The c nanges - Forgotten Books

PREFACE TO THE SEVENTH EDITION.

IN the seventh edition of th is book the text has beencarefu l ly gone over and brought up to date. The cnanges

that have been made are such as seemed necessary tomake the book a more complete guide to students .

A M AN UAL

OP THB

PRACT ICE OF MEDICIN E

PRE PARE D

E SPE CIALLY FOR STUDENT S

A . A . §T E V E N S , A . M M .D.

PROFES SO R OP TH E RAPF I 'T IC'S AN D CLINICAL M E D IC INE IN THE IA'

OHAN’

S N BDICAL COLLRGR OF

PE NNSYLVAN IA ; LE CTURBR ON PH VS ICAL D IAGNOS IS IN T II R OP PE NNS YLVANIA : PHYS IC IAN TO T I I R HPI SCOPAL HOS PITAL AN D TO ST . AGNB

'

QHOS PITAL ; ASS ISTANT PHYS IC IAN TO TH ! PH I LAD E LPH IA HOS PITAL;

FE LLOW U P THE COLLEGE U P PHYS IC IANS OP PH ILADE LPHIA, etc .

i s an arch where thro ugh

Gleams that u n tr ave l led u n r ld “ hose margin fades

Forever and fo rever as we mo ve .

S E VE N TH E D I T I ON . R E V I S E D

l l l u s t xat eb

PHILADELPHIA AND LONDON

W . B . SA UN D E R S COM PA N Y

1 9 0 65

C O N TE N TS .

D i seases or THE D toasr tvs SYSTEM.

General Symptomatology PM “

The Teeth and Gums

The Tongue .

D isco loration o f tiie TongueTremor of the Tongue

l ‘ issum on the Tongue

Scars on the Tongue

Fetor of the Breath

The Appet ite

Dysphagiaom iting, or Emes is

'

l he Vom it

E xamination of the Gastric ContentsAcid ity of the Gastric ContentsRumination ,

or Meryc ismusHiccupAbdom inal Pain and TC IKIC I IILsxThe StoolsAbdominal D istention

Diseases of the Mouth , l ons i ls, l’haryn x ,and Esophagus

Stomatitis

Catarrhal StomatitisAphthous Stomatitis

Ulcerative Stomatitix

Paras i t ic Stomatitis

Gangrenous Stomati tis'

Mercurial StomatitisAcu te Tonsi l l itisHypertrophy o f the Tons ilsl ’hary ngi tis

Acute Pharyngi tisAngina Ludov ici

Chron ic PharyngitisRetropharyngeal Absces sStenos is of the E sophagus

Spasm of the Esophagus

Organ ic E sophageal Obstruc tio n:

teases of the Stomach PAGB

Acute Gastr it isChron ic Gastr it isAtony of the S tomachNervous Dyspeps ia

Hyperchlorhyd riaGastrosuccorrhea

GastralgiaPept ic UlcerCancer of the Stomach

D i latation of the S tomach

Gastmptosis and E n teroptos is

Hematemes is

;eases of the Intestines

Habitual ConstipationIntest inal Co l icD iarrhea

Intestinal CatarrhAcute I leocoh tis

Cholera In fantumDysenteryChol era MorbusAppend ici tisIntestinal ObstructionAn imal ParasitesCestodes, or Tape -wom b .

Nematodes, or Round - worms

seases of the Pancreas

Hemorrhage in to the Pancreas

Acute Pancreati tis

Chron ic Pancreatitis

Cancer of the Panc reas

Cysts of the ’ancrcas

Panc reat ic Calcu l iseases of the Live r

Area of Liver Du lnes sI’al pation of the Liver

Percussion o f the Liver

Jaun t l ice, or Icterusl cterus N eonator um

Cho lem iaCatarrhal Jaund iceAcute Cholecyst i tisCholel ith ias isI Iyperem ia of the I tver

Cirrhosis of the I tver

Atroph ic Cirrhos is

Hype rtm ph ic Ci t rhos isOther I‘ orms of Cirrhos i s 0 1 I

Abscess o f Live r

Cancer of the Liver

CON TE N TS .

Diseases of the Liver PM -B

l l ydatid Cyst of the LiverAmyloid LiverAcute Ye l low Atrophy of the Liver

Diseases o f the Peritoneum

Acute Peri ton i tis

Chron ic Diffuse I’eriton itis

Ascites

D l sEAS l-ZS o r rm . Kt tmavs.

General Symptomato logyThe Urine

Po lyur iaAnuria

Urea

Lithuria

Urates

Leuc inuria and TyrosinuriaPhosphatu ria

Ch loridsOxaluriaTube - cas ts

Urobil inu t ia

HematoporphyrinuriaGlycosuriaAlbuminuriaAcetonuria

Diaceturia and Ox vhu tyr ia

Hematuria

HemoglobinuriaIndicanuriaChol ttrta

E hrl ich '

s Diazo react ion

Diseases of the Kidneys and Pe lvis of the KidneyFloat ing KidneyHyperemia of the KidneysUrem ia

Acu te N eph ritis

Chron ic Parenchymatous Neph ritis

Ch ron ic Intets tit ial Neph rit i s

Amylo id Degenerat ion of the KidneyPye l it isN ephro l ith iasisI Iyd ronephros is

Tubercu los is of the Kidney

6 CONmm :

DISEASES o r w e BLOOD AND rm: Ducrwss Ow ns.

E xamination of the BloodPlethoraHydremiaAnhydremiaMe lanemia

Poi lt ilocytos is

Nuc leated Rwed Cel lsLeukocytos is

Hypo leu ltocytos is

Ol igochmmemut

Ol igocythemiaAnemia, Addison’5Disease, Exophthalmic Goiter, and Myxedema

Anemia .

SecondaryAnemia

Hodgk in s Dis-emSp lenic AnemiaAdd ison's DiseaseExophthalmic GoiterMyxedema

DISKASES o r THE Ctacuu troav Svs'rw .

Genera l SymptomatologyThe Apex

‘ beat

Displacement of the Apex bu tChanges

'

tn the Force and E xtent of the Apex - beatAbnormal Centers of Pu lsationPrecord ial Prominence

Auscu l tationThe Intensity of the Heart - soundsAlteration in the Rhythm of the Heart -soundsAdventitious Sounds, or MurmursPericardial Friction- soundPleuropericard ial FrictiowsoundCan l iorespiratory Murmur

CON TE N TS .

General Symptomato logy (Conf i rm ed n ot:

Aneurysmal Murmur, or Bruit

I l em ic Murmurs

The Pu lsePalpitationDropsyGeneral Cyanos ts

D iseases of the Pericard tunt

Pericard itisHydropericard iuml Ietnopericard iumPneumopericard ium

Diseases of the HeartE ndocard itis .

Chronic Valvu lar DiseasePer iod of CompensationAort ic Stenos is, or Aortic Obs truct i onAortic Insuffic iency , or Aortic Regurgi tationMitral Stenosis, or Mitral ObstructionMitral Insuffic iency

,or Mitral Regurgi tation

Tricuspid Stenos is , or Tricuspid ObstructionTricuspid Insufficiency, or Tricuspid Regurgi tationPu lmonary S tenos is, or Pu lmonary ObstructionPu lmonary I nsufii ciency , or Pu lmonary RegurgitationPeriod of Broken CompensationE n largement of the Heart

Acute Myocard itisChron ic Myocard ial D iseaseFatty I nfil tration of the Heart

Fatty Degeneration of the HeartFibro id I ndurat ionAngina Pectoris

Aneurysm of the Aorta

Thorac ic AneurysmAneurysm of the Abdominal AortaArteriosc leros is

D ISEASES OF THE RES PIRATORY SYSTEM .

General Symptomato logyMovement of the Alec Nas i during Res pirationNasal D ischargeThe Sense of Smel lEpistax isSpasm of the Laryngeal AdductorsAphon ia, or Loss of Vo ice

DyspneaNumber of Respirations per MinuteCheyne- Stokes or T idal wave Breath ingCough

E x pectoration

8 cow s zvrs.

Rachit ic ChestEm ous Ch

Local na mes and DepressionsE xpansion

m Phe nomenon

Auscu ltationMensaration

Diseases of the Nose and LarynxCoryzaCh ronic Nasal CatarrhAcute Catarrhal Laryngi tis

Chronic Laryngitis .

ryngismus Str idulusEdema ot

'

the LarynxDiseases of the Ltmgs

Acute Catarrhal Bronchi ti sChron ic Bronchit is

Fibrinous Bronch itisBronch iectasis

E ssential AsthmaHay Asthma

Pulmonary EmphysemaHypertroph ic Emphysema

Hypostatic Congestion of the Lungs

E dema oI the Lungs

Cronpous Pneumon ia

Catarrha l Pneumon iaCh ron ic Interstit ial Pneumonia

Abscess of the LungGangrene of the LungPulmonary Tuberculosis .

Diseases of the PleuraPleurisy

CON TE IV?'

5.

Ac r r t: I s t‘

tzc u ovs D l sEASE S.PAGE

Fever

Period of IncubationDate at which Rashes,

AppearProtection from Future AttacksTermination by CrisisInfections m wh ich Jaund ice is Like ly to Occu r

Chronic Malaria]Cachex iaScarlet FeverMeaslesRubel laSmal lpoxVaccin ia

Varicel laDiphtheria

E rys ipelasInfluenzaMumps .

Ye l low Fever

Acute Genera l Tubercu lou sWhooping-cough

CholeraTetanus

Dengue

Hydrophobia

Consr trur tonu . D i saAsas .

Rheumatic Fever

Ch ron ic At ticu lar Rheumat isttt

Other Man i festations o f l x'

h t ttttta l l sm

Gout

Rheumato id Arth ritisR icketsDiabetesDiabetes Insipidu sScurvyHemoph i l iaPurpura l lmmo rrhagica

IO CON TE N TS .

Dtsaasas or THE Naavous SYSTEM .

D irty rban re: of Motion .

ParalysisIrregu lar Paralysi sMonoplegiaHem iplegiaParaplegia .

Convu lsions

E pi leptiform Convu lsions

Tetan ic Convu lsionsHysteroidal Convu lsionsLocal Convu lsionsSaltatory SpasmSalaam Convul sionsChoreiform Movements

Athetosis

Tremors

The Gait

The ReflexesParadox ical Contraction

D is/u rban rrs of Sensation .

Anesthesia

Hem ianesthesia

Monanesthesia

Paranesthesia

Thermo anesthesia

AnalgesiaRetardat ion of SensationsThe Sen s e of Space

I Iyperesthesia

Paresthesia

NeuralgiaCausalgiaPressu re Sense

Muscu lar SenseD i stu rbaum of A

'

u l n'

ti tm .

Muscu lar AtrophyReaction o f Degenerat io n

Arth ropath ies

l lce rat ion Resul ting i tom l’erve tt ed N utr ition

l h'

sl u r l um rrs of Chm r iou m ess .

Coma

Trance

Somnatnbu l istn

E cstasyCatalepsy

CON TE N TS .

D istu rban ce: of (It : Sperr'

a l Senses. n o :

Psy ch i t D ir/u rbana'r .

De lusionI l lusionHal lucinationImperative Conceptions

Morbid Impu lseDel ir ium

D tsu sm or THE BRAIN, Coat) , N ERVES , AND MUSt ‘

I E S .

Acute Cerebral Leptomen ingit isChronic Cerebral Leptomen ingitisChronic Pachymen ingi tisHemorrhagic PachymeningttisChronic HydrocephalusParetic Dementia

Cerebral Paralysis tn Ch ildrenCerebral HyperemiaCerebral AnemiaCerebral Hemorrhage .

Obstruction of the Cerem Arteri es

Morbid Growths tn the BrainAbscess oi' the BrainAphas ia

Spinal Leptomen ingitisCh ron ic Spinal Pachymen ingiiisAcuteM yel i tisChron ic Myel itis .

Acute Anterior Pol iomye l it i

Progressive Muscu lar AtrophyBu lhar Paral ysiAcute Ascend ing ParalysisLocomotor Atax iaPrimary S

plastic Paraplegia .

AmyotrOp tc Lateral Sc leros isAtax ic ParaplegiaDissem inated Cerebrospmal S t lem s .s

Hered itary Atax iaSyringomyel iaCaisson Disease

Diseases of the Nerves

N eurttts

Mu ltiple Neuri tisSciatica

Fac ial Paralysis

1 2 CON TE N YS .

Functional Nervous DiseasesHeadacheMeniere’s Disease

Chorea

Artisans’ Cramp

Writers’Cramp

Thomsen’

5Disease

Raynaud'ss DiseaseAcute Angioneurot ic Edema

Trophic Disorders, Sunstroke. and Intox ication;Id iopath ic Muscu lar AtrophyPseudobypenroplri c

Faciac miflrophyAcromegalySunstrokeAlcoho l ismChronicOpium Poison ingChron ic Lead -

poisoning

DISEASES or“

run SKIN AND rts APPENDAGES .

General Symptomato logyThe Color of the Skin

Hardness or l nduration of the Sk inGlossy Sk inE n largement of the Superfic ial Vei nsCaput MedusaCutatwous EmphysemaAbnormal Cond it ions of the Nai lsAtrophy of the Nai lsCurvmg of the Nai lsOnych ia

Cutaneous E ruptions

Macu lesPurpuric Spots, or Hemorrhagic MaculesBmwn Macu lesWh ite or Pale Yel low MaculesDi ffuse Erythema or Inflammation ot the SkinVesic lesBlebs or Bul lm .

Pustu les

(”

OA’TE N TS.

Cutaneou s E ruptions (Con/z'

nm -d r u m.

Whea ls or Pomph iCrusts

ScalesUlcers

Diseases o f the Sweat -

glandsAn idrosisl l yperidros is

Brom idrosisChrom idrosis

SudamenFunct ional D iseases of the Sebaceous Glands

SeborrheaComedoMi l iumSteatoma

Inflammatory Diseases of the Sk inE rythema S implexE rythema Intertr igoE rythema Nodosum

E rythema Mu lti forme

Urt icaria

Urt icaria Pigmentosa

Herpes S implexl l erpes Z osterHerpes I risAcne

Acne Rosacea

Furuncu lusCarbuncu lusPsoriasis

Lichen Ruber, Li chen Planus, and Lichen Scrofu losisPrurigo

Dermatitis Herpetiform is

Dermatit is

E cthymaPemph igus

Impetigo Contagiosa

Mi l iar ia .

Atroph ic Afl'

ections of the Sk inAlbin ism

of theHairandNails

Atrophy of the HairAtrophy of the Nai lsAlopec iaAlopec ia Areata

Sycosis

14 cozvn sy rs.

Atl'

ections ol'

the S lcin

yx

Keratosis Pi laria

s us Pigmentosusl ch thyosis

Hypeflmph ic Afl'

ect ions of the Halt end Nai lsOnychaux is

NewGm ths of the Ski n

Lupus E rythematosusLupus Vu lgarisSyph i l is CutaneaLeprosyEpithe l ioma

AinhumNeuron s of the Ski n

Pruritus

Tinea VersicolorT inea Favosa

INDEX 0 0 I O O O O 0 Q

Dl S EAS E S

OF THE

DlGE ST l VE S YS T EM.

GUMS.

Delay ed dentition and the eruption of badly formed teethmay resu l t from rickets or congen i tal syphi l is .Canes of the teeth resu lts from many conditions , notably

an unnatura l softness of the teeth , lack of c lean l iness , theuse of certain drugs

,dyspepsia

,and diabetes .

Hutchinson'

s Teet/z.

—The latera l inc isors of the upperjaw are pegged

,and the centra l inc isors of the same jawhave convex sides and c rescentic notches on their cu tting

edges . These pecu l iari ties indicate hereditary syphi l is,and

are noted on ly in the permanent teeth.

A bl ue l ine on the gums near the insertion of the teethusua l ly indicates chron ic lead - poison ing. Copper and

si lver - poison ing occasiona l ly produce sim i lar l ines .Spongy ,

bl eed ing gums are often assoc iated with scurvy.

Swe l l ing of the gums , with tenderness and sal ivation,is

indicative of mercu rial poison ing (ptyal ism) .

Par on the Tom a—This consists for the most part ofaccumu lated epithe l ial ce l ls

,partic les of food , and m icro

organ isms,and occurs in a great variety of diseases, both

local and general .2

1 8 0 1554535 or m s omen /m s ys ru r.

A [rig/rt, un'

y'

orm coat is often noted iin those who sleep with the mouthnd itions are (t ) Febri le diseases .

Catarrhal conditions of the nose and

d iagnostic sign ificance can be attached to the appearance of

the tongue in diseases of-the stomach .

Cironmsm’

bed f umi ng often indicates local disturbance , as

a jagged tooth or tonsi l l i ti s.Unil ateral f um

’

ng' may resu lt from distu rbed innervation

,

as in conditions affec ting the second and th ird branches ofthe fifth nerve . I t has been noted in neuralgia of thosebranches

,and in fractu res of the sku l l involving the fora

men rotundum .

The dry ,brown and fissured tongue is noted in low fevers,

as typhoid fever, typhoid pneumon ia,typhoid dysentery .

A red , beefy tong ue is noted in ch ron ic was ting dism es .

I t is of qu ite frequent occurrence in dysentery and in diabetes .

77“ strawberry tongue" is characteri zed by a white fu r

,

through which project bright - red and prominent papi l la .

I t is seen in the early stage of scarlet fever.

Black Tangue—This is a parasitic affection of

the tongue ,characterized by the appearance of black patches

on the center of the dorsum ,with great prolongation of the

fil l ifo rm pap i l lae .

Bl each - black d i v a/oration of tire tongue is observed inAddison's disease .

b ebop/akin But t ons—In th is condition there are sl ight lyelevated , smooth , opaque,

whitish plaques on the l ingualor bucca l mucous membrane . There are no subjectivesymptoms . E xcessive smoking is a common cause. Syphi l is appears to be a factor in some cases .

Trembl ing of the tongue is noted in many conditions ; i tre particu larly marked in low fevers (typhoid), in alcohol ism

,

and in paretic dementia.

D VSPHAG/A. 9

Fissures on the tongue may resu l t from severe glossitis ,syphi li s, carc inoma, tubercu los is , or the impact of a jagged

Scars on the tongue often resu l t from syphi l itic lesions orfrom the tooth wounds of epilepsy.

This is often due to loca l inflammation , as chron ic rhin i tis,

tonsil l iti s. etc . ; to the retention of decomposing food , tocaries of the teeth

,to certain l ung diseases

,especial ly gangrene and bronch iectasis , to dyspepsia, and to the ingestion

of certain foods or drugs .

Bul imia , or inordi nate appeti te, is a common symptom in

nervous dyspepsia,hysteria , diabetes , and in certain in san

i ties , no tably in paretic dementia. I t may be due to intes

Anorcx ia,or loss d appetite, is a symptom common to

many cond itions .Pica is a craving for unnatural art ic les of food , and is

noted partic u larly in chlorosis, insan ity , and pregnancy .

Dysphagia, or difficu lt swal lowing, may resu lt from : (1 )Loca l in flammation , espec ial ly tubercu lous u lceration of the

throat or larynx. (2) Strict u re due to the heal ing of an

u lce r (corrosive poisons , s s,typhoid fever) . (3) Can

ect of the esophagus . (4) m of the esophagus (bysteria). (5) A foreign body . Pressure on the esophagus(aneurysm,

mediastinal tumor en larged glands, pericardia leffus ion). (7) Paralysis , l oca l , as in diphtheric paralysis , or

centr ic , as in bulbar disease.

20 DISEASES OF THE DIGESTIVE S YS TE M

-(I ) Toxic, from ptomains, drugs,and the specific fevers. (2) Cen tric disease, as

tumors and men ingitis ; th is type is often unacco

with nausea,and does not re l ieve

(3) D iseases of the stomach, as u lcer,cancer, di latation,

catarrh , etc . (4) Reflex, as from pregnancy, uter ine or

ovarian disease, irri tation of the fauces , worms, bil iary co l ic ,etc . (5) Intestinal obstruc tion : th is is often fecal . (6) D isturbed cerebral c ircu lation ,

as in swinging and in seas ickness . (7) Certain nervous afl

'

ections , as hysteria, migraine.

(8) Periodic vom iting may be i n i tse lf a neurosis , ormay beassoc iated with the gastric crises of locomotor ataxia. (9)E sophageal vomiting resu l ts from obstruction, and the vomi tis alkal ine in reaction.

m vou rr .

Watery or mucous vomit is noted in chronic gastri tis, in

certain forms of nervous dyspeps ia ,in cerebral disease

,

and after persisten t emesis , as in cholera.

Bil ious or green vomit is not diagnostic of any specia lcondition ; it may occur in any case in which there are

persistent vom i ting and retching .

Bloody Voimt (Hematem si r) .—For causes,see page 6 2

When present in large amount, the blood can usual ly berecogn ized by the unaided eye ; smal l amounts may bedetected by the microscope, by the spectroscope, or bychem ica l tests .

E vaporate some of the fi ltered cofl'

ee

grounds vomit in a watch - glass , sc rape off some of the driedmaterial ; add a trace of fi ne ly pu lveri zed salt ; place th em ixture on an object - glass , and cover. A l low one or twodrops of glac ial acetic ac id to run under, and again evapo

rate ; when dry , al low one or two drops of disti l led wate rto flow under to dissolve the crystals of sa lt . Under themicroscope brown rhombic crystal s of hematin appear.

Pum la t vomit may resu l t from the ruptu re of an abscess

E XAM INATION OF THE GASTRI C CON TE N TS . 2 !

in to the esophagus or stomach or from ph legmonous gas

Fecal vomit (sterco mreous vomit) indicates intestinal ohstruction or a gastro - colic fi s tula, the resu lt of ul cer or

cancer. I t is recogn i zed by its odor and appearance.

Pay” : Vomit—The ejection of large quanti ties of frothyfermen ted materia l is highly signi fican t of gastric di latation.

di stress,or

W M occurs in certain neu roses of the stomach , inhyster ia, u remia,

and in brain disease, as tumor or as a

precursor of apoplexy.

The ta t- breakfast of E wald and Boas consists of a rol land from 10 to 14 fluidounces of water or weak tea. I t isgiven in the morning on an empty stomach , and is removedin one hour by aspiration or express ion . The roll shou ldbe thoroughly masticated. This breakfast afl'

ords the mostsatisfactory means of determ ining the secretory ac tivity ofthe stomach . Riege l ’s test-meal , however, is better adaptedto determ in ing the tota l functional activity of the stomach .

I t consi sts of a plate of meat - broth,a beef- steak weighing

from 5to 7 ounces , 1 } ounces of mashed potatoes , and a

roll . The conten ts are removed in three or four hou rs afterthe ingestion of the meal .Test for Free Acid 8 .

—Fi l ter- paper soaked in a so l ution of Congo- red and dr ied tu rns bl ue in the presence of

free ac ids . A saturated alcohol ic solution of tropeoli n 0 0tu rns from a brown ish ye l low to a dark brown whenbrought in contact with flu ids contain ing free acids .Qual itat i ve Tests for HCL—Gii nzbu rg

'

s ph lorogl u

cin - van i l li n test wi l l react with 1 part of HCl inparts of wate r. The solution consists of 2 parts of ph lorol uc in , 1 part of van i l l in ,

and 30 parts of absolu te a lcohol .en a few dro of this solu tion are heated with an equa l

quantity of the ltrate contai ned in a porce lain dish , a beauti fu l red color appears at the margin of the flu id . Boasstates that th e test is sti ll more del icate when 10 0 parts of

80 per cent alcohol are substituted for the 30 parts ofabsol ute al cohol.

22 D ISE ASE S 0 1" THE D IGE S TI VE S YS TE M .

Boas ' reso rcin - sugar test gives a sim i lar reaction. The

reagent consists of 5parts of resorc in, 3 parts of sugar,

and 1 0 0 parts of dil uted alcohol .Aci di ty —This is determ ined by al lowing a dec i

normal alkal i solu tion (water, 1 0 c .c . ; potassium hydrate ,

56 mg.) to flow from a buret, drOp by drop, into a beake rcontaining 1 0 c .c . of fi ltered gastric j u ice,

to which havebeen added as an indicator two drops of a 1 per cent. alcohol ic solution of phenolphthale in. The test is completedwhen the red color produced no longer disappears on shaking the sol ution . Ten c .c . of normal gastr ic j u ice usua llyrequ ire from 4 to c .c . of the standard alkal i solu tion.

S ince 1 c .c . of the alkal i solu tion is equ ivalent togram of Hc l , i t fol lows that the percentage of the latter ina given spec imen wi l l equa l the number of cubic centimetersof the al kal i solu tion requ ired mu l tipl ied by 1 0 ,

and againby 0 0 0364

fd ints'

: Col or Mot/mafi—To 1 0 c .c . of the fi ltrate add a dec inormal solu tion of sodi um hydrate from a buret unti l adroplet (removed with a pla tinum l oop) of the fl uid no

longer reacts with Gii nzbu rg ’

s reagent. The number of

cubic cent imeters of the alka l ine solution used , mu l tipl iedby 1 0 and then by gives the pe rcentage of free

hydroch loric ac id . This met hod , which is sufl‘ic1ent ly accurate for c l inical pu rposes , is based upon the suppositionthat the alkal i fi rst un ites with the free acid before it affec tsthe ac id in organ ic combinations .Test for Lacti c Aci tL—The presence of lac tic ac id in

the stomach - contents simply indicates the existence of sub

ac id ity and of stagnat ion . These two conditions are neverso constant ly present nor so intense as in carcinoma (R iege l ) .When free HCl is presen t in sufli c ient quanti ties , it is unnecessary to test for lactic ac id .

Ufl'

e lmann recommends a m i xtu re of 1 0 c .c . of a 4 per

cent. carbol ic ac id sol ution and 20 c .c . of dist i l led water, towhi ch is added one drop of the offic ia l liquor ferri ch loridi.This makes a c lear amethyst - blue solu tion . The reagentmust always be prepared at the t ime of mak ing the test.

D I SE ASE S OF THE DIGESTIVE SYSTEMthe test- tube into the thermostat at 1 0 0 ° F. If sufficientpepsin is present, the discs wi l l be completely dissolved infrom one - ha lf to one hou r.

Test for Carboh y dratea—When starch digestion isarrested too ear ly

,as in cases of excess ive sec retion of HCl ,

Lugol ’s solution gives a bl ue or purple coloration with thegastric con tents . Complete absence of color reaction indicates very active starch digestion (subac idity) .Th e Absorp tive Power of th e Stomach .

—This 18usual ly determ ined by the time requ ired fo r free iodin toappear in the sal i va after the ingestion of potassium iodid.The sa liva is received on fil ter- paper impregnated w ithstarch , a drop or two of fum ing n itr ic ac id is then added ,and the appearance of a blue color proc laims the presenceof iodin . Norma l ly the sal iva shou ld yie ld the reactionfor iodin in from ten to fifteen m in u tes after the ingestionof a capsule contain ing gram of potassium iodid. Care

must be taken that none of the drug adheres to the outs ideof the capsu le . This test cannot be regarded as being veryrel iable .

Th e Motor Power of th e Stomach .—E wald has

suggested the use of salol,which escapes from the stomach

in to the intestine ,where it is broken up into sal icyl ic acid

and phenol . Normal ly sal icylu ric ac id appears in the urinein from forty to seventy five m inu tes after the ingestion of 1

gram of salol . Fi l ter- paper moistened with u rine contain ingsa licylu ric ac id assumes a violet color when treated with a

1 0 per cent. ferric ch lorid sol u tion .

R iege l 's test is more re l iable . If it is found that sevenhou rs after a test- mea l of broth , beef- steak , mashed potatoes

,and a rol l (see p. 2 1 ) much food is sti l l left in the

stomach , the motor power is reduced .

No remains of the test- breakfast shou ld be found after

two hou rs .If much water is recovered in one and one- half hou rs

after the ingestion of 50 0 c .c . of cool water, there is motorinsufl‘i ciency ,

probably the resu lt of m uscu lar weakness, andnot retention from pylori c obstruction .

m eow . 25

N ormal aci d i ty is due to hydrochl oric ac id,but other

ac ids are frequent ly formed du ring the digestive process ,such as lactic , butyric , and acetic acids . The quanti ty of

hydroch loric acid in normal gastric j u ice varies fromto per cent ,

more ac id being sec reted after a heavy mealthan after a l i ht one.

B ty (h yperch l orh ydria) resu lts from a

variety of causes . Ear ly life, the nervous temperament

,

mental overexertion,and the persistent use of high ly sea

soned foods are genera l predisposing factors . I t is frequen t ly present in neu rasthen ia and in hysteria. I t mayattend the gastric c rises of locomotor ataxia . I t may resu ltfrom the abuse of tobacco. I t is present

,as a ru le

,in u lcer

of the stomach . I t is a common symptom in ch lorosis . I tsometimes occu rs in cholel ith ias is and in nephrol ith iasis .

(Hy poch y l iaand Ach y l ia Gastri ca) .—Dec reased sec retion of gastricj u ice i s seen in chron ic gastri tis ; in gast ric cancer ; in

atrophy of the gastri c tubu les ; in passive congestion of the

stomac h ; often in febri le diseases ; often in severe anem ia ;and in certai n neuroses , as neu rasthen ia, hysteria , and someforms of nervous dyspepsia.

Rum ination is a condition , rare ly observed in man,in

which the food is regu rgitated from the stomach and sub

jected to a second mastication . I t is the result of a neu rosis ,and is ene ral ly found in assoc iat ion with hyster ia , epi lepsy ,neu raSSi en ia,

or idiocy. I t is sometimes hered itary or

acquired by imitation .

HICCUP.

Hiccup, or singu ltus , resu lts from a c lon ic spasm of the

diaphragm , and is often noted as a temporary condition aftereating o r drink ing. Persistent h iccup is somet imes presentin extreme exhaustion fol lowing acute or chron ic diseases .I t may also resu lt from irri tation of the phren ic nerve , as

DISEASES or 7’

l DIGESTIVE S YS TE M.

from the pressu re of a thoracic aneurysm . I t may be reflexfrom stomachic

,hepatic

,intestinal

,or peri tonea l disease. I t

may be due to hysteria.

D if use abdominal tenderness is noted in peritoni tis, inhysteria,

and in rheumatism of the abdom inal musc les .Persi stent abdominal pai n resu lts from the various visceraldiseases , ch ronic pe ri toni ti s , abdom inal aneu rysm, and disease of the spinal vertebrae .

Col ic is a painfu l spasm of a mucous canal . The com

mon varieties are bi l iary,intestinal

,renal

,uterine

,and

pancreatic .

Painful de/eeaabn res u lts from constipation ,anal fissu re,

dysentery, pi les, u lceration ,strictu re

, pro lapse of the rectum ,

and inflammatory cond itioii s of neighboring organs, as the

uterus or prostate gland .

THE STOOLS.

Blood in tire S tool s (E ntrorr/zagi a or Mel ena).—The bloodis nearly normal in appearance after profuse hemorrhages ,o r when it has been qu ick ly discharged , as in pi les and

fissure. Retained blood imparts a black or tarry appearance to the stools .Me lena resu lts from : (1 ) Traumatism ; (2) acute inflam

mation of the bowe ls , as in enter itis and dy sentepassive congestion , as in chronic heart and l ivervicarious menstruat ion (extreme ly rare) ; (5) blood dyscrasia,

as in sc urvy, purpu ra , infectious fevers, etc. ; (6) ruptu re of

an aneurysm ; (7) u lcers in the intestines , as simple duodena lu lcers,typhoid

,dysenteric .

tube rcu lar, or mal ignan t u lcers ;(8) intussusception ; (9) the assage of blood from the

stomach in hematemesis ; (1 0 hemorrhagic infarction of

the bowe l from embolism or th rombosis of the mesenteric1 ) pi les , fissu re ,

fistu la.

or serous stool s are noted in choleraic diseases,in

nervous diarrhea ,in the col l iquative diarrhea which term i

As aone/mu. oesmw eozv. 27

nates wasting diseases, in severe enter it is,and in corros ive

poisoning, as by arsenic or antimony.

Green stools may resu lt from an excessive amoun t of bi le.

They are al so common in the diarrheas of young chi ldren,

and in these cases the green color may be due to bacteria lgrowth (Hayem) or to an alka l ine condition of some partof the intestinal canalBloet stools fol low intestina l hemorrhage and the use

of certain drugs,as charcoa l

,bismuth

,iron

,tann in

,etc .

Red stool s usual ly indicate blood , but they may be tingedred after the administration of hematoxyl in (logwood) .Mucous stool s are noted in intestinal catarrh , part icu larlywhen the lower bowe l is afl

'

ected , as in enterocolitis anddysentery.

Fatty stools resu lt from the ingestion of large quanti tiesof fats

,from the absence of bi le

,and from chronic pancre

atic diseases .Ptmdent stools resu lt from fistu la in ano ,

dysen teric , syphi l itic , or mal ignant u lceration

,or the ruptu re of abscesses

into the bowe l , as prostatic and pe lvic abscesses .Lienterie stools , those which con tain much undigested food

,

are noted in inflammatory conditions of the stomach and

upper bowe l.

—(l ) En largemen t of the various organs fromtumors o r other causes . Recogn ized by the history , i rregular en largement, and spec ial symptoms refe rable to the

organ affected. (2) Asc ites . Recogn ized by movable du lness with superincumbent tympany , and fluctuation . (3)Chron ic periton itis (tubercu lous or cancerous) with efl'usion .

Recogn ized by the h istory, progressive emac iation,presence

of a primu y lesion e lsewhere , and detection of tumor- l ikemasses , with , perhaps , pain and tenderness . (4) Tym n ites.Recogn ized by un iversa l tympany on percussion . (5 Pregnancy . Recogn ized by suppression of menses morn ingemesis , pigmentation of mammary areola, softening of the

cerv i x , interm ittent uterine contractions, etc . (6) D isten

28 DISEASES or 7715 DIGESTIVE s Vsnmr.

tion of the bladder. Recogn ized by the hi story, locationof du lness

,and resu lts of catheteri zation .

Defini ti on .—Inflammation of the mouth .

E tiol ogy Mechan ical,chem ica l , thermal , or para

si t ic irri tation. (2) Mercu ria l poisoning. (3) Cachec ticstates , as in phthisis, cancer, and diabetes . (4) I t is mostcommon ly seen in young chi ldren in assoc iation with gastro- intestinal distu rbances

,brought about by artific ial feed

ing, warm weather, and bad hygien ic su rroundings .Vari eti es Catarrhal . (2) Aphthous . (3) U lcerative . (4) Parasitic (thrush) . (5) Gangrenous . (6) Mer

curia l.General Symptom8 .

—Heat and pain in the mouth , ihcreased flow of sal iva

,fetor of the breath , rest lessness , lan

gnor, disinc l ination to nu rse ,and perhaps some fever.

CATARRHAL STOMAT ITIS.

(Simple Stomati tis.)Symptoms.

—General symptoms of stomati tis, and , on

inspect ion , a diffuse red swe l l ing of the mucous membrane .

Treatment —The cause must be removed . E rrors ofhygiene shou ld be correc ted. The diet and the state of the

al imentary tract shou ld rece ive carefu l atten tion . The

mucous membrane of the mouth shou ld be washed at frequent interva ls with cool an tiseptic solu tions . In m i ldm tarr ltal stomatitis a sol u tion of boric ac id , 5to 1 0 grains tothe ounce

,wil l su ffice . In obstinate cases the mou th , after

being carefu l ly c leansed , may be l ightly painted with a sol ution of si lver n itrate , 4 grains to the ounce .

(Fol l icular Stomati tis ; Vesicular m um.)S ymptoms —General symptoms of stomatitis , and , on

inspection,numerous smal l white vesic les on the cheeks ,

lips, and tongue ; these ves ic les soon break , and leave l itt le

sha l low u lcers with a red areola.

S TOMA n 29

Treatmen t —The same as for catarrhal stomatit is . The

fol l owing appl ication is u sefu l :8 . Acid i borici

This is thought by some to be an infec tious disease, because it often occurs in epidem ics , and may attack both chi ldren and adu l ts when congregated and subjected to badhy

'

en ic condi tions.pboms .

—General symptoms of stomati tis .Inspect ion .

—Thc gums of the lower jaw are chieflyaffected. They are swol len , red , and spongy. Linearu lcers , with gray, sloughing bases , soon form , and mayex tend to the check. The glands under the jaw are

swol len . In severe cases loosen ing of the teeth and necrosis of the bone may fol low .

PrognOS iB.—Guardedly favorable.

Treatmen t —Hygien ic conditions must be improved .

Potassium ch lorate is a lmost a spec ific . I t shou ld be usedboth loca l ly and interna l ly. The dose for a chi ld of threeyears is from 1 to 3grains , we l l di luted , every th ree hou rs .The u lcers may be painted with a sol ution of si lver n itrate,

1 0 grains to the ounce. Ton ics , l ike qu in in and iron ,are

cal led for in some instances .

(Thrush Magnet .)E x ci ting Canse .

—Oidium albicans .Symp toms—General symptoms of stomati tis , and ,

on in

spection , numerous m i lk - white e levations which , on remova l,

leave a raw su rface. The disease may extend to the pharyux , esophagus ,

and larynx. MicroscOpic exam ination re

veals the fungu s .Prognosi s—Good .

Treatment—E verything that comes in contact with the

30 D ISE ASE S OF THK DIGESTIVE S YS TE M.

chi ld 's mouth shou ld be rendered absolute ly c lean . Gastro - intestinal derangements shou ld rece ive attention . The

mouth shou ld be c leansed at frequent intervals, especial ly

afte r feeding, with one of the fol lowing solutions : Sodiumbicarbonate (1 dram to 5ounces) ; sodium hyposu lphite (20grains to 1 ounce) ; potassium permanganate (Q grain to 1ounce).

This form is seen most frequent ly in debi l itated chi ldrenbetween the ages of two and six years, and usual ly fol lowsone of the spec ific fevers , espec ia l ly meas les and whoopingcough . I t may be a seque l to u lcerative stomati tis .Various m icro- organisms have been isolated , especial ly

the diphtheria baci l l us and a th read - li ke parasi te of the

leptothrix type.

Symptoms .—The general symptoms of stomati tis are

marked The cheek is the part usual ly afi’ected .

‘ E xternal ly

,i t is swol len

,hard

,red ,

and glazed ; internal ly thereis noted an irregu lar, s loughing u lcer . The putrefactioncauses an intense ly fetid odor . The du ration of the diseaseis from one to three weeks .Comp l i cati on s.

—Perforation,septicem ia ,

lobu lar pneumon ia from aspirated s loughs

,and diarrhea from the swal

lowing of fetid materia l .Prognod 8 .

-Grave . In the large maj ority of cases (85per cent.) the chi ld dies from exhaustion or complications .Recovery is u sual ly attended with deform i ty.

Treatmen t —The s loughing su rface and the tissue immediately su rrounding it shou ld be prompt ly destroyedunder anesthesia with the actual cautery or strong n i tricac id . After the operation the mouth shou ld be c leansed atfrequent interva ls with a solu tion of hyd en dioxid (1 3)or of potassi um permanganate (1 per cent. Concentratednutri tious food , stimu lan ts , and ton ics are urgen tly indicated .

V1 11 girls noma somet imes attacks the vulva.

32 D ISE ASE S OF THE D I GE S TI VE S YSTEMImpu re air

,as the efil uvium from fou l drains or sewers ,

a rently may cause i t.ari eties . S imple or catarrhal . (2) Foll icu lar or

lacunar. (3) Phlegmonous (quinsy) .Sympm —The chief sym toms are chil liness

,head

ache and backache , high fever (P1 03

°- 1 05

° pain in theth roat

,d ifii cu lt deglu ti tion ,

an al tered nasa l voice , sal ivation ,

fetor of the breath,and swe l l ing and tenderness behind the

angles of the jaw.

In the catarr lml form the tonsi ls are un iform ly swol len,red , and covered with tenac ious mucus .In the foll icu lar form the tonsi ls are red and swol len,

and

present l itt le ye l low spots on their su rfaces . These spotsco rrespond to col lections of desquamated and degeneratedepithel ial ce l ls in the lacuna: or c rypts of the gland.During convalescence the contents of the lacunae are oftenexpel led in the form of cheesy pe l lets having a characteristicunp leasant odor.

In thepkl egmonous form the tonsi ls are extreme ly swol lenoften so much that they almost meet ; the pain is inten seand of a throbbing charac ter. One gland soon becomeslarger than the other

,softens

,fluctuates

,and turns yel low

from suppu ration . Swal lowing is a lmost impossible, the

voice is lost,and breathing is difficu l t.

Comp l i cati ons.—A lbum inu ria is frequent . E ndocar

ditis , otitis media, and a diffuse erythema occas ional lyoccur. Suffocation from ruptu re into the larynx and u lceration into the carotid artery are extreme ly rare term inations .Diagnosi s.

—Fol l icu lar tonsi l l itis must be distingu ishedfrom scar let fever and diphtheria.

Scarlet Pen n—The early and persistent vom i ting, the veryfrequent pu lse , the

“ strawbe rry tongue , and the pecu liarpunctiform eruption wi l l suggest scar latina.

Diphther ia—In th is disease there is an ashy- gray membrane, which cannot be readi ly detached

,and which

,if re

moved forcibly, leaves a bleeding su rface. The membranedoes not rema in l im ited to the tonsi ls

,but soon spreads to

the pi l lars,uv u la, and pharyn x . In doubtfu l cases the on ly

ACUTE TON S/LLI T/S . 33

cr i terion is the presence or absence of the Klebs- Loffler

Prognosi 8 .—Favorable ; accidents are very rare. The

duration varies from a few days in the mi ld catarrhal formto a week or more in the phlegmonous form .

Treatmen t—The patient shou ld be confined to a warmroom , and if there be much feve r, to bed . A mi ld aperientis indicated at the outset. The diet shou ld be l ight butsusta ining. The sucking of ice affords re l ief. The mostrel iable in ternal remedies are the sa licy l ic compounds andsodi um benzoate. These shou ld be given in fu l l doses atfrequent intervals .

8 . Atnmonn sal icy latis

Aquz menthre piperi q . a. ndSIG—A teaspoonful every three hours for a

Guaiac is a lso recommended . A dram of the ammon iated tinctu re of guaiac may be given in m i lk every th reehours . Febri le symptoms , if pronounced , may be controlledby smal l doses of phenacetin or by a combination of acon iteand spirit of ni trous ether. The pain may be so intense as

to requ ire the use of Opi um .

Treatment —E xterna l] cold appl ications aid in

br inging about resol ution ; if, owever, s uppuration be inevitable

,warm appli cations shou ld be employed to hasten

the process. Antiseptic spra) s , l ike Dobe l l ‘s sol ution (seep. 37) or a sol ution of hydrogen dioxid are of de

cided benefit . Direct appl icati ons to the surface of the

glands of the t inctu re of ferr ic ch lorid, of a satu rated ethereal solu tion of i odoform

,or of dry sodium carbonate are

ohen usefu l .8 . “ M u ch lora tis . gr . x 11

Tincturte ferri ch loridi

Glycerini

Scarification, fol lowed by gargling with hot water, isanother measu re which frequen t ly affords rel ief.Pus shou ld be evacuated as soon as its presence can be

34 DISEASES OF THE DIGESTIVE SYSTEMdetected. In the major i ty of cases i t is best to make theinc is ion not in the tonsi l itse lf, bu t in the soft palate, a l i tt leabove and to the outer side of the gland .

E ti ol ogy .—Hypertrophy of the tonsi ls occu rs most fre

quent ly in chi ldhood . Whi le it is often exc i ted by repeatedattacks of tonsi l l i tis , in some cases there appears to be no

other cause than a congen ita l predisposition .

Path ol ogy —Ir may be a true hypertrophy , but in mostinstances e ither the glandu lar st ructu re or the connect ivetissue predom inates ; the firmness of the gland increases inproportion to th e overgrowth of the latter. The fo l l ic les are

often di lated and fi l led with cheesy material wh ich resu ltsfrom the accumu lation of fatty degenerated epithe li um .

Nasopharyngeal catarrh , hyperplasia of the l ingual tonsil ,and adenoid growths in the nasopharynx are often associated conditions.Symptoms —The symptoms consist in mou th - breath

ing,snoring du ring sleep, difficu lt deglu ti tion , a th ick voice

of a nasa l qual ity ,fetor of the breath , impai rment of hear

ing ,a l ist less expression of countenance, menta l du ln ess ,

and ma lnu tri tion. N ight - terrors are common . Persisten tinterference with breath ing through the nose gives ri se to

the fol lowing deform ities : narrowing of the nostri ls , contraction of the superior den tal arch , e levation of the hardpalate , and ,

espec ial ly, a ch est conformation l ike that of

ypert rophy of the tonsi ls increasesthe l iabi l i ty to acute catarrh of the nasopharynx , to fol licu lartonsi l l i tis , and to diphtheria. Chron ic catarrh of the m idd leear ,bronchia l asthma, and fac ial chorea are possible sequel s .

Prognosi s.- Favorable ,

if proper treatment be adopted .

Tra nsi ent —Attempts to reduce the en largement byapplying tinctu re of iodin , t inctu re of ferric chlorid , a l umand glycer in , etc .

,usual ly fai l . When the glands are ve ry

large and the genera l health is suffering , no time shou ld belost in resorting to tonsi l lectomy . Pharyngeal adenoidsshou ld also be removed .

PE ARm a r /s. 35

Const itutional treatment shou ld not be neglected . I t ine l udes systematic bath ing , breath ing exerc ises

,attention to

diet and c lothing, and the adm in istration of s uch drugs ascod - livei' oi l, hypophosphites , and iodid of iron.

(Acute“ 8m Throat Simpl e Angi na )

Defin i tion —An acute catarrhal inflammation of the

mucous membrane of the pharynx , soft pa late, and uvu la.

I t 1s uently assoc iated with tonsi l li tis and laryngi tis .E t i ogy .

—E xposu re to cold and wet is the most common cause. I t may be of rheumatic or gouty origin . I tmay be exc ited by local irr itants , such as hot drinks or theinha lation of noxious gases .I t is a lso met with in scar let fever, meas les , and other

infect ious feve rs.symptoms.

—Chi l l iness,s light fever with its assoc i

ated phenomena,stiffness and tenderness of the musc les of

the neck , soreness in the throat , painfu l degluti tion,a sen

sation of dryness or t ick l ing,and a hacking cough . E x

ten sion to the larynx may cause hoarseness ; to the car,

through the E ustachian tube ,deafness . Inspection reveals

a red and swol len mucous membrane.

Prognosi s —Favorable .

W en t —In mi ld cases a gargle of potassium ch lorate wi l l suffice . In severe cases the appl ication to the

throat of c loths wrung out of cold water proves gratefu l .The sucking of pieces of ice affords much re l ief. Garglesor sprays of the disti l late of hamame l is 50 per cent.) areusefu l . A spray of menthol , 2 grains to e ounce of l iqu idpetrolatum, is also efficac ious . Lozenges contain ing cocainwi l l often re l ieve pain and al lay the tick l ing sensation in thethroat The fol lowing form u la , recommended by Bosworth

,

answers the pu rpose adm irablyB. Cocaine hydrochlon tis .

E x tracti kramerix

Sod i i bimrhonat is

E x tracti glycy rrh izaView ttocbi i ci No . xx x .

36 0 155451 153 or m ; DIGESTIVE SYSTEMInternal ly a m i ld aperient may be given at the outset .

Sodium benzoate (5grains fou r times dai ly) has a beneficia leffec t . Be l ladonna with acon i te is a lso recommended . The

rheumatic form usual ly yie lds promptly to a m i ld sa l icylicpreparation l i ke salophen (5to 8 grains three or four timesa day ).

This is a very grave and rapid form of phlegmonousinflammation of the tissues about the floor of the mouthand sides of the neck . I t may occu r in the cou rse of

var ious spec ific fevers, o r it may be exc ited by traumatismo r carious processes at the roots of the teeth . I t may end

in abscess - formation or gangrene, and frequently leads togenera l septicem ia.

E tiol ogy .—Chronic sore throat may resu lt from re

peated acu te attacks , from overuse or improper use of the

voice,o r from the prolonged action of irr itan ts

,l ike tobacco

smoke. I t is a frequen t attendan t upon chronic nasa lcatarrh and indigestion .

Vari et i es HypertrOph ic ; (2) atrophic .

Symptoms —The voice is husky , and its use is fol lowedby distress ; secretion is increased , so that there is a con

stant des ire to c lear the throat ; disagreeable sensations, asfu lness , tickl ing, and the l ike, are frequent ly noted .

In (It: hyper tropl u'

c f orm (granu lar sore th roat, c lergyman

’s sore throat , chron ic fol l icu lar pharyngitis) the mucou smembrane is th ick , swol len , traversed by di lated veins, andstudded with numerous e levations wh ich correspond to mstended fol l ic les and overgrown lymphatic tissue.

In (I n lu mp/tic f orm (pharyngitis sicca) the mucous membrane is pale ,smooth , glossy , and dry .

Treatmen t —The remova l of the cause is of prime

PHARm om s. 37

avoided. Patients shou ld be instructed to expe l sounds bythe aid of the diaphragm and abdom inal musc les insteadof the m usc les of the throat . Nasa l obstruc tions and adenoid growths must be removed. The habit of hawk ingand scraping to c lear the throat shou ld be rigid ly interdicted. D igestive distu rbances shou ld receive carefu l attention. Ton ics, l ike iron, strychnin , and cod - l iver oi l

,are

sometimes required .

Local Treatment—The nasopharynx shou ld be kept c leanby frequent spraying with an antiseptic al kal ine l iqu id

,l ike

Dobe l l’

s sol ution :3. Sodu bicarbonatis

Sod ii horatis

Acidi carbol ieiGlycerini

Astringen t applications are often of service ; one of the

fo llowing may be employed : Z inc su l phate , 5grains to theounce ; tannin ,l dram to the ounce of glycerin ; si lver

n i trate,to to 20 grains to th e ounce . In the fol l icu lar

variety it is advisable to destroy the en larged fol l ic les bymeans of the galvanocautery , after which the astringentappl ications may be made .

This is a suppu rative inflamma tion of the pharyngeallymphatics , usua l ly secondary to one of the Spec ific fevers ,to fo l l icu lar tonsi l l i tis , suppu rative rh in itis , otitis media

,or

to caries of the cervica l vertebra . I t occu rs espec ial lyin children . I t may be recogn ized by pain in the th roat ,dysphagia,

dyspnea, alteration in the voice ,and the detect ion,

inspection or palpation ,of a swe l l ing projecting from

the posterior pharyngea l wal l .Treatmen t —As soon as pus can be detected it shou ld

be evacuated by mean s of a guarded bistou ry , the head ofthe chi ld being he ld forward to preven t the escape of the

pus into the larynx .

38 0 1554 355 or 7115 DIGESTIVE s ysm u .

Vari eti es —(i ) Functiona l obstruction due to spasm(esophagismus) . (2) Organ ic obstruction .

E t iol ogy .—It usua l ly occu rs in women as a man ifesta

tion of hysteria. I t may occu r as a symptom of hydrophobia or of chorea. I t may be due to reflex irri tati onoriginating in the e50 phagus itse lf or in some di stant organ .

Sympt of Hyster ie E sophag ismua—Ir is man ifested by paroxysma l dysphagia,

a sense of constriction inthe chest

,and sometimes by choking and the regurgitation

of food.Diagnosi s —Ir may be recogn ized by the age and sex

of the patient,the paroxysmal character of the obstruction ,

the ease with which a bougie can be passed , the presenceof emotiona l distu rbances , the absence of emac iation ,

and

the absence of any other obviouscause .

Prognosi s—Good .

Treatment —The under lying neu rosis shou ld receiveappropr iate treatment . The systematic passage of a bougieoften resu lts in a cure.

E ti ol ogy .— (t ) An external tumor pressing on the

esophagus . Th is is most common ly an aneu rysm . (2) Atumor owing from the esophageal wal l , general ly a can

cer. (3 A c icatrix from u lcerat ion . The u lcer may be

due to syphi l is or to the ingestion of some corrosive poison,

as a strong ac id or alka l i . (4) A fore ign body.

Symptoms—The chief symptom is s lowly increasingdifficu l ty in deglu tition ,

with the regu rgitation of food.The esophagus is often much di lated above the constric

tion,and the food may col lec t in the pouch thus formed ,

so that regu rgitation may be de layed for several hou rs .The passage of a bougie meets with a permanent obstruetion . There is much loss of flesh.

40 D ISE ASE S or 7715 DIGESTIVE S YS TE M .

are more marked,particu lar ly the nausea and vomi ting.

There may be also moderate fever (1 0 2°—l o3° th irst,herpes , distention of the epi trium

,loca l tenderness , and

considerable prostration . T e vom itus is composed at fi rstof sour, fermented food ; later, of mucus and bi le. Jaundicemay fol low from the extension of the catarrh to the duode~num and bi le- ducts

,and diarrhea from its extension to the

intestines.Tat ic gasm

'

a'

s is man ifested by in tense bu rn ing pain in thethroat, gu l let , and stomach , persistent vom iting of foodremnants m ixed with blood and mucus

,marked abdomina l

tenderness , and the phenomena of col lapse .

Atrophy of the mucosa and c icatric ia l stenosis of the

orifices are common seque ls in cases that do not prove immediately fatal .D iagram - It may resemble the onset of scarlet fever,but the his tory of contagion, the

“ strawberry tongue, soreth roat, very rapid pu lse , and eruption wi l l lead to the recogn ition of the latter.

PrognM —S imple acute gastrit is runs a favorab lecourse, and rare ly lasts more than a few days .Absolute rest is essential . If the stomach has not been

complete ly emptied, an emet ic , such as warm water or ipecac ,shou ld be employed. Loca l ly , a mustard - plaster or a turpentine stupe wi l l aid in re l ieving distress . As a ru le , no

food shou ld be given by the mou th unti l the stomach becomes retentive . Ice

,howeve r, may be al lowed to quench

the th irst. In de l icate subjects nutrien t enemata wi l l be re

quired . If there is constipat ion ,a mercu rial laxative may

be given with advantage . Such a combination as the fo l

lowing usual ly acts favorablyB. Hydn rgyri ch lor id i mitis gr . j

Bismuthi subn itrat is . gr . “ P M.

Finnt chu tulz No . vj .Sta—One on the tongue every hour , to be fol lowed by a Seidl itzpowder, if necessary .

Severe pain , nausea ,res tlessness , and insomn ia are best

rel ieved by opium suppos itories . Persistent vom i ting maybe re l ieved by bismuth subn itrate (1 0 grains) combined with

CHRONIC GAS TR I TIS . 4 1

creasote (I minim) , with coca in grain) , or with hydrocyan ic ac id , as in the fol lowing formu la !

8 . Bismuthi subnim tit

Acid i hydrocyanici di l utiA are

.A ake we l l . A desaertspoonful everyThe fol lowing combination of ipecac and nu x vomica isoften serviceable

K. Ti nctum nuc is vomica:Vini ipeeacuanhz

Sta—Two drops every hour.After the lapse of twenty - fou r or th irty- s ix hou rs it isgeneral ly possible to give bland nou rishment by the mouth .

Bar ley- water, champagne with soda- water, m i lk and l imewater , pepton i zed m i lk , and l ight broths may be given in

sma l l quanti ties at frequent intervals . The retu rn to sol idfood shou ld a lways be carried out very gradual ly .

The treatment of tox ic gasm'

a'

s consists in the immediateneutral ization of the poison by chem ical antidotes , in the

evacuation of the stomac h (except in the late stages of

poison ing by causti cs) by the stomach - pump or emetics ,and in the admin istration of dem u lcents and opium.

u fSIj F—M.

(Chronic Gastric Catarrh : Ontarrhal Dy spopd n . )

E tiol ogy —Ir may be exc ited—(l ) By prolonged irri tation of the stomach , such as resu l ts from errors in diet(exces ses in eating and drinking , indigestible food , excessive,irregu lar mea ls, defic ient mastication , etc.) or from the ex

cessive use of alcohol , tobacco , condiments , or pu rgatives ;(2) by passive congestion the resu lt of chron ic heart diseaseor c irrhosis of the l iver ; (3) by chron ic diseases that dist u rbmetabolism, such as tubercu losis , diabetes , ch ron ic Bright 'sdisease , gout, chl oros is

,etc. ; (4) by chron ic diseases of thestomac h itse lf, such as cancer

,u lcer

,gastrec tasis, etc .

Path ol ogy .—The mucous membrane is of a grayish or

s laty co l or, swol len , and cove red with tenac ious mucus .The veins are dilated

,and there may be ecchymoses .

42 D ISE ASE S or THE DIGESTIVE S ysm y .

Microsc0 pical ly ,there is a cel l u lar infi ltration in the inter

sti tial tissue. The glands are di lated , e longated , and tortuous

,and their epithe l ium is more or less degenerated and

detached. The interglandu lar prol iferation may be so pronounced as to cause great thickening of the mucous mem

brane (bypertrop/u'

r gastn’

txlr) , o r,on the other hand

,the

new- formed fibrous tissue may contract to such a degree as

to cause extreme thinn ing of the coats of the stomach andatrophy or complete destruction of the glandu lar e lements

subj ecti ve symptoms are very variable

,and

,for the most part , not characteristic . The ch ief

phenomena are fu rring of the tongue ,fetor of the brea th,

anorexia,fu lness and distress , espec ial ly at the height of

digestion,be lching, eructations , heartbu rn ,

constipation ,

headache,vertigo, and attacks of palpitation . Nausea and

vomiting are not uncommon. The latter may occur beforebreakfast or at the he ight of digestion . If it occu rs onr is ing in the morn ing

,the vom it consists of tough masses

of mucus ; if i t occu rs after meals,the vom it is composed

of undigested food remnan ts intimately m ixed with moreor less glai ry mucus . The entire epigastrium may be sen

sitive to pressu re.

The obj ective symptoms are characteristic . E xam inationof the stomach - contents revea l s an excess ive secretion of

mucus , a marked reduction in the secretion of HCl and of

the digestive ferments,and imperfect digestion of album ins .

In uncompl icated cases there is no motor insu ffic iency .

Chronic gastric catarrh rare ly term inates in arrop/ric garm

'

tis (w iry /{a gasm'

m) , the most important symptoms of

which are paroxysma l pain ,more or less persistent vom it

ing , constipation alternating with diarrhea, pronouncedemaciation and anem ia

,and absence of free Hc l and of

digestive ferments from the stomach - contents after a tes tbreakfast.D iag

'

nosi s.—Atony of the Stomach —In simple atonyflu ids exc ite as much distress as sol ids , vom iting is not common

,the sec retion of m ucus is not increased

, the secretion‘ In n re instances the oeeretion of HCl is increased .

cmeozvzc GAS TRI TIS. 43

of HCl is not usual ly decreased , and considerable quanti tiesof undigested food can be recovered from th e stomachseven hou rs after a test- mea l .Hy pocrchlcrhy dria.

—In th is condition the genera l health isnot unpai red

,the appeti te is usua l ly good

,there is more or

less severe pa in short ly after eating, a lbum ins and al kal is

re l ieve the a

pain ,and excess of HCl is found in the stomach

contents ; album in - digestion is good , starch - digestion is t etarded ,

and there is no excess of mucus.Nervous Dy spepm .

—In this syndrome the severity of thesymptoms varies cons iderably from day to day according tothe menta l state of the patient

,and is not materia l ly influ

enced by the quanti ty or the qual ity of the food ; the general heal th is not often impai red

,the nervous symptoms are

very prom inent , the secretion of the stomach is usua l lynormal, and there is no excess of mucus .Peptic mea n—The seve re

,local ized paroxysms of pain

short ly after eating, the loca li zed tenderness , hematemesis ,and hyperac i dity wi l l serve to d is tingu is h u lcer from catarrh .

cancer of the Stomach —The history, rapid course , ca

chexia,persi stent vom i ting, hematemesis

, pal b le tumor,signs of gastrectasis , and the ear ly absence of ree HCl fromthe gastric j u ice

,with the presence of large quanti ties of

lact ic ac id and of the Boas - Oppler bac i l l i , wi l l usual lyrender the diagnosis c lear.

Care must be taken to determ ine whether the catarrh ispr imary or secondary to Some constit utional or visceraldisease.

Prognosi s —The primary forms of chron ic gastri tis,when not too far advanced

,are frequent ly cu red . The

prognosis is unfavorable when there is much atrophy of thegastric mucosa. In the secondary forms the prognosis isd dent on that of the primary d isease .

tal en t —The cause shou ld be ascerta ined and re

moved if possible. Regu larity in the time of meals , s lowness in eating, and thorough mastication of food must heinsisted upon . The patient shou ld be cautioned againstovereating and the taking of large quantities of l iqu id , especial ly of iced water

,during meals . Overindu lgence in al co

44 D ISE ASE S or THE D IGE S TI VE S YS TE M.

hol, tobacco, coffee , and tea shou ld be forbidden. The re

sumption of menta l or physical work immediate ly after

meals shou ld also be avoided .

A mi xed diet of bland,readi ly digestible food is requ ired.

I t may usual ly inc lude boi led, baked , or gri l led beef andmu tton

,chicken,

sweetbread,boi led fish

,oysters , soft - boi led

or poached eggs, pu l led bread, fresh bu tter, baked potato,young s tring- beans , sma l l peas , spinach , hearts of celery

,

thorough ly cooked cerea ls , calves '- foot je l ly, and j unket.Tea

, cofl'

ee,and cocoa may or may not be perm issible.

An exc l usive mi l k diet acts exceedingly we l l in somecases . Systematic lavage is of great val ue in severe cases

,

espec ial ly when there is excess ive secretion of mucus .When lavage cannot be tolerated , the stomach may be

c leansed by a glass of hot al kal ine water s lowly sipped aha lf- hour or more before breakfast . The fo l l owing artificialCar lsbad sa lt may be used as the alkali

B. Sod ii sulphatis

Sodi i chlorid iS te—A ten poonfu l i n a glass of hot water an hour before

In m i ld cases the adm in istration of a bitter—cal umba,gen tian ,nu x vomica—some time before meals often proves

efl'

i cacious . In many cases an al kal i may be added withadvantage to the bitter, as in the fol lowing formu la

3. Sodfi bicarbonatis

Infusi gentinnz com iti

S ta—A tablespoonful be ore mealsWhen the stomach is h igh ly sens i t ive ,

si lver n itrate wi l lbe found a val uable remedy. I t may be given in pi l l formin combination with hyoscyamus

, as in the fol lowingformu la

11 . Argenti nitrnt is

E x tract i hyoscyamiP unt pilulae No. x x .Sum—One pi l l a half- hour before mea ls.

Bismuth subn itrate is al so of service in such cases .Di l u ted hydroch loric acid is sometimes serviceable in re

ATOIVY OF THE s ros m61 1. 45

placing the natu ral acid of the gastric j u ice . In manycases

,however, better resu lts are secured from the adminis

tration ,during mea ls , of pancreatin with sodi um bicarbonate.

Flatu lence and fermen tation may be control led by suchbismuth salicylate, creasote, bismuth - beta

oi , etc . The foll owing combination is often of val ue.

Si o .—One after menl s.

So far as ss ib le, constipation shou ld be overcome byregu lation diet, systematic exerc ise , and the use of

enemas or suppos itories.Change of scene , a sunny c limat e , good hou rs , and free

dom from business worry and household cares often provemo re benefic ial than any other measu re employed .

Defin i tion .—Atony of the stomach consists in re laxa

t

o

ion of the musc u lar coat of the stomach and insuffic iencyi ts ropu ls ive powers . I t frequent ly leads to gastrecms is.

l og y .—Motor insufii ciency is of common occur

rence . I t may be congen ita l ; it may be caused by intemperance in eating and drink ing ; it may fol low acute infections ; i t may occ u r in the cou rse of chron ic diseasesattended by malnutrit ion ; i t may appear acutely after

traumatism or intense emotiona l exc itement , it may be a

complication in other d iseases of the stomach , especial ly i ngastroptosis , chronic gastri tis , nervous dyspeps ia,

and hyperSymp toms —In simple atony the chief symptoms are

a fee l ing of fu lness and discomfort after meals , espec ial ly ifthe latter have been large, and frequent be lching of gas .

The sever ity.

of the symptoms often bears a defini te relationto the quant ity of food taken . Fl u ids are as li kely to exc i tedistress as so lids . As a ru le

, there is neither vomitii ig nor

DISEASES OF THE D IGE S TI VE S YS TE Mpain . The appetite is u sua l ly good , the general heal th isnot serious ly affected , and the sym toms en ti re ly abate uponthe evacuation of the stomach . here are no signs of gastrectas is. When the intestines are s im i lar ly affected, theremay be marked nervous symptoms—headache, vertigo, andparesthesia—and considerable distu rbance of nutrition.

The diagnos is is rendered certain by the recovery of a

considerabl e quanti ty of undigested food from the stomachseven hours after the ingestion of the R iegel test-mea l .Progn 0 8 i 8 .

—Favorable ,if the cause can be removed .

Treatmen t —The fi rst indication is to remove the cause.

The food shou ld be readi ly digestible,sma l l in bu lk

,fine ly

divided,and nutritious . Flu ids

,except in moderate quan

ti ties,and coarse vegetables are to be avoided. The diet mayinc l ude tender meats , eggs , oysters , boi led fish

,we l l - cooked

cerea ls , steamed rice , sta le bread , fresh butte r, baked potatoes , tender spinach string- beans , and asparagus- tips . I t i srarely necessary to i ncrease the number of meals. Rest forat least an hou r after large meals is to be u rged . E xerc i sein the Open air and frequen t tepid baths are general measu res of value. Lavage is u nnecessary un less there are

gastrec tas is and fermenta tion .

General ton ics , espec ial ly iron , are often needed . The

most usefu l direct remedies are the bitters (quassia, gentian ,

and calumba) , particu lar ly the t inctu re of nux vom ica,

which may be given in doses of from 5to to m in ims , gradual ly increased , before mea ls . A lkal is are indicated whenthere is hypersecretion . Antifermentatives—bismuth sa licy late ,

beta- naphthol - bismuth , sa lol , and creasote—are use

fu l in reduc ing flatu lence.

Constipation is best rel ieved by diet, abdominal massage,and enemas .

Defin i tion —The characteristic featu re of this syndromeis pronounced discomfort du ring the period of digestion ,

out of al l proportion to the disturbances of gastric secre

48 ss s or 71 15 TI V5 3VS T5111 .

are often indicated . Short cou rses of an un irr itating bromid,

l ike that of stronti um , sometimes do good . The fol lowingcombination of antispasmodics is usefu l in certa in cases :

3. Z inci valeriauatis

E x tract i sumhulAcidi arsenosiE x tructi gentiana: gr. x .

—M.

Fiant°

lulze No. xx .Si c. ne p i l l after each meal .

Defin i ti on .—These terms are used to des ignate an

abnorma l increase in the secretion of hydroc h loric aciddu rin the digestive act.

Ol ogy .—Thi s anomaly of secreti on is most frequent ly

seen in neu ropathi c subjects between the ages of fifteen and

forty . Mental overexertion,the excessive use of tobacco,

overindu lgence in condiments , and insuffic ient masticationare important

pred isposing factors . I t is a common com

pl ication in ch orosis,in gastric u lcer, and in chole l ith ias is .

Sm pM s .—The symptoms do not appear immediate ly

after eating, bu t at the acme of digestion , and inc lude sen

sory irri tation ,varying in degree from s l ight discomfort to .

agoni zing pain ,ac id eructations , heartbu rn , th irst, di ffuse

tenderness over the stomach,and occasional ly vom iting .

These symptoms are re l ieved by eating smal l quanti ties of

a lbum inous food and by the ingestion of a lkal is , and d is

appear spontaneously upon evacuation of the stomach .

They may be continuous or periodic .

The stomach- c ontents obta ined after a test - breakfast areexcessive ly rich in hydroch loric ac id , both free and com

b ined . A lbum in digestion is rap id ; starch digestion isretarded . The resting stomach is empty. There is no

motor insuffic iency.

Progn 0 8 i 8 .—In the absence of compl ications the prog

nosis is favorable .

Treatmen t —The cause shou ld be ascertained and re

moved , if poss ible ; thorough mastication is imperative.

casm osoc cox x 49

The diet shou ld be un irri tating , and composed large ly of

album inoid foods . Coarse substances, vinegar, spices , condiments ,

cofl'

ee, and alcohol shou ld be avoided. A moder

ate amount of water or weak tea at meals is des irable .

Fats , in the form of cream and butter, are usual ly we l lborne. S tarchy foods shou ld be used sparingly and on lywhen thoroughly cooked . I t is sometimes des irable toincrease the number of meals .A lkal is , in the form of sodium bicarbonate or magnesia ,

adm inistered at the height of digestion,re l ieves the symptoms. S i lver n itrate Q grain) wi th extract of be l ladonna

gra in) thr ice dai ly, on an empty stomach , is usefu l . S i lvern i trate (i zzooo to I 1 0 0 0 ) may also be given as a stomac hdouche wi th advantage.

(Belchmann’

s Disease.)

Defini ti on .—This is a funct ional condition characteri zed

by the secretion’

of large quant ities of gastric j u ice, evenwhen the stomach is empty . I t is often assoc iated withhyperchlorhydria. Two forms have been recogn ized—(i )the continuous and (2) the interm ittent .

auses of gastrosuccorrhea are the sameas those which exc ite hyperchlorhydria.

Symptoms — In the continuous form the symptomsappear regu larly, but with varying intensity , and consist inmore or less severe pain,

both at the acme of digestion and

in the n ight ; vomit ing of large quan ti ties of ye l lowish , acidfl u id

, even when the ingesta are no longer in the stomach ;marked thirst ; ac id eructat ions ; and headache, sometimesof a migrainous type . The ingestion of a smal l quanti ty of

a lbuminous food us ual ly re l ieves the pa in . A lbum in digestion is good

,but starch digesti on is retarded . The diag

nos is is rendered certain by the finding of from 50 c .c . to50 0 c .c . or more of gastric j u ice ,

wit/rou t ( my adm lrmre offood , in the stomach before breakfast, part icu lar ly if lavagehas been ed the n ight before .

Cm pfimns—Gastrectasis may resu lt from immrfect

4

so DISEASES or DIGESTIVE S YSTE M .

digestion of starches or from spasm of the pylorus exci tedby excessive acidity. Ulcer may coexist. In rare instancestetany deve lops.Diagnosi s

—In hypercldor l iy dnb the resting stomach i s

empty and pa in does not occu r at n ight. Care m us t betaken to exc l ude locomotor atax ia ,

of which interm i tten tgastrosuccorrhea may be an early symptom.

Prognosi 8 .—Guardedly favorable in uncompli cated

cases . Re lapses are common.

Treatmen t —This is much the same as that for hyperchlorhydria. The painfu l attacks may be re l ieved by theadm in istration of alkal is

,or

,be tter, by thorough lavage .

Be l ladonna appears to posses s some power to reduce gastr icsecretion.

GASTRALGIA.

(Gu trodynia ; Neuralgia of the Stomach. )

Defini ti on .—Violent paroxysmal gastric pa in , occu rri ng

independent ly of any organ ic disease of the stomach and of

any distu rbances of secretion or moti li ty.

E t i ol ogy .—It is more common in women than in men .

Overwork , worry, sexual excesses , abuse of tobacco, reflexirr itation , and anemia predispose to it. I t may be a symptom of neu rasthen ia.

S ymptoms.- The charac teristic features are paroxysms

of intense pa in,occurring suddenly at irregu lar intervals ,

radiating to the chest and back,bearing no defin ite re lati on

to eating, and lasting from a few m inutes to several hou rs.Vom iting is rare. Pressu re over the stomac h may rel ievethe pain ,

and so may the taking of food .

Diagnosi s .—l diopath ic gast ra lgia must be separated

from the paroxysmal pa in that occurs in gastri c u lcer, gastric cancer , hype rchlorhydria,locomotor ataxia, angina pectori s , and in rena l and bi liary col ic .

Gastric (“cer .—Pain is exc ited by food and digestion , dis

appears upon evacuation of the stomach , is assoc iated withhyperac idity ,

and often with vomiting,hematemesis, and

local tenderness.

0 457794 1. 6 1A. 5i

Gastric Qu een—The pain is usual ly more or less continuous ,

and is aggravated by digestion . There may be

persistent vomi ting, hematemesis , cachexia, inacidi ty wi thlact ic -ac id ferm en tation,

and a palpable tumor.Hypereh lorhwdrh .

—The pain is digestive, and is rel ievedby a l kal is and by a lbum inous food . E xamination of the

stomach - con ten ts revea ls excess of HCl .Grin s of Tahoe—Unsteadiness of gai t and of station

,

Argy l l - Robertson pupi l , shooting pains in the l imbs , abnormal ities of sensa tion , and aboli t ion of deep reflexes wi l l indicate locomotor ataxia.

An gina. Poem - The pa in radiates from the heart to thenec k and arm ,

is frequent ly exc ited by exertion or indisc re

tions in diet , is general ly of short du ration, is often attendedwi th immobi l ity of the body and a fee l ing of imminent dis.so l ution

, and is usual ly assoc iated with the signs of arteriosc leros is .Beu l Col i c—The pain radiates from the k idney into theureter of the affected side

,and concretions or blood may be

found in the urine.

Bi l iary Col ic—The pain is usual ly in the right hypochondriac region , and is often accompanied by chi l l , fever, andjaund ice. The l iver and gal l - bladder may be en larged and

Prognosis —Favorable in uncompl icated cases .W ent—7h Attack—Hot appl ications are usefu l .

Ga lvanization (the anode over the stomach and the cathodenear the spina l col umn) often affords prompt re l ief. The

most general ly efficac ious remedies are an tipyrin (8 grains) ,brandy '

(l to 2 flu idrams), aromatic spirit of ammon iaGflu id ram ) , chloroform (2 to 5m in ims) , and di l uted hydrocyan ic acid (2 m inims). These remedies are most efli caciouswhen given in hot water. Such a combination as the fo l

lowing is frequent ly successfu l :

i la: n g i n—M.

Sim—A teaspoonfu l in hot water every fifteen or thirty minutes .

52 OF TI/Iz’ DIGESTIVE S YS TE M

In very severe cases it wi l l be necessary to resort tomo h in .

1 ntrm al .—The cause must be ascertained , and , if possible

,removed. The habits of the patient must be corrected .

Methods of treatment intended to improve the generalnutri tion are of the greatest val ue . When there is anem ia

,

iron wi l l be found very usefu l . Among spec ia l remediesarsen ic, valerianates , sumbu l , quin in , and cannabis indica are

avai lable. The fol lowing combination often proves effi ca

cious :

B. Acidi arsenosi'

nxe val erianatis

erri pymphosphatisE x tract i sumbu l u gr . x x .—M.

Fiant in pi l ulz No . xx.S ta—One pi l l after each meal .

In some cases a complete change of scene or enforcedrest in bed for a given period is the on ly means of effectinga cure.

PEPTIC ULCER.

(Bound most of the Stomach ; Perfi rating Ul cer .)

Defin i ti on —A c ircumscribed loss of tissue in the

stomach, usua l ly involving both the mucous membraneand the deeper structures , and characterized c l in ical ly byparoxysma l pain ,

local ized tenderness , vom iting, hematemesis , and hyperac id ity of the gastric j uice.

S im i lar les ions occur in the duodenum and in the lowerend of the esophagus.E t i ol ogy .

— l t is more common in women than in men.

The majori ty of cases occu r be tween the ages of twentyand forty . Ch loros is and anem ia are important predisposing

Duodena l u lcer not infrequently fol lows large superfic ialbu rns .

Path ogenesi s—It is general ly adm itted that these u lcers

are due to the digestive action of high ly ac id gastric j u iceupon a part of the stomach that has been devita l ized inconsequence of embol ism or th rombosis wi th infarc tion,

PEPTIC ULGE R. 53

spasm of the blood - vesse ls, disease of the vessel - wal ls , orexternal inj ury .

Path ology —As a ru le, the u lcers are single, but theymay be mu ltiple. The most frequen t seat is the posteriorwal l , in the lesser curvatu re, near the pylorus . They havea punched - out appearance, are round or oval in out l ine, and ,if recent , are funne l - shaped, with the apex toward the

serous coat . The edges are usual ly smooth , rare ly ragged.They vary in diameter from a few m i l limeters to severalcentimeters , and may extend to the muscu laris or even tothe se rosa.

Symptoms .—Symptoms of indigestion are general ly

present. The characteri stic symptoms are :l . Pam—This is usual ly paroxysmal , severe, and local

ized . I t may radiate to the back or s ides . I t is c lose lyassoc iated with eating, reaches its acme at the height ofdiges t ion

,is aggravated by coarse ,

ve ry hot , ac id and spicyfoods , is often affected by certain positions of the body, isarrested by vom it ing, and subsides spontaneously upon thenatu ra l evacuation of the stomach .

2. Local iscd Tendt rne: s.

—Two smal l areas of tendernesscan often be e lic ited

,one in front be low the ensiform car

ti lage, and one behind, in the dorsal region,a l itt le to the

left of the spine .

3. Vom'

h’

ng .

—This frequent ly occurs in from one- hal f toN o hou rs after eating. The vomit usual ly consists of undigested food and ac id fl u id .

4. Htmak mesir .—This occ u rs in at least one- hal f of al l

cases . I t proves fatal in about 3per cent. of the cases ofu lcer. The blood is genera l ly flu id and unal tered , but ifretained in the stomach for some time, it may have a coffeeground appearance. Occasional ly the blood is dischargedentire ly by the bowe l.5. Hyperaa

’

d ity .—An increase of HCl is almost invariably

noted after a test - mea l.In some cases on ly the symptoms of dyspepsia are pres

ent, whi le in others al l symptoms are absent , the disease

passing unrecogn i zed until sudden perforation or profusehemorrhage occurs .

54 DISEASES OF THE DIGESTIVE S YSTEMSequel s —(n) Perforation . This occurs most frequently

in u lce rs on the anterior wal l and in about 4 per cent.of al l cases . (2 ) General o r c i rcumsc ribed periton i tis. General peri ton itis is usual ly the resu lt of perforation ; c ir

cumsc ribed productive peri ton itis is a conservative processand resu lts from the di rect extension of the inflammatoryprocess through the stomach - wal ls . (3) Subph ren ic abscess.Th is is us ua l ly the resu lt of perforation after the formationof adhesions . (4) Stenosis o f the pylorus

,stenosis of the

cardia,or hour- glass constric t ion of the stomach may resu lt

from the contraction of cicatrices . (5) Cancer no t infre

quently deve lops on the basis of an old u lcer.

Diagnosi s.—Hyprrcldor lzy dr ia .

—In this condition the

pain does not occu r so regu lar ly nor so soon after eating ;i t is not modified by position ,

but is often complete ly re

lieved by eating a lbum inous food . Hematemesis is absentand there are no tender spots .Gastm/g

‘ia .

— In th is affection the pain occu rs at i rregu larinterva ls , is not dependent upon eating (often occu rringwhen the stomach is empty) , is re l ieved by pressu re

,and is

not assoc iated with tender spots,hematemesis , or hyper

Cana '

r (f the S fomack .

—The h istory,rapid cou rse , ad

vanced cachexia, palpable tumor, vom it ing of large quantities of undiges ted food at long and irregu lar inte rvals ,coffee - ground vom it , abundance of lact ic ac i d with BoasOppler bac i l l i

,and the absence of free hydrochloric ac id

wi l l point to cancer.

Duodenal (f law— In th is disease the pa in is fu rther to theright and occu rs later after the meals ,

’

the blood is usual lyevacuated th rough the bowe l , and there is no vom it ing .

Cli o/cIi I/u'

aszs— In th is condition the pains appear moresudden ly, occur at more i rregu lar intervals , and often independent ly of eati ng, u sua l ly radiate toward the right shou lder, and are often assoc iated with swe l l ing and tendernessof the l iver, en largement of the gal l - bladder, and s l ightjaundice .

Prognosi s.—Guardedly favorable in recent cases . The

morta l i ty in al l cases is from 8 to to per cent. Some u lcers

56 5123 or m e DIGESTIVE s YSTE M.

Pain and vom i ting usual ly yie ld to complete rest, rectalfeeding, and the adm inistration of si lver n i trate or bismuthsubn i trate. In some cases it may be necessary to use mor

phin hypodermica l ly. E xternal ly, stupes or sinapisms are

some times usefu l . The treatment of hematemesis is con

sidered on page 63.

Surgical Treatment—In al l cases of perforation an operation shou ld be done at the earl iest possible moment . Whenlife is th reatened by repeated hemorrhage, Operation in theinterval between the attacks offers the best method of re l ief.Again

,an operation (gastro- enterostomy, pyloroplasty, or

partial gastrectomy) shou ld be considered i f the diseasedoes not yie ld to medical treatment and the l ife of the

patient is endangered by malnutr i tion .

E ti ol ogy .—8u .

—Cancer of the stomach is somewhatmore common in men than in women.

Age—The majority of cases occur between the ages offorty and sixty. I t is rare before thirty.

Heredi ty .—About 8 per cent. of the cases appear to be

hereditary .

Prolonged Irritationa - Cancer occasional ly deve lops on thebasis of an old u lcer.

Path ol ogy .—Cancer of the stomach is almost always

primary. The pylorus is the part most frequently attacked .

After the pylorus the points of predi lection are the lessercurvature and cardia The fol lowing varieties are encoun

tered : Sc irrhus or hard cancer , medu l lary or soft cancer,

adenocarc inoma (cyl indric - ce l led epithe l ioma) , col loid can

cer,and squamous- ce l led epithe l ioma. Ulceration is rare

i n sc irrhus, but common in medu l lary cancer and adenocarc inoma. Col loid cancer appears most common ly as a

diffuse infi l tration of the stomach - wal l . Squamous- ce l ledcancer is rare , and occu rs on ly at the cardia.

Owing to stenosis of the pylo ru s the stomach is usual lydi lated. Stagnation of the stomach - contents and the ab

sence of hydroch loric - ac id secretion favor the deve lopmentof lactic - ac id fermentation .

CANCE R as w e 570 1114 0 1 . 57

Symptom —Symptoms of dyspepsia are general lypresent. The characteri stic phenomena are

t . Pain—This is rare ly intense ; though aggravated byeating, i t is often more or less contin uous . I t may radiateto the back.

2 . Vom h’

ng .- This is very common. When the pylorus

is obstructed, the vom iting is persistent and occurs longafter eating, sometimes at intervals of several days . The

vom it is frequent ly large in amount, and is composed chieflyof undigested food and tu rbid fl u id. I t very rare ly con

tains sarcinaz, but long, thread - l ike bac i l li (Boas- Opp!”bacil l i) are a lmost constantly present and possess somediagnostic significance.

3. Hemaremesis .—As the bleeding is s l ight and the blood

remains for some time in the stomach , the vomi t in manycases acqu ires a cofl

'

ee ground appearance.

4. Car/ren d —The anemia, weakness , and emac iation are

often d isproportionate to the loss of nou rishment.5. Palpabl e Tamen—A movable, tender mass can be de

tected sooner or later in a large proportion of al l cases .

absence of free HCl and the presence of large quantit ies oflactic acid , whi le not pecu l iar to cancer

,are strongly indica

tive of the disease .

In addition to these featu res the symptoms and signs ofgastrectaris are freq reuent lyCompl ications and geqnels—Metastases in ne ighboring structu res—l iver, lymph - glands, pancreas , and peritoneum—are of common occurrence. Asc i tes and edemaare occasional ly encountered . Perforation

,subphren ic ah

scess,tetany , venous thrombosis , mu ltiple neurit is , and coma

(from o x y buty ric' ac id intoxication) are rare complications .

D ing-

nod s .—The difl'

erential points between cancer and

u lcer and cancer and ch ronic gastrit is have already beenconsidered .

Prognosi s —The disease is a lmost invariably fatal . Theaverage duration of l ife is from one to two years . Markedtemmrary improvement frequent ly occu rs under treatmentand may prove very m is leading .

58 m ss ass s or 71 15 0 1 05571 3455rsTE N .

Treatmen t .—In the ear ly stages of the disease ,when

the pylorus is sti l l patu lous , a mixed diet of readi ly digestedfood is often we l l borne. Later, when there is retention

,

food shou ld be se lec ted that wi l l make sma l l demands onthe stomach and that wi l l leave li tt le res idue . Bittersca l umba, gentian, condu rango—are sometimes employedwith advantage. In many cases , but by no means invariably, hydroch loric ac id and pepsin are usefu l . Lavageaflords the best means of re l ieving the distress ing symptomsres u lting from retention . Vom iting not dependent uponreten tion may be treated with such remedies as carbonatedwater, hydrocyan ic ac id . c reasote, cerium oxa late ,

and bismuth subni trate . In obstinate cases recta l feeding may be

requ ired fo r a time . Ac id eructations and flatu lency are

sometimes re lieved by antac ids and interna l antiseptics , butgeneral ly lavage is much more efl

'

ective. Pain wi l l requ ireOpium

,sedatives l ike hydrocyanic ac id or ch loroform, and

hot appl ications .Early ope rative interference may prolong l ife for severa l

months or several years .

(Gastroctasia )

E t iol ogy .—Gastrec tasis may resu lt from—( l ) Atony of

the stomach - wa l ls (see p . (2) from stenosis of the

pylorus .S im on lr q

’

{be py lorus may be cau sed by—(a) Congenita lstrictu re ; (b) carc inoma of the pylorus ; (c) c icatrix fromu lcer ; (d ) hypertrophy of the pylorus from gastr ic catarrho r frequent spasm exc i ted by hypersec retion ; (4 ) pressu refrom withou t , as by tumors , adhes ions , floati ng kidney , etc .

Path ol ogy .—A | l degrees of di latat ion are encountered .

The most severe form s are usual ly the resu lt of pyloricstenosis . In atonic di latation the stomach - wal ls are thinand atroph ic ; in di latation from obstruction there may be

marked muscu lar hypertrophy at the pyloric end .

Symptom8 .—These vary with the cause and the degree

of di latation. In wel l -marked cases the chief symptoms are

m r 1 o1v 05 71 15 0 1 1 . 59

a fee l ing of fu lness and discomfort after mea ls , frequentbe lching and ac id eruc tations , inc reased thi rst , constipation ,

defic ient urination ,and more or less emac iation. Ow ing to

reflex irri tation or autointoxication nervous symptoms oftendeve lop.

Vomit ing is a characteristic symptom,espec ial ly when

there is stenosis of the pylorus . I t occu rs long after mea ls ,sometimes at interval s of seve ral days . The vomi t is oftenexcessive in amount

,is sou r and fer

mented ,and on standing separates into a

sed iment of undigested food and a super O

natant l iqu id, which is tu rbid and frothy.

Not infrequent ly the vom it contains remnants of food that was eaten several daysbefore . Microscopic exam ination may te

veal,in atonic di latation, numerous yeast

ce l ls and sarc inze , and in cancerous di latation

,the thread - l ike bac i l l i of Oppler.

Phy l ical fi n s—Inspection—The abdo Fto . x .—a . S a l ome

men may be undu ly prom inent. In some R owena h Torule

cases the out l ines of the en larged stomach “ revisit :

are distinct ly visible . Perista lt ic waves extending from left to right are frequently seen, espec ial ly instenotic di latation.

Palpa tz'

on .-When the stomach - wal ls are suffic ient ly tense

,

the boundaries of the organ may be determ ined by pa lpation. In many cases of obstruc tive di latation a tumor can

be fe lt at the pylorus .Percussion—When the stomach contains fluid , an area

of du lness is found at the leve l of the umbi l icus, or be low it

when the patient is erect , bu t not when he is lying down.

This area of du lness also d isappears upon the completeevac uation of the stomach .

After artificia l inflation of the stomach with air or car

bonie- ac id gas percuss ion reveals an increased area of gastri ctympany.

Aux u/tahom—The detec tion of splashing sounds over thestomac h in the morn ing before breakfast or seven hoursafter a Riege l test- mea l points to di latation .

6 4 8 71?05 AND 51vr550 1 >70 31s. 6 1

bandage nearly a lways affords comfort and gives mechanica lsupport to the stomach . In cases due to atony exerc ise inthe Open air, hydrotherapy, and

,un less there be marked

gaseo us fermentation,abdom ina l massage are va luable aids .

Farad i zation of the stomach may also be used to promotemuscu lar contraction. In di latation from muscu lar re laxation nux vom ica is very usefu l . Such rem edies as c reasote

,sa lol, and bismu th - beta- naphthol are sometimes of servicein check ing fermentation , but the re l ief they afl'o rd is not tobe compared to that obta ined by systematic lavage . Con

stipation is best treated by simple enemas or by glycerinsuppositories.Surgical Treatment—In the large majority of cases Of

non- Obstructive di latation medica l treatment suffices. Occas ional ly , however, surgica l intervention is demanded on

account of persistent su ffering and progressive emac iation .

The Ope ration indicated in these.cases is gastroplication .

In cases of pyloric obstruction of a ben ign charac ter an

operation is indicated when it is impossible to maintainnutri tion by proper medica l treatment. As Loreta

'

s digitaldivu ls ion of the pylorus has been large ly abandoned , owingto its high morta li ty pe r cent ) , there may be said tobe but two operations avai lable—pyloroplasty and gastroenterostomy. The treatment of pyloric cancer is consideredon page 58 .

(Gl‘nsrd'

s Disease.)

Defin i ti on .—Prolapse of the stomach and transverse

colon caused by congen i ta l or acqu ired weakness of the

abdom ina l musc les and l igaments .E t i ol ogy .

—The condi tion is much more common in

women than in men . Tight lacing, repeated pregnanc ies ,abnorma l formation of the thorax , en largement of otherabdom inal organs , gastrec tas is , and constitut ional weaknessare important predisposing fac tors .Symptoms —The chief objective featu re is a more or

less pronounced downward d isplacement of the pylorus , in

62 0 1354553 05 71 15 DIGESTIVE 5vsTE M .

consequence of which the stomach assumes a vertica l o rsubvertical position . D islocation of the whole stomachdownward is rare. D i latation of the pyloric extrem ity is acommon seque l . The position and size of the viscus canbe determ ined accu rate ly on ly after art ific ial inflation . The

transverse colon shares in the downward displacement ofthe stomach and occupies a position immediate ly below thegreater cu rvatu re. Ptosis of other abdominal organs, especia l ly of the right k idney and l iver, is also present in manycases . Separation of the rec ti musc les is often seen. A

floa ting tenth rib is less frequent.The subjec tive symptoms are those of motor insufl‘i ciency

or atony of the stomach,

—fu lness and distress after meals ,splashing

,gaseous eructation ,

pain in the back , and constipation ,

—combined,in many cases , with more or less marked

neu rasthen ia.

Treatmen t —The diet shou ld be adapted to the digestive and motor powers of the stomach . Mechan ical supportof the pylorus by means o f a snugly fitting abdom inalbandage affords re l ief in m i ld cases . In severe cases

, especial ly when the nervous phenomena are pronounced , a

modified rest- c u re may prove effective . Lavage is not

indicated un less there is genera l di latation with retention o r

excessive secretion of m ucus . In very obstinate cases su r

gica l intervention shou ld be conside red .

64 DISEASES 05 7115 DIGESTIVE “ 375111 .

gastritis , gastrectasis , gastric cancer , obs tructive jaundice ,

and ch ron ic intestinal catarrh . (3) Sedentary habits . (4)Improper food . (5) Atony of the bowe l and weakness ofthe abdomina l musc les . (6 ) Muscu lar spasm exc ited byirr i table prostate, u terine disease, u lceration of the rectum

,

or strictu re .

Symptm —Some persons continue to enjoy excel len thealth even though thei r bowe ls are evacuated at very infrequen t in tervals . Genera l ly

,however

,retention of feca l

matter in the intestines longer than is customary with theindividual gives rise to unpleasant symptoms

,common

among which are headache,dizziness

,mental s l uggishness,

lassi tude ,fetor of the breath

, a coated tongue,and anorexia.

Sequel 8 .—Severe persistent constipation may lead to pi les ,fissu re, u lceration of the colon

,diarrhea from irri tation ,

or

feca l impaction .

M ul l a h—The removal of the cause is a matter ofthe fi rst importance . Cathartics shou ld be avoided

,if poss i

b le . In some cases the activity of the bowe ls is restoredby repeated dai ly attempts at defecation at some spec ia lhou r. Systematic exerc ise and cold bath ing are of the

greatest benefi t. Abdom ina l massage,espec ial ly digital

kneading in the direction of the colon,is often qu ite

effectua l .Un less the state of digestion ofl

'

ers a contraindication,

such laxative artic les of food as green vegetables oatmeal ,cornmea l , whole- wheat bread , oi ls, and cooked fru i ts shou ldbe ordered . Water- drink ing shou ld be encou raged . In

m i ld cases a glass of cold water before breakfast maysufl

'

i ce.

Genera l ton ics , l ike iron and strychn in ,are sometimes

needed. M ineral waters , l ike Friedrichshal l ,Hunyadi Janos ,or the m i lde r Saratoga or Bedford waters , are very u sefu l ,but possess no spec ial advan tages over the sal ine laxat ives(sodium phosphate or Roche l le sa lt) , when the latter are

taken in smal l amounts we l l di l uted . E nemas of soapywater or of glycerin or suppositories of gluten

,soap , o r

glycer in ,often prove high ly satisfactory . Vegetable cathar

ti es are usual ly necessary in obstinate cases . The m i ld ones

INTESTINAL COLI C. 65

shou ld a lways be tried first, and even with these considerab le care shou ld be exerc ised lest the patient comes to re lyupon drugs to the ex c lusion of the hygien ic and dieteticmeasures already indicated . Of the mi ld laxatives

,cascara

sagrada is one of the best : from to to 30 m in ims of thefluid extract , or a corresponding dose of an agreeable el i xi r,

may be admin istered at bedtime and repeated, if necessary,in the morn ing.

In many cases a combination of several laxatives (rhubarb, aloes , podophyl l um ,

euonymi n, and colocynth) ac tsbetter than any one singly. As adj uvants , nux vom ica or

physostigma may be added to overcome intestina l atony,

and be l ladonna or hyoscyamus to prevent griping. The

most suitable combination must be determ ined in each caseby expe rience. A pi l l , l ike one of the fol lowing, wi l l general ly prove satisfactory

Strychn ina sul phatis

E x tracti bel ladonna gr. nj .- M.

P lant pi l u la: No. xxiv .

Sta—One pil l at bedtime.

B. Pu lveris rhei

Ex tracti rhamni pu sh ianaE x tract i euonymt

E atracti as gr . iv.—M.

Finn! pi lnlre NO. x x iv.

S te - One pi ll at bedtime.

(w ; Tannin . )

Defini tion —Intestina l pain Of a spasmodic character.

E t iol ogy .—It usual ly resu l ts from irr i tating food , flatu

lence, or feca l accumu lation . I t is sometimes of a rheumaticor gouty origin . I t is a common symptom of structu ra lles ions of the bowe l—enteri tis , dysentery, appendic i tis , intestinal obstruction . I t is an important symptom in chron iclead- poisoning. I t may be reflex from disease of the ova

ries , uterus , l iver, vertebra , etc . I t may occur as a cr is is oflocomotor ataxia.

6

66 0 1554555 05 7115 DIGESTIVE 5vsSymptoms .

—Paroxysms of severe pain of a twistingcharac ter, cen tering around the umbi l icus , and re l ieved bypress u re. The abdomen is usua l ly distended . Severe at

tacks may lead to col lapse , indicated by cold sweats , pinchedfeatu res

,feeble pu lse

,and vom i ting. The attack lasts from

a few m inutes to severa l hours,and usual ly ends with a dis

flatus .

M —Load Col ic—History.blue l ine on the

gums,retracted abdom ina l wa l ls , wrist- drop, and lead in the

unne .

Bil iary Ool ic .—Pain radiating from the l iver to the back,

jaundice , loca l tenderness, and ca lcu l us in the stool .Renal Od i e—Pain extending from the k idney along theureter to the pen is and testic le, frequent m ictu rition,

bloodor cal cu l us in the urine.

Rheumatism of the Abdominal Muscles—Pain is superficial , persistent, and increased by pressu re and movementsof the body.

Chronic Appendi ci tis—Local ized tenderness (McBurney’

s

point), muscu lar rigidity , and indu ration .

Intestinfl Obstruction .— Local ized tenderness , more or

less continuous pain,persistent constipation , and incessant

vom iting , often stercoraceous .Treatment —The indications are to re l ieve pain and to

remove the cause . Tu rpentine stupes are usefu l . In severecases it wi l l be necessary to give morphin to grain)and atropin (Th grain) hypoderm ical ly. Carm inativespepperm int , ginger, oi l of c loves , Hoffman's anodyne—oftenafford re l ief.Col ic exc ited by i rr i tating food or fecal accumu lation isprompt ly rel ieved by sal ine o r mercu ria l purges.

DIARRHEA.

Defin i ti on —A condition in which the stools are toofrequent o r too l iqu id . Like dyspepsia

,i t is a symptom of

many pathologic conditions .E fi ol ogy .

—(t ) I t resu l ts from inflammation of the intestines—enteri tis, i leocol itis , dysentery (inflammatory diar

IN TE S TINAL CA TARKH. 67

rhea). (2) I t is a symptom of certa in infectious d iseases ,such as ty phoid fever and cholera (symptomat ic diarrhea).(3) I t may be exc ited by cathart ic d rugs. (4) I t often oc

curs as a final symptom in cachectic states,as in cancer

,diabetes,and chronic Bright ’5 disease (col l iquative diarrhea .

(5) I t sometimes marks the c risis of acute infections,suc

as typhus fever and pneumon ia (c ri tica l d iarrhea) . (6) I tmay resu lt from nervous excitement (nervous diarrhea).

E tiol ogy —Warm weather, ch i ldhood,improper food

,

and bad hygien ic su rroundings are general predisposingfactors . The disease is usua l ly ex c ited by irri tating prodnets in the intestinal canal or by sudden changes in tem

perature. Poisons produced in the decomposition of m i lkand other foods by bacte ria are the most common exc i tants .Inorgan ic poisons (arsen ic , antimony

,mercu ry) may al so

induce acute diarrhea.

Pathol ogy .—The mucosa is swol len

,s l ightly injected

,

and covered with a mucous exudate composed of desquamated and degenerated epithe lial cel ls and leukocytes.The lymph fol l ic les are e nlarged and occas ional ly u lcerated.Chronic m tm a

’

: may resu lt from acute attacks or frompass ive congestion in consequence of heart or l iver disease .

The mucous membrane is pigmented , and,in the early

stages , u sual ly thickened from prol iferation of the fixedconnec tive- tissue ce l ls. In th e later stages atrophy mayensue from destruction of the glands and sh rinking of the

stroma.

Symptoms.—Acute Enteri tis—The chief symptoms are

s l ight fever , with its attending phenomena, col icky ains

,

rumbl ing noises (borborygm i) , and frequent th in stoo of

a ye l lowish or green is h color, offensive ,and contai n ing undi

gested food . The number of stools varies from three totwe lve or more a day . The attack usual ly lasts from a few

days to a week .

Chronic enteritis is man ifes ted by frequent l iqu id stools,

68 DISEASES OF THE m eas u re s ys rs u .

which vary in color and character according to the seat of

the catarrh , col icky pains, impa i red nu tri tion ,and anemia.

The presence in the stools of much undigested food(l ientery) indicates involvement of the smal l bowe l

,and the

presence of much m ucus , involvemen t of the large bowe l .Membrane“ Enteritis—This term has been appl ied totwo conditions : (1 ) A true croupous enteritis , which is asso

c iated with the formation of a fa lse membrane, and whichis seen in cachec tic states , in acu te infec tious diseases , andas a resu l t of m ineral poison ing. (2) Mucous colic , o r

mucous coli tis , a ch ron ic form of col itis usual ly occu rringin women of a marked nervou s temperament , and characterized by paroxysms of severe pain and the discharge of

gray,translucen t casts which , however , are not membranous,

bu t mucoid in character.

M M —M m h ry .—The smal l mucous and blood

d ischarges and the severe tenesmus wi l l indicate dysentery.

nooool i tis.—This disease may be separated from simple

enteri tis by the continued high fever, more frequent discharges

,the presence of blood and mucus

,the tenesmus

,

and the greater prostration.

Peri tonttim—This disease i s readi ly d istingu ished fromenteri tis by the more intense pain and tenderness, thegreater tympany, the marked constitu tiona l distu rbance

,

the constipation,and the immobi l ity of the patient.

Ty phoid Pen n—The gradual onset,nose- bleed , splen ic

en largement, characteristic fever, Widal reac tion ,and eruption wi l l lead to the recogn i tion of typhoid fever.

Prom —Favorable in uncompl icated cases . Chronicdiarrhea often pers ists for many years and is very resistan tto treatment .Treatmen t —Acute Dim /tea in Adul ts—Rest in bed

and the substitu tion of bland nou rishment for the ordinarydiet are al l that is requ ired in many cases . Boi led m i lk ,m i l k and arrow - root , and mu tton veal , or chicken brothare suitable foods . I f the pat ient rs seen at the ou tse t andthere is reason to be l ieve that i rri tant material is st i l l present in the bowe l

,it is advisable to adm in ister an un irri ta ting

purgative, such as castor oi l, E psom sal ts , or fractiona l

IN TE S TINAL CATARKH. 69

doses of calome l. Occasi onal ly a second dose of the purgative may be given with benefit. E xternal ly, stupes or sinapism s are frequen tly efficacious . If the diarrhea continues

,

opium and mi ld astri ngents, l ike bismuth subn itrate and

cha lk , are indicated . They may be combined advantageous ly with antiseptics, as in th e fol lowing formu las :

xxxBismuthi subnitrutis

Fl am chm u lz No. x ij .S ta—One powder every three hours.a. Bismuthi sal icy latis 3m

Pu lveris acacia: 5.

Aqua cinnamom i q. 5. ad GVj .—M.

StG.—A tablespoonfu l every three hours .

Cirrom'

c Dian /cem—The cause must be ascertained and

removed,if possible . The diet, c lothing , habi ts , occupa

tion,and mode of l iving of the patient shou ld rece ive care

fu l atten tion . No definite ru les can be la id down in refer

ence to the diet. When the disease is not very severe and

is confined for the most part to the colon , a selected m ixeddiet may be al lowed . Many patients do we l l upon an

exc l usive m i l k diet . Foods that are bu lky and leave muchresidue are always inadm iss ible.

Protect ion of the body aga inst chi l l ing is of vital importance . Woolens shou ld be worn next to the sk in . Asnugly fitti ng abdom inal bandage may be worn as an addil innal safeguard . Rest in bed is sometimes essen tia l .When the general nutri tion is not too much impaired , achange of air and scene may prove very benefic ial .Minera l astringents , es pec ial ly bismuth subn itrate (30 to

40 grains) , si lver nitrate to grain) copper su lphate to1 gra in) , and lead acetate (1 to 3grams) are o f se rvice .

Intestinal ant iseptics—sa l ol , bismuth sa l icy late , betanaphthol - bismu th—are usefu l adj uvants . Opium is oftenrequ ired in acu te exacerbations . When the disease is situated chiefly in the colon, irr igation of the bowel two or

W al l nou rishment forhou rs , a ll owing noth ing by the mou th

boi led water. Subsequen tly, a

ui ce,vea l broth , o r a l iqu id pepton

be given in l ieu of m i l k . Mi l k feedingresumed very gradual ly . Absolu te res t

position is essentia l. Remova l to the seasis often of the greatest benefit.To remove i rr itant matter from the bo

ca lome l shou ld be given,preferably the

stomach is sensitive . In most cases it islow the pu rge with a sedative astringen t lni trate o r cha lk . From 5to to gra ins of on.

may be given every two o r three hou rs wilantiseptic (sa lol , beta - naphthol - bismuth

,b isn

some such combination as the fol lowing ma)8 Bismu lhi subn itratis

Mistime t re iz'

e

Sta—A teaspoonfu l eve ry two hours .

A more active astr ingent , l ike tannalbin or

graim ) , may be given in addition to th eitrate o r cha lk when the discharges are e

d watery.

D ISE ASE S OI" TIIE DIGE S TI VE S YS TE M .

ounces) and bismuth s ubn itrate (2 drams) may be givenevery three or four hours . E xt reme tenesmus is sometimes relieved by smal l suppositories contain ing of a grainof cocain (Rotch).

Defin i tion —An acute gastro- intestinal affect ion characterized by severe choleriform symptoms. Compared withacute catarrhal enterit is and i leocoli tis , it is a rare disease .

E t iol ogy .—Hot weather, fau lty feeding, bad hygienic

surroundings, denti tion ,and indigestion are important predisposing factors . The disease is probably exc ited by a

speci fic m icro- organ ism .

Pathol ogy f—Beyond a s l ight catarrh of the gastro

intestina l tract there are no gross lesions. The grave con

stitutional symptoms are no doubt due to the absorption of

a bacter ial poison.

M M —The symptoms deve lop rapid ly. Vomi ting and pu rging begin almost simu ltaneous ly and becomei ncesm t. The stools are th in and watery and have a

mu sty odor and an alkal ine reaction . Thirst is intense ;there is great rest lessness ; the pu lse is rapid and feeble ;the surface temperatu re is low , but the recta l temperatu re isve ry high (t05° to (06 ° F.) the u rine is a lmost suppressed .

Col lapse soon fol lows , and rs indicated by pinched featu res,

hol low eyes,sunken fontane l , pal l id sk in ,

and cold su rface.

E ven at this time a reaction may set in ,but in the large

majori ty of cases death resu lts in from twenty - four to fortyeight hou rs from exhaustion . The end may be characterized by the symptoms of spurious hydrocephalusde li rium

,stupor

, convu lsions , and coma. As these nervousphenomena are unassoc iated with any cerebra l lesion, theyare probably toxem ic .

Prognoeia—The prognosis is very bad . The outlookis more favorable when the ch i ld has su rvived the severesympt oms of the fi rst two day5. Recovery rs always tedious .Tm mren t .—The stomach shou ld be washed out withwarm water

,and the bowe l irr igated with cold water.

D YSE IVTE R Y.

At first noth ing should be given by the mou

steri li zed ice- cold water and iced brandy or

When the stomach is whol ly unretentive,

shou ld be given hypoderm ica l ly . Hot packsare very usefu l in combat ing col lapse . In unormal sa l t so l ution (40 grains to the pinsubcutaneously

,from 2 to 3ounces be ing

four times dai ly. If vom iting and

smal l doses of morphin and atropinhypodermica l ly. Holt givesf i t of a grain of atropin for

peats the dose , if necessary .

Afte r vom i ting has ceased,bar ley - water,

and fresh beef- j uice may be given by the mou

feeding shou ld a lways be res umed ve ry gradually.

Defin i tion —An acute or chron ic infiammatoof the colon ,

man ifested c l in ical ly by abdom inalmus, and the frequent passage of smal l stoolsmucus and blood .

Vari eties —(r) Catarrhal (2) amebic ; (3) baE t i ol ogy .

—(t ) Warm c l imates and warmbad hygien ic su rroundings ; (3) ingestion of

(4) exposu re to cold and wet ; (5) cachecticpredisposing factors .The catarrhal form is u sual ly sporadic and appears tohave no spec ific etiology. I t is common in tcmmrate zones.The amebic form is d ue to the Amceba col i , an organ ism

from th ree to five times the s i ze of a red blood- ce l l , consisting of a centra l mas s of gran u lar protoplasm surrounded bya narrow rim of c lea r protoplasm . It may be endem ic or

sporadic .

In the bac i l lary form the pathogen ic agent is the bacil l usry

'

S lugger, a moti le, flagel late rod be longing to the colontyphoid group of baci l l i and possess ing pronounced agglutinating propert ies . Bac i l lary dysentery is common ly epidem ic

,though it may be sporadic.

74 or w e D IGE S TI VE S 3/37e .

Wh i le the amebic and bac il lary forms are frequent lyencounte red in temperate c l imates , they are espec ia l ly prevalen t in the tropics .In the maj ori ty of instances dysentery is a water- home

Path ol ogy —In the catarrhal form the mucous membrane of the colon is red , swol len ,

and edematous . Fo l l icu

lar u lceration is sometimes seen .

The amebic form is marked by great swe l l ing and infil

tration of the mucosa and serpiginous u lcers with irregu laroutli nes and underm ined edges . Abscess of the l iver occu rsin about 20 per cent. of the cases . In bac i l lary dysente rythe inflammation is often diphthe riti c . U lcers are alsofound, but, un l ike those of the amebic form . they begin inthe mucosa and extend regu lar ly into the deeper coats .

PIG. 2 ,—Amc ba co l i .

The baci l l us is found with great difficu lty in the ch roniccases . Abscess of the liver is uncommon .

S ymptoms. Catawba! s w tery . Moderate fever(tOt

°- IO3

°abdominal pa in

,tenderness ove r the colon

,

constan t desi re to defecate,prostration

.tenesmus

,and the

passage of n umerous smal l stools containing mucus and

blood . Recovery usual ly fol lows in from a week to ten

days . The disease occasional ly becomes chronic . Com

pl ications are rare.

Am bit Dy sm ta y .

—In this form the onset is more gradual

,fever is not so high , tenesmu s is less marked , and the

discharges con tain l iving amebae . In favorable cases thesymptoms abate in from si x to twelve weeks . In the

majori ty of cases , however , the cou rse of the disease isessentia l ly chron ic , and marked by periodic recrudescences .The chief featu res of the chronic form are du l l abdominal

D YSE IVTE R y. 75

pain,tenderness over the colon

,frequent stools cons isting

of scybalous masses covered with tenac ious mucus and

perhaps with blood and pus . S l ight tenesmus , and u ltimate ly extreme anem ia and emaciation . Death usual lyresu lts from compl ications , the most common of which isabscess of the l iver.

Bacil lary [ b rewery —The symptoms begin acute ly, andare often severe. In addi tion to mucus and blood , thestoo ls may contain false membrane and gangrenous tissue . Tympan ites is common. Typhoid symptoms—d e li rium ,

stupor,subsu ltus tendinum ,

etc—are a lso frequent.Asthenia and emacia tion rapidly deve lop. The blood - serumyie lds an agglutination reaction with the S higa bac i l l us . In

some epidem ics the mortal ity has reached 40 per cent .Death usual ly resu l ts from exhau stion or col lapse

, and veryrarely from abscess of the l iver or other compl ications.Occas ional ly the disease loses its acute character and

becomes chron ic .

Compl i cati on s and Seqne18 .—Hepatic abscess is the

most common compl ication . I t occu rs chiefly in the amebicform . Peritonitis from pe rforation or from extension of

the inflammation ,hemorrhage ,

mu ltiple neuri tis , and intestinal strictu re are rare accidents .D iagn osis.

—Acute Catarrhal Enter i tis—In th is diseasetenesmus is absent ; the stools are not bloody and mucoid

,

and are neither so frequent nor so scanty.

M om—The abrupt onset , persistent vom iting,and presence of a sausage- shaped tumor in the abdomenwi l l general ly make the diagnosis c lear.

Treatment —Rest in bed is imperative . In acu te casesthe diet shou ld be l iqu id—m i lk with l ime - water, an imalbroths , and egg

- white . In chron ic cases soft~boi led eggs ,pu l led bread , steamed rice

,oyste rs , and tender meats may

be al lowed.

The stools should be immed iate ly disinfected.

An unirritating pu rgative (E psom sa l ts or calomel ) isnear ly a lways indicated at the onset . Subsequent ly, opiumshou ld be given to check perista ls is and to re l ieve tenesmus.I t may be given hypoderm ical ly in the form of morph in,

76 D ISEASE S or 7115 0 1 05377115 5vsm y .

bowe l in form of starch - water flu idounce) and(to to 20 drops) injec tions . Turpentine stupes oraflord re l ief Pers istent tenesmus is sometimesby ice suppos itories or iodoform sup ositories

l ly, bismuth subnitrate 30 to 40l ike beta - naphthol - bismu th (1 0r benzonaphtlro l (5to 1 0 grains),combination is often of val ue :

3. Pul veris ipecacuanhz et q mBisrnuth i subn itrat isBismuthi betamnphthol

Fiant chart uln: No. x ij .

S ta —One powder every two hours.

In many cases the adynam ia is so pronounced that stimmethods of treatment have been found c ificaipecac and th at by sa l ines

[pecan—On the first day a s ingle large dose of from 30to 40 grains of powdered ipecac is given stirred up in

water. S ubsequent ly from to to 20 grains are given dai lyfor three or fou r days . To prevent emesis, laudanum (15to 20 drops) is given twenty minu tes in advance of the

ipecac. A s inapism is appl ied to the epigastri um ,and abso

l ute quiet is enjoined. A successfu l issue is indicated bythe appearance ,

usual ly with in twenty - fou r hou rs,of a

copious b lack stool .Sal i nas—A pu rgative dose of magnesium su lphate is

adm inistered at once ,and after the bowe l has been thor

ough ly emptied ,smal l doses (1 d ram ) are given severa l times

a day ,preferably in combination with aromatic su lphu ric

ac id,as in the fol lowing formu la :

a . Magnet " su l phatis iss

Acidi su lphuric i aromatici ijAqua cinnamom i q . 5. ad vj .—M.

S ta—A tablespoonfu l four times a day .

Th is tre atment shou ld be continued for several days afterthe s tool s have ceased to be dysen teric .

Oh rm i c W atery —Bismuth subn itrate dram) with intestinal antiseptics is of va lue. Stenge l and others have

CHOLE RA MORBUS.

lphur very serviceable in amebic dysentery. Ten

ou ld be given th ree or four times a day , combinedamount of opi um.

i rr igation with solu ti ons of si lver ni trate 1 0 to1 pin t of cold water) is of the greatest benefit.ons shoul d be given two o r three times a week ,

very gently and s lowly by meanssyringe. When the rectum is very irri table, itto inject a smal l quan ti ty of cocain solutionbefore introduc ing the i rrigator. In amebic

arm injections of qu in in (r : 50 0 0 toper cen t. m ixtu res) , and benzoyl - acetyl peroxidhave also been found efl‘icacious.

(Engl ish cholera ; Cholera Rm .)

tiom—An acute sporadic disease, resembl ingnot exc ited by the comma bac i l l us of

summer season predisposes , and irrifru it

,and a sudden change of tempera

sual exci ting causes . An organism reseml lus of true cholera is often presen t in the

—There are intense cramps in the stomach,purging of bi l ious materia l

,th irst

,moderate

In severe cases the dischargesms of col lapse deve lop.

disease there isoften no history of dietetic indiscretions ; etiologic re lationwith another case can usual ly be establ ished ; the stoolshave a characteristic rice- water "

appearance ; there are

e legs ; and the typical cholera bac i l lus—The history, bu rn ing pain in the gu l

let and rec tum , erosion of the mouth and th roat,and

raucous , bloody discharges wi l l usual ly lead to a correctdiagnos is.

78 D ISE ASE S or 771 15D IGE S TI VE S YS TE M .

Progn0 8i 8 .—Favorable. Death rare ly occurs, except in

old or debil itated subjec ts . The duration is usual ly fromtwenty- fou r to forty - eight hours .Treatment —The hypoderm ic injection of morphingrain) and atropin (Th grain) is usual ly necessary. Hot

app l ications to the abdomen are also usefu l . Thirst is bestrel ieved by cracked ice. Calome l in fra c tiona l doses servesto al lay vom i ting and to rid the bowe l of irri tating matter.In many cases an anodyne m ixture li ke the foll owing wi l l

act admi rablyB. Sptntus campho

Oler caryophy l hChloroformi

Tinctura: opsu deodom ti

Tincturae capsici

Sim—Shake we l l . Thirty to forty drops in water every hal fhour to two hours, as requi red. (H. C. WOOD. )

Co l lapse wil l require hot baths , diffusible stimu lants (ammonia,

ether,brandy ), and subcu taneous injections of sal t

sol ution.

APPENDICITIS.

(Turphl it is zPefi ty phl ius . )

Defin ifiom—An inflammation of the appendix verm iform is .Path ol ogy .

—There are three varieties : Catarrhal,u lcer

ative ,and inte rsti tia l .

Ca larr lral Appendic itrS—In m i ld cases the appearances

are , no doubt , sim i lar to those observed in catarrh e lsewhere ,

but in severe cases the wal l of the appendix is infi l tratedwith r'ound - ce l ls , and the m ucou s membrane is denuded of

epithel ium and presents a granu lar su rface . This lattercondition may eventuate in septic pe riton it is , chronic appendic itis with re lapses (recurrent appendrkitrk) , or un ion of the

granu lating su rfaces with complete obl iteration (appendrkr'nkUlccrah

'

wAppendr'

d h lr.

—In th is type the wal l of the ap

gzndix is the seat of a more or less loca l ized u lcer. I t mayassoc iated with the presence of fecal concretion or a

80 OF 71 15 0 1 0557 1 PE 3VS n ew.

dominal wal ls,the bowe l, bladder, or vagina

,or i t may

escape into the t issues of the l umbar region or th igh . Apo

pendicitis occasional ly exc ites hepatic abscess,the infec tion

bein carried through the portal ve in.

osi s.—Typhoid raven—The gradual onset, char

acteristic temperature- curve,

epistax is, menta l hebetude,

diarrhea, splenic en largement, and,later

,the rash and

Widal reac tion wi l l ind icate typhoid fever.

Rah al 001 ic .—This may be recogn ized by the absence of

fever and of loca l rigidity , and the presence of hematu riaAcute Inflammation of the Gal l -bladder .

—Pain and tenderness in the right hypochondri um, a smooth , mobi le tumor,and a history of bi l iary col ic wou ld sugges t this condition .

Tubal Discu s—The history and resu lts of pe lvic ex ami

nation wi l l usual ly prevent an error in diagnosis.Prom - The prognosis depends on the type. The

average mortal i ty is about 14 per cent.Treatmen t —The patient shou ld be kept in bed at

absolute rest. The diet shou ld be restricted to smal l quanti ties of bland liqu ids—m i l k , a lbum in - water, and broths.Cons tipation is best re lieved by enemas of warm water.Local ly , cold or heat may be appl ied , according to the sen

sations of the patient. If the pain is very severe,morphin

may be adm in istered hypoderm ica l ly ; on ly the m in imum

amount necessary to afford a measu re of re lief is to be used,however, as by obscu ring the symptoms, the drug prevents

an accu rate study of the progress of the case.

An operation shou ld be u rged—(I ) At once in al l casesin which the onset is very severe,

the symptoms indicatingspec ial severi ty be ing marked right- sided tenderness and

ri°dity, distention , and vom iting , with or withou t fever ;

(51

mcases of moderate severi ty wh ich man ifest no improvement after the lapse of forty- e ight hours ; and (3) in cases inwhich the symptoms , after dec ided improvement

,retu rn .

On the contrary , operation is rarely requ i red,at least du ring

the attack - (t ) In cases of a m i ld type ,in which the pa in is

unaccompan ied by rigidi ty,distention , nausea , or vom i ting ;

and (2) in cases of moderate severity in which improvementis noticeable with in forty - e ight hours . Operation du ring

1 1117 5577d 0 35m UCTIO/V. 8 1

the quiescent stage, when the e lement of danger is almostentire ly removed

,is to be recommended When an

acute attack has been fol lowed by persistent tumefac tionand tenderness , intestinal distu rbances ,

or impairment of thegeneral hea lth ; (2) when there have already been twoattacks, even of moderate severity ; and (3) when mi ldattacks occur with such frequency as to induce disabili ty.

mem . )

Intestinal obstruction may be e ither acute or chron ic.

The chief causes of the acute f orm are : (1 ) S trangulation ;(2) intussusception ; (3) volvu l us ; (4) impac tion of fore ignbod ies or gal l - stones ; (5) paresis of the intestine , (6) congen i tal malformation or str icture.

Clm mic obstruction may be due to—(t ) Impaetion of feces ;(2) strictu re ; (3) tumors of the bowel or of neighboringorgans .Symptoms of Acute Obstruction . S udden ah

dom inal pain—at fi rst paroxysma l,but later continuous ;

(2) constipation ,soon becom ing absol ute 3) vom itin persistent and u ltimate ly of a stercoraceous character ,Eflab

dom inal distention ; (5) visible perista ltic waves ; (6 ) co llapse , indicated by pinched featu res , sunken eyes

,a cold,

c lammy su rface,and a frequent feeble u lse.

Symptoms of Ch ron ic Obstru —The symptomsusual ly deve lop gradual ly . Ac ute symptoms may appear,howeve r, when the occ l usion becomes complete . The chieffeatu res are intractable consti pation

,colicky ains , distention

of the abdomen,and gradual fai l ure of heali h . The stools

may be ribbon - shaped or in the form of scybalous masses,and are sometimes coated wi th m ucus and blood . Vomitis not common.

0 818 .—Early vom iting

,sl ight distention

,suppression of urine , and rapid col lapse point to an obstruction 111211

smal l im am .

Acute General i zed Pa nama—The history,early appeah

82 w su szs or 0 1 053771 113 3 1 1975111 .

ance of fever and of diffuse tenderness,sig ns of effusion

,and

absence of stercoraceous vom iting wi l l indicate peri ton i tis .M M .

—This often occurs in external hern ia,when

i t can be recogn ized by an exam ination of the inguinal,

femoral , and umbi l ica l rings.I nternal strangul ation is very common. I t may be dueto the sl ipping of a coi l of intes tine under. bands of adhe~

sions , the resu l t of a former pe ri ton i tis,or under Mecke l ‘s

divert icu lum that is abnormal ly attached to the abdom inalwa l l , o r th rough a s li t in the omentum or mesentery

,the

foramen of Winslow , or the diaphragm . I t usual ly occu rsin young adu l ts ; there is often a history of inj u ry or of peritonitis , and the symptoms are very acute .

Intussuacept im or Invad nation .—This is the s l ipping of a

portion of the intestine into the part immediate ly be low it.I t occu rs espec ia l ly in chi ldren . I ts exc i ting cause is probably irregu lar peristals is , whereby one part of the bowe l isconstricted whi le the adjoining part is d i lated. The usualseat is the i leocecal region.

Mu l tiple invaginations are frequently found postmortem ,

which have resu lted from the i rregu lar peristals is occurringj ust before death they possess no inflammatory characterist ics . In invaginations not cadaveric the parts are injected ,swol len

,and covered with lymph .

The age of the patient , the sudden abdominal pa in,the

vom i ting, the passage with tenesmus of mucus and bloody

feces , and the presence of a sausage - shaped tumor in the

region of the ascending colon are the diagnost ic featu res .Occas ional ly the invaginated portion can be fel t in the

rect um .

Death usual ly resu l ts from gangrene,periton i tis , o r co l

lapse. A favorable term ination sometimes resu lts from the

escape of the incarcerated part , or by a s loughing off of

the strangu lated portion and adhesion of the serous su rfaces .Volvul us or Twi st or Knot. of the Bowel —Volvu l us occurs

most common ly in m idd le - aged men. The usual seat is thesigmoid flex ure. A re laxed and lengthened mesentery is apredispos ing factor. I t cannot be recogn ized with certaintywithout abdominal section.

[W E S T/AMI . 0 33m o'

er / 0 1V. 83

Impaction of f oreign Bodies—Foreign bod ies swal lowedby acc ident o r design ,

gal l - stones , o r.

enterol i ths may causeacute intestinal obstruction. The history may aid in the

diagnosis.Gal l - stone i l ens is most frequent ly met with in women

after the fiftieth year. The il eoceca l region is the usual seatof the obstruction.

Parents of the Bowel —This occasiona l ly deve lops idiopathica l ly in nervous women. I t may also resu lt from peritonitis , an abdominal operation ,

the reduction of a hern ia, ortraumatism.

Congeni ta l Mal formation—Th i s rare form of obstructionusual ly consists in an imperforate condition of the anus orrec tum. I t may be recogn ized by digita l exam ination.

Impact lon of Pecos—Thi s may occu r at any age, but it ismost often seen in persons past midd le l ife. The usual seatof the impaction is the rectum or colon . The conditionmay be recogn ized by the gradual onset of the symptoms ,the history of habitua l cons tipat ion ,

and by the presence of

a fecal mass in the rectum or of an irregu lar, pain less ,doughy tumor in the region of the colon .

Stricture and Tumors .—Cicatricia l contraction may re

su l t from syphi l i tic,tubercu lous , or dysenter ic ulce ration.

The rectum is the part most frequently involved . The

most common tumor of the bowe l is cancer. I t is usual lyseated in the rectum. The diagnos is may be es tabl ishedby the history of the case , the gradual onset of obstructivesymptoms, impairment o f hea lth , painfu l defecation , the s izeand form of the stools , the presence o f blood and pus in thestools

,and the resu lts of a physica l exam ination.

Treatmen t —Acu te Obstruction—Food by the mouthshou ld be withhe ld. Ice may be given to quench th irst.N utritive enemata shou ld be employed in the weak . Cal /mtria are contra indicated . Pa in is best re l ieved by warm app l i

cations and the admi n istration of morphin hypoderm ica l ly .

Washing ou t the stomach three or fou r times dai ly is recommended for the persistent vom i ting. D istention of the

large bowe l with warm water o r gas shou ld be practised indoubtful cases and intussusception. I t is best done under

84 sans 0 1v~

THE DIGESTIVE 5vsm y .

anesthe sia with the patien t in knee - e lbow posi tion. Afterfai l u re wi th these methods operation shou ld not be de

layed ; the ear l ier i ts performa nce, the greater the chanceof success .Chrome Obstruction—The treatment wi l l vary with the

cause. S u rgica l interference is frequently required .

In feca l irnpact ion injections of warm water, of oi l (4 to 6flu ido unces), or of aqueous sol u tions of ox - gal l (2 drams to1 pint) are efli cient . Sa l ines may be adm in istered by themou th . Massage is sometimes usefu l . Hard recta l accumu lations may have to be removed by the fingers or a

AN IMAL PARASITB .

Varieti es —Ta n ia sol i um ; Ta nia saginata ; Bothrio

rm are ingestedby anima ls (the intermediary host) , and embryos or proscolices are l iberated in the stomac h ; these m igrate to the

m usc les or organs , where they become transformed intoencysted larva or scol ices . The encysted larvae are knownas cyst icerc i o r meas les .

" When flesh infested with cysticerc i is eaten by man (the host), the scolex is l iberated , fastens itse lf to the mucous membrane of the bowe l , andrapidly deve lops into a matu re worm .

Tan ia Sol ium .—Th is worm ex ists in the larval state in the

hog. The matu re worm is two o r th ree yards in length .

Its head , which is the size of a pin- head

,is provided with

fou r pigmented , cup- l ike suckers , su rrounded by a doublerow of hook lets , and is attached to the body by a th readl ike neck . The sexual orifice is in the center of the broadsu rface of the segment. This parasite is rare in America.

Tania Saginaw or Mediocanol h ta—The larval formoccu rs in the ox. The matu re worm is five or s ix yards inlength . The head is larger than that of the Tmnia sol ium ,

and has fou r large suckers , bu t no hook lets . The segmentsare fatter, and the uter ine branches are finer and more

AN IMAL PARAS I TE S . 85

numerous than in the Taen ia soli um. I t is the common tapeworm of th is country.

Bothriocephal us Lotus—The intermediate host is someform of fish (pike) . The adu lt worm is from five to tenyards in length . The head is flattened and c l ub- shaped

,

presents two groove- l ike suckers,bu t is wi thou t book lets .

This worm is frequent in certain parts of E u rope, but it israre in America.

Tonia Behinococm —This worm in its adu lt form occu rsin the intestine of the dog ; in man it appears on ly in thelarval condition (see Hydatid Cysts of the Liver).Symptoms —In many cases there are no subjectivesymptoms. Some patients , however, present the symptomsof dyspepsia, bu l im ia,

col icky pa ins,progressive emac iation ,

anem ia,and certain reflex man ifestations—vertigo , pa lpita

tion,itching of the nose

,spasms , and choreic movements .

The diagnosis rests on the discovery of the ten ia segmentsor eggs in the stools .The bothriocephal us may produce a very severe anemia

,

which has been ascribed to the sec retion of substanceshaving a destructive action on the red blood - ce l ls .Treatmm t .

—By way of preparatory treatment it is advisable to restrict the diet for a day or two to liqu ids and toempty the bowe l as complete ly as poss ible by sa l ine rges .

The best anthe lm intics are oleo resin of aspidium to 1

dram ), pumpki n seed (2 to 3ounces) , and pe l leti erin 5to 8grains) .a. Oleoresinm aspid u Gas

Pu lveris acacia ct sacclum at q . s .

Aqum c innamomi q. 5. a d (Km—M.

S ta—One mblcspoouful , to be repeated if necw ary .

A pu rge shou ld be given a few hours after the anthel

m intic. The treatment is successfu l on ly when the head ofthe worm is pas sed .

Ascar is Lumbr icoi des (Common Round - worm) .Round - worms deve lop from eggs which have ente red thebody through water or food . They are of a brownish or

86 DISE ASE S or 7715 D I GE S TI VE 313779111 .

pinki sh color, and in form resemble earth - worms . Theyocc upy the smal l intestines , bu t occas ional ly m igrate,

en

tering the stomach , bi le - ducts , and even the larynx. Theyare most common ly found in chi ldren .

Symptoms—Often absent. Sometimes there are dyspepsia, m ucous stoo ls , col icky pains, vorac ious appetite

,

anem ia , and reflex nervous phenomena—night- terrors, grinding of the teeth

,pru ri tus of nose and an us, ch oreic move

ments,and convu lsions.

Treatment —Santon in grain ) ; wormseed oi l (1 0drops in capsu le o r on su fl u id extract of spige l ia (1 to3fluid rams) are effi c ient remedies. The anthe lm intic shou ldbe fol lowed by a pu rge.

B. Sautoo in l gr. vjHydrnrgy ri ch lorid i mit is gr . vjSacchari gr . xx iv.

—M .

Piwut'

m chartulm No. 11 1j .

S IG. powder morning and even ing. (STARR)Ox y uris Vermi cu laris (Soar-worm H

'

n- worm) .—Pin~

wo rms are from one- e ighth to one - half inch in length . Theyare most common ly seen in chi ldren,

infec tion probably takingplace through water o r green vegetables . They occupy therectum and colon

,and are often present in great numbers.

They produce intense itching , particu lar ly at n ight.Treatmen t .—Copious inject ions of a cold infusion of

quass ia (1 o unce to 1 pint) o r of a solution of sodium chlorid(1 dram to 1 pint) usual ly prove successfu l . In obstinatecases ant helm intics (santon in o r chenopodium ) shou ld be givenby the mou th . Care shou ld be taken to prevent re infectionwith the e gs

,which are produced in large numbers .

Anch yfostoma Duodenal e , or Uncinaria Duoden

al i s .—This worm is abou t half an inch °

1n lengt h , and infeststhe duodenum and jej unum . It is no t uncommon in blu rOpe ,

Egypt , and India,and is occasiona l ly enco untered in Ame rica.

It has been detected most frequently in m iners and brickmakers , who are probably infected by drinking water containing the eggs of the parasite . The worm inhabi ts the smal lin testine .

It causes an intense anem ia,which has been termed

88 D ISEASE S OF THE D IGE S TI VE S YS TE M.

resemble those of typhoid fever. In f avorable cases recov

ery is efl'

ected in from two to e ight weeks.Diagnosi 8 .

—Ty phoi d Pen t —The history, the presenceof eosinophi l ia

,of intense m uscu lar soreness , of edema, of

paras ites in the stools or in a fragmen t of musc le removedfrom the arm

,and the absence of a typica l rash and of the

Wida l reaction wi l l lead to a correct diagnos is .Muscular Rheumatism—The h istory , the presence of gas

tro- intestinal symptoms,of edema

, and of eosinoph il ia wi l lsu gest t rich in ias is .

gum —This depends upon the number of wormsingested . Early diarrhea is favorable. The mortal i ty rangesfrom 5to 30 per cent .Treatmen t —The most effic ient prophylactic measureis the thorough cooking of al l po rk products . In the fi rststage cathartics are indicated . Anthe lm in tics—santon in ,

aspid ium , and thymol—have been recommended . After m i

gration,the indications are to re l ieve pain by means of opiates ,

hot baths,and ‘warm embrocations , and to support the

strength by concentrated liqu id diet and stimu lants .

D ISEASES OF THE PANCREAS.

E t i ol ogy .—Hemorrhage into the panc reas may resu l t

from traumatism . I t may be due to passive congest ion , tohemo rrhagic diseases (scu rvy ,

pu rpu ra,

or to acuteinfections . I t is very common ly assoc iated with organ icdisease of the pancreas—acute pancreati tis , arteriosc leros is,cysts

, and cancer.

Symptom8 .—Sudden severe pain in the epigastrium ,

vom it ing, tympan ites , dyspnea ,and collapse are the chief

symptoms . The diagnosis can rare ly be made with certa inty.

Prognosi s —Most cases prove fata l wi thin twenty - fouror th irty - s ix hou rs

,death be ing due to an arrest of the

heart from inju ry to the ce liac plexus (Z enker) o r sem i l unargang l ion (Friedre ich). Pancreati ti s , cyst of the pancreas,

ACUTE PAN CRE ATI T/s. 89

and peri tonitis are possible term inations . Complete recov

eryTreatxnenh Morph in is requ ired for the pain, andstimu lants for the col lapse. If the patien t survives theinitial col lapse and symptoms of suppuration develop,operation is ind icated.

Varieti es.—Hemorrhagic, suppurative, and gangrenous .

E t iol ogy . This may resu lt from ga l l - stone impaction,bi le being retrojected into the pancreatic duct ; (2)

from inflammatory affect ions in neighboring parts—gastroduodenal catarrh , gastr ic u lcer, or cancer ; (3) from generalinfections—spec ific fevers and py emia ; (4) from traumatism.

The immed iate cause is bacteria l infect ion.

Pathol ogy .—In the hemorrhagic form the organ is

i rregu lar ly en larged and the seat of hemorrhagic ex trava

sation . Opaque , white spots of a ta l lowy consistence are

frequently found in the inter lobu lar tissue , omen tum , and

su rrounding parts , and represen t areas of f at necrosis .

In suppurative pancreati tis there may be mu l tiple abscessesor one large col lec tion of pus . More or less extensiveareas of necrosis are found. Th rombos is of the porta l andsplenic oveins is frequent ly encountered. Pancreatic abscessesmay become encapsu lated or they may rupture into theper itoneum

,stomach , or duodenum .

Gangrenous pancreati tis is usual ly secondary to one of theother varie ties.Symptoms .

—The chief symptoms are sudden intensepain in the epigastri um , distention of the epigastri um

,vom

i ting and col lapse ,fol lowed in suppu rative cases by °

1rregu

lar fever , const ipation,sl ight jaundice, de l iri um , and rapid

loss of we ight.D iagnosis .

—Inmfi nal Obstruction —In this conditionthe onset is usual ly less severe ,

feca l vom iting is common,

pain and distent ion are less frequent ly l im ited to the ep igas

trium ,and constipation is absolu te ,not evenflatu s beingpassed .

The history wi l l sometimes serve to difl'

erentiate the con

go D I SE ASE S OF TIIE DIGESTIVE S YS TE M.

dition from bil iary col r°

c, pcrf orat1

°

ag gastr ic u/ccr, and the

efl'

ec ts of an wr itaat poi so n .

Prognosi s.—Very unfavorable. The du ration varies

from a day or two in the hemorrhagic form,to severa l

weeks in the chron ic suppu rative variety . Recovery mayfol low operation or rupture of the abscess into the bowe l .I t may rare ly end °

m chronic pancreati tis.Treatment —Operation after the initia l col lapse ofl

'

ers

some hope of cure.

(Cirrhosis of the Pancreas . )

E tiol ogy —It may resu lt From c losu re of the pan

creatic duct by ga l l - stones impacted in the common bileduct ; (2) from extension of inflammation in gastroduodena lcatarrh or pyloric u lcer ; (3) from syphi l is o r alcohol ism ;

lerosis of the panc reatic arteries,and

,possibly,

u te pancreati tis .chief lesions are an overgrowth of the

fibrous tissue and more or less degeneration or atrophy of

the ce l lu lar e lements .Sa ptoma—The symptoms are obscure. Flatu lentdyspepsia, paroxysma l epigastric pain ,

a tendency to diarrhea,

and s l i ht jaundice are the u sua l featu res . A lbum inu ria and g%y cosuria may occu r. Fatty stools have beennoted in a few instances . When the is lands of Langerhansare involved 1n the degenerative process , the symptoms ofd iabetes mc/l ttus deve lop.

Prognosis —The disease ru ns a slow cou rse . If gly cosu ria deve lops,the ou t look 15 more grave.

Treatment .—The use of fats and s tarches shou ld berestricted . Carbonated wate rs are sa id to inc rease pan

creatic sec retion . Panc reatin is recommended . Su rgica lt reatment offers a good chance of recovery in ga l l - stonecases .

E ti ol ogy —The disease most frequent ly occurs in malespast forty years of age .

CYSTS 0 1? THE PAN CRE AS . 9 1

Patho l ogy .—Pancreatic cancer is usual ly primary ; it

general ly involves the head of the gland,and is common ly

of the sc i rrhous variety .

Symptoms .—The5e inc l ude distu rbances of digestion,

rapid loss of flesh and s trength ,anem ia , intense deep- seated

epigastric pain,and the presence of a tumor. The latter is

usua l ly found a l ittle above the nave l ; it is but s l ightlymovable , deep seated , and often pu lsati le from i ts re lation tothe aorta. The pain often occurs in paroxysms, especia l lyat n ight, and may be associated with the symptoms of co l

lapse. Progres sive ly increas ing jaundice,with en largement

of the ga l l - bladder , is a frequent symptom ,and resu l ts from

the pressu re of the tumor upon the common bi le- duct .Pressu re on the porta l ve in may cause asc ites . Glycosu riais an occasional symptom . The stools rare ly conta in freefat, but the presence of abundant undigested muscu lar fibersin the dejections in the absence of diarrhea is , according toFitz

,high ly suggestive .

D iagnM —Gastric cancer . In° this condition the

tumor is more freely movable,is usual ly associated with

di latation of the stomach and with marked gastric symptoms.Pain is not usual ly so seve re . Jaundice is rare.

Var ieti es Retention cysts from impact ion of a cal

cu lus,strictu re . or tumor ; (2) apoplect ic cysts from hemor

rhagic extravasation(5) prol iferation cystsPath ol ogy F Pancreatic cysts may be single or mu l tiple .

They l ie behind the stomach , and may contain from a few

ounces to several gal lons of a grayish o r brown ish , visc idflu id

,of an al kal ine react ion ,

of a spec ific gravity between1 0 1 0 and 1 0 24 , and present ing the characteris tics of panc reatic sec retion .

S ymptom s.—These are very variable

,the most common

being epigastric pain ,vom i ting , constipation

,or diarrhea,

distu rbances of digestion ,loss of flesh , and occasional ly in

testinal hemorrhage . Free fat and much undigested mus

92 DISEASES OF THE DIGESTIVE S YSTEMcu lar fiber may be found in the stoo ls and sugar in the

u rine. Physica l exam ination often revea ls in the upper partof the abdomen a smooth

,e lastic , fluctuating tumor which

on aspi ration yie lds a fl uid capable ‘

of emu lsifying fats , ofconverting starch into sugar

,and of digesting album in .

Prognosi s and Treatmen t —The prognosis is guarded ly favorable under operative treatmen t.

Pancreatic ca lcu l i are probably due to a l tered glandu larsec retion or infection. The ir passage th rough the duc texc i tes pancreatic col ic

,the symptoms of which resemble

bil iary colic , but the pain is more apt to radiate to the leftand is unattended with jaundice. The coexistence of g ly cosuria with fatty stools

, and the discovery in the stools of

concretions contain ing chiefly carbonate or phosphate of

l ime,wou ld confirm the diagnos is .

DISEASES OF THE LlVER.

The l iver is s ituated in the right hypochondrium , with a

smal l part projecting through the epigastrium to the lefthypochondri um .

Area of Liver Duma s—The absolu te du lness (part uncovered by lung) extends in the mammary line from the

upper border of the sixth ml : to the costa l margin ; in theaxi l lary l ine ,

from the seventh rib to the e leventh rib ; in

the scapu lar l ine,from the n inth rib to the e leventh rib ; in

the median l ine,the upper border is lost in the cardiac du l

ness , whi le the lower border l ies m idway between the ensiform cart i lage and the umbi l icus. S l ight du lness in the

mammary l ine begins at the fifth rib .

Pal pation .—Palpation of the l iver is practised to determ ine

position,size,

form ,and consistence and to detect any ten

derness or pu lsation .

Cond itions in wide/i the l iver is palpabl e

I . In thin subjects the edge is sometimes palpable undernormal conditions .

D IS IEASE S or THE L IVER. 93

2. In very young chi ldren in whom the liver is alwaysproport ionate ly large.

3. In depression of the l iver, as by a pleural efl'

usion or

by a consol idated lung.

4 When the suspensory l igaments are relaxed and the

l iver wanders ."5. In en largement of the organ from any cause.

6 . In certain abnormali ties of form,as in the corset

l iver.

Superficial Irr cgwlan'

tics.

—Smal l irregu lari ties may be

noted in cancer of the l iver,syphi l is of the l iver, and very

rare ly ln atrophic c irrhosis .Large pronu ncaces are sometimes noted in tumors, ab

scesses , and hydatid cysts .Consi stenca—The l iver is firm to the touch in hypert ro

ph ic c irrhosis , cancer, congestion ,leukemic infi ltration , and

amyloid disease. In abscess and hydatid disease the resistance is less marked and sometimes fl uctuation can be noted.

Tenderness—The l iver is tender in congestion, abscess ,cancer

,hypertmph ic c irrhosis , and in afl

'

ections commicatedwith pe ri hepati ti s .Pic/satin" may be detected in the venous congestion resu lt

ing from tricuspid regu rgitation , in abdom inal aneu rysm,

and in tumors of the left lobe resting on the aorta.

Percussion.—Perc ussion determ ines si ze and resistance.

77“ l i ver is un iformly enl arged 1n : (1 ) Congestion , activepass ive . (2) Fatty 1nfiltrat10 n (3) Amy lo1d infi ltrati onHypertm ph ic c irrhosis. (5) Leukem ic infi ltration.

Infiltrating carc inoma.

Irregul ar enl argements of the l iver are noted 1n : (1 ) Cancer. (2) Abscess . (3) Hydatid disease . (4) Syphi lis .The l iver is cl imm is l i ed in size in : (1 ) Atroph ic c irrhosis ,late stage . (2) Fatty degeneration. (3) Acu te ye l lowatrophy. (4 ) Sen i le atrophy . The area of hepatic du lnessmay be dim in ished from certain extrinsic causes , namely ,

pu lmonary emphysema,excessive tympani tes, and perfora

tion of the stomac h or bowe l .

94 DISEASES OF THE DIGESTIVE S YSTEM

Defln i tion .—Pigmentation of the tissues and sec retions

with bi le - pigments .Var i et i es Obstructive jaundice . (2) Non- obstruetive jaundice .

E t i ol ogy of Obstructi ve J aundice .—Obstruct ion to

the outflow of bi le leads to its accumu lation and reabsorption .

Obstruction may be due to the fol lowing causes1 . Strictu re of the bi le - duct , congenita l o r acqu ired .

2 . Ca tarrh of the bi le - ducts o r of the duodenal mucousmembrane around the orifice of the ductus cho ledochus .3. Fore ign bodies in the ducts , as gal l - stones or parasi tes .

4. Tumors of the l iver o r of adjacent viscera compressingthe ducts . Feca l accumu lations

,a pregnant uterus , and dis

placed organs may sim i larly compress the ducts .5. Spasm of the bi le- d ucts . This has been advanced as

the cause of the jaundice that occas ional ly fol lows emo

tiona l exci tement .Synaptoms.

—The sk in , m ucous membranes, and secre

tions are stained ye l low . The discoloration is usual ly fi rstnoticed in the conj unctiva; The stools are l ight

,the urine

is dark,and in bad cases resembles porter. The pu lse is

usua l ly slow,and the temperatu re s l ightly subnormal . There

is often more o r less menta l depression ,and in chron ic

cases de l irium , convulsions , and coma occasiona l ly develop.

I tching of the sk in is often noted,and u rticari a is a com

mon compl ication . In grave cases subcutaneous cechymoses may appear.

D iagnM —Other discolorations , l ike the bronze hueof Addison ’s disease and the green tint of chlorosis may re

semble jaundice ,but in these cases the conj unctiva remains

white and th e u rine lacks bile .

E ti ol ogy of N on - obstru ctive J aundi ce .—This form

of jaundice may resu lt from The absorption of ex

travasated blood ; (2) the act ion of poisons which destroythe red blood - ce l ls—n itrobenzol , chlorates

,snake- venom ,

to luy lenediam in ; (3) certain in fections, li ke ye l low fever

96 DISEASES OF TIIE DIGESTIVE S YS TE N .

The cause of th is condition is supposed to be the retention in the blood of toxic matters which the l iver normal lyconverts or e lim inates.

(Catarrhal Hepati tis ; Qatari-ital W W ; Oatan h of the

Bil e' ducts.

E t iol ogy The most common cause is the extension of a gastroduodenal catarrh into the ducts: (z) Primary inflammation of the ducts may resu lt from exposu reto cold and wet (3) I t may be induced by irritation fromgal l - stones . (4) I t may be infec tious, compl icating malaria ,

pneumo n ia, re lapsing fever, and sim i lar diseases .Path ol ogy .

—The large ducts are particu lar ly afl'

ected ;the mucous membrane is swol len and covered with tenac ious mucus . When the gal l - bladder is compressed

,bi le is

ejec ted through the duodena l orifice with less case than isnatu ral .Symptoms Symptoms of gastroduodenal catarrh

u sual ly precede. These are : Coated tongue ,anorexia,

fetidbreath

,epigastric distress , vom iting , and perhaps diarrhea

(2) Obstructive jaundice ,indicated by ye l low skin and con

j unctivee ,l ight stools

,and dark u rine, is a constant symp

tom . 3) In acute cases there is sl ight fever with swe l lingand tenderness of the l iver.

D iagnos is —This is based upon the acute cou rse,the

m i ld character of the symptoms , the history of precedinggastric catarrh

,and the youth of the patient.

Progn0 8i 8 .—Favorable . I t rarely becomes chron ic .

The average du ration of the disease is from two to sixweeks .Treatmen t —The diet shou ld be simple and digestible .

Fatty and saccharine food shou ld be avoided . M i lk , broths ,eggs

,lean meats , oysters , and we l l - cooked cereals are ad

m issible. Sodium phosphate (1 dram three times a day ) ,si lver nitrate (Q grai n th ree times a day ) , and ammoniumchlorid (5to 1 0 grains three times a day ) are of value in re

l ieving the primary gastroduodenal catarrh. In obstinate

ACUTE CIIOLE C YS TI TI S. 97

cases n it rohydroch loric ac id may prove benefic ial . Dailyirrigation of the colon with from 1 to 2 quarts of cold wateris sometimes of service. Free water- dr inking between mealsis to be recommended . A lkal ine m inera l waters (Vichy,Vals , Hathorn ) often act we l l .Ohroni c catarrhal jaund ice may fol low repeated acute

attacks ; in the large maj ori ty of cases,however , i t is a

seque l of stenosis of the common bi le- duct from gal l - stones ,stricture, or press u re from without. A constant symptomis chron ic jaundice. In some cases there are rec urrentattacks of intermi ttent fever with ch i l ls and sweating (Charcot's interm i ttent hepatic feve r).

Defini ti on —Acute inflammation of the gal l - bladder.

E t iol ogy .—The disease is always infectious, the organ

isms most common ly present be ing the colon bac i l lu s,typhoid bac i l lus , pneumococcus , staphylococcus , and streptococcus . Inj u ry to the mucosa by gal l - stones is an importantpredisposing factor. I t is not an uncommon seque l oftyphoid fever and pneumon ia.

Path ol ogy .—The inflammation may be catarrhal or

suppu rative . S uppu rat ive cholecys titis (empy ema of the gal lbladder ) is usual ly assoc iated with pu ru lent inflammation of

the bi le- ducts,and , un less promptly re l ieved by operation

,

proceeds to u lceration o r gangrene and general periton itis .Sym ptoms —Ia catar rhal cases the symptoms are

s l ight feve r,pain in the hepatic region , tenderness and

en largement of the gal l - bladder , and , occas ional ly, jaundice.

In the suppu rative form there are severe paroxysmal pain,

a septic type of fever, le ukocytosis , en largement and tenderness of the a l l - bladder, and ,

in some cases , jaundice .

D iagnosis —It must be distingu ished from appendiciti s,subphrenic abscess , and acute pancr eatiti s. The discrim inatingfea tu res are the history of prev ious cholel ith ias is, typhoidfever, o r pneumon ia,

and the local ity of the pain, tenderness,and swe l l ing.Prognosi s —Very grave in suppu rat ive cases . Earlyoperat ion ,

however, offers considerable hope of success.

98 DISEASES OF TIIE DIGESTIVE S YSTEM.

CHOLELI‘

I'

HIASIS.

(Gal l - stones ; Bi l iary Calcul i . )

E tiol og y .—Ga l l - stoncs are three or fou r times more

common in women than in men . They occ ur most frequently after m idd le l ife , and are rare ly seen befo re twen tyfive . Sedentary habits , h igh l iv ing, tight lac ing, obstructionof the duc ts

,and other factors that favor stagnation and

inspissation of the bi le predispose to their formation . Thei rocc u rrence after typhoid fever and other infections is not

uncommon . The direc t cause appears to be a m icrobicinfec tion of the gal l - bladder, in consequence of which excess ive quan tities of choleste rin and l ime are excreted bythe irri tated m ucous membrane and deposited upon des

quamated epithel i um or c lumps of bac teria.

Path ol ogy .—Gal l - stones may be found in the ducts, but

in the large majori ty of cases they originate in the gal lb ladder . There may be one or several hundred . Whenmu ltiple

,they are found with facets

,from attrition. The

size varies from that of a grain of sand to that of a largewalnut . The color varies from l ight ye l low to dark green .

The chief constituent is cholesterin ,bu t bi le - pigments and

lime~salts also ente r in the ir composit ion . On section ,they

usual ly present a concentric arrangement.E vents Gal l - stones often remain qu iescen t in thega l l - bladder. (2) In consequence of violent expu lsiveeflorts

,exc ited by irritation of the gal l - bladder , they may

be ext ruded into the bowe l,intense

mark ing thei r pas sage through the dumak ing a comp lete ex i t

,they may s l ip back into the gal lbladder or they may become impacted in the cystic duct ,

o r,more often , in the lower part of the common duct. (4)They may perfo rate into the duodenum ,

peritoneum,l ung

,

stomach , or kidney , or external ly. Perforation may be fo llowed by strictu re of the ducts or by fistu lous communica

tions between the ducts and the gastro- intestinal canal .Perforation into the duodenum is not a rare cause of intestinal obstruction . (6) Invasion of the gal l - bladder withpathogen ic m icrobes in cases of choleli thiasis is not infre

D ISKASE S OF TIIE DIGESTIVE S YS TE M .

jcet to distinc t exacerbations ; (3) recu rrent attacks of inte rmittent fever, with chi l ls and sweats (Charcot ’s hepaticfever). The l iver is not en larged ; the gal l - bladder is not

distended , but often atrophied from antecedent attacks ofcholecystitis . This condition may last fo r months o r years .I t not infrequently leads to suppu rative angiochol it is

,to

bi l iary c i rrhos is,o r to acu te or chron ic panc reatitis.

Di ag nos is —Obstruction or the Common Duct fromWi thout (Cancer) .—The jaundice increases steadi ly and is withoutrem ission

,the gal l - bl adder is en larged

,and characteristic

col ic and hepatic fever are wan ting.

Prognosis —In the absence of comp l ications the prognosis of chole l ithiasis is good . I t must be borne in m ind,however, t liat grave compl ications (S uppu rative cholecystitiso r angiochol itis

,perforation ,

hemorrhagic pancreatit is) mayari se most unexpectedly .

Treatment .—E fi'

o rts mu st be directed to keeping thestones quiescent by preventing irritation or catarrh of the

gal l - bladder. The food shou l d be plain and readi ly digestible. Saccharin matters

,fat meats , and high ly seasoned

dishes shou ld be avoided . Water- drinking between mea lsshou ld be encou raged . Regu lar exerc ise in the open air,

provided the symptoms are latent , is extreme ly beneficial .

D igestive distu rbances shou ld receive appropriate treatment. Among d rugs , alkal is and alkal ine m ineral watersare undoubtedly efficac ious . Sodium bicarbonate or sodiumhosphate may be taken we l l di luted in the morn ing an

hou r before breakfast and al so between mea ls . If thereis dec ided constipation , a smal l quanti ty of Roche l le sal to r sodium su lphate may be added to each potati on . The

natu ra l mineral waters , notably those of Carlsbad andV ichy

,have acqu ired a high repu tation . When there is a

tendency to so - cal led bi l ious attacks , an occasiona l cou rseof calomel in fractiona l doses wi l l be found of b enefit.Su rgical intervention is cal led for : (1 ) When , despite

medical treatment , attacks of col ic occ u r so frequen tly and

are of such severi ty as to cause disabi l i ty .

o r make the

addiction to morphin a l ikel ihood (2) in pers i stent obstrue

HYPE RE MIA OF THE LI VE R. 1 0 1

tion of the common duct ; 3) in hydrops of the gal l - bladderdue to impaction or stri ct u re of the cystic duct ; and (4) insuppurative inflammation of the gal l - bladder or gal l - ducts .Hepati c Ool i c.

—Morphin grain) and atropin (Th grain)shou ld be given hypodermical ly . Agonizing pain oftenyiel ds very promptly to a few whiffs of ch loroform . In them i ld but rather persistent attacks a few doses of anti n

'

u

in hot water may suffi ce. The external appl ication ofpiieat

(pou lt ice or hot bath ) is very usefu l .When vom iting is u rgent , carbonated water o r champagne

may be given. In threatened col lapse diffusible stimu lantsare needed .

Obstruction of theCommon Duct —The measu res best su itedfor promoting the advance of the stone into the bowe l arerest, regu lation of diet

,the free use of al kal ine m inera l

waters , the occas ional exhibit ion of sa line laxatives , and theappl ication of heat to the hypochondriac region. Olive oi lhas been recommended as a spec ia l remedy , but it is of

doubtfu l efficacy. As the seq ue lm of impaction of the com

mon duct are so grave,su rgica l aid shou ld be invoked if

the obstruction is not removed under medica l treatmentwith in a period of three or fou r weeks .

HYPEREMIA OF THE IJ VER.

Varieti es Active hyperem ia. (2) Pass ive hyperenua.

E ti ol ogy .—Amiw bypcr tmia is common ly due to dieteticindiscret ions. I t may resu l t from overindu lgence in alcohol .

I t is .often present in the infectious fevers . It app e

ars toarise idiopathical ly in hot c l imates .

Passe/e lay pernm'

a resu l ts from diseases that obstruct thevenous c ircu lati on . as chron ic heart and l u ng disease.

Path ol og y .—The l iver is en larged and fi l led with blood.

In the passive variety , the center of the lobu le , the area of

the hepatic vein , is deep ly pigmented , whi le the periphery ,the area of the porta l ve in . is pa le . This mo tt led appearance has given rise to the term “

nutmeg liver. In pe rsistent cases pigmentation, atrophy of the l iver- ce l ls , and

1 0 2 DISEASES OF THE DIGESTIVE S YS TE M

overgrowth of the connective tissue resu lt—a conditiontermed cyanotic indu ration.

"

Symptoms .

'—Am‘

wHypt r tmia .

—The l iver is en largedand some what tender. There is a sense of fu lness or evenactual pain in the hepatic region . There may be s l ight jaund ice. D igestive distu rbances—anorex ia, nausea,

flatu lence,headache

,and epigastric tende rness usual ly coexist.

In the passive variety the symptoms are much the same,

though less marked . The l iver is often quite large, and in

extreme cases,such as fol low tricuspid regurgitation

,it maypu lsate.

Prognosi s —In simple act ive congestion the prognosisis good . In pass ive congestion the prognosis depends onthe cause .

Treatment —Active hype remia from dietetic errorsusual ly yie lds prompt ly to res triction of the diet and the ad

m inistration o f a mercurial purge,fol lowed by a sal ine

Roche l le sal t , Seid l itz powder , o r sodium phosphate . In

recurr ing attacks , in addition to hygien ic and dietetic regulations , a pi l l l ike the fol lowing often proves usefu l

8 . Mnssm hydrargyri

Pn lveris thei

Ex tn ct i gent ianae tut 3s:Ole i earyophyl l i gtt . iv.

—M.

Plant pi lulx No . xx .S IG.—One or two occasional ly, as d irected : to be continued . if

requ ired , thrice dai ly for several days .

In passive congestion treatment must be directed to t heprimary disease. In m i ld cases a lkal ine mineral waters(Car lsbad , Congress, and Friederichshal l) do we l l . A mer

cu rial laxative may be used from time to time . In severecases the most effective measu res are absolute rest

,a m i lk

diet,sal ine purges , and wet- cupping over the l iver.

(Chroni c Interst i tial Hepatit is . )

Defin i tion —A chron ic di sease of the l iver characterized by a hyperplas ia of the connective tissue and more or

less extensive retrograde changes in the l iver- ce l ls .

to4 0 1554555 OF THE DIGESTIVE S YS TE M.

is a gradual loss of flesh and strength . The skin is muddyin appearance,

but conspicuous jaundice is very uncommon .

Nervous symptoms—de l iri um ,stupor

, convu ls ions , and

coma—occas ional ly appear toward the end of the disease .

They are probably due to the retention of poisons that thel iver is unable to convert or to e l im inate.

The majority of cases te rm inate fata l ly in from three tofive years , or in from one to two years after the compensatory ci rcu lation fai ls. Death resu lts from exhaustion

,hem

orrhage, u lmonary edema, intercu rrent d isease ,o r toxemia.

Complicati ons —The kidneys , heart, and blood - vesse lsare often coinc identa l ly involved in the c irrhotic process .Tubercu los is

,especia l ly of the peri toneum ,

is a very common compl ication .

D iagnOBi S f—g l n the early stage the diagnosis can on lybe suspected. In the drunkard

,chron ic gastric catarrh

with en largement of the l iver wou ld strongly indicate the

Thrombosi s of the portal vein produces the same c l inicalpictu re

,but the symptoms u sual ly deve lop much more

Chronic Per i tpni tis wi th Bifusion .- This is usual ly tube rcu

lous or cancerous . The history, abdom inal tenderness ,the detection of local i zed masses or i l l - defined indurations

,

the presence of other foc i of disease,the high spec ific gravity

(above 1 0 14) of the asci tic flu id,and the absence of symptoms indicating porta l obstruc tion wi l l general ly suggest

ch ron ic periton itis .Progn osi s —The out look for permanent re l ief is bad .

Treatmen t —A lcohol must be interdicted . A diet ofbland, readi ly digested food is indicated . The gastric ca

tarrh shou ld rece ive appropriate treatment. Lavage of the

stomach is contraindicated on account of the presence of

esophagea l varicosities . Potassium iodid is of service insyphi li tic cases

,but not otherwise . Ammon ium ch lorid

(1 0 grains th ree times a day ) is sometimes usefu l . Portalcongesti on is best re l ieved by the adm in istration of sal ines(sodium phosphate or Roche l le sa lt) in hot water one- hal fhour before breakfast.

ems /{ 0515 or 7715 LI VE R. nos

Assist s can sometimes be removed by the adminis trationof cathartics and diuretics. A concentrated solution of

E psom sa lts (l to 1 ounce) , taken in the morn ing beforebreakfast, is usual ly the most efl‘i c ient pu rgative. Occas ional ly it may be desi rable to substitute compound ja lap powder or e late ri um. The diuret ics of approved val ue are

potass ium acetate or bitartrate,digital is

,and squi l ls.

N iemeyer's pi l l has a we l l - deserved reputation :R. Mm hydrnrgyri

Pu lveris d igital isPulveris sei l lac . . M gr. x x .

—M.

Fiant pi lul ae No. xx .S ic .

-0 ue pi l l thr ice dai ly.When the asc ites is large and does not yie ld readi ly todrugs , paracentesis shou ld be pract ised (see p.

Surgical Treatment—Talma's operation (suture of the

omentum to the margin of the abdom ina l inci sion and irritation of the peritoneal surfaces of the l iver) or one of itsmodifications , has proved of some benefit in a lim ited num

ber of cases of l iver c irrhosis with asc ites . The objec t ofthe operation is to establ ish a coal pensato ry c ircu lation bymaking acc identa l adhes ions and thus increas ing the armstomoses between the vesse ls of the porta l system and thoseof the system ic c ircu lation. The Operation is contraindi

cated when cardiac o r renal disease coexists .

(Hyper-trophic Cirrhosis of m oot .)

Path ol ogy .—The causes of hype rtrophic c irrhosis are

not understood. A lcohol does not appear to be a fac tor.I t is seen chiefly in men between menty and thirty years ofage. The l iver is great ly en larged throughout the enti recourse of the disease . The organ is of yel lowish o r greenish color

, and its su rface is smooth o r fine ly granu lar.

Microscopical ly, a proliferation of connective tissue isfound , but the latter is chiefly intral obul ar , is more ce l l u larthan fibrous , and shows litt le tendency to contract . The

l iver - ce l ls remain intact and not infrequent ly share in the

to6 DISEASES OE THE DIGESTIVE 5ysTE H.

Symptoms —The l iver is much en larged permanent ly,

often tender, and the seat of recu rren t attacks of pain .

Jaundice of a m i ld type is rare ly absent. The stools,how

ever,retain the ir norma l colo r. The Spleen is en larged.

Hemorrhages into the skin and from mucous membranesare not uncommon . Toward the end of the disease ,

symptoms of hepatic intoxication may deve lop. Asc ites , profusehematemesis , and en largement of the superficia l abdom inalveins are rare ly observed . The cou rse is long—often fromfive to ten years .

The treatmen t is that of congestion of the l iver. Calomel and potassi um iodid have been recommended .

Syph i l i ti c Ci rrh osi s of th e Liven—In the diffu seform the appearance of the l iver is sim i lar to that of alcohol ic c irrhosis . In the gummatou s form , however , theorgan is en larged and often coarse ly lobu lated from fibroustransformation of the gummata. A history of syphili tic infect ion ,

an en largement of the l iver that is grossly nodu lar,and a fair preservation of the general heal th wi l l suggest thecondition . The disease often responds favorably to antisyphi l it ic treatment .Bi l iary Ci rrh osi s of th e Liven —This form is due tostasis of the bi le and resu lts from persistent obstruc tion of

the bi le - ducts by calcu l i , stricture ,or tumor . C lin ical ly , it

resembles the hypert rophic c irrhosis of Hanot , bu t, un l ikethe latter , the jaundice is very intense and deve lops rapid ly

,

the stools are devoid of bile,the l iver is on ly moderate ly

en larged , and the cou rse is short—rare ly more than two orthree years .Capsu lar Cirr h osi s (Ch ron ic Per ih epati ti s) .—This

form is characteri zed by enormous thicken ing of the caps uleof the l iver. The symptoms c lose ly resemble those of

atrophic c irrhosis , but the course is extreme ly s low,the

asci tes retu rn ing again and again after tapping. In manycases intersti tia l neph ritis , chron ic capsu li tis of the spleen

,

chron ic periton itis, and pericarditis are a lso presen t.

1 0 8 0 15154553 or THE DIGESTIVE S YS TE M.

Rupture into tl tc l ung is characterised by seve re cough ,weak breathing at the base of the right lung, and th e

expectoration of brown ish matter, sometimes contain ingamebat .

B ingum —M ti d cy sts deve lop s lowly, are not painfu l

, are not assoc iated with septic phenomena,and yie ld

c lear fluid on aspiration .

Cancer of the Liven—The history,marked cachexia, in

vo lvement of other organs,presence of jaundice

,detec tion of

hard nodu les on the su rface of the l iver, and the absence of

septic phenomena wi l l suggest cancer.

Intermi ttent Fever due to Impacted Gal l - stonw—In th iscondition the pa in,

fever , and sweating are often periodic ;the heal th in the interva ls may be we l l preserved ; the jaundice increases at each paroxysm ; the symptoms may persistfor several years .Prognosi s.

—Embolic abscesses are invariably fatal .Traumatic and amebic abscesses may terminate favorablyupon spontaneous or induced evacuation .

Treatment —In mu l tiple abscesses treatment is pal l iative. Large sol itary abscesses shou ld be opened and

drained .

E fi ol ogy .—Cancer of the l iver is more common in men

than in women . I t is infrequent before the age of forty.

Heredity,traumatism

,and ch ron ic irritation from ga l l - stones

are predis s ing factorsPath o ogy .

—Primary cancer of the l iver is rare ; secondary cancer is common . The primary form may appearas a single large nodu le (massive cancer ) or as a wide - spreadinfi l trating growth (nodul ar cancer). The latter form issometimes assoc iated with c irrhos is of the l iver (ci rrhoticw ea r ) . The secondary variety is usua l ly due to the lodgment in the porta l capi l laries of cancerous embol i derivedfrom a rimary growth in one of the neighboring organs ,espec ia ly the stomach . The l iver is much en larged , and

studded with numerous grayish- wh ite nodes,some of which

CANCER OF THE LI VE R. 1 0 9

project from the surface . The superficial nodes are oftendepressed at the center.

Sm ptoms . The l iver is enlarged and very painfu l ,and often presents one or more smooth

,hard nodu les .

The latter may show a centra l depress ion . (2) Cachexiais pronounced and deve lops rapid ly. (3) Jaundice is common

,but it is rare ly intense . (4) D igestive disturbances

are a prominent featu re,and often precede the hepatic symptoms . Asc ites sometimes resu lts from porta l obstruct ion .

Toward the end,s l ight fever

,de li rium

,stupor, and coma

may deve lop (hepatic intoxication).D iagnM —W c ci rrhosis may be distingu ishedby the smooth

,un iform en largement of the l iver, the en

largement of the spleen , the pe rsistence of icterus withoutloss of color in the stools , the absence of marked cachex ia,the age of the patient (between twenty and forty), and the

s low cou rse.

Abscess—This may be dist ingu ished by the history, theseptic fever , and the resu l ts of exploratory puncture.

Syph il i s of the Liver —The history of spec ific disease ,the

age , and the absence of cachex ia wi l l aid i n the diagnosis.Prognosi s and Treatmen t —Absol utely unfavorable.

The duration is from a few months to a year. Treatmentcan on ly be pa l l iative.

HYDA’

I’

ID CYST OF THE LIVER.

(Echinoooecns of tho mvemE ti ology and Path ol ogy .

—Hydatid cysts are formedby the embryos of the Taenia echinococcus , a smal l tapeworm inhabit ing the intestines of the dog. The disease iscommon in Ice land

,Austral ia

,and some parts of E urope,

bu t is rare in America.

The eggs of the worm are acc idental ly ingested by man ,

and embryos are l iberated in the stomach , whence they maymigrate to any organ the l iver, however, is most common lyaffec ted th rough the rta l vein . The fixed embryo soondeve lops in to a cyst t is composed of an external lami

1 1 0 OF THE DIGESTIVE S YS TE Mnated laye r and an interna l breeding layer. A connect iveti ssue layer is formed on the ou tside from irri tation .

The cyst contains a c lear, non - album inous flu id that has a

spec ific gravity of 1 0 05to 1 0 0 7,and which is rich in ch lorids .

Scolices or larvae deve lop from the breeding layer ; theyare provided with fou r suckers and a c i rc le of book lets , and

produce daughte r- cysts within the parent- cyst. When ingested by the dog, the larvze deve lop into matu re tapeworms .Symptom s.

—Smal l cysts exc ite no symptoms . Largecysts produce an irregu lar en largement of the l iver, with asense of weight o r fu lness in the hypochondriac region . If

the cyst is superfic ial,an e lastic , fluctuating tumor may bedetected on pa lpation . On percussion a pecu l iar v ibratorysensation (hydatid th ri l l) may be imparted to the hand .

Aspirat ion yie lds a c lear fl u id contain ing the characteristichooklets . Fever, pain , and jaundice are usual ly absen t .E vents The cyst may reach a certain size and

then become qu iescent . (2) Trifling inj u ry may convert itinto abscess . (3) Ruptu re of the cyst into neighboringorgans may term inate in death or in recovery .

D iagnosi 8 .—The diagnostic featu res are a smooth ,

tense ,e lastic tumor of the liver, of slow growth

,withou t

pain ,fever, o r pronounced distu rbance of the general hea l th ,

and yie ld ing, upon exploratory puncture,a c lear fl u id con

ta in ing hook lets .Prognosi s—In uncomp l icated cases the prognos is isguarded ly favorable .

Treatmen t —Aspi ration under antiseptic precau tions issometimes fol lowed by permanent recovery. S urgeons of

the largest experience , however, prefer free inc is ion and

evacuation of the cysts . Pu ru lent cysts shou ld be treatedas abscesses .

AMYID ID LIVER.

(Wax y Li ver ; Lsrdw eous Liver . )

Defin i ti on .—An en largement of the l iver due to the

deposition of a pecu l iar album inoid substance.

“ 2 DIS E ASE S OF TI IE D IGE S TI VE S YS TE Mspread lesions, and the fact that the disease has occu rredendem ica l ly sugges t a toxic or infectious origin .

Pathology .-The l iver is reduced in size

,flacc id , an d

friable . The su rface 13 ye l lowish red and mott led. M icr oscopic exam ination revea ls advanced fatty degeneration ofthe l iver- ce l ls

,hemorrhagic ext ravasations hematogenous

pigmentation ,and occasional ly sma ll - ce l led 1nfil tration . The

other organs are usual ly the seat of fatty and parenchymatous degeneration.

Sm ptm —(I ) The in it ia l symptoms are those ofcatarrhal j aufldicc. (2) Nervous symptoms (c/tol cmza) soonfol low ; these are severe headache, man iaca l de li rium

,stupor

,

and coma. (3) The u rine is scanty , and usua l ly contains[cucm and ty rosin , bi le, album in ,

and tube- casts . The ex

c retion of u rea is often greatly dim in ished. (4) The area

of hepatic percussion du lness rapidly decreases. 5) Hemor

rhages from the mucous membranes and into the skin are

common. Fever is usual ly absent. The disease rare lylasts longer than a week or ten days . Recovery is extreme ly rare .

D iagnosis —In acute pkosp/wrw -pozkom’

ng acute gastri tis precedes the jaundice, the vom itus and stools may bephosphorescent or have the odor of phosphorus , the l iver 15general ly en larged , and the u rine contains much sarcolacticac id .

In [typcflrop/ric arr/1051'

s the l iver is en larged and oftenpainfu l

,the course is slow , and leuc in and tyrosin rare ly

ap r in the u rine.

fluent —This must be symptomatic .

Defini tion .—An acute inflammation of the peri toneum.

The process may be general o r local ized .

E t iol ogy .—The disease is probably always caused by

bacteria,which enter the peritoneum from the neighboring

visce ra,especial ly the al imentary canal , from the Fal lopian

tubes , from external wounds , o r direct ly from the blood .

The organisms most frequent ly found are the S treptococcus

ACUTE PE A’I TON I Y’

IS . 1 13

pyogenes , S taphylococcus pyogenes , Baci l lus coli , pneumococcus , Bac i l lus py ocy aneus , and gonococcus.Peri ton i tis may follow Pcrf oran

'

on of the pe ritoneumby an external wound , by ruptu re of a gastric or intestina lu lcer, by rupture of a suppu rat ing appendix , gal l - bladder ,or Fal lopian tube ,

or by ruptu re of a visceral abscess ; (2)cx tctmbn of a septic process in adjacent structu res—stomach ,bowe l , gal l - bladder, pancreas , ute rus ; 3) traum as» :

(4)gm cral inf cctiom—septicem ia, spec ific fevers, rheumati sm,

tubercu losis , etc .

Path ol ogy .—Thc serous surfaces fi rs t become red and

l usterless ; later a serofibrinous , fi brinous , or puru lent ex udate is formed . Putrid and hemorrhagic exudates are sometimes observed .

Symptoms—The most prom inent symptoms are intenseabdom inal pain and tenderness . The breathing is shal lowand thorac ic. To re lax the abdom inal parietes , the patientl ies motion less Upon h is back , with the legs and thighsflexed . The featu res are pinched , and the expression isanxious . The abdomen is distended , and its wa l ls are rigid .

Percuss ion at fi rst revea ls genera l tympany , but later theremay be du lness in the flanks from the gravitation of the

exudate. The temperatu re is usual ly moderate ly h igh(1oz

°- 1 0 4

°and the pu lse is smal l , rapid , and wiry.

The bowe ls are usual ly constipated . Vom iti ng and hiccupare common symptoms . In severe cases col lapse speedi lyens ues , and is indicated by a fal l in the temperature , a cold ,c lammy su rface , a rapid , feeble pu lse , and suppression of urine.

In l ocal fscd pe riton i tis the constitu tional symptoms areless severe . Pain, tenderness , and rigidity are c ircumscribed . Genera l tympan i tes is usual ly absent. Abscessformat ion is common .

M om - Acute Enter iti s—In th is disease the painis col icky and less intense tende rness is much less marked ;rigidity is rarely present ; there is diarrhea ; the constitu

tional symptoms are not so grave .

Intest inal Obstruct ion—Constipation is absolute ; vomi tingis sterco raceous ; fever and abdominal tenderness are lesspronounced .

8

I I4 DISE ASE S OF THE DIGE S TI VE S YS TE MHy steric Abdomen .

—This condition may resemble peri ton iti s in al l part icu lars . The personal history m ust be care

fu l ly considered . Fever is no t usua l ly present, the pu lse isnot usual ly rapid and wiry , and when the attention is distracted , the n may disappear

—D iffuse septic periton itis is a lmost invariab ly fatal . The durat ion 1s us ual ly from two to six days .Life is occasiona l ly saved in perforative peri ton itis byprompt operation . In loca li zed pe ri ton i tis the ou tlook ismuch more favorable.

Treatmen t —Early operation ofl'

ers the on ly h0 pe of

saving l ife in pe rforative or septic cases . Apart from laparotomy ,

treatmen t is , for the most part,pa l l iative. When

the stomach is retentive ,sma l l quantities of m i lk and l ime

water or of broth may be given by the mouth . Ice maybe given to suck . If vom i ting be pers istent , nutrient enemasare to be given . Local ly, ei ther very cold or very hot appl ications may afford re l ief. Opium is u sefu l in a l layingpain

, control l ing vom i ting, and dim in ishing peristal tic movements . Remarkably large doses are often we l l borne. In

non - perforative cases sal ine pu rgatives in concentrated sol ution (1 to 2 drams every two hours) may be given unti l thebowe l s move free ly. These sa l ts

,whi le not increasing peri

sta lsis,attract serum from the tu rgid blood - vesse l s and th us

re l ieve congestion .

E t iol ogy .—Chron ic pe riton itis may be a seque l of acute

periton i tis. In a few instances it has seemed to have resu ltedfrom syphi lis . In the vast majori ty of cases it is tubercu lousor cancerous.Path ol ogy —The intestines are matted together bybands of fibrous lymph . The omentum is often contractedand greatly thickened . Efl

'

u sion is usual ly present, but itvari es considerably in amount ; it is h ighly album inous , andin the tubercu lous and cancerous variet ies it may be bloody .

Smm —Fever is sl ight and may be absent. Painis not severe , and is frequently paroxysmal . There isusual ly more or less difl'use tenderness. Anemia and ema

1 16 DISEASES or 7715 D IGE S TJ VE s ysm v.

weight 1n the abdomen ,dyspnea

,scanty u rination ,

and edemaof the feet may resu lt from pressu re.

Ph ysi cal S i gns .—Inapection .

—The abdomen is d istended ; the surface is smooth and shin ing the base of the

thorax 1s broadened , the nave l 13 more or less obl iterated ,

the superfic ial veins are frequently enlarged ,and

,when the

patient l ies 1n the dorsa l posit ion ,the flanks bu lge .

Palpafi on may el ici t fluctuation,and m the flanks a sense

of resistance.

Percussion revea ls du lness and resistance in dependentparts , with super

incumben t tympany. The du lness ismoveable and i s detected in the flanks when the patientocc upies the dorsal position .

Aspi ration —The flu id is u sua l ly c lear, straw - colored , andalbum inous . The spec ifi c gravity is from 1 0 1 0 to 1 0 20 .

In cancerous and tube rcu lous peri ton i tis the flu id 15 sometimes bloody . Occasional ly , chylous flu id 15present.Diagnosi s.

—This yie lds un iversal hyperresonance on percussion .

Ovarian Cy sts—The en largement is at first un i latera l .As the intestines are pushed aside , the du lness is anteriorand the resonance is in the flanks . Vaginal exam inationoften fu rnishes important data . The flu id of the cyst has a

higher spec ific gravityDistention ot

'

the madden—The history , the location of

the du lness and the resu l ts of catheteri zation wi l l renderthe d iagnos 1s apparent.Treatmen t .—Treatment shou ld be directed to the

origina l cause. Hydragogue cathartics and diu retics are

sometimes usefu l . Concentrated sal ine sol utions , compoundjalap powder (20 to 40 grains ) , and e lateri um Q grain) arethe most u sefu l cathartics. Infusion of digita l is (3 to 4flu id rams) , ci trated cafl

'

e in (2 to 3grains) , potassium c i trateo r acetate (20 grains) , and N iemeyer's pi l l (see p. 1 05) arethe most rel iable diu retics .

B Potassii ei tu tis

Infusi d igi tal isS ta—A tablespoonful thrice dai ly .

When the efl'

usion is large and causes discomfort or great

ASCI TE S . 1 17

diminution in the quanti ty of u rine, paracentes is shou ld beperformed .

Persecuted : Abdomini s—The bladder having been emptied,the patient is placed in a sem irecumbent position , and

3 Spot in the median l ine m idway between the umbi l icusand the symphys is pubis is anesthetized by means of a

block of ice sprink led with sal t. A stou t trocar is nowintroduced with a quick thrust into the abdom ina l cavity , arubber tube is attached to the cannu la for the pu rpose of

conveying the fl uid into a pai l placed be low the patient'sbed

,and the trocar is then withdrawn . Whi le the flu id is

escaping,a many - tai led bandage is adj usted to the abdomen

and gradual ly tightened . The appl ication of such a bindershou ld never be om itted . I t gives support to the re laxedabdom inal wal ls , and tends to prevent syncope and hematemesis. When the fluid ceases to flow , the cannu la isremoved , and the Open ing seal ed with an antiseptic pad and

a few strips of adhes ive plaster.

In tubercu los is , peri ton itis , and in c irrhosis of the l iverwith recurrent asc ites surgica l treatment sometimes provessuccessfu l .

DISEASES OF THE KIDNEYS.

THE URINE .

Normal u rine is a pa le . amber- colored fluid,of ac id reac

tion , having a spec ifi c gravity of 1 0 15to 1 0 25, and amounting in quanti ty to abou t 50 ounces in twen ty - fou r hou rs.Pol y ufim—An increased flow of urine .

Temporary poly ur ia may resu l t from E xcessive ingestion of fl uids . (2) Adm in istration of diu retics . (3) Suppress ion of perspiration. (4) Crises of certain febri le diseases ,and certain neu rotic man ifestations

,such as neu ralgia and

hyste ria. 5) Absorption of serous effusions and transudations . (6 ) Remova l of some temporary obstruction in theun nary passages .Permanent pobmrz

'

a may resu lt from D iabetes me l l i ~tus . (2) D iabetes insipidus . (3) Chron ic interstitial ne

ph ritis . (4) Amyloid k idney .

D im inu ti on of th e amount of urine or su ppreso

sion of ur i ne (annria) occu rs When there is ex

cess ive secretion through other channe ls , as in perspiration and diarrhea ; (2) in feve r ; (3) in severe congest ionof the kidneys ; (4) in acute neph ritis and late in chron icparenchymatous nephritis ; (5) in col lapse ; (6 ) in certa in

‘

nervous condit ions,as in some cases of hysteria ; and (7)

from mec han ica l obstruction,as in compression of the u reters

by tumors and in en largement of the prostate gland .

Urea—Urea is the fina l product of the decomposition of

pr’ote ids in the body . A large part is formed in the l ive r.

I t is complete ly soluble in u rine ,but the n itrate of urea

crysta l l izes in the fo rm of t ransparent imbricated plateswhen n itric ac id is added to u rine that has been partial lyevaporated.

1 1 8

D ISE ASE S OF THE A'

IDNE VS.

of l iquor ammoniaz, and the beautifu l purple color ofmurex idis developed .

Uni tes—The u rates are present in smal l quantity in nor

mal urine. They may become perceptible or transientlyincreased : (1 ) In u rine exposed to a coldIn u rine made scanty by free perspirationWhen the ac idity of the u rine is temporari ly increased .

(4) After excess ive indu lgence in nitrogenous food .

The u rates are inc reased pathologica l ly in many diseaseswhich di rect ly or indirect ly interfere with tissue or food

FIG. 3.—Urie a md and u ric ac id sal ts.

metabol ism,notably in : (1 ) Gout ; (2) fever ; (3) leukem 1a

(4) indigestion ; 5) diseases of the l ungs—from interferencewith oxidation .

Leuci nuria and Ty rosinnria .—Leuc in and tyrosin are

found in the u rine in certain Spec ific fevers , and espec ia l ly infatty degeneration of the l iver resu lt ing either from phosphorus

- poison ing or from ac ute ye l low atrophy .

They may be detec ted by evaporating a few drops of theu rine on a glass sl ide . Leuc in appears in the form of smal l ,round , gl istening spheres , resembl ing fat - drops, but, un l ike

THE URINE . I 2 I

the latter, they are inso l uble in ether . Tyros in appears inthe form of intersec ting tufts of fine acicu lar crysta ls .mwpmm —t t es occu r in two forms, amorphons and crysta l l ine.

Amorphous earth} plum/cates are found in alkal ine urine,

Fro. 4.—c , Tyrosin c rystals ; 6. leucin crystals.

and are prec ipitated by adding a few drOps of l iquor am

mon iac to the urine.

Cry stal/12m ! plwsp/wte of l ime appears as ste l lar orcrystal s which are sol uble in acetic ac id.

F11 1. s.—’I‘rip le phosphate.

ammom'

omagma’

um phosphate, or triple phosphate,appears in decomposing u rine as transparent , cofl‘in - shapedprisms . They may resemble c rysta ls of oxalate of lime,but

,unlike the latter, are free ly soluble in acetic acid.

DISE ASE S OF THE KID/V5VS.

The presence of phosphates in the u rine is no indicati onof excess , for when normal in amount , they are often precipitated in u rine that is temporari ly alkal ine.

The detection of triple phosphates in newly voided u rineindicates decomposition in the bladder, a condition resu l tingfrom vesica l catarrh .

Phosphaturia resu lts from many causes—certain nervousdiseases

,nervous dyspepsia ,

r ickets,osteomalac ia

,leukem ia,

and gout. Cases of polyu ria with phosphatu ria have beendescribed (d iabetesCh loride—The quanti ty of these sal ts is increased : (1 ) After

exert ion . (2) Du ring the absorption of serous effusions .

FIG. 6 .—Oxa late of l ime .

The quantity is decreased . (1 ) In most febri le diseases .(2) In neph ri tis . (3) In many wasting diseases . (4) E special ly 1n pneumon ia.

Test .—We may thus rough ly estimate the quantity . Add

a few drops of strong n i tric ac id to the u rine , remove anyalbum in that may be present, and then add to the c learurine a l itt le of a strong solu tion of n itrate o f si lver. The

abundance of the white prec ipitate wi l l indicate the quantityof ch lorids presentox al uria.

- Oxalate of l ime appears in the urine as

1 24 D ISE ASE S OF THE KIDNE YS .

casts , but they are usual ly much longer and often taper offat one end to a th read . Moreover , they frequen tly showconstrictions at d ifl

'

erent points . Their presence is not aproof of nephri tis . They often occu r in condi tions of renali rri tation .

Urob i l inur ia.—Urobi lin is the coloring agent of normal

urine . When present in ex cess,the u rine is dark brown .

When deposited in the t issues , it causes a brown ish pigmentation known as u robi l in icteru s . The u robi lir) in the

u rine may be pathological ly inc reased In pern ic iousanem ia ; (2) after the absorption of hemorrhagic effusions ;(3) 1 11 pyrexia ; (4) 1n advanced l iver disease .

Hematoporph yfi nM —Hematoporphyrin is a produet of the decomposition of hemoglobin . I t 15 hematin deprived of i ts iron . Large amounts impart to the u rine 3dark - red color. I t is found in the u rine in a large numberof d iseases

,and in chronic poisoning by su lphonal and

trional .Gl y cosur ia .

—Grape- sugar in the u rine .

Causes—Normal urine contains a trace, but this is notrecogn i zable by the ordinary tests . Dec ided glycosu ria isseen In diabetes me l l itus ; (2) after the digestion of

large amounts of saccharine matter ; 3) in poison ing bycertain drugs

,such as phloridzin,

n itrites , ch loroform ; (4) 1npregnancy ; (5) in diseases or inj uries to the floor of the

fourt h ventri c le ; (6) 1n lesions of the pancreas involving theis lands of Langerhans, (7) in many nervous diseases and

acute infections—epi lepsy , tetanus , cholera,pertussis, etc.

Qual itative Tests f or Gl ueose.—The copper. tests are com

monly employed, and depend on the power which glucose

possesses of converting blue oxid of copper into the orangeye l low suboxid .

Trammer’

s Test—Add to the suspected u rine half itsvol ume of l iquor potassz ,

and if any precipitate fa l ls , fi lterthe solution then add one or two d rops of a weak sol ution(1 : 30 ) of su lphate of copper, and heat the resu lting m ixtu re . If sugar is present , a dense ye l low or red prec ipitatefa l ls .S imple decolori zation of the fluid is no proof of sugar.

THE (JR/NE . 1 25

Fe/zl i ng‘

s Test—As the fluid employed in th is test spoil son keeping, i t shou ld be fresh ly repared when required bym i xing in equa l proportions the o l lowing sol utionsFirst sol u tion : D issolve 34 64 grams of pu re cupric su lphate in disti l led water and di lu te up to 50 0 c .c .

Second sol u tion : D1sso lve 1 80 grams of pu re Roche l lesa lt and 70 grams of caustic soda in 40 0 c .c . of disti l ledwater

,and heat to boi l ing ; on coo ling, make up to 50 0 c .c .

w ith dis ti l led water.

To about ten m inims of each solution in a test - tube add

about a flu id ram of di sti l led water, and boil fo r a few

seconds ; if the sol ution remains c lear, add the suspectedu rine drop by drop, and occas iona l ly heat the tube . If

sugar is abundant , a yel low ish - red deposi t wi l l be produced.If no prec ipitate fa l ls , continue the addi tion of the u rineuntil an equal vol ume has been added , and al low to cool ;then if no precipitate fal ls , sugar is absent.The Bkeny l lry dras in Trst.—Put - in a test - tube ha lf fi l ledwith water phenylhydrazin (hydroc hlorate) 2 grains and

sodium acetate 3 grains . Dissolve by heating. Fi l l thetube with suspected u rine , and stand in boil ing water fortwenty minutes. Then place in cold wate r. On coo l ing

,

ye l low,radiating groups of needle- shaped crystals of phenyl

glucosazon fa l l , which may be detec ted under the m icro

Test .—Add to a couple of drams of suspectedurine which is free from album in an equal volume of l iquorpotassae and a few grains of subn itrate of bismuth

, and

boi l ; if sugar is present . it wi l l reduce the sal t of bismuth toblack meta l l ic bismuth . S ubstances contain ing su lphu r

,

l ike albumin, yie ld a sim i lar black precipitate .

TIce Fermentation Test—Fi l l a fou r- o unce bott le th reeparts fu l l of u rine , and add a flu id ram of ordinary yeast or asmal l portion of compressed yeast ; l ight ly cork , and subjectto a temperatu re of 70

° to 80 ° F. for ten o r twe lve hou rs.If sugar is present , fermentation resu l ts with the evol utionof carbon dioxid , and the specific gravi ty of the urine fal ls.Quanti tative Tests—Fermen tation test : Employ two bott les of urine, and to the one add the yeast ; at the end of

1 26 D I S E ASE S or 771 15 1170 s ys.

twenty - four hou rs take the spec ific gravi ty of each spec imen.

E very degree lost in the fermented u rine indicates a grainof sugar to the flu idounce.

Fe/tl iag’

s Test—TO 1 c .c . of Feh l ing’s so lution add 4 c.c .

of d isti l led water, and boi l if the solu tion stil l remains c lear,add 1

16 c .c . of the urine from a graduated pipet, and gently

heat . Continue the addition of the u rine, l i tt le by littl e ,

unti l al l blue color has disappeared . If 1 c .c . of u rine hasbeen added

,it wi l l have contained ha lf of 1 per cent. of sugar.

If 2 c .c . are used,i t wi l l have contained per cent. If bu t

ha lf of a cubic cen timeter is used, i t wi l l have contained1 per cent.If the spec ific gravi ty indicates that the amount of sugar

is great, di l ute the u rine with a defin ite amount of water,and estimate accordingly (Tyson).Al buminufla —A lbum in in the u rine .

Cannes—It occu rs In al l forms of neph ritis ; (2) inconges tion of k idneys from diseases of the heart , l ungs , andl iver ; 3) in conditions profoundly affecting the blood , as pernicious anem ia

,leukemia,

pu rpu ra ,and poison ing by many

drugs ; (4) in acu te febri le diseases ; (5) often in pregnancy ;(6) occasional ly in certain pe rsons in health . as in youngadults after exert ion , exposure ,

or a diet rich in album in(cyc l ic albuminu ria) ; (7) when the u rine contains pus o r

blood (acc identa l album inu ria) ; (8) in many nervous discases , as apoplexy , cerebral concussion . tetanus , epi lepsy.

Testsf or Albumin .

—Hel/er '

s Test—Pour a smal l quantityof colorless n itr ic ac id in a test - tube

,and al low an equa l

q uantity of fi ltered u rine to trick le from a pipet down the

sides of the tube and to come in contact with the acid . If

album in is present , a sharply defined white ring is fo rmed atthe l ine of j unct ion .

Tu rpent ine ,copa iba ,

and othe r oleores ins el im inated inthe u rine yie ld sim i lar rings

,but the latter are redissolved

on the addit ion of alcohol .Uric ac id produces an undefined pink ring , but it is not

exact ly at the l ine of contact , and is redissolved on the

app l ication of heat .j ohnson

’

s Test—Fi l l a six - inch test- tube two- thi rds fu l l

1 28 up 71 15 KIDN E YS .

the spec ific fevers ,scu rvy , ma laria,

pern ic ious anem ia,etc . ;

(6 ) tumors and tuberc le of the k idney o r bladder , (7)varicose veins at the neck of the bladder (occas ional ly seenin old persons) ; (8) vicariou s menstruation (ve ry rare) ; (9)paras ites in the gen ito - u rinary tract, such as the Filariasangu inis hom in is and D istoma haematobium .

Diagnosis—By the color of the u rine and by microsc 0 p icand spectroscopic exam ination .

Hel l er’

s Test—Bo i l the u rine with a solu tion of causticpotash : phosphates are prec ipitated , which ass ume a red

color from the freed hematin .

Source of the Hemorrhage.—Ura lzm .

—The u rine fi rstpassed is bloody

,and the other symptoms point to the

u rethra .

BIaddcr .

—Bleeding often at the end of m ictu ri tion and

other symptoms point to the bladder.

KMuqm—Blood intimately m ixed . There may be bloodcasts or c lots , and the other symptoms point to the k idneys .Hemogl obi nur ia.

—Blood - pigment in the u rine . The

chief causa l conditions are—( l ) Blood disintegration fromacute infec tions (malaria,

typhoid fever, ye l low fever) , seupurpu ra,o r poisons (potassium chlorate , carbolic ac id

,ea) ;

(2) absorption of hemorrhagic effusions and the transfusionof blood ; (3) some cases of Raynaud 's disease . I t occas ional ly resu lts from exposu re or overexertion (pen in sul a!

hemog lobinun'

a ) .Ind i cannM —Indican , or indoxyl su lphate ,

is a productof indol derived from the bacte rial decomposit ion of prote idsin the intestine . I t does no t color the u rine, but by oxidation it is converted into indigo- blue . I t occu rs 1 ) Frequent ly m norma l u rine ; (2) from the undue retention of

materia l in the sma l l intes tine , as in intestinal obstruction ,

peri tonitis , and obstinate constipation ; (3) in carc inoma ;(4) in pu ru lent inflammations .

Tests f or l ndicam—M ix equal volumes of urine and freshhydroch loric ac id , and add

,d rop by drop, a fresh coneen

trated solu tion of ch lorid of l ime (5: Indican isindicated by the appearance of an indigo - blue color.

Chand a —The presence of bi le - pigments and bi le ac ids

THE UR IN E . 1 29

in the u rine. I t is most marked in obstructive jaundice ,

but it may also occu r in the non - obstructive form . The

un ne varies from a green ish - ye l low to a dark brown color.

Tests f or Bil e.

—Gmd m'

s Test.—A l low a few d rops of

u rine and a few drops of fum ing n itric ac id to come togetheron a white plate . If bi le is presen t , there wi l l be an i ri

descent play of colors—green , blue, violet, and red—at the

l ine of contact .Pr i /m éof t r

’

s Test—Add a few grains of cane - sugar and

a drop of su lphu ric ac id to the suspected u rine in a testtube ; heat gently , and if bi le ac ids are present, a violet- redcolor is produced.Hay

'

s Test—N a very smal l amount of flowers of su lphurbe spri nk led upon the su rface of the u rine

,it wi l l at once

begin to fa l l to the bottom if the sl ightest traces of bi le are

present.Chy l nfim—Chyle in the u rine . The u rine presents a

m i lky appearance. The emu lsion of the fat 13 so completethat m icroscopic exam ination rare ly revea ls distinct oi lglobu les. E ther dissolves the fat and renders the u rinec lear . Chylous u rine is often s l ightly pink from the adm i xtu re of blood . The chief cau se of chylu ria 1s the obstructionof the lymphat ic ducts by the Fi laria sangu in is hom in is .

Pyad a —Pus 1n the u rine. I t resu l ts (I ) from suppu rative inflammation of any part of the genito- u ri nary trac t,and (2) from the ruptu re of abscesses into the tract .i t appears as a du l l

,green ish - ye l low prec ipi tate that is

co nverted into a c lear ge latinous mass by the addition of

liquor potassze . I t ca n a lways be detected by the m icroscope .

Source.—When pus is from the k idney , it is intimate ly

m ixed with th e urine ; the latter has an ac id o r neu tra lreaction,

and the assoc iated symptoms point to the k idneys .When the pus is from the bladder, it is not so intimate ly

mixed with the u rine,the latter 1s often a lkal ine 1n reaction ,

and the assoc iated symptoms point to the bladder.

E hr l i ch ’s Diazo- reaet ion .—In certa in diseases the

u rine contains aromatic bodies that produce a charac teris ticcolor with su lpho—diazobenzo l .

o

130 DISEASES OF THE 117mm VS.

Process—Two solutions shou ld be prepared and kept in separate bottlesI . Su lphan i l ic acid 2 . Sod ium nitri teHydroch loric ac id, pure Disti l led waterDist i l led water .

In order to apply the test, 50 c .c. o f No . I are added to t c .c . of No. 2 .

The mi xture is added to the urine in a test - tube in the pm rt ion of half uri neand half m i xture . One c .c. of ammon ia- water is then std ed and the tes t - tubeis vio lently shaken . The reaction i s pos iti ve on ly when the resu l ting frothacquires 11 rose - red (not brown ) co lor .

The diazo- reaction is common ly present in typhoid fever.

i ts va lue 1n d tagnosis is lessened by its frequent occurrence1n tubercu los1s

,measles

,pneumonia

, and septic diseases.

(Movable Kidney Nephroptosi s . )Defini tion —A condition in which the kidney man ifests

a high degree of mobi l ity .

E t i ol ogy .—It is m uch more frequent in women than in

men. Tight lac ing,frequen t pregnanc ies, rapid loss of flesh ,

and overexertion are repu ted causes . Congen ital laxity of

the perineph ric ti ssues is probably the chief factor.

Sm pt0m 8 .—The right k idney is the one usual ly

affected , probably from its re lation to the l iver, which movesdu ring the respiratory acts . The kidney may be found inany part of the abdomen as a movable tumor , ren iform in

shape ,somewhat tender to the touch , and rarely impart ing

the pu lsation of the renal artery . Not infrequent ly gastrOptos is and enteroptosis coexist .The re may be no subjective symptoms . In many cases ,however , there is a sense of discomfort in the abdomen,

accompan ied by digestive distu rbance ,hysteric man ifesta

tions,and hypochondriasis. Occas ional ly painfu l parox

y sms occu r simulating rena l col ic (Diet l ’s c rises) . Thesehave been attributed to engorgement of the kidney fromtwisting of the rena l vesse ls .Diagnosis .

—The ren iform shape of the tumor, its freemobi l ity

, its stationary size ,the lessened resistance on per

cuss ion ove r the renal region of the afl'

ected side ,and the

absence of cachexia wi l l se rve to diagnose a floating kidneyfrom other abdom inal tumors.

132 0 1554555 or 7715 KIDN E 1's .

blood- ce l ls. Symptoms of the primary disease which hascaused the genera l venous stasis (dyspnea, cyanos is , and

edema) are oflen superadded. Urem ia does not occu r.Prog0 0d 8 .

—Th is depends upon the gravity of the prima disease .

tmeuL—The patient shou ld be kept at rest. The

diet shou ld cons ist chiefly of m i lk and farinaceous food .

D ry cupping is of service . As a diu retic , infusion of digital is (2 to 4 drams) is distinctly usefu l . Hydragoguecathartics (sa l ines and com und jalap powder) may beemployed as adjuvants . In chifon ic heart disease such a pi llas the fol lowing may be of se rvice

B Ph l veris d igi talisPul veris sci l lz 33gr . xxE x tracti oacis vomica: gr . iv

Mass: fcn i carbonatis gr . x xx .—M.

Final in pi lu la: NO. 11 x .

Sta—One pi l l four times a day .

Defini tion .—The name appl ied to a group of symptoms

resu lting from the retention of poisons in the blood whichshou ld have been e l im inated by the kidneys .Sm ptm —It may deve lop slowly or abruptly in any

form of neph rit is,and may be man ifested by any of the

fol lowing phenomena : Headache , vertigo , de l iri um , epi leptiform convu l sions

,coma, s udden bl indness (unassoc iatedwith any retinal change) , and transient paralysis from

congestion or edema of the brain or spinal cord .

Pulmonary Symptoms.—Dyspnea (urem ic asthma) ,Cheyne

Stokes breath ing.

Game - intestinal Symptoms.—Hiccup , obstinate vom iting,

and pu rging.

General Symptoms—The skin is d ry , the breath has a

u rinous odor, the pu lse is sl ow and often of high tension ,

and the u rine is scanty or suppressed . The temperatu re isusua lly normal or subnorma l , but s l ight fever is not un

common .

D iagnosi s .—The u rinous odor of the breath , the scanty

u rine,the decreased u rea excretion , and the assoc iated

ACUTE NE P IIRI TIS . 133

symptoms of nephri tis wil l usual ly lead to a correct diagnosis . The differentiation of u rem ic coma from other formsof coma is considered on page 376 .

Prognosi s—This is always grave . Recovery is possible

,however, even afte r the most severe symptoms .

Treah nenL—The chief indication is to favor e l im inat ion .

Two drops of croton oi l , di l uted with ol ive oi l or glycerin ,

or grain of e lateri um,shou ld be given at once. Sweating

shou ld be promoted by hot - ai r or vapor baths and the

hypoderm ic admin istration of pi locarpin. If coma o r con

vu lsions appear, and the patient is not too feeble, venesection may be pract ised , the removal of from i s to 20 ounce s ofblood sometimes exerting a very happy effect . In chi ldrena few ounces of blood may be abstracted from the loins bymeans of wet - c ups .After the blood has been withdrawn,

normal sal ine sol ution may be injected subcu taneous ly. Recta l irrigationwith hot sa l ine sol ution is another potent measure. Con

vu lsions may be control led by chloroform inhalations o r

by an enema of ch loral (Qto l dram) . Morphin has beenrecommended , but it shou ld be used with great caution,

especial ly in ch ron ic interstit ial neph ri tis .

Defini tion .—An acute inflammatory disease of the k id

ney ,involving espec ial ly the epithel ium of the tubu les and

glomeru l i.E fi 0 10gy .

—Thc chief causes are : (1 ) Infec tious diseases ,espec ial ly scarlet fever ; (2) poisons which are e l im inatedthrough the kidneys , such as cantharides , turpen tine ,

etc . ;

3) exposure to cold and wet ; (4) pregnancy. Inflamma

tory sk in diseases and extensive bu rns may a lso cau seacute nephri t is .Path ol ogy

—The k idney is swol len and the capsu lenon- adherent. At first the organ is bright red in color ; i t

134 DISEASES OF THE 1ivos vs.

soon,however, becomes pa le and mott led in appearance,

a lthough the Malpighian tufts sti l l reta in the ir deep- red tint.Hi stol ogy —The epithe l ium of the tubu les and glom

eru l i is the seat of c loudy swe l l ing and ,later

,of fatty

degeneration . Desquamated epithe l i um,blood- corpusc les ,

and an album inous exudate block the tubu les . The capi l

laries are di lated , the ir wal ls are degenerated , and bloodyextravasations are not infrequent ly seen . The interstitialt issue is more or less infi ltrated with leukocytes .Symptoms—The general symptoms are moderate fever

and its assoc iated phenomena ; du l l lumbar pain ; nauseaand vomi ting ; dropsy , beginn ing in the face and becom inggeneral ; and pronounced anem ia. Urem ic symptoms maydeve lop at any t ime .

The Urine—The u rine is scanty and at times suppressed.

I t is smoky in appearance ,of high spec ific gravi ty, and con

tains a large amount of a lbum in , free blood , hya line ,blood

,

and e ithel ial casts , and epithe l ia l ce l ls . Granu lar castsmay also be found. The da i ly sec re tion of u rea is dec reased .

D iagnosi s—As the gene ra l symptoms are often sl ight

,

the diag nosis must rest on the examination of the u rine.

The history and the absence in the u rine of wide,high ly

fatty casts wi l l serve to distingu ish am te y ep/mks from an

am t: ex acerbation (y'

chron ic parenchy matous nap/0 12119.Prognod s .

—Guardedly favorable . I t may ki l l by ex

haustion ,urem ia,

or edema of the l ungs . I t may becomechronic . The average durati on is from two to six weeks .Treatment —Abso l ute rest in bed for from fou r to sixweeks is impe rati ve. Mi lk large ly di lu ted with carbonatedwater , Vichy , or lime - water is the best food . Beef- tea and

broths shou ld be interdicted .

In the absence of any direct remedies the indications are

to divert the blood from the inflamed kidneys , to lessenthei r work as much as possible by inc reasing the act ion of

the bowe ls and skin ,and to meet the symptoms as they

ari se .

At the onset , if there be pain or suppression of u rine,

dry cupping, or , in severe cases , wet cupping over theregion of the k idneys is of value . Fol lowing the cupping

136 DISEASES on m a A’

IDNE i fs.

adheren t. The reduced size depends on destruction of the

renal epithel i um and the cont ract ion of th e overgrown con

nective tissue.

Symm - The symptoms usual ly deve lop insidiouslyand consist in progressive weakness

,marked anem ia

,dropsy

(often first noted i n the face on rising in the morn ing) , digestive distu rbances , and sooner o r later a moderate degree of

card iac hypertrophy with high arteria l tension and accentuation of the second aort ic sound . Uremic symptoms maydevelop at any t ime .

The Urine—The u rine is usua l ly dim inished in quantity ,is often turbid

,is of rather low Spec ific grav i ty , is highly

albuminous,and contains w ide dark granu lar casts

,fatty

casts , waxy casts , and fatty epithe l ial ce l ls .Compl i cati ons .

—These are numerous and often suggestthe diagnosis . The most common are u rem ia ,

extens iveserous effusion into the tissues or serous cavities

,latent

inflammation of the se rou s membranes , pneumon ia,valvu lar

heart disease , album inuric retin i tis,apoplexy , and acu te ex

Prognoei s.—Unfavorable. The du ration is from a few

months to several years .Treatmen t —The treatment is large ly dietetic and

hygien ic . Res idence in a d ry , warm ,and equable c l imate

serves to prolong l ife . Rest is an essentia l e lement in thetreatment. The underc loth ing shou ld be u oo l len o r si lk .

The diet shou ld be non - n itrogenous , and in severe cases anabsol ute m i lk diet may be of extreme value. Warm bathswith friction are usefu l in promoting free action of the skin

,

but great care must be exerc ised after their use to avoidchi l l ing. The bowe ls shou ld be kept active by natu ralm ineral waters or sal ine laxatives . When the u rine isscanty , digi ta l is , caffe in

,potassium c itrate ,

o r theobrom inmay prove efficac ious . The fol lowing combination sometimes acts happi ly

B. Sparte ina sulphatis

Cafl‘e inse ci traueLith i i benroatis

Fi ant chartuhe No . x i) .

S ta—One powder four times a day .

C”ROtVIC IN TE RS TI TIAI. N E PIIA‘I TIS . I37

Basham’s m ixtu re is often usefu l as a hematinic , but on lysma l l doses shou ld be used . Strychnin and the s implebitte rs are va luable adj uvants to i ron in many cases . E x

cess ive dropsy wi l l cal l fo r hydragogue cathartics E psomsa l ts

,compound jalap powder, o r e lateri um), for diap oretics

(hot- ai r baths and pi locarpin ), and perhaps fo r operativemeasu res (punctu re of the legs and scrotum , insertion of

Southey’s tubes , inc is ions near the ank les, aspiration of

serous sacs) . Urem ia wil l demand spec ial treatment (seep . acute exacerbations shou ld be treated as primaryattacks of acute neph ritis .

(Bed Granul ar Kidney ; Contracted Kidney ; Gouty Kidney . )

Defini tion .—A chronic inflammatory disease of the

kidney characterized by a marked overgrowth of its con

nec tive- tissue e lements , and a lmost invariably assoc iatedwith genera l arteriosc lerosi s and hype rtrophy of the heart .

E ti ol ogy —It is much more common in males than in

females , and is most frequent ly encountered between the

ages of forty and sixty . I t is sometimes secondary toparenchymatous neph ritis

,but is very often primary. The

chief causes are gout , chron ic rheumatism, al coholism

,

syphi l is , chron ic plumbism ,and pass ive congestion from

heart disease.

Path ol ogy —The k idney is smal l and red in color. The

surface is granu lar and the capsu le adheren t. The organ isfirm

,cuts with difficu lty

, and on section often revea ls sma l l

cysts or calcareous deposits . The cortica l substance isgreat ly reduced in th ickness . M icroscopic examinationshows an overgrowth of connective tissue , which in con

tracting has partia l ly destroyed the glomeru l i and narrowedthe l umen of the tubu les . The epithe l ium a lso is more o r

less atrophied and degenerated . The arteries th roughoutthe body are the seat of sc lerotic changes , in consequence of

which hypertrophy of the heart , espec ia l ly of the left ventr ic le , has resu lted .

Symptoms —The symptoms deve lop most insidious ly.

138 D ISE A555 or m s 570 1115 ys.

There is s low loss of strength,with increasing anem ia.

Gastric distu rbances are common. Vascu lar symptoms areprom inent, and inc lude th icken ing of the vesse ls

,high

arterial tens ion , accentuation of the second aortic sound,and

hypertrophy of the heart. Dyspnea is present in the latestages , and may resu lt from cardiac weakness

,edema of the

l ungs,or u rem ia. Headache ,

vert igo,and insomn ia often

resu lt from the disturbed circ u lation or from u rem ia. Dim

ness of vis ion from album inu r ic retinitis is a serious symptom . Dropsy is often absent

,o r is sl ight and late in

appearing . Urem ia is of ve ry frequent occu rrence .

The Urine.—The u rine is very copious (80 to 150 ounces) ,pale in color,of low spec ific gravity ,— 1 0 05to 1 0 1 2—and

conta ins but a trace of album in and few narrow hyal ine or

pale granu lar casts .Compl i cati ons.

—A lbum inuric retinitis , valvu lar heartd isease

,apoplexy resu lting from the weakened arteries and

large heart , u remia,latent infl ammation of serous mem

branes,pneumon ia , and bronchitis .

D iagnosi 8 .—0hroni c parenchymatous nephrit is usual ly

occu rs in younger subjects and runs a shorter cou rse .

There is dec ided edema,and the u rine is dec reased in quan

tity and contains m uch album in and wide fatty casts .Progn0 8i 8 .

—The disease is incurable,but may last manyyears . The poss ibi l ity of u rem ia occurring sudden ly m ust

be borne in m ind .

Treatmen t —The dietetic and hygien ic treatment is thatof chron ic parenchymatous neph ri tis . Frequent tepid bathswith friction of the sk in are advantageous . The bowe lsshou ld be kept regu lar with m i ld sa l ine cathartics or alkal ine m ineral waters . N itroglycerin (rt1: to fu» grain) 1s oftenusefu l when arterial tension becomes excessive and cau sesheadache

,vert igo

,palpitation

,and dyspnea. Basham '

5m ix

tu re in smal l doses (1 flu idram ) is sometimes of se rvice whenthere is pronounced anem ia. When there is severe insomn ia

, brom ids ,chloral . paraldehyd , and trional may be tried

in the orde r named . Opium shou ld be avoided . Heartfai lu re with low arteria l tension wi l l requ ire the use of suchstimu lants as digitali s

,strychn in

,caffein

,and alcohol.

140 DISEASES or THE 117 0 s rs

to u rethri tis and cystitis . (3) I t may be tubercu lous or

cancerous . (4) I t may be exc ited by i rri tant diu reticscantharides , tu rpentine ,

etc . (5) I t may occu r in the cou rseof specific fevers. (6) I t is rare ly the resu lt of exposu re tocold and wet .Path ol ogy .

—The mucous membrane is swol len ,in

jec ted ,and covered with desquamated epithe l ium and

mucus or mucopus . In severe cases the su

fppu rative in

flammation may extend to the substance 0 the k idneyIn calcu lous and tubercu lous pye l i tis ,

espec ial ly when the u reter is.obstructed , the pe lvis of thekidney may become greatly distended from the accumu la

tion of pus In such cases the pus is occasional ly discharged into the perineph ric tissues , and u ltimate ly even into the colon o r other neighboring organs .Symptom —In Sim/ti c catarr lza l joy s/itt} the chief symptoms are du l l pain over the kidney and the passage of

turbid,ac id u rine , contain ing mucus , epithe l ial ce l ls , and

pus- corpusc les. In Scrum suppurative cases the kidney

region is often distinct ly painfu l and tender. A t umor or

swe l l ing can sometimes be detec ted . Symptoms of sepsisirregu lar fever

,profuse sweats

, chi l ls , leukocytos is , and

pa l lor—are frequently present. The u rine is usual ly ac idin reaction and conta ins more or less pus , mucus

,blood

,

albumin, and desquamated pe lvic epithe l i um .

D iagnosis .— In cy stit is pain is referred to the hypogastric region

,there is frequent m ic tu ri tion with dysu ria

, and

the u rine is more l ike ly to be alkal ine in reaction than ac id .

In perinephritic abscess the lumbar swe l l ing is usua l lymore c ircumscribed ; the supe rfic ia l t issues are often edematous ; and the u rine is free from pus .

culoun Py el i tim—Sharp pain ,inc reased by jarring move

ments , and reflected down the u rete rs , and the presence o f

m uch blood in the u rine point to ca lcu lous pyel it is .Tuberculous pyel i tis may be recogn ized by the history , thepresence of tubercu lous foci in other organs , and the discovery of tuberc le bac i l l i in the u rine . The tubercu l in testmay a l so aid in the diagnosis .Prognosi s —Mi ld forms resu lting from exposure or the

N E PHROLI TII IASIS . 14 1

spec ific fevers usual ly recover in a few weeks . In suppu rative pye l itis the prognos is is grave

,although recovery mayoccu r under operative treatment.

Treatment —The patient shou ld be kept in bed and

placed upon a m i lk diet. In acute cases warm appl icationsare usefu l . A lkal is and a lkal ine m ineral waters are of

service. S uch a combination as the fol lowing may be pre

B. Sodu bromidi511 gr . cl x

E x tracti bel ladonnse gr . iv

E x tracti buchu,

“

iSyrupi m mri l lse compositi q . 5. ad {gnu—M.

S ta—A teaspoonfu l in water th ree or four times a day .

Urotropin (5grains) or sa l ol (3to 5grains) may be givenfor its antiseptic efl

'

ect. Calcu lous pyel itis wi l l require thetreatment indicated for rena l ca lcu lus . In suppu rative casesOperative interference oflers the on ly hope of saving l ife.

NEPHROLITHIASIS.

Defini ti on —Rena l ca lcu l i are concretions formed in thek idney by the prec ipitation of various sol id cons ti tuen ts ofthe u rine .

E fiOl ogy .—The disease is more common in males than

in females. Heredity and sedentary habits are given as

predisposing causes . The formation of stones is favored bythe presence in the u rine of any sparingly sol uble substancein excess . Mucus, blood, pus , or epithe l ium may fu rn ishthe nuc leus .Path ol ogy —The size of renal concretions varies fromthat of coarse sand grave l to that of a large bean . The

most common forms are those composed of Uric ac idand its compounds ; (2) oxalate of l ime ; (3) phosphate of

ca lci um and of ammon iomagnes ium phosphate . S tonescomposed of xanthin and cyst in are rare .

Uric aci d are the most common ca lcu l i . They are usual lysmooth

,of a reddish- brown color

,and comparative ly hard.

142 DISEASES OF THE KID/VB VS .

Ox ah wof-hmo ca lcu l i are very hard,of a dark - brown color

,

and uneven (mu lberry ca lcu l i). Phosphatic calcul i are grayish - white in color

,soft, and mortar- l i ke.

E vents Smal l partic les are frequently passed without serious disturbance. (2) Larger conc retions may be

extruded with intense pa in (rena l col ic ). (3) Ca lcu l i mayremain in the pe lvis and exci te pye li tis or pyelonephri tis .

(4) They may obstruct the u reter and cause hydroneph rosiso r pyoneph rosis .Sy tfiptoms.

—Pain and tenderness in the k idney regionare common symptoms . The pain is aggravated by roughmotion ,

and tends to radiate along the u reter. The u rinefrequently contains bl ood

, pus, epithel ium , and cry sta ls indieating the natu re of the stone.

Symptoms of Sepsis—I rregu lar fever , chi l ls , sweats , leukocytosis , and pal lor mark the occu rrence of suppu rativepye l it is . Col t}: is exc i ted by the entrance of the stone intothe u reter.

Ru ral col ic is characteri zed by intense pain radiating fromthe k idney downward into the groin ,

th igh,and testic le.

The testic le is often retracted . There are often nausea,

vom iting, and col lapse . After such an attack the urinemay con tain blood or partic les of stone.

D iagnosis—In bi l iary colic the pain radiates to theshou lder ; there is often jaundice ; the ga l l - bladder isusua l ly tende r and en larged ; the u rine is negative ; a stonemay be found in the stoo ls .Prognosi s .

—In uncompl icated cases the prognosisshou ld be guardedly favorable .

Treatment —This shou ld be di rected to the u nderlyingdiathesis. In cases of u ric - ac id ca lcu l i a lkal is and a lkal inem ineral waters are usefu l . A quart of water contain ing 40grains of potassium bicarbonate and 20 grains of l ith iumc itrate may be taken dai ly. Spec ial remedies , l ike piperazin ,

ly ceto l , and u ros in , have been recommended as solvents ,but they are of doubtfu l val ue . When phosphatic calcu l iare present , benzoic or boric acid (5 to 15grains th ricedai ly) may be employed in a sim i lar manner.

Operation (neph ro l ithotomy ,nephrotomy, or nephrectomy)

D ISEASES op TI/E KIDN E i'

s.

Treatmen t —Large accumu lations wil l demand surgica l treatment ; smal l ones shou ld not be distu rbed .

E tiol og y .—The etiology of rena l tubercu los is IS that of

tubercu losis 1n genera l . Males are more frequent ly attackedthan fema les . The maj ori ty of cases are encountered beimeen the ages of twenty and forty years .Path ol og y .

—Two forms of renal tubercu losis havebeen recogn ized—the m i l iary and the caseous . The formeris near ly a lways bi latera l , is an acu te process

, and is general ly unm istakably secondary to tubercu los is e lsewhere inthe body. The caseous variety runs a ch ron ic cou rse ; itusual ly beg ins as a uni lateral affection a l though the otherorgan is common ly u ltimately involved , and a primaryfoc us may or may not be apparent in some other structu re.

Symptoms —The chief symptoms are : pain in the lumbar region

,usual ly du l l , but somet imes sharp , l ike that of

renal col ic ; tenderness on pressu re ; s light, irregu lar fever,and more or less cachexia. The u rine is usual ly ac id inreaction , and may contain pus , blood , album in , tuberc lebac i l li , cheesy partic les ,

and debris . Tube -casts are rare lyfound . In many cases en largement of the affected organcan be detected by bimanual pa lpation .

D iagnosi s.—0al culous Py el i tis—In this condition pain

is usual ly more severe and mo re apt to be affected bymovement. Hematu ria is more profuse ,

and is often ex

c ited by exertion . Cachexia is no t so marked , and thereare no tube rc le bac i l l i in the u rine . The tubercu l in - test andthe Rontgen rays may aid 1n the diagnosisPrognosi s .

—A lways grave. Withou t interventi on the

du ration 15 from a few months to th ree years .M M en t .—When the renal d isease appears to beprimary and the patient's strength wi l l perm it , neph rectomyshou ld be recommended . The mortal i ty in operative caseshas been abou t 28 per cent . In other cases the treatmentmust of necess ity be pal l iative .

DISEASES OF THE BLOOD AND THE

DUCTLESS GLANDS.

In health the blood amounts to about one- thirteen thof the body - we ight. Norma l ly there are approximate ly

red blood - corpusc les in th e cubic m i l l imeter .

Th is numbe r is temporari ly dim in ished du ring menstruation , gestation , lactation , and fatigue ,

and after the ingestionof much fl u id . Fasting and profuse sweating inc rease thenumber of red ce l ls by concentrating the blood . In the

first few days of l ife the n umbe r in a cubic m i l l imeter maybe to In h igh al titudes the number isal so inc reased . There are from 50 0 0 to white ce l lsin the cubic m i l l imeter

,the ratio of white to red ce l ls be ing

about 1 to 50 0 . The numbe r of blood- plates is fromto

EXAMINATION OF THE BLOOD.

A c l in ica l study of the blood has fo r its objec t the determ ination of the percentage of hemoglobin ,

the spec ificgravity ,

the alka l in ity,the numbe r

,form , and re lat ive proportion of the various corpusc les , and the detecti on of free

pigment , bac teria ,and an ima l

pa rasites .0E st imati on of Hemog bin —The percentage of

hemoglobin may be determ ined by e ither Fl e isch l’

s or

Gowers ’ apparatus , although the former is preferable .

Gown s"

Am og lM'

nomcfrr consists of 1 ) A sma l l sealedtube containing coloring-matter represent ing the color ofnorma l blood di luted with 10 0 parts of water ; (2) an empty

to 145

146 OF 51 . 0 0 0 AND o nen e ss ca nvas.

tube of the same s ize, graduated up to 1 20 per cent ; a

smal l bott le with a pipet stopper, fo r disti l led water ; a

capi l lary pipet for measu ring 20 cm. of blood ; and 5) asma l l lancet To obta in a spec imen of blood the tip of thefinger or the lobe of the car

,after be ing thorough ly c leansed,

is deeply pricked with the lancet , so that the blood flowsfree ly without squeezing ; 20 cm . of blood are then drawninto the capi l lary pipet, and are immediately blown into thegraduated tube

,in which have been previous ly placed a few

d I'OpS of disti l led water to prevent coagu lation . After

shak ing the m ixtu re to secu re diffusion of the blood , moredisti l led water is cautiously added , with occasional shak ing ,unti l the tint in the sealed tube is reached. The height ofthe column of the fluid in the graduated tube wil l indicatethe percentage of hemoglobin .

Hei st /11’

s instrument consists of a meta l stand with a ci r

cu lar apertu re in the cente r , under which is p laced a re

flector made of plaster- of- Par is . The apertu re is fitted witha smal l ce l l hav ing a glass bottom

, and divided into twoequal compartments . A graduated wedge of colored g lassis employed as a standard

,the 1 0 0 on the sca le be ing in

tended to represent the percen tage of hemoglobin in norma lblood . This wedge of glass is so arranged that whenmoved under the stand , one compartment of the ce l l wi l lrece ive white l ight from the reflector

, and the other , red

l ight from the tinted glass . A smal l capi l lary tube is he ldover a drop of blood unti l fi l led

, and is then washed in one

of the compartments of the ce l l , in which has been pre

vious ly placed some disti l led water. Both compartmentsare then equal ly fi l led with water

, and the wedge of glass ismoved by means of a thumb- screw unti l the tints in the twochambers are exact ly the same

,when the percentage of

hemoglobin may be read ofl’.In the exam ination it is necessary to use art ific ial l ight.

The 1 0 0 mark on the sca le,which is intended to represent

the percentage of hemoglobin in normal blood,is too h igh

for the average person , 85o r 90 per cent. rarely being exceeded .

Th e Specific Gravi ty of th e B lood .—The spec ific

148 DISE ASE S OF BLOOD AND DUCTLE SS GLANDS .

divided cel l . The drop in the cel l shou ld be.

free from bubbles , and the cover- glass so adj usted that concentric ringsof co lor appear at the points of contact between the coverglass and the glass plate . Before counting , a few m inutesshou ld be a l lowed for the corpusc les to settl e to the bottomof the ce l l . The number of corpusc les is then counted in40 0 smal l squares . To avoid repetition in counting, corpusc les on the upper and left boundary - l ines shou ld becounted

,but those on the lower and righf boundary - l ines

shou ld be disregarded . The number of corpusc les in eachcubic m il l imeter of blood is determ ined by mu lt iplying thenumber of corpusc les counted by the degree of di lution(20 0 ) and again by the cubic contents o f each squareand then dividing the product by the number of squarescounted Thus

,if 20 0 0 corpusc les were counted in

40 0 squares , the number of corpusc les in each cubic m i l l imeter wou ld be

20 0 0 x 20 0 x 40 0 0

After using , the mélangeu r shou ld be carefu l ly washed inwater, alcohol , and ether .

E numerati on of Wh i te mood - empuscl es.—For

counting the white blood - ce l ls a mélangeu r shou ld be usedwhich al lows a di lution in the proportion of 1 1 0 and an

aqueous per cent . so l u tion of ace tic ac id , to which maybe added a l itt le methyl - v io let

,

'shou ld be se lected as

a di l ut ing flu id . The red ce l ls disappear in th is sol ution ,

and the white ce l ls remain and are readi ly counted . The

latter shou ld be counted in 80 0 smal l squares . The num

ber of leukocytes in each c ubic m i l l imeter is then determinedby mu l tiplying the whole number counted by 40 0 0 , and

again by to,and dividing by 80 0 .

Th e Stud y of th e Wh i te Bl ood - corpuscl es.—In

si ze of the red blood - comusc les . The nuc leus is very largeand spheric, and stains intense ly with bas ic stains (methylene

E XAM INA TION OF THE 149

blue). With E hrl ich 's triacid mi xtu re the nuc leus is pale.The narrow rim of protoplasm su rrounding the nuc leus 13non- granu lar (hyal ine) . Sma l l lymphocytes constitute from25to 35per cent. of a l l leukocytes .2 . Largo Lymphocy tes—These ce l ls resemble those j ustdescribed ,

but they are considerably larger. The nuc leusis re lative ly not so large, and stains less deeply. In someform the nuc leus is more o r less bent or indented (transitional leukocytes) . Norma l ly , large lymphocytes make upfrom 5to 1 0 per cent. of the blood - corpusc les .Pol ymorphonnclear Neutroph i l es.

—These ce l ls are somewhat smal ler than la rge lymphocytes , and are active ly ame

boid. The nuc leus appears to be divided into two or moresegments and stains deeply. The protoplasm is studdedwith fine granu les , which do not stain we l l with either simplebasic stains (methylene- blue) or simple acid stains (cosin).With E hr l ich ’s triac id m ixt ure the granu les are coloredviolet and the protoplasm pa le pink . Neu trophi les makeup from 60 to 70 per cent. of the white ce l ls of normalbloodBoeinoph i l es .

—These resemble the polymorphonuc learneutrophi les

,but are more irregu lar in outl ine ,

and the

granu les are larger, more high ly refrac tive , more loose l

attached , and have a spec ia l afl‘i nity for ac id stains (eosinE osinophi les make up from 1 to 4 per cent. of the leukocytes .Hu t - cel l s (Bu ophi l ea).—These ce l ls have a lobu lated

nuc leus . The protoplasm is studded with gran u les havingan intense ly basic reaction . These granu les remain un

sta ined with E hrl ich 's triacid m ixtu re, but with methylenebl ue they stain deep blue. Mast- ce l ls are on ly occasional lyencountered in norma l blood .

In disease, additional forms are sometimes found . Thusin leukem ia large ce l ls are found which are non - ameboidand which have a single round o r oval nuc leus imbedded inprotoplasm contain ing neutroph i l ic granu les . These havebeen termed my elocy tes.With the aid of a one- twe lfth inch oi l - immersion lenslarge and smal l leukocytes can readi ly be d istingu ished inpreparations of fresh blood

,but to study sati sfactori ly the

150 or swoon AND o uen s ss ca nvas .

various forms i t is necessary to dry and then stain the spec imen .

The Drying and Stain ing of Bl ood .—A smal l d rop

the finger, is spread into a

11 two perfec t ly c lean coverapart and exposed to the ai r

ses shou ld be handled with forhe fingers distorts the corpusc les .

is fi rst fixed by heating on a copperone- half to one hour at a temperature of from

7 .—Blood in l ienomed u l lary leu kem ia, showi ng several mononuc lear(myelocytes ) . one po l ymorph onuelear neu troph i le, and an eosiwlea i r d red corpusc le and a lymphocyte are seen in the lowe r partion S tained wi th Eh rhch

'

s triple mi xtu re (from S tenge l ‘s Tex tsm Paw zaw .

1 0 0° to 1 1 0

° C o r by immersing fo r from five to fifteenminutes in a mixtu re of equal parts of absolute alcohol and

A conven ient method of stain ing is the one suggested byStenge l . The fixed preparation is imme rsed for a few

minutes in a 1 per cent. sol ut ion of eosin in 60 per cent .alcohol , to wh ich has been added an equal quanti ty of

water at the time of stain ing . The cover- glass is thenwashed in water and counterstained in De lafield

'

s hematox y l in for a m inute, and final ly washed , dried , and mounted .

The eosinophile granu les are dark red,the red corpusc les

152 DISEASES OF BLOOD AND D UCTLE SS GLANDS .

parts . I t is observed temporari ly 1n the newborn , in re

covery from certa in anem ias , after transfusion of blood , andin blood concentrated by excessive discharges . Markedpolycythem ia 13 sometimes produced by residence in highal ti tudes and by certa in poisons , such as phosphorus and

carbon monoxid .

M icrocytosis and mac rocytosis are condit ions in whichthe red ce l ls are respective ly dim inished and inc reased insize . They may occur in any form of severe anemia,

but

they are espec ial ly marked in pern ic ious anem ia.

Poiki locytosis , a condition in whi ch the red ce l ls are

irregu lar in shape ,15 common in grave anem ias, especial ly

pern icious anem ia.

N uc leated red ce l ls (eryth roblasts) are divided into threeforms—no rmob lasts , macroblasts , and m ic roblas ts . The

first resemble in size and color a normal red ce l l , the sec

ond are larger, and the third sma l ler. Nuc leated red ce l lsare not found normal ly m the c ircu lating blood

,they are

present, however , in grave forms of anem ia.

Leukocytosis , or hyper leukocytosis , is an increase in thenumbe r of white ce l ls

, espec ia l ly of the polymorphonuc learforms , in the peripheral blood . I t occu rsin the new- born , during digestion , in pregnancy , partu ri tion ,

and after heavy exertion,cold bath ing , and massage .

Fal kobg zk Im boqrtosrlr is obse rved in the fol lowing con

d itions : (1 ) Inflammat ion . There 1s an absolute 1ncrease in

the polymorphonuc lear neutrophi les . (2) Infectious diseases .Mos t infec tions exc ite leukocytosis

,but the condition is

usual ly wanting in typhoid fever,malaria, meas les , influen za ,

and m il iary tubercu losis . In any infection m which the tox

E OSJ NOPHILIA 0 1. [ 6 0 0 mOME N /A. 153

em ia is 1ntense or the resistance of the individual is sl ight,

leukocytosis may be wanting. (3) Mal ignant d isease ,when

sufl‘i c ient ly extensive. (4) Afte r hemorrhage . 5) After theadm in istration of certa in drugs

,such as pi locarpin

,an ti

pyrin , sal icylates, ergotin, and tube rcu l in . (6 ) In certainautoi ntoxica tions, such as gout and u rem ia.

A re lative or absolute increas e of the eosinophi les occursin certain diseases caused by animal parasites

,such as

trichiniasis , filarias is , and ankylostom iasis ; in bronchialasthma,

in osteoma lac ia, and in ce rta in sk in diseases , notably

in pemphigus , ec zema, psoriasis , a nd dermatit is herpetiform is .

Leukopenia,or hy po leukocy tos is , is the name appl ied to

a defic iency in th e numbe r of leu kocytes . I t occu rs incertain infections , particu larly in those that do not produceleukocytosis , such as typhoid fever, malaria, and m i l iarytubercu losis ; also in pern ic ious anem ia and inan ition .

Lipem ia, the prese nce in the blood of m inute fat - globu les ,may be noted in heal th . Abnormal quantities of fat maybe found in the blood in diabetes , chron ic nephri tis , alcoholism

,and pu lmonary tubercu losis .

The fol lowing parasites have been detected in the bloodFi laria sanguin is hom in is , hematozoan of malaria, spi ri l lumo f relapsing fever , pneumococc us , bacil lus ofanthrax , typhoidfever, tetanus, tubercu losi s , influenza ,

leprosy , gla nders,bubonic plague,

mal ignant edema,and diphtheria ; the strep

tococcus , staphylococcus , men ingococcus , gonococcus , trypanosoma,

and colon baci l lus .

Oligochromem ia ,or deficiency of hemog lobin , is usual ly

proportionate to the reduction in the number of red cfi

154 or 31. 0 0 0 AND o nen e ss GLANDS .

but there are two exceptions , name ly , in ch lorosis,in which

disease the red ce l ls may be reduced on ly 20 or 30 per

cen t , whil e the hemoglobin may be reduced 50 or 60 per

cent , and in pernic ious anem ia,in which di sease the blood

count is very low,whi le the corpusc les are re lative ly rich 1n

hemoglobin .

The color - i ndex represents the re lation between the num

ber of ce l ls and the quant i ty of hemoglobin. In a patienthaving red ce l ls per cubic m i l l imeter (50 per cent .)and 40 pe r cent. of hemoglobin , the color- index wou ld be1 9

50= o &

Oligocythem ia,a dim inu tion in the number of red ce l ls

,

occu rs in al l forms of anem ia,but it is espec ial ly marked in

pern icious anem ia and in advanced mal ignant disease,where

the number may fa l l be low in a c ubic m i l l imeter.

Defin i ti on .—A deterioration of the blood , with al tered

re lati ons of the flu id and sol id parts (Sten c l) .Vari et i es Secondary anem ia , (2 primary anem ia.

Symptoms .—Any forms of anem ia may present the fo llowing symptoms : Pa l lor of the sk in and mucous mem

branes,loss of strength , and ,

in severe cases , febri le paroxsms .yCirculafion.

—A fu l l , rapid pu lse , unnatu ral pu lsation of

the cervical vesse ls , palpitation of the heart , a hem ic mu r

mu r , a hum ove r the jugu lar ve in ,and sl ight dropsy , be

ginn ing in the feet . In severe forms there may be cechymoses and bleeding from m ucous membranes .m m .

—Hu rr ied breath ing.

Digest ion—Dyspepsia.

Nervous Sy stem—Headache, vertigo, disturbed sleep ,neu ralgi c pains , and tendency to syncope.

156 0 13154 5155 or AND Dvc ru sss OLA/VHS .

corpusc les , and a dec rease in the number of the po lymor

phonuc lear neutroph i les .E tiol ogy .

—In many cases no adequate cause is apparent. The disease usual ly appears abou t m iddle l ife ,

and issomewha t more frequent in males than in females. Formsof anem ia c l in ica l ly identica l with pe rn icious anem ia mayresu lt from the action of intestinal parasites , espec ial ly theBo th ri ocephal us latus and the Anky lostomum duodenale.

The mos t plaus ible theory is that the disease is due to thehemolytic ac tion o f some poison absorbed from the gastrointestina l trac t .Path ol ogy —The skin has a lemon - ye l low hue , the sub

cu taneous fat is often we l l preserved , and the musc les areunu sual ly red . The organs are pigmented and fatty . I ron

espec ial ly abundant in the o u ter zones of the

u les . Marked atrophy of the gastric mucosa issometimes observed . The bone - marrow is dark red

,soft

,

and contains large numbers of nuc leated red ce l ls,espec ial ly

macroblasts . The hemolymph glands are frequently eh

larged , congested , and pigmented. The spleen is sometimes en larged . In many cases there is found advancedsc lerosis of the posterior and latera l columns of the spinal

Symptoms —The general symptoms are intense anem ia,

with its usual man ifestations ; a lemon- ye l low tint to theskin ; progressive weakness , without marked emac iation ;moderate , i rregu lar fever ; seve re gastric i rri tabi l ity ; and

sometimes dark - colored u rine from the presence of u robi l in .

77a Blood—The drop is pale and watery . Coagu lationis s low . There is a great reduct ion in the number of red

ce l ls,often to or less ; the hemoglobin is a lso re

duced ,but not proportionate ly. The red ce l ls usual ly show

decided changes both in size and in shape . N uc leated red

ce lls are more or less abundant. As a ru le , the large forms(megaloblasts) predom inate . There is no leukocytosis . The

neutrophi les are often decreased in number, and the lymphocytes relat ive ly increased.D iagnosi s .

—The parasitic form may be recogn ized bythe discovery of the paras ites or their ova in the stoo ls .

CHL0 190513.

'

157

Cancer rarely produces such extreme ol igocythem ia,the

color- index is not high,macroblasts are rare ly present, and

there is often leukocytosis .M M —Pernic ious anem ia usua l ly ends fatal lywith in one or two years . I t is doubtfu l whether recoveryever occu rs except in the parasitic forms . Periods of

marked improvement are not uncommon .

Treatmen t —Fresh air, rest , and a diet as l ibera l as thedigestive power o f the patient wi l l perm i t are requ isite .

Warm sa lt baths and massage are val uable adj uvants toin ternal treatment. The teeth shou ld receive carefu l attention. If there be gingivitis or py orrhaza alveolaris , ant isepticmou th - washes shou ld be used at frequent intervals .Arsen ic is the most val uable drug. I t may be given in

the forn . of Fowler's solution , the dose be ing gradual lyincreased from 2 or 3 to 15or 20 minims th ree timesa day . I ron is rare ly of servi ce. Bone - marrow is somet imes efli cac ious. Inhalations of oxygen have been recom

mended (Shattuck) . Appropriate anthe lm intic remediesshou ld be given ,

of cou rse , in the cases in which intestina lparas ites are present . D igestive distu rbances are oftenbenefited by the adm inistration of di l uted hydrochloric ac idand a bitter

(Green Sickness ; Primal-

y u m . )

Defin i tion —A form of anem ia occu rring exc lusively inyoun women and characte rized by marked oligochromem ia

ol ogy .—The disease u sual ly occu rs between the

fifteenth and twenty - fifth years . Heredity , bad hygien icsu rroundings , and overwork are predisposing factors . The

rea l cause of the disease has no t bee n determ ined .

Path ol ogy —ui some fata l cases imperfec t developmentof the vascu lar and generative systems has been obse rved .

Symm - In addition to the general symptoms of

anem ia the conspicuous featu res are a greenish hue of the

sk in pa l lor and weakness without marked loss of flesh per

versions of appetite (pica) ; menst rual disorders ; and a ten

deney to hysteri c outbreaks. The blood ( hang-

rs are char

158 D I SE ASE S or BL OOD AND D UCTLE SS GLAND S.

acteristic . The number of red ce l ls is moderate ly reduced(not often be low the hemoglobin , on the otherhand

,is great ly reduced—usual ly to be low 50 per cent.

There is no leukocytosis .Comp l i cati ons.

—Gastroptosis , peptic u lcer, gastralgia,amenorrhea

,and

,occas iona l ly , thrombosis of the cerebra l

s inuses or veins of the extrem ities .Prognos i s

—The prognos is is good , but re lapses arecommon.

Treatmen t —Fresh ai r, sun l ight, open- ai r exerc ise , and

nourishing food are valuable a ids in treatment. Very severecases requ ire complete rest in bed . If there be a good reac

tion,warm baths

,fol lowed by short cold douches , are ethea

c ions . I ron is almost a spec ific . I t is most frequent ly prescribed in the form of Blaud 's pi l ls , of which the dose isthree pi l ls

,gradual ly inc reased to n ine ,

3 day .

3. Massa ferri carbonat is

Potassii

Potassi i

Acac ia:

Al thu u q. s.—M.

P unt‘

l ulm No . 11 11 11 .

S tc . e pil ls dai ly, increased to n ine pi l ls dai ly . (ENGLAND . )

Laxatives , prefe rably m i ld sal ines , rank next in importance to i ron . Arsen ic is d istinct ly less val uable thani ron . Superacidity of the gastric j u ice is best treated byalkal is.

Defini ti on —A disease characteri zed by a persistent inc rease in the number of white blood - corpusc les and bypathologic changes in the bone- marrow

,spleen

, and lymphafic lands

Ol ogy .—The causes are obsc u re. More males are

aflected than fema les . The d isease occu rs most frequent lyin m iddle l ife . He redity ,

malaria, syphi l is , pregnancy , and

traumatism are given as predisposing factors . An infec tiousorigin has been suggested .

1 60 DISEASES OF BLOOD AND D UCTLE SS GLANDS .

D iagnosi s.—Lenkocy toais .

—In this condition the whi tece l ls are not so enormously increased and are chiefly polymorphonuc lea r neu trophi les .Malaria] 0achex ia.

—This may be recogn ized by the discovery of the parasites and by the absence of leukocytosis .Progn0 8 i 8 .

—Absolute ly unfavorable. The average duration of the ch ron ic form is from two to th ree years . Acuteleukem ia may prove fata l with in a few weeks .Treatmen t —An effort shou ld be made to maintain the

regu lating the diet and attending tou res . Rest is often advisable . Among drugs ,

arsemc appears to be of some se rvice. Ope rative treatment15 of no avai l .

Defini tion —A rare disease characterized by hyperplas ia of the lymphatic glands and progressive anem ia,

withou t a marked excess of white corpusc les.E ti ol og y .

—The causes are unknown . I t is most commou ly seen in young adu l ts of the male sex . In some lnstances it has apparent ly fol lowed an ordinary adeni tis . An

infectious origin has been suggested .

Path ol ogy .—There is a marked hyperplasia of the lymphatic glands ,—cervica l

,axi l lary , mediastinal , inguinal , and

retroperitoneal ,—thc spleen and bone- marrow often sharingin the process .Symptoms —The disease resembles lymphatic leukem ia ,

bu t there is an absence of leukocytosis . The glands of theneck are u sual ly fi rst affected ; the swel l ings are pain less ,free ly movable ,

and on ly very rare ly suppu rate.

D iag nosi s .—Tube rcu lou s aden itis is more apt to afl

'

ect

the submaxi l lary glands , and is often un i latera l . Fusion of

the glands and suppuration are common . The tuberc u l inreac tion may be obtained , and section of an exc ised g landshows tubercu lous e lements .Prognosi s .

—Unfavorable . The average du ration isfrom two to th ree years . Treatment is that of leukemia.

ADDISON 'S 0 155455. 1 6 1

Senn has recent ly reported marked improvement in 2 casesfrom the use of the x - rays .

SPLENIC ANEMIA.

Splen ic anem ia is a chron ic affection characterized by anenormous en largement of the spleen ,

moderate o l igocythemia (ave rage count 0 0 0 ) dec ided ol igochromem ia(average 45to 50 per cent”) leukopen ia , and a marked tendeney to hemorrhage ,

espec ia l ly from the stomach . In the

term inal stage there may be ,in addit ion , asc ites , jaundice,

and c irrhosis of the l iver (Bann '

.r di sease) . Splen ic anemiau sual ly lasts for many years. In 7 of 1 8 cases studied byOsler the duration of the disease was more than ten years,and in 1 1 more than fou r years . Of 19 cases of splen icanemia treated by Splenectomy , in 14 recovery fol lowed(Harr is and Herzog) .

Defini tion —A rare disease characteri zed anatomica l lyby lesions of the suprarenal glands or of the abdom inalsympathe tic gangl ia , and c l inica l ly by bronzing of the sk ind profound asthen ia.

E t iol ogy .—It occu rs most frequen tly i n m idd le l ife

, and

is more common in men than ln women . The deve lopmentof Addison ’s disease is favored by the predisposing causesof tubercu losis .

Pathol ogy—In most instances tubercu los is of the

suprarenal bodies is d iscovered . Rare ly other les ions of

the suprarenal bodies , such as carcinoma, have been found .

In a few cases there have been found degenerative changesin the abdom inal sympathetic gangl ia, e ither in connect ionwith

,or in the absence of

,di sease of the suprarenal bodies .

Sy ntptoms .—The chief featu res are moderate anem ia,

bron zing of the skin ,pigmentat ion of the mucous mem

branes , espec ia l ly of the mouth , extreme weakness , and

marked gastric irri tabi l ity .

Prognosis .—The disease is fata l . The average du ration

is from one to three years .1 !

1 64 DISEASES OF BL OOD AND D UCTLE SS GLANDS .

E ti ol ogy .—The disease is much more frequen t in women

than in men . I t is occas ional ly hereditary . I t usual lydeve lops in m idd le l ife. The immediate cause is the loss offunc tion of the thyroid gland .

A congeni tal form of myxedema is observed in eretx'

mlvm,

and an analogous condition (operative my x edema o r ( ac/remstrumpr iva) frequent ly fol lows total extirpation of the thyroid gland .

Symptoms .—It is man ife sted by a gradual swe l l ing of

the subc utaneous tissues , particu larly of the face , suprac lavicu lar regions

, and hands . Un l ike edema,the parts

do not pit on press u re , but are fi rm and e lastic . The

skin is d ry and harsh . The hair is dry and bri tt le . The

thyroid gland is atrophied . A pec u l iar s lowness in thou ht ,speech,and movements is a characteri stic symptom . he

temperatu re of the body is subnormal . There is impairment of the spec ia l senses. Sensory phenomena are com

mon , such as coldness,numbness

,and tingl ing. The u rine

is often inc reased in quant ity, and occasional ly contains al

bumin,sugar

,and tube - casts .

Sequel s.—Tube rcu losis , dementia, and,

occas ional lv

exophthalmic goiter.

Diagnos is.—The menta l du lness

,the extreme d ryness of

the sk in,and the absence of pitting on pressu re wi l l serve

to distingu ish myxedema from Br ight ’s disease with edema.

Prognosi s —The disease was formerly considered ineurable,

but it is now known that marked ame l iorat ion or evena cu re can be effec ted by appropriate treatment.Treatment —As patients with myxedema are extreme lysusceptible to low temperat u res , they shou ld be warm ly c ladand protected from exposu re to cold. Residence du ring thewinter in a warm ,

sunny c l imate is des irable . Warm bathsare often benefic ial . Modern treatment cons ists in the adm inistration of extract of sheep's thyroid (3to 5grains th ri cedai ly) . By continuing this remedy th roughou t l ife i t is possible in many cases to hold the symptoms in complete

DISEASESOFTHE C IRCULATORYSYSTEM.

INSPECTION .

INSPECTION determ ines the position ,force

, and extent ofthe apex - beat ; any abnormal centers of pulsation ; and anyunnatu ra l prom inence over the precordia l region.

Th e Apex beat .—The normal pos ition of the apexbeat is in the fifth intercosta l space, abou t an inch withinthe mammary l ine (a l ine drawn from the m iddle of the

c lavic le para l le l with the stern um) The beat can usual ly bedetected by inspection or pa lpation

,but when these meth

ods fai l,it may be loca l ized by ausc u ltation ,

the point in theregion of the apex where the fi rst sound 1s heard with maximum intensity corresponding to the beat.Tire Ej ect of Resp1

° °

raaoee and Position 0 11 the Apex - brat

The location and force of the apex - beat are modified bythe posture of the patient and the stage of the respiratoryact. In the recumbent position the apex - beat may be e le

vated half an inch or more , and ,when the body is inc l ined

to the left,the heart being a more o r less movable organ ,

the beat may be detec ted in the mammary l ine ,or even

some distance to i ts outer side .

Du ring forced inspiration the beat may become imperceptib le ,

or,if such is not th e case ,

i t may be found somedistance be low its usua l place,on account of the upward

movemen t of the ribs in the inspi ratory act. Du ring forcedexpiration the air , be ing driven from the lung- tissue in frontof the heart , the beat becomes more forc ible ,

and its position e levated on account of the descent of the ribs whichocc u rs in expiration .

In view of the influence exerted by respiration and position on the apex - beat the patient

,as a ru le , shou ld be ex

166

1 66 0 1554 3153 OF 7715 cmcuza roe 1°

3 i s

am ined in the erect or sitting posture,whi le breath ing

qu iet ly.

D isplacement of the Apex - beat .—D ispl acement toMe left may resu lt from

1 . Hypertrophy o r di latation of the heart (down and tothe left).2. Pericardial effusion

(up and to the left).

3. Chron ic diseases 0 the left l ung and pleu ra, associated with retract ion—as fibroid phth isis and pleu ral adhe310 115.

4 . Abdom inal tumors and effu s ions (up and to the lefl ) .5. The pressu re of a pleu ral effusion on the right side (up

and to the left) .Displ acement to the r ight may be caused by1 . Chron ic disease of the right l ung or pleu ra assoc iatedwith retraction.

2 . Pressu re of a pleu ral effusion on the left side.

3. Transposi tion of the viscera .

Di rp/aeemem dou vm 'ard may resu l t from :

1 . Hypertrophy or dilatat ion of the heart , chiefly of the

left ventric le .

2 . Pressu re of sol id growths in the upper mediastinum .

3. Aneu rysm of the aortic arch .

Deform ity of the chest from spina l cu rvatu re may alsocause considerable displacement of the heart .

Changes in Force and E x tent of th e Apex - beat .Thef orce and ex tent of [he pu lsation may be iuereared by1 . Hypertrophy of the heart .2 . Forc ible action of the heart caused by emotional o rphysica l exc itement , reflex i rritation ,

drugs ,Graves '

s disease ,

CIC .

3. Thinn ing of the chest- wal ls and sh rinking of the lungs ,as in phthisis .A weak apex

- beat may be noted :1 . In hea lth .

2 . Degeneration o r di latation of the heart .3. Pericardial effusion .

4. E mphysema.

5. Col lapse or shock .

1 68 DISEASES or THE CIRCULAm a y S 1'e ”.

1 . Hypertrophy of the heart.2 . D i latation of the heart.3. Pericardia l effusion.

This not on ly determines the pos ition,force

,extent, and

rhythm of the apex - beat,but also detects the ex is tence of

any frem itus or thri l l.A thril l is a vibratory sensation l ikened to that rece ivedwhen the hand is placed on the back of a pu rring cat .

Thri l ls at th e base of the heart may resu lt from aort ic stenos is

,atheroma of the aorta, aneu rysm ,

and from roughenedpe ricardia l su rfaces , as in pericarditis .A presystol ic thri l l at the apex is a lmos t pathognomonic

of m itra l s tenos is .PERCIM ON .

This determ ines the shape and extent of the cardiac du lness .The norma l area of supwj feia l or aosol ute percussion

- dul

11eSS (the part uncovered by lung) IS detected by l ight pe rcuss ion

,and extends from the fo u rth left costostemal j unc

tion to the apex- beat ; from the apex - beat to the j unctionof the xiphoid carti lage with the sternum ,

and thence up theleft border of the sternum .

The normal area (I deep percussion - du l ness (the heart projected on the chest- wal l) is detected by fi rm percussion ,

and

extends from the third left costostemal art icu lation to theapex - beat ; from the apex - beat to the j unction of the xiphoidcarti lage with the sternum , and thence up the right borderof the sternum to the th ird rib . The lower leve l of thecardiac du lness fuses with the l iver du lness , and can rare lybe determ ined by percussion .

The area of eara'

iae is inc reased in : (1 ) Hypertrophy and di latation of the heart . (2) Pericardial effusion .

I t 13 apparently increased in sh rinking of the l ungs , as inphthisis .

area o/ eardiae dul ness is d im in ished 1n : (1 ) Emphysema. (2) Pneumothorax . (3) PneumOpericard ium (rare) .(4) Gaseous disten tion of the stomach.

AUSCULTA TIOtV. 1 69

This determ ines the qual ity,intensi ty , and rhythm of the

heart - sounds , and detec ts the presence of any adven ti tioussounds , as mu rmurs . The two sounds heard over the hearthave been represented by the sy l lables , l ubb, tup.

"

The

fi rst sound (sy stol i c) resu lts from the muscu lar contraction of

the heart and the c losu re of the au ricu loventricu lar valves ,and is synchronous with the apex - beat and carotid pu lse.

This sound is prolonged and du l l . After the first soundthere is a short pause , and then fol lows the second sound(diastol ic), which resu lts from the c los u re of the aortic and

pu lmonary va lves . This sound is short and h igh -

p itched.

After the second sound a longer pause fol lows before the

first is aga in heard .

The In tensi ty of th e Heart - sounda—Botu sound s

are accentuated in : (1 ) E xc itement of the heart from anycau se. (2) Anem ia. (3) Cardiac hype rtrophy . (4) S ub

jects with thin chest - wal ls . (S) Consolidation of the lung ,as in phth isis and pneumon ia.

Accentuation of the aor tic second sound resu lts from : 1 )Hypertrophy of the left ventric le. (2) High arte r ia l tension ,

as in chron ic interstitial neph ritis with arteriosc lerosis. (3)Aortic aneu rysm.

Weakening of tire aor tic second sound ind icates weaknes sof the left ventric le.

Accentuation of tlre pulmonary second sound resu l ts from(1 ) Pu lmonary obstruct ion ,

as in emphysema, pneumon ia.

and the congest ion of the lungs fo l lowing m i tral disease.

(2 ) Hypertrophy of the right ventric le.

Weakness of Ike pulmonary sound indicates fai lure of the

right ventric le , and ,occu rring in diseases in which it shou ld

be accen tuated , is of grave omen .

Weakness of the mitral sou nd is noted in : f 1 ) Generalobesi ty. (2) General exhaustion. (3) Degeneration or

di latation of the heart . (4) Pericardia l o r pleu ra l effus ion .

(5) Emphysema.

Al teration in th e Rh y thm of th e Heart - sounds.

Rcduphcatfon 1] the Diastol ic Shanda—This is probably

170 355 or THE CIRCULA TOR y s i sTE M.

due to a lack of synchron ism in the c losu re of the aorticand pu lmonary valves . I t is frequently noted in hea l th atthe end of a long inspirati on. Patho logic reduplicationmay occu r whenever the pressu re in either the pu lmonaryc ircu lation o r the peripheral arteries is abnormal ly inc reased .

I t ts a common sign in m itra l stenos is , emphysema,arterio

sc leros is, and pericardi tis .Emory/warm .

—This term is used to indicate a rhythmthat resembles that of the feta l heart. The pau ses betweenthe sounds are of equal length , and the two sounds are

exact ly al ike. Embryocardia indicates great enfeeblementof the heart and may be observed in low fevers and in car

diac fai lu re from any cause .

Gal lop or —This suggests the hoof- beatsof a gal loping horse . One of the cardiac sounds is doubledand the diastol ic pause is shortened . I t indicates extremeweakness of the heart .Adven ti ti ous Sounds —Murmu rs are abnormal soundsproduced in the heart or blood - vesse ls . They may resu ltfrom : (I ) Obstruction or regu rgitation at the va lves in con

sequence of va lvu lar endocarditis . (2) D i latation of the

ventr ic le o r re laxation of its wa l ls , in consequence of whichthe au ricu loventricu lar valves become re lati ve ly insuffic ient.(3) Roughen ing of the valves or of the int ima of the greatvesse ls . (4) Aneu rysm (bru it) . (5) Anem ia (hem ic mu rmu r) .E x ocardzal murmurs are advent itious sounds of cardiacorigin produced in the pericardium (pericard ial frictionsound) or in the pleu ra or l ung

,adjacent to the heart

(ple t

im pericard ial friction- sound and cardiorespiratory mur

mur

Pericardial Pd ct ion -aonnd .—This is an adventitious sound

produced in pericarditis by roughen ing of the serous mem

brane. I t is a harsh , grating , to- and - fro sound . quite superficia l

,often intens ified by pressure with the stethoscope, and

genera l ly heard best in the fou rt h interspace near the sternum. I t often varies in intensity from hou r to hou r, and israre ly transm itted beyond the precordial region .

Pl enmpericardh l Pricfion-mM —This is a sound c lose lyresembling the pericardial friction - sound , but produced by

THE PULSE . t73

occasional . There is often marked irregu lari ty in uncom

pensated m itral regurgitation and ch ron ic myocardial disease . E xtreme i rregu larity with rapidi ty of the heart - beatsis spoken of as del ir ium cord is . I t occu rs in the late stagesof uncompensated heart disease .

The Pulsus Pen da nts—This is a pu l se in which the wave

Ftc . 8 .4 phygmogram o f the trigem inal pu lse .

becomes smal l and feeble du ri ng fu l l inspiration . I t issometimes observed in hea l thy persons . It is not infrequentin adherent pericardium .

The Dietetic Pulse.—Thi s is a pulse in which the main beat

is qu ickly fol lowed by a secondary wave or sl ight rebound ofthe vessel . It is especial ly apt to occu r when the tension islow and the arte ries are re laxed , as in low fevers . l ike typhoid .

Oth er Var iat i on s in th e Pu l se —The High - tension

Pul se .—This is a pulse in which the force of the beat is

re lative ly increased . The tension may be roughly estimatedby noting the amount of pressu re of the fingers that is re

Ftc . 9 .—S ph ygmogn m of a d iero tie pu lse .

qu ired to arrest the beat . It may be determined more accu

rate ly by means of the sphygmograph .

A l ug/t tension is observed in many condi tions , notably incardiac hypertrophy ; in ch ron ic neph ritis , espec ial ly interstitia l neph ri ti s ; in arteri osc lerosis ; in certain intoxications ,l ike gou t, ch ron ic lead -

poisoning , and u rem ia ; in cerebralaffections irritating the vasomotor cen ters , such as apoplexy

174 D I SE ASE S OF THE CIRCULA TOR Y S YS TE M .

and tumor ; and in contrac tion of the arterioles , as in chi l lsand in some paroxysms of angina pec tori s .The Low- tension Pul se.

—A low- tension pu lse is one thatis soft and compressible . It is observed in many condi tions

,

notably in marked cardiac degeneration,in col lapse ,

in lowfevers , and in states of great exhaustion and depression .

pu lsation occurs in tricuspidin the dorsum of the handi t of the blood through the

ompensatcd aort ic regurgi tation,or to ex

ation of the arterioles , pe rm i tting the transm ispu lse - wave , as in grave anem ia.

Pul se—This may be detected by the occ urrenceflush ing in a hyperem ic area of the skin (preferd ) caused by friction ,

or in the evertedsomewhat blanched by pressu re of a

l lafy pu lse is occasional ly observed inin grave anem ia, and in neu rasthenia.

Asymmeh'lc radial pu l ses may resu lt from (t ) Anomal ies

in the di s tribu tion ,size ,

o r div is ion of one of the vesse ls .(3) An embolus or an atheromatous(4) Fractures , l u x ations , o r inflamma

tory exudations causing compression of the vesse l . 5) Compression of one vesse l by tumors with in o r withou t the thorax .

“ Water - hammer Pulse (Garri son'

s Pul se).—This pu lse ischaracteri zed by a qu ick , powerfu l beat , which sudden ly

des . The pecu l iar pu lsation may be dist on ly in the carotids , but th roughout theThis pu lse is d iagnostic of aort ic regu rgitatie n du ring the period of compensation ,

and its force is dueto the excessive ventricu lar hy pe rtmphy and to the largeamount of blood expe l led with each systo le ; its sudden re

cession is due to the incompeten t valves fai l ing to supportthe col umn of blood in the aorta.

Defin i ti on —A rapid and tumu ltuous action of the heartperceptible to the patient . Rapidity not perceptible to thepaduat is not termed pa lpi tation.

r76 0 1354 353 or m s: CIRCULA TOR r s ysw as.

D ISEASES OF THE PERI CARD IUM.

Defini t ion — Inflammation of the pericardium.

E t iol ogy I t is usua l ly secondary to infectious diseases , such as rheumatism , chorea,

the spec ific fevers , sept icem ia, and tubercu losis . (2) I t may resu lt from the extension of inflammation from the pleu ra, lung , esophagus , orthe heart itse lf. (3) I t may be due to traumatism . I t occas ional ly occurs in Bright ’s disease. The organ isms mostcommonly found in the exudate are the streptococci , staphylococc i , pneumococc i , and tuberc le baci l l i .Pathol og y .

—In the early s tages the membrane is red ,

sticky,and luster less . An exudate is soon formed , which

may be serofibrinous ,fibrinous , or puru lent

In the seroflbr inous form there is but l i tt le inflammatorylymph , the exudate being composed main ly of straw - coloredfluid (from a few ounces to two pints or more) , which infavorable cases is gradual ly absorbed .

In the 11m form serum is scant. The membrane iscovered with a butter- l ike exudate

,which subsequent ly or

ganizes into fibrous tissue and un ites more o r less firm ly thepericardial su rfaces . In some cases the deve lopment offibrous pericardi tis is insidious and unattended by any acutesymptoms . The adhes ions ofl

'

er resistance to the ventricu

lar contractions , and u ltimate ly induce hypert rophy and dilatation of the heart.In the purulm t form the sac may contain from a few ouncesto two or three pints of pus. Death usual ly resu lts

,but

evacuation of the pus is occasional ly fol lowed by un ion of

the pericardia l su rfaces and s low recovery.

In al l forms of pericarditis the myocardi um is more o r

less involved .

Symptoms of Serofibr i nous Per icard i ti s —Thech ief symptoms are moderate fever, precordial pa in, pal

pitation , dry cough , and dyspnea. The pu lse is at firstrapid and forc ible ; later, weak and irregu lar.

M eal Siam—The on ly typica l s ign of the fi rst stage

P E RI CA£0 1 773. r77

(dry pericarditis ) is a rough , to—and - fro friction rub , usual lyheard best at the fou rth left intercosta l space, and not transm itted beyond the precordium . Pericardial effusion is man ifested by several defin i te signs.Inspection—The precordium may bu lge, espec ial ly in chi ldren .

Pa lpatiom—A friction frem i tus is occasional ly fe lt . The

apex - beat is feeble or lost. A pu l sation is sometimes fe l t inthe fou rth interspace to the left of the mammary l ine .

Percussion .

—There is a large pyram ida l area of du lness,

with the apex di rected upward A triangu lar area of dulness in the fifth right interspace or cardiohepatic angle(Rotch '5 sign) rs a trustworthy sign . A du l l area i s sometimes detected posteriorly tn th e left infrascapu lar region .

Am en/tation .

—The heart - sounds are indistinct and muffled .

They are often disproportionately feeble compared wi th thestrength of the pu lse.

Purul ent Pa k is tanis—The symptoms are those of serofibrinous pericarditis pl us those of sepsis—irregu lar fever,chil ls , sweats , pal lor ,and marked leukocytosi s . Occas ional lythe precordia l tissues are edematous . I t may be necessaryto aspi rate in doubtfu l cases .Adherent Per iou dium.

—The diagnosis cannot always bemade du ring l ife . The fol lowing signs are suggestive :(t ) Enlargement of the heart , especial ly of the right ventriele ; (2) systol ic retraction in the region of the apex andposteriorly in the region of the eleven th and twe lfth ribs(Broadbent 's sign) ; (3) col lapse of the cervica l veins duringdiastole ; (4) fixation of the apex - beat , so that it does not

move with resp iration or change in postu re ; (5) the pulsusparadoxus (see p. t73) With these s igns there are oftensymptoms of heart - fai l u re—dyspnea, cyanosis , edema, and

hepatic en largement .M om - Acute Endom dit is.

—The endocardia l mu r

mur is soft , not harsh ; i t is systol ic or diastol ic , not to andfro ; it is more distant ; it is heard loudest at a valve - point ,not at theb ase of the heart ; i t is not confined to the precordium,

and is not fol lowed by signs of effusion.

Cardiac hypertrophy develops slowly ; the impulse is powI8

178 19 15154 555 or 7715 cm cvu r os y 5mm ”.

erfu l , the apex - beat is displaced downward , and the sounds

Oarfi ac Dilatation—In this condi tion the area of du lnessis not pyram ida l in shape ; the en largement is chiefly downward and does not extend beyond the apex - impu lse , as in

effusion ; the impu l se is usual ly visible and undu latory ; thel ine ofdemarcation between flatness and pu lmonary resonanceis not so abrupt as in effusion ; and the sounds are usual lyc lear and sharp .

Prognosi s —In the d ry and serofibrinous forms theprognosis is good unde r favorable conditions . In the pu rulent form the outlook is extreme ly grave. The fibri nous

form , though not immediate ly fatal , is very serious on ac

count of the secondary changes that it induces in the cardiacmusc le .

Treatment —Absolu te rest is imperative . Mi lk is themost su itable diet. Loca l ly , an ice - bag is serviceable .

Leeching is beneficial in robust subjects . Bl isters are u sefu lwhen there is great pain. Opium is often necessary to secu rerest and to al lay pain. If heart - fai lu re occurs , such stimu

lants as whisky,strychnin

,digital is

,and caffein must be

employed .

Prn'

m ra’

ial E]usion .

—When the efi'

usion is serous, ab

sorption may be aided by the app l ication of smal l bl isters,

by the adm inis tration of diuretics ,—infusion of digita l is

,

and by the adm inistration of sa l ine purges . Potassium iodidis of doubtfu l efficacy . D iaphore tics

,particu larly pi locarpin ,

shou ld not be used . When pressu re symptoms becomeu rgen t or the effusion does not yield after a thorough trialto the measu res just mentioned , paracentesis shou ld be performed. The most su itable si te for the punc tu re is in theleft fifth intercostal space , abou t an inch or an inch and a

half from the edge of the sternum .

l n per icardi ti s wi th pu ru lent effu sion the indications are toind se the sac and to afford the freest possible ou tlet for thepus . The mortal ity of incision is abou t 60 per cent . In

adherent pericardium the t reatment is that of di latation.

1 80 D ISE ASE S or THE CIRCULA ros y S YS TE MThe u lcerative type is prone to deve lop on valves al ready

the seat of chronic inflammation , but i t may be primary . I tgeneral ly fol lows septicem ia , pneumon ia, pneumococcusmen ingi tis , gonorrhea ,

or one of the specific fevers . I t isvery rarely due to rheumatism or chorea. The m icroorgan isms most frequently detected in the lesions are the

staphylococcus , streptococc us , and the pneumococcus .Chronic endocard itis may be congeni tal , may fol low an

acute attack , or may resu lt direc tly from chron ic rheuma

tism,gou t

, alcoholism , syphi lis , or ch ron ic nephri tis . Severemuscu lar strai n sometimes induces it .Path ology .

—Postnatal endocarditis most common ly involves the valves of the left side of the heart Prenatalendocarditis most common ly involves the val ves of the rightside of the heart .In simple endocarditis the su rface of the valve becomes

red ,swol len ,

and lu sterless . Later, a row of bead - l ikevegetations (th rombi ) appears al ong the l ine of maximum

contact , which is about 2 mm. from the free margin of the

valve. Microscopical ly , the endothel ium beneath the vege

tations shows evidence of necrosis,and the adjacen t tissue

,a

round - ce l l infi ltration . The vegetations may be whippedoff by the blood - c u rrent and carried to distant organs , as thebrain , k idney , or spleen ; bu t in the vast majori ty of cases , ifl ife is reserved , they are gradual ly replaced by fibroustissue filtram'

c m do mrdzh’

s) , which not on ly thickens thevalves , but , by contracting , so shortens and distorts themthat they are rendered in one instance obstructive to theonward flow of blood

,and in another incompetent to c lose

the orifice over which they preside . Fina l ly , the process iscompleted by the val ve becom ing the seat of cal careousinfi ltration and by the new fibrous tissue undergoing fattyand hyal ine degeneration .

The myocardium is probably more or less invo l ved inevery case of endocardi ti s .The u l cerative type is characteri zed by more extensive

necrosis , the development of u lcers , and the passage into theci rcu lation of septic embol i .Symptoms of Acute S impl e E ndocard i ti s.

—S ub

E NDOCARD I TI S. 1 8 1

jective phenomena are often absen t , and auscu l tation mayfu rnish the on ly indication of endocarditis—namely , a prolongation of the heart - sound , which later deve lops into a

distinct mu rmu r.

In many cases fever , an irregu lar and rapid pulse , pa lpitation , precordial distress , and dyspnea are associated symptoms .The general symptoms may resemble those of septicem ia or

typhoid fever. Thus , there may be moderately high and

irregu lar fever , profuse sweats , chi l ls , leukocytosis , del i ri um ,

and stupor . D iarrhea is not uncommon .

Cardiac Symptoms—There may be precordial pain ,palpita

tion,dyspnea,

a rapid and i rregu lar pu l se , and a mu rmu r at

one or other of the valve - points. This mu rm u r is prone tochange considerably in intensi ty and in timbre from day today . Occasional ly there is no m urmu r or other evidenceof cardiac inflammation .

3. m ol ic 8m ptoms.—Emboli in the peripheral vesse l s

may occasion a petechial rash ; renal embol ism may occasionhematun

’

a ; splenic embol ism , a painfu l en largement of thespleen and cerebral embol ism , paralysis .D iagnosis.

—Ty phoi d Pen n—The gradual onset,the

more regu lar fever, the abdom inal symptoms,the roseolar

rash,the Widal reaction , the bronchial catarrh , the ear ly en

largement of the spleen ,and the absence of leukocytosis and

of embol ic phenomena wil l serve to separate typhoid feverfrom u lcerative endocardit is .W i l l Pen n—This may be recogn i zed by the presence

of the malarial parasite in the blood .

Prognosi s —Acu te simple endocarditis does not oftenprove fatal , but it rare ly leaves the valve undamaged . Unde rfavorable conditions , however , compensatory hypertrophy ofthe heart ensues and good heal th is preserved for an indefi

ni te period . Rapid di latation of the heart indicates concu rrent myocardi tis and is a ser ious sign . Ulcerative endocardi tisgeneral ly proves fatal in from one to eight weeks. Occas ional ly the disease lasts seve ral months .Treatment —The treatment of acute endocarditi s is

1 82 D I SEASE S or 7715 cm cvza roe y S YS rear.

mainly that of the cau sal condition . Prolonged and romfleterest is of the greatest importance . The patient shou ld beconfined to bed not on ly du ring the attack , but for severalweeks after i t has subsided , in order to al low sufl‘i cient timefor the damage to be repaired or for compensatory hypertrophy to be established .

E xternal ly ,an ice - bag is often usefu l in al laying exci tementof the heart. Mi ld mercurial or sa l ine aperien ts may beused from time to time for thei r depu rative effect . Digital ismay be of service when the pu lse is weak and irregu lar, butgeneral ly it is not indicated . Heart - fai lure is to be combatedby such stimu lants as alcohol

,ammonia,

strychnin ,and

cafl'

ein . Repeated vesication and the prolonged use of

potassium iodid have been wa rm ly advocated .

PERIOD OF COMPENSATION .

Compensation is effected by an increase in the strengt hand size of certain cardiac chambers suffic ient to enable thearterial system to receive i ts norma l supply of blood

,notwith

standing obstruction or regu rgi tation at one or more of the

val ves .The duration of th is period is indefini te , and dependslargely on the amount of da e sustained by the heart andthe hygien ic condi tions to wh ic the patien t is subjected.

During perfect compensation endocarditis is indicated byphysical signs

,symptoms be ing en ti re ly absent .

Aort i c Stenosis or Aorti cM ana m a —DennisonObstruction to the flow of blood into the aorta from thickening or adhes ion of the aortic segments . Uncomplicated aorticstenosis is a rare lesion . I t occu rs usual ly in e lderly persons .Phy sical 81m .

—1 nsprd ion .—l f the heart is strong , the

apex - beat is forcible and is noted downward and to the left.Pct/patio»: confirms inspection ,

and often detects a systol icthril l at the base of the heart .Percussion may yield an inc reased area of cardiac du lness

,

espec ial ly to the left .

Aurcul tah'

on .—There is a harsh systol ic murmur, heard

1 84 D I SE ASE S OF 7’

l CIRCULATOR Y S YS TE Mshort and receding. E levation of the arm du ring pa lpationof the rad ia l artery makes th is pu lse more apparent, as theposition favors regurgitation . A capi l lary pu lse is sometimespresent. It may be noted at the root of the finger- nai l byan al ternate blushing and pa l ing , synchronous with the

heart - beats .Oompem ation .

—D i latation and hype rtrophy of the leftventric le. D i latation resu l ts from the reception of such a

large quan ti ty of blood du ring diastole,and hypertrophy

fol lows from the increased effort which the ventric le mustput forth in emptying itself of this extra quantity of blood .

This extreme ly di lated and hypertrophied heart has beenca l led the cor bam

'

awm, or ox

- heart .Bequence.

—Mi tra l regurgi tation. The di latation and

weakening of the ventric le prevent perfect c losure of the

m i tra l orifice, and re lative insu ffic iency resu l ts .

—Obstruction to the flow of blood through the m itral orifice,

from thicken ing or adhesion of the m itral segments .I t is usual ly seen in early l ife, and is more common in

females than in males .Phy si cal Signs—Impa tiom—The apex - beat is not muchdisplaced . There is sometimes bu lging over the lower partof the sternum .

Palpa tion—There is a rough presystol ic thri l l near the

a x .pe

Percussz’

ou .—The area of du lness is increased to the right

of the sternum .

Ausrul tah’

om—A presystol ic mu rm ur is heard a l itt lewithin the apex , and is not t ransm i tted . This mu rmu r isprolonged , rough , and churn ing in character, increases inloudness as i t approaches the fi rst sound

,and ends in an

abrupt systol ic shock . The pu lmon ic second sound isaccentuated .

Pulse—Du ring the riod of compensation the pu l seis smal l and regu lar . fter fai l ure of compensation thereis often extreme irregu larity , both in force and in rhythm .

Compenu tion .—From obstruction to the outflow of blood

the left auric le becomes en larged ; when it loses power,

CHRON IC VALVULAR D ISEASE . 1 85

the blood accumu lates in the l ung, and to overcome thispu lmonary resistance the right ventric le becomes hypertro hied.here is no strain on the left ventric le,

and hence thatchamber is not en larged .

Sequence—Tricuspid regu rgitation. D i latation of the

right ventr ic le prevents perfec t c losu re of the tricuspidorifice , and re lative insufli c iency resu l ts .Magnesia—The loud systol ic shock , accentuation of the

pu lmon ic second sound, and en largement of the ri ght ventrie le wi l l serve to distinguish this murmur from the Hint

Dominica— Imperfec t c losure of the m itra l orifice fromruptu re or inflammatory con traction of the m i tral segmentsor from di latation or weakening of the left ventric le, preventing perfect coaptation of norma l valves . Mitra l regurgitation is the most frequent of the val vu lar defec ts .Phy sical 81m —Imperfiom—The apex is usual ly to theleft and downward. There may be bu lging of the precotdium . Palpation confirms inspec tion .

Pm m’

on .—The area of du lness is increased transverse ly ,

espec ial ly toward the right.Am i tah

’

om—The murmu r is systol ic,loudest at the

apex , and transm itted to the left axi l la and angle of the

scapu la The pu lmon ic second sound is accentuated .

fi lm—Du ring the period of compensation the pulsemay be fu l l and regular. I t u sual ly becomes quite irregu lar when the heart weakens .W h om—The left au ric le en larges from the extra

amount of blood that it rece ives ; when i t weakens , the

l ungs become congested and r ight ventr icu lar hypertrophyfol lows .The left ven tric le a lso becomes hypert roph ied

, from i tseffort to move the large quanti ty of blood which it rece ivesfrom the distended auric le during each diastole .

Sequenco.—Tric uspid regu rgitation . Weaken ing and di

latation of the right ventric le prevent perfect c losu re of the

1 86 0 1354 353 or m e CIRCULA TOR r S KS‘

TE M.

Tri cuspi d Stenosis or Tr i cuspi d Obstruction .

This lesion is extreme ly rare , and difficu lt to dist ingu ishfrom m itral stenosi s

,with which it is usual ly assoc iated. I t

gives rise to a transverse en largement of the heart and a

presystolic mu rm u r, which is heard loudest over the baseof the en siform carti lage.

tion .—Deflnitton .

— Imperfec t c losu re o f the tricuspid orificefrom inflammatory shortening of the valves ; or, more com

mon ly ,from di latation of the right ventric le secondary to

m itral disease or to chron ic lung disease.

Phy sical Sin e—The characteris tic signs are en largementof the heart , espec ia l ly to the right of the ste rn um a sy stol ic m u rm u r , loudest over the lower portion of the sternum ; a systol ic pu lse 1n the j ugu lar ve ins and in the l iver.

Pulmonary Stenosis or Pulmonary Obstruct i on .

This very rare lesion 1s always congen ita l . I t may be sus

pected when there are marked en largement of the rightventric le

,a systol ic mu rmu r in the second left inte rcosta l

space which is not transm itted into the vessels of the neck ,a systol ic thri l l in the same area , and pe rs istent cyanosis .

Pulmonary Regurg itatton .

—This is very rare and is usual ly congenital . I t produces a d iastol ic mu rmu r 1n the second left intercosta l space .

Broken compensation usual ly resu lts from : (1 ) Inc reas ingdamage to the valves ; (2) sen i l ity , leading to arteria l and cardiac degeneration ; 3) some intercu rrent disease , throw ingaddit ional strain on the heart , or (4) undue physical exertion .

Du ring this period subjec tive symptoms appear. In ca r

diac insuffic iency , no matter what the original valvu lar lesionmay have been , the heart becomes unable to fi l l the arteries

,and the blood 15dammed back 1n the lungs , and venous

congestion of the organs fol lows .Symptoms .

—Pu lmonary congestion produces dyspnea ,

hemoptysis, and often chron ic bronchial catarrh wi th cough

and expectoration .

Hepatic,stomachic , and intestinal congestion produces

1 88 0 1334 355 OF THE CIRCULA TOR 1' 3 12375111 .cial ly when there are degenerative changes in the heart .Mercu rial and sa l ine aperients are usefu l in lowering venoustension ,

and withou t their aid digital is may fai l . When theright ventric le is greatly overdistended and cyanosis ismarked, venesection to the extent of a pint or more mayprove l ife - saving. I ron and arsen ic are very serviceablewhen there is anem ia. They may sometimes be combinedadvan tageously with digita l is and strychn in,

as in the fol lowing pi l l :

B. Acidi arsenosiMam ferr i carbonatis

Strych niuz m l is

Pu lver is is

ment pi lu li e No . 11 11 .

S ta—One pi l l after mea ls .

Special Sy mpl omS .

—Dropsy .—The most usefu l measu res

are hydragogue cathartics (sal ines in concentrated solu tion ;compound jalap powder , 30 to 40 grains ; and elate ri um ,

grain) ; diu retics (digital is , cafl’ein , vegetable sa l ts of potass ium) ; the appl ication of smooth , firm bandages to the l imbsthe introduction of fine si lver cannu lae (Southey 's tubes), andinc is ions behind the ankles .Dy s

fm a may yie ld to cupping, sinapisms , the admin istra

t ion 0 Hoffmann’s anodyne , and , in cases of high arterial

tension , to n itri tes . Morph in is espec ial ly usefu l in re l ievingnocturnal dyspnea.

Rest/(fi nes and Insomn ia—On the whole,morphin

(t grain) with atropin (Th grain) is the best sedative. Tri

onal , brom ids , and chloralam id are worthy of confidence .

Fai th—Temporary Oppression is often re l ieved by warmor cold applications and the adm in istration of Hofl

'

mann'

s

anodyne . Severe continuou s pain may yie ld to leeching or

bl isteri ng . In anginoid pains n itrites and potassium iodidare often efficac ious .Sudden hear t-fa il u re must be met by the adm in istration

of difl'

usib le stimu lants , such as ammon ia,whisky

, and ether.

The application of heat to the precordium is usefu l .

E NLARGE ME N T or 7715 HE ART. 1 89

Vari eti es. S imple Hypertr ophy —The musc le of theheart is increased in thickness, but the cavi ties are of normal

(2) E am tr ic Hyper tropky (Hyper tropky wit/1 Di latation ).The muscl e is th ickened and the cavities are increased in

3) S imple Dil atation—The musc le is thinned and the

cavities are increased 1n si ze .

E tiol ogy .—Hyprr tropky is always the res u lt of increased

demands upon the functions of the heart . Thus,i t may be

due to Valvu lar disease ; (2) abnormal resistance inthe periphera l c i rcu lation , as in arteriosc lerosis and ch ronicBright 's disease (left ventric le) ; (3) abnormal resistance inthe pu lmonary circu lation ,

as in emphysema and cirrhosisof the l ung (right ventric le ) ; (4) prolonged exertion

,as in

ath letes ; (5) long - continued pa lpitation or tachycardia. as in

exophthalmic go i ter or tobacco heart ; (6) interference withthe ventric ul ar contrac tions by pericardia l adhesions .Dil atation of fl u frear t resu l ts from the same causes . Itis more apt to occur than hypertrophy when the demandsare sudden and severe

,or when they fal l upon a heart the

wal l s of which are al ready degenerated.

Path ol og y .— In Iryprrtrop/ry the musc le of the heart is

firm and of a dark - red color . The normal weight (8 or 9ounces) may be doubled or trebled . When the left ventric leis chiefly involved , the organ is increased in length . Whenthe right vent ri c le is chiefly involved

,the organ becomes

more globu lar. Microscopica l ly , the fibe rs are increased insize and in number.

In d il atation the heart musc le is softer , more flabby,and

often l ighter in color from degenerative changes .Sm ptoma—Hypertrophy .

—Un less the hypertrophy ismore than compen satory

, no symptoms result. E xcessivehypertrophy may give rise to precordia l distress and symptoms of cerebral hype rem ia—headache ,

tinnitus au rium ,

flashes of light , etc—and the fol lowing physical sign s .

bu lgi ng of the preco rdium ,a heav ing impu l se, di splacement

[90 DISEASES OF THE CIRCULATOR Y S YS TE M .

of the apex - beat downward and to the left, an increase inthe area of cardiac du lness , a loud

,booming first sound

,

accentuation of the aortic second sound or of the pu lmon icsecond sound, accordi ng as the hypertrophy involves theleft or ri ght ventric le ,

and a strong,fu l l pu lse .

Dil atation al so gi ves signs o f cardiac en largemen t . but theimpulse is feeble or imperceptible

, the first sound is shortand weak (c licking) , the pu l se is rapid and feeble

,and often

i rregular or interm ittent , and usual ly there are symptoms ofvenous congestion—dyspnea

, cough , edema,flatu lent dys

pepsia,and deficient u rination . Soft sys tol ic mu rmu rs

,the

Bea

r]

;of relative m itral or t ricuspid insufl‘ic iency ,

may be

ea

hyper trop/ry treatment is rare ly cal ledfo r. Mercu rial and sal ine aperients are usefu l in loweri ngarterial tension . Acon ite may be u sed cau tiously. The

cerebral symptoms wi l l general ly yield to brom ids or tovasodi lators , l ike the n itri tes .The treatment of di latation is for the most part that ofvalvu lar disease in the stage o f broken compensation . Digital is

,strophanthus

,and strychnin are the most re l iable

remed ies in chronic cases. In acute cases d ifl'u s ib le stimu

lants—alcohol , ether , ammon ia—wi l l be requi red . Whenthe right heart is especial ly embarrassed and there is or

thopnea with cyanosis , venesection is often of the greatestvalue.

Defini tion .—Acute inflammation of the heart musc le .

E t iol ogy .—It resu lts from the same cau ses as acute

endocarditis .Path ol ogy .

—Ir is usual ly assoc iated with endocarditisor pericarditis . Occasional ly the myocardi um is the on lypart of the heart aM ted . The inflammatory process isalways accompan ied with more o r less pa renchymatous orfatty changes in the musc le - fibers . The essen tial lesion isthe infi l tration of the intersti tial ti ssue with round ce l ls .Symptoms —The symptoms are often masked by theprimary disease. Dyspnea,

precordial distress , palpitation ,

l 92 D ISE AS E S OF THE CI RCULATOR Y S YS TE MSymptoms of Fatt y Infi l trat i on —In fatty infi l trationsymptoms are not marked un less the musc le - fibers themsel ves are affected . I t may be suspected in an obese subjcet , when the on ly symptoms present are dyspnea on

exertion , pa lpitation , weak heart - sounds , and a feeble butregu lar pu lse .

Symptoms of Fatty Degeneration and of Fi broidM uta ti on —These two conditions cannot be di fferentiatedc l inical ly . The symptoms are very variable. There is often a

sense of oppression or discomf or t in the region of the heart .Attacks of ang ina pector is may occu r. Dy spnea is rarelyabsent . Toward the end Cleey ne - Stoées h ea t/ring may de

vel op. The pu l se is usual ly weak and irregu lar , both inforce and in rhythm sometimes it is intermi ttent. and occasionall y i t i s extremely s low (40 o r 50 a m inute). The firstsound of fire lrear t is f eebl e and mafi a ! the second aorticsound is often re latively accen tuated . The heart is not necessaril y en larged . There may be no mu rmu rs

,but a systol ic

mu rmu r is often heard at the apex in consequence of relaxation of the m itral sphincter. There may be edema of the feet ,and even anasarca. H og ressine weakness and or oftendevelop from increased venous tension and inte erence withabsorption . Attacks of asy stol e (orthopnea , cyanosis , pu lmc nary edema, and de l iri um cordis) are occasional ly ob

served . In rare instances the Adams - Stokes sy ndrome (permanent slowness of pu l se with syncopal or vertigi nousattacks) is present .The lristory , ag e of tirepatient, and cond ition ci t/re arter ies

must al so be considered in making the diagnosis .P rognosi 8 .

—Serious . S udden death may occu r at any

Treatm en t ofFatty and F ibroi d Heart .—Laborious

work , menta l strain , and exci tement shou ld be avoided , as faras possible. The diet shou ld be simple and easi ly digestible .

When the pathologi c changes are not far advanced , and particu larly if they consist in fatty overgrowth rather than in de

generation of the m usc le- fibers , graduated exerci se , coupledwith warm sa l ine baths, as in the we l l - known Nauheim treatmen t

,may be very efl‘i cacious. Constipation must be rel ieved .

ANGINA PE CTORI S . 1 93

As to special treatment , strychn in (315 to grain th ri cedai ly ) is the most general ly usefu l drug. hen there isanem ia , iron and arsenic are exce l lent adj uvants . Nitritesare benefic ia l in cases w1th high arteria l tension

, anginoidpains , or cardiac asthma. Digita li s is serviceable in somecases ; i t shou ld be given cau tious ly , however, and in

smal l doses.

(Neuralgia of the Heart ; Stenocardia . )

Defin i ti on .—A symptomatic aflection mos t common ly

associated with occ lusion of the coronary arteri es and degeneration of the myocardium

, and characterized by severeparoxysmal pain in the region of the heart and a sense of

imminent death .

E ti ology .— It usual ly deve lops after m iddle l ife, and is

very much more common in men than in women . The predisposing causes are those of arterioscl erosis c. , alcoholism , gout , and syphi l is . In some instances an hereditarytendency has been noted , and not infrequen tly the attackshave been preceded by prolonged menta l anxiety .

A fal se angina pseudo- angi na peetor rlr) is sometimes associated with hysteria, reflex irri ta tion , or the excessive use of

tobacco.

Path ol ogy .—Obstru c tion of the coronary arte ries from

atheroma,th rombosis , or embolism, with resu l tant degenera

tion of the myocardium ,is the condition usual ly found after

m ptoms.—The attacks are usual ly ex cited by strong

emotion ,muscu lar effort

,or flatu lent indigestion , and are

characteri zed by agon iz ing pain , radiating from the heartto the shou lde r and arm (usua l ly the left) , a sense of im

pending death , immobi li ty of the body , dyspnea , and a pale ,

anxious face. The pu lse is very vari able. The attacks lastfrom a few seconds to several m inutes . Death may occu rin the first attack , or there may be recu rr ing attacks over a

peri od of many years .W e Anzins .

—This neurosis is seen chiefly in women ,

whereas true angina is very rare in women there is no evi

1 94 D ISE ASE S OF THE CIRCULATOR Y S YS TE M .

dence of organ ic heart disease ; the attack is longer in

duration ; there is no immobi l i ty of the body ; emotionaloutbreaks , such as moan ing and crying, are common ,

and

vasomotor phenomena are often pronounced .

Ga m b ia—The pain is apt to appear when the stomachis emmy, and is re l ieved by stimu lating food ; i t does not

radiate to the shou lder and arm ; there is no sense of im

pending death , no fixation of the body,and no evidence of

structu ral heart di sease .

Prognosis —Grave. S udden death may occu r at anytime . In fal se angi na the prognosis is favorable .

Treatmen t —The gene ra l treatment is that of ch ronicmyocardial disease . The most valuable spec ial remedies , inthe order of their efl‘icacy ,

are the n itri tes , iodids , and arsen ic .

Tlre Attack—No d rug is so general ly usefu l as amyl n itri te (3to 5m in ims on a handkerchief). Marked flatu lencyshould be met by the prompt administration of Hofl

'

mann'

s

anodyne or spi ri t of mint . When the attacks are severe andprolonged , morphin to grain ) shou ld be given hypodermical ly . When these remedies fai l , recourse shou ld be hadto chloroform inhalations . The appl ication of heat to theprecordium is usefu l . Cardiac depression fol lowing the

seizu res shou ld be combated by strychn in , ammon ia, cam

phor,or ether.

DiSEASES OF THE ARTERI ES.

Defin i ti on .—A more or less local ized di latation of the

aortaE t iology .

—The predisposing causes are those of arteriosc lerosis—syphi l is , alcohol ism , gout , rheumatism ,

leadpoison ing , and neph ri tis . Of these , syphi l is is by far themost potent factor . Immoderate physical exertion is themost common exc iting cau se. More than 80 pe r cent . ofal l cases occu r in males . It is most frequent between the

ages of thirty and fifty .

Path ology .—Aneurysms are divided

,according to shape ,

196 0 1554 555 or m e cm cuu ron r s ysn w.

y rmal eronpy eong lz may be exc ited by pressu re on the

trachea or rec u rrent laryngeal nerve . Ap/wnia may a lsoresu lt from pressu re on the rec u rrent laryngeal nerve.

Dy rplrag ia may resu lt from pressure on the esophagus .Pain of a boring or lanc inating character may ari se frompressu re on neighboring nerve- trunks or bones . D il atation

or contraction of one pupi l and unil ateral sweating may be

exc ited by pressu re on the sympathetic .

Edema and cy anosis of the one arm and shoul der mayfol low pressure on the large venous trunks.Diagnosi s.

—Med in thn l tumor may simu late aneu rysm,

but 1n the former the pu lsation 15 not expansi le ,there is no

diastolic shock , the trachea l tug is usual ly absent , and theremay be cachexia

,en largemen t of superfic ial g lands

,and

leukocytosis .Pain ting Burn ou t —A left- sided pu ru lent effusion maytransmit a cardiac pu lsation,

but there is no diastol ic shock ,no thri l l

,and no murmu r. The history, moreover, w i l l

usua l ly suggest pleu risy .

Aort ic Simona—In th is condition there are no evidencesof a tumor, no pressu re symptoms , and no changes in theu l ses.pPrognosis .

—Grave. Death usual ly occu rs in from one

to two years from ruptu re , asphyxia, exhaustion , cerebralembo l ism ,

or inflammation of a lung (“ aneu rysmal phthisisRuptu re may take place into the trachea

,a bronchus , the

esophagus , lung , pleu ra , or pericardium ,o r external ly. In

rare instances recovery fol lows from c lot- formation .

Treatment —The treatment common ly employed is amodification of Tu fne l l

'

s method , and consists in absoluterest in bed for a period of six or e ight weeks , a comparatively d ry diet , and the adm in istration of potassium iodid1 0 to 20 grains thrice dai ly). For severe pa in the mostefl

'

ective measu res are the application of an ice' bag and the

adm in istration of n itroglycerin or morphin . When there rs

marked dyspneawith cyanosis , venesection may afford promptre l ief. Attempts have been made to favor coagu lation byinjec ting ge latin (1 0 0 c . .c of a 5per cent. steri l ized solution)subc utaneously , or by inserting i nto the sac fine gold wi re

AR rap /asa 530315. 197

and passing through the wi re a strong gal vanic current(Moore- Corradi treatment) .

Seat —It is most frequent ly located near the cel iac axis .Symptoms —It may be recogn i zed by sharp pain in theback , radiating along the spina l nerves , by a de lay in the

femoral pu lse, by gastro- intestinal symptoms , and by phys ical signs simi lar to those of thorac ic aneurysm.

D iagnod a—An abdominal tumor may receive a pu lsat ion from the aorta and simu late aneu rysm , but in the

former the pu lsation is not expansi le,and is frequently lost

when the patient is placed in the knee - breast posture.

Bx pansi l o Abdominal Aorta —This is most frequent ly seenin women ,

in whom abdom ina l aneu rysm is very rare ; the

pu l sation is often paroxysmal ; there is no distinct tumor,and there are no pressure symptoms .Prognos is —Very grave. Death usual ly resu l ts from

ruptu re . Occasional ly the fatal issue is effected througherosion of the vertebrae and paraplegia, or through embo lism of the superior mesenteric artery.

Treatment —Same as in thoracic aneu rysm .

(Athemma ; Chroni c Endartertt ia.)

Defin i tion —A c ircumsc ribed o r di ffu se th ickening ofthe arterial wal ls , espec ial ly o f the intima ,

secondary to certain degenerative changes in the media.

E t iol ogy .—It is a natura l accompan iment of old age .

The causes that favor its ear ly deve lopment are alcohol ism,

syphi l is, gout , Bright 's disease , rheumatism,ch ronic lead

poison ing , and excessive m usc ul ar strain .

Path ol ogy .—The arteries are th ickened

,tortuous

,and

ri gid . The intima of the large vesse ls revea ls roughenedand Opaque areas that may be the seat of ca lcareous deposits . In extreme cases there may be spots of necroticsoften ing in the subendothe l ia l tissue

,form ing so- ca l led

atheromatous abscesses. "

1 98 0 1554 353 or 771 15 cm cuu TOR Y S YS TE M.

Microscopical ly, the muscu lar fibers of the media are atrophied and the seat of fatty degeneration or ca lc ification . In

the intima there is marked hyperplasia of the subendothe

l ial connective tissue, the ce l ls of which may be the seat ofhyal ine

,fatty

,or calcareous degeneration . The adventi tia is

also the seat of connective- tissue overgrowth .

Symptoms .—These vary with extent and distribution of

the sc leros is . When the process is general , i t may be rec

ognized by rigidity of the peripheral vesse l s , a s luggish ,high - tension pu lse

,accentuation of the second aort ic sound ,

and en largement of the left ventric le.

When the coronary ar ter ies are espec ia l ly involved , thesymptoms of chron ic myocardia l disease appear. When therenal vessels are espec ia l ly affected , there may be symptomsof chron ic intersti tia l neph riti s . Involvement of the cerebral

ar ter ies may be indicated by headache , vertigo , insomnia,

menta l s luggishness,and ,perhaps , transient paralysis .

Sequel a—Cerebral hemorrhage or thrombosis , chronicmyocardial disease

,angina pectoris , interstitial neph ri tis ,

aneurysm , and gangrene of the extremi ties .h ab i tant —Treatment shou ld be directed to the underlying diathesis . A lcohol shou ld be forbidden . Overex ertion

,both mental and physical , is inj u rious . Gent le exerc ise

in the open air,however, may be recommended. Heavy

feeding must be restricted . The periodic u se of m i ld me r

cu rial or sa l ine aperients is very benefic ial . Potassium iodidand the n itrites are often usefu l when the blood -

pressu rebecomes too high .

RE SP IRA TIOM

phy sema,edema,

phthisis , a,

bscess and gangrene.

g)Pleural effusions. (6) Cardiac disease . (7) Paralysis ofm usc les of respi ration. (8) Abdom ina l distention . (9)Anem ia.

Inspiratory dyspnea. is frequently . seen with tumors or

fore ign bodies in the larynx .

E xp iratory rim “ is noted in emphysema and occas ional ly in movab le tumors situated be low the glottis . In

asthma,a lso, the dys nea may be large ly inspi ratory.

Th e N umber of)

Respi ratione a M inute —In the

hea lthy male adu lt the numbe r of respirations is about 1 8a minute . In women and ch i ldren breath ing is somewhatmore rapid . The ratio between respi rat ions and pu lse- beatsis as t is to 4 or

o

4,5Rapid respiration: are noted rn exc itement

,in pyrexia ; in

inflammatory diseases of the l ungs ; in anemia ,in certain

affections involving the base of the brain ; in poison ing fromcertain drugs that affect the respiratory center ; in hysteria ;in painfu l aflections of the respiratory musc les

,as pleu ro

dy nia and pleu risy .

[afrequent respiration: are observed in certain diseases ofthe brain , as men ingitis , tumor, apoplexy in advanced fattydegeneration of the heart ; in certain forms of coma, par

ticu larly uremic and diabetic ; in poison ing with certa indrugs

,especial ly opi um ; in obstruct ion to the air- passages ,

as in asthma and rn lary ir ea spasm .

Cirq ue- S tokes, or law -wave Breath ing—In th istype the respi rations gradual ly increase in rapidity and

volume unti l they reach a c l imax . then gradual ly subside ,

and final ly cease entire ly fo r from five to fifty seconds , whenthey begin again . I t depends on some distu rbance of the

respiratory cen ter the exact nature of which is sti l l undetermined . It is usual ly a forerunner of death

,but cases have

ed in which it has lasted several months .1 ) Certain cerebral diseases , as apoplexy ,

meni ngiti tumor. (2) Advanced cardiac disease ,

especial ly fatty degeneration . (3) Cert ain forms of

coma, espec ial ly that produced by u rem ia, opium - poison ing ,and sunstroke .

ZOQ D ISE ASE S OF THE R E SP IRA TOR Y S YS TE M.

Cough may be induced by : (1 ) Most organic diseases ofthe pharynx

,larynx , bronchi , and lungs . (2) Foreignbodies in the air- passages . 3) Certain infections which are

assoc iated with catarrh,such as typhoid fever, meas les ,

whooping - cough,and influenza . (4) Inha lation of irri tant

dusts or vapors . (5) Reflex irritation , as from pressu re on

the rec u rrent laryngeal nerve or from disease of the abdom i

nal organs . 6 ) Hysteria.

Lary ng Cough —This cough has a hard , metal l ic ,

ringing intonation,and has been termed “

croupy. I t isobse rved in laryngi tis ; in whooping- cough ; in tubercu losisand syph il is of the larynx ; when a fore ign body rs lodgedin the larynx ; when the recurrent laryngea l nerve i s irritated by pressu re of a tumor o r aneu rysm ; and in hysteria.

Dry Cough —Cough without expectoration is espec ial lyobserved in the beginn ing of inflammatory diseases of thebronchi and l ungs ; in pleu risy ; in most chest diseases ofear ly chi ldhood ; and in reflex i rri tation of the larynx .

Moi st or l oose cough occurs espec ia l ly in bronchitis ,bronchiectasis , abscess of the l ung , convalescent pneumon ia,

and phth is is .

Mucoi d sputum is noted espec ial ly in the beginn ing ofacute bronchitis ; in asthma ; in the early stage of pneumon ia and phthisis ; and in pu lmonary edema . In edenra the

sputum is very frothy and watery.

Mucopttrnl en t Spu tum .—This is observed in subacute

and chron ic catarrhal affect ions of the lungs and bronchi ,espec ia l ly 1n subacute and ch ron ic bronchitis , convalescentpneumon ia, and phthisis .

Purul en t Spu tum .—Spu tum rs rare ly composed of pu re

pus . E xpectoration almost entire ly pu ru lent rs somet imesobserved in bronchiec tasis, in phthis is with cavit ies

,in ab

scess of the lung, and when an empyema ruptu res into thelung.Prune - ju i ce spu tum is tinged with altered blood so asto resemble prune - j u ice. It resu lts from retention of blood

204 D ISE ASE S OF THE RE SPIRATOR V S VS TE M

They have a lso been obse rved in the sputum of croupouspneumon ia.

Ohureot -Loydou Cry sta ls—These are smal l transparen toctahedral crystal s, sim ilar to those found in the blood inleukem ia. They are observed espec ial ly in the spu tum of

asthma. They have also been noted in phthisis , in fibrinous bronchitis

,and in acu te bronchitis .

Crystal s of Fatty Aci ds—These occu r as fine needles ,singly or in bundles , and are often sharply cu rved near

the i r extrem i ties. They are observed in the Sputum of

chron ic bronchitis , of abscess , and of gangrene of the

lungs.Cry stal s of Hometown —These occu r as smal l ye l low

needles , rhombic plates or tu fts , and are found in Spu tawhich contain al tered blood . They may be observed inabscess, gangrene ,

and cancer of the l ungs .Tubercl o Bacil l i —The presence of

' tuberc le bac i l l i in thesputum is an absolute proof of tuberc u losis

,but a fai lu re to

detect them after one or two exam inations is no proofagainst phthisis . The bac i l l us is a fine rod , in length abouthalf the diamete r of a red blood - corpusc le , and often slightlybent and beaded. I ts detec tion depends on its power, whenstained , of res isting the bleaching efl'ect of ac ids. To viewit successfu l ly , a 1 1, inch oi l - immersion lens is required .

Gabbett'

s Method—Se lect with a cl ean needle one of the

m inute caseous masses contained in tubercu lous Sputum ,

spread it out in a very th in film on a cover - glass , dry in the

air, and coagu late the al bum in in the bacteria by passing the

covero

glass , smeared side up ,th ree times through the flame .

Cover the spec imen with Z ieh l 's carbol - fuchsin sol ution(fuchsin 1 alcohol to ; 5per cent . aqueous solu tion of car

bol ie - acid crystal s and hold the cover- glass over theflame for a few m inutes at such a distance that steam isformed . Wash off the excess of stain in water, and counterstain by treating the preparation for thi rty seconds withGabbett ’s sol ution (methylene - bl ue 2 ; su lphu ric acid 25;water Again wash in water, dry , and mount inCanada bal sam . The tuberc le baci l l i wi l l appear as red

rods in a blue fiel d .

Pi ]VSICAL E XAM /AMTIC/V OF RE SP IRA TOR Y ORGANS . 20 5

ORGANS.

Inspection —Inspection determines the shape of the

chest , any unnatu ral prom inence o r depression, the amount

of expansion, and any inequal ity of ex pansion .

Flo. t e.—An outl ine of the normal ches t.

Phthisinoi d Chest—The anteroposterior diameter is short ;the thorax is long and flat the ribs are oblique ; the scapu laprominent the spaces above and bel ow the c lavic les are

Fl o . u . Rach i tic chest.

depre ssed ; and the angle formed by the divergence of the

cos ta l margins from the sternum is very acute.

Backmo Chest —This may resemble the former, but usual lythe sides are considerably flattened and the stern um

20 6 or 7715 RE SP IRATOR y s rsu m.

nent , so that the term pigeon - breas t has been applied tothis particu lar form . The stemal ends of the ribs are en largedor beaded ”

and th is characteri stic has given rise to the

term rachi tic rosary . There is often a circu lar constric

tion of the thorax at the leve l of the xiphoid carti lage (Harrison ‘s groovel .Bmphy sematous Chest —In advanced emphysema the

thorax 18 short and round ; the an teroposterior diameter ISoften as long as the transverse ; the ribs are hori zontal ; theangle form ed by the divergence of the costal marginthe sternum is very obtuse o r qu i te obli terated. The termbarre l - shaped chest " is applied to this configu ration .

Fl a. t e .—Emphysematous chest .

unnatu ral promincnoc or depression is often obse rved over the lower part ofthe sternum , and is general ly congen ital . The term funnelbreast or shoemaker’s breast (because it may resu lt fromthe pressure of tools) has been appl ied to the sternal depresSton.

A uni/art f ul or local deprmsrbn may 61 dirt to (1 ) Chronicphthi sis ; (2) cirrhos is of the l ung ; (3) pleu risy with fibrousadhes ions.A um

'

l atm l or [oral prominence may be due (a : (t )Pleu risy with effusion (2) pneumothorax , hydrothorax .

hemothorax ; 3) an aneu rysm or tumor ; (4) compensatoryemphysema

,resu lting from impai rment of the opposite lung ;

20 8 D ISE ASE S OF Tfll z'

RE SPIRATOR Y S YS TE MEdema of the chest owal l s is recogn ized by pitt ing when

pressure is made with the finger. I t may be observed inempyema ; in deep- seated abscesses of the parietes ; afterthe appl ication of a bl ister ; and in genera l dropsy .

Frict ion Premi tns and Rh ea—The friction - rub of pleurisy and harsh , sonorous tales can sometimes be detec tedby pa lpation.

Vocal fremi tus is the sense of vibration imparted by thevoice to the palpating hand .

In determ ining th e vocal frem itus observe the fol lowingprecautions : Palpate symmetric parts of the ches t ; makefirm pressure ; when comparing, use the same press u re on

the two sides ; apply the hands as nearly paral le l to the ribsas poss ible ; and remember that the fremi tus is normal lystronger over the right chest than the left .The frem itus is usual ly sl ight in women and in chi ldren

,

and in men with thick chest- wal ls and a weak voice.

Vocal f rcmi l us is abnorm al ly incrcascd when the l ung isconsol idated and the bronchi are patu lous , as in —(r)Tubercu losis ; (2) croupous pneumonia ; (3) bronchOpneumon ia.

Vocal fi rmitns is dccrcascd or abscn l in—(r) Pleu ra l efl'

u

sions—a ir,serum

,pus

,blood , or lymph ; (2) emphysema ;

3) pu lmonary col la e from an obstructed bronchus ; (4)pu lmonary edema ; 5) morbid growths of the l ung.

—Percussion determines resonance, pitch ,and resistance .

l mmcd iatc percussion is performed by str ik ing the chestdirect ly with the fingers . I t is not often employed , exceptover the c lavic les , where the bones themse lves act as pleximeters .

Mcdia l c percussion is performed by using the fingers of

one hand as a plexor and those of the opposite hand as a

pleximeter ; or by using a piece of ivory , glass , or hardrubber as a pleximeter, and a sma l l hammer as a plexor.

The use of the fingers alone is preferable, for on ly in th isway can res istance be determ ined .

In percussion the fol lowing preca u tions shou ld be ob

served : Place the finger that is be ing u sed as a pleximeter

PH YS I CAL E XAM INA TION OF RE SPIRATOR l ' ORGAN S . 209

firm ly against the chest, and preferably paral le l to the ribs ;make the finger that is used as plexor strike the one on the

chest perpendicu lar ly ; fix the forearm, and use no moreforce than can be obta ined from a gentle swing of the wrist.When possible, percuss al l parts of the chest anteriorly andposteriorly ; percuss both in inspiration and in expiration.

In comparing the two sides , be sure to percuss symmetricparts .Normal Ra m ona —Oh the right side, pu lmonary reso

nance extends from a half inc h to an inch above the c lav

ic le,downward to the Upper border of the sixth rib in front ,

and to a l ine drawn through the tenth spinous processposterior ly.

On the left side,pu lmonary resonance extends from a

half inch to an inch above the c lavic le, downward, withinthe mammary l ine to the th ird rib

,outside of the mammary

line to the tenth rib,and posteri orly to a l ine drawn through

the tenth spinous process.Tranbc

'

s Scm'

l nnar Spa wn—This is a tympanitic area at

the base of the left chest, bounded above by the l ung(six th rib) , on the right by the l iver, and on the left by thespleen. I t is ob l i terated in pleu ral effusion on the left side .

Kypm eoonance is observed in the fol lowing conditions :(1 ) Pneumothorax . (2) Cavi ties—tube rcul ous or bronch iec

‘tatic . 3) Emphysema. (4) Lowered pu lmonary ten

s ion , as above a pleu ral effusion or consol idation, and in the

in i tia l stage of pneumonia (Skoda's resonance) . (5) Flatulent distention of the stomach or colon (frequently observedover the base of the left chest).Tympanit ic resonance is resonance of a hol low

,drum - l ike

character, l ike that norma l ly obtained by percussing theemp ty stomac h or the colon . I t is e l ic ited over the chestin pneumothorax and cavity - formation .

The cracked - pot sound . or bru it dc po’

t fi lé, is a modifiedtympany , and can be simu lated by percussing over thecheek when the mouth is partia lly open . I t may be nor

mal ly heard over the chest of a c rying infant (Walshe) . In

the adu l t it usual ly indicates a cavi ty that has a free com

mun ication with a bronchus. It is best detected by keepingN

2 10 D ISE AS E S OF THE RE SP IRA TOR Y S YS TE Mthe car near the open mouth of the patient whi le percussrng .

Dnlnsss or flatness on percussion may be caused by thefol lowing condi tions : (1 ) Pleu ra l effusions of al l kinds , except air ; (2) conso lidation of the lung from tubercu losis o rpneumon ia ; (3) col lapse of the lung ; (4 ) congestion and

edema of the l ung ; (5) morbid growths in the lung ; (6)en largement of the l iver or Spleen (at the bases) .Pi tch a

—Pi tch of the note depends large ly upon the volume of ai r

,upon the tension of the wal ls of the cavity

,and

upon the si ze of the Open ing that commun icates with the

cavity. The less the ai r, the greater the tension , and the

sma l ler the open ing, the higher wi l l be the pitch of the

note . I t is obvious , therefore, that conditions that are assoelated with hype rresonance may yie ld ei ther a high o r a

low - pitched note. In beginn ing phthisica l consol idationthe note over the affec ted apex is higher pitched ; but itmust be borne m m ind that normal ly the note over the rightapex is higher pitched than that over the left .Beaistanca—The sense of resistance apprec iated by thepercussing finger i s increased rn proportion as the air in the

l ung rs dec reased . I t rs general ly more marked over a pleu ralefl

'

u sion than over a consolidation with patu lous bronch i .Auscu l tat ion .

—Auscu l tati on of the lungs is practisedto determine the character of the respi ratory and voicesounds , and to detect adventi tious sounds l ike tales .

In immcdiatc auscul tation the ear is placed directly overthe chest , on ly a soft towe l interven ing .

In mediate auscu l tation the sounds are transm i tted th rougha stethoscope ,

whi ch shou ld be applied to the bare chestIn auscul ta tion observe the fol lowing precautions : Do

not exert much pressu re with the stethoscope . When thechest is covered wi th hair

,this shou ld be moistened , other

wise it is l ikely to produce crackl ing sounds resemblingrales . When possible

,exam ine carefu l ly al l parts of the

chest, anteriorly and posteri orly , during qu iet breath ing ,

du ring ful l inspi ration , during fu l l expiration ,and after

coughing . Compare careful ly the sounds el ic ited over symmetric parts of the chest.

2 1 2 D ISE ASE S OF THE RE SP IRA TOR Y S YS TE MCavernous breathing may be heard in the fol lowing con

ditions : (1 ) Phthisical or bronch iectatic cavi ties ; pneumothorax ,

when the open ing in the l ung is patu ous ; 3)areas of consol idation near a large bronchus ; (4) sometimesover l ung compressed by a moderate efl

'

usion .

T/rc Brcatln'

ng of Emplry scma .—This is weak breathing ,

with pro longed low - pitched or inaudible expi ration .

Coggcd~wlrccl or j erky Br catlring .

—The respi ratory mu r

mur is not continuous , but is broken into waves . I t is notindicative of any spec ial disease ,

but i t is frequently observedin hysteria

,pleu rodyn ia,

bronchitis , and incipient phthisis .Weak or Shal l ow Brcatlting .

—This is noted : (1 ) Whenthe chest- wal l s are th ick ; (2) in the old and feeble ; 3) inemphysema , (4) in pleu ra l effusion ; (5) sometimes in incipient phthisis ; (6) i n painfu l affections of the chest

,l ike

pleu rody n ia and beginning pleuri sy ; (7) in pu lmonaryedema.

Vocal a anoe.—This is the confused humm ing sound

heard over the chest when the patient speaks . I t is modifiedby the same condi tions that modify the vocal frem i tus (seep.

Bronc lroplrony .—Thi s is exaggerated vocal resonance . I t

is heard norma l ly over the trachea , and abnormal ly overconsol idated lung (phthisis and pneumon ia) when the bronchiare free , over l ung that is compressed by pleural effusion ,

and over some cavities.Pcctoril oqny .

—This is a modification of voca l resonance inwhich the articu late speech is heard very di stinctly

,as though

com ing direct ly from the chest into the car. I t is more pronounced when the patient whispers .Pectori loquy is heard over : (I ) Cavities that communicatewith a bronchus ; (2) areas of consol idation m the neighborhood of a large bronchus ; (3) pneumothorax , when the

Open ing in the l ung rs patu lous : (4) some p leu ral effusions .Egop/rony .

—This is a modification of bronchophony , inwhich the sounds have a trembl ing or bleating qual ity .

I t is usual ly heard over sl ight pleu ral effu sions near the

upper border of du lness,espec ial ly near the inferior angle

of the scapu la.

PHYSICAL E XJ MI/VATION OF RE SPIRATOR Y ORGAlVS . 2 l3Adventi tious Bounds—These are not modifications of pre

existing sounds , but whol ly new sounds produced in the lungor pleura. They inc l ude rales

,the friction - so und

,metal l ic

tinkl ing,and succussion - splash .

Rdl cs.

—These are new sounds created in the trachea,

bronchi , ai r- vesicl es , or in cavi ties. They may be due to thepassage of ai r th rough l iqu id, through constricted tubes , orinto col lapsed air - vesicles .

Dry {WSibi lant.

(1 0 1.N W “ 1“

Moist Bubbl ingGurg ling.

Vesicular Crepi tant.

Dry rti/cs are probably produced by the passage of air

over very visc id sec retion in the tubes , al though they havebeen ascribed to the passage of air through bmnchial tubesthat are narrowed by s m o r by swe l ling of the mucosa.

They are heard particuiria

riy m bronch i tis and asthma. S ibi~lan t rales are whist l ing and high pitc hed ; sonorous raleshave a humming qual ity and are lower pi tched . Dry tales

may be heard on inspiration , expiration ,or on both .

Moi st ral cs resu l t from the presence of l iquid in the tubes ;the thinner the li qu id and the larger the tube , the coarserwi l l be the tales. They may be heard on inspiration

,ex

piration ,or on both .

Snk rcpitant or crackl ing rél cs are fine moist tales . Theyare heard in al l conditions that are assoc iated with l iqu id inthe smal ler tubes , as bronchi tis

,capil lary bronchitis , pu l

monary edema, and beginning phthisis .

Babbl ing rél cs are coarser than subc repi tant , and are heardin bronchitis , in resolving croupous pneumon ia , ove r phthisical deposits that are soften ing, and over smal l cavi ties .Gar-gang rei/cs are very coarse ,

and resemble the bu rstingof large bubbles . They are heard over large cavities that contain fluid , and over the trachea in the so - ca l led “ death - ratt le .

"

Crepi tant Rain—These are very fine rfiles ,

usual ly heardat the end of fu l l inspi ration . They may be simu lated byrubbing a lock of hair between the fingers . They have been

2 14 0 1? THE RESPIRA TOR v 5vsm y .

especial ly assoc iated with the first stage of croupous pneumonia

,and it has been supposed that they were due to the

forcib le separation of adherent vesicu lar wal ls . Rales verysim i lar to

,if not identical with , these are heard in pu lmonary

edema.

R ad ian - sounds are produced by the rubbing together of

roughened pleural su rfaces . They may be heard both in inspi ration and in expi ration, and often resemble subc repitanttales , but they are more superficial and loca l ized than the

latter,and are not modified by cough or deep inspi ration .

A roughened pleu ra in the neighborhood of the heartmay produce a friction - sound of cardiac rhythm , and one

which wi l l stil l continue when the breath is he ld ; underother conditions pleu ra l friction- sounds cease when respi ration is su spended .

Meta l l ic fi nk/ing—This name is applied to si lvery o r

be l l - like sounds that are heard at interval s over a pneumohydrothorax or large cavity . Speaking , coughing, and deepbreath ing usual ly induce them . Care must be taken not toconfound them with simi lar sounds produced by the presenceof l iqu id in a distended stomach .

Sucm sion - splas/e or Hippocratic Sucm ssion .

—This is a

splashing sound produced by the presence of air and li quidin the chest . I t may be e l ici ted by gently shaking the

patient while auscu l tating . I t is almost pathognomoni c of

hydropneumothorax or a pyopneumothorax .

A sim i lar splashing sound is often heard over a di latedstomach .

Mensurati on .— In measu ri ng the sides of the chest ob

serve the fol l owing precau tions : Measu re from a the m iddleof the sternum to the spinous processes measu re both sidesafte r inspiration and after expi ration ; app ly the tape withequal firmness to the two sides . In compari ng , measurecorresponding leve ls

,and

'

remember that the right side i sfrom half an inch to an inch greater in ci rcumference thanthe left .

The conditions that rende r one side more prom inent thanthe other have al ready been conside red .

Rad i oscopy .—In certain conditions of the chest radios

2 16 0 135457155 or 7115 RE SP IRATOR y s ysm u .

bath , with a fu l l dose ofDover '

3 powder,foll owed 1n the morn

ing by a Seidl itz powder or other sal ine aperient,often gives

exce l lent resul ts . When the patient is fu l ly able to go about ,the fol lowing capsules wil l usual ly afford considerable re l ief

81 . Pul veris camphorae

E x tracti be l ladonnaan gr. iss

Cinchoninx sulphatis gr. x ii —M.

Pone 1n capsules No . zij .Sto - Une every two or three hours.

Warm Dobel l’

s solu tion (see 37) or warm disti l led ex

tract of witch - haze l (di luted with 1 par t of water) used as a

spray at intervals , and fol lowed in a few m inutes by an 0 iapplication l ike the fol lowing , general ly renders satisfactoryservrce :

R . Mentho l gr. tijOle i u i p

um i l iu nis mPetro at i hqu id i q . 5. nd f§ j H—M

Defin i tion —A chron ic inflammation of the nasalmucous membrane.

E t i ol ogy .—Repeated attacks of acu te coryza, impu re

air , the continual inhalation o f i rri tating dusts or vapors ,lowered vita li ty

, and congen i ta l or acqu ired obstruct ion of

the nasa l chambe rs are causal factors . I t is sometimes anexpression of s hi l is .Var iet i es —f) S imp le ch ron ic rhin itis ; (2) hypert rophic

rhin itis ; 3) atr0 ph ic rhin it is .

S ymptom s —These consist in a m ucoid o r mucopu rulent discharge from the nose ; obstruction of the nostri lsfrom swe l l ing or hypertrophy of the mucosa o r from inspissated sec retion ; mouth - breath ing ; a nasal intonation of the

voice ; frontal headache ; and impairment of the sense of sme l l .Symptoms of catarrh of the ne ighboring organs are froquently present. The most common of these are : drynessof the throat and hawking from pharyngitis ; deafnes s fromcatarrh of the m iddle ear ; and watering of the eyes fromcatarrhal occ l us ion of the lacrimal canal .

C/ mom c NASAL CATAR/HI. 2 17

81111916 Ch ronic Rh initis.—The m ucous membrane of the

nose is congested , swo l len ,and high ly irritable. There is

hypersec retion of m ucus or mucopus.M annie Rhini tis—The mucous membrane is red and

the cavities are more or less occ luded from hypertrophy ofthe cavernous tissue covering the tu rbinated bones. In

advanced cases exostoses from the bony framework are

sometimes noted . The secretion is usual ly composed of

th ick mucopus. Adenoid growths are often found in the

nasopharynx.

Atrophlc Rhinit is (0m ) . —This form is seen most frequently in young adu lts

, and is more common in womenthan in men . The nasal chambers are large ; the m ucousmembrane is pa le, dry , and g lazed ; adheren t scabs are

general ly present. The sec retion is very abundant,th ick

,

and of a ye l lowish or greeni sh color. A characterist ic featureis the extreme ly offensive odor, which is probably due to thedecompos it ion of the retained sec re tion . In advanced casesthere may be nec rosis of the bones and sinking in of the

bri dge of the nose .

Prognosis—In the simple and hypertroph ic form the

prognosis is favorable under persistent treatment . In atrophie rhinitis perfec t cu re is rare ly atta inable, but great improvement is possibleTreatmen t —Any consti tutional vice ,

if present, shou ldrece ive appropriate treatment. Fresh air, outdoor exerc ise ,

and frequent bath ing , with fri ction of the sk in ,are to be

recommended . Ton ics , espec ial ly strychnin and cod - l iveroi l

,are often requ ired. The nasophary nx m ust be kept

c lean by means of antiseptic sprays , such as Dobe l l 's sol ution (see p. 37) or the fol lowing :

B. Sod ii hicnrhonatis

Scali bom b s M gr. x xxSor l i i ch lorid i

Thym l

Menthol”lei gaul therireGlycer iniAlcoho l is

2 1 8 0 1554 353 0 1 : 7715 RE SP IRATOR V s ys rs zv.

In the hypertrOph ic form loca l remedies of an astringent oralterative character are often efficac ious . The fol lowing arein common use : A m ixture of iodin and glycerin containing 6 grains of iodin

, 1 2 grains of potass ium iodid , and 1

ounce each of glycerin and water ; aqueous solution of

ichthyol (20 to 40 per cent ) ; solution of zinc su lphocarbolate(2 to 5per cent ) ; and solu tion of si lver n i trate (t to 2 per

cent.hen the hypertrophic process proves resistant, the

obstruction must be removed by means of caustics (chrom icor tr ich loracetic ac id), the ga lvanocaute ry , o r the snare .

In atrophic rhin itis the crusts may be removed by pledgets of cotton soaked in a so lution of hydrogen dioxid . After

the nares have been thoroughly c leansed, an oi ly solutionli ke the fol lowing may be appl ied

Petrolati l iquid iFor destroying the offensive odor one of the fol lowingapp lications may be used : Pledgets of cotton soaked in an

aqueous solu tion of ichthyol (20 to 50 per cent ) ; sprays offormalin (t of Laba rraque’s sol ution (1 or of

potassi um pe rmanganate (2 grains to the ounce) .

Defini ti on .—An acu te catarrhal inflammation of the

larynx .

E ti ol ogy .— Improper use of the voice , exposu re to cold

and wet,and the inha lat ion of irri tating dusts or vapors are

its common causes . I t may be exc ited by the impaction of

a fore ign body. I t is a lso an assoc iated condition in certaininfectious diseases

,l ike whooping- cough

,meas les , diphtheria,

and influenza.

Symptom8 .—The chief symptoms are : Hoarseness of

the voice or aphon ia ; hard , ringing cough ; pain in the

throat, increased by speaking , coughing, and swal lowing ;

expectoration,which is at first scanty and later mucopuru lent

220 DISEASE S OF THE RE SPIRATOR Y S YS TEM

Symptoms .—General ly there has been a l i tt le hoarseness

and cough du ring the day ,and at n ight the chi ld is awak

ened from s leep by a seve re paroxysm of suflocadve cough .

The latter has a pecu l iar, hard , meta l l ic qual i ty , and is assoc iated with the evidences of dyspnea, name ly : anxious face,

di lating nostri ls,prom inent sternoc leidomastoids

,and retrae

tion of the base of the chest with each insp iratory effort .Du ring the paroxysm the ski n is hot and the pu lse is tenseand rapid. In from a few moments to an hou r the coughceases , free perspiration fol lows , and the chi ld fa l ls as leep .

Two or th ree sim i lar attacks may occu r in the same n ight,but on the fol lowing day the chi ld appears qu ite we l l . Arecu rrence of the se iz ures for several success ive n ights is notinfrequent.

(Diphtheria).—Hoarseness and dyspnea deve lop gradual ly ,and the latter is not intermittent. False memb rane may beseen in the throat o r may be coughed up. The constitu

tional symptoms are more severe.

Laryngim us M ul es—This is a pu re neurosis,and is

often assoc iated with the rachitic diathesis . The paroxysmsresemble those of false croup , but are assoc iated with a pecul iar crowing inspiration,

and lack catarrha l symptoms, suchas hoarseness and cough .

Prognosi s .—A lways favorable.

Treatment —A sponge moistened with hot water maybe appl ied to the th roat , or the chi ld may be placed in a hotbath . If these simple meas u res fai l, an emetic wi l l almos tinvariably bring

!

re l ief..Wine of ipecac (r dram) may bese lected . Subsequent treatment shou ld be di rected to the

laryngea l catarrh . A mix tui e l ike the fol lowing wil l befound usefu l

B Tinctures aconiti

re

Fat-ssh citn tis

Sympi tolutaniAqure q . a. nd —M.

Sta—A tm poonfu l every two or three hon a ehfld of twoyears .

CHRONIC LAR l ’NG/TIS . 22 !

l aryngi tis.)

See Laryngea l D iphtheria.

fol low an acute attack , or i t may deve lop gradual ly fromoveru se of the voice, excessive smoking, or inhalation of

dust or irri tant vapors .Symptoms—These consist in moderate hoarseness , apho

nia after continued speaking , s l ight cough , and scanty expectoration of grayish mucus tinged with dust or otherimpu ri ties .Lary ngoscopio ex amination revea ls redness and swe l l ing

of the voca l cords or of the entire larynx.

Treatment—The use of the voice shou ld be restricted .

Coexisting nasal or pharyngea l d isease shou ld receive attention. The patient must learn to use the voice properly,expe l l ing sounds by the abdom ina l musc les and diaphragm,

and not by the musc les of the throat . Flanne l protectorsshou ld be avoided , and the appl ication of cool water to theneck , night and morn ing, instit uted in their stead . Tonicsare frequent ly indicated.

Thorough c leans ing of the nose ,throat , and larynx sho u ld

be secu red by means of m i ld al ka l ine sprays (Dobe l l 's sol ution). Astri ngent spray s l ike the fol lowing are usefu lZ inc acetate

, 3to 5grains to the ounce ; zinc su lphocarbolate . 2 to 3grains to the ounce ; al um , 3to 5grains to theounce . Direc t appl ications of si lver nitrate (3 to 5grainsto the ounce) are also very cfl‘icacious .

Tubercu l ous l a ryngi ti s .—This may be primary , butit is more often secondary to tubercu los is e lsewhere , espe

c ial ly the l ung.

BW These consist in hoarseness , aphonia, hack ingcough , and pain in the th roat, increased by coughing, speaking, and swal lowing.

222 DISEASES OF THE RE SP I RATOR Y S YS TE MLary ngoscopic E ramination .

—The mucous membrane isswol len , pal e, and edematous . The arytenoid carti lages areespecia l ly involved , and the membrane between them isoften the seat of a hi l l - l ike infi ltration . Tubercu lous u lcersare usual ly shal low and have a broad base , an irregu lar outl ine , and an uneven surface. They are extremely painfu l .Treatmen t .—The general treatment shou ld be that of pu l

monary tubercu losis . The parts shou ld be frequentlyc leansed with a lkal ine detergent sprays . Terebene

, com

pound tinctu re of ben zoin,o r eucalyptol may be used in a

respi rator o r inhaled from the su rface of boi l ing water.

Radica l treatmen t consists in rubbing in,under cocain anes

thes ia,lactic ac id (30 to 75pe r cent . solu tions) . Pal l iative

treatment consists in applying cocain in solu tion (4 toper cent.) or o rthoform , morphin ,

or iodoform in powde r.

The fol lowing insufflation is u sefu l :

Acid i boriciMorph inre su lphat is

Sy ph i l i ti c lary ng i ti s may man ifest itse lf as a catarrhalinflammation , mucous patches , gummatous infi ltration ,

o r

u lceration . The u lcers are more or less c ircu lar, deep, andsharply c ircumscribed . They are frequent ly found on the

epiglottis . Rapid necrosis and exfol iation of the carti lagemay fol low . Pain is often sl ight.Diagnosis—The h istory , the presence of other syphi l iti clesions , the deep , c lean - c ut , rapidly spreading u lcers , the effectof treatment , and the absence of marked pain and of pu lmo

nary lesions we l l serve to distingu ish syphi l is from tuber

‘l'm tment .

—Consti tu tional treatment with iodids and

mercu rials is of the first importance . Local c lean l inessshou ld be secu red by thorough spraying with some a lkal ineantiseptic solution . Ulcers may be touched with si lvern itrate (me lted on a si lver probe) , ac id ni trate of mercu ry ( lto 5parts of water) , or chrom ic ac id t to 8 parts of water).Insufflations of iodoform are also usefu l . Cicatric ial stenosis may cal l for gradual di latation or even tracheotomy.

224 D ISE AS E S or rm: RE SP IRA TOR 1' S l'

S'

I‘

fi M

B. Snd i l bromid i

Antipyrini x x - xxx

$16 .- A teaspoonfu l four times a day .

(Bdem of theGl otti sJ

Defin i ti on .—An infi ltration of serous flu id into the sub

mucous tissue of the larynx .

E tiol ogy .—It occas iona l ly resu lts from s evere attacks

of catarrhal laryngitis . I t may be induced by severe in

flammation of neighboring organs—as the tonsi ls , parotidglands , and pharynx. I t may be a complication of someacu te infect ious d isease—l ike diphtheria, scar let fever, or

facial erysipe las . I t 1s sometimes assoc iated with u lcerativeaffections of the larynx , l i ke tubercu los is and syphi l is . I tmay be exc ited by the i rritat ion of burns , sca lds , o r caustics .I t occasional ly occurs abruptly in the course of Bright'sdisease.

Path ol ogy .—The connective tissue of the larynx is in

fil trated with a serous or seropuru lent fluid . The mucousmembrane is tense and changed in color.

Symptoms.- These are : hoarseness of the voice

, and

later aphon ia ; extreme dyspnea,at fi rst on inspiration , but

later on expi ration also ; stridu lous respiration ; barki ngcough ; and the evidences of dyspnea—name ly

, anx iousface

,protruding eyes , blue l ips , prom inent sternoc leido

mastoids , and retraction of the base of the chest. Whenthe epiglottis is involved

,the swe l l ing can be detected by

the finger in the th roat.Lary ngasmpic E x amina tion—The mucous membrane isswol len and of a reddish - pu rple color. The epiglottis mayresemble a round , t rans lucen t tumor. In infraglott ic edemathe upper part of the larynx may appear normal

,but swol len

and edematou s membrane is seen projecting through theglott is . The voca l cords are rare ly affected .

Prognosi s .—F. x treme ly grave .

Treatmen t —Mi ld inflammatory edema sometimes yie lds

BA’ON C/I I TIS. 225

to the suck ing of ice , loca l blood letting , the appl ication of

ice to the neck , astringent sprays (al um ,adrena l in, tann ic

ac id) , and the adm in istration of sa line purges. When the

symptoms become u rgent, the parts shou ld be scar ifiedunder cocain anesthesia

,and if th is fa i ls

,tracheotomy should

be performed at once.

DlSEASES OF THE LUNGS.

Defini tion —An inflammation of the bronchia l tubes ,characterized by substemal soreness , cough , mucopuru lentex

%ecto ration ,

and d ry and moist rales .ar iet i es. Acute catarrha l bronchitis ; (2) chronic

catarrhal bronchitis ; (3) fibrinous bronchi ti s.

E ti ol ogy .—A cold

,damp c l imate ; changeable weather ;

occupations that necess itate confinemen t or the inhalat ionof irr i tating dusts or vapors ; the gouty diathesis ; and

chron ic heart disease are general predisposing fac tors .E xposu re to cold and wet , particu larly when the body isoverheated , or the inha lation of irri tating gases o r dusts isthe us ua l exc iting cause . Acute bronchitis is also an assoc iated condition in certain infec tious diseases , espec ial lymeas les , whooping- cough , ty phoid fever, and influenza.

M icro- organ isms (streptococcus , staphylococcu s ,and pneumococcus) are withou t doubt important etiologi c factors .Path ol ogy —E most cases the trachea and large tubeson ly are affected . The mucous membrane is red ,

swol len,

injected , and more or less covered with tenacious mucopus .Microscopic exam ination revea ls desquamation of epithel i um and infi ltration of the submucous tissues with leuko

S ymptoms —The chief featu res are : Chi l l iness ; malaisea sense of soreness and constr iction behind the sternum ,

which is increased by coughing ; sl ight fever (10 0 ° to 1 0 2°

wi th its assoc iated symptoms ; and cough, which is at

10

226 DISEASES OF TIIE RE SP IRATOR Y S YS TE Mfirst dry and painfu l , but late r accompan ied by free m ucopuru lent ex ctoration.

Ph y si cal) e

— Inspection,palpation,

and percussionusual ly give negative resu lts .Auscu ltation at first reveals sibi lant and sonorous rales

on both sides of the chest, and in the second stage, whe nsec ret ion is establ ished

,mois t rales .

Diagnos is .—Influenza .

—High fever, severe pain in the

head,back

,and l imbs

,and great prostration wi l l serve to

distingu ish influenza from bronchitis when the former ispreva lent.Catarrhal Pneumonia.

—Moderately high and irregu la rfever , prostration.

pronounced dyspnea,cyanosis , and phy

s ica l signs indicating conso lidation wi l l aid in the recogmtionof pneumon ia.

Prognosi s.—Favorable. In the old, young, and feeble

there is danger of its leading to capi l lary bronchitis o r ca

tarrhal pneumon ia . The du ration is from one to th ree weeks .Treatment —Ir the patient be weak or old , he shou ld

be confined to h is room or even to bed ; the atmosphereof the room shou ld be kept warm and moist. If the patientbe seen at the outset, it is usefu l to promote free d iapho

res is , and this may be accompl ished by means of a hotfoot - bath , with hot drinks and a fu l l dose of Dover's powder . Counteri rri tation to the chest in the form of sinapismso r stupes is very benefic ia l . The food shou ld be s imp le

and readi ly digestible,and the bowe ls shou ld be kept reg

u larly open by the aid of m i ld aperients . In the earlystage ,

when there is no sec retion,sedative expectoran ts

ipecac , potassium c itrate,tartar emetic , and apomorphin

are indicated . I t is usual ly necessary to add a sedative ,

l ike opium or one of i ts derivatives (code in ,to grain , o r

heroin, 11, to grain) to al lay the distressing cough . S uch

combinations as the fol lowing wi l l be found usefu l :8 . Potassn c itrat is . .

Vini ipecacuanhxe

Tincturre opi i camphoratse

Sucei l imonis

Syrupi

Sta—A tablespoonfu l every four houn .

238 353 0 1"

R l z'

SP l Ral TOR r s I’

S TE J I .

E tiol og y .- It may resu l t from th e continuation of an

acute attack ; but more frequently it deve lops gradual ly inassoc iation with gout o r chronic heart o r k idney disease .

I t is espec ial ly common in th e old . I t is an assoc iated condition in emphysema

,phthisi s

, ch ron ic intersti tia l pneumon ia,and in many cases of asthma.

Path olog y.—The m ucous membrane of th e bronch i issometimes thickened and roughened from an overgrowthof the connective tissue ; in other cases the m ucosa is th infrom atrophic changes . The su rface is usual ly covered withmucopus ; u lcers are occasional ly noted.

Long- standing bronchitis leads to di latation of the tubes(bronchiectasis) and to emphysema.

Symptoms—The chief featu res are : Pe rsistent coughwith more o r less mucopu ru lent expectoration ; a sense of

soreness behind the sternum . Fever is usual ly absent , andun less the disease is very severe, the genera l hea l th may be

fairly we l l preserved . Dyspnea on exertion is sometimesa troublesome symptom ; it, however, be longs more to theresu lti ng emphysema than to the bronchitis .Ph ysi cal S igu 8 .

—Un less emphysema has deve loped ,inspection

,pa lpation , and percussion give negative resu lts .

Auscu l tation reveals rales , some of which are dry and

wheezin whi le others are mois t and bubbling.

S Varieti es Rheumatic bronchit is ; (2)bronchorrhea ; (3) d ry catarrh .

Rheumatic Bronchiti s—This form occu rs in those of a

rheumatic diathesis , and is characterized by severe paroxy smal cough , the expectorat ion of scanty , tenac ious m ucus ,and aching pa ins in various parts of the chest. I t is especia l ly influenced by atmospheric changes

,and does no t

yie ld to the ordinary treatment of bronchitis .Bronchorrhu .

—This term is appl ied to cases of ch ron icbronchitis wh ich are assoc iated with a very copious ex pec

toration . The spu tum is general ly mucopuru lent, and

sometimes very ofl'

ensive (fetid bronchitis) .

BRONCE / 773. 229

Dry Catarrh .—This form , desc ribed by Laennec as m

ta rr/r: Se’t' , is characteri zed by severe spe l ls of coughing thatare accompanied by l ittle or no expec toration. I t is general ly seen in the old in association with emphysema or

asthma.

D iagnosi s.—Phthisis.

—The absence of fever, of hemorrhage ,

of bac i l l i in the Sputa,and of signs indicating con

sol idation wi l l serve to distingu ish chron ic bronchitis fromphthisis .Bronchiactu im—This often res u l ts from chron ic bron

chitis . I t is characterized by paroxysms of cough attendedwith the expec toration of large quantities of pu ru lent sec ret ion of an extreme ly offens ive odor . There may be , al so,phys ica l s igns of one o r more cavities near the root or baseof the lung.

Emphysema—Marked dyspnea, distention of the chest ,hype rresonance on percussion

,and a prolonged feeble ex

pi ration on auscu ltation wi l l indicate emphysema.

Sequel e .—Emphysema, bronchiectasi s. and di latation of

the right ventri c le.

Prognosi s—Perfec t recove ry is rarely attainable , but the

disease is not incompatible with long life .

Treatment —Treatment m ust be directed toward the

preven tion of recu rrent attacks , and the removal . if possible ,of the underlying cause . Change of c l imate , especially inwinter, is most benefic ia l. When there is much sec retion, a

d ry ,warm c limate is general ly to be recommended , whereas

if there be l itt le ex pectoration , a moist warm c l imate ispreferable . When patients cannot afford to t ravel

,they

should remain indoors as m uch as possible in bad weather,and take every precau tion aga inst exposu re . Flannel shouldat al l times be worn next to the skin , the feet shou ld be keptdry , and night air shou ld be avoided .

Unde rlying chronic diseases shou ld rece ive appropriatetreatment . When cardiac insufficiency is present , digital isor strychn in wi l l be requ i red . When there is genera lmalnutrition ,

such remed ies as i ron , arsen ic ,cod - l iver oi l

,and

hypophosphites may be given with advantage. When gou tis a factor, iodids and al kal i s wil l prove se rviceable.

230 D ISEASES OF THE RESPIRA TOR Y S YS TE M.

The most usefu l direct r emedies are the stimu lant expectorants , such as terebene, oi l of eucalyptus , myrtol , oi l ofsantal , oi l of copaiba

,oi l o f cubeb, and tar. When the

sputum is heavy and pu ru lent,no drug acts so wel l as c rea

sote or the carbonate of guaiacol . Potassium iodid may betried when the expectoration is scanty and viscid. Mi ldanodynes—heroin or codein—are often necessary to controlharassing cough . The fol lowing formu las wi l l i l lustrate themanner in which these remedies may be combined

3. Terebi ni

Olei eucnl priOlei san i . M f3j- iss

. gr . i ij - vj . M .

Pone in capsules No. xx iv.0

StG.—One after each meal and at bedt ime .

B. Terpini hydn t is

Guaiaco l carbonatisStrychninm su lphetis

Pone in capsules No . x x iv.

S IG—One or two capsu les th ree o r four times a day .

t . i ij .—M.

B. Apomorph inte hydroch lorat is . .

Syrupi pruni vi rgin iana:

Syrupi picis l iquid s:

Sta - A tablespoonfu l thrice dai ly. (MURRE LL )

Inhalations (euca lyptol , terebene ,oi l of Scotch fir

,com

pound tinctu re of benzoin , etc .) are often efficac ious . Sucha mixtu re as the fol lowing may be employed several times aday in an oronasa l respirator :

R . Chlorofiortn i

'

l'

erebini

Olei pin i sylvestri s an fg iss

Alcoho l is q . 5. ad fzj .S tc —From 5to 20 drops to be used in the inhaler several times

a day.

Counter-inflation , preferably with iodin or smal l bl isters , isoften of great se rvice in lessening the severi ty of acuteexacerbations .

232 DISEASES OF THE RE SP IRA TOR Y S YS TE M .

bronchitis. In the ch ronic form potassi um iodid may alsobe given .

Defini ti on .—A uniform o r ci rcumscribed di latation of

the bronchi .E ti ol ogy .

—Ir is most frequently t he resu lt of chron icbronchitis , weakening of the wal ls of the bronchi from the

inflammation and increased pressu re from the violent coughing be ing the determining factors . I t is occasional ly ex ci tedby obstruction to a bronch u s from a foreign body or thepressure of an aneurysm. Final ly

,the contraction of over

grown connect ive tissue in fibroid pneumon ia,

chron icphthisis , and chron ic pleu ral thicken ing sometimes inducesmarked ectasy.

Path ol ogy .—Two forms are noted : (I ) The cylindric

form , in which the t ubes , particu larly those of medi um size ,

are uniform ly di lated in one o r both l ungs ; and (2) thesaccu lar form , in which the tubes swel l out , here and there ,

in to c ircumscri bed di latations that may reach several inchesin diameter. Bronchiectatic cavities are l ined with mucousmembrane ,

but the latter is often atrophied,indurated , or

u lcerated .

Sm ptoms —The chief symptoms are paroxysmal cough ,dyspnea,and copious expectoration . The last is character

istic ; i t is apt to occu r periodica l ly in gushes ; the materialhas a high ly offensive odor , and when al lowed to stand in a

glass vesse l , separates into th ree layers : an upper layer ofdirty brown froth , a m iddle layer of tu rbid mucus , andunder layer of decomposed pu s . Microscopical ly, it containspus

- corpusc les , fat crystal s , crystals of hematoidin ,and

numerous micro- organ isms , bu t no tuberc le baci l l i . E lasticfibers are rarely found . Hemoptys is is not uncommon.

Ph ysi cal S im —In the cylindric var iety the signs arethose of chronic bronchi tis . The saccu lar vari ety may present the sign s of tube rcu lous cavities— l ocal i zed tyrapany .

cavernous breathing , gu rgl ing rales , and pectori loquy. Bron

4 37m m. 233

chiectatic cavities are usual ly near the root or the base of theInn

M .—t —The marked constitu tional symptoms

,the apical location of the cavities , the signs of consol i

dation around the cavities , and the presence of tuberc le bac i l l iin the spu tum wi ll establish the diagnosis .Prognosis

—There rs l i tt le prospect of cure, but l ife maybe prolonged indefin itely.

Treatmen t .—The general treatment is that of ch ronicbronchitis . The most usefu l expectorants are oi l of euca lyptus ,oi l of santa l , terebene , tar, guaiacol carbonate , and crea

sote . Inhalations of terebene , carbolic ac id , creasote , etc .,

lessen cough and aid in destroying the fetid odor of the

breath . When a single large cavity can be definite ly locatedin the lower lobe , inc i sion and drainage may be considered.

ASTHMA.

Defin i tion —Paroxysmal dy spnea due to spasm of the

bronchi or to sudden swe l ling of the bronchial mucosa.

E t i ol ogy .—Asthma is a symptom of several diseases ,

but a hypersensiti ve condition of the mucous membrane of

the respi ratory tract appears to be essen tial to i ts produc tion .

When this condi tion preva i ls , asthma may be induced— (l )By the pu lmonary congestion of cardiac disease (cardiacasthma) ; (2) by the urem ic intoxication or transient pu lmonary edema of Bri ght’s disease (renal asthma) ; o r (3) bysome irri tant from without , as the pol len of plants (hayasthma) ; (4) sometimes the paroxysms are exc ited by themost tri via l causes , as an atmospheri c change or a pecu l iarodor , and to this form many wri ters restrict the term asthma.

This last wi l l be disc ussed under the head of E ssentialAsthma.

(Bronch ial Asthma ; Nervous Asthma ; Spasmodic Asthma.)E ti ol ogy .

—Hered ity ,a neu rotic temperament , and les ionsof the upper air - passages (hypertrophic rhini tis

,polyps , etc . )

are predisposing factors . More males are affected thanfemales . I t may deve lop at any age. Atmosphe ri c changes ,

234 or 71 1 15 RE SPIRA f or v s vs 72541 .

the inhalation of certain kinds of dust , the odor of certainan imal s or plants , reflex i rri tat ion , indigestion ,

a change of

loca li ty,o r bronchial catarrh may serve as an exci ting cause .

Path ol ogy —The disease is a pu re neu ros is, and the

paroxysms probably resu l t from spasm of the bronchia lmusc les or a sudden vasomotor tu rges cence of the bronchia lmucosa.

Sm ptomS .—The paroxysms often appear sudden ly , but

in some cases certain symptoms precede and give warningof the approaching attack ; among these are chil l iness ,flatu lence ,

sneezing , and a copious discharge of pa le u ri ne.

The attacks most often occur at n ight . There is a sense of

oppression and anxiety , fo l lowed by dyspnea so intense thatthe patient runs to the window for ai r, o r sits Upright withhis arms in such a pos i tion that he can bring into play theauxi l iary musc les of respi ration . The face is pa le and

anxious, the l ips are bl ue , and the su rface is cove red with

profuse pe rspi ration . The respirations are not rapid , bu tlabored and noisy . Cough is usua l ly present , and is assoc iated with the expectoration of thick

,tenac ious muc us .

On cl ose exam ination l itt le gray ish pl ugs can be detected inthe sputum . These , under a pocket - lens , are seen to consistof del icate spi rals of mucus that have been molded in the

fi ner bronchioles (Cu rschmann 's spiral s) .Micro scopic examination al so reveal s eosinophi le ce l ls andoctahed ral crysta ls (Charcot - l . eyden c rystal s).The paroxysms may last from a few m inutes to manyhou rs , and may recu r fo r several successive nights , or maydisappear entire ly fo r weeks o r months .Ph ysi cal S igns.

— I~sped iorz reveals expi ratory dyspneaand distention of the chest .Percussion revea l s hyperresonance .

Aux u l tntrbfl.

—Vesicu lar breathing is weak and obsc u redby abundant sibi lant and sonoro us rales . The latte r are especial ly marked in expi ration ,

which is greatly p rolonged andwheezy .

D iagnosi 8 .—0ardiac and renal asthma are to be distin

gu ished from essential asthma by the history and by theevidence of organ ic heart o r kidney disease .

236 0 1354 555 OF THE RESPIRATOR y s rsn zu .

a few whifl'

s of chloroform . If such measu res fai l toafford rel ief

,in ternal remedies must be used . In some

cases strong hot coffee acts most happi ly ; in others morebenefit is derived from hot whisky and water. Among thenumerous spec ia l remedies tha t have been advocated thefol lowing appear to be the most re l iable : opium , be l ladonna,

brom ids, ch lora l, paraldehyd , Hoffmann 's anodyne, lobel ia,

and quebracho.Few attacks wi l l res ist the act ion of morphin hy poder

m ical ly with atropin,but the greatest cau tion must be ex

ercised in order that the patient may not become addictedto the drug. Heroin hydroch lorid hypodermical ly , i n dosesof from 1

1, to 116 grain,

may often be substitu ted for morph inwith great advantage. When the attacks are assoc iatedwith bronchial catarrh , a comb ination l ike the fol lowingsometimes proves efficacious

B. Tinetune bel ladonna .

‘

l‘

ineturae lobe l ia

uss

E l i x iris uromntic i q. s. ad fgiv.-

.M8 10 -A dessertspoonfu l i n water every two or three

Among other measu res that have been found usefu l inal leviating asthmatic attacks may be mentioned the appl icat ion of sinapisms to the chest , the inhalation of compressedair

,and the in ha lation of oxygen .

HAY ASTHMA.

(Bay - fever ; Autumnal Catarrh ; Bose- col d. )

Defin i tion —A catarrha l affection of the upper air- passages , characterized by coryza and asthmatic se izures , andevoked by irritation of a hyperesthetic nasa l mucous membrane .

E t iol ogy .—An inheri ted tendency , nervous tempera

ment,indoor l ife , and chron ic nasa l d isease are predispos

ing factors . The attacks , as a ru le, occur in the autumn

(autumnal catarrh) or in the spring (rose - cold) , and are ex

c ited by certain dusts,vapors

,or odors . The pol len of

I’L

’

I.MONA )?Y E MF}! VSE MA. 237

plan ts seem s to be a common exc itant. The sei zures mayoccu r at any time if the pecu liar irri tant is present.Path ol ogy .

- An essen tial feature is the hypersensitivecondi tion of the mucous membrane

,and this i s often

,though

not invariably , assoc iated with hyper trophic rhin i tis .Symptoms.

—Redness of the conj unctiva: and swe l l ingof th e eye l ids ; pru ri tus of the nose and eyes ; sneez ing ;obstruction of the nostri ls ; watering of the eyes ; a copiousdischarge of mucus from the nose ; headache ; cough ; andasthmatic attacks are the usual phenomena.

Rose- col d usual ly begins in May or June and runs to thelatte r part of j u ly. Au tumnal catarrh begins in the latterpart ofAugust and ends with th e first frost.Progn0 8i 8 .

—The disease never proves fatal , bu t permanent cure is very rare .

Treatmen t —Carefu l search shou ld be made for chron icnasa l disease

,and if found ,

appropriate treatment insti tuted.A change of c l imate du ring the period of susceptibi l ity

exempts most pat ients . A sea- voyage or a sojourn in somehigh - mountain district

,l ike the White Mountains , Ad iron

dacks,Catski l ls

,or A l leghan ies , may be recommended.

Ton ies such as qu in in , arsen ic , and stry chn in are oftenvery usefu l when adm in istered before and du ring an attack .

To al lay itching and lac rimation the eyes may be washedwith a sol ution of boric ac id (1 0 grains to the ounce) o rsu lphate of zinc (t to 2 grains to the ounce). Sneezing,nasa l fu lness , and disc harge are oflen re l ieved by medicated sprays (Dobe l l 's so lut ion ) o r the appl ication, on

pledgets of cot ton ,of adrenal in solution (I

Defin i tion .—Abnormal disten tion of the l ungs with air.

Var iet i es —( i ) Inter lobul ar Emphy sema .—This form is

rare,and resu l ts from the rupture of the air- vesic les and the

escape of ai r into the in tersti tia l t issue.

2) compensatory Emphy sema—This is a vicarious distention of one part of the lung ,owing to pathologic changes in

another part of the organ . I t is primarily physio logic,

240 OF THE RESPIRA TOR Y S YS TE /V.

be placed under the mos t favorable hygienic conditions.I ron is indicated in the anem ic. S trychn in (1 15 to 315grain)is a valuable respiratory and cardiac st imu lant , and may becombined with digital is when there are symptoms of heartfai l u re.

Ferri reduct i n gr . x x .—M.

Fiant pi lula: No . x x .

S lO.—One thrice dai ly .

The inhalation of oxygen , o r the inspiration of compressedai r, fol lowed by expiration into rarefied air, is sometimes ausefu l measure.

HEMOPTYSIS.

Defin i tion —The ex pectoration of blood .

E ti ol ogy .—The chief causes are : (l ) Traumatism. (2)

Certain organ ic diseases of the l ung , espec ia l ly tubercu los is ,lobar pneumon ia

,bronchiectas is

,gangrene

,infarct, and can

cer. (3) Passive congestion the resu lt of heart disease ,

espec ial ly m itra l lesions . (4?Ruptu re of an aortic aneu r

y sm . (5) D iseases profound y affec ting the blood , such as

purpu ra, hemophi l ia,scurvy

,and leukem ia. (6) U lcers ,traumatic , syphi l i tic , or mal ignant , of the trachea or larynx.

(7) Vicarious menstruation (ve ry rare).Sm ptoms.

—Sometimes the bleeding is preceded bycough , dyspnea, or substemal warmth or tenderness

,but

often there is no premon ition , and the fi rst indication is thepresence of a warm sal ty flu id in the mouth . The blood isgeneral ly raised by coughing , and is bright red and frothy.

I t is alka line in reaction, and in timate ly m ixed with air and

m ucus . The hemorrhage is rare ly profuse un less it resu ltsfrom the ruptu re of an aortic aneurysm or the u lceration of

a large vesse l in advanced phthis is . Auscu ltation of the

chest reveals bubbl ing rales . The s ubsequent expectorations are tinged with blood , and if much is swal lowed

,it

may exc ite vom i ting or pass into the intestine and impart a

tarry appearance to the stools .

HE N ORA’IIAGIC INFARCT OI" THE LUNG. 24 !

D iagnosi s.—The differen tia l d iagnosis between m(men

'

s and hemoptysis has been considered on page 63.

Prognosi s.—Th is depends upon the cause . I t is rare ly

fata l , except in aneurysm and in advanced phth isis with a

la e cavity.

uncu t —Absol ute rest is essential . An ice - bagmay be placed over the suspected seat of the hemorrhage ,

butit shou ld be removed if i t aggravates the coughing. Bitsof ice may be gi ven to the patient to suck . There is nomore usefu l remedy than morphin,

which serves to al layexci tement and to check cough. I t is best given hypodermica l ly . The application of firm l igatures to the l imbs mayprove efficacious by lowe ring the intrapu lmonary pressu re .

When the hemorrhage is protracted ,a sa l ine purge is sometimes u sefu l . Among other remedies that seem to be of

se rvice may be mentioned oi l of erigeron,flu id extract of

hamame lis , and ge latin. E rgot is use less,and so is the

inhalation of vapori zed sol utions of astringent drugs.

(Pulmonary Am la y . )

Defin i tion —A c i rcumscribed area of necrosis infi ltratedwith blood .

E ti ol ogy —The most common cause of pu lmonaryinfarct is obstruction of a branch of the pulmonary arteryby an embolus com ing from the right heart o r the genera lvenous system. In some cases the obstruction is caused bya thrombus , the formation of wh ich has been favored bycardiac weakness .Path ol og y —The infarct is usual ly located in the per

iphery of the l ung it is conic in shape , with its apex pointing inward . The port ion affec ted is firm ,

airless , and of a

dark - red color. Microscopic exam ination shows a denseaggregation of blood—corpusc les .If the process lasts long enough , the dead tissue and

blood are slowly absorbed and replaced by a c icatri x .

Symptom —When the infarct is large,the usua l symp

toms are dyspnea ,cough , and the expectoration of dark

242 D ISE ASE S OI" 7'

HE RE SP IRATOR Y S YS TE Mblood contain ing few air- bubbles . These symptoms occu rring in chron ic heart- disease are espec ia l ly suggestive.

Ph ysi cal SW —Ve ry la rge infarcts may give du lnessand bronchia l breath ing.

Treatmen t .—The condition i tse lf is not amenable totreatment . Remedies shou ld be directed to the primarydisease.

ACTIVE OONGB TION .

E t iol ogy .

to the l ungs . V iolent exerc ise ,mountain c l imbing , and the

inhalation of irritants may produce i t I t is an assoc iatedcondition in a l l severe inflammatory diseases of the lungs .In the vast majori ty of cases i t marks the in itia l stage of

croupous pneumonia.

Path ol ogy .—The lung 15 bright red in color, heavy, and

less crepitan t. When inc ised and pressed , copious frothyblood exudes .

Symptoms —The chief symptoms are dyspnea ; a short ,dry cough , fol lowed by frothy , blood- streaked sputum ;and a rapid , fu l l pu lse. The presence of fever indicatescommenc ing pneumonia.

Mower) ! a d m iration reveal s s light du lness, crepitant rales ,

and bronchoves icu lar breath ing.

Treatmen t —The measu res most l ike ly to effec t dep letion of the lung are complete rest, the appl ication of dry or

wet c ups to the chest , and the admin istration of veratrumvi r ide and a sa l ine pu rge .

E ti ol ogy .—This resu lts from obstruction to the flow of

blood from the lungs to the heart. The chief cause is cardiac disease , pec ial ly lesions of the m itra l valves and weakness of the lgft ventric le from fatty o r fibroid changes .Path ol ogy .

—The l ungs are dark red i n color, and oftensomewhat edematous . When the condition has lasted a

long time, the organs become brown ,dense, and tough

244 DISEASES OF THE RESPIRA TOR Y S YS TE M

Defini ti on —An effusion of serous flu id into the air

vesic les and interstitial t issue o f the lungs .E ti ol ogy .

—(i ) It is frequent ly caused by passive hy perem ia

,the resu l t of ch ron ic heart disease . (2) I t may be a part

of a general dropsy induced by Br ight 's disease . (3) I t isa common cause of death in conditions that lead to heartfai l u re , such as grave anem ia

,cerebra l lesions

,and acute

infections .Loca l pu lmonary edema is often found around abscesses ,infarcts , and areas o f consolidation .

Path ol ogy —The lungs, espec ial ly the dependent po rtions,are heavy ,

red in color, and boggy to the fee l . When

the affec ted port ion is inc ised and subjec ted to pressu re , abundant blood - stained

,frothy serum exudes .

Symptoms—These cons ist in dyspnea, cyanosis , cough ,and the expectoration of large quantities of frothy , serousflu id . Occasional ly the Sputum is blood - stained . The sk inis often cold and l ivid . There is no fever.

Pig/aka! ex am ination revea ls feeble tacti le frem itus , du lness , weak breath - sound

,and numerous fine ,

moist rales.D iagn osis .

—0ronpous Pneumonia—This is characteri zedby a chi ll

,fever

,pa in

,rusty expectoration ,

and signs of consohdafion .

Hy dmthm .—In th is condition there may be enlargement

of the affec ted side ,with displacement of the apex - beat.

The upper leve l of du lness is often movable,and frothy

sputum and t it les are absent .Prognosi s .

—A lways grave. I t is often a term ina l symptom of the disease in which it occu rs . When not far ad

vanced,and the primary disease is amenable to treatmen t

recovery may fol low .

Treatment —When there is much cyanosis and the

patient ’s strength wi l l perm i t it , the appl ication of wet cupsto the chest or bleeding from the arm is o f great va lue .

Hot fomentations shou ld be appl ied to the chest . Hyd ragogue cathart ics are indicated . E psom salts in coneentrated solution or e laterium ( i grain) may be se lec ted.

m at/P oe's PR E UMOII IA. 245

Cardiac stimu lan ts l ike alcohol , ammon ia, camphor, digi ta lis ,and especia l ly strychnin are requ ired and may be givenhypodermica l ly.

Cafl'

ein is a usefu l di uretic and cardiac and respiratorystimu lant.

(Low Pneumonia ; Pneumoni tis ; Lang Fever . )

Defini ti on .—An acute spec ific disease, characterized ana

tomical ly by an inflammation of the lungs , fol lowed by arapid infi l tration of the ir a lveol i and man ifested c l inica l lyby high fever, cough , dyspnea ,

rusty sputum,and phy-

O

sical si ns indicative of consol idation.

E t io —Age, sex,and c l imate exe rt but li ttle pre

disposing influence. Lowered vita l ity from bad hygienicsu rroundings or from some preexistent disease, li ke dia»betes , Bright's disease, or one of the infectious fevers, favorsi ts deve lopmen t. One attack renders the patient morel iable to subsequent infection . A lcohol ism is a strong predisposing factor. E xposure to cold and wet often precipitates the attack .

The exci ting cause is the invas ion of the l ung bypathogen ic bacteria

,espec ia l ly by Franke l ‘s Diplococcus

pneumon ia .

Path ol ogy .—Anatom ica l ly th ree stages have been rec

ognized : (i ) That of congest ion ; (2) that of red hepat ization ; (3) that of gray hepati zation .

Stag e 1 .

- The affected portion remains distended whenthe chest is opened ; it is of a deep- red color

,and is more

resistant to the touch than the norma l l ung. On sect ion ,a

frothy , blood - sta ined se rum free ly exudes . Mic roscopic,

exam ination revea l s a di lated and tortuous condit ion of the

capi l laries , swe l l ing of the a lveolar ce l ls , and a s l ight corpuscu lar exudate.

Sarge 2 .—The hepatized portion is increased in vol ume ,

is qu ite fiim, is of a dark - red color, and so heavy that it

sinks in water . I t is very friable , and the torn su rface isd ry and a gran u lar appearance , owing to the pro

us plugs from the alveol i .

246 or THE RESPIRA TOR Y s ys rs zv.

Microscopic exam ination reveal s a mesh of coagu latedfibrin incl osing numerous red blood - corpusc les and someleukocytes. The latter are also noted in the inter lobu lartiss ue. In sec tions proper ly treated the diplococcus isdetected.S tage3.

—The red color gives p lace to a mott led gray,

and the sol idified area begins to soften . The change incolor is due to the compression of the capi l laries , to thedisappearance of red corpusc les and thei r replacement byleukocytes

,and to fatty degeneration of some of the e le

ments .The consol idation usual ly begins at the base and extendsupward. The most frequent seat is the lower lobe of the

right lung . The bronchi and the adjacen t pleura are in

volved in th e inflammatory process .meow—Resolution common ly occurs

, the exudatebe ing removed rapidly by absorption . Death may occu rat any period of the disease from general toxem ia , the

severi ty of which is often altogether disproportionate to thearea of l ung involved ; from di latation of the right ventriele ; from asphyxia ; or a pneumococc ic compl ication, suchas men ingitis or endocarditis .Abscess , gangrene, and chron ic interstitial pneumonia

are rare term inations .Sm ptm —The disease usua lly begins with a dec ided

d ril l and a sharp pain in the side, fol lowed by a rapid riseof l emprrature. The latter often attains its maximum (1 0 4°i 05

°F.) in twenty - fou r hou rs

,and general ly continues

h igh,with sl ight diu rnal rem issions , unti l the fifth , seventh ,

n inth , o r e leventh day , when i t fal ls by cris is , frequent lyreaching the norm within twenty - fou r hou rs . Occasional lythe temperatu re fal ls by lysis . There i s marked d yspneathe respi rations are shal low and rapid

,ranging from 40 to

80 a m inute ,thus mak ing the ratio between respiration and

the pulse as i is to 3or as l is to 2 . ( mag ic is a prom inentsymptom : at fi rst it is short and d ry , but later it is aecompanied by bloody or rusty trans/mm ! and {marinas spa/a .

Microscopica l ly the sputum contains red blood - corpu sc les ,free pigment, pus- corpusc les , diplococci , and other micro

248 0 15154 3153 or THE RE SP IRATOR y 5VS raw.

Pneumonia of Dm nkards .—The onset is often gradual the

dyspnea is marked ; th e tempe ratu re is not high ; violentman iaca l del iri um common ly deve lops and death from ex

haustion is exceedingly frequent.Massiw Pneumon ia—In this form the bronch i , as we l l as

the air- ves ic les,are fi l led with fibrinous exudate. The phy

sical signs resemble those of ple u ral effusion .

Cm tm l Pneumonia—In th is form the inflammatory process commences in the center of a lobe ,

and in consequencethe characteristic physical s igns may not man ifest themse lves for two or three days .M g ml ory Pneumon ia—In th is type the spec ific inflam

mation shows a tendency to spread and to involve successive ly fresh areas of lung tissueCm pl i cati ons .

—These are usual ly due to pneumococcicinfection . Pleu risy is the most common compl ication. I tmay be e ither serous or pu ru lent. Pericarditis and endocarditis are not very infrequent. The latte r is often u lcerativein type . Among less frequent compl ications may be men

tioned men ingitis, arth ri tis , paroti tis , nephritis , jaundice,

and

de layed resolu tion (consolidation may last for five o r sixweeks and then gradual ly disappear). Abscess , gangrene,and chron ic intersti tia l pneumon ia are rare seque ls .D iagnosi 8 .

—Pleurisy .—There is rarely a distinct ch i l l ;

fever is not so high nor the pu l se so rapid ; there is norusty sputum ; nervous symptoms are wanting ; there isoften bu lging of the interspaces , with displacement of theapex - beat ; the leve l of du lness may change with the posture of the patient ; voca l frem itus and voca l res onance are

dim in ished ; and the breath - sounds are general ly weak anddistant.Acute Ph th isis—The history

, the mode of onset, the long

duration ,the rem i ttent fever

,the rapid emac iat ion , profuse

sweats, and presence of tuberc le bac i l l i and e lastic fibersin the Sputum wil l suggest phth isis .M ann y Belem — In edema there is absence of ch i l l ,

fever, and pain ; the expectoration is frothy and se ro u s ;bot h lungs are common ly affected ; auscu l ta tion rem ls

abundan t subc repitant rid es and weak breathing.

CROUPOUS [we UMON IA. 249

Typhoid raven—Typhoid pneumon ia may readi ly be m istaken for typhoid fever with pneumonia ; but pne umon iaas a complication occu rs late in the disease

,so that the

h istory of the onset gives much ass istance.

Progn 0 8 i 8 .—In young , robust subjects of good habits

the prognosis is good . After the age of sixty the outlookis grave . In drunkards the disease is especial ly fatal . The

coexi stence of heart or kidney disease makes pneumon iaexceedingly dangerous .In individual cases continued h igh fever (above 1 0 3.5

° F

a pu lse more rapid than t zo a m inute , severe nervous symptoms , extensive consol idation,and absence of leukocytosis

are unfavorable factors . The average mortal i ty is about 1 8per cent .Treatment —The temperature of the sick - room shou ld

be between 65° and 70° F. The diet should be fl uid or

semiflu id . Mi l k,j unket , wine - whey , broths , eggs , and grue l

are suitable forms of nou rishmen t. Cool water shou ld begiven freely. In the absence of any indication fo r spec iallocal treatment the chest may be enve loped in a cottonjacket .In robust subjects , at the very onset , when the invasion isviolent and attended with a bounding pu l se

,marked dyspnea,

and severe pleu ritic pain , the abstraction of from to to 20ounces of blood may afford great rel ief. Later in the courseof the disease ,

if cyanosi s and orthopnea deve lop in conse

quence of overdistention of the ri ght ventric le,venesection

may also prove useful .Can /iat Weaknrss .

—Alcoho l i s the best stimu lant . Whenthe pu lse becomes compressible and the diastol ic sound atthe pu lmonary area loses its force ,

it shou ld be gi ven free ly.

The atients who need it most are the old , the debi l itated ,and e al cohol ic . Digital is is undo ubtedly usefu l in somecases , bu t i ts action is uncertain and often disappointing.

As a ci rcu latory stimu lant strychn in general ly provesmuch more efficac ious than digital is . It shou ld be given inascending doses of from 1

1, to 11 ; of a grain . In order that

there may be immediate abso rption .large doses shou ld

always be given hypodermical ly. Caffei n is a usefu l adj uvant

250 D ISE ASE S or m e RESPIRA rowy S YS 7E M.

to strychnin , but it shou ld not be used when there is markedinsomn ia. In th reatening col lapse camphor hypodermical ly(t to 2 grains in steri le ol ive oi l every two o r three hou rs) isvery effic ient . S ubc utaneous injections of normal sa l t sol ution have also been found u sefu l in overcoming adynamia .

Pom—Morphin hypode rm ica l ly is the best analgesic .

Hot or cold appl ications are u sefu l . When the pain is verysevere ,

a few wet cups,fol lowed by pou l tices

,wil l be found

serviceable .

Cough—Hard , dry cough is best re l ieved by code in to

tgrain) , heroin (1 13 grain) , o r Dover 's powder (3to 5grains).

x pectorants are rare ly needed . When,howeve r

,there is

much bronchial catar rh , ammon ium carbonate may be givento fac i li tate expectoration .

Fawn—Persis tent high fever is best control led by theapplication of ice - bags to the affected side

,cold sponging , or

cool baths .

Dy spnea .

—Cardiac and respi ratory stimu lants (stry chni n ,

cafi'

ein,ammon ia) are of serv ice . Oxygen makes the breath

ing easier, lessens - cyanosis,and conduces to sleep , and to

this exten t aids in conserving energy .

Insomnia and Del iri um—Opium is general ly the bestsedative. Of course it shou ld not be used when there isextreme dyspnea or when there are evidences of pu lmonaryedema. Brom ids or ch loralamid may be tried .

Delay ed Resolution—Smal l bl isters may be appl ied over

the affected area,and potassi um iodid may be adm in istered

internal ly .

B. Ammonn iod id i

Ammon i i ch lor id i

Mistune glycyrrh irae compo s ites;

S ta —A tablespoonfu l in water fo ur t imes a day .

(Capi ll ary Bronch itis ; Bronchopneumonia ; Lobular Pneumonia.)Defin i ti on —An inflammation of the term ina l bronchioles

and ai r- vesic les .E ti ol ogy .

— Ir is most frequently observed in the veryyoung and the old. I t is a common seque l of the spec ific

CA TARRHAL [we (IMO/VIA . 253

Can aan /u . Pnsuuomn. Ceourous Puw uouu .

Usual ly secondary to bronchi tis or an Usuall y a primary d isease.

acute infectious d isu se .

The onset is gradual and without a The onset is abrupt and with a disdi sti nct chi l l . t inct ch i l l .The fever is moderate l h igh. very The fever is h igh , regular, and genirregu lar, and ends by ys is after an eral ly ends by crisis between theindefinite period, sometimes o f two s ixth and ninth day .

or threeweeks' durationfro wn! is mucopuru lent or glairy The sputum is rusty and trans lucent.

nn tenacious.

Both lungs are common ly affected . In the majori ty of cases on ly one lungis affected .

The hysical signs are ind istinct and The physica l signs are d istinct andin

'

cate scattered areas of consol i ind icate a large uniform consol idat ion.

Bronchit is—I h simple bronchitis the fever is not high ;the dyspnea is sl i ht, there is l ittle prostration.and there areno signs of conso 'dation .

Prognosi s—In previously heal thy chi ldren the prog;nosis is good . In cachectic chi ldren the outl ook is verygrave. Aspiration pneumon ia i s general ly fatal . The averagemorta l i ty is about 35per cent .The du ration of the disease i s from one to three weeks ; a

lon er duration shou ld suggest t ubercu losis .h uen t —Much can be done by carefu l managemen t

in preven ting bronchitis from gaining access to the smal lerbronchi.On the supervention of catarrhal pneumon ia the patientshou ld be confined to bed , and the tempe rature of the roommaintained between 68° and 70 ° F. The atmosphere shou ldbe rendered moist with steam . The diet shou ld be l iquidand nu tri tious .Alcohol is often requ ired . When the ci rcu latory depression is pronounced , whisky may be given in doses of

from to to 30 m inims in mi lk to a child of two years everytwo or three hours .At the outset it is advantageous to adm inister a mi ld pur

gative ,prefe rably cal omel or castor oil . A jacket of cotton

wool shou ld be worn th roughou t the attack . When thereis a harsh , d ry cough , the appl ication of the tinctu re of

0 1" TIIE RESPIRA TOR Y S YS TE M .

trength general ly affords some re l ief. In

may be used instead of the iodin .

by cold . Compresses wrung outbe wrapped around the chest and changedtervals of twenty m inutes . E xpectoran tsd . In the early stage potassium ci trate isI t may often be combined advantageously

t of n i trous ether and ammon ium acetate, as in the

form u la :8 . Pom ati c itral

'

ts

Spi n' °

tus c theris nitros i

Liquoris ammonti acetat is

Syrupi tol utani

Aqua u q . 3. ad Git —M.

S tc .—Dessertspoon ful every three hours for a ch i ld of threeyears.

the ammoni um sa l ts,espec ial ly the carbonate,

are

cacious . From l to 2 grains of the latter may hery three or four hou rs to a chi ld of two years .m iodid is al so usefu l , and may be employed as an

uvant , as in the fol lowing form ula :3. Ammonu carbonat is

Ammon ii iod idiSyrupi tolutan i

Syrupi acac ia: n q . 3. ad

Phi—M.

S tc .—Teaspoonfu l every two or three hours or a chi ld of threeyears.

When the chi ld is unable to expel the mucus and the

breathing becomes much oppressed, an emetic (ipecac or

al um) may prove of great service. Inhalations of oxygensometimes make breathing easier. Strychnin is al so of

benefit at this time in combating respiratory fai lu re .

If symptoms of cardiac fai l u re are pronounced , digital ismust be given in addition to alcohol and strychnin . E x

treme rest lessness and insomn ia wi l l sometimes requi re the

use of the bromids or some other mi ld sedative .

when they may be necessary to re

nd to control harassing cough,opiates

ust be guarded. Tonics l ike cod - l iver

PUL.VON'

AR y TUE E RCUL 257

d ifl'

use . The afl'

ected part is converted into a green ishblack , so ft mass having an extreme ly fetid odor. Whenthe softened mate rial has been expec torated

,there is left

behind a cavity with ragged wal ls , conta in ing a fou l - smel ling l iqu id . The tissues around the cavity are inflamed and

edematous.Sy ntptoms .

—The symptoms of gangrene are assoc iatedwith the original di sease . Cough , dyspnea, moderate fever,and great prostration are genera l ly present.The expectoration is charac terist ic ; it is profuse ,

and has

a penetrating ofl'

ensive odor. When al lowed to stand in a

glass vesse l , it separates into three layers : a frothy layeron top, a translucent se rous layer in the m iddle , throughwhich hang strings of pus

, and at the bottom a layer of

reddish- green puru lent material . A l tered blood may giveit the appearance of prune - j u ice. Microscopical ly it contains shreds of t issue,

c rysta ls of fatty ac ids , c rysta ls of

hematoidin , and numerous pyogenic bacteria.

Phy sical ex amination may revea l bubbl ing rifles , and latercavernous breath ing, pec toril oquy, and loca l ized tympanyon percussion. Physica l signs of pyopneumothorax maysu rvene from perforation into the pleu ra.

gnosis .—Grave

,but no t hope less . Qu ite a number

of cures have been recorded . Death may resu l t from ex

haustion,hemorrhage ,

or cerebral abscess the resu lt of

embolism.

W h—Nutritious food and strychn in ,qu in in , and

a lcohol are required to support the system . Inhalations ofcreasote or of formal in (2 per cent. gradual ly increased to 5pe r cent.) may be employed to lessen the

.fetor of the

Surgica l interference is indicated when the gan

greno us process can be local ized and is not a compl icationof an incu rable disease.

(Phthiais ; Pu lmonary Consumption .)

Defini t ion .—A spec ific inflammatory disease of the l ungs

caused by the Baci l l us tubercu los is ; characterized anatomiI7

260 DISEASES or 7715 RESPIRATOR y S YS TE M .

by an evening exacerbation ,du ring which the face is flushed

,

the eyes are bright , and the m ind an imated . As the diseaseadvances the cough becomes troublesome and the ex pec

toration more abundant. In we l l - deve loped cases the ex

pectoration is green ish in color, is in coin - shaped plugs(nummu lar) , is heavy and sinks in water, is often bloodstreaked , and on m icroscopic examination is found to contain bac i l l i and fibers of e lastic tissue.

Phth is is is in i tse lf not a painfu l disease, but the assoc iatedd ry pleu risy often causes much su ffering. Hemoptysis occu rsat al l stages , but the profuse hemorrhages occu r late. The

blood is bright red in color,frothy

,and m ixed with mucus .

Dyspnea is rare unti l the disease is far advanced. Profusesweat ing during sleep is a troublesome featu re of advancedphthisis.The final stage is characteri zed by extreme emac iation,

weakness,pa l lor, high rem ittent or interm ittent fever, and

edema of the feet. The m ind is usual ly c lear and pecu l iarlyhopefu l to the end . The average du ration is about twoyears .Phy sical Ex amination—The chest may be we l l formed.

Often , however, i t is long and flat, with hol low suprac la

vicu lar and infrac lavicu lar spaces , prom inent scapu lx , and

obl ique ribs . When the disease is we l l advanced,there

may be retrac tion with dim inished expansion over one apex .

Palpation .

—This revea ls imperfect expansion and ex

aggerated voca l frem itus .Percussz

'

om—Du lness can be detected at an early periodof the disease . I t may be obtained first above or be low thec lavic les, in the supraspinous fossze ,

between the scapu la ,or

in front,near the stemal border.

A cavity may yie ld tympany or a c racked - pot note. Thelatter is best obtained with qu ick

,l ight perc ussion strokes ,when the patient's mouth is open .

Aru m /{anom—In the earl iest stage respi ration may beinaudible over the afl'

ected area Later the breath ing isharsh and the expi ration is prolonged (bronchial) . The voca lresonance is increased . Crack l ing rales are usual ly audible,

and are produced by liquid in the smal l tubes. If not

P ULMONAR y TUBERCULOSIS. 26 :

present, coughing wi l l usual ly deve lop them . Auscu ltationove r cavities may detect cavernous or amphoric breathing

,

bronchophony or pec tori loquy, and large gurgl ing rales.Anomalous Phy sical Signs—The vocal frem itus is dimin

ished when there is much pleural thicken ing. Norma lresonance or hyperresonance may replace du lness whenthere is much emphysema between smal l tuberc u lous foc i.Weak breath ing may replace bronchia l or cavernous whenthe tubes or cavity are fi l led with mucopus . The signs ofcavity are somet imes produced by consol idation in the

neighborhood of a large bronchus.

Acute Ph th isis.—Clinica l ly this form resembles pneu

monia, and is marked by a chi l l , high fever, rapid pu lse ,

dyspnea,sputum at fi rst rusty and then puru lent

,flushed

face,profuse sweats , and the signs of consolidation. Instead

of ending by cris is at the e ighth or n inth day , as in ordinarypneumon ia, the symptoms gradual ly grow worse ,

signs of

soften ing deve lop , bac i ll i and e lastic fibers appear in the

sputum , emac iation and anem ia become pronounced, anddeath resu lts in from a few weeks to a few months.

Fibroi d Ph th i si s.—This is a disease of long du ration.

It is characteri zed by very gradual loss of flesh and strengthand by an abundant mucopu ru lent expectoration , which isat times fetid from be ing reta ined in di lated bronchi . Dy spnea

,sweating

,and fever are sl ight . There is very marked

retraction on the affec ted side from the shrin king of the

fibrous tissue ; with th is exception the physical signs aresimi lar to those of u lcerative phthis is .

Compl i cations of Ph th i si s —The chief are : hemopty s is ; catarrha l pneumon ia ; pleu risy ; pneumothorax ; stomatitis ; gastric catarrh ; diarrhea ; amyloid degeneration of

the viscera ; fistu la in ano (tubercu lous) ; and secondarytubercu losi s of other organs , espec ia l ly of the larynx , cerebral men inges

,intestines , peri toneum ,

or k idneys .Diagnosi s.

- The i rregu lar fever , cough , pal lor , emac iation

,hemoptysis

,n ight - sweats , signs of consol idation , and

26 2 0 1554 353 or 7715 RE SPI RATOR y s ys rzw.

the presence of bac i l l i and e lastic fibers in the sputa are the

diagnost ic phenomena.

Progn osi s—In acu te phth is is the outlook is whol lyunfavorable. In ch ron ic phthisis the prognosis is dependentupon the stage of the disease

,the constitu tional vigor of the

subject, and the hygien ic conditions under which he isobl iged to l ive . The acc identa l discovery of calc ified tuberc les at autopsies fu rn ishes abundan t proof of the cu rabi l ityo f the disease. The mortal i ty is very high in young subjects (fifteen to twenty - five years) and those of feeble cou

sti tu tion . Unfavorable prognostic signs are a persistenth igh tempe ratu re , rapid pu l se (1 to to involvementof both lungs , continued indigestion

,progressive loss of

flesh , and the deve lopment of tubercu lous lesions in otheror ans .

tu l ent .—Propky 1an lr.—Tubercu lous patients shou ldbe taught to expectorate on ly into proper receptac les contain ing a dis infectant solution (5per cent . carbol ic acid) orinto moistened rags o r pape r napkins that shou ld be bu rnedbefore the sputum becomes d ry . They shou ld sleep alone .

Their rooms shou ld be sunny , we l l venti lated , and keptscrupu lo usly c lean .

Much can be done by the S tate to l im it the dissem inationof the disease . Laws shou ld be enacted providing for thesystematic inspection ,

by ski l led veterinar ians of al l da iriesand slaughter- houses with the view of dec lari ng unmarket

able the m i lk and meat of tuberc u lous animals .Compulsory registration of phthis ica l patients is desirable .

Spitt ing upon sidewa lks and the floors of publ ic bui ldingsand conveyances shou ld be made a penal oflense. Final ly,the State shou ld provide spec ia l hospita ls for the indigentsuffering from tuberc u losis .Persons with a predisposi tion to tubercu losis can do muchto increase the ir powers of resistance by strict attention tohygiene . Fresh air and sun l ight , a healthy residence ,

an

outdoor occupation,the wearing of warm c lothes , with flan

ne l next to the sk in , and a diet of wholesome and nutr itiousfood

, temperate l iving, systemat ic exerc ise , and dai ly coldsponging

,fol lowed by friction of the skin , are the fac tors to

264 DISEASES or rm : RE SP IRA TOR y s YS TE M .

rest shou ld be insisted upon . As much nouri sh ing foodshou ld be al lowed as he is capable of digesting.

Media'

nal Treatment.—When we l l tolerated and digested ,cod - l iver oil (I to 4

'

flu id rams th rice dai ly) is of service inimproving the general nutri tion . Creasote is u sefu l whenthe expectoration is free and pu ru lent . The dose shou ld becautiously increased from 2 or 3m in ims to 15or 20 minims

,

three times a day . A lcohol is usefu l in some cases . Mal tl iquors and wines are usual ly the best preparations . Ton ics—arseni c , iron , hypophosphi tes—are often serviceable . I odinappears to be eflective in chron ic cases . A sma l l amount ofan oin tment of eu rophen (1 0 per a cornpound containing much loose ly combined iodi n, may be rubbed into thechest twice dai ly. Coun terirri tation by means of smal lbl isters is also efficacious in ch ronic forms .Sy mptoma tic Treatmm t.

—Cougk .—In many cases cough

is indispensable and is best treated by promoting expectoration. For this purpose creasote , guaiacol ca rbonate , terebene ,

oi l of eucalyptus , and myrtol are re l iable remedies .Inhalations of ipecac ,

creasote , compound tinctu re of ben

zoin,or terebene are often very effec tive. Local bl istering

is also of service . When the cough is very severe, sedatives must be given . Of these ,

the least objec tionable are

code in,he roin

,hydrocyan ic acid

,and spiri t of chloroform .

S uch combinations as the fol lowing wil l be found usefu l3. Codeinz sulphatis gr. vj - vi lj

Spiritus ch loroform i

GlycerinSuec i l imonis

Aqua q . s ad

Std —A teaspoonfu l as common emands.

R . Codeine sul phatis

Ac id i hyd rocyanici di l utiSyrupi to lutani

S tG.—A teaspoonfu l as required .

Mght- swm ts.

—Sponging the body at bed time with a sol ution of al um in alcohol and water or dusting it with a powderof tannoform (1 part) and zinc oxid (3parts) is sometimesve ry effective. The mo st re liable in ternal remedies are

atropin (rim to Th grain) , pic rotoxin (f t, to 1 15grain), aro

n evu s 265

matic su lphuric acid (5to 1 0 drops), and t oric acid (5to 1 0 grains) .R. A inm su lpbatis gr.

Amsu l phurici aromatict f i ij‘

A u months: piperi tae q. s igni—Measpoonful in water at bedtime .

Ryren'

a .

— In many cases the fever yields to absol ute restin bed or in a rec l ining chair, combined wi th l ife in the openai r. Cold sponging is usefu l when the temperature is high .

In obstinate cases the admini stration of phenacetin (3to 5grains) may be tried .

Pl euritic Pains—Mi ld attacks gene ral ly yiel d to sinapismsor the appl ication of iodin . S trapping the affected side al soaffords relief. Severe pains shou ld be treated by the appl i

cation of smal l bl i sters and the subcutaneous administrationof morphin.

Dav in a—Diarrhea, the resu lt of indigestion , usual lyyields promptly to restri ction of the die t, rest , and the administration of a m i l d mercu rial . Persistent diarrhea wi l l demandthe use of bismuth subnitrate (20 to 30 grains) combinedwi th opium and in testinal antiseptics—salol , bismuth - be tanaphthol

,or creasote . Combinations of tannigen (5to 15

grains) or tannalbin (5to 15grains) with bismuth compoundsare also usefu l

V Tannigen

S td —One every four hom .

D ISEASES OF THE PLEURA.

PLEURISY.

Defini tiom—Inflammation o f the pleura.

Vari etiw —According to cau se ,i t may be divided into

primary or secondary ; according to extent, into uni lateral ,

266 D ISE AS E S or w e RE SPIRATOR y s rsu m.

bi lateral , or l ocal according to time, into acute or ch ronic ;and according to the exudation , into serofibrinous, fibrinous,or puru lent.E ti ol ogy .

—Pleu ri sy may be : (1 ) Idiopath ic , ari sing fromexposu re to cold and wet. (2) Traumatic . (3) Secondary toinflammatory diseases of adjacent viscera. as pneumonia and

phthisis . (4) Secondary to some general morbid process , asrheumatism ,

Bright ’s disease ,and the infec tious fevers . 5)

Tuberculosis. (6 ) Cancerous (rare).At least th ree - fou rths of al l cases of serofibrinous pleu risy

are tube rcu lous .Path ol ogy .

—In the ear ly stage the membrane is red ,

sticky,l usterless ,

and covered wi th a thin film of lymph ; ifthe process now ceases , the condition is termed dry pleur isy .

If,howeve r , the inflammation continues , an exudate is formed

which may be : (I ) Serofibrinous ; (2) fibrinous ; or (3) pu ru lent (empyema). In the scrnfifin

'

nous form there is l ittlelymph

,the exudate being main ly composed of straw - colored

serum (a few ounces to several pints) which in favorablecases is gradual ly absorbed . In large efl

'

usions the adjacentorgans are displaced and the l ungs are compressed . In the

fibn’

uous form serum is scan t and the membrane is coveredwith a butter- l ike exudate that subsequently organ izes and

un i tes more or less c lose ly the pleu ral su rfaces . causingMmm

’

c pl eura l Ila’

rkm ing . A l iqu id effusion,which is ci r

cumscribed and confined to pockets formed by adhesions , istermed I l l tT l /[d fl ’d plm n lry .

Pam /m t plm n lfy is always the resu lt of micro - organ ismalinfection . Left to itse lf, i t may ki l l by sepsis , i t may becomeinspissated and encysted (very rare) . or i t may rupturespontaneously into the lung and bronchi . o r more rarelythrough the ches t - wal l s . After the discharge of the pus ,the pleu ral su rfaces may eventual ly become united by firmadhes ions.Htmorr/mgrk Pl eurisy .

—A bloody effusion is often oh

served in tubercu lous and cancerous pleu risies and in pleurisyassoc iated with scurvy , grave anem ia, and other cachecticstates .Sy mptoms —The disease usual ly sets in with a sharp

268 D I SE ASE S or THE RE SP IRA TOR y 5vsM M .

Pleurodynia (Rheumatism of the Intercom Muscl es) .—Ihth is affection the pain and tenderness are difl'use ; moreover,fever, friction - sounds

,and signs of effusion are absent .

Diaphragmati c Ma rx i sm—This may present the fol lowingsymptoms : Intense pain under the margin of the nb s , withtenderness on pressu re ; thoracic breath ing ; tenderness overthe ph renic nerve , which is accessible between the two rootsof the sternoc leidomastoid at the base of the neck ; hiccup ;and seve re dyspnea. The physical signs are not marked .

Per icardi ti s with Bflnsi om— In th is condition the percuss iondu lness has a characteristic shape , the sounds of the heartare distant and mufli ed

,and there is greater embarrassment

of the ci rcu lation .

Hy drothm x té l n this condition pain and fever are absent.There is often a history of cardiac or renal disease , and the

fl u id on aspi ration is found to contain less than 3per cent.of albumin and to have a specific gravity below 1 0 15.

Py othorax.—This may be recogn ized by the general

symptoms of sepsis—pe rsistent irregu lar fever, increasingpal lor , profuse sweats , chi l ls , and leukocytosis . In doubtfu lcases it wi l l be necessary to aspirate.

Prognosi s— In simple se rofibrinous pleu risy the prog

nosis is guardedly favorable . Fever usual ly subsides in froma week to ten days , and absorption of the flu id in most casesis complete in from fou r to six weeks . S udden dea th occasional ly occu rs when the flu id is excessive . In about onethird of the cases tube rcu los is sooner or later devel ops .Treatmen t —The patien t shou ld be kept in bed and re

stricted to a l iqu id diet . Mer cu ria l or saline aperients maybe prescr ibed at the onset . Fo r the severe pain the app l ication of a bl ister or of wet o r d ry Cups , together with theadm in istration of morphin ,

wi l l be found effec tive . Strappingthe affected side with broad strips of adhesive plast e r is al souseful . Acute sthenic cases with decided fever are oftenfavorably influenced by the adm inist ration of sal icylates (1to 1 } drams of the sodi um o r ammonium sal t a day ) . In

asthen ic cases sal icylates are of no avai l .m ml (f Scrol l s Ejfi/siau .

—The most usefu l measu resfor promoting absorption are the application of iodin or of

PLE b R/S Y. 269

flying bli sters, and the admi nistration of hydragogue cathartics and of diuretics . From Q to 1 ounce of magnes iumsu lphate may be given in as li tt le wate r as possible an hou rbefore breakfast , and the flu id consumed by the patien tdu ring the day restricted to a m in imum . The most serviceable diuretics are digita l is , caflein , and potassium acetate.

Potas sium iodid (5to 1 0 grains th rice dai ly) is also em

ployed for its absorbent cflect. Diaphoretics are of l i ttle vlaue .

Para na/m l: is demanded When the effusion is cons iderab le and shows no signs of receding after the lapse of

two weeks ; (2) when there is sufl‘i c ient fluid to cause severedyspnea, cyanos is , persistent cough , o r fa i l ing pu lse ; (3)

when. the fluid reaches the leve l of the second rib and thereis marked d islocation of th e ne ighboring organ ; (4) whenthe presence of pus is suspec ted .

The most favorable site for the puncture is usua l ly in thesixth or seventh intercostal space ,

between the mid - axi l laryline and the angle of the scapu la. After anesthetizingthe part, the needle shou ld be introduced with a qu ickstroke along the upper margin of the rib. The flu id shou ldbe removed slowly , and under no c ircumstance shoul d ex

treme efl'

orts be made to obtain the largest possible amount.The Operation shou ld be term inated at once if incessantcough , severe pain, dyspnea , palpitation ,

tendency to sy nuntoward symptoms appear.

(Py oth orax ) . - The effusion may be pri

mari ly puru lent , having been exc i ted by pyogen ic m ic roorganisms, or a serofibri nous effusion

,th rough subsequent

infection,may become pu ru lent . Traumatism o r the rup

tu re of a pu ru lent acc umu lation into the pleu ral sac is anoccasi ona l cause. I t frequent ly fol lows pneumon ia ,

part ienlar ly in chi ldren ,

in whom the most common form of pleu risyis empyema . I t is often secondary to tubercu losis o r one

of the infectious fevers .The organ isms most frequent ly presen t are the pneumo

coccus, staphylococcus, streptococcus, tuberc le baci l l us, andtyphoid bac i l l us .Symptoms—The physical s igns and symptoms are s im i

lar to those observed in serofibrinous pleu risy. Pus is

272 or THE RE SP I RA TOR r S YS TE M .

Treatmen t —In tube rcu lous cases the indications areto re l ieve distress by morphin and to combat col lapse bysuch stimulants as ether, ammon ia, camphor, alcohol , andstrychn in . Aspiration occasional ly afl

'

o rds temmrary re

l ief. In l l Ol‘

lr tUbC l ‘CUlOUS cases of pneumopyothorax operat ive interference is general ly advisable.

Defin i ti on .—Blood in the pleu ral cavi ty.

E t iol ogy . I t usual ly resu lts from wounds of the

chest - wa l l , fractu re of the ribs , or the ruptu re of an aneu r

y sm . A sangu ineous inflammatory (hemorrhag ic pl eur isy )ex udate frequently occu rs in cancerous and tubercu louspleu risy and in simple pleu r isy when the individual is profound ly anemic .

Symptoms . The symptoms and physica l s igns are

those of pleural efl'

usion.

ACUTE INFECTIOUS DISEASES.

FEVER is an abnormal condition , characteri zed by e levatedternperature ,

quickened respiration and c ircu lation,fau lty

sec ret i ons, and inc reased tiss ue - waste . I t IS dependent upona perversion of the phys io logic processes whereby the gencration and the loss of heat are so ba lanced as to maintain a

uniform normal temperatu re.

Th e Detecti on of Fever .—There is only one re l iable

way of detect ing fever, and that i s by means of the c l inica lthermometer. The instrumen t may be placed in the axi l la,mouth

,rectum ,

or vagina.

When the axi l la is se lected , the fol lowing precautionsmust be observed : Wipe ofl

'

the perspiration and d ry thesk in ; insert the bu lb o f the instrument deep in the armpit ,and see that the arm is kept c lose to the side . The the rmometer shou ld be kept in position unti l the merc ury ma intains the same leve l fo r two minutes ; this wil l usual lyrequ ire in al l about six or seven m inutes .

When the mout h is se lected , the bu lb should be placedunde r the to ngue and the l ips kept c losed . Hot or colddrinks recently ta ken mar the resu l t. For obvious reasonsthe mouth shou ld not be used in de li rious patients .The rectum may be se lected in chi ldren . The rec taltemperatu re is about a degree higher than that of theaxil la.

Febri l e Stages .—The cou rse of al l fevers i s marked by

three stages . (1 ) Invasion ; (2) fas tigi um,o r stadi um ; (3)defervescence,

o r dec l ine.

Invasion“

.—Du ri ng this period the temperatu re gradual ly

rises unti l i t reaches its maximum.

1 8

274 ACUTE INFE CTIOUS D ISE ASE S .

Fashlg‘im .

—In th is period , though there may be markedvariations , the temperatu re shows a tendency to touch againand again i ts highest point.DJ em escma x—In this period the temperature gradual ly

fal ls unti l it reaches the norm .

Terminati ons of Fever .—Fever term inates by lys is or

en s 1s .

Ly n } .

—The temperature fa l l s slowly by sl ight gradationsunti l i t reaches the norm .

Cr isis .

—The temperature fal ls sudden ly—often fou r o r

five degrees in twe lve or twenty - fou r hou rs .Th e

gDegree of Pyrex ia—The fol lowing is Wunder

lich 's c lassification of febri le temperatu res :1 . S ubfebri le, temperature - 1 0 0 4

° F.

2 . S l ightly febri le ,temperatu re F.

3. Moderate ly febri le,temperatu re —1 03 1

° F.

4. Dec idedly febri le,temperatu re - 104

° F.

5. High ly febri le, temperat u re above 10 3. 1° F. in the

morn ing and above F. in the even ing .

6 . Hyperpyretic , temperatu re above 1 0 6°F.

Febr i l e Rm i 8 8 i 0 n8 .—A l l fevers show a di urnal varia

tion . The max imum is usua l ly reached at abou t 6 P. M.

and the m inimum at abo ut 6 A. 111 . Occasional ly these ex

tremes are reversed and the maximum is in the morn ingand the m inimum in the even ing. The da i ly difl'

erence

amounts to about 1 ° F.

Types of Beva n—According to the degree of the

diu rna l variation th ree types are recogn i zed1 . Confi rmed Fa wn—The diu rna l variation is s l ight

1° F. Typhus fever, pneumonia,

and scar let fever areex ammes of continued fevers .2 . Remi ttm t Fa wn—The diu rnal variation is marked , but

the m in imum temperatu re is sti l l above the norm . Typhoidfever , rem ittent fever, and septic fever are examples of th is

3. Interm ittent Fawn—The diur nal variation is marked ,and the m in imum is norma l or subnormal . The foll owingfevers show mu l tiple inte rm iss ions :

1 . Interm ittent malaria l fever .

276 ACUTE IN FE CTIOUS DISE ASE S .

or with alcohol and water and the admin istration of suchdrugs as spiri t of n itrous ether, sol ution of ammoni umacetate , or neutral mixtu re afford comfort. High fever isbes t control led by cold : cold sponging, the cold pack , orthe cold bath .

In applying the ( old park the bedding is fi rst protectedby water- proof sheeting ; the patient is then st ii pped and

enve loped in an ordinary shee t wrung out of wate r at a

temperatu re of 70°—60 ° F. The pack is usual ly continued

for from ten to fi fteen m inutes,and during this time i t is

necessary to sprinkle the shee t at frequent in terval s withwater sufli ciently cool to main tain a uniform temperatu re .

771: Cold Ba l ls—The patient is wrapped in a sheet andthen placed in water at 70 ° F. Whil e in the bath an ice - capis kept upon the head and the trunk and l imbs are vigorous ly rubbed

,so as to bring new re lays of blood to the

su rface . A st imu lant is sometimes given before the bath tolessen the shock . At the end of fifteen or twenty minutesthe patien t is carded back to bed and covered with a dryshee t and a light blanket. After he has been thoroughlyd ried the damp coverings are removed and replaced by dryones. If the patient be del icate ,

i t is preferable to place himin a bath at 90

° F. and then gradual ly lower the temperatu re of the water to 70 ° F.

Drugs may al so be used to lower temperature,but the

appl ication of cold is general ly preferable . Phenacetin,anti

pyrin,acetan i l id , and qu inin are the an tipyretic drugs most

commonly employed .

Per iod of In cubat ion —The peri od e lapsing betweenthe occu rrence of the infection and the deve lopment ofsymptoms .It varies considerably in the same disease , being more o r

less influenced by the susceptibi l i ty of the patient and the

vi ru lence of the con tagion . The average peii od of incubation in the van’ous fevers is as fol lows :

Typhoid fever : two to th ree weeks .Typhus fever : a few hou rs to two weeks.Measles : ten days to two weeks .

FE VE R .

Rothel n or rubel l a : one to th ree weeks .Scarlatina : a few hours to a week .

Smal lpox : ten days to two weeks.E rysipe las : th ree to seven days .Diphtheria : two to seven days .Varice l la : fourteen to sixteen days .Tetanus a few days to th ree weeks.Mumps : two to three weeks .Ye l low fever : from two to three weeks .Cholera : two to five days .

Th e date at wh i ch rash es appear in th e variousacute infi eti ous :

Typhoid fever : seventh to the ni nth day .

Typhus fever : fou rt h or fifth day .

Smal lpox : third or fou rth day .

Meas les : th ird o r fou rth day .

Scarlatina : fi rst or second day .

Rothe ln or rube lla : fi rst or second day .

Varice l la : fi rst day .

Protecti on from Fu ture Attack s —Few diseasesconfer absol ute immunity against futu re attacks , but the fo llowing are fai rly protective :Typhoid fever : relapses are common ,

but second attacksare infrequent .Typhus fever : second attacks are very rare .

Meas les : second attacks are not very uncommon.

Rube l la : second attacks are rare .

Scar let fever : second attacks are rare .

Smal lpox : second attacks occasional ly occur.

Mumps : second attacks are rare .

Vari ce l la : second attacks are uncommon .

Yel low fever : second attacks are rare .

The fol lowing spec ific fevers do not confer immuni tyE rysipelas . Malarial fever.

Relapsing fever. Influenza.

D iphtheria. Croupous pneumon ia.

Rheumatic fever .

278 ACUTE INFECTIOUS 0 1354 3153.

Terminati on by Cr isis —The fol lowing infectious feversare apt to end by cri sisTyphus fever Meas les .Pneumonia. Re lapsing fever.

Malarial fever. E rysipe las .I nfect i ons in wh i ch j aundi ce is l i k el y to occur

Ye l low fever.

Re lapsing feve r.

Acute ye l low atrophy of the liver .

Rem ittent malarial fever .

Temperatu res be low F. may be considered sub

norma l . They are observed in the fol lowing conditions1 . Du ring convalescence from certa in febri le diseases .

After pneumon ia and typhoid fever the temmratu re mayremain subnorma l for seve ral days .2 . In col lapse from various causes .3. In cholera . In this disease the temperature may bevery low (90 °- 85

° F.) for seve ral days .4. In ce rtain ch ronic diseases

,espec ia l ly myxedema

,d ia

betes,cancer

,chron ic cardiac , cerebral , and spinal diseases.

SE EPLE CDN I'

INUED FEVER.

(Pebrlcula ; Ephemeral Pom .)Defin i ti on .

—An acu te febri le disease ,of short duration

,

withou t defin ite lesions or a spec ific etiology .

E t i ol ogy —R is general ly met with in young and sensitive individual s . E xposu re to the sun

,prolonged physical

or emotional exci tement, and e rrors in diet seem to excite i t .

Symptom8 .—The disease usual ly begins abrupt ly with

chi l l iness , headache, ma laise , and fever which soon attains amax im um of 1 0 2

°or 1 0 3

° F. The face is flushed ; thepu l se is fu l l and rapid ; the u rine is scanty and high colored ;the tongue is coated ; the appetite is lost ; and the bowe l sare constipated . There is no characteri stic eruption

,but

herpes is frequently observed on the l ips .

280 ACUTE INFE CTIOUS D ISE ASE S .

the source of the contagion,and drink ing- water contam i

us ted by them is the chief medium of tran sm ission . M i lkcontam inated after leaving the cow is a fruitfu l source of in

fection . E xc rementa l contam inat ion may cause infectionalso th rough the medium of certain art ic les of food , such asoysters , ce lery

,and lettuce. Fl ies may be an important

agent in dissem inating the d isease. Occasional ly nurses ,physic ians

,and washerwomen are infected direct ly .

Path ol ogy —TM characteri stic lesions are found in theabdom ina l lymphatics , name ly, in Peyer's patches, sol itaryglands , and mesenteric glands . The changes in Peye r'sglands are best studied in the lower part of the i leum ,whichshou ld be opened on the side of the mesente ric attachmen t .In the first few days the glands are swol len and hype rem iclater there is a marked ce l l- prol iferation , the blood - vesse lsare compressed , and the glands become pa le and prom inent(medu l lary infi ltration) . If the disease advances , necros issets i n

, the glands becom ing ye l low and so ft. In a few daysthe nec rotic ti ssue is discharged , leav ing an oval , u lceratedsurface with somewhat i rregu lar margins , and a smoothbase formed by the submucous coat , muscu lar coat

,or pe ri

toneum.

In the fou rth week c icatr ization begins , and the gland isu ltimate ly replaced by a smooth depressed scar.

In addition to th ese glandu lar lesions the mucous membrane of both large and smal l intestines shows catarrha lchanges .In m i ld cases the stage of u lceration may not be reached ,

the prol iferated ce l ls be ing removed by fatty degenerat ionand absorption withou t ruptu re of the gland. The sol itaryand mesente ric glands pass th rough sim i lar changes , but thelatter rarely ruptu re . Other les ions are found that are not

characterist ic . The Spleen is soft and swol len . The l iver ,k idneys , and heart reveal parenchymatous degene rat ion .

The respiratory tract is common ly the seat of catarrhal infiammation .

In rare instances there appears to be a gene ra l infectionwithout lesions of the intestina l glands (Up/wed septra rma) .Per iod of Incubation —Two to three weeks.

TYP/IOID FE VE R. 28 1

8m m .—Prod roma1 Symptoms .

—These consist ingradual wea kness , headache ,

vague pains , nosev b leed ,and

often s l ight diarrhea.

Tfrt Al l : rck .

—f i s rer .

—The temperatu re rises gradua l ly,reaching its maximum (t 04°- 105

° F.) by the end of the firstweek ; it remains at th is e levation for another period of fromone to two weeks , when a gradua l defervescence begins andoccupies a th ird pe riod lasting from one to two weeks .

Throughout its course the fever is characteri zed by markeddai ly rem iss ions , the even ing ternperatu re be ing from one

to th ree degrees higher than the morning.

In some cases, espec ial ly in the young , the temperatu rerises quite abruptly. S l ight di u rnal remissions indicate a

protracted case. As defervescence advances the tempera

FIG. t3.—Tempe ratu re - c u rve in typho id fever .

tu re becomes more irregu lar ; the rem issions are more decided , and not infrequent ly the higher temperatu re is recordedin the morn ing. An abrupt fal l of several degrees shou ldsuggest intestina l hemorrhage o r perforation .

Rapiratory Sy mptoms—These inc l ude hu rried breath ing,sl ight cough , and bronchia l rales .Symptoms—The pu lse becomes rapid

,weak ,

and dicrotic . The rapidity is often less than such tempera,

tures genera l ly produce. The heart - sounds become feeble .

The fi rst may be espec ial ly weak , and resembles the second .

T/u' Face—The expression is du l l and heavy , the cheeksare somewhat fl u shed , the conj unctivze are c lear

,and the

pupi ls di lated .

The tongue is tremu lous ; at first it is red at the tip and

edges,and covered posteriorly with a whitish fur. In severe

282 ACUTE INFE CTI OUS D ISE ASE S .

cases the tongue becomes dry ,brown

,and fissu red

, and

507d col lect on the teeth .

T/u' S tomac/z. - Gastric symptoms are not common ,but

obstinate vom iting sometimes deve lops and becomes a seriouscompl ication.

I ntestinal symptoms—The abdomen is d istended .

‘

Ten

demess is frequent ly noted on palpation it may be genera lor confined to the right i l iac fossa. Gurgling may also bedetected in the latter region

,but it has l i ttl e sign ificance .

D iarrhea is general ly present,though it is not a constant

symptom . The discharges vary in numbe r from three tos ix o r more a day ; they are thin , offensive , and of a y e llowish color (l ikened to pea- soup) ; on standing, a turbidl iqu id r ises to th e top and a granu lar sediment fal ls to thebottom .

The E ruption—This appears from the seventh to the n inth

day ,and is mos t abundant on the abdomen

,though it is

not infrequent ly observed on the chest and back . I t iscomposed of sma l l

,sl ightly e levated , rose- colored spots that

disappear on pressu re. I t comes out in successive cropsover severa l days . I t may be absent particu lar ly m the oldand very young . Rare ly

,in mal ignant cases , is the eruption

petec hial .Sudam ina are al so noted ,

and res u l t from free perspiration.

Spl enic m largm m t is rare ly absen t. Rupture has occurredin a few instances .N cm ous Symptoms

— In mi ld cases apathy ,headache , and

sl ight deafness may be the only nervous symptoms. In

severe cases there may be mu tteri ng de l irium ,stupor , twitch

ing of the tendons (subsu l tus tendinum) , picking at the bedc lothes or imaginary objects (carphologia) , and coma.

The Blood s—The red ce l ls and hemoglobin are reduced.

The re is no leukocytos is , but , on the contrary , leukopen ia.

Wida l Reach'

on .

—Blood - serum of typhoid patients whenm ixed with a fresh bou i l lon - cu l ture of the typhoid bac i l l us ,alter the lapse of a few ho u rs , c lears the l iqu id and throwsdown a floccu lent prec ipitate. M icroscopic exam inationshows that th is prec ipitation is d ue to a loss of the moti lityof the baci l li and thei r aggl utination or aggregation in c l umps .

284 ACUTE INFE CTIOUS D ISE ASE S .

Pneumonia (croupous or catar rhal) and hypostatic conga:

tion of the l ungs are common complications .Among the less frequent compl ications or sequelze may

be mentioned : Neu ri tis , nephri tis , py e l itis , cholecysti tis , appendicitis , otitis media,

periostitis , parotitis , phlebitis , and tempo rary insanity.

Relapse and Reerudescenee .—Relapses are quite com

mon they repeat the symptoms of the original attack , butthey are general ly m i lder and of shorter duration,

and se ldomprove fatal .Rem d t scm ce.

—This is a sudden temporary e levation of

temperatu re oc cu rring du ring convalescence ,and is not asso

c iated with a return of the other symptoms . I t is usual lydue to constipation

, excitement, or irr i tating food .

Diagnosi 8 .—Acute mi l iary tubercul osis often c lose ly re

sembles typhoid fever. In tube rcu losis the temperatu re isgeneral ly mo re i rregular ; the abdominal symptoms are lessmarked ; pu lmonary symptoms , espec ial ly dy spnea,

aremoremarked ; the rash is absen t ; the Wida l reaction is absent ;tube rc les may be detected on the retina ; and symptoms ofbasi lar men ingitis may be present , such as irregu lar pupi ls,ptosis

,and strabismus .

Incen tive Endocardi tis —The diagnosis may be impossible ,

but the fol lowing featu res would suggest endocarditis : Thehistory of a primary disease which m ight induce u lcerativeendocarditis ; irregular feve r ; intercu rrent ri gors ; markedleukocytosis ; precordial pain and endocardial mu rmu rs ;and the absence of a rose - colored rash , of the Widal reaction ,

and of marked abdom inal symptoms .Enter itis—The absence of high fever

,of eruption ,

of

splen ic en largement , of epi staxis , and of bronchial catarrhwil l serve to distingu ish enteri tis from typhoid fever.

Meningi t is —The abrupt onset , the early deve l opment ofce rem sy mptoms , the irregular fever, the leukocytosis , andthe absence of the characteri stic rash , ofabdom inal symptoms,and the Widal reaction wi l l indicate meningi tis .Prognosi s —The prognosis should always be guarded .

No case is too m i ld to prove fa tal , and no case is too severeto recover. The morta l ity vari es in different epidemics.

TYPHOID FE VE R. 285

Under pre sent methods of treatment the average mortali ty isabout 8 per cent.Continued high fever with sl ight di urnal remissions , ex cessive diarrhea, severe cerebral symptoms

,and repeated hemor

r are unfavorable features.emi nent —As soon as the natu re of the disease is

recogni zed the patient shou ld be confined to bed . The roomshou ld be large and ai ry , and provided wi th efficient meansof secu ring thorough venti lation . The temperatu re of the

room shoul d be maintained between 65°and 70

° F. The

bed -

pan must be used from the beginning unti l conval escenceis wel l advanced . The stools and u rine should be renderedinnocuous before being disposed of. This may be done bytreati ng the evacuation wi th twice i ts volume of a 1 per

cent . solu tion of ch lorinated lime o r a 5per cent . sol ution ofcarbol ic acid

,and a l lowing it to stand in a covered vesse l for

two hou rs before emptying it into the cl oset Soi led c lothingshou ld be thorough ly boi led .

The diet shoul d be liquid o r semi sol id , un irri tating , andeasi ly assim i lable . As a ru le, mi lk is the best food . Mostpatients wi l l be able to take from 2 to 4 pints in the twentyfour hou rs

,given in portions o f from 4 to 6 ounces every

two or three hou rs. I t is general ly advisable to d il u te them i lk wi th l ime - water. If curd s appear in the stools

,the

quantity of m il k shou ld be reduced . Among other permissible art ic les may be mentioned buttermi l k , kumi ss , j unket ,m i lk - whey , ice - c ream

, album in - water , oyster, mutton, or

chicken- broths , chicken je l ly , and consommé. The ret u rnto sol ids shou ld not be commenced

,as a ru le , unti l the

temperatu re has been normal for a week . Cool water or

ice wi l l be u ired to al lay thi rst , and even if the latter isabsent, i t is$31 to give one or the other at regu lar in tervals .When the first sound of the heart weakens and the pul sebecomes soft , stimu lants shou ld be adm in istered . It is desirable to give the alcohol with the m i l k so as to stimu

late the stomach to digest the latter , and at the same time

to dim in ish the number of adm ini strations of food and medicine . From 4 to 8 ounces of brandy or whisky may be re

286 ACUTE I NFE CTIOUS 0 1554 353.

qu ired in the twenty - fou r hou rs,the amoun t being deter

m ined by the gene ra l eFfect.The use of the cold bath o r the cold pack wi l l be found an

excel lent method of control l ing fever and of preventing thedeve lopment of severe nervous symptoms . I t is espec ial lyval uable as a stimu lant to the nerve - centers

, and may be employed whenever the tempe rature ex ceeds F. Hemor

rhage and perforation cont raindicate i ts use (see pageFaw n—When circumstances prevent the use of the coldbath , sponging with cold water and the adminis tration of

phenacetin (5to 8 grains) may be substi tu ted .

Heart-fad ur f .

—Cold bath ing and the time ly use of alco~hol do much to guard against heart - fai l u re. When the ten

deney to cardiac fai lure is pronounced , strychn in may be

given in doses of from to ,10 grain every three o r fourhou rs . In severe cases t e drug shou ld be given hy poder

mical ly . D igi ta l is or strophanthus may al so be tried , but inthe presence of fever these remedies ofte n prove ineffectual.I f col lapse is threatened, ether, alcohol , or, better sti l l , camo

phor (t to 2 grains in steri l e ol ive oi l) may be given subc utaneous ly every two or th ree hou rs .Diarrhea—When the diarrhea exceeds three or fou rstools a day ,

a suppository o f opium (Q to 1 grain) may beused once or twice dai ly . If the diarrhea be troublesome

,

bismuth subn itrate or si lver n itrate may be given by themouth in combination with opium

R. Mo b

l

inc sulpbntis

Bismuth

i

i subn itrai isFiant chm No . x v.

S ta—One powder every three or fou r hours.

B . A nti nitratis

Pu veris opi i

Fiant pi ln lm x i i .S ta—One pil l every th ree or fou r hours .

In very obstinate cases copper su lphate with opium in pi l lproves eff icac ious .Constipatrbn .

—This may be re l ieved by enemas o f soapand water o r by the adm in istration of fractiona l doses of

ca lome l .

28 8 ACUTE IA’

FIE’

CTIOLKS‘ DISEASES.

Russia. Bad food,impure water, overcrowding, and fou l

ai r are predisposingPathol ogy .

—There are no characteris tic lesions . As in

other fevers , the l iver and spleen are swol len,and the tissues

revea l parenchymatous and fatty degeneration. The bloodis dark and fl u id.

Period of I nenbati on .—From a few hou rs to two

weeks .Sm ptoms.

—Typhus fever begins abruptly with pain inthe head, back , and l imbs ; extreme prostration ; and feverthat reaches its maximum (1 04° to 1 05° F.) in from two tothree days. The temperatu re remains high unti l the twe lftho r fou rteenth day ,

when i t fa l ls by cris is .The pu lse is rapid , weak , and often dicrotic . The tongueis at first moist and covered with a whitish fur

,but it soon

becomes dry and brown.

The face is dusky ; the conj unctiva are injected ; thepupi ls are contracted.Nervous Sy mptoms

—In severe cases these are prominent,and cons ist of headache, stupor, del i rium , subsu l tus tendinum , carphologia, and coma- vigi l .The Emption.

—About the fourth o r fifth day rose- coloreds ts appear over the body ; these rapidly become hemo r

riggic o r petechial , and fai l to disappea r on pressure . Therei s a dis tinct re lation between the amount of eruption and

the severi ty of the attack . In add ition to this “ mu lberryras h " there is often a diffuse

,dark - red

,subc uticu lar mott

l ing.

Gastre r’

ntrm'

nal Symptoms—The stomach is reten tive and

the bowel s are constipated .

Ur ine—The u rine is scanty,high - colored

,and often albu

m inous.Comp l i cations.

—These are not very common,but ca

tarrhal pneumon ia,l ocal ized gangrene ,

neuritis,neph ri tis ,

and abscesses may occu r.

Di agn osi s.—Oerebrosp inal Meningit is—In th is affection

the pain in the back is greater ; the fever is much moreirregu lar ; there is greater tendency to opisthotonos and

facial pa lsies ; vom iting is much more common,and the

RE LAPS I /VG FE VE R . 289

eruption , though it may resemble that of typhus,is incon

stant and without a spec ia l time fo r appearing.

Typhoid Pen n—The resemblance is in the nervous phenomena on ly. In typhoid fever the fever rises and fa l l s verygradual ly ; the eruption appears later, remains rose - red

,and

does not become petechial the face is no t dusky ; the eyesare not injec ted ; the blood yie l ds the Wida l reaction, andthere are marked abdom ina l symptoms .

Prognosi s—The mortali ty varies in different epidemics .

Fm . xm—Temperatu re - ebart of typhus.I t may exceed 20 per cent. Advanced years and alcoholism render the pro os is very grave.

Treatmen t —T e patient shou ld be isolated,and all

the exc reta d is rnfected . The general treatment is the same

as that of typhoid fever.

RELAPSING FEVER.

(Spi ri llum Fever ; Famine Fever . )

Defin i tion —An acute contagious d isease exci ted bythe Spirochze ta Oberme ieri , and characterized by rec urringparoxysms of high fever lasting for from five to seven days .E tiol ogy .

—The exci ting cau se is the Spirochazta Obe rmeieri , a spiral- shaped m ic robe three o r four times as longas the diameter of a red blood - corpusc le. Bad water, poorfood , overcrowding, and fou l a ir predispose to epidem ics .The disease is high ly contagious .Path ology —There are no characteri stic lesions. The

liver and spleen are much en larged , and the latter is frequent ly the seat of infarctions . There is us ua l ly catarrhal

290 ACUTE INFE CTIOUS DISEASES.inflammation of the stomach and bi le - ducts . The spirochmta is found in the blood during life , but on ly du ring theparoxysms ; after death it is found in al l the organs .

Per iod of Ineubafi om—From five to e ight days.

Symptoms —The disease begins abrupt ly with a chrl l

fol lowed by fever, which reaches its max imum (105°- to6

F.) in twenty- four hou rs , and remains high for from five toseven days , when i t fa l ls by cris is . After an interm issionof five o r six days it again rises rapid ly and remains highfo r a sim i lar period . Conva lescence usual ly begins at theend of the second paroxysm ,

but it may not begin unti lafter the third or fourth . Other noteworthy symptoms are

intense pains in the head , back , and joints , and the presenceof the spirochazta in the blood. Gastr ic i rritabi l ity and

F16 . 15.—Temperature curve tu re laps ing feve r.

jaundice are also common. Not infreq uentl y there is anecchymotic rash .

Compl i cat ions —The chief compl ications are hyperpyrexia,nephrit is , pneumon ia ,

ophthalm ia,and hemorrhage

from the kidneys , stomach ,o r bowe ls .

D iagnosis.—The characte ris tic febri le paroxysms with

the long interm issions and the presence of the spirocha ta

in the blood are the distinc tive features .Prognos is —Favorable in uncomplicated cases.Treatmen t —As in a l l contagious diseases , isolation ,

free venti lation, and disinfection of exc reta and c lothing are

important safeguards agains t the spread of the virus. The

treatment is pu re ly symptomatic. Absolu te rest , goodnurs ing

,and proper diet wi l l do much to avert complica

29 2 ACUTE INFECTIOUS DISEASES.head is ben t backward and the back is straightened ; insevere cases the body may be arched in a state of opisthotonos . Kern ig'5s ign is an almost constant phenomenon .

‘

De l iri um ts rare ly absent, and in severe cases it is fol lowedby stupor and coma.

Im 'olwmm t of tire Cranial N ames—Pressu re of the ex u

date upon the cran ia l nerves may produce the fol lowingsymptoms . Nystagm us (tremor of the eyeba l l) , strabismus ;ptosis ; irregu la r, sl uggish pupi ls ; and partial deafness or

blindness .Invol vement qf t/w Spinal N antes—There is ex treme

cutaneous hyperesthesia, so that the s l ightest touch exc i tespain . The m usc les of the extrem i ties are stiff and maytwitch , but are rare ly pals ied . The pate l lar reflex is usual lydim in ished . The joints are occasional ly red ,

swol len,and

painfu l .Febr il e Sy mptoms

—The temperatu re is irregu lar in itscou rse and indefinite in its du ration ordinari ly it ranges between 1 0 1

°and 1 03

° F.,but in some cases it is a lmost

normal,and in others it is very high . The pu lse is rapid

and fu l l ; the bowe ls are constipated ; and the u rine maycontain album in and sugar. There is usual ly rapid emaciation . Polyu ria is an occasional symptom .

77¢e Er uption .

—The eruption is ne i ther constant nor peenl iar . In many cases a blotchy pu rpu ric rash appears overthe enti re body . Herpes fac ia l is is also frequent ly oh

served In other cases u rticaria o r a roseolar or erythematous rash appears .77mBl ood .

—Leukocytosis is always present.Lumbar P uncture—In a large proportion of the casesdiplococc i are found e i ther on m icroscopic exam ination or

by cu l tu re .

The du ration is from a few hours to severa l weeks . In

favorable cases recovery is a lways slow .

Pnhninant Forum—There is an abrupt onset, with a chi l l ,fol lowed by vom iting , headache , moderate fever, convu l

This consists in an inabil ity to stra ighten the leg completely when the

pati ent is in the recumbent posture and the th igh ts flexed at a righ t angl e withthe pelvis.

CEREBROSPINAL E E VE Ii'

. 3

sions, a petechial o r pu rpuric rash , and death in a few hou rs

from col lapse .

Abor ti ve Pom —The disease begins abruptly with gravesymptoms

,but term inates in a few days in recovery.

Intermi ttent Form.—The fever is characterized by inte r

m iss ions o r marked remissions that occu r dai ly or everyother day .

BM W —Typhoid Fever .—The gradua l onset , the

regu lar fever, the diarrhea and tympan ites , the Widal react ion, and the absence of rigidity

,of intense pain in the

back and l imbs , of fac ial pa ls ies , of leukocytosis , of Kern ig 'ssign, and of herpes, wi l l serve to distingu ish typhoid fromcerebrospinal fever.

Ty phus Pen n—The regu lar fever, the absence of intensepain in the back and l imbs , of fac ial palsies ,

of Kern ig 'ssign

,and of musc u lar rigidity wi l l d istinguish typh us from

cerebrospinal fever.

Acute articular rheumatism may resemble cerebrospinalmeningitis, but the early involvemen t of the joints , the ac idsweats

,and the absence of rigidity, of eruption ,

and of fac ialpalsies , wi l l distingu ish it from cerebrospina l men ingitis.Tuberculous Meningitis—In this disease the onset is less

abrupt ; there is less tendency to Opisthotonos ; herpes israre ; petechia: are always absent Lumbar puncture affordsa re l iable means of diagnosis and a primary focus of tubercu los is ca eneral ly be detected e lsewhere in the body.

n osi s —The morta l ity varies in different epidem icsfrom 20 to 80 per cent. The prognosis shou ld always beguarded ; the m i ldest cases may prove fata l . Severe cere

bra l symptom s usual ly indicate a fatal term inationCompl i cations and Sequelm.

—These inc l ude defectivevision from inflammation of the cornea o r retina o r fromatrophy of the optic nerve ; defec tive hearing from inflammat ion of the auditory nerve o r from suppurative inflamma

tion of the interna l o r middle ear ; pneumon ia , arthri tis ,

aphasia,

riphe ral pa lsies ; imbec i l ity ; chronic hy d roceph:alus ; and

pgersistent headache from chronic men ingitis .

Treatmen t —Cerebrospina l fever is probably not con

tagious, hence rigid isolation is not usual ly regarded as

294 ACUTE INFE CTIOUS D ISE ASE S .

absol utely necessary. I t is advisable,however, to disinfect

the discharges , bed - l inen ,etc . The sick - room shou ld be

quiet, darkened , and we l l venti lated . The diet shou ld beliqu id and supporting. In some cases , in orde r to sec u rethe ingestion of enough nou rishment, it may be necessaryto resort to nutrient enemas o r forced feeding by meansof a stomach - tube. Cardiac fai l u re must be combated bystimu lants , of which the best are whisky and brandy.

In sthen ic cases the withdrawal of several ounces of bloodby wet- c ups app l ied along the cervica l vertebrzr. may proveusefu l. Cold applied to the head and along the spineaffords cons iderable re l ief. Bl isters to the nape of the neckare of doubtfu l value

,at least du ring the irri tati ve stage .

Morphin hypodermica l ly is the best drug fo r the re l ief ofpain

,restlessness , spasms , and insomnia. In m i ld cases

bromi ds may sufl‘i ce.

Fever is control led best by cold sponging o r the coldpack , or , if the tempe ratu re is very high

,by systematic cold

bathing . Repeated lumbarlpu

nc

tu re

shave been found use

fu l in re l ieving excruc iating eadache , de l irium , somnolence,and coma .

Ton ics—iron ,strychnin , and cod - l iver oi l—are general ly

indicated du ring convalescence. Loca l palsies wi l l requiremassage and e lectric i ty.

(chi l l s and Pever ; Pever and Ague ; Pal adism .)

Defini t ion .—An infec tiou s disease , exc ited by a proto

zoan parasite—the hematozoon or Plasmodium malariae of

Laveran and characteri zed by splenic en largement . feverwith nod ic interm issions o r rem issions

, chi l ls , and anem ia .

ol ogy .—Man becomes infected with the organ ism of

malaria usual ly,if no t invariably th rough the bite of certain

mosqu itos , name ly,those be longi ng to the genus Anophe les ,which serve as hosts fo r the pa ras ite . The usual source

from which the mosqu ito derives the parasite is man . The

conditions predisposing to infection are those which are

296 ACUTE INFECTIOUS DISEASES.intermi ssion

Eda /bl e quar tcm f ever ) . When th ree groups

coexist, a chil occurs every day (quotidt'

an f ever ).[Swim - autumnal Paran

'

te.

—The latter half of the l ife- cyc leof this pa rasite is carried ou t in the internal organs. The

endocorpusc u lar form is smal ler than that of either thetertian or the quartan ,

and conta ins much less pigment. As

the parasite deve lops the corpusc le acquires a pecu liarshriveled and brassy apmarance . The al teration of the

hyal ine bodies into figures resembl ing a signet ring is characteristic . Segmen tation does not occur in the periphe ralblood , but in the spleen and other internal parts . After the

infection has lasted a week or more ,ovoid bodies apm r in

the red ce l ls . These gradual ly become transformed intocrescentic forms having central c lumps of pigment , the co r

pusc les meanwhile be ing reduced to thin , transparent shel ls.

Fl o . t6 .—Varlous forms of h ematozoa .

The developmental cyc le of this parasite exhibits a ma rkedi rregu larity.

In addin’

on to the forms al ready desc ribed ,flagel late bodiesare 0 encountered . The deve lopment of flage l laappears to have some importan t bearing upon the reproduction of the parasite .

Pathol og icpm —The destruction of the red cel ls

by the parasites is fol lowed by anem ia, me lanemia, and pig

mentation of the organs . The spleen becomes greatly enlarged from congesbon . In chron ic cases (malari al cachexia)it becomes hard and to ugh from hype rplasia of the fibroustissue . E xtreme disintegration of the blood may occasionthrombosi s of sma l l vesse ls and also hemoglobinu ria.

Variefi es of M ari s —The fol lowing c l in ical formsare recogn ized : (t ) Interm i ttent malarial fever

, (2) estivoautumnal feve r ; (3) perniciou s malarial fever ; (4) chronic

MALAR IAL FE mm. 297

Intermi ttent malarial fever is excited by tertian or quartanparasites . I t is characterized by paroxysms of fever occurring at definite periods

,each paroxysm consisting of a cold

,

a hot,and a sweating stage .

Cold S tage.

—This stage is characteri zed by lassitude,

aching in the limbs,and great chi l liness . The featu res are

pinched ; the l ips are blue ; and the s u rface is cold and

rough (cutis anseri na) . The rectal temperature ,however

,is

high (1 05°- l o6° F. Vom i ting may occu r. The chil l maylast from a few minu tes to an hou r or more .

Hot Stage.—The su rface temperatu re gradual ly rises ; the

skin becomes hot ; the face flushed ; the eyes injec ted ; andthe pulse fu l l and rapid . The temperature in the axi l la mayreach 1 0 6

°or 1 0 7

°F. The patient complains of severe

pain in the head , back , and l imbs, and of intense thirst. The

u rine is scanty and dark colored. This stage usual ly lastsfrom one to five hou rs.Sweating S Iage.

—The fever gradual ly subsides ; the painsgrow less

, free perspiration fol lows , and the u rine becomesplentiful . Within an hour or two the attack is over and thepatient fal l s into a refreshing sleep .

In addi tion to the recu rring paroxysms,interm ittent

malarial fever presents symptoms common to al l form s ofmalari al infecti on

,name ly, enlargement of the spleen , anemia,

pigmentation of the leukocytes , and the presence of hematozoa in the blood . There is no leukocytosis.

(Remnant Fever ; Scimitar-tin t Fem .)

In temperate zones this type occu rs chiefly in the latesummer and autumn . In tropical countries

,where it often

assumes a most severe form ,it occu rs at al l seasons.

The symptoms of estivo - autumnal fever are often qu iteirregular . The hot stage of the paroxysm often las tstwen ty - fou r o r thirty- six hours , or even longer, and the

inte rm issions are very short . In many cases there are no

actual intermissions , but simply rem iss ions (remi ttent fever) .

298 ACUTE INFECTIOUS DISEASES.The chi l l and the sweat may be as severe as in intermi ttentfeve r, but usual ly they are s light and of short duration .

There is often s light jaundice (bi lious rem ittent fever) . In

some cases there is mil d de l iri um , making t he condi tion t e

semble very c lose ly typhoid fever. Prostration is alwaysmarked . The spleen is en larged. The characteri stic parasite is found m the blood

This type is exc ited by the estivo- autumnal parasite . I tprevai ls in tropica l and subtropica l countries

,and is rare in

temperate regions . The second or th ird paroxysm mayassume a pern ic ious type

,but never t he first. The symptoms vary with the loca l i zation of the paras ite . When the

la tter accumu late in the capi l laries of the brain and men

inges , the attack may be man ifest by de l irium , aphas ia, andrapidly deve loping coma (comatose type). Wh en the local ization is gastro - intestinal , there may be vomiting and pu rging of se rous materia l , c ramps , suppression of u rine

, coldness of the su rface , profuse sweating , and fata l col lapse(alg x

'

d type) . In other cases , in consequence of a suddenand intense hemolysis , the paroxysms are assoc iated withjaundice, bi l ious vom i ting , and hemoglobinu ria . Bleedinginto the subc u taneous tissues and from the mucous mem

branes may also occur Memory /mgr};

(ype).Ch ron i c Malar lal Cachex ia .

—Malaria l cachexia maybe a seque l of repeated attacks of interm ittent o r estivoautumnal fever, or i t may deve lop insidious ly as a primarycondi tion .

There is intense anem ia with its attending phenomena.

Pigment granu les are found in some of the leukocytes andin the plasma. The parasites are at times absent from the

blood . The complexion is sa l low o r muddy. The temperature is usua l ly subnormal . bu t there may be occasionals l ight attacks of fever. The spleen is great ly en larged .

Weakness and emac iation are marked . Indigestion ,flatu

leney , and constipation are common symptoms . Periodicheadache

,neu ralgia , and hematu ria are sometimes observed .

D iagnosis of Mal ar ial Infect ion .—E st ivo - autumnal

30 0 ACUTE INFE CTIOUS DISEASES.

Qu inin is the only re liable remedy for malarial fever.

Methylene- blue (2 to 5grains with half i ts we ight of powdered nutmeg thrice dai ly) and Warburg’s tincture possesssome va l ue, but, being distinct ly less efficac ious than qu in in ,

they shou ld be employed on ly when the latter is not we l lborne.

In ordinary intrnm’

l tm t f ez/er the quinin shou ld be givenin dai ly doses of from 15to 20 grains, so divided that thelast dose is taken about th ree hou rs before the expectedchi l l .The remedy shou ld be contin ued in fu l l doses unti l theparoxysms fai l to appear, and then gradual ly withdrawnover a period of severa l weeks . The admin istration of a

laxative dose of calome l as a pre l iminary measure increasesthe effi cacy of the quin in

,probably by fac i l itating i ts absorption.

For adu l ts quin in is best presc ribed in capsu les , cachets ,or fresh ly made pi l ls . For chi ldren i t may be given suspended in syrup of yerba santa, syrup of chocolate , or

e l ixir of l icorice. During convalescence i ron and arsenicmay be advantageous ly given with the qu inin ,

as in the fo l

lowing formu la3. Ferr i pymphospbal is

Acid i arsenos iQu ininm su lphntis

Pul veri s caps ic i .

Pone i n capsu les. No . x ii .S td—One thrice dai ly after meals.

In ( Saba- au tumnal f ez/t r larger doses of quin in (30 to 40grains a day ) are usual ly requ i red. In pm ia ous mal ar i al

f ever the patient shou ld be c inchon i zed as qu ick ly as possibleby injec ting at once into the tissues of the thigh or bu ttockabou t 30—40 grains of a so luble sal t of qu inin l ike the d ihyd rochlorate .

Sy mptomah’

: Trea/mm t.—During the cold stage of the parox y sms the patien t shou ld be wel l covered wi th warmblankets and given hot drinks . Opium in the form of paregoric is sometimes usefu l in mitigating discomfort . I t maybe combined wi th a few m in ims of aromati c spiri ts of ammo

scan s ? FE rs e . 30 :

nia. ch loroform. or Hofiinann'

s anodyne. l n the hot stagemuch re lief is afforded by frequen t ly sponging the body withcool water . giving cold drinks , and administering, if thesymptoms are very seve re

,a smal l dose of phenacetin. In the

algid type of pernic ious malarial fever i t may be necessary togive alcohol free ly, with digi tal i s and strychnin,

to tide the

patient over the paroxysm.

Mal ar ia! car/wr it: requires tonic and hygienic treatmentArsenic , iron ,

and cod - liver oil are espec ial ly val uable . As

in other man ifestations ofma laria, qu in in is ind icated so longas the blood shows parasites . According to Wood , it ismuch bet ter to produce distinct c inchonism at interval s thanto give the drug continuously in mode rate doses . Whenthere is constipation,

mi ld bi tter laxatives are benefic ial .Change of l ocal ity is sometimes necessary ' to effect a cure.

Defini tion —An acute, contagious disease , characterizedby high fever, a rapid pu lse , a punctiform scarlet rash , sorethroat , and a marked tendency to neph ritis.E t i ol ogy .

—The spec ific mic ro- organ ism of scarlet feverhas not been isolated . The Streptococcus pyogenes ispresen t in most of the compl icating lesions . The contagiumi s usual ly carried through cl othes o r other fom ites , or infood , particu lar ly m i l k . The poison is tenacious and of ex

treme vital ity ; infected c lothes , unused for years , have ledto ou tbreaks. The disease i s probably contagious at al l

peri ods , but it is most so du ring the stage of desquamation .

The young d , but not equal ly so .

One attack immun ity,but second

attacks are very uncommon.

Pathology .—The th roat is inflamed and some times u lcer

ated ; the l iver and spleen are engorged ; and the musc lesrevea l granu lar degeneration . The kidneys frequently showthe lesions of hemorrhagic neph ri t is , the glomeru l i being especial l y invo lved . The rash i s rarely detected after death.Varieties —( t) Simple ; (2) anginmd ; (3) mal ignant.

30 2 ace/7'

s INFE CTIOUS 0 1554 555.

Per iod of Ineubati om—From a few hou rs to a week .

S ymptoms —The disease general ly begins sudden ly, occasional l y with a chi l l , but more common ly with vomiti ng orconvu lsions.1

'

Irm a! Sy mptoms.

—These consist in pain and diffi cu l ty 1nswal lowing ; fu l lness and tenderness beneath the Jaw ; and enlargement of the lymphatic glands. The tongue is at firstheav i ly coated and red at the tip and edges ; in a few daysthe coating almost entire ly disappears and the papi lkebecome bright red and swol len . This appearance has givenri se to the term strawbe rry tongue . The pi l lars , tonsi ls ,uvu la, and pha ryngeal vau l t are deeply injec ted and mayreveal a punctiform effiorescence before the rash deve lops onthe skin . In severe cases the tonsi ls may be the seat offol licu lar inflammation

,or may be covered with fal se mem

brane .

Empl ion .—A scarle t - red pu nctiform ras h appears at the

end of the first o r at the beginn ing of the second day ,on the

neck and chest , and rapidly spreads over the enti re body . I tdisappears on pressure ,

a white l ine remain ing for a secondor two when the finger - nai l is drawn th rough it . I t may beun iform o r i t may occu r in discrete patches su rrounded byheal thy skin . The rash lasts fo r from five to seven days ,and is fol lowed by flaky desquamation . The period of desquamation may last for from two to six weeks .In some cases the rash is pale and scarcely visible 1n

others it is s l ightly papu lar o r vesicular (scarlatina mil ian s'

)in mal ignant cases it may be petechial .Febril e Symptoms—The fever rises abruptly , reaching its

maximum (1 0 4°

- 105°F.) in from twenty - fou r to forty - e ight

hou rs , remains nearly uniform fo r th ree o r fou r days , andthen fal ls by lysis . The duration of the febri le period isfrom seven to nine days . The pu l se is very rapid—out ofproportion to the fever ; the respi rations are hu rried ; theappeti te is lost ; the bowels are constipated ; and the u rineis scanty , high - colored

,and often albuminous . There is a

wel l -marked leukocytosis .Nm row Sy mptoms .

—Rest lessness , headache ,insomn ia,

del i ri um,and convu lsions may occu r in the course of the

304 ACUTE w a ger /0 05 0 1554 555.

remi ssion on the second or th ird day ; and the pul se is propo rtionate to the fever.

Rotheln .—This may be difficu lt to distingu ish from scarlatina, but the fever is not so high , nor the pu lse so rapid ;

the postcervical glands are more swol len ; there is no ten

deney to nephritis ; and the rash is not punctiform .

Accidenu l M a—Ce rtain drugs l ike be l ladonna,quin in,

and copaiba , and certain foods , l ike crabs and oysters , mayproduce a rash l ike that of scar let fever, but it is not punctiform ,

and is not assoc iated wi th high fever,sore throat, and

rapid pulse .

Progn0 8 i 8 .- A lways guarded . The mortali ty varies in

different epidem ics from 5to 40 per cent .Treatmen t —The patien t shou ld be isolated fo r fromsix to e ight weeks . A l l artic les used in the sick - roomshou ld be tho roughly disin fected before be ing removed .

To prevent dissem ination of the sca les some bland ointment(cold cream or cocoa - butter) shou ld be appl ied to the

patient’s body at least once a day unt i l desquamat ion is comp lete . The patient shou ld not be al lowed to leave his bedfor at least a week afler the fever has subsided .

The diet shou ld consist of m i l k , j unket, kum iss, icec ream ,

fru it- j u ices,and grue ls . Water shou ld be given

free ly to re l ieve thirst and to keep the sec retions active .

Vomiting wi l l cal l for antiemetics—c racked ice,carbonated

water, bismuth subnitrate,or di l uted hydrocyan ic acid.

Fran z—Tepid sponging is ve ry gratefu l throughou t thefebri le period . Fever above 1 03

° F. shou ld be combatedwith cold packs or baths (80 ° and by cold appl icationsto the head .

When the tempe ratu re is not very high , a mi ld febrifugel ike the fol lowing wi l l be found usefu l

8 . Spiri tus c theris n itrosi

Liquor ammon ii acetatis q . 3. ad

S tG.—Decsertspoonful with water every threefive years.

Throat Symptoms—The nose and throat shou ld be

c leansed with m i ld antiseptic sprays , such as a weakDobel l

’

s sol ution or a so lution of hydrogen dioxid (l

w ussE S. 30 5

When tonsi l l i tis is severe , the fol lowing application wi l l befound efl‘icac ious '

gr. xxTi nctume ferri ch lorid i

Glycerini M w

Aqua q. 5. ad ii .—M .

Sta—Apply to the tonsib se veral times a day with a union swab.Cardi ac weakness m ust be combated with such drugs as

alcohol , strychnin ,and digi tal is .

Cm bral w yrow are best control led by the appl icationof an ice - cap and the adm in istration of brom ids or smal ldoses of chlora l o r phenacetin . When the nervous symptoms are due to high temperature, cold bath ing is most

In acute otitis media nothing,affords so much rel ief as

gent ly syringing the auditory cana l wi th hot water. The

application of a leech behind the ear is a lso usefu l. Whenthe tympan ic membrane bu lges , indicating the presence of

pent- up pus, the latter shou ld be evacuated by puncture.

Shou ld seve re nrp/m'

fis deve lop,dry c upping over the

loins , fol lowed by warm fomentations , wi l l often prove of

val ue. Aperients , espec ial ly sa lines , are indicated . Warm

baths , hot packs , vapor- baths, or pi locarpin (11; to 110 grain)

shou ld be used to promote diaphoresis . When the urine isscanty , un irritating diuretics, l ike potassium acetate or bi

tartrate and digita l is,are of service.

(Rubeola ; Morbil l i . )Defin i tion .

—An acute contagious disease , characteri zedby catarrh of the respiratory tract, moderate fever, and a red

papular eruption,which appears on the fou rth day , lasts

fou r o r five days , and is fol lowed by bran - l i ke desquamation .

E t i ol ogy .—Measles is h igh ly contagious , and the poison

may be transm itted th rough c lothes and other fomites . Thecontagi um is apparently assoc iated with the nasal and bronchia l secretion , but it has not been isolated. Meas les is mostcommon ly observed in chi ldren,

but unprotected adu lts are

30 6 ACUTE INFECTIOUS 0 1354 553.

very l iable to be attacked. I t is essential ly an epidem ic disease ,but now and then sporadic cases occur. One attack

is fairly protec tive,but does not give absolute immunity .

Path ol ogy.—The lesions consist in catarrh of the entirerespiratory tract. Castro- in testinal catarrh is not uncom

mon . In fatal cases such compl ications as catarrha l pneumon ia and pu lmonary col lapse are frequently observed .

Per iod of Incubati on —Ten days to two weeks .Symptoms .

—The 1nvas ion is characterized by catarrhalsy mptoms

—photophobia,redness of the eyes, inc reased lacri

mation, sneezing , discharge from the nose, hoarseness, cough ,and

,in older chi ldren ,

expec toration.

771: Fawn—The temperatu re rises rapid ly to 10 3°

or

1 04° F. ,but on the second day there is often a dec ided re

m iss ion which continues unti l the fou rth day ,when the

eruption appears ; at this time i t again rapid ly runs up toor beyond its origina l he ight, where i t remains for three o r

fou r days and then fal ls by rapid lysis or crisis .The Emph

'

om—This appears about the thi rd o r fou rthday on the face, and rapidly spreads over the entire body .

I t is composed of sma l l , dark - red ,ve lvety papu les

,which

form groups having crescentic borders . There are oftenmuch bu rn ing and i tching of the skin . In th ree o r fou rdays the eruption begins to fade ,

and a branny desquamation soon fol lows .Minute blu ish - white specks surrounded by a red areola

may be seen on the mucou s membrane of the cheeks andl ips one or two days before the sk in eruption appears (Kopl ik

'

s sign) .Mal ignant or Hemorrhagi c Measles—This form occu rs

under bad hygien ic condi tions , and is characterized by a

petechial rash , by hemorrhages from the mucous membranes

, and by profound prostration .

Comp l i cation s and Sequel e .—Bronchopneum0 n ia

and acute gastro- intestinal catarrh are the most commoncompl ications . Among the less freq uen t compl ications orseque lze may be mentioned membranous or u lcerati velaryngitis , o titis , chron ic conj unctivitis

,pu lmonary tubercu

los is, canc rum oris, and neu ri tis .

30 8 ACUTE INFE CTIOUS 0 1354555.

RUBELLA.

(Bothcln ; German Measl es ; Ep idemic Roseola.)

Defin i tion .—An acute contagious disease resembl ing

both scarlet fever and meas les, but differing from these inits short course,

sl ight fever, and freedom from sequelee .

E tiol ogy .—The disease is highly contagious

,and the

poison may be carried on c lothes or other fomites . I t genera l ly occu rs in epidemics , but sporadic cases are not uncommon . I t is most frequent ly observed in chi ldren,

but nuprotected adu lts are not exempt One attack usuall yprotects from another, but no t from measles o r sm rlet fever.

Per iod of I ncubat ion .—One to three weeks .

Sy ruptoms.—Prodromes are s l ight or altogether absen t.

The disease begins with drowsiness , s l ight fever, and sorethroat. The eruption appears on the fi rst o r second day ,

and varies considerably in its character. In some cases therash is composed of pale- red ,

scarcely e levated papu les ,which are more or less disc rete (rubel la mort al /J am e) ; inothers the rash is bright red and diffuse

,l ike that of scar let

fever (rubel la scar ladm'

formc). I t begins on the face and

rapid ly spreads over the enti re body,but it fades so rapid ly

that the face may be c lear before the extrem ities are affected .

S l ight desquamation frequently fol lows , though it is oftenabsent. Apart from the sore throat

,the catarrhal symptoms

are sl ight. A very constant and somewhat characteris ticfeatu re is marked swe l l ing of the postcervical glands .The du ration is from three to five days .Prognosi s .

—Good. Compl ications are very rare.

Treatmen t is that of measles .

SMALLPOX.

(Varicla )

Defin i tion .—An acute contagious disease characterized

by vomi ting ; l umbar pains ; an eruption which is at firstpapu lar , then vesicu lar , and final ly pustu lar ; and by feverwhich is marked by a distinct rem iss ion . beginn ing with theadvent of the eruption and lasting unti l the latter becomespustu lar.

su azzp ox . 309

E ti ology . The poison of smal lpox is extreme ly tenacious : i t may remain latent in c lothes or othe r fomites fo r along time ,

and then be capable of exc iting the disease . The

viru lent princ ip le is doubtl ess con tained in the pustu les andin al l the exc ret ions of the body

,but it has not been iso

lated . Several observers c laim to have found a spec ificorgan ism of the protozoan group. Un less protected byvacc ination or a previous attack

,nearly every one is sus

ceptible ,from the aged to the chi ld i n utrro. The colored

race seem espec ia l ly predisposed .

Path ol ogy —The eruption consists in an infi ltration of

ce l ls into the ” It macomw or into the true sk in. The ce l lsu ltimate l undergo l iquefaction necrosis , when suppu rationsoon fo l ows. Genu ine pocks are frequent ly found in the

Fi tz. t7.—Temperature - cu rve in smal lpox .

mouth,esophagu s , and larynx , and rare ly in the stomach ,

trachea , and bronchi . The spleen is engo rged . The organsand musc les revea l fatty and parenchymatou s degeneration .

Var iet ies .—Disc rete ; confluent ; mal ignant ; varioloid .

Per iod of Incubati on .—Ten days to two weeks .

Symptoms .—Discretc Smal lpox —The disease usual ly

begins with a chi l l or se ri es of c hi l ls,fol lowed by vom iti ng

and intense l umbar pains . The feve r rises rapid ly , reachingits maximum (1 04

°—1 05° F. ) in forty- eight hou rs , and con

t inues high unti l the third or fou rth day ,when it fal ls sev

era l degrees ; this rem ission lasts unti l the seventh or eighthday

- that is unt i l the time of pustu lation—when the tem

pe rature agai n rises . The secondary or suppu rat ive fevershows marked fluctuations ; its height is proporti onate tothe number of pustu les ; and it fal ls by lysis about the

3I0 ACUTE INFE CTI OUS D I SE ASE S .

eighteenth day of the disease . The pu lse is fu l l and rapid(1 20 the breath ing is hu rried ; the sk in is d ry ; thebowels are usual ly constipated , though diarrhea is not

uncommon ; and the u rine is scanty and frequent ly a lbum inous .T/u’ Emptzbtz.—About the third or fou rth day smal l redspots are noticed on the forehead , face , and wrists ; these are

rapidly converted into smooth , round papu les that fee l l ikeshot under the sk in. The eruption rapidly spreads over theentire body. About the th i rd day the papu les are con

verted into c lear vesic les,which present a depression or

umbi l ication at their summ it. They are also loc u lated ,i . c. , divided into compartmen ts by fibrinous part itions ,—so

that when pricked wi th a need le a l l the contained fluid doesno t escape . In two or three days the c lear fl uid becomes

turbid and the vesic les are g radual ly converted into pustu les . The latter soon 10 56 the umbi l icated appearance .

Between the lesions the sk in is edematous,so that the body

is swol len and the featu res are un recogn izable . In three daysmore the pustules d ry up, o r break and form soft ye l lowc rusts that exhale a pecu liar , offensive odor ; they adhere tothe sk in for a week o r mo re . When the scabs fal l off, scarso r pock - marks general ly remain

,consti tuting a pe rmanent

deform ity .

At the beginn ing of the di sease , before the true variolou seruption appears

,e i ther a red bl ush or a macu lar rash is

often observed on the inner side of the a rms and thighs .Confluent Smal l pox .

—The papu les are abundant and sooncoalesce. The ex trem ities are swol len and painfu l . The

secondary fever is very high and irregu lar . True pocksnear ly always devel op in the air- passages and give rise to acopious fetid discharge from the nose and th roat , to hoarseness

, and to cough . De l iri um,stupor

,and subsu l tus are

frequent symptoms . If the patient recove rs , i t is after a

tedious convalescence,with great fac ial disfigu rement , and

often with defective vision or hearing.

Mal ignant Smal l pox —In some cases the disease is usheredin with high fever , l umbar pains , and reat prostration.

Soon ecchymoses appear on the sk in ; b eeding from the

31 2 ACUTE INFECTIOUS D ISE ASE S .

the mal ignan t,almost hopeless . In the unvaccinated the

mortal ity ranges between 20 and 60 per cent. Among thosehaving one or two typi vaccine scars

,the death - rate is

very low—usual ly less than 3per cent.Treatment —The preventive measures against smal lpox

inc lude the complete isolation of the patien t (preferably in a

special hospi tal ) , the thorough disinfection of al l objects thathave been in contact wi th him

,and

,above al l

,the vaccina

tion of al l who have been or who are l i kely to be exposedto the contagion . Absolu te rest in bed

, l ight bed - c lothing,

a we l l - ven ti lated room of a temperatu re of 65° F an easi ly

ass imi lable but sustain ing diet, and the free use of cooldrinks are requ i sites of treatment. The severe lumbarpains wil l requ ire opium and the applica tion of hot - waterbags . Fever is best combated by hydrotherapy—col dsponging, cold packs

,or cold baths . Antipyretic drugs

shou ld be used with caution.

Gastri c irritabi l ity may be control led by dil uted hydrocyanicacid (2 m in ims) , subni trate of bismuth (1 0 grains) , o r cocain(l grain). When nervous symptoms are not re l ieved byhydrotherapy , opium with brom ids o r chloral with bromidsshou ld be tr ied . A lcohol ic stimulants are frequen tly demanded , especial ly in confluen t cases .An attempt shou ld be made to keep the nasopharynx

c lean by means of anti septic sprays o r douches. The eyesshou ld al so be kept cl ean by frequent appl ications of a warmboric - ac id sol ution (15grains to the ounce) .

B i ting—The room should be darkened

and the exposed parts covered wi th c l oths wrung out of aweak solu tion of carbol ic acid (t : 20 0 ) o r of corrosive sub

l imate o r Unfortunate ly, when the

lesions are deeply seated , there are no efficient means of

preventing pitt ing.

In the stage of desiccation ,warm bat hs fol lowed by in

unctions with cold cream or olive oi l are usefu l in al layingitching and in hastening the removal of the crusts .

VACCIN IA. 313

VACCINIA.

(Vaccination ; (low- pox )Defini tion .

—A general disease with a loca l manifestationresembling the pock of variola, and acqu ired by inoculationwith the virus of cow- pox .

Hi story and Obj ect —The val ue of vaccination as a

means of protection against smal lpox was fi rst made knownto the world in a paper published by Edward j enner in 1798 .

Recent vacc ination gives almost complete immunity againstvariola ; the mortal i ty of smal lpox acquired after vaccination is almost inversely proportionate to the numbe r of truevacc i ne scars .E ti ol og y .

—Vacc inia is induced by inoculating the arm

o r leg with fresh vi rus obtained from the udder of a cal f

suffering from cow- pox (bovine vi rus) . Fo rmerly virustaken from a human vaccine vesicle was also employed(humanized vi rus) , but on account of the ri sk of transm itting syphi l is and other diseases , this sou rce has been praetical ly abandoned .

I t has been shown that the addition of g lycer in to vacc inelymph se rves to prese rve it and to free it from pathogenic

Time of Performance —The fi rst vacc inati on shou ld beperformed , as a ru le

,abou t the second or third month , the

second at the seventh year, and the thi rd at pube rty . Vac

cination shou ld always be repeated when smal lpox is prevalent .Performanee of Vaccinati on —The part selectedshou ld be thorough ly c leaned with soap and water , thenwith alcohol

, and final ly with pu re wate r. A number of

cross- scratches shou ld next be made over an area aboutof an inch in diameter, with a steri l ized needle o r spec ia lscarificator, deep enough to al low of a l i tt le oozing of pinkish serum. The viru s shou ld then be appl ied and we l l rubbedinto the exposed lymph - spaces by additional sca rificat ion . A

shie ld may be worn for a few hou rs unt i l the wound hasbecome perfec t ly dry ; after that it shou ld be discarded .

Sm ptm —About the th ird or fourt h day after the

314 ACUTE INFE CTIOUS 0 1554555:

operation a papu le su rrounded by a red areola forms atthe seat of inocu lation . In two or three days the papu lebecomes transformed into a c lear vesic le with a centra l depress ion. The tissues su rrounding the vesic le are red

,infil

trated,and tender, and the seat of intense itching. The

vesic le reaches its fu l l si ze by the e ighth or n inth day ,

when it ruptures and discharges or dries to a c rust The

latter remains for from one to three weeks , when it fal ls off,leaving a red c icatri x that later becomes white and pitted .

Du ring the cou rse of the eruption there may be s l ightfever

, malai se , restlessness, and en largement of the axi l laryglands .Comp l ications —Abscess o r erysipe las may resu lt fromsecondary infection . Various general ized eruptions , suchas urticaria or erythema m u l tiforme , are occasional ly ex c itedby vaccination. Tetanus has occu rred in a few instances .

VARICELLA.

Defin i tion —An acu te contagious disease of short duration

, characterized by s light fever and a disc rete vesicu lareruption ,

which disappears in two or three days bydesiccation .

E t iol ogy .—The disease occu rs sporadica l ly and epidem i

cal ly. I t is obse rved chiefly in chi ldren , but adu lts are not

exempt. One attack usua l ly protects from others . I t bearsno re lation to smal lpo

Peri od of Incubation —Fou rteen to sixteen days .Symptoms.

—In most cases there rs s light fever, °— l oo

1 0 2°F. ,—with chi l l iness and ma laise. Not infrequent ly,

however, constitu tional symptoms are whol ly wanting .

E rupti'

on .—This appears within the fi rst twenty - fou r hours.

At first it is macu lopapu lar, but within a few hou rs it becomes vesicu lar. The vesic les are usua l ly sparse are mostabundan t upon the tru nk ; come out in crops ; are superflc ial and very variable in size ; are un i locu lar ; and are

rare ly umbi l icated . In two o r three days desiccation begins ,the ves ic les becom ing irregu larly puckered at the peri phery

31 6 ACUTE INFE CTIOUS D ISE ASE S.

t he underlying tissues , and when forcibly removed , leaves araw and bleeding su rface. Microsc0 pical ly ,

i t is composedof fibrin,

epithe l ia l ce l ls , and leukocytes (more or lessdegenerated) , Klebso Lofli er bac i l l i , and pyogen ic cocc iThe lymphatic glands near the seat of infection are

swol len . Foca l nec rosis,d ue to the ac tion of the toxin

,is

found in the l iver and othe r organs . The heart , k idneys ,and l iver are the seat of fatty and pare nchymatous degeneration . Intersti tia l hemorrhages are frequent ly observed and

are the resu l t of hyal ine degeneration of the capi l lary wa l lsand thrombotic obstruction . S uch lesions as congestion ,

edema,bronchOpneumonia

, and ate lectas is are frequent lyencountered in the lungs.Ty pes .

- D iphtheria may be divided according to the l ocation of the exudate into : (1 ) Fauc ial ; (2) laryngeal , and (3)nasal . According to t he seve rity of the attack it may bedivided into : (I ) Mi ld ; (2) grave ; (3) mal ignant.Per iod of In cubafi om—Two days to a week .

Symptoms —PanchoDiphtheria.—The disease common ly

begins with chi l ls. moderate fever, malaise , and sore th reat.

The fever, as a ru le,is not very h igh (1 0 2°- 1 04

°and

i ts cou rse is qu ite irregu lar. The pu l se is rapid and feeble ;the bowe ls are constipated ; the uri ne is scanty and fre

quently album inous ; and the prostration and pal lor are

often out of al l proportion to the severity of the febri lesymptoms.1 0 m! Phenomena—The chi ld commains of difli cu ltswal lowing

,the musc les of the neck fee l stiff ; there is

tenderness under the jaw ; the lymphatic glands are con~

siderably swol len and t he tonsi ls , faucial pi l lars , uvu la, and

posterior pharyngeal wal l are covered with a grayish - whi temembrane which

,when stri pped off, exposes a raw bleeding

su rface . The membrane may spread to the nose o r larynx .

The cou rse of the disease is indefinite ,but the ave rage

du ration is from one to two weeks .Laryngeal Diphtherim—Th is is usual ly secondary by ex

tension from the fauces , bu t it is occasional ly primary . I t isrecogn i zed by hoarseness o r aphonia , crou

‘py cough ,

gressive dyspnea, and stri du lous breathing. he aim of the

D IP/l 317

nose play ; the sternoc leidomastoids are prom inent ; thesuprasternal notch is deepened ; and the base of the chest isretracted. Shreds of fal se membrane are sometimes ex pectorated in the violent fi ts of coughing. The pulse is rapidand feeble

,but the temperatu re is rarely h igh . Death often

resu l ts from suffocation,but rccovery is not impossible even

in the most unpromis ing cases .Nasal Diphtherim—This is usual ly secondary . It is char

acterized by grave cons ti tu tional symptoms—high fever,marked glandu lar involvement , and great prostration by anoffensive discharge from the nose ; by epistaxis ; and by exco riation of the l ips. The fal se membrane may be detectedon inspection.

Compl i cati ons and Sequel e .—The most common

compl ications are bronchopneumonia,myocardi tis , gastro

enteri tis, and hemorrhage from the u lce rated su rfaces . Oti tis ,

nephritis,cerebral hemorrhage ,

and th rombosis are among theless frequent compl ications . The most important seque l ispastdip/rtherr

’

c paraly sis. Thi s general ly occurs during convalescence ,

and is observed in about 15per cent . of al l cases .There is no re lation between the severi ty of the attack of

diphtheria and the l iabi l ity to paralysis ; mil d cases,which

are thought to be simple pharyngitis,being sometimes fol

lowed by troublesome paralysis . The phary nx is the mostcommon seat , and the pal sy is recogn i zed by difficu lt swal lowing and t he regu rgitation of l iqu ids t hrough the nose . Nextin frequency the eyes are involved , and strabism us or ptosisdevel ops . The heart may be affected , and if sudden deathdoes not resu lt , the condition may be manifested by tachycardia or bradycardia. In some instances there is an extensive involvement of the extrem i ties . The paralys is is due totoxic neu ri tis .W M Pen n—Th is can be distingu ished by

the character istic strawberry tongue, the very rapid pu l se,

the

fiifl

'

use punct i fo rm ras h , and the absence of the diphtheriabaci us .Fol l icular roam s—The differential diagnosis betweenth is di sease and diphtheria has already been considered(see p. 32)

31 8 ACUTE INFECTIOUSPrognosi s.

—This must a lways be guarded . The diseaseis very fatal during the fi rst two years of l ife. The averagemorta l i ty at the present time ranges between I5and 20 per

cent. The nasal and laryngeal forms are always grave.

Death may be due to exhaustion from the toxem ia,involve

ment of the larynx , bronchopneumon ia , cardiac paralysis, or“manent .—Prophy lax i s.

—As diphtheria rs prone to attack unheal thy mucous membranes , nasopharyngeal catarrhin chi ldren shou ld receive carefu l attention. Large tonsil sand adenoid growths shou ld be removed . Those who havebeen exposed to the contagi on shou ld receive immun i zingdoses of anti toxin (30 0 to 50 0 un its) . Patients with diphtheria shou ld be kept isolated unti l their throats are freefrom viru lent bacil l i . The bedroom

,bedding , c lothing , and

al l utensi l s used by the si ck shou ld be thoroughly disinfected .

Trm tm mt of the Amid e—The sick - room shou ld be we l lventi lated, and the temperatu re maintained at about 70 ° P.

I t is desi rable to have the atmosphere moist , and th is maybe accompl ished by generating steam in an ordinary kett leor in a steam atomizer

,or by slaking large quan ti ties of

qu ickl ime in the room . Young chi ldren , especial ly whenlaryngeal symptoms are present , are best treated in a steammoistened tent . Absolu te rest must be enforced. The dietshou ld be of the most nutri tious and easi ly digested character. Cool wate r shoul d be given free ly . Antitoxin shou ldbe admini stered in every case at the earl iest possible moment.In pharyngeal cases the init ial dose shou ld be from 1 0 0 0 to30 0 0 uni ts . If no decided improvement fol lows with intwe lve hou rs , the dose shou l d be repeated . Laryngea l casesrequ ire from 30 0 0 to 40 0 0 un its . The injections may bemade into the l oose subcu taneous ti ssue of the pectoralregion

,side of the abdomen ,

or interscapu lar space . S trictantisept ic precautions shou l d be taken in the operation .

Apart from anti toxin ,the most importan t remedies are

those which tend to maintain the bodi ly strength . A lcohol icstimu lants are usual ly indicated ,

espec ial ly in the late stageof the disease . In septic cases alcohol is particularly we l lborne

,a chi ld of three years often being able to take several

320 ACUTE INFE CTIOUS D ISE ASE S .

pose. One attack does not protect against a recu rrence,but rather favors it. E rysipe las was formerly divided intotraumatic and idiOpath ic varieties ; but the two are identica l ,and i t is probable that in those cases in which there is noconspicuous wound there rs a sl ight abrasion through whichthe poi son gains adm ittance.

The ex a t mg cause is the S treptococcus pyogenes .Path ol og y .—E rysipe las most frequently man ifests itse lf

on the face. The part is bright red in color, swol len,indu

rated,and sharply circumscribed . The various strata of the

skin are infi ltrated with serum ,and leukocytes and strepto

cocc i are found in the lymph - spaces . In severe cases theinflammatory products are converted into pus, and abscessesform .

Per iod of Incubati on —Three to seven days .Sm ptoma—Prodromes are sometimes present, and consist of s l ight fever, chi l l iness , malaise, and tingling of the

part to be affected. In many cases the disease is ushered insudden ly with a chi l l

,fol lowed by pain in the head and limbs

and a high , irregu lar fever. The temperatu re may reach1 0 4

°o r 1 05

° F. in twe lve or twenty - fou r hou rs . The pu lseis- fu l l and rapid the tongue is heavi ly coated ; the appeti teis lost ; the bowe ls are constipated ; and the u rine is scantyand often slightly album inous. There is usua l ly a markedleukocytosis .Local Pheno mena—The inflammation usual ly begins in

the neighborhood of the nose,and spreads upward and

lateral ly ove r the head to the neck , where it freq uentlystops. The afl'

ected part has a crimson hue ; it is swol lenand tense, and frequent ly ends in a sharply defined ridge

,

beyond which , however , projec tions can be fe lt advanc inginto the subc u taneous tissue. The su rface of the inflamedpatch is at fi rst smooth and glazed , but later it is coveredwith m inute vesic les or blebs. The patient comp lains ofburn ing and tingl ing ; th e surrounding parts are extreme lyedematou s , so tha t the featu res may be scarce ly recogn iza

ble . In four o r five days the redness begins to fade and the

swe l l ing to subside ; desquamation fol lows ; the generalsymptoms improve ; and the fever fal ls by cri sis. The aver

E R YS I PE LAS. 3z r

age du ration is from aweek to ten days . Re lapses are ex

treme ly common .

£0 3:c Ambulam .

—Sometimes the inflammation disappears in one place and reappears in another, and so continues indefinite ly. In such cases typhoid symptoms

,such

as muttering de l iri um,a brown,

fissured tongue,and subsu l

tus tendinum ,deve lop.

Comp l i cati ons —These are not very common. Septieemis , u lcerative endocarditis , nephri t is, acute rheumatism

,

edema of the larynx , pneumon ia, and men ingitis are occasronal ly seen.

DiagnosIa—Bxy thm —The absence of high fever,of

marked swe l l ing, and of an abrupt ridge wi l l serve to distinguish erythema from erysipe las .

Eczem a—The swe l l ing is less marked ; the itching

is intense ; the swel ling and redness are not c ircumscribed,but shade gradua l ly into hea l thy tissue ; and there is no

fever.Prognosi s —In the robust the prognosis is favorable.

In the old, in alcoholic subjects , and in those suffering from

ch ron ic neph rit is the prognosis must be guarded . Ambulatory erysipe las may k i l l by exhaustion .

Treatment f —As in other contagi ous di seases , isolationand dis infec tion are the most important prophylac ticmeasu res .E spec ial ly necessary is it to guard partu rient and su rgi calpatients from the contagi on .

A supporting liquid diet shou ld be given. Al cohol icstimu lants are sometimes requ i red in considerable quanti ties .High fever is best contro l led by cold sponging or the coldpack . Restl essness , del irium ,

and insomn ia wi l l ca l l for applications of ice to the head , and perhaps the administrationof morphin , chloral , o r brom ids .Of the numerous spec ial remedies recommended fo r ery sipe

las, the one which has enjoyed the most favor is the tinctu reof ferric chlorid (15to 30 m inims every three hours) .Local Trm fmm t—Among the n umerous loca l appl ications recommended may be mentioned : Lotions of leadwater and laudanum,

of carbol ic ac id of picri c acid(1 10 0 ) and of sodium sal icylate (1 In the hands of

322 ACUTE INFE CTI OUS 0 1554 355.

the author oin tments of ichthyol (20 per cent .) and of

sol uble si lver (unguentum Credé) have proved most sati sfactory .

The fol lowing combination often acts extreme ly wel lB. Ichthyo l gr . x xx

Resorcin i

Unguent i hydrargy riAd rpis lame hydros i 3v.

—M.

(Roswsm. PARK. )

Loca l abscesses shou ld be inc ised and treated antiseptical ly .

E xtension to the nose and th roat wi l l ca l l for antisepticsprays or washes .

(La Grippo ; Catarrhal Fever ; Bridemic Catarrh .)Defini tion —An acu te infectiou s di sease characteri zedby fever, marked prostration

,severe muscu lar pains , and

catarrhal inflammation of certain mucous membranes,espe

cial ly those of the respiratory tract .E ti ol ogy .

—The disease occu rs in epidem ics that usual lyhave their origin in Russia,whence they spread wi th won

derfu l rapidity over both con tinen ts . The exci ting causeis the ex treme ly smal l , non - moti le bac i l lus di scovered byPfeifl

'

er in 1 89 2. I t is readily obtained from the sputum.

When prevalent , no age and nei ther sex is exempt . Oneattack does not confer immu n ity against others.Path ol ogy .

—Influenza does not often ki l l except by itscompl ications. The latter are most frequently assoc iatedwi th the respi ratory tract , and consist chiefly of catarrhalpneumonia, croupous pneumonia , and pleu ri sy .

Symptoms.—The di sease begins abruptly with lassitude ,

malaise , chi l l iness , severe pain in the head and back , feverranging between 10 2

°and 1 0 4

° F. , and extreme prostration .

which is out of proportion to the fever and any existingloca l inflammation . The catarrhal symptoms are injectionof the eyes , sneezing , hoarseness , and hard paroxysmalcough . In simple cases the temperatu re fal ls 1n three or fourdays by cri sis , but complications not infrequently prolongthe case for several weeks .

324 ACUTE INFE CTIOUS D ISE ASE S .

doses of phenacetin and th e appl ication of an ice- cap to thehead .

Heart - fai lure shou ld be combated by alcohol and strychn in .

Bronchial catarrh wi l l requ i re the remedies indicated in simplebronchi ti s . S leep may be induced by opi um,

sulphonal,or

chloralamid .

Defin i ti on .—An acute contagious disease, characteri zed

by inflammation of the parotid and other sal ivary glands .E t i ol ogy .

—The disease occu rs sporadica lly and ep i

dern ical ly . I t is most frequent ly observed in young chi ldren,

but unprotec ted adu lts are not exempt. Males are moresusceptible than females . The disease is h ighly contagious

,

and the virus is probably contained in the sal iva, but it hasnot been isolated . One attack confers immunity againstothers .Path ol ogy .

—As the disease is so se ldom fatal,very

l itt le Opportunity is afforded for studying its intimate pathology . The parotid glands are the seat of an inflammato ryinfi l tration ,

but suppu ration very rare ly occ u rs . In ma lesthe inflammation shows a marked tendency to leave the

parotids and to involve the testic les . In girls,transference

of the inflammation to the ovary , vu lva, or mammary glandis occasional ly seen .

Per iod of Incubati on —One to three weeks .S ymptoms —The disease is ushered in with ch i l l iness

,

ma laise , and moderate fever (1 0 1 ° - 1 0 3° fol lowed by

swe l l ing of one parotid gland . The swe l l ing is observedbe low and in front of the ear

,is pyriform in shape,

and has

a doughy fee l . The su rrounding ti ssues are edematous, the

submaxi l lary glands are often swol len ,and the featu res may

be distorted beyond recogn it ion . The movements of the

jaw are restricted and painfu l . The sal iva is usual ly muchdim in ished

,but occasiona l ly it is increased . In most cases

the other parotid becomes sim i larly afl'ected . The du rationof the disease is from five to seven days .Comp l icati ons.

—Orchi tis is the most important com

ys zzow FE VE R. 325

pl ication. I t is usual ly seen in adolescence ; in chi ldhoodit is very rare. Atrophy of the testicle sometimes fol lows .Deafness, neph ri tis, suppuration of the gland

,and pneumon ia

are rare ly encountered .

Prognosis.—Favorable.

Treatmen t—The patient shou ld be kept in bed . I solation shou ld last three weeks from the onset of the d isease .

Mi ld aperients and refrigerants are usefu l . When the painis severe. hot fomentations contain ing laudanum provesoothing. In mi ld cases, covering the gland with cottonbatting wil l sufli ce .

Orchitis wi l l requ ire rest , suspension of th e afl'

ected gland ,and the application of lead - water and laudanum or

,better

sti l l , of an ointment of guaiacol (1 0 per cent ). After the

tenderness has subsided , an oin tment of mercury and be l ladonna wil l be found usefu l in reducing the swe l l ing.

YELLOW FEVER.

Defin i tion —An acute infect ious , endemic or epidem icdisease, characterized by fever of one or two paroxysm s

,

jaundice,album inu ria, and a marked tendency to hemor

rhage , espec ia l ly from the stomach .

E t iol ogy .—The bacteriology of ye l low fever is sti l l

obscu re . Sanare l l i has described a fine,moti le

,c i l iated rod ,

—the Bac i l l us ictero ides ,—but its spec ific ity is doubtfu l .

Man is inoc u lated through the bites of a ce rtain spec ies of

mosqu ito,

—Stegomyia fasciata ,—which serves as the inter

mediate host for the parasite . The mosquito reta ins thepower of infecting for at least fifty - seven days. The disease.s not conveyed by fom ites .Ye l low fever occu rs endem ica l ly in tropical sea- ports ,whence it occasional ly spreads to temperate zones . The

predis sing factors are those which are favorable to thegro of mosqu itos—high temperatu re ,

su rface drainage ,

and swampy soi l . The colored race are less susceptiblethan the white . S trangers in an infected dist rict are morel iable to be attacked than res idents . One attack usua l lyconfers immun ity from others.

326 ACUTE IN FE CTI OUS DISEASES.Path ol ogy

—TM tissues are stained ye l low. The l iverpresen ts a reddish - ye l low (autumn - leaf ) mott led hue, and isthe seat of extensive fatty degeneration . The k idneysusual ly show the lesions of acute hemorrhagic nephri tis .The gastro—intestinal mucous membrane is swol len , con

gested,and frequently infi ltrated with blood. The heart

musc le is pa le and fatty .

Per iod of I ncubati on —Two to three weeks .Symptoms —Fm: S tag s—The disease begins wi th a

chi l l , fol lowed by pain in the head , back , and l imbs . The

temperature ri ses rapidly unti l i t reaches i ts maximum(1 0 3—1 05

°

The pu lse IS at first acce lerated , but as the temperatu rerises it shows a marked tendency to fal l , sometimes droppingin grave cases to 80 or even to 70 a minute by the thi rd day .

The face is flushed ; the conj unctiva: are injected ; the pupi lsare smal l the tongue is coated ; the epigastrium is tender ;the stomach is irri table and unretentive ; the bowe l s are con

stipated ; and the u rine is scanty and often album inous bythe end of the fi rst day .

j aundice is rare ly marked before the second or third day ,

al though a sl ight icteroid tinge of the conj unctiva: is oftennoticeable within the first twenty - four hou rs . The fi rst stageusual ly lasts from th ree to five days , and is fol lowed by arapid fal l in the temperatu re and an improvement in al l the

symptoms (stage of ca lm or rem ission). At this time con

valescence may begin or the patient may pass into thesecond stage .

The second stage is characteri zed by deep jaundice, persistent vomiting , vomiting of dark blood (black vomit ) .markedalbum inuria

,and often by suppression of u rine and hemo r

rhages from the m ucous su rfaces. The mind usual ly re

mains clear un ti l very near the c lose,but in some cases

de l iri um and stupor devel op . Th is stage may be afebri le ,

but not infrequently the temperatu re ri ses again after the

period of ca lm,while the pu l se remains extreme ly low (50 to

40 a minu te) . Death usual ly resu l ts from col lapse or u rem ia .

The du ration of the disease 13 from th ree to ten daysDiagnos is .

—Dengne.—This di sease does not ex hibit a

328 ACUTE INFECTI OUS D ISE ASE S.

simu ltaneous formation of mi l iary tuberc les in many partsof the body.

E t i ol ogy .—The disease usual ly deve lops in ear ly adu l t

l ife. Certain infec tious diseases , l i ke meas les and whoopingcough , seem to predispose . General tubercu los is is almostalways secondary to local tubercu losis—pu lmonary phthisi sor a scrofu lous lymphatic gland . The bacil l i are probablydisseminated by the veins .Path ol ogy .

—A l l the organs may be uni formly infiltrated with discrete tuberc les , but more common ly ce rtainorgans

,l ike the brain and l ungs

,are more affected than

others .S ymptoms.

—The onset is gradual and characterized byanorexia , malaise, headache , i nc reasing prostration ,

and feve r.

The temperatu re is mode rate ly high (1 0 2 - 104° very

irregu lar, and marked by even ing exacerbations and morningrem iss ions . The respi rations are hu rri ed and the pulse i srapid (140 to 150 ) and feeble. Cough may or may not be

presen t. As the disease advances typhoid symptoms deve lop—brown

,fissu red tongue ,

mu ttering de li rium , subsu l tus tendinum , carphologia, and stupor. Tuberc le baci l li are rare lyfound in the sputum or in the blood.

When Ilse l ungs are ( firefly afleeted , there are : Dyspnea,

rapid breath ing (40 to 60 a m inu te) , hard cough , mucopu rulent and bloody expectoration,and cyanosis. S igns of con

sol idation can rare ly be e l ic ited,but au scu l tation usual ly

reveals sibi lant and moist rales .When the meninges are ( ki t/1} aj ected , there are : Intenseheadache,

convu lsive sei zu res , photophobia , de l irium , facial

pa lsies,stupor

,coma

,and Cheyne - Stokes breath ing. Tu

berc les may occasional ly be detec ted on the retina.

W/rm the intesti nes and f ed /0 1mm : are af ar /ed, there are

Pain ,tenderness , abdom ina l distention , and diarrhea.

Prognosi s—The disease is a lways fata l. The duration

is from three to e ight weeks .Diagnosi s —The disease c lose ly resembles ty phoi d m ,

and there is no doubt that the morta l ity of the latter is enhanced by inc luded cases of unsuspected general tube rculos is.

WHOOP ING 6 0 0 0 1 1 . 329

Tvm om a . Acun Gm Tvm cuwsi s.

Infrequent.

Temperature runs a very i rregu larDiarrhea is frequent. In frequent.A roseo lar eruption is generall y present. Rare ly present .Respirat ions are rapid . Usual ly much more rapid .Pu lse is rapid . Usual ly much more mpid .

Cyanosis rare ly marked . Often d ist inct .Facial palsies are absent . Are occasional ly noticeable .

Widal reaction is present. 15absent.Treatmen t —This l S pure ly pal l iative. The diet shou ld

consist of mi l k , eggs ,aand broths. S timu lants are required .

Fever shou ld be control led by cold sponging or smal ldoses of phenacetin. Severe cough and msomnia wi l l cal lfor morphin.

(PM )

Defini tion —An infectious disease , characteri zed by catarrh of the respiratory tract and pecu l iar paroxysms of

cou h ending i n prolonged crowing or whooping inspiration.

og y .—The disease occurs both Sporadica l ly and

epidem ica l ly. I t is most frequen tly met wi th in chi ldren,

but unprotec ted adults are not exempt. The disease isunquestionably contagious , and the vi rus seems to be assoc iated with the Spu tum . One attack protects from others .Path ology .

—No characteris tic les ions are observed afterdeat h . The poison exc i tes an inflammation of the respiratory mucous membrane , and probably i rritates the peripheral fi laments of the pneumogastric nerve , and so causesthe paroxysma l cough . In fata l cases pu lmonary complica tions are usual ly discovered , such as catarrha l pneumon ia

,

pu lmonary col lapse , and emphysema.

Symptoms .—There are th ree stages : (I ) The catarrha l

stage ; (2) the paroxysma l stage ; and (3) the stage of

dec l ine.

Calm /m1 Stage—The disease begins with the symptoms

of coryza and bronchial catarrh ,—s l ight fever,sneez ing ,

running from the nose,d ry cough

,and rales

,—but it does

330 ACUTE INFECTIOUS D ISE ASE S.

not respond to the ordinary remedies for catarrh , and after

lasting one or two weeks passes into the paroxysma l stage.

Paroxy smal S tage—The cough becomes more violent

and paroxysmal . Du ring the paroxysm the face is cyanosed.the eyes are injec ted , and the veins distended. The coughfrequently induces vom iting, and , in severe cases , epistaxiso r other hemorrhages. The c lose of the paroxysm is

marked by a long - drawn , sh ri l l , whooping inspiration dueto the spasmodic c losu re of the glottis .The number of paroxysms , or kinks

,varies from ten

or twe lve to forty or fifty in the twen ty - fou r hou rs . Fromthe forc ible propu lsion of the tongue against the lowerinc iso rs , an u lcer is frequent ly formed on the frenum. The

duration of th is stage is three or fou r weeks.Stage of Decl ine—The paroxysms grow less frequent a ndless violent and final ly cease . Protracted cases are fol lowedby anemia and prostration.