microscopic examina- 
 tion. Treatment with caustic potash and centrifuging, facilitate 
 their detection when they are scanty. They merely denote a destruc- 
 tive process, hence are also found in abscess, gangrene, infarction 
 and pneumonia. Detritus, pus cells, red cells, alveolar, bronchial 
 and buccal epithelium, myelin droplets and pigment, are also found. 
 The so-called lung calculi are sometimes voided; they are calcified 
 particles from old areas of caseation, from bronchial obstruction, 
 or from peribronchial lymph glands ; from the glands large calcar- 
 eous masses may cause fatal obstruction of the trachea, or suffocation 
 may be averted only by immediate low tracheotomy. (See Plate 
 IX for tubercle bacilli and elastic fibers.) 
 
PLATE IX 
 
 Tubercle Bacilli and Elastic Fibers. 
 
TUBERCULOSIS. 309 
 
 (c) Hcemoptysis. — Haemoptysis (haemoptoe, spitting of blood) 
 occurs in a variable percentage. Prior saw it in 37 per cent, of 
 1,000 cases ; others place it at 66, 80 or even 90, per cent. ; it is 
 more frequent in adult males than in females and is rare before 
 puberty, (a) Early hcemoptysis is due to erosion of a small vessel 
 by tubercles in its perivascular lymph sheath. The toxins usually 
 prevent extensive early hemorrhage by causing coagulation in the 
 vessels in and near the affected lung area. Haemoptysis is the first 
 symptom in 4 per cent, of phthisis cases and in 16 per cent, the only 
 symptom, the patient never having future trouble; in most cases, 
 however, other symptoms develop ; bacilli and elastic fibers may be 
 seen at the time of bleeding. Eeiche recently corroborated the old 
 statement that early haemoptysis is not unfavorable. The bleeding 
 develops in quietude in 66 per cent, of cases but may be induced 
 by coughing, laughing, exertion or excitement. Often without cause, 
 it comes on suddenly with a warm, salty taste in the mouth and the 
 evacuation of a dram or more of bright frothy blood, clear or mixed 
 with mucus; small particles of darker blood are brought up, for a 
 few days, after which it disappears; in 4,125 of the Brompton Hos- 
 pital cases, 69 per cent, evacuated less than half an ounce. Bubbling 
 rales may be heard on the side of the lesion, and moulds of the 
 bronchioles may be voided. F. Strieker collated 900 cases of haemo- 
 ptysis in the German army among 1,728,505 soldiers; in 480 cases 
 there was no apparent cause and of these 87 per cent, were tubercu- 
 lous; of 43 cases brought on by exertion, 74 per cent, were tubercu- 
 lous ; and of 24 cases due to trauma, half were tuberculous. The oc- 
 currence of early hemorrhage, before other symptoms of phthisis, led 
 Hippocrates, Boerhaave, Van Swieten, Morton, Graves and Niemeyer, 
 to think that haemoptysis caused phthisis, while Laennec, Louis and 
 Traube, correctly regarded it as a symptom of already established 
 phthisis. The earlier idea is explained by the fact that in bleeding, 
 blood and bacilli may be aspirated into other parts, in which the 
 process develops anew ; fever, rapid pulse and dyspnoea following hae- 
 moptysis are ominous (v. i. Acute Forms), (b) Late licemoptysis 
 may be slight or profuse. Profuse bleeding is usually due to erosion 
 of blood vessels running across, or in, the walls of cavites, which are 
 frequently aneurysmatic (Rasmussen) ; Kidd found ruptured aneu- 
 rysms in 70 of 82 fatal cases ; occasionally larger vessels, as the pul- 
 monary artery, are ulcerated. A pint or a quart may sometimes 
 spurt out of the mouth, causing acute anaemia, suffocation or rapid 
 exsanguination. Blood may accumulate in large cavites, never reach- 
 ing the air passages. Haemoptysis is usually a sign of tuberculosis 
 but also occurs from other causes (v. Diseases of the Lujstgs). 
 
 (d) Dyspnoea. — This is infrequent, even when the respiratory area 
 is enormously contracted, just as it is absent in pleurisy of gradual 
 onset; it is often absent even with great infiltration, great cavity for- 
 mation or induration of two-thirds of the respiratory space, whereas 
 in sudden miliary tuberculosis the dyspnoea is great. In some cases 
 
310 
 
 TEE SPECIFIC INFECTIONS. 
 
 dyspnoea is neurotic, or it may follow pressure of swollen glands 
 on the vagus, anaemia, stagnating secretion, extensive vicarious em- 
 physema or massive pleural adhesions. It is most often due to the 
 rapid heart action. In the last stages it may cause orthopnoea and 
 can result from intercurrent bronchitis, pneumonia or pneumo- 
 thorax. Germain See has described a tuberculous pseudoasthma. 
 
 (e) Pain. — Pain is observed in 66 to 75 per cent, of cases. Its loca- 
 tion may be apical, basal, diaphragmatic, anteriorly from the clavicle 
 to the third rib or under the scapula. Its character is usually stick- 
 ing and intermittent, but not intense ; the skin is often hypersesthetic 
 to percussion and palpation. Its cause is chiefly acute pleurisy, 
 for lung disease and chronic pleurisy are generally painless; other 
 causes are muscular fatigue from coughing, intercostal neuralgia and 
 less often intercostal neuritis. Pain may be intense in pneumothorax. 
 
 2. General Symptoms. — These result from absorption of the 
 toxins secreted in the local lesions. 
 
 (a) Fever. — This is present in the great majority of cases and is 
 almost invariable in the early stages. Probably the dominant cause 
 is the tuberculous toxin, whose febrile action is analogous to tubercu- 
 lin; secondary infections undoubtedly may cause fever, though not 
 necessarily, for the associated streptococci are usually far from 
 virulent. Fever marks the tubercle formation, fusion of foci, ad- 
 vance of the disease, degeneration of the tubercle, and probably 
 secondary infection; its cessation is synchronous with temporary or 
 permanent arrest of the disease, as manifested by improved health, 
 strength and weight. Its height and course are somewhat influenced 
 by the individual ; labile individuals possess labile temperature cen- 
 tres (de Renzi) ; it is easily increased by exercise, excitement or 
 more trivial causes. 
 
 Fig. 20. 
 
 104 
 
 DAY 1 
 
 2 
 
 „ 
 
 4 
 
 5 
 
 6 
 
 103 
 
 
 
 
 
 A 
 
 
 102 
 
 
 
 
 
 \ / 
 
 \ 
 
 101 
 
 
 
 
 
 / 
 
 \ 
 
 100 
 
 
 
 
 
 / 
 
 \ 
 
 99 
 
 
 
 
 
 v 
 
 \ 
 
 
 
 
 
 V 
 
 \ 
 
 98 
 
 
 
 IV 
 
 
 
 Hectic fever-curve in phthisis. 
 
 Types. — There is no typical curve nor can fever be classified as 
 initial or ulcerative fever. The vesperal hectic is the most common 
 curve, and indicates slow disintegration and absorption of toxins. In- 
 termittent fever may resemble malaria and usually indicates rapid and 
 marked tissue-disintegration; remittent fever most often occurs late 
 
TUBERCULOSIS. • 311 
 
 in the clinical course ; continuous fever occurs early or in acute con- 
 sumption, but rarely resembles the typhoid curve; in some cases 
 the fever falls from high to subnormal registers, sometimes with col- 
 lapse, which was regarded as unfavorable by Riihle; the typus in- 
 versus with morning exacerbation and vesperal solution is very un- 
 common. Fever may be absent in cases with old cavities and fibrous 
 induration. Chills have no relation to the fever or its intensity. 
 As fever is indicative of toxaemia, it is often associated with anorexia, 
 emaciation and other symptoms (v. i.). 
 
 (b) The Blood. — (i) The red cells rarely number less than 2 mil- 
 lion, though Limbeck records a case with but 730,000 ; anaemia may 
 antedate all other symptoms, whence the frequent confusion of chloro- 
 sis and incipient phthisis. Again, anaemia may be inconspicuous or 
 late. In some cases the red cells are increased, notably in individ- 
 uals prone to haemoptysis (Mircoli). (ii) The haemoglobin averages 
 75 per cent. ; it may be decreased more than the number of red cells, 
 therein resembling chlorosis (chlorancemie tuberculeuse). (iii) The 
 leukocytes may be normal ; in cavity formation (secondary infection) 
 their number may rise to 12,000 or 15,000 ; they are increased in cases 
 of caseous pneumonia or protracted pyrexia; after injection of tuber- 
 culin the eosinophiles show a decided increase. (iv) Tubercle 
 bacilli are seldom found in the blood except in the death agony. 
 
 (c) Sweating. — Night sweats are more important than in any other 
 disease and occur in 90 per cent, of cases (Louis). The most plau- 
 sible cause is the action of toxaemia on the sweat-centre in the me- 
 dulla. Heavy coverings sometimes induce sweating. The term 
 " night sweats " is used because nearly all of them occur in the night, 
 chiefly between 2 and 5 a. m. It is more frequent in acute than in 
 chronic phthisis, in younger than in older subjects, when cavities 
 are forming and the fever is variable. 
 
 (d) Pulse. — The rapid pulse is associated with disturbed digestion, 
 reduced muscular strength and depreciated nutrition (v. i. Com- 
 plications, for details). 
 
 3. Physical Signs. — In adults, the apex of an upper lobe, more 
 often the right than the left, is first affected (Laennec). The reasons 
 ascribed are various, such as a poor apex blood-supply, slower lymph 
 current and less expansion, — which are scarcely proven. It is more 
 correctly held that coughing drives infection upward from the bron- 
 chi, and that the clavicle or first rib compresses the bronchi passing 
 to the apex and thus lessens its ventilation. The summit of the apex 
 is not invaded first. Birch-Hirschfeld, in early cases which died 
 from causes other than tuberculosis, found that in 24 per cent, the 
 disease began in the fourth or fifth order of bronchi in the upper lobe 
 and that the posterior were affected earlier than the anterior divisions. 
 
 (a) Inspection. — (i) The nutrition may be good, but, later, ema- 
 ciation is marked. The face is pale, the cheeks hectic, the nose 
 pointed, the eyes hollowed and glistening, the neck thin and the chest 
 is altered in various ways ; in some cases it is long and narrow, with 
 
312 TEE SPECIFIC INFECTIONS. 
 
 wide interspaces, sharp costal angles, prominence of Louis' angle, 
 atrophy of the scapular muscles and more vertically directed ribs; 
 in others it is flattened anteroposteriorly and the ribs are closely 
 apposed; in still others the funnel-chest may be seen. Laennec 
 recognized that the " paralytic chest" was the result and not the 
 cause of phthisis. Examining the patient in a good light, the fol- 
 lowing may be noted: (ii) Deficient expansion above or below the 
 clavicles, especially when examined from behind and above; in the 
 lower chest, an impaired or absent excursion of the diaphragm. 
 Deficient expansion may be due to pleural adhesions, to atelectasis of 
 the lung resulting from caseous nodes obstructing the bronchi, to a 
 cavity, or to gradual induration of the focus, which is an effort to- 
 wards encapsulation and recovery, (iii) Distention of the chest 
 may be due to vicarious emphysema, effusive pleurisy or pneumo- 
 thorax, (iv) The cardiac impulse may be widened by retraction of 
 the left lung away from the heart. 
 
 (b) Palpation. — Palpation shows (i) decreased expansion, elicited 
 by standing behind the patient with the thumbs above either clavicle 
 and the fingers below it, or by standing in front of the patient and 
 applying the spread fingers and hands over the anterolateral parts 
 of the thorax, (ii) Increased vocal fremitus, obtained when the lung 
 is infiltrated (caseous foci or pneumonia), indurated or is the seat of 
 cavities, all of which increase conduction of the voice-sounds from 
 the bronchi. Superficial show more clearly than deep lesions ; thick 
 pleural adhesions or plugging of the bronchi with caseous material 
 decrease the fremitus, (iii) The systolic distention of the pulmonary 
 artery and the second pulmonic closure are better felt when the lung 
 retracts from the heart or when it is infiltrated in its vicinity. 
 
 (c) Percussion. — (i) Incipient infiltration of the apex gives a 
 short percussion note, which later becomes dull. According to Graw- 
 itz the apex is first involved in 88 per cent, of cases. Dulness is de- 
 tected in the apex or under the middle of the clavicle, at which level 
 Birch-Hirschf eld found the anatomical beginning of tuberculosis. The 
 apices are best percussed when standing behind the patient, and it 
 should be remembered that the right apex is normally less resonant 
 than the left. The lung tissue lying behind or near, the clavicle 
 can be well tested by gently tapping the clavicle with one finger. To 
 detect slight early alterations in note, percussion should be gentle, 
 symmetrical parts should be compared and the patient should hold 
 his breath in full inspiration; the muscles must be relaxed, and it 
 should be recalled that each patient has his own percussion note, 
 which varies with the individual's muscles, fat and bones. The 
 apex reaches 1 to 2 inches above the clavicle, and behind to the ver- 
 tebra prominens. Piorry, Friedreich and Eichhorst demonstrated 
 that impaired resonance is produced only by consolidation measuring 
 li by 2-J inches in area and within f inch of the surface, and that 
 foci of these dimensions lying deeper than 2 inches escape detection. 
 Oesterreich holds that a focus as large as a cherry may cause dulness. 
 
TUBERCULOSIS. 313 
 
 Small, multiple or deep foci give a tympanitic note. The dulness 
 may extend from the clavicle to the second and third costal cartilages, 
 then to 1.5 inches below the apex of the lower lobe at the level of the 
 fifth dorsal vertebra; this area is almost always involved when the 
 upper lobe shows distinct consolidation; extension occurs outward 
 and downward along the interlobar fissure; then it extends to the 
 apex of the upper lobe on the other side. Often the first dulness 
 of consolidation is found behind, in the supra- or interscapular region, 
 (ii) Shrinking, fibrous induration and a thickened pleura give 
 apical or other dulness. Sometimes the lung becomes vicariously 
 emphysematous about an old focus which is thus hidden clinically and 
 pathologically, (iii) A tympanitic or cracked-pot resonance may 
 be obtained over cavities (v. i.). 
 
 (d) Auscultation. — This is the most important aid, next to the 
 microscopic examination of the sputum, (i) The vesicular murmur, 
 especially at the apex, is altered, — for detection of which the patient 
 is best examined without deep breathing or coughing; the jerky 
 "cog-wheel" breathing, described by Jackson (1833), may be due to 
 small tubercles in the bronchi, somewhat stenosing their lumina; it 
 is only suggestive and occurs in normal individuals in forced, muscu- 
 lar breathing ; Potain considers it due to pounding of the heart on the 
 lung during inspiration. The breathing may be wavy, weak, indeter- 
 minate or puerile. A rude, rough inspiration may be heard, which 
 is due to peribronchial tubercles compressing the bronchioles. The 
 expiration is frequently prolonged, rougher and higher pitched, in 
 apical " catarrh " ; it is long, sharp and bronchial, in older foci. It 
 must be remembered that what seems clinically to be catarrh is often 
 consolidation pathologically. The breath-sounds are physiologically 
 higher pitched on the right than on the left side, (ii) Bronchial 
 breathing is caused by various consolidations (tuberculous, pneumonic, 
 neoplastic or gangrenous) and by cavities, tuberculous and otherwise. 
 Bronchial breathing of moderate degree is physiological in the inter- 
 scapular region, but is considerably less intense than that of consolida- 
 tion, (iii) Bales are rather an evidence of infiltration (consolida- 
 tion) than of " catarrh." If they are heard in the apex, the presence 
 of tuberculosis should be suspected, though they may occasionally 
 occur there physiologically. The vibrations of the accessory muscles 
 of respiration, when the patient takes a long forcible breath, may be 
 confused with rales, but are easily differentiated after a little ex- 
 perience. Rales may not be heard unless the patient breathes deeply 
 or coughs ; auscultation should be made before, and then after, cough- 
 ing noiselessly and inspiring with the least muscular force. In incip- 
 ient consolidation, small crackling crepitant rales are heard over the 
 alveoli and smaller bronchioles, at the end of inspiration; thev later 
 become larger, ringing and resonant, which proves that the alveoli 
 and bronchioles have become airless over a considerable area, or that 
 softening or formation of cavities is in progress; scattered, clear 
 large, crackling rales are heard over small cavities in the apex or in 
 
314 TEE SPECIFIC INFECTIONS. 
 
 the smaller bronchi, and indicate a viscid secretion. Clicking rales 
 are generally attributed to softening ; they may occur near the heart 
 in the systole, as the heart beats upon an adjacent infiltration. 
 Gurgling and consonating rales suggest cavity or bronchiectasis. In 
 emphysematous patients, whose chests exhibit sibilant and bubbling 
 rales, diagnosis of developing tuberculosis may be most difficult, (iv) 
 Bronchophony (a bronchial quality imparted to the voice-sounds) is 
 heard when the patient counts or speaks during auscultation ; it indi- 
 cates infiltration or cavity formation but is absent when the bronchi 
 are plugged. /Egophony is merely a higher grade of bronchophony 
 and occurs as Skoda demonstrated, in cases of consolidation, in 
 medium-sized cavities and above pleural exudates, (v) Pleural fric- 
 tion results from fibrinous pleurisy or rough tubercles in the pleura, 
 (vi) A systolic bruit over the subclavian artery is probably due to 
 pleural adhesions to the artery. 
 
 (e) Roentgen Rays. — Shadows may be due to consolidation, thick- 
 walled cavities, calcified foci, gangrene, pleural callus or pleural ex- 
 udate. The excursion of the diaphragm can be followed; shadows 
 toward the apices, due to the muscles, may be readily eliminated by 
 moving the arms ; the results are often confusing. 
 
 Summary. — The findings of inspection, palpation, percussion and 
 auscultation may now be grouped together, because they are found 
 together clinically, one part showing the signs of consolidation, an- 
 other those of cavity formation or of induration, (a) The signs of 
 consolidation are decreased expansion, increased vocal fremitus, initial 
 tympany followed by dulness, high-pitched expiration, then distinct 
 bronchial breathing, crepitant rales and bronchophony, (b) The 
 signs of induration are retraction or lagging behind of the fibrous 
 area on breathing, increased vocal fremitus, dulness, usually large 
 rales, bronchial breathing and bronchophony, (c) The signs of cavity 
 formation are: (i) Increased vocal fremitus, if it is near the surface; 
 (ii) tympanitic note, which may increase in intensity when the cavity 
 is percussed with the mouth open (Wintrich's change of note), when 
 it is percussed during inspiration (Friedreich's change of note), or 
 when it is percussed with the patient in the sitting posture (Gerhardt's 
 change) ; the note may be metallic; the cracked-pot note, Laennec's 
 bruit de pot fele, is obtained in cases of superficial cavities measuring 
 2-J inches with thin walls, which communicate with an open bronchus 
 by a small opening ; variation in the percussion note from accumula- 
 tion (dulness), or emptying of secretion (tympany), is most suggestive 
 of cavity formation ; percussion may cause the patient to cough and 
 void much sputum; (iii) the breathing, which is loudly bronchial, or 
 if the cavity is quite large, metallic, amphoric or metamorphosing; 
 metamorphosing breathing is breathing which begins normally and 
 suddenly becomes bronchial or vice versa (Seitz) ; (iv) bronchophony 
 and segophony ; (v) large, resonant rales, which are the most frequent 
 and important finding ; metallic rales in the apices are most suggestive 
 of cavities; they may acquire an amphoric character in very large, 
 
TUBERCULOSIS. 315 
 
 thin-walled excavations ; (vi) nummular sputum ; (vii) systolic mur- 
 murs, which are sometimes booming or metallic, and are due to propa- 
 gation of the heart tones; they are occasionally heard at some dis- 
 tance from the patient. 
 
 Cavities are due to the breaking down of caseous areas and are 
 usually connected with the bronchi. Their evacuation into the 
 bronchi is partly favorable, in that the infective material is evacu- 
 ated; partly unfavorable, because it opens up avenues for infection 
 by aspiration. Once formed, they generally remain or increase ; they 
 may leave fistulous cicatrices (Laennec's cicatrices fistuleuses) ; if 
 they are held by adhesions the cavities remain, contracting cicatriza- 
 tion being impossible ; there is always danger of their further exten- 
 sion by secondary infection, or of gangrene. The cavity has a well- 
 marked limiting membrane, from which pus, nummular sputum, 
 elastic fibers, and grayish granular detritus composed of masses of 
 tubercle bacilli, are voided ; the cavities are frequently multilocular, 
 may heal on one side and extend on another, and sometimes occupy 
 an entire lobe or even an entire lung. They may rupture into the 
 pleura, pericardium or bloodvessels; in one instance the author saw 
 a cavity rupture into the mammary gland, resulting in diffuse sub- 
 cutaneous emphysema. 
 
 Stages of Pulmonary Tuberculosis. — Tuberculosis usually develops 
 for six to eighteen months before any symptoms appear. 
 
 1. Phthisis Incipiens. — In incipient phthisis the general and 
 local symptoms appear as above described, with fever, anaemia and 
 rapid pulse. The modes of onset are various. The most frequent 
 picture is that of a patient with an obstinate cold or a " grippe " 
 which does not resolve; the sputum may show tubercle bacilli and 
 the apex some rales. In others, disordered digestion and a rapid 
 pulse awaken suspicion. The voice may be lost, passing as a simple 
 laryngitis. There may be only a moderate depreciation of health 
 and, in young girls, a chlorosis may be hastily diagnosticated. Ma- 
 laria is a common escape in explaining an indeterminate fever. 
 Tuberculosis may appear in other more directly suggestive forms, 
 such as haemoptysis, pleurisy or cervical adenitis. The physical 
 findings are uncertain or absent. 
 
 2. Phthisis Confirmata. — The appearance of distinct physical 
 findings indicates not incipient phthisis, but confirmed established 
 phthisis. 
 
 3. Phthisis Constjmmata. — This is advanced consumption, with 
 marked hectic fever, cavity formation and emaciation. 
 
 Course. — The average case of " chronic ulcerative phthisis," with 
 the symptoms and signs already described, stands midway between 
 the following very acute and extremely chronic groups : 
 
 1. Acute, Galloping or Florid Consumption. — This type con- 
 stitutes 10 per cent, of phthisis and probably always develops from 
 some old focus, such as tuberculosis of the bronchial glands, or from 
 a small cavity which by intrabronchial rupture disseminates the 
 
316 THE SPECIFIC INFECTIONS. 
 
 process ; possibly the virulence of the germ is greater in these cases ; 
 pregnancy, diabetes, alcoholism, measles, whooping-cough, influenza 
 or trauma, may be the immediate cause. 
 
 (a) Acute Pneumonic Form. — The acute pneumonic form is acute 
 caseous pneumonia. The term is employed because of the great 
 clinical resemblance to, and confusion with, acute lobar pneumonia ; 
 but it must be remembered that genuine lobar pneumonia does not 
 caseate, and that this form is not synonymous with tuberculosis com- 
 plicated by acute pneumococcic pneumonia, which, in this association, 
 runs its usual course. Acute caseous pneumonia begins in an indi- 
 vidual in seemingly perfect health, or perhaps in one whose health is 
 somewhat but not suggestively reduced. An initial rigor is fairly 
 common, or the spitting of blood may be the first symptom. There 
 is often herpes, cough, pain in the side, rapid breathing and sudden 
 fever, which frequently exactly imitate the onset of genuine pneu- 
 monia. The resemblance may persist but often certain variations 
 arouse suspicion. The fever is remittent or intermittent, and more 
 variable than in lobar pneumonia; dyspnoea and cyanosis are less 
 frequent than a gradually increasing pallor; sweating is usually 
 copious. In a few days dulness prevails over a lower lobe but much 
 more often over an upper lobe or over an entire lung. The breathing, 
 which is at first indistinct, may remain so (Traube), but quite often 
 becomes bronchial and is associated with crepitant and coarse mucous 
 rales. The sputum is often typically pneumonic, viscid and rusty, 
 or of an olive or grass-green color (Traube), but elastic fibres are 
 seldom found. Tubercle bacilli are sometimes found, but in this 
 case originate not from the fresh pseudopneumonic patches, but from 
 the causal focus ; in few cases the physical signs of the primary cavity 
 in an upper lobe can be elicited. The physical findings change but 
 little, though the crepitant rales are replaced by coarse mucous rales ; 
 the anticipated crisis does not occur, and most cases are still called 
 unresolved pneumonia until the increasing anaemia, loss of strength 
 or rapid pulse, suggests a tuberculous pneumonia. Albuminuria is 
 uncommon; the diazo reaction is nearly always present. Of 13 
 cases reported by Frankel and Troje, 11 died within six weeks, 
 and Tindeloo observed a fatal issue in six days. In some few 
 cases considerable regression may occur and it is barely possible for 
 the course to last three months or more. The findings at autopsy are 
 most interesting; usually an old focus of tuberculosis is found, a 
 ruptured cavity or gland ; from it caseous material, containing bacilli 
 and tuberculous toxins, is aspirated into many finer alveoli and 
 bronchioles, where they excite a miliary caseous lobar pneumonia, 
 depending on the size of the affected area only. The inflammation 
 is seemingly due wholly to Koch's bacillus or its toxins, and is (i) 
 partly fibrinous and desquamative, red and white polynuclear and 
 mononuclear cells being poured out ; proliferative changes are noted, 
 as the epithelioid and giant cells seen in the typical tubercle; casea- 
 tion ensues, as shown in the already fused and fusing yellowish-gray 
 
TUBERCULOSIS. 317 
 
 areas; (ii) the most rapid exudation is serous, Laennec's "gelati- 
 nous or smooth pneumonia/' which is probably due, as Frankel and 
 Troje insist, to the toxins of the tubercle bacillus and not to mixed 
 infection, as Ortner and others maintain ; this part of the inflamma- 
 tion may regress, and does not necessarily caseate. Cavities rarely 
 form in this type. 
 
 (b) Acute Disseminated Form. — Acute disseminated tuberculosis 
 may occur as a special acute type, or may complicate the ordinary 
 form of phthisis. Following the rupture of a small centre of soften- 
 ing, which is usually located only at the postmortem, and following 
 dissemination by aspiration, there develop (i) fever, repeated hae- 
 moptysis, chills, rapid pulse, rapidly increasing dyspnoea, diffuse 
 crepitant or bubbling rales, considerable delirium, or even a pro- 
 nounced status typhosus, (ii) The sputum is absent or scanty, and 
 the bacilli are sometimes absent throughout the course. At this stage 
 death may occur acutely in three to four weeks without physical 
 signs having appeared and without breaking down of the foci, or a 
 remission may take place, after which there is (iii) breaking down 
 of the indistinct foci which cause slight dulness and distant bronchial 
 breathing; lobular pneumonia is frequently diagnosticated. At au- 
 topsy, scattered, opaque, yellow, partly caseous peribronchial nodular 
 foci are seen; in some cases the presence of tuberculosis is proven 
 only by microscopic examination, for, without caseation, the foci 
 may resemble the ordinary bronchopneumonic patches. Secondary 
 infection with streptococci is usually said to cause this form, but 
 Prudden demonstrated that the above lesions may result from the 
 tubercle bacilli alone. 
 
 (c) Acute Disseminated Ulcerative Form. — The acute dissemi- 
 nated ulcerative type is often observed in children between two and 
 six years of age (Grancher), in pregnancy, alcoholism, diabetes and 
 influenza. The foci, which vary from the size of a pea to that of a 
 walnut, are widely disseminated; they fuse, break down early and 
 develop cavities without walls, which are only ulcers or consist of 
 necrotic caseous material. There are present clinically hectic or 
 continuous fever, pronounced anaemia, exhausting sweats, rapid ema- 
 ciation and viscid sputum, which is purulent and contains many 
 bacilli ; diffuse fine and large rales and bronchial breathing may be 
 heard, but the physical signs are often vague. The course is gallop- 
 ing, and ends fatally in one to four months. 
 
 (d) Acute Miliary Form. — Acute miliary tuberculosis (q. v.) de- 
 velops in 3 per cent, of the cases of pulmonary phthisis. 
 
 2. Chronic Tuberculosis. — (a) Chronic Ulcerative Form. — 
 The ordinary chronic ulcerative phthisis may run a course which is 
 long latent, except for anaemia, dyspepsia or other undistinctive 
 symptoms. Improvement may follow the detection of such positive 
 lung findings as an apical catarrh, and the cough, fever, sweats and 
 anorexia may subside ; another relapse may occur after years of qui- 
 escence, or exacerbations develop, with loss of weight and strength. 
 
318 THE SPECIFIC INFECTIONS. 
 
 Kecovery may occur, even with pronounced physical signs. Cornet 
 regards the breaking out, after years, of new tuberculous manifesta- 
 tions as reinfections rather than relapses. 
 
 (b) Phthisis Fibrosa. — Phthisis fibrosa is the slow development of 
 fibrous connective tissue excited by the tubercle bacillus. It may 
 begin acutely or follow an insidious course from the onset. Its ex- 
 planation is difficult ; Auclair thinks the bacillus secretes two toxins, 
 one with a necrosing action which leads to caseation, and another with 
 an indurating action which leads to fibroid phthisis. There may be 
 no cough, sputum, fever, emaciation or anaemia. Bacilli may or may 
 not be found in the sputum. Ulceration may result only from mixed 
 infection. Sometimes there is haemoptysis. If left-sided, the spleen 
 rises higher and the retraction of the lung away from the heart 
 makes its apex wider, the cardiac shock more diffuse, and the pulsa- 
 tion of the pulmonary trunk more visible. If right-sided, the liver 
 rises, the right ventricle is apparently enlarged (from lung retrac- 
 tion) and is often actually hypertrophied and dilated from increased 
 tension in the pulmonary circuit. The heart may be drawn to the 
 right or left by the inevitable pleural adhesions, bronchiectases are 
 not uncommon, the sound lung is vicariously emphysematous, and the 
 diseased lung is smaller, flatter and depresses the shoulder, impairing 
 expansion and often presenting bronchial breathing and large rales. 
 
 (c) Pleuritic Form. — The pleuritic form follows small latent foci 
 in the lungs, lymph glands, etc. ( See Pleurisy. ) Exudates not due 
 to rheumatism, inflammation in contiguous organs, tumor or ne- 
 phritis are always suggestive of tuberculous pleurisy. Pleurisy, in 
 fact, more often precedes than succeeds pulmonary tuberculosis and 
 repeated attacks are frequent, with moderate irregular or continuous 
 fever, perhaps with rales in the apex of the affected side (not the 
 rales frequently heard just above the upper level of the exudate), or 
 with dulness in the contralateral apex. Bowditch, following up 90 
 cases of pleurisy, found that 33 per cent, developed pulmonary tu- 
 berculosis. 
 
 Variations According to Age. — 1. Children. — Tubercle bacilli easily 
 pass the bronchial mucosa . and produce tuberculosis of the bron- 
 chial and mediastinal glands; the wide lymph-vessels and more 
 active metabolism have already been noted. In children the process 
 in the glands attacks secondarily the hilum of the lung and the lower 
 lobes (80 to 98 per cent.). This invasion explains the frequency of 
 miliary tuberculosis from involvement of the thoracic duct and blood- 
 vessels. 
 
 (a) Chronic Generalized Tuberculosis. — The younger the child 
 the less local and the more general is the tuberculosis. Measles, per- 
 tussis and influenza are very prone to arouse a latent tuberculosis in 
 the bronchial glands. The course is generally more active than 
 chronic, like that of tumors in children. Emaciation, anaemia, en- 
 largement of the spleen and liver and moderate intumescence of the 
 peripheral lymph-glands are the variant features of this type. Fever 
 
TUBERCULOSIS. 319 
 
 may occur only toward the end of the process. Hectic fever is seen 
 chiefly in children over three years. The sputum is swallowed, but 
 washing the stomach recovers bacilli-laden sputum. 
 
 (b) Acute Miliary Tuberculosis (v. s.). 
 
 (c) Localized Lung Tuberculosis. — Localized lung tuberculosis 
 may be (i) of the acute caseous type resembling pathologically bron- 
 chopneumonias of other causation, and the microscope may be neces- 
 sary to detect its nature; haemoptysis is rare, though Henoch has 
 observed over a dozen cases under six years of age. (ii) Chronic 
 localized forms are very infrequent under six years of age. 
 
 In children, the physical findings are often absent; when present 
 they are usually over the lower lobes, very seldom near the clavicles. 
 Cavities are rare and if softening develops, do not freely com- 
 municate with the bronchi. In half the cases the wrong diagnosis is 
 made (Henoch). Percussion is more difficult than in adults, because 
 of the small chest and its thinner walls ; for example a cracked-pot 
 resonance can be obtained in a normal young chest by strong percus- 
 sion. Children, too, breathe irregularly, and puerile respiration is 
 physiological. Induration is rare. 
 
 2. The Aged. — In the aged, haemoptysis is rare, physical findings 
 are less frequent than in adolescence, because the breathing is weaker 
 and emphysema is more common. Cough and fever are also less 
 conspicuous. 
 
 Diagnosis of Pulmonary Tuberculosis. — Early diagnosis is most im- 
 portant. A positive family history is of some value, but it does not 
 establish the diagnosis in a doubtful case, nor does its absence ex- 
 clude tuberculosis, (i) The Bacillus tuberculosis distinguishes pul- 
 monary tuberculosis (a) from other catarrhs, such as acute and 
 chronic bronchitis or influenza; (b) from other consolidations, e. g., 
 pneumonia, bronchopneumonia, actinomycosis, neoplasm or syphilis ; 
 (c) from other vomicae, such as the cavities of abscess, gangrene, acti- 
 nomycosis, echinococcus, syphilis or bronchiectasis; (d) from indura- 
 tions other than tuberculous. Every sputum, however trivial, should 
 be examined. Cultures and inoculations may be made in doubtful 
 cases, (ii) In doubtful cases, repeated physical examinations are 
 imperative; auscultation is more valuable than percussion; too great 
 reliance should not be placed on negative findings; any lesion in a 
 lower lobe with findings in an upper apex is almost surely tuber- 
 culous. 
 
 (iii) Tuberculin Tests. — (a) The ophthalmo-reaction of Wolff- 
 Eisner and Calmette (1907) consists of dropping in the eye one 
 drop of 1 per cent, old tuberculin which is followed in a few hours 
 (12 to 24) by a reactive conjunctival hypersemia. In 6300 tests, 
 Calmette found a positive reaction in 90 per cent, of tuberculous 
 patients, in 57 per cent, of suspected tuberculosis and in 17 per cent, 
 of apparently healthy persons ; the only complications were keratitis 
 in three instances, conjunctivitis in 20 and a reaction lasting over 
 three weeks in 72 instances. Ulcers may develop if tuberculin is in- 
 
320 TEE SPECIFIC INFECTIONS. 
 
 stilled into diseased eyes. The reaction fails in advanced tuberculosis 
 and may develop in typhoid, (h) Von Pirquet's test is vaccination of 
 the skin under a drop of 25 per cent, old tuberculin (in salt solution) ; 
 in 24 hours a small papule appears. This method is absolutely safe, 
 most adapted to children, more prone to show latent tuberculosis and 
 rather too delicate to be valuable in adults unless it is negative, (c) 
 Hypodermic injections of Koch's tuberculin produces a local exudative 
 reaction, and after four or five to ten hours, a systemic reaction, 
 which is characterized by chill, fever elevation of even 5 degrees, 
 headache, general pains, malaise, nausea, sometimes by erythema 
 nodosum, an increase of sputum, rales or even a slight area of pul- 
 monary dulness ; the first injection of Koch's older tuberculin should 
 be small, in adults 0.2, 0.5, 1 or 5 milligrams — in children 0.1 to 1 
 milligram. The reaction is probably specific and generally means 
 that there is a tuberculous focus in the body, but not necessarily in 
 the lungs, unless rales develop at the suspected spot after the injec- 
 tion. Positive reactions have been recorded in syphilis, leprosy, can- 
 cer and actinomycosis, but they were not proved by autopsy (to show 
 absence of tuberculosis). Latent tuberculosis lessens the value of 
 positive reactions ; thus, a case with enlarged mediastinal and supra- 
 clavicular glands, without other physical findings, gave a positive 
 tuberculin reaction, though the autopsy showed that they were car- 
 cinomatous from a clinically latent gastric carcinoma, and the reac- 
 tion came from a single tuberculous mediastinal gland which was of 
 no diagnostic significance. In veterinary medicine it is more valu- 
 able, leading to a correct diagnosis in more than 90 per cent. (Bang) 
 or 97 per cent. (Yoges). The author admits a reluctance to use 
 tuberculin freely; four cases of miliary tuberculosis apparently re- 
 sulted from its employment. 
 
 Sticker recommended the use of potassium iodide in small doses 
 (gr. iij); it congests the lungs at the seat of the lesion, possibly 
 makes the auscultation findings clearer, and carries bacilli into the 
 sputum ; its use is not wholly free from danger. 
 
 Pseudotuberculosis. — The Ehizomucor parasiticus (Lucet and 
 Constantin), the ray fungus, streptothrix (Eppinger) and the asper- 
 gillus may cause pseudotuberculosis. The form caused by the Asper- 
 gillus fumigatus is described as a primary lung affection by Dieula- 
 foy and others, but many writers consider it secondary only. The 
 symptoms of streptothricosis are haemoptysis (23 per cent.), fatigue, 
 anorexia, dry cough and, later, a greenish purulent sputum. The 
 physical findings are bronchitis, less often slight consolidation or 
 cirrhosis of the lung. Ashton and Wright (1905) collated 26 cases 
 of streptothricosis pulmonum, of which most had symptoms resem- 
 bling phthisis; over 50 per cent, were unmixed infections and 76 
 per cent. died. 
 
 Prognosis of Pulmonary Tuberculosis. — Two issues are possible, re- 
 covery and death. 
 
 1. Eecoveey. — Autopsies on hospital cases show 25 to 97 per cent. 
 
TUBERCULOSIS. 321 
 
 of healed tuberculosis. Many of the recoveries are only relative, since 
 Kurlow's inoculations from seemingly latent caseous foci into guinea- 
 pigs were positive in 77 per cent. ; such foci may be aroused by inter- 
 current disease, though some writers regard recurrence as fresh in- 
 fection rather than recrudescence. Watson observed a clinical course 
 of fifty-four years, and Fagge one of thirty-five years. Recovery is ef- 
 fected by agglutinins (precipitins), elaborated by the infection, and by 
 other specific antibodies (opsonins) which aid the leucocytes in the 
 process of phagocytosis. The result is encapsulation, scar forma- 
 tion and the deposit of lime salts. Liebermeister believes recovery is 
 possible in 50 per cent, of incipient cases. The outlook depends on 
 several factors : (a) The hereditary vital endowment of the patient ; 
 (b) his environment, social situation, habits and intelligence; (c) 
 whether the localization of the disease is single or multiple; (d) sec- 
 ondary or mixed infection; (e) digestion; (/) degree of toxin absorp- 
 tion (fever and emaciation) ; (g) youth, diabetes, pregnancy and 
 lactation are unfavorable; (h) pulse rate; 80 per cent, with normal 
 pulse were alive after 4 years and 97 per cent, with rapid pulse were 
 dead (Schneider) ; and (i) complications (v. i.). 
 
 2. Death. — The clinical course is variable, even in chronic cases ; 
 it averages two years (Bayle, Laennec, Andral), over two and a 
 half years (Pollock), three years (Cornet) and seven years (Wil- 
 liams and Dettweiler, though the latter' s cases did not include acute 
 forms or cases in children). The process of death is usually peace- 
 ful and painless, though at times it comes with dyspnoea (stagnant 
 secretion), delirium or convulsions. Mechanism of death : (a) Heart 
 failure is the common cause, associated with oedema, asthenia, anae- 
 mia and marasmus. Other causes are less frequent, as (b) profuse 
 fatal hsemoptoe; (c) pneumothorax; (d) pulmonary embolism (clots 
 or gas); (e) uraemia; (/) meningitis; (g) perforative peritonitis; 
 (h) sudden death without adequate pathological findings. In cases 
 of sudden death, Arnold, Brissaud and Toupet, have found in the 
 liver large numbers of bacilli, which probably caused an acute intoxi- 
 cation, since Mafucci's experiments demonstrated that the injection 
 even of dead bacilli causes rapid marasmus and death. 
 
 Complications. — Tuberculosis in other organs will be considered 
 below. 
 
 1. Respiratory. — (a) Tracheitis and bronchitis occur in almost 
 every case ; and laryngitis in many cases results from the toxins. (&) 
 Dysphagia usually results only from local involvement of the pharynx 
 or larynx ; swallowing into the larynx is usually the result of paraly- 
 sis of the epiglottic depressors. Hoarseness, dysphonia and aphonia 
 always suggest laryngeal tuberculosis, but may develop from such 
 other causes as syphilis or catarrh; from paralysis of the recurrent 
 laryngeal nerve from pressure by lymph glands ; from inflammation, 
 on the right side by pleural scars, and on the left by large pleural 
 effusions; or from thickening at the hilum. (c) Pulmonary gan- 
 grene may develop in the cavity wall. Lobar pneumonia is not in- 
 21 
 
322 TEE SPECIFIC INFECTIONS. 
 
 frequently a cause of death, (d) Dry pleurisy is an almost invariable 
 complication, and is a conservative process, which lessens the proba- 
 bility of pneumothorax. Exudative pleurisy more often develops 
 previously to lung phthisis than during its course. In the latter 
 instance it is usually serofibrinous, and is generally not extensive. 
 Hemorrhagic pleurisy is more common in pleural than in pulmonary 
 tuberculosis. Chyliform or adipose effusions may occur (see Chylo- 
 thorax and Chylous Ascites) ; purulent forms result from mixed 
 infection, from cavities or from pneumothorax. Some pleurisies 
 appear to result from toxaemia rather than from direct bacterial in- 
 vasion. Effusions, by compression, sometimes seem to exert a favor- 
 able effect on a lesion of the lung. Litten thought that their sudden 
 absorption might occasion miliary tuberculosis, (e) Pneumothorax 
 is observed in 5 per cent, of the cases (Powell, West), and results 
 from rupture of superficial cavities which were forming rapidly 
 without a limiting membrane. Perforation occurs most frequently 
 between the second and fourth interspaces, and between the mam- 
 mary and axillary lines. Its onset is spontaneous, or results from 
 straining or coughing. Its occurrence is usually marked by sudden 
 symptoms, as great dyspnoea, orthopnoea and cyanosis, and sudden 
 physical signs, as lying on the side of rupture, sudden ectasia, im- 
 mobility, dislocation of the heart, spleen or liver, weak vocal fremi- 
 tus, voice sounds and breathing, a tympanitic note, and when serum 
 or pus forms, succussion. The onset is occasionally gradual and less 
 urgent, so that pneumothorax may be an accidental finding. Death 
 in a few hours may result, but life may be prolonged weeks or months. 
 Infrequently pneumothorax (q. v.) may exert a beneficial effect on 
 the lung trouble. 
 
 2. Circulatory. — (a) The typical rapid pulse first appears only 
 after meals or exertion, but later becomes permanent. It is probably 
 toxczmic, but may be due to mechanical pressure of large lymph- 
 glands on the vagus, or to compression or inflammation of the vagus 
 from mediastinitis, pleurisy or pericarditis. There is a constant 
 and early lowering of the blood-tension, and the vasomotor instability 
 causes the bright-red cheeks. The pulse may be soft and full through- 
 out the course, (b) The heart is pale, fatty, flabby and weak, and has 
 been described as atrophied since the time of Laennec, but Potain 
 considers that the small heart is merely accommodative to the mal- 
 nutrition and anaemia. Cardiac hypertrophy is due to renal disease, 
 pericardial or pleural adhesions, valvular disease, arteriosclerosis or 
 emphysema. Hypertrophy and dilatation of the right heart may 
 follow pulmonary induration or massive pleural adhesions, and the 
 second pulmonic tone is accentuated in one third of the cases. Ad- 
 hesive or effusive pericarditis may result by extension from pleurisy 
 or caseated lymph-glands, but may be due to tuberculosis or pyogenic 
 infection. Endocarditis tuberculosa is very infrequent; tubercle 
 bacilli may be deposited in cardiac clots, or in endocarditic ex- 
 crescences of non-tuberculous origin (Kundrat and Heller) ; Tripier's 
 
TUBERCULOSIS. 323 
 
 case of tuberculous endocarditis was the first clear one ; according to 
 Benda, this endocarditis is due to miliary deposits in the intima, and 
 clinically escapes recognition in most cases, (c) A functional, sys- 
 tolic murmur over the pulmonary valves or apex is very common. 
 (d) Thrombo-phlebitis occurs in about 1 per cent, of the cases. 
 
 3. Nekvous and Muscular. — (a) In some instances the mental 
 power may be normal ; oftener there is a slight mental weakness, irri- 
 tability, psychical lability, self-concentration, lack of endurance 
 and triviality. Sleep is often disturbed. Consumptives are usually 
 optimistic, and they may plan for the future on the day of their 
 death (Spes phthisicorum) ; occasionally melancholia or mania 
 develops ; fever, anaemia, toxaemia, marasmus and vasomotor changes 
 in the brain, such as oedema, may cause terminal aberration, (b) 
 Neuralgia and hyperesthesia are not uncommon. Multiple neuritis 
 not infrequently results from toxaemia ; it may be latent, cause slight 
 sensory disturbance or result in amyotrophy ; it may in part explain 
 oedema not due to cardiac weakness or thrombo-phlebitis. (c) The 
 same toxins which reduce the body weight one-half or more, result in 
 marked muscular degeneration and atrophy, which cause the flat 
 chest, and possibly also the cardiac wasting. The muscular and adi- 
 pose wasting is expressed in the terms synonymous with tuberculosis 
 ■ — consumption, phthisis, tabes. The muscles are dry, pale, fatty; 
 they show transverse rents, separation of the sarcolemma, poor mark- 
 ings, granular degeneration or hyperplasia of the connective tissue; 
 myositis is described by Delorme and Reverdin. Their wasting and 
 the nervous toxaemia explain the asthenia and incapacitation for 
 work, a matter of national economical importance. The muscles 
 are often irritable, show fibrillary contractions and when tapped or 
 pinched show local contraction or lumps, known as myoidema. 
 
 4. Digestive. — (a) The tongue may be furred, or red and clean. 
 Aphthae are frequently distressing. Excessive redness of the gums is 
 frequent, (b) Stomach disorder is present in 33 to 66 per cent, of 
 cases ; it may be the initial symptom of toxaemia, or appear only late 
 in the process. The appetite may be unimpaired, and Cornet in- 
 stances an advanced patient who complained that he could only eat 
 four beefsteaks for dinner. " The patient, with fever, who eats and 
 digests well, is tuberculous" (Lesegue). Anorexia varies in degree 
 and occurrence, being most marked toward evening, when the fever 
 is higher, and most frequent in those with previous dyspepsia or poor 
 appetite; it is sometimes nervous (anorexia nervosa) with normal 
 gastric chemism; again it may be due to glands compressing the 
 vagus (Peter, de Mussy). Brieger found the chemism normal in 50 
 per cent, in the incipient stage, in 33 per cent, in moderately severe, 
 and in but 16 per cent, in severe advanced cases. After eating there 
 may be a sense of fullness or pain. Nausea, gagging and vomiting 
 may result from pharyngitis, forced feeding or coughing (Morton's 
 "emetic cough"). In advanced cases, nausea and vomiting occur 
 from over-eating, toxcemic gastric catarrh, swallowing of sputum, weak'- 
 
324 THE SPECIFIC INFECTIONS. 
 
 ness of the stomach musculature and deficient secretion; anatom- 
 ically, the stomach shows anaemia, catarrh, fatty degeneration of the 
 glands (36 per cent.), interstitial hyperplasia and sometimes amy- 
 loid infiltration (12 per cent.). 
 
 (c) Intestines. — Constipation may be caused by gastric hyper- 
 acidity. Diarrhoea is usually late ; it may be caused by the toxin in 
 the blood or in swallowed sputum, by intestinal catarrh, toxaemic ob- 
 literation of the lymph- and bloodvessels in the gut, tuberculous 
 ulcers or amyloid degeneration in the gut. Tuberculous ulcers may 
 exist without symptoms or may cause colic, tenderness, pain and 
 diarrhoea ; much depends on their location. According to Eothnagel, 
 ulcers in the small gut, caecum and ascending colon probably cause 
 diarrhoea only when combined with catarrh or amyloid degeneration ; 
 ulcers in the lower colon and rectum almost constantly induce diar- 
 rhoea, which may, therefore, occur from causes other than ulceration, 
 and ulcers may exist without it. Blood, pus, haematin crystals and 
 tubercle bacilli may be present, but not always. Tubercle bacilli do 
 not necessarily indicate intestinal tuberculosis, as they may pass 
 through with the sputum swallowed. Anal fistula occurs in 1.3 to 5 
 per cent, of the cases, (d) The liver is fatty (in 10 to 15 per cent.) ; 
 Jonescu (1902) collected 33 cases of cirrhosis cardiotuberculosa, — 
 induration from stasis, with tuberculous granulations and fatty de- 
 generation, (e) Tuberculous peritonitis (v. i.) occurs in 5 to 15 per 
 cent, of pulmonary tuberculosis. 
 
 5. Amyloid Degeneration. — This occurs mostly in chronic ul- 
 cerative phthisis. According to Blum, 80 per cent, of all amyloid 
 degeneration is due to tuberculosis, and 68 per cent, to pulmonary 
 tuberculosis; it is found in 8.8 per cent, of tuberculous autopsies. 
 The spleen is affected in 93 per cent., the kidney in 77, the liver in 
 62, the intestines in 28 and the stomach in 12 per cent, of cases. 
 
 6. Genito-iteinary. — Urinary. — The loss of weight causes phos- 
 pliaturia, increase of nuclein and chlorides (0.5 to 1 or even 12 
 gm. ) . More proteid is excreted than is ingested. Albumose is some- 
 times present. Albuminuria usually indicates nephritis, amyloid- 
 osis or local tuberculous disease. Acute and chronic parenchyma- 
 tous nephritis is not infrequently due to long-standing toxaemia. 
 Amyloid disease of the kidney produces albuminuria in but 50 per 
 cent, of the cases ; in amyloid of the kidney, nephritis is also present 
 in 75 per cent., and the chronic parenchymatous type in 66 per cent. 
 Flick and Walsh found tubercle bacilli in 84 per cent, by inoculating 
 the urine in guinea-pigs; tubercles were found in 63 per cent. Ehr- 
 lich's diazo reaction is very frequently present, and is usually of 
 unfavorable import ; the prognosis is not necessarily good if the reac- 
 tion is absent. 
 
 Sexual. — In some individuals, the sexual desire is more intense, 
 though its increase is grossly exaggerated. The menses often disap- 
 pear early, and pregnancy is less apt to occur. Pregnancy often tem- 
 porarily betters the condition of the lungs, but a more rapid course 
 
TUBERCULOSIS. 325 
 
 is usual after delivery. The occasional hypertrophy of the mam- 
 mary glands, described by Bedor in 1836, particularly in males, is 
 rather a chronic interstitial mastitis than an actual hypertrophy. 
 
 7. Skin. — Cyanosis is not common. Pityriasis versicolor occurs 
 very frequently in the tuberculous; it is due to the tinea furfur 
 (Eichstedt). Chloasma, desquamation, coarseness of the hair, herpes 
 zoster, lichen scrofulosorum and purpura are sometimes observed. 
 Clubbing of the fingers (the " Hippocratic fingers") and toes de- 
 velops chiefly in chronic cases, is largely due to hypertrophy of the 
 soft tissues (see Acromegaly) and is not pathognomonic of tuber- 
 culosis, for it occurs also in congenital cardiac disease, aneurysm, 
 bronchiectasis, emphysema, etc. Emphysema of the skin is very un- 
 common; it follows interstitial emphysema of the lungs, and results 
 from rupture of the alveoli, pneumothorax or cavities. (Edema re- 
 sults from anaemia, cardiac weakness, phlebitis, nephritis or neuritis. 
 
 Treatment of pulmonary tuberculosis is considered later, after de- 
 scription of other localizations of the tubercle bacillus. 
 
 IV. Tuberculosis of the Lymph Glands. — Of glandular adenopa- 
 thies 68 per cent, are found in the first ten years of life (Wohlge- 
 muth) . It occurs fairly often in adolescence and sometimes even in the 
 aged. It is found anatomically in 99 per cent, of tuberculous chil- 
 dren (Sterner and Neureuther), or according to other statistics in 80 
 to 90 per cent. ; it is found in 25 per cent. (Muller) to 50 per cent. 
 (Babes) of all autopsies on children. Scrofula is glandular tubercu- 
 losis, but it presents different characteristics from those of pulmonary 
 infection, in explanation of which it is held by Arloing that the viru- 
 lence of the bacilli is less in scrofulous glands ; others explain it as an 
 infection with very few bacilli. Neither of these explanations is 
 wholly adequate, whence the assumption of a special glandular ten- 
 dency to infection; it has been suggested that the glands invaded 
 are poorly developed. The skin, mucous membranes and lymph- 
 vessels are physiologically more patent or more permeable in the very 
 young, and an increase of this condition or its persistence in older 
 children is regarded as an infantilism or embryoism, i. e., a struc- 
 tural tendency toward infection. The accessory causes are the same 
 as in pulmonary tuberculosis: (a) An hereditary tendency; (b) poor 
 hygiene, dark damp dwellings, inadequate nutrition and coarse food 
 given to the very young; (c) infections, such as pertussis and measles, 
 to a less extent scarlatina, diphtheria, variola or syphilis. 
 
 General Characteristics. — (a) It usually runs an extremely chronic 
 course, (b) [Recurrence is very frequent, (c) Multiple lesions are 
 usual. (d) Glandular involvement is frequently associated with 
 affections of the skin (as eczema, scrofuloderma or lupus), inflam- 
 mations of the mucous membranes (as conjunctivitis, otitis, rhinitis 
 or bronchitis), and disease of the bones or joints (as coxitis or 
 Pott's disease). This association is frequently known as scrofula of 
 which some authors, as Cornet, distinguish two varieties — (i) the 
 
326 THE SPECIFIC INFECTIONS. 
 
 tuberculous and (ii) the pyogenic, caused by the staphylococcus ot 
 less often by the streptococcus. It seems incongruous to unnecessarily 
 associate tuberculous lymphadenitis and arthritis with non-tubercu- 
 lous forms. 
 
 General Anatomy. — (a) Few bacilli cause but little inflammatory 
 reaction and little cellular proliferation; regression is possible, (b) 
 If the infection is sharper, conglomerate tubercles form, with the 
 following issues : Death of the bacillus in the central caseation, soften- 
 ing and external rupture, sometimes calcification or extension locally 
 by the lymph, or generally by the blood current, (c) Hyperplasia 
 with epithelioid proliferation may occur, without caseation or with 
 very late caseation (Ziegler) ; this form results from infection with 
 few bacilli. The lymphadenoid tissue is compressed by epithelioid 
 spindle-shaped cells; the glands may reach the size of an egg, and 
 their cut section may show no gross evidence of tubercle, (d) Mixed 
 infection causes rapid caseation, necrosis, softening and early rup- 
 ture ; their cut section appears " like that of a raw potato but not so 
 moist " ( Virchow) ; the inflammation is often not limited to the 
 glands, but causes a periadenitis, whereby the glands fuse, a phleg- 
 mon results, and generalization of the process throughout the body 
 ensues. In purely pyogenic lymphadenitis, the glands may become 
 homogeneous and dry (the hyperplastic lymphoma of Virchow), or 
 productive inflammation may result in fibrous induration. 
 
 1. Cervical Tuberculous Adenitis. — Infection occurs through 
 the nose, eye, scalp, pharynx or ear; the primary atrial lesion may 
 leave no mark; or the bacillus may pass through the mucous mem- 
 branes without producing any lesion in them. Writers who describe 
 scrofula as a special symptom-complex, distinguish four stages: (a) 
 The initial skin or mucous membrane inflammation ; (b) the lymph- 
 adenitis; (c) involvement of the joints and bones; and (d) various 
 complications, as amyloid degeneration or miliary tuberculosis. 
 
 The figures of Balman (first column) and Wohlgemuth (second 
 column) show the following localizations: 
 
 Per cent. Per cent. 
 
 Cervical and occipital glands 81 93 
 
 Axillary (from the mamma) 6 2.78 
 
 Inguinal (from the hip, ilium, testicle and 
 
 knee) .. ... 7 0.93 
 
 Cubital (from the fingers) 5 0.23 
 
 Popliteal (from the foot) 0.7 0.23 
 
 Pre- and postauricular 2.9 
 
 The cervical glands constitute 96 per cent, of Wohlgemuth' s series. 
 In cervical scrofula, the glands at the angle of the jaw and beneath 
 or anterior to the sternomastoid muscle are most often involved; in 
 bilateral involvement, the glands of one side are usually larger. The 
 glandular swelling is slow in onset, intermittent in progression, usu- 
 ally unattended by pain or other symptoms and frequently an acci- 
 dental finding. In some cases the first symptoms are acute, but the 
 
TUBERCULOSIS. 327 
 
 trouble subsides in two or three weeks. The intumescence first is 
 discrete and freely movable. Later the nodes may blend into large 
 nodular masses, and periadenitis may fuse the glands and cause their 
 adherence to the skin, which becomes ©edematous, dough-like and 
 reddened. Softening and fluctuation are then frequent, with burrow- 
 ing of the pus in various directions and external rupture through 
 small fistulse. The fistulas widen, discharge cheesy and milky ma- 
 terial and form ulcers covered with granulation tissue and difficult 
 to heal. Cicatrization leaves deep, deforming, depressed scars. Ex- 
 tension may occur to the deeper or subpectoral or axillary glands. 
 Fever, ansemia and other toxsemic manifestations may develop as in 
 lung tuberculosis, or the adenopathy may be the sole clinical fact. 
 
 2. Bronchial Glands. — In autopsies on tuberculous children 
 they are almost invariably affected (in 98 per cent, of Steiner's and 
 Neureuther's and in 100 per cent, of Northrup's series) ; in adults 
 they are affected in 40 to 80 per cent. In children, tuberculosis of 
 the bronchial glands is primary, the bacillus passing the intact 
 bronchial mucosa, and tuberculosis of the lung is secondary. In 
 adults, lung involvement is usually primary and bronchial adenitis is 
 secondary. Small tuberculous foci cause neither glandular enlarge- 
 ment nor symptoms. Biedert, in 1,346 autopsies on tuberculous chil- 
 dren, found the lungs diseased in 80 per cent., the bronchial glands 
 in 78, the intestines in 32 and the mesenteric glands alone in 40 
 per cent. 
 
 Symptoms. — In most cases no symptoms develop; in others, pul- 
 monary lesions overshadow the bronchial involvement; in others, 
 miliary tuberculosis develops, promoted by the close contact of the 
 bronchial glands with, and easy rupture into, the pulmonary vessels ; 
 in still others, mediastinal pressure symptoms result; in very few 
 cases are there actual physical findings. 
 
 Pressure Symptoms. — Pressure on the vagus, known to Wrisberg, 
 causes the rapid heart, so frequently remarked in tuberculous chil- 
 dren; paroxysmal asthma, dyspnoea, or spasmodic cough which 
 sometimes closely resembles that of whooping-cough ; lessening of the 
 sensitivity of the bronchi, which favors infection; and it finally leads 
 to cardiac dilatation and death. Pressure on the recurrent laryngeal 
 nerve is marked by hoarseness, aphonia, dyspnoea or laryngospasm. 
 The air passages, trachea or bronchi may be compressed, as evidenced 
 by dyspnoea, impaired expansion of one or both sides of the chest, 
 and holding the head backward. The pupils may be unequal from 
 pressure on the sympathetic nerve. Other pressure symptoms are: 
 Hypertrophy of the heart, or the paradoxical pulse, from pressure 
 on the aorta; oedema and cyanosis of the face and arms, from com- 
 pression of the superior vena cava ; cough, rales or hsemoptysis, from 
 stenosis of the pulmonary veins ; a murmur over the innominate vein 
 on throwing the head backward; and dysphagia, from oesophageal 
 compression. 
 
 Signs. — Bronchial breathing is occasionally heard between the 
 
328 TEE SPECIFIC INFECTIONS. 
 
 second and fourth dorsal vertebras, more clearly behind than in front ; 
 more on the right than on the left side ; and more markedly than the 
 high-pitched breathing heard physiologically over this region. If the 
 bronchus is compressed there is neither bronchial breathing nor in- 
 creased vocal fremitus. An irregularly outlined dulness is elicited 
 on exceptional occasions either between the clavicle and third rib, 
 on either side of the sternum, or behind between the third and fifth 
 dorsal vertebrae. It is due to enlarged glands near a bronchus^ or 
 sometimes to a distended obstructed vein. Sometimes a tympanitic 
 note in the upper lobes results from relaxation of the lung. Both 
 the symptoms and signs are extremely variable, appearing suddenly 
 and remitting unaccountably. 
 
 Issues. — (a) Tuberculosis of the lung (in children) ; (&) miliary 
 tuberculosis; (c) tuberculous pleurisy or pericarditis; (d) pressure 
 by calcification or fibrosis; (e) adhesion to and rupture into the air 
 passages, causing sudden suffocation; (/) fatal hemorrhage into the 
 air tubes, which is less frequent, as the vessels yield before pressure, 
 but which may result from rupture simultaneously into a bronchus 
 and a vessel; (g) rupture into the oesophagus or traction upon it, 
 causing an oesophageal diverticulum. 
 
 Diagnosis. — The direct diagnosis rests upon tuberculous adenopa- 
 thies elsewhere, pressure symptoms, physical signs and evidences of 
 extension, general or local. As Henoch puts it, "A diagnosis can 
 rarely be made (from the physical signs), but if made, is nearly 
 always correct," as the bronchial glands are nearly always enlarged 
 in infantile tuberculosis. 
 
 3. Mesenteric Glands. — The bacilli pass the intact intestinal 
 mucosa and settle in the mesenteric glands, precisely as they pass 
 the bronchial mucosa and lodge in the bronchial glands. Carriere 
 found that but 1 per cent, of his cases were primary ; of the secondary 
 cases, the primary focus was in the peritoneum in 40 per cent., in the 
 lungs in 30 per cent., in the intestines in 20 per cent., in other glands 
 and bones in 5 per cent. each. Hess (1908) holds that in over 60 
 per cent, of the primary cases, the infection is by bovine tubercle 
 bacilli ; in adults, it is by the human type. There are few character- 
 istic symptoms. The glands may be palpable as thick nodular masses 
 through a thin abdominal wall, but are often obscured by the abdomi- 
 nal distention. The general emaciation (tabes mesaraica) contrasts 
 strikingly with the tumid belly. Digestive disturbance is most fre- 
 quent, and there is usually a diarrhoea with thin, stinking stools. 
 Compression is less frequent in the more distensible abdomen than in 
 the less yielding thorax, though the veins of the abdomen may stand 
 out and oedema of the legs may appear. The glands sometimes heal 
 by induration and calcification, or, by softening, rupture into the 
 intestine or peritoneum (plastic or exudative peritonitis). Amyloid 
 degeneration may result from cases of long standing. 
 
 4. Generalized Lymphadenitis. — This may closely resemble 
 Hodgkin's disease, as was first pointed out by Richard Paltauf and 
 
TUBERCULOSIS. 329 
 
 his co-worker, Sternberg, though the latter goes too far in declaring 
 that most cases of pseudoleukemia are glandular tuberculosis. In 
 two personally observed instances of supposedly clear pseudoleu- 
 kemia, the clinical and gross pathological findings were typical of 
 that disease, and only the epithelioid hyperplasia and the bacillus 
 tuberculosis stamped them as tuberculous. This form is rather com- 
 mon in the negro. 
 
 The treatment of tuberculous lymphadenitis is that of tuberculosis 
 in general (v.i.), and is surgical if the process is accessible and local- 
 ized. In 175 cases of cervical adenitis treated surgically, 58 per cent, 
 were cured after three years, 8 per cent, had recurrence, 11 per cent, 
 developed pulmonary tuberculosis and 23 per cent. died. In another 
 series of 700 cases treated medically, 28 per cent, developed tuber- 
 culosis in some other organ (Demme). The writer relies largely 
 upon full feeding, ample sunlight and fresh air and, if possible, a 
 warm sea-side climate. The syrup of the iodide of iron and cod- 
 liver oil are very largely used. Inunctions of green soap, recom- 
 mended by Richter (1846) and Kappesser (1878) are considered 
 beneficial by Hoffa ; 3ss-j should be thoroughly rubbed into the back 
 two or three times a week. 
 
 V. Tuberculosis of the Serous Membranes. — These membranes 
 may be involved simultaneously or separately. Multiple involvement 
 is known as multiple serositis or polyorrhomenitis. Multiple sero- 
 sitis may be acute, subchronic or chronic, serous, fibrinous or puru- 
 lent, solitary or with visceral tuberculosis. 
 
 1. Pleura. — Tuberculous pleurisy has been touched upon as a com- 
 plication of phthisis, and must be separately considered under Pleu- 
 risy (q. v.). It may develop as an apparently primary infection, 
 it may be clearly secondary to unmistakable phthisis, or it may ap- 
 pear as a terminal infection. Miliary tubercles in the pleura may 
 occur without coincident pleurisy. Pleurisy develops in some form 
 in 66 to 100 per cent, of pulmonary phthisis. It may be acute, 
 subacute or chronic ; it is most often serous or serofibrinous ; it may 
 be serohemorrhagic, purulent, less often chyliform or adipose. Pleu- 
 risy may result from direct bacillary invasion from the bronchial 
 glands, lung, spine or peritoneum, or possibly from simple toxic 
 action without the agency of bacilli. In some cases the pleura pro- 
 liferates and forms a thick, massive, adhesive, obliterative membrane. 
 Sometimes the interstitial tissue of the lung is invaded, resulting in 
 pulmonary cirrhosis (pleurogenous cirrhosis). 
 
 2. Pericardium. — Accidental miliary deposits must be sharply dis- 
 tinguished from tuberculous pericarditis wherein inflammation pre- 
 dominates. It is less common than pleural and peritoneal involve- 
 ment, but is a pathological finding in 2 to 3 per cent, of pulmonary 
 tuberculosis. Tubercles may be detected beneath the fibrin deposits 
 or adhesions, as they are in pleurisy of the same type. Without as- 
 sociation with some other tuberculous lesion (especially that of the 
 
330 TEE SPECIFIC INFECTIONS. 
 
 pleura) it is rarely separable clinically from the ordinary forms of 
 pericarditis. Like these forms it may be symptomatically latent, 
 it may form an unessential part of a generalized tuberculosis, or it 
 may present the ordinary symptoms of pericardial effusion or con- 
 cretion (q. v.). Only eight primary cases are recorded (Scagliosi, 
 1904). 
 
 3. Peritoneum. — Tuberculosis of the peritoneum was known to 
 Bayle, Laennec, Bichat and others, a century ago, but became a 
 clinical entity when Louis, in 1825, declared that nearly all chronic 
 peritonitis was tuberculous. Though some chronic peritonitides are 
 due to trauma, alcoholism, nephritis, portal and cava-stasis, most of 
 them are tuberculous. 
 
 Frequency. — It complicates 10 per cent, of pulmonary tubercu- 
 losis and was found in 2 per cent, of 13,422 autopsies (Grawitz and 
 Brunn). It constitutes one-quarter of all peritonitides (Cummins). 
 
 Age. — It is almost equally frequent in the second, third, fourth 
 and fifth decades (20 per cent, in each) ; 66 per cent, of all cases 
 occur between ten and forty years of age; it is infrequent in the 
 extremes of life. 
 
 Sex. — -Ninety per cent. (Eothnagel), or 78 per cent. (Konig), 
 occur in women. More cases are found in autopsies on males, though 
 more women are operated on. In America it is more common among 
 the negroes. It is very seldom primary (0.7 per cent.), but is sec- 
 ondary to (a) lung, bronchial gland or pleural tuberculosis (in 80 
 per cent., Leube) ; (b) intestinal ulcers or mesenteric and retroperi- 
 toneal adenitis, especially in children. Tubercle bacilli may pass the 
 intestinal wall without localizing in it and reach the peritoneum. It 
 is thought by some that intestinal lesions are the most frequent cause ; 
 (c) tuberculosis of the Fallopian tubes, which some consider causa- 
 tive, is secondary to some small focus in the bronchial glands. The 
 writer believes that tuberculous peritonitis is Jicematogenous. 
 
 It is a frequent complication of liver cirrhosis (Rokitansky, 
 Forster and Weigert), though it is strange that tuberculosis should 
 develop in any stasis. It also complicates ovarian tumors or trauma, 
 which disseminates infection from a preexisting quiescent focus. 
 Sixty-two cases are reported in a hernial sac (tuberculosis herniosa). 
 
 Types. — A clinical description is impossible, for the disease may be 
 acute, subacute or chronic, latent or stormy, circumscribed or diffuse;, 
 it may be marked by adhesions, by free or encapsulated ascites or by 
 large tumor-like masses; it may be obscured by coincident miliary 
 tuberculosis, liver cirrhosis, exudative pleurisy or ulcerative phthisis, 
 or may appear as a seemingly primary clinical fact. Though the 
 forms are similar and atypical cases are common, certain types may 
 be described. The unessential forms of miliary tubercle, and the 
 small and usually non-inflammatory tubercles seen over intestinal 
 ulcers or in chronic phthisis, are not taken into clinical consideration. 
 
 1. The acute form usually begins with severe symptoms, which 
 include fever, rapid pulse, abdominal tenderness and pain, free fluid 
 
TUBERCULOSIS. 331 
 
 in the peritoneal sac, which shifts with change of position, consider- 
 able meteorism from paresis of the gut, and vomiting. This type 
 may resemble typhoid when the intoxication is more marked than 
 the local signs. The peritonitic manifestations — local signs — may be 
 sharply marked, but always less so than in suppurative peritonitis. 
 On the other hand, certain cases simulate ileus, which at times actu- 
 ally results from tuberculous adhesions or incarceration beneath 
 bands. The writer has seen three cases precipitated by delivery, 
 resembling a puerperal infection. Indicanuria, so frequent in other 
 acute peritonitides, is usually absent. The ascitic fluid is usually 
 lemon-colored, serous or slightly flocculent, and of a specific gravity 
 of over 1,014; red blood-cells sometimes impart to it a hemorrhagic 
 hue ; the leukocytes are usually mononuclear. In rare instances the 
 acute peritonitis is suppurative; 26 cases are on record, due to per- 
 foration of a tuberculous ulcer in the gut. In some cases the acute 
 type is a terminal infection. Though commonly diffuse, there is 
 sometimes acute local pain or circumscribed effusion, for instance, 
 over an intestinal ulcer. Plastic adhesions occasionally modify the 
 freedom with which this ascitic form shifts with alteration of posture. 
 Acute tuberculous peritonitis comes more often under the care of the 
 physician than of the gynecologist or surgeon. 
 
 2. Subacute or chronic forms present diffuse peritoneal involve- 
 ment, (a) The fibrino-plastic form, causing adhesions, may result 
 from the acute form or may develop slowly and insidiously; symp- 
 toms and signs are usually lacking, or when present are not distinc- 
 tive, (b) The fibrino-caseous form is characterized by the develop- 
 ment of tubercles, which by fusion often form large solid masses. 
 There are adhesions and thickening of the intestine, mesentery and 
 omentum. Between the recesses formed by the inter-intestinal ad- 
 hesions, or by the growth of the gut to the liver or spleen, pockets of 
 exudate frequently occur, containing blood-stained serum, cold ab- 
 scesses or cheesy material ; the intestine is thickened and contracted, 
 the mesentery deformed and the omentum shrunken, (c) The effusive 
 form is marked by serous, serofibrinous, serohemorrhagic and less often 
 by puriform or adipose exudate, which is more or less encapsulated. 
 All these types and subtypes vary so much that the individual 
 symptoms will be considered separately. 
 
 Individual Symptoms. — 1. Adhesions and Retraction.— The infil- 
 trated omentum gradually indurates and retracts so that it is found 
 above the navel (Bamberger) or along either costal arch as a fibro- 
 caseous tumor-Jike mass; it may often be palpated, even when there 
 is much exudate, and becomes clearer after paracentesis; it may be 
 mistaken for carcinoma of the stomach, enlarged liver or distended 
 gall-bladder, especially when in chronic forms there is little fever; 
 it is more suggestive of tuberculous than carcinomatous peritonitis. 
 The walls of the gut are frequently so thickened that intestinal sten- 
 osis results; the gut may measure but one-half or one-third of its 
 original length; it may be thickened, adherent, surrounded by exu- 
 
332 TEE SPECIFIC INFECTIONS. 
 
 date, and may also resemble a tumor. Adhesions may continue to 
 retract until the entire peritoneal sac is deformed (Kleb's 'peritonitis 
 deformans) ; this is a species of spontaneous recovery but is attended 
 by danger of intestinal stenosis. The mesenteric thickening and 
 retraction (mesenteritis retrahens) affects the character of the phys- 
 ical findings and the tympany and the dulness; the mesentery may 
 measure one-half to one inch in thickness. 
 
 2. Ascites; Exudate. — The abdomen is often moderately en- 
 larged by serous exudation and meteorism. Large exudates may 
 cause some widening of the abdominal veins, as in ascites (q. v.), 
 because the cava is compressed. When the abdomen protrudes, its 
 centre is not usually flattened nor are its sides bulging as in the ordi- 
 nary ascites of liver or cardiac disease, but it is often prominent 
 in the median line, as in ovarian cyst. Lohlein states that most of his 
 cases were sent to him with a diagnosis of ovarian cyst. In cases 
 without adhesions the dulness shifts easily with change of posture, 
 so that tympany exists over the supernatant gut and dulness is found 
 over the settling fluid. The physical signs differ from those of a 
 common ascites in that the tympany is often on the right side; 
 Thomeyer pointed out that the mesenteritis retrahens pulls the 
 small gut to the right side, and that its chief cause is tuberculous 
 (less often carcinomatous or simple) peritonitis; nevertheless, a 
 tuberculous mass may develop in the right iliac region, in which 
 case it dislocates the tympanitic intestines to the left, or in the median 
 line or pelvis. In general the abdominal distention is asymmetrical 
 and less extensive than in liver cirrhosis, with which it may co-exist. 
 In very rare cases the fluid may rupture into the bowel or externally 
 through the navel. Dulness does not always indicate fluid but may 
 result from adhesions, thickening of the gut, caseous masses or en- 
 larged glands. 
 
 3. Meteorism. — This may result from sudden paresis of the gut 
 in the acute type, or from chronic fibrous obstruction in cases of long 
 standing. Tuberculous tumors may also impede peristalsis and thus 
 cause gaseous accumulations. Meteorism is one of the stigmata of 
 tuberculosis of the mesenteric glands (tabes or phthisis mesaraica) 
 and then is often due to coincident peritonitis ; in both conditions but 
 most often in children, the stools are fatty (Berggriin and Katz). 
 
 4. Palpation. — A doughy sensation is often experienced on palpa- 
 tion, which is usually referred to peritoneal adhesions or constricted 
 intestine, but in some instances is due to early infiltration of the pre- 
 peritoneal, subserous tissues. 
 
 5. Other Symptoms. — In some cases the Beatty-B right friction- 
 rub can be elicited. Pelvic effusion is particularly common in wo- 
 men, who also suffer from painful and disturbed menstruation. Fever 
 frequently is irregular, sometimes continuous, remittent or hectic ; it 
 is most frequent in acute types or in acute exacerbations of chronic 
 cases. In some chronic cases it is absent or subnormal. The dis- 
 ease therefore cannot be excluded by the absence of fever. Fever, 
 pain and tenderness usually distinguish tuberculous encapsulation 
 
TUBEBCULOSIS. 333 
 
 from simple ascites. Pain and tenderness are generally conspicuous, 
 though moderate in degree and by no means constant; they are less 
 acute than in suppurative peritonitis. Emaciation has been espe- 
 cially emphasized by Vierordt; Konig, however, remarks upon the 
 frequency with which cases of tuberculous peritonitis present a good 
 color and robust appearance. Gastro-intestinal disturbances are 
 fairly frequent; the usual constipation is occasioned by impaired 
 peristalsis; in some cases diarrhoea is possibly caused by toxaemia. 
 The spleen is difficult to find in the majority of cases. In rare in- 
 stances there are icterus, pylethrombosis and other complications due 
 to special localizations of the process. 
 
 Diagnosis. — The diagnosis is usually made correctly, though some- 
 times there are no just grounds for even suspecting the presence of 
 the disease. Considerable importance should be attached to tuber- 
 culous lesions elsewhere, as in the lungs, pleurae, glands or Fallopian 
 tubes. Multiple serositis is extremely suggestive. If another tuber- 
 culous lesion cannot be established, tuberculous peritonitis, which 
 constitutes nearly all chronic peritonitides, is very probably present ; 
 malignancy and traumatism must be considered. The tuberculin 
 reaction does not prove that the lesion is peritoneal or tuberculous. 
 Inoculation may be made with fluid withdrawn by paracentesis (see 
 Pleurisy). Exploratory laparotomy is justifiable, as simple abdomi- 
 nal section is the foremost therapeutic measure. 
 
 Course. — The onset is usually insidious with marked but not ex- 
 treme pain, tenderness, anorexia, vomiting, colic, fever and consti- 
 pation. The course, independent of all therapeutic measures, shows 
 spontaneous remissions, as Yierordt and Nothnagel have particularly 
 insisted. 
 
 Treatment. — Simple rest in bed, good hygiene and full feeding 
 very often arrest the process. The tumors, exudate and adhesions 
 may recede and no symptom reappear for months or even years. 
 Spontaneous recovery was first described by Bamberger but was 
 ignored until relatively recent times. In 1884 Konig proved what 
 Spencer Wells had observed twenty years earlier, that healing may 
 follow laparotomy. Then Lindner, Phillips, Yalenta, Rorsch, Hin- 
 terberger and others, showed that recovery occurred in 25 per cent, 
 of the cases without medication or laparotomy. Experimental re- 
 searches have shown that the tubercles heal by simple degeneration, 
 vascularization and development of connective tissue. 
 
 Operation gives various results, recovery occurring in 33 per cent. 
 (Frees), 55 per cent. (Chrobak), 64 per cent. (Konig), 91 per cent. 
 (Dohrn) and 94 per cent. (Mazzoni). In 1300 cases 73 per cent, 
 recovered. Early operation — in the first three or four months — 
 is contraindicated, as Gelpke has shown that the early exudate has 
 strong bactericidal properties. Simple paracentesis is much inferior 
 to laparotomy. Lavage is superfluous. It is thought that the access 
 of air or sunlight, manipulation or lavage, is the potent curative 
 factor in operative treatment. Veit advances the plausible theory 
 that the withdrawal of fluid allows the access of fresh serum with 
 
334 TEE SPECIFIC INFECTIONS. 
 
 increased antitoxic properties. Operation, in the author's opinion, is 
 clearly of great value ; but it may be mentioned that some conserva- 
 tive writers believe that the tubercles which heal after operation 
 were already in process of healing spontaneously. 
 
 VI. Tuberculosis of the Brain and Meninges. — Involvement may 
 result from (a) the miliary tubercle, (b) the solitary, or, as Virchow 
 prefers to call it, the conglomerate tubercle, (c) the tuberculous 
 abscess and (d) meningitis. The miliary form and tuberculous men- 
 ingitis have already been described : the solitary or conglomerate tu- 
 bercle produces symptoms identical with those of brain tumor (q. v.). 
 
 Primary cerebral tuberculosis is extremely rare. TVarfringe, 
 Frankel, Alvarez and Diirck have described primary meningitis, 
 but it is extremely probable that small or microscopic foci elsewhere 
 escaped detection. Frankel found tuberculous meningitis in 4.7 
 per cent, of adults dying with pulmonary phthisis. 
 
 VII. Tuberculosis of the Eye. — Only 50 cases of eye tuberculosis 
 occurred in 141,000 eye patients. The total number of reported 
 cases of conjunctival tuberculosis is 150, of which but 100 were 
 proven tuberculous. 
 
 VIII. Tuberculosis of the Alimentary Tract.— 1. Lips. — The lips 
 are very seldom affected; lupus or tuberculous ulcers may invade 
 them. The latter are very painful and may be confused with cancer 
 or chancre. 
 
 2. Gums. — The gums are seldom involved, though tuberculosis has 
 followed caries and extraction of the teeth. 
 
 3. Tongue. — This is involved in 1 to 2 per cent, of cases. Tuber- 
 culous tumors in its substance are sometimes mistaken for gumma 
 or cancer, and may break down into cold abscesses. Tuberculous 
 ulcers develop on the dorsum or edges ; they have rough caseous 
 bases with uneven or undermined edges : they are almost never 
 primary; they are differentiated from syphilitic ulcers by the ineffi- 
 ciency of mercury and iodides, from cancer by the absence of glands 
 in the neck, and from both by the presence of bacilli and the results 
 of inoculation. 
 
 4. Pharynx. — Pharyngeal involvement was known to Morgagni but 
 was especially studied by Ricord (1865). Primary disease is most 
 infrequent, and involvement, secondary to pulmonary or laryngeal 
 phthisis, is also infrequent; Heller saw but 4 instances in 8,000 
 throat cases. The process begins largely in the lymphoid structures, 
 which are infected by tuberculous sputum or food, or it extends by 
 the lymph-vessels from the larynx. Three-fifths of the cases are as- 
 sociated with tuberculous disease of the intestine (Martineaux), and 
 15 per cent, with oral tuberculosis (Barth). The cervical glands 
 may be affected in acute, but rarely in chronic, cases. The ulcera- 
 tions are usually superficial; when propagated from the larynx, the 
 most distressing dysphagia results. Betropliaryngeal abscess usu- 
 
TUBERCULOSIS. 335 
 
 ally results from suppuration of the lymph glands and from spinal 
 or osseous disease. 
 
 5. Palate. — The palate is ulcerated in 1 per cent, of cases of 
 phthisis ; in coughing, tubercle bacilli from the sputum come in close 
 or forcible contact with the palate. Lubinski observed three in- 
 stances among 16,000 throat cases. 
 
 6. Tonsils. — The tonsils are diseased in 4 per cent, of cases of pul- 
 monary tuberculosis (Warthin) ; their crypts contain bacilli ; the 
 process may stop at the tonsils, for they act as barriers to the infec- 
 tion or a tuberculous cervical adenitis may develop. Their infection 
 may be primary, and Dieulafoy holds that tonsillar infection may be 
 followed by a descending tuberculous adenitis, which in turn infects 
 the lungs. Some maintain that the tonsils are infected by the sputum 
 in half or more of the cases of phthisis. The lesions are more often 
 miliary than caseous. 
 
 7. Salivary Glands. — These are fairly, but not absolutely, immune. 
 
 8. (Esophagus. — The oesophagus is infected less frequently even than 
 the throat. "No clear primary case is recorded, and Cone could col- 
 lect only 48 secondary cases. Infection by contiguity, from the peri- 
 bronchial glands, is more common than infection by tuberculous spu- 
 tum ; these glands may occasion oesophageal perforation, hemorrhage, 
 diverticula or stenosis. Extension from the larynx or pharynx along 
 the lymph tracts or from the spine or lung cavities, is possible. Mil- 
 iary deposits have no clinical importance. 
 
 9. Stomach. — There are only four cases on record in which the 
 smallest claim for primary involvement can be made. Secondary 
 disease is estimated at four-tenths of one per cent. Glaubitt found 47 
 tuberculous ulcers in 2237 tuberculous autopsies. Ricard and Chev- 
 rier assert that there are on record sixteen cases of tuberculous stenosis 
 of the pylorus. The HC1 is inimical to gastric tubercle. Tubercu- 
 lous ulceration of the stomach occurs from the sputum, from inva- 
 sion by contiguity (glands, peritoneum or colon), or in few cases 
 from hsematogenous infection. 
 
 10. Intestinal Tuberculosis. — This was first observed by Bayle 
 (1810). (a) It is usually secondary to ulcerative lung tuberculosis 
 from infective sputum; its frequency is 30 per cent. (Eichhorst), 
 51 per cent. (Heinze) or 90 per cent. (Weigert, Orth, Warthin). 
 Tubercle bacilli may be swallowed without causing intestinal tuber- 
 culosis. Of all intestinal ulcerations, tuberculous ulcers are the most 
 frequent. Infection from the peritoneum, mesenteric glands or hae- 
 matogenous infection is barely possible. (&) Primary intestinal tu- 
 berculosis is much more rare, occurring in 0.3 per cent. (Eisenhardt), 
 and in only 0.1 per cent, of adult cases. The intestinal mucosa in 
 children, like the bronchial, often allows of the passage of tubercle bacilli 
 to the intestinal lymph glands without disease of the intestine itself ; 
 this is due to the loose infantile mucosa and the large lymph vessels. 
 Infection may occur by infected milk. Koch takes an extreme view 
 in denying infection by milk, and Behring takes the opposite extreme 
 in affirming that it is the chief cause of tuberculosis. 
 
336 TEE SPECIFIC INFECTIONS. 
 
 The ulcers are most frequent in (i) the ileo-ccecal region and next 
 in the colon, (ii) They always originate in the lympliadenoid folli- 
 cles or Peyer's patches ; they are promoted, by erosions or obstipation. 
 Small tubercles fuse into large ones, which caseate and ulcerate; in 
 exceptional cases the caseous nodes do not rupture but cause the peri- 
 toneum and mucosa to bulge out. (iii) The ulcers are irregular in 
 shape and (iv) their disposition is ring-like; i. e., they are located 
 transversely around the gut, because extension occurs by the lymph 
 vessels (lymphangitis tuberculosa) . Occasionally they lie in the long 
 axis of the gut and are ovoid, corresponding, though incompletely, to 
 Peyer's patches, (v) They are single or multiple, and sometimes 
 cover nearly all the surface of both the large and small intestines, 
 (vi) Their bases are rough or caseous and their edges infiltrated; the 
 infiltration also invades the contiguous mucosa and submucosa. (vii) 
 Localized adhesive peritonitis is a common issue when the process 
 reaches the serosa. An early stage of this is seen in the serous and 
 subserous miliary tubercles and in the bead-like tuberculous lym- 
 phangitis ; perforation occurs in 5 to 10 per cent, of the cases, but 
 is resisted by the muscular coat and by adhesions ; it results in peri- 
 cecal abscess and in suppurative peritonitis. Stenosis of the intes- 
 tine, single or less often multiple (129 cases collected by Arbuson, 
 1904), may also result; recovery is very rare. Konig in two years 
 saw 5 cases recover, and Eisenhardt saw 10 complete and 26 incom- 
 plete instances in 567 tuberculous ulcerations. Hepatic suppuration 
 or steatosis may result. 
 
 Symptoms. — The symptoms are those of any form of intestinal 
 ulceration (q. v.) ; they usually commence with signs of catarrhal 
 enteritis, diarrhoea, pain and fever. They may for a while resemble 
 typhoid. The only pathognomonic finding is the tubercle bacillus, 
 and it is possible that its presence may result only from swallowed 
 sputum. Rosenblatt's method of detecting the bacilli in the faeces is 
 to give laudanum until the stools become hard ; in the mucus on their 
 surface, the bacilli are usually found on the first examination, for the 
 hard fseces apparently scrape the bacilli from the ulcers. Pus is often 
 found and hemorrhage occasionally results. Girode called attention 
 to the black stools, which are usually ominous, as they indicate mal- 
 nutrition ; the picture of dysentery is rarely observed. Fatal hemor- 
 rhage is infrequent, though cases have been recorded by Vallin, 
 Hanot, Osier, Chandeze and others. An appendicitic form may be 
 noted, with quick or insidious onset and with some induration ; recur- 
 rence is frequent and fistulse occasionally develop. In typhlitis 
 tuberculosa there is great thickening in the csecal region, with a hard, 
 slightly movable or totally adherent, vertically disposed, tender tu- 
 mor. The onset is usually insidious, pain is recurrent, symptoms of 
 increasing intestinal stenosis are present and constipation alternates 
 with diarrhoea. Hemorrhage is infrequent, fever is usually absent 
 and emaciation is sometimes pronounced. Duguet described this 
 condition in 1869 ? and, since it so fully resembles cancer or sarcoma, 
 
TUBERCULOSIS. 337 
 
 it has attracted the especial attention of the surgeons, Bassini (1887), 
 Bouilly (1889) and Billroth (1891). Campiche (1906) collected 
 379 cases of tuberculosis of the appendix and caecum ; 25 per cent, 
 died from the operation; 35 per cent, were well for months or years; 
 and 40 per cent, ultimately died of tuberculosis. The process usu- 
 ally begins in the mucosa and is marked by ulceration, villosities in 
 the mucosa, great local infiltration and hypertrophy of the bowel 
 and destruction of the ileocecal valve. The process may begin, as 
 shown by Conrath, in the serosa, with which tuberculous glands may 
 come in contact. Patients may die of acute obstruction, or only after 
 a chronic course of a decade or more ; recovery by fibrosis is possible. 
 Benoit and Dieulafoy regard the process as primary in 80 per cent, 
 of subjects. It sometimes co-exists with cancer. 
 
 In the rectum, ulcers, either anal or rectal, lupus, tuberculosis cutis 
 verrucosa and periproctal abscess are sometimes seen. Fistula in 
 ano occurs in 1 to 5 per cent, of cases of phthisis, and rarely develops 
 in other conditions ; the general idea that its excision excites pulmon- 
 ary disease is a confusion of cause with effect. 
 
 11. Liver. — The liver is involved less in adults than in children 
 (38 per cent., Leroux), but at all ages it is of greater pathological 
 than clinical interest, (i) Large tubercles may develop in the liver, 
 sometimes with peritonitis and perihepatitis, (ii) Miliary tubercles, 
 in 80 per cent., are of no clinical significance, (iii) Hanot main- 
 tains that there is a primary cirrhosis of the liver, associated with 
 tubercles and fatty degeneration; at the most it is extremely rare; 
 it is said to be associated sometimes with tuberculous peritonitis and 
 perihepatitis (v. s. Tubebculosis of the Lungs: Complications). 
 
 12. Spleen. — The spleen is involved in 45 per cent, of tuberculous 
 children (Leroux and Muller). Franke (1908) collected 29 cases 
 of primary tuberculosis of the spleen ; 19 were not recognized clini- 
 cally ; 10 were operated on, of which 7 permanently recovered. (See 
 Diseases of Spleen: Splenomegaly with Cyanosis.) 
 
 IX. Tuberculosis of the Genito-urinary Tract. — Genito-urinary 
 tuberculosis was described by Morgagni and by Bayle in the begin- 
 ning of the last century, but for the first time fully by Lichtheim, 
 in the cadaver, and by Rosenstein, Babes and Smith, clinically. It 
 is most frequent in the period of greatest sexual activity (twentieth 
 to fortieth year), and 72 per cent, occur in males, in whom the two 
 tracts have more continuity and community of surface. 
 
 Modes of Infection. — 1. Hematogenic Infection. — This is the 
 most frequent variety. It occurs in 5 per cent, of cases of chronic 
 pulmonary tuberculosis. The majority (76 per cent.) of cases are 
 secondary to some lung or peribronchial glandular focus, which very 
 often has produced no symptoms, so that most seemingly primary 
 foci are really secondary. Jani found tubercle bacilli in perfectly 
 sound testes and prostate glands, but they were clearly an invasion 
 of the blood occurring in the death agony. 
 22 
 
338 THE SPECIFIC INFECTIONS. 
 
 2. TTrogenic Infection. — The general opinion previously was 
 that a secondary infection mounted from the lower genital to the 
 higher uropoietic structures. However, hematogenous infection of 
 the kidney descends to the lower urinary tract, not vice versa. Infec- 
 tion by infected fingers, instruments, catheters or sexual intercourse 
 is possible but has been grossly overrated. It may follow syphilis 
 and gonorrhoea. 
 
 3. Infection from the Peritoneum and Contiguous Struc- 
 tures. — The Fallopian tubes are diseased in a third to a half of the 
 cases of tuberculous peritonitis. Jani found tubercle bacilli in the 
 tubes in women dying of phthisis. The bladder, seminal vesicles 
 and vasa deferentia may be invaded per contiguitatem from peri- 
 toneal, vertebral or rectal foci. 
 
 1. Renal Tuberculosis. — The kidney in miliary tuberculosis is in- 
 volved in 90 per cent. (Frerichs), but is marked by no distinguish- 
 ing symptoms. The common clinical form is the caseous-ulcerative. 
 Caseous nodes develop in the cortex, infection reaching it from the 
 blood stream in 90 per cent. ; they often break down into cavities, 
 may form cold abscesses, undergo secondary pyogenic infection or 
 the process may remain localized in one pole of the kidney. Tuber- 
 cles also develop in the apices of the pyramids and pelvis of the kid- 
 ney and form caseous infiltration • and ulcers ; in this form in- 
 volvement was at one time considered the result of an ascending 
 infection, though Caspar, Walker and Israel believe that the process 
 in 41 per cent, of cases descends from the kidney to the bladder. 
 Upward and downward extension in the kidney itself often occurs, 
 so that the entire organ may be more or less diseased. When the 
 process is well developed there is a tuberculous pyonephrosis. The 
 entire kidney may become a large sac of caseous material, detritus 
 and lime salts, — called degenerescence massive by Turner. The kid- 
 ney is often adherent to adjacent structures; its capsule is thickened, 
 its removal strips off particles of renal substance and it is sometimes 
 perforated, causing tuberculous paranephritis. The surface of the 
 kidney may be smooth and normal, lumpy from caseous deposits or 
 softened in many places from diffuse ulceration. In exceptional 
 cases spontaneous healing is possible. Whether one or both kidneys 
 are diseased depends on the stage of the process, and is a most im- 
 portant matter when surgical interference is considered. Israel, in 
 his celebrated observations, stated that he found one kidney involved 
 usually without any other genito-urinary disease. Pallet and Al- 
 barran observed unilateral disease in 80 to 85 per cent, of their cases, 
 while post-mortem figures show unilateral renal disease in but 48 
 per cent. ; naturally, in autopsy figures, bilateral disease is greater 
 than in clinical figures. Compensatory hypertrophy of the sound 
 kidney is frequent. 
 
 Symptoms. — These may be absent if the renal pelvis remains 
 sound. Otherwise the symptoms are (a) urinary, (b) local and (c) 
 general. 
 

 TUBERCULOSIS. 339 
 
 (a) Urinary. — The urinary symptoms are chiefly those of pyelitis 
 (q. v.). The urine is acid, though alkalinity develops in complicat- 
 ing tuberculous or non-tuberculous cystitis, which may be determined 
 by the cystoscope. Urination is often difficult (dysuria) or 
 frequent (pollakiuria), so that the existence of cystitis is at first 
 suspected ; it is a safe rule always to consider the possibility of renal 
 phthisis in every cystitis, the origin of which is not clear and the 
 treatment of which is unsuccessful. Bladder symptoms are reflex 
 from the kidney lesion, without any vesical involvement, or are due 
 to complicating cystitis, simple or tuberculous. Guy on describes an 
 early polyuria in which the urine is clear, and a later polyuria in 
 which it is turbid. Hcematuria (q. v.) is frequent; it may be severe 
 or slight and its occurrence is more often early than late; its frequent 
 recurrence is so marked in some cases as to justify the term " hemor- 
 rhagic type " ; it may last one and a half months to four and a half 
 years (Turner). Pyuria generally occurs when the pelvis is invaded, 
 but is not observed when cortical foci do not communicate with the 
 pelvis or when the ureter is occluded ; the amount of albumin corre- 
 sponds to the pus cells. Epithelial cells, sometimes caseous matter, 
 elastic fibers and necrotic renal tissue are found. The sediment 
 is often a crumbly, rapidly settling detritus ; tubercle bacilli are often 
 found, but must not be confused with the smegma bacillus (v. Gen- 
 eral Bacteriology) ; sometimes bacilli in the urine are found in 
 pulmonary tuberculosis without any disease of the kidneys. Casts are 
 very infrequent. In unilateral renal disease with occlusion of the 
 corresponding ureter, the urine is naturally normal. Urinary segre- 
 gation or ureteral catheterization determines which kidney is involved. 
 
 (b) Local. — Local symptoms are lumbar pain and tumor. Lum- 
 bar pain sometimes results from capsular tension ; it is severe, colicky 
 and reflected to the groins and testes, which may be retracted as in 
 renal colic; colic is due to the passage of caseous particles or blood 
 clots; differentiation from calculous disease (q. v.) may be difficult 
 until tubercle bacilli are found. Tumor, in tuberculous pyonephrosis 
 or hydronephrosis, is a small, tender enlargement, though seldom of 
 the size attained in calculous or other obstructive disease. 
 
 (c) General. — General symptoms are hectic fever, malnutrition 
 and other general toxemic symptoms (see page 310), tuberculosis 
 in the lungs and foci in the testes. The heart is almost never 
 hypertrophied. In 60 per cent, of the cases operated on, the diag- 
 nosis was found correct. The course is chronic and remittent, two, 
 three or even five, years being the usual duration ; recovery from cir- 
 cumscribed lesions is possible; death results from tuberculous gen- 
 eralization, less often from sepsis, perinephritis or amyloid degener- 
 ation, and rarely from nephritis or uroemia. The treatment is 
 surgical. In Kronlein's cases, the operative mortality of nephrec- 
 tomy was 5.8 per cent, and the ultimate mortality was 17.6 
 per cent. ; 70 per cent, recovered. In Albarran's series the operative 
 mortality was 3 and in Caspar's 5 per cent. 
 
340 THE SPECIFIC INFECTIONS. 
 
 2. Ureter and Bladder. — The ureter is thickened, infiltrated, case- 
 ous, ulcerated and often stenosed; it is involved in 80 per cent, of 
 cases of renal tuberculosis (Palet). Secondary involvement from 
 the kidney may be limited to the ureter at its vesical ending or may 
 spread more widely over the mucosa of the bladder. 
 
 Bladder disease is almost invariably secondary per contiguitatem 
 or from hematogenous deposits, as seen by means of the cystoscope. 
 Israel (v. s.) noted tuberculous cystitis in 41 per cent, of cases of 
 renal tuberculosis, and Yignernon in 50 per cent. Cystitis of long 
 standing should always excite suspicion of tuberculosis, even when 
 it has gonorrheal or other antecedents. The diagnosis is based on 
 the specific bacteriology and the cystoscope. Eosving cauterizes 
 with carbolic acid. Surgical intervention is indicated. 
 
 3. Male Genitalia. — The epididymis is more often involved than the 
 testis, except in youth, when the epididymis and tunica albuginea are 
 more frequently affected ; in the first years of life testicular disease 
 results from generalized tuberculosis ; about one-half of Jullien's 
 cases occurred under two years of age. Sometimes no caseation 
 results, as is the case in hyperplastic lymphadenitis, and even micro- 
 scopic confusion with sarcoma is possible unless the bacilli are par- 
 ticularly sought. Testicular tuberculosis is most often confused 
 with syphilis (q. v.), though in the latter there is less pain and 
 fever and more nodular enlargement. The seminal vesicles, vasa 
 deferentia and urethra may be invaded and a rectal examination 
 should never be neglected. Recently the prostate, "the cross road 
 of the urinary and genital tracts," has attracted especial attention; 
 its primary involvement (Lancereaux) is disputed by some, but the 
 gland is affected in 50 to 80 per cent, of genital tuberculosis in the 
 male. The lungs are invaded in primary genital tuberculosis in 
 70 per cent, and the urinary tract in 56 per cent. Treatment is sur- 
 gical. 
 
 4. Female Genitalia. — The female genitalia become tuberculous in 
 1.5 to 2.5 per cent, of pulmonary tuberculosis. Infection is second- 
 ary in 80 to 100 per cent. Tuberculous tubes are found in 1.5 per 
 cent, of abdominal operations ; according to W. Williams, 8 per cent, 
 of the tubes removed for inflammatory lesions were found tubercu- 
 lous. Nearly all cases are due to some small focus in the bronchial 
 glands. The tubes show nodules, infiltration, caseation and ulcera- 
 tion; bilateral involvement is usual, and its true nature may be ap- 
 parent only under the microscope; tuberculous salpingitis may sim- 
 ulate tuberculous peritonitis; tubal disease may be found in very 
 young children. The uterus ranks next and is, as a rule, involved 
 secondarily; systematic microscopic examination would doubtless 
 show higher percentages than those usually given. Ovarian phthisis 
 is almost always secondary. Tuberculosis of the vagina, cervix, 
 vulva and female urethra are most exceptional. 
 
 Mammj. — Schley (1903) collected 65 cases of which 12 were 
 primary. Carcinoma may be closely simulated, for tuberculous 
 
TUBERCULOSIS. 341 
 
 lesions often cause nipple retraction and tumor formation or involve 
 the axillary glands (66 per cent.). When cold abscesses, fistula? or 
 ulcers form, the diagnosis is naturally more definite. A chronic 
 interstitial non-tuberculous mastitis was described by Bedor. 
 
 X. Tuberculosis of the Upper Respiratory Tract. — 1. Nose. — The 
 
 nose is seldom affected, because its irritation excites lachrymation, 
 sneezing and an increased secretion, inimical to the tubercle bacilli. 
 Nasal localization was first described by Willigk (1853). In the 
 rare primary form there are very few bacilli and an exuberant non- 
 caseous growth, which may resemble sarcoma; as in lymphadenopa- 
 thies and in the Fallopian tubes the absence of caseation is not 
 unique; there is little pain and the chief symptom is a chronic 
 coryza. In the secondary form the bacilli are abundant; multiple 
 caseation and ulceration occur as in other localizations; suppressed 
 coughing, with the mouth closed, is thought to force germs into the 
 nose. Nasal infection may occur by picking the nose, and is pro- 
 moted by wounds, ulcers and stagnation of secretion by various ob- 
 structive processes. Infection may spread by the lymph vessels, 
 especially in children, to the cervical glands or even to the meninges. 
 In 33 per cent, lupus affects the nose (Bender). 
 
 2. Nasopharynx. — Its primary involvement is infrequent. Sec- 
 ondary disease, usually late in phthisis, occurs in 20 per cent. ; it is 
 promoted by coughing with the lips closed. It may extend by con- 
 tiguity from the pharynx. The third tonsil may be affected (Ler- 
 moyez) ; adenoids are tuberculous in 20 per cent. (Dieulafoy). 
 
 3. Ear. — Tuberculous otitis media occurs chiefly in late phthisis 
 (according to Frankel in 32 per cent.) ; otitis may occur from mixed 
 infection. It is furthered by measles and scarlatina, is rarely pri- 
 mary, and often causes cervical lymphadenitis. 
 
 4. Larynx. — Laryngeal phthisis is very rarely primary, though some 
 well established cases are recorded. Louis, in 1825, held that it was 
 secondary to lung disease, resulting from infection by sputum, which 
 view still holds; hematogenous and lymphogenous infection is rare. 
 Laryngeal tuberculosis develops in 20 to 30 per cent, of pulmonary 
 tuberculosis in adults, and in only 3 per cent, of pulmonary phthisis 
 in children (Parrot). It complicates 9 per cent, of lupus cases. 
 Adjuvant factors are inflammation, fissure and syphilis. In 700 
 cases Krieg observed unilateral involvement in 275 (39 per cent.), 
 of which 92 per cent, occurred on the same side as the lung lesion; 
 Kreig attributed this to lymphatic extension; Cornet refers it to 
 paresis of the vocal cord on the affected side (which is due to com- 
 pression or neuritis of the recurrent laryngeal nerve), and to stag- 
 nation of the sputum in various recesses on the paralyzed and anaes- 
 thetic side. Unilateral disease usually becomes bilateral from 
 contact. 
 
 Symptoms. — The cough varies with the time of onset of laryngeal 
 symptoms ; in those rare and unfavorable cases in which the trouble 
 
342 TEE SPECIFIC INFECTIONS. 
 
 begins with laryngeal symptoms, the cough is often somewhat dry, 
 brassy or metallic; it may come on in the form of acute laryngitis. 
 In cases clearly following lung disease, the ordinary bronchitic hack 
 alters and frequently becomes brassy; in the last stages it becomes 
 incomplete, ineffectual or like an eructation (Trusseau), as the 
 vocal cords cannot come in apposition. Pain and hoarseness are 
 followed by dysphonia (or, later, aphonia), dyspnoea and the most 
 painful and distressing dysphagia. 
 
 Forms. — (a) The most common form is the ulcerative; ulcers are 
 found in the interarytenoid region, vocal cords, posterior wall of the 
 larynx and arytenoids ; they are not deep but are broad ; their edges 
 are " nibbled," and, on their rather pale and sometimes caseous bases, 
 papillary excrescences are fairly frequent. Particles may be inhaled 
 into the lungs, causing tuberculous or suppurative foci. They are to 
 be distinguished from syphilitic ulcers (q. v.), which are more often 
 single and redder, have more " cut out " edges, frequently show cica- 
 trization, involve oftener the parts nearer the epiglottis and posterior 
 surface of the arytenoids, and less often attack the vocal cords; 
 show no tubercle bacilli, do not show local reaction on tuberculin in- 
 jection and do respond to mercury and iodides. Ninety per cent, of 
 all laryngeal necrosis is tuberculous. Perichondritis may occasion 
 sudden oedema glottidis, urgent dyspnoea and early death unless 
 timely tracheotomy is performed. (&) In other cases the submucous 
 tissues are infiltrated and the mucosa is thickened or hardened (pachy- 
 dermous form) ; the true cords are less involved than other parts ; 
 stenosis rarely occurs, and if ulceration develops it is inconspicuous, 
 (c) Caseous tumors are not frequent; they may precede the ulcera- 
 tive form or occur independently of it. (d) The vegetative type oc- 
 curs with ulceration, and small excrescences develop on the floor of 
 the ulcers, or without ulceration, in which case they appear on the 
 otherwise intact mucosa, (e) The miliary form is unimportant. 
 
 Treatment. — Treatment is unsatisfactory, as pronounced lung 
 changes already exist and dysphagia occasions rapid emaciation and 
 disinclination to eat. Besides general treatment (v. i.), local meas- 
 ures may be employed, but as a rule they do not essentially modify 
 the process. Insufflations of boric acid, iodoform or iodol and paint- 
 ing with 10 per cent, menthol, 10 per cent, carbolic acid or 20 per 
 cent, lactic acid solution (gradually increased to 80 per cent.), may 
 relieve the local pain ; gr. J of morphine hypodermatically and 10 per 
 cent, solution of cocaine locally, allow the patient to eat, for a time 
 at least, but finally fail to anaesthetize the widespread ulceration. 
 The patient may be able to draw up milk and water by a tube, when 
 the head is turned over the edge of the bed. Caustics, such as silver 
 nitrate, are injurious. In Casselberry's practice, 10 recovered. 
 
 XI. Tuberculosis of the Heart and Vessels. — (a) Pericardium: 
 (v. Serous Membranes), (b) Myocardium: Miliary tubercles are 
 occasionally seen; tuberculous fibrous myocarditis is quite rare; 
 
TUBERCULOSIS. 343 
 
 caseous nodes are very uncommon and occur chiefly in the young; 
 Anders in 1902 collected but 72 cases, (c) Endocardium: Weichsel- 
 baurri, Birch-Hirschfeld, Klebs, Kotlar and Chiari have found 
 tubercle bacilli in cardiac thrombi ; Heller, Kundrat, Tripier, Londe, 
 Petit and Courmont found them in endocarditic vegetations ; Hanot 
 holds that toxins cause the excrescences in which the bacilli are later 
 deposited; Norris found endocarditis in only 1.4 per cent, of over 
 11,000 phthisical necropsies; tuberculous endocarditis is almost al- 
 ways vegetative and very rarely ulcerative or caseous; secondary in- 
 fection is the cause of some cases of endocarditis which complicate 
 tuberculosis, (d) Involvement of the vessels has been described 
 under miliary tuberculosis. Primary disease of the vessels seems 
 highly improbable, though some few cases are reported; 18 cases of 
 tuberculosis of the aorta were collected from the literature by 
 Simmitsky. 
 
 XII. Tuberculosis of the Bones and Joints. — This topic properly 
 belongs to surgery, but its relations to glandular, pulmonary and 
 other lesions demand some consideration. Koch was the first to 
 demonstrate the almost invariably tuberculous nature of caries, 
 fungus joint lesions and tumor albus, and Damsch first determined 
 this relation by inoculations. Schuchart, Krause, Demme and Renke 
 proved that spina ventosa was usually tuberculosis. Konig and Orth 
 found that about 80 per cent, of bone and joint tuberculosis was 
 clearly secondary to pulmonary, glandular, genito-urinary and other 
 tuberculosis. Probably all cases are secondary to tuberculosis else- 
 where. Infection is hcematogenic in the majority of cases, far less 
 often lymphogenic. Trauma has long been considered an important 
 etiological factor, and experimentation shows that it may determine 
 localization in animals already infected with the Bacillus tuberculosis. 
 This factor has probably been overestimated, and Sprengel even 
 maintains that the joints oftenest involved are those least subject to 
 traumatism. Thirty-three per cent, of the cases occur in the first 
 decade of life, and 50 per cent, in the first two decades. Tuberculosis 
 in children involves the bones and joints in 22 per cent, of cases 
 (Muller). 
 
 Localization. — Watson Cheyne, from his own and other cases, esti- 
 mates that the knee is affected in 16.5 per cent, of cases, the hip in 
 14.6 per cent., tarsus and ankle in 14.4 per cent., elbow in 6.3 per 
 cent., skull and face in 5.5 per cent., sternum, clavicle and ribs in 5.2 
 per cent., pelvic bones in 3.5 per cent., femur, fibula and tibia in 3.5 
 per cent., spine in 2.3 per cent., shoulder in 1.5 per cent, and 
 scapula, ulna and radius in 1 per cent. Jaffe finds involvement of 
 the spine in 20 per cent., foot in 21 per cent., hip in 13 per cent., knee 
 in 10 per cent., hand in 9 per cent, and elbow in 4 per cent. 
 
 1. Bones. — Miliary tuberculosis affecting the bones produces no 
 symptoms. In the ordinary type of infection the spongy epiphyses 
 of the long bones are the particular seat of tuberculous osteomyelitis 
 
344 THE SPECIFIC INFECTIONS. 
 
 and periostitis, whence infection easily reaches the joints; the 
 diaphyses and flat bones are seldom involved. Involvement of the 
 short bones of the fingers and toes, and less often of the ulna, may 
 cause bulging, — the spina ventosa, which is seen oftenest at^ about 
 five years of age. In the bone-marrow there develops a grayish-red 
 granuloma which dissolves the bone (caries sicca) ; the trabecule 
 necrose and are discharged through fistula? as sequesters or "bone 
 sand," in a caseous, pus-like fluid. Even large foci may heal by 
 granulating osteitis, in the same manner as tuberculous adenitis may 
 heal. Infection may remain unobserved or semiquiescent until 
 aroused by infections as pertussis or measles or by trauma. Cold 
 abscesses in the bone are lined by granulation tissue. There may be 
 local tenderness, stiffness, fever and nocturnal pain, varying in in- 
 tensity and sometimes radiating. Bone lesions are not incompatible 
 with seemingly perfect nutrition and otherwise robust health. 
 
 2. Joints. — Involvement may occur alone or follow contiguous os- 
 seous disease. Very often there is synovial inflammation and pro- 
 liferation; far less frequently there are isolated tubercles in a non- 
 inflamed synovial sac. Serous or serofibrinous synovitis (or the rice 
 bodies, corpora oryzoidea) may result from toxins in a neighboring 
 focus in the bone, without the actual presence of tubercle bacilli in 
 the joint, exactly as toxic pleurisy or pericarditis may result from 
 contiguous pulmonary or glandular foci. The symptoms, or onset, 
 may be acute or insidious. Pain, especially at night, contractures and 
 fever may be noted. In the later stages of joint disease, granulation 
 tissue forms with large caseous deposits, hydrops, empyema articu- 
 lorum or the tumor albus (so named because of the thickening of the 
 connective tissue, the oedema and glistening appearance of the peri- 
 articular structures). The joint is sometimes quite disorganized. 
 Seventy-five per cent, recover under conservative treatment, as im- 
 mobilization, iodoform or formalin injections, soap inunctions, cod- 
 liver oil and sea air. 
 
 Within a few years Poncet first, and then Leriche, Patel, Tre- 
 beneau, Bezancon and Griffon have called attention to a tuberculous 
 pseudorlaeumatism, in which the incipient arthritis closely resembles 
 genuine rheumatism (rheumatisme tuberculeuse ankylosante) . It is 
 thought by these French writers that the exuded leukocytes are 
 strictly of the lymphocyte type ; inoculations have proven positive in 
 a number of cases, but toxaemia is the most probable cause (Mohr). 
 It is most frequent in children. Lejars found one case of primary 
 tuberculosis of the muscles. 
 
 XIII. Tuberculosis of the Skin. — 1. Lupus. — Lupus is the most 
 frequent form. In 66 per cent, of the cases it is located on the nose, 
 lips and angle of the eye. Besnier found it with pulmonary tuber- 
 culosis in 21 per cent. ; Sachs and Bender found other tuberculosis 
 in 62 per cent, and Block in 79 per cent. It is typical granulation 
 tissue with true tuberculous tumors, which contain few bacilli be- 
 
TUBERCULOSIS. 345 
 
 cause of the low temperature of the skin, and it often advances on one 
 border while it cicatrizes on another. Its various forms, such as 
 lupus maculosus, exulcerans or hypertrophicans need not be de- 
 scribed in detail. 
 
 2. Scrofuloderma. — Scrofuloderma, the subcutaneous granuloma of 
 Neisser, appears as movable, painless, subcutaneous nodes, which 
 later become cold abscesses (the so-called scrofulous gumma, gomme 
 scrofuleuse of Despres and Besnier) ; they discharge a milky fluid 
 and leave a sharply marked granulating ulcer. 
 
 3. Lichen Scrofulosorum. — Lichen scrofulosorum is often but not 
 always tuberculous ; the eruption originates from the follicles, is con- 
 stituted of thick, oily, epidermal cells which can be scratched off 
 without bleeding, and is usually distributed in sharply marked groups 
 of isolated yellow or yellow-brown nodules as large as a pinhead. 
 
 4. Tuberculosis Cutis Verrucosa. — Tuberculosis cutis verrucosa of 
 Riehl and Pautauf is observed on the backs of the hands and fingers 
 and in the interdigital folds, chiefly in butchers, cooks and horsemen. 
 
 5. Postmortem Tubercles. — Postmortem tubercles were described by 
 Yerneuil, Yerchere, Pick and Pfeiffer. Laennec referred his pul- 
 monary phthisis, though probably incorrectly, to a postmortem tuber- 
 cle. Gerber suffered from tuberculosis of the axillary glands follow- 
 ing a tubercle. They are observed in butchers, veterinary surgeons 
 and pathologists, especially in those beyond middle life. 
 
 6. Tuberculous Ulcers. — Tuberculous ulcers may develop from cuts 
 by broken sputum cups; from bites of tuberculous subjects, ants or 
 flies : from burns, tattooing, skin grafting or leeches ; and from cir- 
 cumcision when the wound is sucked by tuberculous rabbis; lupus 
 has followed vaccination. 
 
 Scrofula is tuberculosis; however, in descriptions dealing with 
 scrofula as a separate clinical picture, affections of the mucous mem- 
 branes are often associated with the skin lesions above described, 
 with adenopathies (q. v.) and with bone or joint disease. Among 
 these may be mentioned chronic ozsena, rhinitis, adenoids, friable 
 carious teeth, otitis media, blepharitis, conjunctivitis or phlyctenular 
 keratitis, bronchitis, intestinal catarrh and leukorrhoea. 
 
 Treatment of Tuberculosis. — (A). Prophylaxis. 1. Antibachllary. 
 Antibacillary prevention concerns the etiological factors in the dis- 
 semination of the bacillus. Cleanliness of the skin; disinfection of 
 contaminated feces, urine or pus ; confiscation of diseased meat ; and 
 regulation of dairies and inspection of cows are important ; but the de- 
 struction of infective sputum is the prime indication. It is well to 
 regard all sputum as dangerous, and to teach the public and patients 
 this doctrine. Tuberculous, as well as pneumonic, grippal and other 
 sputa must be destroyed. An appeal must be made to the conscience 
 or selfishness of tuberculous patients, setting forth the risks of auto- 
 reinfection. Of all educators, Biggs, of New York, and Flick, of 
 Philadelphia, have rendered the greatest service. Patients should 
 
346 TEE SPECIFIC INFECTIONS. 
 
 carry small spit cups, of which Dettweiler's and Major Appel's are 
 the best ; the sputum should be destroyed by burning or boiling be- 
 fore it dries. Spittoons are dangerous. The patient should sleep 
 alone, and kissing must be interdicted. The bedclothes, linen and 
 eating utensils should be carefully steamed or boiled. Kooms should 
 be cleaned with moist cloths and should be swept with the windows 
 and doors open. The danger of swallowing sputum must be clearly 
 set forth, and the mouth should be washed out with some antiseptic 
 solution before eating, though a few bacilli with the food are not 
 very dangerous, as the gastric juice probably destroys them. The 
 more minute details are as impossible to describe as those of con- 
 sistent surgical asepsis, though they are equally logical and necessary. 
 In Germany the reduction of mortality by 33 per cent, is clearly due 
 to an awakened public intelligence. 
 
 2. Governmental. — Governmental prophylaxis, somewhat less 
 promising in republican than in autocratic states, is important. It 
 comprises : Education of the public by publication of the dangers and 
 preventive measures in tuberculosis, as in the recent excellent and 
 plain pamphlets of the Illinois State Board; the establishment of 
 sanatoria for the poor, among whom the mortality is four times, and 
 the morbidity many times greater than in the rich; the building of 
 separate hospitals, or at least wards, for the hopelessly diseased; and 
 the regulation of the air capacity of dwelling rooms in tenements, 
 factories and stores. Aside from great suffering and sorrow of thou- 
 sands in every large community, there is an enormous economical 
 waste in work and wages, an enormous cost in hospital care and a 
 great loss in live stock, — over 62,000 cattle and 56,000 hogs were 
 condemned in Prussia alone in one year. The comparative soci- 
 ological damage is apparent, as the ravages of tuberculosis involve 
 the working years of life (15 to 60), while 94 per cent, of deaths from 
 diphtheria occur under ten years. 
 
 3. Individual. — Individual prophylaxis includes the increasing of 
 physiological resistance, the maintenance of general health and the 
 aiding of sound development in children. Weakly children should 
 be brought up in the open air, judiciously fed, watched during acute 
 infections, kept but few hours in school, sent into the country during 
 vacation, taught moderation and later, should be informed as to the 
 danger of alcoholism, sexual excesses and infections. 
 
 (B). Hygienic Treatment. — The three great factors are fresh air, 
 proper food and rest. Bodington (1839), in England, treated cases 
 by fresh air, but to Brehmer (1850), in Germany, is due the credit of 
 soundly establishing the fresh-air treatment and the curability of 
 phthisis. A few of his views are untenable, but many of them are 
 the basis of the modern methods practiced by McCormack, Driver, 
 Dettweiler, Trudeau, Knopf and others. Patients were treated in 
 sanatoria, and those at Nordrach and Saranac and many others, 
 have given such excellent results that institutions of this class are 
 growing in number. Results depend on (a) the extent of the disease ; 
 
TUBERCULOSIS. 347 
 
 (b) the condition of organs other than the lungs, as the pleura, in- 
 testines, larynx and heart ; and (c) the social and financial status of the 
 case. Dettweiler states that 30 per cent, of his cases recovered and 
 40 per cent, improved; Trudeau brought about recovery in 31 per 
 cent, of all, and in 66 per cent, of incipient, cases; Turban considers 
 that 88 per cent, recover; Rumpf followed 97 per cent, of his cases: 
 70 per cent, of incipient cases were able to work — " the best test of a 
 cure" ; 55 per cent, of those in the second stage, and 23 per cent, of 
 those in the third, recovered. One of the chief values of sanatorium 
 treatment is that the patient learns the lesson of living properly, 
 which too often in general practice is not sufficiently impressed upon 
 him. 
 
 1. Fresh Air. — This is the chief hygienic factor in treatment, at 
 home, in sanatoria or in change of climate, (a) Treatment at home, 
 for financial reasons, is especially important, as but 5 or 10 per cent. 
 of tuberculous people are able to leave home. The patient should 
 be carefully clothed and should recline in the sun with the windows 
 of his room open, or should lie on a veranda. He should be outdoors 
 for one-quarter to one-half the sunny hours, according to the season 
 of year. At night the windows should be kept widely open; the 
 patient's bed can be brought close to an open window, from which 
 " a window tent " of canvas encloses the head and leaves him out-of- 
 doors. Rain, snow, dampness and extreme cold are no contra- 
 indications, nor are fever, cough and haemoptysis ; but wind, dust and 
 sudden variations in temperature are to be avoided. Very thick 
 clothing, so frequently observed among the poor, is unhygienic. 
 Acute caseous and advanced types should generally be kept at home. 
 Extreme care in disinfection is imperative lest the home itself be- 
 come a menace to the family, (b) Sanatorium treatment offers the 
 advantage of strict discipline, systematic living and the constant 
 presence of a physician who regulates the details of every-day life, 
 gives explicit directions and cheers the patient. Sanatoria should 
 be located near, but well outside of, every large centre of population. 
 
 (c) Change of climate was once considered absolutely indispensable; 
 now it is said " to be not without influence." No climate is specific. 
 High altitudes offer the advantage of purer air, stimulation of 
 breathing, increase of vital lung capacity, increase of the chest 
 dimensions, growth of the muscles of inspiration, increase of metab- 
 olism and stimulation of the appetite and blood-making organs. 
 Colorado, Arizona and New Mexico (four to seven thousand feet 
 elevation) are excellent for cure and for opportunities for en- 
 tering some permanent occupation after recovery; because of the 
 emphysema induced by altitudes, a return to the sea level should 
 be avoided. St. Moritz, Les Avants and Davos (5,200 feet 
 elevation) offer a dry, clear, cold, still atmosphere, where patients 
 may reside in summer and winter; it resembles the climate of Col- 
 orado, Montana and northern "Wyoming. There are also the Peruvian 
 Andes and numerous other altitudes, for details of which see Solly's 
 
348 THE SPECIFIC INFECTIONS. 
 
 Medical Climatology. High altitudes are best adapted to suspected 
 cases, to those with limited or incipient lesions, to those with slight 
 cavity formation and little emaciation, or to more advanced but 
 slowly progressing, or torpid, cases. Slight fever or slight haemop- 
 tysis are not contra-indications to such climates. Emphysema, weak 
 heart, constant fever, great nervousness or repeated haemoptysis are 
 contra-indications. Moderate altitudes (2.000 to 2.500 feet) prob- 
 ably best serve the majority of cases, as Asheville (2.250 feet), the 
 Adirondacks (2,000 feet), AiMn (2,250 feet), Summerville, Thom- 
 asville, etc. The climate of Minnesota, Xebraska and Dakota (1.000 
 feet elevation) is cool and dry ; dryness is usually more desired than 
 lack of variability. Moderate elevations do not induce emphysema, 
 whence return to the sea level is easier. The sea level is the best 
 location for the tuberculous aged, for quiescent cases with great cica- 
 trization or extensive damage, for those with diabetes. albuminuria > 
 nephritis, scrofula, bone disease, marked anaemia, repeated haemop- 
 tysis, emphysema or rapid softening, for those with incurable forms, 
 for thin, nervous subjects and for those with exophthalmic goitre. 
 Sea voyages are always somewhat experimental, and Pobin holds 
 that but S per cent, of cases are benefited by them: those with in- 
 cipient forms, or those with genito-urinary, glandular or osseous 
 disease or with open wounds, are often helped. Moist warm climates 
 (at the sea level) are especially adapted to laryngeal disease. — as the 
 Bermudas. Florida, the Madeira or Canary Islands ; patients with 
 dyspepsia and diarrhoea do well in Corsica, Palermo and Capri. 
 Warm, dry climates, as southern California, Egypt, Algiers or the 
 Eiviera are good for catarrhal types. Climate alone, without proper 
 rest, diet and reasonable hygiene, rarely benefits. 
 
 2. Xuteitiox. — Practice differs : most physicians recommend 5 
 or 6 meals daily, but some achieve better results by giving but three 
 meals, whereby the stomach is allowed some rest. Feeding varies 
 with individuals as to the amount and as to the kind of food. The 
 staple diet is meat, eggs and milk, including cream and butter. A 
 liberal mixed diet should be given of meat, fatty meats and fish: 
 well-cooked leguminous vegetables (which are advantageously given 
 in soups V butter, oil on salads, eggs. milk, cream, bread, pastries and 
 cakes. Anorexia is a common obstacle to full feeding. If it is of the 
 nervous type, patients must be compelled to eat. but long hours in 
 the fresh air usually stimulate the appetite. With habitually light 
 eaters caution is necessary: beef juice, milk and koumyss should be 
 given: the amount should be gradually increased and other foods 
 should be added. Faradization of the epigastrium, cold compresses 
 over the stomach, wine, vermouth, the fluid extract of condurango 
 TTLxv-xxx (ImmermannV or strychnia, gr. %o in solution, half an 
 hour before meals, are valuable appetizers. Raw beef (zomotherapy), 
 especially recommended by Pichet and Hericourt. has lately come 
 into use : fresh lean meat is cut. soaked for two hours in one-fifth its 
 weight of water, is then pressed to extract the blood and fluid, and 
 
TUBERCULOSIS. 349 
 
 administered, 1 to 2 pounds daily for moderately sick cases to twice 
 that amount for severe cases ; it must be freshly prepared each time, as 
 it soon becomes tainted. Raw eggs are often given between meals, be- 
 ginning with 1 and increasing to 4, three times daily, the taste being 
 disguised by orange juice. Fever does not contra-indicate full- or 
 overfeeding. Milk should be given, up to 1 or 1% quarts daily ; more 
 than this amount induces gastric atony ; it is given to advantage with 
 bread, crackers or toast, in order to divide the curds ; it may be pep- 
 tonized, disguised with cocoa or cognac or given by the rectum (v. 
 Gastric Ulcer) ; cream and butter are excellent substitutes for cod- 
 liver oil and buttermilk is indicated when the stomach is weak. Fats 
 and carbohydrates are necessary to offset nitrogenous waste; the 
 dark form of cod-liver oil (v. i.), lipanin (94 parts olive oil and 6 
 parts oleic acid), malt, honey, cocoa, nutrose, eucasin and somatose 
 are valuable foods. In all forms of overfeeding (Debove's surali- 
 mentation) the tolerance of the stomach must be considered, for this 
 is more important than the use of drugs (creosote, cough syrups or 
 cod-liver oil). Debove's method consists of gastric lavage followed 
 by the introduction through the tube of three ounces of powdered meat, 
 a quart of milk and one or more eggs. Alcohol at the present time is 
 administered less often and in smaller amounts than formerly, but is 
 frequently indicated symptomatically (v. i.) ; small amounts of red 
 wine or cognac and whiskey in egg-nogs are very valuable as a food 
 and tonic. Tobacco should be interdicted ; in special cases a cigar or 
 two daily may be allowed, but the smoke must never be inhaled. 
 
 3. Rest. — Rest is one of the essentials of Dettweiler's therapy. 
 Exercise destroys tissue, often induces anaemia and irritates the 
 heart; it is distinctly contra-indicated by fever, emaciation, haemop- 
 tysis, rapid pulse, nausea and coughing. It has been well said that 
 "too many cases of phthisis walk into their graves." Late in the 
 treatment graduated exercise may be taken. Pulmonary gymnastics 
 and pneumatic differentiation are clearly injurious. Patients should 
 lie in the bright sunshine and fresh air, and active mental occupation 
 should be carefully avoided. Hardening and exercise should be 
 obtained by quick, dry rubs with a large coarse towel, after which 
 rapid partial, and then general, wet rubs may be instituted; cold 
 rubs and hydrotherapy are to be shunned when there is any tendency 
 to haemoptysis. 
 
 (C). Specifics. — As yet there are no specifics for tuberculosis and 
 drugs are only of symptomatic value. 
 
 Tuberculin Therapy. — (i) The indications are: Incipient sub- 
 jects who are well-nourished, without fever and come to a stand-still 
 after some improvement, (ii) The contra-indications embrace mal- 
 nutrition, rapid wasting, acute phthisis, rapid heart action, nephritis 
 or great nervousness, (iii) Dosage. Carelessly used, tuberculin is 
 dangerous. One mg. of the "old tuberculin" (O. T.) is too large; 
 the initial dose should be 0.00001 gm. ; the initial dosage for the 
 "bacillus emulsion" (B. E.) is 0.000001 gm., increasing gradually 
 
350 TEE SPECIFIC INFECTIONS. 
 
 towards the decimal point. The maxim-urn dose of O. T. is 1 mg. 
 and B. E. 5 mg. and the course lasts 5 months but is interrupted 
 at once when coryza, cough, indigestion, fever, emaciation or hae- 
 moptysis intervene, (iv) Mode of action: It is thought that the injec- 
 tions stimulate the formation of agglutinins and opsonins ; the latter 
 are bodies which, combining with bacteria, make them an easier prey 
 for the phagocytes, (v) Results. Trudeau conservatively states his 
 belief that " tuberculin immunizes, prolongs life, causes the bacilli 
 to disappear from the sputum, aborts commencing infection and also 
 the smouldering fires of chronic infection." ' The subject is still 
 sub judice and perhaps as one writer puts it, " a chaos of personal 
 impressions." 
 
 (D). Expectant or Symptomatic Treatment. — 1. Fever. — Rest, quiet, 
 digestible food, fresh air or change of climate are indicated in great 
 preference to drugs. Brehmer administered strong wine at the time 
 the fever began to rise; arsenic is recommended by Pollack and 
 Powell, but no remedy in safe doses controls fever. Quinine disturbs 
 the digestion. Sponging is fairly efficacious. 
 
 2. Cough. — A slight morning cough serves to remove secretion and 
 needs no restraint, but, if excessive, it begets coughing by congesting 
 the lungs and tubes ; the dangers of excessive coughing are exhaustion, 
 depression, insomnia, aspiration and vomiting, which necessitate 
 interference. Fresh air and avoidance of dirt, dust and smoke are 
 most beneficial. Rest in general, and especially after eating, should 
 be enforced. The cough can be suppressed, for it is somewhat under 
 the control of the will, as Galen knew; the comment on the absence 
 of coughing, especially at the table, is universal among observers of 
 sanatorium methods; slow breathing, with the head slightly thrown 
 back, moist compresses or the sipping of warm water, with 10 grains 
 of salt, before meals and resting often aid in the suppression 
 of the emetic cough. Creosote was discovered by Reichenbach, 
 in 1832, and was used by Addison, Sonnenberg and Jaccoud; 
 it is not specific, but often increases the appetite, modifies abundant 
 secretion from the bronchi (by which the drug is in part eliminated), 
 and relieves the cough. Administration in the fluid form is better 
 than in capsules. Beginning with one drop (well diluted) after meals, 
 the dose may be increased to ten times that amount, but full dosage 
 often irritates the stomach and kidneys and necessitates constant 
 supervision of the urine ; it should not be given in febrile cases or in 
 haemoptysis. Creosote may be administered in milk, in water with 
 the compound tincture of gentian (Biij) or in sherry wine. 
 
 ]£ Creosoti 3iss. 
 
 Glycerini 3 SS - 
 
 Tr. gentianae co %iv. 
 
 M. et S. — One teaspoonful after meals. 
 
TUBERCULOSIS. 351 
 
 Creosote may be given in pill form as follows : 
 
 I£ Creosoti 3iss. 
 
 Mucilag. acaciae ^iij. 
 
 Pulv. althaeas q.s. 
 
 M. et ft. pil. no. 100. 
 
 S. — One after meals. 
 
 Guaiacol carbonate (gr. v, p. c.) is often better tolerated by the 
 stomach than creosote. Jacobi recommends the following formulae 
 as efficient and very cheap. 
 
 ]£ Guaiacolis 50 parts. 
 
 Tr. nucis vomicae 40 parts. 
 
 Tr. strophanthi 30 parts. 
 
 Liq. potassii arsenitis 10 parts. 
 
 Sig. — A half teaspoonful three times a day in hot milk. 
 
 ]£ Guaiacolis carbonatis 3iij. 
 
 Strychninae nitratis, 
 
 Arseni trioxidi aa gr. iss. 
 
 Sparteinae sulphatis gr. xlv. 
 
 M. et div. in chartulas no. 40. 
 Sig. — One powder after meals. 
 
 Cod-liver oil, first used by Hughes-Bennett, is usually given in doses 
 so large as to disturb gastric and intestinal digestion; the first dose 
 should be 10 drops and the amount should be gradually increased. 
 It is more valuable in tuberculosis of the glands and bones than in 
 the other types. Eructations can be avoided by administering it one 
 or two hours after meals, when the food begins to leave the stomach. 
 The oil is readily absorbed, because of the bile which it contains, and 
 is possibly somewhat alterative; but it is not very superior to butter 
 or cream, and is really more a food than a medicine. Cod-liver oil 
 may be floated on whiskey, beer or milk, and gulped down. Its taste 
 may be partly disguised by a " chaser " of whiskey. Syrup of 
 orange disguises its taste fairly well. It is seldom given when 
 there is fever or indigestion. It is prepared in large capsules, 
 which obviate its unpleasant taste. Opiates may be used, such 
 as paregoric; codeine gr. J with aq. laurocerasi and glycerine aa 
 Til xv and syr. tolutani 3j q.i.d. ; dionin gr. J q.i.d. ; heroin gr. 
 T2 q.i.d. ; even morphine sulph. gr. J with ac. hydrocyanici dil. 
 Tr[ii. Other remedies are myrtol gr. ii. a.m. and p.m. ; terpin hydrate 
 gr. ii to v, t.i.d. ; ol. terebinthinge, TTlij and for unproductive coughs, 
 spts. chloroformi or spts. setheris co. 3ss in whiskey, p.r.n. (Various 
 formula are given under Bronchitis. ) 
 
 ]£ Tr. belladonnae 3ss. 
 
 Spts. chloroformi ^iss. 
 
 Mucilag. acacias 3j. 
 
 Aquae q.s. ad 3iij« 
 
 M. et S. — One teaspoonful after meals, or as indicated. 
 
 Expectorants are to be avoided because of their nauseating ten- 
 
352 TEE SPECIFIC INFECTIONS. 
 
 dencies. Tr. benzoin co., 1 per cent, phenol, and creosote may be 
 vaporized. Menthol and guaiacol aa may be taken internally in olive 
 oil. If the cough is nasopharyngeal, the mucosa should be painted 
 with iodine, potas. iodide and glycerine, in proportions of 1, 10 and 
 100; if laryngeal, 20 per cent, menthol should be applied locally (v. 
 Laryngeal Tuberculosis) ; if due to enlarged bronchial glands > 
 inunctions of green soap and potas. iodide internally, should be given. 
 
 3. Sweats. — The room should be cool at night, the windows open, 
 the bed not too heavily covered, and the body protected by a flannel 
 night-gown. A glass of cold milk, with 3ij of cognac, given at bed- 
 time, is often beneficial. Morphine on retiring is indicated when the 
 sweats are associated with cough and insufficient oxygenation. Atro- 
 pine gr. Yioo to Vso, and camphoric acid gr. xv to xxx, at bedtime, are 
 the most reliable remedies, and are superior to aromatic sulphuric 
 acid Tl\x to xx, agaricin gr. M.6 to %2, tr. nucis vomicae Tl\xxx, picro- 
 toxin gr. %o and muscarin TTtv of a 1 per cent, solution. 
 
 ]£ Quininae sulph 3ss. 
 
 Calcii hypophosphitis 3j- 
 
 Extr. nucis vomicas gr. v. 
 
 M. et ft. pilulse 20. 
 S. — One after meals. 
 
 4. Haemoptysis. — Exertion, loud talking or singing and excesses 
 in alcohol, venery, coffee or tobacco, must be shunned in all cases. It 
 is well to warn patients of the possibility of haemoptysis, in order to 
 prevent undue excitement, if it appears. Effusive pleurisy should not 
 be tapped in a subject who has recently bled from the lungs, as 
 thoracocentesis has produced fatal haemoptysis. The chief indica- 
 tion is absolute rest, physical and mental ; the patient should be kept 
 in the semirecumbent posture ; silence on his part should be enforced ; 
 massage and stimulants are contra-indicated; no physical examina- 
 tion should be made except by auscultation, as percussion is obviously 
 dangerous; and a hypodermic injection of morphine should be given 
 to lessen cough, to quiet the heart, to allay the excitement attending 
 most hemorrhages and also possibly for its slight haemostatic effect. 
 As the tonus of the pulmonary vessels is beyond regulation, ergotin, 
 tannic acid and other haemostatics are useless, though digitalis and 
 fresh suprarenal extract gr. ii to v sometimes seem efficacious. Salt 
 3j is a popular remedy and is supposed to act by stimulating the 
 vagus. An ice-bag should be placed over the heart and one over the 
 lung, if rales are heard. Deep breathing seems to lessen bleeding. 
 Calcium lactate gr. xv t.i.d. for 2 days is valuable. Amyl nitrite, 
 recommended by Francis Hare, is given about midnight, when the 
 vasomotor centre is regaining its tone lost during sleeping. 01. 
 terebinthinae ulij to iij is considered the best drug by Frantzel. In 
 severe or obstinately recurrent hemorrhage, bandaging of the extremi- 
 ties (Hippocrates), to lessen the return flow of blood, injections of 
 gelatin, induction of pneumothorax by gas injection or puncture 
 
TUBEECULOSIS. 353 
 
 (Murphy, Cayley), or even emetics to stimulate the vagus (Frankel) 
 may possibly be indicated. Rest and the administration of morphine, 
 however, are usually effective. 
 
 5. Pain. — Pleuritic pain is treated by adhesive straps or by paint- 
 ing with iodine; if muscular, it should be treated by codeine to relieve 
 coughing, by liniments, massage, fomentations or phenacetin. 
 
 6. Dyspncea. — If due to stagnant secretion, moderate movement 
 or change of posture aids in its evacuation ; if asthmatic, iodide gr. iij 
 after meals is indicated but it must be given with care lest it con- 
 gest the lungs; if dyspnoea results from compression of the vagus 
 by bronchial glands, iodide and green-soap inunctions should be 
 given ; if cardiac, digitalis or strychnia is indicated ; if caused by 
 pleuritis or pneumothorax, these affections should be treated. 
 
 7. Cardiac Weakness. — To relieve cardiac weakness, rest, an ice- 
 bag over the precordia, cognac, champagne, camphor, strychnia, digi- 
 talis or strophanthus are in order. 
 
 8. Insomnia. — The patient should have fresh air night and day, 
 a light, early evening meal, a glass of beer, porter or some whiskey 
 on retiring. Bromides, codeine and morphine are beneficial. 
 
 9. Gastro-intestinae Symptoms. — Nervous anorexia is relieved 
 by fresh air, forced feeding and guaiacol (v. s.). Dyspeptic symp- 
 toms necessitate a scant diet for a few days, feeding by rectum and 
 poulticing of the epigastrium. In gastric atony, frequent meals of 
 small volume, limitation of fluids and strychnia are indicated. For 
 gas formation or pain the following are indicated ; carbolic acid gr. j ; 
 resorcin gr. iij ; fluidextract of gelsemium TTLij ; bismuth gr. x; extr. 
 belladonna? or spts. chloroformi n\xx. Pyrosis may be corrected by 
 sod. bicarb, and magnesia carb. aa gr. xv to xxx. Hyperacidity 
 should be treated by milk diet, belladonna and Carlsbad water or 
 other alkalies ; anacidity is relieved by easily digested foods, as soma- 
 tose or eucasin and hydrochloric acid. Vomiting is caused by the 
 cough, overfeeding, overmedication or irritation of the pharynx 
 (LugoPs solution locally, or gargles [1 to 10] of pot. bromide) ; small 
 doses of carbolic acid (v. Typhoid) are most successful. Constipa- 
 tion (q. v.) is treated by the usual measures. Diarrhoea may be 
 dyspeptic, catarrhal, toxemic, ulcerative or amyloid; the following 
 is indicated : Tannic acid gr. v ; opium ,gr. j ; lead acetate gr. ij ; 
 camphor gr. ij ; tannigen gr. vij to xv, or bismuth 3j (see Typhoid). 
 
 10. Anaemia. — This is benefited by fresh air, change to a high 
 altitude, full diet, iron in small doses and arsenic. 
 
 11. Sexual Symptoms. — Intercourse must be forbidden in in- 
 cipient as well as in advanced cases. Two or three years after re- 
 covery marriage may sometimes be allowed ; it is generally less in- 
 jurious to men than to women. Tuberculous parents may rear 
 healthy children, but tuberculosis and scrofula are rather common 
 in such families. In 66 per cent, of pregnant tuberculous women 
 the prognosis is bad, and laryngeal tuberculosis is almost invariably 
 fatal within a short time. In severe cases abortion may be con- 
 
 23 
 
354 TEE SPECIFIC INFECTIONS. 
 
 templated; opinions vary as to its indication, for some contend that 
 the mother runs the greater risk. Kaminer found that in 70 per 
 cent, of the cases abortion does not alter the clinical course. 
 
 12. Treatment of Other Complications. — The treatment of 
 laryngeal, pleural, peritoneal, intestinal, glandular and meningeal 
 complications (v. s.) is considered elsewhere. 
 
 LEPROSY. 
 
 Definition. — A chronic incurable contagion, caused by the Bacillus 
 lepras and characterized clinically by nodules, which belong to the 
 infective grannlomata (Lepra tuberosa), and are observed externally 
 on the skin and nasal and oral mucosae, and internally in many 
 organs ; or by a perineuritis leprosa, which causes sensory, motor 
 and other symptoms (Lepra maculoansesthetica). The nodular and 
 anaesthetic forms usually co-exist in varying degree. 
 
 Distribution. — The home of leprosy is Egypt, where it existed 2,400 
 years B. C. (Brugsch) or even 4,620 B.^C. (Engel-Bey). The lep- 
 rosy of Leviticus probably includes other diseases. It prevailed in 
 India 700, and in China 400 years B. C. Just before the Christian 
 era, Pompey's soldiers brought leprosy to Italy, whence it spread over 
 Europe and the Crusaders at the end of the thirteenth century fur- 
 ther disseminated the disease. In Europe there were 20,000 asylums, 
 but some cases were probably syphilis; the disease has steadily de- 
 creased since the sixteenth century. It is estimated that at present 
 there are 3,000,000 cases in the world. In Europe cases are found 
 in Sweden, Norway, Finland, Bussia, Dalmatia, Bosnia, Monte- 
 negro, Germany, France, Italy, Spain, Portugal, Turkey, Greece 
 and in some Mediterranean islands ; Arning estimates that there are 
 3,000 cases in the west half of Europe. In Asia numerous cases are 
 found in India (5 cases to each 10,000 of population), China, Malay 
 Archipelago, Formosa, Corea, Persia, Turkestan, Syria and Arabia. 
 In Africa it prevails in Egypt along the Nile, in Tripoli, Tunis, 
 Algiers, Mozambique, Zanzibar, Madagascar and in the Canaries 
 and Azores. In Japan, Australia, Oceanica and Sandwich Islands 
 it is also found. In America foci exist in Canada (New Brunswick, 
 Nova Scotia and British Columbia), in the United States (Cali- 
 fornia, Louisiana, Minnesota, North Dakota, Florida ; in 1902 there 
 were 278 lepers in this country, of whom half were native born) ; 
 in Mexico, West Indies, Honduras, Colombia (5 per cent, of the 
 population), Brazil and Paraguay. 
 
 Bacteriology. — The Bacillus leprae was found by Hansen (1871) 
 and was fully described by Neisser (1879). It is a fine, narrow rod, 
 measuring % to % of a red cell, and closely resembles the tubercle 
 bacillus (q. v.) morphologically and in its staining properties; both 
 bacilli contain fat. Inoculation is the surest differential criterion 
 between the two, ,for the lepra bacillus is not inoculable. In the 
 internal viscera it may exceed the dimensions which it attains in 
 
LEPROSY. 355 
 
 the skin and mucosae five or six times (Cornil). It is motile and 
 cannot be cultivated. It is found in the typical nodes and infiltra- 
 tions of the skin and superior mucosae, in the fresh maculae and recent 
 nerve disease, in the sweat, and sebaceous and hair-glands. It also 
 exists in the nerves and Pacinian bodies of the skin ; in the lymphatic 
 glands, bloodvessels, blood during fever (metastatic distribution), 
 and in practically all the viscera and secretions and excretions. It 
 is not known why the bacillus is found so much more frequently and 
 persistently in the nodular and mixed types than in the nervous 
 forms; Strieker found it in the nasal secretion in 96 per cent, of the 
 nodular, 96 per cent, of the mixed, and in 66 per cent, of the nervous, 
 type. It has never been identified outside of the human body. It 
 corresponds to but one of Koch's criteria ; i. e., it is always present in 
 leprosy; it cannot be cultivated, and the value of successful inocu- 
 lations on criminals under sentence of death has been justly criticized, 
 for these cases developed in a leprous community. That leprosy is 
 contagious can no longer be doubted. Less communicable than syph- 
 ilis or tuberculosis, contagion occurs only by long and intimate con- 
 tact with lepers. The nodular is far more dangerous than the 
 anaesthetic type. Infection may be direct or indirect (by infected 
 linen, utensils, etc.). It occurs chiefly through the skin and nose, 
 possibly through the genitalia. Extension occurs more by the lym- 
 phatics than by the bloodvessels. A predisposition toward leprosy 
 may possibly be inherited, but not the disease, and only 4 per cent, of 
 children of leprous parents acquire it. More cases occur in colored 
 than in white races, more in men than in women, and more in the 
 poorer than in the upper and middle classes. It most frequently 
 occurs between the ages of fifteen and thirty and rarely before the 
 third year. 
 
 The incubation is long, at least three to five, and sometimes twenty, 
 or even thirty-two, years. 
 
 Symptoms. — The chief clinical groups do not include the visceral 
 involvement which is seen in every type; the main types are uearly 
 always somewhat blended. 
 
 1. Nodular Type (Lepra tuberosa seu tuberculosa). — The pro- 
 dromal toxaemic symptoms indicate an infection which has already 
 been established, but has escaped recognition; they are depression, 
 coldness, formication, sweats, pains, vertigo, digestive disturbance, 
 temperature and sometimes nasal irritation. After months or years, 
 maculce appear on the face and extremities, which may itch or may 
 be hyperaesthetic ; they may disappear, leave pigmentation or meta- 
 morphose into nodules, which are present in 75 per cent, of all cases. 
 The nodule or leproma, is a granuloma very similar to the tubercle 
 or gumma ; the nodes are highly vascular and are formed of a scanty 
 fibrillar reticulum, in which lie emigrated leukocytes, small round 
 epithelioid cells and the larger multinucleated lepra cells of Virchow, 
 which contain close clumps of bacilli. The nodes by fusion form 
 infiltrations which are gelatinous, glistening and yellow-red, The 
 
356 THE SPECIFIC INFECTIONS. 
 
 nodes vary in size from that of a millet seed, to that of a hazelnut or 
 walnut; they lie in the skin, are dark red and later become yellow- 
 brown; they are glistening, vascular, slightly desquamating and at 
 first soft but later become harder. Sensation is always disturbed in 
 their vicinity. They are most conspicuous on the face and hands, but 
 also appear on the extensor surface of the knee, elbow and fingers 
 and very seldom on the soles of the feet, the palms of the hands, the 
 scalp or penis. When they develop on the face, the forehead, nose, 
 cheeks, chin, lips and ears are thickened, the nose becomes flatter, 
 the eyebrows, lashes and the beard are shed. The eyes are involved 
 in over 90 per cent, of the cases ; the expression is leonine (leontiasis) , 
 or, as the ancients called it, faun-like (satyriasis). The nodes usually 
 grow and extend slowly, and the lymphatic vessels and glands, of the 
 neck and groin especially, become enlarged and tender. Sometimes 
 the progression is interruptedly acute, with intermittent fever and 
 an eruption resembling erysipelas. They may shrink, but more 
 often necrose, soften and ulcerate. At the same time or later, nodules 
 which are prone to early ulceration and infiltration, occlude the nose, 
 roughen the voice (raucedo leprosa), distort the larynx and throat, 
 impair mastication, swallowing or respiration, and even provoke 
 suffocation. Cicatrization of the face causes added deformity. 
 
 2. ISTeevotts Type (Lepra nervorum, ancesthetica, maculo-ances- 
 thetica, sen mutilans). — The most common prodromes are fever, 
 neuralgia, paresthesia, hyperesthesia and vasomotor cerebral con- 
 gestion. Macula? develop on the face, neck, trunk or limbs ; they are 
 pale or dark-red, flat or slightly raised, growing peripherally and 
 paling centrally and are glistening or present a powdered aspect. 
 Histologically they are identical with the nodules, but contain fewer 
 bacilli, are flatter, contain no large cells and tend more toward 
 fibrous change. Their distribution is asymmetrical, like that of the 
 underlying nerve' lesions; they are often oversensitive, sometimes 
 pigmented (lepra nigra) or leukoderma-like (lepra alba). Early 
 vesicles sometimes develop. If the skin is powdered with dry methyl 
 violet and pilocarpine is then given, the sound tissue sweats and 
 stains, while the maculae remain uncolored because they do not sweat. 
 
 Sensory disturbances are due to lesions in the nerve trunks, which 
 are the seat of a perineuritis and interstitial neuritis which slowly 
 compress the nerve fibers. The connective tissue development and 
 the presence of the bacilli differentiates this from the parenchymatous 
 neuritides. Unlike the ordinary neuritis, the leprous neuritis affects 
 the sensory more than the motor filaments. There is an irregular 
 dissociated anaesthesia in which the perception of pain and tem- 
 perature is usually more dulled than other forms of sensation, and 
 this occurs mostly in the peripheral branches in the arms and legs. 
 Sensation may be perverted or retarded and anaesthesia may come on 
 suddenly, which is considered rather characteristic. Pain may be 
 slight, or agonizing as in a case of ten years duration which was 
 personally observed. The nerve trunks are palpable and tender in 
 
LEPtiOSY. 357 
 
 many cases; the ulnar nerve is most markedly enlarged and in the 
 case cited was thicker than a lead pencil, but the auricular nerve is 
 more often felt (in 90 per cent., Baelz). Motor weakness and 
 atrophy are less common and are rarely extreme ; the eyelids, muscles 
 of the mouth, and sometimes the masticatory and ocular muscles 
 and also the hands and feet are paretic. The ulnar and peroneal 
 nerves are sometimes paralyzed, causing the " claw-hand " and " claw- 
 foot." Facial paralysis occurs in 9 per cent, of cases. The tendon 
 reflexes are often increased, sometimes normal or decreased; there is 
 often fibrillation and increased myotatic irritability. Trophic 
 changes include oedema, glossy skin, " mat perforant" (26 per cent.), 
 loss of hair or nails, gangrene, bone resorption, rheumatoid swellings, 
 ankylosis and pigmentation. Great trophic changes mark the lepra 
 mutilans. 
 
 3. Mixed Type. — This is a combination of the nodose and anaes- 
 thetic types. In all developed forms the internal tissues are invaded: 
 The liver, spleen and lymph glands are enlarged; the lungs show 
 peribronchial foci, cavities or induration; and the intestine is infil- 
 trated. In both sexes the sexual functions are decreased and later 
 lost. Infantilism results in cases developing before puberty. Ca- 
 chexia develops, the patient becomes very sensitive to cold, the 
 temperature, except for intermittent rises, becomes depressed and 
 heart weakness develops. Abortive or long localized forms are de- 
 scribed. 
 
 Course and Prognosis. — The course is slow and progressive, the out- 
 come invariably fatal. The nodular type covers eight to twelve 
 years, the anaBsthetic form fifteen to twenty years, but either variety 
 may endure six or seven decades. According to Hillis, 38 per cent, 
 of cases die of leprosy (exhaustion, diarrhoea, cardiac weakness), 22 
 per cent, of chronic nephritis, 17 per cent, of lung disease, which is 
 more often leprous than tuberculous and 10 per cent, of diarrhoea 
 (leprous infiltration of the gut). The remaining 13 per cent, die of 
 erysipelas, sepsis, amyloidosis and intercurrent diseases, for lepers 
 exhibit a decidedly reduced resistance. 
 
 Diagnosis. — The diagnosis is based on the history of residence and 
 exposure which is often suppressed by the patient, on the macules 
 or leukoderma which are found in 90 per cent., on the anaesthesia, 
 amyotrophy and mutilation, and on the finding of the lepra bacillus 
 necessary for exactness, for which the nasal secretion, nodes and 
 macules should be examined (v. Syringomyelia). 
 
 Treatment. — 1. Prophylaxis. — All suspicious cases should be regis- 
 tered and all clear cases should be sequestrated. 
 
 2. Therapy. — Drugs are useless, though a few are helpful, (a) 
 Gurjun oil 3ss to 3ij in water or lime water; (b) chaulmoogra oil, in 
 milk, beginning with a few minims and increasing to 3j-iij ; (c) 
 salves of 5 to 10 per cent, pyrogallol, 10 per cent, chrysarobin, 10 
 per cent, ichthyol; (d) Calamette's antivenin, 20 to 30 c.c, which 
 was suggested by cases which improved after snake bite; (e) arsenic, 
 
358 INFECTIONS OF UNCERTAIN ORIGIN. 
 
 salicylic acid and corrosive sublimate ; these are the most extensively 
 used remedies. Symptomatic and #-ray treatment of pain and ulcers 
 is also indicated. 
 
 INFECTIONS OF UNCERTAIN ORIGIN. 
 
 FEBRICULA. 
 
 Definition.- — A fever of short duration, due to a number of causes. 
 If only of twenty-four hours duration it is called ephemeral fever; 
 when it lasts a few days, it is called febricula; when attended by 
 herpes, febris herpetica; or when accompanied by gastric disorder, 
 febris gastrica. 
 
 Febricula is no morbid entity, and its varied causes are not exactly 
 known. It embraces (a) benign or abortive forms of various acute 
 infections, such as rheumatism, typhoid, malaria, scarlatina, tonsil- 
 litis and pneumonia; infections with the bacillus coli, proteus or 
 pyocyaneus; and (b) febrile dyspepsias, especially those in children. 
 Gastric fever is a term which was formerly applied to febrile gas- 
 tritis, which is possibly produced by toxins in the food. Sewer-gas 
 is popularly held as the cause of fugitive fever with gastro-intestinal 
 disturbance, but Abbott and others have justly contested its etiological 
 significance. Exposure to cold and heat is also a possible factor. 
 
 Symptoms. — The three common symptoms are (a) chill or chilli- 
 ness; (£>) sudden rise of temperature; (c) a critical resolution, more 
 often prolonged than acute. The onset is abrupt, usually without 
 prodromes. The fever rises quickly to"101°-103°, or higher in the 
 young, with the usual signs of toxaemia, headache, coated tongue, 
 anorexia and febrile urine. Herpes is frequent. Bronchitis, acute 
 splenic tumor, albuminuria and in children, cerebral toxaemia, are 
 sometimes present. The term ephemeral is inappropriate, as the 
 average duration is three days, with a slow crisis. 
 
 Diagnosis and Treatment. — The diagnosis is solely by exclusion, and 
 the treatment is expectant. Rest in bed is advisable as a precaution 
 against some longer and insidious malady, such as typhoid; the 
 bowels should be unloaded, the diet restricted and a drop or two of 
 tincture of aconite and spts. setheris nitrosi oss should be given every 
 three or four hours. 
 
 GLANDULAR FEVER. 
 
 Definition. — An acute infection observed in children and character- 
 ized by pharyngeal infection, a short high fever and a painful intu- 
 mescence of the cervical lymph glands. It was described as Drusen 
 fieber by Pfeiffer, in 1889. Its etiology is unknown but it is evi- 
 dently an infection, as suggested by the clinical signs and by its 
 frequent occurrence in epidemics. It is usually seen in children 
 
MILIARY FEVER. 359 
 
 between five and eight years of age, and during the colder months. 
 Park West observed an epidemic of 96 cases in Bellaire, Ohio. Hoch- 
 singer and Kretz maintain that the disease is a sequel of various naso- 
 pharyngeal infections rather than an independent infection, the pri- 
 mary trouble being overlooked and the secondary adenopathy being 
 the first obvious sign. 
 
 Symptoms. — The symptoms begin without prodromes, with fever 
 of 101° to 103°, pain in the head and neck, redness of the throat, 
 some dysphagia, often pain in the limbs, nausea, vomiting and 
 abdominal pain. On the second or third day the cervical lymph 
 glands become swollen and tender bilaterally, but seldom cause red- 
 ness of the skin. The glands back of the upper part of the sterno- 
 mastoid are most involved. The inguinal and axillary glands are 
 involved in 75 per cent, of cases and the mesenteric in about 40 
 per cent. The glands may reach the size of an egg. After ten to 
 twenty days the swelling subsides, having lasted longer than the 
 fever. In some instances a persistent dry cough suggests involvement 
 of the bronchial glands, and umbilical pain, of mesenteric localiza- 
 tion. The spleen is enlarged in 60 and the liver in 90 per cent. 
 The fever, after a few days, falls by crisis. Complications are rare. 
 Suppuration in the glands is exceptional. Acute nephritis, endocar- 
 ditis, herpes, erythema and otitis media are occasionally observed. 
 
 Prognosis and Treatment. — The prognosis is good, though a, relapse 
 may occur. The absence of a rash excludes the adenopathies of 
 varicella, scarlatina 'and measles, and the generalized glandular 
 swelling excludes the local swelling due to simple pharyngitis. The 
 treatment is expectant. 
 
 MILIARY FEVER. 
 
 Definition. — An acute infection, marked by fever, profuse sweating, 
 a miliary eruption, nervous symptoms, palpitation and precordial 
 anxiety. It first appeared in England after the Battle of Bosworth 
 (I486) and broke out several times in the following century. It 
 was known as the " English sweats " (sudor Anglicu's), and its mor- 
 tality reached even 50 to 80 per cent. In 1529 it caused 3,000 deaths 
 in Dantzig. There have been about 200 epidemics between the epi- 
 demic in Picardy, in 1718, and that in Poitou, in 1887. It is highly 
 contagious (Brouardel). Epidemics have also occurred in Italy, 
 Switzerland, Germany and Austria, with a death-rate of 5 to 25 per 
 cent. Fortunately they last only a week or month. In 1906 Chante- 
 messe reported an epidemic of over 6,256 cases in northern France. 
 
 Symptoms and Treatment. — In mild outbreaks the chief symptoms 
 are fever, profuse periodic sweating and miliary eruptions. The 
 eruption may be erythematous or morbilliform (miliaria rubra), or 
 there may be no redness of the skin (miliaria alba s. crystallina) ; 
 the spleen may be enlarged. In severe cases there are marked cere- 
 bral toxaemia, rapid pulse, precordial distress, palpitation, extreme 
 prostration and hemorrhages into the skin; death results in a few 
 
360 INFECTIONS OF UNCERTAIN OBIGIN. 
 
 hours or days. Its average duration is one to two weeks. Desqua- 
 mation is frequent and convalescence rather tardy. The treatment is 
 supportive and expectant. 
 
 WEIL'S DISEASE.— (ACUTE FEBRILE JAUNDICE.) 
 
 Definition. — An acute infection, characterized by fever, jaundice, 
 herpes, enlarged spleen and liver, sore throat, muscle pain and albu- 
 minuria. It was especially described by Weil (1886), whose name 
 it most often bears, though previously mentioned by Mathieu, 
 Bouchard, Lancereaux and Coynes. ^sTicolaysen describes 63 epi- 
 demics of icterus in Norway and Sweden in the last fourteen years ; 
 3 to 28 per cent, of the inhabitants in certain communities acquired 
 the disease. 
 
 Etiology. — Its etiology is unknown, whence our difficulty in stating 
 whether it is a morbid entity or whether it includes several diseases. 
 It occurs in 90 per cent, in men between twenty-five and forty, 
 especially in butchers and alcoholics ; it also occurs in the warmer sea- 
 sons and sometimes in epidemics. It is either microbic or toxsemic. 
 Bordoni, Uffreduzzi and Jager found the Proteus fluorescens, and 
 Freund a diplococcus, but the intravitam findings are usually nega- 
 tive. Some cases have occurred in this country (Lanphear, Musser, 
 Guiteras) ; the author has seen eight cases in Chicago. 
 
 Symptoms. — The symptoms begin suddenly with fever, chill, head- 
 ache, insomnia and severe pains in the limbs and extremities. The 
 fever reaches 103°; it afterwards shows remissions and falls either 
 by crisis or lysis after -^ve to eight days. The nervous symptoms may 
 resemble typhoid. Jaundice develops on the third day, probably due 
 to catarrhal radicular angiocholitis ; bile appears in the urine and 
 the stools are often acholic, though the author has twice seen deep 
 jaundice without obstruction of the bile-duct. Muscular pains are 
 very common and intense, especially in the calves, which are usually 
 tender. Articular pains are not uncommon. Herpes is very common. 
 The rapid pulse is very marked compared with the usual slow pulse 
 of simple catarrhal icterus. In one case the author observed blood- 
 stained bronchitic sputum. Digestive symptoms are common, as 
 furred tongue, vomiting, epigastric pain, abdominal distention and 
 diarrhoea. The liver is enlarged and tender in more than 50 per cent, 
 of the cases, the spleen in over 66 per cent., and the lymph-nodes are 
 frequently affected. The urine is albuminous in over 50 per cent. ; 
 acute nephritis is frequent; hematuria occurs occasionally and 
 uraemia exceptionally; the urea and the amount of urine are de- 
 creased during, and increased after, the seizure (Chauffard's nitrog- 
 enous and polyuric crises). 
 
 Diagnosis. — Weil's disease must be differentiated from recurrent 
 fever by its spirillum, and from sepsis and typhoid, — in regard to 
 which it may be noted that icterus may produce a weak Widal reac- 
 tion. Differentiation is more difficult from suppurative angiocholitis 
 (q. v.) and acute yellow atrophy {q. v.). 
 
MOUNTAIN FEVER. 361 
 
 Prognosis. — This is usually good and convalescence is generally 
 established in two weeks; in one epidemic, 11 per cent, of the cases 
 died. Recurrence in 40 per cent, may be anticipated if the splenic 
 tumor has not subsided (Mathieu) ; renal or hepatic insufficiency, 
 pregnancy, haemolysis with epistaxis and hsematemesis, render the 
 prognosis less favorable. 
 
 Treatment. — The treatment is directed to (a) the intoxication, for 
 which calomel and salines are indicated; cold water enemata (Krull 
 and Chauffard) increase the renal flow, and, with it, the excretion 
 of toxins; (b) the jaundice, for which salines should be given to 
 lessen duodenal catarrh; (c) the albuminuria, for which a milk diet 
 is indicated; (d) muscular pains, for which heat and massage with 
 chloroform liniment, are most beneficial. 
 
 MILK SICKNESS. 
 
 Definition. — A disease acquired by man from the milk or meat of 
 cattle suffering from the " trembles." Cows with the disease, after 
 being driven too rapidly, suffer from anorexia, injection of the eyes, 
 vertigo, trembling and convulsions ending in death. Young horses 
 and sheep may also acquire the disease. Milk sickness occurs chiefly 
 in newly settled countries, as in the Southwestern states, and it is 
 still seen in North Carolina. Its origin and pathology are unknown. 
 Jordan and Harris describe a Bacillus lactimorbi. 
 
 Symptoms. — In man the nervous symptoms are frequently conspic- 
 uous, as restlessness, convulsions or coma, which appear after a 
 few days of malaise. The tongue is swollen and heavily coated, the 
 breath foetid, the stomach painful and irritable, the fever low, high 
 or sometimes typhoidal. The issue is either fatal, in acute forms, 
 within a few days, or recovery may result after weeks. Flesh, butter, 
 cheese and milk, from infected animals may, even when boiled ; cause 
 death when given to dogs. 
 
 MOUNTAIN FEVER. 
 
 Wilson and Chowning think that the disease is caused by a red- 
 corpuscle protozoon like that of Texas fever and malaria, though 
 not pigmented; Stiles and Craig could not confirm their findings. 
 Howard Hicketts found the disease was inoculable and he and King 
 found the medium of infection was the wood-tick. Kicketts (1909) 
 discovered a bacterium, of which details are lacking at the time of 
 writing. Cases develop in the early spring, and are marked by chill, 
 fever lasting one or two weeks, rapid pulse, epistaxis, albuminuria, 
 rapid breathing, bronchitis, splenic tumor, rapid anaemia, moderate 
 leukocytosis, slight icterus, muscular pains and widely diffused macu- 
 lar rash, — which develops on the third day, disappears on pressure at 
 first, but afterwards persists on pressure. The liver and spleen are 
 enlarged. Quinine may be beneficial in some cases. The death rate 
 may be 70 per cent. 
 
362 INFECTIONS OF UNCEBTAIN ORIGIN. 
 
 FOOT AND MOUTH DISEASE. 
 
 Definition. — Epidemic stomatitis, Aphthous fever, or Aphthae epizo- 
 oticse is one of the zoonoses and its nature is unknown. Loeffler and 
 Frosch have shown that the virus is ultramicroscopic, as it passes in 
 full virulence through porcelain niters. The disease, first described 
 by von Valentini, in 1695, and known, since the middle of the fif- 
 teenth century, chiefly affects cattle, sheep and pigs, but sometimes 
 also goats, horses, dogs and even fowl. In cattle there is fever, 
 swelling of the mouth, salivation and the formation of small, clear 
 vesicles on the tongue, gums, lips, udders, hoofs and between the toes. 
 These vesicles soon become opaque, and bursting, form small ulcers ; 
 emaciation is rapid, and the milk becomes yellowish and mucoid. 
 Embolism or fatal apoplexy may result. Recovery is usual in one to 
 two weeks. The disease spreads very rapidly. It is observed in 
 Hungary, Germany, France, Switzerland, England and occasion- 
 ally in this country. 
 
 Etiology and Symptoms. — In man infection occurs from diseased 
 milk (as proven on himself by Hertwig), butter and cheese, but not 
 by diseased meat. Open wounds may be directly infected. Cattle 
 have been inoculated from man. The incubation is three to five days. 
 There are fever, salivation, aphthous ulcers, angina, nausea, vomit- 
 ing and vesicles on the skin — which have caused confusion with 
 vaccinia. Hemorrhages occur in severe epidemics. Ebstein has sug- 
 gested that Foot and Mouth Disease may be kindred with the ordi- 
 nary aphthous stomatitis of nurslings or pregnant women. Children 
 are more endangered than adults. The death-rate is 2.3 per cent, 
 (Hulin) to 8 per cent. (Siegel). Recovery is usual in three weeks. 
 
 Treatment. — Prophylaxis concerns the boiling of suspected milk, 
 the segregation of diseased animals or human subjects, and vaccina- 
 tion, as discovered by Loeffler. A dram of 5 per cent, solution of 
 potas. chlorate, t. i. d., should be given, and the aphthae should be 
 touched with borax or silver. 
 
SECTION II. 
 DISEASES OF THE CIRCULATION. 
 
 DISEASES OF THE HEART MUSCLE. 
 
 DILATATION OF THE HEART. 
 
 Definition. — Dilatation means distention and diminished tonicity 
 of the chambers of the heart ; it may be partial or complete. Hyper- 
 trophy is thickening of the walls of one or more chambers. The two 
 conditions are quite separate in themselves, though they are fre- 
 quently combined ; some clinicians consider that dilatation is the in- 
 centive to increased nutrition i.e. hypertrophy. Lancisi (1706— 
 1728) described hypertrophy and dilatation. 
 
 Etiology. — 1. Mechanical Causes. — The normal heart may yield 
 to increased blood-pressure or a weak heart may yield to normal 
 pressure. Rarely, if ever, is dilatation an independent condition, 
 (a) Valvular disease, e. g., dilatation of the left ventricle in 
 aortic insufficiency, or of the left auricle and right ventricle in 
 mitral stenosis. Hypertrophy is usually inversely proportional 
 to the dilatation. In combined valvular lesions, as aortic and 
 mitral insufficiency, the heart is enormous — the ox heart, cor hovinum, 
 bucardia. (b) Causes raising arterial blood pressure, as stenosis 
 of the aorta, arteriosclerosis and nephritis produce hypertrophy 
 and dilatation of the left ventricle. Workers in caissons may 
 suffer from dilatation, (c) Causes raising blood tension in the lesser 
 circulation, as spinal deformity, chronic disease of the lungs and 
 pleura, which produce hypertrophy of the right ventricle ; of these em- 
 physema is the most important. Abdominal lesions are thought by 
 French writers to reflexly raise the pulmonary blood pressure and 
 induce right-sided hypertrophy and dilatation. Lichtheim's classic 
 on the lesser circulation proved that the lung vascular area must be 
 reduced to 25 per cent, in order to affect the right heart. The size 
 of the heart varies much physiologically; rapid heart action allows 
 less complete physiological dilatation than does slow action. When 
 there is pulmonary obstruction with its consequent heart changes, 
 the patient stands pneumonia, bronchitis and other infections very 
 poorly. When severe exercise is indulged in, the systole is incom- 
 plete and right-heart dilatation — even tricuspid regurgitation and 
 marked venous stasis — may follow. Physical training increases the 
 power and reserve strength of the right heart; i. e., it increases the 
 
 363 
 
364 DISEASES OF THE CIRCULATION. 
 
 "wind" and endurance. An equal effort in an individual out of 
 training, or with poor nutrition, "breaks his wind" and produces 
 transient or permanent cardiac exhaustion. Air embolism also pro- 
 duces dilatation. 
 
 2. Nutritive Disturbances. — Dilatation may be induced (a) by 
 acute infections, leading to cardiac degeneration or acute myocarditis ; 
 (b) by anaemia, hemorrhages or loss of fluids; (c) by chronic myo- 
 carditis, fatty heart or coronary atheroma, possibly following sud- 
 den heart strain as in athletics ; by endo- or pericarditis invading the 
 heart muscle by contiguity, pericardial adhesions, etc. ; (d) by poisons, 
 alcohol, tobacco or chloroform anaesthesia; (e) it very frequently 
 follows hypertrophy or is associated with it. 
 
 Pathology. — Dilatation occurs (a) with thinning of the walls, 
 simple dilatation, or (b) with eccentric hypertrophy (q. v.). It 
 is most common in the thin-walled auricles and less resistant right 
 ventricle. The muscle is lax and the heart, when held inverted by 
 the basal vessels, may in extreme instances fall flabbily like a cap 
 over the hand. In extreme dilatation the endo- and pericardium 
 almost touch. 
 
 The papillary muscles and trabecular are flattened (pressure atro- 
 phy) and frequently thickened (pressure sclerosis). Microscopic- 
 ally the heart muscle may be normal, or may show fatty or cloudy 
 degeneration or myocarditis. The precise role of degeneration in 
 the ganglia of the heart has not been determined. There is much 
 blood in the heart's chambers, in the cava? and other veins. Long- 
 standing dilatation is not to be confused with dilatation occurring 
 during the death agony from acute lung disease, suffocation, etc., in 
 which the right heart is chiefly affected and in which on removal 
 of the post-mortem clots the chambers seem more nearly of normal size. 
 
 Symptoms. — The symptoms are those of cardiac insufficiency (v. 
 Uncompensated Valvular Disease), as dyspnoea — which is es- 
 pecially great in pericardial adhesions — cardiac asthma, cough, syn- 
 copal attacks and precordial anxiety. Cardiac failure begins when 
 the systole is unable to expel all the blood from the dilated chambers. 
 
 Physical Signs. — It is not always easy to separate the signs of hy- 
 pertrophy and those of dilatation. 
 
 1. Dilatation of the Left Ventricle. — (a) On inspection, the 
 apex beat is dislocated downward, to the left and is diffuse, undulat- 
 ing and weak, if indeed it is not absent, (b) On palpation, the apex 
 may not be felt even though visible (Walshe). In other cases the 
 apex and heart shock are snappy and may feel strong to the inex- 
 perienced hand; the sharp snappy action contrasts sharply with the 
 weak, rapid and often irregular radial pulse. (A palpable impulse 
 may be due to active diastole of the auricle, to passive distention of 
 the ventricle by blood from the auricle or to closure of the auriculo- 
 ventricular valves during the presystole.) Albertini (1761) dis- 
 tinguished hypertrophy and dilatation by palpation, (c) On auscul- 
 tation, the heart tones are weak, though sometimes snappy. The 
 
DILATATION OF THE HEART. 365 
 
 first apex tone is more valvular. The second aortic sound is weak 
 because of poor arterial tension. In insufficient hearts, the heart 
 tones sound alike, a condition termed embryocardia from its resem- 
 blance to the foetal heart tones. An apical systolic murmur is fre- 
 quent, especially in arteriosclerotic dilatation. It is sometimes due to 
 relative insufficiency of the mitral valve whose normal circumference 
 of three and one-half inches may be stretched to five. Yon Jurgen- 
 sen holds that it is often due to irregular muscular contraction. Best 
 and the administration of digitalis frequently cause it to disappear. 
 Gallop-rhythm, in which three tones are heard, like the rhythm of a 
 galloping horse, consists of either doubling of the first (Potain) or 
 second tone (Frantzel), or of the addition of a presystolic tone caused 
 by the auricular contraction (Bosenbach). It is heard in the 
 failing hypertrophied hearts of nephritics more than in all other 
 conditions combined. It is also found in valvular lesions, atheroma, 
 emphysema and in acute diseases such as pneumonia, typhoid and 
 diphtheria. The auricle cannot long compensate. Whatever its 
 cause, it is a sign of great danger although the heart's tonicity may 
 temporarily improve with rest and heart tonics, (d) On percussion, 
 the heart extends to the left and downward, giving a more oval area 
 of dulness. 
 
 2. Dilatation of the Eight Ventricle. — This is more com- 
 mon, (a) On inspection, a diffuse beat is seen to the right of the 
 sternum or in the epigastrium; and (b) it may be palpated, (c) 
 Auscultation shows weakness of the heart tones, and (d) percussion 
 outlines dulness to the right of the sternum. Extreme dilatation 
 increases the tricuspid orifice from four and one-half to five or 
 six and one-half inches, and the physical findings of relative tri- 
 cuspid insufficiency obtain. 
 
 3. Dilatation of the Auetcees. — Because of the deep location 
 of the left auricle physical signs of dilatation are seldom obtained. 
 A presystolic wave may be seen in the second left interspace. The 
 changes usually ascribed to the left auricle are due to enlargement 
 of the conus of the right ventricle. The distended right auricle is 
 recognized by undulation to the right of the sternum above the right 
 ventricle, by dulness and sometimes by a presystolic wave. 
 
 Dilatation of all the chambers, right and left, combines the physical 
 findings of each type, giving the heart a triangular or a trapezoid 
 conformation. The cardiac symptoms and physical findings of dila- 
 tation may develop gradually, or abruptly after violent exercise, es- 
 pecially when the heart is congenitally weak or its nutrition is altered. 
 
 Diagnosis. — The diagnosis depends on the etiological factors, the 
 weak tones, the increased dulness and cardiac and somatic evidences 
 of cardiac failure. The greater the dilatation, the less marked is the 
 difference between the systole and diastole. The absolute heart dul- 
 ness in middle life is bounded by the left border of the sternum, the 
 fourth or fifth rib and the left parasternal line (or a little more to 
 the left). The relative dulness reaches from the third or fourth 
 
366 DISEASES OF THE CIRCULATION. 
 
 rib above to the apex beat on tbe left and to a line drawn obliquely 
 from tbe third left costal cartilage across the sternum to the fifth 
 right costal articulation. Percussion is difficult in distorted, fatty or 
 oedematous chests. Differentiation concerns the same group of con- 
 ditions discussed under the diagnosis of effusive pericarditis (q. v.). 
 Eest and digitalis greatly benefit dilatation and hydropericardium, 
 sometimes within a very short time, while pericardial effusion is un- 
 affected by this treatment. Consolidation of the adjacent lung mar- 
 gin can usually be recognized by the altered breathing and rales. 
 Mediastinal tumor and aneurysm are suggested by pressure symp- 
 toms. If the margins of the lung are adherent from pleural adhes- 
 ions, especial care in percussion is imperative, and dilatation is diag- 
 nosticated by the relative, more than by the absolute, heart dulness. 
 Palpatory percussion, very lightly made, is most valuable an'd the 
 feel of the increased dulness has greater diagnostic value than the 
 sound elicited. Emphysema may greatly obscure the outlines of the 
 heart, but the heart's outlines are usually disclosed by careful pal- 
 patory percussion for the relative dulness. Encapsulated pleurisy 
 is differentiated by careful puncture, if other signs fail. The fluoro- 
 scope is frequently of aid. In short chests, the apex is seen normally 
 at or even beyond the nipple. This occurs in 12 per cent, of women. 
 Though spinal curvature frequently overtaxes the right heart and 
 thus induces dilatation, the diagnosis must be made with care, for the 
 topographical relations are much disturbed by visceral luxation, and 
 the irregularity of the sternum and ribs makes percussion uncertain. 
 In fat individuals, dulness may result from adipose deposit in the 
 mediastinum, but differentiation is often easy by means of the nor- 
 mal, though perhaps distant, heart tones and by the character of the 
 pulse. Dilatation must not be mistaken for dislocation due to gas- 
 eous, tumor or fluid distention of the abdomen. 
 
 Prognosis. — The prognosis largely depends on the etiology. 
 
 Treatment.- — (a) The cause must be treated, (b) The dietetic, 
 special and general indications of valvular disease (q. v.) must be 
 carried out. (c) OerteVs treatment consists of (i) limitation of the 
 amount of water ingested, and stimulation of its excretion by sweats 
 and deep inspirations ; beer must be interdicted. Many nervous sub- 
 jects tolerate limitation of water very poorly. Water should be given 
 in small quantities at frequent intervals, (ii) Reduction of the body- 
 weight (see Obesity), (iii) Stimulation of the circulation by exer- 
 cise. Mountain climbing is said to stimulate the heart, develop the 
 respiratory muscles, increase the lung capacity and widen the ves- 
 sels. The objections to active exercise are that rest in bed gives 
 better results, and that exercise causes harm when the heart muscle 
 or coronaries are diseased, or when endocarditis, pericardial adhesions 
 or Bright's disease exists, (d) The so-called Schoit method was origi- 
 nated by Beneke and Satherburg, and was elaborated by Nauheim 
 physicians. It consists of (i) baths in springs containing sodium 
 and calcium chloride, iron carbonate and carbon dioxide. The tern- 
 
DILATATION OF TEE EEAET. 367 
 
 perature should be a few degrees below body-beat, and little carbon 
 dioxide should be used in the baths at first. They should be given 
 once daily lasting from five to twenty minutes, for two or three days, 
 and then intermitted. They may be given artificially with good re- 
 sults, using 40 gallons of water, with 3 to 10 pounds of salt, 10 ounces 
 of pure calcium chloride and carbon dioxide generated in a vessel 
 from sodium bicarbonate and hydrochloric acid. The temperature 
 should be reduced from body-temperature to 90°, and the amount of 
 carbon dioxide increased. The bloodvessels are first contracted and 
 later dilated. The pulse becomes slower and fuller, dilatation de- 
 creases, stasis is lessened, diuresis is increased and the metabolism of 
 the muscles and heart is improved, (ii) Resisted movements should 
 be carefully and gradually employed. Though active exercise con- 
 stricts the vessels, gentle movements by the patient, resisted by the 
 operator, dilate the vessels. 
 
 Yeo summarizes the resistance movements as follows : 
 
 Each exercise is made against slight resistance applied by the physician or a 
 trained assistant. 
 
 1. The arms are extended in front of the body at the level of the shoulder, with 
 the palms of the hands touching. The two arms are then moved slowly outward till 
 they are in a line with each other; they are then brought back to their original 
 position. 
 
 2. The arm and hand hanging down with the palm turned forward, the fore- 
 arm is flexed upon the arm (which is kept still) until the fingers touch the shoulder. 
 The forearm is then extended to its original position. This is first done with one 
 arm and then with the other. 
 
 3. The arms, hanging down as in No. 2, are raised outward until the thumbs 
 meet over the head; they are then returned to their original position. 
 
 4. With arms dependent, the fingers, at the first phalangeal joints, are pressed 
 together, and the arms are then raised until the hands are above the head, after 
 which they are brought back to their original position. 
 
 5. The arms, hanging in the position of ' ' attention, ' ' are advanced forward 
 parallel to each other until they are elevated to a vertical position; they are then 
 brought back to where they were before. 
 
 6. Same as No. 1, but with fists clenched. 
 
 7. Same as No. 2, but with fists firmly clenched. 
 
 8. The arms, starting from the position of " attention, ' ' describe a circle by 
 moving forward and upward until they are raised vertically; then each palm is 
 turned outward, and the arms descend backward to their former position. 
 
 9. The body is bent forward, and then brought back to the erect position, the 
 knees not being moved. 
 
 10. The body is rotated, without any movement of the feet, first to the right and 
 then to the left, and then back to its original position. 
 
 11. The body is flexed laterally, as far as possible, first to the one side and then 
 to the other, and afterward restored to its original erect position. 
 
 12. The patient, standing with the feet side by side and supporting himself by 
 leaning with one hand upon any object, flexes the opposite thigh as far as it is 
 possible, and afterward extends it until the feet are again side by side; then, lean- 
 ing on the other hand, he carries out a similar movement with the other thigh. 
 
 13. The patient, supporting himself by one hand, as in 12, and the knee being 
 kept straight, each leg in turn is raised as high as possible in front of the body, 
 and then in the same way behind. 
 
 14. Supporting himself by placing both hands in front on the back of a chair, 
 the patient first flexes one leg and then the other upon the thigh as far as he can. 
 
 15. Each leg in turn is abducted as far as possible, the knees being kept 
 straight, the patient resting on one or other hand the while. 
 
 16. The arms, held horizontally outward, are rotated forward and backward at 
 the shoulder joint. 
 
368 DISEASES OF THE CIBCULATION. 
 
 17 and 18. Flexion and extension, first of the wrists and second of the ankles. 
 
 In resisting these movements the operator places the palm of his hand on that 
 side of the patient 's limb or body toward which the movement is to be made. In 
 the movements of the wrist the operator closes his thumb and forefinger round 
 that joint. 
 
 (iii) Passive movements and massage. Contraindications to 
 Schott's method are aneurysm, angina pectoris, acute cardiac insuffi- 
 ciency, tendency to hemorrhage and embolism and possibly ner- 
 vousness. 
 
 HYPERTROPHY OF THE HEART. 
 
 Etiology. — The causes of hypertrophy of the left ventricle are usu- 
 ally mechanical resulting from (a) valvular lesions (aortic stenosis 
 and insufficiency, mitral insufficiency) wherein dilatation precedes, 
 and incites, hypertrophy; (b) renal disease; usually from a chronic 
 interstitial nephritis but occasionally from hypoplasia of one kidney, 
 hydronephrosis, etc. ; it is caused by mechanical obstruction to the flow 
 of blood or by retention within the blood of waste substances which 
 excite arterial spasm; (c) arteriosclerosis (q. v.), developed by 
 Traube; (d) congenital narrowness {hypoplasia) of the arterial sys- 
 tem, or of the aorta at the isthmus; (e) dilatation of the aorta, diffuse 
 or aneurysmatic, or occurring rarely from general arterial dilatation 
 (]^"othnagel and Frantzel) ; (/) pericardial adhesions q. v.; (g) myo- 
 carditis (q. v.) ; (h) pregnancy ; it is claimed that the placental circu- 
 lation or increased intraabdominal pressure increases the heart's 
 work. The high diaphragm apposes the heart to the chest wall and 
 tips the apex outward so as to simulate hypertrophy; (i) over-ex- 
 ertion; the " irritable heart of soldiers " (Da Costa, Myers, Frantzel) 
 is caused by forced marches, cold and mental excitement; the so- 
 called idiopathic hypertrophy occurs in hard workers, and especially 
 in Munich from excessive use of beer and from the resulting plethora 
 (Bauer and Bollinger) ; hypertrophy results from continued hard 
 work while dilatation follows sudden cardiac strain; (j) nervous 
 causes; these are exophthalmic goitre and tobacco, especially strong 
 Havana cigars, which cause rapid irregular heart action; goitre and 
 tobacco are also probably toxic causes; (Jc) reflex hypertrophy is said 
 to result from abdominal growths, brachial neuritis, etc. (Potain). 
 Putjatin, Ott and others have found degenerative and sclerotic 
 changes in the cardiac ganglia. 
 
 Hypertrophy of the right ventricle depends on (a) hypertrophy 
 consecutive to left heart disease; the entire heart usually hypertro- 
 phies from the intimate connection between the muscular fibres of 
 both sides; (b) right-heart valvular lesions and congenital heart dis- 
 ease; (c) increased pulmonary pressure from disease of the pulmon- 
 ary artery or pressure upon it; (d) emphysema, chronic bronchitis, 
 spinal deformity, pulmonary induration, bronchiectasis and extensive 
 pleural adhesions. 
 
 Hypertrophy of the auricles always coexists with dilatation (as in 
 stenosis of the auriculoventricular orifices). 
 
HYPERTROPHY OF THE HEART. 369 
 
 Pathology. — The muscle fibers increase even tenfold in size (hyper- 
 trophy) and increase in number (hyperplasia). Hypertrophy may 
 exist alone — simple hypertrophy. It more frequently occurs with 
 dilatation — eccentric hypertrophy. Concentric hypertrophy, i. e., 
 with decrease in the size of the ventricle, is rarer and some regard 
 it as merely a postmortem condition; the ventricle may be firmly 
 contracted in death from violence, cholera or hemorrhage, but it 
 can be distended by the finger. The size of the normal heart is 
 that of the fist (Laennec), and the normal weight is about 9f ounces 
 (300 gm.). The heart is sometimes increased four times in weight, 
 even to 59 ounces (1,980 gm., Stokes) — the cor bovinum. Its con- 
 sistence is increased and its color is normal or darker. In total 
 hypertrophy the heart is round ; in partial, the right or left ventricle 
 is larger. The left ventricle is normally nine to ten millimeters in 
 thickness, but this may be more than doubled in hypertrophy; the 
 right ventricle measures three or four millimeters; the left auricle 
 measures three, and the right two, millimeters. In the foetus the ven- 
 tricles are equally thick. Up to the eighth year, the left ventricle 
 is relatively thicker than in the adult, because of narrowing of the 
 aorta at its isthmus. 
 
 Symptoms. — Hypertrophy of the left heart may exist without any 
 subjective sensations, or there may be palpitation, cough, cardiac 
 oppression or pain or cerebral congestion, — tinnitus, flashes before 
 the eyes, headache or vertigo. There is frequently a tendency to 
 hemorrhage — epistaxis, cerebral hemorrhage, excessive menstruation. 
 Polyuria results from high arterial tension. The causal nephritis, 
 valvular disease, arteriosclerosis or emphysema presents its own 
 symptoms. Righ-heart hypertrophy is attended by brown induration 
 of the lungs, haemoptysis, cyanosis or bronchial catarrh. 
 
 Physical Signs. — Much confusion in the clinical description pre- 
 vails because the signs of hypertrophy are very often confounded with 
 those of dilatation ; both conditions frequently coexist. 
 
 Hypertrophy of the Left Ventricle. — 1. Inspection. — This 
 discloses (a) a strong, sometimes heaving, diffuse apex; essential dis- 
 location to the left or downward indicates coincident dilatation, be- 
 cause thickening of the heart muscle alone gives no appreciable in- 
 crease in the size of the heart. Rotatory retraction of the apex beat is 
 sometimes seen, (b) Precordial prominence; and (c) forcible pulsa- 
 tion of the vessels. 
 
 2. Palpation. — Palpation confirms (a) the strong apex beat, de- 
 tects (b) the palpable second aortic tone due to high tension (or 
 atheroma), and sometimes (c) sl systolic apical thrill (transmission 
 of the strong first tone), (d) The pulse is regular, full and hard in 
 simple hypertrophy, but in the eccentric form it is softer and more 
 rapid. It is sometimes weak or almost absent in the arms; this is 
 due to loss of vessel tonus, (e) Thrills over the peripheral vessels 
 from high tension vibration may be felt. 
 
 3. Percussion. — It is usually stated that the left heart is dislocated 
 24 
 
370 DISEASES OF TEE CIRCULATION. 
 
 downward to the left but enlargement means dilatation or an atherom- 
 atous relaxed aorta which allows sinking of the heart. 
 
 4. Auscultation. — This brings out (a) the loud first tone, over 
 the apex (but not in aortic leakage) ; it discloses (b) the accentuated 
 and frequently metallic second aortic tone; (c) systolic arterial bruits 
 from tension and vibration of the walls; (d) the gallop-rhythm in 
 cases of failing hypertrophy, especially in nephritics; (e) a peculiar 
 clink, which is sometimes heard to the right of the apex; (/) an 
 apical systolic murmur is sometimes heard and is frequently of the 
 cardiopulmonary type. Seitz, Gendrin and others have recorded 
 murmurs resembling the pericardial rub, due to the violent beating 
 of the heart or to muscular contraction (Jiirgensen). 
 
 Hypertrophy of the Right Ventricle. — (1) Inspection shows 
 a strong, systolic impulse under the lower part of the sternum which 
 is (2) palpable, as is the strong second pulmonic tone. (3) Auscul- 
 tation brings out the accentuated second pulmonic; and (4) percus- 
 sion is negative, unless there is coincident dilatation. 
 
 Diagnosis. — In left-sided hypertrophy, the cardinal signs are (a) 
 the tense pulse, (b) the strong, hard apex beat and (c) the accen- 
 tuated second aortic tone; in right-sided hypertrophy they are (1) 
 the strong second pulmonic tone and (2) the substernal pulsation. 
 Percussion is useless, for it discloses dilatation only. 
 
 Hypertrophy of the left heart must not be confused with nervous 
 overaction of the heart, in which the apex is not heaving. Retrac- 
 tion of the left lung merely exposes more of the left ventricle, but 
 the heart in this case enlarges upward and to the left. In narrow 
 chests with poor lungs, the heart's dulness is wide, but the cardinal 
 symptoms of hypertrophy are lacking. The same caution in the 
 diagnosis of hypertrophy at puberty is necessary because at this per- 
 iod the heart is nervously unstable, the chest is thin and the heart is 
 normally wider than in the adult. Perplexity may be caused when 
 abundant casts and blood are found in the urine ; these are usually 
 indicative of nephritis, but, if there are other evidences of stasis, 
 such as congested liver, they are compatible, in the minds of some 
 writers, with stasis alone. Nephritis may cause hypertrophy; ne- 
 phritis and hypertrophy may be due to a common cause; or a fail- 
 ing heart may produce renal stasis (see Nephritis, Differential 
 Table). 
 
 Prognosis. — The immediate outlook is good because hypertrophy is 
 usually a compensatory process ; the ultimate outlook is bad, because 
 cardiac insufficiency is the ultimate issue. Symptoms usually ap- 
 pear first either gradually or suddenly in the stage of broken compen- 
 sation from intercurrent fevers, malnutrition or mental and physical 
 strain. The best outlook is in hypertrophy caused by tobacco or ath- 
 letics, for this may regress. Gallop-rhythm is ominous, as is the oc- 
 currence of the first and second apical tones close together. Hyper- 
 trophy leads to fatty and other change in the heart, to sclerosis of 
 the vessels, and in the pulmonary circuit to pulmonary atheroma, 
 acute congestion and oedema. 
 
FATTY HEART. 371 
 
 Treatment. — The therapy is eminently causal and dietetic; alcohol, 
 tea and coffee, tobacco and cold baths are to be avoided and con- 
 stipation must be prevented. The symptomatic treatment and the 
 use of cardiants in the uncompensated stage are identical with the 
 indications in valvular disease. 
 
 ATROPHY OF THE HEART. 
 
 Atrophy of the heart presents more pathological than clinical 
 interest. 
 
 Etiology. — The heart is at times congenitally weak and small. It 
 may then be associated with small vessels, chlorosis (Yirchow) or 
 with hypoplasia of the genitalia (Rokitansky) . Pressure atrophy, 
 coronary sclerosis, pericarditic adhesions, the senile involution and 
 cachectic diseases are the most frequent causes. Anatomically, the 
 heart is reduced in size and weight (even to 1-J ounces), the subperi- 
 cardial fat disappears, the pericardium wrinkles, the coronary arteries 
 are tortuous and the heart muscle is pigmented. The valves, espe- 
 cially the aortic, may waste. The atrophy may be partial, as that 
 of the left ventricle in some cases of mitral stenosis. 
 
 The symptoms are indeterminate, and the diagnosis impossible. 
 
 FATTY HEART, 
 
 Etiology and Pathology. — Fatty heart is no distinct pathological nor 
 clinical entity. Two forms are recognized, (1) fatty infiltration 
 and (2) fatty degeneration. 
 
 1. Fatty Infiltration (Lipoma cordis capsulare, Yirchow). — 
 This form consists of invasion of the heart muscle by the subpericar- 
 dial fat, which is normally found about the heart, in furrows, at the 
 tips of the ventricles and around the basal vessels. The fat extends 
 in parallel lines between the muscle fibers, which it may wholly re- 
 place. The fatty infiltration was considered primary by von Leyden ; 
 Striimpell believes muscle atrophy is primary and fatty infiltration 
 secondary ; Eosenbach holds that fatty infiltration and muscular atro- 
 phy are secondary to a common nutritive disturbance. The fat, 
 which develops most in the outer layers of the myocardium, may reach 
 to the endocardium. Fatty infiltration is most common in obese 
 males over forty years of age. It may occur after the menopause or 
 in sterile women. Plethora, high living, excessive use of alcohol 
 and heredity are factors. The heart is reduced 25 per cent, in 
 weight compared with the body-weight (Hirsch). 
 
 2. Fatty Degeneration. — This form is caused by deficient oxy- 
 genation which is either (a) general, resulting from acute infections, 
 old age, cachexia, marasmus, anaemia, poisons as phosphorus, chloro- 
 form or mercury and from loss of fluids; or (7;) local or cardiac, 
 from pericarditis ; coronary disease, which more frequently produces 
 myofibrosis; and from cardiac failure following hypertrophy. Most 
 
372 DISEASES OF THE CIRCULATION. 
 
 degeneration occurs in the left heart. The fatty heart is large and 
 flabby; it is yellow-brown — the "faded leaf" color of Laennec; the 
 splashes and streaks of fatty degeneration contrast with the normal 
 areas, giving the variegated " tiger " or " tabby-cat " appearance ; oil 
 globules are found in rows in the muscle fibers and may replace them 
 in part or in whole. Frequently the muscle fibers appear dry and 
 granular ("albuminoid" degeneration), probably the first step in 
 fatty degeneration. The striations of the muscle disappear later, 
 its consistence is decreased and its substance is friable. 
 
 The extent of the process is in direct ratio to the intensity of nutri- 
 tive alteration; parenchymatous and fatty degeneration are observed 
 in those segments of the heart where the greatest work and the most 
 nutrition are demanded, as in the papillary muscles of the mitral 
 valves and where pressure is greatest, viz., the interventricular sep- 
 tum and left conus arteriosus. In embryonal life, these conditions 
 obtain in the right heart. The early investigations of von Leyden and 
 those of more recent date by Gobel have determined that these 
 changes are first focal and later diffuse. 
 
 Symptoms and Signs. — No symptoms are characteristic. Extensive 
 fatty changes may occur without clinical symptoms, as in perni- 
 cious anaemia. Leube details a case without symptoms in which 
 the apex was completely fatty. In some obese subjects, cardiac em- 
 barrassment develops with dyspnoea, palpitation, a somewhat charac- 
 teristic wheezing, etc. The autopsy may reveal fatty heart, but far 
 more frequently myocarditis, idiopathic hypertrophy or coronary 
 disease is found; i. e., there is no uniformity in the pathological 
 findings, nor parallelism between them and the clinical signs. 
 Though percussion of obese individuals is difficult, the heart is found 
 dilated. In fatty heart, the tones are weak and distant though pure, 
 the apex beat is weak, diffuse or absent, and sometimes an apical 
 systolic murmur is heard, due to irregular systolic vibration. Gallop- 
 rhythm is heard when the heart is fatigued. The pulse may be rapid 
 from brain anaemia ; it may be somewhat dicrotic, small and arrhyth- 
 mic. Low temperature, sweating and bronchitis are common. 
 
 Much stress was formerly laid on the Adams-Stokes' syndrome, a 
 triad of symptoms including (a) sl slow pulse, even 14 to the minute, 
 due to ischsemic stimulation of the vasomotor centre or to heart 
 changes, and followed by (b) pseudo-apoplectic seizures, unconscious- 
 ness, temporary paralysis or convulsions (pseudo-epilepsy), which 
 are clearly dependent on cerebral anaemia, for one of Stokes' cases 
 warded off these attacks by assuming the genupectoral position ; and 
 (c) Cheyne- Stokes' respiration, in which respiration becomes slower, 
 and is followed by a period of apnoea lasting a half minute or more, 
 with respiration gradually returning to the normal. Narcotics in- 
 crease or induce the condition. The pupils narrow during the apnoeic 
 period and muscular twitching is common. This triad is observed 
 in uraemia, cholaemia and diseases of the vagus and medulla, as well 
 as in heart disease. It seems likely that in Stokes' case the brain 
 
ACUTE MYOCARDITIS. 373 
 
 was also diseased. The syndrome is based on the bradycardia which 
 appears to be most frequent in disease of the bundle of His (see 
 Bradycardia, Cardiac Neuroses ). 
 
 Diagnosis. — The diagnosis is uncertain. Fatty heart may cause no 
 symptoms, or the symptoms observed in the obese may be due to other 
 lesions. Apparently increased dulness is often due to mediastinal 
 obesity. The main point is to exclude valvular lesion and confine 
 the diagnosis to a myocardial affection {v. Myocarditis). 
 
 Prognosis. — The prognosis depends upon the cause. It is grave in 
 diabetic or arteriosclerotic subjects, or when coronary disease, angina, 
 lung oedema or an irregular or very slow pulse intervenes. Sudden 
 death is not uncommon from acute dilatation, pulmonary embolism, 
 brain anaemia or hemorrhage, " heart block " (described under brady- 
 cardia), or rarely from heart rupture. 
 
 Treatment. — The treatment is that of obesity in fatty infiltration, 
 but distinction must be made between (a) obesity with ancemia, in 
 which the subject is obese and pale, with cold extremities, much 
 sweating, scanty urine, weak and easily fatigued muscles and dysp- 
 noea; and (b) obesity with plethora, in which the color is red, the 
 urine increased and uratic, the heart stronger, the muscles fairly 
 developed and exercise possible with little dyspnoea. Schott's treat- 
 ment is beneficial in the first type, and Oertel's method in the latter 
 (see Dilatation" of Heart). Saline cathartics, total abstinence 
 from alcohol and the use of potassium iodide for general or coronary 
 sclerosis are indicated. The brain anaemia and the sudden syncope 
 are met by the aethereal alcoholics. Cardiac insufficiency is treated 
 as in uncompensated valvular lesions and dilatation. Morphine 
 should be used with great circumspection. 
 
 ACUTE MYOCARDITIS. 
 
 Etiology and Pathology. — Acute myocarditis is of the greatest clini- 
 cal and prognostic importance. 
 
 Acute diffuse parenchymatous myocarditis corresponds to granular 
 and fatty degeneration (v. i.) ; to the " mushroom" heart of Stokes 
 (described under Typhus) which, when held inverted by the base, 
 would fall like a cap over the hand ; and also corresponds to the " soft- 
 ened heart " of Laennec and Louis. 
 
 Acute diffuse interstitial myocarditis has been most studied of late 
 years, while formerly the degenerations attracted most attention. 
 Eound cells are found in the interstitial tissue, with or without mus- 
 cular alteration, such as vacuolization, nuclear multiplication, pig- 
 mentary deposit, blood extravasations and waxy changes. It was 
 first discovered by Leyden in scarlatina ; it is found in a very large 
 percentage of cases of diphtheria and typhoid by Ehomberg; it also 
 occurs in acute endocarditis and rheumatism (10 to 20 per cent.), 
 less frequently in other infections. Though the typhoid bacillus, the 
 gonococcus and Bacillus pyocyaneus have been found in the myocar- 
 dium, they are chiefly important as causing toxaemia. 
 
374 DISEASES OF THE CIBCULATION. 
 
 H. Martin found inflammatory thickening of the intima in the cor- 
 onary radicles and Rhomberg a perineuritis in one-half of typhoid 
 and diphtheria autopsies. Virchow, Hay em and Renault hold that 
 inflammation is primary and degeneration secondary; Weber, Blind 
 and others regard the process as degenerative. 
 
 Symptoms and Signs. — During the progress of an acute infection 
 the heart's strength decreases; its tones, especially the first mitral, 
 become fainter. There is often a marked presystolic impulse; the 
 apex is less distinct and is dislocated somewhat to the left by dilata- 
 tion; and the pulse grows weaker and more irregular. Vasomotor 
 relaxation is a very important element in the heart failure. Gallop- 
 rhythm and embryocardia develop, and there is usually a relative, 
 muscular, mitral leakage. Cardiac pain may be severe. These 
 changes may develop during the infection, as is the case in typhoid, 
 scarlatina and rheumatism ; or they may occur two to ten weeks after 
 the infection, as in 15 per cent, of diphtheria cases. Sudden death 
 without symptoms may occur during convalescence. Rheumatic myo- 
 carditis often leads to chronic fibrous myocarditis. 
 
 Diagnosis. — The etiology is important ; acute myocarditis is distin- 
 guished with great difficulty from acute endocarditis (q. v.). 
 
 Treatment. — Prophylaxis. — Hydrotherapy is indicated in typhoid 
 and antitoxin in diphtheria; the patient should have absolute rest 
 well into convalescence, because sudden heart insufficiency or unex- 
 pected death may follow effort, difficult defecation or other exertions. 
 Sexual intercourse should be forbidden. The heart must be carefully 
 watched in every convalescence. See therapy of Typhoid, Diph- 
 theria and Pneumonia. Cardiants are indicated as in valvular 
 incompetency. 
 
 I. Acute Circumscript Myocarditis.^ — Acute circumscript myocar- 
 ditis (the disease of gladiators, Galen) is usually a form of sepsis, 
 and its embolic heart foci are usually multiple. It is usually caused 
 by the pyogenic organisms. The issues are (a) resorption with fib- 
 rosis, (b) caseation or calcification and (c) rupture into the pericar- 
 dium or into the heart cavity, thus producing " heart ulcers " and pul- 
 monary or arterial embolism, heart aneurysm or abnormal communi- 
 cations between the chambers. Sudden valvular insufficiency is some- 
 times suggestive, though it is usually impossible to make a diagnosis. 
 The treatment is that of the fundamental septicopyemia and the 
 resulting cardiac insufficiency. 
 
 II. Fragmentation of the Heart Muscle. — Fragmentation of the 
 heart muscle (Zenker, Yirchow, Rindfieisch, Coats, Renault and Lan- 
 douzy) occurs in two forms (a) segmentation or separation from 
 each other of the heart fibers, and (b) fragmentation or rupture 
 across the normal or degenerated muscle fibers. It has also been 
 called segmentary myocarditis, and though it most frequently occurs 
 in death from violence, it may have some clinical significance in sud- 
 den or gradual heart weakness (see Myolysis under Diphtheria). 
 
CtitiOtilC MYOCARDITIS. 375 
 
 CHRONIC MYOCARDITIS (CHRONIC FIBROUS OR INTERSTITIAL 
 MYOCARDITIS, MYOFIBROSIS CORDIS). 
 
 Etiology and Pathology. — Chronic myocarditis is rarely a disease 
 sui generis, and the term is somewhat ill-chosen. It is a sequel of 
 some previous retrogressive lesion — a secondary process. It compen- 
 sates for destruction of heart tissue, and is in itself a measure of 
 that loss. It is more often a fibroid degeneration than an inflamma- 
 tion. The longitudinal incision of the heart muscle discloses the 
 scar-like tissue which is often unseen in the ordinary transverse 
 sections (Koster and Ruhle). This tissue is seen most frequently 
 in the lower two-thirds of the anterior wall of the left ventricle and the 
 upper two-thirds of its posterior wall near the auricle, as glistening 
 sunken areas under the pericardium or endocardium. It also occurs 
 in the papillary muscles or interventricular septum. The scars 
 appear as streaks, flecks or stellate plaques, sometimes measuring . 
 three or four centimeters, or more. The foci may be macro- or micro- 
 scopic, circumscribed or general. Gross changes in the heart include 
 the following: 
 
 1. Hypertrophy. — This is vicarious and occurs when the fibrosis 
 is not great. The relation is two-fold; (a) hypertrophy often com- 
 pensates for moderate muscular destruction and maintains the heart ; 
 or (b) fibrosis develops in tired hypertrophied hearts. Hypertrophy 
 is inversely proportional to the number of scars. 
 
 2. Dilatation. — This follows extensive fibrosis and decreased 
 power to resist pressure. Fibrosis of the tissue can neutralize dilata- 
 tion to some extent, and is therefore a conservative agent. 
 
 3. Atrophy of the Myocardium. 
 
 4. Valvular Disease. — Valvular disease and myocarditis are in- 
 directly associated. A relative mitral insufficiency may follow 
 myocarditis in the mitral papillary muscles (Hamernjk). Dittrich 
 first described the genuine heart-stenosis, a cicatricial contraction of 
 the left conus arteriosus in the adult, or of the right conus in the 
 foetus, following myocarditis at those sites. Relative aortic insuffi- 
 ciency may follow enormous dilatation and myocarditis of the left 
 ventricle (personal observation). 
 
 5. Partial Heart Aneurysm aistd Heart Rupture. — Partial 
 heart aneurysm, a localized bulging of the heart wall, is seen largely 
 near the apex (left ventricle, 68 per cent, of cases, Pelvet), where 
 .acute myomalacia cordis or chronic fibrosis occurs most frequently; 
 it is seen more rarely at the base or in the interventricular septum 
 which may bulge into the right heart; and it occurs most infre- 
 quently in the right ventricle or auricle. The heart aneurysm is 
 usually small, but may equal the size of the heart ; it is usually single 
 (though four were found by Thurnam), and may communicate with 
 the heart cavity by a neck-like constriction ; its walls consist of con- 
 nective tissue which is rarely ossified, as in Corvisart's case ; it often 
 contains thrombi and is adherent to the pericardium. In unfavor- 
 
376 DISEASES OF THE CIECULATIOX. 
 
 able cases it ruptures or tears loose a valvular attachment. During 
 twenty years ending in 1903, D. G. Hall found 112 cases recorded 
 (26 had aneurysm in the valves, and 25 in the coronary vessels) ; 
 Volker alone made a diagnosis. Rupture of the heart occurs through 
 the left ventricle (80 per cent.). 
 
 Pathogenesis. — The most frequent cause is disease of the coronary 
 arteries, which are incessantly active and are end-arteries, and anasto- 
 mose with each other only through their capillaries. The vessels 
 of Thebesins, entering the muscle from the auricles and ventricles 
 may carry on some collateral circulation when the coronary arteries 
 are occluded. Coronary narrowing may be gradual, by obliterative 
 endarteritis or by the occlusion of the vessel from an atheromatous 
 plaque in the aorta; or it may be sudden and fatal by embolism or 
 thrombosis in an already narrowed vessel. The most common loca- 
 tion for coronary obstruction is in the left ventricle ( anterior coron- 
 ary artery which is relatively small) and in the interventricular 
 septum. In acute coronary obstruction, the heart muscle becomes 
 isehamiic, pale and opaque and the necrotic area becomes swollen 
 and prominent (coagulation necrosis) ; a wedge-shaped anaemic in- 
 farct is less common. The muscle fibers become fragmented, lose 
 their nuclei and disappear : this process may lead to rupture of the 
 heart or sudden death. Ziegler named it myomalacia cordis. If 
 the subject lives, scar-tissue develops — a dystrophic sclerosis. Such 
 " myocarditis " is not inflammatory. Huchard employs the terms, 
 arteriosclerosis of heart and arterial cardiopathy, to emphasize the 
 causal role of arterial disease. Coronary arteritis most frequently 
 runs a subacute or chronic course. Its causes are those of arterio- 
 sclerosis (q. w.). A less frequent cause is actual chronic myocarditis 
 following acute myocarditis due to rheumatism, typhoid or diphtheria. 
 French writers describe an acute endarteritis following acute infec- 
 tions and leading to myofibrosis. Koster, Ruble and others have 
 found myocarditis in valvular disease. Dehio holds that myocarditis 
 or myofibrosis, is a result of dilatation, that it occurs where the mus- 
 cle is destroyed and is therefore a necessary and protective process, 
 conforming with Thoma's conception of arteriosclerosis (q. v.). 
 
 Symptoms. — (a) In the latent type there are no symptoms and 
 sudden apoplectiform death occurs, while the subject is apparently 
 in perfect health, (b) Most cases present chronic symptoms of car- 
 diac insufficiency. The cervical veins are enlarged and there is 
 general venous congestion. The pulmonary circulation suffers espe- 
 cially, as is shown by cyanosis, duskiness of the skin, infarcts which 
 are often large (Ruble), hydrothorax, oedema of the lungs, bronchitis 
 and by dyspncea which is often nocturnal or develops on exertion. 
 The heart symptoms are precordial oppression or dull pain, palpita- 
 tion, cardiac asthma or genuine angina pectoris. Examination of 
 the heart sometimes gives negative results, but dilatation and hvper- 
 trophy are usually present (cardiomegalia). The heart tones at first 
 are often clear, but later become faint and irregular, so that in the 
 
CHEONIC MYOCARDITIS. 377 
 
 resulting delirium cordis, the tones are disorderly and the phase of 
 the murmur, due to relative muscular insufficiency or to arterio- 
 sclerotic dilatation, cannot be distinguished. The second pulmonic 
 sound is accentuated or split and the second aortic tone is weak, be- 
 cause the arterial tension is low. The pulse is usually irregular 
 (Kuhle, Kiegel, Bard, Phillippe), either from the beginning or 
 becoming so later, with paroxysms of arrhythmia which may be 
 an extension of the degeneration and sclerosis. Irregularity usually 
 precedes the cardiac insufficiency and persists during restoration of 
 compensation. A regular pulse may be present throughout (Ebstein 
 and Eenoy), or a number of regular strong beats is followed by a 
 wave of rapid tumbling heart action. Simple intermission and the 
 pulsus bigeminus are also seen. The pulse rate is often slow at first, 
 and gradually increases to 90 or 100, with ominous crises of tachy- 
 cardia. In some instances the pulse is persistently slow and is 
 associated with syncope from brain ansemia (v. i. Bradycardia). 
 It is seen, then, that the rate and rhythm of the pulse vary, and 
 though irregularity is of important diagnostic value there is no 
 constancy in the pulse findings. 
 
 (Edema is present, but as a rule is less common and intense than 
 it is in valvular disease (q. v.). Embolism may occur. Digestive 
 disturbances are almost constant (Buhle), and Huchard maintains 
 that they have an important bearing on the heart's action ; alimentary 
 autotoxgemia from carelessness in diet, may cause paroxysmal cardiac 
 symptoms. Potain and Barie hold that digestive disorders induce a 
 reflex contraction of the lung vessels and thus lead to dyspnoea. The 
 urine is that of stasis in the later stages, but early in the disease poly- 
 uria may prevail from high blood pressure. Renal insufficiency may 
 lead to renal toxaemia (Houchard). 
 
 Diagnosis. — There are irve cardinal points : (a) In the majority of 
 cases arteriosclerosis is most important. Its causes should be sought 
 in the anamnesis and the peripheral arteries and aorta should be 
 examined for its usual signs {q. v.). Arteriosclerosis is usually gen- 
 eral, but may exist in the heart without being seen in the radial 
 arteries, and the converse is also true, (b) The heart is usually di- 
 lated and hypertrophied ; i. e., its transverse measurement is in- 
 creased, (c) No valvular murmur exists, in uncomplicated cases. 
 The systolic apical murmur of arteriosclerotic dilatation may be 
 heard or the soft variable bruit of relative mitral leakage, which 
 often disappears with rest and catharsis, (d) The pulse is fast and 
 irregular. A regular pulse does not absolutely exclude myocarditis. 
 Arrhythmia, whether congenital, neurasthenic or caused by tobacco, 
 must be excluded, (e) Dyspnoea and pulmonary stasis are suggestive. 
 
 Differentiation is often so difficult that many clinicians limit the 
 diagnosis to muscular insufficiency; for fatty heart, idiopathic hyper- 
 trophy and dilatation, or pericardial adhesions may be found at 
 autopsy instead of the anticipated myocarditis. Sometimes when 
 myocarditis is suspected, the heart shows nothing microscopically or 
 
378 DISEASES OF THE ClBGVLATlON. 
 
 macroscopically, thus demonstrating that the causes of heart failure 
 are often beyond detection by the microscope. A diagnosis is 
 made by exclusion, and then is often only a " probability diagnosis." 
 In distinguishing myocarditis from the " heart of renal disease," long 
 observation, the gallop-rhythm (more common in the cor renale) and 
 ursemic manifestations are helpful. Myocarditis and renal disease 
 are frequently associated. From mitral stenosis: Both lesions cause 
 irregularity and a weak radial pulse and apex beat; when the pre- 
 systolic stenotic murmur is absent, the loud second pulmonic sound, 
 the loud snapping apical tone and the wide right heart are most 
 suggestive of mitral stenosis. Digitalis very frequently fails to act in 
 myocarditis. From cerebral apoplexy: The sudden " stroke " or " car- 
 diac apoplexy" of coronary disease may be the first sign of myo- 
 cardial disease and may be mistaken for cerebral apoplexy or em- 
 bolic processes ; the autopsy, in cases of sudden death often discloses 
 coronary closure with myomalacia cordis or fibrous myocarditis. 
 
 Prognosis. — The prognosis is that of uncompensated valvular lesions 
 with the extra consideration that the muscle itself and its nutrient 
 arteries are involved. Because of the facts that digitalis is often 
 inefficient in these cases, and that angina pectoris, cerebral anaemia, 
 heart rupture or coronary closure may occur, the outlook is most 
 unpromising. Some patients, especially elderly subjects, may live a 
 decade or more, until intercurrent pneumonia or another secondary 
 affection causes their death. Early digestive symptoms are less 
 favorable than early oedema or congested liver. 
 
 Treatment. — The therapy is (a) that of the causal factor, arterio- 
 sclerosis (q. v.) being the most common cause. Potassium iodide 
 relieves pain and lessens the atheroma ; it should be given in doses of 
 5 to 10 grains after meals, freely diluted in milk or water — 
 
 J$. Potassii iodidi . 3iiss. 
 
 Syr. sarsaparillse co ^iv. 
 
 M. et S. — One teaspoonful in a glass of water after meals. 
 
 (b) Dietetic; stimulants should be used carefully and overexertion 
 and excitement should be avoided, (c) The Schott treatment (v. s.). 
 (d) Cardiants. Digitalis is beneficial in the early stages — less so in 
 advanced cases. It is to be avoided when the pulse is slow. Strych- 
 nine is frequently valuable. When there are anginal seizures or 
 hard vessels, nitroglycerine should be given (see Therapy of Val- 
 vular Disease). Caffeine, camphor, morphine and alcoholics should 
 be administered for cardiac asthma. 
 
 RUPTURE OF THE HEART. 
 
 Etiology. — (a) Spontaneous rupture is practically unknown, (b) 
 Rupture through the altered heart muscle occurs in myocarditis ; heart 
 aneurysm, in which case it may even perforate the chest wall ; myo- 
 malacia cordis from coronary atheroma and embolic occlusion; 
 
TUMORS OF TBE BE ART. 379 
 
 coronary aneurysm; fatty heart, abscess, gumma or neoplasm of the 
 heart, ulcerative endocarditis, obstructive valvular disease and sten- 
 osis of the isthmus of the aorta. It occurs largely in men over sixty 
 years of age. It may occur during sleep or may be caused by trauma, 
 vomiting, great effort, excitement, delivery, coitus or by the abuse of 
 digitalis. Kroll collected 332 cases of rupture of the heart. 
 
 Pathology and Symptoms. — (a) Partial rupture of the valves in- 
 duces sudden valvular insufficiency, (b) Total rupture of the heart 
 is usually single, though a case having five rents is recorded, and 
 takes place in the left ventricle (80 per cent.) where the pathological 
 factors come most into play. Sudden death may occur without pro- 
 dromes, or death may result after a few hours to eleven or seventeen 
 days. The symptoms are a sense of something giving way in the 
 chest, great precordial pain, incoercible vomiting or diarrhoea, cere- 
 bral anaemia or irritation of the vagus from haemopericardium, col- 
 lapse and death from pressure of the blood on the heart or the venae 
 cavae (Cohnheim). Haemopericardium (q. v.) may be suspected 
 because of greatly increased triangular dulness, faint heart tones 
 and absent or weak apex beat within the left border of the dulness. 
 
 Diagnosis and Treatment. — The diagnosis is rarely made. It de- 
 pends on (a) the etiology, (b) increased dulness, (c) cardiac insuffi- 
 ciency and (d) symptoms of internal hemorrhage. The outlook is 
 bad and the treatment wholly symptomatic; the most absolute rest 
 should be enforced. 
 
 Heart injury was first operated on by Farina (1896). The first 
 cardiorrhaphy for rupture was by Rehn (1897). Frazier (1906) 
 collated 102 "operations for injury, of which 42 per cent, recovered. 
 
 Disease of the Coronary Arteries. — This has been sufficiently con- 
 sidered under myocarditis (heart aneurysm) and rupture of the 
 heart. It will be considered again under angina pectoris, which 
 anatomically belongs to disease of the heart muscle though it is usu- 
 ally described under cardiac neuroses. 
 
 TUMORS OF THE HEART. 
 
 These are most rare because the heart is rather insusceptible even 
 to neoplasms in its immediate vicinity. They cannot be diagnosti- 
 cated. Carcinoma and sarcoma are the most frequent, and lipoma, 
 myxoma, fibroma and myoma are infrequent. They are usually sec- 
 ondary. Cardiac insufficiency, valvular compression or embolism 
 sometimes develops. 
 
 Parasites are most often accidental postmortem findings. In 
 Hosier's monograph echinococcus is the most frequent and occurs 
 twice as often in the right ventricle as in the left. Grulee (1905) 
 collected 55 cases of echinococcus of the heart. Cardiac rupture, 
 sudden death from occlusion of the pulmonary trunks, relative pul- 
 monary insufficiency or cardiac incompetence may occur. The 
 cysticercus, the pentastomum and trichina are of purely anatomical 
 interest. 
 
380 DISEASES OF THE CIRCULATION. 
 
 SYPHILIS OF THE HEART (See Syphilis). 
 CARDIAC THROMBOSIS— THROMBOSIS CORDIS. 
 
 This usually occurs at the time of or after death, and is of little 
 clinical interest. 
 
 Symptoms. — (a) Entire latency, (b) Thrombosis sometimes de- 
 velops during life and leads to pulmonary or arterial embolism, (c) 
 Sudden cardiac weakness. (d) Sudden valvular stenosis, a ball 
 thrombus (kugelthrombus) forming in the auricle, and occluding, for 
 instance, the mitral orifice ; it is beyond clinical recognition, although 
 according to von Ziemssen, it is frequently associated with gangrene 
 of the lower extremities ; in Curschmann's case an ascites resembling 
 chronic peritonitis was the sole finding. 
 
 DISEASES OF THE ENDOCARDIUM. 
 
 ENDOCARDITIS. 
 
 Definition. — Inflammation of the endocardium. Its clinical im- 
 portance attaches to the fact that chiefly the valves of the heart are 
 involved. Two main varieties are distinguished, the acute and the 
 chronic. Known to Morgagni and Boerhaave, Bouillaud, in 1840, 
 first placed the disease on a scientific basis. 
 
 I. Acute Endocarditis.- — This is always a secondary ,' general dis- 
 ease, and is mycotic in origin, excepting atheromatous endocarditis. 
 Two main clinical varieties are described: (a) Malignant or ulcera- 
 tive endocarditis, and (b) simple or verrucose endocarditis. They 
 differ only in degree, and the term benign is only relative, as most 
 endocarditides entail serious sequels. Litten divides endocarditis 
 into (a) the benign forms produced by rheumatism, chorea, gonor- 
 rhoea, scarlatina, measles, variola, typhoid, diphtheria, pneumonia, 
 etc.; and (b) malignant, (i) non-suppurative and (ii) suppurative 
 or septicopyemic. 
 
 (A). Malignant Endocarditis. — This variety is also known as ul- 
 cerative or septic. 
 
 Etiology. — The heart lesion is either (1) secondary to some clearly 
 causal infection or disease; or (2) crypto genetic, when the causal 
 infection is not apparent, but care in examination and at autopsy 
 usually reveals the cause. The atrium, bacteriology, mode of ex- 
 tension and symptoms are described under Septic Infections. 
 
 The disease is more common in women than in men, even excluding 
 puerperal infections ; it is most frequent between the years of twenty 
 and forty. Its frequency is 2 per one thousand patients. Seventy- 
 five per cent, of cases develop upon an old valvular lesion by which 
 the local physiological resistance is lessened. The literature contains 
 11 cases developing at a patent ductus Botalli (Hart, 1904). 
 
ACUTE ENDOCABDITIS. 381 
 
 Pathology. — Malignant endocarditis most often involves the left 
 heart, because it is far more frequently the seat of previous lesions 
 and its arterial blood favors the growth of microorganisms, although 
 the right heart is involved more frequently than it is in other types of 
 endocarditis. Lenhartz found the left heart affected in 86 per cent., 
 the right in 12 per cent, and both sides in 2 per cent., of his cases. 
 
 Though the process may involve the walls (parietal or mural endo- 
 carditis), it most frequently attacks the valves (valvular endocard- 
 itis), which are often already indurated by previous simple endo- 
 carditis, are most washed by the circulating blood and are subject to 
 greater mechanical activity. The endocardium becomes opaque, and 
 irregular deficits occur on the under surface of the aortic or the 
 auricular surface of the mitral valves; later there is injection of the 
 endothelial coat and a grayish deposit. Exudation is abundant on 
 the mitral valves, but is late or scanty on the less vascular aortic or 
 pulmonary valves. Thrombi and excrescences develop on the erosions, 
 whose removal discloses subjacent ulceration. The thrombi, espe- 
 cially in pneumococcic and gonococcic infections, consist of lamel- 
 lated fibrin and bacteria. The vegetations may attain the size of a 
 walnut and often extend from one valve to another by contact infec- 
 tion; some thrombi are purely mechanical deposits of fibrin, but 
 genuine endocarditis is always mycotic. Heiberg first found micro- 
 organisms (1869) and Weichselbaum first obtained pure cultures. 
 Efforts to classify endocarditis by the bacteriological findings are 
 more or less impracticable (v. i.). The following bacteria have been 
 found: Streptococcus, staphylococcus, pneumococcus, less frequently 
 the gonococcus, colon, diphtheria, influenza, tubercle and typhoid 
 bacillus, meningococcus and, very exceptionally, other bacteria. The 
 same organism may produce either the benign or malignant form. 
 Experimental endocarditis (Wyssoko witch, Ribbert, Koster) has 
 been produced by inoculations of various organisms, usually after 
 wounding the valves by a sound introduced through the cervical 
 vessels, but also without trauma. The pyogenic organisms are said 
 to attack more frequently the mitral, and the pneumococcus rather 
 selects the aortic valves. The mitral valves in general are more 
 often involved than are the aortic. The process may invade the aorta, 
 the pulmonary artery or the lung. Destructive changes by ulcera- 
 tion through one leaf of the valve may produce acute valvular 
 aneurysm, which, when aortic, projects toward the ventricle, and 
 when mitral, projects toward the auricle. If the necrosis destroys 
 both lamellae of the valve, the perforation leads to valvular insuffi- 
 ciency. Ulceration of the chordae tendineae or papillary muscles 
 also produces valvular insufficiency; necrosis of the parietes results 
 in a " heart ulcer," which sometimes leads to communication between 
 the ventricles or to rupture of the heart. Dislodgment of tissue 
 particles, thrombi or bacteria occurs frequently, and usually in the 
 arterial circuit. The effects vary with the location of the infarct 
 (see Symptomatology) and with the character of the microbes ; i. e., 
 
382 DISEASES OF THE CIRCULATION. 
 
 emboli act mechanically and infectively. Streptococci are said to 
 produce anaemic infarcts, while staphylococci result in suppuration. 
 Pathological changes in other organs are those of (a) general sepsis, 
 such as parenchymatous degeneration or splenic tumor, (b) em- 
 bolism, mechanical or infective, (c) stasis when the heart fails and 
 (d) the primary disease. 
 
 Symptoms. — The clinical features vary to such an extent, according 
 to the basic disease, the visceral involvement by embolism and the 
 virulence of the microorganisms, that a general description is im- 
 possible. The onset may be violent or most insidious. The autopsy 
 findings in the latent cases may be surprising, as, for example, the 
 discovery of a mural gonorrheal endocarditis in a case of septico- 
 pyemia. In the majority of cases, the septic element prevails. The 
 various types, artificial though convenient for description, are: 
 
 1. The Typhoid Form. — The toxemic symptoms, such as apathy, 
 delirium, dry tongue, distended abdomen, diarrhoea and splenic tu- 
 mor are suggestive of typhoid. The resemblance may be heightened 
 by hemorrhage of the bowels, rose-like spots and the diazo reaction. 
 Dilatation of the right heart and cardiac murmurs, so important in 
 endocarditis, are not uncommon in typhoid. But at this point certain 
 variations arouse doubt ; there is no Widal and no typhoid bacillemia 
 and certain septic symptoms or cardiac signs come to the front. In the 
 skin, embolism appears as spots with a white or yellow centre and hem- 
 orrhagic periphery, or as pemphigus, gangrene or suppurative foci. 
 Analogous areas may be seen in the upper air-passages. Infarcts 
 sometimes occur in the conjunctiva, but in the retina, simple hemor- 
 rhage or actual infarcts with yellow centres are frequently detected. 
 The entire eyeball may suppurate. The frequent splenic infarction 
 is characterized by sudden pain, tenderness, enlargement and some- 
 times perisplenitic friction. Embolism is often accompanied by 
 fever, chill and vomiting. Renal infarction is very frequent, and is 
 attended by pain in the loins, hematuria, albuminuria and some- 
 times anuria or dysuria. Severe nephritis is common. Cerebral 
 embolism usually occurs in the left Sylvian artery and results in the 
 usual stroke and hemiplegia with aphasia. Pulmonary infarcts are 
 caused by lesions of the right heart or by auricular thrombi, and 
 occasion sudden pleuritic pain, dyspnea, hemoptoe, temperature and 
 possibly a small area of crepitant rales, pleural friction or consoli- 
 dation. Embolism also occurs in the liver, in the mesenteric artery 
 (with enterorrhagia and peritonitic symptoms), in the muscles and 
 joints, testes and parotid ; in the heart and the various mucose ; in the 
 meninges, pleure, pericardium, peritoneum and in the peripheral 
 arteries, sometimes causing gangrene or embolic aneurysm. The 
 pneumococcus is often the cause of this type. 
 
 The course may be per acute (two to four days), acute (a few 
 weeks) or chronic (several months). Death occurs from the septic 
 typhoid state, from embolism, or from cardiac failure. 
 
 2. The Septic ok Intermittent Type. — This form has an ir- 
 
ACUTE ENDOCARDITIS. 383 
 
 regular fever-curve, with chills and drenching sweats, and the spleen 
 is enlarged. Heart symptoms may be absent or indeterminate, the 
 moderate relaxation of the right heart and the murmur often being 
 called functional. The paroxysms are more irregular than in malaria 
 and no response to quinine is obtained. Sepsis is considered but the 
 localization is not immediately determined. The streptococcus is 
 often causal. Cardiac findings, embolism or clearly septic mani- 
 festations may establish the diagnosis. The course is usually several 
 weeks but may cover several months to even a year. 
 
 3. The Visceral Forms. — These forms embrace the cases in 
 which some one organ is especially involved. In the cardiac form, 
 anaemia exists and the heart murmur seems accidental, until a typical 
 valvular lesion develops, or, if one already be present from older 
 valvular disease, until another appears, as a diastolic following a 
 systolic murmur. The diagnosis may be difficult even when chronic 
 valvular disease is present. In the cerebral form, meningitis, apo- 
 plexy, coma or psychoses may dominate the clinical picture. The 
 symptoms referable to any organ which is the seat of embolism (lung, 
 pericardium, etc.) may seem to indicate a primary disease. In this 
 way acute yellow atrophy, pernicious anaemia, tuberculosis, nephritis, 
 rheumatism, cholera, etc., have been incorrectly diagnosticated. 
 
 Special Symptoms. — (1) All types of fever, from intermittent to 
 continuous, have been noted, although it may be absent for a long 
 time. (2) The heart is always somewhat disturbed in its action, 
 cardiac unrest being common. Its action is usually more frequent, 
 but is quite variable, now being rapid, again slow and often irregu- 
 lar. The heart seems to beat harder and the pulse may throb, 
 although the irritable overaction is attended by low arterial tension. 
 The heart tones are dull. Palpitation is frequent. Cyanosis is not 
 common. (3) Respiration is always increased, from toxsemic centric 
 stimulation, pain or respiratory complications (septic pneumonia, 
 infarcts, pleurisy, pneumothorax, etc.). (4) The digestive tract may 
 be affected. Nausea, vomiting and diarrhoea may occur from the 
 general sepsis. Embolism has been mentioned. The liver is en- 
 larged, may be tender or may be the seat of friction. Icterus may be 
 marked, is ominous and is referable to duodenal catarrh or to over- 
 secretion of bile (polycholia). (5) The spleen is almost always 
 palpably enlarged from sepsis or embolism. (6) The urine shows 
 evidences of the sepsis or stasis by albuminuria, with or without cylin- 
 druria, and of the " blood dissolution " and embolism by hsematuria. 
 Malignant endocarditis may run a course similar to that of subacute 
 nephritis, which is present in 33 per cent, of all cases of the ulcerative 
 type. (7) The nervous system may be irritated or dulled by the 
 sepsis toxins, or embolic lesions, such as meningitis or encephalitis, 
 may intervene. (8) The muscles are frequently tender and actually 
 inflamed and may undergo suppuration. The bones are often tender 
 and the joints tender or swollen, although the swelling is more fre- 
 quently peri-articular than intra-articular. Bacteria are seldom 
 
384 DISEASES OF THE CIECULATION. 
 
 found, and this may heighten the resemblance to rheumatism. (9) 
 The skin may be the seat of embolism (v. s.) or of eruptions, such as 
 sudamina, erythema, purpura or polymorphous septic rashes from bac- 
 teria or their products in the circulation. Bullae, gangrene, phleg- 
 mons or bed sores are also observed. (10) The blood usually ex- 
 hibits marked anaemia ; when there are no heart findings, the anaemia 
 and splenic tumor have been confused with pseudoleukemia. The 
 leukocytes are often but not always increased. Bacteria may be 
 cultivated from the blood by modern methods of inoculation from a 
 large quantity of blood in much bouillon; the latter is considered 
 under Septicopyemia (q. v.). 
 
 Bacteriological Forms. — (a) Streptococcic Endocarditis. — The 
 streptococcus is the usual cause of rapidly fatal and of chronic ulcera- 
 tive endocarditis, both with severe repeated chills and high irregular 
 fever, (b) Staphylococcic endocarditis is less frequent. The course 
 is nearly always acute and is attended by high fever, pustules in the 
 skin, disseminated hemorrhages and septic infarcts, especially in the 
 kidneys, (c) Pneumococcic endocarditis (see Pneumonia) is usu- 
 ally acute; frequently follows pneumonia, less often cholecystitis; 
 begins with gradual fever rise associated commonly with chills ; and 
 is often attended by suppurative meningitis, (d) Gonococcic endo- 
 carditis (Picord, 1847) may result from Eeisser's coccus or from 
 mixed infection. Cases of recovery are instanced. 
 
 Diagnosis. — Bamberger's remark of half a century ago still holds: 
 " The diagnosis of acute endocarditis is seldom easy, usually difficult 
 and often impossible.'' Unless there are physical changes in the hearty 
 the diagnosis is only presumptive. A proper etiology, the presence 
 of an old valvular lesion, fever or other evidences of sepsis, signs of 
 cardiac insufficiency, such as blue nails, cold extremities, irregular 
 weak pulse with apparently strong cardiac shock and dilatation are 
 very suggestive and may be confirmed by continued observation, in 
 the course of which there may develop embolism, change in the valvu- 
 lar murmur and positive blood-cultures. Actual hypertrophy of the 
 heart not only requires time for development but adequate nutrition, 
 of which the disease seldom admits. The misleading visceral forms 
 have been discussed (v. s,). In 37 per cent, of cases, the heart is 
 negative, in 44 per cent, the murmur is systolic and in 5 per cent, 
 diastolic. Absolute certainty rests upon our ability to diagnosticate 
 by physical signs, the presence of a mitral regurgitation (q. v.) which 
 is the most frequent form, or of an aortic regurgitation (q. v.), plus 
 the signs of sepsis of which the disease is a part (" arterial pyaemia "). 
 (See Typhoid, differential table.) The valvular murmur may dis- 
 appear after embolism. 
 
 Diastolic murmurs are very rarely functional and their appearance 
 is therefore especially suggestive. Myocarditis may produce a sys- 
 tolic murmur, but is usually attended by marked early muscular in- 
 sufficiency, weak-heart shock and irregular pulse, weak systolic mur- 
 mur and a moderately accentuated second pulmonary tone. 
 
ACUTE ENDOCARDITIS. 385 
 
 Prognosis. — The prognosis is most unfavorable; Herrick (1902) 
 collected 22 cases of recovery. It depends on the strength of the 
 heart, the bacteriology, the number of infarcts and their location, 
 the variability of the heart murmurs (which may indicate danger of 
 embolism), and the intensity of the sepsis. Recovery from the gonor- 
 rheal form is relatively frequent. Musical murmurs with fever are 
 usually ominous. Apparently mild endocarditis may become severe. 
 The course may be rapid or severe, of a few days duration, or a 
 slower evolution of over a year. 
 
 Treatment. — (See Benign Endocarditis and Septic Infections.) 
 
 (B). Acute Verrucose or Benign Endocarditis. — This variety is 
 more frequent, constituting 1.5 per cent, of clinical cases, and is 
 always secondary. 
 
 Etiology. — (a) Rheumatism (q. v.) is the most frequent cause and 
 accounts for 60 to 85 per cent, of the cases. Over 20 per cent, of rheu- 
 matic patients develop endocarditis, particularly in the severe in- 
 fections. In children it is very frequent, for in them the heart 
 "resembles an articulation." Muscular rheumatism, angina or ery- 
 thema nodosum may occasion endocarditis. Chronic rheumatism 
 predisposes to it. (b) Chorea is frequently complicated by endo- 
 carditis (30 per cent, of clinical and 82 per cent, of fatal cases). 
 By some writers chorea is considered rheumatic but the majority hold 
 that it is only correlated, -(c) Of other specific infections, scarlatina 
 ranks first and causes 10 per cent, of the cases. Endocarditis is 
 far more uncommon after typhoid, diphtheria, tonsillitis, measles, 
 erysipelas, gonorrhoea, variola, grippe, tuberculosis, etc. (d) Occa- 
 sionally it is associated with trauma, burns, syphilis, cancer, Bright's 
 disease, gout or diabetes, (e) It is most common in males between 
 the years of twenty and thirty. 
 
 Pathology. — The vegetations, due to bacteria, are verrucose. wart- 
 like, papular or even pedunculated, are usually small and occur 
 at or above the lines of closure of the valves, whereby their function 
 is interfered with and valvular insufficiency or stenosis results. At 
 times the vegetations are cauliflower-like or resemble condylomata. 
 They are grayish, gelatinous and transparent; they become whiter 
 and firmer with age and consist of two strata, the deeper being gran- 
 ulating endocardium and subendocardial tissue and the superficial 
 layer consisting of thrombi from the coagulable elements of the blood. 
 The signs of active inflammation, such as redness or swelling, are 
 usually lacking, redness being sometimes confused with post-mortem 
 imbibition of haemoglobin from the blood. Vegetations must not be 
 confused with Albini's nodes, which are seen in infants and children. 
 The vegetations are at an early stage, quite cellular from leukocytic 
 exudation and tissue proliferation and usually contain bacteria (see 
 IJeceeative Type). The outgrowths becoming detached, emboli are 
 released and produce mechanical hemorrhagic or anaemic infarcts, 
 not suppurative infarcts as in the ulcerative type. The fate of the 
 vegetations is (a) embolism; (b) organization with the bare possi- 
 25 
 
386 DISEASES OF THE CIRCULATION. 
 
 bility of restoration to normal; (c) more often, organization with val- 
 vular lesions resulting from retraction, induration and calcification; 
 (d) being a locus resistentio? minoris, recurrent endocarditis may 
 be observed ; (e) the intensity of the inflammation may increase, lead- 
 ing to malignant endocarditis. 
 
 Location. — As in the first type, the vegetations are largely on the 
 same surface of the same valves and in the left heart, because of its 
 greater physiological activity and its arterial blood : these same 
 conditions in foetal life predispose to endocarditis of the right heart, 
 either on the valves or on foetal openings or defects. In general, 
 the mitral valves are most affected (50 per cent, of the cases alone 
 or 80 per cent, when combined with other lesions), next the aortic 
 (13 per cent, alone or 40 per cent, when combined with other lesions), 
 and far less frequently, the tricuspid, the pulmonary and the walls 
 of the heart, chorda? or parietes. 
 
 Symptoms. — The symptoms are not characteristic and a diagnosis 
 is impossible or only presumptive unless the valves are considerably 
 involved. Simple endocarditis therefore is found far more fre- 
 quently at autopsy than at the bedside; i. e., it is very often latent. 
 With such heart symptoms as increased rate or palpitation, it is diffi- 
 cult or impossible to determine whether they are caused by a valvular 
 lesion or a myocarditis, though the latter is the more likely cause. 
 Systematic daily examination of the heart in such diseases as rheu- 
 matism may reveal the gradual involvement of the endocardium, with 
 moderate fever and dyspnoea, cardiac unrest, oppression, palpitation 
 or insufficiency. Pain is more often pleuritic or pericardiac. The 
 diagnosis depends on the valvular bruit, which often follows muffling 
 or irregularity of the cardiac sounds, and is still later followed by 
 the signs of mitral or aortic insufficiency (q. v.). The infrequent 
 diastolic murmurs are more distinctive than the systolic, for they are 
 rarely functional. Emholism is very distinctive, as it is in the first 
 type, and is important mechanically rather than bacteriologically. 
 It also occurs in parietal endocarditis; embolism may be so minute 
 as to escape recognition. 
 
 Diagnosis. — Conservatism in making the diagnosis is necessary, 
 because acute benign endocarditis is much too often diagnosticated. 
 The most conspicuous symptom is fever, though it is not characteristic 
 and may blend with that of the causal disease; the most important 
 findings, objectively, are the signs of valvular heart disease : for these 
 findings, one must often wait, because in many cases the evolution, 
 alone, is final. More stress should be placed upon the results of 
 percussion than on the murmur itself. The murmurs are mistaken 
 for functional murmurs accompanying febrile relaxation of the heart- 
 chambers or myocarditis, which also always accompanies endocarditis. 
 
 Becurrent endocarditis shows not only the fever and other symp- 
 toms caused by the fresh lesions, but also the hypertrophy of the older 
 valvular lesion. An aortic diastolic or a mitral presystolic murmur 
 is more likely to indicate an old lesion. With repeated examinations 
 
ACUTE ENDOCARDITIS. 387 
 
 fresh murmurs may be heard in addition to the old ones. (See 
 Mitral Insufficiency, Ulcerative Endocarditis and Pericar- 
 ditis.) 
 
 Prognosis. — (a) As to life, the ontlook is generally good, unless (i) 
 emboli lodge in important structures, such as the basilar or coronary 
 arteries, or (ii) the process becomes malignant, (b) As to complete 
 recovery, (i) valvular lesions are usual which are anything but 
 " benign " ; (ii) fresh recurrent endocarditis is very common ; and 
 (iii) complete recovery is uncommon. 
 
 Treatment. — The treatment of the two forms of endocarditis is 
 considered together, (a) Prophylaxis resolves itself into the treat- 
 ment of the causal acute infection, such as rheumatism or sepsis. 
 Preventive treatment, such as the administration of salicylates and 
 alkalies in rheumatism, is uncertain except that they shorten the 
 rheumatic attack, (b) Rest spares the heart and probably lessens 
 the percentage of cases involved. Complete rest, psychical, physical 
 and cardiac is the prime essential and cardiac stimulants are to be 
 avoided, at least in the early stages. Pest in bed must be enforced for 
 weeks after temperature and signs of heart weakness have wholly 
 disappeared. Should relative recovery occur, the general care of 
 the heart's strength must be insisted upon as in chronic valvular 
 disease and, with intercurrent affections or with the appearance of 
 temperature, the patient must be confined to bed. Senac (1749- 
 1783) recognized the causal importance of inflammation in heart 
 disease, the necessity of avoiding strain and of regulating the amount 
 of fluid and food ingested, the relations of liver and stomach disturb- 
 ance and the advantages of mental quietude, (c) The sepsis is 
 treated by alcohol (see Pneumonia) ; quinine, gr. x to xv, once or 
 twice daily, with three ounces of red wine every hour or two, is recom- 
 mended by Frantzel ; bichloride of mercury and other antiseptics are 
 futile; for pure or dominating streptococcic infections Marmoreck's 
 antistreptococcus serum is indicated in doses larger than those usually 
 prescribed and should be frequently repeated, (d) The irritable 
 heart may be quieted and slowed by the use of the ice-bag. Sina- 
 pisms sometimes act favorably but blisters are to be avoided. Car- 
 diac stimulants should be employed with caution and only coffee, 
 ammonia or brandy should be given. Digitalis is usually to be 
 avoided, but it is indicated when very tumultuous heart action 
 threatens to induce embolism. 
 
 (e) Symptomatic Treatment. — For nervous symptoms, sodium 
 bromide is indicated. Sulphonal and trional are to be avoided when 
 the heart weakens. For the fever, hydrotherapy, aside from simple 
 sponging, is inadvisable, for the joints and muscles are very tender 
 and movement, on account of the possibility of embolism, is danger- 
 ous. Diarrhoea of septic origin should not be checked at once, because 
 it is nature's effort at derivation and elimination. Fluid diet should 
 be given because of the fever. Potassium iodide is usually admin- 
 istered as a resolvent after the acute stage has passed, 
 
388 DISEASES OF THE CIRCULATION. 
 
 II. Chronic Endocarditis. Chronic Valvular Disease. — Etiology. — 
 
 Valvular heart disease constitutes 5 per cent, of all diseases. It most 
 often develops from (a) acute verrucose endocarditis and therefore 
 has the same etiology ; in 60 per cent, the cause is rheumatism. One- 
 half the cases of valvular disease are in children and over one-third 
 occur between 20 and 30 years of age. Some cases develop without 
 symptoms and are apparently primary or possibly hereditary; they 
 are seen mostly in young or adolescent subjects and in women, but 
 doubtless some minor or forgotten infection explains this group, (b) 
 Atheroma is also an important cause; it is promoted by overexertion, 
 as in the working classes, by advanced years or by chronic nephritis, 
 gout, diabetes, syphilis, alcoholism and lead poisoning. It is a more 
 common cause in males. Though chronic valvular disease may de- 
 velop from other causes than chronic endocarditis, both topics can 
 well be considered together. Valvular lesions less often result from 
 (c) rupture of the valves; this occurs most often in the aortic valves 
 during supreme physical efforts and, of course, is favored by previous 
 valvular lesions, although sometimes observed in perfectly normal 
 valves. Healing is most rare, (d) Relative valvular insufficiency is 
 a condition in which the normal valves are unable to close the orifices 
 to which they belong because the heart is dilated. It is most com- 
 monly tricuspid and mitral, although it rarely occurs in the aortic 
 and pulmonary valves. Relative stenosis is not clearly established, 
 (e) Other rarer causes are aortic aneurysms, neoplasms, valvular 
 aneurysms and cardiac thrombi. 
 
 Pathology. — Small grayish-red swellings are sometimes seen in the 
 early stages; they somewhat resemble atheroma plaques. Foci of 
 endocardial thickening and retraction {endocarditis retrahens) are 
 seen, in which calcification and even ossification of the valves may be 
 present. The valves become less translucent, are not infrequently 
 rigid, unable to unfold, adherent to each other or distorted by their 
 own thickening and retraction or that of the chordae or papillary 
 muscles. Mural changes are unimportant, except when associated 
 with myocarditis. Acute exacerbations may occur and then the 
 ordinary vegetations appear. Embolism occurs in about 30 per cent, 
 of the cases. The myocardial changes are hypertrophy, dilatation 
 and myocarditis. The valves most often involved are the mitral (78 
 per cent.), especially in adolescence, then the aortic (20 per cent.), 
 which are especially subject to change in arteriosclerotics and finally 
 the tricuspid (1 per cent.) and the pulmonary valves. Combined 
 valvular lesions occur in 33 per cent, of cases. The process often 
 extends by continuity of surface from the mitral to the aortic valves. 
 When one valve is but moderately involved, the others of the same 
 valvular orifice may compensate by stretching in order to cover the 
 defect, especially in aortic disease. In foetal cases the valves of the 
 right heart are more frequently involved (v. Congenital Val- 
 vular Disease). 
 
 Valvular insufficiency is usually caused by (a) thickening and re- 
 
AORTIC INSUFFICIENCY. 389 
 
 traction or even calcification of the valves and also of the chordae ten- 
 dinese and of the papillary muscles; (b) massive vegetations; (c) 
 growing together of the valves, or of the valves with the wall of the 
 heart or aorta; or adhesions between the papillary muscles and ten- 
 dons; (d) valvular aneurysm, perforation, rupture, or tearing of the 
 tendons or muscles. Valvular stenosis (stenosis of the orifice) results 
 from (a) adhesions between the valves, (b) retraction, calcification, 
 fibrosis of valves or ring of insertion and (c) vegetations. Com- 
 bined valvular insufficiency and stenosis in one valvular mechanism, 
 especially the mitral, are very common. 
 
 Symptoms. — The symptoms of valvular disease are (a) the cardiac 
 findings peculiar to each lesion, which will be first considered, and 
 (&) the general symptoms more or less common to all forms of cardiac 
 insufficiency, the description of which will follow the individual lesions. 
 
 III. Aortic Insufficiency. (Corrigan's Disease.) — Aortic regurgi- 
 tation was described by Cowper (1705), Vieussens (1715) and 
 Hodgkin (1829), but the first full description dates from Corrigan 
 (1832). 
 
 Etiology. — 1. Endocarditic Form. — The sinuses of the valves may 
 fuse, vegetations are present, or the valves grow together at their 
 margins and shrink ; this is more frequent than valvular perforation 
 or ulceration, which is rapidly fatal. If calcification develops, there 
 may be coincident stenosis, which is less common in the atheromatous 
 form. This form usually follows a previous mitral lesion. The 
 endocarditic form occurs at an earlier age and is not attended by the 
 arteriosclerotic changes in the aorta and coronary arteries which 
 characterize the atheromatous form. 
 
 2. Atheromatous Form. — Atheroma may be slight in the aorta 
 and located mostly on the valves. It is a slow, degenerative process 
 (see Arteriosclerosis) with marginal valvular retraction; it is 
 caused by excessive use of alcohol, by continued hard work or ath- 
 letics and by syphilis, which may dilate the aortic ring, even without 
 directly involving the valves (syphilitic aortitis). It is often 
 therefore seen in middle-aged men. A relatively slight anatomical 
 lesion may produce disproportionate symptoms. The valves may 
 become adherent to the aorta. Their edges are rounded and are not 
 the seat of endocarditic masses. The atheromatous process may 
 overlie or actually invade the coronary orifices; this is obviously 
 dangerous. Coincident stenosis is uncommon. The following forms 
 are infrequent: 
 
 3. Relative Insufficiency. — This form occurs mostly in cases 
 of aortitis, aneurysm and arteriosclerotic dilatation of the root of the 
 aorta, which is a more or less physiological process, as the aorta usu- 
 ally relaxes one centimeter in circumference after the fortieth year. 
 It may also occur in cases of dilatation of the left ventricle, resulting 
 from idiopathic hypertrophy, myocarditis or renal disease. 
 
 4. Congenital Defects. — These are rare ; absence of a valve may 
 be in part compensated for by the others, though anatomical anomalies 
 
390 DISEASES OF THE CIRCULATION. 
 
 predispose to sclerosing endocarditis. Valvular fenestration is unim- 
 portant clinically and pathologically. 
 
 5. Trauma. — This is a most uncommon cause, only 46 aortic cases 
 in a total of 72 being recorded (Druyfuss). 
 
 Mechanism. — From aortic valvular incompetence, a diastolic regur- 
 gitation of blood into the left ventricle takes plaCe from gravity and 
 contraction of the aorta. Blood currents and vibrations are caused by 
 the blood flowing (normally from the left auricle and pathologically 
 from the aorta) into the left ventricle,, thereby producing the diastolic 
 murmur. The left ventricle becomes dilated to accommodate its 
 added volume and hypertrophied, because it must propel the normal 
 plus the regurgitated blood. The left heart becomes enormously in- 
 creased and may even weigh 50 ounces, whence the name " ox-heart," 
 ■ — cor bovinum. The hypertrophied left ventricle suddenly forces an 
 unusually large amount of blood into the arteries, and thus causes 
 the many arterial phenomena; H. A. Stewart finds that the amount 
 of regurgitated blood is small. 
 
 Physical Signs. — 1. Inspection. — (a) Precordial prominence is ob- 
 served chiefly in plastic chests and in the endocarditic type and, 
 therefore, is most common in women and children. Mensuration 
 may confirm the prominence, although the right chest normally 
 measures nearly an inch more than the left, (b) The heart shock is 
 powerful and diffuse, (c) The apex beat is dislocated downward 
 (6th, 7th, 8th interspace) and outward, beyond the nipple or an- 
 terior axillary line. The apex also lies low in arteriosclerotics, from 
 relaxation of the aorta. It is heaving, pulsating and superficial. 
 The lung is pushed back and some slight rotatory systolic retraction 
 of the chest wall is seen. These findings are referred to the dilated 
 and hypertrophied left heart, (d) Pulsation in the first and second 
 right intercostal spaces is usually dynamic, because the blood thrown 
 with extra force into the aorta causes dilatation of the aortic arch, 
 (e) The peripheral vessels pulsate with unusual violence and the 
 carotids hop: pulsation in the jugular fossa or in the abdominal 
 aorta may simulate aneurysm, and the temporals and radials often 
 attract attention before the patient undresses for examination. The 
 crossed leg may pulsate and the head may throb. These are all caused 
 by ventricular hypertrophy, the extra volume of blood thrown into 
 the vessels or an accommodative dilatation of the peripheral vessels 
 (Stewart). Pulsation may also be seen in the retina, either spon- 
 taneously or by pressure on the eyeball, as occurs also in Basedow's 
 disease. The liver may pulsate, though this is rare because a strong 
 heart action with stasis is necessary. The liver also pulsates in cases 
 of tricuspid incompetency, but this throb is due to venous filling of 
 the organ during the systole. Pulsation also may occur in the spleen, 
 palate and penis. (/) The capillary (Quincke's) pulse occurs in 
 over 80 per cent, of the cases, but is not pathognomonic, for it is also 
 seen in health, in fevers or anaemias. It is a symptom of overfilling 
 of the arteries and capillary dilatation and is best observed when the 
 
AORTIC INSUFFICIENCY. 
 
 391 
 
 hypertrophy exceeds the dilatation; it disappears when the heart 
 weakens. It is elicited by exerting slight pressure on the tips of the 
 finger nails, on the lips by a glass slide or by rubbing the forehead 
 until it is red ; there is a systolic reddening and a diastolic paling in 
 these parts. It is sometimes found in the retina, in the palate or in 
 cases of complicating erysipelas, (g) The passing over of the blood 
 from the arterioles into the veins may produce the centripetal venous 
 pulse, — most obviously in the forearm, and caused by relaxation of 
 the vessels, as in fevers, some nervous lesions and chlorosis; by 
 delicate skin; and full heart action, (h) The arteries are actually 
 lengthened, (i) Patients often assume the dorsal decubitus, for 
 gravity increases the leakage; subjects with mitral insufficiency usu- 
 ally sit. The findings by inspection are practically pathognomonic. 
 2. Palpatio^. — (a) The hand corroborates the results of inspec- 
 tion, — as the heaving, throbbing apex and the diastolic impulse. (b) 
 A diastolic thrill over the base is infrequent, occurring mostly in 
 cases of endocarditic origin, but when present is usually proportionate 
 
 Fig. 21. 
 
 Sphygmogram of case of uncomplicated aortic leakage. 
 
 to the degree of leakage, (c) In the jugulum, especially in arterio- 
 sclerotics, the widened aorta can be felt, (d) The pulse findings may 
 seem paradoxical, but it must be noted that the arteries are filled 
 violently (the pulsus durus), though the tone of the vessel wall is 
 less than normal. 
 
 The radial artery is suddenly filled, the " pistol pulse" or pulsus 
 celer; this is due to hypertrophy of the left ventricle. The condition 
 of the heart muscle and therefore of the pulse, depends largely on 
 the type or etiology of the case ; hypertrophy is usual and marked in 
 the endocarditic form, though in the atheromatous type coronary 
 atheroma and fibrous myocarditis lessen the myocardial activity, 
 render the pulse atypical and make the prognosis less favorable. 
 The sphygmographic tracing shows the high up-stroke with an acute 
 apex (the pulsus alius). The dicrotic wave is ill-marked and the 
 pulse rapidly recedes (the "collapsing pulse"), due to the inability 
 of the aortic valves to hold the receding blood. (Stewart's explana- 
 tion is that there is a reflex dilatation of the peripheral vessels and 
 heart stimulation by the increased pressure within the left ventricle.) 
 The falling away of the pulse is sometimes increased by lifting the 
 
392 DISEASES OF THE CIRCULATION. 
 
 arm. The pulse is not absolutely characteristic, because it also occurs 
 in fevers or anaemias, but it is strongly suggestive. The typical 
 findings are altered when atheroma of the aorta or vessels occurs; 
 when other valvular lesions develop, as aortic stenosis or mitral regur- 
 gitation; or when the heart muscle is weak or degenerated. When 
 the pulse findings precede the murmur it is claimed that the lesion is 
 due to disease of the aorta. Thrills may be felt over various periph- 
 eral vessels. The peripheral pulse is delayed in about half of the 
 cases, because the regurgitation continues into the first part of the 
 systole. 
 
 3. Percussion. — (a) The heart area is oval and is increased 
 downward and to the left,, as could well be anticipated from the 
 mechanism. Dulness reaches the second or third rib to the left of 
 the sternum (see Plate X, Fig. C). The heart is somewhat more 
 horizontal than normal. The dulness extends slightly beyond the 
 apex and is largely due to dilatation of the left ventricle. Because 
 physical laws demand its equal dilatation in all directions, it is not sur- 
 prising that the right heart may be somewhat crowded to the right, 
 and the left auricle upward, although dulness to the right of the 
 sternum is infrequent. The papillary muscles are found flattened 
 and even thickened at autopsy, from the pressure of the regurgitant 
 blood. (&) A small area of dulness in the first and second right 
 interspaces denotes mechanical dilatation of the arch, which results 
 from the cardiac hypertrophy. 
 
 4. Auscultation. — (a) A diastolic murmur is heard over or to 
 the left of the sternum at the level of the second or third rib. It is 
 caused by the retrograde blood passing through the incompetent 
 valves into the left ventricle. When heard over the so-called " pul- 
 monic area," it is increased downward along the sternum, for the 
 regurgitant column follows this direction (Plate X, Fig. C). It has 
 a blowing, deep and less often sawing, musical or whistling sound 
 (which latter suggests a relative aortic leakage). When slight, it 
 may easily escape recognition, but when well developed it is very 
 characteristic, sounding like the word " who" It may best be heard 
 with the bare ear against the chest. It sometimes disappears before 
 death when the heart is weak and the lesion is great, but generally 
 corresponds to the degree of leakage. It rarely reaches theT neck or 
 abdomen. Cases of valvular rupture have produced a murmur which 
 could be heard at a distance. (&) A slight systolic murmur over the 
 valves or aorta is common, but the too frequent diagnosis of aortic 
 stenosis (q. v.) is not justified. It is soft in the atheromatous and 
 often harsh in the endocarditic type. Its various explanations are : 
 Eough aorta or valves, physiological stenosis (the rigid valves lying 
 between a wide aorta and a dilated ventricle) ; vibration of the aorta; 
 or leakage continuing into the beginning of the systole, (c) Weak- 
 ness or absence of the second aortic tone is explained by imperfect 
 closure of the valves. As the second tone is normally "heard over 
 the carotid artery it should be listened for there, because it is 
 
■* %* 
 
 O CD 
 
 CD >&3 
 
AORTIC INSUFFICIENCY. 393 
 
 removed from the murmur and the second pulmonic tone. If it is 
 present, the usual conclusion is that one or more valves are closing, 
 though probably imperfectly. By lifting the stethoscope a little from 
 the skin over the aortic region, the second sound, which was pre- 
 viously obscured by the bruit, may be heard, (d) The first mitral 
 tone is often weak or lost, because the papillary muscles are flattened 
 and indurated by the regurgitant column. If the change is pro- 
 nounced, a mitral systolic murmur may be heard in place of the 
 first tone, (e) An apical presystolic {Flint's) murmur is heard in 
 50 per cent, of the cases, and is due to aortic leakage continued in 
 the systole, or to pressure on the mitral valves, which hinders the flow 
 of blood from the left auricle into the left ventricle. Thayer found 
 it in 60 per cent, of 74 cases, and in less than one-quarter of these 
 was there a mitral stenosis. (/) Arterial tones and murmurs may 
 result from vibration of the vessel wall ; these tones may become mur- 
 murs, when there is great difference in tension. The systolic vessel 
 tone is increased by the larger volume of blood and increased ven- 
 tricular action, and is most plain when the vessels are not sclerotic. 
 It is also found in anaemia. Over the femoral artery, a systolic tone 
 is heard which is convertible into a murmur on pressure. Traube's 
 double femoral sounds consist of two spontaneous tones (produced 
 without pressure) which are variously explained, probably most 
 satisfactorily by sudden change in tension. They are heard best 
 when the heart is strong and the vessels soft. They occur in other 
 conditions and other valvular lesions, and may be confused with the 
 double venous (Friedreich's) tones, which are heard over the vein 
 in tricuspid leakage. Duroziez s double murmur is analogous, but 
 consists of two murmurs, which may be elicited by slight pressure 
 and are due to the progress and recession of blood in the artery. It 
 also occurs in other conditions. 
 
 Diagnosis. — Physical examination by inspection, palpation, percus- 
 sion and auscultation, in the order named, prevents many errors in 
 the interpretation of murmurs. The cardinal findings are: (a) 
 Dilatation and hypertrophy of the left ventricle; (&) the pulsus celer 
 and altus; (c) the arterial phenomena ; and (d) the diastolic murmur. 
 
 Comparing the two main types, endocarditic aortic insufficiency 
 is generally of rheumatic origin and occurs in younger subjects; 
 precordial prominence and diastolic thrill are more common; the 
 heart muscle hypertrophies and the pulsating vessels are more con- 
 spicuous; the pulse is more typically "pistol-like" and collapsing, 
 as the vessels are not sclerosed; the capillary pulse and vessel-tones 
 are more frequent; on auscultation, the diastolic murmur is rather 
 harsher and nearer the valves, Flint's murmur is more common and 
 if a systolic aortic bruit is heard, it is often harsher and coincident 
 aortic stenosis is more frequent. 
 
 In the atheromatous form, sexual excesses, manual work and alco- 
 holism are more evident and syphilis may be declared by the im- 
 mobile pupil, lightning pains of tabes, etc. As arteriosclerosis readily 
 
394 DISEASES OF TEE ClBCVLATlOtf. 
 
 involves the heart, coronary symptoms, myocarditis, dyspnoea and 
 dilatation may stand forth. The dilated aorta is more frequently 
 palpable in the jugulum and allows the heart to sag lower in the 
 chest. The diastolic murmur is more characteristically deep and 
 blowing down along the sternum and the typical vascular phenomena 
 are modified by the rigid arteries and arterioles or are not apparent 
 at all. 
 
 Relative aortic regurgitation (see Etiology) is difficult to differ- 
 entiate from the valvular; the murmur is not the typical protracted 
 diastolic bruit, but rather a short presystolic or postdiastolic mur- 
 mur (Eosenbach) which produces a short " huff " after the second 
 aortic tone. This character is said to be almost pathognomonic. The 
 pulse in relative regurgitation is frequently small, tardy and tense, 
 but not quick. Hypertrophy of the left ventricle is not very great. 
 The murmur varies from time to time; it is sometimes short, then 
 longer, sometimes blowing, and again coarse, or it may be difficult 
 to fix as to systole or diastole. 
 
 Diastolic murmurs are rarely ancemic (cardiopulmonary or func- 
 tional). Clear instances exist, however, of such bruits in the cava and 
 other veins. These murmurs are uneven and are stronger in the 
 beginning of the diastole. Aortic aneurysm (q. v.) may cause con- 
 fusion. In mitral lesions, the capillaries are poorly filled and the 
 skin is cyanotic; in aortic regurgitation the arterioles are overfilled 
 and the skin is red. In mitral disease, congestion of the lung, brown 
 induration and dilatation of the right heart obtain ; these are absent 
 in aortic leakage; a hemorrhagic nephritis takes the place of the 
 analogous brown induration of the lungs of mitral lesions. 
 
 Relative healing by vicarious stretching of sound valves, by in- 
 creasing stenosis and by calcification is possible but infrequent. 
 Mercurials may work a cure in cases due to syphilitic aortitis. 
 
 IV. Aortic Stenosis. — Aortic stenosis is the most infrequent of 
 left-heart lesions. In Khomberg's figures, its frequency as a solitary 
 lesion was 2.5 per cent. It may occur congenitally, in which case 
 the conus arteriosus is often constricted (Dittrich's genuine heart 
 stenosis). It occurs, however, largely in the aged; the valves become 
 interadherent or fibrously thickened from atheroma, or chronic endo- 
 carditic calcification or retraction at the valvular insertion obstructs 
 the orifice. Acute endocarditis, with massive vegetations, may pro- 
 duce some stenosis. It is usually associated with aortic incompetency, 
 although aortic double lesions are far less common than mitral. 
 Stenosis of the aortic orifice is a better term than aortic stenosis. 
 
 Mechanism. — The rigid valves narrow the orifice and at the ob- 
 struction a systolic murmur originates. The resistance to the onward 
 flow of blood from the left ventricle leads to its hypertrophy. The 
 pulse becomes small and slow because of obstruction. 
 
 Physical Signs. — 1. Inspection. — Some precordial prominence 
 may be seen in yielding chests. The apex beat is sometimes strong, 
 somewhat dislocated to the left, but often no apex is seen, either on 
 
A0UT1G STENOSIS. 395 
 
 account of coincident emphysema or of diminution of the heart's 
 recoil. The apex sometimes retracts during the systole from lack 
 of tension in the aorta and from lessened systole. 
 
 2. Palpation. — (a) A most pronounced systolic thrill is often 
 felt over the second right interspace, and sometimes is propagated 
 over the heart and into the cervical vessels, (b) The pulse is infre- 
 
 FlG. 22. 
 
 Pulse tracing in stenosis of the aortic orifice. 
 
 quent (pulsus rarus), because the systole is prolonged and the coro- 
 nary arteries are not well filled ; it is small (p. parvus) from ob- 
 struction to its flow; it is tense (p. durus) from hypertrophy of the 
 left ventricle and arteriosclerosis ; and it is exceedingly slow (p. 
 tardus) with tardy up-and-down stroke and some retardation. A 
 strong apex beat and a tense but small radial pulse suggest aortic 
 stenosis. 
 
 3. Percussion. — This may be wholly negative. Concentric hyper- 
 trophy (i. e., hypertrophy, with the left ventricle smaller than nor- 
 mal), is very frequent. Concentric and simple hypertrophy, which 
 are the more common, as- the stenosis is purer, naturally give no 
 change on percussion. Dilatation is sometimes present, giving slight 
 dulness to the left, especially with aortic regurgitation, renal com 
 traction or atheroma. In rare instances both hypertrophy and dilata- 
 tion are absent. 
 
 4. Auscultation. — Auscultation reveals (a) a systolic murmur 
 over the aortic area, which is sometimes soft but more often long, 
 sawing, whistling or musical and is transmitted with the blood cur- 
 rent into the aorta, the descending aorta in the back and its vessels 
 (Plate X, Fig. A). It is frequently heard over the entire heart and 
 at times is heard at some distance from the chest (Stokes, Ebstein). 
 It is not proportionate to the intensity of ,the lesion and disappears 
 with broken compensation. (&) The second aortic sound is weak, 
 from poor filling of the aorta and weak closure of the altered valves, 
 or it is absent when combined with aortic regurgitation; (c) when 
 the second aortic sound is absent, the second mitral tone, or indeed all 
 the heart tones, are weak or absent, (d) A systolic tone is heard over 
 the aorta. 
 
 Diagnosis. — The lesion may be a favorable sign, because it is some- 
 times a healing of an aortic regurgitation. Aortic stenosis is a fre- 
 quent surprise at autopsy, having run a latent course. The cardinal 
 signs are (a) systolic murmur with propagation into the large vessels 
 or over the entire heart; (b) a systolic fremissement over the aortic 
 area; (c) the small, tardy, slow pulse, in contrast to the strong apex, 
 beat. A diagnosis should be reserved unless these signs are present. 
 As the lesion is uncommon, its frequent diagnosis implies confusion 
 with (i) accidental murmurs, which are variable, (ii) Acute endo- 
 
396 DISEASES OF THE C1BCULATI0N. 
 
 carditic vegetations; these usually give a soft murmur which becomes 
 harsher if actual stenosis ensues, (iii) Atheroma of the aorta,, or 
 acute aortitis, where the murmur is more localized over the aorta, 
 the second aortic tone is ringing or metallic and the pulse is gen- 
 erally proportionate to the apex beat. Atheroma, the most frequent 
 cause of diagnostic error, is very common, while experienced clin- 
 icians see few cases of pure aortic stenosis, (iv) Aneurysm (q. v.), 
 which is often distinguishable by its pressure symptoms. 
 
 V. Mitral Insufficiency.- — Mitral insufficiency (incompetency, re- 
 gurgitation) is the most frequent valvular lesion and is more often 
 of endocarditic than atheromatous origin. It is (a) valvular, from 
 adhesions between the valves or chordae and ventricular wall, from 
 vegetations, from thickening with retraction, from valvular aneurysm 
 or perforation, or from shrinkage or rupture of the papillary muscles 
 or chordae; or it is (b) muscular, from relative insufficiency due to 
 such relaxation of the ventricular muscle that the valves will not 
 cover the orifice ; this form is common in hypertrophy with dilatation, 
 resulting from hard work, atheroma, nephritis, syphilis, alcoholism, 
 myocarditis and adherent pericardium; (c) rupture of the mitral 
 cusps is very uncommon. Barie collected 35 cases of valvular rup- 
 ture, of which 45.7 per cent, were aortic, 45.7 per cent, were mitral 
 and 8.6 per cent, were tricuspid. 
 
 Mechanism. — During the systole, a backward flow occurs through 
 the incompetent valves into the left auricle, which, as it also receives 
 blood from the lung veins, first dilates and later hypertrophies as 
 far as its slight musculature can admit. The left ventricle dilates 
 because it receives in the diastole more blood than normal (i. e., the 
 usual inflow plus the already regurgitated blood) and, responsive to 
 the dilatation, it hypertrophies because its work is increased. In 
 aortic lesions, the first and greatest strain is felt in the left ventricle, 
 but mitral lesions, by congesting the lungs, throw the most work on 
 the right heart. The stasis in the left auricle is transmitted to the 
 pulmonary veins, capillaries and arteries, thus leading to increased 
 engorgement and blood pressure in the pulmonary circuit, because 
 (a) of this backward pressure, and (b) of the onward pressure from 
 the right ventricle, which dilates and then hypertrophies. The 
 lungs are enlarged and engorged, their vessels dilate and may become 
 atheromatous, possibly causing infarcts in the lung and connective 
 tissue development (brown induration). When the final inevitable 
 weakening of the right ventricle occurs from dilatation, i. e., broken 
 compensation, the right auricle is engorged and relative tricuspid 
 leakage follows from dilatation. The venous system is overloaded 
 and this results in stasis and cyanotic induration of the liver and 
 kidneys, and often in oedema. 
 
 Physical Signs.— 1. Inspection.— (a) The apex may be normally 
 located or displaced to the left — much dilatation luxating the apex 
 even into the axilla. The heart may then lie lower than normal. 
 A normally strong apex beat in mitral insufficiency is evidence of 
 
MITEAL INSUFFICIENCY. 397 
 
 hypertrophy. (&) Systolic pulsation in the second left interspace 
 indicates a wide pulmonary artery from increased tension or stasis, 
 and (c) a diastolic shock there is due to closure of its valves; (d) 
 precordial prominence occurs in yielding chests from marked cardiac 
 dilatation; (e) pulsation, either epigastric or to the right of the 
 sternum, results from dilatation and hypertrophy of the right ven- 
 tricle. (/) The veins are enlarged and pulsate during the diastole 
 from stasis, and sometimes during the systole from tricuspid incom- 
 petency (q. v.). 
 
 2. Palpation. — (a) The apex is dislocated to the left; (b)[ 
 the pulmonary artery pulsation is felt ; (c) the diastolic shock of the 
 forcibly closing pulmonary valves is very often palpable ; by placing 
 one finger over the valves and another over the apex the two shocks 
 alternate ; (d) pulsation is felt to the right from right ventricle dila- 
 tation; (e) a systolic apical thrill is often palpable after excitement, 
 or when the patient lies on his left side, but is not pathognomonic. 
 (/) In pure cases the pulse is about normal in tension, or becomes 
 lessened with rupture of compensation. Irregularity is not very 
 common and the sphygmographic tracing is not characteristic. 
 
 3. Percussion. — (a) Dilatation of the right ventricle is commonly 
 followed by hypertrophy, in compensated cases. Dilatation shows 
 dulness and palpatory resistance to the right of the sternum (see 
 Plate X, Fig. B). Hypertrophy without dilatation is usually found 
 in the early and well compensated lesion. It should be remembered 
 that the right heart bears the stress of this lesion. (&) The left ven- 
 tricle usually but not always dilates to respond to the increased 
 amount of blood, and hypertrophies because of increased work or the 
 raising of arterial pressure by carbon dioxide. 
 
 4. Auscultation. — (a) The systolic murmur is due to abnormal 
 eddies in the left auricle or to the vibrations caused by them in the 
 mitral valves ; it most often gives a hlowing sound, is best heard over 
 the apex, which is less covered by the lung, but at times is localized 
 over the pulmonary area or auricle, where it really originates and 
 where it is heard especially in early lesions. It is transmitted 
 chiefly to the left towards the left interscapular region, and more 
 rarely to the aorta, carotids and abdomen (see Plate X, Fig. B) ; 
 it is at times heard intermittently, in certain postures only, and it 
 may disappear with weakening of the heart. In very rare cases it is 
 entirely absent (latent). (?;) The first mitral tone is usually absent 
 because the valves cannot vibrate; if present it is referable to con- 
 duction from the tricuspid valve or to contraction of the ventricle. 
 When obscured by the murmur, it may sometimes be heard by lifting 
 the stethoscope a little from the chest wall. In cases of extreme 
 leakage, the murmur replaces all tones, (c) The second pulmonic 
 sound is accentuated, " hammerlike," and is a measure and result of 
 the right ventricular hypertrophy (Skoda). It sometimes reaches 
 the vessels of the neck. When the tricuspid valves become relatively 
 insufficient, it usually weakens; accentuation is absent in those rare 
 
398 DISEASES OF THE CIRCULATION. 
 
 cases where the right ventricle does not hypertrophy. The second 
 tone at the base is sometimes split, (d) A systolic murmur over the 
 pulmonary area is usually propagated from the apex or is due to 
 vibrations in the distended pulmonary artery. 
 
 Diagnosis. — The cardinal features are (a) the systolic murmur, (b) 
 accentuated second pulmonic tone and (c) right-heart changes. 
 
 Excepting the etiological diagnosis and the clinical evolution, there 
 are no positive criteria by which we can differentiate a muscular 
 (relative) from a valvular insufficiency, though in the former the 
 murmur is more variable, lessens with digitalis and is not associated 
 with a diastolic stenotic murmur which is common in valvular incom- 
 petency. Pure insufficiency is very exceptional, being usually com- 
 bined, anatomically at least, with some mitral stenosis into which in- 
 sufficiency may eventually pass. An organic valvular defect is prob- 
 able when the apex, dislocated to the left, is forcible. 
 
 From the functional, accidental, hsemic or cardiopulmonary mur- 
 mur, the diagnosis is usually easy. The murmur is inconstant, is 
 often basal, often depends on posture and coughing efforts, is cir- 
 cumscribed, sometimes disappears on pressure, is not typically trans- 
 mitted, follows fever, anaemia and emphysema, is often associated 
 with the venous hum in the neck, but is never associated with typical 
 mitral changes in the heart tones and right ventricle. The intensity, 
 timbre or fremissement of the murmur must not alone be depended 
 upon. So-called " functional " murmurs are usually systolic. 
 
 In chlorosis, we may obtain a hsemic murmur, apparently large 
 heart (because the lungs are poorly expanded), and a displaced apex, 
 since the diaphragm stands high in chlorosis ; deep breathing rapidly 
 decreases the heart's dulness. 
 
 Pericardial friction (q. v.) may simulate any endocardial murmur 
 (Skoda), though little difficulty attends the differentiation. 
 
 Frantzel's general rules are excellent and aid in accuracy: (1) 
 Never make a diagnosis just before death. (2) Eemember the great 
 infrequency of right-heart lesions. (3) Avoid complicated diagnoses. 
 (4) Murmurs are subordinate in value to physical findings by in- 
 spection, palpation and percussion. 
 
 VI. Mitral Stenosis. — Anatomically pure stenosis of the mitral ori- 
 fice, without associated mitral leakage is rare. In one group, espe- 
 cially in young girls, the stenosis is clearly endocarditic and the 
 valves are irregular, calcareous and deformed. In another group, 
 seen in old subjects of both sexes, the sclerosing process is probably 
 endocarditic and the last group, almost exclusively observed in 
 women, the nature of the lesion is uncertain ; the mitral valves are 
 so grown together or the ring so constricted as to well justify the 
 name used by Corrigan, a the button-hole contraction"; the orifice 
 in extreme cases is funnel-shaped. 
 
 Mechanism. — The stenosis obstructs the diastolic passage of the 
 blood from the left auricle into the left ventricle, which consequently 
 dilates and later hypertrophies, The enlarged auricle may compress 
 
MITRAL STENOSIS. 399 
 
 the adjacent bronchus or recurrent laryngeal nerve. The stasis is pro- 
 pagated backward through the lungs to the right ventricle, whose dila- 
 tation and hypertrophy cause the large right heart and the increased 
 pressure in the lesser circulation. The effects on the right heart 
 and lungs are more severe than in mitral insufficiency. The right 
 auricle also dilates when the later venous stasis follows. Thrombi 
 in either auricle may dislodge and produce pulmonary or arterial 
 infarction. The arterial system is naturally filled but poorly. 
 
 Physical Signs. — 1. Inspection. — This reveals (a) precordial dis- 
 tention, (b) epigastric pulsation and (c) a diffuse cardiac shock; 
 (d) the apex beat may in comparison be small, and (e) two impulses 
 or shocks may be seen in the second left interspace; one is systolic, 
 from systolic filling of the pulmonary artery, and the other is dias- 
 tolic, from pulmonary valve closure under high tension. All these 
 findings depend on the right heart hypertrophy and dilatation. 
 
 2. Palpation. — Palpation confirms the above, especially (a) the 
 apex beat, which is often weak in comparison with the diffuse heart 
 impulse, (b) the snap of the second pulmonic sound, (c) the pulsat- 
 ing right heart, and also (d) sl presystolic (more rarely diastolic) 
 thrill, fremissement cataire, which is usually limited to the apex, ends 
 with the snappy first apex-tone, and is felt sometimes only in the left 
 lateral posture or after exertion. Its mechanism is identical with 
 that of the murmur (q. v.). (e) The pulse is often irregular in cases 
 of pure stenosis, because dilatation interferes with the conductivity 
 of the heart's action, and is usually small and of low tension, because 
 the aorta is poorly filled; its weakness contrasts conspicuously with 
 the active heart impulse. It sometimes seems hard. The pulse is 
 not pathognomonic but merely suggestive; the sphygmograph con- 
 firms the palpatory findings. 
 
 3. Percussion. — (a) The right ventricle in the earlier stages may 
 be only hypertrophied, which does not show on percussion. Dilata- 
 tion without hypertrophy exists in few cases fortunately, for the 
 prognosis is then poor. Most commonly hypertrophy and dilatation 
 coexist, the latter giving increased dulness to the right, as is the case' 
 in mitral insufficiency, (b) The left ventricle in many cases of domi- 
 nant stenosis shows concentric atrophy, so that at autopsy it looks 
 like a mere appendage to the huge right heart. It is sometimes both 
 hypertrophied and dilated, for which the following reasons have 
 been assigned: Marked concomitant mitral leakage; stasis with in- 
 crease in the blood of carbon dioxide, which raises the blood pressure ; 
 coincident adherent pericardium, nephritis, atheroma or aortic dis- 
 ease, all of which lead to changes in the left ventricle, (c) The 
 auricles are distended, much of the dulness under or to the right of 
 the sternum being due to the dilated right auricle and that above 
 and to the left, to the left ventricle. (The right conus arteriosus 
 and the pulmonary trunk are found widened at autopsy.) Increased 
 dulness, due apparently to dilatation of the various chambers, is 
 often caused merely by their dislocation by the wide right ventricle, 
 
400 DISEASES OF TEE CIRCULATION. 
 
 4. Auscultation. — (a) An apical 'presystolic murmur is impor- 
 tant. It occurs at the end of the diastole just before the ventricular 
 systole, i. e., during the systole of the hypertrophied auricle which 
 forces the blood through the narrowed ring or rigid adherent valves. 
 Corresponding with the energy of that chamber, it is loudest at the 
 incipiency and ending of the auricular systole. It so closely pre- 
 cedes the ventricular systole that it is often called systolic by phy- 
 sicians and is almost invariably mistaken by students. It is rarely 
 a blowing sound, but usually snoring, rolling, sounding like R-R-R, 
 after which comes the loud first tone, sounding like P (R-R-R-P). 
 It is poorly propagated as a rule, corresponding to the localized 
 thrill, but may in exceptional cases be heard in the axilla or back. 
 It is most variable, often being absent even with great stenosis 
 and when the heart weakens and before death, whence the impor- 
 tance of Rule 4 of Frantzel (see Diagnosis of Mitral Insuffi- 
 ciency). It is rarely diastolic. (&) Marked accentuation of the 
 second pulmonic sound is the proof and measure of hypertrophy of 
 the right ventricle from pulmonary congestion. Its absence is a 
 poor prognostic. It usually weakens when relative tricuspid leak- 
 age lessens the tension in the lungs. The accentuation rarely reaches 
 the cervical vessels, (c) Splitting or reduplication of the second pul- 
 monic sound is due to difference in tension in the two arterial 
 trunks, the aortic valves closing first and more weakly. The doub- 
 ling is best heard at the base and is often propagated into the neck or 
 axilla, (d) The usually loud first mitral tone is explained in 
 various ways; viz., by difference in tension of the valves during 
 the systole and diastole or by a vigorous contraction of the left ven- 
 tricle upon little blood. It is sometimes heard at a distance of sev- 
 eral feet, (e) The second mitral tone is weak because of poor filling 
 of the aorta or because the right heart comes forward more than 
 usual. This tone may be split at the apex (the " postman's knock "), 
 and may be present early in this lesion ; the cause of the splitting is 
 the subject of variant discussion. 
 
 Diagnosis. — The cardinal signs are (a) the presystolic thrill and 
 bruit; (b) the involvement of the right heart; (c) the accentuated 
 second pulmonic sound; (d) loud first apical tone and (e) the small 
 pulse, which is less important. 
 
 The thrill and bruit are also found in other conditions, as in aortic 
 insufficiency (Flint's murmur), in which the vascular phenomena 
 and the involvement of the left heart are sufficiently distinctive, 
 though one out of every three cases of aortic leakage is complicated 
 by mitral stenosis. The bruit has also been heard in lesions leading 
 to dilatation of the left ventricle, such as adherent pericardium, 
 whence the rule that the diagnosis of mitral stenosis must be conserva- 
 tive when there is a clear history of pericarditis or where the left ven- 
 tricle is dilated. 
 
 When the thrill and murmur are absent, the diagnosis can usually 
 be made by the other cardinal symptoms, 
 
PULMONARY INSUFFICIENCY. 
 
 401 
 
 An absence of the murmur indicates a slight lesion; a presystolic 
 murmur argues for a strong left auricle; a diastolic murmur indi- 
 cates a severe stenosis; when tricuspid leakage intervenes, the mur- 
 mur of mitral stenosis is either absent or diastolic — never presystolic 
 — because both auricles are atonic. Absence of the murmur with 
 irregularity is indicative of the most serious lesion. The left auricle, 
 in a way, guards the mitral orifice ; consequently when the auricle is 
 strong, it may suppress the systolic murmur of a coincident mitral 
 leakage; when the auricle weakens, the systolic murmur appears. 
 
 Differential Table of the Common Chronic Valvular Lesions. 
 
 Etiology. 
 Pulse. 
 
 Left Ventricle. 
 
 Right 
 
 Ventricle. 
 
 Murmur. 
 
 First Mitral 
 Tone. 
 
 Second Aortic 
 Tone. 
 
 Second Pulmon- 
 ary Tone. 
 
 Peripheral 
 Vessels. 
 
 Aortic 
 Insufficiency. 
 
 Aortic 
 
 Stenosis. 
 
 Mitral 
 Insufficiency. 
 
 Often arterio- 
 sclerosis. 
 
 Pulse small, 
 slow, tense. 
 
 Arteriosclerosis 
 chiefly. 
 
 Pulsus celer. 
 
 Water-hammer, 
 
 collapsing. 
 
 Hypertrophied Hypertrophy 
 and dilated usually concen- 
 
 greatly ; heaving trie, 
 apex. 
 
 Endocarditis 
 chiefly. 
 
 Mitral 
 Stenosis. 
 
 Ditto. 
 
 No characteristic Small and often 
 alteration — ! irregular, 
 
 often normal. 
 
 Some hyper- No essential or 
 
 trophy and dila- regular change ; 
 tation.. may be small. 
 
 No change. 
 
 Diastolic ; blow- 
 ing over sternum 
 near second rib ; 
 propagated 
 toward apex. 
 
 Usually weak. 
 
 Weak or absent. 
 
 Not accentuated. 
 
 Violent pulsa- 
 tion ; capillary 
 pulse ; arterial 
 tones ; skin red. 
 
 No change. 
 
 Harsh systolic 
 murmur over 
 aortic area with 
 systolic thrill ; 
 propagated into 
 neck. 
 
 Strong usually. 
 
 Weak only. 
 
 Not accentuated. 
 
 Absent. 
 
 Hypertrophy 
 and dilatation 
 marked. 
 
 Systolic at apex, 
 blowing, trans- 
 mitted into left 
 axilla and be- 
 hind scapula. 
 
 Usually present, 
 perhaps covered 
 by murmur. 
 
 Somewhat weak. 
 
 Loudly accentu- 
 ated, and often 
 palpable. 
 
 Absent. 
 
 Skin cyanotic. 
 
 Both marked, 
 also in auricles. 
 
 Presystolic 
 (oftener than di- 
 astolic), apical, 
 accompanied bv 
 presystolic thrill, 
 fairly localized. 
 
 Loud and sharp, 
 clearly palpable 
 and following 
 murmur. 
 
 Somewhat weak. 
 
 Ditto; often 
 split, redupli- 
 cated. 
 
 Absent. 
 
 Skin cyanotic. 
 
 In conjunction with this table, Plate X should be consulted. 
 
 VII. Pulmonary Insufficiency. — Pulmonary insufficiency of which 
 Barie has collected 58 cases, is most uncommon and is often combined 
 with pulmonary stenosis or other rare right-heart anomalies. It is 
 (a) congenital, resulting from foetal endocarditis or from supernum- 
 erary or rudimentary valves; (b) acquired, from rheumatism, sepsis, 
 which destroys the valves by ulceration, or from atheroma; or it is 
 very rarely (c) relative from extreme intrapulmonary blood pressure 
 or from embolism of the pulmonary trunk or its branches. 
 
 Mechanism. — The mechanism is analogous to that of aortic insuffi- 
 26 
 
402 DISEASES OF THE CIRCULATION. 
 
 ciency except that the right heart suffers instead of the left and the 
 arterial phenomena are manifest in the area of the pulmonary artery. 
 Physical Signs. — 1. Inspection. — The right heart is dilated and 
 hypertrophied, and pulsates under and to the right of the sternum. 
 It may slightly dislocate the apex to the right. A systolic dynamic 
 pulsation may be seen over the dilated pulmonary trunk. 
 
 2. Palpation. — This determines the diffuse right-heart impulse 
 in 20 per cent, of cases, and a diastolic thrill over the pulmonic area ; 
 the apex beat and radial pulse are normal or weak. 
 
 3. Percussion. — Percussion confirms the schematic expectation 
 that the right ventricle should be dilated because of the backward 
 fall of the regurgitant column of blood and should be hypertrophied 
 to maintain the onward flow under this burden. The left ventricle 
 is normal or sometimes atrophic. (See Plate X, Fig. E.) 
 
 4. Auscultation. — A diastolic murmur is heard, which is propa- 
 gated down the sternum over the right ventricle. This bruit may be 
 confused with that of aortic leakage, aneurysm, a dislocated aorta, 
 functional venous murmurs, congenital anomalies of the vessels or 
 patent foramen ovale. The second pulmonic and the second tricuspid 
 tones are weak or absent and are replaced by the murmur. The 
 bruit is but rarely heard in the neck and the normal second arterial 
 tone is heard over the carotids (see Aortic Insufficiency). A sys- 
 tolic murmur, heard in 25 per cent, of cases over the pulmonary trunk, 
 is due to vibrations in its walls or to coincident stenosis of the pul- 
 monary ring. A double tone has been heard over the lung, as well 
 as variation in the respiration during the systole, — a capillary pulse 
 in the pulmonary vessels. 
 
 VIII. Pulmonary Stenosis. — The etiology will be considered under 
 diagnosis and under congenital heart lesions. 
 
 Mechanism and Physical Signs. — 1. Inspection. — Inspection shows 
 precordial bulging over the right heart, a diffuse heart shock from 
 hypertrophy and dilatation of the right heart, and a weak or absent 
 apex beat. 
 
 2. Palpation. — Palpation confirms the above and reveals a sys- 
 tolic thrill in the left second interspace. The pulse is weak. 
 
 3. Percussion. — Percussion shows an area of increased dulness 
 over the right heart from dilatation. 
 
 4. Auscultation. — On auscultation, a loud and usually whistling 
 or musical systolic murmur, caused by the stenosis, is often but not 
 always heard and the first and second pulmonic tones, hence also the 
 second tricuspid, are weak or absent from poor filling of the pul- 
 monary vessel and from valve alteration. (See Plate X, Fig. E.) 
 
 Diagnosis. — The most frequent form is (a) the congenital, which is 
 due to malformation, myocarditis or endocarditis, and is usually as- 
 sociated with kindrecUesions (e. g., open ductus Botalli or foramen 
 ovale). The obstruction may be below the valves, from myocarditic 
 scars narrowing the conus arteriosus, in which case the second pul- 
 monic sound is accentuated; or it may be at the valves or in the 
 
TRICUSPID INSUFFICIENCY. 403 
 
 trunk of the artery. Congenital cyanosis and acquired pulmonary 
 tuberculosis are common. The murmur may be heard in the neck. 
 (b) The acquired valvular form is rare. Atheroma or gummata 
 may be causal. The thrill is also, though far less frequently, felt in 
 accidental murmurs which are most common over this area because 
 the walls of the artery are so thin and compressible as to vibrate 
 easily. These " functional " murmurs are so common in this locality 
 as well to justify Frantzel's rule to observe extreme caution in the 
 diagnosis of right-heart lesions in the adult. Functional murmurs 
 may occur (i) in health; (ii) fevers; (iii) ansemia; (iv) as the 
 cardiopulmonary murmur. The organic murmur rarely reaches the 
 jugular or cervical vessels. The left heart is frequently atrophic. 
 When the acquired stenosis is beyond the valve in the pulmonary 
 trunk or lungs, the murmur is heard most advantageously along 
 the right border of the sternum or in the back, and the second 
 pulmonic sound is loudly accentuated, from which points a diagnosis 
 occasionally may be made. In atresia of the orifice 80 per cent, of 
 the subjects die in the first year. 
 
 IX. Tricuspid Insufficiency. — Etiology. — (a) The congenital form 
 is most rare, isolated tricuspid disease occurring in 0.8 per cent, 
 of cases of valvular lesions. The venosity of the blood in the right 
 heart tends to prevent endocarditis, except in foetal life when the blood 
 is arterial. Myocarditis or ulcerative endocarditis may exceptionally 
 occur, (b) Of acquired forms, the relative insufficiency is very com- 
 mon, resulting from (i) valvular lesions of the left heart, especially 
 mitral stenosis ; (ii) obstructive lung lesions, such as induration or 
 emphysema; (iii) possibly abdominal lesions which reflexly contract 
 the pulmonary vessels; and (iv) in severe anaemias (Leube), in 
 which, however, cyanosis and dyspnoea are not observed. 
 
 Mechanism. — Whatever the cause of the high pressure in the lesser 
 circulation, it leads to dilatation and hypertrophy of the right ven- 
 tricle. Extreme dilatation stretches the tricuspid orifice so that the 
 valves cannot cover it, and relative leakage occurs. The leak back- 
 ward into the right auricle produces its dilatation and hypertrophy, 
 a systolic murmur and a systolic pulse in the veins of the neck and 
 liver. 
 
 Physical Signs. — 1. Inspection. — (a) A positive (systolic) pulse 
 in the jugular veins is absolutely pathognomonic and is due to systolic 
 entrance of blood into the veins from the right ventricle through the 
 insufficient valves. It is presystolic-systolic and is known as positive 
 to differentiate it from the negative or diastolic venous pulse which is 
 observed in many other conditions, and either physiologically, as on 
 deep inspiration, caused by temporary damming back of the blood by 
 the auricular systole, or pathologically, as in stasis. It is seen best 
 on the right side because of the more direct vertical connection 
 with the right innominate vein. A certain degree of heart force is nec- 
 essary for its production, and it may cease therefore when the heart 
 grows weak. Digitalis may cause it to reappear in cases of relative 
 
404 
 
 DISEASES OF THE CIRCULATION. 
 
 and sometimes of organic leakage. It is best seen when the patient is 
 in the dorsal decubitus. To avoid confusion with pulsation transmitted 
 from the carotids, the carotid should be compressed as low down as 
 
 Fig. 23. 
 
 Negative (diastolic-presystolic) venous pulse. (After Riegel and Sahli.) 
 
 possible, or the pulsating jugular vein should be compressed at the 
 middle ; the upper part will then pulsate if the carotids beat against 
 it (transmitted pulsation) and the lower part will beat if the pulsa- 
 tion is in the vein itself. Though it is seen most advantageously 
 in the internal jugular vein, it is sometimes seen in the inferior vena 
 cava or in the veins of the chest and extremities. It is difficult to 
 
 Fig. 24. 
 
 Positive (presystolic-systolic) venous pulse. (After Riegel.) 
 
 determine when the heart is rapid or irregular. (&) A liver pulse, 
 systolic in time, venous regurgitant in origin, is also pathognomonic 
 of this disease, (c) The right heart pulsates widely, while the apex 
 beat is weak. 
 
 2. Palpation. — (a) This aids in determining the systolic phase of 
 the venous pulse, and (b) it establishes the systolic venous pulsation 
 of the liver, which expands in the bimanual examination. It is easier 
 to find, and often earlier to appear than the jugular pulsation. It 
 must not be confused with an arterial liver pulse, which occurs in 
 cases of aortic leakage, exophthalmic goitre and liver inflammation, 
 but is less expansile than throbbing, (c) A systolic thrill over the tri- 
 cuspid area; (d) tones or thrills over the peripheral veins; and (e) 
 a weak apex and radial pulse are also found. 
 
 3. Percussion. — This shows increased dulness to the right, from 
 distention of the right auricle and ventricle. Changes in the left 
 heart may indicate an older valvular lesion which causes the tricuspid 
 leakage. (See Plate X, Fig. D.) 
 
T BICUSPID STENOSIS. 
 
 405 
 
 4. Auscultation. — (a) A faint systolic murmur is heard over the 
 tricuspid region; the causal mitral murmur is higher pitched, more 
 superficial and louder. Unlike the murmur caused by mitral lesions, 
 
 Fig. 25. 
 
 Illustrating the influence of respiration on the positive (presystolic-systolic) venous 
 pulse of the jugular vein. (After Kovacs.) 
 
 it is rarely heard in the back but is heard to the right of the sternum. 
 The murmur is absent when the right heart is weak, because it then 
 fails to produce the necessary vibration or eddy, (b) The second 
 pulmonic sound is weak because the pulmonary circuit is poorly filled. 
 This tone often varies with the changing activity of the right ventricle. 
 It may remain accentuated even with tricuspid leakage when the ven- 
 tricle is fairly strong, (c) Over the cervical veins may be heard a 
 systolic tone referable to closure of valves in the veins; the tone 
 may be double, or presystolic-systolic; or venous murmurs may take 
 the place of the single or double tone. 
 
 Diagnosis. — An isolated lesion is most rare. The relative insuffi- 
 ciency is diagnosticated by means of (a) the etiology, (b) the very 
 large right heart, (c) the faint systolic murmur, (d) the positive 
 venous pulse in the neck, disappearing under digitalis and rest and 
 (e) the weak second pulmonic tone. Even when tricuspid incom- 
 petency is apparently the only lesion, it should be remembered that 
 rest or digitalis very often brings out a causal mitral lesion. The 
 " safety valve " action of the tricuspid valves is compensatory. 
 Guarding as they do the door between the venous and arterial cir- 
 culation, their insufficiency indicates most serious cardiac failure. 
 
 X. Tricuspid Stenosis. — Tricuspid stenosis is rarer than tricuspid 
 insufficiency; it occurs alone in only 10 per cent, of the cases; it is 
 more often associated with insufficiency, or with aortic or mitral 
 stenosis; the latter is coincident in half the cases. In about half 
 the cases there is a history of rheumatism or chorea; three-quarters 
 of the cases occur in women. Obstruction of this orifice induces 
 hypertrophy and dilatation of the right auricle, and this produces 
 dulness to the right of the sternum. In the single lesion the other 
 heart chambers and the large vessels are small. The pulse is weak. ' 
 The second pulmonic sound is weak; a diastolic or presystolic mur- 
 mur and thrill to the right of the sternum are detected if the heart 
 is sufficiently strong, but they are often absent. The lesion is most 
 serious, because it taxes the weak auricle and greatly engorges the 
 venous system. In the jugular vein there is a presystolic wave. The 
 diagnosis is usually impossible. (See Plate X, Fig. D.) 
 
406 DISEASES OF THE CIRCULATION. 
 
 XI. Combined Valvular Lesions. — These occur, clinically, in 33 
 per cent, of valvular cases. From an anatomical standpoint, a pure 
 lesion is rare, and double lesions are found oftener than physical 
 signs would indicate. Pure lesions occur most often on the arterial 
 valves. One lesion may follow another; for instance, stenosis may 
 gradually result from insufficiency, sometimes with good results; or 
 combined lesions may develop simultaneously. 
 
 (a) Combined mitral lesions are most frequent, though one lesion 
 usually predominates; (b) combined mitral and aortic lesions, e. g., 
 aortic vegetations reaching the nearest mitral cusp, are next in fre- 
 quency; (c) double aortic lesions are less common; (d) combined 
 aortic, mitral and tricuspid lesions, e. g., stenosis of each orifice with 
 no signs other than slowing of the circulation, occur in 16 per cent., 
 and (e) combined mitral and tricuspid lesions (especially relative 
 tricuspid insufficiency) occur still less often (in 9 per cent.). 
 
 Diagnosis. — The diagnosis depends upon the character of the pulse, 
 the quality and direction of transmission of the different murmurs, 
 and the hypertrophy and dilatation of the right or left heart. Skoda' s 
 rule was that a murmur is usually most intense at its point of origin 
 except in cases of aortic insufficiency; and Oppolzer held that when 
 listening to the mitral and pulmonary valves, murmurs transmitted 
 to them disappear as examination is made more to the left, while 
 murmurs due to lesions on these valves remain ; on listening further 
 to the right, the true tricuspid and aortic murmurs remain and those 
 which are transmitted disappear. In diagnosis, the seeking out of 
 the main lesions and the avoidance of too complicated diagnoses lead 
 to the most practical results. 
 
 In cases of combined aortic and mitral disease: (a) Aortic insuffi- 
 ciency and mitral insufficiency lead to dilatation and hypertrophy of 
 both ventricles; the combination is frequent in children; the aortic 
 findings as to pulse are frequently modified ; the mitral insufficiency 
 may be relative (muscular) or organic (valvular), and this can be 
 determined only by close and continued observation. (&) Aortic 
 stenosis and mitral insufficiency are next in frequency and are the 
 most common combination in adults; less blood reaches the arteries 
 than in simple aortic stenosis; the right heart suffers disproportion- 
 ately, whence the severity of this complication. The systolic murmurs 
 usually vary from each other in location, transmission and quality, 
 (c) Aortic insufficiency with mitral stenosis is a relatively frequent 
 and favorable combination, because the left ventricle is usually less 
 dilated; both may produce presystolic apical murmurs and therefore 
 the state of the right heart and the second pulmonic tone are all- 
 important diagnostically. (d) In combined aortic and mitral stenosis 
 the greater the aortic stenosis the more is the hypertrophy of the left 
 ventricle ; the more dominant the mitral stenosis the less is the hyper- 
 trophy of the left ventricle and the greater is the dilatation and 
 hypertrophy of the right ventricle. Differentiation is often difficult. 
 
SYMPTOMS OF VALVULAR DISEASE. 
 
 407 
 
 General Symptoms of Valvular Disease. — The heart possesses not 
 only a certain reserve power but in favorable instances its muscula- 
 ture hypertrophies. Symptoms may easily be lacking in the early 
 stages, but later compensation to meet the lesion may fail, either 
 temporarily, " disturbed compensation," or permanently, " loss or 
 rupture of compensation." This is the asystolie of French writers. 
 Every hypertrophy is more or less temporary in its compensation, 
 and ultimate cardiac failure is inevitable. All lesions, practically 
 speaking, tend to reduce arterial tension, increase venous pressure, 
 retard the capillary flow and promote embolism. Circulatory dis- 
 turbances may be spontaneous or induced by psychical excitement, 
 physical exertion, intercurrent disease, recurrent endocarditis, mal- 
 nutrition, excessive use of alcohol or tobacco, or changes in the heart 
 muscle. The symptoms and physical findings are more or less com- 
 mon to all lesions, but some are more frequent in certain forms of 
 valvular disease. 
 
 1. Constitutional Symptoms. — Ansemia is frequent (aortic insuffi- 
 ciency) ; polymorphonuclear leukocytosis is present in half the mitral 
 cases ; Andral spoke of a " heart cachexia " ; the body temperature is 
 normal or subnormal from slow circulation. Fever is due to recur- 
 rent endocarditis, embolism or intercurrent disease. In tricuspid 
 stenosis the red cells may be increased (polycythemia). The nails 
 are often clubbed in congenital lesions. Skin hemorrhages are due 
 to " blood dissolution " or less frequently to embolism. 
 
 2. Cardiac Signs and Symptoms. — Apart from actual change in the 
 chambers, such as dilatation and hypertrophy, the heart itself is not 
 well nourished in " breaking compensation," for it receives less ar- 
 terial blood and is engorged with venous blood. The heart muscle is 
 in some cases fatty, and in others is the seat of myocarditis about the 
 arteries or some cyanotic induration about the veins. These changes 
 are less the cause than the effect of lack of compensation;. the autopsy 
 and the microscope may fail to demonstrate the cause of broken 
 compensation. Here and there pressure atrophy occurs, as in the 
 papillary muscles (aortic regurgitation). The rhythm is frequently 
 
 Pig. 26. 
 
 Pulsus trigeminus. 
 
 disturbed, especially in mitral lesions (stenosis). The sphygmo- 
 graph sometimes shows two ventricular contractions occurring very 
 close together (pulsus bigeminus) ; when the pulse intermits to the 
 finger, the tones of the abortive contraction may be heard over the 
 heart with the stethoscope, the weaker wave failing to reach the 
 periphery. In general, the pulse beats are fewer than the heart 
 
408 DISEASES OF TEE CIRCULATION. 
 
 beats. The gallop-rhythm is sometimes heard (Bouillaud 1847). 
 In great irregularity tones and murmurs are indistinguishable (de- 
 lirium cordis). The pulse is slow (the bradycardia of aortic sten- 
 osis) or faster than normal, tachycardia (mitral lesions). 
 
 Among the complications are pericarditis (aortic lesions) and re- 
 current endocarditis. Palpitation is frequent, either continuously or 
 intermittently, and is sometimes induced by lying on the left side. 
 It may be absent with the greatest heart alteration. A sense of 
 tension over the heart is not infrequent, and pain like angina pectoris 
 occurs in aortic oftener than in mitral disease (Nothnagel). 
 
 3. Nervous Symptoms. — These are not frequent. Syncope (aortic 
 stenosis especially) occurs from arterial anaemia of the brain. Ven- 
 ous congestion is evidenced by repeated epistaxis, vertigo, tinnitus 
 or muscce volitantes. Brain hemorrhage is infrequent (mostly in 
 aortic insufficiency). Chorea, epileptiform seizures and embolism 
 of the Sylvian arteries are sometimes observed; the psychoses are 
 delirium, mania, melancholia and suicidal tendencies, and are usu- 
 ally of unfavorable import ; stasis, inanition, carbon-dioxide narcosis 
 and renal inadequacy are their cause. Retinitis hemorrhagica and 
 simple retinal hemorrhages result from stasis and anaemia. 
 
 4. Respiratory Symptoms. — Lung stasis is sometimes confused with 
 independent lung disease on account of dyspnoea, cough and expec- 
 toration. Cyanosis occurs more often in mitral than in aortic disease 
 and is most intense in lesions of the pulmonary orifice. Bronchitis 
 and hcemoptysis are most common in mitral affections. Bronchitis 
 results less from congestion in the lesser circuit than from congestion 
 in the cava superior, into which (and the azygos) the bronchial veins 
 empty. Though usually bilateral, it may predominate on one side 
 from local causes as pleural adhesions. Haemoptysis results from 
 lung stasis with vessel rupture, from embolism emanating from right- 
 heart clots, thrombosis in the pulmonary and less frequently in the 
 peripheral veins, or from sclerosis in the pulmonary artery. The 
 sputum may resemble that of pneumonia, though it is darker, more 
 venous and less viscid. It contains the so-called " heart-disease 
 cells" (E. Wagner). They are large granular delicate cells with 
 oval nuclei, which often contain hemosiderin or more rarely hsema- 
 toidin; they are probably alveolar epithelial cells and also occur in 
 other lesions than brown induration (as emphysema, asthma, pneu- 
 monia and phthisis). (See Plate XL) Pulmonary oedema (q. v.) is 
 either (a) due to weakening of the left ventricle while the right heart 
 beats more strongly or (b) far less frequently is inflammatory. 
 Crepitant rales are frequently heard. In mitral disease the lungs 
 frequently become distended and rigid from engorgement of the capil- 
 laries, and closely resemble emphysema if not identical with it (von 
 Basch's Lungenschwellung und Lungenstarrheit) . Brown induration 
 (cyanotic induration) of the lungs has for its anatomical basis, (a) 
 capillary engorgement, often with fatty change in the intima, (b) 
 increased inter-alveolar and perivascular connective tissue, (c) hem- 
 
PLATE XI 
 
 Heart Disease Cells, showing Alveolar Epithelial Cells, Loaded 
 Down with Granules of Heematin. (Simon.) 
 
SYMPTOMS OF VALVULAR DISEASE. 409 
 
 orrhage into the lung from vessel rupture, (d) consequent pigmen- 
 tation by the altered blood-pigment of the lungs and sputum, and 
 (e) the "heart-disease cells." Dyspnoea, the "cry of distress of the 
 myocardium" (Sansom), constant, intermittent or nocturnal, is 
 caused by unbalanced slow circulation, the bulging of the turgid 
 capillaries into the alveoli, pressure of the heart on the lower left 
 lobe or left bronchus, ascites, hydrothorax, oedema, bronchitis or 
 infarcts. The intimate mechanism of dyspnoea is obscure. F. Kraus 
 has shown that the change of air is the same as in health ; he regards 
 the disturbed circulation as at fault; Hofbauer fixes the blame on 
 the decreased elasticity of the lung; Francois Frank assumes a reflex 
 from the coronaries or aorta which causes a spasm of the pulmonary 
 vessels ; Jellinek and Cooper describe a sclerosis of the right coronary 
 artery ("cardiac asthma is a right-sided angina"). It may come 
 on even without exertion when there is constipation or poor digestion ; 
 or it may occur especially at night when the voluntary deep and 
 diaphragmatic respiration of the waking hours is not in play, whence 
 the respiratory centre becomes anaemic. The dyspnoea is not expira- 
 tory as in asthma but is mixed in type. The gallop-rhythm is rarely 
 absent, and this threatens relapse of the dyspnoea ; arteriosclerosis and 
 nephritis are important elements in its production. Exertion not 
 only increases the heart's work but the carbon dioxide and fatigue 
 substances from the muscles irritate the respiratory centre, and the 
 respiratory muscles ultimately become tired. The breathing is more 
 rapid. It may be Cheyne-Stohes in type (aortic stenosis) ; cerebral 
 anaemia, arteriosclerosis and uraemia are its causes. Hypostasis and 
 lobular pneumonia may develop. Hydrothorax may hasten death 
 within a few hours (Andral). 
 
 5. Gastro-intestinal Changes. — Gastralgia, anorexia, hemorrhagic in- 
 filtration and erosion, vomiting or haematemesis, result from passive 
 congestion and may be mistaken for independent gastric disease, such 
 as cancer or ulcer. Delayed digestion and constipation are usual. 
 The secretion of hydrochloric acid is normal except in cases of 
 marked weakness of the heart. Intestinal hemorrhage may result 
 from capillary congestion, rarely from embolism of the mesenteric 
 artery, and most infrequently from mesenteric venous thrombosis. 
 
 6. Changes in the Liver. — The liver suffers stasis through the con- 
 gested cava and hepatic vein ; this leads to cyanotic distention of the 
 central veins of the liver lobules (appearing dark) and to cloudy and 
 fatty degeneration of their periphery (appearing lighter), the "nut- 
 meg liver." This occurs particularly in mitral disease. The liver is 
 not uniformly affected. Pigmentation occurs and connective tissue 
 develops in the liver and its capsule (perihepatitis, "iced liver"). 
 Small granulations develop on its surface and in some instances a 
 liver shrinkage results from "cyanotic induration" (cardiac cir- 
 rhosis). The liver is symmetrically large before oedema appears; 
 when disturbed compensation is being restored, it is one of the last 
 symptoms to disappear. Occasionally, from local changes, a tumor- 
 
410 DISEASES OF THE CIRCULATION. 
 
 like enlargement of the liver may simulate cancer. There is a 
 feeling of tension and weight in the right hypochondrium and the 
 organ is tender and variable in size; it may become smaller from rest 
 or digitalis. Its edge is rounded and not hard except in the late 
 stages. (See Differential Table of Hepatic Diseases.) The 
 icterus viridis develops gradually and is a combination of mild icterus 
 and cyanosis ; icterus is rarely intense but is of the " urobilin " type ; 
 it is rarely sudden except in the infrequent embolism, which may 
 cause a clinical picture resembling acute yellow atrophy. Ascites 
 is usually late and secondary to the liver congestion ; its early appear- 
 ance is indicative of independent liver disease or peritoneal affections. 
 It is sometimes chyliform. 
 
 7. Changes in the Spleen. — The spleen is sometimes increased from 
 embolism or liver disease, but is often hard and small. 
 
 8. Changes in the Kidneys. — The kidneys are enlarged from hyper- 
 emia, the capsule strips readily, and scattered areas of blood extrava- 
 sation are seen. The stellulce Verheynii are prominent, as also are 
 the glomeruli. Epithelial degeneration follows malnutrition and, in 
 cases of long standing, " cyanotic induration " occurs. Deformity 
 from the stellate scars of healed embolism and fresh infarcts are 
 often encountered. 
 
 Renal symptoms are greater, the higher the venous and the lower 
 the arterial blood pressure. The urine is decreased — its daily amount 
 being an accurate gauge of the heart's force ; it is of higher specific 
 gravity (1020 to 1030), very acid, and is highly colored from 
 urates and increased uric acid; the urea is decreased and also the 
 chlorides when oedema exists; albumin is frequent, and there may 
 possibly be a few red disks though these are usually due to embolism 
 or acute nephritis. The kidneys are slow to eliminate methyl blue 
 or potassium iodide. Krehl has found granular as well as hyaline 
 casts, contrary to the usual experience. (See Differential Table 
 of Diffuse Renal Diseases.) Chronic nephritis may coexist. 
 Rest and digitalis increase the amount of urine and decrease or re- 
 move the albumin. Iu women, menstruation is frequently increased 
 by passive congestion. 
 
 9. Embolism. — Embolism occurs as in acute endocarditis but its 
 significance and effects are wholly mechanical. Embolism occurs in 
 about one-third of the cases. Though it is most common in the kid- 
 ney (77 per cent.) and spleen (54.7 per cent.), it also occurs in the 
 left Sylvian artery of the brain (22.7 per cent.), in the extremities, 
 retina, liver, aorta (with paraplegia) and mesenteric vessels (in 1 
 percent,). In the lungs it results from right-heart clots or throm- 
 bosis in the large peripheral or pulmonary veins. The special visceral 
 features of embolism will be discussed under Diseases of the Brain, 
 Lung, Kidney, etc. 
 
 10. (Edema. — This is a result of venous stasis, transmitted to the 
 lymph-vessels and interspaces, and is also an evidence of changes in 
 the vessel walls from actual blood alteration (hydremia). It ap- 
 
PROGNOSIS OF VALVULAR DISEASE. 411 
 
 pears first in the connective tissue of the lower extremities (right 
 leg) ; it disappears over night ; and it extends upward to the vulva or 
 scrotum, abdomen, chest and serous sacs (ascites, hydrothorax and 
 hydropericardium) and brain ventricles. The loss of fluid to the 
 system is unfavorable; the anasarca also impedes the arterial circu- 
 lation, threatens life from involvement of the glottis or lungs, in- 
 creases the tendency to secondary infections and may lead to hyper- 
 trophy of the connective tissue about the genitalia, — cardiac elephan- 
 tiasis. It is most common in mitral disease. The prognosis is less 
 favorable if the liver becomes very large before oedema appears. 
 
 11. Changes in the Joints. — Swollen joints and tabes dorsalis (aortic 
 insufficiency) are occasionally associated with valvular disease. 
 
 Course and Prognosis of Valvular Disease. — Patients may live for 
 years with compensated valvular affections; a case of aortic leakage 
 lived for twenty-five years and one of mitral leakage lived for 
 sixty-six years. As a rule the course is chronic and unfavorable, and 
 is influenced by the following conditions: 
 
 1. State of the Heart Muscle. — This muscle is the basis of hyper- 
 trophy and compensation. Myocarditis is most unfavorable whether 
 associated or not with coronary disease, for digitalis then has less 
 effect on the heart muscle. In cases where digitalis has immediate 
 effect, the prognosis is favorable. The size of the heart is more im- 
 portant than valvular murmurs. Great dilatation or dilatation with- 
 out hypertrophy is most unfavorable. 
 
 2. Sex. — The prognosis is generally better in women, because they 
 are less exposed and less subject to physical strain and coronary dis- 
 ease. Pregnancy as a rule is a rather unfavorable complication. 
 Peter advises, " In girls (with valvular lesions), no marriage; in 
 wives, no pregnancy; in mothers, no nursing." 
 
 3. Age. — In the first decade of life the prognosis is poor, even 
 though the heart and coronary vessels are young, because hypertrophy 
 and dilatation are extreme, exercise is difficult to regulate, the valvu- 
 lar lesion tends to recur and the endocarditis tends to develop into 
 pericarditis or pancarditis. After puberty the outlook is better, 
 except, of course, in congenital types. 
 
 4. Valve Involved. — Opinions vary widely. In aortic insufficiency, 
 the outlook depends on the type, being fair in the endocarditic and 
 most ominous in the atheromatous type. Clinicians disagree as to 
 the relative outlook in mitral and aortic lesions, although subjects 
 of mitral insufficiency seem to have the more favorable prognosis. 
 Broken compensation is more likely to be restored in mitral insuffi- 
 ciency than in mitral stenosis or in aortic lesions. Mitral stenosis is 
 less favorable, although it is often found in women at an advanced 
 age. Aortic stenosis is also found at an advanced age. Combined 
 or multiple lesions, with some few exceptions, are unfavorable. The 
 writer observed a complete recovery from a double mitral lesion; in 
 eight years after the causal rheumatism the outlines and tones became 
 
412 DISEASES OF TEE CIRCULATION. 
 
 perfectly normal. Pulmonary lesions predispose to early tuberculosis. 
 
 5. Mode of Life. — The social scale, hygiene, necessity of hard work, 
 psychical excitement, alcoholism, exposure and the individual con- 
 stitution are most important factors. 
 
 6. Unfavorable Symptoms. — Cardialgia, angina pectoris, embolism, 
 persistent palpitation, dyspnoea and irregular or intermittent pulse 
 are unfavorable symptoms. The " reserve heart power" of Martius 
 is not present in all cases ; this is due to failure of the coronary ves- 
 sels to increase their calibre (Verney). 
 
 7. Favorable Conditions. — As described by Sir Andrew Clark, these 
 are good general health, just habits of living and absence of special 
 rheumatic tendencies, endocarditic (not atheromatous) origin, no 
 changes in the heart after three years observation, sound ventricles 
 and arteries, and freedom from stasis in the lungs, liver and kidneys. 
 
 8. Sudden Death. — In most cases, sudden death occurs in aortic 
 affections from coronary disease, but it may also result from cerebral 
 or pulmonary embolism, thrombosis cordis occluding a valvular ori- 
 fice, heart rupture, sudden ventricular dilatation and glottis oedema. 
 
 9. Intercurrent or Associated Disease. — Tabes, syphilis and chorea 
 have been mentioned. The acute fevers greatly tax the myocardium. 
 Tuberculosis (q. v.) is found in 8 per cent, of autopsies on valvular 
 subjects. 
 
 Treatment of Valvular Disease. — (A) In Compensated Lesions. — In 
 
 compensated lesions medicinal treatment is unnecessary. With some 
 exceptions, the patient is informed of the nature of his trouble that 
 his cooperation may be enlisted. The mode of life is important, i. e., 
 regular orderly living, as free as possible from psychical or sexual 
 excitement, worry or hurry. Especial care should be enforced in 
 aortic cases because of danger of sudden death. Much depends on 
 the social status of the patient. The diet should be simple but not 
 too schematic. Tobacco and alcohol should be interdicted as a rule ; 
 beer and champagne are poorly tolerated, though some red wine and 
 brandy or cognac are permissible in some adults and in the aged. 
 Coffee may be given in the morning but should not be strong/ for 
 cardiac irregularity frequently results. A breakfast of milk may be 
 taken before rising, and the noon meal should be the heartiest of the 
 day. Nitrogenous food is best, with light carbohydrates, as toast; 
 foods which ferment, such as cabbage, beans or brown bread, should 
 be avoided and the amount of fluid ingested should be moderately 
 restricted. Foods which load the stomach heavily are prone to ele- 
 vate the diaphragm, and every meal somewhat taxes the heart. A 
 light meal at night is- the best precaution against gastric and cardiac 
 oppression during the sleeping hours. A milk diet is recommended 
 in cases of stasis, especially when there is much hepatic congestion, 
 but it necessitates the ingestion of too large quantities of fluid. 
 
 Exercise.— Exercise in cases not too far advanced is advisable 
 for the muscles can accommodate all the blood of the body, but their 
 
TREATMENT OF VALVULAR DISEASE. 413 
 
 activity renexly stimulates the heart muscle. Palpitation, recurrent 
 endocarditis and intercurrent fever necessitate keeping the patient in 
 bed. Moderate massage is beneficial, but care must be taken lest it 
 produce dilatation of the abdominal vessels. Deep breathing and 
 singing are beneficial. Plethoric patients should be given an enema 
 of salines, which should be allowed to remain in the bowels over 
 night. Tepid are more beneficial than cold or hot baths. 
 
 Climate. — High altitudes are to be avoided, although moderate 
 elevation is tonic. The seashore often disagrees with rheumatic or 
 catarrhal subjects. A warm climate should be chosen for the winter. 
 
 (B). Broken Compensation. — Broken compensation may be acute, 
 gradual or terminal, as by coronary occlusion, and is evidenced by 
 dyspnoea which develops on exertion or spontaneously during the 
 night, by anaemia, by irregular pulse (of special coronary significance 
 in aortic cases) and by dilatation. The indications are as follows: 
 
 1. Absolute Rest in Bed. — This is frequently curative. Lieber- 
 meister's case of severe cardiac disease which recovered while in bed 
 with a broken leg, is an example of compensation restored without 
 digitalis or other drugs. Rest is imperative in intercurrent fevers, 
 bronchitis, recurrent endocarditis and acute cardiac insufficiency. 
 Bed sores can be prevented by the use of water-cushions and by 
 cleanliness. Some patients are obliged to sit up because of dyspnoea. 
 The head may be -propped up by back-rests, but they should have side 
 supporters so that falling to sleep will not waken the patient. Rest 
 should be combined with purgation (v. i.). 
 
 2. Saline Purgation. — Epsom or Glauber salts 5ss-j in concen- 
 trated form should be given in the morning or compound jalap 
 powder 3ss-j at night. These remedies deplete or bleed, as it were 5 
 the portal circulation and relieve the heart. Constipation per se often 
 increases the size of the left heart. 
 
 3. Venesection. — This is necessitated by extreme venous en- 
 gorgement evidenced by cyanosis, orthopnoea, dilatation or tricuspid 
 leakage. One pint to nearly a quart may be drawn. The effects are 
 often transient but are sometimes wonderful. In two cases appa- 
 rently dying of valvular disease, where no blood could be obtained 
 from the arms, the external jugular veins were opened, and the 
 patients lived more than a year afterward. Venesection is not to be 
 left until the patient is in extremis. It may be necessary to have the 
 patient "actively move the arm so as to bring the blood from the 
 capillaries into the veins" (Liebermeister). 
 
 4. The Oeetel and Schott Methods. — (See page 366.) 
 
 5. Digitalis — Digitalis was first recommended by Wm. Wither- 
 ing (1785) and its physiological action demonstrated by Traube. 
 Its general indications are (a) dilatation: digitalis restores tonicity 
 to the heart-muscle upon which the drug exercises its main influ- 
 ence; (b) functional dissociation: it is claimed that the ventricles 
 have different innervation and that the drug is most efficacious when 
 the pulmonary and venous circulations are engorged from too weak 
 
414 DISEASES OF THE CIRCULATION. 
 
 systole of the right and too strong systole of the left ventricle. When 
 the pulse is irregular, digitalis coordinates the cardiac energy 
 (rhythmicity) by action on the heart muscle and its ganglia or upon 
 the terminal branches of the vagus, (c) Rapid, weak, heart action: 
 digitalis slows the heart by action on the vagus and by increasing 
 arterial pressure. It tends to abolish abortive cardiac contractions 
 (v. s. pulsus bigeminus), and synergizes the systole of the chambers, 
 as is shown by the strong systolic spasm of the heart in cases of digi- 
 talis poisoning. The slower and stronger systole empties more com- 
 pletely all the heart-chambers, forces the venous and arterial blood 
 into the main arteries, and squeezes the venous blood out of the 
 heart muscle itself, thereby improving the intrinsic heart circulation. 
 The slower and more complete diastole allows of better filling of the 
 heart and drainage of the engorged veins. Digitalis raises the 
 arterial tension by increasing the working power of the heart and by 
 its centric and local action on the vasomotors. 
 
 In the individual lesions: (a) in mitral stenosis, the longer diastole 
 drains the left auricle and lung vessels and the stronger systole forces 
 the retarded blood through the stenotic orifice; (b) in mitral insuffi- 
 ciency, the best results are obtained; the leaking cusps are better 
 coapted and the stronger systole fills the aorta and pulmonary artery ; 
 (c) in aortic stenosis, when dilatation occurs or the hypertrophy is 
 inadequate, digitalis is valuable; (d) in aortic regurgitation, it is 
 theoretically contraindicated since it increases the diastole and hence 
 the leakage ; it is, however, valuable in decompensation. 
 
 Digitalis is contra-indicated (a) in balanced compensation; (&) in 
 adequate hypertrophy; (c) unless rest and purgation have first been 
 tried; (d) when the vessels are fragile, as in aneurysm and advanced 
 atheroma (on account of danger, e. g., of brain hemorrhage) ; (e) in 
 fatty degeneration of the heart, except when resulting from stasis 
 and malnutrition; (/) in vascular contraction. It is in this case 
 combined with nitroglycerine, strophanthus or potassium iodide, for 
 the purpose of " unlocking the arteries " (Balfour). The drug is not 
 absolutely contra-indicated in the high tension of arteriosclerosis and 
 nephritis, for it may relieve the condition, paradoxical as this may 
 seem, by lessening dyspnoea and carbon-dioxide narcosis and equal- 
 izing the circulation, (g) In idiosyncrasy to the drug, e. g., when 
 there are gastrointestinal symptoms which, however, are more often 
 due to stasis. Digitalis also causes contraction of all unstriped mus- 
 cular tissue (gastric, vascular, muscular). It may cause insomnia, 
 delirium, headache, diplopia, blindness to green colors, etc. Digitalis 
 is said to dilate the left and contract the right coronary artery ; there- 
 fore when the right coronary vessel is diseased, it may dilate and 
 cause excessive contraction of the right ventricle and thus dissociate 
 the heart's action. 
 
 Cumulative action is averted (a) by intermittent administration, 
 although some patients tolerate digitalis continuously for months or 
 years, as Thomeyer's patient who used digitalis eight and a half 
 
TREATMENT OF VALVULAR DISEASE. 415 
 
 years, taking in all over 15 ounces of the solid digitalis; (b) by great 
 care in ambulatory cases; (c) by care in cardiac dropsy, on relief of 
 which toxic quantities may be resorbed from the tissues ; (d) by care 
 in intercurrent febrile affections, for toxic effects often follow the 
 fall of temperature; (e) by withdrawal on the appearance of vomit- 
 ing, syncope, reduced urine or irregular pulse (with twice as many 
 heart as pulse beats); in the latter condition Hewlett combines 
 atropine and digitalis. Twenty-seven cases of pulsus bigeminus from 
 the use of digitalis are reported. 
 
 Digitalis may fail to operate unless free purgation, venesection 
 and mechanical removal of the anasarca have been first employed. 
 
 Preparations. — Some physicians prefer the powder, gr. j, others 
 the tincture, TTLxv to xx, or the infusion Sss— j. The infusion is 
 considered more diuretic (containing digitalein and digitonin). 
 
 ]£ Infusi digitalis 3iij- 
 
 Spts. SBtheris nitrosi 3j. 
 
 Potas, bicarbonatis 3ss. 
 
 Aquae 3ij. 
 
 M. et S. — One tablespoonful after meals. 
 
 Larger doses may be given though with risk. It is excellent for rectal, 
 use when the stomach is irritable. The tincture is thought to be the 
 best cardiant because it contains digitalin and digitoxin. The 
 writer has found digitalin almost inert. Digitoxin has seemed of 
 doubtful value, but in the author's hands it has often slowed and 
 strengthened the weak and irregular heart (gr. /4oo t. i. d.), when 
 digitalis has failed ; it easily disorders the stomach, and often cannot 
 be given for more than six or eight doses. Digitoxin is often ad- 
 vantageously combined with champagne. Cloetta's digalen is a 
 soluble non-irritant digitoxin, and may be given intravenously, 1 c.c. 
 equalling 0.3 mg., or %so grain. The preparation acts promptly, 
 though it is somewhat irritating when given hypodermatically. For 
 hypodermic use, the fluidextract, TTlij to iv, is non-irritant. 
 
 6. Othee Cardiants. — (a) Strophantus, TTLv to x of the tincture 
 every eight hours, may be given. Advantages : it is more rapid in 
 action than digitalis, has no cumulative effects, perpetuates the ef- 
 fects of digitalis and is indicated in the irregular heart of mitral 
 disease, in children under twelve years, in cases where we are waiting 
 for the digitalis to act, and in dilatation where the blood pressure is 
 high. Disadvantages: it is less certain and less energetic; it is in- 
 ferior in oedema and does not give tone to the vessels (which may 
 be an advantage in atheroma), (b) Strychnine stimulates the vagus 
 and heart muscle, besides being a splendid vascular tonic (see Pneu- 
 monia, Treatment) and tonic to the nervous, gastric and blood- 
 making tissues. Given carelessly, it may irritate the heart, decrease 
 the urine by spasm of the renal vessels, or even induce rupture of the 
 vessels, (c) Sparteine sulphas (gr % to % every six or eight 
 hours) is given in capsule because of its bitterness ; larger doses may 
 
416 DISEASES OF THE CIRCULATION. 
 
 be given, gr. j to gr. iss; it seems to quiet the nervous system and 
 regulate the heart better than other cardiants (See) but is inferior to 
 digitalis. It does not contract the vessels. Convallaria and adonis 
 are very unsatisfactory. 
 
 7. Symptomatic Treatment. — (a) Dropsy. — Saline or hydra- 
 gogue catharsis often relieves moderate oedema. Digitalis, alone or 
 combined with calomel or blue mass and squills (Guy's pill) is often 
 efficacious — 
 
 I£ Digitalis gr. x. 
 
 Massas hydrargyri gr. vj. 
 
 Scillae gr. x. 
 
 M. et ft. capsular x. 
 
 S. — One after meals for one or two days. 
 
 Mercurials, which were recommended by Jendrassik, must be used 
 with the greatest care. The author saw, in consultation, a case com- 
 plicated by nephritis in which the tongue sloughed off after five grains 
 of calomel had been given. Desperate stomatitis may result in alco- 
 holic, myocarditic or nephritic subjects. Excess of digitalis, it must 
 be recalled, is held to suppress the urine by inducing renal spasm. 
 It is better to use potassium salts, as potassium acetate gr. xxx, t. i. d., 
 which are less abundant in the tissues than the sodium salts; the 
 potassium acetate, e. g., passes through the tissues and kidneys, taking 
 fluid with it (Bunge). Houchard proved that the diuresis following 
 digitalis was associated with increase of sodium chloride elimination. 
 Caffeine with digitalis is beneficial in dropsy when the pulse is slow, 
 the mind dull and the digestion sluggish; it may cause nervousness 
 or insomnia (therefore should be given early in the day), irregular 
 pulse (therefore should be combined with rum or brandy), or bilious- 
 ness ; gr. v should be given, but not for more than three days — 
 
 ~fy Caffeinae citratae 3ss. 
 
 Sodii benzoatis 3ss. 
 
 Aquae V. 5iij. 
 
 M. et S. — One hypodermicful (3ss) as indicated. 
 
 Diuretin (daily dosage of 60 to 90 grains) may have marvelous ef- 
 fects or may absolutely fail ; chemically it is sodio-salicylate of 
 theobromine; it contains 50 per cent, theobromin and operates on 
 the renal cells directly, and possibly also on the heart and vessels. 
 Canadian hemp (fluidextr. apocyni TTlxv) is hard to obtain pure but 
 sometimes justifies Benjamin Hush's term, "a vegetable trochar." 
 Sweats and the use of pilocarpine are both dangerous and injurious. 
 Mechanical drainage is recommended, by scarification, by multiple 
 knife or pinpricks, or by Southey's capillary tubes; but the best 
 method is by a single long deep incision down to the bone. Sodium 
 chloride should be excluded from the diet. (See Treatment of 
 Chronic Nephritis.) Ascites, from heart disease alone, rarely 
 necessitates puncture; it is indicated chiefly in coincident liver cir- 
 
TREATMENT OF VALVULAR DISEASE. 417 
 
 rhosis or chronic peritonitis. Hydrothorax is far more important, 
 and thoracocentesis should not be delayed when dyspnoea is urgent. 
 
 (b) Ancemia. — The administration of digitalis with iron, arsenic 
 and zinc phosphide often produces remarkable improvement; iron 
 and arsenic may be useful without employing digitalis at all. 
 
 ~fy Digitalis gr. xx. 
 
 Ferri reducti 3ss. 
 
 Arseni trioxidi gr. ss. 
 
 Zinci phosphidis gr. j. 
 
 M. et ft. pilulae, xx. 
 
 S. — One pill after meals; take for a week only. 
 
 Cod-liver oil is excellent in children. 
 
 (c) Insomnia. — It is often difficult to relieve insomnia or unrest- 
 ful sleep, broken by nightmare or sudden " heart starts." Spts. 
 chloroformi, spts. camphorse and spts. setheris compos, aa 3ss are 
 often helpful. Sulphonal (gr. xx in hot milk at bed-time) may be 
 tried but is somewhat dangerous in stasis, when used more than three 
 nights in succession. In morphia we place our chief reliance. 
 
 (d) Dyspnoea. — The ice-bag and spiritus glycerylis nitratis Tltj 
 are of value for high tension. Morphine may be given in the early 
 stages without hesitation and especially at night, for restlessness 
 and dyspnoea ; it is excellent while waiting for digitalis to act. It is 
 almost specific and lessens the irritability of the respiratory centre. 
 It requires care when the heart weakens or Cheyne-Stokes' breathing 
 is present. Dyspnoea is often renal or due to right-sided hydrothorax, 
 chronic bronchitis or excessive dilatation, and appropriate treatment 
 is indicated by catharsis, paracentesis, potassium iodide or digitalis, 
 respectively. 
 
 (e) Respiratory Symptoms. — Cough, cyanosis, pulmonary oedema 
 and haemoptysis are usually cardiac symptoms and have for their 
 anatomical basis pulmonary engorgement or brown induration ; they 
 are relieved by the cardiants. Balfour recommends the following 
 combination for associated bronchial catarrh : 
 
 ]£ Ammonii carbonatis 3j. 
 
 Tr. hyoscyami 3iv. 
 
 Potassii iodidi 3j. 
 
 Tr. digitalis 3j. 
 
 Infusi calumbse q.s. ad ^vj. 
 
 M. et S. — One teaspoonful every four hours. 
 
 Expectorants usually nauseate. Haemoptysis is often beneficial; it 
 may be regarded as a species of lung venesection and is seldom ur- 
 gent or fatal. For cyanosis, alcohol and camphor are indicated. Pul- 
 monary oedema necessitates phlebotomy, a 30-grain dose of lead ace- 
 tate, gr. %oo of nitroglycerine and gr. % of morphine. 
 
 (/) Palpitation and Pain. — For palpitation and throbbing, the ice 
 bag is the best calmative ; a precordial blister or a few minims of tr. 
 belladonnse and tr. aconiti are often helpful, 
 27 
 
418 DISEASES OF TEE CIECULATION. 
 
 ]£ Fluidextracti belladonnse gtt. xv. 
 
 Tr. digitalis 3j. 
 
 Aq. laurocerasi q.s. ad 3J- 
 
 M. et S. — One teaspoonful two or three times daily. 
 
 Care regarding the evening meal (see Diet) and the condition of the 
 colon is important. Ten grains of iodide of potash and nitroglycer- 
 ine (or gr. ss of erythrol tetranitrate which produces a more lasting 
 effect) are valuable for the pain of aortic lesions, especially when 
 accompanied by weakness, pallor, neuralgia, vertigo or headache. 
 
 (g) Gastric Symptoms. — These are troublesome and ominous when 
 the liver is enlarged and there is not much oedema. They are due to 
 portal stasis more often than to a cumulative effect of digitalis, which 
 should then be given by rectum. Small doses of phenol, gr. % every 
 half hour for five doses, and rectal nourishment are indicated. 
 
 CONGENITAL HEART-DISEASE. 
 
 These cases are infrequent, most complicated and occur largely in 
 the right heart, upon which more work devolves in foetal life. The 
 causes are (a) developmental errors, by far the most frequent cause ; 
 (b) foetal endocarditis is nearly always sclerotic and very rarely 
 verrucose; (c) foetal myocarditis or (d) adult endocarditis developing 
 upon developmental anomalies. They are most often seen in male 
 children, and heredity seems occasionally a factor. 
 
 1. Pulmonary Stenosis. — This, by far the most frequent con- 
 genital lesion, occurs in various forms; (a) stenosis or actual atresia 
 of the orifice itself from endocarditis or myocarditis. In this form 
 the second pulmonic tone is weak or absent. (&) Changes in the 
 conus arteriosus, which obstruct the onward flow of blood. The second 
 pulmonic sound is clearly heard, if the valves are normal. The con- 
 striction may make, as it were, a second ventricle, (c) The pul- 
 monary vessel beyond the valves is narrowed or converted into an 
 impervious cord; this is a grave type of pulmonary stenosis. The 
 second pulmonic sound is usually heard. 
 
 The physical signs are hypertrophy and dilatation of the right ven- 
 tricle, a thrill over the pulmonic area, and a systolic murmur prop- 
 agated into the neck when there is a defect in the interventricular 
 septum. These cases are more favorable than those in which such 
 defect does not obtain, because in them the right ventricle is atrophic 
 and the subjects rarely live over a year. In pulmonary stenosis other 
 congenital abnormalities are most common. If the closure or stenosis 
 arises before the end of the second foetal month, the interventricular 
 septum fails to close in 75 per cent, of cases and is pushed to the 
 left, so that the aorta may partly or entirely originate in the right 
 ventricle. If the closure develops after the second month, the fora- 
 men ovale remains patent (6 per cent.). Upon these openings acute 
 endocarditis is prone to develop. The ductus Botalli usually remains 
 open and thereby conducts blood from the aorta to the pulmonary 
 
CONGENITAL HE ART '-DISEASE. 419 
 
 artery and lungs. Should the ductus Botalli and the pulmonary ori- 
 fice be closed, collateral circulation is possible through the oesophageal, 
 pericardial and bronchial arteries. The right ventricle usually 
 hypertrophies, especially at the conus, but hypertrophic changes in 
 this chamber are not constant; the left heart is atrophic. 
 
 2. Defects of the Interauricular Septum. — The foramen ovale is 
 open to some extent in 44 per cent, of all autopsies, and the membrane 
 is deficient, cribriform or wholly absent. The foramen ovale usually 
 closes in the first week of life, but fails to adhere when low pressure 
 in the left auricle exists. Entire absence of the septum is the most 
 extreme defect possible ; this is called the " reptilian heart" or 
 cor biloculare when the interventricular septum is also absent, or 
 the cor triloculare when the ventricular septum is present. Its 
 patency aids compensation in this condition or when the valvular 
 orifices are narrowed or closed or when the great vessels are trans- 
 posed. Symptoms are absent or are those of the more important 
 associated trouble, for its patency is almost a necessity in some con- 
 genital lesions. Rare occurrences are presystolic murmur at the 
 level of the third or fourth ribs ; " crossed or paradoxical embolism/' 
 which may occur, for instance, in the brain from venous thrombosis in 
 the leg, the clot passing directly from the right to the left auricle ; and 
 positive venous pulse in mitral regurgitation. Several cases have 
 been found in living subjects over seventy years of age. 
 
 3. Defects of the Interventricular Septum (Maladie de Roger). 
 These have been spoken of under pulmonary stenosis. They may be 
 single, associated with other anomalies, or may result from myocar- 
 ditis. Sometimes a canal-like opening connects the aorta with the 
 right ventricle. The deficit occurs oftenest in the upper "unde- 
 fended " part of the septum. When it is wholly absent the heart has 
 but three chambers, the "trilocular heart" {cor triloculare biatria- 
 tum). Symptoms are absent, complicated or ambiguous. At times 
 the signs are those of mitral leakage without the lung symptoms of 
 stasis. A loud systolic murmur is heard over the upper third of the 
 precordium but does not reach the large vessels. 
 
 4. Patency of the Ductus Botalli. — The duct is usually closed by 
 proliferation of its coats within the first month of life, because the 
 pulmonary blood-pressure is lowered after birth. Thus premature 
 closure follows pulmonary stenosis, which necessitates poor filling of 
 the lungs with blood. Permanent patency of the duct is favored by 
 other congenital lesions or by atelectasis or pneumonia in the new- 
 born. It leads to increased blood tension in the lung. The second 
 pulmonic sound is accentuated, and the artery is frequently dilated, 
 whence the dulness in the second left interspace, with thrill, pulsation 
 and loud vibratory systolic murmur which may reach the cervical 
 vessels or the fourth dorsal vertebra behind. Sometimes the vessel is 
 so dilated as to compress the recurrent laryngeal nerve and thus cause 
 hoarseness. The right ventricle is hypertrophied and dilated; it is 
 distinguished in clear cases from pulmonary stenosis by the greater 
 
420 DISEASES OF THE CIBCULATION. 
 
 cyanosis of the latter lesion, the less frequent propagation to the neck 
 and the absence of the second pulmonic sound. 
 
 5. Persistent Isthmus Aortse. — The foetal developmental throm- 
 botic or inflammatory narrowing at a point between the left subclavian 
 artery and the ductus Botalli was described by Paris (1789). Maude 
 Abbott finds 198 cases on record. The narrowing is located in 46 
 per cent, below the duct, 37 per cent, at the duct, and 17 per cent, 
 over it and is characterized (a) by hypertrophy of the left ventricle 
 (50 per cent.) to overcome the stenosis, and sometimes by a systolic 
 murmur in the interscapular region; (b) by largeness and fulness 
 of the aorta above the isthmus, of arteries of the head, neck and arms 
 (full radials) ; (c) by a small, retarded, abdominal and femoral pulse, 
 corresponding to the anatomical smallness of the vessels below the 
 isthmus; (d) by a pronounced collateral circulation between the 
 branches of the aortic arch and those of the thoracic and abdominal 
 aorta, especially the internal mammary, inferior thyroid and trans- 
 versalis colli arteries. Other anomalies are present in 37 per cent, 
 of cases. 
 
 The pathologist makes the diagnosis, as he cuts through the large 
 vessels in the chest and abdomen, and the clinician suspects the lesion 
 when he feels the large vessels (present in 25 per cent, of the cases) 
 and the thrill in them or hears the systolic or less often, diastolic 
 murmur. Valvular lesions, especially aortic insufficiency, may co- 
 exist. Broken compensation may intervene, though all cardiac signs 
 may be lacking. Aneurysm and mediastinal tumor are frequently 
 confused with it. The aorta sometimes ruptures. The lesion is 
 nearly twice as common in the new-born as it is in adults. 
 
 6. Aortic Atresia or Stenosis. — The lesion is uncommon. The 
 conus arteriosus may be greatly constricted. If the lesion is develop- 
 mental, the interventricular and -auricular septa are open; if endo- 
 carditic or myocarditic, they are closed, provided the lesion develops 
 after the third month of foetal life. The left ventricle hypertrophies 
 in stenosis or atrophies in atresia, while the right ventricle hyper- 
 trophies in order to force the blood from the pulmonary artery 
 through the ductus Botalli into the aorta. The lesion may be asso- 
 ciated with other cardiac anomalies, with myo- or endocarditis, or 
 with chlorosis, tuberculosis or hemophilia. 
 
 7. Tricuspid Stenosis or Atresia.— This is developmental or in- 
 flammatory. In atresia the interventricular and -auricular septa are 
 open and the right heart is atrophic. Tricuspid insufficiency is 
 most rare. 
 
 8. Transposition of the Arteries and Veins.— In this lesion the 
 foramen ovale remains open ; the aorta originates in the right heart. 
 
 9. Valvular Anomalies.— These are largely of anatomical interest! 
 The semilunar valves, especially the pulmonary, may be increased 
 in number from three to ^Ye ; or they may be decreased to two, which 
 occurs especially in the aortic valves. Whether developmental or in- 
 flammatory in origin, accessory or abnormal valves are particularly 
 prone to acute or chronic endocarditis. Mitral anomalies are rare f 
 
CONGENITAL HEART-DISEASE. 421 
 
 10. Anomalies in Location and Development. — These are absence 
 of the heart, acardia, double heart or ectopia cordis, where the heart 
 lies in the abdomen, or in the pectoral (with fissured sternum) or 
 cervical regions. 
 
 Dextrocardia (dexiocardia) occurs with situs viscerum inversus; 
 the mitral valve has three cusps, the tricuspid has but two ; the pul- 
 monary veins empty into the right auricle; the pulmonary artery 
 arises from the left, and the aorta from the right, ventricle ; the aorta 
 runs to the right of the spine, to the right of the oesophagus and to 
 the left of the cava; the vena azygos is on the left and hemiazygos 
 is on the right ; the innominate artery is left-sided ; the right lung 
 has two lobes, the left three ; the bronchial fremitus is greater on the 
 left side, the left bronchus being larger; the spleen, liver, stomach 
 and colon are transposed ; the right kidney and testicle are higher than 
 the left. The heart is rarely transposed alone. In one case com- 
 plete transposition of all the viscera except the caecum occurred. 
 
 Symptoms of Congenital Heart Disease.- — Cyanosis is present in 90 
 per cent, of cases, whence the name " morbus cseruleus " ; it is more 
 intense than in acquired lesions. It usually appears early, and is 
 either general or limited to the nose, fingers, etc. ; the skin may be 
 actually purple, and this is due to mixing of the arterial and venous 
 currents, to a sluggish circulation in the small veins or to impaired 
 function of the red cells. Sometimes the cyanosis is paroxysmal, with 
 convulsions and dyspnoea ; then the anatomy is displaced aorta, septal 
 defect and pulmonary stenosis. Some subjects are anaemic, but a 
 most striking increase of the red cells up to 10 or 12 millions 
 (polycythemia rubra) is seen in some cases, probably as a compenr 
 satory effort. The haemoglobin may register 230 and the specific 
 gravity 1,077. Dyspnoea, cough, convulsions and marked clubbing 
 of the fingers and toes are frequent. The pulse is variable and the 
 temperature often subnormal. Mental and physical development is 
 incomplete and exophthalmos, swelling of the face, lips and nose 
 and of the optic disk are frequent. (Edema and stasis are not fre- 
 quent. Coincident maldevelopment occurs (in 10 per cent, of cases) 
 in other organs, such as the stomach, colon, kidney and spleen ; imper- 
 forate anus, hypospadias, cryptorchismus, polydactylia, hare-lip, spina 
 bifida, acrania, anencephalus and uterus bicornis also occur. The 
 murmurs are usually systolic and rough, although very complicated 
 lesions may exist with normal heart tones. In a few instances the 
 foetal murmur was heard before birth (Peter). The dulness concerns 
 the right ventricle chiefly. 
 
 Prognosis. — The prognosis is poor, for the lesion is incurable and 
 compensation is incomplete. The patient usually succumbs to cardiac 
 failure or to pulmonary tuberculosis (25 to 40 per cent, of cases) 
 in the second decade (81 per cent.), hence Rokitansky's rule, that cy- 
 anosis protects the lungs from tuberculosis, is not absolute. 
 
 Treatment. — The treatment is wholly symptomatic. The body 
 should be kept warm; baths should be employed to guard against 
 
422 DISEASES OF TEE CIECULATION. 
 
 colds; mental and bodily strain should be avoided; and in general 
 the therapy of adult valvular disease should be followed, except that 
 the heart stimulants must be used with considerable caution. 
 
 DISEASES OF THE PERICARDIUM. 
 
 PERICARDITIS. 
 
 Definition. — An inflammation of the pericardium, secondary to in- 
 fectious diseases, inflammation in contiguous tissues, other diseases 
 of the pericardium or dyscrasise ; it is fibrinous or plastic, exudative, 
 or adhesive. Known anatomically to Morgagni, it was first described 
 as a clinical condition by Senac (1749). 
 
 Etiology. — The disease is rarely primary, and final analysis usually 
 demonstrates that the so-called primary cases are tuberculous, rheu- 
 matic or septic. Cold, exposure and trauma only reduce the physi- 
 ological resistance of the tissues to bacterial invasion. Pericarditis is 
 mycotic, the organisms of suppuration, pneumonia and tuberculosis 
 being most frequently found ; perhaps toxins alone may excite inflam- 
 mation. 
 
 Pericarditis is almost invariably secondary (a) to infectious dis- 
 eases, of which rheumatism (40 per cent.) is foremost, and it is most 
 frequent when many joints are involved in rapid succession. Peri- 
 carditis may be the only manifestation of rheumatism. Many " pri- 
 mary" cases are probably rheumatic. It occurs with recurrent 
 rheumatism, endocarditis and sometimes chorea. It usually develops 
 within half a week to two weeks, but may precede arthritis, especially 
 in children. It is commonly serofibrinous. 
 
 It is common in pneumonia, septicopyemia, puerperal fever, ulcera- 
 tive endocarditis, osteomyelitis, scarlatina, and more rarely in other 
 exanthemata, and in pulmonary or multiple serous tuberculosis. In 
 children, scarlatina and rheumatism are most important. 
 
 (&) It is secondary, by contiguity, to disease of adjacent organs; 
 to pleurisy, pneumonia and aneurysm; to disease of the ribs, ster- 
 num, bronchial glands, spine, oesophagus, stomach, spleen, liver, peri- 
 toneum, myocardium and endocardium; and to cervical cellulitis. 
 Trauma of these parts, from without or within, may be included here. 
 
 (c) It is secondary to certain diseases of the pericardium, as tuber- 
 culosis, carcinoma and other processes. In 30 per cent, of Matter's 
 "cryptogenetic" cases, tuberculosis was found at autopsy. Scaglios 
 (1904) could find but 8 cases of primary pericardial tuberculosis. 
 
 (d) It is secondary to cachexia? or dyscrasice, e. g., nephritis (3 to 
 10 per cent, especially in contracted kidney), gout, diabetes, car- 
 cinoma, alcoholism, blood diseases and scurvy ; and often, as a terminal 
 infection, to reduced physiological resistance, in which case it may 
 
PEBWABD1TIS. 423 
 
 easily escape clinical recognition. This class is usually found in 
 adults. Though encountered at any age, pericarditis is most fre- 
 quent between the fifteenth and thirtieth years. 
 
 Fibrinous (Plastic) Pericarditis. — A strict division into dry 
 (plastic) and exudative (effusive) pericarditis is impossible, because 
 the forms are usually combined. Dry (plastic, fibrinous) pericar- 
 ditis is circumscribed over the base and large vessels, or is diffuse, and 
 consists pathologically of vascular injection, punctate ecchymoses, loss 
 of the smooth, glistening, mirror-like appearance of the serous mem- 
 brane, and exudation of plastic lymph in small particles or irregular 
 lamellae, which may appear smeared as with butter, spongy, shaggy 
 or hairy (cor villosum). Some fluid is usually found in the meshes 
 of fibrin. Stripping off of the fibrin may reveal tubercles. The sub- 
 jacent myocardium often suffers infiltration and degeneration in the 
 more intense or protracted cases. 
 
 Symptoms. — Symptoms are lacking in most cases; pain, is incon- 
 stant and when present, is by no means characteristic. 
 
 Physical Findings. — Inspection and percussion are usually negative. 
 The writer has seen a strong apex beat where the autopsy revealed a 
 fibrin deposit which was an inch in thickness. Palpation may dis- 
 close a friction fremitus, usually over the sternum, which may be 
 obtained as frequently as is friction on auscultation (described under 
 Pericarditis with Effusion, to which refer also for diagnosis, prog* 
 nosis and treatment). 
 
 Pericarditis with Effusion. — This form has been called the second 
 stage, the fibrinous or dry form being the first stage. The fluid may 
 be serous with much or little cellular or fibrinous admixture (sero- 
 fibrinous) ; it may be hemorrhagic, this type being observed in the 
 aged, in scurvy or cancer, in tuberculosis, purpura, hemorrhagic 
 exanthemata or Bright' s disease; the exudation may be tinged with 
 fresh or with darker altered blood ; it may be purulent, and is usually 
 fibrino-purulent rather than purely purulent, and is often associated 
 with pyaemia or contiguous suppuration ; it may be putrid, when caused 
 by pyaemia, carcinoma of the oesophagus or stomach, or by lung cavi- 
 ties. Sixty-seven per cent, of pericarditis are sero-fibrinous, 19 per 
 cent, hemorrhagic and 14 per cent, purulent (Breitung). The 
 pathological sequences of pericarditis are fatty and cloudy degenera- 
 tion, inflammatory infiltration, or actual exulceration of the heart 
 muscle; rupture of a purulent exudation externally into the tissues 
 of the chest, or possibly into neighboring organs or cavities ; inflam- 
 matory extension outside of the pericardium (pericarditis externa) 
 and thence to other tissues, such as the mediastinum or pleura ; forma- 
 tion of polypi, which, becoming detached, may, in rare cases, pro- 
 duce foreign bodies in the pericardium; complete resorption of the 
 exudate and restitutio ad integrum, which is a rather uncommon 
 issue; organization of connective tissue, either as local adhesions, 
 which are mostly observed near the fixed base of the heart, because 
 the heart's movements probably detach apical adhesions, or as general 
 
424 DISEASES OF THE CIBCULATION. 
 
 obliteration of the sac (concretio pericardii) ; and, finally, desiccation 
 of the exudate, leaving a cheesy mass which may calcify. Coincident 
 endocarditis is less a sequence than an associate or cause of pericar- 
 ditis. 
 
 Symptoms. — All symptoms are frequently absent (Latham, Graves, 
 Stokes), and no symptom is diagnostic. Leudet found total latency 
 of symptoms in 55 per cent, of his cases. Daily examination of the 
 heart in those diseases which are most likely to cause pericarditis is 
 the only certain method of avoiding diagnostic errors. Fever may 
 exist from the disease or from the causal affection, but is irregular 
 (Wunderlich). It is often absent, especially in secondary pericar- 
 ditis, and the temperature may be subnormal, even in purulent effu- 
 sions. High fever is infrequent even in rheumatic cases. 
 
 Dyspnoea or thoracic oppression occurs in 90 per cent. Oppolzer 
 observed cyanosis without dyspnoea when the pulmonary circuit re- 
 mained intact. Dyspnoea is due largely to heart compression by 
 the exudate or extension of inflammation to the myocardium, and is 
 less frequently due to vagus irritation, phrenic-nerve inflammation, 
 venous, pulmonary and arterial compression. It is remarkable that 
 patients may sometimes walk into the hospital with enormous peri- 
 cardial effusions. The respirations are increased. 
 
 Pain is variable, is often absent in secondary pericarditis and is 
 said to be more common in small effusions. Sibson found pain in 90 
 per cent, of his cases. Severe pain oftener indicates pleurisy than 
 pericarditis (Eouillaud). Epigastric pain may precede pain else- 
 where (Gueneau de Mussy) and the writer observed initial pain over 
 the appendix. Anginal pain (Andral) radiating to the shoulder, 
 arm and neck is rare. Barlow's patient put on a belt to relieve his 
 pain. Precordial tenderness is at times present, and palpitation is 
 common. 
 
 Cerebral Symptoms. — Delirium, anxiety, restlessness, insomnia, 
 mania, convulsions, psychoses or even coma may be due to pericar- 
 ditis or to complicating uraemia or endocarditis. The symptoms 
 may be suggestive of gastritis, while pericarditis is found on examina- 
 tion. Vomiting, singultus, dysphagia, recurrent laryngeal paralysis 
 and tracheal cough are symptoms of pericardial pressure. 
 
 Physical Findings.— The definite diagnosis depends on the physical 
 findings. These are as follows: 
 
 1. Inspection. — Precordial prominence, voussure, first noted by 
 Louis, may occur when the chest is plastic, as in women and children, 
 and when the intercostal muscles are paretic from inflammatory 
 oedema. The left chest often moves less than the right, since the left 
 lung is usually compressed. The apex-beat is somewhat lower when 
 exudation depresses the diaphragm; it is more horizontal, more to the 
 left and the dulness transcends the apex to the left. The neater 
 the effusion^ the weaker the apex becomes, and disappearance* of the 
 previously distinct apex heat is all-important There maybe only an 
 indefinite, diffuse cardiac impulse. On bending forward the apex 
 
PERICARDITIS. 425 
 
 beat or cardiac impulse usually reappears. The interspaces may 
 bulge. Collateral oedema of the chest wall (Rendue) and undulation 
 (Senac) due to the heart itself are most rare. Graves and Stokes 
 described tumor-like extrusion of the compressed lung above the clav- 
 icle. According to Ewart, the upper edge of the first rib can be felt 
 as far as its sternal attachment, being separated from the clavicle 
 ("first rib sign"). An epigastric tumor-like bulging of the luxated 
 liver was noted by Auenbriigger and Corvisart. The veins of the 
 thoracic wall are large. During convalescence the apex may retract 
 during the systole, from adhesions. The decubitus is usually dorsal 
 or left-sided, rarely right-sided, for this compresses the sound lung; 
 the head and shoulders are usually elevated, and the attitude is fixed 
 and rarely changed. The knee-hand position was noted in Zehet- 
 mayer's case. 
 
 2. Palpation". — The friction rub is often felt. Palpation confirms 
 the location of the apex. Disappearance of an apex beat previously 
 observed, and the presence of a strong radial pulse, are very im- 
 portant; mere absence of the apex is observed in many conditions. 
 Epigastric tenderness on either side of the ensiform, or tenderness 
 between the attachments of the sterno-mastoid, is due to inflamma-. 
 tion of the phrenic nerve (Gueneau de Mussy and Peter). Fluctua- 
 tion is never felt. 
 
 3. Percussion. — Dulness was first described by Auenbriigger. 
 Three to five ounces of fluid are usually necessary to produce dis- 
 tinct physical signs, though Frantzel has detected the presence of 
 one and one-half ounces. There are two complementary re- 
 cesses in the pericardium : one over the basal vessels, where the fluid 
 may accumulate, in which case it is early revealed by a triangular 
 dulness, whose apex is directed downward (Skoda, von Dusch, Op- 
 polzer), which may compress the large veins or arteries ; and the other 
 in the fifth right intercostal space (Rotch, Ebstein), where the fluid 
 exudate replaces the relative liver dulness, and is most easily recog- 
 nized by palpatory percussion. Extensive exudates produce an out- 
 line usually designated as triangular, with the blunted apex upward, 
 or as pyriform with the base directed downward. The dulness may 
 even reach the interclavicular notch, the right nipple, or the left axilla, 
 and may impinge on Traube's semilunar space, extend beyond the 
 left lobe of the liver, compress the lungs and markedly depress the 
 diaphragm and liver. The dulness is, at times, trapezoidal rather 
 than triangular. (See Plate X, Eig. E.) Very massive exudates 
 may be mistaken for pericarditis plus pleurisy with effusion. 
 Though the outline is roughly triangular, the right border is more 
 vertical than the oblique left border, which is beyond the apex beat, 
 if the latter remains visible (Skoda). The apex beat is dislocated 
 abnormally when the patient lies on his side, because the pericardial 
 sac is larger than normal, and permits greater cardiac movement. 
 German writers, following Skoda' s teaching, hold that the heart falls 
 back in the fluid, but the heart lies above the bulk of the fluid and 
 
426 DISEASES OF THE CinCULATION. 
 
 close to the chest wall. The dulness varies with fluctuations in the 
 effusion and with resorption. When the patient is in the erect pos- 
 ture, the dulness may be one-third to one-half as broad again as when 
 he is in the dorsal position; it also is not so high (Gerhardt) ; this 
 is not invariable, because the lung borders must be normal and the 
 exudate freely movable to allow free shifting of the fluid. Sahli 
 found the same increase in dulness in the sitting posture in enlarged 
 heart and valvular disease. Change of the dulness, especially when 
 the patient lies on the right side (Rosenbach), is important, for this 
 is uncommon physiologically, whereas the shifting of dulness in 
 the left decubitus is of minor value. 
 
 Dulness may persist from cardiac dilatation, massive adhesions 
 or pulmonary retraction. The effusion may be enormous (10 
 quarts, Kyber; or 8 pounds, Corvisart), and may lead to a diagnosis 
 of pleurisy, or pleurisy plus pericarditis. As the normal pericardial 
 sac holds only two-thirds to three-quarters of a quart (650 to 800 
 c.c.), the pericardium must be greatly relaxed by the inflammation, 
 to allow such large effusions. The pericardial dulness may not be 
 typical when the effusion is largely covered by emphysematous 
 lungs, or when the borders of the lung are adherent and cannot be 
 pushed back by the effusion. 
 
 4. Auscultation. — Auscultation reveals the chief and most reli- 
 able diagnostic sign, the pericardial friction due to attrition of the 
 inflamed pericardial surfaces. It was first fully described by Col- 
 lin, Laennec's assistant, in 1824. (a) It is usually a " to-and-fro" 
 rubbing which is not exactly synchronous with either the systole or 
 diastole, which character is most clear when the heart is slow. It 
 is less often single, and then is late in the systole ; it may be triple, 
 i. e., presystolic, systolic and diastolic. It is often absent in fibrin- 
 ous, hemorrhagic or purulent inflammation. In contradistinction 
 to pleurisy, where the effusion of fluid abolishes the primary friction, 
 it usually persists, even with great exudation (Stokes), especially at 
 the base, since here the heart may touch the parietal pericardium. 
 Balfour claims that friction, once heard, is never effaced by even 
 the greatest effusion. A certain consistence of the fibrin seems neces- 
 sary to friction, for the latter is absent in very soft fibrinous deposits. 
 (6) Ixi quality, it may be harsh, soft like a gentle and interrupted 
 scratching of the ear with the finger, whistling, creaking, crunching, 
 musical or even metallic (resonance from the stomach or intestines), 
 (c) In location, it is most often heard over the base or the tricuspid 
 region, where it is especially significant. It may also be heard over 
 the apex. Sears describes a case in which the friction was heard 
 most clearly at the angle of the left scapula, (d) It is very super- 
 ficial and dose to the_ ear, not deep as in endocardial murmurs. 
 Superficiality of the friction sound is absent when partial adhesions 
 exist anteriorly, andthe pericarditis is most intense behind the heart, 
 (e) Its propagation is not wide (il nail et meurt sur place, Jaccoud)' 
 though it has been heard at a distance of nine feet. In children 
 
PERICARDITIS. 427 
 
 it may be heard over the whole chest, and the author has once seen 
 the same in an adult. Coincident hydrothorax (Graves) has been 
 thought to favor its propagation, and cardiac hypertrophy, by bring- 
 ing the heart closer to the chest wall, diffuses the friction more 
 widely (Stokes). The murmur usually ceases abruptly when the 
 stethoscope has been removed a short distance. It does not follow 
 the same lines of propagation as in valvular heart disease. Propaga- 
 tion along the sternum is not uncommon. (/) Inspiration usually 
 increases the murmur (Traube), due to the closer apposition of the 
 pericardial leaves, caused by the wedge of expanding lung. (Some- 
 times it is more marked during expiration, particularly when ad- 
 hesions exist between the heart and lung.) (g) Moderate pressure 
 usually increases the friction, especially in plastic chests. Change 
 of posture e. g., leaning forward, often makes the murmur clearer 
 (Corrigan, Stokes), (b) The murmur is variable, now present, now 
 absent, now systolic, or again systolic and diastolic, varying in 
 acoustic properties, or changing with change of posture; it is often 
 short lived, lasting sometimes but two to six hours. . It is not depend- 
 ent on the intensity of the inflammation, but rather upon the acci- 
 dental quality of the effused lymph and its location. Disappearance 
 of the rub is explained by regression, adhesions or weak heart. As a 
 rule, the heart tones gradually become more or less weakened and 
 distant. The .r-rays outline the pericardial effusion. 
 
 Secondary Physical Signs. — There may be evidences of cardiac in- 
 competence, which is due to the mechanical hindrance, by the fluid, 
 of the diastole, especially of the auricles ; then the face is pale ; it 
 is also due to myocardial degeneration or coincident valvular disease ; 
 then the face is cyanotic. The signs of cardiac incompetence are 
 hepatic and renal stasis, ascites, oedema, cyanosis, dyspnoea, cerebral 
 anaemia (syncope), distention and pulsation in the jugular veins 
 and oedema of the lungs. The pulse at first undergoes irritative ac- 
 celeration, but a lasting frequency indicates myocardial change. 
 It may, in exceptional cases, be normal, or even slow (to 36), as a 
 result of compression. There is no characteristic pulse ; dicrotism is 
 frequent: there may be the pulsus paradoxus, weakening or inter- 
 mitting with each inspiration (Traube). A very strong or water- 
 hammer pulse may suggest underlying aortic disease. Irregularity 
 is occasional, as is the pulsus differens and difference in the pupils. 
 Lung compression is frequent. Bamberger observed a small area of 
 compression, the size of a dollar, at the angle of the left scapula, 
 where bronchial breathing, dullness (or tympany) and increased 
 fremitus are noticed; the compression clears up when the patient 
 assumes the knee-chest posture (Pins). Pleural puncture excludes 
 the possibility of fluid in doubtful cases, and the absence of crepitant 
 rales excludes pneumonia. Bamberger's sign occurred in cases of 
 hsemopericardium (Allbutt). There may be tympany (or dulness) 
 under the left clavicle and to the left (and sometimes to the right) 
 of the heart in fair-sized effusions. Ewart describes tubular breath- 
 ing near the right mamma. 
 
428 DISEASES OF THE CIRCULATION. 
 
 Thrombosis of the innominate veins may result from compression. 
 Walshe observed tracheal compression. The second pulmonic sound 
 may be accentuated, which Warthin regards as an early sign. The 
 second tone may be split (Skoda). Metallic heart tones may be 
 due to an adjacent cavity, pneumothorax or the distended stom- 
 ach and intestines. A systolic non-valvular murmur over the aorta 
 has been explained by pressure on, or inflammatory relaxation of, 
 the vessels, thus interfering with their normal vibration. 
 
 Diagnosis. — Differentiation rests upon (1) the friction and (2) the 
 dulness, or on both, with constant attention to (3) the apex heat. 
 Subdivision into types, such as acute or chronic, fibrinous, sero- 
 fibrinous, seropurulent, purulent, ichorous or hemorrhagic is inad- 
 visable, as puncture alone reveals the character of the exudate. 
 Fibrin formation and serous exudation usually coexist (Latham). 
 
 1. The Pericardial Eub. — The 'pericardial rub is practically 
 pathognomonic of pericarditis (von Dusch). (It has occurred on 
 rare occasions in cholera from tissue dryness, in tubercles, cancer, 
 soldier's spots, hemorrhage, hypertrophied heart, and inflammation 
 of the diaphragm or the peritoneum, the heart beating against the in- 
 flamed surface.) 
 
 (a) In distinguishing it from endocardial murmurs, the acoustic 
 quality, superficial character, lack of rhythmic precision, variability, 
 slight propagation, palpatory difference in the rub, the basal location 
 and increase of the pericardial friction by pressure or inspiration 
 are most decisive. The distinction is rarely difficult, between an 
 aortic to-and-fro murmur and pericardial friction. Valsalva's ex- 
 periment — i. e., a long inspiration with closed glottis followed by 
 expiration with tense abdominal muscles — intensifies pericardial fric- 
 tion and decreases endocardial murmurs. The frequency with which 
 pericarditis is a complication or coordinate pheuomenon of endocar- 
 ditis, necessitates reserve in the prognosis, because the valvular dis- 
 ease remains and may first become manifest, after the pericarditis 
 subsides. 
 
 (b) It must be differentiated from pi euro pericardial friction 
 (pseudo- or extrapericardial) originating in the inflamed pleura, 
 where friction depends not only on respiration, but also on the 
 heart's action. The usual distinction lies (i) in the close connection 
 of the pericardial rub with the cardiac activity, persisting dur- 
 ing expiration, and (ii) in the location of the" pleuropericardial 
 friction in the sinus mediastinocostalis (along the lingual lobe), in 
 its intimate relation to respiration and in its usual cessation, either at 
 extreme inspiration or expiration (Stokes, Addison). This method 
 of differentiation is not infallible, for inspiration also augments true 
 pericardial friction, which is, however, increased by bending forward. 
 Valsalva's test (v. s.) is also useful. Pericardial friction toward 
 the base or sternum is less often confused with pleural friction. Eos- 
 enbach findsdifferentiation most difficult when the basal vessels come 
 in contact with a tuberculous cavity or pneumonia. 
 
PEBICARDITIS. 429 
 
 (c) Differentiation from precordial emphysema is possible on ac- 
 count of the crackling sounds of interstitial emphysema (air) in the 
 anterior mediastinum. The sounds resemble rales, but are closely 
 associated with the heart's action and are often metallic. The con- 
 dition of the heart tones is decisive. 
 
 (d) Pericardial splashing (see Pneumopericardium). 
 
 (e) Crepitant rales are easily differentiated. 
 
 2. The Dulness of Pericardial Exudation is* typically pyri- 
 form or triangular. The markedly increased relative cardiac dul- 
 lness should be considered rather than the absolute dulness (which is 
 often little altered in pleural adhesions or pulmonary emphysema). 
 
 (a) Hydropericardium and effusive pericarditis may be confused, 
 because the friction may be absent or disappear, and fever may be 
 lacking (chronic pericarditis). Hydropericardium shows its etio- 
 logical factors (q. v.). It is distinguished by anasarca or. hydro- 
 thorax which almost always develops first, by lower dulness, by resorp- 
 tion under digitalis and purges, by absence of friction, and para- 
 centesis, which reveals the usual differences between exudates and 
 transudates in their opacity, specific gravity and percentage of albu- 
 min (see Pleurisy). 
 
 (b) Hcemopericardium, resulting from trauma, rupture of a coro- 
 nary artery or ventricular or aneurysmal rupture, is usually sud- 
 den, is attended by syncope and blood is removed by puncture. 
 
 (c) Pneumopericardium (q. v.). (d) From cardiac dilatation the 
 differentiation may be most difficult, especially when there is dilata- 
 tion plus hydrops pericardii, in which case drastics, digitalis, fric- 
 tion, the history and evolution only, may decide. In dilatation the 
 dulness is rarely triangular but rather is increased laterally, the 
 shock-like impulse of the heart is more marked and often contrasts 
 sharply with the weak radial pulse, compression of the lung is much 
 more uncommon, and the heart tones are more clear and " snappy." 
 The very distinctive relation between the apex and the outer dulness 
 to the left is rarely fallible (v. s.). If the pulse is strong and the 
 apex weak, pericarditis is present (with, of course, the typical dul- 
 ness) ; but compression or weakness of the heart in pericarditis necessi- 
 tates a weak rapid pulse. In both affections the heart's dulness is 
 increased by leaning forward, but this may clearly demonstrate the 
 apex within the dulness of the exudate. When the patient lies on 
 his right side the apex in pericardial effusion becomes visible (Ros- 
 enbach), which does not obtain in cases of enlarged heart. In child- 
 ren the diagnosis of pericardial effusion is often made incorrectly, 
 as dulness oftener signifies dilatation, (e) When there is retraction 
 of the left lung away from the heart, the diaphragm is high, the 
 apex and outer cardiac dulness coincide, the spleen is high, the pul- 
 monary artery is exposed, and the proper signs of pulmonary 
 retraction are elicited (Leube). (/) In cases of mediastinal tumor 
 the dulness is irregular; there is no variation of dulness on postural 
 change; the signs of increased conduction and bronchial breathing 
 
430 DISEASES OF THE CIRCULATION. 
 
 are noted with the absence of the cardinal signs of pericarditis. 
 (g) From aneurysm the differentiation is usually possible, as well 
 as from marginal infiltration of the lung; callous pleura, encapsu- 
 lated pleurisy, redundant fat; and anterior mediastinitis (usually 
 with friction, but with more vertically elongated dulness). 
 
 Diagnosis of the Character of the Exudate. — The fluid is serofibrin- 
 ous in rheumatism ; ichorous in perforation from hollow viscera ; hem- 
 orrhagic in scurvy, carcinoma, tuberculosis, hemorrhagic exanthe- 
 mata and alcoholism; and purulent in sepsis and empyema. 
 Paracentesis is the only certain test. Tuberculous pericarditis, even 
 in clearly tuberculous cases, can be diagnosticated positively only by 
 detection of tubercle bacilli in the aspirated exudate; a chronic peri- 
 carditis is probably tuberculous. In children 30 per cent, of pericar- 
 ditides are suppurative and 17 per cent, are tuberculous (Baginsky). 
 
 Course. — The clinical course is variable ; exudation may follow the 
 friction in a short time or only after many days. The exudate may 
 be rapidly absorbed in a few days or may endure for weeks or 
 months. The average duration is one or two weeks. In convales- 
 cence the heart may long remain irritable on exertion. 
 
 Prognosis. — The prognosis depends largely upon the physiological 
 resistance, the causal disease and the character and quantity of the 
 fluid ; it is usually good in rheumatic and serofibrinous cases. Septic, 
 purulent, putrid or hemorrhagic types are serious. The pneumo- 
 coccic form is fatal in 50 to 75 per cent. Pericarditis is most dan- 
 gerous in the very young or aged. Death may be rapid in hemor- 
 rhagic cases; it usually is due to cardiac exhaustion, especially in 
 chronic cases, and results from myocarditis rather than from simple 
 pressure. The prognosis is more favorable in men than in women 
 and children. Seemingly benign cases may result seriously from 
 concretio cordis. 
 
 Treatment. — 1. The hygienic treatment should be managed as in 
 any acute infection with cardiac involvement. 
 
 2. Absolute rest in bed is indicated, in order to spare the heart, 
 even during convalescence. The patient should never be allowed to 
 sit up or leave the bed, even to urinate or defecate, for severe or fatal 
 syncope may follow the effort. 
 
 3. Laxatives should be given, for constipation per se may increase 
 the heart action, and difficult bowel movements, with the "attendant 
 straining, may precipitate syncope. Sod. phosphate 3ss to ij is an 
 excellent laxative. 
 
 _ 4. The diet should be light or fluid and tea and coffee, which ex- 
 cite the heart, should be avoided. Alcohol may be given when a 
 septic process prevails or when the patient has used it regularly. 
 
 5. Local antiphlogistic measures. An ample ice-bag upon the pre- 
 cordium quiets and regulates the heart-rate, relieves palpitation and 
 pam and, the author believes, is often a better cardiant and sedative 
 than drugs. Of all drugs, none quiets the heart like opium. Leeches 
 may be applied after drawing some blood by small scratches over 
 
PERICARDITIS. 431 
 
 the heart; their action is regulated by applying salt, which causes 
 them to release their hold. A Spanish-fly blister, as large as the 
 hand, often not only relieves pain but stimulates resorption. It must 
 be dressed carefully with weak carbolic salve and gauze. 
 
 6. Causal therapy. Therapy of the underlying disease is indi- 
 cated, — such as the use of salicylates, in the rheumatic form. 
 
 7. Heart stimulation is indicated when the pulse is irregular, fast 
 or small, for this is due to early cardiac irritation or to later mechan- 
 ical compression of the heart and lungs by the exudate. Alcohol 
 should frequently be given. Strychnia, coffee and camphor operate 
 more quickly than digitalis; they can also be used to follow up its 
 action. Cardiac depressants, such as aconite, are to be carefully 
 avoided. 
 
 8. Treatment of the fever depends on the basic disease. Hydro- 
 therapy is preferable to the antipyretics. 
 
 9. Compression symptoms, such as dyspnoea, insomnia and vomit- 
 ing, when mild in degree or not of long standing, are met by the 
 judicious use of morphine hypodermatically. When the face is 
 pallid, the heart is compressed by the exudate and tapping is indi- 
 cated. Tardy resorption of large exudates or sudden or severe symp- 
 toms therefrom necessitate tapping of the pericardial sac, under the 
 general precautions observed in pleural aspiration. The puncture 
 is made in the fifth left (or right) interspace about an inch from the 
 sternum, where the sac is not covered by the pleura. Care and 
 gentleness in passing the trocar enable us to feel the giving way of 
 the parietal pericardium and to avoid cardiac trauma. Removal of 
 but a small quantity frequently provokes absorption by relaxation 
 of the vessels in the tense pericardium, although results are some- 
 times disappointing. The fluid is withdrawn very gradually by the 
 gravity or siphon method. (See Pleurisy.) Sudden or extreme 
 cardiac embarrassment may necessitate free venesection. 
 
 10. Delayed absorption is treated by potassium iodide gr. x to xx, 
 by diuretin 60 to 90 gr. per diem, and by small doses of calomel fol- 
 lowed by salines. Hot packs, alcohol sweats and pilocarpine should 
 be entirely avoided lest collapse occur. 
 
 11. Early pericardiotomy is indicated in suppurative or putrid 
 forms. About one-half of the cases recover. 
 
 Adhesive Pericarditis. — {Pericardial Concretion {Synechia) ; Cic- 
 atricial {Callous) Mediastino-Pericarditis.) — Though pericarditis 
 may resolve completely, local adhesions within the sac or more ex- 
 tensive bands to the chest wall, pleura, spine or other structures are 
 frequent. They develop in 41 per cent, of cases of pericarditis 
 (Breitung) and are found in 6 per cent, of autopsies (Leudet). In 
 one group of cases, complete obliteration of the sac may occur with 
 absolute clinical latency ; the heart may beat itself loose from fresh or 
 lax adhesions, especially when they are located about the apex. In a 
 second group, there are undistinctive evidences of cardiac insufli- 
 
432 DISEASES OF THE CIRCULATION. 
 
 ciency. In a third series, distinctive physical signs exist. Adhesions 
 most frequently follow serofibrinous pericarditis. A clear history or 
 the actual observation of a previous pericarditis is one of the strongest 
 points in the diagnosis. 
 
 Symptoms. — 1. Cardiac Insufficiency. — Cardiac insufficiency is 
 caused by pressure on the coronary arteries, by myocardial fibrosis 
 and degeneration, but more often by dilatation or atrophy. While 
 severe heart symptoms without valvular disease in advanced life are 
 indicative of myocardial degeneration, in the young they suggest 
 pericardial adhesions (Wilks). Failure of the right ventricle with- 
 out valvular, renal or pulmonary disease, or sudden break in com- 
 pensation in the usual valvular lesions, directs attention to pos- 
 sible pericardial adhesions. Weiss and Pick have called attention to 
 an isolated ascites, associated with large liver and sometimes with 
 fibrous peritonitis; it is probably due to the extension of inflamma- 
 tion along the vessels from the pericardium to the peritoneum ; it has 
 been produced experimentally. Sudden death is sometimes due to 
 pericardial synechias (Aran). 
 
 2. Systolic Retraction of the Interspaces at the Apex. — 
 This may occur even with slight basal adhesions which hinder the 
 systolic descent of the heart, while diffuse adhesions other than basal 
 often produce no symptoms. It is especially significant when the 
 normal systolic protrusion has been gradually replaced after peri- 
 carditis by systolic retraction, for retraction of the apex also occurs 
 in other conditions. Systolic retraction is merely an expression of 
 impaired locomotion of the heart and of lack of space at the apex. 
 It is best seen on deep inspiration and disappears when the heart 
 grows weak. Retraction of the apex can be seen and felt. 
 
 3. Retraction. — Retraction, not merely of the apex, but of the 
 sternum, epigastrium (Oppolzer), diaphragm and lower chest wall 
 may be observed when adhesions also exist outside of the pericardium 
 in the mediastinum (Skoda) ; it is indicative of indurative medi- 
 astinals, which attaches the heart anteriorly to the chest wall and 
 posteriorly to the spine, and necessitates retraction until cardiac 
 weakness develops. Broadbent's sign is a systolic retraction of the 
 eleventh and twelfth ribs posteriorly on the left side. 
 
 4. The Diastolic Recoil. — Friedreich described a diastolic re- 
 bound of the diaphragm and chest wall which were retracted in the 
 systole ; it is recognized by palpation and by auscultation as a dull 
 vibration which may cause the second tone to appear doubled. 
 
 5. Diastolic Collapse of the Cervical Veins (Skoda). This 
 
 is of great diagnostic value, and is due to their aspiration by the 
 heart ; it is sometimes dicrotic and may produce diastolic pallor of the 
 face. The cervical veins often swell with the systole. 
 
 6. The Pulsus Paradoxus.— The pulsus paradoxus, a pulse in- 
 termitting with inspiration, strongly suggests cicatricial mediastino- 
 pencarditis, particularly when observed with the signs previously 
 mentioned. It is observed to a moderate extent physiologically and 
 
PERICARDITIS. 433 
 
 sometimes in other conditions which lessen the entrance of air into 
 the lungs or render the heart sensitive, especially in myocarditis 
 (Riegel). It is due in mediastinopericarditis to inspiratory stretch- 
 ing of the great vessels by well-attached mediastinal adhesions, 
 which shuts off the blood supply to the extremities. It is a medi- 
 astinal symptom, and occurs (a) when the arterial system is poorly 
 filled, and hence is more significant when the heart tones are normal 
 
 j 
 
 E 
 
 
 Pulsus paradoxus (Kussmaul) ; E, beginning of expiration, and J, of inspiration. 
 
 or stronger than normal, and (&) when the return venous flow is 
 retarded. Schreiber holds it pathognomonic when (i) it appears 
 without forced inspiration, (ii) when the radial and all other pulses 
 are Completely suspended by inspiration, (iii) when the heart's action 
 is regular and (iv) when it is combined with inspiratory swelling of 
 the cervical veins (v. i.). Striimpell observed slowing of the pulse 
 during inspiration. This was explained by him as irritation of the 
 vagus by the mediastinal connective tissue. 
 
 7. Inspiratory Swelling of the Neck Veins. — Inspiratory 
 swelling of the neck veins (Kussmaul), which normally collapse 
 during inspiration, is due to the same mechanism as the pulsus para- 
 doxus. Inspiration stretches the mediastinal bands, which constrict 
 the large venous trunks and interrupt the return venous flow. Cya- 
 nosis may occur with each inspiration. 
 
 8. Other Signs. — The other signs are fixation of the heart by 
 adhesions, which gives no change of dulness by change of posture 
 (von Dusch) ; absence of respiratory excursion over the heart ; de- 
 crease of Traube's semilunar space by pleural adhesions ( Jaccoud) ; 
 decreased movement of the left half of the epigastrium (dia- 
 phragmatic adhesion to heart) ; cyanosis and dyspnoea due to ad- 
 hesions with the diaphragm impeding respiration (Wenckebach) ; 
 expiratory weakening of the apex by pleural adhesions (Tuczek- 
 Riegel) ; weak right heart with no accentuation of the second pul- 
 monic tone; loud, even musical, murmurs, especially in the aged; 
 systolic emptying of the veins of the thorax due to systolic dilatation 
 of the internal mammary veins (Broadbent) ; a rumbling presystolic 
 murmur at the apex, especially in children, without signs of mitral 
 stenosis (Fischer, Hale White) ; precordial creaking (Perez) when 
 the patient moves the arm; and other mediastinal symptoms, e. g., 
 left recurrent laryngeal paralysis, venous thrombosis in arm, etc. 
 
 Diagnosis. — In the diagnosis, two groups of symptoms are observed ; 
 first, the myocardial (dilatation, hypertrophy, relative tricuspid in- 
 sufficiency) ; and second, the mediastinal (pulsus paradoxus, etc.). 
 (See Pick's Pericarditic Pseudocirrhosis, under Diagnosis of 
 Hepatic Cirrhosis.) 
 
434 DISEASES OF THE CIRCULATION. 
 
 Prognosis.— The prognosis depends upon the condition of the myo- 
 cardium. Cardiac concretion is the usual cause of heart failure in 
 iuvenile rheumatic cardiopathies. 
 
 Treatment.— The treatment is identical with that of valvular dis- 
 ease (q. v.) or of myocardial insufficiency in general. Brauer advo- 
 cates surgical solution of the adhesions (cardiolysis) ; about a dozen 
 operations are reported. The heart muscle must, however, be in 
 good condition to warrant surgical interference. 
 
 PNEUMOPERICARDIUM. 
 
 Gas or air in the pericardium is very infrequent. But 38 cases 
 were collected in 1904 by W. B. James, from whom the figures be- 
 low were taken. 
 
 Etiology.— It results (a) from trauma (18 cases), such as per- 
 forating wounds; 7 cases resulted from crushing of the ribs or 
 sternum; (6) from perforating processes from cavities or viscera con- 
 taining air or gas (15 cases) ; pulmonary cavities; gangrene, pneu- 
 mothorax, oesophageal ulcers or neoplasms; gastric ulcer, liver ab- 
 scesses or caseated bronchial glands. There is almost always fluid, 
 which may be ichorous, hemorrhagic, purulent (pyopneumoperi- 
 cardium), or more rarely serous (hydropneumopericardium). (c) 
 Exceptionally spontaneous gas development without solution of con- 
 tinuity has been observed, due to the Bacillus aerogenes encapsulatus. 
 
 Diagnosis. — On inspection, there is precordial bulging and absence 
 of the apex beat, though this may reappear upon leaning forward. 
 On palpation, the vocal fremitus about the heart, and the apex beat 
 are gone, friction and occasionally splashing, churning, gurgling 
 sounds may be felt. On percussion, when the patient is sitting, a 
 tympanitic, cracked pot, or even metallic note is obtained above or 
 indeed over the entire heart, especially when percussion is made with 
 the plessimeter and the hard part of the percussion hammer or the 
 finger-nail. Fluid is usually detected when the patient is in the 
 sitting or lateral decubitus. 
 
 The tympanitic note heard above, and the fluid below, is present 
 only when no adhesions are present and varies during the systole and 
 diastole; it becomes higher in the erect posture and varies with the 
 amount of exudation. The change in note on change of posture and 
 the condition of the apex depend upon hydrostatic laws, as is the 
 case in pneumothorax. ^ The lung is compressed. On auscultation, 
 the heart tones vary with the fluid, being loud if there is no great 
 effusion, and usually metallic or musical, like the sound from a zither. 
 The same is true of the quality of the friction (for pericarditis is 
 almost invariably present). The tones, the metallic tinkling (in 63 
 per cent.) or splashing, the falling-drop sound, the mill-wheel churn- 
 ing (in 50 per cent.) and succussion, may be heard at a distance. 
 They may keep the patient awake and may be heard in an adjacent 
 room, as in cases of Stokes, Laennec and Graves. 
 
H^MOPEBICABDIUM. 435 
 
 Differentiation is required from cavities or encapsulated pyopneu- 
 mothorax near the heart. Consideration of the heart dulness, even 
 though it be dislocated, and of the apex beat renders the diagnosis 
 easy; in James' series all but 6 were recognized. Confusion with 
 distention of the stomach, which imparts a metallic note to the heart 
 tones, is similarly excluded. 
 
 Prognosis. — Death occurs in 70 per cent, of the cases and usually 
 results within two weeks, from the inherently fatal causal disease 
 and from cardiac insufficiency. Recovery is most probable in the 
 traumatic cases. 
 
 Treatment. — Treatment is the same as in pericarditis. Puncture to 
 void the gas, and operation for putrid or purulent processes, are 
 indicated. 
 
 HYDROPERICARDIUM (HYDROPS PERICARDII). 
 
 Hydropericardium is always secondary to (a) circulatory disturb- 
 ances, such as heart or pulmonary lesions, or, infrequently, local 
 obstruction in the pericardial veins; or (b) cachectic conditions pro- 
 ducing blood alteration and transudation, such as Bright's disease 
 or carcinoma. 
 
 Symptoms. — They are much the same as in pericarditis, except that 
 friction is absent. The heart region is sometimes prominent, the 
 apex beat is lost, the heart tones are distant, the fluid changes with 
 change of posture and the dulness is clearly triangular or trapezoidal 
 since no adhesions exist. In most autopsies a small amount of fluid 
 is found which transudes during the death agony or after death. In 
 hydropericardium, the fluid is yellow-green, and is sometimes slightly 
 tinged with blood. Cholesterin crystals are sometimes found. Evi- 
 dences of inflammation are absent. The fluid is alkaline, contains 
 some albumin, sugar and urea, and is of low specific gravity. Chyle- 
 like effusions (chylopericardium) are very rarely seen. 
 
 Diagnosis. — The signs of fluid are the same as in pericarditis (q. v. 
 for differentiation), but there is no temperature, tenderness or 
 friction murmur. Dilatation of the heart causes the most frequent 
 diagnostic confusion and is differentiated as in pericarditis. The 
 etiological diagnosis is most important, such as finding a cardiac 
 lesion in the first and renal lesion in the second group. 
 
 Prognosis and Treatment. — The prognosis and treatment depend 
 wholly on the cause. Cardiac stimulants, blisters over the heart, 
 laxatives, etc., are indicated. 
 
 KEMOPERICARDIUM. 
 
 Blood tinges the exudate in certain forms of pericarditis. A large 
 quantity of blood may escape into the sac in trauma of the heart or 
 of the sac, rupture of the heart (q. v.) or of aneurysms (q. v.). 
 
 The symptoms and physical signs relate to (a) the acute ancemia, 
 with pallor, syncope and rapid pulse, which usually ends, in a few 
 
436 DISEASES OF THE CIRCULATION. 
 
 hours or possibly a few days, in death; (&) signs of fluid in the peri- 
 cardial sac. The prognosis is favorable only in the traumatic cases ; 
 death may be postponed 11 days. The treatment is expectant; the 
 heart should be stimulated and salt solution infused. 
 
 NEUROSES OF THE HEART. 
 
 Palpitation of the Heart. — Palpitation is also known as cardiopal- 
 mus, cardiogmus or hyperkinesis cordis, and is purely a symptom. 
 It is closely related to the hyperdiastole caused by vagus stimula- 
 tion. In health and in many cases of heart disease the patient is 
 not conscious of his heart-action ; the most extreme irregularity, or the 
 pounding heart of aortic insufficiency, may escape the patient's notice, 
 while the normal heart action may cause palpitation after overwork, 
 abuse of coffee and other causes. 
 
 Etiology. — 1. Nervous Causes (Hyperesthesia of the Centripetal 
 Fibers from the Heart to the Brain). — Nervous excitability is com- 
 mon especially in medical students, whose hearts must be examined 
 when they first study physiology or physical diagnosis. Even phy- 
 sicians are not wholly free from heart egotism. Peter Frank had 
 violent palpitation while writing his " Diseases of the Heart," 
 so that he thought he had aneurysm. It is common in school 
 children, from nervous tension, fear of examinations and public 
 exercises; it is more frequent in females at puberty, the climac- 
 teric or with menstruation. It occurs constantly in exophthalmic 
 goitre and in 50 per cent, of neurasthenics, so that a neurasthenia 
 cordis has been recognized, which is attended by turgid face, red eyes, 
 contracted temporal arteries and angioneurotic oedema, which symp- 
 toms disappear when the seizure is over. Hysteria is a less impor- 
 tant cause. Nervous exhaustion, anemias, acute infections, lactation, 
 poor hygiene, the beginning of tuberculosis and sexual excess or per- 
 version may produce palpitation. The " irritable " heart of soldiers, 
 observed by Da Costa in our Civil War, associated with arrhyth- 
 mia, diarrhoea, emotional causes and physical strain and often placed 
 under this head, is better classified as muscular insufficiency. 
 
 2. ^ Refeex Causes. — This type might be included under nervous 
 palpitation. It follows dyspepsia, especially after a heavy meal, 
 and the products of digestion or mechanical gastric distention have 
 been thought causal. It may also result from constipation, intestinal 
 parasites, gall-stones (Kehr), renal calculi (Potain and Houchard), 
 puncture of ascites, prostatic, uterine or ovarian disease and float- 
 ing kidney. 
 
 3. Toxic Causes. — Palpitation may result from the use of coffee, 
 tea, alcohol, tobacco, narcotics and from gout. 
 
 4. Cardiac Causes. — Palpitation may occur in organically in- 
 competent hearts, viz., valvular disease, acute or chronic myocarditis, 
 hypertrophy, dilatation, coronary atheroma and in obesity. 
 
 Symptoms. — The patient complains of " feeling the ' heart beat " 
 
NEUROSES OF TEE HEART. 437 
 
 "goneness," "fluttering," forcible, irregular or intermittent action 
 of the heart, dyspnoea, anxiety, vertigo, tinnitus and spots before the 
 eyes. In some instances the symptoms recur periodically. Intermit- 
 tent epigastric throbbing is not infrequently present. Vasomotor 
 symptoms, as flushing of the face, pale urine, etc., are not uncommon. 
 
 Physical Examination. — Sometimes the heart is absolutely normal. 
 Conceptions of palpitation differ widely, and. some authors describe 
 it under tachycardia. The heart's rate is often increased, going up 
 suddenly after exertion or fright to 100 or 150, with violent arterial 
 throbbing. The increased rate may be due to stimulation of the 
 accelerator nerves. The heart is rarely slowed, as in Binswanger's 
 case. The rhythm may be normal or disturbed. A series of rather 
 rapid beats followed by a series of slower beats is possibly some- 
 what characteristic of nervous palpitation. If the pulse is irregular 
 when the "patient is quiet it sometimes becomes regular after exer- 
 tion. The first apex tone is often accentuated, is even metallic or 
 may be heard by the patient or by the physician at some distance 
 from the patient's chest. In some nervous subjects the systole 
 sounds short (Miiller). The second tone at the base is more often 
 strong than weak. A murmur at the base is usually functional. 
 
 Diagnosis. — (a) The etiology is Of the greatest importance. It is 
 confirmed by (b) negative results of examination of the heart dur- 
 ing the attacks, but particularly in the intervals. Coronary disease, 
 arteriosclerosis, myocarditis, etc., are usually excluded with ease, but 
 it should always be remembered that nervous palpitation may co- 
 exist with organic difficulties. Palpitation is held by some to lead 
 to dilatation or hypertrophy, but this is probably confusion of cause 
 and effect, (c) If pain be present in nervous palpitation, it is more 
 often lower (an "epigastric cramp") than the pain of organic lesions 
 which radiates to the shoulder or arms. 
 
 Prognosis. — Though palpitation is sometimes lifelong, the outlook 
 is generally favorable, but this depends on the etiology. The old 
 belief that fright could cause death is as unfounded as most popular 
 conceptions, and few such instances are recorded (Bollinger, Laache). 
 
 Treatment. — Treatment must be based on the cause, (a) If the 
 cause is nervous, suggestion is valuable and repeated examinations 
 are essential, to assure the patient and avoid error. Regulated exer- 
 cise, tepid baths with active friction, light meals, regular habits 
 and possibly the rest cure of Mitchell are indicated. It seems from 
 personal experience that isolation often increases introspection. In 
 anaemic cases iron, arsenic and strychnine should be given. God- 
 dell's combination of the three valerianates is valuable: 
 
 ]£ Ferri valeratis. 
 
 Quininge valeratis. 
 
 Amrnon. valeratis aa gr. xx. 
 
 M. et ft. in pil. xx. 
 
 S. — One pill after meals. 
 
438 DISEASES OF THE CIRCULATION. 
 
 In cases of violent throbbing, a few doses of veratrum often qniet the 
 general and cardiac nervousness. A belladonna plaster or a few 
 drops of the fluidextract helps the patient greatly, probably affecting 
 the peripheral fibers of the vagus. Sexual hygiene must be strictly 
 observed. 
 
 ]£ Fluidextr. veratri gtt. x. 
 
 Fluidextr. belladonna? gtt. xv. 
 
 Aquae q.s. ad Jj. 
 
 M. et S. — One teaspoonful every half hour for two or three doses. 
 (b) When the cause is reflex, flatulency and constipation must be 
 treated. Bromides are of value but must be given well diluted to 
 avoid added gastro-intestinal disorder. 
 
 I£ Sodii bromidi 3j- 
 
 Spts. ammon. aromat ^ss. 
 
 Syr. zingiberis 3iij. 
 
 Aquae q.s. ad ^ij. 
 
 M. et S. — One teaspoonful in hot water every half -hour for four doses. 
 
 A light evening meal of non-nitrogenous food is beneficial in children 
 afflicted with night terrors or palpitation, (c) The toxic type is 
 easily treated when the noxa is recognized, (d) In valvular disease 
 (q. v.), the cardiants, morphia, belladonna and the ice-bag are indi- 
 cated. Digitalis is of little use in the truly nervous type. 
 
 Tachycardia. — Definition. — Tachycardia is the usual term for rapid 
 heart action, although polycardia and pyknocardia are better etymo- 
 logically, for tachycardia implies quick (not rapid) heart action 
 like the pulsus celer. Tachycardia, like palpitation, is only a symp- 
 tom. Mackenzie regards it as a series of extra systoles. Some 
 hearts normally beat 90 to 100 (120 in the case of Congreve). 
 
 Etiology. — Larcenia's division, somewhat modified, is as follows: 
 (a) Heart and vascular disease; coronary or valvular affections and 
 acute or chronic myocarditis, (b) Nervous affections; (i) brain 
 and cord disease, as of the medulla (vagus centre), tumors, softening, 
 hemorrhage, multiple sclerosis, bulbar paralysis, etc.; (ii) neuritis, 
 compression of the trunk of the vagus by tumors, irritation of the 
 accelerator nerve, neuroses as exophthalmic goitre, emotional tachy- 
 cardia and reflex tachycardia from uterine or ovarian disease 
 or the menopause, (c) General diseases as fevers, chronic troubles 
 (tuberculosis, cancer) ; and convalescence, exhaustion or excesses, 
 (d) Toxic causes; tea, coffee, alcohol, lead, digitalis, atropine, amyl 
 nitrite, etc. Cases are recorded in which individuals by voluntarily 
 moving the ear or skin muscles of the neck can raise the heart's rate, 
 through the spinal accessory nerve and the vagus (Tarchanoff). 
 
 A special variety is the tachycardia paroxysmalis, described first by 
 Probsting (1881) and later by Nothnagel, Bouveret and Martius. 
 Nothnagel described the affection as a slumbering of the vagus centre. 
 Paroxysms of rapid heart action occur abruptly, last from a few 
 
NEUROSES OF THE HEART. 439 
 
 seconds or minutes to days or even weeks, and usually end abruptly. 
 This type is seen mostly in strong hard-working men, who indulge in 
 excesses in alcohol, tobacco, etc. Broadbent saw a case at ten years 
 of age. 
 
 The pulse becomes small, is usually weaker and soft, and its rate 
 reaches 150, 250 (Bowles), or even 280 (Bristowe). It is at times 
 strong (Brieger, Nothnagel) and is usually regular, though arrhyth- 
 mia may develop at the beginning and end of the seizure. The 
 sphygmogram reveals more beats than does palpation. The heart 
 often dilates (Martius), for the tachycardia and dilatation are co- 
 ordinate to the causal factor. The pause of the heart (the time be- 
 tween systoles) is lessened (Francois Frank), the systole is incomplete 
 and the diastole is often shortened. The systolic tone is often clicking. 
 The apex is apparently strong, but throbbing is an index of weak- 
 ness and dilatation. Embryocardia is frequent (Stokes, Huchard), 
 while heart murmurs are rare. The vessels, especially the carotids, 
 pulsate violently and the patient is anxious, depressed and, late in the 
 course, shows signs of venous stasis or cyanosis, although the face is 
 at times flushed or pale. The urine is of low specific gravity. The 
 lungs are usually normal but Kiegel, Tuczek, Edinger and Kredel 
 describe an acute distention of the lungs like that observed in valvu- 
 lar disease, which may be caused by vagus or phrenic irritation or 
 tonic contraction of the diaphragm. 
 
 Diagnosis. — Permanent tachycardia suggests organic disease of the 
 centres in the medulla or nerve trunks. The physiology of the vagus 
 and accelerator nerves from the clinical standpoint is still obscure. 
 It has been held that (a) increase in the pulse up to 120 indicates 
 sympathetic irritation (accelerator stimulation), which is relieved 
 by morphine; (b) increase from 120 to 180 indicates paralysis of the 
 vagus, which is relieved by pressure on the vagus trunk; (c) increase 
 over 180 is indicative of sympathetic irritation in addition to paraly- 
 sis of the vagus. Sympathetic symptoms may prevail, as protrusion 
 of the eyeball, wide pupils and increase in the interpalpebral fissure. 
 Evidences of centric vagus involvement may exist, such as respiratory, 
 laryngeal or gastric crises, polyuria, etc. ; sudden onset and cessation 
 suggest a bulbar origin. The diagnosis of vagus neurosis rests upon 
 (a) the exclusion of organic heart and brain disease, (b) a high pulse 
 rate, e. g., 150; (c) occurrence in paroxysms with intervals of nor- 
 mal pulse rate; (d) inhibitive action of manual compression or of 
 electrical stimulation of the vagus. 
 
 Prognosis. — The prognosis varies with the cause and type; the 
 permanent variety is less favorable than the paroxysmal and tem- 
 porary forms. The outlook is generally good. Bouveret holds that 
 permanent cure is rare and has reported four cases of sudden death. 
 The infrequent autopsies (only 16 in 135 cases collected by Hoff- 
 mann in 1900) show degeneration of the heart muscle. It is well to 
 regard with doubt and caution all cases of tachycardia other than 
 those resulting from emotional causes. 
 
440 DISEASES OF THE CIRCULATION. 
 
 Treatment. — Stimulation of the vagus is effected by faradization of 
 the neck, holding of the breath, by Valsalva's experiment, by firm 
 bandaging of the abdomen, pressure on the right vagus, the use of the 
 ice-bag, lying down, swallowing ice, or by induction of vomiting by 
 apomorphine. Hoover describes two instances in which inverting 
 the patient brought relief, by depleting the splanchnic circulation 
 or stimulating the medulla by hyperemia. Morphine, asafoetida, 
 valerian and the bromides are frequently of value. The causal fac- 
 tors must receive consideration. 
 
 Bradycardia. — Definition. — Bradycardia, spanocardia or brachycar- 
 dia is the usual term for slow heart but oligocardia is a better desig- 
 nation. A pulsus tardus is normal to some individuals and in cer- 
 tain families may be seen in successive generations. It is often an 
 accommodative effort as in aortic stenosis. The apparent pulse rate 
 must be verified by cardiac auscultation because the pulse record is 
 often but half as frequent as the actual heart . rate. Paroxysmal 
 bradycardia may occur with weak heart, palpitation, difficulty in 
 breathing or gastric distress. 
 
 Following Riegel's classification, two types are distinguished: (1) 
 Physiological bradycardia, which is rather infrequent in occurrence; 
 it is observed in starvation, during the puerperium, etc. ; the rate is 
 from 34 to 60. ' (2) Pathological bradycardia may show 6 to 9 
 beats a minute (ISTorfleet), and the pulse and breathing may run 
 parallel. 
 
 Etiology. — The etiological factors of the pathological type are : (a) 
 Acute infections; bradycardia is very common during or after ty- 
 phoid, pneumonia, diphtheria and rheumatism ; it is probably caused 
 by acute myocarditis, which induces lessened conductivity or " heart- 
 block," or by a vagus neuritis, (b) Digestive disorders caused the 
 majority of Riegel's collection; jaundice, constipation, gastric cancer, 
 ulcer, distention or vomiting (which causes bradycardia and arrhyth- 
 mia in children), and gall stones are the most frequent causes, \c) 
 Respiratory disease is a less frequent cause ; emphysema occurs fre- 
 quently with a slow strong pulse, which is sometimes an unfavorable 
 symptom, (d) Circulatory disease, such as aortic stenosis, fatty 
 heart, coronary atheroma or chronic myocarditis, is an etiological 
 factor and lessens the conductivity and contractility of the heart 
 muscle. Dehio uses atropine to distinguish between (i) disease of 
 the heart muscle, upon which the drug has but little effect, and 
 (ii) slow heart due to inhibition of the vagus (trunk or centre), in 
 which it brings the heart to or above the normal rate, (e) Toxic 
 conditions such as poisoning from lead, alcohol, tobacco (coronary 
 spasm), muscarine, digitalis and other drugs may cause bradycardia; 
 it also occurs in cholsemia and early in uremia, in which cases it is 
 unfavorable. _ (/) General troubles are also causative, such as dia- 
 betes, cachexia, anaemia or exhaustion, all of which lessen the irri- 
 tability of the heart muscle, (g) Nervous conditions, apoplexy, 
 
NEUROSES OF TEE HEART. 441 
 
 epilepsy, meningitis, brain tumor, disease or injury of the medulla 
 or cervical cord, vagus stimulation by tumors, compression of the 
 vagus trunk, are factors in its development. Jacob describes an an- 
 giospastic form (bradycardia with chills, wide pupils, cold skin, loud 
 second aortic tone, etc.). 
 
 The Adams-Stokes* syndrome (described under fatty heart) is due 
 to disturbed conductivity of the heart action through the bundle of 
 His, who in 1903 found a band-like muscular bundle connecting the 
 auricles and ventricles. It measures 18 millimeters in length, 2.5 
 millimeters in width and 1.5 millimeters in thickness, and courses 
 posteriorly in the septum ventriculorum, whence it reaches the right 
 and left ventricles and their valves. According to Erlanger (1906) 
 slight compression of His' bundle increases the inter-ventricular 
 pause; marked compression causes intermittency in the ventricular 
 contractions ; complete compression results in independent contrac- 
 tion of the auricles and ventricles, known as " heart-block." Its 
 causes are various ; mild, transient or incomplete heart block may 
 occur after infections as typhoid, diphtheria, etc., from the prolonged 
 use of digitalis or possibly from nervous causes. In the more severe, 
 complete and permanent cases, organic changes are discovered in 
 His' bundle. In the 16 published autopsies, gummata were fre- 
 quent ; in Stengel's case, an endocarditic patch affected the bundle ; 
 the writer sectioned one case in which marked myofibrosis obtained ; 
 acute post diphtheritic myocarditis (A. S. Dunn), acute necrosis or 
 myomalacia cordis (Jellick, Cooper and Ophiils), tumors and changes 
 in the medulla have been observed. 
 
 Symptoms. — The affection is recognized by the independent con- 
 tractions of the auricles and ventricles. With the normal pulse of 70, 
 one-fifth of a second intervenes between the auricular and ventricular 
 systole ; if this interval is much increased, there is disturbance of con- 
 duction and the transmission of the peristaltic contraction wave from 
 the auricle to the ventricle is " blocked " ; the ventricles contract two 
 to four or more times less frequently than the auricles, whose move- 
 ments may be seen in the pulsating cervical veins, the fluoroscope or 
 in polygraph tracings. The heart beats may be reduced to 2 a 
 minute. When the ventricles do not contract, a systolic tone may be 
 heard due to closure of the auriculo-ventricular valves. The com- 
 plete syndrome consists of (i) bradycardia; (ii) cerebral disturbance 
 (syncope, apoplectiform or epileptiform seizures) ; and (iii) acces- 
 sory symptoms (Cheyne-Stokes' respiration, angina pectoris, etc.). 
 
 In " heart-block " the vagus loses control of the ventricle but the ac- 
 celerator does not. The epileptiform attacks of the syndrone are 
 due to cerebral anaemia and the apoplectiform attacks result from 
 cerebral venous congestion. 
 
 Prognosis. — The constant is less favorable than the paroxysmal tvpe. 
 
 Treatment.. — The causal therapy alone is of value. Morphine "and 
 atropine must be given with care where there is disease of the cen- 
 tral nervous system. Strong cardiants, such as digitalis, are usually 
 
442 DISEASES OF THE CIRCULATION. 
 
 contra-indicated and in the Adams-Stokes' syndrome are actually 
 dangerous. Alcohol is injurious. In the Adams-Stokes' syndrome, 
 nitroglycerine is indicated, while bromides are deleterious. 
 
 Arrhythmia. — There are five major varieties: (1) The respiratory 
 or juvenile; (2) extra systole; (3) perpetual; (4) heart-block; and 
 (5) the alternating pulse. 
 
 1. The juvenile or respiratory form is especially frequent between 
 8 and 10 years of age and is found in all children at some time. 
 Normally inspiration increases and expiration decreases the pulse 
 rate but it is pathological when induced by quiet breathing or per- 
 sists in apnoea. It indicates nervous irritability. Peters maintains 
 that most of the arrhythmias following scarlatina and diphtheria are 
 respiratory in type. It also occurs in brain lesions and vagus disease 
 (whence atropine often controls it). 
 
 2. Extra systole is the most frequent irregularity and the usual 
 cause of intermittent pulse. Its general causation is an irritable 
 myocardium, which answers to some abnormal stimulus and initiates 
 a " premature," " abortive," " futile " contraction during the diastole. 
 The specific causation; in one group of cases, there is no heart dis- 
 ease and the extra systole is physiological, as in young people or if the 
 subject is nervous, as women at puberty or the menopause or the 
 individual has overdone, mentally or physically; in a second group, 
 the cause lies in poisoning (tobacco, alcohol, coffee, digitalis), in re- 
 flex alimentary origin or sometimes in infections where it is ominous ; 
 in the third group, there is organic heart disease, or increased arterial 
 tension from atheroma or nephritis. If the extra systole occurs early 
 in the diastole, no change in the pulse is noted, as the aortic valves 
 are not opened and a muffled third sound is heard; if it falls later 
 in the systole, the aortic valves are opened and the pulse shows the 
 extra beat (pulsus bigeminus, trigeminus, polygeminus). The com- 
 pensatory (diastolic) pause is usually lengthened. It is often recog- 
 nized by the patient as a thump. 
 
 3. In perpetual arrhythmia, the pulse is permanently irregular for 
 weeks or months, without tachy- or bradycardia, is unaffected by res- 
 piration, atropine or digitalis and is always associated with a ven- 
 tricular (positive) venous pulse and with no auricular wave in the 
 jugular tracing. There is no underlying rhythm (delirium cordis), 
 and its cause is apparently always intracardial, from serious arterio- 
 sclerotic or myocarditic lesions. 
 
 4. Heart-block (see bradycardia). 
 
 _ 5. The pulsus olternans shows in the sphygmogram as alternating 
 high and small waves. It indicates lasting disturbed conductivity 
 and is always serious, occurring in mitral lesions, angina, high blood 
 pressure and cardiac fatigue. If the small wave is retarded it is 
 the genuine form. 
 
 Angina Pectoris.— Angina pectoris (stenocardia, breast-pang) was 
 first described by Heberden and then by Hunter. Edward Jenner 
 
NEUROSES OF THE HEART. 443 
 
 first recognized the connection between angina pectoris and coronary 
 disease. By far the best treatises are Osier's classic on Angina Pec- 
 toris and Allied States, and JNeusser's Heft 2, Ausgeivahlte Kapitel 
 der hlinischen Symptomatologie. 
 
 Definition. — An arteriosclerotic cardiopathy, characterized (a) by 
 paroxysms of excruciating pain over the heart, which radiates to the 
 neck and arms, (b) by mental anguish, a sense of dying and (c) 
 frequently by sudden death. 
 
 Etiology and Pathology. — The chief and practically constant path- 
 ological finding is arteriosclerosis involving the heart muscle directly 
 by coronary atheroma, or indirectly by plaques in the aorta at the 
 coronary orifices. The aorta is often atheromatous without coronary 
 involvement and coronary sclerosis is frequent without much change 
 in the aorta. 
 
 Though it is usually described under cardiac neuroses, its proper 
 place is under arteriosclerosis. It is notable that atheroma is fre- 
 quent and angina pectoris is rare. The etiology is that of arterio- 
 sclerosis (q.v.) , — syphilis, gout, alcohol, contracted kidneys, sometimes 
 infectious such as rheumatism or influenza. A history of its occur- 
 rence through several generations of a family is sometimes elicited. 
 It occurs chiefly in men (80 to 90 per cent, of cases or more), usu- 
 ally after the fortieth year (although cases in the second decennium 
 have been reported) and in the well-to-do classes, professional men, 
 hard workers and luxurious livers. Angina is far more common in 
 private than in hospital practice. 
 
 Symptoms. — Mode of Ois t set. — (a) In some cases the onset is 
 gradual, and is preceded by dyspnoea (especially when dressing or 
 undressing, lacing the shoes, emptying the bowels, sitting up or 
 beginning to exercise), by short deep respiration, precordial oppres- 
 sion, pulmonary oedema, bronchial catarrh, strong beating in the 
 second or third left interspaces, and difficulty in moving the left arm. 
 This cardiac weakness ("cardiac asthma"), is followed by genuine 
 angina. Heart weakness and angina are coordinate phenomena, sec- 
 ondary to coronary disease, (b) In other cases angina is the first im- 
 portant symptom of cardiac disease. It is excited by muscular effort, 
 as walking up hill; mental excitement, as anger or coitus; chilling 
 or bathing; flatulent dyspepsia or overloading the stomach, which 
 may induce the attack when the patient is quiet or just going to sleep, 
 by way of the vagus, (c) Death may be the first symptom. 
 
 Paroxysm. — The attack itself consists of (1) sudden agonizing 
 pain, which is lancinating and feels like an iron hand squeezing the 
 heart. Its explanation is disputed and nearly one hundred theories 
 have been elaborated. The pain emanates from the cardiac plexus 
 lying behind the aorta, and in the nerve branches from it to the 
 coronary arteries, whence its reflection to other parts, which will be 
 mentioned later. The best explanation, pathologically, is that during 
 the seizure the heart muscle is ischemic from coronary obstruction 
 or possibly from superinduced spasm of the vessel (Allan Burns, 
 
444 DISEASES OF TEE CIBCULATION. 
 
 Potain). In man and in the horse, atheroma or thrombosis of the 
 abdominal aorta or its branches to the legs, shuts off the blood neces- 
 sary during exertion; with moderate exercise the collateral circula- 
 tion is sufficient, but prolonged exertion produces tingling, cramps 
 and transient paraplegia (" intermittent claudication"). The heart- 
 pang is caused by an analogous cardiac ischsema when unusual stress 
 is thrown on the diseased coronaries. In the case of the author's 
 father, two seizures of angina were followed by " claudication," albu- 
 minuric retinitis and the Adams-Stokes 7 syndrome; the abdominal 
 aorta was clearly to be seen and felt as a hard, uneven rigid tube. 
 The " unutterable " pain is usually substernal and radiates to the left 
 shoulder, neck and arm. Irradiation may be observed to the chin, 
 ear, jaw, occiput, larynx, and even to the gall-bladder and renal 
 region, spine, stomach, left leg and testis (which may swell). In 
 aortic disease, pain is propagated to the first four dorsal areas; in 
 angina it also reaches the cervical and lower dorsal areas. Pain 
 along the ulnar nerve to the fingers may precede the angina; it is 
 usually associated with some motor weakness and, in Eichhorst's 
 remarkable case, with ulnar atrophy. Numbness or hyperesthesia of 
 the arm, chest or mammary regions is frequent. The anginal pain 
 produces vasomotor symptoms, such as great pallor, low temperature 
 and profuse sweating. The patient may fall, perhaps in a fatal 
 syncope, or more often may support himself for a few seconds or 
 minutes until the paroxysm has passed. 
 
 (2) The mental anguish, the angor animi, which was first recog- 
 nized by Latham, is the second component of the seizure and con- 
 sists of a sense of dying, with great anxiety, complete consciousness, 
 immobile attitude and perhaps inability to articulate. 
 
 (3) The danger of sudden death is the third element. Death may 
 come without pain, in syncope (syncope anginosa) in the first seiz- 
 ure, after subsequent seizures years after the initial paroxysm, or 
 after constantly and closely repeated attacks (the etat angineuse of 
 Houchard). Osier has called the anterior branch of the coronary 
 artery the " artery of sudden death." Death in angina resembles 
 death from experimental injury to Kronecker's point in the septum. 
 It usually occurs in the second or third attack. 
 
 Other Signs and Symptoms. — The heart is variable, is sometimes 
 normal in rate and strength, and again shows a tense or weak, slow or 
 rapid or irregular pulse. The left radial may be smaller than the 
 right. A slow pulse usually results from partial " heart-block." 
 Dunin found the arterial pressure low in 45 per cent, and high in 
 20 per cent, of his cases. Delirium cordis, gallop-rhythm and short- 
 ening of the long pause are but signs of cardiac fatigue. 
 
 The second aortic tone is often loud and metallic ; a rough or blow- 
 ing systolic (and sometimes a diastolic) murmur is heard over the 
 aorta, which is sometimes dilated; and the left ventricle may be 
 dilated, thus sometimes relieving the attack by relative mitral leakage 
 (Broadbent and Musser) . These incidents are simply arteriosclerosis 
 
NEUROSES OF THE RE ART. 445 
 
 and its sequences. Constitutional disturbance very frequently occurs, 
 as disturbance in nutrition, loss in weight, color and physical endur- 
 ance. Dyspnoea is not a part of angina pectoris, but is solely sympto- 
 matic of heart insufficiency. Involuntary evacuations or unsuccessful 
 straining at stool are not frequent. The urine is often pale and 
 abundant after the seizure. Dysphagia, singultus or gastric symp- 
 toms are due to sympathetic, phrenic and pneumogastric participation. 
 
 Diagnosis. — When the attack is typical and severe, there is little 
 difficulty in diagnosis. Mild or early attacks may be confused with 
 cardiac asthma, because angina may be preceded by cardiac distress, 
 or associated with it. Seizures of angina involving the abdomen (an- 
 gina abdominis) or legs (angina cruris) are easily mistaken unless the 
 case is closely watched ; these forms may appear first or may alternate 
 with the more usual type — angina pectoris. The classical picture, 
 together with hardness of the arteries and atheroma of the aorta or 
 aortic valves, makes the diagnosis practically certain. The respira- 
 tion is essentially normal during the attack. Atheroma with cardiac 
 asthma is not angina pectoris. 
 
 Pseudo-angina (Latham and Walshe) is the most frequent cause of 
 diagnostic error. Its varieties are (a) nervous pseudo-angina, which 
 occurs in cases of neurasthenia and hysteria, in other neuroses and 
 in the crises of tabes (which in Oppenheim's case was due to vagus 
 neuritis). Huchard's widely quoted table is substantially as follows: 
 
 True Angina vs. Pseudo-angina. 
 
 Most common in men between forty Commonest in women, at any age. 
 and fifty. 
 
 Paroxysms induced by exertion, etc.; Spontaneous; often nocturnal and 
 diurnal; few in number. periodic; frequent. 
 
 Pain intense, of short duration, pre- Less severe, lasting hours; epigastric; 
 
 cordial, inarticulate; immobile atti- agitation, activity; sensation of dis- 
 
 tude; sensation of cardiac compres- tention. 
 sion. 
 
 No nervous symptoms. Neurasthenic or hysterical stigmata. 
 
 Vasomotor form rare. Common. 
 
 Prognosis grave or fatal. Never fatal. 
 
 Lesions; from coronary sclerosis. From neuralgia. 
 
 Arterial medication. Neuralgic medication successful. 
 
 (b) Vasomotor angina (Eothnagel) is attended by vasomotor 
 spasm, coldness and numbness in the extremities, f aintness and great 
 pain in the heart. It may be reflex in origin. 
 
 (c) The toxic pseudo-angina (Beau, Graves and Stokes) is due to 
 coffee, etc., but especially to tobacco. Vasomotor symptoms, amau- 
 rosis, dyspepsia, weak, rapid or irregular heart action, palpitation 
 
446 DISEASES OF THE CIRCULATION. 
 
 and anginal pain are common. Functional angina from tobacco, 
 which results, according to Huchard, from coronary spasm, heals 
 when tobacco is withheld ; but actual coronary disease, due to tobacco 
 and other heart poisons, is not curable, (d) The crises of tabes and 
 precordial pain due to brachial neuritis, vagus involvement or gout, 
 etc., may be difficult to diagnosticate. 
 
 Prognosis. — The prognosis is self-evident. Death is frequent. In 
 one instance the patient lived forty years. Few clear recoveries are 
 reported. 
 
 Treatment. — The treatment concerns (a) the etiology, in which 
 arteriosclerosis is the essential factor. Vierordt advises that the possi- 
 bility of syphilis should always be considered. Gout and diabetes 
 necessitate appropriate diet and therapy, as colchicum. Attention 
 must be directed to the question of stimulants. Aside from syphilis, 
 the iodides are valuable and should be given two-thirds of the time, 
 for months and years. Small amounts are frequently tolerated less 
 well than 10 or 20 grain doses. Care in their use is necessary in 
 nephritis and even when they are well diluted, gastric disorder may 
 result and possibly induce an attack of angina. Nitroglycerine or its 
 derivatives are indicated in the intervals, in doses of gr. %oo to %o 
 four or more times daily, but it should be remembered that its effects 
 last less than an hour. It may cause headache, flushing or (in larger 
 doses) cyanosis or pallor, muscular relaxation, dyspnoea and irregular 
 pulse. Erythrol tetranitrate in doses of gr. ss. t. i. d. has a more lasting 
 effect than nitroglycerine. These vasodilators will be again consid- 
 ered under Arteriosclerosis. (b) The causes precipitating parox- 
 ysms. Prophylaxis should be maintained regarding exertion, excite- 
 ment, worry, coitus, chilling, constipation and dyspepsia; late sup- 
 pers and foods favoring flatulency should be avoided, and a light 
 evening meal should be taken. The patient should be provided with a 
 mixture of aromatics in order to dispel gastric flatulency; a single 
 dose is contained in the following : 
 
 5 Spiritus ammoniae aromatici 3 SS . 
 
 Spiritus chlorof ormi 3 SS- 
 
 Spiritus glycerylis nitratis gtt. i. 
 
 Spiritus setheris compositi 3 SS< 
 
 M. et S. — To be taken in hot water. 
 
 (c) The paroxysm, Amyl nitrite was first advised by Brunton 
 (1867); it is an analgesic and a vasodilator; the patient should 
 carry pearls of the drug, which were invented by Solger and contain 
 three minims of the remedy. They often operate powerfully and 
 instantaneously, though sometimes they are useless. It may be better 
 to have the patient carry the spts. glycerylis nitratis with him, for the 
 physician but rarely sees the attack. Some member of the patient's 
 family should be taught how to give a hypodermic injection of mor- 
 phine and atropine. Morphine, and chloroform by inhalation have 
 been held dangerous, especially when brain trouble exists, as is 
 
AktEhimCLEmm: 44? 
 
 Sometimes the ease iii the Adams-Stokes 1 ' triad. Nevertheless they 
 must be Used itl some cases. Yeo called attention to the iarge doses 
 of morphia required and tolerated by subjects having angina, (d) 
 Cardiac weakness is treated by diffusive stimulants as ammonia, cam- 
 phor, alcohol and strychnine. When arterial tension is low, digitalis 
 may be administered between paroxysms : 
 
 £ Tr. digitalis 3iv. 
 
 Tr. strophanthi 3ij. 
 
 Tr. Valerianae q.s. ad 3iv. 
 
 M. et S. — One teaspoonful after meals. 
 
 Yierordt says that morphine should be carried in one hand and 
 stimulants in the other. Coffee is said to be prophylactic against 
 cardiac weakness and the paroxysms, and is said to dilate the 
 coronaries. Pseudo-angina is treated according to the type. Elec- 
 tricity and arsenic are valuable. 
 
 DISEASES OF THE ARTERIES. 
 
 ARTERIOSCLEROSIS. 
 
 Synonyms. — Atheroma, arteriocapillary fibrosis (Gull and Sutton), 
 endarteritis deformans (Yirchow), angiosclerosis (Thoma). 
 
 Definition. — A regressive change, evidenced first by malnutrition in 
 the walls of the large or small vessels and later by compensatory thick- 
 ening, either localized or diffuse. Morgagni recognized atheroma. 
 
 Etiology. — 1. Age. — Arteriosclerosis is the essential element in 
 senile involution, although some individuals attain their hundredth 
 year with no arterial change. Cazalis said, " A man is as old as his 
 arteries." Though usually found after the fiftieth year, hereditary 
 influences or certain infections, as syphilis, may develop hard arteries 
 between the twentieth and fortieth year. In adolescence or even in 
 infancy it is sometimes found as a result of the acute infections; 
 Chiari found it in 27 per cent, of those under 25 years. In 1908 
 Fremont Smith collected 144 cases in children. 
 
 2. Sex. — Eighty per cent, of cases occur in men, from causes to be 
 enumerated below. In women it usually occurs a decade later than in 
 men. In factory women Jusserand found even a larger percentage 
 than in men. 
 
 3. Aeteeial Poisons. — Chronic alcoholism causes 25 per cent, of 
 all cases (Edgren), but it is not known how alcohol operates; it does 
 not raise arterial pressure; lead, coffee, tea and tobacco (which is 
 said to affect especially the coronary vessels) are causative factors. 
 Angiosclerosis has been produced experimentally by adrenalin. 
 
448 DISEASES OF THE CIRCULATION. 
 
 4. Overwork. — This is second only to alcohol in importance. 
 Physical exertion brings one-third of the circulating blood to the 
 muscles, thus lowering the tension in other vessels (v. i. Thoma' s 
 Theory). According to an older theory exertion raises arterial 
 tension. 
 
 5. Poisons Produced Within the Body by Perverted Metab- 
 olism. — Interstitial nephritis bears a threefold relation to arterio- 
 sclerosis: (a) It results from diffuse arterial hardening; (b) it raises 
 arterial pressure mechanically (Traube) by increased peripheral 
 resistance in the arterioles, or by alteration in the quality of the 
 blood (Bright) ; (c) both processes are coordinate to a common cause. 
 Gout, diabetes, high living, overeating, obesity and overindulgence in 
 meat come under this head. 
 
 6. Specific Infections. — Edgren and Camac consider syphilis 
 of first etiological importance in 33 per cent, of cases. It operates by 
 chronic toxaemia and endarteritis. Tuberculosis (in 16 per cent.) 
 may produce local changes in the vessels. Typhoid, rheumatism, in- 
 fluenza, scarlatina and other infections are held by French writers 
 to have a direct bearing on vascular sclerosis and endarteritis. Op- 
 penheimer has recently described arteriosclerosis in children nine 
 and ten years old, obviously due to acute infections (v. s.). 
 
 7. Other Causes. — Nervous factors (worry, high tension, neuras- 
 thenia) cause variations in blood pressure. Excessive brain effort 
 tends toward cerebral localization, precisely as digestive excesses 
 may develop changes in the mesenteric vessels, as working with 
 the arms, as in butchers, may develop changes in the brachials, and 
 as excessive walking may produce arteriosclerosis in the femorals. 
 Extreme heat is thought to induce sclerosis in bakers and stokers. 
 
 Pathogenesis and Pathology. — (A) Thoma considers angiosclerosis 
 a compensatory process which follows widening of the vessels and 
 alteration of the blood. To restore the caliber of the widened vessels, 
 the tunica media contracts, or when it cannot contract, the vessel 
 increases in thickness by growth of the subendothelial connective tis- 
 sue of the intima. Thus in the foetus there is no connective tissue in 
 the tunica intima, but it appears when the foetal circulation changes 
 at birth, new areas of circulation being opened up. All bloodvessels 
 have a nervous supply ending in the Vater-Pacini bodies. They re- 
 spond to persistent low pressure, or dilatation, by increased prolifera- 
 tion of the connective tissue. Thoma observed arteriosclerosis in 
 experimentally produced aortic insufficiency. (B) Others regard 
 arteriosclerosis as due to inflammation in the nutrient vessels, the vasa 
 vasorum, leading to growth of connective tissue, i. e., mesarteritis and 
 periarteritis (Huchard, Koster, Hipp, Martin). Arteriosclerosis 
 in vessels with no vasa vasorum must be simply degenerative. 
 
 Conceptions of its morbid anatomy differ widely, atheroma of the 
 aorta and endarteritis or arteriocapillary fibrosis being sometimes 
 described under separate headings, but the difference is rather ana- 
 tomical than pathological. Large vessels, as the carotid, contain more 
 
ARTE RIO SCLEROSIS. 449 
 
 elastic than muscular tissue, but the small vessels are largely muscu- 
 lar. Two main forms are distinguished, (1) the diffuse and (2) the 
 nodular. Without distinction as to form, Rokitansky found that 
 arteriosclerosis occurred in the following order of frequency : ascend- 
 ing aorta, arch, thoracic, abdominal aorta, splenic, iliac, femoral, 
 coronary (next after the aorta, according to Huchard and Sansom), 
 cerebral, brachial and carotid arteries. It is rare in the gastric, 
 mesenteric and hepatic vessels and least frequent in the pulmo- 
 nary trunk. Bergmann found the two varieties as follows: 
 
 Diffuse Form. Nodular Variety. 
 Per cent. Per cent. 
 
 Eadial 89 2 
 
 Ulnar 88 8 
 
 Tibial 87 8 
 
 Popliteal 64 25 
 
 Splenic 64 17 
 
 Femoral 58 14 
 
 Axillary 53 16 
 
 External iliac 49 15 
 
 Brachial 49 '9 
 
 Subclavian 45 43 
 
 External carotid 44 22 
 
 Cerebral 40 43 
 
 Internal carotid 28 60 
 
 Ascending aorta 19 56 
 
 Common carotid 10 69 
 
 Abdominal aorta 75 
 
 (Both forms may co-exist in the same vessels.) 
 
 It will be noted that where the diffuse variety is most frequent the 
 nodular form is least observed and that the converse is true. The 
 diffuse form is most frequent in the extremities where arterial ten- 
 sion is most variable and more collateral circulation prevails; the 
 nodose form is most common in the aorta and its primary branches, 
 but is also seen in the circle of Willis, where arterial pressure varies 
 greatly (Meynert). 
 
 To the naked eye the intima may be normal and smooth but most 
 often is uneven and thickened. Small gelatinous or yellowish fatty 
 areas are seen which though at first circumscribed, often fuse into 
 large plaques; they occur where arterial pressure is greatest, as in 
 certain places in the aortic arch (see Aneurysm), or where the vessel 
 divides or gives off branches, as the subclavian or intercostal branches. 
 These plaques of atheroma or nodular arteriosclerosis represent na- 
 ture's effort to fill out areas of degeneration and dilatation and thus 
 even the caliber of the vessel. Microscopically the intima may be 
 increased three or four fold from swelling of its tissue, increase of 
 connective tissue and round-cell infiltration. Granular detritus, fatty 
 needles and cholesterin plates are seen in the atheroma plaques, a 
 name indicating their pulpy, grumous appearance. Formerly they 
 were wrongly called atheromatous abscesses. An atheromatous area 
 rupturing into the lumen produces the atheromatous ulcer, which 
 29 
 
450 DISEASES OF THE CIRCULATION. 
 
 may cause embolism, thrombosis or occlusion. Secondary deposit of 
 carbonate or phosphate of lime in the atheromatous areas leads to 
 calcification of the arteries or may produce rough areas in the aorta 
 which break on manipulation or if handled carelessly may cut the 
 finger. The lumen of the smaller vessels is often decreased or ob- 
 literated (endarteritis obliterans). The middle and outer coats 
 of the smaller vessels are at times thickened from hyaline degenera- 
 tion and fibrous tissue; the muscular coat may waste and all elastic 
 tissue may disappear ; the essential changes are in the elastic tunic. 
 In the larger vessels dilatation or even aneurysm may develop where 
 thickening of the intima fails to protect the vessel wall. 
 
 The general results of arteriosclerosis are (1) vascular, consisting 
 of loss of arterial elasticity, deformity, tortuosity, obliteration, 
 aneurysm and high arterial tension, and (2) visceral alterations in 
 the heart, brain, kidney and other organs (v. %.). 
 
 Sclerosis in the 'pulmonary artery is most common in the stasis and 
 increased pulmonary tension of mitral lesions and emphysema; the 
 rare cases of Bhomberg, Klob and JSTeusser have shown that pulmo- 
 nary atheroma may occur alone, sometimes with aneurysmatic dilata- 
 tion of its branches and with pulmonary regurgitation. 
 
 The term angiosclerosis (Thoma) also includes phlebosclerosis, 
 which frequently accompanies arteriosclerosis and sometimes occurs 
 independently, in the lower extremities, lung and portal tributaries 
 in cases of liver cirrhosis or pylephlebitis. 
 
 Symptoms and Diagnosis. — In diffuse forms there may be no symp- 
 toms, i. e., the process is latent. When it is local, visceral symptoms 
 may develop. The clinical picture is extremely variable. 
 
 1. The peripheral arteries may be involved alone or there may be 
 changes in the aorta, heart, brain and kidneys. The small arteries 
 are visible and appear tortuous, pulsating and lengthened, as in the 
 temporals or brachials when the elbow is fiexed and the arm is rotated 
 outward; lifting the arm is said to decrease the pulsation. A dis- 
 tinction must be made between hardness of the vessel walls and in- 
 creased arterial tension, although both conditions usually occur to- 
 gether. The normal systolic blood pressure ranges from 100 to 140 
 mm. of mercury. Dunin holds that the systolic pressure ranges be- 
 tween 130 and 150 mm. in arteriosclerosis, and that 21 per cent, have 
 normal or decreased arterial tension. It must be remembered that 
 normal blood pressure does not mean a normal movement of the 
 blood, since ^ accommodative vascular contraction may follow poor 
 vascular filling. It is asserted that increased arterial tension pre- 
 cedes actual sclerosis of the vessels but in these early cases it is 
 probable that some angiosclerosis has already developed. Pressing 
 on the radial with one finger should obliterate the pulse beyond that 
 point if the arteries are not sclerotic, unless there is an anastomotic or 
 recurrent pulse from the ulnar to the radial vessel; this source of 
 error is easily eliminated by simultaneous pressure on the ulnar ves- 
 sel. The wall of the artery is firm, hard, often uneven or nodular, 
 
ABTERIOSCLEEOSIS. 451 
 
 and the serial atheromatous plaques sometimes feel like a rosary or 
 the trachea of a goose. In extreme instances the vessel feels calcare- 
 ous — the "pipe stem artery." The Roentgen rays clearly show the 
 arterial change. The pulse is hard (pulsus durus), retarded (pulsus 
 tardus) or slow (pulsus varus) ; it rises slowly and is long main- 
 
 Pig. 28. 
 
 Pulse tracing in arteriosclerosis. 
 
 tained (p. rotundus), the vessel is firm between the pulse beats 
 (Broadbent), the elastic wave is lessened or absent, the tracing has a 
 rounded or flat top, and the pulse in the two radials may differ 
 (pulsus diff evens). The pulsus tardus and bigeminus are most rare 
 unless there are coronary changes. In vessel obliteration or abso- 
 lutely rigid walls the pulse cannot be felt. Very slight pressure on 
 the vessels often elicits a systolic murmur (Litten). The right 
 
 Pig. 29. 
 
 Pulse tracing in extreme arteriosclerosis (Sahli). 
 
 radial is normally larger and more often shows changes than the left. 
 It must be remembered that changes may occur in internal vessels 
 without change in the radials (and conversely). 
 
 2. Heavt changes, (a) Simple hypertrophy of the left ventricle 
 may occur, with heaving apex, loud second aortic tone, tense pulse 
 and thickening of the arteries, which lead to a certain and immediate 
 diagnosis. Some " consensual " right heart hypertrophy is common 
 because of anastomosis between the ventricular muscular fibers or 
 because of stasis in the lungs or emphysema. Those cases in which 
 there is increased tension in the aorta without increased tension in the 
 radials are more difficult of diagnosis. The heart is not hypertrophied 
 in all cases nor, according to Rhomberg, in the majority of cases; 
 hypertrophy, he maintains, does not necessarily follow arteriosclerosis 
 in the extremities or brain, but most often occurs when the splanchnic 
 vessels are involved ; Hasenfeld also believes that cardiac hypertrophy 
 only occurs when these vessels and the aorta are sclerosed. The apex 
 may sink outward and to the left when the patient sits, from relaxa- 
 tion and lengthening of the aorta (Traube). (b) Hypertrophy plus 
 dilatation, with heart insufficiency, dyspnoea, scanty urine and hydro- 
 thorax is very common. When the patient in this stage has a sys- 
 tolic murmur, a wrong diagnosis of mitral insufficiency may be made. 
 Interstitial nephritis (q. v.) may be the cause, in part at least, of the 
 hypertrophy and dilatation. There may be cardiac weakness even 
 when the blood pressure registers 200 to 300 mm. In high arterial 
 tension a double impulse may be felt and seen at the apex, which is 
 
452 DISEASES OF THE CIRCULATION. 
 
 menacing as it precedes cardiac weakness. (Edema is not frequent. 
 Gallop-rhythm is uncommon without coincident coronary or renal 
 disease. The heart muscle may show various changes, such as 
 atrophy, myocarditis, fatty heart, myofibrosis, myomalacia cordis, the 
 cor renale, senile heart, heart aneurysm, angina pectoris, coronary 
 embolism, cardiac asthma and arrhythmia, or sudden death may 
 occur. Two forms of visceral sclerosis may be distinguished: (i) 
 inflammatory, occurring about the vessels, and (ii) dystrophic (mal- 
 nutritive) sclerosis, which is often somewhat distant from the vessel 
 involved ; the visceral sclerosis is best illustrated by the heart changes, 
 such as myofibrosis or myomalacia cordis, induced by coronary 
 atheroma, (c) Valvular lesions occur from what we may term 
 cardiosclerosis. 
 
 3. In the aorta dilatation may occur, giving slight dulness in the 
 second (and third) right intercostal spaces ; this is confirmed by the 
 fluoroscope; the aorta may be felt in the jugulum or abdomen. The 
 normal aorta may be felt in these situations when the heart action is 
 strong, but when there is atheroma, plaques or even a crackling may 
 sometimes be felt. The normal aorta propels the blood onward 
 during the diastole after the aortic valves close ; if the aorta loses its 
 tone the peripheral vessels receive inadequate blood, depending wholly 
 on the ventricular systole; then the pulse may resemble the pulsus 
 celer. The subclavian or innominate arteries may be felt even 
 through their entire length when the aorta is dilated. A short systolic 
 murmur over the aorta often results from atheromatous roughening 
 or dilatation, and the second aortic tone is then accentuated and 
 metallic. Its vibration may sometimes be felt; when much emphy- 
 sema is present it is best heard in the jugulum. The accentuation 
 may be caused by increased tension, widening or rigidity of the 
 aorta. The murmur and sharp tone are often heard in the neck and 
 back. A burning substernal pain may indicate involvement of the 
 outer coat of the vessel. Atheroma of the arch may, by downward 
 extension, cause aortic stenosis or more often aortic regurgitation. 
 
 4. Renal findings are next in frequency. The kidneys are often 
 contracted (the senile arteriosclerotic and the genuine contracted 
 kidney). The discussion, whether the renal findings are primary or 
 secondary, is a separate literature in itself (see Interstitial Ne- 
 phritis). The urine may be increased as a result of simple in- 
 crease in the blood pressure. 
 
 5. Brain symptoms are next in importance. Syncope, vertigo, 
 insomnia, headache, tinnitus, neurasthenic symptoms, transient 
 aphasia or hemiplegia result from transient ischsemia. Brain hemor- 
 rhage and miliary aneurysms are frequent sequences. Softening of 
 the brain (encephalomalacia) results from embolism or thrombosis 
 of the cerebral arteries. Brain atrophy, dementia (cortical sclerosis), 
 epileptic seizures and the Adams-Stokes' triad have been attributed 
 to cerebral atheroma. Vascular brain lesions occur fairly often in 
 cases which show arteriosclerosis in the extremities and temporal 
 

 ARTERI0SCLEB0S1S. 453 
 
 vessels, though sclerosis of the aorta, coronary or splanchnic vessels 
 occurs more often without peripheral angiosclerosis. 
 
 Charcot's claudication intermittente (Erb's dysbasia intermittens 
 angiosclerotica, intermittent limping, angina cruris) occurs especially 
 in nervous or neurasthenic subjects. It is chiefly due (a) to ather- 
 oma in the abdominal aorta and its branches in the limbs ; it is seen 
 in abdominal aneurysm in the horse. It appears also to result (&) 
 from vessel spasm or (c) from atheroma in the spinal vessels, of 
 which Dejerine has seen but three cases. Erb, reviewing 127 cases 
 in 1904, found that 94 per cent, were in men over 40 years of age ; 
 heredity is sometimes causal; 33 per cent, were Jews; syphilis (in 
 23 per cent.) was less frequently causal than tobacco; alcohol was 
 not proven an etiological factor; most cases developed in the upper 
 classes. Pain, paresthesia? and sometimes local cyanosis occur in 
 the legs, which " give way " after moderate exertion. The legs are 
 most comfortable when dependent. The dorsalis pedis (sometimes 
 also the tibial and femoral vessels) usually cannot be felt. Gangrene 
 may result (Boerhaave). 
 
 Some vasomotor neuroses — as erythromelalgia, Reynaud's disease, 
 acroparesthesia — and some neuritis and neuralgia are sometimes as- 
 sociated with angiosclerosis ; sclerotic vessels are prone to spasm. 
 
 6. The gastro-intestinal symptoms probably rank next in fre- 
 quency. Hasenfeld, Huchard, Allbutt, Litten, Edgren and others 
 have described dyspepsia, round ulcer, arteriosclerotic gastritis, gas- 
 tro-intestinal hemorrhages, intestinal perforation and ulceration. 
 Some cases resemble gastric cancer. Severe abdominal pain (angina 
 abdominis) has attracted some attention lately; it is due, as is angina, 
 to local anemia (Ortner's intermittent claudication of the abdominal 
 vessels, Schiitzler's intermittent dysperistalsis) ; Pal thinks spasm 
 occurs in the mesenteric and gastric vessels; it develops in two or 
 three hours after eating, and is often accompanied by dyspnoea. 
 Abdominal angina, in the writer's experience, is rather often asso- 
 ciated with angina pectoris and angina cruris ; in three cases these 
 conditions appeared alternately. 
 
 7. The retinal vessels are not infrequently embolized, narrowed 
 or aneurysmatic, which leads to softening, hemorrhage and exudation. 
 
 8. In the respiratory tract, emphysema is common and is some- 
 times regarded as a compensatory effort. The breathing is often 
 somewhat irregular. Hemoptysis is referable to stasis, infarction 
 or possibly to atheroma of the pulmonary arterioles. 
 
 9. In the peripheral vessels the so-called spontaneous or senile 
 gangrene results from obliterating endarteritis. Thrombosis or em- 
 bolism may occur in the aorta, brain, or in the coronary, pulmonary, 
 mesenteric, pancreaticoduodenal and other arteries. 
 
 10. The general nutrition varies. Some writers distinguish be- 
 tween (a) a plethoric type, which occurs in elderly individuals and 
 the symptoms of which are good color, wide vessels, increased thirst, 
 hemorrhages from the nose, increased urine, respiratory catarrh. 
 
454 DISEASES OF THE CIRCULATION. 
 
 profuse sweats, muscular rheumatism, headache, enlargement of the 
 liver, emphysema, tense pulse, thick bloodvessels and marked hyper- 
 trophy of the heart; and (b) an ancemic type, with chlorotic habitus, 
 anorexia, dyspepsia, few external vascular findings, dilated heart 
 and endarteritis. This type occurs in individuals between 30 and 
 50 years of age. French writers speak of a cachexie arterielle, in 
 which the pallor is distinguished from the dusky anaemia of cardiac 
 disease. Alfred Stengel has noted that the anaemia is more often 
 apparent than real (pseudo-anaemia). 
 
 Early Diagnosis. — Early symptoms are referable to local disturb- 
 ances in circulation and may only appear after exertion. The patient 
 tires more easily and the arterial tension may rise ; dyspnoea on mod- 
 erate exertion, slight oedema of ankles or epistaxis are suggestive. 
 Early nervous symptoms are headache, irritability, somnolence, diffi- 
 culty in concentration or in undertaking new work, vertigo, neu- 
 ralgias, insomnia, or neurasthenia appearing for the first time after 
 40 years of age. A slight albuminuria always should attract atten- 
 tion. Ocular and vasomotor disturbances may characterize the 
 insidious onset. The above symptoms are important since successful 
 therapy depends on the early recognition of what Huchard terms the 
 " presclerotic " symptoms. 
 
 Prognosis. — The prognosis is relatively unfavorable, because the 
 symptoms are frequently latent until the process is well established or 
 far advanced. In the early stages arteriosclerosis may be arrested or 
 may remain stationary for a long period, but there is constant danger 
 of apoplexy, angina pectoris, myocardial paralysis, "heart block" 
 or uraemia. It is a most common finding after death from acute in- 
 fections, so that many deaths attributed to acute affections are more 
 properly deaths from arteriosclerosis. Increased blood pressure may 
 overcome moderate obstruction. The prognosis is most favorable in 
 angiosclerosis of the peripheral vessels, and, as a rule, is rather un- 
 favorable in atheroma of the aorta, because of the danger of coronary 
 disease and aneurysm. Intestinal hemorrhage is ominous. A slow 
 pulse is less favorable than arrhythmia and moderate increase in rate. 
 The plethoric form is less dangerous than the anaemic. 
 
 Treatment.— Prophylaxis regarding the etiological factors and the 
 patient's mode of life is most important, Alcohol and tobacco should 
 be forbidden, iodides should be given in syphilis, the diet should be 
 regulated in diabetes, colchicum should be given in gout, etc. In early 
 cases the process may sometimes be arrested. Many cases seem to im- 
 prove on a milk diet, although Rumpf claims that" manv of the salts 
 ingested are deposited in the arteries. He found that milk sufficient 
 to meet the needs of metabolism (70? or 2,175 c.c.) for 24 hours 
 contained over one dram (5 grams) of calcium and magnesium. 
 Iodide of potash has been advised, especiallv bv Huchard, who s;ives 
 15 to 45 grains daily for twenty days; then " after ten clavs inter- 
 mission, nitroglycerine is used. (See Angina Pectoris and Treat- 
 ment of Syphilis for details.) Iodides are also used in cases where 
 
ANEURYSM. 455 
 
 no suspicion of syphilis exists. Some physicians oppose its use and 
 find on experimentation that it has no vasodilator effects. Eosen- 
 bach claims that it actually irritates the endothelial tissues. Income 
 cases at least it has beneficial effects and in a non-syphilitic series of 
 personally observed cases the walls of the nodular, hard vessels 
 distinctly improved with administration of iodides. Khomberg 
 thinks that iodides operate less by vasodilatation than by decreasing 
 the viscosity of the blood. It has been recently claimed that nitro- 
 glycerine dilates the peripheral vessels only, but on this assumption 
 it is hard to explain the cerebral flushing, which follows its use; 
 indiscriminate resort to nitroglycerine is to be condemned, as in- 
 creased arterial tension, though pathological, is probably conservative. 
 Massage, a warm climate, passive exercise and the Schott method 
 of treatment may be employed as outlined on page 366. It is in- 
 teresting to note that Skoda employed hot hand- and foot-baths 
 to reduce peripheral resistance. Coffee may relieve anginal and 
 abdominal pain. 
 
 Eest in bed, venesection, iron and digitalis are indicated when the 
 heart muscle weakens. Huchard advises the following pill : 
 
 I£ Sodii iodidi 3j. 
 
 Sparteine sulphatis gr. xv. 
 
 Pulv. glycyrrhizae q.s. 
 
 M. et fac in pil. no. xl. 
 S. — One after meals. 
 
 Rest is more efficacious than are cardiants. Morphine is a valuable 
 nervous sedative and tonic for severe cases of cardiac asthma, but 
 must be used with great care. 
 
 ANEURYSM. 
 
 Definition. — A dilatation, usually localized and sac-like, of an 
 artery. Aneurysm was described by Galen, Vesalius who made the 
 first diagnosis of thoracic and abdominal aneurysm, Pare, Lancisi and 
 Morgagni. 
 
 Etiology. — (a) Arteriosclerosis is the most important cause. The 
 importance of syphilis is estimated at 36 per cent. (Frankel), 80 per 
 cent. (Malmsten) and 100 per cent. (Drummond). The author 
 thinks the relationship between syphilis and aneurysm is as well 
 established as that between syphilis and locomotor ataxia, and prob- 
 ably with the same percentage. Lancisi, in 1728, was the first to 
 recognize the importance of lues and described " venereal aneurysm." 
 (b) Trauma is an important factor but is probably overestimated. 
 Sudden effort in strong men with weakened aortas is a direct factor 
 in partial rupture of the aorta and formation of aneurysm, (c) 
 Sex: aneurysm is from two to eight times as frequent in males as 
 in females, (d) Age: the old statement that aneurysms occur before 
 the fiftieth year and arteriosclerosis after that age is still valid ; they 
 occur between 30 and 40 (Crisp), 30 to 50 (Orth), 30 to 60 (Eoki- 
 
456 DISEASES OF THE CIBCULAT10N. 
 
 tansky), 40 to 50 (v. Schrotter) ; later compilations, however, set 
 the age higher. Eighty cases under 20 years of age were collected 
 by Le Boutillier (1903). (e) Embolic and mycotic aneurysms are 
 usually small and may be multiple in the small vessels. Arterial 
 tuberculosis was found by Weinberger. (/) The traction aneurysm 
 at the ductus arteriosus Botalli is rare (Thoma). 
 
 (g) The arrosion aneurysm, in which the inner coats bulge out 
 when the adventitia is eroded, occurs largely in tuberculous cavities. 
 The " aneurysmal diathesis " is spoken of by older writers ; Pelletier 
 found 63 in one case. Dieulafoy considers that multiple aneurysms 
 of the arch are clearly syphilitic. 
 
 Pathology. — In relation to the lumen, aneurysms are axial or periph- 
 eral. According to Quain, the varieties are: (a) true aneurysm, in 
 which the sac consists of one or more coats. Strictly speaking, a 
 true aneurysm should contain all three arterial coats in its walls, 
 but this is most uncommon. The sac is usually (i) fusiform and 
 diffuse, or (ii) sacculated and circumscribed, (b) False aneurysm, 
 in which all the coats rupture, or in which, according to some, one 
 coat ruptures through the others, like a hernia. These are circum- 
 scribed or diffuse, especially in the transverse arch and in the abdomi- 
 nal aorta, (c) Dissecting aneurysm, wherein the intima of the vessel 
 ruptures and the blood makes a channel down the vessel between the 
 intima and media or between the layers of the latter. It is a partial 
 rupture. The rupture back into the aorta is an attempt of nature 
 toward recovery; the patient may live for years. (d) Varicose 
 aneurysm, wherein the sac ruptures into a vein, especially the innomi- 
 nate vein or vena cava; this form is also called arteriovenous or 
 aneurysmal varix, when the main change is in the vein. 
 
 Atheroma is held to be a common cause, though it occurs very fre- 
 quently in comparison with aneurysm. It is thought that intimal 
 changes induce aneurysm when the outer coats do not undergo vicari- 
 ous thickening quickly enough to prevent dilatation. Koster held 
 that mesarteritis was the principal change, but Eppinger found the 
 greatest change to be loss of the elastic and muscle-tissue in the 
 media. Syphilitic changes are discussed under Syphilis and are very 
 important. In the sac, thrombi form from the roughened intima and 
 slowed circulation and to a small extent guard against extension and 
 rupture. Aneurysm occurs at those points in the aorta on which the 
 blood stream impacts most strongly; 59 per cent, of thoracic aneur- 
 ysms occur on the anterior surface of the ascending aorta, 29 per 
 cent, on the convexity of the arch and 12 per cent, on the posterior 
 surface of the descending segment. In 915 aneurysms the seat was 
 in the pulmonary artery in but 0.4 per cent. (Crisp). 
 
 Symptoms.— Bramwell distinguishes three classes of cases: (a) 
 Those which are entirely latent, and become manifest only by rupture 
 or at the autopsy. (&) Those presenting symptoms of intrathoracic 
 pressure but giving no positive physical signs, (c) Those signalized 
 by distinct physical signs, e. g., by pulsating expansile tumor 
 
ANEUBYSM. 457 
 
 The Purely Subjective Evidences of Aneurysm. — The clin- 
 ical signs are most variable, and often change or disappear entirely 
 when the aneurysm changes the direction of its growth; the latency 
 of a large proportion of aneurysms gives a disproportionate value to 
 symptoms per se. 
 
 1 Pain. — Pain is either intrinsic, resulting from subacute aortitis, 
 relieved by reduction of the arterial tension, localized, and dull or 
 aching in character; or it is extrinsic, resulting from pressure on 
 nerve trunks especially in deep-seated tumors, or from the weight 
 of the aneurysm, as illustrated by a case of Stokes in which pain was 
 relieved by the use of crutches. Early pain is of the greatest diag- 
 nostic value. Sudden pain in the left chest, whether anginal or not, 
 yielding to treatment, is suggestive of aneurysm. Pain in the 
 majority of cases is the first, the most notable, and often the most 
 enduring symptom. It is often alleviated by iodides; it is usually 
 paroxysmal, sharp, lancinating or boring in character (when, for 
 instance, the spine is eroded) ; it is augmented by movement, but 
 may cease when the part compressed is entirely eroded. The pain is 
 local or is reflected into the brachial plexus, the arm, neck or along 
 the intercostal nerves and may cause numbness and paresis of the 
 arm. Though it is more usual anteriorly, it is sometimes felt in the 
 interscapular region. Anginal pain follows involvement of the 
 cardiac plexus. Intercostal neuralgia is always suggestive of 
 aneurysm. 
 
 2. Dyspnoea. — Dyspnoea is frequently out of all proportion to the 
 findings. It is often a vagus neurosis, but is also due to narrowing of 
 the chest space by compresison of the aneurysm upon the heart, 
 phrenic nerve, trachea, bronchi, lungs or pulmonary artery; or to 
 compression of the plexus cardiacus or pulmonicus, producing bron- 
 chial spasm, and laryngeal spasm or paralysis. Dyspnoea may occur 
 with change of posture (Leube) and is paroxysmal; it is at times 
 more or less urgent, or may sometimes subside entirely. 
 
 3. Cough. — Cough is frequent, but is one of the least distinctive 
 features. It results from pressure on the air passages, vagus irrita- 
 tion, bronchitis or laryngeal involvement. It is often unproductive. 
 Like all other eccentric pressure symptoms, it varies with the size and 
 direction of the aneurysm; it is paroxysmal (Morgagni) and is prone 
 to appear or disappear hand in hand with the pain and dyspnoea. 
 
 4. Difficult Swallowing. — Dysphagia results from direct com- 
 pression, from pressure on the recurrent laryngeal nerve, inducing 
 oesophageal spasm, or most often from adhesions between the aneur- 
 ysm and the oesophagus. It occurs particularly in low aneurysms of 
 the "recurrent type" (v. i. Larynx) and may produce distinct pul- 
 sations in a water tube introduced into the oesophagus. One of the 
 earliest aneurysms reported by Stokes was the size of an egg, and 
 produced pain, dysphagia and compression of the left bronchus, 
 with rupture into the latter. Traube described a case of obstruction 
 of the subclavian artery and compression of the left recurrent laryn- 
 
458 DISEASES OF THE CIRCULATION. 
 
 geal nerve in which aneurysm was suspected; but the autopsy re- 
 vealed carcinoma of the oesophagus, embracing in its regional in- 
 vasion the left subclavian artery and the recurrent laryngeal nerve. 
 Dysphagia may be intermittent or present only in one posture. Its 
 infrequency is explained by the ready lateral luxation of the oesopha- 
 gus. The danger of sounding the oesophagus is well known, for dis- 
 tressing lethal hemorrhages have occurred in the physician's con- 
 sultation room. 
 
 5. Compression of the Vagus. — Vagus compression results in 
 asthma, laryngeal spasm, vomiting, stenocardiac attacks, hiccough, 
 dysphagia and pulmonary symptoms. 
 
 The Physical Signs of Aneurysm. — 1. Inspection. — Stokes de- 
 scribed two areas of pulsation in the chest, each distinct " like two 
 separate hearts/' This is most significant when the cardiac impulse 
 is the weaker. Inspection is most advantageously made with the 
 eye just below the level of the shoulder and near the chest. The 
 typical expansile pulsation is best detected in superficial thin-walled 
 aneurysmata in the ascending arch, or in those presenting in the 
 jugulum. Pulsation is less a question of the size than of the location 
 of an aneurysm, and visible pulsation may be absent even in the 
 largest varieties ; deeply situated aneurysms give diffuse or no pulsa- 
 tion, or the pulsation appears only during expiration. Throbbing 
 over the aorta is least important when there is also marked arterial 
 pulsation (aortic regurgitation). The pulsation must be expansile 
 to render the diagnosis absolutely sure, though at autopsy the 
 author saw one case which presented clinically an expanding throb- 
 bing aorta and dulness over the arch which was due to an enormous 
 mass of callous connective tissue involving the pleura and peri- 
 cardium. Another instance of a truly expansile pulsation low down 
 in the left side of the chest, as well as near the spine, was observed in 
 pernicious anaemia ; the hands placed over it were lifted widely apart, 
 and the pulsation was seen at a distance of forty feet; the autopsy 
 revealed no aneurysm. Pulsation lent to a tumor, a collapsed lung, 
 the liver or a pleural exudate can usually be distinguished without 
 difficulty. 
 
 2. ^ Palpation. — Pulsation is felt slightly later than the heart shock ; 
 this interval is more obvious the slower the heart rate becomes. The 
 expansile character of the pulsation is sometimes more easily detected 
 by the fingers than by the eye. Palpation may reveal remittent ten- 
 sion of the sac, tenderness on deeper pressure, resistance caused by 
 thick lamellated thrombi and, in rare cases, elasticity or fluctuation 
 of the tumor during the diastole. Pulsation in a deeply situated 
 aneurysm is best elicited by placing one hand anteriorly and the 
 other posteriorly on the chest. A thrill may be felt which is most 
 commonly systolic. A diastolic shock sometimes occurs in the jugu- 
 lum and over the aortic area (Lancisi), and this is not due to recoil 
 from the aortic valves, but to retraction of the hypertrophic aorta 
 lying between the heart and the aneurysm (Kosenbach). Bough 
 palpation may induce embolism. 
 
ANEURYSM. 459 
 
 3. Percussion. — Dulness (Walshe) is an important finding only 
 when it is present on either side of the sternum, but not when con- 
 fined to the sternum. Dulness may be detected in the left interscap- 
 ular region, though in this case percussion is less valuable, because of 
 the thickness of the chest wall. Aneurysms are often obscured by 
 an emphysema, and they may grow from a deep origin into the lung 
 substance. The dulness may so merge with that of the spine, heart, 
 liver or spleen that no certain statement can be made. Dulness 
 when once detected may cease or shift to another place; this is an 
 almost certain indication of aneurysm (Br am well). 
 
 It is inexplicable that aneurysms often grow toward and press upon 
 relatively unyielding structures, while the softer parts in their im- 
 mediate vicinity, as the lungs, are less compressed (v. Schrotter). 
 
 4. Auscultation. — Auscultation is sometimes wholly negative, 
 even in large sacs — explained" by thrombi in the sac and weak heart 
 action. Two clear tones are most frequently heard; the second 
 tone, heard over a circumscribed area, is pathognomonic of aneurysm 
 (v. Schrotter), and originates in the aneurysm itself; some writers 
 attribute it to closure of the aortic cusps; it is most often heard in 
 aneurysms near the ascending arch. Two tones in the abdominal 
 aorta are scarcely ever heard normally. A systolic murmur is fre- 
 quent, and is usually blowing, roaring or scraping; it is due to 
 vibrations in the aortic wall, to entrance or exit of blood from the 
 aorta into the sac, to blood waves initiated by angles in the direction 
 of the current, by thrombi, or more rarely by pressure of the sac 
 upon the aorta itself. 
 
 The less frequent diastolic murmur is most probably caused by 
 (relative) aortic insufficiency, when the aneurysm lies in the first 
 part of the aorta. It may be due to folds in the aorta, vibrations 
 of clots, dilatation of the left ventricle, or to dissection of the aneu- 
 rysm into the sinus Valsalva? (Stokes, Marey). It is usually com- 
 bined with a systolic murmur. A continuous murmur is rare. Of 
 132 cases (Sansom) in which the diagnosis was made, only 12 
 presented a systolic murmur, 25 gave systolic and diastolic murmurs, 
 and in 6, diastolic murmurs alone were found. Douglas-Powell 
 detected murmurs in about half of his cases of sacculated aneurysms. 
 
 The Heaet.- — Its position varies with the size and location of the 
 aneurysm, (a) Large aneurysms of the ascending aorta not only de- 
 press it, but cause such axial rotation that the left lies lower than the 
 right ventricle ; aneurysm in this location may cause pressure atrophy 
 of the right ventricle. (b) Aneurysm of the under surface of the 
 arch may dislocate the heart to the median line, (c) Aneurysm of the 
 descending segment may flatten the heart against the chest wall 
 (Neusser), thus simulating mitral regurgitation, (d) Secondary 
 aneurysmatic outgrowths from the chief aneurysm complicate the 
 physical findings; these growths sometimes attain incredible propor- 
 tions and produce confusing symptoms, (e) In uncomplicated cases 
 myocardial alteration is entirely accidental (Stokes, Key and Skoda). 
 
460 DISEASES OF THE CIBCULATION. 
 
 Failure of the heart to hypertrophy is explained by anaemia, arterio- 
 sclerosis, coronary disease or compression of the pulmonary artery, 
 thereby decreasing the flow of blood to the left heart and coronary 
 arteries. Hypertrophy of the left ventricle bears an intimate rela- 
 tion to aortic leakage; it may in rare cases result from aneurysm 
 involving the entire periphery of the aorta. Stokes states that the 
 most violent aneurysmal pulsation he ever witnessed occurred with 
 marked myocardial atrophy. Compression of the pulmonary artery, 
 early observed by Eindfleisch and Obermeier, may cause relative tri- 
 cuspid regurgitation or pulmonary insufficiency (v. Schrotter). 
 
 The symptoms of aneurysm are given in their entirety in Stokes' 
 early observations. 
 
 The Vessels. — The pulsus dif evens is frequently physiological, 
 due to irregularities in the size or branches of the radial vessels. 
 Stokes explicitly stated that the right radial is normally larger than 
 the left, whence if the right radial pulse is smaller, it means more than 
 if the left were slightly smaller. When one radial is small, its fel- 
 low ulnar is often vicariously larger. A pulse may grow smaller and 
 later return to its normal size ; this is due to change in the size and 
 the direction of the aneurysm. When the radials differ essentially 
 in volume it is advisable to compare the brachials. Asymmetrical 
 sphygmographic and manometric findings may be due to other causes 
 than aneurysm, as atheroma, coagula, embolism or reduction of the 
 lumen of a vessel by the dragging of the aneurysm ; v. Schrotter in- 
 stances a case in which the aorta was so compressed by a sac lying 
 between it and the spine that the abdominal and femoral pulsation 
 was obliterated. Changes are observed most often in the carotid and 
 subclavian vessels. The pulsus paradoxus and capillary pulsation 
 may occur with large aneurysmatic sacs (Quincke). Retardation of 
 the pulse occurs especially in fusiform aneurysms. The location of 
 an aneurysm may sometimes be determined by regarding the vessels 
 altered. If pressure is exerted upon the superior cava, dropsy of the 
 upper portion of the body, of one or both arms, swelling of the face 
 and of the tongue, sometimes exophthalmos and a "brawny" or 
 " collar-like " distention of the neck occur. Obstruction above the 
 azygos vein causes lividity and oedema which are confined to the 
 head and arms; when it occurs below that vessel the chest is also 
 congested. Obliteration of the innominate and azygos veins or the 
 venae cavse may occur. Rupture into the superior cava is attended 
 by cyanosis, and a continuous bruit like the bruit de diable is often 
 present ; in E wart's case (not suspected during life) phlebotomy was 
 performed, and bright-colored blood escaped in jets. The continuous 
 murmur may occur in vascular sarcomata or in aneurysms rupturing 
 into the pulmonary artery or right ventricle. 
 
 The Eespiratory Tract. — Tracheal tugging, described by Oliver 
 and Cardarelli simultaneously, is elicited by lifting the larvnx with 
 the fingers; a tugging sensation in the trachea is then felt with each 
 systole ; this symptom occurs in cases of cardiac overaction, left ven- 
 
ANEURYSM. 
 
 461 
 
 tricle hypertrophy, aneurysmata of the arch and of the innominate 
 and carotid vessels, and in adhesions to the trachea. 
 
 Tracheal pulsation is present in many cases of aneurysm and may 
 be demonstrated by the laryngoscope. The examination should be 
 made by direct sunlight, and the observer should sit before the stand- 
 ing patient. Tracheal pulsation also occurs in tumors which com- 
 press the trachea ; it may also be physiological. Drummond has de- 
 scribed a systolic murmur over 
 the trachea. A short murmur, 
 synchronous with the systole, 
 can sometimes be heard when 
 the patient breathes quietly with 
 the mouth open. 
 
 Recurrent laryngeal paralysis 
 was first described by Morgagni 
 and Todd was the first to note 
 laryngeal muscular atrophy on 
 the affected side. Unilateral 
 paralysis with the cadaveric 
 position of the vocal cords, in 
 the absence of obvious cause, is 
 indicative of intrathoracic aneu- 
 rysm, neoplasm or mitral sten- 
 osis. The cough is hoarse, 
 clanging or brazen. It is a par- 
 alytic cough, i. e., an imperfect 
 expiration which lacks forcible 
 closure of the glottis observed in 
 ordinary coughing efforts; it 
 was called the bovine cough by 
 Wyllie from the fact that cattle 
 have no false cords whose closure 
 is an important mechanism in 
 coughing. The right recurrent 
 laryngeal nerve, curving around 
 the subclavian artery, does not 
 enter the thorax, and is therefore 
 seldom involved; whereas the 
 left recurrent nerve passes into 
 
 the chest and curves between the aorta and left bronchus ; Dieulaf oy 
 described a " recurrent type of aneurysm," which is usually small, 
 syphilitic in origin, often multiple, involves the left recurrent nerve, 
 and causes spasm of the larynx, due to recurrent laryngeal irritation 
 contracting the posterior transverse arytenoid muscle and inducing 
 dyspnoea and inspiratory stridor. Irritation of other vagus branches 
 induces spasmodic dysphagia, anginal pain, etc. 
 
 Lung Symptoms. — Stenosis of the right bronchus is less frequent 
 than that of the left, which lies nearer the aortic arch. The lung 
 
 Dieulafoy's diagram of the region in which 
 he describes his " recurrent type " of 
 aneurysm ; posterior view. A, aorta, in 
 contact with the trachea and left bron- 
 chus ; L, larynx (seen from behind) ; p, 
 left and p', right vagus ; r, left recurrent 
 laryngeal nerve, passing under the aorta, 
 and r', right recurrent, in relation to the 
 subclavian artery. 
 
462 
 
 DISEASES OF THE CIRCULATION. 
 
 Fig. 31. 
 
 moves less freely than normal ; it suffers inspiratory retraction, and 
 the breath sounds and fremitus are diminished. A short note elicited 
 over the left upper lobe may arouse suspicion of an aneurysmal com- 
 pression. It is common in the " recurrent type " of Dieulafoy. 
 
 Kokitansky's dictum that large aneurysms are almost never asso- 
 ciated with pulmonary tuberculosis, was disproven by Stokes, Fuller 
 
 and Jaccoud. Tuberculosis results 
 in 13 per cent, of cases of aneurysm 
 from trophic change, compression of 
 the pulmonary artery or decreased 
 lung excursion. 
 
 Bronchiectasis, bronchorrhoea and 
 suppuration of the lung is well called 
 "aneurysmal phthisis" by Osier 
 and Eoss. Pulmonary retraction 
 is observed from compression, adhe- 
 sive pleurisy or interstitial pneu- 
 monia. Pleurisy with effusion may 
 complicate and entirely obscure an 
 aneurysm. Pulmonary gangrene 
 occurs from compression of the nu- 
 trient artery of the lung or stagnation 
 of mucus. Gangrene of the bron- 
 chial mucous membrane also occurs. 
 Gangrene may produce subcutaneous 
 emphysema. Pulmonary hemorrhage 
 may occur from gross rupture into a 
 large tube, from mere granulations in 
 a compressed tube, or from an aneu- 
 rysm slowly leaking into the paren- 
 chyma of the lung. The hemorrhage 
 may be fatal, premonitory or continuous ; it may be seen as necks in 
 the sputum, as rusty sputum, as prune-juice expectoration with alve- 
 olar epithelium and as discharges of pure blood or more frequently of 
 imperfectly coagulated blood. 
 
 Sympathetic Symptoms. — The pupils are often involved ; myosis 
 results from sympathetic paralysis and high blood pressure, and 
 mydriasis from sympathetic stimulation and low blood pressure. 
 Irregular pupils may be syphilitic. Pallor, redness and sweating 
 are infrequent. 
 
 Diagnosis. — The clinical signs and symptoms are most variable 
 (Stokes). The presence of an aneurysm should be suspected when 
 marked pain or paroxysmal dyspnoea occurs. Variability of physical 
 signs is suggestive of aneurysm. 
 
 Diagnosis of Location. — 1. Aneurysm of the ascending portion 
 is called by Broadbent the " aneurysm of physical signs." The 
 usual signs are most often observed in the first interspace to the right 
 of the sternum, which is often eroded. Luxation of the heart to the 
 
 Dieulafoy- 
 
 -I-VII, Multiple syphilitic 
 aneurysms. 
 
ANEURYSM. 463 
 
 left, slowing of both radials, right recurrent paralysis, compression of 
 the superior vena cava and pulmonary artery with hypertrophy of 
 the right ventricle, dyspnoea and phthisis occur. Anginal or other 
 cardiac symptoms frequently occur, and the aneurysm, though small, 
 is usually rapidly fatal from rupture into the pericardium, pleura, 
 upper cava or heart-chambers. Aneurysms just above the valves 
 tend to grow downward because of the reflux of blood from the 
 aorta, whereas those located higher grow upward, because of impact of 
 blood from the left ventricle. Sympathetic involvement is common. 
 
 2. In the arch, the " aneurysm of symptoms " is observed with 
 left recurrent paralysis or spasm, stridor, pulsation in the jugulum, 
 unusual prominence or luxation of the sternal ends of the clavicles, 
 prominence of the subclavian arteries, dulness to the left of the ster- 
 num, myosis, slowing or lessening of the left radial pulse, compression 
 of veins particularly the left innominate, of the trachea, thoracic duct, 
 sympathetic ganglia, bronchi and left upper lobe, and disturbance 
 in the brain circulation (hemiplegia) when the carotid artery is oc- 
 cluded. These aneurysms usually grow backward. 
 
 3. In the descending segment, the " aneurysm of latency " is 
 most often encountered. If there are symptoms, pulsation in the left 
 interscapular region, slowing of the femoral pulse, pressure on the 
 azygos or hemiazygos, pressure on the spine with erosion and tender- 
 ness to touch, intercostal neuralgia (sometimes with recurrent attacks 
 of herpes zoster) , stenosis of the left bronchus or oesophagus, pressure 
 upon the heart forcing it against the sternum, and increased heart- 
 rate from plexus pressure, are present. The x-ysljs alone detect 
 aneurysms lodged in the lung substance. 
 
 Differentiation. — Differentiation from solid tumors is deter- 
 mined by their propagated non-expansile pulsation, their more rapid 
 development, leukocytosis and cachexia. In aneurysm the lymph 
 glands are rarely enlarged from lymph stasis or inflammation; ade- 
 nopathy is frequent in mediastinal tumor, and continued increase is 
 directly indicative of neoplasm. Pain, recurrent paralysis and dys- 
 phagia are common to all tumors, both aneurysmatic and neoplastic. 
 Venous ectasia is more common in tumor. A few rare instances of 
 coincidence of tumor and aneurysm are observed. The pulsation in 
 carcinoma is rarely associated with a diastolic " back stroke," which 
 is frequent in aneurysm. An unequal pulse indicates aneurysm or 
 atheroma. The bruit in tumor is usually systolic, but murmurs are 
 frequently absent in aneurysm. Tugging is present in both but 
 more common in the latter. Signs of aortic atheroma argue in favor 
 of aneurysm. Aneurysm runs a much more protracted course than 
 tumors. Exploratory puncture and diagnosis ex juvantibus with 
 iodides are of differential importance. 
 
 Other causes for pulsation, such as a dynamic throbbing (aortic 
 regurgitation),' throbbing in acute aortitis, pulsation in an aorta dis- 
 located from kyphosis, and pulsation in pneumonia (Graves), anae- 
 mias or in vascular tumor of the lung or pleura, are usually differen- 
 
464 DISEASES OF THE CIRCULATION. 
 
 tiated when all symptoms and signs are carefully considered. In 
 pulsating empyema the dulness is usually low in the chest and largely 
 left-sided ; puncture reveals pus and stops the pulsation. 
 
 Prognosis. — Eecovery is rare, though spontaneous cure is possible 
 by compensatory thickening of the intima, by organization and calci- 
 fication of thrombi in the sac or by its inflammation. Sometimes one 
 aneurysm obliterates another. The course is generally two years 
 after the diagnosis is made. Patients have been known to live 
 and work hard ten or twenty years. The author watched for twelve 
 years a blacksmith who worked though he had an aneurysm of the 
 ascending aorta, which was as large as his fist, and which protruded 
 beyond the ribs. The size of the sac is of no prognostic value. Those 
 of the small "recurrent type" are most dangerous, and large ones 
 may be protected by connective tissue. Arteriosclerosis is prog- 
 nostically unfavorable. 
 
 Mechanism of Death. — (a) Rupture occurs in 75 per cent, of cases: 
 20 per cent, into the left and 13 per cent, into the right pleura; 16 
 per cent, into the left bronchus; 12 per cent, into the pericardium; 
 9 per cent, into the left lung ; 6 per cent, externally ; 5 per cent, into 
 the oesophagus; 4 per cent, into the trachea; (b) suffocation; (c) 
 marasmus, especially in large aneurysms; (d) intercurrent disease; 
 (e) embolism; and (/) brain lesions, are also immediate causes of 
 death. Hemorrhage usually shortens the course, but in one case 
 rupture into the bronchus occurred five years before death. Another 
 patient suffered external rupture of the sac; he collected the blood 
 in a basin and though he fainted from the hemorrhage he lived four 
 months, only to die of typhus fever. Stokes described an external 
 rupture in which the presence of mind of the nurse, in stuffing some 
 cloth into the sac, kept the patient alive for a considerable time. 
 
 Treatment. — 1. The Tufnell treatment of rest, low diet and limited 
 fluid is the result of the methods used by Morgagni, Albertini, 
 Valsalva and Bellingham, without the venesection recommended by 
 Valsalva. Absolute mental and physical rest is required for several 
 months, and food is reduced to the minimum. The heart action and 
 blood pressure are greatly lessened. The treatment is of value only 
 in cases of sacs with small necks. Active individuals will not tol- 
 erate this method. Relative quietude, and moderation in every 
 phase of life must then be insisted upon. Ergotin, hypodermatically, 
 has little effect. Tr. aconite, TT\,i to iv, may relieve the throbbing. 
 
 2. The iodides have been given prominence by Balfour, though 
 they were used first by Bouillaud and later by Graves, Nelaton and 
 others. They are of equal value in syphilitic and non-syphilitic 
 cases. It is not clear how they operate. They increase the secretions 
 but do not inspissate the blood. It is questionable from the experi- 
 mental standpoint whether arterial tension and dilatation of the sac 
 are lessened; it is certain that pain is alleviated. Ten to twenty 
 grains are given at a dose as in arteriosclerosis. The dose is lessened 
 if the pulse rate increases, Aside from relief of pain, the iodides are 
 
ANEURYSM. 465 
 
 useless in large aneurysms with wide communications or in fusiform 
 varieties. 
 
 3. Cold applications may relieve pain when the sac is near the 
 surface. Supports may relieve the pain and protect against rupture. 
 Calcium chloride in doses up to ten or fifteen grains has been used 
 to promote coagulation, but apparently without effect. 
 
 4. Gelatin injections (1 or 2 per cent, solution) are recommended 
 by Lancereaux to produce coagulation in the sac. It cannot be said 
 that the results are convincing. Gelatin has been used for centuries 
 in China and Japan to aid coagulation. There is danger of embolism 
 and 23 deaths from tetanus were reported by Dieulafoy, 1903. 
 
 5. Electrolysis, introduction of fine wire, compression and surgical 
 intervention have given discouraging results. A few cases of recov- 
 ery are reported but one cannot help comparing their small number 
 with the probably equal number of spontaneous recoveries (Borger, 
 in 1906, compiled 19 cases of dissecting aneurysms of the aorta which 
 recovered). Fatal thrombosis may follow what in a lesser degree of 
 thrombosis might have been beneficial. Total embolism of the aorta 
 may also occur. 
 
 6. Dyspnoea is treated as in cardiac disease. Venesection may 
 afford temporary relief, and morphine is finally indicated. Trach- 
 eotomy may be necessary in laryngeal spasm (reflex recurrent irrita- 
 tion) but the actual compression by the sac is usually too low for 
 operative interference. Digitalis is at all times contra-indicated. 
 
 Abdominal Aneurysm. — This type constitutes 5 per cent, of aneu- 
 rysms of the aorta. Over two-thirds occur in the upper part of the 
 abdomen and 40 per cent, either at or above the coeliac axis. The 
 average size is that of an orange and the tumor develops from the 
 anterior surface of the vessel, less frequently from its lateral or 
 posterior wall, and grows downward. Most of them are false 
 aneurysms. 
 
 Symptoms and Signs. — Four per cent, of abdominal aneurysms are 
 latent clinically; a good sized sac may be hidden under the arch of 
 the diaphragm. Pain is severe, constant and boring or paroxysmal. 
 It may become less severe after hemorrhage from rupture. Relief 
 is sometimes obtained by lying on the stomach. Indefinite symptoms 
 are common in the stomach though they are less frequent than in the 
 duodenum, where obstruction and hemorrhage may occur. Inspection 
 shows pulsation in 65 per cent., expansile pulsation in 15 and tumor 
 in 57 per cent. Palpation may elicit the expansile pulsation and in some 
 cases a thrill. Percussion may reveal dulness but the close relations to 
 the liver, spine, kidneys and heart are -prone to give indefinite findings. 
 The diaphragm bounds the aneurysm above; the kidney to the left; 
 the liver, pancreas and kidney to the right ; and the stomach, pancreas 
 and colon in front. The tissues about the sac thicken and produce 
 adhesions. On auscultation, a systolic murmur obtains in 50 per cent. 
 or two tones are heard; a diastolic murmur is sometimes heard. 
 30 
 
466 DISEASES OF THE CIRCULATION. 
 
 Rupture, diffusion by dissection, great thickening of the sac and 
 thrombi formation may easily obscure all auscultatory signs. 
 
 Diagnosis. — In two-thirds of the cases an incorrect diagnosis is 
 made. 
 
 1. Compression Symptoms. — Compression symptoms, gastric and 
 duodenal, have been mentioned. Abdominal aneurysm may be mis- 
 taken for gastric ulcer or cancer. The spine is eroded in 10 per cent, 
 of cases ; lumbar neuralgia, lumbago, muscular rheumatism, myelitis, 
 Pott's disease and spinal tumor may be simulated. Pulsation should 
 be searched for along the spine. The affection may suggest renal 
 colic, kidney tumor, perinephritis or psoas abscess (fluctuating blood 
 from rupture). The ureter may be compressed. Pressure on the 
 splenic vein may produce much splenic enlargement. The heart is 
 rarely compressed and dyspnoea is uncommon. Retardation or ab- 
 sence of the femoral pulse may be of value in differentiation. 
 
 2. Abdominal Pulsation. — " Instead of being your first, it 
 should be your last idea that abdominal pulsation is due to aneu- 
 rysm" (Jenner). Epigastric pulsation may be confused with hyper- 
 trophy of the right heart or pulsation of the liver. The greatest 
 danger of error lies in diagnosticating as aneurysm the pulsation 
 which is so often seen in acute hemorrhage, or especially in neuras- 
 thenic subjects, who complain of pain and throbbing and in whom 
 thrills, systolic and, according to Rosenbach, even diastolic murmurs 
 may be felt and heard, especially when atheroma is developing. 
 Rosenbach especially emphasizes the diagnostic importance of " inter-, 
 mittent dilatation of the aorta" which is frequently diagnosticated 
 as aneurysm. The pulsation must be distinctly expansile (even then 
 occasional errors are made) and a definite sac must be felt; other- 
 wise constant errors will be made. The dynamic pulsation of aortic 
 regurgitation concerns the same points. 
 
 3. Communicated Throbbing. — Communicated throbbing, lent 
 to a tumor of the stomach lying on the aorta, may also be attended by 
 a systolic murmur but the differentiation is usually made with ease, 
 except in certain soft neoplasms. Tumors are often felt to better 
 advantage when the subject is in the genupectoral attitude; they are 
 more movable, more often produce dilated veins, ascites and peri- 
 toneal friction. Aneurysm of the abdominal aorta or of its branches 
 may, in exceptional cases, be movable. Stokes held that tumors 
 developed upward and aneurysms downward. 
 
 4. Aneurysm of the Branches of the Abdominal Aorta. — 
 (a) Aneurysms of the cceliac axis are difficult or impossible to dis- 
 tinguish and may occur with aneurysm of the main trunk. More 
 than 20 cases are recorded. They are often traumatic or embolic 
 (mycotic), (b) Superior (20 cases, Baccelli, 1904) or inferior 
 mesenteric aneurysms are very uncommon; they occur most fre- 
 quently in children, from sepsis, (c) Over 20 cases of splenic aneu- 
 rysm are recorded. The spleen is often enlarged, (d) In the hepatic 
 artery (38 cases, Schupfer, 1906) it is induced by acute infections 
 
ACUTE AORTITIS AND ARTERITIS. 467 
 
 (73 per cent.), trauma, embolism or gall-stones; 41 per cent, develop 
 in the main trunk and 25 per cent, in its right branch; there is but 
 one case in which it developed in the artery of the cystic duct. Pain 
 (in 71 per cent.), hemorrhage (in 58 per cent.), icterus (in 63 per 
 cent.), vomiting and large spleen have been noted; in 79 per cent, 
 rupture occurred (in 10 cases into the peritoneum) ; they never pul- 
 sate, and in only one case was there a systolic murmur; Kehr op- 
 erated on one case successfully, (e) Over 10 cases of aneurysm of 
 the coronary artery of the stomach are recorded. (/) In the renal 
 artery aneurysm is rare (26 cases, Skillern, 1906). Three cases were 
 successfully operated on. Von Schrotter found only 1 case in nearly 
 20,000 autopsies. 
 
 Prognosis. — Death is usual and the clinical course averages one 
 to three years. Rupture occurs in 66 to 75 per cent, of cases : 33 per 
 cent, into the peritoneum; 16 per cent, into the pleura, though the 
 crura of the diaphragm offer considerable resistance; 7 per cent, 
 into the duodenum; and 7 per cent, into the retroperitoneal tissue. 
 Death does not necessarily nor at once follow rupture even into the 
 peritoneum. 
 
 Treatment. — Treatment is as in the thoracic type. From its acces- 
 sibility, operative procedures are more common and somewhat more 
 successful. Continued compression of the aorta has benefited cases 
 of aneurysm located low in the abdomen. 
 
 ACUTE AORTITIS AND ARTERITIS. 
 
 These are rare lesions, occurring in the aorta as part of a sepsis, 
 benignant or malignant endocarditis, or in the peripheral vessels after 
 influenza or other infections. Acute aortitis was often confused with 
 chronic atheroma, acute arteritis and with organizing thrombi in the 
 arteries. Syphilis (q. v.) is a factor in aortitis, of which the symp- 
 toms are retrosternal burning, actual anginal pain, dyspnoea, anxiety 
 and acute dilatation of the arch without violent throbbing of its 
 branches. The diagnosis is uncertain and the treatment symptomatic. 
 
 Periarteritis nodosa was first described by Kussmaul and Maier 
 (1866) and is called "arteritis proliferans nodosa" by Fletcher. 
 This is a rare affection of which Verse in 1905 could find but 20 
 published cases; it consists of localized proliferation and round cell 
 infiltration of the intima, with its rupture through the other coats, 
 and leads to thrombosis or aneurysm. It is probably an infection. 
 It occurs largely in men between twenty and thirty-five years of age ; 
 one case occurred in an infant three months old. The nodes are seen 
 in the vessels of the muscles, heart, kidney, intestines and skin ; they 
 produce hydrops, muscular pains, nephritis, convulsions, paralysis, 
 vomiting, diarrhoea, alimentary hemorrhage, epigastric pain, low 
 temperature and a rapid pulse. The affection is fatal within six to 
 twelve weeks, is usually mistaken for typhoid or meningitis and treat- 
 ment is purely symptomatic. In one-quarter of the cases there were 
 
468 DISEASES OF THE CIRCULATION. 
 
 syphilitic antecedents and Schmc-rl saw one cure with the use of 
 mercury. 
 
 RUPTURE OF THE AORTA. 
 
 Eupture of the aorta may be traumatic or the result of severe 
 strain, endarteritis or narrowing of the vessel. Tolot and Sarvonat 
 (1904) collected but six cases of rupture of a sound aorta. All coats 
 may be ruptured and this usually occurs in a transverse direction. 
 If the rupture is partial, a dissecting aneurysm results which may 
 burrow even to the popliteal arteries. It most often occurs in the 
 first segment when ha?mopericardium results. Rupture into the lung, 
 mediastinum or retroperitoneal connective tissue may occur. The 
 symptoms are sudden pain, a sense of " something ruptured " and 
 the signs of hemorrhage; sudden death usually occurs, though 
 prolongation of life for from one to eleven years has been recorded in 
 cases of dissecting aneurysm. 
 
 Embolism of the aorta has a close relation to thrombosis, being due 
 to impaction of atheromatous plaques, tumor tissue, echinococcus 
 cysts, endocarditic plugs or ordinary thrombi. It is very uncommon. 
 Sudden death results if the site is in the first part of the vessel. If 
 it occurs near the division of the iliacs, collateral circulation is pos- 
 sible. There are pain and stiffness in the legs, sensory disturbances, 
 paresis and contractures from anaemia of the spinal cord. The 
 femoral pulsation is absent. The clot may back up toward the heart 
 or it may resorb. The bladder and rectum are disturbed. Hemor- 
 rhage from the stomach, bowels and kidneys has been observed. The 
 prognosis is bad and the treatment is symptomatic. 
 
 Thrombosis usually results from several coincident causes, as 
 acute infections, weak heart, aneurysm, atheroma or compression. 
 Most cases occur in the transverse arch between the left carotid and 
 subclavian vessels or in the abdominal aorta at its point of division. 
 The pain, paraplegia or anaesthesia produced is sometimes confused 
 with spinal cord disease. It may be sudden ; if gradual, collateral 
 circulation may be established. 
 
SECTION III. 
 DISEASES OF THE RESPIRATORY TRACT 
 
 DISEASES OF THE NOSE. 
 
 ACUTE RHINITIS, CORYZA. 
 
 Definition. — An acute nasal infection. 
 
 Etiology. — (a) It is an independent infection, sometimes epidemic 
 and contagious; it occurs oftenest in the spring and fall and is pro- 
 moted by variations in temperature. Cold is only a predisposing 
 factor ; various bacteria are held causative, but Thompson and Hew- 
 litt have shown that 84 per cent, of cultures are negative, (b) It is a 
 concomitant of various infections, notably of influenza, measles, per- 
 tussis, glanders, syphilis, etc. (c) Toxic factors, as iodides, bro- 
 mides, ipecac dust, dust, etc., may cause coryza. (d) Local disease, 
 as chronic catarrh, polyps, ulceration and possibly gout, are predis- 
 posing factors. 
 
 Symptoms. — The initial symptoms are malaise, depression, ano- 
 rexia, chilliness, fever of 101° to 102°, pains in the limbs and some- 
 times, in the young, delirium and convulsions. The mucosa is dry, 
 reddened, burning, painful, swollen and obstructed. There is re- 
 peated sneezing and anosmia. Herpes is common. There follows a 
 clear, watery, nasal discharge (coryza) for one or two days, which 
 subsides at night and recurs in the morning; within two days it be- 
 comes thickened and purulent. Extension may occur to the eyes, 
 frontal sinus, antrum of Highmore, ear by the Eustachian tube or 
 to the pharynx or larynx. In infants nasal occlusion prevents nurs- 
 ing and may cause dyspnoea or suffocation, because the tongue lies 
 high in the mouth near the palate. Acute rhinitis lasts one-half to 
 one week and is seldom confused except with incipient measles. 
 
 Treatment. — At the very onset lavage with simple hot water is 
 often sufficient; Dobell's solution (sod. borat. and sod. bicarb, aa 3ij, 
 ac. carbolici 3ss to water 3x), diluted freely to avoid irritation, is 
 beneficial; adrenalin solution 1 to 1,000 is excellent, but excessive 
 application may induce oedema of the throat and epiglottis. A co- 
 caine solution (the plain alkaloid gr. j to albolene 3j) relieves 
 turgescence and frontal pain, but is a dangerous remedy to give into 
 
 469 
 
470 DISEASES OF THE BESPIBATOBY TRACT. 
 
 the patient's hands. Dover's powder gr. x, a saline aperient and a hot 
 bath at the onset, usually give relief, especially when followed by : 
 
 ]£ Extr. belladonnae gr. iiss. 
 
 Fluidextr. aconiti 1H.X. 
 
 Acetphenetidini > gr. xv. 
 
 Camphorse monobromatae gr. xv. 
 
 M. et ft. capsular x. 
 
 S. — One capsule every hour for five or six doses. 
 
 ]£ Phenolis gr. iii. 
 
 Mentholis gr. iv. 
 
 Olei theobromatis q.s. 
 
 M. et fac suppositoria no. x. 
 
 S. — One locally in nose every 2 hours. 
 
 Drugs are of little use unless the patient remains in bed to relieve 
 internal congestion and to avoid extension or recurrence. Salicylates 
 mitigate the frontal pain. Cool baths aid in averting recurrent 
 attacks. 
 
 HAY FEVER. 
 
 Catarrhus sestivus or summer catarrh, was first described by Bos- 
 tock (1819). Morill Wyman first described the "June" or "rose 
 cold." 
 
 Etiology. — Its etiology is not known, but the disease has long been 
 associated with the pollen of various plants and grains. Dunbar be- 
 lieves that pollen contains toxalbumins. It prevails especially in 
 the United States and England, develops in persons between fifteen 
 and thirty years of age, and twice as frequently in males as in females. 
 It is more common in the upper educated classes, and perhaps in 
 gouty individuals; it is most prevalent in the warm months and in 
 cities. Three special factors are noted: (a) A predisposition in the 
 form of nervous instability or other systemic tendency. (fr)An irri- 
 tability or other nasal abnormality, as undue nasal turgescence, or 
 irritability to dust, odors, etc., hyperesthesia of the inferior turbi- 
 nates, polyps or septal irregularities ; Austin Flint became asthmatic 
 from sleeping on feather pillows, (c) The exciting cause or irritant, 
 as pollen, dust, sudden change of temperature and apparently in some 
 cases, mental excitement. 
 
 Symptoms. — The onset is that of the vulgar coryza, but the disease 
 is attended by more constitutional reaction and greater depression. 
 Injection of the eyes with lachrymation and photophobia usually ac- 
 companies or precedes the coryza. The throat, larynx and bronchi 
 are dry and burning. Fever, 100° to 101°, is fairly common. There 
 is pam over the frontal sinuses and sometimes over the temporal 
 and occipital regions. The nasal vessels are congested and the nose 
 itself becomes swollen and injected, resembling closely the alco- 
 holic facies. In many cases cough develops ; this is frequentlv fol- 
 lowed by asthmatic seizures which simulate bronchial asthma (q 
 v.). Incurrences are usual and attacks of corvza may alternate with 
 
CHRONIC RHINITIS. 471 
 
 asthmatic paroxysms. With the first frost the affection stops, as if 
 by magic. The outlook is good as to life, for only isolated instances 
 of death from asthma are recorded; as to recovery, the outlook is 
 much less favorable. 
 
 Treatment. — (a) Prophylactic treatment; cauterization of irritable, 
 congested or hypertrophic areas, and correction of polypoid or other 
 abnormalities cure some cases and alleviate suffering in others, (b) 
 Nasal treatment ; much relief may be given, when curative measures 
 fail, by nasal douches, by painting or irrigating the nose with 1 to 
 1,000 adrenalin or other astringent solutions; suprarenal extract in 
 doses of gr. ij to v has been recently used internally, as has nearly 
 every drug in the Pharmacopoeia, (c) The general physiological 
 resistance is increased by fresh air, cool rubs, tonics and nervines. 
 
 (d) Change of climate is advisable before the date on which, with 
 certain regularity, hay fever appears; a sojourn at the seaside, in 
 northern Michigan, in Canada and especially in a high altitude, 
 often greatly relieves or sometimes wholly checks the symptoms. 
 
 (e) Asthma (v. Bkonchial Asthma). (/) Dunbar s serum, pat- 
 ented as pollantin, is used in the nose (not hypodermically) every 
 morning, as a powder. In 1,240 cases Dunbar claims that 56 per 
 cent, were greatly helped, 31 per cent, benefited and 13 per cent, 
 unaffected. 
 
 CHRONIC RHINITIS. 
 
 Chronic nasal catarrh properly comes under the care of the spe- 
 cialist, but minor cases are treated by the practitioner; some are 
 due to scrofula, syphilis, ansemia or to other constitutional causes. 
 Chronic catarrh may develop from repeated acute attacks, or may be 
 chronic from the onset. 
 
 The Hypertrophic Form. — The nasal mucosa is red, swollen, 
 spongy, and is covered with thick, gray-yellow secretion which may 
 desiccate and sometimes form the basis of rhinoliths. Microscop- 
 ically, the bloodvessels are wide and are surrounded by round cells, 
 and the submucosa is thickened. The nasal obstruction necessitates 
 oral breathing, partially nasal speech, obtunded taste and smell, and 
 produces an elevation of the hard palate and a peculiar facial ex- 
 pression. The secretion is usually thick, yellow and purulent, rarely 
 thin and abundant (rhinorrhoea). This type is often associated with 
 adenoids and follicular hyperplasia in the pharynx. The lachrymal 
 duct may be obstructed, and Eustachian occlusion may induce per- 
 manent deafness; laryngitis, bronchitis, bronchial asthma, polyps 
 and sinus disease are not infrequent complications. Nasal disease 
 may be the cause of blepharospasm or other facial spasms, limitation 
 of the field of vision, vertigo and mental depression; and even psy- 
 choses are attributed to nasal reflexes. Fliess attributes dysmenor- 
 rhea to chronic rhinitis. In its treatment possible constitutional 
 factors, as anaemia, syphilis or scrofula, are to be considered. 
 Douches of carbolic t acid, insufflations of equal parts of alum and 
 
472 diseases of the respiratory tract. 
 
 calomel, and cauterization by the galvanic cautery or by chromic 
 acid, are indicated. Douches should be given under low pressure, 
 lest fluid reach the middle ear. 
 
 The Atrophic Form. — It is disputed whether this form begins as 
 an atrophic process or results from hypertrophic disease. It is more 
 frequent in females and usually begins early in life. The mucosa is 
 pale and dry, its epithelium has suffered marked metaplasia, the 
 erectile tissue wastes, the nasal passages are unduly roomy and the 
 secretion dries in the nose and emits a most offensive odor (ozcena). 
 Its actual cause is not determined. Various microorganisms have 
 been found, as the Bacillus foetidus, Bacillus mucosus and Bacillus 
 fluorescens liquefaciens. Grosheintz and Meiser have noted its 
 association with a widening of the face in 33 per cent, of cases. Its 
 sequences are similar to those of the hypertrophic variety. 
 
 Treatment. — The results of treatment are not satisfactory. Douches 
 of a 1 per cent, permanganate of potash solution, iodoform insuffla- 
 tions, massage with iodine one part, potas. iodide 10 and glycerine 
 100 parts, and packing with gauze soaked in balsam of Peru are 
 usually employed. Paraffin injections beneath the mucous membrane 
 are recommended to restore the normal lumen of the nasal passages. 
 
 RHINITIS FIBRINOSA. 
 
 Phinitis flbrinosa has been considered under nasal diphtheria, to 
 which it is most often due. It may result from streptococcus and 
 staphylococcus infection ; it occurs in measles, scarlatina, pneumonia, 
 typhoid and also as an independent lesion. Irrigation with 1 per 
 cent, carbolic acid or 1 to 1,000 sublimate solution is efficacious. 
 Antitoxin is indicated in infection by the Klebs-Loefner bacillus. 
 
 EPISTAXIS. 
 
 Epistaxis is a symptom only. Its causes may be grouped as fol- 
 lows: (a) Local nasal lesions, trauma, chronic and acute catarrh, 
 picking of the nose, foreign bodies, ulceration (simple, tuberculous, 
 syphilitic, carcinomatous) and angioma. Osier reports cases of 
 epistaxis associated with telangiectasis of the skin and nasal mucosa. 
 (b) Hyperemia, either venous, as in cardiac, respiratory and other 
 obstructive lesions, or arterial, as in hypertrophy of the left ventricle 
 caused by aortic leakage, interstitial nephritis, atheroma, apoplectic 
 habitus and gout. Some cases are seemingly vicarious to suppressed 
 menstruation or hemorrhoidal bleeding, (c) Acute infections, prin- 
 cipally typhoid, less frequently the others, (d) Hemorrhagic dis- 
 eases, as pernicious anaemia, chlorosis, leukaemia, pseudoleukemia, 
 scurvy, haemophilia, Werlhof s disease and cachexiae. (e) Other con- 
 ditions, as liver cirrhosis, pregnancy, icterus, diabetes and puberty 
 balloon ascensions or high altitudes are also causative. 
 
 The most frequent point of hemorrhage is the lower anterior part 
 
ACUTE CATARRHAL LARYNGITIS. 473 
 
 of the cartilaginous septum. The symptoms are chiefly the local 
 hemorrhage from the anterior nares, but occasionally bleeding may 
 occur further back in the nose and? trickling into the pharynx, may 
 simulate hemorrhage from the stomach when vomited, from the in- 
 testine when passed with the stool, or from the lung when coughed up. 
 
 Occasionally urgent acute anaemia or even death may occur, espe- 
 cially when there is " blood dissolution " as in blood diseases. 
 
 Treatment. — The patient should be kept quiet, in the semi-erect 
 posture. After douching the nose with hot or ice-cold water to which 
 adrenalin 1 to 1,000 or tr. ferri chloridi has been added, the nose 
 should be tamponed by Bellocq's catheter, or in less serious cases the 
 patient should be enjoined not to blow the nose, for this only dis- 
 lodges the forming clot. Gelatin may be injected into the nose, be- 
 sides being injected hypodermatically. Internal remedies, as ergotin, 
 are very unsatisfactory. Erosions or ulcers may be cauterized later. 
 
 DISEASES OF THE LARYNX. 
 
 ACUTE CATARRHAL LARYNGITIS. 
 
 Etiology. — Though acute catarrhal laryngitis is observed at every 
 age and in all climates, most cases occur in males between twenty 
 and forty, and in cold, windy, changeable weather, (a) Cold is fre- 
 quently an apparent factor, but probably operates only by lessening 
 the resistance, and this occurs to a greater extent in delicate than in 
 robust subjects; the bacteriology of these " rheumatic" cases is un- 
 known but its occasionally epidemic prevalence is suggestive of an 
 infection. (&) Acute laryngitis may complicate acute (or chronic) 
 affections such as measles, scarlatina, pertussis, typhoid, hay fever or 
 syphilis and tuberculosis, (c) Extension may be caused per con- 
 tiguitatem from the nose, pharynx or bronchi; oral breathing is a 
 somewhat predisposing factor, (d) Chemical, thermal or mechanical 
 agents, as dust, foreign bodies, trauma, overuse or abuse of the voice, 
 alcoholism, inhalation of tobacco smoke, chlorine or bromine, and in- 
 ternal use of iodides are etiological factors, (e) Stasis from thoracic 
 lesions or enlarged thyroid, local ulcerations in the larynx, nephritis, 
 liver disease and rhachitis are also causes. 
 
 Symptoms. — A sudden onset, with fever, chill or rapid pulse, is 
 seldom observed. The local symptoms are a sense of rawness or 
 tickling, dry, even spasmodic cough, and moderate pain on breathing, 
 as the larynx is hypersensitive; sometimes external tenderness or 
 some dysphagia may occur, usually from coincident pharyngitis. 
 After a day a thin, transparent and slightly cellular sputum appears, 
 which later becomes purulent, yellow or in very rare cases, hemor- 
 
474 DISEASES OF TEE RESPIRATORY TRACT. 
 
 rhagic. Some cases void no sputum (laryngitis sicca). The voice 
 becomes hoarse or is wholly lost. The laryngoscope reveals diffuse 
 or circumscribed redness, viscid mucus, some swelling and occasion- 
 ally epithelial erosions. The false cords are often swollen. The true 
 cords lose their smooth, glistening appearance and become injected 
 and uneven, so that their even coaptation is hindered. The swollen 
 mucosa may get between the cords, and their infiltrated muscles are 
 often paretic. The acute symptoms last for a day or two and the 
 catarrh remains about a week longer. 
 
 Diagnosis. — Diagnosis is usually easy; nervous aphonia and cordal 
 paralysis are distinguished by means of the mirror. (See Vagus 
 Disease, under Nervous System.) 
 
 Treatment.— Prophylaxis covers the etiological factors; alcohol and 
 tobacco should be forbidden. The general resistance is increased by 
 cold rubbings, douches or baths ; mufflers should be avoided and cold 
 compresses should be applied over the larynx. The voice must be used 
 carefully and the nose, uvula and pharynx should be examined for 
 predisposing lesions. 
 
 The therapy of the established lesion is as follows: At the onset 
 sweating should be induced by hot drinks and by a hot bath ; Dover's 
 powder and quinine, each gr. x, or aconite, are indicated as in 
 coryza ; rest in bed is necessary. The voice must not be used. If the 
 symptoms persist, an ice-bag should be applied locally; codeine or 
 morphine with bromides, and inhalations of moist air or steam should 
 be given, as described under Acute Bronchitis. 
 
 I£ Heroin hydrochloridi gr. j. 
 
 Terpini hydratis gr. xl. 
 
 Ammonii chloridi 3ss. 
 
 Extr. glycyrrhizae 3j. 
 
 M. et ft. capsulae xxx. 
 S. — Two after meals. 
 
 Painting the larynx with a 3 per cent, silver nitrate solution is con- 
 demned by some physicians as promoting submucous extension. 
 
 In children acute laryngitis is often attended by great swelling 
 above and below the cords and by stenotic manifestations in the small, 
 infantile larynx. The symptoms closely approach those of genuine 
 croup (laryngeal diphtheria), from which it is distinguished as false 
 croup, faux croup (Guersant) or laryngite striduleuse (Bretonneau). 
 After an attack of mild laryngitis, coryza or sore throat, the child 
 becomes restless and anxious, usually during the night when the 
 secretion accumulates. Inspiratory dyspnoea develops, there is in- 
 spiratory retraction of the interspaces and epigastrium, the accessory 
 muscles of respiration come into play, cyanosis appears and asphyxia 
 seems imminent. The paroxysm subsides, spontaneously or after an 
 emetic has been given, to recur on the next two or three nights. The 
 catarrhal symptoms may last from three days to a week. Trousseau 
 remarked that there is rarely that complete aphonia observed in 
 
CHRONIC CATARRHAL LARYNGITIS. 475 
 
 laryngeal diphtheria. The diagnosis is made from the history of 
 coryza ; the absence of diphtheritic patches in the pharynx, for diph- 
 theria is eminently a descending infection ; the absence of diphtheria 
 bacilli, found in diphtheria even when the throat seems normal ; and 
 the absence of severe constitutional reaction. Laryngismus stridulus 
 (v. Vagus Nerve) is not attended by fever, laryngitis or aphonia. 
 The laryngoscope may reveal the simple oedematous laryngitis, but 
 examination is notoriously difficult in easily frightened children. 
 Treatment is the same as in acute laryngitis of adults; hot drinks, 
 inhalation of steaming water, and ipecac should be given to induce 
 vomiting and evacuation of laryngeal secretion; von Niemeyer 
 awakened the patient at intervals and gave a hot drink to evacuate the 
 mucus. Widerhofer also noted excellent results from washing away 
 any pharyngeal mucus, which he considered causative of the attacks. 
 The attendant should be prepared, in doubtful cases, for intubation 
 or tracheotomy. 
 
 Other Acute Forms. — Other acute forms are (a) laryngitis acuta 
 nodosa, which is observed in acute rheumatism and yields to sali- 
 cylates, (b) Laryngitis fihrinosa, which is usually diphtheritic, but 
 may be caused by a streptococcus infection in measles, scarlatina or 
 other infections, and sometimes results from inhalations of steam or 
 chlorine, (c) Laryngitis submucosa acuta invades the submucous tis- 
 sues and is seropurulent. This rare affection may develop as an in- 
 dependent lesion, may follow a similar process in the pharynx or 
 may represent a septic localization. During invasion the symptoms 
 are severe, with fever, rigor, delirium and other septic phenomena. 
 The laryngoscope shows injection and yellow-white bulging areas of 
 submucous suppuration which, without operation, almost invariably 
 cause death by oedema of the larynx or by sepsis, for spontaneous rup- 
 ture is exceptional. For treatment (a) an ice-bag should be placed 
 over the larynx, morphine given for pain and whisky for the sepsis ; 
 (b) incision of the foci is indicated; and (c) if necessary, intubation 
 or tracheotomy should be performed. 
 
 CHRONIC CATARRHAL LARYNGITIS. 
 
 Etiology. — The etiology is practically identical with that of the 
 acute form, of which it frequently follows repeated attacks ; it is often 
 associated with or is dependent on pharyngitis or rhinitis. 
 
 Symptoms. — The symptoms are those of the acute form, though 
 less intense. Hoarseness alternates with fairly normal phonation. 
 By the mirror there may be seen injection, darker than in the acute 
 form, swelling, secretion and sometimes small hemorrhages. There 
 are forms with no secretion (laryngitis sicca chronica) ; the secre- 
 tion is rarely like that of ozama, with glandular atrophy. In some 
 forms granules appear, less from glandular hyperplasia than from 
 proliferation of connective tissue {laryngitis granulosa). Erosions 
 and rhagades may develop on the edges of the cords or arytenoid 
 cartilages. Ulcers are most often syphilitic or tuberculous. 
 
476 DISEASES OF THE RESPIRATORY TRACT. 
 
 Treatment. — Treatment of the cause and prophylactic measures are 
 the same as in the acute form. Inhalations of 1 per cent, tannic acid 
 or of 1 per cent, turpentine and sod. bicarbonate in solution ; insuffla- 
 tions of tannic acid, lead acetate and alum aa gr. i; and painting 
 the larynx every third day with a 2 to 10 per cent, solution of silver 
 nitrate with the aid of the laryngoscope, are valuable. Terpine hy- 
 drate gr. iij t. i. d. is often helpful. Cold water applied over the 
 larynx, faradization and sea air may be beneficial. 
 
 Other Chronic Forms. — Chorditis tuberosa occurs as small grayish 
 nodes on the cordal edges at the junction of their anterior and middle 
 thirds, especially in singers and in alcoholics (Stork) ; they are com- 
 posed of fibrous and epithelial hypertrophy. Scarification and lactic 
 acid are indicated (v. Tuberculosis). 
 
 Pachydermia laryngis (Virchow) is an increase of the submucous 
 tissue and transformed epithelium into which connective tissue grows ; 
 it is circumscribed or diffuse. Warty excrescences are common be- 
 tween the arytenoids, and the thick mucosa is sometimes umbilicated 
 and may resemble cancer. Topical application of salicylic or lactic 
 acid, iodine in glycerine, electrolysis and the cautery are indicated. 
 Polyps may result from chronic laryngitis. 
 
 Laryngitis hypertrophica inferior is a hyperplasia of the mucous 
 and submucous tissue below the cords, and is identified by some 
 clinicians with rhinoscleroma, which is due to the extension of the 
 rhinoscleroma bacillus from above downward. It may cause stenosis 
 of the larynx, which the author saw in one of Kolisko's autopsies. 
 It is treated by scarification, dilatation, prolonged intubation, iodides, 
 or, when extreme, by tracheotomy. 
 
 (EDEMA OF THE LARYNX. 
 
 (Edema laryngis is a more proper designation than oedema glottidis, 
 as the vocal cords are very seldom involved. It is most marked where 
 the submucous tissue abounds and is greatest therefore about the 
 epiglottis and ary-epiglottidean folds ; it may develop under the cords. 
 It varies with its cause, and may be bilateral, unilateral, diffuse or 
 circumscribed. According to Sestier, 70 per cent, of cases occur in 
 males and 89 per cent, in those over fifteen years. 
 
 Etiology. — There are three etiological forms besides some obscure 
 cases, (a) Inflammatory oedema results from various inflammatory 
 diseases of the larynx, submucous suppuration or perichondritis; 
 from typhoid, syphilitic, tuberculous or cancerous ulceration; from 
 iodides, trauma, surgical measures, thermic, chemical and allied 
 causes; extension from pharyngitis, parotitis or cervical cellulitis; 
 and from infections, as typhoid or measles. (6) Congestive and 
 hydrcemic forms result from chronic heart and lung disease, from 
 tumors and nephritis, in which it may antedate oedema elsewhere or 
 from cachectic conditions as carcinosis or amyloidosis, (c) Angio- 
 neurotic oedema, as in K. S. Morris' fatal case, is the last type 
 
PEEICHONDEITIS LABYNGIS. 477 
 
 Symptoms. — Symptoms appear with varying acuity, sometimes 
 most suddenly, as in Bright's disease, at other times more gradually 
 but progressively, and again quite slowly. Hoarseness or aphonia, 
 and a metallic cough are common. The chief sign is inspiratory 
 dyspnoea, which characterizes nearly all forms of laryngeal stenosis. 
 It is usually stridulous or wheezing; and is attended by retraction 
 of the interspaces, cyanosis, up-and-down excursion of the larynx 
 and ultimate suffocation. The mirror shows a pallid swelling in the 
 parts enumerated, incision of which allows the escape of a clear 
 serum. (Edema of the epiglottis and ary-epiglottidean folds may be 
 felt with the finger if the mouth is held open and the tongue drawn 
 forward, or it may be seen even without the mirror if the larynx is 
 pushed up and the tongue deeply depressed. 
 
 Treatment. — Treatment is urgent, irrespective of the cause, for the 
 large mortality (75 per cent.) is due to delay until the patient's 
 strength is exhausted. The placing of ice over the larynx, the swal- 
 lowing of ice, drastic purgatives and painting the larynx with 10 per 
 cent, silver solution are at best palliative. The oedematous tissue 
 should be fully incised, and, in case this should fail, intubation or 
 tracheotomy should be performed. 
 
 PERICHONDRITIS LARYNGIS. 
 
 Purulent inflammation beneath the perichondrium of the laryngeal 
 cartilages is very seldom primary, but nearly always results second- 
 arily to various inflammations or ulcerations. Pus accumulates 
 between the perichondrium and cartilage, most frequently the aryte- 
 noid or cricoid, or less frequently the thyroid or epiglottic. The 
 cartilage may become secondarily necrosed. Perichondritis laryngis 
 most often develops in males between twenty and forty years of age. 
 
 Symptoms. — Its symptoms are commonly obscured by the causal 
 disease. The rare primary cases are the most acute. Well localized 
 pain and tenderness are peculiarly significant. Dysphagia, especially 
 from arytenoid involvement, is frequent, and even aphagia may result. 
 Phonation is impaired by the fundamental disease, by cord paresis 
 and muscular infiltration. The cervical glands sometimes tumefy. 
 Stenosis and dyspnoea are present. The mirror discloses focal accu- 
 mulation of pus, swelling, redness, oedema and perhaps fistulse which 
 signify intralaryngeal rupture. The probe may elicit tenderness 
 or may scrape on eroded cartilage. The diagnosis from laryngitis 
 and oedema is often impossible, or at best but probable unless definite 
 pus pockets are seen. The outcome may be suddenly fatal from 
 rapid oedema; pus and cartilage fragments may rupture, thus 
 giving relief or perhaps occluding the larynx; fistulse, internal or 
 external, may remain, and may burrow to the mediastinum, or sepsis 
 may follow; aspiration pneumonia is not uncommon, and if immed- 
 iate recovery ensues, a distorted or stenosed larynx may remain. 
 
 Treatment. — Treatment is similar to that of acute laryngitis; the 
 
478 DISEASES OF THE RESPIRATORY TRACT. 
 
 pain should be relieved by opiates, but early incision under cocaine is 
 necessary, and the physician should be prepared to perform trache- 
 otomy or intubation. 
 
 ULCERATIONS AND NEOPLASMS OF THE LARYNX. 
 
 The tuberculous and syphilitic ulcers have been considered. Super- 
 ficial erosions may follow catarrh; deep ulcers result from submu- 
 cous suppuration or from perichondritis, pressure ulcers from for- 
 eign bodies or laryngeal "bed sores" (v. Typhoid) which are 
 ulcerations analogous to intestinal ulceration. There are also the 
 specific ulcerations of leprosy, glanders, etc. 
 
 Tumors include benign single or multiple papillomata located on 
 the true cords (singer's nodes v.s.), fibromata, cysts, amyloid accre- 
 tions, enchondromata, lipomata and the malignant tumors, of which 
 carcinoma is far more frequent than sarcoma. Primary cancer de- 
 velops slowly on the posterior third of the cords or in other locations 
 as an excrescence which gradually assumes a cauliflower appearance ; 
 the basis of the later ulceration is nodular and there is no scar for- 
 mation (v. Syphilis,. Laryxx) ; hoarseness is an early symptom ; 
 all kinds of incipient tumors are frequently mistaken for laryngitis. 
 Pain which may radiate to the ears or temples, cough and dysphagia 
 are constant in the advanced stage. Early operation, either intra- 
 laryngeal or by splitting the thyroid, will alone afford relief; inoper- 
 able cases must necessarily be narcotized. 
 
 Nervous aphonia, the paralyses and spasms of the larynx are con- 
 sidered under affections of the vagus nerve. 
 
 DISEASES OF THE TRACHEA AND BRONCHI. 
 
 The trachea is seldom involved alone. Tracheitis is frequent with 
 inflammation of the larynx and bronchi. Hemorrhage may result 
 from diapedesis or from ruptured varices. Tuberculosis, syphilis 
 and tumors are very infrequent. 
 
 ACUTE BRONCHITIS. 
 
 Acute bronchitis is a most frequent primary or secondary disease, 
 in some localities constituting 10 to 15 per cent, of all diseases. It 
 occurs most frequently in cold, dusty or variable weather ; three-fourths 
 of all cases occur between December and April. Its forms are (a) 
 inflammation of the larger air tubes, bronchitis, tracheobronchitis or 
 macrobronchitis, and (b) inflammation of the smaller tubules, known 
 as bronchiolitis, capillary bronchitis or microbronchitis, which in 
 
ACUTE BRONCHITIS. 479 
 
 children is identical with bronchopneumonia (q. v.). Badham 
 (1819) first used the term bronchitis but the condition was first de- 
 scribed by Laennec, who remarked everything essential up to its 
 bacteriology. 
 
 Etiology. — (a) It is a symptom of various infections, as measles, 
 pertussis, influenza and typhoid; it also occurs frequently in scarla- 
 tina, pneumonia, diphtheria, syphilis, tuberculosis, sepsis, etc. In 
 these maladies bronchitis is secondary and results from the germs or 
 their toxins, (b) Cold and bacteria are also etiological factors. 
 It is disputed whether cold alone is an adequate factor without the co- 
 operation of bacteria, but it at least plays a potent predisposing part. 
 Even in cases of apparently primary bronchitis the pneumococcus, 
 pyogenic cocci, Friedlander's pneumo-bacillus and other bacteria 
 are found (v. s. ). Pfeiffer's micrococcus catarrhalis is found 
 in 59 per cent, of cases (Ghon, Pfeiffer) ; it is larger than the 
 staphylococcus and often occurs in pairs, (c) It may result from 
 the toxic effects of potassium iodide or bromide, tobacco, less often 
 carbolic acid, cantharides, mercury and alcohol which according to 
 Hoffman, acts locally on the air passages, (d) Mechanical irritants 
 are dust and other foreign particles, as particles of wool, stone, etc., 
 which exist in many factories; overuse or abuse of the voice is also 
 a mechanical irritant, (e) Constitutional conditions, as obesity, 
 nephritis, rhachitis, gout, diabetes and cachexia of various kinds, 
 such as cancer, syphilis or scurvy, are important etiological condi- 
 tions. (/) Venous stasis in the lesser circuit favors bronchitis, by 
 congesting the pulmonary veins, which empty chiefly into the vena 
 cava superior and vena azygos ; mitral lesioiis are the most important 
 but other valvular disease, arteriosclerosis, scoliosis, abdominal tu- 
 mors, ascites or pleurisy, all of which affect the diaphragmatic ex- 
 cursion, are possible factors, (g) Respiratory diseases, as pneumonia, 
 tuberculosis, abscess or gangrene of the lung, asthma and bronchiec- 
 tasis are usually associated with bronchitis, (h) Age. Acute bron- 
 chitis may develop at any age, but is peculiarly frequent in the aged 
 and in children between six months and three years old. 
 
 Symptoms. — 1. Acute bronchitis of the larger tubes (macrobron- 
 chitis or tracheobronchitis) begins (a) with some constitutional de- 
 pression, sometimes with fever and chilliness, or in children even 
 with marked toxsemic symptoms. It often follows acute coryza or 
 pharyngitis, (b) The local symptoms are substernal rawness or 
 tickling ; actual pain or tenderness over the sternum is mostly tracheal 
 or muscular, for the bronchi have apparently no pain nerves. On 
 inspection of the trachea there is visible inflammation, redness, diffuse 
 or circumscribed injection, submucous ecchymosis, swelling and lax- 
 ness of the mucosa, and dryness, which is followed by the appearance 
 of a viscid, transparent, glairy mucous secretion ; the mucous glands 
 are often distended by globules of mucin which slightly resemble 
 young tubercles ; most of these findings are also noted in the bronchi 
 in the rare cases which come to autopsy, but injection and redness 
 
480 DISEASES OF THE RESPIRATORY TRACT. 
 
 largely disappear after death. Microscopically the cardinal signs 
 of inflammation are found, snch as paresis of the vessels, round cell 
 emigration and desquamation of the ciliated epithelium, (c) The 
 cough is at first dry and unproductive and may remain so. Later a 
 viscid, transparent sputum is raised, consisting almost wholly of 
 mucin and very few white cells (sputum crudum). A day or two 
 later the coughing efforts become less severe as the sputum grows 
 more abundant and mucopurulent (sputum coctum) : it contains 
 polymorphonuclear and sometimes abundant eosinophilic leukocytes, 
 epithelial cells showing myeloid degeneration, and rarely ciliated 
 epithelium. Localized inflammation at the tracheal bifurcation 
 causes special irritation (Nothnagel). (d) The symptoms resulting 
 from cough are disturbed sleep ; hoarseness from forcible closure of 
 the glottis in coughing efforts ; pain in the side or at the diaphragma- 
 tic insertion, from unusual strain on the expiratory muscles during 
 coughing; venous stasis which induces headache, vertigo, swollen 
 cervical veins, cyanosis and epistaxis ; mechanical sequences, as vom- 
 iting, involuntary urination, especially in weak and old subjects; 
 and in women, even abortion, uterine prolapse or hernia may occur. 
 (e) Physical findings are usually bilateral; unilateral signs, though 
 possible, suggest other lesions, especially tuberculosis. Auscultation 
 reveals rhonchi, which result from swelling of the bronchial mucosa, 
 slight stenosis by bronchial secretion and air passing through or dis- 
 lodging the secretion. The rhonchi at first are dry (r. sicci), and 
 later moist (r. humidi). Over the large tubes these rales are sonorous, 
 in the smaller tubules they are sibilant, and in both they vary acous- 
 tically. They may be heard simultaneously over the large and small 
 passages, or over the large and then, by extension, over the small tub- 
 ules. These rales, large and small, may be felt with the hand 
 (mucus fremitus) or may be heard without the stethoscope. The 
 breathing may be " cog-wheel," lengthened, slowed or sometimes in- 
 creased by fever, but in quality it is only exaggerated or puerile, never 
 bronchial. Thoracic breathing develops in men when the tubes in the 
 lower lobes are invaded (Riegel). Percussion is wholly negative. 
 Macrobronchitis lasts a few days, possibly longer than a week. 
 
 2. Microbronchitis or capillary bronchitis is essentially the same 
 pathological process as macrobronchitis but will be considered under 
 bronchopneumonia, because of its great, though not necessary, ten- 
 dency toward pulmonary inflammation, especially in the aged and in 
 children. 
 
 Treatment. — In the early stage a full hot bath may be given, fol- 
 lowed by a hot alcoholic drink. A hot Turkish bath should never 
 be taken, for exposure afterward is dangerous. Hot fomentations 
 over the sternum are beneficial ; a hot water bag or a large poultice 
 may be applied over the sternum, but cold packs over the neck and 
 chest are even more efficacious. Patients should always be kept in 
 bed, for but few cases recover promptly without this treatment. 
 A drink or two. q| well diluted whiskey is valuable, When the 
 
CHRONIC BRONCHITIS. 481 
 
 initial symptoms appear, gr. x of Dover's powder should be given; 
 it not only relieves pain, muscular soreness and coughing but also 
 appears to modify the inflammation; in children it should be given 
 with great caution because of the frequently unequal mixture of its 
 constituents, and the peculiar susceptibility of the youthful nervous 
 system to narcotics; in the aged it should likewise be administered 
 with care, because the kidneys in old persons excrete slowly, and 
 cerebral atheroma may induce psychical disturbance, Cheyne-Stokes' 
 breathing and other basilar disturbances. The administration of 
 opiates should be followed by some saline aperient. Other treatment 
 is frequently superfluous, but if the symptoms and cough persist or if 
 the initial symptoms are rather severe we administer: 
 
 I£ Vini antimonii 3iv. 
 
 Heroin hydrochloridi gr. iss. 
 
 Vini ipecacuanhae 3v. 
 
 Syr. tolutani q.s. ad ^ij- 
 
 M. et S. — One teaspoonful every three or four hours. The physician 
 should watch lest gastric symptoms appear. 
 
 Brown's mixture may be given (see Chronic Bronchitis). 
 
 ]£ Potassii citratis 3iiss. 3j. 
 
 Codeinae sulphatis gr. iv. gr. j. 
 
 Syrupi ipecacuanhae 3iv. 3iss. 
 
 Succi limonis 3J. 3 SS - 
 
 Aquae q.s. ad gij. gij. 
 
 M. et S. — One teaspoonful every two hours. The first column is the 
 dosage for adults, the second for children. 
 
 The fever rarely requires treatment ; if high, aconite and belladonna 
 may be given, as in coryza, but tepid sponging is more beneficial. A 
 kettle of water (with co. tr. benzoin 3i-Oj) should be kept boiling in 
 the room to moisten the atmosphere, or a steam tent may be advisable 
 as in croup (see Diphtheria). If the bronchitis lingers longer, the 
 formulae given under chronic bronchitis will be useful. 
 
 CHRONIC BRONCHITIS. 
 
 Etiology. — The etiology is essentially that of the acute type. 
 Chronic bronchitis is more common in advanced life, and may develop 
 slowly as a chronic process, or, more often, follows repeated acute 
 attacks. It most often develops on change of weather or in the cold 
 season, as the "winter cough." 
 
 Pathology. — The larger and medium sized bronchi are most in- 
 volved. Their color is a gray red or brown; the bloodvessels are 
 thickened, and the bronchi become thicker from extravasation of leu- 
 kocytes and proliferation of the peribronchial connective tissue; the 
 mucous membrane is sometimes hypertrophied, and even protrudes 
 in polypoid and papillary excrescences, or is atrophied, and appears 
 thin and pale like a serous membrane. Erosions are not common 
 
482 DISEASES OF THE RESPIRATORY TRACT. 
 
 but are sometimes seen at the tracheal bifurcation, especially in the 
 aged. Stagnation of secretion is common. The inner surface of the 
 bronchi is at times reticular, due to the prominence and hyperplasia 
 of some elastic fibers and the wasting and sinking of other elastic or 
 muscular fibers. Emphysema and some interstitial fibrous over- 
 growth are frequently found at autopsy. 
 
 Symptoms. — Fever and pain are absent, except in the frequent 
 acute exacerbations. The usual intrinsic physical findings in chronic 
 macrobronchitis are large sonorous rales, and sibilant rales when 
 acute exacerbations cause invasion of the finer tubules. The cough 
 varies with the intensity of the inflammation, with the amount and 
 character of the secretion, or with changes in the weather. The 
 sputum varies greatly, and upon its character is based the division 
 into the following forms: (a) Dry bronchitis, the bronchitis sicca of 
 Laennec, which is seen in the aged and is almost always associated 
 with emphysema ; in this type the sputum is wholly absent or very 
 scant and viscid. (7;) Bronchorrhoea, in which the excessive bron- 
 chial secretion may be mucous, serous or purulent; in the serous 
 form the secretion is thin and transparent, as in Laennec's case, in 
 which two quarts were raised daily for twelve years; Striimpell 
 observed a serous bronchorrhoea resulting from enlarged peribronchial 
 glands ; the purulent form may be confused, on account of its abun- 
 dant sputum, with bronchiectasis, lung abscess or rupture of an 
 empyema into the bronchi, (c) Putrid bronchitis, which has been 
 described by Laennec, Andral and Traube. It may complicate 
 chronic bronchitis but occurs more often with bronchiectasis, foreign 
 intrabronchial bodies and tuberculosis; in this form the sputum 
 stinks and is acidulous, particularly when first voided. It con- 
 sists of three layers; an upper foamy, a middle serous and a 
 lower one of granular gray-green or bluish sediment, in which are 
 the mucotic plugs of Dittrich (1850) ; these plugs contain various 
 bacteria, leptothrix, strepto- and staphylococci, etc. " Acid-fast " ba- 
 cilli are found in putrid bronchitis and in gangrene of the lung ; they 
 closely resemble tubercle bacilli, though they are narrower, more 
 pointed at their ends and do not give inoculation results. Tat and 
 myelin droplets, fatty needles, leucin and tyrosin are also present. 
 Fever is common, " drum stick " fingers may develop, and complica- 
 tions may follow, as lung induration, diphtheroid ulceration, gangrene, 
 pleurisy, haemoptysis, cerebrospinal abscess, meningitis or pseudorheu- 
 matism. (d) Blood-stained sputum occurs particularly in the brown 
 induration of the lungs, due to stasis (see page 408). 
 
 Chronic emphysema (v. i.) is an almost regular complication and 
 is marked by a tympanitic percussion note, voluminous lungs, pro- 
 longed and, on exertion, difficult expiration, weakened vesicular mur- 
 mur, hypertrophy of the cervical muscles, right heart dilatation, and 
 eventually tricuspid insufficiency, liver congestion and oedema. 
 
 Diagnosis.— The diagnosis is generally easy. Determination of its 
 relation to tuberculosis and other causal factors is most important. 
 In every case chronic nephritis should be considered. 
 
CHRONIC BRONCHITIS. 483 
 
 Prognosis. — The prognosis depends on the etiological factors. Ab- 
 solute recovery is most unlikely. 
 
 Treatment. — 1. Prophylaxis. Causal affections require treatment. 
 Woolen underwear should be worn to protect against sudden changes 
 of temperature. 
 
 2. Climate. — When feasible, a dry, warm, even climate is bene- 
 ficial, as that of Florida, southern California, New Mexico, the 
 Carolinas, Egypt and the Riviera. 
 
 3. Cough. — Codein, morphine, creosote, cod-liver oil and other 
 remedies are employed as in tuberculosis (q. v.). Amnion, carb. (v. 
 Pneumonia) gr. iij can be given with syr. senegas 3j ; syr. scilhe 5j is 
 incompatible with ammon. carb. but may be combined with ammon. 
 chlor. gr. v to x. 
 
 I£ Ammonii chloridi 3iss. 
 
 Misturse glycyrrhizse composite %iv. 
 
 M. et S. — One teaspoonful after meals. 
 
 The mistura glycyrrhizse composita (Brown's mixture) contains 
 twelve parts of paregoric, six parts of antimonial wine and three 
 parts of sweet spirits of nitre, which enhance its sedative action; it 
 may be given in doses of from one to four drams. If the heart is 
 weak, it is contraindicated because of the antimony it contains. Prom 
 all cough preparations, the stomach may become deranged by the am- 
 monium, syrups, etc. Chloroform is particularly valuable in parox- 
 ysmal unproductive coughs, which opiates may not alleviate because 
 they dry up the secretion. 
 
 ]£ Ammonii carbonatis 3j. 
 
 Spiritus chlorof ormi 3i ss - 
 
 Syrupi senegse q.s. ad ^iij- 
 
 M. et S. — One teaspoonful in hot water as indicated. 
 
 ]£ Apomorphinse hydrochloridi gr. ss. 
 
 Heroin hydrochloridi gr. j. 
 
 Spiritus chloroformi 3g. 
 
 . Aquae q.s. ad ^ij. 
 
 M. et S. — One teaspoonful two or three times a day. 
 
 Syr. scillse compositus (Hive Syrup) also contains senega and tartar 
 emetic and is given in doses of gtt. xx to xl. The antimony it con- 
 tains may depress the heart. Terpini hydras is excellent, gr. iii t. i. 
 d., given in capsules with equal amounts of benzoic acid. The bal- 
 sams are even more efficacious, as emulsum 61. terebinthince 3j in milk; 
 ol. santali Tr[x to xx in emulsion is less likely to disturb the kidneys 
 than is turpentine; balsamum Peravianum 3ss ranks with the best. 
 The balsams and creosote are directly indicated in foetid bronchitis. 
 Eetention of secretion which does not yield to the action of drugs, 
 may be treated by rhythmical compression of the chest during expi- 
 ration. Potas. iodide gr. v to x t. i. d. is excellent. 
 
 4. Cardiac Weakness. — Cardiac weakness is relieved most effi- 
 caciously by strychnine, which is more valuable than digitalis, 
 
484 DISEASES OF THE RESPIRATORY TRACT. 
 
 5. Coincident Emphysema. — Coincident emphysema and asthma 
 (q. v.) necessitate the prolonged use of iodides and belladonna. 
 
 FIBRINOUS BRONCHITIS. 
 
 Etiology. — There are three types of fibrinous or croupous bron- 
 chitis, (a) The primary form is an infrequent disease, of which 
 McPhedran collected 204 cases (1907) ; it occurs in males i (66 per 
 cent, of cases) principally between ten and thirty years of age,, arid in 
 weakly and anaemic subjects; it results from the Bacillus diphtheria?, 
 pneumococcus, strepto- and staphylococcus, aspergillus fungus and 
 protozoa, or from their toxins, (b) The secondary type develops by 
 extension from laryngeal and pulmonary disease, or in infections, as 
 diphtheria, pneumonia, typhoid, measles and scarlatina; tuberculosis 
 causes 50 per cent, of this group; some cases occur in skin disease. 
 (c) Mechanical, thermal and chemical agents are causative factors 
 in a few cases, and some have occurred in connection with valvular 
 heart disease and exophthalmic goitre. Fibrinous bronchitis was first 
 clearly described by Clark, in 1697, though Hippocrates and Galen 
 mentioned the condition. 
 
 Symptoms. — The early symptoms are those of bronchitis, sometimes 
 with fever, chills and haemoptysis (in 33 per cent.), but they are am- 
 biguous until bronchial casts of fibrin or mucin are expectorated, 
 after a severe coughing paroxysm. The casts may measure even 
 eight inches long, and may be as thick as a lead pencil or a finger; 
 their upper and larger parts are circular or somewhat flattened, solid 
 or hollow, but the lower small portions are branched, solid, spiral 
 and often beaded with air and clubbed at their tips. Though 
 usually termed fibrinous or croupous, many casts do not take Wei- 
 gert's fibrin stain ; these are bronchitis mucinosa or pseudomembrana- 
 cea. Liebermeister holds that fibrin is more frequent than mucus 
 formation. The microscopic appearance of the casts is hyaline, their 
 texture is fibrillar, and their surface is often covered with blood disks, 
 hsematoidin or Charcot-Leyden crystals. Smaller casts may not 
 be seen until the sputum is agitated in water, which washes off the 
 adherent blood, pus or mucus. Pending their evacuation, there are 
 signs of unilateral bronchial stenosis, e. g., dyspnoea, cyanosis and 
 inspiratory retraction, and absence of breath sounds in the correspond- 
 ing lung area. Slipping or moving of the casts in the bronchus may 
 cause peculiar flapping rales. After their evacuation new casts form 
 in one or more days. Niemeyer observed the daily shedding of a 
 complete cast of a bronchus and its divisions. 
 
 Diagnosis. — In some cases casts are not voided during life, so that 
 the autopsy alone determines the diagnosis. Asthma (q. v.) and 
 bronchitis fibrinosa have certain common symptoms, as paroxysmal 
 occurrence, eosinophilia, crystals and spirals, but are usually differen- 
 tiated with ease. 
 
 Course and Prognosis. — In the acute form, which lasts two weeks or 
 
BRONCHIAL DILATATION. 485 
 
 less, there is great risk of sudden asphyxia during the evacuation of 
 the casts ; there is a death rate of 75 per cent, in the young and 50 
 per cent, in adults. In chronic forms the process lasts for months or 
 even years (cases of twenty-three and twenty-five years duration 
 have been observed). The prognosis is uncertain. Complications 
 include splenic tumor, pneumonia, pleurisy, emphysema and albu- 
 minuria. 
 
 Treatment. — Treatment is unsatisfactory if not wholly futile. In- 
 halation of steam and alkaline vapors, and pilocarpin should be given 
 in order to loosen the casts. Emetics may facilitate their evacuation 
 and iodides and mercurial inunctions may inhibit their reformation. 
 The iodides are the most effective. 
 
 BRONCHIAL DILATATION, BRONCHIECTASIS. 
 
 Etiology and Pathology. — Laennec first described bronchiectasis, in 
 1819. It is found in 2 per cent, of autopsies and is always secondary 
 (a) to bronchial disease, stenosis preeminently, and then influenza, 
 pertussis, inhalation of dust, foreign bodies or pressure from aortic 
 aneurysm; (b) to lung disease, tuberculosis, interstitial or broncho- 
 pneumonia, hypostasis or atelectasis; in these conditions coughing 
 increases the expiratory pressure, even forty fold; (c) to pleural 
 disease, such as adhesions pulling on the bronchi. Nearly all cases 
 are acquired and occur mostly in middle aged males (77 per cent.). 
 Rare congenital cases are recorded. These may be divided into (i) 
 the unilateral, universal or diffuse form (Grawitz), (ii) those due 
 to congenital atelectasis (Heller) or atrophy and (iii) those resulting 
 from prenatal bronchial (syphilitic) stenosis. 
 
 There are two forms of bronchiectasis : (a) The cylindrical or fusi- 
 form, multiple or pater noster form, which develops from the atrophy 
 of the muscular and elastic fibers induced by protracted severe cough- 
 ing and perhaps by stagnation of secretion; it may follow measles, 
 catarrhal pneumonia, whooping cough or emphysema, (b) The rarer 
 sacculated form, in which the bronchus may reach a diameter of even 
 3 inches and which might be called a bronchial aneurysm. The con- 
 nective tissue usually disappears, the ciliated epithelia are replaced 
 by flat cells and the mucosa is thin, red, swollen and sometimes villous 
 or varicose. The sacs close at their necks, particularly when caused 
 by aneurysm, syphilis or tuberculosis; this converts them into sacs 
 filled with gelatinous, cheesy or calcareous contents. Lung stones 
 may develop, of calcium carbonate and phosphate with traces of 
 magnesia ; they have an organic nucleus and sometimes cause " bron- 
 chial colic," or symptoms like phthisis. 
 
 Bronchiectasis is seldom single ; in multiple bronchiectasis the lung 
 sometimes resembles a sponge or porous cheese. It occurs principally 
 in the lower lobes and in bronchi of the third and fourth order. It is 
 bilateral in 60 per cent, but the congenital forms are always unilateral. 
 Adhesions are very common when the cavity reaches the pleura. 
 
486 DISEASES OF THE RESPIRATORY TRACT. 
 
 Symptoms. — Most cases are not discovered clinically, and Weil 
 therefore concluded that "most cavities escape detection and most 
 diagnoses of cavities are incorrect." Sacculated forms produce more 
 symptoms and signs than do the cylindrical forms, which are almost 
 always impossible to recognize. 
 
 1. Sputum and Cough. — The sputum and cough are paroxysmal. 
 When secretion fills the sac and flows over onto the normal sensitive 
 mucous membrane beyond it, cough develops and quantities of muco- 
 pus are voided in the " mouth full " fashion described by Wintrich. 
 Change of posture produces similar effects. The largest amount is 
 raised in the morning and is frequently followed by vomiting. The 
 daily quantity may amount to a quart. Its odor is acid, sweat-like 
 and offensive, but it does not attain the foetor of putrid bronchitis or 
 the mature foulness of gangrene. When collected it forms in three 
 layers; the upper one is foamy, the middle serous and the lower 
 purulent. A nummular or globular sputum may be noted, as in tuber- 
 culosis, but if put in water it is more flocculent, more granular and 
 airless; and microscopically it contains altered leukocytes and fatty 
 needles, occasionally red cells, hsematoidin crystals and very rarely, 
 when the bronchial wall is ulcerated, elastic fibers. 
 
 2. Physical Examination. — (a) Inspection may reveal dimin- 
 ished respiratory movement, inspiratory retraction over the cavity 
 or flattening of the chest wall. The patient generally leans toward 
 the diseased side, to lessen the trickling out of the secretion. In the 
 rare cases of bronchiectasis in an upper lobe the constant escape of 
 the secretion results in exhausting inauspicious coughing (Skoda). 
 The #-rays may show the location of the cavity. In rare cases the 
 cavity may bulge through the interspaces. (6) Palpation and (c) 
 percussion give variable results depending on whether the cavity 
 is full or empty. Dulness prevails when it is full ; when it is empty 
 a tympanitic note results. A higher note on opening the mouth, 
 on inspiration or on change of posture has the same value as in tuber- 
 culous cavity (q. v.). (d) On auscultation, bronchial or metallic 
 breathing may be heard when the cavities are superficial but it is 
 absent in dilatations which are small, deep or full of secretion. 
 Metamorphosing breathing is a certain sign of a cavity. Skoda's 
 superficial, " veiled-puff " sound is frequent. Large and small rales, 
 if heard persistently in the same locality, are suggestive of a deep 
 bronchiectasis. The sound tissue over the cavity Imparts a metallic 
 consonance. 
 
 3. Complications.— The general nutrition sometimes remains 
 normal; slight cyanosis together with anaemia is frequent. Hectic 
 fever is often absent, but death may result, with symptoms resembling 
 those of phthisis. Putrid bronchitis is frequent. Hemoptysis from 
 ulceration of varices occurs in 40 per cent, of cases ; pneumothorax 
 pleurisy, empyema, lung induration or gangrene, emphvsema lobular 
 pneumonia, amyloidosis and hypertrophy and dilatation of the ri^ht 
 ventricle are fairly common. Marie's osteo-arthropathie hypertro- 
 
TEACH EAL AND BEONCHIAL STENOSIS. 487 
 
 phiante pneumonique, rheumatoid affections (Senator), suppurative 
 meningitis or abscesses in the brain are occasional. 
 
 Diagnosis. — Diagnosis depends upon the character of the sputum, 
 its paroxysmal voidance and the signs of cavity formation. Differ- 
 entiation is required (a) from tuberculous cavities; this is made by 
 means of the habitus, presence of elastic fibers and tubercle bacilli in 
 the sputum, which are definitely determined by inoculation; tuber- 
 culous cavities are most often apical, but frequently bilateral; they 
 void less sputum and suffer less rapid variation in their physical 
 signs. Bronchiectatic cavities occur mostly in the lower lobes, void 
 more sputum, less often induce hemorrhage and more frequently cause 
 right heart changes. (&) From perforating empyema, in which chol- 
 esterin and haematoidin crystals are far more frequent than in bron- 
 chiectasis; (c) from abscess; (d) from gangrene of the lung (v. i.) ; 
 (e) from putrid bronchitis, in which there is no sudden volume of 
 evacuated sputum or signs of cavity; (/) from encapsulated pyo- 
 pneumothorax, which may be very difficult of differentiation ; and (g) 
 aneurysm or tumor causing bronchiectasis. 
 
 Prognosis. — The immediate prognosis is rather favorable, but ulti- 
 mate recovery is exceptional, except in acute cases, e. g., postinfluen- 
 zal; patients have lived half a century. The complications require 
 consideration (v. s.). 
 
 Treatment. — The therapeutic indications are (a) evacuation of the 
 secretion, for which expectorants and expiratory compression of the 
 chest, as in bronchitis, are somewhat useful ; sedatives should never be 
 given, lest gangrene develop; (b) modification of putrescence by 
 balsamic remedies, as in foetid bronchitis ; inhalations of creosote may 
 be given, though they are most irritating at first (Chaplin, 1895) ; a 
 dram of creosote is slowly vaporized over a flame, and the patient, in 
 a closed room, inhales the fumes with the eyes closed and the anterior 
 nares plugged ; the procedure may be gradually lengthened from a 
 few minutes to half an hour; the irritation evacuates the residual 
 secretion; (c) surgical drainage. An accessible cavity may be in- 
 cised and drained, though accurate diagnosis of its location is difficult, 
 the mortality high and the affection multiple. In Garre's collection of 
 57 cases (1902), 63 per cent, recovered and 37 per cent, died; (d) 
 change of climate (v. Tuberculosis). 
 
 TRACHEAL AND BRONCHIAL STENOSIS. 
 
 I. Tracheal Stenosis. — Etiology. — The cause is less often within 
 than without the trachea. Tracheal causes are rhinoscleroma (Stork, 
 1874), syphilis which in 40 per cent, of cases also implicates the 
 bronchi, tumors (cancer, polyp, fibroma, enchondroma, sarcoma 
 or aberrant thyroid), foreign bodies, tracheotomy granulations, 
 and in rare cases perichondritis. Causes outside the trachea are more 
 frequent, as thyroid enlargement, particularly the retrosternal, cystic 
 and circular forms, or struma in which hemorrhage or inflammation 
 
488 DISEASES OF THE RESPIRATORY TRACT. 
 
 has occurred; in some cases sudden death results, notably when the 
 cartilages have been absorbed. Aneurysm, adenopathies, mediastinal 
 tumors, vertebral tumor or caries and thymus hyperplasia are other 
 factors. Thiesen (1906) collated 135 cases of tracheal tumor, of 
 which 89 were benignant and 46 malignant; 24 were fibromata and 
 10, intratracheal struma (penetrating the rings of the trachea, 
 Paltauf). 
 
 Symptoms.— The symptoms may be ranged in three series or stages; 
 
 (a) when there are no symptoms or when they occur only on exertion ; 
 
 (b) when there is constant dyspnoea, and (c) when suffocative attacks 
 terminate in final asphyxia. The dyspnoea is of a mixed type, i. e., 
 inspiratory and expiratory; the number of respirations is lessened, 
 there is inspiratory stridor and intercostal retraction, all the acces- 
 sory muscles come into play, the head is held well forward and there 
 is little or no laryngeal excursion. The pulse is more tense, varies 
 in rate and is sometimes of the paradoxical type. Tracheoscopy may 
 reveal the location of the lesion, most advantageously in the strong 
 sunlight ; the patient should stand with his back to the light and with 
 the head bent forward, and the observer should be seated on a low 
 seat before him. Frankel affirms that in 25 per cent, of tracheal 
 stenoses due to tumor or aneurysm, there is coincident paralysis of 
 the vocal cords. 
 
 II. Bronchial Stenosis.— Etiology. — Intrabronchial causes are most 
 common and consist of pus, mucus, blood, fibrin and foreign bodies; 
 obstruction due to the latter is laryngeal in 33 per cent., tracheal in 26 
 per cent, and bronchial in 41 per cent., of the cases. Extrabronchial 
 factors are next in frequency ; aneurysm, mediastinal lymphosarcoma 
 and perilymphadenitis leading to fibrosis occur most often; less 
 common are pericarditis with effusion, dilatation of the left auricle, 
 cancer of the oesophagus, tumor of the lung and thyroid or thymic 
 strumas. Twenty cases have been reported in which lymph glands 
 ruptured into the trachea or bronchi, causing suffocation ; only three 
 were saved by tracheotomy. Interbronchial causes (i. e., in the bron- 
 chial wall) are the least common, as syphilis, glanders, rhinoscleroma 
 and tumors. Thirty-six cases of primary cancer are recorded. The 
 right is stenosed nearly twice as often as the left bronchus. 
 
 Symptoms. — Occlusion of a bronchus lessens the amount of air en- 
 tering the lung which it supplies, whence the vocal fremitus and 
 breath sounds are immediately weakened or suspended and the respir- 
 atory excursion and Litten's diaphragmatic sign are decreased. There 
 is inspiratory retraction of the intercostal spaces on the affected side. 
 Inspiratory dyspnoea occurs, particularly in acute cases. The head 
 is thrown forward and the larynx moves up and down but little. The 
 percussion note is not essentially altered; and this excludes many 
 causes of dyspnoea, as pneumonia, etc. ; after a time a somewhat tym- 
 panitic note may result from relaxation of the lung or acute emphy- 
 sema. A local stenotic murmur over the bronchus is present in a 
 few cases. Paroxysmal dyspnoea may result from stagnating secre- 
 
BRONCHIAL ASTHMA. 489 
 
 tion. Coughing is usual and may resemble that of pertussis. The 
 pulse is more tense and often slower. The #-rays may locate the 
 obstruction. Bronchoscopy is sometimes helpful, but it is difficult to 
 perform even for the experienced specialist. Death results from (a) 
 the original disease, as aneurysm or tumor; (b) failure of the right 
 heart, (c) asphyxia, with delirium, cyanosis, convulsions or Cheyne- 
 Stokes' breathing, or (d) pulmonary oedema, abscess, gangrene, tuber- 
 culosis, lobular pneumonia or hemorrhage. 
 
 Diagnosis. — (a) Of the location of stenosis : In laryngeal obstruction 
 there are local findings and free up-and-down laryngeal excursion; 
 the subject holds the head well back, and the ingress of air to both 
 lungs is equally impaired; tracheoscopy, bilateral lung involvement, 
 the absence of laryngeal excursion and the holding of the head for- 
 ward are sufficient proof of tracheal obstruction ; in bronchial stenosis 
 but one lung suffers for air, the larynx is nearly immobile and the 
 head is thrown forward, (b) Of the nature of stenosis, exact diag- 
 nosis is more difficult, and is impossible without distinct physical 
 signs, as those of aneurysm, or without history of the presence of for- 
 eign bodies. 
 
 The prognosis depends on the cause. 
 
 Treatment. — Treatment is also largely that of the cause, as syphilis, 
 tuberculosis, etc. Thyroid extract and iodine are efficacious in over 
 50 per cent, of cases of thyroid swellings. When the obstruction is 
 aneurysmatic, rest, mercury, iodides, venesection and gelatin injec- 
 tions often afford considerable relief. When there are foreign bodies, 
 the patient should be inverted, sharply struck on the back and shaken ; 
 the physician should have long forceps and tracheotomy instruments 
 in readiness. The mortality in foreign bodies of the lower air pas- 
 sages is 52 per cent, with expectant treatment, and 23 per cent, with 
 operation. 
 
 Bronchial and lung stones (v. s.) result from tuberculosis of the 
 bronchial glands, from bronchiectasis, petrification of the bronchi, 
 calcification and ossification of the lungs, gout and foreign bodies. 
 Boerhaave described the case of the botanist, Vaillant, who expec- 
 torated 400 calculi. Symptoms are frequently absent or are those of 
 the primary disease; purulent bronchitis, asthma ("bronchial 
 colic"), hectic fever and haemoptysis mark some cases. 
 
 Stenosis of the bronchioles may result from bronchiolitis fibrinosa 
 obliterans (Lange and Frankel). 
 
 BRONCHIAL ASTHMA. 
 
 Definition. — A paroxysmal dyspnoea, due to stenosis or spasm of the 
 smaller bronchioles, which is nervous or reflex in origin and is charac- 
 terized by expiratory dyspnoea, slowing of respiration, congestion of 
 the bronchioles, a peculiar mucous exudation and acute emphysema. 
 It is also known as asthma spasmodicum or nervosum, to distinguish 
 it from other so-called asthmas, as the cardiac or renal types. 
 
490 DISEASES OF THE EESPIEATOEY TEACT. 
 
 Etiology. — When due to no obvious cause, asthma is termed essen- 
 tial or primary, and when due to a clear cause it is called sympto- 
 matic or reflex asthma (which occurs through the vagus), (a) Nasal 
 and nasopharyngeal disease is the source of the reflex asthma in num- 
 bers of cases, as proven by Voltolini, Hack, Hanisch, Porter, Daly, 
 Roe and others ; it may be caused by rhinitis, tonsillar hypertrophy, 
 adenoids or pharyngitis granulosa; the nose may be so hypersensi- 
 tive that the odor of flowers, dust, hot air or smoke precipitates an 
 attack, (b) Asthma may be initiated by pressure on the vagus trunk, 
 by thyroid tumors or enlargement of the bronchial glands, following 
 tuberculosis, measles, pertussis or rickets, (c) Abdominal diseases 
 are possible though not frequent causes; the asthma dyspepticum of 
 Henoch, Meyer and Pribram has been especially emphasized of late 
 by Hayem who describes asthma resulting from gastric dilatation. 
 Ovarian and uterine disease and pregnancy have been considered 
 causal factors, (d) Asthma toxicum has been reported in lead and 
 mercurial poisoning; urwmic and gouty asthma are due to toxins. 
 (e) It occurs especially in weakly, anaemic, nervous, scrofulous and 
 rhachitic subjects, in males (66 per cent.) between the ages of twenty 
 and forty (though it has recently been claimed that 33 per cent, of the 
 asthma cases develop under ten years), in the upper classes and in 
 professional men. 
 
 There are various theories as to the mechanism of the asthmatic 
 attack: (a) It is a spasm of the bronchial muscles (Trousseau, Rhom- 
 berg and Biermer). Trousseau spoke of asthma as " an epilepsy of 
 the lungs"; (b) it is a very acute catarrh (Louis and Traube) ; 
 Stork found the larynx and trachea deeply injected; (c) it is a 
 vasomotor disturbance (Weber) ; or (d) an acute exudative bron- 
 chitis, causing bronchial spasm (Curschmann, Lebert). Its pathol- 
 ogy is uncertain, as but half a dozen autopsies are recorded; the 
 ciliated epithelium is desquamated, the bronchioles are congested and 
 there is eosinophilic exudation. 
 
 Symptoms. — The attack begins very suddenly, often at night and 
 with or without such causes as fright, cold, heat, change of residence, 
 etc. Sometimes there are prodromes, as conjunctivitis, coryza or flat- 
 ulence and sometimes the attack coincides with the menses, (a) Dys- 
 pnoea is the first and the essential symptom ; though at first slight, it 
 soon becomes urgent; the patient opens the windows, sits upright, 
 grasps the arms of the chair to brace the accessory respiratory mus- 
 cles, and exhibits extreme distress, anxiousness and pallor, which is 
 followed by cyanosis ; the dyspnoea is expiratory and the abdominal 
 muscles are board-like during expiration; inspiration is somewhat 
 lengthened and expiration is greatly prolonged, wheezing and whist- 
 ling; respiration is generally slow. (6) There is marked cyanosis 
 in tlrefa.ce and extremities, the cervical veins bulge out like cords, 
 the skin is clammy, and the pulse indicates poor oxygenation by its 
 tenseness, smallness and frequency; carbon dioxide intoxication causes 
 the occasional headache, delirium, tinnitus, twitchings, convulsions 
 
PLATE XII 
 
 ,^-;::-' 
 
 
 $ 
 
 
 ■& 
 
 WWik 
 
 '. .•-•:';Ks~. 
 
 ?'.;•-' V 
 
 N 
 
 X 
 
 ^ ; 
 
 '■'. ■?;'•• 
 
 Sputum from a Case of Bronchial Asthma, showing large 
 numbers of Eosinophilic Leukocytes and Free Granules. 
 (Simon.) 
 
 It will be noted that the leukocytes are all mononuclear. 
 (Eye-piece 1, objective 1-8, Bausch & Lomb.) 
 
/ 
 
BBONCHIAL ASTHMA. 
 
 491 
 
 and coma, (c) The cough is dry and unproductive, (d) The voice 
 is faint and hoarse, (e) Other physical signs are as follows: On 
 palpation, the vocal fremitus is found decreased by the bronchial 
 spasm or secretion ; rales are often felt. The normal percussion note 
 is replaced by a tympanitic note, due to acute pulmonary emphysema; 
 the lungs are voluminous, and distend the thorax, cover the heart 
 and push down the diaphragm, whose excursion is thus reduced to a 
 minimum. On auscultation, the vesicular murmur is usually faint 
 or absent (Laennec) because of secretion in the bronchioles, and loud 
 whistling, piping or sibilant rales are heard often without the stetho- 
 scope and largely during expiration. They are due to bronchial ste- 
 nosis. (/) Sputum is voided for the first time toward the end of the 
 attack; this occurs as a species of crisis to the threatening, but very 
 seldom fatal, asphyxia. A few drams of tenacious mucus, resembling 
 egg albumin, are voided. Minute gray balls are seen; these are the 
 " perles " of Laennec ; when unrolled the " pearls " are seen to con- 
 tain the spirals of Ley den, Ungar and Curschmann; they are best 
 detected with the naked eye, and on a black background ; they measure 
 2 or 3 to 10 x ^ to 1 mm. ; they are mucin casts of the bronchioles, 
 to which may cling leukocytes, epithelia, fat or myelin droplets ; some 
 show a central band of mucin ; it is thought that they occur from the 
 passage of mucin through the contracted bronchioles ; they disappear 
 
 Fig. 32. 
 
 Spirals and crystals in bronchial asthma. B, Charcot-Leyden crystals ; A, spirals mag- 
 nified, and C, their natural size. 
 
 within a day or two ; spirals are also present in catarrhal or fibrinous 
 bronchitis and in pneumonia. The Charcot-Leyden crystals may be 
 seen in yellow dots in the sputum ; they are pointed and octahedral, 
 consist of an organic basis with phosphoric acid, and originate from 
 the eosinophile leukocytes which are increased in the sputum and 
 blood, constituting a quarter to more than half of the white cells. 
 The crystals, spirals and the occasional fibrinous casts are a result 
 rather than a cause of the asthma. (Plate XII.) 
 
492 DISEASES OF THE RESPIRATORY TRACT. 
 
 The attacks last one or two hours and may be repeated at long 
 or short intervals. In the hebdomadal form, attacks recur every 
 Sunday or Monday ; they are probably due to change in routine or to 
 digestive excesses. The urine after the attack contains increased 
 uric acid ; constipation and flatulence may result from fatigue of the 
 diaphragm and expiratory muscles. 
 
 Diagnosis. — The diagnosis is made by (a) the paroxysmal occur- 
 rence of asthma, (&) the expiratory dyspnoea and (c) the acute tran- 
 sient emphysema. 
 
 Differentiation. — (a) All diseases causing inspiratory dyspnoea 
 can be at once excluded, such as oedema or spasm of the glottis, par- 
 alysis of the post, crico-arytenoid muscles and tracheal and bronchial 
 stenosis. In spasm of the glottis, the spasm is inspiratory and of 
 short duration, the larynx moves up and down, and the epigastrium 
 retracts during inspiration ; there is no emphysema and no spirals are 
 found. Spasm of the diaphragm is very rare (v. Phrenic JSTerve) ; 
 it lasts a much shorter time, the epigastrium bulges during inspira- 
 tion, there is spasm of all the inspiratory muscles, hysterical stigmata 
 are often observed and the lungs are normal, (b) Expiratory dys- 
 pnoea may also occur in (i) chronic bronchitis with emphysema. In 
 these cases the emphysema is constant, the lungs show constant rales 
 and few eosinophiles are present in the sputum, (ii) It also occurs 
 in immovable tumors below the vocal cords which may turn upward 
 during expiration (this is shown by the laryngoscope), (c) Asthma 
 cardiale is of a mixed type, i. e., inspiratory and expiratory, and 
 is therefore readily differentiated. The " lungenstarr " or lung dis- 
 tention (v. Signs of Valvular Heart Disease), due to its engorged 
 vessels, may simulate the emphysema of bronchial asthma. Cardiac 
 asthma may occur either with high or low arterial tension, whence 
 the condition of the pulse is no certain criterion. The eosinophiles 
 are not increased to the same degree as in bronchial asthma. 
 
 Prognosis. — The prognosis is uncertain and depends on the eti- 
 ological accessibility of the asthma. It is more favorable in young 
 individuals than in those of advanced years. Cases which recurred 
 for 64 years are recorded. Chronic bronchitis and emphysema are 
 likely to develop. Death in an attack is very rare. 
 
 Treatment. — 1. Of the Attack. — A hypodermic injection of mor- 
 phine, gr. %, with atropine gr. % and spt. glycerylis nitratis TTtij 
 gives the most prompt and reliable results. Other measures are 
 purely accessory. Chloral is almost useless, for the condition usually 
 requires single doses of gr. xxx to xl, which are too large for safety. 
 Adrenalin solution, 1-1000 ulv-x hypodermatically, usually gives 
 instant relief; it is not without danger in arterio-sclerotics. Fresh 
 air, strong coffee, whiskey, a cigar or cigarette, the application of 
 cocaine to the nose, fluidextract of grindelia TT\,x to xx, especiallv in 
 bronchitic types, nitrite of amyl pearls, or a few whiffs of chloroform, 
 sometimes give relief. The vexing question arises as to leaving chlor- 
 oform or morphine in the hands of the patient whose attacks often 
 
BBONCEIAL ASTHMA. 493 
 
 come and go without medical aid; as a rule they should never be 
 left with the patient. Inhalation powders, which are burned like 
 incense, are very generally used ; they all contain some such palliative 
 as lobelia, stramonium, belladonna, hyoscine, etc. (Lobelia, pow- 
 dered black tea and powdered stramonium leaves, each one ounce; 
 soak well in two ounces of a saturated solution of potassium nitrate ; 
 dry.) Excellent cigarettes are made containing arsenic, potas. 
 nitrate, belladonna and stramonium ; their antispasmodic effects on 
 deep inhalation of the smoke is sometimes remarkable. According to 
 Burney Yeo, the celebrated Cigarettes d'Espic are said to be made of 
 the following ingredients : 
 
 Belladonna leaves 5J parts. 
 
 . . Hyoscyamus leaves 2| parts. 
 
 Stramonium leaves 2| parts. 
 
 Phellandrium aquaticum 1 part. 
 
 Extract of opium J part. 
 
 Cherry-laurel water a sufficiency. 
 
 Oxygen is occasionally efficacious and strong coffee may sometimes 
 abort the attack. 
 
 2. Of the Tendency. — (v. Etiology.) — The nose requires espe- 
 cial attention; cauterization of sensitive areas, even when there are 
 no gross lesions, is imperative. Strumpell has effected 11 cures with 
 sweating by strong lamps. The diet should be regulated ; the eve- 
 ning meal should be light, and carbohydrates and tea should be re- 
 stricted ; an emetic may abort an attack of the gastric type. Nervines 
 (valerian, arsenic, bromides) may be used when necessary. The best 
 remedy between attacks is potassium iodide ; this treatment should be 
 continued for months; potassium iodide is combined to advantage 
 with Fowler's solution and belladonna, not only to correct the action 
 of the iodides on the skin and secretory glands, but also for their 
 direct nervous and antispasmodic effects: 
 
 J$_ Liq. potassii arsenitis 3j. 
 
 Tr. belladonnas 3j- 
 
 Potassii iodidi 3ij. 
 
 Fluidextr. grindeliae (U. S. P.) 3vj. 
 
 Aquae q.s. ad %iv. 
 
 M. et S. — One teaspoonful after meals, in water. 
 
 Alkalies may be vaporized and inhaled, as sodium bicarbonate or so- 
 dium chloride. Climatic treatment is as beneficial as in bronchitis ; 
 a low level near the sea and in a semitropical climate is an ideal loca- 
 tion. General hygiene and the hardening of the patient by fresh air 
 and cold rubs are important, 
 
494 DISEASES OF THE BESPIEATOEY TEACT. 
 
 DISEASES OF THE LUNG. 
 
 EMPHYSEMA. 
 
 Definition. — A permanent disease of the lungs, characterized patho- 
 logically by atrophy of the alveolar walls and great distention of the 
 alveoli, and clinically by a large chest of the inspiratory type, dis- 
 tended lungs with poor excursion, and hypertrophy and dilatation of 
 the right ventricle. Emphysema means a " blowing up " or dis- 
 tention of the lungs, of which the various types will be considered 
 under Differentiation. It was first described by Laennec (1826). 
 It constitutes -/o per cent, of all autopsies (Yirchow). 
 
 Etiology. — Substantive or alveolar • emphysema occurs mostly in 
 individuals over 30 or 40 years of age, in men more than in women, 
 and in cold climates. The immediate cause is chronic bronchitis 
 and bronchiolitis (Laennec), catarrhe sec; it may follow pertussis, 
 bronchial asthma, etc. ; its comparative infrequency is not generally 
 understood, whence many writers assume a congenital weakness or hy- 
 poplasia of the elastic tissue of the lung. Coughing, blowing, as in 
 the use of wind instruments, straining during parturition or physi- 
 cal toil, artificial respiration in the new-born, and alcoholism are also 
 considered causative. 
 
 Pathology. — On opening the chest at autopsy, the lungs are found 
 distended (volumen pulmonum auctum, Traube) ; they overlap the 
 heart, depress the diaphragm and narrow the mediastinum. Their 
 surface is pale rose-colored, is somewhat anaemic, and presents numer- 
 ous small vesicles, -J to 4 mm. in diameter, representing the fusion 
 of several alveoli. Some large bullous areas are found under the 
 pleura. The lungs crepitate slightly to the fingers, under which they 
 feel, as Laennec put it, " like a pillow of down." The lungs collapse 
 but little on section. In some places the pigment deposit is less than 
 usual, — called albinism by Virchow. Emphysema is most marked 
 on the surface of the lung, particularly over the upper lobes, on their 
 convex anterior aspect, and behind near the spine. The normally 
 thin edges of the lung are greatly rounded. Histologically, two find- 
 ings are characteristic : (a) There is atrophy of the interalveolar 
 elastic tissue, so that the alveoli fuse, corresponding to the vesicles 
 seen on the surface; slight intercommunication of the alveoli is nor- 
 mal, but the coalescence of several alveoli is extreme in emphysema ; 
 these changes account for nearly all the clinical findings in the lung. 
 (b) The capillaries are obliterated by thrombosis, which explains the 
 clinical hypertrophy, dilatation and ultimate failure of the right 
 heart. The bronchi are frequently inflamed, thickened, shortened 
 and sometimes dilated. 
 
 Pathogenesis.— It is not wholly clear whether the elastic tissue 
 wasting or the vascular occlusion is the primary change; or, if the 
 elastic atrophy is primary, whether it is acquiredV congenital. The 
 changes may be brought about (a) mechanically by forced inspiration 
 
EMPHYSEMA. 495 
 
 (Laennec, Rokitansky, Gairclner) or by forced expiration (Jenner, 
 Mendelsohn). This theory is most favored by clinicians, though 
 pathologists think that emphysema is due to (&) nutritive alterations, 
 as vascular changes or atrophy of elastic or muscular tissue ; calcifica- 
 tion of the costal cartilages is probably more sequential than causal. 
 
 Symptoms. — Symptoms may be considered under two general head- 
 ings: (1) Those of expiratory insufficiency of the lungs, due to 
 their distention which results in turn from the loss of elastic tissue ; 
 and (2) those of cardiac insufficiency, which follow the above and re- 
 sult from obliteration of the vessels in the lesser circuit. 
 
 1. Expiratory Pulmonary Insufficiency. — Normally expira- 
 tion is wholly passive, resulting from the elasticity of the lungs and 
 collapse of the chest. Expiration in emphysema is incomplete, as 
 shown by Waldenburg's pneumotometry and Biegel's stethography ; 
 in the latter the curve resembles one resulting from division of the 
 vagus. The cyrtometer shows that the chest is more circular; the 
 spirometer shows a decrease of 20 to 60 per cent, in the normal vital 
 capacity (2—4000 c.c.) ; and mensuration shows a decided reduction 
 in the normal expansion of 2 to 3 inches. Upon inspection, dyspnoea 
 is the most conspicuous finding ; it is expiratory and is due to the loss 
 of lung elasticity and consequent impairment of lung circulation and 
 oxygenation; it is enhanced by exertion, by bronchial catarrh, by 
 accessions of true asthma and by cardiac insufficiency. If emphy- 
 sema develops gradually it may cause no dyspnoea (Traube). The 
 frequency of respiration is increased to twenty-five or thirty and 
 the type is costal. The fades and habitus are most characteristic; 
 the eyes are somewhat prominent, the nose is bluish and slightly 
 thickened, the head is thrown back and the chest forward to give 
 play to the accessory muscles of respiration, and the skin is cyanotic 
 even during rest and when dyspnoea is not urgent. A network 
 of dilated veins is often seen over the lower chest, resulting merely 
 from venous obstruction. The jugular veins fill enormously on 
 expiration and often pulsate during the diastole. The neck is short, 
 and the hypertrophied sternomastoids, scaleni and trapezii protrude 
 rigidly. The back and abdominal muscles are rigid, and thus sup- 
 plement the inadequate action of the diaphragm. The shoulders 
 are elevated, though stooped; the chest is of the permanent inspira- 
 tory type and is usually barrel-shaped (from loss of the elastic 
 tissue), rarely of the paralytic type; the anteroposterior, oblique and 
 sometimes the transverse dimensions of the chest are increased. The 
 raised clavicles accentuate the supraclavicular notches, in which the 
 apices sometimes protrude, on coughing, as hernial tumors. The 
 angle of Louis is prominent and the interspaces are wider in the 
 upper and narrower in the lower parts of the chest, and retract 
 with each inspiration. The lower thorax shows a groove indicating 
 the attachment of the expiratory muscles. The play of the dia- 
 phragm is limited, as shown by the rc-rays and by the absence of 
 litten's sign- Palpation detects the rigidity and dilatation of the 
 
496 DISEASES OF THE EESPIBATOEY TEACT. 
 
 thorax, its poor excursion, the hardness of the muscles, the thick, 
 often calcined costal cartilages and decreased vocal fremitus. ^ The 
 edge of the liver may be found depressed, though the spleen is sel- 
 dom palpable. Percussion, absolutely essential to a diagnosis, gives 
 a note which is loud and deep — hyperresonant — or on the sides and 
 back is actually "box-like" or tympanitic; it is also described as 
 muffled or wooden and in extreme cases impresses one as dull (Skoda). 
 The voluminous lungs narrow or wholly cover the cardiac dulness, 
 depress the upper level of the splenic and hepatic dulness, invade 
 Traube's space, and show either no respiratory excursion or move- 
 ment not exceeding a finger's breadth. At the back the lungs may 
 reach the twelfth dorsal or even the second lumbar vertebra. Upon 
 auscultation, expiration is found greatly lengthened so that it is to 
 inspiration as 2 or 4 to 1, the converse of the normal. Vesicular 
 breathing is absent, or the breathing is indeterminate ; even when the 
 stethoscope rises and falls there may be no audible sound. A rub- 
 bing sensation may result from muscular contraction or possibly 
 from the emphysema vesicles. Rales result from bronchitis or stasis ; 
 a pearly-colored mucin with few cells may be evacuated after much 
 coughing. 
 
 2. Cardiac Insufficiency. — The work of the right ventricle is 
 increased because the pulmonary arterioles are in part occluded, and 
 because the imperfect expiration allows neither free aspiration of 
 venous blood into the auricles nor adequate filling of the aorta. 
 The right ventricle, therefore, hypertrophies, and this causes the 
 accentuated second pulmonic tone; hypertrophy occurs mostly about 
 the pulmonary conus arteriosus. The diaphragm is low, and there- 
 fore the hypertrophied and more horizontal heart beats in the epigas- 
 trium. Dilatation soon follows and is accompanied, in advanced 
 cases, by tricuspid leakage, nutmeg liver, congested kidneys, ascites, 
 oedema and other signs of cardiac insufficiency. The alteration 
 in the heart, so marked at autopsy, is often obscured during life, 
 for the lungs cover the heart and muffle its tones. Functional heart 
 murmurs are mostly systolic, very rarely diastolic, and result chiefly 
 from degeneration or relaxation of the heart muscle. 
 
 The clinical course is long and often covers decades. Patients 
 may acquire emphysema in childhood and live to be 60 or 70 
 years old. 
 
 Diagnosis. — Developed types are easily recognized by the barrel- 
 chest, its hyperresonance, the low borders of the lung, their lack of 
 excursion, the obscuration of cardiac dulness, the expiratory dyspnoea 
 and cardiac stasis. 
 
 Differentiation. — (a) Acute distention of the lung or acute 
 emphysema, as after asthma or pertussis, cannot be distinguished by 
 one examination. It is seen repeatedly in bronchial stenosis due to 
 aortic aneurysm. It regresses rapidly even after months, when its 
 cause is removed, (b) Vicarious or compensatory emphysema often 
 develops in one lung when contralateral pleurisy or cirrhosis of the 
 
EMPHYSEMA. 497 
 
 lung exists; it may occur on the same side with the lesion; marked 
 apical emphysema almost certainly indicates some deeper induration; 
 it may develop in the death agony ; it may eventually cause wasting 
 of the lung, (c) Emphysema senile, or Jenner's "small-lunged" 
 emphysema, is merely atrophy; the connective tissue wastes and the 
 alveoli fuse, but the lungs are not enlarged ; they are indeed smaller, 
 the diaphragm stands higher, the cardiac dulness is increased, the chest 
 flattened, the ribs oblique, the respiratory muscles wasted, the right 
 heart is not hypertrophied and respiratory excursion is retained. 
 (d) From interalveolar interstitial emphysema the first differential 
 point is the etiology; (i) it may be caused by trauma, external or 
 internal, which occurs in 57 per cent, of tracheotomies (Money), and 
 is promoted by raising the deep fascia from the trachea during the 
 operation (Champneys) ; it is especially frequent with pneumothorax, 
 (ii) It may result from foreign bodies, (iii) Ulceration of the air 
 passages, gangrene, abscess or tuberculosis and less often gastric ulcer 
 or cancer may be its cause. Other etiological factors are (iv) forced 
 entrance of air, as in resuscitation of the new-born; (v) severe cough- 
 ing efforts, as in whooping cough ; (vi) severe pressure efforts, as in 
 parturition; and (vii) spasm of the glottis. The second point is 
 a series of symptoms which are not, however, always present, as 
 creaking in the mediastinum, sometimes with each systole; emphy- 
 sema and crepitation of the cervical cellular tissue, bulging of the 
 interspaces, creaking and tympany at the edge of the ribs when the 
 emphysema is under the costal pleura ; absence of the vesicular mur- 
 mur ; sometimes pneumothorax ; and obliteration of the heart dulness, 
 dyspnoea and air embolism. It is usually fatal, (e) In congenital 
 hypertrophy of the lung (pulmo excessivus) the lungs are very volu- 
 minous, but their excursion, auscultation and percussion note are 
 normal. To the author it appears especially common among Poles. 
 (/) Pneumothorax (q. v.) is unilateral, is associated with fluid in 
 the pleura, has a more tympanitic note and is associated with suc- 
 cussion, tinkling rales and other pathognomonic signs. 
 
 Prognosis. — Recovery is unusual in the genuine substantive form, 
 which is permanent. Transient forms resulting from pertussis, 
 foreign bodies or asthma, often or usually regress completely. Life, 
 even relative comfort, may be sustained for years or decades. Much 
 depends on associated conditions, as frequent severe bronchitis, 
 chronic nephritis, arteriosclerosis or myocarditis. Extreme forms 
 impede the flow of chyle which, with dyspnoea and fatigue, impairs 
 nutrition. Severe complications are failure of the right heart upon 
 which compensation devolves, cyanosis, gastric disturbance, diarrhoea, 
 hemorrhage from the lungs or bowels (in arteriosclerosis or infarc- 
 tion), scanty urine and anaemia (in the aged). 
 
 Death usually results from cardiac failure or from oedema pul- 
 
 monum. It may occur from apoplexy, pneumothorax, haemoptysis, 
 
 ura3mia and very rarely from pulmonary inflammation, to which 
 
 subjects of emphysema show no predisposition. The teaching that 
 
 32 
 
498 DISEASES OF THE RESPIRATORY TRACT. 
 
 tuberculosis (Kokitansky) or valvular disease (Bouillaud) excludes 
 emphysema, is incorrect. 
 
 Treatment. — (a) Prophylaxis concerns chiefly the concomitant or 
 causal bronchitis. Severe exercise is to be avoided, (b) Coincident 
 gastric, renal or gouty disease must be treated, (c) Climate is as 
 important a factor as it is in chronic bronchitis, an almost insepar- 
 able associate of emphysema; high altitudes are to be avoided 
 as they directly promote emphysema, (d) Pneumotherapy is some- 
 times beneficial. It includes inhalation of thinned air, or, where 
 there is marked catarrh, of compressed air. Two or three treat- 
 ments of ten minutes should be given daily, and the time should 
 soon be extended to half an hour, (e) Chronic bronchitis (q. v.), 
 and (/) asthma (q. v.) are important considerations in treatment. 
 (g) Rhythmic compression of the chest, three or four times daily, 
 should be practiced during 20 to 30 expirations ; it increases the circu- 
 lation in the lung but not respiration, (h) Cardiac insufficiency is 
 treated as in valvular or myocardial disease (q. v.) and strych- 
 nine, venesection and other measures should be used. The topic is 
 discussed briefly, as no remedy or measure can restore lost elastic 
 tissue or return resilience to atrophied contractile fibers. 
 
 BRONCHOPNEUMONIA. 
 
 This affection, partially outlined by Sydenham and Gebhart, was 
 first well described in 1 840, by Eilliet and Barthez, who separated it 
 from lobar pneumonia and recognized it as a secondary disease. It 
 might be well classed among the infections, such as fibrinous pneu- 
 monia, except that unlike the latter it is not due to a single specific 
 microorganism. 
 
 Definition. — Bronchopneumonia is defined with difficulty; (a) etio- 
 logically it is due to various microbes, is generally secondary to the 
 bronchiolitis of some specific infection, as measles or pertussis and 
 occurs chiefly in children; (b) pathologically it develops about the 
 bronchioles (bronchopneumonia) and in a few lobules (p. lobularis, 
 p. insularis or nodosa) rather than throughout a lobe; its exudate 
 is rather catarrhal (p. catarrhalis) than fibrinous, and its distribu- 
 tion is usually multiple and often disseminated (p. disseminata) ; 
 (c) clinically it is identical with capillary bronchitis, which, if it 
 occurs in the first years of life, almost never spares the lung tissue ; 
 it is marked by fever, cough, dyspnoea and cyanosis, which may often 
 co-exist without obvious signs of hepatization. 
 
 Etiology. — (a) Some cases, especially in children under two years 
 are primary; these are estimated by Holt and Connor at 35 per cent., 
 by others at a much lower figure; (b) most cases are secondary to 
 infections affecting the upper air passages. In 279 cases of infantile 
 bronchopneumonia reported by Samuel West, 32 per cent, followed 
 measles, 24 per cent, pertussis, 16 per cent, diphtheria, 15 per cent, 
 macrobronchitis, 7 per cent, ileocolitis, 3 per cent, scarlatina, 2 per 
 
BRONCHOPNEUMONIA. 499 
 
 cent, influenza, -§ per cent, each varicella and erysipelas, (c) Pre- 
 disposing causes in the young are poor sanitation, malnutrition, 
 syphilis, tuberculosis and rickets. Bronchopneumonia causes 9 per 
 cent, of deaths in foundling asylums (Miiller). (d) Age. Most 
 cases are observed in children two or three years old. Seventy-five 
 per cent, of cases of pneumonia in children under five years of age are 
 lobular (Holt). It is less frequent in adults; in weak, cachectic, 
 nephritic and aged persons it may cause death, (e) In some cases 
 microbes may act directly on the lungs, as in the primary cases in 
 children, in the influenza of adults, and in aspiration or inhalation 
 pneumonia. " Schluck pneumonie " is prone to develop in diseases 
 in which the laryngeal sensibility is decreased, as in diphtheritic 
 pareses or bulbar palsies ; in ether anaesthesia in which the germ- 
 laden saliva is drawn into the lungs ; in comatose states, as apoplexy 
 or uraemia; in mental diseases; in the new-born; in cases of partial 
 drowning; in operations on the throat; or when there is persistent 
 vomiting. Smoke, vapors and dust are exceptional causes. (/) It is 
 probable that infection may sometimes occur by the lymph or blood 
 streams, especially in septic affections. 
 
 Bacteriology. — Bronchopneumonia is no specific bacteriological dis- 
 ease. According to better, in adults about one-third of the cases 
 show more than one organism, among which the pneumococcus ranks 
 first and the streptococcus second ; and about two-thirds show one germ, 
 of which the pneumococcus constitutes 39 per cent., the streptococcus 
 31 per cent., Friedlander's bacillus 23 per cent., and the staphylococ- 
 cus 7 per cent. ; in children mixed infection is present in half the cases, 
 the streptococcus predominating, while in the other half there is but 
 one organism, the pneumococcus being the most common. In Woll- 
 stein's cases, 67 per cent, were pneumococcic. Other germs found are 
 the influenza, typhoid, tubercle and colon bacilli, Pfeiffer's Micro- 
 coccus catarrhalis, Micrococcus tetragenus and meningococcus. The 
 tubercle bacillus is often associated with the pneumococcus. 
 
 Pathology. — The foci of consolidation are usually diffused in the 
 lower and sometimes in the upper lobes, posteriorly and usually 
 bilaterally. They vary in size from a pin head to a walnut or larger ; 
 many or most foci lie near the pleura, through which they may often 
 be seen and felt; the pleura is often granular or slightly fibrinous, 
 sometimes ecchymotic. On section the consolidated nodes appear 
 reddish-brown and later yellowish from fatty degeneration of the 
 cells ; they are firm, airless, whence they sink in water, and on section 
 are generally smooth and glistening, though some pneumococcus in- 
 fections show the granulation and viscid secretion of genuine fibrin- 
 ous pneumonia. The bronchioles supplying the consolidated nodes 
 are plugged with muco-pus, so that air cannot be forced through 
 them ; the bronchioles are reddened, swollen, sometimes ecchymotic or 
 dilated. Many areas are collapsed, which some consider is prelim- 
 inary to consolidation, but though atelectasis is frequent its impor- 
 tance has been overestimated. In fortunately made sections a den- 
 
500 DISEASES OF THE EESP1EATOBY TBACT. 
 
 dritic racemose or grape-like arrangement may be seen in which 
 the bronchioles correspond to the stems and the alveoli to the leaves 
 or grapes. Microscopically the bronchioles show dilated vessels and 
 leukocyte emigration, the alveoli show epithelial desquamation and 
 proliferation, serous exudation, leukocyte outpouring and a scatter- 
 ing of red cells ; the alveolar walls show much interstitial inflamma- 
 tion. The usual statement that no fibrin is found is a mistake; 
 though influenza pneumonia is strictly cellular (catarrhal), aspira- 
 tion, pneumococcic and other forms not infrequently show a fibrin 
 network, though decidedly less than in lobar types. Near the foci 
 and in the upper lobes compensatory emphysema often develops. 
 The bronchial lymph glands are hypersemic, swollen and succulent. 
 Extension occurs directly from alveolus to alveolus or along the peri- 
 bronchial connective tissue. In some forms numerous lobular foci 
 increase in size and perhaps fuse so that the greater part of a lobe 
 may be consolidated ; this pseudolobar form is often due to the pneu- 
 mococcus, is seen in measles and diphtheria and may clinically 
 present a close resemblance to lobar pneumonia, though pathologically 
 areas of collapsed, dark, vascular or sound tissue lie between the 
 bronchopneumonic patches. 
 
 Symptoms. — The clinical picture varies considerably, accordingly 
 as the bronchopneumonia is primary or secondary. In the primary 
 form, most often pneumococcic, the onset is brusque, with chill, 
 convulsions, vomiting or pain in the side. The fever rises sud- 
 denly, remains high and often falls by crisis. Capillary bronchitis 
 is absent and the consolidation is often marked. The course is short 
 and the death rate is low. In adults this form is frequently unilat- 
 eral. The more common secondary form begins insidiously, espe- 
 cially if it follows a microbronchitis ; it is often obscured by the dis- 
 ease which it complicates. The fever gradually rises to 103° or 104°, 
 if fever were already present, and is generally irregular or remittent, 
 rising with the formation of each new focus ; it may be low or absent 
 in marantic subjects. There may be no physical findings, or if 
 present they are frequently indeterminate. If recovery ensues, lysis 
 is the usual solution. Yon Ziemssen held that fever in bronchitis 
 seldom exceeds 102° and that higher registrations indicate pneumonia. 
 
 Subjective axd Genebae Manifestations. — These are often 
 more obvious than the objective or pulmonary symptoms. The pulse 
 rises to 120 or even 180 and in convalescence is more tardy in reach- 
 ing normal than is the fever. The respiration is often 60* or 80, the 
 expiration is frequently catchy or grunting, and the respiration-pulse 
 ratio, normally 1 to 1, becomes 1 to 3 or 2 ; dyspnoea develops early and 
 with it restlessness and irritability. Cyanosis develops in the^ face 
 and then in other parts from impaired flow of the blood to the heart 
 which is due to continued coughing and stagnant secretion. The 
 cervical veins are prominent. Pain is not as common as in lobar 
 pneumonia. The cough becomes drier and more distressing • the 
 sputum is usually swallowed in patients under seven years of a^e but 
 
BRONCHOPNEUMONIA. 501 
 
 if obtained shows nothing characteristic, though von ISTiemeyer found 
 that it sank in water or floated under the surface. Meteorism is not 
 uncommon in severe or moribund cases. 
 
 Lung Findings. — On inspection, irregular excursion is sometimes 
 seen. The accessory muscles of the nose, neck, chest and abdomen 
 are in full play. The interspaces, ribs, sternum and epigastrium 
 in young plastic chests, retract greatly with each inspiration; this 
 must not be confused with the slight physiological retraction ob- 
 served in the beginning of inspiration. Palpation may show in- 
 creased fremitus in a focus near the surface and measuring 2x5 em. 
 Stagnant secretion in the air tubes may temporarily suspend fremitus. 
 Percussion is often negative for a few days or even throughout the 
 course, as it is obvious that deep, isolated foci cannot produce dulness. 
 In the thin, infantile thorax, percussion must be made lightly and 
 special importance should be attached to palpatory percussion. Dul- 
 ness obtains over a focus having an area of 2 x 5 cm. It is most 
 often found along the spine over the lower lobes, but sometimes also 
 over the scapular spines. Dulness is most marked in the pseudo- 
 lobar (confluent) forms. Atelectasis may cause dulness but not bron- 
 chial breathing. A hyperresonant note in front indicates emphy- 
 sema ; behind it shows relaxation. Auscultation reveals subcrepitant 
 or crepitant rales; they are often heard over an area not exceeding 
 the bell of the stethoscope. Bronchial breathing and bronchophony 
 are fairly frequent, and occur especially when the child cries. In 
 other cases the breathing may be rude or puerile. 
 
 Special Types. — Special types have been considered under 
 measles, pertussis, etc. Abt (following Holt, Carmichael, Ashby and 
 Wright) offers the following pathological classification, which " un- 
 doubtedly gives the clearest basis for an understanding of the phys- 
 ical findings: (a) In capillary bronchitis there is no sign of con- 
 solidation in any part of the lung. Sibilant rales, coarse and 
 fine crepitant rales are distributed over one or both lungs. The 
 sibilant rales are due to congestion and swelling of the mucous 
 membrane of the larger and smaller tubes. A feeble respiratory 
 murmur indicates areas of congestion. (&) In disseminated bron- 
 chopneumonia, which is characterized by small areas of consolida- 
 tion, percussion usually gives negative results, though sometimes there 
 is very slight dulness. The vocal fremitus is usually not altered. 
 As a rule the consolidated areas are situated deeply in the lung, or 
 are too small to cause any appreciable difference in the percussion 
 note. Auscultation reveals crepitant rales and bronchovesicular 
 breathing over the consolidated areas. Vocal and crying resonance 
 is exaggerated, (c) In acute generalized bronchopneumonia, the 
 percussion note is dull over a large area, even an entire lobe. Palpa- 
 tion shows an increase in vocal fremitus. Auscultation reveals bron- 
 chial breathing and fine moist rales over the dull areas, while the rest 
 of the lung shows evidence of bronchitis." 
 
 Issues. — Death may occur from carbonic acid narcosis, irritability 
 
502 DISEASES OF THE RESPIRATORY TRACT. 
 
 passing into apathy, the harassing cough becoming less marked and 
 causing stagnation of bronchial secretion in the large tubes (" suffoca- 
 tive catarrh"); delirium develops, the pupils narrow and Cheyne- 
 Stokes' breathing and heart failure result. Complete resolution 
 is the rule in cases which recover. Delayed resolution with remis- 
 sions and exacerbations may occur. Complications may develop; 
 (a) pleurisy is the most frequent; (b) gangrene; (c) abscess, espe- 
 cially in aspiration and. influenzal forms ; (d) pulmonary induration ; 
 (e) bronchiectasis; (/) tuberculosis, which is less often a sequel than 
 a previous condition awakened by the new infection; (g) pericarditis, 
 endocarditis, otitis, emphysema and fibrinous bronchitis are other 
 possible complications. 
 
 Diagnosis. — Reliance on physical signs alone leads to many errors 
 and a diagnosis is often determined by the development of sudden 
 high fever or mild fever suddenly rising during bronchitis, by 
 dyspnoea, irregular rapid respiration, cyanosis and pain in the chest- 
 In very young or marantic children and in the aged the onset and 
 symptoms may be very atypical. Lobar pneumonia (q. v. variations 
 in children) occurs mostly in sound children over three years of age, 
 runs a shorter cyclical typical course, ends by crisis, is unilateral and 
 involves the greater part of one or more lobes; while bronchopneu- 
 monia occurs more often in younger weakly children, is often a sequel 
 of bronchiolitis, runs a longer, more atypical, unfavorable and re- 
 lapsing course, resolves by lysis, is bilateral and is less marked by 
 definite pulmonary findings. Tuberculosis is often distinguished 
 only by the course; it invades the upper lobes more than does bron- 
 chopneumonia, and bacilli-laden sputum may be recovered by wash- 
 ing the stomach or by swabbing the throat when the child raises mu- 
 cus after coughing. Pleurisy (q. v.) is diagnosticated by means of 
 the aspirating needle. 
 
 Course and Prognosis. — The course may be (a) acute, lasting about 
 a week, of which the measles-pneumonia is the prototype; (b) sub- 
 acute, lasting from tAvo to eight weeks, exemplified by the pertussis- 
 pneumonia, or\c) chronic, covering months, as in tuberculous bron- 
 chopneumonia. 
 
 The prognosis depends on the patient's social situation, previous 
 history, age, the disease of which the pneumonia is a complication 
 and the extent of the pneumonia. The outlook in general is serious, 
 especially in secondary forms, among which measles and pertussis 
 represent the more serious types; in the very young it is almost as 
 fatal as infantile diarrhoea ; aspiration forms are very serious, as are 
 those in marantic and aged subjects. In private practice the death- 
 rate ranges from 10 to 33 per cent., in hospitals 33 to 50 per cent, 
 and in asylums even 50 to 100 per cent. Early cyanosis, dyspnoea 
 and rapid pulse are unfavorable signs. 
 
 Treatment.— 1. Prophylaxis— (a) In infections which produce 
 nasal or pharyngeal inflammation the nose and throat should be fre- 
 quently cleaned with mild alkaline antiseptics, (b) When there is 
 
BRONCHOPNEUMONIA. 503 
 
 laryngeal or bronchial inflammation, congestion and atelectasis should 
 be avoided by frequent and regular change of posture, (c) Deep 
 breathing should be encouraged in older subjects, or enforced in the 
 young by affusions of cold water on the neck and upper thorax, (d) 
 Exposure should be avoided, especially at night, by pinning the bed- 
 clothes or firmly fastening the nightgown to the foot of the bed. 
 
 2. Therapy. — Actual treatment is symptomatic, as the varied 
 etiology precludes specific therapy, (a) The patient should have 
 plenty of fresh air. The temperature of the room should be 
 maintained at 67° to 70° with constant moderated ventilation. 
 (b) The diet should be fluid, diluted or predigested; egg albu- 
 min, milk and plenty of water are indicated. At the onset or during 
 the course calomel gr. M.o every hour for Hve or six doses should 
 be given, followed by castor oil, particularly if there is indi- 
 gestion or tympany, (c) Expectorants, as ammonium carbonate, 
 tartar emetic or ipecac, should not be given generally, as they de- 
 range the digestion, and good digestion is of great importance to 
 strong as well as to weak subjects. Aromatic spirits of ammonia, 
 TTtv to xx, every three or four hours, is least deranging and is a 
 diffusive stimulant, (d) Pain rarely necessitates the use of opiates, 
 which induce stagnation of secretion; dyspnoea, pain, restlessness, 
 cough, cyanosis and rapid pulse may be relieved by paregoric, which 
 is preferable to Dover's powder or morphine; but great care is 
 imperative in the use of any opiate in young, old or weak subjects. 
 Fresh air is better than drugs, (e) Local applications, as poultices or 
 pneumonia jackets and blisters, are useless. (/) In the treatment of 
 fever, antipyretics, aconite, antimony and other cardiac depressants 
 should be wholly avoided; cool applications are equally efficacious; 
 they also lessen tympany and carbon dioxide narcosis, stimulate the 
 heart and brain centres and deepen the respiration. A cold pack 
 should be applied over the neck, chest and abdomen and should be 
 changed frequently. Cold must be used with care in very young and 
 in marantic subjects; in such cases a warm sponge or bath may be 
 given, during which cold water may be poured on the neck to stimu- 
 late deep breathing, (g) For cardiac stimulants, whisky and brandy 
 may be given in daily doses of 3ss to 3iij, very well diluted in water 
 or in peptonized milk. Aromatic spirits of ammonia, digitalis, saline 
 infusions or enemata, camphor or strychnine may be used. (See 
 page 91 for dosage in childhood.) Hypodermics of ether may cause 
 sloughing, (h) Eespiratory stimulants include tr. belladonna, oxygen, 
 thoracic faradization and mechanical compression of the chest. (*) 
 Emetics are unreliable; ipecac and similar remedies have no effect 
 when there is pronounced carbon dioxide intoxication, whence it 
 has been recommended to combine them with coffee, camphor or 
 cognac. For carbon-dioxide intoxication phlebotomy should seldom 
 be practised. (/) Inhalations of steam (v. Diphtheria and Croup) 
 may be beneficial ; compound tincture of benzoin and sodium bicar- 
 bonate are often added to the vaporizing water, (h) During con- 
 
504 DISEASES OF THE RESPIRATORY TRACT. 
 
 valescence fresh air or a sojourn in the country or in a warm climate 
 is advisable. 
 
 INDURATIVE PNEUMONIA, LUNG CIRRHOSIS, FIBROID PHTHISIS. 
 
 Definition. — An almost invariably secondary overgrowth of the pul- 
 monary connective tissue. 
 
 Etiology. — 1. Diseases of the Lung. — These may induce local, 
 lobular or lobar, unilateral or bilateral fibrous induration. Local 
 induration frequently occurs about tumors, parasites, tubercles, gum- 
 mata, abscess, gangrene, trauma or pneumokoniosis, and is of no 
 essential clinical importance, except as it demarks dangerous foci of 
 disease. Diffuse induration is important, (a) Fibrinous pneumonia 
 sometimes results in lobar induration; Frankel observed it seven 
 times in 1,000 cases ; it occurs notably in marantic or aged subjects 
 from delayed resolution and lack of regeneration of the alveolar epi- 
 thelium; the lung becomes airless and dense from development of 
 fibrous tissue within the alveoli whence it involves contiguous struc- 
 tures; on section its surface is smooth, and the connective tissue is 
 strikingly translucent. Subacute induration may reach considerable 
 development in one or two months, (b) Bronchopneumonia in the 
 course of measles, pertussis or influenza, sometimes leads to subacute 
 or chronic induration, beginning from an alveolitis or peribronchitis. 
 (c) Foreign bodies and aspiration pneumonia; (d) chronic tubercu- 
 losis; and (e) syphilis, gangrene, etc., are etiological factors. 
 
 2. Bronchial Affections. — (a) Bronchiectasis, which was noted 
 by Corrigan, who first used the term lung cirrhosis; (b) bronchial 
 stehosis, as by aneurysm or gumma; and (c) pneumoconiosis and 
 putrid and chronic bronchitis, may cause indurative pneumonia. 
 
 3. Pleural Affections. — It is still disputed whether pleurisy is 
 primary to lung induration or secondary; primary pleurisy may 
 sometimes invade and cirrhose the lungs — the " pleurogenous " inter- 
 stitial pneumonia of Charcot ; strands of connective tissue run into 
 the lung and approach and fuse toward the hilum. 
 
 Other causes are uncertain, e. g., diabetes, alcoholism and malaria. 
 
 Pathology. — The pathology of an affection with such numerous 
 causes can scarcely be described. The early induration is reddish, 
 and the older connective tissue is darker, slate colored or gray; to 
 them Charcot gave the names of induration rouge and induration 
 grise, respectively. The new connective tissue may be formed in the 
 bronchi, septi, alveoli, bloodvessels or pleurae. The alveoli nearly 
 always show a hyperplasia of connective tissue. The lung is airless 
 and dense; is cut with difficulty and on section presents either a 
 granulated or a smooth surface, the latter in cases following lobar 
 pneumonia and sometimes in those consecutive to gangrene or aspira- 
 tion pneumonia. The volume of the lung is decreased. Its shrink- 
 ing produces changes in the mediastinum, heart, diaphragm and 
 sound lung, which will be considered under Symptoms. 
 
INDURATIVE PNEUMONIA, LUNG CIRBH0S1S. 50,5 
 
 Symptoms. — Incipient or localized lesions are usually undetected 
 unless they are observed in the course of pneumonia or tuberculosis. 
 Symptoms may be inseparable from the causal affection (tuberculosis, 
 bronchiectasis) or may follow closely upon it (pneumonia, pleurisy). 
 There may be a low fever, cough, dyspnoea on exertion, pain in the 
 side, rapid pulse, cyanosis, ansemia, malnutrition and night sweats. 
 In cases where the original malady has ended, there may be only 
 slight cough or some shortness of breath on exertion. 
 
 Physical findings of the typical chronic case are as follows: (a) 
 On inspection the interspaces are narrowed on the affected side, 
 the nipple and scapula are nearer to the median line, the shoulder is 
 lower, the spine is convex toward the sound side and the measure- 
 ment is unilaterally decreased. In left-sided induration the lung re- 
 tracts from the heart, leaving its pulsation more widely exposed and 
 disclosing the pulmonary artery, over which may be seen and felt its 
 systolic filling and the strong diastolic closure of the pulmonary 
 valves; in right-sided induration the heart beat may appear to the 
 right of the sternum or may be covered up by the compensatory 
 emphysema of the left lung, (b) Palpation corroborates these find- 
 ings, and, as a rule, shows increased vocal fremitus. The second pul- 
 monic tone is much accentuated, corresponding to the hypertrophy of 
 the right ventricle and the occasional atheroma of the pulmonary 
 artery, (c) Percussion elicits dulness below and sometimes a slightly 
 hyperresonant note above the indurated area ; the apex of the upper 
 lobe is on a lower level and the diaphragm stands higher (the liver 
 rising or Traube's space increasing) ; there is no respiratory excur- 
 sion, (d) Auscultation brings out the absence of breath sounds below, 
 and bronchial breathing and subcrepitant, crepitant and bubbling rales 
 above. Additional signs result from the right heart hypertrophy and 
 dilatation and from coincident bronchiectasis or cavity formation on 
 the same side, and the well developed compensatory emphysema on 
 the opposite and otherwise healthy side. There is nearly always 
 some sputum. 
 
 Diagnosis. — Diagnosis is more easily made in the very chronic than 
 in the subacute forms; subacute post-influenzal or post-pneumonic 
 induration may easily suggest tuberculosis or interlobular suppura- 
 tion. Slow-growing tumors of the lung may cause confusion. 
 
 Prognosis. — The prognosis varies with the etiology. Ulcers may 
 form from arterial occlusion or from infected bronchial secretion, 
 whence the frequency of lung hemorrhage (in 50 per cent.) and its 
 occasional role as a cause of death. Amyloidosis sometimes results, 
 but death is usually caused by right heart failure, which may occur 
 during some acute intercurrent disease. 
 
 Treatment. — Therapy is unavailing, though life may be prolonged 
 for decades under proper hygiene. Exercises with the arms may 
 check the early shrinking, but nothing can remove an established in- 
 duration. Warm climates at the sea level or at slight elevation are 
 beneficial. Some writers hold that turpentine is of benefit in check- 
 ing induration. 
 
506 DISEASES OF THE RESPIRATORY TRACT. 
 
 PNEUMOKONIOSIS. 
 
 Zenker employed the term to include various indurative diseases 
 of the lungs due to " dust " inhalation. 
 
 Etiology and Pathology. — 1. Anthracosis is due to inhalation of 
 carbon, coal dust, soot, charcoal or graphite, and is known as " coal 
 miner's disease " or phthisis melanotica. (a) Moderate amounts of 
 carbon inhaled into the trachea and bronchi are absorbed by the 
 leukocytes, worked upward by the ciliated epithelial cells and ex- 
 pectorated, (b) Larger amounts penetrate the bronchial mucosa and 
 lodge in the connective tissue, or enter the lymph stream whence they 
 reach the small lymph nodes around the bloodvessels, bronchi, pleurae 
 or mediastinal lymph glands. A moderate lung pigmentation occurs 
 in all city inhabitants, while the lungs of countrymen are pink and 
 devoid of soot deposit. It is possible that the lymph nodes may later 
 throw out some of the pigment into the bronchial lumen, (c) Very 
 large amounts may reach the alveoli. In these cases the lungs are 
 ink-black. When they are, as it were, saturated, connective tissue 
 proliferation develops in insular foci (endoperialveolitis nodosa and 
 endoperilymphangitis fibrosa) ; this is sometimes called fibrous bron- 
 chopneumonic induration because of its localization; it occasionally 
 measures 5x15 cm. ; on section the foci are hard and exude an inky 
 fluid. Diffuse induration is common. The mediastinal lymph glands 
 are indurated, and the process often extends outside the glands (peri- 
 lymphadenitis) ; by this latter process the glands may become ad- 
 herent to and rupture into the pulmonary veins, whence pigment- 
 metastases into the liver, spleen, kidneys and mesenteric glands are 
 not infrequent. Bronchial perilymphadenitis may also lead to medi- 
 astinoperiearditis, stenosis of the trachea, bronchi, oesophagus, cava, 
 vena azygos and pulmonary artery, to oesophageal diverticulum, to 
 fatal hemorrhage into the pericardium or into the bronchi when the 
 aorta is also eroded, to aspiration pneumonia by intrabronchial rup- 
 ture or to recurrent laryngeal paralysis by pressure. 
 
 2. Siderosis pulmonum (Zenker) is a very similar change, due to 
 inhalation of metallic dusts, as iron, brass or bronze; there are the 
 same interstitial deposit, lung induration, bronchial gland cirrhosis 
 and metastases. ^ The irritation is greater, nodes are more frequent 
 and induration is more intense than in anthracosis. The iron de- 
 posits are yellow or red from the oxide, or black from the phosphate. 
 The lungs contain 1% per cent, of iron. 
 
 3. Clialicosis pidmonum (Peacock) is due to inhalation of alu- 
 mina, quartz or sandstone, known as "stone-cutter's or millstone- 
 maker's phthisis," " grinder's rot " or " potter's asthma." Calcium is 
 less irritating than silica or quartz. Of all forms, the most nodules 
 and induration occur in chalicosis. 
 
 4. Similar changes are observed from inhalation of wool flax 
 cotton, gram, tobacco, glass, porcelain, pepper, cinnamon, bone and 
 horn. Claisse and Jossue place special stress on bacterial cooperation 
 
ATELECTASIS. 507 
 
 Symptoms. — These may appear only after many years, when the 
 symptoms of chronic bronchitis, asthma, emphysema and finally of 
 lung cirrhosis appear. The sputum contains coal dust, soot, charcoal 
 particles, as in Traube's celebrated case, and yellow oxide or dark 
 phosphate of iron, quartz and silica. Cavities may form from bron- 
 chiectasis, softening of the nodose indurations or tuberculous compli- 
 cations; in some cases lung stones, set free by ulceration, may be 
 raised. The mediastinum may be exposed by retraction of the lungs. 
 Tuberculosis is common, occurring, according to Philip, in 13 per 
 cent, of anthracosis and in 44 per cent, of chalicosis. Scissor-grinders 
 rarely live beyond forty years of age and blasters in mines usually 
 succumb in four years. 
 
 Treatment. — Treatment is largely prophylactic and that of the con- 
 comitant bronchitis and emphysema. 
 
 ATELECTASIS. 
 
 Atelectasis is a congenital or acquired " absence of air." It is also 
 called apneumatosis. 
 
 I. Congenital Atelectasis.- — The congenital atelectasis, first de- 
 scribed by Jorg (1834), who differentiated it from pneumonia, is 
 the persistence of the normal foetal condition of the lungs ; it develops 
 in various forms of dystocia, and in weakly or premature infants. 
 
 Etiology and Pathology. — This variety is due to deficient inspira- 
 tory efforts from weak muscles, insufficient stimulation of the medulla 
 centres and aspiration of mucus or meconium. The base, lower 
 anterior margin and lingual lobe are most involved and the distribu- 
 tion is lobular. The color of the lung is steel-blue, and if the subject 
 lives, the atelectatic portions do not become pigmented, for no air 
 enters them. The airless areas are superficial, sunken, lax, do not 
 crepitate and sink when put in water ; in the early stage the part can 
 be distended by inflation of the bronchus supplying it and on section 
 exudes a serous or slightly blood-stained fluid. Cylindrical and cystic 
 bronchiectasis may result ; the ductus Botalli and foramen ovale are 
 usually patent, the right heart is commonly dilated and thrombosis is 
 frequent in the brain sinuses, kidney and right heart. 
 
 Symptoms. — The new-born with atelectasis breathe superficially and 
 cry but little. Inspiration is marked by retraction of the epigastrium, 
 subclavicular and intercostal spaces, for the lungs cannot follow the 
 inspiratory distention of the thorax. If the undistended area meas- 
 ures 2 by 5 cm. it may be dull and increased fremitus with bronchial 
 breathing may be detected, but more often the breathing is weak or 
 entirely absent. Carbon dioxide narcosis develops, the pulse becomes 
 small, the sensorium becomes dulled and, without active intervention, 
 asphyxia causes death. If the patient lives, the chest is peculiarly 
 deformed, its lower parts being sunken, so as to show the ribs. Kost- 
 lin describes a total collapse of one lung in a man aged twenty-two. 
 
 Treatment. — Removal of meconium and mucus by swabbing or 
 
508 DISEASES OF THE EESPIBATOEY TRACT. 
 
 aspiration through a catheter, Sylvester's artificial respiration. 
 Schultz's swinging, faradization and warm baths with cold affusions 
 to the neck and upper chest are indicated. 
 
 II. Acquired Atelectasis. — Acquired atelectasis in children was 
 first described by Legendre and Bailly (1844), and that in adults by 
 Traube. 
 
 Etiology. — It may be due to marasmus, obstruction or compression ; 
 the lungs, already distended and ventilated, collapse and the air con- 
 tained is absorbed, (a) The marantic form occurs in individuals 
 reduced by typhoid, infantile diarrhoea or cachectic conditions, and 
 by lying for a long while in the dorsal decubitus, (b) Obstructive 
 collapse develops most frequently in bronchopneumonia, as the bron- 
 chioles in the young are disproportionately narrow; it may develop 
 in any laryngeal, tracheal or bronchial stenosis. These forms affect 
 the posterior parts particularly, (c) Compressive apneumatosis fol- 
 lows compression by aneurysm, dilated heart and exudative peri- 
 carditis, by pulmonary tumors, pleural exudates or pneumothorax, 
 by mediastinal tumors or adenopathies and by abdominal tumors, 
 ascites or meteorism. The part of the lung involved depends on the 
 direction of the compression. In kyphoscoliosis permanent compres- 
 sion of the lung frequently leads to atelectasis, and if it occurs early 
 in life, to hypoplasia. 
 
 Pathology. — Pathologically the same general findings obtain as in 
 the congenital type. The lung is darker, red-brown or bluish. In the 
 congenital and acquired types, hyperemia may cause a flesh-like ap- 
 pearance (carnification), or serous transudation may cause a spleen- 
 like aspect (splenization). There may be coincident inflammation 
 or, in the healthy parts, vicarious emphysema. Long-standing atelec- 
 tasis results in bronchiectasis, fatty degeneration of the alveolar epi- 
 thelium and hyperplasia of the inter alveolar and interinfundibular 
 connective tissue, known as collapse induration. 
 
 Symptoms. — Symptoms are easily obscured by pleural effusion and 
 by the causal bronchopneumonia, with whose foci it may be confused. 
 Inspiratory retraction, lessened vesicular breathing, a slightly tym- 
 panitic note from relaxation of the collapsed lung and crepitant rales 
 are common. The vocal fremitus is seldom increased and bronchial 
 breathing is uncommon, unless the foci are both large and superficial. 
 Dilatation of the right heart is common. In recent cases the physical 
 signs disappear after a jew hours of change of posture, or after deep 
 breathing either voluntary or induced by cold affusions; this, with 
 absence of fever, pain and cough, effectually differentiates from 
 infarct, pneumonia or effusive pleurisy. After sleep for some hours 
 on the back, a few crepitant rales may be heard physiologically over 
 the lower posterior parts for three or four inspirations. 
 
 Prognosis and Treatment. — The prognosis and treatment vary ac- 
 cording to the cause. Sudden death is not uncommon in persons" hav- 
 ing deformed spines. In all fevers, as typhoid, and in all respiratory 
 inflammations, the posture must be changed frequently ; orders to this 
 
ABSCESS OF THE LUNG. 509 
 
 effect should be written, and the change should be recorded on the 
 history sheet. Cold affusions to the neck, Brand's hydrotherapy and 
 cardiac stimulants are indicated. 
 
 ABSCESS OF THE LUNG. 
 
 Suppuration is not a common lesion, but may occur in a sound or 
 diseased lung. 
 
 Etiology.— (a) Lobar pneumonia causes 62 per cent, of the cases 
 (Tuffier) ; localization in an upper lobe, alcoholism, marasmus, pneu- 
 monia complicating emphysema and lung induration, and hemor- 
 rhagic types are the predisposing factors. (&) Lobular pneumonia 
 may suppurate, especially in the influenzal type, (c) Aspiration 
 pneumonia is causal in 18 per cent. (Tuffier), particularly in insane 
 or delirious persons ; foreign bodies, food, saliva or pus from lesions 
 in the upper respiratory tract, severe vomiting, oesophageal cancer or 
 diverticulum rupturing into a bronchus, are its usual causes, (d) 
 Embolic suppuration produces 17 per cent, of the cases, (e) Trauma 
 is an etiological factor. (/) Abscess may complicate other pulmonary 
 or bronchial affections, as tuberculosis, bronchiectasis, echinococcus, 
 etc. (g) Rupture into the lung of contiguous foci of suppuration, 
 such as empyema, suppurating peribronchial glands, subphrenic 
 abscess, spinal caries and gastric ulcer, is the cause of 3 per cent, of 
 lung abscesses. Most of the cases occur in middle-aged males. 
 
 Bacteriology. — The staphylococcus is most frequently the causative 
 microorganism ; the streptococcus, pneumococcus, pneumobacillus, in- 
 fluenza bacillus, colon bacillus and leptothrix are also found. 
 
 Pathology. — The cavity varies from the size of a hazelnut to an 
 orange ; in rare instances it may occupy an entire lobe or lung. The 
 abscess is usually single, except in the embolic form. Its shape is 
 irregular and it is sometimes multilocular. Its inner surface is 
 irregular with floccular mural shreds, and is walled with pus-secreting 
 granulations, which in some cases fill and obliterate the cavity. Fi- 
 brous tissue develops about the cavity, and in chronic abscess becomes 
 dense and scar-like. The cavity is usually near the lung's surface, 
 whence the frequency of complicating pleurisy; 80 per cent, of lung 
 abscesses are in a lower lobe (Tuffier). 
 
 Symptoms. — The development of symptoms varies according to the 
 causal factor ; in lobar pneumonia the crisis or lysis is delayed and 
 resolution is incomplete ; in influenza the respiratory symptoms and 
 fever persist ; in sepsis, multiple lung involvement perpetuates the 
 septic process, (a) The sputum is purulent, creamy, is often of- 
 fensive or rancid without putridity, is alkaline and may measure a 
 pint to a quart daily. It separates, on standing, into two layers, a 
 granular sediment and a serous upper layer, sometimes with frothy 
 surface if the coughing is intense. In metapneumonic cases the 
 sputum is sometimes grass-green. The sediment almost invariably 
 reveals shreds of lung tissue (Traube and Leyden) and yellowish- 
 
510 DISEASES OF THE RESPIRATORY TRACT. 
 
 green or gray flocculi; these are absolutely essential to diagnosis 
 and consist of elastic fibres to which alveolar epithelium adheres. 
 Hcematoidin crystals or platelets, short sheaths of fatty crystals,, bac- 
 teria (v. s.) and in chronic cases cholesterin and scar-like connective 
 tissue are also found. The sputum is voided periodically, as from 
 cavities of other causation ; " mouthful expectoration " is the rule. 
 
 (b) The decubitus varies with the location of the cavity; for instance, 
 the patient assumes the erect posture if the cavity is in a lower lobe, 
 to prevent leaking of the secretion into the contiguous air passages. 
 
 (c) Signs of cavity are found if the exulceration is large and super- 
 ficial ; 80 per cent, of them occur in the lower lobes. They are essen- 
 tially those of tuberculous or bronchiectatic cavities (q. v.) and vary 
 with the stagnation or evacuation of the pus ; thus a tympanitic note, 
 bronchial or amphoric breathing and increased vocal fremitus are 
 found when the vomica is empty, and dulness, weakened breath 
 sounds and decreased fremitus are present when it is full. The sp- 
 rays also serve to localize, but when their findings and the physical 
 signs differ the latter are more trustworthy, (d) Hectic fever, sweats, 
 rigors and leukocytosis occur from resorption. 
 
 Diagnosis. — The etiology and cavity formation are often, and the 
 sputum is always, characteristic, (a) Abscess breaking into the lung 
 from the spine or from the subphrenic or pleural spaces, is sudden, 
 sometimes suffocative in onset, and the hsematoidin crystals and 
 shreds of pulmonary tissue are absent. (b) Gangrene (v. i.). (c) 
 Tuberculosis usually occurs in an upper lobe ; abscess in a lower one ; 
 elastic fibres and hsematoidin crystals are more abundant in abscess, 
 and tubercle bacilli are found in tuberculosis, (d) In bronchiectasis 
 elastic fibres are seldom voided. = 
 
 Prognosis. — Spontaneous recovery may follow granulation and cica- 
 trization, especially in lobar pneumonia, where recovery is the rule. 
 In influenzal or aspiration pneumonia or in sepsis the outlook is far 
 less favorable ; marasmus, hectic fever, amyloidosis, lung induration, 
 empyema, pneumothorax and pericarditis are frequent issues. 
 
 Treatment— (a) The general strength should be maintained by a 
 full diet, tonics and alcohol. (&) Decomposition, if present, should be 
 modified as in bronchiectasis or gangrene, by administration of creo- 
 sote or turpentine internally, (c) Surgical intervention is indicated, 
 according to Frankel, (i) when the abscess is large, shows no ten- 
 dency toward spontaneous cure and the contents decompose; (ii) 
 when rupture into the pleura occurs; and (iii) when the abscess re- 
 sults from the breaking into the lung of a contiguous focus of sup- 
 puration. Of Korte's 78 operative cases, 80 per cent, recovered; in 
 Garre's 96 cases, 80 per cent. ; in Turner's series, 77 per cent. ;' in 
 Freyhan's acute cases, 90, and in his chronic cases 14 per cent. 
 
 GANGRENE OF THE LUNG. 
 Definition.— A necrosis and mortification of lung tissue. Gangrene 
 though more common than abscess, is an infrequent affection; Eich- 
 
GANGRENE OF THE LUNG. 511 
 
 horst found gangrene in 0.1 per cent, of his clinical cases and Hensel 
 in 1.6 per cent, of his autopsies. 
 
 Etiology. — Reduced physiological resistance, e. g., from diabetes, is 
 apparently a necessary etiological factor. Lobar pneumonia may 
 terminate in gangrene when, as in abscess, the patient is weakly, dia- 
 betic, addicted to alcohol or suffering from putrid bronchitis ; its fre- 
 quency is but 0.4 per cent. (Frankel) or in less than 1 case in 1,500 
 pneumonias (Aufrecht) ; pneumonia causes 23 per cent, of lung gan- 
 grene (Coupland and Hensel). Lobular pneumonia is less frequently 
 causal, though grippal pneumonias may terminate in gangrene (7 per 
 cent, in Frankel's series). In Coupland and Hensel's combined 
 cases, 14 per cent, were due to pulmonary tuberculosis and 10 per 
 cent, to tumor of the lung. Gangrene may complicate lung abscess 
 or echinococcus. Aspiration pneumonia resulting in gangrene occurs 
 particularly in insane, delirious, paralyzed or emaciated subjects; 
 foreign bodies, necrotic diseases of the throat, bronchi or larynx, 
 bronchiectasis, putrid bronchitis and bronchial stenosis promote 
 gangrene. Embolic gangrene, a cause of 19 per cent, of lung gan- 
 grene, may result from suppurative gangrenous lesions in peripheral 
 parts, as in the appendix, uterus or extremities. Rupture into the 
 lung, as of oesophageal cancer or diverticulum, putrid pleurisy, sub- 
 phrenic abscess or gastric ulcer may cause gangrene. Gangrene usu- 
 ally occurs within the second to fourth decades of life and in males. 
 
 Bacteriology. — Some maintain that certain germs produce the ne- 
 crosis and other germs the gangrene, but probably one microorganism 
 may produce both changes. The staphylococcus is found, also the 
 streptococcus, colon bacillus and pseudotubercle bacillus which retains 
 its stain when treated with acids like the bacilli found in putrid 
 bronchitis and bronchiectasis ; the Bacillus pyocyaneus and the Micro- 
 coccus tetragenus are also found; Hirschler and Terray have culti- 
 vated a micrococcus which liquefies gelatin and produces skatol and 
 indol, and therefore causes a putrid odor in the cultures. Babes de- 
 scribed bacilli resembling those of malignant oedema. 
 
 Pathology. — Genuine gangrene must not be confused with softening 
 of the lung, which i§ due to regurgitation of the gastric juice into 
 the king during the death agony or after death. In rare cases there is 
 non-putrid pneumomalacia, analogous to myomalacia cordis. Lung 
 gangrene, according to Hensel, occurs in the right lung in 45 per 
 cent., in the left in 37 per cent, and in both lungs in 18 per cent, of 
 the cases. Laennec, who first described pulmonary gangrene, dis- 
 tinguished two types, the circumscribed and the diffuse, (a) Cir- 
 cumscribed gangrene occurs chiefly in the lower lobes near the sur- 
 face, and oftener on the right than on the left side. The focus may 
 attain the size of an orange. Laennec distinguished three stages: 
 (i) The formation of a yellow, green or brown slough, which may be 
 expectorated entire; (ii) liquefaction, or moist gangrene; and (iii) 
 formation of a cavity which is irregular in shape, has ragged walls 
 and contains a stinking liquid resembling the sputum of gangrene 
 
512 DISEASES OF TEE RESPIRATORY TRACT. 
 
 (v. i.). The cavity is limited by granulations and later by connective 
 tissue, or gradually extends, corroding more and more lung tissue. 
 Extension may also result from aspiration of the septic matter from 
 the bronchi into other lung areas. Kecovery may follow localization, 
 organization of granulations and contraction of connective tissue. 
 Microscopically there is (i) an inner zone of offensive fluid or ne- 
 crotic tissue, bacteria and emigrated leukocytes; (ii) outside of this 
 is a zone of granulations, beyond which is (iii) congested or oedema- 
 tous lung, (b) The rarer diffuse gangrene has no demarkation, and a 
 large area, an entire lobe, or even the whole lung may be macerated, 
 stinking and discolored. The diffuse form occurs more often in the 
 upper lobes, and in the right more frequently than in the left side. 
 In both forms the sputum irritates and injects the bronchial mucosa, 
 the bronchial glands are tumefied and degeneration or metastasis may 
 occur in various viscera. 
 
 Symptoms. — 1. Sputum. — The sputum is characteristic and almost 
 absolutely essential to a diagnosis, and it is absent only when the 
 putrid focus has no bronchial connection. Its odor is extremely of- 
 fensive, faecal, stinking, garlicky or sometimes sweetish. This odor 
 is less marked in diabetics ; it is most offensive at the moment of 
 evacuation, and on standing may gradually lessen. The sputum, 
 which is voided periodically and sometimes in mouthfuls, is usually 
 abundant (a pint to a quart), is alkaline, and on standing separates 
 into three layers, an upper layer of foam, a middle of green or gray 
 serum, and a lower one of green or brownish granular sediment. In 
 the sediment various important structures are found ; there are flocculi 
 of lung tissue, which are seen best against a dark background, and 
 which vary in size from small particles to pieces as large as the thumb 
 and show alveolar arrangement ; elastic fibers are not nearly as com- 
 mon as they are in abscess of the lung, unless the process is very acute, 
 for a trypsin-like ferment rapidly digests the fibers ; Dittrich's plugs 
 are usually found, consisting of detritus and bacteria, and emitting 
 a most foetid odor (described under Putrid Bronchitis and Bron- 
 chiectasis) ; long fatty needles (Virchow), lung pigment, pus cells, 
 red corpuscles, hgematoidin crystals, bacteria, infusoria, triple phos- 
 phates, leucin, tyrosin, formic and other allied acids, phenol, indol, 
 skatol, ammonia and sulphuretted hydrogen are also found. 
 
 2. Chest Findings. — Besides the findings of bronchitis caused by 
 the offensive sputum, signs of infiltration or cavity formation are ob- 
 tained if the focus is superficial and measures two and a half inches. 
 In the common circumscribed form the signs of cavity are identical 
 with those in tuberculosis, bronchiectasis or abscess, i. e., a tympanitic 
 note, increased vocal fremitus, bronchial or amphoric breathing and 
 metallic rales are obtained when the cavity is empty, or dulness. de- 
 creased fremitus and weak breathing when it is full. In the rare 
 diffuse form there are signs of infiltration as in pneumonia, which 
 signs are also found in the initial stage of the circumscribed gan- 
 grene. The z-rays are valuable in localization of the gangrene. The 
 
GANGRENE OF THE LUNG. 513 
 
 patient lies so that the cavity is dependent, to avoid constant trickling 
 of the secretion into the bronchi, i. e., on his back when it is posterior 
 or on his face when it is anterior or in an upper lobe. 
 
 3. General Symptoms. — General symptoms result from the 
 causal disease or from sepsis. Remittent fever, chills, sweats, pros- 
 tration, emaciation, pallor, rapid bounding pulse, vomiting, diarrhoea, 
 leukocytosis, albuminuria and in severe cases a profound typhoid state 
 mark the degree of intoxication. 
 
 4. Complications. — Complications may dominate the clinical 
 picture, (a) Pleurisy (in 12 per cent.), usually purulent or putrid, 
 may be one of the chief symptoms, and operation may evacuate most 
 offensive fluid with large fragments of necrotic lung. (b) Haemop- 
 tysis is seldom fatal though frequently profuse, and the blood raised 
 may be dark brown, (c) Pyopneumothorax, or (d) rupture into the 
 thoracic wall, oesophagus, aorta, mediastinum, pericardium or peri- 
 toneum may occur, (e) There may be metastatic deposits in the 
 brain, liver, joints or muscles. (/) Clubbed fingers occasionally 
 result from septic absorption, (g) Amyloid degeneration sometimes 
 results from chronic gangrene. 
 
 Course and Prognosis. — The course may be acute, subacute or 
 chronic ; in general it is more rapid and usually fatal within a week 
 in diffuse and more chronic in circumscribed forms. The prognosis 
 depends on the etiology, physical strength of the patient, degree of 
 absorption, localization and surgical accessibility (v. Therapy). 
 
 Diagnosis. — Exploratory puncture is dangerous, for it favors dif- 
 fusion, (a) In fcetor ex ore the breath is foetid but the sputum, if 
 any, shows no characteristic findings of gangrene, (b) In putrid 
 bronchitis the sputum shows Dittrich's plugs and foetor, but no fatty 
 crystals, elastic fibers or pulmonary tissue, (c) In abscess elastic 
 fibers and pus are more abundant, the fatty crystals are oftener in 
 sheaths than in long needles and hsematoidin crystals are more com- 
 mon; bronchial plugs and foetor are absent, (d) In bronchiectasis 
 elastic fibers are very rare and lung tissue has never been found, (e) 
 In tuberculosis coincidence of the two affections and the pseudotu- 
 bercle bacillus may alone cause confusion (v. Tuberculosis) 
 
 Treatment. — 1. Surgical. — Expectant treatment results in a mor- 
 tality of 53 per cent. (Eichhorst) to 80 per cent. (Lenhartz). In 15 
 personal cases, 66 per cent, recovered under medical treatment. With 
 operative treatment Tuffier gives the death-rate as 40 per cent., and 
 Freyhans 30 per cent. ; Garre in 122 cases records 34 per cent, of 
 fatalities. The surgical indications are (a) the vital indication when 
 acute gangrene assumes the foudroyant type, or (b) when, in chronic 
 forms, there is no tendency toward spontaneous healing. Bull reports 
 recovery even in multiple gangrene. Accurate localization by physical 
 findings or by the tf-rays was possible in 65 per cent, of Turner's 74 
 cases. 
 
 2. Expectant Treatment. — This is indicated in deep-seated gan- 
 grene, in hopeless metastases as in the brain or in apparent demarka- 
 
514 DISEASES OF THE RESPIRATORY TRACT. 
 
 tion. The patient should be kept on his back to avoid leakage into 
 sound bronchi. The diet should support the strength and include 
 full alcoholic stimulation. Carbolic acid, balsam of Peru or creosote 
 may be given internally. Turpentine is most efficacious when there 
 is a complicating hemorrhage (Skoda). 
 
 TUMORS OF THE LUNG. 
 
 I. Carcinoma. — Cancer of the lung may be primary or more often 
 secondary to that of the mamma or the digestive or genital organs. It 
 occurs in 0.17 per cent, of autopsies or in 1.8 per cent, of cancer 
 autopsies (Passler). Most primary cases develop between forty and 
 sixty years of age. In primary forms Passler found 73 per cent, in 
 males ; the secondary forms are more frequent in women. 
 
 Etiology. — Trauma is an uncertain factor. Cancer usually develops 
 in the bronchi, in which previous ulceration, syphilis or adherent rup- 
 turing lymph glands are predisposing factors. Carcinoma probably 
 may develop from the bronchial mucous glands or even from the 
 alveolar epithelium. Histologically the cylindrical type is by far the 
 most frequent, though medullary ; scirrhous and other forms may be 
 encountered. Cancer usually begins at the hilum, and may extend 
 toward the pleura, either by contiguity along the bronchi or by the 
 lymph spaces. The upper lobes are more often involved than the 
 lower and the right twice as frequently as the left. The disease is 
 generally unilateral. In 85 per cent, of cases metastases occur in the 
 liver, bones, brain, mediastinum, testes and kidney. Secondary cancer 
 is generally bilateral ; the lungs are strewn with miliary nodules re- 
 sembling miliary tubercles, or present many larger nodules. Calcifi- 
 cation and ossification may occur in tumors of the lung. 
 
 Symptoms. — With a primary accessible tumor in another part of 
 the body, cyanosis, dyspnoea, blood-stained sputum and signs of lung 
 infiltration or of cavity, facilitate a diagnosis of lung metastasis. 
 When there is a hidden primary focus or a primary lung tumor, 
 diagnosis is for a long time difficult or impossible. 
 
 1. Early General Symptoms. — These are usually ambiguous; 
 they are suggestive of tuberculosis, pleurisy or bronchitis, all of 
 which may indeed complicate neoplasm. Thoracic oppression, asth- 
 matic attacks, stridor and dyspnoea result from pressure on the 
 trachea^ and vagus or wide substitution of tumor for lung tissue. 
 Cyanosis, dyspnoea, rapid breathing, emaciation and sweats may sug- 
 gest miliary tuberculosis ; this resemblance may also be noted at 
 autopsy in miliary carcinosis ; fever develops in over half the cases. 
 Cough is common. 
 
 2. Sputum. — The sputum in over half the cases is rather charac- 
 teristic. Altered blood gives it a reddish-brown color or it resembles 
 raspberry jelly in hue and in consistency; it is sometimes grass- 
 green or prune-juice in color. Occasionally macro- and microscopic 
 bits of cancer tissue, in characteristic nest-like arrangement, are seen. 
 
TUMORS OF THE LUNG. 515 
 
 3. Physical Signs. — (a) Inspection: The patient usually lies on 
 the affected side to give freer play to the sound lung. Marked ectasia 
 may result; sometimes the diseased side is shrunken from compli- 
 cating lung cirrhosis, atelectasis or bronchial stenosis. (&) Palpation 
 elicits increased fremitus if the tumor grows into the bronchial lumen 
 or compresses it from without, (c) Percussion gives an irregular dul- 
 ness, increasing to absolute flatness, in outlining which the finger 
 perceives greatly increased resistance; it most often occurs over an 
 upper lobe or under the sternum, (d) Auscultation varies with the 
 patency of the bronchus, giving bronchial breathing when it is open 
 and weak or absent breathing when occluded. 
 
 4. Compression Symptoms. — Besides the early dyspnoea and 
 cough, (a) the heart is often luxated or its yielding auricles 
 are "crowded, (b) The venous trunks suffer compression with fre- 
 quent cyanosis and oedema of the face, neck and arms and with dila- 
 tation of other veins of the thorax, due to formation of a collateral 
 circulation, (c) There is compression of the vagus, with rapid or 
 slow heart, and recurrent laryngeal compression with phonic changes. 
 (d) Dysphagia, (e) intercostal neuralgia, brachial neuralgia or par- 
 alysis, and (/) bronchial stenosis are other symptoms of compression. 
 
 5. Metastasis. — This occurs in 85 per cent, of cases ; there may 
 also be extension, by contiguity, to the axillary or cervical glands. 
 
 6. Complications. — These include haemoptysis from necrosis and 
 cavity formation; gangrene and bronchiectasis; and pleurisy, which 
 is usually serous ; hemorrhagic effusions occurred in 12 per cent, of 
 Moutard-Martin's 200 cases; the fluid may resemble venous blood; 
 adipose or chyliform effusions are rare ; hydropic, fatty and granular 
 cells may be obtained by puncture, and Hellendall advises aspiration 
 for flocculi of tumor tissue, with the syringe and needle partly filled 
 with salt solution, before aspiration. Carcinomatous nodes may de- 
 velop at the site of puncture, though hard nodules at the site of tap- 
 ping not infrequently occur after puncture of simple pleuritis. 
 
 II. Sarcoma and Lymphosarcoma. — Sarcoma and lymphosarcoma 
 may be primary or secondary, and are more frequent than cancer. 
 They probably begin chiefly in the lymph nodes of the bronchi, and 
 oftener on the left than on the right side. Extension in all directions 
 occurs along the peribronchial tissues from the hilum. A primary 
 very malignant lymphosarcoma develops in the lungs of miners in 
 the cobalt mines of Saxony ; it causes 75 per cent, of the deaths among 
 them; secondary sarcomata in the liver are common. Ulceration is 
 less common than in cancer, but the symptoms are, in the main, 
 identical. Sarcomatous tissue is occasionally voided in the sputum 
 or aspirated by the exploring needle. The diagnosis of malignant 
 lung tumors must be made chiefly from aneurysm (q. v.) and pleurisy 
 (q. v.). The x-rajs may be of some value. There are three main 
 clinical groups, (a) in which a neoplasm, perhaps its exact type, can 
 be diagnosticated; (b) in which some growth is present but differen- 
 tiation from aneurysm is uncertain; and (c) in which the disease 
 entirely escapes detection or is only suspected. 
 
516 DISEASES OF THE BESPIEATOBY TRACT. 
 
 Prognosis. — Death generally occurs in less than a year with cachexia 
 or suffocation, but it may result in a few weeks after the first symp- 
 toms appear. 
 
 III. Other Tumors of the Lung. — Fibroma, lipoma, osteoma, hy- 
 pernephroma and enchondroma are of solely anatomical interest. 
 
 Treatment. — The treatment of tumors of the lung is only palliative. 
 Morphine must be used when the dyspnoea and cough are extreme. 
 The x-mjs offer little encouragement. Arsenic seems to help when 
 given in full doses. 
 
 CIRCULATORY AFFECTIONS OF THE LUNG. 
 
 I. Acute Congestion. — As a secondary lesion acute hyperemia oc- 
 curs commonly with acute tuberculosis, pneumonia, influenza, effu- 
 sive pleurisy, with inhalation of hot vapors or with cardiac strain; 
 when extensive lesions occur in the lungs the obstructed blood may 
 seek other parts of the lungs and possibly produce collateral con- 
 gestion, though this is justly disputed. French writers describe an 
 acute primary congestion to which they give the name of Woillez 
 (Maladie de Woillez), though previously described by Dechambre, 
 Legendre, Bailly and Fournet. Its status as an independent lesion is 
 doubtful; some cases are apparently larval or abortive pneumonia 
 which occurs in any large epidemic. According to Carriere it is due 
 to attenuated pneumococci, which he has demonstrated by puncture 
 of the lung. Cold, exposure, alcoholism and violent exertion are 
 alleged causes. It develops like pneumonia, with chill, fever of 101° 
 to 103°, pain in the side, dyspnoea, cough and a sputum which is 
 at first scanty and later is more abundant and viscid but not blood- 
 stained. Physical examination is said to elicit somewhat impaired 
 resonance, weak or occasionally bronchial breathing, rales which are 
 coarser than in pneumonia and at times a pleural rub. All these 
 symptoms and signs strongly suggest atypical fibrinous pneumonia. 
 Venesection and vasodilator remedies, as aconite or veratrum, are 
 said to be of benefit. 
 
 II. Passive Congestion ; Hypostasis. — In broken compensation, par- 
 ticularly in mitral stenosis, the lungs are distended, heavy, indurated, 
 pigmented and on section are brownish-red ; this is brown induration 
 (induratio pulmonum fusca). Histologically the capillaries are tur- 
 gid, the connective tissue is increased, the lungs are tinged with 
 altered blood pigment and the sputum contains the so-called heart 
 disease cells (see Symptoms of Valvular Disease). The breath- 
 ing is sometimes puerile and the lungs voluminous. 
 
 Hypostasis is a species of passive congestion which results from 
 weak heart, in typhoid and other fevers, in old age, cachexias, mar- 
 asmus, in opium and other narcoses or in apoplectic and other 
 comas. Even under these conditions it rarely occurs if the patient's 
 position is changed every few hours. The lung is dark red, engorged 
 with blood and serum, and may also show aspiration pneumonia and 
 atelectasis ; the latter conditions are often incorrectly called hyposta- 
 
EMBOLISM OF THE LUNG. 517 
 
 tic pneumonia. On physical examination, there is moderate dulness 
 over the lower lobes posteriorly ; in apoplexy this may occur only on 
 the paralyzed side ; the breathing is more often weak than bronchial, 
 and moist or sometimes crepitant rales are heard. Fever is no part 
 of hypostasis. 
 
 Treatment. — Treatment of passive congestion is that of the funda- 
 mental lesion; phlebotomy, cardiac stimulation and in hypostasis, 
 frequent change of posture and cardiants are indicated. 
 
 III. Infarct; Embolism. — Etiology. — Embolism was first observed 
 by Laennec ; Virchow, Cohnheim and Litten established its pathology. 
 The most frequent source of lung embolism is (a) fibrinous coagula 
 from the right heart, the frequency and mechanism of which have 
 been discussed under Acute and Chronic Endocarditis and Sep- 
 tic Infections. Clots may also reach the lung from peripheral throm- 
 boses, and are either simple (i. e., non-suppurative, marantic) or 
 inflammatory and septic. Earer causes are (b) tumor or hepatic 
 tissue, (c) fat embolism after fractures and liver injury, (d) air 
 embolism or (e) echinococcus cysts. 
 
 Pathology. — The embolus may obstruct a main branch of the pul- 
 monary artery, straddle one of its secondary bifurcations or lodge 
 in a smaller vessel. Not every embolism produces an infarct, for 
 death may be instantaneous, the occlusion incomplete or collateral 
 circulation possible. Occlusion of an end-vessel results in the hemor- 
 rhagic infarct, which is often wedge-shaped with its base toward 
 the pleura, is dark at first and later lighter, is airless, on section 
 projects above the cut surface, often measures 2 to 6 cm., and is 
 attended by extravasation of blood into the lung cells and sustenta- 
 cular tissue, though the lung is not torn. This is known as a fibrin- 
 ous or simple infarct. If the embolus contains pus or putrefactive 
 microorganisms, it develops abscess or gangrene. Infarcts occur in 
 the right lower lobe in 46 per cent., right upper in 21, left lower 
 in 15, left upper in 12 and right middle lobe in 6 per cent. (Tie- 
 dermann) . They are often multiple. Small infarcts may be wholly 
 absorbed, but the larger ones leave pigmented cicatrices. 
 
 Symptoms. — (a) Infarction of the main pulmonary trunk may re- 
 sult in immediate death, as sudden death from sitting up after 
 childbirth (two-thirds of the puerperal cases die). In other cases 
 death occurs in a short time from cerebral anemia attended by con- 
 vulsions, dyspnoea and cardiac failure. The infarct may cover 
 the greater part of the lobe involved; if the patient lives for some 
 time, a sudden systolic murmur may develop over the pulmonary 
 artery (Litten). (b) Infarction of a smaller vessel is often ushered 
 in with chill, vomiting, dyspnoea, cyanosis and fever, even with bland 
 embolism. The sputum contains dark blood and there is a " stitch 
 in the side" from pleuritic participation. Physical examination 
 frequently elicits a pleural rub and later, in some cases, slight dulness, 
 especially behind, between the spine and scapular line ; crepitant rales 
 and bronchial breathing are frequently present. Pyogenic or putrid 
 clots cause abscess, gangrene, empyema or pneumothorax. 
 
518 DISEASES OF THE RESPIRATORY TRACT. 
 
 Diagnosis. — Diagnosis is often at best merely a probability. Sud- 
 den cardiac failure is very difficult to differentiate from an embolic 
 occlusion of a main pulmonary trunk, especially wben death occurs 
 without haemoptysis. The etiology, the sudden onset and circum- 
 scribed chest signs are of diagnostic importance. Treatment lies 
 solely in cardiac stimulation and prophylaxis, in rest during endo- 
 carditis, cardiac insufficiency or phlebitis. 
 
 IV. (Edema of the Lungs. — Etiology. — Pulmonary cedema was de- 
 scribed by Laennec (1819). In the etiology of this secondary, com- 
 mon, frequently terminal or agonal affection, three important causes 
 stand in the foreground, viz., heart, kidney and lung disease. (Edema 
 consists of the pouring out into the air cells and interstitial tissue of 
 a serous transudate. A precise classification of the mechanism of 
 pulmonary oedema is difficult: — (a) Stasis due to weakened heart is 
 probably its most frequent mechanism. Cohnheim and Welch de- 
 monstrated experimentally that it may result from failure of the 
 left ventricle, whereas there is continued activity of the right ven- 
 tricle; this may be common in the death agony, but the explanation 
 is not entirely satisfactory, as cases of pulmonary oedema occur in 
 which the pulse (and therefore the action of the left ventricle) 
 is strong; however, general cardiac anasarca may occur when the 
 radial pulse is apparently sufficiently strong, though it is known that 
 the heart must be weak. Grossmann advances the theory that 
 there is a spasm of the left ventricle. Weak heart may result from 
 any disease of the endo-, myo- or pericardium. Sahli explains cer- 
 tain cases by (b) paralysis of the pulmonary vessels. Under either 
 (a) or (b) nephritic oedema or the toxic oedemas, such as those from 
 the iodides, ether, adrenalin, pilocarpine or muscarin may be in- 
 cluded, (c) Inflammatory oedema, such as that around a fibrinous 
 pneumonia and numerous other pulmonary diseases, cannot be strictly 
 brought under oedema, for it is an exudation, not a transudation. 
 However, in this form the pulse is usually strong and there is often 
 fever, (d) Angioneurotic oedema is sometimes described. It is also 
 possible that (e) occult changes in the blood and bloodvessels are 
 causal factors. These varied mechanisms, though generally stated to 
 be most common in cardiac, renal and pulmonary lesions; may also 
 operate in cachexia, anaemia, cerebral disease, old age and innumer- 
 able other conditions. 
 
 Pathology. — Pathologically oedema may be circumscribed or oftener 
 diffuse. The lungs are large, heavy and spongy; they pit and on 
 section, especially of the bases, a frothy serosanguineous fluid exudes. 
 Symptoms. — Symptoms usually come on precipitately, with hurried 
 breathing, dyspnoea, cyanosis and carbon dioxide intoxication. The 
 sputum is copious, foamy, serous, somewhat resembling soapsuds 
 or at times tinged with blood ; it is rich in albumin and poor in mu- 
 cus and cells. The bubbling breathing indicates serum in the alveoli. 
 The second pulmonic sound is accentuated, the pulse is weak the 
 lung note is slightly tympanitic from relaxation and coarse ' and 
 
HEMOPTYSIS. 519 
 
 fine rales are heard everywhere. If the lower lobes are filled, the 
 physical signs may closely resemble those of consolidation, i. e., there 
 may be increased fremitus, bronchial breathing and dulness. The 
 diagnosis is determined from the sputum and lung findings. 
 
 Treatment. — Treatment may be beneficial in some cases, though too 
 often oedema is the death agony itself, (a) Prophylaxis concerns 
 the causal disease, for example, cardiac weakness or anasarca in 
 nephritis, (b) Rapidly acting, diffusive stimulants are urgently 
 indicated hypodermatically, as camphor, ether, strophanthus and 
 strychnine, and coffee or champagne by mouth, (c) Morphine 
 with atropine is at times almost specific, (d) Venesection relieves 
 the right heart and therefore the lungs, (e) Stimulating expector- 
 ants, as senega, and rapid purgation by croton oil, u\iij, on the tongue, 
 are sometimes of value. The author has obtained no results from 
 the acetate of lead, recommended by Traube in doses of gr. ss to i 
 every hour and by Nothnagel in a single dose of gr. x to xx. 
 
 V. Haemoptysis. — Haemoptysis or haemoptoe refers to " spitting of 
 blood," while profuse hemorrhage is known as pneumorrhagia. 
 
 Etiology. — (a) Laryngeal ulceration or inflammation; (b) tracheal 
 ulceration or aneurysm bursting into the trachea; (c) severe inflam- 
 mation or ulceration of the bronchi, stasis from cardiac disease, bron- 
 chiectasis, putrid and fibrinous bronchitis, rupture into the air pas- 
 sages of aneurysm or anthracotic lymph glands, and thermal, chemical 
 or mechanical irritation are etiological factors ; haemoptysis may also 
 occur in the acute exanthemata, in such affections of the blood as 
 haemophilia, scurvy, purpura haemorrhagica and leukaemia, and in 
 gout, renal disease and cholaemia; haemoptysis occurring as vicar- 
 ious menstruation was mentioned by Hippocrates, and though rare, 
 is an established variety; vicarious haemoptysis after ovariotomy 
 or suppression of hemorrhoidal bleeding is still more uncommon and 
 its existence has been regarded with just scepticism, (d) . Lung 
 disease is the most important etiological factor, and the chief lesion 
 is (i) tuberculosis (q. v.), which causes 80 to 90 per cent, of cases 
 of blood-spitting. It is commonest between the fifteenth and thirtieth 
 years, and very rarely occurs under six years of age, as children 
 seldom develop cavities. As stated under tuberculosis, it occurs as 
 capillary or profuse hemorrhage. It was noted long ago that hae- 
 moptysis sometimes occurs rather epidemically among tuberculous 
 cases; in such an outbreak, Flick, Ravanell and Erwin found the 
 pneumococcus in the sputum, (ii) Infarcts are usually characterized 
 by haemoptysis, (iii) Pneumonia, abscess and gangrene; (iv) tu- 
 mors; (v) parasites of the lung, trauma; and (vi) syphilis and 
 leprosy, are more uncommon causes, (e) Haemoptysis nervosa is 
 most rare, though authentic cases have occurred in cerebral trauma- 
 tism, hysteria (where it has caused death), epilepsy and in other 
 neuroses. (/) A toxic haemoptoe may occur from mercury or iodides, 
 but it is very rare. 
 
 Symptoms. — Symptoms follow those of the causal tuberculosis, mi- 
 
520 DISEASES OF THE EESPIEATOEY TEACT. 
 
 tral stenosis or aneurysm, or develop in apparent health. Haemopty- 
 sis is in itself only a symptom. Blood poured out into a cavity or 
 into the lung substance is not always voided, especially in very weak 
 or moribund persons. Prodromes are unusual; without learning, 
 a salty taste in the mouth, substernal warmth, a sense of something 
 rising from the chest and coughing are followed at once by a few 
 spoonfuls or more of blood. At times a previously mucous sputum 
 may be accidentally noted to be blood-stained. The blood varies in 
 amount from the merest stain to 5 quarts (Laennec) ; it may appear 
 but once or may recur repeatedly. It is generally bright red and 
 well mixed with air ; the formation of rouleaux is uncommon. If the 
 blood has clotted in the lung or air passages, the clot, too, is mixed 
 with air and perhaps with mucus. Casts of the bronchioles may be 
 voided. If there is gangrene or abscess, the blood may be brown 
 or buff-colored and the red cells may be disintegrated. Brown hse- 
 mosiderin granules or, if the blood has remained as a clot two 
 weeks, hsematin crystals may occur. Asthma crystals are occasion- 
 ally seen. 
 
 Physical Fixdi^gs. — Physical findings, other than those of the 
 fundamental condition, are frequently lacking ; if the blood stagnates 
 in a fairly large bronchus, there may be bronchial breathing, broncho- 
 phony, increased fremitus and dulness if the affected area measure 
 2 by 5 cm. In the bronchioles, blood gives rise to small rales, in the 
 bronchi to coarser rales. 
 
 Complications. — Fever, aside from the causal disease, may result 
 from resorption (ferment fever). Urobilin icterus, functional heart 
 murmur, relaxation of the right heart, albuminuria and puffiness of 
 the ankles are possible but not conspicuous complications. 
 
 Diagnosis. — Examination of the nose, gums, throat and larynx 
 readily excludes hemorrhage which may simulate hsemoptoe. It is 
 often difficult to distinguish at the time of bleeding between bron- 
 chial and pulmonary bleeding, but the question may be decided by 
 the history, later physical examination and the clinical evolution. 
 
 H^MATEMESIS. VS. HEMOPTYSIS. 
 
 (a) The blood is acid (unless a very Is alkaline, 
 large amount is voided). 
 
 (&) The patient nearly always recognizes whether it is vomited or coughed up. 
 (Blood from the lung is very rarely (Haemoptysis, very rarely, causes con- 
 swallowed and then vomited.) sensual vomiting.) 
 
 (c) Is often dark (though large Nearly always bright (though when 
 
 amounts of bright red blood may stagnating in a canity it may become 
 
 be vomited, as in ulcer). dark or buff). 
 
 (d) Is mixed with food, HG1, ferments, Mixed with air, which is also found in 
 
 etc. the clots. (Not infrequentlv tubercle 
 
 bacilli or heart disease 'cells are 
 found.) 
 
 (e) In 16 per cent, of cases blood is Is very rare in stools. 
 
 in the stools. 
 
CIRCULATORY AFFECTIONS OF TEE LUNG. 521 
 
 Prognosis and Course. — The duration is variable, but spontaneous 
 cessation is the rule. The immediate prognosis is good, as early 
 death from hemorrhage is rare, except in cases of profuse pneumor- 
 rhagia, resulting, for instance, from aneurysmal rupture, but even then 
 the patient may live years after the aneurysm has broken into the lung 
 substance. Drowning or suffocation of the patient in his own blood 
 is rare. The final outcome depends on the etiology. In Ware's 
 386 cases 62 per cent, recovered ; early death occurred in 3 per cent. 
 
 Treatment. — Prevention. — In tuberculosis (q. v.) the patient 
 should be kept quiet, the cough suppressed and exertion and vocal 
 efforts avoided; in heart disease and marantic thrombosis, rest is 
 indicated to obviate detachment of the thrombi. 
 
 Therapy. — Absolute physical and mental quiet should be enforced 
 when haemoptysis occurs. 'No movement should be allowed ; coughing 
 should be suppressed by hypodermatic injections of morphine, which 
 also allay the attendant mental excitement (opiates are employed 
 guardedly in very large hemorrhages, for bronchial occlusion may 
 result). The patient should be assured of a favorable outcome; 
 no physical examination should be made except auscultation of the 
 chest in front, for immediate treatment takes precedence of diagnosis ; 
 if rales indicate the side of the hemorrhage, the patient should 
 lie on that side to prevent aspiration into the contralateral bronchus. 
 
 Arterial pressure should be reduced by administration of amyl 
 nitrite or aconite, which lessens tension in the pulmonary and arterial 
 circulation. A liquid, simple, spare diet should be given. Alcohol, 
 coffee and tea should be interdicted. Even if the patient collapses 
 cardiants should be avoided, for syncope is nature's readiest haemo- 
 static ; the old practice of venesection in this way promoted thrombosis. 
 Cardiac excitement is lessened by placing a large ice-bag over the pre- 
 cordium. Active purgation by croton oil is very beneficial. 
 
 Haemostatics are not proven to control the lesser blood circuit, 
 which appears to be rather independent of drugs which operate on 
 the arterial circuit. Ergot, if anything, rather raises the blood pres- 
 sure in the lungs and should therefore not be given. Calcium 
 chloride gr. v to x, and common salt on the tongue are of some value 
 (salt acts reflexly, by way of the vagus, on the pulmonary vessels). 
 Gelatin (2 per cent.) may be used in urgent cases and the beneficial 
 effects of turpentine have long been known. Nature, as a rule, effects 
 the cure ; drugs do not, though opiates reinforce nature. Hippocrates 
 employed ligature of the extremities, i. e., binding tightly for a few 
 minutes the vessels of the groin and axilla, in order to lessen the 
 return flow of blood toward the point of hemorrhage. Artificial 
 pneumothorax, to compress the bleeding lung, has been advocated in 
 cases of desperate profuse and persistent haemoptysis. 
 
522 DISEASES OF THE RESPIRATORY TRACT. 
 
 PARASITES OF THE LUNG. 
 
 Echinococcus of the Lung. — Man may become infected with the 
 tinea echinococcus from dogs by their licking their master's hands or 
 from faeces contaminating human food, especially vegetables. The 
 unilocular form is much more common than the multilocular. Infec- 
 tion occurs either (a) primarily, the embryo skipping the liver, or 
 (b) much more often secondarily, by metastasis or breaking through 
 the diaphragm from the liver. In Neisser's 000 cases, 50 per cent, 
 occurred in the liver, 9 per cent, in the kidneys, 8 per cent, in the cra- 
 nium and 7 per cent, in the lungs. The small miliary white cysts may 
 grow to the size of an adult's head. They may calcify, indurate, sup- 
 purate, putrify or rupture into contiguous parts (see Animal 
 Parasites). 
 
 Symptoms. — Many cases produce no symptoms and are unexpected 
 findings at the post mortem. Dieulafoy described three clinical 
 stages: — (a) the initial, (b) the tumor stage and (c) the suppura- 
 tive or rupture stage, (a) The initial stage often has no symptoms, 
 but may be marked by scanty haemoptysis, cough, emaciation and 
 possibly fever, all of which may closely simulate incipient phthisis. 
 (b) In the tumor stage, there are bronchial (or weak) breathing, in- 
 creased fremitus and circumscribed dulness, which occur in the 
 lower lobes and twice as frequently on the right side as on the left ; 
 it sometimes causes bulging of the chest wall. There is a sharp 
 transition between it and the note of the sound contiguous lung. Dis- 
 location of the heart and compression of the lung may occur. The 
 x-tsljs often confirm the physical signs. The dulness curves upward, 
 but is quite different from the curve of pleuritic effusion which is 
 concave upward. Tumor of the lung gives a larger, harder flatness. 
 Puncture (v. i.) reveals a clear, aseptic fluid of 1,009-15 specific 
 gravity with little or no albumin, very rich in sodium chloride and 
 the characteristic succinic acid ; the inosite is of no practical impor- 
 tance; the hooklets 'are pathognomonic. (c) In the stage of 
 suppuration or rupture, as in liver echinococcus, rupture may occur 
 into the pleura (in which primary disease is 25 times as rare). 
 Pneumothorax may result. Par oftener rupture into a bronchus 
 occurs, with pain, dyspnoea, collapse and sudden " mouthful " expec- 
 toration of pus, small vesicles, lamellated cyst wall and hooklets. At 
 the time of rupture a curious urticaria develops (Finsen) which is 
 probably toxic, as the fluid from echinococcus cysts produces it when 
 inoculated into animals. Profuse hsemoptoe is common. If it comes 
 from the liver, the sputum is ochre-yellow from undissolved bilirubin, 
 even when there is no direct connection with the bile vessels ; choles- 
 terin is often present. The vesicles or cyst wall may cause suffoca- 
 tion. Rupture may also occur into the pericardium, stomach or 
 peritoneum. In this stage hectic fever is usual. 
 
 Diagnosis. — Diagnosis is determined only from the sputum, or from 
 puncture which has decided dangers; sudden, probably toxic death 
 was observed 11 times by Maydl. 
 
PLEURISY. 523 
 
 Prognosis. — The course varies much. A cyst in two or three 
 months becomes as large as a hazelnut, and in five months as large 
 as an orange (Dieulafoy). Death may result from suffocation, hem- 
 orrhage, gangrene, hectic fever or toxaemia from rupture or puncture. 
 
 Treatment. — If puncture is made and is followed by severe symp- 
 toms, the case should be instantly operated upon. There is no medi- 
 cal treatment. Without surgical intervention 57 per cent. (Hearn) 
 to C6 per cent. (Davaine) die. Tuffier and Garre report but 10 
 per cent, mortality with operation. 
 
 Distoma of the Lung. — This affection was first described by 
 Biilz in Japan, Formosa and Corea. The worm is plump, wide, egg- 
 shaped, measures 8 to 10 x 4 to 6 mm., is brownish red and is pro- 
 vided with two small suckers. Its eggs are oval, brown and measure 
 0.08 to 0.1 x 0.05 mm. Little is known of its origin. It is found 
 in the bronchi and in the infarcts and cavities, which it produces. 
 The cavities contain red disks, a mucoid substance and shreds of lung 
 tissue, and are surrounded by fibrous tissue. The parasite is also 
 found in the liver, diaphragm, mesentery and brain. The course 
 of the disease is chronic, though most cases terminate favorably; it 
 is marked by (a) bronchitic symptoms, (b) haemoptysis and (c) a 
 viscid clear sputum in which minute brownish-red dots, the distoma 
 eggs, are seen. In exceptional cases death results from emaciation, 
 exhausting haemoptysis or brain embolism. 
 
 Tuberculosis, syphilis and actinomycosis of the lung are described 
 under Infections. 
 
 DISEASES OF THE PLEURA. 
 
 PLEURISY. 
 
 Definition. — Pleurisy is a'n inflammation of the pleura, usually sec- 
 ondary to tuberculosis or other lung disease, general infections, 
 septicaemic affections and disease in contiguous tissues. To Hippo- 
 crates, pleurisy meant pain in the side; though Boerhaave firsts con- 
 fined the term to pleural disease, the first full description dates from 
 Laennec. 
 
 Pleurisy constitutes 3 per cent, of internal maladies and is the 
 most common of all post mortem findings (in over 50 per cent.). 
 It is susceptible of division into infinite varieties, acute, subacute or 
 chronic according to its course, dry or effusive according to its con- 
 sistence, .primary or secondary as to its cause, diffuse or circum- 
 scribed as to its distribution and serofibrinous, hemorrhagic or sup- 
 purative as to its nature. Any such classification is more or less 
 artificial, whence it seems preferable to describe all its symptoms 
 first and group special types later. 
 
 Etiology. — 1. Tubebculosis. — So-called primary, spontaneous or 
 cryptogenetic pleurisies are often tuberculous (Barrs, better, Le- 
 moine, Vaillard, Coston and Dubville). Landouzy considers that 
 
524 DISEASES OF THE RESPIBATORY TRACT. 
 
 98 per cent, of all pleurisies are tuberculous and that 60 per cent. 
 of all cases of phthisis pass through the so-called pleuritis a f rigor e; 
 Netter holds that 70 to 80 per cent., and Ashoff that nearly all 
 "primary" cases, are tuberculous. Le Damany in 55 "primary" 
 pleurisies proved by inoculation that 92 per cent, were tuberculous. 
 Lord states that two-thirds of pleuritics have no obvious disease in 
 other organs and three-quarters respond to tuberculin. The causal 
 lesion may be recognized at autopsy in calcined bronchial glands 
 or in small lung foci. Tuberculous pleurisy is often bilateral. Its 
 special relations will be discussed later. 
 
 2. Diseases of the Lung Substance. — Pneumonia, abscess, gan- 
 grene, infarcts, tuberculosis, tumors, pneumothorax, tertiary syphilis, 
 actinomycosis, etc., are etiological factors; according to Koplik, 95 
 per cent, of pleurisies in children follow pneumonia. It is less fre- 
 quent in diseases involving the bronchi, as in grippe or measles. 
 
 3. Acute Infections. — Rheumatism, sepsis, endo- and pericar- 
 ditis, scarlatina, measles, diphtheria and other acute infections may 
 result in pleurisy. It develops in about 2 per cent, of typhoid 
 cases; it may develop in secondary syphilis without lung lesions. 
 
 4. Diseases of Adjacent Organs. — (a) Intrathoracic affections, 
 involving the ribs, spine, oesophagus, mediastinum, lymph glands, 
 diaphragm and pericardium; (&) abdominal affections, as of the 
 stomach, spleen or liver (abscess, tumor or cirrhosis (in 16 per 
 cent.)), subphrenic abscess, suppurative or tuberculous peritonitis 
 (in 25 per cent.), perinephritic abscess, abdominal malignancy, etc., 
 may promote pleurisy; pleural infection may occur by direct local 
 invasion or by the lymph and blood streams ; in neglected appendi- 
 citis, hepatic and diaphragmatic invasion are the steps to pleural 
 infection. 
 
 5. Tumors. — Echinococcus and endothelioma (Wagner and Fran- 
 kel) are the most important types; endothelioma is an infectious 
 process (Neelson), a lymphangitis proliferans (Schwenniger) or a 
 lymphangitis carcinomatosa (Schottelius). Carcinoma, sarcoma, 
 ecchondroma and rarely lipoma are also factors ; pleural neoplasms 
 are far more frequently secondary than primary. 
 
 6. Altered Conditions of the Blood (Dyscrasle). — Gout, 
 nephritis, scurvy and tertiary syphilis are often causative of pleurisy 
 and frequently bilateral pleurisy; reduced physiological resistance 
 predisposes to infection. 
 
 7. Terminal Infections. — Various forms of sepsis are often 
 fatal to subjects of chronic disease of the heart, liver and kidneys; 
 bilateral pleurisy is frequent. 
 
 8. Age, Sex, Localization. — Age : most cases occur between the 
 twentieth and fiftieth year, but no age is exempt. Sex: Eichhorst 
 observed pleurisy in 3 per cent, of all his male and 2 per cent, of all 
 his female cases, and found the following localization: rio-ht-sided 
 in 54 per cent., left-sided in 42 per cent, and bilateral in 4 per cent. 
 Cases following nervous disease, cold or exposure, venous thrombosis 
 
PLEURISY. 525 
 
 or trauma can usually be brought within the above given classification. 
 Bacteriology. — The etiological classification above given does not 
 correspond to the bacteriological division. Suppurative pleurisy 
 may result from the streptococcus, pneumococcus, tubercle bacillus or 
 less often from the staphylococcus or typhoid or colon bacillus ; serous 
 pleurisy may be due to the tubercle or pyogenic organisms. The 
 frequently negative cultural results have favored the hypotheses 
 that chemical products, as tuberculin in phthisis, may produce pleur- 
 isy or that bacteria produce pleurisy and then die. It must be 
 remembered that cultures are made, not from the pleura directly, 
 but from the fluid effused from it. The organisms found are most 
 frequently the pneumococcus, tubercle bacillus and streptococcus; 
 less often the staphylococcus, pneumobacillus of Eriedlander, typhoid, 
 colon, influenza and diphtheria bacilli, gonococcus, ray fungus or 
 glanders bacillus, (a) Purulent pleurisy (empyema) is due most 
 often to the streptococcus in adults and to the pneumococcus in chil- 
 dren. About 10 per cent, of empyema is tuberculous ; empyema 
 giving no results culturally or by inoculation is usually tuberculous 
 and may be regarded as a cold abscess of the pleura (Kelsch and 
 Vaillard). The staphylococcus, Micrococcus tetragenus and pyo- 
 genes tenuis, pneumobacillus, typhoid and colon bacilli are infre- 
 quent factors, (b) Serous pleurisy is usually tuberculous, as shown 
 by the constantly increasing percentage of cases in which inoculations 
 are successful. Tubercle bacilli when found, suggest a direct com- 
 munication with a tuberculous focus in the lung or lymph glands; 
 negative results are due either to an insufficient amount of fluid (less 
 than 10 to 20 c.c.) being inoculated or to the effusion being due to 
 toxins rather than to the bacilli. Eichhorst found tubercle bacilli 
 by direct examinations in but 15 per cent, of serous pleurisies, 
 though his inoculations were positive in 62 per cent. Jousset recom- 
 mended that the fluid be allowed to coagulate and the clot digested 
 with pepsin, centrifuged and then stained ; his method is termed 
 inoscopy. (c) So-called primary pleurisy which is non-tuberculous is 
 usually pneumococcic. (d) Meta- and para-pneumonic pleurisy is 
 most frequently due to the pneumococcus, but also to the streptococ- 
 cus and staphylococcus, even when no pus is formed, although mixed 
 infections have a tendency to suppuration. 
 
 Symptoms. — Physical findings are absolutely essential for diagnosis 
 and all subjective symptoms are ambiguous or may be wholly absent. 
 In the main, all types have much the same signs which differ more 
 quantitatively than qualitatively; serous pleurisy nearly always 
 shows friction, and fibrinous pleurisy is almost always accompanied 
 by some exudation. 
 
 Inspection. — (a) Inspiratory retraction of the intercostal spaces 
 may result from imperfect ingress of air, pain or adhesions. Epi- 
 gastric retraction during inspiration is due to contraction of the 
 diaphragm, (b) The patient often lies during the dry stage on the 
 sound side to avoid pain from pressure on the inflamed surfaces ; later, 
 
526 DISEASES OF THE EESPIEATOEY TEACT. 
 
 during the exudative stage, he lies on the diseased side in order to 
 allow a freer expansion of the sound lung, especially when the exu- 
 date is large. Traube believed that continued lying on the diseased 
 side aggravated pain by congesting the pleural and subpleural veins. 
 The patient may sit up for breath, or assume the diagonal decubitus 
 (Andral). (c) Ectasia (distention) of the affected side occurs espe- 
 cially in children, and is determined by mensuration and inspection. 
 The interspaces are obliterated, the costal arch is immobile during 
 respiration, the skin glistening, the spine curved toward the diseased 
 side, the shoulder higher and the nipple and scapula are further from 
 the median line. (The right chest is normally one or two centimeters 
 larger than the left.) The sound side exceeds, by three centimeters, 
 its normal dimensions on account of compensatory emphysema (Ger- 
 hardt and Kerlias). In some very large effusions the writer has 
 observed an apparent retraction of the diseased side, (d) Respira- 
 tory movement of the affected side is decreased or absent both in dry 
 and exudative pleurisy. Respiration is renexly decreased on the 
 diseased side, and the breathing lags on the affected side. The 
 frequency of respiration is increased from lung compression, heart 
 luxation, the low diaphragm, fever, pain or paresis of the intercostal 
 muscles. Pain alone may reflexly decrease the respiratory expansion 
 and variation on the same side may occur, there being more move- 
 ment above and less below, (e) The .r-rays often show a dark 
 shadow. (/) Inspection also reveals cyanosis, dislocation of the apex 
 beat and oedema of the chest wall in suppurative pleurisy and 
 occasionally in other forms; (g) absence of Littens phenomenon 
 and (h) rarely pulsation of the effusion, (i) C. L. Greene describes 
 a rhythmic lateral displacement of the heart peculiar to pleurisy: 
 " Such movement is most marked in medium-sized effusions. The 
 heart approaches the affected side in inspiration and moves outward 
 in expiration. The extent of movement often amounts to two inches. 
 It may be measured by fluoroscopic examination, auscultatory percus- 
 sion, by simple deep percussion of the free cardiac border, or in some 
 instances by mere inspection of the apex beat. Deep breathing and 
 especially forced expiration are essential to the success of the ma- 
 neuver, and to obtain this morphine must sometimes be administered. 
 Marked rhythmical lateral movement has not been found by the writer 
 in pneumonia, tuberculous infiltrations of the lung, malignant disease 
 of the pleura or lung or in subdiaphragmatic abscess." 
 
 Palpatiox. — Palpation confirms the findings of inspection, (a) 
 An up and down (less often horizontal) friction rub is felt; it in- 
 creases on pressure, which also increases the pain and tenderness, and 
 it is the more readily distinguished the coarser the rub and the more 
 capable the chest wall of vibration. The friction develops before 
 the effusion, is often present with it and after it is absorbed. The 
 rub is due to roughening of the pleura, which loses its glistening ap- 
 pearance and looks like glass upon which one has breathed (Klebs) ; 
 the two raw pleural surfaces scrape on each other. It may be very 
 
PLEURISY. 527 
 
 transient, lasting a few hours or days, or even disappearing when the 
 patient takes a deep breath ; or it may last for months or even years. 
 It is usually absent in obese individuals, (b) Pressure on a tender 
 interspace during deep inspiration may cause a sudden contraction of 
 the upper part of the rectus muscle on the side of lesion (Schmidt). 
 (c) Vocal fremitus,, normally greater on the right than on the left 
 side, varies according to the level at which it is tested, (i) Above the 
 effusion it is normal, (ii) Near the spine, over the compressed and 
 relaxed lung it is increased, (iii) Below, it is weak or absent, from 
 exudation of thick fibrin or fluid, though less change is observed in 
 dry pleurisy than in the effusive form. Irregular findings are due to 
 the presence of adhesions bringing the lung closer to the chest wall in 
 some places than in others. The condition of the lung and the 
 bronchial secretion are important in diagnosis, whence before testing, 
 the patient should cough and take a few deep breaths. The results 
 are irregular in cases of loculated effusion, (d) By tapping with the 
 finger tips the increased resistance is clearly palpated, (e) (Edema 
 of the chest wall on the diseased side may be inflammatory both in 
 serous and purulent pleurisy, or mechanical and more intense from 
 pressure on the azygos or hemiazygos veins. (/) Fluctuation in 
 massive effusions is extremely rare, (g) Palpation determines the 
 dislocated apex beat, the dislocated liver or spleen, the bulging of the 
 diaphragm and sometimes a furrow between the diaphragm and liver 
 (Stokes). 
 
 Percussion. — Percussion is negative in dry pleurisy, except when 
 a very thick fibrinous exudate causes dulness and weak breathing; 
 after an effusion has resorbed the residual plastic lymph causes 
 dulness. When there is effusion (a) dulness is found between 
 the fifth and eighth ribs in the left axilla or over the liver and pos- 
 teriorly on the right side. Dulness also results from old adhesions, 
 atelectasis of the lung or a very thick chest wall. As in pneumo- 
 thorax, emphysema of the lungs and calcification of the ribs may 
 somewhat obscure the dulness of an effusion. In doubtful cases the 
 apparently sound side should be percussed first. According to Fer- 
 ber's experiments on the cadaver, thirteen ounces (400 c.c.) of fluid 
 are necessary in the adult for recognition and four ounces (120 c.c.) 
 in children ; post mortem experiments, however, do not exactly fulfill 
 the conditions obtaining during life. The effusion must be one inch 
 (2 c.c.) thick to produce dulness. Sometimes, however, even six to 
 seven ounces (200 c.c), which produce a dulness two fingers in height, 
 may be recognized. In some doubtful cases smaller amounts may 
 be detected, as proven by puncture, especially in persons having thin 
 thoracic walls, as children and women. Light percussion is necessary 
 when the effusion is small, lest other normal parts be brought into 
 vibration. Before percussion the patient should breathe deeply 
 several times to eliminate partial collapse of the lung and impaired 
 ingress of air from accumulated bronchial secretion. Percussion is 
 absolutely essential to diagnosis. Not merely the audible dulness 
 
528 DISEASES OF THE BESPIBATOBY TBACT. 
 
 should be regarded, but also the palpable sense of resistance, ou light 
 percussion. The dulness usually amounts to distinct flatness. In 
 larger effusions, the flatness, at first located posteriorly, increases 
 along the spine and laterally in the axilla. In massive exudates, flat- 
 ness may reach from the lower limit of the pleura to above the 
 clavicles. 
 
 The dulness is highest posteriorly as the patient lies on the back. 
 When he sits the line of dulness describes a parabolic curve (courbe 
 de Damoiseau) which is lowest behind and due according to Gerhardt 
 to the uneven thickness of the chest wall or according to Eichhorst 
 to irregular adhesions. If the fluid should effuse with the patient out 
 of bed, the upper level would be horizontal. Dulness is found one to 
 two centimeters higher than the upper level of the fluid, due to 
 plastic exudate, (b) Eight-sided effusions merge with the liver dul- 
 ness, but the lower limit of left-sided effusions can usually be de- 
 termined, because they invade Traubes semilunar space. This " half 
 moon" space lies between the fifth and sixth costal cartilages above 
 and tenth rib below, representing the supplementary pleural space 
 and is designated as the " half -moon " space because of the curve at 
 its upper portion, produced by the apex of the heart ; its tympanitic 
 note is decreased or replaced by flatness in left-sided effusions (with- 
 out adhesions). Dulness here may not be confused with that of the 
 spleen, for there is no respiratory excursion in pleurisy, and the 
 dulness lies more toward the heart than toward the splenic region. 
 Scybala or food in the stomach or bowels may also impinge on 
 Traube's space, (c) Respiratory excursion and Littens sign are 
 absent in effusions of any size, (d) The change of the upper line of 
 didness with change of position has been emphasized by most writers. 
 According to personal experience, it is difficult to detect because ad- 
 hesions are present at the level of the fluid; the patient must lie 
 hours in another posture before any alteration occurs. 
 
 The following findings are rather less important: (e) A vertical 
 strip of tympany along the spine, often measuring three centimeters 
 wide, may be detected when there is a large exudate ; it is due to com- 
 pression of the lung. Tympany in the lower left chest results from 
 gaseous distention of the stomach and intestines. (/) Tympany is 
 observed over an upper lobe from compression or relaxation of the 
 lung. It was first observed by Avenbriigger and Skoda, and is 
 usually called the Skodaie note, (g) "Cracked-pot" resonance oc- 
 casionally appears on short forcible percussion over the upper lobe, 
 and results from sudden expulsion of air through the rima glottidis. 
 (h) William's tracheal note is observed on the left more than on the 
 right side and most clearly in the first and second interspaces. It is 
 obtained chiefly when the entire side is dull and is due to transmission 
 of percussion vibration from the fluid to the trachea, giving a tym- 
 panitic note. A change of pitch with opening and closing of the 
 mouth, like that observed in lung cavities by Wintrich, mav some- 
 times occur, (i) Grocco's sign is a small triangular dulness on the 
 
PLEURISY. 529 
 
 sound side along the vertebrae, due to the interposition of fluid be- 
 tween the sound lung and the spine whieh thus cannot vibrate; it 
 also occurs in subphrenic abscess, cysts or ascites; Koranyi first de- 
 scribed this sign in 1897 and Grocco independently in 1902. (/) 
 Dislocation of other organs. There is no parallelism between the 
 amount of exudate and the amount of luxation, which, of course, is 
 absent if the organs are adherent. The heart is usually dislocated in 
 toto but seldom suffers torsion or change of the direction of its axis. 
 The right ventricle may be seen to pulsate to the right of the sternum, 
 even at the right nipple line, when the effusion is left-sided. In 
 right-sided effusions the apex is pushed to the left and downward, for 
 the diaphragm is lower. The liver is less easily displaced than the 
 heart, but in right-sided effusions is pushed down and the left lobe 
 tipped somewhat upward, though both lobes may be dislocated down- 
 ward in very extensive pleurisies (Traube and Frantzel). In left- 
 sided effusions the spleen is dislocated downward and forward, under- 
 goes some torsion and may stand perpendicular to the costal arch. 
 Auscultation. — This is most important in dry and effusive pleu- 
 risy, (a) The friction rub (see Palpation) may be hard or soft, is 
 superficial (i. e., close to the ear) and resembles the sound made by 
 scratching the finger upon the ear or the crunching of snow under the 
 shoe ; it often develops in the first twelve hours. It is most frequent 
 during inspiration, but is very often detected in expiration ; it seldom 
 occurs during expiration alone. Inflammation of one leaf of the 
 pleura is sufficient for its production. It may disappear after 
 several long breaths which smooth the pleural roughening. The in- 
 terrupted rub is due to pleural irregularities. It may be increased 
 by pressure and is subject to no law as to its duration. Gerhardt 
 heard a pleural rub which lasted six years. It is heard most fre- 
 quently over the anterolateral portion of the chest, and is detected 
 more clearly with the stethoscope than with the naked ear, but may 
 sometimes be heard at a distance of several feet, as in a case seen by 
 the writer with Dr. H. M. Richter. If it is apical, it is probably due 
 to tuberculosis. It may rarely be present in miliary tuberculosis (v. 
 Jiirgensen) and in tumors of the lungs or pleura without actual 
 pleurisy. It usually becomes less clear when exudation develops, and 
 its reappearance indicates the beginning of absorption or extension of 
 the pleuritis. (b) The breath sounds are modified not only by the 
 effusion, but also by the condition of the lung, the strength of breath- 
 ing and the conditions of conduction existing in the pleura and 
 thoracic walls. In general, and especially in men and children, the 
 respiratory sounds are weakened, even in fibrinous pleurisy, from re- 
 pressed breathing and perhaps from pain alone ; cog-wheel breathing 
 is common. In moderate effusions three zones are observed: (i) 
 Absence of breathing in the lower parts from compression of the lung 
 by the exudate, which lessens the conduction of the vesicular sounds ; 
 (ii) bronchial breathing in the middle zone from moderate collapse 
 of the alveoli of the lung, with fair conduction through the bronchi ; 
 34 
 
530 DISEASES OF THE EESPIEATOBY TEACT. 
 
 (iii) an upper zone of sharp or exaggerated vesicular breathing. In 
 larger effusions the lower zone extends higher and bronchial breathing 
 may be heard near the clavicle or between the scapula and spine. In 
 the largest effusions the breathing is indistinct everywhere, with 
 areas of metallic bronchial breathing when the lung is wholly col- 
 lapsed. Amphoric breathing is exceptional, (c) The voice sounds 
 are not heard over the fluid or over very thick, plastic exudate. They 
 may persist in various places, when islets of the lung are adherent to 
 the chest wall, (d) Bronchial breathing and increased fremitus may 
 be present, especially in children with empyema, under the following 
 conditions ; if the chest wall is not the seat of oedema, if the bronchi 
 are patent, if there is no great fibrin deposit on the pleura and if the 
 lungs are retracted but not absolutely compressed. The bronchial 
 breathing may sometimes be as intense as in pneumonia or tumor. 
 In adults increased fremitus may be observed between the spine and 
 scapula where the lung is compressed, (e) Bronchophony depends 
 upon the same conditions as bronchial breathing, viz., patent bronchi, 
 moderate retraction of the lung and conditions favoring good conduc- 
 tion of sound. (/) zEgophony, which is an exaggerated bronchoph- 
 ony, was described by Laennec ; it is found chiefly in middle-sized 
 effusions, usually at the level of the fluid. It occurs less often in 
 large cavities and in infiltrations of the lung. In large effusions it 
 is rare, the compression being too great. It is caused by the voice 
 sounds passing through the compressed smaller bronchi to the chest 
 wall ; it maybe present when the exudate is increasing or decreasing at 
 a given point, (g) Baccellis symptom is the " whispering voice," which 
 Baccelli thought was more frequent in serous effusions, but it also 
 occurs in other forms of pleurisy, in chronic induration of the lungs, 
 pneumonia, hydrothorax and cavities, (h ) A wide propagation of the 
 heart tones indicates consolidation rather than effusion; if consolida- 
 tion is excluded, the hearing of the heart tones more widely than nor- 
 mal suggests dislocation of the heart by an effusion. Murmurs may 
 result from bending of the large vessels by dislocation of the heart, as 
 well as accidental murmurs resulting from a weakened heart, tox- 
 aemia or high temperature. 
 
 Diagnostic Puxctuee. — This determines: (a) the existence of 
 pleurisy, excluding pneumonia, hypostasis, tumor or atelectasis; (b) 
 the character of the fluid; and (c) the prognosis. It is indicated in 
 all doubtful cases. Puncture with aspiration is also an important 
 therapeutic measure. Negative results from puncture may result 
 from a thick fibrinous exudate, from failure to reach an encapsulated 
 effusion, as in interlobar pleurisy, and from the membrane being 
 pushed in before the needle so that the fluid is not reached. In nega : 
 tive dry taps, after withdrawal of the needle, examination should ' be 
 made to see that no plug of fibrin or cells has collected in the needle. 
 If a plug is obtained it should be emptied upon a glass slide and ex- 
 amined under the microscope. Care should be taken that no carbolic 
 acid or alcohol remain in the syringe or needle, which, by coagulating 
 
PLEURISY. 531 
 
 the serum, may cause some dry punctures. The puncture should be 
 made with a large needle. Positive results: when the needle is intro- 
 duced, resistance may be felt, which is due to a callous pleurisy or an 
 indurated lung. Often after introducing the needle, the point may 
 be felt to be freely movable, as in a cavity. Sometimes the results 
 differ according to the level of the puncture ; in rare cases serum may 
 be obtained from a high puncture and from a lower one a cellular 
 deposit, the cells settling to the bottom. Again, puncture in different 
 localities may show serum in one and hemorrhage or pus in other 
 sacs, which Galliard calls polymorphous pleurisy. Bacteriological 
 examinations made with 10-20 c.c. of the serum give frequent re- 
 sults. The special chemical, bacteriological, cellular and other char- 
 acteristics will be discussed under individual forms. 
 
 Symptoms, — Symptoms may be absent (latent pleurisy) ; if present 
 they are not distinctive and there is no fixed relation between the 
 symptoms and physical findings, (a) The temperature is variable. 
 Its rise is usually gradual and without a rigor. For weeks there may 
 be no temperature, even in purulent exudates, especially in marantic 
 and diabetic subjects and in terminal infections. When present it 
 is more frequently subcontinuous or remittent than continuous. The 
 average elevation is 101° to 102°. Temperature is no positive index 
 as to the character of the fluid. Exacerbations of temperature are 
 important prognostically, especially when the appetite is poor and no 
 change occurs in the physical findings. Recovery is not expected until 
 the temperature has been normal for some time, (b) The pulse is 
 increased; it is sometimes small and is occasionally of the para- 
 doxical type or unequal in the two radial vessels, (c) Dyspnoea 
 seldom attends pleurisy, for effusions may attain enormous propor- 
 tions without respiratory difficulty, particularly when they are 
 gradual in development. Dyspnoea is usually referable to coincident 
 bronchitis, pneumonia, lung congestion, pericarditis, arteriosclerosis, 
 nephritis or bilateral pleuritis. (d) Pain is usually an initial symp- 
 tom. It is in no way proportional to the physical findings. It may 
 be absent when auscultation shows a marked rub. Its character is 
 usually dull, tearing, stabbing and sometimes very severe ; it may be 
 crampy or colicky. The pain is pleural (Cruveilhier) and is present 
 in the diseased side, well down over the ribs, over the liver, epigas- 
 trium or low in the back, and sometimes may radiate to the sound side 
 (Laennec and Gerhardt), into the arm or spine or into the abdomen, 
 especially in children, in which case it may simulate appendicitis. 
 (e) Coughing, an early and frequent symptom, results from acci- 
 dental bronchitis or more often from pleural irritation. It may 
 occur after change of posture or after tapping. It is usually un- 
 productive. (/) Other symptoms are anorexia, vomiting, headache, 
 difficult swallowing due to involvement of the foramen oesophageum 
 (Ferber) and marked sweating; the sweats of pleurisy rank third in 
 importance after those of sepsis and rheumatism. The urine is 
 scanty but increases during resorption, when peptonuria and transient 
 
532 DISEASES OF THE RESPIRATORY TRACT. 
 
 albuminuria are often found. The skin may be pale and cachectic 
 from purulent accumulations, red from high temperature, cyanotic 
 from poor oxygenation or suddenly pallid from hemorrhage into the 
 pleura, when also there is a sudden increase of fluid. Emaciation 
 is common in chronic tuberculous or purulent pleurisy. 
 
 Special Forms. — 1. Character of the Inflammation. — In 790 
 cases Eichhorst found serous pleurisy in 81 per cent., fibrinous in 
 12 per cent., purulent in 5 per cent., ichorous and hemorrhagic, each 
 in 1 per cent. 
 
 (a) Serous pleurisy is the prototype of pleuritis. As stated, most 
 cases are tuberculous. The fluid is lemon-colored. Its specific gravity 
 ranges between 1,015 and 1,023, Avhich Mehu considers characteristic 
 of inflammation. Albumin amounts to 3 to 7 per cent. ; sugar is fre- 
 quently present. The fluid clots after puncture. All pleuritic exu- 
 dates, serous and otherwise, contain white blood cells, red blood cells 
 and endothelial cells ; the cells may show fatty degeneration. 
 
 Cytodiagnosis. — Much emphasis has been placed on the character 
 of the leukocytes found in tuberculous pleuritis; Widal, Sicard and 
 Kevault (1900) especially insisted — and later writers confirm the 
 statement — that lymphocytes are characteristic of primary pleural 
 tuberculosis and afford early diagnostic data long before the results 
 of inoculation are available; the fluid must be examined before it 
 coagulates, to which end the fluid is received into a pint of salt solu- 
 tion; in other pleurisies the polymorphonuclears prevail; in other 
 words, the " lymphocytic formula " indicates tuberculosis, the " poly- 
 morphonuclear formula " indicates pyogenic infection or pleurisy 
 secondary to well-developed phthisis, and the " endothelial formula " 
 indicates irritation, transudation or malignancy. The tuberculous 
 nature of pleurisy is established by inoculation tests, which are posi- 
 tive in 66 to 94 per cent., by apical involvement or that of other 
 serous membranes, by the finding of tuberculosis in cases of sudden 
 death in the course of pleurisy (Lendouzy, Dujardin, Beaumetz, 
 Dieulafoy, Kelsch, Binet), and by the fact that 25 to 33 per cent, of 
 cases later become obviously tuberculous. It is well to suspect the 
 tuberculous nature of all so-called rheumatic pleurisies (pleuritis a 
 frigore ) . The sputum and lungs should be carefully watched in such 
 cases for some time. For the tuberculin tests see page 319. The 
 leukocytes are not increased in the blood count. 
 
 (b) Fibrinous pleurisy usually shows some fluid, serous or puru- 
 lent, if systematic punctures are made. 
 
 (c) Purulent or suppurative pleurisy (empyema) usually begins 
 as a serous exudate which soon becomes opaque and purulent. The 
 sterile tuberculous form has been discussed (v. s. Bacteriology). 
 In contrast to serous pleuritis two-thirds of this group are secondary. 
 The most frequent types are (i) the streptococcic form, which "is 
 observed chiefly in adults, in which the fluid is thin and separates on 
 standing into an upper serous layer and a lower denser layer, in which 
 fibrin formation is slight; and (ii) the pneumococcic form, which is 
 
PLEURISY. 533 
 
 more common in children, in which the fluid is more homogeneous 
 and viscid, like the " laudable " pus of the early writers, in which the 
 fibrin and membrane formation is abundant and the odor peculiar; 
 it is more often accompanied by endocarditis, pericarditis and menin- 
 gitis, and is more often febrile and more susceptible of spontaneous 
 recovery than the streptococcic form. In better's series of empyema 
 the streptococcus was causal in 47 per cent., the pneumococcus in 39 
 per cent., the tubercle bacillus in 11 per cent, and the staphylococcus 
 in 3 per cent. Over 80 per cent, of juvenile empyemas are pneumo- 
 coccic. The fact that the pneumococcus has far less pyogenic propen- 
 sities in the lung than in the pleura has excited frequent comment. 
 Microscopically, various bacteria are present (v. Bacteriology), 
 polymorphonuclear and often fatty white cells, and sometimes chole- 
 sterin and Charcot-Leyden crystals. The distention of the chest 
 may be enormous; Krause reported 22 pounds of pus in one case. 
 Greater visceral luxation than in any other type may occur. Leuko- 
 cytosis and hectic fever are mentioned under symptoms. 
 
 Empyema pulsans (Walshe) ; Sailer collated 95 cases in 1904; 
 95 per cent, of all pulsating effusions are purulent; 93 per cent, are 
 left-sided. A pulsating tumor as large as the fist may be noticed, 
 which usually decreases during inspiration, or the effusion may 
 simply pulsate behind the ribs; in either case the pulsation may be 
 expansile. The pulsating tumor is usually between the second and 
 fourth ribs, anteriorly, but may be seen lower on the side or even well 
 below in the back. Pulsation is probably propagated from the 
 aorta ; it has been attributed, though without satisfactory reason, to 
 necrosis of the pleura, coincident pneumothorax (Fereol), atelec- 
 tasis of the lung (Comby) or adhesions and paresis of the inter- 
 costal muscles (Traube, Keppler). The most apparent conditions for 
 pulsation in an empyema are considerable cardiac energy, massive 
 exudation and paresis of the intercostal muscles. Empyema pulsans 
 may be confused with aneurysm, which latter is much slower in its 
 evolution, is much oftener located above and to the right, and has its 
 own signs, murmur and thrill ; it may be confused with pulsating ab- 
 scess, pneumonia, gangrene or tumor of the lung. The pulsation 
 ceases after aspiration. Aneurysm may co-exist with pleurisy. Ex- 
 pansile pulsation of the chest wall has been observed twice without 
 exudation, aneurysm or any organic change (Lafleur and Edwards). 
 Empyema may rupture externally, empyema necessitatis. Rupture 
 is usually along the sternum or lower ribs. Gravitating abscesses may 
 result, as pulsating tumors in the groin and loin, which may be con- 
 fused with aneurysm or spinal caries. Rupture into the lung may 
 cause suffocation during sleep; according to Wetter, 25 per cent, of 
 post-pneumonic empyemas rupture into the bronchi. Fistula?, hectic 
 fever and amyloidosis are frequent sequela*. Hippocrates knew of the 
 " mouth full " expectoration and also the fact, later described by 
 Traube, that pus may penetrate the lung like a sponge without per- 
 foration or pneumothorax. Unverricht thinks, however, that perfora- 
 
534 DISEASES OF TBE RESP1BAT0BT TBACT. 
 
 tion into the lung without pneumothorax is probably caused by a 
 small opening which allows the escape of fluid into the lung but does 
 not allow the escape of air into the pleura, because of the higher 
 tension in the exudate. Hellin (1905) found 114 cases of bilateral 
 empyema recorded in the literature; 67 per cent, occurred in males 
 and 90 per cent, in young persons under fifteen years old ; the mor- 
 tality was 30 per cent. 
 
 (d) Putrid pleurisy is usually associated with gangrene of the 
 lung, pneumothorax, oesophageal carcinoma, appendicular abscess and 
 kindred lesions. The fluid is extremely foetid; fat, leuein, tyrosin, 
 cholesterin and sometimes hamiatoidin crystals are found; the colon 
 bacillus and other gasogenic bacteria are frequently present. 
 
 (e) Hemorrhagic pleurisy is usually serofibrinous and the exudate 
 is tinged with blood. Five to six thousand red cells per c.mm. are 
 necessary to produce a reddish tinge. Its character is seldom sus- 
 pected before puncture, (i) Most cases are tuberculous. Dieulafoy 
 speaks of these cases as having " haemoptysis into their pleurae." 
 After puncture more fluid is frequently formed but recovery is pos- 
 sible, (ii) Some cases are cancerous; Moutard-Martin has found 
 hemorrhagic pleurisy in but 12 per cent, of pulmonopleural cancer ; 
 pain, dyspnoea, luxation and rapid pulse are frequent symptoms ; the 
 fluid is dark red, contains little fibrin and is usually formed rapidly ; 
 a case of Desnos was punctured 30 times in six months, (iii) Some 
 cases occur in liver cirrhosis (of which Laennec published the first 
 case in 1826), in nephritis and in hemorrhagic fevers or exanthem- 
 ata ; profuse hemorrhage into the pleura was called pleural hemat- 
 oma by Wintrich and pachypleuritis hemorrhagica by Chouppe from 
 its resemblance to hemorrhagic pachymeningitis. 
 
 (/) Chyliform pleurisy (v. i. Chyeothokax). 
 
 2. Location of the Exudate. — (a) Pleuritis diaphragmatica 
 produces notable subjective disturbance. Radiating pain is often ex- 
 perienced, which may resemble angina pectoris (Andral). Pain and 
 tenderness in the epigastrium and between the tenth rib and the 
 xiphoid is pathognomonic, according to Gueneau de Mussy. 
 
 Schmidt's respiratory abdominal reflex, an inspiratory spasm of 
 the upper part of the rectus muscle, is indicative of phrenic involve- 
 ment. Dysphagia from inflammation of the foramen oesophageum 
 may result. If left-sided, vomiting and singultus may be noted, and 
 if right-sided, icterus is not uncommon. Cough may occur spon- 
 taneously or on pressure. Pressure in the lower interspaces near the 
 spine elicits tenderness; tenderness over the cervical portion of the 
 phrenic nerve may be noted, together with pain reflected along the 
 acromial branches of the cervical nerves to the shoulder. Dys- 
 pnoea is usually great, the temperature is generally normal, the lower 
 chest moves but little, the respiratory murmur is very weak and 
 friction may be heard over the liver or in the " half-moon " space of 
 Traube. If there is no exudate, the diaphragm may remain hiffk 
 Fluid, accumulating between the diaphragm and lung without reach- 
 
PLEURISY. 535 
 
 ing the chest wall, causes no dulness. Fibrinous is more common 
 than serous effusion. 
 
 (b) Interlobar pleurisy occurs most frequently after lobar pneu- 
 monia or in tuberculosis. Previous pleurisy may favor its localiza- 
 tion by obliterating the general pleural space. As Laennec noted, it 
 is almost always suppurative. Its early diagnosis is uncertain, for 
 the fever, rales, cough and dyspnoea suggest a lesion of the lung; 
 the symptoms may resemble those of lung abscess from which differ- 
 entiation is sometimes impossible; later a zonular surface dulness is 
 found conforming to an interlobar fissure; the dulness is bounded 
 above and below by a normal or somewhat over-resonant note. The 
 heart may be pushed to the right, when there is left-sided localization, 
 but the liver is not luxated in right-sided localization. Interlobar 
 pleuritis may be shown clearly by the o>rays. Large effusions may 
 break internally, pus suddenly appearing in the sputum. Haemop- 
 tysis may occur. Puncture is attended with some danger, as the lung 
 may be infected by the needle, during its withdrawal. Spontaneous 
 recovery is infrequent. The outlines of the lobes are shown in Figs. 
 33, 34 and 35. 
 
 (c) Mediastinal pleurisy , described by Laennec and Andral, is 
 most often tuberculous or pneumococcic, and more frequently puru- 
 lent than serous. The symptoms of lung compression are less dis- 
 tinctive than are those of compression of the mediastinal tissues. 
 There may be wheezing, dyspnoea, dysphagia, intrathoracic oppression 
 or pain, a pertussis-like cough, enlarged thoracic veins from azygos 
 compression, deviation of the larynx or trachea, and dulness between 
 the scapula and spine ; the x-ray picture may be suggestive. The sud- 
 den onset and febrile course differentiate it from aneurysm, tumor 
 and adenopathies. The outlook is unfavorable without operation. 
 
 (d) Peri- (para-) pleuritis (Wunderlich, Bartels, Billroth) is an 
 inflammation outside of the parietal pleura, and is usually purulent. 
 Some cases follow glanders, but most of them are due to actinomy- 
 cosis. Fistula? and the evacuation of the characteristic sulphur gran- 
 ules are common. The symptoms are more local and irregular than 
 those of pleurisy ; fluctuation is more frequent ; heart dislocation and 
 lung compression are rare ; the respiratory excursion is free, and on 
 heavy percussion lung resonance may be elicited beneath the dulness. 
 Metastatic inflammation, perforation and burrowing are common. 
 
 3. Pleurisy in Children. — In children pleurisy is attended by 
 more general symptoms, higher temperature, higher pulse and more 
 rapid respiration. Bronchial breathing is more frequent, there is 
 less dulness, less luxation and less friction. It often follows pneu- 
 monia, where, in the majority of cases, the empyema is more benign. 
 Tuberculosis is less frequently causative in children than in adults. 
 According to Lemoine, metapneumonic pleurisy is distinguished from 
 the parapneumonic type, by its slower course. 
 
 Course. — The course of uncomplicated pleurisy averages three to 
 six weeks; acute cases last two, subacute three to eight and chronic 
 
536 
 
 DISEASES OF THE RESPIRATORY TRACT. 
 
 eight or more weeks. No general rule can be laid down, and the onset, 
 whether mild or stormy, is no index of the issue. No cycle is seen in 
 any form of pleurisy. Pleuritis acutissima, with high fever, typhoid 
 symptoms and early death is fortunately rare. Friction along the 
 lowest limits of the pleura and in front rarely attends great effusions 
 
 Fig 
 
 Fig. 34. 
 
 Fig. 35. 
 
 Cuts from Dieulafoy, showing : Fig. 33, the posterior surface of the lungs and tneir 
 interlobar fissures ; Fig. 34, the lateral aspect of the left lung ; and Fi<* 35 that of 
 the right lung. 
 
 and therefore, after the exclusion of tuberculosis, carcinoma or py- 
 aemia, the prognosis is relatively good. In the average case dry 
 pleurisy precedes and succeeds exudation. Eecurrence and exacerba- 
 tions render the prognosis unfavorable. Partial absorption with per- 
 sistence of temperature or with dyspnoea is indicative of tuberculous 
 pleurisy. Eheumatic pleurisies heal more readily than tuberculous. 
 The author has seen recovery of secondary carcinomatous pleurisy. 
 
PLEUBISY. 537 
 
 Issue. — 1. Resorption.— Resorption may occur; even purulent 
 pneumococcic pleurisy may, in exceptional cases, be absorbed in part 
 without operation or rupture, leaving inspissated caseous accumula- 
 tions. Serous pleurisies may be absorbed after three to six months, 
 during which time persistent friction is common over the lower chest. 
 
 2. Adhesions. — The thickness of pleural adhesions is more im- 
 portant than their extent. Universal obliteration of the pleural sac by 
 thin adhesions is of no consequence. Compensatory emphysema, pain, 
 thoracic oppression, obliteration of the complementary pleural space, 
 dulness, decreased vocal fremitus and breathing, failure of Litten's 
 phenomenon, decreased respiratory excursion and stagnation of bron- 
 chial secretion may occur when the adhesions are thick. If there is 
 .exudate around the heart, the apex beat may increase during the in- 
 spiration; this also occurs in bronchial catarrh (Eichhorst). Fail- 
 ure of the right heart and stasis may ensue, though most extensive 
 adhesions sometimes exist without cardiac embarrassment. Periton- 
 itis, mediastinitis and obliterative pericarditis may complicate the 
 case. In some instances the pleura calcines or ossifies, leaving a de- 
 posit measuring three cm. or more in thickness. 
 
 3. Sudden Death. — Fatal syncope may result after exertion, 
 coughing, urination or defecation; it results from paralysis of the 
 left ventricle, cardiac thrombosis, pulmonary oedema, bending of the 
 aorta, compression of the cava and rarely from pulmonary embolism 
 caused by venous thrombosis, rupture of fluid into the lung or bronchi, 
 which may drown the patient during sleep, and death from hemor- 
 rhage into the effusion, pneumothorax or brain embolism. 
 
 4. Retractio Thoracis. — Retraction is characterized by in- 
 creased resistance, decreased fremitus, decreased circumference of the 
 affected side and often by bronchiectasis. The percussion note is dull 
 and the breathing is usually decreased, but sometimes is bronchial. 
 The causative factors are atmospheric pressure, retraction of the 
 pleural scars, extension of the inflammation into the lungs (pleu- 
 rogenous interstitial pneumonia), which is also known as pleuritis 
 deformans, and which sometimes divides the lung up into lobes or 
 islets. Retraction is generally a slow process but the writer has seen 
 marked deformity develop in three weeks. 
 
 5. Changes in Other Organs. — When retraction occurs, other 
 organs may be dislocated. The liver may be higher when the right side 
 is involved, and in left-sided retraction the lung may shrink away 
 from the heart, the spleen and the heart may lie higher and Traube's 
 space may be increased. Organs displaced by exudate may in rare 
 cases remain luxated after the exudate is absorbed. Pleural callosi- 
 ties may produce recurrent laryngeal paralysis which may also fol- 
 low the pressure of a fluid exudate or enlargement of the glands. 
 Other complications are acute and chronic infiltration in the lung; 
 inflammation and degeneration in the chest muscles; extension to 
 other serous surfaces ; septicopyemia ; stasis in the liver, stomach, 
 extremities, etc. ; hemorrhages into the skin ; chronic nephritis ; 
 
538 DISEASES OF THE BESPIKATOBT TBACT. 
 
 amyloid, degeneration and pulmonary, glandular, genito-urinary or 
 miliary tuberculosis. Seagiiari reports forty-seven cases of paralysis 
 of the arm, probably due to brachial neuritis. 
 
 Diagnosis. — The physical findings only are final; symptoms are 
 most unreliable. Diagnosis of the malady is the first step, and the 
 second is the determination of its cause. 
 
 Diffekextiatiox. — 1. The diagnosis of pleuritis sicca is estab- 
 lished only by feeling or hearing the friction rub. (a) The crepitant 
 rale is largely inspiratory, and is heard as a number of small crackles at 
 the end of inspiration. Bronchitic rales or rhonchi are continuous, 
 Coughing and deep inspiration alter or remove rales but the pleural 
 rub is increased by pressure and deep inspiration and is less ex 
 tensive. It may disappear after a number of deep inspirations, be- 
 cause this makes the two surfaces temporarily smooth, (&) It must 
 be differentiated from sacculated breathing and from the physiolog- 
 ical, bilateral cracking in the chest muscles on deep breathing, (c) 
 Intercostal neuralgia is intermittent, occurs in typical attacks and is 
 limited to the interspaces ; Valleix's points are usually present at the 
 angle of the ribs, in the middle of the axilla and anteriorly, and cor- 
 respond to the points of exit of the posterior, lateral and anterior 
 perforating branches of the intercostal nerves. Intercostal neuralgia 
 is increased less on deep breathing than is pleuritic pain, (d) In 
 caries of the ribs pain is localized directly over one rib and not 
 between the ribs, (e) Differentiation from rheumatism of the tho- 
 racic muscles may be very difficult, for both affections may iuduce 
 pain on breathing, tenderness and disturbed breathing ; there may be 
 a history of cold or exposure or of repeated attacks. There is usually 
 no fever or cough. Faradization decreases the pain and movement 
 increases it more than is the case in pleurisy. (/) The rub in 
 pericarditis (q. v.) is more distinctly cardiac and depends upon the 
 cardiac movements. In pleurisy along the border of the heart, on 
 holding the breath the pleuritic rub is heard near or over the heart, 
 and decreases after five or six heart beats. On very deep inspiration 
 the pleural rub ceases and the pericardial rub is increased. Differen- 
 tiation is most difficult when there is pleurisy over the lingual lobe 
 and left border of the heart, though pericarditis most commonly pro- 
 duces a rub at the base of the heart, especially over the conns pul- 
 monalis arteriosus. 
 
 2. Pleuritis humida (pleuritis effusiva) must be distinguished (a) 
 from infiltration of the lung substance (see table in Dtagxosis of 
 PxefmoxeO. (b) Tumors of the lung produce cachexia, narrow- 
 ing of the chest behind on one side and the characteristic exudate; 
 this is often brown (Frankel) and sometimes chyliform, and contains 
 fat globules (Quincke) and degenerated large cells which mav show 
 mitoses ; the glands above the clavicle may be'enlarged, as well as those 
 in the mediastinum, which produce recurrent larvneeal paralvsis. 
 Tumor particles are rarely obtained by puncture or in the sputumj 
 and are only found in carcinoma, for sarcoma rarelv ulcerates.' 
 
PLEURISY. 539 
 
 When tumors of the lung are suspected, a trocar rather than a needle 
 should be used. There is more resistance to puncture in tumor than 
 in pleuritis. Unverricht observed the development of carcinoma 
 at the seat of puncture. In tumors there is ]ess displacement, less 
 invasion of Traube's space and less widening of the chest than in 
 pleurisy, and the breathing is often bronchial, the flatness is intense 
 and the fremitus is increased, (c) Hydrothorax (q. v.), usually 
 described as bilateral, may be unilateral, especially in disease of the 
 liver, kidneys and heart, where right-sided hydrothorax is observed. 
 Unilateral hydrothorax is sometimes explained by obliteration of the 
 other pleural cavity by adhesions. The fluid readily shifts its level 
 on change of posture, which does not occur in pleurisy. The claim 
 that salicylic acid, iodine and potassium iodide pass readily into 
 transudates and but slowly and in small amounts into exudates has 
 been disproven by Weintraub, Leuch and Feldmann. In hydro- 
 thorax, the specific gravity is below 1,014, the albumin is 1 to 3 per 
 cent, and the sediment shows few white cells and some endothelial 
 cells. Bacteriological tests are negative, (d) The presence of Jice- 
 mothorax is determined only by puncture. 
 
 3. Circumscribed pleurisy requires differentiation (a) from peri- 
 carditis; pleurisy shows a more irregular outline, the apex beat is 
 not altered and there is no cardiac insufficiency or pericarditic 
 friction, (b) Lung cavities show dulness when full of secretion and 
 resonance when the secretion is voided ; the fluid obtained by puncture 
 (which is made under a wrong diagnosis) has a higher specific 
 gravity and a larger percentage of fat than that of pleurisy, (c) 
 Differentiation from splenic tumors is determined by respiratory ex- 
 cursion and palpation of the lower edge of the spleen, (d) Liver en- 
 largements rarely occur solely upward, save in echinococcus and in 
 abscess of the convexity; these are prone to occur anteriorly, and 
 pleurisy is more frequently detected posteriorly. In tumors of the 
 liver there is usually respiratory excursion which is absent in pleurisy. 
 (e) Subphrenic abscess (v. Localized Peritonitis) may be intra- 
 peritoneal (as from liver abscess) or extraperitoneal (e. g., perineph- 
 ritic). The liver stands higher in the chest because of the paretic 
 diaphragm. There may be a history or physical signs of previous 
 disease of an abdominal organ. The needle, when thrust toward 
 the abscess, reaches the pus only when thrust deep in the lower inter- 
 spaces. The pus has frequently a faecal odor. The manometer 
 shows increased pressure during inspiration and decreased pres- 
 sure during expiration, the converse of the findings in pleural effu- 
 sion. (/) Abscess of the liver. Pleurisy, serous or suppurative, 
 may complicate abscess of the liver. Differentiation is easy when 
 abscess of the convexity is located forward ; when it is situated poster- 
 iorly, aspiration alone will distinguish it ; the pus shows liver cells, 
 amoebae, cholesterin or bile, (g) 43 cases of pleural echinococcus 
 are reported; 11 per cent, of hepatic cysts reach the lung and pleura. 
 
 Prognosis. — The immediate mortality is about 5 per cent., though 
 
540 DISEASES OF T3E RESPIRATORY TRACT. 
 
 an early prognosis cannot be made, (a) The etiology is an important 
 factor, (b) The nature of the fluid is of prognostic import. Fibrin- 
 ous pleurisy (except when it occurs at the apex of the lung) is the 
 most favorable type. Prince Ludwig Ferdinand considers the prog- 
 nosis in the effusive forms as follows: (i) most favorable in meta- 
 pneumonic serous or purulent pleurisy; (ii) next most favorable in 
 serous pleurisy due to the staphylococcus, (iii) less favorable in 
 staphylococcus empyema, (iv) least favorable in tuberculous, foetid or 
 putrid forms. The prognosis is usually poor in hemorrhagic, chyli- 
 form, peracute and bilateral (generally hemorrhagic or purulent) 
 effusions. It is more favorable in effusions which are relatively 
 rich in solid constituents (Mehu and Bernheim) ; effusions contain- 
 ing little solids are apt to recur. When the freezing point of the 
 exudate is found by cryoscopy to be below that of the blood, spon- 
 taneous absorption is unlikely to occur (Rothschild). Since the 
 time of Hippocrates, the belief has prevailed that right-sided are less 
 favorable than left-sided effusions, -(c) The persistence of tempera- 
 ture and sweats, anaemia, recurrences and external rupture are unfav- 
 orable, (d) Sudden death is more frequent than it is usually be- 
 lieved to be. The author saw three cases in one year. 
 
 Opinions vary as to the ultimate prognosis. Eighty-seven per cent, 
 of cases become tuberculous in one to two years (Fiedler) ; 33 per 
 cent die in five years (Bars) ; 6 per cent, are curable (Osier) ; 15 
 per cent, die of tuberculosis, 90 per cent, are in good health after 
 two to five years and 80 per cent, are healthy after five years (Cabot). 
 
 Treatment. — Etiological treatment is applicable only to the rheu- 
 matic and syphilitic forms. 
 
 Treatment of fibrinous pleurisy, which remains fibrinous, or of the 
 fibrinous or first stage of exudative pleurisy. Pain is the main indi- 
 cation; morphine may be given in severe cases, especially when 
 coughing is severe ; the ice-bag, poultices, blisters, cups and hot fomen- 
 tations give little relief when the pain is acute ; blisters may eventu- 
 ally cause as much pain and discomfort as the disease itself; the 
 pleura should be splinted by three or four strips of adhesive plaster 
 two inches wide, overlapping the median line before and behind 
 by about three inches, and running around the chest horizontally 
 and obliquely; these should be applied with considerable pressure 
 during expiration, that the lung in its lower part and the pleural 
 surfaces may be well immobilized ; zinc oxide adhesive plaster is least 
 irritating to the skin. Personal experience with the early use of sali- 
 cylates, has not been satisfactory. The patient should be kept in bed. 
 
 In serous pleurisy, the patient should be kept in bed, and the cough 
 and fever treated expectantly. Laxatives are given solely to obviate 
 straining at stool, which may induce cardiac weakness ; they do not 
 reduce the effusion. If at the end of the second week the' effusion 
 shows no sign of being absorbed, various measures are indicated; 
 Schroth's treatment consists in limiting the amount of fluid ingested 
 to about one quart (1000 c.c.) daily, but the method gives no results 
 
PLEURISY. 541 
 
 as exudation is an active, not a passive process ; tincture of iodine is 
 seldom beneficial, and when old is distinctly a local irritant; potas- 
 sium iodide, digitalis, drastics to produce copious evacuations, pilo- 
 carpine (combined with cognac to support the heart), cotton jackets 
 and sweats are often given. Of late a salt-free diet (dechlorination) 
 is advised, as in nephritis (q. v.). The author cannot agree that any 
 of these measures are helpful and believes pilocarpine is always dan- 
 gerous. Transudates may be removed in this way but not exudates. 
 
 Aspiration. — Trousseau's indications were (a) the vital indica- 
 tion (when life is threatened, because of large exudates) ; (b) 
 moderate effusions with slow resorption, and (c) persistent or re- 
 sidual exudates. The author believes that early puncture (thoraco- 
 centesis) and aspiration are indicated in every case, where two 
 quarts or more (2,000 or 2,500 c.c.) of fluid are effused, whether the 
 temperature is still high or not, and whether pressure symptoms or 
 dyspnoea are present or not. This amount of effusion causes dislo- 
 cation of the heart, liver or spleen, compression of the lung or ectasia 
 of the chest; high intrathoracic pressure may cause sudden death, 
 sometimes without any warning symptoms of cardiac insufficiency. 
 Early puncture does not irritate the pleura or favor recurrence or 
 suppuration. Early and repeated punctures obviate compression of 
 the lung and atelectasis, as well as compression and torsion of the large 
 arteries. Aspiration was first performed by Hippocrates and ex- 
 ploited by Schub and Skoda (1841) and Trousseau (1844). 
 
 Method of Aspiration, — After the usual surgical antisepsis, a 
 small trocar or large aspirating needle is introduced, which has an 
 elbow connecting with a rubber tube, to siphon the fluid to a vessel 
 below, or connecting with a bottle which can be exhausted by a pump. 
 There is no absolute rule as to the site of puncture. This must be 
 governed solely by the physical signs ; for instance, adhesions which 
 hold the lung to the surface vitiate any set law; fluid is usually 
 obtained between the scapular and post-axillary lines and low down 
 in the chest. The trocar should be introduced perpendicularly to 
 the chest wall and not obliquely, in order to avoid injuring the inter- 
 costal artery lying above the rib, as a result of which the author 
 twice saw fatal hsematoma and hsemothorax. Whiskey and hypo- 
 dermics should be at hand, because of the possibility of syncope. The 
 use of the pump is necessary in but 10 per cent, of cases, for the 
 fluid can usually be siphoned readily ; a tube is attached to the needle 
 or trocar, filled with boric acid solution, clamped with an artery 
 forceps and undamped, when it is placed in a basin containing the 
 same solution and at a lower level than the seat of puncture. The 
 fluid, if pumped, should be withdrawn gradually ; caution is necessary 
 lest air be pumped the wrong way, i. e., into the pleura. The 
 amount removed need not be great, as moderate relief of intrapleural 
 tension often promotes absorption. The blood pressure during aspir- 
 ation should be controlled by the sphygmomanometer. The amount 
 to be withdrawn is estimated arbitrarily at one quart (1,000 c.c, 
 
542 DISEASES OF THE EESPIBATOEY TRACT. 
 
 Naunyn and Dieulafoy) or three pints (1.500 or 1.600 c.c, Frankel 
 and Bowoliteh). Complete or nearly complete evacuation may cause 
 the accidents enumerated below and is thought by Litten to induce mil- 
 iary tuberculosis. Aspiration should be discontinued when the exu- 
 date becomes bloody (from lung injury), when friction develops, 
 when pain is felt or when coughing (from congestion of the relaxed 
 lung) begins. Repetition of puncture; a second puncture is necessary 
 in 25 per cent, and a third in 5 per cent, of effusions. Favorable 
 results are slowing and strengthening of the pulse, relief of oppression, 
 increased diuresis, return of luxated organs to their place and im- 
 proved appetite ; but relief of pressure on the lung and absorption of 
 the exudate are of the greatest importance. Unfavorable results are 
 
 (a) syncope due to cerebral ana?mia which results from reflux of 
 blood to the expanding lung which contained little blood before it 
 was relieved by the puncture, a relatively uncommon occurrence; 
 
 (b) pulmonary oedema, the albuminous expectoration described by 
 Terillon, Besnier, Johnson, Diiffin and Scriba. which is due to the 
 sudden withdrawal of too much fluid (two to five liters) at one tap- 
 ping: it should take a half -hour to evacuate one and a half quarts 
 or 1,500 c.c. (Frantzel) ; oedema pulmonum is treated most success- 
 fully by hypodermics of morphine, gr. J and some clinicians advise 
 giving it before aspiration: Sears records 10 deaths from simple 
 puncture: ( c) sudden death from pulmonary embolism or cerebral 
 embolism : the latter results from discharge of clots from vessels in 
 the relaxing lung, and causes the so-called pleuritic hemiplegia; 
 some reported cases are hysterical; (d) injury to the heart, liver 
 or spleen; (e) pneumothorax and subcutaneous emphysema may occur 
 though the author has never seen them. (/) The author twice 
 witnessed an extensive hemothorax and subcutaneous hematoma in a 
 pleural puncture, in which the trocar was impatiently thrust in and 
 out during an unsuccessful thoracocentesis. Xaunyn writes of death 
 following puncture of an atheromatous intercostal artery, (g) Fi- 
 brinous bronchitis has followed paracentesis. "When repeated punc- 
 tures fail to produce the desired results, the advisability of operation 
 (as in empyema) should be considered. 
 
 Empyema in all cases necessitates operation (practiced by Eury- 
 phon and after him by Hippocrates). Some cases may recover 
 spontaneously, but this cannot be depended upon. A day or two 
 before operation, aspiration is indicated when the fluid is under high 
 tension, thereby relieving the heart. Some surgeons advocate treat- 
 ing tuberculous empyema without operation, as Volkmann treated 
 other cold abscesses : Kronlein observed, after operation on these cases, 
 recovery in 36 per cent., improvement in 28 per cent, and death in 
 36 per cent. Results depend on the etiology and bacteriology. The 
 mortality in Velpeau's cases was 100 per cent, and that of Dupuy- 
 tren was 92 per cent. ; Dupuytren himself " chose to die of empyema 
 at the hands of God rather than to die at the hands of man under 
 operation.'*'' In Schede's series the mortality of tuberculous empyema 
 
PNEUMOTHOBAX. 543 
 
 was 77 per cent., of metastatic 32 per cent., of metapneumonic 13 per 
 cent, and of primary, 8 per cent. 
 
 Hemor7'hagic effusions may necessitate injections of gelatin sub- 
 cutaneonsly; the amount aspirated should not exceed one pint (500 
 c.c.) and aspiration should be repeated as seldom as possible. 
 
 After-treatment is directed toward prevention of thoracic retrac- 
 tion, to which end gymnastics and deep breathing are essential. 
 A patient having suffered from a "primary " effusive pleurisy should 
 be treated as one with latent tuberculosis. 
 
 PNEUMOTHORAX. 
 
 Definition. — Pneumothorax is an accumulation of gas or air in the 
 pleural sac. It was named by Itard of Paris (1803) and was 
 described fully by Laennec (who in 1819 made the first diagnosis) 
 and Skoda. Hippocrates described succussion. As it excites pleur- 
 isy in 90 per cent, of the cases, the following varieties are distin- 
 guished : pyo-, sero- and hwmopneumothorax. 
 
 Etiology. — 1. Diseases of the lung and pleura cause about 95 per 
 cent, of all cases. In Biach's collection of 918 cases in Vienna, pul- 
 monary tuberculosis was causal in 77 per cent., gangrene in 7 per 
 cent., empyema 5 per cent., trauma 3 per cent., bronchiectasis and 
 abscess each 1 per cent., the etiology was unknown in 2 per cent, and 
 the remaining 4 per cent, were due to emphysema, infarct, thoraco- 
 centesis, echinococcus and contiguous disease perforating into the 
 pleura, as gastric or oesophageal ulceration or caries of the sternum. 
 By other writers (a) tuberculosis is thought to cause 80 or over 90 
 per cent. ; acute forms are more important than chronic tuberculosis 
 in which there are protecting pleural adhesions ; pneumothorax de- 
 velops in two (Prasche) to six (Eichhorst) per cent, of tubercu- 
 lous cases, (b) Ulcerative lesions of the lung (v. s.) may erode 
 the pleura and admit air. (c) Trauma, rupturing of the lung 
 directly or by contra-coup, thoracocentesis or stab wounds, occur far 
 less frequently than one would expect, (d) Empyema may rup- 
 ture into the lung without allowing ingress of air from the opposite 
 direction, (e) Rupture of a healthy lung by tearing away of the 
 lung as pleural adhesions give way in coughing, muscular straining 
 or violent coughing in pertussis is very exceptional. 
 
 2. Perforative lesions in the mediastinum, oesophagus, peritoneum, 
 stomach or colon and subphrenic abscess are uncommon causes (v. s.). 
 
 3. Pneumothorax may occur spontaneously. The view held by 
 Oppolzer, Biermer and others that putrefaction may occasionally 
 develop primarily (without rupture) has received confirmation by 
 discovery of the Bacillus aerogenes capsulatus and other gasogenic 
 organisms (Lewy, Welch and Frankel). It is always possible, how- 
 ever, that a point of rupture in the lung is overlooked or has healed 
 over, and the fact remains that air enters the pleura chiefly from 
 the lung or from a gas-containing organ. 
 
544 DISEASES OF THE RESPIRATORY TRACT. 
 
 Pneumothorax occurs largely in adults and four to seven times as 
 frequently in males as in females. Cozzolino (1906) found only 41 
 cases in children ; of these but 40 per cent, were tuberculous. Eich- 
 horst and Drasche find it more often on the right side. 
 
 Pathology. — When the chest is opened, air or gas escapes with a 
 force sufficient to blow out a candle. The volume of air may exceed 
 2,000 c.c, and its tension, studied first by Wintrich and Weil, com- 
 presses and collapses the lung, dislocates the heart and mediastinum 
 and depresses the diaphragm and subphrenic organs. The gas may 
 be odorless or foetid. The pathological and clinical findings vary 
 
 (a) as the gas is encapsulated or occupies the entire pleural cavity; 
 
 (b) as the air is aseptic (producing a pure pneumothorax, or one 
 with slight exudation) or is infected by the organisms of the primal 
 disease Avhich excite serous, purulent or putrid pleurisy; (c) as the 
 air-containing cavity is "closed," "open" (into a bronchus, or some- 
 times also open externally) or possesses a valve, thus allowing pas- 
 sage of air in one but not in the opposite direction. These points will 
 be considered below. 
 
 Symptoms. — The onset is usually sudden, occurring spontaneously 
 or following coughing or muscular exertion; it is characterized by 
 sudden pain in the side, cyanosis, dyspnoea and collapse, due to reflex 
 action on the vagus ; there may be sudden evacuation of pus from the 
 breaking into the lung of an empyema ; an urticaria occasionally 
 develops (Gerhardt, Senator) ; decreased diuresis, albuminuria, stasis 
 and subcutaneous emphysema are sometimes observed. The onset 
 may resemble angina pectoris, pulmonary embolism or abdominal 
 perforation. The onset may be insidious for pneumothorax some- 
 times constitutes an unexpected post mortem finding. In other in- 
 stances the previous history or the course may justify a presumptive 
 diagnosis, as in a case clearly tuberculous ; and in still other cases, a 
 latent lung lesion (a small caseous focus) may burst and thus pro- 
 duce its first symptom. 
 
 Physical Findings. — 1. Inspection. — (a) The affected side is dis- 
 tended 2 to 4 inches (5 to 10 cm.) and immobile, and contrasts 
 sharply with the widely-moving sound lung, (b) The interspaces 
 are obliterated, (c) The heart and liver or spleen are dislocated, 
 (d) There is dyspnoea and cyanosis, (e) The attitude is characteris- 
 tic; the patient most often lies on the affected side to afford ample 
 play to the sound lung; sometimes there is orthopnea and if the 
 point of rupture opens into the lung or bronchus, a peculiar decubitus 
 may be assumed, in order to drain the pleura. (/) The x-r&js 
 show the lung flattened near the spine, the diaphragm depressed and 
 motionless, and the shadow of the effusion. 
 
 2. Palpation. — (a) Vocal fremitus is absent, unless adhesions 
 hold the lung to the chest wall, (b) The chest wall feels resistant 
 and (c) sometimes splashing, fluctuation or a "pillow sensation" is 
 noted, (d) The dislocated apex beat and the edge of the liver or 
 spleen are felt. 
 

 PNEUMOTHORAX. 
 
 545 
 
 3. Percussion. — Somewhat different results are obtained accord- 
 ing to the tension of the gas and the chest walls, (a) In open pneu- 
 mothorax the note is full, tympanitic and even metallic when percus- 
 sion is made on a solid object, as a coin; this metallic reverberation, 
 called hruit d'arain by Trousseau, is found in 75 per cent, of cases; 
 cracked-pot resonance and Wintrich's change of note may be elicited 
 when the mouth is opened, (b) In closed pneumothorax the note 
 is full and loud ; it is tympanitic when there is moderate pressure and 
 the intercostal muscles are relaxed; again the note may be dull 
 (Skoda) if the tension is great or if the chest muscles are spasmodi- 
 cally contracted, as in sudden pneumothorax (vagus reflex action), 
 (c) Flatness over the lower thorax usually results from pleural 
 effusion. This dulness may Occur without coincident pleurisy, and 
 conversely, the author has seen tympany prevail over the entire side, 
 even where there was great pleural effusion. Skoda said that the 
 fluid is twice as much as we anticipate, (d) On change of pos- 
 ture, a changing level of the fluid is readily elicited, the gas being 
 found above and the fluid below, for the gas acts in this respect as 
 
 Fig. 36. 
 
 II 
 
 I. Left-sided effusive pleurisy, showing relative heart dulness (A), effusion (B), 
 liver flatness (C), and fluid impinging on Traube's half-moon space, of which but a 
 small part remains resonant (D). 
 
 In larger effusions reaching, e. g., up to the dotted black line, the relative heart 
 dulness may be pushed over to the dotted line (over C). 
 
 II. Left-sided pneumothorax marked by tympany (T. T.), pushing over the medi- 
 astinum and also the heart to the right, and pushing down the left lobe of the liver 
 and the spleen. 
 
 a spirit-level ; this change is far more important than in simple pleur- 
 isy, as there are no adhesions, (e) The pitch over the gas-distended 
 part changes with change of posture (Biermer's change of note). 
 It becomes deeper as the patient sits up, because the vertical dimen- 
 sion of the chest is thus increased by the pushing down of the dia- 
 35 
 
546 DISEASES OF THE EESPIEAIOEY TEACT. 
 
 phragm. (/) The heart dulness is replaced by resonance in left- 
 sided pneumothorax, and is found to the right of the sternum: in 
 right-sided pneumothorax the luxation is less and towards the left ax- 
 illa, (g) The liver or spleen dulness is pushed well downward. 
 
 4. ArscrLTATiox. — (a) The breath sounds are usually absent 
 in the closed variety of pneumothorax, and this, with ectasia and hy- 
 perresonance. is most characteristic. In the open and sometimes in 
 the closed form, the breath sounds are bronchial, amphoric or metallic, 
 the voice sounds, especially under the clavicle, are metallic (metallic 
 bronchophony), and coincident rales in the bronchi are also metallic. 
 Amphoric sounds were referred by Laennec to a fistula but probably 
 are due to the air acting as a sounding board, (b) Air passing 
 through the point of rupture may produce curious snapping or whist- 
 ling sounds; the point of rupture is oftenest between the second and 
 fourth interspaces and between the mammary and axillary lines. 
 (c) The gutta cadens (the metallic ** falling drop'') may be due to 
 rales or dripping of fluid from fibrin shreds as the patient's posture is 
 changed, (d) The Hippocratic splashing (s-uccussio Hippocratis •) 
 was first carefully described by Laennec and is elicited by placing the 
 ear to the chest and sharply shaking the patient ; it is sometimes heard 
 at a distance from the patient and in one of James" cases wa> heard 
 over a large clinical amphitheatre : in three cases patients have spon- 
 taneously called the author's attention to a " splashing in the chest " : 
 it is oftenest heard in the side or in the interscapular area and in 
 three-quarters of the cases : succussion usually declares the fluid be- 
 fore dulness develops, (e) The heart tones may be metallic, and the 
 heart's action may even cause splashing sounds. Hellin collected 
 5T cases of double pneumothorax : it is not incompatible with life. 
 
 Diagnosis. — The ectasia, the resonant note, suppressed or amphoric 
 breathing, cardiac and other hvxations and succussion are most char- 
 acteristic. 
 
 Type. — Contrary to the usual statement, Weil proved that dislo- 
 cation occurs in all types, though it varies in degree. ( a ) In the 
 open form TVintrieh's change of note on opening the mouth, metallic 
 sounds, the fistula murmur, periodic expectoration of large amoimts 
 of pus, moderate cardiac and other dislocations and no manometric 
 increase of the tension in the pleura are distinctive. Methyl blue 
 injected into the pleura is coughed up. (b) The closed type is dis- 
 tinguished by increased manometric tension, absence of breath sounds, 
 marked ectasia, change of note on sitting but not on opening the mouth 
 and marked luxations, (c) In the valvular form air may enter the 
 pleural cavity but cannot escape back and therefore pus cannot be 
 voided. Some of the auscultatory findings of the open type are 
 noted. The manometer shows increased pressure. The fistula may 
 become permanently closed by organic change (organic type), so 
 that aspiration of the air is not followed by further accumulation: 
 or the fistula may be only mechanically closed, and air may reaccum- 
 ulate after its aspiration. 
 
PNEUMOTHORAX. 547 
 
 Differentation. — (a) Cavities may be simulated by circum- 
 scribed pneumothorax, but in cavities the interspaces are sunken, 
 the fremitus is increased when they are empty, luxation is absent 
 and the Hippocratic succussion and coin sound are extremely rare. 
 (b) Pleurisy can be distinguished on careful examination, (c) 
 Meteorism is at once excluded by filling the stomach or colon with 
 water, (d) Diaphragmatic henna is very frequently confused with 
 pneumothorax; out of 433 cases collected by Grosser only 12 were 
 recognized. In Dehio's recent case the sc-rays determined the con- 
 dition. Respiratory excursion is present and the tympany and metal- 
 lic sounds are usually accompanied by such symptoms of marked in- 
 carceration as vomiting, colic, obstipation and indicanuria. The in- 
 testines push the heart to the right. Nutty per cent, of cases of 
 diaphragmatic hernia are left-sided, (e) Pyopneumothorax subphren- 
 icus (q. v. under Peritonitis, Localized Forms), described espe- 
 cially by Leyden, results from abdominal lesions, such as cancer, 
 ulcer, appendicitis, disease of the gall-tracts, trauma and foreign 
 bodies whose histories are at least suggestive. Thoracic symptoms, as 
 cough, sputum and dyspnoea, are not conspicuous, at least early in the 
 process and the lungs may show perfect excursion, though the dia- 
 phragm is sometimes paretic. The manometer shows that the pres- 
 sure is increased during inspiration and decreased during expiration, 
 the converse of which is true in pneumothorax. The arrays show 
 that the diaphragm is above the fluid, while in pneumothorax it is 
 below the fluid. 
 
 Prognosis. — The prognosis varies with the cause, the condition of 
 the lungs and the character of the fluid, but it is always serious. 
 Cases in a healthy lung following exertion, trauma or infarct are 
 relatively favorable. The closed and open are more auspicious than 
 the valvular type. In tuberculosis, pneumothorax seems to arrest 
 the tuberculous focus if it is small (Herard, Toussant, Frantzel) 
 and if no mixed infection occurs, but even in these cases complete 
 ultimate recovery is infrequent. Eichhorst observed one case which 
 lasted for five years. Gabb records a case which recovered and 
 relapsed four times, the attacks being two to four years apart. Ac- 
 cording to Weil 25 per cent, die within a week and 50 per cent, 
 within a month ; West observed a mortality of 70 per cent., of which 
 three-quarters died within two weeks, nine-tenths in less than a month 
 and one case in twenty minutes. 
 
 Treatment. — The results of treatment are disappointing, (a) Nar- 
 cotics and stimulants are imperative at the time of the rupture, for 
 collapse, dyspnoea and cyanosis, (b) Aspiration is of most value in 
 the serous forms: early aspiration may open a healing fistule. (c) 
 The radical operation is indicated in putrid or purulent pneumothorax. 
 Though some prefer not to interfere in the tuberculous cases on the 
 ground that the compression exerted upon the lung by the pneumo- 
 thorax is semicurative, others advise operation; Leyden reported 66 
 per cent, and Richardiere 50 per cent, of recoveries. 
 
548 DISEASES OF THE RESPIRATORY TRACT. 
 
 HYDROTHORAX. 
 
 Definition. — Hydrothorax is a serous transudation into the pleura. 
 
 Etiology. — (a) Stasis, from cardiac, pulmonary or vascular factors 
 is a frequent cause. In failure of the right heart the superior cava 
 is imperfectly drained, which congests the vena azygos and hemiazy- 
 gos and this leads in turn to pleural transudation. It may occur 
 alone or precede dropsy but is of tener a part of general dropsy. Local 
 venous obstruction from mediastinal tumor or aneurysm may induce 
 hydrothorax. ( b ) Blood changes resulting from multitudinous anaemic, 
 marantic or cachectic states, as nephritis, cancer and blood diseases. 
 Under these captions may be brought diseases which alter the walls of 
 the vessels. The chief factors are cardiac and renal. 
 
 Symptoms and Diagnosis. — 1. The symptoms of hydrothorax do not 
 include pain or fever. The condition accentuates, sometimes con- 
 siderably, the dyspnoea attending the causal stasis or cachexia. The 
 amount of fluid varies from ounces to quarts (or even to two gallons). 
 
 2. The physical signs are essentially those of moderate effusive 
 pleurisy, except that the rub is absent; the fluid shifts with much 
 greater facility on change of posture and produces a moderate com- 
 pression of the lungs and luxation of the heart, liver and spleen. 
 The transudate is usually described as bilateral (in 83 per cent., 
 according to J. Dutton Steele), but in over half the cases it is uni- 
 lateral and often right-sided, in cardiac, renal and hepatic disease, 
 or less often, when previous adhesions obliterate the opposite pleura. 
 Stengel explains right-sided hydrothorax by pressure on the azygos 
 by the dilated right heart or cava or the luxated root of the lung. 
 
 3. The fluid is clear, slightly green, possibly moderately blood- 
 tinged if it develops during the death agony, and shows a specific 
 gravity of about 1,010 to 1,015'; it contains but little fibrin and at the 
 most develops only light delicate flocculi ; the albumin ranges between 
 1 and 3 per cent. Centrifuging brings down only a few leukocytes, 
 endothelial cells and red disks, but no bacteria. Right hydrothorax 
 may prove very obstinate, probably because a low grade of inflamma- 
 tion eventually supervenes. 
 
 The prognosis and treatment are those of the cause; aspiration 
 often prolongs life. 
 
 HEMOTHORAX. 
 
 Blood effusion into the pleura is a rare malady. It may be caused 
 by trauma, scurvy or allied blood diseases, by aneurysmal rupture, 
 by ulceration of the pulmonary or pleural veins and by various ne- 
 crosing lung diseases. It may occur with pleurisy and pneumothorax 
 and has resulted from thoracocentesis. Its symptoms are essentially 
 those of hydrothorax; it is suspected only by a sudden onset with 
 signs of acute ansemia, and is proven only by the exploring needle. 
 Its treatment is symptomatic; for the occasional syncope, the usual 
 stimulants should be given; ice should be applied to the chest or a 
 
MEDIASTINAL TUMORS. 549 
 
 2 per cent, gelatin solution injected for haemostasis ; operation is in- 
 voked when indicated by the causal lesion. 
 
 CHYLOTHORAX. 
 
 A very rare affection, in which true chyle or chyliform fluid is 
 found in the pleura. Its etiology is much disputed; (a) in the 
 genuine chylous cases true chyle containing sugar is found, though 
 of late years sugar has been found in very many forms of serositis 
 and in most transudates ; only 60 cases of this type are recorded. In 
 11 cases (of which 4 died and of which 9 were right-sided), trau- 
 matic rupture of the thoracic duct has been found. In others the 
 duct was obstructed by thrombosis of the subclavian vein or by glands 
 and tumors. (&) In a second group, the pseudochylous (chyliform or 
 adipose), there is no chyle and the milky appearance is due to fatty 
 or minute albuminous granules held in suspension. This variety is 
 chiefly tuberculous or carcinomatous. It has been thought that old 
 empyemas may become chyliform. The characters of both forms of 
 fluids will be considered under chylous and adipose ascites, with 
 which they are frequently associated. The signs are those of trans- 
 udation or exudation. 
 
 PLEURAL TUMORS. 
 
 Pleural tumors are nearly always secondary to pulmonary, medi- 
 astinal or extrathoracic growths. Carcinoma and sarcoma are the 
 most frequent forms ; enchondroma, lipoma, hypernephroma and 
 dermoids are very uncommon. The pleura is involved by contiguity 
 or metastasis. Wagner, Frankel and Eiedel described a primary 
 endothelioma of the pleura, of which 50 cases are reported, but, as 
 stated under the etiology of pleurisy, it is considered by some as solely 
 inflammatory; clinically it presents the picture of chronic pleurisy 
 plus occasional metastatic deposits in the liver, lungs, kidneys, 
 muscles and lymph glands. The signs are those of lung tumor plus 
 those of pleurisy; the clinical diagnosis of primary tumor is at the 
 best but probable, even if tumor particles are obtained by puncture. 
 
 DISEASES OF THE MEDIASTINUM. 
 
 MEDIASTINAL TUMORS. 
 
 Mediastinal tumors are very rare. They are usually primary. 
 Sarcoma is the most common form and then carcinoma; lipoma (7 
 reported cases), substernal struma, thymic growths, fibroma, myoma, 
 
550 DISEASES OF THE BESPIRATORY TRACT. 
 
 osteoma, enchondroma, echinococcus, dermoid (64 cases collected by 
 Christian, 1908), teratoma, gumma, tubercle, leukemic, pseudoleu- 
 ksemic and chloromatous adenopathies are rarer forms. Sixty per 
 cent, occur in males between twenty and thirty years of age. 
 
 Symptoms. — Symptoms develop gradually. (1) Local signs: — (a) 
 Bulging may be present in the jugulum or under and near the 
 sternum, especially in lymphosarcoma, or it may show in the anterior 
 mediastinum and cause stretching of the 'skin, (b) There may be 
 pulsation, imparted by the heart, aorta or its branches; expansile 
 pulsation is rare, (c) The tumor or secondarily involved glands may 
 be palpable deep in the jugular notch. The vocal fremitus varies. 
 (d) The sternum may be exquisitely tender from erosion, (e) Dul- 
 ness may be elicited under or near the sternum, or, if the posterior 
 mediastinum is involved, in the back; the dulness may blend with 
 the heart, suggesting aneurysm or effusive pericarditis, though it is 
 more irregular than in either of these affections. (/) Auscultation 
 gives variable results ; sometimes there is bronchial breathing, or if 
 the bronchi are closed the breath sounds may be absent. 
 
 2. Compression symptoms, as in aneurysm, may predominate in 
 tumors of the posterior and middle mediastinum, though local phys- 
 ical findings may be slight or absent, (a) The vagus and its branches 
 may be affected. Paroxysmal asthma and orthopnoea are common. 
 Dyspnoea is the earliest and most frequent symptom of mediastinal 
 tumor, is partly due to compression of the vagus, and partly to tra- 
 cheal, cardiac and pleuritic involvement. Other vagus symptoms are 
 brazen cough from paralysis of the vocal cords, tachy- or bradycardia, 
 hiccough, vomiting or oesophageal spasm, (b) The trachea or bronchi 
 may be compressed from without or occluded by growth into their 
 lumina, in which case the symptoms of tracheal or bronchial stenosis 
 may be pronounced. Tracheal tugging and shrinking of one side 
 of the chest (instead of bulging) may be noted. The sputum may 
 contain blood, tumor tissue or hair. The larynx may show lateral 
 deviation, (c) The arteries of the neck may show a systolic stenotic 
 murmur, but the veins are more often compressed, especially the in- 
 nominates or the superior cava, which cause bilateral or unilateral 
 oedema and, less often, cyanosis of the face, neck and arms ; enlarge- 
 ment of the veins on the thorax indicate the collateral circulation. 
 (d) The heart may be compressed and dislocated, downward and out- 
 ward if the growth emanates from the anterior mediastinum, for- 
 ward if from the posterior mediastinum. Dislocation of the liver and 
 spleen are less common, (e) The oesophagus may be so compressed 
 and dysphagia may be so extreme that death from inanition results. 
 (/) Inequality in the pupils is uncommon, (g) Neuralgia, muscular 
 paralysis or even spinal paraplegia may result. The boring pain of 
 aneurysm is rare. 
 
 Diagnosis. — A diagnosis is positive from the signs, or presumptive 
 from the symptoms. Dyspnoea, ectasia, irregular substernal dulness, 
 
MEDIA S TIN IT IS. 5 5 1 
 
 venous stasis, bronchial stenosis, heart luxation and the rr-ravs picture 
 make the diagnosis probable: puncture may both eliminate the possi- 
 bility of aneurysm and withdraw tissue or dermoid material 
 ( Torek) : the sputum sometimes voids tumor particles, booklets and 
 hair. Deep aneurysm (q. v.) is most difficult to eliminate. The 
 irregular dulness and the apex beat at its extreme limit to the left 
 exclude pericarditis. Tumors of the lung and pleura produce 1- — 
 pressure symptoms, though such differentiation is rather academic. 
 Prognosis and Treatment. — The prognosis is unfavorable, as malig- 
 nant growths cause emaciation and death from inanition, compres- 
 sion, exhaustion or pneumonia results within a few months. Benign 
 tumors run a longer course, sometimes five to seven years, or even 
 forty in Lebert's dermoid case. Treatment is palliative. A few suc- 
 cessful operations are reported : in twenty operated cases of dermoid. 
 70 per cent, recovered (K. S. Morris ). 
 
 MEDIASTINITIS. 
 
 Acute inflammation is uncommon, but may follow various local 
 lesions, as pleurisy, pericarditis, pneumonia, acute lymphadenitis 
 and kindred processes (r. Mediastinal Pleurisy") by contiguity or 
 by metastasis, (a) Acute nonsuppurative cases be°rin with chill, 
 fever, pain in the mediastinum and tenderness anteriorly over the 
 sternum or high in the back ; there may be oedema over the sternum : 
 dysphagia, dyspnoea and vague cardiac symptoms may develop. A 
 presumptive diaeriosis is made from acute inflammatory symptoms 
 with mediastinal localization. The prognosis is grave and the treat- 
 ment is symptomatic : an ice-bag should be applied over the sternum 
 and opiates should be given for pain, (b) Of mediastinal abscess, 
 Hare (1899^) collected 115 cases in most of which the anterior medi- 
 astinum was affected. They occurred chiefly in males. Acute case?, 
 most often traumatic or sequential to the eruptive diseases, were more 
 frequent than chronic cases, which were usually tuberculous (r. 
 Mediastinal PleeeisyV 
 
 Symptoms. — The symptoms are mediastinal, as in simple acute 
 mediastinitis. and general or septic. A throbbing retrosternal pain is 
 common and dyspnoea may result from pressure by large pus pockets. 
 (Edema, fluctuation and pointing in the upper interspaces or in the 
 jusTilar notch may be noted. Fatal hemorrhage may follow simul- 
 taneous erosion of the aorta and bronchus. External rupture may 
 occur in the second interspace fDaude") or internal rupture into the 
 air passages, bloodvessels, oesophagus or pleura : deep burrowing to 
 the abdomen has occurred. The exploring needle is of great diag- 
 nostic aid in doubtful cases. Operation is indicated: Auvray (1904) 
 found in the literature 36 operations with 33 recoveries. 
 
 (c) Chronic mediastinitis is discussed under adhesive pericarditis. 
 
552 DISEASES OF THE RESPIRATORY TRACT. 
 
 MEDIASTINAL HEMORRHAGE* 
 
 Small hemorrhages of no clinical importance may result from 
 " blood dissolution/' as in icterus, hemorrhagic blood diseases or acute 
 infections. Larger hemorrhages may follow trauma or erosion of the 
 large vessels, both of which usually overshadow the mediastinal 
 incident. 
 
 INTERSTITIAL EMPHYSEMA. 
 
 (See Differentiation of Emphysema.) 
 
SECTION IV. 
 DISEASES OF THE DIGESTIVE TKACT. 
 
 DISEASES OF THE MOUTH. 
 
 CATARRHAL STOMATITIS. 
 
 Etiology. — Simple, acute or erythematous stomatitis is the most 
 frequent form. In children it may develop with dentition, improper 
 feeding, rude cleansing of the mouth and digestive disorders, espe- 
 cially in those who are poorly nourished ; it is part of various infec- 
 tions, notably of the exanthemata and syphilis. In adults it results 
 from thermal, mechanical and chemical irritants; hot food, alcohol, 
 tobacco, various chemicals (iodine, mercury, arsenic, copper, etc.), 
 acidulous vomiting, inflammatory extension from the salivary glands, 
 carious teeth, nose and throat disease, uncleanliness, anaemias and 
 stasis are among its causal factors. 
 
 Symptoms. — Symptoms are chiefly redness, swelling and increased 
 secretion, and in the acute forms burning pain which makes eating 
 difficult. The increased saliva is usually acid and irritates the lips or 
 chin if it flows over them. The gums are turgid (gingivitis) and the 
 tongue broadened, lax and therefore indented by the teeth, as is also 
 the buccal mucosa. The tongue is generally coated. Vesicles some- 
 times form and break down into small erosions which heal with cica- 
 trices. The whitish areas sometimes seen are epithelial thickening. 
 Fever, thirst and general symptoms are absent, except in some in- 
 fantile cases. Acute stomatitis lasts but a week or two, but may 
 become chronic. Transient stomatitis is physiological in the new- 
 born. 
 
 Treatment. — In children the mouth should be gently washed after 
 each nursing. Cold water or ice mitigates pain. Boracic acid is ex- 
 cellent and safe. In adults the teeth should be cared for. Tincture 
 of myrrh and tincture of rhatany — equal parts — are excellent astrin- 
 gents. Stronger antiseptics may be used in adults but are dangerous 
 in children, who may swallow them ; for instance, 2 per cent, sodium 
 salicylate, 2 per cent, chlorate of potash, 1 per cent, carbolic solution ; 
 erosions may be touched with 1 per cent, silver nitrate. 
 
 STOMATITIS ULCEROSA. 
 
 Etiology. — Though probably a mycotic affection, its bacteriology is 
 unknown. In some cases the same microorganisms are found as in 
 
 553 
 
554 DISEASES OF THE DIGESTIVE TRACT. 
 
 Vincent's angina. Sporadic cases are more common than epidemics, 
 which may occur in asylums or prisons. It may be induced by mal- 
 nutrition, uncleanliness, oral or dental disease, phthisis, leukaemia, 
 diabetes, toxic factors (principally mercury), and occurs especially 
 at dentition and more in city than in country children. (See Diag- 
 nosis of Diphtheria and Acute Pharyngitis.) 
 
 Symptoms. — The symptoms are those of catarrhal stomatitis plus 
 necrosis and then ulceration. The gums, especially about the in- 
 cisors and canines, are red, swollen and spongy; they bleed readily, 
 secrete pus and ulcerate ; over the ulcers a membrane develops. The 
 teeth are exposed, loosened and perhaps fall out. Necrosis of the jaw 
 sometimes results. The tongue and cheek ulcerate less often and the 
 pharynx is nearly exempt. The breath is foetid, the saliva is in- 
 creased, the submaxillary lymph glands and the salivary glands are 
 swollen and mastication is almost impossible. Fever, prostration and 
 signs of sepsis, as erythema, chills and rapid pulse, may mark the 
 severest cases. Acute cases last one to two weeks and chronic cases 
 weeks or months. 
 
 Varieties. — (a) Mercurial stomatitis may occur in workers in the 
 metals or from clinical administration. The author saw a hospital 
 case of nephritis in which one dose of five grains of calomel caused 
 necrosis of the entire tongue, which rotted off at its root. (See In- 
 toxications. ) Mercurial and other stomatitis may cause " erosions " 
 of the enamel in the developing teeth of children ; they become pitted, 
 discolored and transversely furrowed, (b) Riga's disease, described 
 by Eiga (1881) in south Italy, is an affection in which there is a 
 pearly induration which occurs only between the tip of the tongue and 
 the frsenum, appears with the first dentition, sometimes ulcerates, is 
 occasionally epidemic, is often observed with the status lymphaticus 
 and is invariably fatal, (c) In nursing women, ulcers, 3 to 4 mm. 
 in diameter, may develop from the lymph follicles of the lip and 
 cheek ; they usually indicate malnutrition, sometimes are quite pain- 
 ful and respond to general tonics and hygiene, (d) Herpetic or 
 pemphigoid stomatitis is seen in neurotics and is frequently recur- 
 rent (Jacobi's stomatitis chronica neurotica), (e) Bednar described 
 (aphthous) white plaques on the posterior part of the hard palate 
 near the alveolar border of the upper jaw, which may ulcerate; they 
 occur in the first three months of life, and are apparently due to 
 sucking, are not syphilitic, and are ominous only in marantic chil- 
 dren. (/) Parrot's ulcers occur in marantic new-born children on the 
 hard palate near the median line ; they seldom heal. 
 
 Treatment.— Treatment includes that of catarrhal stomatitis. Po- 
 tassium permanganate 1 to 1,000 relieves the fcetor ex ore. Necrotic 
 areas may be touched with silver nitrate solution or equal parts of 
 tincture of the chloride of iron and glycerine. Potassium chlorate 
 gargles may be combined in children with gr. x to xx of the drug 
 every day internally and twice the amount for adults, but it must be 
 remembered that toxic effects may result. Opium and belladonna are 
 used in severe cases for pain and salivation. 
 
PARASITIC STOMATITIS. 555 
 
 APHTHOUS STOMATITIS. 
 
 Etiology. — It may occur alone or with other diseases, sporadically 
 or epidemically. It is probably contagious but its nature is still 
 undetermined; when due to milk it ceases on withdrawal of the 
 milk. Besides the general causes of stomatitis (v. s.), it occurs 
 chiefly in children between ten and thirty months old. 
 
 Symptoms. — Symptoms begin with restlessness, slight fever, thirst, 
 salivation and pain in the mouth. Round, yellow-white and slightly 
 elevated areas as large as a pea appear on the surface and edges of 
 the tongue and less often on the lip and buccal mucosa. The mucosa 
 is slightly reddened about them. Attempts to scrape them off produce 
 bleeding. Pathologically they are areas of superficial necrosis, into 
 which exudation of fibrin and round cells occurs (stomatitis fibrinosa 
 disseminata). Vesicles seem to be no part of the process, though they 
 may occur on the skin near the mouth. Occasionally there is tume- 
 faction of the lymphatic and salivary glands. Their clinical evolu- 
 tion is rapid ; they last one to two weeks, and recurrence is frequent. 
 The treatment is that of stomatitis. 
 
 PARASITIC STOMATITIS. 
 
 Etiology. — Thrush, muguet, soor or stomatomy costs o'idica is due 
 to the Oidium albicans, closely allied to the saccharomyces, which 
 consists of branching mycelia and ovoid granular and refracting 
 spores. It occurs chiefly in very young or marantic children whose 
 mouths have been improperly cared for, or who have stomatitis. It 
 prevails especially among the poor and in institutions. Dirty nipples 
 are the most frequent mode of inoculation. Thrush may develop in 
 weakly convalescents or in tuberculous and diabetic adults. 
 
 Symptoms. — A few thin, punctate, whitish spots develop on the 
 tongue, cheek and soft palate ; they become yellowish as the areas 
 grow or fuse. The fungus is at first deposited on the epithelium, be- 
 tween the layers of which it proliferates and penetrates. The mouth 
 is dry or, with diffuse stomatitis, is moist from increased salivary 
 flow. In the more severe cases the fungus may reach the pharynx, 
 larynx, oesophagus and even the stomach and intestine. Its deposit 
 is generally limited to areas with flat epithelium, and epithelia of 
 the cylindrical and ciliated order usually escape. It may, in excep- 
 tional cases, cause oesophageal occlusion or bronchopneumonia ; or by 
 unusually deep penetration to the submucous vessels it may cause 
 cerebral, renal and other embolism. The outlook is good except in 
 marantic subjects. 
 
 Treatment. — Prophylaxis is most essential in regard to cleansing 
 of the mouth, sterilization of bottles and nipples and maintenance of 
 the general health by fresh air and early treatment of dyspeptic dis- 
 orders. In some cases the stomatitis persists until a wet-nurse is 
 substituted for the feeding with cow's milk. Cleansing the mouth 
 
556 DISEASES OF THE DIGESTIVE TRACT. 
 
 with borax, boric acid, sodium bicarbonate and lime water is most 
 effective. If unusual extension occurs a teaspoonful of a resorcin 
 solution (1 to 100 or 300 parts) may be given every two hours. 
 
 Stomatitis may in rare cases result from other parasites, as the 
 sarcina or leptothrix, and from such bacteria as the pneumococcus, 
 gonococcus, Friedlander's bacillus, etc. 
 
 GANGRENOUS STOMATITIS. 
 
 Etiology. — " Gangrene of the cheek/' noma or cancrum oris, is a 
 rare affection. Age: of Brun's 415 cases, only 11 occurred in persons 
 over fifteen years of age and only 6 in infants. The author recently 
 saw noma in a man forty years old, which was fatal on the fifth day. 
 Sex: more cases occur in girls than in boys. Malnutrition and 
 neglect cause some cases ; 50 per cent, follow measles ; typhoid, scar- 
 latina, etc., are less frequent factors. A bacillus resembling that of 
 diphtheria has been isolated (Bac. necroseos). Organisms similar to 
 those in Vincent's angina may be seen. 
 
 Symptoms. — Symptoms usually begin with ulceration of the gums 
 or buccal mucosa near the angle of the mouth. Rapid necrosis and 
 gangrene follow with extensive brawny oedema of the face. The 
 foetor is intense and much tissue is frequently sloughed off. Perfora- 
 tion of the cheek, necrosis of the jaw and extension to the throat, 
 orbit or ears are not uncommon. Seventy per cent, of cases die 
 within a week, with such septic symptoms as high fever, weak heart, 
 prostration, diarrhoea, colitis and meningitis or lobular pneumonia. 
 The mortality was 92 per cent, in Springer's collation. 
 
 Treatment. — Treatment is ineffectual. A full diet and free exhibi- 
 tion of alcohol are indicated as in sepsis, and disinfectants should be 
 applied to the necrotic focus; local measures as excision, the live 
 cautery and caustics are employed, usually without success and some- 
 times with aggravation of the necrosis. 
 
 DISEASES OF THE TONGUE. 
 
 ECZEMA. 
 
 In eczema the epithelium thickens and desquamates, leaving red- 
 dish, smooth and circular, serpiginous or geographical areas, which 
 heal centrally and extend peripherally. It may cause local irritation 
 or worry the patient, who may think he has syphilis or cancer. Again, 
 it is an accidental finding. Its cause is unknown, its course is chronic 
 and its treatment by silver nitrate is quite inadequate. 
 
PTYALISH, SALIVATION, HYPERSECRETION. 557 
 
 LEUKOPLAKIA. 
 
 Leukoplakia (psoriasis, ichthyosis, keratosis) is an affection closely 
 resembling the " geographical tongue," in connection with which it 
 is often described. Irregularly-shaped, smooth, pale plaques meas- 
 uring one to two centimeters, develop on the tongue and less often on 
 the lips, cheeks or tonsils ; they consist of thickened epithelium. Eighty 
 per cent, of cases occur in men (98 per cent., Fournier) ; the use of 
 tobacco and alcohol, and gout and gastric disease are probable factors ; 
 Founder's experience with 324 cases convinced him that 80 per cent, 
 came from syphilis and 20 per cent, from tobacco. Its symptoms are 
 not marked, its course is very chronic and its treatment is nearly 
 always without results. Ten per cent, solution of sodium salicylate ; 
 chromic acid, 5 per cent. ; strong silver nitrate applications, especially 
 to fissured places; corrosive sublimate (1 to 500 parts) and the gal- 
 vanocautery are recommended. Excision is necessary for papilloma- 
 tous or epitheliomatous outgrowths, which are said to develop in one- 
 third to one-half the cases. 
 
 ACUTE GLOSSITIS. 
 
 Acute glossitis may be localized or diffuse, and ends in suppuration 
 in 33 per cent. It follows stings, burns, erosions, trauma or the en- 
 trance of pyogenic cocci through the lymph follicles. The tongue is 
 swollen, sometimes so greatly that it protrudes beyond the lips, and 
 is painful. In 145 cases the mortality was 3 per cent (Bennett, 
 1906). Eating and even speaking or oral breathing are impossible. 
 Early scarification and later incision of purulent foci are indicated. 
 
 GLOSSITIS DESICCANS. 
 
 Glossitis desiccans is a rare, chronic, intractable affection in which 
 deep indentations of the margins of the tongue and consequent lobu- 
 lation occur. Melanoglossia (nigrities linguce) results from prolifer- 
 ation of the filiform papillae at the base of the tongue, which appear 
 like hair (melanotrichia linguce, black-haired tongue) ; they are re- 
 moved by a 10 per cent, salicylic acid solution or by curetting. The 
 mucor niger may cause a black coating on the tongue. 
 
 DISEASES OF THE SALIVARY GLANDS. 
 
 PTYALISM, SALIVATION, HYPERSECRETION, SIALORRHCEA. 
 
 Etiology. — The chief causes are (a) disease of the mouth, stomatitis, 
 dentition; (b) toxic substances, as jaborandi, tobacco, digitalis, mer- 
 cury, iodides and various metals; (c) nervous affections, as trigemi- 
 
558 DISEASES OF THE DIGESTIVE TRACT. 
 
 nal neuralgia, diseases of the pons and medulla, paretic dementia, 
 hypochondriasis and hydrophobia; a close distinction should be 
 drawn between oversecretion and lesions in which, like bulbar paraly- 
 sis, the saliva cannot be swallowed; (d) reflex salivation, which may 
 also occur from diseases of the tympanum through the chorda tym- 
 pani, from gastro-intestinal disease (gastric ulcer, pancreatic lesions, 
 etc.) by way of the vagus and sympathetic nerves and from genital 
 conditions, as pregnancy. 
 
 Symptoms. — The physiological salivary flow measures seven ounces 
 to three pints; a pathological flow of over twelve quarts has been 
 recorded. The salivary glands are tense, swollen and hard. The 
 reaction of the saliva may become neutral or acid ; it is chiefly thin 
 and fluid, but may contain some ropy mucus or scattered pus cells ; 
 the ptyalin disappears together with the potassium sulphocyanide. 
 The saliva may trickle into the larynx during sleep, and thus cause 
 violent coughing ; it may flow into the stomach and produce vomiting, 
 of an alkaline or neutral vomitus, especially in the morning; it may 
 stream from the lips and redden the adjacent skin. 
 
 Prognosis and Treatment. — The prognosis depends wholly on the 
 causal affections, whose operation may be transient, intermittent or 
 permanent. Treatment is likewise causal. Any toxic cause should 
 be removed. In nervous and reflex types potassium bromide is often 
 valuable and the iodides are sometimes efficacious in pregnancy. The 
 more severe cases necessitate opium and belladonna. 
 
 XEROSTOMIA. 
 
 Hyposecretion or arrested secretion was first described by Jona- 
 than Hutchinson (1888). Besides its occurrence, as a result of 
 atropine and allied remedies, it occurs in diabetes insipidus and 
 mellitus, in some cases of contracted kidney and finally as an inde- 
 pendent neurosis or a neurotic symptom. Women (80 per cent.) are 
 affected more often than men. The tongue and mouth are dry, red 
 and glistening, which may render speaking, chewing and swallowing 
 most difficult. The tongue may cleave to the roof of the mouth. The 
 digestion of carbohydrates is impaired. Treatment consists in paint- 
 ing the mouth with iodine, potassium iodide and glycerine (1, 10, 
 100 parts respectively), the administration of pilocarpine hydro- 
 chloride Vi 2 to Vs of a grain and galvanic applications to the parotid. 
 
 PAROTITIS. 
 
 Besides acute specific parotitis (mumps), infection may reach the 
 parotid or other salivary glands by way of the blood stream or by 
 infection entering their ducts. Acute parotitis may be simple but is 
 oftener suppurative, the staphylococcus being the most common pyo- 
 genic organism, (a) Any of the acute infections may be complicated 
 by parotitis, of which typhoid is the most common, (b) Affections 
 
SIALODOCHITIS FIBRINOSA. 559 
 
 of the abdominal or pelvic structures are sometimes complicated by 
 acute parotitis, to which Paget drew special attention; they include 
 diseases of or operations on the alimentary and genito-urinary tracts, 
 peritoneal disease, pancreatitis, abdominal trauma, etc. ; many of 
 these cases are clearly attenuated sepsis. Wagner, in 1904, was able 
 to collect 61 cases of postoperative parotitis; 31 were operations 
 upon the genitalia ; he believes the cause is not hematogenous infec- 
 tion, but an infection ascending along the duct from the mouth, (c) 
 A rare acute parotitis in facial neuritis is described by Gowers. 
 
 Chronic parotitis sometimes follows epidemic or symptomatic paro- 
 titis, poisoning by mercury or lead, syphilis or chronic nephritis. 
 The parotid is usually painless, though it is sometimes both painful 
 and tender. Mikulicz has described a " chronic symmetrical hyper- 
 trophy of the salivary and lachrymal glands." 
 
 Treatment. — In acute parotitis, local derivants as leeches, the early 
 application of cold and the later use of hot fomentations, and finally 
 surgical incision, if there is pus formation, are indicated. Chronic 
 forms respond slowly to treatment; iodine or mercurial ointment 
 should be employed. Iodide is useful in Mikulicz's disease. 
 
 ANGINA LUDOVICI. 
 
 Ludwig's angina is generally due to a streptococcic infection begin- 
 ning in the submaxillary gland, and extending to the floor of the 
 mouth and the cervical cellular tissue. In some cases no promoting 
 cause is found, or trauma may be its immediate antecedent, but most 
 cases are secondary to typhoid, diphtheria and kindred acute in- 
 fections. It is the analogue of acute phlegmon of the pharynx and 
 larynx. The inflammation spreads rapidly, causing fever, redness, 
 pain and swelling under the tongue, cellulitis and sometimes gan- 
 grene in the neck (cynanche gangrceneuse) . Mastication and de- 
 glutition may be impossible and glottis oedema is not infrequent. 
 The parotids are sometimes invaded. Resolution is very exceptional 
 and external pointing of pus is not likely to occur, whence, without 
 early surgical intervention, septic and pysemic complications or laryn- 
 geal and pharyngeal oedema or phlegmon very frequently develop. 
 The mortality is 40 per cent. 
 
 SIALODOCHITIS FIBRINOSA. 
 
 Inflammation of the salivary ducts with formation of membrane 
 (Kussmaul) results from infection ascending from the oral cavity 
 and is characterized by fever and tenderness, pain and tumefaction 
 of the salivary gland, due to retained secretion and infection. The 
 duct is kept patent by pressure or sounding. 
 
560 DISEASES OF THE DIGESTIVE TRACT. 
 
 SIALOLITHIASIS. 
 
 Stones of calcium phosphate or carbonate occur more frequently 
 in Wharton's duct than in the other salivary ducts. Their usual 
 cause is stagnation of the salivary secretion by foreign bodies, bacterial 
 or fungus invasion or mechanical stricture following ulceration. Ro- 
 berg (1904) found stones in Wharton's duct fifty times, in the sub- 
 maxillary gland twenty-eight times, in Stenson's duct six times 
 and in the parotid gland twice. Bendixen collected 216 cases (1908). 
 
 DISEASES OF THE PHARYNX. 
 
 ACUTE PHARYNGITIS. 
 
 Etiology. — Acute, superficial, simple angina may be caused by 
 (a) rheumatism, cold or exposure; (b) infections, either acute 
 (measles, scarlatina, variola) or chronic (malaria or syphilis) ; (c) 
 gout, dyspepsia or smoking; (d) in many cases the cause is obscure; 
 though probably always mycotic, no single virus is found. It is 
 most common in youth. 
 
 Symptoms. — (a) Local: — The throat is red, glazed and streaked 
 with mucopus which is easily wiped away. The soft palate and 
 uvula are sometimes swollen; superficial erosions, small vesicles on 
 the palate and swollen mucous follicles are occasionally seen. In 
 some cases the local findings, especially when hidden in the naso- 
 pharynx, are very slight in proportion to the local pain and general 
 symptoms. There is a scratching, tickling sensation in the throat 
 which may radiate into the posterior nares or into the ear. The 
 patient hawks, but raises little, unless there is coincident rhin- 
 itis or laryngitis. Swallowing is rather painful, slight deafness is quite 
 common, the speech is sometimes slightly nasal and the angular lymph 
 nodes are painful and tender, (b) Constitutional symptoms are 
 usually slight. At the onset there are chilliness, moderate fever, 
 aching in the muscles and in some individuals extreme cutaneous 
 hyperesthesia, which, on superficial examination, may be falsely 
 attributed to changes in the deeper parts of the body. With or 
 without coincident tonsillitis, there may be high fever, and in labile 
 individuals, marked nervous intoxication. Herpes facialis occasion- 
 ally develops. Complications, as acute endocarditis or nephritis, are 
 very uncommon. In a few days the process is complete and con- 
 valescence is rapid. 
 
 Treatment. — (a) Local: — Painting the entire pharynx with a 20 
 per cent, silver nitrate solution usually affords local and general 
 relief, (b) General:- — Dover's powder and aspirin (acetylsalicylic 
 acid), each ten grains, may be exhibited for unusual pain, aconite for 
 
CHEONIC PHARYNGITIS. 501 
 
 high fever, calomel, followed by salines, for elimination and a 1 per 
 cent, solution of carbolic acid for the irritated throat. 
 
 The pneumococcic sore throat may be suppurative, pseudodiph- 
 theritic, follicular (like tonsillitis), erythematous or herpetiform ; its 
 onset is severe, like that of pneumonia, it produces a thicker, denser 
 and more adherent membrane than does the streptococcus and the 
 prognosis is generally poor. 
 
 CHRONIC PHARYNGITIS. 
 
 Etiology. — The causes are: (a) repeated acute pharyngitis; (b) 
 smoking or alcohol; (c) abuse of the voice, as in clergymen, venders, 
 etc.; (d) extension from chronic nasopharyngitis or laryngitis; (e) 
 chronic nephritis, syphilis, arthritism, etc. These factors are most 
 common in adolescence and middle life. 
 
 Symptoms. — The mucosa of the nasopharynx is red and lined with 
 turgid venules; the pillars and uvula are relaxed and the drooping 
 uvula may tickle the tongue or epiglottis, causing chronic coughing. 
 The sides of the pharynx may show isolated whitish epithelial thick- 
 ening or more often small, reddish, hypertrophied lymph follicles 
 (pharyngitis granulosa), sometimes in linear distribution. The 
 pharynx is dry and burning, exciting hawking efforts which are un- 
 productive and irritating and may cause morning vomiting. The 
 mucous glands are at times hyperplastic. Slight bleeding occasion- 
 ally causes unnecessary worry. Middle ear involvement is common, 
 through the Eustachian tube. Pharyngitis sicca is an atrophic type, 
 analogous to rhinitis atrophica and marked by a pallid glazing of the 
 posterior pharyngeal wall and by formation of crusts. 
 
 Treatment. — (a) The causal factors, as straining or tension of the 
 voice in speaking, alcoholism or smoking, etc., should be corrected 
 respectively, by rest and avoiding irritant foods or stimulants. Alka- 
 line laxatives are frequently beneficial, (b) Galvano-puncture of the 
 turgid veins or hyperplastic follicles is indicated; marked improve- 
 ment is probably more frequent than aggravation of the condition by 
 over-zealous treatment, (c) Local medical treatment is less effica- 
 cious, as 2 to 20 per cent, solution of tannin in glycerine, equal parts 
 of tr. ferri chloridi and chlorate of potash, 1 to 5 per cent, solution 
 of chloride of zinc or 2 to 20 per cent, nitrate of silver solution. 
 
 fy Phenolis gr. xx. 
 
 Acidi tannici , 3ss. 
 
 Aluminis 3j. 
 
 Glycerini ^ij. 
 
 Aquae rosso q.s. ad |v. 
 
 M. et ft. gargarismus. 
 
 S. — As gargle, properly diluted. 
 
 I£ Tincturae ferri chloridi 3ijss. 
 
 Potassii chloratis 5iij. 
 
 Aquae q.s. f^vj. 
 
 M. et S. — One teaspoonful in one-half glass of water as gargle. 
 36 
 
562 DISEASES OF THE DIGESTIVE TBACT. 
 
 (d) For atrophic pharyngitis, iodine, potassium iodide and glycerine 
 massaged thoroughly into the pharynx, is the best measure : 
 
 # lodi gr. iij. 
 
 Potassii ioclidi 3ss. 
 
 Glycerini 3j. 
 
 M. et S. — Locally. 
 
 PHLEGMONOUS PHARYNGITIS. 
 
 Angina phlegmonosa, especially described by Senator, is not super- 
 ficial but invades the submucosa. It is usually primary but may be 
 metastatic from distant suppuration. The throat is painful, swollen 
 and oedematous, the neck enlarges and suppuration occurs with high 
 fever, septic symptoms and difficulty in swallowing and breathing, 
 especially when the subject lies down. The inflammation may be 
 hemorrhagic or necrotic. Phlegmonous angina is the analogue of 
 suppurative submucous laryngitis and angina Ludovici. Without 
 surgical intervention or early spontaneous rupture into the throat, 
 death occurs from septicopyemia, mediastinitis or glottis oedema. 
 
 RETROPHARYNGEAL ABSCESS. 
 
 Various forms are described, (a) The primary form occurs in 
 children under two years of age; the early symptoms are dysphagia, 
 a nasal voice and retropharyngeal suppuration, as a visible protrusion 
 or a palpable fluctuation on the posterior pharyngeal wall ; dyspnoea, 
 cyanosis and inspiratory retraction of the chest develop. It is a 
 primary lymphadenitis. (b) Secondary types are less common in 
 (i) caries of the cervical spine, (ii) diphtheria, erysipelas, scarlatina 
 and (Hi) suppurative inflammation in the retropharyngeal lymph 
 glands. The secondary type is caused by infection travelling along 
 the lymph vessels, or rarely by metastasis. Unless surgical measures 
 are instituted or spontaneous rupture occurs early, death occurs from 
 asphyxia, mediastinitis, glottis stenosis, inhalation pneumonia or 
 sepsis. After incision the head should be promptly thrown well for- 
 ward to obviate occlusion of the air passages. 
 
 PHARYNGEAL ULCERATION. 
 
 Syphilitic and tuberculous ulceration have been considered. Fol- 
 licular ulcers are superficial and small and, like all ulcers in the 
 mucous^ membrane only, heal without a cicatrix. Ulceration also 
 occurs in diphtheria and the diphtheroid group, due chiefly to the 
 streptococcus. Malignancy too, causes ulceration. Cancer* and tu- 
 berculosis are usually diagnosticated with ease, and in doubtful cases 
 syphilis is excluded ex juvantibus by the use of mercury and iodides. 
 
 Vincent's angina is discussed under Diagnosis of Diphtheria ; 
 according to Vincent, it constitutes two per cent, of all anginas in- 
 
ACUTE FOLLICULAR TONSILLITIS. 563 
 
 eluding diphtheria. It occurs especially in children between six and 
 ten years of age and in medical students and servants in anatomical 
 laboratories, between the years of eighteen and thirty. Tobacco, 
 scurvy, anemia, tuberculosis, syphilis, scarlatina, measles and the 
 eruption of the wisdom teeth are predisposing factors. The two 
 causative organisms were first described by Eauchfus (1893) ; (a) 
 the fusiform bacillus has pointed, sometimes rounded ends, is some- 
 times bent, measures six to twelve p in length and may be flagellated ; 
 (b) the spirillum or spirochete is long, delicate, twisted and always 
 occurs in severe forms. They stain with carbol-fuchsin but not by 
 Gram's method. 
 
 Symptoms. — (1) In the first period, there is congestion and oedema. 
 (2) In the second stage, a grayish yellow membrane forms which 
 is thick, friable and cheesy and usually removable. (3) Under the 
 membrane, an ulcer develops ; it is usually single, round or oval and 
 has an irregular edge, an uneven granulating floor and seldom any 
 extension laterally. 
 
 The general symptoms are lassitude, indigestion, vomiting or epi- 
 staxis; fever is uncommon and complications rare (albuminuria, en- 
 teritis or noma). Syphilis and diphtheria require differentiation. 
 The affection heals under applications of iodine, pencilling with 
 silver nitrate and gargles of hydrogen peroxide or chlorate of potash. 
 
 DISEASES OF THE TONSILS. 
 
 ACUTE FOLLICULAR OR LACUNAR TONSILLITIS. 
 
 Definition. — An acute mycotic parenchymatous inflammation of the 
 tonsils, usually marked by decided constitutional reaction. 
 
 Etiology. — (a) Bacteriologically , the streptococcus is the most fre- 
 quent cause, though the staphylococcus and Frankel's diplococcus are 
 also encountered ; it is claimed that somewhat attenuated diphtheria 
 bacilli are found, particularly at the time of diphtheria epidemics, 
 but in such cases it is more correct to consider it as a sub-type of 
 diphtheria (q. v.). (b) The still unknown virus of rheumatism is 
 thought to gain access to the blood by way of the tonsils or pharynx ; 
 affections commonly regarded as associated with rheumatism, as 
 erythema nodosum, chorea and some forms of endocarditis, may 
 follow acute tonsillitis (Packard). Tonsillitis may begin the rheu- 
 matic cycle, as described under rheumatism in children, or it may 
 appear later in the rheumatic process, with endocarditis, pericarditis, 
 arthritis and chorea. Endemics and the spread of the disease through 
 a household strengthen the conception that tonsillitis is contagious, (c) 
 Cold and dampness are directly predisposing causes ; these conditions 
 obtain largely in the spring, (d) Tonsillitis occurs chiefly in youth 
 
564 /* "~ DISEASES OF THE DIGESTIVE TBACT. j 
 
 and adolescence, (e) Individual predisposition depends on some 
 unknown factor and one attack may induce recurrence, (/) Poor 
 hygiene and possibly sexual activity, especially in young married peo- 
 ple, mav be conducive to tonsillitis (Shepard), 
 
 Symptoms.— (a) The onset occurs with chilliness or rigor, severe 
 pains in the bach and limbs, fever, rising Within a day to 103 OH even 
 to 106 degrees in children or susceptible adults, pain in the throat, 
 particularly on swallowing, and tenderness of the glands at the angle 
 of the jaw. (b) Local findings:— The tonsils are swollen and soon 
 show on the deeply injected surface three to ten yellowish-white or 
 creamy points, corresponding to the crypts or lacurise ; the crypts con- 
 tain bacteria, epithelium, leukocytes and sometimes cholesterin or 
 fatty needles and are essentially small abscesses; the tonsil is the 
 seat of serocellular infiltration. Occasionally there are small super- 
 ficial areas of necrosis, slight erosions or even formation of membrane, 
 The voice may acquire a somewhat nasal twang, the pain increases 
 for a few days and the angular glands remain painful and tender, 
 whence the head is often held rigidly forward and the jaws are opened 
 only with difficulty. Pain in the ear is common, (c) The chief 
 constitutional symptoms have been considered above. ^ Anorexia, 
 heavily coated tongue, feverish breath, hypersesthetic skin, marked 
 depression, accelerated pulse and respiration are common. In some 
 cases the systemic symptoms are disproportionately severe and child- 
 ren, as well as some adults, may exhibit delirium; in two adult cases 
 seen by the writer, retraction of the neck with headache, delirium 
 and vomiting was mistaken for meningitis. Herpes facialis is quite 
 frequent. i 
 
 Complications. — Complications are not common. Acute pericar- 
 ditis, endocarditis or nephritis may develop. Functional heart mur- 
 murs, febrile albuminuria and erythema (from the toxins or from 
 medication) are not very infrequent. As a rule convalescence is com- 
 plete within a week, though marked prostration and considerable re- 
 sidual swelling remain for some time. Repeated attacks may cause 
 nephritis or endocarditis. 
 
 Diagnosis. — The typical case cannot be confused, (a) Diphtheria 
 produces a membrane, more whitish in color, which has an almost 
 pathognomonic tendency to spread to the uvula, soft palate or pha- 
 rynx ; it leaves bleeding raw points when it is stripped off ; it recurs 
 after removal ; it sometimes extends to the larynx ; it is followed not 
 infrequently by paralysis, which almost never results from tonsillitis ;. 
 it responds promptly to serotherapy and shows the Klebs-Loeffler 
 bacillus, (b) Tonsillitis necrotica leaves an ulcer; its bacteriology 
 is disputed, some cases showing the fusiform bacillus and spirillum of 
 Vincent and others are alleged to be due to the Bacillus diphtherias; 
 in some cases there is much fever ; in others none ; the general reaction 
 is severe, (c) The possibility of incipient scarlatina should always 
 be kept in mind. 
 
 Treatment. — 1. Prevention. — The subject should be hardened, by 
 
SUPPURATIVE TONSILLITIS. 565 
 
 cool baths or sponges, and tonsillotomy should be performed. Douch- 
 ing of the nose and gargling with Dobell's solution should be part of 
 the daily toilet. 
 
 2. Locae Measures. — The best of the many local remedies in the 
 author's experience is silver nitrate; after cocainizing the throat, 
 a small probe, bent at right angles near its end, is introduced into 
 each swollen crypt to puncture it and secure free drainage; then 
 Dobell's solution is applied, undiluted, on small bits of cotton in each 
 crypt; this is followed by 20 per cent, silver nitrate solution; the 
 results are often immediate, sometimes aborting the attack. Squeez- 
 ing out the crypts with a spatula is extremely painful but relieves 
 the patient when the physician has no probe at hand. Hot water or 
 hot fomentations may be applied to the neck. 
 
 3. Constitutional Treatment. — In a relatively small number of 
 cases sodium salicylate, given as in rheumatism, affords relief. Hy- 
 drargyri biniodide gr. %oo given every fifteen minutes for ten doses 
 often aborts the process. Guaiac, though generally used, has pro- 
 duced unsatisfactory results in personal experience; the dose is tr. 
 guaiaci ammoniat. n\x to xl every two hours. Aspirin (ac. acetyl- 
 salicylicum) and Dover's powder aa gr. x, relieve pain in the throat, 
 body and limbs. Aconite and belladonna are often beneficial in 
 children with high fever, and rather less so in adults ; they are given 
 as in coryza or influenza. 
 
 SUPPURATIVE TONSILLITIS. 
 
 Etiology. — The etiology is almost identical with that of the follicu- 
 lar type. Suppurative tonsillitis is most common in adolescence, and 
 for unknown reasons individual disposition is an important factor. 
 
 Symptoms. — The early local and general symptoms resemble those 
 of the follicular type but are often more severe from the onset; 
 one, or less often both, tonsils are greatly swollen, tense, oedematous, 
 deep red and may show distended lacunae. The pain often radiates 
 to the ears. The swollen tonsils may come in contact, or if but one 
 tonsil is swollen it may reach over to the sound side. There is often 
 coincident stomatitis and a free salivary flow. The palate and uvula 
 are frequently oedematous and covered with muco-pus. Swallowing 
 causes great pain in the throat, the jaw cannot be depressed because 
 of the swollen, painful angular glands, and the speech is nasal. The 
 toxsemic prostration is often profound, the fever ranges between 103 
 and 105 degrees and the pulse between 100 and 140. 
 
 Incision in the first two or three days evacuates no pus, only blood 
 and serum escaping. In a few days fluctuation is felt in the ton- 
 sil, or anterior to and above the tonsil (peritonsillar abscess). In- 
 troduction of a probe into the early and often unsuccessful incision 
 is followed by escape of pus and by immediate relief. The abscess 
 may break spontaneously, usually forward and rarely toward the 
 throat, when, in rare cases, especially when rupture occurs during 
 
566 DISEASES OF THE DIGESTIVE TRACT. 
 
 sleep, suffocation or aspiration pneumonia may follow. In equally 
 rare instances ulceration may reach the carotid with sudden and 
 fatal hemorrhage. Minute suppurative foci may cause septicaemia 
 (Kretz). 
 
 Treatment. — (a) For prevention tonsillectomy by the galvanic snare 
 is indicated after an individual tendency is manifested, (b) In 
 local treatment an ice-bag placed over the neck is beneficial. Local 
 applications to the tonsils are at the best uncertain remedies. It is 
 good practice, early in the course, to introduce a knife, with extreme 
 care, covered with adhesive plaster to within half an inch of its point, 
 above and inside the tonsil; blood and serum escape, tension, oedema 
 and pain are relieved and the later abscess more readily points 
 toward the cut; the wound is carefully opened with a blunt probe 
 every day. (c) Salicylates apparently help and possibly hasten 
 maturation. Opium and coal tar products relieve the pain to some 
 extent, (d) In exceptional cases, intubation or tracheotomy are indi- 
 cated, because of great swelling or collateral oedema, (e) The diet 
 is necessarily liquid. (/) In convalescence, iron and strychnine over- 
 come the resulting prostration and anaemia. 
 
 CHRONIC TONSILLITIS. 
 
 Symptoms. — Chronic inflammation; tonsillar hypertrophy; hyper- 
 plasia of the pharyngeal or lingual tonsils; adenoids; aprosexia. 
 
 Etiology. — (a) Repeated acute attacks of tonsillitis cause chronic 
 hypertrophy in some cases, and in others the tonsils gradually in- 
 durate and shrink, (b) Waldeyer's " Schlundring " oflymphadenoid 
 tissue consists of the two tonsils, the adenoid tissue in the nasopharyn- 
 geal vault (Kbllicker's pharyngeal tonsil, or "adenoids" in the com- 
 mon acceptation) and the so-called lingual tonsil. Variously com- 
 bined hypertrophies of these structures may be noted, occasionally as 
 congenital growths, but most frequently in young children. They 
 generally begin during the third or fourth year and may develop 
 until puberty. Adenoids are found in 1 per cent, of children 
 (Meyer), though other statistics give 3 per cent, or, higher figures. 
 Kickets, scrofula, the lymphatic constitution and various acute in- 
 fections involving the throat, as diphtheria, are cited as predisposing 
 conditions. 
 
 Symptoms. — 1. Local Changes. — (a) The enlarged tonsil may 
 contain in its crypts cheesy plugs, which occasion an extreme fcetor 
 ex ore. The plugs may be expressed; calculi may result from a 
 deposit of lime salts. The pharyngeal mucus is increased, is some- 
 times tinged with blood and is expectorated with difficulty, (b) 
 Adenoids in the nasopharyngeal vault occur alone or with tonsillar 
 hyperplasia. They are most often papillomatous, reddish, vascular 
 and range up to the size of a bean, (c) Hypertrophy of the " Un- 
 gual tonsil" often disturbs deglutition. Enlarged tonsils and ade- 
 noids produce the following changes by stenosing the posterior nares. 
 
PLATE XIII 
 
 FIG. 1 
 
 FIG. 2 
 
 Types of the "Adenoid" Faeies. (Posey and Wright.) 
 
CHBONIC TONSILLITIS. 567 
 
 2. Sequences. — (a) Oral breathing is the earliest symptom and 
 is first noticed during the night, when sleep is disturbed by night ter- 
 rors (pavor nocturnus) and by disordered and sometimes irregular 
 breathing, for a time stertorous and then interrupted. Lying down 
 may occasion asthmatic seizures or Balne's paroxysmal cough, (b) 
 After some time changes in the mouth are noted. The palatal vault 
 is high from atmospheric pressure in the mouth, and the transverse 
 measurement between the upper teeth is proportionately diminished ; 
 there is less room for the teeth to erupt, (c) In the nose, the anterior 
 nares are small and retracted and the voice is nasal {rhinolalia claus- 
 tra) ; the consonants n and m are pronounced with difficulty. Bloch 
 associated oral breathing with stuttering. The sense of smell or 
 taste is obtunded. Hearing is impaired by pressure of adenoids on 
 the Eustachian tubes, inflammation in the tubes or retraction of the 
 tympana from low atmospheric pressure in the nasopharynx, (d) 
 The fades is characteristic; it is vacuous and apathetic, the nose is 
 pinched, the mouth open and the lips swollen. The so-called " aden- 
 oid habitus " may be observed without adenoids, as a stigma of de- 
 generacy, (e) The mentality is altered in chronic cases; the cere- 
 bral reaction is slow, the memory tardy, the disposition sullen and the 
 power of concentration diminished; this latter condition was named 
 aprosexia by Guye. Woodward refers the physical changes to some 
 cytotoxin elaborated in the hyperplastic lymphoid tissue. (/) Ner- 
 vous symptoms. Headache is common. Adenoids cause some cases 
 of habit-spasm. Night terrors have been mentioned. Enuresis noc- 
 turna results from carbon dioxide operating on the brain during 
 sleep (Schech). (g) Development is sometimes retarded, (h) 
 Changes in the contour of the thorax were noted by Dupuytren 
 (1828), J. M. Warren (1839) and Lambron (1861). The pigeon- 
 or chicken-breast is the most common deformity. The sternum juts 
 forward, from which the ribs slant sharply backward ; at the level of 
 the diaphragm there is a circular depression, and inspiratory re- 
 traction is caused by the contraction of the diaphragm. The funnel 
 breast, marked by a deep depression of the lower part of the sternum, 
 is less commonly due to adenoids, and like the chicken-breast also 
 results from other causes. The "■ emphysema chest " .may result from 
 adenoids, (i) Scheir finds that the cervical lymph glands are also 
 enlarged and the blood evidences decreased haemoglobin, increased 
 white cells and distinct lymphocytosis. (Plate XIII.) 
 
 Diagnosis. — The oral breathing, adenoid facies, mental disturbance, 
 palpation of the adenoids in young children and their rhinoscopic 
 detection in older ones, and the mere inspection of hyperplastic ton- 
 sils determine the diagnosis. In the prognosis of untreated cases, 
 the possibility of deafness, mental deficiency, retarded growth, 
 asthma and emphysema should be borne in mind. Colds, acute re- 
 current tonsillitis, diphtheria and other infections are more likely to 
 develop and produce disproportionate symptoms. In some cases the 
 hyperplastic tissues may indurate and atrophy, but this spontan- 
 eous issue should not influence their management. 
 
DISEASES OE THE DIGESTIVE TRACT. 
 
 Treatment. — Palliative treatment is useless. The general health 
 should be maintained by out-door life, an ample diet, hydrotherapy 
 and by ood-liver oil, iron and other measures employed in scrofula 
 and tuberculosis. Hypertrophied tonsils should be removed by the 
 tery, for details of which the reader is referred to special 
 treatises. Adenoids large enough to cause symptoms should always 
 be removed early under anaesthesia, by the curette or ringer : ether is 
 far less dangerous than chloroform, which frequently causes death in 
 - use of the lymphadenoid tissues i the status thymicus or lymphoid 
 ditution). The sequences described usually subside after oper- 
 ation, though oral breathing is a habit hard to break. At night a 
 bandage should be used to keep the mouth closed. 
 
 DISEASES OF THE CESOPHAGUS. 
 
 INFLAMMATION. NECROSIS. ULCERATION. 
 
 I. CEsophagitis. — This is an uncommon finding at autopsy. Its 
 are i o. | mechanical, as from foreign bodies, strictures or dila- 
 tation of the oesophagus: (b) chemical, as from alcohol, tobacco, 
 corrosive poisons or acid vomitus ; | c | hypostatic, in cardiac or pul- 
 monary atfections : ( d ) rarely extension from pharyngeal or laryn- 
 geal inflammation : (e) acute infections, as smallpox and diphtheria. 
 •E-ophagitis is physiological in the new-born after the ingestion of the 
 first meals of life. Its pathology is that of pharyngeal or nasal in- 
 flammation : it is marked by local or diffuse, acute or chronic red- 
 ness, swelling and hypersecretion. Special pathological forms are 
 follicular catarrh, sometimes resulting in follicular ulcers or reten- 
 tion cysts in the sub mucosa : exfoliative oesophagitis ( o. desiccans su- 
 perncialis ) : the fibrinous form, observed in acute infections, uraemia 
 and rarely iu hysteria : genuine diphtheria : the pustular eruption of 
 smallpox : the toxic form from caustics or acids : only 12 cases are on 
 record of the phlegmonous or purulent form which occurs as a single 
 bulging submucous abscess or as diffuse submucous suppuration and 
 often perforates in many places into the oesophagus which then pres- 
 ents a sieve-like aspect : forms due to the oidiuni albicans or ray 
 fungus, of which primary cases are reported. In chronic cases the 
 epithelium may thicken (leukoplakia) or hypertrophv (papillomatous 
 forms . 
 
 Symptoms. — Symptoms are absent in slight inflammation. In 
 marked cases there is pain, continuous and substernal or elicited by 
 speaking, or •pressure on or movement of the spine. Dysphagia is 
 constant in marked inflammations. Mucus, blood, pus or eschars. 
 depending on the nature of the inflammation, are brought up by rag- 
 ging efforts. Fever i- common in the more severe types, in which the 
 
STENOSIS OR STRICTURE OF THE (ESOPHAGUS. 569 
 
 local symptoms may be wholly subordinate to the causal diphtheria, 
 smallpox, etc. In inflammation due to acids or alkalies, the history, 
 local symptoms and eschars in the mouth and pharynx are distinctive. 
 Treatment.- — Treatment is usually only palliative. Narcotics are 
 given for pain, demulcents as acacia and ice, ice-cream and a liquid 
 diet for the local irritation, and if these cause oesophageal irritation, 
 nutrient enemata are given (v. page 602). 
 
 II. Necrosis. — This may be due to corrosive poisoning; pressure 
 from struma, aneurysm, foreign bodies or sounds left in the oesopha- 
 gus to dilate strictures ; or " bed sores of the gullet," first described 
 by Dittrich (1850) in laryngeal perichondritis, due to pressure of 
 the larynx upon the gullet. Cfisophagomalacia is softening of the 
 part by regurgitation into it of the gastric acid ; it occurs chiefly after 
 death, but some cases appear to develop during the death agony. 
 
 III. Ulceration. — Aside from cancer (v. i.), follicular ulceration, 
 caustic ulcers, syphilis and tuberculosis, there is the peptic or round 
 ulcer. Peptic ulcer was first described by Cruveilhier, who correctly 
 identified it with round ulcer of the stomach. Forty cases were col- 
 lected by Tileston (1908). It appears in four main conditions (a) 
 by extension from the round ulcer of the cardiac orifice, (b) in ulcers 
 at the pylorus or duodenum, which produce gastric dilatation, (c) 
 in multiple hemorrhagic infiltrations of the oesophagus, stomach and 
 duodenum and (d) in alcoholism, arteriosclerosis and other imper- 
 fectly investigated conditions. Its chief symptom is dysphagia (50 
 per cent.) ; its pathology and complications, as hemorrhage, perfora- 
 tion and stenosis, as well as its treatment, are practically identical 
 with those of gastric ulcer, with which it is often associated. 
 
 STENOSIS OR STRICTURE OF THE (ESOPHAGUS. 
 
 Stenosis is the most important and frequent of oesophageal dis- 
 eases. In this connection von Mikulicz's conclusion is important, viz. 
 that the oesophagus is a closed tube only in its cervical segment and 
 that its cardiac orifice is not physiologically closed. 
 
 Etiology. — (a) Interstitial factors, i. e., in the wall of the oesophagus, 
 are the most important; cancer (v. i.) causes 90 per cent, of all 
 stenoses (v. Leyden, Kraus, Eosenbach) ; ulceration by caustics and 
 acids comes next ; then comes stenosis by diverticula or pouches (v. i.) 
 which, bulging out of and beside the oesophagus, exert upon it a lateral 
 compression ; other rarer ulcerative stenoses result from healing gum- 
 mata, tuberculous lesions, smallpox and other suppurative affections, 
 and from peptic and diphtheritic ulcers; muscular spasm causes a 
 few cases; congenital stenosis or atresia, of which 15 cases are re- 
 corded, occurs chiefly as a cul de sac, incomplete development or fistu- 
 lous communications with the trachea or bronchi, (b) Extra-ceso- 
 phageal factors, compressing the tube from without, include aortic 
 aneurysm or abnormal branches from the aorta: vertebral tumor, 
 cold abscess, exostosis or deformation ; anthracotic lymphadenitis and 
 
570 DISEASES OF THE DIGESTIVE TBACT. 
 
 malignant lymphoma; thyroid or thymic inflammation or hyper- 
 trophy; mediastinitis callosa, pericarditis effusiva and pulmonary 
 neoplasms, (c) Intra-cesophageal factors comprise the fewest causal 
 agents, as foreign bodies, pedunculated polyps from the lower pharynx 
 and oidium albicans. 
 
 Apart from the special pathology of these causes, stenosis occurs 
 chiefly (a) at the lower third of the oesophagus, (b) near the level of 
 the bifurcation of the trachea or (c) high up in the oesophagus. 
 The stenosis is more often single than multiple and more often annu- 
 lar than longitudinal; it varies from slight stenosis to complete 
 atresia, in which the tube may be seen as an impervious cord. Above 
 the stenosis the tube is dilated and its musculature is vicariously 
 hypertrophied to force food through the narrowed point. 
 
 Symptoms. — Symptoms vary with the cause and its extent; thus, 
 mechanical dysphagia may be quite secondary to aortic aneurysm and 
 may vary from time to time with the pressure exerted upon it ; in the 
 cicatrizing ulcers dysphagia is the only symptom. In advanced ste- 
 nosis the food and later the fluids taken regurgitate after a short time 
 if the stenosis is low, or at once if the stenosis lies just below the 
 pharynx; as a rule, the subjective localization described by the patient 
 is unreliable. The regurgitated food is neutral, macerated, fermented 
 and often contains round cells, mucus or blood, but never HC1 nor 
 pepsin. (Esophageal pain is common, but its occurrence depends on 
 the causal lesion. Singultus is rather frequent when the lesion lies 
 near the diaphragm. Dyspnoea may result from pressure upon the air 
 passages by the dilated portion of the oesophagus above the stricture. 
 
 Physical Examination and Diagnosis. — The chest should be examined 
 for aneurysm, retrosternal struma and lung tumor and the finger 
 should be introduced as far as possible down the throat, to exclude the 
 possibility of lesions situated high in the oesophagus or larynx. 
 Illumination of the oesophagus (oesophagoscopy) may give excellent 
 results if done by an expert, but its general application is very lim- 
 ited. Local signs are elicited chiefly in three ways — by sounding, 
 by auscultation and by the x-rajs. 
 
 1. Sounding. — A soft sound is far less dangerous than a hard one, 
 at least for the first examination and does the least damage in cases of 
 acute oesophagitis, aneurysmal compression and ulcerating cancer. 
 It is not sufficient to pass one stricture, as there may be others lower 
 down, whence the sound should be passed into the stomach. The 
 length of the oesophagus is 10 inches or 25 cm. ; from the upper in- 
 cisor teeth to the oesophagus 6 inches or 15 cm. ; from the teeth to the 
 cardia 16 inches or 40 cm. Recently it is maintained that the last 
 measurement should be 19.7 inches or 50 cm. The length of the 
 cervical portion is 2 inches or 5 cm., of the thoracic 6f inches or 17 
 cm., and of the abdominal part 1-| inches or 3 cm. From the teeth 
 to the level of the tracheal bifurcation is 9 inches or 23 cm. 
 
 2. Auscultation. — Deglutition is marked, physiologically, by two 
 murmurs, heard with the stethoscope six to eight seconds after the be- 
 
STENOSIS OJi STKICTXJBE OF THE OESOPHAGUS. 571 
 
 ginning of the act, first a short murmur and then a longer one. In 
 cases of marked stenosis the swallowing sound is heard at a point 
 just above the lesion; this is a valuable help when aneurysm is 
 suspected and sounding is feared. In the cervical part of the oesopha- 
 gus the noise results chiefly from the movements of the pharynx ; in 
 the thoracic segment the stenotic murmur is heard to the left of the 
 spine from the first to ninth dorsal vertebra. Stenosis near the trach- 
 eal bifurcation often gives a delayed first murmur, and a gurgling, 
 spurting character in both murmurs ; in the lowest segment the mur- 
 murs are heard just above the cardia, at the ninth or tenth dorsal 
 vertebra. 
 
 3. X-rays. — The x-tslys may show the outline of the dilatation 
 above the stricture (v. i. Dilatation of (Esophagus). 
 
 Prognosis. — The prognosis depends on the cause. Cancerous stric- 
 ture may ulcerate, thus relieving the local symptoms, though the 
 cachexia increases. Strictures resulting from caustics often improve. 
 In cases where the cause cannot be relieved, the same symptoms result 
 as in oesophageal cancer (q. v.). Perforation into the lungs, pleurae 
 or air passages, or into the mediastinum or vessels, may follow. As- 
 piration pneumonia, which is often gangrenous, is not infrequent. 
 
 Treatment. — The remediable etiological factors are few, except that 
 iodides may be given in syphilis or aneurysm. Foreign bodies can 
 sometimes be removed by long forceps, with the direction of the 
 oesophagoscope. In cancerous and aneurysmal strictures, probing and 
 dilatation are dangerous. Dilatation by sounds is attended by the 
 risk of perforating the oesophagus. Sounds should be introduced 
 beside the index finger, with the patient's head thrown slightly back- 
 ward; severe gagging may be overcome by painting the pharynx 
 with cocaine, though it is often as much psychical as oesophageal, and 
 assurance is a better preventive than drugs. The subject should first 
 swallow some olive oil to facilitate passage of the sound. In passing 
 the sound it should be held like a pen and pushed with exceeding 
 gentleness. Trousseau's tapering ivory olive points are excellent, 
 but care is necessary, and successively larger sizes should be used. 
 Sounds may be left in the oesophagus for some minutes or an hour, 
 or even permanently, but pressure necrosis may then result. It is at 
 times necessary to introduce filiform bougies, such as are used in 
 passing narrow urethral strictures. Silver balls (2 to 7 mm. in dia- 
 meter) with threads attached, may be swallowed; they should be 
 carefully pulled out after remaining in over night. When the ob- 
 struction is high, external rather than internal oesophagotomy is ad- 
 visable. As first practiced by von Bergmann, after opening the stom- 
 ach, dilatation may be employed from below. Impermeable stric- 
 tures call for gastrostomy and rectal alimentation. (See Treatment 
 of Intestinal Obstruction, thiosinamin.) 
 
572 DISEASES OF THE DIGESTIVE TRACT. 
 
 DILATATION. DIVERTICULUM. 
 
 Etiology. — Dilatation involves the entire circumference; diverticu- 
 lum involves hut part of it. Secondary dilatation may occur above 
 stenosis of the oesophagus or above the cardiac end of the stomach. 
 It seldom extends more than an inch and a half (4 cm.) above the 
 stricture; it rarely follows pyloric stenosis. Primary (idiopathic) 
 dilatation may be local or total. Marked dilatation above the cardia, 
 Luschka's so-called " fore-stomach " is an example of the local form, 
 which is usually congenital. The diffuse idiopathic dilatation results 
 without organic stenosis and is seen chiefly between the years of 
 twenty and forty. Its actual cause is disputed. Most clinicians in- 
 cline to the view advanced in 1888 by Meltzer, of New York, that its 
 cause is a cardiospasm due to abolition of cerebral inhibition on the 
 cardia ; Kraus reports a case with great atrophy of both vagi ; Rosen- 
 heim maintains that atony and ectasia are primary and cardiospasm 
 secondary. Cardiospasm produces a great hypertrophy of the cardiac 
 muscle, even six times its normal thickness, and diffuse total dilata- 
 tion so that the oesophagus may measure 18 inches (46 cm.) instead 
 of 10 inches (25 cm.) in length or 12 inches (30 cm.) in circum- 
 ference (Luschka). Though Zenker collected but 18 cases in 1878, 
 the number is increasing; nearly a dozen were reported in 1904 
 (Sippy, Tyson, Kinnicutt and Sossen), and up to 1905 over 90 are 
 recorded. The mucosa is catarrhal, thickened or eroded, and the 
 muscularis is hypertrophied or fatty. 
 
 Symptoms. — The symptoms are gradual or sudden in onset. There 
 is dysphagia, which may often be overcome by effort ; the patient feels 
 that the food does not reach the stomach. Regurgitation of the food, 
 especially the portion last swallowed, usually occurs soon after eating 
 or when the patient lies down; it may measure a quart, is neutral, 
 decomposed if retained for some time, and contains lactic and butyric 
 acids but no hydrochloric acid, pepsin or rennet. The regurgitated 
 food may again be swallowed (rumination). Vomiting is impossible. 
 The pressure of the stagnant food or fluid in the gullet may produce 
 vagus symptoms, such as dyspnoea or palpitation. The sound moves 
 freely from side to side, but meets temporary resistance at the cardia, 
 though pressure usually overcomes the obstructing cardiospasm. One 
 sound, introduced into the stomach, may recover HC1, pepsin, etc., 
 but another, introduced to but not beyond the cardia, recovers fluid 
 or food with a neutral reaction; methylene blue solution poured 
 through the first tube returns blue ; that recovered by the second tube 
 is colorless. Distention of the oesophagus with carbon dioxide gives 
 tympany, or with water dulness, to the left of the sixth to the ninth 
 dorsal vertebrae, sometimes above the left costal arch, or even in the 
 epigastrium. The oesophagoscope may reveal the dilatation; a dis- 
 tinct shadow may often, though not always, be seen by using the 
 #-rays after the patient has eaten potatoes or bread mixed with 20 
 per cent, bismuth. The second swallowing bruit may be absent or 
 
(ESOPHAGEAL DIVERTICULUM. 573 
 
 altered or sometimes sounds like fluid running into fluid. Maras- 
 mus, constipation and often death result, but the clinical course may 
 cover years or decades. 
 
 Treatment. — Treatment is rather unsatisfactory. Olive oil gss 
 before meals may help the fluid (or the sound) to pass the cardia. 
 Continued use of the stomach tube may be effective, but in some in- 
 stances causes oesophagitis ; its life-long use is often required. Lock- 
 wood's pneumatic bag may be introduced empty on a sound into the 
 stomach, then inflated and withdrawn slowly and gently through the 
 cardia. Gastrostomy and rectal feeding may be indicated. Opera- 
 tion should not be delayed too long. Mikulicz operated six times — 
 with five cures — by entering the stomach, forcibly distending the 
 cardia and rupturing its fibers submucously. 
 
 Diverticulum. — This involves only an arc of the oesophageal cir- 
 cumference. Two types are distinguished : 1. Zenker s pressure 
 diverticulum (pulsion-diverticulum) of which Rosenthal (1902) 
 collected 180 cases. It is found chiefly in men (77 per cent.), and 
 is a pouch which forms very gradually on the posterior oesophageal 
 wall, usually near the junction of the pharynx and oesophagus, and 
 nearly always consists of only the mucosa and submucosa, — a species 
 of bottle-shaped oesophageal hernia. Its onset is very gradual, for 
 the muscle, probably congenitally weak, yields before intra-oesoph- 
 ageal pressure, trauma, foreign bodies and the stagnating food. 
 The early symptoms are signs of pharyngo-oesophagitis, hawking and 
 dysphagia, and food entering the sac rather than the oesophagus ; the 
 axis of the sac, which dips between the gullet and the spine, is roughly 
 parallel with that of the oesophagus ; many of its symptoms are those 
 of a high oesophageal stenosis. The food stagnates and regurgitates 
 with a foetid odor. In 33 per cent, of cases a tumor appears in the 
 supraclavicular region, which is dull when filled with food or tym- 
 panitic when distended with carbon dioxide; it sometimes can be 
 smoothed out, whereon the food regurgitates. The murmurs on swal- 
 lowing are protracted (in 50 per cent.). A sound usually enters 
 the sac, and another, if slightly bent, enters the gullet ; this also dif- 
 ferentiates a diverticulum lower in the gullet, which is even less com- 
 mon. Examination by the oesophagoscope is generally negative, but 
 the sc-rays may show a characteristic shadow. There may be pressure 
 on the heart, trachea, vagus, recurrent laryngeal nerve and brachial 
 plexus. The clinical course is protracted, even to forty-nine years, 
 and the spontaneous evolution is inanition in over 50 per cent, of the 
 cases, gangrene (15 per cent.) or perforation with cervical phlegmon. 
 Treatment includes feeding by means of the sound, rectal nutrition, 
 gastrostomy and surgical resection; this was first performed by von 
 Bergmann (1890), 24 cases being recorded with 20 per cent, mor- 
 tality. Diverticula low in the oesophagus can only be treated by long- 
 continued sounding. 
 
 2. Rokitansky' s traction-diverticulum is frequent; according to 
 Schmorl it is found in 3.5 per cent, of autopsies. It is due to extra- 
 
574 DISEASES OF THE DIGESTIVE TRACT. 
 
 oesophageal traction, which draws a small part of the gullet out into 
 a funnel-like form. Over 80 per cent, are due to indurative periad- 
 enitis around caseous or anthracotic lymph glands. Cicatricial med- 
 iastinals from pleuritis, pericarditis or vertebral disease may pro- 
 duce the same effects. It usually, therefore, occurs at the level of 
 the tracheal bifurcation. Diverticula may result from both trac- 
 tion and pressure. Traction-diverticulum begins early in life, is usu- 
 ally single, is less marked on the anterior or lateral wall, barely ex- 
 ceeds five to ten mm. in depth and is rarely discovered during 
 life, though some have been seen with the oesophagoscope. Its chief 
 danger is ulceration at its apex and perforation into the trachea, 
 bronchi, vessels, pericardium, pleurae or mediastinum, with result- 
 ing gangrene of the lungs, fatal hemorrhage, pneumothorax or phleg- 
 monous mediastinitis. There is no treatment. 
 
 CANCER OF THE (ESOPHAGUS. 
 
 Etiology. — Its frequency is rated at J to 1 per cent, of autopsies, 
 and it is said by Peter sen-B or stell to rank third among cancers 
 (stomach 33 per cent., uterus 15 per cent, and oesophagus 6 per cent.). 
 Its etiology is unknown, (a) Scars, trauma, ulceration and traction 
 diverticulum are promoting causes; (b) 75 per cent, occur in males 
 and 80 per cent, between the fortieth and sixtieth years ; 8 per cent, 
 occur before the fortieth year; Stewart records a case aged twenty- 
 three and Heimann one aged nineteen. 
 
 Pathology. — Cancer of the oesophagus is almost always single and 
 primary, though cancer of the stomach, pharynx or mediastinum may 
 rarely involve the oesophagus secondarily. Most cases are squamous 
 epithelioma, arising from its pavement epithelium; scirrhus, colloid 
 and medullary forms are rare. Localization; most cases (57 per 
 cent.) develop in the lowest third of the oesophagus; many (33 per 
 cent.) in the middle, and the least (10 per cent.) in the upper third; 
 its favorite sites are near the cardia, at the tracheal bifurcation level 
 and just back of the cricoid cartilage. The muscularis sometimes 
 hypertrophies above the cancer, where some dilatation may occur. 
 
 Symptoms. — The onset is usually insidious. Signs of oesophagus 
 stenosis (v. s.) develop in varying grades; stenosis generally advances 
 slowly but is occasionally sudden. It may lessen as the cancer ulcer- 
 ates. Its symptoms are those of stenosis', as dysphagia, rather indefi- 
 nitely located pain, regurgitation of food and perhaps also of bloody 
 mucus or necrotic cancer tissue. Its signs are also identical, as 
 obstruction on sounding, alteration of the murmurs, sometimes the 
 detection by the oesophagoscope of a papillomatous or ulcerated neo- 
 plasm, and quite rarely tumor particles found in the fenestrse of the 
 tube. Cachexia develops; constipation, indicanuria and peptonuria 
 are usual; acetonuria is frequent. Extension, by contiguity, occurs 
 to the spine, mediastinum and cardia, or in 60 per cent, of cases by 
 metastasis; the mediastinal and peribronchial lymph nodes are usu- 
 ally invaded, the supraclavicular often and the upper cervical seldom. 
 
(ESOPHAGEAL DIVERTICULUM. 575 
 
 Complications. — There may be pressure on the recurrent laryngeal 
 (14 per cent.), vagus, mediastinal veins and arteries, on the sym- 
 pathetic ganglia (13 per cent.) or brachial plexus. Perforation 
 occurs in over 50 per cent., most often into the air passages, when 
 aspiration pneumonia or gangrene may follow ; into the lung, pleura 
 (ichorous pleurisy or pneumothorax resulting) ; into the aorta (fatal 
 hemorrhage), heart, pericardium and mediastinum. Pyaemia, pul- 
 monary tuberculosis and marantic thrombosis, occur in some cases. 
 Death is inevitable, usually within thirteen months, with emacia- 
 tion, subnormal temperature, small slow pulse, slow shallow breath- 
 ing, flattened abdomen and perhaps intoxication coma and fever. 
 
 Diagnosis. — The diagnosis is based (a) on a stricture of the oesopha- 
 gus, which in 90 per cent, of all cases is carcinomatous; (b) on evi- 
 dences of neoplasm, as age, cachexia, cancerous nodes, metastases and 
 perhaps tumor particles on the sound, (c) Other tumors, as lipoma, 
 myxoma, myoma (11 cases, Bryant, 1906), fibroma, or sarcoma are 
 of greater pathological than clinical importance, except accessible 
 fibropapillomata of the upper gullet or lower pharynx. 
 
 Treatment. — The treatment is that of stricture or stenosis ; nutritive 
 enemata, feeding by the stomach tube, gastrostomy and for pain, 
 narcotics are indicated. (Esophagectomy is seldom advisable, as less 
 than 10 per cent, occur in the cervical portion, accessible to surgical 
 interference. As to gastrostomy, Schmidt in 1897 reviewed 236 
 cases, in which 45 per cent, did not live longer than a week and 
 nearly 90 per cent, not more than one hundred days. 
 
 PERFORATION; RUPTURE; HEMORRHAGE OF THE (ESOPHAGUS. 
 
 1. Perforation may result from causes within or without the oesoph- 
 agus. Internal causes include ulcers, foreign bodies, diverticula, 
 cancer and use of the sound ; external causes are aneurysm, gravitat- 
 ing abscess, lung cavities or gangrene, suppurating lymph glands or 
 trauma. It is marked clinically by mediastinitis and cervical cellu- 
 litis, which are usually phlegmonous. (Esophageal fistula? may com- 
 municate with the air passages, from which by the laryngeal mirror 
 fluid or food is seen to be expectorated; a communicating tubercu- 
 lous cavity may become flat when the patient drinks or eats, and the 
 flatness changes to tympany when the food or drink is expectorated ; 
 this is tested by giving the patient milk, which will be brought up 
 from the larynx. Aspiration gangrene, pneumopericardium, pneumo- 
 thorax and fatal hemorrhage are common causes of death. 
 
 2. Spontaneous rupture (so-called) is a very rare affection, there 
 being only 39 cases on record (Cohn, 1908). It is often confused 
 with oesophagomalacia, in which the rupture is not longitudinal or 
 clean-cut as in genuine rupture. The first case, and one of the clear- 
 est, was reported by Boerhaave (1714) ; in all cases, except Boer- 
 haave's, the rupture was longitudinal. It follows over-eating or 
 severe vomiting;, and most victims have been alcoholics. There is 
 
576 DISEASES OF THE DIGESTIVE TRACT. 
 
 great and sudden pain over the lower oesophagus (where most rup- 
 tures occur) and over the xiphoid, severe vomiting, hgematemesis, 
 collapse and subcutaneous emphysema. Death is the rule from col- 
 lapse, phlegmonous or ichorous media stinitis, pleuritis or pneumo- 
 thorax. Treatment is wholly expectant. 
 
 3. Hemorrhage may follow oesophageal ulceration, external or in- 
 ternal trauma, toxic oesophagitis, softening and aneurysmal or other 
 perforations. Varicose veins in the lower oesophagus, first described 
 by Le Berber den (1837), are most often complications of liver cir- 
 rhosis, less often of syphilis, senile atrophy and pylethrombosis. 
 The diagnosis and localization of the bleeding point is at best only 
 suggested by the history and previous physical findings. Treatment 
 consists chiefly of keeping the patient absolutely quiet and giving 
 morphine and rectal feeding, as in gastric hemorrhage. 
 
 MOTOR AND SENSORY DISTURBANCES OF THE (ESOPHAGUS. 
 
 These will be considered under Affectioxs of the Vagus (q. v., 
 under J^ekvous Diseases). 
 
 DISEASES OF THE STOMACH. 
 
 ACUTE GASTRITIS (ACUTE CATARRH, ACUTE DYSPEPSIA). 
 
 Acute gastritis is a better term than catarrh, which implies a super- 
 ficial inflammation of the mucosa. 
 
 I. Simple Gastritis. — Etiology. — It is a very common primary 
 and secondary affection, (a) Its most important mechanical cause 
 is improper food or improper eating ; rich food, an excessive amount, 
 'partial mastication, washing down the food with water, hurried eat- 
 ing when very hungry, idiosyncrasies to certain kinds of food, de- 
 composed articles containing bacteria or ptomaines and excessive in- 
 gestion of cold water and fruit are accessory factors, (b) Thermal 
 factors include too hot or too cold foods, especially when taken on an 
 empty stomach, (c) Chemical causes; aside from acids and caustics 
 (see Toxic Gastritis), alcohol ranks foremost; autotoxins may 
 excite acute gastritis, as in chronic nephritis, cholsemia or gout, (d) 
 Some cases are clearly infectious; the condition may occur in variola, 
 measles, typhoid, grippe and pneumonia, as a secondary manifesta- 
 tion; occasionally it is an independent febrile affection, as in the 
 Christiana epidemic reported by Hausemann (1880), in which 
 6,000 persons were affected within three weeks, (e) Certain con- 
 ditions are somewhat predisposing to acute gastritis; for example, 
 stasis from diseases of the heart, lung or liver, tuberculosis, 
 cancer, syphilis, chlorosis or affections of the higher alimentary mu- 
 
ACUTE GASTRITIS. 577 
 
 cosa. In some cases a familial or even hereditary tendency i- noted, 
 known as " the delicate stomach" by the laity. Nervous factors, 
 as anger or excitement, are sometimes apparently causative, though 
 they may be confused with the digestive neuroses. 
 
 Symptoms. — 1. Digestive Symptoms. — These are sometimes ab- 
 sent, as demonstrated by Beaumont in the celebrated St. Martin 
 case of gastric fistula. The appetite is usually tost or perverted. 
 The tongue is thickly coated with white fur and dry mucus. The 
 mouth is dry and there is a disagreeable taste and great thirst, even 
 though the salivary flow is often increased. Hiccough, eructations, 
 a sense of gastric distention, pressure or pain and tenderness over the 
 stomach, are common. Nausea and vomiting characterize the more 
 marked cases ; the vomitus is pale yellow, bitter and contains little 
 or no hydrochloric acid, though lactic, butyric and fatty acids are 
 common ; there is much mucus, which is frequently necked with 
 blood. Gastric intolerance, pain, nausea and vomiting summarize 
 the situation. Corresponding anatomical changes are found, though 
 few iincomplicated cases come to autopsy; the mucosa, particularly 
 near the pylorus, is red, swollen, smeared with adherent mucus, some- 
 times slightly eroded or dotted with punctate ecchymoses ; the dilated 
 racemous vessels, as seen by the gastroscope or through a gastric 
 fistula, are less conspicuous at autopsy for the blood in great part 
 leaves the organ after death; microscopically the main findings are 
 leukocyte emigration, granular degeneration and swelling of the 
 mucous and other glandular cells. 
 
 2. Gexeral and Other Symptoms. — Herpes is an occasional 
 finding. Constipation is the rule, though diarrhoea or icterus some- 
 times occurs in gastro-enteritis. The urine is scanty because of the 
 vomiting; it deposits a lateritious sediment and sometimes contains 
 indican or acetone. Nervous symptoms — as frontal headache, vertigo, 
 intercostal neuralgia and depression — are common, but convulsions 
 (acetonemia) and other marked nervous manifestations occur infre- 
 quently in young and sensitive individuals. Fever is quite uncom- 
 mon ; when present, it is usually irregular and ephemeral. 
 
 Diagnosis. — The diagnosis is not difficult when the course is short 
 and afebrile, as is usually the case. With fever or some constitu- 
 tional symptoms it is an excellent practice to regard acute gastritis 
 as a symptom, until, at least, typhoid, exanthematous disease or 
 nephritis can be excluded by the later clinical evolution. Confusion 
 is possible with a tabetic crisis or with the vomiting of pregnancy 
 and hysteria. 
 
 Treatment. — (a) Prophylaxis embraces the etiological factors, (b) 
 Complete rest of the stomach for one or more days is the first active 
 indication; no rectal feeding is required for twenty-four to forty- 
 eight hours, by which time the gastric equilibrium is in great part re- 
 stored ; warm water may be given by rectum to unload the bowels and 
 to allay thirst, (c) If gastric irritation persists, the stomach should 
 be thoroughly washed out by the stomach tube, using warm water with 
 37 
 
578 DISEASES OF THE DIGESTIVE TEACT. 
 
 a teaspoonful of sodium bicarbonate to tbe quart. Gastric lavage is 
 a better measure than the use of calomel and salines, which irritate 
 the inflamed, perhaps eroded mucosa. For the same reason emetics 
 (apomorphine hypodermics or ipecac by mouth) are avoided. Epi- 
 gastric fomentations alleviate pain. Obstinate irritation and vomit- 
 ing usually respond to Bartholow's prescription, modified as follows : 
 
 ~fy Phenolis gr. iv. 
 
 Ac. hydrocyanici dil 3ss. 
 
 Bismuthi subnitratis 
 
 Cerii oxalatis aa 3iss. 
 
 Mucilaginis acaciae q.s. 
 
 Aquae menthae piperitae q.s. ad ^ij- 
 
 M. et fac emulsum. S. — One teaspoonful without dilution every half to one 
 
 hour for six to ten doses. 
 
 Opiates give immediate relief, but secondary nausea is an insuper- 
 able obstacle to their use. (d) In convalescence, dilute hydrochloric 
 acid Vfl v to xv and bitters are given after meals, to stimulate and sup- 
 plement the gastric secretion. The food should be simple, moderate 
 in bulk and thoroughly chewed. 
 
 II. Gastritis Toxica (Venenata). — Etiology and Pathology. — Acute 
 toxic gastritis is caused by various alkalies, acids and metallic 
 poisons. Sulphuric acid produces a gray eschar, nitric acid a yellow 
 one, alkalies a brown, copper a greenish blue, silver a deep black 
 eschar, and phosphorus produces an opaque milky stain. The patho- 
 logical changes are usually severe, particularly in places with which 
 the corrosives remain longest in contact, as the pylorus and posterior 
 wall; these changes range from simple epithelial desquamation and 
 catarrh, to hemorrhagic infiltration, diphtheroid patches, suppuration 
 and ulceration. 
 
 Symptoms. — The symptoms are those of gastritis simplex, but more 
 severe ; pain is intense in the mouth, throat, oesophagus and stomach, 
 and is not relieved by the repeated vomiting. The vomitus is often 
 bloody, the epigastrium tender and the abdomen tympanitic. 
 
 Prognosis. — The outcome varies; (a) collapse after a few hours or 
 days is frequent, with small pulse, shallow breathing, subnormal 
 temperature, bloody albuminous urine and other symptoms which 
 vary with the poison ingested, (b) The stomach symptoms may sub- 
 side and death may occur later from blood or visceral changes, (c) 
 Strictures may develop, or (d) there may be atrophy of the secretory 
 glands (achylia gastrica). 
 
 III. Phlegmonous Gastritis.— Etiology.— Only 100 cases are re- 
 corded (1908). It is an acute suppurative inflammation of the stom- 
 ach, usually caused by the streptococcus ; it begins in the submucosa 
 and infiltrates the other coats diffusely or forms a circumscribed 
 mural abscess. It most often occurs secondarily (75 per cent.) in 
 sepsis, the acute infections, anthrax or in local diseases as gastric 
 cancer. The writer has seen only one case, which followed erysipelas. 
 Eighty-five per cent, occur in adult males. Alcoholism and trau- 
 matism are predisposing factors, 
 
CHRONIC GASTRITIS. 579 
 
 Symptoms.— The symptoms are gastric and septic. Besides the 
 symptoms of acute gastritis, the vomitus sometimes contains pus, the 
 epigastric pain is intense, meteorism is well marked and there are 
 many symptoms of peritonitis, which is a most common complication. 
 In a few cases an epigastric tumor marks the circumscribed variety. 
 Sepsis, usually in a severe form, causes the high fever, the pronounced 
 status typhosus, the small pulse, occasional icterus and petechia?. 
 
 Diagnosis and Treatment. — A diagnosis is almost impossible, the 
 outcome is fatal in 96 per cent, during the second week and the 
 treatment is symptomatic, viz., rectal nutrition and stimulation, nar- 
 cotics for pain and vomiting and hydrotherapy for fever. Some cases 
 heal by rupture into the stomach with cicatrization and, if the affec- 
 tion is suspected, operation can be considered. 
 
 IV. Diphtheritic Gastritis. — This form, due to the Bacillus diph- 
 theria?, is very rare. Diphtheroid gastritis, caused by streptococcic 
 and other infections, is more common ; it may develop after gastritis 
 toxica, smallpox, pneumonia and kindred maladies. 
 
 V. Parasitic Gastritis. — This form is, in rare instances, due to the 
 oidium albicans, favus parasite (Kundrat), anthrax bacillus, larvae 
 of insects and tinea?. 
 
 CHRONIC GASTRITIS. 
 
 Chronic gastritis (dyspepsia, catarrh) is characterized pathologic- 
 ally by degeneration of the parenchymatous and infiltration of the 
 interstitial tissue, and clinically by mucus formation and decreased 
 secretion. 
 
 Etiology. — (a) The factors are the same as in acute gastritis, from 
 repeated attacks of which chronic inflammation may result. Abuse of 
 drugs, especially cathartics, is an important factor. Alcoholism and 
 improper eating are most important. Eating hurriedly or at irregu- 
 lar hours, inadequate mastication, washing down the food with much 
 fluid, excessive use of coffee, tea, ice water, carbohydrates, pastries or 
 fried foods are salient factors. Chewing and smoking tobacco may 
 cause chronic gastritis ; stomatitis, carious teeth and pyorrhoea areo- 
 laris are important causes. Most cases occur in adult males, (b) 
 It often accompanies other gastric diseases, as cancer or ectasia, (c) 
 It is frequent in tuberculosis, the anaemias, stasis, nephritis, gout, 
 diabetes, syphilis, amyloidosis and Addison's disease. 
 
 The acid form is usually caused by excesses in eating, drinking and 
 smoking ; the subacid form by the abuse of spirits. 
 
 Pathology. — The pathological changes are observed chiefly in the 
 pyloric region. The vessels are dilated, imparting a reddish-brown 
 color, which later changes to gray. The mucosa is swollen, lax 
 and covered with tenacious mucus. Sometimes punctate hem- 
 orrhages or erosions are observed. In a few eases the mucosa is rough, 
 even papillomatous (gastritis polyposa, etat mamellone). The mus- 
 cularis is not essentially changed, as a rule, but is sometimes hyper- 
 trophied near the pylorus. Histologically, the glandular cells are 
 granular and fatty, or show a mucoid degeneration which extends 
 
580 DISEASES OF THE DIGESTIVE TRACT. 
 
 from the surface toward the deeper layers; the parietal cells can- 
 not be distinguished from the principal cells, the glands are often 
 large, sacculated or cystic and the tubules show irregular rami- 
 fications; the glandular structures may completely atrophy (see 
 Aciiylia). The interstitial tissues show leukocytic infiltration. 
 Symptoms. — The symptoms begin insidiously. 
 
 1. Oral Symptoms. — The tongue is generally coated with moist 
 white fur, reddish at its tip and indented on its edges, which may also 
 result from alcoholic or nicotine stomatitis. There is frequently a 
 bitter, sour, salty taste in the mouth and sometimes a marked foetor ex 
 ore. Increase in the saliva results from the coincident stomatitis. 
 
 2. Gastric Symptoms. — (a) Gastric pain is less frequent than 
 a sense of distention, discomfort or pressure after eating. Soup and 
 fluids, unless they are cold, generally cause no distress ; coarse or hard 
 foods, as beefsteak, hard bread, smoked meat, cabbage, hard-boiled 
 eggs or cheese, cause distress. In nervous dyspepsia, any kind of food, 
 hard or soft, may cause discomfort. In some cases of gastritis there 
 is distress when the stomach is empty. Tenderness is much less than 
 in cancer or ulcer and responds readily to treatment, (b) Belching 
 of gas is common; eructations may be odorless or may contain fatty 
 acids and even inflammable gas. Eructations of hydrochloric acid 
 are rare, (c) Nausea is more frequent than vomiting, which may 
 result from other conditions, notably chronic pharyngitis. The vom- 
 itus shows the same findings as the test meal (see Gastric Chemism). 
 In alcoholics morning vomiting is common (vomitus matutinus pota- 
 torum), chiefly of saliva and mucus swallowed during the night. 
 
 3. Gastric Chemism. — Our intimate knowledge of the chemical 
 changes in the stomach dates from the introduction of the stomach 
 tube by Leube and the vast amount of work done by many workers, 
 especially Eiegel, Ewald and Boas. After washing out the stomach 
 the Ewald test breakfast is given, consisting of a piece of dry bread 
 and a cup of weak tea without sugar or cream. In an hour the 
 stomach tube is again introduced and the gastric contents withdrawn 
 by expression (the patient compressing the abdomen and straining), 
 or by Ewald's aspiration bag. Innumerable errors result from con- 
 fidence in a single examination and assigning undue importance to 
 the gastric chemism alone. It is best to examine the contents chem- 
 ically without filtration. 
 
 (a) The gross examination of the stomach contents shows coarse 
 particles of food when the hydrochloric acid is absent or greatly re- 
 duced, or fine subdivision when it is present in fair amounts" A 
 rancid odor denotes fatty acids, and a foaming appearance is caused 
 bv fermentation. Mucus is seen in practically all cases, and most 
 clinicians do not recognize a simple gastritis without mucus forma- 
 tion, though Ewald distinguishes (i) simple gastritis in which the 
 acid and ferments are decreased; (ii) a mucous gastritis, in which 
 the acid is greatly decreased, the ferments are present and there is 
 much mucus ; and (iii) an atrophic gastritis which will be considered 
 
CHRONIC GASTRITIS. 581 
 
 separately. Mucus usually indicates a reduction in the hydrochloric 
 acid. Normally there is little gastric mucus, though there is rather 
 more with an amylaceous than with a proteid diet. Mucus of gastric 
 origin is intimately mixed with the food and is not yellow, nummu- 
 lar, pigmented or mixed with air or cells, as in mucus from the mouth 
 or respiratory tract. 
 
 (b) The HCl is reduced. It is recognized by the Giinzburg test 
 (2 gm. phloroglucin and 1 gm. vanillin dissolved in 30 c.c. of absolute 
 alcohol) ; a few drops of the solution are added to an equal amount 
 of the filtered gastric contents and slightly heated, without boiling, in 
 a porcelain dish, when a carmine-red color develops, indicating free 
 hydrochloric acid even in dilution of 1 to 20,000 parts, and not react- 
 ing to lactic or butyric acid; the solution should be kept in a dark 
 bottle, for it degenerates in the sunlight. The solution should not be 
 kept over two months. Boas recommends the following test, which 
 gives the same reaction and is less expensive: resorcin 0.5, sugar 0.3, 
 dilute alcohol q.s. ad 10 gm. HC1 exists in a combined form or 
 as free acid, which latter probably serves as an antiseptic. 
 
 The total free HCl. To 10 c.c. of gastric contents is added a few 
 drops of the indicator (0.5 per cent, solution of dimethylamidoazo- 
 benzol in strong alcohol) ; it is placed in a beaker and, if free HCl 
 is present, the yellow color imparted by the indicator will change to 
 bright red; a decinormal solution of caustic soda (4 gm. to 1,000 c.c. 
 of distilled water) is then added drop by drop to the gastric contents, 
 until the color of the indicator has been changed from red to bright 
 yellow ; the number of c.c. of decinormal solution used is multiplied 
 by 0.00365 and again by 10 to give the amount of free HCl. 
 Very often the result is expressed in terms of the number of c.c. of 
 decinormal solution used ; i. e., if 4 c.c. were employed, 4X10 = 40, 
 the free HCl. The usual amount is 30 to 40. 
 
 The total acidity (HCl, lactic and other organic acids, acid phos- 
 phates and albumins, albumoses and peptones) is estimated by add- 
 ing two drops of a 1 per cent, alcoholic solution of phenolphthalein 
 (as an indicator) to 10 c.c. of the gastric contents; to this is added, 
 drop by drop, a decinormal solution of caustic soda (4 gm. to 1,000 
 c.c. of distilled water) until the red color, due to the alkali acting 
 upon the phenolphthalein, is no longer even deepened in hue by the 
 alkali. As 4 to 8 c.c. of the decinormal solution are usually required, 
 4 to 8 X 10 = normal total acidity ; i. e., 40 to 80 expressed in terms 
 of the decinormal solution (corresponding to 0.15 to 0.25 per cent. 
 HCl). In most cases determination of the total acidity is sufficient. 
 A total acidity under 20 gives no reaction with Congo paper; i. e., 
 there is no free HCl. The bread of the test breakfast (phosphates 
 chiefly) accounts for a total acidity of from 5 to 8 ; this indicates that 
 the gastric glands are atrophied. 
 
 In chronic gastritis the hydrochloric acid is found decreased or 
 absent. A few cases, described by Eiegel and Boas, show a total 
 acidity of 40 to 50; this form is called gastritis acida, though its 
 
582 DISEASES OF THE DIGESTIVE TRACT. 
 
 separation as a type is scarcely justifiable; these are usually light, 
 incipient or neurotic cases. 
 
 (c) Rennet and pepsin are rarely absent, though usually decreased. 
 Pepsin is tested by mixing the gastric juice with egg albumin; 25 
 c.c. of normal gastric juice will dissolve 0.05 gm. of serum albumin 
 in one hour, the same amount of fibrin in one and one-half hours and 
 of egg albumin in three hours. Pepsinogen is tested in the same way 
 with the addition of a few drops of hydrochloric acid, which liber- 
 ates the enzyme (pepsin) from the pro-enzyme (pepsinogen). Boas 
 insisted on the importance of the rennet ferment, which coagulates 
 milk ; if no rennet is present the filtrate will not coagulate milk. 
 
 Lactic acid is seldom found. (See Cancer of Stomach.) Leu- 
 kocytes and epithelial cells are found at times, and in rare cases shreds 
 of gastric mucosa (gastritis exfoliativa, Parisier). 
 
 4. Other Symptoms. — (a) Vertigo e stomacho Iceso (Trousseau), 
 gastric vertigo, is probably neurasthenic rather than gastric. The 
 so-called dyspeptic asthma is not really asthma, but a dyspeptic dys- 
 pnoea and probably results from pressure of the distended stomach on 
 the heart. Headache, physical and mental lassitude, a degree of 
 melancholia, intercostal neuralgia, tender points between the shoul- 
 ders or over the lower cervical spines and palpitation are fairly com- 
 mon, (b) The bowels are generally constipated; diarrhoea and tym- 
 pany at times result from marked gastric fermentation or extension 
 of the catarrh to the gut, when catarrhal icterus may result. Boas and 
 Schmidt find undigested connective tissue in the movements, (c) 
 The urine is frequently reduced and shows a lateritious deposit, phos- 
 phates and oxalates, (d) The general nutrition is usually well main- 
 tained if the intestines functionate well, (e) The motive and ab- 
 sorptive power of the stomach may be impaired, normal or even 
 exaggerated, the food sometimes being hurried into the intestine. 
 
 Diagnosis. — Leube insists that chronic gastritis should never be 
 diagnosticated until cancer, ulcer and functional disease have been 
 finally excluded. Its cardinal points are (a) its steady, slow, chronic 
 course ; (b) the presence of mucus and (c) decreased secretion. (For 
 its differentiation v. i. Ulcer.) 
 
 Treatment.— 1. Prophylaxis. — ^Recurrence of the trouble is pre- 
 vented by treatment of the causal conditions ; digitalis is indicated in 
 gastric stasis of cardiac origin and iron in anaemia. 
 
 2. Hygiene.— Hygiene concerns regularity in living, moderation, 
 recreation, massage, rational exercise and avoidance of haste in 
 eating. 
 
 3. Diet.— P. A. Hoffman justly remarks that every one " has the 
 stomach he deserves." Slowness of eating, drinking onlv after the 
 solid part of the meal is eaten and thorough mastication are' frequently 
 curative without medicinal treatment. The importance of thorough 
 msalivation of the food is manifest when we remember that the ptya- 
 lm operates for nearly an hour in the unchurned contents of the 
 cardiac end of the stomach. As Ewald states, " die Diat der Magen- 
 
CHRONIC GASTRITIS. 583 
 
 Kranker fangt im Munde an." The teeth should receive care, 
 as the treatment of pyorrhoea, extraction of carious teeth and fitting 
 of proper plates. Food should be taken in moderate amounts, and the 
 stomach should be given sufficient rest. Pawlow has shown that the 
 relish of food excites the flow of the gastric juice; he names it the 
 " appetite juice." 
 
 Kind of Food. — The term " easily digestible food " is extremely 
 relative, but the kind of food is less important than careful mastica- 
 tion and insalivation. In severe or alcoholic cases an absolute milk 
 diet may be tried, giving equal parts of milk and Apollinaris water, 
 to which grains x of sodium bicarbonate, grains x of sodium chloride 
 and grains v of magnesium oxide are added. Predigested milk 
 soon becomes distasteful to the patient and is indicated chiefly in 
 severe catarrh with much mucus formation or with atrophy. Gen- 
 erally speaking, the diet should be mixed, but proteids are superior to 
 carbohydrates, which are prone to ferment. The proteids given are 
 chopped lean meats, scraped beef, boiled mutton, veal, roasted steak, 
 broiled tenderloin, pigeon, chicken and eggs boiled one minute. Chit- 
 tenden has shown that we eat twice as much meat as is necessary. 
 Beef tea, heavy fresh beef, hard-boiled eggs, pork, game, fish, warmed- 
 over (therefore hardened) meat, turkey, goose, duck, smoked or cured 
 meat (except bacon) and cheese must be interdicted. Carbohydrates 
 are withheld when there is obstinate fermentation. Those allowed 
 are arrowroot, well cooked sago, tapioca or rice, white bread, zwie- 
 back and toast; those occasionally allowed or tried later are mealy 
 potatoes, spinach, pea or bean soups ; those forbidden are substances 
 containing much cellulose, as hard or brown bread, oatmeal, coarse 
 vegetables, uncooked green vegetables, most fruits, pies and pastries. 
 It is interesting to note that most of the carbohydrates ingested reach 
 the bowel very rapidly. Carbohydrates, therefore, should be eaten 
 before the proteids, that they may the earlier leave the stomach. 
 Fats are a necessary part of the diet, especially moderate amounts of 
 butter and cream. Other forms of fat as greasy soups are injuriouSo 
 
 Accessories. — No seasoning is necessary, but liberal quantities of 
 salt may be used. Liebreich insists that condiments in moderate 
 amounts are helpful. Tea, coffee and alcoholic beverages are usually 
 prohibited. Smoking should be interdicted or restricted. 
 
 4. Gastric Lavage. — Lavage is indicated when there is formation 
 of mucus, fermentation, deficient secretion and delayed digestion. It 
 is generally considered the most helpful measure but in the writer's 
 experience is seldom indicated as there is no stagnation of food. 
 Morning lavage is best for removal of mucus, and lavage before the 
 evening meal for delayed digestion or fermentation. Warm water 
 is used, to which sodium bicarbonate, two teaspoonfuls to the quart, 
 is added to dissolve the mucus, or salicylic acid (1 to 1,000) to modify 
 fermentation. The stomach should be washed until the water returns 
 clear. When the use of the stomach tube is resisted or contra-indi- 
 cated, as by exceptional nervousness, modified lavage may be em- 
 
584 DISEASES OF THE DIGESTIVE TRACT. 
 
 ployed, the patient drinking before breakfast two glasses of warm 
 water to which a teaspoonful each of sodium chloride and sodium 
 bicarbonate has been added. This process is essentially the same as 
 drinking the Kissingen, Wiesbaden and other waters. The sodium 
 bicarbonate acts locally and the sodium chloride acts both locally and 
 systemically, for small doses increase the hydrochloric acid and large 
 doses reduce it by increasing the alkalinity of the blood. Carbonated 
 waters may be used, which stimulate secretion and absorption and 
 neutralize abnormal acids. 
 
 5. Medic al Treatment. — (a) The value of hydrochloric acid is 
 disputed. Its first indication is to convert pepsinogen into pepsin, 
 whence it is useless in atrophic gastritis save as it stimulates the flow 
 of bile. Its second indication is as a digestant ; we employ 20 drops of 
 the dilute acid every thirty minutes until 5j to ij have been given. Its 
 third indication is as an antizymotic, which Boas holds is its sole in- 
 dication ; it should not be given until about half an hour after meals, 
 during which period the saliva is acting upon the carbohydrates; 
 Pawlow has shown that it increases the flow of pancreatic juice and 
 perhaps of bile, (b) Boas takes the extreme view that pepsin is use- 
 less. It should be given as a powder, for solutions rapidly deteriorate 
 and are usually strongly alcoholic ; many forms offered on the market 
 are inert. Pancreatin is very frequently ineffective. Taka-diastase 
 is beneficial in some cases, (c) Bitters are best exhibited before 
 meals ; though their mode of action is disputed, they surely act upon 
 the appetite or on the nervous structures and increase the flow of 
 saliva and gastric juice and probably also the pancreatic juice. 
 Strychnine or mix vomica is the best of this group of drugs and is 
 especially valuable in alcoholic cases. All bitters should be given in 
 solution, as their bitter taste is their chief mode of action. 
 
 I£ Strychnina? sulphatis gr. j. 
 
 Acidi nitrohyclrochlorici 3j. ' 
 
 Tr. gentianse comp ^iv. 
 
 M. et S. — One teaspoonful half an hour after meals in half a glass of water. 
 
 Gondurango bark (fluidextract 3ss) is prepared by macerating the 
 bark in cold water. Some bitters, as gentian, may irritate the stomach 
 and induce diarrhoea, (d) Antizymotics (antifermentatives), as creo- 
 sote or betanaphthol, often cause irritation. Phenol gr. j, thymol gr. 
 ss to j, resorcinol gr. ij to v, after meals, act on the stomach and salol 
 gr. x and betanaphthol gr. x (in capsule because of its bitterness) are 
 intestinal antiseptics, (e) Gastric sedatives are seldom indicated ex- 
 cept in the hyperacid type. Bartholow's combination (see page 
 578) meets all indications. Silver nitrate is sedative, astringent 
 and alterative, but may cause nephritis or argyria ; it is given 
 in pill form, half an hour before meals, in doses of one-fourth of a 
 grain (perhaps with quite small doses of opium or belladonna). Zinc 
 oxide, gr. iij to v, given before meals, is valuable in alcoholic gas- 
 tritis. Extract of belladonna in one quarter of a grain doses is help- 
 
ACBTL1A. 585 
 
 ful in pain, especially in hyperacid gastritis. Pyrosis and spasm may 
 be considered under this heading. In pyrosis of fatty and other 
 organic acids, alkalies may be employed, though sparingly; Trous- 
 seau gave sodium bicarbonate grains v, creta preparata grains x and 
 magnesium carbonate grains v after meals. Spasm from gas or over- 
 loading of the stomach is modified by spirits of chloroform TT\,xx and 
 tincture of asafoetida 3j ; spasm suggests erosions near the pylorus, 
 when extract of belladonna gr. % and subnitrate of bismuth gr. x 
 are distinctly indicated, after meals. (/) titer measures, as faradi- 
 zation, massage and hydrotherapy, are less valuable than in gastric 
 atony and sensory neuroses of the stomach. In constipation cathartics 
 should be avoided, as they cause irritation and constipation recurs. 
 Hot water, gastric lavage, colonic flushings and perhaps the mildest 
 saline aperients are indicated. 
 
 Achylia Gastrica. — Etiology. — The term was introduced by Ein- 
 horn in 1892 to designate total suppression of gastric digestion. 
 Atrophy of the stomach was first described by Austin Flint (I860) 
 and by Fenwick (1877), Ewald, Quincke and Einhorn. Achylia 
 frequently occurs secondarily in cancer of the stomach and in toxic 
 gastritis, but also in other gastritides, cancer of distant organs 
 (mammae, uterus, intestine, oesophagus), diabetes, pernicious anaemia, 
 tabes and in neuroses. In rare cases it develops as a seemingly pri- 
 mary affection, possibly as a congenital condition (Martius). It 
 occurs oftenest in middle or advanced life, though isolated cases are 
 reported at eighteen to twenty -five years of age. 
 
 Pathology. — Pathologically two main forms exist, (a) one, cirrhosis 
 ventriculi, in which the stomach is very small and thickened so that 
 its walls may measure several centimeters in thickness, and (b) 
 another, phthisis ventriculi, in which the walls are thin or " wasted " 
 and the stomach is lax or dilated. In some cases atrophy has been 
 found in Meissner's and Auerbach's plexuses. The glandular struc- 
 tures are wasted (anadenia). In neurotic achylia there is no ana- 
 tomical change. 
 
 Symptoms. — Symptoms maybe absent if gastric motility is good and 
 the intestinal glands are normal. If the same process exists in the 
 gut diarrhoea, marasmus and death result. 
 
 1. Gasteic Symptoms — There are no pathognomonic gastric 
 symptoms. Pain is variable; it may be absent or moderate, though 
 in some cases lancinating pain and other symptoms like those of hyper- 
 chlorhydria may exist (Einhorn). The appetite is also variable. 
 Vomiting does not always occur but when present the vomitus always 
 contains coarse, poorly digested particles. 
 
 2. Test Meal. — The recovered food is coarse; the total acidity 
 corresponds to the amount in the food ingested. ~No HC1 is found 
 (achlorhydria), no pepsin (therefore no peptones), no rennet (there- 
 fore no coagulation of milk), no blood and according to most writers 
 no mucus; according to Riegel and Schmidt, some mucus may be 
 
586 DISEASES OF TEE DIGESTIVE TRACT. 
 
 present, due to metaplasia of the gastric mucosa to one resembling 
 that of the intestine, the cells of which secrete mucus ; as they in turn 
 atrophy the mucus disappears. Lactic acid is found but rarely. 
 The gastric motor power is usually increased and the stomach is 
 emptied in less than an hour. In the contracted cirrhotic form, the 
 stomach may hold but a few ounces; in the phthisic form ectasia 
 may occur. In some scleroses of the stomach a sound is introduced 
 into the stomach with difficulty, hydrochloric acid is present, the 
 stomach cannot be distended with gas and its capacity is enormously 
 decreased. 
 
 3. Other Symptoms. — Headache and vertigo are common. Con- 
 stipation is the rule ; in some cases diarrhoea may be the sole salient 
 symptom, so that it apparently indicates an intestinal lesion (Oppler). 
 Symptoms like those of pernicious anaemia (Henry and Osier) or like 
 gastric cancer (author) mark some cases. The increased acidity of 
 the urine, at the height of digestion, is naturally absent. The test 
 meal establishes a clear diagnosis. 
 
 Prolonged observation may be necessary in order to exclude the 
 secondary atrophic gastritis of cancer and amyloid gastric disease. 
 In one instance the autopsy showed only atrophic gastritis, whereas 
 clinically hsematemesis, achylia, lactic acid, oedema, ascites and ex- 
 treme emaciation had led to a suspicion of cancer. 
 
 Prognosis. — Life may be prolonged for years by compensating 
 intestinal digestion, but recovery is impossible after atrophy develops. 
 
 Treatment. — Treatment is necessarily palliative. Thorough masti- 
 cation of food is imperative. Cellulose is to be avoided and thick, 
 plain, leguminous purees should be given. Butter is well tolerated. 
 The meals should be small and frequent (every three or four hours). 
 HC1 should be given in full doses (TT[xx to xxx), Pawlow having 
 demonstrated its stimulating action on the pancreatic flow and its 
 control of the pylorus (thus averting diarrhoea). Water relieves the 
 pain, which resembles that of hyperchlorhydria (Einhorn). 
 
 DILATATION OF THE STOMACH; MOTOR INSUFFICIENCY. 
 
 The nomenclature of this and allied conditions is a matter of dis- 
 pute; dilatation of the stomach (gastrectasia) is only a symptom, and 
 is understood as a more or less lasting dilatation with motor insuffi- 
 ciency. 
 
 I. Acute Dilatation. — Acute dilatation was first fully described 
 by Fagge (1883) ; 217 cases of acute dilatation are recorded (LafTer, 
 1908). 
 
 Etiology. — (1) Most cases follow abdominal trauma or laparotomy 
 (36 per cent.) ; gall-bladder operations are the most frequent type. 
 The two cases seen by the writer were in women over fifty year's of 
 as-e who had been operated on for fibroids of the uterus. (2) It may 
 follow acute infections as pneumonia or typhoid; or (3) overloading 
 of the stomach; in one of Kolisko's autopsies in Vienna the author 
 
DILATATION OF THE STOMACH. 587 
 
 saw an enormously dilated stomach in a man who had, on a wager, 
 taken a large number of charged siphons and died soon afterward 
 from gastric distention and reliex paralysis of the heart. (4) Most 
 cases occur between twenty and thirty years of age. (5) Traction or 
 obstruction of the superior mesenteric artery in the duodenal mesen- 
 tery is the most favored etiological factor, though no proof exists that 
 it is not a result rather than cause. 
 
 Symptoms. — The stomach is enormously distended; there is vomit- 
 ing of brown-gray to black material which often runs out of the 
 mouth, may be very copious and sometimes is offensive. There is 
 usually no free HC1 ; sometimes there is lactic acid ; succussion sounds 
 are fairly frequent. The abdomen is greatly distended. There is 
 much collapse and often abdominal pain. 
 
 Prognosis and Treatment. — Sixty-four per cent, die, usually within 
 five days. The indications are : early gastric lavage ; rectal feeding ; 
 strychnine in large doses and a few doses of atropine (under which 
 the writer observed one recovery) ; salt solution under the skin, and 
 other measures for shock; and in appropriate cases gastrostomy or 
 gastro-enterostomy. 
 
 II. Chronic (Permanent) Dilatation and Motor Insufficiency. — 
 
 In the following discussion it must be borne in mind that various 
 grades of distention and atony may occur, that dilatation may be asso- 
 ciated with increased power of the gastric musculature or with atony, 
 and that motor insufficiency (inability of the stomach to propel food 
 into the intestine) is not necessarily, though very often, associated 
 with dilatation of the stomach. Dilatation and motor insufficiency 
 are most prevalent in middle or advanced life. 
 
 Etiology. — 1. Pyloric Stenosis. — Its causes are twofold, malig- 
 nant and benign. It is most often cancerous, but may follow round 
 or corrosive ulcers, chronic gastritis leading to hypertrophy of the 
 pyloric musculature (stenosing gastritis), benign tumors of the 
 stomach, as pedunculated polyps occluding the pylorus, and con- 
 genital stenosis, of which Shaw and Elting (1905) collected 145 
 cases ; under one year of age 45 cases of congenital hypertrophic sten- 
 osis are reported, most of which were less than four months old. It 
 may also result from congenital duplicature of the pyloric mucosa, 
 volvulus of the stomach (of which 10 cases are reported), angular 
 bending of the fixed pylorus by sinking of the stomach (gastroptosis) 
 or from adhesions due to cholecystitis. Picard and Chevrier collected 
 nineteen cases of tuberculous pyloric obstruction. Stenosis of the 
 duodenum produces essentially the same results as pyloric stenosis 
 and may follow duodenal ulcer, diverticulum or twisting. The py- 
 lorus may suffer compression stenosis from tumors of the liver, colon, 
 kidney or pancreas. Payr in 1904 collected 58 cases in which pyloric 
 stenosis was associated with intestinal stenosis (chiefly from round 
 nicer") . Temporary or permanent pyloric spasm (v. Gastric Neu- 
 roses) from fissure, erosion, ulcer or hyperchlorhydria may cause 
 
588 DISEASES OF T3E DIGESTIVE TRACT. 
 
 the obstruction. The pathological sequence of pyloric stenosis is re- 
 tention of food within the stomach and hypertrophy of its muscula- 
 ture in attempts, sometimes partially successful and at other times 
 vain, to force the food through the narrow or closed pylorus. The 
 analogy is close between this change and that observed in hyper- 
 trophied and dilated bladder from prostatic enlargement or hyper- 
 trophy with dilatation of the heart in obstructive valvular disease. In 
 all three instances the hypertrophied muscle eventually degenerates 
 Dilatation of the stomach may be considered, then, as a disturbed 
 compensation. 
 
 2. Muscular Weakness. — Muscular weakness (motor insufficiency, 
 insufficiency of the stomach, atony, myasthenia gastrica) constitutes, 
 in contrast with the first group of causes, a functional and, generally 
 speaking, a more reparable type, (a) Atony dependent on general 
 causes may occur in acute infections, anaemia and neuroses. The 
 atonic tendency may be acquired or congenital. Rickets is thought 
 to cause certain juvenile cases. (6) Atony may result from gastric 
 conditions, as cancer, gastritis, hypersecretion, peritoneal adhesions, 
 cholecystitis with pyloric adhesions, diaphragmatic pleurisv and 
 diastasis of the musculi recti abdominales. Overloading the stomach 
 with heavy meals, eating indigestible foods or excess of vegetables 
 and carbohydrates, beer drinking, milk in large quantities, much 
 water ingested with heavy meals, as in diabetics, swallowing of for- 
 eign bodies by insane subjects, etc.. may develop muscular insuffi- 
 ciency. The stomach is usually enlarged, contains residual food 
 and shows a lax, often wasted and thinned musculature. 
 
 Symptoms. — The symptoms of dilatation (again emphasized to be 
 a symptom only) differ greatly in degree, ranging from absolute 
 pyloric stenosis to the least motor weakness. The symptoms are 
 partly mechanical, partly chemical. 
 
 1. Gastric. — (a) The appetite is variable; the tongue is some- 
 times coated, sometimes clean. (b) There is usually thirst and 
 dryness of the throat, more frequently in hypersecretion than in 
 cancer, (c) Singultus, pyrosis of fatty acids, oppression over the 
 stomach, a cramped or uneasy feeling and eructation of gas are 
 frequent. Gases are never formed without motor insufficiency; 
 the kind of gas is of more scientific than clinical interest, but in- 
 cludes hydrogen sulphide, hydrogen, oxygen, nitrogen, carbon diox- 
 ide and even inflammable gases, (e) Vomiting is always present in 
 pyloric obstruction and in marked motor insufficiency. It occurs 
 easily and is often rather belched up than vomited. It occurs when 
 the stomach is full, frequently during the night or at intervals of 
 days; Hve quarts may be evacuated. Large amounts argue directly 
 for stagnation and dilatation. The vomitus is acid, sour and often 
 greatly decomposed. Three layers are noted, a brownish foam, a gray- 
 brown fluid and a sediment of food, stones and seeds, which mav have 
 lain for days in the stomach. Gas often bubbles up as the vomitus 
 stands. If gastric juice only is found, it indicates hypersecretion with 
 
DILATATION OF THE STOMACH. 589 
 
 motor insufficiency. Chemically, butyric acid, peptones and, in cancer, 
 lactic acid, are found; when the obstruction lies in the duodenum 
 below the papilla of the common duct, bile is also present. Micro- 
 scopically undigested meat or starch, in benign stenosis sarcinse and 
 in cancer the Oppler-Boas (lactic acid) bacilli, yeast and other bac- 
 teria are found. HC1 is absent in cancer. (/) Pain is frequent; it 
 is cramp-like, boring or burning. 
 
 2. Test Meal, Motility and Resorption. — (a) The chemism 
 depends on the causal affection, particularly if it is gastric (see Ul- 
 cer, Cancer, Hyperchlorhydria, Hypersecretion). Hyper- 
 chlorhydria and hypersecretion are usually present except in malig- 
 nancy and are sequential rather than causative, (b) Motility is 
 best tested by Leubes test dinner, consisting of 13 ounces beef 
 soup, 7 ounces beefsteak, one to two ounces bread and 7 ounces water, 
 which should leave the stomach physiologically in not more than 
 seven hours. If food is found later, stagnation is present; if found 
 in the morning when Leube's meal has been given at night, there is 
 great stagnation. The long stay of food in the stomach shows prac- 
 tically what the vomitus shows, i. e., fermentation. Fluid is not ab- 
 sorbed by the stomach, whence the measure of its residual amount 
 is important. There is more fluid in the stomach than was ingested, 
 which is accounted for by hypersecretion of the gastric juice, actual 
 transudation, mucus and perhaps regurgitation from the intestine or 
 hemorrhage. Other tests are less reliable; — the oil test consists of 
 administering three ounces (100 c.c.) of olive oil, 70 to 80 per cent, 
 of which should leave the stomach in two hours ; if more than 20 to 
 30 c.c. remain after this time it is indicative of motor insufficiency. 
 Salol, grains xv, given just after eating, should normally reach the 
 intestine within an hour, where it is split up into salicylic and car- 
 bolic acids ; in testing the urine passed in forty-five to sixty minutes 
 after eating, salicyluric acid should be found (reacting violet to tinc- 
 ture of the chloride of iron) ; salol is normally eliminated in twenty- 
 four hours, and its presence in the urine for a longer time also indi- 
 cates delayed absorption and dilatation ; two errors are possible in this 
 test, viz., its possible decomposition by alkaline mucus in the stomach 
 and its failure to decompose in the gut when there is acid intestinal 
 fermentation (Brunner and Huber). Resorption may be tested by 
 giving five grains of potassium iodide after eating. It should be 
 absorbed and excreted by the saliva in seven to fifteen minutes ; this 
 is tested by adding nitric acid to the saliva and touching with starch 
 paper, which will show the blue iodine reaction ; a possible error is the 
 prompt absorption of the KI when food is not absorbed. In general a 
 homogeneous chyme means that the motor function is normal ; coarse 
 particles occur when there is motor insufficiency. 
 
 3. Physical Signs. — (a) Inspection in a good light is very im- 
 portant. A visible prominence of the dilated organ may be seen be- 
 low the navel, sometimes showing clearly the abnormally low upper 
 ^ancj lower curvatures, Jthe upper curvature never being seen normally. 
 
590 DISEASES OF THE DIGESTIVE TRACT. 
 
 In obstruction a peristaltic wave passing from left to right or an anti- 
 peristaltic wave in the opposite direction often tells the whole story. 
 " Stiffening " of the stomach is an infallible sign of pyloric stenosis. 
 Peristaltic waves may be elicited by applying ether or ice to the epi- 
 gastrium. The rr-rays show the outline of the viscus after ingestion 
 of considerable bismuth, (b) Palpation confirms the above findings 
 and also elicits splashing (clapotage) of gas and water in the stomach, 
 a sign on which no great reliance is placed, for splashing occurs in 
 healthy stomachs. The hand may palpate the final gush of gastric 
 contents into the gut. (c) Percussion — The normal vertical dimen- 
 sion of the stomach is 4 to 5.5 inches (10 to 14 cm.) and its maximum 
 capacity three pints (1,600 c.c). Filling the stomach with water and 
 percussing, with the patient standing, outlines both the lesser and 
 greater curvatures, which may even reach to the pubes. Siphoning 
 the water and then distending the stomach with air pumped in or with 
 carbon dioxide gas, replaces the flatness by tympany. (The carbon 
 dioxide is produced by giving sodium bicarbonate 3j to ij dissolved in 
 water, followed by an equal amount of tartaric acid in water.) When 
 doubtful, the colon may be distended with gas or fluid. The greatest 
 distention is at the fundus. With both gas and water in the stomach 
 the note changes with change of posture, the fluid being in the lower 
 and the gas in the upper parts, as in ascites; the most experienced 
 acknowledge that they have confused enormously dilated stomachs 
 with ascites and ovarian cysts and have introduced a trocjiar ; Jadon 
 published a case in which the stomach contained 45 quarts. Leube 
 was the first to palpate the lower end of the stomach by means of a 
 rigid sound ; this has justly been practiced less frequently of late years ; 
 the normal distance from the upper teeth to the greater curvature is 
 23.5 inches (60 cm.), (d) Auscultation elicits the splashing which 
 may be heard by the patient, and sometimes metallic heart tones, a 
 fine crepitation or hissing noise as gas is generated or a splashing or 
 dripping sound as the patient drinks. 
 
 Complications. — (a) Constipation is the rule, and the stools are 
 hard because less fluid passes the pylorus, (b) The urine is often 
 alkaline, its chlorides are lessened and its amount is reduced to a 
 pint or less as a result of acid vomiting ; triple phosphates are com- 
 mon and acetone and diacetic acid are occasional, (c) The skin is 
 often dry and (d) emaciation is common, even in benign stenosis or 
 muscular insufficiency, because food is imperfectly absorbed; some 
 of it is lost to the organism by fermentation and possibly by tissue- 
 destroying toxins, (e) Auto-intoxication from fermentation may de- 
 velop, causing headache, vertigo, drowsiness, psychoses, polyneuritis, 
 tetany, slow pulse and nervous dyspnoea. Tetany (Neumann and 
 Kussmaul) occurs oftenest in hypersecretion or stenosis from cancer 
 or ulcer ; its symptoms are considered under Tetany, and it may be 
 merely noted here that 73 per cent, of cases die (101 cases combined 
 from Riesrel, Albu, Frankel-Hochwart, etc.). 
 
 Piagnosjs.— The vomiting, impaired motility, as shown bv Leube's 
 
DILATATION OF THE STOMACH. 591 
 
 test dinner, the visible outlines confirmed by percussion and the low 
 lesser curvature which is not seen normally, distinguish gastrectasia 
 easily; its cause may be determined with difficulty only. The 
 stomach may be physiologically large (megalogastria) , but then there 
 is no motor insufficiency, no vomiting and no stagnation. Gastrop- 
 tosis will be considered later. The degree of stasis is determined by 
 washing out the stomach at varying times after the test dinner. In 
 pyloric stenosis there is greater dilatation than in simple motor in- 
 sufficiency (or atony) and marked peristalsis is always indicative of 
 obstruction. When a diagnosis of pyloric obstruction is established 
 the benign must be differentiated from the malignant type; benign 
 pyloric obstruction runs a more remittent longer course of over two 
 years, even of fifteen years duration; HC1 and the ferments are 
 usually increased and are always present, sarcinse are often and 
 lactic acid seldom present; in the writer's experience stenosis due to 
 round ulcer is, in fully half the cases, attended by subacidity or 
 anacidity; while in cancer (v. i.) the march of symptoms is unfor- 
 tunately progressive and achlorhydria, cachexia, severe anaemia with 
 leukocytosis, hydrops, pyloric tumor, the Oppler-Boas bacillus and 
 metastases develop with relative rapidity. The spasmodic form runs 
 an intermittent course. The prognosis depends on the etiology and 
 amenability to treatment ; spasmodic types are curable ; relative sten- 
 osis may somewhat improve. In infants with spastic obstruction or 
 hypertrophied pylorus the onset within the first week or month of life 
 is characteristic, with vomiting of even the mother's milk, emaciation, 
 visible peristalsis and sometimes a palpable pylorus. 
 Treatment. — 1. Etiological factors should be treated. 
 
 2. General measures, tending to tone the musculature, are (a) 
 abdominal massage, practiced only when ulceration and inflammation 
 are certainly excluded; (b) drugs, especially strychnine, which is 
 often combined with atropine, and the application of an ice-bag to the 
 epigastrium; (c) hydrotherapy; (d) faradization of the stomach; 
 external application is seemingly as efficacious and certainly less diffi- 
 cult than intragastric application; and (e) abdominal binders or 
 supports. This treatment avails only in atony. 
 
 3. Gastric therapy, (a) Gastric lavage removes the fermenting 
 contents, relieves the pressure exerted by accumulated food and fluid, 
 cleans off the mucus, lessens vomiting and auto-intoxication, and may 
 permanently help atony and temporarily mitigates pyloric stenosis. 
 The stomach should be washed with luke-warm water until it returns 
 clear of food and mucus ; salicylic acid and sodium bicarbonate may 
 be added, as in chronic gastritis ; the patient soon becomes accustomed 
 to the tube and welcomes the relief afforded ; it is generally said that 
 morning lavage is best, but washing two hours before the evening 
 meal is preferable, as the organ then suffers less stagnation through 
 the night, (b) The food should be well divided, nourishing and not 
 voluminous ; it should be given with very moderate quantities of 
 water, in small amounts and at intervals of three to four hours, The 
 
592 DISEASES OF THE DIGESTIVE TEACT. 
 
 average diet consists of meat, eggs, leguminous purees, thoroughly 
 cooked rice and small amounts of butter ; generally speaking, fats and 
 carbohydrates are more prone to fermentation. P. Cohnheim advises 
 an ounce or two of olive oil in pylorospasm and in moderate benign 
 stenosis. A dry diet was early advised by van Swieten, but moderate 
 amounts of fluid aid in propulsion of food into the gut. Of course much 
 depends on the causal disease ; a fluid diet is indicated in great pyloric 
 stenosis and when the hydrochloric acid is decreased; meat should 
 be given if the acid is not decreased and the pylorus is not greatly 
 stenosed. Recently there has been a reversion in favor of one or two 
 fair-sized meals a day, thus giving the stomach ample time to empty 
 itself and to rest. Water is not absorbed by the stomach, as proven by 
 von Mering, who also found that the absorption from the stomach 
 of sugar, peptone, dextrin and alcohol is attended by actual excretion 
 of water into the stomach. In pronounced cases peptonized milk and 
 water are given by rectum to supplement gastric feeding. In all 
 cases careful individualization is indicated; the exact degree of 
 insufficiency, i. e. } the time required for absorption, should be tested 
 by Leube's meal and the patient fed accordingly, (c) Posture — The 
 seriously affected patient should lie on his right side one to two hours 
 after eating, thereby relieving pressure upon the greater curvature 
 of the stomach and directing the food toward the pylorus, (d) Gas- 
 tric medication — (See Chromic Gastritis, Ulcer, Cancer, Hyper- 
 chxorhydria). (e) Thiosinamin — (see page 650). 
 
 4. Surgical intervention is imperative in severe or malignant sten- 
 osis and when medical treatment fails. It embraces (a) pylorectomy, 
 of which Drvendorff collected 188 cases with a 57 per cent, mortality; 
 (b) pyloroplasty (29 cases with a 21 per cent, mortality) ; (c) gastro- 
 enterostomy (215 cases with a 43 per cent, mortality). In 153 op- 
 erations for benign stenosis Moynihan had only two deaths. As 
 shown in ulcer and cancer (v. i.) the earlier recorded mortality has 
 been much reduced. According to Shaw and Elting, in the pyloric 
 stenosis of infancy the mortality under medical treatment is 72 per 
 cent., under surgical 56 per cent. In eleven operations for tetany 
 with pyloric stenosis eight cases recovered (Jonnesco). 
 
 CHANGES IN FORM, SIZE AND LOCATION OF THE STOMACH. 
 
 Form. — The antrum cardiacum and fore-stomach are oesophageal 
 rather than gastric anomalies. The antrum cardiacum is a congenital 
 bulging of the oesophagus just below the diaphragm and the fore- 
 stomach is a congenital dilatation above the diaphragm. There also 
 exists a congenital narrowness of the pylorus as well as hour-glass 
 stomach. 
 
 The acquired hour-glass deformity is more common and may result 
 from spastic hypertrophic muscle, cancer, ulcer or adhesions "around 
 the middle of the organ, abdominal tumors, peritoneal tuberculosis, 
 twisting of the stomach or hernia of it through the mesocolon. Mayo 
 
ROUND ULCER OF THE STOMACH. 593 
 
 Robson (1904) in 23 cases found ulcer as the cause in 15, tumor in 4 
 and perigastritis in 4. It may co-exist with pyloric stenosis. Ran- 
 dolph and Thomas observed 2 cases in one family. 
 
 Symptoms may be lacking in the lesser degrees of deformity ; in the 
 higher grades they are those of stenosis. (1) Only a part of a given 
 amount of water introduced into the stomach may be recovered 
 (Wolfler's first symptom). (2) After the stomach has been washed 
 till the water returns clear the fluid may suddenly become clouded 
 (Wolfler's second symptom). (3) The stomach is apparently emptied 
 by the stomach tube and yet splashing is obtained (from the cavity 
 nearest the pylorus) ; Jaboulay called this paradoxical dilatation. (4) 
 Inflation by carbon dioxide produces distention first of the left and 
 later of the right half of the epigastrium (von Eiselsberg's first symp- 
 tom) . ( 5 ) Normally when the stomach is distended and the gas passes 
 through the pylorus into the bowel, there is a sharp gurgle over the 
 pylorus; in the hour-glass stomach the gurgle is heard two to four 
 inches to the left of the median line (von Eiselsberg's second symp- 
 tom). (6) On gastric distention by carbon dioxide Moynihan found 
 tympany only over the upper part of the stomach and not over its 
 lower half. (7) When the stomach is distended a furrow may appear 
 (Eichhorst and Schmid-Monard) ; Moynihan saw the furrow in 10 
 cases. (8) Filling the stomach with water and illuminating it by a 
 light introduced into the stomach, the cardiac portion appears trans- 
 lucent and the pyloric part dark (Ewald). (9) A rubber balloon, in- 
 troduced into the stomach and then inflated through the stomach tube, 
 fills or outlines a part only of the stomach (Hemmeter). 
 
 Treatment is surgical. Moynihan successfully operated on 23 
 cases by single or double gastroenterostomy, gastroplasty, gastro- 
 gastrostomy, partial gastrectomy and dilatation of the stenosis. 
 
 Situs viscerum inversus (see page 421). 
 
 Size. — Megalogastria and microgastria are usually accidental find- 
 ings if not associated with other gastric disease. 
 
 Location. — The stomach at birth is vertical and in adult life is 
 generally held to lie so that three-quarters of it is to the left of the 
 median line. Rosenfeld insisted that the whole stomach is vertically 
 disposed to the left of the mid-line. 
 
 Gastroptosis. — (See Enteroptosis, page 654.) 
 
 ROUND ULCER OF THE STOMACH. 
 
 Definition. — Ulceration of the stomach is characterized in the ma- 
 jority of cases (a) etiologically by its occurrence chiefly in young 
 women or in chloransemic subjects ; (&) pathologically by a " punched 
 out" funnel-like ulcer, oftenest near the pylorus, and (c) clinically 
 by localized pain and tenderness, hgematemesis and hyperacidity. 
 
 Frequency. — It is found in 2.5 to 5 per cent, of all autopsies (W. H. 
 Welch, Orth and von Jaksch). It occurs four times less frequently 
 in America than in Europe. 
 38 
 
594 DISEASES OF TEE DIGESTIVE TRACT. 
 
 Etiology. — The causes of nicer are not exactly known, (a) Age 
 and sea;.— Most cases (70 per cent., Lebert) occur between twenty and 
 thirty years of age; in children E. C. Cutler collected 29 cases; 60 
 per cent, occur in women. In men ulcer develops most frequently 
 between thirty and fifty years of age ; the author has seen five cases 
 in men over sixty. (b) Anemia and chlorosis are strongly predis- 
 posing factors. Anaemia and (c) hyperacidity are usually regarded 
 as important factors; the writer believes Eosenheim and Cohnheim 
 are correct in stating that hyperacidity is only a result ; 73 per cent, 
 of Leube's cases of chlorosis showed hyperacidity, (d) Changes in 
 the vessels. As a normal access to the stomach of arterial blood pre- 
 vents its autodigestion, it is thought by some that interruption in the 
 local circulation is the cause of ulceration; Virchow believed that 
 embolism was causal and Klebs held that arterial spasm was an 
 etiological factor. Embolism and ulceration follow burns. It will be 
 noted, however, that ulcer often occurs at an age when arterial 
 changes are rare, though syphilis, alcoholism, arteriosclerosis, cardiac 
 and hepatic diseases apparently cause some of the cases in later life, 
 (e) Occupation is a factor. Many cases occur in servant girls and in 
 cooks; (/) trauma in cooks, shoemakers and tailors is an accessory 
 factor, for the tasting of hot foods and pressure against the stomach 
 promote the development of ulcer. The pressure of corsets, the 
 swallowing in certain trades of particles of iron, porcelain and glass ; 
 and imperfectly masticated or improper food, may be brought under 
 this caption. External trauma is a distinct factor. Letulle and 
 Martin hold that (g) bacterial necrosis causes ulcer, which is 
 clearly shown by Dieulafoy's cases of pneumococcic hemorrhagic 
 ulceration of the stomach. 
 
 Pathology. — Scars indicating healed ulcers are three times as fre- 
 quent at autopsy as open ulcers. The ulcer is known as ulcus simplex 
 to distinguish it from malignant or syphilitic ulceration, ulcus ro- 
 tundum, as the smaller ones especially are round, ulcus pepticum and 
 perforans. The peptic ulcer occurs almost exclusively in the stomach / 
 lower oesophagus and upper duodenum. (See Duodenal Ulcer.) 
 Its general morphology was first thoroughly described by Cruveilhier 
 (1829) and Eokitansky (1839) ; it has a "punched out," clean-cut 
 appearance ; in contour it is round or oval in small, and irregular in 
 large, ulcers; it is usually small, but sometimes invades most of 
 the surface of the stomach and in one case it measured four by seven 
 and a half inches ; it is funnel-shaped in old cases ; its apex is eccen- 
 tric and directed toward the serosa, its sides are terrace-shaped and 
 its floor is clean. In 80 per cent, the ulcer is single, though as many 
 as 34 ulcers have been reported. Extension is more common in acute 
 than in chronic cases and more toward the peritoneum than laterally. 
 Microscopically there is no infiltration with round cells. Its locali- 
 zation is chiefly near the pylorus on the posterior wall or lesser curva- 
 ture; its complications, as hemorrhage and perforation, and its 
 sequela?, as pyloric stenosis and deformations, will be considered 
 under clinical symptoms. 
 
FOUND ULCER OF THE STOMACH. 595 
 
 Symptoms. — The general clinical picture varies, cases being typical, 
 doubtful or entirely latent. 
 
 In the typical case the symptoms develop gradually with a sense of 
 epigastric pressure after eating, which later becomes a more violent, 
 cutting, localized pain; this is observed one-half to one and a half 
 hours after eating: it lasts throughout the period of digestion and 
 ceases only with vomiting or passage of the food into the bowel. The 
 appetite is usually good: hyperacidity is noted in the test meal or 
 the vomitus : tenderness occurs over the epigastrium, and in fully half 
 the cases bleeding from the stomach or blood in the stools is observed. 
 
 The typical triad of cardinal symptoms, taken together or possibly 
 singly, is characteristic: (1) the pain with localized tenderness, (2 | 
 haematemesis and (3) hyperacidity. 
 
 1. Paix. — The most important, characteristic and constant symp- 
 tom (in 90 per cent. | is pain, which is usually paroxysmal, is local- 
 ized and occurs during digestion. It is boring or burning, seldom 
 lancinating and is due to irritation of the gastric nerves aroused by 
 peristalsis, nerve erosion or hyperacidity. The diet affects the pain 
 greatly: milk, for instance, is well tolerated in certain cases, but solid 
 food usually produces excessive pain and very hot or very cold foods 
 or beverages almost invariably cause discomfort. This disappears 
 quickly with rectal feeding. The seat of the pain varies in different 
 patients, but is the same in a given case. Generally it is epigastric 
 and very often near the ensiform. Ewald describes it as cramp-like 
 in the right mammary line under the liver. Sometimes there is wide 
 irradiation toward the sternum, ribs, shoulder, scapula and infre- 
 quently in the brachial plexus and pulmonary branches of the vagus, 
 resembling angina pectoris ( Traube) or producing pain in the arms 
 and legs (Miiller). The pain varies with change of position, depend- 
 ing on the localization of the ulcer, but there is always pain when the 
 patient lies on the left side. 
 
 In relation to eating, sometimes the pain occurs two to ten minutes 
 after eatins:. the old "wound pain." supposedly due to contact of 
 food with the eroded nerves in the ulcer. Typically, pain occurs at 
 the height of digestion, i. e., one-half to one and one-half hours after 
 ingestion of food, caused by the hyperacidity. Patients fear to eat 
 because of the inevitable pain. Pain may be worst at the time of the 
 menses. Pain from the scars or adhesions of an ulcer is infrequent 
 and is usually drawing or vague. In old ulcers pain is atypical or 
 absent. The time of development of the pain does not locate the 
 ulcer, though if it comes on at once it may suggest oesophageal or 
 cardiac ulcer : or. if it occurs two and one-half hours or more after 
 eating it is suggestive of ulcer of the duodenum. 
 
 Tenderness is most often found under the ensiform. It is usually 
 circumscribed and is more often and more advantageously found on 
 the lightest touch rather than on deep palpation. A diagnosis from 
 tenderness alone is somewhat unsafe. Tenderness in the back fCru- 
 veilhier) suggests ulcer on the posterior wall of the stomach and is 
 
596 
 
 DISEASES OF THE DIGESTIVE TRACT. 
 
 found in 25 to 33 per cent, of cases over an area of one or two inches 
 to the left of the tenth to twelfth dorsal or upper lumbar vertebra-. 
 The abdomen, back and chest are often exquisitely hypersesthetic. 
 Palpation must be guarded, lest perforation ensue. 
 
 2. ILematemesis. — The second cardinal symptom is haematemesis. 
 Its frequency is from 25 to even 80 per cent. ; the average figure is 
 probably 50 per cent. Vomiting of blood in ulcer is most frequently 
 from ulcer in the pyloric region (posterior wall and lesser curvature) 
 or, less frequently, from ulceration reaching the liver, pancreas or 
 spleen. Hemorrhage when small may be overlooked (occult hemor- 
 rhage) or blood may be found only in the stools; melsena alone is 
 found in 11 per cent, of cases. The hemorrhage must amount to a 
 pint to turn the stools black. It may be large and lethal ; no blood 
 may be vomited and the stomach and bowels are found to be filled 
 with one massive clot. The usual signs of internal hemorrhage 
 exist, as collapse, pallor, moderate fever, brain anaemia, hsemic mur- 
 murs, amaurosis and rarely optic atrophy or hemiplegia. If profuse 
 it is voided bright red; if slow and moderate the acid turns it dark, 
 " coffee-ground vomitus/' If red blood cells cannot be found in the 
 vomitus because of complete disintegration of the cells, blood can be 
 detected by treating it with acetic acid, extracting with ether and then 
 testing with the guaiac and turpentine reaction, when blood will be 
 shown even if the spectroscope shows nothing (Bial). " Occult hem- 
 orrhage " occurs in 25 to 50 per cent, of cases (see ILematemesis 
 and Cancer) ; it is not as constantly present as in gastric cancer. 
 The tests for occult hemorrhage are valuable to determine the length 
 of the medical treatment of ulcer and to detect the tendency to bleed- 
 ing during the course of gastric ulcer. Macroscopic blood is found in 
 the stomach washings less frequently than is to be inferred from text- 
 book descriptions, and apparently normal vomitus may show blood 
 microscopically or chemically. Profuse hemorrhage usually indicates 
 deep ulceration. Hemorrhage complicates acute more than chronic 
 cases. The hemorrhage is usually fairly profuse in ulcer ; it may be 
 spontaneous during sleep or rest or may result from excitement, 
 physical exertion or improper diet. In a case of " chronic dyspepsia " 
 with vague symptoms the writer inflated the stomach with the usual 
 amount of carbon dioxide; the patient collapsed in the office and 
 vomited nearly a quart of blood. 
 
 3. Hyperacidity. — This is the third cardinal finding. Hem- 
 meter finds it in 90 per cent, and Leube in 50 per cent. : 
 
 HCl according tc 
 
 Normal acidity. 
 
 Hypochlorhydria. 
 
 Achlorhydria. 
 
 Hyper- 
 chlorhydria. 
 
 Ewnld 
 
 Eichhorst 
 
 Author 
 
 57* 
 46<S 
 
 9* 
 
 34* 
 20* 
 
 23* 
 
 4* 
 
 34* 
 
 7* 
 30* 
 
 The variance noted in these figures is due to combining old callous 
 
BOUND ULCEE OF THE STOMACH. 597 
 
 ulcers with the fresh chlorotic ulcers ; in old ulcers hyperchlorhydria 
 is present in only 10 per cent, and they explain most of the cases of 
 decreased acidity; in fresh ulcers hyperacidity occurs in 70 per cent. 
 Hyperchlorhydria is probably due to irritation of the vagus (Paw- 
 low). Complicating cancer, hypersecretion or catarrh may cause 
 subacidity. 
 
 Test meals should not be given to determine an excess of acid when 
 there is pain, tenderness and vomiting of blood. The stomach tube, 
 however, is used by Riegel, Boas, Rosenheim and Fleiner not only for 
 diagnosis in atypical cases, but also to relieve the more dangerous 
 vomiting and to introduce silver and bismuth into the stomach. Or- 
 ganic acids, as lactic, are absent, the carbohydrates are poorly digested 
 and the albumins are rapidly converted into albunioses or peptones. 
 The motility of the stomach is normal in one-quarter and slow in 
 three-quarters of the cases. If pyloric obstruction exists the HC1 is 
 increased. 
 
 4. Other Symptoms. — Vomiting, present in 75 per cent., is a less 
 valuable diagnostic than pain. Some cases never vomit or do so only 
 several hours after meals. It occurs at the height of the pain, one, 
 two or three hours after eating, whereas in dilatation or hypersecre- 
 tion it occurs much later. Vomiting and pain depend directly on 
 the diet, heavy meals increasing and appropriate diet lessening each. 
 Some degree of parallelism exists between the pain and vomiting, 
 the latter usually relieving the former. The vomitus consists of fine 
 particles, is sour, grits the teeth and shows much acid and no fer- 
 mentation. Dyspepsia occurs from catarrhal gastritis, dilatation or 
 other complications. The appetite is frequently good or exaggerated. 
 Acid eructations (pyrosis) may cause a burning sensation back of 
 the sternum or between the shoulder blades. If there is much oesoph- 
 ageal burning it indicates incontinence of the cardiac orifice. Diar- 
 rhoea is rare. Constipation is due to ansemia, diet, rest, vomiting, 
 possibly reflex inhibition of the motility of the bowel or to impaired 
 peristalsis by scars and adhesions. Dysmenorrhoea and amenorrhoea 
 are not infrequent. The nutrition varies and emaciation may be 
 observed (cachectic type) ; ansemia may become profound. The 
 urinary findings are not characteristic; reduction of the chlorides 
 cannot be used to differentiate from carcinoma ; the urine is slightly 
 acid or alkaline when the stomach is dilated; the phosphates are in- 
 creased ; with dilatation, indican and ethereal sulphates are increased. 
 Acetonuria and diaceturia sometimes result from inanition and 
 rectal feeding. 
 
 Clinical Forms of Lebert. — (a) The hemorrhagic form may be either 
 acute or chronic; hemorrhage may be the first or the last and fatal 
 symptom, (b) In the perforative form there may be entire latency 
 of previous symptoms, (c) In the dyspeptic type dyspeptic symp- 
 toms are most prominent; the evidences of ulcer are absent or there 
 are atypical symptoms, such as pain which is not sharp, vomiting 
 which is infrequent and excess of hydrochloric acid, but no increase 
 
598 DISEASES OF THE DIGESTIVE TEACT. 
 
 in mucus, (d) The cachectic form characterizes old ulcers with a cica- 
 trix producing dilatation and with chronic hypersecretion ; this form 
 may be confused with carcinoma. The other types are as follows: 
 (e) gastralgic or neuralgic form; (/) vomitive form; (g) latent ulcer 
 (scars at autopsy) ; (h) a form with tumor; (i) recurrent type; (j) 
 stenotic type ; (k) carcinomatous type. 
 
 Clinical Course. — The course is usually chronic, for ulceration is 
 frequently long latent before diagnosis is possible and probably lasts 
 some time after all symptoms have disappeared. Pain usually indi- 
 cates incomplete cicatrization or certain other sequences, but cessa- 
 tion of pain is no certain criterion of Healing. The course may be 
 acute and rapid, especially under appropriate therapy. The course 
 lasts from three to five years (Lebert) or even twenty to thirty-five 
 years, usually due to complicating pyloric obstruction, dilatation or 
 adhesions. Very large ulcers probably never heal. They frequently 
 remit with appropriate therapy, but recur with the resumption of the 
 old diet. Ulcer can be considered cured only when all symptoms have 
 been absent for six months. 
 
 Localization- — This can rarely be determined accurately (Riegel 
 and Leube). Tenderness and tumor are indicative of ulcer on the 
 anterior wall, but hemorrhage and dorsal pain suggest posterior in- 
 volvement (Gerhardt). Pain in a lateral decubitus suggests locali- 
 zation in the fundus or pylorus; dilatation, in the pylorus or duo- 
 denum; pain under the ensiform during the act of deglutition sug- 
 gests cardiac ulcer. Ulcers are palpable in only 0.1 per cent, of cases 
 (Leube). The percentage of involvement of the cardia is 6; of the 
 fundus 4; of the lesser curvature 36 ; of the posterior wall 30 ; of the 
 pylorus 12 ; of the anterior wall 9. " In over 80 per cent, of the cases 
 it occurs in a relatively small area about the pylorus, lesser curvature 
 and posterior wall." 
 
 Complications and Sequels. — (a) Perforation (3 per cent.) may oc- 
 cur into the peritoneum, usually with symptoms of collapse, peri- 
 tonitis and cessation of vomiting (Traube) ; (Brunner finds vom- 
 iting in 66 per cent, and Gross in 33 per cent, of such cases). Per- 
 foration may be prevented by omental, peritoneal, pericardial and 
 pleural adhesions. The danger of perforation in ulcer of the anterior 
 wall is seven times greater than of other locations. Perforation of 
 a latent ulcer may be confused with rupturing appendicitis or salpin- 
 gitis. Perforation may occur into the heart, colon, gall-bladder, 
 portal vein, pericardium, thoracic or abdominal wall; or it may 
 reach the space between the liver or spleen and the diaphragm, pro- 
 ducing pneumothorax subphrenicus, which is suggested by pleurisy, 
 epigastric and hypochondriac pain, stiffness in the back, painful 
 eructations and swallowing, singultus or local oedema. (6) Simple 
 peritonitis (perigastritis) may cause a friction murmur over the 
 stomach, (c) According to Eosenheim 6 per cent., Liebert 9 per 
 cent, or Zenger, the majority of cases of cancer develop from ulcer. 
 The author saw with Dr. Harpole a case of carcinoma developing in 
 
BOUND ULCER OF THE STOMACH. 599 
 
 an ulcer scar' in a girl twenty-six years old. The typical symptoms 
 of ulcer are followed by loss of weight and persistence of symptoms, 
 usually by gradual lessening of hydrochloric acid and other evidences 
 of carcinoma, (d) Adhesions about the stomach may interfere with 
 its motility, produce deformation, such as the hour-glass stomach or 
 diverticulum, neuralgia which outlasts the ulcer and obstruction of 
 either orifice of the stomach. Dilatation of the stomach usually indi- 
 cates pyloric stenosis ; it may also result from spasm of the pylorus. 
 Scars may, in rare cases, produce intestinal obstruction. Trouble- 
 some adhesions may be finally so stretched as to relieve all symptoms. 
 
 Diagnosis. — The diagnosis is determined by (a) the etiological fac- 
 tors, (b) the cardinal symptoms and (c) the various clinical types 
 enumerated. In general the diagnosis is easy in the young, but may 
 be difficult in older individuals with chronic ulcer. 
 
 Any two cardinal features confirm the diagnosis. Pain is often the 
 only symptom; if it is atypical, hyperacidity may indicate ulcer, 
 though the former is often observed without ulcer ; "Leube proposes for 
 such cases the therapeutic test, although both cases may respond to the 
 treatment. According to Eiegel the chief difference is that pain in 
 simple hyperacidity is less regular than in ulcer and that localized 
 tenderness is absent. Seemingly primary hyperchlorhydria may be 
 found to be ulcer. Where pain alone exists one must always remember 
 the gastric crises of tabes. Ewald has called attention to the pain of 
 small hernias in the linea alba. Pain in the transverse colon may 
 cause confusion, but it usually ceases on evacuation of the bowels. 
 Without careful examination movable kidney may be confused with 
 ulcer. The pain in gall-stones is paroxysmal, but more irregular and 
 independent of eating. The gall-bladder is tender and may be dis- 
 tended and palpable. The paroxysm in gall-stones is longer and is 
 often attended by fever and a chill. The pain more often radiates to 
 the right side and to the shoulder and the vomiting is not that of ulcer, 
 though hyperacidity and gastric dilatation may follow cholelithiasis. 
 Chronic poisoning, as by arsenic, may be suspected, as in the case of 
 the Duchess of Orleans until Littre diagnosed ulcer. 
 
 Hemorrhagic erosions and fissures of the stomach present no con- 
 stant clinical picture. After eating there is a sense of burning over 
 the entire stomach, which is not altered by change of position. The 
 chemism and tender points of ulcer are lacking, though Cohnheim 
 usually finds hyperchlorhydria ; he also believes that solid food relieves 
 the pain. Shreds of tissue are always found, according to Pariser, 
 which cease with cessation of pain. Fatal hemorrhage is recorded. 
 
 In duodenal ulcer, inflammation, new growths of the liver, peri- 
 hepatitis, cysts and chronic pancreatitis, hyperacidity is absent, al- 
 though in some instances of duodenal ulceration hyperacidity is 
 observed. Duodenal ulcer occurs mostly in men, in alcoholics and 
 after burns. Pain is often absent in duodenal ulcer, but when pres- 
 ent occurs later than in gastric ulcer and in the parasternal line. 
 Vomiting gives less relief and the vomitus is usually alkaline, con- 
 
600 
 
 DISEASES OF THE DIGESTIVE TRACT. 
 
 tains bile and may digest fibrin (Boas). Icterus is *not constant 
 enough for diagnostic reliance. Hemorrhage into the bowels is more 
 common than in gastric ulcer. Its sudden appearance with recur- 
 rence and profound anasmia is most suggestive. 
 
 Pyloric spasm may also occur in myocarditis, aneurysm, coronary 
 atheroma, taenia, ascaris, the spastic form of constipation or chronic 
 nicotinism (Ageron). 
 
 Differentiation from carcinoma is not very often necessary, though 
 in middle-aged patients confusion with ulcer may occur. In Kraus' 
 clinic the author saw two cases ; one was an old man with cachexia, 
 pyloric tumor and decreased hydrochloric acid, which was diagnosti- 
 cated cancer; the other was a young girl with vomiting of blood, in 
 whom the diagnosis of ulcer was made. The post-mortem examina- 
 tion showed that the old man had a round ulcer and the* girl had a 
 cancer. The author has seen five cases of carcinoma under the age 
 of thirty. The table on page 601 considers differentiation from 
 cancer, gastritis, gastralgia and hyperchlorhydria. 
 
 Prognosis. — Though ulcer occurs most frequently between the ages 
 of twenty and forty, it is most fatal between forty and sixty. It is 
 generally stated that the mortality is 6 to 10 per cent., of which about 
 4 per cent, each is due to hemorrhage and perforation. 
 
 
 Recovery. 
 
 Death. 
 
 Improvement. 
 
 No Improvement. 
 
 Eichhorst 
 
 Leube 
 
 Kohler 
 
 85* 
 74* 
 61* 
 
 8* 
 
 2.4* 
 
 6* 
 
 4* 
 22* 
 30* 
 
 3* 
 
 1.6* 
 
 3* 
 
 Very deep, old ulcers rarely heal. The deeper the ulcer the greater 
 the danger of hemorrhage and perforation. Ulcers with hypersecre- 
 tion give a relatively poor prognosis. Carcinoma must be considered 
 when treatment is not successful. One of the author's cases died from 
 exhaustion, although the autopsy showed perfect healing of the 
 ulcer. In over one thousand cases the deaths from hemorrhage and 
 perforation (each 1 per cent.) were about equally divided (Leube). 
 Treatment. — 1. Prophylaxis. — Prophylaxis concerns care of the 
 stomach in anaemia and chlorosis and care in the diet. 
 
 2. Absolute Rest. — Absolute rest in bed for a month or more was 
 first recommended by Cruveilhier, in addition to which Leube advises 
 the frequent application of hot fomentations to the epigastrium, which 
 relieve pain within a few days. Women should remain in bed during 
 menstruation, even after recovery is seemingly complete. 
 
 3. Absolute Rest of the Stomach. — Distention of the stomach 
 by even small quantities of food or water excites peristalsis and se- 
 cretion, distends the ulcer and prevents granulation. Rest permits 
 the stomach to contract and allows the edges of the ulcer to come more 
 completely in apposition. The more absolute the rest of the stomach 
 the more rapidly the ulcer granulates and cicatrizes. The time for 
 
BOUND VLCEB OF THE STOMACH. 
 
 601 
 
 
 Cancer. 
 
 Ulcer. 
 
 Chronic 
 Gastritis. 
 
 Gastralgia. 
 
 Hyperchlor- 
 
 HYDRIA. 
 
 Etiology. 
 
 75$ over 40 years. 
 
 75$ under 40 
 years — 2-4 times 
 oftenerin women. 
 
 Males. 
 
 Women. 
 
 Males. 
 
 Tongue. 
 Appetite. 
 
 Heavily coated. 
 Usually anorexia. 
 
 Usually clean 
 and red. Good; 
 only fears to eat. 
 
 Gray-white fur. 
 Poor. 
 
 Normal. 
 
 Variable. Some- 
 times perverted. 
 
 Clean. 
 
 Good, often 
 increased. 
 
 Pyrosis. 
 
 Often pyrosis. 
 
 Water brash. 
 
 Frequent. 
 
 None. 
 
 Present. 
 
 Belching. 
 
 Usually foetid 
 belching. 
 
 Usually absent. 
 
 Copious. 
 
 Variable. 
 
 Usual. 
 
 Pain. 
 
 The pain is less in- 
 tense, but more 
 constant; sel- 
 dom free i n- 
 termissions, dur- 
 ing which no 
 distress is felt in 
 gastric region. 
 Pain not in- 
 creased at the 
 height of diges- 
 tion. Tenderness 
 less frequent and 
 intense. 
 
 Intense ; appears 
 shortly after 
 meals ; grows 
 severer on pres- 
 sure; disappears 
 at the end of di- 
 gestive period ; 
 perfectly free 
 periods more 
 frequent ; par- 
 oxysmal. 
 
 May be present 
 but not pro- 
 nounced and 
 rarely actual 
 pain but ten- 
 derness of 
 diffuse char- 
 acter. Lanci- 
 nating pains 
 in atrophic 
 gastritis only. 
 
 The pain appears 
 without regu- 
 larity, and not 
 dependent upon 
 meals ; may be 
 relieved by pres- 
 sure ; intervals 
 of several days 
 free from pain. 
 Tenderness 
 rare ; conforms 
 to outlines of 
 the stomach. 
 Electrical test 
 (Leube) during 
 digestion; if 
 pain decreases, 
 it is gastralgia ; 
 if it does not, 
 may be ulcer or 
 gastralgia. 
 
 The pain ap- 
 pears about 
 one or two 
 hours after 
 meals, disap- 
 pears after 
 eating, espe- 
 cially meat, 
 milk or eggs, 
 or after the ad- 
 ministration 
 of bicarbonate 
 of sodium. 
 Pain is less 
 regular. 
 
 Vomiting. 
 
 Usual. Hours 
 after eating or 
 once a day or 
 alternate days, 
 etc. Copious, 
 coarse mucus, 
 fermented. 
 
 Frequen t — at 
 height of diges- 
 tion — s mailer 
 amount, finely 
 homogeneous, 
 no mucus, acid. 
 
 Frequent ; mu- 
 cus. 
 
 Rare ; no mucus. 
 
 Much less fre- 
 quent, then 
 acid and no 
 mucus. 
 
 Hcema- 
 temesis. 
 
 Frequent — small 
 dark, like coffee 
 grounds, decom- 
 posed, usually 
 late in disease. 
 
 Frequen t— co- 
 pious, bright; 
 may be early 
 symptom. 
 
 None. 
 
 None. 
 
 None. 
 
 Test 
 Meal. 
 
 Early reduction 
 HCl and later, 
 total absence ; 
 ferments de- 
 creased or absen t ; 
 lactic acid pres- 
 ent ; impaired 
 motility and ab- 
 sorption ; abun- 
 dant mucus, Op- 
 pler-Boas bacil- 
 lus — yeast — pos- 
 sibly tumor 
 shreds ; coarse 
 undigested par- 
 ticles of food. 
 
 Hyperehlor- 
 hydria often ; 
 ferments nor- 
 mal or in- 
 creased; no 
 lactic or 
 p p 1 e r-B o a s 
 bacilli; food 
 well digested. 
 
 No mucus. 
 
 Decreased HCl 
 (rarely in- 
 creased, gas- 
 tritis acida); 
 later may be 
 achylia. 
 
 Much mucus. 
 
 Normal or vari- 
 able. If HCl is 
 decreased, the 
 ferments are 
 normal. 
 
 As in ulcer. 
 
 Tumor. 
 
 In 80 per cent. 
 
 In but one pro 
 mille (from py- 
 loric spasm, 
 hypertrophy, 
 cicatrix, etc.). 
 
 None. 
 
 None. 
 
 None (very 
 rarely from 
 pyloric 
 
 spasm). 
 
 Collateral 
 Symptoms. 
 
 Cachexia — cedema. 
 
 Absent. 
 
 Absent. 
 
 Absent. 
 
 Nervous stigmata 
 often. 
 
 Absent. 
 
 Course. 
 
 Part of a year. 
 
 Longer ; helped 
 by treatment — 
 aggravated by 
 arsenic. 
 
 Chronic, 
 —ditto. 
 
 Arsenic helps. 
 
 Like ulcer. 
 
602 DISEASES OF TBE DIGESTIVE TRACT. 
 
 complete granulation varies with each case and chronic ulcers show 
 little or no tendency to cicatrize. An ice-bag promotes contraction 
 of the stomach. Rectal feeding is imperative and the usual rules 
 should be followed ; peptonized milk, grape sugar, baby foods, meat 
 juice and eggs, should be given, in amounts not to exceed eight ounces, 
 at eight-hour intervals; they should be injected slowly, with the^ pa- 
 tient on his left side and should be given warm, which precautions 
 obviate excessive peristalsis. A fountain syringe with a soft tube is 
 always used. Nutrient rectal enemata can be retained invariably if 
 the technique is carefully carried out. Wine or spirits almost always 
 irritate the bowel. Eectal tenesmus is obviated by administering, a 
 short time before the enema, an opium suppository of one-half grain 
 of the extract. Though rectal feeding gives the patient but one- 
 quarter of the food necessary to maintain metabolism, it is sufficient, 
 because the patient is absolutely quiet. The mouth should be kept 
 clean to avoid parotitis. Thirst should be relieved by giving two 
 daily warm saline enemata ; the patient may rinse his mouth out, but 
 he should swallow nothing, either water or melted ice. 
 
 4. Pain. — Rest of the stomach relieves the pain in almost every 
 case ; the use of narcotics should be limited ; small doses of opium or 
 morphine by rectum, or atropine, may be given. There is danger of 
 the opium habit. 
 
 5. Supeeacidity. — The treatment of super acidity should be ini- 
 tiated after two weeks of absolute gastric rest. Massive doses of sod. 
 bicarbonate 3ss-3j in starch wafer, followed by a swallow of water, 
 give the best results. Then Carlsbad water should be given ; it should 
 be lukewarm, given in small quantities and taken in sips. Ziemssen 
 and Leube have proven that alkalies are compatible with digestion. 
 Carlsbad water consists of sodium sulphate 50 parts, sodium bicar- 
 bonate 6 parts and sodium chloride 3 parts ; it possesses no value other 
 than its alkalinity; it neutralizes the acid, thereby tending to check 
 the ulceration, aids intestinal digestion and cleanses the stomach. 
 Ziemssen administered half an ounce of the solid salts in a pint of 
 water; this was taken in quarters every ten minutes, the last dose 
 being given one-half hour before meals. Vichy water may be used. 
 Roberts prescribed a lozenge composed of magnesium carbonate grains 
 3^2, chalk grains 2%, sodium chloride grain 1, which dissolved slowly 
 in the mouth, increased the salivary now and neutralized the excess 
 of acid. 
 
 6. Diet. — After ten days of rectal feeding, five or six meals daily 
 of predigested milk with lime water should be given in small quan- 
 tities, that the edge of the ulcer may not be stretched. Cooked milk 
 is more easily digested and curds less. The casein engages and 
 neutralizes the acid. If peptonized milk is distasteful it may be ad- 
 ministered as a thin gruel, especially when the stomach is irritable 
 and painful. Potato puree, arrow-root, wheat-meal, baby foods, meat 
 juice and buttermilk may be given; soups with meal and alkalies 
 which precipitate the casein in finer form, beef peptone jelly and 
 
BOUND ULCER OF THE STOMACH. 603 
 
 ice cream may also be given; but it should be remembered that the 
 milk diet, recommended by Cruveilhier is most efficacious. After 
 the patient has been on the above-mentioned diet for ten days, soups 
 without fat, rice, sago, soft-boiled eggs, calves' brains and chicken 
 may be administered. Slightly boiled or poached eggs are digested 
 better than raw eggs and may be given with bread-crumbs from 
 the inside of the loaf. Custards may be given. Tea and coffee should 
 be forbidden. Sugar was considered deleterious by Cruveilhier, 
 but Strauss has found that it lessens the amount of acid and he recom- 
 mends that the patient should have a dram of a 20 per cent, solution. 
 Cohnheim gives olive-oil freely at all times to relieve spasm and 
 inhibit hyperchlorhydria. After fifteen days Leube permits grated 
 beef, and after about another week tender roast beef, chicken and 
 pigeon, to which others would add lamb, macaroni, thymus gland 
 and bread. After the fifth week roasts and souffles may be given. 
 
 7. The Bowels. — Plain enemata may be administered. 
 
 8. Drugs. — Much has been written in regard to bismuth and sil- 
 ver. Bismuth relieves pain and is taken most advantageously in 
 solution, but it has no curative value and is less efficacious than absolute, 
 prolonged rest of the stomach. Fleiner, Kussmaul and others admin- 
 ister bismuth by means of the stomach tube. Large doses may ac- 
 cumulate in the ulcer, and the drug is expensive. Silver has been 
 used and some writers even wash the stomach of the patient before 
 meals with a solution of 1 to 500 or to 1,000 (Reichmann). The 
 silver is readily precipitated by the acid or the albuminoids and may 
 produce nausea, diarrhoea and even argyria. Iodides are indicated in 
 syphilitics, by whom they are well tolerated. 
 
 9. Symptomatic Treatment. — Pain is best relieved by rectal 
 alimentation, as is vomiting, which sometimes may necessitate the 
 administration of bismuth, minute doses of carbolic acid in mint 
 water or the use of the ice-bag or sinapisms. Hemorrhage is treated 
 by absolute rest of the stomach, intestine, mind and body ; morphine 
 quiets peristalsis and mental excitement. ~No styptics or astringents 
 should be given and ergot is contra-indicated. Syncope promotes 
 spontaneous coagulation and stimulation should be avoided as long as 
 possible. In severe hemorrhages the use of saline transfusions should 
 be considered, but more than one pint should seldom be given, for 
 death has occurred from reaction and renewal of hemorrhage. Gela- 
 tin injections may be indicated for severe hemorrhages. 
 
 10. Surgical Treatment. — Seventy-five to 96 per cent, of cases, 
 according to Leube, heal absolutely or improve greatly under proper 
 medical treatment; this is especially true of fresh ulcers. Leube 
 gives the following indications for surgical interference : (a) When 
 the hemorrhages are small and repeated and persist in spite of rectal 
 nutrition; in single large hemorrhages operation is contra-indicated. 
 Moynihan holds a similar view and lost but 1 out of 70 cases of 
 chronic hemorrhages, which result he attributes to his treating the 
 ulcer instead of performing simple gastro-enterostomy. Savariand 
 
604 DISEASES OF THE DIGESTIVE TBACT. 
 
 estimates the operative mortality at 50 and Eodman at 33 per cent. 
 Turner (1905) finds a mortality of 36 per cent. (56 cases). (b) 
 Gastroenterostomy is indicated for mechanical difficulties, pyloric 
 obstruction, persistent pyloric spasm and pain; obstruction at the 
 cardia, or hour-glass stomach, also requires surgical treatment. Forty- 
 nine cases of jejunal ulcer have followed operation, since Braun's 
 first case; it develops usually after a year or more. Mikulicz in 
 operations for benign gastric disease finds a 7.5 per cent, mortality 
 in his series of 1897-1899. Moynihan in 15 operations for hour- 
 glass stomach had a mortality of 20 per cent, and in 100 cases of 
 gastro-enterostomy a mortality of 2 per cent, (c) Perigastric ad- 
 hesions or abscess and collections of pus beneath the diaphragm, 
 necessitate operation, (d) In cases of perforation if operation is 
 undertaken within 12 hours, 71 per cent, recover. The best figures are 
 those of English and Graff e with 50 per cent, of recoveries and, be- 
 tween 1900 and 1904, of H. A. Hare, with 37 per cent. Donati, of 
 Florence, collected in 1905, 1,041 cases of operation on ulcer cases; 
 the mortality in perforation was 48 per cent. 
 
 Surgical interference is necessary in a limited number of cases. 
 Sahli argues that (i) reports only show that many of the patients stand 
 an operation; (ii) gastro-enterostomy is indicated only for anatomical 
 stenosis; too many cases of spasmodic stenosis are called anatomical 
 and at operation too many contracted pylori are called cicatricial, 
 (iii) Gastro-enterostomy is not proven beneficial for hemorrhage, 
 diet being the important indication. Cases operated on often die 
 from hemorrhage after the operation, (iv) No proof exists that ulcers 
 heal better with gastro-enterostomy than with medical treatment, 
 (v) Excision of the ulcer is too radical. The writer's experience 
 justifies the conclusions that (i) fresh ulcers always and (ii) chronic 
 ulcers in half the instances belong to internal medicine ; (iii) half the 
 inveterate cases respond to medical treatment; (iv) most of the cases 
 with " chronic dyspepsia " and almost none of the cases with hemor- 
 rhage call for surgical interference. 
 
 CANCER OF THE STOMACH. 
 
 Cancer of the stomach is more frequent than cancer of any other 
 organ; it constitutes 33 to 50 per cent, of all cancers and is found in 
 2 per cent, of autopsies. 
 
 Etiology. — This is as obscure as in other carcinomata. (a) Age. — 
 75 to 80 per cent, of the cases occur in subjects after the fortieth 
 year. According to Lebert 1 per cent, occurs in persons under thirty 
 years; 18 per cent, in those between thirty and forty; 61 per cent, in 
 those between forty and sixty and 20 per cent, in those over sixty 
 years of age. The author has seen five cases in persons under thirty 
 years, which leads him to believe that Debove's collection of 32 cases 
 underestimates their frequency. Eare congenital cases are recorded 
 (Wilkinson, Debove, Collingsworth). Of late years cancer is be- 
 
CANCER OF THE STOMACH. 605 
 
 coming more frequent in relatively young persons, (b) Sex. — It is 
 slightly more frequent in males, (c) Heredity is noted as an etio- 
 logical factor in 6 to 17 per cent, and in some families the number of 
 cases of carcinoma is astonishing, (d) Ulcer of the stomach is an 
 antecedent in at least 6 per cent. ; C. Graham found ulcer in 60 per 
 cent, of his cases, (e) Other causes are less definite. Trauma, ex- 
 ternal pressure, as in shoemakers, or internal ulceration by caustics, 
 is noted in some cases. Pulmonary tuberculosis and alcoholism are 
 slightly predisposing factors. Cancer is almost unknown in certain 
 tropical and subtropical localities and in temperate zones a local 
 disposition is occasionally apparent. 
 
 Pathology. — (a) In origin it is an abnormal growth of the glandular 
 epithelium, as was first proven by Waldeyer, which unlike mere 
 adenomatous or papillomatous proliferations, extends beyond the 
 mucosa into the other coats of the stomach and very often into other 
 organs and tissues. Cancer may develop in the normal mucosa, in an 
 atrophied mucosa or in open or cicatrized ulcers. (&) It is almost 
 always primary, is very rarely metastatic or extends to the stomach 
 by contiguity ; secondary growths are usually from mammary or pan- 
 creatic cancer; Welch collected 37 cases. It is almost invariably 
 single. 
 
 Histology and Morphology. — A tumor, in the clinical sense, usually 
 develops, although in some cases the cancer is infiltrative and flat 
 (carcinoma planum). There are three main types: (a) Carcinoma 
 fibrosum (scirrhus), the most frequent type, contains much poorly 
 vascularized stroma and relatively little carcinomatous tissue ; it is 
 hard and, leading to much induration, is prone to stenose the pylorus, 
 where it is especially frequent, or to stenose the cardia ; if it is diffuse 
 it causes the stomach to shrink (carcinoma atrophicans) ; its onset is 
 insidious; it grows slowly and ulcerates less than other types, (b) 
 Carcinoma medullare is next in frequency; the cell elements prepon- 
 derate over the stroma; there is much soft, vascular tissue and the 
 knife scrapes out much " cancer juice " ; it may form cauliflower-like 
 exuberances ; early extensive degeneration, ulceration and metastases 
 are common ; this type includes the cylindrical celled adenocarcinoma, 
 epithelioma or the very vascular fungus forms, (c) Carcinoma gela- 
 tinosum (colloides) is least frequent; it produces nodular tumors or 
 diffuse infiltrations, which contain colloid material ; it inclines rather 
 to extension by contiguity than to metastatic deposits. 
 
 The gastric mucosa shows focal wasting of the peptic- and acid- 
 secreting epithelium and substitution by cylindrical epithelium, 
 round cells and connective tissue. This secondary atrophic gastritis 
 explains the chemism of gastric cancer — viz., diminution in the secre- 
 tion of acid, rennet and pepsin; in some cases it has regressed after 
 surgical extirpation of the tumor, the secretion of acid and pepsin 
 returning. 
 
 Localization. — Cancer occurs (a) in the pylorus in about 60 per 
 cent., (b) in the lesser curvature in 20 per cent, and (c) in the cardia 
 
606 DISEASES OF THE DIGESTIVE TRACT. 
 
 in 10 per cent, of the cases ; in round numbers, therefore, about 90 
 per cent, of cancers occur in these sites; this is explained by their 
 greater exposure to mechanical insult, their relative fixation and the 
 greater muscular activity of the pylorus and cardia ; many tumors, 
 apparently pyloric in origin, really begin in the lesser curvature, 
 whence, in other words, a palpable pyloric tumor often means one of 
 considerable extension ; this is an important surgical point. 
 
 Complications. — (a) Ulceration, which is really more a part than a 
 complication of cancer, results from inadequate vascularization ; it is 
 usually central and does not depend on the size of the tumor. In some 
 cases the tumor may ulcerate almost completely and Ziegler has ob- 
 served total disappearance, though metastases declared the nature of 
 the scar, (b) Hemorrhage or slow seeping of blood is caused by ulcer- 
 ation, as is also (c) perforation (3 per cent.) into the peritoneum or 
 by adhesions into adjacent abdominal organs or vessels, into the lung, 
 pleura or pericardium or into the abdominal wall, of which latter 25 
 cases are recorded (Taussig) ; perforation is not more common be- 
 cause adhesions often prevent perforation, (d) Stenosis of the cardia 
 or pylorus is common, sometimes causing hypertrophy of the muscle 
 fibers, which on section of the stomach appear as red lines, (e) Dila- 
 tation of the stomach follows pyloric obstruction, atrophy is observed 
 in cardiac localization or in carcinoma atrophicans (diffuse cancer) 
 and hour-glass deformation may result when an annular scirrhns de- 
 velops in the mid-stomach. (/) Local extension by contiguity occurs 
 by the submucous lymphatics and there is early involvement of the 
 lymph nodes along the lesser curvature; other lymphatics are soon 
 invaded ; the peritoneum is quite often involved and less often there 
 is extension into the portal vein, (g) Metastases occur in 50 per 
 cent. ; they are distributed as follows: the liver is involved in 28 per 
 cent., the peritoneum in 37 per cent., the lymphatics in 23 per cent., 
 the pancreas in 20 per cent, and the lungs in 8 per cent. 
 
 Symptoms.— General Clinical Picture. — Anorexia, distaste for 
 meats, mild dyspepsia, gastric oppression and eructations after eat- 
 ing, usually mark the insidious onset. Much less frequently the dis- 
 ease begins acutely or follows closely on symptoms of gastric ulcer. 
 Vomiting occurs and then symptoms of gastric distress after eating 
 solid food and of mechanical or secretory insufficiency develop. There 
 is gradual loss of weight together with loss of strength and endurance. 
 Examination reveals ansemia, cachexia, emaciation, lax skin, flabby 
 muscles and often a tumor near the pylorus. A test meal shows im- 
 perfectly digested food and absence of free hydrochloric acid. The 
 symptoms progress steadily or remissions occur, especially early in 
 the disease. The ankles become puffy and the prostration is profound. 
 Ulceration may relieve pyloric or cardiac stenosis, but gradually 
 within a year after the first marked symptoms death results from the 
 exhaustion due to pain or vomiting, from local complications or inter- 
 current disease. 
 
 1. General Digestive Symptoms. — (a) The tongue is almost 
 
CANCER OF THE STOMACH. 607 
 
 always heavily coated, not being cleaned by mastication, and there is a 
 bad taste in the month. The appetite is decreased or absent in 85 
 per cent, and there is a special distaste for meat and fats; the ap- 
 petite is very rarely excessive; a normal appetite may be retained 
 when the motor power is good and cancer develops on an ulcer, (b) 
 Pain is present in 90 per cent. It is usually diffuse, dull, oppressive 
 and less severe than in ulcer. It is increased several hours after eat- 
 ing or in the night, but is not wholly relieved by vomiting. Local- 
 ized pain and tenderness are suggestive of circumscribed peritonitis. 
 Pain may be reflected to the sternum, shoulders and acromion, (c) 
 Vomiting (in 85 per cent.) is an obstinate and rather late symptom, 
 resulting chiefly from pyloric stenosis, with which it runs more or 
 less parallel. It appears late in the day or in the night, and may 
 occur only on alternate days. There may be no vomiting in cancer of 
 the curvatures, in diffuse cancerous infiltration involving the muscu- 
 laris or in pyloric cancer when ulceration is marked. The vomitus 
 contains much mucus, poorly digested food, little or no free hydro- 
 chloric acid, much lactic acid and often blood, which may be obvious 
 or occult. Faecal vomiting usually indicates gastrocolic fistula (of 
 which 70 cases are recorded), (d) Hcematemesis, present in over 50 
 per cent, of cases, is due to parenchymatous oozing and is therefore 
 moderate in amount ; it is dark in color, as the blood is retained long 
 in the stomach and is converted from oxyhemoglobin to hsematin. 
 The author has seen four cases with fatal, profuse, bright hgema- 
 temesis; profuse bleeding occurs in 1 per cent, (e) Constipation is 
 present in 75 per cent, and diarrhoea in 25 per cent, of the cases; in 
 two cases the writer has seen ichorous stools resulting from necrosis 
 of the lower jejunum and ileum. 
 
 2. Special Gasteic Symptoms. — (a) Tumor is felt in 80 per 
 cent, and seen in 40 per cent, of the cases, but is not an early symp- 
 tom. It is most often missed in persons with wide thoraces and rigid 
 abdominal muscles. In most instances it occupies the right epigastric 
 area, as a round, ovoid, irregular mass, best determined when the 
 knees are drawn up and the mouth is open, after the bowels have been 
 flushed out and the stomach distended ; in some cases the tumor may 
 be felt lower or even on the left side. Examination should be made 
 with the patient in several postures, as on the side, on the face, genu- 
 pectoral position, etc. The tumor may be palpable one day and not 
 to be found on the next. Distention of the stomach by gas (von 
 Frerichs) brings forward tumors of the anterior wall and greater 
 curvature, obliterates tumors of the posterior wall and lesser curva- 
 ture and pushes downward and to the right tumors of the pylorus; 
 motility on distention excludes adhesions. Distention must be mod- 
 erate lest the stomach rupture. If the pylorus is incontinent from 
 ulceration or infiltration, the gas escapes rapidly into the gut (Ea- 
 stern). The x-ysljs outline the stomach after administration of bis- 
 muth. With or without distention, a visible peristaltic wave suggests 
 pyloric obstruction. Percussion is wholly subordinate to palpation 
 
608 DISEASES OF THE DIGESTIVE TRACT. 
 
 and inspection, and auscultation occasionally elicits friction or a 
 stenotic murmur over the abdominal aorta. Respiratory excursion, 
 generally stated to be absent if the stomach is not adherent to the 
 liver, is often present, though less in degree than the excursion of the 
 liver or spleen; if adherent to the omentum there is no excursion. 
 The expiratory fixation is more important ; if nonadherent tumors of 
 the stomach, intestine and omentum are grasped at the height of in- 
 spiration their ascent upward during expiration can be prevented 
 (Minkowski's expiratory fixation) ; on the other hand, tumors of the 
 liver and spleen, or tumors of the stomach, if adherent to the liver, 
 must ascend during expiration; i. e., they cannot be retained where 
 they were grasped and felt during inspiration, (b) Chemism. — (i) 
 Bird (1842) found the hydrochloric acid reduced, but Van der 
 Velden (1879) showed the especial frequency of achlorhydria in 
 gastric carcinoma. Absence or decrease of hydrochloric acid is not 
 pathognomonic, as it is also absent, permanently or temporarily, in 
 numerous other conditions, as nervous dyspepsia, fevers, cardiac, 
 renal or hepatic disease, pernicious anaemia, cachectic states, gastric 
 atrophy, amyloid degeneration and toxic gastritis. Benjamin Moore 
 states that the hydrochloric acid is absent in 66 per cent, and de- 
 creased in 33 per cent, of carcinoma involving other organs than the 
 stomach ; the writer has repeatedly seen cases of rectal cancer in 
 which digestive symptoms and achlorhydria have led to an erroneous 
 diagnosis of gastric cancer. In cancer it is due to the secondary 
 atrophic gastritis. After administration of an Ewald test breakfast 
 the food is withdrawn in an hour and tested as described under 
 chronic gastritis. If there is no stagnation the total acidity ranges from 
 6 to 8 ; in stagnation it is higher from lactic and other organic acids. 
 The absence of free hydrochloric acid is often observed early, while 
 the total acidity remains normal ; later the total acidity is decreased. 
 In exceptional cases free acid may persist, both in those cases which 
 develop from peptic ulcer and in those without this antecedent, (ii) 
 The pepsin and rennet are decreased in 66 per cent, of cases (v. 
 Chronic Gastritis), (iii) Lactic acid, which is always pathological 
 in appreciable quantities, is present in 75 per cent, of cases and 
 though present in other conditions, as in atony, gastritis and pyloric 
 obstruction, 85 per cent, of the cases in which it is found are gastric 
 cancer. Boas, who developed this topic, considers it a very early 
 finding; while others, as Biegel, hold that it does not develop until 
 later. The factors involved in its formation are somewhat disputed, 
 but depend on the reduced hydrochloric acid, motor insufficiency, 
 stagnation, pyloric obstruction, slow absorption and probably poor 
 digestion of proteids ; in the normal stomach it is absorbed as fast as 
 formed (Sticker). As a test meal Boas employs 1.5 per cent, oat- 
 meal to 100 parts of water, given at night after lavage ; the contents 
 are removed and tested the next morning; the Uffelmann method is 
 employed as modified by Strauss, for phosphates, alcohol and sugar 
 also give the reaction; 5 c.c. of the gastric filtrate are added to 25 c.c. 
 
PLATE XIV 
 
 <\ 
 
 \ \ s * 
 
 I <r 
 
 V 5 — -- v.F 
 
 ?-# ?•;-- 
 
 
 *•/ 
 
 v*sy J, . ^ A ^ 
 
 
 Oppler-Boas Bacillus in Vomitus. (Musser. ) 
 
CANCER OF THE STOMACH. 609 
 
 of ether and shaken in a burette, which is provided with a cock at its 
 lowest part ; the lower 25 c.c. are drained away and 25 c.c. of distilled 
 water are added to what remains in the burette (the ethereal extract). 
 Two drops of a 10 per cent, solution of ferric chloride and 20 c.c. of 
 water are added; the blue solution turns to green if lactic acid is 
 present, (c) Microscopically the long, thread-like Oppler-Boas ba- 
 cilli are found, which are probably the chief source of lactic acid and 
 are called Gram-positive (Plate XIV). The Oppler-Boas bacilli 
 are also found in the faeces in gastric cancer; the bacilli point very 
 strongly to the existence of gastric cancer, but may occur, in the 
 writer's experience, in gastric ulcer and atrophic gastritis (with hy- 
 pertrophy of the pyloric musculature). Small particles of tumor tis- 
 sue are seen in rare cases, showing carcinoma structure and irregular 
 mitoses. Sarcinae are rarely observed. Occult hemorrhage (v. TLema- 
 temesis), i. e.j blood which can be seen only with the microscope or 
 detected chemically or spectroscopically, has the same significance as 
 in gastric ulcer, but is more frequent (over 90 per cent.) ; pus in the 
 fasting and washed stomach is very important, (d) Motility. — If the 
 stomach is washed out seven hours after eating there are evidences of 
 stagnation in the undigested food, particularly in pyloric localization ; 
 disturbed motility may appear very early in the disease. The stomach 
 is usually much dilated in patients whose appetites persist and little 
 dilated in those with anorexia. If the stomach is empty after seven 
 hours, good motility alone is proven, not good digestion. Every case 
 of stagnation should arouse suspicion of carcinoma. 
 
 3. Other Symptoms and Complications. — (a) Cachexia is some- 
 thing more than malnutrition ; it is probably the result of toxins 
 which break down the proteids. The body iceight is usually greatly 
 reduced; in exceptional cases it may temporarily increase, as in cases 
 of pyloric stenosis ; it may increase from hope, as in a case of Keen 
 and Stewart, who gained TO pounds after operation; or when the 
 intestine digests what the stomach can not. The skin itches and is 
 anaemic or clay-colored, somewhat resembling the tint it assumes in 
 pernicious anaemia, though distinguished (i) by its later appearance, 
 (ii) by its association with loss of weight, (iii) by the red cells being sel- 
 dom lower than two million and the haemoglobin seldom below 40 per 
 cent., though an apparently good count sometimes results from thick- 
 ening of the blood which is due to lack of absorption; and (iv) by the 
 leukocytosis (see Pernicious An.emia). Schneyer has described the 
 absence of the digestive leukocytosis; it occurs in about half the cases. 
 As in nephritis or chlorosis (rubra), the face may not show the real 
 anaemia. The wrinkling and wasting of the hands may be far more 
 significant, (b) The urine is decreased from poor absorption and 
 vomiting, the physiological change in the acidity-curve after eating 
 is absent, the urea is increased from increased toxaemic catabolism, 
 albuminuria is present in 35 per cent, of cases and indicanuria is 
 common, (c) Toxcemic symptoms. Fever of a low, irregular or 
 intermittent type results in half the cases, from the cancer products, 
 39 
 
610 DISEASES OF TEE DIGESTIVE TBACT. 
 
 from septic absorption through the ulcer or froin complications, as 
 pleurisy or peritonitis. A coma closely resembling coma diabeti- 
 cum may result from the cancer toxins or the breaking down of the 
 proteids ; acetonuria has been noted. Phlebitis and the less common 
 multiple neuritis, tetany and amaurosis are probably toxsemic. (d) 
 Metastases or extension by contiguity may occur. Enlargement of 
 the supraclavicular glands may result from any abdominal carcinoma, 
 but 50 per cent, are due to cancer of the stomach (Troisier). Liver 
 deposits may appear before any suggestive stomach symptoms. Ic- 
 terus occurs in 5 per cent. (For other metastases v. Pathology.) 
 (e) Ascites results from the cachexia and, like the swelling of the 
 ankles, appears late in the malady. Some cases are due to carcinoma- 
 tous peritonitis, the fluid often showing blood and cancer cells, with mi- 
 toses (Dock), and others result from glands or tumor compressing the 
 porta hepatis. (/) Perforation may occur (v. Pathology). 
 
 Cancer of the cardia presents symptoms like those of oesophageal 
 cancer (q. v.). The symptoms may be few or absent. The stomach is 
 never distended. There may be tenderness under the xiphoid. The 
 tumor when advanced may be palpated, as well as the perigastric 
 lymph nodes. 
 
 Diagnosis.- — Diagnosis is easy in the typical case outlined in the 
 general clinical picture. ~No single finding, as achlorhydria or even 
 tumor, is pathognomonic; only the grouping of symptoms and signs 
 is final. Single analyses of the stomach contents are often deceptive ; 
 they should be repeated frequently and considered in connection with 
 other findings. Vomiting in middle or advanced life is suspicious 
 when accompanied by emaciation, ansemia, pruritus and insomnia. 
 With absence of hydrochloric acid and the ferments, the findings of 
 tumor, blood, lactic acid, Oppler-Boas bacilli, dilated stomach, and 
 perhaps of cancer tissue, are positive. The diagnosis may be doubt- 
 ful, even in the presence of pyloric tumor, emaciation and gastric dila- 
 tation, when hydrochloric acid is present; the tumor may then be 
 peptic ulcer, hypertrophy of the pyloric musculature or pyloric spasm 
 due to hyperchlorhydria ; in the last instance the tumor is alternately 
 hard and then soft, and often the chyme may be felt or heard as it 
 intermittently squirts through the pylorus. The diagnosis between 
 beginning cancer, nervous dyspepsia and atrophic gastritis must be 
 reserved for a time. Atrophic gastritis is more chronic, often lasting 
 years without emaciation. Youth and adolescence do not exclude 
 cancer ; in the young, gastric cancer is more rapid in evolution, and 
 hydrops and peritonitis are more common. Abdominal atheroma 
 may closely simulate cancer. Ulcer (q. v.). 
 
 The so-called latent, dyspeptic, gastralgic, anasarcous, ascitic and 
 anaemic forms of cancer, and those causing early metastases (for 
 example, in the liver) and intestinal obstruction, show in what direc- 
 tion error may occur, without due balancing of the individual and 
 combined symptoms. 
 
 Differentiation. — (a) Pancreatic tumors (q. v.) are deep, fixed, 
 
CANCER OF THE STOMACH. 611 
 
 immobile and disappear on gaseous inflation of the stomach. They 
 may be accompanied by fatty stools and glycosuria. It must be re- 
 called that the normal pancreas is sometimes palpable in meagre 
 subjects, (b) Cancer of the gall-bladder has respiratory excursion 
 but neither expiratory fixation nor lateral movement; the digestive 
 symptoms, chemism, ectasia and changes on inflation, of gastric 
 cancer are lacking, (c) Duodenal carcinoma is hard to separate, 
 though the gastric chemism is usually lacking; passage of blood in 
 the fseces and icterus are suggestive, (d) Cancer of the colon is 
 usually distinguished by the intestinal signs and absence of stomach 
 symptoms or chemism. (e) Enlarged aortic glands are distinguished 
 by lack of altered chemism, and abdominal aneurysm by presence of 
 expansile pulsation; (/) omental and peritoneal tumors are more 
 diffuse, (g) Hypertrophy of the pyloric muscle (v. s.), felt as a 
 tumor, is less common than is usually assumed; it is usually asso- 
 ciated with the findings of ulcer or of hyperacidity; (h) foreign 
 bodies (hair tumors), subserous lipoma, fibroma, myxoma and other 
 benign gastric tumors, and palpable round ulcers, are much rarer 
 sources of error. Of sarcoma 87 cases are reported; a dozen were 
 successfully operated on. 
 
 Prognosis. — The prognosis unhappily is determined by the diag- 
 nosis, an error in which is the only hope. The average duration is 
 one or two years (three months to three years). Death results from 
 exhaustion by pain or vomiting, hemorrhage, gangrene, perforation, 
 portal pressure, intercurrent pneumonia, nephritis and tuberculosis. 
 
 Treatment. — 1. Medical or Palliative. — (a) Condurango bark 
 (Friedreich) seems for a time to increase the appetite and strength. 
 (b) Vomiting is treated as in gastritis, dilatation and simple ulcer, 
 but with less success ; lavage is indicated in pyloric stenosis ; boric or 
 salicylic acid or resorcinol may be added for fermentation ; narcotics 
 by rectum, rectal feeding, champagne and carbolic acid, as outlined 
 before, are also useful. (c) Hemorrhage is rarely profuse and 
 usually subsides on rectal feeding; iron, ergot and lead should be 
 avoided, (d) The achylia is seldom helped by hydrochloric acid or 
 pepsin, (e) Pain necessitates the use of fomentations, lavage, chlo- 
 roform (3 to 5 drops) with ice, and as a last resort atropine or opium 
 by rectum. (/) For constipation, cathartics are inferior to warm 
 colonic flushings or salts, glycerine or olive oil by rectum, (g) Diar- 
 rhoea is lessened by lavage; when due to pyloric insufficiency, salol, 
 betanaphthol (aa gr. x) and opiates are indicated, (h) Stenosis of 
 the cardia may yield to dilatation, (i) Motor insufficiency, evidenced 
 by food in the stomach seven hours after a test meal, necessi- 
 tates lavage, which should be practiced before supper. (/) The 
 diet should be soft and small in bulk. Meats and fats are digested 
 with difficulty. Vegetables, cereals, small quantities of milk, 
 koumyss, honey, pastries, tea, coffee, diluted wine, peptones, baby 
 foods, somatose and nutrose may be tolerated, but finally the stom- 
 ach rebels at all food, (h) For inoperable cases Jacobi recommends; 
 methylene blue, gr, ii dailv and increasing to gr. vi. 
 
612 DISEASES OF THE DIGESTIVE TBACT. 
 
 2. Surgical Treatment. — Cases having good surgical prospects 
 are few, but operation only can cure. When a tumor is found it 
 usually has a rather wide extension; pyloric tumors, for instance, 
 have often reached the pylorus from the lesser curvature (Israel). 
 For resection of the cancer the cases should reach the surgeon, if pos- 
 sible, before the tumor is palpable, a condition possible only in private 
 practice, for hospital cases are always advanced. Metastases, peri- 
 tonitis and glandular invasion are contra-indications to operation. 
 Pylorectomy results in an immediate mortality of 15.6 per cent, as 
 against the original death rate of 56 per cent, in the time of Bill- 
 roth, who did the first operation (1878). The ultimate outlook is 
 very doubtful, recurrence having been noted after five years. 
 Leriche reports one case well after 16, and Kocher one well after 
 19 years. The Mayos, in 1906, reported 100 resections of gastric 
 cancer, with a mortality of 14 per cent. ; in one group of 25 cases 
 only one case died; 27.7 per cent, of their cases were living three 
 years after operation, and 22 per cent, were well over three years 
 after resection. The Mayo brothers logically plead for an early 
 diagnosis (by exploratory laparotomy) and for early resection. Gas- 
 trostomy is indicated in cardiac cancer and gastroenterostomy for 
 pyloric obstruction. 
 
 HJEMATEMESIS. 
 
 Definition. — Hsematemesis is not absolutely synonymous with gas- 
 tric hemorrhage ; it is the vomiting of blood, which may come directly 
 from the stomach or may reach it from the gums, nose, larynx, lungs, 
 oesophagus, or even regurgitate backward from the intestine. Gastror- 
 rhagia designates profuse hemorrhage from the stomach. It may be 
 arterial, venous or capillary. 
 
 Etiology. — (a) Various forms of ulceration, as simple ulcer, carci- 
 nomatous, tuberculous (of which Letorey, 1895, found only 21 cases), 
 diphtheritic, typhoid, syphilitic, ursemic or phlegmonous ulcers* 
 hemorrhagic erosions, and perforations into the stomach from without- 
 as gall-stones, or aneurysm dissecting down from the arch of the 
 aorta (Minkowski), are etiological factors. Parrot described super- 
 ficial ulcers in the new-born. Dieulafoy describes a pneumococcic 
 hemorrhagic gastritis. Chiari and Murchison, but especially Dieu- 
 lafoy, have described very small simple ulcers causing profuse, often 
 repeated and fatal hemorrhage ; their diagnosis seems probable when 
 they develop in perfect health and with no previous stomach symp- 
 toms ; they are easily overlooked at operation or autopsy because they 
 involve only the mucosa or perhaps some of the muscularis ; some 
 regard this form as the beginning of round ulcer, (b) Trauma, such 
 as external violence, or internal trauma, as from foreign bodies, ther- 
 mal and chemical injury, and violent vomiting, as sea-sickness and 
 hyperemesis, may be causal, (c) The cause may be vascular, such 
 as amyloid degeneration which sometimes involves the stomach and 
 bowels alone; aneurysm, arterial hyperemia, embolism, vicarious 
 
B2EMA TEMESIS. 613 
 
 congestion from suppression of hemorrhoids or menstruation, passive 
 congestion of cardiac or hepatic origin ; and oesophageal varix, though 
 it should be remembered that when due to cirrhosis of the liver, there 
 is in 33 per cent, of cases no other evidence of cirrhosis ; Welch and 
 Powell have found varices in the floor of peptic ulcers; malarial 
 deposits in the liver; acute pylethrombosis, causing profuse hemor- 
 rhage ; and parenchymatous oozing, where no postmortem changes are 
 found (Hale White reports 36 cases of what he terms gastrotaxis). 
 (d) Nervous causes are injuries to the central nervous system, vaso- 
 motor influences and hysteria in which the blood is small in amount 
 and occurs usually in the morning vomit ; tabetic crises ; and general 
 paralysis, (e) Acute infections may be etiological factors, as mala- 
 ria, hemorrhagic exanthemata, yellow fever, sepsis, embolism after 
 operations (von Eiselsberg), appendicitis (Dieulafoy) and genito- 
 urinary sepsis (Guyon) ; Busse (1905) collected 96 cases following 
 operations; they result from direct embolism (of which 35 per cent, 
 were in the mesentery or omentum) or retrograde embolism; the 
 hemorrhage occurred in the stomach or bowels ; 55 per cent. died. (/) 
 Blood diseases, as pernicious anaemia, leukaemia, haemophilia, pur- 
 pura, scurvy and splenic anaemia, may be causal, (g) Poisons, 
 which early erode and later ulcerate, as acids and caustics, those caus- 
 ing fatty degeneration of the vessels as arsenic and phosphorus, and 
 uraemia or cholaemia, may cause haematemesis. 
 
 Most cases occur in women between fifteen and forty years of age. 
 Of all causes, round ulcer and liver cirrhosis are the first suggested. 
 At autopsy it may be impossible to find the point of issue of blood. 
 
 Symptoms. — The symptoms are (a) those of the antecedent disease. 
 (b) In some cases no blood may be vomited up, and the incident re- 
 mains undiscovered, unless the stools are examined. In vomitus 
 cruentus gastric uneasiness is common. The amount vomited varies 
 from microscopic quantities to those sufficiently large to cause death. 
 The occurrence of " occult hemorrhage " has been particularly em- 
 phasized by Boas ; in microscopic examination the diet for days pre- 
 viously should contain no meat, blood, iron or chlorophyll, but should 
 consist solely of eggs, fruit, flour or fat. In profuse gastrorrhagia 
 the blood is bright red, if it remains in the stomach only a short while, 
 as it does in most cases of peptic ulcer. In smaller hemorrhages it 
 is black or rust-colored, as in cancer, uraemia, cholaemia and various 
 poisonings; rust-colored blood may become bright on the edges or 
 surface when it has stood for some time. Blood may issue in the 
 fluid form, or as clots, in which case it is suggestive of valvular 
 disease, vascular diseases or the dangerous haematemesis of cirrhosis. 
 In a fatal typhoid hemorrhage, in a medical student, enormous clots 
 were vomited; the author has seen large clots vomited by patients 
 having carcinoma of the stomach, (c) Melcena may render the stools 
 black, tarry and offensive, (d) Systemic signs. A gradual or sud- 
 den intense anosmia may be noted, with all the usual signs of anaemia 
 (q. v.), with vertigo, syncope, rapid heart action and some dyspnoea. 
 
614 DISEASES OF THE DIGESTIVE TRACT. 
 
 Later there may be amaurosis, slight febrile movements, dicrotic 
 pulse, hsemic murmurs, moderate oedema about the ankles, albumi- 
 nuria and sometimes hemiplegia or convulsions. 
 
 Diagnosis. — Differentiation from haemoptysis (q. v.), from the swal- 
 lowing of blood from the nipples in nurslings or from the vagina in 
 the new-born, fracture of the skull, oesophageal or throat disease and 
 from simulation of blood in the stools from ingestion of bismuth, 
 coffee, tea, claret, iron or blueberries, does not need particular elabo- 
 ration as the microscopic, chemical and spectroscopic examination 
 determines doubtful cases. Treatment is identical with that of the 
 hsematemesis which occurs in round ulcer. 
 
 NEUROSES OF THE STOMACH. 
 
 The neuroses of the stomach occur in nervous individuals, either 
 as a part of a neurosis or as a rather isolated nervous symptom. 
 Their relations will also be considered under neurasthenia and hys- 
 teria. They sometimes occur renexly, as in gall or renal stones or in 
 uterine disease. Though their varieties will be considered as (I) 
 secretory, (II) motor and (III) sensory, combinations of symptoms 
 are more frequent than single symptoms. 
 
 (I). Secretory Neuroses. 
 
 These have been described especially by Reichmann, Rossbach, 
 Sahli and Riegel. 
 
 1. Hyperchlorhydria (Hyperaciditas Hydrochlorica) . — This is a 
 
 qualitative anomaly of gastric secretion in which the free hydro- 
 chloric acid is increased; it is not solely a neurosis, though con- 
 veniently classified as such ; it is attended by no known gastric lesion ; 
 it is an excessive secretion of hydrochloric acid during the height 
 of digestion. 
 
 Etiology. —(a) General etiological factors are as follows: (i) It is 
 most frequent in young and middle-aged persons; (ii) in the better 
 situated classes; (iii) in Polish Jews and (iv) in brain-workers; (v) 
 it is somewhat more common in women than in men; (vi) a neurotic 
 or psychopathic tendency is a predisposing factor, as is also (vii) 
 chlorosis, in which hyperchlorhydria is found in 85 to 95 per cent, 
 of cases, (b) Local causes are (i) rapid eating and cold drinks; (ii) 
 condiments; (iii) smoking; (iv) certain foods and coffee; (v) gall- 
 stones or possibly renal stones; and (vi) habitual constipation. 
 
 Symptoms. — The clinical picture varies much and no single symp- 
 tom is pathognomonic, (a) Pain, the chief symptom, varies from a 
 sense of pressure or discomfort in mild cases to extreme gastralgia in 
 severe cases. It develops at the height of gastric digestion — i. e., 
 one to two hours after eating — and is due to the excess of free hydro- 
 chloric acid; it depends on the kind and amount of food ingested; 
 the more food, especially meat, ingested the later is the pain, for the 
 
HYPEBCSL0RHYDR1A . 615 
 
 food engages the free acid longer. Carbohydrates cause increased 
 pain as they do not engage the acid and amylolysis is decreased, 
 perhaps suspended; in exceptional cases the patient tolerates small 
 and frequent meals better than larger ones. The patient is often 
 aware of the increased peristalsis and feels a cramping or spasm of 
 the pylorus. Pain lasts one-half to several hours. It is relieved by 
 vomiting and unless it has become quite severe is also relieved by 
 ingestion of more food or of alkalies, (b) Belching and pyrosis 
 are frequent and the eructated hyperacid fluid causes a burning in the 
 oesophagus, (c) Vomiting of a burning sour fluid is not frequent, 
 save in severe cases, (d) The appetite is usually good, and most pa- 
 tients desire food frequently, though in small amounts; occasionally 
 it is ravenous, (e) Tenderness over the stomach is usually diffuse, 
 moderate in degree and coincident with the pain; it is sometimes 
 pyloric and is associated with some epigastric distention. Gastric 
 hyperesthesia is as important as the hyperchlorhydria. (/) Stomach 
 tests show that the total acidity is increased to 100, even to 150 or 
 160 ; the digestive power is shown to be increased by the egg-disk 
 test, the proteids are well subdivided, the amylolysis delayed, motility 
 and absorption normal or increased in uncomplicated cases and no 
 lactic acid, no fermentation and no gas are present, (g) Constipation 
 is more frequent than diarrhoea ; headache is common and mi- 
 graine or neurasthenic symptoms may develop ; the gums may retract 
 (Herter) ; in the urine the chlorides are decreased, the acidity les- 
 sened during digestion and frequently an alkaline reaction and phos- 
 phaturia are present. 
 
 Diagnosis. — The diagnosis is determined by the presence of hyper- 
 chlorhydria in the vomitus and test meal, by the relief of the chem- 
 ical pain by vomiting or ingestion of more food or alkalies and by 
 negative physical findings. 
 
 Differentiation. — (a) Ulcer (q. v.) is marked by well-localized ten- 
 derness, hsematemesis or occult bleeding and more symptomatic regu- 
 larity than in hyperchlorhydria. (b) Gastritis is characterized by 
 mucus formation and decreased secretion, (c) Gastrosuccorrhoea or 
 continuous secretion (v. i.). (d) Gastrectasia and gastroptosis are 
 excluded by percussion and by inflation, (e) Gall-stones, in which 
 pain has no relation to eating, occurs at longer, irregular intervals 
 and is associated with tenderness of the gall-bladder. 
 
 Course and Prognosis. — The disease begins slowly and may disap- 
 pear, to recur after a few days to months, from irregular living, 
 nervous strain, excesses, certain articles of diet or without obvious 
 cause. The nutrition is fairly well maintained. The outlook is good 
 if early treatment is instituted ; complications, as continuous secre- 
 tion, gall-stones or gastric atony, modify the prognosis. 
 
 Treatment. — 1. Prophylaxis. — Nervous factors, smoking, haste 
 in eating, chlorosis, etc., should receive appropriate treatment. 
 
 2. Diet. — (a) A proteid diet is most beneficial, for it takes up the 
 largest amount of hydrochloric acid, which is not essentially increased 
 
616 DISEASES OF THE DIGESTIVE TRACT. 
 
 by proteids, as has been maintained; veal, beefsteak, mutton and 
 ham absorb twice as much hydrochloric acid as equal weights of other 
 proteids (Fleischer) ; fish fat is particularly to be avoided; milk and 
 some kinds of cheese may be given, (b) Carbohydrates should be 
 restricted, because the early amylolytic digestion by the ptyalin is 
 delayed or arrested; a slice or two of stale bread, biscuits, toast and 
 zwieback or purees of aleuronat meal, which contains much nitrog- 
 enous matter, may be given; Strauss allows six to nine ounces of 2 
 per cent, grape sugar solution, unless there is a complicating motor 
 insufficiency. Potatoes, salads and most uncooked vegetables should 
 be interdicted, (c) Fats may be given in limited quantities, includ- 
 ing small amounts of cream or unsalted butter (one ounce) ; one or 
 two drams of olive oil an hour after meals inhibit the secretion of 
 acid. (d) Condiments, mustard, pepper, vinegar, spices, lemon, 
 horseradish, coffee, alcohol, cold foods and drinks should be forbidden. 
 Weak tea, cocoa or milk may be given, (e) Thorough mastication 
 must be insisted upon. (/) Small meals, given at frequent intervals, 
 are generally most efficacious, though Bouveret's three meals may 
 sometimes be given if the patient's appetite is good. 
 
 3. Medication. — (a) Alkalies, as sodium and magnesium carbon- 
 ates and bismuth, aa gr. xv to xxx, should be given at the height of diges- 
 tion to neutralize the hyperchlorhydria and relieve its symptoms ; Paw- 
 low maintains that alkalies not only act chemically but inhibit secre- 
 tion by action on the glandular cells. The charged alkaline waters 
 dilute the gastric juice, neutralize the acidity and are sedative, (b) 
 Extract of belladonna, % to % grain, given at meal-time, lessens se- 
 cretion and mitigates pain; opiates should be avoided, (c) Lavage 
 with silver nitrate (1 to 1,000) solution is useful in obstinate types. 
 
 2. Gastrosuccorrhcea (Hypersecretion, Continuous Secretion). — 
 This is a quantitative perversion of gastric secretion, in which a fairly 
 abundant secretion is found in the fasting stomach; i. e., it occurs 
 without the stimulus of food and when the stomach should be empty. 
 In the lightest forms it only occurs when food is ingested (alimentary 
 form) ; in the severest forms it occurs without ingestion of food. It 
 is not denied that some gastric juice may be found in the normal 
 stomach, due to secretion initiated by swallowed saliva or mucus, but 
 if this exceeds one ounce it is rarely physiological. Two forms are 
 distinguished, the continuous (Eeichmann, 1882) and the intermit- 
 tent form (Sahli, 1885). (a) The intermittent form occurs in at- 
 tacks which last a day or two, is often called acute or nervous dys- 
 pepsia and is found in about the same class of patients in whom 
 hyperchlorhydria develops ; it has been observed during tabetic crises. 
 Colic-like pain develops, usually at night, followed by sour eructations 
 and repeated vomiting, first of food, then of three ounces or more of 
 yellow-green fluid which contains hydrochloric acid and ferments. The 
 first vomitus may contain considerable hydrochloric acid and no more 
 mucus than the small amount which the normal stomach contains; 
 there is seldom blood. During the attack the pulse is small and 
 
HYPERSECRETION. 617 
 
 rapid, the skin clammy, the urine scanty and alkaline and headache 
 is frequent. Thirst is great and drinking may give temporary relief, 
 but is followed by increased vomiting. Between attacks the acidity 
 is normal and the appetite and general health are usually good; oc- 
 casionally there is a constant sense of gastric discomfort, (b) The 
 second form is continuous gastrosuccorrhcea. Its etiology is similar 
 to that of hyperchlorhydria (with which it may co-exist), but rather 
 less clearly established. 
 
 Symptoms. — (a) Pain is more marked than in hyperchlorhydria, 
 develops later after eating and very often at night (11 p. m. to 2 a. 
 m.) ; it may occur before meals, for the gastric secretion is constant, 
 or in severe cases it may be present both during the day and night ; 
 it is relieved by eating and vomiting. There may be local or diifuse 
 tenderness. (b) Vomiting closely follows the pain and may occur at 
 its height or during the night ; the quantity of the vomitus varies ; it 
 is large when there is dilatation (a frequent complication and a com- 
 mon cause of this type). It contains hydrochloric acid, ferments and 
 a small quantity of mucus; vomiting may be absent in light cases, 
 (c) Other digestive symptoms. The condition of the tongue varies, 
 being often red and clean, sometimes coated. The teeth are often 
 carious. The appetite is usually good, sometimes ravenous or in ad- 
 vanced cases may be poor. The thirst is marked and is sometimes sug- 
 gestive of diabetes. The bowels are sluggish, (d) The results of the 
 test meal and lavage show that the total acidity ranges up to 100 and 
 free hydrochloric acid to 60. After a test dinner the fluid, when re- 
 moved, separates into three layers, — the upper foamy, the middle con- 
 sisting of yellowish fluid and the lower one of sediment of undigested 
 carbohydrates ; the proteids are found converted into peptones. When 
 the stomach is washed out thoroughly at night to remove all fluid and 
 food, examination on the next morning of the fasting stomach reveals 
 up to ten ounces of hydrochloric acid and ferments — i. e., secretion 
 without the stimulus of food; if the fasting stomach is washed out 
 two or three hours later, gastric juice is again found — i. e., there is 
 continuous secretion when the stomach should be empty, (e) The 
 urine is the same as in hyperchlorhydria. Old cases show marked 
 emaciation, even cachexia, because of the lax muscles and dry, in- 
 elastic skin. 
 
 Course and Prognosis. — The onset is slow and the course protracted; 
 it may last for years. The nutrition suffers and death from exhaus- 
 tion may result in untreated cases. Complications are frequent, 
 especially (a) dilatation, for the stomach is never empty; the hydro- 
 chloric acid does not inhibit the growth of sarcinse or yeast and gases 
 may generate. The dilatation may be primary but is most often 
 secondary ; it is differentiated by thoroughly washing out the stomach 
 at night and when the tube is introduced the next morning it should 
 show nothing in simple dilatation. Dilatation may also result from 
 (b) pyloric spasm. Pawlow has shown that in health the pylorus 
 relaxes intermittently and allows the acid chyme to reach the duo- 
 
618 DISEASES OF THE DIGESTIVE TRACT. 
 
 denum ; the pylorus is reflexly contracted by the acid fluid in the duo- 
 denum until this is neutralized, when it again relaxes. When the 
 secretion is continuous, the passage of acid into the duodenum 
 constantly contracts the pylorus, which may be felt as a tumor. In 
 this case cancer may be suggested, especially when there is ema- 
 ciation or blood in the stomach, until the constant flow of gastric 
 ferments and hydrochloric acid is found, (c) There is some ten- 
 dency toward gastric ulcer, (d) Tetany is a rare complication of 
 pyloric obstruction. 
 
 Diagnosis. — The diagnostic features are (a) the pain at night; (6) 
 vomiting and (c) thirst, both of which are more common than in 
 hyperchlorhydria ; (d) continuous secretion after washing out the 
 stomach and during fasting. 
 
 Treatment. — Treatment is in general (a) that of hyperchlorhydria 
 as to prophylaxis, diet, mastication and stimulants, (b) Rectal feed- 
 ing is a valuable accessory ; water is given by rectum to quench the 
 raging thirst, (c) Oral feeding is allowed at long intervals; over- 
 loading the stomach with fluids is carefully avoided, (d) Lavage 
 relieves pain and hypersecretion. Eeichmann employs irrigation 
 with silver nitrate (1 to 500 or 1,000). (e) Olive oil lessens hyper- 
 chlorhydria (Eiegel). (/) Alkalies and belladonna are indicated as 
 in hyperchlorhydria. (g) Treatment of coincident dilatation; gastro- 
 enterostomy may be indicated by pyloric obstruction, never by hyper- 
 secretion per se. 
 
 3. Hyposecretion. — Hypacidity (hypochlorhydria or subacidity) 
 and anacidity (achlorhydria) refer respectively to reduction or ab- 
 sence of hydrochloric acid, which may occur from nervous as well as 
 from organic causes (Achylia). When the ferments and hydro- 
 chloric acid are absent, achylia gastrica nervosa is a more appropriate 
 term ; the condition may be transient or enduring and Einhorn re- 
 ported a case in which secretion returned after an absence of five 
 years. Suppressed secretion may occur in hysteria or tabetic crises. 
 
 (II.) Motor Neuroses of the Stomach. 
 
 These may be irritative (increased motility) or depressive (de- 
 creased motility). 
 
 1. Irritative Types. — (a) Hyperkinesis or hyp ermotility hurries 
 the food into the intestine, so that it disappears in three to five hours 
 or even less. It exists by itself as a neurosis, but may occur in the 
 hasty digestion of hyperchlorhydria and in gastric achylia, in order 
 that the intestines may earlier digest the unaltered food. (b) 
 Peristaltic unrest (Kussmaul) or tormina ventriculi nervosa occurs 
 particularly in neurasthenia and in organic pyloric stenosis. In some 
 cases the unrest may be wholly subjective, the patient experiencing a 
 rolling or cramping sensation. In others, both neurotic and organic, 
 the peristaltic movements from left to right may be seen, as well as 
 antiperistalsis in the opposite direction. The treatment of hyper- 
 
NERVOUS VOMITING. 619 
 
 kinesis and peristaltic unrest is that of the underlying neurosis, (c) 
 Pyloric spasm occurs very seldom as an independent neurosis; it 
 occurs usually in connection with ulcer, hyperacidity, hypersecretion, 
 erosions, chronic stenosing gastritis, sometimes with cancer of the 
 stomach and poor mastication of food and drinking of cold fluids. 
 Its relation to dilatation has been discussed, (d) Spasm of the cardia 
 occurs in organic disease of the oesophagus and stomach (ulcer, can- 
 cer, erosions, hyperchlorhydria) or in neuroses; it is the cause of 
 idiopathic dilatation of the oesophagus (q. v.), and the spasm in 
 tetanus and hydrophobia. It makes vomiting difficult and is differ- 
 entiated from organic stricture by the fact that in cardiospasm a large 
 sound passes more easily than a small one, and that spasm is often 
 intermittent. The treatment of pyloric spasm is that of the cause 
 (almost invariably gastric) ; the treatment of cardiospasm is dis- 
 cussed under idiopathic oesophageal dilatation, (e) Nervous eruc- 
 tations (Bouveret, Mathieu, Toilet, Stern) occur in various neuroses 
 and psychoses. They occur especially in sexual neuroses. The odor- 
 less ructus does not result from fermentation, but from swallowing 
 or air (aerophagia), which constitutes a most intractable habit. The 
 mechanism by which air is swallowed is disputed ; Bouveret correctly 
 thinks it is forced down by pharyngeal contractions. It is swallowed 
 unconsciously or again it enters during what Matthieu terms false 
 eructations, in which the patient, in attempting to raise gas, swal- 
 lows air. The ructus must be caused by aerophagia, as such large 
 quantities could never generate in the stomach; Bardet estimated 
 that one patient raised twenty quarts in an afternoon. Coincident 
 cardiac and pyloric spasm causes distention (pneumatosis). Treat- 
 ment lies in the use of the sound, suggestive therapy and in the diffi- 
 cult task of breaking the habit; asafoetida is valuable as the ructus 
 becomes offensive. (/) Nervous vomiting occurs (i) only in the 
 neuroses, as hysteria, neurasthenia, migraine and exophthalmic 
 goitre ; but under this caption we may also bring for differential pur- 
 poses (ii) cerebrospinal conditions, as compression of the brain, 
 meningitis, tumor, tabes, general paralysis, disseminated sclerosis 
 and myelitis ; toxic conditions, as urasmia or cholsemia, may cause 
 cerebral vomiting, (iii) Most cases are reflex in origin; they origi- 
 nate in the nose, as nausea from disagreeable odors ; in the respiratory 
 tract ; in pelvic or abdominal conditions, as pregnancy, menstruation, 
 gall-stones, renal calculi and peritonitis. The symptoms may present 
 many incompatible elements; thus the patient may vomit without 
 nausea, almost without effort, so that the vomiting is rather an eruc- 
 tation ; it often occurs without pain or without reference to the fulness 
 or emptiness of the stomach ; even though it is frequent, the nutrition 
 may be remarkably good, the tongue clean and the appetite good. 
 Periodical or cyclical vomiting, described by Leyden, has some re- 
 semblance to tabetic crises ; Edsall considers it an acidosis, for which 
 3ss to ij of sodium bicarbonate is indicated. Robert's conclusions are 
 as follows : 
 
620 DISEASES OF TEE DIGESTIVE T&ACT. 
 
 1. Vomiting of a chronic type, following a gradual epigastralgia, 
 from one-half to three hours after eating, is attributable to gastric or 
 duodenal ulcer. 
 
 2. Chronic vomiting, from ten to fifteen minutes after food inges- 
 tion is attributable to stenosis of the cardia, nervous abnormality, 
 cerebral lesion or acute gastritis. 
 
 3. Copious vomiting ten or more hours after eating indicates mus- 
 cular insufficiency; frequent repetition indicates a permanent me- 
 chanical lesion interfering with the exit of food. 
 
 4. Vomiting in the night occurs in cholelithiasis, periodic hyper- 
 secretion, muscular insufficiency and nervous abnormality. 
 
 5. Vomiting attempts when the stomach is empty indicate a cause 
 other than a gastric lesion, either a reflex cause, a toxaemia, a cerebral 
 lesion or a nervous abnormality. 
 
 6. Morning nausea and retching indicate pregnancy, alcoholism, 
 pharyngitis, nephritis or a nervous abnormality. 
 
 7. Periodic vomiting of clear gastric juice of normal or super- 
 normal acidity in considerable amounts indicates a secretory neurosis 
 or an ulcerative lesion. 
 
 8. Vomiting as a sequel of headache, accompanied by severe nau- 
 sea, but no gastric or abdominal symptoms, characterizes attacks of 
 migraine; in a majority of cases eyestrain is the underlying cause. 
 
 »9. Attacks of sudden vomiting with tinnitus, deafness and vertigo 
 are attributable to disturbances of pressure in the internal or middle 
 ear. 
 
 10. Periodic sudden vomiting, with gastric pain and nausea, re- 
 traction of the abdomen, obstinate constipation during but not pre- 
 ceding the attack and freedom from abdominal tenderness are sug- 
 gestive of the spinal crises, idiopathic nervous vomiting and lead- 
 poisoning. 
 
 11. Periodic attacks of vomiting with colic, constipation and tym- 
 pany suggest chronic intestinal stenosis. 
 
 2. Depressive Motor Neuroses (Lessened Motility). — There are 
 three types : (a) Atony, which has been considered under dilatation ; 
 (b) pyloric insufficiency (Sere and Ebstein), which is seldom a neu- 
 rotic condition, as compared with its frequency in cancer, ulcer and 
 dilatation of the pylorus from duodenal obstruction. Its presence is 
 determined by inflating the stomach with carbon dioxide, which rap- 
 idly passes into the intestine with a gurgling gush, (c) Insufficiency 
 of the cardia causes regurgitation of food and fluid and rumination 
 (merycismus), which is a regurgitation in which the food is again 
 chewed and reswallowed. These are generally involuntary processes, 
 but some subjects can regurgitate at will. The patients" are nearly 
 always neurotic males, psychopaths or idiots. The affection is either 
 hereditary or imitative when it occurs in several members of a family. 
 Its mechanism is disputed ; congenital weakness of the cardia, stimu- 
 lation of the vagus and aspiration into the oesophagus by the inspira- 
 tory act are considered causal. It should be treated by giving small 
 
GASTRALG1A. 621 
 
 meals at frequent intervals; these should be well masticated; intra- 
 gastric electrical applications and suggestive measures are indicated. 
 
 (III.) Sensory Neuroses of the Stomach. 
 
 1. Hyperesthesia. — Hyperesthesia may give the sensation of burn- 
 ing in the stomach or a sense of weight ; this usually occurs when the 
 organ is full, but at times also when it is empty. Carbohydrates, 
 fats or spices may induce the condition. Silver nitrate, gr. % to %, 
 phenol, gr. % to j, or fluidextr. gelsemii TT|,ij given on the empty 
 stomach, often affords relief, besides which the basic neurasthenia 
 should receive treatment. 
 
 2. Gastralgia. — Gastralgia (gastrodynia or cardialgia, which is a 
 poor but widely used term) does not strictly include the gastric pain 
 due to ulcer, hyperacidity or hypersecretion. Rosenthal's etiological 
 classification is as follows: (i) Cerebrospinal causes, including vari- 
 ous brain, cord (tabes), peripheral and functional nervous affections, 
 (ii) Constitutional causes, including chlorosis and debility, (iii) 
 Toxic causes, resulting from gout, rheumatism, malaria, nicotine 
 and constipation, (iv) Reflex causes, from the genito-urinary and 
 alimentary tracts ; floating kidney, intermittent hydronephrosis, 
 splanchnoptosis, uterine or ovarian disease or masturbation. Fliess 
 holds that many cases of dysmenorrhea and gastralgia arise from dis- 
 ease of the lower nasal turbinates. Most cases occur in women be- 
 tween fifteen and forty-five years of age. 
 
 Symptoms. — As the term implies, the affection occurs with severe 
 gastric pain which begins suddenly, often at night, lasts for a few 
 minutes to an hour or so and subsides usually to recur after a variable 
 interval. The pain is epigastric and may radiate widely. It bears no 
 relation to eating, though food sometimes relieves it. Diffuse super- 
 ficial tenderness or hyperesthesia over the stomach is not infrequent, 
 but deeper pressure usually affords some relief. Vomiting is rather 
 uncommon ; hiccough, hunger, headache, depression, polyuria, clammy 
 sweats, small rapid pulse or even collapse may attend the seizure. 
 
 Diagnosis. — A diagnosis is made only by exclusion and usually after 
 the seizure is over. Rheumatic myalgia is more constant. A tabetic 
 ■crisis is at once recognized by the Argyll-Robertson pupil and the 
 absent knee-jerks. Intercostal neuralgia gives Valleix's three tender 
 points which, however, are quite frequent in neurotic subjects. In 
 ulcer (q. v.) or circumscribed peritonitis the pain is associated with 
 localized tenderness. Hyperacidity and hypersecretion should be 
 excluded. Biliary colic (q. v.) is more difficult to differentiate, but 
 a sharp thrust over the gall-bladder during deep inspiration nearly 
 always elicits well-localized tenderness. 
 
 Treatment. — Treatment is that of (a) the etiology, especially the 
 neurasthenic condition, anemia and constipation. Fowler's solution 
 TT[ij before meals is excellent. (&) The attack. Morphine hypo- 
 dermatically affords the only certain immediate relief, but in these 
 
622 DISEASES OF THE DIGESTIVE TRACT. 
 
 very cases may establish the habit. If given at all, it should be given 
 by mouth without the patient's knowledge. Heat and sinapisms may 
 relieve or aggravate the attack. Silver, phenol or gelsemium em- 
 ployed in hyperesthesia often gives relief, as may extract of bella- 
 donna V2 grain, charged waters, chloroform and Hoffmann's anodyne 
 aa Tltxx to xxx and galvanization with the anode to the epigastrium 
 and cathode to the spine, though the attack is often over before ap- 
 plication is possible. 
 
 3. Disturbances in the Sense of Hunger and Appetite.— Loss of 
 appetite (anorexia) may be purely nervous, though more commonly 
 due to gastric affections, fevers, tuberculosis or toxins. As described 
 under Hysteria, anorexia nervosa may be absolute and cause pro- 
 found emaciation, as in the extreme cases of Lasegue, Wallet and Bris- 
 saud. Parorexia is perversion of the appetite, in which the patient 
 craves for unusual kinds of food. In polyphagia the appetite is 
 enormous, but is capable of satiation; in boulimia (hyper or exia) 
 the intense craving for large quantities of food comes on paroxysmally, 
 sometimes with vertigo, palpitation and other neurotic manifesta- 
 tions; polyphagia and boulimia are most frequent in hyperchlor- 
 hydria, hypersecretion and hypermotility, but also occur in diabetes, 
 focal brain disease or tumors, intestinal parasites or from quinine, 
 orexin or even opium. Acoria is loss of the sense of satiation. These 
 anomalies are central and probably result from organic or functional 
 changes in the bulbar hunger centre. The treatment of the neurotic 
 forms is that of the causal neurosis. 
 
 (IV.) Mixed Neuroses of the Stomach. 
 
 Mixed neuroses, dyspepsia nervosa (Leube), neurasthenia gas- 
 trica (Ewald) or pseudodyspepsia, is marked by no stereotyped 
 symptoms. It may occur alone as a species of local neurosis; it is 
 sometimes reflex from other organs, but is much oftener a part of the 
 neurasthenic symptom-complex. Leube' s original contention that 
 digestion itself is normal must be modified, as the hydrochloric acid 
 may be increased, normal or decreased, but perhaps in the majority 
 of cases the gastric functions are nearly or quite normal. Two main 
 groups of symptoms prevail; (a) the centric, neurasthenic or hysteric 
 apathy, irritability and vertigo; (b) the gastric eructations, varia- 
 tions in appetite, oppression and diffuse tenderness, which are prob- 
 ably also cerebral in origin. The symptoms vary greatly in degree, 
 often change their form with considerable rapidity and the general 
 nutrition is generally good. Organic disease must be carefully ex^ 
 eluded by repeated examinations of the secretions and motility of the 
 stomach, for nervous dyspepsia is too often a a collective term to 
 cover incorrect diagnoses." The treatment is that of the neurotic 
 basis ; rest, regulation of worry and strain, self-control and suggestion 
 are important. 
 
ACUTE ENTERITIS. 623 
 
 DISEASES OF THE INTESTINES. 
 
 ACUTE ENTERITIS. 
 
 It is difficult to draw a close distinction between acute catarrhal 
 enteritis, intestinal dyspepsia and simple diarrhoea. Catarrhal en- 
 teritis is the most common intestinal disease. 
 
 Etiology. — 1. Primary Forms. — (a) Errors in diet and the inges- 
 tion of spoiled food containing ptomaines, unripe fruit and impure 
 water are common causes, (b) Disturbance in intestinal secretion 
 may possibly occasion acute enteritis, though little is known of the 
 succus entericus. (c) Cold, trauma, foreign bodies, fsecal retention 
 and toxins eliminated from the blood may initiate inflammation. 
 (d) Some cases are infectious, though our knowledge of them is still 
 imperfect. Bacteria are undoubtedly an important factor; it is 
 stated that one-third of the weight of the normal stool is caused by 
 bacteria, of which 48 species are normally present ; acute inflamma- 
 tion may arise from pathogenic organisms or from virulence at- 
 tained by some inhabitant of the intestine ; the Bac. coli is the most 
 important and Gartner's Bacillus enteritidis is probably one of its 
 manifold forms. In a milk diet the Bacterium lactis aerogenes and in 
 a meat diet the Proteus vulgaris may be possible factors. 
 
 2. Symptomatic Forms. — (a) Enteritis is constant in some in- 
 fections, from the action of microorganisms or their toxins, as in 
 typhoid ; it is frequent in others, as in sepsis or influenza ; and rare in 
 others, as in measles, scarlatina, rheumatism or malaria, (b) Gen- 
 eral diseases, as nephritis; (c) burns; (d) local intestinal diseases, as 
 intestinal parasites, ulcers or tumors; and (e) metallic or other poi- 
 sons are etiological factors; (/) stasis is usually listed as a factor, 
 but is rarely by itself a potent cause. 
 
 Pathology. — The pathology is that of other inflammations of the 
 mucous membranes; viz., redness, swelling, increased mucus secre- 
 tion, parenchymatous degeneration and some interstitial infiltration 
 with leukocytes. In the few cases coming to autopsy these changes 
 may not be at all conspicuous, as they regress soon after death. In 
 some cases follicular swelling or even ulceration may be observed, as 
 well as punctate ecchymoses, catarrhal erosions or slight swelling of 
 the mesenteric glands. 
 
 Symptoms. — The chief symptom is diarrhoea, due to increased peri- 
 stalsis, increased secretion or actual inflammatory exudation. The 
 stools number two to fifteen daily and contain more or less mucus ; 
 they may be brown-yellow with moderately frequent, or colorless 
 and odorless with very frequent evacuations; their reaction is com- 
 monly alkaline or neutral; they contain triple phosphates, calcium 
 phosphate and oxalate crystals, sometimes cholesterin and Charcot- 
 Leyden crystals, but rarely leukocytes in any considerable number. 
 There may be concomitant acute gastritis. Thirst, dryness of the 
 mouth, colic pains, borborygmus, visible peristaltic movements, tym- 
 
624 DISEASES OF THE DIGESTIVE TRACT. 
 
 pany and slopping or gurgling in the intestine are frequent. Fever is 
 unusual, though febrile forms with acute splenic tumor are recorded, 
 which may at first resemble typhoid. Albuminuria, cylindruria or 
 even acute nephritis may develop in exceptional cases; the urine is 
 scanty in proportion to the amount of fluid lost by the bowel ; indican, 
 ethereal sulphates and acetone may be present. In some few cases 
 herpes or muscle and joint pains occur. Collapse is rare in adults, 
 though cases occur which bear a close resemblance to cholera. In 
 the vast majority of cases convalescence is established in a few days. 
 
 Diagnosis. — (a) Duodenitis can seldom be diagnosticated; pain and 
 tenderness over the duodenum are of most uncertain, but catarrhal 
 icterus is of somewhat presumptive diagnostic value, (b) Jejuno- 
 ileitis seldom exists alone; diarrhoea is absent if the colon is not 
 affected ; the stools contain intimately mixed mucus, which often ap- 
 pears as small hyaline globules under the microscope (Nothnagel). 
 (c) In enterocolitis the bile is decomposed below the small intestine; 
 when it is present in the stools it signifies increased peristalsis which 
 moves the bile along before it can be disintegrated and indicates acute 
 enterocolitis ; bile may be found only in the small globules of mucus 
 and not in the fluid evacuation. Many undigested food particles 
 (lientery) are found, and this is rather significant if fever, biliary 
 or pancreatic obstruction and gastric atrophy are excluded; they 
 consist of undigested meat, starch granules (which are more signifi- 
 cant than muscle fibers) and fat particles, (d) Colitis is character- 
 ized by the absence of bile and lientery, by thin stools and by more or 
 less mucus, which is obtained especially on washing out the bowel 
 immediately after a movement (Boas), (e) Proctitis is marked by 
 much tenesmus, dysuria, evacuation of mucus alone and the passage 
 of bloody mucus covering but not mixed with the solid stools; it is 
 also diagnosticated by the local examination with the finger or 
 speculum. 
 
 Treatment. — (a) In the early stage evacuation of the causal irritant 
 is indicated, to which end fractional doses of calomel should be given, 
 followed by castor oil; the stronger evacuants, which irritate or in- 
 flame the intestine, should be avoided. Colonic flushings with pure 
 water or injections of olive oil may be added, (b) Absolute rest in 
 bed is always indicated, (c) The diet should be restricted to barley 
 water, or no food should be given for a day or two. (d) Heat should 
 be applied to the abdomen, (e) A dram each of paregoric and bis- 
 muth should be given after each bowel movement until the num- 
 ber is controlled. A quarter of a grain of extract of belladonna 
 relieves colic. The following preparation is excellent ; the amount for 
 a child being given in the first and the amount for an adult in 
 the second column : 
 
 fy Phenylis salicylates (salol) g r . xx # 51 
 
 Sodii bicarbonatis 3 SS# ta 
 
 Cretan preparatee 3 SS> Tj sg 
 
 Bismuthi subnitratis 3-; zi 
 
 M. et divide in pulveres X. 
 
 S, — One powder in milk or thin arrowroot solution every three hours. 
 
CHRONIC ENTERITIS. 625 
 
 Lack of tone is relieved by gambir (catechu), colic by belladonna 
 and flatulency by ammonia and ginger : 
 
 ]£ Tincturae gambir composite 3J- 
 
 Fluidextracti belladonna? gtt. xij. 
 
 Spiritus ammoniae aromatici 3ij. 
 
 Tincturae kino 3J- 
 
 Syrupi zingiberis 3 SS - 
 
 Misturae cretae q.s. ad Jiv. 
 
 M. et S. — A tablespoonful every two or three hours. 
 
 Other astringents and intestinal antiseptics, as betanaphthol gr. x p. 
 c. in capsules, or 10 to 15 grains of tannigen (a compound of acetic 
 acid and tannin) every two or three hours are seldom indicated. (/) 
 No laxatives should be given for the constipation resulting from this 
 treatment, (g) Opium suppositories (see Dysentery) relieve tenes- 
 mus, (h) The diet may be increased in a few days to bouillon with 
 raw egg, hashed beef or chicken, toast, zwieback, roast beef and milk 
 with equal parts of carbonated water; fruits and vegetables even 
 when cooked should be given only with extreme caution, because re- 
 currence readily predisposes to chronic enteritis, (i) Cramps, col- 
 lapse and other choleraic symptoms are treated as in cholera (q. v.). 
 
 CHRONIC ENTERITIS. 
 
 Etiology and Pathology. — The etiology is essentially that of acute 
 enteritis, from repeated attacks of which, or of " acute indigestion/' 
 the chronic type may develop. 
 
 Chronic enteritis always suggests a causative chronic gastritis, 
 though both affections may result from overeating and drinking. 
 Chronic enteritis may follow chronic gastritis, achylia gastrica and 
 other gastric conditions; or intestinal catarrh may cause anorexia, 
 eructations, abdominal distention and kindred symptoms. Hyper- 
 chlorhydria may disturb the intestines by the escape into them of 
 more acid than they can neutralize; on the other hand hypo- or 
 achlorhydria readily initiates bowel trouble because hydrochloric 
 acid bears an important relation to the intestinal and pancreatic 
 secretions. 
 
 The pylorus remains closed until the food in the stomach is ready 
 for the intestinal juices and then it relaxes; the hydrochloric acid, 
 reaching the duodenum, provokes a flow of bile (which arrests the 
 action of the pepsin) , and the acid also provokes the pancreatic secre- 
 tion (which neutralizes the hydrochloric acid) by acting upon the 
 duodenal mucosa, which gives off a substance known as " secretin," 
 into the blood ; secretin acting upon the pancreas causes it to secrete 
 (Bayliss and Starling). When these ends are accomplished the 
 pylorus again relaxes. When the pancreatic juice is poured out it 
 contains no active proteolytic ferment, but in the succus entericus 
 there is an " activating " ferment (enterokinase) which converts 
 trypsinogen into trypsin; i. e., the intestinal juice " activates " the 
 trypsinogen (Pawlow). 
 40 
 
626 DISEASES OF THE DIGESTIVE TEACT. 
 
 The bile doubtless increases the activity of the pancreatic enzymes ; 
 it activates the fat-splitting pancreatic ferment. 
 
 The pathology of chronic enteritis resembles that of the acute type. 
 The mucous membrane is brown-red or slate-gray. The mucosa and 
 submucosa are often thickened and the muscularis is sometimes hyper- 
 trophied. Polypoid hyperplasia and cystic degeneration of the in- 
 testinal glands as well as atrophic changes may result. Catarrhal 
 erosions and follicular ulcers may occur as described under the last 
 type of dysentery (q. v.). 
 
 Symptoms. — Generally speaking, constipation is more frequent than 
 diarrhoea; in comparatively few cases a single soft morning evacua- 
 tion is noted, or perhaps several; in others constipation is observed 
 most of the time, broken occasionally by short attacks of colic and 
 diarrhoea; continuous diarrhoea indicates inflammation of both the 
 large and small gut. Constipation is due to alteration of the nerve 
 fibers in the gut or to inflammation in the muscular coat. A sense of 
 abdominal tension or colic may be present and is distinguished from 
 gastric discomfort and pyloric spasm in that it occurs independently 
 of ingestion of food. Diarrhoea results from decomposition and faecal 
 irritation. There may be pain, flatulency, borborygmus or occasion- 
 ally tenderness over the bowels, which may occur together or at inter- 
 vals ; but the sole diagnostic criterion is the presence of mucus in the 
 passages ; an intimate mixture with the stool indicates inflammation 
 in the small gut ; a mere coating of the passages with mucus indicates 
 colitis, and evacuations of mucopus alone, proctitis. Small sago-like 
 globules may be mucus or vegetable matter. Mucus globules when 
 bile-stained indicate inflammation of the small gut, as do shreds of 
 bile-stained mucus. Small homogeneous denucleated epithelial cells 
 may be found in the mucus adhering to scybala. Pus cells are rare 
 except in proctitis. The presence of mucus is always indicative of 
 enteritis and never occurs from ulceration or carcinoma alone (a 
 slight coating of mucus over hard faeces is not significant). Blood 
 always indicates a complication, such as piles, ulceration or cancer. 
 The stools may contain much undigested meat, starch or fat. 
 
 Schmidt and Strasburger have proposed the functional examination 
 of the f 83ces ; while their method does not give us as exact information 
 as does the examination of the stomach contents, valuable facts may 
 be determined. Schmidt's test diet includes 3 pints of milk, 3 ounces 
 of zwieback or toast, two eggs, 1.6 ounces of butter, one-quarter pound 
 of rare tender steak,6 ounces of boiled potatoes, 2 ounces of oat-meal 
 and two-thirds of an ounce of sugar ; this total is variously distributed 
 among the three meals. With the first meal a capsule of Rve grains 
 of charcoal or carmine is given and the first examination is not made 
 until the stools become colored black or red. In this way (i) the 
 "period of passage" is established, the normal time being ten to 
 twenty hours, (ii) Mucus is detected, microscopically, by mixing a 
 piece of faeces as large as a walnut with a small amount of water- it 
 appears as translucent, sago-like and often bile-stained flakes, which 
 
CHRONIC ENTERITIS. 627 
 
 must not be confused with starch particles. (Hi) Much connective 
 tissue, recognized by its yellow-white color and its toughness, indi- 
 cates reduction of the hydrochloric acid, (iv) Muscle fibers,^ appear- 
 ing as reddish threads or lumps, may indicate achylia gastrica, lack 
 of trypsin, lack of the activating enterokinase or very active peri- 
 stalsis, (v) Free starch granules always indicate intestinal catarrh; 
 normally only starch enveloped in cellulose is present, (vi) The 
 normal stool shows hydrobilirubin, detected by mixing a small amount 
 of the fluid faeces with an equal amount of a 5 per cent, solution of 
 bichloride of mercury, which mixture turns yellow-red after twenty- 
 four hours ; bilirubin, recognized by a green color in the above test, 
 always indicates catarrh of the small bowel (except in young chil- 
 dren), (vii) The fermentation test is made by mixing a dram of the 
 faeces with sterile water in a bottle which is connected above with a 
 tube containing water ; almost no gas results in normal cases ; if the 
 reaction becomes acid with a pathological fermentation it is due to 
 carbohydrate fermentation ; if it becomes alkaline and foul in odor it 
 is due to proteid fermentation, (viii) With a little experience with 
 the amount of fat normally found it can be readily determined 
 whether the fat is pathologically increased. 
 
 The appetite is usually good. The general nutrition is good in 
 some cases, though in others pallor, emaciation, slow pulse and cold 
 extremities may be noted. Attacks of diarrhoea and undigested food 
 in the stools suggest achylia gastrica (Einhorn, Oppler). 
 
 Prognosis. — The prognosis, save in either extreme of age, is good as 
 to life itself, but is always doubtful at any age as to complete re- 
 covery. Improvement at the best is tardy and often transient. .In- 
 testinal atrophy may develop, though this is less frequent than in 
 puerile forms. 
 
 Treatment. — (a) Moderate exercise and an hygienic conduct of life 
 are most essential. A flannel band should be worn over the abdomen. 
 (b) The diet must be carefully supervised. Though it is impossible 
 to give here a complete dietary, salads, beer, wine, fruits and vege- 
 tables of nearly every description, either raw or cooked, sweets, 
 pickles and acids are among the forbidden foods ;• eggs, fresh butter, 
 lean meats, stale bread, rusks, thoroughly cooked rice or sago and 
 potato puree are permissible; i. e., simple foods, in small amounts 
 and at frequent intervals, controlled by frequent examination of the 
 faeces, (c) Regulation of the boivels is necessary. For constipation, 
 purgatives should be avoided and the bowels moved by enemata of 
 olive oil. Constipation is often due to the careful diet, which does 
 not provoke peristalsis. For diarrhoea, bismuth in dram doses and 
 tannigen (5 to 15 grains) are most efficacious (see Acute Enter- 
 itis). Calcium carbonate and salicylate are recommended by Boas 
 and Javorski (aa 3ss to a quart of charged water; one-half glass q. i. 
 d.). (d) Flatulency — Some flatus is not pathological. As it results 
 from stagnation plus catarrh (chiefly in the ileum, caecum and 
 ascending colon), the first indication is that of the catarrhal enteritis; 
 
628 DISEASES OF THE DIGESTIVE TRACT. 
 
 the second is the restriction of foods which ferment (v. s.) ; and the 
 third is the administration of aromatic remedies (see Therapy of 
 Acute Enteritis). 
 
 I£ Mentholis 3ss. 
 
 Phenylis salicylates 3iij- 
 
 Extracti belladonna gr. iv. 
 
 M. et ft. capsulse XX. 
 
 S. — One after meals. 
 
 (e) Colitis is treated by rectal flushings, 1 to 2,000 silver nitrate ; 
 borax, salicylic acid or ichthyol. (See Treatment of Dysentery.) 
 
 ENTERITIS (COLITIS) MUCOSA OR MEMBRANACEA. 
 
 This disease was first described by Mason Good (1825), though the 
 first classical description was Da Costa's in 1871. The name implies 
 that the malady is an inflammation, but in reality most cases are 
 neither enteritis nor colitis. Nothnagel proposed the name colica 
 mucosa for the non-inflammatory variety, which is a secretory 
 neurosis. 
 
 Etiology. — (a) Eighty to 90 per cent, occur in nervous or hysterical 
 women between twenty and forty years old, 40 per cent, of whom have 
 uterine troubles ; males who are affected are usually nervous or hypo- 
 chondriacal; a few cases have been seen in nervous children, (b) 
 Nearly all cases suffer from years of previous constipation. Its 
 pathology is unknown; in some autopsies no anatomical alteration is 
 noted, in others that of enteritis. 
 
 Symptoms. — (a) Mucus casts of the bowels, shreds or lumps are 
 voided periodically; the mucus may resemble a huge diphtheritic 
 cast, is usually evacuated in large amounts, which often constitutes 
 the entire bowel movement and contains very few leukocytes or other 
 signs of inflammation; it is rarely simulated by curds of milk, (b) 
 There is usually, but not always, colic or pain and tenderness with the 
 attack, which frequently occurs over the splenic flexure of the colon, 
 is sometimes diffuse and occasionally radiates, as into the leg. If 
 the mucus is firmly adherent to the bowel wall the pain is particularly 
 severe and obstruction of the bowels may be simulated very closely. 
 Tenesmus in voiding the mucus is usual, as are formation of gas and 
 increase of the original nervous symptoms, as palpitation, tremor or 
 vertigo. There may also be coincident diarrhoea, achylia gastrica and 
 a periodic sand formation (Dieulafoy). (c) Constipation, abdomi- 
 nal distention or pressure and anorexia exist between the paroxysms, 
 which last a day or even a week and are separated by intervals of 
 weeks or months. It is said that death may occur during an attack. 
 
 Treatment. — Treatment concerns (a) the fundamental neurosis. 
 As a rule the less the neurotic symptoms are in evidence the better 
 are the results of therapy; education, the rest cure and other meas- 
 ures outlined in the treatment of hysteria and neurasthenia (q. v.) 
 
DUODENAL ULCER. 629 
 
 are indicated, (b) Constipation (v. i.) is treated in the usual way 
 and an appropriate diet is essential. Von Noorden advises the use 
 of graham bread, leguminous vegetables, including the husks, vege- 
 tables with much cellulose — which seems to be the most important 
 element — fruits with small seeds and thick skins, as gooseberries, 
 currants or grapes, large amounts of cream, butter and bacon, and 
 olive oil. Von Noorden's results with this diet are: 79 per cent, 
 cured (15.8 per cent, partially cured, 50 per cent, permanently cured, 
 13 per cent, relapsed), 15.8 per cent, unknown result and 5.2 per 
 cent, failure. In White's series 50 per cent, recovered, 13 per cent, 
 improved and 37 per cent, were not improved, (c) Local measures 
 include colonic flushings with normal salt solution, or half a pint of 
 olive oil left in the rectum over night (Kussmaul). (d) Narcotics, 
 purgatives, irrigation with alum, tannin and silver solutions, and 
 operation are. distinctly contra-indicated. The morphine habit may 
 be readily contracted. Belladonna in a suppository is very efficient 
 in types characterized by pain. The patient in an attack is kept in 
 bed and heat is applied to the abdomen. 
 
 DIPHTHERITIC, CROUPOUS AND PHLEGMONOUS ENTERITIS. 
 
 True diphtheria, due to the Klebs-Loeffler bacillus, is very rarely 
 encountered, and practically all membranous enteritis is diphtheroid; 
 it develops in various acute infections, in uraemia and in metallic 
 poisoning and has been described under the third form of dysentery. 
 
 Phlegmonous or purulent enteritis is likewise extremely rare and 
 chiefly of anatomical interest. Most cases develop in the duodenum. 
 The affection may be primary, but more often is secondary to in- 
 testinal ulceration, carcinoma or intussusception. Maragliano de- 
 scribed a form probably due to the colon bacillus, in which multiple 
 purulent foci are found in the intestinal wall, which frequently cause- 
 perforation. 
 
 INTESTINAL ULCERATION. 
 
 I. Duodenal Peptic Ulcer. — This is almost identical in etiology, 
 pathology and treatment with the peptic gastric ulcer. It was first 
 described by Abercrombie (1824). 
 
 Etiology. — (a) Gastric ulcer is 2 to 10 times as frequent as duo- 
 denal ulcer, whose frequency Kinnicutt estimates at %o per cent, in 
 30,000 autopsies. In 121 duodenal ulcers collected by Oppenheimer, 
 gastric ulcer was present in about 6 per cent., and in Lebert's series 
 of 237 stomach ulcers, duodenal ulcer was present in about 10 per 
 cent. Moynihan and ]\Iayo found gastric ulcer in about 50 per cent. 
 Forty-nine cases of jejunal ulcer are reported after gastroenteros- 
 tomy for round ulcer of the stomach (q. v.) ; ulceration may be ob- 
 viated by alkalies after operation, (b) Seventy-nine per cent, occur 
 in males as a result of alcohol, (c) In Collin's series of 279 cases, 
 two-thirds occurred between twenty and sixty years of age, being 
 
630 DISEASES OF TEE DIGESTIVE TRACT. 
 
 about equally frequent in each decade, (d) Other etiological factors 
 are: (i) in extensive burns (Curling, 1842) acute ulcers develop 
 in one to two weeks, rarely earlier or later; Holmes found them in 
 13 per cent, of 125 fatal burns ; their cause is probably vascular ob- 
 struction, though the precise factors are not yet established (fibrin- 
 ferment, toxins absorbed from the skin, aggregation of blood plaques), 
 (ii) Nephritis, which occurs in 17 per cent, of the cases, is suggested 
 as a cause by Perry and Shaw, (iii) It may result from embolism 
 and thrombosis. Endocarditis and sepsis occasionally cause duo- 
 denal ulcer. Thrombosis of the umbilical and other veins produces 
 the cases seen in the new-born (Landau). It has also followed 
 trauma, multiple neuritis, periarteritis nodosa and foreign bodies 
 such as gall-stones. Pathologically the resemblance to gastric ulcer is 
 marked in all details. It is single in 84 per cent., is located in the 
 upper horizontal part of the duodenum in 87 per cent, of cases and is 
 almost always above the papilla. 
 
 Symptoms. — Symptoms are absent in 30 to 60 per cent., at least 
 until hemorrhage or perforation occurs, (a) It is generally stated 
 that gastric symptoms are absent in the great majority of cases. C. 
 Graham, in an analysis of 163 cases, found stomach symptoms, espe- 
 cially vomiting and gas formation, in 70 per cent. The appetite is 
 usually good. Graham found superacidity in half the cases. It must 
 be remembered that associated gastric ulcer is quite frequent. 
 Moynihan describes the symptoms of duodenal ulcer as follows : " The 
 patient tells you that he has certain definite attacks, and if you take 
 the history given in detail, letting the man tell his own story, he will 
 give you the impression of having read something which has been 
 written about duodenal ulcer, which he is recounting to the best of 
 his recollection to please you. He says that his trouble comes on in 
 attacks which are nearly always worse in winter than in summer 
 and are very apt to be precipitated by a chill. Let us follow the 
 patient through the day. He takes a meal at eight in the morning 
 and from two to two and one-half hours after it he is fairly com- 
 fortable ; it is his best time. At the end of that time he has a feeling 
 of discomfort in the epigastrium ; he feels full and heavy and may 
 get some relief from the belching of gas. Some of these patients 
 develop a habit of belching. They may bring up a very sour fluid, 
 which tastes very bitter and acid and makes the mouth dry and the 
 teeth chalky. This pain gradually increases until the next meal time 
 comes. To this I some years ago applied the name of ' hungry pain.' 
 At the next meal the patient almost instantly gets relief and that 
 relief persists for two or three hours again. He probably eats a heavy 
 dinner and will nearly always tell you he has something before he 
 gets into bed, a glass of milk or a cup of cocoa and a biscuit. He 
 sleeps comfortably, until he wakes about 2 a. m. He gets relief from 
 nibbling a biscuit, which he keeps at the bedside. The pain is found 
 to be most relievable by something stodgy and indigestible. Taking 
 an alkali relieves the pain ; so will emptying the stomach by washing 
 
DUODENAL ULCER. 631 
 
 it out. If these symptoms which I have described are recurrent you 
 can diagnose duodenal ulcer." In one of the writer's cases of gastric 
 ulcer in which there was anacidity, Murphy found at operation a 
 gastric ulcer and also a greatly dilated duodenum; in the jejunum 
 there was marked stenosis due to a healed round ulcer, as shown 
 by microscopic examination. This case is, as far as we know, 
 quite unique; Tobieson reports a jejunal ulcer following burns. 
 (&) Pain is present in 80 per cent., occurs 2 to 5 hours after 
 eating, is located over the duodenum and is sometimes accom- 
 panied by tenderness. Both pain and tenderness may be peri- 
 tonitic. (c) Hemorrhage from the bowels occurs in 33 per cent, 
 of cases. The stools are usually tarry, but sometimes bright red 
 from copious bleeding. " Occult" hemorrhage (small or micro- 
 scopic hemorrhage) is even more common and is as important as in 
 gastric ulcer or cancer. Intestinal hemorrhage is often fatal from 
 erosion of the pancreatico- or gastro-duodenal arteries, less often of 
 the aorta or cava. Hsematemesis is infrequent, though it has been 
 said to occur in a quarter of the cases where there is intestinal hemor- 
 rhage and usually indicates duodenal stenosis, in which the blood 
 passes more readily upward than downward. Constipation is 
 frequent. 
 
 Complications and Issue. — (i) Spontaneous healing is infrequent 
 and cicatrization occurs in 11 per cent. ; the clinical course is 
 often long (five to thirty years), (ii) Perforation, total with peri- 
 tonitis, or partial (chronic) with gall-bladder or pancreas symptoms, 
 is very frequent (50 per cent., Perry and Shaw), (iii) Gastric dila- 
 tation occurs in 7 per cent, and duodenal dilatation in nearly 2 per 
 cent. ; both result from duodenal stenosis, (iv) Icterus occurs in 
 less than 3 per cent. ; (v) duodenal cancer is an infrequent sequel. 
 
 Diagnosis. — Leube holds that a certain differentiation from gastric 
 ulcer is never possible and Von Wyl holds that differentiation from 
 gastric ulcer is possible in but 10 per cent, of cases. The other chief 
 cause of error is disease of the gall-bladder. As Graham states, 
 " There will always remain a certain proportion of cases that will 
 mislead the careful physician. Those cases of gall-stones in which 
 the stomach symptoms of gas, distress, sour belching and dilatation 
 predominate, and pain is only of a dull character, will usually be 
 diagnosticated as ulcer; but the duodenal case, of which the chief 
 symptom is the sudden, sharp, intense pain of perforative peritonitis, 
 and in which, with no obstruction or hyperacidity, the other stomach 
 symptoms are in abeyance, will be diagnosticated cholelithiasis. Both 
 conditions are purely surgical and the differentiation in many cases 
 must be made on the operating table." Acute pancreatitis (q. v.), 
 intestinal obstruction and appendicitis must be considered in the 
 diagnosis. 
 
 Treatment. — The treatment is that of peptic ulcer of the stomach 
 (q. v.), including its surgical indications. In 7 perforations, 71 per 
 cent, recovered; in 22 chronic ulcers, 95.5 per cent, recovered; 
 
632 DISEASES OF THE DIGESTIVE TRACT. 
 
 in 22 ulcers associated with gastric ulcer, 95.5 per cent, recovered 
 (Moynihan, 52 operations). 
 
 II. Other Intestinal Ulcers. — Ulceration in acute infections, as ty- 
 phoid, dysentery, anthrax and diphtheria, has been described. In ex- 
 ceptional cases ulceration may occur in erysipelas, variola and sepsis. 
 Chronic infections may cause ulcers, as syphilitic, tuberculous and 
 actinomycotic lesions, which are considered under general infections. 
 Very rare cases of ulceration have been observed from favus and 
 mucor corymbifer. Inflammatory ulcers, as the catarrhal and follicu- 
 lar, usually occur in the colon ; they may be simple or so-called dysen- 
 teric (q. v.) and may develop from the epithelial layer; they are seen 
 in enteritis, infantile diarrhoeas, etc. Stercoral {decubital) ulcers de- 
 velop from the pressure of retained hard faeces or foreign bodies, in 
 the dilated pouches of the colon or above an intestinal stenosis. Con- 
 stitutional affections are occasionally causes, as leukaemia, scurvy, 
 gout and amyloidosis. Toxic ulcers may develop in uraemia (q. v.) 
 and in mercurial and arsenical poisoning. 
 
 Symptoms. — The symptoms are rarely distinctive without sugges- 
 tive etiological factors ; most ulcerations occur without symptoms or 
 with ambiguous symptoms, (a) Diarrhoea is frequent, particularly 
 in ulceration of the large gut; it is often absent with lesions in the 
 small gut or in the upper colon. Diarrhoea results from decreased 
 absorption and from increased peristalsis, due to exposure of the 
 intestinal nerves, (&) Blood in the stools is mixed with them in 
 lesions of the small gut, sometimes covers them in lesions of the large 
 gut and is voided independently of the faeces in rectal lesions. It is 
 more often dark and tarry, especially in tuberculosis, than bright, 
 except in low-situated lesions and in some profuse typhoid, dysenteric 
 or duodenal hemorrhages. Blood is common in other diseases than 
 ulceration, as in cancer, piles, stasis and blood diseases, (c) Pus 
 is seen more frequently in colonic than in ileac ulceration; it is com- 
 mon in cancer, proctitis and croupous enteritis. Pure pus in con- 
 siderable amounts is rather indicative of rupture of extra-intestinal 
 pockets into the intestine, as appendicitic and salpingitic abscesses. 
 (d) The presence of mucus has no special significance, as it indi- 
 cates enteritis only, which of course may complicate ulceration, (e) 
 Shreds of tissue are very rare, save in dysentery. (/) Local symp- 
 toms are likewise ambiguous, as tenderness, pain and tympanites. 
 (g) General symptoms depend on the basic disease; fever is most 
 frequent in cancerous, dysenteric or tuberculous ulcers, (h) Rupture 
 causes peritonitic adhesions, diffuse peritonitis, retroperitoneal cellu- 
 litis or subphrenic pyopneumothorax. 
 
 Treatment. — Treatment is that of enteritis or colitis. Of chronic 
 ulcerative colitis Mehrkorn has published 38 cases in which colostomy 
 resulted favorably. 
 
INTESTINAL DISORDERS IN INFANTS. 633 
 
 INTESTINAL DISORDERS IN INFANTS. 
 
 Etiology. — Classification of the etiological factors is extremely diffi- 
 cult because of the numerous species of bacteria in the intestine and 
 the impossibility of drawing any absolute line between chemical and 
 bacterial factors and between functional and organic changes. Most 
 cases occur in children between six and eighteen months old, in the 
 summer months, July especially, and in the poorer classes. It occurs 
 largely in infants who are not fed at the breast, and for two main 
 reasons; (a) cow's milk is prone to disturb digestion (see Treat- 
 ment), and (b) there is a greater chance for bacterial infection. 
 Bacteria operate in several ways. Vaughan and Flugge have demon- 
 strated that toxins may form in milk. This factor is especially potent 
 when milk is long in transit, particularly in hot weather. Bacteria 
 may cause inflammation of the intestines; the Bacterium lactis 
 aerogenes causes inflammation in the small and the Bacterium coli 
 in the large intestine; the proteus, pyocyaneus, pyogenic cocci and, 
 since 1897, Shiga's Bacillus dysenteric are also factors, but their 
 relative importance is not yet clearly defined. Escherich, Booker 
 and Favel describe a streptococcus enteritis, which, however, can 
 hardly be considered as a distinct type ; Baginsky considers the sapro- 
 phytes of the intestine and of cow's milk causative, and Czerny holds 
 that toxins may develop in the liver. The distinction between intoxi- 
 cation and infection is maintained with difficulty ; intoxication causes 
 such symptoms as erythema, hemorrhagic diathesis, anaemia, nervous 
 disturbances and dyspnoea ; and infection produces certain complica- 
 tions, as lobular pneumonia, nephritis, encephalitis, phlegmon, ar- 
 thritis, purulent pleurisy and necroses in the liver. In institutional 
 epidemics infection may be carried from one individual to another by 
 faecal contaminations. Insects may also convey infection. 
 
 Symptoms. — (1) The symptoms of the acute dyspeptic or fermental 
 form cannot be sharply distinguished from those of the other severer 
 forms, though possibly caused by the same microorganisms. The 
 pathological findings are often, as in adult forms, remarkably insig- 
 nificant. The temperature usually rises suddenly to 103° or 104°, 
 remains high for a few days and falls rather suddenly. The tongue 
 is dry, the face red, the pulse rapid and the breathing sometimes dys- 
 pnoeic. There is considerable restlessness — sometimes initial con- 
 vulsions — anorexia and vomiting. The stools in infants are normally 
 yellow from bilirubin, are thick and slightly acid in reaction; they 
 become greenish from bacterial action or reduction of the bilirubin 
 -into biliverdin, react alkaline from albuminous decomposition or 
 acid from acid fermentation and become thin and offensive; the 
 evacuations become frequent (6 to 10 daily). The microscopic find- 
 ings are those of acute enteritis in adults, as mucus, leukocytes, triple 
 phosphates in the alkaline stools or cholesterin in the acid stools ; 
 blood in any quantity is uncommon. Involvement of the small in- 
 testine is attended by considerable gas, some cramping, large move- 
 
634 DISEASES OF TUE DIGESTIVE TRACT. 
 
 ments and slight tenderness and tenesmus. In severe cases the 
 nervous symptoms may become conspicuous and considerable emacia- 
 tion may result. Albuminuria and cylindruria occur in about 20 
 per cent. The author has seen two cases of extensive oedema follow 
 dyspeptic diarrhoea without nephritis. Kecovery is usual and prompt 
 after thorough intestinal evacuation, though a few cases run a sub- 
 chronic course. 
 
 2. Cholera infantum occurs in severe infections, usually in chil- 
 dren already suffering from some intestinal disorder. According to 
 Holt, it constitutes but 2 to 3 per cent, of summer diarrhoeas. The 
 boivel movements are copious, alkaline and contain nocculi; though 
 at first they contain food and are perhaps offensive, they become 
 watery and odorless. Both the stools and the general clinical aspect 
 resemble the picture of cholera Asiatica and cholera nostras (q. v.). 
 Though there is fever, the extremities are algid and cyanotic, the 
 pulse small, the heart tones weak and all the symptoms of collapse 
 are present ; the eyes are sunken and there are the pinched pallid fades 
 cholerica, the thirst and the incoercible vomiting. The skin is rigid, 
 as though the fatty tissue had hardened (scleredema or sclerema 
 adiposum), and nephritis is almost invariable. These symptoms re- 
 sult not only from loss of great quantities of fluid by purging and 
 vomiting, but also from intoxication which produces the convulsions, 
 irregular and Cheyne-Stokes' breathing, retraction of the neck, stu- 
 por and other symptoms, termed by Marshall Hall the " hydrencephalic 
 state," and explained as oedema of the brain (q. v.), though better 
 explained by intoxication. Oestreich thinks that hypostasis, result- 
 ing from compression of the lungs by the tympany, causes more 
 deaths than does the toxaemia. 
 
 3. Acute enterocolitis (ileocolitis) may follow the dyspeptic form 
 or the various specific infections in children, or may begin as an inde- 
 pendent form. Pathologically it includes types which cannot be 
 separated clinically, as (a) simple enterocolitis, (b) follicular ulcera- 
 tion and (c) diphtheroid enteritis. The growing importance of 
 Shiga's Bacillus dysenterise in infantile enterocolitis is established by 
 the recent work in this country of Vedder, Duval, Flexner, Bassett, 
 Knox, .Park, Zahorsky, Dunham, Wollstein and Kotch. In some 
 epidemics the bacillus produces acid in mannit media, which Shiga's 
 bacillus does not produce. In Botch's cases of infantile diarrhoea 
 the Bacillus dysenteriae was found in 16 per cent. ; it was sometimes 
 found in the dyspeptic or fermental type, but most often in the ileo- 
 colic type (78 per cent.). In one collection of 412 cases Shiga's 
 bacillus was found in 63 per cent.; Geo. Weaver never found it, 
 though the Flexner-Harris type occurred in 25 per cent. (v. Bacil- 
 lary Dysentery). 
 
 The symptoms closely resemble those of dysentery in the adult. 
 The stools are small, yellow, green or brown, are very frequent, are 
 attended by tenesmus and void mucus, blood, pus and sometimes 
 shreds of tissue or membrane. Blood may be present from congestion 
 
INTESTINAL DISORDERS IN INFANTS. 
 
 635 
 
 or acute ulceration. Rotch tabulates the differential features as 
 follows : 
 
 Acute Ferruental Diarrhoea. 
 
 Acute Ileocolitis. 
 
 (a) 
 
 Small intestine, mostly. 
 
 
 Large intestine, mostly. 
 
 (6) 
 
 10 to 12 discharges ; often large. 
 
 
 10, 15 to 50 discharges, usually small. 
 
 (c) 
 
 No or little blood. 
 
 
 Blood and sometimes shreds of tissue or 
 membrane. 
 
 id) 
 
 Mucus. 
 
 
 Mucus. 
 
 (e) 
 
 No tenesmus. 
 
 
 Tenesmus. 
 
 if) 
 
 Not much abdominal tenderness 
 
 and 
 
 Abdominal tenderness and pain. 
 
 iff) 
 
 pain. 
 No or slight lesions. 
 
 
 Lesions marked. 
 
 (h) 
 
 Temperature high — 104° F. for 
 
 one 
 
 Temperature may be high at first (103° 
 
 
 or two days, and then falling 
 
 F. to 104° F.) but usually soon mod- 
 
 
 sharply by crisis. 
 
 
 erates (99° to 101° F.) and falls grad- 
 ually by lysis to normal after some 
 weeks. 
 
 The severity of the symptoms varies greatly; the catarrhal form 
 may cause mild symptoms or result in death, with or without gastric 
 symptoms. The ulcerative and diphtheroid types are less often at- 
 tended by vomiting, but run a fatal course of days or weeks. 
 
 4. Chronic dyspeptic disturbances often occur with gastric dilata- 
 tion. The onset is gradual or it may directly follow the acute forms. 
 The stools are green or gray, contain mucus, gas and sometimes pus 
 and tissue shreds. Food and fluid are not absorbed, or absorbed in 
 part only; undigested food particles and fatty stools are observed; 
 mucus is not common in marked cases of intestinal atrophy. Vomit- 
 ing is rather frequent. There is usually but little general disturb- 
 ance, no fever and little or no colic. The scales show marked loss in 
 weight and in some cases the emaciation may become extreme (psedi- 
 atrophy, athrepsia), the muscles becoming weak, the voice faint, the 
 eyes lustreless, the face of the " Voltaire type," and the abdomen dis- 
 tended. Death results from marasmus or intercurrent infections. 
 
 Preventive Treatment.- — Children should, if possible, be taken to the 
 country in the hot months. Excessive swaddling is to be avoided. 
 
 Diet. — (a) Human milk is superior to all others, and if the mother 
 cannot nurse her child, a wet-nurse should be procured if possible, 
 as few cases of stomach and bowel disease occur in breast-fed in- 
 fants. The wet-nurse must be carefully examined for syphilis and 
 tuberculosis. The milk from the breast should spurt freely iu sev- 
 eral streams. A weak child may become dyspeptic even at the 
 breast ; calomel irritates but magnesium carbonate gives the most 
 rapid relief. Other children thrive, even when the stools are 
 green, for which Heubner blames the digestion of the infant. 
 Sometimes colic and dyspepsia in the child are due to menstrua- 
 tion, beginning pregnancy, excitement, lack of exercise or alcoholic 
 indulgence in the nurse or mother. If a wet-nurse cannot be ob- 
 tained, (&) cow's milk or some prepared food must be used, but most 
 of the latter are objectionable because their carbohydrates are not 
 dextrinized, as shown by the iodine test. Cow's milk differs from 
 
63(> 
 
 DISEASES OF THE DIGESTIVE TRACT. 
 
 human milk in many details ; its contamination is far more likely, 
 whence the importance of pure milk and sterilized nipples and 
 bottles. Human milk contains about 1 per cent, of proteids, 4 per 
 cent, fats and 7 per cent, of milk sugar, but in cow's milk the per- 
 centages are respectively about 3.5, 3.5 and 5 per cent.; in cow's 
 milk the casein constitutes 80 per cent, of the proteids, which are 
 physically and chemically different in mother's milk, e. g., they con- 
 tain more whey proteid and more of certain relatively uninvestigated 
 substances, as nucleon. In cow's milk the ferments and fats are 
 different and the mineral salts, especially phosphates, are increased 
 which, as Blauberg has shown, impede digestion. The first objec- 
 tion is the high percentage of proteid (casein), which must be pre- 
 digested or the milk diluted. Simple dilution, however, necessitates 
 giving too much water or reducing the fat and milk-sugar, fat being 
 essential and milk-sugar being important because the Bacillus lactis 
 aerogenes, operating upon it, produces lactic acid, which is inimical 
 to pathogenic bacteria in the bowel. In modification of milk or in 
 substitute feeding, then, the proteid of cow's milk must be reduced, 
 fat added in the form of cream, and milk-sugar added to attain the 
 normal percentage. The milk may be diluted with thin oatmeal 
 water, as a diastase ferment is present earlier and in larger amounts 
 than previously admitted, though nature doubtless has her designs in 
 withholding starches from mother's milk. The fats of Holstein, 
 Durham, Devon and common breeds can be better emulsified than those 
 of Jerseys and Guernseys, which contain more volatile glycerides. 
 
 Theoketical, Basis for Feeding a Healthy Infant. 
 (According to Rotch.) 
 
 
 
 
 
 Proteids if 
 
 Amoun 
 
 t at each 
 
 « 3 
 
 CO 
 
 bo . 
 
 
 
 
 w 
 
 split. 
 
 feeding, in — 
 
 *2 
 
 □ CO 
 
 ^3 3 
 
 
 "c3 
 
 to 
 
 <» 
 
 
 
 
 aa"* 
 
 
 Age. 
 
 
 
 
 
 £^ 
 
 
 
 CO 
 
 fl 
 
 Whey 
 
 
 
 
 u a 
 
 O^ 
 
 
 
 
 
 pro- 
 teids. 
 
 inogen. 
 
 Ounces. 
 
 C. c. 
 
 SI 
 
 . a 
 
 Premature 
 
 1 00 
 
 4 00 
 
 0?5 
 
 0.25 
 
 25 
 
 i-l 
 
 l 
 
 4 25 
 
 1-1J 
 1-1* 
 
 2 
 
 24 18 
 
 Premature 
 
 1 50 
 
 4 50 
 
 0% 
 
 0.50 
 
 25 
 
 4 25 
 
 24 18 
 
 At term 
 
 2.00 
 
 5.00 
 
 0.50 
 
 0.50 
 
 0.25 
 
 30 
 
 10 
 
 End of second week 
 
 2.50 
 
 5.50 
 
 0.50 
 
 0.50 
 
 0.25 
 
 n 
 
 45 
 
 2 
 
 10 
 
 End of third week 
 
 3.00 
 
 6.00 
 
 0.75 
 
 0.75 
 
 0.25 
 
 2 
 
 60 
 
 2 
 
 9 
 
 End of fourth week 
 
 3.50 
 
 6.50 
 
 1.00 
 
 0.75 
 
 0.50 
 
 2J 
 
 75 
 
 2 
 
 8 
 
 End of sixth week 
 
 4.00 
 
 7.00 
 
 1.00 
 
 0.90 
 
 0.60 
 
 3 
 
 90 
 
 2* 
 
 8 
 
 End of eighth week 
 
 4.00 
 
 7.00 
 
 1.25 
 
 0.90 
 
 0.75 
 
 3£ 
 
 105 
 
 2* 
 
 7 
 
 End of twelfth week. . . . 
 
 4.00 
 
 7.00 
 
 1.50 
 
 0.90 
 
 1.00 
 
 4 
 
 120 
 
 2h 
 
 7 
 
 End of four months 
 
 4.00 
 
 7.00 
 
 1.50 
 
 0.75 
 
 1.25 
 
 4£ 
 
 135 
 
 2* 
 
 6 
 
 End of five months 
 
 4.00 
 
 7.00 
 
 1.75 
 
 
 
 ^ 
 
 165 
 
 3 
 
 6 
 
 End of six months 
 
 4.00 
 
 7.00 
 
 2.00 
 
 
 
 6 
 
 180 
 
 3 
 
 6 
 
 End of eight months... 
 
 4.00 
 
 7.00 
 
 2.50 
 
 
 
 7 
 
 210 
 
 3 
 
 6 
 
 End of nine months 
 
 4.00 
 
 7.00 
 
 3.00 
 
 
 
 8 
 
 240 
 
 3 
 
 6 
 
 End of ten months 
 
 4.00 
 
 6.00 
 
 3.00 
 
 
 
 8 
 
 240 
 
 3 
 
 6 
 
 End of eleven months.. 
 
 4.00 
 
 5.00 
 
 3.00 
 
 
 
 10 
 
 300 . 
 
 3 
 
 5 
 
 End of twelve months.. 
 
 4.00 
 
 4.75 
 
 3.50 
 
 
 
 10 
 
 300 
 
 3 
 
 5 
 
INTESTINAL DISOEDEES IN INFANTS. 637 
 
 " The data are simply a guide for the feeding of the average healthy 
 baby; they are only approximate and not intended to be followed 
 without due consideration to the individual requirements." 
 
 Quite low dilutions should be given at first and they should be grad- 
 ually increased. Attention should be given not only to digestion but 
 to nutrition, as determined by regular weighing. Sterilization of 
 milk destroys ferments and protective substances (Ehrlich). 
 
 Treatment of Acute Dyspepsia. — (a) The stomach should be washed 
 out, if toxic symptoms are at all marked (Heubner) ; plain water or 
 a 1 to 3,000 resorcinol solution should be used, (b) Calomel gr. % 
 and magnesium carbonate gr. j every three hours for about three 
 doses, or one dose of castor oil (3ss to j) are usually administered, 
 but cathartics congest or even erode the mucosa, (c) The bowel 
 should be flushed with warm water; one pint is sufficient in chil- 
 dren of one year, or somewhat more in children two years old. 
 (d) Food should be withheld (Czerny) for two days, and plenty of 
 boiled water should be given. Albumin water, which consists of the 
 whites of two eggs beaten in a pint of water, may then be given, and thin 
 arrow-root water, beef juice and peptonized milk, may gradually be 
 administered until the green color of the stools changes to a normal 
 yellow-brown, (e) Other medication is usually superfluous. Lesage 
 recommends that lactic acid be given for alkaline green stools, 3j of 
 a two per cent, solution (p. c). Resorcinol % grain and dilute 
 hydrochloric acid 171 v may be given after meals. 
 
 Treatment of (Dominating) Enteritis. — If the case is seen early the 
 stomach is washed out ; in all cases feeding must be suspended as out- 
 lined above. The child should have plenty of boiled water and cool 
 applications to the skin are indicated unless the extremities are blue 
 and cool. Tannigen may be given in relatively large doses, 10 to 15 
 grains, several times daily, even in the very young, possibly combined 
 with minute doses of calomel (gr. %o). As in enteritis of adults, 
 bismuth subnitrate is given in large doses, 3ss. Bismuth salicylate, 
 in doses of % to 1 grain, is also given. If these are ineffective, opium 
 may be administered. (See page 91 for dosage.) 
 
 Treatment of Cholera Infantum. — Food should be withheld. Lavage 
 of the stomach and bowels is ineffective, unless it is done in the 
 earliest stages. There are three main indications: (a) fluid must be 
 restored to the tissues ; this is possible only by subcutaneous saline 
 transfusions which support the heart, fill the vessels, stimulate the 
 kidneys and eliminate the toxins; (&) cardiac stimulation, by hypo- 
 dermics of strychnine and camphor and local heat ; champagne quiets 
 vomiting and supports the heart; brandy and whiskey are given in 
 doses like those employed in bronchopneumonia (q. v.), though 
 Heubner believes that alcohol further injures the intestinal epithe- 
 lium; and (c) secretion must be checked by administration of pare- 
 goric every four hours, of small enemas of starch and laudanum or, 
 which is more effectual, of morphine. (See page 91.) In the 
 fortunate cases which rally, nourishment can be resumed only with 
 the greatest caution. The serum treatment is of uncertain value. 
 
638 DISEASES OF TEE DIGESTIVE TRACT. 
 
 The Treatment of (Dominating) Colitis. — This is much like that of 
 dysentery and includes the measures above indicated. Flushings 
 with normal salt solution, 1 per cent, tannin or 1 to 1,000 salicylic 
 acid may be employed. Tannigen and bismuth should be given freely. 
 
 The Treatment of Chronic Dyspepsia. — Treatment in institutional 
 cases begins with nursing; one wet-nurse can nurse several children. 
 Lavage of the stomach with two to three ounces of plain warm water, 
 normal salt solution or 1 per cent. Carlsbad salts solution, increases 
 the functional activity of the stomach. The extract of mix vomica 
 stimulates secretion. The food must be given in the smallest amounts 
 compatible with maintenance of weight and energy. 
 
 APPENDICITIS. 
 
 Definition. — Appendicitis, the chief abdominal malady, is an in- 
 flammation of the vermiform appendix. 
 
 History. — Fitz in 1886 drew attention to the subject and coined the 
 name. Appendicitis was previously confused with typhlitis, inflam- 
 mation of the caecum ; typhlitis is rare and the term " perityphlitis " 
 should be discarded. Our present knowledge of appendicitis is 
 largely due to the work of American surgeons, Willard Parker, who 
 first (1867) advocated operation, Sands, Bull, McBurney, Keen, 
 Senn, Murphy, Weir, Morton, White, Deaver and others. 
 
 Etiology. — 1. Predisposing Factors. — (a) The appendix, being a 
 functionless vestige of the caecum, is inherently less resistant, (b) 
 Its lumen is smallest at its ccecal end, which favors retention of for- 
 eign bodies, promotes microbic growth and decreases or suspends 
 drainage into the bowel, (c) The meso-appendix, which conveys 
 the blood to the appendix, is shorter than the appendix, which there- 
 fore curls; the blood supply is then easily altered by appendiceal 
 oedema and infiltration, (d) Foreign bodies and faecal concretions 
 may produce erosions which apparently promote microbic access and 
 therefore inflammation. In J. B. Murphy's series of 2,140 cases, 
 foreign bodies were found in about 20 per cent, and faecal concre- 
 tions in 38 per cent. J. F. Mitchell found foreign bodies in 7 per 
 cent, of 1,400 cases of appendicitis and Louis J. Mitchell in 1,600 
 autopsies found them in about 1 per cent. Foreign bodies include seeds, 
 capsules, gall-stones, pins, nails, shot, fish-bones, etc. (e) Age. — Over 
 50 per cent, occur under twenty years of age and 30 per cent, between 
 twenty and thirty. It is rare in infancy and with advancing years 
 obliteration and atrophy lessen its frequency. (/) Sex. — Males con- 
 stitute about 80 per cent, of cases ; in women it is thought that an 
 extra blood supply from the ovary lessens the results of infection, 
 though Murphy's large series shows but a slight preponderance in 
 males, (g) Other rare or disputable factors are trauma, severe 
 exertion, exposure and enteritis. 
 
 2. Bacteriology. — The colon bacillus is the most frequent cause 
 and is found in 80 per cent, of cases, though probably in some of them 
 
APPENDICITIS. 639 
 
 it has overgrown some other causal organism. Next is the staphylo- 
 coccus, the virulent streptococcus, then the pneumococcus, proteus 
 and pyocyaneus. Less frequently the typhoid, tubercle, influenza or 
 actinomycosis organism is found; of the last 150 cases exist; Fitz 
 found 5 typhoid perforations of the appendix and Fenwick in a col- 
 lection of 2,000 cases of phthisis recorded 56 per cent, of tuberculous 
 ulcerations in the bowel, of which but 0.8 per cent, was in the 
 appendix. 
 
 Symptomatology and Pathology. — 1. The Early Clinical Course. 
 - — The onset is precipitate, without prodromes in most cases, and is 
 characterized by four main symptoms upon the sequence of which 
 Murphy has placed especial stress, (a) Sudden severe abdominal 
 pain, the intensity of which ranges between colic and agony, is due to 
 acute retention within the appendix caused by the occlusion of the 
 csecal end. It is felt over the right lower abdominal quadrant or over 
 the pit of the stomach, and may even radiate along the genitocrural 
 nerve to the testis, which is sometimes retracted. Reaching its 
 greatest severity in a few hours, the pain persists until the pressure 
 of the pus is relieved by drainage into the bowel, perforation or gan- 
 grene. Sudden relief from pain is ominous, as it often indicates 
 gangrene. (&) Nausea and vomiting result reflexly from occlusion 
 and follow within a few hours after the pain, (c) Abdominal tender- 
 ness soon develops, is rather general at first, and is often associated 
 with a cutaneous hyperesthesia (Sherrin), which covers like half a 
 girdle the right lower abdomen from the spine to the mid-line. The 
 right rectus muscle resists palpation. A little later the general ten- 
 derness disappears, leaving well-localized tenderness over the appen- 
 dix ; McBurneys point is in the right lower quadrant of the abdomen 
 (about two inches from the anterior superior iliac spine in a line 
 drawn between it and the navel) or a little below it in adults or 
 above it in children; less frequently the tender point may be found 
 in the loin, in the pelvis (5 per cent.), near the bladder, rectum or 
 uterus on rectal or vaginal examination, near the gall-bladder or very 
 exceptionally on the left side of the abdomen or in hernial sacs, all of 
 which correspond to possible variations in appendicular location. 
 Pressure with the hand on the left half of the abdomen causes pain 
 in the right side when the pressure is relieved. Palpation must be 
 made gently, lest rupture occur. In the early stage of appendicitis 
 it sometimes seems as though a tumor could be felt, which is usually 
 only the contracting rectus, (d) Fever is almost invariably present 
 in the early stage of acute forms, and develops in a few hours to a 
 day, according to the severity of the infection. An initial chill is 
 rare. The temperature rises to 101°— 102° or higher in some virulent 
 types or in children. It signifies septic absorption and may cease 
 suddenly in gangrene or gradually in rupture and may slowly recur 
 from extension. It does not signify cessation or absence of pus 
 formation, as abscess or peritonitis may co-exist with low tempera- 
 ture. The pulse usually follows the temperature curve, though the 
 
640 
 
 DISEASES OF THE DIGESTIVE TRACT. 
 
 author has seen it remain normal in cases of early gangrene. The 
 leukocyte count runs parallel with the fever, and often — though not 
 always — measures the sepsis; leukocytosis may amount to 12,000, 
 25,000 or even 50,000, but no confident reliance can be placed on its 
 
 Fig. 37. 
 
 Fig. 41. 
 
 Fig. 43. 
 
 Figs. 37 and 38. — Obliterating appendicitis. Fig. 39. — Obliterating appendicitis, 
 with distal enlargement. Fig. 40. — Obliterating appendicitis (at R) witb calculi (C). 
 Fig. 41. — Appendicitis with bending, obliteration and distal distention. Fig. 42. — 
 Appendicitis with curling around its mesentery. Fig. 43. — Strangulation by a band. 
 Fig. 44. — Calculous obstruction. (Dieulafoy.) 
 
 absence as an assuring sign nor on its presence as an indication for 
 operation. Constipation is usual. The urine is often febrile, scanty 
 and usually contains indican and sometimes albumin; dysuria may 
 result from appendicitis in the pelvis. Profuse bowel hemorrhage 
 has been recorded. In Dieulafoy's toxemic type toxaemia may ob- 
 scure the local symptoms. 
 
 2. The Later Clinical Course. — (a) The inflammation subsides 
 gradually by drainage into the caecum. Though the inflammation 
 
APPENDICITIS. 641 
 
 may be very circumscribed, the appendix rarely returns to a com- 
 pletely normal condition ; it suffers necrosis and ulceration from mi- 
 crobes, faecal concretions or both, which leave the appendix infiltrated, 
 thickened, rigid and more or less constricted at one or more points. 
 The mucous membrane may be wholly substituted by granulation 
 tissue. The lumen is obliterated in appendicitis obliterans. Occlu- 
 sion at its intestinal end causes a cyst-like swelling as large as the 
 thumb or even as a sausage. Adhesions to the abdominal wall and 
 gut are common, (b) After a few days a localized peritonitic abscess 
 frequently forms, usually over the psoas muscle at the angle between 
 the ileum and caecum, but occasionally in some unusual localization of 
 the appendix (v. s. under Pain). The appendix perforates, gener- 
 ally near its mesenteric attachment, from necrosis or gangrene, and 
 a localized abscess of yellow, thick, offensive pus forms ; when the 
 abscess is well demarked, the pain, fever and pulse rate decrease. A 
 well-defined tumor may develop, over which no peristalsis occurs; 
 dulness or tympany is elicited according to the depth of the tumor or 
 its fluid or gaseous contents ; fluctuation is present only in very large 
 abscesses; the tumor in infections due to the colon bacillus consists 
 more largely of infiltration than of pus. In the incised abscess the 
 green or black and totally gangrenous appendix may be seen ; it may 
 be difficult to find. The abscess may form without any symptoms 
 other than those of the onset. The result of the abscess may vary 
 greatly: (i) it may rupture into the intestine which forms its wall 
 (2 per cent.), and possibly carry the appendix with it; (ii) it may 
 rupture into the urinary tract, of which cases nearly one-half are 
 fatal ; (iii) it may cause thrombophlebitis purulenta, and any or all 
 of the manifestations of septicopyemia may follow, as secondary 
 fever, suppurative pylephlebitis, liver abscess, subphrenic abscess 
 and vomiting of blood; (iv) it may rupture into the retroperitoneal 
 tissue, which is followed by high temperature; and all possible ex- 
 tensions may occur, as into the groin, scrotum, pelvis, pararenal tis- 
 sue, pleura (84 per cent, are right-sided), lung, gluteal region, back, 
 hip joint, etc. ; and (v) it may rupture into the free peritoneal cavity. 
 (c) The third cardinal issue is diffuse septic peritonitis, which is 
 recognized by all its unfortunate and unmistakable symptoms ; these 
 are a sudden fall of temperature followed by a secondary fever, dif- 
 fuse replacing localized tenderness and rigidity, leukocytosis, persis- 
 tent projectile vomiting, rapid pulse, Hippocratic facies and col- 
 lapse from profound intoxication. It most often follows the local- 
 ized abscess, but may occur directly after a gangrene which is so 
 sudden as to allow of no protective adhesions, or after perforation 
 from a foreign body in the appendix without infection; the latter 
 occurs in 1 per cent, of cases (Murphy). This writer distinguishes 
 variations due to the type of infecting organism: (i) The staphylo- 
 coccic peritonitis which generally produces but little pus, or, if any, a 
 seropurulent fluid; it forms a plastic lymph which prevents absorp- 
 tion for a short time, but, as the peritoneum becomes abraded, leads to 
 41 
 
642 DISEASES OF THE DIGESTIVE TRACT. 
 
 intoxication ; this is evidenced by collapse, an anxious expression and 
 diarrhoea, (ii) The streptococcic form, which produces no pus, but 
 causes a granular, blistered, dry peritonitis, which is quickly followed 
 by rapid pulse, talkative delirium and tympany, (iii) Colon infec- 
 tion, which produces an abundant, creamy, thick, offensive pus and 
 slowly causes death after great depression, low, muttering delirium, 
 somnolence and low arterial pressure. 
 
 3. The More Eemote Sequences. — Intestinal strangulation by 
 adhesions, deformity and traction from chronic changes in the ap- 
 pendix and intractable intestinal, neurasthenic and nutritional dis- 
 turbances may result from chronic appendicitis. 
 
 In children the onset is usually very abrupt; the vomiting is re- 
 peated, the pain is greater, the appendix is more often palpable, 
 diarrhoea is more common and the percentage of diffuse peritonitis 
 is greater than in adults, because the omentum is less able to en- 
 velop the appendix. In aged persons gangrene is more frequent than 
 at other ages. 
 
 Diagnosis. — The diagnosis depends on the four cardinal symptoms 
 of onset, in the sequence named; viz., pain, nausea or vomiting, 
 abdominal tenderness and temperature (Murphy), followed by leu- 
 kocytosis and the other secondary manifestations and by the develop- 
 ments of the later course, as circumscribed abscess or diffuse peri- 
 tonitis. If all these symptoms are considered separately an analysis 
 is necessary of every abdominal lesion causing pain alone, vomiting 
 alone, temperature, sensitiveness, abscess, tumor, disease in the right 
 lower abdominal quadrant, perforation or peritonitis. Acute typh- 
 litis is very rare and should seldom receive consideration. 
 
 Pain occurs in gall-stones, renal calculi, tabetic crises, internal 
 incarcerated hernias, epigastric hernia, intussusception, gastric or 
 duodenal ulcer, tuberculous peritonitis, stone or torsion of the ureter, 
 Dietl's crisis in floating kidney, uraemia, colica mucosa, acute pan- 
 creatitis, the crises of angioneurotic oedema, pelvic peritonitis, rupture 
 of extra-uterine pregnancy, twisted pedicles (ovarian tumors), 
 pyosalpinx, dysmenorrhoea and the reflected pain of vertebral dis- 
 sease, pleurisy and pneumonia. Fever in typhoid precedes the local 
 symptoms. These affections, as well as gravitating abscesses, infected 
 urachus, lesions of the abdominal wall, cancer, hysteria and hypo- 
 chondriacal fear of appendicitis, are almost invariably excluded by 
 regarding the sequence of symptoms and by a careful general exami- 
 nation. In appendicitis larvata (Ewald), pain is slight or absent, 
 and there may be diarrhoea ; the thickened sensitive appendix is often 
 palpable ; appendicitis, chronic ah initio, causes gastric dyspepsia but, 
 more often, flatulency, constipation alternating with diarrhoea and a 
 dragging discomfort in the right lower abdomen. 
 
 Prognosis. — The prognosis is most uncertain, because (a) there is 
 no safe criterion for early diagnosis of the type; (b) the symptoms 
 and signs are not proportionate to the actual lesions — e. g., light cases 
 clinically may prove to be the most severe anatomically; (c) apparent 
 
APPENDICITIS. 643 
 
 improvement to the experienced observer is often only the onset of 
 alarming complications, which are in reality less complications than 
 essential parts of the disease ; Dieulafoy well calls them " treacherous 
 lulls " (accalmies traitresses) ; (d) though appendicitis often subsides 
 clinically, recovery is seldom complete anatomically, whence recur- 
 rence (chronic, relapsing or residual appendicitis) often occurs in a 
 more severe form in 24 per cent. (Hawkins) to 44 per cent, of cases 
 (Fitz). 
 
 Treatment. — Cases of appendicitis may recover, temporarily (70 to 
 80 per cent, or perhaps more), but it is impossible to predict which 
 ones will do so. Personal prejudice was formerly against early, 
 frequent or universal operative treatment as advocated by many, as 
 Deaver, Murphy, Holmes and others. After testing and seeing tested 
 the so-called medical treatment, consisting of rest, starvation, laxa- 
 tives and other placebos, and seeing gangrene, peritonitis with low 
 temperature and even death occur in " mild " cases, the conviction 
 was inevitable that appendicitis is always surgical, regardless of type, 
 time or tendencies, and a surgeon should at once be associated with 
 the practitioner in every case. Medical treatment is out of date and 
 recovery under it is due to good fortune alone. The so-called indica- 
 tions for operation are too often signs of irreparable damage. Of 
 course the results of operation depend upon the experience of the 
 operator. Though this is not the place for discussion of technique or 
 of the indication for simple drainage or appendicectomy, the follow- 
 ing points may be given: (a) Early operation within one to two days 
 of onset is attended by the least danger, (b) Many operators dislike 
 to operate between the second and eighth days or other arbitrary 
 limits, but this position implies that the clinician can diagnosticate 
 the anatomical changes which are present ; gangrene, thrombophlebitis, 
 imminent rupture, etc., cannot be excluded; in this period simple 
 drainage is indicated — possibly, too, appendicectomy, if the appendix 
 obtrudes in the field of incision; lavage, exploration and protracted 
 operation are dangerous, (c) In later cases, when there is apparent 
 regression, treatment may be more conservative; complete demarka- 
 tion may be waited for, but even in such cases thrombophlebitis or 
 rupture into the general peritoneum may intervene, (d) In cases of 
 diffuse peritonitis incision and simple drainage are indicated unless 
 the patient is moribund. The patient is placed in the semi-sitting 
 posture (Fowler) and given frequent or constant normal salt enemas 
 (Murphy). Many cases recover (see Peritonitis), (e) After the 
 attack — Murphy's reasons for operation are : " First, after an attack 
 of appendicitis the patient is prone to recurrence; second, upward 
 of 60 per cent, of the cases operated on by me in the intermediate 
 stage had had more than one attack; third, in the large proportion 
 of the cases in which there was only incision and drainage of the 
 abscess (which was a procedure frequently recorded by me in my 
 first three hundred cases) the attacks recurred; fourth, the adhesions, 
 flexions and stenoses, following a primary attack, favor a recurrence j 
 
644 DISEASES OF TEE DIGESTIVE TRACT. 
 
 fifth, even if there were no danger of recurrence of the inflammatory 
 conditions, the adhesions, fixations, stenoses, flexions and retentions 
 in the appendix produce sufficient disturbance of the digestive tract 
 to necessitate operation; sixth, recurrences are as dangerous as pri- 
 mary attacks ; seventh, the appendix can be removed without danger." 
 Dennis states that under medical treatment the mortality is 16 per 
 cent., relapses occur in 30 per cent, and diffuse peritonitis causes 
 100 per cent, mortality; under surgical treatment 4 per cent, die, 
 there are no relapses, and 30 per cent, of cases of peritonitis recover. 
 
 INTESTINAL OBSTRUCTION. 
 
 Etiology. — Obstruction of the bowels may be due: (I) to intus- 
 susception, the most frequent cause, which is due to invagination of 
 one part of the bowel into another; (II) to strangulation, which 
 ranks next; (III) to twists (volvulus) and knots; (IV) to strictures ; 
 (V) to tumors; (VI) to foreign bodies; (VII) to dynamic (para- 
 lytic and spastic) obstruction. The figures quoted below are from 
 Fitz's series of 295 cases, Leichtenstern's 1,134 cases and Treves' 
 series. 
 
 I. Intussusception (Invagination). — This is the most frequent 
 form of acute obstruction (40 per cent,). The external part (the 
 intussuscipiens or vagina) receives into it the intestine just above 
 (the intussusceptum or invaginatum). The actual cause is unknown ; 
 it develops in perfect health, in various acute and chronic affections, 
 in tumors and strictures of the gut, in diarrhoea and other functional 
 and intestinal disorders and in contusion. Two theories are ad- 
 vanced: (a) that the gut is spastically contracted (E"othnagel) and 
 therefore enters the gut below, and (b) that the gut below is paretic 
 (Leichtenstern). The author saw, with Dr. Walls, a marked case in 
 lead-colic, which recovered under operation. In acute intussusception 
 50 per cent, occur under ten years of age (Leichtenstern and Fitz) ; 
 Wiggin in 103 cases found 50 per cent, in the fourth, fifth and sixth 
 months of life. In chronic intussusception 50 per cent, occur in 
 persons between twenty and forty years of age; 66 per cent, occur in 
 males. Pathologically only the vital form is of clinical importance, 
 in which the mesentery and its vessels are also invaginated; the 
 " agonal " form occurs during the death agony, chiefly in children, in 
 the small gut, is often multiple and does not involve the mesentery. 
 The vital form is usually single, descending (in 99 per cent.) and 
 complete ; incomplete forms may result from polyps or other tumors, 
 usually benign, which drag down the gut. There are three main 
 forms : (a) the enteric, the small gut invaginating into the small gut, 
 30 per cent,; (b) the ileocecal, the small gut entering the large gut, 
 52 per cent. Leichtenstern (75 per cent. Fitz and 89 per cent. 
 Wiggin) ; and (c) the colonic, the large gut invaginating into the 
 large gut (18 per cent.), which includes the colon invaginating into 
 the rectum; in rare cases $ Meckel's diverticulum may invagina|;e 
 into the small gut, 
 
INTESTINAL OBSTRUCTION. 645 
 
 Symptoms. — (a) There is sudden, severe, reflex pain, which is 
 usually umbilical in children but sometimes occurs elsewhere in 
 adults, is continuous or intermittent, or paroxysmal in chronic forms 
 of intussusception. (6) Early reflex vomiting may occur in children, 
 though in adults it is less frequent than in other forms of obstruction ; 
 the later vomiting is seldom faecal (13 per cent., Fitz) ; vomiting is 
 more marked in high than in low invagination and depends consid- 
 erably on the degree of mesenteric invagination and its necessary 
 vascular disturbance, (c) The stools are characteristic, showing 
 blood and mucus in 80 per cent, of acute and in 50 per cent, of 
 chronic cases; in 108 cases collected by Hare and Martin blood was 
 present in the stools in 104; the movements may not stop at once 
 but only after several evacuations. Their evacuation is attended by 
 severe tenesmus (50 per cent.), especially in the young, (d) A 
 sausage- or egg-like movable firm tumor (50 per cent. Leichtenstern, 
 61 per cent. Fitz) may be palpated, most often over the ascending or 
 transverse colon, sometimes by the rectum or vagina, and is occa- 
 sionally visible at the anus, where it has been mistaken for prolapse 
 or polyp and extirpated. It is most common in children and in the 
 ileocecal form. According to Treves it is nearly always to be felt 
 during paroxysms of pain, (e) Meteorism and a depression in the 
 right flank or ileocecal region are infrequent. 
 
 Clubbe's description is excellent : " The very sudden onset in a 
 previously healthy baby is a peculiarity of intussusception. The 
 child is seized suddenly, screams, turns pale, vomits and in -a short 
 time seems to recover itself, only to cry again at intervals as if in 
 pain. Soon after the first scream it may pass a normal motion. In 
 from two to ten hours, in the majority of cases (97 per cent.), blood 
 will be passed by rectum. The mass, which varies much in size and 
 position, can nearly always be made out by careful palpation when 
 the child is under an anaesthetic. The child may not look ill, its 
 pulse rate may be hardly raised and its temperature may be normal." 
 
 Issues. — Peritonitis results in 50 per cent, of acute and nearly 100 
 per cent, of chronic cases; perforation occurs in chronic (15 per 
 cent.) more often than in acute cases ; sloughing off of the gangrenous 
 bowel occurs in 42 per cent, of adult cases, but seldom in children ; 
 in Cruveilhier's case three yards of dead gut were discharged. Spon- 
 taneous reposition and fistula are very uncommon. 
 
 II. Strangulation. — This causes 35 per cent, of intestinal obstruc- 
 tions. Its mechanisms are innumerable ; it is generally due to bands 
 or isolated peritonitic adhesions; Meckel's diverticulum, the remains 
 of the omphalomesenteric duct, which lies within a yard of the ileo- 
 caecal valve and is sometimes continuous as a cord to the navel, has 
 caused strangulation in 183 cases (Hilgenreiner, 1902) ; adhesions 
 from previous peritonitis, appendicitis or salpingitis ; omental strands 
 forming bands under which the gut is caught ; holding of the gut in 
 abnormal positions ; and binding of coils to each other. Incarceration 
 may occur when there are congenital or acquired orifices and clefts 
 
646 DISEASES OF THE DIGESTIVE TUACT. 
 
 in the omentum or mesentery or under the suspensory ligament of the 
 liver, ligamentum teres or ligamentum latum uteri. Hernias in- 
 clude strangulations in the femoral, inguinal, umbilical locations or 
 in the less frequent types, as the obturator, sciatic, lumbar, intersig- 
 moid, retrocecal (Rieux), foramen of Winslow, duodenojejunal 
 (Treitz's retroperitoneal form) or diaphragmatic. Seventy per cent, 
 of cases occur in males, 40 per cent, between fifteen and thirty years 
 of age, 90 per cent, in the small intestine, 67 per cent, in the right 
 iliac fossa and 83 per cent, in the lower abdomen (Fitz). 
 
 Symptoms. — The symptoms are usually acute and urgent, (a) 
 Early reflex vomiting, from shock, voiding in succession gastric con- 
 tents, bile and faecal matter which usually consists of yellow, brown 
 or black fluid or very rarely solid faeces, is strongly indicative of 
 organic strangulation; vomiting usually lasts from the beginning to 
 the end of the disease, (b) There is early severe reflex pain, which 
 is greatest at the navel and lasts until collapse, peritonitis or par- 
 alysis of the gut develops, (c) Collapse, with Hippocratic expres- 
 sion, weak pulse and hurried breathing, results reflexly and may 
 occur early from the disturbed local circulation in the gut or later 
 from peritonitis, (d) Complete sudden stoppage of the bowels may 
 result, in which no faeces or flatus can pass ; some faeces from the 
 lower gut may pass after enemata, but no gas. Meteorism of two 
 kinds occurs — (i) the static variety in which gas accumulates in 
 loops above the obstruction and (ii) the local variety, in which the 
 strangulated loop becomes distended, because its circulation is im- 
 paired ; it may be seen or felt as an immovable tense mass, showing no 
 peristalsis and corresponding to the thick, oedematous, hemorrhagically 
 infiltrated and finally gangrenous gut. (e) The urine is decreased, 
 because of the vomiting, lack of food and nervous collapse; it con- 
 tains indican if the obstruction lies in the small gut. Sometimes 
 casts, albumin or even hemorrhagic nephritis are observed. (/) 
 Strangulation in some cases may be found in the usual or accessible 
 hernia locations. 
 
 Diaphragmatic hernia was first diagnosticated by Lichtenstern 
 (1874); it is left-sided in 88 per cent., is congenital or acquired 
 (from trauma especially) and is recognized in but 3 per cent., of the 
 reported cases; it closely resembles pneumothorax (q. v.). 
 
 In strangulation and other acute obstructions (v. i.) the mucosa in 
 the occluded area may become eroded, more easily penetrated by 
 bacteria, ulcerated and hemorrhagically infarcted, leading to necrosis, 
 perforation and peritonitis. 
 
 III. Twists (Volvulus) ard Knots. — Volvulus is a twisting of the 
 intestine around its mesenteric axis ; twisting of the gut on itself is 
 rare; volvulus occurs in 14 per cent, of obstructions (Fitz) ; 68 per 
 cent, of the cases are males, usually between forty and sixty years 
 old ; it occurs in the sigmoid flexure in 66 per cent., less frequently 
 in the caecum (75 cases collected in 1905 by Corner and Sargent), 
 colon ascendens and small gut, and then especially when the large 
 
INTESTINAL OBSTRUCTION. 647 
 
 and small intestines have a small mesentery; only nine cases of 
 volvulus of the stomach are recorded. The predisposing causes of 
 volvulus are a vegetable diet (said to explain its frequency in Rus- 
 sian peasants), persistent constipation, a long sigmoid flexure with 
 a long narrow mesentery, and mesenteritis. The twist may occur 
 through 180 to 360 degrees or more. 
 
 Symptoms. — The symptoms closely resemble those of the forms 
 described, especially when knots form between two coils of the small 
 intestine. In volvulus of the sigmoid there is pain and vomiting, 
 which is less marked than in strangulation or invagination and is 
 seldom faecal; the local meteorism is more pronounced than in any 
 other type of obstruction, for the huge coil of the obstructed gut 
 passes upward, possibly to the right, in extreme cases pushes up the 
 diaphragm to the third or fourth ribs and seldom shows any peristalsis, 
 which its disturbed circulation prevents. But little water can be in- 
 jected into the rectum. Hemorrhagic peritoneal exudate is common. 
 
 IV. Strictures ( Enter ostenosis). — Strictures more often cause 
 chronic than acute obstruction, (a) Congenital stricture is even 
 rarer than the rare congenital atresia, of which Helmholz (1907) 
 collected 199 cases in the small bowel, (b) Cicatricial stricture 
 results from healing of tuberculous, syphilitic, dysenteric, duodenal 
 and very rarely typhoid ulcers. In 1904 Arbuson collated 129 cases 
 of tuberculous stricture, (c) Annular cancer, (d) compression by 
 various organs or tumors (80 per cent, of which are pelvic) and (e) 
 traction are other causes. (/) Inflammatory hypertrophy of the 
 mucosa and muscularis is exceedingly uncommon. 
 
 Symptoms. — The symptoms are those of chronic obstruction and 
 vary with the location of the stenosis. (1) Stenosis of the small in- 
 testine may occur (a) above the duodenal papilla, as a result of gall- 
 stones or duodenal ulcer and resembles pyloric stenosis, from which 
 differentiation is practically impossible; it may occur (b) in the 
 duodenum below the papilla, as a result of gall-bladder adhesions, 
 duodenal ulcer, tumors or pancreatic disease (pancreatitis, tumor, 
 cyst) ; icterus is frequent, as well as vomiting of bile and pancreatic 
 juice which digests starch and fibrin in an alkaline medium; other 
 symptoms are dilatation of the stomach, pale stools, very slight ab- 
 dominal meteorism, except over the epigastrium, and the absence of 
 indicanuria. (c) Jejuno-ileac stricture may result from healed 
 ulcers, inflammation in replaced hernias and adhesions to the internal 
 genitalia ; the ulcer stricture may be multiple, as many as twelve 
 being recorded in one case; it is remarkable that extreme stenosis 
 may cause no symptoms. There is constipation, which sometimes 
 alternates with diarrhoea, colic, meteorism and visible palpable peri- 
 stalsis, causing " intestinal stiffness" (Nothnagel) until the obstruc- 
 tion is finally overcome by the hypertrophied muscle above the stric- 
 ture, when a gurgling sound is sometimes heard. The colon is col- 
 lapsed. (2) Stricture of the large gut is marked by constipation, 
 which is significant when it develops rapidly in a person not pre- 
 
648 DISEASES OF TEE DIGESTIVE TRACT. 
 
 viously constipated or when cathartics have no effect in constipated 
 individuals ; by paroxysmal or colicky pain, even more than in stric- 
 ture of the small gut, because the stools are harder; eventually by 
 nausea and vomiting, which are successively gastric, bilious and 
 stercoraceous ; by meteorism along the colon and in the lumbar region 
 behind, which is usually dull; by increased, even tetanic, peristalsis 
 in the intestinal coils above the stricture, which possesses a distinct 
 localizing value; and by the evacuations which may be ribbon-like 
 or sheep-stools; these are overestimated diagnostically, for they may 
 occur in tumors, starvation, colica mucosa and spastic constipation. 
 
 V. Tumors. — (See page 651.) 
 
 VI. Foreign Bodies. — Foreign bodies caused obstruction in 12 per 
 cent, of Fitz's series, (a) Gall-stones — of which 250 obstruction 
 cases are on record — lodge chiefly in the upper duodenum or lower 
 ileum, ulcerate through the gall-bladder into the duodenum or less 
 often through the colon, or compress the duodenum through a dilated 
 pouch of the cystic duct. In a surprisingly small per cent, is there a 
 history of colic (19 per cent.) or of icterus. Collapse is usually not 
 marked, a tumor is seldom felt and the constipation is often but rela- 
 tive; indeed, diarrhoea may occur, (b) F cecal masses are far more 
 common than statistics show and form the chief obstruction of the 
 large gut. The writer saw absolute obstruction develop after a 
 Thanksgiving dinner ; there was faecal vomiting and severe collapse ; 
 a mass of not particularly hard food, measuring two inches in 
 diameter, was found ; recovery occurred, though the bowel was partly 
 necrotic. They are found especially in the sigmoid (see Constipa- 
 tion), (c) Enteroliths are not common. They form slowly of 
 phosphates, usually with an organic nucleus; sometimes they are 
 constituted of bismuth, chalk, iron or magnesia. They measure an 
 inch to nine inches in diameter and in one instance an enterolith 
 weighed four pounds. Though most common in the large intestine, 
 they may develop in diverticula of the small intestine, (d) Hair 
 tumors, twisted masses of ascarides, fruit seeds, oatmeal husks (es- 
 pecially in Scotland), stones and foreign bodies (in children or 
 insane subjects), are possible causes. 
 
 VII. Dynamic Ileus. — The above causes are mechanical. Another 
 form of acute obstruction is distinguished, namely, dynamic ileus 
 (paralytic or spastic obstruction). Under this topic may be included 
 obstruction following mesenteric embolism, trauma, abdominal op- 
 erations or inflammation in an undescended testicle; it is largely 
 associated with acute peritonitis. Spasmodic obstruction may de- 
 velop in rare cases without cause, or in neurotics, in gall-stone oc- 
 clusion, ulceration and intestinal crises of tabes. It rarelv produces 
 faecal vomiting; Bregmann (1901) found in the literature 20 cases 
 of hysterical ileus. 
 
 Diagnosis of Intestinal Obstruction. — 1. Of the Fact of Obstruc- 
 tion— The symptoms are generally unmistakable and consist of con- 
 stipation, cessation of flatus, distention, particularly the local form, 
 
INTESTINAL OBSTRUCTION. 649 
 
 compensatory peristalsis and frequently general reaction (collapse). 
 The hernial sites, the rectum and the vagina must always be carefully 
 examined. 
 
 2. Of the Location. — The uncertainties of diagnosis of location 
 are manifold, but the following table emphasizes the leading criteria : 
 
 Obstruction of the Small. vs. Of the Large Intestine. 
 
 General Condition — Earlier and more Later and less impressed, 
 profoundly impressed (reflexly) by 
 toxaemia and peritonitis. 
 
 Symptoms more marked, more stormy Signs more marked, as meteorism along 
 onset, more vomiting (both reflex colon (later becoming general), less 
 
 and faecal), more pain. water can be injected, more peristal- 
 
 tic effort and palpable rigid coils, 
 more results by rectal or vaginal ex- 
 amination, more tenesmus. 
 
 Indieanuria — Develops early, and to Develops later or not at all (also pres- 
 marked degree. ent in cancer and peritonitis). 
 
 Urine — Much decreased. Little decreased. 
 
 3. Of its Nature. — Only the broadest probabilities may be con- 
 sidered, (a) It is practically impossible to recognize obstruction by 
 bands, adhesions, Meckel's diverticulum, clefts and internal hernias 
 (except diaphragmatic), (b) Invagination is not only the most fre- 
 quent but also the most characteristic form, because of its sudden 
 onset (in children), severe intermittent pain, tumor, bloody stool 
 (very rare in hernias replaced by operation or taxis, in strangulation, 
 volvulus or gall-stones), tenesmus, results of rectal palpation and the 
 exfoliation of dead intestine, (c) Strangulation is next in frequency 
 and is differentiated from coprostasis, stone occlusion, compression, 
 stenosis and tumors by its more marked and earlier collapse, more 
 severe initial pain and vomiting, greater local meteorism and more 
 frequent hemorrhagic peritoneal effusion. (d) Volvulus is sug- 
 gested by the advanced age of the patient, constipation, slower onset 
 and course, infrequent faecal vomiting and the meteorism, which is 
 greater than in any other form and is accompanied by little peri- 
 stalsis. The small amount of fluid which can be injected, the 
 hemorrhagic peritoneal fluid, tenesmus and slightness, lateness or 
 absence of indieanuria are also suggestive, (e) Gall-stones often give 
 no positive symptoms ; in some instances the lack of shock, of in- 
 creased pulse and of meteorism and the paradoxical intermittent 
 release of flatus and faeces may be suggestive. In no other type is 
 faecal vomiting, combined with the passage of flatus and faeces, so 
 common. 
 
 4. Differentiation. — Confusion with flatulent colic, gall- or 
 kidney-stones and incarceration of the kidney, uterus or testis is 
 avoided because in intestinal obstruction there is rapid stoppage of 
 the bowels ; the author saw one case of lead-colic with intussusception. 
 The possibility of acute pancreatitis must be considered. Peritonitis 
 
650 DISEASES OF THE DIGESTIVE TBACT. 
 
 is characterized by early fever, early diffuse tenderness, meteorism, 
 cessation of peristalsis, board-like abdominal rigidity, often by fluid 
 in the peritoneum, late collapse, late faecal vomiting, later and less 
 complete obstruction and by frequent singultus. 
 
 Treatment. — In stenosis, which is typified by ulcer cicatrices, a con- 
 centrated fluid or semi-fluid diet should be given and thorough masti- 
 cation of solid food and avoidance of coarse food or food with chaff, 
 skins, stone or gristle should be insisted on. Cathartics are to be 
 avoided and the bowels should be moved with enemata of oil or water. 
 
 Thiosinamin has been recommended to dissolve cicatricial stenosis : 
 
 fy Thiosinamin 3j. 
 
 Glycerini 5iij. 
 
 Aleoholis diluti 3vj. 
 
 M. et S. — Inject 8 to 15 drops subcutaneously every 2 to 3 days. 
 
 Operative measures may be instituted for foreign bodies or for 
 malignancy, in which case the outlook is best in lesions of the colon 
 and ileum. 
 
 1. Medical Treatment of Obstruction. — In every case the 
 physician should at once divide the responsibility with a surgeon. 
 In acute cases, especially in the small intestines, food causes aggrava- 
 tion. Early gastric lavage affords some transitory relief. The possi- 
 bility of chronic fcecal obstruction should be first eliminated by 
 colonic flushings, given with the patient's head down or body inverted ; 
 hard desiccated fseces must be dug out with the finger, with frequent 
 enemata to bring away fragments; in colonic injections a soft tube 
 cannot be passed easily above the sigmoid and hard tubes may cause 
 perforation. High enemata and colonic inflation with air occasion- 
 ally reduce volvulus and intussusception. Laxatives, massage and 
 puncture of the gut with an exploring needle are always contra- 
 indicated. Opium is useful in the early stage to relieve shock; in 
 moderate dosage it does not produce intestinal paresis. Stimulants 
 hypodermatically are frequently indicated. The use of atropine 
 (Theden, 1788) has been recently revived, especially by Batsch 
 (1900) ; some cases are relieved by it and physostigmine. 
 
 2. Operative Treatment. — Medical treatment of strangulation, 
 intussusception or volvulus is of little value. A most convincing sta- 
 tistical argument for early operation is Naunyn's series of 288 cases, 
 in which 75 per cent, of recoveries were obtained by operation in the 
 first two days, while each successive day lowered the patient's chances 
 to 40 per cent., 30 per cent., etc. Obalinski reports 35 per cent, 
 recoveries, Treves 54 per cent, and Kocher in his earlier experience 
 38 per cent, and later 70 per cent. Much depends on the physio- 
 logical resistance of the patient. In intussusception Gibson's figures 
 give 53 per cent, as the average mortality from operation, being 39 
 per cent, for operations in the first two days and increasing with each 
 day of postponement; it was 82 per cent, in children under three 
 months of age; Eydgier's mortality in chronic forms was but 24 per 
 
INTESTINAL TUMORS. 651 
 
 cent. Forty per cent, of adults and 80 per cent, of children die under 
 medical treatment (Leichtenstern). In 100 cases of intussusception 
 in children 63 per cent, of operated recoveries are reported by Clubbe 
 (1905). Fifty- two per cent, of obstruction by gall-stones recover 
 under expectant and 33 per cent, under surgical treatment. For 
 the indications and technique of resection, anastomosis, enterostomy, 
 colostomy, etc., reference should be made to surgical treatises. 
 
 . INTESTINAL TUMORS. 
 
 Carcinoma is the only neoplasm of clinical importance ; it consti- 
 tutes 22 per cent, of all cancers. Its etiology is obscure. Trauma is 
 seemingly an occasional factor and previous ulceration is predis- 
 posing. It is most frequent in males over forty years of age ; accord- 
 ing to Maydl, 17 per cent, occur in persons between thirty and forty 
 and 14 per cent, in those under thirty years of age. 
 
 Pathology. — According to Leube, 80 per cent, occur in the rectum, 
 15 per cent, in the csecum and colon and 5 per cent, in the small in- 
 testine. Hausmann, in 268 cancers of the bowel (excluding the rec- 
 tum), found 91 per cent, in the large and 9 per cent, in the small 
 bowel; if figured more in detail, 37 per cent, occur in the sigmoid, 
 18 per cent, in the csecum, 11 in the descending colon, 9 in the trans- 
 verse and 8 per cent, in the ascending colon, 8 per cent, in the ileum, 
 4 in the splenic and 3 in the hepatic flexure and 2 per cent, in the 
 jejunum. Kanzler (1906) found in the literature only twenty-five 
 cases of cancer in the jejunum and ileum (i. e., in the small intes- 
 tine exclusive of the duodenal and ileocecal regions). The literature 
 records but 53 duodenal carcinomata. The sigmoid, splenic and 
 hepatic flexures are especially predisposed, probably because these 
 sites are more fixed and exposed to irritation. It is usually primary, 
 sometimes secondary by contiguity, but very rarely metastatic. 
 Originating in the intestinal glands, it is usually annular in form 
 and causes stenosis and ultimate occlusion of the bowel; it is less 
 often nodular and is very rarely diffuse and flat. Histologically it 
 may be an adenocarcinoma (especially when it occurs in the duo- 
 denum), scirrhus (in the sigmoid), medullary, cylindrical-celled (in 
 the csecum and sigmoid), colloid or flat-celled (in the rectum). Be- 
 ginning in the mucosa, early involvement of the other coats and 
 lymph vessels usually occurs, followed by later involvement of the 
 peritoneum and metastasis, especially in the liver. McWilliams 
 finds in the literature 105 appendiceal cancers. 
 
 Symptoms. — 1. Disturbance of the Intestinal Function. — (a) 
 There is usually constipation, resulting from narrowing of the in- 
 testinal lumen; it is most marked in tumors of the large intestine. 
 Ulceration frequently causes diarrhoea, (b) The stools are irregular 
 and sometimes assume peculiar forms, as band-like or sheep-like stools, 
 to which, however, undue importance has been attached, as they occur 
 in inanition, constipation, etc. (c) Blood, mucus and pus are com- 
 
652 DISEASES OF THE DIGESTIVE TRACT. 
 
 mon in the faeces, though equally frequent in other ulcerations and 
 in enteritis. The evacuations may be stinking, (d) Fragments of 
 tissue are uncommon ; they also occur in dysentery and are diagnostic 
 only when showing carcinomatous arrangement of the cells, (e) 
 Pain, due to enterostenosis, is usual; it may be sacral when due to 
 sigmoid cancer. (/) Sudden complete occlusion of the bowel may fol- 
 low previous gradual narrowing of the lumen, (g) The lower the 
 tumor in the intestinal tract the greater is the tympany and f cecal 
 retention and the purer the pus and blood (i. e., the less mixed with 
 the faeces). Above the stricture the bowel is dilated and its muscle 
 is hypertrophied (visible peristalsis), (h) Indicanuria has the same 
 significance as in intestinal obstruction. 
 
 2. Cachexia and Marasmus. — These, with the above symptoms, 
 are most suggestive. 
 
 3. Tumor. — Until a tumor is detected the symptoms described are 
 not diagnostic. It is best felt if the bowel is empty; it may be con- 
 fused with a normal contracted colon, the edge of the ileopsoas or 
 with faecal masses; it is irregularly oval in clear cases, though in 
 annular forms it escapes detection, for it merely constricts the bowel. 
 It is usually tender and is movable or immovable accordingly as the 
 bowel involved is naturally free or fixed (incomplete peritoneal in- 
 vestment), or is adherent to other structures by adhesions or exten- 
 sion by contiguity. Whether free or fixed, the tumor is generally 
 below the navel. Gas and fluid are sometimes felt or heard to escape 
 through the stenotic point and distention of the large bowel by intro- 
 duction per rectum of air or fluid may aid in localization of the 
 tumor. If the tumor grows from movable gut it may disappear and 
 reappear from time to time. When no tumor is detected by abdomi- 
 nal palpation and inspection a rectal and vaginal examination should 
 always be made. 
 
 4. Complications. — Complications may first declare the malig- 
 nancy of primarily ambiguous symptoms, as (a) icterus, especially in 
 duodenal cancer; (b) hemorrhage from the bowels; (c) rupture into 
 the bladder or vagina or into the stomach, with faecal vomiting and 
 diarrhoea from partially digested food entering the colon. 
 
 Diagnosis. — The diagnosis is often difficult, except in rectal locali- 
 zation, for latency is common and many symptoms merely indicate 
 stenosis without declaring its nature. According to Leube, differ- 
 entiation is required from other movable and immovable tumors: 
 
 1. Movable Tumors. — (a) These may be pyloric, requiring dif- 
 ferentiation from duodenal cancers ; the symptoms may be identical, 
 but icterus, the presence of free HC1, bile and pancreatic juice in the 
 stomach are aids in diagnosis, '(b) The corset liver, movable spleen 
 and kidney will be considered under those topics, (c) Omental and 
 mesenteric tumors may be confusing, but they do not produce the 
 same enterostenosis. (d) Scybala may co-exist with malignancy; the 
 repeated use of enemata and cathartics determines the diagnosis. 
 
 2. Immovable Tumors. — (a) Renal and retroperitoneal tumors 
 
INTESTINAL TUMORS. 653 
 
 lie beyond the colon, on its inflation, and rarely cause the same degree 
 of intestinal obstruction, (b) Encapsulated peritoneal exudate may 
 be difficult of diagnosis ; the author has seen two chronic appendicitic 
 abscesses in individuals over sixty years of age which were diagnos- 
 ticated as tumor, were hard on palpation, and which recovered by 
 discharging pus into the bowel, (c) Ovarian or uterine tumors are 
 less obstructive and are located more in the pelvis, (d) Localized 
 inflammatory infiltration of the intestinal wall is distinguished by its 
 regressive evolution. Bittorf, particularly, has called attention to 
 circumscribed inflammation of the sigmoid flexure and colon. 
 
 Rectal cancer should receive special consideration in diagnosis. It 
 is usually annular and when developed is rigid, frequently resembles 
 an inverted funnel, becoming narrow upward and may even resemble 
 a hard cervix uteri. The colloid form extends upward and down- 
 ward, is often tubular and causes much regional invasion. A 
 systematic rectal examination — which is unaccountably neglected 
 more often than any other simple method of physical, examination — 
 saves many lamentable errors. The early stricture may yield when 
 ulceration develops, and this usually occurs with discharge of blood, 
 often ichorous pus and sometimes malignant tissue. Pain is usually 
 but not always present, tenesmus is the rule and hemorrhoids are very 
 suggestive. Cachexia develops with great rapidity, though it is no 
 necessary symptom; the author has seen death result from acute ob- 
 struction with perfect preservation of color, nutrition and energy. 
 Intoxication symptoms, as stupor, are frequent. 
 
 Syphilitic strictures are slower and subject to greater variations; 
 tuberculous ulcers are flatter, softer and more undermined. 
 
 Cancer in any part of the bowel cannot be clinically differentiated 
 from sarcoma, of which Lecene (1904) collected 75 cases involving 
 the small bowel ; the course is more rapid and sarcomata seldom sten- 
 ose the lumen. Hellstrom found 45 lipomata and Steiner 34 myomata 
 recorded. 
 
 Prognosis. — The prognosis of all forms and locations is bad. Mar- 
 asmus, coma carcinomatosum, anasarca, thrombosis, embolism, sec- 
 ondary infections, stenosis or perforation may be the cause of death. 
 
 Treatment. — Treatment is that of enterostenosis, in regard to diet. 
 Opium must inevitably be used toward the end. Operation, either 
 palliative enterostomy, colostomy or curative enterectomy, may be 
 indicated. In 1896 Wolfler's series of resection gave a mortality of 
 54 per cent., as against a death rate of 39 per cent, in resection for 
 causes other than malignancy. Hochenegg (1902) in 194 radical 
 operations, reports a mortality of but 12 per cent, and estimates his 
 recoveries at 16 per cent. Czerny (228 operated cases, 1902) reports 
 14 per cent, of permanent recoveries. 
 
654 DISEASES OF THE DIGESTIVE TRACT. 
 
 ENTEROPTOSIS. 
 
 Enteroptosis is not a disease per se, but only a condition in which 
 the abdominal viscera "fall" or prolapse in the abdomen. ^ The 
 stomach (gastroptosis), intestine (enteroptosis), colon (coloptosis) or 
 solid viscera (splanchnoptosis), as the liver, kidney or spleen, may be 
 implicated. The condition, first described by Morgagni, is known 
 as Glenard's disease ; Glenard referred it to laxness of the hepatocolic 
 ligament. Ewald and others combat this view and explain the trans- 
 verse rigidity felt in the abdomen not as the colon, but the pancreas, 
 exposed by sinking of the intestines. Its exact explanation is still 
 disputed, though whatever causes relaxation of the abdominal wall or 
 of the intra-abdominal suspensory structures may induce. prolapse, as 
 trauma, coughing, loss of weight, pregnancy, tumors of the liver, 
 spleen or kidney, spinal deformity and corsets. Seventy-five per 
 cent, of the cases occur in women. Stiller maintains that splanch- 
 noptosis is a congenital asthenic condition whose most frequent stigma 
 is a floating tenth rib (costa fluctuans decima) ; this is found in 80 
 per cent, of cases. He also speaks of a habitus enter opt oticus, which 
 somewhat resembles the habitus phthisicus; in the normal chest the 
 vertical line drawn from the ensiform to the navel is short, compared 
 with the distance from the median line, horizontally, to the tips of the 
 floating ribs ; in the habitus enteroptoticus the vertical line is much 
 longer and the horizontal line is shorter than normal and shorter 
 compared with the vertical line; this habitus is considered a con- 
 genital predisposing cause and enteroptosis is the resulting acquired 
 disease. The tendency develops the disease when the patient's nu- 
 trition suffers. 
 
 Symptoms. — 1. Stomach Findings. — Gastroptosis is characterized 
 by falling of the organ to a lower point in the abdomen, whereby both 
 its upper and lower limits are abnormally low, the epigastrium is 
 flattened and the hypogastrium is distended. Eichhorst finds it in 
 35 per cent, of women and in 5 per cent, of men. Dilatation of the 
 stomach is excluded by finding the lesser curvature at a lower point 
 than normal, which is determined by inflation with carbon dioxide. 
 In marked gastroptosis the lesser curvature lies near the umbilicus ; 
 dilatation and gastroptosis may co-exist. The sharp angle formed 
 at the pylorus or duodenum, too, may cause difficulty in gastric 
 evacuation. Gastric symptoms may be noted, as anorexia, a sense of 
 pressure, eructations, nausea and gastric or intestinal hyperesthesia, 
 or as complications, vomiting, hyperacidity or motor insufficiency. 
 In many cases gastric and other symptoms are entirely lacking. 
 
 2. Intestinal Findings.— -Enteroptosis or coloptosis is frequently 
 found with gastroptosis. The transverse colon sinks in its central 
 segment so as to assume the form of the letter U or V. Constipation, 
 sometimes alternating with diarrhoea, is frequent. 
 
 3. Yisceeal Findings. — Floating kidney, liver and spleen will be 
 described separately ; in this connection the only necessary comment 
 
DILATATION OF TEE COLON. 655 
 
 is that floating kidney is neither cause nor effect of gastroptosis or 
 enteroptosis, but merely coordinate to some general causal factor. 
 
 4. Nervous Symptoms. — These occur in 50 per cent, of cases. 
 Many subjects are nervous, delicate, slight and irritable women. The 
 most common symptoms are depression, cephalic pressure, backache 
 and other neurasthenic manifestations. The abdominal aorta fre- 
 quently throbs with violence. The patient complains of a " falling 
 out" sensation. Emaciation, constipation and anaemia are common. 
 
 Treatment. — (a) For the neurasthenic symptoms the treatment out- 
 lined under neurasthenia (q. v.) is indicated. The diagnosis should 
 not be disclosed to the patient, for this initiates, by suggestion, a long 
 train of additional symptoms. (&) Increase in weight should be 
 sought by ample feeding and rest in bed, which indication is met by 
 the rest cure, (c) Supports to restore and maintain the viscera in 
 their normal location often give considerable and immediate relief. 
 The direction of the pressure should be upward and inward. Strips 
 of adhesive plaster are useful but uncomfortable, (d) No drugs can 
 restore tone to the lax ligaments. Strychnine may be beneficial as a 
 general and digestive tonic, (e) Operation is indicated only in cases 
 with neurasthenic symptoms. Shortening the mesentery, resecting 
 parts of the recti muscles, suture of the liver, stomach and other 
 organs to fixed tissues have been performed seemingly with success, 
 but these procedures can as yet receive no general commendation. 
 
 DILATATION OF THE COLON. 
 
 Colectasia may be classified as follows: (a) Gaseous distention, 
 which may occur in acute toxsemias. Fenwick recorded a case so 
 marked that death resulted from heart paralysis. The treatment is 
 that of tympanites (v. Typhoid and Enteritis), (b) Cases which 
 are due to obstruction by faeces, foreign bodies, volvulus, (c) The 
 so-called idiopathic colectasia, which occurs in children (in 80 per 
 cent, of cases) as a congenital lesion or in male adults over fifty 
 years. Up to 1907, 150 cases were published. It is also known as 
 Hirschsprung's disease, being first described by Hirschsprung, of 
 Copenhagen. Treves holds that it is always due to obstruction, 
 though cases without obstruction are noted, as Formad's case, in 
 which there was great hypertrophy of the muscularis without organic 
 stricture; the circumference of the colon was 30 inches and its 
 weight with the contained fasces was 47 pounds. The leading symp- 
 toms are obstinate constipation and meteorism. Of the reported 
 cases only about 25 per cent, recovered either under medical treat- 
 ment or after resection of the sigmoid or colostomy. Death results 
 from marasmus, auto-intoxication ? intestinal obstruction, perforation 
 or peritonitis, 
 
656 DISEASES OF THE DIGESTIVE TBACT. 
 
 INTESTINAL HEMORRHAGE. 
 
 Etiology. — There are five groups of causes, (a) Abnormal intesti- 
 nal contents, as hard faeces, foreign bodies, gall-stones, caustic poisons 
 or parasites, (b) Intestinal lesions, as the numerous ulcerations, 
 inflammation, invagination, volvulus and trauma, (c) General affec- 
 tions; cardiac or portal stasis, amyloid disease, infarction of the 
 mesenteric vessels, aneurysmal rupture, scurvy, uraemia and cho- 
 laemia. (d) Infections, including typhoid, dysentery, etc., and hem- 
 orrhagic exanthemata. Sepsis is a prominent factor (see Hemor- 
 rhagic Diseases of the New-Born). (e) Blood from the stomach. 
 
 Symptoms. — The symptoms are: (a) Blood in the faeces. It may be 
 obvious or " occult " — i. e., found only microscopically, chemically or 
 spectroscopically. Blood is generally present microscopically a num- 
 ber of hours before it is seen by the naked eye. It is usually mixed 
 with faeces and dark, tarry and offensive when it comes from the 
 small gut; it may coat the movements and be bright in color when 
 it comes from the lower intestine, (b) Acute anaemia may follow 
 profuse hemorrhage, evidenced by pallor, syncope, rapid heart and 
 slight febrile movement, (c) There are finally the symptoms of the 
 causal disease, as typhoid, cancer, etc. 
 
 Diagnosis. — The diagnosis of enterorrhagia concerns (a) the de- 
 tection of blood, which may be simulated by bismuth or blueberries, 
 but its presence is easily established by the red disks, the guaiac re- 
 action and the spectroscope; (b) the question whether the blood 
 comes from the bowel or from the mouth or stomach; (c) whether it 
 comes from the large or small gut (v. s.) ; and (d) its causes, which 
 are most often hemorrhoids, typhoid, dysentery and cancer of the 
 lower bowel. It goes without saying that no extended examination of 
 the abdomen is permissible at the time of the hemorrhage. 
 
 Prognosis and Treatment. — The prognosis and treatment are in- 
 volved in the basic lesion (v. page 51). 
 
 PILES. 
 
 Etiology. — Hemorrhoids result from (a) stasis; portal stasis oper- 
 ates through the superior hemorrhoidal and inferior mesenteric veins 
 and is more potent than cardiac stasis, which congests the middle 
 hemorrhoidal and internal iliac veins; (b) from constipation, preg- 
 nancy and other obstructive lesions, as cancer of the rectum. Accord- 
 ing to Duret, vigorous contraction of the abdominal muscles is a more 
 potent cause than constipation. Piles are most common in the fifth 
 decade of life and in men. Hemorrhoids are usually spoken of as 
 varices, but, as Reinbach has shown, they are often cavernous 
 angiomata. 
 
 Symptoms. — External piles appear as tender, painful, dusky-red or 
 purple swellings outside the sphincter ani ; they occur singly or may 
 grow in a circle around the anus; they may be soft or hard. The 
 pain produced is throbbing and niay be very severe. Inching is very 
 
DI AMERCE A. 657 
 
 common. They may bleed, waste, ulcerate or suppurate. Piles 
 which bleed are called " open " and those which do not are called 
 " blind." Internal piles occur above the sphincter, below which they 
 may prolapse and strangulate. Tenesmus, mucus secretion and dull 
 pain sometimes referred to the back and the sacro-iliac articulation, 
 may be noted. 
 
 Diagnosis. — Mere inspection is sufficient to exclude prolapse, con- 
 dylomata, papillomata, etc. The possibility of carcinoma in their 
 etiology should be borne in mind. 
 
 Treatment. — (a) General treatment should deal with the basic 
 factors. Exercise is indicated for those of sedentary habits, and 
 constipation (q. v.) should be relieved, (b) Local treatment: a small 
 injection of cold water before each movement softens the irritating 
 hard passage and constricts the piles, thereby favoring their reduction. 
 Cleanliness is of prime importance in the relief of itching, for which 
 also a 1 per cent, carbolic salve is of great value. In acutely painful 
 cases a cocaine salve is beneficial. The following formulas are astrin- 
 gent and anodyne: 
 
 ]£ Extracti opii gr. ij. 
 
 Extracti belladonnae gr. ij. 
 
 Acidi tannici 3ss. 
 
 Olei theobromatis q.s. 
 
 M. et ft. in suppositoria No. X. 
 S. — One at bedtime. 
 
 I£ Cocainge (alkaloid) gr. iij. 
 
 Iodof ormi gr. x. 
 
 Orthof ormi . '. gr. v. 
 
 Olei theobromatis q.s. 
 
 M. et ft. in suppositoria No. XII. 
 S. — One at bedtime. 
 
 They must be given with reserve, lest the opium or cocaine habit be 
 acquired. Surgical treatment is indicated when local measures fail. 
 
 DIARRHOEA. 
 
 Definition. — Increased frequency of the stools with decreased con- 
 sistence. Diarrhoea is not synonymous with intestinal catarrh, though 
 a sharp differentiation is often difficult. In some individuals two or 
 three movements a day are physiological. 
 
 Etiology. — (a) Irritation may cause diarrhoea; some cathartics, as 
 the aromatics, increase peristalsis and others, as salts, cause increased 
 transudation; diarrhoea dyspeptica is caused by intestinal or gastric 
 dyspepsia, fruits and vegetables; diarrhoea stercoralis is caused by 
 irritation from the fsecal masses; diarrhoea entozoica is caused by 
 intestinal parasites. In general there are two mechanisms: (i) the 
 stools are hurried through the bowel by increased peristalsis (irrita- 
 tion of the ganglia in the gut), in which case bile is found in them; 
 and (ii) there is increased serum transudation into the intestine when 
 42 
 
658 DISEASES OF THE DIGESTIVE TRACT. 
 
 little or no bile is found, (b) Nervous diarrhoea causes from two to 
 fifteen thin movements, containing no increased mucus ; it is attended 
 by rumbling in the bowels, peristaltic unrest and is chiefly observed 
 after mental excitement or in neurotic individuals; some cases are 
 reflex, as from uterine or dental irritation, (c) Toxic substances in 
 the blood may cause irritation of the ganglia or act upon the brain, 
 e. g., in uraemia, typhoid or sepsis. 
 
 Treatment. — Opium is the most valuable remedy in diarrhoea, ex- 
 cept in stercoral and dyspeptic types; it acts less by checking secre- 
 tion than by suspending peristalsis and mitigating pain and spasm; 
 the crude drug is superior to its alkaloids, as its absorption from 
 the bowel is slower and its effect is therefore more marked; % of 
 a grain of the extract or a dram of the camphorated tincture should 
 be given with bismuth in massive doses as in acute or chronic enteritis 
 (q. v.). Important adjuncts are local heat, which quiets irritation 
 and peristalsis, rest and a spare diet (boiled milk, eggs, toast and 
 later lean meat, as in enteritis). In nervous diarrhoea two drops of 
 Fowler's solution before meals is often advantageous. 
 
 CONSTIPATION. 
 
 Constipation (insufficient amount of faeces) is a relative term, for 
 some persons normally have movements every second or third day and 
 constipation may exist even with daily movements. 
 
 Etiology. — (1) " Physiological " constipation results from irregu- 
 larity in going to stool, as in travel, from obesity, from insufficient 
 exercise or water, from loss of fluid by sweating, from a dietary rich 
 in proteids, as milk, and from various kinds of over-medication. (2) 
 Constipation may be symptomatic of other affections, as (a) gastric 
 ulcer, cancer, dilatation or hyperacidity; (b) intestinal obstruction, 
 cancer, adhesions, catarrh, passive congestion or Glenard's enter- 
 optosis; (c) pelvic conditions, as pregnancy, ovarian or uterine dis- 
 ease or enlarged prostate; (d) infections (which stimulate the in- 
 hibitory nerves) ; (e) nervous disease, meningitis, tumors, myelitis, 
 the neuroses; (/) diabetes and old age. (3) Habitual constipation, 
 constipation per se, may be familial. It may result from insufficient 
 nervous energy (acquired or congenital) in the large intestine. 
 Atony of the intestinal muscle may result from general debility or 
 marasmus ; it is very frequently a sign of neurasthenia, hysteria or 
 hypochondriasis and results but seldom from actual disease of the 
 musculature itself — that is, from atrophy or degeneration. Nervous 
 constipation may be due to a spastic condition of the bowels. 
 
 Symptoms. — Symptoms other than constipation are often entirely 
 absent, and when present are less often general than local (anorexia, 
 coated tongue, bad taste in the month or abdominal uneasiness). 
 
 Two or three movements in one day or a movement every two or 
 three days come within physiological limits. The stools normally 
 accumulate in the sigmoid and pass every twenty-four hours into the 
 
CONSTIPATION. * 659 
 
 lower rectum, causing a desire to defecate, usually at the same hour 
 each day. The constipated stool is dry and accumulates in the 
 haustra of the colon or ampulla? of the rectum. Constipation may 
 occur even with daily movements, a small amount being retained 
 each time. It is difficult to state the quantity of the normal passage, 
 which certainly does not depend wholly on the amount of food in- 
 gested; faeces consist largely of mucus and bacteria and form even 
 during starvation. The stools may resemble sheep's dung, probably 
 due to intestinal muscular spasm. Retained faeces are usually voided 
 spontaneously in a few days with a serous diarrhoea or as scybala 
 covered with mucus which results from irritation. Considerable ob- 
 struction may cause fcecal colic, due to contraction of the gut above 
 the obstruction; there may be stercoral fever and meteorism. The 
 retained fceces may be palpable. Still more marked obstruction may 
 rarely simulate organic enterostenosis, being marked by collapse, 
 vomiting and great vesical or rectal tenesmus, which should always 
 excite suspicion. Extreme neglected cases may occasionally result 
 fatally, especially in the old, debilitated or insane or in cases in 
 which defecation causes great pain, as from fistula or piles. 
 
 Fcecal concrements (coproliths) almost always occur in the large 
 intestine. When large they may simulate tumors of the intestine, 
 omentum, kidney or spleen, from which differentiation may be pos- 
 sible only after thorough purging and flushing. They may be soft 
 and easily indented with the finger, hard, nodular and tender from 
 the bowel ulceration they incite or, far less often, tender from local- 
 ized peritonitis. The history is not conclusive, because faecal tumors 
 may develop with daily though inadequate movements. Gersuny 
 alleges that on pressure the bowel may at first seem to adhere to the 
 fsecal masses and then become free (Grersuny's sign). 
 
 General symptoms are uncommon. Nervous symptoms are causal 
 rather than sequential, as in the neurasthenic who believes he would 
 be well if his bowels would move and who has most unpleasant sen- 
 sations when they do. Vertigo, pressure in the head and mild dys- 
 pnoea are always neurotic and never coprostatic. Copropsychiatry 
 is grossly exaggerated. Intoxication is rare, but has been considered 
 causal of neuralgia, chlorosis and numerous other merely concomitant 
 conditions. The aromatic sulphates of the urine may be increased, 
 due to formation in the gut of indol, skatol and pyrocatechin. 
 
 Treatment. — Treatment of the causal factors (q. v.) is most impor- 
 tant, as of irregularity of habit, insufficient exercise or neurasthenia. 
 
 1. Diet. — (a) Coarse foods, as whole wheat, graham, rye, corn 
 meal and bran breads, act less mechanically than chemically by the 
 production of lactic or oleic acid, (b) Fruits relax the bowels, be- 
 cause of the malic, tartaric and citric acids they contain, as plums, 
 apples, peaches, pears, prunes, strawberries and grapes ; grapes some- 
 times and bananas and persimmons usually cause constipation, (c) 
 Vegetables act by the acids and gases they form; melons, sprouts, 
 cabbage, cauliflower, cucumbers, turnips, carrots, spinach, tomatoes, 
 
660 DISEASES OF THE DIGESTIVE TRACT. 
 
 asparagus, onions, cress, celery and squash should be given freely; 
 excessive amounts may cause fatigue of the bowel and constipation. 
 (d) Sweets, in so far as they do not cause indigestion, are laxative; 
 if used with discretion, sugars, syrup, candy, sauces, molasses, jellies, 
 jams, marmalades and honey are valuable laxatives, (e) Fats. — 
 Moderate amounts of butter and olive oil are helpful ; vegetable are 
 superior to animal fats, which tend to derange digestion. (/) Cold 
 water, taken on rising and through the day, excites peristalsis. 
 Charged waters operate similarly. Hard water, containing an excess 
 of lime, constipates, an important point in drinking and cooking. 
 (g) The following are to be avoided: red wines (containing tannic 
 acid), excess of meat, eggs or carbohydrates (rice, buckwheat, maca- 
 roni and others containing little water), tea, milk (sometimes laxa- 
 tive when not taken in sips but swallowed in larger quantities) and 
 beef tea. The diet recommended affords material for bacterial ac- 
 tion, which follows the idea advanced by Strassburger and Lohrisch, 
 that constipation is due to impaired motility, resulting from too com- 
 plete utilization of the average diet by the intestinal bacteria. 
 
 2. Punctuality at Stool. — The necessity of being punctual at 
 stool was insisted upon by Trousseau. The best time for evacuation 
 is immediately after breakfast, except in cases of piles or prolapse 
 which may come down during the day after the morning stool; in 
 these cases the bowels should be moved at bedtime. 
 
 3. Posture at Stool. — Squatting is the natural posture ; this may 
 be approximated by leaning well forward or by placing the feet on a 
 foot-stool; the thighs thus support and compress the abdomen, a 
 matter of particular importance when it is relaxed. Working the 
 thumb of the left hand downward over the abdomen from the navel 
 to the left iliac fossa is also recommended. 
 
 4. Massage. — Gentle massage for a quarter of an hour, preferably 
 before breakfast, may give relief if continued for months. Its di- 
 rection is along the course of the colon. Sahli rolled over the abdo- 
 men a 7-pound cannon-ball covered with chamois. Massage is indi- 
 cated in atonic but contra-indicated in spastic constipation. 
 
 5. Mild Faradization. — This arouses short contractions in the 
 colon and is given with a moist sponge. Strong applications are to be 
 avoided. Faradization and galvanization are inferior to massage. 
 
 6. Hydrotherapy. — The cold compress to the abdomen is a good 
 adjunct. 
 
 7. Exercise. — Exercise is indicated to develop and contract the 
 abdominal muscles, as in tennis or rowing or by lilting the legs while 
 lying on the back or lifting the rigid body from the lying to the erect 
 posture solely by the abdominal muscles. Walking, bicycle and 
 horse-back riding do not exercise these muscles equally well. In 
 women with ovarian and uterine diseases exercise increases constipa- 
 tion, due to reflex spastic inhibition of peristalsis, as shown by the 
 laxative effect of narcotics (Little John and Brunton). It is claimed 
 that constipation is spastic (not atonic) in 25 per cent, of female 
 
CONSTIPATION. 
 
 661 
 
 cases, as evidenced by colic, palpable or visible knots in the intestine 
 and sometimes by ribbon-iike passages; in these cases an irritating, 
 coarse diet, massage, cold and electricity are to be avoided. Hot 
 Sitz baths or full hot baths, hot compresses to the abdomen for spasm 
 or colic are indicated ; an enema of eight ounces of warm olive oil is 
 given each evening and retained until morning; one-third of a grain 
 of extract of belladonna is given as a suppository one to three times 
 a day to relieve spasm and the frequent rectal tenesmus; the diet 
 should consist of fine carbohydrates, butter and cooked fruit. 
 
 8. Enemata. — Enemata excite peristalsis, lessen intestinal hyper- 
 emia and apparently are beneficial to the hepatic secretion and cir- 
 culation. They do not derange digestion as do cathartics, but after a 
 time they may lose their effect by dilating the colon, whence the 
 indication for their intermittent use. Water and olive or linseed oil 
 may be used; oil enemata (five to eight ounces) are especially indi- 
 cated in spastic constipation and colica mucosa, in which the oil may 
 be left in the bowel over night. Glycerine suppositories are valuable, 
 if used alternately with other methods. In faecal impaction with 
 marked obstruction enemata are invaluable and should be combined 
 with cathartics and digital evacuation of the hardened masses. 
 
 9. Cathartics. — The use of cathartics is governed by the follow- 
 ing general rules: (a) they should be administered in chronic cases 
 only after failure of the measures enumerated above; (b) their most 
 successful employment is intermittent and alternating; (c) drastics, 
 hydragogues and cathartics producing secondary constipation, should 
 be avoided, save in extreme cases. 
 
 Varieties. — Aloes, found in nearly all proprietary and official pills, 
 should be avoided in piles and uterine hemorrhage, because it con- 
 gests the pelvic vessels ; it is given in combination, e. g. — 
 
 ]J Extr. aloes 
 
 Extr. rhei 
 
 Extr. nucis vomicae 
 Resinae podophylli 
 Extr. belladonnas 
 
 (or extr. hyoscyami) 
 Extr. taraxaci . . 
 M. et ft. pil. I. 
 
 . . . gr. ss. Acting in fifteen to twenty hours, on 
 
 the large bowel chiefly. 
 
 . . gr. ij. to v. Actively purgative in four to eight 
 hours; stomachic and tonic. 
 
 . . gr. I. Acting on peristalsis and combating 
 
 atony. 
 
 • • gr. ttj. Acting in ten hours, producing ' ' bil- 
 
 ious stools." 
 
 • gr. I. 
 
 gr.J. 
 
 Relieving spasm (griping) and oper- 
 ating on the intestinal nerves. 
 
 Rhubarb has the disadvantage of griping and of producing second- 
 ary constipation, which is caused by its tannic acid ("a patient sells 
 his soul to rhubarb "), whence it should never be given alone: 
 
 I£ Pulveris rhei compositi 3iv. 
 
 Sodii sulphatis 3iv. 
 
 Sodii bicarbonatis 3j. 
 
 M. et S. — One teaspoonful at bedtime. 
 
662 DISEASES OF TSE DIGESTIVE TRACT. 
 
 Cascara sagrada is an excellent laxative, improves digestion and 
 produces very little constipation afterward; the fluidextract, fluid- 
 extractum rhamni purshianse, TTLxv, is very bitter; the solid extract, 
 extractura rhamni purshianse, is given in doses of from two to eight 
 grains. Licorice is given as pulvis glycyrrhizse compositus, 3ss to 3j. 
 Castor oil is a soothing laxative, relieving irritation and spasm (in 
 nervous or lead constipation, in which latter it may be combined with 
 opium gr. %) ; its offensive taste may be partly overcome by com- 
 bining with glycerine and gaultheria : 
 
 ]£ Olei ricini ^J- 
 
 Olei gaultheriae gtt. xl. 
 
 Glycerini ^ij. 
 
 M. et S. — One teaspoonful to one tablespoonful. 
 
 In anaemic patients the following formula is recommended : 
 
 ]£ Ferri sulphatis gr. x. 
 
 Extracti aloes gr. v. 
 
 Extraeti rhamni purshianae gr. xx. 
 
 Extracti belladonnas gr. iij. 
 
 Extracti nueis vomicae gr. iij. 
 
 M. et ft. pilulae No. X. 
 S. — One after meals. 
 
 Calomel should be given in the evening in fractional doses and may 
 be advantageously combined with podophyllin, which acts in the same 
 time (eight hours) ; they should be followed the next morning by half 
 an ounce of magnesium sulphate. Senna easily deranges digestion; 
 a small amount may be cooked with prunes ; confectio sennce is given 
 in dram doses. Tobacco smoking and coffee in the morning are 
 beneficial, but tea promotes flatulency and constipation. Considera- 
 tion of the salines and drastics is intentionally omitted, as their use 
 is contra-indicated except for emergencies. 
 
 FUNCTIONAL (NERVOUS) AFFECTIONS OF THE BOWEL. 
 
 1. Neuroses of Motility. — (a) Nervous diarrhoea has been partly 
 considered. It may occur in the neuroses, in reflex irritation during 
 dentition or in the crises of tabes; it is usually transient and is 
 marked by absence of inflammatory symptoms, as mucus, pus or 
 blood. There is constant danger that nervous diarrhoea may be con- 
 fused with organic disease. In some cases ingestion of food may be 
 immediately followed by diarrhoea and is treated by giving TTLij of 
 Fowler's solution before meals. (&) Enterospasm is caused by simul- 
 taneous contraction of the circular and longitudinal muscles, which 
 normally contract alternately; the abdomen is temporarily retracted 
 and in very exceptional cases obstruction (ileus spasticus) and faecal 
 vomiting occur. (See Dynamic Ileus, Spastic Constipation and 
 Conic a Mucosa.) (c) Sphincter spasm, aside from local rectal or 
 anal lesions, results from sensory hyperirritability or decreased cere- 
 
AFFECTIONS OF THE MESENTERY. 663 
 
 bral inhibition; it is most common in hysteria and tabes, (d) Peri- 
 staltic unrest may be associated with diarrhoea if the colon is in- 
 volved, but more commonly affects the small bowel only, when con- 
 stipation or normally frequent movements are usual, (e) Nervous 
 constipation (atony) may result from the neuroses, intoxication from 
 carbon dioxide and organic cerebrospinal diseases, in which conditions 
 (/) sphincter paralysis may also result. 
 
 2. Neuroses of Sensation. — Among the neuroses of sensation, neu- 
 ralgia mesenterica (enteralgia, enter odynia) is most important; it 
 is inflammatory, nervous or colicky in origin; strictly speaking, it is 
 always nervous, i. e., not due to organic causes; practically, other 
 forms of abdominal pain are frequently included under enteralgia. 
 The chief symptom is the abdominal pain, which is usually umbilical, 
 and sometimes relieved by pressure and sometimes not; the ab- 
 dominal wall itself may be hypersesthetic. Reflex disturbances in 
 other organs may accompany enterodynia and aid in establishing 
 its functional character; they are hiccough, vomiting, dyspnoea, pal- 
 pitation, rectal or vesical tenesmus, testicular retraction, muscular 
 twitchings, etc. The diagnosis necessitates exclusion of innumerable 
 affections, chiefly abdominal but also general : (a) rheumatism of the 
 abdominal muscles which is superficial; (&) lumbo-abdominal neu- 
 ralgia, in which Valleix's three tender points are found (see Neu- 
 ralgia) ; (c) hysteria, which may simulate many affections; its 
 stigmata should be looked for; (d) tabetic crises; (e) intestinal 
 affections, as appendicitis, peritonitis, coprostasis, parasites, flatulent 
 colic (from beer, milk or spoiled food), excessive catharsis, lead colic 
 or colica mucosa; (/) gout, arthritis or cold; (g) malaria and ty- 
 phoid; (h) renal and biliary calculi. 
 
 Its treatment and that of the motor disturbances is of the funda- 
 mental nervous state. Symptomatically, hypodermics of narcotics 
 produce the quickest but most dangerous relief ; atropine is much safer. 
 
 ]£ Spiritus ammoniae aromatici 3iij. 
 
 Tincturae cardamomi compositae 3iij. 
 
 Spiritus chloroformi 3ij. . 
 
 Tincturae opii camphoratae 3iv. 
 
 Tincturae asaf oetidae 3iv. 
 
 M. et S. — One tablespoonful in hot water every fifteen minutes for three 
 or four doses. 
 
 3. Neuroses of Secretion. — The secretion neuroses are important. 
 The chief types are serous nervous diarrhoea and colica mucosa, which 
 have already been considered. 
 
 AFFECTIONS OF THE MESENTERY. 
 
 I. Inflammation. — Mesenteritis is chiefly important in its relation 
 to ascites, tuberculous peritonitis and other peritonitides (q. v.). 
 
 II. Hemorrhage. — Primary hemorrhage is most rare. It is gener- 
 ally secondary to acute hemorrhagic pancreatitis, retroperitoneal 
 hsematoma, aneurysmal extravasation or the hemorrhagic fevers. 
 
664 DISEASES OF THE DIGESTIVE TRACT. 
 
 III. Diseases of the Mesenteric Vessels. — (a) Infarction by em- 
 bolism or thrombosis was first described by Virchow and involves 
 chiefly the arteria mesenterica superior, which is essentially a ter- 
 minal vessel. Most cases develop in men past middle life. Jackson, 
 Porter and Quimby have collected 225 cases. (See Symptoms of 
 Valvular Heart Disease.) Its onset is sudden, with intense ab- 
 dominal pain, collapse, nausea and vomiting (usually bloody and 
 perhaps faecal, due to intestinal obstruction), diarrhoea (40 per 
 cent.) and 'bloody stools (40 per cent.). Unless there is an apparent 
 cause for embolism, as valvular disease, the diagnosis of infarction is 
 rarely made, for peritonitis or obstruction is usually suspected. The 
 usual outcome is early death from collapse, but if the patient lives 
 long enough acute peritonitis sets in, with distended abdomen and 
 diffuse tenderness. In very rare cases collateral circulation allows 
 of recovery. In the Porter, Jackson and Quimby series, 94 per cent, 
 were fatal. The treatment is purely symptomatic and supportive, 
 but successful operation is recorded by J. W. Elliott, Leclerc and 
 Butter, (b) Periarteritis nodosa (v. page 467). (c) Dilatation 
 of the mesenteric veins and phlebosclerosis occur, especially in cases 
 of liver cirrhosis, (d) Suppuration (thrombophlebitis suppurativa) 
 may mark umbilical pyaemia of the new-born or may carry infection 
 from the appendix or rectum. (See H^matemesis.) (e) Simple 
 thrombosis of the mesenteric veins. Kraft in 1897 collected 16 cases ; 
 in over half of the cases syphilis or liver cirrhosis was the cause. 
 
 IV. Affections of the Chyle Vessels. — These offer more patho- 
 logical than clinical interest. These vessels may become varicose or 
 even hyperplastic (chylangioma). Cysts containing chyle may cause 
 tumors and, by rupture, may result in chylous extravasation in the 
 mesentery or chylous ascites (q. v.). Twenty-four chylous cysts are 
 described by Broca. 
 
 V. Mesenteric Tumors. — These may be dermoid, hydatid, serous, 
 sanguineous, chylous or malignant. In some cases they attract path- 
 ological attention only or they may fill the entire abdomen. Their 
 symptoms are those of an abdominal tumor, which is centrally lo- 
 cated, movable and covered with a zone of resonant intestine. Con- 
 fusion is possible with hydronephrosis or ovarian cysts. 
 
 DISEASES OF THE LIVER. 
 
 ACUTE YELLOW ATROPHY. 
 
 Definition. — An acute fatal degeneration of the liver cells, accom- 
 panied by shrinking of the liver, icterus and nervous toxaemia. Bal- 
 lonius (1600) reported the first case. It is a rare affection; Best 
 collected 450 cases. 
 
ACUTE YELLOW ATROPHY. 665 
 
 Etiology. — (a) Sixty-six per cent, occur in women and 50 per cent, 
 between the years of twenty and thirty; but 22 cases occurred 
 under 10 years of age. (fe) Thirty-three to 50 per cent, of women 
 with the disease (or 27 per cent, of all reported cases) were in the 
 last half of pregnancy; the first three months of gestation almost 
 render the individual immune (Eichhorst) ; it is infrequent in the 
 puerperium. (c) Ten soldiers were affected in Arnould's epidemic 
 series, (d) Infections, as osteomyelitis, diphtheria, sepsis, erysipelas, 
 typhoid, recurrent fever and secondary syphilis (10 per cent., Le- 
 bert) ; or (e) poisoning, as from phosphorus, alcohol and chloroform 
 narcosis, may antedate the disease. 
 
 It may occur primarily in a sound or secondarily in a diseased 
 liver. Worry is a predisposing factor in pregnancy or syphilis. 
 
 Pathology. — The liver is small, the minimum recorded weight being 
 400 grams ; in marked cases it is so lax that it can be rolled up ; the 
 capsule is wrinkled, the color usually yellow (atrophia hepatis fusca) 
 and the lobular markings obscure. The liver cells are granular, 
 fatty, indistinct in contour or tinged with bile; some are necrotic 
 and others show evidences of regeneration. Foci of red tissue are 
 usually considered as an advanced stage in which the fatty necrotic 
 cells have been absorbed ; here the liver is homogeneous and composed 
 of detritus; the left lobe is often red, showing the most advanced 
 process, and the right lobe is yellow, showing more recent changes. 
 The cells of the bile channels are degenerated. Crystals of tyrosin 
 are found. The apparent increase of the connective tissue is relative 
 only. Sometimes infiltration with red or white cells occurs. Icterus 
 staining, small hemorrhages and fatty degeneration are found in the 
 heart, kidneys, muscles, epithelial cells and bronchi, lungs and di- 
 gestive tract. 
 
 In nature the disease is sometimes considered inflammatory (acute 
 parenchymatous hepatitis), but is usually classified as a necrotic 
 process. It is not yet determined whether the disease is an infection, 
 to which it has a certain resemblance, or an intoxication, which ini- 
 tiates autolysis of the liver. The changes in other organs are held to 
 result from the liver change or from a common unknown cause. 
 Bacteria are found inconstantly. 
 
 General Clinical Picture. — Acute yellow atrophy begins with a pro- 
 dromal stage in which gastric disturbance predominates ; icterus de- 
 velops in a few days when the second stage suddenly develops cerebral 
 symptoms, unrest, delirium, oppression, vomiting and convulsions; 
 shrinking of the liver, hepatic tenderness, enlarged spleen, cutaneous 
 and mucous membrane hemorrhages, abortion and hemorrhage if 
 pregnancy exist ; urinary symptoms, as bile, albumin, leucin, tyrosin 
 and other unusual products of metabolism in the urine; and sub- 
 normal or normal temperature. The issue is almost invariably fatal. 
 
 Individual Symptoms. — The prodromal stage may last from a few 
 days to three and a half weeks or more and is not characteristic. In 
 the latter half of gestation, icterus and hepatic tenderness or enlarge- 
 
ti$6 DISEASES OF THE DIGESTIVE THACT. 
 
 ment are suspicious symptoms. The gastric symptoms become 
 marked. Icterus, which is absent only in extremely rapid cases, is 
 obstructive from intrahepatic changes ; the stools are acholic and the 
 jaundice increases with the second stage. 
 
 In the second stage, (a) the hepatic dulness lessens to one-half or 
 one-quarter of its former dimensions and first in the left lobe. The 
 liver is small, flabby and falls back toward the spine so that in some 
 cases there is no liver dulness. The liver dulness may remain nor- 
 mal if death is rapid, as from haematemesis (Leube), if the liver is 
 cirrhotic or if it is adherent to the abdominal wall. The liver is 
 tender and painful, and pain is occasionally referred to other parts 
 of the abdomen. The region of the liver may appear sunken and the 
 liver may feel flabby or may pit to the finger (Leube). (b) The 
 spleen is enlarged in 66 per cent. ; it is not enlarged when perisplen- 
 itis, profuse hemorrhage or diarrhoea is present, (c) Vomiting is 
 almost invariable, the vomitus consisting of mucus, bile and finally 
 blood; it is accompanied by hiccough, a dry brown or white tongue, 
 sordes and constipated, uncolored stools, (d) The nervous symptoms 
 may come on gradually with headache and dulness or very abruptly 
 with delirium, anxiety, meningeal symptoms, grinding of the teeth, 
 trismus, wide pupils, amaurosis, cerebral vomiting and convulsions 
 (in 33 per cent, of adults and almost constantly in children). The 
 nervous symptoms are due to hepatic insufficiency (hepatargia), the 
 degenerated liver being unable to protect the nervous system, as it 
 .does in health, against various ptomaines and leukomaines. (e) The 
 urine is decreased or even suppressed. Bile pigment, albumin, casts 
 and epithelial cells are found. Unusual products are found in the 
 urine, due to the breaking down, autolysis, of the liver cells; leucin 
 and tyrosin occur most frequently, though neither constant nor path- 
 ognomonic; sarcolactic acid, oxyamygdalic acid, peptone and albu- 
 mose are also found. The urea is decreased and may be entirely ab- 
 sent. The ammonium compounds, which normally constitute 2 to 5 
 per cent, of the nitrogen excretion, are increased, even to 17 or 20 
 per cent.,^ because they are needed to neutralize the increased acid 
 products in the blood and because the liver cells cannot convert am- 
 monium into urea. The uric acid and xanthin are increased. Indi- 
 canuria may be noted. Strangely, glycosuria is rare, though the 
 glycogenic function of the liver can hardly be normal. Bouchard, 
 Hervouet, Brouardel and Chauffard speak of urinary crises with 
 increase in the amount of urine voided and in its nitrogenous con- 
 stituents. (/) Fever may occur early in the disease, but the tem- 
 perature is usually normal or subnormal at the height of the process. 
 The pulse may be at first slow, but later becomes very rapid. Dys- 
 pnoea is almost invariably present, (g) Hemorrhages occur in the 
 majority of cases, largely from the stomach and into the skin. Bowel 
 hemorrhage is less frequent, as are those from the nose, mouth and 
 genital mucosae. Uterine hemorrhages occur if pregnancy exist. 
 Hemorrhages in the retina are frequent, together with white flecks 
 
ACUTE YELLOW ATBOPBT. 667 
 
 due to tyrosin deposit and fatty change. Punctate hemorrhages into 
 the serous membranes are common autopsy findings. Erythematous 
 eruptions, muscular pain and articular swellings may occur. In a 
 case seen by the writer herpes was the first symptom. Leukocytosis 
 is infrequent. 
 
 Course. — The clinical course is rapid; 50 per cent, of cases die 
 between the fifth and fourteenth day and 30 per cent, between the 
 third and fifth week. The second stage usually lasts one and a half 
 to three days, rarely more than a week, but may be longer in the 
 rare cases which recover. The more abrupt and severe the cerebral 
 symptoms the more rapid is the course. Pregnancy hastens the issue. 
 Remissions may be observed; temperature may develop during the 
 death agony. The pulse becomes very rapid, the breathing difficult 
 and irregular and the symptoms of nervous excitation are followed 
 by paralysis of the brain centres. 
 
 Diagnosis. — The diagnosis is based upon (a) the icterus, (b) nerv- 
 ous symptoms and (c) shrinking of the liver. Diminution of the 
 liver may be simulated by tympanites or by the colon lying over the 
 liver ; it may not shrink when previously cirrhotic or when bound to 
 the abdominal wall by adhesions, even though the liver cells atrophy. 
 The urine shows distinct disturbances of metabolism, which are 
 valuable diagnostically with the above mentioned symptoms. Con- 
 fusion may occur in icterus gravis or in the so-called bilious typhoid, 
 pneumonia, recurrent fever, puerperal fever, yellow fever, phos- 
 phorus poisoning or Weil's disease; most of these affections are 
 febrile, while acute yellow atrophy is almost always afebrile; the 
 intensity of the icterus, shrinking of the liver, severe cerebral symp- 
 toms and the urinary findings are diagnostic. The greatest difficulty 
 in diagnosis is acute phosphorus poisoning, for which Quincke gives 
 the following differentiation (Leube maintains that the etiology 
 alone is distinctive) : 
 
 Acute Yellow Atrophy vs. Acute Phosphorus Poisoning. 
 
 One to two weeks of moderate symptoms Acute gastro-intestinal symptoms; then 
 from icterus. icterus on the third day. 
 
 Icterus intense. Icterus less. 
 
 Liver sensitive, smaller. If colon is dis- Liver sensitive and swollen, 
 tended, entirely obliterating the liver 
 dulness, the urinary symptoms are 
 suggestive. 
 
 Liver cells greatly degenerated, and but Very extensive fatty degeneration (30 
 little increase in the fat (5 per cent.). per cent.). 
 
 Sudden cerebral symptoms with alter- Cerebral symptoms more of depressive 
 nating irritation and depression one order, 
 
 to two days before death. 
 
 Urine; oxyamygdalic acid, leucin, ty- Sarcolactic acid (though peptone, sar- 
 rosin, more abundant and constant. colactic and tyrosin are found in both 
 
668 DISEASES OE TEE DIGESTIVE TRACT. 
 
 Acute Yellow Atrophy vs. Acute Phosphorus Poisoning. 
 
 Hemorrhages smaller and fewer. Hemorrhages more numerous. 
 
 Duration of one to two weeks. Duration shorter. 
 
 Admitting that acute yellow atrophy may regress, recovery usually 
 indicates error iu diagnosis. From simple atrophy of the liver 
 differentiation is easily made by the general marasmus and the 
 absence of icterus and of nervous and urinary symptoms. Cirrhosis 
 is differentiated by absence of ascites and the presence of a larger 
 spleen, firmer liver and collateral circulation: ascites in acute yellow 
 atrophy has occurred in but S instances i Tileston ) u\ page 695 i. 
 
 Treatment. — Treatment is wholly expectant and entirely negative 
 in its results. The heart depression, vomiting and nervous excite 
 ment are treated as in typhoid (q. v.). 
 
 PORTAL CIRRHOSIS. 
 
 Synonyms. — Laennec's cirrhosis, alcoholic or atrophic cirrhosis. 
 Definition. — Portal cirrhosis is a fibrosis of the liver, characterized 
 (a) etiologically by alcoholism; (&) anatomically by induration 
 
 around the portal vein radicles enclosing numbers of liver lobules, 
 whose cells degenerate: and (c) clinically by portal obstruction 
 ( dyspepsia, hfematemesis. enlarged spleen and ascites I and often by 
 signs of hepatic insufficiency. 
 
 Classification. — The classification of cirrhosis may be made upon 
 an etiological, pathological or clinical basis. From a practical stand- 
 point the chief points are included in the following classification: 
 
 (1). Capsular or f Portal vein syphilis. 
 
 G-lissoniax. (^ Chronic perihepatitis. 
 
 Portal vein cirrhosis, first in clinical importance : 
 its leading type is the alcoholic, atrophic type 
 of Laenneo. (A sub-type is a hypertrophic 
 cirrhosis, like the atrophic save that the liver 
 remains large.) 
 
 Hzi r i-irrhosis. occurring in stasis i cy- 
 
 anotic induration), and. according to French 
 authors, with portal vein cirrhosis. 
 
 (3). Biliary Cirrhosis. Hanot's disease. 
 
 (4). Mixed Cirrhosis. (Portal vein and biliary cm-hoses combined.) 
 
 Of these, two main forms are conspicuous — the portal and biliary. 
 
 Etiology. — (V) Sixty to 75 per cent, of cases are found in men 
 between forty and fifty years of age. Musser (1859 i collected 655 
 cases in children, (b i Alcoholism is the chief, though not the sole 
 cause; cirrhosis may be due to whisky, wine, beer or absinthe, espe- 
 cially in sedentary individuals : alcohol is absorbed by the gastric 
 and intestinal veins and is conveyed to the portal vein radicles. "where 
 its toxic effects are expended on the liver cells or interstitial tissue. 
 
PORTAL CIRRHOSIS. 669 
 
 but in what sequence it is not known. Of late the role of alcohol 
 has been disputed, but it remains a striking though perhaps an in- 
 direct factor, (c) Syphilis is a cause, especially in the young, in 
 whom the spirochetes are conveyed by the umbilical vein to the 
 liver, (d) Other infections, as malaria (especially where it is en- 
 demic), typhoid, tuberculosis, etc., are possible causes; experi- 
 mentally cirrhosis has been caused by the Bacillus pyocyaneus, 
 Bacillus coli and staphylococcus ; and lactic, acetic and butyric^ acids ; 
 local mycotic necrosis is thought to be followed by fibrosis; in this 
 group the toxins probably enter by the hepatic artery, (e) Spices, 
 curry, drastics, lead, phosphorus, arsenic, hemochromatosis, anthra- 
 cosis (Welch), silicosis (Adami) and possibly gastro-enteric auto- 
 intoxication are exceptional etiological factors. It may be associated 
 with gout, diabetes, rickets or other constitutional affections. There 
 may be multiple causes, e. g., syphilis plus malaria or alcoholism. In 
 some cases no cause is discoverable. 
 
 Pathology.— The essential change is fibrosis around the branches of 
 the portal vein. Some consider that the connective tissue growth is 
 primary, causing, as it contracts, atrophic or fatty alteration of the 
 liver cells, sometimes with pigmentation; others maintain that the 
 cells are first injured and are replaced by fibrous tissue. Whatever 
 the pathogenesis, the connective tissue forms and surrounds several 
 lobules at a time (multilobular cirrhosis). Histologically the cir- 
 rhosis is atrophic, and this point is emphasized first, because the size 
 and weight of the liver may vary. Some clinicians maintain that the 
 liver is first large (the so-called hypertrophic stage) and later is 
 shrunken. Undue importance is attributed to size alone, for a 
 normal-sized or enlarged cirrhotic liver is histologically atrophic. 
 An actually atrophic liver may be large from (a) fat deposit, (b) 
 passive congestion, (c) compensatory parenchymatous hyperplasia 
 or (d) active congestion. The weight is as often increased as de- 
 creased, ranging from 2,000 gm. (65 ounces) to 1,000 gm. or less. 
 Its edge is rough; i. e., granulations can be felt which represent the 
 remaining relatively normal liver tissue. Regeneration of the paren- 
 chymatous cells is active but somewhat disorderly, irregular and un- 
 stable, the cells again wasting. The surface is sometimes smooth, 
 and microscopic examination may be necessary for confirmation. 
 Granulations also occur in fatty liver, pylephlebitis and passive con- 
 gestion. Its consistence is increased. The liver is gritty to the knife ; 
 its color is yellow (cirrhosis), perhaps green or brown. The con- 
 nective tissue is increased and prominent, encroaching on the paren- 
 chyma. Injections of the organ through the portal vein are not 
 successful ; i. e., there is portal obstruction, which causes many of the 
 clinical symptoms. There is a lengthening and narrowing of the 
 capillary vessels ; this and the increased arterial pressure in the 
 organ account for the ascites, aside from the connective tissue hy- 
 perplasia (v. Differential Pathology on pages 677-678). 
 
 General Clinical Picture. — The disease often exists for several years 
 
670 DISEASES OF THE DIGESTIVE TRACT. 
 
 without symptoms; this latency is marked by enlargement of the 
 liver, and is due to compensatory cellular hyperplasia. In the minority 
 of cases, swelling, pain or active hyperemia of the liver and dyspepsia, 
 fever or icterus are observed; they last a short time only and are by 
 no means characteristic. With marked shrinking there are symptoms 
 (a) of general disturbance of nutrition, as constipation, emaciation 
 (which is often not noticed because the abdomen remains obese) and 
 an earthy, sallow look to the skin, in which dilatation of the small 
 arterioles (toxaemia or alcoholism), dryness and hemorrhages are also 
 observed; (&') of portal congestion, as early haematemesis, epigastric 
 pressure, ascites, large spleen and disturbed breathing, circulation 
 and digestion; (c) of intoxication, resulting from functional failure 
 of the heart, liver and kidneys; (d) of complications, as hemorrhage, 
 diarrhoea or the so-called cholaemia. 
 
 Symptoms. — 1. The Liver. — The liver is enlarged about as often 
 as it is decreased in size; the left lobe suffers most and earliest con- 
 traction. The liver may be found to be high, as a result of paresis 
 of the diaphragm, due to perihepatitis. Its edge is hard, but often 
 cannot be felt, even after tapping, on account of its shrinkage or be- 
 cause the bowels cover it. The edge is uneven; its granulations may 
 be confused with the small islets of fatty tissue in the abdominal 
 wall, due to unequal wasting of the adipose tissue. Palpation of the 
 liver is the only certain way of determining its lower limit, the re- 
 sults of percussion being decidedly unreliable. In infantile forms of 
 portal cirrhosis the liver and spleen are larger than in adult types. 
 
 2. Portal Stasis. — This results from obstruction to the return 
 portal circulation, (a) The peritoneum is thickened, oedematous and 
 the seat of transudation, i. e., ascites, which occurs in 85 per cent, 
 when the patient dies of the cirrhosis itself and in 50 per cent, when 
 he dies from other causes. It is more common in small than in large 
 livers. Some writers hold that toxaemia and peritonitis are more 
 potent factors than portal obstruction. Ascites usually appears first 
 without general oedema, though later the legs may become swollen 
 as the ascites compresses the inferior vena cava. Pre-ascitic oedema 
 of the legs or abdominal wall may develop from cardiac or renal 
 complications, involvement of the cava by perihepatitis or from 
 thrombosis of the iliac veins. Under ascites its physical signs will 
 be more closely considered. The amount of fluid may be enormous ; 
 Liebermerster reports a case in which he withdrew nine gallons. 
 
 The fluid is usually amber-colored, seldom red from admixture of 
 blood or very rarely turbid from fat (adipose ascites) or lecithin 
 (chyliform ascites) ; the two latter forms also contain nucleo-albu- 
 mm. The specific gravity is 1,008 to 1,015, with 0.6 to 1 per cent, 
 albumin. Though ascites is rarely absent in advanced atrophic 
 cirrhosis, the patient may die before ascites develops— for instance, 
 from hemorrhage, which is dangerous when there is no ascites (Ley- 
 den). An extensive though slowly developing collateral circulation 
 may permanently relieve an earlier ascites. It may disappear after 
 
PORTAL CIRRHOSIS. 671 
 
 hemorrhage, diarrhoea or carcinoma of oesophagus, (b) The spleen 
 is from two to six times its normal size, which is due to the early 
 toxaemia and the later stasis. The splenic tumor is present in 75 per 
 cent, of cases and is a measure of the degree of cirrhosis. Its capsule 
 is hard and thickened (sometimes preventing splenic enlargement), 
 the trabecule are thicker and a systolic murmur is sometimes heard 
 (Bouchard and Leudet). (c) Gastro-intestinal catarrh is due to 
 stasis and alcoholism. Pain after eating, especially in obese persons, 
 a coated tongue, vomiting, singultus, constipation, piles, diarrhoea 
 toward the end of the course and meteorism also occur, (d) A col- 
 lateral circulation may be evidenced by enlargement of the veins 
 about the navel (cirs omphalos or caput Medusce). Prominence of 
 the epigastric veins occurs regularly, but results from compression 
 of the inferior cava. Anastomoses occur (i) between the middle and 
 inferior hemorrhoidal veins (passing by the hypogastric to the cava) 
 on the one hand, and the superior hemorrhoidal (passing by the su- 
 perior mesenteric to the portal vein) on the other hand; (ii) between 
 the coronary veins of the stomach on the one hand and the oesopha- 
 geal and phrenic veins on the other, which empty into the vena azy- 
 gos; (iii) between the veins in the ligaments of the liver and new 
 adhesions and the phrenic veins ; between the veins of the ligamentum 
 teres and the veins of the abdominal wall and epigastric veins, which 
 may sometimes be felt and may produce murmurs (Bamberger and 
 von Jaksch) ; (iv) the mesenteric, peritoneal and parumbilical veins 
 also communicate with those of the abdominal wall. A well-de- 
 veloped collateral circulation is both a favorable and an unfavorable 
 symptom ; on the one hand it relieves the portal stagnation and prob- 
 ably gives the over-taxed liver a better opportunity to perform its 
 functions ; on the other hand, the dilated collateral vessels are likely 
 to rupture and they convey directly into the general circulation toxic 
 substances which the liver normally destroys or alters ; this produces, 
 according to Stockton, the frequent arteriosclerosis, granular kidneys 
 and more acute toxaemia, which resembles uraemia, '(e) The kidneys 
 are congested, degenerated and often show hypertrophy. The urine 
 is decreased in amount, darker and of higher specific gravity, because 
 the arterial tension is low in cirrhosis. More urine is often secreted 
 during fasting than during digestion (opsiuria), which is the con- 
 verse of normal conditions. The urobilin may be increased two-fold. 
 The chlorides are decreased, as they accumulate in the ascitic transu- 
 date. The urea is often decreased, but the ammonium compounds 
 (as in acute yellow atrophy) are often increased, less from interfer- 
 ence with the liver functions than from increase of acid products in 
 the blood (acidosis), which the ammonium salts seek to neutralize. 
 Albuminuria may result from stasis or nephritis (v. i.). Blood may 
 be found in the urine as a result of stasis in the bladder. Glycosuria 
 is uncommon save in the pigmentary cirrhosis (see Diagnosis). Ali- 
 mentary glycosuria may be produced by administration of 3 ounces 
 of grape sugar with a meal. 
 
672 DISEASES OF THE DIGESTIVE TRACT. 
 
 3. General Symptoms. — There is considerable loss in weight, 
 some anaemia and a sallow, earth-like color. Malnutrition is ex- 
 plained (a) by the inability of the liver to handle the carbohydrates, 
 proteids, etc., and (b) by the diversion through the collateral circula- 
 tion of toxins into the general circulation, the liver being the normal 
 barrier against toxins injurious to the nervous system. In three 
 cases with well-developed collateral circulation, scurvy developed 
 which the writer interpreted as toxsemic. It was once thought that 
 bile salts or pigment entered the blood and produced " cholcemia" 
 or that substances were retained which the bile normally excreted, 
 producing " acholia" ; now the term liver insufficiency {hepatargia) 
 is more often employed. Toxsemic nervous symptoms include ady- 
 namia, headache, itching, delirium, stupor, convulsions, paralysis, 
 contractures or coma. The writer twice observed Kussmaul's breath- 
 ing. Much depends upon the activity and integrity of the kidneys, 
 which may for a time maintain adequate excretion. 
 
 Complications. — 1. Hemorrhage. — (a) Cachectic capillary hemor- 
 rhage from the nose, mouth, lungs or stomach is less frequent than it 
 is in biliary cirrhosis. Epistaxis occurs from dilatation of the ves- 
 sels on the anterior part of the septum, (b) Of mechanical conges- 
 tive hemorrhages from the oesophagus, stomach, bowels, kidneys, 
 bladder or uterus, those from the oesophagus are most important. 
 Zenker found oesophageal varices in 20 per cent, of cirrhosis autop- 
 sies. Their rupture causes hcematemesis (which occurs in 23 per 
 cent, of cirrhosis cases), chiefly in adults and rarely in children; if 
 very profuse, blood may come up without vomiting; in one of Osier's 
 cases the blood amounted to 10 pounds ; it often causes blood in the 
 stools. It may seep out slowly and form dark clots ; it is usually 
 attended by less collapse than in hemorrhage from gastric ulcer but 
 acute anaemia or slight fever may follow it. Preble, in a careful 
 study of the subject, concludes that: (i) Hemorrhage occurs chiefly 
 in atrophic forms, (ii) In 33 per cent, the first hemorrhage is fatal ; 
 in 66 per cent, hemorrhages occur over a period of several months to 
 eleven years, (iii) In 33 per cent, a diagnosis of cirrhosis was pos- 
 sible at the time of the first hemorrhage, (iv) (Esophageal varices 
 were present in 80 per cent, and in over half of these macroscopic 
 rupture was detected; yet (v) fatal hemorrhage may occur without 
 macroscopic rupture and is due to a simultaneous rupture of many 
 capillaries, (vi) Hemorrhage may be the first symptom of cirrhosis, 
 but other signs are usually found first. (vii) The symptoms of 
 cirrhosis were typical in but 60 per cent, of cases of oesophageal varix. 
 
 2. Peritonitis. — (a) Chronic retracting peritonitis (in 15 per 
 cent., Gratia) may occur with shortening of the mesentery and in- 
 testines; according to Botazzi it prevents absorption of the ascites. 
 (b) Tuberculous peritonitis (20 per cent.) may occur with fever, 
 pain and often an hemorrhagic exudate. It usually follows the ascites 
 of cirrhosis and hastens the fatal outcome. One would think that 
 stasis would tend to prevent the development of tuberculosis. 
 
 3. Nephritis. — Nephritis occurs in 33 per cent, of cases. 
 
PORTAL CIRRHOSIS. 673 
 
 4. Heart. — The heart is " arteriosclerotic " in 60 per cent. ; chronic 
 myocarditis, endocarditis, fatty degeneration and dilatation of the 
 right ventricle often occur. The arterial tension is low in cirrhosis. 
 
 5. Lungs. — In the lungs bronchitis, emphysema and in 15 per 
 cent, pulmonary tuberculosis occur; the latter is rare in infantile 
 cirrhosis. Eight hydrothorax occurs from stasis in the vena azygos 
 and right intercostal veins ; right-sided pleurisy, due to extension of 
 perihepatitis through the diaphragm, occurs in 10 per cent, of cases. 
 
 6. Brain. — Pachymeningitis or apoplexy may occasionally occur. 
 
 7. Fever. — "Intermittent hepatic fever" may result from hepa- 
 targia (hepatic intoxication), perihepatitis or complications. The 
 temperature is usually subnormal in advanced cases, though terminal 
 temperature and leukocytosis are observed in terminal infections. 
 
 8. Icterus. — In atrophic cirrhosis jaundice is a genuine compli- 
 cation; it is due to duodenal catarrh or a radicular cholangitis; 
 few pass through the disease without a muddy yellow areola under 
 the eyes. If present it is incomplete. Its frequency is 15 per cent. 
 
 9. Anasarca. — Anasarca results from pressure on the cava by an 
 extensive ascites, from perihepatitis with cicatricial involvement of the 
 cava and from complicating cardiac or renal disease and marasmus. 
 
 10. Other Complications. — These are rarer; for instance, pyle- 
 thrombosis, clubbed fingers, alcoholic multiple neuritis or delirium 
 tremens; acute yellow atrophy and venous thrombosis seldom occur. 
 
 Course and Prognosis. — The clinical course is essentially chronic 
 and seldom exceeds two or three years, but its duration is more often 
 months than years; the maximum is fifteen years. All acute cases 
 must be stricken from the category of cirrhosis. Compensatory fac- 
 tors include (a) the collateral circulation, though this may throw 
 toxins directly on the nervous centres and produce symptoms like 
 uraemia; (b) hyperplasia of the liver cells, which may produce veri- 
 table adenomata. As Hanot puts it, the diagnosis is based on the 
 condition of the connective tissue, but the prognosis depends on that 
 of the liver cells, (c) The kidneys may compensate to a small de- 
 gree. Hale White holds that ascites is ominous and that the patient 
 rarely survives the second tapping; this does not conform to the 
 author's experience, though ascites is a late symptom ; the author has 
 seen numerous cases which survived frequent tappings, and he has 
 felt justified in excluding perihepatitis, which White considers ex- 
 planatory of these cases. The prognosis is relatively favorable in 
 subjects under forty years with large livers and small spleens. Re- 
 covery is possible, especially if the diagnosis is made early. In ad- 
 vanced stages death is the usual outcome, although the author has 
 seen relative recoveries lasting for five or six years follow adhesions 
 from multiple paracentesis. 
 
 Death results from hepatargia (cholsemia, acholia), marasmus, 
 hemorrhage, ascites or intercurrent terminal infections; exhausting 
 diarrhoea or vomiting; cardiac, renal or other complications (v. s.). 
 
 Differential Diagnosis. — Two classes of conditions require differen- 
 43 
 
674 DISEASES OF THE DIGESTIVE TRACT. 
 
 tiation: those in which the liver is large and those in which it is 
 small. 
 
 1. When the Liver is Large. — (a) The fatty liver is soft and 
 presents no evidences of portal stasis. (To avoid repetition the dis- 
 ease is differentiated later, in tabular form on page 695.) (b) The 
 amyloid liver is hard ; the spleen, kidneys and alimentary mucosae are 
 almost always involved, icterus is very rare and occurs only when 
 amyloid glands at the porta hepatis produce mechanical icterus; 
 anaemia is common, (c) Leuhwmic deposits in the liver cause hepatic 
 intumescence, but the blood examination is decisive, (d) Some 
 swelling of the liver may result from simple icterus, but the history, 
 absence of portal stasis and shorter course are distinctive, (e) Pas- 
 sive hyperemia from heart or lung disease produces an evenly^ en- 
 larged tender liver, subicterus and cyanosis. (/) Cancer of the liver 
 is usually clearly marked by hard and nodose enlargement, by detec- 
 tion of the primary growth (e. g., in the stomach), by icterus and 
 cachexia ; in some cases early cirrhosis may simulate cancer, as in a 
 patient in whom K'ahler diagnosticated cancer, though the later course 
 proved that cirrhosis was present, (g) In syphilis of the liver the 
 history, knobs and depressions, the more rapid course, greater peri- 
 hepatitic pain, the icterus (in 33 per cent.), the findings in other 
 parts and the results of treatment usually make the diagnosis clear 
 (see Syphilis). (h) Pericarditic pseudo cirrhosis, described by 
 Pick (1896), occurs in young, rheumatic and cardiac subjects and is 
 characterized by symptoms which on the one hand resemble extreme 
 passive congestion of the liver and on the other a capsular cirrhosis ; 
 the liver is large and firm, there is recurrent ascites without oedema 
 of the extremities and little or no icterus. Its mechanism is dis- 
 puted; contracting pericarditic adhesions may perhaps cause dilata- 
 tion of the right auricle and vena cava inferior, thereby distending 
 the hepatic vein system ; or possibly the inflammation extends down 
 the cava inferior to the liver ; the liver, however, is permanently and 
 disproportionately congested, (i) The enlarged liver in Banti's dis- 
 ease is cirrhotic, but the spleen is enlarged first and there is early 
 splenic anaemia, while the cirrhosis and haematemesis occur later. 
 
 2. When the Liver is Smaee. — The following possibilities 
 should be considered : (a) Syphilis, characterized by stellate scars, 
 nodes and pain, (b) Passive congestion; the nutmeg liver may 
 atrophy, but anasarca is observed first and usually there are primary 
 and sufficiently characteristic heart findings, (c) Simple marantic 
 atrophy is of little clinical interest; the liver is small, there is no 
 portal stasis and arteriosclerosis is found elsewhere, (d) Pylethrom- 
 bosis is characterized by a rapid onset with swelling of the spleen, 
 severe or repeated haematemesis, dilated veins and rapid recurrence 
 of the ascites after tapping; it is due to some special cause, as pres- 
 sure of a tumor, nearby ulcers, suppuration or gall-stones. (e) 
 Perihepatitis has a very much slower course than has cirrhosis; it 
 lasts for years with intermissions and very often results from peri- 
 
PORTAL CIRRHOSIS. 675 
 
 carditis. (/) In chronic peritonitis the fluid is turbid, often hemor- 
 rhagic, with high specific gravity and many leukocytes ; it is charac- 
 terized by absence of symptoms of portal vein stasis; there may be 
 pain, fever and, in the tuberculous form, positive results from inocu- 
 lations ; for the differentiation of chronic peritonitis ^ see pages 
 731, 732 and 733. (g) The peculiar pigmentary cirrhosis of 
 hemochromatosis (diabete bronze) was first described by Troisier 
 (1871), was named by Eecklinghausen and was particularly elab- 
 orated by Hanot, Chauffard and Letulle. Its symptoms are three- 
 fold: (i) cirrhosis (which causes the hemorrhages, indurated liver 
 and enlarged spleen), (ii) diabetes and (iii) pigmentation of the 
 skin, which somewhat resembles Addison's disease. It is thought that 
 some toxic substance destroys the red blood cells (hemolysis)., and so 
 operates on the cells of the liver, pancreas and other organs that they 
 transform the soluble blood pigment into insoluble hemosiderin and 
 iron-free hemofuscin. These pigments are found in the muscles, 
 intestine, heart, liver and pancreas, whose cells become pigmented; 
 degenerated and necrotic; the pigment passes into the connective 
 tissue of the part. The essential lesions are pigmentation of the liver, 
 skin and pancreas, with the fibrosis of the liver and of the islands of 
 Langerhans in the pancreas, which latter causes the diabetes. Dia- 
 betes has occurred in all but five of the French cases, but seems less 
 common in those reported in this country. In Futcher's series of 35, 
 33 were males. 
 
 Treatment. — 1. Causal Therapy and Prophylaxis. — These have 
 but limited application, save in preventing further injury to the 
 affected liver by syphilis and by the use of alcohol. All forms of 
 liquors or medicinal tinctures are absolutely interdicted, but too 
 frequently with no effect. Syphilitic forms are greatly benefited by 
 appropriate treatment, which some clinicians think may help all 
 forms of cirrhosis. 
 
 2. Medicinal Treatment. — This is of little value, for cirrhosis 
 cases come under observation only after contracting connective tissue 
 has already formed. Naunyn has used ten grains of ammonium 
 chloride three times daily, but it does not arrest cicatrization. Rol- 
 leston believes that potassium iodide and ammonium chloride are 
 beneficial in acid intoxication (acidosis) ; he never gives arsenic and 
 salicylates. 
 
 3. Diet. — The diet should exclude rich proteids, for meat is less 
 well tolerated than milk. Skimmed milk is best for it contains but 1 
 per cent, of fat. Eich or highly seasoned foods are to be avoided. 
 
 4. Symptomatic Treatment. — The same treatment which is 
 instituted in chronic gastritis or alcoholism (q. v.) may be indicated. 
 Flatulence should be met by calomel in fractional doses, then by salol 
 10 grains after each meal, or possibly by betanaphthol 10 grains, 
 though it may cause renal irritation. Diarrhoea should not be 
 checked until the bowels have been thoroughly cleansed, for it is 
 eliminative. Unusual splenic intumescence may be treated by purg- 
 
676 DISEASES OF TEE DIGESTIVE TEACT. 
 
 ing, for it is often a forerunner of hsematemesis. Hsematemesis 
 should be treated by absolute rest and by rectal feeding, as in gastric 
 ulcer (q. v.); calcium chloride 3ss to j may be given by rectum for 
 two or three doses. Pain is controlled by local heat, calomel, am- 
 monium chloride and salines. Nervous symptoms necessitate the 
 same treatment as uraemia, namely, laxatives, sweats and transfusions, 
 to which sodium bicarbonate may be added as in diabetes, for the 
 acidosis. 
 
 5. Ascites. — Ascites is seldom benefited by the cardiants, sweats, 
 diuretics or purges. Early repeated punctures may induce adhesions 
 and consequent collateral circulation (see page 733). 
 
 6. Operation. — Talma and Van der Meulen (1889) recom- 
 mended operative measures, which were later amplified in various 
 ways, to induce a collateral circulation; these consist of sewing the 
 omentum to the abdominal wall, rubbing the surface of the liver until 
 it is abraded to promote adhesions and other similar measures. 
 Montprofit, in 224 operations, found 30 per cent, cured. Bunge col- 
 lected (1905) 274 operations of the Talma-Drummond type; the 
 immediate mortality of the operation was 3.6 per cent. ; of the sur- 
 viving cases, 14 per cent, were somewhat improved, 30 per cent, 
 recovered and 56 per cent, were not improved. Perhaps better re- 
 sults will be recorded if operation is resorted to early in the disease, 
 but it must be recalled that the ascites and collateral circulation in- 
 volve vital as well as mechanical considerations. How the operation 
 is beneficial is still a matter of doubt ; its mechanical collateral side 
 is known; perhaps lessening of venous tension in the portal circuit 
 helps the liver cells to a better functional activity. 
 
 BILIARY CIRRHOSIS. 
 
 Definition. — A cirrhosis occurring chiefly in adolescence and char- 
 acterized by fibrosis of a mono- and intralobular type, enlargement of 
 the liver without contraction, splenic enlargement, chronic icterus 
 without gross obstruction of the bile vessels, paroxysmal fever and by 
 absence of portal stasis. It is known as Hanoi's disease, for it was 
 first clearly described by him in 1876. The term hypertrophic cir- 
 rhosis is unfortunately ambiguous. 
 
 Etiology. — Its etiology is obscure. Alcoholism is not a factor. 
 Sometimes it apparently results from (a) infection, either an ascend- 
 ing cholangitis due to the Bacillus coli or pneumococcus or an infec- 
 tion through the blood stream, (b) Age. Most cases develop between 
 the twentieth and thirtieth years of age; it is rare in persons over 
 forty; a considerable percentage occurs in the young, especially in 
 India (Gibbons, Gnoses), (c) Sex. Over 80 per cent, of adult cases 
 are males; in the young the sexes are equally involved. 
 
 Symptoms. — The onset is usually characterized by the early develop- 
 ment of icterus and less often by malaise, muscular asthenia, fever, 
 splenic pain, dyspepsia^ diarrhoea or abdominal pain. 
 
BILIARY CIBRHOSIS. 
 
 677 
 
 Cardinal Symptoms.— 1. The liver is uniformly enlarged and 
 may weigh five to ten pounds (2,000 to 4,000 gm.). Its surface is 
 smooth and its edge is fairly even, though somewhat blunt. Its path- 
 ological characters will be considered under diagnosis. Its dulness 
 extends from the fourth rib in the nipple line to the umbilicus or 
 even to the iliac crest ; it visibly bows outward the right costal arch 
 and possibly by its weight drags down the right shoulder. The gall- 
 bladder is not enlarged for there is no obstruction of the large bile- 
 ducts. The liver progressively increases in size, often paroxysmally 
 with fever, pain over the liver and increase of the icterus. It never 
 shrinks, except when combined with portal cirrhosis. 
 
 2. Icterus develops early and is constant, permanent and charac- 
 teristic. It varies in degree, though it is usually quite intense. It is 
 due to obstruction of the smaller bile vessels ; it is not certain that it 
 is due to over-secretion of bile (polycholia) or of bile pigments (poly- 
 chromia). In extreme cases the skin becomes green or brown. It 
 is frequently accompanied by itching, xanthelasma and eczema. 
 
 3. The spleen is hypertrophied, is usually increased relatively more 
 than the liver, averaging one to two pounds (400 to 1,000 gm.) in 
 weight, but sometimes actually outweighs it (2,600 gm.), especially 
 in infantile forms. It is hard, smooth and evenly increased in all its 
 elements and dimensions. It is often clearly visible and is dis- 
 tinctly palpable. 
 
 Other Symptoms. — Digestive. — The condition of the tongue and 
 appetite is variable. Nausea, vomiting, dyspepsia and tympanites 
 are uncommon. Diarrhoea is frequent. The normal or diarrhoeal 
 movements contain bile in over 90 per cent, of cases. 
 
 Nutritive. — Nutrition is often maintained for years, despite the 
 icterus, but wasting subsequently appears. Development is retarded 
 in young subjects and infantilism may be as marked as in cretinism 
 or congenital syphilis. Clubbed fingers, from hyperplasia of the soft 
 tissues, is not an uncommon development; Gilbert and Lereboullet 
 collected 40 cases in 1901. 
 
 Urinary. — The urine is highly colored, bile-stained and is usually 
 increased in amount; its freezing point is high and it may contain 
 urobilin, indican or albumin. 
 
 Circulatory. — The pulse is not slow; the heart is often dilated 
 and may reveal a systolic murmur; dyspnoea is frequent from pres- 
 sure on the diaphragm by the swollen liver and spleen; the blood 
 shows secondary anaemia, decreased coagulability and sometimes mod- 
 erate leukocytosis. Arthritis and multiple neuritis are rare com- 
 plications. 
 
 Diagnosis. — The following table shows the essential pathological 
 and clinical points of contrast with the portal type : 
 
678 
 
 DISEASES OF THE DIGESTIVE TRACT. 
 
 Portal (atrophic) cirrhosis. vs.~ 
 
 1. Etiology; alcoholism; over forty 
 
 years of age. 
 
 2. Liver, large or small (possibly both 
 
 in succession) ; shrinks often. 
 
 Granulations; larger. 
 Yellow. 
 
 3. Connective tissue and inflammation 
 
 ensnaring several lobules (mul- 
 tilobular or annular), and around 
 portal vein radicles. 
 
 Distinction between connective tis- 
 sue and lobules sharp. 
 
 Connective tissue, firmer, more 
 fibrous; more elastic tissue. 
 
 Scar-like and contracts. 
 
 4. Liver-cells, early fatty, degenerate, 
 disappear. 
 
 5. Portal system cannot be injected by 
 portal vein. 
 
 6. Bile vessels. (Proliferating bile 
 and are probably merely com 
 
 7. Icterus infrequent, a complication; 
 
 when present, usually catarrhal. 
 
 8. Ascites rarely absent in advanced 
 
 cases. 
 
 9. Collateral circulation — usual. 
 
 10. Hcematemesis, frequent, early, me- 
 
 chanical. 
 
 11. Constipation usual. 
 
 12. Duration of two to three years. 
 
 Death results from hgematemesis, nephri- 
 tis, tuberculosis, peritonitis. 
 
 —Biliary (hypertrophic) cirrhosis. 
 Infection; under forty years. 
 
 Always large and to greater degree. 
 Never shrinks in pure forms. 
 
 Small; very fine. 
 
 Dark, icteric, green. 
 
 Begins in lobule (monolobular or insn 
 lar) around smaller bile radicles 
 (cholangitis), in early stages at least, 
 later less clear. 
 
 Not sharp. 
 
 More delicate, reticular, richer in cells, 
 embryonal. 
 
 Does not contract (elephantiasis hepa- 
 tis). 
 
 Seldom fatty, remain normal for long 
 time, may regenerate, more pig- 
 mented. 
 
 Easily injected. 
 
 in biliary form are not characteristic, 
 rows of liver cells.) 
 
 Constant throughout course, though the 
 stools contain bile. 
 
 Absent in all (except mixed forms). 
 
 Never. 
 
 Very rare, late, cachectic or toxgemic. 
 
 Diarrhoea quite frequent. 
 
 Five to ten years. 
 
 Eare; death from hepatargiaf (so-called 
 cholaemia) with fever, nervous symp- 
 toms, delirium, typhoid state, coma. 
 
 It is a rare affection and a diagnosis of biliary cirrhosis is too 
 often made. If the cardinal features under its definition are borne 
 in mind it can usually be separated with ease from the following 
 affections: (a) In hepatic cancer the subject is older and more ca- 
 chectic, the course is shorter, there is no splenic tumor, the primary 
 growth, e. g., in the stomach, may be recognized, the liver often pre- 
 sents irregularities, the neoplastic obstruction of the bile duct pro- 
 duces acholic stools and obstruction of the portal vein causes ascites. 
 (b) Multilocular echinococcus (q. v.) also produces icterus and en- 
 larged liver and spleen, but is exceedingly uncommon, (c) Fatty 
 and amyloid liver are unattended by jaundice and in amyloidosis the 
 
ABSCESS OF THE LIVER. 679 
 
 enlargement of liver and spleen is usually associated with albumi- 
 nuria, diarrhoea, oedema and cachexia, {d) Obstruction of the bile 
 ducts may produce an enlarged gall-bladder- (v. Icterus) ; the stools 
 are usually but not necessarily acholic (e. g., in stone of the common 
 duct). The spleen is not large. In this connection it may be stated 
 that some recognize a (so-called) biliary cirrhosis due to chronic ob- 
 struction of the duct, as described by Charcot and Gombault in 1876 ; 
 simple mechanical obstruction never causes fibrosis, though it may 
 follow ascending cholangitis. The liver is far less large in this 
 obstructive type and is seldom hard, (e) In hemochromatosis and 
 pigmentary cirrhosis icterus is absent and glycosuria is present in 
 about 85 per cent, of cases. (/) For Banti's disease see diagnosis of 
 portal cirrhosis. (See Differentiation, page 695.) 
 
 Treatment. — The treatment is that of portal cirrhosis; no means 
 are known which stop the formation of connective tissue. A gener- 
 ous diet may be given. Cold and dampness are especially to be 
 avoided. Calomel in small doses (grain %o to /4o t. i. d.) may be 
 given for weeks at a time and the salicylates and simple salines 
 are sometimes beneficial. Operative relief by drainage of the gall- 
 bladder is suggested, but in the reported cases the true biliary cir- 
 rhosis is often confused with obstructive icterus ; operation might be 
 helpful in cirrhosis due to ascending infections. 
 
 ABSCESS OF THE LIVER. 
 
 Suppurative hepatitis may be considered as a local affection, though 
 it is sometimes a part of septicopyemia (q. v.). Virchow found it in 
 1.5 per cent, of autopsies. Ninety-seven per cent, occur in males. 
 
 Varieties. — 1. In the septic type (55 per cent, of cases, Baren- 
 sprung and Luda ) the hepatic artery is the usual carrier of infection ; 
 the primary focus is usually in the external parts, especially the skull 
 (Hippocrates). It may result from osteomyelitis, external inflam- 
 mations, pulmonary abscess or gangrene, putrid bronchitis and, less 
 often, from ulcerative endocarditis. Liver abscess occurs in 15 per 
 cent, of cases of surgical septicopyemia (Barensprung). Infected 
 thrombi in the peripheral veins may become detached, infarct the 
 lungs and thence reach the arterial circulation. In rare cases infec- 
 tive material may fall back from the cava into the hepatic vein, 
 known as retrograde embolism. The bacteria are those enumerated 
 under sepsis — the pyogenic organisms, pneumococcus, colon and ty- 
 phoid bacilli. 
 
 The symptoms of septic abscess are not distinctive because, first, 
 they are obscured by the general toxemia and, second, the multiple 
 abscesses when scattered through the liver usually produce few de- 
 cisive local symptoms.' The liver enlargement is uniform and gen- 
 erally indistinguishable from the cloudy swelling of sepsis ; fluctua- 
 tion is rare; the portal circulation is rarely obstructed; pain and 
 tenderness are usually present; jaundice is inconstant; the spleen is 
 
680 DISEASES OF TEE DIGESTIVE TRACT. 
 
 swollen from sepsis; the course is rapid. The septic type may oc- 
 casionally, and the traumatic often, consist of a single large abscess. 
 2. The second variety results from infection through the tribu- 
 taries of the 'portal vein (31 per cent.) (Kelsch contends that 85 per 
 cent, of 500 liver abscesses were due to dysentery). It has been 
 known since Morgagni's time and is clinically the most important 
 type. Any ulcerative or suppurative affection in parts containing 
 these branches may be causal, for instance, amoebic dysentery (the 
 most frequent cause), appendicitis (in 6 per cent, of its fatal cases), 
 neglected hemorrhoids, gastric ulcer or cancer and disease of the bile 
 vessels. Pyogenic organisms, the Amoeba dysenteriae, foreign bodies 
 (as fish-bones, pins and parasites) may enter by the portal circula- 
 tion. Pus organisms may enter and infect tuberculous, echino- 
 coccic or actinomycotic foci, of which latter 40 cases are recorded. 
 The form of lesion varies ; (a) there may be the solitary or tropical 
 liver abscess, which will be considered separately, or (b) there 
 may be suppurative pylephlebitis, which is less a suppuration of 
 the liver substance than an extension of inflammation in the portal 
 vein itself, following in a dendritic fashion through all of its intra- 
 hepatic ramifications; its branches are distended and present small 
 accumulations of pus, which may appear as yellowish foci through the 
 capsule, but show more clearly on section as portal vein suppuration ; 
 the whole liver may be involved or certain areas may be exempted by 
 total thrombotic occlusion of the larger branches. In some cases the 
 purulent thrombophlebitis may be traced back to the original lesion 
 in the stomach or intestine ; the liver is enlarged but the diagnosis is 
 rarely more than a probable one. 
 
 3. The third variety is infection by the bile vessels (10 per cent.), 
 in which an ascending cholangitis (q. v.), often calculous in origin, 
 produces multiple small abscesses through the liver substance ; this is 
 rather similar in appearance to the pylephlebitic form. These three 
 varieties account for 96 per cent, of cases of liver abscess. 
 
 4. The infrequent fourth variety is infection in infants through the 
 navel. 5. The fifth variety is direct involvement of the liver by con- 
 tiguity, which may occur in suppuration of the gall-bladder or ulcer 
 of the stomach. 
 
 I. Solitary or Tropical Abscess. — The abscess is solitary in 75 per 
 cent, of cases ; in 11 per cent, there are two and in 14 per cent, more 
 than two foci. Twenty to 30 per cent, of cases of amoebic dysentery, 
 by far the most common cause, are complicated by liver abscess. 
 Amoebic abscess may even occur without intestinal ulceration, though 
 amoebae are found in the stools ; in 5 out of 27 of Futcher's cases there 
 were no intestinal symptoms. Over 50 per cent, of tropical abscesses 
 operated on in England by Manson contained amoebae. Shiga's bacil- 
 lary dysentery is rarely a cause. Single abscess may occasionally 
 occur from trauma, pyaemia, typhoid or in hydatid cysts. It occurs 
 chiefly in the tropics, though seen in the Southern states and some- 
 times in the North. In the tropics it is thirty-five times as frequent 
 in Europeans as in the natives; alcoholism and a rich diet are par- 
 
ABSCESS OF TEE L1VEB. 681 
 
 ticularly predisposing factors; 97 per cent, occur in males and 50 
 per cent, in those between twenty and thirty years of age. 
 
 Pathology. — Amoebae reach the liver by the portal vein and cause 
 necrosis by their toxins; this is followed by suppuration. The 
 smaller, sometimes miliary, foci contain glairy, gelatinous, trans- 
 lucent fluid; the larger foci contain white, yellow, green, reddish 
 (like anchovy sauce, Budd) or chocolate-colored fluid, which may be 
 serous, bloody or viscid. Lafleur and Councilman consider that the 
 absence of leukocytes in the wall and contents is pathognomonic of 
 amoebic abscess. Red disks and necrotic liver cells are frequent. As 
 Kartulis pointed out, the pus is usually sterile. The amoebae are 
 more abundant in the abscess wall than in its contents and may be 
 found in the vessels outside of the abscess, necrosing the liver cells. 
 In contrast to other abscesses, the walls of the amoebic type are soft, 
 ragged and produce but little granulation tissue or fibrous encap- 
 sulation. 
 
 Symptoms. — Absence of all symptoms (latency) occurs in 13 per 
 cent, of cases. Symptoms may be classified as (1) septic, (2) he- 
 patic and (3) other symptoms and complications. 
 
 1. Septic Symptoms. — (a) Fever is the most important; it is 
 remittent or intermittent, is less often continuous and in chronic 
 cases there may be a normal or subnormal register, (b) Rigors and 
 sweats, even independent of fever (Lafleur), are frequent. (c) 
 Leukocytosis occurs in 50 per cent. only. In 43 uncomplicated 
 dysentery cases, the leukocyte count was above the average count of 
 the abscess cases in 23.4 per cent. (Futcher). (d) The pulse is 
 small and frequent, (e) Progressive emaciation is usual, and the 
 facies is a combination of hectic, depression, subicterus and cachexia, 
 which is difficult to describe. (/) The urine is febrile and may 
 contain albumin or albumose. 
 
 2. Hepatic Symptoms. — The liver is enlarged from the abscess 
 and from sepsis. The abscess in 70 per cent, is located in the right 
 lobe; Serege by injections has shown that venous blood from the 
 pancreas and intestine is conveyed to the right lobe (whence the right 
 lobe is chiefly involved in intestinal ulceration or cancer), while the 
 blood from the stomach and spleen finds its way to the left lobe. The 
 enlargement is more often upward than downward, wherein abscess 
 differs from cancer and resembles echinococcus. The swelling is 
 often localized, occasioning a dome-like dulness on the upper border 
 of the liver (Frerichs) ; in other cases there is bulging of the lower 
 interspaces or of the hypochondrium. In very large abscess the en- 
 tire organ is greatly swollen, as in one reported abscess which con- 
 tained 2% gallons of fluid. When it occurs below the ribs, fluctua- 
 tion in the liver and. less often, oedema of the abdominal wall may be 
 noted. The liver consistence may be increased at first, (b) Pain is 
 usually present at some time in the clinical course and is due to in- 
 creased weight or to capsular tension and inflammation; perihepa- 
 titis or pleurisy may cause a friction rub from fresh inflammation, 
 
682 DISEASES OF THE DIGESTIVE TRACT. 
 
 or adhesions in more chronic cases. The patient usually lies on the 
 back or right side to avoid the pain caused by sagging of the liver 
 which occurs in the left lateral decubitus. Pain is present in the 
 right shoulder in 17 per cent., being reflected from the phrenic fila- 
 ments on the liver convexity along the phrenic nerve to the acromial 
 branch of the fourth cervical nerve, with which the phrenic nerve is 
 connected; in rare cases the deltoid may waste; the left shoulder is 
 seldom the seat of referred pain, (c) Tenderness over the liver is 
 usually circumscribed, but sometimes general. The right rectus 
 muscle is frequently tense. 
 
 3. Other Symptoms ; Complications. — (a) Icterus occurs in 16 
 per cent, of cases ; it may be slight from sepsis or compression of some 
 bile ducts within the liver, or it may be complete from catarrh of the 
 common duct, (b) The spleen is seldom enlarged, except from a 
 causal septicopyemia, (c) A dry spasmodic reflex cough may be 
 noted (tussis hepatica). (d) Rupture may be the first sign of abscess 
 of the liver. In Waring' s 300 cases, 56 per cent, remained intact, 
 16 per cent, were operated on and 28 per cent, ruptured, (i) It 
 occurs into the lungs in 43 per cent, (average of the figures of War- 
 ing and Cyr) ; abscess of the lung results more often from direct . 
 rupture than from indirect metastasis by the hepatic vein. The 
 patient presents signs of lung abscess (q. v.) and expectorates 
 chocolate-, anchovy- or cream-colored pus containing amoebae, often 
 liver and lung tissue, hsematoidin crystals and perhaps bile. Death 
 may be caused by profuse haemoptysis, (ii) Rupture into the pleura 
 (15 per cent.) causes empyema. Pleurisy, both fibrinous and serous, 
 may also occur without rupture, resulting from infection passing 
 through the lymphatics of the diaphragm ; a right-sided friction rub, 
 serothorax or empyema should always suggest the possibility of an 
 hepatic etiology, (iii) Rupture into the peritoneum (15 per cent.) 
 causes localized or diffuse peritonitis. A subacute serofibrinous 
 peritonitis rarely results, but the author has seen this form, as well 
 as an encapsulated serous effusion, cover the convex and anterior 
 surf aces of the liver, (iv) Rupture into the bowels (colon 2 per cent, 
 and duodenum 1 per cent.) causes pus to be voided, sometimes in 
 large amounts, by the stools, (v) Less frequent are ruptures into the 
 stomach, pericardium, pelvis of the kidney, portal or hepatic vein, 
 inferior cava, bile vessels or abdominal wall, (e) Less frequent com- 
 plications are pyloric obstruction (from abscess of the left lobe), 
 pseudorheumatism or clubbed fingers (from toxaemia), cerebral ab- 
 scess and intestinal obstruction. 
 
 Diagnosis. — Diagnosis is based on (a) an etiological factor; (b) 
 symptoms of sepsis; (c) hepatic signs, localized enlargement, pain 
 and tenderness ; the x-tsljs may be useful when there is bulging of the 
 convexity covered by the lung; (d) exploration with the aspirating 
 needle, which may be dangerous ; the author has seen, as a result of 
 puncture, two deaths from peritonitis and one from an enormous 
 hemorrhage into the peritoneal cavity in a case of abscess with in- 
 
TUMORS OF TtiE LtVEH. 683 
 
 tense icterus ; puncture should be performed only when an operation 
 can be done immediately after pus is found; pus is far less often 
 found in multiple small abscesses than in the large solitary form. 
 
 Differentiation. — Five types of liver abscess are often de- 
 scribed: (a) The latent, (b) typhoid (see table, page 42), (c) ma- 
 larial, intermittent, (d) phthisic, and (e) a type declared by rupture, 
 either pulmonary, peritoneal or pleural. 
 
 Subphrenic abscess simulates pneumothorax (q. v.) rather than 
 liver abscess, because of the presence of tympany ; in its etiology and 
 treatment it resembles liver abscess (see Localized Peritonitis). 
 In gall-stones, with or without suppuration, the fever usually occurs 
 in paroxysms separated by fairly long intervals, jaundice (if present) 
 is apt to become more intense with the fever, the history is different 
 and marasmus is rare. Abscess of the abdominal wall shows no respi- 
 ratory excursion in the exploratory needle introduced into it. Differ- 
 entiation from pleurisy, echinococcus and cancer of the liver is consid- 
 ered under these topics and also in the differential table (page 695). 
 
 Prognosis and Treatment. — Ninety-three per cent, of unoperated 
 cases die from unfavorable ruptures (peritoneal, pleural, pulmon- 
 ary), sepsis, marasmus and amyloid disease, which may occur after 
 weeks or months. It is possible for an abscess to desiccate or to heal 
 after breaking into the lung or bowel, but this cannot be depended 
 upon. The treatment is solely operative ; 40 per cent, reach the oper- 
 ating table in extremis; Solonoff (1903), in a collection of 1,094 
 cases, estimates the mortality at 30 per cent. 
 
 TUMORS OF THE LIVER. 
 
 Tumors of the liver are chiefly carcinomata. Benign tumors pos- 
 sess little clinical interest, as fibroma, lipoma, teratoma, adenoma or 
 angioma, which latter is more frequent in the liver than in any other 
 organ. Single adenoma may develop from the liver cells or bile 
 ducts; multiple adenomata occur chiefly in cirrhosis. Three cases 
 are reported of adrenal "rests." Sarcoma is rarely primary, there 
 being hardly twenty clear cases on record ; it may develop from the 
 connective tissue, endothelium of the lymph or bloodvessels or Kup- 
 fer's cells, as a single primary tumor, multiple primary tumors, dif- 
 fuse infiltration or possibly as a primary melanotic growth, which, 
 however, is almost always secondary to melanotic sarcoma of the 
 eye or skin. 
 
 Cancer of the liver occurred in 2.7 per cent, of Virchow's autopsies, 
 and ranks third among internal cancers ; the usual order of frequency 
 is cancer of the uterus, stomach, mamma and liver ; Eichhorst's order 
 is uterus, stomach, mamma, oesophagus and liver, (a) Primary can- 
 cer is 20 to 48 times as infrequent as secondary cancer; 66 per cent, 
 occur in males. It originates from the liver cells (88 per cent.) or 
 bile vessels (12 per cent.). The main forms are observed (i) as a 
 sharply outlined massive local swelling (in 23 per cent, of Eggel's 
 
684 DISEASES OF TSE DIGESTIVE TRACT. 
 
 163 cases reported in 1901) ; (ii) as sharply demarked multiple 
 nodes of moderate size (in 65 per cent.) of which one of the tumors 
 is primary and the rest secondary; (iii) as diffuse infiltration, fusing 
 with the parenchyma (in 12 per cent.) ; (iv) there is a fourth form, 
 which develops in hepatic cirrhosis. The writer has seen primary 
 cancer develop from an hepatic cyst. Metastases occur in 66 per 
 cent, (b) Secondary cancer results from primary cancer in the 
 stomach (33 per cent.), in the colon (12 per cent), oesophagus, pan- 
 creas, gall-bladder, uterus, ovaries and mamma, by metastasis or ex- 
 tension by contiguity; cancer cells may enter by the portal vein and 
 hepatic artery or much less frequently by retrograde metastasis 
 through the hepatic vein; the lymph vessels do not carry cancer in- 
 fection, as their current flows from within to without the liver. Their 
 structure is that of the primary type. 
 
 Symptoms. — 1. Hepatic Symptoms. — (a) The liver enlarges rap- 
 idly; it may increase to six or eight times its normal size and may 
 weigh 30 to 40 pounds. Its edge is uneven though fairly sharp ; on 
 its surface are lumps which may present a central umbilication. 
 Great unevenness is more characteristic of secondary than of primary 
 tumor, in which the liver is more uniformly swollen. The enlarge- 
 ment is chiefly downward, though the liver is sometimes high because 
 of ascites, tympanites or adhesions. Nodules in the falciform liga- 
 ment may be felt near the navel or linea alba. Sudden increase in 
 size occasionally results from hemorrhage due to icterus. There is no 
 enlargement when the nodules are few and small, and the liver is 
 smaller than normal in 10 per cent, of cases (liver cirrhosis plus 
 malignant adenomata), (b) Hepatic pain is more conspicuous than 
 in any other liver lesion. It may be caused by capsular tension, 
 increased weight, perihepatitis, pleuritis or, less frequently, from 
 rupture of tumor particles into the bile passages, which may simu- 
 late the pain of gall-stones, (c) The liver is often tender, (d) Ex- 
 ceptionally pulsation may be transmitted from the aorta or there may 
 be a venous hum over the liver. 
 
 2. Cachectic Symptoms. — These are adynamia, marasmus, anor- 
 exia, secondary ansemia, leukocytosis (in any carcinoma, but espe- 
 cially in hepatic), insomnia, stupor and illusions. Cachexia prob- 
 ably results from the katabolic toxins elaborated by the tumor, and 
 possibly also from hepatic insufficiency (v. Cirrhosis). Fever may 
 result from the tumor alone, from cholangitis and from secondary or 
 terminal infection. The rare peripheral neuritis and some of the 
 urinary findings may be referred to cachexia. Earely there may be 
 no cachexia. 
 
 3. Compression Symptoms. — (a) Jaundice occurs in over 50 per 
 cent, and more frequently in secondary than in primary cancer. It 
 usually results from mechanical pressure on the larger bile ducts by 
 the tumor or carcinomatous glands. Pressure on the ducts within 
 the liver often produces moderate jaundice and some bile then appears 
 in the stools ; complete icterus may result from concomitant catarrhal 
 
TUMORS OF THE LIFER. 685 
 
 or calculous obstruction, especially significant when there is no 
 ascites. Exceptionally the tumor grows into and along the bile ducts, 
 thereby totally obstructing them. (&) Ascites is present in 50 per 
 cent, of cases. It is usually moderate in degree and results from 
 pressure on the portal vein or its larger branches, peritonitis or portal 
 vein thrombosis (pylethrombosis) ; occasionally it is due to the cir- 
 rhotic form of cancer, growing of the tumor into the hepatic or portal 
 vein, rupture — perhaps with syncope and great hemorrhage — of a 
 cancer nodule into the peritoneum, or rarely to plugging of the liver 
 capillaries by the pigment of a melanosarcoma (Hektoen and Her- 
 rick). A collateral circulation may develop. Friction from peri- 
 hepatitis may be noted. The fluid is usually serous or hemorrhagic, 
 less often adipose, chylous or opaque (v. Cirrhosis) and very rarely 
 contains melanin (sarcoma), (c) Other compression symptoms in- 
 clude splenic tumor from marantic pylephlebitis or pressure on the 
 splenic vein (14 per cent.), hydronephrosis, vomiting from pyloric 
 obstruction, dyspnoea from pressure on the heart and lungs and 
 oedema from pressure on the cava inferior. 
 
 4. Other Symptoms. — The cervical glands are seldom swollen 
 unless there is coincident gastric cancer. Carcinomatous nodes at 
 the navel or in the skin over the liver are due to regional extension. 
 In liver cancer combined with cirrhosis any cirrhotic symptom may 
 occur. The urine shows increased destruction of the tissue nitrogen ; 
 the nitrogenous extractives are increased from the normal 0.6 or 0.8 
 per cent, to 13 or 23 per cent. Acetone and diacetic, lactic, beta- 
 oxybutyric acids, indican, leucin and tyrosin are not infrequently 
 present. The urine is decreased, high-colored and is often icteric. 
 Albuminuria is due to stasis and toxaemia (Teissier speaks of hepa- 
 togenous albuminuria). Melanuria (sarcoma) is sometimes de- 
 tected by adding to the urine a solution of ferric chloride ; the pig- 
 ment exists in the blood as melanin or melanogen, the latter of which 
 is precipitated as the urine stands, or by the addition of some oxy- 
 dizing agent as nitric acid; melanuria nearly always indicates in- 
 volvement of the liver by a melanotic tumor and is often confounded 
 with indicanuria and alkaptonuria. 
 
 Diagnosis. — The chief features are rapid enlargement of the liver, 
 irregular tumors, pain, icterus, ascites, cachexia and in 50 per cent, 
 of cases the recognition of the primary tumor. Other causes of liver 
 enlargement must be considered as in cirrhosis. (See also Differen- 
 tial Tabee, page 695.) Icterus with ascites is always suggestive. 
 In some cases liver involvement is not suspected. 
 
 Differentiation".— (a-) Cirrhosis (see both forms), (b) Syph- 
 ilis (q. v.) produces smaller, harder tumors, of less rapid growth, 
 more often associated with splenic tumor and albuminuria, much less 
 often complicated by ascites or icterus and responding to mercury 
 and iodide, (c) The amyloid liver is equally large and causes con- 
 fusion only when complicated by gummata ; amyloidosis of the spleen, 
 kidneys and intestines usually co-exists with amyloid liver, (d) 
 
686 DISEASES OF THE DIGESTIVE TRACT. 
 
 Hydatid cysts develop more slowly and earlier in life and cachexia 
 appears late if at all. The rare multilocular echinococcus produces 
 enlarged liver, ascites and icterus, but the spleen is also enlarged; 
 puncture may give characteristic findings, (e) Liver abscess is sel- 
 dom accompanied by icterus and ascites; puncture often excludes 
 those doubtful cases of cancer in which there are fever, leukocytosis 
 and semifluctuation of the necrotic neoplastic nodes. (/) In con- 
 gested liver the causal heart or lung disease, the symmetrical liver 
 swelling, other signs of stasis, diffuse tenderness and subicterus, to- 
 gether with cyanosis, are distinctive, though the writer knows of four 
 cases of nutmeg liver in which stasis caused more local than general 
 hepatic enlargement, (g) The corset liver can be easily differentiated 
 if the general symptoms, such as cachexia and the compression symp- 
 toms of cancer, are duly considered, (h) Cancer of the stomach (q. 
 v.) is readily differentiated by its peculiar chemism and signs of 
 stagnation; gastric cancer may cause hepatic involvement. (i) 
 Renal or adrenal tumors are covered by the inflated colon, encroach 
 less upon the thorax, evert the ribs less, have (less or) no respiratory 
 excursion and often are separable from the liver by an intervening 
 strip of tympany, which occurs in but 13 per cent of hepatic tumors. 
 (/) Differentiation between primary and secondary tumors is diffi- 
 cult, yet somewhat irrelevant, as the causal growth leading to hepatic 
 metastasis is latent in 50 per cent. Great caution should be exercised 
 in diagnosticating primary liver tumor; the following characteris- 
 tics are subject to many exceptions: the solitary tumor, its rapid 
 growth, infrequent jaundice and ascites, less emaciation, more rapid 
 course and death in less than four months. Secondary tumors cause 
 death within seven months from cachexia, ascites and intercurrent 
 disease, as pneumonia. 
 
 ^ Treatment. — Treatment is entirely palliative for the pain and as- 
 cites except when, in very exceptional cases, early operation (for 
 primary growths) can be performed. Lucke reported the first re- 
 covery, which afterward proved to be a gumma; his operation was 
 followed by a few others, the cases of Nothnagel, Keen, Mayo Eobson, 
 Bardeleben, D'Urso, Israel, Hochenegg, von Bergmann and others, 
 which included recovery from cancer, sarcoma and malignant 
 adenoma. 
 
 ECHINOCOCCUS CYSTS OF THE LIVER. 
 
 The parasite will be considered under Animal Parasites and we 
 will here consider its hepatic localization, which constitutes 60 per 
 cent, of echinococcus disease ; the adult parasite occurs in the intes- 
 tine of the dog, wolf, fox and jackal; its cystic form occurs in man 
 alone. 
 
 Symptoms. — Fully half the cases of liver echinococcus are clinically 
 latent. Cases with symptoms show the following liver findings: (i) 
 A cyst on the lower border or anterior surface may produce a visible, 
 palpable, round and smooth bulge which everts the right costal arcl} 
 
CYSTS OF THE LIVEB. 687 
 
 or much less often distends the left lobe. In some cases cysts in the 
 right lobe lead to compensatory hypertrophy of the left lobe, which 
 may equal the size of a normal liver. The tumor is as large or larger 
 than an orange. It is tense, elastic, semi-solid and on percussion is 
 dull ; it may fluctuate and give the " hydatid thrill " of Briancon and 
 Piorry, a vibration which is elicited by laying three fingers over the 
 cyst and tapping with the middle one; the thrill is not a frequent 
 finding and may also occur in ascites and sarcoma. The cysts rarely 
 contain gas, due to the Bacillus coli. In large cysts (36 to 70 pints 
 are reported to have been found), the liver may tip so that the right 
 lobe is lower and the left higher than normal, (ii) Cysts on the con- 
 vexity crowd the diaphragm upward, may cause symptoms resembling 
 those of pleurisy (q. v.), produce a dome-like dulness, as in cancer and 
 may compress the lung or even the heart. (ii) Liver pain and 
 tenderness are rare without suppuration, which may induce perihepa- 
 titis ; pain, as in cancer, may be referred to the right shoulder. Pleu- 
 ritic pain follows rupture into the pleura, (iv) Exploratory punc- 
 ture (Recamier and Cruveilhier) is dangerous, because severe nerv- 
 ous toxaemia and cardiac collapse may follow, as described under 
 echinococcus of the lung and pleura, where also the finding of pus, 
 the characteristic membrane, chemical contents and hooklets are 
 enumerated. 
 
 Rupture may occur into the lungs (in 11 per cent, of liver echino- 
 coccus) ; it may simulate phthisis or gangrene of the lungs ; cysts may 
 rupture into the pleura, peritoneum, kidney, stomach, bowel, bile 
 passages, pericardium, portal or hepatic vein and cava inferior; 
 heart embolism or external rupture may occur. 
 
 Pressure symptoms are rare, as icterus (5 per cent.), ascites, albu- 
 minuria, caput Medusa? or oedema of the legs. Dyspnoea may result 
 from pressure on the lungs or vomiting from pyloric stenosis. In 
 some cases there is a distaste for fat or meat. Hemorrhage from the 
 alimentary tract is rare. The blood is usually normal, though the 
 eosinophiles are usually increased in nonsuppurating cysts. Urti- 
 caria may occur after puncture or rupture or without either incident. 
 
 Diagnosis. — Diagnosis depends on (a) the history of the case, in- 
 cluding contact with dogs; (b) the smooth, round tumor; (c) the 
 thrill; (d) slow development; (e) the infrequency of constitutional 
 disturbance, pain and fever, the signs predominating over the 
 symptoms. 
 
 Differentiation. — (a) From other liver cysts; the small cysts in 
 cirrhosis and obstructive icterus are of no clinical importance. Sim- 
 ple serous cysts may, in exceptional cases, hold several (even 13) 
 pints ; they rarely cause symptoms, rupture or hemorrhage. Diffuse, 
 congenital, cystic disease may cause dystocia; in adults also the 
 cysts are probably congenital or developmental in origin and are 
 associated with cystic kidneys, in 4 to 27 per cent, of cases (Lejars, 
 Luzatta and Johnson). Moschcowitz (1906) collected 85 cases of 
 'non-parasitic cysts of the liver; they are usually multiple and sub- 
 
688 DISEASES OF THE DIGESTIVE TRACT. 
 
 capsular and are often associated with other congenital anomalies, 
 such as hare-lip, spina bifida, hypospadias or supernumerary fingers. 
 He concludes that (i) they are always associated with congenitally 
 aberrant bile ducts; (ii) they are embryonal " rests"; (iii) the cysts 
 are due to inflammatory hyperplasia of these ducts or to congenital 
 obstruction in them. Hoffman reported 18 operated cases, (b) 
 Malignant disease causes cachexia, more pain (than does echinococ- 
 cus), multiple tumors, ascites and icterus, (c) Syphilis of the liver 
 (q. v.) more often causes albuminuria or splenic tumor and responds 
 to antisyphilitic remedies, (d) From pleurisy; the x-rays may show 
 the localized tumor on the liver convexity ; but the upper line of pleu- 
 ritic dulness is much less often convex upward; there may be thoracic 
 symptoms, as haemoptysis, when there is rupture into the lung ; care- 
 ful examination of the sputum or aspirated fluid shows the diagnostic 
 hooklets. (e) In rare cases a pendulous, pedunculated, movable cyst 
 (v. Frerichs) may resemble a pancreatic cyst, enlarged kidney, gall- 
 bladder or ovarian cyst. Rupture into the bile passages may simulate 
 the pain of gall-stones. (/) Liver abscess is usually distinguished 
 with ease, though one may remain in doubt in cases of suppurating 
 cysts ; the eosinophiles are not increased in liver abscess ; both condi- 
 tions are strictly surgical. (See table, page 695.) 
 
 Prognosis. — The prognosis depends largely on whether surgery is 
 invoked. Cysts may, however, calcify or indurate spontaneously. 
 According to Cyr, the mortality of rupture into the peritoneum is 
 90 per cent., into the pleura 80, bile ducts 70, bronchi 57, stomach 40, 
 intestines 15 and externally 10 per cent. 
 
 Treatment. — When drainage by the trochar is performed (Hip- 
 pocrates), it is said that 45 to 77 per cent, of cases recover. A few 
 die suddenly from a toxalbumin, formed when the parasite dies ; it 
 causes urticaria, convulsions, cardiac failure and other symptoms 
 similar to those produced by myrtilotoxin in mussel-poisoning. Di- 
 rect surgical intervention is attended with the least risk. Prophy- 
 laxis is necessary, such as the burning of slaughter-house offal and 
 avoiding close contact with dogs. 
 
 Multilocular or Alveolar Echinococcus.— This form is due to an- 
 other parasite (see Animal Parasites) ; it is extremely infrequent 
 and only about 100 cases are recorded. 
 
 Symptoms. — The right lobe of the liver alone is involved in 65 per 
 cent, of cases and the left alone in 10 per cent. The liver is fibrosed, 
 nodular and seldom fluctuates. This rare affection is attended by 
 splenic tumor (90 per cent.), icterus (80 per cent.), dyspepsia, as- 
 cites and, less commonly, by fever, polyuria, collateral circulation, 
 gastro-intestinal hemorrhage, late emaciation (cachexia) and meta- 
 stases in the heart and lungs by way of the lymph or bloodvessels; 
 death may occur after years from cholsemia or hemorrhages. The 
 diagnosis is very difficult, though it is sometimes aided by explora- 
 tory puncture and the most frequent confusion is with cancer of the 
 liver. The only hope of recovery is in extirpation, which has been' 
 successfully done by Terillon, Bruns and others. 
 
AMYLOID LIVER. 689 
 
 FATTY LIVER. 
 
 The term "fatty liver" (hepar adiposum) includes fatty infiltra- 
 tion and fatty degeneration ; as a distinction between them is of more 
 speculative than clinical interest, they may be considered together. 
 
 Etiology. — (a) Obesity and (b) decreased oxygenation from carci- 
 nosis or any other cachexia, rickets, profound or pernicious anaemia, 
 phthisis, cardiac stasis and kindred causes may produce fatty liver. 
 
 (c) Toxaemias, as tuberculosis, the acute specific infections, infantile 
 diarrhoea, acute yellow atrophy and suppuration, (d) poisons, as 
 phosphorus, alcohol, arsenic or chloroform, and (e) local diseases of 
 the liver, as cirrhosis or nutmeg liver, are etiological factors. 
 
 Pathology. — The fat, which is normally found in the liver up to 2 
 to 5 per cent, of its weight, may amount to over 40 per cent. The 
 liver is enlarged and may weigh as much as 12 pounds or 4,500 gm. 
 Its surface is smooth, its edges are rounded, its consistence is de- 
 creased and its color is yellow. On section it is anaemic, yellow and 
 smooth, though the lobules may be slightly prominent. The color is 
 yellow when oleic acid predominates and pale when there is more 
 palmitin and stearin. Slight quantities may be detected only on 
 microscopic examination. When cut with a warm knife the fat may 
 be seen on the blade. Microscopically, fat is seen which, in fatty in- 
 filtration, is located principally in the periphery of the lobules and 
 obscures the liver cells ; when the fat is dissolved by ether, the normal 
 liver cells are clearly seen. In fatty degeneration, fat forms at the 
 expense of the liver cells, i. e., the percentage of albumin is decreased. 
 The statement that fatty infiltration occurs in large globules and 
 fatty degeneration in smaller ones is not wholly correct. Pathologists 
 are inclined to consider infiltration of more importance than de- 
 generation. 
 
 Symptoms. — (a) The positive findings are as follows: the liver is 
 symmetrically enlarged and smooth and rarely extends below the 
 navel. Its edge is rounded, soft and can usually be palpated, even in 
 obese persons, (b) The negative findings are absence of pain, tender- 
 ness, icterus, splenic tumor, ascites or gastro-intestinal hemorrhage. 
 
 The diagnosis is easily made and liver stasis, amyloid degeneration 
 and cirrhosis can be readily excluded (see page 695). The treatment 
 is that of the causal factors. 
 
 AMYLOID LIVER. 
 
 Amyloid degeneration was first clearly described by Rokitansky. 
 
 Etiology. — (a) Ulcerative tuberculosis of the lungs or bones causes 
 over 50 per cent, of amyloidosis, (b) Inveterate syphilis, particu- 
 larly ulcerative and osseous types, produces 25 per cent, of amyloid 
 disease, (c) Chronic suppuration has become uncommon since the 
 introduction of asepsis and antisepsis. Krawkow produced amyloid 
 degeneration experimentally by inoculations of the staphylococcus. 
 
 (d) As exceptional causes, intestinal ulcerations, exhausting diar- 
 44 
 
690 DISEASES OF THE DIGESTIVE TRACT. 
 
 rhceas, rickets, leukaemia, pseudo-leukaemia and ulcerating neoplasms 
 may be mentioned. Seventy-eight per cent, of cases occur in males 
 (Frerichs). 
 
 Pathology. — Amyloid degeneration is much less frequent in this 
 country than in Europe. Its localization, in order of frequency, is 
 in the spleen, kidneys, liver and intestines. The liver is uniformly 
 enlarged and may weigh 13 to 16 pounds (5 to 6,000 gm.), even in a 
 child. It is hard, smooth and very pale. Its edges are more blunt 
 than normal, though somewhat sharp. On section the general ap- 
 pearance is waxy, speckled, resembling raw ham, the edges are 
 slightly translucent and the lobules are indistinct. If a thin slice is 
 placed in diluted Lugol's solution, the amyloid areas assume a brown 
 color (Virchow), the name (amyloid) referring to this starch-like 
 reaction; the waxy substance, however, is a proteid and reaches the 
 liver by the hepatic artery, whence it is first deposited in the middle 
 zone of the lobule, and later infiltrates the central and peripheral 
 zones. It is essentially an infiltration, affecting primarily the capil- 
 laries of the hepatic artery. Slight lesions may necessitate the mi- 
 croscope for detection. Amyloid liver may co-exist with gumma, 
 cancer or cirrhosis. 
 
 Symptoms. — The large, tense, symmetrical, painless, smooth liver, 
 with rounded edges, is characteristic. Its dimensions may attain 
 those of cancer. The onset and development are usually slow, but 
 acute amyloid has developed within a month. Splenic amyloid en- 
 largement is usually also noted, as well as albuminuria from renal 
 amyloidosis (q. v.). In only 0.8 per cent, of amyloid degeneration is 
 the liver alone involved (Fehr). Gastro-intestinal symptoms, as 
 nausea, vomiting and diarrhoea, may result from amyloidosis of the 
 alimentary capillaries. In advanced cases cachexia, oedema and 
 ascites may develop. Hepatargia is rare. 
 
 Diagnosis. — Diagnosis depends on (a) the recognition of a cause; 
 (b) the characteristic, smooth, symmetrical enlargement, which is 
 less hard than that of cirrhosis; (c) the associated amyloid disease 
 of the spleen, Jcidney and alimentary tract ; (d) the absence of icterus 
 (which very rarely results from amyloid portal glands) and of portal 
 stasis (ascites is an infrequent, late symptom and results from renal 
 implication) ; and (e) the small amount of urobilin in the stools. 
 Differentiation from cirrhosis (q. v.) and cancer (q. v.) presents no 
 difficulties. Gummata in the liver plus amyloid disease may cause 
 confusion. No diagnosis is possible in the exceptional cases in which 
 the liver is slightly enlarged, because it is only slightly diseased, or 
 in those cases in which splenic .tumor and albuminuria are absent. 
 Other diffuse and focal hepatic diseases are differentiated on page 695. 
 
 Prognosis. — The prognosis of pronounced cases is unfavorable 
 though light grades may exceptionally regress (Budd, Bamberger, 
 Frerichs, Graves). 
 
 Treatment. — Treatment is unavailing ; it is solely that of the causal 
 condition and of the symptoms as they arise. 
 
ANOMALIES OF FORM OF THE LIVEE. 691 
 
 ANOMALIES OF FORM AND LOCATION OF THE LIVER. 
 
 In situs viscerum inversus the liver lies on the left side, which in 
 pathological conditions may lead to serious diagnostic error. Fenger 
 and Billings mention a case of icterus and gall-stones in situs in- 
 versus which was diagnosticated as acute yellow atrophy ! 
 
 Tilting of the Liver. — Tilting of the liver (ante- and retroversion), 
 dislocation downward by pleuritis, pneumothorax or tumors, or up- 
 ward luxation require but passing mention. 
 
 The liver may be found in the thoracic cavity as a result of con- 
 genital malformation or severe trauma. 
 
 " Wandering Liver." — Wandering liver (He-par migrans s. mo- 
 bile) occurs in women (88 per cent.), usually after several pregnan- 
 cies. Its causes are those of enteroptosis, with which it usually oc- 
 curs, viz., flaccid abdominal walls, possibly congenital laxness of the 
 suspensory ligaments, tight lacing or very rarely from traction, as 
 by a tumor. Clark and Dolley collected 118 cases; one case had a 
 mesohepar attached to the diaphragm and absence of the coronary 
 and right lateral ligaments. 
 
 Symptoms. — Symptoms may be entirely lacking. In 5 per cent, 
 the onset is acute (Graham), though usually gradual. Subjectively, 
 vague pain or oppression over the liver, gastro-intestinal disorders 
 or nervous symptoms may be present. Objectively, the liver is 
 lower and more mobile than normal; there is sometimes cardioptosis, 
 usually gastroptosis and in 20 per cent, nephroptosis. Its notch can 
 be distinctly felt, often also its convex surface and sometimes the 
 tense, stretched ligaments. It can be replaced. The entire liver, in 
 extreme instances, may be below the costal arch, and tympany, due 
 to the bowel, may exist between it and the lung. In a recent case 
 there was tympany between the left costal arch and the prolapsed 
 spleen and tympany between the right arch and the liver, even 
 though the patient was five months pregnant. In very rare instances 
 there may be pain similar to that of gall-stones; ascites or splenic 
 tumor results from torsion of the portal vein. 
 
 Treatment.— The treatment is (a) mechanical, which consists of 
 replacing and supporting the liver with appropriate binders or pads; 
 (b) symptomatic, with due consideration of the neurasthenic mani- 
 festations; (c) dietetic, in order to increase the body-weight and (d) 
 operative, in which the liver is sewed to the diaphragm or abdominal 
 wall. In 39 cases hepatopexy cured about 75 per cent. 
 
 Corset Liver. — The corset liver is found in 25 per cent, of female 
 cadavers (Leube), but much less frequently here than abroad. Cor- 
 sets cause pressure-atrophy of the liver substance, followed by indura- 
 tion, deformity and peritoneal thickening; these changes are most 
 conspicuous and usual in the right lobe. The liver may be merely 
 constricted, dislocated upward or the part below the constricting zone 
 may hang loosely as upon a hinge ; this may cause diagnostic con- 
 fusion with floating kidney, enlarged gall-bladder or other tumors. 
 
692 DISEASES OF THE DIGESTIVE TRACT. 
 
 The gall-bladder is dilated in 60 per cent, of cases, though icterus is 
 infrequent. Subjective manifestations are often absent, though there 
 may be a sense of tension in the part. Sometimes paroxysmal syn- 
 cope and vomiting may occur, due to congestion of the snared-off 
 portion of the liver. Physical examination often determines the 
 condition, especially when, by careful palpation, the hinged and hard 
 part can be proven directly continuous with the liver's known mar- 
 gins. Eespiratory excursion is naturally imparted to it in most 
 cases. Confusion arises when the intervening gut causes a narrow 
 zone of tympany between the hinged segment and the liver proper, 
 but even then careful palpation frequently demonstrates its con- 
 tinuity with the liver. Congenital tongue-like lobes may be confused 
 clinically with corset liver; they are often cirrhotic and relatively 
 often the seat of malignancy, suppuration or syphilis. Corset liver 
 is regarded as a disposing factor in gall-stone formation. Treatment 
 is seldom possible nor is it important, though prophylaxis and per- 
 haps resection should be mentioned. 
 
 AFFECTIONS OF THE BLOODVESSELS OF THE LIVER. 
 
 I. Active Hyperemia of the Liver. — A degree of arterial hypere- 
 mia in the portal circulation is physiological during digestion. An 
 accentuation of this condition is common in heavy eaters and drink- 
 ers and acute infections, in which it may be combined with venous 
 hyperemia. Heat is probably not the cause of " tropical hypere- 
 mia. " The alleged vicarious hyperemia from suppressed menstrua- 
 tion, the menopause or diseases of the internal female genitalia is 
 based wholly on theory. The symptoms resemble those of passive 
 hyperemia (v. i.), viz., some hepatic enlargement, moderate discom- 
 fort in the right hypochondrium and also, it is alleged, slight icterus. 
 Treatment is seldom indicated, save in cases of dietetic excesses, 
 where gastro-intestinal symptoms obtain. Then a simple, moderate 
 or milk diet and calomel and saline purgation are indicated. 
 
 II. Passive Hyperemia of the Liver. — Etiology. — Passive conges- 
 tion of the liver results from various kinds of stasis, the stress in all 
 of which is felt in the efferent hepatic (sublobular) veins within the 
 liver. It results (a) from cardiac insufficiency, caused by valvular 
 diseases, particularly mitral, myocardial maladies or pericardial 
 lesions; (&) from pulmonary stasis, due to emphysema, chronic bron- 
 chitis, asthma, induration or obliterative pleurisy; (c) from stasis 
 caused by spinal deformity, aneurysm, mediastinal tumor, perihepa- 
 titis or pressure on the cava inferior. 
 
 Pathology. — The essence of passive congestion is over-filling of the 
 sublobular or the hepatic venous circulation, malnutrition of the liver 
 cells (fatty degeneration) and in some advanced cases, increased con- 
 nective tissue. The liver is usually symmetrically enlarged, firmer 
 and a darker red than normal, though hepatic hyperemia lessens after 
 death. The capsule is often thickened or edematous. On section 
 
AFFECTIONS OF BLOODVESSELS OF LIVEB. 693 
 
 the so-called nutmeg appearance is noted, but seldom over the entire 
 liver; it is not pathognomonic of passive congestion. The central 
 veins with their radiating offsets are dark, cyanotic and sometimes 
 sclerotic from stasis, while the periphery of the lobule is yellow-white 
 from cloudy or fatty change (malnutrition or impaired oxygenation). 
 Long-standing congestion results in atrophy and pigmentation of the 
 cells in the periphery of the lobule (Virchow's red atrophy) ; there is 
 usually increased connective tissue with fine granulations, the atro- 
 phic cyanotic liver or cardiac cirrhosis of the French; fibrosis is 
 probably for the most part relative or apparent, for the liver paren- 
 chyma atrophies ; true cirrhosis may co-exist with cardiac disease. 
 
 Symptoms and Diagnosis. — (a) The causal heart (or lung) lesion 
 has its appropriate symptoms, (b) The liver is evenly enlarged, both 
 on percussion and palpation, sometimes also on inspection ; if ascites 
 is present thrusting palpation with the finger-tips usually outlines 
 the organ; the liver may reach to the navel or even lower and may 
 evert the ribs. Its edges are firmer than normal, somewhat rounded, 
 sensitive (from capsular tension) and descend with inspiration; the 
 incisure is clearly felt. If there is relative tricuspid insufficiency, a 
 systolic expansile pulsation is detected by palpating with both hands, 
 which are separated from each other with each systole. This is 
 readily differentiated from the non-expansile pulsation which is 
 transmitted to the liver from the aorta, (c) The hepatic intumes- 
 cence varies greatly, as the heart responds to rest or to digitalis, or 
 fails in compensation, (d) The skin shows cyanosis and is also 
 tinged with slight icterus; to the experienced eye it has a characteris- 
 tic appearance, which is probably due to a static catarrh of the finer 
 intrahepatic bile radicles, (e) For other symptoms, see Signs of 
 Stasis under Valvular Disease. The spleen is seldom enlarged 
 save from cardiac infarcts or complicating liver cirrhosis. Hsema- 
 temesis is infrequent. Albuminuria and gastro-intestinal symptoms 
 are referable to the heart. Ascites is usually late in onset and mod- 
 erate in degree; the earlier statement, that an ascites, which is dis- 
 proportionately marked in comparison with the general oedema, in- 
 dicates the atrophic (indurated) nutmeg liver, is incorrect, because 
 a cardiac ascites sometimes occurs without general oedema. Toward 
 the end of the course there may be signs of renal and hepatic in- 
 sufficiency. 
 
 Differentiation is seldom complicated, for the fundamental heart 
 lesion, the evenly enlarged, tender liver, which varies in size from 
 time to time, and the slight icterus with cyanosis are usually unmis- 
 takable. Certain features may sometimes mislead, as the occasional 
 unequal distribution of the liver changes, which may suggest tumor ; 
 the tenderness in two cases which the author saw was thought to be 
 suppurative. (See page 695.) The treatment is that of uncompen- 
 sated valvular disease (q. v.). 
 
 III. Pylethrombosis — Pylephlebitis. — Thrombosis or phlebitis of 
 the portal vein is practically always secondary to compression or ob- 
 
694 DISEASES OF THE DIGESTIVE TRACT. 
 
 struction, as liver cirrhosis, with which 33 per cent, of pylephlebitis 
 cases occur; to cancer, ulceration, abscess or inflammation of con- 
 tiguous structures, gall-stones, cholangitis and chronic proliferative 
 peritonitis ; and to diseases of the intima, as phlebosclerosis and syph- 
 ilitic endophlebitis ; all cases are promoted by slowing of the portal 
 current. Parasites and embolism are rare causes. Pylephlebitis and 
 thrombosis occur chiefly in males over forty years of age. A fatal 
 obliterating endophlebitis exists with symptoms very closely resem- 
 bling those of atrophic cirrhosis; Hess in 1905 collected 23 cases. 
 
 Symptoms.- — These may be entirely absent because of collateral com- 
 pensation through the hepatic artery or Sappey's accessory portal 
 vein. The onset is usually sudden, with symptoms of acute portal 
 stasis. The spleen is enlarged in 75 per cent., unless fibrous changes 
 in its pulp or capsule prevent its swelling. Ascites develops in 66 
 per cent, and rapidly recurs after tapping. Gastro-intestinal symp- 
 toms are usual, as hemorrhage (44 per cent.), intense sudden epi- 
 gastric pain, vomiting, diarrhoea or sometimes acute intestinal ob- 
 struction. The portal vein is sometimes varicose below and is gen- 
 erally obliterated at and above the point of obstruction (pylephlebitis 
 adhsesiva) ; this leads to shrinking of the liver, particularly if the 
 hepatic artery is sclerotic, in which rare event the entire liver may be 
 hemorrhagically infarcted. The liver is said to become lobulated, 
 but this probably results from antecedent syphilis. Symptoms of 
 hepatargia (hepatic insufficiency) and alimentary glycosuria may 
 develop. (Edema of the abdominal wall, development of a collateral 
 circulation and icterus are uncommon. 
 
 Diagnosis. — Diagnosis is difficult, unless the onset is typically sud- 
 den, in which case pylethrombosis may be considered. Save for 
 their acuity, the findings are those of atrophic cirrhosis; a caput 
 Medusae rather indicates occlusion of the portal radicles than of the 
 portal trunk. The ascites may suggest carcinoma or peritonitis or 
 the hemorrhage may simulate gastric ulcer or hepatic cirrhosis. 
 
 Course and Treatment. — Death may occur in a few days or after 
 months or six to twenty years. Treatment is ineffectual, save in early 
 syphilitic cases. Citric acid (3j) may be given every few hours to 
 lessen thrombosis. Talma's operation may be considered. 
 
 Pylephlebitis suppurativa has been considered under liver abscess. 
 It is a pyaemia of the portal vein ; metastasis or extension occurs in 
 the main portal trunk and its branches from infection of its radicles 
 of origin; ulcerations and inflammations in the gastro-intestinal tract 
 are its cause in 75 per cent, of cases ; appendicitis causes about 40 
 per cent. (Dieulafoy's " appendicular liver") and gall-stones, in- 
 fected piles and pancreatic or umbilical suppuration cause most of 
 the other cases (v. s. Livee Abscess, Second Variety). 
 
 The symptoms are those of the original disease, those of sepsis and 
 those of portal stasis. In very rare cases the thickened vein may be 
 palpated. The spleen is enlarged, chiefly from sepsis, though some- 
 times from stasis. The liver is tender and somewhat enlarged, ic- 
 
DIAGNOSTIC TABLE OF LIVER DISEASES. 
 
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696 DISEASES OF TEE DIGESTIVE TBACT. 
 
 terns occurs in over 50 per cent, and the usual signs of sepsis prevail. 
 The diagnosis is always difficult, but is based on symptoms suggesting 
 liver abscess (though without the findings of solitary abscess) on the 
 one hand and those of sepsis on the other. The treatment is prac- 
 tically futile, being supportive and rarely, if ever, operative. 
 
 IV. Affections of the Hepatic Artery and Vein. — These are chiefly 
 of pathological interest. Infarction of the hepatic artery with com- 
 plete necrosis of the liver is very rare. 
 
 Aneurysm (q. v.) can seldom be diagnosticated. Pulsation is un- 
 known; pain is nearly always present, icterus and a tumor occur in 
 the majority of cases, ascites is uncommon and death usually results 
 from gastro-intestinal hemorrhage. 
 
 Thrombosis of the hepatic veins is very infrequent, only 12 cases 
 being reported. It may follow perihepatitis or, less often, compres- 
 sion by a neoplasm or fibrous obliteration of the inferior cava. As- 
 cites and splenic tumor sometimes result. Suppurative thrombosis 
 is always secondary to liver suppuration. Eetrograde embolism 
 (Heller) is mentioned under liver abscess. 
 
 V. Syphilis of the Liver (see Syphilis). 
 
 DISEASES OF THE GALL-BLADDER AND BILE 
 
 VESSELS. 
 
 ICTERUS. 
 
 Icterus or jaundice is a symptom of various affections of the liver 
 and bile vessels; it usually results from obstruction to the bile flow 
 and is characterized by staining of the skin, mucosae and urine by 
 retained bile pigments. 
 
 Etiology. — Most cases of icterus are due to obstruction within or 
 about the liver and biliary system ; but slight obstruction is necessary 
 because the bile is secreted under low pressure, (a) Hepatic diseases. 
 It is (i) frequent in acute yellow atrophy, biliary cirrhosis, multilocu- 
 lar echinococcus, carcinoma, passive congestion and syphilis ; (ii) infre- 
 quent in atrophic cirrhosis, unilocular echinococcus and abscess ; (iii) 
 absent in fatty and amyloid liver and in simple pylephlebitis. (See 
 page 695.) Pick, Liebermeister and Minkowsky believe that occa- 
 sionally functional liver disturbance may produce icterus (para- 
 pedesis of bile, " diffusion-icterus " or paracholia) which is analogous 
 to transient albuminuria (in its relation to Bright's disease). (&) 
 Diseases of the biliary tract, as (i) catarrhal, croupous or purulent 
 inflammation; (ii) calculous obstruction; (iii) congenital and (iv) 
 cicatricial occlusion; (v) malignant growths; (vi) parasitic obstruc- 
 tion by ascaris, distoma or hydatid vesicles, (c) It may result from 
 
ICTERUS. 697 
 
 disease in contiguous structures, as (i) duodenal ulcer, cicatrix, ca- 
 tarrh or cancer; (ii) tumors of the colon or lymph glands; (iii) 
 tumors or inflammation of the pancreas, stomach, kidney, omentum, 
 mesentery and peritoneum, and (iv) rarely from visceroptosis or aneu- 
 rysm, (d) So-called hcematogenous or urobilin icterus. It was for- 
 merly maintained that toxic and toxaemic conditions, breaking down 
 the blood cells (haemolysis), cause icterus (cytohaemolytic icterus). 
 It is now thought that most of these cases are essentially obstructive 
 (thickening of the bile or cholangitis of the smallest radicles), though 
 the obstruction of the small bile ducts within the liver is not complete. 
 Eppinger maintains that the smaller bile radicles dilate and some- 
 times rupture, letting the bile into the lymph vessels which absorb it ; 
 mechanical obstruction lies in the capillaries blocked by fibrin or bile 
 thrombi. The jaundice in these cases is slight, bile pigment (bili- 
 rubin) is not found in the urine and the stools are bile-stained. This 
 type occurs (i) in various infections, relapsing fever, septicopyemia, 
 etc., (ii) in pernicious anaemia, and (iii) in toxic conditions, poison- 
 ing by phosphorus, chloroform, etc. 
 
 Icterus neonatorum may be considered here, (a) The physiolog- 
 ical type occurs in 66 per cent, of children; it appears on the second 
 day, lasts two weeks and is never fatal ; its cause is not clear, though 
 haemolysis, increased blood pressure within the liver and persisting 
 patency of the ductus venosus are suggested. (&) The much rarer 
 pathological type may be caused by sepsis, syphilis, Winckel's disease, 
 or still more exceptionally by congenital obstruction, gall-stones (10 
 cases collected by Skormin), acute yellow atrophy (7 cases) or ca- 
 tarrhal icterus (but 3 cases recorded). Glaister reported a family in 
 which 6 cases of jaundice developed after birth. Krannhals recently 
 published 26 cases of congenital " family icterus," most of which had 
 an enlarged spleen. 
 
 Symptoms. — Bilirubin, found normally in the bile, enters the blood 
 in biliary obstruction, by the lymph vessels and possibly also by the 
 bloodvessels and produces the following symptoms : 
 
 1. Skin and Mucosa. — Staining of the skin and mucosae occurs 
 in three days. The sclerse, skin and mucosas are yellow and in chronic 
 cases dark brown. The skin itches because of its dryness or the action 
 of the bile on the nerves. Urticaria or xanthoma may occur. 
 
 2. Urine. — The urine contains bilirubin before icterus is seen in 
 the skin. Adding nitroso-nitric acid to the urine in a porcelain dish 
 or on filter paper gives the Gmelin play of colors, of green, yellow, 
 violet and red. If the urine is agitated the yellow color appears in 
 its foam. Confusion is possible with melanuria, haematuria, uro- 
 bilinuria or staining of the urine with rhubarb, picric acid, santonin, 
 senna, etc. The subject of urobilinuria and urobilin-icterus has 
 caused much discussion; urobilin is formed in the intestine by the 
 reduction of bilirubin, whence it is absorbed and excreted by the 
 urine; it never stains the skin and icterus results from bilirubin 
 alone. There are three classes of cases; (a) in complete biliary 
 
698 DISEASES OF THE DIGESTIVE TRACT. 
 
 obstruction with icterus only bilirubin is found in the urine, for none 
 of it reaches the intestine to be converted into urobilin; (b) in partial 
 obstruction bilirubin is found in the blood and urine and also some 
 urobilin, which is produced in the intestine from the bilirubin by 
 intestinal fermentation; (c) in slight obstruction there is no bili- 
 rubin but much urobilin in the urine. Albuminuria may occur or 
 cylindruria alone and the hyaline casts and desquamated epithelium 
 are then bile-stained. The sulphates, normally 14 to 25 per cent, of 
 the sulphur output, may be increased to over 40 per cent. Indican- 
 uria is often marked and is due, like the sulphate increase, to greater 
 intestinal putrefaction. 
 
 3. The Digestive Tract. — The tongue is coated, the breath has 
 a disagreeable odor and the mouth may have a bitter taste, due to 
 toxaemia. There may be an especial aversion to fats and sometimes 
 to proteids and there may be nausea. The abdomen is distended, 
 which is thought to be due to the absence of the antiseptic action of 
 the bile, though the importance of this action has been overestimated. 
 Starchy food is not wholly absorbed, albumin digestion is somewhat 
 impaired and fat is found in large amounts in the stools (steator- 
 rhcea). The function of the pancreas in this respect is far more 
 important than that of the bile. Vegetable are absorbed better thau 
 animal fats. The normal amount of fat found in the faeces is 7 to 
 10 per cent., and this is increased in icterus to 50 or 80 per cent. 
 The stools are clay-colored, constipated and stinking; they may 
 shimmer when the fatty soap crystals are abundant ; they are also dry 
 (the bile in the faeces normally amounts to nearly a quart a day). If 
 the obstruction is incomplete — as in many intrahepatic diseases — the 
 stools are merely somewhat lighter than normal; a nitrogenous diet 
 may impart a brownish color to the faeces. The faeces may appear 
 deceptively dark if voided with the urine which lends a yellow color 
 to their surface. 
 
 4. Chol^mia. — Cholaemia (hepatargia or hepatic insufficiency) 
 may finally develop. It probably results from injury to the liver cells 
 which fail to destroy the usual intestinal toxins and those formed in 
 excess by the increased putrefaction. Its symptoms resemble acute 
 yellow atrophy, i. e., nervous excitation followed by stupor, irregular 
 breathing or cutaneous and other hemorrhages. Most subjects of 
 icterus are depressed, irritable, sleepless and somewhat emaciated. 
 The hemorrhages are thought by Mayo Eobson to result from co- 
 incident pancreatic involvement (diminished lime salts or the gly- 
 cerine formed by fat necrosis). 
 
 5. Other Symptoms. — (a) The heart rate is slow, particularly 
 in catarrhal forms or recent cases and in the absence of pain, fever 
 and intoxication; it may fall to 21 (Frerichs) ; it has been explained 
 by degeneration of the heart muscle or action of the bile-salts on the 
 intracardiac ganglia, but it is probably caused by vagus stimulation, 
 for atropine will raise the rate (Weintraud). The arterial pressure 
 is low and the capillaries wide. A functional heart murmur may 
 
CHOLELITHIASIS. 699 
 
 develop ; this is usually caused by myocardial weakness ; Potain holds 
 that the lung capillaries contract reflexly, thereby increasing the 
 work of the right heart and causing its dilatation. The respiration 
 rate is decreased, even to 7 a minute; the temperature is usually 
 normal. (b) The blood shows the bile stain and in severe cases de- 
 layed coagulation, anaemia and leukocytosis. The blood may give a 
 partial Widal reaction (typhoid cholecystitis?), (c) The liver cells 
 may suffer mechanically and chemically from bile stasis and may be 
 smaller, altered in form, pigmented, necrotic and bile-stained. The 
 gross and minute anatomy varies with the cause. The bile vessels 
 are often dilated, sometimes thickened and occasionally ruptured. 
 The condition of the gall-bladder will be discussed under gall-stones 
 and pancreatic cancer. As stated under biliary cirrhosis, it is ques- 
 tionable whether simple biliary stasis ever causes induration of the 
 liver, (d) The spleen is occasionally enlarged, especially in chil- 
 dren, from infection or portal stasis, but splenic tumor is no part of 
 bile stasis, (e) Nearly all tissues, secretions and excretions are bile- 
 stained. The muscles and nervous tissues (except in the severe type 
 of icterus neonatorum) are seldom icteric. (/) Xanthopsia, yellow 
 coloring of objects seen, is fairly common and is due to the action 
 of the bile pigment on the nervous tissues. The explanation of nyc- 
 talopia and hemeralopia is uncertain, (g) Of xanthelasma multiplex 
 23 cases were collected by the London Pathological Society in 1882 
 Putcher in 1905 reported three cases; 80 per cent, of reported cases 
 occur in chronic icterus (in women more frequently than in men), 
 due to gall-stones, stricture of the bile-ducts, cirrhosis, hydatids and 
 cancer. They are often symmetrical, often begin on the eyelids or 
 the folds and creases of the skin, in one case were found in the bile 
 ducts, rarely disappear and are probably due to some toxic substance. 
 Few cases are probably hereditary. 
 
 Diagnosis. — A diagnosis is easily made. Icterus is not noticed in 
 artificial light and daylight is absolutely essential for its certain de- 
 tection. It is seldom confused with anaemia, cachexia, Addison's 
 disease or the pigmentation of vagabondism. Pingueculae on super- 
 ficial examination are often mistaken for scleral staining. 
 
 Prognosis and Treatment. — The prognosis and treatment cannot be 
 considered, as icterus is but a symptom. The details depend on the 
 basic affection. (See Catarrhal Jaundice for treatment in gen- 
 eral.) The patient may recover after four years (Budd) ; cases of 
 icterus lasting six years (Murchison, Barth, Bosnier), ten to twenty- 
 five years (Legendre, Galliard) or even fifty-two years (Masing) have 
 been reported. 
 
 CHOLELITHIASIS. 
 
 Gall-stones are found in 8 per cent, of autopsies. Among the 
 many literary contributions to this subject are those of Naunyn, 
 Kehr, Riedel, Lange, Robson, Keen, Fenger, Murphy and Mayo. 
 
 Etiology. — 1. Immediate Cause. — The causes are (i) catarrhal 
 
700 DISEASES OF THE DIGESTIVE TRACT. 
 
 inflammation of the gall-bladder or bile vessels and (ii) stagnation of 
 bile. Bacteria play an important role, especially the typhoid (found 
 in 33 per cent.) and colon bacilli; they have been found in calculi, 
 and cholelithiasis has been experimentally produced by their inocu- 
 lation ; the Bacillus typhosus may live seven years in the gall-bladder. 
 
 2. Predisposing Factors. — (a) Age; 75 per cent, of cases occur 
 in persons over forty years of age and only 1 per cent, in those under 
 twenty years, (b) Sex; 70 to 80 per cent, occur in women, in whom 
 pregnancy, menopause, lax abdominal walls, enteroptosis, constipation, 
 sedentary life and lacing are regarded as promoting factors; Bol- 
 linger and Bother found that 40 per cent, of women who have gall- 
 stones also have the corset liver. According to Naunyn, gall-stones 
 are found in 25 per cent, of autopsies on women over sixty years; 
 90 per cent, of women affected have borne children, (c) Other pos- 
 sible but only accessory factors are sedentary habits, obesity, luxuri- 
 ous living, insanity, cancer of the stomach and foreign bodies in the 
 biliary tract; Kehr holds that stone-formation is induced by long 
 intervals between meals. Cholelithiasis is more common in cool 
 than in warm climates. 
 
 Properties of Gall-stones. — (a) Site; they are almost invariably 
 formed in the gall-bladder ; very rarely do calculi develop in the in- 
 trahepatic ducts as in McArthur's recent case, (b) Size; they range 
 from the size of sand or gravel to that of an egg ; a calculus 12 inches 
 in length is recorded; the heaviest weight reported is over four 
 ounces (135 gm. Ritter). (c) Form; they are usually round and 
 rarely spinous ; when multiple they are polygonal and facetted. In- 
 trahepatic calculi may be cylindrical or branching like coral (Cru- 
 veilhier). (d) Their number averages a dozen; according to Riedel 
 44 per cent, are single; Otto reports 7,802 stones in one case. Cho- 
 part instances a case in which the liver could scarcely be cut because 
 of the numberless stones in the intrahepatic ducts, (e) Consistence; 
 gall-stones can usually be indented by the finger. (/) The time re- 
 quired for their growth is about six months, (g) Chemistry ; the 
 most common form consists of cholesterin and bile-pigment (bilirubin 
 and biliverdin) with some lime as a cementing substance; these 
 calculi are small, numerous, usually yellow, laminated and contain 
 about 75 per cent, of cholesterin. Cholesterin stones are not common ; 
 they are translucent, become opaque when dry, are light in weight 
 and color and are combustible; they present a crystalline fracture 
 like that of camphor, they dissolve in ether and alcohol, from which 
 the crystals are precipitated and produce a red tinge on addition of 
 chloroform and sulphuric acid ; cholesterin comes from the bile or 
 the inflamed mucosa of the gall-bladder. Pigmentary stones are un- 
 common ; bilirubin imparts a brownish and biliverdin a greenish tint 
 to them. Calcium carbonate stones are rare, are grayish in color and 
 heavy. Stones in the liver are constituted of calcium and bilirubin. 
 Traces of magnesium, bile acids, fatty acids, iron and copper have 
 been found. The nucleus may consist of mucin, bacteria, epithelium, 
 
CHOLELITHIASIS. 701 
 
 blood-clot, cholesterin, calcium, bile pigment or rarely of foreign 
 bodies. 
 
 Symptoms. — Kehr, Eiedel and Paulsen assert that 95 per cent, of 
 cases of gall-stones have no symptoms, especially in elderly subjects 
 with atrophic gall-bladders. Stones may be felt or may crepitate in 
 the gall-bladder, or be found in the faeces in old people with lax tis- 
 sues, without any subjective symptoms. The writer believes that 
 latency is less common than above figured and that gastric symptoms 
 are exceedingly common. 
 
 Biliary Colic. — An attach embraces several important elements. 
 (a) Colic is usually sudden in onset and very frequently begins at 
 night. The pain is great and many women state that it is more 
 severe than labor pains. It begins in the right upper abdominal quad- 
 rant and may radiate to the back, navel, hypogastrium, left side and 
 even to the arms, legs, testes or chest. Irregular or large stones cause 
 the greatest agony, controlled only by large or repeated hypodermics of 
 morphine. The pain usually endures for a few hours and may soon 
 recur. The cause of biliary colic is mechanical, — the attempt of the 
 stone to migrate produces the spasm of the cystic and common ducts 
 during its passage — or inflammatory, Kehr maintaining that chole- 
 cystitis starts the stones moving by the exudation it induces. The 
 pain is less or shorter if the ducts are patulous. The author has seen 
 violent colic result from this mechanism, as well as from cholecystitis 
 without stones. It is thought that quiescent gall-stones may be 
 started onward by palpation of the gall-bladder, trauma, muscular 
 exertion, pressure by corsets, particularly after reduction of flesh, 
 menstruation or delivery, (b) Reflex nausea and vomiting are fre- 
 quent; Kehr thinks that they indicate cholecystitis (Mierzkowski 
 found the bile sterile in only 22 per cent.). Vomiting relieves the 
 pain and this frequently causes an erroneous diagnosis of gastralgia. 
 Torsion of the cystic duct may cause vomiting but not colic, (c) 
 Chills and fever occur in 66 per cent, and indicate bacterial inflam- 
 mation, (d) The gall-bladder is always tender, there being hyper- 
 esthesia over the ninth costal cartilage or over a point two-thirds of 
 the distance between it and the navel. In 33 per cent, the gall-bladder 
 is palpable. The right rectus muscle is rigid from peritoneal in- 
 volvement. Boas and Gruh describe a right-sided hypersesthetic zone 
 which lies between the spine and posterior axillary line and at the 
 level of the lower dorsal or upper lumbar vertebra, (e) Icterus, so 
 often emphasized as a diagnostic point, is present in but 15 per cent. 
 (Eiedel and Kehr). It may be calculous, infectious or compressive. 
 (/) Other symptoms of the paroxysm are rapid pulse, sweating, pros- 
 tration, concentrated urine, constipation, abdominal retraction and, 
 after the seizure, marked prostration. In some cases hysterical mani- 
 festations may be precipitated. Attacks of migraine are not infre- 
 quent (Kehr). There may be reflex coughing or reflex contraction 
 of the pulmonary capillaries, which imposes extra work on the right 
 heart and causes its dilatation. The patient may suffer actual col- 
 
702 DISEASES OF THE DIGESTIVE TRACT. 
 
 lapse and in nine cases death has occurred in the attack (ISTaunyn). 
 Glycosuria, albuminuria, leukocytosis and splenic swelling are in- 
 flammatory in origin. The stone may fall back into the gall-bladder 
 or pass into the bowel if it measures under 1 cm. It is detected by 
 washing of the stools through a cloth ; confusion with lumps of olive 
 oil, given to relieve the colic, is unnecessary. The passage of a round 
 calculus suggests, but does not prove, that it is the only one. Stones 
 passing into the bowel may be dissolved, unless coated with chole- 
 sterin ; this may explain why stones are not more often found in the 
 fasces. The great importance of gall-stones lies in their complications. 
 Complications. — Complications may be grouped as mechanical or 
 inflammatory, but as this involves descriptive repetition, both forms 
 are combined topographically. Such complications as liver abscess 
 or pyaemia may develop from " latent " stones. 
 
 1. Gall-bladder. — Mechanical complications include pressure on 
 the duodenum or pylorus and rupture of the gall-bladder, which, 
 however, are generally inflammatory ; pressure on the common duct ; 
 hyperchlorhydria and hypersecretion; and cancer of the gall-bladder 
 (q. v.). Inflammatory complications are more serious; all forms 
 and sequences of cholecystitis (q. v.) may develop, as hydrops, 
 empyema, gangrene, ulceration, deformity, hemorrhage, atrophy, 
 calcification or liver abscess; also pylephlebitis, adhesions producing 
 pyloric obstruction with hyperchlorhydria, dyspepsia and sometimes 
 hemorrhage into the stomach; adhesions causing duodenal obstruc- 
 tion; and peritonitis, either local (near the gall-bladder or sub- 
 phrenic abscess) or diffuse; Courvoisier reported 49 cases of the 
 localized and 70 of the diffuse type. A friction rub may be heard 
 over the gall-bladder a day or two after the colic. The distended gall- 
 bladder rarely exceeds the size of the fist, is pyriform, can be moved 
 laterally and moves with the liver, from which it may seem separated 
 by a groove; it may be sometimes confused with appendicitis, the 
 kidney, ovarian cyst or ascites and has even been found in a femoral 
 hernia. 
 
 2. Cystic Duct. — Mechanical impaction causes icterus by spasm 
 or catarrh of the common duct (in 12 per cent., Kiedel) or by di- 
 rectly compressing it. The duct may become twisted, stenosed or 
 obliterated. 
 
 3. Common Bile Duct. — Its mechanical occlusion is usually but 
 not invariably preceded by colic; impaction occurs oftenest at its 
 lower end (50 per cent. Courvoisier or 67 per cent. Eobson), and is 
 caused most frequently by one stone; 88 have been found (Mayo 
 Eobson). Permanent occlusion by stone in the common duct or in 
 the cystic duct pressing upon it causes marked icterus, usually with- 
 out sepsis. The occlusion may be partial or intermittent, by a ball- 
 valve action of the stone, described by Osier and Fenger, which al- 
 lows some bile to enter the gut and, unfortunately, some bacteria to 
 enter the duct, thus adding bacterial to mechanical injury. In 
 isolated cases there is no icterus but usually the icterus is sudden in 
 
CHOLELITHIASIS. 703 
 
 onset and slow in subsidence. In partial or intermittent obstruction 
 there is often the intermittent hepatic fever, first described by Char- 
 cot and later clearly defined by Osier. Budd well compared it to 
 urethral fever. During the paroxysms the fever rises to 103 or 105°, 
 often with chills, sweats, leukocytosis, vomiting and increased ten- 
 derness, pain and icterus. The spleen may swell, and also the 
 liver from cylindrical or saccular dilatation of the channels and 
 cholangitis. Osier correctly insisted that these symptoms occur 
 without suppurative cholangitis, though with infection. The gall- 
 bladder is not enlarged, but is usually shrunken, following Cour- 
 voisier s law; Courvoisier (1890) found the gall-bladder enlarged 
 in 92 per cent, of non-calculous obstruction of the common duct 
 and shrunken in 80 per cent, of calculous obstruction; this is 
 caused by infection (Hanot) ; Eichlin, in non-calculous obstruction, 
 found the gall-bladder dilated in 87 per cent, and contracted or nor- 
 mal in 6.5 per cent, each; in calculous obstruction the gall-bladder 
 was contracted in 66 per cent., normal in 19 per cent, and dilated in 
 15 per cent. In some cases suppurative cholangitis may complicate 
 stones of the common duct, with remittent fever (rather than the 
 above described intermittent fever), enlarged liver, septic symptoms 
 and more intense and more rapidly fatal course. Mechanical dila- 
 tation may distend all the bile-vessels which may be seen under the 
 capsule ; ascending cholangitis may cause subcapsular abscess. Cica- 
 tricial stenosis of the common duct is rare; pylephlebitis may de- 
 velop. Malaria is excluded by examination of the blood ; malignancy 
 will be considered under tumors of the pancreas, though in obstruc- 
 tion of the common duct the nutrition is generally little impaired. 
 Practically, special stress may be placed on (a) the periodic fever, 
 (b) the icterus sudden in onset and subsiding slowly, and (c) ten- 
 derness (without pain over the liver). 
 
 4. Ampulla of Vater. — Calculous retention in the ampulla may 
 obstruct the flow of the pancreatic juice, though the accessory duct 
 may carry it into the intestine ; retention may allow bile to enter the 
 pancreatic duct, and result (a) in acute pancreatitis, caused by bile in 
 the pancreatic ducts (Opie) ; (b) chronic induration of the head of 
 the pancreas resembling malignancy (Riedel, Robson, Barling) ; (c) 
 pancreatic fibrosis with pancreatic calculi due to stasis and infection ; 
 or (d) rarely glycosuria. 
 
 5. Intestinal Obstruction (q. v.). — Two hundred and fifty 
 cases have been collected. The stone usually ulcerates its way into the 
 bowel from the biliary channels or gall-bladder. The obstruction is 
 often incomplete and may not occur for some time, sometimes re- 
 ceiving new layers of magnesia or phosphates. According to Cour- 
 voisier, the obstruction is in the ileum in 6Q per cent., duodenum in 
 21 per cent., ileocecal valve in 10 per cent, and sigmoid in 3 per 
 cent. ; 50 per cent, of cases die. 
 
 6. Fistula. — Courvoisier assembled 499 cases. The external 
 form constitutes about 50 per cent, of cases ; they are most often lo- 
 
704 
 
 DISEASES OE THE DIGESTIVE TRACT. 
 
 Brewer's Diagnosis of Diseases 
 
 Pathological 
 
 Pain. 
 
 Fever. 
 
 Vomit- 
 
 Jaun- 
 
 Tumor of Gall- 
 
 Condition. 
 
 
 
 ing. 
 
 dice. 
 
 bladder. 
 
 I. Calculous Disease. 
 
 
 
 
 
 
 (a) Stoue in healthy 
 
 No. 
 
 No. 
 
 No. 
 
 No. 
 
 May be present 
 
 gall-bladder, ducts 
 
 
 
 
 
 from large num- 
 
 free. 
 
 
 
 
 
 ber or size of 
 stones. 
 
 (6) Stone in healthy 
 
 May be absent ; generally 
 
 No. 
 
 May be 
 
 No. 
 
 May be present 
 
 gall-bladder, cystic 
 duct temporarily ob- 
 
 present during obstruc- 
 
 
 present 
 
 
 from d i s t e n- 
 
 tion ; paroxysmal. 
 
 
 when 
 
 
 tion. 
 
 structed. 
 
 
 
 colic 
 occurs. 
 
 
 
 (c) Stone impacted in 
 
 No. 
 
 No. 
 
 No. 
 
 No. 
 
 Present ; may at- 
 
 cystic duct. 
 
 
 
 
 
 tain large size. 
 
 (d) Stone in hepatic 
 
 Frequently present; 
 
 Occasion- 
 
 May be 
 
 Frequent. 
 
 No. 
 
 duct. 
 
 irregular type. 
 
 ally pres- present 
 
 
 
 
 
 ent. 
 
 during 
 
 
 
 (e) Stone in common 
 
 Present; acute paroxys- 
 
 Generally 
 
 Present 
 
 Present. 
 
 No. 
 
 duct ; acute obstruc- 
 tion. 
 (/) Stone in common 
 
 mal radiating to back. 
 
 present. 
 
 
 
 
 Periodic attacks of acute 
 
 Present 
 
 Present. 
 
 Present ; 
 
 Karely present. 
 
 duct; movable; 
 
 radiating pain. 
 
 with 
 
 
 intermit- 
 
 
 chronic. 
 
 
 chills and 
 sweats. 
 
 
 tent. 
 
 
 (g) Stone in common 
 
 May be absent ; frequently 
 
 May be 
 
 Often 
 
 Present ; 
 
 Rarely present. 
 
 duct ; impacted; 
 
 present early ; may be 
 
 present ; 
 
 present. 
 
 progress- 
 
 
 chronic. 
 
 intermittent ; variable. 
 
 variable. 
 
 
 ive ; may 
 
 vary in 
 
 intensity. 
 
 
 II. Inflammatory 
 
 Disease. 
 (a) Cholecystitis sub- 
 
 
 
 
 
 
 Present; paroxysmal dur- 
 
 Present 
 
 May be 
 
 No. 
 
 Present during 
 
 acute. 
 
 ing periods of cystic duct 
 
 during 
 
 present. 
 
 
 attacks of cys- 
 
 
 closure from stone or 
 
 attacks 
 
 
 
 tic duct o b- 
 
 
 swollen mucous mem- 
 
 of colic. 
 
 
 
 struction. 
 
 
 brane. 
 
 
 
 
 
 (b) Cholecystitis acute. 
 
 Acute paroxysmal radiat- 
 
 Present 
 
 Present; 
 
 No. 
 
 Present ; tender- 
 
 
 ing pain ; extending to 
 
 with 
 
 often 
 
 
 ness ; often 
 
 
 back and shoulder ; may 
 
 chills and 
 
 severe. 
 
 
 muscular rigid- 
 
 
 be very severe. 
 
 sweats. 
 
 
 
 ity. 
 
 (c) Cholecystitis 
 
 Severe radiating pain at 
 
 Present ; 
 
 Present 
 
 No. 
 
 Present ; with 
 
 chronic (empyema 
 
 first ; may disappear 
 
 severe at 
 
 at first. 
 
 
 ten dern ess ; 
 
 of gall-bladder). 
 
 later ; tendency to recur. 
 
 first, may 
 
 diminish 
 
 later. 
 
 
 
 may attain 
 large size. 
 
 (d) Cholecystitis in 
 
 Present; often severe; 
 
 Present ; 
 
 Present. 
 
 No. 
 
 No (occasion- 
 
 previously diseased 
 
 paroxysmal. 
 
 often 
 
 
 
 ally present, 
 
 and contracted gall- 
 
 
 with 
 
 
 
 due to peri- 
 
 bladder. 
 
 
 chills and 
 sweats. 
 
 
 
 cystic exudate). 
 
 (e) Cholangitis of he- 
 
 May be absent; generally 
 
 Present ; 
 
 Present. 
 
 Present ; 
 
 No. 
 
 patic and common 
 
 present when obstruction 
 
 chills ; 
 
 
 variable. 
 
 
 ducts. 
 
 exists, or severe infection; 
 tenderness and pain over 
 liver in intrahepatic chol- 
 angitis. 
 
 sweats ; 
 severe 
 prostra- 
 tion; gen- 
 eral sep- 
 
 
 
 
 III. New Growths. 
 
 
 sis. 
 
 
 
 
 (a) Carcinoma of gall- 
 
 No ; may occur late in dis- 
 
 No. 
 
 No. 
 
 Present 
 
 Hard, irregular, 
 
 bladder. 
 
 ease. 
 
 
 
 late (por- 
 tal 
 
 movable tumor 
 
 
 
 
 
 at first, later 
 
 
 
 
 
 glands). 
 
 diffuse infiltra- 
 tion. 
 
 (6) Tumor of cystic 
 
 No ; may occur late. 
 
 No. 
 
 No. 
 
 No. 
 
 Present when ob- 
 
 duct. 
 
 
 
 
 
 struction exists. 
 
 (c) Tumor of hepatic 
 
 No ; may occur late. 
 
 No. 
 
 No. 
 
 Present ; 
 
 May be present 
 
 or common duct. 
 
 
 
 
 progress- 
 ive. 
 
 from distention 
 with bile. 
 
 (d) Tumor of neighbor- 
 
 No ; may occur late. 
 
 No. 
 
 No. 
 
 Present ; 
 
 Present ; gener- 
 
 ing viscera produc- 
 
 
 
 
 progress- 
 
 ally from dis- 
 
 ing chronic obstruc- 
 
 
 
 
 ive; may 
 
 tention with 
 
 tion of common duct. 
 
 
 
 
 become 
 extreme. 
 
 bile. 
 
CHOLELITHIASIS. 
 
 705 
 
 of the Gall-Bladder and Ducts. 
 
 Urine. 
 
 Stools. 
 
 Liver. 
 
 Spleen. 
 
 Ascites. 
 
 Eemarks. 
 
 Negative. 
 
 Normal. 
 
 Not enlarged. 
 
 Not enlarged. 
 
 No. 
 
 Generally discovered by acci- 
 dent ; often unrecognized. 
 
 Negative. 
 
 Normal. 
 
 Not enlarged. 
 
 Not enlarged. 
 
 No. 
 
 All symptoms promptly relieved 
 as soon as obstruction removed. 
 
 Negative. 
 
 Normal. 
 
 Not enlarged. 
 
 Not enlarged. 
 
 No. 
 
 Hydrops of gall-bladder often 
 unrecognized. 
 
 Contains 
 
 May be clay 
 
 Frequently 
 
 Not enlarged. 
 
 No. 
 
 Diagnosis extremely difficult ; 
 
 bile pig- 
 
 colored if 
 
 enlarged. 
 
 
 
 symptoms generally due to co- 
 
 ment at 
 
 obstruction 
 
 
 
 
 existing cholangitis. 
 
 times. 
 
 occurs. 
 
 
 
 
 
 Contains 
 
 Clay col- 
 
 Not enlarged. 
 
 Not enlarged. 
 
 No. 
 
 Symptoms rapidly disappear 
 
 bile pig- 
 ment. 
 Contains 
 
 ored. 
 
 
 
 
 when stone passes papilla. 
 
 Clay col- 
 
 May be en- 
 
 May be en- 
 
 No. 
 
 "Fievre intermittente hepa- 
 
 bile pig- 
 
 ored. 
 
 larged during 
 
 larged from 
 
 
 tique" of Charcot resembles 
 
 ment. 
 
 
 attack. 
 
 pressure of 
 stone on vein. 
 
 
 malaria; all symptoms disap- 
 pear during interval. 
 
 Contains 
 
 Clay col- 
 
 Enlarged. 
 
 May be en- 
 
 No. 
 
 Condition may remain for many 
 
 bile pig- 
 
 ored. 
 
 
 larged. 
 
 
 years; may only be jaundice 
 
 ment. 
 
 
 
 
 
 with digestive disturbances and 
 loss of weight ; history of pre- 
 vious attacks (?) Ascites may 
 be present from pressure of 
 large stone or possibly from 
 hydrsernia. 
 
 Negative. 
 
 Normal. 
 
 Not enlarged. 
 
 Not enlarged. 
 
 No. 
 
 Tenderness over gall-bladder ; 
 tendency to recurrence ; gener- 
 ally associated with stones in 
 gall-bladder. 
 
 
 
 
 
 
 May con- 
 
 Normal. 
 
 Not enlarged. 
 
 May be en- 
 
 No. 
 
 May follow typhoid or other sep- 
 
 tain albu- 
 
 
 
 larged (sepsis). 
 
 
 tic diseases ; onset often sudden ; 
 
 min and 
 
 
 
 
 
 rapid development of severe 
 
 casts. 
 
 
 
 
 
 symptoms resembling appendi- 
 citis ; may be necrosis of walls 
 
 
 
 
 
 
 
 
 
 
 
 of gall-bladder with perforation ; 
 
 
 
 
 
 
 local or general peritonitis. 
 Frequently follows acute chole- 
 
 Negative. 
 
 Normal. 
 
 Not enlarged. 
 
 Not enlarged. 
 
 No. 
 
 
 
 
 
 
 cystitis ; occasionally becomes 
 
 
 
 
 
 
 quiescent, presenting practically 
 
 
 
 
 
 
 no symptoms. 
 
 Negative. 
 
 Normal. 
 
 Not enlarged. 
 
 May be en- 
 larged (sepsis). 
 
 No. 
 
 Generally tenderness over gall- 
 bladder area, but no tumor; 
 local peritonitis ; diagnosis 
 often extremely difficult. 
 
 May con- 
 
 May be 
 
 Enlarged. 
 
 Enlarged 
 
 No. 
 
 Often follows severe infections of 
 
 tain bile 
 
 clay 
 
 
 (sepsis). 
 
 
 gall-bladder ; generally asso- 
 
 pigment, 
 
 colored. 
 
 
 
 
 ciated with stones in common or 
 
 albumin 
 
 
 
 
 
 hepatic ducts ; severe sepsis ; 
 
 and casts. 
 
 
 
 
 
 generally fatal in virulent infec- 
 tions (streptococcus). 
 
 Negative 
 
 May be 
 
 Enlarged late 
 
 May be en- 
 
 Present 
 
 Digestive disturbances, progress* 
 
 (at first). 
 
 clay colored 
 
 in disease. 
 
 larged late 
 
 late. 
 
 ive loss of weight and asthenia ; 
 
 
 late. 
 
 
 (pressure on 
 vein) 
 
 
 cachexia ; rapidly fatal. 
 
 Negative. 
 
 Normal. 
 
 Not enlarged. 
 
 Not enlarged. 
 
 No. (?) 
 
 Very rare ; both benign and ma* 
 lignant growths have been re- 
 ported ; diagnosis difficult. 
 
 Contains 
 
 Clay 
 
 May be en- 
 
 Not enlarged. 
 
 May be 
 
 Very rare ; diagnosis difficult. 
 
 bile pig- 
 
 colored. 
 
 larged. 
 
 
 present 
 
 
 ment. 
 
 
 
 
 late. 
 
 
 Contains 
 
 Clay 
 
 Enlarged. 
 
 May be en- 
 
 Present 
 
 Malignant tumors most common ; 
 
 bile pig- 
 
 colored. 
 
 
 larged late. 
 
 late. 
 
 chronic interstitial pancreatitis 
 
 ment. 
 
 
 
 
 
 from previousinfection of biliary 
 passages may remain after cause 
 has disappeared; enlarged portal 
 glands ; Hodgkin's disease. 
 
 
 
 
 
 
 45 
 
706 DISEASES OF THE DIGESTIVE TRACT. 
 
 cated near the navel and about 40 per cent, of them heal. In the 
 duodenal form (28 per cent.) the fistula is between the duodenum 
 and gall-bladder and less often between the common duct and the gall- 
 bladder. In 13 per cent, there is a fistulous opening into the colon. 
 Courvoisier and Graham collected 34 cases of bronchial fistula. In 
 rare cases stones enter the stomach (five cases recorded, Snively, 
 1903), portal vein, hepatic artery, kidney, urinary bladder (200 
 gall-stones evacuated in the urine in the case of Barraud-Palletan), 
 pericardium, retroperitoneal tissue, vagina or even the pregnant 
 uterus. 
 
 7. Renal Calculus, Glycosuria. — In 700 cases of gall-stones 
 Krans found complicating renal calculus in 6 per cent., glycosuria in 
 7 per cent., diabetes in 4 per cent, and gout in 2 per cent. 
 
 Diagnosis. — The diagnosis is easily made when colic, vomiting, 
 tenderness of the gall-bladder and icterus are present; icterus is 
 absent in at least 80 per cent, of all cases and the rr-rays are uncertain. 
 
 1. The Colic. — This is most apt to be confused with (a) gas- 
 tralgia, for both conditions are relieved by vomiting; due regard for 
 other symptoms of gall-stones and the habit of doubting every diag- 
 nosis of gastralgia will save many mistakes, (b) A diagnosis of 
 hepatic neuralgia should always be made with reserve, though pain 
 near the liver does occur in neurotics, (c) Gastric or duodenal ulcer 
 (q. v.) and (d) hyperchlorhydria and hypersecretion (q. v.) are 
 easily distinguished, (e) Lead colic has the characteristic gingival 
 lead line, obstinate constipation and often neuritic manifestations. 
 (/) Tabetic crisis is attended by the Argyll-Robertson pupil, absent 
 knee-jerk and ataxia, (g) Renal colic (q. v.) is distinguished by 
 pain reflected down the ureter, hematuria and pyuria and Dietl's 
 crisis in floating kidney, by bimanual examination of the abdomen. 
 (h) Mucous colic (colitis) is differentiated by the characteristic 
 stools and neurasthenic symptoms, (i) Appendicitis is character- 
 ized by its four cardinal symptoms (q. v.) ; Ochsner finds 10 per 
 cent, of his appendicitis cases complicated by gall-stones and 33 per 
 cent, of his gall-stone cases by appendicitis. (;') Acute pancreatitis 
 (q. v.) which may complicate gall-stones, causes greater collapse and 
 more frequent intestinal obstruction, (k) Febrile syphilis may simu- 
 late gall-stones (Riedel) as may also (I) the abdominal crises occa- 
 sionally observed in angioneurotic oedema. / 
 
 2. Other Affections of the Gall-bladder and Bile Ducts 
 (see Brewer's Table on pages 704 and 705). 
 
 Prognosis. — The prognosis is difficult to formulate. Stones may 
 pass without recurrence of colic and the passage of smooth calculi 
 may justify some hope that they are the only ones. The first attack 
 is usually the worst. Fever, infection, cancer and obstruction of the 
 common duct and intestine must be covered in forecasts to patients 
 refusing operation. Riedel held that 10 per cent, recover spon- 
 taneously under expectant treatment, while in 90 per cent, of cases 
 surgical intervention is indicated. 
 
CHOLELITHIASIS. 
 
 707 
 
 Treatment. — 1. Prevention. — Exercise and deep breathing aid the 
 How of bile. Lacing is a factor to be regarded. Plenty of water 
 increases the secretion of bile. Digestive derangements should be 
 corrected. Alcohol is contra-indicated. The predisposing gall-blad- 
 der inflammation seldom comes under the physician's care, but in 
 suspicious cases, sodium salicylate, gr. x to xv t. i. d. given alternate 
 weeks, acts as a cholagogue — increasing the bile two or threefold — 
 and antiseptic; hexamethylenamine (urotropin), 5j per diem, is 
 excreted by the bile (Crowe). Mercurials seem to stimulate bile 
 formation less than to aid in its evacuation. Potassium iodide and 
 mild salines (sodium phosphate, 3ss to j) are beneficial. 
 
 2. Colic. — Hypodermics of morphine must be given, gr. 34 being 
 combined with nitroglycerine gr. %oo and (for the first injection in 
 the attack) with atropine gr. Moo ; repeated doses of morphine and 
 nitroglycerine are often necessary. Inhalation of chloroform is in- 
 dicated in severe cases until the morphine acts, but none of these 
 drugs should be left in the possession of any patient. A full hot 
 bath and hot fomentations over the liver are valuable accessories. 
 Drinking warm water facilitates vomiting, which in turn relieves 
 the pain. 
 
 3. Medical Treatment. — This in no way influences the solution 
 of gall-stones. Durande's solvent (oil of turpentine 1 part to ether 4 
 parts) is useless and, like chloroform, is only antispasmodic. Olive 
 oil only facilitates their final passage. Salicylates, calomel, salines 
 (v. s.) and various " cures," as at Carlsbad, Vichy, Kissingen, Las 
 Vegas or Bedford Springs, are useful in quieting concomitant or 
 causative inflammation. Local massage is obviously injurious. 
 
 4. Surgical Treatment. — The author believes that gall-stones 
 should be operated on when recognized, thus saving time, suffering 
 and danger. The following indications are given by Kehr : " (a)" 
 The latent state ensues in many cases of cholelithiasis after rest-cures 
 or alkalies and in certain cases is permanent, particularly in the so- 
 called cases of chronic recurrent cholecystitis. But I doubt whether 
 an absolute cure will frequently occur, i. e., the passage of all the 
 stones, by medical means. We should never endeavor to force a 
 passage of the stones; it is much better to seek to render them 
 quiescent in the gall-bladder and quiet the inflammation. The con- 
 tinuous use of hot applications for weeks, with rest in bed and Carls- 
 bad waters, will give the best results, (b) Biedel's theoretical justi- 
 fication for early operation — the removal of the calculi while they 
 remain in the gall-bladder — holds good now as ever, as in many cases 
 an early operation is the only salvation for the patient against such 
 grave dangers as perforation, cholgemia and carcinoma. Universal 
 application of early operation, however, in general practice, is abso- 
 lutely impossible, (c) I decline operative interference if the at- 
 tacks run a mild course and in the intervals when complete latency 
 exists, i. e., entire absence of sensitiveness in the region of the gall- 
 bladder, (d) Acute obstruction of the choledochus is to be treated 
 
708 DISEASES OF TEE DIGESTIVE TEACT. 
 
 medically. Should cholangitic symptoms appear or should the jaun- 
 dice induce loss of strength and absolute loss of appetite operation 
 should be performed, (e) Operation is necessary when frequent 
 colics occur, even without jaundice or the passage of stones, which 
 damage the general health, deteriorate the earning capacity and de- 
 stroy the pleasure of living. (/) Cases of jaundice which are al- 
 ways accompanied by the passage of stones belong to the physician; 
 should the attacks multiply, the patient become vitally depressed and 
 no hope be present for the passage of all the stones, the propriety of 
 the operation is established, (g) Hydrops, empyema of the gall- 
 bladder and pericholecystitic abscesses belong to the province of 
 surgery, (h) Surgical treatment should not be postponed too long 
 after the failure of a Carlsbad cure, (i) Gall-stone patients who 
 have become addicted to the use of morphine must be operated upon. 
 During the after-treatment the best opportunities are afforded for 
 curing the opium habit. (/) Treatment of carcinoma of the gall- 
 bladder can only be of lasting benefit if the case is operated upon 
 early, but everyone dreads early operation and late operations are not 
 of much use. (k) Those suffering with chronic jaundice not de- 
 pendent upon stone in the common duct or incurable disease of the 
 liver must be operated upon at the latest three months after the ap- 
 pearance of the icterus, for it not infrequently occurs that in place 
 of a suspected carcinoma of the head of the pancreas a curable chronic 
 interstitial pancreatitis will be found. (I) The decision for opera- 
 tion will be rendered easy for both physician and patient upon demon- 
 stration of tumor of the gall-bladder, a swollen liver and the appear- 
 ance of jaundice and fever. We may also operate on cases without 
 demonstrable local lesions of the gall-bladder and liver which exhibit 
 severe and continuous symptoms which do not prove amenable to 
 internal medication. We find in such cases, particularly often in 
 men, adhesions of traumatic origin without stones. (m) The 
 sequelae of cholelithiasis, purulent cholangitis, abscess of the liver, 
 peritonitis due to perforation, subphrenic abscess, pyloric and duo- 
 denal stenosis and gall-stone ileus must be treated surgically, (n) 
 Concluding: To present general indications for operation is not 
 readily possible. One must decide each case on its own merits. Men, 
 particularly corpulent ones, do not bear the operation well. Women 
 who have borne children lend themselves particularly well to this 
 surgical procedure. If possible one should refrain from operating 
 in cases of diabetes, arteriosclerosis, chronic nephritis and diseases of 
 the lungs and heart." 
 
 In Mayo's 1,500 operated cases the mortality was but 1 per cent, 
 in 416 uncomplicated cases, while those complicated by suppuration 
 or cancer brought the average mortality to 5 per cent. ; the death 
 rate in operations on the common duct was 11 per cent. These fig- 
 ures appear to the writer as the best possible argument for early oper- 
 ation. Cholecystotomy was attended by a 2.5 per cent, mortality 
 and it is therefore the better operation, as cholecystectomv entailed 
 
CHOLECYSTITIS. 709 
 
 4.3 per cent, of fatalities. In Kehr's last 500 cases (1904) the mor- 
 tality was 3 per cent, in uncomplicated cases and 13 per cent, with 
 cancer and cholangitis ; stones were left in 2.5 per cent., hernia de- 
 veloped in 3 per cent, and adhesions and inflammatory colic occurred 
 in 5 per cent. 
 
 CHOLECYSTITIS. 
 
 Etiology. — Inflammation of the gall-bladder may occur before, after, 
 with or without inflammation of the bile passages, (a) Predisposing 
 factors are gall-stones (especially large ones which cannot pass, 
 which cause 65 per cent, of cholecystitis and cholangitis (Dominici) 
 or 90 per cent, in other statistics), bile stasis, trauma, foreign bodies 
 or previous attacks, (b) The exciting cause is bacterial; the colon, 
 typhoid, pyogenic, pneumococcus or other organisms are responsible. 
 They may ascend the bile channels or enter with the blood current. 
 Inflammation from typhoid infection (Louis and Andral) may occur 
 without actual typhoid or may develop twenty years later (Osier). 
 
 Symptoms. — The symptoms vary with the intensity of infection, 
 which is almost synonymous with the type (simple, membranous, 
 suppurative, phlegmonous, ulcerative or gangrenous). In light forms 
 the symptoms may not be recognized ; this corresponds to post mortem 
 adhesions in cases with no history of cholecystitis. In other cases, 
 perhaps more severe ones, symptoms are obscured by the causative 
 typhoid or by gall-stones. In the average case there are (a) pain over 
 the part, which may be severe or paroxysmal and may radiate toward 
 the appendix or back, (b) Tenderness as in gall-stones,; it is often 
 first general and then local and the right rectus is tense ; it is clearly 
 elicited by a thrust over the part during inspiration, (c) Fever, in- 
 creased pulse rate, vomiting or nausea ; fever is absent in mild infec- 
 tions ; in typhoid, cholecystitis may be confused with typhoid relapse 
 (Musser). There may be colic, (d) There may be a palpable gall- 
 bladder. Its contents may be purulent (empyema cystidis fellese) or 
 serous (hydrops cystidis fellese). Hydrops may enlarge the gall- 
 bladder to the size of the fist or in extreme cases so that it weighs 50 
 to 60 pounds, contains thirty to forty quarts and fills the entire ab- 
 domen; experienced observers have mistaken such cases for ascites; 
 the fluid is alkaline or neutral, serous or mucoid. If very tense the 
 gall-bladder may not fluctuate or if very lax may not be palpable (see 
 Floating Kidney). There may be pus in the gall-bladder without 
 enlargement. In chronic cases it may shrink, (e) Severe sepsis may 
 intervene in diffuse suppurative cholangitis or pylephlebitis ; this is 
 evidenced by septic fever, chills, leukocytosis, bacterisemia, swollen 
 liver and spleen, nephritis and ulcerative endocarditis. Icterus occurs 
 in 33 per cent. (See pages 704 to 705.) 
 
 Prognosis. — Many cases with cholangitis die in spite of operation. 
 Mild cases may subside, but recurrence and formation of gall-stones 
 are frequent. Under expectant therapy the outlook is serious in 
 severe cases, for perforation, localized or general peritonitis, adhe- 
 
710 DISEASES OF THE DIGESTIVE TRACT. 
 
 sions (in 75 per cent.) and duodenal or pyloric obstruction may 
 result. 
 
 Treatment. — Rest, milk diet, local heat and morphine may suffice 
 for light cases, but in the more severe infections drainage is indicated. 
 
 CHOLANGITIS, CATARRHAL ICTERUS, CONGENITAL OCCLUSION. 
 
 Suppurative Cholangitis. — Suppurative cholangitis usually is dif- 
 fuse, co-exists with suppurative cholecystitis and results from gall- 
 stones with infection. Infection is usually hoematogenous through 
 the hepatic artery or the portal vein, but may be ascending from 
 cancer or stone in the tracts. The symptoms of cholangitic sepsis 
 have been described under cholecystitis. Drainage is indicated. 
 (See page 704.) 
 
 Acute Catarrhal Jaundice. — Acute catarrhal jaundice (cholangitis 
 catarrhalis, icterus simplex seu gastroduodenalis) results from gas- 
 troduodenal catarrh which causes swelling with obstruction of the 
 papilla and probably catarrhal inflammation of the lower portion of 
 the common duct ; few cases come to autopsy, though a small plug of 
 mucus usually occludes the opening. Eppinger found swelling of the 
 lymphoid follicles in that part of the common duct which lies in the 
 wall of the bowel. Its usual causes are practically those of acute 
 gastritis or enteritis. Favoring factors include passive congestion 
 (cardiac or portal), acute infections, toxic causes (as phosphorus), 
 nephritis and other diseases of the liver or bile tracts (cirrhosis, 
 cancer, stones, parasites). Epidemic forms occur or forms which 
 seem to be a separate type of infection (v. Weil's Disease). 
 
 Symptoms. — G 'astro-intestinal catarrh occurs first in many cases 
 and after a few days to a week or so icterus appears, with its usual 
 symptoms, sudden decolorization of the stools and bright yellow stain- 
 ing of the skin and urine (v. Icterus) . However, the physician must 
 not expect to always find an antecedent gastroduodenitis, because a 
 primary infectious catarrh of the bile ducts is equally frequent. 
 Other findings are inconstant ; the liver is not enlarged at first, but 
 may become slightly swollen later ; there is no pain over the liver or 
 ducts, emaciation if present is slight, the spleen and gall-bladder are 
 seldom enlarged and the diagnosis depends entirely on the mode of 
 onset in young, healthy subjects, sequence of symptoms and exclusion 
 of other causes of obstruction. In advanced life catarrhal jaundice is 
 uncommon and gall-stones and cancer are always to be thought of 
 first. See pages 704, 705. 
 
 Prognosis. — The prognosis is almost always good, the jaundice last- 
 ing four to eight weeks. The author has seen cases clear in a week 
 and others last five months, though a course of over four to eight 
 weeks renders the diagnosis uncertain. Cases with fever may run a 
 prolonged course. Death rarely occurs. Cases of fatal hemorrhage 
 (Toelg and Neusser), and in the aged, of exhaustion (Leichtenstern) 
 and of suddent death with sudden heart-failure are reported. 
 
TUMORS OF GALL-BLADDER AND BILE VESSELS. 711 
 
 Treatment. — (a) Causative factors, as gastritis or cardiac failure, 
 should be appropriately treated; dyspeptic symptoms yield most 
 readily to gastric lavage ; fractional doses of calomel at night followed 
 by a mild saline in the morning, should be given ; but it should be re- 
 membered that active catharsis augments or indeed initiates catarrh. 
 
 ]£ Acidi hydrochlorici diluti 3.1- 
 
 Tincturae nucis vomicae 3iv. 
 
 Tincturae gentianae co q.s. ad %\v. 
 
 M. et S. — One teaspoonful after meals in half a glass of water. 
 
 Calomel was formerly given because it produced green "bilious 
 stools"; this color is not due to bile but to mercuric sulphide, (b) 
 In the diet fats are particularly to be avoided, as neither the stomach 
 nor intestine can digest them; tea, coffee, alcohol and coarse foods 
 should be interdicted ; skimmed milk is given and well-cooked carbo- 
 hydrates are gradually added to the diet ; toast, eggs and mealy soups 
 may be given; meat is often poorly tolerated, seemingly because of 
 exclusion of the pancreatic secretion, (c) As long as acute dyspepsia 
 exists, rest in bed is indicated, in order to maintain nutrition on the 
 lowest possible diet, (d) The bowels should be regulated by copious 
 injections of water which are thought to incite peristalsis and there- 
 fore dislodge the obstructing mucus plug, (e) The itching is allayed 
 by 1 per cent, carbolic solution, the use of which requires care, as the 
 urine sometimes becomes cloudy ; acetanilide, gr. v q. i. d. ; potas- 
 sium bromide, 3ss, well diluted, by rectum once or twice daily; an 
 occasional hypodermic of pilocarpin hydrochloride gr. Vs, warm baths 
 to relieve the dryness of the skin and calcium chloride gr. x to xx 
 t. i. d. for a few days are indicated. 
 
 Chronic Catarrhal Cholangitis. — Chronic catarrhal cholangitis 
 rarely follows the acute form but more often results from occlusion of 
 the common duct by calculus, cancer, stricture or pressure from with- 
 out (v. gall-stones, pancreatic cancer and icterus). 
 
 Congenital Occlusion of the Bile Ducts. — Sixty-three cases are re- 
 corded (Lavenson). Rolleston thinks that some poison initiates 
 cholangitis, which results in a mixed cirrhosis and obliteration of the 
 ducts. Lavenson holds that the ducts are congenitally atresic. Ic- 
 terus develops within a month after birth and death results in a few 
 weeks or months — nearly always within a year — from cholsemia or 
 hemorrhages. 
 
 TtJMORS OF THE GALL-BLADDER AND BILE VESSELS. 
 
 I. Cancer of the Gall-Bladder.. — Tumors other than cancer are rare 
 and of purely anatomical interest, as papilloma, fibroma, lipoma or 
 adenoma. Rolleston states there are but 9 recorded cases of sarcoma. 
 Fiitterer (1901) collected 268 cases of cancer, which is certainly 
 more frequent than these figures indicate. 
 
 Etiology. — The most striking etiological factor is gall-stones, pres- 
 
712 DISEASES OF THE DIGESTIVE TRACT. 
 
 ent in 70 per cent. (Musser) to 91 per cent. (Courvoisier) ; it is 
 estimated that 9 per cent, of cases of gall-stones result in cancer of 
 the gall-bladder, but this seems a very high percentage. Eighty per 
 cent, occur in women, caused by lacing (Fiitterer) ; the average age 
 of subjects is fifty-eight years. 
 
 Pathology. — The tumor may be scirrhus or medullary, but histo- 
 logically is usually of the columnar type (adenocarcinoma) ; the 
 spheroidal and squamous types are rare. 
 
 Symptoms. — (a) Gall-stones which irritate the mucosa and cause 
 most cases, usually produce no symptoms, though previous colic may 
 be noted in the history. (&) A tumor of the gall-bladder is palpable 
 in over 66 per cent., first as a smooth oval swelling and later as a 
 larger and more nodular one ; it is usually due to the growth, for the 
 gall-bladder itself is generally shrunken. The fundus is the usual 
 point of origin, being most irritated by calculi; much more rarely 
 the neck of the gall-bladder or least frequently the cystic duct is the 
 point of origin. The tumor appears below the edge of the liver with 
 which it moves and with which it is consecutive on palpation, percus- 
 sion and inflation of the colon. There may be local discomfort and, 
 in rare cases, severe pain like that of gall-stones, (c) Cachexia ap- 
 pears with all its attendant symptoms. 
 
 Complications. — Secondary growths in the liver occur in 58 per 
 cent, by lymphogenous routes or by invasion from contiguity and 
 sometimes cause hepatic enlargement ; from the liver extension by the 
 hepatic veins may occasion systemic metastases. Icterus occurs in 
 69 per cent. (Musser) from malignant or inflammatory involvement 
 of the bile ducts; cholsemia is a common termination. Using Mus- 
 ser' s figures, growths in the peritoneum occur in 12 per cent., in the 
 lungs or pleura in 10 per cent., in the abdominal lymph glands in 
 16 per cent, and ulcerative fistula into the colon in 10 per cent. 
 Warthin records adrenal metastases with pigmentation like that of 
 Addison's disease and with vitiligo. Pressure on the pylorus may 
 cause its stenosis, vomiting or dyspepsia. Ascites occurs in 25 per 
 cent, and is due to mechanical compression of the portal vein or to 
 malignant peritonitis. Suppurative cholecystitis and cholangitis may 
 develop and the case then terminates by sepsis, ulcerative endocar- 
 ditis, etc. The differential diagnosis is considered under gall-stones. 
 The clinical course averages six months. Treatment is merely pal- 
 liative, unless the affection is diagnosticated early enough for opera- 
 tion or is accidentally found in operating for other conditions. Re- 
 moval of the gall-bladder cancer has resulted in a few permanent 
 cures (Hochenegg, Robson, Warren). 
 
 II. Tumors of the Extra-Hepatic Bile Ducts. — Rolleston states that 
 80 cases are reported. These tumors are usually small, show little 
 tendency to infiltrate and are cancers of the columnar type. The 
 common duct is most often affected, the hepatic duct less frequently 
 and the cystic duct least frequently; these tumors usually occur be- 
 tween the years of sixty and seventy and two-thirds occur in males. 
 
ACUTE PANCREATITIS. 713 
 
 The salient symptom is intense icterus, which develops early, in- 
 creases steadily, occurs in nearly all cases, causes icteric necrosis of the 
 liver cells in the central zone (Fiitterer) and precipitates early cho- 
 lsemia before metastases or cholangitic sepsis have time to develop. 
 The gall-bladder is almost always dilated anatomically in tumors of 
 the common duct and is felt clinically in over 50 per cent. Pain is 
 not common, though gall-stones may be simulated (q. v.). Ascites, 
 dyspepsia and gastro-intestinal hemorrhages from choleemia may 
 develop. Differentiation from duodenal or pancreatic tumors (q. v.) 
 is usually impossible. Palliative treatment consists of draining the 
 gall-bladder to relieve the icterus ; radical treatment is extirpation of 
 the deeply located tumor (Kehr, Halsted). 
 
 DISEASES OF THE PANCREAS. 
 
 ACUTE PANCREATITIS; FAT NECROSIS. 
 
 Etiology. — Infection ascending from the intestines is the leading 
 cause, (a) Calculus obstructing the common duct, by allowing 
 bile to regurgitate into Wirsung'.s duct, may cause acute pancreatitis 
 (Opie), especially when the gall-bladder, the natural reservoir for 
 obstructed bile, is shrunken. Egdahl (1907) found gall-stones in 42 
 per cent, of acute fat necrosis of the pancreas. According to Quenu 
 and Duval (1906) 118 cases are recorded in which pancreatitis 
 occurred in the course of cholelithiasis. Flexner concludes that bile 
 salts may initiate inflammation and fat necrosis, even when there is 
 no infection. Though the accessory duct of Santorini may carry off 
 the pancreatic juice when there is obstruction of Wirsung's duct, 
 it is too small for much compensation in 66 per cent, of cases (Opie) ; 
 
 (b) metastatic infection is an infrequent cause ; in one case the author 
 observed acute pancreatitis in which an acutely inflamed ulcer of the 
 leg was the atrium of infection; (c) in some cases suppuration or 
 ulceration in contiguous tissues is causative. 
 
 Predisposing Factors. — (a) Age and sex; in Korte's collection 
 90 per cent, occurred in males beyond middle life, (b) Obesity; 
 
 (c) alcoholism; (d) trauma; (e) gastro-intestinal catarrh; and (/) 
 parturition in 6.6 per cent, of Peiser's collection of 128 cases are 
 factors. 
 
 Symptoms. — The clinical picture was clearly described and defined 
 by Fitz (1889), though cases were reported earlier (Oppolzer). The 
 onset is sudden in adult stout males who have enjoyed previous good 
 health or who have a history of alcoholism or of gall-stones. 
 
 1. Epigastric pain is the initial symptom; it is very sudden and 
 severe, is often agonizing, may be constant or paroxysmal and may be 
 confused (or coincident) with gall-stone colic, though it is even more 
 
714 DISEASES OF TEE DIGESTIVE TRACT. 
 
 intense; it is diffusely epigastric, to the right or left of the median 
 line, or rarely over the head of the pancreas. The author has seen 
 radiation into both axillae. The intensity of the pain is referable to 
 pressure on the coeliac plexus (neuralgia or possibly neuritis coeliaca). 
 Much less often the pain is gradual in onset. 
 
 2. Epigastric tenderness is usual, often over the head or sometimes 
 more over the tail of the pancreas, whence the inflammation may 
 extend to the left pleura with tenderness and friction, as in one of the 
 author's reported cases. The recti are tense and the epigastrium is 
 swollen. 
 
 3. Vomiting is early and severe and brings up food, mucus and 
 sometimes blood. 
 
 ' 4. Collapse soon follows; it is often very severe, threatens im- 
 mediate dissolution and too often prevents surgical interference. It 
 is due to pressure on or actual inflammation of the closely contiguous 
 coeliac plexus and semilunar ganglia. There may be marked cyanosis. 
 In one of the author's cases there were relapsing shock with cyanosis 
 and a pulse of 140, which was so weak that no surgeon would operate 
 during the two weeks before recovery. Collapse usually causes death 
 in 2 to 4 days in unoperated cases. 
 
 5. Fever is not constant ; there may be no elevation or an irregular 
 rise to 103 or 104 degrees. Chills are most common in late suppuration. 
 
 6. The pancreas can rarely be felt because of its deep position and 
 because the epigastrium is tense and tympanitic. 
 
 7. The bowels are constipated, simulating obstruction, though 
 flatus is passed. Operation or autopsy at this stage shows an acute 
 pancreatitis, with swelling, a variegated yellow-red or black color, ex- 
 udation of fibrin, pus cells, blood (hemorrhagic pancreatitis) and 
 areas of acute fat necrosis (Balser, 1882). Fat necrosis is caused 
 by the fat-splitting steapsin (Langerhans, Hildebrand, Dettmer and 
 Flexner), which produces glycerine and insoluble fatty acids from 
 the pancreas and contiguous adipose tissues, i. e., omentum, mesentery 
 and peritoneum; the glycerine is absorbed, the fatty acids are pre- 
 cipitated with lime as opaque white areas of necrosis and some of the 
 ferments occasionally escape into the blood, producing toxemic symp- 
 toms or necrosing fatty tissue elsewhere, as in the pericardium or 
 skin. 
 
 8. If the patient lives the symptoms of localized peritonitis develop 
 in the upper half of the abdomen and sometimes more to the left side ; 
 a pus sac may fill the lesser peritoneal cavity ; the localized pain may 
 become general from diffuse fat necrosis. In one of the author's 
 cases great dyspnoea attended diaphragmatic pleurisy. 
 
 9. Septicopyemic symptoms may appear, as rigor, hectic fever, 
 delirium, pleurisy, hiccough, icterus, diarrhoea and loss of weight and 
 strength; in one case the author saw acute splenic tumor, acute 
 nephritis and universal swelling of the lymph nodes. 
 
 9. Acute glycosuria is not common, though present in one of the 
 author's cases. 
 
ACUTE PANCREATITIS. 715 
 
 In the third week rupture into the colon may occur ; this is attended 
 by lancinating pain, intestinal hemorrhage, even passage of the pan- 
 creas by the bowel (Chiari) and relief from all symptoms. 
 
 Suppurative types, of which Korte collected 46 cases, may begin 
 gradually, without acute gangrene, fat necrosis or hemorrhage. The 
 symptoms are less acute and severe than those of the acute type. The 
 suppuration is localized or there is a diffuse purulent infiltration; it 
 may cause pylephlebitis, liver abscess, subphrenic abscess, burrowing 
 of pus into the peritoneum, loin (which Korte considers rather char- 
 acteristic), peripheral tissues or alimentary tract. Protracted sup- 
 puration is said to cause glycosuria, skin pigmentation and anasarca. 
 Korte found 40 cases of acute gangrenous pancreatitis. 
 
 Diagnosis. — The cardinal features are (a) the sudden onset, (b) 
 violent epigastric pain and tenderness, (c) vomiting, (d) collapse, 
 (e) epigastric distention. The absence of indican under these cir- 
 cumstances is suggestive of a pancreatic lesion, because trypsin con- 
 verts albumin into peptone, which in turn becomes partly converted 
 into indol, the source of indican in the urine. Since leucin and 
 tyrosin are formed in the normal intestine as a result of the action 
 of the pancreatic juice upon proteids, Ulrich attaches much im- 
 portance to their absence from the urine. Robson finds calcium 
 oxylate crystals in 30 per cent, of all varieties of pancreatic disease. 
 
 The pancreatic reaction of Robson and Cammidge is a test for gly- 
 cerine in the urine ; it is complicated and still sub judice. 
 
 Differentiation. — (a) Acute poisoning is eliminated by the his- 
 tory and gastric contents, (b) Intestinal obstruction is less severe 
 in onset ; collapse is usually attended by distention and often by in- 
 testinal rigidity or peristalsis above the obstruction; indicanuria is 
 usual ; epigastric distention alone is unusual ; in one pancreatic case, 
 the author saw obstruction lasting nine days. Operation, indicated in 
 either instance, may be necessary for diagnosis, (c) Gall-stone colic 
 is sometimes hard to differentiate but is rarely as severe as pancreatic 
 pain; collapse or epigastric distention is infrequent, (d) In per- 
 forating duodenal or gastric ulcer the later collapse, pain and the 
 history are significant, (e) Mesenteric embolism and appendicitis 
 must be considered. 
 
 Prognosis. — The malady generally evinces a severe progressive ten- 
 dency. A fatal attack may be the last of several milder seizures. 
 Fitz has found at autopsy fibrous tissue and crystals or granules of 
 hsematoidin which he regards as evidence of previous hemorrhage and 
 inflammation. Death may occur within a few hours to three days 
 from collapse, in two or three months from sepsis or in six months 
 from diabetes (Fitz). Death at an even later period may result from 
 sepsis or diabetes. The pancreas may slough into the intestine, as 
 in Trafoyer's and Chiari's cases, with recovery. 
 
 Treatment. — Rectal feeding and stimulation, morphine hypoder- 
 matically and heat are indicated during the initial shock. Though 
 early operation is dangerous because of shock and hemorrhage, the 
 
716 DISEASES OF THE DIGESTIVE TRACT. 
 
 author considers that it is indicated lest local extension or general 
 toxaemia develop. In 21 cases (Quenu and Duval), 62 per cent, of 
 the acute cases died after operation, 100 per cent, of the hemorrhagic 
 and 45 per cent, of the acute suppurative cases. 
 
 CHRONIC PANCREATITIS. 
 
 Etiology and Pathology. — (a) Gall-stones in the common duct may 
 induce chronic catarrh of Wirsung's duct, leading to chronic pan- 
 creatitis (Eobson). (b) Cancer, gastroduodenal catarrh and ulcera- 
 tion (alcoholism, syphilis and pancreatic calculi) may produce the 
 same results. In these instances ascending infection appears to be 
 the potent factor, causing interlobular fibrosis (Opie), i. e., fibrosis 
 around the pancreatic lobules; diabetes is a late and uncommon se- 
 quence, (c) In liver cirrhosis and hemochromatosis (see Diagnosis 
 Portal and Biliary Cirrhosis) an interacinar fibrosis occurs, de- 
 veloping in the lobules, diffusely invading the islands of Langerhans 
 and causing glycosuria (Opie) ; it does not result from obstruction 
 of the common duct. 
 
 Symptoms. — Eiedel, who first described the affection, and Eobson 
 state that chronic inflammation is found more frequently with increas- 
 ing thoroughness of operations for gall-stones. Symptoms may be 
 lacking. They vary with the cause. In catarrh due to gall-stones 
 there is a history of colic, jaundice and sometimes intermittent fever. 
 Tenderness in the epigastrium, a fulness above the umbilicus and loss 
 of flesh are noted and if pancreatic symptoms predominate the pain 
 passes from the epigastrium to the left side, to the scapular or renal 
 regions. If gall-stones are not the cause, there may be merely aching 
 or painful attacks which are not at all pronounced ; pain may be ab- 
 sent. The gall-bladder may enlarge from obstruction of the common 
 duct when the liver becomes enlarged and frequently cirrhotic (Hob- 
 son). According to Eobson marked enlargement of the spleen is 
 frequent, bile is found in the urine in 60 per cent., calcium oxalate 
 crystals in 40 per cent, and glycosuria in 5.5 per cent. (90 cases). 
 Opie found glycosuria but once in 22 cases. Eiedel, Korte, Eobson, 
 Moynihan and others have described a tumor-like induration of the 
 head of the pancreas, which simulates cancer because of the emacia- 
 tion and deep icterus it produces ; differentiation may be impossible, 
 even during laparotomy; it is more common in subacute than in 
 chronic cases. As in tumor, excessively copious, pale stools, laden 
 with fat and undigested muscle-fibers, are noted. Polyuria has been 
 reported. 
 
 Differentiation from stone in the common duct and from cancer 
 is very difficult. 
 
 Prognosis. — Without surgical intervention death is likely to occur 
 from emaciation, cholsemia, diabetes or hemorrhagic diathesis. 
 
 Treatment. -Drainage of the gallbladder or anastomosis is indi- 
 cated. Eobson operated on 62 cases with 13 per cent, mortality, 
 
PANCREATOLITHIASIS. 717 
 
 Quenu and Duval on 62 cases with 13 per cent, mortality and 
 Moynihan on 14 cases without a death. Hemorrhage is a dreaded 
 complication ; calcium lactate, gr. xx to 3j t. i. d. before operation, is 
 said to increase the coagulability of the blood. 
 
 PANCREATIC APOPLEXY. 
 
 Pancreatic hemorrhage has been described by Spiess (1866), Klebs 
 (1870) and Zenker (1876) ; Anders (1899) collected 40 cases. The 
 anaemias, syphilis, alcoholism, acute infections and local lesions of 
 the pancreas seem to be predisposing causes; 66 per cent, occur in 
 men. Doubtless many reported cases are acute hemorrhagic pan- 
 creatitis. Sudden onset, severe collapse, epigastric pain, intestinal 
 obstruction, vomiting, restlessness and normal or subnormal tem- 
 perature mark the affection; death sometimes occurs within a few 
 hours. If the patient survives the initial stage suppuration may de- 
 velop in the pancreas and tissues into which the hemorrhage bur- 
 rows. Hemorrhagic cysts may form, which should not be confused 
 with cysts into which secondary hemorrhage has occurred. The 
 diagnosis from acute pancreatitis is rarely made and the treatment 
 of both affections is identical. 
 
 LITHIASIS. 
 
 About 100 cases of sialolithiasis pancreatica are recorded. The 
 etiology is probably like that of gall-stones, infection of Wirsung's 
 duct; stagnation of secretion is a predisposing factor, whence the 
 occasional association with gall-stones, pancreatic inflammation and 
 tumor. 
 
 Symptoms and Diagnosis. — Confusion with gall-stones is often in- 
 evitable, for colic without icterus is indicative of either condition and 
 their co-existence is not uncommon. The pain may radiate to the 
 left side and shoulder ; Lancereaux, Lichtheim, Leichtenstern, Min- 
 nich, Holtzmann, Moynihan and Kinnicutt have recognized cases. 
 In some of them the stones were found in the faeces during life, in 
 others at autopsy. Salivation is reported. In Lichtheim's case there 
 was colic, glycosuria (found in 45 per cent of cases) and diarrhoea. 
 The stones are single or multiple (even 300), white-gray, round, oval, 
 irregularly outlined or branching, hard or friable and vary in size 
 from that of almost impalpable gravel to that of a hazel-nut. They 
 consist largely of calcium carbonate and phosphate. Shattuck de- 
 scribed an oxalate calculus. Their sequelae are (a) obstruction and 
 inflammation of Wirsung's duct and (&) acute suppurative pan- 
 creatitis. The treatment in the cases which are fortunately diag- 
 nosticated is surgical; Moynihan recognized and successfully oper- 
 ated on a case. Gould operated on a case which did not recover. 
 
718 DISEASES OF TEE DIGESTIVE TBACT. 
 
 PANCREATIC CYSTS. 
 
 To Nicholas Senn (1885) belongs the credit of establishing their 
 clinical picture. Bessel-Hagen (1900) collected 149 cases. 
 
 Etiology and Pathology. — Probably many reported cases are extra- 
 pancreatic, especially (a) the traumatic cysts of which Honigmann in 
 1905 collected 69 cases, (b) Duct obstruction (ranula pancreatica, 
 Virchow) by calculi, strictures, parasites, tumors or inflammation in 
 the smaller ducts is an etiological factor, (c) Cystadenoma is the 
 cause of most cysts (Lazarus), (d) Cysts rarely result from an old 
 hemorrhage. In all forms the cyst causes considerable parenchy- 
 matous atrophy, (e) Sex. Traumatic and inflammatory forms are 
 most frequent in men and the cyst adenoma tons type in women. (/) 
 Age; over 50 per cent, are found in the third decade of life, though a 
 congenital form, sometimes with cystic liver and kidneys, is found 
 (Richardson). 
 
 Symptoms and Diagnosis. — 1. In cysts, (a) a deep retroperitoneal 
 swelling is found, (b) the location of which is more or less central, 
 but is above the navel in 87 per cent., where other cysts are most un- 
 common; it lies behind or between the inflated stomach and colon; it 
 sometimes lies below the colon but rarely above the stomach; very 
 large cysts (which contain 10 to 20 quarts) may fill almost the entire 
 abdomen. A cyst may in rare cases develop in the tail of the pan- 
 creas, when it points toward the spleen or left kidney, (c) Its form 
 is round, oval and smooth; (d) its consistence often varies; (e) it is 
 immobile on palpation and on inspiration, or at the most can be moved 
 slightly in a vertical direction. (/) The fluid is alkaline, 1,010-25 
 specific gravity, usually mucoid, blood stained in 82 per cent. 
 (Korte), and in 45 per cent, contains one or more pancreatic fer- 
 ments (diastatic, saponifying or tryptic) of which the latter is alone 
 characteristic, for the other ferments occur in various exudates. The 
 fluid sometimes contains fat and cholesterin ; aspiration is dangerous, 
 because the tension of the cyst is great and fat necrosis or peritonitis 
 may result from leaking after exploratory puncture. 
 
 2. So-called pancreatic symptoms are rare, as emaciation, saliva- 
 tion, stools laden with undigested fat or muscle-fibers or glycosuria. 
 
 3. Symptoms of peritonitis or of intestinal obstruction may occur 
 in traumatic or inflammatory types and after rupture. The author 
 saw a case of Murphy and Wittwer in which the picture after rupture 
 was exactly that of subacute tuberculous peritonitis; after two rup- 
 tures the case was successfully operated on. Rupture into the bowel 
 is followed by diarrhoea and disappearance of the tumor. 
 
 4. Pain like that of cholelithiasis may be present, but it more 
 often radiates to the left side, shoulder and neck. Pressure symptoms 
 include dyspnoea, vomiting, icterus, emaciation and polyuria. 
 
 Differentiation from ovarian, renal and other cysts is largely a 
 topographical question. Ovarian cysts have their pelvic origin and 
 connection, but hydronephrosis is movable and originates in the 
 
TUMOBS OF THE PANCBEAS. 719 
 
 flank to which pancreatic cysts seldom penetrate. Fluid in the lesser 
 peritoneal sac or mesenteric, omental and retroperitoneal cysts are 
 difficult to distinguish. Cysts of the liver present respiratory excur- 
 sion and other obviously hepatic symptoms. 
 
 Treatment. — Aspiration is never permissible. Enucleation of the 
 sac is more difficult and more dangerous than simple drainage. In 
 Bessel-Ha gen's 149 cases the operative mortality was 6.7 per cent. 
 Diabetes has followed operation (Bull and Kronig). 
 
 TUMORS OF THE PANCREAS. 
 
 Cancer of the pancreas constitutes 67 per cent, of all pancreatic 
 diseases but possibly this estimate must be discounted because con- 
 fusions with benign induration have been frequent until of late 
 years. It occurs in 0.6 per cent. (Eppinger) to 1 per cent. (Soyka) 
 of autopsies. In 132 cases of pancreatic tumors (Segre) 127 were 
 cancer, 2 sarcoma, 2 cysts and 1 gumma. Sarcoma is usually secon- 
 dary from contiguous lymphosarcoma in the retroperitoneal glands; 
 21 cases are reported. 
 
 Cancer is usually scirrhus, less often of the medullary, colloid or 
 adenomatous type. It most often begins in the head of the organ. In 
 some cases it may be secondary to pyloric cancer. 
 
 Symptoms. — (1) Tumor is the commonest and surest symptom, oc- 
 curring in 25 to 50 per cent. ; it lies deep, beside the spine at the level 
 of the navel and between the pylorus and colon. It is tender, prac- 
 tically immobile and varies from the size of a walnut to that of a 
 child's head, though small tumors are commonest ; in some instances 
 it may show propagated pulsation from the aorta or a bruit from its 
 compression. Palpation should be made with the stomach and bowels 
 empty. (2) Icterus occurs in 72 per cent., increases gradually and 
 is more often continuous than remittent. In some cases there may be. 
 rigors and pain as in biliary calculi ; occasionally, just before death, 
 the growing ansemia seems to lessen the jaundice. Bard and Pic 
 state the liver is usually rather small. (3) The gall-bladder is usu- 
 ally enlarged (Battersby, Bard and Pic) ; see differentiation. Cochez 
 holds that it shrinks when the hepatic or cystic duct is obstructed. 
 (4) Fain and early vomiting are usual. The pain is epigastric, se- 
 vere and sometimes neuralgic (neuritis coeliaca) or radiating as in 
 pancreatitis or lithiasis. (5) Cachexia is marked and rapid; great 
 prostration, emaciation and a syncopal tendency occur in tumor as in 
 other pancreatic lesions. The temperature is usually subnormal. 
 (6) The stools may contain much fat (Kuntzmann, 1827, and Bright, 
 1833) ; in steatorrhea the fatty acids and neutral fats are more abun- 
 dant than the fatty soaps (Miiller) ; its significance grows if diar- 
 rhoea and icterus are not present. The stools also contain many un- 
 digested muscle-fibers (lientery) and sometimes blood is present. 
 (Sahli's test for albumin digestion is made by giving salol in divided 
 doses in glutoid capsules ; as the glutoid is not dissolved, no carbolic 
 
720 DISEASES OF THE DIGESTIVE TRACT. 
 
 acid appears in the urine.) (7) The urine may contain sugar; 
 Mirallie holds that glycosuria occurs in 26 per cent., though in Rob- 
 son's 15 cases it was absent. It is said to be an early symptom and 
 to disappear before death or with the increasing icterus. Albumin- 
 uria is more frequent than glycosuria. The indican is decreased. 
 Peptone, maltose (once, by v. Ackeren) and fat (Clark and Bow- 
 ditch) have been found. Polyuria and bronzing of the skin are rare 
 findings. Complications include pyloric or duodenal obstruction; 
 compression of the aorta or cava; retention cysts of the pancreas; 
 and extension by contiguity to the portal vein, colon, peritoneum, 
 ureter or lungs. 
 
 Differentiation. — 1. Chronic pancreatitis with icterus and tumor 
 may not be differentiated even by laparotomy (Riedel), though 
 ascites indicates neoplasm and recovery means inflammation. The 
 pancreatic cachexia of French writers, occurring in many lesions of 
 the pancreas, may be confused with the cachexia of cancer. 
 
 2. In duodenal cancer (q. v.) the growth is also fixed and is at- 
 tended by icterus, but cancer above the papilla causes rather the 
 picture of pyloric stenosis ; in cancer below the papilla pancreatic 
 juice may be recovered from the stomach. 
 
 3. Liver disease, with the frequent icterus, ascites and splenic 
 enlargement, causes little difficulty in differentiation. 
 
 4. Calculus in the Common Duct. — vs. — Compression of Common Duct by 
 
 Pancreatic Tumor. 
 
 1. History of colic usual. Absent. 
 
 2. Tenderness of gall-bladder usual. Absent. 
 
 3. Icterus, often remittent. Permanent. 
 
 4. Liver less large than in — pancreatic tumor. 
 
 5. Intermittent fever, and rigors. - Subnormal temperature. 
 
 6. Gall-bladder (see gall-stones) shrunk- Dilated in 92 per cent. (Courvoisier's 
 
 en in 80 per cent. law). 
 
 7. Slower course. Very rapid emaciation. 
 
 According to Bard and Pic the icterus, enlarged gall-bladder, rapid 
 emaciation, cachexia, subnormal temperature and normal or smaller 
 liver of pancreatic cancer can only be confused with some few cases 
 of gall-stones, cancer of immediately adjacent parts, primary cancer 
 of the liver or bile-passages and primary duodenal or gastric cancer 
 with early diffuse generalization in the liver. Kehr states that 
 chronic obstruction of the common duct is cancerous in 70 per cent., 
 pancreatitic in 20 per cent, and calculous in 10 per cent. 
 
 Treatment is largely symptomatic; morphine should be given for 
 pain, the gall-bladder should be drained (cholecystotomy) or it should 
 be sutured to the intestine (cholecystduodenostomy). Very few per- 
 manent recoveries follow extirpation, 
 
ACUTE DIFFUSE PERITONITIS. 721 
 
 DISEASES OF THE PERITONEUM. 
 
 ACUTE DIFFUSE PERITONITIS. 
 
 Acute inflammation of the peritoneum was at one time far more 
 important as an independent affection than at present ; we now regard 
 it as chiefly symptomatic of some other disease, e. g., appendicitis, 
 salpingitis, puerperal sepsis, etc. 
 
 Etiology.- — The actual cause is probably always my colic. Some 
 writers classify peritonitis as bacterial (especially suppurative 
 forms), chemical (serous and sero-hemorrhagic forms) and mechan- 
 ical (adhesive forms). The Streptococcus pyogenes (puerperal and 
 traumatic forms) and Bacillus coli (forms due to intestinal lesions) 
 are the two most frequent organisms. The staphylococcus, pneumo- 
 coccus and tubercle bacillus are fairly frequent and less often the 
 Bacillus pyocyaneus, proteus, anthracis, typhosus, aerogenes encapsu- 
 late, the ray fungus, Bact. lactis, gonococcus, Amoeba coli, etc. 
 Generally speaking, mono-infections are less common than mixed 
 infections. 
 
 Factors causing lessened physiological resistance include nephritis 
 (in 10 per cent.), alcoholism, cardiac disease, scurvy, etc.; in other 
 words peritonitis may be a terminal infection, fatal to reduced 
 subjects. 
 
 Atrium. — Compared with pleurisy and pericarditis, peritonitis is 
 seldom primary. Though it may follow inflammation of every ab- 
 dominal viscus, it is most commonly a secondary manifestation of 
 intestinal disease (e. g., appendicitis) or of pelvic diseases in wo- 
 men, (a) Infection through the alimentary tract; appendicitis, 
 bowel ulceration (typhoid, carcinomatous, tuberculous), bowel ob- 
 struction, perforation, traumatism and infarction may cause it. 
 Gastric are less frequent than intestinal lesions and ulcer and cancer 
 rank first, (b) The internal female genitalia; it may result from 
 gonorrhoea (Nogerrath), extra-uterine pregnancy, puerperal infec- 
 tions and septic abortion; peritoneal infection from diseases of the 
 male genitalia is rare, (c) Liver and bile vessels; local or general 
 peritonitis may result; peritonitis is more common as a result of 
 hepatic abscess and syphilis than of echinococcus, cancer, pylephlebitis 
 or cholecystitis, (d) Pancreas; acute pancreatitis. (<?) Kidney and 
 bladder ; pyonephrosis, calculi or ulcerations of the bladder. (/) Rarer 
 causes are splenic affections, retroperitoneal adenopathies, spinal or 
 costal caries, lesions of the thoracic duct or the abdominal parietes or 
 extension through the diaphragm, (g) Metastatic peritonitis is not 
 common, though observed in septicopyemia and acute infections. 
 (h) In children foetal peritonitis has been observed by transplacental 
 infection; in the new-born the umbilical vein may convey infection, 
 though peritonitis occurs in but 8 per cent, of fatal cord infections. 
 It occurs more commonly through the lymphvessels of the cord. 
 
 Age and Sex. — Most cases occur between the ages of fifteen and 
 forty and women are more often affected than men. 
 46 
 
722 DISEASES OF THE DIGESTIVE TRACT. 
 
 Symptoms. — Symptoms are local and general. 
 
 1. Local or Abdominal. — (a) Pain, the usual initial symptom, 
 is almost invariable, is continuous, begins near the navel and re- 
 mains greatest there ; a causal gastric ulcer may produce pain in the 
 back, salpingitis is attended with early pelvic pain and appendicitis 
 has its own initial localization, but the pain of diffuse peritonitis is 
 felt at or below the navel, (b) Tenderness accompanies pain; the 
 tenderness is deep rather than superficial; tenderness and pain are 
 very rarely absent and are caused by inflammation ; at the operation 
 or autopsy both the visceral and parietal investments are injected, 
 reddened, lustreless, covered with a thin film of fibrinous exudate 
 which binds the intestinal coils together; not infrequently the peri- 
 toneum is dotted with minute petechias (c) The attitude is charac- 
 teristic ; the knees are drawn up and the head lifted to relieve tension 
 and, in marked cases, to keep the bedclothes from contact with the 
 abdomen, (d) Vomiting is reflex; it occurs early and greatly aggra- 
 vates the pain; the vomitus contains food and later bile; it may be 
 green (the vomitus herbaceus of the older writers), rarely dark 
 brown or faecal. It is accompanied by redness and dryness of the 
 tongue, great thirst and singultus which is a sensory phrenic symp- 
 tom; toward the fatal issue vomiting and singultus cease, (e) The 
 abdomen on inspection and palpation is at first tense, retracted and 
 scaphoid, but later becomes tympanitic from paresis of the inflamed 
 intestinal coils (Stokes) and decomposition of their contents; the 
 diaphragm stands high and its movement is restricted; in some, 
 especially muscular subjects, the abdomen may be retracted through- 
 out the course. Exploration by percussion may elicit dulness, which 
 is usually due to serous, seropurulent or perhaps serohemorrhagic 
 exudation, which may be effused in small pockets between fresh ad- 
 hesions or may fill the entire cavity, amounting to even 30 or 40 
 quarts and sometimes fluctuating to the hand ; as a rule a tympanitic 
 note prevails; in some cases dulness suggests the presence of fluid 
 which, however, is not found on exploration; because of adhesions, 
 the fluid changes little on change of posture. On auscultation a 
 friction rub is sometimes heard (Beatty and Bright), chiefly over the 
 liver. (/) Constipation is usual and results from inflammatory in- 
 filtration of the intestine (Stokes) ; in the puerperal (streptococcic) 
 and in pneumococcic peritonitides, diarrhoea is common. 
 
 2 General Symptoms. — (a) Shock is a conspicuous symptom. 
 Cdlapse may occur early and directly from perforation or later 
 from toxsemia. The pulse is frequent, hard, wiry and about 120 ; 
 later it becomes thready and runs to 140 or 170. The fades- Hippo- 
 craticais pronounced, with its anxious expression, wrinkled, clammy, 
 cyanotic, lead-colored skin, pointed nose, hollowed temples and sunken 
 eyes. The voice whispers (vox cholerica) to avoid movement of the 
 diaphragm and the breathing is costal, shallow, difficult and rapid. 
 (b) Fever is usually but not always present. It may rise abruptly 
 with a chill at the onset but follows no one type ; it may be continu- 
 
ACUTE DIFFUSE PERITONITIS. 723 
 
 ous or remittent and there is usually elevation of temperature by rec- 
 tum, even during collapse. The fever and pulse curves may run 
 parallel in peritonitis with a slow course, (c) The lungs and heart 
 are crowded upward by the abdominal distention. The apex-beat is 
 high and further to the left as the heart lies more horizontally, (d) 
 The urine is scant from lessened absorption and from cardiac weak- 
 ness ; albuminuria is frequent ; indicanuria is constant from increased 
 putrefaction in the paretic bowel ; dysuria is usual ; tenesmus, due to 
 involvement of the vesical serosa, is less common than retention. 
 
 Course. — Though recovery is possible, the issue is fatal within two 
 days in the rapidly fatal toxemic form in which there is only rough- 
 ening of the peritoneum without exudation; the slower cases rarely 
 last more than five days. Consciousness is usually preserved to the 
 end, though stupor or delirium occasionally intervenes; the pulse 
 becomes thready, the breathing shallow and sighing, the superficial 
 temperature is low and the patient succumbs to cardiac failure from 
 toxaemia. In exceptional cases death occurs within a few hours or 
 relative recovery results with encapsulation of pus. Treves found 
 inhalation pneumonia in 17 per cent, of his cases and Tilger found 
 serous pleurisy in 25 per cent.; of the latter, 63.3 per cent, were 
 right-sided, 3.3 per cent, left-sided and 33.3 per cent, bilateral. 
 
 Types.- — (a) Peritonitis serosa usually follows the fibrinous form; 
 the fluid is yellow or light green, its specific gravity is 1,015 or more, 
 it contains 2 to 3 per cent, of albumin and flocculi of fibrin, epithelial 
 cells, red cells and leukocytes. (&) P. purulenta may occur in pock- 
 ets or as a massive pyoperitoneum, amounting to 30 or 40 quarts, 
 (c) P. putrida occurs in septicopyemia and puerperal fever, but 
 especially in perforating carcinoma; Obermeyer and Schnitzler have 
 proven that foetid peritonitis may occur without perforation, (d) 
 P. perforative!, is characterized by two groups of symptoms, (i) those 
 of peritonitis and (ii) those of gas in the peritoneal sac (pneumo- 
 peritoneum, pneumatosis peritonei) ; there is often (but not always) 
 the initial subjective sense of perforation, sudden pain, collapse and 
 retracted abdomen; in four to twelve hours diffuse peritonitis sets 
 in, unless death occurs from the initial shock ; free gas may obliterate 
 the dulness of the liver and spleen, though this also results from great 
 tympanites without perforation ; the liver dulness may be found only 
 in the posterior axilla, but when the patient is turned on his left 
 side the free gas entirely obscures it ; the abdominal contents may be 
 putrid or faecal, though when due to perforating gastric ulcer (q. v.) 
 there is seldom any odor (Czerny). The diaphragm is pushed to 
 its highest possible level ; a succussion splash may be elicited and the 
 intestines may be compressed against the spine. It has been held 
 that gas may develop in peritonitis without perforation through the 
 action of the Bacillus pyogenes fcetidus and Bac. aerogenes encapsu- 
 latus, but pneumoperitonitis without perforation is rare. (e) P. puer- 
 peralis, usually streptococcic, is described under sepsis on page 127 ; 
 it is characterized by moderate pain, enormous tympanites, diarrhoea 
 
724 DISEASES OF THE DIGESTIVE TEACT. 
 
 and the usual septic manifestations. (/) P. pneumococcica has been 
 described by Sevestre, Moizard, Galliard and Dieulafoy. Jensen 
 has collected 106 cases. Annand and Brown found 91 cases under 
 15 years of age; one-third were secondary to thoracic lesions; two- 
 thirds probably were enterogenous ; of the latter 84 per cent, were in 
 girls. The lower abdomen is especially involved, thereby often simu- 
 lating appendicitis, which it also resembles in its abrupt onset, pain, 
 fever and vomiting; pneumococcic peritonitis is nearly always at- 
 tended by early, continuous, foetid diarrhoea. It often points at the 
 navel, through which a creamy, greenish pus may rupture. Some- 
 times it ends by crisis ; an encysted pus sac often remains. The 
 inflammation is usually nbrinopurulent. The pneumococcus may be 
 found in the blood, (g) The streptococcic, colon and staphylococcic 
 peritonitides are described under appendicitis. 
 
 Diagnosis. — Peritonitis is usually diagnosticated with ease from 
 the cause (appendicular, salpingitic, gastric ulcer, septic abortion), 
 by the febrile onset, pain, tenderness, vomiting, distention, effusion and 
 collapse. Puncture with an aspirating needle is dangerous. In cer- 
 tain cases only the fact of peritonitis can be established, perhaps even 
 at operation, though the autopsy usually demonstrates a cause. 
 
 Differentiation is necessary (a) from intestinal obstruction (q. v.) ; 
 (b) from the pain of biliary or renal calculi; (c) from acute pan- 
 creatitis (q. v.) ; (d) from ruptured tubal pregnancy, in which the 
 menstrual history, pelvic localization and symptoms of acute anaemia 
 and shock are present; (e) from ruptured abdominal aneurysm; or 
 infarction of the superior mesenteric artery in which a cause for em- 
 bolism, acute obstruction and bloody vomiting or diarrhoea with later 
 peritonitis are often distinctive; (/) from acute enterocolitis, which 
 is attended by less pain and tenderness and by more diarrhoeal colic, 
 tenesmus and collapse due to desiccation of the tissues and to tox- 
 aemia; (g) from hysteria (q. v.), which may simulate peritonitis, as 
 it may resemble every other disease; if its presence is once suspected 
 the other stigmata are usually definitive, (h) The referred abdomi- 
 nal pain of thoracic disease (pleurisy and pneumonia) is very seldom 
 accompanied by tenderness, and is easily distinguished by examina- 
 tion of the chest, especially of its posterior parts, (i) Mild infections 
 with much exudation may simulate ascites (q. v.). 
 
 Treatment. — Surgical treatment alone is of any value. In most 
 statistics the percentage of recoveries is not large; Korte estimates 
 it at 35 per cent., Haenel at 37 per cent, and Krogius (680 cases) at 
 28.5 per cent. The author has seen, in Murphy's service, 48 out of 
 57 consecutive cases of diffuse purulent peritonitis recover under 
 operation, the last one being a case of streptococcic peritonitis; 
 Murphy institutes drainage, puts the patient in Fowler's semi-erect 
 posture and administers continuously enemata of normal salt at 
 low pressure. 
 
 Palliative treatment is of little value, (a) The opium treatment 
 only controls pain and though suffering must be relieved by drugs or 
 
LOCALIZED PERITONITIS. 725 
 
 operation, the doses recommended by Alonzo Clark (more than 1,000 
 grains of opiivm in one week!) are now only of historical interest. 
 Morphine, given hypodermatically, produces the best results. (6) 
 The patient should have absolute rest, (c) Tait's method of saline 
 purgation to increase osmosis is productive of more harm than good. 
 (d) Vomiting is treated as in acute gastritis; the stomach should be 
 washed out; all medication, food and water by mouth should be 
 withheld and given only by rectum, (e) Tympanites should be 
 treated by the turpentine stupe and by enemata containing emulsum 
 asafcetidse oiij, spts. chloroformi 3j and ol. terebinthinse 3ss. 
 
 CHRONIC DIFFUSE PERITONITIS. 
 
 Aside from tuberculous peritonitis, chronic diffuse peritonitis is 
 uncommon, (a) The serous or serohemorrhagic form will be con- 
 sidered under ascites; (&) the diffuse adhesive form results from 
 acute peritonitis and from tuberculous peritonitis ; in this form the 
 peritoneal sac is obliterated and at operation or necropsy the knife 
 cuts directly into the intestine, (c) Chronic proliferative peritonitis 
 may occur in peritoneal cancer or tuberculosis, chronic alcoholism, 
 cirrhosis of the liver or cardiac disease. It may develop with or with- 
 out adhesions, as a diffuse sclerosis of the peritoneum and as a 
 subperitoneal proliferation. In its extreme forms it was described by 
 Virchow (1885) as peritonitis deformans. The peritoneum is white, 
 lustreless and diffusely thickened, though in some places more than 
 in others. The omentum is retracted upward, so that it lies as a hard, 
 transverse roll above the navel and the mesentery is indurated (mes- 
 enteritis retrahens), as described under tuberculous peritonitis. As 
 the mesentery retracts it may gather the intestinal coils into a ball 
 the size of a child's head, lying centrally or to the right of the median 
 line. Here and there may be found multilocular serous encapsula- 
 tions or there may be no serous exudation when the case comes under 
 observation. There may be palpable tumor-like thickenings. The 
 spleen, liver, stomach, csecum or colon may be particularly indurated. 
 In some cases it is but part of a multiple serositis (polyserositis, 
 polyorrhomenitis), invading also the pleura and pericardium. Mili- 
 ary fibromata, resembling miliary carcinosis or miliary tuberculosis, 
 may sometimes form around parasitic ova or cholesterin crystals. 
 
 LOCALIZED PERITONITIS. 
 
 I. Suppurative Forms. — 1. Subphrenic Abscess and Pyopneumo- 
 thorax Subphrenicus. — Subphrenic suppuration was first diagnosti- 
 cated by Barlow (1845) and was especially described by Ley den 
 (1879). Maydl's monograph (1894) comprised 179 cases, upon 
 which the following figures are based; sixty cases are described by 
 Korte (1903). 
 
 Etiology. — (a) Gastric ulcer causes 19 per cent.; gastric cancer is 
 
726 DISEASES OF TEE DIGESTIVE TRACT. 
 
 a less frequent cause. (b) Appendicitis causes 14 per cent.; (c) 
 trauma, 14 per cent.; (d) intestinal ulceration, 7 per cent.; (e) 
 cholangitis and cholecystitis, 11 per cent. ; echinococcus, 7 per cent. ; 
 liver abscess, 10 per cent.; (/) metastatic' abscess, 6 per cent.; (#) 
 perinephric abscess, 6 per cent.; (h) occasionally, ulcerative lung 
 lesions, 5 per cent. ; (i) splenic infarct, abscess or echinococcus, dis- 
 eases of the spine, ribs, pericardium or uterus are uncommon causes. 
 
 Symptoms. — Pus is ensacculated beneath the diaphragm (pyotho- 
 rax subphrenicus), associated in 50 per cent, with gas formation (pyo- 
 pneumothorax subphrenicus ) . The subphrenic abscess is usually right- 
 sided, is limited by the suspensory ligament of the liver and may be 
 intra- or extraperitoneal; in the latter instance the abscess is most 
 often appendicular or perinephric and lies well back in the abdomen. 
 Cases with simple pus formation are often difficult to localize; their 
 symptoms are those of sepsis, with pain, tenderness or dulness on the 
 liver convexity, which suggest liver abscess. The retroperitoneal 
 forms give most dulness posteriorly, but in intraperitoneal forms it 
 is chiefly located anteriorly; oedema of the chest wall may occur 
 without suppuration; the x-rays may produce a subphrenic shadow. 
 
 In pyopneumothorax subphrenicus there are signs " of a cavity be- 
 neath the diaphragm, filled with gas and pus, pushing the diaphragm 
 upward and simulating pyopneumothorax" (Ley den), (a) Tym- 
 pany and absence of vesicular murmur and of vocal fremitus are 
 found from the third rib downward, above which is the compressed 
 lung and below which is (&) the dulness of the liver whose exposed 
 surface and edge, dislocated downward, are easily percussed and 
 palpated. Sometimes the tympany entirely covers the liver dulness. 
 As in pneumothorax (c) succussion and, on change of posture, the 
 clearly shifting line of dulness may be elicited, (d) Puncture evacu- 
 ates gas and putrid pus; sometimes on a higher puncture serum is 
 found in the pleura, for pleurisy develops in 66 per cent, of the cases. 
 The needle ascends during inspiration and descends during expira- 
 tion, which is the converse of the findings in pleural exudation 
 (Fiirbringer). If a manometer is attached to the exploring needle, 
 a rise in the indicating column during inspiration and a fall during 
 expiration denote a subphrenic lesion (Pfuhl). (e) The x-rays may 
 show movement of the diaphragm and a shadow between it and the 
 liver; in three cases the writer found no respiratory excursion. (/) 
 Perforation into the lungs occurs in 16 per cent, (more often in 
 extra- than in intraperitoneal forms), into the pleura in 19 per cent, 
 and into the pericardium in 1 per cent. At the beginning and until 
 perforation there is generally an entire absence of. such thoracic symp- 
 toms as cough or sputum; this is of value in differentiation from true 
 pyopneumothorax, (g) The history of the subphrenic pyopneumo- 
 thorax is usually that of some abdominal lesion (v. Etiology). 
 
 Treatment is surgical. Korte's experience with 60 operations gives 
 66 per cent, of recoveries. 
 
 2. Suppuration in the Lesser Peritoneum. — This may result from 
 
CARCINOMA OF THE PERITONEUM. 727 
 
 gastric or duodenal ulceration, acute pancreatitis, etc. Closure of the 
 foramen of Winslow confines the pus; a tumor appears in the epi- 
 gastric, umbilical or left hypochondriac region, bounded above by the 
 stomach, which also in part covers it, below by the colon and behind 
 by the pancreas and retroperitoneal tissues. Its relations are like 
 those of pancreatic cyst; variability in its size occurs when the 
 stomach is filled with gas and fluid. When gas and pus co-exist the 
 diaphragm and liver are pushed upward. Treatment is surgical. 
 3. Other Forms. — The appendicular abscess has been described. 
 The pelvic abscess occurs especially from tubal, but also from uterine 
 and ovarian inflammation; it follows abortion, puerperal fever, gon- 
 orrhoea, tuberculous and pneumococcic peritonitis in young girls. 
 Other types are suppuration around the gall-bladder, colon and sig- 
 moid and in other rare localizations. 
 
 II. Adhesive or Indurative Forms. — Local thickening or adhesions 
 may occur over any abdominal viscus but especially over the spleen, 
 next over the liver and less commonly over the intestines ; it may bind 
 together two coils or form bands under which loops may become 
 strangulated. 
 
 Perisplenitis is most common over chronic malarial, leukemic and 
 pseudoleukemia enlargements of the spleen and less frequent over 
 acute splenic tumors. 
 
 Perihepatitis may cover small areas of the liver like soldier's spots 
 in the pericardium or may engross its entire surface. General peri- 
 hepatitis was described by Budd (1852), by Curschmann (1884), 
 who called it the " icing liver" (ZucJcergussleber) , and by Fagge, 
 Hale White, Nichols, A. 0. J. Kelly and others. It is frequently 
 associated with deforming proliferative peritonitis. Nichols de- 
 scribes it as a hyaline degeneration, hyaloserositis. There are three 
 groups of cases; (a) multiple serositis (polyorrhomenitis, Con- 
 cato's disease) ; this borders closely on Pick's " pseudocirrhosis peri- 
 carditica." Kelly has assembled 27 cases in which perihepatitis was 
 associated with adhesive pericarditis. (&) Arteriosclerosis and inter- 
 stitial nephritis occurred in 86 .per cent, in Hale White's series, 
 (c) Rarer factors are syphilis, tuberculosis, malignancy and alcohol- 
 ism. Its symptoms may be those of cirrhosis ; it will be differentiated 
 under ascites (v. i.). 
 
 III. Chronic Hemorrhagic Peritonitis.- — This rare disease was de- 
 scribed first by Virchow, who likened it to pachymeningitis hemor- 
 rhagica. It occurs chiefly in the pelvis and is most often circum- 
 scribed. Pachyperitonitis is characterized by hemorrhagic inflam- 
 mation; from the laminae of the resulting fresh connective tissue, 
 deposited layer by layer, repeated fresh hemorrhages arise. 
 
 CARCINOMA OF THE PERITONEUM. 
 
 Primary malignant growths of the peritoneum are endotheliomata, 
 and are very rare. 
 
728 DISEASES OF TEE DIGESTIVE TEACT. 
 
 Cancer is most frequently secondary to cancer of the stomach, 
 ovaries, intestines, pancreas and liver. Histologically it is that of 
 the primary growth. Its gross forms are (a) miliary carcinosis, re- 
 sembling miliary tubercles; (b) vegetative; (c) ulcerative; (d) 
 cystic and (e) infiltrative. The primary tumor may be quite latent 
 clinically, so that the peritoneal complication is apparently primary. 
 The secondary growths spread by contact, the lymphatics and im- 
 plantation of free particles. They may be felt in the omentum, 
 mesentery and Douglas' cul de sac and in some cases may be con- 
 fused with tuberculous masses. The diagnosis is usually reached by 
 the symptoms and signs of the initial growth or by those of an ascites, 
 which is serous, hemorrhagic, pseudochylous or adipose; its progress 
 is rapid and attended by cachexia. Groups of cancer cells may be 
 found in the aspirated fluid and secondary cancer may develop at 
 the point of puncture. Differential features are tabulated under the 
 next topic. 
 
 ASCITES. 
 
 Ascites (hydroperitoneum) is a symptom and sometimes the chief 
 symptom of various diseases. 
 
 Etiology. — (a) It may result from stasis, of which the chief va- 
 rieties are valvular and other cardiac lesions, pulmonary, mediastinal 
 or pleural disease and portal stasis, due to disease of the liver or 
 portal vein. Stasis causes increased pressure in the portal system, 
 followed by malnutrition of the vessels and pouring out of serum, 
 (b) Hydrcemia or cachexia causes malnutrition and increased per- 
 meability of the vessel walls; it occurs in amyloidosis, chronic ne- 
 phritis, marantic conditions, profound anaemias and occasionally in 
 acute affections, (c) Inflammation, as simple, tuberculous, suppura- 
 tive or cancerous peritonitis. (d) Abdominal tumors, leuksemic 
 spleen, etc. In many cases more than one factor may operate ; tuber- 
 culous peritonitis may complicate liver cirrhosis or ascites may be 
 due to the hydremia of nephritis, accentuated by weakness of the 
 heart. 
 
 Symptoms. — 1. Inspection. — A symmetrical enlargement of the 
 abdomen in the average case presents rather more lateral than an- 
 terior bulging. The abdomen resembles that of a batrachian (ventre 
 de batracien). The skin is pale, tense, striated, oedematous; the 
 pouting navel and diastasis of the recti muscles are noted. A caput 
 Medusae may be noted in cirrhosis cases. Dilated veins over the ribs 
 and upper abdomen indicate compression of the cava inferior. Some- 
 times the heart imparts systolic waves to the fluid. 
 
 2. Palpation. — Fluctuation (ballottement) , due to the transmis- 
 sion of a fluid wave from side to side, is usually present but may 
 be absent because of tense abdominal walls or great accumulation of 
 fluid. Pseudofluctuation may be caused by accumulation of fluid 
 other than ascitic, as intestinal contents, or by lax, obese abdominal 
 walls ; in the latter condition a third hand placed in the median line 
 
ASCITES. 729 
 
 of the abdomen will break the deceptive wave, which is due to super- 
 ficial or parietal vibration. Fluctuation is felt in ascites even where 
 great tympany exists. In women the water-pillow fluctuation (Lan- 
 dau) may be elicited by vaginal examination and Tripier remarks 
 that the uterus seems remarkably movable. Thrusting palpation may 
 disclose the outline of the liver, spleen or possibly some neoplasm even 
 through the abundant fluid; it is performed by placing the fingers 
 vertically on the abdomen and suddenly thrusting them inward, thus 
 anticipating any rigidity of the muscles and pushing aside the 
 ascitic fluid. 
 
 3. Percussion. — At least a pint to a quart (500 to 1,000 c.c.) of 
 fluid must be present for clinical detection. With small effusions the 
 patient should be examined in the genupectoral position (Leube). 
 Elevation of the buttocks causes scanty fluid to gravitate to the 
 flanks where its presence is more easily demonstrated. Classically, 
 the fluid in dependent parts gives dulness and the supernatant in- 
 testines are located by tympany in the highest parts of the abdomen. 
 These areas vary with change of position, always giving, in uncom- 
 plicated cases, tympany above and dulness below, in any posture the 
 patient may assume. When the patient lies upon his back the tym- 
 panitic area is central and elliptical. This rule is void when the 
 mesentery is retracted and does not allow the gut to float, in which 
 event there is dulness over the highest areas on light percussion, 
 though tympany can be elicited on deep percussion over the same 
 area; adhesions between the intestinal loops prevent shifting of the 
 fluid; two lines of tympany in the flanks mark the ascending and 
 descending colon; when the gut is adherent anteriorly there is per- 
 manent tympany in that location and the author knows of an in- 
 stance of ascites in which a physician perforated the intestines; 
 immovable tympany in the flanks in ascites may be due to extensive 
 adhesions of intestinal coils to the lateral abdominal parietes. Light 
 percussion is employed in the determination of ascites, because heavy 
 tapping elicits tympany from the adjacent or more deeply-situated 
 intestine. 
 
 A large quantity of free fluid may, in very rare instances, exist 
 without dulness. The author withdrew two gallons of ascitic fluid 
 from a patient in whom no dulness could be elicited in any position. 
 
 (Edema of the subcutaneous tissues renders percussion of the 
 abdomen difficult, as do fatty abdominal walls, fatty omentum and 
 fatty mesentery. The manometric pressure in the abdomen amounts 
 to 6 to 40 mm. of mercury. 
 
 Diagnosis. — Although ascites is usually one of the most easily dem- 
 onstrable conditions, excellent clinicians have mistaken it for other 
 affections. Fcecal accumulations cause dulness in either flank, simu- 
 lating fluid, but the history of the case, the immobility of the 
 dulness and the use of enemata or catharsis preclude error. Large 
 quantities of semifluid faeces in the ascending and descending- 
 colon may closely resemble free fluid; on thrusting palpation a 
 
730 DISEASES OF THE DIGESTIVE TEACT. 
 
 splashing sound may be elicited over the colon and Kiissner pub- 
 lished a case in which fluid in the intestines was mistaken for 
 ascites. Leube confused ascites with an enormously dilated stomach. 
 Preperitoneal lipoma, hydronephrosis, hydatid cyst, pregnancy, di- 
 lated bladder, ovarian cyst and tympanites are frequently sources 
 of error. 
 
 Rostan (1837) noted that tympany might be absent in ascites when 
 the intestines contained little or no gas, a point sometimes forgotten 
 in differentiation between ascites and ovarian cyst; the latter may 
 thrust itself in between the coils of gut and simulate ascites ; ovarian 
 cyst usually produces a central flatness with tympany in the flanks, 
 and neither the dulness nor tympany shifts with change of posture. 
 Adami has collected 42 cases of fatty tumor {fibrolipoma and myxo- 
 lipoma) in which ascites was very closely simulated. 
 
 Etiological Diagnosis.— 1. Stasis. — In cardiac disease the dyspnoea 
 develops early, but that caused by ascites pressing upward on the 
 diaphragm is a late symptom ; swelling of the feet usually antedates 
 the ascites, though Strumpell (1883) pointed out that pericarditis 
 and valvular disease may exceptionally produce ascites without ana- 
 sarca. It must be borne in mind that a marked ascites may crowd the 
 heart upward and outward. The liver is peculiarly an etiological 
 factor in ascites (see Differential Chart on page 695). Portal 
 ascites commences almost invariably in the peritoneum; the legs 
 swell secondarily from pressure on the vena cava inferior or from 
 cardiac weakness due to great ascites (Giovanni) ; the legs may swell 
 disproportionately, cicatrices may involve the portal vein and cava 
 simultaneously at the notch in the posterior surface of liver, and 
 finally the legs may swell first. In some cases the ascitic fluid may 
 lie between the diaphragm and the liver, which latter is then pushed 
 downward and may appear large, though it is merely dislocated. An 
 attempt should be made to exclude perihepatitis, which, according to 
 Fagge, causes one death to every five fatal cases of cirrhosis, and is 
 more apt to be attended by albuminuria (see Table given below). 
 
 2. Hydremia. (Cachexia, Increased Vascular Permeabil- 
 ity). — In renal disease the eyelids often become oedematous ' before 
 other symptoms develop and the nephritic ascites is seldom great 
 unless the liver and heart are involved. ^Cachectic ascites is not un- 
 common in leukaemia and kindred affections. Slight serous effusions 
 occurring in acute infectious diseases in children may come under 
 this title. The author has seen three instances of ascites in typhoid 
 convalescence. 
 
 3. Peritonitis. — The specific gravity and the percentage of albu- 
 min in the fluid are important factors in differentiating between 
 exudate and transudate. Three divisions are distinguished: (a) a 
 specific gravity of 1,010 or lower indicates a cachectic transudate, 
 e. g., in nephritis, with less than 1 per cent, albumin. A very low 
 specific gravity and percentage of albumin occur in amyloidosis. 
 (6) A hypostatic transudate has a specific gravity which ranges be- 
 
ASCITES. 731 
 
 tween 1,010 and 1,014 and has between 1 and 3 per cent, of albumin. 
 (c) An exudate has a specific gravity of more than 1,015 (or 1,018) 
 and the albumin reaches 4 to 6 per cent. The lower strata are 
 heavier and the specific gravity should be measured several times 
 during the paracentesis. When there is less than 1 per cent, of albu- 
 min, no disease of the peritoneum or portal vein exists. Keuss' 
 formula to compute the albumin percentage from the specific gravity 
 is subject to an error of less than % of 1 per cent. ; the percentage of 
 albumin = % (specific gravity minus 1,000) minus 2.8. A specific 
 gravity of 1,017 to 1,020 positively indicates an exudate. There are 
 certain exceptions to this rule, and certain confusions may arise; 
 thus an ascites due to a carcinoma in the liver substance has a low 
 specific gravity and albumin is present to 1 or 2 per cent. If a 
 carcinomatous peritonitis develops, the specific gravity and per- 
 centage of albumin increase. An ascites due to nephritis has a 
 low specific gravity but the figures rise when stasis due to weak 
 heart or intercurrent inflammation develops. In many cases of 
 simple transudation (ascites and hydrothorax), the characters of an 
 exudate may develop, due to the long-continued irritation of the 
 serosa. 
 
 Ascitic fluid always contains the constituents of the blood — albu- 
 min, globulin, urea, uric acid, sugar, etc. (a) Ascitic fluid due to 
 stasis is clear yellow or yellow-green, opalescent and alkaline and 
 microscopically contains some lymph cells, erythrocytes and perito- 
 neal endothelium. (&) Exudates show a microscopic picture varying 
 with the cause; fibrin threads, pus, blood, adipose, chylous or chyli- 
 form fluid, intestinal contents, cancer cells, tubercle bacilli, diplococci 
 or pyogenic organisms, may be found. In exudates are found the 
 polymorphonuclear leukocytes and some erythrocytes; lymphocytes 
 and red cells are detected in tuberculous exudates (see page 532) ; 
 the fluid must be examined at once or formalin should be added for 
 the cells readily degenerate and shrink. Rieder, Dock and others 
 describe cells in carcinomatous peritonitis in which asymmetrical 
 karyokinetic figures appeared. Quincke states that red disks, lymph 
 cells and peritoneal endothelium are found in every ascites. 
 
 Primavera differentiated between transudates and exudates by 
 means of glacial acetic acid; a single drop will leave a white cloud 
 as it falls to the bottom of a vessel containing an exudate, while its 
 addition to transudates gives no reaction. 
 
 " Essential " ascites is usually tuberculous peritonitis. 
 
 Differentiation Between Serous and Tuberculous Peritonitis. — 
 Chronic serous peritonitis is generally tuberculous. In tuberculous 
 peritonitis (q. v.) there are usually temperature and emaciation and 
 bacilli in the exudate. According to Tepret and Vierordt, chronic 
 nontuberculous peritonitis occurs especially in women, the causes of 
 which are Bright's disease, trauma, portal stasis, alcoholism and 
 heart affections. The ascitic forms of nontuberculous peritonitis 
 may pass into the membranous or adhesive variety (peritonitis de- 
 
732 DISEASES OF THE DIGESTIVE TRACT. 
 
 formans or pachyperitonitis). The diagnosis of simple nontubercu- 
 lous peritonitis is most difficult to establish, even at autopsy. 
 
 Differentiation Between Tuberculous Peritonitis and Ascites. — 
 Portal ascites is accompanied by other circulatory disturbances, as 
 splenic tumor, piles and caput Medusae. The spleen is rarely enlarged 
 in tuberculous peritonitis. The specific gravity and percentage of 
 albumin are almost final in determining between peritonitis and 
 ascites. The fluid is generally clear in ascites and cloudy in perito- 
 nitis. Pain and fever usually indicate encapsulation. The liver is 
 small in the terminal stage of atrophic cirrhosis, which is marked by 
 various urinary changes ; these are evidences of incomplete discharge 
 of the hepatic function. In tuberculous peritonitis, the hydrops 
 ascites saccatus gives an irregular form to the abdomen from meteor- 
 ism produced by adhesions and from irregular nodules sometimes 
 simulating carcinoma ; it was described by Hippocrates. Free tuber- 
 culous exudations differ according to Thomayer, from simple ascites 
 in that the tympany in tuberculous forms is often right-sided, due to 
 retraction of the mesentery (mesenteritis retrahens) to the right side, 
 carrying with it the small intestine. Mesenteritis retrahens is 
 usually tuberculous or carcinomatous. The author recalls instances 
 in which right-sided tuberculous masses pushed to the left both the 
 tympany and the fluid. Hemorrhagic ascitic fluid occurs frequently 
 in tuberculous peritonitis and rarely in cirrhotic transudate. 
 
 The " apparent tumors " of tuberculous peritonitis (Bamberger) 
 are always suggestive where the nature of an ascites is in question. 
 In two instances observed personally, the omentum was so retracted 
 and adherent to the normal liver as to resemble closely the edge of 
 a cirrhotic liver. Intestinal or pulmonary tuberculosis, adhesive pleu- 
 ritis and meteorism from intestinal adhesions or an irregular form 
 of the abdomen with a " doughy " feel on palpation, indicate tuber- 
 culous peritonitis. A good working rule is that a peritoneal exudate 
 is tuberculous, when cancer, sarcoma and trauma can be excluded- 
 Exploratory incision is often the only direct route to diagnosis and 
 appropriate therapy. In the case of Heidenrich, in which the fluid 
 was encapsulated, each of about 20 separate sacs was filled with fluid 
 differing from that found in the others ; in one was clear serum ; in 
 another paler fluid; in others, the effusion was brown, purulent, 
 thick or sanguinolent. 
 
 Nichols gives a differential table, presented on the following page. 
 
 4. Tumoes. — Tumors, other than peritoneal, as uterine fibromata, 
 may produce hydroperitoneum. There is no relation between the size 
 of the tumor and the amount of fluid transuded, because very small 
 uterine myofibromata may excite considerable peritoneal effusion. 
 There is, nevertheless, a direct relation between the malignancy of 
 the tumor and the amount of the fluid found (Terillon). As a gen- 
 eral statement, ascites is infrequent in uterine tumors (Cruveilhier) 
 but when observed is most common in adenomyoma (Freund). It 
 is more often seen in papillomatous cysts; in glandular cysts whose 
 
ASCITES. 
 
 733 
 
 Nichols' Table. 
 
 Age. 
 Sex. 
 
 Previous his- 
 tory. 
 
 Alcoholism. 
 Syphilis. 
 Heredity. 
 Incidence. 
 
 Chronicity. 
 Fever. 
 
 Pain. 
 
 Digestive dis- 
 turbance. 
 
 Ascites. 
 
 Anasarca. 
 Jaundice. 
 
 Liver. 
 
 Spleen. 
 Omentum. 
 
 "Zuckerguss- 
 
 leber"; Chronic 
 
 Perihepatitis. 
 
 Occurs about mid- 
 dle life or later. 
 
 Both sexes equally 
 liable. 
 
 Often a history of 
 acute pericarditis 
 or perihepatitis. 
 
 No influence. 
 
 No influence. 
 
 No influence. 
 
 Acute becoming 
 chronic or insid- 
 ious from first. 
 
 Cases last for 2-10- 
 16 years. 
 
 Generally absent 
 except during ex- 
 acerbation or some 
 complication. 
 
 Indefinite and tri- 
 fling. 
 
 Trifling or none. 
 
 Constant and ex- 
 treme ; nutrition 
 long maintained — 
 Eumpf's case tap- 
 ped 301 times ; may 
 resemble perito- 
 nitis, albumin 3 
 per cent., fibrin. 
 
 Constant but slight. 
 
 Absent in pure 
 cases. 
 
 Not cirrhotic ; at 
 first enlarged, then 
 small ; smooth. 
 
 Gradual enlarge- 
 ment. 
 
 Thickened and con- 
 tracted. 
 
 Atrophic Cirrho- 
 sis of Liver. 
 
 Oftenest about mid- 
 dle life. 
 
 More frequent in 
 males. 
 
 History of alcohol- 
 ism, syphilis or di- 
 gestive disturb- 
 ances. 
 
 Frequently present. 
 
 Occasionally. 
 
 Unimportant. 
 
 Insidious. 
 
 May last for years. 
 
 May be afebrile ; 
 when present is 
 slight. 
 
 Trifling. 
 
 Constant ; dyspep- 
 sia, nausea, vomit- 
 ing, gastric hemor- 
 rhage, melsena. 
 
 Constant. 
 
 Relatively slight. 
 
 Occurs in 27 per 
 cent, of cases. 
 
 Cirrhotic ; at first 
 enlarged, then 
 small and warty. 
 
 Gradual enlarge- 
 ment. 
 
 Normal. 
 
 Chronic Tubercu- 
 lous Peritonitis. 
 
 Commonest between 
 ages of 20 and 40. 
 
 Predominates in fe- 
 males. 
 
 Often a chronic 
 cough, diarrhoea, or 
 genital tuberculo- 
 
 Uniniportant. 
 
 Unimportant. 
 
 May be family taint. 
 
 Onset may be acute 
 or insidious. 
 
 Prolonged. 
 
 Usually slight; often 
 absent. 
 
 Apt to be trouble- 
 some. 
 
 Fairly common. 
 
 Never extreme, may 
 be absent, may be 
 hemorrhagic. 
 
 Trifling. 
 
 May occur excep- 
 tionally. 
 
 Often enlarged. 
 
 Nothing special. 
 Often matted up. 
 
 Carcinoma op 
 Peritoneum. 
 
 Occurs late in life. 
 
 More frequent in fe- 
 males. 
 
 In some cases a his- 
 tory of cancer of 
 stomach or ovaries. 
 
 Unimportant. 
 Unimportant. 
 Unimportant. 
 Insidious., 
 
 Fairly rapid course. 
 
 Earely absent ; due 
 to complication. 
 
 Variable. 
 Often marked. 
 
 Moderate grade; may 
 be hemorrhagic or 
 pseudochylous. 
 
 Slight. 
 
 Common when liver 
 is enlarged. 
 
 May be enlarged, 
 with nodules. 
 
 Nothing special. 
 Often matted up. 
 
 walls rupture by fatty degeneration and pour out their contents into 
 the abdominal cavity; serum is secreted by the peritoneal surface 
 because of the irritation, even though the ruptured cyst be very small 
 (Quenu). The fluid in cysts contains more solids (50 to 60 pro 
 mille) than does the ascites of renal disease (25 pro mille, Mehu). 
 Ascites is most often observed in solid ovarian tumors. 
 
 Treatment. — The treatment of ascites varies with its cause, for 
 which reference should be made to valvular heart disease, atrophic 
 cirrhosis, tuberculous peritonitis and nephritis. 
 
 Paracentesis in peritoneal carcinoma and chylous ascites (v.i.) 
 hastens the fatal issue. Hale White asserts that cases of cirrhosis sur- 
 
734 DISEASES OF THE DIGESTIVE TBACT. 
 
 vive but few punctures, while cases of perihepatitis may be punctured 
 more than 200 times. Lecanu reports a case of ascites in which 886 
 tappings were performed in fifteen years. In puncture, surgical anti- 
 sepsis is most necessary, for reduced subjects are easily infected. 
 The bladder should be emptied by catheterization. The trochar 
 should be introduced in the linea alba to avoid injury to the blood- 
 vessels. It should be pushed carefully and is felt to penetrate the 
 parietal peritoneum by the sense of something giving away. A dull- 
 pointed probe should be sterilized, with which to push back the 
 omentum if it should prolapse against the canula. The fluid should 
 be evacuated slowly to obviate collapse which may result from dila- 
 tation of the abdominal veins, if they are suddenly relieved of the 
 pressure of the effusion. A cat-o'-nine-tails bandage may be applied 
 as the tapping progresses, to compress the abdominal contents. 
 
 Chylous and Adipose Ascites. — The peritoneal cavity, more fre- 
 quently than any other serous sac, is the seat of those unusual exu- 
 dates known as chylous, chyliform, lactiform or adipose ascites. The 
 first authentic case is Poncy's (1699). During the last two cen- 
 turies the literature gives about 200 cases. Seven have come under 
 the author's observation. 
 
 Much confusion has arisen from inaccurate nomenclature. Chylous 
 ascites properly designates an effusion of chyle. Adipose ascites 
 contains a large percentage of fat with no chylous admixture. Some 
 authors use the terms " adipose," and " chyliform " interchangeably. 
 Chyliform ascites is a chyle-like fluid in which lymph or chyle is 
 mixed with exudates or transudates. 
 
 1. Chylous Ascites. — Straus 7 case is the clearest example, in which 
 typical chyle was extravasated through two fistulse. Ingested butter 
 was recognized in the fluid withdrawn by paracentesis. Senator's 
 latest case gave similar results with the administration of olive oil. 
 Chylous ascites contains sugar, which is said to be diagnostic when 
 diabetes is excluded. Sugar when primarily present may disappear 
 later (Whitla). Its presence is very rare and very suggestive; it 
 has been detected not more than two dozen times. Of late many 
 clinicians discount the importance of the presence of sugar as a diag- 
 nostic test; Bock found sugar (0.04 to 0.07 per cent.) in all cases of 
 hydrops, and Eichhorst in ten out of seventeen cases of pleural exu- 
 date. A small amount of fat (0.9 per cent.) indicates chyle. Chylous 
 ascites is rich in solids, mineral salts and albumin. Albumin and fat 
 occur in small punctiform granules, susceptible of chemical differen- 
 tiation. The escape of chyle may occur through a visible rupture or 
 by transudation through the walls, of the chyle vessels; among the 
 most frequent causes of lymph or chyle obstruction are compression 
 of the thoracic duct or lymph system by glands, neoplasms, periton- 
 itis, occlusion of left subclavian vein, pressure efforts, lifting or 
 coughing, filarial disease or occlusion of the thoracic duct. Eupture 
 may occur in any part of the lymphatic system, in the thoracic duct, 
 receptaculum, lacteal vessels, lymph glands and chylous cysts. Chyle 
 
ASCITES. 735 
 
 may extravasate into a serous effusion by mural alteration of the 
 lymphatic vessels. 
 
 2. Adipose or Chyliform Ascites. — Adipose ascites is characterized 
 by the absence of sugar and a higher percentage of fat. The degree 
 of opacity is no index of the amount of fat, because turbidity may be 
 due to emulsionized albumin. Fat is found in most cases ; its greatest 
 amount is 5.25 per cent. (Schmidt), and in one of the author's cases 
 6.5 per cent. The granules of albumin and fat are much coarser in 
 adipose than in chylous ascites. Hydropic and fatty carcinoma cells 
 may, if numerous, cause a creamy layer. Red blood disks may occur, 
 also fibrin, casein, mucin, sodium alkali albuminate, peptone, leci- 
 thin, cholesterin, fibrinogen, etc. Among the numerous etiological 
 conditions are tuberculosis of the peritoneum and glands ; carcinoma 
 of the glands, peritoneum and lymph vessels ; chronic peritonitis ; liver 
 cirrhosis, heart disease and sarcoma of the omentum or mesentery. 
 
 Diagnosis. — A diagnosis has never been made prior to puncture, 
 except in Morton's early case. The local signs and symptoms do 
 not differ from those of serous ascites. It is probable that some cases 
 diagnosed as the vulgar ascites, healing without treatment, are in- 
 stances of chylous hydrops. It is not easy to differentiate between 
 chylous and adipose effusions, even at necropsy. 
 
 Prognosis. — About 90 per cent, of both types die. Continuous 
 chylous fistulas are always fatal. The immediate prognosis is seem- 
 ingly more favorable in the adipose form. 
 
 Treatment. — Surgical interference is chiefly indicated in tubercu- 
 lous peritonitis. Paracentesis should be avoided as much as possible 
 for it is weakening and precipitates the fatal issue. 
 
SECTION V. 
 DISEASES OE THE KIDNEY. 
 
 ACUTE NEPHRITIS. 
 
 Etiology. — (a) Acute nephritis may result from infections. The 
 scarlatinal nephritis (#.u.) is the most frequent type and develops 
 during the third week after desquamation. It occurs in diphtheria, 
 at the height of the disease ; it is found in a large percentage of cases 
 of acute enterocolitis in children ; it may result from malaria, variola, 
 sepsis, ulcerative endocarditis or pneumonia; there is scarcely an 
 infection in which acute nephritis may not occasionally develop, as 
 typhoid, typhus, measles, tonsillitis or epidemic meningitis ; it is 
 rare in German measles, varicella or purpura. It may develop in 
 tuberculosis and syphilis. Infections operate (i) more often by their 
 toxins than (ii) by the causal microbe, though the typhoid bacillus, 
 pneumococcus, streptococcus and others, have been found in the 
 kidneys and urine; (iii) in some instances (nephritis hemoglobin- 
 uria) hemolysins apparently cause acute nephritis, (b) Toxic sub- 
 stances, taken internally or applied to the skin, may induce acute 
 nephritis, as turpentine, salicylic compounds, carbolic acid, potas- 
 sium chlorate, cantharides and kindred substances, (c) Exposure 
 to cold and dampness (with alcoholism) is frequently the apparent 
 cause ; possibly it lessens the tissue resistance or acts as a hemolysin, 
 as in the hemoglobinuric type, (d) Skin diseases, burns, eczema and 
 psoriasis, may lessen the skin functions or produce hemolysins, (e) 
 Pregnancy (v. i.) may result in nephritis. (/) The cause is often 
 obscure; chronic Bright's disease, cardiac affections and the dys- 
 crasie predispose to acute nephritis, (g) Acute nephritis may 
 occur independently of any known cause; this primary form may be 
 epidemic. 
 
 Pathology. — Gross changes may not be apparent in mild cases, 
 though in some the kidneys are swollen from marked interstitial 
 exudation and are dark and heavy. In other cases the kidney is 
 yellow-white and perhaps mottled from small hemorrhages. The 
 edematous capsule strips readily and the cut section drips blood. 
 On section the cortex is swollen and granular, and its striations are 
 blurred and pale in contrast with the dusky medulla; the glomeruli 
 are frequently visible as red or later as yellow dots. Without the 
 microscope, lesser degrees of acute nephritis may be confused with 
 fatty or parenchymatous degeneration. Microscopic changes are 
 usually diffuse, (a) Glomerular changes. Glomerulonephritis, espe- 
 47 737 
 
738 DISEASES OF THE KIDNEY. 
 
 cially described by Klebs, is caused by toxins reaching the tufts 
 through the blood current. It is best exemplified by the scarlatinal 
 form (q.v.). The glomerular capillaries show infiltration with leuko- 
 cytes, an albuminous or cellular exudate escapes into the capsule and 
 the epithelium of Bowman's capsule degenerates, desquamates and 
 later proliferates ; in some cases red disks escape with the serum and 
 leukocytes. (b) Tubular changes. Cloudy swelling, hyaline and 
 fatty degeneration occurring especially in the cortex may be difficult 
 to differentiate from febrile and other degenerations, though inter- 
 stitial exudation occurs in every case of nephritis. In severe cases 
 some cells necrose entirely and desquamate; the diphtheritic form is 
 the best type. The swelling around the convoluted tubules is one 
 cause of the kidney enlargement. (c) Vascular and interstitial 
 changes are essential to the pathological diagnosis and are more focal 
 than diffuse. Serum exudes into the connective tissue, tufts and 
 tubules and coagulates in them ; it is probably the cause of the casts ; 
 leukocytes escape into the parenchyma and interstitium and in some 
 cases red cells also (hemorrhagic nephritis). Councilman describes 
 Unna's plasma cells, which he thinks are conveyed to the kidney from 
 the spleen and marrow. 
 
 Symptoms. — The onset may be sudden, especially in cases following 
 exposure. In other cases it develops gradually in the course or con- 
 valescence of the causal infection, as scarlatina, diphtheria, etc. In 
 many cases it may be unrecognized unless frequent analyses of the 
 urine are made or until ursemic symptoms develop. 
 
 1. Urinary Findings. — (a) The urine is decreased to ten or 
 twelve ounces or in severe cases is suppressed; this is due to glom- 
 erulitis or stoppage of the tubules by coagulated albumin and desqua- 
 mated epithelium; the decrease usually runs parallel with the in- 
 tensity of inflammation and hydrops. During convalescence the urine 
 becomes abundant and clear, (b) Its color may range from that 
 of febrile urine to a dark smoky tinge ; it is seldom red or actually 
 bloody; in the haemoglobinuric form it is chocolate-colored, (c) 
 The specific gravity averages 1,025 to 1,030 and (d) the reaction is 
 acid, (e) Albuminuria is almost invariable ; the albumin amounts to 
 Vz to 1 per cent, and one to two drams (5 to 8 gm.) daily. There is 
 serum albumin, considerable quantities of globulin and if there are 
 many cells, as in tubular nephritis, nucleo-albumin. The author has 
 seen six fatal cases of acute diffuse nephritis, confirmed by autopsy, 
 in which there was no albuminuria. Similar cases are reported by 
 Quirolo, Henoch, Senator, Fermi, Sanne and others. (/) Urea is 
 decreased even to % its normal quantity, as are also the chlorides and 
 nhosphates; the uric acid remains normal and the xanthin (alloxur) 
 bases may be increased ; for the molecular constitution of the blood 
 and cryoscopy, see page 749. (g) The sediment in mild acute tubu- 
 lar nephritis consists of many epithelial cells, some red and white 
 corpuscles and hyaline casts with crystals of oxalate of lime and 
 uric acid and sometimes haemoglobin granules, which may be also 
 
ACUTE NEPHRITIS. 
 
 739 
 
 found as free granules. In diffuse glomerular nephritis there 
 are almost always red cells, mono- and polynuclear leukocytes, epi- 
 thelium, fatty, hyaline and granular casts, granules of fat and often 
 of haemoglobin, uric acid and calcium oxalate crystals. Senator 
 
 Fig. 45. 
 
 Casts. 1-4, amyloid ; 5, cast, epithelial in its upper, and granular in its lower, part. 
 
 maintains that the leukocytes from the kidney are mononuclear. 
 Waxy and epithelial casts are found only in the severest types. 
 Blood and casts may appear before and may also outlast the albumin- 
 uria. The significance of casts (cylindruria) will be considered 
 under chronic parenchymatous nephritis. 
 
 2. Hydrops (Anasarca). — This is often the first symptom to 
 attract attention, (a) It occurs about the eyes early in the morning 
 
 Fig. 46. 
 
 mm 
 
 Urinary casts. 1, hyaline, 
 
 with fat droplets and cells 
 3, cast with fat droplets. 
 
 with leukocytes 
 
 and later in the day in other parts, as the limbs and external genitalia. 
 As the process advances it may become general, (b) It changes its 
 location readily and with anwmia gives a rather characteristic fades. 
 (c) Anasarca occurs most commonly in cases due to scarlatina and 
 exposure, less commonly in pregnancy, malaria, alcoholism and skin 
 
740 DISEASES OF THE KIDNEY. 
 
 diseases and seldom in sepsis, pneumonia, typhoid or diphtheria. 
 (d) It is caused by inflammation of the skin vessels, which is identical 
 with the inflammation in the glomerular vessels and is nearly always 
 associated with glomerulitis. (e) Identical changes may occur in the 
 serous sacs (pleura, pericardium or, far less often, peritoneum, men- 
 inges and joints), mucous membranes (glottis or intestinal tract) or 
 viscera (pulmonary or cerebral oedema). (/) It parallels the in- 
 tensity of the nephritis and the decrease of urine. 
 
 3. Anjemia. — Anaemia is often an early symptom and with the 
 dropsy is suggestive of acute nephritis. The red cells and haemo- 
 globin are reduced, the specific gravity of the serum is lowered and 
 the freezing point is raised (v. Chronic Nephritis). 
 
 4. Cardio- Vascular Symptoms. — The right heart may become 
 dilated. Hypertrophy of the left ventricle is very uncommon, though 
 observed by Riegel and Leube within ten days of the beginning of 
 the disease. The pulse is usually slow and tense; the sphygmogram 
 shows increase of the tidal and decrease of the dicrotic wave and the 
 sphygmomanometer shows the blood tension increased even to 180 or 
 200 mm. ; these phenomena are probably due to vascular contraction 
 induced by metabolic products retained in the blood. The second 
 aortic tone may become accentuated and, if heart fatigue develops, 
 the gallop-rhythm is heard. 
 
 5. Temperature. — Fever and rigors are exceptional. 
 
 6. Pain. — Occasionally there may be pain and tenderness in the 
 back, frequent and painful urination, emaciation and epistaxis. Con- 
 stipation is the rule. The skin is generally dry. 
 
 Diagnosis. — The urinary findings are characteristic; albuminuria 
 (q. v.) may result from other causes, as fever, amyloidosis or stasis; 
 casts, leukocytes, epithelia and even red cells, may also occur in 
 chronic nephritis, but the history and evolution determine the diag- 
 nosis (v. i. Differential Table of Diseases of the Kidney) ; 
 cases without urinary findings are extremely rare. The greatest dan- 
 ger lies in the diagnosis of an acute nephritis when the condition is 
 only an acute exacerbation of a chronic process; fully half of the so- 
 called idiopathic acute cases which the author has seen belong to this 
 category. In renal hematuria the urine contains no casts (save per- 
 haps red cell casts), few leukocytes and practically no epithelia; 
 there is no anasarca ; the urine is clear at one time and is laden with 
 blood at another. Anasarca (v. s.) occurs in certain types only and 
 also in various cachectic states. 
 
 Diagnosis of Types. — (a) The kidney of pregnancy usually de- 
 velops in the last half of gestation and infrequently before the third 
 month. Its pathogenesis is vigorously disputed, though toxaemia due 
 to the double task imposed upon the maternal kidneys seems the most 
 probable cause. It has been suggested that decreased antitoxic ac- 
 tivity of the thyroid gland is a causal factor. The placenta is thought 
 by some to elaborate toxins (syncytiolysins). The urine is decreased, 
 pale and of low specific gravity; it contains much albumin and not 
 
ACUTE NEPHBITIS. 741 
 
 much sediment, though red and white cells, lymphocytes, fatty epi- 
 thelia and sometimes casts are found. The attendant anasarca, like 
 that of stasis, develops from below upward. When retinitis develops 
 its prognosis is more favorable than in other nephritides. The con- 
 vulsive seizures (eclampsia) are generally uremic, though Ingerslev 
 collected 106 cases in which there was neither clinical albuminuria 
 nor renal alteration at necropsy. Fehling remarks on the slight 
 anatomical changes in the kidney and on the fact that but 5 per cent, 
 of pregnant patients having an old nephritis develop eclampsia. The 
 exact explanation of the convulsions remains obscure, though it seems 
 that the brain centres during gestation are unduly susceptible to irrita- 
 tion. The embolism of placental cells in the brain or lungs (Schmorl) 
 is considered by some rather as a result than a cause of eclampsia. 
 Zweifel maintains that the oxidation of the albumins is decreased, the 
 nitrogen output is decreased, the ammonia (as in diabetic coma) is 
 increased and that sarcolactic acid is found in the blood and urine. 
 The maternal mortality is 25 to 30 per cent, and that of the child over 
 50 per cent. Very few cases develop chronic nephritis, (b) The 
 cholera nephritis is parenchymatous and chiefly tubular. Various 
 factors are operative, as toxaemia, arterial anaemia, venous hyperemia 
 and heart weakness. By some it is considered renal ischemia rather 
 than nephritis. The urea, chlorides, calcium and magnesium salts 
 are decreased and much indican, aromatic sulphates, acetone and 
 ammonia are found. The anuria may last three or even fifteen days. 
 (c) Hcemoglobinuric nephritis is probably due to hemolysins, which 
 disorganize the blood and irritate the kidneys by the haemoglobin thus 
 set free. It is found in burns, acute infections (typhoid, pernicious 
 malaria, scarlatina, yellow fever, Winckel's disease of the new-born) , 
 exposure, hemoglobinemia and various drug poisonings, notably that 
 of chlorate of potash. Hemoglobinuria, red disks in the urine, casts, 
 leukocytes, epithelial cells and abundant albuminuria are indicative 
 of hemoglobinuric nephritis, (d) Acute recurrent (chiefly hemor- 
 rhagic) nephritis is uncommon. 
 
 Prognosis. — The prognosis of acute nephritis is always dubious. 
 The following factors are important: (a) Recovery is usual in light 
 forms not involving the glomeruli. Atypical forms are generally 
 favorable, (b) The prognosis varies according to the causal affection; 
 the scarlatinal type has a mortality of 33 per cent. ; the virulence of 
 the epidemic is an important factor, as are also heart complications. 
 (c) Complications may affect the prognosis, as (i) intercurrent in- 
 flammations, such as pneumonia, pleuritis, pericarditis or erysipelas; 
 (ii) oedema of the pharynx, larynx, lungs or serous sacs; and (iii) 
 uraemia, which will be fully covered under chronic interstitial ne- 
 phritis ; uraemia is more often an adult than an infantile and a late 
 rather than an early complication; headache, delirium, dyspnoea, 
 convulsions, coma and vomiting are among its salient signs. 
 
 Course. — The course is seldom fatal within a few days. In general 
 there are more recoveries than deaths. The average duration is less 
 
742 DISEASES OF THE KIDNEY. 
 
 than two weeks, though one or two years may elapse before recovery. 
 Convalescence is usually complete, though gradual transition into 
 chronic nephritis sometimes results. 
 
 Treatment. — Most of the points mentioned will be considered more 
 fully in the treatment of chronic nephritis, (a) Prophylaxis is of 
 limited value. Drugs which irritate the kidneys should be carefully 
 avoided in acute infections or in pregnancy. In fevers, with or with- 
 out albuminuria, water should be given freely by mouth or by enema ; 
 hydrotherapy is prophylactic, save in scarlatina when all prevention is 
 seemingly futile and cold baths are contra-indicated. Induction of 
 labor is indicated in severe cases in pregnancy, (b) Diet. Milk is 
 diuretic, non-irritant and contains little or no extractives or salt. It 
 should be given as in typhoid (q. v.). Thoroughly cooked carbohy- 
 drates, as gruels, are well combined with it. Broths, meats and beef- 
 tea are to be avoided. Alcohol is contra-indicated, save as excep- 
 tionally necessitated by the causal disease, (c) Absolute rest in bed 
 is imperative ; rest with the body covered protects the skin and spares 
 the kidneys from the products of the tissue waste ; the patient should 
 lie between flannel blankets and should be dressed in flannel night- 
 gowns, (d) No drug modifies the nephritis; tannin and ergotin (of 
 each five grains three times daily) seem to restrict renal hemorrhage. 
 Salt should be withheld, because it increases albuminuria and oedema 
 (see Treatment of Chronic Nephritis), (e) The best diuretics 
 are water and milk, which flush out detritus from the kidneys. The 
 alkaline charged waters seem to search out waste substances in the 
 tissues and facilitate their removal by the kidney ; excessive quantities 
 are often given; potassium citrate and sodium benzoate are said to 
 have the same effect ; the citrate may be given in doses of half a dram 
 with sweetened weak lemonade. Sweet spirits of nitre 3ss to 3j, 
 q. i. d., is diuretic and also dilates the bloodvessels. All stronger 
 diuretics are to be avoided. (/) Shin. Warm baths are diuretic and 
 stimulate some vicarious elimination through the skin. Careful 
 covering and rest in bed keep the skin relaxed and not only materially 
 aid its functions but also relieve renal hyperemia, (g) Management 
 of the bowels is as important as that of the skin. Saline catharsis 
 lowers arterial tension and aids compensatory elimination. As salts 
 often derange the stomach, an ounce should be given by rectum with 
 two ounces of glycerine and one of water. One-half to one dram of 
 compound jalap powder or %o grain of elaterin is indicated when 
 uraemia is imminent, (h) Treatment of urcemia. For suppression 
 of urine a full warm bath lasting fifteen to twenty minutes should 
 be given; a hot pack should be applied followed by wrapping in 
 blankets and covering heavily with a rubber sheet; or the alcohol 
 sweat or hot-air sweat may be given as described under Treatment 
 of Chronic Nephritis. Cups applied to the back may divert blood 
 away from the kidneys, because the vessels of the loin anastomose 
 with those of the kidney. Pilocarpine hydrochloridum, gr. % in 
 adults and one-half as much in children, causes profuse sweating and 
 
CEBONIC NEPHRITIS. 743 
 
 salivation but the author abandoned its use after two deaths from 
 sudden pulmonary oedema in patients with apparently strong hearts ; 
 it should never be employed when the heart is weak. Active, rapid 
 catharsis is effected by giving two drops of croton oil on the tongue; 
 this may be repeated in two hours if necessary. If ursemic symptoms 
 (in an oedematous patient) appear slowly, an incision two inches long 
 should be made over the lower tibiae down to the bone, thereby directly 
 draining away the serum with its retained toxins ; this is better than 
 the use of small punctures or Southey's capillary tubes, which are 
 attended by all the dangers of puncture-wounds. If uraemia devel- 
 ops suddenly the legs should be incised and a pint or more of blood 
 should be withdrawn from the veins of the arm ; whether venesection 
 relieves the circulation mechanically or removes toxins is still a mat- 
 ter of theory, but relief is often obtained. It should be followed by 
 subcutaneous normal salt infusions — or plain water without the salt 
 — which stimulate the heart and kidneys and lower the molecular 
 concentration of the blood. Pleural or ascitic hydrops should be 
 aspirated. The heart must be stimulated by strychnine and digitalis 
 as in cardiac insufficiency, though hypodermics are better than oral 
 administration. A hypodermic of morphine is beneficial and harm- 
 less when there is much dyspnoea and restlessness. Chloral and bro- 
 mides modify sudden convulsions (v. Cheonic Nephritis). (Edema 
 of the lungs (q. v.), vomiting and diarrhoea are caused by several 
 factors, viz., cardiac stasis, uraemia, oedema of the alimentary mucosa 
 and the vicarious elimination of urea, which breaks up in the digestive 
 tract into irritating ammonium; vicarious vomiting and diarrhoea 
 should not be checked at once; if persistent, the vomiting is treated 
 as outlined in chronic gastritis (q. v.) or typhoid; gastric lavage is 
 beneficial and dilute hydrochloric acid, Tr[x to xv, neutralizes the 
 ammonium, (i) In convalescence, iron and other mild tonics should 
 be given, irritating foods and beverages interdicted, exercise carefully 
 restricted and cold and exposure avoided by sending the patient, if 
 possible, to a warm climate. 
 
 CHRONIC NEPHRITIS. 
 
 Our knowledge of chronic Bright's disease dates from Richard 
 Bright's communications in 1827. Aetius, Avicenna, Cotugno 
 (1770) and other writers mentioned the association of hydrops and 
 albuminuria, but to Bright is due the credit of correlating renal dis- 
 ease, albuminuria and dropsy; he also noted the etiological impor- 
 tance of alcohol and cold, as well as the cardiac hypertrophy, uraemia, 
 brain hemorrhage, coma, convulsions, blindness and the tendency to 
 serositis. 
 
 The following classification of nephritis covers typical cases, 
 though combined or mixed types are equally frequent. As a cause 
 of death chronic nephritis ranks sixth, after pneumonia, tuberculosis, 
 heart disease, endocarditis and unknown causes. 
 
744 DISEASES OF THE KIDNEY. 
 
 I. Chronic Parenchymatous Nephritis. — Definition. — Chronic 
 Bright's disease, with special involvement of the parenchyma 
 (though the interstitial tissue is always affected), with much albumin- 
 uria and with abundant formed elements in the urinary sediment. 
 The affection constitutes 3 per cent, of all diseases. 
 
 Etiology. — It may result from (a) infections, as tuberculosis (which 
 causes 25 per cent.), malaria and syphilis; (b) from exposure to cold 
 and dampness; (c) from toxic factors, as alcohol and lead and less 
 frequently mercury or arsenic; (d) from cardiac disease, which ac- 
 counts for 14 per cent, of nephritis, (e) Exhausting discharges. 
 suppuration and ulceration may cause it. (/) Acute nephritis seldom 
 becomes chronic, though it is a somewhat predisposing factor, (g) 
 Age and sex. Most cases occur between twenty and fifty years of age ; 
 it is rare in children. Males are affected more often than females. 
 
 Pathology. — Three types of the disease exist, besides the mixed 
 forms. 
 
 1. The " Large White Kidney " or " Inflamed Fatty Kid- 
 ney." — This is never decreased in size and may weigh 10 to 12 
 ounces (300 to 360 gm.) and measure two or three times the normal 
 size. 
 
 Gross Characters. — The capsule is loose and non-adherent ; the sur- 
 face is smooth, yellow-gray, with prominent stellate veins and some- 
 times dots of hemorrhage. On section the cortex is broader than 
 normal, the striations are poorly marked and when cut streaks of fat 
 may show; the glomeruli and convoluted tubules are yellow and 
 contrast with the gray bands of newly formed connective tissue. The 
 medulla shows fewer changes and is red, in sharp contrast with the 
 light cortex. 
 
 Microscopic Characters. — The most essential changes are hyaline 
 and fatty degeneration and atrophy, chiefly in the convoluted tubules, 
 in which lie desquamated epithelia and coagulated albumin. The 
 glomeruli are always diseased, but to a varying degree; they are 
 enlarged, their vessels show hyaline and fatty degeneration and nu- 
 clear multiplication; albumin is found in their capsules and the 
 epithelium is swollen, fatty or even necrotic. The connective tissue 
 is always increased, which histologically separates chronic nephritis 
 from acute nephritis and mere degeneration. These changes are 
 never equally diffuse. 
 
 2. The " Large Eed " or " Variegated Kidney." — Gross Char- 
 acters. — It is also large, but is firmer than the kidney just described 
 or that of acute inflammation, for it has more connective tissue, which 
 may cause some tearing and loss of the cortex when the capsule is 
 stripped off. The surface may be perfectly smooth. The cortex is 
 swollen, indistinctly striated, dotted yellow from fatty glomerular 
 change or red from minute ecchymoses and sometimes streaked yellow 
 and red from similar tubular changes. 
 
 Minute Characters. — These are essentially those of the large white 
 kidney, with the exception that fatty degeneration is less marked and 
 connective tissue alteration and hemorrhages are more conspicuous. 
 
CHRONIC NEPHRITIS. 745 
 
 3. The Secondary Contracted Kidney. — This form may de- 
 velop after a year or two from the above forms. Some consider it a 
 primary independent form. 
 
 Gross Characters. — It is seldom decreased in size and may be as 
 large as the " large white " or " large red kidney " ; the name refers 
 rather to its connective tissue than to any visible renal shrinkage. 
 The capsule is adherent in places and, when stripped, tears off small 
 areas of the renal substance. The surface is rough and shows in some 
 places reddish depressed areas (fibrous contraction or granulations 
 and parenchymatous atrophy) and in others yellow areas (which are 
 more normal, though fatty). Section shows decrease in the cortex 
 corresponding to the reddish foci. It differs from the genuine con- 
 tracted kidney (primary interstitial nephritis) in the following re- 
 spects : it is secondary, much more rapid in development, contains 
 fewer cysts, is more yellow and its red granulations and yellow 
 prominences are larger. 
 
 Minute Characters. — Epithelial changes resemble those of the two 
 forms described. The membrana propria of the tubules thickens, 
 adheres and obliterates many tubules. The glomeruli collapse, 
 thicken and shrink to small dark-gray granular bodies, which some- 
 times calcify. The retracted areas, capsular adhesions and cortex 
 shrinkage correspond to connective tissue contraction. 
 
 Symptoms. — The onset is in most cases gradual and insidious, the 
 earliest symptoms being loss of strength, pallor, emaciation, simple 
 decline of health, indigestion, anorexia, headache, shortness of breath 
 on exertion or chronic bronchitis. Sometimes there is tenderness 
 over the kidneys. 
 
 1. Urinary Findings. — Except in the secondary contracted kid- 
 ney (a) the urine is decreased to seven ounces or a quart (200 to 
 1,000 c.c.) ; (b) the color is dark yellow-red, opaque or rarely smoky; 
 the urates are held in suspension by the albumin; sometimes its sur- 
 face is shimmering from fatty cells and casts ; (c) the specific gravity 
 is 1,020 to 1,040 and (d) the reaction is acid; (e) albumin is almost 
 never absent, is more abundant in the day time than at night and 
 amounts to 1 to 3 per cent, and one-half to one ounce (15 to 30 gm.) 
 daily; it coats the bubbles formed by agitation of the specimen and 
 preserves them for a long time. (/) The absolute amount of solids 
 is generally decreased; for example, the urea (which normally con- 
 stitutes 90 per cent, of the nitrogen output and amounts to about an 
 ounce (35 gms.) daily), kreatin and sodium chloride are decreased 
 and the freezing point of the urine is lowered (v. i.). (g) The 
 sediment is abundant and hyaline, granular, fatty and epithelial 
 casts abounds (first noted by Simon and E"asse) ; coarsely granular 
 and waxy casts appear late in the disease; the granular type is due 
 chiefly to fat particles, which may darken the casts. They have been 
 long regarded as significant of nephritis. Key, Nothnagel, Rosen- 
 stein and others afterwards observed their occurrence in the urine of 
 normal individuals and of late there has been a tendency to under- 
 
746 DISEASES OF THE KIDNEY. 
 
 estimate their importance. According to Senator, casts originate in 
 the kidney chiefly from epithelial cells and always indicate some renal 
 disease. They may be dissolved in the bladder by the pepsin con- 
 tained in the urine (Sehrwald). Leukocytes and fatty epithelia and, 
 in some forms of nephritis, red cells occur in considerable amounts. 
 In Ackermann's case no casts were found in the urine, but were 
 found in masses in the renal pelvis at necropsy. 
 
 In the secondary contracted kidney the urinary findings are the 
 same except that the urine amounts to three pints or two quarts 
 (1,500 to 2,000 c.c), is clearer, is somewhat lower in specific gravity 
 and contains somewhat less albumin and casts. 
 
 2. (Edema. — (Edema is very frequent. Its absence argues for little 
 glomerular involvement. It commences about the eyes, changes its 
 location readily and is at first evanescent, but soon becomes general, 
 obstinate and ominous. It is more pronounced in the " large white 
 kidney " than in other types and increases as the urine decreases. 
 The puffy eyes, pale swollen cheeks, dull expression, distended ab- 
 domen and shapeless wrists and ankles often suggest the diagnosis. 
 The serous and mucous membranes are similarly involved, though to 
 a lesser degree, and also as possible terminal events, pulmonary or 
 cerebral oedema may develop. (Edema is caused (a) by hypalbumi- 
 nosis and hydraemia of the blood ( Bright 's theory) or (b) by altera- 
 tions in the' vessel walls, i. e., abnormal permeability, a theory ad- 
 vanced by Cohnheim and Lichtheim. 
 
 3. Anemia. — Anaemia distinguishes chronic parenchymatous ne- 
 phritis from the genuine interstitial type. There is usually retention 
 of urea, uric acid and chlorides ; sometimes the blood is cloudy. 
 
 4. Cardiovascular Findings. — The pulse is more often small, 
 soft, rapid and associated with a weak apex, indicating dilatation, 
 than tense and associated with a loud second aortic tone and strong 
 apex, indicating hypertrophy. Secondary contraction and mixed 
 nephritis are likely to develop findings similar to those of the genuine 
 interstitial nephritis ; Senator finds hypertrophy with dilatation (ec- 
 centric hypertrophy) in parenchymatous and simple or concentric 
 hypertrophy in interstitial nephritis. Myocardial degeneration is 
 common. 
 
 Complications and Causes of Death. — (a) Marasmus results from 
 the anaemia, indigestion, diarrhoea, oedema of the alimentary mucosa 
 or its irritation by decomposed urea, (b) Intercurrent infections 
 may result, as inflammation of the pleurae or pericardium, cellulitis 
 and especially pneumonia; many pneumonia deaths really result 
 from nephritis; in one instance the writer saw acute necrosis and 
 sloughing of the scrotum, after which the patient improved remark- 
 ably. Other complications are (c) oedema of the lungs, larynx, 
 serous sacs and extremities, impeding respiration and obstructing 
 the arterial flow in the peripheral vessels; (d) hemorrhages (in 8 per 
 cent.) in the brain or other organs; (e) retinitis (in 18 per cent.) ; 
 (/) urcemia, with its numerous nervous, circulatory and digestive 
 
CHRONIC NEPHRITIS. 747 
 
 symptoms (v. page 750) ; (g) acute exacerbations, particularly in the 
 chronic hemorrhagic type; and (h) cardiac insufficiency. 
 
 Diagnosis. — The diagnosis rests upon three cardinal symptoms: 
 (a) the urinary, which are characteristic when twenty-four-hour 
 specimens are carefully and repeatedly examined in every case com- 
 ing under our care; (b) the anasarca, which is usually present, 
 though sometimes absent in secondary contracted kidney and in 
 Wagner's hemorrhagic type; and (c) the anosmia. (For differentia- 
 tion, see pages 764 and 765.) 
 
 Prognosis. — Though some cases suggesting an arrest of the process 
 are found at autopsy and some cases recover after a year or two, the 
 clinical course is usually progressive and fatal. Dropsy usually 
 causes death in a few months to a year, though the author has seen 
 five typical cases recover after two and a half years ; these cases did 
 not result from acute infections like the cases of recovery reported by 
 Senator and Rosenstein. The outlook is better in children than in 
 adults. The "large, white kidney'' causes death in one-half to one 
 year, the " large, variegated kidney " in one and a half to three years 
 and the secondary contracted kidney in one and a half to three years. 
 The treatment is considered on page 754. 
 
 II. Chronic Interstitial Nephritis. — Definition. — A primary, inter- 
 stitial, contracting sclerosis of the kidney, characterized clinically by 
 abundant urine of low specific gravity, with small amounts of albu- 
 min and few cellular elements ; and by marked cardiac hypertrophy, 
 arteriosclerosis, retinitis and ursemia. 
 
 This genuine contracted kidney must not be confused with secon- 
 dary contracted kidney, arteriosclerotic contraction, embolic contrac- 
 tion or the contraction resulting from ascending infection. 
 
 Frequency. — In ten years Eichhorst treated 31,562 cases, of which 
 1.4 per cent, had contracted kidneys; he finds this form six and a 
 half times as frequently as the parenchymatous form, though with 
 us the latter is at least equally frequent. 
 
 Etiology. — The etiology is essentially that of arteriosclerosis, with 
 which contracted kidney has a three-fold relation: (a) arteriosclerosis 
 may cause the arteriosclerotic kidney; (b) contracted kidney may 
 cause arteriosclerosis; or (c) both may result from a common cause. 
 The noxa or toxin reaches the kidney through the blood stream. 
 
 The disease may result from (a) chronic alcoholism combined with 
 exposure or over-eating; (&) chronic lead-poisoning, proven a cause 
 by clinical and experimental evidence (Lancereaux and Ollivier) ; 
 
 (c) gout (Todd), caused by uric or oxalic acid and the alloxur bodies ; 
 
 (d) syphilis; (e) diabetes (Senator), caused by sugar, acetone or 
 oxybutyric acid; the diabetes lessens or ceases when induration de- 
 velops; (/) age; it begins between the years of thirty and fifty and is 
 clinically manifest after fifty years of age. Sawyer collected 24 cases 
 in children, 13 of whom were under ten years, (g) Sex. The disease 
 is two to three times as frequent in men as in women. In the in- 
 
748 DISEASES OF THE KIDNEY. 
 
 fantile form most cases occur in girls, (h) Other infrequent causes 
 are acute nephritis, the kidney of pregnancy, hereditary tendency, as 
 in Dickinson's series through four generations, and endocarditis. 
 
 Pathology. — It is undecided whether the process is inflammatory or 
 atrophic ; Weigert believes that cellular degeneration occurs first and 
 induration follows. 
 
 Gross Pathology. — (a) The kidneys are contracted even to one- 
 third their original size and may weigh but 0.6 ounces (21 gm.) ; 
 contraction is rarely symmetrical in both. (b) Their consistence 
 is increased, (c) The capsule is thick, tendinous, wrinkled, vascular 
 and adherent and strips off particles of cortex when removed, (d) 
 The surface is uneven; there are small reddish or sometimes paler 
 prominences, measuring 0.5 to 5 mm. and representing the more 
 normal tissue; the paler retracted areas are fibrous retraction, (e) 
 Small cysts are frequently found, usually with clear contents; they 
 vary in number and their size ranges from that of a pin-point to a 
 cherry ; they apparently result from glomerular and tubular constric- 
 tion by connective tissue (retention cysts). (/) On section the cortex 
 is shrunken, even to 1 mm., irregular and gray from fibrillar con- 
 nective tissue. The medulla is less changed, though also shrunken; 
 pale fibrous lines alternate with red dilated vessels; uric acid or 
 calcium salts are deposited, (g) The pelvis is large and much fat 
 surrounds the kidney. 
 
 Minute Pathology. — The changes are largely cortical, focal, 
 asymmetrical and interstitial, (a) The glomeruli early contain round 
 cells, nuclear increase, desquamated cells and albumin; later they 
 atrophy from degeneration of the afferent artery; multiplication of 
 cells is noted between the loops and hyaline change occurs in the 
 glomerular vessels ; in the extreme stage the glomeruli become hyaline 
 and fibrous; some tufts remain normal and others may visibly hyper- 
 trophy, Sabourin's compensatory adenomata. (&) The epithelium is 
 always changed, though much less than in parenchymatous forms ; in 
 the sunken areas many tubules disappear and degenerated cells are 
 seen in the prominent surface granulations ; in the medulla the col- 
 lecting tubules are larger, even cystic, and are filled with colloid 
 material, (c) The connective tissue is increased everywhere, but 
 more in the cortex than in the medulla ; round cell infiltration occurs 
 early and induration late ; the vessels are sclerotic in all their coats, 
 but especially in the intima, and many writers consider that the 
 vascular change is the earliest and causative alteration. 
 
 Symptoms. — Long latency for years, insidious onset and protracted 
 compensation by heart hypertrophy are characteristic of this type. 
 Many cases are first discovered during an acute infection, as pneu- 
 monia, on examination for life insurance or at the coroner's autopsy 
 after accidents. It may appear to be a physiological, intermittent or 
 cyclic albuminuria. Polyuria, cardiac symptoms, retinitis, indiges- 
 tion or depreciation of health may be the first symptoms. The 
 oedema, pronounced urinary findings (in a single specimen) and 
 
CHRONIC NEPHRITIS. 749 
 
 anaemia of chronic parenchymatous nephritis are seldom conspicuous 
 and almost never early symptoms in this type. The condition may be 
 first declared by heart incompetence, ursemic coma or convulsions. 
 1. Urinary Findings. — Urinary findings are generally the earli- 
 est signs. Twenty-four-hour specimens should be examined repeat- 
 edly in doubtful cases (with a fresh specimen for microscopic exami- 
 nation) . (a) The amount, at first normal, is gradually increased (poly- 
 uria) ; this is a frequent cause for consulting the physician. Nagel 
 found polyuria in only 47 per cent. The urine is also passed fre- 
 quently (pollahiuria) , especially at night; this is always suspicious 
 when the prostate is normal. In well-developed cases it totals two to 
 three quarts (2 to 3,000 c.c), rarely more, though 8 to 10 quarts (8 
 to 10,000 c.c.) were passed in a case of Lecorche and Talamon and 
 12 quarts in Bartel's case, (b) It is pale and (c) weakly acid, (d) 
 The specific gravity averages 1,010 (1,005 to 1,012). (e) A per- 
 manent foam due to the albumin is frequent. (/) Albumin is pres- 
 ent in most cases, but is not abundant; the merest traces are found up 
 to 8 grains (0.5 gm.) pro mille, and a daily total of one-half to one 
 dram (2 to 5, rarely 10 gm.). It is often absent in single specimens, 
 especially in the morning, whence a twenty-four-hour specimen 
 should always be examined. Delicate tests are often necessary (v. 
 Albuminuria). It may appear only after eating, exercise, excite- 
 ment or fatigue, whence its greater frequency toward night ; it may 
 increase after dyspepsia or bronchitis. Senator's statement that its 
 alleged absence is due to an arteriosclerotic kidney and not to inter- 
 stitial nephritis is not invariably correct, according to personal ex- 
 perience. Albuminuria may be absent for weeks or months, (g) 
 Solids are decreased, i. e., the urea, uric acid, ammonium, chlorides 
 and phosphates. The determination of the freezing point, cryoscopy, 
 first employed by Koranyi to estimate the amount of soluble mole- 
 cules in the blood and urine, is not of great practical value in medical 
 cases, (h) The rapidity of elimination is decreased. Methylene 
 blue was employed by Achard and Castaigne (1897) to test this point. . 
 One cubic centimeter of a 5 per cent, aqueous solution is injected 
 subcutaneously ; normally it should stain the urine in one-half to one 
 hour, reach a maximum in three to four hours and cease in thirty-six 
 to seventy-two hours ; elimination may be nearly normal or even more 
 rapid in chronic parenchymatous, but it is much slower in interstitial 
 nephritis (Bard). The permeability of the kidneys may also be 
 tested by a hypodermic injection of one cubic centimeter of a one-half 
 per cent, solution of phloridzin (Achard), which produces glycosuria 
 in normal kidneys; phloridzin glycosuria is reduced or absent in 
 interstitial nephritis, (i) The sediment is scant, absent or can be 
 obtained only by the centrifuge. Hyaline, granular and epithelial casts 
 are found in small numbers when the light is moderated by the dia- 
 phragm ; the granular form is found in some cases only after repeated 
 search; the granular casts are often wide, originating in the dilated 
 tubules of the medulla. A few epithelia, leukocytes and crystals of 
 uric acid and oxalate of lime are found. Eed cells are infrequent. 
 
750 DISEASES OF TEE KIDNEY. 
 
 The urinary findings are somewhat modified by intercurrent 
 uraemia, fever and heart failure, all of which concentrate the urine, 
 raise its specific gravity and deepen its color. 
 
 2. Cardiovascular Symptoms. — Cardiovascular symptoms were 
 noted by Bright, but their significance was first established by Traube. 
 They appear in 50 to 90 per cent, of cases and later than the urinary 
 findings. Cardiac hypertrophy is more quickly detected clinically 
 than pathologically, especially in the young, because the urine is 
 increased early before the physical signs of hypertrophy prevail and 
 again because concentric hypertrophy is present long before dilatation 
 appears. Emphysema may obscure the precordial evidences of hyper- 
 trophy, such as the heaving apex beat and double impulse at the 
 apex, and one must therefore depend on the evidences presented by the 
 tense pulse, the hardness of the arteries, the sphygmographic tracings 
 with a square apex, the loud ringing second aortic tone or other mani- 
 festations of increased arterial tension, as epistaxis, vertigo, head- 
 ache, tinnitus, palpitation or cardiac asthma. The systolic blood 
 pressure in interstitial nephritis may amount to 200 mm. or more. 
 High tension is one of the most constant and early symptoms ; its 
 early occurrence leads some writers to incorrectly regard contracted 
 kidney rather as a disease of the arteries than of the kidneys. The 
 cause of the hypertrophy is not definitely known; theories of me- 
 chanical obstruction to the blood-flow by the renal contraction and of 
 vasomotor constriction excited by retained waste substances have been 
 advanced. Loeb's explanation is plausible; the increased blood pres- 
 sure is of a regulatory nature and is produced by changes in the 
 glomeruli ; whether reflex or chemical agencies induce the increased 
 pressure is not known. Though hypertrophy should be looked for in 
 interstitial rather than in parenchymatous nephritis, the two types 
 often mingle, with the urinary findings of the " large white kidney " 
 and the cardio-vascular findings of a renal contraction. In the last 
 stage of contracted kidney the hypertrophied heart weakens, the pulse 
 tension falls, the apex becomes weaker, a systolic murmur appears 
 from myocardial insufficiency and Potain's gallop-rhythm, a sign of 
 heart fatigue, is heard. 
 
 3. Eetinitis. — Eetinitis may be the first declaration of the disease 
 and may come under the observation of the ophthalmologist. It oc- 
 curs more frequently than in any other renal lesion, 22.4 per cent. 
 (Gronauw) to 28 per cent. (Eates). Its various forms are stellate 
 white areas of fatty and fibrous tissue, a white zone surrounding the 
 disk, degeneration of the disk, retina or of both together, " flame-like " 
 hemorrhages and the choked disk whose large veins are compressed 
 where the arteries cross them. (See Plate VIII, Fig. 8.) The 
 retinitis albuminurica is not specific, identical findings occurring in 
 other conditions. 
 
 4. Uremia. — Ursemia is the most dreaded and frequent compli- 
 cation ; its nature and immediate cause are unknown ; it can only be 
 stated that it is an auto-intoxication, due to disturbance of renal 
 
UEJEMIA. 751 
 
 function, probably with retention within the blood of nitrogenous 
 substances. Further explanations are wholly theoretical, such as de- 
 creased alkalinity of the blood (acidosis) ; failure of the normal "in- 
 ternal secretion " of the kidney ; the toxic action of abnormal products 
 of metabolism or breaking up of the proteids, resulting from destruc- 
 tion of the renal tissue (nephrolysins, Ascoli) ; it is not due to reten- 
 tion of urea alone nor to mechanical conditions alone, as oedema or 
 anaemia of the brain. It occurs most often in chronic interstitial, next 
 in acute, then in chronic parenchymatous nephritis and is much less 
 common in other diseases of the urinary tract, as pyelonephritis, etc. 
 Ursemic symptoms may be acute or chronic, but will be considered 
 as nervous, digestive, respiratory and cardiac. 
 
 Nervous Symptoms. — (a) Acute convulsions (eclampsia) are due 
 to irritation of the cortex by toxins; they closely resemble the epi- 
 leptic attack. There are usually prodromes, as pain or pressure in 
 the head, migraine, neuralgia, insomnia, vertigo, visual disturbance, 
 tinnitus, nausea, vomiting or dyspnoea ; there is usually no " epileptic 
 cry." In less than a day clonic or tonic convulsions appear, usually 
 generalized and involving especially the flexor or extensor muscles of 
 the arms and legs ; the abdomen is retracted ; there are dyspnoea, 
 cyanosis and involuntary evacuations ; the reflexes, especially the 
 patellars, are increased; the pupils are wide and without reaction; 
 the pulse is full and slow before the attack but becomes rapid during 
 the convulsions. The skin is covered with sweat and the temperature 
 is usually elevated. The convulsions cease after fifteen to thirty 
 minutes and coma intervenes, during which the convulsions may re- 
 cur. Death is the usual outcome, but recovery is possible, as in one 
 of the author's cases in which the anterior third of the tongue was bit- 
 ten off. (b) Other motor manifestations. The general statement 
 regarding ursemic nervous phenomena is as follows : paralysis affects 
 especially the sensorium, to a lesser degree the special senses and 
 rarely motility; irritation seldom affects the sensorium (e. g. } pro- 
 duces delirium), it acts principally upon the motor paths (convul- 
 sions) and very seldom upon the special senses. Ursemic convulsions 
 are usually general but may resemble focal symptoms, such as con- 
 vulsions of only half the tody, e. g., of one-half the tongue, of the left 
 arm and leg or deviation of the head to the left. They may rarely 
 occur with convergent strabismus, facial spasm, Jacksonian epilepsy, 
 nystagmus, tremor, localized trembling and twitchings, muscular 
 cramps, grinding of the teeth, tetanic convulsions, trismus, convul- 
 sions on one side and contractures on the other, rigidity of the neck 
 or opisthotonos. In seven cases seen by the author the symptoms 
 were those of an acute focal brain lesion; in two, treated by lumbar 
 puncture, relief was immediate. 
 
 Paralyses in uraemia are infrequent, are chiefly transitory hemi- 
 plegias and are due to cerebral oedema, capillary hemorrhage, soften- 
 ing, apoplexy or cortical overstimulation by toxins. Hemiplegia 
 may occur with aphasia, amnesia, deafness, crossed oculomotor paraly- 
 
D'2 
 
 DISEASES OE TEE KIDXET. 
 
 sis. glossoplegia or conjugate deviation of the eyes. The author has 
 reported nve eases in which uraemia resembled meningitis very closely. 
 Other cases have been suggestive of brain tumor. (Yi Acute coma 
 often occurs without antecedent eclampsia, being preceded "by head- 
 ache, stupor or apathy : coma may last for days or even months. : : 
 One of the most common chronic svmi 
 
 is is a 
 i dull. 
 
 no;: it 
 
 and anxiety. Obstinate headache oi 
 on : it often begins in the early nion 
 ranic. Insomnia is common, though during 
 :eu sleepy. Delirium and mania are more 
 itis in adults than in juvenile cases : melan- 
 niry occur : these mental states may assume 
 as to "lie testamentary capacity of the pa- 
 . Sudden, complete and bilateral blindness 
 is amaurosis may be an initial symptom; 
 al findings and the condition lasts but a few 
 nal cases oedema of the disk (Schmidt) or 
 L The pupils are wide and reactionless in 
 mall and mobile in chronic uraemia. There 
 
 uraeniie deafness and tinnitus auriuin. 
 -These rank second to the nervous svnrptoms 
 
 each i ; often offensive an 
 enator refers to trimethyl 
 value, for it often precedes ecla 
 
 h is inflamed and the saliva is 1 
 
 :-•>:.•;- are nsiYv c ^m r al and nam 
 
 Psychical sympt: n s. 
 characteristic re sties-: 
 throbbing nature is c 
 mav be occipital 01 h 
 the day the' patient : 
 frequent in chronic r 
 eholia an: delusional 
 medico-legal imports 
 tient. (e) Specie s 
 is cortical in origin 
 there are usually no ] 
 hours, though in ex: 
 even choked disk is i 
 acute eclampsia, but 
 mav be sudden or gra 
 
 Digestive Swnfior. 
 in frequency. The 
 odor of urine, which 
 it of prognostic- 
 posed urea, eliminate:! ~ 
 -aid of hiccough and dk 
 these symptoms mav h 
 ivsenterie from the Bet 
 in a recent s T udv of 23 c 
 ■1559 . found them eh 
 jects under twenty years 
 rhcea is common, but b 
 They are seemingly pro 
 is verv rare and Ye nroi 
 
 EespirateryanaCardi 
 is sometimes toxic and 
 cerebral manifestations, 
 when the mind is absolutely clear a 
 the heart. P red re ma 1 . Yac'oa of cb 
 quent in incipient uraemia. The c 
 paroxysmal and is often nocturnal. 
 develop in the day time or during si 
 though recovery is r :-ssible. Obstina 
 laryngeal spasm are recorded. 
 
 5. Othzs Complications and Symptoms. — 'ad Various Ynm- 
 ges occur : in the brain in 12 per cent, of cases; also in the dura. 
 
 en ; Lne - 
 
 :he He 
 
 IVSt 
 
 Fie: 
 
 Ma 
 
 in 
 
 4.X. 
 
 ' uraem: c 
 case- of 
 
 ulcers, d 
 advanced 
 
 I: 
 
 Yes has an 
 
 ae considers 
 The tongue 
 
 v increased. 
 
 Y:m decom- 
 e mav be 
 mt. 'All 
 erous or 
 nd Eoux 
 , v T rr :- Z 
 
 orrhage and constipation are rare. 
 necrosis due to toxaemia. Healing 
 
 :ms.—Bys::^ra is very con-ion. It 
 •ccurring in close parallelism with 
 
 m develops 
 referred to 
 eats is fre- 
 ciuuous or 
 ;thing may 
 rable sign, 
 ire form of 
 
 jta a a l i n 1 1 
 
 d is the:: 
 
CHRONIC NEPHRITIS. 753 
 
 skin, nose, bronchi, stomach, bowels, uterus, conjunctiva or retina. 
 The author has observed 9 cases of profuse gastro-intestinal hemor- 
 rhages in uraemic subjects, (b) Inflammations may develop. Chronic 
 bronchitis always suggests kidney disease. Pericarditis, pleuritis 
 and pneumonia especially, may develop as terminal infections. Many 
 deaths from pneumonia are due to nephritis, which was previously 
 unnoticed. Laryngitis and acute (inflammatory) oedema glottidis 
 may occur, (c) (Edema is a late symptom and results not from the 
 nephritis, unless it is of the mixed type, but from failing of the heart. 
 Ascites also is nearly always cirrhotic or cardiac, (d) The skin is 
 usually dry and harsh and is sometimes covered with urea crystals — 
 the "urea frost" or uridrosis. Itching, erythema, urticaria, eczema 
 and numbness or " dead fingers," unusual susceptibility to cold (cry- 
 aesthesia), neuritis or rheumatoid pains are probably toxaemic. 
 
 Diagnosis. — There are three cardinal findings, cardiovascular, uri- 
 nary and retinal; as Senator says, he who invariably examines the 
 urine and heart in every instance rarely fails to diagnosticate ne- 
 phritis correctly. 
 
 Cardiac Symptoms. — The very interdependence of cardiac and 
 renal changes may prove confusing; thus primary cardiac disease 
 may cause renal congestion, embolism or even acute or chronic ne- 
 phritis ; again alcohol or syphilis may be a common cause of arterio- 
 sclerosis, myocarditis and nephritis ; and finally, the heart lesion may 
 be secondary to renal disease. Renal stasis is considered in the dif- 
 ferential table given below. In terminal cardiac weakness caused 
 by contracted kidney, the hydrops, dyspnoea, rales or systolic murmur 
 may suggest myocarditis with renal stasis ; gallop-rhythm is more 
 common in the heart of renal disease than in primary cardiac 
 affections. 
 
 The Urinary Fi^di^gs. — In diabetes mellitus there is an in- 
 creased flow of urine, in which the high specific gravity, glycosuria 
 and less prominent heart findings are distinctive ; in diabetes insipi- 
 dus the absence of albumin, casts and cardiac changes are characteris- 
 tic ; and pyelitis is characterized by albumin and pyuria but not by 
 casts or cardiac changes. In the arteriosclerotic kidney arterial and 
 cardiac antedate the urinary changes (the converse is true in inter- 
 stitial nephritis), the specific gravity is higher, albumin less in 
 amount and in frequency of occurrence and the course is much more 
 rapid. For differentiation from other renal diseases see page 764. 
 
 Diagnosis of Uremia. — Skull-fracture, miliary tuberculosis, lep- 
 tomeningitis, cerebral abscess, sepsis and other diseases may be diag- 
 nosticated uraemia simply because nephritis is also present. Senator 
 has said that without a previous history we can often only diagnosti- 
 cate a renal disease and suspect the presence of other (latent) affec- 
 tions. The danger of mistaking uraemic symptoms, as hemicrania, 
 nervous symptoms, dysentery, etc., for independent disease is greater 
 in direct ratio to the difficulty of diagnosis of the nephritis itself and 
 many authors have remarked on the lack of correspondence between 
 
754 DISEASES OF TEE KIDNEY. 
 
 the clinical and pathological findings in nephritis. According to 
 Leube, uraemic intoxication is assumed to be the cause of nervous 
 symptoms only when other causes may be excluded, because in the 
 course of renal disease organic nervous lesions, as hemorrhage and 
 meningitis, may simulate uraemia. Though the urine is usually de- 
 creased before an attack of uraemia, Liebermeister instances a case 
 in which, immediately before a uraemic seizure, both urine and urea 
 were increased two-fold. Biermer reports an anuria which lasted 
 two hundred and twenty-two hours before uraemia developed. 
 
 Apoplexy is probably present when pressure symptoms, as vomit- 
 ing or slow tense pulse, complete hemiplegia or conjugate deviation 
 exist; it is rarely completely simulated by uraemia. Meningitis, 
 insolation and alcohol or opium coma are rarely simulated; in very 
 exceptional instances, focal symptoms and fever may cause diag- 
 nostic error. The author has seen a few cases in which uraemia 
 simulated typhoid or sepsis by the constant high temperature and two 
 cases with no bacteriological evidence of terminal infection. 
 
 Prognosis. — Because the onset is insidious it is often detected only 
 when the patient suffers from cardiac insufficiency, beginning uraemia, 
 apoplexy or intercurrent inflammations ; for this reason this incurable 
 malady is seldom treated in its early stages. The clinical course 
 usually runs five to ten years after albuminuria is found ; a course of 
 twenty years is reported by Senator and Aufrecht, of twenty-three 
 years by Oppolzer and of thirty by Rosenstein. Much depends on 
 the docility and financial ability of the patient. Marked arterio- 
 sclerosis hastens the fatal issue. Retinitis is an ominous symptom ; 
 in Belt's 419 cases 72 per cent, died in one and 90 per cent, in two 
 years. Retinitis increases the gravity of the outlook four-fold. 
 Staub's and Griining's figures are almost identical. Webster, Wert, 
 Hare, Mix and the author have seen cases which lived from four to 
 ten years after retinitis was found. Uraemia, pneumonia, apoplexy 
 and other complications are decidedly unfavorable. 
 
 Treatment of Chronic Nephritis, Parenchymatous and Interstitial. — Both 
 forms are considered together, because they often blend (mixed 
 or diffuse nephritis). 
 
 1. Prophylaxis. — Prevention and treatment of the cause have a 
 very limited practical application. Irritating foods, excessive eating, 
 all forms of intemperance, over-work, neglect of infections and dys- 
 pepsia come under this head, but are usually treated too late. 
 
 2. Rest, Exercise. — The kidneys should be relieved by rest in the 
 horizontal posture, because exertion and even the erect position, which 
 per se may cause albuminuria, only increase preexisting albuminuria. 
 If in severe cases exercise seems advisable it should be given passively 
 with the patient in the recumbent posture. The rest should be abso- 
 lute as long as the heart is weak, the urine scanty or hydrops con- 
 spicuous. The importance of rest in bed was recognized by Bright 
 and Bartels. When there is moderate renal involvement or in the 
 
CHRONIC NEPHRITIS. 755 
 
 intervals of improvement relative restriction of exercise should be 
 enforced. Rest in bed lessens the amount of waste products to be 
 eliminated by the kidneys and so protects the skin and dilates its 
 vessels that the cutaneous functions become more active and relieve 
 the vascular hypertension, just as a patient with a cold should remain 
 in bed in order to increase the activity of the skin and kidneys. The 
 author treated two severe cases of parenchymatous nephritis by rest 
 in bed for a year and absolute recovery resulted. It is a question if 
 lying covered in bed is not one of the reasons why nephritics pass 
 more urine at night than in the day time. Fatigue, dampness and 
 cold must be avoided; these indications are best carried out by rest 
 in bed during the time of severe symptoms or of acute exacerbations 
 and by relative rest and warm clothing in cases of moderate severity. 
 Practitioners do not sufficiently insist on psychical rest ; in men lead- 
 ing a strenuous life moderate nephritis has often decreased and some- 
 times disappeared when nervous tension was relieved ; too often these 
 subjects take physical exercise or courses of training after they are 
 already exhausted by head-work; in any event exercise should sup- 
 plant work and not be taken after hard nervous strain. 
 
 3. Springs, Climate. — " Cures " at water resorts have the general 
 advantage that the importance of diet and hygiene is impressed on the 
 patient; the psychical or suggestive element is also an important 
 therapeutic agent. Diffuse nephritis (with considerable parenchy- 
 matous and interstitial change) is most benefited. Only patients 
 without oedema or serious heart involvement should be sent to such 
 places as Poland Springs, Bedford Springs, Saratoga, Yichy or 
 ^"euheim. A stay in the California, Mississippi or K"orth Carolina 
 climate during the winter, at least, will materially benefit. 
 
 4. Diet. — The diet must be non-irritative, must not especially tax 
 the kidneys in its elimination, must not burden the circulation and 
 must maintain nutrition. Disease of the glomeruli alone may be 
 compensated by vicarious excretion of water through the lungs, skin 
 and intestines, but disease of the tubules whose function is elimination 
 of the end-products of albuminoid metabolism, cannot well be com- 
 pensated by other structures, whence the indication, for limitation of 
 albuminous foods and substitution by fats and carbohydrates. The 
 small amount of albumin lost through the kidneys can be offset by a 
 glass or two of milk daily; in this respect nephritis differs from 
 diabetes in which the system is irritated by unappropriated sugar and 
 loses a vast number of units of heat and energy each day. Albumin- 
 ous food is restricted only to spare irritation of the excreting renal 
 cells and no absolute rule can be laid down for all cases. Chittenden 
 has recently shown that we eat twice as much meat as we need. It 
 is an obvious mistake to gauge the severity of a nephritis by the de- 
 gree of albuminuria or to estimate improvement by the influence of 
 diet upon the albuminuria alone. Fats as butter, olive and cod-liver 
 oils and cream, are very important, because they supply energy and 
 heat units in place of the restricted albumin. As in diabetes the re- 
 
756 DISEASES OF THE KIDNEY. 
 
 striction of diet must not merely concern renal irritation, but most of 
 all, the maintenance of nutrition, especially when the patient suffers 
 from parenchymatous nephritis, the very form in which restriction of 
 diet is theoretically most needed; anaemia and malnutrition are the 
 most distinguishing features of the parenchymatous as contrasted 
 with the interstitial type of nephritis. The patient is considered 
 more than the disease or the type of the disease. 
 
 The milk diet is free of extractives and salt, easy of digestion and 
 diuretic. It has its restrictions; it is bulky, over four quarts being 
 necessary to maintain nutrition and it therefore may cause dyspepsia ; 
 it lacks iron, but this can be easily compensated ; four quarts contain 
 an excess of about 60 per cent, of proteid ; it contains too much water, 
 thereby possibly overloading the blood and straining the heart ; and 
 its phosphates tax the kidneys. One to one and a half quarts of milk 
 with a pint of cream, fats and carbohydrates (baby foods, sago, rice 
 or potatoes) will meet the needs of metabolism; and sometimes over 
 half of the phosphates of the milk can be precipitated and kept in the 
 intestine and away from the blood and kidneys by giving calcium 
 carbonate gr. v to x with the milk (von Xoorden). It should be 
 taken slowly, in sips, as it is a food, not a beverage. Milk was one of 
 the chief articles of diet of the older masters of medicine ; a very short 
 time ago we heard that it contained an excess of water ; now we are 
 told it is excellent because it contains so little salt. Part-truths are 
 misleading. 
 
 In regard to a meat diet, probably the present reaction in favor of 
 the meat diet is extreme, as Strubell's experiments demonstrate that 
 meat promotes uraemia. The average daily amount is three ounces 
 (100 gm.). There is absolutely no difference between red and white 
 meats as to extractives or purin bodies. Some meat is preferable to 
 overloading the stomach and bowels with a bulky vegetable diet, save 
 when uraemia is imminent. 
 
 Raw eggs increase (perhaps induce) albuminuria; not more than 
 two should be given daily. Substances excreted with difficulty include 
 the following, according to von Xoorden: urea (in meat), creatinin 
 (in meat broths, extractives and to a less extent in eggs), urinary 
 pigments (in haemoglobin), hippuric acid (in cranberries, fruits with 
 pits, prunes, plums and gages), phosphates (in milk) and inorganic 
 sulphates (in meat) ; nric acid and alloxur bodies, contrary to general 
 opinion, are, according to von Xoorden. eliminated readily (they are 
 found in glandular organs, — such as the thymus, sweetbreads, ]iver 
 and kidney, — in broths and coffee). The "chlorides are especially 
 avoided in parenchymatous nephritis with oedema. As pointed out 
 by Widal, Lemerre, Javal, Mercklen and Courmont in 1903, admin- 
 istration of salt (which is retained in the blood) increases the body- 
 weight, induces oedema and aggravates albuminuria, while " de- 
 chloridation " of the food reduces weight, oedema and albuminuria. 
 Probably the entire truth is not yet known ; Rumpf found cases with 
 oedema, uraemia and retinitis in which the chlorides of the blood were 
 
CBR0N1C NEPHHITIS. 757 
 
 decreased. Widal's dechloridation diet is Vz pound meat, 1 pound 
 potatoes, 3 ounces sugar, 3 ounces unsalted butter and 2% quarts 
 milk. Irritants, as cheese, relishes, horseradish, onions, rhubarb, 
 asparagus, spices, sauces, broths, beef -tea and alcoholics, should be 
 absolutely avoided; tea and coffee must be limited because they may 
 aggravate or produce nephritis (Penzoldt, Hubach). 
 
 5. Water. — In regard to water, the same extremes of opinion are 
 noted; fluids were once excessively restricted and later undue quanti- 
 ties were recommended; von Noorden states that flooding the vascu- 
 lar system with water overtaxes the heart ; " water can only be ex- 
 creted by the kidney if the blood pressure is increased ; many patients 
 having weak hearts give a history of excessive water drinking ; in such 
 cases improvement is frequent if the ingestion of water is limited; 
 about three pints should be the average amount." Nevertheless re- 
 lief of high arterial pressure and minor uraemic symptoms may 
 follow copious drinking of water. 
 
 The following therapeutic measures are hut symptomatic: — 
 
 6. Diuretics. — Diuretin is said to produce no renal hyperemia 
 but to act directly on the epithelium and, according to Griinwald, to 
 sometimes reduce the albuminuria; it may sometimes be employed 
 with success {v. Treatment of Valvular Disease). The use of 
 diuretics is indicated by increase of hydrops, scanty urine and immi- 
 nent uraemia. The refrigerants (cream of tartar, 3j) or potassium 
 citrate (gr. xx to xxx) are the only safe diuretics ; they are thought to 
 abstract water from the tissues and facilitate the excretion of urea, 
 uric acid and similar products ; they are apparently most active in the 
 effervescent form. Basham's mixture (liq. ferri et ammonii acetatis) 
 as a tonic and diuretic should be given in doses of 1 or 2 drams. 
 Diuretics which act through the circulation will be considered below. 
 
 7. Hydrops. — Hydrops necessitates treatment because it prevents 
 movement, threatens suffocation by pulmonary or laryngeal oedema, 
 increases the danger of secondary infection, as erysipelas or cellulitis, 
 embarrasses the circulation by pressure on the afferent capillaries and 
 efferent lymphatics and venules, interferes with digestion and in- 
 creases the danger of uraemia, (a) Though cathartics may eliminate 
 fluids as well as solids, drastics must be given with due care for the 
 digestion and nutrition, — pulv. jalapae co. 3ss to 3j at night; vegetable 
 are better than saline cathartics, (b) Sweats are generally given, 
 possibly less so of late. Though the functional relation between the 
 skin and kidneys cannot be overestimated, profuse sweating elimi- 
 nates fluid rather than solids. Leube holds that sweats concentrate 
 the blood and predispose to uraemia; he states that when a patient 
 sweats one quart (1,000 c.c.) only 7 to 15 grains (0.5 to 1 gm.) of 
 urea are eliminated. The author has more often seen aggravation of 
 symptoms or a fatal issue result from sweating than relief and hence 
 prefers the old-fashioned full warm bath, recommended by Osborne 
 and Liebermeister, to the more active methods; an ice-bag is placed 
 on the head to prevent brain congestion. Commencing with water at 
 
758 
 
 DISEASES OF TSE KIDttEY. 
 
 body temperature this is raised five or six degrees. After twenty or 
 thirty minutes the patient is removed and wrapped — without drying 
 blankets. A hot-air bath may be given by placing a lamp 
 
 -in 
 
 under one end of a stove-pipe which runs by an elbow into a tent 
 built over the patient, as illustrated in the following cut. In the 
 
 Fig. 47. 
 
 Sweat bath employed in nephritis. 
 
 alcohol sweat, hot bricks protected by flannel are placed around the 
 heavily covered patient ; equal parts of alcohol and water are poured 
 on the bricks and the patient is covered again ; the heat produces a 
 steam vapor which is well tolerated unless the heart is weak, when 
 fatal collapse may ensue. It is often unsafe to give pilocarpine (v. 
 Acute Nephritis) because it may produce vomiting, diarrhoea, syn- 
 cope and pulmonary oedema, (c) Mechanical relief by means of in- 
 cision is superior to all other measures which must first bring the 
 fluid with all its urea and extractives into the circulation, with the 
 danger of inducing uraemia. If the kidneys and other emunctories 
 cannot relieve the blood, how can they remove the additional refuse 
 in the anasarcous fluid, which comes to the blood from the tissues ? 
 The author makes deep incisions, three inches long, over the lower 
 leg (not over the malleoli where infection from the feet is likely) 
 whenever the hydrops is at all extensive. Iu testing the fluid evacu- 
 ated there has frequently been 0.1 per cent, urea which may serve 
 as a measure for other retained products of kindred nature; when 
 quarts seep out during the first twenty-four hours one is well justified 
 in incising the legs, despite the slight danger of occasional infection. 
 Sweats and drugs never achieve equal results. Free incision is ob- 
 viously less dangerous than punctures or Southey's capillary tubes. 
 
CHRONIC NEPHRITIS. 759 
 
 8. The Circulation. — Treatment often resolves itself into the 
 care and stimulation of the heart. Mental excitement, nervous strain, 
 physical exertion, constipation, tobacco, coffee, alcohol and expo- 
 sure to heat must be avoided. The more the heart hypertrophies 
 the better is the outlook, although ultimate cardiac dilatation is the 
 inevitable fate of every hypertrophy. In the uraemic seizures, with 
 precisely the same symptoms in other respects, the heart may vary; 
 it may beat strongly or very weakly, (a) With cardiac over-action 
 observed early in uraemia, the angiospasm or the high tension must be 
 corrected by vasodilators. Iodides are beneficial when there is no 
 urgency in doses of grs. v to x t. i. d. ; iodism, especially salivation, 
 may result from renal retention. When extreme tension and im- 
 minent uraemia exist, tr. veratri viridi H[vtox every half hour for 
 three or four doses may be given; the author prefers spiritus gly- 
 ceryls nitratis TT\,ij until results are produced; he believes that the 
 vasodilators are often given to excess, as hypertrophy and increased 
 arterial tension are less pathological than compensatory conditions. 
 Bleeding may so relieve the intracranial blood pressure as to avert 
 for a while the uraemia, but too often it does not ; salines may be given 
 afterwards, either subcutaneously or by rectum; they "lavage the 
 blood" and stimulate the kidneys if enough sound tissue be left. 
 Venesection lessens the molecular concentration of the blood (i. e., 
 its toxicity) and relieves the laboring heart; infusions act in the 
 same way; an excess of salt may be given in the infusions (v. s.) and 
 when they are repeated the salt should be left out, for it may produce 
 oedema of the lungs. Bouchard states that the abstraction of 32 gm. 
 of blood removes more toxins than 280 gm. of fluid faeces or 100 liters 
 of sweat. Increased intracranial tension may be relieved by lumbar 
 puncture; the normal pressure of 120 mm. (as indicated by the 
 manometer) is often increased, sometimes to five or six hundred 
 mm. ; the author has seen marked, sometimes protracted relief 
 in medical and eclamptic cases; the headache, vomiting, convulsions 
 and coma are often decreased or entirely relieved, (b) When the 
 heart is weak, rapid, irregular or galloping, cardiac stimulation by 
 digitalis and strychnine is indicated. Infusion of digitalis by mouth 
 may cause vomiting and nxij to v of the" fluidextract may then be 
 given hypodermatically or by rectum. Its combination with squills or 
 calomel is inadvisable ; the latter may cause the most intense saliva- 
 tion; in one case necrosis of the entire tongue occurred. Cardiac 
 unrest, palpitation or dyspnoea should be relieved by a hypodermic 
 of morphine, by application of ice to the heart or by champagne, nitro- 
 glycerine, bromides and valerian. Pilocarpin and sweats are dis- 
 tinctly contra-indicated, because they over-tax or fatally depress the 
 heart. Yon Ziemssen gave champagne and digitalis by mouth as long 
 as the patient could swallow and then digitalis by rectum and cam- 
 phor subcutaneously. 
 
 9. Vomiting. — Vomiting and diarrhoea are as often vicarious as 
 toxaemic and should not be checked at once. Gastric lavage and 
 colonic flushings are beneficial. 
 
760 DISEASES OF THE KIDNEY. 
 
 10. Convulsions. — For convulsions, hypodermics of morphine 
 should be given (Loomis and Mackenzie) ; the author never saw harm 
 result from its use, though medical opinion is generally against it. 
 Chloral (gr. xv every hour for not more than four doses) aids the 
 morphine; bromides generally act too slowly. 
 
 11. Operation. — Surgical treatment is still sub judice. It is cer- 
 tain that many cases of " decapsulated " kidney were not genuine 
 nephritis, but rather albuminuria from floating kidney or ascending 
 infection. Again, it is still a question whether chronic nephritis is 
 merely a renal disease or perhaps a result of a general blood condi- 
 tion ; this idea, advanced by Semmola, is not yet disproven. 
 
 PASSIVE CONGESTION.— INFARCTION. 
 
 I. Passive Congestion. — Venous hyperemia is an important renal 
 lesion compared with arterial hyperemia, of which latter little is 
 definitely known, though it occurs in renal inflammation, left ven- 
 tricle hypertrophy, diabetes, perhaps also in nervous lesions and after 
 the administration of diuretics. 
 
 Etiology. — (a) Among the chief causes of general stasis are cardiac 
 insufficiency from valvular disease, myocarditis and pulmonary em- 
 physema, (b) Local stasis has scarcely any part in the renal path- 
 ology (Cohnheim). Berkmann (1859) described renal stasis and 
 thrombosis of the renal veins occurring in the new-born or in nurs- 
 lings after severe diarrhoea ; when unilateral there is renal pain, great 
 albuminuria, some hematuria, swelling of the kidney and decreased 
 urine ; most cases of bilateral thrombosis die from anuria and ursemia. 
 Thrombosis of the cava and pressure by large tumors may cause pas- 
 sive congestion in the renal veins. 
 
 Pathology. — Anatomical changes result from slowing of the arterial 
 flow, lessened arterial pressure and to a less degree from venous 
 hyperemia, which changes alter the integrity of the secreting renal 
 structures, notably the glomeruli. In experiments, arterial insuffi- 
 ciency causes initial glomerular alteration, while venous obstruction 
 causes primary congestion in the medullary portion. 
 
 Early Changes. — The kidney is swollen, dark red and firm and its 
 stellate veins are prominent. On section it expands beyond its close- 
 fitting capsule, which is readily stripped off. The organ is very vas- 
 cular and may drip blood. The glomeruli are seen as dark red points 
 and the medullary bloodvessels are clearly defined. Microscopically 
 the conspicuous changes are hyperemia, occasionally with punctate 
 hemorrhages, fatty and cloudy degeneration of the epithelium of the 
 tufts and convoluted tubules, escape of albumin into them, forming 
 hyaline casts in the tubules and finally some thickening of the vessels. 
 
 Late Changes. — Prolonged stasis leads to greater atrophy of the 
 secreting structures and to increase of connective tissue; this " cy- 
 anotic induration " has been rather overdrawn in clinical descriptions, 
 but may result from extreme and protracted stasis. The kidney be- 
 
AMYLOID DEGENERATION OF THE EIDNEt. 761 
 
 comes pale and firm, the cortex shrinks, the capsule may become 
 somewhat adherent and connective tissue develops in the medulla. 
 Microscopically, fibrillar connective tissue, thickening of Bowman's 
 capsule and epithelial degeneration are found. 
 
 Symptoms. — Aside from the causal heart or other lesion and the 
 signs of stasis in other parts the urinary findings are of chief interest. 
 The urine is decreased and its amount follows directly the heart's 
 activity. It is acid, dark, concentrated (specific gravity 1,025 to 
 1,030) and it has a lateritious sediment of urates and often of uric 
 acid crystals. Albumin and globulin are present, usually in mod- 
 erate amounts. Microscopically a few leukocytes, epithelial cells and 
 hyaline casts are found ; granular casts are seldom found and should 
 arouse suspicion of nephritis ; red cells almost always indicate ne- 
 phritis or infarction rather than congestion. 
 
 Diagnosis. — The urinary findings are significant in association with 
 the causal lesion; oedema begins in the legs; the nutmeg liver, dys- 
 pnoea, cyanosis and pulmonary stasis are present. The percentage of 
 albumin runs parallel with the strength of the heart, increasing with 
 its failure or decreasing if digitalis or strychnine improve its action. 
 If cardiants increase the urine and if abundant albumin and casts still 
 remain there is probably coincident nephritis. (See page 764.) 
 
 The treatment is that of chronic valvular disease (q. v.). 
 
 II. Infarction — Embolism. — Though infarction may rarely occur 
 from local disease of the renal arteries, acute or chronic valvular 
 disease of the left heart is its predisposing cause. Sixty-six to 75 
 per cent, of all embolisms are renal. Stoppage of a renal terminal 
 artery causes the well-known wedge-shaped anaemic infarct in twenty- 
 four to thirty-six hours ; the local ischsemia causes fatty degeneration, 
 necrosis and a finely granular transudation into the connective tissue 
 and glomeruli. After a while fibrous substitution occurs with ulti- 
 mate shrinkage and deformity. After repeated infarctions the irreg- 
 ular " embolic contracted kidney " is seen. As in other infarctions, the 
 process may be innocent (mechanical) or less commonly suppurative. 
 
 Symptoms. — In most cases there are no symptoms. Exceptionally 
 a diagnosis is possible, based on (1) the valvular lesion; (2) sudden 
 onset with fever, chills and vomiting; (3) lumbar pain and tender- 
 ness and (4) hsematuria and albuminuria. 
 
 There is no treatment. 
 
 AMYLOID DEGENERATION OF THE KIDNEY. 
 
 Etiology. — The etiology of amyloid kidney is that of amyloid liver 
 (q. v.) ; its three principal causes are ulcerative tuberculosis, pro- 
 tracted suppuration and inveterate syphilis. The most plausible 
 theory is that toxins produce, either in the blood or in the organ in- 
 volved, an albumin which is deposited in and about the bloodvessels. 
 Amyloid kidney was first described by Rokitansky (1842) and its 
 symptomatology was developed by Wilkes, Todd and Traube. 
 
762 DISEASES OF THE KIDNEY. 
 
 Pathology. — Amyloidosis seldom occurs in the kidneys without 
 associated changes in the liver and spleen. To the naked eye the 
 kidneys generally appear enlarged,, weighing together even as much 
 as 26 ounces (870 gm., Johnson) ; when amyloid infiltration is slight, 
 there may be no alteration in size or weight ; in some cases the kidneys 
 are large from coincident chronic parenchymatous or small from 
 interstitial nephritis. The capsule strips readily, showing a pale, 
 smooth surface. On section the cortex is enlarged, glistening, waxy 
 and pale and its edge translucent; the glomeruli stand out as glisten- 
 ing points and become brown when treated with Lugol's solution. 
 Microscopically the amyloid substance can be seen clearly; it is so 
 named because of its starch-like reaction, though chemically it is an 
 albuminoid. It is either deposited from the blood in the small vessels 
 or more probably formed in situ, whence it is found especially in the 
 glomeruli, then in their afferent vessels and in the straight vessels of 
 the medulla. The renal interstitium is involved secondarily and the 
 epithelial cells never suffer primarily, though the membrana propria 
 may be affected and the cells may suffer secondary compression, 
 degeneration and atrophy. As the changes indicate, amyloid disease 
 cannot be classified with Bright's disease, though their association 
 is not uncommon (v. i.). 
 
 Symptoms. — Its symptoms are variable, (a) Urinary symptoms 
 are exceptionally absent (Rosenstein and Litten). The urine is gen- 
 erally limpid and increased, but may be decreased when amyloid de- 
 generation is associated with parenchymatous or greatly increased 
 when associated with interstitial nephritis ; some writers place undue 
 importance upon variability in its amount. The specific gravity is 
 1,010 to 1,015 or higher in syphilitic cases. Albuminuria is usual, 
 being absent only in those exceptional cases which invade the vasa 
 recta and evade the glomerular capillaries ; albuminuria results from 
 increased permeability of the glomerular vessels and may amount to 
 1 or 2 per cent. ; Senator has remarked on the frequently large amount 
 of globulin in the urine. There is little change in the solids ; indi- 
 canuria is not infrequent. Microscopically hyaline casts may be 
 present and perhaps a few leukocytes and epithelia, but the sediment 
 is scanty in most cases ; the so-called waxy or amyloid casts found in 
 severe nephritides have no relation to amyloidosis of the kidney. (6) 
 Cardiac hypertrophy, uraemia and retinitis do not occur in renal 
 amyloidosis, except when it is associated with nephritis, (c) Amy- 
 loid degeneration of both the spleen and liver and sometimes the ali- 
 mentary tract is associated in 66 per cent, of cases; these and the 
 causal disease are necessary for diagnosis, (d) (Edema and anosmia, 
 which is almost cachexia, are usual in diffuse amyloidosis. Hydrops 
 of the serous sacs, especially ascites, is less common than oedema and 
 usually occurs as a late or terminal event. Differentiation (v. p. 764). 
 
 Prognosis. — Amyloid disease is incurable, though light grades may 
 recede. Amyloid of the kidneys in most cases runs its course in a 
 year or less, particularly when associated with parenchymatous ne- 
 
MOVABLE KIDNEY. 763 
 
 phritis. Cases may endure for several, even fifteen years, but these 
 are generally complicated by contracted kidney. 
 
 Treatment. — Treatment consists chiefly of prophylaxis; with mod- 
 ern surgical treatment amyloid disease is less common than formerly. 
 Early treatment of tuberculosis and syphilis decreases the percentage 
 of amyloidosis ; for the developed disease there is no treatment. 
 
 .MALFORMATIONS OF THE KIDNEY. 
 
 I. Malformations and Structural Anomalies of the Kidney. — To 
 
 malformations and structural anomalies in general but little clinical 
 importance is attached. Complete absence or rudimentary develop- 
 ment of both kidneys occurs only in unviable infants. 
 
 One kidney, usually the left, may be absent or rudimentary, 
 whereon the normal kidney vicariously hypertrophies; the enlarge- 
 ment may be mistaken for malignant disease, whence its removal is 
 fatal. Before operation cystoscopy is imperative in doubtful cases 
 to determine the presence of two ureters or a preliminary incision 
 should be made to ascertain that there are two kidneys. Two ureters 
 may come from one kidney. Ballowitz collected 184 cases in which 
 one kidney was lacking; 61 per cent, occurred in males and in 63 
 per cent, the left kidney was lacking. According to Gerard, unilateral 
 absence of one kidney is usually associated with unilateral malforma- 
 tion of the internal genitalia, but this is not true in unilateral renal 
 atrophy or in cases where the two kidneys fuse. 
 
 Double kidney and deformation from lacing or scoliosis, are of 
 pathological interest only; 15 cases of supernumerary kidneys are re- 
 corded (Graser) and in two cases there were four kidneys. 
 
 The " horse-shoe " kidney (ren arcuatus) due to the fusion of both 
 kidneys, is fairly common. Errors in diagnosis are common, espe- 
 cially if the kidney is dislocated and are inevitable if the renal pelvis 
 is inflamed or dilated. The ren arcuatus has been mistaken for a 
 tumor and extirpated, obviously with fatal results. 
 
 II. Movable Kidney. — Congenital dislocation occurs twice as fre- 
 quently in males as in females and is usually left-sided, in which re- 
 spects it differs from the acquired form. It frequently coincides with 
 congenital anomalies of the genitalia and intestines and is of more 
 anatomical than clinical interest. The kidneys may lie one upon the 
 other (dystopia renum cruciata), of which Chatelin could collect but 
 15 cases. The kidney may lapse into the pelvis. The ureters are 
 sometimes quite short. 
 
 Acquired dislocation, described by Rayer nearly a century ago, is 
 much more common and important. It is called movable or floating 
 kidney, ren mobilis s. migrans, ectopia renis acquisita or nephroptosis. 
 
 Etiology. — (a) Sex; 88 per cent, occur in women, as shown in 
 Kuttner's collection of 667 cases; Dietl claimed that women consti- 
 tuted 99 per cent, of the cases. (b) Age. Most cases occur between 
 the twentieth and fiftieth years. Comby reports 18 and Abt 5 cases 
 
764 
 
 DISEASES OF TEE KIDNEY. 
 
 
 
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DIAGNOSIS OF DIFFUSE RENAL DISEASES. 
 
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766 DISEASES OF THE KIDNEY. 
 
 in children, (c) The actual cause is disputed. The kidney is sup- 
 ported by the fat around it, the peritoneum in front of it and by its 
 own bloodvessels. Among the alleged causes are: atrophy of the 
 perirenal fat; the presence of a mesonephron (Gerard) surrounding 
 the kidney to a variable extent ; weakening of the abdominal walls by 
 pregnancy and other causes ; alterations in the intra-abdominal pres- 
 sure by malpositions of the uterus, e. g., prolapse (Landau) ; pressure 
 exerted by corsets on the liver (Cruveilhier) ; congenital laxness of 
 the supporting structures, in connection with which Stiller claims 
 that the tenth rib is usually " floating " like the eleventh and twelfth 
 ribs (costa fluctuans decima) ; tumors of the kidney, which drag it 
 downward ; and trauma or sudden efforts. Several of these causes are 
 also thought to produce enteroptosis, in connection with which float- 
 ing kidney is very frequently observed. 
 
 Symptoms. — Symptoms are absent in many, probably in most cases ; 
 they may date from the time when the physician incautiously remarks 
 upon the presence of " a floating kidney." There are two main symp- 
 toms, the subjective pain and the objective-tumor. 
 
 1. Pain. — Pain may be merely a dragging sensation or may amount 
 to severe renal colic, which is said to result from stretching of the 
 renal nerves; it may be lumbar, abdominal or may shoot toward the 
 heart, thigh or sciatic region; it may occasion intercostal neuralgia, 
 even of the opposite side of the body. Pain may be constant or 
 intermittent, mild or severe or like a crisis (v. i.). 
 
 2. Objective Kidney Findings. — On bimanual examination with 
 one hand over the kidney in front and the other pushing it up from 
 behind, the findings vary; (a) frequently the kidney is not painful or 
 tender, but palpable, which condition has no significance, especially in 
 women; (&) the kidney may be movable, descending on deep inspira- 
 tion, maybe to the navel, where it can be retained by pressure during 
 expiration; movable kidney is found in 20 per cent, of women 
 (Tuffier) ; (c) the kidney may be floating (the most extreme type), 
 in which it may fall or wander to the lower abdomen or pelvis. In 
 76 per cent, of cases the right kidney is involved, in 11 per cent, the 
 left and in 13 per cent, both kidneys (Kuttner) ; the right kidney has 
 longer vessels, but the left renal vein is more firmly connected with 
 the suprarenal vein and the pancreas. When the kidney is grasped 
 a sickening sensation sometimes results as when the testicle is com- 
 pressed. The tumor is smooth and is usually recognized by its shape. 
 In rare cases the pulsating renal vessels are felt (v. Frerichs and 
 Eichhorst). If not clearly felt when the patient is lying on the back, 
 palpation is made in the standing posture or with the patient lying on 
 the left side. Little confidence can be placed in percussion along the 
 spine, though occasionally tympany can be found over the normally 
 dull area along the spine occupied by the kidney; the renal dulness 
 merges with that of the liver and spleen above and extends outward 
 2.5 inches on the left and 3.5 inches on the right side. In thin sub- 
 jects the sinking in of the back and the tumor in front may some- 
 
MOVABLE OR FLOATING KIDNEY. 767 
 
 times be clearly seen. Rarely the kidney may be found in a 
 hernial sac. 
 
 3. Other Symptoms and Complications. — (a) The same train 
 of neurasthenic, hysterical or hypochondriacal symptoms are present 
 as in enteroptosis ; Tuffier believes that these symptoms are causal 
 rather than sequential. Nervous dyspepsia is particularly common. 
 (b) Dietl (1864) described attacks of sudden severe pain and col- 
 lapse known as " DietVs crises'"; they are marked by fever, chill, 
 vomiting, collapse, severe pain, sometimes with swelling and tender- 
 ness of the kidney, scanty urine containing blood, pus, uric acid and 
 oxalates and in some instances peritonitic manifestations; Dietl' s 
 theory that the kidney became "incarcerated" between the connec- 
 tive tissue and peritoneum is now abandoned; Gilewski maintains 
 that the ureter is twisted, causing acute renal retention and hydro- 
 nephrosis and in one of Sutton's cases the ureter was found twisted 
 three times. Landau holds that the renal vessels suffer torsion and 
 Mosler explains the crises by acute nephritis, ureteral stoppage or 
 peritonitis, (c) Dilatation of the stomach is neither causal nor se- 
 quential. It is only a coordinate and not at all a common coincidence. 
 (d) Dysmenorrhea , constipation and enteroptosis are common com- 
 plications. Colitis mucosa is reported by Morris. Compression or 
 actual stenosis of the intestine, icterus, abdominal aneurysm by tug- 
 ging through the renal vessels upon the aorta, compression of the 
 cava inferior and adhesions to the gall-bladder are rare (and ques- 
 tionable) sequences. Albuminuria may occur periodically, on palpa- 
 tion of the kidney or when the patient stands (orthostatic type). 
 
 Diagnosis. — The diagnosis is rarely difficult. The finding on bi- 
 manual examination of the sensitive kidney-shaped movable tumor 
 is more important than the inconstant subjective or ambiguous neu- 
 rasthenic symptoms. Severe pain may be confused with a tabetic 
 crisis, appendicitis or the passage of gall- or kidney-stones. The 
 kidney may possibly be mistaken for some other movable tumor, as 
 omental, gastric, intestinal and gall-bladder tumors or corset liver. 
 Morris reported cases in which an enlarged gall-bladder has been mis- 
 taken for movable kidney; both tumors are movable, may induce 
 icterus or dyspeptic disturbances and both may be attended by colic 
 and a dull (or resonant) note over the tumor. Doubtful cases are 
 determined by repeated examinations, perhaps under anaesthesia. 
 Particular reserve is necessary in the diagnosis of left-sided floating 
 kidney. 
 
 Prognosis. — Death is an extremely rare occurrence, though it may 
 result from " incarceration " and peritonitis. 
 
 Treatment. — The patient should never be told of a movable or float- 
 ing kidney, because the symptoms, chiefly the neurasthenic, may 
 date from the diagnosis, (a) A rest cure may develop adipose tissue 
 and relieve the nervous symptoms, (b) A well-fitted bandage, with 
 padding to prevent renal descent, is excellent in many cases, (c) 
 In obstinate and extreme cases, nephrorrhaphy or nephropexy, as 
 
768 DISEASES OF THE KIDNEY. 
 
 recommended by Hahn, is indicated. According to Czerny and 
 Giess, 82 to 85 per cent, are cured. Turner gives results of 163 cases 
 as follows: absolute recovery, 53 per cent.; improvement, 30 per 
 cent. ; temporary improvement, 5 per cent. ; and failure, 12 per cent. 
 Frank gives the results of Hahn's clinic as 75 per cent, complete 
 recovery, 15 per cent, decidedly improved and 10 per cent, failures; 
 the mortality was under 1 per cent. Nephrectomy is seldom indi- 
 cated, (d) The crises are treated by morphine, reposition and later 
 by operation. 
 
 ALBUMINURIA AND OTHER ANOMALIES OF RENAL SECRETION. 
 
 I. Albuminuria.- — Albuminuria, discovered by Cotugno in 1770, 
 results (a) from leakage of albumin through the glomeruli and tub- 
 ules {albuminuria vera, renalis) or (b) from blood, pus, semen or 
 fluid of tumors (albuminuria spuria). The genuine form will be first 
 considered and the spurious or accidental form later under pyuria 
 and hematuria. 
 
 The most common albumin is serum albumin (or simply albumin) 
 with which serum globulin is frequently associated. 
 
 Etiology. — (a) Its incidence in the diffuse renal diseases, the ne- 
 phritides, amyloidosis and passive congestion has already been dis- 
 cussed, (b) Blood alterations are frequent causes; (i) blood diseases 
 proper, as anaemia, leukaemia, pseudoleukemia, pernicious anaemia, 
 scurvy or purpura in which the poverty of the blood or toxins induce 
 renal degeneration; (ii) toxaemic states, as the acute and chronic 
 infections, in which "febrile albuminuria" (Gerhardt) evidences the 
 renal degeneration; this condition borders very closely on or merges 
 into mild cases of acute nephritis ; (iii) diabetes, icterus and poison- 
 ing by lead, mercury, ether, etc. (c) Nervous maladies possibly act 
 by lowering the local blood pressure, as epilepsy, exophthalmic goitre, 
 migraine and the psychoses, (d) Affections of the digestive tract, 
 as intestinal incarceration, hepatic diseases and lead colic may pro- 
 duce albuminuria, (e) In the new-born it was first noted by Virchow. 
 It is almost regular in the first week or ten days of life (Ruge, Mar- 
 tin) and occurs with hyaline casts, urates and epithelium. It is 
 hardly explained by change of metabolism or of circulation or by 
 uric acid infarcts. Ribbert holds that it is due to imperfect develop- 
 ment of the glomeruli. (/) Pregnancy ; it occurs in 40 per cent, of 
 cases in the last few months of gestation (from increased tax on the 
 kidneys and from pressure) and in the same percentage after de- 
 livery (from effort and strain), (g) Is there a "physiological albu- 
 minuria " f Various types are described, as Pavy's cyclical albumi- 
 nuria, which appears and disappears; intermittent albuminuria; 
 adolescent albuminuria, in young anaemic subjects, often with 
 vasomotor disturbances; orthostatic albuminuria, also termed pos- 
 tural or orthotic, which appears only when the subject stands. Some 
 bring under this caption albuminuria after heavy eating, severe exer- 
 
ALBUMINURIA. 769 
 
 cise, coitus, mental strain or cold baths. Senator, Bradford and 
 Grainger Stewart, whose names alone carry weight, insist that there is 
 a physiological albuminuria, in which signs of nephritis, as casts or 
 cardiovascular changes, are absent. The author regards every case 
 of albuminuria as pathological; its cause may be an insidiously de- 
 veloping nephritis, a receding nephritis, stasis or maybe " constitu- 
 tional," as Martius calls it, but it is always a sign of glomerular or 
 tubular lesion (see Prognosis). The amount of albumin in this 
 type rarely exceeds 0.5 per mille (Senator). 
 
 Detection. — The urine must be clear and acid; if turbid it should 
 be filtered and if it then remains turbid it should be cleared by shak- 
 ing with magnesia ; it must be acidulated, if necessary, with acetic 
 acid ; if very concentrated, dilution with distilled water is advisable. 
 
 1. Boiling Test. — A test-tube, two-thirds filled with urine, is held 
 by its lower part and the upper layers are boiled. Albumin pro- 
 duces clouding, which may also result from phosphates and car- 
 bonates (dissolving when nitric acid is added), balsams (dissolving 
 in alcohol) and, it is said, urotropin and formaldehyde. Nitric 
 acid should not be added before boiling, for a soluble acid-albumin 
 may result. 
 
 2. Nitric Acid or Heller's Test. — Urine, somewhat diluted, is 
 placed in a test-tube or conical glass and nitric acid is run under it 
 by a pipette. Albumin, globulin, mucin and albumose are precipi- 
 tated at once or after a few minutes at the contact point ; albumose 
 dissolves by heating, the others do not. These tests are very sat- 
 isfactory. 
 
 3. Ferrocyanide Test. — To a test-tube half full of urine 10 drops 
 of acetic acid are added, which may precipitate uric acid, urates, 
 oleoresins or nucleo-albumin (mucin). These are filtered out and 
 one dram (5 c.c.) of a 10 per cent, solution of potassium ferrocyanide 
 is added. A precipitate indicates albumin, globulin or albumose, 
 which latter alone dissolves on heating. 
 
 4. Acetic Acid and Salt Test. — Adding to the urine acetic acid 
 to an acid reaction and then an equal volume of saturated sodium 
 chloride solution precipitates albumin and albumose, but the latter 
 dissolves on heating. The above tests detect one part in 10,000. 
 
 5. Spiegler's Test. — This should be used if more delicate tests 
 seem necessary. Nucleo-albumin (mucin) is removed by adding 15 
 drops of dilute acetic acid and filtering. To the urine is added a 
 quantity of Spiegler's reagent (bichloride mercury 8, tartaric acid 4, 
 glycerine 20 and distilled water 200) when albumin or albumose 
 develops at the contact zone. One part in 350,000 may be detected. 
 Jolles' modification: bichloride 10, succinic acid 20, sodium chloride 
 20 and 100 parts of distilled water. 
 
 Globulin occurs chiefly in renal congestion, acute and chronic ne- 
 phritis and amyloid degeneration. It dissolves in an excess of acetic 
 acid. It is precipitated by boiling. Flocculi of globulin are thrown 
 down, when 2 drops of dilute acetic acid are added to 1.6 ounces of 
 filtered urine diluted 10 times with distilled water. 
 
 4? 
 
770 DISEASES OF THE KIDNEY. 
 
 Nucleo-albumin (formerly called mucin) occurs in acute desquama- 
 tive nephritis, icterus, poisonings causing necrosis of the renal cells 
 and regularly in catarrh of the urinary passages. It is precipitated 
 by boiling and by acetic acid and unlike globulin, does not dissolve 
 in an excess of acetic acid. Shreds of mucus, voided with colic, have 
 been observed by von Jaksch and Baumuller; the condition seems 
 analogous to colica mucosa and spasmodic asthma. 
 
 Peptone or albumose is of little clinical importance ; the terms in- 
 clude albumins which do not coagulate by heat. When the urine is 
 boiled the albumin is precipitated and filtered out. Albumose in the 
 filtrate causes clouding and precipitation on cooling. What Kuhne 
 once called peptone is now termed albumose. (a) Bence Jones' albu- 
 mose is rather a peculiar albumin than an albumose; described by him 
 in 1848, albumosuria has also been called Kahler's disease. Muffat 
 (1905) collected 38 cases. Its significance is uncertain; it has been 
 found in osteomalacia and in multiple myeloma. It is precipitated 
 by cold nitric acid, dissolves on heating and reappears on cooling. 
 (b) Albumose may be found in various acute infections (meningitis, 
 rheumatism, pneumonia), septicaemia, peritonitis, empyema, etc. 
 Albumin in the kidney, bladder or urinal may be converted by pepsin 
 into albumose. 
 
 Diagnosis. — The diagnosis of albuminuria is easily determined by 
 the tests enumerated; blood or pus may give albumin reactions (acci- 
 dental or spurious albuminuria, v. hematuria and pyuria). 
 
 Prognosis and Treatment. — These are etiological. The outlook is 
 not favorable, though not necessarily bad. In seemingly " physio- 
 logical " cases, the condition of the heart must be watched and casts 
 carefully looked for. In youth and adolescence albuminuria may be 
 *' physiological " but in middle and later life it is usually nephritic. 
 Shattuck and Osier, however, hold that " albuminuria is more com- 
 mon apart from Bright's disease than is commonly supposed, that it 
 increases with advancing years and that a small amount of albumin 
 with finely granular casts of small diameter in those over fifty years 
 of age is of small importance." Life insurance companies are sus- 
 picious of " physiological " albuminuria, for figures show that it 
 entails double the average death-rate. Albuminuria is said to result 
 solely from high arterial tension, but the author regards these cases 
 as incipient arteriosclerosis or contracted kidney. Hawkins reported 
 a case in which albuminuria lasted, without any unhappy symptoms, 
 for forty-three years after Bright had given a fatal prognosis.. 
 
 II. Hematuria. — Etiology. — Like albuminuria, blood in the urine 
 (haematuria) is only a symptom and is observed in many diverse 
 conditions, (a) It is most frequently renal, (i) General conditions 
 may cause it, as intoxications (by quinine, carbolic acid, turpentine 
 or salicylic acid), acute infections (of which malaria is. the most 
 common, acute exanthemata, particularly the hemorrhagic types) or 
 the blood diseases (purpura, scurvy, haemophilia, leukaemia and the 
 anaemias), (ii) Other causes are local renal conditions, as trauma. 
 
EMMATUKIA. Ill 
 
 vascular maladies (thrombosis of the renal veins, infarct, aneurysm, 
 varicose veins, arteriosclerosis and rarely passive congestion) ; in- 
 flammation (acute, chronic, hemorrhagic and suppurative nephritis) ; 
 rarely amyloidosis or parasites (distoma, filaria, nephrophages san- 
 guinarius) ; tumors ; tuberculosis ; calculous ulceration and pyelitis ; 
 sometimes floating and cystic kidney, especially after bimanual ex- 
 amination, (iii) Hematuria may be "idiopathic" or "essential." 
 In some very rare cases it occurs in " apparently healthy kidneys," 
 to which phrase there has been a just objection. This condition has 
 been called renal epistaxis (Gull), angioneurotic hematuria (Klemp- 
 erer) and renal purpura (Senator). M. L. Harris collected 18 cases 
 in which simple nephrotomy gave relief. In Eshner's series of 48 
 cases of unilateral renal hematuria nothing was found at operation 
 in 33 per cent., floating kidney existed in 12.5 per cent., renal pelvic 
 changes in 19 per cent, and diffuse renal disease in 24 per cent, (b) 
 It may occur from lesions in the lower urinary tract. The chief 
 types of these lesions are stone in the ureter or bladder ; ruptured 
 varices anywhere in the urinary tract ; stasis from liver cirrhosis 
 or thrombosis of the iliac veins; inflammation (pyelitis, ureteritis, 
 cystitis, prostatitis or urethritis, sometimes called " Russian gonor- 
 rhoea") ; and tuberculous, malignant or other ulcerations. 
 
 Symptoms and Diagnosis. — Hemorrhage may be macro- or micro- 
 scopic. The urine may be clear or turbid, red or smoke-colored. It 
 is usually acid, but may be alkaline when there is copious vesical 
 hemorrhage. The color is generally brighter when the urine is alka- 
 line. Confusion with concentrated, icteric, carbolic, fuchsin, hema- 
 toxylin and senna urines is possible. The presence of blood is posi- 
 tively determined (a) by the microscope; the red cells remain normal 
 for a long time in acid urine, but may become pale in dilute and 
 mulberry-form in concentrated urine; (&) by the spectroscope; if no 
 red cells are present with positive spectroscopic findings it indicates 
 hemoglobinuria (v. i.) ; and (c) by chemical tests, as Heller's (boil- 
 ing with caustic potash, which throws down a rusty phosphate and 
 hematin precipitate), the Almen guaiac test (acidulating the urine 
 and adding old turpentine and fresh guaiac) which gives a blue reac- 
 tion (also produced by pus) and Teichmann's test (treating the sedi- 
 ment with sodium chloride and glacial acetic acid, slightly heating 
 and cooling, when hemin crystals are deposited. 
 
 Diagnosis of the origin and cause of hematuria is often most diffi- 
 cult, (a) In cases of renal origin, the blood is intimately mixed with 
 the urine, as much with that first voided as with the last. The color 
 is often that of water in which raw meat has soaked ("beef water" 
 color). Clots are infrequent in renal hematuria, save from trauma, 
 tumors, aneurysm or varicosities. The red cells are seldom seen in 
 rouleaux-form and, according to Gumprecht, are fragmented from 
 action of the renal cells on the red disks ; this does not occur in vesical 
 hemorrhage. If there is some other renal lesion, as nephritis, there 
 is more albumin than the red cells would account for, and albumin 
 
772 DISEASES OF THE KIDNEY. 
 
 is present after careful filtering; according to Goldberg, if there is 
 albumin with a red cell count, by the hemocytometer, of less than 
 3,000 per c.mm., the albuminuria is renal. Blood casts, granular 
 casts and renal epithelium are indicative of renal origin, (b) Hema- 
 turia originating in the pelvis and ureter is more often marked by 
 clots and possibly by caudate epithelium, (c) Blood from the blad- 
 der is more apt to clot and the last part voided is more bloody than 
 the first. Other symptoms, as tenesmus, alkaline urine reaction and 
 perhaps pieces of tumor, very often indicate a vesical origin, (d) 
 Urethral hemorrhage stains most deeply the first urine voided. It 
 must always be borne in mind that the presence of blood may be 
 accidental, from menstrual or other contamination. 
 
 Treatment. — The treatment is etiological and can be but briefly 
 considered here. Rest and sometimes morphine are indicated. Aside 
 from the local treatment of vesical disease, urethritis and calculous 
 pyelitis, tannic acid, ergotin, thyroid extract and calcium chloride 
 aa gr. v. t. i. d. may check bleeding. Aromatic sulphuric acid Tr[x, 
 well diluted, is also given at three-hour intervals. Adrenalin solu- 
 tion 1 to 1,000 parts, given by the catheter, may stop vesical hemor- 
 rhage. In essential (idiopathic) renal hematuria, simple incision 
 of the kidney is frequently efficacious. 
 
 III. Hemoglobinuria. — This is haemoglobin in the urine without 
 hematuria. Though first described by Dressier (1854), most of the 
 early accounts are English, from Harley, Dickinson, Gull and Pavy. 
 There are two main groups, the toxic and the paroxysmal. 
 
 Etiology. — The toxic form may follow transfusion of blood, injec- 
 tions of glycerin, poisons, organic and inorganic, as potassium chlo- 
 rate, phosphorus, mercury, quinine (in malarial cases only), carbolic 
 acid, carbon monoxide ; it may also result from burns, severe icterus, 
 pernicious anaemia, scarlatina, acute nephritis, Winckel's disease in 
 the new-born and estivo-autumnal malaria. The paroxysmal form, 
 of which Gilman Thompson recently collected 206 cases, occurs 
 largely in England, France and Germany; 96 per cent, are males, 
 chiefly between thirty and forty years of age. Cold seems to be the 
 most important factor; exercise, excesses or menstruation may pre- 
 cipitate an attack. It is observed in horses after cold and exertion: 
 hemoglobinemia and hemoglobinuria appear, paresis of the hind 
 legs develops and death results from disturbed circulation and respi- 
 ration. In cattle and sheep epidemics occur in which Babes, Krogius 
 and others have found a hematococcus. In the majority of human 
 cases, hemoglobinuria is preceded by hemoglobinemia, though genu- 
 ine renal hemoglobinuria (without hemoglobinemia) seems to occur 
 in some cases of nephritis and from certain intestinal nematodes. 
 
 Symptoms. — Symptoms occur only after destruction of at least one- 
 sixth of the blood. After a chill, fever, lumbar pain which radiates 
 to the legs, cyanosis, oppression and gastric symptoms, the urinary 
 findings appear ; the urine is dark and contains clumps of blood pig- 
 ment, casts and epithelium stained with hemoglobin or methemo- 
 
PYURIA, 773 
 
 globin, albumin and sometimes oxalate of lime crystals and bile 
 pigments. In most cases the haemoglobin is already altered to meth- 
 aemoglobin, as shown by the spectroscope. There may be slight jaun- 
 dice, oedema or urticaria. The blood shows increased coagulability 
 and diminution in the number and redness of the red cells, which do 
 not form in rouleaux. There may be swelling of the liver and spleen 
 from haemoglobin deposits in them. The paroxysm lasts one-half to 
 several hours and in the interval the general health is fairly good. 
 The course is most chronic. No death is known from the paroxysm 
 itself and very rarely from the disease. 
 
 Treatment. — Prophylaxis in regard to colds and exertion may 
 modify the attacks. Chvostek was able to abort attacks by giving 
 nitrite of amyl inhalations. Warmth may modify the seizure. Cal- 
 cium chloride and thyroid extract have been recommended. 
 
 IV. Pyuria. — Etiology.: — (a) Pus may originate from pyelitis or 
 pyelonephritis. It may occur intermittently, as in pyonephrosis or 
 continuously, as in calculous or tuberculous inflammation. The 
 urine is usually acid in tubercle and colon infections; it is acid in 
 proteus and in some infections ascending from the bladder; the 
 staphylococcus may render the urine less acid than normal or alkaline 
 (v. i. pyelitis). (&) Pyuria may result from cystitis; the urine may 
 be acid or alkaline and contains ropy mucus and triple phosphates. 
 Pus is seen especially in the last urine voided, (c) Urethral pyuria, 
 usually gonorrhoeal, is greatest in the urine first evacuated, (d) 
 Accidental pyuria occurs from leucorrhoeal contamination and is 
 easily excluded by catheterization. Under this heading may be 
 brought pyuria from rupture into the urinary tract of appendicular, 
 pelvic or psoas abscess ; much pus is voided at first, but it gradually 
 lessens and disappears. 
 
 Symptoms. — The urine in pyuria is yellow-white, turbid and has 
 a ropy sediment becoming gelatinous when caustic potash is added. 
 The reaction is often ammoniacal, due to germs decomposing the 
 urea, as the proteus and staphylococci. Gas may be voided with the 
 urine (pneumaturia) ; this occurs particularly in enterovesical fistula 
 and in diabetic cystitis. Alkalinity was formerly thought character- 
 istic of cystitic, and acidity of pyelitic pyuria, but this distinction has 
 been dropped. Albumin is found, the amount of which in simple 
 pyuria corresponds with the number of pus cells. Albuminuria may 
 be absent if there are not over 6-800 pus cells to the c.mm. It is less 
 or may disappear when the urine is filtered. The question often 
 arises whether the albuminuria is simply accidental or is combined 
 with renal albuminuria, for instance, whether cystitis is coincident 
 with contracted kidney. Besides consideration of the amount of 
 urine, its specific gravity, cardiovascular findings and retinitis, be- 
 sides washing out the bladder and ureteral catheterization, a study of 
 the characteristics of the pus cells and their number is of great value. 
 Senator has shown that leukocytes coming from the renal parenchyma 
 in nephritis are mononuclear and those from suppuration are poly- 
 
774 DISEASES OF TEE KIDNEY. 
 
 morphonuclear. Goldberg found that when (a) there is more than 1 
 part per mille of albumin in the clear urine, as determined by Es- 
 bach's method, with (b) 50,000 pus cells per c.mm., as determined 
 by the hsemocytometer, the albumin is partly renal. De Lint altered 
 Goldberg's method by gravimetric determination of the albumin; 
 when there is one part per mille of albumin and less than 7,000 pus 
 cells the albuminuria is (a) renal and (b) it results from the pus 
 alone when there are more than 40,000 pus cells; no conclusion can 
 be drawn if the pus cells number between 7,000 and 40,000 per c.mm. 
 Treatment. — The treatment is that of the fundamental tuberculosis, 
 calculus, pyelitis, cystitis, etc. Phenylis salicylas and hexamethy- 
 lenamina aa gr. x t. i. d. are excellent antiseptics for the urinary tract. 
 
 V. Chyluria. — The endemic or tropical form is found in Florida 
 and South Carolina, Brazil, the Antilles, Zanzibar, India, Egypt 
 and Japan. It is due to the filaria, first recognized by Bancroft and 
 Leurs in the scrotum, by Wucherer in the urine and by Lewis in the 
 blood. It enters the body by the drinking water in which mosquitoes 
 have on their death liberated filaria embryos. The filaria plug the 
 lymph vessels, which dilate and rupture in the kidneys, as proven by 
 Mackenzie's autopsy. They are found in the blood at night (see 
 Animal Parasites) . The non-tropical forms are not understood and 
 have rarely occurred in Europeans who have never been in the tropics ; 
 the rare autopsies have shown no marked renal alteration (Roberts). 
 
 The urine resembles chyle, is weakly acid or neutral in reaction, 
 may present a fatty, creamy surface and contains 2 to 10 per cent, 
 albumin (serum albumin, globulin or albumose), cholesterin, lecithin, 
 fat and stearic and palmitic acids. Its specific gravity is normal. 
 Sugar is seldom found. Microscopic findings are fat globules, leuko- 
 cytes, sometimes red disks and the filaria parasites, usually in the 
 fibrin clots, which sometimes occasion dysuria. Casts are never 
 found. Chyluria is often intermittent ; it occurs especially at night 
 and may be initiated by exercise and changes of posture. In some 
 cases there is considerable free fat in the blood (lipcemia). Its course 
 is chronic, covering months to years. Recovery is the rule, though 
 death may occur from anaemia and marasmus. Treatment is unsatis- 
 factory. Potassium picronitrate gr. % t. i. d. is said to accelerate 
 recovery. Prophylaxis regarding drinking water must be considered ■ 
 in the tropics. 
 
 VI. Lipuria.— Lipuria or adiposuria is symptomatic of (a) lipce- 
 mia, or fat in the blood. The clearest instance is after bone fractures, 
 contusions of the liver or after delivery in which fat enters the blood 
 from the pelvic cellular tissue. Eatty foods, as cod-liver oil ; acute 
 yellow atrophy; diabetes ; diseases of the pancreas and various poison- 
 ings and tumors are possible causes, (b) It is also symptomatic of 
 renal lesions (from fatty epithelial cells, degenerated tumors or fatty 
 pus cells). 
 
 Under the microscope small fat globules are seen which stain black 
 with osmic acid or red with the alcanna test. The fat may be saponi- 
 
OXALURIA. 775 
 
 fied by alkalies, emulsified by albumins or dissolved by alcohol, ether, 
 xylol or chloroform. Lipuria is often simulated by bacteria or phos- 
 phates or by oil from catheters, suppositories or greasy urinals. 
 
 VII. Phosphaturia. — Phosphoric acid is chiefly excreted in com- 
 bination, mostly with sodium and potassium, forming the alkaline 
 phosphates and with calcium and magnesium, forming the earthy 
 phosphates. The sodium exceeds the potassium and the calcium is 
 in excess of the magnesium salts. Phosphoric acid is chiefly derived 
 from the food, but some is derived from decomposition of lecithin, 
 nuclein and protagon. It averages thirty to forty-five grains daily. 
 Amounts over one dram or alteration of the normal relation of the 
 phosphorus to the nitrogen (17 or 20 to 100) are pathological. An 
 excessive deposit which occurs in dyspepsia is not synonymous with 
 an actual increase. Phosphaturia may be observed in neurasthenia, 
 pulmonary tuberculosis, diabetes (largely from the diet), acute yellow 
 atrophy, leukaemia and in anaemia. As much as two drams daily 
 have been reported by Teissier and Ralfe, who termed the condition 
 diabetes phosphaticus. Earthy phosphates may cloud the last part of 
 the urine, which is mistaken by the laity for " spermatorrhoea." The 
 addition of an acid rapidly clears the urine. The diet, recommended 
 for this condition, consists of meat, fish, bread, potatoes and apples. 
 Coffee, nux vomica, arsenic, cod-liver oil and ammonium benzoate 
 (gr. x to xxx t. i. d.) are also given. 
 
 VIII. Lithuria. — No subject has occasioned more clinical absurdi- 
 ties than uric acid. It normally bears to urea a ratio of 1 to 70. 
 Futcher has found a ratio in gout of 1 to 300 or 500 (v. Gout). It 
 is deposited in larger amounts than normal when the urine is very 
 acid and the mineral salts or pigments are decreased. An increased 
 precipitation is far more common than an absolutely increased excre- 
 tion of uric acid. The sediment is clearly seen as red granules re- 
 sembling red pepper. Uric acid combines chiefly with ammonium 
 and sodium and less with potassium, lithium and calcium, which 
 formurates (sedimentum lateritium) of the pink or "brick-dust" color 
 so frequently seen in febrile urine and urine of high specific gravity 
 or of excessive acidity. They are soluble when heated and precipitate 
 on cooling. 
 
 IX. Oxaluria. — Oxalates first detected by Donne (1838) in the 
 normal urine amount to less than 10 mg. daily. Quantities larger 
 than this daily are pathological. Helen Baldwin decided that they 
 are not formed during normal metabolism and are taken in with the 
 food. The actual conditions of oxaluria are in doubt. It has been 
 observed in gout, emphysema, dyspepsias (especially in hyperacidity 
 and increased intestinal putrefaction), neurasthenia, icterus and 
 diabetes. Oxalates occur as octahedral and dumb-bell crystals, which, 
 according to Klemperer, occur in 50 per cent, of renal calculi. Can- 
 tani maintains that oxaluria is associated with nervous depression, 
 irritability, hypochondriasis, lumbar pain, sweats and nervous dys- 
 pepsia, though the consensus of opinion is against any definite clinical 
 
77(3 DISEASES OF TEE KIDNEY. 
 
 picture or diathesis. Klemperer advised a diet of meat, fat and 
 vegetables (except spinach and cabbage) ; he excludes milk and eggs 
 and administers magnesium sulphate oss once daily. Xitromuriatic 
 acid "n\ ij with tincture of mix vomica TT\x is an old and excellent 
 empirical treatment. 
 
 X. Indicanuria. — Potassium indoxylsulphate is present in small 
 amounts in normal urine. It is colorless as a rule, but may be voided 
 blue or violet in alkaline urine. When acid or some oxidizing sub- 
 stance is added it decomposes and frees indigo. The steps in its 
 production are as follows: the action of the pancreatic juice on albu- 
 mins produces indol, which is absorbed, oxidized in the tissues to 
 indoxyl and unites with potassium sulphate to form potassium indoxyl- 
 sulphate. Its absence in some pancreatic diseases has been discussed. 
 It has been rarely found in urinary calculi. It is increased in 
 cachexia? in which albuminous substances are decomposed, in intesti- 
 nal obstruction, particularly of the small bowel and in carcinoma, 
 suppuration and peritonitis. Boiling the urine and adding nitric 
 acid, as in the ring test for albumin, gives a blue ring; adding half 
 a dram [2 c.c.) of chloroform and shaking brings down the violet or 
 blue-stained chloroform. 
 
 XI. Other Anomalies. — Alkaptonuria was discovered by Badecker. 
 It is a crystalline, aromatic body, probably derived from proteid decom- 
 position, whose chief clinical significance is that (a) it reduces 
 Fekling's solution, thereby simulating glycosuria, though it is nega- 
 tive to polarization and fermentation tests: and (b) it imparts to 
 the urine a dark brown color, usually apparent only after it has stood 
 or after caustic potash is added (alkaptonuria by derivation means 
 urine which "absorbs" an ''alkali" freely). Adding a drop of a 
 very dilute solution of ferric chloride causes a dull green color which 
 at once disappears. It is said to be homogentisic or uroleucinic acid. 
 Sometimes it occurs as a familial affection. Garrod collected 47 
 cases, 73 per cent, of which were males ; in 32 congenital cases, 19 
 of them occurred in 7 families. Virchow (1S66) described a case 
 of ochronosis, a discoloration of the cartilages and ligaments. Osier 
 described 2 cases associated with alkaptonuria, making in all 11 
 cases in the literature : it may occur with pigmentation of the face, 
 chronic arthritis and deformation of the lumbar vertebrae. Chronic 
 phenol poisoning is a possible cause. 
 
 Hydrocliinon, from carbolic acid poisoning, may cause a somewhat 
 similar discoloration. 
 
 Ucematoporpliyrinuria, discovered by Hoppe-Seyler. imparts a 
 dark color to the urine. It occurs in pulmonary tuberculosis, rheu- 
 matism, intestinal hemorrhage, sulphonal- and lead-poisoning, etc. 
 Haematoporphyrin resembles haematin. save that it contains no iron. 
 
 Acet anuria is of clinical importance, chiefly in diabetes (q. v.). 
 
 For fuller details the reader may consult works on clinical diag- 
 nosis, such as the recent treatises by Simon, Emerson and others. 
 
PYELITIS. PYELONEPHRITIS. 777 
 
 PYELITIS— PYELONEPHRITIS— SUPPURATIVE NEPHRITIS. 
 
 I. Pyelitis. — Pyelitis and pyelonephritis are inflammations of the 
 pelvis, and pelvis and kidney, respectively. They were first described 
 by Payer. 
 
 Etiology. — Pyelitis is invariably mycotic. The kidneys usually elimi- 
 nate bacteria without injury to their structure, but when the general 
 vitality or the local resistance of the kidneys is lowered inflammation 
 of the pelvis or kidney may result. Various bacteria may be found, 
 including the tubercle bacillus (v. %., Suppurative Nephritis). 
 (a) Foreign bodies, as large, hard or sharp calculi, less often cancer 
 or tubercle, and still more rarely parasites, promote infection, (b) 
 Ascending infections from the lower urinary tract are peculiarly dan- 
 gerous when associated with urinary obstruction, as urethral stric- 
 ture or hypertrophied prostate. When the bacteria which produce 
 cystitis cause decomposition of urea, the ammonia evolved acts as an 
 additional eroding factor. According to Rosving, certain streptococci 
 act in this way, but not the tubercle or colon organisms. Infection 
 usually ascends from cystitis along the ureters, producing ureteritis, 
 then pyelitis and perhaps a pyelonephritis, but it may reach the kid- 
 ney along the lymph vessels, the microbes entering through erosions 
 in the vesical mucosa. James Goodhart has shown that 50 per cent, 
 of cases with obstruction to the flow of urine die of renal suppuration. 
 (c) Infection may be hematogenous, as in typhoid, the exanthemata 
 or intestinal catarrhs of infancy, (d) Less common factors include 
 traumatism, extension by contiguity from neighboring inflammations, 
 as pyelonephritis (pyelonephritis is usually an ascending process, in 
 which the kidney is secondarily involved, and only rarely is it a 
 process descending from the kidney to the pelvis), toxic factors, acrid, 
 irritating diuretics, such as turpentine, and hemorrhagic measles 
 or scurvy ; cold, venous stasis and diabetes are somewhat predisposing 
 factors ; arteriosclerosis induces the form of pyelitis described by 
 Ollivier, attended by hemorrhage and the formation of fibrin coagula. 
 Pyelitis is most prevalent in women. 
 
 Pathology. — Pyelitis may be acute or chronic ; solitary or combined 
 with cystitis ; catarrhal, suppurative or ulcerative ; unilateral or less 
 often bilateral. Acute catarrhal forms present redness, oedema, 
 desquamation, formation of mucopus and minute ecchymoses. Chronic 
 forms show grayish to brown pigmentation and thickening. In any 
 form croupous or diphtheritic inflammation or even gangrene may 
 develop. Urates and triple phosphates may precipitate. Small re- 
 tention cysts may form in the pelvis or ureter ; the small lymph 
 nodes may enlarge and in rare cases the epithelium may hypertrophy, 
 causing cholesteatoma (v. i., -issues). 
 
 Symptoms. — (a) There are no certain symptoms in the rare cases 
 in which a suppurative nephritis descends to the pelvis, (b) In the 
 ascending type early vesical symptoms antedate and often obscure the 
 pyelitis, (c) The symptoms are most clear in primary pyelitis from 
 calculus or from acute hematogenous infection. 
 
778 DISEASES OF THE KIDNEY. 
 
 Pyuria is the chief symptom. The amount of pus is usually pro- 
 portionate to the albumin- (v. Pyuria). Its amount varies, as well as 
 its constancy ; when the ureter is obstructed, pyuria is suspended and 
 when the obstruction is removed the pus escapes in increased amounts. 
 Polyuria and a low specific gravity are usual in chronic cases; the 
 writer has observed a case in which 6 quarts were voided, simulating 
 diabetes insipidus; polyuria results from decreased absorption of 
 water from the medullary portion or from compensatory hypertrophy 
 of the sound kidney. In acute cases the urine is decreased. Other 
 urinary findings. The urine is usually acid but quite often alkaline 
 from coincident or causal cystitis or from bacteria decomposing the 
 urea. It is often cloudy. It is true that large, caudate, club-like 
 epithelial cells, often overlapping each other like shingles, are pres- 
 ent in moderately severe pyelitis, but they may occur, though less fre- 
 quently, in ureteritis and cystitis. When pyelitis extends to the 
 papillae Or higher (pyelonephritis), cylindrical plugs of pus cells, 
 epithelium, but chiefly of cocci, are seen (Fischl). Red cells (calcu- 
 lus), triple phosphate or uric acid crystals, fibrin (croupous or 
 diphtheritic pyelitis) and various bacteria (usually the colon bacillus, 
 perhaps the tubercle bacillus) may occur. Pain over the kidney is 
 usually dull, but in acute cases may suggest stone. There is a desire 
 — probably reflex — to urinate frequently ; this symptom may lead to 
 an erroneous diagnosis of cystitis. Fever and rigors are common, 
 especially in severe calculous, colon bacillus or tuberculous types or 
 those invading the kidney substance. Temperature is sometimes 
 sudden and high ("irritative") and at other times is intermittent 
 from septic absorption. 
 
 Complications. — (a) There may be extension to the renal substance 
 (pyelonephritis) and it may be reduced to a pulpy, inspissated and 
 even calcified mass, (b) Prolonged inflammation may lead to fibrosis 
 of the kidney (Ackermann, Albarran), known as the "ascending 
 contracted kidney." (c) Plugging of the ureter may occasion dis- 
 tention of the pelvis by retained urine (hydronephrosis) or pus (pyo- 
 nephrosis), both of which conditions will be described below, (d) 
 Anuria, described by Morgagni and later by Israel, is occasioned by 
 reflex suppression of the sound kidney or by extensive lesions in both 
 kidneys, (e) Amyloidosis may develop. (/) Intoxication may occur 
 by bacterial toxins and renal inadequacy. The condition resembles 
 uraemia in some respects, but oedema, retinitis and convulsions are 
 absent. Senator described a dyspnoea like that of diabetic coma. 
 Treitz and v. Jaksch believe that intoxication results from absorption 
 of ammonia (ammonicemia) from decomposed urea. (g) Perfora- 
 tion outward causes the paranephritic abscess (v. i.). In some cases 
 an interesting condition called " spinal paraplegia " has been de- 
 scribed, probably resulting from an ascending neuritis. 
 
 Prognosis. — The prognosis is influenced by the basic simple, tuber- 
 culous or calculous infection and by the complications as described. 
 In acute cases the outlook is generally good. Chronic cases without 
 much necrosis may last many years and may even recover. 
 
SUPPURATIVE NEPHRITIS. 779 
 
 Diagnosis. — Much depends on careful analysis of pyuria (q. v.). 
 Cystitis may be confused with as well as combined with pyelitis. 
 Their differentiation is often difficult from examination of the urine 
 alone; the albumin and pus correspond in both and possibly there is 
 more albumin in pyelitis; no absolute reliance can be placed on the 
 reaction, acidity or alkalinity occurring in either condition, though 
 pyelitic urine is more often acid. The tailed, clubbed or shingle-like 
 epithelia are more common in pyelitis, though not pathognomonic. 
 Von Bergmann's method consisted of thorough vesical irrigation and 
 then gentle compression of the suspected kidney to force into the 
 bladder and thence into the catheter, pus or cells; pain over the 
 kidney extending downward is significant; the only certain method is 
 cystoscopy and ureteral catheterization. In nephritis the urine con- 
 tains more albumin than is explained by the pus, though the amount 
 may be slight in interstitial nephritis ; the leukocytes are mononuclear 
 and the presence of casts and cardiovascular changes are usually 
 decisive. 
 
 Treatment. — Prophylaxis involves care in the use of catheters or 
 irritating diuretics, the expectant treatment of gonorrhoea, etc. 
 Water, milk and mineral waters should be used freely to flush out the 
 urinary tract. Pain is relieved by hot applications to the kidney; 
 opium is seldom indicated. For pyuria, phenylis salicylas and hexa- 
 methylenamine aa gr. x p. c. are most efficient. Methylene blue gr. j 
 to ij, t. i. d. may also be given, but digestive disturbances must be 
 watched for. These remedies are superior to lead acetate, santal oil 
 or turpentine. Surgical interference may be necessary when ureteral 
 drainage is incomplete. Nephrotomy is the best operation, nephrec- 
 tomy being seldom indicated. 
 
 II. Suppurative Nephritis. — Its etiology is partly that of pyelitis. 
 The microorganisms encountered are the staphylo-, strepto- and pneu- 
 mococcus, Bacillus coli, gonococcus, proteus, typhoid and tubercle 
 bacilli and actinomyces. (a) The embolic form results from sup- 
 purative processes elsewhere and represents merely one phase of sep- 
 ticopyemia of more pathological than clinical interest. The sup- 
 purative foci are chiefly bilateral and cortical; the glomeruli are 
 filled with microorganisms and, as the foci enlarge, they show as 
 yellowish areas through the cortex; some deposits may also occur in 
 the medulla ; the kidneys are enlarged and lax. Clinically, pyuria, 
 hematuria and cylindruria are seldom seen and a diagnosis can sel- 
 dom be made ; anuria or oliguria may result from multiple glomerular 
 involvement, (b) The ascending type is essentially a cystopyelo- 
 nephritis, which has been already described, and forms the so-called 
 " surgical kidney " ; infection and urinary obstruction are its usual 
 antecedents ; pyuria, polyuria and albuminuria its usual symptoms ; 
 and suppuration in the medullary rays its usual anatomical evidence ; 
 very rarely necrotic renal tissue is evacuated, (c) Suppuration of 
 the kidney may result from its invasion by contiguity from adjacent 
 pus foci, as appendicular, peri-uterine or vertebral foci; much pus 
 
780 DISEASES OF TEE KIDNEY. 
 
 may be voided at once with later gradual cessation of the pyuria. 
 The diagnosis is always uncertain, save when sequestra come away, 
 the prognosis always ominous and the treatment always surgical. 
 
 PERINEPHRIC ABSCESS. 
 
 A distinction is sometimes made between perinephritis, inflamma- 
 tion of the fibrous capsule and paranephritis, inflammation (suppura- 
 tion) of the fatty capsule and surrounding tissue. 
 
 Etiology. — (a) The most common cause is suppurative disease of 
 the kidney, as pyelitis, pyelonephritis, pyonephrosis (v. i.) and tuber- 
 culosis, from which extension occurs by actual rupture or along the 
 blood or lymph vessels. (b) Extension by contiguity may occur from 
 vertebral caries, appendicular, pelvic or pancreatic suppuration, liver 
 abscess, cholecystitis or even from the lung and pleura, (c) It may 
 result from trauma plus infection, (d) The so-called idiopathic cases 
 are probably embolic. Most cases occur in persons between thirty 
 and forty years of age and 70 per cent, occur in males. 
 
 Symptoms. — (a) The onset is acute, with a rigor and sudden fever 
 in the embolic (so-called primary) cases, but it is insidious in the sec- 
 ondary group, (b) Fever of a continuous or remittent type is usual, 
 though absence of fever does not exclude suppuration, (c) Pain and 
 tenderness are experienced over one kidney, somewhat more often 
 over the right than the left. Sometimes, with coincident involvement 
 of the kidney, pain shoots along the ureter to the pubes or thigh. To 
 relieve tension the patient frequently lies on the back with the knee 
 flexed and the thigh rotated outward. Though we are discussing sup- 
 puration about the kidney (paranephritis), pain may arise from 
 simple inflammation of the fibrous capsule (perinephritis) ; this is 
 relieved by simple nephrotomy, (d) Local findings may be marked 
 or absent. In some patients there are lumbar oedema, redness and 
 swelling. The physical signs anteriorly are seldom marked, as sup- 
 puration usually occurs behind the kidney. The surgeon finds at 
 operation a diffuse phlegmon and less often diffuse serous infiltration 
 or circumscribed abscess ; the pus may be odorless ; it may smell of 
 urine when the abscess has arisen from perforation outward of a 
 pyelitic lesion ; a faecal odor results from infection (without perfora- 
 tion) from the bowel or appendicular abscess. Necrotic fat and some- 
 times altered blood are voided, (e) The urine is negative, unless 
 there are (i) a pyelitic origin and (ii) rupture of the abscess into the 
 urinary tract. (/) The chief complication is rupture, which occurs 
 in about a quarter of the cases ; in 15 per cent, it occurs upward 
 (Kiister), into the lung and pleura and in 8 per cent, downward, 
 chiefly into the intestine. Burrowing occurs, according to Gerota, 
 along the ureter toward the pelvis, when the abscess is anterior to the 
 renal fascia and toward the lumbar region or iliac fossa when the 
 abscess is behind the fascia. Amyloidosis may result from neglected 
 or obscure cases of paranephritis. Serous pleurisy, subcutaneous 
 
HYDKONEPHROSIS. 781 
 
 emphysema, compression of the portal vein, icterus and septicaemia 
 may result. 
 
 The course averages two to four weeks, perhaps longer. 
 
 Diagnosis. — Diagnosis depends on (a) local pain, (b) oedema or 
 swelling, (c) fever and (d) exploratory aspiration. Lumbago causes 
 no serious confusion. Other affections causing occasional errors are 
 psoas abscess, appendicular abscess behind the kidney or rupture 
 downward of empyema, though these are more often etiological factors 
 than separate questions for differentiation. 
 
 Treatment. — The only treatment is incision and drainage. In the 
 cases of Schede and Schmieden complete recovery occurred in 73 
 per cent. 
 
 HYDRONEPHROSIS. 
 
 Definition. — Hydronephrosis is a sac-like dilatation of the pelvis 
 and calices, with accumulation there of a watery fluid ; obstruction to 
 the urinary flow is its cause and atrophy of the renal substance is its 
 result. It was first described by Tulp (1674) and named by Rayer. 
 
 Etiology and Pathology. — There are two forms, the congenital and 
 acquired, (a) The congenital form is most often due to anomalies 
 in the ureters ; these include atresia, stenosis, valve formations, twists, 
 compression by peritonitic bands, vestiges of Miiller's or Gartner's 
 ducts, abnormal bloodvessels, imperfect insertion into the bladder or 
 insertion too high into the pelvis, in the lower part of which the 
 urine accumulates. Of the latter form the author has seen two cases 
 in young men and J. B. Murphy has observed four others. When 
 there are double ureters, one may end blindly in the bladder wall and 
 dilating may compress its fellow of the same side. In some few cases 
 no obstruction is apparent. Hydronephrosis may occasion dystocia 
 and is rather commonly associated with other congenital malforma- 
 tions; 65 per cent, of congenital cases are bilateral (Roberts), (b) 
 The acquired form may be bilateral or unilateral, depending on its 
 cause. This may, in rare cases, be in the kidney itself (Rayer, Cho- 
 part, Christian Fenger), producing partial hydronephrosis. Enu- 
 meration of all possible causes of obstruction is unnecessary; one or 
 both ureters may be compressed by malignant pelvic growths, as uter- 
 ine cancer, and this in part explains the large proportion (67 per 
 cent., Newmann) of bilateral hydronephrosis which occurs in autopsy 
 figures; in clinical cases 62 per cent, are unilateral (Roberts). 
 Ureteral obstruction may arise from calculus, tumors, tuberculous 
 detritus, ulceration, cicatrization, floating kidney or rarely clots from 
 trauma or parasites. Large sacs are usually caused by affections of 
 the ureter. Other possible types are obstruction from urethral stric- 
 ture, enlarged prostate or more rarely phimosis and atresia of the 
 hymen. 
 
 As Cohnheim contended, a slow development with intermissions 
 is more potent in the production of large sacs than is acute obstruc- 
 tion, for slow compression permits more continued renal secretion, 
 
782 DISEASES OF TEE KIDNEY. 
 
 The results of urinary accumulation are (a) distention of the 
 pelvis, (b) flattening of the papillae, (c) atrophy of the renal tissue, 
 though some normal tissue usually remains and (d) the formation 
 of a fibrous sac. 
 
 Symptoms. — The chief finding is a fluctuating renal tumor, (a) It 
 is located at first in the renal region but later assumes an abdominal 
 importance, (b) Its size varies, being largest when the ureter is 
 obstructed and in slowly developing cases becoming as large as the 
 head and even simulating ascites; Peter Frank mentions a case in 
 which it contained 60 quarts, (c) It may in the same case vary 
 from time to time ; this is known as intermittent hydronephrosis, 
 and its chief causes are valve formation, stenosis or abnormal inser- 
 tion of the ureter into the renal pelvis. The amount of urine is (i) 
 normal from hypertrophy of the sound kidney, (ii) decreased in bi- 
 lateral disease or from increased pressure in the diseased kidney, 
 reflexly lessening the secretion from the sound kidney (Israel) ; or 
 (iii) when the sac evacuates, suddenly very abundant and then the 
 tumor disappears ; this point is often volunteered in the patient's 
 history, (d) Its form, on bimanual palpation, is irregularly oval; 
 in moderately severe cases the kidney itself may be palpated, as well 
 as its irregularly protuberant calices. (e) Sometimes the dilated 
 ureter can also be felt. (/) The ballottement renal is a repercussion 
 shock obtained by tapping the tumor with one hand while the other 
 is spread broadly over it. (g) Small tumors are covered by the colon, 
 which imparts a modified tympanitic note on percussion. Distention 
 of the colon by air or gas brings out tympany over the tumor. Very 
 large sacs push the colon aside. The ren saccatus may develop in a 
 floating or horseshoe kidney, (h) Its contents are albumin, paral- 
 bumin, mucus, urea and other urinary constituents, which are usu- 
 ally absorbed only after a long time. Diagnostic puncture is not 
 always safe, (i) Sometimes it is tender from tension of the capsule ; 
 pain may arise from torsion of the ureter. The author has seen 
 hematuria and renal colic occur in hydronephrosis due to an inser- 
 tion of the ureter high up in the renal pelvis. (_/) Complications 
 include rupture, infection (pyonephrosis) or anuria and uraemia if 
 both kidneys are implicated. 
 
 Diagnosis. — Diagnosis is quite easy (a) by recognizing the cause, 
 if possible, as stone or tumor; (b) by careful bimanual palpation and 
 (c) by cystoscopic proof that urine does not flow from one ureter. 
 Differentiation concerns especially — 
 
 1. The Exclusion of. Other Kenal Tumors. — (a) Pyone- 
 phrosis, a dilatation of the pelvis and calices bj purulent fluid (in- 
 stead of water-like fluid as in hydronephrosis), is caused by obstruc- 
 tion plus infection, especially from pyelitis with obstruction. It 
 occasions the same kind of tumor as to location and physical exami- 
 nation, but presents some other features ; it is generally smaller and 
 more irregular than hydronephrosis ; its walls are thicker and more 
 tender, for infection is superimposed on obstruction; there is more 
 
HYDRONEPHROSIS. 783 
 
 renal necrosis ; systemic septic symptoms prevail ; its contents are pus, 
 pulpy detritus, triple phosphates, bacteria, disorganized blood, fat, 
 cholesterin, foetid ammonium compounds and even gas. Puncture is 
 always dangerous, in doubtful cases more so than operation. Its 
 prognosis also is clearly more unfavorable, (b) Cystic kidneys, (c) 
 malignant renal growths and (d) echinococcus will receive consider- 
 ation below. 
 
 2. Other Abdominal Tumors. — (a) Ovarian tumor is connected 
 with the uterus, grows upward and may be associated with changes in 
 the mammary glands and genital functions. Ovarian tumor with a 
 long pedicle may deceive, but it pushes the caecum backward. The 
 dulness is greater, though in large renal sacs the colon is pushed 
 aside. The slight respiratory excursion and ballottement in hydro- 
 nephrosis are of quite secondary diagnostic value. Confusion is 
 likely when hydronephrosis develops in a floating kidney. Explora- 
 tory puncture is an unsafe procedure; when made, the fluid from 
 ovarian cysts shows a high specific gravity (1,020) ; much paralbu- 
 min is present, also cylindrical epithelium, colloid or chocolate- 
 colored material and of course no urea. Under narcosis the entire 
 hand may be introduced into the rectum to determine the point of 
 origin of the tumor, though this severe method is seldom necessary. 
 (b) Ascites and pregnancy are readily differentiated, (c) Encapsu- 
 lated peritonitis may be harder to differentiate, but the urinary con- 
 ditions and sac-like distention are usually decisive. (d) Splenic and 
 hepatic tumors are more flat on percussion, encroach more upon the 
 lungs and are above or anterior to the gas-distended colon. In a renal 
 growth a furrow and tympanitic loop of bowel may lie between it and 
 the liver or spleen. 
 
 Prognosis. — The prognosis is generally unfavorable, as the cause is 
 often inaccessible or the process well advanced. The prognosis is bet- 
 ter in cases of renal stone than in cancer or in the generally inviable 
 congenital forms. The course is often intermittent and protracted. 
 
 Treatment. — Treatment is surgical. Nephrotomy is indicated; 
 nephrectomy is considered poor surgery since Ayrer and others have 
 shown that some sound renal tissue nearly always remains. For 
 the same reason ligature of the renal vessels should be avoided (Nico- 
 lai). The mortality resulting from nephrectomy for hydronephrosis 
 is 5.7 per cent., for pyonephrosis 15.3 per cent. (Schmieden) ; Ros- 
 ving reports per cent, and 19 per cent, mortality in his cases of 
 nephrotomy for hydro- and pyonephrosis, respectively ; 34 per cent, of 
 his cases recovered completely, 27 per cent, recovered though with 
 fistula, and secondary operation was necessary in 20 per cent. Fenger 
 advised conservative operations, especially in partial hydronephrosis. 
 Reference should be made to surgical treatises for details of opera- 
 tions on the ureter, excision of the pelvic sac, etc. Caspar and 
 Kiimmel maintain that the phloridzin and cryoscopic tests are of 
 great value in determining which side is involved, by testing the 
 urine obtained from each ureter by ureteral catheterization; Israel 
 
784 DISEASES OF THE KIDNEY. 
 
 has a very different opinion, as has Rosving, who prefers to cut down 
 on both kidneys before extirpating either one. 
 
 RENAL CALCULUS (NEPHROLITHIASIS). 
 
 Etiology. — Stone in the kidney or its pelvis results from deposition 
 therein of the solid constituents of the urine. It is probable that stone 
 formation is due to bacteria. The kidneys usually eliminate bacteria 
 without changes to themselves, but sometimes bacteria, especially the 
 colon and typhoid bacilli, form the nucleus of stones. Ebstein, 
 Moritz, Mendelsohn and others have shown that an albuminous ce- 
 ment substance is found even in very slight urinary deposits or renal 
 sand. Renal stone has been known since the time of Hippocrates. 
 
 The predisposing factors are obscure, (a) A sedentary life and 
 over-indulgence in food and alcohol are apparently predisposing fac- 
 tors. Galen noted the coincidence of gout and renal calculus. Stones 
 are said to be uncommon in very active persons, (b) Most cases 
 occur between thirty and sixty years of age; in the extremes of life 
 vesical calculus is more common, (c) Seventy-five per cent, of cases 
 are in males. Stones are passed more easily and therefore are pos- 
 sibly less often detected in women, (d) Renal calculus occurs most 
 frequently in Asia and there are certain foci, more of them in Eu- 
 rope than in America, where it is particularly frequent, as central 
 Russia, Holland, Italy, Altenberg, Munich, Hungary, Scotland, west 
 Trance and southeast England. (e) Other possible factors are 
 heredity, which is especially a factor in formation of uric acid and 
 cystin calculi ; paraplegia (Miiller reported 10 cases of spinal frac- 
 ture with calculus formation) and foreign bodies in the renal pelvis, 
 as blood clots from trauma and parasites, as the distoma. The older 
 classification of primary and secondary calculus has been abandoned. 
 
 Chemistry and Pathology. — According to their size, these urinary 
 deposits are spoken of as sand, gravel or stones; sand and gravel 
 nearly always consist of uric acid or its salts. They may range from 
 the size of a pea to that of a hazel-nut. The heaviest recorded stone 
 weighed thirty-six ounces. Though most often round, oval or cylin- 
 drical, they may be dendritic or coral-shaped. Sometimes they are 
 facetted. A number of them may exist, perhaps 15 or 20; in rare 
 cases 1,000 to 2,000 may be found, (a) The stone caused by uric 
 acid and urates (described first by Scheele, 1776) constitutes 66 per 
 cent, of renal stones. It is hard, smooth or slightly uneven, sometimes 
 facetted or lamellated and consists of uric acid, ammonium and 
 sodium urates, urinary pigment and a small amount of xanthin. Its 
 broken surface is amorphous. Its color is yellow, red or brown, de- 
 pending on the amount of urinary pigment. It may contain some 
 oxalates and phosphates. Under the microscope needles are seen. 
 Uratic calculi turn carmine red on adding nitric acid and ammonia. 
 They dissolve in caustic potash. They are deposited in acid urine, 
 but the exact reason is not known ; the normal sodium urate may lose 
 
RENAL CALCULUS. 785 
 
 part or all of its sodium by action of the alkaline phosphates, so that 
 free uric acid and the less soluble bi- and quadriurates are formed; 
 Roberts and Klemperer consider a decrease of the urinary pigments 
 of great importance; disturbed metabolism or indigestion may oc- 
 casion uratic deposits, though little is known of the " uric diathesis." 
 (b) Oxalate stones (Fouccoy and Vauquelin) are next in frequency; 
 Klemperer holds that oxalates occur in even 50 per cent, of cases. 
 They are very hard, rough, warty or prickly (the mulberry calculus) ; 
 for this reason they cause more pain and hematuria than the uratic 
 stones and are more often removed surgically. They are usually 
 single and gray, but may be dark-colored from the bleeding they in- 
 duce. Lamellation is never observed. Uric acid, calcium carbonate 
 or xanthin may also enter into their composition. No effervescence 
 occurs on adding acetic acid unless carbonates are also present. They 
 dissolve in mineral acids and oxalate of lime crystals gradually pre- 
 cipitate on the addition of ammonia. Oxalates precipitate from acid 
 urine, (c) Phosphatic calculi (Bergmann) are formed in alkaline 
 or neutral urine. They are usually calcium salts, but if the urine is 
 ammoniacal triple phosphates may be formed. Admixture of bac- 
 teria, calcium carbonate and xanthin may be noted; phosphatic 
 stones are small, soft and clay-colored. They are infrequent and 
 usually only form a coating to calculi of other composition, (d) 
 Other forms are rare. Calculi of (i) calcium carbonate and more 
 rarely ammonium or magnesium carbonate may occur in the aged, 
 though rarely in man compared with their frequency in cattle ; they 
 are white and dissolve with effervescence in mineral acids, (ii) 
 Cystin calculi ( Wollaston) are smooth, yellow and waxy ; they never 
 exceed the size of a pea, are soluble in acids and alkalies and deposit 
 hexagonal crystals when dissolved in acetic acid and ammonia. Only 
 60 cases are reported (Riegler, 1904). (iii) Xanthin stones (Mar- 
 cet) occur almost exclusively in children; only 10 cases are recorded; 
 they are smooth, yellow or brown, dissolve in nitric acid and on 
 evaporation leave a residue which turns red on adding caustic potash, 
 (iv) Only 3 cases of indigo stones are on record, (v) The fatty 
 stones (urostealiths) described by Heller probably do not originate in 
 the kidneys, but result from fatty substances deposited in the bladder ; 
 they are 85 per cent, fat and are soft, rubber-like and combustible. 
 
 Infarcts may be considered here, (a) Uric acid infarcts occur in 
 gouty subjects and in 50 per cent, of the new-born, chiefly in the 
 medullary collecting tubules ; they are most common in the still-born 
 or in weakly infants and are thought to result from destruction of the 
 tissues or cells (nuclein). (b) Lime infarcts are chiefly phosphates 
 and carbonates, sometimes oxalates ; they are deposited principally in 
 the pyramids and in the membrana propria when the renal cells are 
 destroyed; they occur in the aged and in poisoning by mercury, 
 arsenic, phosphorus or bismuth, (c) Pigmentary infarcts of hsema- 
 toidin, bilirubin, haemoglobin or methaemoglobin are uncommon. 
 
 Symptoms. — Stones may be first discovered accidentally at autopsy 
 
 50 
 
786 DISEASES OF THE KIDNEY. 
 
 or, very exceptionally, may pass without symptoms. Gravel or renal 
 sand is more often latent than is stone. 
 
 1. Pain. — Pain is the most common symptom. It is of two kinds : 
 (a) The dull pain in the loin, often associated with local tenderness 
 over the kidney; Penwick describes localized pain without any uri- 
 nary changes, indicating that the stone lies in the medullary sub- 
 stance. Pain may be felt over the opposite kidney, (b) The renal 
 colic, which arises from incarceration of the stone as it attempts to 
 leave the pelvis, where it nearly always originates; it is often pre- 
 ceded by pain in the loin and may be initiated by exercise, as riding, 
 or by indigestion ; Eichhorst mentions a surgeon who had renal colic 
 every time he drank white wine. The pain in renal colic begins over 
 the kidney and radiates down the ureter to the testis, labia, bladder or 
 urethra; the testicle is retracted (in the descent of the testis, its en- 
 velopes receive a twig from the first lumbar nerve). It may rarely 
 radiate to the chest, heart, shoulder, epigastrium or to the opposite 
 side. During the colic, the kidney is sensitive; when it is not so, 
 Israel hesitates to diagnosticate stone. The pain is cutting and very 
 severe; it often occasions reflex nausea and vomiting, sometimes chills, 
 sweats and fever or in children convulsions and rarely collapse or 
 even death in most exceptional cases. Vesical tenesmus is frequent. 
 If the stone passes, the pain is greatest as it enters the bladder. Con- 
 stipation of a spastic order is much more frequent than diarrhoea or 
 involuntary movements. Some observers hold that renal colic occurs 
 oftenest at night. It lasts, with intermissions, a few hours, rarely 
 days ; movement may excite recurrence. The patient lies on his back 
 with the leg drawn up and the abdominal wall rigid. After the 
 attack there may be dull pain (v. s.), which may be caused by large, 
 numerous or sharp stones. Eichhorst records a case in which the sole 
 symptom was the patient's attitude; he leaned far forward and de- 
 pressed one shoulder to avoid the pain induced by the erect attitude. 
 
 2. Urine. — The urine is almost invariably altered, (a) Hema- 
 turia occurs independently of pain and colic, as well as after them. 
 Absence of hematuria after a renal colic speaks strongly against a 
 diagnosis of stone (Israel). It is often macroscopic and red disks 
 are found with the microscope, except in the rare cases when stone is 
 imbedded in the renal tissue or there is permanent occlusion of the 
 ureter. At the time of the colic the scanty, bloody urine is frequently 
 voided with considerable tenesmus. In exceptional cases early pro- 
 fuse hematuria may result from vascular erosion. Musser found 
 hyaline casts in nearly every case, (b) Anuria (suppression of 
 urine) is not common. It may occur (i) with stone in one ureter and 
 disease or atrophy of the other kidney, (ii) with bilateral calculi 
 (Albarran), (iii) with stone in one ureter and reflex suppression 
 (Morgagni) of the other sound kidney through the splanchnic nerve 
 or (iv) by urethral stoppage by a stone. Legeau (1891) collected 30 
 autopsied cases of calculous anuria; there was stone in one kidney 
 and the opposite kidney (a) contained a calculus in 14 cases, (/?) 
 
RENAL CALCULUS. 787 
 
 was hypoplastic in 3, (y) sclerotic in 6, (8) its ureter was stenosed in 
 6 and (e) in one case the opposite kidney was absolutely normal. 
 The resulting symptoms resemble those of uraemia. However, in 41 
 cases collected by Herter convulsions were present in but 12 per 
 cent., headache in 14 per cent, and vomiting in 29 per cent. Con- 
 sciousness is usually preserved, the pupils are usually narrowed and 
 the temperature is low. Roberts speaks of this condition as " latent 
 uraemia"; 11 cases of anuria persisted over four days, 18 cases seven 
 to fourteen days and seven over fourteen days. Russel records re- 
 covery after twenty-eight days of anuria. With its relief large quan- 
 tities of urine are voided, (c) Pyuria results in protracted cases 
 from pyelitis, which is usually secondary to the calculus ; infrequently 
 a renal intermittent fever is observed, resembling the hepatic inter- 
 mittent fever of gall-stones. Pyelitis may be catarrhal, suppurative, 
 ulcerative or perforative, (d) Crystals of uric acid and oxalates are 
 considered especially important in the diagnosis by some writers, as 
 Leube; Ulzmann regarded the pointed uric crystals as particularly 
 suggestive of renal calculus, (e) Stones in the urine determine the 
 diagnosis, though not frequently found. 
 
 3. The X-Rays. — Oxalate stones throw a dark shadow in every 
 instance ; uric acid stones seldom are visible. Opinions differ regard- 
 ing the value of the x-rays. The difference may be wholly technical, 
 as Leonard reports the unusual figures of but 3 per cent, of errors; 
 he found calculi in the ureter twice as often as in the renal pelvis. 
 Kummel insists that 90 per cent, of stones cast a shadow. 
 
 4. Physical Findings. — The physical findings are generally less 
 important than the urinary findings and the colic. Local tenderness 
 has been mentioned (v. s.. Pain). Enlargement of the kidney 
 (hydro- or pyonephrosis) is not common. Palpation of the stone in 
 the ureter is rarely possible, either from without or by the rectum or 
 vagina ; once the writer felt a calculus at McBurney's point. Stones 
 have rarely been felt to crepitate in the renal pelvis (Piorry). 
 Cystoscopic examination and catheterization of the ureters are meth- 
 ods which can be employed only by the most expert and have some 
 disadvantages. M. L. Harris' segregator may determine which kidney 
 is affected. 
 
 Complications. — Ulcerative pyelitis may lead to perforation and 
 paranephric abscess. Pyelonephritis may develop. Hydronephrosis 
 results from mechanical occlusion of the ureter and pyonephrosis from 
 obstruction with infection. Injury to one kidney may be compen- 
 sated by hypertrophy of its fellow. Amyloid degeneration, renal 
 tuberculosis or even cancer may develop. The ureter may rupture 
 from ulceration or tension. Pregnant women may abort and Troja 
 instances a case in which 14 abortions occurred after 14 attacks of 
 colic. 
 
 Diagnosis. — The diagnosis is based on (a) the association of the 
 pain and colic, (&) hsematuria, (c) pyelitic pyuria, (d) x-ray find- 
 ings and (e) less often, the anuria and swelling of the kidney. If the 
 
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790 DISEASES OF THE KIDNEY. 
 
 large, it may fall forward. It is tender and usually firm, though its 
 degeneration may occasion slight fluctuation. The form of the kidney 
 is usually preserved, though nodules may he palpated. It usually 
 attains a large size (v. s.), compressing and dislocating the liver and 
 spleen upward and crowding the abdominal viscera. Fiirbringer 
 reports a case in which the heart was pushed up to the clavicle. On 
 tapping, a repercussion wave is sometimes noted (ballottement renal). 
 Percussion gives a dull note, except so far as the intestines lie over it, 
 when mixed flatness and tympany are elicited. The colon overlies the 
 kidney, running from left to right, from above downward ; on the left 
 side this relation is more clearly distinguished; on inflation of the 
 colon with air or gas its tympanitic note in some degree obliterates 
 the renal dulness; in a recent study by Kofmann, this condition was 
 found in less than 50 per cent, of large renal tumors; in tumors on 
 the right side the colon is often dislocated laterally or even downward. 
 There is but little if any respiratory excursion. In rare instances 
 the tumor may pulsate and produce by pressure on the aorta a systolic 
 murmur, which, as in Richard Blight's case, may simulate aneurysm. 
 If the tumor grows into the ureter hydronephrosis may augment 
 the swelling. 
 
 2. Paix. — Pain is an early and frequent symptom, due to pressure 
 exerted on the lumbar plexus. For this reason also there may be 
 slight sensory disturbance in the legs. Pain is usually dull and only 
 rarely is it lancinating or colic-like, due to passage of clots or bits 
 of tumor (r. i.). 
 
 3. Hematuria. — Haernaturia is an early symptom. According to 
 Guillet it occurs in 50 per cent, and is the first symptom in 25 per 
 cent, of cases ; Israel holds that it occurs in 92 per cent, and is the first 
 manifestation in 70 per cent. It is less frequent in children (16 
 per cent.) than in adults. Sometimes worm-like clots are pa-ssed, with 
 great colic ; they sometimes measure one-half to one inch ; clots in a 
 clear urine are almost pathognomonic' (Israel). The cystoscope and 
 ureteral catheterization prove that the hematuria is unilateral. The 
 hemorrhage usually originates in the diseased kidney but may come 
 from the opposite hypersemic kidney. In other respects the urine is 
 generally normal. It is usually held that albuminuria corresponds 
 to the amount of blood, but Albarran asserts there is more albumin 
 than the blood accounts for. Very rarely bits of cancer tissue pass. 
 The urea is increased as in all cancers. Pyuria is no part of renal 
 cancer. 
 
 4. Cachexia. — Cachexia develops in most cases. 
 
 Complications. — Compression symptoms include paraplegia dolor- 
 osa, constipation, intestinal obstruction, oedema from compression of 
 the iliac veins and ascites ; varicocele, first noted by Guyon, is said to 
 seldom occur in other renal tumors and is due to late compression of 
 the spermatic vein by the tumor or contiguous lymph nodes. Meta- 
 stases, enlarged glands, rarely growth into the lumbar muscles or 
 skin and perforation into the peritoneum or intestine with fatal 
 
TVMOHS OF T&E KlDttElS. 791 
 
 hemorrhage, uraemia, fever from cachexia or terminal infection may 
 be observed. According to Israel, tumor of the renal pelvis causes 
 greater haematuria and more hydronephrosis (therefore greater varia- 
 tions in the size of the tumor) ; it sometimes grows down the ureter 
 and is seen with the cystoscope to project into the bladder ; particles 
 of tumor tissue and cells are more often obtained. Albarran and 
 Imbert collected 65 cases of tumors in the pelvis and ureter; 27 were 
 ureteral. Savory and Nash collected 60 cases of painful villous tu- 
 mors in the pelvis. 
 
 Course and Prognosis. — Death is invariable without operation; it 
 usually results from cachexia, in two years in adults and in eight 
 months in children (Rohrer and Roberts). Guillet states that 6 
 cases have lived longer than ten years and 1 lived seventeen years. 
 
 Diagnosis. — The following are important: (a) renal tumor, (b) 
 pain, (c) haematuria and (d) cachexia. Imbert speaks of the com- 
 plete type (tumor and haematuria), the haematuric type (without 
 tumor, 6 per cent.) and the tumor type (without haematuria, 23 
 per cent. ) . 
 
 Differentiation. — Differentiation is necessary, from (a) liver 
 tumor ', which encroaches much more upon the diaphragm and is 
 characterized by its respiratory excursion, by the location of the 
 tumor within the edge of the liver and by such complications as 
 icterus and ascites. The colon lies below the liver and there are no 
 urinary findings. Bimanual palpation clearly differentiates uncom- 
 plicated cases. Between a kidney tumor and the liver a furrow and 
 loop of resonant intestine are frequently found. (5) A splenic tumor 
 maintains the form of the spleen, lies above the colon (whose dis- 
 tention does not modify the splenic dulness), moves on inspiration, 
 shows the characteristic notches and seldom causes confusion except 
 when it so rotates that only its convexity can be felt, (c) An ovarian 
 tumor projects upward from the pelvis, with which its connection can 
 be demonstrated, save when it has a long pedicle. It is more central 
 and sustains no characteristic relation with the colon, (d) Retro- 
 peritoneal growths are much more difficult to differentiate, especially 
 enlarged lymph glands and lymphosarcoma. They are generally more 
 central and less movable. Of perirenal retroperitoneal lipoma 50 
 cases are reported, (e) Other renal conditions must be differentiated, 
 (i) Cystic degeneration (v. i.) is usually bilateral and runs a most 
 chronic course, (ii) Sarcoma cannot be differentiated, (iii) Hydro- 
 or pyonephrosis (q. v.), in which the tumor varies exceedingly and 
 has characteristic urinary changes. (iv) Tuberculosis is distin- 
 guished by hectic fever, tuberculosis elsewhere, pyuria and finding of 
 the tubercle bacilli in the urine. 
 
 II. Sarcoma. — Sixty-six per cent, occur under ten years of age; 
 Walker in 145 cases found that most cases occurred in the first two 
 years of life. Albarran and Imbert state that sarcoma constitutes 
 20 per cent, of renal growths. It is slightly more common in girls 
 than in boys and in the left than in the right kidney. Cohnheim's 
 
792 DISEASES OF TEE KIDNEY. 
 
 theory of embryonal inclusion is supported by the occasional presence 
 of " cartilage, bone and striated and unstriated muscle. Sarcoma is of 
 the round, spindle or melanoid cell type, may contain fatty, vascular 
 and even carcinomatous tissue and may weigh 6,000 gm. Secondary 
 sarcomata may develop by metastasis from other organs or by invasion 
 by contiguity. 
 
 Its symptoms are essentially those of carcinoma, from which an 
 intravitam diagnosis is rarely possible, except when sarcomatous 
 tissue is passed in the urine or excised at operation. Hematuria and 
 cachexia are infrequent; age and glandular involvement are of no 
 diagnostic value. A remarkable overgrowth of the pubic and axillary 
 hair and pigmentation of the skin may be observed. Operated cases 
 live on an average sixteen months and non-operated ones half as long 
 (G. Walker), but death is frequently a direct result of the operation. 
 
 III. Hypernephroma, — This " struma lipomatodes aberrans renis " 
 of Grawitz develops from aberrant (included) particles of adrenal 
 tissue. Small tumors are not a rare autopsy finding. They constitute 
 20 per cent, of renal tumors and consist of a scanty but vascular 
 connective tissue stroma, containing fatty cells like those of the 
 adrenal bodies. Hemorrhage, cystic degeneration, a tendency to 
 invade the veins and a large proportion of glycogen and perhaps 
 cholesterin or lecithin are considered characteristic. Fatty cells may 
 be found in the urine. Hematuria occurs in 80 per cent, of cases. 
 Metastases may develop. Bone metastasis is the first symptom in 16 
 per cent, but may develop as a late symptom only. Fever is noted 
 in 57 per cent. ; it occurs in but 1 to 2 per cent, of other tumors of 
 the kidney (Israel). 
 
 IV. Other Tumors. — Fibroma, lipoma, myxoma, angioma and 
 rhabdomyoma are of little importance. Hematuria occurred in only 
 one case, an angioma. Thirty-three cases of tumor of the capsule are 
 on record. 
 
 Treatment of Renal Tumors. — This is symptomatic and surgical. 
 The former concerns the pain, by anodynes, chiefly opiates. Surgical 
 treatment alone is of value. The mortality resulting from total 
 nephrectomy in Kuster's figures was 24 per cent. Schmieden col- 
 lected 329 cases; 33 per cent, died from the operation; the mor- 
 tality in the first decade of renal surgery (dating from Gustav Simon, 
 1869) was 64, in the next 43, in the third 22 per cent. The mor- 
 tality of nephrectomy for all causes is at present 17 per cent, and 
 for tumor 22 per cent, (in children, 28 per cent.). Thirty-three 
 recoveries after radical operation are on record, one patient being 
 alive after eighteen years. Israel in 43 cases reported a mortality of 
 18.6 per cent., of which two-thirds died of heart paralysis; 19 per 
 cent, enjoyed permanent recovery after three and a half to fourteen 
 years. Schede in 18 operations obtained 22 per cent, permanent re- 
 coveries after four to nine years. Recurrence after two years is very 
 exceptional. The extraperitoneal operation is three times as safe as 
 the transperitoneal. Operations are usually performed too late; ad- 
 
CYSTIC DEGENERATION. 793 
 
 vanced cachexia, very large tumors, metastases and growth into the 
 cava are contra-indications. The other kidney must be in good 
 condition. 
 
 CYSTIC DEGENERATION. 
 
 Various renal cysts are observed, (a) Those which occur in 
 chronic interstitial nephritis are the most frequent ; they result from 
 snaring off, by fibrous tissue, of the tubules and glomeruli, (b) 
 Parasitic cysts (v. i.) are next in frequency, (c) But two dermoid 
 cysts are on record, (d) Cysts of the fatty capsule, retroperitoneal 
 cysts and degenerated lymph glands are very rare, (e) Complete 
 cystic degeneration (hydrops renum cysticus, degeneratio renum poly- 
 cystica) was first separated by Bayer from the above mentioned va- 
 rieties and constitutes cystic degeneration, as it is generally understood. 
 
 Etiology. — Over 50 per cent, are observed in men between forty 
 and fifty years of age. Sieber (1906) collected from the literature 
 32 cases of cystic kidneys in persons under and 211 in those over 
 twenty years of age. Cystic kidneys are observed in later foetal life, 
 at birth and in the adult. It is often difficult to determine whether 
 they are acquired or congenital, though the latter conception is most 
 favored; the cysts are thought to remain latent until middle life. 
 
 Pathogenesis. — Three main theories obtain; (a) that they are re- 
 tention cysts, (&) new formations, i. e., neoplastic (cystadenomata), 
 the most acceptable hypothesis, and (c) malformations. 
 
 Pathology. — Congenital cases are usually bilateral; Lejars found 
 one unilateral case in 67 and Luzzatto 41 in 226 cases. The kidneys 
 may contain innumerable small cysts, when the shape of the kidney 
 is preserved, or it contains larger cysts, when its contour is more 
 irregular. According to Englander, only 23 unilocular cysts are on 
 record. The size of the kidneys may be that of a child's head ; they 
 may weigh twenty-one pounds. On section the kidney is honey- 
 combed. The cyst walls consist of fibrous tissue. The cysts usually 
 contain thin, yellow, transparent fluid, less often milky, gelatinous or 
 brownish contents (altered blood). They are uni- or multilocular, 
 are lined with cells like the urinary tubules or with flat polygonal 
 cells and contain albumin, oxalate of lime, leucin-like crystals, red 
 disks, epithelial detritus, fat granules and rarely urea or uric acid. 
 Between the cysts, vestiges of renal tubules or glomeruli are found, 
 which here and there may be vicariously hypertrophied. Cysts may 
 occur in the pelvis, ureter and liver (v. i.). In congenital cases other 
 deformities are sometimes found, particularly in the genito-urinary 
 tract, brain and fingers. 
 
 Symptoms. — In congenital forms the cystic kidneys may obstruct 
 delivery; if the infant is born alive death from asphyxia is usual, 
 for the diaphragm is crowded upward. In adult forms 90 per cent, 
 of cases come to autopsy undiagnosticated or with the diagnosis of 
 some other renal disease, as nephritis. The symptoms may be classi- 
 fied as follows : (a) Renal cysts are detected clinically in 29 per cent. 
 
794 DISEASES OF THE KlDttET. 
 
 of cases only (Luzzatto) or in 12.4 per cent. (Sieber). Their general 
 characteristics are those of solid kidney tumors, but they are almost 
 always bilateral {v. s.). Fluctuation seldom occurs. In very few 
 cases the individual cysts can be palpated; in two cases which the 
 author demonstrated they could be clearly palpated. Echinococcus 
 cysts, hydro- and pyonephrosis, sarcoma and cancer of the kidney are 
 only distinguished by their unilateral occurrence ; if bilateral, differ- 
 entiation is almost impossible, (b) The urine is variable; it may be 
 normal, increased or decreased. The urinary findings are typically 
 like those of interstitial nephritis, i. e., the urine is abundant, with 
 few solids, low specific gravity and traces of albumin. Red disks 
 are found in 20 per cent., sometimes in great numbers. In two of the 
 author's cases many red cells appeared each time the kidneys were 
 palpated. Leucin-like bodies may appear in the urine or in explora- 
 tory punctures. Beckmann first described these small colloid bodies 
 ("rosettes") with structureless centres and one to five concentric 
 rings and clearly radiating striations. (c) Cardiovascular changes 
 (left .ventricular hypertrophy and sclerosed arteries) are common 
 and heighten the resemblance to contracted kidney. The changes 
 were well marked in the three cases which the author was able to 
 diagnosticate, (d) Urcemia is the common cause of death. The 
 clinical course is very chronic and is broken by attacks of " periodic 
 uraemia." The digestive disorders of uraemia are very frequent (see 
 page 750). Lejars observed a case living fifteen years and Senator 
 one living twenty years after the cysts were found. 
 
 Diagnosis. — The diagnosis can be made when there are (a) bilateral 
 (perhaps palpably cystic) renal swellings; (b) the cardiovascular 
 and urinary findings of contracted kidney, with haematuria and col- 
 loid "rosettes," obtained in the urine or by puncture; (c) uraemia 
 and (d) perhaps renal pain and tenderness or congenital cysts in the 
 liver (in 28 per cent., Lejars) ; in a case of Dr. W. F. Dickson renal 
 cysts were found with cystic liver, atrophic heart and pain resembling 
 appendicitis (see Echinococcus of the Liver, Differentiation). 
 Hanot describes cases resembling calculous colic. 
 
 Treatment. — Operation is permissible only in the exceptional, uni- 
 lateral cases or when suppuration develops. About one-third of the 
 operated cases die immediately and in few are any lasting results 
 obtained. The treatment is that of chronic nephritis. 
 
 RENAL PARASITES. 
 
 I. Echinococcus Cysts. — Echinococcus cysts of the kidneys occur 
 in 9 per cent, of echinococcus disease (Neisser's 900 cases). In 970 
 cases (Vegas and Cranwell) the liver was diseased in 64 per cent., 
 the lungs in 7 per cent., the spleen in 3 per cent, and the kidneys in 
 2 per cent. Baradulin in 1906 collected 142 cases of renal echino- 
 coccus (see Animal Parasites). 
 
 Symptoms. — (a) A renal tumor is found in 50 per cent, when the 
 
RENAL PARASITES. 7 95 
 
 cyst attains large dimensions. It is easily confused with other cysts, 
 hydronephrosis, cancer or tuberculosis without the exploratory punc- 
 ture and the urinary findings. Fluctuation and the hydatid thrill are 
 not often found (see Liver Echinococcus). The cyst begins in 
 the cortex, usually in either pole of the kidney; it is unilateral in 96 
 per cent, of cases and is left-sided in 62 per cent. If the cyst calcifies 
 it may be seen by the arrays. The opposite kidney may hypertrophy. 
 (b) Exploratory aspiration may show (i) fluid or pus" containing 
 urinary constituents, cholesterin, succinic acid, much sodium chlo- 
 ride and a reducing substance; (ii) vesicles, hooklets or particles 
 of lamellated membrane. (c) The urine may contain vesicles, 
 hooklets, membrane, pus from pyelitis and blood from rupture. As 
 many as 100 vesicles have been passed, (d) Passage of vesicles is 
 attended by severe colic, fever, chill and vomiting. 
 
 Complications. — Seventy-five per cent, rupture, chiefly into the 
 renal pelvis; perforation may occur into the intestines, lumbar 
 muscles, lung or pleura; the patient may feel the rupture. The 
 toxic substances, liberated by rupture or puncture, may cause urti- 
 caria, severe heart symptoms or even fatal syncope. Adhesions to 
 the liver, spleen and intestine may form. Suppuration or gangrene 
 may develop (pyonephrosis or paranephritis). Obstruction of the 
 ureter causes hydronephrosis; vesicles which plugged the lower end 
 of the ureter have been seen with the cystoscope. 
 
 Prognosis and Treatment. — The course is very chronic, covering 
 even twenty to thirty years. Suppuration may cause pyaemia. The 
 cyst may shrink or calcify. Bilateral involvement makes the prog- 
 nosis unfavorable. Spontaneous recovery by rupture into the urinary 
 tract occurs in 32 per cent. (Beraud). Operation should be extra- 
 peritoneal. Nephrotomy is indicated, as there is seldom more than a 
 single cyst. Nephrectomy entails a higher mortality (8 per cent.). 
 In 30 operations (nephrotomy) by Schede there were no fatalities; 
 87 per cent, completely recovered and 10 per cent, recovered but had 
 fistulse. 
 
 Enstrongylus Gigas. — The enstrongylus gigas which occurs fre- 
 quently in dogs or wolves, is very rare in man. It is a nematode 
 whose ova appear in the urine. It causes pyelitis, haematuria, colic, 
 tenesmus and sometimes chyluria. 
 
 Distoma Haematobium. — The distoma haematobium described by 
 Bilharz (1851) in Egypt, causes endemic haematuria. It is a 
 trematode and enters the alimentary tract by the drinking water. 
 Reaching the veins, its ova obstruct them and cause pyelitis, haema- 
 turia, tenesmus and sometimes form the nucleus of renal stones. 
 Salol is said to be beneficial. 
 
 Filaria. — The Filaria has been mentioned under Chyluria. 
 
 Tuberculosis and syphilis of the kidney (v. Infections). 
 
SECTION VI. 
 DISEASES OF THE BLOOD. 
 
 Anaemia is a reduction in the blood as a whole or more often a 
 reduction of its important constituents, as the red corpuscles, their 
 number, haemoglobin or albumin. Every anaemia has a cause, yet in 
 our present ignorance we adhere to the older division of anaemia into 
 primary and secondary forms. Primary anosmia includes chlorosis 
 and pernicious progressive anaemia. 
 
 CHLOROSIS. 
 
 Definition. — Chlorosis is a disease of haemogenesis, occurring ex- 
 clusively in women, chiefly in the developmental years and in the 
 decennium following, in which the cardinal symptom is anaemia; 
 the red cells are reduced but the haemoglobin is disproportionately 
 reduced; chlorosis develops spontaneously, usually runs an uncom- 
 plicated course, tends to recur and responds to therapy by iron. 
 Chlorosis is a disease, while anaemia is but a symptom. 
 
 Etiology. — Its etiology is uncertain, (a) All cases occur in women, 
 especially in girls who menstruate before the pubes and mammae 
 develop (Niemeyer). It is more common in blondes than in bru- 
 nettes, (b) Chlorosis occurs largely between the fourteenth and 
 seventeenth years. It is rare after the twenty-fourth year (chlorosis 
 tarda), except from relapses, (c) Heredity is a marked factor 
 (Bramwell). Chlorosis, tuberculosis or hysteria is not infrequently 
 associated in the family history, (d) Malnutrition, lack of hygiene, 
 working in dark quarters, insufficient or excessive exercise, nostalgia, 
 improper clothing, wearing of corsets and emotional or sexual factors 
 are indirect causes. Various theories have been advanced as to the 
 nature of the disease, as deficient development of the genitalia, hypo- 
 plasia of the vascular apparatus, adynamia of the blood-making 
 organs, inability of the blood-making organs to respond to the bodily 
 needs at puberty, insufficient absorption of iron, auto-intoxication 
 from the internal genitalia at the time of puberty and intestinal 
 auto-intoxication. 
 
 General Symptoms. — Among the early symptoms are rapid tiring, 
 dyspnoea and palpitation, which are rarely absent and are most notice- 
 able in the morning. Pallor is the earliest and most constant sign 
 and affects the skin and mucosae, the skin being of a yellowish-green 
 hue (chlorosis, as named by Varandel in 1670). Sometimes the 
 
 797 
 
798 DISEASES OF THE BLOOD. 
 
 color is maintained, the face being flushed, probably from peripheral 
 vasomotor irritability {chlorosis rubra) ; hence the mucous mem- 
 branes should be examined, even more than the skin. The eyes are 
 often brilliant. Psychical changes are noted, as stupor and lack of 
 mental and muscular energy (Sydenham and Morton). Associated 
 symptoms are headache, which may be dull or sharp, sometimes mi- 
 graine-like or increased at the time of menstruation, spots before the 
 eyes, tinnitus, vertigo and syncope which occurs especially from 
 standing, travel and exposure to the sun. Menstrual disturbances 
 are frequent, the flow being often decreased in younger subjects. 
 Digestion is very frequently disturbed and there may be anorexia, 
 perversity of appetite, craving of sour articles, hunger between meals, 
 pain in the stomach, eructations and gastralgia. Constipation is 
 frequent. The hands are cold, the skin dry and the peripheral cir- 
 culation sluggish. Circulatory symptoms appear, as the bruit de 
 diable in the neck veins, anaemic heart murmurs and rapid pulse. 
 
 Special Symptoms. — 1. The Blood. — The blood is fluid and its 
 coagulability is increased. The red blood cells are decreased (oligo- 
 cythemia) and average three to four millions at the first examina- 
 tion; as few as one million red cells have been observed. In some 
 rare cases they are not decreased (Duncan, Hayem, Laache). For- 
 mation of rouleaux is poorly marked. The red cells appear pale and 
 their average size is reduced. Irregularity in contour (poikilocy- 
 tosis) is not frequent; megalocytosis and microcytosis are rare; 
 normo- and megaloblasts are found only in the severest cases ; normo- 
 blasts are sometimes present in " blood crises." More suggestive than 
 the red cell reduction (oligocythemia) is the reduction of haemo- 
 globin (oligochromwmia) , which is reduced more than the red cells 
 (Duncan, 1867) ; the haemaglobin averages 30 to 40 per cent. This 
 reduction in the color index to one-half or less always suggests chlo- 
 rosis, is most marked in the first seizure in young individuals and is 
 less conspicuous in relapses or in older individuals. Some writers 
 claim that the reduction in haemoglobin is more apparent than real, 
 because there is more rapid regeneration of the cells than of the 
 haemoglobin. The white cells are essentially normal, therein differing 
 from many other forms of anaemia; occasionally lymphocytosis and 
 eosinophilia occur. The iron and nitrogen of the blood and its specific 
 gravity are reduced proportionately to the decrease in haemoglobin. 
 
 2. The Vascular System. — (a) Rokitansky and Virchow ob- 
 served hypoplasia of the aorta and vessels, which may co-exist with 
 hypoplasia of the genitalia, muscles and bones, but cannot be re- 
 garded as causative, (b) Palpitation is almost constant on exertion; 
 the apex-beat is strong to compensate for the poverty in haemoglobin. 
 (c) Heart murmurs occur in two-thirds of the cases ; they are largely 
 functional and may be caused by insufficient tension of the mitral 
 valve, dilatation of the left ventricle causing relative mitral insuffi- 
 ciency, weakened heart muscle (producing a muscular murmur in 
 place of the tone), tricuspid insufficiency or vibration of the pul- 
 
CHLOROSIS. 799 
 
 monary artery. The murmurs are largely systolic; undoubted dia- 
 stolic venous bruits have been heard, (d) Dilatation of the heart 
 occurs from anaemia or myocardial degeneration, though according 
 to Leube and Grunmach, the dilatation is not real but apparent, being 
 due to retraction of the lungs away from the heart, because of insuffi- 
 cient lung expansion; this has been confirmed by the z-rays. (e) 
 The pulse findings are not constant ; the pulse may be rapid, throb- 
 bing or excitable. The arterial tonus is reduced, dicrotism and capillary 
 pulsation are frequent and double tones have been noted in the crural 
 vessels from decreased tension and diastolic recoil. (/) A venous 
 bruit de diable in the neck occurs in over 50 per cent, of cases and 
 more frequently than in other anaemias; it may be palpable and is 
 heard more frequently over the right jugular vein, because it is more 
 vertical than the left ; it also is heard in other veins and in sound indi- 
 viduals. It is increased in the sitting posture by turning the head to 
 one side and by deep inspiration. Its explanation is difficult; it is 
 referred to change in the tonus of the vessel, waves in the veins above 
 their valves and a change of the blood plasma, (g) Arterial mur- 
 murs may be heard, as over the subclavian artery; pulsation in the 
 peripheral veins, angiospasm and erythromelalgia have been observed. 
 (h) (Edema is seen in 12 per cent, of cases and is usually slight, oc- 
 curring chiefly about the ankles and eyes and rarely in the serous 
 cavities. 
 
 3. Respiratory Tract. — Dyspnoea is a common complaint, ex- 
 plained by Eichhorst as an haematogenous respiratory insufficiency. 
 The respiration rate is 26 to 30. Sometimes a paroxysmal cough 
 develops. 
 
 4. Digestive Tract. — The digestive tract is involved in one-third 
 of the cases. There is sometimes foetor ex ore. (a) Pain in the 
 stomach is frequent ; it may occur near the ensiform with tenderness, 
 especially in nervous individuals. It sometimes results in vomiting ; 
 similar pains occur in the transverse colon. Sensitiveness at the tip 
 of the twelfth costal cartilage is due to pressure from corsets, (b) 
 Dyspepsia may be purely nervous. The stomach is exceptionally 
 dilated and atonic, but as a rule no motor insufficiency occurs, (c) 
 The hydrochloric acid is increased in 90 per cent, of cases, probably 
 from nervous irritability, (d) Constipation is probably no more fre- 
 quent than in the average case ; intestinal fermentation may co- 
 exist, but it is not the cause of chlorosis. 
 
 5. Sexttae Sphere. — The uterus infantilis and small ovaries are 
 but coordinate with chlorosis. Menstruation is decreased or absent 
 in 80 per cent. ; menstrual disturbance is neither the cause nor result 
 of chlorosis ; both result from a common factor. Conception is un- 
 likely to occur during chlorosis. Chlorotics are often first treated by 
 the gynaecologist for leucorrhoea (in 22 per cent, of cases). 
 
 6. Special Senses. — The usual symptoms of anaemia, as spots 
 before the eyes and weakness of accommodation, are observed. The 
 retinal vessels may be transparent or pulsating; retinitis and neuro- 
 
800 DISEASES OF THE BLOOD. 
 
 retinitis with degeneration and exudation, or " choked disk," occur in 
 exceptional cases and simulate brain tumor. Retinal hemorrhage 
 is rare. 
 
 7. Skin. — The skin is usually anaemic; angiospasm, coldness and 
 paresthesia occur. In chlorosis rubra the cheeks are flushed. Sebor- 
 rhea and acne are very common. Sweats, urticaria, eczema, purpura, 
 chloasma and trophic disturbance of the hair and nails may occur. 
 
 8. Nervous System. — Chlorosis often brings out a latent neu- 
 rosis, — especially hysteria, — and psychosis, the latter of which is 
 frequently curable. Neuralgia is infrequent. 
 
 9. Metabolism. — Metabolism is not essentially disturbed. The 
 body-weight is maintained, less from decreased oxygenation than 
 from inactivity. Some cases are emaciated and occasionally an 
 actual gain in weight is noted. The urine is clear, of low specific 
 gravity, often alkaline with decrease of urea and uric acid and some- 
 times albuminuria. Leube found fever frequently in mild chlorosis. 
 When present it is always well to differentiate " tuberculous pseudo- 
 chlorosis." 
 
 Complications. — Chlorosis may induce acute infections, as typhoid, 
 pneumonia, influenza and scarlatina, and may render their clinical 
 course severe. Venous thrombosis complicates 2 per cent, of cases, 
 occurring largely in the femoral veins, sometimes in the cerebral 
 sinuses and axillary and other vessels. It is probably inflammatory. 
 In Leichtenstern's series 56 per cent, involved the veins of the leg 
 and 34 per cent, the cerebral sinuses. Pulmonary embolism occurred 
 in 25 per cent, of 52 cases of thrombosis of the lower extremities 
 (Welch). Yirchow emphasized the frequency of septic endocarditis. 
 Rheumatic endocarditis with organic valvular lesion is frequent, as 
 also are ulcer of the stomach, tuberculosis and Basedow's disease. 
 The spleen is enlarged in 16 per cent. (Leube). The thyroid gland 
 is often moderately enlarged. Hemorrhages are not infrequent from 
 the nose, stomach or intestine, although it is usually stated that they 
 occur mostly in severe or pernicious ansemias. 
 
 Clinical Course and Prognosis. — Chlorosis develops rather suddenly 
 and runs a relatively short course of two to four months. The prog- 
 nosis is generally good. The tendency to recurrence is great, espe- 
 cially in unmarried or childless women; the blood may not return 
 absolutely to normal, shown by persistent pallor or irregular men- 
 struation. Acute chlorosis is observed especially in young girls after 
 their first menstruation; it is attended by severe headache, nervous 
 symptoms, great weakness and optic neuritis or "choked disk," 
 which may be confused with organic disease, as brain tumor. The 
 periodic type, according to von ISToorden, occurs in the higher classes 
 and in those who acquire the disease in their seventeenth to nine- 
 teenth year. The course may be chronic; the disease may last for 
 years with chlorotic blood, menstrual, dyspeptic, muscular and nerv- 
 ous symptoms, with alternate exacerbation and amelioration, indi- 
 cating inactivity or hypoplasia of the blood-making organs ; this form 
 
CHLOROSIS. 80 1 
 
 begins early in life in individuals with poor development of the bones, 
 muscles, genitalia, mamma? and adipose tissue ; marriage, pregnancy 
 and iron often benefit these cases, but they may last until the meno- 
 pause. 
 
 Diagnosis. — The diagnosis can be made by the entire group of 
 symptoms, positive and negative, for no single symptom is pathog- 
 nomonic. The diagnosis is based upon the ancemia, especially when 
 there is disproportionate reduction in the hcemoglobin, when the color 
 index is less than one and the white cells are normal; a diagnosis, 
 however, cannot be made from the blood findings alone. (Ehomberg 
 has described exceptional cases in which the blood was normal.) 
 Chlorosis is infrequent before the twelfth and after the twenty-fifth 
 year, unless the attack is a relapse. Its rapid development and 
 periodic manifestation are important features. Successful treatment 
 with iron is practically diagnostic. Secondary ancemia is most diffi- 
 cult to differentiate (seeDiFFERENTiATioN under Pernicious Anae- 
 mia) ; it is usually attended by some leukocytosis. Anaemia from 
 intestinal parasites, hemorrhage from latent ulceration of the stomach 
 or bowel, renal disease, early pregnancy in unmarried girls, the 
 anaemia of heart disease, incipient brain disease, rheumatism and lead 
 and arsenic anaemias must be considered. Splenic ancemia, especially 
 in children, requires differentiation ; cases of chlorosis with enlarged 
 spleen are regarded as a transitional form between chlorosis and 
 splenic anaemia proper. Malignant disease usually causes little diag- 
 nostic difficulty after careful examination. There is sometimes diffi- 
 culty in differentiation from incipient tuberculosis. Frequent phys- 
 ical examination and watching of the temperature usually establish 
 the diagnosis. 
 
 Treatment. — 1. Prophylaxis. — Prophylaxis includes general hy- 
 giene and proper nourishment, in that development of adipose tissue 
 to a reasonable extent is prophylactic. More albumin should be given 
 to growing children than to adults, although fruit and vegetables, for 
 their iron, and butter, cream and oils, rather than animal fats, should 
 also be administered. Physical culture and trips to the country are 
 valuable and constipation should be prevented. Education should 
 not be hurried ; all children at this age are confined too much to the 
 school-room; they should be kept children as long as possible. In 
 society and in the struggle for existence young girls too often overtax 
 their strength. 
 
 2. Specific Therapy. — Iron exists in the haemoglobin of the blood 
 cells as an oxygen carrier and is a food as well as a medicine ; it is 
 found in blood, meat, oatmeal, peas, spinach and beans. 
 
 Physiological Action of Iron. — (a) The tonus of the nervous sys- 
 tem is increased, though an excess produces frontal headache from 
 constipation; some persons exhibit a peculiar intolerance of iron, 
 as shown by headache, vertigo and palpitation, (b) Circulation; 
 locally astringent, it contracts the bloodvessels and increases the num- 
 ber of red disks and the amount of haemoglobin, (c) Its action on the 
 51 
 
802 DISEASES OF THE BLOOD. 
 
 gastro-intestinal tract is as follows : Iron stains the teeth because of 
 the acid which it contains. Small doses stimulate digestion, improv- 
 ing, by their astringent action, the tone of the tissues. Hydrogen is 
 generated and from it sulphureted hydrogen, which causes eructations. 
 Small doses cause constipation but large doses relax the bowels; 
 diarrhoea also sometimes follows small doses. Sulphide of iron is 
 found in the dark stools, (d) The amount of urine is increased. 
 Iron is found in the urine in very small quantities. The kidneys may 
 be irritated by very large doses, (e) In regard to its absorption there 
 is great conflict of opinion, but it is absorbed from the stomach and 
 intestines as an albuminate ; it reaches the blood and is deposited first 
 in the spleen and then in the liver, whence it is then carried by the 
 bloodvessels to the intestines for elimination. (/) Elimination occurs 
 by the intestines, the kidneys and liver. 
 
 Administration. — It may be advantageously combined with qui- 
 nine, particularly when the spleen is enlarged ; it may also be given with 
 oxygen, normal salt transfusions and massage; the patient should 
 have rest and change of environment. Soluble preparations would 
 seem to be better than insoluble ones, but Quevenne has shown that 
 they are precipitated by the gastric juice. Headache is obviated by 
 using laxatives, bromides or ferrous salts, which derange digestion 
 less than ferric salts. Iron is said to be best absorbed when some 
 gastric catarrh exists (Brunton), hence some practitioners give large 
 doses at first to improve absorption. There are only 38 to 45 grains 
 of iron in the body and the ordinary daily diet contains but one-sixth 
 of a grain of iron, but the nucleo-albumin preparations, which are 
 sufficient as food, are not sufficient as medication, because they do 
 not stimulate the blood-making centres. The rules for administra- 
 tion, according to von Noorden, are: (a) The doses should not be 
 too small (Niemeyer and Immermann). (b) Every physician has 
 his own method, therefore no one form especially excels any other. 
 (c) The administration should be regular, for irregularity is in- 
 jurious. Statements of the patient that she has previously taken iron 
 should not be regarded, for its administration may have been ir- 
 regular, (d) Administration should continue for six weeks to three 
 months. In the first week the dose should be gradually increased; 
 for three weeks the maximum dose should be given and for the last 
 two weeks it should be gradually decreased, (e) If iron is not bene- 
 ficial it should not be repeated but other methods tried. (/) Relapses 
 are less easy to treat than the first attack, (g) Idiosyncrasy, as 
 gastro-intestinal disturbance, is only a relative contra-indication. 
 The administration should then be subcutaneous, (h) At mineral 
 springs hygiene is more important than iron; the water should be 
 taken on an empty stomach, for the gas promotes absorption of iron. 
 When bottled it is precipitated as a carbonate. 
 
 Iron may be given in the following forms: Ferrum reductum (re- 
 duced iron) which is iron gray (if it is black it is impure) and taste- 
 less; it is least astringent, but may cause eructation; gr. j. (See 
 
CHLOROSIS. 803 
 
 formula on page 417.) Pilula ferri carbonatis, a ferrous salt nearly 
 free from astringency; grs. ij to v. Ferri sulphas (green vitriol). 
 a ferrous salt which is very astringent, whence its use in chronic 
 diarrhoea. It stimulates digestion. In large quantities it is toxic, 
 causing vomiting or diarrhoea; gr. ij should be given with one 
 dram of magnesium sulphate p. c. Ferri sulphas exsiccatus gr. ss 
 to ij may also.be given. Liquor ferri et ammonii acetatis (Bashams 
 mixture) is a vascular tonic and diuretic; it is excellent for chlo- 
 rosis in the obese; 3j to iv should be given after meals, well di- 
 luted. Tinctura ferri chloridi is the chloride of iron plus hydro- 
 chloric acid and alcohol, which develop hydrochloric ether. It is 
 yellow-red, astringent, somewhat corrosive and diuretic, increas- 
 ing the amount and frequency of micturition. It is used to best 
 advantage when the tongue is white, flabby and indented. In 
 weak, anaemic girls, with vomiting, neuralgia and epigastric pains, 
 full doses should be given ; when poorly tolerated, one drop in a full 
 glass of water is more beneficial than chalybeate waters. Syrupus 
 ferri iodidi is transparent and has a greenish color ; iron and iodine 
 given separately are usually more beneficial, but the syrup may be 
 given in doses of 30 to 40 drops in adults and of 5 to 10 in children. 
 Ferri citras in doses of gr. v, is efficacious in children and in persons 
 having delicate stomachs. Ferri phosphas solubilis, gr. v, is almost free 
 from astringency and taste. Most organic preparations are useless. 
 
 Arsenic may be given with the iron or in its place; it acts on the 
 blood-making centres; it should be given as in pernicious anaemia 
 (q. v.) uninterruptedly, with gradually increasing doses, sustained 
 doses and then decreasing doses for a period of four to six weeks. 
 
 High altitude increases the number of red cells and the amount of 
 haemoglobin. Phlebotomy, sweating and organotherapy (bone mar- 
 row, splenic and ovarian extracts) have been suggested. 
 
 3. Dietetic Treatment. — Regular meals should be given at three- 
 hour intervals. The amount of albumin should be increased, even in 
 the obese. The heavy English breakfast with meat is the best one, be- 
 cause the albumins are absorbed more rapidly than fats and carbohy- 
 drates. In administering milk care should be observed lest the ap- 
 petite be spoiled, lest too much fat be deposited and the stomach suffer 
 atony. Equal parts of milk and cream should be given. Milk should 
 be avoided in the obese. Alcohol is indicated in thin rather than in 
 obese individuals. Patients should always rest before and after 
 eating. The patient should retire early. In thin subjects the diet 
 should be concentrated, consisting of albumin, vegetables, fats, alco- 
 hol and milk at breakfast and at bed time, but without increase of the 
 carbohydrates. Iron produces better results in such cases after limit- 
 ing the amount of water to about one quart. Sweats may produce the 
 same result. When there is much gastric disturbance, eight meals 
 may be given at two-hour intervals and fluid and solid meals should 
 be alternated. Gastric disturbance disappears after administration 
 of iron and increase in weight. Hydrochloric acid, strychnia and 
 
804 DISEASES OF THE BLOOD. 
 
 belladonna are helpful. Exercise may be prescribed in convalescence, 
 but during chlorosis the patient should rest in bed. Cool rubbings 
 early in the morning are advantageous. Cold baths are avoided be- 
 cause they produce chills, insomnia and digestive disturbances. Mar- 
 riage may help mild cases, but is injurious in the severe type. 
 
 PERNICIOUS ANEMIA. 
 
 Definition. — A primary anaemia, in which are observed progressive 
 diminution of the red cells, with changes in their form and color, 
 and reduction in the haemoglobin, without changes in the white cells ; 
 this form of anaemia is due to haemolysis and to defective haemo- 
 genesis; it is characterized by pallor, adynamia, oedema and cardiac 
 symptoms and usually results in death from vomiting, diarrhoea, 
 hemorrhages, fever and exhaustion. It was described by Andral 
 (1826) and Channing of Boston (1832) ; Addison gave the best early 
 description and Biermer later and more fully drew attention to the 
 subject. It is sometimes called Addison's anaemia. Since Ehrlich 
 drew the blood picture, little has been added to our knowledge of the 
 disease. 
 
 Etiology. — The disease occurs in 0.2 per cent, of cases, especially 
 in the third and fourth decades of life ; six-sevenths of the cases occur 
 after the thirty-fifth year (1,200 cases collected by Cabot, from whom 
 the following figures are taken). Baginsky could collect but 16 
 cases in children. Sixty per cent, occur in males. The ultimate 
 cause is to be sought in some hemolysin, but its cause is unknown. 
 Although called a primary or essential anaemia, some undoubted sec- 
 ondary cases may be included under this head, because the symptom 
 complex is the same. Bothriocephalus and ankylostoma anaemias 
 present identical blood findings, symptoms and pathology ; not merely 
 the parasite but also its toxins are causative. Pregnancy and the 
 puerperium, in certain localities at least, are causative. Syphilis, 
 poor hygiene, infectious diseases, as typhoid or malaria, and diar- 
 rhoea, vomiting and oral or gastro-intestinal sepsis have been con- 
 sidered factors. 
 
 Symptoms. — 1. The Blood Changes (Sorenson, 1874). — The 
 amount is decreased, several punctures often being necessary to ob- 
 tain enough for the blood-count ; it is often watery or dark or amber- 
 colored in some instances. The specific gravity is low, even 1,027; 
 the dry substance is reduced, even to 9 or 10 per cent, of the normal. 
 There is an increase in the albumin in the individual red cell (hyper- 
 albuminaemia rubra, von Jaksch). The serum does not contain free 
 haemoglobin, as has been asserted by Limbeck. If injected into nor- 
 mal individuals the serum has an haemolytic action. In contrast to 
 chlorosis and secondary anaemias, the coagulability of the blood is 
 decreased and the blood may remain fluid for some time after 
 death. Dropped on filter paper, there is a white zone outside the 
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PERNICIOUS ANEMIA. 805 
 
 more than 50 per cent, of the normal and may be reduced to 10 per 
 cent. In some instances severe symptoms may be present, with 65 
 to 70 per cent, haemoglobin. In 90 per cent, of cases and in contrast 
 to other anaemias, the haemoglobin per corpuscle is proportionately 
 increased, i. e., the color-index is more than one (even 1.75). 
 Laache's explanation is that certain red cells, especially giant forms, 
 contain a large compensatory individual amount of haemoglobin, 
 which is also true of the microcytes, but less so of normal-sized red 
 cells. Schmidt, Ponfick and others of the Dorpat school, maintain 
 that the free haemoglobin, acting on the white cells, produces a fibrin 
 ferment, which causes fever, hemorrhage and capillary embolism. 
 The red blood corpuscles are greatly reduced in number, the average 
 being 1,200,000. (See Plate XV.) Patients often die when this 
 figure is reached. Lower counts have been noted, as 143,000 
 (Quincke). The lowest count the writer has seen was 380,000. 
 Poihilocytosis is marked, the irregularity in form and size of the cor- 
 puscles being great; great deformities, as Litten's horse-shoe or pes- 
 sary-shaped corpuscles, are noted. In 90 per cent, the red corpuscle 
 is above the average size, i. e., 11, even 18/* instead of 5 to 8/*, the 
 highest normal measurement. Megalocytes may be observed in num- 
 ber, with less marked or absent umbilication. Polychromatism is 
 frequent. Megalocytes in pernicious anaemia are probably evidence of 
 megaloblastic degeneration of the bone-marrow. ( See Fig. VIII, Plate 
 XVI.) Megaloblasts are found but rarely in large numbers, seldom 
 more than six or eight being seen in a single preparation (Ehrlich) ; 
 in rare cases they may be abundant, as just before death, whence 
 their generally ominous significance ; they may be absent for months 
 or weeks at a time. Normoblasts occur in nearly all cases, especially 
 in the " blood crises " of von Noorden, but are not numerous ; they 
 are immature cells and indicate activity of the blood-forming organs. 
 Microblasts are frequently absent; their teleologic significance lies 
 in the increase of the respiratory surface of cells thus afforded. Cell 
 divisions are found. (Plate XVI, Pig. 3.) Granular deposits (stain- 
 ing with basophilic dyes) in the protoplasm are noted as in malaria, 
 cachexia, leukaemia and suppuration; according to Ehrlich, they are 
 not due to polychromatophile degeneration but to nuclear degenera- 
 tion. The cells may stain only at their margins. Decreased forma- 
 tion of rouleaux is observed as well as amoeboid movement of the red 
 cells. The white corpuscles are decreased absolutely, the lowest rec- 
 ord being 1,500 ; the polymorphonuclears are decreased. Leukocytosis 
 is a distinct complication, is often ominous and indicates inflamma- 
 tion or suppuration. Apart from complications, the lymphocytes are 
 relatively increased, even to 62 per cent, of the total white cells. The 
 leukocytes are readily increased in children in any variety of anaemia. 
 Marked decrease of the eosinophiles is an unfavorable sign (Neusser). 
 Pernicious anaemia due to parasites shows increase in the eosinophiles 
 from 1 to 4 (normal) to 6, 36 and even 50 per cent. (See Plate 
 XVI, Fig. V.) 
 
806 DISEASES OF TEE BLOOD. 
 
 2. Subjective Symptoms. — The most marked are general weak- 
 ness, muscular adynamia on exertion, vertigo, palpitation, dyspnoea 
 and the ordinary signs of anaemia. 
 
 3. Skin. — The skin presents a peculiar pallor, often of a lemon 
 color, which is somewhat characteristic. Slight icterus is not infre- 
 quent. The skin, usually dry, may become drenched upon exertion. 
 (Edema is invariable, especially about the ankles and eyelids. It is 
 usually not marked, but is obstinate and may produce pronounced 
 general anasarca ; it is due to vascular degeneration and permeability. 
 Hemorrhages, usually punctate, are frequent in the skin and mucosae. 
 Large hemorrhages occur in 25 per cent, of cases. Pigmentation is 
 sometimes as marked as in Addison's disease. The author once saw 
 herpes zoster and once herpes along the crural nerve. Sometimes 
 before death the skin emits a foul, cadaverous odor (Eichhorst). 
 
 4. Metabolism. — The nutrition is maintained in 61 per cent, of 
 cases because tissue waste is lessened and water is retained in the 
 tissues; in 39 per cent. (Cabot) the weight and strength finally de- 
 cline with persistent vomiting and diarrhoea. Opinions differ as to 
 the destruction of the albumins. In the urine indican, putrescin, 
 cadaverin, leucin and sometimes tyrosin, acetone and albumose are 
 found. Albuminuria, due to tubular degeneration, is frequent. 
 Urobilin is frequently increased, sometimes imparting a dark color 
 to the urine, and indicates haemolysis. The chlorides are decreased. 
 The iron in the urine and uric acid are sometimes increased and the 
 phosphates are greatly increased. Fever, present in 80 per cent, of 
 cases, bears no constant relation to the severity of the disease. It may 
 rise considerably ; the temperature may fall below normal in the 
 ante-mortem coma. The type is irregular. Its cause is ill-under- 
 stood; it is probably due to the production of a ferment from the 
 destroyed red cells or, according to Schmidt, Ponfick and others, 
 from a fibrin ferment formed from the leukocytes (v. s.). 
 
 5. The Circulation.- — Palpitation, precordial anxiety and dys- 
 pnoea are observed, sometimes only on exertion. The heart impulse 
 is fallaciously strong to the palpating hand. Its outlines are usually 
 normal, save that dilatation of the right heart or hydrops pericardii 
 may develop. Almost always a blowing systolic murmur is heard, 
 usually with a clear diastolic tone ; the murmur is rarely presystolic 
 or diastolic. The second pulmonic sound is variable, sometimes ac- 
 centuated. No parallelism exists between the degree of anaemia and 
 the loudness of the murmur. Leube reports cases of chlorosis and 
 pernicious anaemia in which there was relative tricuspid insufficiency ; 
 the positive venous pulse was present, but no cyanosis. A venous hum 
 in the neck, carotid pulsation and thrills, a loud, clear systolic tone 
 and murmurs and double tones over the peripheral arteries are often 
 present. The pulse is collapsing and decreased in tension and its 
 rate increased, being rarely below 80 and usually between 90 and 
 120. Anatomically the heart shows vestiges of hemorrhage, degen- 
 eration and atrophy, from haemolysis. The fatty, " tabby-cat heart " 
 
PEEK1C10US ANEMIA. 807 
 
 is almost constant. Degeneration in the smaller vessels has been 
 noted, especially in the brain. 
 
 6. Digestive Teact. — Anorexia, distaste especially for meats, 
 gastric achylia, pain and sensitiveness throughout the alimentary 
 tract are noted. The tongue and gums are sensitive and circum- 
 scribed or punctate hemorrhages are often noted in them. Pain in 
 the mouth (50 per cent.) and oesophagus is due to the anaemia or 
 administration of arsenic. The gums may ulcerate; erythema bul- 
 losuni and other eruptions may occur. Vomiting is frequent in 
 various stages of the disease and is often continuous or incoercible; 
 the vomitus consists of food, greenish mucus and sometimes traces 
 of blood. The writer has observed profuse haeniatemesis and cyclic 
 vomiting as the first symptoms. Crises of abdominal pain occur in 60 
 per cent. Epigastric pulsation, moderate abdominal distention and 
 achylia are observed. The author once saw expansile abdominal pul- 
 sation, wrongly diagnosticated as aneurysm. The glands in the 
 gastro-intestinal tract may atrophy, which probably toxaeinic con- 
 dition is coordinate with and not causal of pernicious anaemia. The 
 mesenteric glands are not infrequently enlarged. Paroxysmal diar- 
 rhoea occurs in 50 per cent., constipation in 35 per cent, and an alter- 
 nation of these conditions in 15 per cent. The stools are not charac- 
 teristic, although sometimes acholic from poor absorption of fat. 
 Parasites or their eggs may be noted. Leucin and tyrosin crystals 
 are frequently caused by diarrhoea, but are not characteristic of the 
 disease. Fermentation in the bowel (with indican in the urine), 
 some oedema, hemorrhage and follicular swelling in the bowel are 
 frequently observed. Some ascites is found in the terminal stage. A 
 deposit of iron (siderosis) in the liver, in the outer and middle zones 
 of its lobules, in the spleen, bone marrow, kidneys and lymphatic 
 glands is usual and results from haemolysis : it is very unusual in 
 other anaemias. There is most hepatic siderosis in acute cases. The 
 liver is slightly swollen and tender in one-third of the cases. 
 
 7. Beood-atakixg Oegaxs. — The lymph glands are not usually 
 enlarged. The prevertebral haemolyrnph glands have been carefully 
 studied by "Warthin, who found their sinuses dilated and evidences 
 of haemolysis in their tissue, shown by increased phagocytosis and 
 sometimes hyperplasia of the glands : Warthin holds that the un- 
 known poison stimulates the phagocytes of the spleen, lymph nodes 
 and haemolyrnph glands to increased haemolysis. The hones are ten- 
 der, especially over the sternum and tibiae and sometimes painful and 
 their fatty marrow may become lymphoid (leucoblastic degenera- 
 tion) ; this transformation may occur in other forms of anaemia, in 
 cachexia or in fevers : in pernicious anaemia the red cells of the 
 marrow are abnormally large, abnormally dark from increase of the 
 haemoglobin and are oval rather than round: the megaloblastic de- 
 generation develops at the expense of the other elements in the bone 
 marrow. These probably secondary bone changes were first described 
 by Wood, Pepper and Tyson (IS 75). The spleen is not enlarged 
 
808 DISEASES OF THE BLOOD. 
 
 save from accidental causes; in it are found phagocytosis and evi- 
 dences of haemolysis. 
 
 8. Sexual Sphere. — The menses cease, otherwise no characteris- 
 tic changes are observed. 
 
 9. The Nervous System. — The psychical functions are decreased, 
 the memory is weak and psychoses, delirium, hallucinations, mania 
 and intractable insomnia may develop either temporarily or ante- 
 cedent to the terminal coma. Sometimes improvement is noted after 
 severe mental symptoms or coma. The pupils are rather wide and 
 sometimes their reflexes disappear. Paresis, apoplectiform attacks, 
 cramps, convulsions, paresthesia, aphasia, vertigo or in women and 
 children the hydrencephaloid state may develop. The cord is more 
 frequently involved (in 84 per cent, of cases) than the brain. The 
 weakness may amount to paresis, not due simply to muscular ady- 
 namia but to spinal changes. The picture may resemble tabes as 
 concerns the eyes, patellar reflexes, ataxia, bladder and rectal changes, 
 pains, anaesthesia and paresthesia ; or, less often, the symptoms of 
 spastic spinal paralysis prevail, as increased reflexes and spastic 
 paresis. In one group of cases the nervous symptoms are slight, and 
 in a second they are so conspicuous as to even overshadow the anaemia 
 itself. Early paresthesia occurs in all cases, usually in the hands and 
 feet, sometimes in the mouth; sometimes there is hyperesthesia or 
 disturbance of the temperature sense, spasticity and ataxia. The 
 sexual function is decreased in males and amenorrhea is regular in 
 women. There is a sclerosis of the posterior and lateral columns, 
 most marked in the lower cervical and upper dorsal segments, not 
 always diffuse but sometimes focal, and involving chiefly the white 
 substance, but not the entire neuron. Degeneration is found in the 
 upper part of the cord or possibly throughout its length. The white 
 substance suffers more extensively than the gray ; the changes usually 
 occur in the posterior column, which rarely wholly escapes. Small 
 foci of degeneration with secondary connective tissue growth occur 
 about the bloodvessels, which foci may fuse into plaques of small size 
 with secondary degeneration, hence the symptom complex of a sys- 
 temic disease. 
 
 The discrepancy between the anatomical and clinical findings is 
 remarkable, i. e., there may be many symptoms with few autopsy 
 findings and the converse is also true; consequently it is probable 
 that the spinal and nervous symptoms are less sequences of anemia 
 than coordinate toxic manifestations. The peripheral nerves present 
 few symptoms. Anatomically, capillary hemorrhages and dissemi- 
 nated foci of softening may be observed in the brain and meninges. 
 
 In the eyes the general symptoms of anemia occur; hemorrhages 
 in the retina are almost constant ; occurring on a pale background, 
 with tortuous veins and a strong light reflex from the vessels, the 
 hemorrhages form a striking picture (see Plate VIII, Fig. 9). They 
 are punctate and their resorption is infrequent. The other senses are 
 obtunded ; labyrinthine hemorrhage with vertigo is recorded. 
 
PEENICWVS ANEMIA. 809 
 
 Clinical Course and Prognosis. — The pallor and weakness which 
 are first observed increase insidiously and later dyspnoea, weak heart- 
 action, oedema, complete anorexia, langor, spinal and violent gastro- 
 intestinal disturbance and finally capillary hemorrhages and fever 
 develop; this vomiting and diarrhoea may at times resemble acute 
 poisoning. In other instances remissions may occur with treatment 
 or independently of it, perhaps after violent gastro-enteric manifesta- 
 tions. The symptoms may partially or wholly disappear, as in Ehr- 
 lich's case, where the red cells in seventeen days rose from 1,340,000 
 to 4,115,000. According to Laache, in simple anaemia the red cor- 
 puscles gain more rapidly than the haemoglobin, but in pernicious 
 anaemia improvement increases both equally. The disease with re- 
 missions may cover a period of years, the longest duration being 15 
 years. Death usually occurs within half a year. The writer ob- 
 served recovery for five years after a count of 400,000. 
 
 The prognosis is usually poor when many megaloblasts are present 
 or when the color index is over one. In some cases the blood is 
 rapidly regenerated. 
 
 Cabot's description of the disease recognizes two forms: — 
 
 The Severe, Bapidly Fatal Type — axd the Less Severe, Slow Type. 
 
 (a) Extreme progressive anaemia. Eemissions. 
 
 (Z>) Color index high. Xormal or low. 
 
 (c) Eed cells increased in size. Normal. 
 
 (d) Degenerative changes. None. 
 
 (e) Many megaloblasts. Many normoblasts, few megaloblasts. 
 (/) Lymphocytosis. Normal ratio of the various white cells. 
 
 Death usually occurs in coma or possibly from cerebral hemor- 
 rhage or other rare complications. Pye-Smith collected 20 cases of 
 recovery; there are only 6 recoveries, according to Cabot, yet he found 
 27 cases which lived 8 or more years. The mortality in the parasitic 
 form is 17 per cent. 
 
 Diagnosis. — Xo single finding is absolutely characteristic, though 
 the pallor, apathy, adynamia, oedema, weak heart, retinal hemor- 
 rhages, maintained nutrition and the blood findings are highly sug- 
 gestive. The yellow color is very often mistaken for icterus. Ewing 
 states no importance should be attached to the increased diameter of 
 the red cells unless 33 per cent, of the red disks show it. Megalo- 
 blasts are highly suggestive. The diagnosis must be made from the 
 negative as well as from the positive findings. 
 
 Differextiatiox. — (a) From metastatic hone-tumors, in which 
 the white cells are increased (not merely the polymorphonuclear but 
 the neutrophile and eosinophile marrow cells) ; (b) from parasitic 
 anaemia, for which the stools should be examined for parasites and 
 their eggs; (c) fever, if dominant, may suggest typhoid or menin- 
 gitis; acute endocarditis may be simulated by the fever, anaemia, 
 heart murmurs and cardiac insufficiency of pernicious anaemia; (d) 
 from latent carcinoma, the gradual cachexia, anorexia, nausea, vom- 
 iting, hsematemesis and decrease or absence of hydrochloric acid may 
 
810 
 
 DISEASES OF TEE BLOOD. 
 
 suggest gastric carcinoma, but the blood examination with thorough 
 physical examination usually determines the point; (e) spinal disease, 
 Addison's disease and hemorrhagic pleuritis are usually excluded 
 with ease ; and (/) from other anosmias. The following is constructed 
 after Cabot's table: 
 
 Red Cells Number. 
 Shape. 
 
 Size. 
 Haemoglobin. 
 
 Staining 
 Nuclei. 
 
 Rouleaux. 
 Color index. 
 
 Leukocytes. 
 
 Lymphocytes. 
 Myelocytes. 
 
 Adult Leukocytes 
 
 Coagulation 
 
 Pernicious 
 Anemia. 
 
 Average number 
 1,000,000. 
 
 Poikilocytosis 
 great, sausage- 
 shape, etc. 
 
 Average increased, 
 some dark. 
 
 Increased per cor- 
 puscle yet many 
 Ponfick's shadow 
 corpuscles. 
 
 Polychromatophile 
 cells. 
 
 Micro-, megalo-, 
 normoblasts. 
 Megalo- more 
 numerous than 
 normoblasts and 
 constitute major- 
 ity of nucleated 
 R. B. C 
 
 Not present, or 
 decreased. 
 
 High color index 
 (not in chronic 
 or mild cases). 
 
 W. B. C decreased, 
 except in blood 
 crises, hemor- 
 rhage, suppura- 
 tion. 
 
 Lymphocytosis 
 
 (relative). 
 
 Small number 
 only. 
 
 Rarely increased. 
 Usually de- 
 creased. 
 
 Slow. 
 
 Chlorosis. 
 
 Rarely under 
 2,000,000. 
 
 Somewhat de- 
 formed. 
 
 Diminished, light 
 colored. 
 
 Reduced per 
 corpuscle. 
 
 Megaloblasts rare 
 though recorded. 
 Normoblasts 
 more than 
 megaloblasts. 
 
 Index less than 1 
 always low ; lower 
 than in secondary 
 anaemias. 
 
 Usually normal. 
 
 Lymphocytosis 
 
 Rare ; less than 
 in pernicious 
 anaemia. 
 
 Decreased. 
 
 Rapid. 
 
 Secondary Anaemia. 
 
 Findings as in chlorosis May be 
 1,000,000 or less, though rarely. 
 
 Various, not increased. 
 
 Normoblasts far more than megalo- 
 blasts in malignant diseases. ~ w 
 
 Normoblasts common (more than in 
 chlorosis). 
 
 Relatively low (this rule does not hold 
 positively). 
 
 Polymorphonuclear leukocytosis in ma- 
 lignant disease, when R B. C are low 
 in number, e. g. one million, speaks for 
 secondary anaemia ; positive of more 
 value than negative findings (i e. no 
 leukocytosis) . 
 
 Rarely increased (no decrease). 
 Myelocytes very rare. 
 
 Usually increased. 
 
 Often rapid. 
 
 Aplastic ancemia, generally regarded as a type of pernicious 
 anaemia, is characterized by its low blood count and reduced haemo- 
 globin. It was so named by Ehrlich because the bone marrow was 
 aplastic ; therefore in the blood there are no evidences of regeneration, 
 such as nucleated red cells. The white cells may number only 200 
 per c.mm. and 80 to 90 per cent, of them are lymphocytes. Two- 
 thirds of the cases are women. There may be hemorrhages, fever or 
 hyperplasia of the spleen and lymph glands. The outcome is rapidly 
 fatal, 80 per cent, dying within three months. 
 
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 DRAWN BYJ.NZ CHASC 
 
PLATE XVI 
 
 BLOOD. 
 
 (Ehrlicll triple stain.) 
 (Prepared by Dr. I. P. Lyon.) 
 
 Fig. I. TYPES OF LEUCOCYTES. 
 
 a. Polymorphonuclear Neutrophile. b. Polymorphonuclear Eosinophile. c. Myelocyte 
 (Neutrophilic), d. Eosinophilic Myelocyte, e. Large Lymphocyte (large Mononuclear). 
 /. Small Lymphocyte (small Mononuclear). 
 
 Fig. II. NORMAL BLOOD. 
 Field contains one neutrophile. Reds are normal. 
 
 Fig. III. ANAEMIA, POST-OPERATIVE (secondary). 
 
 The reds are fewer than normal, and are deficient in haemoglobin and somewhat 
 irregular in form. One normoblast is seen in the field, and two neutrophiles and one 
 small lymphocyte, showing a marked post-haemorrhagie anaemia, with leueoeytosis. 
 
 Fig. IV. LEUCOCYTOSIS, INFLAMMATORY. 
 
 The reds are normal. A marked leueoeytosis is shown, with five neutrophiles and 
 one small lymphocyte. This illustration may also serve the purpose of showing the 
 leueoeytosis of malignant tumor 
 
 Fig. V. TRICHINOSIS. 
 A marked leueoeytosis is shown, consisting of an eosinophilia. 
 
 Fig. VI. LYMPHATIC LEUKAEMIA. 
 
 Slight anaemia. A large relative and absolute increase of the lymphocytes (chiefly 
 the small lymphocytes) is shown. 
 
 Fig. VII. SPLENO-MYELOGENOUS LEUKAEMIA. 
 
 The reds show a secondary anaemia. Two normoblasts are shown. The leueoeytosis 
 is massive. Twenty leucocytes are shown, consisting of nine neutrophiles, seven myelo- 
 cytes, two small lymphocytes, one eosinophile (polymorphonuclear) and one eosinophilic 
 myelocyte. Note the polymorphous condition of the leucocytes, i.e., their variations 
 from the typical in size and form. 
 
 Fig. VIII. VARIETIES OF RED CORPUSCLES. 
 
 a. Normal Red Corpuscle (normocyte), b, c. Anaemic Red Corpuscles, d-g. Poikiloeytes. 
 h. Microeyte. i. Megaloeyte. j-n. Nucleated Red Corpuscles. j,k. Normoblasts. I. Micro- 
 blast, to, n. Megaloblasts. 
 
PERNICIOUS ANEMIA. 811 
 
 Leukcemia (see Differentiation of Leukaemia). 
 
 Treatment. — 1. Hygienic. — The patient should have absolute rest 
 in bed and if possible should be in a warm climate. An excessive 
 nitrogenous diet is unwarranted because it increases tissue waste, 
 patients have an, instinctive disinclination to nitrogenous foods and 
 albumins frequently produce diarrhoea. A vegetable diet is better 
 tolerated, with bread, zwieback, beef tea, peptones, milk, honey or 
 porridge. Nutrient enemata are indicated in the gastric crises. In 
 pregnant women labor should not be induced. 
 
 2. H^imatinic. — (a) Transfusion of defibrinated human blood 
 has been practiced, though seldom beneficial. Human blood may be 
 transfused in toto. (b) Lepine recommends the physiological salt 
 solution, based on Maragliano's findings that the serum in cases of 
 pernicious anaemia has a globulicidal action on the red blood cells. 
 The serum destroys the haemoglobin in pernicious anaemia (the blood 
 of a patient clears in a test tube on standing). Salt solution should 
 be given frequently and acts temporarily on the serum, (c) Phos- 
 phorus is without value and iron is often injurious, (d) Arsenic, 
 recommended by Bramwell, is said to have cured the disease, though 
 most cases have not been followed out thoroughly ; it is, nevertheless, 
 the best remedy known, probably acting upon the blood-forming 
 centres. Birsch-Hirshfeld explains its action by assuming that it 
 operates in some way upon the serum, while Litten holds that it 
 increases the number of white cells. 
 
 Physiological Action of Arsenic. — (a) The smallest dose merely 
 increases the appetite, (b) Small doses stimulate the appetite by 
 gastric irritation, by increasing secretion and stimulating peristalsis ; 
 tissue waste and elimination of nitrogen are lessened. It is an altera- 
 tive, increases the muscular strength and endurance, improves the 
 quality of the blood, the complexion, sexual powers and lung ca- 
 pacity, (c) Continuous administration produces constitutional 
 effects, as puffiness of the eyes, first seen in the morning (Wier 
 Mitchell) ; this may be followed by general oedema, due to vascular 
 and sometimes renal alteration. Administration should be stopped 
 when puffiness is observed, (d) Large doses result in anorexia, nausea, 
 diarrhoea, abdominal uneasiness or colic and sympathetic headache. 
 
 The circulation is stimulated by small doses. Arsenic is absorbed 
 by the bloodvessels. Full doses lessen the force and rate of the heart, 
 for they act directly upon the heart muscle. Arterial pressure is 
 reduced by peripheral vasomotor paralysis. Kespiration and diges- 
 tion are stimulated by small and depressed by large doses, although 
 some deny the stimulant action of any dose. Elimination is very 
 rapid and mostly by the kidneys and intestinal mucosa, but also by 
 the skin, bile, lungs, saliva and mother's milk. 
 
 Administration. — Children tolerate large doses, though the aged 
 stand the drug poorly and their digestion suffers ; after the fifth year 
 adult doses are given ; girls tolerate the drug better than boys. When 
 susceptibility is marked a few drops of laudanum may be added, but 
 
812 DISEASES OF THE BLOOD. 
 
 its administration should always be stopped when (a) the eyes be- 
 come puffy or (b) itch and (c) the tongue becomes furred. It may 
 be given in the following forms: — (i) Arseni trioxidum gr. %o p. c, 
 with ext. glycyrrhizse and piper (black pepper) aa gr. iv ("Asiatic 
 pill"). (See formula on page 417.) (ii) Liquor potassii arsenitis 
 (Fowler's solution, 1786) ; for hypodermic use it must be sterilized, 
 because fungi are likely to grow in it. Even with great care abscess 
 may develop. Minims v equal gr. %o of arseni trioxidum. Treat- 
 ment should commence with TTL ii j and each day the dose should be 
 increased a drop until TTtx or xij are given; rarely can larger doses 
 (Tllxv-xxv) be given, (iii) The cacodylate of soda pill (gr. %) may 
 be given one to five times daily (Gautier). 
 
 3. Symptomatic Treatment. — This includes opiates for diar- 
 rhoea, cardiants for weak heart and dilute HG1 for gastric achylia. 
 
 SECONDARY ANJEMIA. 
 
 1. Acute Post-Hemorrhagic Anaemia. — Etiology. — It may result (a) 
 from trauma of large vessels; (b) from post-partum hemorrhage, 
 abortion or tubal pregnancy; (c) from hemoptysis, aneurysm, car- 
 diac disease or tuberculosis; (d) from carcinomatous ulcerations in 
 the uterus, gastro-intestinal tract, etc.; (e) from round ulcer of the 
 stomach or duodenum; (/) from varicosities, as in the leg, stomach 
 or oesophagus and liver cirrhosis ; (g) from blood conditions, hemor- 
 rhagic states or constitutional diseases. 
 
 Symptoms. — 1. The blood is (a) hydrcemic, the loss of fluid being 
 supplied by the tissues, and its specific gravity is lowered, (b) The 
 red disks are reduced to 50 or even to 20 per cent., are often irregu- 
 lar in contour (poikilocytosis), pale and poor in haemoglobin; their 
 diameter may be increased; generally there are some normoblasts. 
 (c) The haemoglobin is lessened even more than the red cells, (d) 
 The leukocytes at first show a moderate increase; the polymorpho- 
 nuclears are decreased and the mononuclears increased. In sudden 
 anaemia with rapidly resulting death the red cells are seldom nucle- 
 ated and there is no leukocytosis, because the bone marrow makes no 
 effort to regenerate the blood. (See Plate XVI, Fig. 3.) 
 
 2. There is marked anwmia of the skin and mucous membranes. 
 Some oedema results from chemical changes in the blood or malnu- 
 trition and increased permeability of the vessel walls. The pulse is 
 weak and becomes frequent with the least exertion. Nevertheless, 
 the vasomotor system accommodates itself to a loss of one-quarter of 
 the blood volume; a greater loss produces cardiac weakness. Some- 
 times the heart action seems more violent and respiration deeper 
 and more rapid than normal. 
 
 3. Albuminuria. After a large hemorrhage no obvious microscopic 
 change in the renal epithelium is detected, whence it seems that 
 albuminuria is due to undue permeability of the renal vessels. 
 
 4. The nervous and eye symptoms may be marked. Amblyopia 
 
SECONDARY ANEMIA. 813 
 
 and amaurosis, known to Hippocrates, are at first functional, but 
 usually later degeneration or inflammation of the retina develops ; as 
 the blood pressure rises, retinal hemorrhages may follow. The pa- 
 tient sees spots before the eyes. Occasional nervous manifestations 
 include aphasia or vertigo; delirium and hallucinations are chiefly 
 terminal events ; in some cases lasting psychoses develop. 
 
 5. The autopsy findings in fatal cases are fatty degeneration, par- 
 ticularly of the heart, endothelium of the vessels, liver, brain, stomach 
 and kidney cells, which is usually caused by imperfect oxygenation. 
 Hemorrhages in the uterus, gums and retina are due to impaired 
 nutrition of the vessel walls. The bone marrow changes from a 
 yellow to a red color and abounds in normoblasts. 
 
 Prognosis. — The patient may survive the loss of more than one- 
 third or one-half of the blood; Hayem reports recovery after the 
 number of red cells fell to 550,000. Men stand hemorrhage better 
 than women and young children ; the loss of a pint may cause death 
 in arteriosclerotics. Recovery is more rapid in acute than chronic 
 hemorrhage. In moderately severe hemorrhage recovery may be 
 complete within a week ; water and albumin are readily yielded to the 
 blood by the tissues; the red cells regenerate more slowly and the 
 haemoglobin is the last element to reach normal. Increase in the 
 coagulability of the blood is a favorable prognostic. According to 
 Bierfreund, a loss of 10 to 15 per cent, of the blood is restored in 
 eight days; of 16 to 20 per cent., in twenty days; of 21 to 25 per 
 cent., in twenty-two days and of more than 25 per cent., in twenty- 
 nine days or more. 
 
 Treatment. — This has been considered under gastric ulcer and in- 
 testinal hemorrhage in typhoid, viz., absolute rest, morphine to insure 
 quiet and salt infusions only in extreme cardiac failure. 
 
 II. Chronic Secondary Anaemia. — Etiology. — Its possible causes are 
 numerous; the chief types are (a) hemorrhages like those listed 
 under acute post-hemorrhagic anaemia, but frequent and per- 
 sistent, as chronic hemorrhoidal bleeding, (b) Poor hygiene; 
 overwork, long hours in poorly-ventilated, sunless offices or factories ; 
 insufficient food or food poor in iron, (c) Exhausting discharges 
 or loss of albumin, as frequent pregnancies with prolonged lac- 
 tation, albuminuria, respiratory or alimentary catarrh or pro- 
 tracted suppuration, with its attendant loss of nuclein. (d) Acute 
 infections, as typhoid, diphtheria, rheumatism or malaria, in which 
 the activity of blood-making centres is diminished and food is 
 poorly assimilated; chronic infections, as syphilis and tuberculosis. 
 (e) Gastro-intestinal and possibly other intoxications. (/) Neo- 
 plasms acting as mechanical obstructions (as those of the oesophagus 
 or pylorus), affecting sometimes the bone marrow by metastases de- 
 posited there, sometimes causing repeated losses of blood or elab- 
 orating toxins, which break down the tissue albumins ; in neoplasms 
 the reduction of the blood in red cells and haemoglobin averages 55 
 to 66 per cent, of normal, (g) Parasites (oxyuris, ascaris, echino- 
 
814 DISEASES OF THE BLOOD. 
 
 coccus, etc.) ; and (h) poisons (alcohol, lead, arsenic or phosphorus) 
 may produce anaemia. 
 
 Symptoms. — The blood is pale and its specific gravity is lowered. 
 As a rule the red disks and haemoglobin are reduced in rather close 
 parallelism. The haemoglobin may fall to 18 or 14 per cent, of nor- 
 mal and the red cells may, in rare instances, approach the count of 
 pernicious anaemia. The red cells stain unequally and their umbili- 
 cation is clearer, so that the haemoglobin may even appear as a slight 
 peripheral ring. They show less poikilocytosis than in acute post- 
 hemorrhagic anaemia and many of them are undersized. Some nu- 
 cleated erythrocytes appear, but less than in the acute post-hemor- 
 rhagic form. The white cells vary with the causal conditions. As a 
 rule the polymorphonuclear neutrophiles are increased and the eosino- 
 philes (normally 4 to 6 per cent.) are decreased. The latter are often 
 increased in parasitic anaemias, up to 10 or even 50 per cent. In 
 some chronic anaemias the leukocytes are diminished. 
 
 As to general symptoms it is frequently difficult to decide whether 
 they result from the anaemia or from its cause. An anaemic skin, 
 muscular adynamia, irritable weakness and a tendency to oedema and 
 hemorrhage into the skin, mucosae and serosae may be noted. The 
 appetite is poor and tenderness over the stomach, nausea and decrease 
 or increase of the HC1 may be observed. The intestinal functions 
 are usually normal, though the motor power may be tardy. The aro- 
 matic sulphates of the urine are frequently increased. Exceptionally 
 symptoms resembling those of pernicious anaemia may develop, as 
 alteration of the bone marrow, fatty heart, cerebrospinal degeneration, 
 atrophy of the gastro-intestinal cells and retinal hemorrhage. For 
 differentiation see Pernicious Anemia. 
 
 Treatment. — The treatment depends upon the cause, for which thor- 
 ough and repeated search should be made. The hygiene of the home 
 and place of work should receive consideration. Fresh air, sunlight 
 and proper food are often difficult to obtain for the lower classes. 
 Iron and arsenic are valuable in simple types (v. Chlorosis and 
 Pernicious Anemia). 
 
 LEUKEMIA. 
 
 Definition. — Leukaemia (leukocythaemia) is a disease of haemogen- 
 esis, characterized by an increase of the leukocytes, a decrease in the 
 red cells and haemoglobin, hyperplastic alteration of the bone marrow, 
 lymph glands and spleen and by secondary infiltration into various 
 organs and tissues. It was discovered by Bennett and independently 
 by Yirchow (1841). 
 
 Classification. — The older classification embraced (a) the splenic 
 and (b) the glandular (Yirchow) types to which Neumann added (c) 
 the medullary form; Behier described a gastro-intestinal form and 
 Phillippart, Sachter and Kaposi a dermal variety. This classification 
 is clinical, but that of Ehrlich is based on the blood findings; he 
 classifies the disease as follows: 
 
LEUKEMIA. ' 815 
 
 T. Lymphatic leukaemia, (i) The acute form, which runs a very 
 rapid course and resembles an acute infection, with lymphaemia, 
 moderate or no splenic enlargement, fever, hemorrhages, lymphatic 
 enlargement and stomatitis, (ii) The chronic form, with lymph- 
 semia, enlarged spleen and glands and a protracted course. 
 
 II. Myelogenic leukaemia with great polymorphism in the blood. 
 
 I. Acute Lymphatic Leukaemia. — Acute lymphatic leukaemia (acute 
 lymphcemia) includes nearly all acute leukaemias. The term does 
 not imply that the lymph glands are the cause, because there is grow- 
 ing evidence that the bone marrow may be the seat of the causal 
 change and that it may contain a parent cell for both leukocyte and 
 lymphocyte. The chief pathological finding is hyperplasia of the 
 lymphadenoid tissue. The course is that of a rapid infective disease, 
 usually with an acute onset, lymphaemic blood findings, asthenia and 
 often fever; it is fatal in a few days to a few weeks. The disease 
 occurs at any age, but especially in children, and 66 per cent, of cases 
 are in males. The bacteriological findings are inconstant ; the amoeba 
 described by Lowit is considered an artifact by haematologists. The 
 disease is infrequent. 
 
 Symptoms. — The prodromal symptoms may be headache, pain in 
 the neck, spleen, joints or head, epistaxis, mental obscuration, dys- 
 pnoea or stomatitis, after which four cardinal findings develop : — 
 
 1. Lymphadenoid Changes. — Lymph gland intumescence is very 
 frequent, is usually moderate and sometimes disappears after the 
 initial swelling; splenic enlargement occurs in 66 per cent, and is of 
 slight degree ; in children it may be enormous ; tonsillar hypertrophy 
 occurs in 50 per cent., sometimes with hemorrhage and necrosis. Reed 
 published a case of acute lymphaemia without glandular enlargement. 
 
 2. Hemorrhages. — Hemorrhages are most characteristic and fre- 
 quent; they occur (a) in the skin, as petechiae or larger effusions, 
 with necrosis or ulceration in areas of lymphaemic infiltration; (b) 
 in the mouth, gums, palate and pharynx, as petechiae, erosions or 
 extensive necrosis, developing in areas of lymphaemic infiltration; 
 (c) in the retina in practically 100 per cent, with the same ana- 
 tomical basis ; (d) visceral hemorrhages, in the brain, cerebral nerves, 
 labyrinth and spleen; (e)' from mucous surfaces, the vagina, urinary 
 passages and intestines ; and (/) from the serous membranes. 
 
 3. Necrosis. — Necrosis in the infiltrated foci of the mouth occurs 
 in 70 per cent, and is per se highly suggestive in the diagnosis (Brad- 
 ford and Shaw). 
 
 4. Lymphaemia. — Lymphaemia is the crucial finding. The ratio 
 between the white and red cells is 1 to 2, 10 or 20; the number of 
 lymphocytes may reach 918,000 to the cubic mm. In general, the 
 increase of leukocytes is less than in the splenomedullary form and 
 averages 350,000. The polymorphonuclears are usually normal or 
 decreased, the eosinophiles constitute about 1 per cent, of the white 
 cells, a few myelocytes may be found, but the salient increase is in the 
 lymphocytes and chiefly in the larger forms; the lymphocytes may 
 
816 DISEASES OF THE BLOOD. 
 
 constitute 90 or even 99 per cent, of the leukocytes. Some very large 
 primordial cells are found, from which the red and white cells are 
 probably derived. The red cells vary between 1 and 3 million and 
 some nucleation may occur. The haemoglobin usually falls below 50 
 per cent., or much lower in per acute cases. (For varieties of leuko- 
 cytes, see Plate XVI, Fig. I. For blood picture see Plate XV, Fig. 
 2, and Plate XVI, Fig. VI.) 
 
 Other findings are pallor, frequent pulse, priapism, exophthalmos, 
 swollen, infiltrated liver, increased flow of urine, with increased urea 
 and uric acid (increased nuclein destruction) ; albuminuria, ne- 
 phritis and endocarditis are sometimes observed. Lymphomatous 
 masses may cause dyspnoea. The fever is irregular, both in type and 
 occurrence. Intercurrent sepsis reduces the splenic and lymphatic 
 enlargements, the white cells decrease even to normal and sometimes 
 an ordinary polymorphonuclear leukocytosis replaces the typical blood 
 findings. The bone marrow is constantly involved, especially in the 
 long bones; it is mostly red and jelly-like in color, more rarely red- 
 gray or hemorrhagic. The typical granular neutrophile myelocytes 
 are few, while large and small lymphocytes abound as in the circu- 
 lating blood; this is known as "the lymphoid marrow." Opinions 
 vary as to whether the lymphatic or the medullary lesions are the 
 primary change. Lymphatic deposits occur in the mouth, stomach, 
 intestines (simulating typhoid ulcers), muscles, liver, kidneys and 
 thymus. In a personal case the teeth were hidden by the infiltrated 
 gums. The patient usually emaciates. Fatty and degenerative 
 changes in the heart and other viscera are observed. 
 
 Diagnosis. — Though the splenic and lymphatic enlargements, pete- 
 chia?, stomatitis, fever, ulceration and hemorrhages are frequently 
 most suggestive, the blood findings alone are distinctive ; they exclude 
 typhoid, purpura, scurvy, trichinosis, diphtheria, septicaemia, severe 
 acute anaemias and chloroma (v. i.). 
 
 II. Chronic Lymphatic Leukaemia. — Chronic lymphatic leukaemia 
 is rarer than acute lymphaemia and runs a clinical course of from 
 months to years, with lymphadenoid hyperplasia and lymphaemia; 
 it is closely associated by some writers with malignant lymphoma 
 and Hodgkin's disease. 
 
 Etiology. — No constant bacteriological cause has been proven. 
 
 Symptoms. — The symptoms begin insidiously and the disease may 
 be first detected by (1) swelling of the lymph glands, usually in the 
 neck, which may reach enormous dimensions. The axillary glands 
 are large, while the inguinal are less massive; glandular swelling, 
 as a rule, extends from above downward. Sometimes the internal 
 glands alone are swollen and in rare cases the lymphatics are not 
 enlarged. The glands are discrete, without periadenitis, oval and 
 soft, being much less hard than in pseudoleukemia. Sometimes 
 moderate pain is experienced and there may be compression of vital 
 structures, as the vagus, trachea and portal vein. The glands con- 
 tinue to grow until death, unless an intercurrent affection, as ery- 
 sipelas ? causes them to shrink temporarily. 
 
LEUKEMIA. 817 
 
 2. Splenic hyperplasia and intumescence is practically constant, 
 though less extreme than in the myeloid type or in Hodgkin's disease. 
 The spleen often projects from beneath the costal arch bnt an inch 
 or so, it grows as the disease progresses and is usually proportionate 
 to the duration of the disease. In a case of Virchow the spleen was 
 not enlarged. Intercurrent sepsis, cholera, erysipelas, etc., may cause 
 the splenic tumor, lymphsemia and the lymph nodes to temporarily 
 disappear, but all three findings may persist in such infections. 
 Diarrhoea and treatment by arsenic or quinine may likewise effect 
 splenic reduction. Perisplenic adhesions and thickening are common 
 and the organ is soft or hard according to the duration of the disease. 
 The tonsils are often swollen, in which hemorrhages, with or without 
 necrosis, are frequently observed. 
 
 3. The changes in the bone marrow seldom cause pain. The essen- 
 tial character of the marrow alteration is undetermined. 
 
 4. The blood reveals an absolute and a relative lymphcemia. The 
 red and white cells may have a ratio of 100 to 1, and yet the lympho- 
 cytes constitute 90 to 99 per cent, of all the white cells. They are 
 mostly small lymphocytes (Pinkus), whereas the larger forms occur 
 in the acute lymphatic leukaemia. (Ehrlich holds that large lympho- 
 cytes predominate.) Many of them are altered, degenerated or 
 swollen. The polymorphonuclears are reduced from 70 to 10 or 
 even 1 per cent. Myelocytes are usually absent. The red cells aver- 
 age 4,000,000, but seldom fall lower than 2,000,000. The lympho- 
 cytosis may temporarily disappear during infection and in one in- 
 stance this was permanent. (See Plate XVI, Pig. 1.) 
 
 5. The shin may itch or be the seat of papular eruptions. Lym- 
 phomata form in the skin, sometimes of considerable size ; infiltrated 
 reddish deposits may precede the lymphsemic blood findings. (Edema 
 occurs, while hemorrhages are rarer. Pacial growths are observed 
 similar to chloroma (v. Medullary Form, Diagnosis) or to the sym- 
 metrical swelling of the lachrymal and salivary glands. 
 
 6. The heart is degenerated, as are the vessels, from which hemor- 
 rhages may occur. Intraperitoneal hemorrhages from ruptured 
 adrenals are reported. The nerve trunks may degenerate with bulbar, 
 spinal and nerve trunk symptoms. Retinitis leuksemica or optic 
 nerve involvement may impair vision. The liver is swollen from 
 degeneration and from lymphatic infiltration. Dyspnoea is most com- 
 mon and occurs early from the anaemia, mechanical compression of 
 the air tubes, vessels or nerves or from leukemic changes within the 
 follicles of the mouth and air passages. Renal infiltration is frequent. 
 
 Course. — The course of the disease is slow; it develops gradually 
 and passes slowly into cachexia, though now and then extension in 
 the glands is " explosive " (Trousseau). Remissions of weeks or 
 months are not uncommon. Intercurrent disease may be fatal, as 
 pneumonia and mechanical stasis, suffocation and acute exacerbations 
 of the disease itself may hasten the course. 
 
 Diagnosis. — The diagnosis, suggested, perhaps by the skin lesions, 
 52 
 
818 DISEASES OF THE BLOOD. 
 
 lymphomata, splenic enlargement or hemorrhagic tendency, is posi- 
 tively made only by the blood examination. 
 
 III. Myeloid Leukaemia. — Myeloid leukaemia (myelcemia, myelo- 
 genic or medullary leukoemia) is the most common form of leukaemia 
 and occurs for the most part between the twentieth and fiftieth years ; 
 67 per cent, of cases occur in males. Bacteriology has shown no 
 cause. The disease is frequent among the Polish Jews and the poorer 
 and working classes. A history may be obtained of malaria, syphilis, 
 typhoid, influenza, stomatitis, tonsillitis, digestive disturbance, preg- 
 nancy, disturbed menstruation, the climacteric and trauma, though 
 they are only accidental occurrences. The disease has been noted 
 in three generations. Leukaemia has been also observed in animals. 
 Symptoms. — 1. Blood. — The specific gravity is decreased from 1,055 
 to 1,045-36 ; it is watery or sometimes chocolate-colored; it coagulates 
 slowly. In extreme cases the coagula are white (leukaemia) or 
 slightly greenish. Large white clots are observed at autopsy and 
 Yirchow thought he had incised an abscess when he opened the left 
 ventricle in his first autopsy. Microscopically the white cells are 
 enormously increased, even as much as 1 to 1, or in Robin's case, 2 
 whites to 1 red cell. The highest count the author has seen was in 
 Mercy Hospital in 1908 ; the whites and reds numbered 1,200,000 
 each. Amoeboid movement is greatly decreased. (Plate XYI.) 
 
 The characteristics of the white cells are: (a) The large mononu- 
 clear neutrophils ("mark cells," myelocytes), are found early and 
 amount to 30-50 per cent, of the leukocytes. They are not pathog- 
 nomonic, having been found (in small numbers) in pneumonia, 
 uraemia, chlorosis, skin diseases, syphilis and in normal blood, (b) 
 Mononuclear eosinophiles occur in other diseases, but in myeloid 
 leukaemia are absolutely, though not necessarily relatively, increased. 
 They are absolutely necessary to the diagnosis, (c) The "mast 
 cells" must be absolutely increased; they are polymorphonuclears 
 with basophile granulations which do not show with the tri-acid stain. 
 Often they are relatively increased from 0.28, the normal percentage, 
 to 1 or indeed 18 per cent. They are constant in this type, (d) 
 The polymorphonuclear neutrophils and eosinophiles constitute 30- 
 60 per cent, of the leukocytes. ( e ) The lymph ocytes are increased. (/) 
 Atypical leukocytes, dwarf forms and white cells containing mitoses, 
 fat globules or red cells may also be found. ( See Plate XYI, Pig. I. ) 
 
 The red cells are decreased to three or two million, though leukaemic 
 patients are not always anaemic and an excess of red cells has been 
 described. Toward the end the red cells may decrease to even 300,000 
 and thus resemble pernicious anaemia. The reds may become de- 
 generated, necrotic, polychromatic or acquire amoeboid movement, 
 nuclei and mitoses. Xucleation occurs more frequently than in any 
 other anaemia (Ehrlich"), normoblasts being found regularly. The 
 color index is 1 or less than 1. (See Plate XY, Fig. I, and Plate 
 XYI, Pig. YII.) 
 
 2. Splenic Enlargement. — This is usually the first symptom 
 
LEUKEMIA. 819 
 
 to attract attention; it appears with the blood findings and is most 
 constant ; spleniculi, if present, are enlarged. Instead of a weight of 
 5 to 7 ounces, 18 to 28 pounds are reported; from the normal meas- 
 urements, 3 to 5 inches, dimensions of 15 inches are frequently ob- 
 served. The form of the organ is preserved. The notches are usually 
 clearly palpable and the edges are plump, rounded and hard. It 
 may reach to the navel or into the pelvis, displacing other organs. 
 The size varies during intermissions ; without cause ; from adminis- 
 tration of arsenic and quinine and from diarrhoea or hemorrhages. 
 It is enlarged after meals. A systolic murmur or pulsation is some- 
 times detected. Crackling under the fingers and tenderness indicate 
 soft adhesions (perisplenitis). Firm adhesions may develop and the 
 capsule may thicken. Though at first soft, it later becomes very firm, 
 the pulp and trabecule hypertrophy and new lymphoid deposits are 
 clearly marked against the reddish pulp (myeloid metaplasia). The 
 author has seen three cases of leukemic floating or wandering spleen, 
 two of which had been operated on as uterine tumors. Rupture is a 
 rare complication. 
 
 3. Glands. — The glands are enlarged in 33 per cent. According 
 to the most recent views, the glands are heteroplastic, due to new- 
 formed myeloid tissue, " metastases " from the bone-marrow. Soft 
 at first, they later become hard. Caseation and suppuration are most 
 infrequent. As in the other types of leukaemia, recurrent compres- 
 sion of the vagus, trachea, portal vein and bronchi may result. Retro- 
 sternal dulness has been observed. 
 
 4. Bones. — Bone changes, recognized first by Neumann, occur in 
 the spongy and long bones (ribs, tibiae, sternum and vertebrae). The 
 bone is mostly rarefied and there may be tender or yielding areas. 
 The histological changes in the marrow are (a) the lymphoid (Neu- 
 mann), in which the marrow resembles currant jelly, is reddish and 
 consists of small lymphocytes ; it is sometimes hemorrhagic ; the 
 normal fatty appearance disappears. (&) The pyoid, which is seen 
 mostly in the myelogenic type; the marrow is not transparent, but 
 gray; its cells are rich in protoplasm with one or many nuclei. In 
 both forms nucleated red cells abound, also eosinophile cells and large 
 cells with neutrophile granules and large nuclei. 
 
 5. Vascular System. — The heart is moderately distended with 
 white clots and, as Virchow described in his first autopsy, opening 
 the heart was like incising an abscess. The muscle is pale and fatty 
 and nodules of leukaemic infiltration in the myocardium, foci of hem- 
 orrhage and pericardial nodes and transudation are frequent. Car- 
 diac dislocation from pressure by enlarged glands and spleen, anaemic 
 bruits, venous pulsation, bruit de diable, palpitation, systolic mur- 
 murs from pressure by the glands on the vessels and centripetal ven- 
 ous pulse are observed. The radial pulse is rapid. Dyspnoea results 
 from weak heart, vagus pressure, nodules in the lung, bronchitis, 
 hydrothorax, pressure of the spleen on the diaphragm, tilting of the 
 heart upward and compression by the glands. 
 
820 DISEASES OF TEE BLOOD. 
 
 6. Respiratory Tract. — Modules are frequently seen in the 
 larynx, trachea, thyroid and thymus, often with hemorrhage, some- 
 times resulting in tracheal, bronchial or laryngeal stenosis. In the 
 lungs (Deiter) lymphoid nodules may necrose and cavities like those 
 of caseous tuberculosis may appear (Bottcher). Small myeloid foci 
 of leukocytes may resemble miliary tuberculosis (Yirchow). Bron- 
 chitis with many eosinophile cells in the sputum, nodes along the 
 pleural vessels and pleural hemorrhage, transudation and exudation 
 have been observed. 
 
 7. Fever. — Fever occurs in the majority of cases. It is rarely 
 high ; temperature may be normal for months or it may resemble re- 
 current fever, typhoid, sepsis or malaria, though it follows no one type. 
 
 8. Digestive Canal. — Anorexia, stomatitis or pharyngitis with 
 ulceration of the lymphoid deposits, dysphagia from glandular pres- 
 sure on the oesophagus, eructations and vomiting are occasional symp- 
 toms. Diarrhoea is very common, leucin and tyrosin being found in 
 the stools. An enteric type is described by Behier and others, in 
 which the bowel symptoms are conspicuous ; the lymphadenoid struc- 
 tures in the ileum are prominent and Friedreich once confused this 
 type with typhoid on account of the ulceration, enlargement of the 
 spleen and hemorrhage from the bowel. The abdominal lymph glands 
 may be enlarged alone. The liver is much enlarged and may weigh 
 13 to 25 pounds. Its surface is smooth, its consistence increased and 
 its edges plump. Myeloid deposits occur in the liver and dislocate or 
 deform the rows of liver cells. The portal lymph nodes may be en- 
 larged. Icterus is infrequent and ascites is common from cachexia 
 or leuksemic peritonitis. The fluid contains many white cells and 
 the myelocytes predominate as in the blood. 
 
 9. Kidneys. — The kidneys are frequently involved ; there may be 
 " myeloid " infiltration and cloudy, fatty and amyloid alteration. 
 The urine is decreased, pale and strongly acid. The uric acid 
 may amount to 20 or 105 grains (Yirchow, Laache). Normally 
 uric acid is as 1 : 50-80 of urea, but in leukaemia it is 1 : 16. The 
 uric acid results from increased formation of the acid. The xanthin 
 bodies are increased. Albuminuria is usual only in the last stages. 
 The amount of urea depends on the degree of cachexia. Priapism 
 occurs from nervous lesions or thrombosis of the dorsal vein. Amen- 
 orrhoea is frequent in women. 
 
 10. Nervous Symptoms. — Nervous symptoms may develop, as 
 delirium, neuralgia, headache, syncope, vertigo or mania or rarely 
 bulbar palsy, facial paralysis, apoplexy or symptoms like those of 
 brain tumor. 
 
 The Eye. — Lymphoid nodules may develop in the orbit, possibly 
 with exophthalmos. The retinitis leukcemica, first described by Lie- 
 breich, is not inflammation, but leuksemic infiltration and occurs in 
 33 per cent. ; the retina is pale, its arteries small and veins large; the 
 papilla is " washed" and yellow spots with red borders appear; 
 hemorrhages also occur (Plate VIII, Fig. 9). 
 
LEUKJBM1A. 821 
 
 The Ear. — Vertigo, deafness, tinnitus and an atactic gait may re^ 
 suit from growths in the labyrinth ; sudden deafness from hemorrhage 
 is described by Steinbriigger, Pepper, Wagenhausen and Lanois ; the 
 author saw three such cases within one year. 
 
 11. Skin. — There may be acne, pigmentation, oedema, pruritus, 
 lymphoderma perniciosa ( diffuse or tumor-like infiltrations) or sweats. 
 
 12. Hemorrhages. — Mosler found them in 52 and Cabot in 80 
 per cent. Epistaxis is the most common and may be fatal. Stomach 
 and bowel hemorrhages rank next and those from the respiratory and 
 genito-urinary tracts, the skin, joints, muscles, subcutaneous tissues 
 or brain are rarer. The writer has seen three massive hemorrhages 
 under the skin of the thorax, one in Leube's clinic and two in his own 
 practice. Death has followed the extraction of teeth in a leukaemic 
 subject. The writer saw Kolisko autopsy a case in which a slow 
 ascending paralysis followed hemorrhage between the spinal pia 
 mater and arachnoid. 
 
 Complications. — Complications are nephritis, pneumonia, endo- 
 carditis, amyloid degeneration, diabetes and gangrene. Sussmann 
 could collect but 25 cases of complicating tuberculosis; this number 
 was increased by Dock to 27 ; the author saw a case with E. W. An- 
 drews, in which tuberculous pleurisy developed ; tubercle bacilli and 
 mononuclear white cells were recovered from the blood-stained fluid. 
 In another case miliary tuberculosis developed. 
 
 Diagnosis. — The diagnosis was formerly a matter of great difficulty, 
 because the difference between leukaemia and leukocytosis was made 
 one of degree only and various limits were placed, beyond which 
 leukocytosis was said to cease and leukaemia begin. The mere num- 
 ber of white cells is no criterion, because a ratio of 1 to 20 may be 
 leukocytosis (as in Strauss' case of gastric cancer), and on the other 
 hand, 1 to 200 may be leukaemia (von Eoorden) . Leukocytosis from 
 digestion, fasting, marasmus, pregnancy, acute infections or in the 
 death agony is of the ordinary polymorphonuclear neutrophilic type. 
 (Plate XVI, Fig. IV.) Leukocytosis is a symptom, but leukaemia is 
 a disease. The polymorphism of the blood is striking; according to 
 Lazarus, there must be (a) mononuclear leukocytes with granulations 
 (myelocytes); (b) increased mono- and polynuclear eosinophiles ; 
 (c) absolute increase in the "mast cells," and (d) nucleated red cells 
 must be readily found. The gross splenic, medullary or lymphatic 
 lesions are of but presumptive value in diagnosis and the poly- 
 morphic blood picture alone differentiates from pseudoleukemia, 
 typhoid, purpura, anaemia, sepsis, etc. 
 
 Caution should be exercised (a) during remissions, when the blood 
 is rarely morphologically normal, no matter what the number of 
 leukocytes. In one of the author's cases the leukocyte count dropped 
 from 1,250,000 to 9,000 in a week, though the myelocytes still con- 
 stituted 33 per cent, of the white cells, (b) Care is also necessary 
 during acute infections when the leukaemic characteristics may disap- 
 pear, as during typhoid, acute miliary tuberculosis, influenza or 
 sepsis, (c) The blood findings may become atypical before death. 
 
822 Diseases of tSe blood. 
 
 Similar Conditions. — 1. Chloroma. — Chloroma is considered a ma- 
 lignant type of leukaemia or a " neoplastic hyperplasia of the red 
 bone marrow/' by Dock and Warthin; 46 cases are on record. It is 
 closely related to acute lymphaemia. Lymphomata form, causing 
 orbital pain, tinnitus, deafness, temporal and orbital swellings and 
 such ocular symptoms as exophthalmos, strabismus and disturbed 
 vision. The lymphomata are greenish, whence the name chloroma. 
 It usually develops before the twentieth year. Retinal infiltration 
 and hemorrhages occur. Other findings are ataxia, pallor, sternal 
 tenderness, hemorrhages, severe anaemia, often but not always chang- 
 ing to leukaemic characteristics, greenish urine and greenish lymphom- 
 atous infiltration of the bone marrow, periosteum (sometimes with 
 Charcot-Leyden crystals), the liver or lungs and greenish lymph- 
 adenoid changes. The haemoglobin and red cells are reduced, even to 
 15 per cent, and 500,000 respectively. The leukocytes number about 
 50,000, but have been as numerous as half a million; they are chiefly 
 lymphocytes. The affection is always fatal, usually within six months. 
 
 2. I/EUKANiEMiA. — Leukanaemia is described by Leube as a severe 
 blood disease in which the myelogenous formation of both the red and 
 white cells is disordered, i. e., it combines some features of both 
 leukaemia and pernicious anaemia. Its features are (a) a progressive 
 anaemia, waxy color and asthenia; (6) numbers of normoblasts, but 
 especially megaloblasts ; (c) no abnormal pigments in the urine, no 
 enlargement of the lymph glands (though since reported by Mat- 
 tirolo) and no siderosis of the tissues; (d) no true leukaemic blood 
 findings, but considerable myelocytosis and lymphocytosis; (e) firm 
 connective tissue in the bone marrow and (/) enlargement of the 
 spleen and prevertebral haemolymph glands. 
 
 3. Secondary Cancer in Bone. — There are 13 cases in the litera- 
 ture in which cancerous bone metastases have produced blood findings 
 rather like those of pernicious anaemia and increase of the leuko- 
 cytes (of which the myelocytes constituted 4 to 17 per cent.). 
 
 Prognosis. — The prognosis is bad. It may last 5 to 8 or even 10 
 years after a diagnosis has been made, but a little over 1 year is the 
 average course. The beginning is insidious and enlargement of the 
 abdomen, dyspnoea, anaemia and enlarged glands are the cause for 
 seeking medical treatment. The nutrition is usually good. Sudden 
 death may occur, either without discernible cause or from hemorrhage 
 of the brain, haematemesis, marasmus, anasarca, diarrhoea, pleuritis, 
 peritonitis, deep coma or pneumonia. Remissions occur, but the 
 blood findings persist. Ewing observed 3 acute cases arid Billings 
 and Capps published 2 and collated 7 others from the literature 
 (which resembled an infection with hemorrhages, moderate splenic 
 and lymphatic hyperplasia, severe anaemia, often necrosis of the 
 throat and jaw, with 16,000 to 540,000 leukocytes and often with 
 low fever). A permanent cure after erysipelas has been reported 
 by Richter. 
 
 Treatment. — Hygienic measures, rest and a careful diet are of some 
 
PSEUDOLEUKEMIA. 823 
 
 benefit. Fats and carbohydrates cause dyspepsia, whence Litten gives 
 animal foods, eggs, milk, raw chopped meat, koumyss, peptones, 
 oysters, beer, wine, zwieback, spinach, etc. ; an ice-bag to the spleen 
 may mitigate pain over it. Splenectomy is most irrational, for 
 leukaemia is a primary disease of the bone marrow; 94 per cent, of 
 Bissel-Hagen's group of 35 died. The great danger is hemorrhage. 
 Great caution must be observed in using purges, which, as in Addi- 
 son's disease, may cause sudden collapse and death. Inhalations of 
 oxygen, blood infusions, spleno- or organotherapy and iron are in- 
 ferior to arsenic , which decreases the number of white blood cells and 
 the size of the spleen. Hemorrhages may cease and the number 
 of red cells increase. Ebert gives arsenic with quinine. It is in- 
 jected locally by Mosler into the glands and spleen, but in the author's 
 experience without success. Phosphorus may soften the glands. 
 Special care should be employed in tapping an ascites, for peritonitis 
 is prone to develop. The x-rays may prove decidedly beneficial. In 
 1 case already alluded to the patient lived 19 months after the day he 
 seemed to be dying. The way it helps is still a mystery. The x-rays 
 produce a leukolytic substance (Capps and Smith). Wendell thinks 
 90 per cent, are benefited. In some cases the glandular and splenic 
 enlargements and the blood findings have wholly disappeared, as in 
 1 case observed by the writer. 
 
 PSEUDOLEUKEMIA. 
 
 Definition. — A disease resulting in chronic anaemia or cachexia, of 
 which the chief symptoms or signs are enlargement of the spleen or 
 lymph structures. The definition of the disease as "leukaemic ap- 
 pearance without leukaemic blood findings " no longer holds. Such 
 conceptions would include glandular tuberculosis, Kundrat's lympho- 
 sarcomatosis, etc. It is also called Hodgkin's (1832) disease, pseudo- 
 leukaemia (Cohnheim), adenia (Trousseau), malignant lymphoma 
 (Billroth) and anaemia (cachexia) lienalis or lymphatica (Wilkes). 
 
 Etiology. — The etiology is not clear. The disease occurs after local 
 lymphatic disturbances in the neck, following otorrhoea, coryza or 
 tonsillitis. Like chloroma and leukaemia, 75 per cent, of cases occur 
 in males between twenty and thirty years of age. The disease is not 
 uncommon in children and often occurs in the lower animals. It also 
 sometimes runs through a family. Malaria, syphilis, scrofulosis, 
 alcoholism, rhachitis, diarrhoea, typhoid, measles and scarlatina are 
 often noted in the patient's history, but their relation, if any, is ob- 
 scure. Suspected to be mycotic, many negative and variant examina- 
 tions have been made. Spirochaetes are recently reported. The dis- 
 ease has no well-established relation to leukaemia, as Cohnheim held, 
 yet Fleischer, Penzoldt, Mosler and Senator have observed transitions 
 from pseudoleukaemia to leukaemia. Neumann held that the leukaemic 
 blood changes depended solely on the hyperplastic marrow changes 
 and that as long as the hyperplasia involves only the spleen and glands 
 
824 DISEASES OF THE BLOOD. 
 
 pseudoleukemia results. Sternberg and others have maintained that 
 it is tuberculosis, a theory disproven by Dorothy Reed and Simmons. 
 Symptoms. — Its types are (a) lymphatic; (&) lienal, pseudoleu- 
 kemia splenica, splenomegalia ; (c) mixed and (d) myelogenic. 
 
 1. Lymph Glands. — Swelling of the lymph glands is generally the 
 earliest symptom; the cervical glands first become enlarged, then the 
 axillary glands after a variable period and later the subpectoral, 
 inguinal and other groups. They are soft and elastic ; at first the in- 
 dividual glands are round or oval, discrete and smooth; later, with 
 increasing size, they fuse into harder, irregular masses as large as the 
 fist or a child's head, particularly those in the neck. They may 
 be painful from periadenitis, but never transcend the gland capsule 
 and seldom caseate or suppurate. From the neck, where the jugular 
 veins may be compressed, the glandular enlargement often passes to 
 the intrathoracic glands, which are more often enlarged than the 
 other internal nodes; this often occasions dyspnoea, compression of 
 the superior cava (whence the development of a large collateral cir- 
 culation on the chest-wall), dysphagia, bronchial compression and 
 recurrent laryngeal or vagus paralysis. The veins of the arm may 
 be compressed, causing oedema. In the abdomen the retroperitoneal, 
 mesenteric, periportal, iliac and other groups may enlarge greatly; 
 according to their location, abdominal pain, oedema of the legs, para- 
 plegia, hydronephrosis, ascites and jaundice may ensue. Histolog- 
 ically, the lymphadenoid changes are (a) increase in the endothelial 
 and reticular cells ; (b) hyperplasia of the lymphoid cells ; (c) forma- 
 tion of peculiar giant cells; (d) fibrosis and chronic inflammation 
 and (e) great increase of the eosinophile cells (Dorothy Reed). 
 
 2. Spleen. — The spleen is enlarged in 75 per cent, of cases. It 
 reaches dimensions rarely attained in leukaemia, but maintains its 
 form, is hard and tender and presents the same histological appear- 
 ance as in leukaemia, viz., nodes of lymphoid cells in a fibrous reticu- 
 lum. The greatest swelling of the spleen is usually observed when 
 the lymphatic glands are large and hard, yet splenomegaly may be 
 the sole symptom ; splenic hypertrophy alone, with relative increase in 
 the lymphocytes, may be classed as Hodgkin's disease, according to 
 Pinkus. 
 
 3. Bone-marrow. — The bone-marrow is less frequently involved 
 than in leukaemia. A myelogenous pseudoleukaemia has been re- 
 corded, but its exact status is still doubtful. The eosinophiles are 
 abundant in the lymph nodes and bone-marrow. 
 
 4. The Blood. — The ratio between the red and white cells is 
 normal. The haemoglobin is decreased and the color index is usually 
 1 ; the haemoglobin may be rapidly decreased as in Litten's case, from 
 85 to 40 per cent, within a week. There is usually moderate anaemia, 
 especially in advanced cases. Poikilocytes and microcytes often oc- 
 cur, megalocytes rarely and normoblasts sometimes, but the eosino- 
 philes are not increased. The blood plates are increased, but the 
 Charcot-Leyden crystals are never found. Concerning the white 
 
PSEUDOLEUKEMIA. 825 
 
 cells, there is a relative increase of lymphocytes, the chief criterion 
 of the disease, according to Pinkus and Ehrlich. The polymorpho- 
 nuclear neutrophiles are decreased. These changes may not be ob- 
 served in the earliest stage of the disease. The total of white cells is 
 not essentially increased; in the case of Askanazy the disease was 
 pseudoleukemia for two and a half years, when it became leukaemia 
 and lasted another one and one-half years. Leukocytosis in some 
 instances is a leukocytosis of the death agony or a terminal infection. 
 
 5. Other Organs. — (a) The urticarious eruptions and lymphatic 
 growths in the skin occur rather more frequently than in leukaemia ; 
 the lymphoderma perniciosa of Kaposi may be considered pseudoleu- 
 ksemic in cases with an absolute lymphocytosis. Erythema, purpura, 
 furuncles, pemphigus, prurigo from irritation of the lymphatic de- 
 posits around the sweat glands and pigmentation have been observed. 
 According to Dubreuilh (1905), 18 cases of prurigo are reported. 
 Severe sweats are frequent. (&) Symptoms of anaemia occur, as a 
 feeling of cold, vertigo, syncope, dyspnoea, oedema, hemorrhage, 
 palpitation, anorexia, dyspepsia and severe diarrhoea, (d) Local 
 pain over the liver and spleen may indicate perihepatitis or peri- 
 splenitis. Swelling of the liver may be marked and is due to lymph- 
 oid deposits. Severe muscular pain has suggested trichinosis, (d) 
 Gangrenous stomatitis or pharyngitis may occur in degenerated lymph 
 nodes in the mouth, tonsils and throat. Gastric and intestinal ulcera- 
 tions and sometimes perforation are noted, though less frequently than 
 in lymphosarcoma. Neusser noticed gastric crises like those of tabes. 
 (e) Ross and Osier described lancinating pains in the feet and oedema 
 from involvement of the spine and cava by the lymph nodes. (/) 
 Amyloidosis, bronchial catarrh and pulmonary phthisis have been 
 noted, (g) The uric acid in the urine is not increased, (h) The 
 lymphatic hyperplasia may also involve the lymphatic structures in 
 the tonsils, circumvallate glands of the tongue, the muscles, mammse, 
 eye-lids, thyroid or thymus ; secondary deposits may be noted in the 
 lungs, liver, heart, pleura and more rarely in the brain, genitalia 
 and pelvis. 
 
 6. Fever. — Fever is common. Gowers and Murchison observed a 
 chronic recurrent type, later described by Pel and Ebstein ; the term 
 is a misnomer and classification of this febrile variety as a separate 
 form is incorrect, for it has been observed in chronic malaria, lympho- 
 sarcoma, cancer and glandular and splenic tuberculosis. The urine 
 may show the diazo reaction with the fever. When the disease in- 
 volves the internal glands only, the fever may simulate typhoid. 
 Winnewarter stated that fever occurred when the glands decreased 
 in size under the administration of arsenic. Fever is rather indica- 
 tive of glandular tuberculosis or of intercurrent (terminal) infections. 
 
 Course. — The clinical course is long. The glandular swelling some- 
 times decreases with or without therapeutic measures. The extension 
 from the cervical to other lymphatic glands is generally gradual, but 
 may occur with great suddenness, as in Trousseau's case. An acute 
 
826 DISEASES OF THE BLOOD. 
 
 form of Hodgkin's disease is not well established; many are sepsis, 
 tuberculosis or acute sarcomatosis. Death may occur from intercur- 
 rent diseases, but it most frequently results from chronic cachexia. 
 Obstruction of the air passages occurs more frequently than in leu- 
 kaemia. Death may also occur from twisting of the pedicle of the 
 spleen or from hemorrhages from the nose, uterus, stomach, intestines 
 or larynx, which sometimes resemble purpura hemorrhagica of Werl- 
 hof. Very exceptionally transition into leukaemia is observed. It 
 is a question whether patients with well-developed cases ever recover. 
 Pleural effusions, diarrhoea, dysentery and vomiting from pressure 
 of the splenic tumor are unfavorable complications. 
 
 Diagnosis, Allied Affections and Differentiation. — There are two cri- 
 teria; (a) the lymphadenoid hyperplasia and chronic inflammation 
 observed when an excised node is examined histologically; other 
 kinds of cells or other degenerations excite suspicion that the disease 
 is not pseudoleukemia ; and (b) according to Pinkus, an absolute 
 lymphocytosis, with a practically normal number of white blood cells. 
 Differentiation from similar affections is as follows : 
 
 1. Glandular Tuberculosis. — Hodgkin's disease may be com- 
 plicated by or confused with, tuberculosis; in pseudoleukemia the 
 typical structure of the tubercle is lacking, but in tuberculous aden- 
 itis there may be an accumulation of large endothelioid cells between 
 which lie tubercle bacilli (Ziegler) ; after a long course caseation and 
 giant cell formation may result ; the forms of glandular tuberculosis 
 are (a) Ziegler's large cell infiltration, (b) purely hyperplastic 
 lymphoid proliferation or (c) anatomical tubercles. Of late the 
 number of reported instances of glandular tuberculosis simulating 
 Hodgkin's disease has increased enormously. The author examined 
 2 cases of supposed pseudoleukemia in which tubercle bacilli (with- 
 out anatomical tubercles) were found in the spleen and lymph nodes. 
 In the neck tuberculous adenitis is more often in the submaxillary 
 than in anterior and posterior glands, in the latter of which pseudo- 
 leukemia is more common. Tuberculosis is more frequently a local 
 than a general adenitis and is more often attended by secondary sup- 
 puration. Tiirck believes that fever and glandular tenderness indi- 
 cate tuberculosis and that node-like swellings of the lymph vessels in 
 the mouth are symptomatic of pseudoleukemia. Excision of a node 
 determines the question. 
 
 2. Anaemia Infantum Pseudoleukemia. — This disease was 
 first fully described by von Jaksch, though earlier observed by Sena- 
 tor; it is known in Italy as ancemia splenica infettiva dei bambini; 
 it is called " anemia splenica " or " pseudopernicious anemia of 
 children'' by Ehrlich. It is a profound anemia in which the blood 
 findings suggest pernicious anemia; there are normoblasts, megalo- 
 blasts, decrease of the red blood cells (1% to 3 million) and some- 
 times poikilocytes or polychromatophilia ; there is often increase of 
 the leukocytes, but rarely more than 50,000. It occurs in children 
 from nine to eighteen months of age ; the convalescence is very slow 
 
PSEUDOLEUKEMIA. 827 
 
 or death may result. Its symptoms are hardness and enlargement of 
 the spleen, swelling of the liver (less than in leukaemia and less than 
 the swelling of the spleen), profound anaemia and hemorrhages into 
 the skin or from the nose, mouth, stomach or intestines. The status, 
 of the disease is not yet determined, because the lymphocytes are fre- 
 quently increased in children and leukocytosis in general has less 
 significance than in adults. The diagnosis is especially difficult when 
 it occurs in syphilitic children; syphilis, rickets and dyspepsia are 
 common antecedents. 
 
 3. Anemia Splenica. — It is doubtful whether it should be classed 
 as an essential anaemia, liver cirrhosis, chronic splenitis or as a 
 splenic form of Hodgkin's disease, (a) The spleen is enlarged, its 
 capsule thick, its stroma increased and the endothelium of the lymph 
 sinuses sometimes proliferated (endothelioma). The cause is un- 
 known; possibly it is toxic, (b) There is an anosmia of the secondary 
 or chlorotic type; the red cells average 3,500,000, the haemoglobin is 
 even more reduced and the whites are decreased to 3 or 4 thousand. 
 (c) Hemorrhages, particularly from the stomach, occur in one-third 
 to one-half the cases, (d) In many cases there is a terminal liver 
 cirrhosis (Banti's disease), with icterus and ascites, (e) Its course is 
 very chronic, covering years. In some cases there are profound alter- 
 ations of nutrition, as stunted growth, clubbed fingers or pigmenta- 
 tion of the skin (in 8 of Osier's 18 cases). In several cases Dock 
 and Warthin found portal thrombophlebitis and hyperplasia of the 
 haemolymph glands. Of Armstrong's cases 23 recovered and 9 died. 
 
 4. Lympiiosakcomatosis. — This is sometimes difficult to differen- 
 tiate and some, as Hoffmann, class the two diseases together. Accord- 
 ing to Kundrat, lymphosarcoma is largely a local disease, with local 
 glandular involvement, especially of the cervical glands, leading to 
 infiltration of the throat by contiguity ; the disease may begin in the 
 tonsils, air-passages, portal glands, etc. Lymphosarcoma ulcerates 
 and transgresses the gland capsule; this never occurs in leukaemia 
 or in pseucloleukaemia. The glands in leukaemia and pseudoleukaemia 
 may compress neighboring structures but never actually invade them. 
 Unless lymphosarcoma extends beyond the capsule of the glands it 
 cannot be distinguished by physical examination unless it lies in 
 parts which can be easily inspected, as the mouth. The spleen may 
 enlarge enormously. According to Pinkus, the leukocytes are increased 
 in pseudoleukaemia, while in lymphosarcoma they are decreased. 
 
 5. Other Splenic Enlargements. — The most common are: 
 Cirrhosis of the liver, malarial spleen, sometimes carcinoma, chlorosis 
 with enlarged spleen (Chvostek), chronic polycythaemic cyanosis and 
 rarer forms, as miliary tuberculosis of the spleen, actinomycosis, 
 syphilis, rhachitis or echinococcns. (See Diseases of Spleen.) 
 
 6. Multiple Myeloma. — This is characterized pathologically 
 by lymphoid hyperplasia of the bone marrow, in the ribs and body- 
 ends of the long bones chiefly and more often in the proximal than in 
 the distal bones ; no metastases occur. The bones soften or sometimes 
 
828 DISEASES OF THE BLOOD. 
 
 sclerose. Clinically, it occurs in males over forty-five years and is 
 characterized by severe, deep-seated pain in the body, chest, spine, 
 neck and more rarely in the extremities. Prominences in the bones, 
 •spontaneous fractures, especially of the sternum and ribs, and ky- 
 phosis, from softening of the vertebrae, may result. The growths may 
 pulsate or rupture externally. The x-rays may clearly define them. 
 Severe anaemia without leucocytosis ; neuralgia, motor and sensory 
 paralyses, which develop late and involve the opticus, hypoglossus, 
 facialis, cord (paraplegia dolorosa) and sciatic nerve; fever and the 
 Bence-Jones albumosuria are observed. To call this disease a myelo- 
 genic form of pseudoleukemia or myelogadenia there must, accord- 
 ing to Pinkus, be a lymphocytosis. 
 
 7. Other Affections. — Syphilitic lymphatic glands; symmet- 
 rical simple lymphoma of the lachrymal and salivary glands of 
 Mikulicz, reacting to arsenic, and resembling pseudoleukemia ; and 
 secondary carcinoma or sarcoma must be differentiated. Difficulties 
 of diagnosis are met when the enlarged glands in internal parts pro- 
 duce topical symptoms, thus simulating hypertrophic cirrhosis, etc. 
 
 Treatment. — 1. Local Applications. — These are useless, excepting 
 the x-rays; W. A. Pusey states that two of his cases, seen by the 
 author nine years ago, wholly recovered. In some cases the rays have 
 no influence on the spleen and glands and in others the cachexia in- 
 creases, though there may be improvement in the local findings. 
 Inunctions of green soap, once or twice daily, are sometimes beneficial. 
 
 2. Drugs. — Arsenic is most efficacious (v. Pernicious Anemia for 
 details) ; it acts on the glands more than on the spleen. Some believe 
 that the fever which it sometimes produces, reduces the adenopathy. 
 Winnewarter and Billroth recommended its parenchymatous injec- 
 tion into the glands, but the results are not very encouraging. Iodides 
 are seemingly injurious. Berberin hydrochlorate gr. xv increases the 
 appetite and contracts the spleen (Litten). For hemorrhages Litten 
 uses a decoction of quercus cortex, which disturbs digestion; formalin 
 and rectified spirits aa locally (which may irritate a delicate skin) 
 and guacamphol gr. iij to iv once daily may be given. 
 
 3. Surgical Treatment. — Extirpation of the glands is seldom 
 beneficial. The removal of the spleen is attended by constantly de- 
 creasing mortality. In 1900 Bessel-Hagen collected 360 operations 
 for various indications; the average mortality was 38 per cent, (for 
 splenomegaly, 61 per cent, before 1891 and since then 13 per cent.). 
 In Lichty's 25 cases 8 were operated on with 37 per cent, mortality. 
 Scott added 6 cases, of which 33 per cent. died. Carstens, 1905, col- 
 lected 739 cases of splenectomy; 72 per cent, recovered. 
 
PURPURA. 
 
 829 
 
 THE HEMORRHAGIC DISEASES. 
 
 The hemorrhagic diseases may be classified as follows : 
 
 / a n a • -. I 1- Purpura. 
 
 (A). Acquired types. j 2> ScTirvy> 
 
 (B). Congenital (hereditary) type. 3. Haemophilia. 
 
 PURPURA. 
 
 Purpura includes a number of affections, more or less similar in 
 kind and differing chiefly in degree, some of which are symptomatic, 
 while others are independent, though obscure affections. 
 
 I. Symptomatic Purpura. — Symptomatic purpura is observed as a 
 symptom in: — (a) Various infections, as endocarditis, scarlatina, 
 measles, smallpox, rheumatism, sepsis, yellow fever, plague, syphilis 
 or tuberculosis, (b) Toxic conditions, as nephritis, cholaemia, snake- 
 bites and drug-poisoning (copaiba, ergot, belladonna, quinine, mer- 
 cury, iodides, bromides or arsenic), (c) Cachexia; old age, mal- 
 nutrition, carcinoma, sarcoma, leukaemia, pseudoleukemia or per- 
 nicious anaemia, (d) Nervous states; cerebrospinal lesions, as tabes, 
 myelitis; neuroses (bloody stigmata of hysteria) ; neuralgias or vaso- 
 motor fluxions, (e) Mechanical conditions, as trauma, embolism 
 or stasis. 
 
 II. Purpura Simplex — Purpura simplex (Zeller, 1684) is pur- 
 pura in which cutaneous hemorrhages are the chief symptoms. Its 
 etiology is obscure. It develops most often in middle-aged males. As 
 in the other forms, whose description follows, there is no constant 
 or characteristic pathology, though vessel thickening, hyaline and 
 fatty degeneration, thrombosis, hemorrhage and pigmentation some- 
 times occur. In the blood itself no change is observed other than its 
 tardy coagulation; this requires 10 to 30 minutes instead of 3 to 5, 
 which is the normal time. The blood platelets are decreased (Pratt, 
 Hayem). The eruption begins as small red spots, which gradually 
 become green and black ; they occur largely on the extensor surfaces 
 of the limbs and more often on the legs than on the arms or trunk. 
 They do not fade upon pressure. The initial eruption may be macu- 
 lar, papular or urticarious (purpura maculosa, papulosa or urticans), 
 but soon becomes blood-tinged. Constitutional symptoms are usually 
 absent; there may be slight fever, gastric disorder or diarrhoea 
 (Graves). The usual duration is 1 to 2 weeks, the prognosis is good 
 and the treatment hygienic rather than medicinal. Relapses are 
 common. 
 
 III. Purpura (or Peliosis) Rheumatica. — Purpura rheumatica, de- 
 scribed by Schonlein, is still listed by itself because of the articular 
 symptoms. As joint symptoms also occur in Werlhof's disease (v. i.), 
 scurvy and haemophilia, its separate classification is somewhat arbi- 
 trary. Most cases develop in males between fifteen and thirty years 
 of age. It has no relation to rheumatism, being a pseudorheumatism. 
 Its pathology is obscure. 
 
830 DISEASES OF TBE BLOOD. 
 
 Symptoms. — (a) As prodromes, indisposition, low fever, muscular 
 pains, colic and, particularly, sore throat may be noted. The devel- 
 oped disease is manifested chiefly by various forms of purpura and 
 by joint symptoms; (b) the purpura may occur before, with or after 
 the joint-symptoms. It occurs as simple hemorrhages of the skin, 
 which vary from red to green-black, according to their age, or as 
 urticaria, erythema, pemphigus or oedema, which become stained with 
 blood; the legs are most often involved, largely on the extensor sur- 
 faces, (c) Articular symptoms are most common in the knees and 
 ankles, being less frequent in the elbows and rare in other joints; 
 there may be only stiffness and pain or actual swelling ; if the joints 
 are first involved their symptoms frequently abate with the appear- 
 ance of the purpura, (d) Other symptoms are inconstant, as fever, 
 which may rise to 102° or 103°, splenic tumor, albuminuria or 
 nephritis. The author had 3 cases at one time in the Cook County 
 Hospital, in which there was severe sloughing of the tonsils. Osier 
 (1904) described 29 cases in which visceral lesions occurred with 
 purpuric, urticarious and erythematous symptoms; they occurred 
 chiefly in children and relapses were frequent; (i) digestive compli- 
 cations occurred in 25 cases; vomiting in 15; colic in 8 (resembling 
 renal stone or appendicitis) ; blood in the stools in 8 and diarrhoea 
 in 15 ; (ii) acute nephritis occurred 14 times and 5 cases died of 
 ursemia; (iii) arthritis occurred in 17 cases; (iv) swelling of the 
 fauces, oedema of the larynx, aphasia, transient hemiplegia and least 
 often endocarditis may occur. 
 
 Diagnosis. — The diagnosis chiefly concerns affections characterized 
 by hemorrhages of the skin, articular symptoms and perhaps tempera- 
 ture. Acute leukaemia, septicopysemia and endocarditis must be 
 excluded. Genuine rheumatic polyarthritis is differentiated with 
 ease by the earlier migrating, inflammatory joint involvement, the 
 temperature, sweating, characteristic cardiac complications and the 
 later, rather accidental and wholly secondary occurrence of the 
 purpura. 
 
 Prognosis. — The prognosis is generally good, though relapses are 
 common and sometimes periodical. Its course is rarely longer than a 
 week or two. 
 
 Treatment. — Treatment is symptomatic. The joint-symptoms yield 
 somewhat to acetanilide, though the salicylates exert no specific 
 influence. 
 
 IV. Purpura Hemorrhagica. — Purpura hemorrhagica {Morbus 
 maculosus Werlhofii, Werlhof, 1775) closely resembles the types 
 already described, but differs in that not only are the skin and joints 
 the seat of hemorrhage, but also the mucous membranes, serous mem- 
 branes and perhaps the viscera. 
 
 Etiology. — Of this little is known ; staphylo-, strepto- and pneumo- 
 cocci and Bacillus pyocyaneus and coli have been found. It occurs 
 oftener in young weakly women than in robust adults. Exposure to 
 cold or dampness and malnutrition seem predisposing causes. It 
 
PUBPUBA. 831 
 
 usually develops as an apparently primary affection, but it may 
 occur in some of the conditions listed under symptomatic purpura. 
 
 Symptoms. — Perhaps after inconstant and variable prodromes, as 
 fever, vomiting or vertigo, (a) hemorrhages appear on the extremities; 
 the face is not often involved; they occur as spontaneous petechias, 
 blood-stained bullae or vibices or may result from slight trauma, as 
 by pinching the skin, (b) The mucous membranes bleed to a varying 
 degree; the nose and mouth bleed most often; less frequently there 
 is haemoptysis, haematemesis, enterorrhagia, haematuria or metror- 
 rhagia in various combinations, sequences and degrees. The conjunc- 
 tivae may be blood-stained. The writer saw one rapidly fatal case in 
 which there was hemorrhage from the middle ear. (c) The serous 
 membranes and the joints, particularly the knees, ankles and elbows, 
 are least often implicated. Ecchymoses in the endo- and pericardium, 
 pleura, peritoneum and meninges are common findings at autopsy. 
 (d) Other hemorrhages are much less common, as retinal hemor- 
 rhages, hemorrhage into the brain, cord or testis. The connective 
 tissues, fasciae and bones are practically exempt. 
 
 General symptoms and complications. As to the blood, there is 
 delayed coagulation and some anaemia, but the red cells and haemo- 
 globin are rarely much reduced; some nucleated red cells may be 
 found, as well as leukocytosis, reduction in the blood plates and some 
 methaemoglobinaemia. Fever is inconstant and atypical. The pulse 
 rate may be raised; palpitation, delirium, vertigo, albuminuria, he- 
 patic enlargement, splenic tumor, subicterus and nephritis are occa- 
 sional symptoms. In J. S. Cutler's case there was extensive intestinal 
 ulceration; perforation also has been reported. 
 
 Diagnosis. — Most errors in diagnosis result from confusion with 
 purpura cases symptomatic of sepsis, hemorrhagic exanthemata or 
 blood affections. The difficulties in diagnosis are often great; in an 
 anaemic old man, who suddenly vomited blood and passed bloody 
 urine, the diagnosis of purpura was made; the autopsy revealed a 
 round ulcer of the stomach and a papilloma of the bladder. Scurvy 
 is distinguished by its gingivitis and muscular hemorrhages, and 
 haemophilia by reason of its hereditary facts. Henoch's purpura 
 occurs chiefly in children and is characterized (a) by cutaneous le- 
 sions, which resemble erythema nodosum rather than purpura; (b) 
 by hemorrhages from the mucous membranes; (c) by gastrointesti- 
 nal crises of vomiting, diarrhoea and abdominal pain; (d) by pains 
 in the joints and (e) by frequent relapses, often extending over a 
 number of years (v. s. Osier's group). Of chronic purpura, Ben- 
 saude and Rivet collected 34 cases (1905). 
 
 Prognosis. — The prognosis is uncertain. According to Gross, 50 
 per cent. die. Unfavorable symptoms are high temperature, nephritis 
 and cerebral hemorrhages. Purpura fulminans, of which Stybr 
 (1906) collected only 14 cases, may be fatal in 24 to 48 hours ; it was 
 originally described by Guelliot, 1884. Recurrence is not uncommon. 
 
 Treatment. — This has advanced but little beyond Werlhof's therapy 
 
832 DISEASES OF THE BLOOD. 
 
 of dilute sulphuric acid Tl\x and quinine gr. v after meals. Every- 
 thing of a supportive nature, as sufficient nourishment, rest in bed, 
 iron and arsenic, is helpful. The hemorrhages are arrested with 
 difficulty and the author doubts the value of drugs in their control. 
 Turpentine and ergot may be given (as in haemoptysis, q. v.). 
 Adrenalin solution to the nose and mouth, gelatin by mouth (see 
 K"ext Section), and especially calcium lactate gr. xv, t. i. d., to 
 increase the coagulability of the blood, are indicated. 
 
 HEMORRHAGIC DISEASES OF THE NEW-BORN. 
 
 Syphilis Hemorrhagica Neonatorum. — Syphilis hemorrhagica ne- 
 onatorum appears soon after birth. In some instances the syphilitic 
 child may be born with hemorrhages in the skin, mucosae, internal 
 organs and from the navel. Occasionally deep jaundice develops. 
 The cause is probably vascular disease; Mracek found endarteritis, 
 especially of the capillaries, in 14 per cent. In other cases an added 
 sepsis is apparently causative. 
 
 Winckel's Disease. — Winckel's disease, epidemic hemoglobinuria, 
 is (a) an affection of the new-born of unknown causation; (b) it 
 appears epidemically in hospitals; (c) it develops in the first four 
 days of life; (d) it is characterized clinically by fever, gastrointesti- 
 nal symptoms, icterus, dyspnoea, cyanosis, albuminuria, methaemo- 
 globinuria and large mortality, and (e) pathologically by internal 
 hemorrhages, fatty degeneration and splenic tumor. 
 
 Morbus Maculosus Neonatorum. — Morbus maculosus neonatorum 
 is no clearer etiologically than Werlhof 's disease in adults ; some cases 
 are congenital syphilis ; others with fever, jaundice and epidemic oc- 
 currence are infections (pyogenic cocci, pneumococci, a bacillus like 
 Triedlander's, pyocyaneus and colon bacilli) and still others seem 
 embolic, thrombi forming in the auricles when the heart is weak 
 (Landau). Injuries to the head, causing hemorrhages in the fourth 
 ventricle and cerebral peduncles, and other vasomotor disturbances 
 (von Preuschen and Pomarski) are questionable causes. It occurs 
 once in 500 to TOO births. 
 
 Symptoms. — In the first week of life hemorrhages occur from the 
 navel and mucous membranes ; in Townsend's 50 cases they occurred 
 in the following frequency: from the bowel (melsena), 40 per cent. ; 
 navel, 36 per cent. ; mouth, 28 per cent. ; stomach, 28 per cent,, and 
 nose, 24 per cent. Death occurs within a week in 63 per cent. Dus- 
 ser, in 78 cases, found the mortality was 55 per cent. 
 
 Treatment. — Iron, ergot and adrenalin are useless. Diffuse stim- 
 ulants should be given when there is a weak, rapid pulse. Injections 
 of gelatin are dangerous, for it possibly contains some ptomaine; its 
 local use and administration by mouth are safer (Abt). 
 
SCUEVY. 833 
 
 SCURVY. 
 
 Definition. — A general disease, more often endemic than sporadic, 
 caused by neglect of hygienic conditions and characterized by gingi- 
 vitis, hemorrhages, inflammations, cachexia and chronicity of course. 
 
 Etiology. — It was first observed in the Crusades and was described 
 most fully by Vasco de Gama; in his voyage around the Cape in 
 1498, 33 per cent, of his sailors were stricken with scurvy. It has 
 developed among prisoners, Canadian lumbermen, Pennsylvania 
 miners and among workers on the Chicago Drainage Canal, where in 
 1893-95 the author saw 100 cases. Insufficient, monotonous, possibly 
 spoiled food causes the majority of cases, sometimes in conjunction 
 with lack of fresh meat, impure water, damp quarters and over-exer- 
 tion; a lack of fresh meat, vegetables (potassium salts, malic and 
 citric acids) and fats predispose to scorbutus, though no single group 
 is solely responsible. The Drainage Canal cases were all Poles and 
 lived on coffee, bread and preserved and fresh meats. It develops 
 principally in middle-aged males of the poorer classes. The disease 
 is becoming less frequent. In 1780 Admiral Gleary had 2,400 cases 
 in the English fleet. In 1849 there were 260,444 cases in Eussia and 
 60,598 deaths ; it is still endemic there and is regarded as an infection. 
 
 Symptoms. — Scorbutus begins slowly and progresses insidiously; 
 its earliest symptom is (1) anaemia (cachexia scorbutica). The skin 
 is scaly, pale, lustreless and may become pigmented. The mucous 
 membranes are livid and the expression is apathetic. The blood 
 findings are not characteristic ; coagulation is slow, the red cells and 
 haemoglobin are proportionately reduced and leukocytosis is absent, 
 except with intercurrent inflammation or severe hemorrhage. Emaci- 
 ation, mental depression, muscular weakness, anorexia, reduction of 
 HC1 in the gastric juice, intestinal fermentation, constipation, palpi- 
 tation, weakness with irregularity of the heart's action, a systolic 
 functional murmur and oedema about the ankles accompany the 
 anaemia. Splenic enlargement,, albuminuria, peptonuria and oliguria 
 are common. 
 
 2. Gingivitis begins with turgescence of the gums, which is due 
 to a serohemorrhagic infiltration, usually noticed first about the 
 canine teeth; the gums are spongy, painful, particularly on eating, 
 bleed readily and may become so swollen as to hide the teeth. Gin- 
 givitis is absent when there are no teeth or roots. The breath is 
 extremely foetid. In severe cases the gums necrose and bleed pro- 
 fusely; deep ulcers, on healing, leave cicatrices; the teeth may loosen 
 and fall out, the salivary and cervical lymph glands and tongue may 
 swell. 
 
 3. Hemorrhages may occur (a) in the skin, especially on the ex- 
 tensor surfaces of the legs ; small hemorrhages often occur, first about 
 the hair follicles; they are at first small petechiae, but later become 
 larger and stretch the skin. Less frequently the first eruption may 
 resemble acne, herpes or pemphigus, hemorrhages appearing later in 
 
834 DISEASES OF THE BLOOD. 
 
 these exanthems. The trunk is less frequently involved and the face 
 is usually exempt. As the hemorrhages increase, the legs are diffusely 
 mottled with red, green and black and are swollen and tense. Similar 
 stains may be noted running upward in streaks along the lymph ves- 
 sels. Some of these changes are due to (b) muscular hemorrhages 
 (scorbutic sclerosis). They occur mostly in the calf and thigh, less 
 in the buttocks or abdominal wall. The legs are large, extremely 
 hard, blood-stained and later pigmented. As the disease regresses 
 the muscles usually recover their function, but in some instances 
 ulceration (scorbutic ulcers), suppuration, muscular cicatrization or 
 shortening of the tendons may leave permanent deformity and con- 
 tractures, (c) Mucous membrane hemorrhages are less common than 
 in purpura or haemophilia, though epistaxis is fairly frequent. In 
 some cases hemorrhages occur in the conjunctiva, air passages and 
 stomach, but in more cases in the bowels, perhaps with intestinal 
 ulceration, (d) Of serous membrane hemorrhages, articular hem- 
 orrhage (haemarthrosis) is the most frequent. Next in order of 
 frequency are those in the pleura, pericardium, peritoneum and men- 
 inges. They are usually sudden in onset, extreme in degree and un- 
 favorable in outcome, (e) Parenchymatous hemorrhages are least 
 common, as in the eye-tissues, brain and other viscera. Subperiosteal 
 and epiphyseal hemorrhages are rare, unless Barlow's disease is 
 included (see !N"ext Section). Scorbutic ulcers in soft tissues may 
 reach the bone, causing necrosis. 
 
 4. Scorbutics are subject to various inflammations, (a) Painful 
 joint swellings are the most frequent and occurred in 35 per cent, of 
 the author's cases and chiefly in the knees; they may be serous or 
 hemorrhagic or in severe cases the cartilages or bones may become 
 eroded and ulcerated; sometimes suppuration intervenes; deformity 
 and ankylosis are possible sequences, (b) Hemorrhagic pericarditis 
 and pleuritis are very dangerous, (c) Onychia, paronychia, choroid- 
 itis and panophthalmitis are occasional incidents. Fever is uncom- 
 mon, except from extreme inanition or terminal infection. 
 
 Course and Prognosis. — The onset is insidious, the course chronic 
 and convalescence protracted. Most cases recover and recurrence, is 
 not frequent. Death may occur (a) from cachexia, and the autopsy 
 then shows fatty degeneration of the heart, liver and bloodvessels; 
 (b) from profuse hemorrhages, into the pleura, pericardium, gastro- 
 intestinal tract or rarely into the brain or meninges; (c) from infec- 
 tions, as dysentery, pleurisy, pneumonia or septicopyemia, probably 
 of the terminal type, promoted by the reduced physiological resistance. 
 
 Diagnosis. — The diagnosis is made without difficulty by (a) the 
 anaemia or cachexia, (b) gingivitis, (c) tendency to hemorrhage and 
 (d) inflammation, (e) the chronic course, and (/) the temporary 
 nature of the condition (as contrasted with the permanent tendency 
 to hemorrhage in haemophilia). 
 
 Treatment.— (a) Hygienic; avoidance of " cured " or smoked foods 
 is both prophylactic and curative, In Hansen's polar expedition, 
 
INFANTILE SCURVY. 835 
 
 which lasted three years, not one case of scurvy developed. His 
 meats were cooked and plenty of cooked and raw fruits and vegetables 
 were used. Berries, sauerkraut, potatoes, radishes, cress, apples, 
 oranges and lemons are especially valuable. A monotonous dietary 
 is particularly to be avoided, (b) The anosmia (q. v.) should be 
 treated by strychnine, quinine, iron and arsenic. Yeast, gij three 
 times daily, is recommended, (c) The gingivitis is treated by local 
 applications of silver nitrate (10 per cent.). Cocaine may be painted 
 on the gums before meals so that the patient may eat, but great care 
 must be taken lest the habit be contracted or toxic symptoms develop. 
 (d) Symptomatic treatment; hemorrhage is benefited by rest only. 
 Stimulation is required in intercurrent infections. Drastic cathartics 
 are to be avoided. Complicating arthritis necessitates rest and the 
 application of cold, but rarely aspiration or drainage. 
 
 INFANTILE SCURVY— BARLOW'S DISEASE. 
 
 Moller (1852-62) described the affection as acute rhachitis, and 
 Ingerslev (1871), Jalland (1873), Cheadle and Gee (1878), but 
 particularly Barlow (1883), described a cachexia with hemorrhages, 
 which occurred in the very young. In 1898, 379 cases were collected 
 in the United States. 
 
 Etiology. — Unlike scurvy in adults, the hygienic conditions are 
 good in 80 per cent, of cases, and it occurs largely in the better classes. 
 (a) The obvious cause is feeding with malted, condensed or cooked 
 milk or baby foods ; these foods lack some unknown substance essen- 
 tial to health. In 713 cases only 2.5 per cent, occurred in infants at 
 the breast (S. Weiss, 1905). (b) Ninety per cent, of cases occur 
 between the sixth and twelfth months (Heubner and Neumann). 
 
 Symptoms. — These are not always typical; there may be anaemia 
 without hemorrhages or hemorrhages without anaemia, though in 
 typical cases they occur together. 
 
 1. Subperiosteal hemorrhage is the leading symptom. The pri- 
 mary vague symmetrical swelling over the epiphyses later becomes 
 more obvious, though no oedema is noted. There is pain and tender- 
 ness usually in the thighs or legs, which are drawn up, flexed or 
 everted, immobile and semiparalytic (pseudoparalysis). At autopsy 
 the anatomical findings are subperiosteal hemorrhages ; a colloid and 
 fibrillar alteration in the marrow of the diaphyses ; arrest of ossifica- 
 tion ; decrease of the osteoblasts ; rarefaction of the bones, sometimes 
 leading to fractures ( spontaneously or after slight trauma) or to epi- 
 physeolysis (usually at either end of the femur or the upper end of 
 the tibia) ; the joints are normal. Seventy per cent, of the lesions 
 are in the thigh, 24 per cent, in the leg and 6 per cent, in the orbit ; 
 the arms, ribs, spine, skull, sternum and scapulae are seldom involved. 
 Bib involvement results in depression of the sternum. 
 
 2. The cachexia is evidenced by the anaemia (usually moderate and 
 sometimes attended by slight lymphocytosis), sallow skin, asthenia, 
 
836 DISEASES OF THE BLOOD. 
 
 anorexia, constipation, irregular temperature (in 66 per cent.) or 
 subnormal registration and the almost invariable severe sweats. 
 
 3. Gingivitis is noticed when the teeth have already erupted or 
 are about to erupt; the gums are normal in but 15 per cent. (Heub- 
 ner and Neumann). 
 
 4. Other symptoms embrace hemorrhages in the skin in 50 per 
 cent., from the bowels (10 per cent.), nose (9 per cent.), kidneys (9 
 per cent.) and rarely in the conjunctivae, muscles or meninges. The 
 spleen is rarely swollen. 
 
 Diagnosis. — Diagnosis is not difficult, after one typical case has 
 been seen; it is based upon the etiology, subperiosteal hemorrhages, 
 gingivitis and anaemia. Confusion with genuine paralysis is unneces- 
 sary, for the immobility is voluntary to escape the pain of movement. 
 Syphilitic bone disease (syphilitic pseudoparalysis or Parrot's dis- 
 ease) is rather similar as to the crepitus, epiphyseolysis and pain, but 
 other syphilitic stigmata or scorbutic symptoms are present. 
 
 Prognosis and Treatment. — Proper treatment secures marked and 
 immediate improvement in the great majority of cases. Death is 
 uncommon; in unfavorable cases it occurs in the third or fourth 
 month of the disease. The diet consists of raw cow's milk, potato 
 puree and beef juice (not broth or extracts) ; orange juice, apple 
 sauce, pears, cooked berries and spinach are most beneficial. Treat- 
 ment by drugs is generally superfluous. 
 
 HEMOPHILIA. 
 
 Definition. — A congenital and hereditary affection, characterized by 
 deficient coagulability of the blood and a consequent tendency to 
 profuse hemorrhages, which are spontaneous or traumatic and most 
 difficult to arrest. It was named by Schonlein. 
 
 Etiology. — Its real cause is unknown and the few pathological 
 changes described in the blood and the bloodvessels are insufficient 
 factors. Sahli believes that there is an hereditary deficiency in the 
 fibrin-forming substances (thrombokinase). (a) Heredity is the 
 only clear etiological fact, which Pordyce noted in 1784 ; as Grandi- 
 dier (1877) remarked, hsemophilia is "the most hereditary of all 
 hereditary diseases." Osier quotes Brown as tracing hsemophilia 
 through seven generations in 200 years. Sometimes a generation may 
 be exempt, (b) Broadly speaking, the males of the " bleeder families " 
 are the "bleeders," and the females — the "conductors" — transmit 
 the disease to their male offspring without manifesting the disease 
 themselves. In 200 families of "bleeders," Grandidier found 609 
 cases in males and 48 in females (8 per cent.) ; Stahel in 1,880 
 families found only 24 cases in males. In the Mampel family, first 
 reported by von Chelius in 1827, Lossen (1905) found 212 members 
 of which 111 were males ; of these exactly one-third were bleeders and 
 48.7 per cent, of the male bleeders died of hemorrhage; none of the 
 females were bleeders and all transmission of the disease occurred 
 
HEMOPHILIA. 837 
 
 through the women, (c) The disease occurs most frequently in 
 Germany, England, North America and France. Consanguinity and 
 family tendencies (gout, rheumatism or tuberculosis) have been sug- 
 gested as causes. " Bleeders " are generally healthy individuals with 
 soft, blond, delicate skins and blue eyes. 
 
 Symptoms. — In 75 per cent, of cases, hemorrhages develop in the 
 first two years of life; rarely do they first appear after puberty, in the 
 third decade or after the seventieth year ; only 46 congenital cases are 
 known (Pratt). The hemorrhages are spontaneous or traumatic; 
 they most often occur as capillary oozing from a mucous surface; 
 deep interstitial bleeding is most unusual. They are copious and 
 hard to still. Epistaxis is the most common (50 per cent.) ; hemor- 
 rhages from the gums (12 per cent.), intestine (12 per cent.), lungs, 
 kidneys and stomach (each 6 per cent.) and uterus are next in fre- 
 quency. Arthropathies are the rule. According to Konig, the joint 
 findings are (a) an haemarthros, with pain, swelling and fluctuation; 
 (b) then panarthritis, whose gross pathology resembles tuberculous 
 arthritis, with flexion of the joint; (c) regression, or ankylosis and de- 
 formity, which rather resembles arthritis deformans. The knees 
 and elbows are most often affected. Subcutaneous hemorrhages may 
 occur. The first bleeding may occur from the navel or may result 
 from vaccination, extraction of teeth, circumcision, from a trifling 
 prick or cut, from delivery or from rupture of the hymen on the 
 wedding night. In various attacks, one part after another may bleed 
 or the haemophilic disposition may be confined to one part, as a kidney 
 (renal haemophilia) or nose; in Agnew's celebrated case, the patient 
 bled from cuts on the head but never from lesions lower. Haemophilia 
 differs from purpura, in that the bleeding seldom occurs into a serous 
 membrane (excepting the joints) or into the viscera. The amount 
 of blood lost may be enormous and in Litten's case amounted to 
 24 pounds in eleven days. The coagulation time of the blood is de- 
 layed to thirty or sixty minutes (Wright) ; the clot, when formed, is 
 porous, but retracts normally; the coagulum does not retract in pur- 
 pura and the blood plates are reduced. 
 
 Of general symptoms there are few except changes in the joints 
 (like those in subacute rheumatism), a neuropathic tendency (neu- 
 roses and neuralgia, particularly of the fifth nerve) and anaemia 
 (though haemophilics tolerate loss of blood better than other individu- 
 als, and recover from it more readily). 
 
 Diagnosis. — The diagnosis may be for a time uncertain, when hem- 
 orrhage develops after an operation or occurs from one organ only, as 
 the kidney. The family history clearly stamps the affection and 
 readily differentiates it from scurvy, purpura and hemorrhages in 
 the new-born. It is peculiar that patients often deny that they are 
 bleeders. The 16 cases of multiple hereditary telangiectases with 
 recurring hemorrhages, described by Osier, may be haemophilic. 
 
 Prognosis? — The prognosis is grave. Any hemorrhage may prove 
 fatal. Sixty per cent, of cases die before the eighth year and only 11 
 
838 DISEASES OF THE BLOOD. 
 
 per cent, reach the twenty-second year ; if middle life is reached the 
 danger gradually lessens. It is more favorable in girls, despite the 
 apparent menstrual dangers. De Bovis (1905) found 69 excessive 
 hemorrhages among 150 deliveries in hemophilic women; he believes 
 pregnancy has a rather favorable effect on the disease. De Lee has 
 reported premature detachment of the placenta in haemophilia. The ru- 
 dimentary or local forms are more favorable than general haemophilia. 
 
 Treatment. — 1. Prophylaxis. — Grandidier lays down the following 
 rules: (a) Women, with an hemophilic family tendency, whether 
 they are "bleeders" or not, should not marry, (b) Men, if not 
 " bleeders " themselves, may marry, (c) Men should not marry when 
 their family history indicates that male " bleeders " have begotten 
 hemophilic children. It is obvious that in hemophilic families, 
 general measures to elevate the physiological resistance and avoidance 
 of trauma or any but life-saving operations, are indicated. Vaccina- 
 tion is rarely contra-indicated. 
 
 2. Control of Actual Hemorrhage. — This is almost impossible. 
 
 (a) Wounds should be cauterized or enlarged, as Fordyce discovered 
 that in hemophilics large bleed less than small wounds. Other sur- 
 gical hemostatic measures need not be further considered. The 
 Esmarch constrictor controls some hemorrhages of the extremities. 
 
 (b) Styptics, as MonselFs solution, or tannic preparations are useless. 
 
 (c) Adrenalin, locally and internally, has no apparent effect, (d) 
 Calcium lactate is more beneficial ; grs. xv t. i. d. should be given in- 
 termittently, because protracted administration decreases the coagula- 
 bility of the blood, (e) Gelatin may be given by mouth or in unusu- 
 ally severe hemorrhages by subcutaneous infusion (v. page 832). (/) 
 Saline cathartics are sometimes efficacious, possibly by diverting 
 blood from the seat of hemorrhage, (g) Very acute anemia necessi- 
 tates injection of salines under the skin; when the hemorrhage is 
 over, regeneration of the blood is remarkably rapid, (h) Joint in- 
 volvement is treated by rest, immobilization and rarely aspiration. 
 
SECTION VII. 
 DISEASES OF THE DUCTLESS GLANDS 
 
 DISEASES OF THE SUPRARENAL GLANDS. 
 
 ADDISON'S DISEASE; OTHER AFFECTIONS OF THE SUPRARENAL 
 
 GLANDS. 
 
 Definition. — A disease characterized (a) pathologically by lesions 
 (usually tuberculous) in the adrenal glands or by degenerative 
 changes in the adjacent abdominal sympathetic ganglia, and (b) 
 clinically by muscular and mental adynamia, digestive disorders, 
 pigmentation of the skin and a fatal issue. 
 
 Etiology. — 1. Suprarenal Disease. — Suprarenal disease was first 
 associated pathologically with melanoderma by Addison in 1855. 
 By far the most common lesion is (a) chronic fibrocaseous tubercu- 
 losis of the adrenal glands; the tubercles of the adrenal glands are 
 usually bilateral, destroy most of the suprarenal structure and fre- 
 quently involve the semilunar ganglia and solar plexus by the atten- 
 dant formation of connective tissue ; in rare cases only is the adrenal 
 tuberculosis primary (Symes and Fisher) ; there is a primary focus 
 in the lungs in over 50 per cent., in the genito-urinary, alimentary or 
 glandular system. (&) Less common are tumors, simple atrophy, 
 fibrous induration (usually tuberculous), cirrhosis (26 cases re- 
 corded), gumma, amyloid degeneration, acute inflammation (as by 
 contiguity from perinephric abscess), acute hemorrhage, embolism, 
 echinococcus, adenoma or other very rare lesions. In what way supra- 
 renal lesions produce Addison's melasma suprarenale is still a dis- 
 puted question, for our knowledge of adrenal physiology is incom- 
 plete. It seems (i) that the glands contain a substance (sphygmo- 
 genin) which maintains vascular tonus and stimulates the vasomotor 
 centres, the vagus and respiration; when secreted in excess, as in 
 hypernephroma, the blood tension may be much elevated (Frankel, 
 Neusser, Kolisko) and this may induce cerebral hemorrhage; (ii) 
 the glands apparently elaborate an internal secretion necessary to life 
 which renders less toxic substances produced by other tissues, e. g., 
 the "fatigue stuffs" of muscle metabolism. Chemically, sphyg- 
 mogenin, pyrokatechin, neurin and lecithin have been found. Able 
 holds that the active glandular substance is epinephrin. 
 
 There are, however, cases of Addison's disease in which the adre- 
 nals are normal. Lewin's statistics from 500 cases are as follows : In 
 typical cases the adrenals are diseased in 88 per cent, and apparently 
 
 839 
 
840 DISEASES OF THE DUCTLESS GLANDS. 
 
 sound in 12 per cent. ; on the other hand, disease of the adrenals is 
 attended by pigmentation of the skin in 72 per cent, and unattended 
 by it in 28 per cent. There is no wholly satisfactory explanation for 
 such cases. Perhaps compensatory hypertrophy or accessory glands 
 may prevent symptoms in some cases of adrenal disease. 
 
 2. The Adjacent Sympathetic Structures — the solar plexus 
 and semilunar ganglia, — may be involved directly, or indirectly as by 
 fibrous changes in the adrenals and pressure from contiguous aneu- 
 rysm or lymphomata. Pigmentary atrophy, hyaline degeneration and 
 round cell infiltration of their vessels and degeneration extending 
 upward to the cord or downward along the nerves have been described. 
 Some writers explain Addison's disease as a disease of the sympa- 
 thetic system ; others endeavor to reconcile conflicting facts by assum- 
 ing a decreased adrenal activity plus sympathetic disturbance. 
 
 3. Minor Etiological Factors. — (a) Age; most cases occur be- 
 tween the fifteenth and fortieth years ; the youngest case recorded was 
 congenital and the oldest was eighty years; (b) sex; 66 per cent, oc- 
 cur in males; and (c) 90 per cent, in the laboring classes. 
 
 Symptoms. — 1. Adynamia. — Marked physical and mental adynamia 
 is usually the initial symptom and persists, with increase after pos- 
 sible remissions, from onset to death. The insidious languor, weak- 
 ness, apathy, lack of initiative and muscular relaxation contrast 
 sharply with the healthy appearance of the patient in the early stages. 
 These symptoms are probably toxsemic, partly from reduced internal 
 secretion and partly from the tuberculous lesion. Obstinate early in- 
 somnia and headache and somewhat later attacks of vertigo, tinnitus, 
 spots before the eyes and syncope are frequent. The intellectual 
 functions are weakened, neuralgias occur in the epigastrium, inter- 
 costal spaces, back and extremities, periodic attacks of irritability are 
 frequent and the deep reflexes are usually somewhat reduced. 
 
 2. Digestive Symptoms. — Digestive symptoms generally appear 
 next. The tongue is coated and moist ; there are anorexia, thirst, a 
 sense of abdominal fulness, eructations and sensitiveness over the 
 abdomen. Paroxysmal pains in the epigastrium or back radiate 
 widely, especially into the chest ; they resemble tabetic crises and are 
 most severe. Vomiting is the most distressing, ominous and in- 
 tractable alimentary symptom; it may follow eating or occur inde- 
 pendently of it. At first intermittent, it later hastens the fatal issue. 
 Early constipation gives way to terminal diarrhoea. 
 
 3. Pigmentation. — Pigmentation (melanoderma, bronzed skin, 
 melasma suprarenale) develops after the adynamia and alimentary 
 disturbance. Its cause is obscure ; Neusser refers it to involvement 
 of the sympathetic nerves or ganglia. It is found in the deep layers 
 of the rete Malpighii, to which it is apparently brought from the 
 blood by leukocytes. At first the shin has a dirty, yellow-gray color 
 and small areas appear which gradually fuse and then slowly become 
 darker and more diffuse ; extended pigmentation may occur with focal 
 areas of deeper discoloration. Pigmentation develops particularly (a) 
 
ADDISON'S DISEASE. 841 
 
 where it is normally deepest, as about the nipples, anus and genitalia ; 
 (b) where pressure or friction is greatest, as over folds of the skin, 
 over the clavicles, spine, ischia, scapulae or waist (from belts or cor- 
 sets) ; (c) where there is exposure to the sun, as in the face, neck or 
 arms; (d) where accidental irritation occurs, as by blistering, eczema 
 or parasitic affections. The soles of the feet, palms of the hands, 
 nail-beds and hair are seldom stained. Previous scars may or may 
 not be stained; sometimes they are surrounded by a zone of deeper 
 discoloration. The skin is dry, is sometimes bathed with profuse 
 perspiration and may have a iish-like odor. Scattered spots of pig- 
 ment may atrophy (vitiligo) and impart to it a strange appearance. 
 The mucous membrane of the lips, gums, cheek and palate show pig- 
 mentation later than the skin. The spots and horizontal ink-like 
 stains on the cheek where the teeth touch it are particularly of diag- 
 nostic value. The conjunctivae are pearly white and are usually said 
 to be exempt, though frequently small aggregations of pigment can 
 be seen on careful examination (Leva). Staining of the larynx, 
 nymphae, vagina, glans penis, serous membranes and internal organs 
 is infrequent. 
 
 4. Other Findings: (a) The heart shares in the general ady- 
 namia ; it frequently shows brown atrophy at autopsy ; its tones and 
 apex are weak. Pain over the heart is frequently reflected from the 
 abdomen ; palpitation and dyspnoea are common, but functional mur- 
 murs are rare. The pulse is compressible and somewhat accelerated, 
 seldom slow or arhythmic. The peripheral vessels and abdominal 
 aorta pulsate actively. Atheroma is common, even in young subjects 
 (Kolisko). (b) Anosmia was considered characteristic by Addison, 
 though Eothnagel and others have demonstrated its infrequency; in 
 a recent case the writer observed a red-cell count of 2 million. In- 
 crease in the red cells (polycythaemia rubra) and in the haemoglobin 
 results from concentration of the blood, due to vomiting and diar- 
 rhoea. The lymphocytes are somewhat increased, (c) The lymph 
 nodes and Peyer's patches are sometimes hyperplastic. The spleen, 
 thyroid, thymus and pineal glands are often enlarged, probably vi- 
 cariously, (d) Emaciation and cachexia are terminal conditions. 
 (Edema of the ankles is infrequent even toward the end. Character- 
 istic metabolic changes are not found; pigment in the urine is rare, 
 acetonuria is occasional, the urea is often decreased and terminal 
 albuminuria may develop, (e) The temperature is most often normal 
 or subnormal and a subjective chilliness is experienced. (/) The 
 genital functions decline as in any cachexia, (g) Tuberculosis of 
 the lung or bowel may somewhat modify the symptoms. 
 
 Clinical Course. — The cardinal symptoms described progress slowly, 
 with occasional intermissions, and in nearly all cases death results 
 after a year or two ; the terminal symptoms are often violent ; there 
 may be delirium, hallucinations, convulsions, incoercible vomiting 
 and diarrhoea, irregular respiration, small pupils, occasionally pseudo- 
 meningitic symptoms and finally collapse and coma. The course may 
 
842 DISEASES OF THE WCTLESS GLAttDS. 
 
 vary: (a) acute cases may resemble typhoid, digestive disease or 
 acute poisoning; (b) chronic cases sometimes last ten or thirteen 
 years; (c) sudden death may occur before pigmentation develops, the 
 suprarenal lesion at autopsy disclosing Addison's disease; (d) the 
 course may be modified by pulmonary or intestinal tuberculosis. 
 
 Diagnosis. — Diagnosis is based on (a) the prostration, psychical 
 and physical; (b) digestive disorders, vomiting, diarrhoea and neu- 
 ralgia; (c) pigmentation of the skin and oral mucosa; (d) cardiac 
 weakness and (e) the chronic lethal course. 
 
 As Addison's disease usually indicates the presence of tuberculosis, 
 the advisability of injecting tuberculin may be considered; a reaction 
 may easily occur from tuberculosis in other tissues. Adrenal tumors 
 may cause metastases in the brain or (like tumors of the thyroid, 
 prostate and mammae) in the long bones, skull and spine. 
 
 Differentiation. — Pigmentation occurs in numerous other con- 
 ditions: (a) poisoning by silver (argyria), in which the reduced 
 metal forms a gray deposit in the extracellular tissue of the skin, 
 sweat-glands, conjunctivae and nail-beds; by arsenic, which seldom 
 stains the mucosae; in pellagra, which is endemic and intermittent 
 in occurrence, with exacerbations in the spring and fall, is preceded 
 by erythema, is rarely associated with tuberculosis, but with eosino- 
 philia, diarrhoea and voracious appetite and is exempt from mucous 
 membrane pigmentation (Eeusser). (b) Chronic icterus (which, 
 however, stains the sclerae and urine), cyanosis (arteriosclerosis and 
 heart disease, also sometimes pigmenting the oral mucosa), various 
 physiological pigmentations and dirt and parasites, as in tramps 
 (vagabondism), (c) Abdominal diseases; dyspepsia, gastric ulcer, 
 tumor (cancer, lymphomata and Hodgkin's disease), hypertrophic 
 cirrhosis and haemochromatosis (hepatic and pancreatic cirrhosis, 
 diabetes and skin pigmentation, diabete bronze), (d) Pelvic condi- 
 tions; pregnancy, uterine and ovarian tumors (after the removal of 
 which pigmentation may regress), (e) Phthisis, malaria, melano- 
 sarcoma of the skin, exophthalmic goitre or rarely scleroderma. In 
 these conditions, pigmentation of the oral mucosa is rare. 
 
 Treatment. — 1. Supporting and Tonic. — Absolute rest is impera- 
 tive because of exhaustion and proneness to lethal syncope. Alco- 
 holic stimulation is poorly tolerated. Careful feeding is necessary 
 because of the sensitiveness of the stomach and bowels. Strychnine, 
 arsenic and nitroglycerine may be given. 
 
 2. Symptomatic— Narcotics for pain, gastric sedatives for vomit- 
 ing (v. Gastritis), astringents and opiates for diarrhoea (v. En- 
 teritis) should be administered; strong cathartics are always contra- 
 indicated, for they may precipitate fatal collapse; one case in the 
 Cook County Hospital died suddenly after taking a dram of com- 
 pound jalap powder. 
 
 3. Organotherapy. — Adrenal extract by mouth has surely helped 
 some cases and apparently arrested the development of others 
 (Oliver, Sansom, Lloyd, Jones, Osier, Ringer, Langlois, Dupaigne). 
 
ACUTE SPLENIC TUMOR. 843 
 
 In Adam's review of 97 cases, one-third were benefited and one-sixth 
 recovered. The medullary portion of the gland is best. It may in- 
 crease the vascular and muscular vigor or even lessen pigmentation. 
 Some practitioners advocate the hypodermatic administration of 
 adrenalin chloride, 3j of 1 to 1,000 in salt solution on alternate days. 
 Some advanced cases are unfavorably affected by organotherapy. 
 
 Other affections of the suprarenal glands are of slight clinical in- 
 terest, (a) In developmental anomalies the glands are sometimes 
 absent or hypoplastic, chiefly with other defects, as encephalocele, etc. 
 (b) Hypertrophy in one gland may compensate for hypoplasia in the 
 other. Supernumerary glands are not uncommon, (c) Atrophy is 
 usual in advanced age. (d) Degenerations embrace the parenchyma- 
 tous, fatty, hyaline and amyloid types, (e) Circulatory disorders are 
 hyperemia, embolism, thrombosis and hemorrhage, which latter may 
 occur in trauma in the new-born, tumors, inflammation and the 
 hemorrhagic diathesis. (/) Inflammation, acute and chronic, is un- 
 common, (g) Granulomata, chiefly syphilitic and tuberculous, are 
 rarely primary, (h) Tumors, carcinoma, sarcoma , (20 cases re- 
 corded, Affleck and Leith) and hypernephroma (v. page 792) are 
 chiefly of anatomical importance. In 23 published operations the 
 mortality was 50 per cent., recurrence developed in 21 per cent, and 
 29 per cent, recovered (in nine months to six years). At the Johns 
 Hopkins Hospital three tumors of the suprarenal glands were suc- 
 cessfully operated on \ Osier), (i) Parasitic disease (echinococcus) 
 is extremely infrequent. 
 
 DISEASES OF THE SPLEEN. 
 
 Lesions of the spleen are usually secondary. 
 
 ACUTE SPLENIC TUMOR. 
 
 This occurs (a) in acute infections, due to the local action of 
 microorganisms and their toxins or to toxemic paralysis of the 
 splanchnic nerve, which normally controls the vascular supply of 
 the organ; it is most common in typhoid, malaria, recurrent fever 
 and septic conditions ; (b) in acute stasis, usually from portal obstruc- 
 tion; and (c) in embolism (v. i.) and trauma. Symptoms are in- 
 frequent; much pain usually indicates involvement of the capsule 
 (perisplenitis). On objective examination: (a) The spleen may 
 sometimes be seen during deep inspiration. (&) Palpation alone is 
 wholly reliable. By the bimanual method and with the examiner 
 sitting at the right side of the patient the edge of the spleen comes 
 in contact with the fingers and slips sharply down below them ; splenic 
 crenations are seldom palpable. A palpable spleen always indicates 
 
844 DISEASES OF THE DUCTLESS GLANDS. 
 
 enlargement or much less often, downward dislocation by pleurisy, 
 emphysema, pneumothorax or thoracic tumor, (c) Percussion, valu- 
 able in outlining the upper splenic level, is unreliable in determining 
 the lower border. 
 
 CHRONIC SPLENIC TUMOR. 
 
 Chronic enlargement is symptomatic of (a) chronic infections, as 
 malaria, tuberculosis and syphilis, (b) continued portal stasis, (c) 
 repeated embolism, (d) blood affections, as leukaemia, pseudoleukemia 
 or splenic anemia, and (e) rickets, amyloidosis, neoplasms, cysts, 
 polycythemia (v. i.) } arthritis deformans and chronic acetanilide 
 poisoning. 
 
 EMBOLISM. 
 
 Embolism occurs frequently in the spleen, because of the wide ar- 
 teries and slow current; it ranks second in frequency to kidney em- 
 bolism. It usually develops in the course of acute endocarditis or 
 chronic valvular lesions and seldom follows local lesions, as sinus 
 thrombosis or splenic vein thrombosis. The symptoms vary some- 
 what as the embolus is simple or infective; sudden chill, fever, pain 
 in the side, acute splenic tumor and perisplenitic friction may de- 
 velop, which with a cause or embolic symptoms in other organs 
 justify a diagnosis of embolism. Frequently no distinctive symptoms 
 occur. If septic, symptoms of abscess may be present (v. i.). Treat- 
 ment is symptomatic. 
 
 ABSCESS (SPLENITIS APOSTEMATOSA). 
 
 Abscess of the spleen may result from embolism, trauma or in- 
 vasion by contiguity. It occurred in 9 per cent, of 430 cases of 
 pyemia (Paget). It is largest in non-embolic cases; in embolic the 
 abscesses are small and multiple. Symptoms are: (a) those of the 
 cause, which may mask the lesion; (b) of embolism; (c) of splenic 
 tumor, perisplenitis, friction or pain; (d) of rupture into the pleura, 
 kidney or peritoneum; (e) aspiration may determine the diagnosis 
 and surgical evacuation is then indicated. 
 
 PERISPLENITIS. 
 
 This affection may be primary or secondary, simple or suppurative, 
 an isolated lesion or part of a chronic peritonitis (see " Icing Liver," 
 Chronic Perihepatitis). It usually accompanies the various 
 splenic affections enumerated. Without local peritonitic friction, 
 pain or tenderness its diagnosis is impossible. There is no therapy. 
 
MOVABLE OB FLOATING SPLEEN. 845 
 
 AMYLOID SPLEEN. 
 
 Its etiology is considered under amyloid liver and kidney. Path- 
 ologically its two types are (a) the sago spleen, in which there are 
 amyloid deposits in the vessels of the Malpighian tufts, and (b) the 
 more important, diffuse amyloid infiltration. It is diagnosticated by 
 (i) the etiological factors, (ii) its usually large size, hardness, smooth- 
 ness and thick edge, and (iii) coincident amyloidosis of the liver 
 and kidneys. 
 
 SPLENIC ANAEMIA. 
 
 Springthorpe observed six cases in one family. Umber advises 
 operation in every case, because he believes that the spleen destroys the 
 red cells. The ;r-rays have been of therapeutic value. ( See page 827. ) 
 
 TUMORS AND CYSTS. 
 
 New growths are very infrequent. They are more often secondary 
 than primary. They include carcinoma, sarcoma (of which 19 pri- 
 mary cases were reported by Adolph, 1905), enchondroma, fibroma 
 and lymphangioma. They are rarely differentiated from splenic 
 anaemia and like affections. The chronic endothelioma of Gaucher 
 clinically resembles splenic anaemia ; pathologically, large endothelial 
 cells replace the splenic tissue; this was seen macroscopically in 
 Stengel's case. 
 
 Echinococcus cysts are found in but 0.2 to 3 per cent, of echino- 
 coccus disease and usually with concomitant cysts in the liver. One 
 dermoid cyst is reported (Andral, 1829). Only 38 non-parasitic 
 cysts are found in the literature. 
 
 Granulomata (see Tuberculosis and Syphilis). 
 
 RUPTURE OF THE SPLEEN. 
 
 Rupture may be traumatic or spontaneous ; the latter variety has 
 been observed in embolism, malaria, typhoid, acute leukaemia and 
 pregnancy. It is more common in India and tropical climates than 
 in temperate zones. Aspiration and even palpation have occasioned 
 rupture. The treatment is surgical; 104 splenectomies for rupture 
 are reported, with 29 per cent, mortality (Hortz). 
 
 MOVABLE OR FLOATING SPLEEN. 
 
 Permanent mobility {lien mobile) and dislocation are due to the 
 same factors observed in enteroptosis, with which it may be asso- 
 ciated: (a) lax, elongated or ruptured ligaments (ligamentum gastro- 
 lienale, phrenicolienale and most important, ligamentum phrenico- 
 colicum) ; (b) relaxed abdominal walls; and (c) enlargement and 
 increased weight of the spleen operating with the above factors. 
 
846 DISEASES OF THE DUCTLESS GLANDS. 
 
 Symptoms. — Symptoms are often absent. Pain or a dragging sen- 
 sation is frequent, which is either local or radiates to the thorax, left 
 shoulder or legs, similar to that observed in neurotics or women with 
 uterine or ovarian disease. There may be headache, insomnia, psy- 
 chical alteration, dyspepsia, constipation, menstrual anomalies, ves- 
 ical tenesmus and paresthesia in the legs ; most of these are neurotic. 
 Objectively: (a) The most important sign is palpatory detection of 
 the spleen in an abnormal location, (i) It is located most often in the 
 left ilio-inguinal region, near the ilium, but may lie just below the 
 left costal arch, near the navel, in a hernial sac, in the pelvis or above 
 the pubes. (ii) Its hilum usually points upward, either directly, if 
 it lies across the vertebrae or in the pelvis, or with slight inclination to 
 the right or left if it lies to one side, (iii) The form, notches and 
 possibly the pulsating vessels are those of the spleen, (iv) In size it 
 is usually enlarged, either from some causal hypertrophy or some 
 later congestion ; torsion of its pedicle may lead to softening, atrophy, 
 gangrene or even liberation of the spleen as a free body, (v) As a 
 rule it can be replaced and its position changes with posture; peri- 
 splenitis, causing a friction rub, may result in firm adhesions to the 
 colon, bladder, rectum or uterus, thereby causing insuperable diag- 
 nostic difficulty; in such cases the spleen ceases to " wander." (b) 
 The spleen is absent from its normal location, the splenic area being 
 replaced by tympany from the colon (which changes to dulness when 
 water is introduced into the colon), (c) Pressure symptoms include 
 intestinal obstruction, gastric dilatation, vesical and rectal com- 
 pression. 
 
 Diagnosis. — Diagnostic confusion with floating kidney and pedun- 
 culated ovarian tumors is infrequent when the abdomen and pelvis 
 are carefully examined. The author knows of three laparotomies 
 performed for supposed uterine or renal disease in which abundant 
 adhesions rendered differentiation impossible. On the other hand, a 
 hard, immovable suprapubic tumor was correctly diagnosticated as 
 leukemic spleen from the glands and blood findings. 
 
 Treatment. — (a) Bandages are more difficult to apply than for 
 movable kidneys, though some cases can be benefited by them, (b) 
 The spleen may be replaced by operation and its vicinity well packed 
 with gauze; the resulting adhesions often retain the viscus. (c) 
 Splenopexis (Rydygier) may be performed, the spleen being sewed 
 in place or deposited in a peritoneal pocket. Of 43 cases operated 
 upon in the last decade only 3 died (Bessel-Hagen). (d) Splenec- 
 tomy (see Pseudoleukemia) may be performed as a last resort, the 
 mortality being about 27 per cent. 
 
 SPLENOMEGALY, WITH CHRONIC POLYCYTHEMIA AND 
 
 CYANOSIS. 
 
 This condition is also known as erythemia and Vaquez's disease 
 (1892). Anders (1907) collected 53 cases, (a) The red cells are in- 
 
LYMPEATISM. 847 
 
 creased, even to 9 or 13 million (polycythemia rubra or polyglobul- 
 ism) ; the haemoglobin may reach 200 per cent. ; the white cells num- 
 ber from 4,000 to 31,000. The viscosity, specific gravity and volume 
 of the blood are increased, (b) There is chronic cyanosis, without ade- 
 quate cause and (c) splenomegaly. There may be headache, dyspnoea, 
 enlarged liver, mental and physical weakness, albuminuria, constipa- 
 tion, vomiting and an hemorrhagic diathesis. The arterial tension is 
 increased and the heart hypertrophies. De Lee sent the author 
 what appeared to be a forme fruste, a case with splenomegaly and 
 cyanosis but without polyglobuly. The etiology is obscure ; in about 
 one-third of the cases it was tuberculosis of the spleen and 8 of the 11 
 operated cases recovered; it seems probable that in most cases the 
 cause is an undue activity of the bone-marrow, which at autopsy is 
 livid purple and hyperplastic. The treatment is rr-rays, venesection, 
 nitrites, iodide of potash or splenectomy. 
 
 LYMPHATISM (STATUS LYMPHATICUS). 
 
 Lymphatism is a condition in which there is hyperplasia of the 
 various lymphoid and kindred tissues and a tendency to sudden 
 death. It is also known as the constitutio lymphatica, status thymicus 
 and status lymphaticus. (See Thymus Gland.) 
 
 Its etiology is obscure. The affection is rare and occurs most 
 often in women and children. Felix Plates (1614) observed it as a 
 familial affection. 
 
 Symptoms. — 1. There is lymphoid hyperplasia, (a) The lymph 
 glands of the chest and abdomen are more often involved than the 
 external, cervical, axillary or inguinal glands, (b) The tonsils, naso- 
 pharyngeal, lingual and intestinal lymphadenoid tissues are fre- 
 quently hyperplastic, (c) Moderate splenic enlargement is usual. 
 
 (d) The thymus is swollen, sometimes giving retrosternal dulness. 
 
 (e) The bone-marrow often changes to a reddish color. 
 
 2. Associated findings may include hypoplasia of the heart and 
 aorta, thyroid enlargement, poor development, infantilism, rickets, 
 tetany and laryngismus. 
 
 3. Sudden death is often the first evidence of the condition and 
 may occur without seemingly adequate cause, (a) It has occurred 
 during or after anaesthesia, especially with chloroform. In one case a 
 patient with enlarged glands died suddenly after receiving but 20 
 drops of chloroform, (b) Operations with local anaesthesia have also 
 been fatal, (c) Administration of antitoxin has caused death, as in 
 the well-known case in Professor Langerhans' family, (d) It may 
 occur while bathing or after falling in the water, (e) Sudden deaths 
 during convalescence from acute infections or some collapses during 
 hydrotherapeutic treatment (Escherich) may be attributed to the 
 lymphatic constitution. (/) Children with eczema may die suddenly ; 
 lymphatism causes 75 per cent, of these deaths. ' It is said to be due 
 to cardiac excitability (Kundrat), to lessened physiological resistance 
 
848 DISEASES OF THE DUCTLESS GLANDS. 
 
 with a tendency to heart paralysis (Paltauf ) and to a toxic condition 
 (Blumer, who suggests the term lymphotoxism). 
 
 DISEASES OF THE THYROID GLAND. 
 
 GOITRE. 
 
 Definition. — Hypertrophy of the thyroid gland. Sporadic cases are 
 common in Europe and America. Goitre occurs endemically in 
 Switzerland and Italy, though we have no knowledge of its cause; 
 the drinking-water has heen thought causal. It is usually acquired 
 and is seldom congenital. 
 
 There are three main forms: (a) The parenchymatous or follicular 
 type, with more or less symmetrical enlargement and formation of 
 colloid material in the hyperplastic follicles; (b) the cystic; and (c) 
 vascular or congestive type, with dilatation of the bloodvessels, which 
 form borders closely on those physiological variations observed at 
 puberty, in defloration, pregnancy, chlorosis and psychical trauma. 
 
 Symptoms. — 1. The thyroid enlargement may be diffuse, as in the 
 soft, symmetrical and moderately vascular form, or partial or nodose, 
 implicating but one lobe or the isthmus. In most cases there are only 
 local findings. 
 
 2. Compression symptoms are not common. The carotid artery 
 and jugular vein are pushed to one side and the sternomastoids be- 
 come thin. The trachea may be compressed, its lumen becoming 
 shaped like a sword scabbard; asthma, dyspnoea, bronchiectasis and 
 dilatation of the right ventricle follow stenosis of the air-passages. 
 Laryngeal paralysis occurs in over 10 per cent. Erankel states that 
 in 25 per cent, of cases in which there is tracheal stenosis, there is 
 also laryngeal paralysis. From the isthmus or lower horns of the 
 thyroid, goitres may grow in a retrosternal or retroclavicular direction 
 (5 to 10 per cent.) causing compression of the vagus, sympathetic 
 nerves and vena cava. A goitre may disappear into the chest with 
 each inspiration and appear on expiration (goitre en dedans). It 
 may become incarcerated in the chest. 
 
 3. An aberrant or accessory thyroid may occasionally form a tu- 
 mor anywhere from the tongue to the aorta, from the spine to the 
 anterior chest wall, in the retropharyngeal or retrooesophageal tissues 
 (causing dysphagia or dysarthria), in the trachea, larynx, root of the 
 tongue, pleura or mediastinum; it may compress an entire lung; 75 
 benign and 16 malignant growths are recorded in retrosternal acces- 
 sory thyroids. Storrs (1904) collected 32 lingual goitres; there are 
 three cases in the literature of retrosternal accessory thyroids, which 
 became cystic and calcareous (Collins, 1905), and fourteen whicli 
 were intratracheal (Pfeiffer, 1905). 
 
EXOPHTHALMIC GOITRE. 849 
 
 4. Sudden death may occur in large goitres ; it may be due to pres- 
 sure on the vagus, spasm or oedema of the glottis, sudden hyperemia 
 of the gland and pressure on the trachea, hemorrhage dissecting into 
 the chest or status lymphaticus. 
 
 Diagnosis. — Confusion is possible with tumors, as sarcoma, car- 
 cinoma or adenoma, for whose differentiation and symptoms refer- 
 ence to surgical treatises should be made. There are 25 cases in the 
 literature of echinococcus cysts. In 83 per cent, of cases cancer de- 
 velops from a preexisting goitre ; early metastases are specially com- 
 mon and characteristic; only 10 per cent, recovered among 110 
 operations (Madelung). There are 20 cases recorded in which meta- 
 stases throughout the body occurred from benign tumors of the thyroid 
 (chondroma or myxoma). Thyroid inflammation (strumitis) is 
 usually metastatic or traumatic, rarely primary; it may occur in 
 sound or goitrous glands; it is most often due to the streptococcus 
 but may be caused by the colon, typhoid, pneumonia or other or- 
 ganisms. 
 
 Treatment. — In regions where goitre is prevalent the drinking water 
 should be boiled. Medical treatment is of uncertain value. Iodine 
 may be used externally or by injection (Maunoir, 1825). Potassium 
 iodide (Coindet, 1820) is beneficial in some subacute cases, according 
 to Bruns, in 75 per cent. ; Kraus found it particularly beneficial in 
 the vascular type, with cardiovascular symptoms, as moderate tachy- 
 cardia and full arteries. The arrays are valuable in some cases. 
 Thyroid extract is occasionally beneficial. Surgical treatment is 
 indicated in large or growing goitres. Reverdin's collection of 6,103 
 operations shows a mortality of 2.8 per cent, and in Kocher's series, 
 now several thousand, one death occurred in each 600 operations. See 
 Cachexia Thyeeopriva, Myxcedema. 
 
 EXOPHTHALMIC GOITRE. 
 
 Definition. — A malady due to excessive activity of the thyroid gland 
 and characterized by three cardinal symptoms, exophthalmos, en- 
 larged thyroid and tachycardia and by other accessory symptoms, as 
 tremor, increased metabolism and ocular, vascular, digestive and 
 other symptoms. It was first described in England by Parry (1786) 
 and Graves (1835) and later in Germany by Basedow (1840). The 
 claim of the Italians that Flajani (1800) first described the affection 
 is ill-founded. 
 
 Etiology. — (1) The most probable cause is over-activity or per- 
 version of thyroid secretion (Mobius, Johnston and Greenfield). 
 Exophthalmic goitre contrasts sharply with myxcedema (v. i.) of 
 which the anatomical basis is thyroid atrophy, as shown below : 
 
 Exophthalmic Goitre. vs. Myxcedema. 
 
 (a) Hypertrophy of gland; excessive Atrophy; deficient (hypothyrea) or ab- 
 internal secretion (hyperthyrea sent secretion (athyrea). 
 
 or hyperthyroidism). 
 54 
 
850 DISEASES OF THE DUCTLESS GLANDS. 
 
 Exophthalmic Goitre. m. Myxcedema. 
 
 (5) Increased nervous excitability. Dulness, apathy, cretinism. 
 
 (c) Vascular erythrism; flushed, moist, Skin dry, thick and cool, and pulse slow. 
 
 warm skin; rapid pulse. 
 
 (d) Increased diuresis and active me- Decreased. 
 
 tabolism. 
 
 (e) Thyroid extract increases symp- Thyroid extract improves or cures. 
 
 toms; it may produce in normal 
 individuals symptoms like ex- 
 ophthalmic goitre, tachycardia, 
 tremor, even exophthalmos. 
 
 (/) Surgical (partial) excision relieves, Some cases result from removal of thy- 
 and often cures. roid. Transplantation of new gland 
 
 improves or cures. 
 
 (g) Exophthalmic goitre (glandular hypertrophy with excessive function) may 
 occasionally become myxcedema (insufficient function from glandular 
 atrophy). 
 
 2. Other etiological explanations are less probable, as (a) vaso- 
 motor neurosis or (b) lesions in the corpus restiforme of the medulla. 
 
 3. Disposing or exciting factors are: (a) Sex; in Eschner's 200 
 cases 80 per cent, were women (95 per cent, in other series). Fi- 
 broids, pregnancy and puberty are sometimes promoting factors, (b) 
 Age; most cases occur between the twentieth and thirtieth years. 
 Barrett (1904) could collect only 42 cases in persons under fifteen 
 years, (c) Psychical trauma, as fear, excitement or concussion, are 
 apparent causes, (d) Anaemia, debility, excesses, neuropathic family 
 tendencies, other neuroses or psychoses favor its development, (e) 
 After thyroidectomy, symptoms resembling those of exophthalmic 
 goitre may develop; this postoperative thyroidism is rare. 
 
 Symptoms. — 1. Cardinal Symptoms. — (a) Tachycardia is the 
 earliest and most constant cardinal symptom. The pulse ranges 
 from 100 to 120 and in severe cases to 140 (or even 200) ; it varies 
 greatly from time to time. It is associated with other cardiovascular 
 symptoms, as (i) increased cardiac action, manifested by a diffuse 
 cardiac impulse, sharp tones sometimes heard at a distance of sev- 
 eral feet (Graves) and hypertrophy of the left ventricle eventuating 
 in dilatation; (ii) a functional systolic murmur over the apex; (iii) 
 palpitation, which usually antedates tachycardia and is an evidence 
 of intoxication (thyroidism) ; (iv) vascular symptoms; a pulse rather 
 weaker than the apex beat ; active arterial pulsation in the carotids 
 and abdominal aorta ; systolic capillary pulsation in the fingers, fore- 
 head or even in the retina, palate, liver and spleen ; even the periph- 
 eral veins may pulsate; (v) irregular and failing heart action occurs 
 late and in severe cases. Hemorrhages, notably epistaxis, are not 
 uncommon. 
 
 (b) Exophthalmos is usually a later symptom than tachycardia or 
 sometimes than the goitre. It is present in about 90 per cent, of 
 
 v 
 
EXOPHTHALMIC GOITRE. 851 
 
 cases and results from dilatation of the orbital vessels. In developed 
 cases the protrusion of the eyeballs and the staring, fixed expression 
 are very characteristic (exophthalmos may also occur in extreme 
 myopia, tumors of the orbit and sympathetic irritation). The con- 
 dition is generally bilateral, though often unequal; in one instance 
 the author saw unilateral exophthalmos with homolateral goitre. 
 The eyelids are unable to cover the eyeball entirely and a rim of the 
 white sclera shows about the iris. The protrusion may be very ex- 
 treme, even amounting to dislocation of the bulb ; in these cases there 
 may be corneal ulceration and loss of the eye by panophthalmitis. 
 Under this topic may be mentioned the associated eye-symptoms, 
 which are: (i) von Graefe's sign, the failure of the upper lid to 
 follow the eye-ball when it is rolled downward, is present in at least 
 33 per cent, and is of considerable diagnostic value, though present 
 also in Thomsen's disease, (ii) Stettwag's sign, which is rarely ab- 
 sent, is widening of the interpalpebral fissure (Dalrymple, 1849) 
 with infrequent winking (Stellwag, 1869) ; it also occurs in mania 
 and in old age. (iii) Mdbius' sign consists of weakness of the internal 
 recti, whereby convergence is less complete or unsustained when a 
 finger on which the eyes are focused is brought close to the nose ; it 
 occurs also in other conditions, as paretic dementia, (iv) Beckers 
 sign (1873) consists of pulsation of the retinal vessels, (v) In 
 Jo ff 'roy's sign the patient's forehead remains smooth (instead of be- 
 coming wrinkled) when he glances upward with the head bent some- 
 what downward, (vi) Gifford's sign is the difficulty in everting the 
 upper lid; (vii) Jellinek and Rosin describe an oedema and pig- 
 mentation of the upper lid. Boston noted a spasm of the lid in elicit- 
 ing v. Graefe's sign. Tremor of and a sense of pressure behind the 
 eyeball are common. Eye paralyses and retinal or pupillary changes 
 are infrequent. 
 
 (c) The goitre is rarely an initial symptom and usually develops 
 later and in a remittent fashion, i. e., swelling, recession and renewed 
 swelling. It is present in 100 per cent, (i) Its typical form is 
 vascular, though it may develop upon any of the ordinary forms of 
 goitre, as in an acute fatal case, seen in 1905, with Dr. Dorsey of 
 Streator, in which exophthalmos, tachycardia and thyroid thrills 
 and murmurs developed in a chronic cystic goitre. Acute thyroidism 
 may develop in- thyroid malignancy. The goitre is smaller than the 
 ordinary bronchocele ; it is diffuse or oftener more developed on the 
 right side (an accentuation of physiological proportions), shows a 
 vascular, rough surface and is dry, gray and granular on section (in- 
 stead of the norinal amber-red color) ; microscopically, according to 
 MacCallum, the alveoli are not rounded, full of colloid matter or 
 lined with cubical epithelium, but are extremely irregular in sizq 
 and form, smaller or ramifying and encroached upon by epithe- - 
 lial proliferations and the epithelium becomes columnar ; in ex- 
 treme or severe cases there is some epithelial desquamation; the 
 colloid matter is scanty and stains faintly and some lymphoid tissue 
 
852 DISEASES OF THE DUCTLESS GLANDS. 
 
 develops ; in the later stages some fibrous tissue may develop, (ii) 
 It is usually soft, elastic, variable in size from time to time, pulsating 
 on inspection, thrilling on palpation and revealing on auscultation a 
 loud systolic bruit or a double murmur, which, according to Gutt- 
 mann, is pathognomonic. The goitre may be retrosternal. 
 
 2. Accessory Symptoms. — (a) Tremor, described first by Base- 
 dow, is classified as a cardinal symptom by Charcot and Marie. It is 
 present to some degree in most cases and is conspicuous in 50 per 
 cent. It is characteristically fine, regular and rapid, numbering 8 
 or 9 vibrations to the second. It affects the wrist more than the 
 fingers; sometimes it affects the trunk, (b) Nervous symptoms. 
 Some cerebral symptoms are usual, as headache, vertigo, impaired 
 memory, insomnia, irritability, depression or change in disposition. 
 Psychoses are infrequent, as the mania sometimes observed in fatal 
 cases. Choreiform movements were described by Kahler. " Giving 
 way of the legs" (Charcot) and weakness of the respiratory muscles 
 (scant inspiratory increase in the chest measurement, Bryson's sign) 
 are expressions of iveakness of the muscles, whose strength is reduced 
 to one-third or one-fifth of normal (Muller). The reflexes are often 
 increased. Rheumatic pains may be noted. Vasomotor symptoms 
 are common,, as violent reddening of the face, subjective warmth, dry 
 mouth, sweats of a peculiar, penetrating odor, or intermittent swell- 
 ing of the joints. Rarer complications are cerebral paralyses, tabes, 
 syringomyelia or various neuroses, (c) Respiratory symptoms in- 
 clude dyspnoea and dry cough. The author has seen two incipient cases 
 diagnosticated as phthisis, (d) Digestive symptoms. Severe nervous 
 vomiting and diarrhoea may simulate organic disease; their persist- 
 ence is ominous, (e) Cutaneous symptoms. Pigmentation may be 
 extreme (Drummond, Chvostek). Pigmentation of the eyelids, vaso- 
 motor oedema, urticaria (particularly in acute cases), itching and 
 falling of the hair may also occur. A peculiar fulness above the 
 clavicles may develop, sometimes with pain in the neck. The elec- 
 trical resistance of the skin is decreased, perhaps to one-fifth of the 
 normal (Charcot, Chvostek, Yigoroux) ; it is probably occasioned by 
 profuse sweating and has no pathognomonic importance. (/) Con- 
 stitutional symptoms. Emaciation and anaamia are common, espe- 
 cially in blondes. Metabolism is almost always increased; this is 
 evidenced by the nitrogenous excretion, increased diuresis and the 
 frequent, slight, but wholly atypical, elevation of temperature ; these 
 symptoms may be intermittent (Huchard). Gilman Thompson de- 
 scribes fever and symptoms resembling ulcerative endocarditis. 
 Amenorrhoea, albuminuria, glycosuria, persistence of the thymus 
 gland (in 80 per cent.) and the occasional hyperplasia of the spleen 
 are difficult to explain. In the leucocyte count the polymorphonu- 
 clears are decreased and the lymphocytes increased (Kocher). 
 
 Diagnosis.- — The diagnosis is unequivocal when the cardinal triad 
 of symptoms is present, reinforced by the secondary symptoms. 
 Atypical forms (formes frustes) may cause confusion, but careful 
 
EXOPHTHALMIC GOITRE. 
 
 853 
 
 watching of the clinical course usually settles all doubt. The affec- 
 tion is often incorrectly diagnosticated in young girls at puberty,^ in 
 whom thyroid turgescence, moderate tachycardia and vascular excita- 
 bility occur without particular significance. Incipient tuberculosis 
 and neurasthenia may be simulated. 
 
 Course and Prognosis. — (a) The onset is usually insidious and the 
 course chronic. Kemissions are very common. Chronic cases some- 
 times begin rather acutely. Acute cases are unusual; they occur 
 chiefly in men; Lloyd records a case which was fatal in three days 
 and Trousseau one fatal in eight days. The author has seen three 
 cases in which death occurred in from two to five weeks. The acute 
 type is usually fatal, though Solbrig mentions a recovery after ten 
 days, (b) Death occurs in 12 per cent, of cases; it is almost always 
 due to cardiac failure, hypertrophy passing into dilatation, (c) 
 The outlook is best in the less typical (rudimentary) forms, (d) 
 Complete recovery is rare, though 20 to 50 per cent, of cases improve 
 (relative recovery), (e) Unfavorable prognostics are its occurrence 
 in the very young and in men, emaciation, extreme tachycardia, per- 
 sistent vomiting or diarrhoea, fever, corneal disease, lymphatism and 
 intercurrence of myxcedema (v. i.). 
 
 Treatment. — 1. General. — Rest is the first indication. Travel, 
 sojourn at the various springs and resorts, gymnastics and excitement 
 are always injurious. A simple diet and interdiction of alcohol, 
 coffee, tea and tobacco are essential. A quiet life at a moderate ele- 
 vation or at the sea-side is very beneficial. 
 
 2. Drugs. — Except for symptomatic indications, drugs have a 
 limited use. The heart tonics are disappointing ; digitalis fails to 
 slow the heart and strophanthus and spartein sulphate are rather 
 more efficient but do not adequately control tachycardia. Belladonna, 
 in large physiological doses (until it produces mydriasis and dry 
 mouth), is recommended by Gowers; in personal experience the an- 
 noying palpitation and abdominal throbbing are most relieved. Er- 
 gotin, quinine, arsenic, iron and strychnine are of uncertain value, 
 but the latter seems rather more beneficial ; iron is apparently useful 
 only in chlorotic girls (Mobius) and is directly injurious in men, for 
 it aggravates digestive and vasomotor disturbances. Constant appli- 
 cation of an ice-bag to the heart is very helpful; it relieves palpita- 
 tion and somewhat slows the heart rate. 
 
 3. Electricity.— This is chiefly valuable as a suggestive remedy ; 
 galvanization is particularly recommended by Erb, who uses the 
 anode over the cervical spine and the kathode over various peripheral 
 areas. Electrotherapy effects only transient results. 
 
 4. Organotherapy. — Thyroid extract aggravates the symptoms 
 in nearly all cases. Thymus extract has apparently helped some 
 cases, but recent reports concur with the rather negative results ob- 
 tained by Mackenzie and Kinnicutt. The use of serum or milk from 
 thyroidectomized animals is still in the experimental stage; Bau- 
 mann (1895) demonstrated that the thyroid gland contained an 
 
854 DISEASES OF THE DUCTLESS GLANDS. 
 
 iodine body which Ross proved was the main functional constituent 
 of the organ. The active element of the gland presents two clinical 
 phases: {a) it neutralizes toxins (failing in which myxoedema re- 
 sults), and (b) if not itself neutralized, Basedow's disease results; to 
 neutralize the hyperthyrea of this disease, it was suggested that the 
 serum of thyroidectomized animals be used (Ballet, Enriquez, Lanz, 
 Burghart and Blumenthal) ; some good results have recently been 
 obtained (Rogers). 
 
 5. Thyroidectomy. — The earlier objections to partial thyroidec- 
 tomy are now weakening because of convincing surgical statistics. The 
 average mortality is about 5 per cent. In Kocher' s large experience 
 of 315 operations, naturally on severe types, only 3.5 per cent, died; 
 not one case died in the last 91 operated upon ; 83 per cent, were cured. 
 Kocher considers (a). the blood pressure, size of the heart and tachy- 
 cardia; (6) he hesitates to operate if there is great nervousness, in- 
 toxication or absence of lymphocytosis, and (c) if the gland is very 
 large, pulsating or vascular. The Mayos' last series shows 8 per 
 cent, mortality; they consider general preferable to local anaesthesia, 
 Death may also occur under local anaesthesia, which latter is a very 
 unpleasant procedure. Removal under nitrous monoxide gas gave 
 excellent results in two of the author's cases. Kocher prefers trying 
 the rr-rays first and then proceeding by stages, first ligating the 
 thyroid arteries (after which tetany may occur and once within 
 half an hour) and later performing partial thyroidectomy ; the danger 
 of a " heart " death is avoided by relatively early operation. Hirst 
 states that the mortality of operation, for any indication, in an ex- 
 ophthalmic subject, is increased 15 per cent. Division of the cervical 
 sympathetic is inadvisable. 
 
 MYXCEDEMA. 
 
 Definition. — Myxoedema is a chronic constitutional disease, charac- 
 terized (a) by loss of thyroid function (athyrea), (&) by myxoedema 
 (an elastic ©edematous change in the subcutaneous tissue), (c) by 
 cachexia or (d) by cretinism (mental failure). It was described by 
 Gull (1873) as a cretinoid manifestation and later by Ord (1877) 
 in England and in France by Charcot, Bourneville, d'Olier and others. 
 
 The symptoms vary as to cause and combination, whence (i) 
 cretinism, (ii) adult myxoedema and (iii) operative myxoedema will 
 be considered separately. 
 
 Etiology. — The thyroid may be aplastic, hypoplastic, cirrhotic from 
 an infective sclerosing thyroiditis (syphilis, tuberculosis, rheuma- 
 tism or erysipelas) or hypertrophied (goitre) or it may be removed 
 by operation, but in all cases the thyroid function (internal secretion 
 or antitoxic action) is suspended or lost. 
 
ft* 
 
 MYXEDEMA OF ADULTS. 855 
 
 CRETINISM. 
 
 Cretinism may be congenital, in which instance life is not long 
 protracted; it usually develops in the first year and is noticed near 
 the time of weaning (infantile form) ; it may develop between the 
 fourth year and puberty (juvenile form). The endemic form occurs 
 in regions where goitre is prevalent, in Switzerland, Italy, France, 
 Great Britain, Spain and Sweden; according to Kocher, when both 
 parents are goitrous, the child is invariably a cretin, is myxoedema- 
 tous and may also have goitre. The sporadic form may develop from 
 thyroid aplasia, sclerosing thyroiditis or from goitre. In 1905, 100 
 cases were collected in America (Howard). 
 
 Symptoms. — In the last part of the first or in the second year of 
 life, retardation of mental and physical development is apparent. 
 The head is disproportionately large, the fontanelles persist, the fore- 
 head is narrow and the base of the skull is shortened. The face is 
 turgid, pale and imbecile, the lids are swollen, as are the nose, the 
 protruding tongue and pouting lips. Dentition is retarded and caries 
 is frequent. The skin loses its tone and is dry, and the hair is thin. 
 The neck is short, which condition is accentuated by supraclavicular 
 deposits of fat. The abdomen is large and pendulous; umbilical 
 hernia is very frequent. The body is dwarfed and the extremities 
 are short, stumpy and weak or helpless. Metabolism is slow, the gase- 
 ous interchange being reduced to 60 to 50 per cent, of the normal. 
 
 Diagnosis. — (a) The mental alteration is marked, though mild com- 
 pared with the grimaces, grinding of the teeth and compulsory move- 
 ments caused by gross lesions of the brain, (b) In hyperplasia of the 
 bone cartilages (chondrodystrophia fcetalis) there are great enlarge- 
 ment of the head and joints, dwarfing of the body and shortness of the 
 extremities (micromelia), but no essential mental change; court fools 
 were probably of this type, (c) Infantilism concerns only the infan- 
 tile appearance of the genitalia and the absence of the primary and 
 secondary evidences of sex ; general malnutrition, aplasia and cretin- 
 ism are absent, though some cases of infantilism are due to thyroid 
 hypoplasia. 
 
 MYXCEDEMA OF ADULTS. 
 
 Symptoms. — Myxoedema spontaneum adultorum, or cachexie pachy- 
 dermique (Charcot) is characterized by (1) thyroid atrophy, (2) 
 myxoedema (pachydermia), (3) intellectual and physical weakness 
 and (4) certain accessory symptoms. It is most frequent in England 
 and France. Most cases occur between thirty and fifty years of age. 
 
 1. Thyroid Atrophy. — This is difficult to detect clinically. It is 
 less a clinical than a histological condition, as evidenced by the lack 
 of function sometimes observed in gross enlargement of the gland; 
 Magnus Levy, in 34 cases observed by him, found the thyroid hard 
 and large in 5 cases. Eighty-six per cent, occur in women and it is 
 possibly related to the uterine functions or to the physiological con- 
 
856 DISEASES OF THE DUCTLESS GLANDS. 
 
 gestive, thyroid enlargement observed in women. It may be heredi- 
 tary or familial. It sometimes occurs in a family (or in individuals) 
 in which there are cases of exophthalmic goitre. 
 
 2. Myxcedema. — Mucin has been found in the skin and subcutane- 
 ous tissues. These structures are inelastic, semigelatinous and semi- 
 oedematous, but do not pit upon pressure ; the skin is pale, waxy, dry, 
 rough, firm and its electrical resistance is increased; the hair and 
 teeth may fall out and the nails thicken and break. The loss of the 
 outer half of the eyebrow is described by French writers. The 
 facies is somnolent, coarse and swollen, and the features are individu- 
 ally changed, rather resembling those of a cretin; the cheeks are 
 patchy-red, pendulous and tremble like jelly and the tongue is big. 
 The supraclavicular tissue is enlarged in lumps and rolls, though this 
 is also observed in healthy persons (Verneuil's pseudolipomata). S. 
 Kuh observed a painful swelling over the clavicle alone, which rather 
 resembled keloid. The hands and feet are infiltrated. The swellings 
 may change rapidly. The oral mucous membrane is dry and thick, 
 sometimes also the pharynx, larynx and even the rectum ; polypi are 
 frequent and secretion of tears is scanty. 
 
 3. Mental Weakness. — Intellectual and physical weakness is 
 apparent. Somnolence is more frequent than insomnia. Charcot 
 compares the condition to hibernation. Headache is common. The 
 patient is apathetic, irritable, weak in memory and slow in thought, 
 speech and movement; sometimes delirium and mania precede the 
 ultimate dementia. The gait is clumsy ("hippopotamus gait") and 
 muscular fatigue follows moderate exertion. 
 
 4. Other Symptoms. — The accessory symptoms are variable, as 
 cardiac hypertrophy, arteriosclerosis, palpitation; small, sluggish 
 pupils, tremor, vertigo, night terrors, sensitiveness to cold; indiges- 
 tion and constipation ; anaemia ; amenorrhea ; scanty urine with little 
 urea and low specific gravity, sometimes albuminuria and less often 
 glycosuria ; hemorrhages, especially from the uterus ; and subnormal 
 temperature. The thymus is usually enlarged, sometimes the hy- 
 pophysis; Hunt describes it with adrenal tuberculosis. 
 
 Course. — The course is chronically progressive and covers ten to 
 twenty years. Remissions may occur in the warm weather, from 
 change to a milder climate or during pregnancy. In the last stage, 
 the myxoedema often disappears. Transient cases of acute myxcedema 
 have been observed by Sollier, Osier and others. Osier reported an 
 acute case with melsena, mania, glycosuria, tachycardia and death in 
 six months. Sudden death is occasional, but most patients die of 
 intercurrent tuberculosis or acute infections. 
 
 CACHEXIA THYREOPRIVA OR OPERATIVE MYXCEDEMA. 
 
 Horsley reported that myxoedema, tetany contractures, apathy and 
 coma occurred in the monkey after complete thyroidectomy; when 
 kept warm the monkeys did not manifest myxoedema, but a species 
 
CACHEXIA THYBEOPBIVA. 857 
 
 of cretinism. Cachexia follows extirpation in man and herbivora; 
 convulsions develop in carnivora, resulting from the fact that the 
 antitoxic elements of the thyroid are not present to neutralize the 
 nuclein of ingested meat. The toxaemia strumipriva is manifested by 
 anaemia (2 million red cells), leukocytosis (30 to 38,000) and de- 
 generation in the walls of the bloodvessels. Kocher observed cachexia 
 strumipriva in 70 per cent, of cases, more often after the complete 
 than after the partial operation. Keverdin made similar observations 
 and von Eiselberg reported it in about 23 per cent, of complete ex- 
 cisions made in Billroth' s clinic. Accessory thyroids (v. Goitre) 
 may avert this operative complication. The author knows of two 
 instances in which removal of an accessory lingual thyroid (under 
 a mistaken diagnosis) caused myxoedema. Schiff (1884) and later 
 von Eiselsberg cured operative myxoedema by transplantation of a 
 thyroid. Bircher (1899) first successfully made a transplantation in 
 the human being. Unfortunately, the function of the transplanted 
 gland is seldom maintained, though Cristiani reports excellent results. 
 In some cases ablation of the thyroid gland seemed to produce 
 tetany (tetania thyreopriva) . Gley was the first to connect tetany 
 with extirpation of the parathyroid glands, first described by Sand- 
 strom (1880). Vassali and Generali maintained that absence or 
 ablation of the thyroid causes cachexia and trophic disorder, and that 
 absence or ablation of the parathyroid glands causes tetany (without 
 cachexia). In thyroidectomy the thyroid should be removed care- 
 fully in order to spare the parathyroids located alongside the lower 
 part of the lateral lobes. 
 
 Treatment of Cretinism, Myxoedema and Cachexia Thyreopriva. 
 
 — For these allied conditions we possess in the thyroid extract (Glan- 
 dulse thyroideae siccae) one of the few actual specifics of medicine and 
 most cases of cretinism, adult myxcedema and operative myxoedema 
 can be cured — in a sense we can seldom employ this term. Horsley's 
 pupil, Murray, first used the thyroid extract hypodermatically ; this 
 method soon gave way to its administration by mouth, advocated by 
 Horwitz of Copenhagen (1892), and Mackenzie and E. L. Fox in 
 London. The powdered extract should be prepared from the glands 
 of young sheep, for the thyroid soon atrophies in older animals. Be- 
 ginning with gr. ij t. i. d., the dose may be increased to gr. v or even 
 xv. In a short time the evidences of increased metabolism appear, as 
 loss of weight, increased diuresis, increased urea and elevation of 
 bodily temperature; normal growth is stimulated, myxoedema and 
 cretinism disappear, the pulse becomes full and lively, the skin moist- 
 ens and regains its lustre and in every regard the results are magical. 
 In some instances toxic effects (thyroidism) are apparent, as tachy- 
 cardia, nervousness, delirium, dyspnoea, palpitation, flushing, sweat- 
 ing, tremor, less often tonic spasms and rarely exophthalmos, soften- 
 ing of the bones, particularly in young rhachitic subjects, or even 
 death; these symptoms are allied to those of exophthalmic goitre 
 
858 DISEASES OF TEE DUCTLESS GLANDS. 
 
 (hyperthyrea) ; thyroidism is seemingly more frequent in myocarditic 
 and arteriosclerotic subjects. Ewald thinks that administration of 
 arsenic lessens the liability of thyroidism, which after all is an in- 
 frequent condition. Larger doses may be given in winter than in 
 summer. At first large doses are indicated and later, after relief is 
 obtained, smaller doses should be given, averaging gr. j. to ij, or 
 whatever size experience in the individual case may determine. Ke- 
 lapses are common after withdrawal of the extract and in most cases 
 it becomes rather a food than medication. Change of climate and 
 warm baths are of decided benefit. A milk or a salt-free diet is also 
 advocated. 
 
 DISEASES OF THE THYMUS GLAND. 
 
 The thymic functions are unknown. Among other hypotheses it is 
 said that the thymus is concerned in neutralizing infection or in 
 certain vegetative functions, as the growth of bone and that it bears 
 some relation to cerebral function. Some class it as a ductless gland. 
 The gland is epithelial in origin, but becomes lymphoid in structure. 
 Its secretion in the first two years of life is milky and contains iodine, 
 cells and a molecular substance. It weighs two to four drams at 
 birth, about an ounce in the second year, after which it wastes, weigh- 
 ing but one dram at twenty-five to thirty years of age. 
 
 There is an intimate, though obscure, relation between the thymus, 
 thyroid, pituitary body, parathyroids, testes, ovaries and possibly also 
 the bone-marrow. The thymus wastes as the testicles and ovaries 
 develop. Thymic extract causes a fall in blood pressure, cardiac 
 acceleration and, in large doses, fatal collapse. 
 
 (a) Hemorrhages into the thymus may be found in cases of con- 
 genital syphilis and asphyxia of the new-born, (b) Thymic cysts. 
 Chiari claims that 50 per cent, are merely accentuation of the normal 
 findings, in which the lymphoid elements overgrow into the convolu- 
 tions of the gland. -l(c) Abscess of the thymus, described by Dubois 
 (1850), is often mistaken for softened gummata, cysts and post- 
 mortem softening, (d) The most frequent tumors are sarcoma and 
 lymphosarcoma. Less frequent are dermoids and granulomata. 
 
 (e) Persistence of the gland after puberty is described; the term is 
 ill-chosen, as the gland normally persists into adult life. 
 
 (/) Some cases of " persistent thymus " are hypertrophy or hyper- 
 plasia, which is the most common thymic lesion. Microscopically, we 
 find lymphoid hyperplasia, Hassal's concentric epithelial corpuscles, 
 eosinophiles and even myelocytes, (i) Physical signs. Dulness of 
 more than 1 cm. to each side of the sternum is pathological. The gland 
 may weigh one-half to five ounces, (ii) Plater (1614) associated en- 
 largement of the thymus with sudden death. Grawitz, Jacobi and 
 others have described cases of thymic hyperplasia which has caused 
 sudden dyspnoea, usually in infants, followed by early death ; the idea 
 is advanced that the gland presses on the vagus, cava or trachea. The 
 cases are thought to be lymphatism (q. v.), as are the cases described 
 
ACROMEGALY. 
 
 859 
 
 by Nordmann, Kecklinghausen, Kolleston, Paltauf and Keyer, who 
 collected eight cases of sudden death in robust young men while 
 bathing, by Kundrat, who found thymic hyperplasia in 10 cases of 
 death from chloroform and by Schlomicher's similar series, (iii) 
 The existence of thymic asthma (Kopp, 1830), also known as Millar's 
 asthma, was denied by Friedleben (1858). The stridor, caused by 
 thymic compression of the trachea, is pronounced, progressive and 
 usually fatal from asphyxia. The enlarged gland may actually flat- 
 ten the trachea (Summa and Benecke), as the distance between the 
 sternum and spine is but little more than an inch and compression in 
 this region is critical. Rehn, in a case of thymic asthma, stitched 
 the gland to the skin, which relieved all symptoms ; Konig and Ehr- 
 hardt each cured a case by partial excision of the gland ; 9 operations 
 are recorded. Hochsinger (1905) found 20 cases of thymic stridor 
 in 26 enlarged thymi in children; enlargement was determined by 
 the x-rajs. (iv) Hyperplasia has been frequently found in Graves' 
 disease, status lymphaticus, myxoedema, syphilis, acromegaly, epi- 
 lepsy, myasthenia gravis and in atrophy of the splenic, lymphatic or 
 myeloid structures. Besides operation, sc-rays, quiet, iodides and 
 mercury are advised. 
 
 DISEASE OF THE HYPOPHYSIS : ACROMEGALY. 
 
 Acromegaly (large extremities), first described by Marie (1886), 
 is a nutritional affection, probably caused by disease of the hypophy- 
 sis, and marked clinically by unusual overgrowth of the bones, tissues 
 of the face, hands and feet and by general symptoms, glycosuria and 
 sexual disturbance. 
 
 Etiology. — The hypophysis is almost always diseased. In 1902, 
 Woods-Hutchinson collected 262 cases; in 77 autopsies the gland was 
 diseased in 73. The process may be hyperplasia, adenoma Or soft 
 malignant sarcoma, less commonly colloid degeneration, fibrosis, soft- 
 ening or hemorrhage. Dean Lewis found hyperplasia of the chromo- 
 phile cells, which confirms Benda's theory that acromegaly is due to 
 excessive activity of the cells in the anterior lobe of the hypophysis. 
 From its association with acromegaly, the gland has been thought to 
 be the "growth centre." The growth may compress the cerebral 
 nerves, cavernous sinus, bone, dura or even the brain. According to 
 Sternberg, the sexes are about equally affected, and in 50 per cent, 
 the affection begins between twenty and thirty, in 75 per cent, be- 
 tween twenty and forty and in 14 per cent, under twenty years of age. 
 
 Symptoms. — 1. Acromegaly. — Enlargement of the extremities is 
 usually the first clear symptom, but is preceded by paresthesia? and 
 pains in the extremities, often extreme and due to expansion, (a) A 
 remarkable change occurs in the face; the superciliary ridges pro- 
 trude, the maxilla? enlarge and the nose, ears, lips, tongue and chin 
 attain massive proportions. The general contour of the face is hex- 
 agonal. The teeth separate and the tongue sometimes protrudes be- 
 
860 DISEASES OF THE DUCTLESS GLANDS. 
 
 yond them. The eyes by contrast appear small. Pathologically, the 
 change in the bone is simple hypertrophy; there is increase in the 
 vascular furrows, widening of some of the foramina (with narrowing 
 of others) and some roughening of the bones and localized protuber- 
 ances which are not osteophytes; the skull is thicker and larger, es- 
 pecially the sphenoid, superciliary ridges, mastoid and occipital pro- 
 tuberances; the orbit may be narrowed by ethmoid bulging and the 
 sinuses and sella turcica are increased. (b) The hands and feet are 
 greatly enlarged, not deformed but symmetrically hypertrophied. 
 The fingers and toes show two types (Marie), the long and the thick 
 types ; they are square at their ends — the " spade-like fingers." The 
 palms and soles become flattened. The arrays show simple hyper- 
 trophy of the periosteal and subperiosteal tissues and of the soft parts ; 
 in some cases the soft parts are more hyperplastic than the bones. A 
 common statement in the history is that the patient " must each year 
 buy larger-sized hats, gloves or shoes." The nails are thin and 
 small. The antithesis of acromegaly is micromelia (Hutchinson), 
 (c) The changes in the trunk are less conspicuous. The sternum is 
 increased anteroposteriorly and the ribs and clavicles are thickened. 
 The anteroposterior dimension of the thorax is increased, the head is 
 held backward and the dorsal kyphosis is rather characteristic. The 
 muscular weakness and lean arms and legs contrast sharply with the 
 first impression of strength imparted by the massive face and ex- 
 tremities. The breathing is largely abdominal, (d) The skin is 
 hyperplastic and also the mucous membrane of the nose, tongue, phar- 
 ynx and larynx. The larynx is enlarged (Marie), which may explain 
 the deep, low, rough, monotonous voice. 
 
 2. Nervous Manifestations. — (a) Symptoms of brain tumor 
 (hypophysis) are common, as headache, vertigo, mental alteration, 
 vomiting, periodic loss of consciousness, early and frequent bitem- 
 poral hemianopsia, optic atrophy (40 per cent.), ocular paralysis, 
 anosmia, auditory disturbance and exophthalmos. Hertel in 175 
 cases found eye symptoms in 52.5 per cent, (b) Changes in charac- 
 ter, anxiety, apathy and insomnia which deepens into terminal somno- 
 lence, are common ; severe pains, paresthesia, acroparesthesia and sub- 
 jective warmth are frequent. 
 
 3. Constitutional Symptoms. — (a) Glycosuria is more frequent 
 than Hansemann's figures indicate (12 per cent.). Its relation to 
 acromegaly is uncertain, probably being a coordinate manifestation. 
 Sometimes polyuria occurs without glycosuria, (b) Profuse sweats 
 are common, even with glycosuria; the skin is sometimes pigmented; 
 obesity is common, (c) Sexual disturbance is the rule; in women 
 amenorrhea is practically constant and is often preceded by dysmen- 
 orrhea; in men impotence is not unusual; the genitalia are much 
 oftener infantile than hypertrophied. (d) The heart is often dilated 
 and hypertrophied from the frequent concomitant arteriosclerosis, 
 deformed chest and rarely from actual overgrowth (cardiomegaly). 
 The vessels are wide and thick. Splanchnomegaly may be observed 
 
ACROMEGALY. 861 
 
 (intestines and other viscera). In most cases the lymph nodes, par- 
 ticularly the cervical, are palpably enlarged, the tonsils, spleen, thy- 
 mus and sometimes the thyroid are hyperplastic. 
 
 Course and Prognosis. — (a) Acromegalic subjects seek advice for 
 the enlargement of the extremities or tonsils, sweats, pain, eye- 
 symptoms or polyuria; (b) remissions are common, the constitutional 
 symptoms and. to a slight extent, the enlargements subside; on the 
 other hand, a fitful advance may be noted, (c) The average course 
 is chronic, covering ten to twenty years, though relatively benign cases 
 occur, lasting thirty or even fifty years, and acute malignant cases are 
 known, which are always due to sarcoma ; they may develop in a few 
 weeks and average two to four years in duration, (d) Death is 
 inevitable; it may result suddenly, as in brain tumor or from gradual 
 marasmus ; diabetic coma, intercurrent infection, cardiac insuffi- 
 ciency or pyelonephritis may explain the fatal issue. 
 
 Diagnosis. — In this connection, Striimpell quotes Charcot's maxim 
 that physicians in general see and diagnosticate only what they have 
 seen and learned to diagnosticate ; the diagnosis is made at a glance 
 by one who has seen a single case ; undue regard to a single symptom, 
 as the skin changes, amenorrhea or glycosuria, may cause error, but 
 the grouping of acromegalic findings is unmistakable. 
 
 DiffeeentiatiojS". — 1. In the cranium progenium, the lower jaw 
 protrudes and its teeth are directed forward ; the lower j aw is hyper- 
 plastic, the upper jaw is hypoplastic. Cranium progenium may 
 occur in acromegaly, cretinism, healthy individuals after variola, in 
 degeneracy and in idiocy. 
 
 2. Gigantism occurs in over 20 per cent, of acromegaly, particu- 
 larly when acromegaly develops early in life. Forty per cent, of 
 giants are acromegalic (Sternberg). The interrelation of these con- 
 ditions is incompletely understood. Gigantism proper implies sym- 
 metry of overgrowth ; there are normal " giants " and giants with 
 acromegaly, leontiasis (v. i.), facial hemihypertrophy and hereditary 
 syphilis. Bassoe's report of the autopsy of the giant Wilkins covers 
 the entire subject (Journal of Mental and Nervous Disease, 1903). 
 
 3. Diffuse hyperostosis (Starr, Putnam, Prince) occurs in the 
 young, involves all the skull bones, and seldom the extremities or 
 spine; exophthalmos, blindness, deafness, bilateral facial palsy, dys- 
 phagia, dyspnoea and other basilar symptoms are noted, which cul- 
 minate fatally with stupor, idiocy, epileptiform convulsions and 
 paralysis of the extremities. A sub-type (leontiasis ossea, Dana, 
 1893) occurs in the form of tumor-like protuberances on the skull 
 and other bones. Prince (1902) collected 20 cases from the litera- 
 ture. He maintains that it is a form of osteitis deformans. 
 
 4. Osteitis deformans (Paget's disease, 1887) is a combined rare- 
 fying and hypertrophic osteitis. It begins slowly in subjects over 
 forty years old, with pains and. deformity of the thighs, legs and 
 spine ; the legs bow widely outward and somewhat forward, the cer- 
 vical and upper dorsal spine becomes kyphotic, the thorax narrows 
 
862 DISEASES OF THE DUCTLESS GLANDS. 
 
 transversely and widens anteroposteriorly, the abdomen is diamond- 
 shaped and crossed by a sulcus and the head hangs forward. The 
 soft parts do not hypertrophy as in acromegaly, the face is rarely 
 involved, the head is larger above than below and the arms are little 
 altered. About 70 cases are on record. 
 
 5. Hypertrophic osteoarthropathy, known since the time of Hippoc- 
 rates, was especially described by Bamberger and simultaneously by 
 Marie, in 1889. The ends of the fingers and perhaps the toes become 
 clubbed or " drumstick " in appearance. While the nails are thin 
 and small in acromegaly, in hypertrophic osteoarthropathy they are 
 large, thick, wide and curved downward. The alteration typically 
 involves the terminal phalanges, but also in severe cases the ends of 
 the ulna, radius, tibia and fibula. The pathology is a toxsemic, 
 chronic periostitis, with hypertrophy and osteophytic growth. The 
 most common cause is chronic lung disease (chronic phthisis, bron- 
 chiectasis, emphysema or fibrosis), whence Marie's name of osteo- 
 arthropathie hypertrophiante pneumonique ; it may develop in con- 
 genital heart disease or aneurysm or, much less frequently, in icterus, 
 gastric dilatation, syphilis, cystitis or various infections. 
 
 Treatment. — -The treatment of acromegaly is merely symptomatic. 
 Extract of the hypophysis has been given and in a few cases with 
 temporary success. Hochnegg operated upon one case successfully. 
 
SECTION VIII. 
 CONSTITUTIONAL DISEASES. 
 
 DIABETES MELLITUS. 
 
 Definition. — A disease of metabolism characterized (a) by a per- 
 manent lessened capacity of tbe organs fixing, storing and consuming 
 grape sugar; (b) by excess of sugar in the blood (hyperglycemia), 
 resulting in (c) grape sugar in the urine (glycosuria) ; and (d) 
 causal changes in the pancreas. 
 
 Willis (1674) differentiated between diabetes mellitus and dia- 
 betes insipidus and Dobson (1776), of Liverpool, fully described 
 the clinical symptoms, although Aretseus (150 A. D.) used the 
 term diabetes. 
 
 The liver, the reservoir for carbohydrates, may contain even 14 
 per cent, of glycogen. It collects carbohydrates from the portal vein, 
 stores them as glycogen and again imparts them to the blood as grape 
 sugar, for use in the tissues. The muscles also manufacture glycogen 
 from the grape sugar of the blood and are more tenacious of it than 
 is the liver. Glycogen may also be produced from the albumins. 
 When there is a temporary carbohydrate shortage, the reserve store of 
 glycogen is drawn upon. Fat is converted in the liver into sugar 
 when neither the carbohydrates nor the albuminates suffice to maintain 
 the normal proportion of sugar in the blood. The fate of carbohy- 
 drates when ingested in excess is: (a) glycogen storage (up to 10 
 ounces) ; (b) conversion into fat ; (c) glycosuria from hyperglycemia, 
 when the sugar in the arterial blood exceeds 0.2 per cent.; this is 
 known as " alimentary glycosuria," which is physiological, wholly 
 distinct from diabetes mellitus, and occurs when the blood-sugar 
 exceeds the assimilation limit. The test for alimentary glycosuria 
 consists of giving 3 ounces of grape sugar, after a light breakfast of 
 bread and coffee. If more than 1 per cent, of sugar appears in the 
 urine or if 2 or 3 per cent, of the entire amount administered is 
 found it is indicative of diabetes rather than of glycosuria. Most 
 absorbed sugar goes to the liver, but some absorbed by the lymphatics 
 appears in the urine, whence its presence is not necessarily a sign 
 of diabetes; in liver cirrhosis, sugar may reach the blood with the 
 collateral circulation. Traces of sugar (0.01 to 0.02 per cent.) are 
 normally present in the urine, but are not detected by the usual tests, 
 whence healthy urine is regarded as free of sugar. 
 
 Etiology. — 1. The pancreas (q. v.) has long been considered an 
 etiological factor in diabetes. Opie (1900) discovered atrophic 
 
 863 
 
864 CONSTITUTIONAL DISEASES. 
 
 changes in the cells of the islands of Langerhans, by microscopic 
 examination. These cells are thought to produce an internal secre- 
 tion, concerned in breaking up sugar in the tissues and muscles. 
 This internal secretion from Langerhans' islands is wholly distinct 
 from the external secretion of the pancreatic juice voided into the 
 intestine. Lepine (1892) spoke of a "glycolytic ferment," which 
 entered the blood from the pancreas and broke up the sugar molecules ; 
 in diabetes resulting from the absence of the ferment the sugar is not 
 broken down. This ingenious argument has received much experi- 
 mental corroboration, since (a) total pancreatic extirpation in ani- 
 mals and man produces glycosuria; (&) after partial extirpation and 
 suture of the remaining portion to the abdominal wall, diabetes fails 
 to appear, but develops if this portion is later removed; (c) when 
 about a tenth part is left, a mild form of diabetes ensues and glyco- 
 suria occurs only after the ingestion of carbohydrates ; (d) subsequent 
 destruction of the remaining portion of the gland produces a severe 
 form; (e) when more than one-tenth of the functionating gland is 
 left behind no diabetes ordinarily results ; (/) diabetes does not occur 
 in simple ligature of the pancreatic duct, excluding the juice from 
 the intestine, nor when the fluid escapes through a cutaneous fistula, 
 whence the argument that there is an internal secretion (Minkowski 
 and v. Mehring). (g) Cohnheim's experiments (1903) suggest that 
 a ferment or pro-enzyme secreted by the pancreas, joins another fer- 
 ment secreted by the muscles and that the united ferments break down 
 the sugar molecules to produce heat and energy. In 167 patients, 
 Thoinot and Delamare found " Langerhans' insufficiency " in 80 per 
 cent., and chiefly in " lean diabetics." 
 
 2. There is a neurogenous diabetes, the relations of which (if there 
 are any) to the pancreas are wholly obscure. This and the following 
 type might be considered as symptomatic diabetes. Nervous lesions, 
 as Claude Bernard's well-known puncture of the fourth ventricle 
 (1844), may possibly alter the circulation in the liver. Among them 
 are apoplexy, tabes, brain tumors (particularly those located near the 
 base), general paralysis, multiple sclerosis, meningitis, syphilis, soft- 
 ening of the brain, diseases of the cord, vagus and sympathetic sys- 
 tem, trauma, traumatic neurosis, paralysis agitans, mental diseases, 
 Basedow's disease and acromegaly. Hoffman distinguishes between 
 (a) neurogenous diabetes, which occurs chiefly in men, with no ten- 
 dency to furuncles, carbuncles or cataract, with no connection with 
 gout, and which passes away in a comparatively short time if the 
 brain affection is curable; and (b) diabetes of the obese, which occurs 
 as frequently in women as in men, often produces carbuncles, is often 
 connected with gout and is very chronic, often lasting ten or twenty 
 years. 
 
 3. Obesity may be a cause; according to von Noorden, " There are 
 (a) cases in which the consumption of sugar and its conversion into 
 fat are simultaneously restricted — glycosuria which varies in severity, 
 and in degree of emaciation (ordinary diabetes) ; (6) cases in which 
 
DIABETES MELLITUS. 865 
 
 only the consumption of sugar and not its conversion into fat is inter- 
 fered with — obesity without glycosuria (masked diabetes) ; these 
 pass readily at a later period into (c) cases in which the consumption 
 of sugar is restricted, and the collecting of carbohydrates in the fatty 
 tissues is also more or less interfered with — obesity with consecutive 
 glycosuria (ordinary diabetes of the adipose)." 
 
 4. Gout, arteriosclerosis, various liver lesions (cirrhosis) and pos- 
 sibly acute infections have apparent though obscure relations with 
 diabetes. Adrenalin may produce glycosuria (Blum and Herter). 
 Eenal diabetes (glycosuria without excessive sugar in the blood) may 
 occasionally develop in nephritis, renal hemorrhage, chyluria and 
 from administration of phloridzin. Lactosuria may occur in late 
 pregnancy, the puerperium and nurslings ; von ISToor den's hypothesis 
 is that inthe " puerperal state the capacity of the tissues for breaking 
 up milk-sugar is diminished, an instance of adaptation to an end in 
 that the cells of the mother refuse a material which is preeminently 
 suited to the nutritive wants of the nursling." 
 
 5. Predisposing factors are (a) sex; men (3:2) are especially 
 subject to diabetes; (b) age; though it occurs at any age, its fre- 
 quency is as follows: In persons from thirty to forty years, 18 per 
 cent.; forty to fifty years, 25 per cent.; fifty to sixty years, 30 per 
 cent. ; in Stern's collection of 117 infantile cases one was apparently 
 congenital, (c) Heredity. A family history of obesity, consanguin- 
 ity, neuropathic taint (20 per cent.) or gout is especially significant; 
 cases are reported in which the grandfather was diabetic, the son 
 gouty and the grandson again diabetic (hereditary alternating dia- 
 betes), (d) Race. Diabetes is comparatively rare in the colored 
 race and is especially common in Jews. It is rather less common in 
 America than in Europe, (e) Occupation. Diabetes is more often 
 seen in private than in hospital practice. Wealth and culture increase 
 ten-fold the predisposition to diabetes (von Noorden). It is fre- 
 quently found in scientists, lawyers, musicians, poets, teachers, states- 
 men, merchants, speculators and in those leading a luxurious or self- 
 indulgent existence with sedentary habits ; it also results from over- 
 work, excitement, over-eating and over-drinking. Diabetes is ap- 
 parently increasing: in frequency. 
 
 Symptoms. — 1. The Urine. — Glycosuria. — Sugar in the urine is 
 the leading symptom of diabetes. A daily excretion of 1 to 3 drams 
 (5 to 12 grams) is not uncommon; the maximum amount recorded is 
 1,500 gm. ; the largest quantity of sugar is voided late in the morning 
 or after 6 p.m. A percentage of from 1 to 4 is not uncommon, 8 or 
 9 per cent, is rare and the maximum is 20 per cent, (personal obser- 
 vation). The estimation of a diabetic's capacity to consume sugar, 
 suggested simultaneously by Seegen and Traube is as follows: Ac- 
 cordingly as the urine, after a diet absolutely free from carbohydrates, 
 is free from sugar or not, a distinction is made between (a) mild 
 and (b) severe cases of glycosuria, (a) Mild glycosuria is charac- 
 terized by the urine becoming sugar-free within a few days after 
 
 55 
 
866 CONSTITUTIONAL DISEASES. 
 
 carbohydrates are withdrawn and by sugar reappearing when carbo- 
 hydrates are again ingested. The test diet consists of ham, eggs, roast 
 beef, cucumber with vinegar, olive-oil and salt and pepper; brandy 
 with Appolinaris water ; coffee without milk or sugar ; clear bouillon ; 
 butter, green salad, green vegetables and sardines; this diet is free 
 from carbohydrates. With increasing additions of starch, sugar at 
 some time is again voided, i. e., the limit of tolerance or of assimila- 
 tion is reached, (b) Severe glycosuria is characterized by continued 
 excretion of sugar in spite of withholding all carbohydrates from the 
 diet and signifies (i) that even those carbohydrates which are slowly 
 formed from the albumin are not wholly consumed; (ii) that the 
 functions of glycogen storage and (iii) of splitting up of sugar in the 
 tissues are seriously affected; of this type there are many degrees. 
 Fat and alcohol never increase the severity of glycosuria. Muscular 
 exercise and massage usually decrease it. It is often increased by 
 psychic disturbances and may be suspended or lessened during an 
 acute intercurrent infection, especially typhoid; chronic diseases 
 with fever, especially pulmonary tuberculosis, have less influence. It 
 is reduced or absent in the final stages of diabetes and may be absent 
 in diabetic coma. Glycosuria very often disappears when granular 
 atrophy of the kidney develops (Frerichs, Stokvis, Fiirbringer) ; the 
 diabetes is then cured in some unknown way. Gouty diabetics as a 
 rule pass no sugar during an attack of gout (diabetes alternans). 
 
 Tests for Sugar. — (a) For FeMing's test, two solutions are kept 
 separate ; one contains copper sulphate, 34.64 gm. in 500 c.c. of water, 
 and the other sodium and potassium tartrate 173 gm., and sodium 
 hydrate 125 gm. in 500 c.c. of water. Equal parts of these solutions 
 are heated, but not boiled, and the urine is added drop by drop. The 
 volume of urine should never exceed that of the solution. Reduction 
 of the blue copper solution to the yellow-red suboxide of copper 
 occurs when sugar (its aldehyd group) is present. Chloral, phen- 
 acetin, chloroform, formalin, morphine, uroleukinic and homogenti- 
 sinic acids (the probable causes of alkaptonuria), glycuronic acid, 
 cascara, rhubarb and salicylates may also reduce Fehling's solution, 
 particularly after boiling. In doubtful cases, or as corroborative tests, 
 (b) the fermentation test may be used; yeast is shaken thoroughly 
 with a quantity of urine, the air allowed to bubble up and the mixture 
 placed in a saccharometer, — a tube closed at the top and graduated 
 for estimation of percentages. The sugar, fermenting, is measured 
 by the amount of carbon dioxide formed. A control test should be 
 made, (c) The polarization test, showing dextro-rotary reaction, 
 may be employed, (d) The very delicate and reliable phenylhydrazin 
 test of E. Fischer may be used. 1 
 
 1 Cipollina 's method is the simplest : 5 minims of pure phenylhydrazin, eight 
 drops (0.5 c.c.) of glacial acetic acid, and a dram (4 c.c.) of urine in a test-tube 
 are gently boiled for one minute with frequent agitation. Four or five drops of 
 sodium hydrate solution are added, the mixture is boiled again, and allowed to 
 cool; in a few minutes (to a half an hour) yellow rosettes of phenylglucosazon 
 precipitate; maltose and certain pentoses, the crystals of which melt at different 
 degrees, may alone cause error. Plate XVII. 
 
PLATE XVII 
 
 Crystals of Phenyl-glueosazone. (Musser.) 
 
 (Oc. 4, Obj. D.) Drawn by J. D. Z. Chase. 
 
DIABETES MELLITUS. 867 
 
 Quantity of Urine and Specific Gravity. — The urine is almost 
 always acid even after fermentation (lactic acid) and has a sweet 
 taste. As a general rule the quantity of urine secreted during the 
 night is less than that secreted in the day-time ; this is an important 
 point because in other polyurias frequently % to % of the entire 
 amount of urine is secreted during the night (Lecorche and 
 Quincke). A secretion of ten quarts is not rare. The largest amounts 
 recorded are 17 or 28 quarts in a day. Higher figures suggest simu- 
 lation, patients having been known to add sugar to the urine. Polla- 
 Jciuria (frequency of urination) is common. The urine is pale. 
 If dark and if uratic deposits are present, the prognosis is good 
 (Seegen and Pavy). Foam often remains long on its surface and the 
 sediment is very scarce or absent. Prout considered that the onset of 
 diabetes began when the urine ceased having a turbid, uratic deposit. 
 An increase in the amount of sugar usually brings an increase in the 
 amount of urine, but ordinarily the amount of urine rises less rapidly 
 than does that of the sugar. The specific gravity is higher, the greater 
 the amount of urine secreted. 
 
 Amount in 
 liters or quarts. Specific gravity. Sugar. 
 
 1.5 to 2.5 1.025 to 1.030 2 to 3% 
 
 2.5 to 4 1.030 to 1.036 3 to 5% 
 
 4 to 6 1.032 to 1.046 4 to 7% 
 
 6 to 10 1.036 to 1.046 6 to 9% 
 
 Two or three per cent, of sugar may cause no change in specific 
 gravity. The average is 1,030-40, it is rarely more than 1,050, and 
 the highest record is 1,074 ; very high specific gravity suggests fraud ; 
 the lowest records are 1,008 and 1,002. If under the influence of 
 meat diet the urine becomes entirely or nearly free from sugar the 
 quantity approaches normal. The specific gravity remains high 
 because the urine is rich in meat end-products. There is no absolute 
 parallelism between the percentage of sugar and the specific gravity ; 
 (a) glycosuria is often preceded by premonitory polyuria. (b) 
 Though diabetes may be cured, polyuria may persist without glyco- 
 suria ; this may be caused by the habit of drinking large quantities 
 of water, (c) In some cases, though there is a large percentage of 
 sugar, only a pint or a pint and a half of urine is excreted, described 
 by Peter Frank a century ago as " diabetes decipiens." Crystals of 
 sugar may be seen on the shoes, clothing or in the vessel. 
 
 Nitrogenous Constituents of the Urine. — Diabetic patients excrete 
 considerable urea ; 2 ounces are not infrequent and over 5 ounces have 
 been noted ; larger figures are reached in no other disease ; it is occa- 
 sioned by the abundant ingestion of proteids and possibly by fermen- 
 tation of the tissue albumins ; the condition is pathological when the 
 amount of nitrogen in the urine exceeds that in the food. Naunyn 
 and von Mehring deny that there is an increase in the urea save in 
 severe and exceptional cases. 
 
 Ammonium,, normally 8 to 15 grains per diem, may increase to 
 
868 CONSTITUTIONAL DISEASES. 
 
 20 or 180 grains, although the highest figures are seen exclusively in 
 diabetic coma. The organism excretes increased amounts of am- 
 monia in order to neutralize pathological acids (acidosis). The 
 diabetic diet is acid ; phosphoric acid forms from the ingested meat, 
 and much sulphuric acid is produced by oxidation of sulphur in the 
 albumin molecule. The quantity of creatinin may reach 20 to 30 
 grains per diem for similar reasons. The amount of uric acid is 
 nearly normal. 
 
 Albuminuria is found in 35 per cent, of cases; it is almost always 
 slight and is due (a) to cystitis, pyelitis, intercurrent diseases as gan- 
 grene or infection, pulmonary tuberculosis or without relation to 
 diabetes, as in the arteriosclerotic and gouty types of diabetes, liver 
 cirrhosis, etc.; (b) to diabetes in nervous individuals, and (c) to 
 circulatory disturbances; (d) in uncomplicated diabetes it may be 
 due to the action of the sugar, /?-oxybutyric and other acids and toxins 
 on the kidneys. Albuminuria is a frequent forerunner of diabetic 
 coma, as a coordinate manifestation or a determining factor (de- 
 creased renal permeability with retention in the blood of toxins). 
 Diabetes may develop into chronic interstitial nephritis and the 
 sugar then disappears. 
 
 Non-nitrogenous organic substances. Lipuria has been observed. 
 Acetone, aceto-acetic acid and beta-oxybutyric acid are most frequent ; 
 they are derivatives of fat. Beta-oxybutyric acid is absent in dia- 
 betics in good physical condition and not infrequently also in those 
 who are suffering from marked loss of albumin. The urine may be 
 odorless or may smell like chloroform, fruit or wine. The daily 
 amount excreted varies from a few grains to 2 to even 7 ounces. 
 Its abnormal excretion once begun, is uninterrupted, sometimes lasts 
 years and shows a constant tendency to increase. It is of the gravest 
 prognostic significance because in most cases, at the end of days, 
 weeks or months, fatal diabetic coma develops. An excretion of more 
 than an ounce indicates imminent coma. Acidosis is most accurately 
 estimated by the output of ammonium; according to Magnus Levy, 
 2 gm. of ammonium correspond to 6 gm. of /?-oxybutyric acid, 5 gm. 
 to 20 gm., and 8 gm. to 36 or 40 gm. /?-oxybutyric acid is thought by 
 some to be the parent substance of acetone and diacetic acid. Acetone 
 and diacetone are present in the urine in diabetes, fevers, cancer, in- 
 anition or auto-intoxications and indicate malnutrition. When the 
 amount of acetone progressively rises from 15 grains upward, the 
 outlook is unfavorable. It is not proven that the acetones cause coma, 
 but they at least accompany acidosis. They impart a fruity or wine- 
 like odor to the urine and breath. Legal's test for acetone : To 10 c.c. 
 of urine a few drops of a freshly made solution of sod. nitroprusside 
 are added ; the addition of caustic soda gives a red color if acetone is 
 present. 
 
 Gerhardfs test for diacetone is as follows: a dram of urine is 
 treated with a strong solution of ferric chloride added drop by drop. 
 A precipitate of phosphates is filtered off and more of the iron solu- 
 
DIABETES MELLITUS. 869 
 
 tion is added to the filtrate. If a bordeaux-red color now appears, 
 another portion of the urine is boiled and similarly treated. If in the 
 second test no reaction is obtained a third portion of the urine is 
 treated with sulphuric acid and extracted with ether. A positive 
 reaction, when the ethereal extract is tested with ferric chloride, the 
 color disappearing upon standing for twenty-four to forty-eight hours, 
 indicates diacetic acid, particularly if the urine is rich in acetone. 
 
 Mineral Constituents. — Sodium chloride, sulphuric and phosphoric 
 acids and the ethereal phosphates are abundant; they are caused by 
 the increased amount of food ingested. The oxalates are increased 
 in mild cases. Much lime is excreted, which suggests osseous waste. 
 
 Pneumaturia. — The butyric acid bacillus, the Bacillus coli, yeast 
 fungus and other bacteria may cause fermentation in the bladder, 
 producing carbon dioxide, hydrogen and methane gas. 
 
 2. Direct Consequences of the Glycosuria and Polyuria. — 
 (a) The exaggerated thirst (polydipsia) is always secondary to the 
 polyuria, (b) Nutrition. Much sugar is lost to the tissues; two 
 quarts of urine with 5 per cent, of sugar produces loss of 400 
 calories, one-seventh of the total. Therefore the nutritive require- 
 ments are great, the appetite is excessive (polyphagia) and in severe 
 cases emaciation and fatigue are pronounced. The loss of sugar 
 must be met by increase in albumin and fat. Increase in weight may 
 follow reduction in the sugar. The temperature in uncomplicated 
 cases is subnormal from inanition. 
 
 3. Complications. — Complications and other symptoms result 
 from various causes: (a) the sugar in the blood, (b) impaired nu- 
 trition and lowered physiological resistance; both conditions predis- 
 pose to (c) infection, particularly by the bacillus tuberculosis, (d) poi- 
 soning (acidosis) and other ill-understood degenerations and toxaemia. 
 
 1. Nervous. — (a) Intellectual depression, insomnia, headache and 
 neurasthenic symptoms are common ; psychoses are less frequent. In 
 rare instances focal symptoms may develop without anatomical find- 
 ings, as in uraemia. Brain symptoms may result from coincident 
 syphilis, arteriosclerosis, etc. (b) Diabetic coma occurs in 20 per 
 cent, and causes about half the deaths in diabetes; it is most fre- 
 quent in youth and in acute and severe types ; Naunyn holds that it 
 is favored by a strict antidiabetic diet. All coma in diabetes is not dia- 
 betic ; patients may succumb (i) to cerebral apoplexy, embolism, throm- 
 bosis, sepsis or urcemia, (ii) to heart failure, which may cause sudden 
 death, or coma with death after a short time or (iii) diabetic coma 
 proper, which is probably due to acidosis (Stadelmann) and closely 
 resembles experimental acid poisoning. Most writers believe that 
 /?-oxybutyric acid is causal, though in three of the author's cases it 
 was not present in the urine (Long). Coma is imminent when the 
 daily output of ammonium exceeds 45 grains. It may occur sud- 
 denly without obvious cause or may follow severe exertion, excesses, 
 excitement or gastro-intestinal disorders. In some cases there are 
 prodromal headache, vertigo, stupor, restless anxiety or symptoms re- 
 
870 CONSTITUTIONAL DISEASES. 
 
 sembling those of acute alcoholism. The pupils are dilated, the 
 reflexes abolished, the pulse is small and averages 100 to 120 and 
 the temperature is usually subnormal. Convulsions are most un- 
 common. The breath has the wine-like acetone odor. The breathing 
 is characteristic; inspiration is deep, long-drawn and energetic and 
 expiration is short and slightly sighing ; in this, KussmauVs dyspnoea 
 (1876), the inspiratory energy contrasts strongly with the general 
 bodily weakness; respiration may be normal in rate, but is generally 
 somewhat accelerated; there is no stridor, nor, at the onset, any 
 cyanosis. The urine is generally albuminous and almost always con- 
 tains small granular casts (Kiilz) ; the addition of a few drops of 
 ferric chloride gives the Burgundy wine color; sugar is present, 
 though it may disappear as the coma develops. Partial consciousness 
 may return, but, with few exceptions, death occurs within a few hours 
 to two days, with subnormal temperature, slowed respiration and 
 cardiac weakness. The autopsy reveals no constant brain changes, 
 (c) Degeneration (toxsemic) in the posterior columns of the cord 
 may develop, (d) The peripheral nerves. Neuralgia is common 
 and may indicate incipient neuritis or may appear and disappear, 
 varying with the amount of sugar in the blood and urine. It is often 
 an early symptom ; it may be unilateral or more often bilateral, most 
 frequently affects the sciatic nerves and is a most obstinate and re- 
 current symptom. Neuritis occurs in the severe forms of diabetes and 
 in its later stages. It may be manifested only by obstinate neuralgia, 
 painful paresthesia in the legs, muscular cramps or in 50 per cent, 
 of diabetics, decrease or abolition of the patellar reflexes (Bouchard). 
 Neuritis may involve the cranial nerves, mostly the abducens, then 
 the oculomotor, hypoglossus, spinal accessory and facial, or with 
 greater frequency the spinal nerves; the lower are affected more 
 often than the upper extremities and, like diabetic neuralgia, bilateral 
 involvement of the crural or sciatic nerves is the most common type. 
 Neuritis may be single or multiple. Its symptoms are those of neu- 
 ritis or polyneuritis (q. v.), as paralysis, altered sensation, abolished 
 reflexes, reaction of degeneration and trophic disturbances, as falling 
 of the hair and nails, glossy skin and perhaps also herpes or per- 
 forating ulcer of the foot (mal perforant). In severe cases tabes is 
 simulated, pseudotabes diabetica, first described by Fischer (1886) 
 (see Multiple Neuritis), (e) The special senses. Retinal dis- 
 eases (Jager, 1856) occur under three forms: (i) albuminuric reti- 
 nitis', accompanying contracted kidney; (ii) retinitis centralis punc- 
 tata with characteristic small, shining central spots, usually with 
 hemorrhagic points and always bilateral; (iii) the ordinary hemor- 
 rhagic type (see Plate V, Fig. 1). Retinitis occurred in 19 per 
 cent, of Galezowski's 114 cases. Neuritis, neuroretinitis and retro- 
 bulbar neuritis with consecutive atrophy are progressive and occur 
 more frequently in severe than in mild cases, sometimes as early, 
 sometimes as late, complications. Twenty per cent, of diabetics 
 with retinitis die within one year and 60 per cent, live over two years 
 (Nettleship). 
 
DIABETES MELL1TVS. 871 
 
 Amblyopia and amaurosis are complications of early diabetes and 
 often first induce the patient to seek medical advice. Paralysis of 
 the ocular muscles occurs in 7 per cent, of cases; accommodation 
 paralysis is the most frequent type, and then that of the external 
 rectus; the most probable cause is neuritis; Mauthner assumes that 
 there is a nuclear hemorrhage. Cataract occurs in 4 per cent, of 
 cases. Other ocular changes are rare. Aural complications include 
 external furuncles and otitis media, which latter has a tendency to 
 hemorrhage and diffusion, as mastoiditis. 
 
 2. Circulatory. — (a) The blood may become somewhat concen- 
 trated, for much water is required to eliminate the sugar ; the amount 
 of sugar (normally 0.1 to 0.15 per cent.) is increased in diabetes to 
 0.3 or 0.5 per cent. Fat in the blood (lipsemia) is a frequent finding; 
 what appears to be fat is sometimes albumin (Futcher) or cholesterin 
 m combination with fatty acids; Frazer in one case found 14 per 
 cent, of fat. Bremer s test is based on changes in the haemoglobin; 
 thick smears of blood are made on a slide, which is heated and treated 
 with 1 per cent, congo red solution for two minutes ; diabetic blood 
 will not stain, but the control slide of normal blood stains ; this reac- 
 tion, according to Bremer, often results during remissions in the 
 glycosuria and in the preglycosuric stage; it sometimes occurs in 
 other conditions, as Hodgkin's disease. Williamsons test is based on 
 the fact that diabetic blood decolorizes a weak alkaline solution of 
 methyl blue. It is as follows: 20 c.c. of blood, 40 c.c. of distilled 
 water and 1 c.c. of 1 to 6,000 aqueous solution of methylene blue are 
 added to 40 c.c. of liquor potassse and are placed in test-tubes in a 
 beaker of water, which is boiled for four minutes; the blue color 
 disappears^ The alkalescence of the blood, which is reduced in va- 
 rious conditions of inanition, is greatly lessened in diabetes, particu- 
 larly when /?-oxybutyric acid engages the ammonium and other salts 
 and when coma develops. (&) The arteries are frequently sclerosed 
 in diabetes. Arteriosclerosis causes many common symptoms, as 
 cardiac hypertrophy or dilatation, angina pectoris, cardiac asthma, 
 hemiplegia, albuminuria, senile gangrene and intermittent claudica- 
 tion, (c) The heart may be altered in various ways (v. s.). Hyper- 
 trophy occurs in about 10 per cent, and is less ominous than atrophy, 
 which occurs in uncomplicated diabetes of the young. Heart-failure 
 may occur after moderate exercise or may develop precipitately, end- 
 ing in coma or asphyxia and correctly separated by Frerichs from 
 genuine diabetic coma. Yon Noorden observed five instances of sud- 
 den death in 140 fatal cases. " Functional heart symptoms " occur in 
 10 per cent, of cases. The pulse is usually accelerated and its tension 
 is elevated. Cardiac or renal dropsy is uncommon in diabetes. 
 
 3. Respiratory. — (a) Tuberculosis is most frequent in the poor 
 classes and in the young, but much less so in older, obese and gouty 
 subjects; about 25 per cent, of diabetics contract tuberculosis. 
 Haemoptysis is very rare; the sputum is abundant; it is usually 
 stated that the tubercle bacilli are scant or absent; in the secondary 
 
872 CONSTITUTIONAL DISEASES. 
 
 necrosis, to which all diabetics are prone, the marked clinical and 
 pathological lung-findings may sharply contrast with the small num- 
 ber of tubercle bacilli found in the sputum. The course is rapidly 
 fatal, (fe) Gangrene is much less common than tuberculosis. Fever, 
 pulmonary hemorrhage and purulent sputum are common. Foetor 
 is less conspicuous than in other forms of pulmonary gangrene, (c) 
 Intercurrent pneumonia may develop and is usually fatal. 
 
 4. Digestive. — (a) The mouth is generally dry and acid (from 
 decomposition of sugar) ; the saliva is scanty and poor in ferment ; 
 stomatitis is common and the growth of aphthae is promoted by the 
 acid reaction of the mouth, though it is preventable by cleanliness. 
 The teeth may decay from alveolar periostitis or drop out from 
 trophoneurotic changes, (b) The stomach is affected with remark- 
 able infrequency, considering the oral findings and the polyphagia. 
 Marked anorexia is uncommon, though the patient may refuse fatty 
 and nitrogenous foods. The stomach is usually dilated, (c) The 
 bowels are generally costive. Schmitz claims that obstinate constipa- 
 tion predisposes to coma, though in the author's experience, most 
 diabetics are constipated. Intestinal or gastro-intestinal catarrh 
 sometimes seems to precipitate coma, but it may be merely an asso- 
 ciated symptom, (d) The liver is usually enlarged (hyperemia and 
 fatty degeneration) and sometimes tender. Gall-stones are con- 
 comitants in 10 per cent, of cases, but JSTaunyn correctly denies that 
 they have any intrinsic relationship to diabetes. French authors 
 (Hanot and Chauffard) have described a pigmentary cirrhosis in 
 diabetes (diabete bronze), which has already been referred to under 
 liver cirrhosis and chronic pancreatitis; this syndrome probably de- 
 velops in the following sequence; (i) haemolysis, (ii) pigment de- 
 posit in the liver, pancreas and skin from the altered blood (hemo- 
 chromatosis), (iii) chronic interstitial inflammation, chronic hepatic 
 cirrhosis and (iv) chronic pancreatitis, causing diabetes, (e) Pan- 
 creatic symptoms are few, because the external pancreatic secretion is 
 essentially normal, and only the internal glycolytic secretion is affected. 
 
 5. Genito-urinary. — (a) Albuminuria may be present (see Urine). 
 The kidneys are frequently hypertrophied and hyperaemic; various 
 degenerations may be noted, including Ehrlich's glycogenic degenera- 
 tion. Interstitial nephritis may follow and replace diabetes, chiefly 
 in gouty and corpulent individuals, (b) Cystitis is common; the 
 urine may ferment in the bladder, just as it readily decomposes in 
 the urinal; this may lead to pyelonephritis or pneumaturia (v. s.). 
 Cystitis may cause temporary disappearance of the glycosuria, (c) 
 In the female, menstruation may be disturbed or suspended. The 
 sexual inclination is usually lessened in severe cases, but may be 
 increased from genital pruritus (v. i.). Conception may occur even 
 in advanced cases, but in 33 per cent, there is spontaneous abortion 
 or premature delivery. In severe diabetes interruption of pregnancy 
 is indicated; the maternal danger in uninterrupted pregnancy is 
 great, from exacerbation of the disease, coma, collapse and infection. 
 
DIABETES MELLITUS. 873 
 
 Fungi develop about the labia and vagina ; this is promoted by les- 
 sened general resistance and local contact with the saccharine urine. 
 Aphthae, leptothrix and other parasitic deposits are frequent, par- 
 ticularly in careless subjects; pruritus pudendorum, vulvitis, vagi- 
 nitis, urethritis, furunculosis and even gangrene may develop, (d) 
 In the male, the sexual appetite may be increased early in the disease 
 but later is replaced by impotence, probably due to spinal degenera- 
 tion. Phimosis, balanitis, small erosions near the urethra, urethritis, 
 itching at the meatus causing tenesmus, curious nodes on the corpora 
 cavernosa, furuncles and necrosis may first engage the physician's 
 attention. Genital symptoms in men are less conspicuous than in 
 women. 
 
 6. Cutaneous. — The skin is dry, harsh and itches when there is 
 much polyuria and emaciation. Sugar is said to be present when the 
 patient sweats. Itching is caused by toxaemia irritating the cutaneous 
 nerves, as in uraemic and cholaemic pruritus. Skin eruptions include 
 pityriasis tabescentium, urticaria, erythema, eczema, bullae, acne, pur- 
 pura and herpes. Infection is favored by reduced physiological 
 resistance and hyperglycaemia ; furunculosis (10 to 25 per cent.) is 
 due largely to the staphylococcus and may initiate lymphangitis, 
 phlegmon or gangrene; erysipelas is promoted by reduced general 
 and local resistance. Gangrene is most frequent in late or middle 
 life, and in mild cases; it usually begins on the toes and extends 
 upward, as dry or moist gangrene ; it is said to result from obliterating 
 endarteritis, but in the writer's experience occurs three times less 
 frequently than the ordinary plaque-like atheroma. Unfortunately 
 gangrene is usually progressive. Wounds in diabetics heal better 
 than in pre-antiseptic times, but delayed healing, infection and gan- 
 grene are still frequent. Enlargement of the lymphatic glands is 
 seldom absent in severe, progressive forms with emaciation; the 
 glands are hard, painless and probably secondary to skin infection 
 or irritation. 
 
 Course and Prognosis. — The onset may be acute or chronic and the 
 course may be short, covering weeks, or protracted and remittent, 
 covering twenty years or more. Complications modify the duration 
 and outcome. Von Noorden's summary of the prognostic signs 
 covers the ground completely : Favorable signs are : (a) onset late in 
 life; (b) long duration prior to the time of observation, with no 
 grave complications or any considerable emaciation; (c) traumatic 
 or (d) syphilitic origin; (e) the occurrence of mild forms of diabetes 
 in the family of the patient; (/) precedent and co-existent obesity; 
 (g) co-existent uric acid diathesis; (Ji) slight glycosuria and toler- 
 ance of moderate amounts of carbohydrates ; (i) marked oscillations 
 and increasing tolerance of carbohydrates; (j) circumstances which 
 permit of dietetic and general hygienic prescriptions. Unfavorable 
 prognostics are: (a) onset in early life, especially in childhood; (b) 
 great loss of strength, despite a brief duration of the diabetes; (c) 
 a history of severe forms in the family; (d) early appearance of 
 
874 CONSTITUTIONAL DISEASES. 
 
 grave secondary diseases and complications; (e) a high degree of 
 glycosuria, with complete intolerance of carbohydrates ; (/) excretion 
 of ^-oxy butyric acid; coma; (g) circumstances rendering impossible 
 dietetic treatment or avoidance of bodily and mental overwork. 
 
 Diagnosis. — The diagnosis is certain only when the urine in every 
 case is examined as a routine procedure, because only then can the 
 lighter cases, amenable to treatment, be discovered. In many cases 
 the thirst, polyuria, emaciation, itching and the complications per se 
 are suggestive. Pentosuria; 19 familial or hereditary cases are 
 recorded. Pentose reduces Fehling's solution, even after fermentation 
 of the urine. Bial's test is made as follows : a small amount of the 
 following solution, orcin 1 gm., liq. ferri chloridi 25 drops, and 30 
 per cent, hydrochloric acid in 500 c.c. of water, is heated to boiling 
 and added to the urine, which turns green if pentose is present. 
 
 Treatment. — 1. Diet. — Eegulation of diet, dating from Kollo 
 (1797), is the most essential point. The carbohydrates normally 
 supply nearly half the bodily requirements for food and energy. The 
 diabetic loses a large part by their escape through the kidneys. Fur- 
 thermore, their ingestion implies a waste of digestive energy, an irri- 
 tation of the tissues by the unused sugar and a growing decrease of 
 the tolerance of the tissues for them. A man weighing 70 kilograms 
 (150 lbs.) requires a diet representing 2.500 calories, i. e., roughly 
 35 calories for each kilogram. The dietary must therefore regard not 
 merely the glycosuria, but the maintenance of body-weight , and 
 energy. It is useless to suppress the symptom, glycosuria, when the 
 patient emaciates. The therapeutic aim is to limit the carbohydrates 
 and replace them with albumin and fat. Naunyn and Weintraud 
 have proven that exclusion of carbohydrates for some weeks increases 
 the tolerance for carbohydrates taken afterward ; i. e., the " sugar- 
 consuming function " is rested and in part restored. 
 
 General Outlines of Dietary. — Explicit written directions should 
 be given to each patient. All diabetics may eat the folloiving foods: 
 meat, the muscular parts of beef, veal, mutton and game, and the 
 tongue, lung, heart, brain, marrow and sweet-breads ; also fatty liver, 
 which contains little glycogen; meat peptones, somatose and kindred 
 preparations, gelatin and meat jellies; fish, caviar, cod-liver oil, 
 clams, oysters, lobsters and crabs; eggs (10 to 20 per cent, of fat) ; 
 animal and vegetable fats, bacon, suet, olive oil, cocoa butter ; butter 
 contains 85 per cent, fat, and should be used on meats, eggs or spinach 
 or melted in milk; rich cream; all cheeses (3 to 30 per cent, fat), 
 especially Swiss varieties ; vegetables, cress, tomatoes, cabbage, cauli- 
 flower, sprouts, artichokes, mushrooms, truffles, olives, onions, garlic, 
 celery leaves, lettuce, cucumbers and radishes ; of fruits, only whortle- 
 berries, young raspberries and green gooseberries should be eaten, 
 though fruit sugar (levulose) is better tolerated than starch or cane- 
 sugar. Desserts (suffles) of eggs, gelatin and lemon; tea, coifee, dia- 
 betic cocoa (Rademann's) and von Hoevel's saccharine chocolate may. 
 also be taken. 
 
DIABETES MELLITUS. 875 
 
 To some cases, and in definite amounts, von Noorden allows the 
 following (after determining the limit of tolerance, as outlined under 
 glycosuria, v. s.) ; beans and peas (3j) ; turnips, carrots, celery bulbs, 
 wax beans (gj); radishes (§j); walnuts 6; hazel-nuts lGj; almonds 
 8; (no chestnuts) ; apples, pears, apricots, peaches (gj to ij) ; berries 
 (Bss to j) ; cooked apples, plums, pears, peaches, cherries (3j) ; and 
 milk (oviij, of which many practitioners allow a larger measure). 
 
 Gradual withdrawal of carbohydrates is tolerated better than 
 abrupt restriction. Glutin flours differ but little from ordinary flours 
 in their percentage of starch. Aleuronat flour contains 7 per cent, 
 of starch. Von Mehring believes that fat is best absorbed when some 
 carbohydrates are given with it. If some starch can be given, Mosse 
 prefers potatoes, which are more easily assimilated and contain but 
 16 to 24 per cent, of starch (bread contains 55 per cent.). Ingestion 
 of more than 5 ounces of butter daily may increase the /3-oxybutyric 
 acid, but even more may be taken if the butter is carefully washed 
 in cold water, which extracts the lower fatty acids. Saccharin 
 should be used in place of sugar, gr. iss daily; it is 280 times as 
 sweet and is antifermentative, but an excess may occasion dyspepsia. 
 ]STaunyn advises an occasional fast day and Austin Flint kept his cases 
 in bed and without food from Saturday night until Monday morning. 
 As the disease is eventually progressive, a schematic diet should not 
 be insisted upon ; reasonable restriction, with occasional dietetic treats 
 is less often violated by the diabetic, who is always hungry for bread 
 and potatoes. The patient's weight, color and strength are of more 
 significance than the urine. Alcohol aids in the absorption of fat, 
 prevents tissue waste and contributes energy and heat. 
 
 Special diabetic treatment of the individual forms (according to von 
 Noorden). (a) Mild forms of glycosuria; in elderly persons it is not 
 necessary to determine with great accuracy the sugar tolerance. The 
 patient may eat bread, potatoes and vegetables, according to his de- 
 sire, for the quantity of sugar in the urine is usually insignificant 
 ( 1 to 2 per cent. ) . The older the patient and the more corpulent, the 
 more carefully should the body-weight be reduced ; fatty foods should 
 be increased, butter being used freely on bread, potatoes, vegetables 
 and meat ; and the patient should have bacon, eggs, fatty cheese, light 
 wine, coffee, tea and carbonated water. Muscular exercise should be 
 regulated according to the bodily strength and condition of the heart. 
 A course at Carlsbad is beneficial for obesity, gout or mild circulatory 
 weakness. In young persons, carbohydrates should be given with 
 much greater caution, as carelessness in diet is more frequent and the 
 glycosuria more often progressive. The limits of tolerance for carbo- 
 hydrates should be closely watched. All carbohydrates must be for- 
 bidden excepting bread and potatoes, in addition to which the patient 
 should have the following articles: 2 ounces of butter, with bread, 
 cheese and potatoes (480 calories) ; 2 eggs (150 calories) ; 3 to 4 
 ounces of olive oil with salad, cucumbers, etc. (90 calories) ; 1 ounce 
 of fatty cheese (115 calories) ; 1 quart of milk (590 calories) ; and 
 
876 CONSTITUTIONAL DISEASES. 
 
 one ounce alcohol (210 calories) ; meats, v. s. (b) Moderately severe 
 forms embrace cases in which the excretion of sugar is reduced to 1 to 
 2 per cent, only by total abstinence from carbohydrates. The rise or 
 fall of the tolerance limit should be watched every month, and every 
 four or six months all carbohydrates must be withdrawn for three 
 weeks. The diet must contain much fat; butter, 3 to 4 ounces (890 
 calories) must be weighed out every morning and eaten on bread, 
 vegetables, meat, fish, etc., either in solid form or melted. Olive oil, 
 two-thirds of an ounce (186 calories), should be taken on salad (let- 
 tuce, chicory, cress, cucumbers, tomatoes, red cabbage) and the same 
 amount as mayonnaise dressing for salad, cold meat, fish, lobster, etc. 
 Bacon, two-thirds of an ounce (140 calories), 5 eggs (390 calories) 
 and one ounce of brandy (280 calories) should be given. In addi- 
 tion the patient should have meats and some of the articles mentioned 
 in the conditional list under general diet, (c) In severe forms, des- 
 pite a continued rigid diet, sugar is constantly excreted. These cases 
 usually occur in early life with emaciation, frequent complications 
 and a fatal issue after a few months or years. Careful dietetic treat- 
 ment may retard the progress of the disease, prevent complications 
 and delay the fatal issue. The dietetic treatment is the same as in 
 moderately severe cases. Carbohydrates aggravate the diabetes, but 
 cannot be wholly interdicted. Less starch and more fats and alcohol 
 are given than in other cases. 
 
 2. General Treatment. — Zimmer demonstrated the value of (a) 
 exercise in lessening glycosuria, but as in obesity we have to deal with 
 an added factor, the improved appetite. The condition of the heart 
 must govern the amount of exercise to be taken, as Frerichs early 
 noted that fatal syncope and diabetic coma may follow exhausting 
 exertion, (b) The mouth and skin require special attention. Clean- 
 liness averts in large part gingivitis, furunculosis and genital com- 
 plications. Frequent warm (not cold) baths and change of under- 
 wear, gentle brushing of the teeth and soothing salves for eczema and 
 similar eruptions are imperative, (c) Diabetics for the most part 
 should be kept at home and at work, for they often become restless 
 and desire to wander. A prolonged stay in a quiet place is better 
 than travel. Sea bathing and exposure to cold and dampness are to 
 be avoided, (d) Suggestive treatment may often be combined with 
 the dietetic and medicinal therapy in depressed subjects, particularly 
 in neurotics, (e) Mineral springs are suitable only for mild cases 
 and those with obesity, gout and slight circulatory disturbance, in 
 whom there is increased tolerance for carbohydrates. Carlsbad and 
 other spas are contra-indicated in severe, youthful, very aged, reduced 
 and nephritic cases. (/) The mode of life should be quiet and avoid- 
 ance of excesses is indicated. 
 
 3. Treatment of Complications. — (a) Tuberculosis is the most 
 serious complication. The liberal diet, necessitated by tuberculosis, 
 is contra-indicated by glycosuria. A low altitude and mild climate 
 should be selected, (b) Gastro-intestinal catarrh often precipitates 
 
DIABETES MELLITUS. 877 
 
 diabetic coma. As in infantile disorders, starvation for one or two 
 days is more efficient than attempts at intestinal disinfection; only 
 water should be given ; red wine is often indicated when there is ex- 
 haustion, acting as a stimulant and astringent, (c) Constipation 
 (q. v.) should be relieved by rhubarb and sodium bicarbonate; 
 severe purges must be avoided. (d) Nervous symptoms of the 
 neurasthenic order are observed in neurogenous diabetes; sodium 
 bromide, opium, codeine or acetanilide may be indicated. Of all 
 remedies, opium alone exerts an appreciable influence upon the gly- 
 cosuria; it was recommended by Dobson (1776) ; it affects the severe 
 more than the light type, i. e., it decreases the transformation of 
 albumins into sugar, but does not control the transformation of carbo- 
 hydrates into sugar; the average dose may be gradually increased 
 without the patient exhibiting toxic symptoms or suffering from its 
 reduction afterward. Codeine may be given in doses of gr. j. to x, 
 though less effective than opium; it may be combined with sodium 
 bromide 3ss. Inunctions of mercury are seldom valuable, but are 
 indicated when cerebral or pancreatic syphilis is suspected. (/) 
 Neuralgia (q. v.) and neuritis should be treated dietetically ; the sali- 
 cylates may benefit mild cases as well as somewhat modify coincident 
 gout or intestinal fermentation, (g) Acidosis, acetonemia and dia- 
 betic coma are serious complications. Acidosis is said to be promoted 
 by a rigid dietary (Naunyn, von Mehring) ; in pronounced acidosis 
 even von Noorden, who opposed Naunyn's view, recommends an oat- 
 meal diet, with butter, aa Sviij at frequent intervals; he adds the 
 whites of 8 eggs to this dietary which is preceded for a few days by a 
 vegetable diet; this diet is indicated in adolescent or juvenile diabetes, 
 particularly in severe types with acidosis and in moderately severe 
 cases in which it helps to develop carbohydrate tolerance. Sodium 
 bicarbonate and citrate 3ij to ^iij? t. i. d., and calcium carbonate 3j 
 once or twice a day may possibly postpone threatening coma. Much 
 water should be given by mouth, by rectum or subcutaneously with 
 sodium carbonate Jiss to Oij. Developed coma is practically in- 
 curable. Oxygen inhalations, alcoholic stimulation, strychnine, mild 
 laxatives (not drastics) and subcutaneous or intravenous injections 
 are given, but rarely with success, (h) Gangrene should be treated 
 expectantly until there is a possible halt in the process and definite 
 demarcation ; positive rules of treatment are laid down with difficulty. 
 If there is no acidosis diet is usually efficacious ; if acidosis obtains, 
 surgery is indicated. In personal experience, advanced diabetics 
 stand operative shock and anaesthesia poorly. Most of them have 
 died from alarmingly rapid syncope or from typical dyspnoeic coma. 
 Other operations may be performed, when indicated as absolutely 
 necessary life-saving procedures and only, if possible, after strict 
 dieting. Boils, furuncles, etc., are treated expectantly. 
 
878 CONSTITUTIONAL DISEASES. 
 
 DIABETES INSIPIDUS. 
 
 Definition. — A chronic malady characterized by large amounts of 
 urine of low specific gravity. It was described by Willis (1674), 
 who first differentiated between diabetes mellitus and insipidus (with- 
 out taste, i. e., non-saccharine). Eichhorst observed 7 cases in 35,942 
 cases (0.02 per cent), Futcher 7 in 403,535 (0.001 per cent.) and 55 
 occurred in 113,600 in the Berlin Charite (0.048 per cent.). 
 
 Etiology. — Two groups of cases are observed: (a) the idiopathic 
 (nervous or vasomotor) and (b) the symptomatic, which occur in (i) 
 brain disease, especially basal syphilis and less often tumors of the 
 medulla and the floor of the fourth ventricle, cerebral traumatism, 
 basilar meningitis, apoplexy, hydrocephalus and lesions of the middle 
 cerebellar lobe or corp. trapezoides of the pons. It is possible that the 
 kidneys may be at fault, losing their power to concentrate the urine, 
 (ii) It may result from abdominal diseases, aneurysms, tumors or 
 tuberculous peritonitis, (iii) Insolation, diabetic ancestry (Trous- 
 seau), malnutrition (Ralfe) with tuberculous, syphilitic or gouty 
 antecedents, acute infections and alcoholism are numbered among 
 its possible causes. Most cases occur in males. In Strauss' collection 
 of 85 cases, 10 per cent, were under irve years old, 14 per cent, under 
 ten and 45 per cent, were between ten and twenty-five years of age ; 
 according to Jacobi, 25 per cent, occur under ten years. Weil col- 
 lected 36 cases among individuals of four generations, all of whom 
 enjoyed good health. Rare congenital cases are recorded. 
 
 Symptoms. — The onset is usually gradual, though abrupt symptoms 
 have followed fright, (a) The urine is greatly increased; a secretion 
 of 20 to 40 pints daily is not rare and even one of 90 pints is on rec- 
 ord. More urine is passed at night than by day. It is said that less 
 urine is excreted than water ingested. It is passed rapidly after in- 
 gestion of water (tachyuria). Its specific gravity ranges between 
 1,000.5 or 1,001 and 1,005. It is pale and the total solids are usu- 
 ally normal, though sometimes the urea, chlorides and phosphates are 
 increased, being washed out from the tissue. Albumin, sugar and 
 inosite are very uncommon, (b) Polydipsia is secondary, though per- 
 haps the earliest symptom noticed. In one case, a physician with 
 brain syphilis, 2 gallons of water were drunk each night between 10 
 p. m. and 7 a. m. (c) The skin is dry; carbuncles are rare. The 
 saliva is decreased. The appetite is usually not increased, though 
 phenomenal polyphagia marks some cases. Nervousness, headache, 
 irritability, increased knee jerks, impotence and severe lumbar pain 
 radiating into the legs, are quite frequent. Nutrition is often good in 
 the idiopathic cases and no unusual metabolic findings are noted; 
 in the symptomatic variety the nutrition depends on the causal 
 disease ; in children growth may be retarded. The temperature is low 
 and chilling occurs readily. Aside from causal lesions, there is no con- 
 stant autopsy finding except hypertrophy of the kidneys from increased 
 activity, and sometimes dilatation of the bladder and renal pelvis. 
 
GOUT. 
 
 879 
 
 Diagnosis.— Diagnosis is easy. Differentiation is required (a) from 
 diabetes mellitus, with which it has no common symptoms except 
 polyuria and polydipsia ; there is no glycosuria, acidosis, complicating 
 gangrene, carbuncles or neuritis; (b) from interstitial nephritis, in 
 which the "specific gravity is higher, the urine is less abundant, is 
 albuminous and contains casts, and which is associated with cardio- 
 vascular, retinal and ursemic manifestations; (c) from primary poly- 
 dipsia with secondary polyuria, which is exceedingly rare; and (d) 
 from transitory polyuria, which is distinguished by its course alone, 
 as well as by its obvious etiology, as recent fever, hysteria, resorption 
 of massive exudates, excessive medicinal diuresis and transient ure- 
 thral obstruction with sudden release of urine. 
 
 Prognosis. — The prognosis is obviously more favorable in idiopathic 
 forms, although cerebral syphilis doubtless causes many obscure cases. 
 Less than one-half of the patients recover, though death results less 
 frequently from the disease itself (save cerebral or abdominal tumors) 
 than from intercurrent infections, notably pulmonary tuberculosis. 
 
 Treatment. — Aside from antisyphilitic therapy, drugs are of little 
 use. Iodides benefit some cases in which there is no reason to suspect 
 syphilis other than the therapeutic results. Opium may be useful, 
 as in the saccharine form, and large doses are often well tolerated 
 Valerian (5j of the root, t. i. d.), ergot (fluidextract u\xx, t. i. d.), 
 sodium bromide (3ss, t. i. d.) and acetanilide (gr. v to x, t. i. d.) 
 are recommended. Strychnia has clearly helped some cases. Tal- 
 quist considers a vegetable more efficacious than a meat diet. Posner 
 advocates chewing gum, which apparently decreases the polyuria 
 and polydipsia. 
 
 GOUT. 
 
 Definition. — An obscure metabolic disease, characterized by acute 
 periodic or chronic inflammation of the joints with uratic deposits. 
 
 Mentioned by Hippocrates, gout was clearly described by Thos. 
 Sydenham (1683), who suffered from the affection for forty years. 
 Murray Forbes (1792) and Wallaston (1797) recognized the uratic 
 nature of the joint deposits. 
 
 Etiology. — 1. The actual cause is unknown. In 1848 Garrod ad- 
 vanced the hypothesis that uric acid accumulated periodically (before 
 the gouty seizure) in the blood. His, Yogel and Magnus Levy and 
 others deny Garrod's statement and maintain that uric acid in gouty 
 subjects is increased all the time ; and that the urine contains less uric 
 acid before and more during and after the seizure. Pf eiffer holds that 
 the uric acid is usually decreased, and that it is really less a question 
 of its amount than of its insolubility or form. Again the idea is ad- 
 vanced that uric acid is not produced in excess, but is retained in the 
 body because of periodic attacks of renal insufficiency. Whether the 
 real metabolic change concerns the uric acid, the alloxuric or purin 
 bodies is yet undetermined. 
 
 2, Extrinsic, predisposing factors, (a) Heredity is an apparent 
 
880 CONSTITUTIONAL DISEASES. 
 
 factor in 60 per cent. ; transmission by the father is more common 
 than by the mother and the younger rather than the older children 
 suffer from hereditary influences. (b) Mode of life; lack of exercise, 
 over-eating, an almost exclusively meat diet and alcoholism are potent 
 factors. The old verse read that " Wine was the father,' Eating the 
 mother, and Yenus the midwife " of gout. Though often true that 
 gout affects the well-to-do (arthritis divitum) and arthritis deformans 
 the poor (arthritis pauperum), gout is not uncommon among the 
 lower classes. As alcoholism is a widespread scourge, it would seem 
 that the heavy ales and beers of England and Germany are more 
 injurious (in this respect) than whisky and light wine. Gout may 
 occur in temperate individuals. Obesity, diabetes, arteriosclerosis 
 and calculous tendencies are concomitant or coordinate rather than 
 causal conditions, (c) Lead poisoning is observed in 15 per cent, of 
 cases, particularly in England, and its relation to gout is puzzling, 
 though saturnine nephritis may explain it. (d) Men are particularly 
 prone to gout (1 to 13 or 25). (e) Age. Gout begins between thirty 
 and forty years in 38 per cent, and thirty and fifty in 60 per cent. 
 Much less than 1 per cent, of cases begins before the seventeenth year ; 
 Gairdner observed one case in a nursling, (f) England leads in fre- 
 quency of its occurrence. In the United States it is rare, though 
 Futcher shows that the cases in Baltimore and London hospitals 
 stood as 2 to 3 ; again, relatively few cases seek hospital treatment. 
 
 Symptoms. — These may be considered under two captions, (1) 
 acute, and (2) irregular, chronic and visceral gout. 
 
 1. Acute' (regular, sthenic or) typical gout usually appears with- 
 out prodromes, though an attack is sometimes heralded by digestive 
 disorder (pyrosis, gastralgia, constipation), "cerebral congestion" 
 (insomnia, vertigo, tinnitus, irritability, depression), paresthesia, 
 cramps or pain in the muscles, dark lateritious urine or other vague 
 symptoms. The paroxysm is remarkably characteristic, (a) Local 
 findings: The patient is awakened one to three hours after midnight 
 by an agonizing pain in the metatarsophalangeal joint of the large 
 toe (podagra). The pain is described as crushing by a vise or like 
 burning by a hot iron. Localization in the toe is so frequent (95 per 
 cent., Garrod, or 73 per cent., Scudmore) as to be practically diag- 
 nostic of gout. The skin over it becomes hot, red, tense, slightly 
 oedematous and exquisitely sensitive. Serum exudes into the joint. 
 The pain abates toward morning, but the inflammation increases. 
 Each early morning sees a repetition of the pain for three to ^ve or 
 less often for six to seven days ; the paroxysmal pain and the local 
 findings then gradually subside by lysis ; in two-thirds of the cases, 
 the skin desquamates over the joint. Later attacks may involve 
 the thumb, knee and other joints, though less commonly than in 
 chronic irregular gout (v. i.). The local symptoms vary in intensity; 
 as a rule the shorter the attack the severer are the symptoms. The 
 pathological changes probably develop in this sequence: (i) local 
 stasis (inflammation), (ii) necrosis and (iii) uratic deposit; the 
 
GOVT. 881 
 
 I 
 
 ordinary urates (biurate of sodium in conjunction with sodium phos- 
 phate) do not cause such local reaction, but the biurate alone, even in 
 most dilute solutions (0.004), produces inflammation (Pfeiffer) ; 
 acute residual swellings (acute gouty tophi) consist of this biurate 
 which has been precipitated by the carbonates of the blood and tissues. 
 Convalescence is complete in ten to fourteen days, often with greatly 
 improved spirits and health after the gouty attack. During the seiz- 
 ure (b) constitutional symptoms are not absent. The temperature 
 rises to 100.5° or 101°, rarely 102°. The pulse is usually slow and 
 hard, sometimes arhythmic and seldom exceeds 100. The heart may 
 palpitate. Furring of the tongue, slight leukocytosis, anorexia, 
 nausea, vomiting, epigastric cramping and eructations are not un- 
 common. The urine is dark, usually decreased, acid and higher than 
 normal in specific gravity; the difference of opinion regarding uric 
 acid has been mentioned under etiology; Bain and Futcher find a 
 close parallelism between the uric and phosphoric acids, both being 
 derived from disintegration of nuclein ; they both fall below normal 
 in the quiescent period and increase during the attack. Garrod's 
 test for urates in the blood, exudates or transudates, consists of allow- 
 ing it to clot, adding 10 drops of 30 per cent, acetic acid to 3ij of the 
 serum and obtaining the crystals after twenty-four hours. 
 
 Subsequent acute seizures may sometimes be averted by diet and 
 exercise, but they are likely to recur, notably in the spring and fall. 
 Excesses in alcohol or in eating may precipitate acute gout; indeed 
 in one case it would occur within fifteen minutes from drinking a 
 glass of champagne ; trauma, exertion or excitement may favor relapse. 
 Retrocedent or suppressed gout was once thought to develop when 
 an acute paroxysm abated " too rapidly " ; many symptoms attributed 
 to it are doubtless due to coincident arteriosclerosis or uraemia (e. g., 
 gastralgia, vomiting, cardiac pain, dyspnoea, delirium, convulsions, 
 apoplexy, coma and death). 
 
 2. Chronic, irregular, atypical gout generally follows acute attacks 
 which increase in frequency, decrease in acuity and show slight ten- 
 dency toward resolution. Pfeiffer claims that gout deposits (tophi) 
 cannot occur without acute attacks. In some cases it appears to 
 begin as chronic gout, particularly in the aged, the cachectic and in 
 women with a gouty family history, all of whom lack reactive power 
 (atonic or asthenic gout), (a) Local findings: there are less pain, 
 fever and redness but greater and more permanent swelling than in 
 the acute form, until the condition eventually becomes fixed and 
 chronic ; the " attacks " may be most rudimentary and remissions 
 may alternate with exacerbations. The lower extremities and hands are 
 most often affected; it may also develop in the thumb (chiagra), knee 
 (gonagra), elbow (pechiagra) and spine (rhachisagra) , but the shoul- 
 der is very seldom and the hip almost never invaded. In some cases 
 its moving from joint to joint (urarthritis multiplex seu vaga) may 
 cause confusion with acute rheumatism. Uratic deposits (tophi 
 arthritici) form in the cartilage and later in the capsule and liga- 
 56 
 
882 CONSTITUTIONAL DISEASES. 
 
 ments, and the swelling never recedes essentially. These prominences 
 and the attendant fibrosis lead to deformation, subluxation, crackling 
 on movement, ankylosis and contractures. Sometimes fluctuation is 
 noted, especially in the big toe. The proximal joints of the fingers 
 may point to the radial and the others to the ulnar side. Tophi may 
 rupture, evacuating yellow-white urates, though incompletely, as they 
 are partly diffused through the tissues; these gouty ulcers heal tar- 
 dily, if at all, for their basis is fibrous and but slightly granulating 
 tissue. Tophi occur also on the ear (25 per cent.), bursas, tendons, 
 aponeuroses (which may explain some cases of Dupuytren's palmar 
 contracture), and even in the skin, eyelids, nose, larynx, penis or 
 scrotum, (b) Visceral gout includes a curious mixture of real gouty 
 complications and incongruous doubtful symptoms ("gouty disposi- 
 tion, 7 ' arthritisme, herpetisme and the so-called " uric acid diathesis "). 
 
 Complications. — Renal complications are the most important visceral 
 complications and sometimes dominate the clinical picture. In 1,440 
 cases, Garrod observed albuminuria in 26.5 per cent., more often in 
 advanced than in early cases. Its exact relation to gout is hard to 
 define ; it may follow the metabolic changes, or, according to Ebstein, 
 may possibly constitute a primary gout. At first albuminuria may be 
 considered toxic, marantic, congestive or arteriosclerotic, but later the 
 renal, cardiovascular and retinal findings of interstitial nephritis de- 
 velop with all its accidents and complications; uratic deposits occur 
 in the intertubular tissue and sometimes in the secreting tissue of the 
 cortex and medulla, in 15 per cent, of cases (Moore). Uratic deposits 
 (calculi) are not uncommon in the renal pelvis; hsematuria, oxaluria, 
 pyelitis and cystitis may also occur. 
 
 Arteriosclerosis of the ordinary type is promoted by the individu- 
 al's mode of life, by metabolic changes, alcoholism, plumbism and 
 nephritis ; it develops early and, with nephritis, causes most of the so- 
 called visceral symptoms, as the cerebrospinal (headache, vertigo, 
 brain congestion, epileptiform and apoplectiform attacks, encephalo- 
 malaeia), the circulatory (cardiac hypertrophy, myocarditis, angina 
 pectoris, atheromatous valvular lesions, phlebosclerosis), the respira- 
 tory symptoms (stasis, bronchitis, asthma) and retinitis. 
 
 Eczema (18 per cent.), scleritis and episcleritis (with small cir- 
 cumscribed points of inflammation and sometimes semimicroscopic 
 tophi), neuralgia or less often neuritis, lumbago, sciatica and pain in 
 the brachial plexus, burning and psoriasis-like patches on the tongue, 
 digestive symptoms (v. Prodromes) and burning in the eyeballs are 
 probably often gouty. On the other hand, the " gouty disposition " — 
 in some descriptions — consists of very vague symptoms ; on analysis 
 neurotic, paroxysmal (calculous colic, migraine or asthma) and 
 other conditions which are common in persons not suffering from 
 gout, account for many so-called visceral gouty manifestations. 
 
 Diagnosis. — (a) Acute gout is most typical in its etiology, history 
 and localization, with acute, circumscribed redness. In a few cases 
 (urarthritis multiplex), a diagnosis of acute articular rheumatism 
 
govt. 883 
 
 may be made ; fibrous rheumatic nodes may be confused with tophi, 
 but if the possibility of gout is recognized there is usually no error. 
 
 (b) Chronic gout often has a history of acute attacks, usually involves 
 the extremities and distal joints of the hands and feet, is marked by 
 unequal distention and thickening of the soft parts and is often known 
 by its association with early arteriosclerosis, contracted kidney, 
 obesity, renal calculus and diabetes. The x-rajs cannot determine 
 the diagnosis (see Arthritis Deformans, Diagnosis). Visceral 
 gout is an entity only when it develops in a patient undoubtedly gouty. 
 
 Prognosis. — Gouty patients may live to an old age, but the recur- 
 rence every two months to two years gives a tendency to chronic gout, 
 of which the issues are (a) uraemia, (b) arteriosclerotic complica- 
 tions, as coronary disease or apoplexy, (c) terminal infections, as 
 pericarditis, pneumonia and pleurisy, which may be induced by the 
 (d) gouty marasmus or cachexia. In general the outlook is better 
 in frank gout than in irregular gout and better in cases which develop 
 after forty years of age. 
 
 Treatment. — 1. The Acute Paroxysm.- — (a) Absolute rest is indi- 
 cated, (b) For pain, the use of colchicum is empirical (Storck, 
 1763) ; some believe that it increases the elimination of uric acid, 
 though the claim that it enables the tissues to break down and dispose 
 of the uric acid seems more reasonable; nevertheless, in gout it re- 
 lieves pain and inflammation and acts as a cholagogue; 3iss of the 
 vinum colchici radicis (not seminis) should be given daily. It must 
 be administered with care in nephritic and marantic subjects. If 
 long used, a tolerance to its action is acquired. It should be stopped 
 when pain is alleviated and it does not act well when diarrhoea inter- 
 venes, which interferes with its diuretic effect. (Full therapeutic 
 doses produce a slow pulse, nausea, vomiting, pain and purging; in- 
 versely to its action on the bowels there are diaphoresis and diuresis. 
 It is eliminated by the kidneys, bowels and skin. After toxic doses, 
 great nausea, retching, serous and finally hemorrhagic purging, great 
 pain, headache, vertigo, prostration, paralysis of the peripheral sensory 
 nerves, motor part of the cord and finally of the respiratory centre 
 (the usual cause of death) develop ; ecchymoses of the gastro-intestinal 
 tract with swelling may be seen at the postmortem examination.) 
 
 If colchicum produces no effect, sodium salicylate should be given, 
 gr. xv every two hours (3j to ij daily) ; it usually relieves the pain 
 and swelling and probably aids in solution of the uric acid ; its early 
 effect is greatest and it usually fails after the second or third day. 
 Finally, acetphenetidinum (gr. viij to x) and morphine are indicated 
 in severe paroxysms. In prolonged attacks, potassium iodide gr. v 
 (given with care in nephritis) and wine of colchicum Tr[x are useful. 
 
 (c) The diet, according to Pfeiffer, should consist of foods which 
 "release uric acid in a free form," as meal soups, rice and other 
 carbohydrates; meat and eggs should be withheld (though given in 
 chronic forms and in the intervals between attacks). Plain or acid 
 water, as Seltzer (not alkaline water as Yichy) should be given 
 
884 CONSTITUTIONAL DISEASES. 
 
 freely; alcohol and lemonade must be forbidden. If laxatives are 
 indicated, calomel, rhubarb or castor oil should be used, (d) Local 
 measures should be largely avoided lest added necrosis and tophi de- 
 velop, especially vesicants, the use of the ice-bag and massage ; warm 
 applications of 50 per cent, alcohol or lead water (tinctura opii, 
 liquor plumbi subacetatis, aa 3ij and water ^j) m ay be used. 
 
 2. The Interval Between Attacks. — (a) Regulation of diet is 
 the cardinal indication. Moderation in the quantity is more im- 
 portant than the quality of the food. Quantity: sl full diet increases 
 the uric acid, taxes resorption which is usually impaired and favors 
 acid fermentations which engage the diphosphates and carbonates of 
 the food necessary for the formation of soluble uric acid salts ; three 
 medium-sized meals a day are allowed. Quality: (i) alcohol should 
 be absolutely forbidden; (ii) water may be given freely, little with 
 the meals but large amounts on an empty stomach, (iii) Moderate 
 amounts of fat are allowed, (iv) Fruits and vegetables increase 
 diuresis and their malates and citrates help to dissolve the uric salts. 
 (v) Meats are allowed (though there are various opinions on this 
 subject) . The urea they produce seems to dissolve uric acid which the 
 meat, if given in moderation, does not increase. Meat is essential, 
 particularly in marantic cases. There is no difference between the 
 effect of light and dark meats; those rich in nuclein (sweet-breads, 
 liver and kidneys) must be avoided, (vi) Carbohydrates should be 
 largely decreased; this rule is empirical, though it appears that fol- 
 lowing their ingestion the uric acid (as compared with the urea) 
 increases nearly two-fold. Milk should be avoided, for its lactic acid 
 is injurious, (b) Exercise is indispensable, but prolonged or fa- 
 tiguing effort, hurry and worry are to be avoided, (c) Medicinal 
 treatment is rather secondary. Alkalies produce an increased output 
 of uric acid, but they operate only by preventing decomposition of 
 the neutral (bi-) sodium phosphate (the chief uric solvent). The 
 kind of alkali used is not essential ; lithium carbonate is inferior to 
 sodium carbonate or bicarbonate, which acts first by promoting the 
 formation of bisodium phosphate and second by neutralizing the acid 
 formed by fermentation; it may be given (in doses of gr. x upward) 
 for a long period of time, and has no effect on the blood; but the 
 twenty-four-hour collection of urine should not become alkaline (lest 
 alkaline deposits develop in the renal pelvis). Mineral waters merely 
 operate in the same way, as those of Saratoga and Bedford Springs 
 in this country, Bath and Buxton in England, Aix-les-Baines and 
 Contrexville in France, and Fachingen, Carlsbad, Homburg, Wild- 
 bad and Teplitz. Luff advises the use of guaiacum resin, gr. v to x, 
 t. i. d. Piperazin, lysidin, urotropin, urosin and sidonal are much 
 inferior to the simple sodium salt. 
 
 3. Chronic Gout. — This is difficult to treat. For general dietetic, 
 hygienic and medicinal measures, see above. Colchicum wine, n\x, 
 and potassium iodide, gr. v, may relieve the joints, the gouty asthma, 
 neuralgia and eczema. Tonics, principally arsenic, are indicated in 
 
ARTERITIS DEFORMANS AND CHRONIC RHEUMATISM. 885 
 
 marantic forms. Bier's stasis may benefit. Tophi should not be 
 operated on; local measures are useless, save gentle massage, dry 
 heat, moist applications or salicylate salves (ac. salicylic. 4, lanolin 
 40, and oleum terebinthinse 1 part), though all treatment generally 
 fails. 
 
 ARTHRITIS DEFORMANS AND CHRONIC RHEUMATISM. 
 
 Excluding gouty, tuberculous, syphilitic, gonorrheal and hemo- 
 philic affections, there remains a group of articular affections of 
 which the chief are arthritis deformans and the so-called chronic 
 rheumatism. Several totally different affections are gathered under 
 these names. Their classification is most unsatisfactory. 
 
 Arthritis deformans is a progressive or at least chronic affection, 
 marked by changes in the synovial sac, cartilages and bone, causing 
 functional disturbance and usually deformity in the articulations, 
 usually symmetrical and polyarticular. 
 
 Etiology. — (a) The predisposing factors are (i) heredity, which is 
 causative in 13 per cent. (Garrod) ; (ii) age; 55 per cent, of cases 
 occur between twenty and fifty years of age ; 5 per cent, under twenty 
 years and 40 per cent, over fifty years of age (Garrod) ; (iii) sex; 
 though Stewart and McCrae consider that the sexes are equally in- 
 volved, Garrod observed 82 per cent, in women; (iv) fatigue, cold, 
 dampness, poor hygiene or trauma may be predisposing factors. 
 (b) The immediate cause is unknown. There are many theories: 
 (a) the abandoned neuropathic theory (Mitchell) is that it results 
 from a cord lesion; (b) the infective theory is based upon finding 
 bacteria in the joints, enlarged spleen and lymph glands and its oc- 
 casional development after infections; (c) the rheumatic theory, 
 according to which it is a chronic rheumatism; Garrod and Banna- 
 tyne find few heart lesions; Pribram finds one-fifth as many as in 
 rheumatism. 
 
 Pathology. — Whether the synovia or cartilages are first involved is 
 undetermined; the a;-rays do not solve the question; practitioners, 
 who see cases early, hold that the serous sac is first affected and sur- 
 geons find the cartilage most often diseased. The synovial villi hyper- 
 trophy and the cartilage slightly fibrillates, cleaves and finally atro- 
 phies. The bone becomes thin in some places and tuberous in others 
 from periosteal proliferation (Hay garth's nodosities) ; the joint sur- 
 faces become eroded and in part grow together. 
 
 1. Diffuse Progressive Type. — (a) The acute form is less com- 
 mon. There is some fever, rise in the pulse rate and depression and 
 the joints become red and swollen, resembling in some ways acute 
 articular rheumatism, but differing from it in that arthritis de- 
 formans is less fugitive, involves the small joints more frequently, is 
 attended by less sweating and seldom by heart complications, does not 
 react to salicylates and runs a longer course. In some cases it has 
 even resembled typhoid, because the fever and splenic enlargement 
 
886 CONSTITUTIONAL DISEASES. 
 
 lasted for some time before the joints became affected, (b) The 
 more frequent chronic form develops insidiously, with uncomfortable 
 sensations in the joints, pain or tearing nocturnal pains about the 
 joints and vasomotor skin symptoms. It begins most often in the 
 small joints of the hands, with or without swelling, and remits and 
 recurs. The hands often sweat. The fingers become fusiform from 
 joint changes, capsular thickening and collateral oedema which sepa- 
 rate the fingers from each other. The oedema often disappears, show- 
 ing more clearly the bone and the capsule thickening. The cartilages 
 become uneven and crackle on movement, loosened villi may become 
 free bodies and the adjacent bursa? and tendons may become swollen. 
 The fingers deviate and become angular from flattening of the saddle- 
 shaped epiphyses and muscular contractures (now extensor and again 
 flexor in type). Extension to other joints occurs; the elbow becomes 
 flexed, the shoulder often crackles and becomes fixed; the large toe 
 is bent out and lies under the other toes, which are often extended at 
 their first and flexed at their two distal articulations; the ankle is 
 
 Fig. 48. 
 
 Rheumatoid arthritis. (Musser.) 
 
 often abducted ; the knee is swollen, shapeless and flexed from effusion 
 or contracture; in a few cases the hip, jaw and spine are involved. 
 Motion is limited by the swelling, muscular contractures, articular 
 fixation by interlocking extracapsular nodosities and capsular in- 
 duration. The contiguous muscles atrophy from disuse, local inflam- 
 matory invasion or reflex influence on the cord. The skin may be- 
 come puffy, glossy or atrophic. The reflexes are increased. Neuritis 
 is not uncommon. When the vertebra? were involved, Braun found 
 nervous symptoms in 88 per cent., as weak muscles, occipital neu- 
 ralgia, involvement of the brachial plexus and anaesthesia. The heart 
 was not affected in any of Garrod's 500 cases. Anaemia, episcleritis 
 and other complications are uncommon. The majority of patients 
 do not improve or recover and recurrence of the disease is very com- 
 mon. In some cases the process is arrested. Aside from atheroma 
 and nephritis few intercurrent diseases develop. 
 
ARTHRITIS DEFORMANS AND CHRONIC RHEUMATISM. 887 
 
 2. Partial or Monarticular Type. — Pathologically this type 
 resembles the form described, but differs from it in that it presents 
 more profound changes and is limited to one or few articulations. 
 There is the same capsular thickening and cartilaginous fibrillation ; 
 the cartilage often softens, ossifies or hypertrophies ; the bone rarefies 
 or becomes cystic and soft in some places, with flattening of the bone 
 heads and widening of the sockets, particularly in the shoulder and 
 hip; in other places bony overgrowths form, known as Haygarth's 
 nodes or a new socket may develop; the bone may eburnate and the 
 joint may be either smooth or ridged. As a rule the atrophic prevail 
 over the hypertrophic changes. They resemble the extreme senile 
 change (morbus coxes senilis) ; trauma or a nervous basis is con- 
 sidered causal; it occurs in old persons and largely in males. Clin- 
 ically, compared with the general progressive type, it is single or at 
 least rarely symmetrical, occurs in the proximal large joints (hip and 
 shoulder), and is less often attended by subluxation. The elbow, 
 spine and smaller joints are less involved. 
 
 3. Vertebral Type. — Striimpell (1885) named this type chronic 
 ankylosing spondylitis; vertebral arthritis deformans occurs with 
 ankylosis of the spine, shoulders and hips. Marie (1898) made it a 
 separate type (spondylose rhizomyelique), characterized by complete 
 vertebral ankylosis, scoliosis, ankylosis of shoulders and hips, exemp- 
 tion of all other joints, incidence almost exclusively in males, and its 
 appearance in the young immediately after bony development has 
 ceased. Von Bechterew (1892) described a similar type due to 
 heredity, trauma or meningeal inflammation and characterized by 
 paresis of the muscles of the neck, trunk and extremities, some 
 atrophy of the back and shoulder, involvement of the spinal nerves 
 (hyperesthesia, pain and paresthesia) and an ascending degeneration 
 in the cord. These are probably but subtypes of arthritis deformans. 
 
 4. Juvenile Type of Still. — (a) The ordinary progressive 
 (adult) form may be observed, running an unfavorable course, and 
 often with almost universal ankylosis ; in some cases the great toes are 
 lengthened, (b) "Still's type" occurs in poor children largely; TO 
 per cent, of cases are girls ; 30 per cent, occur between the second and 
 seventh years, 32 per cent, between the seventh and thirteenth years, 
 and 20 per cent, between the thirteenth and seventeenth years. The 
 onset is often subacute. The multiple arthritis affects chiefly the 
 extracapsular tissues and there is seldom crepitus. The spleen is 
 always enlarged and the lymph glands near the affected joints are 
 hard and large. Anaemia and retarded development are common. 
 
 5. Heberden's ^N"odes. — Bony nodes develop on the sides of the 
 end phalanges near the joints. They begin between thirty and forty 
 years, but are seen chiefly at about sixty years of age. At first soft 
 and sometimes painful and red, they become hard, indolent and as 
 large as a pea. Their growth is more often intermittent than con- 
 tinuous. Disturbance in function is not uncommon, but only in ex- 
 treme cases is deformity observed, as flexion of the end phalanges into 
 
888 CONSTITUTIONAL DISEASES. 
 
 the palm or deviation toward the radial side. Involvement of the 
 large joints is rather uncommon, whence the prognosis is favorable. 
 Some consider them gouty, though Heberden dissented strongly. 
 
 Diagnosis. — (a) In gout, the history, localization, fine (not coarse) 
 crackling in the knee-joint and radial articulation of the elbow, 
 greater spontaneous pain, infrequent generalization and symmetry, 
 
 Fig. 49. 
 
 Heberden's nodes. (Musser.) 
 
 the uratic deposits and tophi in the ear are characteristic, (b) 
 Acute rheumatism (v. s. Acute Form), (c) Multiple tuberculous 
 arthritis may cause diagnostic difficulty, particularly when it occurs 
 in children, for pulmonary tuberculosis may complicate arthritis de- 
 formans ; but the tuberculous hip and knee involvement, the fusiform 
 fingers, the hectic fever, involvement of the glands and serous mem- 
 branes are generally distinctive. Poncet has recently called atten- 
 tion to an ankylosing tuberculous pseudorheumatism, which may 
 cause confusion (v. Tuberculosis), (d) Syphilis (q. v.) of the 
 joints occurs particularly in persons between four and fifteen years of 
 age and in about 40 per cent, of hereditary forms ; the epiphyses are 
 irregularly deformed, (e) Hemophilic arthritis is distinguished by 
 the unmistakable family history and its three stages, hsemarthros, 
 panarthritis and adhesions, erosions, deformity and ankylosis. (/) 
 Chronic articular infections (chronic pseudorheumatism), especially 
 subchronic gonorrheal arthritis (q. v.), begin acutely, usually affect 
 the knees first, then possibly after months the ankles, hands (in 
 women particularly) and sternoclavicular and other joints; similar 
 chronic arthritides may follow scarlatina, diphtheria, pneumonia and 
 grippe, (g) Nervous arthropathies present much the same path- 
 ological findings; (i) the arthropathies of tabes (q. v.) occur rapidly 
 and early, without pain, tenderness or other inflammatory evidence; 
 are attended by much effusion, are atrophic or flail-like rather than 
 hypertrophic, in 80 per cent, involve the lower extremities and are 
 accompanied by other signs of tabes, (ii) In syringomyelia (q. v.) 
 the effusions are great, painless, in 80 per cent, involve the upper 
 
ARTHRITIS DEFORMANS AND CHRONIC RHEUMATISM. 889 
 
 extremities and are associated with the syringomyelic dissociated 
 anaesthesia and panaritia. (h) "Chronic rheumatism" may rarely 
 follow acute rheumatism, in which the changes involve less the bone, 
 cartilage and serous sacs than the capsule which becomes fibrous. 
 The cartilage may become somewhat fibrillated and fibrous, but is 
 seldom hypertrophied or destroyed. The vascular bands become cal- 
 lous ( Jaccoud's fibrous rheumatism) and ankylosis may result. Some 
 maintain that ankylosis by connective tissue and the joint obliteration 
 differentiate fibrous rheumatism from arthritis deformans, but clin- 
 ical differentiation is often impossible. 
 
 Treatment. — Treatment is notoriously futile and arrest of the pro- 
 cess results rather from spontaneous exhaustion of the disease than 
 from therapeutic efforts, (a) " Rheumatic " influences, as exposure 
 to cold and dampness, overheating while at work and resting in damp 
 garments are to be carefully avoided. Woolen underwear should be 
 worn. General hydrotherapeutic measures are illy borne. A warm 
 climate benefits especially those cases resembling (or including) 
 chronic fibrous rheumatism, as Mexico, West Virginia and Arkansas. 
 (&) Diet is not of such importance as in gout; indeed, liberal feeding 
 is strongly indicated, (c) In acute exacerbations rest and coal-tar 
 derivatives are indicated; salicylates are generally useless save in 
 really secondary rheumatism, (d) Passive movements and massage 
 relieve stiffness and muscular contractures. Massage reduces the 
 oedema and adhesions. In some cases forcible pressure, as with the 
 thumb, will cause absorption of the fresh osteoplastic nodes; it may 
 be easily overdone, and once every day or two on the same area is 
 sufficient. Cautious active exercise is also essential, (e) Extension 
 by pulley weights sometimes produces wonderful results, according to 
 Hoffa, in lessening pain and exostosis, though the author has never 
 observed any essential results. (/) Local measures may be of some 
 use. The x-rays and strong electric lights may afford temporary alle- 
 viation from pain but do not seem to affect the basic change ; fibrous 
 rheumatism is more benefited than arthritis deformans. The same 
 may be said of local applications of warm water. Hot air causes 
 hyperemia of the parts and is sometimes of real benefit; cages of 
 wire, asbestos and felt are devised to enclose the joint, leaving around 
 it an air space ; the temperature is gradually raised by a lamp placed 
 under a connecting elbow to 200 or 250° F. and is gradually lowered. 
 Bier's method of venous hyperemia, used in tuberculous joints, is also 
 advocated; the Esmarch constrictor above the joint should produce 
 swelling but not pain. " Firing " the skin with the Paquelin is bene- 
 ficial in lighter grades of deforming arthritis and in fibrous rheuma- 
 tism. Encouraged by the results in one case in which injections of 
 iodoform and olive oil were given, the author used it in six other 
 cases, and either without benefit or with great increase of pain and 
 swelling. Operation; resection may be considered in nonprogressive, 
 monarticular forms, but the general poor health and age of the patient 
 rather contra-indicate it. (g) Internal medication, as cod-liver oil, 
 
890 CONSTITUTIONAL DISEASES. 
 
 arsenic, thyroid extract and syrup of iodide of iron may help a few 
 cases. Luff uses guaiacol carbonate; the initial dose of five grains, 
 t. i. d., is increased two grains every week till a single dose of twenty 
 grains is given. 
 
 RICKETS. 
 
 Definition. — A metabolic affection of early infancy, characterized 
 chiefly by hyperemia and deficient calcification of the growing bones. 
 The disease was first well described by Glisson (1650). The name 
 is derived from an old English word meaning " twisted," and Glisson 
 suggested the Greek " rhachitis " (vertebral inflammation) because 
 the spine was often involved, and the term sounded like " rickets." 
 
 Etiology. — Its etiology is obscure. All theories advanced, such as 
 deficient absorption of lime salts, infection or reduced activity of 
 the thymus, are insufficient, (a) The diet is of prime importance; 
 proprietary foods, condensed milk, cow's milk, excess of carbohy- 
 drates, prolonged lactation or nursing during pregnancy are probable 
 factors. Cheadle considered that a deficiency in animal fats and pro- 
 teids was causative ; after 20 litters of lion cubs had been lost from 
 rickets in the London Zoological Gardens, Bland Sutton found that a 
 diet of milk, powdered bone, meat and cod-liver oil prevented rickets. 
 (b) Unsanitary surroundings may be causal, as lack of fresh air and 
 sunlight, crowded quarters and kindred factors observed largely 
 among the poor classes in large cities, particularly in Europe. Among 
 nurslings Kassowitz (Vienna) observed it in 89 per cent, and Jou- 
 cousky (St. Petersburg) in 90 per cent. ; in children's clinics abroad, 
 Marfan (Paris) found rickets in 50 per cent. ; in Holland, London, 
 Christiania, Naples and Kio Janeiro about the same figures prevail 
 (50 to 80 per cent.) ; in the United States it is most frequent 
 among negroes and Italians. Hereditary syphilis is a predisposing 
 factor., (c) Age. In more than 600 cases Baginsky did not observe 
 it in children under three months of age ; his figures show 7 per cent. 
 in children between three and six months, 28 per cent, between six 
 and twelve months, 35 per cent, between one and one and a half 
 years, and 18 per cent, between one and a half and two years (e. g., 
 88 per cent, of cases occurred between three months and two years of 
 age). The occurrence of congenital rickets (apart from achondro- 
 plasia, see Diagnosis of Barlow's Disease) is usually denied but 
 there is some authoritative testimony for it. Pickets which develops 
 later, up to puberty, is called rhachitis tarda. 
 
 Symptoms. — An experienced observer may diagnosticate the gradual 
 onset from the prodromes, as the irregular or tardy dentition ; rest- 
 lessness, irritability, insomnia and throwing off of the bedclothes; 
 sweating about the head and neck; bronchitis; digestive disturbances, 
 coated tongue, anorexia, malnutrition, meteorism or diarrhoea; im- 
 mobility, the child crying when moved or touched and general hyper- 
 esthesia. However, a positive diagnosis is not justifiable until the 
 bone symptoms develop. 
 
RICKETS. 891 
 
 1. Bone Symptoms. — (a) The skull usually shows the earliest 
 changes, generally in the first year of life; the bone changes (v. i.) 
 are most marked in the skull and thorax. The face appears small 
 and the head large. Nodes of bone appear on the frontal and parietal 
 regions, which with the occipital flattening produce the caput quad- 
 ratum {tete caree) ; the head may be dolichocephalic. The anterior 
 fontanelle increases forward. The fontanelle and sutures (which nor- 
 mally close about the fifteenth or eighteenth month) remain open, 
 even until the fourth year, i. e., there is lack of normal involution. 
 The occiput softens (craniotabes) in 33 to 50 per cent., near the 
 lambdoid suture; the occipital protuberance remains hard. Cranio- 
 tabes may less frequently occur elsewhere, as in the frontal bones ; be- 
 sides the actual bone changes (v. i.), the pressure of the pillow and of 
 the brain further its development. In extreme cases the peri- and 
 endocranium actually touch, and in moderate degrees the skull feels 
 " parchment-like." Though it is not absolutely pathognomonic of 
 rickets, and though it occurs also in syphilis, craniotabes is rather 
 characteristic when there are also the tender quadrate head, head 
 sweating, thin occipital hair and blue scalp veins. Craniotabes may 
 be an element in the general and local spasms which occur in rickets. 
 The frequent systolic murmur heard over the greater fontanelle is 
 also heard in other affections or in health; it seldom endures beyond 
 the fifth year and is said to occur only in conjunction with a similar 
 bruit in the carotids. The upper jaw becomes long and narrow and 
 the lower jaw becomes hexagonal, probably from muscular traction 
 on the soft bones. The eruption of the teeth is delayed until the 
 second or even the third year ; the second teeth are crowded, carious, 
 curved and eroded, (b) In the thorax, the rhachitic "rosary" ap- 
 pears toward the end of the first or early in the second year ; it is so- 
 called from the bead-like succession of enlarged chondrocostal joints; 
 they are enlarged epiphyses. The chest is altered toward the end of 
 the second year; this is due to the softness of its bones, the traction 
 exerted by the diaphragm, atmospheric pressure and sometimes by 
 external influences, as holding of the child with a hand on the chest 
 or coincident respiratory inflammation. Louis' angle is often promi- 
 nent, and the sternum juts forward, causing "chicken breast" (pec- 
 tus carinatum). There is also a depression outside of the costochon- 
 dral junctions which extends outward and downward, and is accentu- 
 ated by some eversion of the costal arch. The thoracic deformity 
 promotes respiratory complications and dyspnoea, which in turn ag- 
 gravate it. With the deformity of the chest we may group lumbar 
 kyphosis which is arcuate and not angular, the thickened or bent 
 clavicle and the thickening of the spine or edges of the scapula, (c) 
 In the extremities, the epiphyses, particularly of the ulna, radius ; 
 tibia and fibula, are enlarged; this occurs about the end of the first 
 year, at the same time as the rosary, craniotabes and wide fontanelle. 
 The epiphyses, like the ribs and skull, are tender and painful. It 
 may look as though there were "double joints." Deformities may 
 
892 CONSTITUTIONAL DISEASES. 
 
 develop from muscular traction or from the weight of the body; the 
 arms may incline outward and forward; the forearms may become 
 convex toward their extensor surfaces. The thighs sometimes be- 
 come convex anteriorly and outwardly; the legs bow outward or less 
 often forward, especially when early walking is encouraged. Spiral 
 or other extreme deformities are less frequent. The gait is waddling. 
 Greenstick or actual fractures sometimes occur, (d) The flat rha- 
 chitic pelvis develops by the weight of the body pushing the sacrum 
 into the pelvis and the counter-pressure of the thighs narrowing the 
 anterior pelvis, so that the pelvic aperture may become heart-shaped ; 
 the acetabula lie more anteriorly and the iliac crests flare outward, 
 (e) Pathology. Normal bone grows in length as follows: there are 
 two zones in the epiphyseal surface facing the shaft; (i) the first zone 
 is nearest the shaft, is faintly yellow and measures % mm. ; it is the 
 zone of preliminary calcification, into which normally the blood- 
 vessels grow and form medullary canals by absorbing small areas of 
 bone, and in which osteoblasts appear and calcification develops. (In 
 rickets the calcification is imperfect and irregular in this zone and 
 the bloodvessels grow not merely into these calcified areas but beyond 
 them, even into the cartilage area, and absorb what little new bone is 
 formed.) (ii) The second zone lies outside the one described, is 
 sharply demarked from it, is normally bluish, measures 1 to 2 mm. 
 in thickness and is known as the hyperplastic zone, in which the car- 
 tilage cells divide and proliferate. (In rickets this zone becomes 
 larger, proliferates irregularly and is invaded by bloodvessels and 
 irregular foci of abortive calcification; the demarkation between the 
 first and second zones is ill-defined.) Normal bones grow in thick- 
 ness by bony increase beneath the periosteum. (In rickets this layer 
 becomes several millimeters thicker, irregular and nodose.) Normal 
 bone develops in the skull and face in the connective tissue. (In 
 rickets the lime salts are either not deposited, are insufficiently de- 
 posited (craniotabes) or over-deposited as bosses (osteosclerosis).) 
 The essential element of these rhachitic changes is undue hyperemia 
 and irregular, deficient calcification; which one is primary remains a 
 disputed point; the bones may contain but 20 or 30 per cent, of the 
 normal amount of lime salts. 
 
 2. General Symptoms. — (a) Muscular weakness is pronounced, 
 as evidenced by impaired breathing, the tardy efforts to hold up the 
 head and disinclination to walk, (b) Nutrition is usually poor; 
 there is anaemia, sometimes with leukocytosis and often with emacia- 
 tion; the irritability and sweats have been mentioned under pro- 
 dromes, (c) Nervous system. Mentality is unimpaired. Khachitic 
 patients frequently grind their teeth. Spasmodic conditions are not 
 infrequent, as generalized convulsions, tetany and spasm of the 
 glottis, all of which will receive separate consideration, (d) Tem- 
 perature is not symptomatic of rickets and always denotes complica- 
 tions, (e) Digestive disturbances are common; there may be ano- 
 rexia, diarrhoea without pain or tenesmus, more commonly constipa- 
 
RICKETS. 893 
 
 tion and distention of the abdomen which can occur without any 
 digestive disorder, from enlargement of the liver and spleen, and 
 possibly from the thoracic changes. The amount of chalk in the faeces 
 may he increased (Baginsky). The spleen is enlarged in 70 per 
 cent., and, less often and less markedly, the liver. (/) Eickety chil- 
 dren catch cold easily and bronchitis frequently leads to atelectasis 
 and bronchopneumonia, (g) The heart may be luxated from the 
 altered thoracic conformation, which also frequently causes hyper- 
 trophy of the right ventricle, (h) The urine remains normal. (*) 
 Eczema is common. 
 
 Course, Complications and Prognosis. — (a) The onset is insidious 
 and the clinical course covers a year or more, (b) Complications in- 
 clude but few of immediate danger, as bronchitis, pneumonia and 
 spasm of the glottis which may result fatally. Later complications 
 include the contracted rhachitic pelvis of obstetrical importance, 
 kyphosis and pulmonary tuberculosis, which is found in 36 per cent, 
 of the fatal cases, sometimes with abdominal complications (tabes 
 mesaraica) ; its early diagnosis depends almost entirely upon auscul- 
 tation, for percussion is peculiarly deceptive when the chest is de- 
 formed, (c) The prognosis is, with these exceptions, excellent as to 
 life, and with care, as to deformity, for many protuberances and 
 deformities may regress. 
 
 Diagnosis. — The diagnosis is based chiefly, — and then with cer- 
 tainty — upon the changes in the skull and skeleton. Errors are 
 easily possible from precipitate diagnosis, based on the purely pro- 
 dromal phenomena, (a) Barlow's disease (q. v.), which is misnamed 
 acute rickets, has no connection with it. (b) Syphilis predisposes to 
 rickets but is otherwise distinct and separate; it usually develops at 
 a time (first to sixth month) when rickets is most uncommon and is 
 usually stamped by other syphilitic stigmata, as cutaneous and mu- 
 cous syphilides ; when it invades the epiphyses, the femur is usually 
 its seat, and there may be, between the cartilage and bone, a wall-like, 
 very tender, painful and usually doughy swelling which also is rather 
 fusiform, compared with the rounder rhachitic nodes; epiphyse- 
 olysis with great dislocation of the fragments, may occur in syphilis, 
 but never in rickets ; in doubtful cases an ex juvantibus diagnosis may 
 be made, (c) Vertebral tuberculosis (q. v.) is easily distinguished; 
 the rhachitic kyphosis is arcuate, not angular ; other symptoms of either 
 disease are almost invariably present, (d) Hydrocephalus (q. v.). 
 
 Treatment. — 1. Hygiene. — Fresh air and sunlight produce wonder- 
 ful results, particularly in the country, mountains or at the sea-side. 
 
 2. Dietetic. — In nurslings (who seldom develop the disease) or 
 in quite young babies, the use of a wet-nurse may entirely cure the 
 disease. In older children it may be less a question of food than of 
 digestion, which may require pepsin, taka-diastase, nux vomica or 
 hypophosphites. 
 
 3. Medicinal. — No specific remedy is known, but the results pro- 
 duced by phosphorus make it more important than any other drug. 
 
894 CONSTITUTIONAL DISEASES. 
 
 Under its use the child becomes easier and brighter; the nervous 
 symptoms abate, as the insomnia, convulsions, tetany or laryngo- 
 spasm; the osseous symptoms are improved, bone is deposited and 
 dentition occurs, though less obviously in clinical experience than in 
 animal experiments in which it seems certain that small doses stimu- 
 late bone formation directly and rapidly. Phosphorus itself is given 
 in doses of gr. %oo to M.00 in pill form or as the ol. phosphoratum (1 
 per cent, solution) TIXj, t. i. d. ; the oil or emulsion should be freshly 
 prepared, for both deteriorate readily on exposure to light. (Its toxic 
 symptoms are malaise, fever, thirst, anorexia and weakness; vomit- 
 ing of food, mucus, bile, later blood and sometimes phosphorescent 
 material, may occur; there may be abdominal pain, diarrhoea or 
 constipation, phosphorescent, clay-colored or bloody faeces; jaundice 
 may develop ; the liver at first may be large, but becomes small ; there 
 may be cholaemia ; albumin, bile, casts, leucin and tyrosin in the 
 urine and hemorrhages from the uterus, abortion or miscarriage and 
 bleeding from other surfaces.) Cod-live?* oil was recommended by 
 Bretonneau in 1827 ; it carries out Cheadle's theory that animal fats 
 and proteids are essential and conforms with Sutton's experience 
 (v. s.). If it is well tolerated by the stomach, the general level of 
 health may be elevated by its use ; if not, cream and butter should be 
 given. Iron (syr. ferri iodid.) is a good tonic. Calcium salts are 
 now less used than formerly, as it has been proven that a sufficient 
 quantity is present in the food and is absorbed. 
 
 4. Orthopedic. — During the florid stage the child should be kept 
 quiet upon a firm mattress and off his feet. Later, corrective meas- 
 ures are indicated for the kyphosis and deformity of the limbs, 
 Mikulicz holds that the apparently monosymptomatic genu valgum 
 adolescentium is only a rhachitis tarda, and that genu valgum and 
 varum should always be treated with rest, cod-liver oil and phosphorus. 
 
 OBESITY. 
 
 Etiology. — Obesity (adiposity, corpulence or polysarcia adiposa) 
 is favored (a) by heredity; it frequently occurs in entire families; 
 congenital cases are known; (b) by mode of life; lack of exercise, 
 over-eating and alcoholic indulgence are potent factors, (c) The 
 menopause is frequently attended by increase in weight, (d) Vari- 
 ous diseases may cause it, as those of the nervous or osseous system, 
 making exercise impossible; and gout, diabetes, various anaemias, 
 chronic valvular disease and emphysema, which act rather by pre- 
 venting adequate exercise than by deficient oxygenation or from the 
 condition of the blood. Adipose tissue may develop from tissue 
 albumin. 
 
 Symptoms. — The general habitus requires no description. Fat 
 develops in the subcutaneous tissues, in parts where it is normally 
 found, as in the omentum and around the kidney and it may cause 
 fatty infiltration and degeneration of all internal organs excepting 
 the brain and spleen; even the blood may contain fat (lipaemia). 
 
OBESITY. 895 
 
 1. Cardiac Symptoms. — The heart is embarrassed by increased 
 resistance to the capillary flow, by the fatty infiltration and degen- 
 eration of the myocardium, and by fat accumulation in the chest wall, 
 omentum and mediastinum. The pulse is more often frequent than 
 slow, though cases of bradycardia are noticed (see Fatty Heart). 
 Cardiac hypertrophy may occur. (Edema is not uncommon. 
 
 2. Eespiratory Symptoms. — The breath sounds and heart tones 
 are faint and thoracic percussion is difficult because of the subcutane- 
 ous fat. Bronchitis is common and probably results from the ready 
 sweats and consequent chilling. Dyspnoea may occur on exertion 
 only, or may develop from pulmonary oedema. 
 
 3. Digestive Symptoms. — Digestive disturbances may develop. 
 The large liver is less frequently fatty than congested and hyper- 
 trophic. Constipation and hemorrhoids are frequent. 
 
 4. The Urine. — The urine may be scant in comparison with the 
 fluids ingested; coincident oxaluria, lipuria, lithuria, albuminuria 
 or glycosuria may be noticed. Actual impotence is not uncommon, 
 as well as mechanical obstacles to coitus. 
 
 Two other groups of symptoms mark extreme obesity, viz.: (5) 
 lessened physiological resistance to infections, as typhoid or pneu- 
 monia and to surgical measures or phlebotomy, and (6) such asso- 
 ciated affections as diabetes, gout, calculous disease and less often 
 contracted kidney, arteriosclerosis and apoplexy. Somnolence may 
 be marked. 
 
 Treatment. — Treatment is (a) that of the fundamental condition, 
 as gout or diabetes, and (b) dietetic. Various "cures" have been 
 formulated which are enumerated because they possess more than 
 historical interest. — (i) Banting's cure. Banting, a merchant, was 
 treated so successfully by Wm. Harvey for obesity that he addressed 
 a " Letter to the Public on Obesity" (1863). This diet was largely 
 albuminous and consisted of fish, meat, eggs, tea without sugar or 
 milk, vegetables, fruit, some red wine and toast without butter. This 
 diet may cause indigestion, nervousness, insomnia, palpitation or 
 gout, (ii) Ebstein, himself a sufferer, proposed (1872) a diet with 
 larger proportions of fat; his diet consisted of meat, fish, eggs, tea, 
 leguminous vegetables, fruit, fats and butter, but restricted the 
 carbohydrates ; digestive disorders may also occur under this system, 
 (c) Oertel allowed more carbohydrates, limited the fats and fluids and 
 insisted upon sweats and graduated exercises. From the following it 
 will be seen that all these methods are " starvation cures," with 
 restriction of water in Oertel's method. The average man requires 
 118 gm. (45) of nitrogen, 56 gm. (23) of fat and 500 gm. (178) of 
 carbohydrates (Yoigt and Pettenkofer), equaling 3,054 calories. 
 
 The diet of Banting contains 172 gm. (5.73) of nitrogen, 8 gm. 
 (23) of fat, and 81 gm. (2.73) °f carbohydrates, equaling 1,112 
 calories. 
 
 The diet of Ebstein contains 102 gm. (2.33) of nitrogen, 85 gm. 
 (2J) of fat, and 47 gm. (1.63) of carbohydrates, equaling 1,401 
 calories. 
 
896 CONSTITUTIONAL DISEASES. 
 
 The diet of Oertel contains 183 gm. (6g) of nitrogen, 38 gin. 
 (1.3g) of fat > and 143 g m - (4.85) of carbohydrates, equaling 1,690 
 calories. (A calorie is the temperature required to raise 1,000 gm. 
 of water, 1° C. ; a gram of albumin equal 3.2 calories, of fat, 8.4, 
 and of carbohydrates 3.8 calories.) 
 
 Banting's method supplies to the body about 33 per cent, of the 
 heat and energy normally required; Ebstein's less and Oertel's 
 slightly more than 50 per cent. The lesson taught then is moderation 
 in eating (v. Gout). In any reduction-cure the patient may suffer 
 from breaking down of the body proteids, which causes the weakness 
 that is experienced. In all cases the total amount of nitrogen in the 
 urine, which constitutes 90 per cent, of the nitrogen excreted, should 
 be watched; if more is excreted than ingested the nitrogenous food 
 should be increased to obviate weakness, both muscular and cardiac. 
 The diet then should consist, as in gout, of moderation in all foods, 
 with restriction of the carbohydrates, whose easy reduction into 
 water and carbonic acid spares the tissue waste. The fluid ingested 
 should be measured and with due individualization reduced to 2 or 
 3 pints daily. Alcohol should be forbidden, as it is a carbohydrate. 
 Beer contains not only 3 to 5 per cent, of alcohol, but sometimes 
 double this percentage of soluble starch and dextrine. 
 
 (c) Active and graduated exercise is indispensable, except in 
 marked cardiac disease. It should be regular, induce sweating and 
 bring all muscles into play, but should not cause exhaustion. Passive 
 movements (v. Fatty Heart, Myocarditis and Dilatation), and 
 massage are indicated when active exercise is contra-indicated. 
 
 (d) The patient should sleep not more than seven hours and should 
 bathe daily to avoid skin complications and to promote perspiration. 
 Thyroid extract is not to be taken, except perhaps under special indi- 
 cations, for it breaks down the albumins rather than the fats, often 
 excites the heart, sometimes induces glycosuria and is wholly super- 
 fluous (with proper dietetics and exercise). 
 
 ADIPOSIS DOLOROSA OR DERCUM'S DISEASE. 
 
 This dystrophy was described by Dercum (1892), as a " disorder 
 characterized by unequal symmetrical deposits of fatty masses in 
 various parts of the body, preceded or attended by pain." There 
 were only 47 reported cases up to 1907, most of which were females. 
 It usually develops in middle life, chiefly after the fortieth year, 
 though the author has a case under treatment, aged thirty-five years. 
 
 Pathology. — Its pathology is not yet developed, as but five autopsies 
 have been made (1903). In the cases of Dercum and Burr an inter- 
 stitial neuritis was found, which is likewise noted in the fatty tumors 
 which have been removed during life. It is interesting to note that 
 symmetrical lipomatosis has been observed in multiple neuritis. In 
 Dercum's and Burr's cases the thyroid gland was atrophied. Adeno- 
 carcinoma and gliosis of the hypophysis have been reported. 
 
ADIPOSIS DOLOBOSA. 897 
 
 Symptoms. — Two cardinal clinical features are observed, as the 
 term adiposis dolorosa indicates; (1) the obesity is either diffuse or 
 may be localized fatty tumors or sometimes both in combination; 
 lipomata occur on the trunk and proximal parts of the extremities, 
 but never on the face, forearms, hands, legs or feet. Indeed the thin- 
 ness of the wrists and legs contrasts sharply with the massive body, 
 thighs and upper arms. The fatty tumors range from the size of a 
 pea to large dimensions. The pendulous abdominal fat may hang 
 down like an apron. In one of the author's cases the localized abdom- 
 inal fat was disposed in the shape of a circular life-buoy, sagging 
 down over the thighs. In another it almost resembled oedema or 
 myxosdema, save for its circumscribed distribution and facial ex- 
 emption. 
 
 2. The pains may be neuralgic or paresthetic. The trunk is often 
 tender. 
 
 Subcutaneous hemorrhages, hsematemesis, epistaxis and metror- 
 rhagia are not uncommon. The patients are often nervous, perhaps 
 hysterical. Asthenia is common and subjects often lack initiative 
 and readily tire on exertion. In the later stages epilepsy has devel- 
 oped and death from asthenia, psychosis, nephritis or intercurrent 
 affections is recorded. A number of cases, including one of the au- 
 thor, have improved under administration of thyroid extract. 
 
 57 
 
SECTION IX. 
 DISEASES OF THE NERVOUS SYSTEM, 
 
 DISEASES OF THE BRAIN. 
 
 CEREBRAL LOCALIZATION. 
 
 The anatomy and physiology of the brain are most important in 
 topical diagnosis. Autopsy findings in carefully studied cases, animal 
 experimentation' and the Constantly increasing surgical intervention 
 have developed not merely the nature of lesions, but also important 
 results regarding their localization. The old doctrine of Flourens 
 that all parts of the brain were equally important met its first contra- 
 diction in Broca's discovery (1861) that motor aphasia was due to 
 disease of the third left frontal convolution. In 1870 Fritsch and 
 Hitzig discovered that stimulation of certain, areas, now known as 
 the motor cortex, invariably resulted in contraction of definite muscles 
 of the opposite side of the body. Since then Bevor, Horsley, Meynert, 
 Jackson, Flechsig, Ferrier, Munk, Glotz, Nothnagel, " Charcot, Wer- 
 nicke and others have contributed to the development of brain locali- 
 zation, although much still remains unclear and tentative. 
 
 I. The Motor Cortex. — This embraces chiefly the central convolu- 
 tions on either side of the fissure of Rolando (the ascending frontal 
 and ascending parietal lobes and anterior two-thirds of the superior 
 parietal lobe), the foot of the three frontal convolutions, especially 
 the lower, and on the inner surface of the hemisphere, the paracentral 
 lobule. In this area lie the large pyramidal cells which Betz dis- 
 covered were the origin of the motor or pyramidal tracts. The cen- 
 tres are not sharply marked, but run somewhat into adjacent areas, 
 especially those with physiological associations. The leg centre occu- 
 pies the upper quarter of the ascending frontal and ascending parietal 
 convolutions and part of the superior parietal lobe (all adjacent to 
 the longitudinal fissure) and passes over to the inner aspect of the 
 hemisphere to the paracentral lobule, which is the centre for the 
 thigh, pelvis and gluteal muscles (Fig. 51). A lesion in the falx 
 cerebri, or dura near the longitudinal fissure, may, in rare cases, 
 involve both paracentral leg centres and produce cerebral paraplegia, 
 although most paraplegias are spinal in origin. The arm centre is 
 the largest, covers the middle two quarters of the central convolutions, 
 lies below and probably somewhat overlaps the leg centre. In Fig. 
 52 it is seen that there are certain general as well as separate centres 
 
 899 
 
900 
 
 DISEASES OF THE NERVOUS SYSTEM. 
 
 for the thumb and fingers. The head centre is below that of the arm, 
 covering the lowest quarter of the central convolutions (i. e., the 
 entire operculum), the upper part of the Sylvian fissure and the pos- 
 terior part of the lowest frontal convolution (and possibly the first 
 and second frontal gyri). The face centre lies directly beneath the 
 arm centre, and is mostly located on the anterior ascending convolu- 
 tion, the upper facial component lying higher than the lower facial 
 centres. The eye centre of the facial is bilateral and probably con- 
 
 FiG. 50. 
 
 General distribution of centres in cerebral localization ; outer surface of brain. 
 
 sists of several foci. The mouth apparently has several centres. The 
 motor speech area is principally in the lower left frontal gyrus and 
 is probably the chief centre for chewing. The trunk centre is less 
 clearly defined; it probably lies in the posterior part of the first 
 frontal convolution and also on its median aspect, just anterior to 
 the paracentral lobule. The more complicated the function, the 
 larger is the centre (as for the tongue, fingers, mouth) and the more 
 unilateral the localization in the brain. Muscles used rhythmically 
 or in pairs are supplied to some extent from both hemispheres, as the 
 muscles of the forehead and of respiration, swallowing, chewing, vocal 
 cords and to some degree of the legs and trunk. Protrusion of the 
 tongue to one side has a monolateral centre, though its protrusion in 
 the median line and its withdrawal depend on both hemispheres. 
 
 Total lasting hemiplegia of the opposite side of the body, with 
 sensory disturbance, aphasia and intellectual disturbance, results 
 
CEBEBRAL LOCALIZATION. 
 
 901 
 
 from complete destruction of the entire motor cortex of one side. 
 Cortical hemiplegia is less common than monoplegia, which results 
 from partial cortical foci. Monoplegia (paralysis of one member, 
 
 Fig. 51. 
 
 Cerebral localization ; inner surface of hemisphere. 
 
 as of the arm alone) always suggests a cortical lesion. The paralyzed 
 limbs are flaccid and later undergo contractures. Pure monoplegias 
 of cortical origin are rare, although the arm or leg may be paralyzed 
 alone from a small softening, hemorrhage, cyst or tumor, or from trau- 
 matism. Crural (leg) monoplegia is rare (few instances being re- 
 ported by French writers) and is due largely to vascular lesions in 
 the paracentral lobule (anterior cerebral artery). Some sensory 
 disturbance may be noted. Pure brachial (arm) monoplegia may 
 result from vascular lesions, small tumors or trauma ; complex move- 
 ments, as writing, are most involved. The finest differentiation or 
 selection, as of the thumb alone, fingers or wrist, is noted in this 
 form. Sensory disturbance is common (v. i.). Pure facial mono- 
 plegia is unknown, although a faciolingual form with motor aphasia 
 is observed. Associated monoplegia is more usual. It consists most 
 commonly of paralysis or paresis (partial paralysis) of the arm and 
 face (brachiofacial monoplegia, passing under this name, although 
 strictly not a monoplegia). Next in frequency is the arm-and-leg 
 type (brachiocrural) in which two contiguous centres are involved. 
 A leg-and-face type never occurs, because their centres lie too far 
 apart. A lesion involving one cortical area after another speaks for 
 cortical localization. Cortical paralyses are not attended by the 
 reaction of degeneration. In cortical lesions with paralysis, twitch- 
 ings or convulsive movements are common and, from their resem- 
 blance to epileptic convulsions, are called " cortical, partial or 
 
902 
 
 DISEASES OF THE NEBVOUS SYSTEM. 
 
 Jacksonian epilepsy" ; 50 per cent, of cases are small cortical tumors 
 or cjsts; the lesion partly destroys the motor cortex (paralysis) and 
 at the same time causes irritation (convulsions) precisely as contrac- 
 tions are produced in animals by electrical stimulation of the cortex ; 
 they are mainly (a) mechanical, as irritation or increased intra- 
 cranial tension (rapidly growing tumors), or (b) due to a vascular 
 affection (hemorrhage, embolism or inflammation). Stationary le- 
 sions rarely produce Jacksonian epilepsy unless they are located in 
 the cortex. The spasms may involve but one part, as the arm {mono- 
 spasm), which is exclusively a sign of cortical irritation, or they may 
 pass from one centre to others. They always commence in one centre 
 locally and extend in a fixed order. If the arm-region is the seat of 
 
 Fig. 52. 
 
 HEAD TO OPPOSITE SIDE 
 
 HEAD AND EYES TO 
 OPPOSITE SIDES 
 
 TO MID LINE 
 CHEWI 
 
 ASSOCIATED 
 
 MOVEMENTS 
 OF EYES 
 
 FINGERSJVLONE 
 THUMB.ALONE 
 
 FISSURE OF ROLANDO 
 A' FISSURE OF SYLVIUS 
 
 ; Cerebral localization in detail. 
 
 Fi„F 2 , F 3 , first, second and third frontal convolutions. AF, ascending frontal con- 
 volution and AP, ascending parietal convolution. SP, supramarginal and AR, angular 
 convolution. 1? 2 , 3 , first, second and third occipital convolutions. T lt T 2 , T 3 , first, 
 second and third temporal convolutions. The explanation of line AA is' given under 
 INTERNAL CAPSULE. 
 
 a tumor the Jacksonian epilepsy flexes the fingers, moves the thumb, 
 then the forearm, arm and shoulder and then passes down the cortex 
 region (see Fig. 50 for leg, arm, face centres), so that it involves the 
 face, month and finally the leg. If the lesion is in the face area, the 
 various facial muscles contract and the eye deviates, then the next 
 area above the arm centre participates, and finally the higher leg 
 centre is implicated. That is, the spasm never skips from the face 
 
CEEEBBAL LOCALIZATION. 903 
 
 to the leg centre, but it involves the arm first. If the leg area is 
 involved, the spasms pass consecutively down to the arm and then to 
 the face, i. e., they never skip the arm, nor involve the face before the 
 arm is convulsed. 
 
 The spasms are often preceded by a tingling in the part, are mostly 
 clonic, or clonic broken by tonic spasms, and consciousness is very 
 often maintained. Unconsciousness may intervene when the fits 
 reach the other side of the body, when they are very frequent or 
 when the lesion is deep and below the cortex. The opposite side is in- 
 volved through the commissural fibers of the corpus callosum; " bilat- 
 eral representation in both hemispheres, which saves certain groups 
 of muscles in hemiplegia, necessitates their involvement in severe 
 spasms" (Gowers). Jacksonian differs from regular epilepsy in that 
 no cry is observed, the commencement is local and more gradual and 
 consciousness, if lost, disappears gradually, not precipitately. The 
 convulsions may precede or accompany the paralysis. The seizure 
 lasts several seconds to a minute or two and is followed by some 
 vertigo, nausea, stupor or disturbance of speech; if spasms occur 
 without paralysis, paresis in the involved parts follows, due to tran- 
 sient exhaustion of the cortex. Jacksonian epilepsy in its lightest 
 forms may be sensory. 
 
 Regarding sensory localization in the cortex opinions vary and our 
 knowledge is far less exact. Munk' holds that the sensory and motor 
 areas are the same, while Charcot, Nothnagel and Ferrier hold that 
 the sensory areas are separate (v. i.). Some vasomotor disturbance 
 is common in cortical lesions, and Landois and Eulenberg have dem- 
 onstrated a vasomotor centre here. 
 
 Sequences of disease in the motor centres depend on the nature and 
 extent of the lesion. After total lesions of the central convolutions, 
 the hands improve very little in adults; other members improve, to 
 some extent at least, through assumption of function by the sound 
 side of the brain; in young individuals the sound pyramidal tracts 
 in the cord may hypertrophy to even double their original size. The 
 motor fibers running from the pyramidal cells of the cortex to the 
 anterior horns of the spinal cord, constituting the upper motor 
 neuron, undergo descending degeneration, that is, degeneration in 
 the direction of the motor impulse. 
 
 II. Cortex of the Parietal Lobes. — Our knowledge of the func- 
 tion of this cortex is less definite, (a) Lesions of the first lobe (Pj 
 Fig. 52, the precuneus in Fig. 51), supplied by the anterior cerebral 
 artery, cause disturbance in motility of the leg, with altered muscle 
 sense, "mind blindness," inability to read (alexia) and, according 
 to some authorities, hemianopsia, (b) Disease of the supramarginal 
 convolution (S.P. Fig. 52), also involving the motor cortex, produces 
 greater disturbance of sensation than when the lesion is confined to 
 the motor centres; muscular sense is disturbed, usually with some 
 motor paralysis or paresis. Three cases are reported of disturbance 
 of muscle sense without paresis. Muscle sense is disturbed in 23 per 
 
904 DISEASES OF THE NEBFOUS SYSTEM. 
 
 cent, of all cases of cerebral hemiplegia, though in more than 50 per 
 cent, of cerebral paralyses, no special sensory disturbance is noted. 
 Disturbance in muscle sense indicates that a cerebral lesion is 
 probably located in the cortex, if indirect pressure can be excluded. 
 There may be loss of the stereognostic sense, whereby the patient fails, 
 when his eyes are closed, to recognize the geometric form of solid ob- 
 jects, as a key or ball. Cortical incoordination (ataxia) sometimes 
 results, probably on account of disturbance in the association fibers. 
 It differs from the tabetic and cerebellar ataxias in that the muscu- 
 lar strength is usually diminished and the finer movements are 
 impossible, though the coarser movements may sometimes be car- 
 ried out. Cortical hemianesthesia is not frequent. (c) Ptosis 
 and paralysis of the orbicularis palpebrarum are said to result from 
 lesions of the gyrus angularis (A.R. Fig. 52) and, according to Mona- 
 kow, inability to read (alexia), optic aphasia and " mind blindness." 
 Wernicke correctly diagnosticated softening in this lobe by conju- 
 gate deviation of the eyes and head as the only symptom. Disease 
 of the posterior inferior part probably causes crossed amblyopia. 
 
 III. The Cortex of the Occipital Lobes. — This is undoubtedly the 
 visual centre. Its exact seat is somewhat disputed, but the weight 
 of evidence shows that it is in the cuneus (Fig. 52) and the first 
 occipital lobe. A lesion of the occipital cortex produces (a) bilateral 
 homonymous hemiopia (hemianopsia) (for details of which and 
 the following see Affectioxs of the Optic ^ t eeve). (&) Hemi- 
 chromatopsia, an homonymous color blindness, especially for green 
 and red, in which the color perceptions are confused rather than lost ; 
 the lesion in such cases is superficial and anterior; (c) total cortical 
 blindness, if the lesion is bilateral, or both optic radiations are de- 
 stroyed, (d) "Mind blindness" results from a lesion in the anterior 
 outer surface of the left occipital region, especially the second occipi- 
 tal lobe or from disease of the gyrus angularis. The visual memory 
 is lost; things actually seen are misinterpreted and the patient con- 
 fuses persons and things, (e) Alexia, inability to read, also called 
 "word blindness," wherein the patient can read but fails to under- 
 stand the letters or words he sees and reads. His memory for words 
 is lost. It is due to destruction of the subcortical association fibers 
 in the second occipital lobe (von ITonakow) and the gyrus angularis; 
 it most commonly follows vascular disease. (/) Optic aphasia re- 
 sults from foci in the left occipital lobes (and also in the angular and 
 supramarginal convolutions) and consists of misinterpretation of 
 visual impressions, so that the patient miswrites and misnames ob- 
 jects seen, though able to name them when he feels them. (g) 
 Crossed amblyopia sometimes occurs. 
 
 IV. The Cortex of the Temporal Lobes (T„ T 2 , T„ Fig. 52).— 
 The outer surface of the posterior half of the first (and second) tem- 
 poral convolution is the auditory centre; it is said to be larger on the 
 left side; disease in this cortex produces (a) deafness in the opposite 
 ear ; atrophy of this lobe is encountered in congenital deafness. Deaf- 
 
CEBEBBAL LOCALIZATION. 905 
 
 ness is usually transitory, because fibers seemingly pass to both ears 
 from each centre. If this lobe is destroyed on both sides, total deaf- 
 ness results, (b) Conjugate deviation of the eyes has been observed 
 and is said to be a reflex from auditory impressions, (c) Disease of 
 the first temporal lobe produces "word deafness/' also known as 
 " mind deafness " ; it is a loss of the comprehension of speech. Some- 
 what in front of this lobe it is supposed that musical memories are 
 stored. In the uncinate gyrus (Fig. 51) the special sense of smell 
 probably has its centre. Ferrier refers the general sensory centre to 
 this lobe. The gyrus fornicatus (Fig. 51) is said to be the centre for 
 taste and possibly for the sense of pain. 
 
 V. The Frontal Cortex and Aphasia. — Regarding the frontal lobes 
 anterior to their participation in the motor cortex we have little defi- 
 nite knowledge. Profound disease may develop without clinical 
 symptoms. They have long been thought to be the residence of (a) 
 the psychical functions, especially for ethical and abstract thought 
 (Meynert and Flechsig). " Defect in character" followed the pas- 
 sage of a large crowbar, 1% inches thick and 3% feet long, through 
 both frontal hemispheres, in the famous crowbar case of Harlow. 
 Psychical functions probably concern the frontal lobes, although the 
 relative integrity of the entire brain is necessary for them, (b) 
 Flechsig considers the frontal lobe the anterior association centre, 
 the middle one, being the cortex of the island of Reil and the posterior 
 one the large area posterior to the motor cortex, (c) Bruns has ob- 
 served ataxia similar to the cerebellar type, but this probably results 
 either from pressure transmitted to the cerebellum or from involve- 
 ment of the trunk centre, (d) The motor speech area lies in the lower 
 frontal convolution. Its function and relations can be well con- 
 sidered in connection with motor and other varieties of aphasia. The 
 history of aphasia marks the beginning of cerebral localization and 
 three French writers have determined its motor centre. Bouillaud ; 
 in 1825, referred aphasia to the frontal lobes; Dax, in 1836, nar- 
 rowed the localization to the left frontal region and the motor centre 
 was finally confined to the posterior part of the lower left frontal 
 convolution in 1861 by Broca, whose name is given to this convolu- 
 tion. The sensory element, necessary to all voluntary movements, 
 was unknown until later, when Meynert and Wernicke discovered 
 the auditory centre in the first temporal convolution ; Wernicke local- 
 ized "word deafness" in the same convolution of the left side and 
 Naunyn and others emphasized the importance of the gyrus angu- 
 laris and adjacent parts of the occipital lobes in cases of disturbance 
 of writing, visual aphasia, etc. 
 
 Motor Aphasia. — The motor speech centre lies in Broca's lobe, the 
 posterior part of the left third frontal convolution; it controls the 
 motor centres next described and retains the impressions or memories 
 necessary to their exercise. The corresponding lobe on the right side 
 is the actual centre in left-handed persons and often assumes the 
 functions of the left speech centres after disease of the latter, espe- 
 
906 DISEASES OF THE NERVOUS SYSTEM. 
 
 cially in children. Articulate speech depends upon the integrity of 
 the lower part of the ascending frontal convolution, in which lie the 
 centres for the mouth, lips, tongue, jaw and larynx, (a) These con- 
 stitute the cerebral mechanism of speech, whose disturbance is desig- 
 nated motor aphasia. Motor fibers run from the cortex through the 
 centrum ovale, internal capsule (lying in front of the pyramidal 
 tracts), crus (inside the pyramidal tracts) to their nuclei in the pous 
 and medulla, whence the peripheral bulbar nerves to the tongue and 
 larynx take their origin, (b) These lower tracts constitute the bulbar 
 mechanism of speech, disease in the components of which causes 
 abolition of articulation (anarthria) or more often imperfect articula- 
 tion (dysarthria). The elements of speech are correct in dysarthria, 
 but articulation is imperfect, the labials, palatals or Unguals being 
 imperfectly delivered or consonants run together. To speak, the 
 individual must have ideas, conceptions. To illustrate, a cortical 
 lesion in Broca's convolution, as small as a hazel-nut, may produce 
 motor aphasia, either absolute or partial ; the patient may pronounce 
 correctly some few words, possibly only under emotion or in certain 
 relations, or he may pronounce words wrongly, although he recog- 
 nizes his mistake. He comprehends what is said to him, for the 
 lesion involves no special sense element. He can read writing and 
 print, especially if educated, because " sight may stimulate images 
 without intervention of the motor centre, " but he cannot speak volun- 
 tarily nor repeat what is said to him ; he cannot read aloud ; as a rule 
 he cannot write (agraphia), because impulses cannot pass to the hand 
 centre. He may be able to copy (v. i. Table). The cortical is the 
 usual form of motor aphasia. 
 
 A subcortical lesion in the centrum ovale may sever the fibers be- 
 tween Broca's convolution and the motor cortex for the tongue, lips, 
 etc. The patient cannot speak, but the speech centre is normal. It 
 is a rare lesion, known as pure motor aphasia (Lichtheim). The 
 patient can write. It involves the commissural fibers of the corpus 
 callosum to the right side and usually produces permanent aphasia, 
 because the possibility of compensation by the right hemisphere is 
 precluded ; if the lesion is in the internal capsule the aphasia is tran- 
 sient, since compensation through the corpus callosum is established. 
 
 Sensory Aphasia. — In speech, as in every voluntary motion, sensa- 
 tion and sensory memories are necessary. The sensory relations of 
 speech are hearing, sight, taste and, in the blind, touch. 
 
 Auditory Aphasia. — Hearing is most important and develops in the 
 child long before speech. When a child begins to talk, or when one 
 who has lost speech relearns it, the brain cortex, through an associa- 
 tion of centres, learns to connect certain sounds or words with definite 
 objects or conditions. The child hears through the auditory nerves 
 which run from each side to both auditory centres in the first temporal 
 convolution of either side. He hears mechanically, just as we may 
 hear without understanding a foreign language, and learns to associ- 
 ate the sounds with objects, conditions or ideas, for which an auditory 
 
CEBEBBAL LOCALIZATION. 907 
 
 speech centre in the left first temporal convolution (in right-handed 
 persons) is developed. Here sounds coming from the two centres of 
 hearing are remembered, associated and controlled. Eemembering a 
 sound he has heard but perhaps has never spoken, the child calls into 
 play Broca's convolution, the cortical centres for the lips, tongue, etc., 
 and speaks. Hearing is necessary to articulate speech, unless, as in 
 deaf mutes, education replaces, by sight and touch, the associations 
 usually acquired by hearing. Destruction of the auditory speech 
 centre profoundly disturbs speech. The patient then hears by the 
 auditory nerves and centres or reads by the visual apparatus, but does 
 not understand what he hears or reads; this is kndwn as sensory 
 (auditory) aphasia or word deafness. It is rarely absolute and re- 
 covery is more jCommon than in motor aphasia. The subject in 
 speaking transposes words (paraphasia) but does not realize his 
 mistakes, an important distinction from motor aphasia. Often he 
 later becomes speechless. He cannot repeat words nor write from 
 dictation. Voluntary revival of words is lost (Gowers). Voluntary 
 writing is impossible, but copying of words is sometimes maintained. 
 
 Subcortical auditory aphasia or pure word deafness (the rarer 
 form), results from disease between the auditory speech centres and 
 the two centres for hearing. It must therefore be below the cortex 
 in the white matter, hence called subcortical. Auditory impressions 
 cannot reach the auditory speech centres of the patient, who cannot 
 understand what is said, cannot repeat or write from dictation. As 
 the auditory speech centre is normal, memory for words is retained 
 and the patient can read, speak and write. 
 
 "Amnestic" aphasia may be a simple difficulty in recalling certain 
 words in speaking or writing, or it may be very pronounced (word 
 deafness). It is also poorly called conduction aphasia (Wernicke) 
 and is due to interruption, probably in the island of Reil, of the fibers 
 between the motor and sensory speech centres. Gowers states that it 
 may result from partial recovery from motor or sensory aphasia. 
 
 Visual Aphasia. — Sight is very important in sensory speech. The 
 child who has learned sounds (words) and is able to speak them, 
 reads by associating the sounds heard and spoken, with words, letters 
 or symbols seen by him. Memory of these visual concepts is stored in 
 the supramarginal and angular gyri. Reading music, etc., is learned 
 in the same way. While in most individuals mental processes are 
 carried on by the memory of words, in rare instances visual memory 
 may be more important. Destruction of the angular and supra- 
 marginal convolutions by causing a loss of the visual memories pro- 
 duces alexia, word blindness, an inability to read. In some cases the 
 patient can read, but without understanding. Isolated alexia is al- 
 ways due to lesions in these convolutions. He usually cannot write 
 (agraphia) and cannot copy, but can speak fairly well and under- 
 stand what is spoken. If the optic centre in the occipital lobes is 
 intact he cannot name objects after seeing them, since the visual mem- 
 ory centre is destroyed, but may recognize a watch by hearing it tick or 
 
908 
 
 DISEASES OF THE NEBVOUS SYSTEM. 
 
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CEBEBBAL LOCALIZATION. 909 
 
 by feeling it. Lesions just below the visual memory centre, involving 
 the afferent fibers, produce pure subcortical word blindness, or alexia, 
 that is, inability to read, with hemianopsia and preservation of volun- 
 tary speech and writing. Word deafness and word blindness often 
 co-exist. Sixteen cases of congenital word blindness were collected 
 by Stephanson (1904). 
 
 Pure motor and sensory aphasias are less common than complicated 
 forms. The diagrams employed to illustrate the mechanism of apha- 
 sia are hypothetical. The anatomical lesions, mostly arterial, are 
 largely the result of softening, the entire sphere of speech being sup- 
 plied by the artery of the fossa of- Sylvius. Motor aphasia is likely 
 to occur with disease of the motor cortex or cerebral pyramidal tracts, 
 and the sensory form with disease of the optic fibers. Apoplexy, 
 trauma and in children tuberculosis of the brain or meninges are also 
 causative. Lasting aphasia in children is usually due to mental 
 causes, since in early life the right frontal area usually takes up the 
 function of Broca's convolution. Congenital aphasia may follow 
 bilateral meningeal hemorrhage. Aphasia also occurs in idiocy in 
 adults, in melancholia, migraine, convulsions and is especially apt to 
 occur from functional causes in children, as from fever, fright, worms, 
 etc. In adults the outlook is less favorable than in children. Partial 
 recovery is possible in cases of hemiplegia and sometimes with care, 
 reeducation may yield fair results. The table on page 908 is bor- 
 rowed from Church's excellent work on Nervous Diseases. 
 
 VI. Centrum Ovale. — Focal symptoms may be entirely absent, if a 
 lesion occur between the associative, commissural, motor or sensory 
 fibers (corona radiata). When present, symptoms are usually those 
 of (a) a cortical, or (b) an internal capsule lesion. A lesion must be 
 (a) very near the cortex to produce either Jacksonian or general con- 
 vulsions. A monoplegia, hemianopsia and subcortical aphasia may 
 occur in this location. Aphasia from a lesion in the island of Reil 
 may produce conduction aphasia. Psychical symptoms may result 
 from interruption of the association fibers which run from one part 
 to another of the same hemisphere. (Commissural fibers are those 
 running from one hemisphere to the other, as through the corpus 
 callosum, disease of which presents no pathognomonic sign.) (b) 
 Internal capsule symptoms result in lesions low in the centrum ovale. 
 
 VII. The Internal Capsule. — It is compacted and consists of nearly 
 all the motor, sensory and special sense fibers from the brain to the 
 lower parts. The capsule is divided into an anterior limb, the knee 
 and a posterior limb. 
 
 Anterior Limb. — Its function is not clear, although it contains fibers 
 from the frontal cortex to the optic thalamus and fibers which, in 
 lower horizontal sections, run into the knee and are found in the basal 
 median bundle of the crus, whence they run to the pons nuclei for 
 the eye, head, neck and probably also for the larynx, tongue and 
 mouth. Lesions here are very rare. 
 
 JCnee, — The knee (see Pig. 53) contains from before backward 
 
910 
 
 DISEASES OF THE NEBVOUS SYSTEM. 
 
 fibers for opening of the eyes, associated movements of the eyes and 
 head, the fongue and mouth; Horsley and Beevor have been able to 
 stimulate them electrically, one by one. This segment contains the 
 phonation fibers for speech, probably including those of the larynx. 
 
 Posterior Limb. — The posterior limb contains in its anterior third 
 the fibers for the shoulder, elbow, wrist, fingers, thumb and body ; in 
 its middle third those for the hip, ankle, knee and toes ; in its posterior 
 third (Charcot's "sensory crossway"), those for sensation and the 
 special senses. The number of fibers to a part depends less on the 
 size of a muscle than on its development in fineness of movement ; for 
 instance, the fingers receive a relatively large number of fibers. If a 
 ruler be placed anterior to the line (AA) in Fig. 52 and slowly moved 
 to the right, preserving its parallelism, the cortical motor areas 
 touched will approximately correspond with their order in the in- 
 ternal capsule. The most common sequence of lesions of the internal 
 capsule is cerebral hemiplegia of the opposite side of the body. 
 Though hemiplegia may result from lesions elsewhere in the motor 
 tract, in the vast majority of cases, hemiplegia is the result of dis- 
 
 Fig. 53. 
 
 Localization in internal capsule. 
 
 ease of the internal capsule. If the internal capsule is destroyed, total 
 hemiplegia results, paralysis of the arm, leg and lower part of the 
 face (the upper part of which and the head escape because they have 
 a bilateral supply from both hemispheres). The hypoglossus is but 
 moderately involved and aphasia is usually temporary. With the 
 hemiplegia are also associated hemianesthesia, hemianopsia and uni- 
 lateral disturbance of smell, taste and hearing, by lesion of the fibers 
 ascending from the tegmentum; with the hemiplegia are observed 
 
CEREBRAL LOCALIZATION. 911 
 
 contractures, descending degeneration, decrease or absence of the skin 
 reflexes, especially the cremasteric, and increase of the tendon re- 
 flexes. Monoplegia is rare, because the tracts are so compact that the 
 face, for example, is rarely alone involved, though Duplay and Diday 
 record isolated cases. It is possible that a linear lesion may involve 
 the outer part of the capsule's knee, that is, it may involve the face 
 and also the leg, leaving the arm free (Wernicke, Charcot, Kolisko). 
 Hemianesthesia (skin sensation and muscle sense) rarely exists with- 
 out some paresis of the leg. Some tingling or, in incomplete lesions ; 
 some pain may result, even when the leg-arm areas are alone involved, 
 for some sensory fibers course with the motor fibers. Hemi-tremor, 
 -athetosis and -chorea result from lesions of the sensory area, usually 
 associated with disease in or just below the optic thalamus. (The 
 course of the sensory paths will be considered under Localization 
 in the Spinal Coed.) Back of the general sensory tracts disease 
 may injure the optic radiation (running between the occipital sight 
 centre and the lateral geniculate body) or interrupt the auditory and 
 other special sense fibers. Psychical disturbance, aphasia, alexia, 
 agraphia and involvement of any cranial nerve are not symptomatic 
 of disease of the internal capsule. 
 
 VIII. The Corpus Striatum. — This is composed of the caudate and 
 lenticular nuclei. It is doubtful whether it is connected with the 
 cortex. The lenticular nucleus is extensively connected with the 
 superior peduncle of the cerebellum and the tegmentum of the crus. 
 The caudate nucleus is connected with the internal capsule and with 
 the crus; these fibers seem to end in the pons and cerebellum. An 
 apoplexy in the corpus striatum probably causes rise of temperature ; 
 Nothnagel's law still holds that hemiplegia is permanent only when 
 the internal capsule is directly injured, although indirect transient 
 hemiplegia from simple pressure on the capsule may result from 
 disease of the corpus striatum Landouzy reports a case of contra- 
 lateral hemiathetosis from isolated disease of the lenticular nucleus. 
 
 IX. The Optic Thalamus. — This is surrounded by gray matter, 
 continuous with that surrounding the third ventricle and central 
 canal of the cord and is connected by fibers with all parts of the 
 cerebral cortex, the tegmentum and superior cerebellar peduncle. 
 JSTothnagel (1879) was the first to describe its topical symptoma- 
 tology. Sometimes disease in this locality is latent; again, the 
 following findings are observed, alone or in combination: (a) 
 Contralateral hemianopsia may develop from a lesion in the pos- 
 terior part of the thalamus, the pulvinar (Gowers) or a lesion 
 which also invades the lateral geniculate bodies (von Monakow). 
 These areas are connected by the optic radiation with the optic centre. 
 This hemianopsia is distinguished from that caused by a cortical 
 lesion by the hemianopsic pupillary reaction and the absence of the 
 marginal field of vision. (&) Disturbance of the mimetic movements 
 of expression may develop (Nothnagel, Bechterew). The optic thala- 
 mus is the reflex centre of the involuntary movements of expression, 
 
912 DISEASES OF THE NERVOUS SYSTEM. 
 
 as weeping or laughing. A patient with hemiplegia from destruction 
 of the left internal capsule cannot voluntarily move the lower right 
 part of the face, but the paralyzed portion of the face moves when 
 the patient laughs, for the centre is in the posterior part of the 
 thalamus. On the other hand, in isolated disease of the optic thala- 
 mus the opposite side — indeed both sides of the face — can be volun- 
 tarily moved, since the facial nerve runs in the internal capsule, but 
 the patient cannot laugh or weep, (c) Sensory disturbances may 
 occur, such as hemi anaesthesia, hemichorea, hemitremor, pain in the 
 opposite arm (Edinger) or hemiataxia, but it is not absolutely certain 
 in these cases that the sensory portion of the internal capsule was not 
 involved. There may be vasomotor changes, atrophy and disturbance 
 in the evacuation of the bladder and rectum. Yon Monakow thinks 
 that all the symptoms referred to the thalamus are probably referable 
 to disease exterior to it. 
 
 X. The Corpora Quadrigemina. — These are masses of gray matter 
 whose fibers lie over the aqueduct of Sylvius and the tegmentum. 
 There is a variance of opinion regarding their function. They are 
 connected with the third nerve nucleus and some hold that they con- 
 tain the centres for contraction of the heart and stomach. 
 
 Disease in the anterior corpora quadrigemina produces (a) mod- 
 erate involvement of sight; slight disturbance has a greater localizing 
 significance if there is no coincident optic neuritis. These bodies 
 are connected with the external geniculate bodies and, by way of the 
 internal capsule, with the optic radiation, (b) In acute lesions, 
 narrowing of the pupil is suggestive. In old lesions, one or 
 both pupils are wide and without reaction to light or accommoda- 
 tion, (c) The eye muscles may be partially paralyzed; this results in 
 ptosis and upward movements of the eyes ; these symptoms are not 
 positively indicative of this localization, because the lesion is always 
 so near the nucleus of the third nerve. Disease in the posterior cor- 
 pora quadrigemina may result (a) in ataxia, according to Nothnagel, 
 though others refer it to actual cerebellar disease, to connections with 
 the cerebellum through the nucleus ruber or to disease in the fillet 
 of the tegmentum; (b) in trochlearis paralysis, in which the eyes 
 cannot be turned inward or outward ; sometimes it results in abducens 
 paralysis; (c) in difficult mastication from involvement of the de- 
 scending branch of the quintus; (d) in contralateral disturbance of 
 hearing, since the posterior corpora quadrigemina are connected with 
 the fillet of the tegmentum and, by means of the " sensory crossway " 
 of the internal capsule, with the hearing centre in the first temporal 
 lobe. 
 
 XI. The Crus (Cerebral Peduncle). — Focal symptoms are motor 
 or sensory. The motor fibers to the cranial nerves decussate higher 
 than the pyramidal tracts which decussate in the medulla ; the fibers 
 to the third nerve cross in the upper crus, although some enter the 
 nucleus of the same side. Crossed paralysis (hemiplegia alternans 
 oculomotor ia superior) is common in crus lesions. It consists of a 
 
CEREBRAL LOCALIZATION. 
 
 913 
 
 hemiplegia of the side of the body opposite to the lesion and a 
 paralysis of the third nerve on the same side as the lesion, often known 
 as Weber's paralysis, though first described by Gendrin. From Fig. 
 54 it is seen that a lesion involving the right pyramidal fibers may 
 also catch those of the third nerve on the same side, giving a left- 
 
 Fig. 54. 
 
 Lesion in crus (shown by dotted lines), producing a superior alternating or crossed 
 hemiplegia; the lesion involves the pyramidal tract (FR), the cranial nerves (tongue 
 and face, CR) and the oculomotor nerve (III, F) which is paralyzed on the same side 
 as the lesion, while PR and CR are paralyzed on the opposite side. AS, Aqueduct of 
 Sylvius ; III, nucleus of third nerve : CGI, Corp. geniculatum int. ; F lf upper part and 
 F 2 , lower part of fillet ; NR, nucleus ruber ; SN, substantia nigra. 
 
 sided hemiplegia (face, arm and leg) and right-sided oculomotor 
 paralysis, which is peripheral and usually complete, with strabismus, 
 ptosis, inability to look up or down and a wide reactionless pupil. 
 The crossed or alternating hemiplegia is called superior because in- 
 ferior alternating hemiplegia may occur in lesions of the pons. One 
 must be sure that one lesion only exists. In tumors near the internal 
 capsule which press on the third nerve, the same symptom complex 
 may occur, recognized by noting whether the hemiplegia and paralysis 
 of the third nerve occurred together (indicating a crus lesion) or 
 whether the third nerve paralysis followed the hemiplegia (indicating 
 a lesion near the internal capsule pressing secondarily on the oculo- 
 motorius). 
 
 A lesion in the tegmentum of the crus may cause (a) sensory dis- 
 turbance, as hemianesthesia, which involves skin sensation and 
 muscle sense, and of which over thirty cases are recorded; such a 
 lesion is in the fillet; hypsesthesia (reduced sensation) is more com- 
 (b) The special senses are sometimes involved, producing 
 
 mon. 
 
 hemianopsia or poor hearing in the opposite ear. (c) Ataxia 
 been seen alone (6 cases) or together with other symptoms. It 
 differs from the cerebellar type in that it is manifest only on motion. 
 
 58 
 
914 DISEASES OF THE NEEVOUS SYSTEM. 
 
 Involvement of the red nucleus (which is connected with the cere- 
 bellum or with its arm) produces cerebellar ataxia, (d) Oculomotor 
 paresis on the side of lesion is characteristic when combined with 
 crossed hemiataxia, hemiplegia or hemianesthesia. Fig. 54 shows 
 how a tegmental focus can rarely miss the diffuse nuclei of the third 
 nerve. If the lesion is in the lower part of the eras, the oculomotor 
 paralysis is usually complete, but if in the tegmentum it is always 
 partial, electing the pupil, the lid or the superior or internal rectus. 
 XII. The Pons. — Its structures are so closely arranged that some- 
 times both sides are implicated, thus producing bilateral hemiplegia, 
 though a small lesion, as a long thin tumor, may give no localizing 
 symptoms. Lesions of the pons (commonly tumors, hemorrhage, 
 softening or abscess) usually produce a typical picture. From a 
 lesion of the upper pons, i. e. } above the* facial nucleus, a hemiplegia 
 results like that produced by lesions of the internal capsule, which 
 affects the face, arm and leg, all on the same side of the body. (See 
 Fig. 55, focus A.) The facial paralysis is supranuclear, partial and 
 with no reaction of degeneration. In a focus in the lower pons (focus 
 B, Fig. 55), where the facial fibers have already crossed, the tongue, 
 arm and leg are hemiplegic on the side opposite to the focus and the 
 facial paralysis is on the side of the lesion ; this crossed or alternating 
 paralysis (hemiplegia alternans facialis) was first described by 
 Millard (1856) and Gubler (1859). The facial paralysis is periph- 
 eral and nuclear, involves all branches and gives the reaction of de- 
 generation. Sometimes there is also some slight paralysis of the 
 face on the hemiplegic side from involvement of some fibers from the 
 cortex. Other alternating paralyses are also observed, as hemiplegia 
 with crossed paralysis of the third, fourth, fifth and sixth nerves, the 
 paralysis of which is usually both central (nuclear) and peripheral. 
 Hemiplegia may occur with conjugate paralysis or paresis of the 
 lateral eye muscles, as the external rectus (abducens nerve) of one 
 side, and the internal rectus (third nerve) of the other, due to a lesion 
 just in front of the abducens centre, involving its fibers, or sometimes 
 also including its nucleus. In the conjugate paralysis, the antagonist 
 muscles pull the eyes to the other side and the eyes look away from 
 the side of the lesion toward the paralyzed side. This is not to be 
 confused with the " forced position" of the eyes due to irritation, 
 known as conjugate deviation, in which the eyes look to the sound 
 side of the body. In this form even the paralyzed internal rectus 
 will functionate and converge when one eye is tested at a time. In 
 some cases both internal recti and one abducens may be paralyzed, 
 resulting in fixture of the eye in the median position ; accommodation 
 and convergence are preserved. Involvement of the motor branch of 
 the fifth nerve produces difficult mastication. While alternating 
 paralysis is the usual pons lesion, sometimes double hemiplegia oc- 
 curs, or again, involvement of the third to seventh cranial nerves 
 without hemiplegia. The auditory nerve is rarely involved, save in 
 acute or very extensive lesions affecting the lateral lemniscus. Im- 
 
CEEEBKAL LOCALIZATION. 
 
 915 
 
 plication of the cortical fibers of the hypoglossus produces impaired 
 movement of the tongue (dysarthria), nasal speech and poor enun- 
 ciation of consonants, though the vocal cords are normal. Dysarthria 
 and dysphagia, due to disease of the cortical motor paths of the hypo- 
 glossus and vagus, are less common in lesions of the pons than are 
 affections of their nuclei in diseases of the medulla oblongata. Ataxia 
 may result from involvement of the fillet and possibly of the longi- 
 tudinal bundle of the formatio reticularis and produces incoordina- 
 
 Fig. 55. 
 
 DECUSSATION OF PYRAM 
 
 B 
 
 A illustrates a lesion in the upper pons, producing the usual hemiplegia (face, arm 
 and leg paralyzed on the opposite side). B illastrates a lesion in the lower pons, pro- 
 ducing alternating paralysis; all branches of the face (peripheral paralysis) and tongue 
 on the side of lesion are paralyzed with paralysis of the contralateral arm and leg. 
 
 tion on voluntary movement only. An alternating sensory paralysis 
 may occur, as (a) hemianesthesia involving the muscle sense and 
 cutaneous sensation of the extremities opposite the lesion, caused by 
 disease of the tegmentum, and (&) an anaesthesia of the fifth nerve on 
 the side of the lesion. Irritative symptoms sometimes develop, as 
 pain, paresthesia, painful convulsions, which usually occur in acute 
 cases and are peculiar in their involvement of both arms or both legs, 
 tonic and clonic spasms in the opposite arm and leg, contractures, 
 paroxysms of coughing and trismus. The patient may " look toward 
 the lesion" when the eye muscles are irritated. A tendency to fall 
 toward the side on which the lesion is located is indicative of disease 
 of the middle peduncle of the cerebellum. It is sometimes difficult 
 to decide whether the focus is located in the pons or in the medulla. 
 
916 DISEASES OF THE NEBVOUS SYSTEM. 
 
 Though the topical symptoms of the medulla oblongata are described 
 under its individual diseases, it may be stated that an alternating or 
 crossed paralysis, involving the third to seventh nerves inclusive, in- 
 dicates disease in the pons, and that aphonia, dysarthria and dys- 
 phagia are symptomatic of localization in the medulla, especially 
 when the hypoglossus is paralyzed, shows the reaction of degeneration 
 and produces atrophy of the tongue. Glycosuria, albuminuria, dis- 
 turbed respiration or heart action (by involvement of the vagus) and 
 vomiting are other bulbar symptoms. Disease in the medulla may 
 cause paralysis of both arms and legs or rarely of one arm and the 
 opposite leg (hemiplegia cruciata). 
 
 XIII. The Cerebellum. — Physiology. — The functions of this organ 
 are not fully known. Certain physiologists admit the possibility of 
 some psychical function. Its sensory relations are important, because 
 of its reception of numerous fibers from the spinal cord, including the 
 direct cerebellar tract and the posterior median column of Goll. 
 It is an " end organ'' (Luciani) for these tracts, through which and 
 its relations to the motor tract and the special senses, it is supposed 
 to coordinate and harmonize the movements of the body, to maintain 
 equilibrium, conserve muscular strength and inhibit the contralateral 
 cerebral motor cortex. In other words, it associates (a) the sensory 
 impressions ascending from the spinal cord with (b) those gained by 
 hearing (the auditory nerve having connections with the middle 
 cerebellar lobe) and (c) probably with those impressions resulting 
 from the eye movements. 
 
 General Pathology. — Disease of a lateral lobe affects the same side 
 of the body, but lesions of the middle (vermiform) lobe influence 
 both sides. Results of extirpation in animals vary somewhat and will 
 be considered only from their clinical aspect. Krauss found, in 100 
 cases of cerebellar disease, tumors in nearly 80 per cent., abscess in 
 10 per cent., cysts in 7 per cent, and softening and hemorrhage con- 
 stituted the balance. Agenesis, sclerosis and gliomatosis are also oc- 
 casionally found. Disease of one hemisphere, or indeed extensive 
 lesions of both hemispheres may be fully compensated by the cere- 
 brum. Acute disease of the cerebellum produces symptoms more 
 frequently than does chronic disease, in which latter the cerebellum 
 has opportunity for accommodative compensation. Rapidly growing 
 tumors, abscess and sometimes acute vascular disease often produce 
 the following symptoms, in part typical and in part secondary : 
 
 Typical Symptoms. — 1. Cerebellar ataxia is almost always present 
 and occurs when the patient stands ; equilibrium is disturbed and the 
 body sways (static ataxia). Ataxia also occurs when the patient 
 moves (dynamic ataxia) and concerns especially the trunk and legs. 
 The incoordination is due to disease of the middle lobe or vermis 
 and the consequent withdrawal from the cerebrum of the cerebellar 
 coordination. The gait is that of an inebriate {demarche d'ivresse) ; 
 the body sways and the individual stumbles a zig-zag course, some- 
 times toward the side of the lesion. The arm and hand movements 
 
CIBCULATOEY DISEASES OF THE BRAIN. 917 
 
 are usually normal. Ataxia may also result from lesions of the 
 nerves, spine or brain (cerebral cortex, internal capsule and prob- 
 ably tegmentum). In the ataxia resulting from other cerebral locali- 
 zation the incoordination affects the finer movements, is associated 
 with disturbed muscle and stereognostic sense and very often with 
 paresis. Bouillaud first described cerebellar ataxia and differenti- 
 ated it from the tabetic type. The essential differences are (a) that 
 in the cerebellar form the ataxia disappears when the patient is 
 lying down and (b) that closing the eyes does not increase it (indeed 
 it may often disappear). 
 
 2 Vertigo is very frequent and usually occurs rather when the 
 patient sits than when he lies down. He thinks that objects are turn- 
 ing around him or he may feel himself being turned. The vertigo is 
 either constant or paroxysmal and is due to lesion of the vestibular 
 nerve which connects the semilunar canals with the cerebellum by 
 means of the corpus restiforme. 
 
 Secondary Symptoms. — The following secondary symptoms are im- 
 portant but less significant than ataxia and vertigo: (a) Choked disk 
 is rarely absent in cerebellar tumors and amaurosis often results from 
 increased pressure on the third ventricle, leading to hydrocephalus 
 internus and then to pressure on the chiasm or optic nerves. (b) 
 "Forced" postures and movements are generally considered due to 
 disease of the middle peduncle (crus cerebelli ad pontem). Forced 
 postures of the head and trunk are observed; one eye looks upward 
 and inward, while the other is directed downward and outward. 
 Forced movements consist of the turning of the patient constantly to 
 one side, movement in a circle and a tendency to fall toward the side 
 of lesion and sometimes backward, (c) Muscular weakness is fre- 
 quent in animals (Luciani) and occasional in man. A hemiparesis 
 occurs on the side of lesion. The patient may not be able to rotate 
 the trunk, straighten the body after bending or get up after falling, 
 (d) The patellar reflexes are usually normal or increased. Sometimes 
 they are lost from pressure on distant structures or from spinal dis- 
 ease, (e) Vomiting and pain in the head or nape of the neck are 
 frequent and of some localizing value. (/) Occasionally the follow- 
 ing symptoms develop; nystagmus, rhythmical contractions of the 
 head, convulsions, paralysis of the cerebral nerves from pressure on 
 the midbrain, disturbed hearing, intention tremor, muscular rigidity, 
 irritability and weak memory. 
 
 XIV. Medulla. — (See Diseases of Medulla Oblongata.) 
 
 CIRCULATORY DISEASES OF THE BRAIN. 
 
 I. Anaemia of the Brain. — This term has been much abused. 
 Differentiation from hyperemia is sometimes impossible. 
 
 Etiology. — (a) General systemic anaemia may result from cachexia 
 and hemorrhages of medical, surgical or obstetrical nature. (b) 
 Decreased blood supply, due to cardiac insufficiency, valvular sten- 
 
918 DISEASES OF TEE NEBVOUS SYSTEM. 
 
 osis, stenosis of the vessels by aneurysm or tumor, evacuation of 
 an enormously distended bladder and tapping of pleurisy or ascites 
 leading to paresis of the thoracic or abdominal vessels may be causal. 
 Easting seems a cause in individuals who faint when the stomach is 
 long empty, (c) Capillary compression by hydrocephalus or tumors, 
 but especially by cerebral hemorrhage, may produce anaemia. Ven- 
 ous hyperemia may act in the same way. (d) Local causes in the 
 vessels will be considered under softening. Ligature or compression 
 of one carotid produces symptoms only when the other vessel is ather- 
 omatous. Gerhardt induced convulsions by pressure on one carotid 
 and considered them indicative of atheroma of the cerebral vessels. 
 
 Pathology. — The meninges and brain are pale, the brain firm and 
 dry and puncta vasculosa fewer. The fluid in the ventricles is often 
 increased. Geigel terms the slow capillary flow " diamorrhysis." 
 
 Symptoms. — Local anaemia of the brain leads to imperfect function, 
 then loss of function and finally to necrosis, as in embolism or throm- 
 bosis (q.v.). In sudden general ancemia after hemorrhage or fainting, 
 the subject becomes drowsy, syncope occurs and after return to con- 
 sciousness amaurosis is frequent. There is ringing in the ears and 
 the pupils at first contract from irritation of the third nerve and later 
 dilate from its paralysis, a sign of danger. The skin is pale and 
 clammy, the muscles lax and nausea frequent. Epileptiform con- 
 vulsions often occur when much blood is lost. Anaemia of the medulla 
 causes the slow, sighing respiration and yawning. Death after syn- 
 cope was called nervous apoplexy by the old writers. In gradually 
 developing anosmia, as pernicious anaemia, the brain power is les- 
 sened, and irritability, delirium, insomnia, headache, vertigo, weak 
 muscles, spots before the eyes, impaired sight, ringing in the ears 
 and sometimes deafness may result. These symptoms are aggravated 
 by sitting or standing and are relieved on lying down. Palpitation 
 and thoracic oppression are common symptoms. The pulse varies in 
 rate and rhythm. Increased reflexes, paraesthesia and jerking of the 
 muscles are frequent. 
 
 Marshall Hall has described liydrencephaloid, a variety of cerebral 
 anaemia, seen in children suffering with acute diarrhoea, and charac- 
 terized by contracted and later dilated pupils, depressed fontanelles, 
 sunken face, pallor, early irritation followed by stupor or even coma. 
 It may resemble meningitis from the strabismus, rigidity of the neck 
 and convulsions. It is usually amenable to treatment. 
 
 Treatment. — Treatment, as well as diagnosis and prognosis, is 
 chiefly that of the cause. The ancemia is treated by putting the patient 
 in the recumbent posture and instituting rest in bed, iron, arsenic, a 
 full diet and sometimes small doses of opiates. Acute anaemia neces- 
 sitates absolute rest, free stimulation, coffee by rectum and enemata 
 or subcutaneous infusions of salt solution. Eirm bandaging of the 
 extremities, sometimes called autotransfusion, is valuable. For hy- 
 drencephaloid, warmth, stimulation and fluids are necessary. Nitro- 
 glycerine is valuable in cases possibly due to vasomotor spasm. 
 
CIRCULATORY DISEASES OF THE BRAIN. 919 
 
 II. Hyperemia of the Brain. — Congestion of the brain is an ob- 
 scure lesion. Andral (1836) described 8 varieties, and when Trous- 
 seau, in 1861, attempted to refer some varieties to epilepsy and 
 Meniere's disease, he drew down upon him the wrath of the entire 
 Academy. The hypersemia in nephritis is usually uraemic and the 
 arterial fluxion once attributed to erysipelas is entirely toxemic. 
 Geigel has proposed the term " endiamorrhysis " for the normal 
 flushing of the brain by its capillaries. The essential element is the 
 rapidity of the capillary flow. When the vessels dilate from paralysis 
 of the sympathetic system the rapidity decreases, whence there is no 
 hyperaemia but a lessened capillary flow, adiamorrhysis. When the 
 vessels contract from sympathetic irritation, the brain is not anaemic, 
 but the capillary flow is accelerated, hyperdidmorrhysis. General 
 arterial tension is not important, but the tension of the vessel wall is 
 the essential element (Geigel). 
 
 Etiology. — Hyperemia may result from active or passive conges- 
 tion. The prevailing description may be adhered to provisionally. 
 
 Active congestion results (a) from cardiac overaction; (6) from 
 overfilling of the brain vessels, as in stenosis of the isthmus of the 
 aorta ; '(c) from contraction of the arterioles in other parts ; (d) from 
 dilatation of the brain vessels by alcohol, nitroglycerine, coffee, exoph- 
 thalmic goitre, excessive brain work, neurotic states and insolation, 
 (e) It may occur as the first stage of inflammation. (/) In plethoric 
 men with florid faces, thick necks and short thoraces, active conges- 
 tion may cause certain passing brain symptoms. 
 
 Passive congestion results (a) from general venous stasis, as in 
 valvular heart lesions; and (b) from local venous stasis, as sinus 
 thrombosis ; Geigel held that venous stasis leads to capillary anaemia. 
 
 Pathology. — The pathological findings are few, for congestion dis- 
 appears after death; the brain may appear anaemic after death by 
 strangulation and the head may become congested after death because 
 of its posture alone. The sinuses and veins are usually turgid and 
 the color of the brain is darker. Microscopic examination shows dis- 
 tention of the capillaries, at times increased blood pigment or actual 
 rupture into the perivascular lymphatic sheaths or into the brain 
 substance. 
 
 Symptoms. — No symptoms are characteristic. In active congestion 
 the symptoms vary with the cause; chronic cause fewer symptoms 
 than acute factors. Whether toxaemic symptoms of the acute infec- 
 tions are due to hyperaemia is an open question ; the headache in early 
 typhoid has often responded to ergot in personal experience. ISToth- 
 nagel and Gowers report cases with paroxysmal throbbing of the ves- 
 sels, flushing, headache, delirium, sometimes nausea and fever, relieved 
 by nosebleed and venesection. Irritability, insomnia, spots before the 
 eyes, ringing in the ears and increased pulse are said to occur. In 
 progressive paralysis the transient pyrexia, heat in the head or coma 
 is referred to congestion of the brain. In middle and advanced life 
 the so-called congestive apoplexy has been noted, which consists of 
 
920 DISEASES OF THE NERVOUS SYSTEM. 
 
 coma, sometimes with transient hemiplegia, though most cases are 
 due to small hemorrhages, softening or disease of the vessels. 
 
 Passive congestion, if gradual in onset, may be well tolerated or 
 may produce stupor, dulness or even delirium. If intermittent, as 
 from coughing, the symptoms are a sense of fulness in the head, 
 headache and sometimes convulsions ; these are increased by exertion, 
 by the dorsal decubitus and constipation. 
 
 Diagnosis. — Focal symptoms, as hemiplegia, indicate organic dis- 
 ease. Such symptoms, as flushing, heat or pressure in the head, can- 
 not be used for diagnosis, because they are often due to neurasthenia 
 or to hypochondriasis. Marie and Leube have never made the diag-- 
 nosis of brain hyperemia. The great similarity between the symp- 
 toms of ansemia and hyperemia of the brain has been noted. 
 
 Treatment. — Active congestion is treated by slight elevation of the 
 head; by venesection in extreme or very plethoric cases in adults or 
 in children by application of leeches over the mastoid bone, the veins 
 of which connect with those of the brain; by free purgation, by 2 
 drops of croton oil, followed by mercurials and concentrated salines, 
 to draw the blood to the large abdominal vessels ; by hot baths, to draw 
 the blood to the periphery; bromides and vaso constricting measures, 
 especially digitalis. Alcohol and opiates (save in small doses) should 
 be avoided ; ice may be applied to the head and carotids ; a fluid diet 
 should be given. 
 
 III. (Edema of the Brain. — Etiology. — (Edema of the brain results 
 from the same causes as general oedema : (a) circulatory disturbances, 
 as venous congestion in cardiac disease, emphysema and the acute 
 infections; and (6) the marantic group, including cachexia and ne- 
 phritis. Collateral and inflammatory oedema may develop around 
 brain tumor, abscess or hemorrhage. In some instances brain oedema 
 occurs in the death agony. It may also develop when the brain 
 shrinks, hydrops ex vacuo. 
 
 Pathology. — The brain is pale, moist and glistening on section, the 
 so-called a wet brain." The affection may be general or local; the 
 ventricular and subarachnoid fluid is increased. The volume of the 
 brain may be increased in the generalized form. 
 
 Symptoms. — The symptomatology is indefinite and a certain diag- 
 nosis cannot be made between oedema and lessening of the capillary 
 velocity. When the oedema is localized, transient focal symptoms 
 may develop, as unilateral convulsions or hemiplegia; even crossed 
 paralysis was observed personally in cases of nephritis. Traube held 
 that brain oedema causes the ursemic manifestations of nephritis, a 
 view vigorously opposed by Cohnheim. Great variability in the 
 symptomatology of organic brain disease may be due to associated 
 oedema. 
 
 IV. Cerebral Hemorrhage. — This most common and important of 
 all brain lesions involves an enormous part of brain pathology. It is 
 usually hemorrhage into the brain substance and is spontaneous. 
 
CEREBRAL HEMORRHAGE. 921 
 
 Although apoplexy strictly refers to a " stroke," which is sympto- 
 matic of various other lesions, it is used to indicate hemorrhage into 
 the brain (Rochoux). 
 
 Etiology. — (a) Miliary aneurysms are the chief or sole cause of 
 cerebral hemorrhage; the leading issue at present relates to their 
 pathogenesis. According to many authors, the causes are (b) those of 
 arteriosclerosis (alcoholism, plumbism, syphilis, hard physical work, 
 contracted kidney, gout, diabetes and over-eating), but others maintain 
 that atheroma does not per se predispose to hemorrhage. Eighty per 
 cent, of hemorrhages occur after the fortieth year of life. It may oc- 
 cur in early life from glioma, whooping-cough or trauma. More 
 cases occur in men (80 per cent.) than in women. Heredity is not 
 an uncommon factor, but relates rather to renal and arterial lesions 
 than to an actual heredity of hemorrhage; this is especially empha- 
 sized by English writers and by Dieulafoy. Hemorrhage is most 
 common among civilized races and in temperate zones, because of the 
 strenuous habits of life. For years the importance of the apoplectic 
 habitus (plethora, ruddy face, short, thick neck, wide shoulders and 
 chest, round, small body and large muscles) has been emphasized, 
 although Gowers finds most cases in thin individuals. Contracted 
 kidneys are found in 33 per cent, of cases of cerebral hemorrhage and 
 are among the chief causes of atheroma and miliary aneurysm, (c) 
 Increased arterial tension is usually considered an important etio- 
 logical factor. Hypertension alone is less important than its relation 
 to arteriosclerosis and miliary aneurysms, which occur where the 
 blood pressure is greatest, as where the vessels branch. Rupture is also 
 seen in cardiac hypertrophy from stenosis at the isthmus of the aorta. 
 Syphilis is usually considered a factor, but it more frequently pro- 
 duces softening than hemorrhage ; it is a causal factor of aneurysms 
 of the large vessels of the brain. Violent exertion, alcoholic excesses, 
 excitement, coitus, straining, overeating, vomiting, coughing or con- 
 vulsions may rupture an already-diseased vessel or a miliary aneu- 
 rysm. A healthy vessel almost never bursts, however high the blood 
 pressure. Embolism from heart disease may produce the " embolic 
 aneurysm." Sometimes trauma is a factor, usually, however, with the 
 causes mentioned, (d) Permeability of the blood vessels causes a few 
 cases, as in nephritis, purpura, anaemias and infections, by hemor- 
 rhage by diapedesis through the arterial wall. 
 
 Pathology. — Hemorrhage most often occurs in the branches of the 
 arteria fossa? Sylvii. Among its branches the lenticulostriate artery 
 of Duret, called by Charcot the artery of hemorrhage, is the seat of 
 hemorrhage in 75 per cent, of cases. Though the vessel is small, it 
 is likely to rupture because (a) it is so near to the large internal 
 carotid and its course is very direct; (b) the blood pressure is high; 
 (c) the vessel has no special external support; and (d) there is no 
 collateral circulation, hence no relief to pressure, rendering the ves- 
 sel tortuous. Rupture occurs very often in the long direction of the 
 nerve fibers of the internal capsule. The veins stagnate very easily 
 
922 DISEASES OF TBE tiEBVOtJS StSTEM. 
 
 in this locality. Hemorrhage is almost always arterial. Miliary 
 aneurysms were described by Brunner in 1700, but Charcot and 
 Bouchard (1866) emphasized their frequent relation to brain hemor- 
 rhage. They are fusiform, more rarely sacciform, enlargements of the 
 arterioles, sometimes multiple, like a bunch of grapes, and measuring 
 %oo to %5 of an inch ; they may be seen with the naked eye, but are 
 best observed by careful washing or macerating in water, and exami- 
 nation on a slide under a low power. They are found in persons 
 over forty years of age and in the locations where hemorrhages are 
 most common, i. e., in the central ganglia. Their pathogenesis is 
 obscure. Charcot and Bouchard described a change in the outer 
 tunic (periarteritis) but Eichler and Zeigler held that intimal changes 
 were primary. Eoth finds that miliary aneurysm is due to atrophy 
 of the muscular coat ; this is at present the generally accepted theory. 
 They are the chief or sole cause of spontaneous hemorrhage. Large 
 aneurysms will be considered separately. 
 
 Localization. — Hemorrhage is most common about the lateral ven- 
 tricle, i. e., in the caudate and lenticular nuclei, the internal capsule 
 and the adjacent centrum ovale, extending to the optic thalamus, but 
 rarely beginning in it. Hemorrhage in the white matter has usually 
 an elongated form. It is much less common in the cortex, pons, crus, 
 cerebellum or medulla. Though it occurs mostly in the substance of 
 the brain, hemorrhage may either rupture on the surface or break into 
 the ventricles, causing sudden death ; this is the usual autopsy finding 
 in recent apoplexy. Hemorrhage is usually single. The multiple 
 form is observed in anaemia. When the skull is removed after large 
 hemorrhages the dura is tense, the convolutions flattened and pale, the 
 falx pushed toward the other side and the fissures indistinct. Fluc- 
 tuation may be felt in rare cases and on section the focus is seen ; it 
 sometimes involves the entire hemisphere or may be no larger than a 
 pea, but usually the size of a hazel-nut or walnut. The brain around 
 the focus is softened from pressure, oedematous and in the focus torn 
 and pulpy. The dark clot later becomes chocolate-colored, then 
 yellow-red and finally yellow-white. The wall of the focus is irregu- 
 lar in the gray nuclei and regular in the white matter and threads of 
 bloodvessels run through it. Microscopically, leukocytes laden with 
 fat drops, hsematoidin and disorganized tissue are found. As the 
 blood absorbs, the cavity becomes more regular and encapsulated by 
 inflammation and contains a serous or milky fluid; this is the apo- 
 plectic cyst of Virchow. Final replacement of the focus by an apo- 
 plectic scar is much less common. Traumatic hemorrhage may occnr 
 infrequently near the point of injury or contre coup on the opposite 
 side; it sometimes takes place after a week or more; this is the late 
 traumatic hemorrhage of Bollinger, which occurs near the fourth ven- 
 tricle and aqueduct of Sylvius, and probably in areas of traumatic 
 softening. Brain hemorrhage may indirectly press on other parts, 
 may press on their arteries and veins or directly sever the internal 
 capsule. 
 
CEREBRAL HEMORRHAGE. 
 
 923 
 
 Secondary degeneration occurs in the pyramidal tracts, mostly as a 
 result of lesions of the internal capsule. It is usually partial, and 
 sound and diseased fibers intermingle ; it descends through the cms, 
 pons, medulla and cord, in the latter of which it involves the inner 
 part of the anterior columns of the same side (the direct anterior 
 
 Fig. 56. 
 
 INTERNAL 
 
 CAPSULE ^p TIC 
 
 THALAMUS 
 
 MEDULLA 
 -EXTREMITIES 
 
 CORD 
 
 Showing course of individual fibers of motor tracts. 
 
 pyramidal tract) and part of the lateral columns of the opposite side 
 (the crossed lateral tract). These areas become progressively smaller 
 and cease just above the conus medullaris. In children a cerebral 
 lesion may cause degeneration in the anterior horns of the cord and 
 their fibers. An ascending degeneration occurs only when the large 
 pyramidal tracts of the cortex are diseased, except in the young, in 
 whom degeneration of all neurones is prone to follow the destruction 
 of one neurone. (See figures under Localization in the Spinal 
 Cord.) Other degenerations: (a) The optic radiation degenerates 
 when a lesion occurs in the cortex of the cuneus and also degenerative 
 changes in the external geniculate body and pulvinar. After years it 
 may reach the optic nerve, (b) Hemorrhage in the second and third 
 frontal lobes leads to degeneration in the anterior limb of the capsule, 
 median basal fibers of the crus and the fibers connecting the optic 
 thalamus with the cortex, (c) Lesions in the temporal lobes cause 
 degeneration in the lateral part of the crus. (d) Degeneration in the 
 median lemniscus follows diseases of the cortex, the subthalamic 
 region and the upper part of the pons ; it crosses to the opposite nuclei 
 of the medulla and after years destroys the ganglion cells in the pos- 
 terior columns of the cord. Cerebellar hemorrhage may rarely cause 
 degeneration of the arm of the pons and of the corpus restiforme. 
 
924 
 
 DISEASES OF THE NERVOUS SYSTEM. 
 
 Symptoms. — Prodromes are most rare. Miliary aneurysms produce 
 no symptoms until they rupture and premonitory symptoms are due 
 to atheroma. !None of them are pathognomonic. They may be (a) 
 general, as described under congestion and softening (v. i.) ; (b) 
 cardiorenal, as hypertrophied heart, high arterial tension and the 
 urinary findings of contracted kidney; or (c) sometimes focal, as 
 diplopia, alexia, facial paresis, dysarthria or preparalytic chorea. 
 
 Fig. 57. 
 
 Horizontal section through the right hemisphere ; 1, Cortex ; 2, white substance ; 3, 
 internal capsule ; 4, optic thalamus : 5, lenticular nucleus ; 6a, anterior horn ; and 6&, 
 posterior horn of the lateral ventricle. (After Dejerine.) 
 
 Possibly in some cases prodromal symptoms are due to an initial 
 small hemorrhage or to hemorrhage developing very slowly. 
 
 1. The Ixstjet or Stroke astd Its Primary Symptoms. — The 
 " stroke " or apoplexy is usually sudden; its most common geueral 
 symptom is coma, which may be absent in small lesions and its most 
 
CEREBRAL H HEMORRHAGE. 925 
 
 common focal symptom is hemiplegia. It may develop during effort 
 or excitement, or again without cause, as during sleep, when the 
 head is low. In ingravescent apoplexy the onset may be gradual, 
 with delirium, convulsions and finally coma; it is due to hemor- 
 rhage external to the lenticular nucleus, which later involves the in- 
 ternal capsule (hemiplegia). Death may, in rare instances, occur 
 in five minutes (Abercrombie) from rupture into the ventricles or 
 from direct pressure on the medulla (fulminating apoplexy). 
 
 The insult, or stroke, is due chiefly to anosmia of the cortex and to 
 some extent to direct brain trauma, pressure by the hemorrhage on 
 other vessels, serous infiltration and alterations in the cerebrospinal 
 fluid (in which lumbar puncture sometimes shows blood). Its car- 
 dinal typical symptoms are coma, which is greater the nearer the 
 lesion is to the optic thalamus and third ventricle; flushed face, or 
 sometimes pallor or cyanosis ; usually a full, tense, regular and slow 
 pulse; long, deep, stertorous breathing (due in part to palate paraly- 
 sis) ; the cheeks puff out, but are drawn in on inspiration, as a result 
 of paralysis of the buccinator muscle; inspiration is less irregular 
 than it is usually said to be; yawning is frequent (Todd) ; the tem- 
 perature usually suffers an initial fall, but rises when reaction sets in, 
 though lesions in the pons, medulla or central ganglia may cause an 
 initial rise. The pupils are variable, usually wide, from paralysis 
 of the third nuclei or from sympathetic stimulation ; they are some- 
 times unequal and in deep coma reactionless. They may be narrow 
 from irritation of the oculomotor nucleus in lesions of the pons, or 
 when the ventricles are involved. Convulsions are infrequent. The 
 head and eyes look toward the side of the brain lesion (" conjugate 
 deviation "), a flaccid hemiplegia occurs, in which the limbs fall limp 
 when they are lifted; the paralyzed muscles appear semi-fluid and 
 lax ; the reflexes are gone, which symptoms will be described in detail 
 below. There are involuntary evacuations of urine and fseces. 01- 
 livier described an increase of the urine with a low specific gravity 
 (1,004) and transitory albuminuria and glycosuria, usually due to a 
 large lesion producing indirect pressure on the medulla or to a lesion 
 in the medulla itself. 
 
 2. The permanent damage can only be estimated when the reac- 
 tion is passed. The direct focal symptoms are those of the hemor- 
 rhage itself and the subsequent cyst or scar; they are permanent if 
 essential structures are involved, as the internal capsule. Indirect 
 focal symptoms are those of other structures disturbed by pressure, 
 oedema or inflammatory reaction. Time is required to separate these 
 two classes of symptoms. The pulse and respiratory symptoms, 
 conjugate deviation, albuminuria and temperature are usually in- 
 direct symptoms. 
 
 3. Details oe Important Symptoms. — 1. Convulsions are not 
 common ; they indicate involvement of the pons, ventricles, cortex or 
 corpus striatum. 
 
 2. Conjugate deviation, described by Vulpian, but especially by 
 
926 DISEASES OF TEE NERVOUS SYSTEM. 
 
 Prevost, is a transitory phenomenon in which the lateral muscles of 
 the head and eyes are paralyzed; their fellows on the sonnd side eon- 
 tract, so that "the patient looks at his lesion" (Prevost) ; that is, in 
 left hemiplegia the eyes and head look toward the right side of the 
 brain, where the lesion is located. The centres paralyzed are in the 
 lower parietal lobe (gyrus angularis and gyrus supramarginalis, Lan- 
 douzy). It disappears in a few days because the sound side of the 
 brain compensates or because it is a distant pressure symptom, or at 
 the most only a moderate paresis remains, shown by nystagmus. 
 Conjugate deviation may also be due to irritation or convulsions 
 (Jacksonian epilepsy), when the patient "looks away from his le- 
 sion " (Landouzy), i. e., toward the side affected with convulsions. 
 These differ from the deviation in localization in the pons (q. v.). 
 
 3. The hemiplegia (see Localization, Internal Capsule) is due 
 to a lesion of the internal capsule (75 per cent, of cases). During 
 deep coma it is often difficult to determine which side is paralyzed. 
 The affected side is usually flaccid and the mouth shows greater 
 puffing on the hemiplegic half. If the coma is not profound the 
 sound arm and leg may move. Sometimes, especially with hemor- 
 rhage into the lateral ventricle, the paralyzed side is rigid (early 
 rigidity or contracture). The temperature is at first lower on the 
 hemiplegic side from paralysis of a cortical centre. Later, during 
 reaction, it is higher on the side of paralysis and may occur with 
 oedema in this arm and leg. After consciousness returns the contra- 
 lateral hemiplegia is more clearly seen. The lower two-thirds of the 
 face (nose, mouth, cheek) are paralyzed, but the upper third (eye 
 and forehead) is usually quite free; in very rare cases only, a total 
 facial paralysis is seen. The lids can be moved, but the nasolabial 
 fold is obliterated, the lips cannot be puckered as though to whistle, 
 the mouth is oblique or a little triangular when the teeth are shown. 
 The upper part is so often unaffected because it is innervated from 
 both hemispheres or because it has two distinct centres and paths, 
 whereas in peripheral facial paralysis all branches are involved and 
 atrophy and the reactions of degeneration occur. If the optic thala- 
 mus (q. v.) is intact, the paralysis is not apparent on emotional move- 
 ments, as laughing. The tongue is slightly involved ; when protruded 
 it deviates toward the diseased side (Schiff, Heidenhain) because the 
 sound genioglossus muscle pulls the tongue forward and over toward 
 the hemiplegic side ; the base of the tongue is higher on the paralyzed 
 side which may lead to some difficulty in the external speech mechanism 
 (dysarthria), while internal speech (i. e., aphasia) is not often dis- 
 turbed unless there is psychical alteration. The palate may hang 
 lower on the paralyzed side, but this is of little importance because 
 it varies physiologically. Deglutition, mastication and phonation 
 are but little or only transitorily involved ; marked difficulty in masti- 
 cation is usually associated with total hemiansesthesia. In the trunk 
 paralysis of the trapezius and levator anguli scapulae causes sagging 
 of the shoulder, while other muscles of the neck are relatively free. 
 
CEEEBEAL HEMORRHAGE. 927 
 
 (Wernicke thinks certain cerebral fibers of the spinal accessory are 
 involved.) The accessory muscles of respiration, as the scaleni, are 
 involved on deep inspiration, and ordinary respiration is somewhat 
 less complete, to which some would refer certain lung complications, 
 as atelectasis. Hughlings-Jackson finds respiratory movement 
 greater on the paralyzed side in automatic breathing and greater on 
 the sound side in forced breathing. Early, the paralysis of the arm 
 and leg is often absolute, sometimes partial (hemiparesis). The arm 
 is usually more involved than the leg. In rare cases the arm may be 
 free in linear lesions; again the leg may be unaffected or the face 
 remains free (see Internal Capsule Localization) ; monoplegia is 
 much less common than in cortical and subcortical disease and when 
 one member is more affected than the others there is still partial or 
 " dissociated " hemiplegia. In the typical case the arm is most in- 
 volved, though all parts on one side usually are somewhat paralyzed. 
 The arm abductors, hand flexors and finger extensors are most af- 
 fected. In the leg, the extensors of the leg, dorsal foot flexors and 
 knee flexors are most implicated. The paralysis is flaccid. Consid- 
 erable improvement may follow (see Secondary Symptoms). The 
 hemiplegia is almost invariably contralateral, i. e., opposite to the side 
 of the lesion. (In the older literature hemiplegia on the same side, 
 or collateral hemiplegia, was described ; Lederhose collected 45 cases, 
 due (a) to more than one lesion, (b) to a focus pressing on the other 
 side of the brain, or (c) to mistaking the early rigidity of the par- 
 alyzed side for the normal side. 
 
 4. Sensory disturbance has been considered in the topography of 
 the internal capsule. It is observed mostly during the insult or 
 reaction, is less important than hemiplegia, less frequent, less distinct, 
 less complete and less stable. Some hemianesthesia is frequently 
 found in early cases after careful examination, as disturbed tactile 
 sensation, stereognostic sense and sometimes muscle sense, pains and 
 hyperesthesia or paresthesia. A large lesion only can cause a com- 
 plete hemianesthesia, which very seldom occurs without some paresis. 
 Its affects the skin and mucosa of the nose, mouth, palate and eyes, 
 but leaves the cornea intact (Grasset), which is supplied by the oph- 
 thalmic ganglion (see Diagnosis). Cortical hemianesthesia is usu- 
 ally partial and most often associated with a monoplegia ; lesions a 
 little above the capsule, may produce hemianesthesia, involving the 
 fibers from the thalamus to the cortex. Hemianesthesia also occurs 
 in lesions of the crus, pons, medulla and cord (q. v.). 
 
 5. Special senses. Hemianopsia, due to pressure on the optic 
 thalamus, is frequent, usually occurs with conjugate deviation, is 
 temporary and is often overlooked. 
 
 6. The t re flexes of the skin, cornea, pupils, mucosae and tendons are 
 suspended when there is complete coma, in which the central nervous 
 system is almost wholly paretic. After the stroke they return slowly, 
 first on the sound side. On the hemiplegic side they return more 
 slowly, the periosteal, tendon and patellar reflexes often become exag- 
 
928 DISEASES OF THE NERVOUS SYSTEM. 
 
 gerated from interrupted inhibition ; the patellar reflexes may return 
 only after a considerable time. The skin reflexes return slowly, espe- 
 cially the epigastric, cremasteric, scrotal and mammillary; this is a 
 point of early diagnostic value; they probably have a higher centre 
 than the tendon reflexes, although the explanation of their conduct is 
 not clear; it has also been suggested that there is a cerebral centre 
 controlling Setchenow's inhibitory reflex centre in the medulla ; when 
 this higher centre is affected the medulla centre wholly inhibits the 
 reflexes. 
 
 The Bdbinski sign (toe phenomenon) indicates organic pyramidal 
 disease and may be found very early; when a sharp object is slowly 
 drawn over the outer part of the sound sole there is plantar flexion 
 of the large and sometimes of the other toes ; when drawn over the 
 diseased sole there is great dorsal flexion (extension) of the great toe. 
 After the primary insult, coma and reaction are over, the chronic 
 symptoms can be studied to the best advantage. 
 
 4. The Chroxic or Secoxdary Symptoms. — The indirect symp- 
 toms, the inflammatory reaction and collateral oedema disappear; 
 this is usually followed by considerable improvement. 
 
 1. If the hemiplegia is indirect, from a lesion without the capsule, 
 marked improvement or rarely total recovery ensues. Complete 
 lasting hemiplegia follows total division of the pyramidal tracts, due 
 to hemorrhage from the anterior choroid artery (Kolisko). The 
 face may recover rapidly: certain muscles are entirely unaffected or 
 are involved for a short time only ; this is explained by Broadbeni's 
 theory that muscles used in pairs are little involved or escape entirely ; 
 with some modification of his theory, we find that: the inter costals, 
 masseters and trunk muscles used together, innervated from both 
 hemispheres and having little differentiation in function, escape per- 
 manent paralysis. The functions of the arm and hand are especiallv 
 complicated, are more often used alone, are innervated almost wholly 
 from one hemisphere and therefore suffer the greatest permanent 
 damage. In adults the hand is usually disabled for life. The legs 
 are much used together, have some innervation from both hemispheres 
 and often show improvemeut after paralysis. Just how compensation 
 occurs is undetermined. Broadbent thinks that the bilateral spinal 
 and bulbar nuclei enable " paired muscles " to be innervated from the 
 sound hemisphere. Possibly uncrossed fibers in the anterior (and 
 lateral) columns may explain the phenomenon. Compensation is 
 not an absolute advantage, for Brown-Sequard found the sound side 
 reduced in strength in 50 per cent, of his cases. The face often im- 
 proves after an attack. In the arm the residual paralysis affects func- 
 tionally associated muscle groups rather than individual muscles, as 
 the muscles supinating the forearm, those abducting and lifting the 
 arm and shoulder, those moving the elbow, opening the hand and 
 apposing the thumb (Wernicke and Mann). The shoulder improves 
 a little, the elbows considerably, the hands very little. In the leg the 
 flexors, dorsal flexors of the foot which " shorten " the leg in walking. 
 
CEREBRAL HAEMORRHAGE. 929 
 
 abductors and internal rotators of the hip are most involved. The 
 hemiplegia gait is awkward, the foot is swung out and around in a 
 half circle and scrapes the ground. The power of the paralyzed leg 
 is greater when it is used with the sound leg, as in walking, than when 
 it is used by itself. 
 
 2. The contracture, the important posthemiplegic manifestation, is 
 the transitory or permanent fixation of a joint in an abnormal posture 
 from nutritive or functional factors. Passive contractures are me- 
 chanical, as from muscular shortening, while active contractures 
 result from disease of the central nervous system. Early contractures 
 are often regarded as tonic spasm (myotatic irritability). The late 
 contracture develops in two to four weeks and is quite typical ; the 
 shoulder is lifted, the arm adducted to the chest, the elbow rigid, the 
 forearm pronated, the wrist flexed and the fingers flexed even vio- 
 lently into the palm. When the wrist is passively flexed the fingers 
 can sometimes be extended. In general the contracture involves both 
 extensors and flexors, but more often the latter. The contractures 
 occur in the muscles which are least paralyzed. In the lower ex- 
 tremity, the contracture is not marked (in the thigh there is often 
 only a trace), the knee is extended, plantar flexion of the foot occurs 
 (pes equino-varus) , the great toe is dorsally flexed. Locomotion is 
 difficult, for there is bending of the trunk to the sound side, lifting 
 of the pelvis because of the adduction paralysis and swinging of the 
 foot over the sound foot. There may be pain in walking and the 
 sound leg also suffers some slight contracture. Contracture may 
 occur in the face, platysma and sternomastoid, but the trunk is rarely 
 affected. Hitzig regards them as involuntary associated movements. 
 In rare cases, and largely in children, the paralyzed side remains lax 
 (hemiplegie flasque of Bouchard). 
 
 3. Associated movements are variously explained; by Westphal as 
 due to lessening of reflex inhibition, by Hitzig as movements at- 
 tempted in paralyzed muscles but reflected to their associates and by 
 Leube as due to bilateral representation in the hemispheres ; an effort 
 to grasp with the sound hand produces a similar movement in the 
 one paralyzed; movement of the diseased side occurs after passive 
 movement of the sound one; movement of the paralyzed foot results 
 when the patient attempts to flex the hip. 
 
 4. Hemitremor is uncommon. The muscles are stimulated, but 
 not enough vibrations occur for actual involuntary movement. 
 
 5. Atrophy may occur in both spastic and flaccid cerebral forms, 
 though more in the latter; Steinert concluded that atrophy is as fre- 
 quent in cerebral as in peripheral paralysis. Charcot referred it to 
 degeneration of the anterior horns of the cord, while Quincke and 
 Senator assume an injury to some trophic paths. It develops in a 
 month or two, has no relation to the degree of paralysis, is often asso- 
 ciated with disturbed sensation and muscle sense, affects principally 
 the arm and occurs in large lesions which are either cortical in the 
 region of the third branch of the artery of Sylvius or central in the 
 
 59 
 
930 DISEASES OF THE NERVOUS SYSTEM. 
 
 distribution of the lenticulothalamic artery. The electrical irrita- 
 bility of the muscles is normal or somewhat depressed. The skin may 
 atrophy. 
 
 6. Posthemiplegic chorea (Wier Mitchell, Charcot, Eaymond) 
 results in 80 per cent, of cases from lesions in the internal capsule or 
 near it, in the optic thalamus, the lenticular or caudate nucleus, from 
 which irritation is reflected to the brain cortex. It develops months 
 or years after small lesions, when the hemiplegia and rigidity are 
 largely gone. It occurs especially in the arm, causes movements simi- 
 lar to but coarser than those of chorea, sometimes resembles the 
 tremor of multiple sclerosis or paralysis agitans and is often associ- 
 ated with pain and sensory disturbance (see Localization, Internal 
 Capsule). It sometimes is preparalytic. In posthemiplegic athe- 
 tosis (Hammond) the fingers and toes are incessantly moved, athe- 
 tosis meaning " without fixed position." It is a "mobile spasm" 
 consisting of somewhat spasmodic, slow, coordinated movements in 
 paralyzed members ; it is frequent in partial paralysis acquired early 
 in life, is slow in development, appears after the paralysis has re- 
 gressed and has the same localization as hemichorea. The follow- 
 ing differentiation by Greidenberg and v. Monakow gives their main 
 characteristics : 
 
 Hemichorea. vs. Hemiathetosis. 
 
 1. Face, trunk, whole extremity in 1. Chiefly or alone in forearm and hand 
 
 volved; may pass to all extremities. (fingers) and in leg and foot 
 
 (toes) ; simultaneous innervation of 
 antagonists; other parts paretic 
 and stiff. 
 
 2. Excursion active, manifold, tremor- 2. Slow rhythmic hyperextension, elas- 
 
 like, purposeless, increased by ex- tic resistance, seems purposive,, 
 
 ertion, tension lost by irritation. joints fixed. 
 
 3. Contracture little or none; limbs re- 3. Contracture frequent, but spasmus 
 
 laxed; no great deformity. mobilis often great. 
 
 4. Hemianaesthesia frequent. 4. Hemianesthesia rare. 
 
 5. Quiet in sleep. 5. Not always quiet in sleep. 
 
 6. Increased by movements and at- 6. Lessened to some extent by move- 
 
 tempts to suppress them. ment. 
 
 7. In trophic and vasomotor disturbance (v. s., Muscular 
 Atrophy) the paralyzed members are usually cool, moist and some- 
 times oedematons. The skin is glossy, even livid and fissured, ^"oth- 
 nagel observed in some cases paralysis of the cervical sympathetic 
 causing increased temperature, redness, narrowing of the eye fissure, 
 drooping of the upper lid, retraction of the eyeball, lachrymation and 
 narrow pupils. Sometimes there is overgrowth of the hair. Bedsores 
 were considered trophic by Charcot, but can usually be avoided by care 
 regarding pressure or heat and by cleanliness. Swelling of the joints 
 and hypertrophic neuritis (Charcot) on the hemiplegic side are rare, 
 
CEREBRAL HEMORRHAGE. 931 
 
 8. Psychic disturbance is not symptomatic of brain hemorrhage 
 and is chiefly referable to arteriosclerosis. It is^ evidenced by self- 
 concentration, weak memory, insomnia and irritability. Carpani 
 found more mental alteration when the left half of the brain was dis- 
 eased. Laughing and weeping are referable to disease of the optic 
 thalamus (q. v.) or to disease of the median fibers of the pons 
 (Brissaud). 
 
 Diagnosis of Brain Hemorrhage. — Two cardinal features, coma and 
 hemiplegia, together with the typical insult, facilitate diagnosis. In 
 cases with slow onset, differentiation from thrombosis (q. v.) is 
 difficult. 
 
 1. Coma. — In syncope the pulse is fast, weak and often irregular ; 
 in " cardiac apoplexy " an insult follows heart rupture, myocarditis 
 and various forms of heart failure, and differentiation from rapidly 
 fatal brain hemorrhage may be impossible. It is always dangerous to 
 make a diagnosis of alcoholic coma; an intoxicated individual may 
 suffer injury, basal fracture or actual apoplexy; an opinion should 
 be withheld until such complications can be excluded, though the alco- 
 holic coma is usually incomplete, the vomitus and breath smell of 
 alcohol, violent struggling is frequent and early convulsions and focal 
 symptoms are rare. Opium coma is characterized at first by slow 
 onset, slow respiration, slow, hard pulse, flushed skin, great con- 
 traction of the pupils, opium in the stomach washings and absence 
 of convulsions and focal symptoms; later there are Cheyne-Stokes' 
 respiration, rapid pulse, clammy cyanotic skin and dilated pupils. 
 In opium and similar intoxications the focal symptoms and reflexes 
 of apoplexy are lacking. Hemorrhage in the pons produces narrow 
 pupils, which are often unequal. While in general the diagnosis 
 of apoplexy during the coma is precarious, urcemic coma rarely occurs 
 without premonitory symptoms, as headache, drowsiness, delirium, 
 restlessness, vomiting, myosis, retinitis or less often convulsions ; the 
 coma is often less profound than in cerebral hemorrhage. The renal, 
 cardiac and arterial findings of nephritis may also occur in apoplexy, 
 of which nephritis is a frequent cause (33 per cent.) and it must be 
 remembered that focal symptoms sometimes occur in ursemia ; the 
 author has repeatedly observed hemiplegia and even crossed paralyses. 
 In deep coma rigidity may be observed in both ursemia and apoplexy, 
 but in ursemia it is often variable. In diabetic coma the fruity, ace- 
 tone breath, acetone in the urine, headache, unrest, Kussmaul's breath- 
 ing and absence of focal symptoms are characteristic. The coma may 
 be sudden and granular casts are frequent ; the diagnosis is suggested 
 by a clear history of glycosuria. Symptomatic apoplexy is of more 
 theoretical than practical importance ; transient coma and hemiplegia 
 sometimes occur in brain oedema, congestion, progressive paralysis, 
 multiple sclerosis and more rarely in epilepsy and tabes. 
 
 2. Hemiplegia. — This is a prominent finding in embolism and 
 thrombosis (q. v., for Differentiation) ; an exact diagnosis is often 
 impossible, Kolisko states that most cases with the clinical diagnosis 
 
932 DISEASES OF THE NEEVOUS SYSTEM. 
 
 of embolism prove to be hemorrhage and vice versa. Hemiplegia may 
 occur in brain abscess and meningitis. When it occurs in meningitis 
 with coma, there are headache, generalized convulsions, rigidity, hy- 
 peresthesia, optic neuritis, eye-paralyses and fever. In extradural 
 haematoma and pachymeningitis the Jacksonian epilepsy followed by 
 cortical paralysis is distinctive, i. e., the focal symptoms are promi- 
 nent compared with the general symptoms of early apoplexy. Hemi- 
 plegia may also occur in hysteria (q. v.), syphilis, brain tumor, 
 trauma, chorea or paralysis agitans. Hemiplegia, not resulting from 
 any lesion, may occur in alcoholism, plumbism, gout, uraemia, dia- 
 betes, pneumonia, etc. 
 
 3. Other Locations of Hemorrhage. — (a) Hemorrhage may 
 occur in the meninges (see Diseases of Meninges), (b) It may 
 occur, though rarely, in the cortex; Jacksonian epilepsy in subcorti- 
 cal lesions, convulsions and rigidity may be severe and lasting 
 (Mills), (c) Ventricular hemorrhage is usually secondary to hem- 
 orrhage in the corpus striatum or optic thalamus and usually reaches 
 all the ventricles. It may in rare cases be primary from aneurysms 
 or ruptured veins in the choroid plexus (Dana). One-third of all 
 cases are in persons under forty years of age. It occurs usually with 
 violent symptoms, convulsions (33 per cent.), early and sometimes 
 bilateral rigidity. The conjugate deviation changes to the other side, 
 the pulse is slowed, the temperature falls, the reflexes are suspended. 
 Cheyne-Stokes' breathing, glycosuria and polyuria develop and death 
 usually results within a day; the onset is sometimes slow, (d) 
 Hemorrhage in the eras {q. v., Localization) is usually descending, 
 from bleeding near the internal capsule. Crossed hemiplegia oculo- 
 motoria (Weber's type), crossed ptosis or diplegia may be observed, 
 (e) Apoplexy in the pons (q. v.) occurs in 10 per cent, of cases, often 
 in the median line and frequently with convulsions. Paralysis and 
 convulsions may occur in the arms or legs only; the trunk muscula- 
 ture is involved more frequently than in higher hemorrhages. The 
 eyes look away from the side of the lesion. The pupils may be large 
 from paralysis or small from stimulation of the third nerve; in the 
 latter instance opium poisoning must be differentiated. Respiration 
 is affected early, vomiting is frequent, there is often early high fever 
 and death is usual within twenty-four hours ; it has occurred in 
 seven minutes. (/) Hemorrhage in the medulla will be considered 
 later. Early or instantaneous death is frequent, but a gradual onset 
 is known. It is rarely diagnosticated. It may very rarely induce 
 gastro-intestinal hemorrhage, (g) Cerebellar apoplexy occurs in 5 to 
 8 per cent, of cases. Vomiting is very frequent (50 per cent.). The 
 insult is sometimes less marked than in the usual type and " the ab- 
 sence of hemiplegia is more significant than its presence " (Gowers). 
 Hemiplegia is due to indirect pressure or secondary ventricular hem- 
 orrhage. Cerebellar symptoms, as ataxia, may result. 
 
 Prognosis. — The prognosis concerns (a) the immediate danger and 
 (b) the ultimate outcome, (a) The immediate prognosis is always 
 
CEHEBHAL tt^MOKBHAGE. 933 
 
 serious. In hospital cases 75 per cent, die but in general practice 
 66 per cent, survive the first stroke, 33 per cent, the second and very 
 few the third. When death occurs it is nsual in one-half to two days, 
 but the outcome is uncertain for a week, because light cases, even 
 rare forms without coma, may rupture into the ventricle with rapidly 
 fatal result. Coma lasting more than twenty-four to thirty hours is 
 dangerous. Early low fall of temperature or its rapid early rise is 
 unfavorable, indicating a large focus. For the same reason, conju- 
 gate deviation, relaxed sphincters, impaired breathing, tracheal rat- 
 tling, bilateral or ventricular symptoms, marked glycosuria or albu- 
 minuria, decubitus in the first week, convulsions and rapid pulse are 
 unfavorable. The mode of death is as follows : the breathing becomes 
 more rapid, irregular, of the ominous Cheyne-Stokes' type, and 
 rattling from accumulated secretion in the air-passages ; the slow and 
 regular pulse becomes rapid, small, irregular, often with a rise of 
 temperature and finally ceases, but respiration for a time continues; 
 death occurs in total coma. 
 
 (&) Ultimate Outcome. — The symptoms of shock disappear and the 
 patient becomes partly conscious or delirious ; the period of reaction 
 begins usually within forty-eight hours after the onset. The pulse 
 becomes faster, the temperature rises, pain develops in the head and 
 limbs and rarely the paralyzed limbs become rigid. Life still hangs 
 in the balance and the patient may die from the reaction, hypostatic 
 pneumonia (called trophic by some writers), pulmonary oedema or 
 hemorrhage, acute decubitus or from a second hemorrhage. Reaction 
 is over in one to six weeks. If the patient survives there is im- 
 provement, depending on the extent and localization of the injury, 
 determined only after weeks or months. If movement appears in 
 three weeks the outlook is good ; if it does not return in three or four 
 months it is not likely to develop later. Disappearance of indirect 
 pressure leads to bettering (i) of damage to the sensory nerves and 
 those of special sense, (ii) of motility, first of the trunk and face, 
 then of the leg and less of the arm. Absolute recovery is improbable. 
 Uemichorea and hemiathetosis are incurable. Broken neurones never 
 unite and secondary degeneration, contractures and increased reflexes 
 result. Exaggerated reflexes, developing a few weeks after the injury, 
 are forerunners of contractures and ankle clonus, which preclude full 
 regression. The outlook is fairly good in children when the hemor- 
 rhage is not due to blood affections, because compensation is likely to 
 occur. Recurrence is possible in decrepid and aged subjects, although 
 less common than usually believed; the average duration of life is 
 five years (Dana). 
 
 Treatment. — 1. Prophylaxis. — Prophylaxis regarding worry, hard 
 work, syphilis, the use of alcohol, eating and excesses is necessary 
 when there is hereditary tendency toward hemorrhage or when one 
 hemorrhage has already occurred. 
 
 2. The Insult. — (a) Absolute quiet is indicated, and any move- 
 ment, transportation or extended examination should be avoided. 
 
934 DISEASES OF THE NERVOUS SYSTEM. 
 
 (&) The head should be slightly elevated, but flexiou of the neck, 
 tight clothes or anything hindering the return venous flow should be 
 avoided. Bowles thinks that stertorous breathing is due to the 
 position of the paralyzed palate and that turning the patient on his 
 side relieves it more effectively than does venesection, (c) Venesec- 
 tion was discountenanced by Trousseau and Traube. It is certainly 
 indicated only in robust individuals with strong hearts and tense 
 vessels; about 12 ounces of blood should be withdrawn; the chief 
 objection to venesection is the difficulty in diagnosis of cerebral hem- 
 orrhage. Any physician will admit that he has occasionally bled 
 patients with thrombosis, embolism, syphilis or tumor. In thrombosis 
 and embolism venesection increases the anaemia of the brain, and Crush- 
 ing has shown that the high tension is a vicarious effort to keep the 
 medulla supplied with blood. The same objection holds to compres- 
 sion of the common carotid, (d) Leeches and sinapisms are useless. 
 (e) The ice-cap may be used, but cannot influence the deep circula- 
 tion in the brain. (/) Evacuation of the bladder and bowels is indi- 
 cated. Two drops of croton oil will act in an hour or two and in 
 case of failure the dose may be repeated. Croton oil was Hughlings 
 Jackson's only remedy, (g) The diet should be fluid and adminis- 
 tered by the nasal catheter or by rectum, (h) The shin: decubitus is 
 prevented in practically all cases by care regarding posture and 
 cleanliness. Heat and sinapisms must be used with greatest circum- 
 spection because the hemiplegic side is prone to necrosis and inflam- 
 mation, (i) Symptomatic treatment of cardiac and of respiratory 
 failure is by champagne or ammonia, but this should not be given 
 until necessary ; treatment of restlessness or convulsions is by chloral 
 per rectum or by morphine which theoretically congests the brain but 
 quiets it without detriment. 
 
 3. The Keaction. — During the inflammatory reaction the treat- 
 ment is expectant and if possible should be conducted without drugs. 
 
 4. The Chronic Stage. — (a) Gentle massage of the muscles, 
 movement of the joints and alcohol rubs are instituted as soon as the 
 coma subsides. (&) Potassium iodide is indicated when the reaction 
 subsides, (c) As soon as the leg improves, in four to eight weeks, the 
 patient should be encouraged to sit up and walk, (d) The faradic 
 current is valuable after four weeks and, supplemented with massage 
 of the paralyzed groups and their antagonists, minimizes the con- 
 tractures, (e) Hydrotherapy: cool baths or rubs are efficacious except 
 in anaemic or poorly nourished individuals. Warm baths are to be 
 avoided in old people and strychnia in all cases. 
 
 V. Cerebral Embolism.— Embolism and thrombosis of a brain 
 artery result in brain softening (encephalomalacia), which is next 
 after hemorrhage in importance and frequency and is one of the best 
 known subjects in brain pathology. Brain softening from arterial 
 occlusion is not the " softening of the brain " known to the laity, who 
 give that name to progressive paralysis of the insane. Encephalo- 
 
CEREBRAL EMBOLISM. 935 
 
 malaria must not be confused with inflammatory softening (en- 
 cephalitis). Softening was first recognized by Abercrombie (1818) 
 and Kostan (1820), while those coming after them usually considered 
 it inflammatory. Virchow's researches on embolism confirmed the 
 views of Kostan and Abercrombie, while Cohnheim elaborated the 
 vascular relations, and Panum, Piltz, Prevost, Cotard and Cohn 
 worked out Virchow's views. 
 
 Etiology. — In embolism, Spierling found the kidneys involved in 
 77 per cent., the spleen in 54 per cent, and the brain in 22 per cent, 
 of cases, (a) About 90 per cent, are due to heart disease. Most com- 
 mon is acute endocarditis or acute exacerbations of chronic valvular 
 lesions, in which the embolism is benign (mechanical) or malign 
 (mechanical and septic). Calcareous fragments from the valves or 
 parts of torn valves, may be thrown into the brain. Of valvular dis- 
 eases, mitral stenosis produces embolism most frequently because of 
 stasis in the left auricle. Less frequent are cardiac clots formed in 
 the weak hearts of decrepid, cachectic subjects, in myocarditis or in 
 such acute diseases as typhoid. Weakened heart action and slow 
 circulation are never the only causes. (b) Atheroma of the arch and 
 aneurysm are far less frequent causes, as are (c) lung lesions, as tu- 
 berculous cavities, abscess, gangrene or empyema (after irrigation), 
 tumors, echinococcus, gumma or abscess of the heart, (d) In the 
 rarest instances lung tissue (Bottcher), fat embolism from fractures, 
 pigment embolism in malaria (Frerichs) or liver cells in acute yellow 
 atrophy may produce cerebral embolism, (e) With a patent foramen 
 ovale, thrombi may reach the brain from the venous system; it has 
 been observed in manual expression of the placenta. (/) Most cases 
 occur in youth (and middle age) when acute infections are most fre- 
 quent, as chorea, scarlatina or endocarditis. 
 
 Pathology. — (a) The embolus in fresh cases is gray-red and later 
 becomes paler, drier and more friable. The " riding emboli " straddle 
 the point of arterial branching; they may in rare cases soften and 
 disappear, or by slipping produce another embolism further on (La- 
 borde). Secondary thrombosis may occur at the infarction, (b) 
 The artery beyond, save where the embolus retracts or softens, be- 
 comes a thin, hard, impervious cord. Behind the plug an aneurysm 
 may form. If the embolus is septic, inflammation intervenes in and 
 around the vessel, (c) The fate of the brain tissue depends wholly 
 on (i) the degree of occlusion and (ii) the collateral circulation, (i) 
 If the stoppage is partial, only stasis, oedema and swelling occur ; if 
 total, necrosis results, (ii) The brain arteries are "end arteries," 
 as Cohnheim pointed out, whence complete collateral circulation is 
 unlikely, although the necrosis is rarely as extensive as the distribu- 
 tion of the artery occluded, even where, as in the basal ganglia the 
 anastomoses are few. There is more chance of collateral compensa- 
 tion at the cortex than at the base and the least collateral compensa- 
 tion occurs in the deep parts of the centrum ovale (Duret and Heub- 
 ner). The brain tissue is ischcemic or its blood is venous (Mar- 
 
936 DISEASES OF TBE KEUVOVS SYSTEM. 
 
 chand). The collateral vessels (arteries or venules) allow regur- 
 gitation around the focus, the vessels become more pervious and some 
 white and red cells often escape; this collateral fluxion saves the 
 tissue more often than is usually admitted, especially if the heart is 
 strong. With a weak heart or diseased collateral arteries, ischemic 
 necrosis must follow. Some pathologists hold that shutting off of a 
 large bloodvessel raises the tension in the adjacent (collateral) vessels 
 and thus causes the small capillary hemorrhages often observed ; but 
 a marked hemorrhagic infarct is not common, for it is prevented by 
 swelling of the nervous tissue (Weigert). Ischsemia lasting a few 
 hours probably produces necrosis, but microscopic changes are seen 
 only after one or two days ; the brain becomes cedematous, gelatinous, 
 grayish, marbled, fusing with the slightly (edematous brain tissue 
 surrounding the focus ; necrosis develops rapidly, the brain becomes 
 fluid and pulpy, although its remarkable cohesion is a matter of 
 frequent comment. The gray matter contains yellow plaques (v. i.) ; 
 certain convolutions may waste or disappear ; the gray and white sub- 
 stance, especially after plugging of the posterior cerebral artery, may 
 wholly disappear, as the hippocampus, lingual and fusiform lobules. 
 The white matter often disappears and is replaced by lax cellular 
 tissue, in whose meshes are cystic formations with turbid fluid and 
 flocculi of brain tissue. The meninges are often thickened. Durand- 
 Fardel described three forms of softening: (a) The red softening is 
 usually fresh and is found most often in embolism ; there is capillary 
 extravasation, which lends it the red color; it is irregularly oval or 
 wedge-shaped in basilar lesions ; it usually measures but a centimeter 
 or two ; it is prominent on section from blood and serum ; it is soft, 
 but not fluid in the centre ; is mostly located in the cortex or central 
 ganglia and lasts one or two weeks, (b) Yellow softening follows the 
 red ; the yellow color is due to old blood pigment or to fatty change ; 
 it is sunken on section, from atrophy of the brain substance ; is fairly 
 demarked and may contain fluid, hydrops ex vacuo; it may last years 
 and is found especially in the cortex, (c) White softening may rep- 
 resent (i) a fresh lesion about tumors or abscesses or in various ca- 
 chexias, is sunken below the cut surface and occurs where few vessels 
 are involved and little regurgitation from adjacent vessels occurs ; (ii) 
 lesions which are several years old, occurring when the blood and fat 
 are absorbed, whence their snow-white appearance ; demarkation is 
 often slight, and if diffuse gives rise to the spongy Stat crible. 
 
 Demarkation may occur after weeks, producing a " cyst " of spongy 
 structure and milky contents. More rarely neurogliar increase may 
 lead to shrinking and a scar may result. Microscopically myelin and 
 fat drops, leukocytes laden with granules and fat, collapsed vessels, 
 relics of necrotic nervous tissue and some increase in neuroglia are 
 observed. Location of embolism is considered on page 937. Secon- 
 dary degeneration occurs when the pyramidal tracts are involved 
 (see page 923). 
 
 Symptoms. — As in apoplexy, we consider (1) the insult and (2) the 
 
CmmUAL EMBOLISM. 937 
 
 permanent symptoms, to which might be added the symptoms of the 
 causal disease, e. g., those of mitral stenosis, etc. 
 
 1. The insult is almost always (a) sudden and without pro- 
 dromes (save when the embolism does not wholly occlude the vessel 
 and symptoms appear only when secondary thrombosis develops). 
 Embolism in a small vessel may occur without symptoms. The patient 
 may be stricken without coma and sit " astonished " at the stroke. 
 The insult is caused by brain ancemia, negative pressure and shock 
 (the etonnement cerebrate of Trousseau and Jaccoud). In some 
 cases (b) coma occurs, generally less profound and less protracted 
 than in hemorrhage; irritative symptoms, as (c) convulsions, tonic 
 spasms and conjugate deviation are more common; convulsions are 
 often unilateral, corresponding with the hemiplegia, (d) All possible 
 intermediate types of focal disease are observed; for instance, cases 
 with vertigo ; tendency to fall to one side ; hemianopsia, alexia, hemi- 
 anesthesia, motor or sensory aphasia or only confusion, delirium and 
 aphasia (Fagge). (c) The pulse is full but not slow. (/) The 
 temperature rarely suffers initial depression and later may rise. 
 
 2. The permanent symptoms and secondary degeneration are the 
 same as in hemorrhage. 
 
 Localization of Embolism. — 1. The Artery of the Fossa of Syl- 
 vius. — This is most frequently involved (80 per cent.) because it is 
 the largest and most direct branch of the middle cerebral which is 
 practically a continuation of the internal carotid. Convulsions occur 
 in 33 per cent., with or without loss of consciousness, and are most 
 frequent when the smaller branches are embolized. High tempera- 
 ture is common. The clinical picture varies with the site of infarc- 
 tion; embolism at A (Fig. 58) where the perforating branches 
 (P. P.) are given off to the internal capsule, corpus striatum and 
 anterior part of the thalamus, must involve (a) these structures, and 
 (b) the motor and sensory cortex, with hemiplegia, fairly complete 
 hemiancesthesia, motor aphasia (alexia), deafness and word deafness 
 (if it occurs on the left side). Convulsions are absent, because the 
 injured internal capsule cannot convey the cortical irritation to the 
 extremities ; the large areas at the base and cortex thus rendered 
 anaemic may cause marked reaction (Huguenin), sometimes resulting 
 in death. In rare cases only the central perforating branches are 
 involved and the cortex obtains the blood by anastomoses with the 
 posterior and anterior cerebrals. The left Sylvian artery is more 
 frequently involved, because the left carotid comes directly from the 
 arch; 59 per cent, are left-sided (Gelpkel). If the lesion is at (B) 
 (Fig. 58), the motor speech area, F3, which produces motor aphasia, 
 the anterior and posterior motor convolutions (A.C.C. and A.P.C.) 
 which produce hemiplegia or hemiparesis, the parietal convolutions, 
 gyrus angularis and gyrus supramarginalis (P2) which produce 
 alexia, and the temporal convolutions (Tl and T2) which produce 
 deafness or word deafness, are involved. Somnolence and delirium 
 are common ; convulsions almost invariably occur, because the internal 
 
938 
 
 DISEASES OF THE NEBVOUS SYSTEM. 
 
 capsule escapes. Convulsions and pain are most frequent in embolism 
 of the smaller vessels. Little hemiansesthesia is observed. A lesion 
 at (C) is the most frequent site. It affects the island of Eeil (I.E.) 
 in part; cortical convulsions, hemiplegia, monoplegia, sensory 
 aphasia (Tl, T2), alexia (P2) and sometimes sensory disturbance 
 occur. It is easily seen how an isolated lesion at (D) could produce 
 motor aphasia; at (E) a monoplegia; at (F) alexia; or at (G) 
 word deafness. 
 
 2. Posterior Cerebral Artery. — Embolism of the posterior 
 cerebral (in 2 per cent.) comes from the vertebral artery (and often 
 occurs with embolism of the Sylvian artery) ; it supplies (a) all the 
 
 Fig. 58. 
 
 Embolism of artery of the fossa of Sylvius. 
 
 IC, internal carotid ; PC, post, communicating ; AC, anterior cerebral artery ; AS, 
 art. fossse Sylvii and 1, 2, 3, 4 and 5, its main branches. CR, corona radiata from 
 cortex to internal capsule. (See text for explanation of lesions at A, B, C, D, E, 
 F or G.) 
 
 ventricles, the thalamus, ant. corp. quadrigemina, the geniculate body 
 and the peduncle by its central branches, and (b) the mesial aspect 
 of the occipital, part of the parietal and most of the temporosphen- 
 oidal lobes. The most common general symptoms are convulsions, 
 coma, vertigo, conjugate deviation and nystagmus; while the most 
 important focal symptoms are sensory hemianoesthesia, sensory 
 
CEREBRAL EMBOLISM. 939 
 
 aphasia and bilateral homonymous hemianopsia. The lesions are 
 sometimes symmetrical. 
 
 3. Embolism of the Anterior Cerebral Artery. — Few clear 
 cases are recorded, since the artery originates at a right angle to the 
 carotid. 
 
 4. Internal Carotid Artery. — In embolism of the internal 
 carotid (in 4 per cent.) the plug must be large to produce much dam- 
 age, for if the vessels of the circle of Willis are normal, only transient 
 hemiplegia results. Disease of these vessels or abnormalities in size 
 may produce permanent, alarming or fatal results. Secondary throm- 
 bosis is especially dangerous. Sepsis is a frequent factor. 
 
 5. Basilar Artery. — Embolism of the basilar artery occurs in 6 
 per cent. ; the clot never fills the vessel, because it first passes the 
 smaller vertebral artery; symptoms occur less frequently at the time 
 of embolism than later when secondary thrombosis occurs. They are 
 convulsions, trismus, paralysis of the third, fifth and seventh nerves, 
 crossed hemiplegia, diplegia, narrow pupils and conjugate deviation. 
 The temperature often falls low and then rapidly rises. Death may 
 follow in two to fi.ve days from respiratory failure. 
 
 6. Vertebral Artery. — Involvement of the tongue, larynx, lips, 
 pharynx and spinal branch of the fifth nerve result in anaesthesia, 
 dysphagia or other signs of acute bulbar palsy. Hemiansesthesia, 
 hemiplegia and hemiataxia may develop. It is often fatal. 
 
 7. Cerebellar Arteries. — This is the rarest of all embolisms. 
 Diagnosis. — The main points are (a) recognition of the cause, which 
 
 is usually cardiac; (b) absence of prodromes; (c) sudden insult, 
 frequent convulsions and infrequent coma. (For details and differ- 
 entiation, see table on page 943.) 
 
 Prognosis. — The outlook depends (a) on the primary disease, being 
 most favorable after acute infections and in youth; (b) on the in- 
 tensity of the onset itself, during which death may occur; (c) on the 
 localization; the initial symptoms may improve; the outlook is more 
 favorable than in hemorrhage. Psychical symptoms are cortical in 
 origin, while the vegetative or trophic are due to a lesion in the basal 
 ganglia; basilar and vertebral embolisms are most unfavorable, (d) 
 Eecurrence is possible, although it is less likely than usually stated. 
 (e) The condition of other organs, as the vessels of the circle of 
 Willis, the strength of the heart muscle, etc., determine the prognosis. 
 
 Treatment. — (a) The insult is treated as in hemorrhage in regard 
 to diet, keeping the patient quiet and general measures, (b) All 
 derivative measures, as drastics and venesection, are absolutely to be 
 avoided, (c) The heart must be steadied and stimulated, if hemor- 
 rhage is clearly excluded, with a view first of relieving the brain 
 ischsemia by a strong collateral circulation and second of strength- 
 ening the heart to avoid recurrence. Digitalis acts too slowly, and 
 camphor, strychnine and ammonia are preferable, (d) Convulsions 
 should be treated by chloral given by rectum, avoiding alcohol and 
 supporting the heart. The administration of more than a dram of 
 
940 DISEASES OF TEE NEBVOUS SYSTEM. 
 
 chloral in three hours is very dangerous ; gr. x to xv should be given 
 forty-five to sixty minutes apart, (e) The after treatment should be 
 followed out as in the corresponding stage of apoplexy. 
 
 VI. Cerebral (Arterial) Thrombosis. — Thrombosis is more com- 
 mon than embolism. Once it was thought that fibrin was thrown out 
 of the circulating blood by a ferment. Virchow held that slowing of 
 the current was the chief cause, while Zahn, Weigert and others 
 attributed great importance to coagulation necrosis of the leukocytes. 
 Bizzozero, later also Ebert and Schimmelbusch held that the blood 
 plaques played a large part in coagulation. Briicke taught that the 
 living healthy vessel prevented coagulation. 
 
 Etiology and Pathology. — 1. Changes in the Vessel Wale. — (a) 
 Arteriosclerosis (q. v.) is the chief cause of this most important 
 group. It affects the basal arteries especially and usually several 
 vessels. Blood plaques are deposited on the rough intima and in the 
 tortuous, inelastic, calcareous, fatty vessels, with their unequal 
 calibre ; layer after layer of fibrin is deposited, aided by local slowing 
 of the blood stream and by weakening of the heart. Thrombosis may 
 be local or extensive. Tumors, abscesses and traumatic meningitis 
 may initiate thrombosis. Brain atheroma usually occurs with gen- 
 eral atheroma (see Arteriosclerosis). The vessels most involved 
 are, in order of frequency, the carotid, middle cerebral and its Sylvian 
 branch, basilar, vertebral and posterior cerebral. (b) Syphilitic 
 endarteritis occurs in young subjects, 84 per cent, being found be- 
 tween the twentieth and fortieth years. The initial proliferation may 
 of itself, without thrombosis, obliterate the vessel lumen (see Brain 
 Syphilis). The pathological sequence is the same as in embolism; 
 ischsemia, necrosis (softening) and loss of function occur, save that in 
 gradual thrombosis the focus is less homogeneous than in the sudden 
 lesion of embolism. The foci are often multiple, for example, in the 
 Sylvian artery and in the posterior cerebral vessel of the opposite side. 
 
 2. Changes in Heart. — Sudden cardiac insufficiency in arterio- 
 sclerosis may precipitate thrombosis, as brought out especially by 
 Kolisko. An acute infection in the aged, low arterial tension from 
 exhaustion, grief and similar causes may precipitate encephalomalacia. 
 
 3. Changes of the Blood. — -This constitutes the smallest class of 
 cases. Burns, poisoning by carbon monoxide and illuminating gas, 
 gout, chlorosis, leukaemia, metallic poisons, jaundice and marasmus in 
 very young children or in extreme old age may cause thrombosis. 
 Mechanical factors, acute infections and heart weakness are frequent 
 factors in this class. Malarial thrombosis might possibly be included. 
 Thrombosis affects the smaller vessels and is usually multiple. 
 
 Symptoms. — In some cases thrombosis is found at necropsy without 
 previous symptoms ( " latency ") . 
 
 1. Prodromes. — These are frequent and may appear hours, days, 
 and even weeks or months before focal symptoms develop. The most 
 common are headache, which is severe in the syphilitic variety, ver- 
 
CEREBRAL THROMBOSIS. 941 
 
 tigo, tingling, numbness and weakness in a limb or in one-half of the 
 body, disturbance in sight, mental changes, poor articulation, irri- 
 tability, loss of appetite for work or change in character. 
 
 2. Onset. — The onset varies; (a) an acute onset with insult is 
 not frequent. If consciousness is lost, the coma is less deep and pro- 
 tracted than in hemorrhage ; a " stroke " indicates thrombosis in one 
 large or in several vessels. Conjugate deviation, flaccid ity and 
 paralysis are frequent during the coma. Consciousness is usually 
 preserved in the syphilitic type. With acute onset the later course is 
 usually slow, (b) The onset is usually gradual. Layer after layer is 
 added to the clot but strengthened heart action may for a time help 
 the collateral circulation. When the heart weakens, the clot increases 
 and the collateral blood supply decreases, so that, after alternating 
 advance and regression, the final thrombosis with irreparable isch- 
 semia and softening results. The cardiac strength and the number and 
 size of the vessels involved determine the acuity or chronicity of the 
 course. Reaction may be marked, especially in the aged, (c) In the 
 chronic or long latent variety, prodromes are absent, psychic altera- 
 tion is apparent and focal symptoms are usually developed. 
 
 3. Chronic Stage. — In the chronic stage focal symptoms, as 
 monoplegia, hemiplegia, hemianopsia or aphasia, are common. Apo- 
 plectiform seizures mark the advance of the process in new vascular 
 areas. The motor or sensory paralysis, at first transitory, is prone to 
 recur and presents much the same picture as hemorrhage and em- 
 bolism in their chronic stage. 
 
 Localization. — It is impossible to determine the localization when 
 multiple foci exist, as in the Sylvian artery of one side and the pos- 
 terior cerebral artery of the other; to the few reported cases Senator 
 adds one in which left-sided hemiplegia was associated with aphasia. 
 The favorite sites are the cortical branches of the Sylvian artery and 
 the branches of the posterior cerebral vessels. 
 
 1. Sylvian Artery. — The most common cause of this localization 
 is syphilis or atheroma. When the main trunk is involved, the same 
 symptoms appear as in embolism, viz., hemiplegia, aphasia, hemi- 
 ansesthesia and hemianopsia with this modification; the focal symp- 
 toms are more severe in thrombosis, because other vessels are some- 
 what diseased ; the general symptoms are less severe. Prodromes ap- 
 pear first, as vasomotor changes and tingling, then hemiplegia possibly 
 with delirium or loss of consciousness ; the symptoms may improve, 
 then there may be recurrence with aphasia and coma. The course 
 is a " step-like " progression and regression. Monoplegia is more 
 common than in embolism, because thrombosis seeks the cortical 
 vessels, whence the face and arm may be affected, aphasia may exist 
 alone, or alexia, mind blindness or deafness. When the basal arteries 
 are diseased, the vegetative functions are involved, that is. trophic 
 changes with involuntary evacuations occur (gdtisme). 
 
 2. Anterior Cerebral Artery. — This artery is rarely totally 
 occluded. A clot beyond the anterior communicating vessel often 
 
942 DISEASES OF TEE NERVOUS SYSTEM. 
 
 produces crural monoplegia with some paresis of the arm. Very 
 gradual ancemia produces wasting without softening; sudden anaemia 
 produces softening. The brain may atrophy three to seven ounces, 
 with senile dementia, mania or hypochondriasis and though not strictly 
 softening, its close arterial connection is obvious. The frontal lobes 
 present the " worm eaten " atrophy, with abundant hydrops ex vacuo. 
 
 3. Posterior Cerebral Artery. — Thrombosis in this artery is 
 fairly common and may result in hemiplegia alternans oculomotoria, 
 hemihypgesthesia and hemianopsia with irregular defects in the 
 crossed fields ; optic changes vary accordingly as the optic radiation, 
 cuneus or other parts are affected. 
 
 4. Basilar Artery. — If the thrombosis is acute the symptoms are 
 like those of embolism. If slow, ophthalmoplegia may develop which 
 is rarely lasting, or other motor paralyses, hemiplegia with alternating 
 palsy of the fifth, sixth and seventh nerves. 
 
 5. Vertebral Artery. — (a) Acute bulbar palsy, with stormy 
 symptoms, cannot be distinguished from embolism; or (b) subacute 
 bulbar palsy, with dysphagia, paralysis of the larynx, disturbed artic- 
 ulation, hemianesthesia, homolateral ataxia, contralateral hemi- 
 analgesia or hemiplegia with crossed paralysis of the tongue may 
 result from this localization. 
 
 Diagnosis and Differentiation. — The prodromes, gradual onset and 
 cortical location are most distinctive, although the analysis may be 
 greatly confused and differentiation of complicating conditions in the 
 heart and kidneys may be wholly theoretical or impossible. (See 
 Table, page 943.) Thrombosis may be confused with brain tumor, in 
 which the course is slower, stabile focal symptoms less frequent, head- 
 ache, vomiting and convulsions more frequent than permanent paraly- 
 sis ; and choked disk and Jacksonian epilepsy are frequent. In this 
 connection, we may consider hemiplegia in the aged and Marie's 
 les lacunes de desintegration cerebrale; degeneration clefts occur, 
 chiefly in the large basal ganglia, sometimes in the internal capsule or 
 pons (25 per cent.) and but seldom in the centrum ovale (13 per 
 cent.) ; there are usually several foci. Marie holds that the lesion 
 is a rarefaction (cavity formation) of the brain tissue due to chronic 
 sclerosing encephalitis, without vessel occlusion. It is said to cause 
 90 per cent, of " insults " in the aged, which occur usually with 
 partial paralysis; sometimes with aphasia, dysarthria or dysphagia; 
 rarely with loss of consciousness ; and never with sensory disturbance 
 or contractures. The gait is the demarche a petits pas. The prog- 
 nosis is fairly good; great improvement may occur and the patient 
 may live eight to ten years, though hemorrhage may intervene. 
 
 Prognosis. — The prognosis depends on (a) the cause; it is unfavor- 
 able in arteriosclerosis, because collateral vessels are probably dis- 
 eased and the cause is progressive. If the other vessels are sound, 
 enormous disease may be compensated, as in Kussmaul's case of oc- 
 clusion of both the subclavian and carotid arteries. In recent syphilis 
 the prognosis is more favorable, though old specific thrombosis is 
 
CIRCULATORY DISEASES OF THE BRAIN. 
 
 943 
 
 Hemorrhage. 
 
 (1) Predisposing etiology. Before 
 third year (glioma j; 80 per cent, 
 after fortieth year. 
 
 Miliary aneurysms ; atheroma and 
 cardiac hypertrophy. 
 
 Heredity. Nephritis; cause in 33 
 percent, "granular kidney." 
 
 (2) Attack precipitated by heavy 
 meal, acute alcoholism, high art. 
 tension (excitement, effort, shock). 
 
 (3) Prodromes unusual, unless from 
 causal arteriosclerosis. 
 
 (4) Insult : Usually sudden ; with- 
 out prodromata; long duration 
 (fatal if more than two days); 
 Cause ; positive pressure produc- 
 ing brain anaemia. 
 
 (5) Intra-cranial pressure: "Pres- 
 sure symptoms" present, polyuria, 
 albuminuria, glocosuria, red face, 
 beating arteries, Cheyne-Stokes 
 breathing ; slow, hard pulse is the 
 fundamental difference (Brissaud); 
 bruit de gallop speaks strongly for 
 hemorrhage. Irregularity, if com- 
 bined with strength not against 
 hemorrhage. Pulse may be fast 
 (Brissaud). 
 
 (6) Temperature: Rectal temperature 
 usually depressed at first, may fall 
 till death. May rise later (inflam- 
 matory reaction). Early rise (pons, 
 medulla, ganglia). Sudden rise of 
 bad omen ; rises before death. 
 
 (7) Coma: More frequent, greater 
 in degree, longer in duration, usu- 
 ally complete. If lesion seems 
 small, coma speaks for hemorrhage. 
 Deep and prolonged speaks for 
 hemorrhage and usually fatal if 
 over twenty-four hours. 
 
 (8) Paralysis, sudden, complete, 
 hemiplegic, non-progressive after 
 first seizure. Foot gains more 
 rapidly than hand. Persistent 
 aphasia exceptional. Spasmodic 
 laughing and weeping common. 
 
 (9) Convulsions: Usually general- 
 ized ; very rare from cortical irri- 
 tation or in corpus striatum ; post- 
 hemiplegic are rare. 
 
 (10) Sensation: Anaesthesia usually 
 transient. 
 
 Postplegic chorea, trembling, atheto- 
 sis, common. 
 
 (11 ) Atheroma retinal arteries, hence 
 retinal hemorrhage (not significant 
 unless large). Aneurysms very 
 rare but speak strongly for hemor- 
 rhage. Retinitis albuminurica. 
 
 (12) Secondary reaction ; not much. 
 Psychical symptoms ; far less. 
 
 Thrombosis. 
 
 After eightieth year more frequent 
 than hemorrhage. Twentieth to 
 fortieth year syphilis (of which 84 
 per cent, occur between these 
 years). 
 
 Weak irregular heart ; fevers, 
 cachexia. Atheroma, especially 
 syphilis, alcoholism, plumbism. 
 
 Rare. 
 Rare. 
 
 Low arterial tension ; by sleep, 
 grief, exhaustion, fatigue. 
 
 Very common, mental irritability, 
 weak memory, headache, vertigo, 
 numbness, tingling, weakness in 
 extremities. 
 
 Rarely acute onset (unless in a 
 large vessel) ; usually gradual, 
 especially in senile softening. 
 If an insult, focal and general 
 symptoms usually appear during 
 the coma. 
 
 None. 
 
 Pulse soft, weak. 
 
 Initial depression, usually lasting. 
 Seldom temperature unless lesion 
 in pons. More probably early 
 reaction. Especially in the aged. 
 
 Less frequent and shorter. Recovery 
 possible after several days of coma. 
 None in syphilitic thrombosis. If 
 lesion seems large, consciousness 
 speaks for softening. If coma, usu- 
 ally focal symptoms are then seen 
 Coma in large bilateral lesions 
 
 Gradual, incomplete, monoplegia, 
 hemianopsia ; repeated, often sym- 
 metrical paralysis. 
 
 Converse 
 
 Aphasia common Absence of focal 
 symptoms rather more common 
 (central ganglia). Laughing and 
 weeping exceptional. 
 
 Less than in embolism. More local- 
 ized, Jacksonian epilepsy speaks 
 for softening. May recur. Post- 
 plegic frequent. 
 
 Paraesthesia persists and more 
 marked. Cerebral pains (hyper- 
 esthesia dolorosa) . 
 Less common. 
 
 Arteriosclerosis. 
 
 Greater secondary reaction. 
 Often greater ; intelligence, mem- 
 ory aphasia, word deafness, etc. 
 
 Embolism. 
 
 Youth ; hemorrhage practi- 
 cally never in youth. 
 
 Endocarditis (rheumatism, 
 sepsis), especially mitral. 
 Weak, fatty, dilated heart. 
 In heart disease Eichhorst 
 found in 60 per cent, hem- 
 orrhage and in 40 per cent, 
 embolism. 
 
 Rare 
 
 Rare. 
 
 By exertion, dislodging 
 clot. 
 
 Absolutely none. 
 
 Sudden, shorter and less 
 severe than in hemorrhage. 
 Cause ; negative pressure. 
 Slow insult only with sec- 
 ondary thrombosis. 
 
 None (pallor 
 congestion). 
 
 rather than 
 
 Temperature may rise high 
 at once without bad omen 
 Temperature no absolute 
 guide ; occurs especially 
 when large trunk embol- 
 ized. 
 
 No coma usually. 
 
 More like hemorrhage. 
 Monoplegia rare. In 63 
 per cent it is in the left 
 side of the brain. 
 
 Fairly common. 
 
 More common (33 percent.) 
 than in hemorrhage or 
 thrombosis (lesion corti- 
 cal). 
 
 Ditto. 
 
 Less common. 
 
 Optic retinitis sometimes 
 from endocarditis (Broad- 
 bent and Mackenzie). 
 
 Occasionally embolism in 
 retinae. 
 
 Very seldom ; after attack 
 may be some delirium. 
 
944 DISEASES OF THE NERVOUS SYSTEM. 
 
 incurable. The younger the patient the better is the outlook, (b) 
 The onset; a brusque beginning is unfavorable because most cases 
 of this class die. Coma indicates thrombosis in large vessels or in 
 both hemispheres and is therefore ominous. If there is no insult the 
 focal symptoms are usually irreparable, i. e., there are no indirect 
 symptoms. The first seizure does not usually threaten life, (c) The 
 location and extent of the lesion. The number of vessels involved 
 is obviously important. In Sylvian thrombosis involving the 
 branches to the central ganglia, cachexia and more trophic disturb- 
 ance occur and the patient dies in four to six weeks with involuntary 
 evacuations and bed-sores (Marie). Cortical lesions, on the other 
 hand, are more prone to produce psychical alteration. Basilar or 
 vertebral thrombosis is directly dangerous, (d) The focal symp- 
 toms are likely to persist and recur. Ophthalmoplegia may regress. 
 (e) The condition of other organs, above all that of the heart, is of 
 prognostic import. 
 
 Treatment. — (a) The general treatment is the same as in hemor- 
 rhage and embolism, (b) The causal treatment relates to the iodides, 
 which are of value in atheroma and are specific in early syphilis. 
 (c) The heart must be stimulated with strychnine, digitalis and 
 strophanthus ; absolute quiet in the prone position and free adminis- 
 tration of food and fluid by rectum and by nasal catheter are indi- 
 cated. Drastics and all depleting measures must be avoided. On the 
 heart devolves the entire possibility of collateral compensation, (d) 
 In the period of reaction alcohol should be avoided, for it accentuates 
 the inflammation. For delirium and headache, bromides are most 
 useful; no cardiac depressants, chloral or coal-tar products may 
 be used, (e) The chronic stage is treated as in hemorrhage. At all 
 times catheterization must be conducted antiseptically and great care 
 exercised against bed-sores. 
 
 VII. Intracranial Aneurysms. — Etiology. — Aside from miliary an- 
 eurysms, aneurysms may occur in the large brain vessels. They are 
 seen in 0.2 to 1 per cent, of autopsies. They are more frequent in 
 males (60 per cent.) and in middle age, although they may visit 
 either extreme of life and a few more (53 per cent.) occur before 
 than after the fortieth year. The causes are those of aneurysm else- 
 where (q. v.) ; they are (a) atheroma in whose causation alcohol is 
 particularly important; (&) trauma, initiating arteritis, especially in 
 the internal carotid, as after basal fracture (Killian) ; (c) syphilis, 
 especially productive of basilar aneurysm, which often occurs within 
 a year after infection; (d) embolism, the most frequent cause in 
 early life. Endocarditis is the usual cause when trauma and syphilis 
 are excluded (Lebert and Church). The embolus produces arteritis 
 from which the vessel dilates. The clot may later disappear. 
 
 Pathology. — Location. — The statistics of Lebert, Durand, Bartho- 
 lon and Osier combined show the following frequency ; middle cere- 
 bral, 29 per cent. ; basilar, 26 per cent. ; internal carotid, 14 per cent. ; 
 
SINUS THROMBOSIS. 945 
 
 anterior cerebral, 8 per cent. ; anterior communicating, 6 per cent. 
 They are rather more frequent on the left side, in 20 per cent, are 
 multiple, are usually sacculated, of the size of a pea or walnut (rarely 
 large as an egg) and are genuine aneurysms involving all coats. 
 
 Symptoms. — Symptoms may be absent until rupture occurs. They 
 are (a) general, as headache, which is the most common sign, or 
 convulsions, which result from aneurysm of the Sylvian branch; a 
 systolic murmur, neuralgia or epileptiform seizures may be noted. 
 (b) They may be local; according to their location, hemianopsia, 
 paralysis of the ocular nerves, hemiplegia, optic neuritis (extension 
 of inflammation from the sac), aphasia and symptoms referable to 
 the pons or medulla may be noted. Rupture occurs in 75 per cent. ; 
 (i) into the meninges or (ii) into the brain substance or ventricles, 
 from which death rapidly results ; healing has been observed. 
 
 Diagnosis. — Rupture is often the first symptom and differentiation 
 from hemorrhage is therefore necessary. A general cerebral hemor- 
 rhage in a young individual with a history of trauma, heart disease 
 or syphilis is rather suggestive of aneurysm, especially when the 
 location is basilar. If symptoms have been present they are often those 
 of a basal tumor; syphilis (q. v.. Cerebral Syphilis) and trauma 
 are causes of tumor and aneurysm, but iodides and mercury usually 
 are not beneficial in aneurysm. The murmur is suggestive but is 
 rare and may be found in tumors which compress vessels or in very 
 vascular brain tumors. The location of the aneurysm is important ; 
 they are most often embolic in the Sylvian and specific in the basilar 
 artery. Loss of sight in an eye, sometimes with impairment of smell, 
 rather indicates aneurysm of the anterior cerebral or, if the eye mus- 
 cles are paralyzed, of the internal carotid artery. Oculomotor paraly- 
 sis without loss of vision suggests aneurysm of the posterior communi- 
 cating artery. Some cases closely resemble arterial thrombosis. 
 
 Treatment. — The indications are the same as in aortic aneurysm 
 (q. v.), viz., rest and iodides. Surgical intervention is occasionally 
 opportune, as ligation of the carotid. 
 
 VIII. Sinus Thrombosis. — The marantic form was known to the 
 oldest authors, while Abercrombie, von Dusch and Bright described 
 the pysemic form. Lebert (1854) diagnosticated the first case and 
 with Tonnele built up its clinical recognition. 
 
 Etiology and Pathology. — There are two varieties, (1) the marantic 
 and (2) the inflammatory types. 
 
 1. Marantic thrombosis of the sinuses and veins is the primary 
 non-inflammatory type, due to altered blood states and weakened cir- 
 culation. It occurs (a) in children mostly, especially in the first six 
 months of life and after acute infections, particularly infective diar- 
 rhoeas; (b) less frequently in the aged from weak heart and venous 
 stasis; (c) in cachexia, from cancer, gout and tuberculosis; (d) in 
 the anaemia of pregnancy and in chlorosis; (e) compression of veins 
 or sinuses, as by tumor, is rare. Its most frequent site is the superior 
 longitudinal sinus, especially in children, because the sinus is fixed, 
 60 
 
946 DISEASES OF THE NERVOUS SYSTEM. 
 
 its lumen is triangular and irregular, crossed by trabecules and com- 
 pressed by the Pacchyonian granulations ; the tributary veins empty 
 against the current of the sinus, the veins ascend and their stream is 
 very weak. Gowers believes that thrombosis in veins entering the 
 superior longitudinal sinus may cause hemiplegia in children. Ex- 
 perimentation shows that simple slowing of the current is not suffi- 
 cient for coagulation and that the vessel wall must be altered; in 
 chlorosis there is fatty degeneration of the endothelium. In the 
 aged, marantic thrombosis rather elects the cavernous or transverse 
 sinus. The older the antemortem clot the lighter is its color and the 
 more laminated and adherent it is to the sinus wall, wherein it differs 
 from the reddish, loose and separable postmortem clot. The marantic 
 clot may be total, occluding the vessel, or partial. It may be short 
 or fill the whole sinus and enter the tributary veins which are then 
 seen as firm cords over the hemispheres. 
 
 2. The inflammatory thrombosis, thrombophlebitis, is secondary to 
 disease near the sinus ; as (a) ear disease, chiefly chronic, sometimes 
 acute, suppurative otitis media, caries of the bone, sometimes syphilis, 
 tuberculosis or cholesteatoma. Infection from the ear reaches the 
 sinus by (i) infecting the mastoid cells, which infect the transverse 
 sinus; (ii) by the passage of the virus from the middle ear to the 
 sinus by infecting small communicating veins (Politzer) or (iii) its 
 passage along the petromastoid canal (Voltolini). (b) Acute infec- 
 tions, with otitis media; (c) sepsis, puerperal fever, pyaemia; (d) 
 trauma, tuberculous meningitis, erysipelas, disease of the orbit, nose 
 and face. The most common sites are the transverse, petrosal and 
 cavernous sinuses, whence it may extend to their branches. The clot is 
 puriform, foetid, soft, discolored and contains pyogenic organisms; 
 the process is frequently associated with meningitis and brain abscess. 
 
 In both types brain changes may result, as oedema, swelling or 
 softening of the cortex. Most frequently the thrombosis is bilateral ; 
 suggillations in the pia, bloody imbibition of the brain or reddening 
 of the cerebrospinal or ventricular fluid may occur. Pulmonary 
 infarcts occur in 50 per cent, and are simple or septic according to 
 the type of thrombosis. 
 
 Symptoms and Diagnosis. — Clinical signs may be absent or ob- 
 scured by the primary affection. Diagnosis depends upon signs of 
 (1) extra- and (2) intracranial venous stasis. 
 
 ^ 1. Extracranial Stasis. — (a) In thrombosis of the superior lon- 
 gitudinal sinus, stasis in the nasal veins is often shown by epistaxis 
 (connection through the foramen caecum) ; this was first observed by 
 von Dusch. It is an effort of nature to deplete the cerebral congestion. 
 Gerhardt observed cyanosis in the anterior frontal veins and oedema, 
 especially in children, in the temples between the great fontanel! e 
 and ear (by way of the emissaria Santorini through the foramen 
 parietale). (Edema is often absent in chlorotic thrombosis, (fe) In 
 thrombosis of the cavernous sinus stasis develops in its tributaries, 
 producing exophthalmos, oedema of the lids and conjunctiva (vena 
 
SINUS THROMBOSIS. 
 
 947 
 
 ophthalmica) ; retinal stasis, more rarely choked disk or retinal 
 thrombosis, results from congestion of the vena centralis retinae. 
 Sometimes oedema of the forehead results from stasis in the vena 
 facialis ant. Epistaxis is rare, (c) In thrombosis of the lateral 
 sinus a hard, tender oedema behind the ear (Griesinger) and in the 
 
 Fig. 59. 
 
 COMMUNICANS WITH THE NECK 
 
 Diagram showing the connections* of the transverse and cavernous sinuses (Leube). 
 
 neck (communicating with the posterior auricular vein) occurs in 
 over 50 per cent, of cases. Occasionally the swollen thrombotic in- 
 ternal jugular vein may be felt. The external jugular frequently col- 
 lapses, or if the internal jugular is thrombosed it becomes overfilled 
 (Gerhardt). In 33 per cent, the disk is hypersemic and in another 
 33 per cent, there is choked disk from complicating abscess or men- 
 ingitis (Jansen). (d) In thrombosis of the sinus petrosus Gowers 
 questions whether any signs are distinctive. 
 
 2. Intracranial Stasis. — Progressive clouding of the mind, de- 
 lirium in adults, convulsions in children, conjugate deviation of the 
 eyes and head, stiff neck, vomiting, headache, irregular pupils, nys- 
 
948 
 
 DISEASES OF TEE NERVOUS SYSTEM. 
 
 tagmus or strabismus are noted. Hemiplegia and sensory symptoms 
 are occasional. Bilateral symptoms, as paraplegia, are due to the 
 involvement of the veins in both hemispheres or more often to menin- 
 gitis. Bouehut thought that antemortem convulsions in children were 
 often thrombotic in origin. Many of these symptoms resemble the 
 hydrencephaloid (Marshall Hall) of brain anaemia. The fontanelles, 
 sunken at first in infantile diarrhoea, may later become prominent 
 (increased cerebrospinal fluid). Sometimes in chlorotic thrombosis 
 the process may extend to the vena Galeni magna, producing hydro- 
 cephalus internus and resulting in early stupor, coma and death. 
 Irritation or paralysis of the third, fourth and sixth nerves may oc- 
 cur because of their intimate relation to the cavernous sinus ; involve- 
 
 FlG. 60. 
 
 VEINS COMMUNICATING THROUGH 
 THE PARIETAL FORAMEN WITH 
 THE EXTERNAL SKULL VEINS. 
 
 CONFLUENS 
 SIM. 
 
 1\ /■ 
 
 VENA JUGUL.INT. 
 
 VENA JUGULARIS EXT. 
 
 Leube's diagram showing the connections of the superior longitudinal sinus with the 
 
 external veins. 
 
 ment of the first branch of the fifth nerve may result in ophthalmia 
 neuroparalytica. Rarely is there paralysis of the hypoglossus and 
 spinal accessory. 
 
 Other Symptoms. — Other symptoms are those of the causal affec- 
 tion. The temperature is often normal in the simple variety. The 
 pulse is slow at first and rapid later. The thrombophlebitic variety 
 is usually attended by fever, chills, sweats, diarrhoea and other septic 
 manifestations. 
 
 Differentiation. — Differentiation from meningitis (q. v.) and 
 brain abscess (q. v.) is often impossible; the cause, the extracranial 
 stasis and evidences of sepsis are of diagnostic importance. Korner 
 held that metastases occur in the lungs from sinus thrombosis and in 
 the bones and joints from mastoid caries. 
 
INFANTILE CEREBRAL PARALYSIS. 949 
 
 Prognosis. — The prognosis is almost always unfavorable; death 
 occurs in the second week, or possibly later. A few recoveries from 
 both types are on record. Local atrophy of the brain has resulted 
 after recovery from the marantic type. 
 
 Treatment. — Prophylaxis relates chiefly to the otitic variety, because 
 discharges from the ear are much too lightly regarded by the laity. 
 In marantic thrombosis stimulation and avoidance of constriction of 
 the neck are the chief indications. In septic types operation is indi- 
 cated ; recovery is most likely when there is early diagnosis and early 
 operation. Opening and packing the lateral sinus was first performed 
 by Zaufal in 1884. He also recommended ligature of the internal 
 jugular veins, which was first performed by Thersley and Lane in 
 1888. Eecovery occurs in 50 per cent, of operated cases and in 72 
 per cent, of Macewen's series. Eecovery has occurred even with com- 
 plicating lung abscess (Ballance). Gravitating pharyngeal abscess 
 and extradural foci also necessitate surgical interference. 
 
 IX. Infantile Cerebral Paralysis. — Cerebral infantile palsy is 
 classed under circulatory diseases because of the frequent etiological 
 hemorrhage, embolism and thrombosis. Pathologically it is some- 
 times described under encephalitis, sclerosis or porencephalia. Clin- 
 ically it is variously classed according to the dominant syndrome, 
 hemiplegia, diplegia, Little's disease, paraplegia, hemiathetosis and 
 athetosis. The disease is a clinical picture, but with varying etiology 
 and pathology. Osier, Sachs, Striimpell, Freud and Rie have con- 
 tributed most valuable monographs. 
 
 1. The Hemiplegic Form. — Etiology. — It is equally frequent in 
 either sex. Most cases occur in the first year. Gowers finds 60 per 
 cent, in the first two years, 75 per cent, in the first three and 88 per 
 cent, in the first five years of life. Infections, as scarlatina, measles, 
 less frequently variola, pertussis and diphtheria are apparent, and 
 heredity, maternal syphilis and trauma are doubtful causes. The 
 causes may operate before, during or after birth. The pathology is 
 considered under the next type. 
 
 Symptoms. — (a) Initial symptoms, present in 66 per cent., are 
 severe in character, consist of fever, vomiting, convulsions, delirium 
 and coma, and last from a few hours to several days. Convulsions, 
 present in 50 per cent., are often unilateral and are usually followed 
 by coma. In 33 per cent, of cases the onset is insidious. (&) The 
 paralysis (hemiplegia) usually develops when consciousness returns. 
 It is more frequently right- than left-sided. The lower face is in- 
 volved, but usually soon improves, the leg improves more than the 
 arm and hand, and the paralysis, at first flaccid, soon becomes 
 spastic and permanent. Sometimes the eye muscles are involved 
 and hemianopsia may be noted. The tactile and stereognostic sense 
 may be somewhat reduced, but sensation is slightly implicated, be- 
 cause the other hemisphere compensates, (c) The residual symptoms 
 are the same as in adults, with some exceptions; the paralysis is 
 
950 
 
 DISEASES OF THE NEBVOUS SYSTEM. 
 
 %c (spastic infantile hemiplegia, Heine) but also atactic and 
 athetotic. Because it occurs in the young growing body and brain, 
 marked trophic changes or, at puberty, retarded development appear, 
 intellection is retarded or actual idiocy results and epileptiform seiz- 
 ures are common. Contractures are frequent, the reflexes are in- 
 creased and the gait is somewhat impaired, the foot dragging. In 
 rudimentary {formes frustes) or benign cases the paralysis may 
 almost disappear and, after months or years, may be so replaced by 
 epileptic seizures, hemiathetosis, hemichorea, hemitremor (described 
 under hemorrhage) or hemihypertonia (rigidity with but little 
 paralysis) that the paresis readily escapes recognition. Aphasia is 
 rarely lasting; (a) reflex aphasia is very common in childhood from 
 fever or digestive difficulties; (b) the brain readily compensates in 
 childhood; (c) permanent aphasia indicates great or total loss of 
 intelligence. Trophic changes are in part a moderate atrophy and 
 in part lack of later development, though seldom so marked as in the 
 spinal type of paralysis. They are noted in the extremities, body, 
 sometimes the face and in the skull, which often thickens ; they are 
 most common in porencephalia (v. L). Epilepsy increases in fre- 
 quency after the paralysis and is rated at from 13 per cent, to even 
 QQ per cent.; it occurs (a) at the onset, (b) with the paralysis or (c) 
 a year or two later; it is not commensurate with the degree of 
 paralysis but is more marked in rudimentary palsy ; it may be slight 
 like a vertigo ; it is most often like the Jacksonian type, but may end 
 in total loss of consciousness. In infantile cerebral paralysis there are 
 less violence, initial cry, trauma, foaming at the mouth and fewer 
 involuntary evacuations than in ordinary epilepsy. After a decade 
 or more it often becomes very marked, although it may disappear 
 between the fortieth and fiftieth years. 
 
 Diagnosis. — The chief differential interest centres in its separation 
 from the spinal type (poliomyelitis) : 
 
 
 Cerebral Type. 
 
 Spinal Type. 
 
 Tendon reflexes. 
 
 Increased. 
 
 Decreased or abolished. 
 
 Muscular atrophy. 
 
 Only after a long time. 
 
 Eapid. 
 
 Electrical reaction. 
 
 Normal, or little quantita- 
 tive decrease. 
 
 Partial or total reaction of 
 degeneration. 
 
 Distribution of paralysis. 
 
 Hemiplegic — diplegic. 
 
 Chiefly monoplegic. 
 
 Intelligence. 
 
 Often involved. 
 
 Usually not. 
 
 Epilepsy and hemichorea. 
 
 Common. 
 
 Eare. 
 
 2. The Double Hemiplegic or Diplegic Form. — Etiology. — (a) Pre- 
 natal causes, apparent in 20 per cent., include fright, trauma, mal- 
 
INFANTILE CEREBRAL PARALYSIS. 951 
 
 nutrition or syphilis. These causes seem most common in cases which 
 develop athetosis, (b) Anomalies of labor, suggested by Little and 
 proven to be a factor by Sarah McNutt, include difficult or long 
 labor, malpresentation, resistant maternal tissues, twin pregnancy, 
 version, cord prolapse and instrumentation, although delivery by 
 forceps is less important than the causes calling for their use. As- 
 phyxia is an important etiological factor. Premature delivery is 
 also causal, possibly because the soft skull is injured (-Gowers) or 
 because venous stasis occurs from precipitate delivery, (c) Extra- 
 uterine causes include trauma and acute infections. 
 
 Pathology. — The pathology presents many obscure points. The 
 initial lesion cannot always be determined, (a) In the traumatic 
 class, meningeal hemorrhage causes 66 per cent, of the diplegic cases; 
 Sarah McNutt found hemorrhage spreading over the motor cortex 
 on both sides. It is promoted by asphyxia and the sliding of the skull 
 bones of one side under or over those of the other side ; hemorrhage 
 is often basal in head presentations and on the convexity in the 
 after-coming head. The blood is absorbed slowly, especially if the 
 brain is lacerated, resulting in atrophy of the motor areas of both 
 sides ; hemorrhage rarely results from hereditary syphilis. (6) Vessel 
 disease (18 per cent.) may be arterial (thrombosis, embolism or 
 hemorrhage) or venous (in the cortical veins, Gowers). (c) Strum- 
 pell advanced the views of Vizioli and Marie that acute encephalitis 
 in the motor cortex (poliencephalitis) causes the acute onset, an 
 argument largely based on analogy (poliomyelitis in children), 
 though seldom verified. 
 
 Chronic Lesions. — The most important are diffuse lobar sclerosis 
 and porencephalia, which are peculiar to infantile brain palsies : (a) 
 Diffuse lobar sclerosis and atrophy of the brain occur in 55 per cent. 
 (Osier). The meninges are normal or somewhat thickened. About 
 the atrophic areas and in the ventricles the cerebrospinal fluid is 
 increased. One or both hemispheres may be involved but usually 
 unequally. The lobe affected is shrunken, hardened and the white 
 matter is decreased, while the gray seems increased. The convolu- 
 tions are wasted and smooth or a worm eaten." The nervous tissue 
 is wasted, the neuroglia increased and the bloodvessels tortuous, some- 
 what thickened and their perivascular lymph spaces widened five- or 
 six-fold. The nature of the initial lesion is disputed; it is thought 
 to be encephalitis (Bourneville), poliencephalitis (Strumpell) and 
 embolism, (b) Porencephalia (Heschl, 1859) consists of loss of 
 brain substance and cavity formation. It occurred in 26 per cent, of 
 Osier's cases. The nature of the initial lesion causing porencephaly 
 is a matter of doubt; it is ascribed to agenesis, encephalitis or men- 
 ingoencephalitis, trauma during labor or to the uterus during preg- 
 nancy, or anaemic necrosis (Kundrat) ; the latter is the most widely 
 accepted view. It is most frequent in the distribution of the Sylvian 
 or occipital vessels. Most often it is congenital and then the convo- 
 lutions radiate from the' defect, while in those cases resulting post 
 
952 
 
 DISEASES OF THE NERVOUS SYSTEM. 
 
 natum, the convolutions stop short of the defect " as though cut off." 
 Bourneville and Sollier hold that the congenital type communicates 
 with the lateral ventricle, while the acquired form does not. Sixty- 
 six per cent, are bilateral and somewhat symmetrical, (c) The hyper- 
 trophic nodular sclerosis described by Bourneville consists of multiple ; 
 discrete, prominent, often umbilicated nodes the size of a quarter or 
 half dollar. They are overgrowths of the neuroglia. 
 
 Symptoms. — Diplegic cases are half as frequent as the hemiplegic. 
 Freud describes the following forms: (a) General rigidity, or Little's 
 disease, 33 per cent, of which are caused by asphyxia. The main 
 characteristics are (i) predominance of the rigidity over the paresis, 
 and (ii) predominance of the leg paresis over that of the arms, the 
 converse of adult cerebral paralysis (hemorrhage occurs most often 
 over the leg centres). Convulsions often usher in the symptoms. 
 
 Fig. 61. 
 
 Spastic paraplegia, cross-legged progression. (Dercum.) 
 
 which appear after birth or a few months later. The rigidity is gen- 
 eral but most conspicuous in the flexors and adductors, leading to un- 
 usual postures. The face is slightly involved, the maximum mani- 
 festation being spasm of the mouth; in rare cases the child cannot 
 nurse or swallow. Speech is slow in development and stuttering is 
 common. In 33 per cent, the head cannot be lifted or the trunk 
 
INFANTILE CEREBKAL PAH ALT SIS. 953 
 
 flexed, due to involvement also of the uncrossed pyramidal tracts. 
 The arms may be but slightly paretic, but the legs suffer extensor 
 spasm on movement and the toes turn down (talipes equinus or 
 equino-varus). The child learns to walk late, if at all, because of 
 the adductor rigidity, which may even cause crossing of the legs. 
 The reflexes are greatly increased. The intellect is somewhat affected 
 in 66 per cent. Nutrition in the paretic members is usually intact. 
 Later epilepsy is uncommon. The paresis may regress and the 
 mind improve, but the legs remain spastic, (b) Paraplegic rigidity 
 resembles type (a) except that the arms are but little or not at all 
 affected and the legs alone are rigid. The name Little's disease is 
 also given to this form. Strabismus is common (40 per cent.). Pre- 
 mature delivery is a factor in 50 per cent, of cases, (c) Paraplegia 
 is rare and is referred to extra-uterine causes or infantile infections. 
 The legs are rigid and paralyzed. In severe types there may be 
 strabismus and imbecility, (d) In bilateral spastic hemiplegia (spas- 
 tic diplegia) the symptoms may vary on the two sides. Mental de- 
 generation is frequent; nystagmus, convergent strabismus (25 per 
 cent.), bulbar symptoms and speech involvement (60 per cent.) are 
 frequent, (e) General infantile chorea is also called " choreatic 
 diplegia " ; asphyxia is a factor in 25 per cent. Its clinical charac- 
 ters are (i) paralysis, (ii) rigidity, (iii) chorea-like movements 
 which are irregular, usually slight in degree and wide in distribution. 
 (/) In bilateral athetosis the mind is less involved than in the pre- 
 ceding types. The paralysis may precede it or it may be primary. 
 
 Forms resulting from premature delivery are less subject to con- 
 vulsions, athetosis or mental changes and are more regressive than 
 those due to birth trauma or later acquired lesions. (See Diseases 
 of the Spinal Cord for the allied Family or Hereditary Forms, as 
 Hereditary (Friedreich's) Ataxia.) In all forms epilepsy may (i) 
 replace the regressing paralysis; (ii) remain so prominent that the 
 paralysis is overlooked; (iii) paralysis may appear only after years 
 of epilepsy, or (iv) may not appear at all, " cerebral paralysis with- 
 out paralysis." 
 
 Diagnosis. — The diagnosis cannot always be made at once, although 
 later, characteristic symptoms develop and leave little diagnostic 
 difficulty. Separation from the family spastic paralysis (q. v.) may 
 be difficult or impossible. As a rule, aside from compression of the 
 cord, confusing spinal cord disease is very rare in children. 
 
 Treatment. — Therapy is most unsatisfactory. In the initial stage 
 convulsions may be treated by chloral. Some regression in the 
 paralysis is frequent, but the hemiplegia, mental changes and epi- 
 lepsy are incurable. Marked improvement can be expected in the 
 syphilitic cases alone. Orthopedic devices are valuable. The result- 
 ing epilepsy is usually intractable and bromides are of little avail. 
 Flechsig advises their use in combination with opium. Operative 
 interference has been suggested. Twenty-five per cent, die from the 
 operation, but the surviving cases seem to improve, especially in re- 
 gard to the convulsions. 
 
954 DISEASES OF THE NERVOUS SYSTEM. 
 
 BRAIN TUMORS. 
 
 Etiology and Pathology. — Eichhorst found brain tumors in % of 1 
 per cent, of his cases. Sixty-six per cent, of tumors occur in the 
 male sex, especially glioma and tubercle, while sarcoma occurs equally 
 in the two sexes. Age. In the first decade, 18.5 per cent, of cases 
 are observed ; in the second, 14 per cent. ; third, 20 per cent. ; fourth, 
 18.5 per cent., and in the fifth, 14 per cent. (Gowers). The causa- 
 tion is that of neoplasms in general, as developmental errors, granu- 
 lomata, metastatic growths and parasites. Trauma is a certain but 
 infrequent cause; it may clearly cause growths, especially glioma, 
 acting as the "agent provocateur" in gumma, sarcoma, osteoma, 
 tubercle or aneurysm. The author has seen endothelioma of the dura 
 develop years after and directly at the seat of an unhealed skull 
 fracture. Syphilis may induce sarcoma. 
 
 Classification. — 1. The Infectious Granulomata. — (a) Tubercle 
 constitutes 50 per cent, of cerebral tumors, 50 per cent, being found 
 in the first and 75 per cent, in the first and second decades (Gowers). 
 The subject is usually poorly nourished and often exhibits lung 
 changes; 33 per cent, occur in the cerebellum, 33 per cent, in the 
 cerebrum and the remainder in the pons, central ganglia, crus, med- 
 ulla and corpora quadrigemina. With equal frequency they are 
 single or multiple and may number even 20 or 80. They originate 
 from the meninges or vessels of the brain substance and are firm, 
 rather rounded tumors, with grayish-red periphery and yellow case- 
 ated centre. Tubercles range from the size of a pea or walnut to that 
 of an egg or of the fist, from fusion of many small growths. They 
 grow along the lymph vessels, cause vascular thrombosis, present the 
 degenerations of tubercle of other tissues and may be shelled out of the 
 brain tissue, which is compressed and atrophied, but neither infil- 
 trated nor softened, (b) Gummata (see Brain Syphilis) occur 
 more frequently than statistics indicate, for they respond to treatment 
 and often disappear spontaneously. In the adult they are the most 
 common type of tumor. They are most frequent in the cerebral hemi- 
 spheres and pons and are rare in the cerebellum and central ganglia ; 
 they are most often the size of a pea or hazel-nut, sometimes larger 
 or miliary in size. Their centre is yellow-gray and their periphery 
 is reddish-gray, gelatinous, rich in cells and ultimately cicatricial. 
 Gummata are usually multiple. The adjacent brain tissue is not 
 infiltrated, but commonly softened and compressed. Microscopically 
 they closely resemble tubercle, but Virchow described them as more 
 nodose, angular, irregular, more distinctly connected with the dura 
 even when deeply located, more gelatinous and less caseated; both 
 have been confused with actinomycosis. 
 
 2. Eeuro-epithelial Growths. — (a) Glioma constitutes 25 per 
 cent, of brain growths ; 50 per cent, occur in the hemispheres, espe- 
 cially the cortex; 25 per cent, in the cerebellum and the balance in 
 the central ganglia, pons, medulla, crus and corpora quadrigemina. 
 
BRAIN TUMORS. 955 
 
 They occur more frequently in the brain than in the cord or retina, 
 to which three structures they are peculiar. Gliomata are, in 90 per 
 cent., single and are seen most frequently in adults (first to twentieth 
 year, 20 per cent. ; twentieth to fortieth year, 50 per cent. ; fortieth 
 to sixtieth year, 25 per cent., Gowers). Gliomata originate largely 
 in the gray substance, which they so closely resemble in tint that de- 
 tection is difficult at operation or indeed at autopsy, and secondary 
 hemorrhage or softening in them may be confused with primary 
 hemorrhage. Cases formerly called brain hypertrophy were prob- 
 ably gliomata. Their size varies from that of a pea almost to that of 
 a hemisphere. Glioma infiltrates without sharp demarkation rather 
 than compresses the brain tissue and does not form adhesions. The 
 cells resemble the neurogliar structure and usually have round or 
 oval nuclei; Klebs found ganglionic cells. Their processes are fine; 
 numerous and branched delicate band-like lines result from fiber 
 degeneration, (b) The rare cerebroma of Hayem was held by Vir- 
 chow to be heterotopic gray matter in the white substance, (c) 
 Adenoma of the pineal gland and hypophysis may be brought under 
 this heading, as also may (d) growths from the plexuses and (e) 
 neuromata. 
 
 3. Connective Tissue Tumors. — (a) Sarcoma is the most fre- 
 quent, and constitutes 20 per cent, of brain tumors ; it may develop in 
 the meninges, periosteum or vessels. It is most common in adults. 
 Though it infiltrates more than tubercles or gummata, it does so less 
 than would be expected. Many are well demarked and cause more 
 softening than infiltration. Its structure and degenerations are those 
 of sarcoma elsewhere. Though it is most commonly single, diffuse or 
 multiple sarcomatosis is sometimes encountered. Endothelioma (Zieg- 
 ler), cylindroma (Billroth), angiosarcoma and melanosarcoma are 
 but varieties. The sand tumors (psammomata) of the pineal gland, 
 Pacchyonian bodies and choroid plexus are sometimes described as 
 angiolithic sarcomata. The " pearly tumors" (cholesteatomata) are 
 formed of flat endothelial cells, (b) Benign connective tissue growths 
 (lipoma, fibroma and osteoma) are very infrequent. 
 
 4. Metastatic Tumors. — Cancer is not infrequent (7 per cent, of 
 brain growths), especially from mammary or lung carcinoma, just as 
 lung suppuration often secondarily involves the brain. It often in- 
 vades the hemispheres and basal ganglia and may attain huge dimen- 
 sions. Like sarcoma, it infiltrates. Cancer is very rarely primary. 
 
 5. Cystic Tumors. — Cysts may result from hemorrhage or soften- 
 ing, degeneration in neoplasms, infantile inflammations or defects 
 (porencephalia), trauma or inflammation in the choroid plexus. 
 Dermoids and teratomata are most rare. Parasitic cysts occur largely 
 in persons between the tenth and thirtieth years; echinococcus cysts 
 may be single or multiple; they occur chiefly on the surface of the 
 brain or in the meninges. Gysticercus cysts develop mostly on the 
 pia and arachnoid over the cortex along the sulci or in the ventricles. 
 They occur in %o of 1 per cent, in certain autopsies, though Diamond 
 
956 DISEASES OF THE NERVOUS SYSTEM. 
 
 (1899) could collect but 8 cases from the American literature; they 
 vary from the size of a pea to that of a hazelnut, are usually multiple 
 (200 in Snell's case) and contain clear fluid with black dots, the heads 
 of the parasites. Fibrous encapsulation and calcification may occur 
 later. The cysticercus racemosus may reach a great size. 
 
 6. Aneurysms. — Aneurysms have been considered. 
 
 Localization. — The localization in Gower's figures was: cerebrum, 
 42 per cent. ; cerebellum, 25 per cent. ; base, 11 per cent. ; pons, 8 per 
 cent. ; central ganglia, 7 per cent. ; medulla, 4 per cent. ; corp. quad- 
 rigemina, 2 per cent. ; crus, 1 per cent. 
 
 Symptoms. — In rare instances, tumor is found at autopsy without 
 clinical symptoms (latency). This is due to location of the tumor in 
 a " silent " or tolerant brain area ; it may occur in tuberculous menin- 
 gitis, mental disease, aneurysm, cysticercus, psammoma, cholestea- 
 toma or meningeal tumors, which slowly compress the brain. As a 
 rule, symptoms result from the following mechanisms: (a) Direct 
 pressure exerted on the brain, which may flatten the convolutions, ob- 
 literate the sulci, force open the skull fissures in children, absorb or 
 perforate the cranium. Pressure is conspicuous in growths of the 
 posterior fossa closed by the rigid tentorium. (&) Internal hydro- 
 cephalus, distention of the ventricles, may follow closure of the aque- 
 duct of Sylvius or compression of the veins, particularly of. the 
 choroid plexus and the vena Galeni magna, and especially by tumors 
 of the cerebellum and corp. quadrigemina. (c) The brain may be 
 softened by pressure on its vessels (Bouveret), inflamed, or hemor- 
 rhage may develop (as in glioma), (d) Infiltration or destruction 
 of the brain matter may result, (e) Meningitis, local as in gumma, 
 or general as in tubercle, may develop. (/) Auto-intoxication from 
 the growth is possible, as suggested by Klippel. (g) Distortion of 
 the cerebral or spinal nerves (Dinkier, Mayer) may cause their 
 degeneration, or changes in the posterior columns of the cord and its 
 posterior roots. 
 
 The symptoms produced are general (diffuse) and focal (local). 
 
 1. General Symptoms. — The general symptoms usually come 
 first in the evolution and include the following: (a) Headache is 
 present in almost all cases, is usually constant, with accessions (espe- 
 cially in the morning), is general, rarely unilateral, is severe enough 
 to keep the patient awake at night, is increased by alcohol, exertion 
 and coughing, and rarely corresponds with the tumor's site except 
 when the pain is persistently local and the tumor near the surface. 
 Headache is usually referred to irritation of the dural branches of 
 the fifth nerve, an explanation which is not always satisfactory. It 
 may be pulsating in aneurysm. (&) Choked disk is the most impor- 
 tant general symptom and occurs in 85 per cent. It consists of a 
 grayish-red swelling of the disk to even two or three times its normal 
 dimensions, which lessens its sharpness of outline and physiological 
 cupping; the arteries become less lustrous and smaller, the veins 
 turgid and tortuous, extravasations of blood and white patches of 
 
BRAIN TV MOBS. 957 
 
 fatty degeneration or exudation appear. (See Plate VII, Fig. 3.) 
 It is due to increased intracranial tension, which causes mechanical 
 hydrops of the optic sheath ( Schmidt-Rimpler, Matz, Schwalbe) or 
 to inflammation from choking of the veins by toxic products (Leber 
 and Gowers). It is bilateral (90 per cent.), although more marked 
 on the side of the lesion, is not an early symptom and depends neither 
 on the size of the tumor nor on its location. It is almost always 
 present in growths of the cerebellum and corp. quadrigemina, is less 
 frequent in cortical and meningeal localizations and is often absent 
 or appears later in those of the pons, medulla and corp. callosum. 
 There is often, but not always, limitation of the field of vision (sco- 
 toma for color and lessened acuity of vision). In many cases it 
 develops into atrophy, oftener still into stasis and blindness, while in 
 some it may regress or very rarely recur. Transitory amaurosis 
 results from compression of the optic tract or chiasm by the distended 
 third ventricle, (c) Convulsions occur in 50 per cent., are called the 
 " signal symptoms " by Seguin and may be general ; general tonic 
 precede clonic convulsions in no special order ; the pupils react poorly, 
 the skin reflexes are increased unless deep coma develops, the tendon 
 reflexes are not suspended, respiration is labored and coma occurs. 
 Convulsions are more frequently late than early. Slight seizures, 
 like the petit mal of epilepsy, may occur. Jacksonian epilepsy be- 
 longs to the focal symptoms, (d) Vomiting is usually an early gen- 
 eral symptom, indicating irritation of the vomiting centre (it is some- 
 times a focal symptom). It is of the cerebral type, occurring without 
 effort, nausea or pain, often on an empty stomach, as in the morning, 
 or at once after eating, regardless of the kind of food ingested ; it is 
 initiated by sitting up, turning of the head or excitement. Later 
 the tongue is often coated. Vomiting is closely associated with head- 
 ache and is due to intracranial pressure or meningeal irritation. 
 It is rarely absent in growths of the cerebellum or medulla, is very 
 frequent in disease of the corp. quadrigemina and occurs in 25 per 
 cent, of tumors in the hemispheres, (e) The sensorium is often in- 
 volved. The most common change is dulness, which often deepens 
 into stupor and coma. It is not surprising that tumors affecting 
 the association fibers and avoiding the motor centres may cause dis- 
 turbance of intelligence, judgment or memory only; they are fre- 
 quently discovered at autopsy in the frontal or temporo-sphenoidal 
 lobes in subjects committed to asylums for psychoses or general 
 paralysis. Hysteria may occur in subjects of organic brain disease. 
 (/) Vertigo is often an early symptom ; it may be mere " giddiness " 
 or it may affect the labyrinth, pons or cerebellum and be a sense of 
 actual rotation. It is present in 31 per cent. (Mills and Lloyd), 
 occurs especially in the locations mentioned and as a focal symptom 
 when the middle cerebellar peduncle is implicated, (g) Slowed pulse 
 may result from direct, but more often from indirect, pressure on 
 the vagus fibers behind and lateral to the hypoglossal nucleus. The 
 vagus fibers become accustomed to pressure of long standing and the 
 
958 DISEASES OF THE NEBVOUS SYSTEM. 
 
 heart rate increases. It is often associated with yawning, hiccough, 
 Cheyne-Stokes' breathing, glycosuria or polyuria. 
 
 2. Focal Symptoms. — Focal symptoms may be absent when the 
 disease is limited to " silent " or " tolerant " areas, when the tumor 
 does not destroy nerve structures and when vicarious compensation 
 by other parts is possible. Focal symptoms of irritation or paralysis 
 may result directly from actual lesion of a centre or its fibers or in- 
 directly from " distance pressure " upon them. They are, therefore, 
 most significant when no particular increase of intracranial tension 
 exists. 
 
 (a) Frontal Lobes. — The reported changes in mentality are much 
 discussed ; early observers, as Bernhardt, claimed that mental changes 
 were no more frequent in frontal localization than in localization else- 
 where. Many cases show the symptoms indicated above. Jastrowitz 
 describes a condition designated as moria, a dementia with character- 
 istic irritability and excitement. A tendency to make jokes (Witzel- 
 sucht) is described by Oppenheim. Psychical changes, especially 
 those developing early, justify a " probability " diagnosis only. 
 Allan Starr records the first diagnosis confirmed by operation. " The 
 two prominent characteristics of the mental state are apathy and 
 suffering, which may be associated or alternate" (Church). Early 
 or late mental alteration sometimes follows other localizations. Some- 
 times tumors in the frontal lobes are thought to be in the motor areas 
 from indirect pressure upon the latter. The head and eyes may 
 deviate and the neck and back are sometimes rigid. Bruns has re- 
 corded frontal tumors with cerebellar ataxia, which is caused by 
 unequal innervation with disturbance of the sensorium (Oppenheim) 
 or involvement of the trunk centres (Strumpell). Some would 
 associate with frontal lesions a lack of initiative. Bradyphasia 
 (slow speech) is probably psychical and differs from the separation 
 of syllables sometimes seen in tumor of the pons. In "laryngeal 
 aphasia " the patient moves his lips and attempts to speak, but finds 
 the voice lacking (Oppenheim). 
 
 (b) Motor Cortex. — (i) Jachsonian convulsions are often (50 per 
 cent.) dissociated, and follow a given sequence (see Cortex Locali- 
 zation) ; consciousness is often preserved unless the other side of the 
 body is involved. The convulsions may be few or run into the hun- 
 dreds (17,000 in eleven months, as reported by Gowers). They 
 may be preceded by the general convulsions described above. When 
 the conducting fibers are destroyed they cannot occur, whence they 
 may be observed in the part nearest the seat of greatest damage. As 
 long as convulsions are present the motor centres cannot be wholly 
 destroyed. Tapping the tendons or the skull may initiate spasms and 
 convulsions can sometimes be aborted by electricity, by grasping the 
 arm, etc. (ii) Cortical paralysis or paresis is usually monoplegic and 
 is associated with cortical spasm ; at first a weakness from exhaustion 
 follows the spasms; later it becomes more marked. In some cases 
 paresis (or total hemiplegia) may be the first sign of tumor and may 
 
BBAIN TUMORS. 959 
 
 be narrowly localized, as in the thumb alone, the four fingers or 
 great toe; paralysis is accompanied by increased reflexes, rigidity 
 and rarely by muscular atrophy. Surgical extirpation has relieved 
 both spasms and paralysis. In infrequent cases the paralysis may be 
 bilateral, as when a cortical tumor near the median line presses on 
 the opposite hemisphere or when there are bilateral symmetrical 
 growths; these, however, are still rarer, (iii) Sensory changes are 
 less frequent, because the sensory area is larger than the motor area 
 and extends posterior to it and it is possible that sensory representa- 
 tion is bilateral. (The gyrus fornicatus is thought by some writers 
 to be the seat of tactile and muscular sensibility.) Hypeesthesia, es- 
 pecially for tactile and muscular sensibility and paresthesia, are not 
 rare. Cortical pains are rare. Vasomotor symptoms, tachycardia 
 and salivation are observed, but are not localizing. 
 
 (c) Parietal Lobes. — Some sensory disturbance is fairly common. 
 Incoordinate movements, ataxia and athetosis have been observed. 
 Wernicke observed a tumor in the lower parietal lobe with conjugate 
 eye movements and Weil noted incoordination of the extremities on 
 the opposite, and of the eyes on the same side of the body. Sensory 
 aphasia, hemianopsia, deafness and word deafness are also observed. 
 
 (d) Temporal Lobes. — Symptoms may be confused with those of 
 the contiguous occipital lobes ; hemianopsia, disturbance of eye move- 
 ments, chiefly toward the opposite side, ptosis and agraphia are 
 recorded. 
 
 (e) Occipital Lobes. — Hemianopsia is the most constant finding; 
 it results from any occipital lesion large enough to compress the optic 
 radiation in the white substance (Henschen). Optical hallucinations 
 indicate a cortical occipital localization rather than one in the optic 
 radiation. Alexia, optic aphasia and psychical blindness are seen. 
 
 (/) Pons. — Focal may precede the general symptoms; they have 
 been enumerated under cerebral localization. Hemiplegia with alter- 
 nating paralysis of some of the first eight cranial nerves is the most 
 common type (in 50 per cent.). Foci in the substance of the pons 
 involving the sixth nerve usually also involve the third nerve of the 
 opposite side; foci near the surface involving the sixth nerve do not 
 involve the third nerve. Sometimes the nerves may be involved 
 without hemiplegia (25 per cent.), but rarely without crossed motor 
 irritation or hemianesthesia ; hemiplegia alone occurs in 25 per cent. 
 Unilateral tumor of the pons may also compress the opposite motor 
 tracts (paraplegia or diplegia) and cranial nerves. Motor irritation 
 is not uncommon, as trismus, facial spasm and sometimes trigeminal 
 neuralgia, convulsions in the contralateral limbs, etc. Tetanic rigid- 
 ity is rare. Sensory disturbance is usual, as a result of involvement 
 of the lemniscus and formatio reticularis and occurs as hemianes- 
 thesia cruciata (in arm and leg of one side and in the face of the 
 opposite side when the focus is low in the pons), hemianesthesia of 
 face, arm and leg of the same side (tumor in the upper pons) and 
 anesthesia of one or perhaps of both sides. Dysarthria, dysphagia, 
 
960 DISEASES OF TEE NERVOUS SYSTEM. 
 
 difficult urination or defecation and disturbed respiration on change 
 of posture have been observed. 
 
 (g) Medulla. — It is remarkable that not only cystic but also solid 
 tumors may produce no symptoms or only such that localization in 
 the pons or cord is first suggested. In a small number of cases only 
 are the symptoms not ambiguous. Bilateral paralysis of the ninth 
 to twelfth nerves with degeneration and atrophy of the lips, tongue, 
 palate, pharynx or larynx is characteristic and presents a picture like 
 progressive bulbar palsy. Alternating hemiplegia is rare. Sensory, 
 motor, atactic and nerve involvements are usually bilateral. Growths 
 outside the medulla may cause paralysis of the neck muscles. Slowed 
 or rapid pulse, singultus, embarrassed breathing, glycosuria and poly- 
 uria are not uncommon. Degeneration in the posterior columns of 
 the cord from pulling of the medulla on the posterior cervical roots 
 or from toxaemia was found by Batten and Collier (1889). 
 
 (h) Cerebellum. — Cerebellar ataxia, referred by Nothnagel and 
 Gowers to lesions of the vermis in 85 per cent, of the cases, occurs 
 but half as frequently in disease of the cerebellar hemispheres. 
 Compression of the pons, medulla, corpora quadrigemina and fifth to 
 twelfth cranial nerves is somewhat characteristic. Sachs regards 
 involvement of the sixth nerve as almost pathognomonic. Of the 
 general symptoms, choked disk is severe and almost invariable; occip- 
 ital headache and rigid neck are very frequent. Convulsions are 
 common and opisthotonos with tetanic rigidity of the body and ex- 
 tremities is most suggestive. 
 
 (i) Optic Thalamus. — In most cases spastic hemiplegia results 
 from invasion of the internal capsule; hemichorea, hemiathetosis, 
 hemianesthesia and Nothnagel's mimetic paralysis are not infre- 
 quent. Less common are unilateral convulsions, forced movements or 
 postures, contralateral hemianopsia, paralysis of the eye muscles, 
 widening of the opposite pupil and monoplegia. 
 
 (j) Corpus Callosum. — According to Bristowe, dementia (in 90 
 per cent.), absence of initiative in speech and action, paraplegia, 
 dysarthria and few general symptoms, as choked disk, are character- 
 istic. Oppenheim holds that there are no distinctive symptoms. 
 
 (k) Corpora Quadrigemina. — Paralyses of the third nerve are 
 common, sometimes associated as double ptosis, and bilateral paralysis 
 of the internal recti. The pupils are usually free. Oculomotor 
 paralysis may exist with crossed hemi ataxia from tegmental involve- 
 ment or cerebellar pressure. Disturbed hearing from destruction 
 of the upper layer of the tegmentum, amblyopia and intention tremor 
 are also observed. No paralysis, except of the third nerve, is present 
 unless the tumor extends beyond the corp. quadrig. (Oppenheim). 
 
 (1) Pineal Gland. — The symptoms are the same as when the corp. 
 quadrigemina are affected, save that the fourth and sixth nerves are 
 involved more than the third and compression of the pons or medulla 
 is more common. 
 
 (ra) Tumors at the Base. — These include bone tumors, aneurysms, 
 
BEAIN TUMORS. 961 
 
 hypophysis growths and those from the nerves or meninges, (i) In 
 the anterior fossa, hypophysis tumors (see Acromegaly) disturb 
 vision and produce bitemporal hemianopsia with amblyopia or some- 
 times irregular or transverse hemianopsia. In some instances there is 
 amblyopia of one eye and hemianopsia of the other. Usually there is 
 no choked disk, but simple optic atrophy is present. The third nerve 
 is paralyzed in most cases and sometimes other ocular trunks are 
 affected. Exophthalmos is occasional and the growth may perforate 
 externally into the eye, pharynx or nose. Loss of smell (anosmia) 
 and mental symptoms are observed in tumors of the anterior fossa, 
 (ii) When they occur in the middle fossa mental symptoms and con- 
 vulsions are less common. The Gasserian ganglion may be com- 
 pressed and result in neuroparalytic ophthalmia. Other cerebral 
 nerves, as the third and sixth, sometimes suffer. It must be recalled 
 that a tumor elsewhere may indirectly compress the basal structures. 
 Syphilis and sarcomatosis may be diffusely basal, (iii) Lesions in 
 the posterior fossa may simulate bulbar palsy. The lower eight 
 cranial nerves usually suffer more readily and earlier than the pyra- 
 midal tracts ; the grouping of the cranial nerve implication is differ- 
 ent; thus paralysis of the sixth nerve is rarely associated with the 
 conjugate fourth nerve, as occurs when the lesion is central. The 
 seventh and eighth nerves are often conjointly paralyzed in disease 
 of the posterior fossa and but rarely so in central tumors. The symp- 
 toms often resemble those of lesions of the pons, medulla or cere- 
 bellum. 
 
 Diagnosis. — Diagnosis depends upon the combination of focal and 
 general symptoms. Four general groups of cases are encountered : — 
 (1) Absolute clinical latency; (2) general and focal symptoms, the 
 typical case; (3) general but not focal symptoms; (4) definite symp- 
 toms of some brain disease but of equivocal significance. According 
 to Bruns, 80 per cent, of cases can be detected. 
 
 Analysis of the General Symptoms. — (a) Headache is sug- 
 gestive when it is severe, keeps the patient awake and when the skull 
 is tender to percussion or pressure (the parietal regions are normally 
 somewhat sensitive). Its associates, as choked disk or vomiting, are 
 equally important. Organic irritative brain disease, as abscess or 
 inflammation, may cause headache, but mere increase of intracranial 
 tension, as in hydrocephalus, need not do so. Functional nervous 
 disease may cause headache, as migraine, neurasthenia, hypochon- 
 driasis, hysteria ; it may result from eye disease, morbid conditions 
 of the blood or intoxications (uraemia, gastro-intestinal disorder and 
 poisoning by nicotine, opium, alcohol or lead), and from arterio- 
 sclerosis. '(b) Choked disk in 80 or 90 per cent, of cases indicates 
 brain tumor (Oppenheim) and if very marked it is seldom due to 
 other causes. It is less frequent in abscess and meningitis, in which 
 neuritis optica is more frequent. It is most rare in embolism, soften- 
 ing, hemorrhage, hematoma durse matris, arteriosclerosis, polienceph- 
 alitis, encephalitis, the acute fevers, lead poisoning, neuritis multi- 
 
 61 
 
962 
 
 DISEASES OF THE NERVOUS SYSTEM. 
 
 plex or alcoholism (in which central scotoma is present). Uraemia 
 must be excluded ; although the two diseases have much in common, as 
 headache, epileptiform or apoplectiform attacks, hemiplegia, aphasia 
 and slow pulse, neuroretinitis is more common in nephritis. The 
 choked disk of chlorosis is rare, but responds readily to rest and treat- 
 ment by iron. Optic atrophy has the same significance as choked 
 disk, (c) General epileptiform convulsions occur in meningitis, 
 pachymeningitis, abscess, vascular disease, syphilis, alcoholism, 
 plumbism, multiple sclerosis, paretic dementia, uraemia and gastro- 
 intestinal disease in children. 
 
 Epileptic Convulsions. 
 
 Convulsions Eesulting from Or- 
 ganic Brain Disease. 
 
 More coarse; more biting of tongue; 
 more frequent cry; more sudden and 
 complete loss of consciousness, fre- 
 quently a visceral (epigastric) aura; 
 usually longer interval between at- 
 tacks. 
 
 Convulsions more orderly, slow, clonic, 
 broken by tonic contractions; often 
 with gradual local commencement, 
 without loss of consciousness, and 
 with paresis in the Jacksonian type. 
 
 (d) Vomiting is probably cerebral and organic and due to tumor, 
 if hysteria, migraine, anaemia, toxaemia and gastric disease can be 
 excluded. It occurs on getting up in the morning. 
 
 Combination of General Symptoms. — Headache and choked 
 disk occur in chlorosis (v. s.), in plumbism (also with delirium, con- 
 vulsions and coma, but distinguished by the lead line on the gums) 
 or in uraemia in which special examination for albumin, casts and 
 cardiovascular changes are definitive. The same combination may 
 also prevail in hypermetropia in anaemic girls, in amenorrhoea 
 (Broadbent) and in injuries of the head, but care usually distin- 
 guishes them from brain tumor, which is characterized by its slow 
 onset and usual focal signs. 
 
 Focae Symptoms and Topical Diagnosis. — Focal symptoms usu- 
 ally follow the general, whereas, in apoplexy, for example, the focal 
 symptoms, as hemiplegia, are early. In tumor with hemiplegia, 
 contracture or spasticity accompanies the paralysis rather than fol- 
 lows it, as usually occurs in hemorrhage or embolism. Hemiplegia 
 from a tumor is less pure, less circumscribed, less systematic (Four- 
 nier). A tumor at the base may cause hemiplegia from pressure on 
 the middle cerebral artery with encephalomalacia. Jacksonian epi- 
 lepsy with paresis is, in 50 per cent, of cases, due to cortical tumors. 
 It is also produced by hemorrhage, softening and inflammation and is 
 then earlier, is not confined to as small an area and is not as pro- 
 gressive as in neoplasm. The cortical paralysis and epilepsy observed 
 in alcoholism, paretic dementia, plumbism, uraemia and rarely in 
 tuberculosis, cancer and diabetes (Senator) are not dissociated and 
 are but transitory. 
 
 Nature of the Growth. — (a) Location, Cortical growths are 
 
BRAIN TUMORS. 963 
 
 probably gumma or tubercle (possibly glioma, cysts, cysticercus 
 or sarcoma) ; subcortical, glioma or sarcoma; pons, tubercle, gumma, 
 glioma ; cerebellum, tubercle or glioma ; extracerebral, sarcoma ; mul- 
 tiple occurrence, tubercles or gummata. (b) Course. A rapidly 
 growing tumor is probably glioma or sarcoma. An apoplectic attack 
 indicates glioma or ruptured aneurysm. Growth with remissions is 
 characteristic of tubercle or glioma. A very slow course suggests fi- 
 broma or osteoma. Coincident meningitis indicates tubercle or syphilis. 
 
 Differentiation. — Tumor must be distinguished from brain 
 abscess; abscess and tumor have much in common, as their general 
 symptoms ; both may result from trauma, but brain abscess is almost 
 always secondary to trauma or to a pus focus (otitic or metastatic) ; 
 unilateral optic neuritis is more common than choked disk, and ab- 
 scess (q. v.) when once " manifest " is more apt to produce fever, 
 chills, a rapid course and apoplectic seizures than is tumor, while 
 involvement of the cranial nerves is less frequent. It must be borne 
 in mind that tumors may cause fever and that in abscess, for a time 
 at least, there is a normal or subnormal temperature. Differentiation 
 from paretic dementia, pachymeningitis hemorrhagica interna, menin- 
 gitis, syphilis and hydrocephalus will be considered under each disease. 
 
 Chronic syphilitic or tuberculous meningitis or meningoencepha- 
 litis may be confused with diffuse tumors at the base. 
 
 Multiple sclerosis. In both affections intention tremor, disturb- 
 ance of speech, mental change, vertigo, nystagmus, apoplectiform or 
 epileptiform attacks and tonic spasms of the extremities may occur, 
 but marked brain symptoms rather speak against multiple sclerosis, 
 at least in its earlier stages. The pressure symptoms of tumor and 
 increase of cerebrospinal fluid are absent and in the disk there is an 
 incomplete optic atrophy. If undue stress be placed on the tremor it 
 may be confused with incoordination tremor of tumor in the optic 
 thalamus, pons or cerebellum. 
 
 Course and Prognosis. — The first symptoms are usually general, 
 followed by the focal symptoms. The disease runs a fatal course in 
 one-half to two years, in rare cases four to fourteen years. A long 
 latent tumor may appear to begin acutely. Exacerbations result 
 from aneurysmal rupture, hemorrhage into a glioma, cyst formation, 
 ventricular effusions, meningitis or local neuritis. Remissions are 
 not uncommon; healing of parasitic and simple cysts, aneurysms, 
 tubercles (in the young) , and gummata is possible. It was thought 
 that aneurysms and gliomata may be cured with iodide treatment 
 (Wernicke). Unfavorable symptoms are pronounced mental change, 
 incoercible vomiting, irregular rapid pulse, repeated fits, apoplecti- 
 form seizures or festinating neuritis optica. The mechanism of death 
 is (a) exhaustion from vomiting, pain or cachexia; (b) inhalation 
 pneumonia; (c) coma with disturbed respiration, circulation or other 
 bulbar signs; (d) sudden death in tumors of the base (rarely of the 
 cortex) ; (e) meningitis or arterial disease ; (/) intercurrent infections. 
 
 Tre,atpent, — Medical treatment does not produce encouraging re- 
 
964 DISEASES OF TEE NERVOUS SYSTEM. 
 
 suits save in cases of syphilis, but every patient should be given a 
 course of mercury and iodide for at least three months. Tubercle 
 may sometimes be arrested by increasing the physiological resistance 
 by forced feeding, fresh air and administration of cod-liver oil and 
 arsenic. The headache is often relieved by iodide, in any kind of 
 tumor, by the ice-bag, morphine, atropine, hyoscine, the coal tar 
 products and by decompression operations. Convulsions should be 
 treated by chloral. Brain congestion from alcoholism, excitement, 
 exertion, overeating or obstipation should be avoided. 
 
 Surgical Interference. — Macewen, Horsley, Bennett, Ferrier 
 and Godle are the pioneers in brain surgery, (a) In radical opera- 
 tion the outlook is not very encouraging. Allan Starr estimates that 
 but 18 per cent, of tumors are accessible, and but 7 per cent, remov- 
 able ; Siedel finds only 3 per cent, are operable. Thirty-four per cent, 
 are basal. At operation the tumor is found in 64 per cent, of cases. 
 The best results are obtained in meningeal and the next best in 
 cortical growths, especially of the motor and occipital zones. Duret 
 (1903) analyzed 344 operations; 18 per cent, died, 64 per cent, 
 improved and vision was completely restored in 60 and partially in 18 
 per cent. In cerebellar tumors sudden death is frequent, because of 
 manipulation compression of the medulla. In 116 operations for 
 cerebellar growth the mortality was 38 per cent. (Frazier, 1905). 
 
 All varieties, even the syphilitic scar or tubercle, may be removed, 
 excepting metastatic growths. Recovery from the operation is fre- 
 quent, although the mortality ranges from 20 to 50 per cent. But 
 few ultimately recover. Recurrence is common. Death occurs from 
 hemorrhage, sepsis, dislocation of the brain, basal compression, brain 
 oedema and shock. Horsley and Macewen have suggested that the 
 operation be performed in two steps; first exposing the tumor and 
 later removing it after the brain has accommodated itself to the 
 change of relations, (b) Palliative decompression may be beneficial. 
 Removal of a button of bone with incision of the dura often greatly 
 relieves the headache and growing blindness, allows fluid to escape 
 and permits the tumor to grow outward when it cannot be removed. 
 Henschen claims that the palliative procedure hastens death twice as 
 frequently as it relieves the symptoms, (c) Ventricular drainage has 
 not proven helpful ; from lumbar puncture 17 cases of sudden death 
 are reported. 
 
 INFLAMMATION OF THE BRAIN. 
 
 I. Encephalitis. — " Inflammation of the brain" as understood by 
 the laity, is meningitis. Encephalitis does not include the inflam- 
 mation about tumors, hemorrhage, softening, syphilis and menin- 
 gitis. It was once held by Durand-Fardel that all softening was 
 encephalitis (cerebritis). Gluge (1837) suggested that some cases 
 were encephalomalacia ; Coswell and Hasse (1850) definitely dis- 
 tinguished between them; and Virchow anatomically and Hayem 
 clinically described clear cases. 
 
ENCEPHALITIS. 965 
 
 Etiology. — There are three main etiological factors: (a) Intoxica- 
 tions, chiefly from alcohol, and far less often poisoning by sulphuric 
 acid, ptomaines in decayed meat and fish, nicotine and sunstroke. 
 (b) Infections, especially influenza, then scarlatina, measles, hydro- 
 phobia and numerous others. In such cases microbes may invade the 
 brain alone. Some relation to chlorosis, sinus thrombosis, chorea 
 insaniens or maniacal forms of exophthalmic goitre is possible, (c) 
 Trauma, by laceration or concussion, may produce a locus resistentice 
 minoris for secondary microbic invasion. 
 
 Pathology. — The process begins as multiple disseminated and often 
 symmetrical foci, principally in the gray matter; these grow and 
 diffuse, sometimes most widely. They vary in size from microscopic 
 dots to a diameter of several inches, but usually are the small "flea 
 bite " areas of capillary hemorrhage, which glisten and stain the ad- 
 jacent tissues, show above the cut section and later become foci of 
 softening. Microscopically, hyperemia, perivascular exudation of 
 red and white cells, serous effusion and changes in the nervous ele- 
 ments are observed. Aggregations of mononuclear cells are seen, 
 somewhat resembling a tubercle, and degenerated, fatty and swollen 
 ganglion cells ; the medullary sheaths and later the axis cylinders de- 
 generate. Its issues are: — (a) regression (recovery); (b) necro- 
 biosis with softening; (c) cyst formation; (d) cicatrix formation 
 or (e) possibly diffuse brain sclerosis or multiple sclerosis. Associ- 
 ated nervous changes are optic neuritis, multiple neuritis and polio- 
 myelitis, and general changes are enlarged spleen, retinal or general 
 hemorrhages and parenchymatous degeneration in the kidney, etc. 
 
 Special Pathology and Symptomatology. — 1. Porencephalitis 
 Acuta Superior Hemorrhagica or Ophthalmoplegia. — This 
 was said by Wernicke (1881) to occur in alcoholic subjects and 
 therefore in adults; it attacks the gray matter about the third and 
 fourth ventricles and aqueduct of Sylvius, whence it may spread up- 
 ward or downward; it results in eye paralysis and is analogous to 
 acute poliomyelitis. The general symptoms are delirium tremens, or 
 somnolence in non-alcoholics, headache, vomiting and rigid neck. 
 The local symptoms consist of an early extensive ophthalmoplegia, 
 which involves associated eye muscles, as the two internal recti, or 
 the internal rectus of one eye and the external of the other and usu- 
 ally leaves the pupil and the levator palpebral superior free. The 
 gait is atactic from involvement of the corpora quadrigemina. 
 Speech is frequently difficult. Neuritis is observed in the optic disk 
 and sometimes in the peripheral nerves, as evidenced by the absent 
 patellars, ataxia, tender muscles, etc. Sometimes there is hemiparesis 
 and facial paresis. The temperature is usually normal or subnormal, 
 though respiration and pulse are increased. Death occurs within two 
 weeks after these violent symptoms. This type is most easily recog- 
 nized, although syphilis, tumors or encephalomalacia may affect the 
 same nuclei. Some cases thought to be nuclear have been shown by 
 Badecker, Thompson and Jacobaeus to be polyneuritic, and others 
 have shown no pathological alteration at autopsy. 
 
966 DISEASES OF TEE NERVOUS SYSTEM. 
 
 2. Encephalitis or Porencephalitis Hemorrhagica. — 
 Striimpell (1884) described primary cases of infantile paralysis (q. 
 v.) in which he referred the lesion to inflammation of the motor 
 cortex ; though his theory is too general, it has some anatomical con- 
 firmation. In 1885-86 Leichtenstern saw cases which resulted from 
 the infections named under etiology. Foci are found in the cortex, 
 subcortex or central ganglia, containing pus cocci and influenza ba- 
 cilli. In some cases the autopsy showed nothing and intoxication 
 was then assumed. The disease occurs mostly between the fifteenth 
 and thirtieth years. After an influenza there may be (a) general 
 symptoms, as headache, vomiting, delirium, mental obscuration, con- 
 vulsions in the young, high fever, slowed pulse becoming rapid, 
 irregular breathing or sometimes stiff neck or optic neuritis; (b) 
 focal symptoms appear after a few days, as hemi- or monoplegia, 
 aphasia, conjugate deviation, focal convulsions or hemichorea. The 
 reflexes are affected as in apoplexy. The course lasts one-half to 
 three weeks and is often fatal. This form may resemble hemorrhage, 
 syphilis or softening, but occurs in the young with normal arteries, 
 and the paralysis is preceded by signs of infection, fever, enlarged 
 spleen, somnolence or convulsions. Meningitis is usually differen- 
 tiated with ease. 
 
 3. Subtypes. — These consist of the following: (a) poliencephalitis 
 inferior acuta, involving the pons or medulla and giving acute bulbar 
 symptoms; there is paralysis of the sixth, seventh to twelfth nerves 
 when it occurs in various combinations or with types (1) and (2). 
 Some of the cases (chorea insaniens, Basedow's disease with mania) 
 may show nothing at autopsy, whence the diagnosis is very uncertain. 
 Confusion with softening, hemorrhage, the late hemorrhage of trauma 
 or tumors is possible. (&) Another form is poliencephalomyelitis, 
 acute, subacute or chronic, in which the type of Wernicke or of Striim- 
 pell-Leichtenstern may co-exist with inflammation and paralysis, 
 frequently symmetrical, of the anterior spinal roots. Hutchinson's 
 facies is observed, viz., fixed eyes, fallen lids, prominent eyebrows, 
 obliterated nasolabial folds and atrophic paralysis of the arms. Dif- 
 ferentiation from multiple neuritis is usually possible, and Oppen- 
 heim's criteria are well established in its separation from myasthenia 
 gravis, in which there are (i) no atrophy, but (ii) remissions in the 
 paralysis, (iii) great muscular adynamia, (iv) absence of reaction 
 of degeneration and (v) negative anatomical findings. 
 
 Prognosis. — The prognosis is unfavorable, as a rule. The peracute 
 cases may die in two days ; acute cases last one-half to three weeks 
 and death is most frequent ; Oppenheim has shown that they may 
 recover. Much involvement of the mind, decubitus, alcoholic de- 
 lirium, chlorosis, sinus thrombosis and weak pulse are unfavorable 
 elements. In children recovery is common, but epilepsy,, paralysis, 
 mental alteration and possibly multiple sclerosis are sequences. 
 
 Treatment. — This is wholly symptomatic, (a) The causal factor 
 must be eliminated, (&) cerebral congestion avoided and (c) the skin, 
 
BBAIN ABSCESS. 967 
 
 bowels and bladder, delirium and convulsions, diet and patient's rest 
 must be cared for as in brain hemorrhage, softening or tumor, (d) 
 Mercurial inunctions, iodoform inunctions and potassium iodide give 
 the best results, (e) Electricity is indicated in the chronic stage. 
 
 II. Abscess of the Brain. — Encephalitis suppurativa or apostema- 
 tosa is not a common disease. Eichhorst found but three among 
 13,563 medical cases. 
 
 General Etiology. — All cases are caused by microorganisms, of 
 which the streptococcus is the most frequent, the staphylococcus com- 
 ing next and then the pneumococcus and other bacteria. Mixed 
 infections are common; old abscesses are often sterile. Sixty-six to 
 75 per cent, occur in men. It is most frequent between the twelfth 
 and thirtieth years. Twenty per cent, occur in the second and 33 
 per cent, in the third decade (Gowers). The cerebrum is involved 
 in about 75 per cent, and the cerebellum in 25 per cent. ; the pons and 
 medulla are rarely involved. 
 
 General Pathology- — The focus is single in 80 per cent, of cases. 
 The average size is from one to two inches, but may be almost micro- 
 scopic or occupy nearly the entire hemisphere. The surrounding 
 brain may be inflamed. A zone of oedema is common. The right 
 side of the brain is more often affected than the left. Pressure is less 
 common and less intense than in tumor; very large abscesses flatten 
 the brain and may produce internal hydrocephalus. The abscess 
 consists of pus of variable consistency, yellow or green, acid, some- 
 times rancid, foetid or putrid; flocculi of disorganized brain tissue 
 are common. The pus cells are often disintegrated and fatty needles, 
 cholesterin crystals and sometimes corpora amylacea or foreign bodies 
 are found. Putridity is due to communication with the nose or ear or 
 embolism from putrid lung foci. Encapsulation occurs in 50 per 
 cent., chiefly in old, slow cases, and requires from two weeks to two 
 months. The capsule rarely completely or permanently limits the 
 abscess, which usually grows and often ruptures ; ultimate quiescence 
 from inspissation and successful demarkation is barely possible. 
 
 Special Etiology and Pathology. — 1. Infective Foci near the 
 Brain. — Infective foci near the brain are its usual causes, and for 
 this reason brain abscess is seen by internalists, neurologists, sur- 
 geons and otologists, (a) Ear disease explains at least 25 per cent, 
 of brain abscess. Otitis media, the most frequent cause, is chronic 
 in 91 per cent. (Griinert). Insurance companies recognize the risk 
 in these cases. Jansen found one abscess to 500 cases of chronic 
 and one to 2,650 of acute otitis. The ear disease may date back 
 thirty or forty-five years and is especially dangerous when it recurs 
 and when granulations and polypi exist. The acute infections are 
 thus indirectly causative of brain abscess. Infection traverses the 
 bone (92 per cent., Korner) to the dura by way of the thin tegmentum 
 tympani, by the roof of the antrum, sometimes through the petro- 
 squamous suture (in children), by the mastoid cells, lateral sinus, 
 
968 DISEASES OF TEE ttEBVOUS SYSTEM. 
 
 labyrinth or aqueduct along the sheaths of the seventh and eighth 
 nerves. Korner's figures show that in 42 per cent, there is a fistule 
 between the abscess and the causal focus; in 15 per cent, the dura 
 interposes between the two foci; in 15 per cent, there are dural ad- 
 hesions and in 17 per cent, the intervening substance is softened brain 
 tissue. Toynbee (1885) remarked that (i) disease of the roof caused 
 temporosphenoidal abscess, but (ii) disease of the mastoid cells chiefly 
 produced cerebellar abscess. Of otitic abscess, temporosphenoidal 
 constitutes 67 per cent. (75 per cent, in children under ten years) 
 and cerebellar abscess 33 per cent. (Korner) ; the latter is rarely due 
 to any cause other than otitis and almost invariably occurs in the 
 anterior part of its hemispheres. Otitic abscess infrequently in- 
 volves the occipital, frontal (two personal observations) or parietal 
 lobes. The abscess is single (87 per cent.) and lies in the white 
 substance of the brain just beneath the cortex. The smaller the ab- 
 scess the nearer it lies to the cortex. Cholesteatomata may cause some 
 cases. (b) Traumatism produces 25 per cent, of the cases. Punc- 
 tured wounds are more dangerous than open compound fractures. 
 Fractures of the base may result in abscess by infecting the middle 
 ear. Splintering of the inner table and operations on the brain are 
 possible causes; abscess may occur without skull fracture, contused 
 areas becoming infected through the blood. The injury may be 
 direct or in rare cases on the opposite side by contre coup. Gowers 
 states that but 20 per cent, occur under ten years of age. Ninety- 
 three per cent, are solitary abscesses (Oppenheim). Infection travels 
 along the perivascular and perineural lymph sheaths (Biswanger), 
 but may pass by other routes (arterial thrombosis, or by way of the 
 diploe veins, with or without thrombosis, for " retrograde infection " 
 is possible by the valveless veins). The early traumatic abscess is 
 usually cortical; the late variety is usually subcortical, (c) Other 
 contiguous disease is much rarer, causing but 4 per cent, of brain ab- 
 scess. Disease of the nose and communicating sinuses (frontal, an- 
 tral, sphenoidal, ethmoidal) may cause abscess of the frontal lobes 
 and in antrum disease sometimes of the parietal lobes. Disease of the 
 orbit, as phlegmon or penetrating wounds, and still more rarely cer- 
 vical cellulitis, cranial osteomyelitis, ulcerative tuberculosis, syphilis 
 or tumor of the cranial bones may cause abscess by contiguity. 
 
 2. Metastatic Abscesses. — Metastatic abscesses cause 25 per 
 cent, of brain abscess. The abscesses may number from 2 to over 
 100; they are multiple in 66 per cent. In location they are cortical 
 or subcortical, less frequently in the central ganglia and almost never 
 in the cerebellum alone. The embolus is almost never found, (a) 
 Lung lesions: " pulmonal cerebral abscesses" are due to empyema, 
 putrid bronchitis and bronchiectasis (45 per cent.), gangrene, abscess 
 and sometimes tuberculous cavities. This form rarely encapsulates. 
 (b) Ulcerative endocarditis, pyaemia, osteomyelitis, etc., are less 
 common causes; paradoxical embolism may occur through an open 
 foramen ovale, whereby the clot escapes the lungs. Actinomycosis,. 
 
BRAIN ABSCESS. §69 
 
 suppurating tubercle and oidium albicans have been described; in 
 thrush Wagner directly traced the growth from the throat to the brain. 
 
 3. Idiopathic Brain Abscess. — Gowers found it in 16 per cent. ; 
 it may result from a forgotten trauma or ear abscess. Martius and 
 Strumpell believe the meningococcus causes some of these cases. 
 
 Symptoms. — Symptoms are absent in 10 per cent, of cases. Symp- 
 toms of the causal affection are described under diagnosis. 
 
 1. Symptoms of Sepsis. — (a) Fever is frequent. Oppenheim 
 considers it the most important general symptom; Eichhorst de- 
 scribes cases closely resembling typhoid; it is present in acute cases 
 and during the last stages when the abscess spreads or meningitis or 
 sinus thrombosis develops; the original disease may cause it. 
 Macewen's cases showed normal or subnormal temperature. (b) 
 Chills are not frequent, (c) The pulse is often accelerated, but may 
 later become slowed to 30 or 40, the compression pulse, (d) Other 
 septic signs (see Septic Infections). 
 
 2. Diffuse Brain Symptoms. — These are due to increased intra- 
 cranial tension, oedema, inflammation, meningitis or internal hydro- 
 cephalus and include (a) headache, which is most common and usu- 
 ally severe, though less so than in brain tumor ; it is usually localized, 
 but even then the stiff, painful neck and headache are general rather 
 than focal symptoms. It is frequently associated with (b) vomiting 
 and (c) vertigo, which also occur in simple ear disease, (d) Mental 
 symptoms are like those of tumor, " slow cerebration, heavy compre- 
 hension and a want of sustained attention" (Macewen). (e) Gen- 
 eral convulsions are frequent only in the last stages, in cases of ex- 
 tensive abscess or rupture into the ventricle. (/) The pulse is often 
 slowed, even with co-existent fever, to 40 (even 10) and sometimes 
 with slow or irregular respiration, (g) Optic neuritis is more com- 
 mon than choked disk; it occurs in 33 to 40 per cent., develops rapidly 
 and may produce amaurosis and atrophy. 
 
 3. Focalizing Symptoms. — Focalizing symptoms are often absent 
 and when present are less conspicuous than in tumor because they are 
 obscured by the primary affection or the general symptoms and occur 
 in areas of less physiological dignity. When present they usually 
 signalize advance of the abscess, increase of oedema, softening or 
 increased brain tension. 
 
 Frontal or mental symptoms may occur (see Tumor), but foci as 
 large as the fist may remain latent. They may impinge on the motor 
 cortex. The symptoms are those of a cortical lesion (dissociated 
 paralysis), which extends more rapidly than tumor and is attended 
 by Jacksonian fits, rigidity and increased tendon and decreased skin 
 reflexes on the contralateral side; in subcortical lesions from trau- 
 matic and metastatic (pulmonal) abscess, hemiparesis occurs in 50 
 per cent., is sometimes progressive, is usually incomplete and at 
 times is apoplectiform in onset (three personal observations), even 
 when not embolic. If hemiparesis is early it rather indicates involve- 
 ment of the internal capsule, which also causes hemihypsesthesia. 
 
970 DISEASES OF THE NERVOUS SYSTEM. 
 
 Conjugate deviation is not common. TemporospJienoidal lesions are 
 largely otitic, are frequently latent and are less frequently cortical 
 than subcortical, whence the centres are less involved than the deeper 
 association fibers. The left side is more important ; lesions here lead 
 (in 42 per cent.) to sensory aphasia, partial word deafness, alexia, 
 agraphia, amnestic and optic aphasia. The right side concerns the 
 memory for letters and figures (Oppenheim). Occipital lesions or 
 those deeper in Gratiolet's optic radiation, produce hemianopsia 
 (more in traumatic or metastatic than in otitic abscess). Cerebellar 
 abscess results almost exclusively from ear disease and is often latent. 
 Ataxia may also be caused by the ear affection or abscess elsewhere, 
 even in the frontal lobes. Occipital headache and stiff neck occur; 
 there may be a tendency to fall forward or backward and hemi- 
 paresis or yawning may result from the compression; cranial nerve 
 paralyses are not frequent and result from coincident meningitis. 
 Paralyses of the seventh and eighth nerves are often due to bone 
 disease. Abscess of the pons, medulla (of which Cassier, in 1903, 
 found only 16 cases) and cms is exceptional. (See Cerebral Lo- 
 calization. ) 
 
 Symptoms by Stages. — (a) The initial stage is observed mostly 
 in acute traumatic or metastatic abscess. Pus formation usually 
 requires ten to thirty days. The causal symptoms, those of sepsis, 
 and general brain symptoms, appear rapidly but focal symptoms 
 usually appear only after one-half to three months ; death may occur 
 from coma, fever and meningitis or the next stage may appear, (b) 
 The latent stage has no fever, is seen in chronic abscess, probably 
 corresponds with demarkation and encapsulation, lasts for months, 
 years or even decades and is either complete or interrupted by symp- 
 toms of the third stage, (c) In the "manifest" stage symptoms of 
 sepsis and general or focal brain symptoms appear continuously or 
 remittently, with evidence of extension. Most cases are seen in this 
 stage. Gowers estimates that after nervous symptoms once develop, 
 (d) the next, the fatal or terminal stage, appears in five days (20 
 per cent.), in ten days (33 per cent.), fourteen days (50 per cent.) 
 and in thirty days (75 per cent.). This stage may immediately fol- 
 low the latent stage when rupture into the lateral ventricle occurs. 
 
 Diagnosis. — Recognition is impossible in latent cases affecting 
 " silent " areas, whence " no brain disease of equal severity so often 
 escapes recognition." When focal symptoms are absent, various psy- 
 choses may be thought of. The diagnosis is often made only in the 
 last two stages. Few cases can be detected without consideration of 
 the etiology, which is definitive in 75 per cent., the sepsis, general 
 and focal brain symptoms. 
 
 Otitic abscess may be confused with the otitis itself, especially in 
 children; otitis may produce general symptoms, as headache, vomit- 
 ing, convulsions and even optic neuritis (probably due to serous 
 meningitis), cranial nerve symptoms (nystagmus, diplopia), but all 
 symptoms disappear when the middle ear, attic, mastoid or subperi- 
 
BEAIN ABSCESS. 
 
 971 
 
 Ketina : 
 
 Meningitic evi- 
 dences : 
 
 Focal symptoms: 
 
 Spinal symptoms : 
 
 Brain Abscess (Otitic). 
 
 Etiology : 
 
 Ear disease. 
 
 Onset : 
 
 Acute or subacute, but often 
 some latency. 
 
 Course : 
 
 Acute, subacute, chronic 
 (latency stage), from weeks 
 to seldom over one year. 
 
 Fever : 
 
 Normal, subnormal, moder- 
 ate. 
 
 Pulse: 
 
 Slow. 
 
 Sensorium : 
 
 Simple dulness, merging into 
 coma. 
 
 Headache, vomit- 
 ing, vertigo: 
 
 Headache almost constant ; 
 others less constant. 
 
 General convul- 
 sions: 
 
 Not frequent. 
 
 Optic neuritis common. 
 Choked disk not common. 
 
 Less by far. 
 
 Stiff neck rare save in cere- 
 bellar abscess. 
 
 Frequent, especially tempo- 
 rosphenoidal, internal cap- 
 sule and sometimes cerebel- 
 lar; paralysis of third 
 nerve. 
 
 Seldom. Few cases of absent 
 patellars. 
 
 Diffuse Suppurative 
 Meningitis. 
 
 Lumbar puncture: Bather dangerous. 
 
 Same; favored by imperforate 
 tympanum and childhood. 
 
 Acute, stormy, even apoplectic. 
 
 Acute, stormy, more rapid than 
 abscess (66 per cent, last under 
 one week). 
 
 High and continuous. 
 
 Usually fast and irregular. 
 Unrest, delirium; dulness later. 
 
 Headache and vomiting almost 
 invariable. 
 
 Usual, clonic and tonic. 
 
 Usually negative because of rapid 
 course. 
 
 More common psychical and mo- 
 tor unrest, jactitation, hyper- 
 esthesia of special and gen- 
 eral sensation, trismus; re- 
 traction of abdomen; general 
 rigidity. 
 
 Diplopia, strabismus, unequal 
 pupils, conjugate deviation, 
 paralysis seventh and eighth 
 nerves; these are diffuse, trans- 
 itory and variable ; rarely hemi- 
 or monoplegia; very rarely 
 aphasia, hemianopsia (more 
 frequent in meningitis tuber- 
 culosa). 
 
 Almost always stiffness and ten- 
 derness of neck, back and gen- 
 eral muscles, Kernig's sign; 
 paresthesia and hyperesthesia, 
 dysuria, involuntary evacua- 
 tions, absent patellars. 
 
 Positive findings (see pages 170 
 and 171). 
 
972 DISEASES OF THE NEltVOtJS SYSTEM. 
 
 osteal foci are cared for; otitic brain abscess runs an acute rather 
 than a chronic course ; the period of latency rarely exceeds one to one 
 and a quarter years and usually averages two months or less. Tem- 
 perature is often lower than in other forms, the headache may be 
 local and oedema may be seen over the temporal region, with tender- 
 ness on percussion and a higher percussion note (Macewen). 
 
 Otitis may also cause suppurative meningitis,, extradural abscess or 
 sinus thrombosis, either with or without brain abscess, from which 
 they must be differentiated. The table on page 971 is borrowed from 
 Oppenheim's classical description. 
 
 Serous meningitis (Billroth and Quincke) is often mistaken for the 
 suppurative form and is very important in ear disease. It is attended 
 by slight temperature, internal hydrocephalus, paralysis of the 
 basal nerves, often gives a serous fluid on lumbar puncture and is 
 often cured. Extradural abscess was found in 78 per cent, of cases of 
 brain suppuration by Jansen, sinus thrombosis in 18 per cent, and 
 brain abscess in barely 3 per cent. It is more common in acute 
 otitis (43 per cent.) than is abscess (9 per cent.). Local symptoms, 
 as oedema and tenderness, are commoner than diffuse and focal symp- 
 toms. Sinus thrombosis (q. v.) is more often attended by pysemic 
 symptoms, high fever, chills, sweats, icterus, foci in the lungs, rapid 
 pulse, choked disk, general convulsions and external symptoms of 
 altered brain circulation. 
 
 Traumatic abscess develops early, is associated with hsematoma, 
 concussion, contusion or diffuse meningitis, from which differentia- 
 tion is often impossible or difficult, except that the abscess is slow 
 in evolution. Its presence is often suspected because of delayed heal- 
 ing of the wound. It is usually cortical (whence its focal symp- 
 toms) and often provokes fever and other general symptoms. It must 
 also be differentiated from traumatic hemorrhage, which occurs days 
 or weeks after the injury and often in the corp. quadrigemina, pons or 
 medulla ; from acute encephalitis, whose course is more rapid ; from 
 concussion, in which the symptoms are more diffuse and may involve 
 the brain nerves or arouse fever, though cortical symptoms are ab- 
 sent ; from traumatic neuroses, which lack focal and septic symptoms. 
 In late traumatic abscess latency may last even thirty years. The 
 abscess is not cortical (affecting the centres), but subcortical (affect- 
 ing the conduction or association fibers). Cerebral tumor (q. v.). 
 
 Abscess by metastasis. It is well known that lung suppuration 
 affects the brain with especial frequency, whence the chest must be 
 examined; localization is largely in the hemispheres, thus obeying 
 the general topography of simple embolism. The Sylvian district 
 and occipital lobes are most often affected and the multiplicity of 
 localization should be remembered. The course is usually precipitate. 
 
 A diagnosis of idiopathic abscess without proper etiology is always 
 unsafe and usually impossible. 
 
 Prognosis. — Spontaneous recovery by demarkation, inspissation, cal- 
 cification or external rupture is very unusual. Without operation, 
 
DEMENTIA PARALYTICA. 973 
 
 death is practically inevitable, (a) from rupture into the lateral ven- 
 tricles (16 per cent., chiefly in metastatic and otitic abscess) and into 
 the membranes (28 per cent., in cerebellar abscess), (b) from hydro- 
 cephalus internus, (c) from sinus thrombosis, (d) from pressure on 
 the medulla, or (e) from brain oedema. Sudden death may occur, as 
 in tumor, without adequate postmortem explanation. 
 
 Treatment. — (a) Prophylactic therapy concerns the etiological fac- 
 tor. Adequate drainage is always necessary, although granulations 
 in the middle ear are protective and should not be curetted in any 
 routine manner (precisely as uterine curettage in puerperal sepsis is 
 now discountenanced). (b) Palliative treatment is that of brain 
 tumor and meningitis. Special care regarding vomiting is indicated, 
 lest it rupture the abscess, (c) Surgical intervention is indicated. 
 Successful cases were those of Morand 1868, Roux 1848, and Schede 
 1866. Macewen, Barker, Greenfield, Terrier, Horsley and Schwa rtze 
 are the pioneers in its practical treatment. Von Bergmann's rule 
 was that operation should never be performed unless the diagnosis 
 was certain, but adherence to this rule would have cost. many lives. 
 The contra-indications are (a) metastatic abscess, (b) a fatal etio- 
 logical disease, (c) inability to stand the anaesthesia or shock, (d) 
 ventricular rupture and (e) diffuse meningitis, although in the last 
 two cases isolated recoveries are recorded. Sinus thrombosis, circum- 
 scribed meningitis and incipient pyaemia do not contra-indicate op- 
 eration. In Korner's cases (otitic abscess), 51.6 per cent, recovered, 
 Oppenheim reported recovery in 45 per cent, (traumatic cases), 
 Wheeler's series gave 87.5 per cent, and Macewen's series showed 
 96 per cent. 
 
 III. Dementia Paralytica. — It is also known as paralytic or paretic 
 dementia, general or progressive paralysis of the insane and among 
 the laity as softening of the brain. Bayle, 1822, and Calmeil, 1826, 
 first accurately described the affection. It is often classed among the 
 mental rather than the brain diseases, but it is so important in 
 everyday practice and constitutes such a large proportion (10 to 25 
 per cent.) of all insanities that its description is in place. 
 
 Definition. — Dementia paralytica is a chronic inflammation or de- 
 generation of the brain, characterized by progressive vasomotor, 
 motor and psychical disturbances and ending in death after two or 
 three years. 
 
 Etiology. — (a) Syphilis is the cause in at least 75 per cent, of 
 cases (Mendel and Strumpell). That it is not the sole cause is shown 
 by its rarity in Egypt and Japan where syphilis is endemic, (b) 
 Other causes, as modern life, with its strenuousness, competition, 
 hurry and worry aid the syphilitic toxins which cause degeneration 
 of the brain after the syphilis is apparently spent (a parasyphilitic 
 affection, Fournier). Short sleep, dissipation, overwork and city life 
 account for its increasing frequency. Krafft-Ebbing summarized the 
 etiology as " syphilization and civilization." These causes may co- 
 
974 DISEASES OF TEE NERVOUS SYSTEM. 
 
 operate with (c) hereditary nervous taint (20 per cent.) and (d) 
 alcoholism (20 per cent., though this is denied by many), (e) 
 Certain occupations, as those of officers, artists and actors, are predis- 
 posing factors and, generally speaking, the higher classes are more 
 subject to it. Krafft-Ebbing found no clergymen among his 2,000 
 patients. (/) It occurs between the thirtieth and fiftieth years, and 
 (g) is 7 to 10 times as frequent in men as in women. Other factors 
 are less prominent, as exposure to heat, trauma of the head, plumbism 
 or chronic toxaemia. 
 
 Pathogenesis. — The causes enumerated probably produce (a) vaso- 
 motor paresis in the forebrain, followed by (b) lymph stasis in the 
 cortex and pia mater, (c) degeneration and atrophy of the brain and 
 cord, and (d) interstitial inflammation. Though all cases end in 
 brain atrophy, opinions still differ regarding the role of the inflam- 
 mation; some regard encephalitis interstitialis (chronic meningo- 
 encephalitis) as primary (Mendel) and others hold that it is secon- 
 dary to encephalitis parenchymatosa (Tiiczek and Wernicke), just 
 as in liver cirrhosis it is now thought that the connective tissue forma- 
 tion is secondary in time and importance to cellular alteration. 
 
 Pathology. — (a) The calvarium is thickened in 33 per cent. The 
 Pacchyonian granulations are often enlarged, (o) The dura in 50 
 per cent, is thick, opaque, vascular and adherent to the skull (pachy- 
 meningitis, which is often hemorrhagic). In attempting to strip off 
 the pia it is found granular and adherent to the brain cortex (in 80 
 per cent.), especially over the frontal and motor areas, supplied by 
 the internal carotid artery. Later the adhesions may disappear, (c) 
 Gross brain changes are constant. There is less opportunity to in- 
 spect the brain in the early stages, when it is swollen and hypersemic 
 than in the later stages when it is wasted; it may weigh but a third 
 or quarter of the normal (40 ounces or 1,260 gm.) ; atrophy affects 
 largely, if not wholly, the areas supplied by the internal earotid 
 artery, especially the frontomotor cortex and the island of Eeil. 
 The gray matter is yellow-gray, soft and wasted, but the atrophied 
 white substance is firm. The convolutions are greatly narrowed and 
 the sulci are widened, the degree of atrophy corresponding to the 6 
 or 8 ounces of serum which fills the deficit (hydrops ex vacuo). In 
 80 per cent, granulations are seen on the ependyma of the lateral 
 ventricles, resembling the back of a " cat's tongue," and the ventricles 
 contain excess of fluid (hydrops ex vacuo). Areas of hemorrhage, 
 softening and cyst formation are due to complicating vascular dis- 
 ease, (d) The minute alterations in the brain are as follows: the 
 ganglion cells are early swollen and cloudy; the later findings are 
 vacuolated, degenerated and atrophied ganglion cells ; toasting of the 
 medullary sheaths and of the axis cylinders, especially in the associa- 
 tion or tangential nerve fibers running parallel to the cortex (Tiiczek), 
 which are said to waste before any inflammation can be seen ; corpora 
 amylacea represent what is left of them; the same changes occur in 
 the cranjal nerves; the bloodvessels show mural proliferation, e^uo^ar 
 
DEMENTIA PARALYTICA. 975 
 
 Hon, colloid or hyaline metamorphosis, thickening and later atrophy 
 or obliteration; the lymph vessels show proliferation, transudation 
 and compression of the cortex, where lymph cysts, from snaring off 
 of lymph vessels, sometimes cause cystic degeneration of the cortex ; 
 the neuroglia increases even sevenfold (sclerosis), (e) Alteration of 
 the spinal cord, described first by Westphal, is present in 90 per cent. ; 
 the lateral columns often show descending degeneration, but most 
 commonly changes like those of tabes are found in the posterior col- 
 umns and in the posterior roots. Pachy- and leptomeningitis are seen 
 in 40 per cent. As in tabes, the cerebrospinal fluid contains chiefly 
 mononuclear cells. (/) Changes in the cranial nerves, especially the 
 first to the seventh, may result from syphilis or alcoholism. 
 
 General Symptoms. — As a rule, the symptoms are first vasomotor, 
 second psychical, and third motor, in the order of their usually slow 
 development. It is possible for the psychical symptoms to appear 
 first, with the motor, or more rarely to follow them. The leading 
 symptoms are referable to alteration in the frontomotor cortex. 
 Three stages are usually distinguished : 1. In the prodromal stage, 
 recognition is often difficult, because the first symptoms are equivocal 
 or point to (a) neurasthenia because of the " irritable weakness," 
 ready fatigue in mental processes, headache or sense of cephalic pres- 
 sure, introspection and rheumatic pains. Again, the initial symp- 
 toms are (b) congestive, as headache, migraine or attacks similar to 
 petit mal. (c) Most important are mental changes. The patient is 
 described as " not himself " but " he does not remark his own altera- 
 tion" (Schule). Krafft-Ebbing gives a lucid picture of these altera- 
 tions. The intellect is cloudy ; the patient is confused as to time, and 
 comes too early to work or remains after time; he confuses places 
 and may smoke in church; his observation is faulty as well as his 
 judgment; he confuses dreams with actualities and his memory is 
 confused, for he forgets entire epochs, especially recent impressions. 
 ^Esthetic and social lapses are common; the subject becomes vulgar, 
 careless, neglects duties, disregards amenities and from lack of will 
 power may steal or dissipate most openly. Emotional outbreaks 
 occur, as violent or brutal conduct or maudlin sentiment over soon 
 forgotten incidents. The patient is often perniciously active, (d) 
 Focal symptoms, especially amnestic aphasia, may appear. (e) 
 General findings are noted after a time, as small and unequal pupils 
 or other tabes-like findings, double vision, unequal innervation of the 
 face, fibrillary contractions of the tongue, tremor, pains, headache, 
 vertigo, congestive attacks, slow pulse, rough, unmodulated voice, 
 skipping of words in reading (paralexia) and irregular, incorrect 
 writing (paragraphia). This stage covers months or years. In rare 
 instances the symptoms may follow tabes ; this is " the ascending form 
 of general paralysis." 2. At the height of the disease, (a) the psy- 
 chical symptoms take various types, as maniacal exaltation, melan- 
 cholia, hypochondriasis or simple progressive dementia. Psychical 
 blindness or deafness occurs, (b) Congestive, apoplectiform attacks 
 
976 DISEASES OF THE NERVOUS SYSTEM. 
 
 are frequent and the general findings become more distinct, as im- 
 mobile and unequal pupils, hesitant speech with elision of syllables, 
 altered expression, trembling or paresis of the face, incoordination 
 of the hands and gait, disturbances in writing and reading and reten- 
 tion of urine. During the not uncommon remissions some of these 
 symptoms can almost always be found. 3. The terminal stage is 
 characterized by complete dementia (the final type of all initial 
 varieties), complete disorder of speech, incoordination so extreme as 
 to necessitate feeding the patient and keeping him in bed, sensory 
 disturbances, vasomotor paralysis, grinding of the teeth, trophic 
 complications and death from pyelonephritis, bed-sores, complications 
 or bulbar symptoms. 
 
 Symptoms in Detail. — 1. Psychical Symptoms. — The weakness, 
 alteration in character, loss of memory and reason and the ethical, 
 aesthetic and moral loss have been described. During the height of the 
 disease there is one of three main mental manifestations: (a) megalo- 
 mania, with simple exaltation or mania. This classical expansive 
 type occurs in 66 per cent., is associated anatomically with the char- 
 acteristic meningoencephalitis, and is characterized by ideas of 
 grandeur, the patient believing he is a king, God, a millionaire, 
 an athlete, etc. He makes ridiculously large plans, buys extrava- 
 gantly, lacks will power, indulges himself excessively, changes 
 with great " facility" from one thing to another, is optimistic, 
 friendly, even philanthropic and rapidly runs through his capital. 
 He loses himself, forgets names and confuses the real with the 
 unreal. Periods of acute mania, with fever and grinding of the 
 teeth are expressions of brain congestion; complete dementia is the 
 final outcome, even though remissions occur, during which some 
 mental or somatic change can be detected. (&) The melancholic or 
 hypochondriacal form is thought to occur with cystic degeneration of 
 the cortex. It may be of the dull or agitated type. The patient 
 dwells on the condition of his bowels; one subject thought they would 
 " burst and flood the world." There is often micromania, character- 
 ized by " self-belittlement," in which the individual fears everything 
 and thinks himself a " dot, nothing, or denies his existence." These 
 cases may commit suicide. Dementia is the outcome, (c) Simple 
 primary dementia may be present from the beginning; this type is 
 increasing in frequency, while the first classical form is decreasing. 
 It is thought to be based anatomically on simple cortical atrophy 
 in which inflammation is absent or late and secondary. These sub- 
 jects are often deceptive in the early stage, being quiet, urbane and 
 optimistic. In the ultimate dementia of all types, mentality is wholly 
 gone, " there is no sense of time, place or identity," and the patient 
 babbles or is speechless. 
 
 2. Motor Disorder. — This usually occurs with mental changes, is 
 constant, though variable in its expression, incomplete in degree, ex- 
 tensive as to parts involved and progressive, (a) Speech is pathog- 
 nomonically disturbed as a result of mental change, wasting of asso- 
 
DEMENTIA PARALYTICA. 977 
 
 ciation fibers and later bulbar atrophy. It is incoordinate, involving 
 letters ("literal" ataxia) or syllables. In pronouncing such words 
 as " electricity " the patient characteristically stutters over syllables. 
 It is worse in the morning and after resting. Loss of word memory 
 is the primary trouble; the patient forgets expressions, speaks un- 
 grammatically and " does not notice it." Speech becomes atactic, 
 there is paraphasia, the voice is unmodulated, gives out suddenly, is 
 sometimes hoarse, nasal or slow, but never scanning. Later, speech is 
 disturbed from bulbar alteration, causing dysarthria from disease of 
 the facial and hypoglossal nuclei ; it is ultimately unintelligible (abso- 
 lute aphasia). Closely associated with speech disturbance is (b) 
 disordered reading (paralexia), which is rather characteristic and 
 occurs early, (c) Writing is disturbed first because of the mental 
 alteration ; the patient has difficulty in collecting his thoughts, al- 
 though he does not realize the cause (the ataxia by which he drops 
 syllables, repeats words or sentences — paragraphia) ; and it is dis- 
 turbed secondly because of tremor. The writing is uneven, up and 
 down or zig-zag. These changes are diagnostic, (d) Paralysis of 
 the eye muscles (in 6 per cent., Marie) is usually partial and transi- 
 tory. When total, syphilis or tabes is the probable cause, (e) The 
 pupils: Myosis may occur, often just before maniacal outbursts. 
 Mydriasis is frequently unilateral and results from sympathetic 
 irritation. In 60 per cent, of cases the pupils are now large, now 
 small, and this is considered as especially ominous. They are often 
 irregular or triangular. The Argyll-Robertson pupil, responding to 
 accommodation but not to light, usually appears early, is marked in 
 47 per cent., partial in 20 per cent, and absent in 33 per cent. 
 Reichert holds that it is always due to degeneration in Bechterew's 
 column (*. e., between that of Groll and of Burdach). (/) The facial 
 nerve: The paresis of the lips is cortical, as are fibrillary twitchings 
 in speaking or mimetic movements, automatic chewing movements and 
 almost constant grinding of the teeth. The " fatuous " or " masked " 
 expression is psychical. Salivation results from cortical irritation. 
 There may be difficulty in swallowing, (g) The limbs: (i) The 
 cortical changes cause the small-waved, rapid, constant tremor, the 
 ataxia, loss of muscle sense and the uncertain, ungraceful, tripping 
 paralytic gait, (ii) The gait may be tabetic, with absent knee jerks, 
 immobile pupils and vesical symptoms; or it is more often spastic 
 with increased patellar reflexes, ankle clonus, contractures and 
 changes in the joints. The patellars are usually increased in the 
 early stages, (iii) Neuritic atrophy of the cranial nerves may occur 
 as in tabes, (h) Apoplectiform and epileptiform attacks may occur. 
 (i) Apoplectiform seizures result from vasomotor paralysis and brain 
 oedema and differ from apoplexy in their incompleteness, evanescence, 
 increased temperature and increased reflexes. They last part of an 
 hour and may produce temporary hemiplegia, but especially aphasia 
 with paresis of the right arm. (ii) Epileptiform attacks occur later, 
 result directly from cortical disease, are usually partial (involving 
 62 
 
978 DISEASES OF THE NERVOUS SYSTEM. 
 
 the face or arm) and are either Jacksonian or are attended by partial 
 loss of consciousness; conjugate deviation of the eyes and increased 
 temperature are also observed. They are not frequent but, once ini- 
 tiated, recur and aggravate the mental alienation. 
 
 3. Sexsation and Special Senses. — Coincident neurasthenia, 
 tabes and pachymeningitis may emphasize the sensory manifestations, 
 as the lancinating pains of the tabetic form. Sensation is often 
 dulled and, like the analgesia, is cortical in origin. It is suggested 
 that the hypochondriacal complaint that certain organs, as the bowels, 
 are absent, is due to visceral anaesthesia. Attacks of migraine, when 
 they first appear late in life, may indicate an organic origin, and 
 Charcot described a form with hemianopsia and symptoms like glau- 
 coma. Migraine is cortical when associated with paresis of the face, 
 tongue or arm. Alteration of the special senses includes optic neu- 
 ritis and atrophy (4 per cent.), optic hallucinations and psychical 
 blindness. 
 
 4. Other Symptoms. — (a) Vasomotor changes occur in the skin 
 (lividity, oedema and sweating) and in the brain, lungs, bladder, 
 intestines and stomach (resembling the so-called bilious attacks). 
 (b) Trophic symptoms are sweating of blood, rough skin, phospha- 
 tnria, perforating ulcer of the foot (3 per cent.), bed-sores and 
 friability of the bones, which may be broken without the patient 
 knowing it. The " insane ear " is frequent. Many of these symp- 
 toms are spinal and neuritic. 
 
 5. General Symptoms. — The pulse is often slow and monocrotic, 
 the temperature low, although the heat centres may be involved in 
 congestive seizures with great febrile elevation, and the body weight 
 is often reduced in the early and late stages, though at the height of 
 the disease it often increases, especially before the congestive seizures. 
 The sexual instinct, at first increased and sometimes perverted, later 
 declines. Insomnia may be severe, protracted or absolute. 
 
 Diagnosis. — The diagnosis depends upon (a) the etiology, as syph- 
 ilis with mental strain or excesses; (b) the grouping of the psychical 
 symptoms, as character, aesthetic or ethical changes with (c) motor 
 symptoms, as the speech, writing or tremor ; (d) vasomotor symptoms, 
 as migraine or apoplectiform insults, and (e) the progressive course. 
 
 Differentiation. — 1. Diffuse Braix Diseases. — (a) Cerebral syph- 
 ilis may be confused with diffuse meningoencephalitis. 
 
 Progressive Paralysis. vs. Syphilis. 
 
 Headache absent or vague and transi- Headache present and severe, 
 tory. 
 
 Psychical alteration characteristic; Somnolence, variability in mental symp- 
 
 mental symptoms are coordinated. toms. Merely coincident. 
 
 Epileptiform mono- or hemiplegic seiz- More frequent. \ 
 
 ures rare. 
 
 Focal symptoms very rare. Focal symptoms common, together 
 
 with diffuse symptoms. 
 
DEMENTIA PAEALTTICA. 979 
 
 Progressive Paralysis. vs. Syphilis. 
 
 Greater speech disturbance, literal para- Less or no tremor; speech far less fre- 
 phasia, and fibrillary tremor of face quently disturbed; no literal para- 
 
 and tongue. phasia. 
 
 Argyll-Kobertson pupil. Absent; oculomotor affections and optic 
 
 neuritis much commoner. 
 
 Progressive, slower. No therapeutic re- In installments, more rapid jumps, re- 
 sults, missions. Therapy helps or possibly 
 
 cures. 
 
 A parasyphilitic disease. Active syphilis. 
 
 (b) Diffuse cerebral sclerosis cannot be diagnosticated; though it 
 leads to dementia and attacks of delirium, there is not the speech and 
 mental alteration which is present in general paresis, (c) Senile 
 dementia seldom occurs until after sixty years of age. Its course is 
 longer, the symptoms more gradual and less intense, memory is 
 maintained longer and there is less megalomania than fear of perse- 
 cution and poisoning, (d) Multiple sclerosis occurs earlier, is not 
 syphilitic, is complicated by late and mild mental symptoms and an 
 intention tremor, which is wider in amplitude and ceases during 
 repose. The speech is scanning, staccato, and there is no literal 
 ataxia. Nystagmus is common, while it is rare in general paralysis. 
 Motor symptoms are largely referable to lateral column disease. 
 
 2. Focal Brain Diseases. — (a) Although migraine, headaches, 
 apoplectiform attacks and partial sensory or motor irritation of the 
 Jacksonian type may occur in brain tumor, it does not cause difficulty 
 in pronouncing syllables, peculiar mental alteration or immobile 
 pupils; it is characterized by general symptoms, as choked disk or 
 vomiting and focal symptoms, which are foreign to general paralysis. 
 In tumor there is simple dulling of the intellect and dementia only 
 with marked internal hydrocephalus. (b) Hemorrhagic pachy- 
 meningitis complicates 20 per cent, of cases of dementia paralytica ; 
 when it exists as an independent affection, it often leads to intense 
 local headache, vomiting, recurrent hemiplegia or monoplegia, cor- 
 tical irritation and more rapid course, (c) Softening usually pro- 
 duces focal symptoms. 
 
 3. Psychoses and Neuroses. — (a) Mania and hypochondriasis. 
 Every case of mania or hypochondriasis between the twenty-fifth 
 and forty-fifth years not due to alcoholism or to acute somatic disease 
 should arouse suspicion of general paralysis (Mendel). (6) Neuras- 
 thenia. In it the onset is more acute ; headache accompanies the 
 lassitude and " irritable weakness," the memory is fatigued but never 
 lost, the patient recognizes his incapacity; and oxalates and urates 
 abound in the urine. In dementia paralytica there is phosphaturia, 
 hypochondriasis with absurd conceptions, changes in the pupils, 
 disk and field of vision, alterations in character, speech and intellect 
 which are never seen in neurasthenia. 
 
 4. Intoxications. — These may cause many of the forms known as 
 
980 DISEASES OF THE NERVOUS SYSTEM. 
 
 general pseudoparalysis due to alcohol, lead, etc. (a) Chronic alco- 
 holism is not progressive, recovery is frequent, delirium tremens and 
 convulsions are common, the course is acute and the alcoholic tremor, 
 headache, hallucinations and neuritis are found, (b) Chronic plumb- 
 ism (saturnine encephalopathy) is often progressive, even fatal, and 
 in its last stages indistinguishable from dementia paralytica. It is 
 more acute and 80 per cent, of cases recover. There are headache, 
 cardiac distress, anaemia and gingival lead line. (c) Chronic 
 bromism is distinguished by its stupor, dementia, bromide acne, foetid 
 breath, coated tongue, pharyngeal anaesthesia, weak heart and acute 
 and usually favorable course. 
 
 Prognosis. — The disease is fatal in 66 per cent, of cases within two 
 years, though remissions may occur. Krafft-Ebbing saw no recov- 
 eries in 2,500 cases ; recovery indicates an incorrect diagnosis, pseudo- 
 paralysis generalis. The following courses are distinguished: (a) 
 acute or galloping form, which lasts months to a year; (b) classical,, 
 expansive type, which lasts three to four years; (c) the depressive 
 type, which lasts two to three years; (d) dementia forms, which last 
 four to five years; (e) circular form, in which depression alternates 
 with mania ; (/) female variety which has a longer course than in 
 males; (g) spinal form, with a relatively long course; (h) juvenile 
 or adolescent; and (i) senile form. Death results in 50 per cent, 
 from the disease itself, by apoplectiform seizures, suicide, inanition 
 or bulbar symptoms. In 50 per cent, it results from complications, 
 tuberculosis (18 per cent.), bed-sores, with sepsis (10 per cent.), 
 lung gangrene (6 per cent.), pneumonia (5 per cent.), choking (10 
 per cent.) and cystitis. 
 
 Treatment. — (a) Etiological treatment. Recovery is barely possible 
 in the early stages and many physicians advise that mercurial inunc- 
 tions be given. The disease is a parasyphilitic disease, not active 
 syphilis and some consider mercury distinctly injurious. Iodides pro- 
 mote resorption and favor a milder course, (b) Hygienic treatment, 
 as rest, protection from heat, and quiet surroundings, is indicated. 
 (c) The patient should be put in an asylum, for suicide or other 
 violence is always possible. In the simple dementia form alone may 
 the patient be treated at home, (d) Hydrotherapy is valuable within 
 limits. Cold rubs lessen excitation, although full cold baths are 
 contra-indicated, (e) Medicinal treatment is unsatisfactory. Drugs 
 produce disproportionate effects and must be exhibited with caution. 
 For delirium and insomnia bromides are most efficacious, but chloral 
 and opiates should be given less frequently or only in combination 
 with hyoscine, digitalis and bromides, or with the ice-cap. Ergot is 
 said to produce remissions, but is valuable chiefly as a vascular tonic 
 for brain congestion. (/) The skin, bladder and rectum should re- 
 ceive treatment as in apoplexy and spinal diseases. 
 
DEGENEEATION OF THE BRAIN. 981 
 
 DEGENERATION OF THE BRAIN. 
 
 I. Cystic Degeneration. — Cystic degeneration occurs mostly in the 
 shrunken brain of aged persons and largely in the perivascular spaces 
 of the cortical and basal white substance. No essential symptoms 
 result from the fluid ; they are those only of the causal atrophy. Pos- 
 sibly the vessels are prone to dilate and rupture from shrinkage of the 
 brain and consequent lack of support. 
 
 II. Chronic Progressive Softening. — Chronic progressive soften- 
 ing, when not due to vascular disease, is a rare affection; it was 
 described by Wernicke. It affects the white matter chiefly, occurs 
 mostly after the sixtieth year, its pathogenesis is obscure and its 
 clinical symptoms are weakness on one side, slight irritative phenom- 
 ena, as tingling or pain, and involvement of the intellect. The course 
 varies from a month to a few years and remissions are uncommon. 
 
 III. Multiple or Insular Sclerosis. — (See Spinal Coed.) 
 
 IV. Diffuse Sclerosis. — This may involve one or both hemispheres 
 of the brain or cerebellum, (a) It is often secondary to meningeal 
 hemorrhages at birth, infantile hemiplegia, arrest of development and 
 trauma. In these cases the sclerosis is secondary to brain atrophy. 
 (b) Sclerosis without atrophy may develop in congenital syphilis, 
 chronic alcoholism or contracted kidney. The symptoms are indefi- 
 nite. Hemiplegia, impaired mentality, convulsions, contractures, 
 spontaneous movements, vertigo, syncopal attacks and slow speech 
 have been noted. Miliary sclerosis is very rare and consists of minute 
 foci in the cortex, where the gray and white substance join. Many 
 reported cases are due to artefacts in hardening. 
 
 V. Atrophy of Brain. — Genuine atrophy is always acquired. It 
 is often associated with microcephaly and the brain is usually normal. 
 Unilateral atrophy is observed in some cases of chronic insanity. 
 Local atrophy may occur anywhere, is usually associated with scler- 
 osis (q. v.) or neuroglia increase, is usually acquired and is very often 
 secondary to trauma, tumor or hydrocephalus. Some reported cases 
 are clearly agenesis and arrested development. The symptoms are 
 not distinctive. Hemiplegia, hemiathetosis and imbecility may ac- 
 company the infantile forms ; they occur bilaterally when both hemi- 
 spheres are diseased. Senile atrophy occurs in old age, when the 
 brain becomes smaller and firmer and hydrops ex vacuo occurs in 
 direct proportion to the shrinkage. Mental changes are not as com- 
 mon as is usually stated. 
 
 VI. Hypertrophy of the Brain. — This is most infrequent. In- 
 crease of the neuroglia is sometimes present and so-called local hyper- 
 trophy is frequently only gliomatous infiltration. Hypertrophy oc- 
 curs at birth, in the first year, when it is often associated with rickets, 
 and sometimes in older subjects. The skull is enlarged, the ventricles 
 decreased and the convolutions flattened. Coincident hypertrophy of 
 the lymphatic glands, thyroid and thymus has been observed. The 
 diagnosis is impossible. 
 
982 DISEASES Of THE NEZVOUS SYSTEM. 
 
 VII. Chronic Bulbar Paralysis. — Although mentioned by Robin- 
 son (1815) and Dumesnil (1859), this affection was first thoroughly 
 described by Duchenne (I860), as labioglossopharyngeal (laryngeal) 
 paralysis, and his observations were confirmed by Trousseau, who 
 made the first autopsies. Wachsmuth (1864) advanced the name, 
 progressive bulbar paralysis, and Charcot and v. Leyden demon- 
 strated alteration in the bulbar nuclei. 
 
 Etiology. — Most cases occur in persons between fifty and seventy 
 years of age. Heredity is a factor only when the disease is associated 
 with progressive muscular atrophy. Sixty-four per cent, of cases 
 occur in males. Trauma, cold, infection, mental or physical exhaus- 
 tion and toxaemias are uncertain factors. Rheinhardt holds that it 
 may follow acute inflammation of the medulla. 
 
 • Pathology. — To the naked eye the medulla usually appears normal, 
 though sometimes shrunken. Microscopically, (a) the motor nuclei 
 are symmetrically and bilaterally wasted, their cells and processes 
 shrunken. The hypoglossal nucleus suffers most and few normal cells 
 remain; its accessory nucleus is usually normal. The spinal acces- 
 sory nucleus is next most frequently affected, but the vagus nucleus 
 suffers less. Degenerative atrophy may invade the glossopharyngeal 
 or exceptionally the facial and fifth nuclei. In some cases perivascu- 
 lar exudation occurs within the nuclei and the nerve elements are 
 degenerated (the parenchymatous form), but in others increase of 
 connective tissue or vascular thickening; may be seen, (b) The respec- 
 tive nerve trunks in their course or in their terminal endings show 
 parenchymatous and interstitial change, even within the medulla, 
 and the posterior longitudinal fibers waste in direct ratio to the hypo- 
 glossal nuclear atrophy, especially those which form the anterior 
 fundamental fibers of the spinal cord. Sometimes the loop of the 
 seventh nerve wastes, (c) The muscles supplied by the above nerves 
 waste, as those of the lips, tongue, palate and larynx (the process 
 sometimes extends to the neck and arms). The greatest change is in 
 the tip of the tongue. The changes are those of progressive muscular 
 atrophy, i. e., atrophy unequal in its distribution, granular, fatty or 
 waxy alteration, increased nuclei in the muscular sheaths and in the 
 connective tissue, reddish pigmentation, and sometimes overgrowth 
 of the fatty tissue. If the nuclei of the medulla are the sole seat of 
 the disease, the disease runs a rapid course of a few months to a year 
 (Reraak). (d) In many cases pyramidal tract degeneration may be 
 traced down into the cord or up into the eras. 
 
 Symptoms. — Labioglossopharyngeal paralysis, the name proposed 
 by Duchenne, designates the parts paralyzed by the wasting of the 
 motor nuclei. It is almost invariably bilateral and but one case 
 showed unilateral disease. It is slow in onset, afebrile and painless. 
 The first symptom is usually paresis of the tongue (hypoglossus) 
 which first shows fatigue and much later actual paralysis. It is 
 difficult to protrude or move up, down or transversely. The Unguals, 
 L, ~N, R and S are formed with difficulty and also later the lingual 
 
BULBAR PARALYSIS. 983 
 
 palatines, as T and D. The tongue is most often wrinkled and 
 wasted. The lips become weak and whistling and formation of the 
 labials (O, U, P, B, M) become impossible. The tongue and lips 
 are more closely associated than any other muscles of the body ; ana- 
 tomically it is probable that the facial fibers for the orbicularis oris 
 originate in or very close to the hypoglossus nucleus. Forced atten- 
 tion may for a while overcome imperfect enunciation, but later the 
 paralysis is complete, the mouth cannot be closed, the lower lip sags 
 and the zygomatic muscles overcome the weak fibers of the upper lip 
 and accentuate the nasolabial furrow. The lips are frequently thin. 
 The expression is peculiar, the forehead is corrugated, the eyebrows 
 somewhat lifted, but the mouth is passive, its expression is " dead " 
 and laughing and emotional displays produce a strange effect, which 
 Trousseau compared to the mask of the Greek actors. The original 
 descriptions graphically picture the patient constantly holding a hand- 
 kerchief before the lips to collect the free flow of saliva from the 
 open mouth; the salivary secretion is probably also increased from 
 disease of its bulbar centre. The chin muscles are weak. Swallowing 
 becomes difficult from the inability of the tongue to propel the food 
 to the pharynx, so that the subject must push the food back with the 
 finger, and again the palate (controlled by the spinal accessory and 
 vagus nerves) is weakened, producing a nasal voice and allowing food 
 to regurgitate into the nose. The pharynx is also paretic (supplied 
 by the glossopharyngeal and vagus nerves) and the larynx suffers 
 (spinal accessory and vagus nerves). Semi-solid food can best be 
 swallowed, because fluid more easily regurgitates into the nose and 
 solids more easily reach the larynx. The larynx is often involved. 
 The adductors are much more often affected than the abductors, but 
 the palsy is usually incomplete. Talking and coughing are difficult 
 or impossible. Fibrillary twitchings are very common, sensation is 
 normal, but the reflexes of the skin and mucosa are usually lost. The 
 electrical reactions are seldom much changed, though there is some- 
 times a partial or mixed form of reaction of degeneration. The intel- 
 lect is normal. The patient may be somewhat emotional and forced 
 laughing and weeping are not uncommon. The general nutrition 
 suffers from the dysphagia. In some cases the process extends beyond 
 the nuclei mentioned; the eyes may be involved, as in progressive 
 nuclear ophthalmoplegia (which is an identical process in the pons), 
 chiefly in young subjects and in "family forms"; occasionally the 
 cervical, facial, masseteric, temporal and pterygoid muscles are in- 
 volved; affection of the latter was considered ominous by Duchenne. 
 The optic nerve is very rarely implicated. Bulbar paralysis fre- 
 quently co-exists with progressive muscular atrophy of spinal origin, 
 affecting the limbs or trunk, and Kussmaul first pointed out that the 
 two processes are identical in nature and differ only in location. 
 The spinal disease may progress upward to the medulla, causing 
 secondary bulbar palsy, or the bulbar palsy may be primary, followed 
 by the secondary and analogous spinal atrophy. In typical bulbar 
 
984 DISEASES OF THE NEEVOUS SYSTEM. 
 
 paralysis there are wasting, paralysis and absence of the reflexes. In 
 some atypical forms there is paralysis but no wasting, and at times 
 the reflexes are increased (clonus in the muscles of mastication) ; 
 in these cases it is probable that the lesion is in the supranuclear 
 fibers, " the bulbar analogue of amyotrophic lateral sclerosis of the 
 cord," with which it may also be combined. 
 
 In the progressive course of the malady the pulse becomes rapid 
 (120 to 150) and irregular; tachycardia is often preceded by running 
 together of the heart tones, which Duchenne compared to the " heart 
 beating in water." Respiration is difficult, dyspnoea develops and the 
 expiration is weak. 
 
 Diagnosis. — This is based on (a) the distribution of the process in 
 the motor nuclei; (&) its bilateral symmetry; (c) gradual onset, and 
 (d) chronic progression. Neuritis of the bulbar nerves is very rare; 
 the lips escape, because the nerve fibers to the orbicularis oris, arising 
 in or near the hypoglossus nuclei run to the pons and leave it by the 
 facial nerve fibers; there is more atrophy, more rapid course, more 
 sensory disturbance and the reaction of degeneration is present. . It 
 occurs in acute infections, etc. Brain tumor within the medulla 
 occurs most often in young subjects and gives the general and local 
 signs of tumor; growths, exostoses, dislocations, caries or aneurysms 
 without the medulla but rarely produce bilateral or exactly symmet- 
 rical paralyses; the lips escape, dysphagia is the leading symptom 
 and other symptoms foreign to bulbar palsy develop, as convulsions, 
 vomiting or hemiplegia (see Brain Tumors, page 960). The 
 bulbar symptoms of multiple sclerosis and syringomyelia are almost 
 never symmetrical. Pseudobulbar paralysis may be confused. Bi- 
 lateral disease of the cerebral hemispheres, sometimes in the cortex, 
 but more often in or near the internal capsule, especially when due 
 to arterial lesions, may cause dysarthria (Joffroy, 1872). One lesion 
 may be in the cortex and the other in the lenticulostriate area (Hali- 
 pre) ; Jolly found this condition in symmetrical sclerosis of both 
 hemispheres. Pseudobulbar palsy causes cerebral symptoms, as men- 
 tal change, aphasia, hemiplegia, double facial paralysis and hemian- 
 opsia; one side is involved after the other and it is attended by no 
 wasting, no loss of reflex action and no reaction of degeneration. 
 
 Prognosis. — The disease is almost invariably fatal in one to three 
 years, especially in advanced life or when co-existent with spinal 
 muscular atrophy. Remissions are possible, and in the rarest in- 
 stances the disease may be arrested in youth or middle life. Death 
 results from inanition, inhalation pneumonia, intercurrent disease or 
 paralysis of the cardiac or respiratory centres. 
 
 Treatment. — Treatment is discouraging. Nutrition must be main- 
 tained by feeding with the nasal catheter, to which a funnel is 
 attached. Iron and strychnine may be given. Electrotherapy is of 
 little value. Faradization of the neck and tongue may help deglu- 
 tition ; the positive pole should be applied to the spine and the negative 
 pole to the throat. The disease steadily progresses in spite of treatment. 
 
APOPLECTIFORM BULBAR PARALYSIS. 985 
 
 Asthenic Bulbar Palsy ; Myasthenia Gravis, — Chronic bulbar palsy 
 without anatomical lesion may be discussed in this connection. It 
 was first described by Wilkes (1877), then by Erb (1879), who 
 recognized its light forms, and Goldflam (1891), who with Oppen- 
 heim published reports of severe and fatal cases. It is sometimes 
 known as the Erb-Goldflam syndrome. E. Bramwell has collected 
 90 cases. Its etiology is unknown, but it occurs most often in persons 
 under the thirtieth year, and in 25 per cent, a neuropathic heredity 
 is demonstrable. The cardinal feature is extreme exhaustion {myas- 
 thenia) after the slightest exertion. Weakness slowly develops in the 
 eyelids, face, palate, masseters, pharynx, vocal cords and the tongue, 
 although but slightly expressed by ptosis (the first symptom in 33 per 
 cent, of cases), dysphagia, dysarthria and difficult mastication, and 
 disappears after rest, to return anew after a few muscular efforts. 
 In six cases myasthenia was confined to the eyes. From these bulbar 
 symptoms the affection is also called asthenic bulbar paralysis. In 
 some cases the arms, legs and trunk are similarly involved, so that 
 walking or arm movements become impossible after short exer- 
 tion; this, together with the bulbar symptoms, is known as myas- 
 thenia gravis pseudoparalytica. The symptoms are symmetrical. 
 The myasthenic reaction of Jolly consists of normal tetanic response 
 to faradic stimulation, but becoming weaker with each repetition, 
 until at last no reaction is elicited. The reflexes are normal or per- 
 haps exaggerated but soon also become exhausted. Some atonicity 
 of the digestive tract is fairly common. The mind, special senses, 
 sensation, muscles and sphincters are usually normal, although Col- 
 lins noted a rapid exhaustion of the special senses and Buzzard re- 
 marked sensory alterations. Remissions are usual, four years being 
 the maximum clinical duration. About JfO per cent, of cases die 
 from exhaustion of the cardiac and respiratory centres but the autopsy 
 findings are negative (in 66 per cent.) or doubtful. Kalisher found 
 hemorrhages in the medulla, and C. Mayer found vascular and nuclear 
 alterations. Lymphoid cells have been found between the muscle 
 bundles, and Hun and Blumer describe lymphoid and glandular hy- 
 perplasia in the thymus gland. The diagnosis is based on (a) absence 
 of atrophy; (b) absence of reaction of degeneration; (c) absence of 
 twitchings and sensory phenomena; (d) the presence of muscular ady- 
 namia occurring with (e) remissions in the course of the disease; (/) 
 Jolly's myasthenic reaction; (g) the slight involvement of the hypo- 
 glossus. 
 
 Treatment. — Rest and massage are helpful, but iodides and strych- 
 nine are less useful. Galvanization of the head and neck is recom- 
 mended by Goldflam, who has reported recovery from its use. 
 
 Apoplectiform Bulbar Paralysis, — Sudden apoplectiform bulbar 
 paralysis does not properly come under degenerative brain disease, 
 but deserves discussion in this place for the sake of topical differenti- 
 ation. Its usual causes are hemorrhage, embolism, thrombosis and 
 
986 DISEASES OF TEE NERVOUS SYSTEM. 
 
 less frequently bulbar encephalitis, trauma or compression, bulbar 
 neuritis, the ascending paralysis of Landry and paralysis after acute 
 infections. 
 
 Symptoms. — Its symptoms are as follows : (a) The onset is apoplec- 
 tiform with symptoms which are rarely focal, as vertigo, vomiting, 
 dyspnoea, yawning, slowed heart, which often occur without coma. 
 They may progress or regress, (b) Motor symptoms are frequent, 
 as double hemiplegia; monoplegia is possible, or if the lesion occurs 
 at the pyramidal decussation there may be hemiplegia cruciata, i. e., 
 paralysis of one arm and the opposite leg. A unilateral focus may 
 produce bilateral symptoms rarely, however, symmetrical. The pyra- 
 midal tracts in the medulla are supplied by the inferior cerebellar 
 artery. Descending pyramidal degeneration follows severe involve- 
 ment of these tracts, (c) Sensory symptoms may develop, as hemi- 
 ataxia or hemiansesthesia (possibly without disturbance of muscle 
 sense), (d) The bulbar nerves may be affected; paralysis of the 
 tongue, pharynx, masseters, larynx and, because of the vascular sup- 
 ply, frequently of the eyes, face and other pons centres may result. 
 The reflexes of these parts are often suspended, though in the extremi- 
 ties they are increased. The lesion may be at the level of the nuclei 
 or supranuclear. The hypoglossal and spinal accessory nerves are 
 supplied by the anterior spinal and vertebral arteries; the vagus, 
 glossopharyngeal and auditory nerves by the vertebral; the fifth, 
 seventh and eye-nerves (third, fourth and sixth) by the basilar artery. 
 There may be hemiplegia with paralysis of the opposite side of the 
 tongue if the lesion is in the anterior part of the medulla. 
 
 Diagnosis. — The diagnosis is usually easy from the acuity of the 
 lesion in the medulla. Chronic bulbar palsy is excluded by the onset 
 and the asymmetry and irregularity of the bulbar symptoms, as 
 double hemiplegia, which is unequal on the two sides, or dysphagia 
 without paralysis of the tongue or lip. Exact differentiation between 
 hemorrhage, embolism and thrombosis is frequently impracticable. 
 Pseudobulbar paralysis of cerebral origin presents the characters of 
 disease of the hemispheres and is clearest when one attack is followed 
 by a second. Differentiation is impossible in simultaneous lesions. 
 
 Prognosis and Treatment. — The prognosis is most grave at the onset, 
 but later there is less danger of progression. Improvement and 
 even recovery are possible. Treatment concerns chiefly the under- 
 lying vascular disease, as in hemorrhage or embolism (q. v.). 
 
 VIII. Progressive Nuclear Ophthalmoplegia. — This is a degenera- 
 tive atrophy of the oculomotor nuclei, similar pathologically to 
 chronic bulbar paralysis. It is more conveniently considered under 
 affections of the third nerve (q. v.). 
 
 HYDROCEPHALUS. 
 
 Acute hydrocephalus is an acute accumulation of fluid either be- 
 tween the dura and the brain (acute external hydrocephalus) or in 
 
EYDH0CEP3ALVS. 987 
 
 the ventricles (acute internal hydrocephalus). In some cases the 
 fluid is a transudate, being part of a general oedema, resulting from 
 cardiac or renal disease, or due to local causes, as sinus throm- 
 bosis. In most cases it is an exudate. Acute meningitis is the only 
 certain cause of acute hydrocephalus and is tuberculous in 80 per 
 cent. ; it is less often the serous meningitis of Billroth and Quincke. 
 It is difficult to distinguish between transudation and exudation, and 
 diagnosis is uncertain. Quincke thinks some cases are angioneurotic. 
 
 I. Chronic Hydrocephalus. — External form (fluid between the 
 dura and brain). — The causes are (a) compensatory hydrops ex 
 vacuo, occurring where brain development is arrested (the congenital 
 form) or when the brain wastes (paretic dementia, softening, hemor- 
 rhage, sclerosis, senile atrophy, porencephaly). The hydrops transu- 
 date under the dura in the arachnoid meshes or between the pia and 
 brain has no clinical importance, (b) Stasis, as in sinus thrombosis ; 
 and (c) chronic diseases, as cancer, nephritis or alcoholism are also 
 causes. The symptoms are indeterminate. 
 
 II. Chronic Congenital Internal Hydrocephalus. — Etiology. — The 
 etiology is uncertain. It has been thought that the cause was foetal 
 meningitis, inflammation in or obstruction of the choroid plexus, or 
 obstruction in the branches of the vena Galeni, in the lymphatics, 
 lateral apertures of the fourth ventricle near the glossopharyngeal 
 roots, aqueduct of Sylvius or in the foramen of Magendie or 
 Luschka. Hereditary influences and syphilis (10 per cent.) are 
 sometimes suggested; parental alcoholism and trauma are question- 
 able causes. 
 
 Symptoms and Pathology. — The large head may be an obstacle to 
 labor. It may measure over 5 feet (167 cm.) in circumference. If 
 it appears after the seventh year the head is not enlarged, and in 
 cretins the head may be undersized. Often the head cannot be held 
 upright. The skull is thin, even membranous and translucent to the 
 candle test. If the disease halts, the bones may thicken and Wormian 
 bones develop. The head projects beyond the base, the sphenoid is 
 luxated forward and downward, the ear meatus points downward, 
 the occiput is forced back, the sella turcica is flattened and widened, 
 the roof of the orbit may be pushed down so as to become palpable, 
 the fontanelles are large, the fissures gape and fluctuation may be 
 felt. The hair is thin, the veins are large and a systolic murmur may 
 be heard, the cause of which is doubtful. The brain is pale and may 
 be flattened almost beyond recognition. The membranes are often 
 thickened and the ependyma thick, granular and sclerotic. The 
 average amount of fluid is 1 quart, the maximum 13 quarts. The 
 ventricles, especially the lateral, are enlarged; sometimes the third 
 or fourth ventricle escapes. The enlarged third ventricle easily com- 
 presses the optic chiasm. The foramen of Monroe is often very large. 
 The fluid is usually clear, sometimes slightly yellow and rarely blood- 
 stained. It may contain epithelial flocculi ; it is neutral or alkaline, 
 its specific gravity is 1,001 to 1,009 ; and the albumin is 0.2 to 2.0 
 
988 DISEASES OF TEE NERVOUS SYSTEM. 
 
 per mille; more than 2.5 per mille of albumin or a specific gravity 
 higher than 1,009 indicates inflammation. 
 
 The face is small, triangular, and the eyes are prominent. Much 
 of the sclera is shown and the upper lid is small, though the lower lid 
 may cover much of the iris. Nervous symptoms are not unexpected, 
 for the brain may be reduced to a small fraction of an inch in thick- 
 ness and is a mere flask for the fluid. The demarkation between gray 
 and white matter is lost and in marked cases the convolutions and 
 sulci are obliterated, the basal ganglia flattened, the cerebellum forced 
 into the spinal canal and many structures, such as the fornix or corpus 
 callosum have disappeared. Mentality, as a rule, is impaired or 
 abolished, speaking is learned late if at all, will power is lacking and 
 irritability is common. Epileptiform attacks, psychoses, headache 
 and vomiting are fairly common. Eye symptoms are frequent, as 
 diminished vision or blindness from initial optic hyperemia and 
 subsequent atrophy, strabismus, nystagmus and wide, possibly reac- 
 tionless, pupils. Other special senses suffer. All the limbs, or the 
 legs alone, often present spasticity, contractures, paresis and in- 
 creased reflexes, if not secondary degeneration in the pyramidal tracts. 
 The child walks late, if at all. Sensation is practically normal. 
 Puberty may be delayed or the infantile testes may persist. Lumbar 
 puncture shows increased intraspinal pressure (36 mm. of mercury). 
 
 Complications. — Complications are largely anomalies of develop- 
 ment, as syringomyelia, hydromyelus meningocele, microcephaly, 
 porencephaly, anencephaly and encephalocele. 
 
 Course. — The course varies considerably. Some subjects die dur- 
 ing or after birth. Many die in the first three years from increase of 
 brain pressure with coma, intercurrent disease or diarrhoea. In some 
 cases temporary remissions are seen, and in still rarer instances per- 
 manent arrest of the process occurs, the mind improves, the speech 
 shows some defects or the gait remains paretic and spastic. In very 
 exceptional cases rupture externally is observed after head trauma or 
 spontaneous breaking into the ear or nose occurs, as in Lebert's case, 
 which " leaked" for five years. Gall reported a case which lived 
 fifty years, and Golis one of seventy-one years duration. 
 
 III. Acquired Chronic Hydrocephalus. — Etiology. — The causes are 
 (a) stasis, either general (cardiac or pulmonary) or local (brain 
 tumor or sinus thrombosis) ; (b) cachectic transudation, as in car- 
 cinoma or nephritis; and (c) inflammation, beginning as acute 
 meningitis of the sporadic or epidemic type, or as slowly beginning 
 chronic basal meningitis, especially in young children. The same 
 points of obstruction may exist as in the congenital variety, (d) Rick- 
 ets is pdssibly a cause or frequent associate. Some forms may be 
 angioneurotic. Some cases show nothing at autopsy. 
 
 Symptoms. — Meningitic symptoms usher in some cases in which 
 after weeks new evidences of brain pressure appear, as alteration in 
 the pulse and breathing, unequal pupils or coma. Headache, vomit- 
 ing, visual disturbance, spastic paresis, epilepsy, altered mentality, 
 
PACHYMENINGITIS. 989 
 
 idiocy or involvement of the cranial nerves are seen, as in the chronic 
 congenital form. The shape of the head, however, is not altered. 
 
 Diagnosis of the chronic congenital and acquired forms. — Differen- 
 tiation between the two forms is very difficult, unless there is an 
 accurate history. (a) From rhachitis: The two affections are often 
 associated, for some unknown reason. The rhachitie head is square 
 rather than globular, it protrudes more in front and laterally than 
 behind, the sutures are less widely separated, the fontanelles are wide 
 but do not bulge, and there are no signs of brain tension. The rha- 
 chitie head should be measured, because it seems larger than it actu- 
 ally is. (b) From brain tumor: The two conditions are sometimes 
 coincident. In each, symptoms of brain pressure are observed. The 
 congenital form is more easily distinguished by the history of the 
 disease from birth and its slower course, but focal symptoms are less 
 common, as hemiplegia, monoplegia and hemianesthesia, and spinal 
 symptoms are more common than in tumor, (c) Hyperostosis of the 
 skull (Paget's disease), brain hypertrophy and acromegaly increase 
 the size of the head, but. are separable by the same arguments as in 
 rhachitis. 
 
 Treatment. — Few therapeutic results can be obtained. Bandaging 
 the head is sometimes helpful, but must be carefully done, lest it 
 aggravate the brain compression. Puncture of the lateral ventricles 
 dates from the time of Hippocrates. Isolated recoveries are recorded, 
 but the evacuation must be slow. Permanent drainage is usually 
 fatal, but occasionally has resulted in cure. Attempts to obliterate 
 the ventricles have recently been made, as in Mikulicz's. Troje's and 
 Leur's efforts to effect anastomosis between the ventricles and the 
 subdural space; ACeArthur was successful in three cases. Lumbar 
 puncture in acquired forms may be useful; death may result. 
 
 DISEASES OF THE CEREBRAL MENINGES. 
 
 Inflammation of the dura is termed pachymeningitis, and inflam- 
 mation of the arachnoid and pia, leptomeningitis or meningitis. 
 
 PACHYMENINGITIS. 
 
 External pachymeningitis is a surgical disease, being secondary to 
 skull disease (syphilis, trauma), infections and cerebral atrophy. 
 Its symptoms are indefinite, as pain, headache, possibly hemiplegia, 
 or are those of the primary lesion; diagnosis is difficult. Surgical 
 treatment in ATaceweus 22 cases gave 100 per cent, recovery. 
 
 Internal pachymeningitis is divided into (a) the purulent form, 
 which follows bone disease or leptomeningitis; and (£>) the pseudo- 
 
990 DISEASES OF THE NERVOUS SYSTEM. 
 
 membranous type, sometimes with fluid between its layers, known as 
 serous pachymeningitis and seen chiefly in general paralysis or in 
 children with perisplenitis. These varieties are not as important as 
 (c) the third variety, known as pachymeningitis hemorrhagica in- 
 terna, described by Heschl (1855), and a year later named by Vir- 
 chow; he regarded the inflammation as primary and the hemorrhage 
 as secondary. Kremiansky (1868) developed the etiology and pro- 
 duced the disease in dogs by administration of alcohol. 
 
 Etiology. — (a) Most cases occur in middle and advanced life, 
 although a few are seen in marantic children. Fifty per cent, occur 
 in persons over fifty years of age, 40 per cent, in those over sixty and 
 25 per cent, in those over seventy (Gowers). (b) Seventy-seven per 
 cent, of cases occur in males, (c) Paretic dementia causes 19 per 
 cent. Pachymeningitis is common in other dementias and chronic 
 psychoses, whence its far greater frequency in asylums and poor- 
 houses than in private or hospital practice. It also occurs in arterio- 
 sclerosis and encephalomalacia. (d) Chronic alcoholism, frequently 
 with cardiac and renal disease, is a more frequent cause than the 
 statistics of Konig show, viz., 6 per cent, (e) Trauma, as during 
 birth, from forceps delivery or from small pelvis. (/) Hemorrhagic 
 diathesis (scurvy, haemophilia, leukaemia, pernicious anaemia), chronic 
 nephritis, (g) Infective diseases, as typhoid, scarlatina, puerperal 
 fever (9 per cent.), heart disease (18 per cent.), hereditary syphilis 
 (11 per cent.), tuberculosis (23 per cent.), bronchitis and pertussis 
 are also causes. 
 
 Pathology and Pathogenesis. — 1. Gross Pathology. — In slight 
 cases the inner surface of the dura is cloudy, yellow or brown from 
 punctate hemorrhages or haematoidin deposits. In pronounced cases 
 the dura shows membranous laminae, which are adherent by prolifer- 
 ation of bloodvessels and by organization. The laminae may be a 
 quarter of an inch thick. Those layers nearest the brain are the most 
 newly formed. Repeated hemorrhage into the layers of the newly 
 formed tissue or between them is very frequent, and may be an inch 
 thick or reach the size of an egg. The free hemorrhage may spread 
 over the entire surface of the brain, even reaching the retina; older 
 foci are apt to be encapsulated. Cyst formation in the clot, suppura- 
 tion and calcification are rare issues. The leptomeninges are tinged 
 and often somewhat inflamed. Corresponding to the most frequent 
 seat of pachymeningitis, the convexity of the brain is compressed, 
 especially over the motor areas. The process is bilateral in 56 per 
 cent, of cases and the basal cranial nerves are seldom implicated. 
 
 2. Minute Examination. — The fresh fibrin of the earliest hemor- 
 rhage and the exudation contain red cells and, nearest the brain, a 
 covering of endothelial cells. Later the exuded fibrin develops capil- 
 laries, organizes and again hemorrhage occurs from the newly formed 
 vessels. This organizes in turn, so that successive laminae develop. 
 The older layers become firm and fibrous. 
 
 3. Pathogenesis. — Yirchow viewed the affection as primary 
 
PACHYMENINGITIS. 991 
 
 pachymeningitis, but Spierling and Huegnenin held that the hemor- 
 rhage was primary. Jores has proven that two classes of cases exist : 
 (a) In traumatic cases the hemorrhage is primary and a simple clot 
 forms which later organizes into firm connective tissue; this variety 
 is called regressive. The same sequence is thought to occur in cases 
 due to the blood diseases, acute infections and arteriosclerosis. (6) 
 In chronic pachymeningitis proper the inflammation is primary, the 
 process is progressive, the connective tissue formed in layers is looser, 
 more vascular, and its inner, successively formed layers are the seat 
 of repeated hemorrhages. 
 
 Symptoms. — In most cases there are no symptoms, because the 
 hemorrhage is slight or the pachymeningitis is overshadowed by the 
 original disease. 
 
 1. General Symptoms. — The most frequent is headache, which 
 is per se of little differential value. It is diffuse and is most marked 
 in alcoholics. The symptoms increase in value when mental dulness 
 or irritation and coma develop with focal signs (v. i.). There may 
 be prodromal delirium. The pulse is sometimes slow and irregular. 
 Choked disk is not rare. Moderate albuminuria sometimes occurs. 
 The temperature may be slightly elevated. 
 
 2. Focae Signs. — The most important is hemiplegia, which is pre- 
 ceded for some time by coma (Fiirstner). The paralysis is contra- 
 lateral, rarely complete, varies with increase or decrease of the clot, 
 often involves the cortical facial and hypoglossal centres, is sometimes 
 bilateral and associated with aphasia (33 per cent.), hemihypses- 
 thesia (especially involving the muscle sense, causing hemiataxia), 
 hemiamblyopia, contractures in the paretic members and Jacksonian 
 epilepsy. Conjugate deviation of the head and eyes, nystagmus and 
 forced postures may be observed. The patient may grasp at his 
 clothes or at his hair or beard (Fiirstner). The pupil contralateral 
 to the lesion is usually larger (Griesinger) ; the pupils react poorly 
 and later both are wide. The tendon reflexes are increased, but the 
 skin reflexes are decreased or abolished during the coma. The basal 
 nerves are very rarely involved ; trismus and rigidity of the neck are 
 uncommon. 
 
 Course and Prognosis. — Death may occur in the first seizure or the 
 symptoms may subside for months, years or possibly permanently. 
 Residual signs are common and include headache, ataxia, psychical 
 alteration, paresis and aphasia. Recurrence is frequent, with stupor, 
 coma and hemiplegia until death occurs (a) from the fundamental 
 disease, (b) from hemorrhage or (c) from intercurrent affections. 
 The outlook depends on the etiology. 
 
 Diagnosis. — A correct diagnosis is rare. A patient with paretic 
 dementia may die from a pseudo-apoplectic shock or from pachy- 
 meningitis or a nephritic subject may succumb to pachymeningitic 
 hemorrhage, uraemia, brain oedema or heart failure. A presumptive 
 diagnosis can be made from (a) the age, (b) causal disease (paretic 
 dementia, alcoholism), (c) preceding dulness or coma, (d) hemi- 
 
992 DISEASES OF THE NERVOUS SYSTEM. 
 
 plegia, or (e) irritative phenomena (small pupils and convulsions), 
 (/) from variability and (g) recurrence of the symptoms. 
 
 Differentiation. — It should be distinguished from localized 
 brain disease, as (a) paretic dementia (q. v.) and (b) cerebral 
 hemorrhage. Differentiation may be impossible, especially when 
 pachymeningitic hemorrhage is very large. The etiology is different, 
 and in pachymeningitis there is more cortical irritation, the coma 
 and paralysis are more variable and temperature, narrow pupils and 
 optic neuritis are more common, (c) In encephalomalacia, the hemi- 
 plegia is more often attended by aphasia and hemianesthesia, and 
 there is less cerebral irritation, (d) Brain tumor is easily distin- 
 guished. Apoplectiform attacks and progression with remissions occur 
 in both affections. Tumor appears earlier in life and focal signs, 
 intense headache and choked disk are much more common. 
 
 Treatment. — Treatment should be (a) prophylactic and etiological; 
 and (&) that of the seizure. The use of the ice-cap, quiet, elevation 
 of the head, application of leeches back of the ear, and possibly vene- 
 section are indicated. Nourishment should be given by rectum. 
 Morphine and chloral relieve the headache, excitement or convulsions. 
 Lumbar puncture has not proven beneficial (Ricken). Operation was 
 first performed by Ceci in traumatic cases and by Annandale, Jabou- 
 lai, Monroe and Ballard in other varieties. In the future surgery 
 will probably benefit a larger number of cases. 
 
 MENINGEAL HEMORRHAGE. 
 
 Meningeal apoplexy may be extradural, subdural, arachnoideal, 
 subarachnoideal and subpial. 
 
 Etiology and Pathology. — (a) Trauma may rupture the anterior, 
 middle or posterior meningeal arteries, with or without fracture of 
 the skull. Rupture occurs usually at the site of trauma, but some- 
 times by contre-coup. The corresponding veins may rupture, also the 
 sinuses or the pial vessels, from the latter of which blood may perco- 
 late to the base of the brain, affecting the basal nerves, or reach the 
 spine. The internal carotid may be ruptured and death then occurs 
 precipitately. External hemorrhage is either diffuse or circumscribed 
 and results most frequently from middle meningeal rupture. The 
 blood clot may weigh 3 to 17 ounces or reach the size of the fist, com- 
 pressing the brain and dislocating the falx. If the dura is injured, 
 blood may be found in its substance. During birth (see Infantile 
 Cerebral Paralysis) trauma may be a factor and hemorrhage has 
 even occurred during gestation from maternal trauma, but asphyxia 
 and precipitate labor are more important; large symmetrical hemor- 
 rhage of the convexity is common, (b) Arteriosclerosis and rupture 
 of cerebral aneurysms; (c) acute infections, hemorrhagic diathesis, 
 sinus thrombosis and rarely heart and lung disease; (d) 50 per cent, 
 of cases occur under forty years of age. Small clots may be absorbed 
 or microgyria, porencephalia, cysts or brain sclerosis may result. 
 
ACUTE SUPPURATIVE LEPTOMENINGITIS. 993 
 
 Symptoms. — Clinical latency is not rare in the new-born. Small 
 hemorrhage in the adult may produce no symptoms. Very large ones 
 result in early sudden death. In rupture of the middle meningeal 
 artery there are (a) symptoms of brain pressure with those of brain 
 concussion or contusion, as loss of consciousness, irritative symptoms, 
 increased breathing, slowed pulse, pallor, vomiting and slight fever 
 (100° to 101°). Either death or improvement may result, (b) 
 In other cases improvement from the concussion and contusion oc- 
 curs ; there may be an interval of hours to often of days when hemor- 
 rhage occurs or recurs, with coma, pressure symptoms, mono- or 
 hemiplegia and convulsions, as in pachymeningitis. Rigidity is less 
 frequent than in meningitis. The pupils are variable. Hemorrhage 
 of the sinuses and pia are said to cause monoplegia frequently; the 
 brain nerves are sometimes reached by infiltration to the base. In 
 the new-born there are asphyxia, slow then rapid pulse and coma, fol- 
 lowed later by epilepsy, idiocy and spastic paralyses. 
 
 Differentiation. — From concussion: an exact diagnosis is possible 
 only after trephining or by the clinical evolution. From cerebral 
 hemorrhage: the course is very rapid. Differentiation from slow, 
 ingravescent cerebral hemorrhage is impossible. 
 
 Prognosis and Treatment. — Ninety per cent, of cases die from ex- 
 pectant treatment (Wiesmann) ; 33 per cent, die in twenty-four hours 
 and, when the hemorrhage is due to aneurysmal rupture, 30 per cent, 
 die in ten hours (Lebert). Early surgical treatment is indicated; 
 this was especially described by Kronlein. 
 
 ACUTE SUPPURATIVE LEPTOMENINGITIS. 
 
 In 1768, Whytt noted the acute hydrocephalic symptoms of men- 
 ingitis, but failed to recognize the meningitis, which Quinn (1779) 
 described. In 1855 Rilliet and Barthez distinguished the suppura- 
 tive, secondary, tuberculous and other forms. 
 
 Etiology. — Suppurative meningitis is generally a secondary process. 
 
 1. Teauma. — Microorganisms from the ear or nose may find ready 
 access to the brain when its resistance is lessened by trauma. 
 
 2. Regional Extension. — (a) From the ear: acute or chronic 
 disease of the middle ear, antrum or petrous bone may result in sup- 
 purative or serous inflammation (see Brain Abscess), (b) Erom 
 the nose : extension by this route is less common. The disease may be 
 acute or chronic, spontaneous or operative (by sounding with a 
 probe), syphilitic, tuberculous, meningococci c, neoplastic or suppura- 
 tive, of the nasal mucosa or of the ethmoidal, sphenoidal or antral 
 cells. Infection may travel through the bone, along the veins to the 
 dura or along the olfactory nerve endings, (c) Erom the eye: the 
 avenues to the brain are numerous, and yet disease of the eye itself, 
 even panophthalmitis is less important than orbital cellulitis or enu- 
 cleation, which exposes the sheath of the optic nerve, (d) Extension 
 may result from parotitis^ carbuncles of the face, whose veins corn- 
 ea 
 
994 DISEASES OF THE NERVOUS SYSTEM. 
 
 municate with the cavernous sinus ; scalp affections ; erysipelas ; bone 
 disease; and sinus thrombosis. 
 
 3. Metastatic or Secondary Extension. — (a) Septicopyemia, 
 from lung suppuration, empyema, arthritis, endocarditis and kindred 
 affections; (&) pneumonia (about 0.5 per cent, in 5,540 cases) ; and 
 (c) rarely exanthemata may produce it. In this group there is prob- 
 ably an intermediate link, as otitis media in scarlatina and empyema 
 or lung infarct in typhoid. 
 
 Bacteriology. — (a) The pneumococcus is probably the most frequent 
 variety. This form may be primary or secondary to pneumonia. 
 (b) Pyogenic organisms, especially the Streptococcus pyogenes and 
 the Staphylococcus pyogenes aureus; (c) the typhoid, colon and in- 
 fluenza bacilli, Friedlander's pneumobacillus and many other organ- 
 isms have been found. 
 
 Pathology. — 1. Macroscopically a purulent exudate is found between 
 the dura and leptomeninges and in the meshes of the arachnoid. The 
 dura is tense and its inner surface dry. The leptomeninges are red- 
 dish, cloudy and are often dotted with punctate hemorrhages. The 
 exudate is clearly purulent, yellow or whitish-green and succulent. 
 The infection spreads rapidly, follows the perivascular lymphatics, 
 as streaks of pus, imbeds the vessels and nerves in its meshes, obliter- 
 ates the sulci and involves the brain and cord membranes ; it is a 
 misapprehension that the epidemic cerebrospinal form involves the 
 spinal meninges and that other suppurative forms do not. The brain 
 is always altered; it is succulent, swollen, springs out as the mem- 
 branes are cut, is vascular and sometimes locally anaemic from com- 
 pression by the exudate ; its surface is most affected, by such changes 
 as small abscesses, punctate hemorrhages or minute islets of softening 
 or encephalitis. The convexity is most often involved in the meta- 
 static form (convexity meningitis) and the base most frequently in 
 ear disease. There may be primary or secondary sinus thrombosis. 
 The ventricular fluid is often increased and is cloudy, purulent or 
 sometimes serous. The apertures of the ventricles may be occluded 
 (see Hydrocephalus) ; inflammation may be noted in the velum 
 interpositum, choroid plexus or ependyma. In the spinal membranes 
 the changes are similar and are most marked over the posterior part 
 of the dorsal region. The process is usually diffuse. On incising the 
 membranes the swollen cord bulges out and the same changes are seen 
 as in the brain. The process may extend along the nerve trunks and 
 bloodvessels, even into the orbit. 
 
 2. Microscopically there are perivascular exudation of red and 
 white cells and fibrin formation. Vascular dilatation and exudation 
 are seen in those cases in which the membranes appear normal to the 
 naked eye. Exudation is most marked over the cortex and near the 
 ventricles, but may also occur deeper in the medullary substance. 
 The ganglionic cells show degeneration. Analogous findings are 
 present in the cord, on its surface or about the central canal. In the 
 optic nerve, exudation, hemorrhage and oedema are seen, possibly 
 
SERO US MENINGITIS. 995 
 
 also in other cranial and spinal nerves. Various bacteria are found 
 (v. s.), as the pyogenic organisms, the pneumococcus and the menin- 
 gococcus. Mixed infections are not uncommon. It must be remem- 
 bered that pathologically (though not bacteriologically), the sup- 
 purative and epidemic forms are identical. 
 
 Symptoms. — Prodromal phenomena are ambiguous and vary with 
 the causal disease ; otitis, pneumonia or pyaemia may long overshadow 
 or totally obscure meningeal manifestations. Complete latency is 
 possible, as in a case seen by the author with Dr. Besley ; a convales- 
 cent pneumonia patient, while dining, felt dizzy and died in a few 
 minutes. The autopsy revealed a massive, purulent cerebrospinal 
 meningitis, which had not produced a single sign or symptom, (a) 
 The onset may be sudden with chill and fever, (b) Headache is 
 usually the first and most prominent symptom, and is often associated 
 with vomiting, (c) The sensorium is disturbed and there is delirium 
 which is succeeded by stupor and finally by coma, in which headache 
 still persists, (d) Convulsions may occur; they are particularly 
 equivocal in children, (e) Optic neuritis may develop if the course 
 of the disease is not too precipitate. (/) Rigidity of the neck and 
 spine is soon noted, as well as (g) hypercesthesia, hyperalgesia and 
 muscular rigidity, (h) Fever is usually present, although in very 
 rare instances it may be absent. It is usually higher than in other 
 types, perhaps 104° to 105°, and rather more continuous. Toward 
 the end it may be 107° or may drop to subnormal, (i) The pulse is 
 faster and irregular. (/) Irritation and paralysis of the cerebral 
 nerves develop (they are considered more fully under the epidemic 
 form) and are manifested by ocular paralysis, nystagmus, strabismus, 
 pupillary inequality and tardy reaction to light, facial paresis, grind- 
 ing of the teeth or trismus, especially if the inflammation is basal. 
 (Jc) If the process involves the convexity, cortical irritation may be 
 manifested by Jacksonian epilepsy and mono- or hemiplegia. (I) 
 Lumbar puncture reveals purulent or clear fluid and frequently the 
 organisms of suppuration. Increased tension is also observed, (m) 
 Kernig's sign (see Epidemic Form) is present, (n) Other symp- 
 toms. Constipation is usually present. The abdomen is often re- 
 tracted, there may be vomiting, the urine is febrile and frequently 
 contains albumin and peptone. The course is generally rapid; it 
 lasts a few hours to more usually a few days (two to ten) and almost 
 invariably results fatally in coma. The diagnosis, differentiation and 
 treatment are considered under the epidemic type. 
 
 SEROUS MENINGITIS. 
 
 This is more frequently seen at the bedside than at autopsy. It 
 is often tuberculous. The inflammation is slight, the membranes 
 are glistening, clear or flocculent fluid is seen in the arachnoid meshes 
 and ventricles, which may be the sole seat of the disease, and the pia 
 especially shows exudation. It is often mistaken for oedema of the 
 
996 DISEASES OF THE NEEVOUS SYSTEM. 
 
 brain. The microscope may be necessary to demonstrate inflamma- 
 tion, which frequently is circumscribed. 
 
 Symptoms. — In the serous form no definite symptoms can be out- 
 lined. The disease certainly exists, although it is relatively infre- 
 quent, but with equal certainty it is too frequently diagnosticated. 
 Headache is common; vomiting, rigidity, fever, slow and labile 
 pulse, optic neuritis, hyperesthesia, spasms and paralyses of the 
 cerebral nerves are much less frequent than in the other forms of 
 meningitis, though they are occasionally observed. The symptoms 
 resemble those of brain tumor. Lumbar puncture in some instances 
 has given absolute relief ; the prognosis is most favorable in this type. 
 
 CHRONIC LEPTOMENINGITIS. 
 
 Etiology. — (a) It may result from acute leptomeningitis, (b) 
 The leptomeninges thicken after trauma, in atrophic and sclerosing 
 brain diseases, as paretic dementia, hydrocephalus and softening and 
 in alcoholism, gout, nephritis or plumbism. (c) Chronic productive 
 inflammation occurs in syphilis, tuberculosis and suppuration. 
 
 Pathology and Symptoms.. — The leptomeninges are diffusely or locally 
 dense, thick, opaque and microscopically show fibrous tissue. In the 
 chronic tuberculous form the membranes are thick, fibrous and case- 
 ous; they compress the cortex, especially the psychomotor areas and 
 produce generalized and Jacksonian convulsions, headache, mono- 
 plegia, aphasia and mental changes. It may sometimes heal. In 
 the chronic suppurative form the pus loculi are situated in a firm, 
 fibrous tissue. The symptoms, if cortical, are like those of the 
 chronic tuberculous form ; if basal, nerve paralysis and optic neuritis 
 are common. In the chronic simple form (Gee and Barlow) the 
 process may begin acutely and may persist, especially at the base and 
 in the posterior fossa. Possibly it is a sequel of a localized epidemic 
 type (this theory was rather favored by Koplik in a recent paper) 
 or of hereditary syphilis, trauma or otitis. It is seen especially in 
 children (" simple meningitis of children"); 76 per cent, of cases 
 occur in the first year of life. Eigid neck is the leading symptom, 
 though convulsions and rigidity of the extremities do occur. Par- 
 alyses are rare. Fifty per cent, of patients die. The alcoholic form 
 is slight, diffuse and cortical ; meningitic symptoms are obscured by 
 alcoholic disease of the liver, kidneys, heart or peripheral nerves. 
 Headache is little developed; there is moderate delirium and slight 
 optic neuritis. Diagnosis is difficult, and therapy is wholly etiological. 
 
SPINAL LOCALIZATION. 
 
 997 
 
 DISEASES OF THE SPINAL CORD. 
 
 GENERAL ANATOMICAL, PHYSIOLOGICAL AND SYMPTOMATIC 
 
 CONSIDERATIONS. 
 
 The nervous system is made up of numerous similarly constituted 
 units, called neurones (Waldeyer). Each neurone comprises (a) a 
 central nerve cell; (&) protoplasmic processes or dendrites from the 
 cell which conduct (cellulipital) impulses to the cell; (c) an axis 
 cylinder or axone arising from the cell and conducting impulses 
 (cellulifugal) from the cell; and (d) the terminal ramifications of 
 the axis cylinder, known as end brushes or arborizations. The axis 
 
 Fig. 62. 
 
 LEG AND ARM 
 
 Illustrating the course of the two motor neurones : A, cortical cell of origin of 
 motor tract ; B, decussation in medulla ; C, course in lateral columns of cord : DD, 
 branches to anterior horns in cord ; in second (lower) neurone, E, cells of anterior 
 horns ; E", cells in pons ; F, nerve trunks ; G, motor end plates ; H, muscles. 
 
 cylinder often gives off lateral branches, known as collaterals or 
 paraxones. The nutrition of the nerve cell probably depends upon 
 the integrity of its nucleus, and the nutrition of the cell governs that 
 
998 
 
 DISEASES OF THE NEBVOTJS SYSTEM. 
 
 of its neurone. Disease of the cell causes degeneration of the entire 
 neurone ; division of a process or axis cylinder results in its degener- 
 ation below the point of separation from the nutrient cell. Most 
 authorities favor the view that the neurones are wholly independent 
 of each other. At times, and especially in the retina, some degree of 
 anastomosis between the dendrites of different systems exists (Do- 
 giel). The nerve cells are closely grouped in the gray cortex, gray 
 substance of the cord and ganglia of the peripheral nerves. The axis 
 cylinders largely course through their white substance. To compre- 
 hend the most important point in spinal diseases, the localization, we 
 must recognize that pathological processes are in general of two varie- 
 ties : (a) those involving certain neurones, or system diseases, as tabes, 
 and (b) those not involving given tracts or neurones or the non- 
 system diseases. 
 
 The functions of the cord are (1) conduction of motor impulses to 
 the muscles; (2) conduction of sensory impressions to the brain; (3) 
 
 Fig. 63. 
 
 AXIS CYLINDER 
 OR AXONE 
 
 GANGLION CELL OF 
 CORTEX. BEGINNING 
 'OF 1ST NEURONE 
 
 cp.t: 
 
 TERMINAL FILAMENTS I Vi' 
 END OF FIRST NEURONE — V-r ' 
 
 GANGUON CELL OF ANT. HORN 
 BEGINNING OF 2ND NEURONE 
 
 -END OF 2nd NEURONE 
 IN MUSCLE PLATES 
 
 Illustrating the general outlines of the upper and lower neurones and of the direct 
 (DPT), and crossed (CPT), pyramidal tracts. 
 
 certain reflexes ; (4) centres governing the bladder, rectum, etc., and 
 (5) trophic influences. 
 
 1. The motor tract is composed of two sets of neurones or segments. 
 The upper segment has its origin in the cells of the motor cortex (Fig. 
 
SPINAL LOCALIZATION. 
 
 999 
 
 62, A), and runs through the corona radiata, internal capsule, crus, 
 pons and in the anterior pyramids of the medulla (whence the name 
 pyramidal tracts), it crosses to the opposite side (Fig. 62, B), run- 
 ning down in the lateral columns of the cord (C) and giving oif 
 branches (DD) to the anterior horns, where the tract ends in fine 
 terminal filaments, which surround the motor ganglion cells in the 
 anterior horn. (See Fig. 56.) The lower segment begins with the 
 motor cell in the anterior horn (E), the dendrites of which con- 
 nect with the terminal ramifications of the axis cylinder of the 
 upper segment by contact (Ramon y Cajal) or by concrescence 
 (Held) ; it extends along its own axis cylinder into the anterior nerve 
 roots and nerve (F), and ends in terminal ramifications (G) (motor 
 end plates) in a muscle, e. g., of the arm or leg, which is on the side 
 opposite to the origin of the cortical motor centre. From the cells of 
 both segments the motor impulse travels downward (cellulifugal con- 
 duction) . About 75 per cent, of the upper motor neurones cross as above 
 described, are called the crossed pyramidal tracts (C. P. T. in Figs. 
 62 and 63) and lie in the lateral columns of the cord. Twenty-five 
 per cent, of the motor fibers (rarely 40 per cent.) do not cross in the 
 medulla, but pass down in the anterior columns of the same side and 
 are called the anterior or direct pyramidal tracts (D. P. T. in Figs. 
 62 and 63). The anterior direct pyramidal tract usually ends in the 
 mid-dorsal region, but if small may reach only to the cervical enlarge- 
 ment of the cord, or if large may even reach the fourth or fifth 
 sacral nerves. This tract probably crosses to the anterior horn of the 
 opposite side by way of the white portion of the commissure of the 
 
 Fig. 64. 
 
 ioo£* 
 
 ROOT, 
 
 Showing the different tracts of the cord. (Gowers.) 
 
 cord. There are probably some other motor tracts in the cord. The 
 upper segment is largely (75 per cent.) crossed, but the lower seg- 
 
1000 
 
 DISEASES OF TEE NERVOUS SYSTEM. 
 
 Fig. 
 
 C 1. 
 
 Dl. 
 
 M 
 
 ID 
 
 rnent (or neurone) is a direct tract, the cells in the anterior horns 
 
 supplying muscles of the same side of the body. 
 
 The cord, therefore, contains parts of both neurones, the course of 
 
 which has been ascertained by the secon- 
 dary descending degeneration which follows 
 neurone lesions. Morgagni, Cruveilhier 
 and Rokitansky noted some atrophy in the 
 cord after brain lesions which destroyed 
 the motor paths, but Tiirck first fully de- 
 scribed its occurrence and Bouchard and 
 Barth confirmed his findings. Flechsig, 
 and later Bechterew, added information 
 from embryological studies. After a lesion, 
 as hemorrhage in the internal capsule, the 
 fibers of the upper neurone below the lesion 
 show signs of degeneration. In a few days 
 granule-bearing cells appear and some- 
 what later the axis cylinders swell, degen- 
 erate and stain poorly, especially when 
 studied by the Marchi method. These 
 changes occur because the axones are sepa- 
 rated from the nutrient cortical cells. The 
 neuroglia tissue increases and corpora amy- 
 lacea develop. Degeneration is seen in the 
 opposite lateral pyramidal tract and in 
 the anterior column on the same side as the 
 brain lesion. Sometimes slight degenera- 
 tion occurs in the lateral pyramidal tract 
 of the same side, which probably has some 
 connection with the anterior uncrossed 
 pyramidal tract of the same side (see 
 Broadbent's theory under Chronic Symp- 
 toms of Brain Hemorrhage). Since 
 the vitality of the neurone fibers decreases 
 as their distance from their trophic cell 
 increases, the degeneration is greatest in 
 the most peripheral part of the axone. 
 The degeneration usually stops at the end 
 ramifications of the axone (see Excep- 
 tions, under Brain Hemorrhage, Path- 
 ology). (Some fibers lying between the 
 direct pyramidal tract and the direct cere- 
 bellar tract degenerate downward; pos- 
 sibly they are part of the lateral pyramidal 
 tract (from Deiter's nucleus in the med- 
 ulla, Eussell.) Fibers lying just anterior 
 to the lateral pyramidal tract also degener- 
 ate downward (from the posterior corpora 
 
 10. 
 
 12.. 
 
 LI 
 
 \ 
 
 i 
 
 a 
 
 12 
 
 ■ IS 
 
 Diagram from Gowers, 
 showing relation of verte- 
 bral spines to their bodies and 
 to the nerve-roots. 
 
PLATE XVIII 
 
 C 
 
 B 
 
 7®% 
 
 A. Ascending degeneration in the posteromedian column and anterolateral ascending tracts from 
 
 lumbar lesion. (After Gowers.) 
 
 B. Ascending degeneration after injury to cauda. (After Schultze.) 
 
 C. Descending degeneration of pyramidal tracts from right-sided cerebral hemorrhage. (After Mott.) 
 
SPINAL LOCALIZATION. 1001 
 
 quadrigemina, Boyce and Sakowitsch). Schultze describes a comma- 
 shaped descending degeneration in the anterior third of Burdach's 
 column. See Plate XVIII. 
 
 Degeneration in the Lower Segment. — Disease of the anterior horns, 
 division or disease of the nerve trunk, causes degeneration of the 
 nerve toward the periphery and trophic muscle changes. The degen- 
 erated nerve responds neither to the faradic nor to the galvanic cur- 
 rent. The muscle does not answer to the faradic current, but to 
 the galvanic, it answers slowly instead of sharply (as is the case 
 with the normal muscle). These differences constitute the reaction 
 of degeneration (see Neuritis). 
 
 The two neurones do not correspond in number, because one neu- 
 rone of the upper segment is connected with several lower neurones, 
 i. e., various cells in the anterior horns at different levels are probably 
 excited by a single pyramidal fiber. For complex movements, as of 
 the hands, there are more pyramidal fibers than for simple move- 
 ments, as of the intercostal muscles. The anterior spinal root nerves 
 join with fibers from the posterior roots, and passing downward, leave 
 the spinal cord between the vertebrae, thus forming the spinal nerves, 
 whose area of origin in the cord is called a segment. The peripheral 
 nerves often arise from several segments, which are sometimes con- 
 siderably separated ; muscles with similar function have similar 
 spinal localization, because movements rather than muscles are local- 
 ized in the cord, as well as in the brain. The appended table gives 
 the localization of the muscles, with special regard to their cells (the 
 beginning of the second neurone), as well as of the skin and reflexes. 
 The cord is shorter than the spinal canal, reaching only to the second 
 lumbar vertebra. The nerve roots descend and therefore their level 
 at the point of exit does not correspond with their level of origin. 
 Fig. 65 shows this relation. 
 
 Table giving localization of function in the various spinal segments 
 (from Edinger, Starr, von Ley den, Remak, Thoburn, Ferrier, Yeo, 
 Growers and Kocher) will be found on page 1003. 
 
 2. The sensory tract conducts upward and is more complicated and 
 less clearly understood than the motor tract, because the interpreta- 
 tion of experiments made on animals is frequently confusing. It is 
 composed of three or more neurones. The cells of the first neurone 
 are in the intervertebral ganglia, whose cells end in an axis cylinder 
 dividing into a branch to the skin and another to the cord by the pos- 
 terior root. These ganglia are the homologues of those of the vagus 
 or trigeminus (q. v.). Embryologically studied, it would seern less 
 likely that the axis cylinder of the ganglion cell divided than that the 
 branches from the skin (the peripheral sensory nerves) represented 
 the protoplasmic processes or dendrites of the ganglion cells and the 
 branch to the cord represented the axis cylinder. However, all per- 
 ipheral sensory fibers originate in the ganglia and almost all fibers of 
 the posterior nerve roots come from these ganglia. From the posterior 
 roots the fibers reach the cord ; where (a) some pass into the posterior 
 
1002 DISEASES OF TEE NEEVOUS SYSTEM. 
 
 column, (b) some into the gray matter and (c) others run to the cells 
 of the anterior horns and are clearly part of reflex arcs. 
 
 (a) The fibers entering the white substance (the posterior col- 
 umns) divide into a short descending branch (which probably is 
 concerned in reflex processes, giving off some collaterals and ending in 
 the gray matter) and into a long ascending branch, which is the more 
 important one ; they enter the posterior column obliquely and by the 
 entrance of new fibers at higher levels become more centrally located 
 in the column of Goll (posterior median column) in which the lowest 
 fibers (e. g., the sciatic) are most posterior and the highest (e. g., 
 the cervical) are most anterior. The posterior columns convey fibers 
 for muscle sense (sense of posture and movement association) and 
 possibly also for simple tactile sensation. " Sensations we do not 
 feel" travel in these columns (Gowers). The posterior median 
 (Goll's) column ends in the nucleus gracilis of Goll (or postero- 
 median nucleus) in the medulla. It is uncrossed, i. e., direct. The 
 posterior external (Burdach's) column ends in the nucleus cuneatus 
 of Burdach (or posterior external nucleus) in the medulla. It is like- 
 wise uncrossed or direct. The first neurone ends in these nuclei. 
 The second neurone crosses above the motor decussation in the med- 
 ulla (interior arcuate fibers) to the opposite side and unites with 
 fibers that have already crossed in the cord, thus forming the fillet 
 (see below, b). This neurone is crossed. The posterior nuclei com- 
 municate with the opposite cerebral cortex, with the cerebellum of the 
 same and opposite side and with the external arcuate fibers. 
 
 (b) The fibers entering the gray matter of the posterior horns also 
 divide into ascending and descending branches. Some lie at the 
 zona terminalis, the most posterior part (Lissauer's zone) of the 
 posterior horn. All these fibers end with terminal ramifications 
 about ganglion cells in the gray matter ; they form the beginning of a 
 second neurone which crosses in the commissure of the cord and 
 courses upward in the antero-lateral column and anterior ground 
 fibers of the opposite side (just anterior to the lateral pyramidal 
 tracts) and they unite in the medulla with the fibers of the second 
 neurone of (a) (v. s.). (See Plate XIX.) The fibers entering the 
 posterior horn convey temperature and pain conduction and travel 
 between the posterior median column and the central canal. Tactile 
 sensation is probably conveyed in the antero-lateral column. Gowers 
 holds that the antero-lateral columns convey most of the upward 
 sensory impulses, since their division causes anaesthesia. Both (a) 
 and (ft) then run in the median lemniscus of the fillet and in part of 
 the longitudinal bundles of the formatio reticularis of the pons, 
 tegmentum of the crus and posterior limb of the internal capsule, 
 beyond which their course is somewhat uncertain. Some fibers run 
 directly to the motor cortex or back of it to the parietal lobes, while 
 others end in the optic thalamus, whence perhaps they are connected 
 by a third neurone coursing to the cortex. 
 
PLATE XIX 
 
 Scheme of Sensory Conduction. (Strum pell.) 
 
 A. Entrance of posterior sensory roots into lumbar cord: g.i., intervertebral ganglion; r.p., 
 posterior root; part of the fibers end in the posterior horns, from whose cells other fibers arise and enter 
 the lateral columns, partly on the same and partly on the opposite side; other fibers from the posterior 
 roots, course upward in the posterior columns and form in — 
 
 B. (tbe cervical cord), Goll's columns (G); B.C., Burdach's columns. 
 
 C. Medulla oblongata, G and B are the nuclei wherein Goll's and Burdach's columns end. From 
 these, new fibers arise which decussate and form the fillet (lemniscus, L) in — 
 
 D. L, lemniscus; Py, pyramidal tract; O, the olive; c.r., corpus restiforme. 
 
 E. Pons; IV, fourth ventricle. 
 
 F. L, lemniscus of fillet; n.r., nucleus ruber; Py, pyramidal tract in crus cerebri; N.L., 
 nucleus lenticulaiis; T.H., optic thalamus (beginning of new neurone to cortex?). 
 
GENE HAL CONSIDERATIONS. 
 
 1003 
 
 Segment. 
 
 2-3 Cervical. 
 
 4 Cervical. 
 
 5 Cervical. 
 
 6 Cervical. 
 
 7 Cervical. 
 
 8 Cervical. 
 
 1 Dorsal. 
 
 2-12 Dorsal. 
 
 1 Lumbar. 
 
 2 Lumbar. 
 
 3 Lumbar. 
 
 4 Lumbar. 
 
 5 Lumbar. 
 
 1-2 Sacral. 
 
 3-5 Sacral. 
 
 Muscles. 
 
 Sterno-cl-mastoid. trape- 
 zius, scaleni, neck mus- 
 cles. Diaphragm (3, 4, 5, 
 6 cerv.). 
 
 Lev. ang. scapula?, rhom- 
 boideus, supra- and infra- 
 spinatus, deltoid, sup- 
 inator longus, biceps. 
 
 Supinator brevis, serrat. 
 mag., clavicular portion 
 of pectoralis maj., teres 
 minor. 
 
 Pronators, coraco-brachi- 
 alis, brachialis ant., tri- 
 ceps, long extensors of 
 hand and fingers. Lower 
 neck muscles and middle 
 part trapezius, 6, 7, 8, C 
 and 1 D. 
 
 Costal portion of pectoralis 
 maj., latissimus dorsi, 
 teres maj. 
 
 Long flexors of the hand 
 and fingers. 
 
 Extens poll. long, et brev. 
 Small muscles of hand. 
 
 Muscles of back (also low- 
 est part of trapezius) and 
 abdomen. Intercostals D, 
 1-10. 
 
 Abdominal muscles, quad- 
 ratus lumborum. Ueo- 
 
 Sartorius(orthirdlumbar), 
 flexors of hip. Quadri- 
 ceps femoris (extensors 
 of knee), cremaster. 
 
 Internal rotators of thigh. 
 
 Adductors of hip. 
 Sartorius (?). 
 Abductors of hip. 
 Tibialis anticus. 
 Calf muscles. 
 
 Flexors of knee (?), gluteals 
 (extensors of hip). 
 
 External rotators of hip. 
 Flexors of foot (?). 
 Extensors of toes. 
 Peronei. 
 
 Flexors of foot and toes. 
 Small muscles of foot. 
 
 Muscles of perineum. 
 
 Skin: Sensation. 
 
 Neck and occiput. 
 
 Shoulder (anterior part, 
 Dana). 
 
 Eadial side of arm (volar 
 and dorsal surfaces) to 
 the insertion of deltoid. 
 Post, surface of shoulder? 
 
 Dorsal and volar surfaces of 
 radial side of hand to 
 midline of middle finger, 
 and up to base of hand, 
 narrow strip on volar and 
 dorsal surfaces up to axil- 
 la, connecting with above 
 area. 
 
 Ulnar part of hand (dorsal 
 and volar) from middle 
 of the fourth to middle of 
 third finger and connect- 
 ing with it, a moderate 
 strip on volar and dorsal 
 surfaces of arm. 
 
 Dorsal and volar surfaces of 
 hand to middle of fourth 
 finger, narrow strip on 
 dorsal and volar surfaces 
 of arm up to axilla. 
 
 Narrow strip on ulnar sur- 
 face arm and forearm 
 down to base of hand 
 (The upper part, perhaps, 
 belongs to the second 
 dorsal segment. ) 
 
 Chest, back, abdomen and 
 upper gluteal region. 
 (Umbilicus, tenth dorsal ; 
 ensiform, sixth to sev- 
 enth dorsal). 
 
 Pubic area, anterior aspect 
 of scrotum. 
 
 Anterior and inner side 
 of hip, inner side leg 
 to malleolus, inner 
 side of foot, external 
 surface of hip, lumbar 
 regions. 
 
 ") Posterior surface of hip, 
 thigh, external sur- 
 face of leg and foot 
 
 Back of foot. 
 
 Skin of sacrum, anus, 
 perineum, genitalia. 
 
 Reflexes. 
 
 Sudden inspiration by- 
 sharp pressure below the 
 ribs. 
 
 Widening of pupil from 
 irritation of neck, 4-7 cer- 
 vical. 
 
 Scapular reflex (fifth cerv 
 to first dorsal). Tendon 
 reflexes of this group of 
 muscles. 
 
 Tendon reflexes of muscles 
 named. 
 
 Volar reflex of hand, peri- 
 osteal reflexes of radius 
 and ulna. Tendon re- 
 flexes of muscles named. 
 
 Corresponding tendon re- 
 flexes. 
 
 Tendon reflexes. 
 
 Abdominal reflex. Epi- 
 gastric reflex (according 
 to Dinkier, is at the ninth 
 dorsal, the middle and 
 lower abdominal at the 
 tenth and twelfth, respec- 
 tively). 
 
 Cremasteric 
 lumbar). 
 
 reflex (1-3 
 
 Patellar reflex (2-4 lum- 
 bar). Erection (lumbar 
 cord). Uterus (lumbar 
 cord). 
 
 Gluteal reflex (4-5 lumbar). 
 
 Plantar reflex ; ejaculation 
 (3-4 sacral). 
 
 Achilles tendon reflex. 
 
 Bladder and rectum reflex. 
 
 The brackets to the left concern only the muscles, and indicate the origin of the muscles from 
 several nuclei. 
 
1004 DISEASES OF TEE NEBVOUS SYSTEM. 
 
 The sensory tracts degenerate upward (ascending degeneration). 
 Plate XVIII, Fig. A, shows degeneration in the posterior and antero- 
 lateral columns. Most ascending degenerations stop in the medulla. 
 The direct cerebellar tract, which begins at the first lumbar nerve, 
 also degenerates upward. It increases somewhat in size as it rises 
 because of reception of additional fibers, but most of its fibers come 
 from the lower dorsal and first lumbar nerves; some of them come 
 from the gray substance of Clark's columns to which collaterals are 
 sent from the posterior fibers ; as to its function Flechsig believes that 
 it conveys muscular impressions from the lower part of the trunk and 
 the legs ; its destination is the middle lobe of the cerebellum by way of 
 the restiform body; some fibers then cross to the opposite lobe. 
 
 The spinal sensory nerves descend lower than do the corresponding 
 motor nerves and skin sensation for a given area is often supplied by 
 two, three or more nerves, whence anaesthesia results only when all 
 of them are diseased (Sherrington). See Plate XX. 
 
 Lesions of the conus medullaris down to the fourth sacral nerve 
 produce paralysis of the bladder and rectum and simultaneously 
 saddle-shaped anaesthesia on the anus, gluteal region, perineum, geni- 
 talia, under surface of the thigh (pudendal and coccygeal plexuses), 
 but the scrotum escapes because the spermatic plexus and external 
 spermatic nerve connect with the lumbar plexus. Motor paralysis 
 is absent because the limbs receive their supply from the lumbar 
 and upper sacral segments. The cremaster reflex is normal. If 
 sexual desire and erection are preserved with loss of vesical and 
 rectal function, conus localization is rather indicated. Pain is not a 
 prominent feature. Sensory dissociation, rapidly occurring trophic 
 changes and rapid advance of the disease argue for conus disease. 
 Lesions of the cauda equina (where the roots lie closely together) 
 are usually symmetrical. The onset is insidious and the progression 
 slow; pain is prominent and usually the first symptom; then the leg 
 reflexes are lost, followed considerably later by paralysis, atrophy and 
 anaesthesia (especially in the perineum, ext. genitalia and a narrow 
 zone about the anus). For caudal lesions, speak remission and im- 
 provement in the vesical and rectal functions and the slow appearance 
 of muscular wasting, reaction of degeneration and trophic alteration. 
 In its upper part, the above symptoms with paralysis of both legs are 
 noted; paraplegia dolorosa is frequent (see Plate XVIII, Fig. B). 
 A lesion below the third lumbar vertebra is usually limited to the 
 pudendal and sciatic distributions. 
 
 3. In the gray matter there are reflex centres which are enumer- 
 ated and localized in the table given above. The reflex arc comprises 
 the afferent sensory fiber with its termination in the gray matter and 
 the motor nucleus with its efferent motor fiber. Collaterals probably 
 connect the centres at different levels. Hutchinson first suggested 
 that the fibers of the oculopupillary reflex ran by way of the sympa- 
 thetic nerve (rami communicantes) to the cord. Irritation of its 
 centre produces dilatation of the pupil (mydriasis), especially in 
 
PLATE XX 
 
 "^ A 
 
 2d 
 
 3d" 
 
 ft 
 
 fcM 
 
 J I d 
 
 3s 
 
 ,v 
 
 4H 
 
 U 
 
 5 s 
 
 These figures have been aevised by Wichmann in order to show the distribution of the sensory areas 
 corresponding to the segments of the spinal cord. The colors used correspond to those of the normal spec- 
 trum, red, orange, yellow, green, blue, indigo, and violet, with brown; respectively — the first, second, third, 
 fourth, etc., segments in each portion of the spinal cord- -cervical, dorsal, lumbar, and sacral. The last four 
 segments in the dorsal region are left white. The advantage of the plate is that it shows very clearly the 
 overlapping of the segments that has been demonstrated by Sherrington. The dark heavy black fines 
 on the arms indicate the division between the two sides of innervation — that from the upper portion of 
 the cervical enlargement and that from the lower portion. The heavy black fines of the legs indicate the 
 divisions between the sacral and lumbar areas of innervation. The figures and letters indicate the seg- 
 ments in which the supply has been drawn and have been introduced for the sake of making the diagram 
 more available for ready reference. C — cervical, D — dorsal, L — lumbar, and S — sacral. The horizontal 
 bands of color without dividing lines between them indicate that both segments innervate the areas 
 involved. (Musser.) 
 
SPINAL LOCALIZATION. 
 
 1005 
 
 spinal caries. Paralysis from disease of the centre produces myosis, 
 narrowing of the eye fissure, sometimes retraction of the eyeball and 
 less often flattening of the cheek; Madame Klumpe-Dejerine found 
 that this paralysis was produced by section of the eighth cervical and 
 
 Fig. 66. 
 
 Fig. 67. 
 
 Lesion at the level of the second lum- 
 bar segment (Strtimpell and Muller, from 
 whom also following figures are borrowed). 
 
 Lesion at third lumbar segment. 
 
 Fig. 68. 
 
 Fig. 69. 
 
 Lesion at fifth lumbar segment. 
 
 Lesion at first sacral segment. 
 
 first dorsal segments ; i. e., the localization is the same as for paralysis 
 of the forearm and anaesthesia of the ulnar surfaces of the hand and 
 arm. It occurs more often in disease of the nerve roots than in dis- 
 ease of the cord itself. The tendon reflexes will be considered under 
 
1006 
 
 DISEASES OF THE NEEVOUS SYSTEM. 
 
 the individual cord diseases. They are inhibited from the brain and 
 probably also from the cord. Evacuation of the bladder and rectum 
 is partly a reflex and partly a voluntary process. There are muscular 
 
 Fig. 70. 
 
 Fig. 71. 
 
 Lesion at second sacral segment. 
 
 Lesion at third sacral segment. 
 
 fibers to evacuate the organs and sphincters to retain their contents. 
 The former are stimulated by distention and the latter relax; they 
 are controlled normally by the will. If inhibition fails, the bladder 
 
 Fig. 72. 
 
 Lesion at fourth sacral segment. 
 
 or rectum is evacuated, sometimes with the knowledge of the patient, 
 as in disease of the pyramidal tracts, or at other times unconsciously, 
 as in coma or when the sensory nerves of the parts are diseased. 
 
DISEASES OF THE VEBTEBBM. 1007 
 
 When the lumbar centre itself is affected there is continuous evacua- 
 tion. As to the rectum, Gowers discovered that disease of the centre 
 discloses itself by relaxation of the sphincter on digital examination ; 
 disease above the centre, by normal tonicity of the sphincter. 
 
 From the above considerations, the leading points are given re- 
 garding the level of the lesion and the course of the chief systems. 
 Total transverse disease of the cord produces paralysis of the muscles, 
 at and below that level, and sensory interruption. From these symp- 
 toms the upper level of the lesion is determined, but it might be diffi- 
 cult to decide whether the cord were affected through a narrow hori- 
 zontal level, or whether all the cord, below it, were diseased, unless the 
 reflexes below were noted. Hyperesthesia usually discloses the level 
 of the lesion. Lesions of the pyramidal tract (first neurone) produce 
 motor paralysis at the level of the lesion, increased reflexes and spas- 
 ticity (hypertonic muscular rigidity) but with no muscular atrophy, 
 reaction of degeneration or sensory disturbance. In lesions of the 
 posterior columns the chief alteration is sensory disturbance, espe- 
 cially in the muscle sense, and therefore incoordination or ataxia. 
 The reflex arc may be interrupted. Lesions of the anterior horns or 
 anterior roots produce a flaccid paralysis followed by atrophy and the 
 reaction of degeneration if the process is acute. (If it is chronic 
 the atrophy is more marked than the paralysis and the reaction of 
 degeneration is absent or atypical. The trophic cells are not special- 
 ized in the horn, but all cells are probably trophic.) The motor 
 nerve (Nasse, 1839) and the muscle degenerate; the reflexes are 
 abolished ; the muscle tension (myotatic irritability) is lost, there is 
 vasomotor paralysis (since the fine fibers of the anterior roots are 
 vasomotor) and contractures result (from sensory irritation, Gold- 
 scheider). If the lesion is in the anterior horn there may be fibril- 
 lary muscular contractions. Irritation of the anterior horns may 
 increase the reflexes and induce contractures. In lesions of the 
 posterior horns there are disturbance of the temperature and pain 
 sense and some alteration of the tactile sense ; the reflexes may be dis- 
 turbed. In lesions of the posterior roots the reflexes are disturbed and 
 there is anaesthesia and ataxia. Irritation of these roots causes pain, 
 hyperesthesia in the form of a girdle sensation in the trunk or lan- 
 cinating pains in the extremities and reflex contractures. The im- 
 portance of the spinal ganglion as the trophic centre must be remem- 
 bered (Waller, 1852). Vasomotor fibers leave the cord through the 
 anterior roots by the rami communicantes and course down in the 
 lateral columns or in the intermediolateral tract from the centre in 
 the medulla. Most of the vasoconstrictor fibers leave the cord be- 
 tween the third dorsal and second lumbar segments, while the vaso- 
 dilator fibers are much more diffusely scattered through the cord. 
 
 DISEASES OF THE VERTEBRA. 
 
 I. Fracture of the Vertebrae, — It constitutes but % of 1 per cent 
 of all fractures (Gurlt), 
 
1008 DISEASES OF THE NERVOUS SYSTEM. 
 
 Etiology. — Fracture in the dorsal and lumbar regions occurs mostly 
 in the vertebral bodies (66 per cent.), while in the cervical region the 
 processes are often fractured (50 per cent.). Falls, sudden flexion or 
 blows are the most common causes, though in rare cases it is caused 
 by simple muscular exertion. Previous disease, caries and tabes may 
 favor fracture. Corresponding to the obvious angle in the spine, the 
 upper portion usually slips downward and forward, crushing, com- 
 pressing or even severing the cord, while the abundant epidural plexus 
 of veins ruptures and forms an hematoma back of the cord. Gurlt 
 found fracture most often in the fifth and sixth cervical, the last 
 dorsal and first lumbar vertebras. The cord is the seat of hemorrhagic 
 softening or later of inflammation (myelitis). Marked or permanent 
 injury results in ascending and descending degeneration. 
 
 Symptoms. — They may be (a) local, i. e., direct. Dislocation with 
 deformity (in 68 per cent.) is the most frequent sign; 'pain is fre- 
 quent; crepitation (in 38 per cent.) is uncommon save when the 
 processes are fractured; its elicitation should not be attempted, (b) 
 General symptoms include shock and concussion, (c) Spinal symp- 
 toms are more or less complete paraplegia (in 71 per cent.), i. e., 
 paralysis of both arms, legs or of parts below the lesion. The reflexes 
 are decreased as a result of the shock; in complete division of the 
 cord the patellars are totally abolished, even when their lumbar centre 
 is not implicated, as in cervical fracture (Bastian, Bruns, Bowlby) ; 
 Jackson held that the cause was withdrawal of the cerebellar influ- 
 ence; others have suggested that shock or irritation was causative; 
 the abruptness of the lesion is certainly a factor since the patellars 
 are present in slow compression (Gerhardt). The paralysis may be 
 unilateral (see Brown-Sequard's Paralysis under Trauma of the 
 Cord). Sensation is less involved, but radiating pains into the ex- 
 tremities may occur when the lesion is at the cervical or lumbar en- 
 largement ; they are sometimes associated with muscular spasm. Con- 
 tinuous erection (priapism) is almost constant, especially in cervical 
 fracture, and ejaculation occurs at the time of the lesion. Paralysis 
 of the bladder and rectum is usual. The bladder can often be emptied 
 by suprapubic pressure. Meteorism may result. Decubitus (bed- 
 sores) is common. 
 
 Fracture of the first and second cervical vertebras usually results 
 in sudden death; most cases result from caries (Bergmann). Some 
 subjects die in a few days, while in a few instances recovery is pos- 
 sible. The author has seen two cases with deformity in the spine and 
 pharynx without any cord compression. There are pain in the neck, 
 pain on movement, fixation of the head, often palpable deformity 
 in the pharynx, dysphagia, dyspnoea, vomiting and paralysis of the 
 tongue, palate and of all the limbs, usually with preservation of the 
 reflexes. The temperature may reach 111°. The pulse is often 
 slowed (to 40 or 20) by paralysis of the accelerator fibers of the heart 
 which run from the medulla by way of the lateral columns to the 
 fourth to ninth dorsal anterior roots and cardiac plexus. Their 
 
DISLOCATION OF THE VERTEBRA. 1009 
 
 irritation may produce paroxysmal tachycardia. In fracture of the 
 third and fourth cervical vertebrae involvement of the phrenic nerve 
 results in respiratory paralysis and early death. In fracture of the 
 fourth cervical to second dorsal vertebrae, paraplegia, which increases 
 after the injury from hemorrhage, is the chief symptom. In the arms 
 it is often somewhat asymmetrical. Atrophy may follow injury to 
 the cervical enlargement. Pains, hyperalgesia and tonic or clonic 
 spasms in the arms are frequent. Anaesthesia is usually less marked 
 than the paralysis. The intercostal muscles being paralyzed, the 
 patient breathes with the diaphragm and the accessory respiratory 
 muscles of the neck. Vasomotor manifestations may occur in the 
 pupils, face, trunk or extremities. In fracture of the third to twelfth 
 dorsal vertebrae, paraplegia, anaesthesia and often paralysis of the 
 bowel and bladder result. The temperature is often low in lesions of 
 the lower cord, hum bar fracture, except in the first lumbar vertebra, 
 is infrequent. Paralysis is not a frequent result, unless there is 
 marked dislocation when paraplegia, especially in the peronei, and 
 atrophy, pains in the legs along the sciatic and crural nerves and 
 anaesthesia occur (v. s v Lesions of the Conus and Cauda). 
 
 Diagnosis. — The diagnosis is based on the trauma, cord symptoms 
 and deformity which, though sometimes absent, serve for differen- 
 tiation from spinal concussion. In doubtful cases the examination 
 for tender points, fixation of the spine and radiating pains must be 
 made most carefully lest the cord injury be thereby increased. 
 
 Course. — Healing is difficult, uncertain and incomplete, because 
 callus formation is rarer than cartilaginous and fibrous union, and 
 dislocation may occur after trauma. Early death frequently results 
 from fractures in the higher vertebrae while in those lower down a 
 later death is likely to occur from cystitis, decubitus or sepsis. The 
 prognosis is most favorable in fractures between the third dorsal 
 and second lumbar vertebrae (Gurlt). According to Burrell, — from 
 whose collation of 244 cases (1905) most of the above statistics are 
 taken, — the average mortality is 65 per cent. ; the mortality is 86 per 
 cent, in cervical, 76 per cent, in upper dorsal, 56 per cent, in lower 
 dorsal and 50 per cent, in lumbar fractures. 
 
 Treatment. — Surgical interference is not indicated in fresh cases, 
 unless a comminuted process may press on the cord. If paralysis 
 persists from pressure of a process on the cord, especially in the 
 lumbar region, operation is indicated. 
 
 II. Dislocation of the Vertebrae. — Dislocation is traumatic, or 
 spontaneous from previous vertebral disease. Traumatic luxation is 
 sudden, injures the cord to a greater extent and results from falls or 
 blows on the head or neck. Fracture very frequently accompanies 
 dislocation. Luxation from previous vertebral disease is gradual, 
 sometimes sudden and injures the cord less, since it is often incom- 
 plete (subluxation). It occurs most often in the cervical region, es- 
 pecially in the first and second or fifth and sixth vertebrae. It is 
 64 
 
J 010 DISEASES OF TEE NERVOUS SYSTEM. 
 
 infrequent elsewhere in the spine. The vertebrae sometimes are torn 
 apart without actual displacement- 
 Symptoms. — The head is often bent forward toward the sternum or 
 shoulder. Movement is suspended or limited. Tenderness and pain 
 are elicited and the local deformity may be felt or seen. The cord 
 is injured by direct compression, contusion, hemorrhage and later by 
 myelitis, with much the same symptoms as in fracture. Sometimes 
 no spinal symptoms are observed. Sudden death is very common in 
 the higher dislocations from pressure on the medulla. 
 
 Treatment. — Reduction is indicated even when the cord is not in- 
 jured and may relieve all symptoms. 
 
 III. Caries of the Vertebrae. — Etiology and Pathology. — Pott's dis- 
 ease (Pott, 1779), spondylarthrocace, is the most common vertebral 
 disease involving the cord. Caries is almost always tuberculous. It 
 is most common after the fourth year and in adolescence, but may be 
 seen at any age. Tuberculosis in other organs is frequent in Pott's 
 disease ; it usually begins " spontaneously," in one or several ver- 
 tebral bodies or more rarely in the articulations. It may follow 
 trauma. The spongy portion of the vertebral body is first involved. 
 Granulation tissue is the earliest finding; later caseation occurs with 
 extension to contiguous parts, the connective tissue, ligaments, pro- 
 cesses and cartilage. The collapse of the altered body usually pro- 
 duces an angle and prominence in the spine called Pott's boss, and the 
 diseased body slips backward, sometimes compressing the cord. By 
 extension the nerve roots may be involved; they are bathed in pus, 
 sometimes show connective tissue induration and, in cases of long 
 standing, atrophy. The outer surface of the dura is very frequently 
 inflamed (pachymeningitis externa) ; collections of thick, caseous 
 pus gather in the cellular tissue between the dura and the posterior 
 surface of the body of the vertebra ; the cord is more injured by 
 caseous or purulent pachymeningitis than by deformity of the spine. 
 It was once thought that the cord was not only compressed but also 
 inflamed, whence the name, compression myelitis. 
 
 Compression paralysis (so-called compression myelitis) may result 
 from (a) vertebral disease, tuberculosis, cancer or exostoses; (b) 
 disease of the spinal cord and its membranes, as tumors, pachy- 
 meningitis hypertrophica, syringomyelia or hydromyelia ; or (c) com- 
 pression by aneurysm or echinococcus. Pathologists differ as to the 
 actual changes in the compressed cord. Myelitis may develop in 
 some cases, but "compression myelitis" is probably nearly always 
 softening (myelomalacia). In some cases with marked paralysis, the 
 postmortem examination shows no changes in the cord, whence it is 
 certain that pressure may interrupt nerve impulses without struc- 
 tural cord disease. In other cases all gradations of alteration are 
 found, from a few granule-bearing cells or swollen axis cylinders to 
 marked disintegration, corpora amylacea, neuroglia overgrowth and 
 induration. 
 
C ABIES OF TEE VEETEBBM. 1011 
 
 Symptoms. — Symptoms usually develop in the following order: 
 
 1. Spinal Column. — Angular deformity (kyphosis, gibbus, Pott's 
 boss) is common but not invariable; it is most marked in upper 
 dorsal disease and is at times accentuated by periosteal induration. 
 Frequently there is only lateral deviation (scoliosis) ; ordinary lat- 
 eral curvature of the spine never affects the cord or its nerve roots. 
 Tenderness over or beside the affected vertebrae and pain are 
 usually localized and develop early. The application of heat, which 
 is not felt over the normal vertebrae, may cause pain over the diseased 
 focus. Pain and tenderness are very common in the neuroses, but the 
 hyperalgesia is largely cutaneous, is usually diffuse and varies more 
 than in caries. Rigidity of the spine is most conspicuous in disease 
 of the cervical or lumbar region, where movement is normally most 
 free ; it is usually an effort to spare pain. Gravitation abscesses are 
 frequent and follow along the planes of least resistance in the tissues. 
 Dysphagia from retropharyngeal abscess or low compression of the 
 oesophagus may cause errors in diagnosis. 
 
 2. Nerve Roots. — Eccentric pain is usually the earliest symptom ; 
 it radiates into the trunk or extremities and indicates involvement by 
 pachymeningitis of the posterior nerve roots. It is much less acute 
 than in cancer and is especially elicited by movement. Sensory are 
 more common than motor root symptoms and irritative symptoms, as 
 hyperesthesia, are more common than anaesthesia. Root symptoms 
 are most pronounced in lumbar and sacral disease and least pro- 
 nounced in dorsal disease. 
 
 3. Spinal Cord. — Compression (a) interrupts function at its 
 level, disturbs reflexes, impairs rectal and vesical evacuation and (b) 
 interrupts upward and downward cordal conduction, producing spas- 
 tic paresis or paralysis, anaesthesia affecting all varieties of sensation 
 and increase of skin and tendon reflexes, whereas root disease does 
 not interrupt conduction. Cord symptoms develop slowly; Oppen- 
 heim placed the average time at one year; weakness of the legs is 
 followed by paresis, this in time by paraplegia, which may develop 
 suddenly. Anaesthesia and other sensory manifestations are less 
 common than are motor symptoms, because the sensory tracts are more 
 resistant or more protected, since the greatest compression is exerted 
 on the outer lateral surface of the cord. Ataxia is obscured by the 
 paralysis. Marked anaesthesia, paralysis and atrophy are referred 
 to the cord. The reflexes are increased (unless their arc is destroyed 
 at the level of the lesion) since cerebral inhibition is interrupted. 
 
 Special Localization. — 1. Dorsal Caries. — This is the most fre- 
 quent type. Gradual deformity is usual, with formation of a sharp 
 or obtuse angle. Acute deformity, such as might result from a fall or 
 lifting a heavy burden, is much less common. Paraplegia develops 
 in varying degrees of intensity with increased muscle tonus (spas- 
 ticity), increased leg reflexes, or even clonus, or paralysis of the 
 bladder and rectum; it sometimes develops with contractures but 
 rarely with marked sensory changes, other than intercostal root pains 
 
1012 DISEASES OF THE NEBVOUS SYSTEM. 
 
 in the chest wall, which sometimes produce, precordial oppression or a 
 girdle sensation. Herpes zoster may develop. The level of the lesion 
 may be marked by a zone of hyperesthesia or hyperalgesia. Trophic 
 changes in the skin are common, as glossiness, smoothness or dryness. 
 There is no essential atrophy save from disuse^ nor is there any reac- 
 tion of degeneration, unless the anterior horns are diseased. In 
 cases of partial paralysis the tendon of the tibialis anticus becomes 
 prominent (tibialis phenomenon). The tendon reflexes may be in- 
 creased even when the paralysis is apparently flaccid. They are al- 
 most always increased below the lesion. Exaggeration of the patel- 
 lars is an early symptom, often antedating the paralysis. The skin 
 reflexes below the lesion are often increased, but may be decreased in 
 cases of severe compression, though they are seldom absent. The 
 Babinsky reflex is often found (see Brain Hemorrhage). 
 
 2. Cervical and Upper Dorsal Caries. — This form ranks next 
 in frequency; radiating pains reach the shoulder, arm and hand on 
 one or both sides. Anaesthesia is more common, along the ulnar 
 nerve, over the sternum and scapula, because the posterior roots are 
 more often affected. Paralysis may result from compression of the 
 cord or from disease of the anterior roots, and involves the small 
 muscles of the hand, forearm and triceps. The fore-finger and thumb 
 often cannot be apposed (the ape hand) and from atrophy of the 
 interossei, the main en griff e results (v. i.). The forearms are flexed 
 and pronated, while the arms are adducted (Thoburn). The tendon 
 reflexes usually persist. In other cases marked atrophy occurs in- 
 stead of paralysis and the reaction of degeneration sometimes de- 
 velops. Spastic para-paresis or -plegia in the legs from compression 
 of the pyramidal tracts usually accompanies the diplegia (para- 
 plegia) brachialis, which, however, sometimes occurs alone, when the 
 anterior horns or roots are diseased. Myosis is common from injury 
 to the oculospinal centre (Kollet, 1864) and there may be narrowing 
 of the eye fissure and less often retraction of the eyeball, which is 
 more frequently unilateral than bilateral, or differs in degree on the 
 two sides. Flattening and reddening of the cheek are less common. 
 These are less symptoms of disease of the cord than of the anterior 
 roots. The reflexes of the legs are increased ; total compression of the 
 cord may destroy the tendon reflexes by secondary changes in the 
 lumbar cord; when the paralysis is flaccid the urine is retained at 
 first and later there is incontinence. There is usually constipation. 
 3. Disease of the First Two Cervical Vertebra. — (Bust's 
 Disease.) — In disease of the atlanto-occipital articulation, nodding is 
 impossible, while the involvement of the odontoid-atlas articulation 
 prevents turning of the head. In body-movements the patient sup- 
 ports the head with the hands (Bust). The head may be held as it is 
 in torticollis, and induration under the occiput is common. Pains 
 radiate to the eye, ear and occiput. The typical paralysis in disease 
 of the two upper cervical vertebrae is brachial paraplegia, which 
 usually occurs without atrophy. Spasms in the face, anaesthesia in 
 
C ABIES OF TEE VEETEBEM. 1013 
 
 the neck and upper chest, aphonia and other symptoms indicating 
 involvement of the medulla oblongata may be present. Charcot ob- 
 served a slow pulse with attacks of syncope. The spinal accessory 
 supply to the head and palate and the hypoglossus supply may be 
 affected. The course is usually more rapid (one to two years) than 
 in carcinoma ; recovery is possible (v. Bergmann) . Degenerated axis 
 cylinders do not regenerate. Gravitation abscess may reach the neck 
 or pharynx. Sudden death is not unusual, because dislocation readily 
 occurs, since the disease is in the articulations rather than in the 
 vertebral bodies. 
 
 4. Lower Dorsal and Upper Lumbar Caries. — This type pro- 
 duces atrophic flaccid paraplegia, destruction of the lumbar reflexes, 
 urinary incontinence, anaesthesia of the legs, pain in the abdomen or 
 possibly in the groins or anterior thighs. When it occurs in the 
 lower lumbar region there are flaccid atrophic paralysis, absence of 
 the patellars and spastic paralysis below the knees, with clonus of the 
 Achilles tendon (see Conus and Cauda Localization). 
 
 Diagnosis. — Cases may be classed under three groups (a) those with 
 spine symptoms, (b) those with spine and spinal cord symptoms and 
 (c) those with cord symptoms only. Cases are almost unmistakable 
 in which the paralysis follows signs of bone disease in early life. Re- 
 peated examinations usually determine the nature of doubtful cases 
 in which bone-symptoms develop after compression of the cord or 
 nerve roots and in which there are early increase of the skin or 
 tendon reflexes, root-symptoms, which are usually bilateral, as cer- 
 vical or intercostal neuralgia, lumbago, anaesthesia and muscular 
 atrophy or paralysis. The Rontgen rays may aid in diagnosis. 
 Gravitation abscesses, fever and tuberculosis elsewhere are significant. 
 In persons of advanced years, cancer, tumor within the spinal canal 
 and aneurysm must be considered (see Cancer of the Spine). 
 
 Prognosis. — The prognosis is unfavorable, since about 50 per cent, 
 of cases die. Relative recovery is possible, especially in children, 
 but even then the process may break out anew. A rapidly fatal course 
 is rare. Absolute paralysis may disappear after months or even 
 years. The prognosis is best in disease of the lower dorsal region 
 and is least favorable in disease of the atlas and axis. Gowers 
 remarks that recovery or improvement is more frequent than in any 
 other disease with symptoms of equal severity. There is hope of 
 recovery in most cases and yet there are few in which it is sure. 
 Cystitis is common and leads to pyelonephritis; bed-sores are fre- 
 quent and death results from sepsis, mixed infection, amyloid dis- 
 ease or lung tuberculosis. 
 
 Treatment. — (a) Medical treatment includes administration of 
 iron, arsenic and cod-liver oil; fresh air and a full diet are equally 
 important. The skin and bladder should receive special attention. 
 Electricity is contra-indicated, (b) Orthopedic and x-ray treatment 
 produce the most successful results. Rest in bed on the back should 
 be enforced for months. Extension, fixation by braces of the neck and 
 
1014 DISEASES OF THE NERVOUS SYSTEM. 
 
 back, and for lighter cases or those involving the lower spine, the 
 plaster cast, are described in works on orthopedic surgery, (c) Sur- 
 gical intervention is indicated only when other treatment has been 
 given thorough trial. The results are not encouraging and disease of 
 the affected bodies is difficult of access. The dura should never be 
 incised. According to Chipault, the indications are (i) disease re- 
 stricted to the arches, (ii) cold abscess, (iii) flaccid paralysis, since 
 Babinsky noted that this occurs in moderately severe dorsal disease, 
 and (iv) healing of the bone focus and replacing of granulation tis- 
 sue by connective tissue, as in the cases first operated on (Macewen. 
 1888). The contra-indications are (i) multiple vertebral disease, 
 (ii) lung tuberculosis and (iii) disease of the cord itself. Victor 
 Horsley advises orthopedic treatment for two months in children 
 and then, in case of failure, laminectomy. In adolescents and in 
 those of advanced years, he considers that laminectomy is indicated 
 practically at once. 
 
 IV. Carcinoma of the Spine. — Carcinoma is almost always sec- 
 ondary to carcinoma of the mamma and less often of the digestive 
 tract, uterus, prostate or thyroid; it generally involves the bodies, 
 usually of several vertebrae. 
 
 Symptoms. — Angular deformity is less common than in caries. A 
 tumor may be felt. Bruns considers a sinking in of the vertebra? or 
 softening of the spinal column as rather characteristic. Rigidity is 
 common but is less conspicuous than in caries. Tenderness is com- 
 mon. The spinal symptoms closely resemble those of compression by 
 caries, and are present in 60 per cent, of cases (Schlesinger). Com- 
 pression of the posterior roots is most common and produces neuralgic 
 pain, at first paroxysmal and later constant, lancinating and inco- 
 ercible ; it is located along the spinal column, while in caries pain is 
 felt over the spine or in the side of the chest (Gull). Closely as- 
 sociated are hyperalgesia and anaesthesia, tenderness on pressure, 
 painful reflex muscular spasm and herpes zoster. Compression of the 
 cord is less common and occurs late ; if paralysis develops it is usually 
 rapid and painful. The veins of the lower extremities thrombose fre- 
 quently and fatal pulmonary embolism may result (Schlesinger). 
 
 Diagnosis. — Diagnosis depends upon (a) recognition of a primary 
 cancer (which is sometimes latent or overshadowed by the secondary 
 deposit) ; (b) local signs (tumor, spinal irregularity, arcuate ky- 
 phosis) ; (c) cachexia; (d) advanced age; (e) pain, usually bilateral 
 and increased by movement; paraplegia dolorosa (Cruveilhier) is 
 much more common and incomparably more intense in cancer than in 
 caries, from infiltration of the sensory roots; anaesthesia with pain 
 (anaesthesia dolorosa) is also common; and (/) rapid onset and 
 course. Sarcoma may be primary or secondary. Cachexia is less 
 common; it is more often seen in youth than in elderly persons and 
 is more frequently multiple. Vertebral syphilis is very uncommon, 
 as gummata in the bone or periosteum, but responds to anti syphilitic 
 
DISEASES OF THE SPINAL MENINGES. 1015 
 
 treatment. Syphilis simulates caries rather than carcinoma. Actino- 
 mycosis rarely causes compression of the cord ; it is recognized by its 
 presence in other organs and by the sulphur bodies in the sinuses 
 and aspirated fluid. Arthritis deformans (g. v.) is recognized by 
 exostoses, tenderness, ankylosis, in rare cases by crepitus, by altera- 
 tions in other joints and by root-symptoms caused by narrowing of 
 the foramina (radiating pains, vasomotor symptoms and atrophic 
 paralysis). Aneurysmal erosion of the spine, cervical pachymenin- 
 gitis, hydatids, exostoses, tumors within the spinal canal, glands com- 
 pressing the intercostal nerves and tabetic pains in the trunk must be 
 considered. The prognosis is absolutely unfavorable and the treat- 
 ment is directed chiefly against the pain. 
 
 DISEASES OF THE SPINAL MENINGES. 
 
 Few diseases of the vertebrae and cord do not to some degree affect 
 the meninges but, with few exceptions, the meningeal symptoms have 
 little independent clinical interest. 
 
 I. Hyperemia. — At autopsy the blood gravitates to the dependent 
 parts and congests or discolors the meninges. Stasis, tetanus, eclamp- 
 sia, chorea, carbon monoxide and strychnine congest the membranes. 
 
 II. Hemorrhage. — (a) Between the vertebrae and dura, hemorrhage 
 is frequent from rupture of the subdural plexus of veins. It sur- 
 rounds the nerve roots and is most severe over the posterior cord; it 
 results mostly from trauma and to a lesser extent from tetanus, 
 strychnine poisoning, vertebral disease, stasis or aneurysmal rupture. 
 (b) In the arachnoid sac hemorrhage (haematorrhachis) is equally 
 frequent and results from the above named causes and from asphyxia, 
 extraction by the foot during labor, hemorrhagic diseases or lepto- 
 meningitis. The entire spinal canal may be filled with blood from 
 brain hemorrhage, especially at the base, (c) In the pia, hemorrhage 
 rarely attains pathological or clinical interest. 
 
 Symptoms. — Small hemorrhages cause no symptoms and meningeal 
 apoplexy may be overshadowed by brain or traumatic cord symptoms. 
 Pain, localized in the back or sometimes generalized, rigidity, radi- 
 ating pains from compression of the posterior roots, hyperesthesia 
 or hyperalgesia, painful reflex muscular spasms, motor weakness 
 (and paraplegia), anaesthesia, sphincter disturbance and abolition of 
 the tendon reflexes are the common symptoms. They develop sud- 
 denly, affect the lower more than the upper cord, increase for a day 
 or so, produce inflammatory reaction for two or three days and 
 usually subside in from four to eight weeks. Physical signs vary 
 with the location; for instance, brachial paraplegia is present in 
 cervical, and involvement of the legs in lumbar or dorsal hemorrhage. 
 
 Diagnosis and Treatment. — In diagnosis the most important symp- 
 tom is irritation, while in hemorrhage of the cord (haematomyelia) 
 paralysis prevails and pain is less frequent. In non-traumatic cases, 
 exact diagnosis is impossible. The treatment is symptomatic. Ab- 
 solute rest in the lateral decubitus or on the face should be enjoined. 
 
1016 DISEASES OF TEE NEBVOUS SYSTEM. 
 
 III. Pachymeningitis. — (a) This may be external (peripachymen- 
 ingitis), as described under caries. It may follow penetrating bed- 
 sores, deep cellulitis, psoas or retropharyngeal abscess. Its symptoms 
 are those of compression by vertebral caries (q. v.). Root symptoms 
 and fever are frequent. The prognosis is unfavorable and the treatment 
 is etiological, expectant or surgical, (b) Internal pachymeningitis 
 hemorrhagica. Its causes are those of the cerebral form, as paretic 
 dementia, alcoholism, trauma and sometimes tuberculosis, (c) Char- 
 cot (1871) and JofTroy described a form involving chiefly the 
 cervical region {'pachymeningitis cervicalis hypertrophica) , in which 
 the inner surface of the dura is thickened by annular concentric 
 fibrous deposits. The dura adheres to the vertebras and leptomeninges 
 and compresses the nerve roots, which indurate. Several cervical 
 segments are involved. The process is most marked on the dorsal 
 aspect of the cord, which is flattened anteroposterior^ and shows 
 peripheral induration by extension of the process to it through the 
 pial vessels (meningomyelitis) ; this causes the frequent ascending 
 and descending degeneration. Cold, syphilis, alcoholism and trauma 
 are probable causes. 
 
 Symptoms. — Charcot described three stages; (a) the neuralgic stage, 
 which corresponds to involvement of the posterior nerve roots, in 
 which pains radiate from the nape of the neck into the ulnar and 
 median nerve supply. They are continuous, with paroxysmal ex- 
 acerbations, with localization at times in the arm joints, with rigidity 
 as in caries, paresthesia in the arms and some motor weakness. 
 Hyperesthesia is common, (b) The second stage is atrophic paraly- 
 sis of the arms in which the process involves the anterior nerve roots. 
 The pains are replaced by atrophy and paralysis in the ulnar and 
 median nerve areas, while the radial area is usually unaffected ; this 
 produces flexor paralysis in the forearms and hands, and the claw 
 hand (main en griff e) results from contracture; the wrist is over- 
 extended, the first phalanges are extended, the second and third are 
 flexed ; ulnar and median anesthesia and the reaction of degeneration 
 are found. The shoulder and elbow muscles may be involved. Mus- 
 cular atrophy is not constant and other deviations from Charcot's 
 complex are at times noted, as absence of contracture or extension to 
 the lower cord, (d) In the third stage the legs show a spastic paraly- 
 sis without atrophy and the bladder and rectal functions and some- 
 times the sensory conduction are disturbed from secondary changes 
 in the cord. 
 
 Diagnosis. — The process is usually localized with ease as a disease 
 in the cervical region. Marked pain may also occur in tumors, cer- 
 vical spondylitis, syphilitic meningomyelitis and at times in syringo- 
 myelia. Yon Leyden and others maintain that diagnosis is usually 
 impossible and that the process is only a cervical localization of a 
 meningomyelitis. Amyotrophic lateral sclerosis (q. v.) and pro- 
 gressive spinal muscular atrophy have no such severe pains and 
 syringomyelia (q. v.) is characterized by dissociated anesthesia, as 
 
TtJMOES OF THE SPINAL COED. 101? 
 
 well as by muscular atrophy, painless felons and trophic changes in 
 the joints. Tumors (q. v.) are difficult to differentiate. Neuritis 
 causes symptoms limited to the limbs ; the nerve trunks are tender. 
 
 Prognosis. — This is usually unfavorable and chronic progression, 
 cystitis, etc., usually develop. Instances of recovery are recorded. 
 
 Treatment. — Warm baths, counterirritation, sedatives, narcotics, 
 mercury, iodides and care of the skin and bladder are indicated. 
 
 IV. Spinal Leptomeningitis. — This closely corresponds to the de- 
 scription given under cerebral meningitis, as to the spinal, path- 
 ological and clinical findings. It may occur (a) in the acute form, 
 from trauma, extension from pleuritis, bed-sores or other adjacent 
 infections, from general infections, and from epidemic, suppurative 
 or tuberculous meningitis; or it may occur (&) in the chronic form, 
 from tabes, trauma, myelitis, syphilis (q. v.) or alcoholism. The 
 symptoms are pain in the back, rigidity, hyperesthesia and radi- 
 ating pains ; the course is afebrile. 
 
 V. Syphilitic Affections. — (See Syphilis.) 
 
 TUMORS OF THE SPINAL CORD AND ITS MEMBRANES. 
 
 These are rare; about 200 cases are reported. Brain tumors are 
 six times as frequent (Schlesinger). 
 
 I. Tumors of the Membranes. — These may arise from the dura or 
 leptomeninges. In a collection of 20 extradural tumors Horsley 
 found five sarcomata, four lipomata, four tubercles, three echinococ- 
 cus cysts and one each of myxoma, fibrochondroma, carcinoma and 
 fibrosarcoma. Cysticercus often causes no symptoms. These growths 
 cause more erosion of the vertebrae than compression of the cord. In- 
 tradural tumors: Horsley collected 38, of which there were twelve 
 myxomata, seven sarcomata (endotheliomata), seven fibromata, four 
 psammomata, four tubercles, two parasitic and two syphilitic tumors. 
 Lipomata, echinococci, cysticerci, neuromata and angiomata are 
 rarer. Though usually single, multiple occurrence may be noted in 
 sarcomata, parasitic tumors and neuromata. This group compresses 
 the cord or its nerve roots. The cord is altered as in caries ; there are 
 oedema, flattening, discoloration, peripheral hardening and central 
 softening and secondary ascending and descending degenerations. 
 The membranes thicken and the nerve roots flatten and atrophy. 
 
 Symptoms. — Extradural growths produce more vertebral than cord 
 symptoms. The first symptoms are usually those of compression of 
 the nerve roots, e. g., radiating pains, first on one side, then on both, 
 which run into the arms, trunk or legs, according to their localization, 
 and advance from one root to another; hypersesthesia ; parsesthesia ; 
 anaesthesia, which is less common since it implies involvement of at 
 least three roots (Sherrington's law) ; atrophic paralysis with vaso- 
 motor symptoms; rigidity; and spontaneous muscular contractions. 
 Local tenderness is rare. The symptoms recall those of carcinoma of 
 the spine aside from its vertebral signs. Later, evidences of com- 
 
1018 DISEASES OF THE NERVOUS SYSTEM. 
 
 pression of the cord appear, as paresis, perhaps of one side first (Brown- 
 Sequard's type, v. i. ) or paraparesis with atrophy if the anterior horn 
 is involved at that level, with increased reflexes (unless the arc is 
 broken), with spasticity and contractures; and with sensory changes. 
 In this type, as in carcinoma of the vertebrae, the paraplegia dolorosa 
 of Cruveilhier is common, as is anaesthesia dolorosa (the " eccentric 
 projection" or reference of pain to the anaesthetic areas). Finally, 
 there is total paraplegia, anaesthesia and bladder and rectal paralysis. 
 
 II. Tumors in the Cord Substance.' — These are six times less com- 
 mon than tumors in the membranes; they include glioma (which is 
 most frequent in the cervical and upper dorsal regions), sometimes 
 gumma, sarcoma (in the pia), tubercle (in the gray substance or 
 posterior horn) and cysticercus. Most of them are circumscribed; 
 though glioma tends to vertical diffusion. Unlike meningeal tumors, 
 they are rarely metastatic. 
 
 Symptoms. — In intramedullary growths, root symptoms are absent, 
 especially in gliojnata and, since there is gradual compression of the 
 cord, the clinical picture may resemble chronic myelitis and syringo- 
 myelia. The cord symptoms are disturbed conduction; spastic para- 
 plegia ; marked increase of reflexes (unless the arc is broken or abso- 
 lute cord compression develops) ; bilateral symptoms, or if unilateral, 
 they soon reach the other side; extensive muscular atrophy, if the 
 cervical or lumbar enlargement is diseased, often then with the reac- 
 tion of degeneration; and sensory changes involving all varieties of 
 sensation or certain varieties only, as pain or temperature (dissoci- 
 ated or partial anaesthesia). Some writers, as Bruns, maintain that 
 the lesion and symptoms are at first unilateral. Then the Brown- 
 Sequard complex is found (q. v.). As the tumor grows, total para- 
 plegia and anaesthesia may, in rare cases, develop below the level of 
 the lesion. 
 
 Localization. — Accurate determination of the localization is most 
 important but rarely possible until the cord itself is compressed. 
 The most common error is in locating the tumor too low. Atrophic 
 paralysis, in the cervical or lumbar region, is the most certain aid, 
 and sensory changes are less reliable. The actual lesion is one or 
 two (three or four) segments higher than the anaesthesia (Sherring- 
 ton's law) because anaesthesia results only from involvement of at 
 least three roots. The hyperaesthesia usually represents the level of 
 the lesion and local spinal tenderness, though rare, is very important. 
 Finally, the spinal segment involved must be considered in terms of 
 the corresponding vertebrae (v. s. y page 1000). (a) When the tumor 
 is in the upper cervical cord there are pains in the cervical plexus and 
 perhaps anaesthesia ; at first there may be a spinal hemiplegia differ- 
 ing from cerebral hemiplegia in that the face and hypoglossus escape 
 and the anaesthesia is contralateral to the paralysis; then there is 
 spastic paralysis of all four extremities, which rarely lasts long, since 
 affection of the phrenic nerve causes early death, (b) In tumor of 
 the cervical enlargement there are atrophy, flaccid paralysis and pain 
 
TUMORS OF THE SPINAL CORD. 1019 
 
 in one arm, spastic paresis in the leg of the same side, anaesthesia of 
 the entire opposite half of the body and opposite limbs; and then 
 paralysis of both arms and legs with anaesthesia, (c) Localization 
 in the dorsal cord often produces unilateral signs, as paresis of one 
 limb with its half of the trunk, and anaesthesia of the corresponding 
 parts of the other side; spastic paraplegia of legs and abdomen, re- 
 tention of urine and later incontinence ; and then girdle pains, (d) 
 In tumors of the lumbar enlargement there are unilateral pains in the 
 lumbar plexus and atrophic paralysis in the ileopsoas, quadriceps 
 and adductors; there is total anaesthesia when the cord is involved 
 in the region of the lumbar plexus; later partial anaesthesia (affect- 
 ing the sense of temperature and pain) develops in the region of 
 the sacral plexus; still later there is complete paralysis and anaes- 
 thesia in the region of the lumbar plexus, with atrophy, absence of 
 the patellar reflexes, with the reaction of degeneration, while the legs 
 and feet are spastic, and with clonus of the Achilles tendon, (e) 
 If the localization is in the sacral cord there is atrophic paralysis of 
 the leg and foot, of the posterior muscles of the thigh, of the gluteal 
 and perineal muscles, anaesthesia, total paralysis of the bladder and 
 rectum, impotence, loss of the Achilles tendon reflex (while the pa- 
 tellars may persist), early decubitus and cystitis. (/) If the tumor 
 is in the cauda, the symptoms are usually bilateral from the begin- 
 ning; paraplegia is rarely as symmetrical as it is in cord lesions; 
 there is the reaction of degeneration; pain is violent, since many 
 sensory fibers are in close contact ; Minor described bilateral and even 
 unilateral sciatica as an early symptom. The sacral plexus is chiefly 
 or first involved, while growths of the lumbar enlargement affect both 
 the sacral and lumbar plexuses. 
 
 Diagnosis. — The diagnosis of meningeal tumor, always difficult, is 
 based on (a) local pain and rigidity, which are especially marked in 
 the extradural type; (b) hyperalgesia; (c) radiating pains, i. e., 
 root symptoms which later, by gradual transition, give way to (d) 
 cord symptoms, which are often unilateral at first and then bilateral, 
 as interrupted sensory and motor conduction and increase of the 
 reflexes. Carcinoma of the vertebrae produces more pain on move- 
 ment than other tumors. In caries there is less pain, local vertebral 
 changes eventually appear, and the course is usually more rapid. 
 In myelitis the arms are less often paralyzed ; radiating pains are 
 much rarer than in tumor and a girdle sensation is more common. 
 The local pain sometimes suggests aneurysm, lung disease or periph- 
 eral neuralgias, the tender points of which are always absent. Root 
 symptoms, early interruption of cordal conduction and absence of 
 trophic disturbance in the bones and of dissociated anaesthesia argue 
 for tumor and against syringomyelia. A diagnosis of tuberculosis or 
 syphilis is fortified by its presence in other organs. Age; in youth, 
 tubercle ; at puberty, sarcoma and glioma ; in the third and fourth dec- 
 ades, glioma, tubercle or sarcoma ; and in advanced years gummata are 
 most frequent. Diffuse sarcomatosis is usually cerebrospinal, rarely 
 
1020 DISEASES OF THE NERVOUS SYSTEM. 
 
 invades the cord substance, as do gummata and tubercles, affects the 
 posterior cordal surface most frequently (the lateral surface little 
 and the anterior very rarely) and generally in the lumbar and lower 
 dorsal regions ; it occurs largely in the young and its course is rapid. 
 Abscess of the cord is most rare. Tabes in one remarkable case was 
 simulated by multiple tumors of the posterior roots. Tumors of the 
 cord are more difficult of differentiation, for root symptoms are 
 often lacking. 
 
 Course and Prognosis* — Slow development, progression either steady 
 or " by starts," sometimes remissions and eventual compression of the 
 roots or cord are usual, with death from cystitis or decubitus. Sudden 
 paralysis is less common. The average duration is one to three 
 years, but a longer course is possible (even fifteen years). 
 
 Treatment. — 1. Therapeutics. — Narcotics must be employed to 
 relieve pain, but should be used sparingly in the early stages, because 
 if given freely, their effect may fail later if the course is protracted. 
 Syphilis is always a possible factor; absence of evidence or history 
 of the disease counts for little, and the patient should receive the 
 benefit of antisyphilitic treatment. 
 
 2. Surgical Treatment. — Gowers in 1887 localized a case of 
 fibro-myxoma which Horsley removed successfully; this was the first 
 case on record. Tumors of the cord are less favorable than those of 
 the meninges. Intramedullary tumors may only crowd the nerve 
 paths, but their removal is often attended by laceration or acute 
 myelitis, which may result in damage equal to that of the tumor. 
 Accurate localization is most important. Urban' s osteoplastic resec- 
 tion is valuable ; it consists of folding back the cut muscles and bone 
 that they may be replaced and the strength of the spinal column may 
 not be impaired. Death may result from shock, escape of cerebro- 
 spinal fluid and less frequently, with modern methods, from infec- 
 tion. Starr records 16 complete recoveries. Harte in 1905 collected 
 92 operations ; the operative mortality was 47 per cent. ; of the bal- 
 ance, 59 per cent, were cured, 34 per cent, improved and 7 per cent, 
 not improved. 
 
 CIRCULATORY DISTURBANCES; HEMORRHAGE; TRAUMA OF 
 
 THE CORD. 
 
 I. Hyperemia of the Spinal Cord. — Postmortem hypostatic conges- 
 tion is common, especially in the dorsal aspect of the cord. The 
 white matter is usually pale. The cord may be passively congested, 
 as in cardiac insufficiency. Vascular variability was formerly con- 
 sidered causal of spinal irritation which, however, is hysterical and 
 neurasthenic. !N~o definite clinical picture can be constructed. 
 
 II. Anaemia of the Spinal Cord. — Paralyses referred to anaemia of 
 the cord are mostly due to neurosis, neuritis, hemorrhages in the cord 
 or nerve sheaths, and, in pernicious anaemia, to degeneration. Paraly- 
 sis following profuse hemorrhage from the stomach or uterus may be 
 
KMMA TOMYELIA . 1021 
 
 properly referred to cord anaemia. Stenson (1667) demonstrated 
 experimentally that compression of the aorta produced paraplegia 
 due to ansemia of the cord, the motor cells of which appear to he 
 especially susceptible to ischsemia. Compression of the aorta after 
 ligature of both subclavian arteries has identical effects. 
 
 III. Embolism and Thrombosis (Myelomalacia) of the Spinal 
 Cord.- — Embolism of the spinal arteries is extremely rare, but has 
 been observed in endocarditis (v. Ley den, Weiss). No separate 
 clinical symptoms can be recognized, although experimentally Money 
 observed choreiform movements. Thrombosis is very rare. Venous 
 thrombosis is secondary to other lesions of the cord. Arterial throm- 
 bosis is rather more common. It has been found in syphilis, multiple 
 sclerosis, senility and perhaps bears some relation to acute processes 
 in the cord, as disseminated myelitis. It is often impossible to de- 
 cide whether an area of softening is ischemic (myelomalacia) or 
 inflammatory (myelitis). 
 
 IV. Hemorrhage in the Cord (Hsematomyelia). — Etiology and Path- 
 ology. — Most cases of this rare lesion occur in men between 20 and 40 
 years of age. Trauma causes 90 per cent, of cases of hsematomyelia 
 (Oppenheim). (a) Capillary hemorrhages rarely cause symptoms; 
 they occur in foci of softening, inflammation, stasis, intoxications, 
 infections or blood diseases. (&) The larger hemorrhagic focus may 
 result from trauma, muscular effort, caisson-disease, etc. ; it com- 
 presses and destroys the cord substance; it rarely exceeds the size of 
 a hazelnut (round or oval form) but may extend through the entire 
 length of the cord (tubal form of Levier), following exactly the less 
 resistant gray matter, while the firmer white columns (pyramidal 
 tracts) usually resist its lateral diffusion; if it invades the white 
 matter, hemorrhage usually occurs in the posterior columns ; it occurs 
 mostly in the cervical cord; all large non-traumatic hemorrhages 
 occur in the gray matter. Effused blood undergoes the same fate as 
 in other parts; it turns brown, then yellow-red, and ultimately de- 
 posits dark pigment and hsematoidin crystals. The nervous tissue is 
 disorganized by large hemorrhages, which form in it a cavity. Even- 
 tually a pigmented apoplectic scar or cyst results. 
 
 Symptoms. — The symptoms vary with the different forms, (a) In 
 the accessory form there is bleeding into a tumor, cavity, softening 
 or inflammation (Charcot, Hay em, Koster) ; punctate hemorrhage 
 may accompany other affections, as hemorrhagic purpura, stasis or 
 convulsive disorders, and few or no symptoms develop, (b) The 
 traumatic form is less important in spinal fracture than concussion 
 (see Trauma) ; it may develop during dystocia or foetal extraction, 
 (c) The spontaneous form is rarer than it is in the brain, because 
 the cord is firmer, subject to lower blood pressure, and most rarely 
 the seat of miliary aneurysm ; it results from sudden exertion in man 
 (and more often in the horse), from repeated coitus or rarely from 
 arteriosclerosis. 
 
 The onset is sudden, without prodromes or loss of consciousness. 
 
1022 DISEASES OF THE NERVOUS SYSTEM. 
 
 Previous symptoms may suggest a hemorrhage into an inflammatory 
 focus. Local symptoms must vary with the structures involved and 
 their level ; they embrace paraplegia, monoplegia, the Brown-Sequard 
 syndrome, paralysis with or without atrophy or spasticity, anaesthesia 
 either total or partial, as might be anticipated from its location in the 
 gray substance and posterior horns; pain at the level of the lesion, 
 perhaps from involvement of the posterior horn; less often eccentric 
 pain, girdle sensation and muscular rigidity. The reflexes and 
 sphincters vary with the level. In general the reflexes are increased 
 in small and abolished in large hemorrhages. The symptoms advance 
 rapidly and may suffer an accession from secondary reaction or 
 myelitis. Early death is rare. Late death from cystitis or decubitus 
 is more common. Recovery is rare compared with recovery in cere- 
 bral apoplexy ; it occurs most often in the punctate type ; it is rarely 
 absolute and some disturbance in motility or sensation usually remains. 
 
 Diagnosis. — The diagnosis is usually only probable; it is based on 
 the sudden onset of paresis and anaesthesia and their rapid advance. 
 For differentiation from licematorrhachis, see page 1015 ; in the lat- 
 ter, meningeal irritation is more common, as marked and radiating 
 pains, rigid spine and muscles, hyperaesthesia of the skin and mus- 
 cles; paralysis is absent or incomplete; and recovery is more com- 
 plete. From acute myelitis, differentiation is often uncertain and 
 frequently of only academic interest, since each affection may com- 
 plicate the other and the prognosis and treatment of each are similar. 
 In myelitis and poliomyelitis elevation of temperature is distinctive. 
 
 V. Caisson or Divers' Paralysis. — According to Pol and Watelle 
 (1854), this occurs in workers who are subject to pressure of at 
 least 2, and usually 3 or 4, atmospheres. Symptoms appear when the 
 individual comes suddenly into the open air. They include transient 
 pain in the ears, sometimes deafness and vertigo, headache and pains 
 in the limbs, joints and epigastrium; in 35 per cent, there is para- 
 paresis or paraplegia, sometimes with anaesthesia, and usually with 
 urinary retention; much less often there is hemiplegia or involve- 
 ment of both arms ; epistaxis, mental symptoms ; loss of conscious- 
 ness and symptoms of brain-pressure, as vomiting or slowed pulse. 
 Men of heavy build, alcoholics and " new hands " seem to be predis- 
 posed; hard exercise after coming into the air produces uuhappy 
 symptoms, which are not severe or are absent if the interval of work 
 does not exceed one hour. 
 
 Pathology and Pathogenesis. — The pathology and pathogenesis are 
 undetermined. Hoppe-Seyler (1885) and Bert found that lessened 
 atmospheric pressure liberated oxygen, nitrogen or carbon dioxide in 
 the blood and tissues, which ruptured the vessels and tissues and pro- 
 moted punctate hemorrhage. In the first autopsy v. Leyden found 
 clots in the cord substance, particularly in the posterior and lateral 
 columns, surrounded by round cells (reactive disseminated myelitis) ; 
 most changes were in the less compact dorsal cord : secondary degen- 
 eration is found and changes ill the gray substance from hemorrhage ; 
 
BROWN -SEQTJARD'S PARALYSIS. 1023 
 
 Catsaris actually saw gas bubbles in the blood. Under moderate 
 pressure the gas is given off to the lungs, while in extreme instances 
 it is given off to the tissues. The symptoms apparently result less 
 from the gas bubbles (air embolism) accumulating in the blood under 
 high pressure than from its sudden reduction and the reactive apo- 
 plectic myelitis. Andrew H. Smith holds that the lesion is cordal 
 congestion and stasis. 
 
 Prognosis. — A few subjects die at once; others die from cystitis, as 
 in myelitis; about 50 per cent, recover completely and 50 per cent, 
 partially, with spastic paresis. The mortality ranges from 2.7 to 15.8 
 per cent. 
 
 Treatment. — The return to normal atmospheric pressure should be 
 made gradually; recompression is successfully employed. Smith 
 recommends ergot. 
 
 VI. Trauma of the Cord. — Compression by caries, tumor and car- 
 cinoma have been considered; other surgical lesions can only be 
 touched on here. Crushing of the cord may be associated with hem- 
 orrhage, myelitis and secondary degenerations. Total division of the 
 cord may result from fracture, gunshot or stab wounds; it is ex- 
 tremely rare ; early death is usual ; its symptoms are absolute para- 
 plegia, anaesthesia, bladder paralysis and abolition of the patellar 
 reflexes. Gunshot wounds usually result in fracture, crushing and 
 sometimes actual division; as a rule the prognosis is unfavorable. 
 Stab wounds may produce bilateral symptoms or Brown-Sequard 
 paralysis ; 20 per cent, recover ; 60 per cent, improve and 20 per cent, 
 of cases die (Wagner and Stolper). Restitution of function in lesser 
 injuries results not from regeneration but from compensation by other 
 paths of conduction. Laminectomy is indicated only in crushing 
 injury of the lower half of the spine, because cervical cases almost 
 never recover (Hahn). 
 
 VII. Brown-Sequard 's Paralysis. — This was described by Sequard 
 and Tiirck simultaneously in 1850. According to Brown-Sequard's 
 original proposition, on the side of section (cervical cord) there oc- 
 cur (a) paralysis of voluntary motion, muscle sensibility and vaso- 
 motor tonus; (b) hyperesthesia of trunk and limbs, to touch, pain, 
 heat and cold; (c) vasomotor paralysis of face and eyes (higher 
 temperature, narrow pupils and moderate contracture of certain 
 facial muscles). On the contralateral side there is anaesthesia of all 
 varieties of sensation, except muscle sensibility. 
 
 Symptoms. — Exact hemisection of the cervical cord produces a spinal 
 hemiplegia on the side of the section, but in injuries and experiments 
 the trauma is rarely wholly complete or strictly unilateral. (In some 
 cases decussation of the uncrossed pyramidal tracts may occur in the 
 cord lower down than the usual crossing point in the medulla (Flech- 
 sig) and spinal hemiplegia with contralateral monoplegia may result 
 from unilateral lesion. Dejerine and Thomas speak of a third 
 "homolateral pyramidal" tract, which may permit restitution of 
 motor function.) The most characteristic clinical type is the mid- 
 
1024 
 
 DISEASES OF TEE NERVOUS SYSTEM. 
 
 dorsal lesion, but in cervical section or in pathological foci, paresis 
 of the arm with paralysis of the leg is more usual, because the cervical 
 motor tracts are less compact than they are in the lower cord; i. e,., 
 paralysis is more frequently limited to a group of muscles than to an 
 entire upper extremity. " Conversely, paralysis of the leg may be 
 incomplete, while that of the arm is complete, owing to the escape of 
 fibers for the leg which cross lower down in the cord" (Gowers). 
 The paralysis often decreases with surprising rapidity, and if the 
 anterior cells are intact it gradually becomes simple weakness. The 
 
 Fig. 73. 
 
 Brown-Sequard's paralysis from 
 a left-sided focus. A, vaso-motor 
 and motor paralysis ; B and D, cu- 
 taneous anaesthesia ; C, hyperaes- 
 thetic zone. (Erb.) 
 
 Fig. 
 
 VVS.M 
 
 (Combined from Brown-S£quard.) — F, Fo- 
 cus in left side of cord. V, Pyramidal fibers 
 baving crossed in medulla. V, Vasomotor 
 fibers, not crossing in cord. Sm, Fibers for 
 muscle sense, not crossing in cord. SS S' S', 
 other sensory fibers crossing in the cord. The 
 focus explains the classical signs and also how 
 few of the crossed sensory fibers to the left 
 side are involved (merely a zone of anaes- 
 thesia), while all sensory fibers to the right 
 side are severed (hemianesthesia). 
 
 motor are restored more readily than the sensory functions. There is 
 an inactivity atrophy of the muscles without abolition of faradic 
 irritability and without reaction of degeneration; the paralysis may 
 be spastic or flaccid. Respiration is rarely affected and imperfect 
 movement of the chest has never occurred. Involvement of the 
 thoracic and abdominal muscles usually indicates a bilateral lesion. 
 Swelling and oedema in the paralyzed members have been observed, 
 
CONCUSSION OF COED. 1025 
 
 and also swelling with pain in all the joints on the paralyzed side. 
 The deep reflexes are exaggerated on the side of lesion; they are 
 abolished in a sudden total transverse lesion of the lower cervical or 
 upper dorsal cord. The skin reflexes are abolished or decreased on 
 the side of paralysis and on the opposite anaesthetic side they may 
 be normal, absent or increased. 
 
 Hypercesthesia (Fodera, 1823) occurs on the paralyzed side and 
 also as a zone above the anaesthetic area and near the level of the 
 lesion. If the lesion be cervical or lumbar the anaesthetic or hyper- 
 esthetic areas above are not zonular but irregular. Hyperesthesia 
 has been referred to the wound itself or to paralysis of inhibition. 
 Hyperesthesia or hyperalgesia concerns tactile, pain and heat and 
 cold sensations and their absence infers incomplete section (Kocher). 
 It usually disappears rapidly. The fibers, the section of which results 
 in hemianesthesia, lie in the lateral tracts. 
 
 The zonular ancesthesia on the side of the injury and of motor 
 paralysis is explained since the lesion involves not only the sensory 
 fibers (which are ready to decussate to the other side and produce the 
 crossed hemianesthesia), but also sensory fibers from the contra- 
 lateral side, which have just decussated to the side of section. Aboli- 
 tion of muscle sensation on the side of the lesion is in accord with 
 the uncrossed course of the muscle sense fibers in Burdach's column, 
 entering Goll's column higher up. Muscle sense is preserved on the 
 side opposite to the lesion. Vasomotor paralysis occurs on the side 
 of section, as the vasomotor fibers course in the anterolateral col- 
 umns. " Sensation is affected on the opposite side, but not quite up 
 to the level of the lesion, because the decussation of the sensory tract 
 is not immediate but occurs somewhat above the entrance of the 
 nerve" (Gowers). Complete crossed hemianesthesia occurs in 60 
 per cent, and partial anesthesia (analgesia and thermoanesthesia) in 
 40 per cent, of cases. 
 
 Prognosis. — In clinical and experimental cases almost complete 
 restitution to normal is possible; it is not due to reestablishment of 
 conduction in the severed tracts, in which ascending and descending 
 degeneration occurs, but rather to assumption of function by the un- 
 injured side of the cord (Kocher). The prognosis and treatment of 
 Brown-Sequard's paralysis vary with the etiology of this symptomatic 
 syndrome, which may be syphilis, tumor, sclerosis, myelitis, tuber- 
 culosis, trauma, hematomyelia, fracture or luxation. 
 
 VIII. Concussion of the Cord. — Gussenbauer referred the severe 
 symptoms, as paralysis, to hemorrhage, which is produced in turn by 
 movement of the cerebrospinal fluid. Long ago Ollivier explained 
 the symptoms as being due to molecular alteration in the nervous 
 tissue; this was confirmed by cases of experimental concussion 
 which resulted in degeneration of the cells and axis cylinders 
 (Schmaus and Bikeles). Myelitis and chronic degeneration may 
 follow concussion. Erichsen's " railway spine " is one of the trau- 
 matic neuroses. Obersteiner considers that long continued moderate 
 65 
 
1026 DISEASES OF THE NERVOUS SYSTEM. 
 
 jarring, as in the case of tramway drivers, may injure the cord. 
 Symptoms develop at once or some time later, as paraparesis, para- 
 plegia, retention of urine, and anaesthesia less often than paresthesia. 
 Some cases recover after months to a year or two. In others the 
 symptoms are permanent ; in still others death, usually early, occurs. 
 In diagnosis, fracture, hsematorrhachis, haematomyelia and traumatic 
 neurosis should be considered. Simulation, in order to obtain dam- 
 ages for accidents, may be difficult to exclude, but some railway 
 surgeons and medical experts in corporation employ err in discount- 
 ing the importance of concussion and traumatic neurosis (q. v.). 
 Paraplegia and retention of urine are indicative of structural altera- 
 tion of the cord. Treatment consists of rest, local application of cold 
 and avoidance of neurotic tendencies. 
 
 INFLAMMATION OF THE CORD. 
 
 Myelitis is inflammation of the cord. It was described by Oliver 
 and Abercrombie a century ago; the term has been made to cover 
 many affections not properly inflammatory, as compression paralysis. 
 Oppenheim and Marie disputed the opinion of Gowers, v. Leyden 
 and Erb that myelitis is a frequent affection. 
 
 I. Acute Myelitis. — Etiology. — There are two prominent causes, 
 infections and intoxications. The affection occurs largely in males 
 between ten and forty years of age. 
 
 1. Acute Infections. — Experimental myelitis has been produced by 
 the B. pyocyaneus, B. diphtherise, B. coli, B. typhosus, strepto- and 
 staphylococci, etc. French writers have contributed most to this sub- 
 ject. It has followed epidemic meningitis, variola, measles, rheuma- 
 tism and other infections, caused (a) by the germs themselves or 
 secondary infection (focal myelitis resulting) or (b) by their toxins 
 (disseminated myelitis resulting). 
 
 2. Intoxications. — These include poisoning by alcohol, ergot and 
 lead, and perhaps auto-intoxications, as in cancer or severe anaemia. 
 
 All other causes are doubtful ; trauma or compression by caries or 
 cancer is often considered of etiological importance but probably 
 causes softening or hemorrhage, to which infection may of course be 
 added ; exposure to cold and dampness most likely reduces the physi- 
 ological resistance, thus indirectly favoring localization of bacteria; 
 syphilis (q. v.) may affect the meninges and cord (meningomyelitis), 
 but the so-called syphilitic myelitis is usually ischsemic softening 
 from vessel changes. The etiological importance of sexual excesses 
 and emotional shocks is at present sharply questioned. 
 
 Pathology. — On macroscopic examination we find redness and swell- 
 ing ; on cross section, blurring of the cord tissues and decreased con- 
 sistency, even to fluidity; "red softening" (hemorrhagic myelitis) 
 and in older cases " yellow softening " from fatty change, or " white 
 softening" and cavity formation occur. Myelitis can usually be 
 seen to best advantage after hardening in Miiller's solution j the nor- 
 
ACUTE MYELITIS. 1027 
 
 mal tissue then appears green and the diseased, yellow. In the ulti- 
 mate stages, atrophy, cyst formation, induration and very rarely 
 abscesses are found. Microscopically there are, in fresh cases, 
 degenerated swollen axis cylinders, the disintegrating medullary 
 sheaths from which myelin drops may form ; granules and granule cor- 
 puscles (leukocytes or vessel endothelial cells) ; extravasated red and 
 white cells ; turgid vessels the nuclei of which proliferate ; choking of 
 the perivascular lymph spaces with cells ; degeneration, blurring and 
 vacuole formation of the nerve cells, the processes of which shrink and 
 the nuclei vanish ; granular amorphous deposits of coagulated albumin 
 in and about the cells ; in some cases the parenchymatous far exceeds 
 the interstitial alteration and often parenchymatous myelitis were 
 better called parenchymatous degeneration. The gray matter (polio- 
 myelitis) is involved much more often than the white (leukomyelitis). 
 In older cases there are corpora amylacea, empty spaces corresponding 
 to destroyed nerve fibers ; large " spider " cells with many processes 
 (Deiter's cells) ; and there is substitution of destroyed tissue by in- 
 terstitial proliferation. In rare instances bacteria are found, as 
 streptococci or colon or typhoid bacilli, but probably the toxins are 
 more important than the organisms. The microscope differentiates 
 between the ischsemic inflammation and postmortem softening. The 
 degree and the extent of inflammation vary greatly; transverse mye- 
 litis may destroy an entire cross section; or disseminated foci may 
 involve at random various structures at different levels. Meningo- 
 myelitis (perimyelitis, annular or cortical myelitis) chiefly affects 
 the periphery of the cord, whence concentric invasion along the septa 
 may split the cord structures ; this is frequent in the syphilitic form. 
 Poliomyelitis (inflammation of the gray substance) is a type of mye- 
 litis, but, involving only the anterior horns, is usually classified by 
 itself. Degeneration and inflammation of the motor and sensory 
 roots may follow myelitis in the cervical or lumbar enlargement ; sec- 
 ondary degenerations are common; the inflammation may ascend or 
 descend the cord, but usually affects only one or two segments. 
 
 Symptoms. — The symptoms vary with the extent, form and locali- 
 zation. The localized form, limited to a small segment, is called 
 transverse, while the diffused form is known as disseminated myelitis. 
 
 Acute transverse myelitis is the prototype. The cord symptoms 
 are usually first in time and always first in importance and consti- 
 tutional symptoms, as fever, chills, malaise and in children convul- 
 sions sometimes may precede but usually attend the cord symptoms. 
 The symptoms ^resulting from involvement of the cord are (a) paraly- 
 sis, which is usually early, rapid but not apoplectic in onset and is 
 prominent, paraplegic, progressive, flaccid and rather complete. The 
 flexors are usually weaker than the extensors. The toes alone may be 
 moved ; twitching of the paretic muscles is usually associated with 
 pain ; clonic muscular spasms are sometimes present. The paralysis 
 is often preceded for a short time by sensory phenomena, as numbness 
 pr by moderate darting pains in the limbs, joints or back. The par- 
 
1028 DISEASES OF THE NERVOUS SYSTEM. 
 
 aljzed limbs show a transient rise of temperature, followed by some- 
 what subnormal temperature. The limbs are often dry and may not 
 sweat even after injection of pilocarpin. (b) Sensation is frequently 
 involved. The initial tingling pain has been considered. Anaesthesia 
 may be complete to the level of the lesion, but more often incomplete 
 (hypsesthesia) and rarely partial, according to the cordal tissues 
 involved. It is higher anteriorly than posteriorly; a zone of hyper- 
 esthesia or " girdle pain " marks the upper level ; it is caused by early 
 irritation or late cicatrization. Severe pain suggests vertebral or 
 root disease rather than myelitis ; gastric crises like those of tabes, 
 dysesthesia (Charcot), i. e., diffuse vibrating sensations over the 
 entire limb from local stimulation, as by a needle, and ataxia (usually 
 obscured by the paraplegia) are much less common, (c) At the onset 
 all reflexes may be lost, but they are usually increased below the 
 focus, because of lessening of the cerebral inhibition traveling in the 
 lateral pyramidal tracts, the skin reflexes being increased early and 
 the muscle reflexes later; involvement of their centres causes per- 
 manent loss of the reflexes ; for instance, they are lost in the arms and 
 increased in the legs in cervical myelitis ; lost in the trunk and in- 
 creased in the legs in dorsal myelitis ; lost in the legs in lumbar myelitis. 
 (g) The sphincters are affected almost constantly and early, perhaps 
 even before the onset of paraplegia; initial difficult urination (isch- 
 uria) or urinary retention, possibly with sphincter spasm and later 
 with incontinence, is usual; when the bladder is full it may dribble 
 from relaxation of the sphincter, known as ischuria paradoxa or re- 
 tention with incontinence; the patient may or may not be conscious 
 of the retention, depending on whether the afferent sensory fibers are 
 involved or not ; in lumbar myelitis incontinence prevails from the 
 beginning. The urine is at first alkaline and later ammoniacal on 
 the advent of cystitis. The sphincter ani acts involuntarily, i. e., is 
 spasmodically contracted ; the paresis of the bowel and abdomen are 
 factors in constipation ; in lumbar myelitis the sphincter is paralyzed, 
 (e) Trophic changes. Muscular atrophy and the reaction of degen- 
 eration are caused by disease in the anterior horns and the muscles 
 also waste from inactivity. The skin is usually dry, sometimes 
 glossy or vesiculated. The joints are sometimes swollen and the 
 limbs oedematous. Bed-sores are frequent over the sacrum, tro- 
 chanters, heels, between or even over the knees, from the bed covers ; 
 they result from neglect or in lumbar myelitis from trophic disturb- 
 ance (disease in the gray matter or posterior horns). The same fac- 
 tors are said to cause cystitis, ulceration in the bladder or urethra 
 and the tendency to cellulitis. 
 
 Course and Prognosis. — The onset may take place in a few hours 
 (the apoplectic form), or in several days to a week (the subacute 
 form). Four stages are described, which, however, blend: (a) the 
 more or less acute initial stage; (b) the advancing degeneration; 
 (c) the restitution; and (d) the stationary (residual or chronic) 
 stage. Complete paraplegia aud anaesthesia may persist, but more 
 
ACUTE MYELITIS. 
 
 1029 
 
 often sensation returns after some weeks, while movement returns far 
 more slowly and incompletely, usually with some residual spastic 
 paraplegia. Contractures may develop, especially in the adductors 
 
 Cord Symptoms Grouped According to Localization. 
 
 (Amplified from Morton Prince.) 
 
 In order of fre- 
 quency. 
 
 Paralysis. 
 
 de- 
 
 Atrophy. 
 
 Reaction of 
 generation. 
 
 Sensation. 
 
 Reflexes. 
 
 Sphincters. 
 
 Trophic changes, 
 etc. 
 
 Pupils. 
 Priapism. 
 Mode of death. 
 
 Dorsal myelitis most fre- 
 quent. 
 
 Trunk, back, intercostal 
 and abdominal muscles 
 (favoring mucus stagna- 
 tion in lungs). Arms 
 normal. Paraplegia, first 
 flaccid then spastic (lat- 
 eral columns involved). 
 
 In trunk ; difficult to elicit. 
 In legs ; only from inac- 
 tion. 
 
 Present in trunk muscles ; 
 absent in legs (or only 
 quantitative reduction). 
 
 Girdle pain and hyper- 
 sesthesia, between ensi- 
 form and navel. Anaes- 
 thesia corresponding with 
 motor paralysis. 
 
 Bladder, initial retention, 
 later intermittent over- 
 floworincontinence. Cys- 
 titis common. 
 
 Bowels, usually spasm of 
 sphincter ani ; constipa- 
 
 Then Lumbar myelitis. 
 
 Trunk and arms normal. 
 Paraplegia flaccid 
 throughout (ant. horns 
 involved). 
 
 None in arms or trunk. 
 Atrophy in legs (ant 
 horns involved). 
 
 Present in legs or in mild 
 cases quantitative reduc- 
 tion. 
 
 Pain in loins or legs ; hy- 
 peresthesia in loins. 
 Anaesthesia of legs. 
 
 Superficial reflexes, initial ; Lost. 
 
 loss, rapid return ar 
 
 increase. 
 Deep reflexes, initial loss, Lost. 
 
 slow return and increase. 
 
 Decubitus 
 etc. 
 
 from neglect, 
 
 Incontinence from begin- 
 ning (sphincter paraly- 
 sis). 
 
 Incontinence ("sphincter 
 paralysis) disguised, per- 
 haps, "by constipation. 
 
 Decubitus, cystitis, etc., 
 from neglect and trophic 
 alteration. 
 
 Klumpke's paralysis of I Absent, 
 pupil (if in upper dorsal) 
 
 Often present and painful ; 
 sometimes ejaculation at 
 onset. 
 
 Cystitis, decubitus. 
 
 None. Impotence. 
 
 Decubitus, cystitis. 
 
 Lastly, Cervical myelitis. 
 
 Neck muscles, diaphragm, 
 arms, trunk and legs par- 
 alyzed. Typically, atro- 
 phic flaccid paralysis of 
 arms(ant.hornsinvblved), 
 with flaccid, later spastic 
 paralysis of legs (lat, col- 
 umns involved); however, 
 paraplegia brachialis with 
 paralysis of legs is verv 
 rare. In rare lesions high 
 in the cervical cord, the 
 neck muscles atrophy and 
 both arms and legs "show 
 simple.then spastic paraly- 
 sis, without wasting. 
 
 Atrophy of neck muscles 
 if high lesion (rare). 
 Usually of arms only (ant. 
 horns involved at level 
 of lesion). In legs only 
 from inaction. 
 
 Present in arms (rarely 
 in neck). 
 
 Pain and hyperaesthesia in 
 arm nerves (with highest 
 localization): anaesthesia 
 in arms (lower localiza- 
 tion); and the trunk and 
 legs. 
 
 Superficial reflexes; initial 
 loss, rapid return and in- 
 crease. 
 
 Deep reflexes ; initial loss, 
 slow return and increase. 
 
 Same as in dorsal myelitis. 
 
 Same as in dorsal myelitis. 
 
 As in dorsal lesions. (Oc- 
 casionally very high tem- 
 perature.) 
 
 Paralysis of pupil (lowest 
 cervical region). Optic 
 neuritis in isolated cases. 
 
 Priapism often present. 
 
 Medulla symptoms, vomit- 
 ing, slow pulse; usuallv 
 by involvement of phrenic 
 nerve with early death. 
 
 and the knee flexors, in which case the prognosis is particularly un- 
 favorable, for profound disease is indicated. Contractures, muscular 
 contractions and increased reflexes are caused by secondary degenera- 
 
1030 DISEASES OF TBE NERVOUS SYSTEM. 
 
 tion. The immediate outlook in myelitis is always uncertain and 
 ultimate recovery is usually incomplete; it depends (a) on the 
 etiology, the prognosis being best in acute infections; (b) on the 
 intensity of inflammation; (c) on its transverse or vertical dimen- 
 sions, and (d) on the rapidity or tardiness of signs of improvement. 
 Complete recovery in mild circumscribed forms is barely possible, 
 since indirect symptoms, due to collateral oedema may disappear. 
 Death results from extension to the medulla (causing slow pulse and 
 vomiting), phrenic nerve phenomena, and sepsis following cystitis, 
 pyelitis or pyelonephritis. A form of recurrent myelitis is said to 
 exist {myelite a rechutes). 
 
 Diagnosis. — The early onset of structural cord symptoms, as reten- 
 tion of urine, followed by paraplegia and anaesthesia, is especially 
 significant after acute infections. The upper level of the myelitis 
 corresponds to that of the paralysis or anaesthesia. The lower level 
 may be determined by the condition of the reflex centres. Applica- 
 tion of a weak faradic current shows to what extent the gray matter 
 is involved. Anterior poliomyelitis (q. v.) does not involve sensa- 
 tion and but rarely extends back of the anterior horns. Compression 
 by caries or cancer usually causes local vertebral changes and root 
 symptoms precede cord symptoms. The so-called syphilitic mye- 
 litis is ischaemic myelomalacia; it begins acutely without pain 
 and is rarely relieved by antisyphilitic remedies. Hemorrhage 
 in the cord produces most sudden symptoms and acute spinal pain 
 without prodromes. For differentiation from Landry's paralysis, 
 see page 1038, and from multiple neuritis, see page 1080. Men- 
 ingeal hemorrhage and meningitis produce unmistakable root symp- 
 toms. Abscess of the cord is rare, for few more than a dozen cases 
 are reported; its symptoms are those of myelitis plus meningeal 
 symptoms. Hysterical paraplegia is characterized by other stigmata 
 of hysteria, motiveless variability of the symptoms, little myotatic 
 irritability, little extensor spasm (and then both legs move together 
 when one spasmodically extended leg is lifted) ; rarely by inconti- 
 nence of urine or faeces, no trophic changes, no cystitis, no reaction 
 of degeneration and no decubitus. 
 
 Gower's scheme for diagnosis from the method of onset: 
 
 Disease. Onset. Disease. 
 
 Sudden (few minutes). "1 ,, . T . 
 
 Acute (few hours or days), j ) Vascular Leslons - 
 Pressure | Subacute (1 to 6 weeks). [-Degeneration. 
 
 and ISubchronic (6 weeks to 6 months). 1 ) r „ ,. 
 
 Growths. Chronic (more than 6 months^. f Inflammation. 
 
 * In the chronic stage the diagnosis of what has gone before must be 
 uncertain, unless the history is most definite ; the diagnosis is usually 
 provisional and atypical cervical pachymeningitis, tumors and most 
 often multiple sclerosis of the spinal type should be considered. 
 
 Treatment. — This is symptomatic. In the acute stage the indica- 
 tions are (a) absolute rest in bed for at least two weeks, keeping the 
 
CHRONIC MYELITIS. 1031 
 
 patient on one side or on the face, possibly with local abstraction of 
 blood. Blisters should be avoided lest they develop into decubitus. 
 (&) Gowers recommends spt. etheris nitrosi with digitalis to equalize 
 the circulation and promote diuresis, (c) When hemorrhagic myel- 
 itis is suspected ergotin (grs. iij to v) may be given three times daily. 
 (d) Mercury and iodides are usually without effect in syphilitic 
 myelitis (softening), possibly injurious, although some rationally 
 recommend their use unless unfavorable effects appear, (e) Care of 
 the skin. Though bed-sores may be trophic, experience shows that 
 care greatly reduces their frequency and extension. Pressure and 
 heat should be avoided by change of posture, rubber cushions, soft 
 thick pads of cotton or the water bed. As in typhoid, the use of two 
 beds is very beneficial and the sheets should be stretched smooth. 
 Alcohol rubs are antiseptic and harden the skin. Moisture and filth 
 are most dangerous; the bowels should be irrigated if they move in- 
 voluntarily; incontinence of urine is more dangerous, especially in 
 women ; hard urinals, if left between the legs, may cause equal dam- 
 age ; the urine should be gathered in bags of oiled silk filled with cot- 
 ton ; in women mild antiseptic gauze and impalpable boric acid should 
 be disposed about the genitalia. (/) Care of bladder is imperative. 
 Cystitis develops in most cases in which the catheter is used, or in 
 which there is incontinence with retention; residual urine is easily 
 infected, probably by infection ascending the dribbling, patent 
 urethra; the urethra should be irrigated before the absolutely clean 
 catheter is introduced ; lavage with Thiersch's solution in cystitis 
 with retention or incontinence and grs. v to x, each of urotropin and 
 salol t. i. d. are indicated, (g) The paralyzed muscles should be 
 gently massaged from the very onset. 
 
 In the subacute or chronic stage, tonics, massage after four weeks, 
 mild f aradism of the bladder and rectum are indicated. Contractures 
 are modified or prevented by warm baths and massage. Hot baths 
 are directly dangerous. 
 
 II. Acute Multiple Disseminated Myelitis. — This affection is rela- 
 tively infrequent. It is subacute in onset; foci develop irregularly, 
 together or successively in different parts of the cord or perhaps of 
 the brain (disseminated encephalomyelitis) , with acute ataxia, scan- 
 ning speech, dysarthria, tremor, nystagmus, optic neuritis, spasticity 
 or weakness of the limbs. Sensation and the sphincters are usually 
 not affected. The clinical picture is necessarily irregular, because 
 the inflammation may occur anywhere ; von Ley den distinguishes (a) 
 the atactic and (b) the paraplegic forms. A myelitis which spreads 
 after the first two or three days is of the disseminated type and may 
 be fatal in a few days to a few weeks ; once thought very fatal, num- 
 bers of recoveries have been reported lately. Treatment is as in the 
 acute transverse variety. 
 
 III. Chronic Myelitis. — This may be the stationary stage of acute 
 myelitis or in very rare cases myelitis may be chronic from the be- 
 ginning, *. e., a gradual onset and slow progression. Many deny the 
 
1032 DISEASES OF THE NEBVOUS SYSTEM. 
 
 existence of this form and classify it under the paraplegic state, 
 multiple sclerosis or chronic system-disease. If myelitis, chronic 
 from the onset, is to be recognized, its symptoms differ from the acute 
 form only in the mode of onset. 
 
 IV. Acute Poliomyelitis of Children. — Acute poliomyelitis, also 
 known as atrophic paralysis, was first described clinically by v. 
 Heine (1840) and pathologically by Cornil (1863), although Prevost 
 and Vulpian (1865) first accurately defined the changes in the gan- 
 glionic cells of the anterior horn. The famous contribution of Char- 
 cot and Joffroy (1870) fixed the trophic relation of the special cells 
 involved to the atrophy of the nerves and muscles supplied and stated 
 that the disease was due to primary inflammation of the cells them- 
 selves. Archambault and Damaschino found the primary inflam- 
 mation in the vessels (interstitial myelitis). 
 
 Definition. — An acute, probably independent, infection, character- 
 ized pathologically by acute myelitis of the anterior horns and clin- 
 ically by the incidence in children of an acute flaccid paralysis with 
 wasting in the muscles, loss of reflexes, the reaction of degeneration 
 and later contractures. 
 
 Etiology. — In some statistics it constitutes as high as 8 per cent, of 
 the diseases of childhood. 
 
 1. Age. — The disease largely occurs between the second and third 
 years of life ; 60 per cent, of cases occur in the first three years and it 
 is ten times as frequent in the first decade as in all the others. Its 
 occurrence in youth is explained by Lange by functional activity of 
 the cord, as learning to walk, etc. It has no causal connection with 
 dentition, although often synchronous with it. 
 
 2. It may follow such infections as measles or scarlatina, and 
 Marie thinks that it may result from many others (infectiones in- 
 nomminees) . Angina precedes most cases and is apparently the 
 atrium. In some localities it has occurred as an independent epi- 
 demic, as Caverly's series of 140 in Vermont or Medin's series of 44 
 in Sweden. Alice Woods describes an epidemic of 60 to 70 cases in 
 San Francisco in May and June, 1901. In 1907 there were nearly 
 3,000 cases in New York. Starr collected 54 epidemics. 
 
 3. Eighty per cent, of cases occur in the summer months (Sinkler). 
 Sex is of no importance, save after the tenth year, when the disease is 
 almost entirely confined to males (Gowers). 
 
 Pathology. — The affection is called poliomyelitis (Kussmaul), be- 
 cause it is an inflammation of the anterior gray matter, supplied by 
 the central arteries, branches of the anterior median artery of the 
 anterior longitudinal fissure. A single vessel does not supply all the 
 anterior gray matter, but branches up and down, supplying a cylin- 
 drical vertical area which measures two inches or more; this is the 
 usual dimension of a poliomyelitic focus. The inflammation may 
 extend somewhat back of the anterior horns into the white matter 
 of the antero-lateral columns. Fresh cases are rarely seen, since 
 
ACUTE POLIOMYELITIS. 1033 
 
 death is unusual; to the naked eye the focus is red, soft, juts above 
 the cut section and is mostly confined to the anterior horn, i. e., it 
 involves the beginning of the second or lower motor neurone. 
 Microscopically, the lesion is inflammation in and about the vessels 
 above named, in the anterior roots, and in the vessels even before they 
 enter the cord. The vessels are engorged; their perivascular spaces 
 are full of round cells and granule-cells; there is exudation of red 
 and white cells with actual hemorrhage in the severe cases, as shown 
 by blood pigment ; the ganglion cells in the anterior horn are swollen, 
 glistening, granular, pale, distended, decreased in number and sur- 
 rounded by leukocytes ; their dendrites may shrink, their nuclei disap- 
 pear, or the whole cell may disintegrate, while here and there some 
 cells escape; no definite cells are involved, since the process depends 
 solely on the vessel affected. The involvement is sometimes bilateral 
 and in severe cases is distributed through several segments, especially 
 in the lumbar cord. As may easily be anticipated, disease in the 
 trophic cells of the lower motor neurone must be followed by degen- 
 eration of their axis cylinders, nerve roots, peripheral nerves and 
 muscles (which become granular, fatty and later indurated). In old 
 cases macroscopic inspection shows shrinking of the anterior horns, 
 perhaps also of the contiguous white matter, with lack of differentia- 
 tion between the gray and white matter. Microscopically, the (for- 
 merly inflamed) vessels are thickened and pigmented; groups of 
 ganglion cells have disappeared and their nerve fibers are degenerated 
 or wholly wasted, which led Charcot to hold that the process was 
 essentially in the ganglionic cells, but the connective tissue also is 
 rich in cells and stains deeply with carmine, because it is thicker than 
 normal ; in other words, a cicatrix remains from the primary inflam- 
 mation. In severe cases,, identical changes have been found in the 
 medulla, pons and centrum ovale. Acute poliomyelitis differs from 
 acute myelitis and disseminated myelitis only in its localization, for 
 which there is no universally accepted reason; the gray substance is 
 more vascular and Lamy's experiments, in which he injected powder 
 into the abdominal aorta, always showed embolic softening of the 
 gray matter first. 
 
 Symptoms. — There are three clinical periods: 1. The acute stage 
 (including prodromes). 2. The stage of diffuse paralysis, when de- 
 generation appears and regeneration occurs. 3. The stationary stage, 
 with some improvement and determination of the paralysis to given 
 groups of muscles. 
 
 1. The Acute Stage. — The typical onset is acute, appearing in a 
 child previously well, with fever (75 per cent.), often with vomiting, 
 headache, somnolence and sometimes with convulsions or coma, which 
 are followed by a sudden complete and flaccid paralysis in one limb 
 or more than one limb; it corresponds to the acute inflammation in 
 the anterior horn. The fever averages 101°, may reach 105° or more 
 and lasts about 24 hours. Convulsions are not as common as in the 
 cerebral type; they occur mostly in younger subjects and are attrib- 
 
1034 DISEASES OF THE NERVOUS SYSTEM. 
 
 uted perhaps to teething, which was once thought the cause of the 
 paralysis. The simple motor paralysis usually reaches its maximum 
 in twenty-four to forty-eight hours ; it is not progressive ; its distribu- 
 tion will be considered under the next stage. In many cases pro- 
 dromata exist, as tonsillitis or angina, swollen joints, malaise, ano- 
 rexia, pain in the back and limbs or diarrhoea. Unusual variations 
 in the onset are possible; the fever may last one or two weeks before 
 the paralysis develops, it may last a few hours only or may be absent. 
 The paralysis may develop during the night. Abortive cases are 
 most exceptional and are probably often due to neuritis ; the paralysis 
 may follow some acute infection, as measles or scarlatina. Sometimes 
 paralysis is not noticed for a long time, until, for example, the child 
 fails to walk. In some cases pain is the first symptom in older chil- 
 dren and is referred to the back or extremities. Convulsions involve 
 principally the extremities and sometimes occur in the form of clonic 
 muscular contractions ; Striirnpell observed them for more than a 
 month before the paralysis developed. 
 
 2. The Stage of Degeneration. — This results from localization 
 in the anterior horn, which produces (a) paralysis, (b) disturbed 
 nutrition, (c) vasomotor changes and {d) loss of reflexes, (a) The 
 paralysis is motor only; it is sudden, complete, flaccid and non- 
 progressive; though at first diffuse, it usually regresses, although in- 
 completely, leaving some permanent paralysis. General localization, 
 according to Starr's combined statistics of about 600 cases, gives : (i) 
 Paralysis, most frequently of one leg, then (ii) of both legs, and (iii) 
 and (iv) of all four limbs or of one arm (with equal frequency), (v) 
 of arm and leg of same side (spinal hemiplegia), (vi) of arm with 
 opposite leg (crossed or alternating paralysis), (vii) of three limbs 
 and least often (viii) of both arms. The trunk muscles may be 
 involved, but the cranial nerves are exempt, save in severe and diffuse 
 foci. The bladder is usually unaffected, except in the early stage, 
 from general toxaemia, or in severe cases. As to its special localiza- 
 tion, the leg is paralyzed in 75 per cent, of cases (E. Remak) ; in one 
 form the lasting paralysis affects the quadriceps femoris with the 
 adductors (upper lumbar lesion), but the sartorius is not involved; 
 in another form the muscles below the knee supplied by the peroneal 
 nerve are involved, as the tibialis anticus, extensor digitorum com- 
 munis, ext. longus or brevis, ext. hallucis longus, peronei (lower 
 lumbar and upper sacral lesion) of which some muscles may escape, 
 as the tibialis ant., since total paralysis is rare. If both legs are 
 involved, the paralysis is rarely symmetrical. Poliomyelitis usually 
 involves several segments, because of the arterial distribution. The 
 arm is paralyzed in 25 per cent., chiefly in the form of the combined 
 shoulder paralysis of Remak, involving the deltoid (sometimes 
 alone), biceps, brachialis, supinator longus with the supra- and infra- 
 spinatus and teretes (lesion in upper cervical enlargement, fifth to 
 sixth segment) ; in some cases the forearm type may be seen, with 
 involvement of the flexors or possibly of the extensors, while the 
 
ACUTE POLIOMYELITIS. 1035 
 
 supinator longus often escapes (lower cervical lesion, seventh and 
 eighth segments). The trunk or neck muscles usually show improve- 
 ment in this stage, (b) As to disturbed nutrition, the muscles and 
 nerves corresponding to the level of the poliomyelitis rapidly degener- 
 ate, as shown by early reaction of degeneration and muscular atrophy. 
 The reaction of degeneration consists of failure of the nerve and 
 muscles to respond to the f aradic current and usually appears in one or 
 two weeks (Duchenne) or rarely earlier; it also includes a lack of 
 response of the nerve to the galvanic current and finally too prompt a 
 response of the muscles to the galvanic current and more quickly to 
 the positive than to the negative pole; this latter reaction lasts for 
 two, three or six months and then gradually disappears in a year or 
 two. Muscular atrophy may be apparent in two weeks and is more 
 clearly seen in the arm than in the leg or trunk, whose adipose deposit 
 may obscure it. Fibrillary contractions are rather frequent. The 
 wasted flaccid member hangs and swings in a lifeless fashion, (c) 
 Vasomotor paralysis causes the low temperature (1 to even 10° be- 
 low normal) and the livid cyanotic or sometimes clammy skin, (d) 
 The skin and tendon reflexes are abolished in the limb at first; the 
 skin reflexes usually return later. The sphincters are almost always 
 intact and sensation is very rarely affected. True trophic changes are 
 almost unknown. 
 
 3. Stationary, Chronic, Residual Stage. — Some improvement 
 may occur, but this stage is generally marked (a) by accentuation of 
 muscular atrophy, connective and sometimes adipose tissue replacing 
 the contractile substance; it is most marked in the legs in old cases, 
 and involves also the nerves, arteries and tendons, (b) The bones 
 become thin, flexible, friable, arrested in development and therefore 
 shorter, since the bone cortex wastes and its medulla becomes more 
 spongy ; scoliosis may result, (c) There may be pronounced vasomotor 
 lividity. (d) In the joints, nodules may appear as in cerebral hemi- 
 plegia; the joint structures are relaxed and the " flail joint" may 
 develop with luxation or subluxation, (e) Contractures are due 
 principally to the mechanical influence of the unopposed antagonist 
 muscles on the posture of the joint; if all the muscles are paralyzed 
 they sometimes result from static causes, as from standing or attempt- 
 ing to walk, i. e., from neglect ; trauma and malposition of the lux- 
 ated joints or tendons may also cause contracture or actual deformity; 
 the arm, the shoulder, wrist and fingers are usually flexed and the 
 elbow usually escapes involvement. In the leg, deformity (pes equi- 
 novarus) is more common than in the arm. 
 
 Diagnosis.— The initial vomiting, fever and convulsions are usually 
 misinterpreted until the diffuse purely motor paralysis appears and 
 consequently the physician is unjustly blamed for what he cannot 
 anticipate. The age, acute paralysis, rapid atrophy, reaction of 
 degeneration and loss of reflexes are positive diagnostics, together 
 with the absence of sensory and sphincter disturbance. 
 
 Differentiation. — (a) The various forms of muscular atrophy in 
 
1036 DISEASES OF THE NEMVOVS SYSTEM. 
 
 children are gradual in onset, progressive, symmetrical and often 
 familial. The atrophy precedes and exceeds paralysis and there is no 
 arrest in development. The neural progressive muscular atrophy of 
 Hoffmann, due to disease of the nerves or nerve roots, may produce 
 paralysis, atrophy and the reaction of degeneration, but the affection is 
 progressive, familial and involves sensation, (b) Birth palsies are 
 distinguishable by their history and more favorable course, (c) Mul- 
 tiple neuritis (q. v.) has several distinctive features. Poliomyelitis is 
 due to a local inflammation, is unilateral and spinal in type — or if 
 bilateral, it is asymmetrical. Multiple neuritis is hematogenous and 
 toxic, and therefore affects the spinal, and often the cranial nerves 
 symmetrically and bilaterally and usually involves the arms and 
 legs ; ataxia, sensory disturbance and local tenderness over the nerve 
 trunks are common, its onset is more subacute and convulsions are 
 rare ; the reaction of degeneration is less intense and the issue is much 
 more favorable, (d) The cerebral palsies of children (see page 
 950) affect the upper motor neurone and therefore never produce 
 marked degenerative atrophy or loss of f aradic irritability. Its hemi- 
 plegic form involves the face and its paraplegic form is spastic. Dis- 
 turbance of the intellect, convulsions and hemichorea are common. 
 In rare cases cerebral and spinal paralysis may co-exist, (e) Myelitis 
 also begins acutely, but usually in older subjects. Poliomyelitis may 
 be confused only when it is bilateral, located in the cervical or lumbar 
 enlargement, when sensory changes occur (2 per cent.), the sphincters 
 are involved, producing a flaccid atrophic paralysis of an arm and a 
 spastic paresis of the leg, the latter of which is only transitory. Bed- 
 sores, so common in myelitis, are " almost unknown " in poliomyelitis. 
 (/) Painful affections causing immobility of a joint, hip-joint disease, 
 Parrot's syphilitic pseudoparalysis and infantile scurvy bear a super- 
 ficial resemblance to poliomyelitis. Westphal noted that in the new- 
 born the electrical reaction normally resembles the reaction of de- 
 generation, (g) Hysterical contractures, sometimes with atrophy, 
 disappear under anaesthesia and show no reaction of degeneration. 
 
 Prognosis. — (1) Regarding life; there is little danger after the 
 fever subsides ; life is very rarely threatened from extension to the 
 medulla oblongata. In epidemics the mortality may reach 10 per 
 cent. (2) Regarding relapses; second attacks almost never occur. 
 (3) Regarding recovery; improvement is the rule. The diffuse initial 
 paralysis usually becomes localized, but complete recovery is infre- 
 quent. (Starr asserts that 25 per cent, recover completely.) A local- 
 ized initial paralysis may show but little improvement, and an ex- 
 tensive initial paralysis may diminish greatly. A definite prognosis 
 of the ultimate extent of the paralysis cannot be made for two weeks 
 and then only by the electrical examination. Muscles which show 
 no reaction of degeneration after fourteen days will probably recover ; 
 those showing slight loss of faradic irritability will recover in great 
 part; after six weeks only those muscles are paralyzed which will 
 remain paralyzed ; if there is no recovery in three months there will 
 be none or it will be slight. 
 
CHRONIC POLIOMYELITIS. 1037 
 
 Treatment. — In the acute stage rest, a light diet, laxatives, diaphor- 
 etics and diuretics are indicated. After administration of urotropin, 
 Cushing found formaldehyde in the spinal fluid; Starr recommends 
 urotropin, gr. v every 4 hours. After the fever the patient should be 
 kept in bed for weeks and should be given lukewarm baths. Elec- 
 tricity is contra-indicated. As the paralysis recedes a fuller diet and 
 careful passive movements are beneficial. In the chronic stationary 
 stage, with its inevitable and permanent paralysis, fresh air and lib- 
 eral nourishment are important. Strychnine is valuable because of 
 its general tonic action and its almost specific physiological action on 
 the motor elements of the cord. It should be given for three or four 
 weeks after the paralysis becomes stationary. Full doses may induce 
 muscular spasm, pain and irritating paresthesia. Electricity cannot 
 restore totally destroyed tissue, but it hastens recovery in partial 
 lesions ; if applied to the spine it is useless, but the constant stream 
 to the muscles and the faradic current to the skin are helpful. Con- 
 tractures may be modified as well as deformities due to neglect, to 
 which gymnastic movements, massage and orthopedic apparatus are 
 essential. The child should be kept in bed for a long period. In some 
 cases tenotomy, arthrodesis and tendon transplantation, by attaching 
 the tendons of sound muscles to those of paralyzed muscles (Vulpius, 
 Nicolodoni) are indicated. Nerve transplantation is proving very 
 successful. 
 
 V. Acute Poliomyelitis in Adults. — This is rare in comparison 
 with the infantile form. It was established by Vogt in 1858, Moritz 
 Meyer, in 1861, and anatomically by Gombault, in 1873. The 
 etiology is practically the same as that of the infantile variety ; most 
 cases occur between the twentieth and thirtieth years. The symptoms 
 and course are essentially the same, with the following variations: 
 fever is almost always present, which with the prodromes lasts longer 
 than in children, even a week. There is the same flaccid paralysis 
 with atrophy and the reaction of degeneration, but it regresses less 
 and results less frequently in contractures. The types of Remak are 
 more clearly developed in the adult. Pain is more prominent. Fried- 
 lander observed mixed cases with early, transient anaesthesia. The 
 diagnosis is more uncertain in adults, chiefly because multiple neuritis 
 and to a lesser degree myelitis and hsematomvelia are more difficult to 
 exclude, but in all three affections sensory alterations are usual. 
 
 VI. Subacute and Chronic Poliomyelitis. — Many reported cases are 
 probably multiple neuritis, although Oppenheim published perfectly 
 clear cases. Etiology. — Metallic poisons and syphilis are important 
 factors. Pathologically, two main types are distinguished; in the 
 larger group there is no inflammation but rather a primary atrophy 
 of the ganglionic cells, which heightens its resemblance to spinal pro- 
 gressive muscular atrophy, than which, however, it runs a more rapid 
 course ; in a smaller group of cases there is early perivascular exuda- 
 tion in the anterior horn and later sclerosis, wherein it resembles 
 acute poliomyelitis, although it is slower in its course. The anterior 
 
1038 DISEASES OF THE NERVOUS SYSTEM. 
 
 roots are involved and in most cases there is degeneration in both 
 pyramidal tracts, possibly also in the posterior columns or roots, in 
 Clarke's columns or rarely in the medulla. The course is gradual; 
 one extremity becomes slowly affected (in one to three years), some- 
 times with extension to others after months or years. There are 
 paresis with atrophy, fibrillary tremors, partial or complete reaction 
 of degeneration, decrease or absence of the reflexes and normal 
 sensation. Life is rarely immediately threatened, but the ulti- 
 mate outcome is unfavorable ; if recovery occurs, neuritis, not polio- 
 myelitis, is the actual lesion. Differentiation is as follows: (a) 
 Multiple neuritis (see Acute Poliomyelitis) ; (b) from pro- 
 gressive spinal muscular atrophy, even an anatomical differentiation 
 is not easily made. As a rule, the following clinical distinctions 
 hold ; in progressive muscular atrophy, atrophy precedes and exceeds 
 the muscular weakness, fiber after fiber of muscle very slowly wastes, 
 the atrophy is especially marked in the distal parts as in the hands 
 and fingers, and the reaction of degeneration is usually less complete. 
 In chronic poliomyelitis, atrophy always rapidly follows paralysis ; it 
 is an outright atrophy (atrophie en masse), it occurs more often in 
 the proximal parts, as in the shoulder, and the reaction of degenera- 
 tion is marked, (c) In amyotrophic lateral sclerosis the paralysis is 
 spastic with increased reflexes, contractures and often with bulbar 
 symptoms. Treatment is the same as that of the chronic stage of 
 acute poliomyelitis. 
 
 VII. Landry's Paralysis. — Landry's paralysis (acute ascending 
 paralysis) was described by Landry and independently by Kussmaul 
 in 1859. Landry's description included five cases of his own and 
 five others; the famous Cuvier died of this disease in 1832. Acute 
 ascending paralysis is a symptom complex rather than a disease in 
 itself and may be conveniently classified under inflammatory affec- 
 tions of the cord. The etiology is vague. The affection occurs mostly 
 between twenty and forty years of age and three times more fre- 
 quently in males than in females. It has followed acute infections, 
 as diphtheria, typhoid or influenza and chronic infections as syphilis 
 and tuberculosis. 
 
 Pathology. — In the early and in many recent cases no anatomical 
 findings existed, and on this Westphal (1876) founded his three 
 criteria: (a) that the disease is a progressive, ascending and finally 
 fatal affection with (b) normal electrical reaction and (c) negative 
 findings at autopsy. Though negative findings are frequent, recent 
 cases have given definite though varying postmortem results, as struc- 
 tureless exudation in the cord, disseminated foci of inflammation in 
 the cord, medulla and pons, changes in the pyramidal tracts, anterior 
 horns and in the spinal and sometimes in the cerebral peripheral 
 nerves. By some writers two forms are distinguished : (a) the bulbar 
 or medullary form, in which sensation and electrical reactions are 
 normal, and (b) the peripheral neuritic form, with sensorv and 
 
MULTIPLE SCLEEOSIS. 1039 
 
 electrical alterations. The parenchymatous swelling of the liver, 
 spleen, kidneys and lymphatics indicates a general infection or tox- 
 aemia. Bacteriologically, an anthrax-like bacillus (Baumgarten), 
 the pneumococcus, typhoid bacillus, bacilli in all the peripheral nerves 
 and streptococci (CEttinger and Marinesco) have been found. 
 
 Symptoms. — The onset is acute without or with prodromes, as head- 
 and back-ache, muscular spasms and paresthesia. Paralysis com- 
 mences in one foot, then in the other, and in the legs, thighs, abdomen, 
 back, arms, even in the face or the eyes, possibly with optic neuritis ; 
 the paralysis is progressive and ascending; when the medulla is in- 
 vaded, dysarthria, dysphagia and paralysis of the tongue occur and 
 finally death results by respiratory paralysis or in atypical cases by 
 circulatory paralysis. The proximal parts of the limbs are more 
 involved than the distal and some muscles may be unaffected. Fever 
 is usually absent ; the sensorium, sensation, sphincters and electrical 
 reaction are usually normal. There are no tremors, no twitchings, 
 no convulsions, no contractures, no trophic disturbance. The re- 
 flexes are usually decreased or absent. In rare cases there may be 
 partial reaction of degeneration (which usually has not time to de- 
 velop), atrophy and moderate disturbance of sensation or the sphinc- 
 ters. The paralysis may be of the descending type, in which event 
 the bulbar involvement is fatal before the paralysis in the legs is well 
 developed. 
 
 Course and Prognosis. — The disease lasts two days to two weeks, 
 and usually terminates with a respiratory paralysis. Bulbar symp- 
 toms are ominous, but not necessarily fatal. The central form of 
 paralysis is fatal and the peripheral form probably includes most of 
 the recoveries. In rare cases, death may occur in a few hours or only 
 after months. In the still rarer cases of recovery, some chronic par- 
 alysis may remain. If recovery ensue, the paralysis regresses in an 
 order inverse to that of development. A diagnosis is usually easily 
 made, because of the ascending motor paralysis with loss of reflexes 
 and without marked mental, sensory, sphincter or electrical alteration. 
 
 Treatment. — The treatment is that of myelitis or multiple neuritis. 
 Strychnia and other stimulation are indicated if the bulbar symptoms 
 are manifested. C. L. Greene reports a case which was kept alive by 
 artificial respiration forty-one days after respiratory failure set in; 
 he advises calomel, colonic flushings and oxygen inhalations. 
 
 MULTIPLE SCLEROSIS. 
 
 Insular or disseminated sclerosis, sclerose en plaques disseminees, 
 was described pathologically by Cruveilhier and Carswell (1838) ; 
 Frerichs, in 1849, made the first diagnosis, and Charcot (and Vul- 
 pian), in 1863-64, gave a description of the typical case. 
 
 Etiology. — In fully 50 per cent, of the cases no cause is found and 
 little is known of its etiology. It occurs equally in either sex and 
 90 per cent, occur under the fortieth year ; cases resembling multiple 
 
1040 DISEASES OF THE NERVOUS SYSTEM. 
 
 sclerosis (pseudosclerosis) occurring after the fortieth year are 
 considered arteriosclerotic. Three main factors are thought to exist : 
 (a) Acute infections, as typhoid, pneumonia, measles, smallpox, etc. ; 
 Marie adopted this theory. (&) The idea that chronic intoxications 
 with alcohol, lead, etc., are causal, (c) Strtimpell and Muller favor 
 the developmental theory. 
 
 Pathology. — Macroscopically, the sclerotic foci are usually seen with 
 ease as irregular grayish-red areas as large as a pea or walnut ; they 
 are multiple (numhering even over 100), are distributed at random 
 and occur largely in the white substance, although Oppenheim and 
 Taylor found equal involvement of the gray matter. In most cases 
 their distribution is cerebrospinal, in rarer cases in the cord alone, 
 and most rarely in the brain only ; the brain cortex is less frequently 
 involved than the centrum ovale, central ganglia, corpus callosum and 
 the anterior under surface of the pons and the crus. The medulla is 
 quite often and the cerebellum rarely involved. The white matter in 
 the cord is more frequently affected than in the brain. On section, 
 the focus is a trifle sunken and transparent, is fairly well demarked, 
 firm save in the freshest foci, and on hardening in Muller's solution, 
 appears light green, while the normal tissue is a darker green color. 
 Microscopically, the medullary sheaths in the white substance are 
 thinner or absent and though the axis cylinders are somewhat wasted 
 and at times varicose, their remarkable persistence, first noticed by 
 Charcot, causes the incomplete character of the symptoms and the 
 usual absence of ascending and descending degenerations. The gan- 
 glion cells suffer some atrophy and pigmentation, though in general 
 they resist the sclerosis fairly well. The foci stain deeply with car- 
 mine, are not sharply demarked from the healthy tissue and show 
 corpora amylacea, granule-bearing cells, increase of the fine meshed 
 neuroglia fibrils, nuclear proliferation and sometimes Deiter's cells. 
 In contrast with the system-degenerations, the primary change is 
 interstitial with secondary changes in the nervous tissue. Some 
 pathologists, as Eibbert, see significant changes in the bloodvessels 
 of early cases, as arterial thrombosis, followed by exudation and 
 neurogliar proliferation ; this theory is vigorously opposed by Strum- 
 pell. The cerebral nerves suffer often, especially the optic nerve, in 
 which proliferation of connective tissue is followed by loss of the 
 medullary sheaths, while the axis cylinders are unaffected. The 
 nuclei, roots and nerve trunks of the third, eighth, seventh and other 
 cranial nerves may suffer similar alteration. The spinal nerve roots 
 are not infrequently involved. 
 
 Symptoms. — The clinical picture is so variable that a definite de- 
 scription cannot be made to cover all cases. Charcot's description 
 included the intention tremor, the nystagmus, scanning speech, motor 
 weakness and rigidity and apoplectic insults, although he recognized 
 atypical forms (formes frustes). 
 
 1. Motor Symptoms. — These are the most important, (a) Mus- 
 cular weakness is very common. Paresis is more frequent than par- 
 
MULTIPLE SCLEKOSIS. 1041 
 
 alysis, since some axis cylinders remain intact. The movements are 
 slow and fatigue rapidly follows their repetition; this statement ap- 
 plies to isolated rather than to synergistic movements. The paresis is 
 most apparent in the legs, there is usually some in the arms and fre- 
 quently some in the musculature of the eyes, head and speech. ^ It 
 sometimes does not develop until late in the disease, may at no time 
 be conspicuous, and is commonly associated with increased reflexes 
 and spasticity. The gait is spastic, scuffling and the feet seem to stick 
 to the ground; to this is sometimes added a cerebellar, atactic or 
 paretic element. Muscular atrophy is rare but may result from an 
 adventitious focus in the anterior horn. The electrical reactions are 
 practically normal. (b) Muscular rigidity is the most frequent find- 
 ing, is referred to disease of the lateral columns and is most developed 
 in the legs. It increases with successive movements; for example, 
 each step becomes more stiff in walking. It sometimes amounts only 
 to a sense of stiffness ; in other cases the spasticity is so extreme and 
 the muscles so hard that the limb cannot be moved even with great 
 effort. Contractures develop, which usually affect the adductors and 
 extensors first and the flexors later and draw the heels up to the 
 buttocks. Contractures often affect the muscles of the neck, (c) 
 Tremor is one of the most striking phases of the disease, being present 
 in 75 per cent, of cases. It is caused, as is the paresis, by the loss of 
 the medullary sheaths (Charcot) which allows diffusion of nerve 
 impulses, by foci in the pons or thalamus (Erb) or by lack of co- 
 ordination between antagonistic muscles (Strumpell, v. Ley den) ; 
 the axis cylinders remain intact. There is no tremor during rest, 
 but it appears when voluntary efforts are attempted, whence the name 
 intention tremor. The hand carrying a glass of water to the mouth 
 shakes so much that all the water may be spilled by the rhythmic 
 tremor, which possesses a wide range, and occurs five or six times to 
 the second. It is apparent in the head when the patient sits, because 
 the muscles of the neck are in constant action to support the head; 
 it disappears in the recumbent posture. Similar tremor occurs in the 
 face, larynx, trunk or legs on changing posture, as rising ; in the fin- 
 gers it produces handwriting which becomes more erratic with each 
 word written; and in the thoracic muscles it causes a species of cog- 
 wheel respiration, (d) Nystagmus occurs in 50 per cent, of cases and 
 is elicited by having the patient follow with his eyes the index finger 
 when moved to one side of his field of vision, his head remaining 
 stationary. His eyes show short, jerking lateral movements. It is 
 most common on lateral or vertical movements. Spontaneous nys- 
 tagmus is rarer, as nystagmus on attempting to focus the eyes. It 
 must be remembered that it may occur without organic disease, as in 
 general weakness or convalescence. There is no satisfactory ex- 
 planation; it is considered a tremor or an incoordination, (e) The 
 speech is scanning (54 per cent.) syllabic or staccato; it is slow, 
 monotonous, unmodulated and sometimes explosive, especially for the 
 letters c, p, g and d. The speech muscles become fatigued easily and 
 66 
 
]042 DISEASES OF THE NEEVOUS SYSTEM. 
 
 the end of a sentence is often elided ; the sounds are often nasal, in- 
 terrupted by yawning inspiration or by expiration at the beginning 
 of each syllable. Leube observed the vocal cords oscillate during their 
 movement. The cause of the peculiar speech is not clear ; it may be 
 due to tremor or ataxia from foci in the pons or medulla. (/) 
 Paresis of the eye muscles (in 17 per cent. Uhthoff) affects the third 
 or sixth nerves, convergence or associated movements. About 50 per 
 cent, are nuclear. Transient diplopia, unequal pupils, rhythmic spon- 
 taneous widening and narrowing of the pupils (hippus) and stra- 
 bismus are less common, (g) Apoplectiform seizures (in 20 per 
 cent.) develop without prodromes and are marked by partial, rarely 
 by complete coma, increased pulse, high temperature, aphasia and 
 hemiplegia, which is usually fugitive and flaccid, rarely enduring or 
 spastic. They may recur. In most cases negative pathological find- 
 ings exist, but Leube and Leyden refer them to acute encephalo- 
 myelitis. Though usually hemiplegic, they may exceptionally pro- 
 duce paraplegia, hemianesthesia or ataxia, or monoplegia. Less 
 frequently, unilateral convulsions occur. 
 
 2. Sexsoey Symptoms. — These are less frequent (30 per cent.) 
 because the sensory fibers are more resistant to disease. Freud found 
 sensory symptoms in 80 per cent, of his cases. Subjectively, dull 
 pains, formication and paroxysmal headache are frequent and light- 
 ning pains, crises, girdle sensation, trigeminal neuralgia, palpitation 
 and dyspnoea are very uncommon. Objectively, any species of sen- 
 sation may be involved, especially in distal parts of the extremities, 
 where it is usually transient. Ataxia is usually referred to disease 
 of the posterior columns or sensory tracts of the pons or medulla ; it 
 is marked in 50 per cent, of cases and may produce a typical tumbling 
 cerebellar gait. 
 
 3. Special Sexses. — The optic nerve is affected in 45 per cent., 
 usually as a pallid partial atrophy involving its temporal side, and 
 less often as neuritis or complete atrophy with total blindness. The 
 change is more conspicuous pathologically than clinically. Optic 
 neuritis is transient and runs a rapid course; in 60 per cent, of cases 
 it produces central scotomata. although at times it narrows the field 
 of vision. It may be the first sign of the disease. Hearing and taste 
 may be affected. 
 
 -4. Psychical Symptoms. — Slight mental impairment is common ; 
 the patient is indifferent and singularly complacent ; the memory is 
 weak: psychoses are rare. Compulsory or forced laughing and weep- 
 ing are partly without motive and partly emotional; they probably 
 should be referred like the analogous compulsory yawning and swal- 
 lowing to lesions in the medulla, pons or crus. 
 
 5. Bttlbae Symptoms. — These may. in rare cases, resemble the 
 symptoms of bulbar palsy, as dysphagia, anarthria and tongue atrophy. 
 
 6. Reflexes. — The tendon reflexes are increased, most markedly 
 in the legs. The patellars are exaggerated, there is ankle clonus and 
 tickling of the sole produces dorsal flexion instead of the normal 
 
MULTIPLE SCLEEOSIS. 1043 
 
 plantar flexion of the great toe (Babinsky's sign), showing disease of 
 the pyramidal tracts. The skin reflexes are usually said to be nor- 
 mal, but Strumpell found the abdominal reflexes absent in 70 per 
 cent, of his cases. The pupillary reflexes are usually normal. 
 
 7. Sphincters. — Lasting or severe symptoms in the bladder or 
 rectum are uncommon, though slight disturbance occurs in most cases. 
 The bladder is often hypertonic and irritation is frequent. 
 
 8. Trophic Symptoms. — These are rare ; they consist of skin 
 eruptions, oedema, sweating, chronic arthritis and erythromelalgia. 
 
 Course and Prognosis. — The onset is usually gradual; the spinal 
 symptoms are most prominent and in most cases the weakness in the 
 legs appears first and for a long time is hard to interpret ; it occurs 
 without pronounced sensory symptoms, bladder disorder or atrophy. 
 Sometimes the onset is acute, with loss of consciousness, transient 
 hemiplegia, vertigo, headache, eye symptoms, vomiting and optic 
 neuritis. In the average case the leg paralysis is followed by scanning 
 speech, nystagmus and tremor, which cover a chronic course averag- 
 ing three to six (or even more than twenty years). A rapid course, 
 as twenty-three months, may occur in the bulbar form. The symp- 
 toms remit and recur. Progression to a fatal ending is inevitable. 
 Charcot distinguished three stages (a) the period from the develop- 
 ment of the first symptoms to the tremor and paresis, (b) the period 
 in which the patient is bed-ridden, and (c) the terminal stage with de- 
 mentia, decubitus, sphincter paralysis, cystitis and septicopyemia. 
 
 Diagnosis. — The typical case is unmistakable, because of the cardi- 
 nal symptoms, (1) intention tremor ; (2) spastic paresis ; (3) nystag- 
 mus; (4) scanning speech; (5) ataxia; (6) increased reflexes; (7) 
 optic atrophy; (8) the slow, uneven course with remissions and recur- 
 rences; (9) the variability of the symptoms ; (10) apoplectic insults ; 
 and (11) moderate involvement of the mentality, sensation, bladder 
 and rectum. 
 
 Differentiation. — Transient hemiplegia may suggest hemor- 
 rhage, syphilitic thrombosis, embolism or tumor (q. v.). If these can 
 be excluded, multiple sclerosis or paretic dementia must be differen- 
 tiated (q. v.). Paralysis agitans is usually but rather unnecessarily 
 differentiated ; the absence of the cardinal signs of sclerosis multiplex 
 and the presence of a constant fine tremor of the hands and fingers 
 (not of the large joints, and much less of the head) which is not in- 
 creased by movement, its persistence during rest, the mask-like facies, 
 festinating speech, peculiar attitude, gait, propulsion, retropulsion, 
 muscular rigidity without increased reflexes and the advanced age 
 are clear and characteristic points. 
 
 Multiple Sclerosis. vs. Syphilis. 
 
 Occurs in the medullary substance. Occurs in the periphery of the cord 
 
 (meningomyelitis and root symptoms). 
 
 A focal disease. Diffuse. 
 
1044 DISEASES OF THE NERVOUS SYSTEM. 
 
 Multiple Sclerosis. vs. Syphilis. 
 
 Nystagmus, scanning speech, tremor. More frequent mental obscuration, in- 
 
 sults, hemiplegia, etc. ; speech may 
 be disturbed or slow in pons lesions 
 but is not scanning. 
 
 Transitory amaurosis, hemianopsia, Amaurosis, etc., are frequent, 
 
 complete optic atrophy, choked disk 
 or neuritis are very rare. 
 
 Partial optic atrophy occurs. There is more disturbance of vision. 
 
 Mydriasis 1 per cent., myosis 4 per cent. Mydriasis is very common. 
 
 Argyll-Kobertson pupil never present. Argyll-Eobertson pupil frequent. 
 
 Cortical symptoms may be present; 
 rectum and bladder more frequently 
 involved; results may be obtained 
 in early stages from antisyphilitic 
 remedies. 
 
 Hysteria more than any other disease simulates early multiple 
 sclerosis; the two affections often occur together and in both the 
 symptoms are changeable. In hysteria sensory symptoms are much 
 more prominent, there are often limitation of the visual fields, monoc- 
 ular diplopia, contractures and convulsions, but there is no optic 
 atrophy, nystagmus is extremely rare, as is the scanning speech ; and 
 intention tremor may occur, but is not so wide. The movements in 
 hysteria are often accompanied by contraction of the antagonist 
 muscles, which is a most valuable diagnostic aid. In extremely rare 
 cases, described first by Westphal as pseudosclerosis, similar symp- 
 toms prevail though the autopsy shows nothing; the tremor affects 
 the arms chiefly ; there is no ataxia or nystagmus ; the f acies is some- 
 what rigid and outbursts of anger are frequent ; syphilis is a possible 
 cause. Birth palsies may be accompanied by jerky movements, inco- 
 ordination of the legs and even scanning speech, but the history of 
 very early onset is conclusive. 
 
 Striimpell groups the atypical forms as (a) the latent group; (b) 
 those resembling chronic myelitis, or (c) pure spinal spastic paralysis, 
 maybe resembling amyotrophic lateral sclerosis if the anterior horns 
 are involved or chronic bulbar palsy if the medulla is affected ; optic 
 atrophy in such cases indicates multiple sclerosis, (d) Cases resemb- 
 ling tabes, with ataxia and pains (probably combined system disease, 
 v. i.) ; (e) the hemiplegic form; and (/) the psychical form. 
 
 Treatment. — Treatment is futile. Drugs, as silver and arsenic, are 
 inert and hydro- and electro-therapeutic measures are useless. The 
 patient should live in a warm climate during the winter months. 
 
 SYRINGOMYELIA. 
 
 The term refers to cavities in the cord, and was first employed by 
 Ollivier (1824). The affection was first described by Morgagni. 
 
STBING0MTEL1A. 1045 
 
 Syringomyelia must be distinguished from hydromyelus (hydror- 
 rhackis interna), which is a dilatation of the central canal due to 
 developmental anomalies, possibly to stasis of cerebrospinal fluid re- 
 sulting from pressure ; it is usually an accidental finding at necropsy 
 or if symptoms are present they are those of syringomyelia. 
 
 Etiology. — Sixty-three per cent, of cases occur between the tenth 
 and thirtieth years and 70 per cent, in males. Other factors, as 
 trauma, are wholly uncertain. 
 
 Pathology and Pathogenesis. — 1. Gross Pathology. — A cavity may 
 be seen from without. The cord is often lax, sometimes fluctuating 
 or flat. The cavity is usually localized but may sometimes extend 
 from the medulla to the filum terminale ; it is most often found in the 
 lower cervical or upper dorsal region, less frequently in the dorso- 
 lumbar segments or in the lower brain ; in size it ranges from a nar- 
 row slit to a cavity as wide as the cord itself; it is not absolutely 
 symmetrical and may be unilateral; it may communicate with the 
 central canal, may be multilocular from septa or strands of tissue and 
 diverticula may be found. Its wall is smooth, sometimes pigmented 
 from old hemorrhages. Sometimes the cord is normal, but it usually 
 suffers thickening and sclerosis develops from the ependyma, posterior 
 commissure or posterior horns in the form of hard or soft, tumor-like, 
 somewhat asymmetrical neurogliar proliferations, especially in the 
 cervical region; these later break down and form secondary cavities. 
 The posterior horns and columns are often affected, the anterior horns 
 and columns less frequently and the lateral columns very rarely. 
 Hemorrhage into the gliomatous tissue or the cavity may result from 
 rupture of the new-formed bloodvessels. 
 
 2. Minute Pathology. — The essential finding is overgrowth of 
 the neuroglia, which in part breaks down and forms cavities. This 
 hyperplasia is most probably due to some congenital anomaly, which 
 also explains its frequent association with dilatation of the central 
 canal (hydromyelus). The neurogliar overgrowth is rich in fibers, 
 whereas the ordinary glioma (gliomatosis) especially abounds in 
 cells ; syringomyelia and gliomatosis may co-exist. The proliferation 
 is seemingly embryonic in character, contains some large sharply 
 nucleated cells, here and there a few epithelial cells, is firm as a whole, 
 but somewhat softer towards the posterior horns, is often hyaline 
 nearest the cavity from compression and abounds in bloodvessels. 
 The cavity is usually lined with cylindrical epithelium like that of 
 the central canal, sometimes only with neuroglia ; its contents resem- 
 bles cerebrospinal fluid, but is occasionally blood tinged or less often 
 gelatinous, mucoid or milky. Degenerations occur in parts actually 
 involved and at times in distant parts, as in the medulla. The nerve 
 fibers are not much involved, although secondary degeneration may 
 occur in the posterior and less frequently in the lateral columns. 
 
 The exact 'pathogenesis is obscure. Congenital hydromyelus (with 
 primary neurogliar hyperplasia and secondary cavity formation), in- 
 flammation and hemorrhage are not causal factors. 
 
1046 DISEASES OF THE NEBVOUS SYSTEM. 
 
 Symptoms. — There are three cardinal symptoms. 
 1. Anesthesia. — Partial or dissociated anaesthesia occurs in the 
 typical case, in which the sensation of touch, pressure and locality 
 is preserved while heat or cold and pain are not recognized as such 
 but as simple pressure. Therm o-ancesthesia usually concerns percep- 
 tion of both heat and cold, sometimes of only one of them, or one in 
 one place and the other in another ; analgesia is frequently preceded 
 by hyperalgesia ; it concerns the superficial or deeper structures and 
 usually corresponds with the thermo-anaesthesia. Thermo-anaesthesia 
 and analgesia begin in the hands and fingers and are later found on 
 the upper trunk; sometimes the entire trunk, legs, mucous membranes 
 and face may be affected, depending on the location of the cavity. 
 The patient may suffer burns or injuries in these parts without pain. 
 Dissociated anaesthesia is most probably caused by disturbance of con- 
 duction of temperature and pain in the gray substance of the cord, 
 which is frequently invaded by neurogliar proliferation and the 
 cavity formation ; tactile sensation traverses the white columns. In 
 some cases the partial anaesthesia is unilateral. Anaesthesia may 
 involve all varieties of sensation. Subjective sensory disturbances 
 include paresthesia and burning, tabes-like pain in the neck, arms 
 or trunk and sometimes in the joints, spine or legs. 
 
 2. Muscular Atrophy. — Muscular atrophy is due to involvement 
 of the anterior horn and affects the arms mostly, because the disease 
 is largely in the lower cervical and upper dorsal cord. It is slow in 
 onset, more marked than the attendant flaccid paresis, degenerative 
 and often observed with fibrillary muscular contractions and in- 
 creased myotatic irritability. It usually involves the small muscles 
 of the hand, as the interossei, produces flattening of the thenar and 
 hypothenar eminences and the claw-like hand, as seen in the Duchenne- 
 Aran type. The radial supply is first affected, then the ulnar and 
 median. Sometimes the scapulohumeral type is observed, especially 
 with bulbar symptoms. The muscles of the trunk, and much less 
 often of the legs, may be affected. From cervical compression of the 
 pyramidal tracts, paraplegia results, with increased reflexes and 
 spasticity, in 12 per cent, of cases. Other motor symptoms occasion- 
 ally occur, as tremor, contractures, spasms, opisthotonos or choreiform 
 movements. The gait is normal, spastic or paretic. Romberg's 
 sign and ataxia result from involvement of the posterior columns 
 or coincident tabes. 
 
 3. Trophic Symptoms. — These are frequent. (a) Phlegmons 
 and felons develop, particularly on the fingers. They are painless, 
 chronic, often recurrent and lead to necrosis of the bone, ankylosis 
 of the joints, deformity or mutilation. (&) The joints suffer in over 
 10 per cent., especially in males (75 per cent.), probably due to loss 
 of articular sensation (whereby the joints are used inappropriately) 
 or to lack of the nutritional reflex. These arthropathies are of the 
 hypertrophic form, with thickening and bony formation, like arthritis 
 deformans or of the atrophic form with relaxation of ligaments or 
 
SYRINGOMYELIA. 
 
 1047 
 
 flail joint. There is little exudation, no fever, no pain. On the 
 whole they are similar to the tabetic joints but are more chronic and 
 more often involve the upper extremities (shoulder 32 per cent., elbow 
 28 per cent., hand 16 per cent., hip 8 per cent., ankle 8 per cent., knee 
 6 per cent.), (c) Painless bone necrosis and spontaneous fractures 
 may occur late in the disease ; moderate scoliosis is frequent, usually 
 confined to the dorsal spine, sometimes with kyphosis ; it is probably 
 due to trophic vertebral changes or possibly to atrophy of the back 
 muscles ; perforating ulcer, thick, friable nails and clubbed fingers are 
 less common. Morvan (1883) described an affection as paresie 
 analgesique avec panaris, endemic in Brittany, which is clearly syrin- 
 gomyelia. " Morvan's disease " is marked by trophic disorders, ex- 
 cessive or deficient secretion of sweat, oedema especially on the dorsum 
 of the hands, erythema, urticaria, more rarely local asphyxia and 
 herpes zoster. 
 
 4. Other Symptoms. — (a) The reflexes of the skin are usually 
 normal; the abdominal, cremasteric and plantar reflexes are some- 
 times increased; the tendon jerks are variable, being often decreased 
 in the upper and increased in the lower extremities, (b) The sphinc- 
 ters are not involved, or only late in the disease. Retention of urine 
 and constipation are more frequent than incontinence, (c) Bulbar 
 or pontine symptoms are not infrequent, are usually unilateral and 
 appear in the later stages. They include facial hemiatrophy or 
 paresis, paresis of the tongue with atrophy, partial dysphagia, paresis 
 of the palate (nasal speech), paralysis of the vocal cords, of the ex- 
 ternal branches of the spinal accessory nerve (trapezius paralysis') 
 and trigeminus (sensory symptoms), eye paralyses (abducens), un- 
 equal pupils, nystagmus, tinnitus, salivation, apoplectiform attacks, 
 polyuria, glycosuria and vagus symptoms (disturbed pulse or respi- 
 ration, vomiting and singultus). Complications include hysteria, 
 paretic dementia, tabes, pachymeningitis, Graves' disease and epilepsy. 
 
 Diagnosis. — An almost positive diagnosis can be made from the 
 three combined cardinal symptoms; (1) the dissociated anaesthesia 
 (thermo-ansesthesia and analgesia with practically normal tactile 
 sensation) is the earliest, most constant and widely distributed sign. 
 Gr asset has collected cases of twenty or more nervous diseases (func- 
 tional, traumatic, neoplastic, specific) in which the dissociation of 
 syringomyelia has been found; but it remains highly distinctive in 
 conjunction with (2) muscular atrophy of the upper extremities with 
 paresis and (3) trophic disorders, felons, arthropathies and scoliosis; 
 to which three cardinal manifestations may be added the spastic 
 paresis of the legs and bladder symptoms. Besides the classical form, 
 various varieties are described by Schlesinger; (a) the latent form, 
 (b) the motor form, simulating amyotrophic lateral sclerosis, (c) the 
 sensory type, possibly resembling hysteria, (d) the trophic and (e) 
 the tabetic types. 
 
 Differentiation. — Progressive spinal muscular atrophy and amyo- 
 trophic lateral sclerosis may resemble syringomyelia with poorly de- 
 
1048 DI.SEA.SES OE TEE NSEVOVS SYSTEM. 
 
 veloped sensory symptoms (Clarke and Gull. 1862) but they possess 
 very few sensory signs, no anaesthesia, no trophic disturbance and 
 bulbar symptoms are bilateral. Juvenile muscular dystrophy may be 
 simulated in the scapulohumeral type of syringomyelia. Peripheral 
 ritis rarely produces dissociated anaesthesia, but all variations of 
 sensation are disturbed ; the distribution of the paralysis is peripheral, 
 not spinal or segmental, and there is the reaction of degeneration: 
 neuritis of the upper brachial plexus (Duehenne-Erb paralysis i pro- 
 duces paralysis of the shoulder, arm and supinator longus. a com- 
 bination not found in syringomyelia. Focal disease of the anterior 
 and posterior gray substance, as multiple sclerosis, hemorrhage or 
 myelitis may simulate syringomyelia, but their course is less chronic 
 and there is less trophic disorder. The signs of irritation produced 
 by tumor of the cord are lacking. Located in the dorsolumbar region, 
 syringomyelia may closely simulate tabes, from the lancinating pains, 
 crises and ataxia, but the Argyll-Bobertson pupil is lacking and the 
 sensory impairment is typical. The anaesthetic form of leprosy has 
 caused difficulty but its anaesthesia is peripheral, not spinal, in type ; 
 in the lesions of the skin, ulcers and nasal secretion the Henssen 
 bacillus is often found ; if there are no lesions in the skin, thickness 
 and tenderness of the nerves indicate leprosy. 
 
 Course and Prognosis. — The onset is gradual and the course chron- 
 ically progressive for years or even decades. When recognized, the 
 affection is advanced and recovery impossible. The first symptoms 
 are pain and dissociated anaesthesia, followed by atrophy and paresis, 
 with trophic changes in the advanced course. Death occurs from 
 cystopyelitis. septicaemia and bulbar complication-. 
 
 Treatment. — Treatment is unavailing, being confined to hygienic 
 and symptomatic measures. The danger of self injury, as a result 
 of the peculiar anaesthesia, should be borne in mind. 
 
 SYSTEM DISEASES. 
 
 These constitute a small group of very important diseases and in- 
 volve structures or systems having a common function, thus differing 
 from such indiscriminate or random disease as myelitis or multiple 
 sclerosis. The essential change is a primary slow degeneration of the 
 nerve dements, followed by secondary proliferation of connective 
 tissue (sclerosis'. The pathogenesis of these degenerations is not 
 clear, although hereditary weakness causing nutritional failure at a 
 certain age (the familial form.) and the selective action of toxins 
 in the blood acting on certain nervous structures have been thought 
 causes. 
 
 I. System Disease of the Sensory Tract, 
 
 The sensory type of system disease is locomotor ataxia in which the 
 peripheral sensory neurone is affected, in the posterior roots and 
 columns, while the motor type- are spastic paraplegia, involving the 
 
TABES DOES J LIS. 1049 
 
 upper motor neurone (pyramidal tracts | and muscular atrophy due to 
 lesions in the lower neurone (anterior horns and roots). 
 
 Tabes Dorsalis, Locomotor Ataxia (Duchenne).— Definition. — A 
 disease characterized idi etiological!^ by syphilis ; (b) pathologically 
 by lesions in the posterior spinal roots and posterior columns, in the 
 cutaneous and muscular sensory and also the cerebral nerves : and (c) 
 clinically by incoordination (ataxia), sensory symptoms (pains and 
 defective sensation I, loss of myotatic irritability (of the tendon re- 
 flexes i. loss of the pupillary reflex to light and trophic disturbances. 
 
 It is the best known and most frequent chronic disease of the cord 
 Horn in 1527 partly described the affection, although Todd in 1841 
 gave the first accurate account, eliminated paralysis, and found the 
 posterior columns diseased at autopsy. Stanley first (1840) referred 
 the affection to the posterior columns and peripheral sensory nerves. 
 Tiirck first examined the tissues microscopically and Komberg 
 (1851). and especially Duchenne (1858), popularized the disease: it 
 is still known in Trance as Duchenne's disease. 
 
 Etiology. — Syphilis is the essential causal factor (Founder and 
 Erb ) in 75 per cent. ('Gowers ). 90 per cent. (Erb and Striimpell >. or 
 100 per cent. ( Mobius). In about 10 per cent, of cases the syphilitic 
 history and stigmata are lacking, whence it is sometimes attributed 
 to other causes, as trauma, heredity, concussion, exposure, toxins 
 of soft chancres and ergotism: but it is most probable that these 
 are only incidents and that syphilis is the sole cause. The fol- 
 lowing etiological data of tabes are practically those of syphilis: age: 
 50 per cent, in the thirtieth to fortieth year: 25 per cent, in the 
 fortieth to fiftieth year: less than 25 per cent, in the twentieth to 
 thirtieth year t Gowers i : cases may occur in persons over fifty, under 
 twenty, or even ten years of age. the latter of which are probably due 
 to hereditary syphilis. Eorty-seven juvenile cases were collected by 
 Hirtz (1905 | : of these, the parents in thirteen instances had syphilis. 
 tabes or dementia. Sex: as in syphilis and paretic dementia, ten 
 cases occur in males to one in females. Syphilis is more difiicult to 
 diagnosticate in women and more often runs a latent course. Like 
 syphilis, tabes is sometimes familial: Xonne ( 1904) saw tabes in a 
 mother and two daughters. It prevails largely in cities and among the 
 higher classes ( '" syphilization and civilization"). It is uncommon 
 in the negro, though Hecht has seen cases. Tabes is a meta- or para- 
 syphilitic, degenerative lesion occurring on an average six to twelve 
 years after the chancre. Dalous (1904) collected 21 cases with 
 active syphilis. 
 
 Pathology. — The gross changes are usually visible to the unaided 
 eye : the posterior columns are smaller, outwardly flattened instead of 
 rounded, and appear gray from loss of the medullary sheaths and 
 translucent from primary loss of nerve fibers and secondary increase 
 of connective tissue. The pia may be secondarily opaque and thick- 
 ened. The degenerated areas are somewhat sunken on section. The 
 
1050 DISEASES OF TEE NEfiVOUS SYSTEM. 
 
 posterior horns and roots are always somewhat atrophied and gray 
 or grayish-red in color. As to minute changes, the toxins (Strumpell) 
 bring about a very slow degeneration of the peripheral sensory neu- 
 rone, its fibers and the processes of the spinal ganglia cells, which 
 themselves suffer much less and later obvious changes than their 
 processes. These processes run in two directions: to the periphery 
 and to the posterior roots and posterior columns, (a) The periph- 
 eral spinal sensory nerves are often degenerated (Westphal, Pierret, 
 Dejerine), less in large trunks (sciatic or crural nerves) than in 
 the peripheral filaments of the skin, joints and muscles which 
 are important in the sensory, trophic and atactic symptoms of 
 tabes; their white substance wastes and then their axis cylinders. 
 The trophic centres for these fibers are largely in the root-ganglion, 
 but there is some evidence that there are also some periph- 
 eral trophic cells. (&) The fibers running from the ganglia to the 
 posterior roots are more early, regularly and obviously changed. In 
 the cord the degenerated tracts stain deeply with carmine and include 
 only structures derived from the posterior roots and their collaterals, 
 all others escaping involvement. The posterior root fibers run (i) to 
 the posterior columns, whence there occurs, low down in the cord, 
 degeneration in Burdach's and then higher up in Goll's columns, 
 into which the root fibers are pushed as, new and higher root fibers 
 enter the cord. The location of the degenerated fibers therefore dif- 
 fers at successive levels and the degeneration is an ascending one. In 
 the lumbar cord the posterior columns are most intensively and ex- 
 tensively diseased, especially in their middle and posterior parts, 
 nearest the posterior roots and surface of the cord. Early and marked 
 degeneration is found in the fine fibers of Lissauer's zone which lies 
 just back of the posterior horn. The anterior part of the post. ext. 
 column and the central part of the post. int. column are slightly, if at 
 all, diseased as they are not derived from the post, ganglia. In the 
 dorsal cord the post, columns are degenerated save in the post. ext. 
 part and in the ant. part. In the cervical cord the post. int. columns 
 are diseased (representing the root fibers of the lumbodorsal cord) 
 and also some areas in the post. ext. column where degenerated root 
 fibers have just entered. There is some pathological as well as 
 clinical variation in different cases; Marie holds that one set of 
 sensory fibers after another is involved and that degeneration de- 
 velops by segments. Tabetic changes are usually most developed in 
 the lower cord, but in the rare " cervical tabes " the upper cord suffers 
 severely and perhaps exclusively, (ii) From the post, roots a second 
 series of fibers run to Clarke's column. They and their collaterals 
 are degenerated but the cells of Clarke's column (and their ascending 
 fibers to the cerebellum) usually remain intact, (iii) The post, 
 horns degenerate, because they contain fine root fibers, (iv) The 
 reflex collaterals to the ant. horns also degenerate. 
 
 As already stated, pronounced or early atrophy in the cells of the 
 post, ganglia is rare. Degenerative changes may involve other analo- 
 
TABES D0BSAL1S. 1051 
 
 gous neurones, as the auditory, optic, trigeminus, visceral, sympa- 
 thetic or ocular nerves, or less often the peripheral motor nerves, the 
 pyramidal tracts, the muscles themselves, the medulla and the brain 
 cortex. In old cases, corpora amylacea are found. 
 
 The exact pathogenesis is disputed: (i) Obersteiner believes the 
 initial changes are in the pia through which the dorsal nerve roots 
 pass; (ii) Marie contends that there is a lymphangitis of the post, 
 columns; (iii) Edinger believes the toxins of syphilis attack those 
 nervous structures most in use and therefore most easily fatigued; 
 these are the sensory tracts of the lumbar cord, pupil, bladder and 
 intestine. 
 
 Symptoms. — The symptoms vary chiefly as to their intensity, dura- 
 tion and order of succession. In general three stages are described. 
 (1) The initial, neuralgic or pre-atactic stage, lasting sometimes for 
 years (usually 6 to 8, or even 10 to 20). The earliest symptoms are 
 usually sensory and irritative, as pains which are lancinating or 
 rheumatic, perhaps neuralgic or like migraine or paresthesia. The 
 knee jerk is lost in nearly all cases, usually very early and the pupil 
 reacts to accommodation but not to light. Much less often optic 
 atrophy, sexual, sphincter, ocular, articular or visceral symptoms first 
 attract attention. (2) The atactic stage may last many years ; muscu- 
 lar movements become incoordinate, especially in the legs, but some- 
 times, though later, in the arms. The tabetic gait develops, the 
 patient sways when his eyes are closed (Romberg's sign), sensation 
 is obtunded, especially the muscular sense, urinary and sexual dis- 
 orders develop and in some cases diplopia. The gross muscular power 
 is unimpaired. Trophic, joint, bone and skin lesions and visceral 
 crises occur. (3) The terminal stage, improperly called paralytic, is 
 much like that of other chronic affections of the cord. The patient 
 is bed-ridden, helpless from extreme ataxia and rarely from motor 
 weakness, and bed-sores, lesions in the medulla and cystitis lead to a 
 fatal issue. 
 
 Special Symptoms in Detail. — 1. Motor Symptoms. — (a) Ataxia 
 (incoordination) is of such importance that the disease is named 
 locomotor ataxia. It is present in 80 per cent, of cases, but may 
 develop slowly, only after years or perhaps not at all; it is less com- 
 mon than formerly (Brissaud) ; it occurred in barely 10 per cent, of 
 Babinsky's cases, who explains this decrease by his use of mercury. 
 Ataxia is a disturbance of harmonic efficient muscular contraction and 
 arises not only from tabes but also from lesions in the upper sensory 
 neurones of the cord, medulla, cerebellum, pons and cerebrum. The 
 cause of tabetic ataxia is probably disease of the afferent muscular 
 fibers (muscular anaesthesia, Reynolds 1855), intensified by sensory 
 impairment, disturbance in the reflex collaterals and sometimes by 
 atrophy of the optic nerve. Duchenne first made the valuable distinc- 
 tion between ataxia and loss of muscular power which is preserved 
 until late in the disease. Ataxia is frequently first observed by the 
 patient when he walks in the dark or closes his eyes, as in washing the 
 
1052 DISEASES OF THE NERVOUS SYSTEM. 
 
 face. When he closes his eyes or looks well upward or when the 
 heels and toes are brought closely together, the body sways (Rom- 
 berg's sign) and he perhaps falls, because vision is one of the sensory 
 factors in equilibration. Later, incoordination occurs even when the 
 eyes are open, and the patient can walk only with the support of a 
 cane. It is often increased by removing the shoes, which support the 
 feet. The ataxia is marked when the patient attempts to " about 
 face/' to walk backward (Althaus), to stand on his tiptoes (Bosen- 
 bach) or to stand with the knees half flexed (Brissaud). Ataxia is 
 also seen when the patient, with the eyes closed, attempts to place his 
 heel on the opposite knee or perform with one limb those movements 
 made by the physician in another limb. The gait is atactic, the feet 
 are lifted too high, are thrown too far forward and outward (wide- 
 legged gait) and are brought suddenly and forcibly down in a " stamp- 
 ing" fashion. It has been called the "rooster gait." A tumbling 
 cerebellar gait is less frequent, observed later in the disease and refer- 
 able to involvement of the trunk or hips. Movement in tabetics is 
 characterized by excessive excursion, rapidity, irregularity and un- 
 certainty of execution. The arms usually escape or are involved less 
 markedly and later, save in cervical or brachial tabes. The patient 
 cannot execute finer movements, such as writing or buttoning the 
 clothes. Ataxia is rare in the head, eyes, face and tongue, although 
 in exceptional cases it has been observed in masticatory movements. 
 In women marked ataxia is less frequent than simple awkwardness. 
 (b) Muscular power may be normal even with extreme ataxia. The 
 muscles are hypotonic and this loss of tone allows hyperextension and 
 hypernexion of the joints; it is due to loss of centripetal sensory con- 
 duction. There is a feeling of weakness in the legs in two-thirds of 
 the cases. Attacks of transient muscular weakness are frequent (75 
 per cent.), as in the eye muscles. Paralysis, though usually transient, 
 may be permanent from disease of the pyramidal tracts, ant. horns or 
 peripheral nerves, (c) Atrophy is not" common, but may affect the 
 arm (type of Duchenne-Aran), the leg (the tabetic club foot, usually 
 due to neuritis), or most rarely the face (hemiatrophy), (d) The 
 electrical reactions are usually normal. Sometimes muscular con- 
 tractures occur, due to abnormal sensation. Associated movements, 
 in which one leg moves when its fellow moves, and spontaneous move- 
 ments, taking place without volition or consciousness of them and due 
 to the slight unnoticed reflexes, may occur. 
 
 2. Sensory Symptoms. — Sensory symptoms are prominent. In 
 the majority of cases the disease begins with irritative sensory phe- 
 nomena, (a) Spontaneous pains occur in 85 per cent., are sudden, 
 paroxysmal, lightning-like, lancinating and often nocturnal. They 
 are usually severe, but may be agonizing, though sometimes only dull, 
 burning or like those of muscular rheumatism ; they may be increased 
 by damp and cold. They last from a few hours to a day or two. The 
 legs are the most common seat of pain, then the back, trunk, arms 
 especially in the ulnar distribution and sometimes the head (occipital 
 
TABES DOKSALIS. 1053 
 
 nerves) and face (trigeminus, whose ascending branch represents the 
 sensory parts of most of the other cranial nerves) ; Collet found 
 migraine-like attacks in 40 per cent. ; their bilateral occurrence is 
 very suggestive. The pains are more often deep than superficial and 
 are more often irregular than exactly conforming to a nerve's course. 
 The pain in the trunk may assume the " girdle form' 7 (31 per cent.) 
 over a narrow or broad zone. Sometimes the area affected shows local 
 trophic changes, as herpes, ecchymoses or friable hair, (b) Parces- 
 tkesice are common, as creeping sensations (formication), " pins and 
 needle " sensations, a sense of heat or especially of cold. They occur 
 in the legs in 66 per cent, of cases. If in the arms, the ulnar dis- 
 tribution is especially involved (17 per cent.). The ulnars at the 
 elbows are often insensitive to pressure (Biernacki s sign) and show 
 lessened appreciation of pain, temperature and tactile impressions. 
 In the face a perverted feeling may be noted (" Hutchinson s mask"), 
 (c) In the early stages hyperesthesia (probably from nerve irrita- 
 tion) may be noted. In 86 per cent, of developed cases sensation is 
 reduced; it is most often of the spinal or segmental type, though 
 sometimes peripheral. Tactile sensation is often disturbed, especially 
 in the legs and soles of the feet. Hypesthesia may be observed on the 
 buttocks, scrotum, perineum, penis (the cause of early decreased 
 sexual power) or on the trunk as a zone (80 per cent.) which is 
 hypothetic especially to light touch (Hitzig and Lahr). It is not 
 usually found higher than the third rib, although there may be oc- 
 casional occipital or trigeminal anesthesia. If the arms are affected, 
 it is mostly in the hands and palms. Sometimes a touch to one mem- 
 ber is referred to another (allocheiria). Occasionally a single con- 
 tact feels like several (polyesthesia). Perception of pain is lessened 
 in 50 per cent, of cases, occurring alone or with hypesthesia ; a 
 short stab with a pin is often felt merely as a touch. Pain conduction 
 is often retarded (60 per cent.) ; the sharp stick of a pin is felt at 
 once as a touch, but the pain is perceived only after 7 to 15, even 
 35 seconds. When asked to state his sensations the patient says 
 " now " when stuck and " ouch " as he feels the pain. Analgesia may 
 be the cause of severe injuries, as in syringomyelia. Sometimes the 
 testicles are insensitive to pressure, and inflammations such as pleu- 
 risy may run a painless course. The sense of temperature is rarely 
 affected alone or completely and is usually associated with analgesia; 
 tabetics are often oversensitive to cold. The muscle sense is disturbed 
 not only as regards the location, but also as to active or passive move- 
 ments of the muscles, especially of the legs. A change of angle of 
 one or two degrees in the joints and tendons is noted by normal 
 individuals, while in tabetics much wider movements are not per- 
 ceived, especially those in the small distal joints; the toes may be 
 moved unnoticed by the patient, perhaps in the later stages the 
 fingers also. 
 
 3. Reflexes. — (ft) The skin reflexes may be increased early in the 
 disease. Later the plantar and gluteal reflexes are somewhat de- 
 
1054 DISEASES OF THE NEBVOUS SYSTEM. 
 
 creased. The abdominal and cremasteric may long remain normal. 
 (b) Of the tendon reflexes the knee jerk is lost early (WestphaVs 
 sign) ; this is a most constant finding in tabes (98 to 100 per cent.) 
 and is due to disease of the afferent nerves and collateral reflex paths 
 in the cord. These reflexes should be examined by having the patient 
 sit on the edge of a table with his eyes closed and excluding cerebral 
 inhibition of the reflexes by having him pull, in an outward direction, 
 the locked fingers (Jendrassik's reinforcement). The patellar re- 
 flexes are rarely present save in exceptional cases of cervical tabes. 
 They are sometimes simulated by a reflex movement which occurs 
 after tapping the patellar tendon but in this case the interval is longer 
 before the reaction, and the same reaction may follow a simple pin 
 prick. The knee jerk has been known to return after a cerebral hemi- 
 plegia. The Achilles reflex is often lost, though, less frequently than 
 the patellar (or equally frequently, according to Frankel). The 
 tendon reflexes of the arms are sometimes decreased. 
 
 4. The Eyes and Special Senses. — (a) The pupils contract to ac- 
 commodation but not to light in 85 to 97 per cent. (Argyll-Eobertson, 
 1869). In testing, the patient must look to a distance and one eye 
 must be tested at a time lest accommodation be confused with con- 
 traction to light. The cause of the Argyll-Robertson pupil is not 
 known, but it may depend upon a degeneration of fibers connecting 
 the optic nerve with the oculomotor muscles (see Progressive Par- 
 alysis of Insane). The tabetic pupil rarely dilates on pinching or 
 sticking the skin of the neck (Erb), especially if the pupil is small. 
 In about 50 per cent, it is small (spinal myosis) ; the pupils are often 
 unequal in size and irregular in contour, (b) The eye muscles are 
 affected in 50 per cent, of cases. Mobius holds that ocular paralyses 
 are almost as important as the pupillary changes, especially when 
 they are painless wherein they differ from the rheumatic and syphi- 
 litic forms; he holds that the majority of all eye paralyses in the 
 adult are tabetic. Diplopia (in 16 per cent.) is common and usually 
 unilateral. The order of frequency of involvement is the sixth, third 
 (lev. palpebrarum) and fourth nerves. When one muscle is para- 
 lyzed the others are usually weak. The early form of paralysis is usu- 
 ally transitory; the late form is often permanent. Nuclear de- 
 generation is the probable cause, (c) Optic atrophy (10 per cent.) 
 is generally an early symptom. The disk is pale and shrunken, espe- 
 cially on its temporal side and at the edges, which are sharp. The 
 process is always bilateral; central scotoma and actual neuritis are 
 rare. The process usually progresses to blindness. When optic 
 atrophy occurs early, ataxia may not appear ; this is known as " tabes 
 arrested by blindness." When it develops later it has no effect on the 
 ataxia, (d) Deafness may develop gradually or suddenly, sometimes 
 with vertigo or Meniere's complex. It may be permanent or tran- 
 sient. Auditory defects are present in 80 per cent, of cases. Atrophy 
 of the auditory and olfactory nerves has been found. 
 
 5. The Sphincters and Genital Sphere. — (a) The bladder is fre- 
 
TABES DOBSALIS. 1055 
 
 quently affected (60 per cent.), possibly as the first symptom of the 
 disease. The bladder is slowly or imperfectly evacuated, because its 
 centripetal sensory fibers are diseased. There may be overflow, in- 
 continence and in the later stages cystitis frequently results from 
 decomposition of the residual urine, followed in turn by pyelitis, 
 nephritis and septicaemia, (b) The sphincter ani is somewhat weak; 
 there is rarely incontinence. Constipation is the rule, (c) The 
 sexual appetite and power are reduced (66 per cent.) often early. 
 Labor is sometimes painless. 
 
 6. Trophic Disorders. — The general nutrition sometimes suffers, 
 but local trophic changes are much more common, (a) Trophic 
 alterations in the bones and joints, described by Cruveilhier and 
 Mitchell, were first thoroughly studied by Charcot, after whom they 
 are named, Charcot's disease. They usually appear late and develop 
 in 2 per cent, of cases. The onset of articular changes is usually 
 gradual, sometimes acute with marked swelling or may seem to be 
 traumatic. Two forms are observed; first and more frequently the 
 atrophic form, especially in the hip and shoulder, in which the 
 cartilages are eroded, the articular surfaces waste and crepitate, for- 
 eign bodies sometimes develop and the joint becomes too lax and dis- 
 location of the hip or knee (genu recurvatum) results; second, the 
 hypertrophic form with bony formation, ossification of the ligaments, 
 and rigidity resembling arthritis deformans but more acute, extreme 
 and effusive. The adjacent muscles atrophy — the arthropathic mus- 
 cular atrophy. The large joints are usually involved, as the knee (45 
 per cent.), hip (20 per cent.), shoulder (11 per cent.), elbow (5 per 
 cent.) or ankle (4 per cent.), but smaller articulations may be af- 
 fected, as the tarsus (8 per cent.) or less often the jaw, spine, thumb, 
 etc. The tabetic joint is painless. The cause is the same as in syrin- 
 gomyelia; the anaesthetic joints are moved inappropriately and the 
 nutritional reflex, which normally depends on centripetal influences, 
 is lacking (Marinesco and Serieux). The tabetic foot is character- 
 ized by thickness and roundness of its inner border and arch, flat- 
 tening of the sole, decreased motility and pathologically by erosion 
 and atrophy of its bones. It must be distinguished from the tabetic 
 club foot due to muscular atrophy of the calf muscles with contrac- 
 tures. The bones are friable and break easily but painlessly, as first 
 described by Weir Mitchell. Fracture is due to rarefying osteitis, 
 which renders the medullary substance more porous, the cortex thin- 
 ner and the inorganic base less in amount. If a callus develops it is 
 often exuberant. The tendons sometimes rupture, probably from 
 trophic changes, (b) The perforating ulcer of the foot (mal perfo- 
 rant du pied) is more frequent. It is ■" punched out " in appearance, 
 and thickening precedes ulceration ; it is usually painless, secretes but 
 little pus and is due to nerve degeneration. Similar ulcerations re- 
 sembling syphilis may occur in the nose, ear, buccal mucosa, palate 
 or uvula, (c) In the skin, local sweating, ecchymoses, herpes, blebs, 
 alteration of the hair or nails, gangrene and ichthyosis may occur. 
 
1056 DISEASES OF THE NERVOUS SYSTEM. 
 
 Decubitus is not common save in the last stages, and it may not de- 
 velop even after years in bed. There may be painless falling out of 
 the sound teeth with analgesia of the gums or dental caries (changes 
 in the fourth ventricle). 
 
 7. Visceral Symptoms. — The most important are the 'painful crises 
 described by Delmarre but first correctly interpreted by Charcot. 
 (a) Gastric crises occur in 5 per cent, of cases. There is severe, some- 
 times excruciating epigastric pain, which often radiates into the back, 
 vomiting (with or without nausea) of food, then fluid, finally bile or 
 even blood ; this is often attended by restlessness, epigastric retraction, 
 hiccough, fever and a slow or rapid and irregular pulse. A test meal 
 gives varying results ; hyperacidity is less frequent than hypacidity. 
 The urine is alkaline, contains indican and the chlorides are de- 
 creased. The crisis lasts several hours to days (even 8 or 10) and 
 may greatly reduce the general nutrition ; it recurs and is sometimes 
 the first evidence of tabes. The cause of the crisis is hard to explain ; 
 it is usually considered nervous, but Pal thinks it is due to increased 
 arterial tension, (b) Laryngeal crises are next in frequency but are 
 shorter in duration. They are due to spasm of the laryngeal muscles, 
 and are often dangerous. In some instances only a hoarse cough like 
 that of pertussis is noted; in others there is collapse or death (ictus 
 laryngis). Anatomically, the ascending branch of the fifth nerve 
 and the giossopharyngovagus nucleus or its branches are degenerated. 
 (c) Other crises are far less common, as intestinal crises, which are 
 characterized by colic, diarrhoea and sometimes rectal tenesmus; 
 the author saw one case with severe constipation lasting 12 days, 
 which was immediately relieved by morphine gr. % ; renal crises 
 with scant urine, transient albuminuria or even hematuria, and 
 less often nasal, pharyngeal, hepatic, cardiac, bronchial, vesical, 
 urethral or vulvovaginal crises occur. (d) The pulse frequently 
 reaches 100. Lachrymation, salivation, polyuria or glycosuria is 
 sometimes noted. 
 
 8. Cerebral Symptoms. — Cerebral symptoms other than the eye 
 changes noted above, are not frequent; they are unilateral atrophy 
 of the tongue ; paralysis of the vocal cords, especially of the abduc- 
 tors ; vagus and accessorius symptoms other than those already noted, 
 such as rapid pulse, palatal weakness or rarely paralysis affecting 
 the trapezius and sternomastoid, which is probably neuritic; and 
 very rarely facial or bulbar paralysis. 
 
 Complications. — These include hysteria, neurasthenia, Graves' dis- 
 ease, paralysis agitans; true cerebrospinal syphilis; other meta- 
 syphilitic maladies, as arteriosclerosis, aneurysm (15 per cent.), 
 valvular disease, arteriosclerotic aortic regurgitation (5 per cent.) 
 and especially dementia paralytica, which is an independent although 
 closely correlated affection ; myelitis ; general or local muscular 
 atrophy, particularly the symmetrical form (Dejerine) due to neu- 
 ritis; cerebral thrombosis due to concomitant arterial disease; and 
 apoplectiform seizures which occur as in paretic dementia. 
 
 Course and Prognosis. — The typical progress of the disease by stages 
 
TABES DOBSALIS. 1057 
 
 (v. s.) may be altered. According to Sarbo, pain is the first symp- 
 tom in 68 per cent., while no other single early symptom is the first in 
 more than 3 per cent. The disease in rare cases begins acutely. Not 
 over 50 per cent, are progressive (Gowers). Optic atrophy or in- 
 sanity may arrest tabes. In the early stages or in rudimentary forms 
 there is a slight chance that the symptoms may become stationary, but 
 not after ataxia fully develops. Tabes is incurable. Leube mentions 
 an instance of a man who worked hard for forty years after the onset 
 of tabes ; tabetics may live for twenty years in the last stages of the 
 disease. Crises, especially the gastric crises, alcoholism, traumatism, 
 acute onset, intercurrent affections which may be unnoticed because 
 of their painlessness, and affections of the bladder and kidney with 
 sepsis are unfavorable prognostics. In 1,960 well-observed cases 
 (out of 4,000) 40 per cent, followed a long course with exacerbations, 
 30 per cent, were steadily progressive, 19 per cent, halted for three 
 years or more, 6 per cent, ran a severe rapid course and 5 per cent, 
 almost recovered (Belugou and Faure, 1903). 
 
 Diagnosis. — The diagnosis is usually easily made and is based on 
 the following signs in various combinations : — (a) The Argyll- 
 Robertson pupil, which, according to Mobius, is indicative of tabes, 
 paretic dementia or rare lesions in the corp. quadrigemina. (b) The 
 most common and early symptom, Westphal's sign, loss of the patellar 
 reflex (which most rarely fails in health, marasmus, old individuals 
 or as an hereditary lesion), (c) Lightning pains, " tabetic neural- 
 gia," girdle sensation, gastric and other crises, (d) Sensory changes, 
 subjective and objective, including bladder disturbance, (e) Optic 
 atrophy. (/) Painless ocular paralysis, particularly in the adult and 
 of the nuclear form, producing ptosis and diplopia, (g) Ataxia, 
 which usually does not develop early, with Romberg's sign and the 
 tabetic gait, is practically pathognomonic after exclusion of periph- 
 eral neuritis. 
 
 In less than 1 per cent, of cases (Dejerine) the disease is located 
 in the cervical region; in cervical tabes the sensory changes, pains and 
 ataxia are most manifest in the arms or even in the face. The arm 
 reflexes are sometimes abolished and the patellars may rarely be 
 normal or increased. The characteristic pupils are present and 
 gastric crises appear early and frequently. The diagnosis of atypical 
 tabes may long remain uncertain, as in cases in which ataxia, West- 
 phal's sign and the Argyll-Robertson pupil are absent, or in those with 
 unusual symptoms, as marked motor weakness, atrophy or paralysis. 
 
 Differentiation. — In the earliest stage confusion with neuras- 
 thenia, hypochondriasis and nosophobia is possible, from common 
 symptoms, as pains, paresthesia, girdle sensation and weakness of the 
 legs, but close continued observation determines the diagnosis; the 
 tabes of Hippocrates was probably neurasthenia. One of the forms 
 of peripheral (multiple) neuritis (q. v.), viz., acute ataxia or pseudo- 
 tabes, may require differentiation. Cerebrospinal syphilis, especially 
 of the roots and the membranes, may sometimes cause confusion, 
 67 
 
1058 
 
 DISEASES OF TEE NERVOUS SYSTEM. 
 
 Tabes. 1 
 
 Gradual onset; very slow progress. 
 
 Blindness often complete; marked 
 ophthalmoscopic changes. Hemian- 
 opsia not common; rarely central 
 scotoma. Argyll-Robertson pupil. 
 
 Symptoms bilateral. 
 
 Oculomotor nerve symptoms may cause 
 the greatest difficulty, since the 
 closest relation (Erb) exists between 
 the two diseases as regards this nerve, 
 yet painless in tabes and nuclear in 
 origin. 
 
 Crises and anaesthesia of the fifth nerve, 
 laryngeal paralysis. 
 
 Sensory nerves most involved. 
 
 Paralysis very rare. 
 
 Knee jerk absent. 
 
 Ataxia. 
 
 In syphilis and parasyphilitic disease 
 (tabes), lumbar puncture shows pre- 
 dominance of mononuclear cells. 
 
 -Syphilis. 
 
 More rapid. 
 
 Blindness rarely total; ophthalmo- 
 scopic changes may be few or none, 
 yet with great disturbance of func- 
 tion. Amaurosis, etc., acute or sub- 
 acute, "in installments ' ' ; central 
 scotoma with free periphery. No 
 Argyll-Robertson pupil. 
 
 Often unilateral. 
 
 Oculomotor symptoms with headache 
 (meningitis and nerve trunk involve- 
 ment). 
 
 Crises, anaesthesia of the fifth nerve, 
 etc., rare. Anaesthesia of the fifth is 
 for all varieties of sensation, while 
 tabetic anaesthesia is for pain. 
 
 Motor nerves mostly. 
 
 Paralysis frequent at some period. 
 
 Knee jerk variable, increased. 
 
 Rare. 
 
 Remissions frequent with greater vari- 
 ability and brusqueness than in tabes. 
 
 Tabes and paretic dementia have a common etiology but in tbe lat- 
 ter the psychical alteration is characteristic. For differentiation from 
 Friedreich's ataxia, see page 1072. In cerebellar tumor, the ataxia 
 usually ceases when the eyes are closed and is not characterized by the 
 excessive excursion or rapidity of tabes; in most cases the patellar 
 reflexes are increased, there is no ansesthesia and signs of tumor are 
 often present. In multiple sclerosis there may in exceptional cases be 
 crises, pains and sensory disturbance, but the Argyll-Robertson pupil, 
 ataxia, marked sensory and bladder disturbances are most rare. The 
 reflexes are increased, there are nystagmus, scanning speech, intention 
 tremor and central scotoma and functional oculomotor involvement 
 is more frequent. Paraplegias are not difficult to differentiate, since 
 true motor disturbance is rare or late in tabes; the reflexes are in- 
 creased and spastic rigidity is marked, even in atactic paraplegia. 
 Tabetic pain is often misinterpreted ; pain as a rule suggests disease 
 of the vertebras and membranes rather than of the cord itself, but in 
 vertebral disease or cord tumor the pain is fixed, and is often in- 
 creased on pressure and movement. Tabes may be confused (but only 
 on hasty or partial examinations) with rheumatism, intercostal or 
 trigeminal neuralgia, and gastric ? renal or other visceral disease. 
 
TABES DOBSALIS. 1059 
 
 Bilateral sciatica always suggests tabes, diabetes or nephritis. Strum- 
 pell describes, among workers in tobacco, a nicotine tabes, in which 
 pain, pupillary alteration, atactic gait and absence of knee jerks are 
 observed, but which presents a characteristic tremor and increased 
 cutaneous reflexes in the legs. 
 
 Treatment. — Since the disease is incurable, no therapy is especially 
 efficacious. 
 
 1. Etiological Treatment. — Antisyphilitic remedies are at first 
 indicated, but their frequent and almost regular failure has led some 
 writers to erroneously deny the causal connection between syphilis and 
 tabes. Tabes is not active syphilis; it is a late degenerative para- 
 syphilitic affection. Mercury and iodides are therefore advantageous 
 chiefly in early cases or when gummatous changes co-exist with tabes. 
 They apparently arrest some cases of optic atrophy. Mercury is 
 thought by Erb to be beneficial if it is used carefully; it should be 
 discontinued at once if untoward symptoms develop. 
 
 2. Hygienic Treatment. — Overwork, overexercise, worry, fa- 
 tigue, trauma, exposure and excess in tobacco, alcohol or sexual in- 
 dulgence should be avoided. Tabetics should not marry. The diet 
 should be regulated, since dyspepsia promotes pain. If possible, the 
 patient should live in a warm climate and at a moderate altitude. 
 
 3. Drug Treatment. — There is no specific remedy. Silver, 
 strychnia and nitroglycerine give uncertain results. Gowers con- 
 siders arsenic beneficial. 
 
 4. Balneotherapy. — Warm baths are injurious ; lukewarm baths 
 are best, but exert no specific influence on the disease. The same is 
 true of (5) electrotherapy and (6) massage. 
 
 7. Symptomatic Therapy. — (a) If pain is superficial, sinapisms, 
 chloroform liniments, cocaine (hypodermatically) or the galvano- 
 cautery should be tried; if moderate, acetanilide or cannabis indica, 
 is beneficial, but morphia should be avoided as long as possible, 
 because the habit is readily acquired. Peripheral faradization is 
 often efficacious. Gowers recently described cases in which pain was 
 a salient symptom and existed without ataxia or loss of the patellar 
 reflexes ; for this " tabetic neuralgia," differing from the ordinary 
 pains of tabes, he recommends salicylates and aluminium chloride, 
 gr. v— x t. i. d. (b) Crises resist milder therapy and usually necessi- 
 tate the use of morphine hypodermics. Laryngeal crises often re- 
 spond to nitroglycerine hypodermatically, chloroform by inhalation or 
 cocaine locally. Stretching the spine and cord probably relieves pain ; 
 the patient sits on the floor with the legs extended; without other 
 movement, the body is carefully pushed forward as far as possible. ( c) 
 Eor vesical affections, catheterization for residual urine is indicated, 
 but under most rigid antisepsis ; belladonna and faradization are often 
 helpful. Cystitis is treated by lavage, (d) Secondary infection 
 should be avoided. Corns should never be cut but always rubbed off. 
 
 8. Ataxia. — This may be relieved by H. G. Frankel's systematic 
 exercises, " a reeducation of the central nervous system by repeated 
 
1060 DISEASES OF TEE NEEVOUS SYSTEM. 
 
 exercises/' which teaches that carefully and persistently executed 
 muscular movements, not forceful movements, are desirable. (The 
 nerve stretching of Langenbuch and the suspension method of 
 Mitchell are useless and even injurious.) 
 
 II. System Diseases of the Motor Tract. 
 
 The centrifugal or motor paths may be diseased (1) in the upper 
 neurone, as in spastic spinal paralysis; (2) in both neurones, as 
 amyotrophic lateral sclerosis; (3) in the peripheral neurone, as 
 spinal muscular atrophy or its cerebral analogue, progressive bulbar 
 paralysis; (4) in the peripheral motor nerve, as the neuritic muscu- 
 lar atrophy and finally (5) in the muscles themselves, as the muscular 
 dystrophies. These forms are more or less correlated and some types 
 blend, but separate descriptions are necessary to bring out the clas- 
 sical symptoms and physiology (the classification into those with and 
 without disease of the spinal gray matter is more simple). 
 
 1. Spastic Spinal Paraplegia.- — Lateral sclerosis, tabes dorsal spas- 
 modique, was described first by Erb in 1875 and later by Turck and 
 Charcot. While amyotrophic lateral sclerosis affects both neurones 
 and the muscular atrophies the lower neurone in the cord, nerves or 
 muscles, this malady concerns only the upper motor neurone, espe- 
 cially that part which is in the cord, although it has been traced at 
 times to the cortex. 
 
 Etiology and Pathology. — The disease represents a clinical symptom 
 complex rather than a pathological entity. The causal factors are 
 uncertain, as syphilis, or occasionally an hereditary tendency. In 75 
 per cent, of cases it occurs between the twentieth and fortieth years. 
 It was thought that there was a primary sclerosis of the lateral pyr- 
 amidal tracts, especially in their lower parts, for which unequivocal 
 confirmation is still lacking, for the cases of Erb, Charcot, Strlimpell, 
 Dreschf eld and Minkowski were not wholly confined to these tracts and 
 there were some changes in other neurones, as in the post, columns. 
 
 Symptoms. — There are three cardinal findings. Motor weakness, 
 which is usually paraplegic ; muscular rigidity and increased reflexes. 
 (a) Motor weakness is usually the first sign ; it begins slowly and is 
 evidenced by weakness, fatigue or stiffness in the flexors of the hips 
 especially but also the knees and ankles. Every gradation from 
 paresis to paralysis may be noted in different cases or in different 
 stages. The arms are rarely first affected. Unilateral paresis, as of 
 one arm and one leg, is very exceptional. Striimpell attributes the 
 loss of finer synergistic movements to involvement of the lateral 
 pyramidal tracts ; he holds that the coarser movements for groups of 
 muscles are possible, via the anterior pyramidal tracts. The muscles 
 are large and well nourished, (b) Muscular rigidity (hypertonicity) 
 results also from disease of the lat. pyram. tracts, which lessens the 
 inhibition and is proportionate to the loss of power. The muscles 
 
SPASTIC SPINAL PARAPLEGIA. 1061 
 
 resist passive efforts at flexion, especially quick efforts, but yield to 
 slow, gradual flexion and remain in the position given them; this is 
 the " lead pipe contraction " of Weir Mitchell. The knees are rigidly 
 extended, even when the patient sits on the edge of the bed ; the great 
 toe is strongly flexed dorsally ; when one leg is lifted as the patient lies 
 in bed the other comes with it ; the specially tense adductors prevent 
 abduction of the thighs. The muscles are stiff in the morning ; painful 
 spasms may occur during the night ; hypertonicity may lead to con- 
 tractures which are largely active in character and patients some- 
 times complain of the " tendons getting too short." In active move- 
 ments rigidity is manifest ; the gait is paretic and spastic, the knees 
 are extended and closely apposed, the steps are short, the balls of the 
 feet seem to cleave to the ground and the feet scuffle, (c) Increase of 
 the reflexes is also due to lateral pyramidal sclerosis. The knee jerks 
 are most excessive; ankle clonus and Babinsky's reflex are present; a 
 strong clonic contraction of the quadriceps follows depression of the 
 patella and the gait may be hopping; in short, this is the so-called 
 "spinal epilepsy" (Brown-Sequard). The arms are often normal 
 but may show weakness; there may be rigidity like that of a late 
 hemiplegia, although less in degree, in which the arms hug the chest, 
 the forearm is pronated and partly flexed and the fingers are flexed ; 
 there may be clonic spasm of the fingers and increased tendon and 
 periosteal reflexes. In the trunk there sometimes are weakness in the 
 back and painful contractions of the chest and back muscles with dull 
 aching. The cranial nerves are rarely diseased, although the jaw- 
 jerk may be increased. Sensation, the electrical reactions, the 
 muscular nutrition and the eyes are usually normal. If there are 
 sensory symptoms they are rarely objective; the sphincters are usu- 
 ally affected late. 
 
 Clinical Forms and Diagnosis. — Diagnosis concerns (a) the paresis, 
 (b) hypertonicity, (c) increase in the reflexes, (d) gradual onset and 
 (e) absence of sensory, trophic and other symptoms. Six clinical 
 forms may be described. (1) There are rigidity and spasticity in the 
 legs, arms and perhaps the face, sometimes with compulsory laughing 
 or weeping, as in amyotrophic lateral sclerosis, but without muscular 
 atrophy. 
 
 2. The hereditary or familial form (Erb, Bernhardt, Striimpell, 
 Spiller) commences in persons between twenty and thirty years of 
 age ; the paresis develops late ; this form is characterized anatomically 
 by sclerosis of the (congenitally weak) lateral pyramidal tracts and 
 also by sclerosis of the cerebellar and Goll's columns (more properly 
 classified under combined system disease). 
 
 3. In infantile forms (see Cekebbae Paralysis in Children), 
 the rigidity is less; foot-clonus less common; tonic spasms are rare; 
 athetoid movements, deficient mentality and epileptiform convulsions 
 are common. 
 
 4. In the syphilitic form of Erb there are paresis and slight spas- 
 ticity, plus urinary incontinence, retention and impotence. 
 
1062 DISEASES OF THE NERVOUS SYSTEM. 
 
 5. There are forms which are symptomatic of brain disease (tumor, 
 syphilis, paretic dementia, encephalitis, hydrocephalus), cord disease 
 (tumor, myelitis, compression, syringomyelia, multiple sclerosis) and 
 hysteria (which may closely simulate spastic paraplegia) ; hysteria 
 has not the peculiar extensor spasm, loss of power is rarely complete 
 and ankle clonus is rare, although a spurious half voluntary contrac- 
 tion of the calf muscles may be noted. 
 
 6. Westphal, Charcot, Schachnowitch, but especially Goldnam, 
 have described periodic familial paralysis, which affects the legs and 
 less often the arms, is flaccid and results in decrease of the patellar 
 and absence of the plantar reflexes, decreased faradic irritability, 
 sleepiness, but without sensory symptoms ; it lasts one to three days. 
 The prognosis is good. 
 
 Prognosis. — The disease may be stationary for years and its course 
 is chronic. " It is perhaps the least dangerous to life of any chronic 
 spinal lesion." Recovery or arrest is rare. 
 
 Treatment. — Much exercise, fatigue, electrotherapy and strychnia 
 are to be avoided. Massage and warm baths relieve the spasticity. 
 Otherwise the therapy is expectant. 
 
 2. Amyotrophic Lateral Sclerosis.- — This was often called the 
 Maladie de Charcot, because Charcot (1865) with Joffroy first de- 
 scribed it. 
 
 Etiology. — It occurs mostly between the twenty-fifth and forty-fifth 
 years, more frequently in males, but its exact causes are not known, 
 although cold, trauma and overexertion are possible factors. 
 
 Pathology. — Changes may be found from the cerebral cortex to the 
 muscles themselves, but the name amyotrophic lateral sclerosis, left 
 to us by Charcot, designates the leading changes, which are, amyo- 
 trophy, muscular wasting, from atrophy of the anterior horns, — and 
 sclerosis of the lateral columns, (a) The lateral pyramidal tracts, 
 and to a lesser extent the anterior, show symmetrical primary degen- 
 eration of the nerve fibers, followed by interstitial overgrowth (sec- 
 ondary sclerosis) which is most marked in the cord, i. e., the lower 
 part of the upper neurone, but extends upward in some cases to the 
 medulla, pons, crus or even to the very central convolutions, the 
 ganglionic cells of which may be atrophied. Charcot's belief that the 
 disease starts in the pyramidal tracts and is followed by changes in 
 the anterior horns (v. i.) is not proven. In some cases similar but 
 unimportant changes may be found in the cerebellar tracts or indeed 
 in the posterior columns. (&) The ganglionic cells of the anterior 
 horn are degenerated, so that the anterior motor part of the cord is 
 distinctly smaller and flatter, particularly in the cervical region. 
 Likewise the nerve fibers from the pyramidal fibers, anastomosing 
 with the processes of the ant. horn, are degenerated. With these 
 changes in the trophic centre of the second motor neurone the atrophic 
 changes in the anterior roots, motor nerves and muscles are easily ex- 
 plained. Certain muscles are wasted to a varying degree and show 
 
AMYOTROPHIC LATERAL SCLEROSIS. 1063 
 
 degeneration or complete atrophy, as in the purely spinal progres- 
 sive muscular atrophy, next to be described, (c) The bulbar nuclei, 
 with their nerves and muscles, show identical changes, for they are 
 the analogues of the ant. horns. 
 
 Symptoms. — The symptoms, like the lesions, are strictly motor. 
 
 Stage 1 of Ciiaecot. — The disease begins with weakness and 
 atrophy of the muscles of the hand, first in one and then in the other ; 
 they are most marked in the thenar, hypothenar and interosseal 
 muscles, and are followed by wasting and weakness in the forearm 
 extensors, deltoid and triceps, while other muscles of the arm and 
 forearm escape or are involved later. Sensory symptoms are absent. 
 The decreased power of unwasted muscles is often manifest before 
 they atrophy. Other symptoms of disease of the lower neurone ap- 
 pear, as fibrillary contractions; the reaction of degeneration is present 
 in those muscles which are wholly atrophied, while in others the re- 
 sponse is reduced proportionately to the atrophy; the nerve trunks 
 respond normally. Evidences of involvement of the upper neurone 
 also appear ; paralysis often precedes the wasting and accentuates the 
 weakness from ant. horn involvement ; there is increase of the reflexes 
 (which never occurs in muscular atrophy due to disease of the ant. 
 horns alone), increased biceps, triceps and periosteal forearm reflexes 
 and there are often rigidity and contracture in which the arm hugs the 
 chest, the forearm is flexed and pronated, and the wrist and fingers 
 are flexed. Sometimes the neck is rigid and even trismus is observed. 
 
 Stage 2. — In less than a year the legs are involved; indeed they 
 show symptoms during the first stage. The legs are weak, especially 
 in the flexors of the hip, knee and dorsal flexors of the foot. Spastic 
 symptoms prevail. The legs resist passive movement, because of in- 
 creased muscle tonus and the increased reflexes. The gait is spastic 
 and paretic (see above, Spastic Spinal Paralysis) and walking 
 finally becomes impossible because of the rigidity and the twitching 
 tetanic movements of the extensors. The patellar reflexes are exag- 
 gerated; ankle clonus is frequent ; when the. patient attempts to flex 
 the thigh while the examiner holds the ankle, there is a visible con- 
 traction of the tibialis anticus (the tibialis phenomenon) ; Babinshy s 
 reflex is present (dorsal instead of plantar flexion of the great' toe 
 on stroking the sole) ; there are evidences, in short, of pyramidal dis- 
 ease, which dominate leg symptoms, because symptoms referable to 
 the lower neurone, as atrophy, are much less frequent, less marked and 
 less early in the legs than in the arms. In exceptional cases the leg 
 symptoms develop first. 
 
 Stage 3. — This stage occurs in one or two years with bulbar symp- 
 toms, dysphagia, atrophy of the lips and tongue with fibrillation, as in 
 primary bulbar paralysis (q. v.). On tapping the jaw a marked jerk 
 is elicited, analogous to the increased reflexes in the arm and leg. A 
 tonic tension of the facial muscles may occur, as in spastic spinal 
 paralysis. Spasmodic laughing or weeping almost always occurs and 
 is due to loss of inhibitory innervation. The mind is clear. Death 
 
1064 DISEASES OF TEE NEBVOVS SYSTEM. 
 
 results from respiratory failure, aspiration pneumonia or intercur- 
 rent disease. In rare cases the bulbar symptoms antedate atrophy in 
 the arms and spasticity in the legs. 
 
 Course and Prognosis. — In some cases the spinal, in others the 
 atrophic, symptoms develop first and are dominant. The entire 
 course is rapid compared with other diseases of the group, covers one 
 to four years and is always fatal. 
 
 Diagnosis. — The involvement of both motor segments, muscle 
 atrophy with increased reflexes, rigidity, absence usually of sphincter 
 or sensory alteration (except rarely some pains) and the final bulbar 
 symptoms make the disease easy of diagnosis. 
 
 Treatment. — The treatment is that of spinal muscular atrophy (v. 
 i.), but avails little. 
 
 3. Progressive Spinal Muscular Atrophy. — Duchenne and Aran 
 (1849-50) gave us the first full clinical description of this disease, 
 while Clarke, Luys (1860) and then Charcot, discovered changes in 
 the anterior horns. 
 
 Etiology. — The ultimate causes are not known. Seventy-five per 
 cent, of cases occur in males, mostly between the twenty-fifth and 
 forty-fifth years. Hereditary factors, which are often observed in the 
 muscular dystrophies (v. i.) are infrequent, although Werding 
 (1891), Hoffman (1894), Bruce, Osier and Thompson have de- 
 scribed familial infantile forms. Hard work, mental distress, syphi- 
 lis, trauma, acute infections and acute poliomyelitis are possible 
 factors. 
 
 Pathology. — In the cord, especially in the cervical region, (a) the 
 ant. horns are small and flattened; their ganglion cells are shrunken, 
 deformed, their processes lost; they are wholly wasted in advanced 
 cases. Any interstitial changes are wholly secondary, (b) The 
 anterior roots, especially the cervical, are somewhat degenerated and 
 often also the peripheral nerves, although changes in them are most 
 difficult to distinguish, (c) The muscles are small, stringy and pale, 
 having lost their normal redness. Microscopically their individual 
 fibers are small, although a few normal or even hypertrophic fibers 
 may be seen. Their transverse striation persists remarkably, and 
 waxy, fatty or granular degeneration and longitudinal splitting are 
 not common; sometimes the empty sheaths alone are seen. The 
 muscle nuclei multiply, round cells may wander in, and there is usu- 
 ally increase of connective tissue and sometimes fatty deposit. Just 
 where the process begins is disputed. ~No close distinction can be 
 drawn between this disease and amyotrophic lateral sclerosis, although 
 changes in the upper neurone are absent in spinal muscular atrophy. 
 Gowers and v. Ley den consider them identical ; Kahler and Pick held 
 that both these diseases and bulbar paralysis are one affection. 
 
 Symptoms. — (a) The essential symptoms are those of the motor 
 nerves and all others are accessory. The earliest symptom is muscu- 
 lar atrophy with weakness in the upper extremity (90 per cent.), 
 
PE0GBESS1FE MUSCULAB ATROPHY. 1065 
 
 especially in the muscles of the (right) thenar and hypothenar emi- 
 nences. The abductor and opponens pollicis are first involved, then 
 the flexor brevis and adductor, the wasting of which brings closer 
 together the metacarpi of the thumb and index finger (the "ape 
 hand"). It is finally impossible to appose the thumb to the fingers. 
 The interossei on the dorsum waste and leave marked furrows, pro- 
 ducing the " claw hand," main en griff 'e, from contraction of antagon- 
 ist muscles, the ext. digitorum communis, the tendons of which stand 
 out prominently. The wasting lumbricales make, the palm more 
 hollow. Wasting as above described is known as the Duchenne-Aran 
 type, in which "individual muscles" are selectively involved (Char- 
 cot). The onset and progress are always very gradual and the 
 muscles become lax, soft, thin and flat. The atrophy long exceeds the 
 paresis. The forearm may be next involved, first the extensors, espe- 
 cially those below the int. condyle and later the supinators and flexors. 
 A deep depression between the ulna and radius eventually occurs. 
 Later, often after several years, the shoulder muscles, the posterior 
 and middle third of the deltoid, the biceps and brachialis waste and 
 much later the triceps. Sometimes the wasting of the muscles of the 
 shoulder and arm immediately follows the involvement of the hand, 
 or perhaps the disease begins in the shoulder. The bones of the 
 shoulder stand out clearly, covered only by the skin; these cases are 
 " the living skeletons " seen in museums. The trunk muscles are 
 involved in this order ; trapezius in its middle and lower parts (rarely 
 in its upper third, which is the ultimum moriens of Duchenne) ; pec- 
 tor alis, latissimus dorsi, rhomboidei (causing the shoulder to droop) 
 and extensors of the head (allowing the head to fall forward). 
 Scoliosis may develop, lordosis is common in involvement of the ex- 
 tensors of the trunk and hip and the spine stands out distinctly in 
 cases of extreme atrophy. The platysma and face almost always 
 escape. In most instances the respiratory muscles, intercostals or 
 even the diaphragm are involved, and this is a not infrequent source 
 of danger to life. The abdominal muscles are sometimes weakened. 
 In the leg the muscles are affected late and to a lesser degree, as the 
 glutei, quadriceps and the peronei. In very exceptional cases the 
 disease first develops in them. In the fully developed case there is 
 extreme helplessness in which an added misery in the form of the 
 sister-process, bulbar paralysis, may develop. 
 
 (b) In the wasted and weak muscles there are usually fibrillary 
 contractions; they are involuntary twitchings, tremor- or even wave- 
 like in character, which are sometimes incessant, and again are ini- 
 tiated only by cold or tapping; they show increased mechanical irri- 
 tability. They may appear in muscles not yet wasted and are not to 
 be confused with the similar neurasthenic fibrillation. (c) The 
 electrical reaction depends on the degree of wasting. In the nerves 
 it is normal. In the muscles there is usually only quantitative reduc- 
 tion and the voltaic excitability remains long after the faradic is lost; 
 in the last stages there is a partial reaction of degeneration, (d) 
 
1066 DISEASES OF THE NEBVOUS SYSTEM. 
 
 The reflexes are weakened or abolished; they are roughly propor- 
 tionate to the atrophy and due to disease in the motor side of the 
 reflex arc. They are never increased. The sphincters are intact, but 
 sexual power is often lost, (e) Sensation shows no objective change, 
 and even subjective paresthesia is rare; in some instances there are 
 dull aching pains in the muscles or joints. (/) Vasomotor, secretory 
 and trophic symptoms are lacking. The coolness of wasted parts is 
 due to lack of motility. 
 
 Diagnosis. — The diagnosis is based on (a) the slow course; (b) the 
 involvement of the muscles of the hand and its slow " individualiza- 
 tion " ; (c) fibrillation; (d) partial reduction in electrical irrita- 
 bility or partial reaction of degeneration; (e) absence of increased 
 reflexes and (/) of any sensory signs. 
 
 Differentiation is necessary (1) from disease in which muscular 
 atrophy is but one among several symptoms, (a) Syringomyelia is 
 marked by its trophic characteristics, its analgesia, thermo-ansesthesia 
 and less symmetrical wasting, (b) Meningitis, pachymeningitis, 
 spondylitis, tumors and myelitis are manifested by anaesthesia, pain, 
 tenderness and rigidity, (c) In root neuritis or multiple neuritis 
 there is a clearer reaction of degeneration, more sensory signs and 
 more tenderness in the nerve trunks, (d) The occupation atrophies 
 are distinguished by the history and slight sensory disturbance. 
 
 2. Other muscular atrophies, (a) Subacute and chronic polio- 
 myelitis causes paralysis first and atrophy afterward ; it affects groups 
 of muscles at once, its course is not gradual but rapid and fibrillary 
 contractions are infrequent. (&) The myopathic atrophies (see p. 
 1070). (c) Amyotrophic lateral sclerosis is an allied, perhaps an 
 identical affection ; Charcot held that the atrophy is not " individual- 
 ized," but occurs en masse; the distinguishing features are the in- 
 crease of the reflexes, spasticity and a much more rapid course. 
 Gowers has never seen a case of progressive spinal atrophy without 
 anatomical change in the pyramidal tracts; in describing the two 
 affections together, he distinguishes three varieties (i) extreme 
 atonic atrophy, (ii) muscular spasm and weakness with little or no 
 atrophy and (iii) moderate tonic atrophy with increased myotatic 
 irritability, (d) Arthritic muscular atrophy, probably due to reflex 
 influences, or direct extension of inflammation to the muscles or 
 nerves, may be acute or chronic and involves chiefly the extensors in 
 a moderate wasting; diffuse wasting suggests a nervous cause; the 
 history or evidence of joint disease is distinctive. The electrical 
 reactions are about normal. There is usually distinct increase in 
 myotatic irritability and reflex action. 
 
 Course and Prognosis. — The onset between the twenty-fifth and 
 forty-fifth years is gradual, the course is slowly progressive, remis- 
 sions infrequent, arrest very rare and death usually results from in- 
 tercurrent disease, respiratory affections (tuberculosis) or bulbar 
 palsy. Gowers observed arrest but rarely and then chiefly in cases 
 
MUSCULAR DYST110PHY. 1067 
 
 marked by symmetry and synchronous involvement of both hands; 
 arrest occurs, unhappily, chiefly late in the disease. 
 
 Treatment. — Drugs are of uncertain value. Gowers gives strychnia 
 hypodermatically ; he has seen 7 consecutive cases of arrest of which 
 G were permanent ; it has little effect by mouth. Arsenic and iodides 
 are employed. Massage, active and passive gymnastics and electricity 
 are always indicated but do not stay the disease. 
 
 4. Neuritic Muscular Atrophy.— Charcot-Marie type. Peroneal 
 family type (Tooth). ISTeuritic type (Hoffmann). 
 
 Etiology. — It is often hereditary, even through five generations ; it 
 is usually familial. It occurs in the second half of childhood and 
 rarely after the twentieth year. Sixty-six per cent, of cases are in males. 
 
 Pathology and Symptoms. — The pathological characteristic is neu- 
 ritis, which Hoffman thought might ascend to the post, roots ; secon- 
 dary changes have been seen in (roll's column. Early atrophy occurs 
 in the small muscles of the feet and may not attract attention until 
 bilateral symmetrical peroneal paralysis and atrophy develop, to- 
 gether with paralysis in the long toe extensors, and club feet (pes 
 equinus or varo-equinus) . The calf muscles are the next to suffer 
 and the thigh is involved still later. Then after years, paralysis 
 and atrophy of the hands, as in progressive spinal atrophy, develop, 
 with the " claw hand " ; in involvement of the forearm, the extensors 
 suffer more than the flexors. The shoulder, neck, trunk and face are 
 seldom diseased. Fibrillation is infrequent ; the reaction of degen- 
 eration is generally present, sensory manifestations are common, as 
 pains or anaesthesia (especially plantar) and reflex action is de- 
 creased or abolished, though the patellar reflexes may long persist. 
 
 Diagnosis and Treatment. — The diagnosis is based on the hereditary 
 or family history, the age, localization and signs of slow neuritis. 
 Treatment, as in other forms of muscular atrophy, is unsuccessful. 
 
 5. Muscular Dystrophy. — The progressive muscular dystrophies 
 (Erb) or myopathies (Charcot) are often classed with diseases of 
 the muscles, which indeed show the sole constant pathological lesions. 
 They are so closely related clinically to the less frequent spinal 
 atrophies that they are here considered. Their status is provisional, 
 since changes in the cord, nerve trunks and nerve filaments have been 
 found in some cases of each type. In all types (v. i.), with few ex- 
 ceptions, there are certain common characteristics; (a) heredity is an 
 obvious cause in 56 per cent, of cases; though this factor may be 
 absent, a familial incidence is often observed; the muscular system 
 seems deficient in nutrition, development or vitality, (b) It usually 
 occurs in childhood or pubescence, rarely in adult life, (c) The 
 pathology is practically the same in all types ; the muscles waste, with 
 or without hypertrophy or with increase of fat or interstitial growth 
 (d) Being strictly a muscular affection, fibrillation and the reaction 
 of degeneration are very rare, (e) In localization, certain muscles 
 
1068 
 
 DISEASES OF THE NEEVOUS SYSTEM. 
 
 Fig. 75. 
 
 are involved, as those of the face (orbicularis oculi et oris), shoulder 
 (pectoralis, latiss. dorsi, serrat. magnus, rhomboidei, trapezius), arm 
 (biceps, brachialis, supin. long., triceps), trunk (erector spina? ), glutei 
 and thigh. Others are usually exempt, as the deltoid, supra- and 
 infraspinatus, small muscles of the hands and feet, leg muscles 
 (gastrocnemius) and those of the tongue and pharynx. There are 
 three forms. 
 
 Pseudohypertrophic Muscular Paralysis. — Lipomatous muscular 
 atrophy is the least frequent, but is the longest and best known type 
 
 (Bell 1830, Partridge 1837, Meyron 
 1852, Duchenne 1861). It occurs in 
 males (80 per cent.) and is less 
 marked, less early in life and less fatal 
 in women. It is often transmitted by 
 healthy mothers, the males being im- 
 potent, and may be seen in five genera- 
 tions. It begins early (75 per cent, 
 under ten years) and but rarely after 
 twenty years of age. 
 
 1. Impaired motility is the earliest 
 symptom. The weakest muscles are 
 the invisible hip flexors. Weakness of 
 the hip and knee extensors makes 
 climbing of stairs difficult, causes the 
 waddling gait (paresis of glutei) and 
 interferes with rising from the floor, so 
 that the child must rise by resting on 
 all fours and then by " climbing his own 
 legs with his hands" (Gowers). Par- 
 esis of the back muscles and hip exten- 
 sors causes lumbar lordosis and abdomi- 
 nal protrusion. The ankle extensors 
 also weaken. The child stands with 
 legs far apart. The depressors of the 
 shoulders are weakened early in the 
 disease, later the shoulder muscles, then 
 the biceps and triceps, but the hand 
 remains normal for a long time, or is 
 permanently unaffected. The weak 
 muscles show nuclear increase, atrophy 
 and division of their fibers, which are 
 usually undersized, irregular in width, 
 pale and narrow; fatty degeneration 
 and loss of striation are rare. Increase 
 of connective tissue is a later but most 
 characteristic change. 
 
 2. Certain muscles show apparent 
 Ty ?i,ia'- "SSSSSTmS^T increase in size {pseudohypertrophy), 
 
MUSCULAR DYSTROPHY. 1069 
 
 which is due largely to early adipose deposit or rarely to actual mus- 
 cular hypertrophy. The muscles are lax. The calf muscles are es- 
 pecially enlarged, then the glutei, knee extensors, or infraspinatus 
 which contrasts strongly with the wasted latissimus and deltoid ; the 
 muscles of the face, neck and forearm seldom show enlargement. 
 
 3. As to other symptoms, the electrical irritability is lowered, but 
 there is no reaction of degeneration. The deep reflexes decrease and 
 disappear, from the muscular lesion. Mentality, sensation and the 
 sphincters are normal. Contractures, such as the pes equinus, may 
 occur late in the course. Cardiac hypertrophy was observed by 
 Glotz in 60 per cent, of his cases. The course is progressive, the 
 patient becomes bed-ridden, arrest is rare and death occurs after 
 years from intercurrent disease or from respiratory inflammation. 
 
 Infantile Atrophic Form, with or without Facial Involvement. — There 
 is usually no hypertrophy, but wasting occurs from the beginning. It 
 may be combined with the first form, and the legs then show pseudo- 
 hypertrophy and the arms simple atrophy. The pathology is that of 
 pseudohypertrophic muscular paralysis, save that there is no hyper- 
 trophy, true or false; increased connective tissue characterizes this 
 type of atrophy and also that of the juvenile form (see below). 
 
 The face may be involved, as was first observed by Duchenne. The 
 lids droop and cannot be wholly closed, the forehead is smooth, the 
 cheeks are flaccid and droop, the lips part and functionate poorly, as 
 in whistling, the lower lip protrudes, the nasolabial fold disappears, 
 the face becomes expressionless (the "fades myopathica"). Some- 
 times the buccinator muscles are implicated but rarely the masseters, 
 tongue, palate, larynx, pharynx or eyeball. Simultaneously or more 
 often later, the shoulder girdle wastes as in the first type ; this is the 
 facio-scapulo-humeral form of Landouzy and Dejerine; the latissimus 
 and lower part of the pectoralis are usually first affected, but in the 
 biceps, triceps and often in the supinator longus, the symmetrical 
 wasting and paresis are more conspicuous. The forearm, save for the 
 supinator longus, and the hand usually escape. The neck is seem- 
 ingly lengthened (Brissaud), because of the drooping of the shoul- 
 ders and clavicles. The leg muscles then waste, especially the hip 
 flexors, knee extensors and less often the glutei; lordosis, the wad- 
 dling gait and symptoms observed in the next type (v. i.) may de- 
 velop. The order given may be altered, for facial wasting may 
 follow that of the arms. The course is usually progressive, very 
 chronic (ten to fifty years) and the disease in itself rarely causes 
 death, which results from intercurrent infections, respiratory catarrh, 
 tuberculosis, etc. In the second and third types the prognosis is 
 more favorable than in the first form and the outlook is better when 
 the face is unaffected. 
 
 The Juvenile Form of Erb. — This type begins after puberty, pos- 
 sibly later (twentieth to fortieth year) and is more frequent in women 
 than the above forms. It begins more often in the shoulders and 
 arms than in the legs. The pectoralis, latissimus, trapezius, serratus 
 
1070 DISEASES OF TEE NERVOUS SYSTEM. 
 
 mag., rhomboidei, sacrolumbal, longiss. dorsi, supinator longus and 
 later the triceps are wasted, while the sternomastoid, supra- and infra- 
 spinatus, lev. anguli scapulse, coracobrachialis, teretes, deltoid and 
 the hand and forearm (except the supin. long.) are almost always 
 exempt. If we lift the patient with our hands beneath his shoulders 
 he tends to "slip through"; this is due to "loose shoulders" (Erb). 
 The scapulae stand out prominently from weakness of the serrati. 
 In the lower limbs the glutei, quadriceps and less often tibialis ant. 
 and peronei become atrophied. The lordosis and gait are as above 
 described. 
 
 Diagnosis of Myopathic Atrophies. — (a) Atrophy from cerebral 
 lesions is less marked than myopathic atrophy and more often follows 
 the marked loss of power, (b) Spinal muscular atrophy (according 
 to Leube) is differentiated below. 
 
 (c) Congenital spastic paraplegia occurs in children with weak legs 
 and contractures in the calves but the history, increased reflexes and a 
 regressive rather than a progressive tendency easily distinguish it. 
 (d) As to peripheral neuritis, the hereditary neurotic (neuritic) 
 muscular atrophy (q. v.) is easily recognized. Multiple neuritis 
 (q, v.) is usually toxic, more acute and shows sensory symptoms and 
 local tenderness over the nerves and muscles, (e) In congenital de- 
 fects in the pectoral muscles and trapezius, any progression is natur- 
 ally absent. 
 
 Spinal Progressive Myopathic Progressive 
 
 Muscular Atrophy. vs ' Muscular Dystrophy. 
 
 Begins in small hand muscles. In trunk, shoulder or pelvic girdle, leg 
 
 and upper arm. 
 
 Extends upward (face free). Progresses downward; face sometimes 
 
 affected. 
 
 Muscular atrophy. Frequently with hypertrophy. 
 
 Fibrillation the rule. Very exceptional. 
 
 Tendon reflexes may be increased in the Never increased, 
 legs, if we include the amyotrophic 
 lat. sclerosis. 
 
 Reaction of degeneration, partial, per- Practically never present, 
 haps complete. 
 
 Age; usually begins after thirtieth year. Usually in childhood; rarely after 
 
 twentieth year. 
 
 Heredity — rare. Frequent. 
 
 Bulbar symptoms not uncommon. Never present. 
 
 Treatment.— Electricity is recommended, but a current sufficiently 
 strong to excite the wasted muscles causes too much pain. Massage, 
 but especially reasonable exercise, is advisable, because the patients 
 begin to fail when they cannot walk. In advanced cases the respira- 
 tory tract must be watched, since catarrh predisposes to tuberculosis. 
 
HEREDITARY ATAXIA. 1071 
 
 Under diseases of the motor neurones, ophthalmoplegia, Landry's 
 paralysis, bulbar palsy, myasthenia, acute poliomyelitis, etc., might 
 also be described ; these affections, however, are treated elsewhere for 
 anatomical or differential reasons. 
 
 III. Combined System Diseases. 
 
 In 1867 Westphal described these affections in paretic dementia, 
 but Kahler and Peck in 1877 brought to more general attention this 
 group of cases with simultaneous disease in several systems of neu- 
 rones. Von Leyden and Goldscheider consider them diffuse or even 
 myelitic affections rather than true system diseases, of which, in their 
 opinion, there are but two examples, tabes and progressive muscular 
 atrophy. 
 
 1. Hereditary Ataxia, Friedreich's Ataxia (Friedreich, 1861). — 
 Etiology. — This affection is hereditary in 33 per cent, and in the 
 other instances it is usually familial, although isolated cases are 
 seen. Most cases occur in boys. It is held by some to be a congenital 
 hypoplasia of the pyramidal and other tracts, tending to degeneration 
 (Friedreich, Schultze, Strumpell), though others regard it as a com- 
 bined system disease (Kahler, Pick). Cerebellar atrophy has been 
 held as causal (Senator, Mentzel) but this is more striking in the 
 hereditary cerebellar ataxia, described below. 
 
 Pathology. — The cord or medulla and even the pons are small. 
 The earliest and dominant change is atrophy with secondary sclerosis 
 of the post, roots and post, columns, and in Goll's more than in Bur- 
 dach's columns. Lissauer's " root zone " is less affected than in tabes, 
 but more than in ataxic paraplegia. The direct cerebellar tract and 
 Clarke's gray columns share clearly in the atrophy, as does the ant. 
 lat. ascending tract of Gowers. The lat. pyramidal tract suffers in 
 most cases, its inner portion being usually normal ; the ant. pyramid, 
 tract is less altered and principally in the cervical region. Chronic 
 leptomeningitis, sometimes with annular sclerosis of the cord, is 
 occasional. 
 
 Symptoms. — (a) The cardinal sign and the one first observed is 
 ataxia, which is less rapid, excessive and stamping (as to gait) than 
 tabetic ataxia, and more closely resembles cerebellar ataxia in its 
 tumbling character and involvement of the trunk. Static ataxia ap- 
 pears later but to a marked degree, and the head oscillates as it does 
 in multiple sclerosis or the arms show jerky movements. Romberg's 
 sign is usually present and the subject leans over to watch his feet; 
 this leads to some kyphosis. Testing the sense of location elicits 
 ataxia, as in the knee-ankle test. The arms become atactic after a few 
 years. Nystagmus develops in most cases, though it is a late symp- 
 tom; it is elicited chiefly on lateral (or upward) movements and 
 is atactic, as is also the disturbance of speech, which develops in 
 three to ten years; the speech is monotonous, irregular, unclear, 
 
1072 DISEASES OF THE NEEVOUS SYSTEM. 
 
 slightly scanning, slow and strained; syllables are often elided, the 
 tongue may tremble and a nasal twang may be noticed. 
 
 (&) Kegarding the reflexes, the knee jerks are decreased early or 
 are abolished, being present only in rare atypical cases. The skin, 
 pupillary and sphincter reflexes are usually normal. In some (pos- 
 sibly syphilitic) cases the pupil reflex may disappear, (c) Other 
 signs: Club foot (pes equino-varus) is common and is best seen in the 
 dorsal decubitus; the foot is shortened and widened, the arch is 
 exaggerated (pes cavus), the great toe is strongly extended dorsally. 
 Scoliosis and kyphosis are common. Muscular paralysis or wasting 
 is rare and late. Sensory signs are few ; tactile and muscle sensation 
 is sometimes blunted; the pain sense is but rarely impaired; parses- 
 thesise, crises, lancinating pains and trophic, vasomotor and sensory 
 disturbances are lacking. General or sexual development may be re- 
 tarded at puberty. The pulse is often increased and hsemic murmurs 
 may be heard. Cerebral symptoms, as mental dulness, develop late, 
 if at all. 
 
 Course and Prognosis. — About 33 per cent, develop before the sixth 
 year, 33. per cent, between the sixth and tenth and 33 per cent, after 
 the tenth year. The atactic gait is the first sign, then speech is 
 involved, possibly then the kyphosis and club foot develop, and later 
 the arms are affected ; the course is steadily progressive, possibly with 
 remissions, and the patient becomes bed-ridden in twenty to thirty 
 years. Death follows from acute infections, cystitis and sepsis. 
 
 Diagnosis. — The diagnosis is based (a) on the hereditary or familial 
 etiology; (b) the age; (c) the ataxia; (d) absent knee jerks; and 
 (e) disturbance of speech. 
 
 Differentiation. — 1. In tabes there are also ataxia and absent 
 knee jerks, but in hereditary ataxia the syphilitic stigmata or history, 
 the immobile pupil, eye paralysis, optic atrophy, pains, crises and 
 vesical, trophic and marked sensory disturbances are absent. 
 
 2. Multiple sclerosis (in which there are also speech alteration, 
 nystagmus, ataxia and tremor) is differentiated by the spasticity, in- 
 creased reflexes, optic atrophy, compulsory laughing and other psy- 
 chical signs, apoplectiform insults, intentional tremor and slow, 
 scanning speech. 
 
 3. In cerebellar disease the ataxia is similar, but in tumors there are 
 optic neuritis, headache and vomiting. Marie, Londe and Nonne 
 described a clinically similar affection, hereditary cerebellar ataxia, 
 which is probably due to simple congenital atrophy of the cerebellum 
 (middle lobe), degeneration in Clarke's columns, cerebellar tracts and 
 posterior columns, is also hereditary or familial, but develops later, 
 between the twentieth and thirtieth years. The ataxia is cerebellar. 
 The reflexes are increased (which Patrick thinks is the sole differen- 
 tiating point), often with spasticity; quite frequently there are optic 
 atrophy, limitation of the visual field for objects and color, eye paraly- 
 sis and sometimes an immobile pupil, nystagmus, choreiform move- 
 ments and moderate sensory disturbance and speech disturbance, 
 
COMBINED SYSTEM DISEASES. 1073 
 
 which may be nasal and marked by unequal inspiration and expira- 
 tion. The club foot, scoliosis and Romberg's sign are absent. Sanger 
 Brown has reported 25 and J. H. Neff 13 cases. 
 
 4. Cerebral diplegia of children and ataxic paraplegia are distin- 
 guished by reflex increase and spasticity. 
 
 5. "Amaurotic family idiocy" (Sachs, Peterson, Hirsch) is char- 
 acterized by paresis or paralysis, idiocy, optic atrophy, marasmus and 
 a rapidly fatal course before the third year of life. At autopsy 
 hypoplasia, microgyria, decreased pyramidal cells, tangential and 
 other fibers are noted. Sachs observed 27 cases in Jews and Schaffer 
 collected 86 cases. Vogt describes a juvenile form, after puberty. 
 
 Treatment. — Treatment is wholly symptomatic. 
 
 2. Ataxic Paraplegia (Gowers). — Most cases occur in males be- 
 tween thirty and forty ; cold and concussion are possible causes ; 
 syphilis is a rare cause. Pathologically, there is a lateroposterior 
 sclerosis ; in the lat. column the degeneration is not wholly systematic, 
 symmetrical or pyramidal ; it may invade the mixed zone ; in the post, 
 column the process is not more intense in the lumbar cord and is less 
 intense in the root zone than is the case in tabes. Sometimes the 
 process is so diffuse that it suggests myelitis or arterial obstruction. 
 
 Symptoms. — The early symptoms are those of a gradual spastic 
 paraplegia (muscular weakness, exaggerated reflexes, moderate 
 rigidity), followed by ataxia (mostly in the legs, with Romberg's 
 sign). The arms are involved later and to a less degree. In the 
 last stages the ataxia is obscured by the spastic paraplegia ; vesical 
 or rectal tenesmus and muscle cramps are fairly common. Cranial 
 involvement is infrequent, though sometimes suggested by slightly 
 disturbed articulation, nystagmus, tremulous facial movements and 
 increased jaw-jerk. The mind is usually clear. Sexual activity is 
 often lessened and the sphincters are sometimes moderately dis- 
 turbed. Dull sacral pain is sometimes observed. 
 
 Differentiation. — Differentiation is necessary (a) from tabes. Cer- 
 tain tabetic symptoms are absent, as the high-stepping and sudden 
 stamping gait, the immobile pupils, optic atrophy, eye paralysis, 
 lancinating pains, crises, other sensory disorders and absent knee 
 jerks, (b) Friedreich's ataxia is distinguished by the age, heredity, 
 speech and absence of patellar reflexes, (c) Myelitis is more acute, 
 diffuse and later is regressive, (d) From simple spastic paraplegia 
 it is recognized by the ataxia. 
 
 Prognosis and Treatment. — The prognosis and treatment are those 
 of spastic spinal paraplegia. 
 
 3. Other Combined System Diseases. — Combined sclerosis may be 
 (a) exogenous, as in pellagra (g. v.) with degeneration, and then 
 sclerosis of the posterior lateral columns; as in ergotism (q. v.), the 
 longest known variety, and in lathyrism (q. v.), or it may be (b) 
 endogenous, as in multiple neuritis, diabetes, pernicious anaemia, 
 icterus, leukaemia, brain tumor, plumbism or diphtheria. Some toxin 
 
 68 
 
1074 DISEASES OF THE NERVOUS SYSTEM. 
 
 causes degeneration followed by sclerosis. It was found by Putnam 
 in enfeebled middle-aged persons, especially in women. 
 
 Pathologically , there is posterolateral sclerosis with diffuse or dis- 
 crete degenerative foci. All the columns may be affected. The most 
 diffuse changes are in the cervical and the least in the lumbar cord 
 and sometimes changes exist in the ant. horns and Clarke's columns. 
 There are sensory symptoms (lancinating pains, paresthesia, anaes- 
 thesia, ataxia), motor symptoms (paresis, paraplegia, choreiform 
 movements) or reflex symptoms (the patellars being exaggerated or 
 lost) ; optic neuritis and oedema are occasional findings. 
 
 DISEASES OF THE PERIPHERAL NERVES. 
 
 MONONEURITIS. 
 
 Definition. — Inflammation of a single nerve trunk. 
 
 Etiology. — (a) Injuries, wounds, fractures, dislocations, delivery, 
 violent muscular contractions, as in blacksmiths ; exhaustion or dis- 
 turbed metabolism; anaesthesia (ether) paralyses, the arms being held 
 over the head (in the Trendelenberg position) , the legs bound in holders 
 or when Esmarch's bandage is applied ; ether hypodermatically, mal- 
 positions of the arm during sleep and the use of crutches are causes. 
 (b) Contiguous disease (pleurisy, pelvic inflammation, compression 
 by tumors or aneurysm) may produce neuritis, (c) Cold (rheumatic 
 paralysis) causes inflammation in the sheath, whence extension to the 
 nerve, (d) Toxic causes, as plumbism and alcoholism, and acute or 
 chronic infections (v. i. Multiple Neuritis) are factors. 
 
 Pathology. — In acute cases the nerve is red, swollen, soft and some- 
 times the seat of punctate hemorrhages or extravasation of white 
 cells in the sheath or between it and the nerve fibrils. In some cases 
 inflammation involves the sheath chiefly (perineuritis) and in others 
 the interstitial tissue (interstitial neuritis), in which the included 
 nerve fibrils are readily compressed. The process is either dissemi- 
 nated or focal (where the nerve divides or enters the fascia or bone). 
 In many cases the nerve fibrils are most affected (parenchymatous 
 neuritis). It is often difficult to distinguish between inflammation 
 and degeneration; in both processes there are nuclear multiplication 
 and protoplasmic swelling in the neurilemma ; this compresses the 
 myelin sheath, which becomes varicose, granular, fragmented, shows 
 nuclear increase and finally becomes emulsified. The axis cylinder, 
 composed of thirty to fifty primitive fibrils, becomes granular, di- 
 vided and may largely or wholly disappear. Regeneration is prob- 
 ably accomplished from the spinal or cerebral centres but also from 
 the periphery. 
 
MONONEURITIS. 
 
 1075 
 
 Symptoms. — Symptoms vary with the intensity, extent and seat of 
 the neuritis (see Individual Nerves). Constitutional disturbance 
 may attend acute cases. 
 
 1. Sensory Symptoms. — The chief local symptom is pain, ex- 
 perienced largely in the sensory nerves, either locally or eccentrically 
 over their area of distribution; it is increased by tension or move- 
 ment, is usually intense and is sometimes increased at night. Tender- 
 ness is referable to involvement of the nervi nervorum (Weir 
 Mitchell). Hyperesthesia, hypsesthesia and paresthesia may be 
 noted, but complete anaesthesia is rare except for relatively small 
 areas. Sometimes the swollen nerve or perhaps nodules (n. nodosa) 
 may be felt. 
 
 2. Motor Symptoms. — The muscles supplied are tender to touch, 
 painful on movement, paretic or paralyzed, and atrophied (separation 
 from their trophic centres or loss of reflex connections). They are 
 narrower, less clearly striated, granular and finally indurated. Mus- 
 cular contractures may result reflexly, especially in traumatic and 
 professional or occupation neuritides. The reaction of degeneration is 
 present. The normal nerve is stimulated by the faradic (induced) 
 and by a stronger degree of the voltaic (constant) current ; the faradic 
 
 VOLUNTARY 
 MOTION 
 
 y f GALVANIC 
 d „ + 
 
 S { FARADIC 
 w f GALVANIC 
 z (^FARADIC 
 
 DEGENERATION 
 
 Fig. 76. 
 
 1 
 
 ATROPHY AND NUCLEAR 
 PROLIFERATION OF MUSCLE 
 
 REGENERATION 
 
 1^ WEEK 
 
 VOLUNTARY 
 MOTION 
 
 J f GALVANIC 
 
 U » H 
 
 GALVANIC 
 
 AND 
 FARADIC 
 
 DEGENERATION 
 OF NERVE 
 
 ATROPHY AND PROLIFERATION OF MUSCLE, CIRRHOSIS DEGENERATION 
 
 
 
 
 
 f 
 
 
 
 
 
 90 100 WEEK 
 
 paralysis with early return of motion ; 2. incurable paralysis with complete degene- 
 ration. (Erb, modified by Church.) 
 
 produces a continuous muscular contraction and the voltaic produces 
 a contraction when the circuit is made or broken, — the cathode 
 closing contraction, which is first to appear and stronger than the anode 
 closing contraction. In disease the following changes from normal 
 occur (Church) : (a) " The muscle responds weakly, sluggishly and 
 
1076 DISEASES OF THE NERVOUS SYSTEM. 
 
 deliberately to faradism, and tends to maintain contraction after the 
 current is withdrawn. This is the modal change, the most essential 
 element in the reaction, (b) " The nerve trunk loses progressively 
 and equally its responsiveness to both galvanism and faradism — a 
 quantitative change, (c) " The muscle becomes much more excitable 
 by galvanism and much less excitable by faradism ; the latter reaction 
 and the responses in the nerve trunk are completely lost after two or 
 three weeks. This is the qualitative change, (d) "A polar change 
 appears in the muscle about the second week when directly stimulated 
 by galvanism ; the muscle is not only more readily caused to contract 
 by the constant current, but the normal mastering strength of the 
 negative closing contraction over the positive has disappeared and the 
 positive closing contraction is equal to or greater than the negative. 7 ' 
 
 In the middle or mixed form of Erb there is a normal reaction in 
 the nerves and increased voltaic response in the muscles. 
 
 3. Tkophic Symptoms. — The skin is sometimes red, "glossy," 
 oedematous or more rarely thickened. Increased secretion of sweat, 
 eruptions as herpes, erythema or pemphigus, inflammation or ad- 
 hesions in the joints and perforating ulcers are less common. 
 
 Neuritis may sometimes ascend to the cord or its membranes as in 
 traumatic cases or in bladder disease. The progressive hypertrophic 
 interstitial neuritis of childhood (Dejerine and Sottas, 1893) is a 
 rare affection, in which there is anatomically sclerosis and hyper- 
 trophy of the nerves, ant. and post, nerve roots, and sclerosis of the 
 post, columns as in tabes, and clinically, muscular atrophy, pains, 
 anaesthesia, nystagmus, pupils immobile to light, and kyphoscoliosis. 
 
 Diagnosis. — Diagnosis depends on (a) localization of symptoms to a 
 nerve trunk and its distribution; (&) pain, tenderness and objective 
 sensory alteration; (c) muscular atrophy or paralysis; and (d) tro- 
 phic changes. The early diffuse pain may simulate disease of the 
 bones or joints. Chronic (sensory) forms may resemble neuralgia, 
 in which the pain is paroxysmal, the tender points more localized, 
 the initial tenderness less and objective sensory alteration absent. 
 Disease of the cord or nerve roots usually paralyzes several muscles 
 and affects sensation segmentally. 
 
 Prognosis. — The prognosis depends on the cause and intensity of the 
 process. Acute cases last for weeks ; chronic cases, for months. The 
 outlook is usually good in traumatic cases and bad when they are 
 due to contiguous suppuration. 
 
 Treatment. — The treatment is (a) that of the cause, (b) Absolute 
 rest is indicated. Exertion increases just as it may initiate, neuritis, 
 (c) Pain. The salicylates and iodides are of uncertain value. Local 
 heat may relieve, but sometimes causes burns and ulcerations, for the 
 anaesthetic skin may not perceive its intensity. Coal-tar products 
 should be given in preference to morphine, cocaine or Schleich's 
 infiltration anaesthesia, because habits may be contracted ; opiates are 
 necessary in severe cases. The positive pole of the voltaic current, 
 just strong enough to be felt, may relieve pain, (d) Paralysis should 
 
MULTIPLE NEUBITIS. 1077 
 
 be treated only after the acute stage. The weak interrupted voltaic 
 current (not the faradic) is indicated. Massage and later passive 
 motion are beneficial largely because the veins from the nerves empty 
 into the muscle veins and surround the muscle arteries. 
 
 « 
 
 MULTIPLE NEURITIS. 
 
 Multiple neuritis (polyneuritis, peripheral neuritis) was described 
 by James Jackson (1822) and Ladd (1854), but the first accurate 
 and pathological description was given by Dumeil in 1864, while 
 Joft'roy, 1879, Leyden, 1880 and Stewart, 1881, made important 
 contributions. 
 
 Definition. — Neuritis (or nerve degeneration) due to the selective 
 action of toxic substances on the less resistant peripheral nerves, 
 causing (a) multiple, symmetrical, bilateral, flaccid or atrophic par- 
 alysis with (b) the reaction of degeneration, (c) sensory and (d) 
 often trophic disturbances. 
 
 Etiology. — The causes are (a) poisons; alcohol is the most im- 
 portant; lead, arsenic (in beer), mercury, phosphorus, carbon mon- 
 oxide, silver, aniline and ergot may also produce the disease. (&) 
 The infections, acute, as diphtheria, typhoid, sepsis and also, occa- 
 sionally, almost every active infection, and chronic, as beri-beri, lep- 
 rosy, tuberculosis or syphilis, are etiological factors, (c) Intoxica- 
 tions, as auto-intoxications, diabetes, nephritis, digestive disorders, 
 cachexias and pregnancy, may be causal, (d) Other causes include 
 the seemingly primary cases. Cold and rheumatism may produce it ; 
 our present knowledge cannot explain their mode of action ; probably 
 these cases should be classified as infectious, for spontaneous multiple 
 neuritis has occurred epidemically. Arteriosclerosis of the nerve 
 vessels is a rarer cause. It may occur with tabes. It is a disease 
 of adults (twentieth to fiftieth year) ; in children it may occur with 
 poliomyelitis; Thomas and Greenbaum, 1907, collected 138 non- 
 diphtheritic cases in children. 
 
 Pathology. — In acute cases the nerve may be red, swollen and the 
 seat of punctate hemorrhage, exudation of leukocytes or albuminous 
 exudation in the connective tissue, but usually parenchymatous de- 
 generation predominates. It appears first and most markedly in the 
 smaller nerves. As in mononeuritis, the axis cylinders waste and the 
 medullary sheaths disintegrate. The symmetry and multiplicity of 
 degeneration in the nerve endings are caused by the blood condition 
 or toxins. Acute polymyositis of similar origin may accompany 
 neuritis multiplex. In cases which are chronic from the beginning- 
 there is slow degeneration of the nerves. The connective tissue is 
 increased in certain forms, as gouty or leprous neuritis. The toxic 
 cause may also produce degeneration of the cord or brain and changes 
 in the liver (alcoholic cirrhosis), kidneys (alcohol and lead), etc. 
 
 Symptoms. — The symptomatology varies considerably with the 
 cause. In acute cases it may begin with chills, fever, delirium, head- 
 
1078 DISEASES OF T3E NERVOUS SYSTEM. 
 
 ache, diarrhoea, icterus, bronchitis, acute splenic tumor, albuminuria 
 or other toxsemic symptoms ; these are followed by prodromal numb- 
 ness, tingling, pains, cramps or vasomotor symptoms, while in chrome 
 cases the symptoms develop slowly. 
 
 1. Sensory Symptoms. — Sensory symptoms are usually first ^ to 
 appear, the last to disappear and are throughout the most vexing 
 manifestations. Paresthesia precedes pain and pain precedes paraly- 
 sis. The muscles, nerve trunks and skin are the seat of spontaneous 
 pain, tenderness to pressure and pain on movement. The palms of 
 the hands and soles of the feet are especially hypersesthetic in the 
 tabetic, diabetic and diphtheritic forms. Sensation is often blunted, 
 perverted or less often completely suspended ; the most marked find- 
 ings exist below the elbows and knees, although higher extension, even 
 to the face, is possible. Sensory dulness may concern pain, tempera- 
 ture, tactile or muscular sensation. Some sensory disturbance is 
 rarely absent. Delayed conduction may occur. The joints may be 
 painful and swollen, especially in the hand, causing thickening and 
 limitation of movement. 
 
 2. Motor Symptoms. — Motor symptoms occur chiefly in the 
 peripheral distribution of the spinal nerves; they develop first and 
 are most marked in the extensors of the leg and foot, forearm and 
 hand, and produce the ankle and wrist drop (ext. popliteal and mus- 
 culospiral nerves). The foot is also inverted. The paralysis is flac- 
 cid, being rarely attended by muscular spasm. If the paralysis is 
 only moderately severe in the legs, the " steppage " gait is noted 
 (Charcot) and the patient lifts the legs high to clear the pendant toes 
 ("turkey-gobbler walk"). The paralysis later involves the flexors 
 and the muscles of the arm and thigh. The muscles may show an 
 early increased irritability to both the galvanic and f aradic currents ; 
 this is followed by some or all of the elements of the reaction of 
 degeneration (sometimes before paralysis appears, Popoff). The 
 muscles rarely fail to respond to the galvanic current, even in the 
 extreme cases. Then the muscles atrophy, chiefly in distal parts, i. e., 
 where the sensory and motor changes predominate. Other motor 
 manifestations are cramps, tremor, fibrillation, ataxia and contrac- 
 tures. The patient either lies on the back with the members ex- 
 tended or on the side with flexor contractures, which draw the heels 
 to the buttocks and the thighs to the abdomen. The trunk muscles 
 may be affected as well as those of the neck, eyes, face, tongue or in- 
 deed those supplied by any cranial nerve; rapid pulse, palpitation, 
 dyspnoea and vocal disturbance indicate involvement of the vagus; 
 optic neuritis and amblyopia may occur. Involvement of the cranial 
 and spinal nerves is observed in the neuritic form of Landry's paraly- 
 sis. The tendon and skin reflexes decrease and disappear although 
 initial increase or exceptional persistence has been noted. The or- 
 ganic reflexes are almost always preserved. Involvement of the 
 bladder and rectum, which is very rare, is referable to the mental 
 state or to neuritis of the pudendal plexus. 
 
MULTIPLE NEURITIS. 1079 
 
 3. Trophic Symptoms. — The skin is cold, turgid, harsh, some- 
 times glossy; herpes, erythema, ulceration, bed-sores and trophic 
 changes in the nails or hair are uncommon; oedema over the wrists 
 and ankles, especially in alcoholics, is trophic or vascular in origin. 
 
 4. General Symptoms. — Mental symptoms and malnutrition may 
 result from the antecedent toxaemia or cachexia, pain or disturbed 
 circulation ; Korsakow described the " neuritic psychosis," marked 
 by amnesia for the recent past, confabulation, delirium and halluci- 
 nations. Recovery is the rule. Some visceral symptoms have been 
 referred to involvement of the cardiac, sacral and pudendal plexuses, 
 although mostly without positive evidence. 
 
 Course and Prognosis. — Whether the disease begins acute]y or 
 slowly, the common order of symptoms is parsesthesia, pain, paralysis, 
 amyotrophy, trophic and mental symptoms. The distal parts are 
 involved more early and intensely than the proximal. In most cases 
 recovery requires about a year. Paralysis of the vagus may cause 
 death. The prognosis depends in part on the cause. It is good in 
 sensory types and in forms of slow evolution, when the sensorium, 
 arms and trunk, cranial nerves and sphincters escape involvement, 
 and when visceral disease, as liver cirrhosis, cord or brain complica- 
 tions, and oedema, are absent. The prognosis must regard the possi- 
 bility of recurrence (recurrent type) and cover the progress of the 
 disease, which is inevitably slow, despite treatment. 
 
 Diagnosis. — Early diagnosis is important, in order that etiological 
 therapy may be instituted. The cardinal signs are (a) the motor and 
 sensory symptoms, which correspond in function, peripheral distribu- 
 tion and symmetry; (b) the reaction of degeneration; (c) tenderness 
 of the nerves and muscles; (d) loss of reflexes and (e) the etiology. 
 
 Diagnosis or Type. — (a) The alcoholic form is the most frequent; 
 70 per cent, of cases occur in women; the legs are often involved; 
 there is the " steppage " gait ; sensory and mental symptoms are most 
 marked; the atactic form is not infrequent (v. i.) ; recurrence is 
 probable, (b) When due to lead poisoning, the occupation, lead line, 
 colic and constipation are characteristic ; the arms alone are involved 
 as a rule ; there is little sensory participation ; the involvement rarely 
 extends; the wasting is conspicuous, (c) Diphtheritic form (q. v.). 
 
 (d) In the toxcemic form there are fever and constitutional reaction; 
 it begins in the legs or in all members simultaneously, involves equally 
 the flexors and is attended by slight sensory symptoms (Gowers). 
 
 (e) When due to beri-beri (q. v.), vagus symptoms, dropsy and 
 cardiac failure are frequent. (/) Leprous neuritis, erythromelalgia 
 and Dercum's disease are considered elsewhere. 
 
 Differentiation. — Atactic polyneuritis (pseudotabes, Dejerine) 
 with little motor disturbance, may resemble locomotor ataxia : 
 
 Locomotor Ataxia. vs. Multiple Neuritis. 
 
 History or stigmata of syphilis. Bare; history of infection or intoxica- 
 
 tion. 
 
1080 
 
 DISEASES OF THE NERVOUS SYSTEM. 
 
 Locomotor Ataxia. vs.- 
 
 Argyll-Eobertson pupil. 
 
 Optic atrophy, 10 per cent. 
 
 Eye paralysis frequent. 
 
 Early girdle sensation and lightning 
 pains. 
 
 Muscular sense early and frequently 
 disturbed; ataxia. 
 
 Gait ataxic, stamping, striking heel 
 first. 
 
 Sensory symptoms predominate. 
 
 Paralysis, reaction of degeneration and 
 amyotrophy rare. 
 
 Nerve trunks often insensitive. 
 
 Arthropathies, osteopathies, mal per- 
 forant. 
 
 Crises. 
 
 Sphincters early and frequently in- 
 volved. 
 
 Clinical evolution very slow. 
 
 Disease incurable. 
 
 -Multiple Neuritis. 
 
 Absent (loss of accommodation in 
 diphtheria). 
 
 Bare, but toxic amaurosis is frequent. 
 
 Much more rare. 
 
 Very rare. 
 
 Eare. 
 
 Gait due to motor more than sensory 
 disturbance. Striking toe first. 
 
 Motor predominate. 
 
 In nearly all cases; rapid in develop- 
 ment and symmetrical. 
 
 Tender, as are muscles. 
 
 Unknown; glossy skin more common. 
 
 Almost unknown ; toxemic vomiting, etc. 
 
 Very rarely, if ever, and from delirium, 
 etc. 
 
 Eapid. 
 
 Eecovery usual, if not early death. 
 
 Poliomyelitis . vs.- 
 
 Usually in children. 
 
 More sudden onset. 
 
 Embraces whole limb; random distribu- 
 tion. 
 
 Muscles functionating together. Eeac- 
 tion of degeneration in both, but 
 strong galvanic current not required 
 (during first months) to produce 
 muscular contraction. 
 
 Pain and tenderness most rare. 
 
 Sensory disturbance rare. 
 
 Immediate tendency to regress, but al- 
 ways some deformity. 
 
 Multiple Neuritis. 
 
 In adults. 
 
 Less acute. 
 
 Peripheral and symmetrical. 
 
 Dissimilar muscles involved. 
 
 Muscles respond only to strong galvanic 
 current. 
 
 Common in nerves and muscles. 
 
 Usually (but not invariably) present. 
 
 Tendency to progress. 
 Total recovery the rule. 
 
 In acute myelitis the onset is acute, there are girdle pains, para- 
 plegia, with corresponding anaesthesia, bed-sores, disturbance of the 
 bladder and rectum; there is no tenderness of the nerves or muscles, 
 
NEtJBOMA. 1081 
 
 little or no ataxia and recovery is unusual. Landry's paralysis often 
 cannot be distinguished (one form of Landry's disease is neuritic) ; 
 sensory, trophic and sphincter changes are absent. 
 
 Treatment. — In the etiological therapy alcohol must always be con- 
 sidered and deception guarded against; it should be withdrawn at 
 once. In sepsis, Gowers gives full doses of iron. For treatment of 
 pain see Neuritis. Absolute rest should be enforced. A full diet, 
 rich in fats, should be given if the stomach can tolerate it; tonics 
 should be given to maintain nutrition, but arsenic should be avoided. 
 When the lower cranial nerves are affected, feeding by the nasal tube 
 or by rectum, measures to avoid hypostasis, as in typhoid, and cardiac 
 stimulants are indicated. To overcome contractures from ankle- or 
 wrist-drop, splints or sand-bags should be employed when they do not 
 cause excessive pain. The weight of the bedclothes on the feet may 
 promote contractures, whence frames to lift the bedding should be 
 used. Gentle massage and voltaism may be tolerated after the acute 
 stage, may prevent contractures and may aid the return venous now. 
 Bromides and chloral are the most certain somnifacients, but chloral 
 must be used with care in chronic alcoholism. Orthopedic measures 
 are indicated in neglected contractures. 
 
 NEUROMA. 
 
 Two varieties of neuroma exist, the true and the false. The true 
 neuroma may be medullated or non-medullated, though ganglion cells 
 are exceptional (only 3 cases are recorded) ; they are usually multiple, 
 sometimes very numerous (3,020 in one case) and have been found 
 in instances on every cranial, spinal and sympathetic nerve. They 
 may undergo sarcomatous degeneration. The tubercula dolorosa 
 (Virchow) are small, painful, subcutaneous nodes on the trunk or 
 extremities, the anatomy of which is not well understood. The 
 neuroma plexiforme consists of twisted cords with nodes, is congenital 
 and occurs largely in the distribution of the fifth nerve. The false 
 neuroma is usually fibrous ; glioma is rare ; sarcoma or carcinoma may 
 by contiguity invade adjacent trunks; neuromata have been found 
 in the cerebral nerves in syphilis and in the peripheral nerves in 
 leprosy. The nerve trunks suffer more in the false than in the true 
 form. Neuromata in amputation stumps are frequent. 
 
 Symptoms and Treatment. — There may be no symptoms; local ten- 
 derness and local or projected pain are frequent. Reflex muscular 
 spasm is common from nerve irritation. Mentality, sensation or 
 motility may be affected. Pigmentation has occurred. Diagnosis is 
 certain only when the growths are felt. Treatment is symptomatic 
 for the exhausting pain or radical in localized growths. Recurrence 
 is not infrequent. 
 
1082 DISEASES OF TEE NERVOUS SYSTEM. 
 
 DISEASES OF CRANIAL NERVES. 
 
 Olfactory Nerve. — The end nerves of smell are located on the two 
 upper turbinate bodies and the upper septum ; thence they run to the 
 olfactory bulbs, which are really part of the brain. The central 
 connections are not well understood. The centre is thought to be in 
 the uncinate gyrus and the hippocampus, with relations to the optic 
 thalamus, opposite internal capsule and cerebral cortex. The anterior 
 nares perceive odors, the posterior, flavors. 
 
 Anosmia is loss of smell. Tests are made not with pungent sub- 
 stances, as ammonia, which irritates the fifth nerve, but with musk, 
 asafcetida, cologne water and the essential oils, (a) Disease in the 
 nasal mucosa is the most frequent cause ; it may result from paralysis 
 of the fifth nerve, arrest of secretion or atrophy. (&) Disease may 
 result from congenital absence of the bulb, basal fracture or menin- 
 gitis, tabes, foci in the opposite internal capsule, etc. (c) Central 
 disease may be located in the hippocampus and uncinate convolution, 
 as softening. The prognosis is usually unfavorable and treatment is 
 ineffectual. Kyperosmia, or oversensitiveness of smell, occurs in in- 
 sane and neurotic subjects; it may be cultivated, so that individuals 
 are recognized by their odor. Parosmia, or perverted sensation, is 
 rare and arises from irritation of the nerves or centres. Hallucina- 
 tions of smell may occur. Imaginary odors, as of burning flesh, may 
 constitute the epileptic aura. 
 
 Optic Nerve. — 1. The Retina. — Retinitis occurs in general diseases, 
 as nephritis (in 20 per cent.), especially in interstitial forms and late 
 in the disease rather than early. The degenerative form is most 
 common, the next is the hemorrhagic form, with " flame-like " hem- 
 orrhages along the vessels, and finally the inflammatory type, with 
 swelling of the retina, serum exudation, cloudiness and disk blurring, 
 which may be as marked as that of brain disease ; the white foci are 
 due to exudation, fatty change or sclerosis. Similar findings may 
 occur in syphilis, anaemia, malaria, leukaemia, plumbism, diabetes, etc. 
 (see Plates VII and VIII). There are apparently primary cases. 
 2. Optic Nerve. — Optic neuritis (papillitis, choked disk) has been 
 fully described and differentiated (see Brain Tumor and Plates 
 VII and VIII). Tumors or inflammation in or back of the orbit may 
 be causal. Errors in refraction must be excluded. In the primary 
 form there is no initial inflammation. The edges of the disk are dis- 
 tinct, its arteries nearly normal and its color grayish ; it may develop 
 hereditarily in males at puberty ; it occurs in tabes, paretic dementia, 
 multiple sclerosis, syphilis and less often from exposure, excesses, 
 diabetes, alcoholism, plumbism, the specific fevers, amaurotic family 
 idiocy and familial cerebellar ataxia. The form secondary to inflam- 
 mation commonly follows choked disk and has the same significance ; 
 the disk has an irregular contour, small arteries and is translucent. 
 The symptoms are diminution in acuity of vision, field of vision, 
 color perception and the pupillary reaction. 
 
PLATE XXI 
 
 VISUAL 
 
 *> WSUAL** 
 
 Visual Paths. (After Vialet.) 
 
 OPN optic nerve. OP.C, optic chiasm. OP.T., optic tract, OP.R., optic radiation. V.S., visual 
 soeecn centr A lesion at (1) causes total blindness in that eye; lesion at (2), bitemporal hem - 
 Jnop4 aV (3) unilateral nasal, and lesions at (3) and (3A), bilateral nasal hemianopsia; at (4) 
 Wianops a of bo"th eyes and the hemianopsic pupillary reaction; at (5) or (6),. hemianopsia .of t >oth 
 eyS (pupillary reflexes being noimal; at (7), amblyopia, especially of the opposite eye, at (8), word- 
 blindness. 
 
DISEASES OF THE CBANIAL NEBVES. 1083 
 
 3. Chiasm. — Each half of the retina contains fibers from the corre- 
 sponding occipital lobe (see Plate XXI), that is, each right half 
 receives fibers from the right and each left half from the left occipi- 
 tal lobe. The point of sharpest vision, the macula, receives over- 
 lapping fibers from both sides of the brain. The outer temporal portion 
 of the field of vision is more limited than the inner nasal portion, be- 
 cause the nose cuts off light and it receives fewer nerve fibers. The 
 larger number of fibers from each eye, *. e., those from the nasal 
 retinal half, decussate at the chiasm and lie in its center. Those from 
 the temporal half are direct and lie at the side of the chiasm. While 
 disease of one optic nerve causes blindness in the corresponding eye, 
 lesions affecting the centre of the chiasm (decussating fibers to the 
 nasal half of each retina) cause half blindness in the opposite (tem- 
 poral) visual fields, bitemporal hemianopsia, since oblique rays pass- 
 ing the pupil fall on the opposite half of the retina. The macula 
 receives fibers from both sides of the brain and escapes involvement. 
 Temporal hemianopsia may result from tumors of the pituitary gland, 
 pressure from the third ventricle, gummata and hemorrhage. The 
 " oscillating " or varying bitemporal hemianopsia is often indicative 
 of syphilis. The diagram illustrates effects of lesions of the lateral 
 part of the chiasm (3), lesions affecting both sides of the chiasm 
 (3 and 3A), as calcareous or aneurysmatic carotids; binasal hemi- 
 anopsia is most exceptional; a large lesion might produce temporal 
 hemianopsia in one eye and total blindness in the other; still more 
 extensive disease might produce total blindness; these changes may 
 be successive. 
 
 4. Optic Tract. — Just back of the chiasm the temporal fibers of the 
 right and the nasal fibers of the left side form the right optic tract, 
 i. e., the right tract contains all fibers from the right half of each 
 retina. The tract runs over the crus cerebri, where a lesion very often 
 causes hemiplegia on the same side as the blind field. The fibers 
 enter the geniculate bodies (in which 80 per cent, of the optic fibers 
 end), opt. thalamus and ant. quadrigeminate body, from which gray 
 ganglia the fibers pass by way of the posterior limb of the internal 
 capsule and, by radiating fibers (optic radiation), to the visual centre 
 in the posterior internal part of the occipital lobe, the cuneus. A le- 
 sion (at 5, in diagram) in the optic tract anywhere between the 
 chiasm and cuneus produces lateral or homonymous hemianopsia; 
 for instance, if it occurs in the right optic tract it produces loss of 
 function in the temporal half of the right and nasal half of the left 
 retina, so that the left half of each field of vision is lacking. Hemi- 
 anopsia may be partial and may involve only a quadrant, or only a 
 quadrant may remain after partial recovery. The unaffected fields 
 may suffer some reduction. Heteronymous hemianopsia designates 
 blindness of the right half of one field and the left half of the other 
 or the converse. Disease in the gray ganglia or internal capsule may. 
 produce contralateral hemiplegia; in 50 per cent, of cases of hemi- 
 anopsia this association is observed, and less frequently hemianses- 
 
1084 DISEASES OF THE NEBVOUS SYSTEM. 
 
 thesia. Transient hemianopsia is sometimes seen in migraine. The 
 optic tract is injured in tumors, multiple sclerosis, trauma, hemor- 
 rhage or softening. 
 
 5" Optic Centre (See Cerebral Localization). — A lesion in the 
 cuneus produces (a) homonymous hemianopsia. Sometimes only an 
 upper quadrant is blind (disease in the upper part of the cuneus) or 
 the lower quadrant is blind (disease in its lower part). Purely cor- 
 tical hemianopsia is impossible, and ITonakow held that the optic 
 radiation must be involved; (b) hemichromatopsia, or homonymous 
 color blindness or confusion, in which all colors seem gray, is prob- 
 ably due to lesion of the anterior superficial cuneal cortex. Other 
 results are (c) mind blindness, or loss of visual memory; (d) alexia 
 or word blindness; (e) optic aphasia; and (/) crossed amblyopia, 
 concentric blurring or limitation of the visual fields for form and 
 color ; this is usually referred, however, to disease of the gyrus angu- 
 laris, in which there is thought to be a higher centre in which the half 
 fields are combined and the whole opposite field and part of the field 
 of the same side are represented. 
 
 Diagnosis. — The eyes should be tested separately. Disease of an 
 optic nerve causes loss of sight and pupillary reaction in the corre- 
 sponding eye. Central scotoma (blindness in the centre of the visual 
 field) indicates inflammation or hemorrhage in the central (axial) 
 fibers of the nerve, usually back of the orbit ; it is common in poison- 
 ing from tobacco and alcohol. Peripheral limitation of the visual 
 fields indicates damage to fibers coursing in the periphery of the 
 optic nerve and some damage to all the nerve fibers. Sectorial blind- 
 ness indicates a pronounced but circumscribed affection of the nerve. 
 Bitemporal hemianopsia always results from chiasm disease; uni- 
 lateral temporal hemianopsia in one eye with complete blindness in 
 the other has the same significance, but also implies that the process 
 has extended laterally, possibly even to the optic tract, Lateral 
 homonymous hemianopsia indicates disease of the optic tract between 
 the chiasm and cuneus. If the geniculate (or quadrigeminate) bodies 
 are the seat of the lesion, Wernicke's hemianopsic pupillary reaction 
 is obtained, because the pupil reflex, while not at present perfectly 
 understood, implies that the retina, the optic nerve, the centre and 
 fibers of the third nerve and the iris are intact. A small beam of 
 light in a dark room should be thrown on the hemianopsic half of the 
 retina and the patient should look at a distance to eliminate accom- 
 modation.^ If the pupil does not react to light on the blind half, 
 Wernicke's reaction indicates that the disease focus lies at or some- 
 where to one side of the geniculate (or quadrigeminate) bodies. If 
 the lesion lies between these gray ganglia and the cortex, the reaction 
 of Wernicke is absent. Transient hemianopsia is common in vascular 
 lesions; if it lasts for weeks it will probably remain. In Sequin's 
 case it was present for twenty-three years. It may occur in migraine 
 and very rarely in hysteria. Its association with the crus, internal 
 capsule or cortex symptoms which have been already considered is of 
 
DISEASES OF THE CEANIAL NEEVES. 1085 
 
 localizing importance. Amblyopia and concentric limitation in the 
 fields, marked in one eye and less in the other, may result from (a) 
 optic atrophy, with the absent pupillary reaction, and seen with the 
 ophthalmoscope; (6) disease of one hemisphere, the ophthalmoscopic 
 finding and pupillary reflex being normal (or (c) possibly func- 
 tional disease). 
 
 Functional and Toxic Blindness. — (a) Hysterical blindness is 
 transitory and rarely complete (the eye functionates normally though 
 the visual centre neglects the impressions) ; it is often associated 
 with loss or inversion of the color perception and often with hemi- 
 anaesthesia. (&) In amblyopia from tobacco, vision is gradually im- 
 paired in both eyes, largely as central scotoma with invariable loss of 
 perception for red and green colors ; the fundus is usually normal but 
 sometimes congested; recovery is usual, but atrophy may result, (c) 
 Toxic amaurosis, usually transitory, may occur from uraemia, poison- 
 ing by lead, alcohol or quinine, syphilis, acute anaemia and irritation 
 of the fifth nerve. 
 
 Ocular Paralysis ; Third, Fourth and Sixth Nerves. — General Etiol- 
 ogy. — (a) Trauma to the eye, orbit or base may cause ocular paraly- 
 sis ; it is characterized by a slow course and often imperfect recovery. 
 (b) Compression by tumors in the orbit which often produce exoph- 
 thalmos; tumors at the base, aneurysm and rarely hemorrhage into 
 the nerve sheath may produce it. (c) Neuritis produced by the above 
 factors, orbital cellulitis, meningitis, syphilis, cavernous thrombosis, 
 alcoholism and rheumatism, which is made to cover many obscure 
 cases, may be etiological factors. Neuritis may also result from acute 
 infections, as diphtheria; exophthalmic goitre, plumbism and dia- 
 betes are rarer causes, (d) Nuclear disease is usually due to chronic 
 wasting disease, as in tabes, multiple sclerosis or bulbar palsy, but it 
 is sometimes acute from polio-encephalitis or vascular lesions, (e) 
 Supranuclear disease (v. i. Conjugate Deviation) may be a cause. 
 (/) In rare cases there is a myopathic form, as in muscular dystrophies. 
 
 Anatomy and Physiology of the Motor Nerves of the Eye. — The nerve 
 supply is by the sympathetic (which through the ciliary ganglion 
 dilates the pupil) and by the third, fourth and sixth cranial pairs, 
 which arise from the middle ventricle, Sylvian aqueduct and fourth 
 ventricle and are arranged as follows from before backward: (a) 
 the third nerve nucleus with first the ciliary and behind it the pupil- 
 lary centre, then its muscles in this order : the internal rectus, levator 
 palpeb. superior, inferior rectus and inferior oblique; (b) fourth 
 nerve nucleus for the superior oblique, lying close to the third nucleus, 
 and (c) nucleus of the sixth nerve for the ext. rectus. Their con- 
 nection with the motor cortex (and possibly with the occipital and 
 parietal lobes) is through the internal capsule and corona radiata. 
 The third nucleus is connected with the seventh ; winking and move- 
 ments of the eyelid are thus associated with the pupil reaction and 
 accommodation. The action of the various muscles is indicated by 
 
1086 DISEASES OF TEE NERVOUS SYSTEM. 
 
 their names but convergence is supplemented by the sup. and inf. 
 recti and the two oblique muscles. The inf. oblique turns the eye up- 
 ward, the sup. oblique downward. The upper lid is raised by the 
 levator palp. sup. (acting usually with the sup. rectus) and by 
 Muller's muscle. 
 
 Paralysis of the Third Nerve. — This nerve emerges from the crus 
 and follows the cavernous sinus, and therefore may be involved in 
 disease of these structures. A complete paralysis involves all muscles 
 save the external rectus and sup. oblique and results in drooping of 
 the lid (ptosis), which the patient attempts to overcome by over action 
 of the frontalis. The eye can be moved only outward and a little 
 down and inward. Accommodation is lost, the pupil is wide from the 
 unopposed action of the sympathetic nerve and does not react to light. 
 There is double vision from divergent strabismus, due to action of the 
 unrestrained ext. rectus muscle. Paralysis is often partial, for the 
 levator palp. sup. may escape involvement or be affected alone or with 
 its associate (the sup. rectus), especially in bilateral nuclear disease. 
 Ptosis may be (a). part of an ordinary oculomotor palsy; (b) part of 
 a chronic ophthalmoplegia (v. i.) ; (c) reflex in rare cases of trigemi- 
 nal irritation, as from disease of the teeth; (d) myopathic, as in 
 muscular dystrophy; (e) sl result of sympathetic paralysis, false or 
 pseudoptosis (with a red, hot, oedematous skin, slight recession of the 
 eyeball and contracted pupil) ; (/) an incurable congenital form, 
 usually partial and bilateral; (g) a transient form, observed in the 
 morning in women, usually with a good prognosis; (h) an hysterical 
 form, usually bilateral, in various associations with the sup. rectus, 
 inf. or int. rectus, the eyebrow being frequently lower on the side of 
 ptosis. 
 
 Internal Oculomotor Palsy. — Internal oculomotor palsy in- 
 cludes cycloplegia and iridoplegia. (a) Cycloplegia (paralysis of the 
 ciliary muscle) results in loss of accommodation. Near vision is 
 poor, distant vision is good; extreme myopia or presbyopia make its 
 detection difficult. Isolated cycloplegia in one eye may indicate dis- 
 ease of the lenticular ganglion, in both eyes it is nuclear, as in diph- 
 theria or tabes, (b) Iridoplegia may assume three forms (Gowers). 
 The first is loss of associated action, accommodation iridoplegia, in 
 which there is no pupillary narrowing in the act of accommodation. 
 It is due to the same causes as cycloplegia and is usually but not 
 always associated with it. The second is loss of the light reflex, reflex 
 iridoplegia, the Argyll-Robertson pupil, which is seen especially in 
 tabes and paretic dementia (very seldom in softening, tumors, senile 
 atrophy, hydrocephalus or congenitally). The reflex occurs through 
 the optic nerve, optic tracts, corp. quadrigemina or corp. geniculata, 
 anterior part of the oculomotor nucleus, probably the second branch 
 of origin of the third nerve, its trunk, the ciliary ganglion and its 
 nerves. The pupils are often equally affected and small (spinal 
 myosis) but may be unequal (aniscoria, also observed in some normal 
 persons). If the pupils are not small, cutaneous iridoplegia is not 
 
DISEASES OF THE CRANIAL NERVES. 1087 
 
 present. The third form is loss of the skin reflex, the cutaneous irido- 
 plegia of Erb, in which the normal dilatation of the pupil upon 
 pinching, sticking or faradizing the skin of the neck is lost. It indi- 
 cates, in general terms, disease in the cervical sympathetic nerve, in 
 the fibers between it and the cervical cord, diseases of the cord, espe- 
 cially those affecting sensation, or of the centre, probably situated in 
 the corp. quadrigemina just outside the light reflex centre in the 
 trunks of the first and third nerves. The seat of lesion is probably 
 nuclear, unless special localizing symptoms indicate some other local- 
 ization. Specifically it is characteristic of tabes,, paretic dementia 
 or syphilis. 
 
 Recurrent or Periodic Palsy. — Eecurrent or periodic palsy, to which 
 Gubler (1860) and Mobius particularly drew attention, is a rare 
 form, involving chiefly most (or possibly only one branch) of the 
 third nerve, and rarely the sixth nerve. It occurs chiefly in women, 
 xit intervals of months to years, possibly throughout life, a recurring 
 paralysis develops, lasts a few days or weeks and then disappears. 
 Forms which begin with headache, pain and vomiting were called 
 ophthalmoplegic migraine by Charcot. Its nature is unknown. It 
 is probably peripheral in form (Mauthner), although Mobius thinks 
 it is nuclear; von Monakow considers that its usual cause is tumor, 
 meningitis or tubercle; the lesion affects the eye nerves (or centres) 
 and also the descending branch of the fifth nerve; some few cases 
 are seemingly hysterical. 
 
 Paralysis of the Fourth (Trochlear) Nerve. — The superior oblique 
 muscle moves the eye downward and somewhat inward. Its paralysis 
 is of little clinical importance. In attempts to converge downward 
 the normal inward rotation of the eyeball is lacking. 
 
 Paralysis of the Sixth Nerve. — The eye cannot be moved outward, 
 and is rotated inward by the unopposed internal rectus, marked diplo- 
 pia resulting. This nerve is frequently involved, because of its long 
 and exposed course. The muscles of the eye are involved in the 
 following order of frequency: 1, ext. rectus; 2, sup. oblique; 3, inf. 
 rectus; 4, sup. rectus; 5, int. rectus; 6, inf. oblique (von Grafe). 
 
 Combined Eye Paralysis. — Convergence and accommodation are as- 
 sociated functionally and their centres lie adjacent, whence they are 
 often lost together. The internal recti may fail to contract together 
 but may move separately in lateral eye movements. Conjugate devi- 
 ation may occur (see Brain Hemorrhage and Pons Localiza- 
 tion) ; if a lesion occur above the sixth nucleus, the eyes cannot be 
 directed toward the side of lesion and are, therefore, directed toward 
 the paralyzed side ; if the lesion is at the sixth nucleus the sixth nerve 
 on that side is paralyzed, often also the seventh, and the opposite 
 third nerve is paralyzed, not from lesion in the third nucleus but 
 from the fact that each third nucleus receives afferent impulses from 
 the contralateral sixth nucleus for associated eye movements. 
 
 Symptoms. — The general symptoms of paralysis of the eye muscles 
 are iive (Gowers) : 
 
1088 DISEASES OF TEE NERVOUS SYSTEM. 
 
 1. Limitation of movement in the paralyzed muscle, followed by 
 secondary contraction of the unresisted opponent. The habitual 
 position 'of the head corresponds in every way to the physiological 
 action of the paralyzed muscle (Landholt). 
 
 2. Strabismus (squint), causing lack of parallelism in the visual 
 axes, which are divergent when the int. rectus and convergent when 
 the ext. rectus is affected ; this constitutes the primary deviation. 
 
 3. Secondary deviation is the extra movement of the sound eye in 
 its efforts to see, due to its increased innervation, detected by testing 
 with the diseased eye closed or by testing with ground glass over the 
 sound one. 
 
 4. Erroneous projection in the paralyzed eye. Distance is nor- 
 mally judged by the position of the eyeballs and muscles and there- 
 fore * when secondary deviation from excessive innervation of the 
 sound muscles occurs, it gives the mind an impression of distance 
 greater than is actually the case. 
 
 5. Diplopia (double vision) results from failure of the visual axes 
 to correspond. The sound eye sees the true image, while the par- 
 alyzed eye sees the false one, which is less clear, since the image falls 
 on a less sensitive retinal area. When the images are either near 
 together or else widely separated the false one may be " neglected." 
 Erroneous projection and diplopia always produce vertigo at first. 
 If the false image is on the same side of the true image as the eye by 
 which it is seen, the diplopia is simple or homonymous ; if on the 
 other side, it is crossed or heteronymous. The eyes are tested by hold- 
 ing red glass before one eye and testing vision with a strip of white 
 
 paper. If the red image and covered eye are on the same side the 
 diplopia is simple; if on opposite sides it is crossed. When the eyes 
 converge it is simple, when they diverge it is crossed ; i. e., " when 
 the prolonged visual axes cross, the diplopia is not crossed." Hold- 
 ing the test object stationary and the head being turned in one way 
 or another, in some directions the images converge or perhaps blend, 
 while in the opposite direction they separate. " The affected eye is 
 that one in the direction of whose image the diplopia increases; the 
 paralyzed muscle is the one which would give to the eye the direction 
 of the false image" (Landholt). Monocular diplopia is almost in- 
 variably hysterical (unless there is disease of the eye media or error 
 in curvature). 
 
 Treatment. — Treatment is often unsatisfactory from the etiological 
 standpoint. Surgical interference is sometimes indicated. Syphilitic 
 forms (q. v.) may respond to specific treatment, but often recur or 
 become permanent. In subacute or acute forms counterirritation back 
 of the ear by blisters, leeches or hot fomentations is indicated. Some 
 find mercury useful in peripheral forms. Galvanism is the best form 
 of electrotherapy, but may be painful and is seldom beneficial. 
 Prisms and tenotomy are sometimes helpful. 
 
 Progressive Nuclear Ophthalmoplegia (Nuclear Palsy). — This dis- 
 ease was first described clinically by von Grafe (1856) and later 
 
DISEASES OF TEE CRANIAL NEBVES. 1089 
 
 pathologically by Hutchinson and Gowers. The etiology is not clear. 
 Wernicke and Siemerling found syphilis causal in 17 per cent., which 
 estimate is too low, according to Hutchinson. Lead, alcohol and 
 toxaemia, as from diabetes, grippe or diphtheria, are possible causes. 
 A few cases are hereditary or congenital. Most cases develop in 
 males under thirty years of age. The 'pathology usually consists of 
 degenerative nuclear atrophy resembling bulbar paralysis ; sometimes 
 slow compression or meningitis is found or much more rarely no 
 anatomical alteration is detected, the so-called functional form. 
 
 Symptoms. — The symptoms are those of a slowly progressive par- 
 alysis of the eye muscles ; ophthalmoplegia is called external when it 
 involves the extrinsic muscles, internal when it involves the pupil, or 
 total when both are concerned. The eye muscles are successively 
 affected, but in no given order, until many or all are implicated. The 
 fades of Hutchinson is peculiar, staring, from immobility of the eye- 
 balls, or sleepy from partial bilateral ptosis. Diplopia is uncommon, 
 or only an early symptom, because of the chronicity of the process. 
 Associated muscles are often affected by groups, because of their 
 successive nuclear involvement (v. s. Anatomy) ; as the pupil and 
 convergence, one internal and the opposite external rectus, the two 
 internal recti and the sup. rectus and the levator. Chronic ophthal- 
 moplegia may be associated with the analogous bulbar paralysis or 
 progressive spinal muscular atrophy; with optic atrophy or with 
 double facial paralysis (the rare and obscure infantile or congenital 
 oculofacial paralysis, without pupillary involvement, of which Mobius 
 has collected 44 cases) ; it may be a part or a precursor of tabes, para- 
 lytic dementia or multiple sclerosis. 
 
 Diagnosis. — Nuclear involvement is probable when there is (a) 
 partial and bilateral ptosis; (b) no involvement of the pupil; or (c) 
 involvement of one or more conjugate groups. The lesion may be 
 supranuclear, when the head and limbs are involved, exceptionally 
 when there is isolated convergence paralysis or paralysis of up-and- 
 down movements with ptosis. Sudden apoplectiform nuclear palsy 
 from basilar thrombosis is usually asymmetrical, acute and often 
 associated with hemiplegia. Wernicke's acute superior poliencephal- 
 itis is distinguished by its acuity and toxaemic symptoms. Ophthal- 
 moplegia may result from syphilitic meningitis, polyneuritis, tumors 
 (corp. quadrigem.) and orbital disease, but they are generally distin- 
 guished by their relatively acute course and concomitant symptoms. 
 
 Prognosis. — The disease is very chronic, possibly lasting twenty to 
 forty years and is progressive. Arrest is possible, but can never be 
 predicted. The disease itself causes little risk to life, but its associ- 
 ates are dangerous, as tabes or psychoses, which develop in 18 per cent. 
 
 Treatment. — Treatment is generally ineffectual. Iodides and mer- 
 cury are useless in nuclear disease, but may be given if the localiza- 
 tion is not definitely known. Strychnia and galvanism produce little 
 result. 
 
 Sympathetic Paralysis. — This disease was first described by Hor- 
 
1090 DISEASES OF THE NEEVOUS SYSTEM. 
 
 ner; it produces myosis, due to paralysis of the dilator iridis, and 
 slight ptosis, due to paresis of Miiller's muscle. The ocular tension 
 is decreased, the cheek wasted and the skin reddened and warmer 
 than normal. Irritation of the sympathetic is characterized by wide 
 pupils, widening of the interpalpebral space and by exophthalmos. 
 
 Ocular Muscular Spasms. — Ocular muscular spasms occur in con- 
 jugate deviation, irritation of their nerve trunks when compressed by 
 tumor, and rarely in chorea, facial tic and spasmodic torticollis. In 
 hysteria the eyes may be rolled upward and to one side, concealing 
 the iris, or they are often fixed in convergence ; they never diverge ; 
 there may appear to be ptosis, which is really spasm of the orbicularis. 
 Convergent spasm may also occur in hypermetropia and divergent 
 spasm in myopia. Isolated spasm of the levator palpebral may occur 
 in irritation of the cervical sympathetic nerve, in advanced years, in 
 Graves' disease and in irritation of the fifth nerve. Secondary devi- 
 ation (v. s.) is spasmodic, as is also nystagmus, which latter consists 
 of rapid, rhythmic, clonic, involuntary oscillations, due to muscular 
 spasm with alternating contraction of the opposing muscles. It is 
 continuous, as distinguished from the " tremor of weakness " which 
 occurs in paretic muscles on movement. It is usually horizontal, less 
 often rotatory and but rarely vertical. Its physiology is not under- 
 stood, but it is probably centric. The causes are (a) disease of the 
 eye, as opacities and choroiditis; (h) it occurs very frequently in 
 albinos, and (c) in miners, from working with the head down and 
 eyes strained to one side, (d) It also occurs in numerous, usually 
 degenerative nervous diseases ; as a cardinal sign in multiple sclerosis 
 and Friedreich's ataxia, as a common sign in tumor of the cerebellum, 
 corp. quadrigem. and opt. thalamus, occasionally in meningeal inflam- 
 mation or hemorrhage, sinus thrombosis, brain hemorrhage or soften- 
 ing and very rarely in hysteria. 
 
 Fifth Nerve (Trigeminus; Trifacial Nerve). — The nerve origi- 
 nates from its motor nucleus in the pons, from fibers (which are 
 probably motor) descending from beneath the corpora quadrigemina, 
 and from sensory fibers ascending from the medulla. It is connected 
 with the motor cortex and with the cerebellum. The motor and sen- 
 sory fibers leave the pons separately and join only after the sensory 
 trunk has passed through the Gasserian ganglion. The Gasserian 
 ganglion has three branches; (1) which passes to the orbit by the 
 sphenoidal fissure, supplying the skin of the forehead, anterior scalp, 
 upper lid, bridge and top of the nose; it is connected with the cervical 
 sympathetic nerve; (2) which passes by the foramen ovale to the 
 sphenomaxillary fossa to supply the upper and lower lids, cheek, fore 
 part of the temples, side of the nose, upper teeth, gums, pharynx, 
 tonsils, soft palate, uvula and roof of the mouth ; it has connections 
 with the facial nerve by the Vidian and with the sympathetic nerve; 
 (3) which passes by the foramen rotundum and sphenomaxillary 
 fossa supplying the rest of the temples, anterior and upper part of the 
 
DISEASES OF THE CBANIAL NEBVES. 1091 
 
 ear, auditory meatus, lower cheek near the mouth, lower lip, lower 
 teeth, gums, chin, tongue, mucosa of the mouth, salivary glands, and 
 as a motor nerve to the muscles of the lower jaw, temporals, masseters, 
 pterygoids, mylohyoids and post, belly of the digastric muscle. The 
 lingual branch gives off the chorda tympani which joins the facial 
 nerve. From the otic ganglion arises the small superficial petrosal 
 nerve which connects with the facial nerve and ends in the tympanic 
 branches of the glossopharyngeal nerve. 
 
 Causes of Paralysis. — (a) Lesions of the cortex in very rare cases. 
 (b) Focal disease in the pons, especially of the nerve-root fibers, as 
 hemorrhage and tumors and much less often degenerative lesions, as 
 tabes or bulbar paralysis, (c) Diseases of the base, as syphilis, men- 
 ingitis, tumors, caries or aneurysms, (d) Affections involving any 
 of the three branches, as of the first branch by cavernous thrombosis, 
 pituitary tumor, aneurysm or orbital disease, or of the second and 
 third branches by lesions in the sphenomaxillary fossa, (e) Trauma, 
 puncture or bullet wounds, but rarely fractures, and (/) infrequently 
 neuritis, unless it is secondary. 
 
 Symptoms. — 1. Sensory Portion. — Anaesthesia, generally uni- 
 lateral, is found in one or all branches, and tactile sensation is more 
 involved than the sense of pain. It is often preceded by tenderness 
 along the nerves, irritation or neuralgia. In complete cases the skin 
 and mucosa of the mouth, nose and conjunctiva are anaesthetic. The 
 tongue is furred on its anaesthetic half, because the food is not chewed 
 on that side. The conjunctival reflex is abolished. The secretions 
 are increased by irritation or decreased by paralysis. Smell is 
 blunted and taste is lost (v. i.). Sometimes there is redness, cyanosis 
 or swelling of the face or the teeth may be loosened. Two trophic 
 manifestations are especially important. The first is neuroparalytic 
 ophthalmia, which may run beyond simple inflammation of the eye 
 into ulceration or complete loss of the bulb ; it is due not simply to 
 conjunctival anaesthesia, which may lead to inflammation because of 
 foreign particles remaining unnoticed in the eye, but is rather due to 
 irritation of the fifth nerve, especially of the Gasserian ganglion or 
 nerve trunks anterior to it. (It has not occurred, however, in many 
 cases in which the ganglion has been surgically removed. ) It is rare 
 in lesions of the pons. The second is herpes zoster, which is most 
 common in disease of the first branch, results from irritation of the 
 Gasserian ganglion or the nerves just anterior to it, is often preceded 
 by pain and hyperesthesia and sometimes leads to iritis or ophthal- 
 mitis. For the relation of trigeminal disease to facial hemiatrophy 
 see below. 
 
 2. Motor Portion. — Placing the fingers on the temporal and 
 masseter muscles, when the patient attempts to close the teeth, reveals 
 their failure to contract. Paralysis of the ext. pterygoid is shown (a) 
 by failure to move the jaw toward the sound side and (b) by deviation 
 toward the paralyzed side, when the jaw is depressed. The muscles 
 waste, but they are too deep to distinctly elicit the reaction of de- 
 
1092 DISEASES OF TEE NERVOUS SYSTEM. 
 
 generation, and the role of the tensor tympani and tensor palati in 
 trigeminal paralysis is still in dispute. 
 
 3. Gustatory Portion. — The sense of taste covers only bitter, 
 sweet, sour, salty and metallic substances, while flavors are recognized 
 by the olfactory nerve. The tip and edges of the tongue detect salti- 
 ness or sourness ; the base of the tongue, bitterness and sweetness. It 
 is often stated that the fifth nerve supplies the anterior two-thirds of 
 the tongue and the glossopharyngeal nerve the posterior third and the 
 palate ; but disease of the glossopharyngeal nerve alone does not de- 
 stroy the sense of taste. In a study of 26 cases of extirpation of the 
 Gasserian ganglion, Cushing decides that taste is only temporarily 
 lost and that it does not travel by the fifth nerve. Disease of the 
 lingual nerve (from the fifth), after the chorda tympani joins it, 
 produces loss of taste (ageusia) ; disease of the lingual above the 
 juncture or disease of the central part of the fifth in the pons does 
 not result in loss of taste. It is thought that the gustatory fibers of the 
 fifth run with the chorda to the seventh nerve which they leave by the 
 petrosal nerve to again reach the fifth through Meckel's ganglion. It 
 is interesting to note that anaesthesia of the tongue may result from 
 facial neuritis and disease of the middle ear. 
 
 Diagnosis. — The diagnosis is usually easy when there are motor or 
 sensory symptoms. Organic irritation characterized by pain alone 
 may be difficult or impossible to differentiate from trifacial neuralgia, 
 although Gowers holds that there is less radiation and more hyper- 
 esthesia in organic irritation. Localization: When all branches are 
 anaesthetic the disease probably lies at the base of the brain or in the 
 Gasserian ganglion. In disease of the middle part of the pons the 
 first division alone may be affected ; in disease at its side all divisions 
 are involved, often with implication of the third and sixth or less 
 often of the seventh and eighth nerves. Cortical lesions are ex- 
 tremely uncommon. 
 
 Treatment. — Counterirritation over the occiput or mastoid is in- 
 dicated by an inflammatory causation, but no irritant should be 
 applied over the anaesthetic areas themselves, lest ulceration occur. 
 Galvanization is said to be beneficial. Gelsemium, cocaine and mor- 
 phine must at times be used because of severe pain, but the acqui- 
 sition of drug habits must always be borne in mind. The eye should 
 always be watched and boric acid and castor oil be dropped in several 
 times daily. Antisyphilitic remedies should be tried in every doubt- 
 ful case. 
 
 Masticatory Spasm. — The masticatory spasm of Eomberg is not 
 common. In the tonic type (trismus) the spasm is usually bilateral 
 and the tense muscles are hard and may be tender. The cause may be 
 tetanus, hysteria, epilepsy, tetany, tumor in the pons, cortical hemor- 
 rhage, or it may be reflex from trigeminal irritation, as from dental 
 caries. The clonic type is rare and may be serial or intermittent; 
 chattering of the teeth is an example. It may occur in chorea, epi- 
 lepsy or hysteria. Grinding of the teeth occurs in paretic dementia, 
 
DISEASES OF THE CRANIAL NERVES. 1093 
 
 meningitis or typhoidal states. In diagnosis, tumor, inflammatory 
 irritation and disease of the temporomaxillary joint must be con- 
 sidered. Treatment consists of tonics in nervous subjects, galvaniza- 
 tion, blisters in hysteria and the local use of morphine and cocaine. 
 
 Progressive Facial Hemiatrophy. — This affection, first described 
 by Parry (1825), is rare, only 135 cases having been reported up to 
 1900. Its pathogenesis is not clearly understood, but it is classified 
 under disease of the fifth nerve because the only autopsy on record, by 
 Mendel, showed neuritis of the ascending root of the fifth nerve. 
 Mobius holds that acute infections, as measles or scarlatina, are 
 causal, because some virus enters through the skin or tonsils and re- 
 sults in atrophy. The essential change is a facial hemiatrophy, which 
 develops most often in persons between ten and fifteen years of age, in 
 girls (66 per cent.) and in about 60 per cent, of cases affects the left 
 half of the face. In perhaps a half-dozen cases the atrophy was 
 bilateral. There may be premonitory pains, hyper- or paresthesias, 
 but the cardinal sign is atrophy of the shin, which may show initial 
 infiltration. The skin is decolorized and shrunken, its fat disappears, 
 and later in the disease the muscles waste and the rough skin lies 
 directly on the bone. The hair on the affected side loses its pigment 
 and may fall out, the eyebrows and beard especially, sweat secretion 
 is lessened or absent and the mouth, if involved, is drawn toward the 
 side of lesion. The bones on the affected side waste, especially in 
 young subjects, most notably the maxillse, but even the smaller bones 
 and nasal cartilages are involved. On the wasted side there may be 
 no vasomotor reaction ; sensation is usually normal, although pain or 
 paresthesia may be noted in the distribution of the trifacial nerve. 
 The tongue, tonsils and palate are rarely involved. The course is 
 very chronic and practically always progressive, although remission 
 is possible. The outlook is hopeless and there is no treatment other 
 than administration of thyroid extract and the injection of paraffin 
 to lessen the facial deformity. 
 
 Facial Hemihypertrophy. — Facial hemihypertrophy, of which 13 
 cases only are on record, affects largely the cheek; Werner collected 
 9 congenital cases. Irritative neuritis is its suspected cause. 
 
 Seventh or Facial Nerve. — The face is represented in the lower 
 Rolandic cortex, whence the fibers run through the corona, internal 
 capsule, crus and pons (q. v.), where they decussate and enter the 
 nucleus of the opposite side. The nucleus lies in the floor of the 
 fourth ventricle inside of the ascending branch of the fifth nerve and 
 receives fibers from the third nucleus above for the orbicularis of the 
 eye (whereby ocular movements, winking and accommodation are 
 coordinated) and fibers from the hypoglossus below for the orbicu- 
 laris oris (whereby correlation of lingual and labial movements is 
 affected). It curves around the sixth nucleus, emerging near the 
 juncture of the pons and medulla, and enters the auditory meatus 
 with the eighth nerve, bends sharply, and presents a ganglionic 
 
1094 DISEASES OF TEE NEBVOUS SYSTEM. 
 
 swelling which receives the large superficial petrosal from the Vidian 
 nerve, containing fibers of taste from the fifth nerve. These latter 
 again leave the facial nerve by the chorda tympani. In the Fal- 
 lopian canal the facial nerve gives off branches as follows: (a) a 
 motor branch to the tympanic plexus; (b) & motor twig to the sta- 
 pedius muscle; (c) the chorda tympani nerve with secretory branches 
 to the salivary glands. Passing through the stylomastoid foramen, it 
 supplies (i) a few sensory branches to the external ear; (ii) motor 
 fibers to the external auricular muscles; (iii) motor fibers to the 
 posterior part of the occipitofrontal, and in the parotid gland, (iv) 
 breaks up %to branches which supply all the muscles of the face, the 
 platysma, stylohyoid and post, belly of the digastric. 
 
 Peripheral Facial Paralysis. — Peripheral facial paralysis (mi- 
 metic facial paralysis, prosoplegia, Bell's paralysis, Bell, 1830) is 
 the most frequent peripheral palsy. 
 
 Etiology. — 1. Neuritis is the most common cause. Exposure to cold 
 ("rheumatism") produces 73 per cent, of cases, especially in men 
 between the twentieth and fortieth years, and produces a perineuritis 
 which compresses the nerve trunk. Angina, gout, diabetes, diph- 
 theria, typhoid, erysipelas, mumps, sepsis, etc., are occasional causes. 
 
 2. Disease of the petrous portion of the temporal bone (7 per 
 cent.), especially caries and otitis media in childhood, may cause 
 paralysis. The danger is proportionate to the extent of the bone dis- 
 ease, but infective matter may reach the nerve by way of the vessels ; 
 88 per cent, of cases of disease of the labyrinth cause facial paralysis. 
 
 3. Trauma causes 6 per cent, of cases, as basal fracture by tearing, 
 hemorrhage, inflammation or undue formation of callus ; much more 
 rarely meningeal or cerebellar hemorrhage at birth; the use of ob- 
 stetrical forceps and trauma to the jaw or surgical operations on the 
 parotid gland. Facial paralysis may occur in " head tetanus " (Eose) . 
 
 4. If it results from lesions at the base, syphilis (3 per cent.) 
 should always be considered when the cause is intracranial; syphilis 
 rarely causes a peripheral facial paralysis. Aneurysm, tumor, men- 
 ingitis and hemorrhage are next in frequency and nearly always 
 involve simultaneously the closely contiguous eighth nerve. 
 
 5. In the pom the root fibers or nucleus may be affected, usually 
 with the sixth nerve of the same, or the arm and leg of the opposite 
 side. Degenerative affections, as tabes, bulbar paralysis, multiple 
 sclerosis, and progressive muscular atrophy or acute poliencephalitis 
 rarely invade the seventh nucleus. 
 
 6. Other rarer factors are primary hemorrhage into the Fallopian 
 canal, disease of the parotid or lymphatic glands and leukemic infil- 
 tration. It is suggested by Neumann that disease of the lymph ves- 
 sels at the point of exit of the facial nerve may produce paralysis. 
 
 Pathology.— Few autopsies have been made on simple cases. The 
 nerve has been found severed, its sheath and cylinders destroyed, the 
 nuclei in Schwann's sheath increased, the connective tissue increased 
 and the muscles the seat of fatty change. It is thought that the essen- 
 
FACIAL PARALYSIS. 
 
 1095 
 
 tial and usual change is a perineuritis and that the exudation in the 
 sheath compresses the nerve fibers, which then undergo parenchyma- 
 tous degeneration. In some cases degeneration only has been seen 
 and it is probable that slight swelling interferes with conduction. 
 Facial neuritis differs from multiple neuritis in that alcoholism is a 
 subordinate factor and the chief change is not in its peripheral twigs 
 but in the trunk, usually within the Fallopian canal. 
 
 Symptoms. — The symptoms sometimes begin with prodromes, as 
 vertigo, headache, tinnitus, pain or more often twitchings in the face, 
 even fever or albuminuria, or sometimes without prodromes, in which 
 cases one half of the face is rather suddenly paralyzed and " com- 
 pletely immobile and toneless" within two days. The forehead is 
 smooth, the lids cannot close (lagophthalmos), the tears run over the 
 cheek and when a strong effort is made to close the eyes the eye on the 
 affected side is turned upward by the inf. oblique muscle (Bell's 
 sign) . The orbicularis at times escapes involvement, since it receives 
 some fibers from the third nerve. Smell is impaired because of ab- 
 sence of tears, the nasal aperture is smaller and cannot be dilated, 
 sniffing on the affected side is impossible and the nasolabial furrow is 
 lost. The mouth is lower from paralysis of the levator anguli oris, it 
 cannot be closed and the saliva runs out, although its total secretion is 
 often lessened (v. i.). Labial enunciation is imperfect, puckering the 
 
 Fig. 77. 
 
 ROOT FACIALIS 
 
 ROOT ACOUSTICUS 
 
 GENICULATE GANGLION 
 
 SPHENO-PALATINE 
 GANGLION 
 
 DIAC-ASTRIC NERVE 
 STYLOHYOID 
 
 2' QS TO FACE 
 
 Relations of the fifth and seventh nerves and branches of the seventh. 
 
 lips, as though for whistling, is impossible and expectoration is im- 
 paired. The loss of wrinkles and expression on the affected side is 
 more marked in adult and aged than in young subjects, especially 
 about the eye, since years lessen the elasticity of the skin and the 
 subcutaneous fat. Chewing is impaired by weakness of the buccinator 
 and food accumulates between the teeth and the cheek. The unused 
 
1096 DISEASES OF TEE NEEVOUS SYSTEM. 
 
 half of the tongue becomes furred. The tongue does not deviate 
 on protrusion (but may seem to, on account of asymmetry of the 
 mouth). The tongue is sometimes slightly depressed from weakness 
 of the stylohyoid and digastric muscles. The platysma paralysis is 
 elicited by asking the patient to depress the lower lip. The palate is 
 sometimes described as sagging, the speech as nasal, the uvula as 
 deviating towards the sound side, but the uvula and palate are often 
 asymmetrical in health and there is a growing tendency to regard 
 the spinal accessory as the motor nerve for these structures. 
 
 Taste is lost in disease of the nerve between the geniculate ganglion 
 and the offset of the chorda ; it is lost in half the cases of " exposure " 
 neuritis ; it is not impaired in disease of the pons or in disease outside 
 the skull (see Diagram). The chorda supplies the anterior two- 
 thirds of the tongue and the glossopharyngeal the posterior third. 
 Perverted taste (parageusia) results from irritation of Jacobson's 
 nerve or the tympanic plexus. Hearing may be impaired. Deafness 
 and tinnitus result mostly from coincident disease of the ear. When 
 the stapedius is paralyzed, the unopposed tensor tympani (which 
 arises from the fifth nerve) overacts and results in aural over sensi- 
 tiveness especially to low notes (Lucae), which is termed hyper a- 
 kusis or oxyokoia. 
 
 All facial reflexes are abolished. Wasting may be noticed in thin 
 subjects and the reaction of degeneration appears in a week or two in 
 severe cases. In cases of moderate severity the excitability may be 
 first increased and then gradually decreased in seven to ten days. 
 Sensation is usually normal, since the facial is an almost wholly 
 motor nerve ; pain, even anaesthesia in the ear and tenderness over the 
 nerve trunk are sometimes observed; they are caused either by in- 
 volvement of the fifth nerve or possibly because the facial nerve 
 carries some sensory filaments. Accidental sympathetic oedema and 
 sweating have been observed. Herpes is rare and indicates trifacial 
 involvement. The saliva is decreased (the fibers for its secretion run 
 with the chorda) and secretion of tears is lessened (the fibers from 
 the facial nerve run to the fifth by the large petrosal nerve). 
 
 Diagnosis. — The diagnosis is made at a glance in fresh cases, while 
 in older cases secondary spasm (v. i.) on the paralyzed side may at 
 first cause confusion. The etiological diagnosis is important, as is 
 also the topographical. 
 
 1. Supranuclear paralysis, paralysis in the upper neurone, from 
 the cortex to the nucleus, is differentiated as follows : 
 
 Central or Supranuclear ^ Peripheral (Nuclear and 
 
 Palsy. Infranuclear) Palsy. 
 
 Etiology; vascular disease, tumor, ab- Neuritis, ear disease, etc. 
 scess. 
 
 Distribution of paralysis; partial, lower Complete; orbicularis and occipitofron- 
 
 facial involved or only slight or tran- talis involved. When eyes cannot be 
 
 sient weakness of orbicularis palpe- closed, probably peripheral or nuclear, 
 brarum. 
 
FACIAL PARALYSIS. 1097 
 
 Central or Supranuclear Peripheral (Nuclear and 
 
 Palsy. Infranuclear) Palsy. 
 
 Keflexes persist and increased. Lost. Paralysis flaccid. 
 
 Taste, auditory, salivary and sensory Often present, 
 symptoms lacking. 
 
 Pilocarpin increases salivary flow. Does not increase it. 
 
 Voluntary motion lost, while emotional Both lost, 
 movement very often persists. 
 
 Degenerative reaction and wasting ab- Present, 
 sent. 
 
 Cerebral symptoms present, general as Absent, 
 headache, increased reflexes or focal 
 as cortical epilepsy, hemiplegia, usu- 
 ally weak tongue, alternating paraly- 
 sis (see crus and pons localization). 
 
 In lesions of the pons all parts of the facial nerve are affected, 
 wherein it differs from facial nerve disease in the internal capsule. 
 In nuclear disease the orbicularis oris is less involved or escapes 
 affection, its centre being in the hypoglossus nucleus. 
 
 2. Localization in the peripheral type (see Fig. 77) may be (a) in 
 the pons (q. v.). General disease of the posterior pons also affects 
 the sixth nerve about whose nucleus the seventh nerve curves, (b) 
 In localization at the base, taste is not involved and deafness results 
 from coincident disease of the eighth nerve, (c) If in the Fallopian 
 canal taste is impaired, the salivary flow decreased and hearing often 
 abnormally acute, (d) If external to the skull there is no involve- 
 ment of taste, salivary flow or the stapedius. 
 
 Double facial paralysis is rare and usually indicates disease within 
 the skull. It may occur in bulbar paralysis, disease of both sides of 
 the pons or one focus in its centre, double otitis, especially syphilis, 
 multiple neuritis, tetanus (of which J. H. Lloyd in 1905 collected 7 
 cases) or in a form observed in childhood with ocular paralysis (q. 
 v.). Hysterical facial paralysis is extremely infrequent; organic 
 facial paralysis may exist on one side and an hysterical paralysis on 
 the other. 
 
 Course and Prognosis. — The onset is rapid and the disease is usually 
 manifest during the first day. Its duration varies from a week to 
 over a year, two to three months for moderate, and six to eight months 
 for severe cases. Even in cases which have seemingly recovered and 
 in those lasting over a month, some slight vestige of paralysis usually 
 remains. The prognosis depends (1) on the cause; it is favorable in 
 syphilis, birth trauma and polyneuritis ; in ear disease it is better if 
 the drum has not ruptured; it is unfavorable in tumor or nuclear 
 disease; (2) on the electrical reaction. If after ten days the irrita- 
 bility is not reduced the outlook is good and recovery may be expected 
 in about three weeks; if after fourteen days it is lowered but not 
 lost, recovery occurs within two months; if after fourteen days the 
 
1098 DISEASES OF THE NEEVOUS SYSTEM. 
 
 irritability is lost, the prognosis is doubtful and the course is likely 
 to cover months. Eecurrence is infrequent, although five attacks 
 are recorded. Contracture (secondary 'over action) usually occurs in 
 four to six months and progresses for eight to twelve months, when it 
 lessens and disappears in mild but remains to some extent in severe 
 cases. In old subjects it balances up the facial contour; in young 
 subjects it produces deformity. It is thought to depend on an altered 
 functional state of the nucleus. 
 
 Treatment. — (a) The cause should be reached, if possible; anti- 
 syphilitic remedies and ear-drainage have cured cases even of twenty- 
 three years duration. (&) Antirheumatic drugs are inefficacious and 
 the salicylates do not usually shorten the course. A mercurial purge, 
 hot fomentations, which must be carefully maintained for two^ or 
 three days, keeping the patient indoors, and the invariable applica- 
 tion of a blister over the mastoid and one over the side of the neck are 
 beneficial, (c) Correction of deformity is always necessary. The 
 eye should be douched with boric acid, bandaged closed during sleep 
 and the lids massaged, the cheek and mouth should be massaged up- 
 ward and the placing of a hook in the angle of the mouth (sustained 
 by tape over the ear or by adhesive plaster) prevents deformity to 
 some extent, (d) Electricity should not be used for two or three 
 weeks, and then the galvanic current should be given, for fifteen 
 minutes each day, in strength just sufficient to produce muscular 
 contraction ; the application of the anode over the muscles is the least 
 painful method. The faradic current causes pain, (e) For contrac- 
 ture little can be done, excepting massage and steaming the face. (/) 
 In irreparable cases, surgical transplantation of the facial trunk into 
 the spinal accessory nerve has been successfully performed. Spiller 
 thinks anastomosis with the hypoglossus produces better results. 
 
 Facial and Mimetic Spasm (Tic Convulsif). — Etiology. — The causes 
 are (a) organic disease in the cortex, pons or nerve trunk, which 
 irritates (perhaps later paralyzes) the centre, nucleus or paths. Ir- 
 ritation of the fifth nerve is considered causal, (b) There is an idio- 
 pathic form, which occurs in persons between the fortieth and sixtieth 
 years, most often in women with neuropathic or emotional tendencies 
 (see Habit Spasm under Chorea), (c) There is also a reflex form 
 which results from worms or uterine disease. 
 
 Symptoms. — The spasm begins paroxysmally on one side and is 
 more often clonic than tonic. The clonic form affects the orbicularis 
 palpebrarum (blepharospasm) and zygomatici most frequently, 
 although the frontalis, chin depressors or all the facial muscles may 
 be concerned in severe cases. Pain and paresis are absent save in 
 progressive organic disease. The spasm is lessened by rest and in- 
 creased by cold or emotion. It is usually unilateral, but may spread 
 to the opposite side or exceptionally to the muscles of mastication or 
 the tongue, pharynx, larynx, neck or arm. The tonic form is seen in 
 photophobic disease of the eye, paralysis agitans, tetanus, tetany or 
 hysteria. 
 
DISEASES OF THE AUDITORY NEBVE. 1099 
 
 Prognosis.— The prognosis is unfavorable after the first few months 
 and the disease is then likely to last for years or for life. 
 
 Treatment.'— Treatment is often useless and varies with the cause 
 of the affection. Trigeminal irritation should be removed if possible. 
 Arsenic has proved beneficial in some cases, but nervines and anti- 
 spasmodics generally are useless. Galvanization, if tender points 
 are found, has cured a few cases (Berger). Weir Mitchell has recom- 
 mended freezing of the cheek with ethyl chloride. Stretching of the 
 facial nerve usually affords relief, which is generally but temporary. 
 
 The Eighth or Auditory Nerve. — The eighth nerve in the old no- 
 menclature was the portio mollis of the seventh pair, the facial nerve 
 being the portio dura ; as the names imply, the auditory is softer than 
 the facial nerve and therefore less resistant to pressure. It is purely 
 sensory and consists of two distinct roots, the cochlear and vestibular. 
 At the point where the roots separate is found a group of cells, 
 analogous to the spinal ganglia, from which arises Wrisberg's nerve, 
 an accessory structure with vasomotor and salivary secreting fibers. 
 
 The cochlear nerve is the true auditory nerve and its nuclei are 
 found in the floor of the fourth ventricle. It is connected through the 
 tegmentum of the crus and internal capsule with the contralateral 
 and to a less degree with the homolateral temporosphenoidal lobe. It 
 is distributed to or arises from the cochlea "and ganglionic cells of the 
 organ of Corti. (a) Cortical disease (see Brain Localization) may 
 in rare cases cause word deafness, as may (b) disease of the auditory 
 tracts by lesions of the lateral lemniscus, the post. corp. quadrigemina, 
 internal capsule or less often of the pons. Nuclear disease is almost 
 unknown. Neuromata are rare, but occur on the auditory trunk 
 oftener than on any other cranial nerve. The nerve trunk may de- 
 generate in tabes, (c) Lesions at the base may follow trauma and 
 meningeal inflammation, hemorrhage or syphilis, (d) Most auditory 
 nerve diseases result from disease of the internal ear, either primary 
 or secondary to disease of the middle ear; these affections include 
 acute or chronic inflammation, syphilis, degeneration or hemorrhage 
 in the labyrinth. There are three prominent symptoms: (a) Nervous 
 deafness may result. Deaf-mutism is congenital in 80 per cent, and 
 is acquired in early life in 20 per cent, of cases. Deafness from oc- 
 clusion of the meatus or from disease of the middle ear is excluded 
 by Rinne's test; a vibrating tuning-fork or watch, if held over the 
 meatus, is not heard in these affections, but is heard when its base is 
 placed on the mastoid which conducts vibrations to the internal ear. 
 In disease of, the internal ear, bone-conduction is lacking. Differen- 
 tiation between deafness due to disease of the internal ear and that 
 due to bone disease is only made by means of the associated symptoms. 
 The treatment of nervous deafness is etiological. Iodides are some- 
 times beneficial, as are full doses of pilocarpine. Electricity is 
 useless, (b) Auditory hyperesthesia may result from central or 
 peripheral disease. In genuine hyperesthesia (hyperacusis), sounds 
 
1100 DISEASES OF THE NERVOUS SYSTEM. 
 
 are heard by the patient which other individuals may not hear ; this 
 occurs in hysteria, epilepsy, migraine, meningitis, acute mania and 
 at times after use of caffeine, alcohol or opium. The spurious hyper- 
 acusis results from paralysis of the stapedius. In dysesthesia (dys- 
 acusis) ordinary sounds cause disproportionate sensations or dis- 
 comfort; this is common in headache and cerebral disorders, (c) 
 Tinnitus aurium designates subjective distressing and intractable 
 sensations, as ringing, roaring or whistling in the ears. In 80 per 
 cent, of cases it is caused by disease of the internal ear. It may also 
 occur in any disease of the middle ear, when there is cerumen or 
 foreign bodies in the external meatus, or occlusion of the Eustachian 
 tube, when the individual is subject to long exposure to loud sounds, 
 as in boiler factories, and in the neuroses (hysteria, neurasthenia, 
 migraine, epilepsy), aneurysm, anaemia, gout or cinchonism. 
 Sounds of centric origin are usually continuous and sometimes elab- 
 orate. Wax or bilateral labyrinthine disease may also cause con- 
 tinuous tinnitus, while in anaemia or aneurysm, these sensations are 
 intermittent (Gowers). Hearing may be hyperacute, deranged or 
 lost. Spasm of the palate or musculature of the Eustachian tube 
 may produce a most annoying snapping sound, which is at times 
 audible to bystanders. While nothing is usually heard on examina- 
 tion, in children or less often in adults we may hear a systolic brain 
 murmur (see Brain Tumor). Treatment depends on the cause. 
 Bromides are most useful, combined with a few drops of the tr. 
 belladonna or cannabis indica. Quinine was recommended by Char- 
 cot and Politzer and salicylates by Gowers, but they seldom give 
 relief. Eull doses of nitroglycerine relieve certain cases and counter- 
 irritation over the mastoid sometimes mitigates tinnitus. 
 
 The vestibular nerve arises from the medulla, supplies the vestibule 
 and semicircular canals, subserves sensation of space and equilibra- 
 tion and has cerebral and cerebellar connections. 
 
 Meniere's Disease, Auditory Vertigo (Vertigo ab aure laesa). — 
 Paul Meniere in 1861 described a condition consisting of vertigo, 
 tinnitus, vomiting and sometimes deafness, developing with apoplecti- 
 form suddenness and due to acute labyrinthine disease. The lesion is 
 usually a slightly irritative disease of the vestibular nerve, which sup- 
 plies the organs of equilibration, the semicircular canals. According 
 to Gowers 80 per cent, occur in persons between the thirtieth and 
 sixtieth years, 66 per cent, in males, and 90 per cent, of all cases of 
 vertigo not due to epilepsy or organic brain disease are caused by 
 lesions of the labyrinth. Frankl-Hochwart thus classifies .Meniere's 
 complex, which may be elaborated as follows: (a) Apoplectiform 
 cases, which occur in healthy ears, of which few more than 30 cases 
 are recorded, due to labyrinthine hemorrhage or to trauma ; leukaemia 
 and arteriosclerosis are promoting factors and it is thought that acute 
 angioneurotic transudation of lymph may occur in the canals, (b) 
 Cases developing in ears already acutely or chronically diseased; the 
 internal ear is the usual seat of disease, but the external or middle 
 
MENIERE'S DISEASE. 
 
 1101 
 
 oar may be affected or the branches of the eighth nerve,_ perhaps by 
 tumors, syphilis, tabes, paretic dementia, gout, cold, facial paralysis 
 or drugs, such as quinine and the salicylates, (c) Cases caused by 
 external influences or procedures, as pressure on the drum by violent 
 douching of the ear; (d) pseudo-M eniere's disease, which occurs in 
 the neuroses, as epilepsy, hysteria, neurasthenia, migraine or sea- 
 sickness. 
 
 Symptoms. — The symptoms begin gradually or with a sudden 
 stroke and are paroxysmal ; the attacks may be separated by weeks or 
 months or perhaps occur daily, (a) The vertigo is subjective or 
 objective, perhaps combined; the patient cannot stand; he is likely to 
 fail backward or if standing is possible is ataxic. These symptoms 
 indicate lesion in the vestibular nerve; there is occasionally momen- 
 tary loss of consciousness; some slight vertigo may persist between 
 paroxysms, (b) Nausea and vomiting are usual, save in the lighter 
 forms and are often attended "by headache, sometimes collapse, pallor 
 and clammy skin and rarely by death, (c) The tinnitus of a roaring, 
 throbbing character and (d) nervous deafness, which is usually not 
 absolute, indicate disease of the cochlear nerve. Nystagmus, double 
 vision and ataxia are occasional symptoms and result from the rela- 
 tions between the labyrinth, cerebellum and cerebrum. The prognosis 
 is always uncertain. Acute or progressive disease is unfavorable. 
 The vertigo may cease when complete destruction of the nerve results 
 in deafness. Some cases recover. 
 
 Diagnosis. — Aural vertigo constitutes 90 per cent, of vertigo. Dif- 
 ferentiation is as follows : (a) Gastric disease may cause vomiting or 
 vertigo (a stomacho loeso, Trousseau) but does not produce tinnitus or 
 deafness. Gastric vertigo was once thought to cause 80 per cent, of 
 cases of vertigo; now, but 5 per cent, are attributed to it (Gowers). 
 Many of these cases are neurotic, (b) Epilepsy, especially petit mal, 
 may produce vertigo, very rarely tinnitus or deafness and much 
 oftener loss of consciousness, (c) Cardiac disease, as aortic regurgi- 
 tation or arteriosclerosis, may cause vertigo but not the other symp- 
 toms, (d) Organic brain affections, as tumor, have other distinctive 
 signs, as headache or focal lesions. Confusion is possible with arterio- 
 sclerotic vertigo, and especially with coincident accidental deafness. 
 (e) Ocular vertigo ceases on closing the eyes. Gerlier (188-7) de- 
 scribed a form which is endemic in France and Switzerland and is 
 characterized by vertigo, great depression, paretic weakness of the 
 neck and limbs, ptosis, strabismus, diplopia and retinal hyperemia, 
 hemorrhage or oedema. A similar form occurs in Japan. Recovery 
 occurs in one to four months. 
 
 Treatment. — Labyrinthine disease is little influenced by drugs, ex- 
 cept when syphilis and gout are its causes. Quinine, salicylates and 
 nitroglycerine should be given (see Tinnitus). Bromides are most 
 useful in daily doses of one dram. Galvanization with the anode over 
 the ear and cathode to the neck has seemingly helped some cases, as 
 has blistering of the mastoid, Disease of the pharynx, Eustachian 
 
1102 DISEASES OF THE NEEVOUS SYSTEM. 
 
 tube and accumulation of wax must be recognized and treated. ^ Ke- 
 moval of the malleus and incus with mobilization of the stapes relieves 
 a few cases. 
 
 Ninth or Glossopharyngeal Nerve. — This nerve is almost insepar- 
 ably connected in its course and functions with the vagus and the 
 internal part of the spinal accessory nerve ; their nuclei blend, their 
 sensory and motor filaments supply the digestive tract from the spinal 
 accessory nerve and send motor branches to the lungs, larynx and 
 heart. Compared with disease of the first eight cranial nerves, 
 affections of these visceral nerves are infrequent. Of all the cranial 
 nerves, the ninth is least understood and is almost never the seat of 
 isolated disease. The causes of its disease are essentially the same as 
 those of the vagus (v. i.) ; its nuclei suffer in bulbar palsy and its 
 roots in basal disease. 
 
 It is distributed as follows : (a) its sensory fibers supply the back of 
 the tongue, pharynx, soft palate, tonsil, upper pharynx, Eustachian 
 tube and tympanic cavity. It is probably the nerve of nausea, (b) 
 Its motor fibers supply the upper pharynx and possibly the palate. 
 (c) Taste fibers are usually thought to be distributed to the posterior 
 third of the tongue and palate, but they are not found in the nerve 
 root and are considered to pass through the fifth nerve to the brain. 
 Increased fiow of saliva and loss of taste on the root of the tongue may 
 result from disease of the middle ear due to relations between the 
 nerve of Jacobson (ninth) and the branches of the fifth nerve. The 
 nerve is thought to regulate and inhibit the contractions of the 
 pharynx, which become frequent (spasm) in disease or on section of 
 the nerve. 
 
 Tenth or Vagus Nerve. — This nerve arises in the medulla above 
 the ninth, below the eleventh and outside of the twelfth nuclei. 
 With the internal part of the accessory nerve it has an enormously 
 diffuse and important visceral distribution. It is a mixed nerve, the 
 motor fibers originating from the nuclei and the sensory fibers from 
 the jugular and plexiform ganglia. It is generally maintained that 
 the vagus carries the sensory and the accessory, motor fibers. 
 
 Etiology. — Affections of the vagus result from: (a) jSTuclear disease, 
 as degenerative bulbar palsy or acute vascular lesions, which usually 
 also involve other nuclei; (b) involvement of the root and trunk by 
 meningitis, syphilis, caries, trauma, tumor, aneurysm of the arch or 
 its branches, carcinoma, oesophageal growths, tuberculous or other 
 adenopathies, pleural (right-sided especially) or pericardial effusions 
 or adhesions, mediastinitis, goitres, operations on the neck or rarely 
 neuroma and neuritis from diphtheria or other infections, tabes or 
 plumbism. Cortical, especially functional, causes may occasion 
 symptoms. Irritative and paralytic manifestations occur in numer- 
 ous combinations and will be treated topographically. 
 
 Pharyngeal Branches. — The pharyngeal plexus consists of branches 
 
DISEASE OF THE VAGUS NERVE. 
 
 1103 
 
 from the ninth and tenth nerves. In paralysis, sensation and the 
 pharyngeal reflex are lost; bilateral disease causes dysphagia. The 
 stomach tube can be introduced without sensation or spasm. Pulpy 
 foods are better swallowed than dry foods or fluids. Food is likely to 
 enter the larynx and when the palate is involved there is regurgitation 
 into the nose and nasal speech results. The innervation of the palate 
 is not definitely known, but it is probably supplied by the accessory 
 nerve. Spasm is not frequent, is always functional, is transient or 
 recurrent, does not allow of introduction of the stomach tube and 
 
 Fig. 78. 
 
 The Laryngeal Paralyses. (From Church's Nervous Diseases.) 
 1, normal phonation ; 2, normal deep inspiration ; 3, normal cadaveric position ; A, 
 bilateral adductor palsy; attempted phonation; B, left adductor palsy; attempted 
 phonation ; C, bilateral abductor paralysis ; deep inspiration ; D, left abductor paraly- 
 sis ; deep inspiration ; affected cord in cadaveric postion ; E, left abductor paralysis ; 
 phonation ; affected cord in cadaveric position ; right cord crossing median line ; F, 
 bilateral thyro-arytenoid paralysis ; G, bilateral thyro-arytenoid paralysis and paraly- 
 sis of arytenoideus, giving an hour-glass opening. * 
 
1104 DISEASES OF THE NERVOUS SYSTEM. 
 
 includes the globus hystericus, oesophagismus, pharyngismus, false 
 and genuine hydrophobia and the pharyngeal crises of tabes. The 
 oesophagus is rarely affected except in diseases of the centres or trunk. 
 
 Laryngeal Branches. — There are two laryngeal nerves, the super- 
 ior laryngeal and the recurrent laryngeal. 
 
 The superior laryngeal is (a) the sensory nerve for all parts of the 
 larynx above the vocal cords, (&) the motor nerve for but one larynx 
 muscle, the cricothyroid, which modulates the voice by regulating 
 tension in the cords, and (c) it is the motor nerve for the depressors 
 of the epiglottis, the thyroepiglottic and ary-epiglottic muscles, 
 paralysis of which causes the epiglottis to stand upright, thereby 
 risking entrance of food into the larynx and aspiration pneumonia. 
 
 The recurrent laryngeal curves around the aortic arch on the left 
 and the subclavian artery on the right side ; (a) it is the sensory nerve 
 to the mucosa of the larynx below the cords and the trachea and (b) 
 is the motor nerve to every intrinsic larynx muscle except the crico- 
 thyroid. The physiologically complicated larynx muscles have three 
 main movements: (a) to render the cords tense (this is accomplished 
 by the cricothyroids and to a less extent by the thyro-arytenoids) ; 
 (b) to adduct the cords, which is done chiefly by the lateral crico- 
 arytenoids (also by the thyro-arytenoids and arytenoids) ; (c) to 
 abduct the cords, which is done by the post, crico-arytenoid ; it is 
 especially important because it is the only special abductor; it is 
 very frequently and almost invariably first involved in incomp]ete 
 recurrent paralysis. 
 
 Treatment. — Treatment depends wholly on the cause, which is usu- 
 ally peripheral. In nuclear types there is no therapy. Suggestion, 
 or electrotherapy, is valuable in hysterical forms. The faradic cur- 
 rent may be used with the positive pole to the forehead and the nega- 
 tive to the larynx externally or internally. Other measures include 
 laryngeal gymnastics, in which the patient repeatedly attempts to 
 speak, intralaryngeal insufflations of alum, the administration of 
 strychnia hypodermatically and Ollivier's procedure, in which the 
 thyroid cartilage is compressed between the index-finger and thumb 
 during inspiration and expiration, while the subject attempts to 
 phonate. Tracheotomy and feeding by the nasal catheter are some- 
 times indicated. 
 
 Anaesthesia and Hyperesthesia of the Larynx. — Ancesthesia of the 
 larynx is rare, but may occur uni- or bilaterally in disease of the sup. 
 laryngeal nerve, the vagus roots, its nucleus or in the hemianesthesia 
 of hysteria or organic brain disease. In nuclear disease it is partial ; iu 
 affections of the nucleus, root and trunk the reflexes are lost, but they 
 are present in supranuclear and functional affections. Hyperces- 
 thesia is rarer, being observed in neurotics as a tickling, tendency to 
 cough or spasm; neuralgia and crises also occur. 
 
 Laryngeal Spasm. — The most common form of laryngeal spasm is 
 spasm of the adductors, which are concerned in reflexes inimical to 
 
DIFFERENTIATION OF LARYNGEAL PALSIES. 
 
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1106 DISEASES OF THE NERVOUS SYSTEM. 
 
 entrance of foreign bodies into the larynx ; it may result from centric, 
 local (laryngitis with croup-like cough at night) or reflex irritation 
 from distant or neighboring foci, as elongated uvula, goitre or hyper- 
 trophy of the pharyngeal tonsil. It includes laryngismus stridulus, 
 which occurs in children under three years of age, especially in boys, 
 and was previously referred to the thymus gland, but is due to rickets 
 in 66 per cent, of cases and also to tetany, and renexly to alimentary 
 disorders; it comes on at night or on awakening in the morning, 
 with croup-like cough, and presents all the symptoms of acute suffo- 
 cation, as inspiratory and expiratory stridor, pallor, cyanosis, wide 
 pupils, protruding eyes, low diaphragm, involuntary evacuations, 
 centric vasomotor and cardiac disturbances and convulsions either 
 generalized or of the infantile carpopedal type. The attacks last 
 from a few seconds to one-half or one minute and are sometimes at- 
 tributed to loss of temper when they follow a reproof. In the adult, 
 laryngeal spasm occurs in tabes, hysteria, tetany, hydrophobia, epi- 
 lepsy (the initial cry of which arises from spasm), asthma or mi- 
 graine. The attacks are recognized by the negative laryngoscopic 
 findings, paroxysmal occurrence and the stridor being manifest in 
 both inspiration and expiration. Partial spasm occurs in some types 
 of stuttering, in clergymen's sore throat and in explosive, unmodu- 
 lated speech. 
 
 Nervous cough is present in the explosive hysterical type, in the 
 metallic ovarian form in young girls and in the barking variety in 
 young masturbators. 
 
 Treatment. — Treatment of spasm includes removal of the cause, 
 relief of local irritation, as affections of the ear (which has branches 
 from the vagus) or pharynx, correction of hygiene, administration 
 of tonics, as cod-liver oil in children, and such immediate measures 
 as thrusting a finger into the throat, dashing water in the face, hydro- 
 therapy and for the attack chloral and bromides by enema, local 
 application of cocaine, inhalation of chloroform and in adults nitrite 
 of amyl and morphine. 
 
 Pulmonary Branches. — The vagus and the sympathetic form the 
 pulmonary plexus. Afferent fibers convey sensory impressions to the 
 respiratory centre; these include accelerating fibers which predomi- 
 nate, and inhibitory fibers, stimulation of which (sup. laryngeal 
 nerve) arrests breathing. Afferent impulses are also carried to the 
 vasomotor centre. Efferent motor impulses are conveyed to the 
 bronchi. Division of the vagus causes rapid congestion of the lungs 
 with hemorrhage (also observed in acute lesion of the pons) and 
 slower but deeper breathing; stimulation of the divided end of the 
 nerve accelerates breathing even to its tetanic arrest. Broncho- 
 pneumonic foci are not trophic but aspiration pneumonia from paraly- 
 sis of the palate and larynx. The pulmonary twigs are probably con- 
 cerned in Cheyne-Stokes' breathing, bronchial asthma and hiccough. 
 
 Cardiac Branches. — The vagus and sympathetic nerves constitute 
 the cardiac plexus, (a) Motor fibers from the spinal accessory nerve 
 
SPINAL ACCESSOEY NERVE. H° 7 
 
 inhibit and coordinate cardiac action, which is sometimes under the 
 control of the will ; the heart may at times be slowed by pressure on 
 the neck ; marked irritation of the vagus slows or even arrests the 
 heart. Division may cause sudden death, though this is unusual m 
 unilateral lesions. Paralysis of these fibers allows the sympathetic 
 accelerator fibers to dominate, producing arrhythmia and tachycardia. 
 Digitalis is ineffective in paralysis of the vagus, (b) The sensory 
 fibers are concerned in the cardiac neuroses (q. v.). (c) These are 
 probably trophic fibers, as Eichhorst's experiments show fatty myo- 
 cardial degeneration on division of the vagi. 
 
 Gastric Branches. — (a) Motor branches supply part of the stomach ; 
 they cause nausea and are concerned in reflex, direct or centric vomit- 
 ing, as in brain lesions, wherein the vomiting usually occurs without 
 nausea, (b) Sensory branches ; the vagus is the nerve of hunger and 
 thirst, and its disease often causes anorexia and loss of thirst. Cen- 
 tric disease causes the gastric crises of tabes and cortical functional 
 disease produces the epigastric aura of epilepsy and perhaps gas- 
 tralgia in the neuroses. Vertigo probably causes vomiting through 
 the vagus. Intestinal and splenic symptoms are lacking in affections 
 of the vagus, although the nerve accelerates peristalsis. 
 
 Eleventh or Spinal Accessory Nerve (external portion). — The in- 
 ternal, minor part runs with the vagus, while the major, external 
 segment is really a spinal motor nerve, arising from the lateral 
 portion and ant. horns of the cord between the sixth cervical segment 
 and the medulla. It courses upward through the foramen magnum 
 into the cranium and leaves it with some of the true cranial nerves. 
 It is the chief supply of the sternomastoid muscle and the upper part 
 of the trapezius, the lower two parts of which are usually supplied 
 by the cervical and upper dorsal nerves. 
 
 Paralysis.- — Paralysis is rarely caused by cortical disease, because 
 the muscles have bilateral representation. The usual causes are 
 bulbar paralysis, lesions near the foramen magnum, meningitis (then 
 usually with involvement of the inner accessory branches and the 
 twelfth nerve), syphilis, trauma, tabes, syringomyelia, progressive 
 muscular atrophy, caries or tumor of the spine, or neuritis. The 
 symptoms are paralysis of (a) the sternomastoid, in which there 
 is impaired rotation of the face to the side opposite the lesion ; in old 
 cases contracture turns the face toward the paralyzed side, (b) 
 That part of the trapezius from the occiput to the acromion is para- 
 lyzed, showing a concave instead of a straight line, best seen in 
 deep inspiration or shrugging the shoulders. (Paralysis of the second 
 portion causes imperfect elevation of the arm, some drooping and 
 winging out of the scapula, the lower part of which is drawn toward 
 the spine by the rhomboids and lev. anguli scapulas ; paralysis of the 
 third portion results in weakness in the adduction of the scapula 
 to the spine.) If it is bilateral as in chronic meningitis of childhood 
 or progressive muscular atrophy the head falls forward or back- 
 
1108 DISEASES OF THE NERVOUS SYSTEM. 
 
 ward as the sternomastoids or trapezii, respectively, are affected. In 
 peripheral disease there is wasting and the reaction of degeneration. 
 
 Accessory Spasm, Spasmodic Torticollis or Wryneck. — Etiology- 
 It occurs in women in 66 per cent, of cases (Gowers) ; Osier finds it 
 largely in males between 30 and 50 years of age. A neurotic ten- 
 dency, trauma, overexertion, acute infections, alcoholism, plumbism, 
 cervical caries, brain tumor and diseases of the eye and ear (torti- 
 collis ab oculo lseso, ab aure lsesa) are among its uncertain causes. 
 
 Symptoms. — The symptoms vary as the affection is clonic or tonic, 
 unilateral or bilateral, and also with the number of muscles involved. 
 One sternomastoid is generally involved, especially in tonic spasm, 
 in which the occiput is turned to the diseased side, the face to the 
 opposite side and somewhat upward, and the ear brought nearer the 
 clavicle. The upper part of the trapezius comes next in frequency of 
 involvement and is affected equally by clonic and tonic spasm. The 
 affected shoulder is raised and slightly rotated, the scapula drawn 
 toward the spine and the head backward. The spine is often convex 
 toward the diseased side. The splenius is half as frequently affected 
 (Gowers), the head being drawn backward, the face a little to the 
 affected side and upward. Less often the scalenus, platysma, rectus 
 and obliquus capitis are affected. The muscles in tonic spasm are 
 hard, prominent and sometimes hypertrophied. Clonic spasm disap- 
 pears during sleep, but is increased by fatigue and emotion; it may 
 also invade the face, neck, eyeballs, vocal cords or the arm. There 
 may be pain, fatigue and rarely tender spots from compression of the 
 brachial plexus by the scaleni. Bilateral clonic or tonic spasm of the 
 trapezius draws the head backward (retrocollic spasm) and always 
 involves the frontalis muscle. 
 
 Course and Prognosis. — The onset is gradual, the disease is usually 
 stationary or progressive in its course, rarely recurrent ; recovery is 
 infrequent. The outlook is generally grave in well-developed types. 
 
 Diagnosis. — (a) In congenital or fixed wryneck there is no active 
 spasm. ^ One sternomastoid (but rarely the trapezius) shows atrophy, 
 induration and cicatrization, which Stromeyer considers due to trac- 
 tion on the neck with injury during delivery. Seventy per cent, of 
 cases occur in left occipito-anterior presentations. The disease es- 
 capes notice for years because of the shortness of the child's neck. 
 Wilks always found facial asymmetry. Golding-Bird considers the 
 affection a contracture from a central lesion. Tenotomy cures it. 
 (b) Hysterical torticollis occurs in subjects under thirty years of age ; 
 other stigmata usually develop. Bompaire and Brissaud describe a 
 mental torticollis, clearly a psychical phenomenon, (c) Torticollis 
 may occur in children from dentition to puberty; clonic spasms, 
 especially in the deep muscles, lead to nodding, salaam movements, 
 spasmus nutans, nictitatio spastica. The eyes may show nystagmus. 
 The affection may develop from reflex dental or digestive disorders or 
 from organic cerebral disease. It is sometimes habit spasm, hysteria 
 or even part of an epilepsy or idiocy. 
 
DISEASES OF THE SPINAL NEEVES. 1109 
 
 Treatment. — Treatment is first etiological. Nervines, sedatives and 
 electricity seldom produce permanent results. Morphine is a danger- 
 ous agent, although its local hypodermatic use has led to recovery. 
 Massage and deep compression are occasionally helpful. In chronic 
 cases resection of the accessory nerve is indicated. If many muscles 
 are involved the third and fourth cervical nerves must also be re- 
 sected. Successful results are reported by W. W. Keen and ISToble 
 Smith. 
 
 Twelfth or Hypoglossal Nerve. — This is purely a motor nerve. 
 Paralysis of the tongue is (a) rarely cortical; supranuclear glosso- 
 plegia from lesions between its centre in the lower part of the ant. 
 ascending and the third frontal convolutions, almost always occurs 
 with hemiplegia and paralysis of the lower facial fibers ; there is no 
 wasting or reaction of degeneration. The root of the tongue is higher 
 (hyoglossus paralysis) and on protrusion the tongue deviates to the 
 paralyzed side, being pushed over by the sound genioglossus. (b) 
 Nuclear paralysis occurs often in bulbar paralysis, sometimes in 
 tabes or paretic dementia, and much less frequently in acute inflam- 
 mation or softening in the medulla. Nuclear lesions are almost 
 invariably bilateral since the nuclei are closely contiguous, and show 
 the reaction of degeneration and wasting, the mucosa being wrinkled 
 over the atrophic half. Wasting may be more marked than paralysis. 
 Fibrillation is frequent, as in paretic dementia, from cortical and 
 nuclear changes. In bilateral glossoplegia the tongue cannot be pro- 
 truded, there is impairment of the first act of swallowing, in chewing 
 and articulation, all of which are but slightly marked in unilateral 
 paralysis, (c) Infranuclear paralysis results from lesions near the 
 surface of the medulla, which may produce unilateral paralysis of 
 the tongue, palate and vocal cord. Contralateral hemiplegia may 
 occur. The lesion may affect one or both nerves. Syphilis, trauma or 
 tumors are causal ; there are recorded only 40 cases of peripheral, 
 isolated hypoglossal paralysis (Panski, 1903). Wasting, the degener- 
 ative reaction and fibrillation are present. Treatment is that of 
 other paralyses. 
 
 Spasm. — Spasm is rare either in the tonic or clonic form. It oc- 
 curs in chorea, facial spasm, certain types of stuttering, epilepsy (in 
 which the tongue, protruded by the genioglossus, is bitten), hysteria 
 (in which the tongue is rarely bitten), certain psychoses, meningitis, 
 neurotic spasm in speakers (aphthongia) or musicians. The prog- 
 nosis varies with the cause and in general is favorable. 
 
 DISEASES OF THE SPINAL NERVES. 
 
 The spinal nerves differ from the cerebral in that they contain 
 sensory, motor and vasomotor fibers. Disease or injury therefore 
 suspends motility and sensation, causes vasomotor paralysis, trophic 
 changes or wasting, glossy skin, the reaction of degeneration, atrophy 
 and contracture. 
 
1110 DISEASES OF THE NERVOUS SYSTEM. 
 
 Phrenic Nerve. — Paralysis. — (a) Disease or trauma of the verte- 
 brae, cord, membranes or of the third, fourth and fifth cervical nerves 
 of origin may cause it. In disease of the cord other paralysis is 
 always present, (b) Its trunk is well protected but may be injured 
 in its course or damaged by aneurysm, tumors or pleurisy. Neuritis 
 sometimes occurs in multiple neuritis or degenerative lesions, as 
 tabes or progressive muscular atrophy. 
 
 Symptoms. — The diaphragm is paralyzed, usually on both sides. 
 The abdomen retracts on inspiration and bulges on expiration, the 
 converse of its normal movements. Litten's diaphragmatic sign is 
 absent and there is no inspiratory descent of the liver or spleen. 
 Blowing, coughing and pressing at stool are impossible. Costal 
 breathing is exaggerated, the accessory muscles are strongly in play, 
 dyspnoea and cyanosis are present, especially on exertion, and co- 
 incident bronchitis may cause most alarming symptoms, allowing 
 stagnation of mucus and basal congestion. The nerve may be tender 
 in the neck. 
 
 Diagnosis and Teeatment. — Costal hysterical breathing may at 
 first cause confusion, as may inflammation and degeneration of the 
 diaphragm from diaphragmatic pleurisy. The outlook is always 
 grave. It is more favorable in syphilis, lead or diphtheritic neuritis 
 than in alcoholic forms. Treatment is that of the cause but is usu- 
 ally futile. Faradic phrenic stimulation is sometimes beneficial, as 
 in apparently asphyxiated new-born infants. 
 
 Phrenic Spasm. — 1. Clonic spasm, singultus or hiccup is a form in 
 which the diaphragm spasmodically contracts with a sound due to 
 sudden closure of the glottis, sometimes 50 to 100 times a minute. It 
 is probable that the vagus and respiratory centres are involved, for 
 dyspnoea, dysphagia or dysarthria may occur. Clonic spasm occurs 
 (a) in inflammation, either thoracic (pleurisy, pericarditis) or ab- 
 dominal (peritonitis, appendicitis, obstruction) ; (b) in irritation, 
 oesophageal, mediastinal, hepatic or gastric, directly or reflexly; (c) 
 in nervous affections, as centric disease or the neuroses; and (d) in 
 toxaemia or uraemia. Treatment is that of the cause. Gastric lavage ; 
 apomorphine; circular constriction of the lower chest with the head 
 bent forward ; attempts to sneeze, cough, breathe deeply or press down 
 with the glottis closed ; faradization, freezing, blistering the neck and 
 epigastrium; asafcetida, chloral or bromides; and narcotics and in- 
 halations of chloroform or amyl nitrite may be beneficial, although 
 the affection is often intractable. 
 
 2. Tonic phrenic spasm is rarer. The causes are tetany, epilepsy, 
 tetanus, rheumatism and hysteria. The diagnosis is easy. The 
 lower chest and upper abdomen are distended and often sensitive ; the 
 upper chest moves rapidly and forcibly, with the accessory respira- 
 tory muscles in full play ; there is no respiratory excursion, the lungs 
 are acutely distended, the abdominal viscera are luxated downward, 
 there is dyspnoea, and cyanosis and death may result. Treatment 
 consists of the application of heat, blisters and the faradic current to 
 
DISEASE OF THE MUSCULOSPIEAL NEEVE. 1111 
 
 the lower chest and the use of chloroform inhalations and morphia 
 internally. Analogous spasm may occur in the respiratory muscles ; 
 as yawning, sneezing, coughing, laughing and weeping spasms, pos- 
 sibly from vagus disease or from the neuroses, psychoses, multiple 
 sclerosis, bulbar paralysis or disease of the ear, nose or stomachy 
 
 The Posterior Thoracic Nerve. — This nerve is often affected in its 
 long course, from trauma, muscular strains in overhead work (the 
 nerve originates in the scalenus medius) and from carrying loads on 
 the shoulder — whence its occurrence in men in 90 per cent, of cases; 
 it is also involved in muscular atrophies and in neuritis. The results 
 are impaired fixation of the scapula, movement of the arm and inspi- 
 ration. The scapula wings out when the arm is moved forward and 
 stands less obliquely than normal, its outer part moving forward, 
 while the lower angle is drawn in by the rhomboids and trapezius. 
 The sole sensory change is pain in the neck and shoulder. The course 
 is tedious and rest, especially of the scaleni, is the prime indication. 
 
 Suprascapular Nerve.— It originates in the fourth, fifth and sixth 
 cervical nerves and is affected in disease of the plexus or alone in 
 trauma, shoulder dislocations or falls on the hands. The supra- 
 spinatus and infraspinatus are paralyzed, giving some weakness in 
 fixation of the humerus, as uncertainty in writing, turning of the 
 lower scapular angle up and in, some anaesthesia over the scapula, fre- 
 quently shoulder girdle pain and often involving the Circumflex Nerve, 
 which arises from the fifth, sixth and seventh cervical nerves of the 
 posterior cord of the brachial plexus. Deltoid paralysis (dislocation, 
 crutch paralysis, plexus disease) produces inability to deviate later- 
 ally the arm, changes in the shoulder, which becomes angular, some- 
 times adhesions in the joint, probably trophic from its articular 
 branch and anaesthesia over the lower part of the deltoid. It may be 
 confused with primary joint disease, in which, however, the scapula 
 follows the arm movements. Paralysis of the teres minor is un- 
 important. 
 
 Musculospiral Nerve. — Arising from all the roots in the plexus 
 except the first dorsal and curving around the humerus, it is the most 
 exposed and most frequently injured nerve in the arm or body; in- 
 juries result from fracture, callus, blows, muscular exertion, carrying 
 heavy weights, tying the arms to the side or behind the back, sleep- 
 ing with the arm over the back of a chair, especially in alcoholics, 
 lifting the arms during surgical anaesthesia and Esmarch's constrictor ; 
 less often injury results from cold or lead palsy. Musculospiral 
 (radial) paralysis involves (a) the extensors of the upper extremity, 
 i. e.j the triceps, so that the elbow cannot be extended, and the supi- 
 nators ; the triceps sometimes escapes affection ; the supinator longus 
 is not involved in lead palsy or traumatism below the lower third of 
 the humerus and in centric disease it escapes because its centre is with 
 the flexors. The extensors of the wrist are involved, producing 
 marked atrophy of the back of the forearm and the characteristic 
 wrist drop; the extensors of the thumb and fingers are affected and 
 
1112 DISEASES OF THE NERVOUS SYSTEM. 
 
 * 
 
 become semiflexed and can only be extended by the interossei (ulnar 
 nerve) after the first phalanges are passively extended. Changes in 
 the synovial sac or bones of the dorsal wrist produce the painless 
 carpal tumor of Gubler, from involvement of branches to the wrist 
 or more probably from the mere mechanical action of flexion (see 
 Lead Intoxication). (b) Sensory disturbance, which is slight 
 compared with the palsy, may rarely cause anaesthesia over the deltoid 
 . and over the back of the forearm or more often over the radial side of 
 the dorsum of the hand, thumb, index and half of the middle finger. 
 Most cases recover with rest and immobilization. Flexor contracture 
 can be avoided by careful splinting. 
 
 Median Nerve. — The median nerve originates from the outer and 
 inner cords of the plexus and contains fibers from all its cervical 
 roots. Isolated paralysis is not common. It results from trauma, 
 fractures, stabs, carrying weights in the bend of the elbow and sleep- 
 ing on the arm. (a) Motor symptoms are conspicuous. Both prona- 
 tors are involved, besides all the flexors of the forearm, wrist and 
 fingers except the flexor carpi ulnaris and the ulnar part of the deep 
 flexor of .the third and fourth fingers. In the hand, the palmaris 
 longus, the abductor, opponens and short flexor of the thumb (result- 
 ing in flattening of the thenar prominence and the " ape hand " from 
 the index finger and thumb lying parallel) and the two radial lumbri- 
 cales are affected. The second phalanges cannot be flexed on the first 
 (save in the two ulnar fingers) ; flexion of the first phalanges by the 
 interossei is possible; metacarpophalangeal subluxation may result 
 from the unopposed extensor action of the interossei on the second 
 and third phalanges. The paralyzed muscles may waste and trophic 
 manifestations are quite common, (b) Sensory symptoms are often 
 slight. Anaesthesia, if present, is greatest in the palm, front of the 
 thumb, the first two fingers and half of the third. 
 
 Ulnar Nerve. — Its origin is the last cervical and first dorsal nerves ; 
 its superficial course at the inner condyle, forearm and wrist, exposes 
 it to injury, as by dislocation of the elbow, cuts and pressure on the 
 elbow during sleep and work. IsTeuritis occasionally causes paralysis. 
 It must be distinguished from spinal disease, which ascends from the 
 dorsal to the cervical region; this form is usually bilateral and is 
 preceded by ulnar anaesthesia (Biernacki) in tabes and paretic, demen- 
 tia. The flexor carpi ulnaris is paralyzed (the hand deviates to the 
 radial side in attempts at flexion), and also the ulnar half of the deep 
 flexors of the fingers, the muscles of the little finger, palmaris brevis, 
 the interossei, the third and fourth lumbricals, the adductor and 
 inner head of the short flexor of the thumb (the thumb being rotated 
 toward the palm). The first phalanges cannot be flexed nor the others 
 extended, although this is less marked in the first and second fingers, 
 in which the lumbricals are supplied by the median nerve. The "claw 
 hand" results, although it is less marked than in spinal muscular 
 atrophy; the hypothenar eminence, palm and interosseous spaces be- 
 come thin. Sensory loss is limited to the back and front of the ulnar 
 
BBACHIAL NEUB1TIS. 1113 
 
 side of the hand, the dorsum of two and a half fingers and the front of 
 one and a half fingers on the ulnar side. 
 
 Combined Paralysis of the Arm Nerves. —This affection, described 
 by Erb (1884), is very common and is due to affections of the verte- 
 brae, cord or nerve roots, to tumors, trauma or cicatrices of the neck 
 and wrenches or forcible delivery in obstetrics. Several nerves are 
 involved, as the musculospiral and ulnar in fracture of the humerus, 
 or in subcoracoid luxation; in Erb's case the circumflex, supra- 
 scapular and musculocutaneous nerves, fifth and sixth cervical roots, 
 with some branches from the fourth, were imbedded in a cicatrix 
 and paralyses of the deltoid, teres minor, spinati, biceps, brachialis 
 and supinators, with few sensory signs resulted. Excision of the scar, 
 resection and nerve suture resulted in recovery. Erb found one spot 
 between the 'scaleni where all these nerves could be stimulated and 
 could be simultaneously affected. Neuritis ascending from the 
 median nerve may cause ulnar and musculo-cutaneous or other paraly- 
 sis. Obstetrical paralysis usually recovers, while adult forms depend- 
 ing on their etiology are often protracted or permanent. Flau- 
 bert (1827) described a combined paralysis, which usually bears 
 Klumpke's (1885) name, in which paralysis of the first dorsal and 
 eighth cervical roots (ulnar and median paralysis) also causes nar- 
 rowing of the pupil and the interpalpebral fissure. 
 
 Brachial Neuritis. — This affection was first clearly described by 
 Gowers as a perineuritis of the plexus or nerve roots (radicular neu- 
 ritis), occurring largely in gouty or rheumatic subjects over fifty 
 years of age, but at times due to compression or trauma. The author 
 saw one case which occurred in the right arm of a busy surgeon. A 
 cervical rib may cause compression symptoms; Reisman (1904) col- 
 lected 46 cases of which 24 were operated on with good results. It 
 is marked by great pain, the first, most severe and most enduring 
 symptom. It is constant, with paroxysmal exacerbations, is increased 
 by the least movement and is experienced over the plexus, nerves or 
 referred to the wrist or scapula. Associated with it are tenderness 
 over the trunks or plexus, hypersesthesia of the skin, some muscular 
 wasting, mostly in radicular forms and somewhat less often anaes- 
 thesia, anaesthesia dolorosa, oedema, glossy skin and trophic alterations 
 in the joints. Neuralgia, angina pectoris and aneurysm may cause 
 diagnostic difficulties. Remak holds that reported recoveries of acute 
 poliomyelitis in children (Kennedy's temporary paralysis) are only 
 plexus neuritis. The outlook is usually favorable, but a long course 
 of from a month to more than a year, relapses and even some wasting, 
 cramps, rheumatic pains and joint adhesions must be considered in 
 framing the prognosis, despite early and careful treatment, as in 
 reduction of shoulder dislocations. Treatment, as in neuritis, consists 
 of rest by immobilization, injection of cocaine in severe cases and 
 treatment of the underlying trauma, gout or rheumatism. 
 
 Nerves of the Trunk. — These are rarely involved except in lesions 
 of the spine or cord. The neuritic pain in Pott's disease or cord 
 
1114 DISEASES OF THE NERVOUS SYSTEM. 
 
 tumor and the girdle pain of tabes are of great localizing value. ^ It 
 has been shown that herpes zoster is due to inflammation in the spinal 
 root ganglia (Campbell and Head). 
 
 Nerves of the Lower Extremities. — These nerves, except in sciat- 
 ica, are less frequently affected than those of the arm. 
 
 The Lumbar Plexus.— The lumbar plexus (the first three and a half 
 lumbar roots) may suffer in abdominal tumors, glandular enlarge- 
 ments, parturition, psoas abscess, pelvic inflammations, spinal menin- 
 gitis, vertebral disease or in neuritis ascendens. The symptoms are 
 paralysis of the cremasters, flexors and adductors of the hip and 
 extensors of the knee; all the hip flexors are involved in plexus dis- 
 ease only ; great pain in neuritic forms is noted in the ilio-inguinal, 
 iliohypogastric and genitocrural areas. Anaesthesia exists over the 
 lower abdomen, front and sides of thigh and inner side of leg and foot 
 and adjacent sides of first and second toes. 
 
 Anterior Crural Nerve. — Lesions in the abdomen cause paralysis 
 of the iliacus (not the psoas), the hip flexors and knee extensors, with 
 wasting, loss of knee jerk and anaesthesia over the front and sides of 
 the thigh and the inner side of the leg and foot. It has occurred in 
 1.7 per cent, of labor cases and may result from stab wounds of the 
 thigh, in which case the iliacus escapes involvement. Neuritis of its 
 external cutaneous branch (multiple neuritis, alcoholism, nicotinism 
 or gout) may cause isolated anaesthesia over the lower outer half of 
 the thigh, paresthesia or marked hyperesthesia ; the last condition, 
 known as meralgia, was described by Bernhardt and Eoth and is 
 usually neuritis but may be due to pressure from varicose veins. It 
 is noted, chiefly, on standing or walking. In 1900 Musser and Sailer 
 collected 99 cases (74 per cent, in men). 
 
 Pressure on the cord at the fourth lumbar roots produces the same 
 result as a partial lesion of the ant. crural nerve, as paralysis of knee 
 extensors, loss of knee-jerk and anaesthesia of anterior part of thigh, 
 but foot clonus is present. Disease of the anterior horns on one 
 side may exceptionally occur in adults, but its wider prevalence and 
 sensory exemption are usually sufficiently distinctive. Caudal lesions 
 are usually bilateral. 
 
 Obturator Nerve. — This nerve is rarely alone involved save during 
 parturition. Its paralysis affects the thigh adductors, so that the 
 knees cannot be crossed, and the pectineus and ext. obturator, so that 
 impairment of outward rotation of the thigh results. Sensorv svmp- 
 toms concern the hip and knee joints, which sometimes show'trophic 
 disturbance. The pain of hip disease is referred to the knee bv the 
 obturator nerve. 
 
 Superior Gluteal Nerve.— This arises from the lumbosacral cord, 
 being intermediate between the lumbar and sacral plexuses. Its rare 
 isolated involvement results in loss of thigh abduction and circum- 
 duction (gluteus medius and minimus). 
 
 The Sacral Plexus.— The sacral plexus (half of the fourth the 
 fifth lumbar and the first four sacral nerves) supplies motion to the 
 
DISEASE OF THE SCIATIC NEBVE. 1115 
 
 extensors and rotators of the hip, flexors of the knee and all the foot 
 muscles, and sensation to the gluteal region, the back of the thigh, 
 outside and back of the leg and most of the foot by the gluteal nerves 
 and the two sciatic nerves. The lesser sciatic is affected only in dis- 
 ease of the plexus; it is often involved in pelvic inflammation and 
 tumors, parturition, traction in leg deliveries, plexus neuritis and 
 diseases of the hip. 
 
 Great Sciatic Nerve. — This is the largest, the most exposed 
 throughout its course and hence the most frequently diseased nerve 
 of the lower extremity. Paralysis of the gluteus maximus interferes 
 with rising more than with walking. A lesion near the sciatic notch 
 paralyzes the extensors of the hip, the flexors of the leg and all muscles 
 below the knee. If the lesion lies below the upper third of the thigh 
 the flexors of the leg may escape involvement and walking is still 
 possible, even though all muscles below the knee are paralyzed, if 
 the ant. crural nerve for the hip flexors and knee extensors is intact. 
 Sensation is lessened over the outer half of the leg, most of the 
 dorsum of the foot and all of the sole. Wasting is marked over the 
 back of the thigh and perforating ulcer of the foot may develop. It 
 has two branches: (a) the external popliteal or peroneal nerve, in- 
 volvement of which causes paralysis of the tibialis anticus, peronei, 
 long toe extensors, extensor brev. digitorum; the ankle cannot be 
 flexed dorsally, the first phalanges of the toes cannot be extended,, 
 adduction and lifting the inner edge of the foot is difficult and abduc- 
 tion and lifting its outer edge is impossible. Foot-drop results and 
 contracture assumes the equinovarus type. This nerve is the analogue 
 of the musculospiral in the arm. Wasting is often observed and the 
 anaesthesia covers the anterior outer half of the leg and the dorsum of 
 the foot, (b) Internal popliteal nerve, involvement of which affects 
 the popliteus, tibialis posticus, long flexors of toes and all the foot 
 muscles except the extensors; plantar flexion, abduction of the foot, 
 inability to stand on tiptoe, talipes calcaneus and the claw foot from 
 overextension of the proximal and overflexion of the second and third 
 phalanges result. Sensory alterations are variable; anaesthesia may 
 be observed on the outer lower posterior part of the leg and on the 
 sole of the foot. Its plantar branches are rarely affected alone; (i) 
 paralysis of the internal plantar nerve, which is analogous to the 
 median; anaesthesia on the inner part of the sole and the plantar 
 surface of the three inner toes and one-half of the fourth; paralysis 
 of the short toe flexors, plantar muscles of great toe (except the ab- 
 ductor) and the two inner lumbricals; the big toe is overextended, 
 "the hammer toe"; (ii) paralysis of the external plantar nerve, the 
 analogue of the ulnar, produces anaesthesia of the outer half of the 
 sole, little toe and one-half of the fourth, paralysis of the accessory 
 flexor, small toe muscles, all the interossei, two outer lumbricals and 
 great toe adductor; the results are serious, walking being impaired 
 by flexion of the second and third and extension of the first phalanges. 
 
 Caudal Lesions. — (See Spinal Localization.) 
 
1116 DISEASES OF THE NEBVOUS SYSTEM. 
 
 Sciatic Neuritis. — Sciatica, Ischialgia, Malum Cotunnii (Cotugno, 
 1764). — Sciatica is, after facial neuritis, the most frequent isolated 
 form and is rarely simply neuralgic. 
 
 Etiology. — 1. General Causes. — (a) Sex and age; 88 per cent, of 
 cases occur in men; 16 per cent, in persons between twenty and 
 thirty, 31 per cent, between thirty and forty, 25 per cent, between 
 forty and fifty and 18 per cent, between fifty and sixty years of age. 
 It is very rare in children, (b) Acute infections, rheumatism and 
 grippe are causative, (c) Intoxications; gout, fascial rheumatism 
 (sometimes by extension from lumbago) and diabetes are factors. 
 (d) Anaemias and neuroses are less significant than in neuralgia. 
 
 2. Local Causes. — These include (&) spinal affections, tumor and 
 caudal neuritis; (b) abdominal and pelvic diseases, as aneurysm, tu- 
 mors or inflammation; (c) cold; exposure and dampness, favored by 
 certain occupations; (d) trauma to the spine, pelvis, hip or peripheral 
 course of the sciatic trunk or branches, as from the use of forceps or 
 pressure of the head in labor, fractures, dislocations, falls, protracted 
 sitting or riding, use of the sewing machine, marching, vigorous 
 contractions of the leg flexors, peripheral pressure by popliteal aneu- 
 rysm, tumors, callus or varicosities. 
 
 Pathology. — In the infrequent autopsies or in surgical stretching 
 of the nerve its sheath shows perineuritis with oedema and in some 
 cases increase of connective tissue or varicosities of the sheath vessels, 
 especially in the middle thigh. Sometimes interstitial neuritis is 
 found. 
 
 Symptoms. — The symptoms are unilateral and chiefly sensory, as 
 pain and tenderness over the sciatic roots, trunk and branches, (a) 
 The onset of pain is usually gradual but is sudden and febrile in some 
 rheumatic cases. It is usually constant, with exacerbations which 
 in some cases are agonizing. The pain descends more often than it 
 ascends ; it sometimes radiates to the buttocks and crural region, even 
 into the other leg. Gowers attributes the local pain to perineuritis 
 and the distant pain to interstitial neuritis. Any movement which 
 increases sciatic tension increases or renews the pain (Lasegue's 
 phenomenon) ; pain is increased or initiated by flexing the hip" and 
 extending the knee, walking, stooping or defecation. The patient 
 seeks positions which spare stretching of the nerve and its compression 
 by the. muscles ; he may lie on the opposite side with the thigh ex- 
 tended, knee flexed and foot extended, or on his back with hip and 
 knee flexed and foot extended; in standing, he rests on the sound leg 
 and in protracted cases scoliosis develops (ischias scoliotica, Albert, 
 1886), in which the lumbar convexity is toward the diseased side, 
 heterologous scoliosis, which usually disappears with the disease ; a 
 homologous scoliosis (with the lumbar concavity toward the affected 
 side) may result in case the muscles of that side become spasmodic. 
 (6) Tenderness may be detected over the entire course of the nerve 
 or in certain locations only; (i) over the lumbar region; (ii) near the 
 sacrum and post. sup. iliac spine; (iii) at the lower gluteal fold 
 
SCIATICA. 1117 
 
 where it leaves the sciatic notch; (iv) between the tuber ischii and 
 trochanter; (v) especially over the middle of the posterior surface of 
 the thigh; and (vi) in other lower areas of distribution over the pop- 
 liteal space, head of fibula, calf, internal and external malleoli and 
 sole. The enlarged nerve may occasionally be felt. Pain is often 
 experienced in the hip and sciatic notch when pressure is made in the 
 popliteal space, (c) Other symptoms are less frequent, as vasomotor 
 changes, herpes, muscular cramps, twitchings, fibrillation or wavy 
 movements (myokymia) ; there is usually some diminution in the 
 electrical excitability, but there is rarely a marked degenerative 
 reaction; muscular atrophy may occur from disuse or neuritic 
 atrophy; sciatic paralysis may occur; hypgesthesia, paresthesia, or in 
 severe cases anaesthesia, may develop in the posterior part of the 
 thigh, leg or foot; very rarely there is polyuria or glycosuria. The 
 patellar reflex is usually normal, the Achilles reflex is often decreased 
 or absent and Gibson found the cremasteric usually increased. 
 
 Diagnosis. — (a) The etiological factor should be sought, (b) The 
 pelvis should always be examined in women and the rectum in both 
 sexes, because compression produces more distant than local pain ; 
 the urine should always be examined for sugar and albumin; and 
 free catharsis and bowel lavage should always be given, (c) Bi- 
 lateral sciatic pain suggests disease of the cord, especially tabes, a 
 lesion of the cauda, in both of which there is no sciatic tenderness, or 
 it prompts examination for diabetes, (d) Coxitis, sacro-iliac or psoas 
 disease present appropriate local signs, without however Lasegue's 
 sign or sciatic tenderness, both of which are also absent in (e) hys- 
 teria. (/) Muscular rheumatism is irregular and is chiefly confused 
 with pain over the sciatic branches. 
 
 Prognosis. — The prognosis is generally good, in regard to the ulti- 
 mate outcome. It depends on (a) whether the affection is primary, as 
 from cold, or secondary, as from disease of the cord or pelvic neo- 
 plasm; (b) the amount of rest which the patient accepts; (c) the 
 intensity of the neuritis, which may extend to the lumbosacral plexus ; 
 and (d) the chance (in 33 per cent.) of relapse. The average course 
 is from two to eight weeks, but cases may last over a year, indeed one 
 to three or exceptionally six to thirty years. 
 
 Treatment. — (a) Treatment is that of the cause; the salicylates, in 
 some, but unfortunately few, cases afford relief; gouty or syphilitic 
 taints may be benefited by colchicum or antisyphilitic remedies, 
 which are often given as a last resort in other cases, (b) Rest in bed 
 is the most important indication. In this, extension or Weir 
 Mitchell's long splint is often beneficial, (c) C ounterirritation by 
 blisters over the nerve's course or by touching the tender or painful 
 points with the hot iron, may give temporary though rarely lasting 
 relief, (d) Analgesics and narcotics. Acetanilide has little effect. 
 Gelsemium (flextr. TTlij) at intervals of two to four hours, not in- 
 frequently gives relief, though it is necessary to watch for pulse weak- 
 ness and cutaneous tingling. Codeine and atropine should be given 
 
1118 DISEASES OF THE NEEFOUS SYSTEM. 
 
 before resorting to morphine; morphine is often inevitable, but 
 always dangerous. Chronic morphinism may be promoted by severe 
 pain, the long course and the tendency to relapse. Hypodermics 
 of cocaine are very beneficial, though this method is attended by the 
 same danger. Simple hypodermics of water are sometimes valuable 
 and the author has seen good results from deep hypodermatic use of 
 Schleich's solution given in quite large amounts over sensitive points. 
 Lange advises the use of 160 c.c. of 0.1 per cent, eucain solution into 
 the muscle and nerve at the sacrosciatic foramen. Injections of chlo- 
 roform and ether should be avoided because of the possibility of 
 sloughing and also of accentuating the neuritis, (c) Acupuncture, 
 the old Chinese treatment, is recommended by Gibson ; it resulted in 
 complete relief in 56 per cent, of his cases, much improvement in 32 
 per cent., slight benefit in 10 per cent, and failure in but 2 per cent. 
 (/) Massage may be given. Negro has obtained results from frequent 
 and severe local rubbing and rolling, over the nerve trunk, (g) 
 Electrotherapy may aggravate the pain and is at least of uncertain 
 value. Galvanism is reported to have helped some cases, (h) Nerve 
 stretching may be effected by extension by weights, although it is 
 rarely tolerated by the patient in personal experience. The direct 
 exposure of the nerve has justly fallen into disuse, for the same results 
 attend simple stretching, which should be performed under anaes- 
 thesia. The hip should be strongly flexed, the knee extended, the foot 
 dorsally flexed and the pelvis firmly immobilized. Ordinary care 
 prevents luxation of the hip. The results were excellent in half of 
 twenty personal cases and were seemingly curative in seven. 
 
 THE NEUROSES. 
 
 HYSTERIA. 
 
 Definition. — The neuroses are nervous affections, provisionally iso- 
 lated and often designated "functional," since no anatomical basis 
 has jet been discovered. Hysteria is difficult to define. Mobius 
 considers it " a state in which ideas control the body and produce 
 morbid changes in its functions." The school of Charcot has estab- 
 lished the psychogenic nature of hysteria. It is a cerebral, cortical 
 condition, in which the sensory and motor centres are affected, the 
 perception, association and recollection of ideas are disturbed and 
 trophic and vasomotor disorders occur. As its name implies, hysteria 
 was long thought to be due to the uterus ; Sydenham first called it a 
 nervous affection. 
 
 Etiology.— (a) Age: It is most frequent at puberty and adolescence 
 (fifteen to twenty-five years). It is occasionally seen in children (six 
 
HYSTERIA. 1119 
 
 to ten years or even earlier) and rarely in middle or advanced life. 
 (&) Sex: Women are ten times as frequently affected as men, although 
 in the lower French classes it is more frequent in males, (c) Race: 
 The Jewish, Latin and Slavic races are most frequently affected. 
 (d) Heredity: Charcot and most of the modern Trench school hold 
 that this is the sole cause, other factors being only agents provoca- 
 teurs. Parental intoxications, toxaemias, constitutional diseases, as 
 gout, diabetes, arthritis deformans and a neurotic taint are important 
 in the transmission of a congenitally weak nervous system, (e) 
 Acquired hysteria may be due (i) to various intoxications, notably 
 lead, alcohol and drugs; (ii) to infections, as typhoid, malaria, diph- 
 theria and syphilis; (iii) to constitutional maladies, as gout, diabetes, 
 chlorosis, secondary anaemias or cancer; (iv) to exhaustion from 
 mental or physical overwork or excesses ; (v) to emotional disturbance 
 of any kind; (vi) to trauma, especially factors involving psychical 
 shock, (vii) It may occur as an associate with chronic nervous dis- 
 ease, epilepsy, syringomyelia, tabes, brain tumor and multiple scler- 
 osis, (viii) Imitation is an important factor in schools, hospitals and 
 at religious revivals ; endemics occasionally occur now as they did in 
 the middle ages. (Refer to Zola's Lourdes.) Reference to the sexual 
 organs as causes and to reflex hysteria is purposely omitted, because 
 they have no etiological bearing. The factors enumerated under ac- 
 quired hysteria are, according to the French school, merely incidental 
 causes, making manifest the latent hereditary disposition. 
 
 Symptoms. —There is no typical clinical picture and the disease is 
 much more commonly polysymptomatic than monosymptomatic. 
 French writers distinguish two main groups of symptoms, the stig- 
 mata and accidents. 
 
 Stigmata. — The stigmata are usually but not necessarily persis- 
 tent symptoms. 
 
 1. Sensory Stigmata. — Sensory symptoms are present in 85 per 
 cent., are more frequent than the motor and are often combined with 
 them, (a) Hysterical anaesthesia in some form is very seldom absent. 
 It must often be looked for, but the fact should not be too obviously 
 suggested to the patient. It varies in degree and form. It may be 
 absolute, affecting appreciation of touch, pain, heat and cold. Anal- 
 gesia is its most common form and, in decreasing order of frequency, 
 there may be complete anaesthesia, hypaesthesia, loss of tactile sense, 
 loss of all sensation save to the faradic current or loss of faradic 
 response alone. In the mucosae the same deficit frequently occurs and 
 sometimes the bones, ligaments, joints and muscles are likewise anaes- 
 thetic or analgesic. The distribution varies. In rare cases there is 
 universal cutaneous and muscular anaesthesia; the following are 
 more frequent: Hysterical hemianesthesia, which involves precisely 
 one-half of the skin, often the accessible mucosae and the special 
 senses; segmentary or geometrical anaesthesia, which affects one limb 
 or part of it, is variously described as "mitten or stocking" anaes- 
 thesia and is frequently associated with motor or special sense dis- 
 
1120 DISEASES OF THE NEEFOUS SYSTEM. 
 
 turbance in the part affected, as paralysis, aphonia, amblyopia and 
 deafness; and insular anaesthesia, which affects small areas, and is 
 therefore frequently overlooked. 
 
 Characteristics. — The anaesthesia is psychical, is associated with 
 the functions of the part affected and does not follow the area of 
 distribution of the peripheral nerves or the spinal segments ; it is not 
 noted by the patient, at least until suggested ; fine movements may be 
 conducted with the aid of the eyes, as the using of a pen ; it may be 
 localized because of injury or disease in the part. Most of the re- 
 flexes usually altered by organic disease remain normal, as the pupil- 
 lary, lachrymal, epigastric, cremasteric, patellar and organic reflexes, 
 while the pharyngeal in 90 per cent, of cases is lost, as well as the 
 plantar (though the knee reflex remains) ; the anaesthetic areas may 
 last during life, but they vary, move even under examination (Pat- 
 rick) or disappear from emotion, strongly aroused attention, drugs 
 or on application of various indifferent substances, as metal or wood 
 (transferring it to the opposite side). 
 
 Hysterical hyperesthesia and hyperalgesia are very common in 
 localized areas, but never in universal or hemiplegic distribution. 
 They occur spontaneously or from attention directed to a part or 
 organ, as by traumatism. A joint may be affected with or without 
 contracture (Brodie's joints) and this often leads to great and un- 
 fortunate errors. There is sometimes hypaesthesia in the sphere of 
 any of the special senses. The feeling of a nail in the top of the head 
 (clavus hystericus), sensitive spots in the mammae, epigastrium, 
 groins or spine are the most common forms and may occur in the 
 midst of anaesthetic areas. The so-called ovaralgia is found more 
 often on the left side and is cutaneous; it has no relation to the loca- 
 tion or to disease of the ovary ; it occurs also in men and in women 
 normal as to the pelvis. Because hysterical attacks have been ini- 
 tiated and sometimes stopped by pressure over this and other sensi- 
 tive areas they have been called hysterogenic points or zones, but at- 
 tacks are only so produced in patients already hysterical and the 
 hysterical seizure on pressure results only from some associated mem- 
 ory on the part of the patient; they are often the result of suggestion. 
 The special senses. Taste and smell may be dulled or hypersensi- 
 tive and hearing may be blunted, or more rarely complete central 
 deafness results, which is usually associated with anaesthesia in and 
 about the auditory meatus. Complete loss of vision is both rare and 
 transitory. Hemiopia and scotomata are almost always organic and 
 not hysterical. Partial stigmata are more common. In most cases 
 there is concentric contraction of the visual field, which is usually 
 bilateral but unequal on the two sides and generally greater on the 
 side of the cutaneous defects. Concentric contraction of the field for 
 colors (dyschromatopsia) is more characteristic, even pathognomonic. 
 In the normal eye, blue has the largest field, then yellow, orange, red, 
 green and violet ; m hysteria the red field is often wider than the 
 blue and is the last color lost. Achromatopsia designates the com- 
 
HYSTERIA. 1121 
 
 plete loss of color perception. Errors in accommodation (always 
 excluding abnormal corneal curvatures) may cause double images 
 in one eye — the other being closed — (monocular diplopia), triple 
 images (polyopia) or large or small images (macropsia, micropsia), 
 In hysterical amblyopia impairment of vision in the affected eye is 
 decreased when the other eye is opened. 
 
 2. Motor Stigmata. — These are much less conspicuous but fore- 
 shadow the motor accidents described below. Vountary movements 
 are weaker, more clumsy, slower, less coordinate than normal and 
 there is a slight tendency toward contractures. 
 
 3. Mental Stigmata. — These are in certain cases so pronounced as 
 to justify the term psychosis. Hysteria is always a psychical affec- 
 tion. The most conspicuous alienation is impairment of memory 
 (amnesia), which concerns memory in the ordinarily accepted sense, 
 as memory for persons, things, words, hysterical paroxysms experi- 
 enced, etc., or concerns memory and associations for speech, writing, 
 walking or standing. The amnesia, like paralysis and anaesthesia, is 
 functional and like them returns, save in rare cases. Mental power 
 is distinctly decreased, will power is lost (aboulia) or lessened and the 
 patient becomes the ready victim of impulses, impressions, sugges- 
 tions, fixed ideas and misconceptions both on his own part and on that 
 of others who incorrectly consider him deceitful, vain or erotic. 
 
 Accidents. — The accidents of hysteria are the incidental attacks, 
 also called seizures or paroxysms. They are usually transient or in- 
 termittent, but may become fixed and are then ranked as stigmata. 
 
 1. Motor Accidents. — (a) Convulsions occur in 54 per cent, of all 
 and 84 per cent, of female hysteria. They are much less frequently 
 the hysteria major (grande attaque of Charcot) than the partial, 
 modified type (hysteria minor). The "grand attach" (Charcot, 
 Richer) comprises (i) a prodromal stage, with mental depression or 
 exaltation, palpitation, vasomotor symptoms, nausea, polyuria, an 
 aura beginning in the epigastrium and culminating in feelings of 
 choking (globus hystericus), vertigo and unconsciousness; (ii) a 
 period of epileptiform convulsions (so-called hystero-epilepsy) in 
 which, in exceptional cases, there may be biting of the tongue or even 
 the cry of epilepsy; the face is at first pale, then red; the teeth are 
 ground; the convulsion is most pronounced on the anaesthetic side, 
 toward which the face turns; the tonic spasm lasts less than two 
 minutes and is often characterized by stupor, stertor and slow wide 
 movements of supination, circumduction and overextension, for the 
 trunk and body are tetanically rigid ; then the clonic spasm develops, 
 with sobbing respiration, audible swallowing, abdominal rumbling 
 and small clonic movements. Resolution follows slowly, (iii) There 
 is a period of " clownism," characterized by contortions and grand 
 movements, as opisthotonos (arc de cercle), bowing movements, vio- 
 lent struggling, screams, strikes and bites, (iv) There is next a 
 period of "passional attitudes," in which the subject mimics terror, 
 rage, joy and love; this is followed by (v) a stage of delirium with 
 
 71 
 
1122 DISEASES OF TEE NERVOUS SYSTEM. 
 
 hallucinations, perhaps of animals (zoopsia). The entire attack 
 covers fifteen to thirty minutes and frequent repetitions constitute 
 the " status hystericus." 
 
 The partial attack contains some of the elements of the major type, 
 and infinite variations occur ; in the vertiginous type there is vertigo 
 and sometimes other features of Meniere's disease ; the globus type is 
 extremely common; the epileptiform variety closely resembles epi- 
 lepsy; there are also tetanic, emotional and syncopal types; trance- 
 like sleep, with catalepsy in which the limbs retain any attitude given 
 them, with sleep, which is apparent only, for the subject later recalls 
 everything; there may be attacks of somnambulism, in which patients 
 run miles or even undertake distant travel without recollection of the 
 transpired interval, (b) Paralysis is an accentuation of the stig- 
 matic muscular weakness. In over 50 per cent, it develops after con- 
 vulsive paroxysms ; again it follows emotional causes, traumatism 
 or organic brain disease. It develops suddenly or gradually; it as- 
 sumes the paraplegic Hve times as often as the hemiplegic form; the 
 monoplegic variety is less frequent; the triplegic, diplegic (quadri- 
 plegic) or crossed forms are most common. They are rarely com- 
 plete; often automatic (gesticulatory) movements may be seen; the 
 antagonistic muscles are also involved, thus, in attempted flexion of 
 the knee the knee extensors contract; remissions and relapses may 
 occur ; the paralyzed part may be limp or contractured ; the paralyses 
 may be ephemeral or life-long in duration ; paralysis may be " ideal," 
 i. e., only for standing or walking. Vasomotor changes and oedema 
 are rare ; Weir Mitchell described a hemicedema ; the tendon, skin and 
 electrical reactions are usually normal, although the tendon reflexes 
 may be increased. Hysterical hemiplegia occurs three times as fre- 
 quently on the left as on the right side. Its differentiation from 
 organic hemiplegia is based on Babinski's table: 
 
 Organic Hemiplegia vs. Hysterical Hemiplegia. 
 
 Coma: often complete. Barely complete (automatic movements 
 
 often persist). 
 
 Reflexes: tendon and bone reflexes abol- Rarely abolished; no clonus (or only a 
 ished at first; later increased. Ankle spurious ankle clonus due to contrac- 
 
 clonus - tion of the calf muscles, Gowers). 
 
 Cutaneous reflexes (abdominal and Skin reflexes normal: no toe sign, 
 cremasteric) early lessened or abol- 
 ished; Babinski toe sign; lachrymal 
 reflex abolished. Never abolished (Spiller). 
 
 Paralysis: (1) Unilateral ; (2) not (1) Not always unilateral; if face in- 
 systematized; face, arm and leg are volved, usually on both sides (2) 
 weak during bilateral synergetic Paralysis sometimes systematized ; 
 movements. (3) Involves subcon- and hemiplegic side functionates per- 
 scious as well as conscious voluntary fectly in bilateral synergetic move- 
 movements, producing the platysma ments. (3) Subconscious voluntary 
 sign (lessening of its contraction on movements are not involved- ab- 
 the hemiplegic side, e. g. on opening sence of the platysma sign and that 
 the mouth forcibly), and the com- of combined flexion of the thigh 
 
HYSTEBIA. 1123 
 
 bined flexion of the thigh and trunk and trunk. (4) Variable paralysis, 
 
 (when the patient attempts to sit improvement alternating with relap- 
 
 up). (4) Paralysis slowly improves ses. Absolute aphasia with ability to 
 
 some, but is not variable. write (Charcot). 
 
 The tongue deviates slightly toward the Very slightly, very greatly or even 
 paralyzed side. toward the sound side. 
 
 Lower muscular tone, as lowering of None. Asymmetry of the face is due 
 
 the eyebrow or exaggerated flexion to spasm, and exaggerated flexion of 
 
 of the forearm, especially in early the forearm is absent, 
 cases. 
 
 Contracture cannot be voluntarily re- May be reproduced; variable paralysis, 
 produced; at first flaccid paralysis, now persistently flaccid, now spastic 
 
 then contracture. from onset; flaccidity with increased 
 
 reflexes highly characteristic. 
 
 Hemianesthesia: rarely total; mostly Often total, involving special senses, 
 of stereognostic and muscle sense; in mostly involving pain and pressure 
 
 general rare; coarser; more lasting sense; frequent; variable in duration 
 
 when present; often with bilateral and location; usually with concentric 
 
 hemianopsia. contraction of visual field, and some- 
 
 times with crossed amblyopia. 
 
 In hysterical paraplegia there are usually no trophic changes, no 
 bed-sores, no electrical alteration, no incontinence of urine or fseces 
 and rarely retention of urine; concomitant sensory changes are sig- 
 nificant, but many errors in diagnosis are made. Hysterical mono- 
 plegia usually occurs with anaesthesia of even greater extent and seg- 
 mental distribution ; it is lawless and illogical, viewed from the stand- 
 point of organic disease. In astasia-abasia (Charcot and Blocq) the 
 patient is unable to stand or walk, although the muscles concerned 
 may be efficient in other movements. The condition is essentially hys- 
 teria, although it was thought to result from neurasthenia and hypo- 
 chondriasis. Lesser degrees are called dystasia or dysbasia. The 
 term stasobasophobia is self-descriptive. Mobius' akinesia algera is 
 similar, (c) Hysterical contractures precede, succeed or alternate 
 with paralysis, or occur alone, but, as Church well says, they are 
 " rigid palsies " ; they usually persist during sleep and yield to ether 
 anaesthesia, save in severe protracted cases with great fibrous trans- 
 formation and irremediable deformity ; they develop and terminate 
 suddenly or gradually; their causes of onset and distribution are as 
 in paralysis. In the arms, contracture of the flexors predominates; 
 in the legs, that of the extensors (club foot). Various spinal de- 
 formities may develop, most frequently from pseudosciatica. Weir 
 Mitchell has seen the muscles so contracted as to resemble actual 
 muscle tumors. It is still stated that the face always escapes paraly- 
 sis, but its lower portion may be weak; more often, however, it is 
 contracted early, even when paralyzed; hemispasmus glossolabialis 
 and trismus have been observed. Spastic or pseudo-ptosis may re- 
 semble the paralytic form, but spasticity, the lowered or more level 
 eyebrow and the concentric or parallel folds in the lid are distinctive 
 of contracture. The ocular muscles are seldom involved; voluntary 
 
1124 DISEASES OF THE NEBVOUS SYSTEM. 
 
 movement may be impossible, but associated and reflex movements 
 are normal; convergent squint may occur, but never the divergent 
 type nor contracture of a single rectus or oblique muscle ; pain sug- 
 gests hvsteria. The pupils are usually said to be normal, but Karplus 
 maintains that the light reflex is lost during convulsive seizures. 
 Organic disease of the hip may be simulated ; local hysterical oedema 
 may occur. Brodie (1827) first drew attention to this group of cases, 
 and later Duchenne. Many avoidable diagnostic errors are con- 
 stantly made, (d) There may be rhythmical spasms, tremoror tic. 
 Rhythmical spasms, chorea major, the saltatoric chorea (v. i.) and 
 local manifestations, as barking cough or the various tics, may occur. 
 Hysterical tremor is wholly a " rest tremor " ; that is, it occurs with- 
 out voluntary movement. It may resemble the senile, Basedow or 
 lead tremors or that of paralysis agitans or may be combined with 
 them. It rarely simulates the intention tremor of multiple sclerosis. 
 
 2. Sensory Accidents. — These are frequent and are often severe 
 and painful. Headache may occur ; it is often dull or may be severe ; 
 it may be superficial or deep ; it may resemble trigeminal neuralgia, 
 migraine or the headache of organic disease, as tumor. Meningitis 
 (hysterical pseudomeningitis) may be closely counterfeited. Spinal 
 or vertebral pain is frequent and sometimes suggests tumor or caries. 
 One and three-tenths per cent, of cases of sciatica are said to be hys- 
 terical. Joint disease and various visceral lesions (v. i.) may be 
 closely mimicked. Dieulafoy (1905) collated 59 cases of hysterical 
 blindness, in 5 of which this accident was the only symptom. 
 
 3. Visceral Accidents. — (a) Cardiac accidents include tachycardia, 
 palpitation and pseudo-angina pectoris, (b) Respiratory accidents: 
 Aphonia, usually attended by normal capacity to cough and often also 
 to sing, has been described under paralysis of the vocal cords. It is 
 usually due to an " idea," as in a motor aphasia which allows the 
 patient to write. Stammering, cough and cries may be provoked by 
 local nasopharyngeal disease. Dyspnoea, resulting from paralysis of 
 the diaphragm, and laryngeal spasm have already been considered. 
 Rapid breathing (tachypnoea) also occurs. The combination of dys- 
 pnoea, aphonia and paralysis of the diaphragm constitutes Briquet's 
 syndrome. Haemoptysis may occur, usually in the course of phthisis, 
 but sometimes without it, possibly as a vasomotor derangement, since 
 the blood is thin ; one fatal case is on record, (c) Digestive accidents : 
 Hysterical anorexia results from cortical conception, stomach pain, 
 dysphagia from spasm or simple sensory perversion; it may endure 
 for weeks and cause extreme inanition or even death. Hysterical 
 (pseudo-) hydrophobia is an analogous aversion to water. Vomiting 
 is sometimes simulated by protracted globus or oesophageal spasm, in 
 which the food is simply regurgitated. Vomiting itself may be oc- 
 casional or attacks may last weeks or months, often with remarkably 
 little malnutrition; it is rarely fsecal but substances injected by rec- 
 tum may be vomited in a few hours ; or again vomitus may be blood- 
 tinged, possibly from vasomotor disturbance or more often from 
 
EYSTEBIA. 1125 
 
 actual disease, as round ulcer. Ulcer may also be simulated by pain 
 and tenderness, which are surprisingly well confined not to one spot, 
 but to the exact outlines of the stomach. The vomitus contains vi- 
 cariously large amounts of urea when the urine is suppressed. Eruc- 
 tations are frequent and so much gas escapes that one must conclude 
 that air has been swallowed ; this also probably causes tympanites, in 
 which swallowed air reaches the gut through the incompetent pylorus 
 (Ebstein). Phantom tumors or spurious pregnancy (pseudocyesis) 
 are explained by Gowers as protrusion of the distended bowel by tonic 
 contracture of the diaphragm. Peristaltic unrest, diarrhoea on eating, 
 enteritis membranacea, spastic constipation, simulation of peritonitis, 
 rectal stricture and intestinal obstruction also occur, (d) Genito- 
 urinary accidents: Anuria in some cases has existed for ten days 
 without uraemia. Penal pain is not frequent, but hyperesthesia of 
 the bladder is common. The urine is often greatly increased, with 
 low specific gravity and solids. During attacks of the major type 
 the solids are reduced, the urea one-third and phosphates one-half; the 
 phosphates, which normally have a proportion of 3 of the alkaline to 
 1 of the earthy phosphates, show nearly an equal proportion of each. 
 Depression of the genital functions is more common than exaltation; 
 anaesthesia is frequent; vaginismus may be observed. Lower has 
 found that the hysterical ovarian and other genital pains have no 
 relation to local pelvic disease, a rather gratifying gynaecological 
 observation. 
 
 Hysterical fever is a disputed topic. It is an established fact that 
 severe forms may suffer a rise to 105 or 110° or higher. With 
 visceral manifestations this may lead to a diagnosis of meningitis or 
 peritonitis ; but on the other hand the possibility of simulation by the 
 patient rubbing the thermometer, or more important still, the possi- 
 bility of confusion with tuberculosis or typhoid, must always be kept 
 in mind. 
 
 4. Vasomotor and Trophic Accidents. — These are rare. Erythema 
 is the most common. Gangrene, falling out of the hair or nails, Ray- 
 naud's local asphyxia, cutaneous hemorrhages (crucifixion stigmata, 
 stigmata diaboli), bloody sweats, lachrymation, haemoptysis, haema- 
 temesis, sudden tender swellings in the mammae and angioneurotic 
 oedema, which is sometimes blue in color, have been recorded in 
 exceptional cases. 
 
 Course and Prognosis. — The course is always chronic. If we look 
 on the disease as congenital the prognosis is poor as to total recovery, 
 especially with fixed psychical alteration and major manifestations. 
 Jolly remarks that complete recovery is as rare as death, which rather 
 overstates the facts. In mild forms practical recovery may follow, 
 but relapses may occur on disproportionately slight provocation. The 
 outlook is better in infantile and adolescent forms than in those of 
 middle or advanced life. The stigmata may be ephemeral or life- 
 long. Marriage may prove beneficial in light cases, but, with ma- 
 ternity, it is injurious in the severe types; marriage must never be 
 regarded as a therapeutic agent. 
 
1126 DISEASES OF TBE NERVOUS SYSTEM. 
 
 Diagnosis. — The stigmata, mental, motor and sensory, are highly 
 characteristic. The accidents are either unequivocally hysterical or 
 prove hysterical after consideration of their associations or history. 
 The real danger lies in overlooking concomitant disease (a) nervous, 
 as multiple sclerosis, brain tumor, paretic dementia; (b) postinfec- 
 tious hysteria, as hysteria plus neuritis; (c) lung, heart and other 
 visceral diseases, all of which, as Sydenham remarked, may resemble 
 hysteria. Simulation does not include the common borrowing or 
 mimicry of symptoms by hysterics ; simulation of hysterical stigmata 
 and accidents is practically impossible. 
 
 Treatment.- — 1. Prophylaxis. — This is possible when the earliest 
 manifestations occur in childhood. Home treatment is frequently 
 impracticable because of the family tendency. The etiological factors 
 must be studied, especially the hygiene and the hours of sleep. Useful 
 occupations, as out-of-door gardening, are preferable to less whole- 
 some and more artificial plans of distraction. Cultivation of the 
 cardinal virtues, courage and self-control, is sought. Servants who 
 teach fear of the dark and tell fairy stories should be watched. Self- 
 control should be insisted upon in adult cases. 
 
 2. General Treatment of the Cause. — As the disease depends 
 on disturbed cortical relations between the psychical and material 
 processes, the principal treatment must be psychical. The " fixed 
 idea " must be grasped and eradicated, which is best accomplished in 
 ordinary circumstances by isolation of the patient from home or from 
 other psychical or emotional circumstances surrounding the inception 
 of the disease. Then the undue susceptibility incident to the disease 
 may be turned to therapeutic advantage by the self-confidence of the 
 physician and by his covert suggestions. The Weir Mitchell rest- 
 cure may result in great benefit, and later " vague hints regarding the 
 curative power of nature," and fresh air and sunlight may captivate 
 the patient. Symptoms must not be suggested to the subject, as anaes- 
 thesia or pelvic disease, and examinations, especially of the pelvis, 
 should be omitted. Hysterics should not be allowed to associate with 
 each other for obvious reasons. This general plan is psychotherapy, 
 which of course might include hypnotherapy, as advocated by the 
 Nancy school, Bernheim and others. Hypnotism is generally dan- 
 gerous in its ultimate and often in its immediate effects; though the 
 definition of hypnotism may be a matter of difference or of dispute, 
 its danger is shown by the fact that Striimpell considers it an " arti- 
 ficial hysteria/' and Fere defines it as a " transformation of hysteria." 
 " It is easier to make a sound person hysterical by hypnosis than to 
 cure an hysterical one by it" (Liebermeister). Treatment is some- 
 times frustrated by the patient's vanity. Successful treatment re- 
 quires unusual tact, profound knowledge of human nature, strong sym- 
 pathies (but dominance of the patient) and enormous optimism. ' Of 
 course certain single qualities, in an ignorant quack, may effect cures. 
 
 3. Special or Symptomatic Treatment. — (a) In relieving pain 
 the physician should first acknowledge its existence and intensity in 
 
NEUKASTHEN1A. 1127 
 
 order to soothe the patient and should then apply blisters, liniments 
 or the galvanic current with the anode on the painful area. Ovaralgia 
 in most cases should be ignored ; in exceptional cases pelvic surgery 
 has given relief; Lower's position has already been mentioned (v. s.). 
 (b) Convulsions are treated by dashing cold water into the face, by 
 suggestive measures or, if severe, by etherization. Bromides are of 
 little value, valerian is sometimes beneficial and turpentine is recom- 
 mended by Gowers as most efficient, 10 drops of the oil being given 
 until slight vesical symptoms appear. Pouring water into the mouth 
 or nose, which causes coughing, or Hare's method of holding a towel 
 over the nose and mouth for 15 to 20 seconds, may also serve, (c) 
 Paralysis and contracture should receive early treatment, for late 
 neglected cases may necessitate surgical intervention, as tenotomy. 
 Massage, faradism, blisters and fixation in new postures are indi- 
 cated and especially should their significance be minimized and the 
 patient be assured that they are not organic. In two cases the author 
 has seen the paralysis disappear at once on administration of asa- 
 foetida in an effervescing mixture, (d) Ancesthesia should be ignored, 
 (e) Aphonia is treated by intralaryngeal faradization. Laryngeal 
 and other respiratory spasms usually answer to energetic traction on 
 the tongue and anaesthesia or tracheotomy is rarely necessary. (/) 
 For insomnia, the patient should retire at an absolutely regular hour ; 
 nervines should be given rather than bromides, and hot milk should 
 be very slowly sipped, (g) Dysphagia, vomiting and anorexia may 
 be treated by rectal feeding or by forced feeding through the stomach 
 tube, which is the better method. Constipation is often obstinate and 
 its mixed spastic and paretic character is shown by the faeces which 
 are like those of sheep. Free administration of olive oil by mouth 
 and rectum, cold abdominal compresses and endorectal galvanization 
 are usually effective. 
 
 NEURASTHENIA. 
 
 Definition. — Neurasthenia is a diffuse neurosis, which affects the 
 entire nervous system, but chiefly the brain; it is characterized (a) 
 by morbid irritability of the nervous system with a tendency to its 
 rapid exhaustion (" irritable weakness"), and (b) particularly by 
 psychical, motor, sensory, vasomotor, secretory and vegetative disturb- 
 ances in function. The nervous tissue responds unduly to stimuli, 
 its reaction time is short and ready exhaustion results. It seems 
 probable that the slight cellular and protoplasmic changes in nerve 
 cells, noted by Hodge to follow fatigue, may have some bearing on its 
 pathology. The affection as described and named by Beard in 1869, 
 whose description was first received with some skepticism and ridi- 
 cule abroad, later gained universal recognition. It is possible that 
 the disease is more frequent than formerly because of the more 
 strenuous life and methods of education. The difference between 
 " nervousness " and neurasthenia is only quantitative and while 
 nervousness is no disease in itself it is also characterized by a short 
 reaction time (irritability) and precipitate fatigue (weakness). 
 
1128 DISEASES OF TSE NERVOUS SYSTEM. 
 
 Etiology. — Neurasthenia is the most common neurosis, constituting 
 35 per cent, of all nervous diseases and fully 50 per cent, of all 
 neuroses, (a) A neuropathic tendency is observed in 50 per cent, of 
 cases, especially among Hebrews whose proneness to nervous diseases 
 is referred by Erb to inbreeding and desire of gain. Other neuroses, 
 as hysteria, epilepsy or migraine, the psychoses and parental infirmi- 
 ties or intoxications may be obtained in the family history, (b) 
 Age and sex: It is a disease of adults (75 per cent, of cases occur in 
 persons between the twentieth and fiftieth year). It is a question 
 whether men are more often neurasthenic than women; we may say 
 women are more disposed, men more exposed, to the disease by their 
 excesses in work, sexual activity and alcoholism. (c) Psychical 
 causes include sorrow and care; hard mental or physical work 
 rarely produces neurasthenia. Worry is a prolific factor; it is the 
 irritable weakness of work. Hard work is injurious when combined 
 with excesses in tobacco, alcohol, coffee, drugs or venery. Certain 
 occupations entailing responsibility or emotional factors predispose 
 to nervous weakness, as in railway or telegraph employes, board-of- 
 trade men, teachers, actors, artists and musicians, but even then it is 
 questionable whether the work itself is most injurious. Trauma oper- 
 ates chiefly through psychical causes, as in the traumatic neuroses 
 (q. v.). (d) Intoxications, as from the stimulants above mentioned, 
 from drug habits, lead or arsenic poisoning, acute infections, espe- 
 cially typhoid or grippe, from chronic affections, notably malaria and 
 syphilis, and gout, anaemia or diabetes may be indirect factors, (e) 
 Sexual life: Masturbation, excessive coitus and coitus interrupts, 
 sometimes promote neurasthenia, but their importance is enormously 
 overestimated. Masturbation probably produces less direct physical 
 than psychical injury, for it leads to brooding over its possible results. 
 Continence is never injurious, as sexual indulgence is rather a habit 
 than a necessity. In neurasthenic women gynecological complaints 
 are more often subjective, secondary and neurasthenic than objective, 
 primary and organic. The same statement usually holds true in male 
 neurasthenics with chronic urethritis or prostatitis. Pregnancy and 
 lactation are sometimes apparent causes. (/) Organic diseases may 
 possibly be factors, but it is questionable to what extent enterop- 
 tosis, chronic gastric or other somatic lesions promote neurasthenic 
 symptoms. 
 
 ^ Symptoms. _A clinical description holding for all cases is impos- 
 sible. A patient presents himself for the treatment of some single 
 visceral complaint or describes symptoms in his head, heart, lung, 
 stomach, sexual or other organs. The various types, which are often 
 separately described, will be considered in the' general picture, for 
 pure forms are rare; they are the cerebral (cerebr asthenia) spinal 
 (myelasthema), cerebrospinal (the general type), the sympathetic or 
 vasomotor and the visceral (cardiac, sexual, gastric) types. Some 
 varieties concern the course, as (a) the acute form from 'simple nerv- 
 ous exhaustion in normal individuals, or in those with neurotic stig- 
 
NEURASTHENIA. 1129 
 
 mata; (b) the subacute or chronic acquired form, and (c) the chronic 
 constitutional neurasthenia, which is usually hereditary. 
 
 1. Cerebral Symptoms. — These are most important, because the 
 disease is a psychoneurosis. Headache is almost invariable, is more 
 often dull than acute and produces a sense of pressure ("lead cap" 
 headache) or intracranial paresthesia and in localization is most often 
 occipital. Vertigo is frequent. Insomnia is extremely common, but 
 rarely absolute, which always suggests organic brain disease; sleep 
 is slow in onset, the patient being kept awake by his fear of sleepless- 
 ness, by a rapidly moving circle of uncontrollable memory pictures or 
 by indigestion or palpitation ; sleep, when once attained, is not resting 
 or is too short and the patient awakes in the night or early morning. 
 It is broken by dreams, startings or sometimes emissions. In mild 
 cases distinct alterations in temperament and character develop, as 
 loss of courage and confidence, depression, irrit ability, undue response 
 to emotional stimulation, as on seeing sad plays or hearing hard-luck 
 stories, slight ethical blunting, tendency towards extremes and devel- 
 opment of quiet self-concentration or obtrusive egotism. The brain 
 tires readily on mental or bodily exertion, especially as the irritable 
 patient is often prodigal of time and energy. It is remarkable how 
 in some cases the morning depression may disappear before an after- 
 noon or evening excitement, but this is notably followed by reaction. 
 Psychical processes are disturbed ; perception is blunted and memory 
 is weakened or often temporarily lost (dys-, para-, amnesia), as 
 shown by the copious notes of his symptoms which the patient pro- 
 duces in the physician's office (" V homme aux petits papiers/' as 
 Charcot called him) ; association and combination are difficult, as in 
 thought, composition, judgment or conclusions, whence the speech 
 is often slow and disjointed, names are forgotten and the patient re- 
 reads addresses, runs repeatedly to see if the door was closed, etc. 
 Compulsory conceptions may lead to homicide or suicide in highly 
 psychopathic types. Fear, being an attribute of the weak, is common 
 enough, and may in marked types assume the form of various phobias, 
 as the fear of open places (agarophobia), of enclosures (claustro- 
 phobia), rivers (potomophobia), high places (acrophobia), stars 
 (asterophobia), railways (siderdromophobia), dirt (mysophobia), 
 of high things falling (batophobia), of standing (stasophobia), or 
 walking (basophobia), of darkness (nyctophobia), of a single 
 thing (monophobia), of all things (pantophobia), of places (topo- 
 phobia), of men (anthrophobia) or of disease (nosophobia). The 
 special senses. Fibrillation of the lids and wide, variable, sensitive 
 and unequal (3 per cent.) pupils are frequent, although permanent 
 irregularity is almost always organic. Asthenopia is very common, 
 especially in hypermetropia from weakness of the ciliary and int. 
 recti muscles. The field of vision may be concentrically limited but 
 this is rarely marked or permanent, and Forster's shifting type may 
 be found, in which objects brought from without into the field are 
 better seen than those moved from within the field outward. Hyper- 
 
1130 DISEASES OF TBE NERVOUS SYSTEM. 
 
 sesthesia of the retina and ear, ringing in the ears, Meniere's complex 
 and disturbance of taste or smell are not common. 
 
 2. Spinal Symptoms. — These include the so-called " spinal irrita- 
 tion." Many symptoms ranked as spinal are essentially cerebral. 
 In women they are more common and are localized chiefly to the 
 upper dorsal and coccygeal regions ; in men they are lumbodorsal and 
 most frequent in the sexual type. Sensory symptoms are practically 
 constant. Hyperesthesia is more common in the bodies of the muscles 
 than in their attachments or in the skin; paresthesia is frequent, as 
 tinglings, girdle sensation or even itching. Paralgesia in the form of 
 backache (rhachialgia) is as frequent as headache and the pain may 
 radiate into the various nerve plexuses; it is very often sacral; the 
 spine may be exquisitely sensitive to pressure. Paralgesia is common 
 in the skin about the hair roots, in the trunk and extremities. Neu- 
 ralgia is rare, although it sometimes radiates from the spine into the 
 limbs. Anaesthesia is no part of neurasthenia. Of the motor symp- 
 toms, muscular weakness or myasthenia is the rule. It is probably 
 spinal and cortical in origin and is especially conspicuous in the 
 morning. The muscles often show fibrillary contractions and a tre- 
 mor (85 per cent.) which is as fine and frequent as that of alcoholism 
 or Graves' disease. Muscular fidgets, starts, cramps and increased 
 irritability of the nerve trunks, as in tetany, are also observed- 
 Actual ataxia is most rare, although suggested by the writing. The 
 akinesia algera (Mobius) or the abasia-astasia of Blocq, as in hys- 
 teria or the psychoses, is the result of a phobia or a fixed conception. 
 One of Erb's patients remained in bed for fourteen years. The skin, 
 tendon and periosteal reflexes are increased. 
 
 3. Vasomotor Symptoms. — These produce many central, visceral 
 and peripheral manifestations. Mosso proved that during brain- 
 work the cerebral vessels normally dilate while those of the arm con- 
 tract. According to Anjel this does not occur in neurasthenia. The 
 manometer in normal cases reveals no essential variation during work, 
 while in neurasthenia marked manometric variations occur (Weber). 
 These findings are valuable because they explain many otherwise 
 vague findings. Neurasthenics often suffer from cold and wear more 
 clothes than is necessary ; their skin is cold, even cyanotic or locally 
 asphyxiated. On the other hand, the skin may be flushed and hot. 
 Cold and clammy sweats over the forehead, hands and feet develop 
 without exertion. Salivation or a dry mouth, polyuria, pseudo- 
 angina pectoris (vasomotor changes in the cardiac and brachial plex- 
 uses), the wide temporal vessels, the epigastric pulsation, circum- 
 scribed oedema, urticaria and dermographism are but vasomotor mani- 
 festations. 
 
 # 4. Visceral Manifestations.— (a) Some of the cardiovascular 
 signs and symptoms have already been treated. The arteries are 
 relaxed and often throb, the pulse may be slightly of the "water- 
 hammer " type and capillary pulsation is often apparent in the lips 
 or under the nails. Palpitation and precordial anxiety or dyspnoea 
 
NEUEASTEENIA. 1131 
 
 are frequent. The pulse is frequently faster and may increase 10 or 
 20 beats on pressure over some sensitive area (v. i. Teaumatic 
 Neuroses). Many neurasthenics seek consultation for cardiac dis- 
 ease. Thomeyer describes arrhythmia on leaning forward, ortho- 
 static tachycardia (on standing) and inspiratory acceleration and 
 expiratory retardation of the pulse, (b) Gastric symptoms (in 60 
 per cent.) are functional in character and were first described by 
 Leube. The chemism may be normal or show achlorhydria or hyper- 
 chlorhydria. The stomach is frequently hypersesthetic. Anorexia is 
 usually mental, as are polyphagia, polydipsia and adipsia (see Neu- 
 roses of Stomach), (c) Intestinal symptoms. Diarrhoea is less 
 common than constipation, which, like previous sexual abuses, often 
 occupies the patient's thoughts. They " would be perfectly well if 
 they could have one natural movement, " and when they do they com- 
 plain of " exhaustion during the entire day afterward." Assimila- 
 tion is often incomplete, as shown by the stools ; a sense of pressure, 
 Kussmaul's peristaltic unrest, hyperesthesia, burning and flatulency 
 torment the patient. Enteritis membranacea and Glenard's enterop- 
 tosis are not infrequent, (d) The amount of urine is often in- 
 creased, or seemingly so, yet equally often the 24-hour quantity is 
 decreased. The specific gravity is lowered, but the urates, uric acid 
 and urea are increased. Phosphaturia and oxaluria occur ; the latter 
 is often attended by flatulent dyspepsia, melancholia and nervous 
 depression. Vesical tenesmus is an occasional complaint, (e) Gen- 
 ital symptoms. Fear of the results of previous excesses or of self- 
 abnse may dominate the patient's mind, but the trouble is more a 
 matter of conception than of reality, since the sexual appetite is 
 actually decreased as a rule. In most cases there is premature ejacu- 
 lation and in some patients there is actual or psychical impotence. 
 Emissions are frequent, but their importance is greatly overestimated. 
 
 Course and Prognosis. — Acute cases are rare and fatal cases ex- 
 tremely exceptional. The usual chronic course is one of slow onset, 
 it is attended by evidences of nervous fatigue which are at first re- 
 lieved by rest, but which later persist in spite of rest and incline the 
 patient to stimulants or drug habits. Later the signs of cerebral 
 irritability, disturbed sleep, vasomotor disorders, reduced mental and 
 psychical capacity, pains, spinal tenderness, paresthesia or paral- 
 gesia, sympathetic dyspnoea or palpitation develop, sometimes with 
 temporary remissions. The outlook is poor in severe hereditary forms 
 or when there are complicating psychoses or drug habits. In other 
 types recovery is usual, although long deferred. Complication with 
 other neuroses must naturally modify the prognosis. 
 
 Diagnosis.— The diagnosis is generally made with ease, but several 
 rules must be borne in mind: (1) No, single symptom is pathogno- 
 monic; (2) there must be no sign of organic disease ; (3) neuras- 
 thenia may precede, follow or complicate organic nervous or visceral 
 disease. The subjective signs, irritable weakness, emotivity, muscu- 
 lar weakness, headache, backache, insomnia, amnesia, impaired psy- 
 
1132 DISEASES OF TEE NERVOUS SYSTEM. 
 
 chical coordination and the phobias, together with objective findings, 
 as asthenopia, insufficiency of the internal recti, tachycardia, epi- 
 gastric pulsation, vasomotor alteration, as disturbed secretion of 
 urine or sweat, increased reflexes, fibrillation and tender muscles 
 cannot be mistaken. The neurasthenic prodromes of progressive 
 paralysis (q. v.) are usually distinguished on careful search for 
 organic disease. Hysteria in its stigmata and accidents is so typical 
 that elaborate differentiation is superfluous; anaesthesia, persistent 
 contraction of the fields of vision, dyschromatopsia, achromatopsia, 
 monocular diplopia, convulsions, paralyses, contractures and anuria 
 are foreign to neurasthenia. Hypochondriasis differs from neuras- 
 thenia in these essential points: it is a pure psychosis, its concepts 
 are primary, ill-based, illogical or absurd and cannot be eradicated 
 even for a time. 
 
 Treatment. — 1. Prophylaxis. — Prevention is difficult, for the neu- 
 rasthenic cannot control his ancestry, but even with hereditary stig- 
 mata much may be done. Treatment starts with the education of both 
 child and adult. Children are mimics and the clearest of all observ- 
 ers. The inculcation of self-control, fearlessness, self-sacrifice, mod- 
 eration in all things, truthfulness, prompt decision and constancy of 
 purpose must be based on actual parental example, and in this way 
 the child should also educate the parent. The child must learn to give 
 up, to sleep alone, to stop at the right time, to finish what he has 
 begun, to obey and to learn that he is not the centre of the family. 
 He should be taught without being forced. Out-door living is more 
 important than the school room. The English method of treating 
 children with reserve has some advantages over American demon- 
 strativeness. Simple varied food, without tea, coffee or alcohol, and 
 long sleeps develop a strong nervous system. The sexual instinct 
 requires attention. Parents or patients would do well to read Pat- 
 rick's small classic, " How Not to be Nervous," Jour. Amer. Med. 
 Assn., Feb., 1903. 
 
 2. Therapy. — When once manifested, the disease should be treated 
 as above outlined and causal factors should be investigated. Work alone 
 is seldom injurious and while it is said that the modern complexity in 
 the struggle for existence is increasing the number of neurasthenics, 
 work should not bear the stigma nor should disappointment, for both 
 make character. Work must be systematic but not slavish. Worry, 
 hurry, failure to learn individual limitations, uncontrolled planning 
 beyond the immediate day's work and worry (the irritable weakness of 
 work) cause the damage, especially when work produces indifference to 
 nature, family life, exercise, rest and the things higher and above 
 one's own small life and ambition. The time for exercise should be 
 taken from the work hours, it should not follow them, nor should it 
 be enforced in every case, for some are hurt by it. Of course, 
 work under stimulation is injurious. The chief element in treatment 
 is psychical and the physician accomplishes more than do drugs. He 
 carefully examines and reexamines the patient and his assurance that 
 

 
 NEUEASTHENIA. 1133 
 
 no organic disease exists has its weight for the time. Conversely, 
 careless diagnoses, as of fatty heart, with no objective justification, 
 work damage to the patient's mental balance. The patient's hygiene 
 should be regulated. Strict dietaries and stimulants should be 
 avoided, moderate out-of-door life or exercise enjoined and in very 
 pronounced cases absolute rest from work, with sojourn near the sea 
 or at a moderate altitude in a place not subject to sudden changes or 
 high winds is recommended. Sexual matters should be left alone 
 unless gross violations are found. The patients need sympathy, 
 which they should receive — in moderation for their sake; but im- 
 portant as is the psychical element in therapy, the patient must be 
 taught that he alone can cure his malady by self-control and by 
 avoiding extremes in each and every thing. 
 
 Pronounced cases in thin women, especially those with gastric 
 symptoms, are often helped by the Weir Mitchell rest-cure, which 
 consists of absolute rest in bed, isolation, forced feeding, massage 
 and faradization. The patient is not allowed to lift a hand and sees 
 only the nurse, who is selected for her strength, optimism and lack of 
 nerves. The patient is fed milk every three hours and the muscles are 
 rubbed and faraclized. Thus weight and strength are gained without 
 muscular degeneration. Few men will tolerate this method and obese 
 do not fare as well as lean women. In certain cases it is of distinct 
 benefit. However, no greater mistake is made than to give all cases 
 the rest-cure ; they often want work and occupation, harmonized with 
 rest. 
 
 3. Diet. — That no one dietary is essential is shown by the differ- 
 ent recommendations ; some physicians favor a meat diet, others avoid 
 meat, especially in cardiac types and give well-cooked vegetable albu- 
 mins, cooked fruit, fats, milk and eggs. In mental anorexia, feeding 
 by mouth or rectum must be forced. Water in abundance is indi- 
 cated. Gastric hypercesthesia should be relieved by small doses of 
 carbolic acid and gelsemium. Eructations must be controlled, since 
 the air admitted exceeds the gas expelled; asafoetida is excellent be- 
 cause it makes as strong an impression when swallowed as when 
 eructed. Electricity is largely suggestive in its effects. With mas- 
 sage and vegetable diet, endorectal faradization relieves constipation. 
 In cardiac types alcohol and tobacco are interdicted and small doses 
 of belladonna and bromide usually control palpitation; other vaso- 
 motor symptoms are relieved by these remedies or by ergotin or nitro- 
 glycerine, according as they are angioparetic or angiospastic. Arsenic 
 is valuable in vasomotor troubles with anaemia. 
 
 Sexual symptoms are treated by psychical measures and by sitz- 
 baths. Insomnia is often difficult to relieve. In the order named, 
 the following measures are valuable: avoidance of evening work, 
 stimulants or excitement ; a cool bath, the wet pack or an ice-bag over 
 the heart ; small doses of bromide with valerian for the " expectant 
 attention " which wards off sleep ; 20 grains of sulphonal in hot milk, 
 which should be slowly sipped; codeine with hyoscine; and chloral 
 
1134 DISEASES OF THE NERVOUS SYSTEM. 
 
 (the continued use of which induces vasomotor disturbance). The 
 habit of sleep must be cultivated and the patient must not get up to 
 read. Local, urethral and uterine affections usually receive excessive 
 therapeutic attention. 
 
 THE " TRAUMATIC NEUROSES." 
 
 This is a practical grouping of traumatic neurasthenia, hysteria, 
 chorea or hypochondriasis. Hysterical forms were first described by 
 Walton and Putnam ; Erichsen (1866) wrote on the subject of trauma 
 to the spine, on which the illogical name of railway spine was later 
 conferred, and Oppenheim (1877) termed the group the "traumatic 
 neuroses." All organic affections must be excluded, whether trauma 
 may seem directly or indirectly causal, as vertebral caries, tumor, 
 Bechterew's chronic ankylosis, Kummel's rarefying osteitis which 
 Kocher refers to fracture ; hsematorrhachis, meningeal hematoma or 
 pachymeningitis; and cord affections, as poliomyelitis, myelitis or 
 lateral sclerosis. Experimental trauma may produce molecular nerv- 
 ous changes (Schmauss, Striimpell, Bruns, Vibert and Crocq), a fact 
 which may be of clinical importance, and trauma is thought to hasten 
 arteriosclerosis (Friedmann). Alcoholism and syphilis are predis- 
 posing factors. " Traumatic neuroses " are purely junctional affec- 
 tions caused by trauma, which operates psychically rather than so- 
 matically. The symptoms are those of hysteria, neurasthenia and 
 hypochondriasis, singly or in combination. The patient may feel 
 well for a day or two and then pain develops at the seat of injury 
 or in the spine; anxiety, fear for his financial future or for his 
 family, a " fixed idea " of his incapacity and the development of 
 " litigation symptoms " are typical of hypochondriacal neurasthenia. 
 
 Symptoms. — The psychical symptoms are usually prominent; they 
 are accentuated by the effect on the patient of repeated, sometimes 
 suggestive, physical examinations, visits of lawyers or adjusters, 
 court room suspense, reversals of judgment or appeals. Vertigo, 
 backache, headache, sleepiness by day and nocturnal insomnia may 
 cause great distress. Sensory symptoms. Pain, which seems to be 
 nervous, may prove organic on examination by the a;-rays ; it may be 
 simulated, but is often real, as shown by persistence after award of 
 damages. Tender areas are difficult to pass upon, because of exag- 
 geration or simulation; Mann, Kopf and Eumpf found that pressure 
 on areas which are actually tender increases the pulse rate by 10 to 30 
 beats; this sign is subject to several conditions: (a) it is not always 
 present in real pain; (b) its absence is no proof of simulation; (c) in 
 simulation, the agony and writhing which occur when certain areas 
 are touched may increase the heart's action. Paresthesia and hvper- 
 esthesia of the skin or special senses are frequent. Anesthesia 'indi- 
 cates traumatic hysteria. Hysteric or neurasthenic contraction of the 
 visual fields may remain the same from day to day and not vary with 
 approach or withdrawal of the test object; this is not a sign of simula- 
 
TRAUMATIC NEUBOSES. 1135 
 
 tion, as suggested by some writers; Forster's type cannot be as- 
 sumed (v. Neurasthenia). In all cases the influence of suggestion 
 must be borne in mind. The pupils may vary, especially by dull 
 illumination; reflex immobility indicates organic disease. Motor 
 symptoms may embrace all those of hysteria or neurasthenia, abasia, 
 astasia, paralyses, contractures suggesting vertebral injury or joint 
 disease (Brodie's joints), pseudo-spastic or -tabetic gaits, tremor 
 (forme trepidante) or sometimes muscular atrophy (especially about 
 the joints). Hysterical convulsions are rare; the author has twice 
 seen choreiform affections in telephone girls who sustained slight 
 shocks and once a genuine chorea. Patients must often be watched ; 
 one of the author's cases, with spastic gait, shuffled out of the office but 
 walked perfectly well around the corner. The reflexes are often in- 
 creased, perhaps asymmetrically; ankle clonus, which is probably 
 spurious, is sometimes reported. Cardiac symptoms may be promi- 
 nent and cannot be simulated. When there is albuminuria and 
 glycosuria the question naturally arises whether they were present 
 before the trauma. 
 
 Diagnosis. —The diagnosis concerns several points which are often 
 difficult or impossible to establish, because objective findings are fre- 
 quently few. (a) It is usually possible to state whether one of the 
 neuroses is present or whether organic disease obtains, (b) Exagger- 
 ation and simulation are difficult to estimate, as shown by the change 
 of professional opinion from the idea that all or most cases are simu- 
 lated to the present statement of some writers that these factors are 
 present in 4 (to 10) per cent, of cases only, (c) If disease is present 
 is it directly due to injury? (d) If so, the most difficult of all ques- 
 tions is presented, namely, the degree and duration of the disease and 
 the damages to be awarded. 
 
 Prognosis, —(a) As to life, the outlook is usually good, though some 
 cases become insane or suicidal, (b) As to complete recovery, it is 
 less favorable. In most cases it is surprising how soon symptoms dis- 
 appear after satisfactory legal settlement is made ; this is said without 
 cynicism. Many persons do not then recover completely and symp- 
 toms may endure in those who persistently shrink from litigation. 
 Hysterical symptoms are more favorable in prognosis than the neu- 
 rasthenic or hypochondriacal. It is maintained by some that cardiac 
 overaction may induce organic myocardial changes and that arterio- 
 sclerosis may develop into precocious senility (dementia prsecox). 
 
 Treatment. — Treatment is similar to that of hysteria or neuras- 
 thenia and is therefore largely psychical. The physician, as a rule, 
 dreads the effect of litigation on the patient, assures him that the 
 symptoms are seldom severe or enduring, that there is no organic 
 lesion and advises early settlement and speedy return to work. 
 
1136 DISEASES OF THE NERVOUS SYSTEM. 
 
 EPILEPSY. 
 
 
 Definition.— Epilepsy, by derivation, means " being seized upon 
 it has been called the " falling sickness " and morbus sacer. It does 
 not include Jacksonian or symptomatic epilepsies, which will be con- 
 sidered in its differentiation. Though it is classified with hysteria 
 and neurasthenia as one of the " three great diffuse neuroses/' it will 
 probably be finally shown to include more than one disease. It is a 
 disturbance of balance between the central exciting and inhibiting 
 nervous processes attended by (a) & typical chronic convulsive dis- 
 order, affecting all parts of the central nervous system, each attack 
 being followed by loss of consciousness, (b) partial or atypical mani- 
 festations of these characteristics, or (c) concomitant or consecutive 
 psychical or other symptoms. It occurs in from one to six persons 
 per thousand. 
 
 Etiology. — The ultimate causes must be separated from the inciting 
 causes (Nothnagel). Of the former, the neuro- or psychopathic 
 tendency of Griesinger is the most important, being found in 37 per 
 cent, of cases and lessening the nervous resistance. As in tubercu- 
 losis, only the tendency is transmitted by inheritance, rarely the dis- 
 ease itself. Neurotic or psychopathic antecedents, parental alcohol- 
 ism (51 per cent.), morphinism, plumbism, syphilis, tuberculosis, 
 gout, arthritism, diabetes, trauma during labor or ovarian and testicu- 
 lar diseases lessen the nervous resistance of the offspring. Though the 
 disease may appear at any age, it rarely occurs after the thirtieth 
 year. Seventy-five per cent, of cases (Gowers) develop before 
 twenty; 46 per cent, between ten and twenty, mostly at puberty; 28 
 per cent, before ten. The sexes are about equally affected. 
 
 Inciting causes include (a) infections, as malaria or typhoid; 
 syphilis may be hereditary, induce the Jacksonian type from cortical 
 gumma, or it may be parasyphilitic ; (b) intoxications, especially 
 alcoholism; (c) exhausting affections, as rickets, and diseases of the 
 blood or of metabolism; and (d) trauma or fright. Inciting causes 
 are found in only 37 per cent, of cases (Gowers). 
 
 Reflex epilepsy is said to occur from painful scars, nerve tumors, 
 or foreign bodies in the ear, nose, nasopharynx or larynx ; diseases of 
 the teeth, digestive tract, uterus and heart; onset of the menses or 
 their monthly appearance, pregnancy, phimosis or onanism; from 
 gall-stones, colic or abdominal paracentesis. The importance per se 
 of reflex disturbances is daily lessening. 
 
 Pathology. — There is no characteristic macro- or microscopic change. 
 The usual finding after death is that of any convulsion, viz., venous 
 engorgement and punctate ecchymoses. Induration of the cornu 
 ammonis, induration in the medulla, neurogliar increase in the cor- 
 tex, thickening, asymmetry or deformity of the skull and persistence 
 of the thymus have not been proven causal. 
 
 Symptoms. — The symptoms are best studied from the completely 
 developed attack, in which there are three component parts : (a) The 
 
EPILEPSY. H37 
 
 prodromal stage is not always present. Its " warnings " are either 
 distant or immediate. The distant warnings (in 10 per cent, of 
 cases) may precede the seizure by hours or days, are possibly due to 
 metabolic changes in the cortex and take the form o£ restlessness, dis- 
 positional changes, depression, thoracic or cephalic oppression, in- 
 somnia, vertigo, nausea, grinding of the teeth, hyperesthesia of the 
 special senses, angioneurotic palpitation or cerebral congestion. The 
 immediate warning is the aura proper, which is the beginning of the 
 convulsion rather than a warning. It is a central cortical irritation ; 
 its frequency is 40 per cent. ; it is rarer in sudden, stormy, general- 
 ized seizures. Its forms are varied. The psychical aura is rare and 
 is manifested by emotional or intellectual alteration and anxiety. 
 The sensory aura consists of paresthesia and a sense of deadness in a 
 limb or joint, attacks of migraine and epigastric sensations (from the 
 pneumogastric nerve, pressure or irritation of which sometimes in- 
 hibits the convulsion). The special senses may be irritated or 
 blunted ; for instance, there may be flashes of light or colors, halluci- 
 nations, blackness before the eyes and less often anomalies of hearing, 
 taste or smell. The motor aurse are circumscribed clonic or much less 
 often tonic twitchings, as in Jacksonian epilepsy, from which they 
 are distinguished by a rapid loss of consciousness ; automatic move- 
 ments, like stamping or buttoning the coat, are rarer and motor 
 weakness and singultus, coughing or sneezing are least frequent. 
 Vasomotor aurse may be localized or generalized, as rushing of blood 
 to the head, palpitation, anesthesia, increased temperature, increased 
 arterial tension, pallor or chilling. The patient then falls, pale and 
 unconscious, or is thrown with force, often on his face (Trousseau), 
 when (b) the convulsive stage begins. There is first a tonic convul- 
 sion, which affects all voluntary muscles and is due to infracortical 
 irritation. The initial cry is guttural or groaning, results from tonic 
 abdominal, thoracic and laryngeal spasm and is heard in 50 per cent, 
 of cases. The head is held back; the eyes are open and staring, the 
 jaw set, the face flushed, the neck tense, the body often opisthotonic, 
 breathing and pulse are suspended, the muscles are hard but slightly 
 vibrating to the palpating hand, the arms are turned tetanically in- 
 ward, the hands are clenched with the thumb adducted and under the 
 fingers, the legs are extended, the thighs adducted and the toes flexed 
 or extended and spread apart. In some cases the head, eyes and even 
 trunk deviate and in a few instances the tetanic spasm spreads gradu- 
 ally, instead of the patient having the usual instantaneous tonic 
 spasm. The tonic phase lasts ten, fifteen or thirty seconds, relaxing 
 in inverse order from the limbs to the neck and face. The second 
 phase of clonic convulsion occurs at once, appearing first in the limbs, 
 which are not yet quite free of the tonic spasm. This stage is usually 
 bilateral, highly irregular and violent, with very short remissions, 
 leading perhaps to injury, fracture, luxation, breaking of teeth, lacer- 
 ation of skin, tongue and cheek, or rupture of muscles. It consists 
 largely of alternating flexion and extension; the head strikes the 
 72 
 
1138 DISEASES OF THE NERVOUS SYSTEM. 
 
 ground, the body turns violently, the eyes jerk and protrude, the face 
 is distorted, the tongue is bitten as it is thrust out, bloody saliva is 
 expressed by the masseters, inarticulate sounds arise from the move- 
 ments of the diaphragm and respiratory muscles and gurgling results 
 from intestinal movements ; vomiting movements, filling of the stom- 
 ach with air, cyanosis, swelling of the jugular veins, ecchymoses in 
 the conjunctiva, skin, retina or larynx, involuntary and sometimes 
 forcible evacuation of the bladder, less often of the rectum, and occa- 
 sionally ejaculation, occur. The clonic phase lasts one-half to three 
 minutes, ending in a fine generalized tremor, (c) The comatose stage 
 often begins with a deep sigh; respiration and circulation become 
 normal, the limbs relax and the condition resembles a sound sleep, 
 from which the patient awakes in from fifteen minutes to several 
 hours, sometimes suddenly, more often gradually and in a more or 
 less dazed condition. He recalls nothing of the. attack and the loss of 
 memory may extend back of the seizure (retrograde amnesia). He 
 experiences pain in the muscles, joints or head, nausea, mental irri- 
 tability or depression and finally a group of exhaustion symptoms, to 
 which Fere has especially directed attention; these are (i) sensory 
 exhaustion, expressed by hypsesthesia, anaesthesia, hypalgesia or anal- 
 gesia, (ii) Exhaustion of the special senses, as concentric limitation 
 of the visual and color fields, especially in abortive attacks, dulling 
 of hearing, taste or smell, and (iii) motor exhaustion which also is 
 due to cortical fatigue. 
 
 The seizure has been described with special reference to the domi- 
 nant motor changes, but during the attack other findings are observed. 
 Vasomotor constriction often occurs, as shown by the initial pallor of 
 the face, cardiac overaction or perhaps irregularity. The ecchymoses 
 and retinal congestion are due to the convulsion. The reflexes are 
 affected. The pupil is almost always reactionless, is often narrow at 
 the onset, and usually dilates widely in the second stage ; afterwards 
 it may oscillate; the pupils are sometimes unequal (20 per cent., 
 Fere). The tendon and skin reflexes are weak or lost in complete 
 attacks and for hours afterwards, whence we may judge of the se- 
 verity of the seizures. The temperature is usually considered normal, 
 but may be elevated 2 or 3°. In the urine, Yoisin found albumin in 
 50 per cent., though others consider it infrequent. The author has 
 often noted transient albuminuria and cylindruria (granular casts) 
 after marked paroxysms ; glycosuria is uncommon. The phosphates 
 and nitrogen are increased; polyuria is common in the third stage. 
 The sweat is increased. 
 
 Types of Epilepsy. — 1. The completely developed attack (epilepsia 
 gravior, grand maV) consists of (a) the classic type (29 per cent.), 
 as above described, with complete loss of consciousness, and tonic 
 followed by clonic convulsions; or (b) the well-developed but slightly 
 atypical type (19 per cent.), in which all the classic components vary 
 somewhat ; for instance, the spasm may not always be generalized. 
 
 2. The rudimentary attack (21 per cent.), consists of loss of con- 
 
EPILEPSY. 1139 
 
 sciousness, plus tonic or clonic spasms. This includes the apoplecti- 
 form cases, especially the senile (arteriosclerotic) form; forms resem- 
 bling myoclonus; cases which do not fall but stumble along at the 
 onset (epilepsia procursiva) or turn (epilepsia rotatoria). 
 
 3. The third form is the abortive attach (epilepsia mitior, petit 
 mal, 31 per cent.). Its importance is underestimated by the profes- 
 sion and the public ; two main types, with endless variations, are dis- 
 tinguished: (a) one with loss of consciousness with few or no motor 
 signs, and (b) motor and vasomotor signs with no loss of conscious- 
 ness, or very slight clouding of the intellect. The loss of conscious- 
 ness is often very slight or may last for a few seconds, so that a 
 scarcely perceptible break occurs in the patient's occupation, read- 
 ing, speaking, playing the piano or a game of cards ; it is described 
 by the French as " absence/'' He may move his lips inarticulately or 
 there is slight nystagmus, a chewing or swallowing movement, tremor 
 or twitching of the face, monospasm or vertigo. In children, a cry 
 may be the sole symptom. Some patients seem to fall suddenly 
 asleep. Nothing, or everything, may be remembered. Aurse are very 
 common and may constitute the whole attack, which aborts without 
 unconsciousness or spasms. Vasomotor symptoms are very common. 
 
 4. The psychical equivalent of Sammt, also known as transformed 
 or larvated epilepsy or the epileptoid condition is often mistaken. 
 Mental symptoms may precede, succeed, alternate with or replace the 
 ordinary convulsive type, which must be first recognized to establish 
 this variety. The mental changes are slight (petit mal intellectuel) 
 or marked (grand mal intellectuel) and include excitement, emotional 
 outbursts, narcolepsy, incoherent conceptions, amnestic attacks and 
 mania. The patient may act like an hypnotized subject ; he may take 
 sudden long journeys or commit assault, arson or murder, whence the 
 great medico-legal significance of this variety. Milder forms are said 
 to occur, as sweats, stupor or vacuity at the menstrual epoch. 
 
 The Interparoxysmal State. — If the patient is not seen during his 
 seizures, evidences of epilepsy should be looked for carefully. Signs 
 of psychical degeneration, poor differentiation of the ear, very 
 large, small or prominent ears, hematoma of the ear, deformed teeth, 
 lips or palate, coloboma, congenital strabismus, nystagmus, small eyes, 
 irregular pigmentation of the iris, deformed genitals or fingers, dis- 
 orders of speech or irregular facial innervation may indicate heredi- 
 tary taint. Neurasthenic symptoms are not unusual. The expres- 
 sion is often dull. When idiocy occurs with epilepsy there are two 
 possibilities ; first, that both are coordinate results of a common cause, 
 or second, that early, chronic and repeated attacks have initiated 
 mental degeneration. However, many brilliant men have been epi- 
 leptics, as Julius Caesar, Napoleon, Carl V, Peter the Great, St. 
 Paul, Mohamed, Petrarch and Eousseau. The importance of or- 
 ganic disease of the heart, lungs, stomach and kidney is difficult to 
 estimate. Epileptics often sweat profusely, are usually constipated 
 
1140 DISEASES OF THE NERVOUS SYSTEM. 
 
 and frequently become obese from inordinate eating and the bromide 
 treatment. 
 
 Diagnosis. — The diagnosis concerns the convulsive seizures and the 
 abortive types. Similar convulsions occur in numerous other con- 
 ditions and must first be excluded. They occur in (a) organic brain 
 disease, as syphilis, tumors, vascular lesions, paretic dementia, mul- 
 tiple sclerosis and infantile cerebral paralysis. These affections may 
 produce generalized or Jacksonian fits. J acksonian epilepsy is more 
 clonic (from cortical irritation) than tonic (due to infracortical irri- 
 tation), is often associated with paresis or sensory alteration, occurs 
 less often with coma unless its generalization is unusually wide and 
 in 50 per cent, of cases is due to small cortical tumors. Epilepsy 
 rarely develops after thirty years of age (E. tarda) and 90 per cent, 
 of cases which occur after thirty, — excluding alcoholism and uraemia, 
 — are syphilitic (Fournier, H. C. Wood). After forty-five, vascular 
 lesions are a very common cause, (b) Convulsions may occur in 
 alcoholism, uraemia (eclampsia), plumbism or drug poisonings, (c) 
 Reflex epilepsy results from dentition, worms or digestive disorders ; 
 in some cases genuine epilepsy seems to follow the reflex form (which 
 perhaps is epilepsy in itself). 
 
 Simulation of epilepsy is impossible. In the complete type, the 
 tongue biting, cry, stertor or involuntaries may be absent. Scars are 
 often of diagnostic value. Nocturnal epilepsy occurs in 33 per cent., 
 often coming on when the patient drops off to sleep or on awakening 
 in the morning; it easily escapes recognition for years, but the de- 
 pression, bitten tongue, ecchymoses and involuntary evacuations are 
 unmistakable. 
 
 Differentiation from hysteria, which is usually easy, may be diffi- 
 cult, indeed the two affections sometimes co-exist ; the following table 
 is combined from Gowers and Biswanger : 
 
 Epilepsy. vs. Hysteria. 
 
 Distant warnings: few, mental. Frequent, emotional. 
 
 Aura: more frequent, momentary, of- Less frequent, longer, bilateral, foot 
 tenest unilateral or epigastric. aura, globus. 
 
 Cause: none. Emotional. 
 
 Onset: always sudden, often with pal- More gradual, rarely with pallor or cry, 
 lor cry which is never verbal, imme- which may be repeated or verbal, and 
 
 diate falling and complete uncon- recurs later. Earely brusque falling, 
 
 sciousness, with rigidity, etc. slower and far less complete uncon- 
 
 sciousness, and may react to sugges- 
 tion or pressure on hysterogenous 
 zones. 
 
 Tongue biting, frothing: very common. Exceptional, or seemingly purposive. 
 
 C °Z U ltZ : f neralized ' tonic f oll r e . (1 ^gidity, to carry out semi-intentional 
 by clonic spasms, very rarely tonic movement; struggling; clonic, irreg- 
 
 alone; flexor spasm predominates. u i ar spasinS; see ^ ing f y ' fragm ; nts g f 
 
 partial movements of emotion; ex- 
 tensor spasm predominant "arc de 
 cerele, ' ' clownism, passional attitudes, 
 etc. 
 
EPILEPSY. 1141 
 
 Epilepsy. vs. Hysteria. 
 
 Reflexes: pupils contracted at onset, Pupils usually wide and react (may 
 
 dilated later, immobile (in clonic be immobile, Westphal, Karplus). 
 
 period). Tendon and skin reflexes Sometimes convergent strabismus, 
 
 absent during and after attack. Keflexes rarely absent; or increased. 
 
 Involuntary evacuations: frequent. Absent or most exceptional. 
 
 The urine: solids always increased, both All solids decreased and altered ratio 
 nitrogen and phosphates. between earthy and alkaline phos- 
 
 phates. 
 
 Temperature: sometimes elevated, 2-3°. Practically never. 
 
 Coma: complete. No real coma. 
 
 Duration of seizure: very short. Longer, recurrent, relapsing. 
 
 Post-paroxysmal : sensory and motor ex- Depression, fatigue, pain in head or 
 
 haustion, ecchymoses, absent reflexes, stomach, nausea, some memory of 
 
 mental incapacity, with no memory attack, 
 of transpired events. 
 
 The most difficult forms to differentiate are petit mal and trans- 
 formed epilepsy, in which the history or observation of major attacks 
 is important. Petit Trial may be confused with cardiac syncope, 
 labyrinthine vertigo, etc. 
 
 Course and Prognosis. — When one attack has occurred a second may 
 be expected in 33 per cent, of cases in less than one month, in 33 per 
 cent, in from one to twelve months, in 33 per cent, in over one year ; 
 and when epilepsy is once established, daily attacks occur in 10 per 
 cent., in 50 per cent, they occur at intervals of less than two weeks, 
 and in 75 per cent, they occur at intervals of less than one month 
 (Gowers). The mode of life, stimulation, excitement, pregnancy and 
 sexual excesses may increase their frequency and cessation during 
 fevers is not uncommon. In some, fortunately rare, cases the attacks 
 occur in quick succession (status epilepticus, etat de mal), as many as 
 10 or over 100 occurring in one day. In one case 2,500 seizures 
 occurred during a month; the stage of coma may last from two or 
 three days to a week, with a temperature of 105-7° and death then 
 results. The outlook (a) as to recovery is poor. Five to 10 per cent, 
 of cases may recover spontaneously (Huf eland, Dana, Miiller). The 
 prospects are best in cases which begin before twenty in males, in 
 cases with long intervals between attacks and, though it may seem 
 strange, in hereditary forms. After two years duration the outlook 
 is unfavorable, (b) As to life, the prognosis is more favorable. A 
 few cases drown, suffocate from turning on the face or are fatally 
 burned during the seizure. Some patients die during the insult from 
 vascular lesions of the brain or less often from heart rupture, respira- 
 tory cramp, oedema of the lungs or vomiting into the larynx. Epi- 
 leptics frequently become tuberculous. In 10 per cent, dementia 
 occurs. The average duration of life is probably shorter than normal. 
 Bodily health and intellectual vigor may, however, be remarkably 
 preserved. 
 
H42 DISEASES OF THE NERVOUS SYSTEM. 
 
 Treatment. — 1. Treatment of Cause. — This has a limited scope. 
 Syphilitic epilepsy, unless due to a gumma or to the secondary 
 anaemia, does not respond to antisyphilitic remedies. Avoidance of 
 alcohol may be almost curative in this form. Keflex factors should 
 be removed. In Sweden epileptics cannot marry; 50 per cent, of 
 hereditary epileptics transmit some transformation of the taint to 
 their offspring. 
 
 2. Hygienic Therapy. — New cases in children should receive the 
 general care outlined under the other neuroses. Work in school 
 should be limited to a few hours and country is preferable to city life. 
 For very poor subjects, institutional treatment is indicated. Most 
 neurologists restrict the consumption of meat, although Gowers al- 
 lows it once or twice a day. Toulouse and Richet withdraw salt and 
 give a milk and cereal diet, which they think promotes the affinity of 
 the bromides for the brain cells. 
 
 3. Bromide Treatment. — This was introduced by Laycock 
 (1853) and was developed by Voisin. The bromides act directly on 
 the nervous tissue ; they depress the cortical cells, inhibit reflex action 
 in the brain and cord and lessen centripetal conduction. Untoward 
 symptoms may result even within therapeutic limits. Intellection 
 may be dulled and muscular depression occur, but these may often 
 be counteracted by administration of coffee; the frequent stomach 
 symptoms can be avoided by free dilution of the bromide in water; 
 diarrhoea, which results especially from potassium bromide, is re- 
 lieved by opium if marked, or if less, by salicylate of bismuth and 
 betanaphthol, aa gr. x, after meals; in its elimination by the skin, 
 acne is common, which is lessened or removed by giving large quan- 
 tities of water and small doses of arsenic and by washing the skin 
 with green soap. Belladonna in small doses will modify the respira- 
 tory catarrh or salivation. The anaphrodisiac effects cannot be pre- 
 vented. In some individuals there are marked idiosyncrasies, as 
 mental^ excitement, hallucinations, rapid emaciation (" bromide 
 cachexia") with lessened physiological resistance to acute diseases. 
 Toxic symptoms may be acute, resembling those of paretic dementia, 
 but more commonly are chronic; chronic bromism is most likely to 
 develop in those with weak digestion or circulation and when the drug 
 is given carelessly for a long time, because its elimination is slow. In 
 the former, hydrotherapy, massage and tonics should be used as pre- 
 liminary or concomitant measures. Cardiac symptoms are due almost 
 wholly to the potassium salt, but especial care in the use of all 
 bromides is indicated in cases of senile epilepsy (myocarditis, arterio- 
 sclerosis, endocarditis) or of great nutritive exhaustion, in which 
 combination with digitalis or strychnia is indicated. In bromism 
 the reflexes are decreased, particularly the pharvngeal reflex- Engle- 
 hardt has shown that it is weak in 17 per cent, and absent in 25 per 
 cent, of normal individuals, whence Ziehen watches the corneal reflex 
 which is never normally absent. In advanced bromism there are low 
 temperature, bronzed skin, vasomotor relaxation, somnolence apathy 
 
EPILEPSY. 1143 
 
 paralytic speech, muscular relaxation, ataxia, tremor, foetor ex ore, 
 anorexia, slow respiration (the usual cause of death), weak heart, 
 abolition of sensation in the skin and mucous membranes and of all 
 reflexes and decrease or suppression of urine. The drug therapeu- 
 tically unites with the nerve cell and depresses its activity and metab- 
 olism and toxicologically it causes its degeneration or atrophy. The 
 drug must be used for months or years and the symptoms above 
 enumerated must be watched for; it seems that epileptics have a 
 certain tolerance for bromides, which Voisin considered almost as a 
 food in this affection. 
 
 Results. — Gowers noted immediate relief in 43 per cent., improve- 
 ment in a short time in 47 per cent, and no effect in 10 per cent, of 
 his cases. He gives a dram a day of the potassium salt, for two years, 
 for he finds that larger doses are no more efficacious: in nocturnal 
 epilepsy a large dose should be given at bed-time. Seguin's results 
 were : cessation of attacks in 23 per cent., notable decrease in 40 per 
 cent., no great effect in 26 per cent., no effect in 10 per cent. Charcot's 
 method was to give a daily dose of one dram, which was gradually in- 
 creased to nearly two, and was then slowly decreased to the original 
 amount. Erlenmeyer's formula is extensively used and gives the best 
 results (sodium and potassium bromide each two parts and ammon. 
 bromide one part). The best results are obtained in cases treated 
 early in their course and early in life and in those in which there are 
 long intervals between attacks. Opium, belladonna, nitroglycerine, 
 digitalis, thyroid extract and chloral are of but secondary importance, 
 although with special symptoms they may reinforce the bromides. 
 Nitroglycerine may be useful in petit mat. Children tolerate large 
 doses of bromides. 
 
 4. Treatment of the Attack. — This is confined to cases in 
 which aurae are present. The patient is placed on the bed or ground 
 to avoid injury and a towel inserted between the teeth to prevent 
 biting of the tongue. Compression or manipulation of the limb in 
 which the aura is felt may in a few instances avert the spasm. Char- 
 cot placed an ice-bag over the head and one over the heart. Inhala- 
 tions of amyl nitrite, ether or chloroform are sometimes beneficial. 
 
 5. Surgical Indications in Traumatic Epilepsy (Jacksonian 
 or generalized). — Biswanger's conclusions are (a) that results are 
 disappointing; only a small percentage of cases actually recover; 
 operation is indicated (&) when convulsions emanate from a small 
 cortical focus; (c) when the convulsions are of a type intermediate 
 between the Jacksonian and generalized forms; (d) when, with gen- 
 eralized convulsions, there is a suggestive scar, bone defect or local- 
 ized tenderness on percussion; (e) since the internal lesion does not 
 always correspond with the external scar, the site of trephining 
 should be governed by focal symptoms, motor or sensory aura?, or 
 "exhaustion" signs; (/) cysts, tumors, bone, membrane or scars may 
 be removed, but not the cortex (as recommended by Horsley) ; (g) 
 operation must be followed by the bromide treatment; (h) operation 
 is contra-indicated in ordinary epilepsy. 
 
1144 DISEASES OF THE NERVOUS SYSTEM. 
 
 INFANTILE CONVULSIONS. 
 
 In young children the nervous 'tissues are incompletely developed, 
 many axis cylinders are not yet clothed with myelin sheaths and the 
 lower dominate the upper segments, thus predisposing the child to 
 disproportionate nervous reaction. 
 
 Etiology. — (a) Rickets as a cause was especially emphasized by 
 Wm. Jenner. Many cases of carpopedal spasm, tetany and laryngis- 
 mus stridulus have a rhachitic basis; this form occurs in infants 
 between the eighth and twenty-fourth months of life, is likely to 
 recur and disappears after the second year, (b) Reflex spasms may 
 be caused by peripheral irritation, as from dentition and worms, 
 though the importance of reflex irritation has been greatly overesti- 
 mated; gastro-intestinal irritation or auto-intoxication, phimosis and 
 otitis media are possible causes, (c) They may be due to gastro- 
 intestinal intoxication, which results in debility, malnutrition or a 
 " hydrencephaloid " condition, which has been described above under 
 various captions and is usually of most serious import, (d) Nervous 
 affections, trauma during delivery, meningitis, tumor, sinus throm- 
 bosis, severe coughing, acute encephalitis (cerebral hemiplegia) or 
 acute poliomyelitis are etiological factors, (e) They may result from 
 acute infections, as scarlatina, measles or pneumonia, in which con- 
 vulsions and vomiting rather replace the chill which is more common 
 in adults. (/) Genuine epilepsy may begin in early life; 12 per 
 cent., according to Gowers, and 40 per cent., according to Osier, occur 
 in the first three years of life. 
 
 Symptoms. —The symptoms resemble those of epilepsy in most of 
 its phases, but they are, however, less developed in the eclampsia of 
 children. It usually begins in the hands and the seizure is partial, 
 tonic, intermittent and carpopedal rather than generalized. Scream- 
 ing and grinding of the teeth may occur. The laryngeal spasm has 
 already been described under affections of the vagus". 
 
 Treatment. — The occurrence of the convulsion is the first indication 
 for treatment and should be met symptomatically by inhalations of 
 chloroform or nitrite of amyl, followed by grs. v to x of chloral and 
 3ss of bromide by rectum. The bromide should be given for several 
 days, for its effects are cumulative rather than immediate. Opiates 
 should generally be avoided in children under five years, especially 
 in nurslings; if given to them at all the dosage should be as outlined 
 under scarlatina. Opiates should not be used in weak or marantic 
 infants. The hot bath is of little service. 
 
 The cause is then determined and treated, as (a) the rickets, and 
 (&) the peripheral irritation; lancing of the gums is practiced less 
 and less; (c) in gastro-intestinal intoxication the stomach should be 
 emptied by ipecac or by means of the stomach tube ; lavage of the 
 bowel is indicated in acute cases and stimulants may be indicated. 
 (d) The bromides should be administered as in epilepsy. 
 
CHOKE A AND CB0EE1F0BM AFFECTIONS. 1145 
 
 CHOREA AND CHOREIFORM AFFECTIONS. 
 
 The name is given to several convulsive maladies. Chorea or St. 
 Vitus dance, known to Paracelsus, was endemic in the middle ages 
 and is now often known as chorea major; it was hysteria or possibly 
 epilepsy. Chorea in its usually accepted sense was described by 
 Sydenham and is known as Sydenham's chorea, chorea minor or in- 
 fective chorea. 
 
 Definition.- — Sydenham's chorea is (a) & neurosis of late childhood ; 
 (b) it is characterized by subacute onset, limited duration and, usu- 
 ally, recovery; (c) it is probably cortical in localization, as indicated 
 (d) by involuntary irregular spasmodic movements, and (e) in- 
 creased incoordination on voluntary efforts ; (/) it is always asso- 
 ciated with some psychical weakness, irritability or alteration in 
 character and (g) is frequently associated with rheumatism and (h) 
 endocarditis. 
 
 Etiology. — (a) Age: 80 per cent, of cases occur in persons between 
 the fifth and fifteenth years ; 90 per cent, in those between the fifth 
 and twentieth years ; it is most frequent at the sixth and seventh years 
 of life or at puberty, (b) Sex: Seventy per cent, of cases are in girls 
 (Gowers, Osier), (c) Rheumatism has been considered a cause since 
 Bright's time and especially by English writers. The French writers 
 probably overestimate its importance and the Germans apparently 
 underestimate it. Rheumatism is a factor in at least 20 to 25 per 
 cent. (Hughes and See) ; some consider it causal in 45 or even 70 
 per cent, of cases. Endocarditis, rheumatism and chorea are too 
 frequently associated to escape serious attention. Rheumatism occurs 
 mostly before the chorea, but in 4 per cent, of cases do the two occur 
 simultaneously. Their association is most frequent in the young, 
 but their exact relation cannot be established until the cause of 
 rheumatism is known. Rheumatism, endocarditis and chorea are 
 probably correlated, i. e., are due to a common virus, (d) Other 
 acute infections are causes in 43 per cent, of cases (Neumann). 
 Chorea has been observed after gonorrhoea, puerperal fever, sepsis, 
 pertussis, measles, typhoid, etc. (e) Pregnancy is a predisposing 
 cause in women, particularly before the twenty-fifth year. Chorea 
 occurs in .the first three months, especially in first pregnancies, and is 
 most severe in character. It rarely occurs postpartum. Giles de la 
 Tourette justly holds that many cases classified as chorea are really 
 hysteria. (/) Neuropathic heredity is observed in 16 per cent, of 
 choreic subjects, particularly among Hebrews, (g) Other causes are 
 sometimes operative, as fright^ trauma and reflex irritation from 
 nasal or digestive disease. It occurs more largely in the lower classes, 
 is sometimes due to iodoform or mercurial poisoning and is influenced 
 by the poor hygiene, excitement, exhibition and competition of the 
 school-room ; this is called the " school-made chorea " by Sturges. 
 
 Pathology and Pathogenesis. — The disease is a provisional neurosis, 
 since no constant pathological findings exist. The following changes 
 
1146 DISEASES OF THE NERVOUS SYSTEM. 
 
 have been recorded; hypersemia, exudation about the arteries, areas 
 of softening, punctate hemorrhages, round hyaline bodies in the peri- 
 vascular lymph sheaths and swelling and turbidity of the large pyra- 
 midal cells of the cortex ; but none of these are characteristic or con- 
 stant. In fatal cases endocarditis is the most frequent finding (90 
 per cent. Osier, 94 per cent. Sturges) and Osier notes that its fre- 
 quency is greater even than in rheumatism. Kirke's theory of 
 cerebral embolism has been abandoned. The bacteriological findings 
 are negative or conflicting. It is probable that the irritation, whether 
 the result of exhaustion or of toxaemia, is either cortical or in the 
 basal ganglia, which are closely connected with the cortex or sub- 
 cortex. 
 
 Symptoms. — 1. Onset. — Prodromes are infrequent, but sometimes 
 there is a subacute onset, with irritability, restlessness, depression, 
 disturbed sleep, headache, anorexia, rheumatic pains or sensory irri- 
 tation. The affection usually begins with motor disturbance in the 
 form of involuntary movements and incoordinate voluntary move- 
 ments; the latter are often misunderstood and punished, for the child 
 cannot sit still or breaks or drops things. 
 
 2. Chorea Movements. — These are involuntary, although they 
 may seem voluntary, as the thrusting out of the tongue or the reach- 
 ing of the arm at an object. They are " irregular in time, character 
 and degree" are often long, are not usually attended by fatigue or 
 pain, are incomplete and without motive, are increased by attention 
 being drawn to them and by excitement and almost always cease 
 during sleep. They usually begin in the arms and later extend to the 
 face and legs. Chorea very often begins on one side, especially the 
 right, whence it extends to the other side, but sometimes remains uni- 
 lateral Qiemichorea) ; both sides, however, are always involved to 
 some extent. The face is contorted with varying expressions, now 
 grimaces or again motiveless smiles ; this is the fades choreatica of 
 Sachs. The eyes roll, are disturbed, especially when attempts are 
 made to fix them, and diplopia is not uncommon. The pupils are 
 often wide and react slowly. The author recently saw with Dr. 
 Halbert a case in which many of the teeth were broken. Speech 
 is involved in 25 per cent, of cases; this is due rather to diffi- 
 cult articulation by the tongue and lips than to phonation., Speech 
 is quicker than normal, like the movements of the arm, and may 
 be aggravated by irregular movements of the glottis and respi- 
 ratory muscles, resulting in panting, irregular inspiration or ex- 
 piration or sobbing sounds in which the diaphragm participates 
 Aphasia is less frequent. The arms are most involved; thev are 
 flexed extended, pronated and supinated in tireless succession. 
 -Bonillaud spoke of the movements as muscular insanity (folie mus- 
 culaire). The trunk is sometimes involved in light cases and dis- 
 tinctly so m severe types. The movements are sometimes so violent 
 as to throw the patient out of bed. The legs are usually much less 
 involved; there is a zig-zag gait and walking may be' impossible 
 
CEOBEA AND CBOBElFOftM AFFECTIONS. 1147 
 
 Besides hemichorea, other irregularities are at times encountered, as 
 monochorea, chorea paraplegica or chorea alternans. The muscular 
 power and endurance are often said to be normal. Some writers, as 
 Wallenberg, insist that paresis is no part of chorea, but Gowers and 
 Osier speak of marked muscular weakness. Two forms are dis- 
 tinguished: (a) paresis with chorea, in which the muscular power 
 is reduced, as in the usual case, and (&) limp or paralytic chorea 
 (Todd, West and the choree molle of French writers). The paresis 
 may be of the mono-, para- or hemiplegic type. 
 
 3. Psychical Changes. — These are constant and the undue irri- 
 tability and ready fatigue resemble an acute cerebral neurasthenia. 
 The subject is wilful, forgetful, emotional, irritable, unable to con- 
 centrate the attention or to remember perfectly. Marked alteration 
 may occur, as complications, viz., delirium, mania, melancholia or 
 hallucinations; chorea insaniens has a most unfavorable prognosis. 
 Combination with hysteria is frequent, with epilepsy infrequent. 
 Hughlings Jackson found paroxysmal headache in 90 per cent, of 
 cases. 
 
 4. Sensation. — Sensation is usually normal. Tenderness over the 
 spine and peripheral nerves is not common, though S. Weir Mitchell 
 and Triboulet described a painful chorea. Occasionally there is a 
 tingling sensation and numbness. Blocq and others have insisted 
 that sensory alteration is referable to hysteria, but Triboulet finds 
 that there is usually some reduction of sensation. 
 
 5. The Reflexes. — These are difficult to study and are often said 
 to be normal. They are normal in 50 per cent, and decreased or 
 absent in 50 per cent. Oddo found the tendon reflexes (a) rarely in- 
 creased, (b) normal in light cases only and (c) as a rule decreased 
 or absent (absent on one side in 80 per cent., on both sides in 50 per 
 cent.). The bladder and rectum are usually normal save in the 
 severest forms. 
 
 6. Electrical Reactions. — The electrical reaction and mechan- 
 ical irritability of the muscles are with few exceptions unaltered. 
 
 7. The Heart. — Irregularity is common and is often due to irreg- 
 ularity in breathing (pseudo-arrhythmia). A slight increase in rate 
 is due to the general neurosis. It has been claimed that chorea may 
 affect the " muscles of organic life " ; Ollivier, Roger and Simon have 
 written of cardiac chorea, which probably does not exist. Func- 
 tional murmurs are frequent, especially in thin nervous children, 
 from the altered condition of the blood, the toxaemia and increased 
 cardiac rate. They may be confused with incipient endocarditis. 
 Great conservatism must be exercised in their prognosis and diagnosis 
 (see Diagnosis of Mitral Insufficiency). 
 
 Endocarditis has been mentioned in the definition of the disease 
 and its causation and pathology (90 to 94 per cent, of fatal cases). 
 It was found in 66 per cent, of Osier's cases without rheumatism. It 
 is rarely malignant, but may produce embolism. Mitral lesions, espe- 
 cially insufficiency, are the most common form. The importance of 
 
1148 DISEASES OF THE NEBVOUS SYSTEM. 
 
 latent endocarditis, i. e., without clinical symptoms, has been empha- 
 sized by Osier, Oxley and Grosse. Pericarditis is not frequent, 
 though it is found in 20 per cent, of cases, in certain statistics. 
 Heart disease is found in 50 per cent, of cases in which there have 
 been two attacks of chorea, and in 100 per cent, of those having 
 over three. 
 
 8. The Skin. — Herpetic eruptions and pigmentation result from 
 medication by arsenic. Urticaria, erythema nodosum and purpura 
 are sometimes observed, as well as the rheumatic nodes first described 
 by May net and later by Barlow and Warner. 
 
 9. General Symptoms. — Emaciation occurs chiefly in the severer 
 types. The urea and phosphates are often increased. Albuminuria 
 is rare, except as a result of renal embolism. The temperature is not 
 often elevated, save from cardiac and other complications; even in 
 chorea insaniens it rarely passes 102°. 
 
 Course and Prognosis. — The average course of mild cases is from 
 six to ten weeks, and six weeks to six months is the average duration 
 of all varieties. In very rare instances the disease may last six 
 (Gowers) or even sixty years (Meldner). Three main types are dis- 
 tinguished: (a) The mild type, in which the patient is nervous, 
 irritable, has but slight choreic movements and is often dyspeptic and 
 sometimes anaemic; (&) the severe form in which the spasmodic 
 movements are severe and general; (c) the maniacal type (chorea 
 insaniens), which is most often observed in adult or pregnant women, 
 and sometimes at puberty. The movements are incessant and extreme 
 and are often associated with fever, constant insomnia and great 
 psychical disturbance. As a rule, the shorter the duration the more 
 intense are the symptoms. The tendency to recurrence was noted by 
 Sydenham. Relapses occur in 25 to 33 per cent, of cases. One year 
 is the average interval and when there is no recurrence within one 
 and one-half years it is probable that none will be observed (Gowers). 
 Germain See held that relapses were most likely to occur at the sixty- 
 ninth day. Recovery is the rule; the mortality averages between 2 
 and 3 per cent. Twenty to 25 per cent, of pregnant cases die. 
 Fatality is greatest at the age of puberty and in adults. As Charcot 
 remarked, death occurs less often from complications, as endocarditis, 
 than from toxaemia, fever, mental changes, emaciation, delirium and 
 coma. In all cases rise of temperature or obstinate insomnia is omin- 
 ous. Though the immediate outlook is not influenced by endocarditis, 
 it is a most important feature in the ultimate prognosis of a complete 
 recovery. Intercurrent fevers may dissipate the spasms. While 
 complete recovery is usual, in rare instances distinct psychical 
 changes (Jolly) or permanent chorea remain (v. s.). 
 
 Diagnosis. — Recognition of the disease is usually most easy when 
 one bears in mind the conception (definition, q. v.) of the disease. 
 
 Differentiation. — Simple tremor or the intention tremor of 
 multiple sclerosis is easily separable. The hemichorea of hemiplegia 
 (see Diagnosis of Cerebral Hemorrhage) or the bilateral chorea 
 
CHOEEA AND CHOREIFORM AFFECTIONS. 1149 
 
 of infantile cerebral paralysis (q. v.) is distinguished by the history 
 and course. Friedreich's ataxia is differentiated by its slow, irregular, 
 incoordinate movements, nystagmus, its frequent family incidence, 
 the scoliosis, talipes and slow, scanning speech. Hysterical chorea (so- 
 called) is rhythmic, more regular and frequently produces sudden 
 (" electrical") movements, as bowing or salaaming, nodding the head, 
 etc. Chorea major is easily distinguished. Chorea in the original 
 sense is chiefly of historical interest ; it was a pandemic or epidemic 
 hysteria provoked by religious excitement. Its victims made pilgrim- 
 ages to the shrine of St. Vitus, whence the name of the disease. Simi- 
 lar outbreaks occurred in Kentucky among the early settlers. This 
 form closely resembles the saltatoric spasm described by Bamberger 
 in 1859, in which the legs contract on attempting to stand, causing 
 jumping or springing movements. It may be transitory or may last 
 for years and occurs chiefly in neurotics. Beard and Thornton de- 
 scribed a similar neurosis endemic in Canada among the " jumping 
 Frenchmen." The " holy rollers," and jumpers of Russia and Java 
 probably come under this head or under impulsive tic (v. i.). 
 
 Huntingdon s chorea has no connection with Sydenham's type. 
 Chronic chorea comprises two forms : (a) The senile form, in which 
 the mind is less involved, the course more benign than in (&) the 
 hereditary form of Huntingdon. Although it was described by 
 Walters (1842) and Lyons (1863), Huntingdon in 1872 brought out 
 the cardinal features of the disease as observed on Long Island. 
 These are (i) the late and gradual onset after the thirtieth year, more 
 marked in males than in females ;• (ii) its hereditary character, some- 
 times involving 25 or 50 per cent, of the family, sometimes skipping 
 generations or lasting for generations or even for two centuries in a 
 family (Osborn) ; (iii) its progressive character, and (iv) the result- 
 ing mental degeneration, ending in slow dementia, often with epilepti- 
 form attacks or suicidal tendencies. The precise pathology of Hunt- 
 ingdon's type is not known. Pachymeningitis, hematoma of the 
 dura, or less often chronic encephalomeningitis, vascular disease and 
 atrophy of the convolutions have been present in the isolated autopsies 
 made. The etiology is unknown. Clinically it is characterized by 
 irregular movements, which usually begin in the hands, are some- 
 what controlled by voluntary effort and are more irregular, inco- 
 ordinate and slow than in acute chorea. Slow spasmodic facial con- 
 tortions are observed, and the speech becomes first slow and hesitating, 
 and later quite indistinct. The gait is unsteady and swaying. Writ- 
 ing is interfered with, the reflexes are moderately increased, sensa- 
 tion is normal save that the muscular sense is somewhat blunted, and 
 dementia develops. The disease is incurable, although somewhat 
 benefited by opium and bromides. 
 
 Tic. — The term is now used to designate an "habitual, conscious, 
 convulsive movement resulting in the involuntary contraction of one 
 or more muscles, abruptly reproducing some reflex or automatic action 
 of every-day life" (G. Guinon). There are three forms. 
 
1150 DISEASES OF THE NEBVOUS SYSTEM. 
 
 (a) In simple tic, (i) localized spasm, habit spasm or habit chorea, 
 which is said by S. Weir Mitchell to occur in girls between seven and 
 fourteen years of age, may result from lesions of the nose or throat or 
 possibly from eye-strain, and includes movements such as winking, 
 drawing of the mouth, sniffing, shaking the head and shrugging the 
 shoulders. It usually ceases, but may last into adult life, and the 
 " child's attention should not be drawn to the movements," although 
 the writer believes that judicious reminders and discipline inhibit 
 these habits. Arsenic may be beneficial, (ii) The electric chorea 
 (Henoch and Bergeron) consists of short, lightning-like contractions 
 in special muscles, as those of the neck or shoulders, as though the 
 muscles were electrically stimulated, (iii) Dubinis disease (18-16) 
 consists of contractions of the arms and legs, followed by hyper- 
 esthesia, pain in the head and back, muscular atrophy, paresis and 
 sometimes fever and convulsions. It is endemic in Lombardy, its 
 cause is unknown, and it is usually fatal from apoplexy or coma. 
 (iv) Paramyoclonus multiplex, or myoclonia, described by Friedreich 
 in 1881, is an affection of sudden onset, with symmetrical, involun- 
 tary, arrhythmic, quick, clonic contractions of the upper parts of the 
 arms, legs and trunk, sometimes of the face and tongue, and occurs 
 without loss of consciousness. The contractions number from 10 to 
 150 a minute and may terminate in a tetanic contraction. It affects 
 male adults chiefly (75 per cent.) and follows mental or emotional 
 agitation, so that some would classify it under hysteria. The myo- 
 tatic irritability and reflexes are increased, the mind is usually nor- 
 mal, although sometimes fixed ideas are observed, hiccough is occa- 
 sional from involvement of the glottis or diaphragm, voluntary move- 
 ment is decreased or sometimes arrested, there are no sensory symp- 
 toms and the outlook is usually good, although the course may be 
 long and relapsing. Treatment consists of administration of voltaic 
 electricity, nervines and bromides. The family form, described by 
 ITnverricht, with epilepsy and spasms of the tongue and deglutition, 
 is probably a subtype of hereditary chorea. C. Oddo gives the follow- 
 ing general differentiation between 
 
 Tig and Chorea. 
 
 Form of movement: pseudo-intentional, Incoordination and great variability, 
 with repetition. 
 
 Bhythm: rhythmic, brusque, short, Arrhythmic, slow, not synchronistic, 
 synchronistic. 
 
 Will: suspends movements. No action. 
 
 Accessory signs: muscular power pre- Myasthenia; modified reflexes and 
 served; normal tendon reflexes and sensation, 
 
 sensation. 
 
 Etiology: hereditary degeneration. Neuropathic tendency. 
 
 (b) Tic with explosive utterances, impulsive tic or Gilles de la 
 
CHOREA AND CHOREIFORM AFFECTIONS. 1151 
 
 Tourette's disease, is closely affiliated with hysteria and monomania. 
 It occurs in neurotic individuals between the sixth year and puberty. 
 The cardinal features of the psychosis are: (i) Involuntary move- 
 ments in the face and arms or in all the muscles in severe types, when 
 the movements become violent or explosive, (ii) Explosive utter- 
 ances, resembling a bark, occur; the patient repeats words he hears 
 (echolalia) or mimics movements (echopraxia) ; the child may use 
 obscene or profane words (coprolalia), which was considered by de 
 la Tourette to be most characteristic, (iii) The subject has fixed 
 ideas. These include: arithmomania, in which every action is pre- 
 ceded by counting or doing a certain thing a given number of times ; 
 a fear of contamination {delete du toucher) ; onomatomania, or repe- 
 tition of a given word or name ; folie pourquoi, demanding the reason 
 for everything. The prognosis is usually unfavorable. 
 
 (c) In complex coordinate tic, as thumb sucking, rocking in the 
 bed and bumping the head, the outlook is favorable when it does not 
 occur in feeble-minded children (Gee and Hadden). 
 
 Treatment of Acute Chorea. — 1. Prophylaxis. — This may produce 
 results ; sensible methods of education should be adopted, the hours in 
 the overheated, foul school-room should be short, and the useless 
 forcing of children by marks, prizes and exhibition should be aban- 
 doned. Children can be taught more in an hour or two of judicious 
 individual instruction than in the five or six confining hours which 
 their wandering attention must endure. Prevention may concern 
 other etiological factors {q. v.) ; for instance, the nose should be ex- 
 amined for sources of irritation, as adenoids. 
 
 2. Rest in Bed. — The results obtained by rest in bed and isolation 
 are as rapid as those of any medicinal therapy. It not only saves 
 tissue waste, but is the best prophylactic and symptomatic treatment 
 of possible or actually established endocarditis. 
 
 3. Skin. — The skin is very often dry and harsh, whence it must 
 be given special attention. Diaphoretics frequently produce bene- 
 ficial effects. The stimulation of the skin by proper covering and 
 hydrotherapy is the simplest and least injurious method. The re- 
 frigerant diaphoretics and full warm baths give the best results. The 
 skin must be kept clean and in severe cases the water-bed must be used. 
 
 Trauma. — Trauma is prevented in severe types by padding the 
 beds by mattresses and pillows, since the violent movements may even 
 throw the patient to the floor. Sepsis is a frequent occurrence, and is 
 most dangerous. The temperature must be taken by rectum. 
 
 5. Exhibition of Drugs. — {a) Fowler s solution is the most fre- 
 quently used and the oldest remedy, and apparently gives the best 
 results. It should be given in increasing doses (see Treatment of 
 Pernicious Anaemia for detailed action) ; children tolerate large 
 doses of arsenic exceptionally well. It may be administered hypo- 
 dermatically or by clyster when the digestive tract is irritable. Ar- 
 senic is not without its dangers. C. Gamble, Jr., records an instance 
 of fatal arsenical poisoning in a case to whom about 1% ounces of 
 
1152 DISEASES OF TEE NERVOUS SYSTEM. 
 
 Fowler's solution was given in a month (including an intermission 
 of one week). It appears that rest in bed and administration of a 
 placebo, as mix vomica, has given equally good results, (b) Salicy- 
 lates are of benefit only when rheumatism actually co-exists and 
 acetanilide is indicated only in the initial stages. In other words, 
 antirheumatic remedies are less important in the treatment than is 
 rheumatism in the etiology, (c) Depressomotors: The bromides 
 rarely cure the movements/ although they often quiet the mild psy- 
 chical manifestations. Chloral has been given in large and continued 
 doses to produce sleep or continuous sleep. This method merely 
 demonstrates the tolerance of the body for dangerous remedies and 
 chloral cannot be given safely in amounts exceeding a dram for 
 adults in three divided doses at intervals of an hour. Morphine is 
 generally dangerous and inferior to chloral. Small doses often accen- 
 tuate the mental agitation, but if combined with chloral, hyoscine 
 and bromide, it may give at least temporary relief, (d) Strychnine 
 is valuable (Trousseau), especially in the later stage, when recovery 
 is slow, (e) In chorea gravidarum, abortion or premature delivery 
 is indicated. 
 
 TETANY. 
 
 Definition. — Tetany, first described by Steinheim (1830) and Dance 
 (1831) and named by Corvisart, consists chiefly of (a) peculiar tonic, 
 intermittent, bilateral, painful spasms, mostly in the extremities, 
 without involvement of the sensorium and (b) increased mechanical 
 and electrical excitability of the nerves. 
 
 Etiology. — (a) It occurs endemically or epidemically, especially in 
 Vienna, Heidelberg, Berlin and Syria, and it is prevalent during 
 March and April. It is rare in America, England and Italy. 
 Though once frequent (1830-1860), it is now uncommon in Paris. 
 In the Vienna outbreaks 46 per cent, of cases occurred in shoe- 
 makers and 24 per cent, in tailors who were otherwise healthy. 
 Tetany occurs among the poorer classes. Eighty-three per cent, oc- 
 cur in persons between sixteen and twenty-five years of age. It may 
 develop in an entire family, (d) Digestive affections may produce 
 it, as dilatation of the stomach (Kussmaul, 1871), dyspepsia, ulcer 
 or cancer of the stomach or duodenum, often with pyloric obstruction ; 
 auto-intoxication is the most probable cause of this group. Only 80 
 cases of gastric tetany are on record, (c) Rickets is causal in 85 to 
 90 per cent. (Seeligmiiller) and in 96 per cent. (Cassel) of the in- 
 fantile types. Some writers — incorrectly, we think — consider thai 
 the infantile carpopedal spasm is tetany, (d) Tetania strumipriva 
 is a type of tetany which follows removal of the thyroid in 15 per cent. 
 of cases (Albert, Mikulicz, Kocher). It appears that the thyroid is 
 less important than the parathyroid glands. (See pages 856 and 
 857.) (e) Tetany occurs also in the acute infections, sepsis, ne- 
 phritis, puerperal or nursing women and rarely in intoxications with 
 ergot, morphine or lead. There are recorded only 32 cases of the 
 
TETANY. 1153 
 
 puerperal form. Of the four cases which the author has seen in this 
 country two occurred with florid secondary syphilis, one after an 
 adenoid operation and one with gastrectasis. It may develop with 
 other nervous disease, and French writers have attempted to class it 
 under hysteria. ~No pathological changes have been observed in the 
 brain or nerves ; in a few cases there has been cloudiness with swell- 
 ing of the anterior horns. Fifteen cases are reported in America 
 (Howard, 1906). 
 
 Symptoms. — 1. Muscular Contracture. — The earliest and chief 
 symptom is the muscular contracture, which usually commences in 
 the hand, with stiffness, numbness and pain, and culminates as a 
 tonic, symmetrical, painful contracture. The muscles of the hand 
 are hard; the attitude is that of the accoucheur's hand, the hand in 
 writing or that observed in paralysis agitans ; it is produced by con- 
 traction of the ulnar flexors; less often it resembles the clenched 
 hand of old hemiplegic contracture, and the nails even enter the palm ; 
 rarely the fingers are tonically spread apart. Except in light forms, 
 the spasm cannot be overcome by force. The wrist may be flexed. 
 The foot is affected less often than the hand and the spasm draws the 
 foot into the equino-vams position, with the toes flexed and the sole 
 hollow. The spasm is usually limited to these parts, causes pain, 
 lasts from minutes to hours or even days, disappears and usually 
 recurs later. In rarer and more severe cases the parts above the 
 elbows and knees may participate, with adduction of the arms and 
 thighs, cramping of the face, neck, chest, tongue, diaphragm and 
 ocular muscles, with diplopia, spasticity of the sphincters with reten- 
 tion, dysuria, etc. 
 
 Laryngismus stridulus (Clark, 1815) is common in infantile 
 rickets, in which clonic contractures also occur. The muscles are 
 somewhat weak and tremor is frequent. Pineles describes laryngo- 
 spasm following parathyroid extirpation. 
 
 2. Trousseau's Sign. — This consists in producing the spasm by 
 pressure over the nerves, for example, just above the elbow or over the 
 peroneal nerve, for a few seconds or from one to five minutes. It is 
 wholly due to nerve pressure, not to pressure on the vessels, and is 
 pathognomonic. 
 
 3. Erb's Sign. — There is increased electrical irritability of the 
 motor nerves to the galvanic current with early anodal closing and 
 cathodal opening tetanus. Anodal opening tetanus is found in this 
 disease alone. There is also increased electrical irritability of the 
 sensory nerves (Hoffmann) and of the nerves of special sense (Chvo- 
 stek, Jr.), to faradic and galvanic currents. 
 
 4. Chvostek's Sign. — Increased mechanical irritability of the 
 motor nerves (Chvostek's sign) is observed on tapping or pressing 
 on the facial, median, ulnar or other nerves, which produces contrac- 
 tion of the muscles supplied by them. It is quite constant but may be 
 absent in children and is not pathognomonic, having been found in 
 normal persons, in cases of bulbar paralysis, in the major neuroses 
 
 73 
 
1154 DISEASES OF THE NEBVOUS SYSTEM. 
 
 and in convalescing cases of facial paralysis. (Some of these may 
 have been atypical tetany). The muscles themselves are not over- 
 excitable. 
 
 5. Other Symptoms. — The sensorium is usually clear, except in 
 rare cases with pyloric stenosis. The special senses are normal; 
 optic neuritis is extremely rare. Headache and malaise are fre- 
 quent. In contrast to the pain and paresthesia, objective sensory 
 findings are absent. In rare cases epileptiform seizures are seen, 
 which are probably due to parathyroid changes. The reflexes are 
 usually normal. The temperature is elevated in 15 per cent, of 
 cases, but may be subnormal. In very rare chronic cases, trophic, 
 vasomotor and secretory disturbances may occur, as oedema, polyuria, 
 glycosuria or falling out of the hair. 
 
 Diagnosis. — The diagnosis in typical cases is most easy from the 
 cardinal signs: (a) the peculiar spasms; (b) Trousseau's, (c) Erb's 
 and (d) Chvostek's signs. In epilepsy these signs are absent and the 
 aura, the cry, falling, tonic and clonic convulsions, biting of tongue 
 and involuntary urination are characteristic. Hysteria mimics every- 
 thing, but the cardinal symptoms, except the spasms, cannot be repro- 
 duced ; it has its own stigmata ; certain reported epidemics of tetany, 
 as at Gentilly, were clearly hysterical. In adults atypical forms with- 
 out spasm are recognized by the other cardinal signs, which easily 
 separate tetany from the occupation neuroses and acroparesthesia 
 (v. i.). In children meningitis and brain tumor are distin- 
 guished on careful examination. The rhachitic relations are im- 
 portant even though the extreme statement that all tetany in children 
 is rhachitis, cannot be admitted. 
 
 Prognosis. — The outlook is good in most cases and the course covers 
 from two to four weeks as a rule. Recurrences are not infrequent. 
 The etiological prognosis naturally varies, but generally speaking, 
 death occurs not from tetany but from dilated stomach or ablation of 
 the parathyroids. Cases may die from laryngospasm. In a recent re- 
 view of his cases, Frankl-Hochwart concluded that the prognosis is 
 worse than is usually stated; 20 per cent, of his cases died, 20 re- 
 mained well and the balance had recurrences and serious disabilities. 
 
 Treatment. — The treatment varies with the cause, (a) Rest and 
 quiet are indicated on general principles, although cases of tetany are 
 influenced very little by excitement. Massage, strychnia and elec- 
 tricity should of course be avoided. Change of occupation and loca- 
 tion, at least temporarily, is advisable in the endemic form. (&) 
 In the digestive form, washing out the stomach and bowels in sus- 
 pected cases of auto-intoxication may induce severe spasms. These 
 cases are both dangerous and obstinate. The spontaneous mortality 
 in gastric tetany is 75 per cent,.; with operation for pyloric stenosis, 
 this figure is reduced to 37.5 per cent, (c) In the rhachitic form, 
 dietary regulation and improved hygiene are necessary, and phos- 
 phorus and iron are indicated. Inhalations of chloroform in some 
 cases irritate the sensitive larynx, (d) In so-called tetania struma 
 
OCCUPATION OE FATIGUE NEUBOSES. 1155 
 
 priva the mortality is 80 per cent. ; parathyroid feeding is help- 
 ful, (e) Cases following acute infections usually have a spon- 
 taneously short course ; those occurring in pregnancy rarely indicate 
 abortion; in nursing women, weaning gives prompt relief; for in- 
 toxications there are obvious indications. In general, drugs are of 
 little value ; chloral is indicated a priori, to influence the motor nerves, 
 but is inferior to the bromides, as is also morphine, except for pain. 
 Sweating and digitalis in nocturnal forms of tetany have apparently 
 helped some cases, but the disease usually runs its limited unin- 
 fluenced course. 
 
 OCCUPATION OR FATIGUE NEUROSES; WRITER'S CRAMP. 
 
 The continuous, hard, improper use of coordinate, functionally 
 associated muscles may result in their cramping. Writer s cramp 
 (graphospasms, mogigraphia) was first described by Charles Bell 
 (1830) and especially studied by Duchenne and Benedict. Neuro- 
 pathic tendencies are noted in most cases ; 83 per cent, occur in 
 males, 93 per cent, occur in those between twenty and sixty years of 
 age, and most of these cases develop between twenty-five and thirty- 
 five. Worry is a frequent factor; toxsemia, cold, trauma, neuritis 
 and neuralgia are possibly factors. The disease practically never 
 occurs in those who write properly, i. e., move the arm from the 
 elbow or the shoulder, but develops in those who use the little finger 
 or wrist as the basis of movement. The affection is located in various 
 centres ; some hold that it is in the coordinating cortical or subcortical 
 centres; it is clearly not in the muscles or nerves, for their other 
 movements are often normal ; the occasional atrophy and paresis may 
 suggest localization in the cord. 
 
 Symptoms. — The symptoms come on gradually, with fatigue, pain 
 and cramping in the muscles of the forefingers and thumb, which 
 may extend to the forearm or shoulder. There may be the " lock 
 spasm " of Mitchell, in which the pen is spastically held or it may be 
 thrown from the fingers. On rest, the tonic spasm disappears, but 
 reappears with attempts to write. In Benedict's classification we 
 find the spasmodic, paralytic, tremulous and neuralgic forms, which 
 are of less interest as types than as showing the various symptoms, 
 which are often combined in a single case. Vasomotor symptoms may 
 occur, as flushing or glossy skin. 
 
 Differentiation. — Differentiation, according to the type, from hemi- 
 plegic weakness, paralysis agitans, musculospiral paralysis and 
 neuralgia, is usually easy. Similar cramps are observed in tele- 
 graphists, milkmaids, weavers, cigarette rollers, tailors, shoemakers, 
 watchmakers and violin and piano players. Public speakers may 
 suffer from similar neuroses of the throat and Church mentions jaw 
 spasms in gum chewers and of the lumbar muscles in physicians who 
 drive much. 
 
 The outlook is poor, because the unfortunate sufferer is often com- 
 
1156 DISEASES OF TEE NEBVOUS SYSTEM. 
 
 pelled to write until the affection is firmly fixed and when ahle, usu- 
 ally returns to the same work. In some cases the muscles may waste. 
 Treatment. — Eest is essential to recovery, because treatment for the 
 usual nervous symptoms alone never succeeds. Plaster casts are 
 sometimes successfully employed. Even when the subject learns to 
 write with the other hand it often develops there. Prevention is 
 possible by writing free-hand from the shoulder; holding the pen 
 between the first and second fingers, use of pens with large handles, 
 of quills and of forearm splints with the pen attached to the ex- 
 tremity, are also helpful. Yogouroux and Wolff use with success 
 systematic gymnastics, including passive manipulations and active 
 exercises. 
 
 MYOTONIA. THOMSEN' S DISEASE. 
 
 Myotonia is usually called myotonia congenita from its leading 
 causal element, heredity. It was first described by Ley den, but more 
 fully by Thomsen (1876), who was a victim among 20 cases in his 
 own family, in five generations. This rare affection, of which there 
 are about 100 reported cases, occurs chiefly in males and in Germany 
 and Scandinavia. Its pathology is obscure, for the only necropsy 
 which has been performed (Dejerine and Sottas) showed no nervous 
 alteration. Muscle fibers, excised during life, show hypertrophy, 
 decreased striation, nuclear multiplication and slight interstitial in- 
 crease, leading Leyden and others after him to consider the process 
 myopathic. Some offer the objection that these changes are artefacts. 
 
 Symptoms. — A peculiar transient tonic muscular rigidity develops 
 when the muscles are first used, which limits or arrests movement, 
 but wears off as their use is persisted in. It is intense when a new 
 kind of movement is undertaken. The longer the muscles are rested 
 the more severe is the initial spasm on exertion. Kigidity does not 
 follow passive muscle movement, although firm pressure or a sharp 
 blow initiates it. It appears early in life, perhaps " in the cradle," 
 but generally between the ages of four and ten, it increases as the' 
 muscles develop and then becomes stationary for life. In one case 
 improvement was observed. The legs are more affected than the 
 arms, but in exceptional cases the face, tongue, bladder or the respi- 
 ratory muscles may be affected. They are usually stronger and some- 
 times larger than normal, although some writers speak of muscular 
 weakness. 
 
 ^ Though the tendon reflexes and the mechanical and electrical ex- 
 citability of the nerves are practically normal, application of the 
 galvanic current to the muscles produces sluggish, prolonged closing 
 contractures, which are easily and equally obtained with 'either pole 
 and become tetanic with strong currents ; this is the myotonic reaction 
 of Erb. Undulatory contractures follow strong faradic stimulation. 
 Subjects of myotonia are frequently irritable or hypochondriacal. 
 
 Treatment.— Treatment is of little value. Thomsen believed that 
 exercise retarded the disease. Cold, dampness, excitement and fa- 
 tigue are to be avoided, 
 
PABALYS1S AGITANS. 1157 
 
 The following are allied, if not identical, affections ; the congenital 
 paramyotonia of Eulenberg, consisting of tonic spasms, which last 
 from fifteen minutes to several hours, occur especially in the arms, 
 and often affect the eyes and mouth ; it is excited by exposure to cold 
 (vasomotor spasm in the muscles) ; and the ataxic paramyotonia of 
 Growers, in which tonic spasms may last the entire day, with muscular 
 weakness, ataxia, especially in the hands and disturbed sensation or 
 anaesthesia in the fingers. 
 
 PARALYSIS AGITANS. 
 
 This affection is also known as shaking palsy or Parkinson's dis- 
 ease; it was first described by Parkinson in 1817. 
 
 Etiology. — (a) Most cases occur in persons between the ages of 
 forty and sixty-five. (&) Sixty-six per cent, of cases are men. (c) 
 A neuropathic tendency is present in 15 per cent, (d) It is doubtful 
 if trauma, acute infections or thyroid disease are causes. 
 
 Pathology. — It is classed among the neuroses, because of the absence 
 of any constant pathological finding. It is not strange that arterio- 
 sclerosis and perivascular thickening are often found, since paralysis 
 agitans occurs in " the early degenerative period." Gordinier's col- 
 lection of cases examined by recent histological methods, shows 
 that (a) general arteriosclerosis is less marked than that of the nerv- 
 ous tissue; (b) the arteries in the cord are markedly changed and 
 around them are (c) increased neurogliar sclerosis and (d) pigmenta- 
 tion and atrophy of the nerve cells and fibers. 
 
 Symptoms. — The cardinal symptoms are (a) tremor; and (&) stiff- 
 ness, slowness of movement, shortening and weakening of the muscles. 
 (a) Tremor in 66 per cent, of cases is the first symptom; it may de- 
 velop after the muscular rigidity and is sometimes absent (paralysis 
 agitans sine agitatione). It usually appears first and is most marked 
 in the hands. It affects first one hand and usually next reaches the 
 leg of the same side, then the opposite hand, the opposite leg, and 
 lastly the trunk, so that at different periods of development it is suc- 
 cessively a monoplegic, hemiplegic or finally a diplegic tremor. It 
 is slow (4 to 7 oscillations per second), rhythmic, fine at the onset, 
 but somewhat coarser later and in the large muscles is more marked 
 in peripheral than distal parts, persists during rest, ceases during 
 sleep and ceases momentarily on voluntary action. In rare cases it 
 appears only on movement, as intention tremor; Gerhardt found it 
 increased by movement in 50 per cent. It is difficult to define pre- 
 cisely the muscles involved. In the hands it may affect chiefly the 
 flexors and extensors at the metacarpal joints or the interossei, which 
 give the spinning or pill-rolling movement. The wrists may be ab- 
 ducted and adducted, rarely supinated and pronated, and the arms 
 and shoulders are implicated but little. The writing is tremulous. 
 The feet are mostly involved at the ankles and in the toes but little. 
 The thigh adductors often tremble. Trembling is infrequent in the 
 face, neck and back, while the abdomen entirely escapes. The head 
 
1158 
 
 DISEASES OF THE NERVOUS SYSTEM. 
 
 and body may of themselves tremble, but much of it is imparted to 
 them from the limbs. In the rarest cases the tongue, palate, larynx 
 and epiglottis tremble. 
 
 (b) Muscular rigidity and shortening, weakness and slowness of 
 movement usually follow the tremor; slight symptoms are detected 
 early and anticipate tremor or exist without it. These changes re- 
 sult in the following: (i) The Parkinson fades, which is mask-like 
 and devoid of lines or expression; the eyelids seldom wink. The 
 forehead shows transverse folds because of the bowed head and body. 
 The eyes move tardily in reading, and the entire body must be turned 
 to enable the patient to look laterally. There is also slow, monoto- 
 nous, monosyllabic speech, with hesitation at first, but hurried at 
 the finish, (ii) The attitude is characteristic, because of the flexor 
 
 positions assumed, the head and 
 the chin are held forward, the 
 neck is extended and rigid, the 
 body is inclined forward, the el- 
 bows are fixed and brought some- 
 what forward and away from the 
 body ; . the forearms are brought 
 toward the body, the trembling 
 thumb and index finger are ap- 
 posed, or the fingers deviate 
 toward the ulnar side as in arthri- 
 tis deformans, and in standing 
 the knees are somewhat bent and 
 at times closely apposed. The 
 body expression, we may say, is 
 like that of the face, (iii) 'The 
 gait is equally characteristic. 
 Like the speech, it is initially 
 hesitant, and later hurried. The 
 patient, when once started, may 
 not be able to stop himself. 
 Trousseau spoke of the patients 
 as " chasing their centre of grav- 
 ity." This festination or propul- 
 sion is probably purely mechan- 
 ical from the forward bodily in- 
 clination, although interpreted by 
 Charcot as a kind of forced move- 
 ment. To counteract the throw- 
 ing forward of the centre of 
 gravity the arms may be carried 
 behind the back. In some cases, if the patient is pushed back- 
 ward or sideways, he may not be able to stop for some steps; this 
 is retro- and latero-pulsion. (iv) The palsy is often slight and 
 rarely extreme, although it may be simulated by the helplessness 
 
 Side view of a case of paralysis agi- 
 tans. showing forward inclination of the 
 trunk. Tendency to propulsion 
 cum.) 
 
 (Der- 
 
PEMODIC FAMILY PARALYSIS. 1159 
 
 caused by rigidity. The patient is not inclined to exertion, " moves 
 like a piece of machinery/' as Parkinson describes it, and may 
 not be able to turn over in bed. Patients have drowned from fall- 
 ing on the face in a small puddle of water. Muscular reaction 
 requires 40 per cent, more time than normal. 
 
 Other symptoms are subordinate. ' The mind is clear, but we may 
 say stiff like the face and limbs, and a certain restlessness, irrita- 
 bility or apathy may be detected ; insomnia is common and headache 
 occasional. Sensation is essentially normal, although pains, pru- 
 ritus, paresthesia and hypsesthesia are seen in 35 per cent, of cases. 
 Vasomotor disturbance most often assumes the form of a feeling of 
 heat; indeed the peripheral temperature may be increased several 
 degrees. Severe sweats are quite common. The pupillary, cutaneous, 
 tendon and organic reflexes are normal. 
 
 Course and Prognosis. — The onset is usually gradual and the course 
 covers several decades. The outlook is most favorable in atypical 
 cases. Remissions may occur, but the disease progresses steadily. 
 Death very rarely occurs from the affection itself, but usually from 
 intercurrent pneumonia or advancing arteriosclerosis, cerebral soften- 
 ing, myocardial insufficiency, nephritis and kindred lesions. 
 
 Diagnosis.' — When there is clear development of the cardinal symp- 
 toms the disease is unmistakable. Confusion is possible in the early 
 hemiplegic forms, but the absence of a paralytic stroke and the later 
 course are distinctive. Charcot and Ordenstein (1868) clearly differ- 
 entiated the affection from multiple sclerosis (q. v.). The fine, senile 
 tremor, the hereditary tremor of Dana, tremors due to overexertion 
 or excitement, to toxic causes (alcohol, nicotine, lead, mercury, coffee, 
 opium or chloral), weakness of convalescence from acute infections, 
 paretic dementia or the neuroses (epilepsy, Graves' disease, hysteria, 
 neurasthenia) are easily excluded by the absence of the Parkinson 
 rigidity, facies and festination. 
 
 Treatment. — Treatment of the probably fundamental arterioscler- 
 osis may possibly retard the disease, but prophylaxis is possible in 
 the early stages only. All mental and physical fatigue should be 
 avoided. The administration of full doses of iodide, chloral, opiates, 
 bromides, hyoscine, ergotin, conium or duboisin may mitigate the 
 tremor, but always lower vitality and disturb function. 
 
 PERIODIC FAMILY PARALYSIS. 
 
 This affection was first described by Cavare (1853) and more fully 
 by Westphal (1885) ; Holzapple collected 70 cases (1905). It is a 
 family affection ; Goldflam collected 11 cases in one family and E. W. 
 Taylor 12 in another. Most cases occur in adolescence and nearly all 
 of them in persons under twenty-five ; it recurs every few weeks or 
 months, possibly every day, or only at intervals of years. Its symp- 
 toms are almost wholly motor, producing a flaccid paralysis in the 
 legs and arms, less often in the trunk, and exceptionally in the face, 
 
1160 DISEASES OF THE NERVOUS SYSTEM. 
 
 neck, tongue and throat. It occurs without apparent cause, usually 
 during sleep, from which the patient awakes with a sense of fatigue, 
 weakness or dulness which develops into paralysis within twenty-four 
 hours. Mental and sensory symptoms and those of the cranial nerves 
 and special senses are rare. There is no fever, the pulse is often slow 
 and cardiac dilatation has been observed. The deep reflexes are de- 
 creased or abolished, often also those of the skin, and the faradic 
 excitability of the nerves and muscles is lessened or absent. The 
 patient is well in a few hours or days, until another attack occurs. 
 The disease usually subsides spontaneously after the fiftieth year of 
 life. Its nature is not determined. Goldflam's theory of auto-intoxi- 
 cation is supported (a) by J. K. Mitchell, Flexner and Ebersoll, who 
 found increased secretion of kreatin before and during the attack; 
 (b) by Crafts and Irwin, who isolated toxins from the faeces; (c) 
 possibly by the fact that potas. citrate sometimes lessens or aborts 
 the seizure. Dana thought that the disease was hysterical, but Bern- 
 hardt and others consider it affiliated with myotonia and progressive 
 muscular atrophy. Holzapple administers potas. bromide in doses 
 of thirty grains. 
 
 MIGRAINE. 
 
 Migraine (hemicrania, megrim, sick headache) is an hereditary 
 degeneration or psychoneurosis, with the paroxysmal occurrence (in 
 a complete attack) of aurse, headache, nausea and vomiting. 
 
 Etiology. — (a) Heredity is a conspicuous cause (90 per cent. 
 Mobius), either directly as migraine or indirectly from neurotic, in- 
 sane or epileptic antecedents. Joint affections, as gout, are often 
 noted in the family history. (&) Thirty-three per cent, of cases begin 
 between the fifth and tenth, 40 per cent, between the tenth and 
 twentieth years, and the remainder usually before the thirtieth year. 
 Females are affected a little more frequently than males, (c) Ex- 
 citing causes are acute infections, constipation, dyspepsia, overexer- 
 tion, alcohol or sexual abuse, emotional factors, pelvic disorders and 
 lactation. It is attributed, though probably incorrectly, to adenoids. 
 Refractive errors may explain some cases. 
 
 Symptoms.— Preliminary symptoms are often absent, although the 
 patient may feel depressed, or, in some cases, especially well and 
 energetic. They occur in cases in which the sensory symptoms are 
 least marked (see below). Sometimes the pupils are dilated. Most 
 attacks develop during the night. 
 
 Aum.— In over 50 per cent, of cases, aura- are (a) sensory, as 
 visual aurse, a cloudiness before the eyes, sparks, lightning, zig-zao- 
 forms, etc. ; they are most often bilateral and affect the homologous 
 half-fields; taste and smell may be similarlv affected; paresthesia 
 may occur, usually as hemiparsesthesia ; (&) motor aurge are much less 
 common, as aphasia, dysphasia or motor weakness on the contra- 
 lateral side ; in the very rare form, ophthalmoplegic migraine, there 
 are fugitive ptosis, outward strabismus, double vision and a dilated im- 
 
MIGRAINE. 1161 
 
 mobile pupil; mental auras are uncommon and not usually pro- 
 nounced, as restlessness, anxiety, confusion and double consciousness. 
 The auras last for ten or fifteen minutes. 
 
 The Attack. — (a) Headache is the cardinal symptom. At first it 
 is usually intense and circumscribed, as over the eye, temple, occiput 
 or forehead; then it spreads over one side (Jiemicrania) , sometimes 
 affects the opposite side or rarely reaches the neck or arm. The pain 
 is deep, varies in character, being most often boring, and its intensity 
 may attain that of the pain in brain tumor or meningitis. It is in- 
 creased by movement, stooping or lying down. The special senses are 
 hyperassthetic but the nerve trunks are seldom tender. The mind is 
 usually clear and often acutely active, sometimes there is double con- 
 sciousness, and in rare cases stupor, (b) Nausea follows, often with 
 vomiting of undigested food and finally of bile; this is the so-called 
 " bilious headache." Feeding and medication are quite impossible in 
 severe cases. Vomiting may be attended by hyperacidity or moderate 
 collapse, as in sea-sickness, (c) Vasomotor symptoms may be present. 
 The spastic type was described by Du Bois Raymond in his own case ; 
 with pallor, coldness, wide pupils and retraction of the eyeballs. 
 Thoma found the temporal artery sclerotic on the side of lesion and 
 de Giovanni noted a marked arcus senilis on the same side. The 
 pulse may be slow and tense and the breathing superficial. In the 
 paretic type observed by Mollendorf in himself, there are redness of 
 the skin, small pupils, sweating and increased flow of saliva or tears. 
 Very rarely is there erythromelalgia, oedema or ecchymosis. The 
 paretic may follow the spastic symptoms. It is best to regard these 
 sympathetic symptoms rather as a result than as a cause of the attack. 
 
 The attach ends in various ways. Relief may come with the vomit- 
 ing, after which the patient frequently sleeps. Sometimes the ending 
 is almost critical, with sweating, lachrymation, polyuria or epistaxis. 
 The attack lasts from ten to twelve hours ; the term status hemicran- 
 icus is used for cases of long duration or those in which the attacks 
 overlap. Though the typical seizure comprises the aura, lasting 
 fifteen minutes, and the headache, lasting ten or twelve hours with 
 nausea and vomiting, most attacks are atypical. There is most often 
 headache alone or headache with vomiting; in a few cases the attack 
 aborts with the aura or vomiting exists alone. The auras, pain, gastric 
 and cardiac inhibition, vasomotor symptoms and vomiting prove that 
 migraine is a functional cerebral affection. 
 
 Course and Prognosis. —When the disease has once been established 
 in youth its attacks become more frequent in adolescence and usually 
 last until the forty-fifth or fiftieth year. The periodicity, which was 
 noted in early cases described by Tissot, Trousseau and Liveing, has 
 not been explained. Overwork, worry, menstruation or change of 
 routine may precipitate an attack at a regular or irregular interval. 
 Attacks may cease during an intercurrent pregnancy, tabes or gout. 
 The school of Charcot has emphasized the fortunately rare danger of 
 transformation into epilepsy, labyrinthine vertigo or some psychosis. 
 
1162 DISEASES OF THE NEEVOVS SYSTEM. 
 
 Complete cases are more obstinate and dangerous than light forms. 
 Diagnosis. — When there is a history of heredity and development in 
 childhood, the full attack is most characteristic. " Sick headache " 
 is practically always migraine. In atypical forms there may be diag- 
 nostic confusion, chiefly with various forms of headache, which may 
 be classified as follows : 
 
 1. Those which result from nervous affections, as (a) cerebral 
 neurasthenia, in which there is a sense of pressure rather than actual 
 headache, and which is often constant, without nausea, but with 
 paresthesia, and in location is frontal or usually general, but some- 
 times Qccipital or temporal; (b) hysteria, which is less common 
 (clavus headache, " neuralgic headache"), and sometimes is precisely 
 like migraine (Charcot) ; (c) epilepsy, which some consider as identi- 
 cal with migraine; in epilepsy the aura is shorter and loss of con- 
 sciousness is the most constant symptom; (d) meningitis, which in 
 all types and in all cases is early and severe; (e) hydrocephalus, 
 which is often severe, especially in acquired forms ; (/) brain tumor, 
 which is constant, generalized, often very severe and sometimes typ- 
 ically hemicranic; (g) paretic dementia, in which migraine is fre- 
 quent ; care is always necessary when migraine occurs after syphilitic 
 infection. 
 
 2. Those which result from affections of the special senses, as eye 
 strain, hypermetropia ; glaucoma, which most often produces frontal 
 headache; nasal disease, which may cause sinus involvement with 
 frontal headache; this form is not periodic and is often relieved by 
 iodide, which has no effect in migraine. 
 
 3. Those which result from toxaemia, (a) Those due to acute in- 
 fections are usually frontal and dull, but sometimes occur in other 
 locations and are severe, deep-seated and increased by stooping; in 
 typhoid or malaria they are often frontal or supra-orbital; (&) in- 
 toxication by alcohol, nicotine, lead, nitroglycerine and opium, and 
 (c) constitutional states, as gout or arthritis, (d) In nephritis they 
 are usually frontal, remittent or continuous, but sometimes sharply 
 hemicranic. (e) In gastric affections they are exceedingly common, 
 mostly occipital, but sometimes vertical or frontal. 
 
 ^ 4. Those resulting from circulatory causes, as from wearing a 
 tight collar, repeated coughing, cardiac disease or arteriosclerosis 
 (with vertigo), are usually increased by lying down. 
 
 5. Those which result from anaemia, especially from chlorosis, as 
 a "tugging" sensation back of the eyes or frontal or generalized 
 headache, are often relieved by lying down. 
 
 Treatment.— Prophylaxis is said to be of little value, but many 
 subjects learn to recognize the warnings and avert the attacks by 
 resting on noting unusual mental or physical capacity for work or an 
 unusual appetite, which ushers in some attacks. Migraine subjects, 
 as other neurotics, should observe moderation in eating, especially 
 of meat, in work, exercise or recreation, narcotics or stimulants, as 
 coffee or tobacco, and in sexual matters. Immoderation, indeed is 
 
NEURALGIA. H63 
 
 almost a neurosis in itself. Overwork, hurry, worry and tension must 
 be avoided and their first manifestations must be learned and treated. 
 The extract of cannabis indica gr. % to %, given for weeks or 
 months, after Seguin's plan, is almost the only remedy which helps 
 the condition, and then only in some cases; the author knows of a 
 dozen cases in which migraine has been benefited or wholly relieved 
 under its use. Mobius finds that salicylate of soda, gr. xv, in black 
 coffee, given the evening before the attack, often wards it off. Nitro- 
 glycerine in full doses sometimes aborts it (Gowers), as may washing 
 out the stomach and following the lavage with a saline (Herter). 
 
 In the treatment of the established attach, bromides constitute the 
 best remedy ; they are given not only during the attack in the mild 
 type, but continuously, as in epilepsy, when the type is severe and 
 frequently repeated (Liveing and Charcot). Acetanilide often helps 
 mild forms and may in combination with ergotin, lessen the throb- 
 bing pain, but soon loses its effect. Morphine should be carefully 
 avoided. The stomach sometimes rejects all medication, which must 
 then be given by rectum. Application of cold to the head, hot foot 
 baths and sinapisms to the nape of the neck and epigastrium are 
 subordinate helps. 
 
 NEURALGIA. 
 
 Pain is only a symptom, usually of an affection of a peripheral 
 sensory nerve, although in rare cases centric disease may cause 
 peripheral pain, as affections of the cortex, pons, medulla or parts near 
 the thalamus. The pain of neuralgia, in which there is little or no 
 organic change in the nerve, and the pains of neuritis may be confused. 
 
 Etiology. — (a) Neuralgia occurs mostly in adult life (twenty to 
 sixty) and rarely before puberty or after sixty, in which case it is 
 usually severe and intractable, (b) Most cases occur in women, (c) 
 Heredity is an apparent factor in 25 per cent, of cases, especially in 
 neuropathic, weakly or gouty families, (d) Debility from exhaust- 
 ing conditions, as lactation, ansemia, overwork, sensory fatigue, as 
 from eye strain, sexual or other excesses, emotional conditions and 
 trauma, may cause it. (e) It may result from acute infections, 
 notably influenza, typhoid, especially at its onset, malaria, the causal 
 importance of which has been much overestimated, rheumatism (from 
 exposure to cold) particularly of the fascial type, and sometimes 
 syphilis. (/) Alcoholism, diabetes, plumbism, gout and nephritis may 
 produce it ; most of these are also causes of neuritis, differentiation 
 from which may be difficult, (g) Nerve affections, as sciatica and 
 neuritis, herpes zoster, reflex irritation, as radiated from a carious 
 tooth, compression of a nerve trunk by varices, aneurysms or neurom- 
 ata or the root pains of tabes, may cause neuralgia, (h) Arterio- 
 sclerosis may affect the nutrient nerve vessels (Putnam, Dana, 
 Thoma and Dehio). 
 
 General Symptoms. — The pain presents the following characteris- 
 tics: (a) It is always paroxysmal, with intervals of total or relative 
 
1164 DISEASES OF THE NERVOUS SYSTEM. 
 
 relief; intense pain is never constant, (b) It recurs irregularly ^ at 
 intervals varying from hours to months or with surprising periodicity 
 on a given day or hour, perhaps at the menstrual period ; periodicity 
 is as frequent in non-malarial as in malarial cases, (c) It is usually 
 unilateral, generally constant in its seat, at least for a time, and most 
 often found over the distribution of a single nerve or several nerves, 
 from which it sometimes radiates into other regions ; bilateral pain is 
 usually symmetrical. The pain may shift from place to place, espe- 
 cially when due to systemic causes. It is probable that the spinal cord 
 may be the medium of radiation of pain from one region to another 
 and that pain may follow the distribution of the spinal segments 
 rather than that of the peripheral nerves, as in herpes zoster. How- 
 ever, the exact pathology of neuralgia is still uncertain, (d) Its 
 onset and cessation are sudden and spontaneous; an imminent attack 
 may be precipitated or existing pain may be aggravated by muscular 
 movements, a breath of air or a simple touch; the character of the 
 pain is sharp, shooting, stabbing, rarely pulsating; if it travels along 
 the nerve trunk its shooting direction is usually centrifugal, rarely 
 centripetal; if it is localized it is commonly burning or boring, (e) 
 The pain is usually deep, but the skin is very hypersesthetic. (/) 
 The "tender points" of Valleix (1811), later called maximal points 
 by Head, are found in the nerve (50 per cent.) both in the attack and 
 the free interval, especially where the nerve emerges from the bone 
 or fascia?, lies on hard surfaces, divides or anastomoses. The diag- 
 nostic value of occasional tenderness over the spine at the origin of a 
 nerve (Trousseau's point apophysaire) is overestimated, because it 
 occurs in many other conditions. In neuritis the nerve trunk along 
 its entire accessible course is tender, (g) Vasomotor constriction, 
 followed by dilatation, is fairly common. (Edema, erythema, blanch- 
 ing or falling out of the hair, secretory disturbances, herpes, pig- 
 mentation, numbness or tingling, trophic alteration of the skin, local- 
 ized hypertrophies and reflex twitchings of the muscles are much less 
 frequent than in neuritis. Persistent pain or its etiological factors 
 may decidedly reduce the general nutrition. 
 
 Local Clinical Varieties. — 1. Trifacial neuralgia (prosopalgia, 
 tic douloureux) is the most important, severe and frequent type, be- 
 cause the fifth nerve is most exposed to trauma, compression and in- 
 fection, by way of the eye, nose and ear. The entire nerve is not 
 usually affected, though pain may radiate from one division into 
 another ; indeed only the secondary branches of a single division may 
 be involved. The general features of neuralgia are present, as 
 already described, (a) Involvement of the first branch is the most 
 common form; pain occurs over the eye, forehead and frontal sinus 
 (in which the familiar pain is experienced after eating ice-cream) ; 
 it sometimes radiates into the second and third branches; there are 
 " tender points " over the lower edge of the nasal bone, 'the supra- 
 orbital notch, less often over the supra-orbital nerve, even to the 
 vertex, sometimes over the occiput or over the cervical spines; cold, 
 
NEUBALGIA. 1165 
 
 carious teeth, disease of the sinus, glaucoma, hypermetropia, etc., are 
 causal factors. (&) When the second branch is involved there is pain 
 over the side of the nose and cheek from the infra-orbital region to 
 the upper lip ; there are " tender points " over the lower border of the 
 nasal bone, the malar bone, the infra-orbital foramen, the gums over 
 the canine teeth, and sometimes in the hard palate; among other 
 causes is the dental alveolitis in the aged, due to sclerosis. Diseased 
 teeth may cause neuralgia without local dental symptoms and in every 
 severe case the dentist should be consulted, (c) Involvement of the 
 third branch is the least frequent form; inframaxillary pain, along 
 the lower teeth, tongue, chin, external ear and maxillary region ; and 
 tenderness over the auriculotemporal nerve and inferior dental fora- 
 men may occur. In old persons the loss of the teeth brings the jaws 
 closer and therefore stretches the inf. dental nerve; it is relieved by 
 proper plates. In severe forms vasomotor symptoms and increased 
 secretion from the eyes, nose and salivary glands are usually present. 
 Hyperalgesia is usual so that the face cannot endure simple contact, 
 and drinking, mastication and wiping the nose cause great suffering. 
 Herpes and trophic changes are probably neuritic rather than neu- 
 ralgic symptoms. In rare instances facial spasm, transient reflex 
 ptosis, internal strabismus or myosis co-exists. Differentiation. In 
 headache and migraine there are no tender points; intracranial dis- 
 ease, as tumor or syphilis, is usually excluded by systematic exami- 
 nation. The prognosis is doubtful in severe forms, which are often 
 lifelong in duration and agonizing in degree. 
 
 2. Cervico-occipital Neuralgia. — In cervico-occipital neuralgia 
 there is pain in the first four cervical nerves, especially the inferior 
 occipital and auricularis magnus ; this pain sometimes radiates into 
 the fifth nerve ; there is tenderness half way between the mastoid and 
 spine, over the parietal eminence and over the cervical plexus between 
 the sternomastoid muscle and trapezius ; this form is rarely primary, 
 is often bilateral and is less intermittent than other neuralgias, which 
 facts are explained by its frequent connection, especially with cervical 
 caries and syphilis, and also with tumors, meningitis, root disease 
 and affections of the ear. 
 
 3. Phrenic Neuralgia. — Phrenic neuralgia is rare, though it 
 sometimes occurs in pericarditis and diaphragmatic pleurisy; it is 
 most often left-sided, with pain and tenderness over the insertion of 
 the diaphragm and nerve trunk in the neck ; movements involving the 
 diaphragm are painful. Diagnosis and differentiation are usually 
 uncertain. 
 
 4. Cervicobrachial Neuralgia. — In cervicobrachial neuralgia 
 any nerve may be involved, but especially the ulnar and circumflex. 
 Pain may radiate over the entire plexus and into the chest ; the tender 
 points are most often in the axilla, shoulder and ulnar distribution; 
 it is most often confused with neuritis from trauma, compression, 
 rheumatic arthritis or other organic disease. 
 
 5. Intercostal neuralgia ranks third in frequency after tri- 
 
1166 DISEASES OF TEE NEBVOUS SYSTEM. 
 
 facial and sciatic neuralgias (neuritis). Pain is felt along the inter- 
 costal nerve and tenderness over the points of emergence of its three 
 branches, over the angle of the ribs, in midaxilla and near the mam- 
 mary line. It is more easily distinguished in the upper than lower 
 interspaces. Differentiation may be difficult because of muscular 
 rheumatism in which movement is more painful. Peritoneal disease, 
 gastric ulcer, spinal caries, aortic aneurysm and tabes must be dis- 
 tinguished. It is most common in gastrohepatic affections and m 
 neurotic women. 
 
 Herpes zoster is probably an acute inflammation of the posterior 
 root ganglia, as shown by Barensprung and Charcot and later by 
 Head and Campbell. It is mentioned in this connection because of 
 the acute pain preceding and associated with the rash, which appears 
 after three or four days ; the pain is often protracted and intractable ; 
 the pain on the trunk follows the distribution of the spinal segments 
 rather than that of the intercostal nerves. The ganglion is the seat 
 of a cellulohemorrhagic exudation and its fibers to the posterior 
 column of the cord degenerate. 
 
 6. Lumbar Neuralgia. — Lumbar neuralgia is infrequent; it oc- 
 curs in the iliohypogastric, ilio-inguinal and genitocrural branches, 
 sometimes in the ext. cutaneous, obturator and crural nerves. The 
 pain is felt over the iliac crest, in the inguinal canal, labium or 
 testis (irritable testicle). 
 
 7. Sacral Neuralgia. — Sacral neuralgia is infrequent. Coccy- 
 godynia is neuralgic and occurs mostly in women. The pain is in- 
 creased by sitting, coitus and defecation; it is obstinate and resists 
 even operative measures. 
 
 8. Pododynia. — In neuralgia of the feet there is pain in the heel, 
 called pododynia by Gross ; plantar neuralgia, which is mostly neuritic, 
 occurs in acute infections and caisson disease. Morton's metatar- 
 salgia, which was regarded by him as due to bony compression of the 
 fourth metatarsophalangeal nerve, usually occurs in one foot and 
 mostly in women ; operation is usually indicated. 
 
 9. Visceral Neuralgias. — Visceral neuralgias are considered 
 under diseases of the heart, stomach and kidneys and under hysteria 
 and neurasthenia. Under this caption may be given Head's areas of 
 pain referred to visceral disease : the organ is first given, and follow- 
 ing it is the area to which its pain is reflected : Heart: 1st, 2d, 3d dorsal 
 segments. Lungs: 1st, 2d, 3d, 4th, 5th dorsal segments. Stomach: 6th, 
 7th, 8th, 9th dorsal ; cardiac end from 6th and 7th. Pyloric end from 
 9th. Intestines: (a) Down to upper part of rectum, 9th, 10th, 11th and 
 12th dorsal, (b) Eectum, 2d, 3d and 4th sacral. Liver and gall- 
 bladder: 7th, 8th, 9th, 10th dorsal; perhaps 6th dorsal. Kidney and 
 ureter: 10th, 11th and 12th. The nearer the lesion lies to the kidney 
 the more is the pain and tenderness associated with the 10th dorsai. 
 The lower the lesion in the ureter the more does the 1st lumbar tend 
 to appear. Bladder: (a) Mucous membrane and neck of bladder, 1st, 
 2d 3 3d, 4th sacral. (&) Overdistention and ineffectual contraction, 
 
NEURALGIA. 
 
 1167 
 
 11th and 12th dorsal and 1st lumbar. Prostate: 10th, 11th, 12th 
 dorsal, 1st, 2d, 3d sacral and 5th lumbar. Epididymis: 11th and 
 12th dorsal and 1st lumbar. Testis and ovary: 10th dorsal. Appen- 
 dages: 11th and 12th dorsal and 1st lumbar. Uterus: (a) In con- 
 traction. 10th, 11th, 12th dorsal and 1st lumbar, (b) Os uteri. 
 1st, 2d, 3d and 4th sacral (5th lumbar very rarely). 
 
 Treatment. — Logically the treatment of the cause (q. v.) should 
 precede that of the symptoms, but practically, pain is the prime 
 indication for therapeutic measures. 
 
 1. Local Measures. — Pressure on tender points may diminish or 
 abolish pain. As in sciatica, blisters and sinapisms (both of which 
 may leave permanent pigmentation on the face), the cautery, local 
 heat, acupuncture or injections of water or cocaine may give relief. 
 Freezing the skin by ethyl chloride (Kichardson, Doddard) often 
 gives better results. Menthol, camphor-chloral (equal parts) and 
 liniments are of some value (tr. aconiti, tr. chloroformi, tr. bella- 
 donnse aa 3ij, linimentum saponis §iv). Injections of 1 per cent, 
 solution of osmic acid into the nerve trunk are very successful ; they 
 were recommended by Bennett (1889) and later by Murphy; paraly- 
 sis sometimes results. Schlosser (1900) recommended alcohol in- 
 jections. Massage is often beneficial, for the muscles and nerves have 
 common veins. 
 
 2. Nutrition. — A full diet, with milk and cod-liver oil and also 
 with rest, the Mitchell cure, hydrotherapy and massage, is often bene- 
 ficial, especially with change of climate or surroundings. Alcohol, 
 which is always dangerous, is most often indicated in older subjects. 
 The beneficial effects of castor oil are often great, probably because it 
 promotes elimination. Gouty subjects may thrive on a vegetable diet. 
 
 3. General Drug Treatment. — There are numerous remedies. 
 Iron and possibly phosphorus are valuable in anaemic subjects. Dana 
 gives strychnine hypodermatically in doses of Vzo gr. even up to % 
 gr.). Arsenic is excellent in ansemic, malarial and degenerative 
 types; quinine is beneficial in non-malarial as well as malarial types 
 and in trifacial neuralgia especially, although its value is consider- 
 ably overestimated. Valerian, cannabis indica and bromides should 
 be given for irritability; salicylates for rheumatism and colchicum 
 and cimicifuga for gout; iodides are sometimes of benefit to non- 
 syphilitic subjects ; full doses of nitroglycerine are frequently helpful. 
 
 4. Analgesics. — Acetanilide (gr. v) and the other coal-tars should 
 be used in fresh cases. Extr. cannabis indicse (gr. %) and fluid- 
 extr. gelsemii (Tltii to iv) should be administered every three to six 
 hours in the less severe cases. In acute febrile or rheumatic cases, 
 fluidextr. aconiti (Tl\i to ii) should be given every two hours until 
 tingling in the mouth or extremities and slowing in the pulse inter- 
 vene. Liebreich advocates croton-chloral, gr. v, or with care even gr. 
 xx for several doses. Finally, in severe cases, morphine, as far as 
 possible, should be avoided; sometimes its administration is inevi- 
 table; though some writers find that it tends to prevent recurrence ? 
 
1168 DISEASES OF TEE NEBVOUS SYSTEM. 
 
 the pain often develops again, intensified; it should be combined with 
 atropine, which may be given alone, as it sometimes more per- 
 manently controls the pain than does the morphine. 
 
 5. Electrotherapy. — This sometimes relieves the pain, but it 
 more often fails. Galvanization with a weak current, which should 
 be just strong enough to produce a sensation of burning and should 
 be applied with the sponges warm and with the anode to the painful 
 area, may be beneficial, especially in newly developed cases. 
 
 6. Surgical Therapy. — This includes section, resection, stretch- 
 ing, twisting or divulsion of the nerves ; resection should be tried first, 
 but all these procedures may fail. In incoercible trigeminal neu- 
 ralgia the Gasserian ganglion may be extirpated (Hartley, Krause, 
 Keen, Cushing), but this operation is severe and loss of the eye may 
 result. Horsley opens the skull and divides the root of the fifth 
 nerve above the ganglion, but this is dangerous ; Spiller and Frazier 
 therefore suggest its division without opening the cranial cavity. 
 
 VASOMOTOR AND TROPHIC NEUROSES. 
 
 Vasomotor centres exist in the cerebral cortex and medulla, The 
 fibers probably run in the lateral columns of the cord and leave by the 
 anterior roots. Vasomotor 'paralysis occurs independently or with 
 functional or organic disease. Paralysis of the cervical sympathetic 
 may result from trauma, aneurysm, tuberculous apical or glandular 
 disease or disease of the cord. It is attended by redness, rise of 
 temperature, pulsation and tortuosity of the vessels, sweating, unrest, 
 ringing in the ears and palpitation. In paralysis of the cervical sym- 
 pathetic there are pupillary narrowing from the unopposed action of 
 the third nerve, slight ptosis, narrowing of the interpalpebral fissure 
 from paresis of Miiller's muscle, salivation, lachrvmation and in 
 cases of some standing, retraction of the eye and flattening of the 
 cheek. The pupil reacts somewhat to light but not to stimulation by 
 pain or pinching of the skin of the neck (Mobius) ; the pupil can be 
 widened by atropine, but to a less degree than in the normal eye. 
 
 Vasomotor spasm presents converse symptoms, — pallor, coldness, 
 small vessels and frequently a sense of tingling or arterial pain. Two 
 examples are nervous angina pectoris and Raynaud's disease ; spasm 
 (contraction, irritation) of the cervical sympathetic • produces wide 
 pupils, an increased interpalpebral fissure and exophthalmos. 
 
 Little is known of the trophic nerves, if indeed separate nerves sub- 
 serve nutrition. If they exist they are probably closely related to the 
 vasomotor tracts. Trophic changes may be symptomatic of disease of 
 the nerves or cord, as in neuritis or nerve trauma, facial hemiatrophy, 
 tabes, syringomyelia and myelitis, under which their special features 
 have been already discussed. 
 
 Erythromelalgia. — Erythromelalgia was described first bv Graves 
 (1843) and S. Weir Mitchell (1872) ; the term indicates the chief 
 clinical characters, redness and pain in the extremities. It is rare, 
 
VASOMOTOR AND TEOPHIC NEUEOSES. 1169 
 
 though much more frequent than is shown by Voorhees' series of 70 
 cases (1907). It occurs mostly between the years of twenty-five and 
 forty and is slightly more frequent in males. Its pathology is not 
 wholly clear, although Mitchell and Spiller find neuritis and scler- 
 osed arteries. The toes (less often the fingers) and balls of the toes 
 are the seat of severe, usually paroxysmal pain, swelling and redness ; 
 the arteries throb and the veins are engorged; the color is sometimes 
 blue. Pain is sometimes experienced in the head and neck and ver- 
 tigo and muscular weakness may be noted. The symptoms occur 
 mostly in warm weather and generally disappear in winter. The 
 clinical course is long, the prognosis doubtful and the treatment con- 
 sists of electrotherapy, cool baths, acetanilide and iodides. 
 
 Acroparesthesia. — Acroparesthesia is closely related to erythrome- 
 lalgia. It was described first by Nothnagel, and F. Schultze (1890) 
 named this very frequent affection ; its derivation signifies parces- 
 thesia of the extremities. More than 90 per cent, of cases occur in 
 women between thirty and sixty years of age. The etiology is doubt- 
 ful (stasis or arteriosclerosis). Its chief feature is an unpleasant 
 crawling, tingling sensation, sometimes amounting to actual pain in 
 the fingers or hands, less often in the toes or feet. The discomfort is 
 greatest at night and in the early morning; it is peripheral and sym- 
 metrical but does not correspond with any nerve area. Generally 
 there are no objective findings other than occasional vasomotor dis- 
 turbance or slight sensory blunting. The outlook is favorable, the 
 course is chronic and treatment is symptomatic; the faradic brush 
 frequently affords relief. 
 
 Spontaneous Symmetrical Gangrene, or Raynaud's Disease. — Eay- 
 naud's disease was first described by Kaynaud (1862). Sixty-six per 
 cent, of cases occur in women, who are usually delicate, anemic and 
 neurotic, and most cases develop in persons between twenty and 
 forty-five years of age. In 10 per cent, it is hereditary. Other 
 causal factors are uncertain, as exposure to cold and dampness, ex- 
 haustion, worry and acute infections. Occasional co-existence is 
 noted with hysteria, neurasthenia, epilepsy, tabes, syringomyelia, 
 angioneurotic oedema, neuritis, acute mania, etc. Its pathology is 
 not wholly established, but arterial spasm, endarteritis and neuritis 
 are said to exist. There are three stages: (a) Local ischcemia (or 
 syncope), begins with pallor and coldness of one or two fingers, per- 
 haps of the entire hand or of the toes and is attended by numbness 
 or severe pains. The " dead fingers " or toes appear on exposure to 
 slight cold or on emotion and reaction occurs after a variable period. 
 The process may not pass this stage. (&) Local asphyxia (or cyan- 
 osis) develops in the parts involved, at times with some swelling or 
 anaesthesia. It is most severe in winter and chilblains are regarded 
 as the mildest type of this stage, (c) Local gangrene, which is spon- 
 taneous, symmetrical and fortunately rare, is the last stage. It is 
 dry, sometimes vesicular and its extent is always less than the area 
 of ischemia and asphyxia. The tips of the fingers or toes dry up, fall 
 74 
 
1170 DISEASES OF THE NEBVOUS SYSTEM. 
 
 off and scars mark successive attacks. Less often the tip of the nose, 
 ear, buttock, heel, shoulder or abdomen is involved and very rarely 
 the tongue, penis, elbow or knee. Fever is usually absent. In some 
 instances there is severe general disturbance, as fever, chill, enlarged 
 spleen, colic, hemoglobinuria, uraemia, stupor, coma, convulsions, 
 transient hemiplegia, neuritis and spastic retinal vessels. The se- 
 vere or fatal cases occur especially in children. The course is chronic 
 and consists of repeated attacks, which often abate in summer. 
 
 Differentiation. — Differentiation is usually easy from hysterical 
 gangrene (self-injury), diabetic, arteriosclerotic or embolic gangrene, 
 syringomyelia, leprosy, ergotism and acute arteritis, as in typhoid. 
 
 Treatment. — In treatment narcotics are given for pain ; warmth and 
 elevation promote venous return and nitroglycerine dilates the ar- 
 teries. Gushing advises Esmarch's constrictor for a few minutes, 
 after which the circulation is restored. In actual gangrene surgical 
 interference should be postponed until complete demarkation devel- 
 ops, because the area is much more circumscribed than at first 
 indicated. 
 
 Acute Angioneurotic (Edema. — Acute angioneurotic oedema was 
 first fully described by Quincke (1882), although Milton (1876) de- 
 scribed "giant urticaria." It occurs most frequently between the 
 years of twenty and thirty-five and is slightly more frequent in women 
 than in men. Hereditary forms are known; 22 cases occurred in 5 
 (Osier) and 22 cases in 6 (Milroy) generations of one family. It is 
 allied to urticaria, erythema nodosum and possibly to some forms of 
 purpura and consists of a circumscribed oedema, which is sudden in 
 onset and in disappearance, is tense and pale, does not pit on pressure, 
 sometimes causes burning and appears mostly on the eyelids, lips, 
 cheek, tongue, hands or genitalia, sometimes on the buttocks, in the 
 pharynx, larynx, lung or digestive tract. It sometimes attacks 
 several areas simultaneously. Gastro-intestinal symptoms occur in 
 33 to 50 per cent, of cases, as epigastric pain, vomiting, colic or 
 diarrhoea (see page 830). Hemoglobinuria, albuminuria and poly- 
 uria are less frequent. The outlook is good, except for the dangerous 
 laryngeal or pharyngeal localization which may cause sudden death. 
 Recurrence is not uncommon and sometimes occurs with considerable 
 periodicity. 
 
 Treatment. — Treatment is symptomatic and general ; nitroglycerine 
 has been recommended. Bloodgood employed deep incisions with 
 great benefit. 
 
 Herz recently described a pseudoperiostitis angioneurotic^ occur- 
 ring especially on the thoracic bones ; it is periodic, transitory, pain- 
 ful, tender and associated with paroxysmal, neurotic, cardiac dis- 
 turbance. 
 
 Chronic Hereditary Trophcedema.— Twenty-two cases of chronic 
 hereditary trophcedema in six generations were described by Milroy 
 (1893) of Omaha, and 8 cases in four generations by Meige (1898). 
 A firm, pale, painless oedema, chiefly below the hip or knee, develops 
 toward puberty, without cardiac, renal or apparent local causes. It 
 
VASOMOTOR AND TROPHIC NEUROSES. 1171 
 
 may appear in the arm and leg of the same side, including probably 
 some of the so-called local hemihypertrophies. The first cases re- 
 corded were thought to be phlebitis. Health and life are not threat- 
 ened, although treatment produces no results. 
 
 Hydrops Articulorum Intermittens (hydrarthrosis intermittens). 
 — Hydrops articulorum intermittens occurs with equal frequency in 
 both sexes and 71 per cent, occur in persons between ten and forty 
 years of age. Its etiology is not known. Some cases present malarial, 
 gonorrheal or traumatic antecedents. The knee is usually involved 
 when several joints are affected and in 33 per cent, is alone involved. 
 The effusion wholly disappears after two or three days, but it re- 
 appears obstinately every one to four weeks. There is no fever and 
 usually no pain. Treatment is general. 
 
 Scleroderma, — Scleroderma was described by Lusitanus and Ali- 
 bert, though Thirial (1845) gave the first full account of it. It is a 
 chronic thickening and hardening of the skin, followed by atrophy. 
 It is a rare affection, but is more common than is generally recog- 
 nized. The localized form usually develops before and the general- 
 ized form after the twenty-fifth year. Seventy-five per cent, of 
 cases occur in women. The causation is obscure ; erysipelas, trauma, 
 cold and neuropathic disposition are sometimes considered etiological 
 and association with other neuroses, general and vasomotor, is fre- 
 quent. Anatomically the skin and all the contained structures are 
 fibrosed. In the localized form it occurs in spots or streaks, which 
 often correspond to the course of given nerve trunks or spinal seg- 
 ments. In the general form the body may be literally " hide bound." 
 Its distribution in order of frequency is (a) the upper extremities; 
 (b) the trunk; (c) the head and face; (d) the lower extremities; (e) 
 generalized. The skin is usually first painful and sensitive, then 
 reddened and thickened, and finally pale, glossy, dry, atrophic and 
 parchment-like. It is rigid and without folds, inhibiting the mimetic 
 play of the features. The nose is peaked, the lids cannot close over 
 the eyeball and may become everted. The mouth is so small as to 
 sometimes necessitate extraction of some of the teeth and rigidity in 
 the neck may render swallowing difficult. In the fingers it occurs in 
 5 per cent, of cases (sclerodactylia, Ball). The close skin produces 
 decided deformity and loss of function. Sensation is usually pre- 
 served, the secretion of sweat is usually reduced and pigmentation 
 and trophic changes in the hair and nails are occasionally seen. In 
 some cases it occurs with herpes (the herpetiform morphea of Hutch- 
 inson) . Circumscribed atrophy of the bones is said to occur. Only 
 30 per cent, of cases improve and 15 per cent, recover, whence the 
 outlook is generally unfavorable. 
 
 Treatment. — Treatment is unsatisfactory. Improvement has fol- 
 lowed administration of salol and inunctions with oil; thyroid ex- 
 tract (Osier, Lustgarten, Sachs and Bramwell), especially if used 
 early in the disease, may promote recovery. 
 
 Ainhum. — Ainhum was first observed by Clark (1860) then by Da 
 
1172 DISEASES OF THE NERVOUS SYSTEM. 
 
 Silva Lima (1866). It is a chronic affection, usually limited to 
 the great toe, which at its plantodigital fold suffers a slow, painless, 
 non-inflammatory circular constriction and spontaneous amputation. 
 Ainhum is chiefly found in the colored races of Brazil, Africa, India 
 and sometimes in this country. Its nature is disputed ; an ingrowth 
 of the epidermis and scleroderma haye been thought to be causes. 
 It is not amputating leprosy, as has been claimed. 
 
 DISEASES OF THE MUSCLES. 
 
 MYOSITIS. 
 
 Inflammation in the muscles may be single or multiple ; it may be 
 an independent affection or a secondary one. It may reach the 
 muscles by contiguity from adjacent disease, may result from trauma, 
 trichinosis, infection with cysticercus, echinococcus, myxo-, sarco- 
 and microsporidia, sepsis, puerperal fever, rheumatism, scarlatina, 
 gonorrhoea, syphilis or erythema multiforme. The muscles are the 
 seat of serous or sometimes hemorrhagic or diffuse purulent exudation 
 in septic forms and of fatty degeneration. There is a form, endemic 
 in Japan, in which the Staphylococcus pyogenes aureus occurs in pure 
 culture. The muscles are usually friable and sometimes fragmented. 
 Polymyositis, first described by Wagner (1887), Hepp and L T nver- 
 richt, occurs most often in youth and adolescence and is attended by 
 pain, especially near the tendons, swelling and often oedema in the 
 muscles, the electrical irritability of which is decreased as also are the 
 tendon reflexes. The skin may participate, and herpes, erythema, 
 bulla? or purpura may be present (dermatomyositis) ; the infec- 
 tion may involve the tissue in which the afferent nerves originate 
 (muscle spindles) and topographically a neuritis and myositis may 
 co-exist or coincide (neuromyositis, Senator). In some cases there 
 is arthritis or phlebitis. Oppenheim describes a case of dermatomu- 
 comyodfis with stomatitis, iritis and conjunctivitis. The inflamma- 
 tion occasionally reaches the tongue, pharynx, larynx or respiratory 
 muscles and may cause difficult mastication or swallowing, ptosis 
 or ^ dyspnoea. The systemic reaction is severe, is marked by fever, 
 chills, sweats, splenic tumor, sometimes by angina, bronchitis,' albumi- 
 nuria or leukocytosis. Death is the usual issue. 
 
 Differentiation. — Differentiation concerns multiple neuritis (tender- 
 ness oyer the nerve trunks, motor and sensory findings) ; trichinosis 
 (trichina? in the tender, swollen muscles, eosmophilia and digestive 
 symptoms) ; and periarteritis nodosa (q. v.). 
 
 Treatment.— Treatment is symptomatic and is identical with that of 
 sepsis. Sweats and salicylates are beneficial. 
 
MUSCULAR RHEUMATISM. 1173 
 
 Myositis Ossificans. — Myositis ossificans is characterized by a my- 
 ositis which usually develops acutely in the muscles of the neck or 
 hack before the fifteenth year and leaves residual foci of infiltration, 
 partly in the periosteum and partly in the fasciae and tendons, which 
 gradually calcify. The thigh and arm are most severely and per- 
 manently affected. The process occurs in the strongest muscles and 
 at an age when they develop most actively; it may affect many 
 muscles and runs a chronic course, perhaps of several decades. One 
 hundred and thirty-four cases are recorded (Cahier) ; there were 101 
 traumatic cases (Werner, 1904). Massage is sometimes beneficial. 
 
 MUSCULAR RHEUMATISM (MYALGIA). 
 
 This includes many vague but important affections. It occurs 
 particularly in men, after exposure to cold and dampness, and is 
 obviously promoted by certain occupations. Muscular overexertion, 
 as straining and lifting, is frequently a part of the history. Rheu- 
 matic and gouty subjects are specially exposed and to recurrent seiz- 
 ures. Disorders of metabolism or mental as well as physical over- 
 work mark some cases. Other forms are, as Leube insists, probably 
 infectious, for fever occurs in 33 per cent, and is occasionally followed 
 by endocarditis ; muscular rheumatism in this sense does not generally 
 involve many muscles, but usually one muscle or a single group. The 
 pain is not paroxysmal, as in neuralgia, and is experienced in the 
 muscle or reaches it from its tendons or fasciae. In some cases it is 
 apparently a mild neuromyositis. Its varieties are : Myalgia capitis, 
 affecting the fascia of the head ; omalgia, involving the muscles of the 
 shoulder, or rheumatic torticollis, which is usually unilateral ; pleuro- 
 dynia, which affects the chest muscles, pectoralis, intercostals and 
 serratus, limits respiratory movements and is likely to be confused 
 with intercostal neuralgia, pleurisy, periostitis of the ribs or vertebral 
 disease ; lumbago, which involves the lumbar muscles, and is the most 
 frequent, painful and obstinate form, causing great pain on movement 
 or on efforts of the uninvolved muscles to maintain quiet ; it is prob- 
 ably due in some cases to muscular rupture, as after lifting. In the 
 abdominal muscles and glutei it may simulate pelvic disease. In 
 treatment, rest is urgently indicated, for use of the affected muscles 
 aggravates pain and protracts the condition. Involuntary movement 
 is prevented by careful strapping with adhesive plaster, especially 
 when there is pain in the chest. A hypodermic of morphine into the 
 muscle is often indicated. Deep injection of water into the muscles 
 of the back (or affected part) may relieve pain. Kinger's method of 
 acupuncture with long needles which are pushed three inches into the 
 back and left there for from five to ten minutes is beneficial, but is 
 usually vigorously opposed by the patient. Very energetic massage, 
 with the local application of heat, probably gives the best results. 
 The actual cautery, the application of the constant current and the 
 use of Tesla's coil give good results. The use of belladonna plasters 
 
1174 DISEASES OF THE NEEVOUS SYSTEM. 
 
 gives relief. Gelsemium, acetanilide and salicylates often produce 
 no effect, but may instantly relieve certain cases. 
 
 Chronic cases, with vague, fugitive pains which come on with 
 change of weather, are treated in the same way — usually without 
 result. Confusion with chronic alcoholism, tabes, gout and diabetes 
 is frequent. 
 
SECTION X. 
 INTOXICATIONS. SUNSTROKE. 
 
 ALCOHOLISM. 
 
 I. Acute Alcoholism. — (a) The highest brain centres are first af- 
 fected. The judgment is first involved (emotion predominating), 
 motility next (as shown hy the disordered speech, gait and vision), 
 then the lower centres (respiratory, circulatory and spinal), (b) 
 The circulation is increased and the pulse becomes more rapid, though 
 alcohol does not stimulate the heart. Full doses may make the pulse 
 slow and small. The vascular tone is lax and the face is flushed; 
 for this reason alcoholics suffer little shock from coincident trauma- 
 tism, (c) Respiration is slow, deep and seldom stertorous, (d) 
 The pupils are variable, but more often dilated than narrow and 
 reactionless. (e) The temperature may fall markedly, from vaso- 
 paresis, and usually with some cyanosis and failing of the bulbar 
 centres; Reincke states that temperature has fallen as low as 75°! 
 Involuntary evacuations occur in the severest cases and there may be 
 subcutaneous hemorrhages. 
 
 Dipsomania is intermittent acute alcoholism, an hereditary psycho- 
 sis in which, after intervals of abstinence and of no craving for 
 liquor, the patient becomes intoxicated. 
 
 Diagnosis. — The alcoholic breath is usually suggestive but epileptics 
 and ursemics may drink, and while drunk a man may have his skull 
 broken or suffer an apoplexy. Many mistaken diagnoses result from 
 carelessness, but many are unavoidable, and the apparently drunk 
 patient should be treated for alcoholism, while other possibilities 
 should be carefully considered. As a rule the patient can be aroused, 
 but in " dead drunks " this is not the case and incomplete coma may 
 occur from other causes. The condition of the pupils is not of certain 
 diagnostic value, though they are usually dilated in alcoholic, con- 
 tracted in opium and ursemic, and unequal in apoplectic, coma. 
 Stertorous breathing is strongly indicative of apoplexy or uraemia. 
 Convulsions following delirium and muscular twitchings are less 
 common than in other similar conditions, but at the time of writing 
 the author had a case which showed uni- and then bilateral convul- 
 sions. The urine rarely contains alcohol, as but 1 or at the most 5 
 per cent, of ingested alcohol is excreted by the lungs and kidneys. 
 Sudden death may occur without adequate necropsy findings. One- 
 
 1175 
 
1176 INTOXICATIONS. SUNSTBOKE. 
 
 third of all the fatal poisonings in New York and Berlin are acute 
 alcoholism. 
 
 Treatment. — Gastric lavage is sufficient in most cases. Even the 
 convulsions require little attention, but when severe, yield to a few 
 whiffs of chloroform. Acute mania yields to a hypodermic of apo- 
 morphinse hydrochloridum (gr. %). Collapse, cold extremities and 
 cardiac and respiratory failure are relieved by hot coffee, strychnine, 
 atropine, aromatic spirits of ammonia and local heat, as will be more 
 fully outlined under acute opium poisoning (v. i.). 
 
 II. Chronic Alcoholism. — This is less an hereditary tendency 
 toward drinking than a lack of character, though Plutarch said that 
 drunkards beget drunkards. The constant use of alcohol has vary- 
 ing effects : some people can take beer, wine, spirits or patent medi- 
 cines throughout life without apparent injury; in others, even the 
 mildest alcoholic drinks may induce visceral alterations, so that as 
 in liver cirrhosis, it would seem that there is some other etiological 
 factor; however, alcohol in health is a bad food, an injurious narcotic 
 or stimulant, a protoplasmic poison to the parenchymatous organs and 
 arteries and a check on metabolism. 
 
 Symptoms. — (a) Nervous manifestations. Functional changes in- 
 clude the alcoholic tremor, which is a most common symptom ; mental 
 dulness and weakness; nervousness, jumping from slight stimuli, 
 irritability, impaired judgment and feeble will power; neuralgias 
 and muscular rheumatism. The alcoholic is suspicious, cruel, con- 
 ceited and a degenerate. Quinquad's sign is elicited by having the 
 patient place his fingers vertically to the examiner's hand or body, 
 when a series of jerking shock-like movements is noted ; Fiirbringer 
 decides that (i) if it is absent, alcoholism is absent; (ii) if it is mod- 
 erate there is uncertainty and (iii) if it is marked, in 3 cases out of 5, 
 the patient is an alcoholic. Of organic nervous manifestations, mul- 
 tiple neuritis is the most common ; it may result from small amounts 
 of alcohol, when there is a coincident metallic poisoning; alcoholism 
 is much more often a promoting factor than an actual cause of paretic 
 dementia ; epilepsy may result from alcoholism ; hemorrhagic pachy- 
 meningitis, chronic leptomeningitis, acute polioencephalitis, degenera- 
 tion in the anterior horns or Clark's columns, degeneration of the 
 cerebral nervous tissue and slight optic neuritis may be more or less 
 direct sequences, (b) The circulation. Arteriosclerosis often de- 
 velops with its train of sequences, cardiac hypertrophy and dilatation, 
 angina pectoris, cerebral softening or hemorrhage. (c) Chronic 
 bronchitis, emphysema, chronic pharyngitis and laryngeal thickening 
 are frequent collateral findings, (d) The digestive organs. Alcoholic 
 gastritis (q, v.) is common; the morning vomiting (vomitus matuti- 
 nus) is quite characteristic and is quieted only by another dose of its 
 cause. Beer drinkers usually have large stomachs. Alcoholic cirrhosis 
 has been already discussed ; fatty degeneration, arterial congestion and 
 hypertrophy may antedate or accompany cirrhosis. Beer drinkers 
 have lax bowels, while consumers of spirits are constipated. Hemor 
 
ALCOHOLISM. 1177 
 
 rhoids are common, (e) The kidneys undoubtedly suffer. Dickin- 
 son, Formad and Pitt think that renal disease is less common than is 
 usually believed ; Formad and Pit found that the kidneys were hyper- 
 trophied without other change in 43 per cent. As in cirrhosis, sev- 
 eral factors may be necessary to produce indurated kidneys. Ster- 
 ility is common. (/) Metabolic maladies, as gout, obesity and, ac- 
 cording to Strumpell, some forms of diabetes may result from chronic 
 alcoholism, (g) The shin frequently presents the acne rosacea, a very 
 common but not, as Trousseau says, an " indelible stigma." The 
 vessels of the nose, cheeks and often of other parts are suggestively 
 dilated; the conjunctivae are injected and the eyes water. 
 
 Prognosis. — The prognosis is unfavorable, both from the standpoint 
 of curability and complications. English life insurance companies 
 estimate that the risk is 33 per cent, less in abstainers than in 
 alcoholics. The general resistance is lowered, thus favoring infec- 
 tions, as tuberculosis, and raising greatly the death rate, most notably 
 in pneumonia. Twenty per cent, of suicides are alcoholics. The 
 offspring of inebriates are disposed to numerous nervous affections. 
 
 Treatment. — Treatment consists of correction of the habit and care 
 of the complications, the latter of which have, in great part, already 
 been considered. The cure of the habit is largely personal. Its 
 prophylaxis is better than its cure. No person, however intellectual 
 or strong-willed, can safely drink with any regularity. Institutional 
 treatment is generally necessary. The vomiting should be treated in 
 accordance with instructions given under acute and chronic gastritis ; 
 lavage is probably the most reasonable measure ; a mixture of bismuth 
 (see Typhoid, Vomiting) and small doses (n\i to ii) of Fowler's 
 solution and large ones of tr. nucis vom. (n\x) are valuable just 
 before the administration of hot milk with tr. capsici, TTLx. Hyoscinse 
 hydrobromidum (gr. %2o) should be given two or three times at 3 
 hour intervals, chloral hydrate (gr. x) and sod. bromide (3ss) for 
 three or four doses, before bedtime, or sulphonal (gr. xx) in hot milk 
 before bedtime, in order to induce sleep. Atropine (gr. %2o) and 
 strychnine (gr. %o) four or six times daily, hypodermatically, quiet 
 the nervousness, which occurs in the first days of abstinence. Sipping 
 ice-water, sucking lemons or drinking water with tr. quassia? may 
 satisfy the desire to " drink something." Ergot has little effect on the 
 circulation (Sollmann and Brown). Cocaine and morphine should 
 be avoided, lest a substitution or succession of habits develop. Ke- 
 lapse is very common. 
 
 III. Delirium Tremens. — Delirium tremens (mania a potu) is an 
 acute accident of chronic alcoholism and almost never follows an 
 acute debauch in an otherwise temperate individual. It was noted 
 among sailors by Sutton of Greenwich in 1813, but was probably 
 best described by Ware of Boston in 1831. Sixty-six per cent, of 
 cases occur in men, while multiple neuritis is more common in 
 women (Gowers) ; most victims are between thirty and forty years 
 of age. The patient has been, on the average, an alcoholic for 8 years 
 
1178 IN TOXICA TIONS. 
 
 before delirium tremens develops. The stronger spirits, rather than 
 beer or wine, are the cause of delirium tremens, as they are of alco- 
 holic convulsions. It may be precipitated by trauma to the chest or 
 fracture of the limbs, mental shock, by sudden failure of the stomach 
 to digest and assimilate food, acute withdrawal of alcohol or, in 70 
 per cent, of cases, the shock of onset of an acute infection. ^ 
 
 Symptoms. — The symptoms develop with restlessness and insomnia, 
 which renewed drinking fails to allay; for a day or two the mind 
 wanders, but can be brought back to realities. The patient may be 
 facetious, but is soon disturbed by horrible hallucinations. ^ There is 
 " great versatility of ideas " in delirium tremens. The patient talks 
 volubly, turns suspiciously to the head of his bed, drives his horses 
 vigorously and brushes away the vermin from the coverlet; halluci- 
 nations of hearing are also common. He at first knows that the bugs 
 and snakes are unreal, but they soon become actual torments, so that 
 unless watched he will leap from the window after waiting for his 
 opportunity. The pulse is rapid and soft, the skin is flushed or 
 slightly cyanotic and covered with sweat, the tongue is tremulous and 
 is coated white, the urine is scanty and often albuminous and sleep 
 is constantly absent. There may be moderate fever, 101 to 103°, 
 which some attribute rather to complications. 
 
 Diagnosis and Prognosis. — The diagnosis is rarely uncertain. The 
 chief danger of error is in overlooking coincident causal trauma and 
 infection, as pneumonia. In heavy and constant drinkers a delirium 
 may be delirium tremens or an " associated delirium," as from apical 
 pneumonia. 
 
 The outlook is always uncertain. The early convulsions are of no 
 great moment (Gowers). The prognosis is determined by the pulse, 
 the general nutrition and complicating alcoholic or other lesions. 
 Rigidity of the muscles of the neck is ominous (Putnam and Dana) 
 and indicates oedema of the brain. The average mortality is 15 to 20 
 per cent., but varies as the affection is (a) uncomplicated (1 per cent, 
 die, Lambert) ; (b) associated with other affections (grave outlook) 
 or (c) occurs in the aged or debilitated (probably fatal outlook). 
 Recurrence after recovery is frequent, and 27 attacks in one case 
 have been recorded. In fatal cases death usually results from ex- 
 haustion and heart failure; the tongue becomes dry, the delirium 
 constant and the skin cold and clammy. The autopsy shows oedema 
 of the brain (" wet brain," Dana), degenerative changes in the brain 
 and cord (Bonhoffer), arterial alteration (Collins) and hypostasis of 
 the bases of the lungs. 
 
 Treatment. — (a) The patient should be kept in bed and watched 
 constantly lest he escape. Strapping the ankles and wrists and con- 
 fining him by a straight jacket is a harsh procedure and invites 
 trauma to the hands and feet, but is inevitable when the family is 
 indulgent or the nurses are negligent. (&) Withdrawal of alcohol 
 is usually advocated but is a severe measure; the continuance of 
 moderate doses seems to hold the pulse steady and favors the diges- 
 
OPIUM POISONING. 1179 
 
 tion and is, in the author's belief, indicated, (c) Sleep is induced 
 with great difficulty and as Ware first pointed out, conies when the 
 disease runs its course. Excessive medication should be avoided. 
 Sod. bromide (3ss), tr. capsici (Tt^v) and whiskey (3ii), in hot 
 peptonized milk should be given every three hours, by mouth if pos- 
 sible, or by the nasal catheter, for nutrient enemata are difficult to 
 give and are seldom retained. Chloral is always dangerous in in- 
 veterate alcoholism. Hyoscine with strychnine may be beneficial 
 (v. s.). Morphine should be given only by the hypodermic method, 
 for its absorption can then be measured; it was formerly given to 
 excess. Protracted warm baths may quiet the patient (Bonhoffer), 
 but they are hard to administer. In 6 cases in which the violent 
 delirium became ominous the writer has etherized the patient, and in 
 3 instances with excellent results, though he does not advocate its wide 
 use. (d) The circulation should be treated as in pneumonia. Large 
 doses of digitalis are not indicated; they are tolerated only because 
 they are not absorbed; the original treatment by digitalis is based 
 on the fact that a nurse by mistake gave a toxic dose of digitalis ; 
 the patient improved and the " digitalis treatment " was thus insti- 
 tuted, (e) Cold affusions upon the neck and chest are recommended 
 by Broadbent. 
 
 OPIUM POISONING. 
 
 I. Acute Poisoning. — This is important chiefly from a diagnostic 
 standpoint. In the second stage it is strongly characterized by pro- 
 found sleep, dry, flushed^ skin, narrow pupils, slow, strong " digitalis 
 pulse " and slow deep stertorous breathing. The third or terminal 
 stage is different; the skin becomes cyanotic and clammy, the nar- 
 rowed pupils may dilate, the pulse become weaker (though the heart 
 centers live after the other bulbar centres have died), respiration 
 halts and is very slow. Mistakes in diagnosis are made by attributing 
 undue importance to the " pin point " condition of the pupils. , Mor- 
 phine may be detected in the stomach washings. 
 
 Treatment. — This consists of (a)' mechanical evacuation by re- 
 peated gastric lavage, (b) Chemical antidotes, such as large amounts 
 of tannic acid, should be given with the lavage and removed as the 
 tannates formed may dissolve; 1 to 1,000 permanganate of potash 
 (Moor, of jSTew York) may be given by mouth or hypodermatically. 
 (c) Respiration must be sustained by walking the patient (the ambu- 
 latory treatment), but fatigue must be guarded against; phrenic fara- 
 dization is indicated, but care is necessary lest too strong a current 
 produce paralysis instead of stimulation; strychnine plus atropine 
 may be given hypodermatically, but the total dose of atropine should 
 not exceed gr. %o to V20 ; pulling slowly and rhythmically on the 
 tongue may help respiration; Sylvester-Hall's artificial respiration 
 and oxygen inhalation may be used, (d) The heart should be stimu- 
 lated by coffee, strychnine, heat and digitalis. 
 
 II. Chronic Morphinism (Morphinomania). — The use of morphine 
 
1180 INTOXICATIONS. 
 
 for pleasure only, so common in Asia, is rare with us ; those taking 
 morphine for pain and resisting its attractions are called morphinists ; 
 those using it for pleasure only are morphinomaniacs. The habit is 
 contracted by its use for insomnia or for mental or physical pain. 
 Forty-seven per cent, of morphine victims are said to be physicians ; 
 women, particularly prostitutes and nurses, druggists and — in Ger- 
 many — officers rank next. It may be taken for years without mental 
 or physical deterioration, but morphinists are usually less happy, as 
 increase in the daily dose becomes necessary and the half-oxidized 
 alkaloid produces symptoms (v. i. Treatment) which are only al- 
 layed by larger doses. Morphine acts as a nerve poison. The victim 
 becomes restless and irritable without his dose. The mental and 
 moral attributes are anesthetized and there is a "moral insanity." 
 The patients lie by choice, neurotic symptoms are common, muscular 
 and mental asthenia develop, the pupils are contracted, the sweat and 
 saliva are decreased, the teeth decay, the appetite fails, the skin be- 
 comes sallow, itchy and dry, the hair coarse and gray, constipation 
 is usual and slight ataxia may develop. 
 
 Prophylaxis. — Physicians should not give opiates freely. When ad- 
 ministered for severe pain the habit is less often contracted than when 
 given to neurotics. At least 70 per cent, of cases relapse after a cure. 
 
 Treatment. — Treatment is almost impossible without (a) institu- 
 tional confinement, which must of course be voluntary, (b) The 
 morphine may be withdrawn abruptly, rather suddenly or very gradu- 
 ally • the second method is the best, stopping the morphine entirely in 
 four to seven days. Its withdrawal is attended by awakening of 
 dormant anaesthetized functions ; there is at first paroxysmal yawning 
 and sneezing; roughening of the voice, paresthesia, neuralgias es- 
 pecially in the legs, clammy skin or rapid pulse, wide pupils, tremor, 
 sexual excitement, extreme irritability, vomiting, colic and diarrhoea 
 also occur. The symptoms were attributed by Marme to di-oxymor- 
 phine. poisoning, the antidote to which is morphine; Hitzig believes 
 that they are largely due to hyperchlorhydria, for the gastric nerves 
 under the influence of morphine secrete little hydrochloric acid; relief 
 is obtained by washing out the stomach with a solution of Carlsbad 
 salts. The patient will obtain morphine if possible, (c) The patient 
 should be kept in bed for a week to obviate vasoparetic cardiac col- 
 lapse, (d) Symptomatic treatment is indicated (i) by the collapse 
 (aromatic spts. of ammonia, TT\,xx, strychnia gr. % , heat) ; (ii) by 
 nervousness (warm baths, sodium bromide in doses of one dram every 
 four hours) ; (iii) by the insomnia (hyoscine gr. % 2 o every two 
 hours for two to six doses, sulphonal or trional, gr. xx) ; (iv) bv the 
 gastralgia (gastric lavage with alkaline salts) ; (v) by diarrhoea and 
 colic (as in enteritis, but vegetable astringents, large doses of bismuth, 
 and no opiates should be used) ; (vi) by neuralgia (acetanilide, gr. v, 
 fluidextr. gelsemii, 1T\.iij). Whatever treatment is instituted, alco- 
 holism, chloralism, bromism or cocainism should not be substituted. 
 
LEAD POISONING. 1181 
 
 LEAD POISONING. 
 
 Etiology. — The importance of plumbism or saturnism is increasing. 
 (a) Industrial plumbism is very common. Workers in white or red 
 lead factories usually acquire the disease. Miners of the metal gen- 
 erally escape, but smelters of lead ore and even animals and birds 
 near the furnaces are frequently affected. Painters, plumbers, 
 glaziers, less often tinners, printers, cameo polishers, cartridge mak- 
 ers, etc., may be poisoned, (b) Accidental contamination of food or 
 drink. Poisoning may result from the action of acids in canned foods 
 on the tin or solder, as in cans of sardines ; wine or cider may become 
 poisonous in the same way, as happened in Devonshire and in Poitou 
 (colica pictonum). Chromate foil, covering hams or candy, rubber 
 nipples, bullets in pickled game, bread ground in lead vessels, chro- 
 mate used to color buns (D. D. Stewart's report of the fatal Phila- 
 delphia epidemic), Seltzer or other charged waters, wine and eau de 
 vie sweetened or cleared with litharge, are a few of the many subtle 
 causes of saturnism. Drinking water conveyed through lead pipes is 
 generally protected by the deposit of lime and other salts, but poison- 
 ing is possible when the water is exceptionally pure or soft, thereby 
 depositing little lime in the pipes, or when it is saturated with organic 
 matter or collected from lead roofs, (c) Less frequent sources of 
 plumbism are in the environment, and in such things as hair-dyes, 
 powders or cosmetics, linen, freshly painted walls, candles, sealing- 
 wax, brightly tinted toys, false teeth and thread, (d) Therapeutic 
 and criminal plumbism is rare; it may result from the acetate of 
 lead when given internally or externally, and from impure sub- 
 nitrate of bismuth; its criminal use is very uncommon, (e) Pre- 
 disposing factors are alcoholism, age (it occurs most often in per- 
 sons from thirty to forty) and sex (75 per cent, of cases are females, 
 Olivier). Susceptibility varies greatly; plumbism may cause death 
 within a week or may not develop until after forty-two years of work 
 in the metal (Tanquerel des Planches, 1838). Absorption of lead 
 usually occurs (i) by the digestive mucosa; most of the metal is pre- 
 cipitated by the albumin of the food and eliminated without absorp- 
 tion; (ii) by the respiratory mucosa, by inspiration, as dust in white 
 lead factories; or (iii) by the sound or diseased skin (cosmetics) or 
 even the conjunctiva or vagina (lead douches). It is eliminated 
 chiefly by the urine ; Putnam stated that he found lead in 25 per cent, of 
 150 persons who had no evidence of plumbism; the liver and ali- 
 mentary mucosa eliminate smaller quantities. 
 
 I. Acute Poisoning. — This is uncommon, though it may occur from 
 therapeutic, criminal or professional causes. Its symptoms are (a) 
 gastro-intestinal ; a styptic burning taste occurs in the mouth, thirst is 
 present, there is a lead line on the gums in some cases, though less 
 than in chronic poisoning, nausea and vomiting sometimes of white 
 lead chloride, abdominal colic, retraction of the abdomen, diarrhoea 
 with black (lead sulphide) or bloody movements or sometimes con- 
 
1182 INTOXICATIONS. 
 
 stipation. On postmortem examination, the catarrhal gastroenteritis 
 may he wrongly considered a postmortem change ; white spots may be 
 seen (Orfila's spots). The symptoms may he (b) circulatory; the 
 pulse may he slow (50 to 40) and irregular; anaemia, cyanosis and 
 collapse may occur; (c) they may be nervous; vertigo, stupor, de- 
 lirium, neuralgia, cramps, convulsions and even cerebral and periph- 
 eral paralyses may develop; (d) nephritis with suppression of urine 
 may develop. 
 
 Treatment.— Treatment consists of full doses of sodium and mag- 
 nesium sulphate, in order to precipitate an insoluble lead sulphate, 
 and to remove it, demulcent drinks (eggs and mucilages), opium for 
 pain and cardiants. 
 
 II. Chronic Poisoning.— Symptoms. — (a) Colic is the most common 
 symptom; it occurred in 88 per cent, of Tanquerel's 1,390 cases. It 
 is due to local deposit of lead in the intestinal muscles or mucosa, 
 spasm of the bowel, changes in the nerves or angiospasm. It may 
 develop early or late ; it may he preceded by malaise, lumbago or pain 
 in the legs or may he brought on by alcoholic excesses. It is a colic 
 accompanied by constipation (dry colic), rarely by diarrhoea; it is 
 umbilical, whence it spreads over the abdomen, perhaps to the legs 
 or scrotum ; it is relieved by pressure, though sometimes the abdomi- 
 nal wall is hyperaesthetic ; sometimes vomiting and absolute consti- 
 pation may simulate obstruction, and in one case the author observed 
 intussusception as a result of lead poisoning. There is no fever, the 
 pulse is small and hard (Kiegel) and the urine is scanty. Without 
 treatment colic is protracted; its relief is usually marked by a bowel 
 movement. Relapses are very frequent, (b) The gingival lead line 
 (Burton, 1834) present in over 90 per cent., is a gray-black line, 2 
 to 3 mm. wide, which is seen most clearly on the lower gums and is 
 due to deposition from the blood of lead sulphide, precipitated by the 
 sulphuretted hydrogen of the tartar. The coincident anaemia brings 
 it out very clearly. Similar deposits may occur under the buccal 
 mucosa opposite the molars. It is very frequently mistaken for tartar, 
 which occurs on the teeth, sometimes for the black carbon line seen 
 in miners, or rarely for the silver line in argyria. (c) Other digestive 
 symptoms are coated tongue, foetid breath, parotitis, saturnine dys- 
 pepsia and rarely icterus. Test meals show lactic acid and no HC1 
 (Sailer and Speese). (d) Ancemia is very frequent in the "lead 
 cachexia." The haemoglobin and erythrocytes decrease moderately; 
 the red cells show basophile granules (Grawitz) and 'quite commonly 
 nucleation, even in mild cases (Cadwalader, 1905). The leukocytes 
 may be increased, (e) The heart and vessels. The heart is very often 
 hypertrophied, as evidenced by a loud second aortic tone and aortic 
 regurgitation of atheromatous origin; the arteries are often sclerosed, 
 occasionally causing angina pectoris, frequently myocarditis, irregu- 
 lar heart action and perhaps some of the brain symptoms (v. L ). The 
 asthma saturninum is probably cardiac or uraemic. (/) The kidneys 
 are often sclerotic, as a result of the elimination of the metal. It is 
 
LEAD POISONING. 
 
 1183 
 
 said that the change does not begin around the vessels but in the 
 tubules, which are the seat of a necrosing deposit of carbonate of lime. 
 Nephritis, gout and plumbism may co-exist {v. s.). (g) Nervous 
 manifestations. Peripheral degenerative neuritis occurs in 7 per 
 cent., usually as a later symptom. About one-tenth of these cases 
 have not had colic. It is characterized by the paralysis of muscles 
 with the same function, by muscular atrophy and cramps, tremor, 
 cutaneous hyperesthesia, neuralgia, arthralgia (55 per cent.), my- 
 algia and by varying degrees of reaction of degeneration (v. Mul- 
 tiple Neuritis). The musculospiral type, " wrist drop/' is the most 
 common and is bilateral ; the supinator longus (a flexor) and the small 
 extensor of the thumb escape involvement; tenderness and anaesthesia 
 are rare. Gubler's tumors are swellings of the extensor tendon 
 sheaths and are due to backward dislocation of the carpus or perhaps 
 to a trophic change; they are hard, ovoid, indolent, seldom painful 
 or larger than a pigeon's egg and regress with the paralysis. A second 
 but rare form is the brachial, involving the deltoid, biceps, brachials 
 anticus and supinator longus, rarely the pectorals. A third type is 
 the Aran-Duchenne, which is especially observed in tailors (Mobius) 
 and involves the small muscles of the hand, the thenar and hypothenar 
 eminences ; it resembles that of chronic anterior poliomyelitis (which 
 indeed has been found in a few cases at autopsy). A fourth type, the 
 peroneal, involves the peronei and toe extensors ; according to Tan- 
 querel, but 13 per cent, of lead palsies affect the leg. Lastly, rarer 
 types may involve the larynx, vagus and face ; generalized paralyses, 
 either slow or rapid like Landry's paralysis, are very rare ; primary 
 muscular atrophy may occur, is most often of the Aran-Duchenne 
 type and shows fatty and fibroid muscular changes. 
 
 Cerebral forms (encephalopathia saturnina) occur in 5 per cent.; 
 they are often preceded by headache, colic and insomnia and are 
 attended by amaurosis, limitation of the visual field, retinitis albumi- 
 nnrica or saturnina (with inflammation, engorgement and possibly 
 ultimate atrophy) and paralysis of the eye muscles. The most fre- 
 quent type is the delirious encephalopathy, which is variable or mobile 
 in character, and sometimes resembles delirium tremens ; the next 
 type is the convulsive (epilepsia saturnina) which occurs without 
 aura?, is usually generalized, often fatal and is always considered 
 when epilepsy develops in an adult; the third type is the comatose. 
 Hysteria frequently occurs with plumbic encephalopathy. Neglected 
 or unrecognized cases may become dements (pseudodementia para- 
 lytica saturnina). Deposit of lead in the protoplasm of the brain is 
 the usual cause; sometimes the cerebral symptoms are arteriosclerotic 
 (as hemiplegia) or uremic. 
 
 Lead-poisoning is usually recognized (a) by the etiology, (b) by 
 the lead line, (c) by lead in the urine, (d) by colic and (e) by wrist- 
 drop. In a case of long coma with choked disk, in the Cook County 
 Hospital, no cause was found, until after a second examination, the 
 lead line was seen. The man was a barber, who regularly dyed the 
 
1184 INTOXICATIONS. 
 
 hair of a number of people, and probably absorbed the lead through 
 his hands. 
 
 Prognosis. — The acute forms are more favorable. Vascular and 
 renal changes are largely incurable. Atrophic paralyses are serious. 
 The wrist-drop usually regresses, though it is sometimes permanent ; 
 25 per cent, of cases with coma, convulsions and other cerebral symp- 
 toms die ; after apparent recovery mental degeneration may develop. 
 
 Treatment. — (a) Prophylaxis. A mask should be worn in white- 
 lead factories to avoid inhalation of lead dust ; workers are careless 
 and poisoning is frequent despite precautions. Painters and others 
 may often avoid poisoning by carefully cleaning the hands and nails 
 before eating, (b) Lead colic is treated by hypodermic injections 
 of morphine and atropine to control pain and spasm. Eiegel uses 
 nitroglycerine for the supposedly causal spasm of the vessels. Spts. 
 of chloroform (TT\xx) with other aromatics may be given by mouth. 
 (c) The constipation and removal of any lead salts unabsorbed in or 
 excreted by the alimentary mucosa necessitate catharsis. Full doses 
 of castor oil (oiv or more) with paregoric (5i) evacuate the bowels 
 and relieve pain and spasm ; sodium and magnesium sulphates purge 
 and coincidently precipitate the lead as an insoluble sulphate, (d) In 
 order to eliminate the lead from the tissues potassium iodide should 
 be given. In acute or severe chronic cases it should be given with 
 care, for it transforms the fixed tissue metal into free metal in the 
 circulation. Nevertheless, small doses of potassium iodide (grs. iii to 
 v) should be given, and some writers obtain even better effects from 
 potassium bromide (grs. v to x). Warm baths and pilocarpine (gr. 
 Ys) promote excretion by diaphoresis and plenty of water stimulates 
 the renal elimination, (e) Iron (not arsenic) should be given for 
 anaemia. (/) For treatment of neuritis, see Multiple Neuritis. 
 
 ARSENICAL POISONING. 
 
 Acute poisoning has been considered under pernicious anaemia. 
 
 Chronic Poisoning. — (a) Criminal poisoning is of great medico- 
 legal importance, as in the unfortunate Maybriek case." (b) Poison- 
 ing by reason of occupation is uncommon, (c) Therapeutic poison- 
 ing is not common, but may occur in chorea, leukaemia and pernicious 
 anaemia, (d) Most cases are accidental. The dyes in garments, 
 toys, glazed paper used in kindergartens, wrappers,' artificial flowers 
 and wall paper are important sources of intoxications. The action of 
 moulds (penicillium and mucor) may liberate volatile arsenical gases. 
 Contaminated glucose used in beer caused the Manchester epidemic. 
 Arsenic is absorbed by the lungs and alimentary tract and is chiefly 
 eliminated by the kidneys, which may degenerate. Putnam found 
 arsenic in the urine of 30 per cent, of persons who showed no other 
 symptoms of arsenical poisoning, but in this connection it may be 
 remarked that arsenic is widely found in plants, sea water "and 
 springs. Smaller amounts are eliminated by the bowel, milk and 
 other secretions. 
 
FOOD POISONING. 1185 
 
 Symptoms. — The symptoms are (a) gastro-intestinal, as dry throat, 
 vomiting, purging or colic ; the stools may be like " rice water " and 
 contain flecks of mucus; and (b) respiratory, as dry cough or chronic 
 bronchitis, (c) Emaciation, weakness, fever and ansemia may occur. 
 (d) Cutaneous symptoms, as erythema, keratosis, pemphigus, herpes 
 and brown pigmentation and (e) nervous manifestations, as weak 
 memory, vertigo, headache and multiple neuritis may develop. The 
 neuritis has the same general features as the saturnine form, save 
 that sensory changes are more frequent and the legs are more often 
 affected than the arms; paralysis of the peronei and foot extensors 
 causes the " steppage " gait. The small muscles are less often affected 
 than in plumbic or alcoholic neuritis; paralysis, ataxia, sensory and 
 trophic disturbances and the reaction of degeneration occur as in 
 other neuritides. 
 
 Treatment. — Treatment is that of lead poisoning or neuritis. 
 
 FOOD POISONING. 
 
 Bromatotoxismus (Vanghan) exists in several forms: 
 I. Meat Poisoning (Kreatoxisnms). — Sausages and head cheese 
 are more dangerous than beef or mutton. Sausage poisoning (botul- 
 ism or allantiasis) was known in Germany a century ago. Van 
 Ermingem has isolated an anaerobic organism, the Bacillus botulinus; 
 it contains spores, is flagellated and mobile and grows only on alkaline 
 media at a low temperature (18 to 25° C.) ; it is a saprophyte and 
 causes symptoms by its toxins only, which are not destroyed by the 
 gastric juice. Paratyphoid organisms were found by Durham 
 (1900). Meat may seem to be normal to the taste and smell, and 
 yet contain ptomaines; their nature is still undetermined, though 
 Cobert considers them promatropin. Canned meat has often caused 
 severe symptoms. In one instance botulism was caused by eating 
 salad (Collatz) and beans (Fischer). The symptoms of botulism 
 appear in twelve to forty-eight hours, with nausea, vomiting and 
 sometimes diarrhoea. Paralysis of the soft palate, larynx and oesoph- 
 agus rapidly develop and somewhat later paralysis of the bowel 
 mydriasis, ptosis, disordered vision, adynamia and weak heart action ; 
 the sensorium is clear and fever is unusual. The mortality ranges 
 between 20 and 50 per cent. ; death occurs in four to ten days and the 
 autopsy shows parenchymatous degenerations and ecchymoses, but 
 especially degeneration of the ganglionic cells, as those of the vagus 
 or oculomotorius ; if the patient survives, convalescence is established 
 only after months. In the Wellback cases Ballard noted as early 
 symptoms headache, chilliness or rigors and pains in the chest or back. 
 Symptoms. — The symptoms of other forms of meat poisoning are 
 either those of toxaemia (the typhoid type) or g astro-intestinal inflam- 
 mation (cholera type) ; the typhoidal symptoms, which appear after 
 an incubation of four to six days, are fever, status typhosus and even 
 roseolge; the choleriform symptoms, which develop in two to twelve 
 75 
 
1186 INTOXICATIONS. 
 
 hours, are vomiting, incessant purging, watery stools, clammy skin, 
 collapse and cyanosis. Acute meningitis may be simulated exactly 
 (A. D. Dunn). Mild or rudimentary forms occur in most epidemics. 
 Treatment.— Treatment is unsatisfactory. Early gastric lavage, 
 colonic flushings and purgation are indicated; calomel followed by 
 castor oil is the best aperient. Otherwise symptomatic medication, 
 as in cholera or typhoid, is indicated; champagne, strychnia, hypo- 
 dermatoclysis and opium may be given. The resemblance of botulism 
 to the diphtheria toxins has suggested the use of antitoxine ; its effects 
 in animals have been remarkable, but to the author's knowledge it has 
 not been used in man. 
 
 II. Poisoning by Milk (Galactotoxismus) and Cheese (Tyrotoxis- 
 mus). — The former produces symptoms analogous to those of the 
 infantile affections of the bowel, as vomiting, bloody diarrhoea, fever 
 and collapse. In cheese poisoning Victor C. Vaughan has found 
 tyrotoxicon and other more frequent toxins, which are probably albu- 
 moses. Similar ptomaines were found by him, Novy and Perkins in 
 re-frozen ice-cream and custard. In Norway where tyrotoxismus is 
 most prevalent, the colon bacillus has been repeatedly found. Home- 
 made cheese is more dangerous than the factory product. Various 
 forms of toxaemia result ; some are cholera-like and others resemble 
 belladonna poisoning. Treatment is that of kreatoxismus. 
 
 III. Poisoning by Fish (Ichthyotoxismus) and Shell Fish (My tilo- 
 toxismus). — (a) Ichthyotoxismus, described by Comby (1827), may 
 be caused by poisonous fish or poisonous glands in certain fish, as the 
 roe or testicles, the muscular parts being harmless ; the barbel in 
 Europe and the tetrodon, diodon and fugu in Asia are poisonous (v. 
 Beei Beri). The poisoning due to putrefaction is more common. 
 Paralytic symptoms., like curare poisoning, are most frequent, (b) 
 Mussel poisoning (mytilotoxismus) may cause dyspeptic symptoms 
 in mild infections and cholera-like symptoms or symptoms of bella- 
 donna poisoning in severe forms. Bashes are common. Brieger iso- 
 lated a mytilotoxin, which is found largely in the liver. The danger 
 lies in placing mussel- or oyster-beds near river mouths, so that they 
 feed on poisonous excreta. In restaurants certain glands near the 
 heads of lobsters, considered toxic, are carefully excised. 
 
 IV. Grain Poisoning. (Sitotoxismus). — 1. Ergotism. — Ergotism, 
 which was described by Thuillier (1830) and carefully studied by 
 Tiiczek (1879), results from eating grain mixed with the ergot 
 fungus (claviceps purpurea). Ergotized grain is found largely in 
 bad harvests, resulting from wet springs and hot summers. Epi- 
 demics have occurred in Europe, and sporadic cases are not rare. 
 Acute ergotism, with digestive symptoms, colic, cyanosis, weak heart 
 and generally lethal outcome is less common than chronic ergotism, 
 of which two forms exist ; the first is the convulsive form, attended 
 by paresthesia, lightning pains, headache, delirium, melancholy, de- 
 mentia, muscular relaxation and muscular spasms, either as general- 
 ized epileptiform attacks or as local contractures (flexion of the arms 
 
FOOD POISONING. 1187 
 
 and extension of the toes and feet) ; it is said to result from the 
 alkaloid cormitin. The second form is the gangrenous, due to spha- 
 celinic acid and marked by localized gangrene, usually in the pha- 
 langes and less often in the tips of the ears and nose. Chronic 
 ergotism is characterized by a number of symptoms which suggest 
 tabes, as lightning pains, ataxia of station and movement, and lost 
 knee jerks; and in five autopsies Tiiczek and Siemens found degen- 
 eration with, later, sclerosis of the posterior columns; degeneration 
 in the anterior cornua, and minute foci of softening or hemorrhage also 
 occur. The clinical course is chronic and death is frequent from con- 
 vulsions or cachexia. 
 
 Treatment. — Treatment includes avoidance of diseased grain and 
 symptomatic therapy; opium should be given for convulsions and 
 nitroglycerine for gangrene. 
 
 2. Pellagra. — Pellagra or maidism is a chronic nutritional and 
 toxic affection, due to the use of maize which has been improperly 
 stored, or is decayed, unripe or infected with the aspergillus. An 
 alkaloid (pellagazein) is thought to develop. Pellagra is endemic, 
 chiefly in Italy, Prance, Spain, Hungary and Mexico. It occurs 
 among poor farmers. There are three stages; the first consists of the 
 vernal erythema, which is followed by exfoliation and sometimes by 
 suppuration ; dyspepsia and diarrhoea may develop ; mild cases may re- 
 cover or may pass into the second stage, in which headache, pain in 
 the back and muscular spasms occur, but the most characteristic symp- 
 tom is the ataxic paraplegia; autopsies reveal a posterolateral scler- 
 osis, sometimes with atrophy of the anterior horns, leptomeningitis 
 and variable brain findings. The third stage occurs after repeated 
 attacks and is usually incurable; cachexia, epilepsy and dementia 
 develop ; it is said that 10 to 35 per cent, of Italian insanity is due 
 to pellagra. 
 
 The rarer acute cases may resemble typhoid in symptoms and 
 pathology (status typhosus and swelling with ulceration of the in- 
 testinal lymph structures), or meningitis (foci of acute meningo- 
 myelitis). Other findings at autopsy are atrophy of the digestive 
 mucosa, parenchymatous degeneration and pigmentation, the latter 
 of which is thought to occur from adrenal inflammation. 
 
 Treatment. — Treatment is prophylactic (proper storage of the 
 grain) ; change of diet or of locality is indicated and arsenic should 
 be given internally. 
 
 3. Lathyrism (lupinosis). — Lathyrism is produced by meal made 
 from vetches, chiefly the lathyris sativus and cicera. Irving described 
 the disease in India and it has been seen also in Algiers and Italy. 
 Like pellagra, it probably produces a lateral and possibly some pos- 
 terior sclerosis of the cord, though no autopsies are reported. Clin- 
 ically there is a spastic paraplegia with increase of reflexes and some 
 paresthesia. 
 
 V. Potato Poisoning. — Solanin is contained in potatoes in small 
 amounts (0.06 per cent.) but larger amounts (0.4 per cent.) occur in 
 
1188 SUNSTEOEE. 
 
 potatoes which lie for some time on the ground or sprout^ in cellars. 
 Fever, chills, general and cardiac weakness, alimentary irritation and 
 jaundice may develop. 
 
 SUNSTROKE. 
 
 The difference hetween the two forms, (1) sunstroke, and (2) 
 heat exhaustion, was first recognized by Dowler of New Orleans. 
 
 Sunstroke, also known as siriasis, insolation, coup de soliel and 
 thermic fever, is due to exposure to the sun. A very frequent factor 
 is alcoholism. There is thought to be a paralysis of the bulbar heat 
 centres, leading to excessive production of heat and deficient elimina- 
 tion of it. The theory of infection has also been advanced. 
 
 Symptoms. — Symptoms may develop very abruptly and cause early 
 or even immediate death from asphyxia and paralysis of the heart ; 
 this type was long confused with apoplexy. In most cases there is an 
 interval lasting from a few minutes to an hour, in which there are 
 headache, vertigo, visual disturbances or nausea, and perhaps vom- 
 iting. 
 
 During the coma which develops rapidly, and in which the phy- 
 sician usually sees the patient, the following signs are observed : the 
 face is first flushed, later rather cyanotic, and sometimes stained with 
 petechias. The preliminary pupillary dilatation passes into myosis 
 and the skin has a peculiar odor. The pulse is rapid, usually over 
 100, and is bounding. The rectal temperature ranges from 107 to 
 112° and respiration is deep, labored and stertorous. Save for the 
 laboring chest, the patient is usually quiet; in about 25 per cent, of 
 the author's cases the patients struggled during treatment by the cold 
 bath and in about 20 per cent, of the severe cases there were epilepti- 
 form convulsions. Lewis and Packard (1901) in 92 cases found con- 
 vulsions and unconsciousness in all severe cases ; immobile pupils and 
 absent knee jerks were common. Involuntary evacuations are usual 
 and the thin faeces have a peculiar odor. There is a leukocytosis in 
 about 75 per cent, of the cases. Recovery is frequent ; consciousness 
 returns and the fever falls. Despite treatment, the Cheyne-Stokes' 
 breathing may develop, the pulse may grow smaller and more rapid, 
 and death may follow, usually in a little more than a day. The au- 
 topsy shows early rigor mortis, fluidity of the blood, great venous 
 hyperemia, particularly in the brain and lungs, and dilatation of the 
 right and contraction of the left ventricle. 
 
 After sunstroke the patient becomes extremely susceptible to hot 
 weather. Epilepsy, multiple neuritis and mental symptoms are 
 among its after-effects. The anthor saw one case with a temperature 
 of 109° in which the fever fell with hydrotherapy but rose to 104° ; 
 in a few days the trouble was recognized as typhoid. 
 
 Diagnosis. — The diagnosis is easily made. Practically, there is 
 but one possible cause of confusion, pontine hemorrhage, but the 
 latter never develops nearly as high a temperature and death is 
 almost instantaneous; should the patient survive, paralysis, usually 
 of the crossed type, is obvious. 
 
SUNSTBOKE. 1189 
 
 Heat exhaustion may result from exposure to the sun or to high 
 temperature with humidity; the cases which the author has seen 
 came largely from laundries, basement stores or engine rooms; heat 
 exhaustion occurs also among stokers on steamers. The symptoms are 
 those of a centric vasomotor paralysis. The skin is cool and livid, 
 rather than red, and the rectal temperature is often 3 or 4° sub- 
 normal; the pulse is rapid and weak and the breathing is rapid but 
 not labored. In short, the symptoms of collapse are present. Rest- 
 lessness, anxiety and sometimes delirium are noted, though the sen- 
 sorium is practically normal in most cases. 
 
 Treatment. — In sunstroke the chief indication is reduction of the 
 retained heat, by immersing the patient in a bath gradually cooled 
 by large pieces of ice. Shock is averted by this means; cerebral 
 congestion is lessened by placing a block of ice under the neck, an 
 ice-bag on the vertex and an ice-bladder over the anterior neck; 
 active friction of the body and limbs with the open hands brings 
 to the surface the blood, which is cooled by the bath and the rubbing 
 with pieces of ice. With this treatment, few more than one-third 
 of the cases should die. The patient should be taken from the bath 
 when his rectal temperature is 102°, for the fall usually continues 
 after cessation of treatment. Laxatives are generally unnecessary, 
 for the bowels move freely. Heart stimulants should be given pro 
 re nata. For convulsions, a little chloroform by inhalation and a 
 hypodermic of morphine are indicated. Asphyxia and distention of 
 the right heart are relieved by phlebotomy. 
 
 In heat prostration the treatment is diametrically the opposite; a 
 warm bath or hot bricks for subnormal registration, diffusive cardiants, 
 as ammonia, camphor and strychnine, saline solutions under the 
 skin and applications of mustard are indicated ; cold and venesection 
 are obviously contra-indicated. 
 
SECTION XI. 
 DISEASES DUE TO ANIMAL PARASITES 
 
 DISEASES CAUSED BY CESTODES. 
 
 Tapeworms were known to the Egyptians, Hindus and probably to 
 the Jews. They may cause symptoms by the presence of the mature 
 parasite in the bowels or of the larval form in the viscera. 
 
 I. Taenia Solium. — The Taenia solium or pork tapeworm (Linnaeus, 
 1752) exists as the cysticercus cellulosae in hogs and rarely in dogs, 
 rats or deer, as "measles' 7 (measle or bladder worms). The adult 
 form is peculiar to man. Cysticerci (the larvae) are found in the 
 intermuscular tissue, particularly of the under surface of the tongue, 
 in the masseters, shoulders, neck and diaphragm. They are easily 
 seen with the naked eye and very easily with a low-power lens, as 
 small opaque white bodies. They are vastly more frequent in Asiatic 
 and German than in American pork. Man is infected by eating raw 
 or partly cooked pork ; the cysticerci develop in the upper ileum into 
 the taenia ( a band or ribbon-like") solium (referring to its usual 
 solitary appearance, though 2 or 3, and even 20 or 41, have been 
 found). The worm measures 2 to 8 metres in length. Its head 
 (scolex) is round, often gray or black in its upper part, is smaller 
 than a pin head, and is attached to the upper ileum ; it has 4 sucking 
 disks and 20 to 30 hooklets, arranged 
 in an anterior more numerous row, FlG - 80 - 
 
 and a posterior row, whence the name 
 " armed " tapeworm ; it has no real 
 mouth. (See figs. 80, 81, 82, 83.) 
 Its neck is thin and not jointed, to 
 which the segments ("proglottides") 
 are attached. These number 800 or va of t. solium: a, with yolk; 
 
 900; the segments measure 10 mm. ^^™^Z*&£ fi^g^ 
 in length by 5 or 6 mm. in width; indicated. (Leuckart.) 
 those near the neck are narrower and 
 
 shorter. About a yard from the neck they become squarer, and lower 
 down they are smaller again. Each proglottis is hermaphroditic, con- 
 taining male and female reproductive elements. The uterus is central 
 and vertical, with 7 to 15 lateral branches ; only a few of them 
 mature, chiefly those in the lower links ; the ova (31 to 36/*) are very 
 numerous in each maturing segment and each one shows a shell and 
 an embryo armed with six hooklets. The taenia reaches its full 
 length of two to four yards in three to four months, when the lower 
 
 1191 
 
1192 
 
 DISEASES DUE TO ANIMAL PARASITES. 
 
 segments are detached and voided; if the worm should break and a 
 yard or so appear in the faeces the segments will not reappear in the 
 feces until three or four months later. An ovum ingested by a hog or 
 man loses its shell in the stomach and the freed embryo passes into the 
 tissues, where, encysted, it becomes again the cysticercus cellulosae 
 (or larva). 
 
 Symptoms of the Taenia Solium in the Human Intestine (Intestinal 
 Taeniasis). — Many, possibly most, cases present no symptoms; they 
 may first develop after passing segments are found in neurotic sub- 
 jects. In other cases headache, itching, pupillary inequality, emacia- 
 
 PlG. 81. 
 
 Pig. 82. 
 
 Head of T. solium: x 45. Proglottides of (a) Tcenia 
 
 saginata and (b) T. solium. 
 natural size, and enlarged 
 three times to show arrange- 
 ment of uterus. (After Leuc- 
 kart.) 
 
 tion and dyspeptic disturbances arise, as anorexia (or less often in- 
 creased or ravenous appetite), nausea, abdominal pains, constipation 
 or diarrhoea. Stiles, in an experimental infection on himself, thought 
 that he could feel the parasite move. Vomiting of segments is rare, 
 though several feet of tapeworm have been vomited; in these in- 
 stances the ova (embryos) may enter the tissues as cysticerci; this is 
 a rare condition in which one individual suffers from both the in- 
 testinal and the larval stages. Anaemia is rather uncommon. In 
 children reflex convulsions are possible. The parasite may live for 
 even 10 to 15 years. The diagnosis is determined by the segments 
 and ova and the prognosis is practically always good. 
 
 Treatment.— As to prophylaxis; segments of the tapeworm should 
 be burned ; meat inspection should be more general than it is, though 
 " interstate " meat is well inspected; pork should always be thor- 
 oughly cooked. Hogs obtain ova from human faeces. 
 
 1. To cure the disease a light and chiefly fluid diet should be 
 
DISEASES CAUSED BY CESTODES. 1193 
 
 given for two days and then food should be withheld for 12 to 18 
 hours ; this often causes the parasite to release its hold on the mucous 
 membrane; some writers advise that a meal of onions and herring 
 be given just before drugs are administered. 2. A preliminary ca- 
 thartic is given to clean the bowel to allow more direct access of the 
 vermifuge to the parasite and to prevent its regaining its hold when 
 once detached. 3. Anthelmintic therapy. Of these pomegranate 
 (granatum) ranks first ; a decoction is made of 3 ounces of the root 
 with 8 ounces of water ; this is re- 
 duced to 4 ounces by evaporation; 
 it is taken in divided doses within 
 3 to 4 hours; its sole active prin- 
 ciple is the expensive pelletierine, 
 which is given in doses of 3, 5 or 
 10 grains and is followed by a 
 purge in an hour ( Pelletierinse tan- Eggs of (a) t. saginata; (&) t. solium; 
 nas). Male fern (felix mas) is al- ^tt^m^^^ latuS '' * 30 °' 
 most equally effective; it is given 
 
 as the oleoresina aspidii, or extr. felicis maris sether., 3iss to ijss, may 
 be given in syrup; both are followed by a saline purge in three to 
 four hours. Castor oil is never used, because it promotes absorption 
 of the male fern, which causes toxic symptoms, as icterus or amau- 
 rosis; Sidler collected 78 such cases of poisoning with 15 per cent, 
 mortality and lasting blindness in 25 per cent. ; Leichtenstern advises 
 (a) that more than 10 gm. (3iiss) of the ethereal extract should 
 never be given to adults (3j or less to children) ; (b) that it never be 
 given on an empty stomach and (c) that it never be given two 
 days in succession. The drug decomposes easily, whence reliable 
 preparations must be obtained. Combinations may be made by 
 giving with or after the decoction of pomegranate, spts. chloro- 
 formi (TIXxv) for four doses or croton oil ( TT\ii) for one dose, but 
 pomegranate and male fern produce the best results. Search should 
 the made for the head of the parasite, without removal of which 
 treatment is unsuccessful. If it is not found another trial should be 
 made after a number of days. 
 
 ]£ Oleoresinae aspidii : 
 
 Tr. vanillae aa gtt. xlv. 
 
 Acacias 
 
 Sacchari albi aa 3i: 
 
 Aquae 
 M. et ft. emulsum. 
 S. — Take in one dose. 
 
 Symptoms of the cysticercus cellulosa? (somatic tseniasis). These 
 result when ova of the taenia solium are taken into the stomach ; ova 
 may reach the stomach from the intestines by antiperistaltic move- 
 ments during vomiting or indirectly by handling worms voided from 
 the bowels. Cysticerci in the hog produce few symptoms. In man, 
 symptoms depend largely on the number and localization of the 
 
1194 
 
 DISEASES DUE TO ANIMAL PAEASITES. 
 
 larvae, (a) In the muscles and skin, a few cysticerci cause, no symp- 
 toms; numerous cysticerci cause pain, tenderness and difficult move- 
 ment. Diagnosis is possible only on excision of the subcutaneous 
 nodules. In Stiles' collection of 155 cases the localization was muscu- 
 lar in 20 per cent, and cutaneous in 3 per cent, (b) If they are in 
 the brain (in 75 per cent, of Stiles' series) symptoms depend on their 
 location ; they are often absent : if the location is in the cortex, Jack- 
 sonian epilepsy is frequent, and if in the medulla, diabetes may 
 develop, (c) Other localizations. They may be found clinically in 
 the eye (v. Graefe) and at autopsy in the lungs, kidneys or liver. 
 There is no treatment except surgery. 
 
 II. Taenia Saginata ( Medio canellata). — This form (Goeze, 1782) 
 is the most frequent of large tapeworms in America and Europe. 
 
 Fig. 85. 
 
 Fig. 84. 
 
 Head of Tcenia sagi- 
 nata. (Eichhorst.) 
 
 Tcpnia saginata: natural size. 
 (After Leuckart.) 
 
DISEASES CAUSED BY CE ST ODES. 1195 
 
 It is the " fat tapeworm/ 7 the " unarmed " or beef tapeworm. Its 
 cysticercus bovis is found in masseters of beef nearly seven times as 
 frequently as in other muscles or in the heart or train. They are 
 not so readily seen with the naked eye as the cysticerci in pork. 
 Ingestion of rare beef containing cysticerci produces the taenia sagi- 
 nata in man, in whom alone the adult worm is found. 
 
 The intestinal parasite differs from the T. solium in the following 
 points: (a) its head is larger, measuring 2 mm. and is square. It 
 has no hooklets but four sucking disks, which are larger, more forward 
 and are surrounded by pigment. (See figs. 82, 83, 84 and 85.) 
 (b) Its neck is much shorter, (c) Its proglottides are longer (16 
 to 22 mm.) and broader (5 to 10 mm.) ; even 1,000 segments have 
 been found, (d) The uterus contains 15 to 35 branches, which are 
 less dendritic than pronged or forked; in diagnosis the uterus is 
 more important than the ova or size of the segments, which are hard 
 for the practitioner to distinguish (Stiles), (e) The ova measure 30- 
 40 by 20-30/x. (/) The parasite is larger and longer, measuring 4 
 to 10 meters. Its symptoms and treatment are those of the taenia 
 solium. Ingestion of the ova or segments from human faeces produces 
 the cysticercus mediocanellata, which is common in beef but ex- 
 tremely rare in man. 
 
 III. Other Taeniae Occurring In Man. — The Dibothriocephalus latus 
 (Linnaeus, 1782), or the Russian tapeworm, is found chiefly in Rus- 
 sia, Poland, Norway, Sweden, Switzerland and Japan. It is rarely 
 found in this country unless imported (30 cases reported, Stiles). 
 Its cysticerci are found in the muscles and peritoneum of the pike, 
 trout, salmon and perch and in man's intestines develop into the 
 dibothriocephalus. Its head is flat or ovoid, possesses no hooklets and 
 attaches itself to the intestines by two lateral grooves (suckers). 
 Its neck is long and its segments broad, square and may number 
 3,000 to 4,200. It is long, measuring 8 to 10 yards. It may produce 
 a profound anaemia which in severe cases closely resembles the per- 
 nicious type in its general symptoms and blood findings. (See figs. 
 83, 86.) 
 
 The Tcenia elliptica or cucumerina (Dipylidium caninum) is a 
 form, the larvae of which develop in the lice of dogs and the adult 
 form exists in the intestines of dogs, sometimes in those of cats and 
 rarely in man. (See fig. 87.) 
 
 The Tcenia nana (Hymenolepsis nana) is the dwarf tapeworm. 
 It measures but % to 2 inches in length. Its cysticercus stage is in 
 the intestinal wall of the rat and its adult stage in the rat's intestine. 
 Stiles decided that it is much more frequent in man than previous 
 accounts would indicate and in some places is the most common type. 
 Its head contains four suckers and one row of hooklets. It may occur 
 singly or in myriads. Aspidium alone is of therapeutic benefit. (See 
 figs. 88 and 89.) 
 
 Taenia Echinococcus (Echinococcus Disease) (Zeder, 1803). — We may 
 first consider the adult parasite as inhabiting the intestine of the dog 
 
1196 
 
 DISEASES DUE TO ANIMAL PABAS1TES. 
 
 chiefly and rarely of the wolf, fox or jackal. The head is small and 
 is provided with fonr suckers, and from 30 to 50 hooklets arranged 
 in a double row. The segments number only three or four, and only 
 
 Fig. 86. 
 
 Fig. 88. 
 
 Proglottis of Dir 
 bothriocephalus la- 
 tus: natural size, 
 and enlarged three 
 times. (After Eich- 
 horst.) 
 
 Fig. 81 
 
 Twnia cucumer- 
 ina: natural size. 
 (After Lcuckart.) 
 
 Fig. 89. 
 
 Ova of Hymenolepsis nana. 
 (Smith.) 
 
 Hymenolepsis nana: x 12 
 (After Leuckart.) 
 
 the end one matures; it measures but 0.6 by 2 mm. but contains even 
 5,000 ova. The worm is small, measuring but four to five mm. in 
 length, is very delicate and white, so that it readily escapes detection. 
 When the ovum reaches the stomach of another animal, the hog and 
 
DISEASES CAUSED BY CE ST ODES. 
 
 1197 
 
 ox chiefly, and less often the horse, sheep or man, it loses its shell and 
 migrates to the various organs (v. Symptoms). The geography of 
 echinococcus disease and mode of infection is as follows : In Iceland, 
 where dogs and men live together, the disease in man is common, 
 every seventh person becoming infected. In Australia both men and 
 sheep are often infected. In Europe the malady is much more com- 
 mon than in America, where the reported cases in 1901 numbered 241 
 (Lyon) ; most of these were foreigners. The Icelanders brought the 
 disease to Manitoba in 1874. 
 
 Infection occurs by licking of the hands by the dog, the tongue and 
 anus of which often come in contact. Infection by contaminated 
 drinking water or vegetables is less common. 
 
 General Symptoms and Pathology. — The small embryo, freed of its 
 shell, penetrates the intestinal wall and wanders in various directions, 
 into the muscles or peritoneum or into the radicles of the portal vein 
 or cava, so that almost any tissue or organ may be infected, and the 
 embryo merely stops when it reaches vessels too small for it. Once 
 lodged, its hooklets. disappear and a cyst develops, which is small at 
 first but gradually reaches large or enormous proportions; there are 
 records of cysts containing 30 and 70 pints of fluid. Its layers consist 
 of an inner endocyst which is granular and an outer finely lamellated 
 structureless capsule; a fibrous layer develops outside from reaction 
 of the tissues to the foreign body. After a while a number of 
 " daughter " cysts arise from the endocyst ; these are first " buds " 
 
 Human echinococci. (From Finlayson, after Davaine.) 
 
 A, a group of echinococci, still adhering to the germinal membrane by their pedicles. 
 
 x40. 
 
 B, an echinococcus with head invaginated in the body, x 107. 
 
 C, the same compressed, showing the suckers and hooks of the retracted head. 
 
 D, echinococcus with head protruded. 
 
 E, crown of hooks, showing the two circles, x 350. 
 
 and then miniatures of the original mother cyst ; from these daughter 
 cysts, which number about a dozen, " granddaughter " cysts arise by 
 an identical process. Allen in one case found 8,000 daughter cysts. 
 Finally from the endocyst of the maternal and daughter cysts there 
 develop " brood capsules," in which small buds arise, which gradually 
 
1198 DISEASES DUE TO ANIMAL PARASITES. 
 
 become scolices (the heads of which will be intestinal taeniae in the 
 animal which ingests them). Some cysts do not develop scolices and 
 are therefore called sterile. In animals the daughter cysts may grow 
 outward (exogenous cysts). The well-grown cyst contains fluid (v. 
 Liver and Lung Echinococcus) ; it is clear and neutral, has a 
 specific gravity of 1005-10-15 and contains succinic acid, inosite 
 (possibly sugar) and much sodium chloride but no albumin, unless 
 the parasite dies and' cystic inflammation develops. Then the fluid 
 may become cloudy, buttery, gelatinous, purulent, brownish or grum- 
 ous ; the cysts disappear as well as the membrane, though the booklets 
 of the scolices remain a long time. When the parasites are alive a 
 
 Fig. 91. 
 
 tiff 
 
 i 
 
 
 
 Hooks from Taenia echinococcus. x 350. (Corti.) 
 
 toxin seems to be present, for collapse often develops when the cyst 
 ruptures or is punctured (see Lung Echinococcus). 
 
 The parasite is said to live for years, in one instance it survived for 
 20 years; after a variable time, unless suppuration intervenes, the 
 cysts become cheesy and perhaps calcified or ossified. 
 
 The parasite may rupture into the serous sacs, bloodvessels (caus- 
 ing embolism), into the air passages, urinary tracts or externally 
 (see Echinococcus of the Lung, Liver and Kidney) ; in 50 per 
 cent, it is fatal within five years. 
 
 Visceral Localization. — In 1,912 cases (the total reported by Da- 
 vaine, Einsen, Mosler, Neisser and Cobbold) the liver was involved in 
 51 per cent., the genito-urinary organs in 10 per cent., the intestinal 
 canal in 9 per cent., the lungs or pleura in 9 per cent., the braiu or 
 cord in 7 per cent., the bones in 3 per cent., the heart and vessels in 
 3 per cent., and other organs in 8 per cent. Vegas and Cranwell 
 (1902) reported 970 Argentine cases of which 64 per cent, occurred 
 in the liver and 7 per cent, in the lungs. In statistics from single ob- 
 servers, the percentage of cases with localization in the liver often runs 
 higher (69 to 72 per cent.). Thomas, in 809 Australian cases of 
 single hydatid cyst, found the lungs involved in 16.5 per cent. Hook- 
 lets have been obtained by lumbar puncture (Jacobs). There are 
 reported 142 cases of renal echinococcus, 78 cases with localization 
 in the bones and 23 in the pelvic bones (Baradulin, 1906). Grulee 
 in 1905 found 55 cases with cardiac or pericardial localization 
 
DISEASES CAUSED BY NEMATODES. 1199 
 
 Echinococcus cyst of the thyroid has been reported 23 times (Ehr- 
 hart, 1905). 
 
 There is an unusual form of echinococcus, the multilocular form, 
 probably due to a separate worm, the clinical features of which are 
 described under hydatid disease of the liver, to which it is almost 
 exclusively confined. Yirchow first described it in 1856. It occurs 
 in Bavaria, Wiirtemburg, Switzerland, Austria, Austrian Tyrol and 
 Russia. Few imported cases have occurred in America. It is un- 
 known where the ordinary form is most common. It is rare, few 
 more than 100 cases being recorded. Sixty per cent, occur in males 
 between 20 and 50 years of age. The ova are spheroidal and measure 
 100 to 170 micro-millimeters. The great difference from the ordi- 
 nary form is the outward (exogenous) growth of the cysts. The 
 irregular and diffuse cystic proliferation is an unfavorable feature. 
 The cysts contain a gelatinous material (which sometimes causes 
 confusion with colloid cancer), surrounded by intersecting fibrous 
 strands, which gives the liver a porous appearance, like a sponge or 
 cheese with air cavities. In some vesicles there is cheesy material, 
 with some resemblance to the granulomata. The vesicles sometimes 
 suppurate. 
 
 Echinococcus cysts which cause symptoms belong largely to sur- 
 gery, though, as described elsewhere, spontaneous recovery is not 
 infrequent. 
 
 DISEASES CAUSED BY NEMATODES. 
 
 I. The Ascaris Lumbricoides. — This is the most common intestinal 
 parasite in man. It was described by Linnaeus, 1758. It occurs 
 oftenest in children and with relative frequency in the insane. Un- 
 like the cestodes, no intermediate host is required. The female meas- 
 ures 7 to 12 and the male 4 to 8 inches in length ; it is smooth, pointed 
 at both ends and has transverse rings and four longitudinal ridges, a 
 white one dorsally and ventrally and two brownish ones laterally. 
 (See fig. 92.) The ova measure 0.075x0.058 mm., are oval and 
 reddish and have a thick capsule. It is said that 60,000,000 eggs 
 may develop in a single female. It lives in the upper small intestine ; 
 its mode of infection is obscure. Though they usually occur singly 
 or in pairs, they may exceptionally develop in such numbers that by 
 intertwining, they may obstruct the intestine. The ascaris may 
 rarely rupture through an intestinal ulcer or perforate the sound gut. 
 It has passed through a perforated appendix. With or without vomit- 
 ing, ascarides may pass from the stomach into the oesophagus, nose, 
 bronchi, lungs or middle ear, causing asphyxia, gangrene of the lung, 
 etc. They may migrate into the common or hepatic duct. 
 
 Symptoms are not usually pronounced, though anorexia, salivation, 
 offensive breath, constipation, colic and diarrhoea occur in some cases. 
 Malnutrition is sometimes marked. The parasite secretes an irri- 
 tating substance which is often noted to emanate from it. It is 
 suggested that this secretion, if absorbed, may cause constitutional 
 svmptoms (Peiper), 
 
1200 
 
 DISEASES DUE TO ANIMAL PABASITES. 
 
 Such manifestations as irritability, grinding the teeth, muscular 
 twitchings and convulsions may develop in nervous children; they 
 are said even to resemble meningitis. The author always doubted 
 
 the existence of the typholumbricosis of 
 Chaffard, Marie and Tauchon, until in 
 one adult case, in which there were fever 
 and nervous toxaemia, with otherwise nega- 
 tive iindings, instantaneous subsidence of 
 all symptoms occurred when the parasites 
 were removed; this strongly suggested a 
 relation between the fever and other 
 symptoms and the lumbricosis. 
 
 Treatment — After a fast of one-half to 
 one day, santonin should be given in doses 
 of gr. ss-j, for a child, and gr. ij, iij or 
 v, for an adult; it should be followed by 
 a saline cathartic; if unsuccessful it may 
 be repeated on two or three successive 
 days, though toxic symptoms sometimes 
 develop, as xanthopsia (yellow vision), 
 urticaria (which may result from the para- 
 site itself), vomiting or convulsions. The 
 fluidextractum spigelice (3j) may be given 
 with or without the santonin or calomeL 
 These remedies do not kill the parasite, 
 but merely render it uncomfortable. 
 
 II. Oxyuris Vermicularis (Seat Worm, 
 Pin or Thread Worm). — Children are 
 more often affected than adults, and 
 women more often than men. They are 
 relatively frequent in the insane. The 
 female in length measures 10 and the male 
 4 mm. (See figs. 93, 94 and 95.) Ingested 
 ova develop in the small intestine, where 
 the worms mature and cohabit; afterward 
 they exist chiefly in the lower colon and 
 rectum. The eggs remain in the mother 
 until the worm is expelled, though she 
 occasionally " aborts" in the bowel. In- 
 fection occurs in those who are the most 
 uncleanly, as in children and the insane. 
 Infection may occur from water and green 
 vegetables, and reinfection is not uncom- 
 mon from scratching the anus during sleep 
 and thus crushing the parasite ; Eichhorst 
 frequently found ova in the minute faecal 
 particles about the anus and Zenker demonstrated repeatedly their 
 presence under the finger nails. As the parasites migrate at night ? 
 
 Ascaris lumbricoides , dis- 
 sected and walls thrown back ; 
 a, genital orifice ; b, intestine ; 
 c, oviducts ; d, longitudinal 
 band; e } ovaries. (Heller.) 
 
DISEASES CAUSED BY NEMATODES. 
 
 1201 
 
 the symptoms are greatest at that time ; they may be found on the bed 
 sheet. The anal itching and rectal irritation are often excessive; 
 periproctal suppuration may be excited. If any vaginal discharge 
 moistens the perineum (and only then) they can wander into the 
 
 Fig. 93. 
 
 Fig. 94. 
 
 Eggs of Oxyuris ver- 
 micularis: x 275. (After 
 Eichhorst.) 
 
 Fig. 95. 
 
 Oxyuris vermicularis, mag- 
 nified : a, young female ; b, 
 male ; c, mature female, full 
 of eggs. (Payne.) 
 
 Oxyuris vermicularis: na- 
 tural size. (Eichhorst.) 
 
 vagina, causing irritation, sexual stimulation or masturbation. Dis- 
 turbance of the sleep and appetite, nervous symptoms and ansemia 
 may result. Diarrhoea is due to large numbers of parasites. 
 
 Treatment.- — Santonin may be given in obstinate cases, but local 
 measures are usually sufficient, as high enemata containing small 
 proportions of carbolic acid, quassia and turpentine. They should 
 be repeated daily for two weeks. Itching is palliated by application 
 of V2 per cent, carbolic salve to or within the anus. 
 
 III. Trichina (Trichinella) Spiralis; Trichinosis. — Though Tiede- 
 mann (1822), Hilton (1832) and Paget (1835) saw the parasite, 
 Owen (1835) first fully described it. Leidy saw it in the hog in 
 1847. Zenker (1855—60) first described its pathological and clinical 
 bearings; he found 4 cases in 136 autopsies. 
 76 
 
1202 DISEASES DUE 10 ANIMAL T ABASHES. 
 
 Swine are infected in a manner which is not wholly clear, but in- 
 fection most probably results from eating offal. The disease is rare 
 in some countries, as France, and more common in others, as Ger- 
 many. The hog is more frequently diseased in America than in 
 Germany (a ratio of 1 to 17 (or 48) in the former and but 1 to 
 18.000 in the latter). From the clinical and etiological standpoint, 
 the (a) muscular or larval stage in hogs should be considered first. 
 The small encapsulated, "hair-like" (trichina) worm lies in the 
 abdominal, diaphragmatic, psoas, laryngeal and other muscles. They 
 live for a long while, even twenty to twenty-five years, without ap- 
 parently causing any symptoms ; calcification rarely occurs in swine. 
 Man is infected by eating smoked, "'cured''' or insufficiently cooked 
 pork ; animals may be accidentally or experimentally inoculated, espe- 
 cially the rat, guinea-pig, rabbit, less often the cat and rarely the dog. 
 In much of the literature relating to its alleged presence in fish or 
 worms, the trichina has been confused with other parasites, (b) 
 The adult or intestinal stage in man is the next phase. When it is 
 eaten by man, the small capsules (larval form in swine) are digested 
 and the worms liberated ; in the small intestine they mature (the 
 females measure 3 to 1 mm., and the males are half as long) and the 
 females are fecundated in two to three days. The female trichinae 
 produce one to two thousand embryos at once or possibly in succes- 
 sion, which stage requires another week (from fecundation of the 
 female to birth of the embryos). At the end of the second week the 
 embryos commence to migrate ; they enter the lymph vessels and then 
 the veins, by which they reach the voluntary muscles ; some writers, 
 as Graham, maintain that there is a primary direct entrance into the 
 venous system. They lodge between the muscle fibers, enter them 
 and attain (c) the mature larval form, which is identical with the 
 larval stage (a) in hogs, and differing only in that man is their 
 host. They measure 0.5 to 1 mm. in length. As a result of tissue reac- 
 tion against the foreign bodies, a capsule develops in about six weeks. 
 which surrounds one or more parasites. The capsules are at first 
 transparent, but grow more opaque and. after months, calcify and 
 later the trichina? calcify also. 
 
 Frequency. — Though trichina? are apparently about 40 times as 
 frequent in American as in German swine, the disease is more com- 
 mon in Xorth Germany where raw sausage. Westphalian ham and 
 smoked ham are freely eaten. Trankel denies that German trichi- 
 nosis results from American pork. Williams of Buffalo, in 505 au- 
 topsies, found trichinosis in 5 per cent. lEliller of Dresden found it 
 in 0.98 per cent, of 1.939 postmortem examinations. Other statistics 
 usually show lower figures than ILiillers. and like the above, are 
 taken from accidental postmortem findings. The disease occurs 
 sporadically or epidemically. Perhaps a "thousand cases have oc- 
 curred in America. In Germany the epidemic at Hedersleben num- 
 bered 337. and that at Emmersleben 250 cases. 
 
 Symptoms. — Symptoms may be absent or slight, particularly in 
 
DISEASES CAUSED BY NEMATODES. 1203 
 
 sporadic cases, and with moderately severe infection, as evidenced by 
 accidental autopsy finding of encapsulated parasites. 
 
 In clear cases the symptoms are divisible into two stages; (a) the 
 preliminary or g astro-intestinal stage, which begins in two to three 
 days after eating the diseased meat ; the symptoms are not constant 
 either in sporadic or severe epidemic cases ; they are anorexia, nausea, 
 vomiting, colic and sometimes diarrhoea, which may resemble the 
 evacuations of cholera, (b) The invasion symptoms begin in one or 
 two weeks and correspond to the parasitic migration, (i) Fever is 
 usual, but its onset seldom begins with rigors. It results from the 
 parasites and probably from some toxin which they elaborate ; it may 
 rise to 102, 104 or 106° and its course is remittent and intermittent. 
 Symptoms attendant on any fever may be present, as headache, 
 febrile urine or quickened pulse. In severe cases, as in Zenker's, 
 typhoid may be suggested by delirium, epistaxis, dry tongue, status 
 typhosus, diazo reaction (in 80 per cent.), bronchitis, albuminuria 
 and kindred toxsemic symptoms. In two cases typhoid and trichinosis 
 co-existed (McCrae). (ii) Acute diffuse myositis is always most sug- 
 gestive. Its intensity varies from mild forms of " muscular rheuma- 
 tism " to the most severe and characteristic involvement ; there are 
 pain, tenderness, swelling, flexion to relieve muscular tension, and 
 oedema in the face and other locations. The worms most curiously 
 select only the striated muscles, so that the oedema observed in the 
 abdomen and thighs, for example, never invades the scrotum or 
 vulva. The eyelids are often affected greatly and early. Invasion 
 of the eye muscles causes pain on moving the eyes ; pain during masti- 
 cation, phonation and deglutition mark penetration of the masseteric, 
 laryngeal and pharyngeal muscles by the parasite; dyspnoea results 
 from involvement of the diaphragm and intercostal muscles. The 
 tendon reflexes may disappear, (c) The blood presents two striking 
 features: first, the leukocytosis (15,000 to 30,000) and second, the 
 eosinophilia (T. R. Brown) ; the eosinophiles, normally 0.3 to 4 per 
 cent, of the leukocytes, rise as high as 50 or 68 per cent, and though 
 they increase in the other parasitic diseases, this rise is most peculiar 
 if not absolutely pathognomonic. The eosinophilia is greatest at the 
 time when the trichinae enter the muscles. (See Plate XVI, Fig. 5.) 
 On the 24th day a second oedema appears, (d) Profuse sweats, poly- 
 uria, paresthesia, urticaria and anaemia are inconstant manifestations. 
 
 Diagnosis. — This is based on (a) the possibility of infection, as by 
 eating poorly cooked pork, (&) the discovery of trichinae in the un- 
 eaten portions of suspected meat, (c) the detection by removal of 
 small slivers of the biceps or pectorals for microscopic examination, 
 especially the parts near the muscular insertion, (d) the myositis 
 with oedema, (e) signs of insufficiency, e. g., in the ocular or dia- 
 phragmatic muscles and (/) leukocytosis with eosinophilia. 
 
 Prognosis. — This depends on the number of parasites ingested. 
 Choleraic and typhoidal symptoms, dyspnoea and pneumonia are 
 most ominous. In moderately severe early diarrhoea it is favorable. 
 
1204 
 
 DISEASES DUE TO ANIMAL PARASITES. 
 
 Fig. 96. 
 
 'I 
 
 Children die less often than adults. Convalescence is prompt or 
 tardy as the infection is light or severe. According to Stiles, the 
 German mortality averages 5.6 per cent. In the epidemic at Weimar 
 there were no fatalities in 108 cases. In the epidemic at Hedersleben 
 30 per cent. died. Epidemics have occurred where the mortality 
 was as high as 70 to 100 per cent. 
 
 Treatment. — (a) Prevention comprises the feeding of hogs with 
 clean food, government inspection of meat, and thorough cooking. 
 (b) In the preliminary stage } active and repeated purgation should 
 be given, for moderate and early spontaneous diarrhoea is prog- 
 nostically favorable; calomel should be followed by salts and castor 
 oil; male fern, santonin (v. s.), thymol gr. v, t. i. 
 d., benzene Tllij to v, t. i. d. and oil of turpentine 
 1T[v to x are recommended; glycerine is now dis- 
 carded, (c) In the stage of muscular invasion, 
 the fever is treated as in other infections, the myo- 
 sitis by local applications of ice and by narcotics, 
 and the general nutrition by food and stimulants. 
 IV. Ankylostoma (Unciiiaria). — The uncinaria 
 duodenalis (ankylostoma duodenale) exists in two 
 forms, that of the old and that of the new world. 
 Ankylostomiasis was first well described by Piso 
 (1648) in Brazil and the parasite was recognized 
 in Milan by Dubini (1838). It occurs chiefly in 
 the tropics and sub-tropics ; according to Thornton, 
 it is the most dangerous of all tropical diseases. 
 In Egyptian chlorosis it was found by Griesinger, 
 and is said to be present in nearly every autopsy 
 made there. It is epidemic in Italy (" bricklayers' 
 anaemia"). In India it is found in even 80 per 
 cent, of the healthy coolies and in 300 autopsies in 
 Assam it was present 299 times. Stiles (1902) 
 described the new-world type, caused by the Unci- 
 naria (or Necator) Americana. Thirty per cent, 
 of Porto Rican deaths result from uncinariasis, and 
 Ashford and King state that 90 per cent, of the 
 rural and 50 per cent, of the urban population 
 have the disease; during six months in 1905, 
 18,865 cases were treated in Porto Rico, of which 
 33 per cent. died. It prevails in our southern 
 states. Capps in 1903 reported one case of the 
 European type and collected 50 other American 
 cases. More than twenty years ago, Belfield 
 recognized the parasite in cats. 
 
 In the Westphalian mines, Tenholt himself treated over 4,000 
 cases. It was the cause of the "tunnel anaemia," which was observed 
 in building the St. Gothard tunnel. It is disseminated by Italian 
 and Polish workmen. Infection occurs from ingestion of the larvae 
 
 ' 
 
 
 Uncinaria duodenalis 
 magnified : a, fe- 
 male ; o, male. 
 (Bristow.) 
 
DISEASES CAUSED BY NEMATODES. 
 
 1205 
 
 and not of the ova. Infection conies from the food, drinking water 
 and earth which are infected by dejections from persons suffering 
 from the disease. Loos has proven that it may enter by the skin, 
 producing the " ground itch " which is common in the Southern 
 States. The exact role of the uncinaria in clay-eaters is not yet 
 
 Fig. 97. 
 
 =^^ 
 
 Above : to the left, three ova of Uncinaria Americana in different stages of segmen- 
 tation, from 66m- to 68m in long diameter; to the right, three ova of Uncinaria 
 Americana in varying stages of segmentation, long diameter from 58 « to 62 m. 
 
 Middle: to the left, the head of Uncinaria Americana (dorsal view), exhibiting the 
 smaller size of the head and more tapering anterior extremity of the worm in com- 
 parison with U. duodenalis, and its buccal armature consisting of lips : to the right, 
 the head of Uncinaria duodenalis (dorsal view), drawn to same scale, showing its 
 greater size and the hook armature of the buccal border. 
 
 Below: to the left the caudal border of male Uncinaria Americana (dorsal view, 
 dorsal lobe of bursa thrown forward), showing comparative size of the worm in rela- 
 tion to that of 77. duodenalis, partly divided dorsal lobe and suggestion of a ventral lobe, 
 the dorsal ray divided nearly to base, each of its divisions having a bipartite tip, show- 
 ing also the tip of tail within bursa, the long barbed sexual spicules, and the arrange- 
 ment of the rays of the bursa : to the right, caudal bursa of male 77. duodenalis, show- 
 ing larger size of bursa, entire dorsal lobe, absence of ventral lobe, division of dorsal 
 ray limited to distal third and tripartite tips of each division, with other features 
 in general similar to 77. Americana. (Smith.) 
 
1206 
 
 DISEASES DUE TO ANIMAL PARASITES. 
 
 determined; the parasite certainly exists in some cases, though it is 
 claimed that the dirt eaters instinctively eat clay to remove the para- 
 site. The male is 8 to 10 and the female 10 to 18 mm. in length; 
 the mouth has hooks by which it adheres to the mucosa of the duo- 
 denum. (See figs. 96, 97 and 98.) The ova measure 30 to 60 
 
 Fig. 98. 
 
 Uncinaria duodenalis, with eggs. (After Blickhan.) 
 
 micromillimeters ; they are oval, are covered with a translucent shell 
 and differ from the flat oxyuris ova. They show 1 to 6 yolk segments 
 and may number over four millions. The larvae develop in moist 
 earth, whence they infect the water or the fingers or enter through 
 the skin. 
 
 Symptoms. — Symptoms may be absent or of a mildly dyspeptic 
 character. In pronounced infections (a) an ancemia develops which 
 is first of the secondary type and later of the progressive pernicious 
 type ; anaemia results not only from sucking of blood by parasites, 
 but from haemolysis due to some toxin which they elaborate (in their 
 salivary glands) ; normoblasts are much more common than megalo- 
 blasts. Poikilocytosis is less marked than in the usual pernicious 
 type, and the eosinophiles are increased, and sometimes reach 30 
 per cent, of the total number of leukocytes. (b) Gastrointestinal 
 symptoms are usual, as ink-like patches on the tongue, diarrhoea and 
 colic; epigastric pain and tenderness are the most constant and sug- 
 gestive symptoms. In Herri ck's Panama case (reported by Capps) 
 which the author saw in the County Hospital, there was great nausea, 
 pain and exquisite abdominal tenderness ; the stools contained blood, 
 eosinophile cells, Charcot-Leyden crystals and ova. Stiles suggests a 
 ready test for blood, by which parts of the stool are placed upon blot- 
 ting paper ; after an hour or so a rusty stain develops about the stool. 
 Gastro-intestinal catarrh and small ecchymoses are found at autopsy. 
 (c) Nutrition suffers; as in pernicious anaemia, oedema develops. 
 Clay-eaters are emaciated and apathetic; debility is frequent. In 
 young children puberty is retarded; development is poor and the 
 abdomen is greatly distended. Cardiac atrophy and dilatation are 
 common. The prognosis is grave, though less serious in the new 
 world than in the old world type. 
 
 Treatment. — 1. Prevention — Drinking water should be boiled and 
 the hands should be cleansed before eating. The stools should be 
 received in water-tight closets and disinfected ; careless defecation in 
 mines has caused wide dissemination of the disease. Mines should 
 be disinfected with the milk of lime. 
 
DISEASES CAUSED BY NEMATODES. 1207 
 
 2. Medication. — Thymol is the most efficacious remedy. After a 
 light diet, 3ss should be given, and this should be repeated in two 
 hours and followed by a saline purge two hours afterward. As 
 toxic symptoms (nervous excitation or smoky urine) may develop, no 
 solvents of thymol should be given, as alcohol, chloroform, ether or 
 castor oil. This treatment should be repeated once a week, as long 
 as ova or Charcot-Leyden crystals appear in the stools. The most 
 severe cases do not respond to any treatment. Male fern is considered 
 the best remedy by Tenholt and other Westphalian writers. 
 
 V. Filaria. — Demarquai (1863) first found the embryos of the 
 filaria; Wucherer (1866) found them in the urine and Lewis (1872) 
 in the blood. 
 
 1. Filaria Nocturna. — Its distribution is largely tropical and sub- 
 tropical. It occurs in 30 per cent, of the inhabitants of the Samoan 
 and Friendly Islands. In the United States it has been found in the 
 South and also in New York, Illinois and Pennsylvania, (a) In- 
 fection of man occurs by mosquito bites or possibly by water which 
 the mosquito contaminates with its eggs. In the mosquito, the em- 
 bryos change to the young adult form, (b) The next stage is the 
 presence of adult filaria in the lymph channels, where they cause 
 lymph stasis and lymphangitis. The female filaria measures 155 x 
 0.7 mm. and the male 83x0.4 mm. (c) The embryos enter the 
 blood current from their birth place, the lymph channels ; they are 
 very numerous, measure Vs inch in length and have the same diameter 
 as a red blood cell. Under a low-power lens their active movements 
 are easily seen. They appear in the blood only at night, usually near 
 midnight, and during the day retire to internal organs, as the lungs, 
 but if the patient sleeps by day, they appear in the day time only. 
 
 Symptoms are absent in the majority of cases of human and animal 
 infection and are due to the parent worm, not to the embryos, (a) 
 Chyluria or hsematochyluria is due to plugging by the worm of the 
 lymphatic vessels in the peritoneum, pelvis, vesical and perirenal 
 tissues. Lymph stasis, ectasia and lymphangitis result, with inter- 
 mittent rupture into some part of the urinary tract, and the passage 
 of milky, chylous urine, containing molecular albumin and fat. The 
 amount of the urine varies ; it may be normal or increased. There is 
 usually also some blood. If the blood clots, vesical disturbance re- 
 sults. The embryos are often found in the blood and sometimes in 
 the urine; there is also a non-filarial chyluria (page 774). The 
 affection may last for years without impairment of health. The very 
 rare rupture into the peritoneum causes chylous ascites, (b) The 
 lymph scrotum is due to lymphatic obstruction by the adult worm. 
 The scrotum may weigh 50 to 200 pounds. Rupture into the tunica 
 vaginalis causes chylocele. The labia may be similarly involved. 
 The embryos are often missing from the blood, being apparently con- 
 fined to the local involvement by the lymphangitic thickening, whence 
 the difficulty in stating the relative percentage of parasitic and non- 
 parasitic cases of lymph scrotum and elephantiasis, (c) Elephantia- 
 
1208 DISEASES DEE TO ANIMAL PAEASIIES. 
 
 sis usually develops in the legs, scrotum and labia, less often in the 
 arms, breasts or trunk. In forms (b) and (c) there occur intermit- 
 tent exacerbations with fever and nervous disturbance, which end 
 with critical sweats. 
 
 2. Other Forms of Filaria. — The exact status of the filar ia diurna is 
 not known; f. perstans. which causes pustular eruptions (craw-craw) ; 
 f. loa (the adult stage of filaria perstans) which inhabits the conjunc- 
 tiva : f. Idbialis; and f. oris and broncliialis are other forms. 
 
 Treatment. — (a) For. prevention, mosquito bites and infected water 
 should be avoided. (&) Xo parasiticide is known, (c) Cliyluria is 
 treated expectantly ; a dry and fat-free diet is recommended but it is 
 difficult to understand how it can influence lymph stasis, (d) Lymph 
 scrotum and elephantiasis may necessitate castration, amputation or 
 less radical measures to eradicate the obstructing parasite. 
 
 VI. Dracunculus (Filaria) Medinensis.— This is found on the 
 TVest African coast, the Gold Coast, in Abyssinia and South Egypt ; 
 on the Caspian Sea and Persian Gulf; in the East Indies, parts of 
 India and South America. Guinea-worm disease (drachontiasis) 
 developed in a person who had always lived in Philadelphia. Man is 
 infected by a small water flea (cy clops) which contaminates the water 
 with the larvae (embryos). These embryos, measuring 0.6 mm., 
 enter the stomach, bowel and probably the mesentery, where they 
 copulate ; the male, of which little is known, is either discharged from 
 the bowel or dies in the mesentery. The female is cylindrical in form, 
 measures 50 to 80x2 mm., has a triangular mouth, eight papillae 
 and a blunt tail; its uterus occupies almost its entire length. The 
 female, which is usually solitary, wanders downward in the sub- 
 cutaneous and intermuscular tissues to the thighs, legs and in 66 
 per cent, of cases reaches the feet where, near its head, vesicles, ab- 
 scesses and ulcers develop. Its downward course occupies a year, 
 during which it may be felt subcutaneously. When the skin breaks 
 the parasite discharges her embryos and then leaves the body, to die. 
 
 Treatment. — Treatment by excision, or by 1 to 1.000 bichloride 
 injections, seems most rational. If the worm is ruptured in efforts 
 to extract it. high temperature, alarming nervous symptoms and sepsis 
 are said to result from migration of the embryos which are liberated 
 in the tissues. 
 
 VII. The Trichocephalus Dispar or Whip Worm.— This nematode 
 is found most often in southern Italy and France and but seldom in 
 this country; one case occurred in the Cook Countv Hospital. It is 
 also called trichuris trichura. It requires no intermediate host, enters 
 with the food and drink and is found in the esecnm and lar^e gat 
 The male is slightly shorter than the female, which is 4 to 5 & cm.' in 
 length. The anterior portion of the worm is thin ; the posterior two- 
 fifths is thick, in the male round and in the female pointed. It bores 
 into the mucosa and is nourished by the blood and not by the ali- 
 mentary contents. The eggs measure 0.05 mm., are oval and are 
 marked by a button-like projection. It causes few symptoms; occa- 
 
DISEASES CAUSED BY TEEMATODES. 1 209 
 
 sionally there is severe abdominal pain. Three fatal cases are re- 
 corded. Male fern and thymol internally and benzene oj to Oij of 
 water as an enema are recommended. (See figs. 99 and 100.) 
 
 VIII. The Strongyloides Intestinalis. — This includes a number of 
 nematodes, as the anguillula intestinalis or stercoralis, rhabdonema, 
 etc. They are found in the endemic diarrhoea which occurs in Cochin 
 
 Fig. 99. 
 
 Fig. 100. 
 
 Eggs of Trichuris tricJiura: x 275. TricJiuris trichura, male and female : natural 
 
 (After Eichhorst.) size. (Eichhorst.) 
 
 China. Strong reports cases from Manila and W. F. Thayer reported 
 the first case in America. A few parasites cause no symptoms. 
 Thymol is almost specific. 
 
 DISEASES CAUSED BY TREMATODES (DISTOMIASIS). 
 
 1. Bilharzia disease (endemic hematuria) is due to the blood 
 fluke (Schistosoma haematobium). Bilharz described the disease in 
 1851. It is an African and Japanese affection; it has prevailed for 
 many centuries in Egypt, where Bilharz considered that half of the 
 lower classes were affected. It is equally frequent in Uganda. Im- 
 portation has occurred into India, the Mediterranean Islands and 
 America. Only six cases have occurred in the United States (Gunn, 
 1906). 
 
 Children are more predisposed than adults to infection, which 
 occurs through the drinking water or possibly through the skin. The 
 embryos enter the stomach, penetrate the alimentary mucosa and 
 mature in the veins of the pelvis, spleen, mesentery, liver, kidney and 
 bladder. The male worm measures 4 to 15x0.6 mm., the female 
 15 to 20x0.3 mm. The male is rolled up like a leaf, forming a 
 groove in which the female lies during copulation. Many ova are 
 found in the urine ; they are oval, carry a spine and contain a ciliated 
 embryo. They die in the urine in a day but live for some time in 
 water, where their life history is still imperfectly understood. 
 
 Hematuria is the most common and often the only symptom ; it 
 may be macro- or microscopic and passes chiefly at the end of urina- 
 tion; examination shows many ova and eosinophiles. Cystitis 
 occurs in severe infection. Stones are not uncommon, particularly in 
 Canton, China. Suppuration may develop fistulse. These clinical 
 symptoms result from massive accumulation of ova in the submucosa, 
 
1210 DISEASES DUE TO ANIMAL PAEASITES. 
 
 which leads to papillomatous hyperplasia, hemorrhage, suppuration, 
 necrosis, salt deposits (calculi) and rarely to malignant degeneration. 
 Similar changes in the rectum cause pile-like papillomata, dysenteric 
 evacuations and tenesmus. As complications, pyelitis, prostatitis, 
 urinary fistulas and changes in the uterus, vagina, seminal vesicles 
 and renal pelvis, resembling those in the bladder, may develop. The 
 eosinophiles are increased to 10 to 50 per cent. 
 
 Treatment. — Change of climate is advisable to avoid infection. The 
 parasites usually die, though slowly, and as no local or systemic 
 remedies modify their life history, treatment must be expectant. 
 
 2. Lung flukes cause the endemic hcemoptysis which is observed 
 chiefly in North China, Corea, Japan, the Philippines and Formosa. 
 The parasite is named Distoma pulmonale (Paragonimus Wester- 
 mani) ; it measures 10 x 6 mm. and is found largely in the lungs, 
 but sometimes in the brain and skin. In young males dyspnoea, 
 anaemia, lung induration and a chronic cough develop with bloody or 
 prune-juice sputum, in which are found blood, dark brown ova, 
 eosinophile cells and Charcot-Leyden crystals. The hemorrhages, 
 which are sometimes profuse, result from small infarcts and cysts 
 of ova in the subpleural lung tissue. Epilepsy and hemiplegia may 
 result from brain embolism. The course is usually favorable, though 
 chronic, and is not influenced by treatment. 
 
 3. Liver flukes (Fasciola hepatica, Opisthorchis siensis and at 
 least four other species) enter like the above forms through contami- 
 nated water. The fluke is found in the upper small intestine and the 
 biliary or pancreatic duct. It is found in Japan and certain provinces 
 show a mortality of 20 to 72 per cent. (Balz and Inouye). The liver 
 is enlarged and tender; icterus results from biliary stasis, for the 
 parasites lie in the walls of the biliary ducts and gall-bladder ; diar- 
 rhoea develops, and the dejections contain ova and blood ; anaemia, 
 ascites, anasarca, adynamia and emaciation develop and death in- 
 variably results. There is no treatment beyond the symptomatic 
 support of the heart. Prophylaxis : avoidance of drinking or of swim- 
 ming in canal water, and thorough cooking of fish and mussels have 
 stamped out the plague in one Japanese province (Inouye). 
 
 DISEASES CAUSED BY PROTOZOA. 
 
 I. Malaria and Amoebic Dysentery (v. Acute Infections). 
 
 II. The Trypanosoma. — This is a protozoon found by Gruby 
 (1843) in frogs, Doflein (1845) in rats, and later in many other 
 animals and in man (Neprue, 1890-98). There are many species. 
 It is leech-shaped; its body is granular, measures 13 to 25, by 2 to 4/x 
 and contains a nucleus and micronucleus (centrosome) ; on one side 
 and attached to an " undulating membrane " is a solitary flagellum 
 by which the parasite moves. In cool and moist hanging-drop prepa- 
 rations they may live for a month and a half. Eovy and McNeal 
 cultivated the T. Lewis and Brucei on agar and defibrinated blood. 
 
DISEASES CAUSED BY PBOTOZOA. 1211 
 
 Infection is carried by the tsetse-fly, flea, louse, mosquito and ticks. 
 In man the two clinical forms (v. i.) of trypanosomiasis are conveyed 
 by the tsetse-fly (Glossina palpalis) or possibly by bites from in- 
 fected rats. Animals may be infected during coitus, by subcutaneous 
 inoculation or by the stomach. 
 
 1. Trypanosoma fever was first described by Nepreu. The atrium 
 may be present as an inflamed bite or the history of a bite may be 
 obtained. Parasites in the blood may cause no symptoms ; they occur 
 in the plasma and not in the corpuscles ; some ansemia is present and 
 the large lymphocytes are increased in number (up to 20 per cent.), 
 but the eosinophiles show no increase. Most parasites are found in 
 the lymph glands which are constantly enlarged. Fever is irregular, 
 subcontinuous or remittent, and lasts from three days to three weeks. 
 An erythematous eruption is almost constant. (Edema, particularly 
 of the lower lids, weak and rapid pulse, prostration, splenic tumor 
 and enlargement of the lymph glands which contain the parasite 
 usually occur. In treatment, arsenic and trypan red are apparently 
 most helpful, while quinine is without effect. Careful feeding 
 and cardiac stimulation are indicated. The patient, as is the 
 case in yellow fever, should be so screened that flies can neither con- 
 vey fresh infection to him nor bite him and thus infect others. 
 
 2. Sleeping sickness or African lethargy, which is endemic in Cen- 
 tral Africa, is due to localization of the same trypanosoma parasite 
 in the nervous system, causing a diffuse meningo-encephalomyelitis 
 (Mott). Negroes are chiefly affected but Caucasians may contract 
 the disease. 
 
 The incubation is long and may possibly cover years. Incipient 
 symptoms are those of the trypanosoma fever (v. s.) or less often 
 there are preliminary psychical phenomena, as epileptiform convul- 
 sions, melancholia or mania. Somnolence develops, from which at 
 first the patient can be aroused, but which later develops into pro- 
 found lethargy. The parasite is found in the blood in 92 per cent. 
 (Bruce) and in 60 per cent, of cases in the cerebrospinal fluid when 
 withdrawn by lumbar puncture (Castellani), or in 100 per cent. 
 (Bruce). Malnutrition, decubitus and sometimes secondary infec- 
 tions develop, and after the convulsions deepen into coma the patient 
 dies. The course lasts from months to several years. Treatment is 
 unavailing. More than a quarter of a million people died in Uganda 
 in the last few years from this affection. 
 
 III. Tropical Splenomegaly. — Kala Azar, Assam Fever or Dum- 
 dum Fever, endemic in the eastern hemisphere and India, is caused 
 by a protozoon and is characterized by fever, great splenomegaly and 
 emaciation, usually terminating fatally. 
 
 Etiology. — In 1903 Leischman described the parasite, found in the 
 blood, spleen, liver and bone-marrow. It is 2 to 4//. in diameter, oval 
 and contains two characteristic chromatin masses. It is not certain 
 whether the organism is a piroplasma, trypanosome or flagellate. 
 Eogers cultivated it and Patton found it in bedbugs. 
 
1212 DISEASES DUE TO ANIMAL PARASITES. 
 
 Symptoms. — The disease begins with fever, which is oftenest re- 
 mittent, rising two or three times daily ; it recurs. Marked emacia- 
 tion develops with abdominal tenderness, nervous toxaemia, neuritic 
 or arthralgic pains and various hemorrhages. The shin is dark, even 
 icteric, and pigmented. The spleen is greatly enlarged, tender and is 
 crowded with parasites. The liver becomes swollen and tender from 
 perihepatitis, is packed with parasites and frequently becomes cir- 
 rhotic. There is secondary ancemia; there is relative lymphocytosis, 
 usually with leucopoenia. The course averages 6 to 9 months and the 
 mortality is 96 per cent. 
 
 Diagnosis. — The blood findings are positive in 75 per cent, and the 
 parasites are found constantly and in all stages by splenic puncture 
 (which, however, may entail hemorrhage or rupture). 
 
 Therapy. — Quinine seems to reduce the mortality to 75 per cent. 
 
INDEX 
 
 Abdominal pain, causes of, 642 
 in pneumonia, 133 
 in typhoid fever, 30 
 Aboulia, hysterical, 1121 
 Abortion, in typhoid fever, 36 
 Abscess of brain. See Brain, abscess of 
 cold, 299 
 
 extradural, differentiation of, 972 
 of liver. See liver, abscess of 
 of lung. See lung, abscess of 
 perinephric, 780 
 subphrenic, 725 
 
 differentiation of, 539, 547 
 Acetanilide, 711 
 
 Acetphenetidin, 48, 53, 178, 470 
 Acetonuria, diabetic, 868 
 Achylia gastrica, 585, 618 
 etiology of, 585 
 pathology of, 585 
 prognosis of, 586 
 symptoms of, 585 
 treatment of, 586 
 Achlorhydria in gastric cancer, 608 
 " Acid fast " bacilli, 482, 291 
 Acidosis, diabetic, 868, 869, 870 
 Aconite, 90, 178, 470 
 Acoria, 622 
 Acrodynia, 200 
 Acromegaly, 859 
 course of, 861 
 diagnosis of, 861 
 differentiation of, 861 
 etiology of, 859 
 prognosis of, 861 
 symptoms of, 859 
 treatment of, 862 
 Acroparesthesia, 1169 
 Actinomycosis, 246 
 
 diagnosis of, 250 
 digestive tract, 249 
 etiology of, 247 
 forms of, 247 
 incubation in, 247 
 parapleuritis, 535 
 respiratory tract, 249 
 treatment of, 250 
 Acupuncture, 1118 
 Adams-Stokes syndrome, 372, 441 
 Addison's anaemia, 804 
 disease, 839 
 
 course of, 841 
 diagnosis of, 842 
 differentiation of, 842 
 etiology of, 839 
 symptoms of, 840 
 
 121 
 
 Addison's disease, treatment of, 842 
 
 Adenia, 823 
 
 Adenitis, bronchial, 181, 327 
 
 cervical, 326, 358 
 Adenoids, 566 
 Adhesive plaster, 540 
 Adiamorrhysis, 919 
 Adipose ascites, 734 
 Adiposis dolorosa, 896 
 
 pathology of, 896 
 symptoms of, 896 
 treatment of, 896 
 Adiposity, 894 
 Adrenal glands, diseases of, 839 
 
 syphilis of, 265 
 Adrenalin, 492, 842 
 ^Egophony, 137, 314, 530 
 Aerophagia, 619 
 African lethargy, 1211 
 Agraphia, 907, 908 
 Ague-cake, in malaria, 114 
 Ainhum, 1171 
 
 Air, fresh, in tuberculosis, 347 
 Albumin in urine, 768 
 Albuminuria, 768 
 
 albumose, 770 
 
 Bence-Jones, 770 
 
 diabetic, 868 
 
 diagnosis of, 770 
 
 diphtheritic, 157 
 
 etiology of, 768 
 
 genuine, 768 
 
 globulin, 769 
 
 in malaria, 115 
 
 mucin, 770 
 
 in nephritis, 738, 745, 749 
 
 nucleo-albumin, 770 
 
 peptone, 770 
 
 in pneumonia, 139 
 
 prognosis of, 770 
 
 renal, 768 
 
 rheumatic, 192 
 
 scarlatinal, 85 
 
 spurious, 768 
 
 syphilitic, 765 
 
 tests for, acetic acid, 769 
 boiling, 769 
 ferrocyanide, 769 
 Jolles', 769 
 nitric acid, 769 
 Spiegler's, 769 
 
 in tuberculosis, 324 
 
 in typhoid fever, 35 
 
 in yellow fever, 209 
 Albumose, tests for, 770, 828 
 Alcohol, coma from, 931 
 
1214 
 
 INDEX. 
 
 Alcohol, therapeutics of, 52, 53, 148. | 
 
 1167 
 Alcoholism, acute, diagnosis of, 1175 
 symptoms of, 1175 
 treatment of, 1176 
 chronic, prognosis of, 1177 
 symptoms of, 1176 
 treatment of, 1177 
 delirium tremens, 1177 
 differentiation of, 980 
 Alexia, 903, 904, 909 
 Alkalies. See Sod. bicarbonate 
 Alkaptonuria, 776 
 Allantiasis, 1185 
 Allocheiria. tabetic, 1053 
 Aloes, 661, 662 
 Alum, 561 
 Amaurosis, a. 084 
 
 with idiocy, 1073 
 Amblyopia, 1084 
 Ammonisemia, 778 
 Ammonia, aromatic spirits, 446, 625, 
 
 663 
 Ammonium, acetate, 90 
 
 carbonate, 147, 148, 417, 463, 483 
 chloride, 184, 474, 483 
 Ammonium, in urine, 867 
 Amoeba dysenteriae, 219 
 Amoebic dysentery. See Dysentery 
 Amy] nitrite, 243, 352, 446 
 Amyloid degeneration of kidneys (q. v.) 
 of liyer (q. v.) 
 of spleen, (q. v.) 
 in tuberculosis, 324 
 Anaemia, aplastic, 810 
 classification of, 797 
 in heart disease, 407 
 infantum, pseudoleukemia, 826 
 lienalis, 823 
 lymphatica, 823 
 in nephritis, 740, 745 
 pernicious, 804 
 
 course of, 809 
 diagnosis of, 809 
 differentiation of, 609, 809, 810 
 etiology of, 804 
 prognosis of, 809 
 symptoms of, blood, 804 
 circulation, 806 
 digestion, 807 
 haemolyinph glands, 807 
 metabolism, 806 
 neryous, 808 
 skin, 806 
 subjectiye, 806 
 treatment of, 811 
 pseudopernicious, of children, 826 
 secondary, post-hemorrhagic, acute, 
 812 
 etiology of, 812 
 symptoms of, 812 
 prognosis of, 812 
 treatment of, 812 
 chronic, etiology of, 813 
 differentiation of. 810 
 
 Anaemia, secondary, post-hemorrhagic, 
 chronic, symptoms 
 of, 814 
 treatment of, 814 
 splenic, 827, 845 
 
 splenica infettiya dei bambini, 826 
 tuberculous, 311 
 Anaesthesia, dissociated, 1046, 1047 
 Anaphylaxis, 163 
 Anarthria, 906 
 
 Anasarca in nephritis, 739, 746 
 Aneurysm, abdominal, 465 
 diagnosis of, 466 
 prognosis of, 467 
 signs of, 465 
 symptoms of, 465 
 treatment of, 467 
 of aorta, 455 
 of brain, 271, 944 
 cceliac, 466 
 gastric, 467 
 of heart, 375 
 hepatic, 466 
 intracranial. 266, 944 
 diagnosis of, 945 
 etiology of, 944 
 pathology of, 944 
 symptoms of, 945 
 treatment of, 945 
 of lung, 309 
 mesenteric, 466 
 miliary in cerebral hemorrhage, 
 
 921, 922 
 renal, 467 
 splenic, 466 
 syphilitic, 266, 271 
 thoracic, 455 
 
 death, mechanism of, 464 
 diagnosis of, 462 
 differentiation of, 463, 533 
 etiology of, 266, 455 
 pathology of, 456 
 physical signs of, 458 
 
 heart changes, 459 
 respiratory changes, 
 
 460 
 sympathetic, 462 
 vascular changes, 460 
 prognosis of, 464 
 symptoms of, 456 
 treatment of, 464 
 Angina abdominalis, 444, 445 
 cruris, 444, 453 
 erysipelatous, 102 
 in influenza, 175 
 Ludoviei, 159, 559 
 pectoris, 442 
 
 diagnosis of, 445 
 differentiation of, 445 
 etiology of, 443 
 pathology of, 443 
 prognosis of, 446 
 symptoms of, 443 
 treatment of, 446 
 phlegmonosa, 562 
 
INDEX. 
 
 1215 
 
 Angina, scarlatinal, 83, 90 
 syphilitic, 260 
 in typhoid fever, 29 
 ulceromembranosa, 562 
 Vincent's, 160, 562 
 Angioneurotic crisis, 830 
 
 oedema, 1170 
 Angiosclerosis, 447 
 Anguillula intestinalis, 1209 
 Ankylosis, rheumatic, 188 
 Ankylostoma duodenale, 1204 
 Anorexia, 622 
 Anosmia, 1082 
 Anthracosis of lungs, 506 
 Anthrax, 230 
 
 bacteriology of, 230 
 etiology of, 230 
 external, 231 
 
 diagnosis of, 232 
 differentiation of, 107, 232 
 prognosis of, 233 
 symptoms of, 232 
 treatment of, 233 
 internal, 233 
 
 intestinal, 233 
 
 diagnosis of, 41, 103, 234 
 symptoms of, 233 
 respiratory, 234 
 
 symptoms of, 234 
 treatment of, 235 
 septicaemia, 235 
 Antimony, 481 
 Antitoxin, in diphtheria, 162 
 
 in tetanus, 242 
 Anuria, renal colic causing, 786 
 Aorta, aneurysm of, 455 
 arteriosclerosis of, 452 
 atheroma of, 452 
 dilatation of, intermittent, 466 
 embolism of, 468 
 inflammation of, 467 
 rupture of, 468 
 syphilis of, 266 
 thrombosis of, 468 
 tuberculosis of, 343 
 Aortic insufficiency, 190, 389 
 
 diagnosis, 393, 401, 406 
 etiology of, 389 
 mechanism of, 390 
 physical signs of, 390 
 
 auscultation, 392 
 inspection, 390 
 palpation, 391 
 percussion, 392 
 prognosis, 411 
 treatment of, 412 
 stenosis, 394 
 
 diagnosis of, 395 
 differentiation of, 395, 401, 406 
 etiology of, 394 
 mechanism of, 394 
 physical signs of, 394 
 
 auscultation, 395 
 inspection, 394 
 palpation, 395 
 
 Aortic stenosis, physical signs of, per- 
 cussion, 395 
 prognosis, 411 
 symptoms of, 407 
 treatment of, 412 
 Aortitis, acute, 467 
 chronic, 452 
 syphilitic, 266 
 Aphasia, amnestic, 907 
 auditory, 906 
 conduction, 907, 908 
 differentiation of, 908 
 localization, 905 
 motor, 905 
 sensory, 906 
 visual, 907 
 Aphthae epizooticae, 362 
 Aphthous fever, 362 
 Apneumatosis of lungs, 507 
 Apomorphine, 483 
 
 Apoplectiform attacks in paretic de- 
 mentia, 977 
 bulbar paralysis, 985 
 seizures in multiple sclerosis, 1042 
 Apoplexy, 921. See cerebral haemorrhage 
 cardiac, 378 
 differentiation of, 943 
 habitus, 921 
 Appendicitis, 338 
 
 actinomycotic, 249 
 in aged, 642 
 bacteriology of, 638 
 in children, 642 
 complications of, abscess, 641 
 chronic changes, 642 
 necrosis, 641 
 peritonitis, 641 
 ulceration, 641 
 diagnosis of, 642 
 differentiation of, 133, 642, 706 
 etiology of, 638 
 larvata, 642 
 pathology of, 639 
 prognosis of, 642 
 symptoms of, 639 
 early, 639 
 late, 640 
 remote, 642 
 treatment of, 643 
 tuberculous, 336 
 typhoid, 31 
 Appendix vermiformis, cancer of, 651 
 foreign bodies in, 638 
 inflammation of, 638 
 typhoid ulcers of, 30, 31 
 Appetite, disturbance of sense of, 622 
 Aprosexia, 566 
 Argyll-Robertson pupil, 1054, 1086 
 
 in paretic dementia, 977 
 Argyria, differentiation of, 842 
 Arrhythmia, 442 
 Arsenic, 351, 417, 493, 621, 828, 1151 
 
 action and administration, 811 
 Arsenical poisoning, 1184 
 Arterial tension, 450, 750 
 
1216 
 
 INDEX. 
 
 Arteries, diseases of, 447 
 
 syphilitic endarteritis of, 266 
 Arteritis, 467 
 
 pneurnococcic, 140 
 rheumatic, 191 
 in typhoid fever, 26 
 syphilitic, 266, 270 
 Arteriocapillary fibrosis, 447 
 Arteriosclerosis, 447 
 
 diagnosis of, 450, 454 
 differentiation of, from syphilitic 
 
 endarteritis, 271 
 etiology of, 447, 882, 
 pathogenesis of, 448 
 pathology of, 448 
 prognosis of, 454 
 symptoms of, 450 
 syphilitic, 270 
 treatment of, 454 
 Artery of hemorrhage, 921 
 Arthritis deformans, 885 
 diagnosis of, 888 
 differentiation of, 888 
 etiology of, 885 
 pathology of, 885 
 treatment of, 889 
 types of, 885 
 
 diffuse, acute, 885 
 chronic, 886 
 Heberden's nodes, 887 
 juvenile, 887 
 monarticular, 887 
 partial, 887 
 vertebral, 887 
 divitum, 880 
 gonorrheal, 25 1 
 pauperum, 880 
 pneurnococcic, 141 
 rheumatic, 188 
 in typhoid fever, 37 
 Arthropathies, syringomyelic, 1046 
 
 tabetic, 1055 
 Asafcetida, 51, 585, 663, 725 
 Ascaris lumbricoides, 1199 
 Ascites, adipose, 734 
 
 in cancer of liver, 685 
 chyliform, 734 
 chylous, 734 
 
 in cirrhosis of liver, 670 
 diagnosis of, 729 
 differentiation of, 695, 730-733 
 etiology of, 728 
 in heart disease, 410 
 in pericarditis adhesiva, 432, 674 
 symptoms of, 728 
 treatment of, 733 
 Aspergillus, pseudotuberculosis, 320 
 Aspidium, 1193 
 Aspiration, abdominal, 733, 734 
 
 thoracic, 541 
 Aspirin, 197 
 Assam fever, 1211 
 
 Associated movements in apoplexy, 929 
 Association, centres for, 905 
 Astasia-abasia, hysterical, 1123 
 
 Asthma, bronchial, 489 
 
 diagnosis of, 492 
 differentiation of, 492 
 etiology of, 490 
 pathogenesis of, 490 
 prognosis of, 492 
 symptoms of, 490 
 treatment of paroxysm, 492 
 of tendency, 493 
 cardiac, 409 
 Millar's, 181, 859 
 thymic, 859 
 
 periodic, differentiation of, 181 
 Asthenic bulbar paralysis, 985 
 Ataxia, cerebellar, 916, 1072 
 cortical, 904 
 crus lesion causing, 913 
 Friedreich's, 1071 
 hereditary, 1071 
 
 cerebellar, 1072 
 diagnosis of, 1072 
 etiology of, 1071 
 pathology of, 1071 
 prognosis of, 1072 
 symptoms of, 1071 
 locomotor, 1049 
 pons lesions causing, 915 
 in tabes, 1051 
 Atelectasis of lungs, acquired, 507 
 
 congenital, 508 
 Atheroma, 447 
 
 of aorta, 452 
 Athetosis, in cerebral infantile paralvsis 
 949 
 posthemiplegic, 930 
 Athyrea, 849, 854 
 Atrophia hepatis fusca, 665 
 Atrophy, hemifacial, 1093 
 
 progressive spinal, 1064 
 Atropine, therapeutics of, 90, 91, 98, 
 
 149, 352, 492, 650 
 Aura, epileptic, 1137 
 Autumnal fever, 18 
 
 B 
 
 Babinski's sign, 928 
 Baccelli's sign in pleurisy, 530 
 
 in pneumonia, 137 
 Bacilluria, treatment of, 54 
 
 in typhoid fever, 36 
 Bacillus, acid-fast, 291, 482 
 
 aerogenes encapsulatus, 434 
 in pneumothorax, 543 
 
 anthracis, 230 
 
 botulinus, 1185 
 
 comma, 201 
 
 diphtherial 150 
 
 dysenterise, 217 
 
 influenza, 173 
 
 Klebs-Loeffler, 150 
 
 leprae, 354 
 
 mallei, 235 
 
 Oppler-Boas, 609 
 
 plague, 212 
 
INDEX. 
 
 1217 
 
 Bacillus smegma, 291 
 
 tetani, 238 
 
 tuberculosis, 291 
 
 typhosus, 17 
 Bacteriamria, septic infections, 123 
 Balne's cough, 567 
 Balsam Peru, 483 
 
 Bamberger's sign in pericarditis, 427 
 Banting's cure, 895 
 Banti's disease, 827, 674 
 Barlow's disease, 835 
 
 diagnosis of, 836 
 etiology of, 835 
 prognosis of, 836 
 symptoms of, 835 
 treatment of, 836 
 Basedow's disease, 849 
 Basham's mixture, 757 
 Baths in typhoid fever, 48 
 Baume's law, 282 
 Becker's sign, 851 
 Bednar's plaques, 554 
 Bedsores in typaoid fever, 23 
 causes of, 54 
 treatment of, 54 
 Belladonna, 90, 98, 149, 183, 224, 351, 
 418, 438, 470, 493, 616, 624, 628, 
 657, 661 
 Bence- Jones' albumose, 770, 828 
 Benzoin, 481 
 Beriberi, 227 
 
 diagnosis of, 229 
 
 distribution of, 227 
 
 etiology of, 228 
 
 prognosis of, 230 
 
 symptoms of, 228 
 
 treatment of, 230 
 
 tvpes of, 229 
 Betanaphthol, 223, 625 
 Beta-oxybutyric acid, 868 
 Bichloride. See Hydrargyrum 
 Biernacki's sign, 1053 
 Bile, flow of, 625 
 Bile-ducts. See Gall-ducts 
 Bilharzia disease, 1209 
 Bilious typhoid, 59 
 Bilirubin, test for, in stools, 627 
 Biot's breathing, 167 
 Bismuth. 50, 51, 224, 578, 603, 624 
 Black death, 211, 215 
 
 smallpox, 68 
 
 water fever, 119 
 Bladder, tuberculosis of. 340 
 "Bleeders," 836 
 Blindness, mind, 903 
 
 color, 904 
 Blood, diseases of, 797 
 
 in pneumonia, 138 
 
 pressure in typhoid fever, 24 
 
 in nephritis, 750 
 
 bacilli in, 26 
 Bloodvessels, syphilis of, 266 
 
 tuberculosis of, 300, 343 
 Blue mass, 283, 416 
 Bones, syphilis of, 278 
 
 77 
 
 Bones, tuberculosis of, 343 
 
 Boric acid, therapeutics of, 90, 286 
 
 Bothriocephalus latus, 1195 
 
 Botulism, 1185 
 
 Bouiimia, 622 
 
 Bowels. See Intestines 
 
 Brachycardia, 440 
 
 Bradycardia, 440 
 
 etiology of, 440 
 prognosis of, 441 
 symptoms, 441 
 treatment of, 441 
 Brain, abscess of, 967 
 
 diagnosis of, 970 
 differentiation of, 963, 971 
 etiology of, 967 
 pathology of, 967 
 prognosis of, 972 
 symptoms of, 969 
 treatment of, 973 
 actinomycosis of, 248 
 anaemia of, 917 
 aneurysms of, 944 
 arteriosclerosis of, 452 
 atrophy of, 981 
 cancer of, 272, 955 
 circulatory diseases of, 917 
 congestion of, 919 
 cysts of, 955 
 degeneration of, 981 
 
 lacunar, 942 
 diseases of, 899 
 embolism, see cerebral embolism, 
 
 410, 934 
 glioma of, 954 
 gumma of, 273, 954 
 hemorrhage of, see cerebral hemor- 
 rhage, 920 
 in syphilis, 272 
 hyperseniia of, 919 
 hypertrophy of, 981 
 inflammation of, see Encephalitis 
 lesions of, in diphtheria, 158 
 localization of, see cerebral locali- 
 zation, 899 
 oedema of, 920 
 sarcoma of, 272, 955 
 sclerosis of, 951, 981 
 "softening" of, 934, 981, 973 
 syphilitic, 270, 271 
 syphilis of, 270 
 
 arterial disease, 270 
 gumma, 273, 954 
 meningitis, 271 
 softening, 270 
 thrombosis, 270 
 differentiation of. 978, 953, 
 272, 274, 1043, 1058 
 thrombosis, see cerebral thrombosis 
 see brain, syphilis of 
 see sinus thrombosis 
 tuberculosis of, 954 
 tumors of, 954 
 
 classification of, 954 
 course of. 963 
 
1218 
 
 INDEX. 
 
 Brain, tumors of, diagnosis of, 961 
 
 differentiation of, 963, 979, 
 
 989 
 etiology of, 954 
 localization of, 956, 958 
 pathology of, 954 
 prognosis of, 963 
 symptoms of, 956 
 treatment of, 963 
 Brand bath in typhoid fever, 48, 49 
 Breasts, syphilis of, 281 
 
 tuberculosis of, 340 
 Breathing, metamorphosing, 314 
 Bremer's test of diabetic blood, 871 
 Bright's disease. See Nephritis 
 Briquet's syndrome, 1124 
 Broadbent's sign, 432 
 Broca's convolution, 905 
 Brodie's joints, 1120, 1124 
 Bromatotoxismus, 1185 
 Bromides, 184, 243, 1142 
 Bromism, differentiation of, 980 
 Bromoform, 183 
 Bronchi, dilatation of, 485 
 diseases of, 478 
 inflammation of, 478 
 foreign bodies in, 488 
 stenosis of, 488 
 stones in, 489 
 syphilis of, 268 
 Bronchial adenitis, 327 
 asthma, 489 
 
 breathing in pleurisy, 530 
 in pneumonia, 137 
 in tuberculosis, 313 
 casts in pneumonia, 134 
 glands, anthracosis of, 506 
 
 tuberculosis of, 181, 327 
 stenosis, 488 
 
 diagnosis of, 489 
 etiology of, 488 
 symptoms of, 488 
 treatment of, 489 
 ulcers, syphilitic, 268 
 Bronchiectasis, 425 
 
 complications of, 486 
 diagnosis of, 487 
 differentiation of, 487, 
 etiology of, 485 
 pathology of, 485 
 physical signs of, 486 
 symptoms of, 486 
 treatment of, 487 
 Bronchitis, acute, 478 
 
 etiology of, 479 
 symptoms of, 479 
 treatment of, 480 
 capillary, 501 
 chronic, 481 
 
 diagnosis of, 482 
 etiology of, 481 
 pathology of, 481 
 prognosis of, 483 
 symptoms of, 482 
 treatment of, 483 
 
 Bronchitis, fibrinous, 484 
 diagnosis of, 484 
 etiology of, 484 
 prognosis of, 484 
 symptoms of, 484 
 treatment of, 485 
 in heart disease, 408 
 in influenza, 175, 178 
 mucinosa, 484 
 pseudomembranacea, 484 
 putrid, 482 
 
 differentiation of, 513 
 syphilitic, 268 
 tuberculous, 307, 321 
 in typhoid fever, 34 
 in whooping-cough, 180 
 Bronchophony, 137, 314, 530 
 Bronchopneumonia, 498 
 bacteriology of, 499 
 diagnosis of, 502 
 differentiation of, 502 
 diphtheritic, 158 
 etiology of, 498 
 in influenza, 176 
 issues of, 501 
 measles as cause of, 95 
 pathology of, 499 
 physical findings of, 501 
 prognosis of, 502 
 symptoms of, 500 
 treatment of, prophylactic, 502 
 
 symptomatic, 502 
 types of, special, capillary, 501 
 disseminated, 501 
 generalized, 501 
 in whooping-cough, 180 
 Bronchorrhoea, 482 
 Brown mixture, 483 
 Brown-Sequard's paralysis, 1023 
 Bryson's sign, 852 
 
 Bruit d' arain in pneumothorax, 545 
 de diable, 799 
 de pot fele, 314 
 Bubonic plague, 211 
 Bulbar paralysis, apoplectiform, 985 
 asthenic, 985 
 chronic, 982 
 
 diagnosis of, 984 
 etiology of, 982 
 pathology of, 982 
 prognosis of, 984 
 symptoms of, 982 
 treatment of, 984 
 syringomyelia, 1047 
 Bundle of His, 441 
 Burr bath, in typhoid fever, 48 
 
 Cachexia lienalis, 823 
 
 lymphatica, 823 
 
 scorbutic, 833 
 
 strumipriva, 856 
 
 thyreopriva, 856 
 Cacheooie pachydermique, 855 
 
INDEX. 
 
 1219 
 
 Cacodylates, 812 
 
 Csecum, tuberculosis of, 336 
 
 Caffeine, 416 
 
 Caisson paralysis, 1022 
 
 Calcium lactate, in hemorrhages, 352, 
 
 838 
 Calculus, See Gall-stones and Kidney, 
 
 calculus, etc. 
 Calmette tuberculin test, 319 
 Calomel, 286, 662 
 Camphor, 53, 149, 183, 470 
 Camphor-chloral, 1167 
 Camphoric acid, 352 
 Cancrum oris, 556 
 Cannabis indica, 1163 
 Capsule, internal, localizing signs, 909 
 Caput Medusae, 671 
 Carbohydrates, physiology of, 863 
 Carbolic acid. See Phenol 
 Carbuncle, differentiation of, 232 
 Cardamon, 663 
 Cardiac insufficiency of stomach, 620 
 
 spasm, 572, 619 
 Cardialgia, 621 
 Cardiogmus, 436 
 Cardiomegaly, 860 
 Cardiopalmus, 436 
 Cardiospasm, oesophagus, 572, 619 
 Carlsbad, cure, 708 
 
 water, 602 
 Carphologia in typhoid fever, 27 
 Cascara, 662 
 Castor oil, 662 
 Casts in pneumonia, bronchial, 134 
 
 fibrin, 134 
 urinary, 738, 745, 749 
 Cat's tongue, scarlatinal, 85 
 Catarrhus sestivus, 470 
 Cathartics, 661 
 
 Cauda equina, lesions of, 1004 
 Cellulitis, differentiation of, 104 
 Centrum ovale, localizing symptoms, 909 
 Cerebellar ataxia, 916, 1072 
 Cerebellum, localizing symptoms of, 916 
 Cerebral embolism, 934, 410 
 
 diagnosis of, 939 
 
 differentiation of, 943 
 
 etiology of, 935 
 
 localization of, 937 
 basilar, 939 
 cerebral, anterior, 939 
 
 posterior, 938 
 internal carotid, 939 
 Svlvian arterv, 937 
 vertebral, 939 
 
 pathology of, 935 
 
 prognosis of, 939 
 
 symptoms of 936 
 
 treatment, 939 
 hemorrhage, 920 
 
 cerebellar, 932 
 
 cortical, 932 
 
 cms, 932 
 
 diagnosis of, 931 
 of coma, 931 
 
 Cerebral hemorrhage, diagnosis of hemi- 
 plegia, 931 
 of location, 932 
 differentiation, 943, 378 
 etiology of, 921 
 localizations of, 922 
 medulla, 932 
 pathology of, 921 
 pons, 932 
 prognosis of, 932 
 symptoms of chronic, 928 
 hemiplegia, 926 
 individual, 925 
 insult, 924 
 permanent, 925 
 prodromes, 924 
 reflexes, 927 
 sensation, 927 
 stroke, 924 
 treatment of chronic stage, 934 
 of insult, 933 
 prophylaxis, 933 
 of reaction, 934 
 ventricular, 932 
 localization, 899 
 
 centrum ovale, 909 
 cerebellum, 916 
 cerebral peduncle, 912 
 corpora quadrigemina, 912 
 corpus striatum, 911 
 crus, 912 
 
 frontal cortex, 905 
 internal capsule, 909 
 motor cortex, 899 
 occipital cortex, 904 
 optic thalamus, 911 
 parietal cortex, 903 
 pons, 914 
 
 temporal cortex, 904 
 thrombosis, 940 
 
 diagnosis of, 942 
 differentiation of, 943 
 etiology of, 940 
 localization of, basilar, 942 
 cerebral anterior, 941 
 
 posterior, 942 
 Svlvian artery, 941 
 vertebral, 942 
 pathology of, 940 
 prognosis of, 942 
 symptoms of, 940 
 treatment of, 944 
 Cerebrasthenia, 1128 
 Cerebritis, 964 
 Cerebrospinal fever, 165 
 
 meningitis, epidemic, 165 
 Cerium oxalate. 50. 578 
 Cervical adenitis, 326 
 Cervix, syphilis of, 278 
 Chalicosis of lungs, 506 
 Chalk, 624 
 
 Chancre. See Syphilis, symptoms of 
 Chancroid, 256 
 Charcot-Leyden crystals, 491 
 Charcot's disease, 1062, 1055 
 
1220 
 
 INDEX. 
 
 Cheese poisoning, 1186 
 Chiasm, optic, 1083 
 Chicken-breast, 567 
 
 rhachitic, 891 
 Chickenpox, 78 
 
 complications of, 79 
 diagnosis of, 80 
 differentiation of, 80, 72 
 etiology of, 78 
 sequels of, 79 
 symptoms of, 78 
 Chills, treatment of, 122 
 Chloral, 184, 243, 492, 760, 939 
 Chlorides, absence of, in pneumonic 
 
 urine, 139 
 Chloroform, 51, 105, 122, 183, 184, 243, 
 
 351, 446, 483, 585, 663, 725 
 Chloroma, 822 
 Chlorosis, 797 
 
 complications of, 800 
 course of, 800 
 diagnosis of, 801 
 differentiation of, 801, 810 
 etiology of, 797 
 prognosis of, 800 
 symptoms of, 797 
 treatment of, 801 
 dietetic, 803 
 iron, 801 
 prophylactic, 801 
 specific, 801 
 Choked disk, in brain tumor, 956, 961 
 Cholsemia, 666, 672 
 Cholangitis, catarrhal, 710 
 
 differentiation of, 704, 705 
 suppurative, 710 
 Cholecystitis, 709 
 
 differentiation of, 704, 705 
 etiology of, 709 
 following typhoid fever, 33 
 prognosis of, 709 
 symptoms of, 709 
 treatment of, 710 
 Cholecystotomy, 707 
 Cholelithiasis. See Gall-stones, 699 
 Cholera, Asiatic, 200 
 
 bacteriology of, 201 
 complications of. 204 
 diagnosis of, 204 
 dissemination of, 201 
 prognosis of, 205 
 symptoms of, 202 
 treatment of, 205 
 infantum, 634 
 nephritis, 741 
 nostras, 205 
 Cholerine, 204 
 
 Chondrodystrophia fcetalis, 855 
 Chorea, acute, 1145 
 
 course of, 1148 
 diagnosis of, 1148 
 etiology of, 1145 
 pathology of, 1145 
 prognosis of, 1148 
 symptoms of, 1145 
 
 Chorea, acute, treatment of. 1151 
 types of, 1148 
 
 in cerebral infantile paralysis, 953 
 
 chronic, 1149 
 
 electric, 1150 
 
 endocarditis from, 385, 1147 
 
 habit, 1150 
 
 Huntingdon's, 1149 
 
 posthemiplegic, 930, 953 
 
 rheumatic, 193 
 Choreiform affections, 1145 
 Choroidal tubercles, 303, 306 
 Choroiditis, syphilitic, 276 
 Chyle in urine, 774 
 
 vessels, disease of, 664, 734 . 
 Chyliform ascites, 734 
 
 pleurisy, 549 
 Chylothorax, 549 
 Chylous ascites, 734 
 Chyluria, 774 
 
 parasitic, 1207 
 Chvostek's sign, 1153 
 Cirsomphalos, 671 
 Cladothrix asteroides, 250 
 Claudication intermittente, 444, 453 
 Climate, in tuberculosis, 347 
 Cocaine, 178, 469, 657 
 Codein, 351, 481 
 Coccygodynia, 1166 
 Codliver oil, 351 
 Colchicum, 883 
 Colectasia, 655 
 Colic, biliary, 701 
 
 renal, 786 
 Colica mucosa, 628 
 
 etiology of, 628 
 symptoms of, 628 
 treatment of, 628 
 
 pictonum, 1182, 706 
 Colitis, membranacea, 628 
 
 mucosa, 628 
 Collapse in diphtheria, 157 
 
 in pneumonia, 138 
 
 in typhoid fever, 21, 25, 48, 52 
 Collar of brawn in scarlatina, 86 
 Collargol, 129, 163 
 Colles' law, 282 
 Colon bacillus. See Septic Infections 
 
 dilatation of, 655 
 
 prolapse of, 654 
 Coloptosis, 655 
 Coma, alcoholic, 931, 1175 
 
 apoplectic, 924, 931. 943. 991 
 
 diabetic, 869 
 
 epileptic, 1138 
 
 opium, 931 
 
 in pernicious malaria, 119 
 
 ursemic, 752 
 
 vigil in typhoid fever, 27 
 Comma bacillus, 201 
 Common bile-duct, gall-stones in, 702, 
 
 703, 720 
 Concato's disease, 727 
 Concretio pericardii, 431 
 Conjugate deviation, 914, 925 
 
INDEX. 
 
 1221 
 
 Conjunctiva, syphilis of, 275 
 Constipation, 658 
 
 in colica mucosa, treatment of, 628 
 etiology of, 658 
 symptoms of, 658 
 treatment of, cathartics, 661 
 diet, 659 
 enemata, 661 
 exercise, 660 
 massage, 660 
 in typhoid fever, treatment of, 51 
 Constitutio lymphatica, 847 
 Constitutional diseases, 863 
 Consumption, 306 
 Contractures, in apoplexy, 929 
 
 hysterical, 1123 
 Conus medullaris, lesions of, 1004 
 stenosis, 375, 420 
 in syphilis, 266 
 Convulsions in brain tumor, 957, 962 
 in cerebral embolism, 937, 943 
 hemorrhage, 925, 943 
 thrombosis, 943 
 epileptic, 1137 
 hysterical, 1121, 1140 
 infantile, 1144 
 
 etiology of, 1144 
 symptoms of, 1144 
 treatment of, 1144 
 Jacksonian, 902 
 in syphilis, 273 
 in typhoid fever, 27 
 in uraemia, 751 
 in whooping-cough, 180 
 Coproliths, 648, 649 
 Cor bovinum, 369 
 villosum, 423 
 Cornea, syphilis of, 275 
 Coronarv disease, arteritis, 265, 376, 
 
 443, 451 
 Corpora oryzoidea, 344 
 
 quadrigemina, localizing symptoms. 
 912 
 Corpulence, 894 
 Corpus striatum, localizing symptoms, 
 
 911 
 Corrigan's disease, 389 
 Corset liver, 691 
 Cortex, cerebral, localization, 899 
 Coryza, 469 
 
 in typhoid fever, 34 
 syphilitic, 283 
 Costa fluctuans decima, 654 
 Cough, therapy of, 350 
 Courvoisier's law, 703 
 Cracked pot resonance, in pneumonia, 
 137 
 in tuberculous cavities, 314 
 Craniotabes, rhachitic, 891 
 Cranium progenium, 861 
 Crede's collargol, 129, 163 
 
 silver, 129- 
 Creolin, 105 
 Creosote, 350, 351, 487 
 Crepitant rale, 137 
 
 diseases where present, 137 
 
 Crepitant rale, in pneumonia, 137 
 Cretinism, 855 
 
 diagnosis of, 855 
 
 etiology of, 855 
 
 symptoms of, 855 
 Crie hydrencephalique, 166 
 Crises, tabetic, 1056 
 Croton oil, 92, 743, 934 
 Croup, differentiation of, 181 
 
 diphtheritic, 155 
 
 false, 474 
 
 differentiation of, 181 
 Crus, localizing symptoms, 912 
 Crystals, Charcot-Leyden, 491 
 Culex fasciata, 206 
 Cyanosis in heart disease, 408, 421 
 
 with polycythemia, 846 
 
 with splenomegaly, 846 
 Cyclaster scarlatinalis, 80 
 Cycloplegia, 1086 
 Cynanche gangrceneuse, 559 
 Cystic duct, in gall-stones, 702 
 Cysticercus, of brain, 955 
 
 cellulose, 1191, 1193 
 Cystin calculus, 785 
 Cystitis, differentiation of, 779 
 
 in typhoid fever, 36 
 Cytodiagnosis, 530 
 
 in lumbar puncture, 170 
 Cytorrhyctes vaccinia, 74 
 
 variolse, 63 
 
 Damoiseatj's curve in pleurisy, 528 
 Dandy-fever, 198 
 Deafness, 1099 
 
 cortical, 904, 905 
 Death, sudden, 847, 858 
 Degeneratio renum polycystica, 793 
 Delirium cordis, 442 
 
 in fevers, treatment of, 53, 77 
 tremens, diagnosis of, 1177 
 etiology of, 1177 
 prognosis of, 1177 
 symptoms of, 1177 
 treatment of, 1177 
 Dementia paralytica, 973 
 diagnosis of, 978 
 differentiation of, 978 
 etiology of, 973 
 pathogenesis of, 974 
 pathology of, 974 
 prognosis of, 980 
 symptoms of, 975 
 treatment of, 980 
 paretic, 973 
 senile, 979 
 Dengue, 198 
 
 complications of, 200 
 diagnosis of, 200 
 differentiation of, 200 
 etiology of, 198 
 prognosis of, 200 
 sequels of, 200 
 symptoms of, 199 
 treatment of, 200 
 
1222 
 
 INDEX. 
 
 Dermatitis, differentiation of, 88, 103 
 Dermatomyositis, 1172 
 Dercum's disease, 896 
 Dextrocardia, 421 
 Diabete bronze, 675, 716, 872 
 Diabetes, bronzed, 675, 716, 872 
 coma from, 869 
 decipiens, 867 
 in gall-stones, 706 
 insipidus, 878 
 
 cerebral syphilis, 272, 878 
 diagnosis of, 879 
 etiology of, 878 
 prognosis of, 879 
 symptoms of, 878 
 treatment of, 879 
 mellitus, 863 
 
 cerebral syphilis, 272 
 complications of, 869 
 amaurosis, 871 
 arteries, 871 
 blood, 871 
 coma, 869 
 cystitis, 872 
 dyspnoea, 870 
 heart, 871 
 gangrene, 873 
 
 of lungs, 872 
 genital, 872 
 infectious, 873 
 intestines, 872 
 liver, 872 
 mental, 869 
 neuralgia, 870 
 neuritis, 870 
 pregnancy, 872 
 renal, 872 
 retinitis, 870 
 skin, 873 
 stomach, 872 
 tuberculos 
 course of, 873 
 diagnosis of, 874 
 etiology of, 863 
 physiology of, 863 
 prognosis of, 873 
 symptoms of, glycosuria, 865 
 tests for, 866 
 polydipsia, 869 
 polyphagia, 869 
 urine, acetone, 868 
 albuminuria, 868 
 ammonium, 867 
 jS-oxybutyric acid, 868 
 diacetic acid, 868 
 pneumaturia, 869 
 quantity, 867 
 sugar, 865 
 treatment, complications, 876 
 diet, 874 
 general, 876 
 types, 865 
 phosphatic, 775 
 tuberculous, 311 
 Diacetone, diabetic, 868 
 
 Diamorrhysis,' 918 
 Diaphragmatic hernia, 646, 547 
 Diarrhoea, 623, 657 
 
 in cholera Asiatica, 205 
 etiology of, 633, 657 
 infantile, 633 
 
 cholera infantum, 634 
 chronic dyspepsia, 635 
 
 etiology, 633 
 fermental, 633 
 ileocolitis, 634 
 
 treatment of acute colitis, 638 
 dyspepsia, 637 
 enteritis, 637 
 of cholera infantum, 637 
 of chronic dyspepsia, 638 
 dietetic, 635 
 modified feeding, 636 
 nervous, 662 
 in pneumonia, 138 
 treatment of, 658 
 in typhoid fever, treatment of, 51 
 Diazo reaction, in malaria, 115 
 in measles, 96 
 in pneumonia, 139 
 scarlatinal, 85 
 in tuberculosis, 324 
 in typhoid fever, 36 
 Dibothriocephalus, 1195 
 Dicrotic pulse in typhoid fever, 24 
 Diet, in constipation, 659 
 in diabetes, 874 
 in gout, 884 
 in obesity, 895 
 in nephritis, 755 
 in tuberculosis, 348 
 Dietl's crisis, 767 
 Digitalis, physiological action, 413 
 preparations, 415 
 therapeutics of, 91, 92, 148, 413, 
 
 416, 417, 418, 447 
 toxicity, 414 
 Dietrich's heart stenosis, 266, 375, 420 
 Diphtheria, 150 
 
 bacteriology of, 150 
 complications of, 156 
 alimentary, 159 
 glands, 159 
 heart, 156 
 nephritis, 157 
 paralysis, 157 
 respiratory, 158 
 skin, 156, 159 
 course of, 160 
 diagnosis of, 159 
 differentiation of, 84, 88, 160, 564 
 dissemination of, 152 
 etiology of, 150 
 
 bacillus diphtherias, 150 
 Klebs-Lcefner bacillus, 150 
 laryngeal, 155 
 localization of, special, 152 
 ear, 156 
 eye, 156 
 genitalia, 156 
 
INDEX. 
 
 J 223 
 
 Diphtheria, localization of, special, 
 larynx, 155 
 nose, 155 
 skin, 156 
 nasal, 155 
 pathology, 153 
 pharyngeal, 152 
 prognosis of, 160 
 sequelae of, 156 
 symptoms of, 152 
 
 classifications of, 152 
 special, 152 
 treatment of, 161 
 general, 163 
 local, 161 
 prophylactic, 161 
 serotherapy, 162 
 symptomatic, 163 
 types of, 152 
 
 catarrhal, 153 
 chronic, 153 
 general infection, 154 
 latent, 153 
 
 pharyngitic, 152, 153 
 septic, 154 
 simple, 152 
 tonsillitic, 153 
 Diphtheritic croup, 155 
 enteritis, 629 
 ophthalmia, 156 
 otitis, 156 
 vulvovaginitis, 156 
 Diphtheroid, 150 
 Diplegia, in cerebral infantile paralysis, 
 
 950 
 Diplococcus intracellularis meningitidis, 
 
 165 
 Diplopia, 1054, 1088 
 Dipsomania, 1175 
 Disinfection, by formaldehyde, 76 
 Distoma of kidney, 795, 1209 
 of lung, 523, 1210 
 pulmonale, 1210 
 Distomiasis, 1209 
 Dittrich's mycotic plugs, 482 
 Diuretin, 416 
 Diver's paralysis, 1022 
 DobelPs solution, 469 
 Dover's powder, 560 
 Drachontiasis, 1208 
 Dracunculus medinensis, 1208 
 Dropsy, cardiac, 410 
 
 renal, 739, 746 
 Drug eruptions, 88, 96 
 Driisenneber, 358 
 Dubini's disease, 1150 
 Duct. See Gall-ducts. 
 Ductless glands, diseases of, 839 
 Ductus Botalli, patency, 419 
 Duke's disease, 100 
 Dumdum fever, 1211 
 Dunbar's serum, 471 
 Duodenal ulcer, complications of, 631 
 etiology of, 629 
 diagnosis of, 631 
 
 Duodenal ulcer, differentiation of, 599. 
 600, 601, 631 
 issues of, 631 
 symptoms of, 630 
 treatment of, 631 
 Duroziez's murmur, 393 
 Dysacusis, 1100 
 Dysarthria, 906, 915 
 Dysbasia intermittens, 453 
 Dysentery, 216 
 
 classification of, 217 
 amoebic, 219 
 
 complications of, 222 
 etiology of, 219 
 pathology of, 221 
 symptoms of, 220 
 treatment of, 223 
 issues of, 221 
 liver abscess in, 222, 680 
 indeterminate types, 222 
 catarrhal, 222 
 croupous, 222 
 gangrenous, 223 
 parasitic, 223 
 Shiga's bacillary, 217 
 
 diagnosis of, 219 
 pathology of, 218 
 prognosis of, 219 
 symptoms of, 218 
 treatment of, 223 
 Dyspepsia, acute, 577 
 
 in children, acute, 633 
 
 chronic, 635 
 intestinal, 623, 625 
 nervosa, 622 
 Dysphagia, 915 
 Dyspnoea in heart disease, 409 
 
 Kussmaul's in diabetes, 870 
 Dystrophy, muscular, 1067 
 
 Ear, diphtheria of, 156 
 
 syphilis of, 277 
 
 tuberculosis of, 341 
 Ebstein's cure, 895 
 Echinococcus disease, 1195 
 
 of liver. See liver, cysts of 
 
 of lungs, 522 
 
 renal, 794 
 Eclampsia in contracted kidney, 751 
 
 in kidney of pregnancy, 740 
 Eczema, differentiation of, 80, 103 
 
 of tongue, 556 
 Ehrlich's diazo reaction, 36 
 Eiselberg's sign, 593 
 Elaterin, 742 
 Elephantiasis, 1207 
 Embolism. See aorta, ete. 
 Emphysema of lungs, 494 
 Empyema, 532 
 
 necessitatis, 533 
 
 pulsans, 533 
 
 pneumococcic, 139, 532 
 
 streptococcic, 532 
 
1224 
 
 INDEX. 
 
 Empyema in typhoid fever, 35 
 Encephalitis, 964 
 
 acute hemorrhagic, 966 
 
 ophthalmoplegic, 965 
 in aged, 942 
 etiology of, 965 
 in influenza, 175 
 pathology of, 175, 965 
 poliencephalitis, 965 
 inferior, 966 
 superior, 965 
 poliencephalomyelitis, 966 
 prognosis of, 966 
 suppurative, 967 
 syphilitic, 271 
 treatment of, 966 
 Encephalomalacia, atheromatous, 940 
 embolic, 934 
 syphilitic, 271 
 Encephalomyelitis, disseminated, 1031 
 Encephalopathia, saturnina, 1183 
 Endarteritis deformans, 447 
 
 syphilitic, 271 
 Endiamorrhysis, 919 
 Endocarditis, 380 
 acute, 380 
 
 benign, 385 ■ 
 
 diagnosis of, 42, 43, 190, 
 
 386 
 etiology of, 385 
 localization of, 386 
 pathology of, 385 
 prognosis of, 387 
 symptoms of, 386 
 treatment of, 387 
 malignant, 380 
 
 diagnosis of, 42, 43, 382, 
 
 384 
 etiology of, 140, 380 
 pathology of, 125, 381 
 prognosis of, 385 
 symptoms of, 382, 383 
 treatment of, 387 
 types of, 125, 382 
 
 bacteriological, 384 
 septic, 382 
 typhoidal, 382 
 visceral, 383 
 verrucose, 385 
 chorea, relations of, 1145, 1146, 
 
 1147 
 chronic, 388. See Aortic Insuffi- 
 ciency, etc. 
 etiology of, 388 
 pathology of, 388 
 prognosis of, 411 
 symptoms of, 389, 407 
 treatment of, 412 
 differentiation of, 42, 43 
 pneumococcic, 140 
 rheumatic, 190 
 scarlatinal, 84 
 syphilitic, 266 
 tuberculous, 322, 343 
 in typhoid fever, 25 
 
 Endocardium, diseases of, 380 
 Enemata, nutrient, 602 
 English sweats, 359 
 Enstrongylus of kidney, 795 
 Enteralgia, 663 
 Enteritis, actinomycotic, 349 
 acute, 623 
 
 diagnosis of, 624, 44 
 etiology of, 623 
 pathology of, 623 
 symptoms of, 623 
 treatment of, 624 
 chronic, 625 
 
 pathology of, 625 
 prognosis of, 627 
 symptoms of, 626 
 treatment of, 627 
 croupous, 62 
 diphtheritic, 629 
 mucous, 628 
 phlegmonous, 629 
 Enterocolitis, 633, 624 
 Enterodynia, 663 
 Enterokinase, 625 
 Enteroliths, 659, 648 
 Enteroptosis, 654 
 etiology of, 654 
 symptoms of, 654 
 treatment of, 655 
 Enterospasm, 662 
 Enterostenosis, 647 
 Ephemeral fever, 358 
 Epididymitis in mumps, 185 
 Epilepsy, 1136 
 
 in cerebral infantile paralysis, 950, 
 
 953 
 convulsions in cerebral syphilis, 273 
 course of, 1140 
 diagnosis of, 1140 
 differentiation of, 962, 1140 
 etiology of, 1136 
 Jacksonian, 902, 903, 962 
 pathology of, 1136 
 prognosis of, 1140 
 symptoms of, 1136 
 syphilitic, 271, 273 
 treatment of, 1140 
 types of, 1137 
 Epileptiform attacks in paretic demen- 
 tia, 977 
 Epistaxis, etiology of, 472 
 treatment of, 473 
 in typhoid fever, 34, 53 
 Erb-Goldflam syndrome, 985 
 Erb's sign, 1153 
 Ergot, therapeutics of, 53 
 Ergotism, 1186 
 Eructations, gastric, 619 
 Erysipelas, 100 
 
 bacteriology of, 100 
 complications of, 102 
 circulatory, 102 
 genito-urinary, 103 
 nervous, 102 
 respiratory, 102 
 
INDEX. 
 
 1225 
 
 Erysipelas, complications of septic, 103 
 course of, 102 
 as curative agent, 105 
 diagnosis of, 103 
 differentiation of, 103, 104 
 etiology of, 100 
 
 streptococcus erysipelatos, 100 
 of larynx, 102 
 of lungs, 102 
 of pharynx, 102, 104 
 prognosis of, 104 
 recurrence of, 104 
 sequels, 102 
 stages, 101 
 symptoms of, 101 
 eruption, 101 
 fever, 101 
 incubation, 101 
 treatment of, 104 
 local, 105 
 medicinal, 105 
 prophylaxis, 104 
 serotherapy, 105 
 varieties of, 102, 104 
 Erysipeloid, 104 
 
 differentiation of, 104 
 Erythema, differentiation of, 103 
 infectiosum, 100 
 rheumatic, 191 
 visceral crises in, 830 
 Erythromelalgia, 1168 
 Erythrol tetranitrate, 446 
 Exophthalmos, goitrous, 850 
 Extradural abscess, 972 
 Exudates, character of fluid, 730 
 Eye, diphtheria of, 156 
 syphilis of, 275 
 tuberculosis of, 334 
 
 Facial hemiatrophy, 1093 
 
 hemihypertrophy, 1093 
 Faeces, functional examination of, 626 
 Fallopian tubes, syphilis of, 278 
 
 tuberculosis of, 340 
 Famine fever, 54, 59 
 Farcy, 235 
 
 Fasciola hepatica, 1210 
 Fat necrosis, pancreatic, 713 
 
 in urine, 774 
 Febricula, 358 
 Fehleissen's streptococcus erysipelatos, 
 
 100 
 Felix mas, 1193 
 Felons, syringomyelic, 1046 
 Fever-cake, in malaria, 114 
 Fever, ephemeral, 358 
 
 gastric, 358 
 
 glandular, 358 
 
 hepatic, 673, 703 
 
 herpetic, 358 
 
 miliary, 359 
 
 mountain, 361 
 
 Fever, therapy of, 47, 90 
 Fibrin casts in pneumonia, 134 
 Filaria medinensis, 1208 
 
 nocturna, 1207 
 Fish poisoning, 1186 
 Fissures of lungs, interlobar, 536 
 Fistula in ano, 324, 337 
 Flexner's serum, 172 
 Flint's murmur, 393, 400 
 Food poisoning, 1185 
 Foot and mouth disease, 362 
 
 tabetic, 1055 
 Forced movements, 917 
 
 postures, 917 
 Forcheimer's spots, 99 
 Formaldehyde as disinfectant, 76 
 Fourth disease, Duke's, 100 
 Frautzel's rules, in valvular disease, 398 
 Friction rub, pericarditic, 426, 428 
 
 pleuritic, 526, 529, 538 
 Friedlander's bacillus, 130 
 Friedreich's ataxia, 1071 
 
 change of note, 314 
 
 tones, 393 
 1 Fumigation, formaldehyde, 76 
 Funnel breast, 567 
 Furuncles, diabetic, 873 
 
 Galactotoxismus, 1186 
 Gall-bladder, cancer of, complications 
 of, 712 
 differentiation of, 704, 
 
 705 
 etiology of, 711 
 pathology of, 712 
 symptoms of, 712 
 diseases of, 696 
 
 differential table, 704, 705 
 in gall-stones, 702, 703 
 inflammation of, 709 
 sarcoma of, 711 
 tumors of, 711 
 Gall-ducts, diseases of, 696 
 inflammation, 710 
 occlusion of, 711 
 stones in, 703, 720 
 tumors of, 711, 712 
 Gall-stones, 699 
 
 chemistry of, 700 
 complications of, ampulla 
 Vateri, 703 
 common duct, 702 
 cystic duct, 702 
 diabetes, 706 
 fistulse, 703 
 gall-bladder, 702 
 intestinal obstruction, 648, 
 
 649, 703 
 renal calculus, 706 
 diagnosis of, 706 
 differentiation of, 264, 599, 
 
 631, 704, 720 
 etiology of, 699 
 
1226 
 
 INDEX. 
 
 Gall-stones, following typhoid fever, 33 
 frequency of, 699, 700 
 intestinal obstruction from, 
 
 648, 649, 703 
 prognosis of, 706 
 properties of, 700 
 symptoms of, 701 
 treatment of, colic, 707 
 medicinal, 707 
 prevention, 707 
 surgical, 707 
 varieties of, 700 
 Gambir, 625 
 Gangrene, diabetic, 873 
 
 spontaneous symmetrical, 1169 
 in typhoid fever, 26 
 Gastralgia, 621 
 
 differentiation of, 601 
 Gastrectasia, 586 
 Gastric fever, 358 
 Gastritis, acute diphtheritic, 578 
 parasitic, 578 
 phlegmonous, 578 
 simple, diagnosis of, 577 
 etiology of, 576 
 symptoms of, 577 
 treatment of, 577 
 toxic, 578 
 atrophic, 585, 605, 608 
 chronic, diagnosis of, 582, 601 
 etiology of, 579 
 pathology of, 579 
 symptoms of, 580 
 treatment of, diet, 582 
 lavage, 583 
 medicinal, 584 
 differentiation of, 44, 601 
 pneumococeic, 141 
 stenosing, 587 
 Gastrodynia, 621 
 Gastroenterostomy, 604 
 Gastroptosis. See Enteroptosis, 654 
 Gastrorrhagia, 612 
 Gastrosuccorrhoea, diagnosis of, 618 
 etiology of, 616 
 prognosis of, 617 
 symptoms of, 616 
 treatment of, 618 
 Gelatin injections, tetanus from, 239 
 in aneurysm, 465 
 by mouth, 832 
 Genitalia, syphilis of, 277 
 
 tuberculosis of, 337 
 Gentian, 584, 711 
 Genu valgum, rhachitic, 894 
 Gerhardt's change of note, 314 
 German measles, 99 
 
 diagnosis of, 100 
 differentiation of, 97, 100 
 etiology of, 99 
 prognosis of, 100 
 symptoms of, 99 
 
 constitutional, 99 
 eruption, 99 
 incubation, 99 
 
 German measles, symptoms of, pro- 
 dromes, v9 
 stages, 99 
 treatment of, 100 
 Gersuny's sign. 659 
 Gifford's sign, 851 
 Gigantism, 861 
 Ginger, 438, 625 
 Gingivitis, scorbutic, 833 
 Glanders, 235 
 
 course of, 236 
 diagnosis of, 238 
 differentiation of, 73, 238 
 etiology of, 235 
 pathology of, 236 
 symptoms of, 236 
 farcy, 236 
 glanders, 237 
 treatment of, 238 
 Glandular fever, 358 
 Globulin, tests for, 769 
 Globus, hystericus, 1122 
 Glomerulo-nephritis, scarlatinal, 85 
 Glossitis, acute, 557 
 
 desiccans, 557 
 Glottis, oedema of, 476 
 
 in typhoid fever, 34 
 spasm of, diagnosis of, 180 
 Glycosuria, 863. See Diabetes 
 syphilitic, 265, 272 
 tests for, 866 
 Glvcyrrhiza, 483, 662 
 Goitre, 648 
 
 exophthalmic, 849 
 acute, 851 
 course of, 853 
 diagnosis of, 852 
 etiology of, 849 
 forme fruste, 852 
 pathology, 851 
 prognosis, 853 
 symptoms of, 850 
 accessory, 852 
 cardinal, 850 
 constitutional, 852 
 exophthalmos, 850 
 goitre, 851 
 tachycardia, 850 
 tremor, 852 
 treatment of, 853 
 general, 853 
 medicinal, 853 
 organotherapy, 853 
 thyroidectomy, 854 
 Gonococeus. See Septic Infections 
 
 localizations, 251 
 Gonorrheal infection, 251 
 arthritis, 251 
 
 classification, 252 
 course, 252 
 pathology, 252 
 symptoms, 252 
 treatment, 252 
 regional, 251 
 septicopyemia, 251 
 
1XDEX. 
 
 12 
 
 >ii 
 
 Gout, S79 
 
 complications of. 3S2 
 diagnosis of. 882 
 etiology of. S79 
 pathology of, 880 
 prognosis of, 883 
 symptoms of. acute. 880 
 
 chronic.. 881 
 treatment of. acute. 883 
 alkalies. 883 
 colchicuni, 883 
 diet, 883 
 salicylates, 883 
 chronic, 884 
 Grate's, von, sign. 851 
 Grain poisoning, 1186 
 Graphospasmus, 1155 
 Graves' disease, 849 
 Greene's sign in pleurisv. 526 
 Grindelia, 492, 493 
 Grippe. See Influenza. 173 
 Grocco's sign in pleurisy. 52 S 
 Guaiac, 565 
 Guaiacol, 351 
 Guinea-worm disease, 1208 
 Gumma. See Syphilis 
 Gums, tuberculosis of, 334 
 Gutta cadens. 546 
 
 H 
 
 Habitus enteroptoticus, 654 
 Ha?mateinesis, diagnosis of, 614 
 
 differentiation of, haemoptysis, 520 
 
 etiology of. 612 
 
 in gastric cancer, 601. 607. 609 
 "ulcer, 596, 601 
 
 in portal cirrhosis, 672 
 
 symptoms of, 613 
 
 syphilitic, 261 
 
 treatment of, 603 
 
 in typhoid fever, 29 
 Haematomyelia, 1021 
 Haeniatoporphyrinuria, 776 
 Haunatorrhachis, 1015 
 Hematuria. 770 
 
 angioneurotic, 771 
 
 diagnosis of, 771 
 
 endemic, 1209 
 
 etiology of, 770 
 
 renal stone causing. 7S6, 788 
 tumor causing, 790 
 
 symptoms of, 771 
 
 treatment of. 772 
 
 tuberculosis causing, 339 
 Hemochromatosis, 675, 716, 872 
 Hemoglobinuria. 772 
 
 epidemic, 832 
 
 etiology of, 772 
 
 in malaria. 119 
 
 in nephritis, 733, 741 
 
 paroxysmal, 772 
 
 symptoms of. 772 
 
 syphilitic, 265 
 
 treatment of. 773 
 
 Haemopericardiuni, 435 
 
 differentiation of. 429 
 Haemophilia, 836 
 
 diagnosis of, S37 
 etiology of, 836 
 prognosis of, 837 
 renal, 771, S37 
 symptoms of, 837 
 treatment of, 838 
 Haernoptoe. See Haemoptysis 
 Haemoptysis, 309, 519 
 
 bronchiectasis causing, 486 
 cause of tuberculosis, 309 
 differentiation a* $20 
 endemic, 12 1C 
 etiology. 519 
 forms of, 309, 519 
 frequency of, 309 
 in heart disease, 40S 
 prognosis, 521 
 symptoms of, 309, 519 
 treatment of. 352, 521 
 in tuberculosis, 309 
 Haemorrhoids, 656 
 Haemothorax, 548 
 " Half-moon " space, 528, 545 
 Hanford's tender toes in tvphoid fever. 
 
 28 
 Hanot's disease, 676 
 Hay fever, 470 
 
 etiology of, 470 
 symptoms of, 470 
 treatment of, 471 
 Haygarth's nodosities, 885 
 Head, actinomycosis of, 247 
 Headache, in brain tumor, 956, 961 
 differentiation of, 1162 
 in fevers, treatment of, 53, 77 
 in malaria. 116 
 in meningitis, 166 
 migraine, 1160 
 sick, 1160 
 in typhoid fever, 27 
 Head's maximal points, 1166 
 Hearing, centre for, 906 
 Heart. See also Myocardium, endo- 
 cardium 
 aneurysm of. 375 
 arrhythmia. 442 
 arteriosclerosis of. 443. 451 
 atrophv of. 371 
 block, 441 ' 
 bovine, 369 
 dilatation of, 363 
 
 diagnosis of, 365 
 differentiation of, 365, 420 
 etiology of, 363 
 pathology of, 364 
 prognosis of, 366 
 signs of auricular dilatation. 
 365 
 of left ventricle dilatation. 
 
 364, 451 
 of right ventricle dilata- 
 tion. 365 
 
1228 
 
 INDEX. 
 
 Heart, dilatation of, symptoms of, 
 364 
 treatment of, 366 
 in typhoid fever, 25 
 disease cells, 409 
 congenital, 418 
 
 aortic atresia, 420 
 dextrocardia, 421 
 interauricular defects, 419 
 interventricular defects, 
 
 419 
 patent ductus Botalli, 419 
 persistent isthmus aortse, 
 
 420 
 prognosis of, 421 
 pulmonary stenosis, 418 
 symptoms of, general, 421 
 transposition of vessels, 
 
 420 
 treatment of, 421 
 tricuspid stenosis, 420 
 valvular anomalies, 420 
 valvular combined lesions, 406 
 diagnosis of, 406 
 prognosis of, 407 
 course of, 411 
 prognosis of, 411 
 signs of. See Individual 
 
 Lesions 
 symptoms of, 407 
 cardiac, 407 
 constitutional, 407 
 embolism, 410 
 gastro-intestinal, 409 
 joints, 411 
 kidney, 410 
 liver, 409 
 nervous, 408 
 oedema, 410 
 respiratory, 408 
 spleen, 410 
 treatment of, 412 
 
 cardiants, 413, 415 
 compensated lesions, 
 
 412 
 digitalis, 413 
 exercise, 412 
 hygiene, 412 
 Oertel method, 366 
 purgative, 413 
 rest, 413 
 
 Schott method, 366 
 symptomatic, 416 
 uncompensated les- 
 ions, 413 
 venesection, 413 
 embolism, 410 
 
 failure, diphtheritic, 156, 157 
 fatty, 371 
 
 Adams-Stokes syndrome of, 372 
 
 diagnosis of, 373 
 
 etiology of, 371 
 
 pathology of, 371 
 
 prognosis of, 373 
 
 signs of, 372 
 
 Heart, fatty, symptoms of, 372 
 treatment of, 373 
 hypertrophy of, 368 
 diagnosis of, 370 
 
 etiology of, 368 * 
 
 in interstitial nephritis, 750 
 pathology of, 369 
 prognosis of, 370 
 signs of left ventricle hyper- 
 trophy, 369, 451 
 of right ventricle hyper- 
 trophy, 370 
 symptoms of, 369 
 treatment of, 371 
 intermittence of, 442 
 irritable, 368 
 
 murmurs, anaemic diastolic, 394, 
 799 
 Flint's, 393 
 
 systolic, 398, 403, 428, 798 
 functional, 190, 398, 403 
 diastolic, 394, 799 
 neuroses of, 436 
 operations on, 379 
 palpitation of, 436 
 diagnosis of, 437 
 etiology of, 436 
 signs of, 437 
 symptoms of, 436 
 treatment of, 437 
 pang, 442 
 parasites of, 379 
 retraction of apex of, 432 
 rupture of, 378, 375 
 diagnosis of, 379 
 etiology of, 378 
 pathology of, 379 
 symptoms of, 379 
 treatment of, 379 
 syphilis of, 265 
 thrombosis of, 380 
 tuberculosis of, 342 
 tumors of, 379 
 Heat exhaustion, 1189 
 Heberden's nodes, 887 
 Hemianesthesia, hysterical, 1119 
 lesions in, cms, 913 
 
 internal capsule, 910, 927 
 optic thalamus, 912 
 pons, 915 
 Hemianopsia, 904, 910, 911, 959, 1083, 
 
 1084 
 Hemiathetosis, 930, 949 
 Hemiatrophy, facial, 1093 
 Hemichorea, 930, 953, 1146 
 Hemichromatopsia, 1084 
 Hemicrania, 1160 
 Hemifacial atrophy, 1093 
 
 hypertrophy, 1093 
 Hemihypertrophy, facial, 1093 
 Hemiopia. See Hemianopsia 
 Hemiplegia, in aged, 942 
 alternating, 912 
 
 in apoplexy, 926, 928, 931, 943 
 cerebral embolism, 937, 943 
 
INDEX. 
 
 1229 
 
 Hemiplegia, cerebral, infantile par- 
 alysis, 949 
 thrombosis, 941, 943 
 
 collateral, 927 
 
 cortical, 900 
 
 in diphtheria, 158 
 
 double, 949, 950, 986 
 
 etiology of, 931, 949, 958 
 
 hysterical, 1122 
 
 internal capsule lesion in, 910 
 
 in pachymeningitis, 991 
 
 in pneumonia, 139 
 
 spinal, 1023 
 
 in typhoid, 28 
 
 uraemic, 751 
 Hemorrhagic diseases, 829 
 
 classification of, 829 
 haemophilia, 836 
 infantile scurvy, 835 
 of new-born, 832 
 purpura, 829 
 scurvy, 833 
 Henoch's purpura, 831 
 Hepar adiposum, 689 
 
 migrans, 691 
 
 mobile, 691 
 Hepatargia, 666, 672, 673 
 Hepatic fever, intermittent, 673, 703 
 
 insufficiency, 666, 672, 673 
 
 vein cirrhosis of liver, 668 
 
 vessels, diseases of, 696 
 Hernia, diaphragmatic, 646 
 
 differentiation of, 547 
 
 external, 646 
 
 internal, 646 
 
 of linea alba, 599 
 Heroin, 351, 474, 481, 483 
 Herpes in malaria, 42, 43, 114 
 
 in meningitis, 168 
 
 in pneumonia, 138 
 
 in tuberculosis, 301 
 
 in tvphoid fever, 23 
 
 zoster, 1166 
 Herpetic fever, 358 
 
 Hexamethylenamina, 54, 91, 707, 1031 
 Hiccough, 1110 
 Hippocratic facies, 722 
 
 fingers, 325, 486, 862 
 
 succussion, 546 
 Hirschsprung's disease, 655 
 His' bundle, 441 
 Hodgkin's disease, 823 
 Horse-shoe kidney, 763 
 Hour-glass stomach, 592 
 Hunger, disturbance of sense of, 622 
 Huntingdon's chorea, 1149 
 Hutchinson's facies, 1089 
 
 mask, 1053 
 
 teeth,' 284 
 
 triad, 275 
 Hydatids, 1195 
 
 cysts. See Liver, Cvsts of. 
 Hydatid thrill, 687 
 Hydrargyri chloridum mite, 286 
 corrosivi, 287, 288 
 
 Hydrargyri iodidum, 286, 565 
 massa, 286, 416 
 tannicum, 286 
 unguentum, 288 
 Hydrarthrosis, intermittens, 1171 
 Hydrencephalic state, 634, 918 
 Hydrencephaloid, 634, 918 
 Hydrobilirubin, test for, in stools, 627 
 Hydrocephalus, acute, 986 
 chronic, acquired, 988 
 
 diagnosis of, 989 
 etiology of, 988 
 symptoms of, 988 
 treatment of, 989 
 congenital, 987 
 course of, 988 
 etiology of, 987 
 pathology of, 987 
 symptoms of, 987 
 Hydrochinon in urine, 776 
 Hvdrochloric acid, action of, 625, 584, 
 586, 711 
 tests for, in stomach, 581 
 Hydrocyanic acid, 578 
 Hydromyelus, 1045 
 Hydronephrosis, 781 
 diagnosis of, 782 
 differentiation of, 782, 783, 794 . 
 etiology, 781 
 pathology, 781 
 prognosis of, 783 
 symptoms of, 782 
 treatment of, 783 
 Hydropericardium, 435 
 
 differentiation of, 429 
 Hydroperitoneum, 728 » 
 
 Hydrophobia, 243 
 course of, 245 
 diagnosis of, 245 
 differentiation of, 245 
 etiology of, 243 
 incubation in, 244 
 pathology of, 245 
 prognosis of, 245 
 stages of, 244 
 symptoms of, 244 
 treatment of, 245 
 inoculation, 245 
 late, 246 
 
 primary wound, 246 
 prophylactic, 245 
 Hydrops articulorum intermittens, 1171 
 pericardii, 435 
 renum cysticus, 793 
 Hydrorrhachis interna, 1045 
 Hydrotherapy, in typhoid fever, 48 
 Hydrothorax, 548 
 
 diagnosis of, 548 
 
 differentiation of, from pleurisy, 539 
 etiology of, 548 
 symptoms of, 548 
 Hyoscine, 53 
 Hyoscyamus, 493, 661 
 Hyperaciditas hydrochlorica, 614 
 Hyperacusis, 1099 
 
1230 
 
 INDEX. 
 
 Hyperesthesia of stomach, 621 
 Hyperchlorhydria, diagnosis of, 615 
 
 differentiation of, 601, 615 
 
 etiology of, 614 
 
 in gastric ulcer, 596 
 
 prognosis of, 615 
 
 symptoms of, 614 
 
 treatment of, 615, 602 
 Hyperdiamorrhysis, 919 
 Hyperkinesis cordis, 436 
 
 gastric, 618 
 Hypernephroma, 792 
 Hyperorexia, 622 
 Hyperosmia, 1082 
 Hyperostosis cranii, 861, 989 
 Hypersecretion, gastric, 616 
 Hypersusceptibility, 163 
 Hypertrophy, hemifacial, 1093 
 Hypnotism, 1126 
 Hypochlorhydria, 618 
 Hypochondriasis, 979, 1132 
 Hypodermatoclysis, 206 
 Hypophysis, diseases of, 859 
 Hyposecretion, gastric, 618 
 Hysteria, 1118 
 
 course of, 1125 
 
 diagnosis of, 1126 
 
 differentiation of, 245, 182, 1030, 
 1044, 1122, 1140 
 
 etiology of, 1118 
 
 prognosis of, 1125 
 
 symptoms of, 1119 
 
 treatment of, 1126 
 
 I 
 
 Icing liver, 674, 733, 727 
 Icterus, 696 
 
 acute catarrhal, etiology of, 710 
 prognosis of, 710 
 symptoms of, 710 
 treatment of, 711 
 febrile, 361 
 
 in cancer of liver, 684 
 
 in cirrhosis of liver, 673, 677 
 
 diagnosis of, 699 
 
 differentiation of, 695, 704, 733 
 
 epidemic, 361 
 
 etiology of, 696 
 
 gravis, 667 
 
 hematogenous, 697 
 
 in heart disease, 410 
 
 malarial, 119 
 
 neonatorum, 697 
 
 pneumonic, 141 
 
 prognosis of, 699 
 
 symptoms of, 697 
 
 syphilitic, 265 
 
 treatment of, 711 
 
 in typhoid fever, 33 
 
 urobilin, 697 
 
 in yellow fever, 209 
 Ichthyotoxismus, 1186 
 Idiocy, amaurotic family, 1073 
 Ileocolitis in children, acute, 635 
 
 Ileocolitis in children, dysenteric, 635 
 Ileus, dynamic, 648 
 hysterical, 648 
 Incoordination. See Ataxia 
 Indicanuria, 776 
 Infantile convulsions, 1144 
 diarrhoea, 633 
 paralysis, cerebral, 949 
 
 diplegic form, 950 
 hemiplegic form, 949 
 Infantilism, 855 
 Infarcts. See Kidney, etc. 
 Influenza, 173 
 
 bacteriology of, 173 
 diagnosis of, 176 
 differentiation of, 176 
 etiology of, 173 
 prognosis of, 178 
 symptoms of, 174 
 alimentary, 176 
 circulatory, 176 
 classification of, 173 
 duration of, 174 
 fever, 174 
 genito-urinary, 176 
 joint, 176 
 muscle, 176 
 nervous, 174 
 respiratory, 175 
 skin, 176 
 types of, 174 
 treatment of, 178 
 varieties of, 173, 174 
 Infusions, saline, 149, 
 Insane, paralysis of, 973 
 Insolation, 1188 
 Intermittent limping, 453 
 Internal capsule, localizing symptoms, 
 
 909 
 Intestinal dyspepsia, 623, 625 
 
 obstruction, 644 
 Intestines, actinomycosis of, 249 
 amyloidosis of," 262, 324 
 anthrax of, 233 
 arteriosclerosis of, 453 
 cancer of, 651 
 
 complications of, 652 
 diagnosis of, 652 
 differentiation of, 652 
 etiology of, 651 
 pathology of, 651 
 symptoms of, 651 
 treatment of, 653 
 disease of, 623 
 foreign bodies in, forms of, 648, 
 
 659, 703 
 hemorrhage of, 656 
 diagnosis of, 656 
 etiology of, 656 
 symptoms of, 656 
 treatment of, 656 
 in typhoid, 31 
 inflammation of, 623, 625 
 neuroses of, 662 
 obstruction of, diagnosis of, 648 
 
INDEX. 
 
 1231 
 
 Intestines, obstruction of, differentia- 
 tion of, 649 
 dynamic, 648 
 foreign bodies, 648 
 gall-stones causing, 648, 649, 
 
 703 
 intussusception, 644 
 invagination, 644 
 knots, 646 
 strangulation, 645 
 stricture, 647 
 treatment of, medical, 650 
 
 surgical, 650 
 tumors, 651 
 twists, 646 
 volvulus, 646 
 perforation of, typhoid, 31, 52 
 syphilis of, 261 
 typhoid fever, hemorrhage, 31 
 
 perforation, 31 
 tuberculosis of, 335 
 tumors of, benign, 653 
 cancer of, 651 
 sarcoma of, 653 
 ulceration of, 629, 632 
 syphilitic, 261 
 in tuberculosis, 324, 336 
 in typhoid, 29, 30 
 ursemic, 752 
 Intoxications, 1175 
 Intubation in diphtheria, 164 
 Intussusception of bowel, 644 
 etiology of, 644 
 issues of, 645 
 pathology of, 644 
 symptoms, 645 
 varieties of, 644 
 Iodides. See Potas. iodide 
 Iodine, 472 
 Iodoform, 105, 657 
 Ipecac, 224, 481 
 Iridoplegia, 1086 
 Iritis, syphilitic, 275 
 Iron, therapeutics of, 105, 161, 417, 
 
 561, 661, 662, 757, 801, 802 
 Ischialgia, 1116 
 Isthmus aortse, persistent, 420 
 Itching, treatment of, 711 
 
 Jaboulay's sign, in hour-glass stomach, 
 
 593 
 Jacksonian convulsions. See Epilepsy 
 Jalap, 742 
 
 Jaundice. See Icterus 
 Jellinek's sign, 851 
 Joffroy's sign, 851 
 Joints, rheumatic, 186 
 
 syphilis of, 278 
 
 tuberculosis of, 343 
 Jungle fever, 119 
 Justus test, in syphilis, 267 
 
 K 
 
 Kahlek's disease, 770 
 
 Kakke, 227 
 
 Kala azar, 1211 
 
 Keratitis, syphilitic, 275 
 
 Kernig's sign, 170 
 
 Kidney, anomalies of, 763, 768 
 
 Kidneys, absent, 763 
 
 amyloid degeneration of, 761 
 
 differentiation of, 764, 765 
 etiology of, 761 
 pathology of, 762 
 symptoms of, 762 
 syphilitic, 265 
 tuberculous, 324 
 anomalies of secretion, 768 
 
 of structure, 763 
 arteriosclerosis of, 452, 753 
 ascending infection of, 777 
 calculus of, 784 
 
 chemistry of, 784 
 complications of, 787 
 diagnosis of, 787 
 differentiation of, 788 
 etiology of, 784 
 in gall stones, 706 
 pathology of, 784 
 prognosis of, 788 
 symptoms of, 785 
 treatment of, 788 
 cancer, complications of, 790 
 diagnosis of, 791 
 differentiation of, 791 
 etiology of, 789 
 pathology of, 789 
 prognosis of, 791 
 symptoms of, 789 
 treatment of, 792 
 congestion of, passive, 410, 760 
 diagnosis of, 761 
 differentiation of, 764, 765 
 etiology of, 760 
 pathology of, 760 
 symptoms of, 761 
 contracted, arteriosclerotic, 753 
 embolic, 761 
 primary, 747 
 secondary, 745 
 cystic, 793 
 
 diagnosis of, 794 
 etiology of, 793 
 pathology of, 793 
 symptoms of, 793 
 treatment of, 794 
 degeneration of, cystic, 793 
 diseases of, 737 
 dislocation of, acquired, 763 
 
 congenital, 763 
 distoma of, 795 
 
 echinococcus of, complications of, 
 795 
 symptoms of, 794 
 treatment, of, 795 
 embolism of, 410, 761 
 enstrongylus of, 795 
 floating, 766 
 functional tests, 749 
 
1232 
 
 INDEX. 
 
 Kidneys, horse-shoe, 763 
 hypernephroma, 792 
 infarction of, 761 
 pigment, 785 
 uric, 785 
 large, red, 744 
 
 variegated, 744 
 white, 744 
 malformations of, 763 
 movable, 763 
 
 complications of, 767 
 diagnosis of, 767 
 etiology of, 763 
 prognosis of, 767 
 symptoms of, 764 
 treatment of, 767 
 of pregnancy, eclampsia in, 740 
 rudimentary, 763 
 sarcoma of, 791 
 stone of, 784 
 supernumerary, 763 
 " surgical," 777, 779 
 syphilis of, 265 
 tuberculosis of, 338 
 tumors of, 789 
 Kino, 625 
 
 Klebs-Loeffler bacillus, 150 
 Kopftetanus, 241 
 Koplik's spots, 93 
 Kreatotoxismus, 1186 
 Kussmaul's breathing, 870 
 Kyphosis, rhachitic, 891 
 
 Labioglossopharyxgeal paralysis, 982 
 Lactosuria, 864 
 
 Lachrymal glands, svmmetrical hyper- 
 trophy of, 559, 828' 
 Lactic acid in gastric cancer, 608 
 La Grippe, See Influenza, 173 
 Laminectomy, 1014 
 Landry's paralysis, 1038 
 Langerhans' islands, 864 
 
 insufficiency, 864 
 Laryngismus stridulus, 475, 1106, 1153 
 Laryngitis, acute catarrhal, 473 
 diagnosis of, 474 
 etiology of, 473 
 symptoms of, 473 
 treatment of, 474 
 in children, 474 
 fibrinous, 475 
 nodose, 475 
 submucous, 475 
 suppurative, 475 
 chronic catarrhal, 475 
 
 etiology of, 475 
 symptoms of, 475 
 treatment of, 476 
 hypertrophic, 476 
 pachydermia, 476 
 tuberosa, 476 
 diphtheritic, 155, 164 
 in influenza, 175 
 
 Laryngitis, rheumatic, 191 
 stridulous. 475 
 syphilitic,' 268 
 Larynx, diseases of, 473 
 
 differentiation of, 181 
 erysipelas of. 102 
 oedema of, 476 
 paralysis of, 1103-1105 
 perichondritis of, 34, 477 
 symptoms of, 477 
 treatment of, 477 
 spasm of, 1104 
 stenosis of, 155 
 syphilis of, 268 
 tuberculosis of, 341 
 tumors o^ 478 
 typhoid, 34 
 ulcerations of, 478 
 Lasegue's sign, 188, 1116 
 Lathyrism, 1187 
 Lead, acetate, 519 
 
 colic, differentiation of, 706, 1182 
 poisoning, acute, 1181 
 chronic, 1182, 980 
 Leontiasis ossea, 861 
 Leprosy, 354 
 
 bacteriology of, 354 
 course of, 357 
 diagnosis of, 357 
 differentiation of, 1048 
 distribution of. 354 
 pathology of, 355 
 prognosis of, 357 
 symptoms of, 355 
 treatment of, 357 
 Leptomeningitis. See Meningitis 
 Leukaemia, 814 
 
 classification of, 814 
 lymphatic, acute, 815 
 
 diagnosis of, 816 
 symptoms of, 815 
 chronic, 816 
 
 course of, 817 
 diagnosis of, 817 
 symptoms, 816 
 myeloid, 818 
 
 complications of, 821 
 diagnosis of, 821 
 differentiation of, 822 
 prognosis of, 822 
 symptoms of, 818 
 treatment of, 822 
 Leukansemia, 822 
 Leukocythamiia, 814 
 Leukocytosis in pneumonia, 138 
 Leukopenia in typhoid fever, 26 
 Leukoplakia, syphilitic, 260 
 
 of tongue, 557 
 Leyden-Curschmann spirals, 491 
 Lichen scrofulosorum, 345 
 Licorice. See Glycyrrhizae 
 Lien mobile, 845 
 Lientery, 719 
 
 Life assurance, syphilis and, 281 
 Lips, tuberculosis of, 334 
 
INDEX. 
 
 1233 
 
 Lipuria, 774 
 
 Lithuria, 775 
 
 Litten's sign in pneumonia, 136 
 
 in tuberculosis, 312 
 Little's disease, 949 
 Liver, abscess of, 679 
 amoebic, 680 
 
 diagnosis of, 682 
 differentiation of, 44, 682, 
 
 686, 695 
 pathology of, 681 
 symptoms of, hepatic, 681 
 icterus, 682 
 rupture, 682 
 septic, 681 
 treatment of, 683 
 cholangitic, 680 
 differentiation of, 44, 682, 686, 
 
 695 
 dysenteric, 222, 680 
 etiology of, 679 
 pylephlebitis 680, 694 
 septic, 679 
 solitary, 680 
 tropical, 680 
 in typhoid fever, 33 
 varieties of, 679 
 actinomycosis of, 249 
 amyloid, 689 
 
 diagnosis of, 690 
 differentiation of, 695 
 etiology of, 689, 264, 324 
 pathology of, 690 
 symptoms of, 690 
 anomalies of, 691 
 atrophy of, acute yellow, 664 
 course of, 667 
 diagnosis of, 667 
 differentiation of, 667, 
 
 695 
 etiology of, 665 
 pathology of, 665 
 symptoms of, 665 
 treatment of, 668 
 cancer of, 683 
 
 diagnosis of, 685 
 differentiation of, 264, 685, 695 
 primary, 683 
 secondary, 684 
 symptoms of, ascites, 685 
 cachexia, 684 
 icterus, 684 
 liver, 684 
 treatment, 686 
 cirrhosis of, 668 
 alcoholic, 668 
 atrophic, 668 
 biliary, 676 
 
 diagnosis of, 677 
 differentiation of, 677, 695 
 etiology of, 676 
 symptoms of, 676 
 digestive, 677 
 icterus, 677 
 liver, 677 
 
 78 
 
 Liver, cirrhosis of, biliary, symptoms 
 of, nutrition, 677 
 spleen, 677 
 urine, 677 
 treatment of, 679 
 capsular, 668 
 cardio tuberculosa, 324 
 classification of, 668 
 Glissonian, 668 
 Hanot's, 676, 668 
 hepatic vein, 668 
 in heart disease, 409 
 Laennec's, 668 
 malarial, 115 
 mixed, 668 
 Pick's pseudocirrhosis, 674, 
 
 727 
 pigmentary, 675 
 portal, 668 
 
 classification of, 668 
 complications of, 672 
 cardiac, 673 
 febrile, 673 
 hsematemesis, 672 
 hemorrhages, 672 
 icterus, 673 
 nephritis, 672 
 peritonitis, 672 
 pulmonary, 673 
 course of, 673 
 diagnosis of, 673 
 differentiation of, 673, 677, 
 
 695, 733 
 etiology of, 668 
 pathology of, 669, 677 
 prognosis of, 673 
 symptoms of, 699 
 general, 672 
 liver, 670 
 treatment of, medical, 675 
 surgical, 676 
 tuberculous, 324 
 congestion of, arterial, 692 
 passive, 409, 692 
 
 differentiation of, 695 
 etiology of, 692 
 pathology of, 692 
 symptoms of, 693, 409 
 corset, 691 
 cysts of, echinococcus, 686 
 
 complications of, 687 
 diagnosis of, 687 
 differentiation of, 687, 695 
 multilocular, 688 
 prognosis of, 688 
 rupture of, 687 
 symptoms of, 686 
 treatment of, 688 
 unilocular, 686 
 hydatid, differentiation of. 
 
 695 
 non-parasitic, 687 
 diseases of, 664 
 
 differential table of, 695 
 echinococcus, 686 
 
1234 
 
 INDEX. 
 
 Liver, enlargement of, differentiation 
 of, from pleurisy, 539 
 fatty, 689 
 
 differentiation of, 695, 689 
 etiology of, 689 
 pathology of, 689 
 symptoms of, 689 
 floating, 691 
 flukes, 1210 
 gumma of, 262 
 icing-liver, 733, 674, 727 
 large, causes of, 674 
 lobulated, 263 
 
 nut-meg, in heart disease, 409 
 perihepatitis, 263 
 sarcoma of, 683 
 small, causes of, 674 
 syphilis of, 262 
 
 gummatous, 263 
 interstitial, 263 
 differentiation of, 264, 695 
 tuberculosis of, 324, 337 
 tumors of, 683 
 wandering, 691 
 zuckerguss, 674, 733, 727 
 Lock-jaw, 238 
 Locomotor ataxia, 1049 
 Loeffler's solution, 161 
 Ludwig's angina, 159, 559 
 Lues venerea, 253 
 Lumbago, 1173 
 Lumbar puncture, 169, 173, 759 
 
 and injections, 243 
 Lumpy- jaw, 248 
 Lungs, abscess of, 509 
 
 bacteriology of, 509 
 diagnosis of, 510 
 differentiation of, 510, 530 
 etiology of, 509 
 pathology of, 509 
 pneumonic, 141 
 prognosis of, 510 
 symptoms of, 509 
 treatment of, 510 
 in typhoid fever, 35 
 actinomycosis of, 249 
 anthracosis of, 506 
 anthrax of, 234 
 arteriosclerosis of, 453 
 atelectasis of, 507 
 acquired, 508 
 
 etiology of, 508 
 pathology of, 508 
 symptoms of, 508 
 treatment of, 508 
 congenital, 507 
 
 etiology of, 507 
 pathology of, 507 
 symptoms of, 507 
 treatment of, 507 
 calculi of, 308. 489 
 cavities of, differentiation of, 539, 
 547 
 signs of, 314 
 chalicosis of, 506 
 
 Lungs, circulatory affections of, 516 
 cirrhosis of, 504 
 congestion of. active. 516 
 ' passive, 408, 516 
 
 treatment of, 517 
 
 in typhoid fever, 34 
 diseases of, 494 
 embolism of. See Infarct of 
 emphysema of, 494 
 
 diagnosis of, 496 
 
 differentiation of, 496 
 
 etiology of, 494 
 
 interstitial. 497 
 
 pathogenesis of, 494 
 
 pathology of, 494 
 
 prognosis of, 497 
 
 symptoms of, 495 
 
 treatment of, 498 
 erysipelas of, 102 
 fever. 129 
 flukes, 12 ID 
 gangrene of, bacteriology of, 510 
 
 complications of, 513 
 
 course of, 513 
 
 diagnosis of, 513 
 
 differentiation of, 513 
 
 etiology of, 511, 872 
 
 pathology of, 511 
 
 physical signs of, 512 
 
 pneumonic, 141 
 
 prognosis of, 513 
 
 symptoms of, 512 
 
 treatment of, 513 
 
 in typhoid fever, 35 
 haemoptysis, 519 
 hemorrhage of. 309, 521 
 hypertrophy of, 497 
 hypostasis of, 516 
 induration of, 504 
 
 brown, 408, 516 
 
 pneumonic, 141 
 infarct of, 517 
 
 diagnosis of, 143, 518 
 
 etiology of, 517 
 
 pathology of, 517 
 
 symptoms of, 517 
 
 in typhoid, 35 
 interlobar fissures of, 536 
 oedema of, 518 
 
 etiology of, 518 
 
 in heart disease, 408 
 
 pathology of, 518 
 
 in rheumatism, 192 
 
 symptoms of, 518 
 
 treatment of, 519 
 parasites of, 522 
 
 distoma, 523 
 
 echinococcus, 522 
 
 diagnosis of, 522 
 prognosis of, 523 
 symptoms of, 522 
 treatment of, 523 
 pneumokoniosis, 506 
 senile, 496 
 siderosis of, 506 
 
INDEX. 
 
 1235 
 
 Lungs, stones, 308, 489 
 syphilis of, q. v. 
 tuberculosis of, q. v. 
 tumors of, 514 
 benign, 516 
 cancer, 514 
 
 etiology of, 513 
 physical signs of, 515 
 symptoms of, 514 
 differentiation of, 144, 538 
 lymphosarcoma, 515 
 sarcoma, 515 
 Lupus, 344 
 
 Lymphadenitis, Pfeiffer's, 258 
 glands, tuberculosis of, 325 
 anthracosis, 506 
 Lymphamiia, acute, 815 
 
 chronic, 816 
 Lymphangitis, differentiation of, 103 
 Lymphatism, 847 
 Lymphoma, malignant, 823 
 Lymphosarcomatosis, 827 
 Lyssa, 243 
 Lyssophobia, 245 
 
 M 
 
 Magnesium carbonate, 602, 616 
 oxide, 583 
 sulphate, 413 
 Maidism, 1187 
 Haladie de Roger, 419 
 
 de WoilUz, 516 
 Malaria, 105 
 
 cachexia of, 116 
 
 chronic, 116 
 
 diagnosis of, 120 
 
 differentiation of, 42, 43, 118, 120, 
 
 121, 210 
 etiology of, 106 
 
 Plasmodium, 106 
 
 forms of. sestivo-autum 
 nal, 108 
 half-moons. 108 
 quartan, 106 
 tertian, 107 
 pernicious, 117 
 
 etiology of, 117 
 forms of, 117 
 algid, 119 
 alimentary, 119 
 biliary, 119 
 cerebral, 119 
 comatose, 119 
 convulsive, 119 
 hsemoglobinuric, 119 
 hemorrhagic, 119 
 meningeal, 119 
 typhoid, 117, 118 
 prognosis of, 121 
 relapses of, 116 
 
 relation of, to other diseases, 116 
 spontaneous recovery from, 121 
 svmptoms of, 110 
 blood, 113 
 circulatory, 114 
 
 Malaria, symptoms of, digestive, 114 
 fever, 110 
 
 aestivo-autumnal, 112 
 intermittent, 112 
 quartan, 111 
 tertian, 111 
 genito-urinary, 115 
 nervous, 116 v 
 respiratory, 114 
 skin, 114 
 spleen, 113 
 treatment of, 121 
 
 prophylactic, 121 
 specific, 121 
 symptomatic, 122 
 Mai perforant du pied, 357, 870, 1055 
 Male fern, 1193 
 Mallein, 236 
 Malta fever, 225 
 
 complications of, 226 
 course of, 226 
 diagnosis of, 227 
 etiology of, 225 
 prognosis of, 226 
 symptoms of, 225 
 treatment of, 227 
 types of, 226 
 Mamma, syphilis of, 281 
 tuberculosis of, 340 
 Mania, 979 
 Mania a potu, 1177 
 Marriage after syphilis, 285 
 Mastitis, syphilitic, 281 
 Measles, 92 
 
 clinical course of, 93 
 
 diagnosis of, 96 
 
 differentiation of, 59, 65, 72, 96, 97, 
 
 178 
 etiology of, 92 
 
 German. See German Measles 
 prognosis of, 96 
 stages of, 93 
 symptoms of, 93, 94 
 digestive, 96 
 eruption, 94 
 fever, 95 
 
 general course, 93 
 genito-urinary, 96 
 nervous, 96 
 respiratory, 95 
 treatment of, 98 
 
 of complications, 98 
 Meat poisoning, 1185 
 Meckel's diverticulum, 645 
 Mediastinal hemorrhage, 552 
 pleurisy, 534 
 tumors, 549 
 Mediastinitis, acute, 551 
 
 chronic, 551, 431 
 Mediastino-pericarditis, 431 
 Mediastinum, diseases of, 549 
 Medulla, diseases of, 982 
 Megalogastria, 593 
 Megalomania, 976 
 Melanamiia, in malaria, 113 
 
1236 
 
 INDEX. 
 
 Melanoderma, 839, 840 
 Melanoglossia, 557 
 Melanotrichia linguae, 557 
 Melanuria, 685 
 Melasma suprarenale, 839 
 Meniere's disease, diagnosis of, 1101 
 etiology of, 1100 
 symptoms of, 1101 
 treatment of, 1101 
 Meninges, carcinoma of, 272 
 cerebral, diseases of, 989 
 hemorrhage into, 992, 951 
 inflammation of, 165 
 spinal, diseases of, 1015 
 
 hemorrhage, 1015 
 hypersemia, 1015 
 leptomeningitis, 1017 
 pachymeningitis, 1016 
 tumors of, 1017 
 
 differentiation of. 
 272 
 tuberculosis of, 304 
 sarcoma of, 272 
 Meningismus, 28 
 Meningitis, carcinomatous, 272 
 chronic, 996 
 
 epidemic cerebrospinal, 165 
 bacteriology of, 165 
 clinical forms of, 169 
 complications of, 169 
 diagnosis, 169, 170 
 differentiation, 42, 43, 58, 
 . 170, 171, 172 
 etiology of, 165 
 pathology of, 166 
 prognosis of, 169 
 sequelae of, 169 
 symptoms of, 165 
 treatment of, 172 
 pneumococcic, 140 
 in influenza, 175 
 pachymeningitis, 989 
 sarcomatous, 272 
 serous, 995 
 
 differentiation of, 170, 171, 
 
 172, 972 
 symptoms of, 996 
 suppurative, 993 
 
 differentiation of. 170, 171, 
 
 172, 971, 
 pathology of, 994 
 symptoms of, 994 
 syphilitic, 271 
 tuberculous, 304 
 
 differentiation of, 42, 171, 172, 
 
 273 
 etiology of, 304 
 pathology of, 304 
 symptoms of, 305 
 in typhoid fever, 28 
 Meningococcus intracellularis, 165 
 Menthol, 61, 352, 470, 628, 1207 
 Meralgia paraesthetica, 1114 
 Mercury, 286. See Hydrargyrum 
 Merycismus, 62Q 
 
 Mesenteric glands, suppuration of, in 
 typhoid fever, 30, 
 tuberculosis of, 328 
 vessels, dilatation of, 664 
 embolism of, 664 
 periarteritis of, 664 
 Mesenteritis, 332, 663, 732 
 Mesentery, diseases of, 663 
 embolism of, 664 
 hemorrhage of, 663 
 inflammation of, 663 
 suppuration of, 664 
 tumors of, 664 
 Metabolism, diseases of, 863 
 Metatarsalgia, 1166 
 Meteorism in typhoid fever. 30 
 Methyl blue, 611, 779 
 Micrococcus catarrhalis, 479 
 
 melitensis, 225 
 Microgastria, 593 
 Micromania, 976 
 Micromelia, 860 
 Migraine, 1160 
 
 diagnosis of, 1162 
 etiology of, 1160 ■ 
 ophthalmoplegic, 1087 
 prognosis of, 1161 
 symptoms of, 1160 
 treatment of, 1162 
 Mikulicz's disease, 559, 828 
 Miliaria, differentiation of, 80 
 in pneumonia, 138 
 in typhoid fever, 23 
 Miliary fever, 359 
 
 tuberculosis, 299 
 Milk, diet, 49, 635, 756 
 sickness, 361 
 poisoning, 1186 
 Millar's asthma, 182, 859 
 Mimetic movements of expression, 911 
 " Mind blindness," 903, 904 
 
 centres for, 904 
 Mitral insufficiency, 190, 396 
 
 diagnosis of, 398, 401, 406 
 etiology of, 396 
 mechanism of, 396 
 physical signs of, 396 
 prognosis of, 411 
 treatment of, 412 
 stenosis, 398 
 
 diagnosis of, 400 
 differentiation, 378, 401, 406 
 etiology of, 398 
 mechanism of, 398 
 physical signs of, 399 
 prognosis of, 411 
 treatment of, 412 
 Mobius' sign, 851 
 Mogigraphia, 1155 
 Moller's disease, 835 
 Monoplegia, in cerebral thrombosis, 941 
 cortical, 900 
 
 internal capsule, lesion in, 912 
 Morbilli, 92 
 Morbus cseruleus, 421 
 
INDEX. 
 
 1237 
 
 Morbus coxae senilis, 887 
 
 maculosus neonatorum, 832 
 Werlhofii, 830 
 Morphine, 51, 52, 53, 122, 148, 184, 
 
 243, 351, 352, 417, 492 
 Morphinism, 1179 
 Morphinomania, 1179 
 Morvan's disease, 1047 
 Mosquito, conveyance of malaria by, 
 106, 109, 121 
 yellow fever, 206 
 Motor cortex, 899 
 tracts, 998 
 
 degeneration of, 923 
 Mountain fever, 361 
 Mouth, diseases of, 553 
 syphilis of, 260 
 washes, 49, 553, 554 
 Movements, associated, 920 
 forced, 917 
 mimetic, 911 
 
 resisted, in heart disease, 367 
 Mucin, tests for, 770 
 Muguet, 555 
 Multiple neuritis, 1077 
 
 sclerosis, 1039 
 Mumps, 184 
 
 complications of, 185 
 course of, 185 
 diagnosis of, 186 
 etiology of, 184 
 prognosis of, 186 
 sequels of, 185 
 symptoms of, 185 
 treatment of, 186 
 Muscles, diseases of, 1172 
 syphilis of, 278 
 tuberculosis of, 344 
 in typhoid fever, 36 
 Muscular atrophy, arthritic, 1066 
 neuritic, 1067 
 progressive spinal, 1064 
 
 diagnosis of, 1066 
 differentiation of, 
 
 1036, 1038, 1066 
 etiology of, 1064 
 pathology of, 1064 
 prognosis of, 1066 
 symptoms of, 1064 
 treatment of, 1067 
 dystrophy, 1067 
 
 diagnosis of, 1070 
 differentiation of, 1036, 1070 
 infantile atrophic, 1067 
 juvenile, 1067 
 pseudohypertrophic, 1068 
 treatment of, 1070 
 Myalgia, 1173 
 capitis, 1173 
 rheumatic, 191 
 Myasthenia, gravis, 985 
 
 differentiation of, 985 
 pseudoparalytica, 985 
 Myasthenic reaction, 985 
 Mycosis intestinalis, 233 
 
 Mycotic plugs, 482 
 Mydriasis, syphilitic, 277 
 Myelaemia, 818 
 Myelasthenia, 1128 
 Myelitis, acute, 1026 
 
 course of, 1028 
 diagnosis of, 1030 
 differentiation of, 1030 
 disseminated, 1027, 1031 
 etiology of, 1026 
 localization of, 1029 
 pathology of, 1026 
 prognosis of, 1028 
 symptoms of, 1027 
 transverse, 1027 
 treatment of, 1030 
 annular, 1027 
 chronic, 1031 
 compression, 1010 
 cortical, 1027 
 Myeloma, multiple, 827 
 Myelomalacia, 1010, 1021 
 Myocarditis, acute, 373 
 
 diagnosis of, 374 
 etiology of, 373 
 pathology of, 373 
 symptoms of, 374 
 treatment of, 374 
 chronic fibrous, 375 
 
 diagnosis of, 377 
 differentiation of, 377 
 etiology of, 375 
 pathogenesis of, 376 
 pathology of, 375 
 prognosis of, 377 
 symptoms of, 376 
 treatment of, 377 
 in diphtheria, 156 
 rheumatic, 190 
 segmentary, 156, 374 
 syphilitic, 265 
 in typhoid fever, 25 
 Myocardium, diseases of, 363 
 fragmentation, 157, 374 
 myofibrosis, 375 
 myolysis, 157, 374 
 myomalacia cordis, 376 
 parasites of, 379 
 segmentation, 156, 157, 374 
 tuberculosis, 343 
 tumors of, 379 
 Myoclonia, 1150 
 Myofibrosis, myocarditis, 375 
 Myoidema, 323 
 Myolysis in diphtheria, 157 
 
 myocardial, 374 
 Myomalacia, cordis, 376 
 Myopathies, 1067 
 Myositis, 1172 
 
 ossificans, 1173 
 rheumatic, 191 
 syphilitic, 280 
 Myotonia, 1156 
 
 etiology of, 1156 
 symptoms of, 1156 
 
1238 
 
 INDEX. 
 
 Myotonia, treatment of, 1156 
 Mytilotoxismus, 1186 
 Myxoedema, 854 
 
 of adults, 855 
 
 of children, 855 
 
 differentiated, 849, 855 
 
 operative, 856 
 
 treatment of, 857 
 
 N 
 
 Nasal feeding in typhoid fever, 50 
 Nasopharynx, tuberculosis of, 341 
 Nauheim baths in heart disease, 066 
 Neck, actinomycosis of, 247 
 
 rigidity, meningitic, 166 
 Negri bodies in hydrophobia, 245 
 Nematodes, diseases caused by, 1199 
 Nephritis, acute, 737 
 course of, 741 
 diagnosis of, 740 
 differentiation of, 740, 764, 
 
 765 
 etiology of, 737 
 pathology of, 737 
 prognosis of, 741 
 symptoms of, albuminuria, 738 
 anaemia, 740 
 anasarca, 739 
 casts, 738 
 heart, 740 
 urine, 738 
 treatment, 742 
 types of, cholera, 740 
 hsemoglobinuric, 741 
 kidney of pregnancy, 740 
 recurrent, 741 
 chronic, 743 
 
 interstitial, 747 
 
 complications of, 750, 752 
 diagnosis of, 753 
 
 of cardiac symptoms, 
 
 753 
 of uraemia, 753 
 of urinary findings, 
 753 
 differentiation of, 753, 
 
 754, 764, 765 
 etiology of, 747 
 pathology of, 748 
 prognosis of, 754 
 symptoms of, 748 
 
 cardiovascular, 750 
 digestive, 752 
 hemorrhages, 752 
 inflammations, 753 
 retinitis, 750 
 ursemia, 750 
 urinary, 749 
 treatment of, 754 
 parenchymatous, 744 
 
 complications of, 746 
 death in, causes of, 746 
 diagnosis of, 747 
 differentiation of;, 764, 
 765 
 
 Nephritis, chronic parenchymatous, eti- 
 ology of, 744 
 pathology of, 744 
 prognosis of, 746, 747 
 symptoms of, 745 
 anaemia, 746 
 cardiovascular, 746 
 oedema, 746 
 urinary, 745 
 treatment of, 754 
 treatment of, climate, 755 
 diet, 755 
 diuretics, 757 
 heart stimulants, 759 
 incisions, 758 
 oedema, 757 
 rest, 754 
 sweating, 757 
 vasodilators, 759 
 venesection, 759 
 water, 757 
 in cirrhosis of liver, 672 
 diphtheritic, 157 
 in malaria, 115 
 in pneumonia, 139 
 suppurative, 777, 779, 780 
 scarlatinal, 85, 91 
 syphilitic, acute, 265 
 
 chronic, 265 
 tuberculous, 324 
 typhoid, 35 
 Nephrolithiasis, 784 
 Nephrectomy, 792 
 Nephrolithotomy, 789 
 Nephrorrhaphy, 767 
 Nerves. See also Paralysis 
 anterior crural, 1114 
 auditory, paralysis of, 1099 
 brachial plexus, 1113 
 circumflex, 1110 
 cranial, diseases of, 1082 
 diseases of, 1074 
 eighth, disease of, 1099 
 eleventh, disease of, 1107 
 facial, paralysis of, central, 1096 
 peripheral, 1094 
 spasm of, 1098 
 fifth, paralysis of, 1091 
 
 spasm of, 1092 
 fourth,, disease of, 1085 
 glossopharyngeal, 1102 
 hypoglossal, disease of, 1109 
 lumbar plexus, 1114 
 median, 1112 
 musculospiral, 1110 
 ninth, 1102 
 obturator, 1114 
 olfactory, 1082 
 optic, 1054, 1082 
 peroneal, 1115 
 phrenic, 1110 
 popliteal, 1115 
 posterior thoracic, 1111 
 recurrent laryngeal, paralysis of, 
 461 
 
INDEX. 
 
 1239 
 
 Nerves, recurrent laryngeal, spasm of, 
 461 
 sacral plexus, 1114 
 sciatic, 1115 
 
 seventh, disease of, 1093 
 sixth, disease of, 1085 
 spinal accessory, paralysis of, 1108 
 
 spasm of, 1108 
 superior gluteal, 1114 
 suprascapular, 1110 
 syphilis of, 272, 273 
 tenth, 1102 
 
 third, disease of, 912, 913, 1085 
 twelfth, disease of, 1109 
 ulnar, 1112 
 vagus, 439, 1102 
 Nervous fever, 27 
 diseases, 899 
 Neuralgia, 1163 
 diabetic, 870 
 etiology' of, 1163 
 in influenza, 175 
 in malaria, 116 
 symptoms of, 1163 
 treatment of, 1167 
 varieties of, cervicobrachial, 1165 
 
 cervico-occipital, 1165 
 
 intercostal, 1165 
 
 lumbar, 1166 
 
 phrenic, 1165 
 
 sacral, 1166 
 
 trifacial, 1164 
 
 visceral, 1166 
 Neurasthenia, 1127 
 course of, 1131 
 diagnosis of, 1131 
 differentiation of. 979, 1132 
 etiology of, 1128 
 prognosis of, 1131 
 symptoms of, 1128 
 treatment of, 1132 
 types of, 622, 1128 
 Neuritis, 1074 
 
 brachial, 1113 
 
 diabetic, 870 
 
 diagnosis of, 1076 
 
 in diphtheria, 157 
 
 etiology of. 1094 
 
 facial,' 1094 
 
 in influenza, 175 
 
 lead poisoning causing, 1183 
 
 in leprosy, 356 
 
 multiple, 1077 
 
 diagnosis of, 1079 
 
 differentiation of, 1036, 1079 
 
 etiology of, 1077 
 
 pathology of, 1077 
 
 prognosis of, 1079 
 
 symptoms of, 1077 
 
 treatment of, 1081 
 optic, 1082 
 pathology of, 1074 
 rheumatic, 193 
 sciatic, 1116 
 symptoms of, 1075 
 
 Neuritis, treatment of, 1076, 1081 
 
 in tuberculosis, 323 
 
 in typhoid fever, 28 
 Neuroma, 1081 
 Neurones, 997 
 
 motor, 998 
 
 sensory, 1001 
 Neuroses, 1118 
 
 fatigue, 1155 
 
 occupation, 1155 
 
 traumatic, 1134 
 
 trophic, 1168 
 
 vasomotor, 1168 
 Nigrities linguse. 557 
 Nitroglycerine, therapeutics of. 91, 122, 
 
 417, 418, 446, 492, 759 
 Nitromuriatic acid, 584 
 Nodes, rheumatic, 191 
 Noma oris, 556 
 Nose, diphtheria of, 154, 155 
 
 diseases of, 469 
 
 saddle-back, 267 
 
 syphilis of, 267 
 
 tuberculosis of, 341 
 Nucleo-albumin, tests for, 770 
 Nystagmus, 1090 
 
 in multiple sclerosis, 1041 
 
 Obesity, 894 
 
 in diabetes, 864 
 etiology of, 894 
 symptoms of, 894 
 treatment of, 896 
 Ochronosis, 776 
 (Edema, angioneurotic, 1170 
 cardiac, 410 
 of glottis, 476 
 
 in typhoid fever, 34 
 in heart disease, 410 
 hereditary, 1170 
 of larynx, 476 
 of lungs, 518 
 renal, 739, 746 
 in whooping-cough, 181 
 Oertel's cure, 895 
 
 treatment of heart disease, 366 
 (Esophagitis, etiology of, 568 
 symptoms of, 568 
 treatment of, 569 
 CEsophagomalacia, 569 
 (Esophagus, cancer of, complications, 
 575 
 diagnosis, 575 
 etiology of, 574 
 pathology, 574 
 symptoms, 574 
 treatment, 575 
 dilatation of, etiology of, 572 
 symptoms of, 572 
 treatment of, 572 
 diseases of, 568 
 diverticulum, 573 
 hemorrhage of, 576 
 inflammation of. 568 
 
1240 
 
 INDEX, 
 
 (Esophagus, measurements of, 570 
 necrosis of, 568 
 neuroses of, 572 
 perforation of, 575 
 pulsion-diverticulum, 573 
 rupture of, 575 
 sounding of, 570, 571 
 spasm of, 572 
 stenosis of, 569 
 stricture of, diagnosis, 569 
 etiology of, 569 
 physical signs of, 570 
 prognosis of, 571 
 symptoms, 570 
 treatment of, 571 
 syphilis of, 261 
 traction-diverticulum, 573 
 tuberculosis of, 335 
 tumors of, benign, 575 
 typhoid ulceration of, 29, 30 
 ulceration of, 568 
 varices of, 672 
 Oi'dium albicans, 555 
 Oleum olivse, 573, 603, 629 
 ricini, 662 
 tiglii, 743 
 Oligocardia, 440 
 Oligoehromsemia, 798 
 Ophthalmia, diphtheritic, 156 
 
 neuroparalytic, 1091 
 Ophthalmoplegia, progressive nuclear, 
 1088 
 syphilitic, 277 
 Ophthalmoreaction, 319 
 Opisthorehis siensis, 1210 
 Opium, coma from, 931 
 poisoning, acute, 1179 
 
 chronic, 1179 
 therapeutics of, 148, 224, 351, 560, 
 659, 725, 877, 663. See also 
 Morphine 
 Oppler-Boas bacillus, 609 
 Optic atrophy, syphilitic, 276 
 tabetic, 1054 
 nerve, 1082, 1083, 1084 
 neuritis, syphilitic, 272 
 
 in typhoid fever, 36 
 thalamus, localizing symptoms, 
 911 
 Orchitis, in mumps, 185 
 syphilitic, 277 
 in typhoid fever, 36 
 Orthoform, 657 
 Osmic acid injections, 1167 
 Osteitis deformans, 861 
 Osteo-arthropathie hypertrophiante 
 
 pneumonique, 325, 486, 862 
 Osteo-arthropathy, hypertrophic, 325, 
 
 486, 862 
 Osteochondritis, syphilitic, 284, 893 
 Osteomyelitis. See Septic Infections, 
 127 
 in typhoid fever, 36 
 Otitis, diphtheritic, 156 
 
 media, brain abscess from, 967 
 
 Otitis media, sinus thrombosis from, 946 
 
 measles, 96, 98 
 
 scarlatinal, 86, 91 
 Ovary, syphilis of, 278 
 Oxaluria, 775 
 
 Oxygen, therapeutics of, 149 
 Oxyuris vermicularis, 1200 
 
 Pachydermia, 855 
 
 Pachymeningitis, cervical hypertrophic, 
 1016 
 external, 989 
 
 hemorrhagic, diagnosis of, 991 
 differentiation of, 992, 979 
 etiology of, 990 
 pathology of, 990 
 prognosis of, 991 
 symptoms of, 991 
 treatment of, 992 
 internal, 989 
 Paget's disease, 861 
 Pain, abdominal, 642 
 Pain, centre for, 905 
 Palate, tuberculosis of, 335 
 Palpitation of heart, 436 
 Palsy, shaking, 1157 
 Pancreas, calculi of, 717 
 
 cancer of, differentiation of, 720 
 
 symptoms, 719 
 cysts of, 718 
 
 diagnosis of, 718 
 etiology of, 718 
 pathology of, 718 
 symptoms of, 718 
 treatment of, 719 
 diseases of, 713 
 hemorrhage from, 717 
 inflammation of, acute, 713 
 
 chronic, 716 
 syphilis of, 262 
 tumors of, 719 
 
 differentiation of, 720 
 symptoms of, 719 
 treatment of, 720 
 Pancreatitis, acute, diagnosis of, 715 
 differentiation, 715 
 etiology of, 713 
 gall-stones in, 703, 713 
 prognosis of, 715 
 symptoms, 713 
 treatment of, 715 
 chronic, etiology of, 716 
 gall-stones in, 703, 716 
 pathology of, 716 
 prognosis of, 716 
 symptoms of, 716 
 treatment of, 716 
 Paracentesis, abdomen, 733 
 
 chest, 530, 541 
 Paracolon infection, 44 
 Paresie analgesique avec panaris, 1046 
 Paragonimus Westermanni, 1210 
 Parkinson's disease, 1157 
 
INDEX. 
 
 1241 
 
 Paralysis. See Monoplegia, Hemiplegia, 
 Paraplegia, and Nerves, 
 agitans, 1157 
 
 diagnosis of, 1159 
 
 differentiation of, 1043, 1159 
 
 etiology of, 1157 
 
 pathology of, 1157 
 
 prognosis of, 1159 
 
 symptoms of, 1157 
 
 treatment of, 1159 
 alternating, 912, 914 
 anterior crural, 1114 
 of auditory nerve, 1099 
 Bell's, 1094 
 brachial plexus, 1113 
 Brown- Sequard's, 1023 
 bulbar, apoplectiform, 985 
 
 asthenic, 985 
 
 chronic, 982 
 caisson, 1022 
 circumflex, 1111 
 combined, of arm nerves, 1113 
 compression, spinal, 1010 
 conjugate, 914 
 cortical, 900 
 crossed, 912, 914 
 diphtheritic, 157 
 diver's, 1022 
 facial, 1094 
 
 diagnosis of, 1096 
 
 etiology of, 1094 
 
 localization of, 914, 1095 
 
 pathology of, 1094 
 
 prognosis of, 1097 
 
 symptoms of, 1095 
 
 in tetanus, 241 
 
 treatment of, 1098 
 of fifth nerve, 1091 
 of fourth nerve, 1087 
 Gublers', 914 
 hemiplegia, q. v. 
 hypoglossal, 1109 
 hysterical, 1122 
 infantile cerebral, 949 
 diplegic, 950 
 
 diagnosis of, 953 
 etiology of, 950 
 pathology of, 951 
 symptoms of, 952 
 treatment of, 953 
 hemiplegic, 949 
 
 diagnosis of, 950 
 etiology of, 949 
 symptoms of, 949 
 treatment of, 953 
 of insane, 973 
 labioglossopharyngeal, 982 
 Landry's, 1038 
 laryngeal, 1104 
 
 recurrent, 461, 1103-1105 
 lead, 1183 
 
 lumbar plexus, 1114 
 in malaria, 116 
 in meningitis, 167 
 median, 1112 
 
 Paralysis, inusculospiral, 1111 
 
 obturator, 1114 
 
 ocular, 965, 1054, 1085 
 
 oculomotor, 913, 914, 965, 1054, 
 1085 
 
 paraplegia, q. v. 
 
 periodic family, 1159 
 
 peroneal, 1115 
 
 phrenic, 1110 
 
 popliteal, 1115 
 
 posterior thoracic, 1111 
 
 pseudobulbar, 984 
 
 pseudo-, syphilitic, 835, 836 
 
 pupil, 1086 
 
 sacral, 1114 
 
 sciatic, 1115 
 
 seventh, 1093 
 
 sixth nerve, 1087 
 
 spinal accessory, 983, 1107 
 
 superior gluteal, 1114 
 
 suprascapular, 1111 
 
 of sympathetic nerves, 1089 
 
 third nerve, 1085 
 
 ulnar, 1112 
 
 uraemic, 751 
 
 vagus, 983, 1102 
 
 of "vocal cords, 1103-1105 
 
 Weber's, 913 
 Paramyoclonus multiplex. 1150 
 Paramyotonia, ataxic, 1157 
 
 congenital, 1157 
 Paranephritis, 780 
 Paraplegia, ataxic, 1073 
 
 in cerebral infantile paralysis, 953, 
 952 
 
 dolorosa, 1014, 1018 
 
 hysterical, 1030 
 
 spastic spinal, 1060 
 Paraplegic state, 1031 
 Parapleuritis, 535 
 
 Parasites, diseases due to animal, 1191 
 Parathyroid glands, 857 
 Paratyphoid fever, 19, 44 
 
 differentiation of, 44 
 microorganisms of, 44 
 symptoms of, 44 
 Paregoric, 663 
 Parorexia, 622 
 Parosmia,' 1082 
 Parotitis, acute, 558 
 
 chronic, 559 
 
 epidemic, 184 
 
 post-operative, 186 
 
 secondary, 186 
 
 in typhoid fever, 29 
 Parrot's" disease, 836 
 
 ulcers, 554 
 Pavor nocturnus, 567 
 Peliosis rheumatica, 829 
 Pellagra, 1187 
 
 differentiation of, 842 
 Pelletierine, 1193 
 Pelvis, rhachitic, 892 
 Pemphigus, differentiation of, 80 
 Penis, syphilis of, 277 
 
1242 
 
 INDEX. 
 
 Pentosuria, 874 
 
 Pepsin, test for in stomach, 582 
 
 therapy of, 584 
 Peptone, test for, 770 
 Periarteritis nodosa, 467 
 Pericarditis, 422 
 adhesive, 431 
 
 diagnosis of, 432 
 prognosis of, 432 
 symptoms of, 432 
 
 cardiac insufficiency, 432 
 diastolic collapse of veins, 
 432 
 recoil, 432 
 inspiratory swelling of 
 
 veins, 433 
 paradoxical pulse, 432 
 retraction of apex, 432 
 of chest wall, 432 
 treatment of, 432 
 differentiation of, from pleurisv, 
 
 539 
 effusive, 423 
 
 course of., 430 
 diagnosis of, 428 
 
 character of exudate, 430 
 dulness, 429 
 friction rub, 428 
 pathology of, 423 
 physical signs of, 424 
 prognosis of, 430 
 symptoms of, 424 
 treatment of, 430 
 etiology of, 422 
 externa, 423 
 fibrinous, 423 
 
 physical findings of, 423 
 symptoms of, 423 
 pneumococcic, 140 
 pseudocirrhosis of liver in, 674, 727 
 rheumatic, 190 
 scarlatinal, 84 
 syphilitic, 266 
 tuberculous, 329 
 in typhoid fever, 25 
 Pericardium, diseases of, 422 
 
 tuberculosis of, 422 
 Perichondritis, laryngeal, in typhoid 
 fever, 34 
 of larynx, 268, 477 
 Perihepatitis, 674 
 
 differentiation of, 674, 727, 733 
 Perinephric abscess, 780 
 diagnosis of, 781 
 etiology of, 780 
 symptoms of, 780 
 Perinephritis, 780 
 Periostitis, rheumatic, 191 
 syphilitic, 278 
 in typhoid fever, 37 
 Peripleuritis, 535 
 Perisplenitis, 844 
 Peristaltic unrest, 663 
 Peritoneum, cancer of, 727 
 
 differentiation of, 733 
 
 Peritoneum, diseases of, 721 
 
 tuberculosis of, 329 
 Peritonitis in cirrhosis of liver, 672 
 diffuse, acute, 721 
 
 course of, 723 
 differentiation of, 724 
 diagnosis of, 724 
 etiology of, 641, 721 
 perforative, 723 
 pneumococcic, 724 
 puerperal, 127 
 symptoms of, abdominal, 
 722 
 general, 722 
 local, 722 
 treatment of, 724 
 types of, 641, 723 
 chronic, 725 
 
 differentiation of, 733 
 deforming, 332, 725 
 hemorrhagic, chronic, 727 
 localized, 725 
 
 adhesive, 727 
 
 perihepatitis, 727 
 suppurative, 725 
 
 pyopneumothorax, sub- 
 
 phrenicus, 725 
 subphrenic abscess, 725 
 tuberculous, 330, 672, 733, 730, 
 - 731, 732 
 
 typhoid perforation, causing, 32 
 Peritonsillar abscess, 565 
 Perityphlitis, 638 
 Perles, asthma, 491 
 
 Pernicious anaemia. See Anaemia, per- 
 nicious 
 Pertussis. See Whooping-cough 
 Pest. See Plague 
 Pesticaemia in plague, q. v. 
 Petechiae, in typhus fever, 66 
 Petit mal, 1139 
 Pharyngitis, acute, 560 
 chronic, 561 
 diphtheritic, 153 
 phlegmonous, 562 
 ulcerative, 562 
 Pharynx, disease of, 560 
 erysipelas of, 102, 104 
 paralysis of, 1103 
 spasm of, 1103 
 tuberculosis of, 334 
 typhoid ulcers of, 30 
 ulceration of, 562 
 Phenacetin. See Acetphenetidin 
 Phenol, 50, 90, 470, 561, 578 
 Phenylhydrazin test, 866 
 Phenylis salicylas, 47, 54, 197, 223, 624. 
 
 628 
 Phlebitis, pneumococcic, 140 
 portal vein, 693 
 rheumatic, 191 
 septic, 125 
 syphilitic, 267 
 typhoid, 25 
 Phlebotomy, 149, 413, 759, 934 
 
INDEX. 
 
 1243 
 
 Phlegmon,, differentiation of, 104 
 Phloridzin test, 749 
 Phosphates in urine, 775 
 Phosphaturia, 775 
 Phosphorus poisoning, 667 
 
 therapy of, 893 
 Phthisis, 306 
 
 aneurysmal, 462 
 fibroid, 318, 504 
 ventriculi, 585 
 Pick's pseudocirrhosis, 674, 727, 733 
 Pigeon-breast, 567, 891 
 Pigmentation in Addison's disease, 840 
 Piles, 656 
 
 Pilocarpine, 92, 558, 742 
 Pirquet's test, 320 
 Pityriasis, tuberculous, 325 
 Placenta, svphilis of, 283 
 Plague, 211 
 
 diagnosis of, 215 
 etiology of, 212 
 prognosis of, 216 
 symptoms of, 213 
 treatment of, 216 
 Plasmodium malariae, 105, 106 
 Pleura, diseases of, 523 
 
 tuberculosis of, 318, 523 
 tumors of, 524, 549 
 Pleurisy, 523 
 
 bacteriology of, 525 
 
 course of, 535 
 
 cytodiagnosis in, 532 
 
 diagnosis of, 538 
 
 differentiation of, 144, 145, 428, 
 
 538 
 empyema, 525, 532 
 necessitatis, 533 
 pneumococcic, 532 
 pulsans, 533 
 streptococcic. 532 
 treatment of, 542 
 etiology of, 523 
 forms of, 532 
 
 in children, 535 
 chyliform, 534 
 diaphragmatic, 534 
 fibrinous. 532 
 hemorrhagic, 534 
 interlobar, 535 
 mediastinal, 535 
 parapleuritis, 535 
 peripleuritis, 535 
 purulent, 532 
 putrid, 534 
 serous, 532 
 suppurative, 532 
 tuberculous, 523, 525, 532, 
 v. i. in tuberculosis 
 in influenza, 176 
 issues of, 537 
 physical signs of, 525 
 
 auscultation, 529 
 diagnostic puncture, 530 
 inspection, 525 
 palpation, 526 
 
 Pleurisv. physical signs of, percussion, 
 527 
 pneumococcic, 139 
 polymorphous, 531 
 prognosis of, 539 
 rheumatic, 192 
 symptoms of, 525, 531 
 treatment of, 540 
 
 aspiration, 541 
 in tuberculosis, 318, 322, 329, v. s. 
 
 forms of 
 in tvphoid fever, 35 
 Pleuritic friction, 526, 529, 538 
 Pleurodynia, 1173 
 Pleuropericardial friction, diagnosis of, 
 
 428 
 Pleuropneumonia, 129 
 Plumbism, 1181 
 
 differentiation of, 980 
 Pneumatosis peritonei, 723 
 Pneumaturia, 869 
 Pneumobacillus, 130 
 Pneumococcsemia, 138 
 Pneumococcic pharyngitis, 561 
 Pneumococcus. See Septic Infections 
 and Pneumonia 
 endocarditis, 384 
 peritonitis, 724 
 Pneumokoniosis, 506 
 etiology of, 506 
 pathology of, 506 
 symptoms of, 507 
 treatment of, 507 
 Pneumomalacia, 511 
 Pneumonia, 129 
 aspiration, 499 
 bacteriology of, 129 
 
 pneumobacillus, 130 
 pneumococcus, 129 
 bronchopneumonia, 498 
 central, 135, 142, 144 
 cerebral, 142, 144 
 clinical types and variations of, 141 
 complications of, 139 
 abscess of lung, 141 
 alimentary, 141 
 arteritis, 140 
 arthritis, 141 
 empyema, 139 
 endocarditis, 140 
 gangrene of lung, 141 
 icterus, 141 
 
 induration of lung, 141 
 joint, 141 
 lung, 141 
 nervous, 140 
 pericarditis, 140 
 pleurisy, 139 
 thrombophlebitis, 140 
 crossed, 135 
 course, 130 
 
 death, mechanism in, 139 
 diagnosis of, 143 
 
 differentiation of, 41, 143, 144, 145, 
 316 
 
1244 
 
 INDEX. 
 
 Pneumonia, erysipelatous, 102 
 etiology of, 129 
 frequency of, 129 
 hepatization in, gray, 135 
 
 red, 135 
 immunity from, 130 
 indurative, 504 
 
 diagnosis of, 505 
 etiology of, 504 
 pathology of, 504 
 physical findings of, 505 
 prognosis of, 505 
 symptoms of, 505 
 treatment of, 505 
 interstitial, 505 
 Litten's sign in, 136 
 lobar in influenza, 176 
 in typhoid fever, 34 
 in whooping-cough, 180 
 lobular. See Bronchopneumonia, 
 massive, 142, 144 
 migratory, 142, 143 
 pathology of, 135 
 physical signs of, 136 
 pleurogenous, 504 
 prognosis of, 144 
 rheumatic, 192 
 "schluck," 499 
 secondary, 142 
 symptoms of, 130 
 chill, 131 
 circulatory, 137 
 digestive, 138 
 fever, 132 
 nervous, 139 
 prodromes, 131 
 respiratory, 132 
 skin, 138 
 sputum, 134 
 urine, 138 
 svphilitic, 269 
 total, 142, 144 
 treatment of, 146 
 hygienic, 146 
 prophylactic, 146 
 symptomatic, 146 
 white, syphilitic, 269 
 Pneumonitis, 129 
 Pneumopericardium, 434 
 Pneumoperitoneum, 723 
 Pneumorrhagia, 519 
 Pneumothorax, 543 
 
 diagnosis of type of, 546 
 differentiation of, 547, 726 
 etiology of, 543 
 pathology of, 544 
 physical signs of, 544 
 prognosis of, 547 
 symptoms of, 544 
 treatment of, 547 
 in tuberculosis, 322 
 Podagra. See Gout 
 Pododynia, 1166 
 Podophyllin, 661 
 Poisoning. See Arsenical, etc. 
 
 Porencephalitis, inferior, 966 
 
 superior, 965 
 Poliencephalomyelitis, 966 
 Poliomyelitis, acute, in adults, 1037 
 of children, 1032 
 
 diagnosis of, 1035 
 differentiation of, 950, 
 
 1035, 1080 
 etiology of, 1032 
 pathology of, 1032 
 prognosis of, 1036 
 symptoms of, acute stage, 
 1033 
 chronic stage, 1035 
 degenerative stage, 
 
 1034 
 localization, 1034 
 treatment of, 1037 
 chronic, 1037 
 subacute, 1037 
 Pollakiuria, 339, 747, 867, 879 
 Polysesthesia, tabetic, 1053 
 Polyarthritis, rheumatic, 186 
 Polycardia, 438 
 
 Polycythemia, with splenic tumor, 846 
 Polydipsia, 869, 878, 879 
 Polyglobulism, 846 
 Polymyositis, 1172 
 Polyneuritis endemica, 227 
 Polyorrhomenitis, 329, 674, 727, 733 
 Polyphagia, 622, 869 
 Polysarcia adiposa, 894 
 Polyuria in cerebral syphilis, 272 
 diabetic, 867, 877 
 in malaria, 115 
 in typhoid fever, 35 
 Pomegranate, 1193 
 Pons, localizing symptoms, 914 
 Porencephalia, 951 
 Portal vein phlebitis, 693 
 
 thrombosis, 693 
 Postmortem tubercles, 345 
 Postures, forced, 917 
 Potassium bromide, 411, 1142 
 chlorate, 544, 561 
 iodide, 250, 417, 418, 446, 464, 
 472, 493 
 action, 288 
 
 administration, 288, 378 
 permanganate, 554, 1179 
 Potato poisoning, 1187 
 Pott's disease, 1010 
 Pox, 253 
 
 Pregnancy, effect of syphilis on, 281 
 kidney of, 740 
 tuberculosis and, 325 
 typhoid and, 36 
 Prison fever, 54, 59 
 Prof eta's law, 282 
 Prosopalgia, 1164 
 Prosoplegia, 1094 
 Prostate, tuberculosis of, 340 
 Prostitution, regulation of, 285 
 Pseudoangina, 445 
 
INDEX. 
 
 1245 
 
 Pseudocirrhosis, Pick's pericarditic, 
 
 674, 727, 733 
 Pseudodiphtheria, 150, 152 
 Pseudohydrophobia, 245 
 Pseudoleukemia, 823 
 
 allied affections, 826 
 course of, 825 
 diagnosis of, 826 
 differentiation of, 826 
 etiology of, 823 
 pathology of, 824 
 symptoms of, 824 
 blood, 824 
 bone, 824 
 fever, 825 
 lymph glands, 824 
 skin, 825 
 spleen, 824 
 treatment of, 828 
 Pseudolipoma, 856 
 Pseudomeningitis, 28 
 Pseudoparalysis, syphilitic, 825, 836 
 Pseudorheumatism, 195, 344, 888 
 Pseudosclerosis (multiple), 1044 
 Pseudotabes, 870, 1079 
 Pseudotetanus, 241 
 Pseudotuberculosis, 328, 293 
 aspergillus, 293, 328 
 protozoan, 293 
 streptothrix, 293, 328 
 Psychoses, influenzal, 175 
 Korsakow's 1079 
 rheumatic, 193 
 in typhoid, fever, 28 
 Ptosis, 1086 
 Ptyalism, 557 
 
 Puerperal fever. See Septic Infections 
 erysipelatous, 103 
 lymphangitis, 127 
 peritonitis, 128 
 sapraemia, 127 
 
 scarlatiniform rashes in, 80 
 thrombophlebitis, 128 
 Pulmonary artery, syphilis of, 267 
 insufficiency, 401 
 etiology of, 401 
 mechanism of, 401 
 symptoms of, 402 
 stenosis, 402, 418 
 
 congenital, 402, 418 
 diagnosis of, 402 
 etiology of, 402, 418 
 mechanism of, 402 
 signs of, 402, 418 
 Pulse, alternans, 442 
 bigeminus, 407, 442 
 celer, 391 
 collapsing, 391 
 dicrotic (q. v.) 
 liver, positive, 404 
 "pistol," 391 
 paradoxical, 432 
 Quincke's capillary, 390 
 venous, negative, 404 
 positive, 403 
 
 Pulse, " water-hammer," 391 
 
 Pulsus paradoxus, 432 
 
 Pupil, Argyll-Robertson, 977, 1054, 1086 
 
 reflexes of, 1004 
 
 Wernicke's hemianopsic reaction, 
 1084 
 Purpura, fulminans, 831 
 
 hemorrhagica, 830 
 
 diagnosis of, 71, 831 
 etiology of, 830 
 prognosis of, 831 
 symptoms of, 831 
 treatment of, 831 
 
 Henoch's, 831 
 
 renal, 771 
 
 rheumatica, 829 
 
 diagnosis of, 830 
 prognosis of, 830 
 symptoms of, 830 
 treatment of, 830 
 
 simplex, 829 
 
 symptomatic, 829 
 
 visceral crises in, 830 
 Pus in urine, 773 
 
 Pustule, malignant. See Anthrax 
 Pysemia, 123 
 Pyelitis, 777 
 
 complications of, 778 
 
 diagnosis of, 779 
 
 etiology of, 777 
 
 pathology of, 777 
 
 prognosis of, 778 
 
 symptoms of, 777 
 
 treatment of, 779 
 
 in typhoid fever, 36 
 Pyknocardia, 438 
 Pylephlebitis, 693 
 
 diagnosis of, 694 
 
 etiology of, 693, 680 
 
 suppurative, 694 
 
 symptoms of, 693 
 
 treatment of, 694 
 Pylethrombosis, 693 
 Pylorus, hypertrophy of, 611 
 
 insufficiency of, 620 
 
 spasm of, 600, 618, 619 
 
 stenosis of, 587, 591 
 Pyocyaneus. See Septic Infections 
 Pyonephrosis, 782 
 Pyramidal tracts, 923, 999-1001 
 Pyuria, 773 
 
 diagnosis of, 773 
 
 etiology of, 773 
 
 renal calculus causing, 787 
 
 symptoms of, 773 
 
 treatment of, 774 
 
 tuberculosis causing, 339 
 
 Quincke's pulse, 390 
 Quinine in malaria, 120, 121 
 
 administration of, 105, 122, 
 149, 183 
 
 physiological action of, 122 
 Quinquad's sign, 1176 
 
1246 
 
 INDEX. 
 
 Rabic tubercles in hydrophobia, 245 
 Rabies, 243 
 
 Rag-sorters' disease, 234 
 Ray fungus, 246 
 Raynaud's disease, 1169 
 Reaction of degeneration, 1075 
 Rectal feeding, 607, 602 
 Rectum, cancer of, 651, 653 
 
 syphilis of, 260 
 Recurrent fever, 59 
 
 convalescence in, 62 
 diagnosis of, 61 
 etiology of, 59 
 prognosis of, 62 
 symptoms of, 59 
 treatment of, 62 
 Reiehmann's disease, 618 
 Relapsing fever, 59 
 Ren arcuatus, 763 
 
 Renal calculus. See Kidney, calculus of 
 Rennet, test for, 582 
 Resorcinol, 584 
 Rest cure, 1133 
 Retina, arteriosclerosis of, 453 
 Retinitis, 1082 
 
 albuminuric, 750 
 diabetic, 870 
 leukemic, 820' 
 syphilitic, 276 
 Retropharyngeal abscess, 562 
 Rhachitis. See Rickets 
 
 acute. See Barlow's disease, 835 
 Rhatany, 553 
 Rhubarb, 661 
 Rheumatic fever, 186 
 Rheumatism, acute articular, 186 
 course, 187 
 diagnosis of, 194 
 
 anomalous forms, 194 
 in childhood, 194 
 gonorrheal, 194 
 pseudorheumatism, 
 
 195 
 scarlatinal, 194 
 differentiation of, 194, 195 
 etiology of, 186 
 frequency of, 186 
 prognosis of, 193 
 symptoms of, 188 
 arthritis, 188 
 blood, 192 
 bone, 191 
 circulatory, 189 
 digestive, 192 
 eye, 193 
 fever, 188 
 general, 187 
 genito-urinary, 192 
 muscle, 191 
 nervous, 193 
 prodromal, 188 
 pseudorheumatism, 
 195, 344 
 
 Rheumatism, acute articular, symptoms 
 of, respiratory, 192 
 skin, 191 
 treatment of, 195 
 
 atypical, 190 
 
 cerebral, 193, 189 
 
 chronic, 889 
 
 endocarditis from, 189, 385 
 
 masked, 190 
 
 muscular, 1172 
 
 relations of chorea to, 193, 1145 
 
 scarlatinal, 86, 90 
 
 spinal, 193 
 
 syphilitic, 280 
 
 tuberculous, 344 
 
 visceral, 189 
 Rheumatoides, 195 
 Rhiga's disease, 554 
 Rhinitis, acute, 469 
 
 etiology of, 469 
 symptoms of, 469 
 treatment of, 469 
 
 chronic, 471 
 
 atrophic, 472 
 hypertrophic, 471 
 treatment of, 472 
 
 diphtheritic, 155, 472 
 
 fibrinous, 155, 472 
 
 syphilitic, 267 
 Rhizomucor parasiticus, 320 
 Rickets, 890 
 
 acute, 835 
 
 complications of, 893 
 
 course of, 893 
 
 diagnosis of, 893 
 
 differentiation of, 893, 989 
 
 etiology of, 890 
 
 pathology of, 892 
 
 prognosis of, 893 
 
 symptoms of, 890 
 
 tardy, 890 
 
 treatment of, dietetic, 893 
 hygienic, 893 
 medicinal, 893 
 orthopedic, 894 
 Risus sardonicus, 240 
 Romberg's sign, 1051 
 Rose cold, 470 
 Rosary, rhachitic, 891 
 Roseola in meningitis, 23 
 
 in pneumonia, 23, 138 
 
 in tuberculosis, 23 
 
 in miliary tuberculosis, 301 
 
 in typhoid fever, 23 
 
 in typhus fever, 56 
 Rose spots. See Roseola 
 Rosin's sign, 851 
 Rotheln, 99 
 
 Roth's white spots, 126 
 Rubeola, 92 
 
 notha, 99 
 Rumination, 620 
 
INDEX. 
 
 1247 
 
 St. Anthony' fire, 100 
 St. Vitus dance, 1145 
 Salicylates, action of, 196 
 
 administration, 197, 560, 707 
 
 Saline infusions, 149, 1118 
 
 Salivation, etiology of, 557 
 
 symptoms of, 558 
 
 treatment of, 558 
 
 Sadivary calculi, 560 
 
 glands, diseases of, 557 
 
 inflammation of. See parotitis 
 symmetrical hypertrophy of, 
 
 559, 828 
 tuberculosis of, 335 
 Salol. See Phenylis salicylas 
 Sanatoria, in tuberculosis, 347 
 Santonin, 1200 
 Sapraemia, 123 
 Saturnism, 1181 
 
 Scarlatina. See Scarlet fever, 80 
 Scarlet fever, 80 
 
 diagnosis of, 87 
 differentiation of, 65, 73, 84, 
 
 88, 97 
 endocarditis from, 84, 385 
 etiology of, 80 
 prognosis of, 88 
 sequels of, 82, 87 
 symptoms of, 81 
 blood in, 84 
 bones and joints, 86 
 cardiac, 84 
 digestive, 85 
 eruption, 82 
 fever, 82 
 kidney, 85 
 
 lymphatic glands, 86 
 respiratory, 84 
 special senses, 86 
 stages, 81 
 throat, 83 
 tongue, 85 
 treatment of, 89 
 Schistosoma haematobium, 1209 
 Schmidt's abdominal reflex, in pleurisy, 
 
 527 
 Schoch's, formaldehyde method, 76 
 Schott's treatment of heart disease, 366 
 Schroth treatment of pleurisy, 540 
 Sciatic neuritis, 1116 
 Sciatica, 1116 
 
 diagnosis of, 1117 
 etiology of, 1116 
 pathology of, 1116 
 prognosis of, 1117 
 symptoms of, 1116 
 treatment of, 1117 
 Sclerema adiposum, 634 
 Sclerodactylia, 1171 
 Scleroderma, 1171 
 Scleroedema, 634 
 Sclerose en plaques, 1039 
 Sclerosis, amytrophic lateral, 1062 
 
 Sclerosis, amyotrophic lateral, diag- 
 nosis of, 1064, 1066 
 etiology of, 1062 
 pathology of, 1062 
 prognosis of, 1064 
 symptoms of, 1063 
 treatment of, 1064 
 disseminated, 1039 
 insular, 1039 
 multiple, 1039 
 
 apoplectiform seizures in, 1042 
 course of, 1043 
 diagnosis of, 1043 
 differentiation of, 963, 979, 
 
 1043, 1058, 1072 
 etiology of, 1039 
 pathology of, 1040 
 prognosis of, 1043 
 symptoms of, 1040 
 treatment of, 1044 
 nystagmus in, 1041 
 scorbutic, 834 
 Scotoma, 1084 
 Scorbutus, 833 
 Scrofula, 325, 326, 345 
 Scrofuloderma, 345 
 Scurvy, 833 
 
 course of, 834 
 diagnosis of, 834 
 etiology of, 833 
 
 infantile. See Barlow's Disease, 835 
 prognosis of, 834 
 symptoms of, 833 
 treatment of, 834 
 Secretin, 625 
 
 Semilunar ganglia, in Addison's dis- 
 ease, 840 
 space, 528 
 Senega, 483 
 Senna, 662 
 Sensation, cortical representation, 903 
 
 spinal localization, 1001 
 Sensory crossway, 910 
 Sepsis. See Septic Infections, 123 
 
 scarlatinal rashes in, 80, 88 
 Septic infections, 123 
 atrium, 124 
 
 colon bacillus, sepsis, 127 
 diagnosis of, 128 
 differentiation of, 42, 43, 128 
 from miliary tuberculosis, 
 
 42, 43, 96, 120, 128 
 from rheumatism, 128 
 from typhoid, 42, 43, 128 
 endocarditis, ulcerative, 42, 
 
 43, 125, 127, 380 
 etiology of, 124 
 gonococcic infection, 127 
 groups of, 123 
 liver, abscess, 679, 694 
 osteomyelitis, 127 
 otogenous sepsis, 127 
 pathology of, 124 
 peritonitis, 128 
 
1248 
 
 IXDEX. 
 
 Septic infections, pneuniococcic infec- 
 tion. 126 
 prognosis of, 125 
 puerperal fever. 127 
 pyocyaneus infection. 127 
 staphylococcic infection. 126 
 streptococcic infection. 126 
 symptoms of, 124 
 general, 124 
 special. 126 
 treatment, 125 
 typhoid infection, 127 
 diphtheria. 154 
 Septicemia. 123 
 Septicopyemia. 123 
 gonorrhoea!. 251 
 Sere therapy, in diphtheria, 162 
 in erysipelas, 10: 
 in meningitis, 172 
 in scarlatina. 92 
 in tetanus. 242 
 Serous membranes, tuberculosis of, 329 
 Serum of dethyroidated animals, 853 
 Shaking palsy. 1157 
 Sheep-stools. 648, 659 
 Shiga's bacillary dysentery. See 
 
 Dysentery, Shiga's 
 Sialodochitis fibrin: sa. 559 
 Sialolithiasis. 560 
 
 pancreatica. 717 
 Sialorrhea. 557 
 Siderosis of lungs. 506 
 Silver, 129. 163. 164. 17S. 224. 560. 
 
 7 -4. 603 
 Singultus, 1110 
 Sinus thrombosis. 945 
 
 of cavernous sinus, 946 
 
 diagnosis of. 946 
 
 differentiation. 948, 972 
 
 etiology of, 945 
 
 of lateral sinus, 947 
 
 pathology of, 945 
 
 prognosis of. 949 
 
 of superior longitudinal sinus. 
 
 946 
 symptoms of, 946 
 treatment of. 949 
 Sitotoxisnius. 1186 
 Situs viscerum inversus. 421. 691 
 Skin, bronzing of. 675. 840 
 diphtheria of. 156 
 tuberculosis of. 344 
 Skoda's note in pleurisy. 528 
 
 resonance in pneumonia. 136 
 Sleeping sickness, 1211 
 Smallpox. 62 
 black. 6S 
 
 complications and sequelae of. 69 
 diagnosis of, 71 
 
 differentiation of, 58. 71. 72. 73 
 etiology of, 62 
 prognosis of. 73 
 symptoms of, 64 
 
 purpura variolosa. 68 
 
 Smallpox, symptoms of, variola conflu- 
 
 ens. - 
 pustulosa hemorrhagica, 
 
 liscreta, 64 
 
 varioloid, 
 treatment of. 74 
 
 prophylactic. 74. 76 
 symptomatic. 77 
 vaccination. 74 
 Smegma bacillus, 291 
 Smell, center for, *?"5 
 Sodium benzoate, 184, 416 
 
 bicarbonate. 1S4. 197. 469. 583, 
 
 - »16, 624 
 borate. 41 
 
 bromide. 50 3 184, 43S. 1142 
 iodide. 259. 455 
 salicvlate. 196, 
 sulphate. 223. 413. 661 
 Solar plexus, in Addison's disease, 575 
 Soor. 555 
 Spanocardia, 440 
 Spartein. 351, 415, 455 
 Spasm, cardio-, 572 
 of facial nerve. II 
 of fifth nerve, 192 
 habit. 1150 
 masticatory, ] 
 mobile, 930 
 ocular. 1090 
 phrenic. 1110 
 sphincter, 662 
 
 of spinal accessory nerve. 1108 
 vagus. 1103 
 of vocal cords, 1104 
 Speech, centers for, 905 
 disturbances of. '. " 
 mechanism of. 906 
 scanning. 1041 
 Spigelia, 1200 
 Spina ventosa, syphilitic. 279 
 
 tuberculous, 344 
 Spinal atrophv, progressive muscular. 
 1064 
 cord, anaemia of, 1020 
 anatomy of, 997 
 compression of. 1010 
 concussion of, 1025 
 defeneration of. ascending. 
 1004 
 descending. 1000 
 in pernicious anaemia, 808 
 embolism, 1021 
 functions of, 
 hemorrhage of, 1021 
 hyperemia of, 1020 
 inflammation of. 1026 
 localization of. 997. 1003 
 physiology of. 
 reflexes of. 1003. 1004 
 symptom; tolog 
 syphilis of. 274 
 tracts of, motor. 99S-1001 
 
INDEX. 
 
 1249 
 
 Spinal cord, tracts of sensory, 1001 
 thrombosis, 1021 
 transverse lesion of, 1007 
 trauma of, 1023 
 tumors of, 1017, 1018 
 diagnosis, 1019 
 localization, 1018 
 pathology, 1018 
 prognosis, 1020 
 symptoms, 1018 
 treatment, 1020 
 irritation, 1130 
 meninges, diseases of, 1015 
 paraplegia, spastic, 1060 
 Spine. See Vertebrae, 1007 
 Spirals, Leyden-Curschmann, 491 
 Spirochete pallida, 254 
 
 refringens, 254 
 Spirillum Obermeyeri, 59 
 Splanchnomegaly, 860 
 Splanchnoptosis. 654 
 Spleen, abscess of, 844 
 
 amyloid. 262, 324. 845 
 
 cysts of, 845 
 
 diseases of, 843 
 
 embolism of, 410, 844 
 
 endothelioma of, 845 
 
 enlargement of, differentiation of, 
 
 from pleurisy. 539 
 extirpation of/ 846, 828 
 floating, 845 
 movable, 845 
 neoplasms of, 845 
 rupture of, 845 
 syphilis of, 262 
 
 tuberculosis of, 262, 303. 337. S46 
 tumor, acute. 843 
 
 chronic, 844, 845 
 Splenectomy. 848 
 Splenitis, acute. 843 
 chronic, 844 
 suppurative, 844 
 Splenomegaly, with polycythemia and 
 
 cyanosis, 846 
 Splenopexy, 846 
 Spondylitis, ankylosing. 887 
 Spondylose rhi&omyelique, 887 
 Spotted fever, 165 
 Sputum, disinfection of. 345 
 Squills, 416, 483 
 Staphylococcus. See Septic Infections 
 
 endocarditis, 384 
 Status lymphaticus, 847 
 
 thymicus, 847 
 Stegomyia fasciata, 206 
 Stelhvag's sign, 851 
 Stenocardia, 442 
 
 Stenosis. See aorta, bronchi, etc. 
 Stereognostic sense, 904 
 Still's disease, 887 
 Stokes-Adams syndrome. 372, 441 
 Stomach, abscess of, 578 
 amyloid, 324 
 
 79 
 
 Stomach, analysis of contents, 580, 589 
 anomalies of, 592 
 arteriosclerosis of, 453 
 atony of, 587 
 atrophy of, 585 
 cancer of, 604 
 
 complications of, 606, 609 
 diagnosis of. 610 
 differentiation of. 600, 601, 
 
 610, 611 
 etiology of, 604 
 histology of, 605 
 localization of, 605 
 pathology of, 605 
 prognosis of, 611 
 symptoms of, 606 
 anaemia, 609 
 ascites, 610 
 cachexia, 609 
 digestive. 606 
 general, 606 
 haematemesis, 607, 609 
 metastases, 610 
 pain, 607 
 toxaemia, 609 
 tumor, 607 
 urine, 609 
 vomiting, 607 
 treatment of, medical, 611 
 surgical, 612 
 cardia of, cancer of, 610 
 catarrh of. See Gastritis 
 cirrhosis of, 585 
 congestion of, 409 
 dilatation of, acute, 586 
 etiology of, 586 
 prognosis of, 587 
 symptoms of, 587 
 treatment of, 587 
 chronic, 587 
 
 complications of, 590 
 diagnosis of, 590 
 etiology of, 587 
 signs of, 589 
 symptoms of, 588 
 treatment of, 591 
 dimensions of. 590 
 diseases of, 576 
 form, changes in, 592 
 hemorrhage from. See Haemate- 
 mesis, 612 
 hemorrhagic erosions of, 599 
 hour-glass, 592 
 
 inflammation of. See Gastritis 
 inflation of, 590, 607 
 insufficiency of, motor, 587 
 lavage of, 577, 583, 591 
 location of, 593 
 motility of, tests, 589 
 neuroses of, 614 
 mixed, 622 
 motor. 618 
 • secretory, 614 
 sensory, 62 1 
 pain in, 595, 599, 601, 614, 621 
 
1250 
 
 INDEX. 
 
 Stomach, perforation of, in cancer, 606 
 in ulcer, 598, 604 
 round ulcer of, 593 
 
 complications of, 598 
 course of, 598 
 diagnosis of, 599 
 differentiation of. 599, 
 
 600, 601 
 etiology of, 594 
 frequency of, 593 
 localization of, 598 
 pathology of, 594 
 prognosis of, 600 
 symptoms of, 595 
 general, 595 
 haematemesis, 596 
 hyperchlorhydria, 596 
 pain, 595 
 vomiting, 597 
 treatment of, diet, 602 
 gastric rest, 600 
 hyperacidity, 602 
 medicinal, 603 
 pain, 602 
 rest, 600 
 surgical, 603 
 symptomatic, 603 
 types of, 597 
 size of, 590, 593 
 syphilis of, 261 
 tuberculosis of, 335 
 tumors of, 604, 611 
 ulcer. See Stomach, round ulcer 
 ulceration of, syphilitic, 261 
 typhoid, 29, 30 
 Stomatitis, aphthous, 555 
 catarrhal, 553 
 epidemic, 362 
 gangrenous, 556 
 parasitic, 555 
 ulcerative, 553 
 Stomatomycosis oi'dica, 555 
 Stones, fecal, 648, 659. See Gall-stones 
 
 of kidneys (q. v.) 
 Strabismus, 1086 
 Stramonium, 493 
 
 Strawberry tongue, scarlatinal, 85 
 Streptococcus. See Septic Infections, 
 in diphtheria, 150, 154, 156 
 endocarditis, 384 
 in erysipelas, 100 
 in scarlatina, 80 
 Streptothricosis, 320 
 Streptothrix, pseudotuberculosis, 320 
 Strongyloides intestinalis. 1209 
 Strophantus, 351, 415, 447 
 Struma lipomatodes aberrans renis, 792 
 Strumitis, 849 
 
 Strychnine, poisoning, diagnosis of, 241 
 Strvchnine, therapeutics. 52. 54, 91, 147 
 
 351, 415, 584, 1037 
 Sublingual gland in mumps, 185 
 Submaxillary gland in mumps, 185 
 Subphrenic abscess, 725 
 
 ! Subphrenic abscess, differentiation from 
 pneumothorax, 547 
 pyopneumothorax, 725 
 Subsultus tendinum in typhoid fever, 27 
 Succussio Hippocratis, 546 
 Sudor anglicus, 359 
 Sugar, tests for, 866 
 Sulphonal, 417 
 Summer catarrh, 470 
 Sunstroke, diagnosis of, 1188 
 etiology of, 1188 
 symptoms of, 1188 
 treatment of, 1189 
 Suprarenal glands, degenerations of, 843 
 diseases of, 839 
 physiology of, 839 
 tuberculosis of, 839 
 tumors of, 843 
 Suralimentation, 349 
 Sweats, therapy of, 757 
 Sympathetic nerves, irritation of, 1089 
 
 paralysis of, 1089 
 Synechia pericardii, 431 
 Synovitis, syphilitic, 280 
 Syphilis, 253 
 
 accidental, 75, 254, 255 
 acquired, 253 
 
 associated conditions, 281 
 course of, abnormal, 281 
 etiology of, 253 
 
 accidental, 254 
 sexual intercourse, 253 
 life assurance in 281 
 symptoms of, 254 
 aorta. 266 
 blood, 267 
 bloodvessels, 266 
 bone, 278 
 brain, 270, 954 
 
 arterial disease, 270 
 differentiation, 953 
 gumma. 273, 954 
 meningitis, 270 
 nerves, cerebral, 272 
 chancre, 254 
 
 characteristic*. 254 
 course of. 256 
 differentiation of. 256 
 extragenital. 255 
 female, 255 
 histology of. 256 
 male. 255 
 perigenital. 255 
 circulatory, 265 
 ear, 277 
 eruptions, 258 
 eye, 275 
 
 choroid, 276 
 conjunctiva. 275 
 cornea, 275 
 iris, 275 
 muscles, 276 
 orbit, 277 
 retina, 276 
 fever. 257 
 
INDEX. 
 
 1251 
 
 Syphilis, acquired, symptoms of, gastro- 
 intestinal, 260 
 intestine, 261 
 mouth, 260 
 oesophagus, 261 
 pancreas, 262 
 rectum, 262 
 stomach, 261 
 
 genitalia, 277 
 cervix, 278 
 ovaries, 278 
 penis, 277 
 testes, 277 
 tubes, 278 
 vagina, 278 
 vas deferens, 278 
 vulva, 278 
 
 gummata of aorta, 266 
 of bones, 279 
 of brain, 273, 954 
 of bronchi, 268 
 of ear, 277 
 of eye, 275 
 of heart, 266 
 of intestines, 261 
 of joints, 280 
 of kidney, 265 
 of larynx, 268 
 of liver, 263 
 of lungs, 269 
 of mamma, 281 
 of meninges, 271 
 of mouth, 261 
 of muscles, 280 
 of nose, 267 
 of oesophagus, 261 
 of ovary, 278 
 of penis, 277 
 of peritoneum, 262 
 of pharynx, 261 
 of rectum, 262 
 of skin, 259 
 of spleen, 262 
 of stomach, 261 
 of tendons, 280 
 of testis, 277 
 of trachea, 268 
 of tubes, 278 
 of uterus, 278 
 of vagina, 278 
 of vessels, 266 
 of vulva, 278 
 
 heart, 265 
 
 immunity, 285 
 
 joints, 280, 893 
 
 kidney, 265 
 
 liver, 262 
 
 lymphadenitis, 257, 260 
 
 lymphangitis, 257 
 
 mamma, 281 
 
 muscles, 280 
 
 nervous, 270 
 
 primary lesion, 254 
 
 respiratory, 267 
 bronchi, 268 
 
 Syphilis, acquired, symptoms of, respir- 
 atory, larynx, 268 
 lungs, 269 
 nose, 267, 342 
 trachea, 268 
 secondary, 257 
 enanthem, 257 
 exanthem, 257 
 lymphadenitis, 257 
 skin, 257, 258 
 spleen, 262 
 syphilides, 258 
 tertiary, 253, 258 
 treatment of, 285 
 initial stage, 286 
 local, 286 
 prophylactic, 285 
 secondary, 286 
 tertiary, 288 
 of bones, differentiation of, 893 
 of brain, 270, 953, 1043, 1058 
 of bronchi, 268 
 cachexia, 281 
 congenital, 281 
 diabetes insipidus in, 272 
 
 mellitus in, 272 
 diagnosis, ex juvantibus, 288 
 gummata, 253, 258 
 hemorrhagica neonatorum, 284, 832 
 hereditary, 281 
 
 diagnosis of, 284 
 influence on child, 282 
 parental, 281 
 symptoms of, 283 
 incubation of, 253 
 of larynx, 268 
 leukoderma, 259 
 leukoplakia, 559 
 of liver, differentiation of, 264, 674, 
 
 685, 695 
 of lungs, 269 
 lymph glands, 257, 260 
 malignant, 253 
 nerves, 275 
 of nose, 267 
 parasyphilis, 253 
 polyuria in, 272 
 primary, 254 
 prognosis, 281 
 residual, 254 
 secondary, 253, 257, 258 
 of spinal cord, 274 
 stages of, 253 
 tertiary, 253, 257 
 of trachea, 268 
 Syringomyelia, 1044 
 
 arthropathies, 1046 
 bulbar, 1047 
 diagnosis of, 1047 
 differentiation of, 1047 
 etiology of, 1045 
 felons, 1046 
 pathology of, 1045 
 prognosis of, 1048 
 symptoms of, 1046 
 
1252 
 
 INDEX. 
 
 Syringomyelia, treatment of, 1048 
 System diseases, 1048, 1060, 1071 
 
 Tabes dorsalis, 1049 
 
 complications of, 1056 
 course of, 1057 
 diagnosis of, 1057 
 differentiation of, 1057, 1079 
 etiology of, 1049 
 pathology of, 1049 
 prognosis of, 1057 
 stages of, 1051 
 symptoms of, 1051 
 ataxia, 1051 
 crises, 1056 
 eyes, 1054 
 gait, 1052 
 motor, 1051 
 reflexes, 1053 
 Romberg's sign, 1051 
 sensory, 1051 
 trophic, 1055 
 treatment of, 1059 
 mesaraica, 328 
 Tache bleuatre in typhoid fever, 24 
 
 cerebrale, 168 
 Tachycardia, 438 
 
 diagnosis of, 439 
 etiology of, 438 
 exophthalmic, 850 
 prognosis of, 439 
 treatment of, 440 
 Taenia cucumerina, 1195 
 
 echinococcus, etiology of, 1195 
 localization of, 1198. 
 multilocular form, 1199 
 pathology of, 1197 
 symptoms of, 1197 
 elliptica, 1195 
 mediocanellata, 1194 
 nana, 1195 
 saginata, 1194 
 solium, 1191 
 Talma-Drummond operation, 676 
 Tannic acid, 224, 561, 657 
 Tannigen, 625, 637 
 Tannin, 561 
 Tapeworms, 1191 
 Taste, nerve of, 1092 
 Teeth, Hutchinson's, 283 
 Tender toes of Hanford in typhoid 
 
 fever, 28 
 Tendons, syphilis of, 280 
 Terminal infections, 123 
 Terpine hydrate, 351, 474 
 Test meal, 580, 589 
 Testicles, atrophy of, in mumps, 185 
 syphilis of, 277 
 
 differentiation of, 278 
 tuberculosis of, 340 
 Tetanus, 238 
 
 in children, 241 
 diagnosis of, 241 
 
 Tetanus, differentiation oi, 241 
 etiology of, 75, 163, 238 
 facialis, 241 
 head, 241 
 incubation in, 240 
 neonatorum, 241 
 trismus, 241 
 prognosis of, 241 
 puerperal, 241 
 symptoms of, 240 
 treatment of, 242 
 vaccination as cause of, 75 
 Tetany, 1152 
 
 diagnosis of, 1154 
 etiology of, 1152 
 in gastric dilatation, 590 
 prognosis of, 1154 
 symptoms of, 1153 
 treatment of, 1154 
 thyroid operation causing, 857 
 Thiosinamin, 650 
 Thomsen's disease, 1156 
 Thoracocentesis, 511 
 Thrombophlebitis, in chlorosis, 800 
 
 in septic infections, 125 See also 
 Phlebitis 
 Thrush, 555 
 Thymus asthma, 859 
 
 gland, abscess of, 858 
 cyst of, 858 
 diseases of, 858 
 functions of, 858 
 hemorrhage of, 858 
 hypertrophy of, 858 
 persistence of, 858 
 tumors of, 858 
 Thyroid extract, 772, 857 
 gland, aberrant, 848 
 accessory, 848 
 cancer of, 849 
 chondroma of, 849 
 cysts of, 849 
 diseases of, 848 
 echinococcus of, 849 
 goitre, 848 
 
 hypertrophy of, 848, 851 
 inflammation of, 849 
 myxoma of, 849 
 overactivity of, 849 
 perversion of, 849 
 strumitis, 849 
 tumors of, 849 
 in typhoid fever, 36 
 Thyroidectomy, 849, 854 
 Thyroidism, 849 
 Tic complex, 1151 
 convulsif, 1098 
 douloureaux, 1164 
 simple, 1150 
 
 with explosive utterances, 1150 
 Tinnitus aurium, 1100 
 Tobacco, leukoplakia, 557 
 Toe phenomenon, 928 
 Toes, tender, Hanford's, 28 
 Toluol, 161 
 
INDEX. 
 
 1253 
 
 Tongue, cat's, 82, 85 
 diseases of, 556 
 eczema of, 556 
 glossitis, 557 
 ichthyosis of, 557 
 keratosis of, 557 
 leukoplakia of, 559 
 psoriasis of, 559 
 scarlatinal, 82, 85 
 strawberry, 82, 85 
 tuberculosis of, 334 
 in typhoid fever, 28 
 Tonsillar hypertrophy, 566 
 Tonsillitis, acute follicular, 563 
 
 complications of, 564 
 diagnosis of, 564 
 etiology of, 563 
 symptoms of, 564 
 treatment of, 564 
 chronic, 566 
 
 diagnosis of, 567 
 etiology of, 566 
 symptoms of, 566 
 treatment of, 568 
 diphtheria, 153 
 in influenza, 175 
 rheumatic, 192 
 suppurative, etiology of, 565 
 symptoms of, 565 
 treatment of, 566 
 Tonsils, diseases of, 563 
 tuberculosis of, 335 
 Tophi arthritici, 881 
 Tormina ventriculi, 618 
 Torticollis, 1108 
 Tourette's disease, 1150 
 Trachea, diseases of, 478 
 
 stenosis of, etiology of, 487 
 
 symptoms of, 488 
 syphilis of, 268 
 Tracheal tugging, aneurysmal, 460 
 Tracheitis in influenza, 175 
 Tracheotomy in diphtheria, 164 
 
 laryngeal perichondritis and ty- 
 phoid, 34 
 Transudates character of fluid, 730 
 Traube's space, 528 
 
 tones, 393 
 Traumatic neuroses, 1134 
 Trematodes, diseases caused by, 1209 
 Trembles, 361 
 Tremor, exophthalmic, 852 
 intention, 1041 
 varieties of, 977, 1157, 1154 
 Trichina spiralis, diagnosis of, 44, 1203 
 etiology of, 1202 
 prognosis of, 1203 
 symptoms of, 1202 
 treatment of, 1204 
 Trichinosis, 1201 
 
 differentiation of, 44 
 Trichocephalus dispar, 1208 
 Trichuris trichura, 1208 
 Tricuspid insufficiency, 403 
 diagnosis of, 405 
 
 Tricuspid, insufficiency, etiology of, 403 
 mechanism of, 403 
 signs of, 403 
 stenosis, 405 
 
 congenital, 420 
 Trismus, 240, 241, 1092 
 Trophic neuroses, 1168 
 Trophedema, hereditary, 1170 
 Trousseau's sign, 1153 
 Trypanosoma, fever, 1210 
 Trypanosomiasis, 1210 
 Tubercle bacilli, 291 
 
 "acid-fast" bacilli, 482 
 Tubercles, postmortem, 345 
 Tuberculin injections, 319, 349 
 ophthalmoreaction, 319 
 Pirquet's, 320 
 Tuberculosis, 290 
 
 of alimentary tract, 334 
 
 of aorta, 343 
 
 arthritis, differentiation, 343, 888 
 
 atrium of, 293 
 
 by digestive tract, 294 
 by direct inoculation, 295 
 by respiratory tract, 293 
 bacillus, 291 
 
 chemistry, 291 
 cultures, 291 
 morphology, 291 
 staining, 291 
 of bladder, 339 
 of bloodvessels, 300, 343 
 of bones, 343 
 of brain, 334, 954 
 of bronchial glands, 182, 325 
 choroidal, 303, 306 
 congenital, 295 
 of ear, 341 
 etiology of, 291, 295 
 extension of, mode of, 299 
 of eye, 334 
 
 of Fallopian tubes, 340 
 of genitalia, 340 
 of genito-urinary tract, 337 
 of gums, 334 
 of heart, 342 
 herpes in, 301 
 
 histopathology of tubercle, 298 
 influenza, as cause of, 181 
 of intestines, 335 
 of joints, 343, 888 
 of kidney, 338 
 
 etiology of, 338 
 pathology of, 338 
 symptoms of, 338 
 general, 339 
 local, 339 
 urinary, 339 
 of larynx, 341 
 
 etiology of, 341 
 forms of, 342 
 pathology of, 342 
 symptoms of, 341 
 treatment of, 342 
 latent, 292 
 
J 254 
 
 INDEX. 
 
 Tuberculosis, of lips, 334 
 of liver, 337 
 of lungs, 306 
 
 in aged, 319 
 
 in children, 317, 318 
 
 complications of, 321 
 
 amyloid degeneration, 324 
 circulatory, 322 
 digestive, 323 
 genito-urinary, 324 
 muscular, 323 
 nervous, 323 
 respiratory, 321 
 skin, 324 
 course of, 315 
 in diabetes, 871 
 diagnosis of, 319, 502 
 extension of, 307 
 forms of, acute, 315 
 
 disseminated, 317 
 galloping, 315 
 miliary, 317 
 pneumonic, 144, 315 
 ulcerative, 317 
 chronic, 317 
 
 fibrous phthisis, 313 
 pleuritic, 318 
 ulcerative, 317 
 pathology of, 306 
 prognosis of, 320 
 stages of, confirmed, 315 
 consummated. 315 
 incipient, 315 
 symptoms of, 307 
 general, 310 
 physical signs, 311 
 respiratory, local, 307 
 treatment, v. i. 
 lymphadenitis, differentiation from 
 
 pseudoleukemia, 328, 826 
 of lymph glands, 325 
 
 bronchial adenitis of, 327 
 atrium of, 327 
 diagnosis of, 3z,8 
 issues of, 328 
 signs of, 327 
 symptoms of, 327 
 cervical adenitis, 326 
 
 atrium of, 326 
 pathology of, 326 
 symptoms of, 326 
 characteristics, 325 
 etiology of, 325 
 generalized adenitis of, 328 
 mesenteric adenitis of, 328 
 pathology of, 326 
 treatment of, 329 
 of mammae, 340 
 measles, as cause of, 95 
 meningitis, 301, 304. See Menin- 
 gitis, tuberculous 
 of meninges, 301, 334 
 of mesenteric glands, 328 
 miliary, acute, 299 
 
 diagnosis of, 301 
 
 Tuberculosis, miliary, acute, etiology 
 of, 299 
 prognosis of, 304 
 remissions of, 304 
 symptoms of, 300 
 
 choroidal tubercles, 
 
 303 
 circulatory, 302 
 digestive, 303 
 fever, 302 
 nervous, 303 
 respiratory, 302 
 types, 301 
 chronic, 304 
 
 differentiation of, 41, 42 
 mixed infection, 292 
 of muscles, 344 
 of nasopharynx, 341 
 of nose, 341 
 of oesophagus, 335 
 of palate, 335 
 of pericardium, 329 
 of peritoneum, 330 
 course of, 333 
 diagnosis of, 333 
 differentiation of, 331, 672, 
 
 730-733 
 etiology of, 330 
 symptoms of, 331 
 adhesions, 331 
 ascites, 332 
 exudation, 332 
 fever, 332 
 friction, 332 
 gastrointestinal, 333 
 meteorism, 332 
 pain, 333 
 palpation, 332 
 pelvic effusion, 332 
 retraction, 331 
 treatment of, 333 
 types of, 330 
 of pharynx, 334 
 of pleura, 329 
 prevalence of, in animals, 293 
 
 in man, 292 
 prognosis of, results from treat- 
 ment, 347 
 of prostate, 340 
 pseudotuberculosis, 320 
 quiescent, 292 
 roseolas in, 301 
 of salivary glands, 335 
 of serous membranes, 329 
 of skin, 344 
 of spine, 1010 
 
 of spleen, 262, 303, 337, 846 
 of stomach, 335 
 of suprarenal glands, 839 
 of testicle, 340 
 of tongue, 334 
 of tonsils, 335 
 treatment of, 345 
 expectant, 350 
 cough, 350 
 
INDEX. 
 
 1255 
 
 Tuberculosis, treatment of, expectant, 
 digestive disorders, 353 
 dyspnoea, 353 
 fever, 350 
 haemoptysis, 352 
 insomnia, 353 
 pain, 353 
 
 sexual symptoms, 353 
 sweats, 352 
 hygienic, 346 
 food, 348 
 fresh air, 347 
 rest, 349 
 prophylactic, 345 
 
 antibacillary, 345 
 governmental, 346 
 individual, 346 
 specific, 347 
 tuberculin, 349 
 in typhoid fever, 35 
 of ureter, 339 
 vaccination as cause of, 75 
 Tuffnell treatment, 464 
 Tumor albus, syphilitic, 280 
 Turpentine, 51, 351, 352, 483, 725 
 Tussis hepatica, 682 
 Tympanites, treatment of, 51 
 Typhlitis, tuberculous, 336 
 Typhoid fever, 17 
 
 in aged, 39 
 
 anomalous courses of, 37 
 bacillus, 17 
 bilious, 59 
 carriers, 18 
 in children, 38 
 chills in, 20, 21 
 clinical types of, 19 
 convalescence of, 20, 21, 40 
 diagnosis of, 40 
 differentiation of, from an- 
 thrax, 44 
 from endocarditis, 42, 43, 
 
 382 
 from enteritis, 44 
 from gastritis, 44 
 from influenza, 177 
 from malaria, 42, 43 
 from meningitis, 42, 43 
 from miliary tuberculosis, 
 
 41, 42, 43, 301 
 from paratyphoid, 44 
 from malaria, 42, 43, 117 
 from pneumonia, 41 
 from sepsis, 42, 43, 382 
 from meningitis, 42, 43 
 from trichinosis, 45 
 from typhus fever, 58 
 etiology of, 17 
 
 bacillus typhosus, 17 
 predisposing, 18 
 exacerbations of, 39 
 gall-stones in, relation of, 700 
 hemorrhage, 31 
 immunity from, 19 
 
 Typhoid fever, incubation of, 19 
 onset of, 20, 21 
 paratyphoid, 19, 44 
 perforation, 31 
 prognosis of, 45 
 recrudescences of, 40 
 relapses of, 39 
 " scarlet-typhoid," 85 
 second attacks of, 19 
 sudoral type of, 21, 23 
 symptoms of, 19 
 bone, 36, 37 
 cardinal, 40 
 circulatory, 24 
 contra-indicating, 41 
 dermal, 23 
 digestive tract, 28 
 fever, 20 
 
 genito-urinary, 35 
 joint, 36 
 muscle, 36 
 nervous, 27 
 pulse, 24 
 respiratory, 34 
 secondary, 41 
 special senses, 36 
 splenic tumor, 22 
 thyroid gland, 36 
 treatment of, 46 
 antipyresis, 47 
 antiseptic, 47 
 of bacilluria, 54 
 of bed-sores, 54 
 care of skin, 53 
 of circulatory symptoms, 
 
 52 
 of convalescence, 54 
 diet, 49 
 
 of diarrhoea, 51 
 of epistaxis, 53 
 expectant, 50 
 of hemorrhage, 51 
 hygienic, 47 
 
 of nervous symptoms, 53 
 of perforation, 52 
 prophylactic, 46 
 of respiratory symptoms, 
 
 53 
 specific, 47 
 symptomatic, 50 
 of thrombophlebitis, 53 
 of tympany, 51 
 spine in typhoid fever, 37 
 state, 27 
 | Typhus fever, 54 
 
 differentiation of, 57, 96 
 etiology of, 54 
 exanthematous, 54 
 prognosis of, 59 
 recurrence of, 57 
 symptoms of, 55 
 general, 55 
 special, 55 
 treatment of, 59 
 
1256 
 
 INDEX. 
 
 Typhus icteroides, 209 
 
 recurrens. See Recurrent Fever, 59 
 Tyrotoxismus, 1186 
 
 U 
 
 Ulcus perforans of stomach, 593 
 
 rotundum of stomach, 593 
 Uncinaria duodenalis, 1204 
 Uncinariasis, 1204 
 Uraemia, 750 
 
 coma from, 752 
 
 diagnosis of, 753 
 
 differentiation of, 753 
 
 etiology of, 750 
 
 latent, 787 
 
 scarlatinal, 85, 91 
 
 symptoms of, 751 
 cardiac, 752 
 digestive, 752 
 nervous, 751 
 respiratory, 752 
 
 treatment of, 742, 754-760 
 
 in yellow fever, 210 
 Urates in urine, 775 
 Ureter, calculus of. 786, 789 
 
 tuberculosis of, 340 
 
 tumor of, 791 
 Urethritis in mumps, 186 
 Uric acid, in urine, 775 
 Urine, albumin in, 768 
 
 alkaptone in, 776 
 
 bile in, 697 
 
 blood in, 770 
 
 casts in, 738, 745, 749 
 
 chyle in, 774 
 
 fat in, 774 
 
 febrile, 35 
 
 hsematoporphyrin in, 776 
 
 hydrochinon in, 776 
 
 in icterus, 697 
 
 indican in, 776 
 
 melanin in, 685 
 
 in nephritis, 738, 745, 749 
 
 oxalates in, 775 
 
 phosphates in, 775 
 
 pus in, 773 
 
 tests of, elimination, 749 
 permeability, 749 
 
 urates in, 775 
 
 uric acid in, 775 
 Urobilin, icterus, 697 
 Urobilinuria, 697 
 Urostealiths, 785 
 Urticaria, visceral crises in, 830 
 Urotropin. See Hexamethylenamina 
 Uterus, syphilis of, 278 
 
 tuberculosis of. 340 
 
 Vaccination, 62, 74, 75, 76 
 
 Vaccinia, 74 
 
 Vagina, syphilis of, 278 
 
 I Vagus. See Nerves, vagus 
 
 Valerian, 437, 447 ' 
 j Valleix's points, 1164 
 j Valsalva's experiment, 428 
 Valvular disease, chronic. See Aortic 
 Insufficiency, etc. 
 combined lesions, 406 
 etiology, 388 
 insufficiency. 388 
 pathology, '388 
 prognosis, 411 
 stenosis, 389 
 treatment, 412 
 general symptoms of, 407 
 heart disease. See Aortic Insuffi- 
 ciency, etc. 
 Vaquez's disease, 846 
 von Graefe's sign, 851 
 Varicella. See Chicken Pox, 78 
 Variola, 62. See Smallpox 
 Vas deferens, syphilis of, 278 
 Vasomotor neuroses, 1168 
 Veins, syphilis of, 267 
 Venesection. See Phlebotomy 
 Veratrum, therapeutics of, 438, 759 
 Veronal, therapeutics of, 53 
 Vertebrae, carcinoma of, 1014 
 caries of, 1010 
 
 diagnosis of, 1013 
 etiology of, 1010 
 localization of, 1011 
 pathology of, 1010 
 prognosis of, 1013 
 symptoms of, 1011 
 treatment of, 1013 
 diseases of, 1007 
 dislocation of, 1009 
 fracture of, 1007 
 tuberculosis of, 1010 
 Vertigo, auditory, 1100 
 cerebellar, 916 
 e stomacho lseso, 582 
 ; Vincent's angina, 160, 562, 564 
 Visceroptosis, 654 
 Vision, center for, 904, 1084 
 
 fields of, 1084, 1120 
 Vocal cords, paralysis of. 1103, 1104, 
 1105 
 spasm of, 1104 
 Volvulus, 646 
 
 diagnosis of, 649 
 differentiation of, 649 
 etiology of, 646 
 pathology of, 647 
 symptoms of, 647 
 treatment of, 650 
 Vomiting, in brain tumor, 957, 962 
 differentiation of, 620 
 in gastric cancer, 607, 601 
 in gastric ulcer, 596, 601 
 in meningitis, 167 
 nervous, 619 
 
 causes of, 619 
 differentiation of. 620 
 
INDEX. 
 
 1257 
 
 Vomiting in pneumonia, 138 
 in tuberculosis, 323 
 in typhoid fever, 29 
 
 treatment of, 50 
 Vomitus, coffee-grounds, 596, 601, 607, 
 609, 613 
 cruentus, 613 
 v. Eiselberg's sign, in hour-glass stom- 
 ach, 593 
 v. Pirquet's test, 320 
 Voussure, pericarditic, 424 
 Vulva, syphilis of, 278 
 Vulvovaginitis, diphtheritic, 156 
 
 W 
 
 Weil's disease, 360 
 
 diagnosis of, 360 
 
 etiology of, 360 
 
 prognosis of, 361 
 
 symptoms of, 360 
 
 treatment of, 361 
 Werlhof's disease, 830 
 Westphal's sign, 1054 
 Whip-worm, 1208 
 Whooping-cough, 179 
 
 " after-pertussis," 182 
 
 complications of, 180 
 
 bronchopneumonia, 180 
 convulsions, 181 
 glottis, spasm of, 180 
 hemorrhages, 181 
 
 course of, 180 
 
 diagnosis of, 181 
 
 differentiation of, 181 
 
 etiology of, 179 
 
 prognosis of, 182 
 
 sequels of, 181 
 
 symptoms of, 179 
 
 convulsive stage, 179 
 
 treatment of, 183 
 Widal test, 26 
 Williamson's test of diabetic blood, 
 
 871 
 Winckel's disease, 832 
 Wintrich change of note, 314 
 
 of pitch in pneumonia, 137 
 
 Wintrich palpatory percussion in pneu- 
 monia, 137 
 W'olfler's sign, in hour-glass stomach, 
 
 593 
 Wolff -Eisner reaction, 319 
 Wooden-tongue, 248 
 Woolsorters' disease, 234 
 Word deafness, 904, 905, 906 
 Wound diphtheria, 156 
 Writer's cramp, 1155 
 
 diagnosis of, 1155 
 
 etiology of, 1155 
 
 symptoms of, 1155 
 
 treatment of, 1156 
 Writing, disturbances in, 905 
 Wryneck, 1108 
 
 X 
 
 Xanthoma in icterus, 699 
 Xanthopsia in icterus, 699 
 Xerostomia, 558 
 X-ravs, 823, 828 
 
 Y 
 Yellow fever, 206 
 
 complications of, 210 
 diagnosis of, 210 
 etiology of, 206 
 sequels of, 210 
 prognosis of, 210 
 symptoms of, general, 207 
 stages of, 208 
 special, 208 
 
 black vomit, 210 
 circulatory, 209 
 digestive, 209 
 fever, 208 
 hemorrhages, 210 
 icterus, 209 
 liver, 209 
 nervous, 209 
 urine, 209 
 treatment of, 211 
 
 Z 
 Zinc Oxide, 584 
 Zomotherapy, 348 
 Zoonoses, 230 
 Zuckergussleber, 674, 733 
 
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