IMAGE EVALUATION TEST TARGET (MT-3) V. /. / 5r ^/^ 1.0 I.I 11.25 ■- IIIIM |50 '""^^ 2.0 IIIM i^ ■ 1.6 p>. m '^ %]^^' /a '^ > ^w. ^V' f. V' ^ O^: M Photographic Sciences Corporation 23 WEST MAIN STREET WEBSTER, NY. 14580 (716) 872-4503 ^^ iV ^^ \ :\ ^9> V <> ^ ^ ^t^ 1e.\'^'^^ <^ V ^^p f ■ %^ CIHM ICMH Microfiche Collection de 1 Series microfiches 1- (Monographs) (monographies) vV Canadian Institute for Historical Microreproductions / Institut Canadian de microreproductions historiques 99 Technical and Bibliographic Notes / Notej techniques et bibliographiques The Institute has attempted to obtain the best original copy available for filming Features of this copy which may be bibliographically unique, which may alter any of the images in the repioduction, or which may significantly change the usual method of filming, are checked below. 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L'lnstilut a microfilm^ le meilleur exemplaire qu'il lui a itk possible de se procurer. Le> details de cet exemplaire qui sont peut-itre uniques du point de vuc bibliographique, qui peuvent modifier une image reproduite, ou qui peuvent exiger une modification dans la m6thode normale de f ilmage sont indiques ci-dessous. Coloured pages/ Pages de couleur □ Pages damaged/ Pages endommag^s □ Pages restored and/or laminated/ Pages restauries et/ou pellicultes I I Pages discoloured, stained or foxed/ I I Pages decolor^j, tachetees ou pquees Pages detached/ Pages detachees 0Showthro(feunti8 during and after Typhoid Fever. Pkiii • rn , ^bid., 1895, Chills m Typhoid Fever. j,,^^,^^^ Practical Value of Laveran's Discoveries. Medical News, 1895. n ii 6 CLXIII CLXIV. CLXV. CLXVI. CLXVII. CLXVIII. CLXIX. CLXX. CLXXI. ^ CLXX II. CLXXIII. Visceral Cmplications of Erythema Exu.Iativum Multiforme. American Journal of Medical Sciences, 1895. John Keats Johns Hopkins Hospital Bulletin, 1896 Thomas Dover. y^ ■,; _ j^y^. An Alabama Student. ni,i_^ j^gy^ Six Cases of Addison's Disease. International Medical Magazine, 1896. Addison's Diseiuse. Medical Bulletin, 1896. Heart Hypertrophy with Adherent Pericardium. Archives of Pediatrics, 1896. Hemiplegia in Typhoid Fever. Journal of Nervous and Mental Diseases, 1896. Treatment of Diseases of the Blood and Ductless Glands. Handbook of Applied Therapeutics, 1896. Cerebral Complications of Raynaud's Disease. American Journal of Medical Sciences, 1896. Lectures on Angina Pectoris and Allied States. New York Medical Journal, 1896. ^ >> VI M -ythenia Exudativum 'edical Sciences, 1895. ipUat Bulletin, 1896. /6m/., 189(5. Ibid., 189G. ical Magazine, 1896. i/ca/ Bulletin, 1896. lerent Pericardium. of Pediatrics, 1896. n""'" {"•t'«ie,lidne, a, ^eU::7^I^/T:;'r^ ""' h''"''' M'Tice to^haracterL us rr. ; r''"' T"' ^"^«*-'"» yet been sta.nr.e.i wiS. «', . "^ ^ '^"^ '"'^« "»' «« which 80 „,a„v o m 00 r "' '^'T"'*"""' ""'>«'• I" theextraonilr' l"'''"''""''* '"«'''«'• ''"es hibor. limitation vorH^-^n ?^ '"°'^«'-" '"^''i^i'H^ of a very uatural del« /' • «;g'»"ze(l expression .study. ^ "^'""*' '" ""'^'^ f""- tl'e purposes of On an occasion of this Win/i :* . "ot to discuss an J nL- 1 , ^ ^®^"* ''^s' 'o me /i- /i V' a I ■ ...«ke l,„ rc..„„,e,l Z,U, "Z 'uZ "»■'""»'!« ide. of «o„„,*„„, u,e nee. f;L" I r r 1 ,0 e..«., a„d „po. ,,.pl,ili. „i„,ou. .acriS,°,g lir fmf : mm izatioii. In comparison with Mirope specialism ma- truly be ii'ctive feature in the medical And It ma.v not he iiiapiiro- i few of its advantages and djs- een is that which shall he." o have begun with specialisrs. argely taken up with the con- ies, and centuries later we find iials treatincr special ailments; :es a "rectum specialist" in a c journals would "poke fun" • The tail of our emblematic ts mouth; at no age has spe- follow its gradual develop- century would take more time "i would not be a profitable i of knowledge has made con. ssit)' ; specialism is here, and 3 P'ofessioii which followed lowhere been more striking lid the earnest workers in ?y, dermatology, and other ;d largely to inculcate the ecessity for which is apt to ry and bustle incident to the r work b done all along the - -...J ..,.0 guiie oy lor although we have a few 3 ests in general sur^erv siifli .,,.„ ""fortunately, from t' ; ver ' T ''''"''^'^h '''^'^^ and, likUy to become more u ,c n ^'"'"'"'n"^ "^ ""^ ^-'^ fo'-ting tothegenerd nr M- ""•• V'^'" ''°^^ ''•""'- of the specialist/ We', :kr'''' " ""^ ^^''^^ counsel >='ed and annoyed us the .b "• " T" '^''' '"'« l'"^' fai... and we cin u?t i t ^7'" "^ ''^'''^' '' """''- o"'- experience and til \^ ""written records of He labels hV^^i^^J""'^ — '^ "f our books a beetle, and w^ fed' " Sj^^f °'"''-"*^^ """'"^ his information and hun ,v i, .. '** '*'='="'-acy of '"bel. And if som ti ; '^s ' r ^','^'^0'. of the tween life and .ieatl ) he f, '"'!'"'S ^'^e Aaron be- 'larkness of our i' a ce 1^""' '°" '""'^'''''•^ ^''« I'olden to him for ^::^2:.C.^'' "°^ ^^ "*"'-' ^- in w,;-2'rfi;nrzc^i'^:ji'-the public. I'owever, now so ge.ndZr"'" ''''"''^ "^''"'^'^''S^ id- lest the familydocto s o. i "' " ^ »'"''"« •^«"«er relic of the P^ It n^T lee'ST'' '" 'T' ^^'''^' '- sands to feel that in thl ! -' ^® '^ *'''"'^0''l '« H'ou- pen skill i. z^: : rrjiLT^n^'f '' ^'■^^' -- cialists, no class in our profession h , ^ '''"'P^' ^^ «'«^- abused for nu-dcllesomrwor ^ f" '""'"'^ ™"'''">' aud yet what shall no \l t """ g> "geologists, a^ a direct out« me Tthe verT^"'" -^ ""^ ">^"' «''o have received the Wte est -'."P'''''^ '^'^''*''« ^''i'^b recognize tuba gesta^.f .^ '^'^ '^'"-"^'J '» "bid. other wise ^w.Sr.'etdd'''/" '•''■' ^''^•'"^ '''^^« bave known Kormad 1 . ^'^l''''^ '"'^'^ been lost? I a.lelpbia I'athoLic SV ^v 't "'" ^""' '' "'^ l^'"''- ^'f r"!.tured tubal ne^tne' '" °'" .'^'^'^'^ ^-'''"''P'«« "O'k '(sudden deatli; T SeS -' "/ "'•^l!'-' '««' tbe public reap from sneci^ ,n " * ■ ' ^""^'^'^ ^^'"'^b 1 rom specialism may be gathered from V^: the fact that iu a not much longer period of time I have seen seven specimens of tubal gestation, not re- moved by the pathologist, but by the gynecologist, with the saving of five lives. The conservatism, wliich branded ovariotomists as butchers and belly-rippers, is not yet dead among us, and I say it frankly, to our shame, that it has not always been professional encour- agement which has supported the daring advances on special lines. Humanity owes a great debt of grati- tude to the devoted men who have striven during the past h'llf-century for exactness in knowledge and for its il.is most pathology rou rVverv p t"';i,:' "''^"■"'•'«>' "'"^ tions, and exercised i. These io^v •'^"".""""^^^ ^'^''«- of professional life, the';;ri;^fi J- r:^,^^^^ - Ch»rml,le., : J„wetf8 translation. ' ' „,,^-:fr»,.„,:; 6 and can never, even in the daily round of the most exacting practice, desrenerate into a money-making macliiiie./ And let the younger of my hearers lay this to heart: scan tlia lives of say twenty of the men most prominent in a|)ecia] lines of medicine and sur- gery to-day in this country, and you will tind, with scarcely an exception, the 'early years devoted to^ an- atomical, physiological, or pathological studies. They rose high because the foundations were deep. The most distinguished oculists have been meti trained in physiology^aiid pathology ; and some, like Sir Win. Jiowman, have had rejjutationsso pre-eminent in several departments that the identity of the physiologist has been lost in the ophthalmologist. In the larger cities the work of the specialist en- croaches more and more upon that of the general practi- tioner, and this condition, though in many ways to be regretted, is not likely to be changed. I have known the head of a household pay, in the course of a year, for the professional services of six jdiysicians — a gyn- ecologist, an occulist, a laryngologist, a dermatologist and a surgeon. What remained after this partition of the general practitioner came in sixth and looked after the health of the children. It is interesting to note that to this one pertains the functions to a large extent of the old family doctor, and further advice is usually sought through' him or at his suggestion. In the evolution of the sjjecialist, the children's doctor is the last to appear, not because of any extreme ditl'erentia- tion. but rather he is a vestigiil remnant of what was formerly in cities the general practitioner. May I not sav that there are members of our Society whose in- terest in their work is largely due to this new feature in (ioiuestic life? In tiie (livision of the household among our brethren, the children alone remain, ami fortunately their ailments are too diversided to allow much specialization. a peculiar trait, it. , ^ i;:"/'':;'-'" '"•'•''"-"- ^ we-are-tl.e-,,eonle"stvl f. .' , "" '" "" "surelv- g'eater mi lij em 1 h', ^ ''= ''""""'«'<'« 'i'^ the under ti.e careof nen if ' "" ^I'-culapius, an.l be able to set fr "cture /'"' ''"'^'''''■='*^' ^^''"">"«t as well as fevt; etn ^ . rwd','" "',7'°".' "''^^^ '""« of the bene/its ^f s, eci'li'sm .f ,'' /''" '■''''■ '^^'"'t whose ranks the cities Hrl'l 'V "V^"'^^'"'' <='"«« from is so essential to 1 ^ at o '-""Sr'' ""' T'"^'^ '"^"'"' ment of our hosnitah n,l? "^ "ut-door .It.j.art- Pi'Vsicians tell Se.ecs "'?''""' -'T;™""" ^^ ^"''^ tl'ese people n.rtir., ..I ^ ^ ''"'''"'' k.iowlcige to graver^a„.£r'' ',\t l.;i:;"r^"''"? =*"" '" "'« tlius avail themselve fom b, u T"' '' ^'"' "'°^« *^''« bers who require tednc' I tn /'"'T °^ ^''« "»•"■ diagnosis or treaLe.U " V l^' i t faJ Ih-'^T?" "^ ed«e enables the genenl ll/J '''''''"0"aJ l^nowl- a large propprtiorfo ' I'etse vhl''. '° ^"''^'■''''^ "'""' under the care of the sn LS ' t^' "^'' '".''•'^■'^^ «"«« "self into one of eduS t^ ■ '■" ''"'■'""" '''"'^^^^ sessions to brincr ?!' k! ' /S" '™I'"-^sible in three but in a ..or'e Ironed jri "'\-|'-"-^' -"^"'«' perieiice — the stnd^n/ ^*'"',«<^ — as I know from ex- tbe wards an ] d nnn • ^' '""=''^ I'ractically, i„ to work. He shouh Lil ',f fo<';"lat.on upon which practical application of ^h " '"-'''""'^ '^""^^'"S the 8 /i^ Ii man, ill general practice, sliould know a "clioked- disk"; the exiimiiiation for tiihe-cast8 slioulil bo a fumiliur, evt'i-y-day task; and he sliould be able to tell whether a vocalchord vva^ paralyzed. A surioiis obstacle to this liajipy coiisuniination — whicii can bo reached in a well-ordiM-ed system of education — is tiie absence, in the early years of practice, of material upon which to freshen the" memory and to " keep the haiul ill "; but the man who, as a student, has reached a certain point always retains some measure of the old facility. Tiie post-graduate schools have done much to enable men to revive, and to acquire, technical skill, and have been of great service in generalizing special knowledge. In the practice of a good, all-round man, the number of cases demanding the help of a specialist is, after all, not great. The ordinary run of nervous disorders shouhl be recognized, adenoid vegetationa he would treat with the skill of a laryngologist ; he would know enough not to tinker with a case of glaucoma; and though he might not diagnose a pus-tube from tubal gestation, he would (in this as in other details) have it'arned to know his limits and be ready to seek further advice. With the revival and extension of education the ben- efits of specialism will become more widespread, and to this end the efforts of colleges and hospitals should The organization of societies for the study of partic- ular diseases has been of late a very notable feature in the professional life of this country. Since the foundation of the Ophthalmological Society, more than a dozen associations have been formed, and their union in a triennial congress has proved a remarkable success. These societies stimulate work, promote good-fellow- ship, and aid materially in maintaining the standard of professional scholarship. They are nearly all exclusive ow a " clioked- ;8 slioiiltl l)« a 1(1 be Jible to tell ad. A serious — which can he ucation — is tiie of material upon ' keep the hand , lias reached a lasure of the old lave done much B, technical skill, leraliziiig special 1. all-round man, lip of a specialist ■ run of nervous id vegetations he logist ; he would ise of glaucoma; a pus-tube from in other details) be ready to seek ducation the ben- widespread, and hospitals should le study of partic- ■f notable feature titry. Since the Dciety, more than 1, and their union iiarkable success, lote good-fellow- g the standard of larly all exclusive ;fs£ e"i;:;;cJ;;/:;::;i;;i'j;:;;:;;-'j?^-H".Ji... for a.i- !'0 arb trary privilege in I'ki " " '"?!'"^" •''■^'^'•ci.se 'f.V with the .sul.iec? ,., I V' ^ '"""'"I'ltes familiar- -"'.'«. i."t the unwr,"," p^ itilr'/''''''""^*^''- ""' "'« '*^ 'f they were ven.lor o " „ ' " ""'' •"'"^f. "ctin.. "'."•ket-plare. "^ '''""*''^ '» be hawked in the of?;;Set;s,:Sin:r'''''^''.^^ ^'''' --"- '-"■^t in the stu.iv o i e Lt, ^''"V'^ y^''"^^ <>( U, •^x'steiice of a MH.oi.,1 '''*'■'»««. of cliiJ.lren. The ""'^ 'he ^ucce./;,",- , of'"' .; ""^"', '° "^"'■«^^^- ''•~,sof children te fv ,« .tr-'''"'*'?''''* °^ "'« P="-t ot the profession of the V. ">''"■;«"'''"" on the 'T'' ■^'"•'•V "f tl'is rand Tut"? "" ""^ '""'''^ ^-■ «'l'o are workin.. and te.c ii,. ^'J!'^ "'^'^'••■' '» ««" t""ity of knowing e^h 'u ' '^.ri.r''^^'''''''^ -' "CPor- common inter...str and tW-h "''''.'» '"''J'-'^'^^ "^ f-'-biicationsmaki... ' erair' ^'^ '""""'" "^ "'«'■• 7'ue ,n practice, fi.e ■ ro'^l „ '""'"^ «l'«cial details of ^'early that we are d^^Je^nn''"' ^?" '''•'''='*'«« and may the character of M? ^'''■«'''''' medicine ■ '-.^'•e best }^^suS.:':'Z'::zr' "'-"-"--ons zat'on devoted to the Ifn ). !• "^'"''' "^ 'i" or-ani- tJiat field. "" ''"^>' °^ a particular sectio,M-n /■^ ' s [ReprtoW from THE cimATOLOOIST.^, „sjj G X I K THK irHAUNo OJ.' Tl.I,HI!CUmsj,S.. nv WII.I.IAM OSLKR, M.I)., ,,- „ ,. ,, , '—""'—« --.■..'.:.:;;::;:,:,„ ti»..u. „,„i i,„di i i;avb:rfi ;.:'''■"'' '" "■'""" ''""■■' *""' casco,,, „rc.„, ,,„„<,„„ i,„,,„. '""•''''" ^■'•->""«: » I„. diticw al,.„o tl.o (^.„, ' ^"•"" "'"' I'nic salts. T »o ,.„„- •nJ tli» iLbcKlc mav tl,., l!^ , " "'"'I'''' '■'"■•■'P»"l»t«l, « ..«t Hted that as tiil.crch« K'-^^vinK' in the glandM, "which we call HTcfula " often healed, why Hhonid it not )|o '"HoHauic in Mie Iwiij^s? K.w'cnt studies ha-e nliown that in a considerable |)roi)ortu)n of the bodieg of iK'rsons d\inj,' of all diseases, d, in the case of some observers, as almost to jnHtily the (dd (;crtnan axiom, " Jcdrrindnn hat am Ende dn hinchen Tubtrm- Imr." Mv attention was called to thi' point in 1H7() by Palmer How- ard, of Montreal, who v.as in the haltit of poinlin}r ont tin; ^m^at fre(|nency of puckering at the npices of the lungs in elderly per- sons. Snbse(piently, when I became pathologist to the Montreal (ieneral Hospital, we frerpiently discussed the significance of these changes, whether indicative or not of healed phthisis. Wa see at the apices the following conditions, all of which have been he'd by some to signify healetl tubercular pro(!(>sses : — 1. Thickening of the pleura, usually the posterior surface of the apex, with perhaps subjacent induration of the lung tissue for a distance of n few millimetres. This I do not think indicates more than a local chronic pleurisy, and, as my colleague. Dr. Welch, siitrgests, is possibly analogous to, and has no greater sig- nificant! than, a milky patch on the pericardium. 2. A puckered cicatrix at the apex depressing the pleura, which here may or may not bo thickened. On section, there is a fibrous scar nnich pigmented, the bronchioles in the neigh- borhood arc dilated, but there are neither tubercles nor cheesy masses. Such structures are extremely common, and may in some, but I doubt if in all, cases indicate a healed tubercular lesion. 3. Puckered cicatrices with a cheesy or cretaceous central nodule and with scattered tubercles — "colonies," Laen lec enlleii them — in the vicinity. Identical with these in their true iiuture, though differing in the general appearance, are the solitary or cheesy calcareous nodules found throughout the lungs. The ISSfS^S"*', ■^!m^^rnT2:mSs;.W^SB^^^&*S z'^^m^?;^^- "'""'"'IMW will, l,„„„.„i "''"' ''^ "'""«' "■'""« uml ,.„ra. ;i''-''««M:':r£.;:™r,;:;i;7::!r'r'"''-- -". "" '•'"•-> «'.<' tl.o solitarv 1 ; "7' """ '"™' '''-'-^"in^. of ''••'•-" with U.0 /i,.„.,, ,,,„■,. ' •' " :^'" ='l'I-ar small i„ .on>- ''!^f-tlyn,o,.io.K..lti;at e . ' ; : V " ^ '« ^f^- -- it .-^ 7'""^r- Ofther>f,oaseMlw.s: .uKlerten years 4 1 "'" «^'^^« «^ the eases ^-ere -nt, to thirty, 8; fro. thi;, 'to'b I U) ^V"-"^>^' 2; /ro„, ^'f « -.form eriterion as to wh t she, IdT "'^' '^ '' ^" '^'^--^ -• q»'eseent tnberdes. If the fil ro , ^ ''''^''''^''^ "^ ""^^^'^te «J - some of the followiu; st S'T" "^ '' ^ '•-'^•"'«'^, He,tler analysed the Vienna 1,^'/ ^''''''''^S^ ^^ high. ''•'^^'nlG,562..ases,inwhieh tK T "^ '''''''''^' ""^' «>"nd ''.V phthisis, there were 780 ins tees of T r' ''"'•"^'^ ^--<1 »'fl ; ) I !i 'I f ,.,..>^ funrul ap.'x cirrhosis in 202. Massini found ovi.lcnrcs of lK,,lin- in ;19 per cont. in 22S iH.dics (..xnn.inod. llarr>s, ..f Man- i.h,.ivv iKis ..xaininod 200 iKHli.'S kcopin- tliis .)l)ic(-t specially ni viow 'j'Acl.Kling tlu' (icatl.s from phthisis and persons under twentv, there were left l-!!) cases for analysis, in 54 of wliicli there were relies of former active tuber.'nlosis, ,'58.84 per cent. Tin. -roatcr niinib. r of these, were in the third, lonrth, and fifth ,|,vi(ies 'I'lie lar-e proi«.rtion hero given is accounted for by tJK' inclusion of the fibroid cicatrices as well as the caseous masses. I heard the statement made in Paris that, ot the bodies exam- iunl in tiie moi-iie, the majority of which are of suicides or persons accidentally killed, nearly seventy-five {)er cent, present evidences of old tuberculous lesions. Tliese facts d(-moiistrat(s first, the wide-spread prevalence of ltil)ereulosis; and secondly, the fiiet, as shown by my figures, that at least one-fourth of all infected persons recover sponta- iioously. In the great majority of these cases the disease is very limited and has made no progress, and in many instances could not have given physical signs. JUit even in more advanced dis- ease, wIkh-c the local indications are marked and bacilli and elastic tissue present in the sputum, arrest is by no means infre- quent, and although ])ost-mortein evideuco shows that wo are wrong in speaking of the process as cured, yet tlio condition is consistent with compaiatively good health. Wo may say, then, that in one-fourth of all j)ersons infected the disease is never manifest, but remains local, and the lesions gradually heal. In another fourth of those attacked, local signs develop, but the physiological resistance is sufficient to arrest the process, or in modern language the battle is against the invaders, the day is with the tissues, and a permanent time is agreed -ipon, or sometimes a permanent withdrawal of the enemy. The re- maining fifty per cent, of those infected light, for months and years, losing battles until the final defeat comes. Tlie nature of the fimie mil is the important factor in tuber- euiosis ; the seed is so widely scattered, that upon each one of us, sooner or later, some grains must fldl. I am in the habit of illustrating this poin* to my students by the parable of the sower i tm ?■ ;;■'"> ^vont out to sow Lis soci T„ H. l --"•' ^.-oup iU. bacilli /in,] 1,:,: :,; 'f 'f "'" '-'IMi'l'^r in u ^'"•'V'", as U,o soil conditions - ^ • "n"™^'' '"'^ "'^-^ ^'<^ "»t "over been betfer iHnstnUe.! tl b iT 1 ^"^•''•-""-t has "•;" ^^-J '-abbits, eonfine.1 in . '^, , "f ^^'' « -I'-'-t Jn. ;'"«t others allowed to roan' ! '''"r'' '''•'■^''^'■^•'•'*-'''''''-', ^I'glit l,,.sionH. It is the lu ^'' '''^''^''" ^•^'•■"vere,! or h,\ '">"«-d to the 1.0.:. t^'::: '""'"" ^f^'-^""«^'"^ =' i''-^ ^ «^"'J^', ill-vontilated chvelj^ ^^ H; """■''"'^^^' '"""'-' '•• '" - -"m-, whe..as a patient livi,; I ;J "/^ j '""'""' "' ^'- «'^>aor part of tU. dav lu,s a eh a ■ 1 '1 f ''''^'''■''^' '"- t'- '•al^i.it rnnnino. ^ild. TJ,, ve v ""'"'''-^''''''^ to that of the l^'-^'«l' air and snnsl ine are tie ^^. """^'''" ^^^ *'"vironn.ent p--,aitit..iei.oi..:o:x,;'?,;::;-^^ ya ? M * 4 n«M Published the iSth of each Month. THE o: CLIMATOLOGIST. A MONTHLY JOURNAL OF MEDICINE, DKVOTKP TO THE Kelation of Climate, Mineral Springs, Diet, Preventive Medicine, Eace, Occupation, Life Insurance, and Sanitary Science to Disease. Edited by JOHN M. KEATING, M.D., FREDERICK A. PACKARD, M.D., CxIARLES F. GARDINER, M.D. JOHl ASSOCIAT VmrKNT Y. BOWDITCn, M.D., U.)ston, Mass. NOKMAN lilUIHiE, M.D., I.os AiiK'olfS, (.'ill. PETKU 11. liUYCK. M.D., Tiininto, Ciiiincla. SAML. K. BrUKOrOHS, M.D., Kaymoml, Tpx. ,1. WEI.l.INfiTdN liYEKS, M.D., Chiirliilto, .N C, .1. M. DaCOSTA. ^r.D., I'liilndfipliia, Pa. CHARLES DEN'ISON, M.D., Denver, Colo, (iEORClE DOCK, M.D., (ialvcston, Texas. WM. A. EDWARDS. M.D., San Diego, Cal. J. T. ESKKIDHE, M.D., Denver, Colo. SAMl'ET. A. FISK, M.D., Denver, Colo. F. FREMONT-SMITH, M.D., St. Augustine, Fla. W. II. GEDDINiiS. M.D., Aiken, S. C. JOHN TKATI.l. (iKEEN, M.D., Tucson, Arizona, JOUN B. HA.MII.TON, M.D., Chicago, III. T. S. HOPKINS, M,D., Tlioniasville, Ca. JAMES C. WILSON, E EDITORS: FUEDEKICK I. KNIGHT, M,D,, Boston, Mass. AI.EKED E. EOOMIS, M.D., New York City. llENliV M, EYXLVN, M.D., Chicago, llLs. FRANCIS MINOT, M.D., Boston, Mas.s. . WII-LIAM OSLEH, M,D,, Baltimore, Md. WIl.MA.M PEPPER, M.D., Philackl|)hia, Pa. liOAUDMAN REED, M.D., Atlantic City, N. J. •T. HEI:D, Jr., M.D., Colorado Springs, Colo. GEORGE H. ROUE, M.D., Baltimore, Md. KAIU. VON RUCK, M.D., Asheville, N. C. FREDK. C. SIIATTUCK, M.D., Boston. Mass. S. E. SOLLY, M.D., Colorado Springs, Colo. G. B. THORNTON, M.D., Memphis, Tenn. . E. L. TRUDEAU, M.D. Sarftnac Lake, N. Y. J. B. WALKER, M.D., Philadelphia, Pa. J. P. WALL, M.D., Tampa, Florida. M.D., Philadelphia, Pa. Si- Yearly Subscription, $2.00. Single Numbers, 20 cts. W. B. SAUNDERS, Publisher, 913 Walnut Street, Philadelphia, Pa. CAk~ O^V THE ASSOCIATIOX OP CON- GENITAL WRY-NECK, WITH MARKED FACIAL ASYM- METRY. BV WILLIAM 0SLE8, A, D ' JOHXSHOPKIKS HOSPITAL, „.LTi;OKK,„„. R<-'printed from Archives of Pediatrics, February, 1892. New York- : «-J.Roo.nhv,P„„,hr.«oStat,on.r '3'9 Broadway. i h f 1 tJ s j' t METRY.. ^^^^^'^^ FACIAL ASYM- '•V WlI.r.lA.M OSI.KK, M.l,., ■'■■"- ""i'i<- n„s,„.,i, ,,,„.„„„.,. „', encr'i^U;^;;:^^^^;;,;:^--^^^'^ condition: ..In .efbr- and furt],cr investi. , , "tim in' v""'''^^' °^ observation to this affection tl,c Ikvic n ul f. V ""I>^ l^^''''^""-^ -'^^•bject do not develop as on t e /S i, '„?'• ''''" ^°"tracted side 's a want of symmetry in e c'u i '^""'^"juence there examined from tlie fro, ),' ""^^'^''^^'^^^l''-'" narrowly tlK- other, and the uhc e of t m^l " r''F''''>' '"^^''-^'- than ■VT^aller than on the other ,''i " V""" ^'''''^ ''^"^ head p.tal with heart ch'sease a wrv , L ''' '"'"'>' '" ^J'^^ ''os- and this remarkable want oPsvmm.r''''''^' '"''""^ '"^="^cy, ^" a yonnjr lady patient V tf''^' "■''''-''■>' '-"^''dent. grown, this dispropoti ,'?•'';''" " "^''^rwise well anc face is clear y s own " It i' T T'^'^ "^^he head 's due to some f^dlure o ner. n s n^nJer'?'^'"' ''^■''''''' ^his t>on m the same cause wlHchn-o .?''"- '^'^ ^"""da- Hliether the contracted nn,s ij it ' f' ". ^^''•^"--ck, or on growth, and, if so, w],e he t u ^■^"''■^^ ''" influence mastoKl would allow developmetVl'''"" "^^''^^ '^t'-''-""- referencesto it in the liter^,r ^^'''" ^•^' l'''"ceecl." The '-bitually carrS;rinT^r.2sS"T'- '^''^ ^--' -- ch.n turned to the ri^d, tevact " , . '''y^"^^^ ^'th the pest the explanation b3 them , ' /y' l^'^'on to sug- heavier than the right.'and tlTe tad' u'' 1^^ /^'^^ '^'^'^ "a-^ Krummachers< reports wf-n ''' ''c^'d crooked. |AS':^^,y:;;;'^™j;>;5te,,,/' ,st ditio,,, ,878, S " I!,rli„ Th.-sis •■ ,8So y >'''•«"''■ vol. .vi.. ,882, ' A.neHca,.,...„atW. Society, U..,„,,.,„„,,^,^^, 454. 2 Osi.i-.k : AssiHiittit'ii ,>/ (.\>iioriiitti/ W'ly-Ahrk. asymmcti)-. In tlif •^ihoiuI tlic cliilil, aged twelve, at alK)ut tlic a<,a' of two \ears lill and had paralysis of the extremities on tiu' r'it;hl side. The sternal portion of the ri'dit sterno-niastoid was i;ontracted. The facial asjnunetr)- was strildii.i^; \ er\- little difference in the extremities; no special as\nMiu'trj- in the two sides of the skull. Stanley lioyd reports a case of a L;nl, aged nine years, in whom the torticollis was noticed shortly after birth. The right half of the face was ilistinctly smaller than the left. Careful measurements and the accompanying photograph showed the great difference w'hich existed between the two sides, not onK of the face hu. of the .skull. 1^}- far the most imi)orlanl conniium'cation on the sub- ject is by C. IT Cioldiiig-Hird," who reports six cases of congenital wr> -neck with facial hemi-atrophy. The following case lias come under my observation : Margaret (i., aged fifteen, a well-grown, healthy looking girl, with good famil\' historv'. She was well as a child. Nothing wrong w.is noticed until her tenth year. On the i8th of December. lS.S(). she fell and cut her chin, and the mother states that for two weeks she held her head turned to the right, and for a \ear or more after this she had wr\-iieck. Tiie following >-ear Dr. Tiffany operated, anil there was temporary benefit. Subse- quentlj- b\- gymn.istic exercises she improved very much. The mother is positive that the child had not wry-neck when )'oung. The as}'mmetr_v of the face has been noted for several years, and is thought b>- the mother to be progressive. A photograph taken at four and a half, full face, shows complete ecpialit)' of the sitles; no lowering of the eye or eyebrow s. A second picture at eight and a half shows both sides fairly eipul and the eyes on the same level. Neck; circumference, ,^0.5 cm. The left side is dis- tinctl)- fuller than the right; scarcely perceptible scar above the sternal attachment of the sterno-mastoid. The outline of the sterno-mastoid on the right side is plainer than on the left when the head is straight and the depres- sion between the two portions is better marked. The muscle on the left side is distinctl}' larger and fuller, and is of greater breadth; particiilarl)- well seen when the head is rotateil to the riglit. The clavicular part is \ Illustrated Medical NeioSy l.ontloii, 1889. \Giiy's Ih'SpitttI Reports, Vo!. xlvii, l8ijO. «i( n Sf.KK Iss '"ull and strniu'- 111,1 h, between the ^^^l:;.^!!^.'^-'- . of the d licad ••^ncl claviciil -^ rotated to the left tl ar ivision prominently an.l well. \ , m!' P'-'^IUS of cither side. '''^^"' the T'"^!"' "»" tl.e hea.i die left r;if iMi- .«,... ,1 le .sternal ence a portion.s. VVlicn th portion .stand.s out Pparent in the tra- marked 9"tlicleft,side,fr :'^' •" uie nead .seem free h,,f i '^■'- more than to the .'ht t,'''"; '■"^''^^^^ to =is>-mmetry. The r^^^^^iJ^^ ^^'l ^^Iiovvs th !<-' rnouth, IS e.\a , ^'low theh.be of tl ^jurements are as foil ous: O'-i the other sid -•tl> 10 cm th us to th e IS ^' tij) of the antitr exactly 9.2 cm. F corresponding- ni eeartothean{,rleof c'asiirement om the outer c an- -i^ntai M,;„ .i;™;wi:.i":t;;;ii,."«/'';»4: i.ft, si^ a e.n-«;;r,,r";,:r;;;;'*.v^'-.i^ftp;»f at the passin{,r .it"che "m .^'I'P^'- lid of the other ■irk^'ii of the 1 ']"' passes ej-e. A 1 ine passes through the m ,ih '?': '"^^'^'- "'I of the left e 'e !;i?l>t eyebro!; is t T dS , , "UlSV^I'^^'^'^'' ^^^ owei level than the left. Th e nose is strai-rht '■'<. '>n a distincth- I Th '^Mvhole cheek, includ of the right sid '"k^ the malar b ^m^ Laugl ■■t-'ncc in th ^-^ IS distinctly small ;one and zygoma IS c ears Piipil.^ on both sides of he,- t move well. A littlr- Vnf temple. "'^ ^■^"'-■" are e L'r than the left no ace ill!'' Til qi'al, react alikt ^■qua Ij.. Jioth frontal perhaj '■'^ in the e measurement of the I right note in the h equal. No mol ands and ar lea Th TI con palate le question irs in the I tl, 36.5 ms. Tlie teeth Statement that the chil i-:^ well formed; the sid i^evs whether tl lie mother ower jaw on th cm. Nothing of re well formed. an es o fthe t igenital wry-neck. '\\ ^' right side, ongue equal. until after th f^'-^. wa.s really a ca.se of '■' ''^ quite positi\ JJird info mentions that ar li/'i- f.,..,iri.i ■' e accident at her twe'lftl ;rmed that the ,\^U "ot.ced, but an appeal eral instances showed tl before tl in all but e' in her ■straight year. Goldintr- ormi one of his cases h I" appeal to the phot ^ '""'" "'lat the def, ty had onl)- b ic was 'een recently or kraph album ... mityhad existed 1 It. \n in sev- ong our patient the r^-topl^i'^S^attL'Srhalf --^r- --"-'^^ '-It e.kht and a half years si w in '^ "'' ^'"^ P'^otograph not in the earlier one. Li 1 e ni n =''^>''"'"--try, certainly some have said the sides 1 '''^^ure ar , >„.!,. .„., . . L left side looked th eight 'acial a e smaller •^'ed equal, oth and a half crs that the iorPr!^^^>'^l-tc evident to tl overlooked b>' tl familiar with the lie parents and f 'ic observ er may be Under th ese circ appearance of i] riends, who have be umstan le c ces It 1 s on ly hild fr en om infancy, necessary to sho m tlicin Om,i:k ; .hs( tlu' icllcitinll ildtioll iK f ('<"l.<' iiilnl ]Vrv-Ncck. )f tlic face ill tlic lookinu-k'I'i^'^' ^vliicli briii^^s out tlu a-^; maiiiKi'. •mimtiN l.i't UfCIl tlu Sl( It's in a strilsiiu All of the Ciiscs (.11 rcciM Sli^^ht L;raclis lia\u been on the ri^lit side. com iiion, probal)])' qu skull, but it is only w lien e the term iiemi -atrophy can )f facial asjmmetry are exceeilinj^ te as common as asymmetr)' of the that \treme and pro^n-essive )ln' e\ii atroj was same g nnlieil to it. 'I"he condition lently is quite different trom Koniber-s acial liemi- In none of the cases reported has the umlateral tinL^ been progressive, nor has it pniceeUei jrade as seen in ob.serv'ably chan^a'd, an to the iffection. The skin is not d there does not appear to be the tl lis same loss o f subcutaneous tissue, nor is there uastini: of the sebaceous of the hairs, muscles may follicles, nor any chaiiye in the nutrition The differences in the bones and of thc- how ever, be \er\- strikinL,^ i n the form at present un In the cases der consideration. with torticollis the c< iiulition is rather, as llkS SUL rests W developed propo ra as I f the face on the affected side had not rtioii.itely, so that it is arres t of H'ow th ther than an actual atroph) A perfectly satisfactory explanation of tins a.symmetry and of its relation to torticollis has not yet been offered. (tiuoted by Goldini;-Hird) has si,,;!_;ested that k interfered with the vessels and E ulenbcr! the position of the nee nerves passin^^ to the liead ami but this tloes not seem \e so arres ts th e nutrition, vances r}- likely. Goldin^-Bird ad- the \iew that the facial heini-atroph>- is not a con- f the torticollis, but an integral part of the mmon central origin, which he uence o seq affection, both having a CO believes is a primary polio-encephalitis. He states that 1 the exact similarity between congeni bearing in niim tal torticollis an d a case of infantile paral)'sis wi ith t 111 pes eciuinus, th e cone lusion is, to my mind, all but inevitable that "caput obstipum, w toid, wasting ( " " ith its contractured stcrno-mas- f'the facial muscles and soft parts, and li even of the bones, forms an exact copy o' alipes equinus with contractured calf-muscles, ill-nourished soft parts, and in many instances shortened bones, and must have a similar origin." It certainly appears more reasonable to think that the heiiii-atrophy and the shortened muscles are both the expression of some central lesion, but it IS ( liffi cult to unclers tand, from our present knowledge CuU ct)rtical Id be. )calization, exac tly wnere tl le misc hief ()si,|.:k ''''""■'"^'"" of Cm^i^nufal II >t- AV,/: 5 ti-n of ..aropI,y o, ; he'-^; J' ',;\\7'\ -'-^^^ it is a co,uI . arrest ,„• in, pcHcction i L I. f ''''' " "^ ""^ '^^^h' an 't ^voul,l, as i„ Ko„,|,, "x'''.\, ,^^'-';'I''">-"t. If tlu- former ";anyoftI,c cases >x. rec ,, ''^n^^ '^-■" ^''-^--nt asynimetry may have .level.med Vf. . "' '^■'■^.'■"'^'-"'^' ■''"' facial c<)ii,liti,,„ is such -.s m t ^^^""^ ^''^' '"J^'T. The related t,. the torticollis is :.V\V^^^^^^^^^^^ '" -I'at uay I 'i If^ CLKui^O. ^'^^-^^U^c^tn^ Art , ^ .-^ . /4^^ /e-e^e-^ciy ^ // ^ ' '^'^ '^^^ './^^ 7C ->;' ^'^^A..^ ///J^^^'t ^l^:.U^-fs^/^tUc ^JUw^^^^i^^^ ^c^*jUidJ^ ^'Cj^jr/, ikUJ^x^J '^^'^^^tc^.i^) 7ff. I : , V ^^^fe^ r J. yr^^ ^. ' ^ r. tr T ' I^^V* J'rr>^ \^-4\ ^Irr**-, /Jff. I / ^C'^^f'^^^' /^^^-^^/-c ^^- >;w. A./^.^^ ^^1 ^. ^1U fc^//: /^.^ *^^-^ //^. I''' I .' hi II M i:i fjii ill I ' ■■^= ■ ^ i p« J. ^1 |: ' ^9 1 I : J ' p 1 '■ \' 1 « /1i ,*^ ^y^^ ^ -'W^^ ( ^■^^^.aZ'/t^ ^^ / 1 <. y^^^c^ r"-^^- ^-d*~c -^Yi^ "^A '^7^ '^«-^-^V_~*"9^^ '^/?£ ■/;^v- ^^. ^^i 'i' i'Vi -/-^tt-. m >%^^>. '-^ ^ CX~K -: ^^i 7^ INTERSTITIAL PROCESSES IN THE CENTRAL Nervous System. By .William Oslbb, M.D. H'' ?1 i M ■' I ^^TEUSnTU, PROCESSES m THE C... '^^RVOUS SYSTEM '"^^^ ^y WiLtUM OSL EK, M.D I ! INTERSTITIAL PROCESSES IN THE CENTRAL NERVOUS SYSTEM. BY WILUAU OSLEH, M.D. Protenw nf McAieinr in hejnhm Hiniti'.n;> i'lUivriUii, RiUlmore. liy iirratifremeiit witli the Rofcivu I have agreed to confine my re- marks to a pn'seiititiou of certain pointR for (UHCussion in eonneetion with interstitial processes in the central nerv-Ms system. The snl)ject is heset with difficnlties. If we cannot hope in the present state of our knowledge to dispell thi darkness which surrounds it, we may at least get an inkling of the direction in which to look for li(?ht ; if we cannot expect a solution of the problem which more than any other stretches to tension the pia mater of the neurologist, we oan perhaps get a definite outline for our ignorance, which in any question is a great gain. The connective tissue of the central nervous system is of two kinds, one special and peculiar, the neuroglia, derived from the ectoderm, with distinct morphological and diemical characters ; tlie other, de- rived from the mesoderm, is identical with tlie ordinary collagenous fibrous tissue of the body. Both play impoitant parts in uidurative processes in the brain and cord. A convenient division of the scleroses is into (1) the degenerative, (2), l/ie inflanunatory, and (3), the developmental. Tlic degenerative scleroses comprise the largest and most important subdivision ir "hich provisionally the following groups may be made : {a) The common atrophic, secondary degeneration. Nerve fibres cut off from their idioi)lastic centres, i. e., their ganglia, die and their place is gradually occupied by neuroglia. {b) Toxic forms, among which may be placed the scleroses from lead and ergot and most important of nil the posterior sclerosis due, in pach a large proportion of cases, to the virus of syphilis. Other unknown toxic bodies, as in p.rnicious aniemia, may induce degeneration of the nerve fibres of certain tracts. The systemic paths differ in their sus- ceptibility and the posterior columns appear most prone to undergo sclerosis. (c) The sclerosis associated with clianges in tlie smaller arteries and capillaries. As a senile process, a sclerotic atrophy of the convolutions IS one insula lation in the the pr to whi tion ii arteriei this ])a 'I'he sive gr sonietin seconda tion abi ilistolo^ trix sin parts of litis or 1 niay be consetjue sibly too t'ncephali How far hemiplegi The modt stitutiouaJ change is i tribution, Ntich as wo elements. sclerosis an The diseas cerebi-al atf its true nati sion now an wiiat is the The devei attention hi writers to pi heretofore o cortical sclei condition, w\ ;;• ^'-"•••ai" an in the other or^u ; ; ''''f/'f '^ ^'- q-ti,.„ ,.,ich. •ytcru-sy This i wo„h, ,,,4,1;;; ;•'."<• -'Pallan.. an.i Hmalh-r . ' '''-' ".-..!: p-ts of the hody. ,.,, the s :S^':,;;;;;^'^; ,f ^ -'^^Hio,. i.. ,z. '>t.H or n.e„i„ ,,.,„, ,..,,i^ '-^ »^ follows a prin.ary e-.c-opha- ""^y "^^ termed i„Ha„u„ator; 00^.?^' ^^" "'"^^' '"— -''i-l. con«e,ue„ee of the action of^h il ,?!,^^"^''*' "--'"•^ ^Vstc.n in -hly 00 of .y,,,,i,i,. ,,,^ i,„,,,, , , ', " ^ '.^' «P^-c.fio fevers and pos- eneephaluiH. The terminal ev m 1 , !'.*^''""'>'''''^''^ --'"^ ^s a polio- "o- ar that mo«t interesti i vl Uv tT / "•"'"■ '^■•^-'■^^--ve. ;--Pfe,na i« the outcome of a ,m'! ^^'^rr ^■''""<' '"" i-'f-tile 1- mode of onset in the child Ch fever "'?''" '^ ^^"* ^'«»^tful. « 'tufonal disturbance speaks for an ' '^^"^■"'«'«»« ''»"'* ^narked con- ;'rf " ^"•*'^^'' «^' variable extnt If n"'"""'^ '^'•--^ 'i^'-" tnhntaon, the meninges are adher n 'an,n f 7 ■""' '"^"^ ^'^«^"''^'- <'-" """'• '^^ ^'"»i"« "^ ai ' « t-e nature and with this I wo!^ 1 / T'"" ^J" *^'^'" "'-" - to ->n now and for research hereaf t,. T'""'^ 'l"'"'*^"" f"'' ^"««»«- -i'a . the nature of the primary eXnMrfl"' "'"""'-^ «^ ^•'"''''•-> rhe e/«.e/.^,,,,,,,„^ ^^,,^^ y '^ «n? "'«'*n"natory or vascular v »ttent.on has been paid and an mJ .^7 "Z ^^'^'^^'' "^" '^^^ special enters to place them in a oosiH . ^ """ ^'-'^^^ "'a''^^ by French l^-etofore occupied. Tl e'besr ^^ ""'""""'^ ^^'''^"' t'-e/have .^t -ti^i «derosisof chiidinThi': ::..^::^;f ^V"" ^^ ^-"^- — ^ -en . may appear ^aU^e^ ^l^--— ^^^^t. hi Ufl INTERSTITIAI, PR(K'KSHKS IN TtrK NERVOUS SYSTEM. ncciirriiii,' hxU-r in lift-, ,u'riit haw been made by Dejerine and Lettdle to scpar.itc Kriedrich's ataxia from the ordinary form and to place it anionif the dcvelopnx'iilal scleroses. This disease is dintiii- giiished from Romberfi's tabes by its early onset, its occurrence in members of the same family, and accordiiiL'- to the authofH just named by definite iiistolo'^ical peculiarities. And lastly a most intcrestiufjf study has been made by Chaslin on the brains of ej)ileptic8 on which he claims to have found a sclerotic change of a distinctive kind (]uite apart from the ordinary form and su^o'cstive of an association with a i)rimitive fault of construction. The assertion is made that in these varieties the histological element is |)urely netirogliar, not admixed with ordinary connective tissue as in the other forms. It is in fact an cctodermic not a menodermic sclerosis. These statements have not passed without sharp criticism, particu- larly by Wcigert, who denies the special characters of the anatomical changes in these affections. The sul)ject is still an open one, fresh, and of jieculiar interest, and I would propose as the third question for discussion now — and to some foretliought and woik hereafter: How far can we recognize in the scleroses of the brain :ind cord a separation into an cctodermic, purely neurogliar form, a mesodermic (connective tissue) form, and mixed varieties ?* * Ulubtrationa were shown uf the various forms of cerebral sclerosii. CJryj I ™' '"' T?'S MEATMEN! OF TYPHO/D FEVER.' c (Jkntj.K.ukx . W'IjII ili-'UlIlst I (' IK) IS as to ti of tl prof OIlc H' <'iiiv oC ,|i 'lost; w'lio ,.|, cssidii i'tn- ••an l)n'iio' 's('a.s(; l)v (I I'llL'.- !irn> • 'xcivisr, i'lvsl turn with wate ' iiir, 1111 "'liicli tlu tliat "Oli-lllcJ '"'MlfCtfllo. t|„, j| "'<■ llHI.st 1)0 •1 I'ailiiii accusation iiiii'> tliat pertain "' virtncs (I ic iiso of natiT iciiial anciit er. fcv and tl 1' as a 111,. '<»!■ contiirios it cinand u' M.ocld.v the rel,„k( N -^""'l. as syst<'niati( 'ic atton- scaivcly r('(,viv(' tl '"^ of coi,tr„Ili„„. tl ''-•ii'ticMlarlv is U "<' "SO of |,atli in (I was oil,. ,,f' ^1 '«■ rlic severe,. svin .«'<' since {Ii|),„„.,.;,t,,s. Y isease is i '"' i'atlier of ^[,,,i oil will fi .ureal ■w'oiiiiiieii(l(M| I IS the iptoi (-■ase ns of "yM'K'inV moasi ii-e; ■•'""' "•*.'^ of the liatl. t, Dm ill tl '*'"'<^ ill! adiiiirahl '".\' writers i '1 ev(!ry 'h' writings of :o SOI ■'»«■ the first half of t] , TTH' "'^^ *''« "Hlieatio, :'»*■ "'' "'"V'l' r shall refe is ic /land ^iiished the larm. el of the Imlropaths, I "■■^ cvntiiry hv^h.^,t] '■ iiirain. ' '>y which term "■'■'PV' was largely upon water as '>i<'i.orinoi8te,- Winter.iit/ I ^^•^ of hermaphrodit, ;;---Il;l..itm,de,-tlieg„id pi'actitioiier may l)<. ^isti II- P''''sse.s, (loiiehes, and tl iliice( 'II' varii "•""1, and others, tl '"•<■ of v(.n Z ■s who lo„|^ 'icm.ssen. MIS / Ih'aiid, of SU'tt '•.V cold liati , «.lished by Brand in 1887 made nie determine to adopt it at the earliest possible date; but when the wards of the Johns Hopkins Hospital were first o})ened the arrangements were not adapted, and our stiift' of nurses not large enough, to carry out tiic nictiiod tliorouglily, so that for the first year we followed the ordinary symj)tonuitic and e.vpectant plan of treatment. 1 am not myself personally responsible for its introduction. During my al)sence in Europe, in 1890, my former first assistant, Dr. Lafleur, now of Montreal, after a visit to the wards of Dr. .J. C. Wilson at the German Hospital in Philadelphia, began the practice, and the hospital is under a lasting debt to him for the accuracy and care with which at tlie outset, and fbi more than a year subsequently lie supervised the details of the ti'catment. Most of you have seen the application of the method in the wards but I shall emph;isize certain points in the procedure by having one of tile patients bathed before you, so that you may see the minutise. The ward orders, subject of course to modifications, are as fol- lows : The temperature of typhoid-fever patients is to be taken every two hours ; when above 102.5°, a bath at 70° is to be given every third hour. The patient before you has reached the sixteenth day of the disease. Hv has l)een in iiosj)ital nine days, and has iiad thirty-six baths. The tub is wheeled to the side of the boxl a practice much preferable to that followed in some of the foreign liospitals of carrying the patient to the bath, or indeed allowing Inm, if he is able, to walk to it. The techni(pie of tlie procedui-e is as follows : The tub, as you see, is of \\i<;\it pnpier-vmchr material, and even when filled with water, as at present, is readily portable on wheels. The temi)era- tiu-e of the water is ()8°. Here in tlie amphitheatre we sliall reverse the usual |)roc(Klure and liave the patient w iieeled to the side of the bath. The preparation is extremely si/nple. The heavier lm\- clothes are removed and a light sheet is thrown over the [latient from the neck down, ('nder this his night-shirt is removed, and, if luressary, a light napkin is ai)])lied (.ver tlie genitals. The jiaticnt is given a small (|uaiitity of whiskey. Two orderlies will l>atu.»t J:u,,po„,s t<. 1,0 a Ia,...o <'oinfortal>Iv into ti.e butl 3 stiJI •'^V(".r.I with tho sJu-ot. Tl -"• I'm; .MI \v<'Il-nonnsh«l man, and I, '.•.«.■««;*: i;:,r;:^'"t!«-/° -^ fits Ilis very '**> an a'J'-ciisliion fbriii for thi s'>l>P<>rt of the baoi<. fn one las a sloping plat- '■" thin, eni-iPi.,f.,l .• "• '" "loro deJi( - i-f'^- A doth .:. ^r:;'i:': 'r '^'^ - ^--^-i l>«t;ent's head, and with a sard I .''r'' " ^^^^^'^^ "Po» the 1-t.ont, ^vho takes the baths u^thour nT '" """'"'-^"^ ^^-^^ '"avojust heard hini say, he wo d n V "^ ^'''''''' '^"*' «« you fi-^t-on is now applij'.;^ ;' ,. ^'■;^p'-- wann. Systen/atic --'s of a cloth o,- rndia-..nbb v,^" ""' *'" '""^' ^ '>^ i^ttached to a stielc. The fHetio .' . ?' *^^'"^'^"'"^»^'e may be ""Portant der;,..t ... the t.. 2^ I ''^'f' '''fardel as a ^.^ p^-V'^ ^ • '«* «* ^"" "^' ^t' r '^" ^'«"- ^-» *''^ ^-•••■onsly ...,,,, I,, irip^,o,,,,t^^ hid " ' '^'''^ "^ ''« '«^'t alone, -hen he said: '' H.t tie pe^n whT "T ['"^ ^^ P^-t '•'•^^'■•Jy and ..eserved in his maml.. m? ' '^'■^*'' '^''""W Ih' '>"t others should pour the w'^ ' f ^'^ "'^*'"'"S «- ^i'n.^elf f ^;'7! should nit be .::;m ^ ' x;: r "' -"^ "'-" -^^^ the bed .s prepaml fbr his reeeptio n h '' M "'* '' '" *''« ^'»t'>. ;-' -'^'- *'-- - old linen sh^t fft^^^.''"'''^'!' ^'-^'t' " '^'anket ^•^'•^twenty ,ninut..s the patient waslifl;^ ,7"'"""^^ '" '^' ^ath •'"'t. heavy n.„, and the orderl es we ' , "' '"^ '"^ '^ •^*'''^"g'v •^omo l.ttle diffieultv, owin.r to tho I '" ''"'"^^ '^^ there was "7'- '-th. This; i.owe:t. i2 ;::t:::? 1;^"^ "'- ^" ^'- «-^ :""' then patients eon,plain ,f "..,!.;•' I'"" ^'•■^W>en, but now '" ?' ^^"^ ^^^'*''<' '-th; and tlo^ L"' *''^ '^'•--« ^^ lifti..,. >;-t..st possible ,.,.e, these litt^"tJ, ^ ' " ^"1 ^'^^' -^'' the "■;' --• is now well wrapped p .1" T'' ^'^"^'^ *^ '''Wn. j fia I! ill u'i ly • ill !■ ' 1 ^ .il t(t ten niinutcs, but iiiidcr dtlior (•irciiiiistaneos lie m.-'v ho carcfiillv dried !it once. Vdii sec tliiit this man retains a jiood color in liis i'aco.; the extremities are cold but not livid; and be is now bef)in- ning 1.0 shiver. Very often this shivering is distressing while in Jie iiath, and one of the most unpleasant features of the system. li' the patient is verv cold and the shivering is exti-eme, hot bottles mav be applied to the feet and at the sides. You see by this two- hourly teinperature-cliart the inHu<'nce of the baths; and half an hour after this the temperature will be taken again, and the reeord made. If at the end of three hours the temperature is again above 102,5°, he will have another liatl. sueh as you have just t-een. Now, before the patient is wheeled out, he will l)e given two ounces of hot milk with a little whiskey. Prar'tically what you have I'een in this case is the routine of our treatment. 'I'iie patients receive no medicine other than ahiohol, and that we do not give as a matter of course, but as a rule only, Itefore and after the bath. In othei- eases, when the heart becomes feebl(\ we give strychnine, and in some cases digitalis and ether. The effects of the baths are : first, to reduce the fever, principally l)y i.iV'oriug heat-dissipation and by the direct action of th(! cold water upon the blood that circulates in the superficial vessels; secondly, as a general tonic to the nervous and circulatory systems. Perhaps the most striking effect is seen in the lessening of the nervous irritability, the favoring of sleej), and the clearing of the mind. In patients treated early by this method we rareh- see the dry tongue, inuttering delirium, the subsultus, and the other grave nervous ])lienomena which ai'c of such serious import in ty|)hoid thvvi'. The liaths, too, appear to improve the general nutrition, and the patients take their food better, digest better iiud, as has been said, the vital j)rocesses all seem more active. Do not suppose, however, that you can, as Brand entluisiasticallv says kec]) the ])aticnt in an almost afebrile condition. An ins[)ection of any series of carefully-taken charts will convince you that this is an imjiossiliility ; the temperature rises again in a variable space of time, and in some instances the influence of tlu; bath upon tlu' rectal temperature is exti-ijinely slight. An important (piestion is, shall we bathe all cases indifferently whether the temperature reaches 102.5° oi' not, and whether grave or mild? When the temperature does not reach the point indi- <"''<'' '"''''' ■"" 'l"'- ^I'o very o-ood n,,.soM that ue li /:;"'"'''"''''''' "''■^ l''"' f-" <^" tlH' ..tlu... hand, ;,. ,ll „ • """'^ '"' '""' ^'''' '•---. -■'--'<• !-it..ti.;n i„ ; '•"-'^;"<>tI.,.aMs,. tlu. hit ; '^""-"■'•'-K'- iW.n. tlu. ^''^M'atK.nt« in i„,ds 20 aj 'nj"; 7''r'" ^ a''<--'>>'>t oi- lu.nu.rrl.auv. I„ tlu. ov.. i *■', ' "'■''•' "'"'f<*''' "n '«'ti-. though wc do s '• h r "' '■ " "'"^=^'''^' *'' -"^ ^' -'"-i-Mtly to j„sti,V tlu.ip „,. ' ZZ ''""'"''"" '"•'•'■"^■•■^ 's .-.^ardo,! as a special (.ont.-.; i„d I'""';'"^""'' "-•• l>.'oiu.hitis '•'^"^ -"•'< that its ,.n,I •, / • "■'^""•"' ^" '•'^'"-■'<^''''v i" I.OS- '■-- vonea,ui.vou;:.":;^:r """ •'-■'foroiit hospital; uluVh,.^ ' " '■"'"'"'" ^'"' ■^^^'^'^tics i„ -thod now aviilahh, " S;;"' '"• '"'^ T"'-^ -"•'<« <'" this ^'"■""'■•b- '' Follow of tho Johns Ho ' '•/^'''''''•' ''^ ^'levoland, •^'-v Vopk-. Tlu.s.. littl/l .1 ;? •" '^'■- '^■■'»"" J>anu.h,of f fffi foiitnbiitions to a Hiilyc'ot that I las iiul _v<'t iviiclii'd llic iliiily lives of (lie doctors in tliiw cotiiitiv. I'racti- (•■■iliy, tlic morliility iimlcr the cold-lKitli trciitniciit in hospitals liaw JH'cn reduced from \-') and 2(» oi' 2") per cent., to an averaj^e of (J or 7 j)er cent., takinii' all cases, or even very inneli lower if the crises are sifii cirly. Indeetl, IJrand has figures that show an absence of mortality in some 1,2(M) cases in which the treatment i)e>ian beti)rc the liftli day. But in hospital practice we vun never expect to sw oiir patients before the end of the first week. At the German Hospital in Pliiladelphia, where the method lias been f()llowed most accurately i)v Dr. ,f. (J. Wilson ;.,id his colleagues, lliei'c wei'c ninety-tour consecutive cases treated without a death; but I understand from Dr. Wilson that this remarkable good liirdme has not continued, though the mortality has been kept at a very low rate. Our own more limited experience is also strik- ingly in liivor of the method, and a report is in course of j)id)lica- tion dealing with the first hundred eases S(» tre^ited. In the fii'st year of the opening of the hospital there were thirty-two cases treated on tlie symptomatic and exj)eetant plan, of which eight dieil, a moi'tality of 2o j)er cent., a rate unusually high even for a general hosi)ital. The cases, however, were of unusual severitv • one had acute hemorrhagic nej)l)ritis, with profuse hematuria; one case, admitted at the beginning of the third week, had extensive doid)le ])neunionia. Two cases died of perforation, while another case died of profuse hemorrhage from thi' bowels. On the other hand, in the first hundred cases treated by the cold baths the mortality has been only 7 per cent., a refhietion so striking and remarkable that it nmst l)e attributed to the good results of the bath. Kvcu this rate of mortality, which is about the average for hospitals in which the rigid Brand system is carried out, would l)e considered by the proposer of the method far too high. In the report refi'rrcd to I have given full details of the fatal cases, and it will l)c noticed that one of the seven, an old man of seventv was admitted late in the disease with extensive lol)ar imeumonia, and as the disease was not recognized as typhoid he was not bathed. Two cases were adnu'tted in i'ela])se. You will be pleased to learn that in the cases treatal this vear we are still gratified with the irsults of the method. We are at about the seventieth case in our second series of a hundred cases, and oidy six of these have died. • l>eon rapjKHl over tlu- k„,u ,"'" '" '"-'^'''^^ Pmotuv.' / I"--to p....ti..„ it ,,,, ., :^:;,X^? 7-'<- '-• -yin, tl.at in '"'^■'•^ ^" '^^y that i„ this .,s in ' " ' ^"W"-«' it is n.or. '••''''•%'CM.fhis,.o„vioti,,„s,tho 'n tl "'■'' '"''"''' '""' '"'■^ tho 7'^; a good „,„.,, intdli,.„ti;' "S; * '" '"" "■""'•'•'"' ""«^ :; tl- pationt's fi„,.ij,, the pra^iot^ " ' "" "' ^-•> "-»'-.. '■• favo,. of hydrotherapy an L T '"^'"-^ ''" ^'"^ l>'-"^l"««i<>n '"-; -i>,>o.t of his ..on;:; L'"\^;;;^;^'-'"- '-■ ^^^ '«-t ,,, tho -"- ''owovor, ho ovo,.,.onu.;vith .!^'" 'T' ""^ '''^"''^'^'^' ^^''-'' My preooptor, Dr. I{. |.. i^ , •;'<- J«it.onoo, and a littlo tact. -' ^" rntho.. sot tho vo.^' ^ '.^''"^-^ '■-' to toll a ston' '^-thod. Ka,,, i„ ,,,^: u,>ti,;^^;" ""-."« against tho Hntnd '•'--''« Papo.., D. Howa. :'hi f •■ """" ''" '""^''-^-" ^^ .^'-'- tho fnll dotails, an,l h- , "'"T "" *>'I'''""' ^^^vor, had '"«■-" a snutll town in Western '" ? '.-'r "'" '^^^ ^''''•' P'-a-tis- f^" '- -liysicijiii-, an cMiciiK'ly caiTliil and aMc pnii'tilidiicr, who liiis Imtm iisiui; llic cnld lialli very liiitliliilly. and in s|ical(' lie >ays ; " I'lic |(.'a\<'rs, cntrcallcs, sii|)|»licati(iiis, and last hiit nut lia~t (■llicii\(, ihc lu-ly \rlU (il'diis innally and maintain sniuc nidrtaiitx', at any rale, in iy|ihiiid liver. Tiie patient, admitted ahoiit the scvenlh day <<{' hi- ilhics-, was a struiin', well-hiiilt, healthy man. iii^cd lhirty-se\cn. lie was hath(d from the time of his enlry. and had had almnt forty hatii-. The (hiy iiefore vcsterdjiv the pidsc \\a- licidc .and I'apid al'n r the liath, and it was thoniiht ad\■i^ahle In nrdci' the lialh-- In he ih'-ennlimieih Thd'e was a little tenderness in the alidninen. Iml nnihini: very striking. Vestei'dav, as Slime lA' ynu saw, the si^ns ii\' perliuatinn wer'c well marked, and nf tin- he died. I -Imw ynu here the small intestine, and ynu will -ec a mall ulcers, not lariici- than |)eas, and .almvc ihis ihciv arc j'eycr's palelies nninvolved, with scarcely any inliltralioii. The -spleen is very miieli enlarged and soft. Here was a patient, wilhoiii extremely hii-h tompera- 'III'''- liiilhed from alimil ihc scvenlh day. with everv tavoralilc |'i"'i''"'i"ii-iii'' •!- iil,| (,, |,„.;il conditions in tin- limited area involved, ihe msi- |i:i,| extended deeply, and pass- in- throimh linth muscular cals, the inevitaMe perCrati'oii ocenrred, with lalal pci'iionitis. I i TEACHER AND STUDENT. AN ADDRESS THi, University op Minnesota Minneapolis, Octobeh 4th, 1892* BY WILLIAM OSLER, M. D., P R n P T Baltimore : JOHN MURPHY & CO. 1893. B ii ' ■ t I I ! '^ f^f f ! 1 1 ^Mf 1^^ " ' ' 1^ A University conslit.-, and lifts ever ciniHlBti il, In demand and Hiipply, in w.inln which It alono oiin satisfy and which It does «atl.ify, In the ooiuniunicatlcn of knowledge, and therelalliin and Imiid which I'xislBlielween the teacher and the taught. Its constituting, animating principle Is this moral attraction of one class of persorjH to another; which ia prior In its nature, nay coninionly In its history, to any other tie whatever; so that, where Ihls Is warning, a I'niversity is alive only in name, and lias lost Its true essence, whatever be the advantages, whether of imsitlon or of affluence, with which the civil power or private hcnefactors contrive to encircle It— .IiuiN Uk.nkv Nkwman. It would siciii, Adeimantus, that ihe direction In which education starts a man will determine Ills future lifi'.— I'i.ato, llfpiiblic, iv. ^^i:>n^ss. >'"""fe' lives, to Hh-I a (Wr, ,; "\""^'^l'''"n' l.rigl.tcocl by "'"lt'.gra,luato .students, and Jo I. 1 7' ''" ^'"'''^ '''^'^^ t-t i.in,,solf with the d ; I : ":''f """'•'"'•■"•'■'>• '" ""•- J'e i..vitation .as a ..-eaU , ;" "^^ "'""'^' '"'"'"■"^^- ^hon %^-^ ''-.lied; h,;; 2 r :;:rr'''''^^^ all, to relieve a brotherlv i,. , T' "'"'''"' '' ''' >'«» bmhren in the camp o's ' '"^ '"'^ ^^'•^'■'' ^« ''is ^'^•ven n,e far afield 1 ' '" '"•^^'"^^ ^^'"■'■'' '-s often ^"•-Hlsand pleasant n;;::',,!r ^""•''"' '"^ ""^'^ -^'' ^ood On ih 1/ot:;:: ::7r:hi^''^ ^'"'f '- "^ -•■'^i-t. and public areawaken n! to n ": "'"" ^''^ P-'>-'-on cation, n.y choice was necc a 1 r 'T ?? "' '"^'■^^' -'- ever, of a formal presenta W . " ' ^"''""^' ''«^- medieal study, I hall ,d *''« ^^"'I't'ons and needs of tion of some';; : f , ; ^^ -7-1 f chiefly to a eonsidera '"ct.ons a. teachers, in dealing with > tfi 4 Teacher and Student. which I can incidentally touch upon questions of general interest, and can, nioi-eover, speaking on behalf of the Fac- ulty, say a few words of welcome and encouragement to the classes which have assembled for the year. I. Truly it may be said to-day that in the methods of teaching medicine the old order changeth giving place to new, and to this revolution let me briefly refer, since it has an immediate bearing on the main point I wish to make in the first portion of my address. The medical schools of the country have been either independent, University, or State Institutions. The first class, by far the most numerous, have in title University affiliations, but are actually devoid of organic union with seats of learning. J^ecessary as these bodies have been in the past, it is a cause for sincere congratulation that the number is steadily diminishing. Admirable in certain respects — adorned too in many instances by the names of men who bore the bur- den and heat of the day of small things and have passed to their rest amid our honored dead — the truth must be acknowl- edged that the lamentable state of medical education in this country twenty years ago was the direct result of the inhei'ent viciousness of a system they fostered. Something in the scheme gradually deadened in the professors all sense of re- sponsibility until they professed to teach (mark the word) in less than two years — one of the most difficult arts in the world to acquire. Responsibility! fellow teachers in medi- cine, believe me that when in the next century some historian, standing perhaps in this place, traces the development of the profession in this country, iie will dwell on notable achieve- ments, on great discoveries, and on the unwearied devotion of its members, but he will pass judgment — yes, severe judgment — on the absenc of the sense of responsibility which permitted a criminal laxity in medical education unknown before in our annals, ^ut an awakening has come, and there is sounding Teacher and Student. most Pr'im^slI'lnd^lt^ruiJh TiTir'''''""' ^'"'^ '^^^" «'« tion refen-erl to began some t v / ' '"""''■'• '^''^ '-^^'olu- anceof thePresiaU^e Iti ;,:;'f'''^^ ?'''' ^'^^'-J- -inores, Ti.e advantages of thi! ^^J , "l^ ^ ^"« Sol.ol. .ajores! recprooaJ. The professors i.T ""'""/''•*^ "'^"'^"Jfl and J-- "ot that independZ ' ; ,,^:;7-^'^-^' ^f ■"■" -'''ool under an influence which te,K s "'"' '^'°'^^'"' '"'* are .^-g'' Jevel, and the spi of n 1^' " ''^.^ '' '"'^1^ ^''-' ^^ a •-proves the standa -d of vj a d""""' '" "^''^'' ^-""■•- further eve^ side ahno. eon:):'- ::,:^:;:^ V""^ '•''''^'T'^ '^'^ '« <'-ger lest: r^r iz^c^r "' ""'^'•'' '-^^^^^^^ ^'"- the trne test of vvhieh t^l eV \''"'''' '^^^ ''''^■''"^ Ji^e, -oral standards. 1^ .-e s ,^ '" '''^ '"^«"-'"a' and corroding influence of mamn o„ 'T T''' '''''"^''^ '^ '^^ ^■^ation, and eann, noUdl^^^ ^;::;::: j;""^ ^>^- '-es- Prule of lifj, ^ve forget that fh '"^ "^''^ ""'' ^'^^ "ation to the u-orld is', itl^ t ' TT"" '*' '''^ ^'''"^^ <>^" '"^ -'-^- and that wheat Z^kl^t' 7\ ^'^ '-'-^ '>t>t 7 '>..t '' alone are imperishable. The km,ll '• '"'^^'^^'t^ which 'eaol. and extend it, witl'on :,.° l", ," ff ' •°' t*' '° cold o„d lifeless; gerond a fill "-"■"<:'"»' L-ecoiiie. book. U,t t,.e l,V,n, «: l' et'd f^r, f ™' '■- wivea trom experimental i . -I i J 1 J 's-Im 10 Teacher and Student, and practical work ii. the best laboratories. This {•^w of instructor is fctunately not rare in American schools. Tiic well-gr<)iiii the Lighcst known, and whos':- methods are ihose of tiie ma; ters in J&rael. Third, men who have a sense of ohlir/ation, that feeli^sr which impel. ;( teacher to be also a contributor, and lo add to t!:;, stores iV')in iviiicli he so '"reely draws. And precisely here is the nee "isity io know .'he best that is tausiht in his branch, the world u'.'T. The investigator to be successful must start abreast of ihb "t I pass on with 171 - "eiicdte matter ui coUpap f.i«i,T*: -:;rerr;i:::':ir''i~^^^^ upon -he di^dva,, „g 'a od'orr " "'"" '""""'<» of mature, u„t ,„ ,^,°,,i „, ° ;;^°°, °f ''".;■'"« to" '"any men sixth .l«,les there U^, .o^r j, orrZ'; .'f "T '"' «hertha„to.aurta»:;r.^r'ztr,;:r I:i4 12 Teachir and Student. or later, to sonio oiilv ton piiinCiilly evident, to otliers iincoii- scioiisly, with no piiee perceived. And with most of us this physical ehaniie lias its mental equivalent, not necessarily accompanied hy loss of (lie powers oC application or of judo-- nicnt ; on the contrary, orieii the mind j^rows clearer and the memory more retentive, lint the change is seen in a wealvencd receptivity and in an inaiu'lity to ada|)t oneself to an altered intellectual environment. It is this loss of mental elasticity which makes men ovei" lorty s(» slow to receive new truths. Harvey complained in his day that few men above this critical age seemed able to a(^<'ept the doctrine of the circulation of the blood, and in our own time it is interesting to note how the theory of the baciterial origin of certain diseases has had as other truths to grow to aci'eptance with the generation in which it was announced. Tlie oidy safeguard in the teacher against this lamental)le condition is to live in, and with the third decade, in company with the younger, more receptive, and progressive minds. There is no sadder jiictiire than the Professor who has out- grown his usefulness, and, the ' III. Students of Medicine, Children of the Guild, with whom aie the promises, and in whom centre our hopes — let me con- griitulate you on the choice of a calling which offers a com- bination of intellectual and moral interests found in no other profession, and not met with at all in the common pursuits of life — a combination which, in the words of Sir James Paget, "offers the most complete and cmstant union of those three qualities which have the greatest harm for pure and active minds — novelty, utility, and chanty." But I 'un not here to laud our profession ; your presence on these benches is a guarantee that such praise is superfluouh. Rather allow me, in the time remaining at my disposal, to talk d" the fiictors which may make yt)U good students — now in the days of your pupilage, and hereafter when you enter upon the more serious studies in whiiii the physiciaii finds himself engaged. In the first place acquire early the Art of JMachmcnf, by which I mean the faculty of isol ting yourselves from the pursuits and pi> :isnres in>ident t( youth. J'v nature man is the incarnatiiin of idleness, which quality alone, amid the ruined remnants of Edeinc characters, reniains in all its primitive intensity. iJccasionally wo do find ;;. individual who takes to toil as others to pleasure, but the majority of us have to wrestle hard with the original \''!im, and find it no easy matter to scorn delights 'ind .ve laborious days. Of special importance is this gil thosi of you who reside for the first time in a large cit\ ; i ly attractions o. - lich offer a serious obstacle to actjiw-ition. The diM'ipline uecessary to secure this art brings in its train habits ( ' self- 1 Teacher and Student. 15 :;::;i::"„n;'j°™' ' '« ""■-■"-« -. ...» .,«,„. bntifv..,,,! l-t ,3 ;,,'";■'« '" '"" »"^<<" ;i".v,: -^rWdW, ,1,0 lr,nL ' :i ?''"" "''™ ".ll» I ■"■'»« » e«. ,i ; rr " ■;""- "■"*. "'"-I' - to »t"•", whopra tis^iith L n'tr'" '"r''"=^^"''''"^ ^'- "- to certain wori< c^; ":; "'''"^ ' ^^'«'»»^^ ^-- of th.. d. a little leisure. Hie' \ '""'" '"^'"^ '^ave at any rate "p;v;;uheda.::;:;^::i;:::-;:-^^^ and the,r patient . fn o„e respee 1 , ""^'■''''■'' Phy.^ician is absohueiy oriinin- 1 R 1 ' ""^^^ternatio traries there is sure to be . .^[ ^" ^''''' '^^"' "^' ^'O"" crcaturo to who" ffl"' '"" '? ^^''^ ^«"'^' ^^^'^ rendered miserable b, ;,;e :L , r ;:=';;-''- li^i« a -. "» a man, tlie uiiimg-room ,1 J I 111 16 Teacher and Studnii, table in wliose house is never "elenmi," luul who would un he could "bnuldiist at live o'clock tea and dine on the followiiiij!; day." Tile otiiiT as|H>ct of nu'thixl has a deeper significnuw, liard for you to roach, not consoiinjx when attained, since it lays bare our weaivneHHCH. The pract ico of ■ .(licino is an art, l)aHed on science, Workin-,^ in science, witli stiieiicc, for Hcicncc, it has not rcaciied, pcrhapn never will, the dignity of a complete science like astronomy or cngineerin^f, with exact laws. Is there then no scieii.'c of medicine? Ych, but in parts only, .such as anatomy and physiohtgy, and the extraordinary development of these brandies during the present century has been due to (he cultivation of method, by which we have reached some dej^ree of exactness, some certainty of truth. Thus we can weigh the secretions in the balance and measure the work of the heart in foot-pounds. The deep secrets of generation have been revealed and the .sesame of evolution has given us liiiry tales of science more enchanting than the Arabian Nights entertainment. With this great increase in our knowledge of the laws governing the processes of life, lias been a corresponding, not less remarkable, advance in all that relates to life in disorder, that is, disease. The myst(!ries of heredity are less mysterious, the operating room has been twice over robbed of its terrors ; the laws of epidemics are known, and the; miracle of the threshing floor of Araunah, the Jel)usite, may be repeated in any town out of I3und)le(lom. All this change has come about by the obsei'vation of facts, by their cla.ssilication, and by the founding upon them of general laws. Einula^iug the persistence and care of Darwin we must collect facts with open-minded watchfulness, unbiassed bv crotchets or notions; fact on fact, instance on in.stance, experiment on experiment, facts which fitly joined together by some master who grasps the idea of their relation.ship may establish a general princij)le. But in the practice of medi- cine, where our strength should be lies our great weakness. Our study is man, as the subject of accidents and diseases. Were insteac tion ai this ill only HI are so of read stautly rut of And Thoroui thought tuuately you as s but all ( become I wJjat it n])on wh ology~ii not witJi principle!; fajuiliar v are made, masters h therein. tioning of a degree o; life duties. the emerge that you ar You canno the details ( nize and si mastered cc thoroughneg jS^apoleon, £ 2 Teacher and Student. ,7 ^'"•« I'uve reac.h some t ' ? ',"' [''''"''' ''' should ore o"l>- ".-o the n.a<..^;^^^', ■'::'!'-/"'<••''• art. And not stantly ,„i«]c.,| Uy tf.e ,aso wif "'^^'''vat.ons, a,,,! o„n- "'t "^'o'-o or twoox",;,-!::: ' ""■ '"'"'■'^ ^"^' '-"^^ ^he thoughtof-nmkingitthoonlvsM 1 / ■''"'■'"'''^ ^''"^ ^ ''ad you as students can hope to ot n '■"''•'^"Imn, few of •>"t all can learn its va hie now "7- '''"" " "'^"-"''^ <>f it, '-".o,ivin,exan,>h:': ^::;:; "';;-'^''^-itlM>atience ^viiat it ,neans. A knowledge u.,; T "" >'^'" ^•''^^ upon whieh our art is based -c I i ^""^;""-^«' --noes ology-not a snmttenW h„t 7 '' .T'"^' "'''' !'''>'«'- no. with all the ihets H ,t i! ' •?',"' ''"''* ae.i„ai„tance, PWuoiples l,a«ed npu ^J^ Y ^I ? '"' "'*'' ^''^ ^^^^ 'a...iliar with the metho. bv w ' "' '''''^'''''' '^^««'n« -e .nade, and in the SuXt^ ^T ", 'T'^''^^ masters have trod.lon tho.u/ T ^ "'"'"" ^''« g'-<^at *'-roin. Witha,oodi^^: i^;V"-''"'"''^. ""^^ ^'^ tioning of time you can ,^ae ' , T^ " ^'"' 'P^'''' a degree of accuracy w e t ho "' "'' "■"""^'"' ■^^''^'es ''f« duties. It n^eans .^h a ^o TV"'"^"''^'"^ ^"'- ^«"r the emergencies of lite a d of 1 1 "H '^ '^''''''' '^"^ of ti^at you are safe an, r tworti '"T"^'"' *''"'^ '-^"^^'^^'"n^ You cannot of co„r e rt" b j^^^^ ^"T >'-"• ^^>''o-n.en: the details of the variou b a 2^^ ^ "^ ""l'''«S^^ - g-sp "- and successfully treat 7Z^ Cr T' "^"^'- mastored certain p4.cinles i. !; ^"'' '^ >«" '^ave tI.oroughness-you^ il avoiJ / 7 T "'^ ^«"^«^ ^^ Napoleon, according t S.hl t '^'" '!' ^'-•'-^-•-• 2 ^ ^'^'"*' ^'"^^'> o"e day said when ; L 18 Teacher and Student. somebodv was spoken of in his presence as a charlatan "Charlatan as .nuch as you please but where is there not (.Imrhitanism '^ " Now thoroughness is the sole preventive of this widesprea.l malady, which in medicine is not met sv.th only outside of the profession. Matthew Arnold, who quotes the above from Salute lieuve, defines charlatanism as the "confusin..- or obliteratinj? the distinctions between excellent and inferior, sound and unsound or only half sound, true and untrue or onlv half true." Tlie hi-her the standard of educa- tion in a profession the less marked will be the charlatanism whereas no trreater incentive to its development can be found than in <>" "f ■'.•il.cN a,„l r,„. ,i,o .„i „/,,?■? ',""'" '■•"■ '■'•' ""'n *..„:.■ ,.u .„„ ,„.„ „n,: , i :","?:; "■- - :!■■" "-■"iy since with it comes not n»Iv n '''^ '*''' °^" sake, proper estinu.tio; f e^il:;:;!:'"'" '^"- ^''"^''' '>"^ '^'- a for it More perhaps fl.""'"""'"'''-'*^ "' «"r search doctor has a c„ • !!, ' /!^;''"\ 7/-"-'^' "-", the H-at he regards) pers^t^'LL^ ^ i' 7-"'^^?'^^^ ^« It IS too often accompanied bvn ,^J ^^ ' " "^''*' ''"* a Johnsonian wor' - t'H' I'ost trained facwltie h\V '"'"^"''''^ ^^''^^ ^^'"t'l i" the practice Ja ^f^V"""' ^ ^"''^"^^"^ "".st occur probabilities ;-^LV^vt!;' ^'^'^^'^ ^'^ •^^'--"g of -^ifakeswiHbcacLi:sc „ ;r;;::^^f-'^ a slow process of self-deceptk)n with 1, ' ' '"''''"' "^ to recognize truth you wi I , J ''"'"""'^^'^'^^'''ff '^ability lossons'which nu.y : b vo ?" "r T" "''""''^ ''^ ^^^ .And..rthesaL:;::Ln;;:- -r;fn r Fftious,the.ud:;;:.:^^::;::;^-^^^^^^^ and you will, to use the quaint Jangu. e Si ^T "'' ^"''"'''' allow one o^e for wh2t is laud^dd t ^ .''"ll^lf "^"^' l'"g and nnscemly disputes which Iriv, a ^''^ wrang- our profession arise in u groamioitv f" "' ^''■^^^™^^^^ gicat majonty of cases, on the one i| I i 1 _, I; 1 t ! ■ i i i '; i ■ i 1 ' 1; 1^. »!- t L 20 Teacher and Shident. hand, from this morbid sensitiveness to the confession of error, and on the oihor, from a lack of brotherly consideration, and a convenient forgetfiilncss of our own flulings. Take to heart the words of the son of Sirach, winged words to the sensitive souls of the sons oi' Ks(MiIai)iii~ " Admonish a friend, it may be he has not done it; and if lie have done it, that he do it no more. Admonish thy friend, it may be he hath not said it; and if he li;;ve, that lie speak if 'again. Admonish a friend, for many times it is a sland'er, and believe not /" every tale." Yes, many times it is a slander and believe not every tale. The truth that lowliness is young ambition's ladder is hard to grasp, and when accepted harder to maintain. It is so dif- ficult to be still amidst bustle, to be qui.t amidst noise; yet, " es bildet ein Talent sicli in der Stille " alone, in the calm life necessary to continuous work for a liigh purpose. The spirit abroad at present in this country is not favorable to this Teutonic view,, which galls the quick apprehension and dampens the enthusiasm of the young American. All the same, it Is true and irksome at first though the discipline may be, there will come a time when !ie very fetters in which you chafed shall be a strong defence and your chains a robe of J glory. Sitting in Lincoln Cathedral and gazing lit one of the loveliest of liuman works, as the Angel Choir has been descrilied, there arose within me, obliterating for the moment the thousand heraldries and twilight saints and dim enil)lazon- ings, a strong sense jf reverence for the minds which had con- ceived and the hands which had executed such things of beauty. What manner of men were they who could, in those (to us) dark days, build such transcendent monuuients ? What was the secret of their art ? By what s])irit were they moved ? Absorbed in thought I did not hear the beginning of the music, and then as a response to my reverie and arousing me from it, rang out clear the voice of the boy leading the anti- Teacher and Student. tl'o outward an. "n^r lirf ^'^^/•" ^^'"^ "^"t them. ^'' ''^"' «^ ^^^ >>JeaIs which animated before in the world's 1 '' ^"^'^' '"''' ^^ '''-^1^1'^"^^ weakened the nt L "of ile'T 7'^ ' ^"^^^"'^ '-« ^Jiffevenee between n^Lldt?' 8,,, ' "^ ,^^ ^^-"^' ^^leal Life, the ideal Churcl,--wl L tf ' .'"' ^^*"^^' ^^'« realize them-snch dreamTo I ^'^'^ «••« ^"^ ^ow best to -en, and who can d b TL ttl "" '" ''"'"* '^' -'-'« ^^ ^-.■s the npward ^^^^^ Z:rt:T ^'""^-^^'^ fession, have cherished «fnn,i a ^' ^°^' ^'^ » Pi'o- portray. -^ suDject, I have attempted to bound. The choice it "If ^""^ ^"'"'^ '^ indissolubly Always seelc your ^^^ " Et,!;t ^VjJ^^ ^^^^ yo^ call.ng a sordid business, regard Z r n 1 ^ '"'^ '""'''"^ many tools of trade and [f^T ^ ^^"«^^ ^^^-eaturos as so -ay be yours; bu ' ^^ W f 'T ^'"'' '^^''''■^'^ ^'-^^'^^ ^^^3^ right of a nobe ert.'e n ! ^7''''''^ ^''^y «^« birth- tbe physician s 1 Frlnd If"^ '" well-deserved title of traditions of an aXftZdu/ m ' n"' '^'^''^*^ ^'>« best band r have tried r if :;f^^^ On the other -ay reasonably cherish N„ "1 /'' l'^''^' ^^^'''^h you toxical in conirilo with th. ?-■ '^'°"^'' ^'^^^ ''' P^^a- you work, they\ ;;f ft "7 '""'^'^''^"^ '" ^''•«h l,;i^ »S f.li I I irA 22 Teacher and Student. renown, consistently followed it will at any rate give to your youth an exhilarating zml and a cheerfulness which will enable you to surmount all obstacles— to your niaturity a serene judgment of men and things, and that broad charity without which nil else is naught— to your old age that greatest of all blessings, peace of mind, a realization, maybe, of the prayer of SiKTates for beauty in the inward soul and for unity of the outer and the inner man ; a fulfilment, perhaps, of the promise of St. Bernard, "pax sine crvniine, pax sine tur- bine, pax sine rixa." )ur 'ill a ity est he 'or sr- ir;ji 11 I'KOKESSOR OK THE AM Cxx\V Tuberculous Pericarditis. BY ■-o.«=s„. , Z^„'.^^.^^S;,„^.°;- -^i^^--- ^o™., HOPKINS UNIVERSITV A Mr> „. ™ THE JOHNS HOPKINS HOSPITAL '"'"'="^'^-"*-^^H.a. THE AMERICAN JOURNAL OF THE MEnrr., iHH MEDrCAJL SCIENCES. January, 1893. • s' Irs: r i: i„:.: ii 1 '■M w ,: * I 'i K.vtr; I'/ioKi-: Tf.uci fiudiii.s. WeiC iDiK tiiherciilo relative i] Hoj)kijis Of late y, ''fiH'o, aiul tlie y^rfer M'''/ieu.s *t( i'atlio]()gi(v 'I'lie foil, "ly ohserva <'a'^k I.~ f'xiidato in i Cask 11.. exiidaie; m ami iiiediasi Ca.sk III. 'ii'>ercij]().^i,s' Ca.sk IV.' 'litis- acute i Cask V.- '■eceiit tul)ero Cask \7.- I().sis; cluMiiic Cask Vli 'iiiK'fciilo.sis • „Cask viii '"•ro-caseoiLs ( rhn^ic serum i aljscess; tiiben PL'ricanlitis. l''Stnvtv,\ r|..„„ Tl„. A iiiciicjiM ,;, ''•'' "'■""• ■\rc(lic..,l s,. ''■'"■'■S-'niiii;irv, lyr.',. ■>>mwi:wvs pi:i,,cu:i,iTis r/s. I'liiii-/:.. '!v Wll./j ■I' Ari:i.|. , '1 'f-nKiicfLosis ibJJ„ws iK.nl canliiis. Tiie nil .sonic cases anat '('(■tiiiii Is IISII, "l""i i'lieuinati\' f iilly (ivcrj,,,,), "'^'fo made "imcally. J„ i,„„) kod clii L'ver a.s a cause of tiiI)erciiJ(.iis I relative 1 ' (iH'.Mnlil 'fsion.s ill 7 oi wl.icl I'cal (ieiieral JI, aiilo t».cyniayl,c.ail.,,„,, ' "'i' |icricardii,„ ':^'''^' ^^'•'■^' :^7o eases with Hojikins H, '•■: 'y^'"nl.s af tl.e Pathol ''"'" the foil, Of I iUe V tV;'^ London include l.ut'h- The 7 ''(imivt! my ol)ser\-atioii i,, ^ '"K is a briel siini ve cases to date oiiH of the ,'"«'y of the eases which I <'asi.: r.__j, '""■"'•' '^''"'"Wphia, and I lave c 'xudate "eiiiah >altimor(. '"me luiiler 111 pericardiiii, ex IK an( Casic n.-]yia| i'ate; miji le, aL''ci i'.ired fortv-tl I mil ^reiiera 'iree ^■ ■ears ; ' med Casio Ilf.— j lasiiiial ary tiioer hv e vear.- "«'T tul)erciil.,si sixteen ounces of ,la,k fiiltercul (' ditis laih 'einah •cles on the easeous. easeoiis m peritoneimi and i'sses and fresh viil oil; As <';'s; fresli tiihcculous aj?ed thirty-ei.rl, '" '"'i^s; bronrhial •: IV.-M elite tuhercu ii't", aged sixtv-fi pericarditis, t ve irs , cl: "■""ie pulmonary Cask v.— ]\lai •I's ph'urisy; chr ""; yt'ai's; acute tiil leceiit tuhercul: aged fift Cask \'r.--M; l''"s pericar.litis y years; chr ■•""'e pulnion, •ercuL 'onic piilm iry tiiberciii )us pericai w.ia. osis lie c'lronic tiihercul li^ed i\ 'I'tv-five ve: '""ary tuberculosis' tubi ASK Vll.-Mal ous pericardit"is urs; cl lerculosis; tul Cask VlII— 3[, •ercii <-', aged f "•""ie I'ulnK.nary till >ercii- OMS o weiity-eight years; d, iiiv JJ. 'f J)leu '•'i; acute tubercul roiiic pulnionarv ■ -.ii fihro-casemis ^ilT;^'""''' ^^' ''"^^ tl'irtv-si7;;;;:;':^';"r" l^'f ^nrditis. aoscess; tubercul^ pericarditis. ""s iiifiltrat iged fifty Kui of parietal I years; tuberci' ivcr ei' ous mediastinal '" pel ard """ ; acute >'I* ii! ; /*, I il 1 1 i 1 1: ■ '1 * ^ ,iSLKK ■1 V H !•; K e' U I. O L' S 1' K l< 1 1' A li I ' IT 1 rt , Cnsk X.-M.IX S.. n«o.l torty-Hve ve..r. : l.rinmry tnl...Tul.)sis of hu^^■eh■, d.roni. tuluMTuhus iKTi.'anl.tiH. ll... nu.,nl.ni.u.s tn-.u tluee m four lines ill tliidviu'ss: lii'orirhial ^rlaii.ls cii-cou.-. Cv X .-M>.le. a^-l --"ty two vearn : .leal), h-om ,..unnn.,n.a: lK.a; hm tn.plm.l; ..cri-'anii-nn a-llHTont. jrmUly ti.Hke.R.a .iml tuillMTnliils; cll'.iru;ti!.n ol' hrouchial .^lan.i. ; no ntluT tul.erde. .n '""(''\'.'n- ""rlsK Xni.--Moses B.aKi-l Uvvnty-f mr >Tars; tnia.m.lo.is of n.e- (liaHtinaU'lamls: chronic Hil-onuilous pcncanhtis; .liiatatK.n ol iu art ; a few inl)ri(lc!^ in ]iiii<.'. , . , i „ Cv^K XIV.-Wmi. 11. T.,a^re.iiiftytw. years; .Irop.v; I.v|.ertroi, hy a„,r,lii'atation of l.cart ; elinmic ti.iHmilons pencanlitis ; til)roi veiirs. Parrot, Duckworth, Rolloton and Letulle have re- ported" cases "in infants under a year. In liraekmann's Gottingen Thesis, of (>.") eases collected from the literature 19 were iu children. It does not seem to be at all uncommon in old men, and there are two cases on record in octogenarians. Males seem more prone to the disease than females; there were only four women on my list. Tuberculous pericatdilis is due iu a majority of instaiiees to infection of the membrane from caseous mediastinal lynildi glands. The disease may be conllned to these glands and to the pericardium; thus, iu Case XI. of my series, the patient, an old man, aged seventy-two years, died of pneumonia after a short illne.ss. There was no tuberculosis of the lungs or other viscera; the pericardium was thickened, both layers adherent, and presented cheesy masses and gray nodules. The heart was enlarged, weighing seventeen ounces. The mediastinal glands were calcified, particularly the bronchial group. Case IX. is of special in- terest, showing the mode of extension from the anterior mediastinum to the pericardium. The patient, a man aged lifty years, had pulmonary tuberculosis, and died of acute tuberculous pleurisy with sero-puruleiu exudate. Upon the external layer of tho pericardium, three and a half iiie and pun and wa.' produce! fluid e.Ki 'lisea.sie o, ''•'eognize diverticui lii.s ,'34 eas the |)eric: glands of in tli(. J,s •liioles tlie acute tul)( astinul lyn i-< in a!] (>,• astinal and bronchial ^ tissue, and layers of tl faces roughi ti"ii, but pr easeoiis mas "II botii Jiiye tlie peritonei probability e tiisease. A seeoinl, ''■"III the lun ill Case XV ward F of tj, 'iii'iiia, and dj 'I'ligs and boi was stron^rly .^ a small aniomi "as smooth, a reflection, wjic ti'ated pleura, i And, lastly, be involved wit tfie serous men ■■*liowu to have 1 peritoneuin, wh 'lie peritoneum •'"-"'•^e of t,., .m..lia.tinal ly„,p 1 '""""• '^'"'^ "■"'--'•".ion of '"« J« cases in whid, (1,,. ,»..;,.,,: i ■''' ^'''"''''^ were oa^eous oth, and presented a nn ^ ,"';"'"''^ ^' "^ P-'-tal lave ;«oct.on, where it was adherent " J ^ 7'"""t- "'^ '''^ -1-'- And lastly, there are instani. i w,.^ ,^™'' ':"''"^' ^'"^-'^^e^- -"volved with thopleuruand p : .t ''"'™''f "" ^^'''-^ ''> "e serous n,end)ranes. I„ ,^J^ '.'"'" '" '^ S'^'-^nil tuherculosi. of shown to have been directlv ran! I T ""^ ^'" "^"^^--" -" e f"<>"^'""- while in other: it won ' '" ""' P^"^-«'-''i'Hn into the ) I S ; f .g* ;/ i, ' 1 i t^^^H '! 1 '!^^^^| ■1,' \ ';' 1 III 1 ^1 1 1 ^^^H |l Hi i !' ' IMAGE EVALUATION TEST TARGET (MT-3) // i< i/. ^ ^ 1.0 I.I |50 "™^™ 11:25 i 1.4 IM 1.6 <^ /. V PhotDgmphic Sciences Corporation "^ V -^\^ •17 ^^"^^ <>.\ "^T^N 23 WES1 MAIN STREET WEBSTER, N.Y 14580 (716) 872-4503 %-..*. ^'^~ r/i ^0 4 osi,Ki<: rrHKKCL'i.ors pkuicarditis. Moniiii) Anatomy.- -Tlie pietiiie is cNtrciucly varied. Pnu-tically there are two groiijis of cases: those with firm adiiesioiis between the pericardial layers, usually witii ;,'reat thickenin-j; ; and those with recent exudation, lihrinous, sero-fihrinous, henio, :-liaj^ic, or purulent. Tlie cases wilh adliesious are tiie most numerous. Of the 17 cases in my series,'-' cases, Nos. IX. and XVJI., nia\ he excluded, as in the first there was nih 'uherculniis infiltration of the ])arietal layer, and in the other an eruption of tii5 observa- ations analyzed I)y the former, in 21 there was adherent pericardium while in 12 ( f Lancereanx's 14 cases there were adhesions. IJotli hivers are, as a ruh?, uniformly thickened, and in the extreme instances it is im[iossil)!e to separate them at any point. In other case,', the ])rocess is more local, and the synechia may be limited to the front of the heart, leaving large port ions of the base and of the left auricle free. The reflection of the pericardium at the great vessels and the adjacent mediastinal tissues nuiy be uniliirmly infiltrated ami the vessels sur- rounded by a solid mass. In Case X. " the layers of the pericardium were adherent and measuiod six to ten mm. in thickness, and sh.owed m three t" ten milli- metres, the increase being due to the growth in the leaves of tubercles, the development of caseous ma.sses, and to the new growth of connect- ive tissue. Fre(|uently it can be seen that the two enormously thickened layers are united by a clear, infiltrated tissue, which may itself not present anv tubercles. In the earlier stages of this process the mem- branes are little, if at all, thickened, the tubt'rcles are seen just beneath the endothelial layer, and there may or may not be a fresh exudate of yeUowish fibrin. In other instances the contiguous surfaces of the thickened layers are covered with Hat, yellowish caseous masses, a> noted in Case II. Collections of thick cheesy ])us are occasionally found between the layers. The condition of the heart in this chronic adhesive form is most inter- esting. As is usual in adherent pericardium, particularly when the layere are very *hick, there is enlargement of the organ, which may each an extreme »'rade. In (!ase XI\^. the heart with the thiekeiii'd rei )ierieardial membranes weighed thirty-six ounces. At the tinieof deati -"- "'—.Of.. -...■.„.„,,,„ " ■' '^ J'i lis a; I'le canliac niu.sclc ;- "•^i 'nay Leseen i„ th . '; ""^'•^' ''-i'lv on^or..], an ]!. , 1 "'.^' '"■'t "e had both DltMincv . . "■^'"'■""•"i. aii,I if ,,..,. ff ■ :^'-otu hordes i„ both la vuw" " "'""'^'^ "^' '''-Iv «en n '"' ^'^-nchial „an,,. w • , '^ /'^'-'r"''"-". also ii. ,. , - '■ o.alrea.lyreforml to tho i„H '<''t-«i«le(l e.npvorna. fn k'., '-r.MiAl, HlSTOKV.— 'irH W e ii;ii care. ^'-'V'.- Latent tnhorcloas y recognize f( J>ericar(li(is our groups of oases. A considerable number :"*,'11 6 OSI.EK: TU liKKCUI.OL'S I' K MI C A R DIT I S , of all the cases ni record heloiiji iiere. Tiie disease is discovered acci- dentally in individiiids wlio Imve dieil of other affections, or of chronic ]inlnionarv tui)ereidosis. An interestiiijr illustration of tliis was Case XI., a well-nourished old man of seventy-two years, who was admitted to mv wards in the riiiladelj)liia Hospital with pneumonia, of wiiieh he died. There was no suspicion whatever that the pericardium wad involved. As already mentioned there was found an adherent, greatly thickened, tuberculous pericardium : calcification of the bronchial glands, but no tubercles in other parts of the Ixidy. In Cases VI., XII., XIII., and XIV. the disea.«e was also latent, and there was no suspici(»n of pericarditis during life. Second i/roiiji: With symptom:, of cardiac ii. sufficiency following the dilatation and hypi rtrophy conseijuent up(m chronic adhesive pericar- ditis. The clinical features are reai'y those of cardiac dropsy. 1 tiftv-two vears, admitt<>d to ward F Case XIV.— W. II. T., age. of the ,)ohns Hopkins Hospital, June 27th, l.SS!), complaining of nes liort- if breath, swelling: of the leirs. and incontinence of iirint Family history g I. Fath age, two brotliers died when youn (1 of acute pleurisy, mother of old The patient has had scarlet fever, measles, and malaria; denies syph- ilis. Has had rheumatic pains, but has never been in bed with acute rheumatism. Has used tobacco freely, alcohol in moderation. \Iv. was 11 an feet became swollen vnf rill (litifin : An emaciated man, with ilrv, harsh skin; U'l's and scrotum a'dematons: abdomen not sw illen. Fulse, 104, tens nsion in- creased ; temperature 10-J Heart: Apex beat faintly visible in the fourth interspace; palpal in the nipple line; fi^'cble. Cai'diac dulness begins as high left interspace, near sternum. To tlu' right it extends 2..j cm. beyom )le as .iccoml th- sternum th ere IS no thrill. The sounds are feeble; the se )nd u.-e is louder, more marked than the lirst. At the apex the diastolic j)a shortened — the sounds succeed each other at e.pial intervals of time the .second, at the left margin of .ste rnum, is re luplic iited. Careful exaniinatioiis of the heart on the 1st and L'd of ,Iulv sh owei as a special fi'ature the llatiiess extending into the second left interspace th le impulse was extreme Iv iv II le sounds were clear, and in tlu thiril !llll the fourth rtil interspaces (pii te loud ; the second wi;s accentuated. A lortic eartilaire the second was feeble Lungs: Clear anteriorly ; resonance defective at right ba.se. Thei'i were numerous rfiles at ba.'^e and cracking rales over the left muini nar\ reirion. Abdomen: Soft; liver and spleen normal. Urine clear; no album. n, no casts; sp. gr., lOlO. The case was regarded as one of cardiac hypertrophy nnd dilatat ion osi.KH: Ti; without valve d '^KncvLovfi ''KHICAHDIT IS. h "iirs, iiixl sal i^ease. ffo He fiiilcl rapi.ll "10 piiivos. waa I)roatl *:""!'<'y'''<'pe.i,;,„d| t'le lieart. <^i" ii'liiiission tl ahovc 99 .1 /'-/riiri C-^<-'ept on fl <(lC(i .'.''^•'•'i ti.ifture of ,|i, j-;-ne von- (ivhlc ital '« evorv f;. CI) tl lorax tlier i"ip<'i'atiiro wafi ]()■)' | ,'';.""\'->iin,Lr..friK. -„|' cyiie Stokes "t "'Kt tl,i,< Wi.l Hot risf ;•' wore extc sac was oI,li,,.,,.„^,,, I'sivo adiiesi ). I ?iirfi ace was COIlSIStill^r of fi i-vei ■ywi The 1 leart "lis on l)i)t| •"I'ltoiioiini s ciall Tl y oil (he surf I'm connectiv lere oovereil I ''W'lpied an ui 1 f'i( 'cse exudat f"e thiekc'st h lon.-i i^'f, iininoi timio and a veil averajrod 1 t'liig over tl (MIS en o caseous iii.siiallv wish-wh'it, smooth Tl III the It- pericardial ai'^'o area. Tl f?i'ay and d matt 'Pa.juc ''I", contai ii'iiir, '• 111 thickt es: '«'sy miliary tuherel i;;::':::'-'^ ^'^ Hucken;:, ;;•;::;!;;:,!'":'=- v^' '' ess over tl 10 wholt thirt witl y-six- on mottled (i 'f'the let't iices. ittv The l--a-diun, a;,d ti;:, Z^Jlt^^' ''■'^' ' le ayer, OS pe- es, ee, myocardium w; 10 l)ase of tl iirfa lioart, ventricle the OKoneration.s I tlHM.nlloftlH.jeft I'o were a I 'iioath tl .'^ pale yellowi.sii.l 10; aorta, weighed 10 end The cavities potent. Tl vontricle was LS ''"■ parietal tli '•ere dilated ; th mm.; ofti "oardinni. In i] '•mnhi. Th,. ihi^,); •i'"wn, sort. 10 a "ere a little thid, '<■ iiii^ral orifice ad 10 wall of tl,, e aortie valves sli.d.tlv.L I'lVht, ( Koiieo. Tl mi tied three fi ""Ti;;:";,;;rj''-''«"«"H;i;:„t lore were small n.re,.. 'I'l oiiod, l)ut pex "ess of ' mm. lings wei 'lit tl many gray, til„.oi,i Tl li d rr"!:'^'-^ -•' Pn t u e I lew scattere.i mil iihimic ""« 'ayors, l,i,t 110 111 cers. Tl ■wonted a f mi"y tiihen-les ew Jii the lore Were no tiil 'iio clinical t;.at made either of chronic adhesive i[ )er- 'ii-os may be th I'm "f'tiihereul SI as in the c. mitral insiifh i'SO just mpio hypcrtropl '•"(^ of cardiac d •'lis, as of i impl J,'-' von, there P'ly and dii atatii ''"psy, and a d pencnrditis, The .1 lagnosis of a '■'t'lioy when ther are no s IS at th Pocial auscult; 111 of tho I lagiiosis is loart whei "1 oases adniittcl with d tation, since under th •-""'•^''"■'ory jdivsical "fiorent jioricard .v-^piiioa, dr mm, alwavf pox a hnid 1,1 Uory sij,,) s, or of o"iii.ir murmur. T/iir,/ '/roitji ese circnmst; oxamination. opsy, and the "'"'^■'•fain, is.hMihh moos It is almost •>"is of cardiac dih, possible to inak 1111 a mi acute liibercuh ■iito tiiberciil, lions. I. "is, th( he following '■•'IS, either •sis. TJie clinical ''^ " .irood ilhist ^^oneral or with cerebr picture may be tl lat of glam Is and pnmary disease bei Poricardiuni: iig in a '■""•»" o<' an acute i„i| osjiinal manifest; prohabili h' 1" the me.l lary tiibercii- •To£^'iS!;^]{''^';'!/^:-Urodtwe„tv-fi i jviiis nu.-itjif.'ii .1.. ■- . l"»S')f strength. () " .i-'et any satisfact wing to iiiuary i'.",, ]^qq mr years, admitted to lastiiial ward F of men '"T inlorniation fn,,,, (| t-.l 'i',-''^'' oonipiainin.r of coii,ri, lal diilness anrl .,.,.,,1. '"'■ 'oiigh and **« 'i'i years, admitted to ward F of Johns Hopkins H()s|)ital, Js'ovember "), 1S.S9, con)j)laining of pain in back and head. Patient is well-nourished, not emaciated. ^'••^!-KH; 'I'l^- II •••ll; cl HKliCL'I.ors I' '•■< "'"tiior is dcn.l ; fi,,),,.,. (I tl ree week. ui,|, lu,„ia.<(iiiiilelv .Sil coil; i« iiiotlier .li,.,l tired /eeli "';r' ;"'l Imttles t.. l,i,s fev tL-mpcratiire nwe lo im "" tlie (!tli, tl Aft ii week at iaviii.r i„ ;'"i|>cratiiren.se t v«; l.a.s heen in l,e,I I, '" l)e(l /or two I lor two verv iit « I'.Af. '!'8^ If ^'"'■I'l'd, wliite, f:''»Mt dislike to I '<■ I'xaiiiiiiatioii rev( '""■'It i.s rational pulse, iilcd tlie ti.ll 'I'Hirs with i^'P!<.^«i'e iiiov( '"'i^'iic lieavih- ;"!'^ dnuvn haek, and wl '•T 'iu nai :inuii'y"'J,' tliat it s'ze and act ^f^ii't sounds iic^'ative. '« Jiaiiitnl, 'J"| '"'","" "'>'"M't is n.ad ".' "'^' '"ft side witi, tl flows a 've. Abil '>''c clear at 'icre IS n """■" 'lot swollen paralv e to move liim | 10 liead f';; P'lpils areofnie,| iKJt tender. .Si)le "' resifits, iiini *'" til" 7tli and ,S(1, ■'Pt'x and at base, j ^cii not enlai'ired^ tiie teniperat he >"■<: '-an-ed from It IP 'lote read '," "'" 'Vli, and ti clear." 7" tJie 9th and 10th tl 'fiinie iineonseioiis "iis much worse; be. 'Xaiiiinatioii of ] '' to 102^. II 'Sound.s at 'came apathetit leart was examined "|iex and ba unn^s iml)!ed ' 'ase are lie be Att I" uioningeal svni aL'^ain Muite mies the an 'IIS and l(Mrs and the disi.| larire ptoins wei'e n '.'."•''''•"tflv dilated ,., 'i.t'y distended and 'KS .secme( SllL'' pliysiolou-icjij ^,^ On tl ■ - ■ " neck. 12th, I" 11th tl Abd convergent enirorgc-d '"'K was absent, ici'c was a littl >Uli '"•'■" pi'onounced , V--^ .Pa_ss,.d involuntaril S'r:";i;."^::^!'-''"piis ^'i'lint in left eve; tl -■ tlie retinal v "<' swelling of 'the dii but tl ■eiiH tie omen reti K-">d deal of rigi.lit Tl Tl -'-'■ ^-tht;:ok\E!':!;:';;!:^''^ -•--■'' -'^ le case wa.s i "■'•" werenoii,uiM ■"h'arded place on the nior as one of , ning of tlu '"''V'-zCbv D u^.;:'?'^^'r'''''"te„t neck and' "1 inediast h: AVelcl r:;:^'!h ''r'''-''>'y tuberci Abst 10 land I. ^'"••""t to the pericard 'ly .just beneath il "''"" r"largese (■• ge. and .■lands '^ verv lai On at; root of 'g" caseous c was clo.selv ad- ^vere full of „|j| "111 was ji , and between tl '"^ fi^'HMron, two"t. '"It ventriel weiir ''''■^■'"-- The two lave '^'^ ;'""" ^^"^ ^''^^'klv stud Jiass of partlv P"ricardiiini ) fourteen mill caseous "ere adi larv led partly gelati icrent, Th >inineje was a «n>nli • "nuecre.- ■l'"d.^42.n;;n,:.J"";.l', ™^''^\'il'"d wltl ie;'iiu.sclesul)stan Ventricle. 14 ■famines. Tl 'i"ii. ; of riirlit T'^^: i'l thiek,;ess. O lungs j)resented tl I'licath the pL, f 'lie dia|)hrag 'eiira. Tl niinierou mm. V'al I cheesv fc was fin 'lous look, 'ver the pus. The I lieart s 1 ''''"i?ulai ""':" were no tuberci \'cs were ik ii'eas of I iruial. Wall of left "'. "xtending from tl es. On tl '"iiiorrhage, ehieH '" pleural siirfa ».:iS;.ri,;:1-T "''-l™' •;:;:. !;;*:;r';;™ ™ ii? .^*'^;; 'uhercul siiecial cliam "lis meningitis, '£" ■-' 'f' »ni p;;:;,s :es in livi "iirth til he iij), tl ff'-oi: C'ases witl . , spleen, "- typical jiicture of lie most i '1 s "'P'"'tant in „,„„ ynptonis of acute tii»n of pericarditis is acute and sero-h'brinous, h ace y respects, iiK-Iud pericardit IS. TI Ins >nij)anied with les eases in which 'eiiiorrhagic, or purulent cl more or less exuda- laracter. Hen ■M i !#' 10 O.SLEH: Tl'BEIU'fLOUS I' K R I C A RDITIS. too, tlio procesH may l)c latent, as in Case VII., a young man ngetl twenty-eight years, wlio died under my care, of litenioptysia. There was chronic tiilicrculosis of hotli lungs with extensive pleural adhesions. "Tin; layers of tile pericardium were united by soft adhesions, which could be readily torn through. On each membrane were innumerable small granulations, and here and there a nodular tubercle fnun one to two millimetres in diameter." This case is of special interest, as it shows the first stages of the process which ultimately causes enormous thick- ening of the pericardial niend)ranes with universal adhesions. The tubercles, when small, nuiy be readily overlooked. Acute plastic i)cri- carditis in chronic tuberculosis is not, however, always due to the erup- tion of miliary tubercles. In two recent autopsies on patients with ciironic pulmonary tuberculosis dying in my wards there was siin|)le ])ericarditis witiiout a trace of tubercles, and with little or no exudation. The following case, whicli was admitted to ward E under the care of Dr. Thayer in my absence, illustrates the mode of onset and the clinical features of a tuberculous pericarditis which came on in a strong, well- developed, muscular man, and proved fatal within three weeks: Case XV. — John P., aged thirty-eight years, admitted August 18th, with swelling of the legs and dys|)n(ea. The family history is good. He has been, as a rule, healthy, though in his childhood and youth he had many of the infectious disea.ses. He has been a moderate drinker. He denies syphilis. The present illness began about two weeks ago with pain in the left .shoulder and about tlic heart. Feet l)egan to swell ten days ago, and he has had cough and shortness of breath for about the same length of time. He has had no nausea; his appetite has been fairly good. Witliin the |)ast 'ew days he has become much worse. On admission the patient had intense orthopna-a ; pulse 1,30, but moderately full. He had a distressing cough, with clear watery expec- toration. There was great (cdema of the lower extremities and of the scrotum. The finger-ti[]s and mucous mend)ranes were bluish in color. In the examination of the heart at the time no murmur could i)e detected, i)ut the second sound was accentuated at the pulmonary cartilage. On the following morning the patient was rpiiot; respirations 28 to the minute; pulse 84, the beats irregular both in rhythm and force, the Volume fair, and tension not iliniinished. Thorax apparently .symmetrical, but the manubrium very prominent, expansion e(|ual. In front, resonance on both sides good, though on the left side flatness begins at the fifth rib midway between the nipple and axillary line, and the dulness seems here to be somewhat movable. There are numerous sibilant and sonorous rales to be heard in fnmt. Passing down the left side and into the axilla, the breath-sounds become more feeble and fine moist rales are heard. Pitch of res(mance at the extreme left base is higher than at the right, and the vocal resonance is somewhat diminished. On auscultation there arc numerous coarse and medium fine rales to be heard at both bases. At the cxircme left base the respiratory mur- mur is almost absent. Ffea It: I OSI,Kt{: TV oint of nmxi "ERCUI,()f.s I'E HICA H DITIS. n T'' ''-vi-K ..vj; .rwi;;r '":'::""^;^ ''''««'"'^ "> i.H.i 111 pi'oniinei "»ve at .socnd ril, „n,| 'euli„|,. praTonlial lizc s;=;l; i;;rr'■;li^•r^"''• irr:::^r:''"^"'<'H.i.tor;i "•■™; I'flativ.. ,i,ii„,i' 'i* point (lu-ro is ,1 't' Jiinc'tK.ii of tl 'I' >t<'rniiiii. 'i'l "*'^s extends oiitwiir.l llllli-.«,s '*' inaniihiii ic ni iiiKJ to 11 "vei; a very ]i„,i„,| J'oint nearly .3 c "1. outside Cm I HI' r. "• "i.il ,„■«;,. F. ,.-,,„„,., U'l. tlie nipple. (Chart I ) Tl i - "" p-i^mion in uu. u^s.;;; -«,-•« -1-1 in-;,:;;;; :z lie examination „1' tl j ■ 1 w ' '^'' = *''"•'''« no traclie',] yei nv-colored, „eid. ::^' 1 ""' ;;'f "« ^^ "ej^ative. K '"^ ''Valine casts were found ^ %, -"^'/''^''''ct trace of allnim n remained in nn,.-j/,i ;.. ^'"".'.'-:l'»"t the 20f.h """""" rise in ;'h m nuieh t! teniperatu le isanie condition. On tl t,> 1AA rn . '-'" tl ■ind I'lst ti eliaracter; at ;•« to K)0.5°; the pul le L'lM th iii'ine is several 'e patient noon was slow pu se varied ^reatl ere was a sliidit •-egular, and full, from 70 to 90 .y ni rate and I'er minute, I 12 OSI.KH: TC liKIU'LLorrt I' K K 10 A R 1) 1 T I S. iiiid iiuaiii was as lapiii as 1 l<'. The patii'iil, in riiaiiv ri's|)i'cts, was hi'ltcr. Till' u'di'iiia of till' li';:s had disa|i|ii'are(l. Tlu' iiriiii' had iiii'ri'ascd in t|uuiili'y. Mil till' lilih only \W e.c.aud on the 'Jntli ;}5(l cc. had lii'uii |ia*»i'd. On tlir '_'lst and li2d the amounts wvxv 7iH) und 1100 c.c^ 2!{(/. Till' ti'iuj" liitiin' has Ihtii lu'twii'ii 07 ' and iW^ ; at tlu' nioriiiii;,' visit llif |iiilsi' was 1 l.s, ri':.ailar in fori't- and rliytlini ; llii' rc'S|iirations .'>'2. Tilt' |iatiriit was lyiiii.' ijiiii'lly on li't't side. Tlie jiliysical siiriis |iiai'li('aliy those iioleil above with the exeeptioii that there is an exten- sion of the n'deiiiii at the bases of tli'j liiny. The patient died suddenly at 4.;)0 I'.M. tii-day. Aittit/i.sinhy Hr. FlexiieiM. Lar iKin '■■ XVI.-K. 11 'W'l tl coniHamin. of pain ami mv.i'i iioi.j. WKinaii, Mini S, l)r(itl Tl .IIL'I "'A "1 tlie al)(| I'kins H,.s,,i(al, Julv'l la '■ iift Cllllld |„ KTs and four Nisi ers I '"'i'";'''' '!•<• iiiniilv I •iiiicn, s\vidlin.r",,f ,| •'olori'd ; w feet. 't' pill It'll t i.s ''"'gf- Ha,sJiad 1 Jiiarritd w '\''"K mid w,.|r. iiMiorv i.s d. S|,(. I Ills tUu " "1111111(1 Woman \ui^ l>...i . "!- 'his liad t„o (,i,ii,| '■('11, on Cm f iiiiscar- )ofii,j„,loi(.ir„|ar until I J*. I'll 11 ,,,v:, '■'■ i'"Iat illv;l. 'WO months apo. Since el.il,?i, i i ■ " 'i'«lit, but no ex])ectorati()n. Ou 14 t)Sl,Kl;: TC IIKIUT l.ol'S I'K nil' A It KIT.'S. iulniisjtidii.tlu' note inadi' liv Or. Tliiivt r wii.-i as follows: liiill itT fpart'ly iioiirisjifi! Wdiiuiii : ilorsai ilt'ciiiiitii;*; lips and niiicoiis iiii'iiiltraiicH sonu wiiat jialf; toiiiriic sli;;litly coated; roipiralioiiH ;;() per niiiiiilc; nul.^ H(4, rt'miiar in I'ircc ami rliylliin, li'iision not incicasi i| ; ti itiiicratiir on ailiiii.oio II !tS iOxnansiori ciiiimI on Imtli .sides ot'llic ili ora\. I clear. On aiisculialinn the (tnly almorinal sij^ns are ti during' ins|iiration at l>o||i apices. Heart: There is sliidit lieavin'' in tlii eiciission everywhere ni! moist rales le eanliac urea; I he point ol luaxi- inutn impulse is hard to ijitermine. The area of cardiac diil iicss, as indi- cated on <'li;irt II., I)e;;ins alxait the second rih and extemls far t till' ri^iit of the sit'rnnni. I'lat ne; ';,'ins at the third. TI outline of the ana as iniiicated is triati;.qilar, and it e.\tend.s to the I..., far down into the seventh interspace. Thio flatness in tlie cardiac re^jion ic ;,'eneral ■ft. is di.-tinetly inovai>lt On aiiscniliition the sounds are tcehic at li le apex, liecome louder in the fourth and liftii interspaces, and are still more distinct ;it tiie hase, where the second aortic sound is accentmited. Aliiloniin: The aiidomen is full, i.'eiierally tympanitic, and the walls are a little tense. Tiic liver tlatncvs l.eirin's at the seventli rilt in the nipple line, and extends live finjrers' lireadth helow tiie costal mar-rin. The I'd;.'!' is not distinctly pa!pai)le. "^ The spleen is not paljialili T lere IS now no s well •wolleii four davf of the lej:s, luit slio states that thev were 'J'l le urine was cloudy, acid, sp. ^'r. I0I2; sli-ht trace of al suL'ar, numerous leiik ICVtC! luiiiin, no Diiriiijr the first ten days in hospii;il the patient improved. Tl peratiire chart shows a L'reat incL'uhirilv. Tl lis or its.,") , .,11,1 ill ilu. afteri n. hetueei le teiii- le luoriiini; rciiister was at to 1(»1 sometimes in; A I 1 tour ami six o clocl risiiH I ice-l)a;,' was placed iiver the heart and she \va.s <,'iven stimulants. For the second ten davs, from .Inly 'JDth t,, Vugiist f»th, there wa.s distinct improvement; the temperature wa.s lower and only once reached |I)2\ On AiiLrusf 1st it .f dill mid sternal Hik was iiuted that the ai ness was diminished, and there was a fricti ■iih heard in tl eii tl svmT.roiioiis. I lowever, wi th tl le ciinliiic movements. Oii the .id it was note.l that tliei cspiratory, not with marked ruhliiivir friction jieard in the second and third left iiit and hoard as far out as the nipple line and over the st V. was a we I ersnace,' eriiiim adiacfiil to these spaces. This was the first lime since her admission that t'liei a well-marked frictioi 1 soiimi 1i pulse lias lieeii very variahle, raniniit: Irom US to 1 !•_'. The patient is hri-hU'r and seems to lie impr Between .\ut .Sih and •_'i)th the irrel«' » 1.. . . .. t • ■ ' |H'<'t tl iMiicanliiil Hiivv tilt' ca.s.. ilail lull. iiiiiriiHir, "tti todav "lis as ( *'iii|H'raMnv in t| "HOWS ; Tl "-• inlfriiiittci It I VI ;;;rr! ^v '^■■i-.*.,";;!:, ,; , :,™::;'s= '■:■« .".o... ,■;:, "lore nipid, ( ahdvc l();j., '';;:!:::;^'">:7'-:'-"- ti...... i., ; "'7;^/;v,.r.lK. t;.,u.,i, andlifil Tl If imlsc has 1 'Oi I ('(IS l'''nissi,.n til,. (latMcssd tal ciirlil "•'•'"' ^"""l:f';'"l.- I.cy(in.| til.. n>l,'t | '•|'<'\ aiv (;.,.| "iiiriiiiir wliicl, I l»''< IKit I t'r iiC the st' 'iJ,'<"^(iii the ri-lit sid •Mind tliciv is |„.ard | "?^"' "'"'' a!"'''"""' nil. i '•■ •><(iuiids at' til t'niiiiii. Tl lit patient I'liddcardia! i "•••"IIK'W llKilT disti "■'•« H sliirlit iKTicardial ( niirniiir is | '"•' toward tl liiit !l <'"iii|ilaiiicd (Jii ad V'lnl. Of lato ,1, u' fiisif: I'li'lKih I'lC IS I iiiiswidii has I (' Cd ••^"iiiruliat |,i;r|i(.r || '" •'>:|"ct(initi(iii. Tl toward tl r,W K' iixilli an at the ri,r|,( •('('(line II 'L' |)('iciis>iiiii I "1111 caiiilaT, ".^''' <•'■ wliicl, il, • sdiiicwliat till and ""■n iimre tnniM •' at the left I lul ";;'tl.:|tli liases. Tlic alid Hilar M! Iireall I'aiii III it On llie l;;i| (•liiiraeter. TIht "ny H /eelil eS(>|ii(. m^v is """■" '^ " I'ttio till! and si er, and e arc iiiiiiii.n,ii.s «lii('li did tli( I I a small ic Cd iiiph Ills d( iidi '|iiiiiililv uf 111 iicd |iiini '•'''"!^'''':-■'■'<•^^eill^l^::!,n':;!;'''^"•''^ '''''-•'-! W( atiiiie •■ver^lias persisted, she h, ' nis (III .Viiyiist «||| si 'Vlit; tl '■'""■•''"•"■•< tinie.altl ^h '•nridllsly CMdM.oh, ,,,,,„, j, l-'!th, 114 '^I'liltlnh natidii the not I "» llio 2!)th, 10!) IKiiind ir •e wa I'oiind '"; ".••'-''fac t tl 'loliie on .Sejil einlicr IS with cll iniprdviiin-. I) ^Idll, layer, and the ea l:'''"'"f '"xl I'een niidcr tl sill'jcct (if nriii:,r (|n '"' "'a'li he le/t / so was reu-arded le can or mv time '"■ Ills vacati, >s one i)f pericar- St rated tl in several vei-y careful '^' 'ondiiidi, td Ih l"t'"'l.v the pidl,..,|,| 'o wiis under t'xamiiiatidiii J^raduat in sh *-' seemed to !i, ela.ss of '">■ «;"•*-• i made her tl - "'Ill rejH^ate.llv d i^'ver and tl Ih^ po.«.«ihil 1*' marked iiiv <: '•'•''-e of fhe tronlile. ' Tl le enioii- eiis.sed "> dlth divement of the | ^ existence of tnl lerciil (ISIS. W ,'.ns of the wall of the left ventricle is .'! cm., nearly one-half of which is the thickened pericardium. At the root of the aorta are masses of caseous glands, adheieiit to the pericardium. The weight of the heart with the thickened sac was 1 110 irrammes. The chambers wer<' dilateil. There was no valvular disease. The lungs were voliimiiious, contained many sciittered and conirlom- erate tubercles, many of which were just beneath the pleura. There was diffuse bronchitis, but there were no cavities. The ijronchial inlands were caseous. Li'-er, spleen, and kidney contained tubercK.: ; tliose in the spleen were large and caseous. There were a few small tiilierculous ulcers in the small iutivtines. The mesenteric glands and the glands about the pancreas were caseous Dr.\(;xos[s. — The diagnosis of tuberculous pericarditis is extremely uncertain. In the large group of cases in which the membranes are thickened and united, 'the dillicnlties are those which pertain to the recognition of adherent pericardium, dilliculties which are enormouslv enhanced by tlie state of cardiac insufficiency with which these ca.-es usually come under observation fir the first time. In children with a history of repeated attacks of rheumatism, the bulging pra'cordinni, sys- tolic retraction at the apex, the fixation of the upper liiuit of cardiac duiness, and the diastolic rebound, speak for adherent pericardiiiin ; and if in a case of this snri there has been no history of rheuniatisin, and if, on the olln;r hand, there are indications el.sewhere of tuberciilosi.^. a probable iliagiiosis may be made, in the ca.scs which set in as acute pericarditis, unless there are evidences of tuberculosis in other jiarts, as, tor instance, in the left pKiira or in the peritoneum, or there iire .'^i"■ns "f 'ocal disease in ,|,, |„„ "poctoration, the d .'UHi liilHTcle hacilli I, '■''"It in tiil.ercul cente8i8bepo,.f!,rMu,|"'i I'lvor of tnherciil, '»«"'>.si.s ..an nirelv i lie ous a.s ill i-j H! iiiailc. Tl; "'^■'-^ 1)0011 foiiii.l ix'iiiiiiiti l"-^'-^^'"^'«"ral.l.„„lye.vur()hahe tl,.,. ;.. ,, ' '"'vo hu'ii /;n,i)d 11 XVI 'I' OI.|Jr.s> is ;,| .'■';'. '■" the onlinary f '" '"y «'i-ie.s, the d ore '"t '" Hie acute ^^'« "«;■•■ .... eriteria. th cases with >ur„,s i„ tJ,^> J lUS 111- •0, as in "">' niav, as '■■' not iM.|,n,|,al,|e ,| ''t'l"'oce8sis(„|„,,,,„, oils. ini'etely. I ossi ihly 'I >^iiiiihir })i ■()('('; some (,f tl «''^' instances oHieale.! tul: 'c oases of 111 tile |),.,. ••" luliercnh ^is of '" -'I'l iileroulosis. The el 'i"i|>le adi 'toneiim, ret Jtori- •over 'ii'onie adI '"■'■''lit pericardi com- iim -S-:;r:;:;r";i-5'S:::7:;;;:-:~:;;; ' :"'"""^''^'"- '■" "I'i.'li he dete,.,e ' '""' " '"•"^•"■"•'"lor o.i a c ■ "' ''"-^"'lliointicnt' t-- , '"'"I'oncanlial ruh FT. .'* ^ ^'^ '''""'"' '^ 'iionds. hut aimrove,) M "''"' ""thin- "' ;""oauayto.e,h..r. ' ( )h 1,,', '''"■-""*''•'' "vatment ...id -".5;';:;^;:;;;:;;r'r-!-';:n: ""«'"fl'"l.i.l.it.inPhiladel "•^".vofthecohlof (I I'liiii, of iisin.r J 10 ice hat oiler" oil.lh ■"liiiiis eom- aiid in sueh '■"IimIi which ! i n'l 18 OS sLEH: rrHKHcrLors i- kiuoa u ditis. tlic wairr tlnwi'il .■niitiiiMoiiMy, am! il ('"iild l)c arraiiLTfil t" liavc any tciii|K'nitiirr lliiiiiiilit tii'cossary. Asccniiil iii(liralii>n lu«Ms jntn] in tulinviildiis as in otluT lornis of pcricardilis -wli-n llic dl'iisi varlu's a ivrtain irradc and the pnlse is in'i'i;-iilai' and t\'r\>\r. tlic ri.l.n' licc(iniin,L' I'Uil, tlic rospiralions luirricd, |iara(rntc.-is slmnld lu' pt'i'loriuvd. or, if necfssiiry, tin.' sac fivuly inci.si'd anil drained. V aiiv ■ii:s (il ilsc is rricil, icifsc'il OF THE MEDICAL SCIENCES. MONTHLY, $4.00 rJER ANNUM. WITH 1892 The Ambrican Journal ok the Medical Scibnceb enters upon iu sevent third year, still the leader of American medical magcusiaes. In its long career it ) , developed to perffction the features of usefulness in its department of literature, a 1 presents them in unrivalled attractiveness. It is the medium chosen by the leading mii , of, the profession on both sides of th^ Atlantic for the presentation of elabmate Original Atticl. ; its Reviews are noted for discernment and absolute candor, and its Classified Summaries; ,f Progress each month present an epitome of medical advances gleaned by specialists in tie various departments. According to unquestionable authority, " It contains many original pajris of the highest value; nearly all the real criticisms and reviews which we possess, and sili carifolly prepared summaries of the progress of medical science and notices of foreign works ihu from this file alone, were all other publications of the prc^ts for the last fifty years destroyed, it would be possible to reproduce the great majority of the real contributions of the world to medical science during that period." [_^ ^pi]e Medico I N^^s- WEEKLY, $4.00 PJES ANNUM. THE practical value of The News is proved by its continually increasing subscription list. Every method of conveying serviceable information is utilized. Leading writers, teaclieis, and practitioners furnish original articles, clinical lectures, and brief pi^ctical notes; hospiwl physicians and surgeons detail the latest approved methods developed under ilieir enormous opportunities; progress is gleaned from the best journals of all civilized nations; a special department is assigned io important abstracts requiring ample space for adequate preseuta. tion; able edit- a 1 writers deal with important questions of the day; medical lituratuie is impartially revievd; society proceedings are represented by the pith alone; correspori deuce is Kceived from medical men in position to know all occurrences of medical importance in the districts surrounding important medical centres, and matters of interest are grouped under news items. The News, in short, is a crisp medical newspaper, a necessity to every practitioner. Its sphere is different from and complementary to that of the ideal in<:dical magazine, The American Journal. To lead every reader of either to prove for himself the value of the two combined, the commutation rate has been fixed at the rate of #7.50 per annum. The Year- Book of Treatment for 1892 Gives a classified summary ami review of the r-sal advances In treatment made during 1S91, inall departments of the science of medicine. Price #1.50; or in combination with either or hoih the above journals, 75 cents, /ieoify early in 1892. The Medical News Visiting List for 1892 Published in four styles : Weekly, dated, for 30 patients; Monthly, undated, for l2o patients per| month i Perpetual, undated, for 30 patients weekly per year ; Perpeiaal, for 60 patient a cekiH per year. The iir.st three styles contain 32 pages of important data, and 176 pages ol 'ssortedj biabics; tne oo-paiient peipetuai corsisis of ajG pages of biaiika. TtiKc, vuMt, jfT.i^. ' Original ArticK ; ed Summaries jf specialists in tiie ny original papt'is OBsess, and such foreigi\ works that 'ears destroyed, it ! world to medical liV W.M. USLKR, M.IJ., U"'v.,.s,t3, and •■hy.e,a„-i„.Chii; "" J<'1"'« HopllK AkCHlVES OF PlC.IATKICS, I'V-bruary, 1893. •s. Nkw Vcikk: M.J. ROONRY, I'KINTKH AM, Vuu 114-120 \V, 30th St. ; subscription list, J writers, teachers, f practical notes; sped under their vilized nations; a idequate presoata- dicnl literature is correspor, deuce is mportance in the lUped under news tvery practitioner. 1 magazine, The ! value of the two 92 luring tSi;!, inali either or Imih the 392 r lao patients perl o patient ivcekifl pages of t'ssortedj m, VisniN'i LisiJ 9Jf STRfST. Pr( of pal uni or the hyi stai the or t: deat habi earh' obsti circu with an o]: short a gut vvitJiii A : I'hilac Hug-hi early i more i ally er after t rectal i In his t-'onstip went ni lie was or vomi ON DILATATION OF rur. iUN OF THE COLON IN YOPvr CHlLDRExV* ^OL.\G - -I'lpKins University, ni„| i>i, • H"Pl<.n. Hosp„..,l, ,ia|,i,n„,e, Md. ''>^"^'»"-"-L-hief. Johns s^£ii"^'^-"^itli!^;^i:^:;,:^j'- cco,, by no pat o,; T,f '^°'^"ionIy associated wftlf i'"'""-' P^^'^^'s or of tl,e s^-.'^o 'f ^^'«". either ofth e'S,,? h f.'*!''^ °f there are welvc .w''"''^' ^''"'^ '" the u e '" ?^'^'' earliest takty. "1," t"";'""', " ^ "hk ev""?„'r if'" ^'t.'n-s.+ liie patient- nk "^^ jh r660 by Dr W ir early infancy with Z 'i.nt ^' '^^''^''''^^' ^vas\ro ubkd n eUal injections seemed ra h ,r?. "°'^"^''i^- "ot hard. The or vomiti^'^^lCe'r:"''^' '^'^ ^^'^'-^ ^va.s " eJe 'arfr'"'' -rrr-^ ^ ililf^^^seemed to do but in ^ P^'" -<>,-.'ca! Society, vol. xiii. if Osi.KR: Dilatation of the Colon in Yoniig Children. stroiiy purj^ativci alone sc first seen cinctl to be clTectual. W'lien enlarLTcd, cvct-\ b>- Dr. Hu^^hcs, tlie belly was enormously wliere txmpanitic, and showed tlirough the thin walls' -reatly" distemled coils with waves pf peristalsis.. The' chiUl died in an attack of acute colitis. The autopsy showed nothin^^ remarkable except the colon, which pints of water h was enormously dilated and held fourteen atest dilatation was in the neigh- Tl le trre ur inches borhood of the sigmoid flexure, where it was fo in diameter. The muscular walls were enormously h\i)ertrophied and increased in thickness towards the anus. T lere we re a few shallow, rounded ulcers, and about the middle of the transverse colon a large area of recent inflammation. In this case the excessive dilatation was definitely associated with constipation, and Dr. Hughes was of the opinion that ine continued use of large enemata had aggravated the tendency to distention of tlie intestine. One can rcadil\- understand dilatation and hypertrophy of the colon being graduall\- induced in consequence of protracted constipation, but there are instances in which apparently from the earliest period of life the large bowel is inert and in which there would appear to be a tendency to dilatation without any protracted impaction of i.xicc^,. The following cases are of interest in this connection : Case I. — John T. W., colored, aged ten. was ad- mitted to Ward F of the Johns Hopkins Hospital Feb. 17, 1892, complaining of a swollen and painful abdomen. The boy was brought to the hospital by his relatives, who live outside the city, and as they were not seen b\- the attending ph\'sician. no his- tory could be obtained. It is stated, however, that he had, for many \'ears, trouble with his bowels, and had al'vays had a large, prominent abdomen. Present condition: Sparel\- built, somewhat emaciated lad, weighing only fort}--seven-and-a-half pounds ; lips and mucous membranes of good color. The ends of the bones are not enlarged, and he is not bow-legged. He is able to walk about, but the abdomen looks distended and large. There is no fever ; the pulse is quiet. When stripped the contrast between the distended paunch and the emaciated thin .'imbs is very striking. (See Fig. from photograph.) The thorax is symmetrical. and the lower zone is much distended by the enlarged abdomen. The ribs are a little beaded. The back shows several reddish, superficial ,4 Osi.KR: ^'I'^f'^tionoft/u'Colonin Y, '"'"IX C/iildn scars, wlicrc the cJiiu pulse cannot be Jis- tinctly localized, but is apparently, under the f'j li nbanda little in- £l;'^' the nipple line. j'lo sounds are clear' the secoiul a little ac- centuated. 'J- he ex- amination of the kuH^s 's negative. "" The abdomen is greatly distended measuring sixty-tliree cm- just above the "aval It is uniform- on palpation ten.se,' painless, and no tumo.' masses can be felt. i'ercussion gives every- where a tympanitic "oe. The spleen is no palpable, and the splenic dulness is masked by the t^-m- Pany. The edge of the ''^j'' cannot be felt and dulness is obliter- ated m the middle Parasternnl and nipple Tlie urine was nor- mal. Nothing very de- ^f Tu determined ^f^^'t^boutthe nature °\ the lad's illness. jJiere was certainly "^■'ther ascites nor tiimor. and the sucr. gestion that it might be tabes mesenterica was negatived. The ch.ld was kept in bed and given a good diet Ti. a J'^^-^P-tal he had an ordTnarv mn ■■'' ''^"^' ^^cond day in ""t specially constipated ' "'^^^'^^nt from the howds" 4 Osi.l'.K: Pilatatio)! of the Colon in Yoiiti}:^ Childrin ( 'n tlic J2il, lie had iliarrlui-a, six lar^e liquid niovc- mciits. Oil tlic 23d and 24tli tlieic was only one niovc- mentoncacli day, and then for three daj's he was consti- pate'l. Repeated examinations showed practically tiie same coiulitinn; enormous abdominal distension without any obvious cause. Me complained of" no pain, and we very soon let him yo about the ward. At intervals he would be constipateil, but this was readily relieved b>- a dose of castor oil, and never durin^^ the months of h'ebru- ar)' antl March ilid he go for more than two ila\s without a movement. On several occasions he had, even with- out Ciistor oil, loose fluid motions. All this time he had no fever, and was up andabout the ward, and gained four |)ouiids in weiglit. On tile night of the 23d, the patietit had four loose lluiil movements, and complained of abdominal pain. On the morning of the 24th, lie vomited several times, and the abdomen seemed more distended, and the contrac- tions of the intestinal coils were verj' plainh- to be seen. On the night of the 24th, he was given several large injections which brought away formed masses of f;eces. The abdomen measured in its largest area, seventy-four cm.; was t\'mpanitic throughout; not verj' tender on pressure. The individual coils during peristalsis standout very plainly. The outline of the colorfcoultlbe distinctly seen, extending obliquely from the left lumbar region to the tip of the xiphoid cartilage. The examination exter- nally and per rectum could determine no tumor. No flatus cou'id be obtained with the rectal tube passed high up, but relief was obtained by introducing the tabe far up ami irrigating the bowel thoroughly, and with thisa large t|uantit\- of fluid came away. The distention persisted throughout the 25th and 26th and 27th ; the vomiting, however, was less, and the injections gave relief. The tenderness was less, and the (iistention of the abdomen was not so marked, being only sixty-nine-and-one-half cm. on the morning of the 27tli. He was very much better the next day, but on the 29th he developed facial erysipelas, and was transferred to tlie infectious ward. Here the erysipelas ran a regular course, with very moderate and irregular fever, which persisted with inter- missions until the lOth. When in the isolating ward the abdomen w.is not so distended; he had several attacks of constipation, but the bowels were readily moved by laxatives. During this time he had also several attacks in which there was great pain in the abdomen with in- 5 '''J^lome.i was very lart . m '"'"'"•" ''-■t^rn to Ward F the °[ pan, and vomiting, 'u no t , ''^' l"^^''*'' ''"''^'^•^ !^ttacl<.s was the material 1 ron h V" '"^'^'-^ vomiting ^'•^Tuu-e ahvay.s reiiev J .^^^^^ '" character were given uitl/ tl e hh^' j -'Z^' '"^^'' -'"cmata. uhich '"-,-' '" as possible £,;^',^-'';-'..a"cl l<^tting a^ i"i- increased freciuenrv f m ^ ^ ""^^ '^'<^t- vomiting made me fee tint u T? u'''''^^-'^'" °f Pain and an c.vploratory operu on , '"'' ^^ ''^'v'sable to have -''^■tl.er therc^vL "' ;f 't^ '" cietern^ine definitd; dul not seem possible tntlH.- ^ '^^ /••"^''^'-■. though it a/ the fluids'passe I o fr ;rr'°''^''^'^'''>' ''bstruclio, Accordingly he wnl , '"^ely from the siphon svrin.r, -nt on If^Hl'^l^ra rU "'rir ,''" f '^■-' 'CS: nal section. The follouJn^' • '''■'^'^^' Performed abdomi- f-mthesurgicar/r^S^:^ " '''" '''''^''' "^ the not s Lender ether a Ion • •'• line extending Vrom a Hulebelor.r'^'" I" '^'^ "^'-^^•'■''^n to a little above the pnbe VVh n J' '^"^°'™ ^'-""tilage P etedan enormouslv e„?i,.,,H'^" '^'^^ 'ncisionvvas coni- abdominal walls. The S, " ^ '' ''' °"^ ^'P"" the tJie greatest at the sW; n ^"^ ^^■•■'^ enlarged. ^It was mentwas c.xactly fo/tVfiTe ?f,f "'-^V^ ''^re the measure- C;x-cum was abont ha f\his si '",'-'';:^"niference. The ^'vely increased in c^-L'eer in ;'n' '^'' l""'"'^ P'^^^^ and descending port "is T '1'^^^^nding, transverse -..sted on itself. Ct Z\o alto ."^'"°''^ '^^■^'^"■^ ^V' ' puruig the operation the re?,, ° '''"'^ ^">' obstruction, necl by Dr. Osier, whose fin eTl^onl I '^'■^"gl^'y -^am- tho hand of the operator ami n.^"'^''^''''>' '"'-''t by determmed anj'where A mod . '^^'•."'^ture could be existed in the rectum nof- '"^^'^''-ite sized f;ecal mass tl>'-^ the tube was pa?sei Vut Se'?'-;''"^; ''''^ ---"-v^^o emno- itself through his fe^''^^^"^^' ^olon did not normal in size and appea^^^nJ T*"" 'ntestines were ■ntest.nes were wrapped in "'-,' '""'' "'^'■'>' ^'"Pty- The Padced around the i^S.'on ™ ^'"'^- ^^^^'^'' ^''-^^ also opening uri;'oweTarth:^;;tft '° "'''•'^''^" -^'fi--'^' anus moid flexure. A very hrT '""°"""^"t Pa-^t of the sie-' ^-cal matter esfap^ed^J^f ^„,f -^;;y -' yellowish fli^l ^as. The muscular coats of fr ObLift : riirnfatioit of the Colon in Young Children. the bouol were \ci iiuicli thickened ; the mucous mem- brane seem».Hl normal. Tlie hoy diil remarkably well ami was sitting up in a chair on April J9th. His a|)petitc anil general condition improved ; he f,Mined in weiglit, and he had no further abdominal sj-mptoins whatever. There was no tympa- nites, and he passed the fiuces throuj^h the artificial anus. Unfortunatel}-, we have not been able to obtain any account of the first years of this child's life, further than that he had always had a prominent abdomen, ami had trouble with the bowels. It may be, of course, that the enormous distention present when he came under our observation was only the sequence of protracted consti- pation, but as mentioned in the history, there was not at •ly time during his stay in the hospital impaction of fiicces, and the attacks of distention, colic and vomiting were, as a rule, readily relieved by simple injections, and at no time were hard, scybalous masses seen. The grade of dilatation in this case was extreme, a circumference of forty-five cm. (about eighteen inches), which equalled the circumference of the ascending colon in Dr. Formad's case. I must say that the attacks of vomiting, with in- crease in the distention, great tension of ihe abdominal walls, and visible coils in active peristalsis, excited the suspicion that possibly there was a stricture of some sort in the sigmoid flexure. It was for the purpose of explor- ing the large Mtestine that the laparotomy was performed. To have made an artificial anus in the case seems a seri- ous measure, but the child's condition had become very distressing, and the rapid improvement which loUowed the operation is itself the best justification. Dr. Piatt, under whose care the boy is at present, informs me that the boy's general condition is good, and that it is his intention to try •;'.■ 'eestablish the continuity of the bowel. by Case II. — R. A., i^ L-. ver n.onths, admitted June 12, l89i,withconstipi"i n '"a-V.-; and motherare healthy and well. The first 1 'fti -i. v>r;i Novemh.'. ?o, 1889, natural labor. At about the i,ev. i.^ih month uie child had stom- ach trouble, continued diarrhoea, and died suddenly. m^ ^>.slkk: W,u,Uu.,. oft,. Colon in Youn, CluUnn. 7 '^^rSi. ''S:'\^:^i, When born was a heaithy. chilcls napkins were no ,l.^''^n^;h7'""' '."'■'^ ^''^ swollen and very tens., i,,. fiV i ' '^ '''^''""len became nation, passed a , e't. 'l t"' 'n T'^"" ''" '-■•^■^"^i- were bru'u^lu away Fro^ I '.' ^ '';'>1<. tar-like faces has had only five o, s' Tu I "V '!' '"'•''' ^''^^ '^''''J examination .,f tl,,. rectu u , • "'•'V""P"'- ^ '-'•^'•eful child's birti- '..,(,,,...• '■' "'''•'^' •'Shortly after the was hard an' '"'^tressed by the injection/ irnr^r-''''f'''7^"'' everyday would swell and the cil.l won! I '"■'•' ^''" ■'bdomen t'.mcs large cjnantities ^f rate 'u7,m'' ''''^' '""^■''- ^' bile-stained. Until two w .'l 1 ' ''''''' «<""etimes healthy and looked naturnl A .^^'' "'" .^^'"'''' •'^^''-^■""l reverisl, the ,mu,,, erst^ h^' began t„ be and had much vomitinVul en i ' k ''■^''' '' ^-^'''-'''t ^''-^ hcved, and the mothe is s ,-.. " ^°''''-' "■^'''•-^ ""t re- Pain when the abcio en was Sis "'' I T "^r^'^' •'^■^'' "<" weight and has not nursed 'o t^'''^'^'^' ^^' ''^^ '"^t in wi;'nS;:^s;;:('i;;th- .!;;:5i^l:;f'"^ ^"""- ----tcy no teeth as yet cut T o .hT''' '"'^'r ' ^'">«^^"-^ ''^ clean ; and very teJrse. lM,e c fst-U .r'" ''^ ^^'•?">- distended cartilage are strongly ev^rteclrf'"' 'r'' ^''^ ^"'^'''■"■-"i of the intestines are d.stinci n-„ ■ ^"",'''""' "'^ ^'^^ ^o-'J^ coil passing transverse tt^i en the'' "''T'' '''^' ensiform cartilage. There -m no ',''"''^' ''^"'' the -sible, but the'motherst'ues ImTv"'"' T''""''''' ^^^en verv plainer ()„ rvunnf ?i -' '""^ "f^ten to be •va.scs; no tumorTbe fc/ b / f"'^ pressure; no faxal of flatus. The liver Inl!; ^^^'"''^ '■' "^"^h gurgling spleen is not palpal le'Th^ " '''"^'"^ obliterated f thf by the finger is nej ive iuHd'l, 1"'^'°" "*" '^'^ '"'^^tum sphincter was cspc^i N^-t; J, A^' "°^ ''^"'^ to me that the sequently examined tl c c h d 1 M I"' ^•'^'^^'^- ^ho sub- more resistant and tighter th'mn'^^''' ''"'{' ''^' ^ ''ttle passed withot,t any ciifficultv and 7"'- ^ '''^^'''''^' '^ tance of eight inches ,r;,,^i ^' ^ ^^'^^" '^ reaches a dis- been a prevVoLi i, ectirof\f;Yerfl'^- 'ir' "'^' '^ ^'^^^ ^a^ routine the mothir roU:::;^^^^^^,^^^^^^ 8 Osler: Dilatation of the Colon in Young Children. inject a few ounces of water an hour or two before she passes the catheter, which she then inserts to a distance of about six or seven inches, and gas and faices come away. The abdomen becomes flat and soft at once after the escape of the flatus anti fuces. The contrast between the tense, enormously distended abdomen in the morning after having been for twenty-four hours without an evacu- ation, and immediately after the use of the catheter is very remarkable. The j)atient was only under observation for about two weeks, and presented no change during this time. The distention ditl not seem to be due to obstruction, nor did it appear to be influenced at all by the use of free injec- tions. The mother was advised to relieve the child's bowels with the catheter several times in the day, so as not to allow the flatus and f;vces to distend the colon. The mother wrote seven or eight months after she left the hospital saying that the child's condition remained practically the same. Here we may possibly have an illustration of the early condition which leads ultimately to the enormous dila- tation and hypertrophy met with in the last case and in the one reported by Formad. From birth there seems to have been an inability in the large bowel to empty itself, and this certainly was not, I think, associated with any degree of tightness of the sphincter, through which the index finger passed v/ithout any difficulty. The important matter in the treatment of these cases would be the careful regulation of the diet, and in very young children relieving the distention by irrigation several times in the day so as to prevent the accumulation of liquids. 'dren. fore she itaiice of le away, iter the veen the norning 1 evacu- r is very out two e. The nor did e injec- child's y, so as )Ion. she left mained le early IS dila- and in 2ems to y itself, th any ich the e cases m very igation ulation (Rki'r Physic and Physicia„; AS DEPICTED ,N PLATO. ^""^ ''^'"'' ''->^'- //"//v>„ /,,,.,,„, .,. , . BV w.u.umo.s,.kr,m:d„,,rcp.o , ■SSOK OF (R^^HKIN-rKD PKOM THK ,!oSTON Mkdicai. and Su -- i'KHHUARv 9 ANn ,6. .S^^'""''- ■f"""'^'^'- If I ' BOSTON- ^SJ Washington Street " '«93. I A in ]■ iivu ^-^ /<^^ 8a. \c '"Kimlaurusor at AriLs'^;:;)}'"' V;- ., , , live /l!.| c* / « r* /J^ /^ -tx. A^^^A-"^ <^-- £ ^*4/*i^ -Jac_ J ^^c^'^^ A //A /[.ue^^Cf^ XU ^^^ >^ f-ttyK^/ y ^^ &S^ O--^^ t/^i,-c-c4. >«^«^^9i^ /^< €/• ^. .t^^< ^ ^^^ £.^^ ^:^ _ 3 r^j /iu. \hA ■c ^«^ '■ ( ^_ /s^lLy ^t^ *^** ^< /?. (Vi^t son, uie •• ,!(' ill Kpidaiirc '■o-piiysiciuii, -^''j-icm *[>ius, at jii , -..rusor at Athens irc^if ' V" , , '"* '«"ipiB / /,/ /C^ ^ ^^y^\. /^^ /^/.A^^ iZ^--^ ^' / ^aM a^^^ ^.1^^^/^^^ X/^^^-'^' ^J/l^J^IU/t-wv // '/// ^--^ ^>^^-^^^/ 4-<»^^^j jt ^^^^A' aax^ ^/^ /?5^ ;^ ^^^t*!"^ ^ /J'^, ^ .^^^..^ -^ te ay ill an tht rat wii Dee sev (list cell littl Wlli: ever iiied loss l^Olli flisen \V I'liYsic AND pjrvsrrrAxs as 'X PJ.ATO. 'n;iMCTKI) ductory remarks -i,, 1 ., i • ^f"'''ci"e. After i„tro- systematic .stiidv of tli.." Hi, ," • ' ? l""oceede.| to a '" ;""'-- - f--H.';i- r;;- ;:;x '^'''^ "" and j,'yiia;colo.rv. Am,..,,, , • ' ''>«'«"e, sur;;ery, If'euned. not tL let i ?, '" \"^ "''«r«^ ^vhicli ^e -■'Lout a I-'i. iu t ;/ ei ee o/'a.? /" "'^^ T^'^''''^ "l"!,'.V. Min.ls in„„isitiv7 r! **' ""'"y »"J«;''"" me.lieine on ever. Diogenes La^r i ,s L , " '^'"""critus, how- '"fiicai w7iti,H.s V h : ' '';';;'*^''T' '* '!«' of his )oB.sof the worLs,. i ' rr ■' '" '■*^"'"'^^ '" "'« whose essays. •• O . Tho e """' "'" "^'^' "*' °"« of Cou.d. after , line's '^-itter "•'' .^"'""^^"^ ^i^'' 'ii.sease, which Dare.nE, t ! ,' ''?^'''^'^ «f '^r;:;:Ed^;:i^'t^^f^'i:"2;r-'''°-° -■'iiei.:;:l;X';'r;; 'VhT'^'^v^^ science, with ..vmnastics^'.u',! ■ ." .'"'''"'"•"■'^I'ip. with i'"H,ine an AUien u ^ h^.:' fTl ' '"'H "^>:- ^^"^^-^ century worrie.l alu.ut t e en e M ? "1 "'" ^""'"''^ growing la,is, askin. t m ad vj t f '" ''' "^ "'"^ "^ '''« -Bpiciou. cough, c^s'.dlll^'^'r"'?'^^ laureas for a systematic co,rrs P^Ia^stra of Socrates a.Ivised, " when In, n n .f/*""=*^^"=^ ' «>•, as -king the assistance o 1 H J ' !^' T ^''^'^'^'^'^ " son, the "hero.,,hvsici. n" 1 ^ ^^'""°' """"fe''' ''*« J!' IW.i.laurus o/ at AllsiSf T' ;Vr '^^^^^^^ ''- over his parental trouble^attho^rmrofte^S teeiitJi coutury lie would j,'nt u iiiort; exact tlinjjiiosis ikiid ii more luiiiiiial trciitiiiciit ; In; iiiij^lit travi'l fur to liiid Ko ftiiiiifiit ti '* )ii'(il't't<»ui' " of ^yniiiaxtics as Miccus for Ills l)o_v,aiid in C'liristiaii seiciu'e or failli-lii'aliiif{ he would liiid our liasturd subtititiite for tlii> stuttdy and gracious \vorslii|i of the 4l'lsciila|iiaii Ii'm|de.' From tile llipixieratic vvritiiij^H alone we have a very impertVct knowledge of the state of niedieine in the most brilliant |ierio( thai period; and writers of our own times, like (jrtiorj^e Kliot, hav(! told for future generations in a character such as Lyiigate, the little every-day details of the strnjigles and aspirations of the profession of this cen- tury, of which we (ind no account whatever in the liles of the l.ancet. We are fortunate in having had preserved the writ- ings of the two most famous of the Greek philosophers. The great idealist, Plato, whose "contemplation of all time and all existence " was more searching than his prt^decessors, fuller than any of his di.sciplt^s; and the great I'calist, Aiistolle. to whose inemoiy every depart- ment of knowledge still pays liomage, and who has swayed the master-minds of twenty-two centuries. From the writings of both much may be gathered about (ireek physic and physicians ; and 1 propose this even- ing to give you what I iiave culled from the " l)iak)i:ufs of I'lato." I shall lirsi speak of his jdiysiologioal and pathological sfieculations ; then 1 shall refer to the many interesting allusions to, and analogies drawn ' For ail account of " .Kscul.ipliis at Kpidaunis mid Atliciis" soo DyiT's "(Iciils iif dri-cce" ^Mn(!.Mj|laIl, ISiH), a I'liaptiM- which oi>ri- taiiiK alMi arii'xeidlentilliiciission nii tln' r«iiilii)n of Hcc'iilar to (iriotly liimliciiic. Ill CliaptiM- III of I'atcr's ili'li;;!!!!!!! sloiy, '■ MMriiis i hi- Kpicuii-iii," is a ilcscripliiiii ol .me ol tlic Uoiiinii ,Ksciilii|ji:i, auil an Rccoiiiil ol Uic inclliiiil of proci'ilurc in tlie " cure," tlic riiliculous as- poctH of which are so graphically di'seriheil in the " I'lulus " of .Vriii- lupliaiies. «.J:r';^St!:'e::;i;:''''-''-''-o."y an., ,,,,„, *''''""^."''«rv l.o,i,V.s of ',,'*' •'"^'^'"""^ "f the four «'0""«t,uretoo,s,;a|,' Jr''-. ',''^" ""' «^<'m. of « '"•";" "^'•^''- -'' =*'"' various <''^".'« .see.!. In, „,,,ie ,'0 'fl ,' ' ' ' ''"*' '" '■**'=^'iv« the ''";^"'" "»• M'e marrow '1:7 T^' >*"-' c-H.'-l tint «"'<«Hl wa,s perfected, le' ?'"'"'" "'^'' ^''-' aa ■^•'•"^•e .shonlfl 1,, „, ''', ^'''''^ containinic this S '^''V?' ^" -''tain tie ri:;;''"^ ^t whid. was : 2";'. -Hi |.e ealle.1 .he,a" | ,;'; '"■" '■""■"' -"i elon- ""' '" tl'e.se, as to anchors .r """" '"'arrow'- -'"•... frannnvoJk o, >^^ho h """ ""'""' ''"'•" ' ''." account of the s,ru ' mwV '"'" '" ''""«•" ' ^"-'-- of -pirutioirs^ ,""rr"'""^''-^""'»f „■.'•"« <'-io«„o, Of i,,,n, ,,„ " ""• '*'"' '^"•^■"lation is miiiil<'Ilij;il)'t' to oiirnioilcrii iiotioiiH. I'liito km-w lliat tlio hloiiil \v;iN ill coiiMtiint iiiolioii ; in H|ifakiii^' of in- h|iir:iti()ii iiik) ('\|iiniii(iii, iiiiiI iIk- network of lii'« vvliicli int('i|iciii'ti!iii'H ilic IkxIv. lit' hitvH : '• i''or wlicn tlio rt.'s)iiriition \h mnufi in iiiiil out, iitiil llie tirtt, wliicli it fiiMt liouiiil witliiri, f(illo»8 it, tiiiil ever iiiiil anon mov- ing to mill fro ciiterH tlic liclly ami ri'iitiicH tliti iiiciit mill ilriiik, it lii^^oi^('H ilit'in. ami iliviiiiii;; tht'iii into Biiiitll iiiii'lioiiH, mill ;;iiiilin<; tlicin tliriiu<:li iliu passii^cH vvlii're it j,'ot'H. |)Uin|i.H them iim from li foiintiiin into tlio cliiiiiiu'N oi tilt! Vfiiis, tiiivitli tl.i, llM'itSCS of tllH It'll. ...Its tllil.k» s. an. (|,„s,. „c ,1 vvlioJe c-,.„r.s„ „f ,|,„ |„„| ;y«' ITIMlllCMi |,v ,|is,.,,| Tl llllllll'IIC 11' Worst of Hit of 'in: |iroilu(.,.|j ■" '■*. '•U.ilM,,,.,! to til IH spinal marrow. V M r 'tH'er '/•I tl 'Wl.,.|| .1 I'H, If 01 •''•'i"''|l withia I liT,«i (if r,, ■"»''• Otln.r .1 ^I'lration ; ,,s l.y ,,|,| '•y rcmoii of (|; •lisfjisfs, Ik, '" vvliicli till) asu« lililejfii, '•'^':'"';vi.i...i..k.:u:::; /;:;'':'•'!'•••! '" '^•""•^"H of the |,„a,| wliioh 1 1 ""', •'''« «lt.o,.. I... ir' ""'"'"'•*'^ ..ttacksof "" >t HSHuils tl got li.l of, ,„„| .. I I""'!' wlio an ''itvs, art' not j,,,' tllOHt justly cull,.,| '"■"'i-' ■•" allVctioi, of "wak.. it is liani ■'*«ver.., |)„t O.'.l ici's, t'\ <|i">'iilian f t'lH most "way in a fi <',7>„, a MK red part. til he 18 ever of it'iNt'N a coiKji ''""'"f than either (i »•'«(<•'•. whieh '"■•""■'•'•)•" Of other d'i ">«»s fever; of air, III '■•< a inoro sliiu.rj.sl, 'I'l and f.sy -■---»^™:r.i;;:t:.t:;;,;;,:i Id :oiir ••I.Oloj^ry „, J.i P'-riod, tha ' '» in a qiiartaii f |dlVsio|,|,ry ), "to. in contrast to I lever. ""•ee-lold divj', '"astrai.jrelv „„,d 'l>l"'til.'. represent ""I (>f th. ind int.) re ItTII Sil' '"sanato an. J tl iruy ni/.MJ I .V .stnd.'iit.s .,f til '""""'■'al prineipl.. of tl •••■";"" ".la..)|s in „,„, ■■* ^''ry iniieh the ■as. III. u '10 "H'titai typ, ipirit and l"<'sent (lav. 'ij fi plant '""I ''anil to "''^'"''*arthlyl,„f„f|„ « son I "tl an. I S r „:.. , ,,.'"> ''"' «'<)l«l of COM,. (> more :ra[)h eita.iel •1 oni- £:;™:™'''»"^r;;;;,,!;s:;,:::':^ -•«*/.«.-«,, hen .riven tl lote. r .Iriviiiir liaii ill ,|„; (Comparison of "' the soul i las ever '* pair of win.red | '""I of nohie bree.l ior.se tlio oth "lan to a ch; one of which is and of "t" It'll. (I)|(. c, ij;iiol)le breed, so that "the driving of them of iieces- bhy 1,'ives a great, deal of trouble to liitu." The comparison of the mind of man to a block of wax, " which is of dill'erent sizes in different men ; harder, moister and having more or less of purity in one than another, and in some of an intermediate (]ual- it_v," is one of the hai)piest of Plato's conceptions. This wax tablet is a gift of Memory, the mother of the Muses; "ami when we wish to remember any- thing which we have seen, or lieard or tiiought in our own minds, we hold the wax to the perceptions and thoughts, and in that material receive the impression of them as from the seal of a ring; and that we re- member and know what is imprinted as long as tiie image lasts; but when the image is effaced, or cannot be taken, then we forget and do not know."'' Another especially fortunate comparison is that of tlie mind to an aviary which is gradually occupied bv different kinds of birds, which correspond to the var- ieties of knowledge. When we were children the aviary was empty, and as we grow up we go about ' catching ' the various kinds of knowledge. Plato recognizcil, in the " Timanis" two kinds of mental disease, to wit, madness and ignorance, lie has the notion advocated by advanced psychologists to-day, that much of the [)revalent vice is due to an ill disjjosition of the body, and is involuntary; "for no man is voluntarily bad ; but the bad become bad by reason of ill disposition of the oody and bad tuiucation, things which are hateful to every man, and hajipen to him against his will." A fuller discussion of the ilieorem that madness and the want of sense are the same is found in the " Alcibiades." (II) The different kindf, of want of sense are very graphically described: Sitcratrs. In like manner men e ::^;^o-r--'"-":-'K:t:t;!i.s-^^^ Fi-frir;;.;;;;: 'mention of disease is to ^''e^eis no propor ioT , i " '"""! **"•' ''ody, " fo? '-at hetween soul an,l 2v -' ^'V "'"' ^'^ '''a- "' ^'"'. '-in. hein. j i" j^ '' ^ ' « -loul.le nature '"•Pa^Moned soul ..fore powert I 1 «"'"Pound an ?«"'. I «'*y,convulsesan ms .' I'l" I' '""•'• " "'^' ";'"''■"=""•■« <'^' -nan; and -I en ''''''''"'" ''''' ^^''"'^ of .^onie sort of learnin. ,? "'^'^"- ■" "'« Pursuit "gam. when teachin.. or'^dil , ; ;', '''''■''' ^"«'"'^' ; or an. considerations 1uHi3t'v'''''''"'^"'-'''M'nI.lic an.l dissolves the cotnpo^t , ,^'7 "'''''' ''"""•"«« ''"ces rheutns; and thi ■ L, T """ =""' "'tro- "ot understood l.y ,noV ir X ' ""J '''-"^menoa is ''-•''- it to the 4,pos i ' J: "'■; "' medicine, who ""•'"'""' «»'ould 1,0th he eo ,' „ ' '"";^'^' iiody I'^'auKst this .iisproportion,' I , '; jr'!'!'^-' ^o protect Kv without the soul or hesl v ' T '"''^« "'« ...v., ""-■'""' W'tl'out the hodv. i„ ana A^l I''''-", "o Poeu wrUe poetry buL 1 v -.ItK.logy. J ^'''"'''^'"'"'■tof inspiration this wiiv they will be ou their jjuard uirainst eacii other, and b(!iu'alihy ami well l)alaiict'(l.'' " lie urijcs the ujathi'iuaticiaii to piartise ■jymiiastics, and the i,'yinnast to cultivate music and lJllil()!^()|lily. Tht (ii's of treatment advised are simple, and it is evident that Plato had not luuch faith in medicines. Prfifessor dovvett's coinmeMtary is h(!re worth i)iu)ting: " Plato is still the enemy of the purjjative treatment lysiciaiis. which, except in extreme cases, no man of j)h of sense will evei (loot. For, as he aiids with an insight into the truth, 'eveiy disease is akin to the nature of the living being ami is only irritated by stimulants.' lie is of opinion that nature should he left to herself, and is inclined to think that physicians vain (c. ' Laws,' VI, 761 t', where he says tiiat are in warm ball IS would l)e more beiielicial to the limbs of the ageil rustic than the prescriptions of a not over- wise doctor). If he seems to be extreme in his con- demnation of luedicine and to rely too much ou diet and exercise, he might appeal to nearly all the best physicians of our own age in sup|)ort of his opinions who often 8|i(ak to their patients of the worthlessiiess ofdr and rugs. l*or we ourselves are scepticitl ahout medicine, :;ry ur illi to submit to the purgative treat- ment of physicians. May we not claim for Plato aii auticipatioii of modern ideiis as about some (piestions of astronomy and physics, so also about medicine ? As in the 'C'liarmides ' (150, 7) he tells us that the body cannot he cured without the soul, so in the •TiinaMis' he strongly asserts the sympathy of soul and body; any defect of either is the occasion of the greatest dis- cord and disproportion in the other. Here, too, may be a presentiment that in the medicine of the future the interdependence of mind and body will be more fully recognized, and that the inlluence of the one over the otl ler may be ited i n a manner which is not now thought possible." The elfecl of the purgative method to which Plato was 80 op])osed is probably referrecl to in the following pass When a man jfoes of his own accord to doctor's shop and takes medicine, is he not (juite aware that soon and for many days afterwards, he will be in a slate of body which he would rather die than accept as a perniiiiient condiiion of his life ''. " It is somewhat remaikable that nowhere in the " Dialogues " is any reference made to the method of healing at the uE>culapian temples. The comments ipon physic and physicians are made without allusion tuth lese institutions. Hippocrates and other practitioners " Tiin:i'iia. If. co«co,ve.| i.y !>,„„. w; ; • '' ' 'l'^'' '"' sonl.r, as '""!•'« "f «.hut was iue iCn °;;""^ "'« greatest Pe'-'o'i of the race, wou i ,e n "^ '" "'°^' •"■'"'^"t '/'e'a. which i.,(lic.,te"! ^ f '"" "neruble little obiter -•''v:f''-"--'a;rw,iSr;;:;; "^--'-^e of Z '"'^'^''-'HT.v is out Of ..oar Tl " " "l'/!'^'-'"".st when the charnun^. analosies",ira\vn fm ,*! '"■''','." '"'''■■"■o". manj acute su.,.e.s,io,?s. .ome o ? , T''"'""' '""^ "'■■'"y ce..tur.v flavor. "1.^ 'h e M '"' ,''"'° '' "in.teenth- -•-.- Nestor^:,: ^::';^'-'''" wise phvsiciau «>«".' furnish sonieof the' f , ?"' .'"'*">' '»"-'''«•■ the " f)ialo^n:e8." '°'' '"■''^'"g iH-'strations of M^ici,::! Z';:,::^;:, ;;^';;';;;|;'^ .lefinitions of the Art of »v Hch consi.lers theci.s t '"'T'/''''' """« '« «" A.t l"-".--l'i- of actio, a , 'r " ":: • ^'" 'T'""'^' "'"' '-« ag^iMi, the comprehens 1 vi , ' '^'"''' ™^«-" Or, " ^''"-re is one'science of ,r'l' •'"''"" '" "'« «tate,„ent -•'•' "- inspect,' I'of : S"! ^^'ir'' .■■« -"cernei l"''j«pt. past and futupe." '^"''"•>' '" "" tin'es, "'O''-!^ nle!iic?,.e''if'""' "^^o-'-'t of the origin of the Muildof AscJepi'::'/^ '"'"■"''^'' -"' tl.o a^rt of tt "■'"l" w..;;n!n,aMot',;;r7 ""^ ''"''• "^ '"-"-'hs -ct - p. have b...n ^^^^t^"^^^ =' '"'''it of li?;^ S "'^"■'■"i-N sons of AsHenius o, , "''''' '-'"'"Pellin^r ,|,e ^';S !'<• said, th,.v do i, '• ""' "'"'' *oo, a dis-^raeeV "7;fangled nan...s , o .itl"!"""^- "'^ ->• ^tranj^ri^^i <'"i. Hut Ilerodicns. hi injr a trainer, and Idmsclf of a sickly constitution, hy aconihination of training and (h)ctor- in;,' found l, the n| deati Ati.l J be th with »!' f) you, |3 man done to n a my fo costing you, until >>fi and bur especially of th. .Vou; he .vou k '"'"S aiHl starv youiiurer ones IIIL' youthe'Gitt.:resrs„"!;:;r"'''f'-^«ri; an( fast? ir ' ..V "'^' •'"<' comoe s r,,,. .„ , fr")-f? 110.S m,,els you to h ::'"«'' I procured ;;;''r '"^::'y °/ ^eats ami the 111 th onl "'■you.' Whatd luid siif- ives liunger sweets . P'l.vsiciau would rei.l'yw. /.'"[.'"" '"»'!'»«« that '« P'vdioament .» iCrif ^"""'' ''■' " ' y say : ' in self health,' and tl 'ciii ,■- i"' ' 'ii'l with .1 .,; amoii"'' 'i'h'r 'leii would th siii;h iud.resP it , '"^' J"st be a cl >._• JV"'-^- How thev i.,^..i.i _ ^'. (1 a view to Pn'nciple of con t'ley would cry out] lamour -'"■«''. like the .i!xrj::\'''"'^''7''^ to'\r '"■'• Several strik found. '1' 111^' passages ill 'vus conceived of body as a ^./liole think th «t'i'tly witi i-to-the;,uestio;;:rfc^j;'---'>e J'hied that tl »! -■•»»-««;.. ;r.:--;jM_,„„ "lit kno rus replies, " I J "i,' th is the onl "^^^'"•^ -en of the'bX ;; Z '«: the nature of th 'PPocrates, the AscI fwrtaiice of tre; X5":'f.'™s„rK:;,'s le whole.'" ipiad, sifted upon. I„ th a'l'i;^,' the whoit e case of a "ii'ierstood. and not the 'I'h lie le iui- ""'"' with bad eves theL "* f!^''"*'"^ vvho com cure hl« «..„„ 1...^*^* '"<' sayinur « ., .i,,.^ .i.„. -tire Ins eyes h.- »i. , "".""S li be cured .' L '"^'"^«'^«^«' l»ut tl, th: I'ed his head 'S is " that th part is ill. les to ^>; «ay " that to think of must be treated liat if hi cy cannot ♦^yes are to and then a^ai ''••^!''«'--' of the ij; ^Lo';;^^''^ ';ead alone an^ •V.^".'^."'ebei.rhtoff,.llv" cvS'ti'-i'-r-™.-: folly. could cure him of '"'lich he h.Ki J one of the 't. fie •■"•'It, uhe "crates to ;::";:?.:!^?':-j-'-:ai.ci make bel leve "ai'l that he had that he iX'ysicians of the Th n serving with tl nh iiru!. "■acian kino- lie army, of O' Zamol xis. 12 Tills ])liysici;iti had told Socrates tliut the cure of the part should not be attempted without treatment of the whole, and also that no attempt should be made to cure the body witiiout the soul, "and, therefore, if the iiead and body are to be well you must Ijej^in by curing tlie soul ; that is the first thing. . . . And he who taught me the cure and the charm added a sjiecial direction, ' Let no one,' he said, ' persuade you to cure his heiid until he has lirst given you iiis soul to be cured. For this,' lie said, ' is the great error of our day in the treatment of the human body, that physicians separate the soul from the body.' " The charms to which he referred were fair words by which temperance was im- planted in the soul. Though a contemporary, Hippocrates is only once again referred to in the " Dialogues " — where the young IIip|)0crate8, son of Apollodoruj, who has come to Protagoras, "that almighty wise man," as Socrates terms him in another i)lace, to learn the science and knowledge of human life, is asked by Socrates, " If you were going to Hippocrates, the Coau, the Ascle- piad, and were about to give him your money, and some one said to you, ' As being what, do you give money to your namesake, Iii|)pocrates, O Hippocrates,' what would you answer ? " "I should say," he re- j)licd, " that I give money to him as a physician." "And what will he make of you?" "A physician," ho said — a paragraph which would indicate that Hip- j)Ocrates was in the habit of taking pupils and teach- ing them the ait of medicine; and in the "Eutli\de- mus," with reference to the education of physicians, Socrates says, " that he would send such to those who profess the art, and to those who demand payment for teaching the art, and profess to teach it to any one who will come and learn." We get a glimpse of the method of diagnosis, de- rived doubtless from personal observation, possibly of the great Hippocrates liimself, whose critical knowl- edge of pulmonary complaints we daily recognize in the use of his name in association with the cliilibed lin- gers of })hthisis, and with the succussion splash of pneu- mo-thorax. " Sup[)Ose some one, who is incjuiring into the health or some other bodily (piality of another : he looks at his face and at the tips of his fingers, and then he says, ' Uncover your chest and back to me that I may have a better view.' " An(i then Socrates says to Protagoras, " Uncover your mind to me; re- veal your opinion, etc." One of the most celebrated medical passages is that iu which Socrates professes the art of a midwife prac- i;i tisiii.r on tl "titli or will '"; s"''iniH;on ot' I owled^re |,„, be^J 'i;arning,and whos. 't'en iiresenteil to 1 mil as a silentl I lik e a nv( II sure and l>'%M'e«s in the ,,ath of iiiooth •• (low feel "f'<'tetus is sooi rot 0,1 •__,„,,, .^ ^,^^^^,, iiii; on iiiir of iiiixi( ty- t'litan-led and t'dj^'e cannot shake olf Thiiri. J ver 3<'ii ; hia J ciin assin-e v >■ often, when I ) answer to .rj •an neith liiMi-d the ■oij. SoeraU's, tliat I 1 tioMs whiel would liave Ml ^ive, noi' hear ot ''I' Pi'i-^iiade nnself that 1 | liive trie<| li eanii- from to an,' wer. L' answer: and I ">■ one who aiLswe liave any etus >'/f. 'I'huse ; yon have '"g K) the hirth (•annot -et rid of the .1 •IS as you esMe '»'c the pane's of 1 onieth iig witliin iihor, niv d 'l^heM. \ ,1 yoii which' oar 'I'lii yoii are www '\nd did , "'" of a midwife, b '' !"'t know, Socrates; I arete 'i Snc. M>ii never liear. S I'ave and I only say what I feel. tun •"•'• Yes, J 1 "'i|'li:t„n.tl,at 1 am tl i}> wliose name was I'h ;en- So,: I ■^'I'i that I njvself »ve liearil that. A'.), I never practise midwife lieard that. yon nnist nut •«' nie tell ytn, that I ,1 not found m it'Veal the secret 1 Wit.* am an exceed II' out: ami n end ecet. III! "Ah' f'ti thoii^li, IS the woi'M V oulv •yV my fi-iend ; h lit you ever hear tl tlicrefore the \""^ beilin-, „:ho d in <;eneral hav( 'iiy of me, that 'lat ; I ive men to the ir '■^'>c. Shall I tdl vo„ ,1 yyntet. H ] y al must mak meau.s le reason ""il'^-ive.s, and the "(iman, eoiiceive •■ yjii Icfstand tl as you an 11 you wil 'i;t! my meaning- 1 !>' situation of th. wl and l';>ai-e j.a.st he oear, l>i-olialily aware, wl letter. T/h- ■ctl. ilriiii;-. intends othei llO IS iihle to Tl iroiide; ^^'s, I know, ic i-cason of till women, but only tho. wl of oliildbijth i ■•'i'id to he that A rtemis lo are like '■"■i'''ii to be miihv "' mystery of iissio,,,.,"! ,1 IVes, I '•■■"elf; but si "■ ^"giii, and she 1 'ceaii.-t; :iii art withou !»■ eiiuld iiDt inmaii nature oa I'llff llCiirilirr, 1 is oil lii'e to tl t e.xperiei honors allow tile iinot knii V iiose who bv n and thcief Ore n, 'Wl. ■Jl lononn^. tben, from theii'lil, ■•'iisoii ol ai,'e are '■*''"'■. And I'lt is natural Heness to herself. that tl a naiiira, ami who i !'• midwives k . or rather n not ? now better tl lece.' 'lan uihcrs w'l ry iiifereiu J llHL !Soc '• V'ery true And by the use of jiut lo IS jircgnant on.s and incantations th. I It re iililc to iirtmsi' the inm<;s and to soothe them at will tluM- can lua ki' I lo-^e hear who ha\ c a ilillieultv in hearii ami if liiev clioose, lhi'\ can smother tliu iialie in the wonih. Thr Dhl V on ever reiniirk that lliey aie also most enn- nint: inatehtnakers, ami have an entire knowledge of wiiat nnions an! likely to proilnee a hrave brood Y Th, u:t. I never neait I of tiiis. rid Then let nie tell vim that this is their greatest e, more than eiittim till hilieal eoid. And if von reflect, you will see that the same art which cidtivates and U'ailicrs in the frnits of the earth, will In- most likelv to know in what soils the several jdants or seeds shonld he I'jiositeil 'J'/iml. es, the same art. And do yon siipjiose that this is otherwise in the case or women. n 'lllVl. I. No, that is not likely. No, indeed; hut tin; midwives, who are respeet- ahle women and have a character to lose, avoid this dejiart- nient of practice, because they are afraid of bein'i called pro- cnre-ses, which is a name yiven to those who join toifelher man and woman in an nidawfnl ami nnscientilio wav; and yet the true midwife is also the true and oidy matchmaker. ThuEi. That I understand S«,d I are the mid wives, whose work IS a very im- jiortant one, but not so important as mine; for women do not l.iini; into the world at (nie time real childreti, and at aiiiither time idols which are with dilliculty di>tini,'uishe(l from them; if they did, then the disceruim^nt of the true and false hii th wonlil he the crowninu achievement of the art of nddwifcrv — yon should think uf that? Tliiat. Ves, I ccrtii should. \V( mv iirt of mi iwif theirs; but the dilfeience lies in tl and not w(jmei cry IS in most respticts like iis- -tliat I attend men are in my art is in mind of the yi id I practise on their souls when they labor, and not on their bodies ; and the triinnpb of in;r whether the thon<;lit which the (iol or a iiolile and true creatic man is brin^'ini' to the birth, is a falst I iini liarren, am Itl And like the midwives. iroach which is often made me, that I ask (piestions of others ami have not tl tl lem mvse If, J' aijainst rs ami liave not tlie wit to st ; the reas(ui is, that tlie god compels me to be a midwife, but forbids me to l)rini' forth. And therefore I am not myself wise, nor have 1 my own lose who converse anvthin'j; which is the invention or oilsprin" of soul, but the way is this : — iSonie of those wd with mc, at lii si appear to be absolutely dull, yet aftei'wards, as oiir acquaiuiance rijiens, if the uod is gracious to them, they all 'if them maki! astonishing progress ; and this not only in their own opinion but in that of others. There is )f that they had never learned anything of me, but tl ley Jiavi! accpiircil cliscovere{ 1 m; my uolile of themselves, ahnoiigh the god and I help td dt And )f is, that if tl th •th attributing all to themselves and despising me. either o their own accord or at the instigation of others, liave "one em. lem in their ignorance, )f I "way sooner tlian tl tlu'v I T I'fiyt! i.nxliii.,.,] i',1 15 •iiiiiiicai tiiiin |,y IKII.S itn il i.rl inioi].'. •e re.siili I,„,, been fliat "■';■'' lo.xt (II,. cliil y reason of t| "I'^i-ti viiliie (lian t "■■'"A'lv^ i,|,, ,i ' "I whidi I (I II'"' •■Vil COM! 'Iivcrt'd illir tl nil ic'nselvi..s, as oti I ; iind (licv i \;:r'^'i--''>'-io;;;::; icrs y*iiiiii(,'liiis, is ''w asiiin. /)i !"" triiiinis often rt-t /K'of this sort, and' ti >»'iii a>,'ain- tli( I'ni lo Ml,!, and I lejr Ir then, if niv f ii':oiise and to allav in tl IK^ t'Cfivt'tlic |)iln!,'S willed >nrt' ready to iuniiiar allows, iiiid tlicv I >^<'in ""'■ jiiNt like tl ■ art, I coax tl of (iod J !«'"'; and as I k ioiiiucli o'lie to me uril tieiii. Iiit'h is ev_. And there en '"'"' into anoihe """' that thev I ai>[)areiiliv hav inir ■y liave no need (,f race V' ''0<1 I fan .'radnalK" ,,'" ,"•''■. "'""". and hv the \r ;;!'-• inspired .s^^gc^.-T ," ToVtl' '■".'""'■^' ""•' -'" Ihea'teiiiu I „.." . ''-" 3011 this Onir .»,„... <■ _ ■ if«''eiu.s, hecaiisc I yourself, t| tion. a inidwift 'at you are in hihor yo'< tills k. s.'isi'ect, as indeed 'onie then to ood. "S and some to 11.' ftory, friend you seem lo think and t nil ly t '.who am a niid vat with som II' confer yo;;- And if I ahsi o answer the iiii ;^'te and the son ot I (1 liscovcr I have fi '■act and expose vonrfi d'O'i insjieciion that If '•-^"011 which I will ask rvt-1 '■n. Iieeaiise that cliild «i« a vain shado.::,irnr:;;:i:!r. :!!!''■'' 3- aceoiint, as tl rcn are (aken fn » tl ''' "lanner of woine o not (juarrel witi ou I nie on some who we I'e re a ily to h lein. l.'„r I I « when their first 'lave acliialh viiown ';'"«:« Mi;,".;;:'^;;,^:;"*" !,'''ri~i'^"™ ;'ood will, not k (that nowiiiK 'liat I 11 was not within tl ;;ot ^.erceive ihat' I acted / no i-oil IS tl "t-'r enemy in all :his, | in^je of tl t)iit reli.n, 'II edi^e leir id ill "le enemy of n '0111 nan neither was wuuns/ repeat n,y „,,i If truth. (), vonr.self lik '"111 lio not *av ih ipifstion, " What Iff inure, t yon cannot tell • | is k len, Mnwl- )Ut fiiit you will be .•■'uiseii iiKe a man •.,.,! 1 1 , " "nuoi Ic able to tfll.il ' •*'"' ^y '''« ''«ll' of (iod '-"^'•h into the wo 7 , 'n "'";, ^^'f' vou have l""!'^ •-..„ aroutj the 1 ear 1 vj^ 1 T '"' ''"'" ^^« '«'« worth rearin. or .vTt;" '*''''''•''" ^^''''^''^t- ^ I'e to be reared i7. a i^i^e v ! '" 1^' '""' '' ^''-"• '"•" rejected and uot .Jiin o .l "' *'.'^' >T ^'''*'' '" ^e« yuur /irst-boni ? " 'J^.e ' , '•'*'"."" '^ ' ''^^e away '"■"."^''-t forth witid, a, M ;; "r" ';'■""'' -^"^ '-■' '•'•--'- "Ot worth'hr^in'^^'ir '^«:;;'';f "V""'- • niwutetus. = -^ !■ -I. Hi the dialogue Ifi cikIh as it ln'niiii w iih n reft>rHii'i' ot' ii iiiiilwitc 1, like my iiKillicr, huvc icccivcd from (fod ; nhc dclivt iid lint tlii'V must he ', u woiiifii, and 1 d«"liver I i-.i mull ; iKililc, mid tun iir. From th<^ writini.'^ of Plato we mav "iithnr details al/diit, the status of [iliysiciaiis in liis tiiiie. is vei-y evident tliat tli(' |irolession was fur advanced many it aiK I had lieeii iproj;iessivel_v deve!()|ii period liefore Hijiiiocratt's, wIkiiii we 11.' for Willi a certain iirdjiriety. call tlie Fut/icr of Mnli The little liv-|ilay between Suerates and i'jill HU;rj,'i'sts an advanced condition of medical lit Of ercdiieoMslv, vet cine. lydeimiN (•rature : (Miiirse, von who have so iimiiy hooks are iroini III for l)eiiij,'a doctor,' .says Socrates, and then he^ulds there are so many books on mediciji As Dyv e, voii k now. er remarks, whatever the iiiiality of these hookn may have been, their number must have 1 give |ioiiit to this cha ir. leeii great to It ly be clearly gathered from tli e writings of rialo that, two sorts of |(liysiciaiis (ajiart ultogKl from (|iiack8 and the JO^culapian guild) existT'fl At! Atlieiis, the private practitioner, and the State-pli\> ciaii. The latter, tlioiii'li il le smaller ii iiniencally, rep. resenting apparently the most :Z r" ««»>»:; ^^r'l.i'r'';-''-''-'''--!-; of S, tlie (i ''"'*'"• "'i-lit l,t., I and. \«TV III lie] ■» «reat ii,crt-a aiiios It 8e "« was s,.,luo,;j ll Ct!Il- ' as a iiiodiTii ill salai V liv po| avvav by tli '" ''vi-l-i.t, too.'lVoin'tIi •^'-•'"'••^l'a.las,si.s,a„t.;„;. .Vcratfs, til., t (!r tie 10 ()/}■ yraiit gfiitl. ''"',"■ o{ .Joe a.sk 111,. ,1 it;i-, oiIiiTs to rs, as I a 111(1 ■''" '"«""^' tiiii Slav '"vs," that may I'fiiiind y 't.'8. 'I'Kislafur to What I 'wior to |„ tors' surv iiican I '■"'•<■ ''»-'d doctors. I'^'^i'if^ and olie, .;','!''•■ ''■''"^'^'JS" of i'';ai so we will ask ,| *'"' ^'••ntl.'st ie,i„.dies. are d to -s thfie (JU- di/r :''/'• And HffOrdl,|;r l^, fj >eivii,,r tl III' natural w o ilii'ir iiiastei -r^-vh::,;;;;-i:-^;:^v'n™,,,j art wliich i| 'a^'y inipar Siiei ai-e aware that tl A//i. , f f I'atient w: sure. lere ai '''iiiun makes no '.'I nieilieiinj hv 'j"'l"ri.Mllv and not "' niaiiiier of i^t'lves the iti/ii.MlU- them '"Sti;^;;;'';";ri:"«..,v:; '\ 111 did '■» in st ! Of tors ? .)•"" ever observe that tl; tl till oeioi-s run ahi ;iie III' di; I'cnsaries at and cure tl ■■^'aves and fi d ^r, r:'::^--'-- '■''""■"; and the .s| slaves, or I'aiiints iii,|.:.il| 'ii-'iitioners of tl wait lor tl "iiiividiial eoniol litiit'.. . » naliv IIU'l •-* t"-''lH'ii(ii tin l«y 'Jhe si Irt tl n's sort n live ii'ni in '"■'a talk about tl I'ver talk ave-doetor (0 airown ^''!''^vh-;,XSt.asifi:i;:;,i o'»ui iii.s orders, lik I'i'eseriljes wl oil witi and fi/nal ^o he r assurance t o some othe I I'xact k •-' a t\ rant, I lat now! 'i»- I' rushes ^--n;c master .:r.h::'T:r--^''--'i ''>■' iavali,! slaves! JJ :ilteii and l"-acti>e,« int ll, ^;''|airi..sfarl,ack,aml lie eii.er? '^ ot'a'r doctor, wl ■••""•a; and | njion h liaise of th< o is a f tare of '•L'enian, ■■■* "Ito d,,S( 1^ t'ariies his "■nils, and is at our, ;.;;.";»,«,,„. ,„;,,:x;;;;, ■«-• with tl "am, and also i ""'■i' H'-niu^ iufo, I'aiaiit and will iistruclin"' 1 ,;;" -f l-c.cril,e for ; '■'■^'',».^''<^aliehas h 'a as far as 1 ■Illation fr aiiiler I iiai until he hash he is ah nn till ii Ills sick ''- and he bet ■alth. 1 I'l-'isnasive inll ■"ii-ht the 1 '•■-t convinced I ''^ aiieniot.. ''•'• "-av of ,,r,„.,;,,, lo c/f, n.-iici and is he (I or he wl 'It a cii aticnt nio "'■<- J'ini on Ihe n.aii an ic b aMvoiksi la.tr in a n| re is al 'liiti idea of li "■"r'' '^''" accon,,, N, ?; "'^"''«av,andlhattl ''y-'i'ian and '"" 'vhich is tl in a tra Hill ; more to 'le laidsiii ad 'a'lndcraMd iu'f Ollll, Ulrr ' I' wav, erior '; so iiieiiti rst ( indeed to i '"lied ii, th(! >• ( "'inched o. ■""^■'■"'•'■"ir a,.aii..,itl ' .'laVe 1 ioi'i;ia> and U( ■•-''liiation for s 'V ar;L;iluieiit a/i|)ear oiue of the 18 niitiiiTDiiH HOpliixfA nf thitf. |)i>rinil. Ciorjjiim landiiit^ tilt) viriiit'H i/f I'lii'idi'ii- :iii(i flititiiiiiir tliiit itlic IiiiMh iiiiili';' licr HWiiy all llm iiit'crior iirt, muvh : " Lt't iiio olfcr yiiu u Nlrikin^ uxiitupio of this. On Hovenil orcusioim I liiivo been witli my hrotlmr lluroiliciis, or HOIIH' otlitT pliysiciaii, to see oiio of liix paiientH, who would not allow tlio physician to ^ivu liini iiuMJiciiit) or apply tilt! kiiift' tir hot iron to liiiii : i'.iid I havt; per- Nuiitlt'ii liiiii tti tlo for lilt) what lit) woiiltl not do for tim pliysit'iaii jiiHt hy the list) of rlititoric. Aiiti I say tl'i't if a rhftoriciaii ami a physician wero to go to any city and liati tiit^re to arguu in tliu KcclfBia or any other asMfiiilily as to which of tlitMii shonlti he flfcted tttate- lihyNiciaii, the physician vvt)uld have lit) clianct;; h'.it he who coiilil speak wtiiild ht) chosen if he wish," Jii another plact) (" haws") I'lato hatiri/es this custom: '• For of this you may be very sure, that if one of those empirical physicians, who practise inetlicint) with- out science, were ti> come iiptiii ihe^entleiiian physician talking to his j;eiitle patient, and iisinj,' thi) lani;uai;e almost of [thilosophy — be^^imiinjj at the hi'j;iriiiiiiir of tilt! tiisease, anil tliscoiirsing about the whole nature of the botly, he vvoultl hurst into a hearty lau;;h — lie wouiti say what most of those who are calletl tloctonn always have at their toiiirue's eiul : foolish fellow, he would say, you art; not liealini,' the sick man, but you are t'ilucaiiii'"i"u.'.l. t^ you si.,,02c' once o,- tvvic !. ^, ' '""'■""' «'''"">(. "if '« M.re to ^ro.- '^"''-'"^vxM. 'I'e most violent i.,eeough ralll,''''!' ?'""'"''■'•''' ^V'"(.tom,s,.a,.r.,,, ,""' ;'^a„k tl.e poi«„. ;,i';^;'' '•;•■• "'.•.• Socrates •well; but I „,,v ref,r , • " "'""'Ce-^'arv to ; " ^-.'renee fdt "^ o r , . 'r,,;;r T'^' -^ '■"'"'■a-.i..g ^V'.' «ays that ,1..,,. i, . , "^ ,7"'""'-'"f tl... jailor. •< "to. woowearo,.L to V . •""- ^"'•''« Were, ^f.-.u to |,e.- accorilin. ,o I) "' ? ' "^ ■^"''•'•"'^'« ^''-l-l ''";■•"• ■« •"■'-.ife.t in tl. i i '- '"'"""^ ""•' *-''ose 1'^";- 'V'.'l "M.le,l all ,l.e . "J '^^ ^'"'^'' '-•"'•-I all the '"-•1^% wh.oh cured l.i,,. of i evv^.l '^"'"V"'^ " "'« ^^^'^u --■'^=.n.g„Horeail.fe«ocrate:c;iv:';:S 20 lapius a tliank offeriMi.^ This olFering of a cock to vK-iculupius was plainly intended for liim as the awak- ener of th€. dead to lite everlastinir." And permit me to conclude this already too !on<>- account with the euloijium of Professor Jovvett — words worthy of tiie master, worthy of his great inter- preter to this generation : '• More than two thousant*y^^\ ^a-**"**- ^<. 1^^'t'^^ l^. ^iV^^/Z^ 7u /*- r/^i ^£^ "^-i .^c^/:::^ : ^^^^^ ,/:^__ j2.^£ ■ Z:^ x^^i-ey^ ■7/' /^'*v 2*-*-i*tr >/,*.. j^ ?/it«- ^' ^Zti ^^^-^"-^1 P' pi St of H ki th no me pn bir pit be ^^^Sfi>^?^a^**ta£a^i^ . •^.. i Physician In Plato's RepnWlc.-The Lancet has the .ow.ng scholarly note that reveals the mind of the great lortii To't" '°rr''"^^''^ ^^^^"^°^ medicine?;; [own t me. To those of the profession who are interested in histonc reflections, it will be pleasing to note that Pla o Rave precedence to the physician, empirical t ougl he It ihant -'"?:• pI:: '" r^^^^^^^^y theologian or •..tiero- ^rnT H , ' '"^^■'"^ ^^^ ''^"^^^^ that embrace the artist the ruler and the merchant were those who stood supenor to the physician. The physician stooa fmrth t a ras'sle in'Se Tr '''" '"'"''' ^-^^^ "InTctiou Sfu^i^Co 1 c1,e""hy?rer^of1l''"^H''''''?«"--*'- transmigration of souls Tl p I^n i-^\'\ ^^ctrine of the - , the second degree shall be « liJ f ""'^''t ''"' *"««" •'•"^'' "> the'scale-is'tt «' "'''^'/^ ^°'he Kda ,' 'w '°? ""^, "'"« s-^^r-^i^^^^eS^iliiB^^r^^'^- hierophant .-re"''"^' ""^ever.^o findlharthe .f^'^P^^^i" profeLionii,'5faced"p"' '^i^'^^^^t^tiveVar, Cnlf ''f parativelvlowoif ^^''" lower— viz fifth "p,'™Po«ant J;«ieultt iTde^rS. ^:,i'- P^^T "'-S'°'- i-ot mmmmm w?thouT Vi r'' profession, may read f'hr°.' "^'^ """s'- «••« • mBmmmm C " ~ "V ''''-''^ 'eal med,>„i ^p' ^.ji"^'' chicanery with a - ■■■aittT or wonder thatThn n^M ^'f ' ^"'^ ''- can hardlv . uch pretenders." '^^ Philosopher looked askance , -"T""' l III I I 'i . ,- , ^^^>i*-./t„i(uj ttv^ /f r-/^.4,^ fU-i^ ^^^/ / ^'^. > // y } /,-:-- ^. (-//^^ iLieFOBilIlfiTY YHfiS WITH BIC f IN HEAIIT Wonderful Case of harry B. Travers, a Lawyer of St. Thomas. Ont., Whose Death Has Just Oc- curred in That City. PHYSICIANS OF TWO CONTINENTS PUZZLED (By SpetMnI Wire to Tlu' covirler.) St. Thomnji. Mny Kl.— Harry B. Trav- ei'.«. a harri.'^tt'r. who riled smldonly in tlic AniOH A. Wofiil MnapttMl inid whose fun*'i'nl took placi* on Sniitlity with military linnors und six brnduT liiw- ypr.s actintt: as palllifartTH. Iiui) a nioHt ovontful rart't'c. IM^ [ih.\ sloal coinll- tlnn as vvt-ll h;Mi hoeu a |ni/.zle to the U-adlng phy.slcfiii.s of two .-ontlrn'nts. Mr. 'rravti> whs u Hi*\} of Mayor Travel's, a foriiu-i- K<>v«inor r»f the l.sU; (tf Malta alul raine 110:11 h lonif lin** of oflicfrs in the Hritinh Army. He was born in t'rvlon fi> >(-arH ago and conu' to st. Thomas wlH'n a young man. Hitc he Htudhd law and ht'lng callod to tlif" hai" cnleriMl into partner- Rhlp with John Parli-y. K. (\ He served .several yi-ars in tiic flty eoiin- cH and took a prominent part in nubile affair.'*. HIb w Up. a duuKhter of hla f sears 2.iro. '-v.iiT, h." n-,;*,'!.- n j-i'it'sitOtt ht'n? for life iuHunince and v,us rejected by [the Miedlcal examiner who found that I he was mifferlnj? from a large aneu- I rlsm. Other physlelans in the elty and else- I where after examinations , onflr.ned | thiB (liflKnosIs and gave him hut a Hhort time to live. He went to I,onilon, Kngland and was examined Sir ••'"red- lerlck ireeve.i, Dr. Mcf'ormli-k and I other celebrated rihysleiiiiH and iKcons who gave him but nix ioonihs I to live. HIh case being of Huoh long f '"taiidlm,- ooaslnned ( onslderable In- j|nMi and eomment n the medical uilH at the time. , H who exa^nlned H-t.o«e Mean wh« ,„„a.tureri hy „ rail I jhi!< I fc ho «,'''''■'■ '""'but Hix ..,onth»| ■fo ;ii i i i ni ! I i[ H i l l r . m 1 .1 ..II1.J. 1 11 ijip ,„mr .Wffll'Si ■j.inoa.i nipiiloal rprnrrts. Aftpr his r ■ -i.Jii to th,. city, Mr. Travprs nngaifpii in hoxlne, hasohiill, (TU'kot and ln"vn tonnls Hrid thoiisti at tlmrs In the mlrt- rtlp (if Ihf Raiiic lio rxiK'tlenrnd a "lipart burn" ho wnuM finish ns fi-esh and api.aipntly as upM as thp hpal,nrt a loral physican like "an pnginp piimp- Ing slpani." Wlu'ii tli'^ Ilnpr war brol

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P o £X tr p p CO ) -t o ^ 73 (^- J Wjl R 09 ^' •^ N ?s I I «• PI o 5 ■ Rl o O a IMAGE EVALUATION TEST TARGET (MT-S) /. .// V ^ 1.0 I.I ■ 50 ™^= t 1^ M i.8 1.25 1.4 1,6 ., 6" ► p e -rf /a 7 <^3 5>' > >>• ^ /^ Photographic Sciences Corporation s. 4 ^ ^ 4< o \ />.t % V '^ ci^ 23 WEST MAIN STREET WEBSTER, N.Y. 14580 (716) 872-4503 ^^:^ '4^ 4 n C <^ X a o to Q f «s C XX vn y*It^ ■ --.i^ ,.,jA:M''v Vtl' CASE OF ARTKRIO-VKNOUS ANEURISM OV THE AXILLARY ARTERY AND VITN OF I-OUR- TEEN YEARS' DURATION. Bv WILLIAM OSLER, M. D., PROI-KSSOR 01.M,s|,IClM.: JOHNS HOPKINS r NI VKRSI TV. AM .|0!l\s HOI'KINS HOil'IlAI.. 1 I'HV.iMIAN INCHn;i-- TO THE following case is worth placiii- on record, partlx- on account of its rarity, but more particularly on account of the lonnr duration without serious symptoms and the admirable illustration which it aflhrds of the proprietv of non- -intervention in certain instances of aneurismal varix. On December 28, 1888, I saw in Hamilton, Out., with Dr Malloch, H. B. T.,a£,rcd twenty-fwe, who presented the following condition : He is a stron^^r, healthy younc. man, with a fresh complexior , well developed muscles and a well-shaped thorax I,tspcction.~1hc apex beat of the heart is in the fifth inter- space inside the nipple line. There is a slioht fulness beneath the outer half of the left infra-clavicuL.- space, and pulsation is seen in this re-ion ; there is also slight, but not nearly such marked, sub-clavicular impulse on the right side. The carotids do not throb visibly, but on the left side above the clavicle there is fullness in the lower cervical triangle, and a distinct im- pulse. The position and appearance of the left clavicle are nor- mal. It ,s not elevated. There is perhaps slight fulness in the hrst intercostal space, near the sternum ; there is no special prominence of the first rib, or of the manubrium sterni. Palpation. -T\x^ cardiac impulse at the apex has moderate force ; there is no thrill. There is no impulse upon the sternum or beneath the inner half of the left infra clavicular region' 1 here IS a very distinct impulse in the prominence above referred to in the outer half, upon the clavicie itself, and upon the sub-clavicular fulness. There is a continuon. ^■ibratorv thnll communicated to the hand, which is felt over the whole I.; '•? I "^ iiy/././.i.v <>.s/./:a>, rc-ir,nofpi,lsatinn,anclthe entire Idt side of tl.e n.nt of the neck. Il ,. not felt on the ri-rht side, nor over tlie sterninn. nor on the pr.ecordia. Tliere is no definite t,mmr to be felt either below or above the clavicle; the enlaroenients referred to are sr.lt. and y.eld readdy to pressure. Ili^h up in the axilla there IS a fulness m the course of tlie artery. To tlie touch it does not -ive the sensation of a ls are neither blue nor incurved, and the tips are not clubbed. The pulse in the left radial is not so stron;,^ as in the rii,d)t ; there is no perceptible retardation. /Vmm/.w.-The cardiac dullness is normal. Percussion over the manubrium and on the inner half of the infra-clavicu'ar region is clear; the outer half is distinctly resonant. A;LU-u/taf/o;;.-Thc heart sounds are clear at apex and base Iherc IS no special accentuation of the aortic second sound • no murmur in the ri-ht ■ .d. or in the ri.^dit sub-clavian arte'ries Over the outer half ot the left infra-clavicular area, on the corrcs- pondingr portion of the clavicle, over the lower cervical trian;r to the attachment of Sie trapezius there is a loud continuous /?nat. This murmur is also heard with great intensity in the axilla, down the inner surface of the arm, and on the front and back of the fore-arm It is very loud and distinct in the palm of the hand and in the finger tips In all of these regions the murmur resembles an intense finaV dc diablc, or a venous hum at the root of the neck. At one point only, just below the clavicle, there is a slight systolic intensifica- tion of the murmur. Posteriorly the bruit is heard in the sub- scapular .space and feebly upon the scapula Subsequently, when the patient came under my care in Philadelphia, he was seen by Professor Ashhurst, who noticed that pressure upon the axillary artery high up in the arm-pit caused complete disappearance U the thrill and the murmur in the clavicular region. The diag- nosis of arterio-venous aneurism was made. The history of the patient is as fallows : When fifteen years of age in running cown a sloping grass plot he fell and forced a lead pencil. wh.r> was in his watch [x^cket, into his side higli up t ' ' '/ ' /v'/.S.!/ '" t'lc' axilla \y\ 1 ■* "c niust carpfni , ITnr . "^ 'T-'ii. notJnno should ^-"I quarters n ^ T""''^' '"^"^ ^^'^■'•e -sou-^ht . ""' '"^ at all bv ni r ' '^ ^°™^^'- statin.r tlntl.T ■ , '■^' ^"^'nsclled nn,„,ca,i„,, _, '">"- and b.,o„ „,, ^i^.^oV;--. ' 'lave heard from ,1., -^ -■f '- co,„i„„e,, „.e„, ""'^ ''■''"™' "">". .).e la.st si. ,„„„„, '-*-:r'°L;;;::r---..a,,d .,.,,,,„ "-Aiiaustive artirif- /r WIII.IAM n- /./.A'. beck's Archiv. Btl. 33; was able to collect only ten cases. In several of these the condition lasted for a long time ; in one five ; another seven ; and in a third thirty-three years. In the latter' after persi.stin- for all this len-th of time without anything ,„ore' tiian sh-ht painful sensations in the fin-ers,the left arm increased in volume, became u.'dematous, and the veins were distended a condition which necessitated lif,ration of the sub-clavian artery. In this case the lead i)encil, in all probability, perforated tl'ie artery and vein hiyh up in the axilla, and it is evident that the openin- is in the a.xillary artery, and not in the sub-clavian for the thrill and pulsation above and below the clavicle disap- pear when this vessel is compressed hi-h in the arm-pit The remarkable thrill and fullness in the sub-clavian trianyle and the sub-clavian space is associated probably with distei^sion of the sub-clavian vein and its branches. An intercstinc,^ point in the purring murmur was its intense transmission to' the peri- pheral vessels, and it could be heard loudly even in the fin-er tips- , ^ ^r ten cases. In .' ; in one five ; III the latter, mytliiiif:!; niore arm increased e distended, a :lavian artery. perforated the idcnt t!iat the L' sub-clavian, clavicle disap- uni-pit. The triangle and distension of itiiig point in to the peri- in the finjjer ''''"■'"'"'/' TuK l'„AnTr,ox„, C Jtx v/,K ™' <'"'«'N.O INTEmnTTENT FEVER OF ENDOCARDITIS. ^ ™' ^'HRONIC- INTKR.MJTTKNT FFVFR OV 'J'HK type of cnilocarditis elmractorUn I k ;""' - i".e,u,a.. intennitto rtn sY'^ '^'""^'^'' — Tl'o paroxysms .„ay l^iu^^ ::'''l '^^ ^'^ ^'-onbo.l • 'I'l'^- quotidian typo is L .\ '""' '^' ^''« f^'^^'''- -casionallybeend scrL. .. r ''""'"""' '^'' '''^^^^^ ^^'-^ ■■;■»-'■ D.-. Bo^d'^'o °i:;::,;e ';*:.;;::.;■; -■-•■'■■ -«""" eliiomc valvular diso..se witl, Jnt!/. '""'"' '"^^''^''^^ «f """'f''^. I" a re,narkal,t .o. 7 ^ '' ^''"''^^ Jastod four «;■« o.»,„,. «eu:;fc r:::^^^^^^^ ^'.^■■- "'f ■'•'•""■"« i-Mances, tl,o existence 'i !"''■''" "f'">»" roconk'd by Dr. Uiistowo.- A piititMit liHil nguo in ()ct,(jkT, with chills nun. ,„• twice a ilay, in iin illness of six weeks. After an interval of two or thiv, weeks they reeiureil ii; the second Week in Deceniher, and con- tinued until Dceeniher iW. She was well f„r a few days, an.l then the attacks recurred alter slcpin-' in a cold hed,' an.l persiiitrd iiniil her admission to hospital on February \i. Fei thi. four weeks previous to entrance, the attacks canie ever\ tw.dve hours rej,'ularly. A mitiniur was tiotieiMl; hut tl„ history of aj,nio was so clear, and the attacks «o elia'racteristir, that ii suspicion of malignant endocar.iitis was at first no' • iitirtidiied. It was only after the failure of (piinine, and a variation in the character of the paroxysms, that a diagnosis was reached. In this case, the most protracted with whi, 1 I am 'acipiainted, the cor.dith.n persisted for more thai ''^'' "•''". i""' l->''. IJnstowe has informed me that h, regarded tht' case as (Uie of ulcerative endocarditis from tli. outset. 1 have recently had under oh.scrvation a remarkable cas. wiiieh the symptoms persisted for nearly ten months; ;iii^l through the kindnes.s of Dr. Mullin of Hamilton, Ontario,' 1 ;,,„ able to give the notes of a second case in which the disr,,,, continued for eleven months. The clinical features of tin .. two cases may thus bo summarised : (1) Daily intermittent pyrexia for many months, the tenipn,-, turo rising to 102^'5 and 104°, occasionally preceded by :, distinct rigor, more commonly by feelings of slight (•hillill,■^^ Following the pyrexia then' was more or less sweating. (2) Progressive failure of strengtii, with varving iirtcrvals ,,i improvement. (••}; Physical signs of cardiac disea.se— in the cases h, r^ reported an apex systolic murnuir, with hypertrophv of ijir left heart. (4) Developmout towards the close of the embolic symptnn,. more usually associated with ulcerative endocarditis, ,iii,| cutaneous ecchymoses. ' Xcilnchrifl f. /.Nil. Mill., vol. iv. licrliii. '-' ./!rili\-/i Miilii;il Jiiiirniil, l.Ssl. Ill i'i:\ III! ' I'llf. till' liiu.st l>i. Miistowt'.^ .A or twicu 11 (liiy, in of two or tliri( 'ceiiilifr, and con- V a tow (lays, anJ a cold l)fd, uikI '(■briiary 12. For at'ks cainc aww oticcd ; lint III, so cliaraclrristii was at Hrst \\u< )t' (|iiiiiitu', and ;i tiiat a diagnosis ftod with wlucli for iiioru than cd iin< that Im ■arditis from th, larkahlu case ii, II luoiiths; an^i m, Ontario, I .im hich the disc.iM 'futures of thi- ghs, the tein)iria preceded In a slijjht chillinrs.. veating. ing intervals o| the oases Ik iv ertrophy of i|i,. ibolic synij)tiiiii> iiliicarditis, ww,] '"' I'-'^i'ixMihin.- Tl le anatomical cmdit ••irgo vegetative out. ion in hoti ,\Ii.ss( r.-A. H. ■rout I I ca.si'.s was th IS on the mitral val io .same, n:in ■'I'-fd fortv-tlin Ve ■'y ;"ri lotlieiaivat,. ward' of th,. '., March f.'J, |,S!);> <\Uvn\ ••oni|.l,iinii ';;■ of ""■''••'"lilt, admitted I "'"'^ Ifoj.kins Kospit.d rom ''as an e.v( ^viakiie on 'he onset of th ■"' '"'"ily •■""d persoiuil I ss ;in( lev er. 'i'h '•Evenly ye,i,-.s ago |„. | I'l'-^'iil trouble I winch he w.as e,j man there is mi i dined to hed f '". ••'^•■"■I< of typhoid f was "chronic ma ■iuy exci'sses, e.\e( i"'il''fined history o| aria. '"■''• '•' no hist. I'inl His pres.nt illness l„ .'"ccoinpaiiied by i\.^^ iii'ss; lieadaohe, l„.«s of marked sympt I" I'-'ilnaps in t.ibacco. "•'^'"'•.v, and up t.. ';"s ..njoye.l good health. ''"ver, with young IS or ot "I SIX Weeks: and wl lell a ■'>" attack .d what | "•y "f syphil "•y"". •■'uly i„ I),,,,,ni!„.r |,S!)| ' '•.yL''H'nil malaise, an.l with -•'ppetiti ;.ive us t oiiis, and also, accord "■«e details, marke.l sull MlSomiii; and iii< niiiseiilar s.jr cough WCK " "'•• I5loek, who kindh spli'en was enlarged. Tl "sion of cHint •' '"w days, and he inipiov, lii^^ business. In about thre verity of the sv eiiailC: Th lar its t '"I'tonis abated 111 'h>pnu)a with iner time that weeks, | ' ilttempf to eont :i (la ilvf, ne had a ■t.'.ising cough, and it lowev.T, thei mill' '•' \vas m;iik,.,| h)Ud ystolic murniiir at tl was noted for (J„. fi iiioinin. >-'Ver ofan intermittent type, usuall 'L'apex. 11 e ha.l ■'"Id i-anging from K y siib-i lornial in tl "ccasioiial sweat.- ffe •5 in t '"• '"'dy. particularly in the let (•-"iplainedofpainsin.lirt le eveiiiiiL le with t'li'lerne.ss over thi. foin t f iiigiiinal ''t'.Uioii, ain till' steriuin iroiii Insisted, and there w ," "' ••""' fi»'f'' ''-•ft e.istal cartil, "»'t the winter the int •-''''■lit parts (,f 'liere was igi's near lie wa: i confined to his bed for tl ■cie weakness, cough, and lie conditi.m le greater part of tl crmittent fever 'ly-^pmea, sothat iiiider-sized man of f •"1 iidmission was as foil ■TiiJ'inie, and with a sail "'"1 red; the ""■'I'"'!' volume, the t imt stifFei '"' iiiiiscula,tun le tinu >ws: I'aticnt IS an !ow CO inplex not emaciated; slinhtJ, paj)illa' ]iromineiit. Puis '""• The toiin-, led. The te ension a III bout se IS !)l', normal. Tl perature at the time of was normal. The thorax is well-forme mMisston gives everywhere a full and d le is clean regular, of 't! radials are exanii ation •iif^f^iiltation ther ■0 are heard normal b c'le costal angle good, lear resonance, .nnd on leezy breath-sound '/'///■; cinioxic i.\Ti:u.MiiTi:.\T i'i:vi:i; ffrrirf.—Tho impulse is f'ocbly visible in sixth iuieispatv, •S cm. outside of nipple line. Tlie impulse e.xtends as far as the parasternal line; it is nut forcible, nor heaving. Oi, I>alpitaHoii the shock of the second sound is well felt over th( whole pnecordial area. There is no thrill. The impulse at the point indicated above is visible, but scarcely palpabK It is mo.st forcible in the parasternal line in the fifth interspace. The area of absolute dulncss begins on the fourth rib in thr parasternal line; does not extend beyond the nipple to the left no oyond the mid-sternal line to the right. Auscidtation ir- In the apex region there is a loud sy.stolic murmur of a .son., what musical quality, -.vhich is propagated to the axilla autl is well heard at the angle of the scapula. It almost completelv masks the first sound. Towards the sternum it diminishes ii: intensity, but is well heard at the ensiform cartilage, and is feebl\ heai'd as far as the right parasternal line. Along tho left sternal margin it tliminishes in intensity above tho fourth rib, and is only ju.st audible in the second left interspace. Thc'secou^l sound is very loud along the left sternal margin, particularly be., w tho second interspace. The sounds at the aortic cartilani are clear, and there is no diastolic murmur. Both sounds ai\ audible in the carotids, the second not accentuated. There is no distension in the veins of the neck; the aorta is n„i palpable in the sternal notch. There is no tracheal tugging. .Kxamination of the abdominal urg:>ns is negative; the edoe ( I the spleen cannot be felt: the dulness is almost ent'irely masked by colon and stomach tympany. The liver is not en'- larged ; there is no swelling of the lymphatic glands. Urine— Six gr. lOlD, acid, no albumen. The blood conn! showed above four millions of red corpuscles to the cubic mm., and marked leucocytosis, the ratio being one white corpuscle tu seventy-five red. The patient was under our observation from March 1.-, U) May 10, and his history during this time may be thus snm- marised. Fever : the temperature was taken every four In.nis. During his stay he had no chills, but he frequently had sii .l,t chilly feelings. The usual cour.se of the temperature wa.s^.s follows. The morning record varied from D7°-5 to 0«'. A iis,' took place through tho morning huurs and usually about 4 p.ni <>!■' I'.XlXKWh'Diris, ig", .'111(1 is ffc'bh 'Ik. maximum was reacUl, from 10-. ,,,,,,...,, , 'lie (.■vemiiif hours tl„. f , " - "'<-'ii, tiir,,|,n|„,„t --• P-fuso ; nmre fre,uontIv H. '''"^"""' ""•^'■^'""- '"'•"■» April 14 to •>4 h f V ■ ■'", "'■" ""'•^' ■^"^^''^'^^- '"-^^ ''•'-Shisstayi.l ,,f^:,7'-^^^ '^0^ Thopulsoran'od il si , ,0^"' ''^^'^ ^^"^ '"'"- "- yonoral cunditiun im^n '',""" '""''■ '"'■'•--''• ^"Sl'tly in weight. The H "7'"'' ""' ''^^ ^--'' -y special ga^nctrolj^'H' T" 'V ''^^ ""^-' '-'' V7- at the ap.x '''■term.Me,l in tlu. a,va ofc.,nli! f , * '""■"'"'^ ''""''^' ^^ Mortic region remained cleir Tl '.'"• -^'"-' ^^0"'ih1s in tiie - U. a. the 1.^^^^ ';- of fl.e patients death. From tl i V'"". "^' '" ^''^' tl'^ temjieratnre range throu-d.o^ r , J"^' '' ^'''^''''''^ ^''■■'t ""'•^ • I" .July th, '' ,, ° ""^ f^'^^' ^^•"' •^"■"-' ^va.s from !)7^ to ^'- -- ^>l.nost normal. Earlv i j ,, ^^" V" ^'" ^-"1-- ;--' .-«ps of these were\ ti' f^t: r''^''T"r'''^"*' temperature became normal and rl. ' / ^'^^'"'^ ^^ *''^' but the pulse was weal/.id ,"", T""' ^^ ""^'■' ^'^^ ^^^'' i fi'v^t u-eek in September tl. ' '"■"'^•^- ^'"•i".^- tlie -'''"iy-he:,o;:^t:h::::r''?;r^"^"^''^-^^^ wns frequently 0-,° Thorn,., ''' / '"'"""'""temperature "«' »'i. u,..ii L .icatif ' ,,r;:,r: r, """"""''-'• *-™» '■-Sislcrd 9S", a„,l ,;„. ,. „ , ""' "''» '""Peralme o„ly „„o„ 8 Tiir. ciiuoMc isTi:i{.\iiTri:\T f/:v/:/{ Tliei(! \vci-(j iio brain syiuptoias, unci ho remained conscious until tlie last. Antoptiti (by Dr. Block) made on Hcpteinber 1(J at 9. 1.") a.m.. twenty-one hours after death. Body e.xtrenitily emaciated; abdomen strongly retracted ligor mortis very sliglit; petechia} universally distributed ovci the skin and mucous membranes; cornea.' clouded and pupii.- eipiidly dilated; depmident jiortions of body cedematous. Tliiii'iir. — Left pleural cavity contains about four ounces i,\ serous tiiiid ; no adhesions. The right pleural cavity presented adhesions in the upper lobe, of old date. Posteriorly hypostatic congestion of the lel't lung; right lung he;dthy throughoiii : [)etechial spots well marked on both pulmonary pleura". Ucttvt. — Pericardial sac contains a small amount of fluid, no evidences of pericarditis ; heart firmly contracteil ; left auriiiilu- vontricular orifice easily admits one finger; the valves, chidlv on ventricular surface, e.sjjccially of the posterior leaflet, beiiiM studded with an enormous mass of vegetations, some of which had undergone calcareous degeneration; the chonhe tendinc;c thickened, and studded with similar projections; right auricido- ventricular orifice easily admits two fingers; valves normal, jjulmonary and aortic orifices and valve normal, and the vessels free of clot, seemingly healthy. A few petechina on the sereus coverings of the great vessels, lieart muscle pale and linn. The heart ui tolo, though apparently small, corresponds with the weight of the body. Ahdominal mviUj. — Spleen slightly enlarged and of al).iut normal consistence ; at its inferior extremity an abscess ceii- taining about three ounces of dirty sanious pus, with thickeiici! wall ; a large anaamic infarct just above it. Liver. — In size corresponds to the body. Gall bladder full; iin evider.^es of disease. /v/(///n/.i — Relatively increased in size, pale, capsule easilv detached ; there is an amenuc infarct in the medullary struc- ture near the inferior portion of the left organ. The iKi-iloiuum generally studded with petechial c.\tra\a.si- tions. S/.oii>i(r/i. — Kmpty, small, coated with mucus, walls thrown into longitudinal folds .and somewhat thickened ; mucosa of an '. I OF E.\D0CARDIT/S. 9 r 10 at 9.1. Ml. II bladder full; ii.. cliial extravasi- i"ton.se pinkish hue, .„,! uniformly tin,.o.] wi*I >ub-nuicous extravasations. ° ^'' '""^^"•'^ '^'"1 J'ons, not so intense howeve. , ' ^^^^n^onh^u,, ..i-s; the mesenteric , land; I;: rrdnr^^^^^^ very much reduced in volume. ' '"t^'stuies ^ram not examined. N hir^fn,.; i ■ . ^■"Itures made. bactenolog,,r,l examir,ations or ,,^f'' "• (R^'Po't hy Dr. Mullin).-Miss F r , , '•■'"'er dieil of aneurvsm nf tl r . '' *'^^^'^' -^■ '1'^' aorta, at fiftyl,; "l. ''"■■ '"* '"'''^ "*' ^^e arch of -''.except that sL has IXerwl^riJrtt" '^"^^""' '"■ens.ons. Three brothers and o ^' "' "" ''"''^'^ ;:-ti-j..s disease of ti:3^;l^,r:,r^^ 1 1"-' patient has oenerallv onin, i , '"^'' "-"rgitatmn. y-- of age she In 1 In -ftt cf T"' '"'''' '"' ''^ *-"'- ^'■vere, as^he was mil' "^\r >l'eun.at,sm, apparently not ='""f the tin.e Abo . " ^""" ''''^'' '"'^ ""^ in bed ^''■--''^'-'paintd^gr::^^^^^^ -.""' '""' ^''^•"'•^ '^'' ''.oughtthis.4ther^ n:;:j^::^^7r'^ --1. She sometimes had a act o . "'' "^ "^" '''^ l^'^-«' -^'--^y ou taking a sti u^ n si T ' "^''^' ^°"' '-•1 'ever followed b^ n d" sw Ls ^I ?"" "'^^'^"•' ^-' ^1'*' ^'fternoon. A physician ■.; '' ^''''' ^^^'"« '^'^ i" -- aftbcted and 1 s '""'T '"'' "'" •^''^''' ^'"^ '--t n, and rest S • V'^ ^''^''^''^e^ medic.l t.eat- • "'"^ •■"■'^""'^"'- »'— r. to go about, ad 10 77//; cunoxir intermittent fever n ' frequently took long walks, though on exertion she complained of beii;;r sliort o1 breath. She had fever and sweating at night, and was often so restless that she was obliged to leave her bed and recline on the sofa. Before she came home her hair became very thin, and mucli of it fell out. It was cut short, and afterwards the colour was not so dark. Menses were absent only one montli, until March 1887, when they ceased and did not return. In the first week of July she came home, and was placed under my care. In the forenoon the temperature appeared normal, but every afternoon it rose to 102° or 103°. For a time she was thouglit to have typhoid fever, but no distinctive symptoms appeared. A milk diet was given, but when it bo eamc apparent that the fever was not typhoid, she took such forms of nutritious food as suited her taste. The fever, especially from September, was attended with sweating, more or less profuse. It was often noticed that when sleeping in the iifternoon her hair would become wet with perspiration. No local symptoms arose to account for the fevtr: pain was not complained of to any great extent; sometimes, for a few hours or half a day, there would be aching and pain in the hands and different joints, but these were always transient and at no time after she came home was there marked tender- ness (ir swelling in any of the joints. When she reached honie there was some swelling of the ankles and knees, but this souii passed away as she remained in bed. Not making any exertion she (lid not suffer from dyspnoea. There was a loud systolic murmur at the apex ; and from the first the signs of liyper- trophy showed that mitral disease had existed for some time. Before she came home it was noticed at the outset of the ill- ness that small spots appeared on the hands and feet, also on arms and legs and face, that looked like " hives." These con- tiiuied to appear ; they were erythematous, some as small as a pea, others as large as a five-cent piece, with a white point in the centre. They often passed away in a few hours, and never lasted longer than the evening of the day on which they ap- peared. They were not numerous ; .sometimes they would appear near the tips of the fingers, which for a short time bc- oame swollen. These spots wei-e .seen nmi'!' or less throut^lioiit 11 she coiii[)lainc(l jwoating at night, to leave her bcil ^ thin, and much Is the colour was inth, until March , and was placed erature appeanil or 103°. Fur a ut no distinctive but when it Ihj- id, she took sucli s attended with oticed that when Dconie wet with unt for the fever: tent ; sometimes, ;hing and pain in always transient marked ten(h'i- le reached lioine 3S, but this soiin :ing any exertion a loud systoHc signs of hypei- for some tiino. Litset of the ill- nd feet, also en vs." These con- le as small a.s a I white point in liours, and never which they ap- les they would L short time be- legs througiiout OF FXDOCAI{-)ITf> the illness, th(.iio| .Sli ic haonth remarkably uniform ■ tl Tt in this case fiom July f tyjie of fe below the normal 'e morning record al ver Was in each io;r and pointy, and the evening record ,oacl intervals f,.r a week •sometimes 104'. At ovenmg temperature ,lid not fall bel The anto,,sfj showed moderate eid \\'ays at or !iing 102''-;j, or two the chieHy to hyperti(,,,hy and aortic valves W( Pl'y and .lilatation efthelel low ]00'. trgement of the heart, d ue tu-o fin "•e normal ; tl ;crs ; the valv t ventricle <-' niitral orifice readilv ad iiuinerous I " s_^y'Hents were thickened and' Th mitte( ■"■go vegetations, chiefly on tl ami exteiuling fn),„ the base of tl I'leseiited auricular surfaces the left auricle, Tl "11(1 thickened, and MiDrtened ve.i^vtatioiis. Tl lie chorejt iG posterior .segment to t|, teiidin le SI) many of :he 'a' were a little farets in all ,st •gi's of chan T'^'L'n and kidneys cont 111 eiicru.-^ted with th ained iiumerou.s i, '- •''■"-■'>■ -'"■-^-:"::'''^:;r-:;:-:' *"■ 12 /.\T/:/i'M/TT/:.\T I'LV /■:/,• of EX/)OCA/n)/TlS. ;is in Dr. ^Iiillin's cnsr, tin- disoiise is lit first tlioii,i;lit to bu ty)ili()iil fever. In (Ji(sr. I, prior tu the onset of iiis illness, the patient Wiis not known to be the snhject of valvnhir (ii.seiise wliiie in Case II it is very probable that tiie attack of rlien- niati.sin at the twelfth year laid the foundation for clironii mitral lesions. In chronic valvular lesions, particularly of tlie aortic segments there may be persistent fever, rarely however (jf a typically intei- mittent type, and in a majority of instances the cardiac features of the case predominate. The special interest of thr ^roup illustrated by these cases is the chronic intermittent fevn with progressive failure of health and strength, without dyspn(ea, ana.sarca, or other features of valvular disease. RICHARD CLAV AND SONS, LIMITKP, LONDON AND lllNOAY. Cx X / ^ J^^i>rUac^rom the Journal op .Vervo,-., Avn « ■ ^^^°ll^!^^ff^^TAL_D..SEASE, February. ,<,,,. ''•V WIIJJAM OSLICR, M.D. -■.s l,,.vo p.»s«. si,K.e Huntingdon, in „ r,..t.lZ^Z '7'- ■•'"'•, "'-"fo"-- had observed in L„ng I H,^ .. the whole „n«e ,.f de.seriptive „„s„,„„j. there i7„' .. my tao..,edge, ...„ instance in which" .Z^^^ been so accnratoly and f„„y delineated in .so fc„ „ ^ ^o d tatis were given ; the original cases were not ^ (noM.av^ttey^ee_nMesc.*ed . bnt to H„„ti„gdo„" original ftn.il, y,,,icl the it fr V "'f'>""»«°" "l»i« «.« «..ed „„.., „ji„„ .ot^l™:s:;;:,r ;::'•'■," "r: "'•"""- could not I)e seen. I'^tncss o., the subject, the patients i. I .( 2 ii//./.f.i.M osf.r.h'. account of tlu' symptoinaUiloyy no essential fact has l)ccn added. Within the past ei^^ht years a copious liter- ature lias ^-athcrcd around the subject ( particularlv in this country), which is available to 1.S.S9 in the niono- }4ra])h of lluet.' Since this date the interest has even increased, and the references stand thick and close in the Index Mcdieus ^or the past three years. The recent paper by Sinkler ( JAv/Zo?/ A'fvwv/, March u, i.S(;2) j^ives the literature to date. The ])ractical outcome is that we now know the clinical aspects of this form thorou(,dilv, and I have nothinj^- unu.sual to ol'fer in the history of two Maryland families which I have to report; but the connection of the chronic choreas with each other and their relation to chc -ea minor are questions which niav be discussed, and upon which we need fuller informa- tion. A chronic chorea of adults and a<4-ed was reco«-ni/.ed Ion-;- before 1 luntint^clon's description of an hereditary forni in adults, which was it.self antedated in this country by the observations of Waters, (iorman, and J.von. Provisionally, at least, we may place the eases of chronic chorea in t"our ,L;-roups: I'irst t;-roup, chorea of infants, appearing either at birth or within the first two (jr three years of life. Until recently but little attention has been paid to these inter- estinj;- eases, of wliich there have been several well- uiarked examples at the Philadelphia Infirmary for Nervous ] )iseases ; one has been reported by vSinkler and two by myself, A rrsin/n' ni the literature to date is i^iven by Audry in his recent monograph upon " Double Athetosis." The cases heretofore described may be, as he says, divided into those in which no accurate account is given as to the existence of spasm with the move- ments, and those with explicit statements as to its pres- ence or absence, A majority of these eases are examples really of spastic diplegia, plus movements which may be choreiform, iremulous, or athetoid; or there may even ' De la cliorec cliioiiiiiiic, Paris, 18S9. r.'/™-/7/.;.v,v-rw,v,v/,-, ■//„„■/.., , "l..sc.nxT can , ",,',;«':■ " 'r -;"""-ly .lilliad.. „„, ing- case illustritrs ,.li,>,-,>,v '''^" '^""'^^ • i he I., How. J'cmale, aged four and n h■^}r ,. ^■.U-Inh month. Xothino ., ; I V '"'"^'^ ^'"'f'*'-^'- ^^'^o at '^^^'\v at l>irtli. it\?4 "t/'Z ^'^'''^^"''''^^^'^^ ^^'^o^'t the ^^•^>11- Xo alMi(,rm aii V Jn '/ •^"l>«^"qiientlv throve child beo-an to c vn ' - ^ ^'"til the other ;^nd could not hold .!n to a ,. n.:'"\r'^"'"^'^^ '^^-''<-ard ar movements were noti, tV , ^i' ""'' >'^^'^"' in-emi- have continued. Tect wel nt *; n™'' ''"^-'Uej.s, ami and she beo-an to [a] at the n V'" ^'""''^^^ month, walked. The ciiikl s bi-tl ,• \''',r^ y^"''' ' '^'^'^ "eve; ;vcll-forn.ed head does ^^' dd I i^^^'^^^^""'-^^' -'^h taRmus; talks a Lnbberisl of 1 V t ''""^^ ^'^ "" "V'^- word or two but wh VI ft ^V""^' ^ '"'i" «^"lv catch' a -ell. Movent j^l^ S^^'^^^' "^^-stands ^iite ^I'stinet o-rimaces; mov^LiK of t ""'-'' "'^^'^'^'^^^le; "" arms are in e()ns an \^wV i ^""^'"^^ natural. The n|le, but oceasic^:^;^ ^^^^ f^^^^^ i-egular as" Ihe fingers do not d snl-iv nH, ; f ^^^^'^'^l' objects, cannot use a spoon but rnn^f athetoid mox-ements. She The mother if u^e 1 -t /e"'^ '''''"^'" ''''^' ^^'-^^^^d. e c- -ts up well, but'tl^'hiL"^cSaiK-""""^^^f ^''- with a jerk. The feet are ev?;, i i ' '""'"^^''^ forward varu.s position, and the tois St,' f'^'^ ^'^'^'^^^P^'^ ^quinc,- toid movements. The k- s nr?f, ^^^'^'^^-^'""^^Hy in athe- ently stiif ; the muse eslriar but ./ ^"^^'^'ible, not appar- In taking off the stcK^-nol' i "^ '''''■>' '''^'" ^evelcmcd and were^ hard to Sid "? the I?"'"' '^'. ^"'^^ ^^iff Jn Ji" became strongl;- flexed "'''"• ''"'^ ^^^^ ^^'ff toes ■ 4 WILLIAM osi.r.k. This case. bfl()nf,''injr to Ww j^n-ciup (k-scribcd in litera- ture as clioiva spastica, is more properly a spastic para- plej^na with chorcifonn and athctoid movements. The following- is an illustration of a less common type, in which there was no sp.-ism and the movements were of a more characteristic kind. ^. (r.. aj^ed ei,t,dit and a half vears, the eldest of two children. The mother had twitchinj;- of the evelids when younjr, but there are no nervous troubles oY anv moment in either her own or in her husband's families. The p.ttient was a delicate inf;int. but throve fairlv well" learned to walk and to talk at the iisual time. About the fourth year it was noticed that she had irregular jerkinj^- movements in the arms, which were ni7.ved about wildly and even thrown over the head. She be- came excitable and irritable, and slept l)adly. Within a few months the face became affected, and she made (grimaces, and sometimes a peculiar {^-runtin^- noise. The leys were involved shortly after the face, and at times she walked with difficulty. When seen in iSoc more than four years after the onset, she seemed a well-'orown child for her aj^e, was not ana'inic, a little nervous m her manner and excitable, but intelli<,a-nt lookin<>-. After sittini;- quietly for a few moments, the arms jerked about and the lace twitched. The right arm is inost affected, and is twisted about in an odd wav, and lifted as \\vyy, as the shoulder. The Icf^^s are now not much, if a^t all attccted, though she iitlgets about in her chair. When watched, the movements are much increased. She feed,s herself with great difliculty. There is no spasm in the muscles, which arc well nourished ; the rellexes are not increased. There is no heart affection. Treatment has not been of the slightest benefit. She is very wayward ; and though bright mentally, it is difficult to get her to attend to her studies. There have been no explosive utterances, or any of the mental features of convulsive tic. And lastly, some of the cases of chronic progressive chorea with dementia have begun in early childhood. Second group, comprising cases of chronic chorea without any hereditary anlagc, in which the disease may set in in childhood, adolescence, maturity, or old age. JMany of the eases in Huet's monograph had no history I (.f feat ' Ih'//:///: v or r//A "-'loiva in tlu 11 rc- "V/r (//,)/,•/.;, '•^I'L'Mdani.s. J asc.s t( " M-'ai-CL'lv am- f'"-' 'liseasc has I ^'''•-^KTadually Icl •"Uiiin-,!,,,, "-• 'listinn-iiislici f ^-"" '■" rhil.II,,,,,,, "It in inanv inst >r tile '■"111 the tia. \ ery mail '■(-••-viuly iunn y cas "1 'I van'ahle j or addl :inces L'srcrirf <>nl ^I'^vltiin ^■■^ "'■ this kiini 1 KTK.d .,f tiniL-. t.)d and lave b(jc classed 1 t-'iy IS not ti y .some of til emeu. " I'eportc'd lie IV, e case s o in J I •'^"I'^'e nian\- 'leoiiim '■"" an aeut loi'ea in the /) en-iiii-hai :".^- ""l^'-I indeed in el ••-' '-■"urse, and '•'Med ean he reeov ''»'" I iNSSi » « eritieal rev o^'L'asionally u-jn, ,i le acute lew u^ eoiir '"" chron i-'ven instance; ■ie. le eliorea, iiianv of tl 'J'h it\-, the tl i^'iiinatism, rend ird le occurren '^■^L- are reallv inst (■'•^'up, ineltidinu- th •^"-^•alled Uuntin.'-d inees of e e case,' i"d the a.- ^''" it prohahle th in soeiation It ""I'ea minor. distur V pursue \ears. .- <-'^' in I'amilv M'don s chore nances, and a jm «'""ii])s, a late "•ith marked hereiirth n-'>np,eompnsin ■"«-i-essive and fatal onset, psyeliieal a ehronie md ultimatel eoiir.se, and ea.sesof el eotirse. •"'I'ea miiK "■'"11 the other f y recover, 'i'l persist for montl alvseneeof a '"■^arre m,.vement orms wc have I ley differ e.s.sent "■ which IS or even Pi-ogressive eharaete »ecn eon.sideri Pi'\vei-s. T iie f and the ret r. th e more act iv ially "M", in the elironic form of el olloWIIl!"- is entjon of j] e, quick a < !loi ■ea minor K""d ilhistrati 'le mental Alf tnfir •"i>:<' O., ane> nations in llic inlensii ui mc When I list saw liim the twitchiu- and jerkin^;- of tlu' muscles of tlio ncek and chest were present, bill the facia! snasni liad lessened. There were no mental syiiip loms, aiid l"<>r the greater portion of the period he was able to work. ()tlKr inst;inccs of chronic chorea minor in llu records of the Infirmary are ^iven in my " Lectures on Ch6rea," ' two of which are very interestinj^- from the persistence of the svmploms for more than three years with ultimate recovery. Habit spasm, bej^innin-' in thildhood, m;iy persi.st for years, and is often confounded with chorea minor; there are also a},^t4ravated forms of convulsive tic with move- ments tvpically choreic, but which can usually be sepa- rated from chorc.i minor by the existence of fixed ideas, coprolalia, etc. The following- is a record of two family j^roups of the hereditary form of chronic chorea. The cases present the usual peculiarities described by Iluntinj^don. For the opportunilv of seeing;' the members of the lirst fam- ily and for the details of the pedi-rce, I ;im indebted to Dr. Ellis: lAMiiA \. iiKsi (;i;ni:kai ION. A B., an ICnj^lishman, married C. J)., a native of Coimtv, State of , and had of issue eleven children. A. K. (lied .a<;-ed ei.t;htv-seven, and his wife a^-cd eighty- five. Neither of them, so far as is known, displayed anv mental or bodily peculiarities. Two of the eleven eli:l- dren died choreic and demented. Of the other children, two of the j^irls married N.'s. One died a.-^ed seventv-hve, leaving- children, all of whom are in j family, none of whom have shown any .syniT. ':s ^!" ine disea.se ; Mary, died of an acute illness, a'.r...-- f.iLv-five, leaving healthy i.ssue ; Jane, died Jlcdical Nev.-s, Philailcliihia, Octol)er, 18.S7 I'.iu// ■r//;.s ( '/■• ('//A'i>.\/( f •//,./,/./. ^;aivi. uuKiiLti uvfc' janies and Mar- '""'"'^' Ic-atinvs/l recall w , u-,! , . l'"';' ^'""t'"-"'"is an.I y^^ars. J lis wife. ,li.,l in d .H^^ '"'""'^ ^"■^^■'- ''"'•^v •l^v^;I-I)bc;A.rcsheNvas-fnm-; •r "lUii a few davs bef„rc her i,..,,! ',"• ,"'"^''' ^" «" ah.-u sixty.fiftl^ vear. Kx c^J Vs I, 1 •''''''"^ "^•^'^"•'•e.l in l,e she was „o-L entire vj ,,',:'"; \/''"^- ''^'f'-'-c her deall, ^'"-^ very stn.nn,y-,„^Kd;/;, :::;:•;:: ^'^^ "^-^^^^1 ^ymp -Mar^^aret M. >IV«'M. (.KXKKATIox. ^'"en.bers oHhe "^^Imilv ""^'^^ "''■ ^ '^^ve seeni;;; iii"rteni on a third: •' '■^' Performed a post- tcr..t i^s ln,l eharitvto a;;;;' he thl '!'" "I '""^^ "''^''•^^^- l>retod,sturl)cd mentality TI,>''"7^'"'V'ties of his '-;"e only by his lirst Wife < "''"',"' .^^^lee. but had infancy, but one suryiyin . Vn ''"'' children died m patient I eould not sec' ^ "" '" •^'"•"'^ ''^"alth." This [''••t£tr^e;;^;^^.^S\SS;!d^^ ^'-••- ^-^ >-'■ iK-r mV^.Vhth year She w?s "r ^^'^■^•'"'^^''^ '.^wo. in "early a j-ear befo^- her dl; li 7wf '" '^'-•^- ^'^'^ ^-^ IVnnsyh-ania Uo^viVilfLX 7 ^'''K occurred in the Jiad four children-;^ r,^' ^^"""T ^^''^-^^to.yn. She ;\i"R and in «-ood Sthi ^.u^T^: ^^'•>- •• ''^" are thirty-second year. "''^"-'^^ '^^'^"y '^ow in her .tm 8 witli tlic (IcK'tor. 11'//././. I. V os/./:r. male, ai,'-c(l fil'tv-l He ha ivc. I saw this patient s enjoyed o-ood health, and 1 been able to attend to his business until reeentl about torty-two he be-^-an t( loeomotion' was onv, weJ sion. Tl -built owiiil;- note patient in April, 1.S.S9, man; faee has an intelliwnt ex ic o-ait IS very peeuliar; he ) res- side : the movements "are in sways from side t in ataxie, but resemble rather" those of an aleo'l 'L'S not use a eane ; feet vi^ular. very unlike tho.se of lolie. lie not direeted to th t()<,^ether, with h e .u'round ■e not speeially spread ; eve.' lie ean stand with his heel.- IS eyes shyt ; no movement or arms when at rest, hut in atte sof the hands are lar<>-e irr mptino- to move ther He h; en-ular sweeps of the arms and slioht tre "e s ,^■reat diffieulty in feedintr him.se takes two hours thouH-h with and or more at a meal. He still e mor. sometimes m write, letter, but the pen, in'l inereasmo- (lifficulty. He .sio-ns his name t lip and the si Fourth child, femal since making the IS steadily declined mentallv^ and had live chidren. e, aged fort3'-three, marr One died of scarlet f ied, has "ever; the others "^ [U- oU^^ c^J- ' ^'i^^ this jxitient 1th, and lias itly. Whvn Irrc'i^nlar L'ch iK'caniu ■;<-' of a nod •an. Lately •cen oldiL^vd :1 is steadily ad fi\-c chil- the oldest of basilar Ajiril, 1.S89, ;'cnt ex])res- ■oni side to ke tliose of )holic. lie iread ; eyes .h his lieels r tlie hands nove tliere 4iit tremor, sometimes can write, ; name to a ""ten jerked ii the eyes L'ision and nd strong, nibness or kle elonus ) lij^ht and nterrai)ted "his peeu- t devclop- ;ood ; per- )n several nderstand >;oin<>; on; He still aking- the itally and Tied, has he others ^ y. ^i' o /. *t^ -^Lyl <:>>-^^^l ./ 7 Cr^-^-^^,^ \xt^^ :/^ Atsi-^:^ t-C^'iL^ r^l^ ^2c^«-c.,-*-i_«5^V .-^^ ^:eAe<_^, C^^'-^^-il^^^^t^f^- -Wt-*-^ CX-U^^-XA^ 1 ^ <- 1 "T^. '^''^ ^/ - . A.£y\J? =-'«-*^ --tL-t^/ t-c^y^ 7 'tyi-£>^\^ ^ H?, c.'t^v'' /^ce. :?i^A^^««v&v ^1 «-t-»-t^ -/L^l <::c/*«<_^, ^^e ^e-c^i?' ^:£^^ <^-*Wf^!^ /^ ^^•-t^^^^^^r^ ^ r^ <- ^aL ?^^C^. ^^^ ^<^<-'^^-<:^.. ^ ^^4/- -^^ ^e^C ^''-(.je^^.^L^ ^r 4 C<~-f/ X. f^-^^^-^i^ '^--^^^.^ 'nC<^^^ ^ <-^-£- V If ^^ ^^ ^$-tv^^^_ i5t , <^> '/^'eWi CUaLOtU ^. y^-d:^ ^--^ -M^-^^ ^^ 7f. --^^ -S-^ c^^^ "^3-—^ «0^ A.-t-,^_^ A ^'e-^^t^c^ C-Cc' '<<-e^ ;^ ^^;;.^ -6 '^^'-^^i^icAa,^^ ^^ ^>./^^^^ ';^^^'-^^- I" this ease tl'y others and iert^lin n i^L^^^S'? /■^'''''''^>' ^''^"^ '" ent, aeeord.no- to the doetor s k ei^-'fi ^-'l^'^'c '^^^"" P'"^''^" ^ , While sittino- quie h here n' -''"'^■"' '" ^'"'^ '•^'•^P^'^'t. f ments of her lunls but u •< • . • n "" "•'•^■.^ular n,ove ' jerk of the fin^^er, the V^l M -r "'"'''"f ', ''^'-''■^' ^^'^^'^ '-^ •^Hoht '-i^v, while speaki,v. ' e?^":;;;''"l'l 'nove. f„,d onecM ,- «.ntmetion of ihe facial 'mileTS ''■' ''^ "-'--^"'ar le ton-ne, and the pharvmt' 'l' „ T ''' "^* tremor of ^J^e -rasp is ^.ood; s e e-u n': ""'r^''' ''^^'^ ""rniallv; 'novements, and ean thread am. dl' ^'"•^''f ^'''- ^l^-Iiea'te appear to be the sli^^ 'T?-;.!^-;^-^;-r"^ti.:::;t^S;^ senses normal; the pu ai" ' f ' i '''"•'^^^''"" = •'^P^'^'^al ;; k^■llt ami on aeeo,Sn , bdon "h '"^ '^'^^^ and\-eaet tile preeedmcr note was m nh 1 i V'"-^ ^^^^'^"^ ^'^'ars sinee ana the niusadar ineolo; S^b '] a" '"^ ^"^""^^ ^^P'^"" '"^lie IS ncnv confined to th,> i J^as become much worse of the time to her bed ''""■''• ^^"^^ '''' '^'^ ^'reater part 'ler death, ^5i::f/:^^:;--!'-:aged. •ged, at the time of par her husband notW the b ' '"•^''"^' ^J^^^Xv-sceond ^n jerkmo- nKnxMnents of the L^sf I?"'"''? "-^ ^'^^^ ^^'^^We erect she had a trick of ildsinf h > ?' •'^3"'"R-and when standmj. upon the ball of he "SsT, ''"'', ''"^^^'^'"'-V ^"^^1 of the arms speedily followed Woff"^'"'!""'"^"'"^^"^'^ i8^o, she could walk a mile n, f ^••'^'''' '^^'^" '''-st. in fatigue, and would insist o t- '' '"''^'''''^ apparent mi e distant, repelling the u;."-^" ''] ''^''''■'^'' "^ndv a walk as well as^anothe \PtS f ^^'""^ '^''^ ^"""!^^ "-t ^" ""•'^ t^me, m walkin.^ her H. ^ lr9 'I ,l: »-t-<7' '^L::tuZ^ ^^hJ^^ yL^^c^ ^ ' i 1- lO UllJJAM OSI.ER. inf, with body would l)c l)cnt forward, her head jerk.,.^, „..„ , pcnduhim-likc motion, to and fro, and her le-^-jTmakins sneh irrej^-iihir and lar.L;e movements that slie would make wide exeursions on the sidewalk. A year later she could speech indi- ke no 1 )no-er ,^-o out without assistance." llci eated marked chanj^es very early, in her fortieth v an d th IS wa, ear. s (in 18.S1 and iS.Sj)'aceomi)anied by ^^-reat difhculty in swallowinf>- and frequentlv with c, .„.,,., spells of stran.^lino-. She was a most pitiable siolu. Sli .suffered also from procidentia uteri; yet in June. iSS^. was delivered of her eitrhth alarmin;'- e in her forty-third vear, she child, which survived but a few d perfectly rej-'ular, h avs. II er menses were er menoi)ause occiirrin<^ in her fortv- year. vSix months before her death sh e was con- :i.!4-hth fined to her bed, utterly helpless, and was fed with spoon. She was now cntirelv dcmenled. a II cou Id er deeji rellexes were rather exaj^^j^-eratcd. She ibout the hou.se at night with a.s little help as in tile davli-j-ht. She was exeeedum-1 Th y irritable and cro.ss. e clKircic movements sto]i])ed in sleei) ; there was no n, seven dl are m pai.sv ot the sphincters. Of her eio-lu childre are living-, the oldest in her thirtv-thiVd veai t^-ood health." rosl-MorUui (about thirty hours after death i. - Consid- ble wasting;- of the bodv; no enlaroements of joints; no abn«)rmal position of limbs; face a't^Tcat deal wasted,' presentin;^- several recent scars and abrasions, the result of falls. ei •al The skull-cap of moderate thickness; dura te nse menin--eal ve.s.sels looked stiff; longitudinal sinus con tamed recent clots. On the exposed cortex cerebri th arachnoid was somewhat turljid and iinu .•er.sal from the pia by a considerable laver of serous y separated this was especially maiked over the sulci. Pacch granulations were numei exudate Ionian )us ; cortical veins moderateb full. At the base the arachnoid was turl)id and the larger arteries a little stiff; the meninges were not e.spe- "'^^ ' ""' "' pi''i could be stripped with(mt tearing the substance. Superficial examinati(^n revealed no areas of softenino;, and no special les j:)ec lesions of he mi- spheres or of cerebellum. There was general wa.sting of the convolutions, which were also, on section, ratlier iirm. The gi thinner than normal. Th ly matterjyas dark, and n\ j^laces looked "" e crura presented no signs of descending degeneration; the pt)ns and medulL-rwere natural-looking: anterior pyramids had a clear, normal lAh'iirnr.s of a/A'o.y/, ctioki:.]. forln'™S:if,^™™^^^^^ a,„ i,„k.,,t.d 1,. I.r. Crav w^ m re evi^nu X t^ "T ^"'V^^^^'^'-^'-^'- '^l-'nents scopicallv SeS , s .^- 'T ''"'^ "" f "''"" ^''^'" "^i^'''-- no 's],cci-al f<.c lisc!.se Iv'v'.nTH "^'f''^^'' ^'^"^^•^'^' artcHcs and a shrink': ?'in Sn"'^']'"- '"" ^'^^ c<)nuia(prMbablv-m Hi?!^.;. i ^'''"^ '^*^ ^'''-' -'^"terior cord shio,.ca„d„e„n,,na.. .»;;:--;■:-;;:■ ™- The doctor writes that, prior to the onset of the orea." these patients and tl,eir children are in e o- „ •UK^^n^ht, and the won.en are eomeiy. The n.e^^a ^ i^the a^^oressive.enero-etie. and ferocious; the women cnt> -„eN en. 1 here is no history of infantile chorea in llie pcnod of development of the symptoms covers a vKle rano:e, from the twent.v-seeond to the sixtieU vC; he symptoms have be.un earlier in the women ^aiHn L , "'';• ^ ^ '"^'^;' ^'^ ''^V^-csent no sio-n of disease in anv lAi^ J I If- * 12 nil.I.l.lM OSI.I-R in cmhLTdf ilic third ''cncration. tl cliildrun IV past tliirty-five. TIici 'loiijr-h several of the ivniarkablu inscnsil)ility to pain in th e seems to he th fall about and l)ruise plaint. Shortly befc cast-iron key, lodi-ed in the d cse eases tl ley cniselves sovereh- without eon broke it, n, iturallv l)ruisin; much; l)ul of this she I re the death of No. 4, she struck >r-lock, with her hand and in.!^- her hand very and maim nnel c and the mother of tl 00k no notice what ever. showed much the second i-enerat i'reatcr muscular vi icse patients kept about -nd "■or than memljers of apparently pr the disease ion, in wliom, too, tlie d ementia has ■oRi-cssed more rai)idly. 'J^he pro-ress of ments are l)ut littl nuieh excited 1 i.s marked b) e under control of the >vill and :: n"cat emaciation; th e move- )y volition. When stand mu.scles are mucli affected wh ancinn- the sjiinal column and the head nu onlv th( ire )se stop durin sleencrs .U' slcci). Th \ni\ Tl -an indispositieter has. For manv years she made wild inco-ordinate movements with her arms, and toward the end of her life she c.mld "t ea aW> and had to be fed. Her mind, also, \..l^^ ^\cak. the exact duration of the dise-is(> i',-, h,.,. „ -^ -uld not be obtained, but it extended ove^sJ^i'VJ;^ She IS .said to have died of heart disease. She has one brother ivin^., aoed eiohty-three, who is said to have do di.sease but Dr. Simon visited him and retoorts t at he s only .sub,ect to ordinary senile tremor. No nf S iti< n IS available with reference to her familv Ifer n Sen "-^a^mri-m«mBmm:i iymiyk^ ^mmm '••/A-//^/yA;v OF ruA'o.y.r r;ro,,,. name was SchmirU yi , , '" ' '' U chorea (IeveI<,jH d. be<,nnnim „ "' ''';'" '''^'^^ ^''i"'''' the ''and not ced tI^-l^ ^k? f -^ " "•-' -''"'n'^ first ir,.,- i, ^ itus' danee. "'''"'"^ ^'^-'J^^'^I very much \\k^ st" . 3- Nicholas Neiter -irr,.,! i . >"S: at Kd^ewoocl Y^inS^ ^^;:;%/<;'"'^; 'blacksmith, liv me by Dr. Chas. S mo whn , ' ^^'^- ^^^' ^^■''•^ seen f ," subject to the diseai as he d'^'^T'"'' ^^'''' ^'^ ''^ evident v nate movements of the li^ s arm?" -'iT'^''"^ '"-- - '"'.he IS inclined to be child[ ' ' 'T ^''''''-- ^^^^ntallv e regards himself, howex^r a In r' '" ^''^ emotional.' health and not affected in a, v w' '^ ^'^^^^ition of perfec 4- Peter Neiter, a' ^^'^1 not '••'>m the outset. Thcvhnv, ?'^>;;^"t were general particularly when volmuarv If ''''^"^^">^ become^vor;e are severe enough to Snt hi^T"'' ''''' '''^'^^- They . t I M ir //./../. I. )f OS/. /■:/,: r! ICmotion Of frij^ht always cxaj^j^c rates tlie movcmcMits. He has not had headaches; has as a rule slept well. His appetite has been j^-ood and j^eiieral health excellent. J'^ver since the attack, eif^ht years ai^o. he has been liable to a recurrence of the vomiting whenever he takes cold drinks. He says his memory is quite };'()od. He does not think that his speech has lieen affected. /'/iSi/// C'(>//i/i//;>;/. Thv jiatient is a larj^'c, well-nour- ished, well-built man. The face in rei:)ose looks intelli- i^'cnt, but on smiiii)if-, the exi^ression is fatuous. He answers all (juestions readily and freely; <^ives a .t^ood account of his condition, and it is more in his expression and i^eneral behaviour that an indication is found of mental impairment. When sitting- in a chair, at ease, the arms and hands are in more or less constant irregular motion. The iinj^ers are extended and tlexed alternately; sometimes only one. sometimes the entire .set. At other times the whole hand will be lifted or there are constant move- ments of pronation or of supination, i'or half a minute or .s(j they may be perfectly motionless. The head and trunk present occasional slow movements ; in the latter more of a swavini^' character. The lc<;\s jerk ir'\.-';;ularly and the feet arc llexed or exteitded ; but the mo"emcnts are not so freciuent as in the arms. The face in repose is usually motionless, but the lips are occasionally brought together more tij^-htly and the chin elevated or depressed. There is an occasional mtn-cment of the zvj^'omatic and of the frontal muscles. He puts out the tonj^ue, witli tolerably active associated movements of the face, and it is usually ({uiekly withdrawn or rolled from side to side. It is impossible for him to hold it out for any len^^lh of time. There are no in-egular movements of the palate muscles. He walks with a curious irregular gait, displaying dis- tinct inco-ordination. swaying as he goes, h sitating a moment in a step, keeping the arms out from the bodv and in constant motion. The legs are spread wide apart ; steps arc unequal in length and he seems rather to drag the feet. He stands well with the heels clo.se together. There is a suggestion of stiffne.ss about the g;iit and about the way in which he uses his legs. vSen.sation is unaffected. The deep reflexes are in- creased. There is slight ankle clonus, exaggerated knee- jerk, and slight increase in arm-retlexes. The special senses are unimpaired. Pupils are ol innvcmcnts. »t well. His 1 excellent. ! been liable • takes eold 1. He does _', well-noiir- ooks intelli- tuous. lie ives a j^ood ! expression is found of and hands otion. The ; sometimes r times the -;tant move- If a minute e head and n the latter ir'V'^ularly mo'-ements e in I'epose :illybrou<^ht r depressed. ;-omatie and oni^ue, with face, and it side to side, y lenoih of ■ the palate playin*^ dis- ^ sitating- a n the bodv wide apart ; her to dra^' ^e together. lie g'ait and !xes are in- stated knee- ipil.s are ol /■.//.■//:• //A-.v or ruR "ie^ n(. fever; l),n\x.] •^ IK' speeial ehan ■s are i-i ^•ft : thev ■e is no nv.s. -;'es. lei 'f^iilar, and i\ le '•L'P'Tt of eases of the 1 <'<'es not afford th oth iL'iv are jjrobl iere(h'larv { ■' very wide se.,pe for ,1 or and t '<-''ns ill the relat orni of ehorea i.^cussidti; j„|t literature point (1 o ehor ea miiioi', !""<"■ tlK' forms tueaeh «-re,ssive ehoi '•"■'Kilt, are still f view may ])e \-erv briellv \\'hieh. if I I irom lave read tl •^i-'tlled. M lisorders a.s.soeiated '<-'•'- '-^ a maladv d •■stated: fh le >■ own wntres or path 1 with coarse '■^tinet from t ronic pro- lesions i<-' x'arious ti"n w-hieh (like f ^n-'wu as symptomatic el <'l th famil les or in si ormsof museul lorea- "•regular, ineo-ord ".^■'L' individual '11' atroph\-) m, li.'^turban "aeult <-'<-'.s, and mate movement ■'^. and is eh ^ motor an affee- '>■ "ccur in les. eh Thi Pi •'^. a reel in •"^•i-e.ssive imj,airment 'I'aeterized bv .^•.^ait, speech "I'ea minor, bei of iM-iedreich'sat; "lovciiients d iher from il "' the mental 1.^; slower, and resembl i"se <,ij(^rx tt-T of the for ^-\'ia, without t to the iner disease. M le bru i"J4' rather th III ( )se movements of d ore over, ■^qiie. jerkv char m strikin; ;ic gressive chore, -V cert I are ""•^•;i minor, those of eh ai n number of tl sometimes in/ii, t-'ontrast i""nic pro- le cases of eh "■"Kin infancy and childhood but t.meed by the will I'onie chorea b a very much lar parapleg-ia m- dipl ■«vr number are in'st JL'long- to this cates 'onns of chorea min <-\^'ia; while othe :mces of Ch wholl hav or, i"s rei)i-e.scnt a egin- ;ory, ■ipastie nonialous ronie Pi •o^-ressive chorea is, I bel apait from the affeeticmd leve, a d 111^ nothin ^•ourse of acute ehor y in common with it but th escribed by S.vdenh isease :im. tile arthritis, th ■fa minor, the <-' name. The fre ■quency of endoeard e seasonal relati incidence in child ent characters of iti,' •t( ons. the extr, :iordi ren, nary th e movements ab «ay nothingr of tJie diffei'. I^epanite it as a Well-defined affe <^n a virus as yet unknown. lOV -tion, depend e referred to- rn y y possibly '^-a2i^«^i j» S!^T:^!^!^!^l!^nu^^ ^,,,^,^ j^^^^^^^ ^^^^ 18!)3.) NOTK ON ARSKNICAI. NKIIRITIS POLLOWINfJ TMK •'«E"t-KOWM.:U'.S SOLUTION (,4 ,-,1^,8),. Bv Wm. Oslbr, M.D.. F. R. c. p., j. lONDON. During the first few years of ,„.a„r t "«i"« arsenic somewhat s ar nl r "'"' '" '^*' ''«^'"' °f Hramwell's paper in 877 f.^' "'^'"'' "'^ ^PP'^'^rance of '0 "- i' ™or: free.,, anT l " ^I: t^ "'^ ^^^-''^ anaemia, in leuksemia in rin,J ,b - > " ''"'''""^ '^^'-m^ of have used it i„ w^Jm " ," ^'T, V'^^"^*^' ^""^ «'-^«* ">inor I ^een to begin with tw of th /: t^^ '""• '^^ ^"'^ ^- «raduall, increase the dose ^r. rfi'^^^ " ^^^' ^^ patient took ten, fifteen or ' ., T ^ ^^^^ "»f'' '^e tl'ree times a dal. I Iflrr.d? ™""u"^' '^ ^""'«^'« «°'"'ion either itching of the sk. i" f '?" '^' P'^^'"'"«'^«' ««"-'«. or diarrhoea.' The ^a'^.'th ^h :?;:; ^^^ ^^' ^°"'''"«' varies in different individLrs atl "" '"^^ ^^"^^'^^^^ who bear the drug best seeZt """""'« ^^''^^ 'hose 'argost doses I hate g e Tw" iTT" '':. ""' "P'^'^'" l'^^ in which the patient had taken ^rT ^^^"'''■<>»« ««^«>ia, 'he greatest benefit for se !, ^ f " ^"■""'^>' ^"^^"^ ^''^ -'"tion three times da ;/ k 7"'^ """"'^ ^^ *^°-'«r'« thirty minims three imesa'davl .T'^' '" ^'^ -'«P«« had an attack of itchirof th^e'e rf '^' '"^ '^^ * ^^^^ h« eye brows. ^ "^' '^^ '"^«' »"d «dema over the In the chorea minor of children, who, as is well linown, stand arsenic well, it is a common experience to find that twelve and fifteen minims of the liquor arsenicalis may be civen daily without ill effects. Until two years ago, though I had often seen the symptoms of saturation above referred to, I had never seen any serious toxic symptoms referable to the nervous system, but we had at that time in the ward a patient witli pernicious anremia who had taken for a long time large doses of Fowler's solution, and under its use had feelings of numbness and tingling in the feet and legs, which we thought might he due to the arsenic. This may not, however, have been so, since these advanced cases not infrequently have sclerosis of the posterior columns of the cord, in connection with which loss of the knee jerk and sensory changes in the legs may develop. 1 have repeatedly in my clinics and ward class talks referred to the apparent harmlessness, so far as my experience went, of Fowler's solution. On October 25th, 1892, the patient before you was adrjitted to my wards with Hodgkin's disease, the cervical, axillary, and inguinal groups of glands being involved. Having had under observation for now nearly four years a case of this disease, which has been remarkably benefited by the prolonged use of Fowler's solution taken at intervals, we naturally placed this man upon the same drug The details of his case, so far as they relate to the lymphatic disorder do not concern us. The arsenic was begun on October 27th, given as Fowler's solution, and gradually increased. He took it on the first occasion for ten days ; it was then resumed on November 14tli, and in two weeks the dose reached fifteen minims three times a day. Towards the end of November it was noted that his skin, which was naturally of a somewhat dark colour, had a much deeper tint, and that of the abdomen was very distinctly hronzeil. Throughout the month of Decembe i /^ did not do well. The arsenic was stopped on the 19th, a d '-egun again on the 27th. From the outset the patient has had that inter- esting feature in many cases of Hodgkin's disease, an intermit- tent pyrexia, and as may be seen by his last week's chart, the lfr333S3^«J&iii;'£.'d-■,a^^^af^i:'■ '"> ""'ked closet. He has n„ ra ,v „ fh " «° '""' '''' "^l '» »■» good deal, but the le t „ t ra"'?' '"' "'"""• "-""' ' .-, »ithi„ the past trith, :;eer\t'r''''"r »hich were present on Januar, lOih . 1 "' ■'"'"' On February 2nd D hL , T "'"'"'■ •Wit, of the nerve, of the le li"""""' ""> '"<"« e«i'- reote wa, „„,» m. and h' '™""'" '° '°"' ™- galvanic ,timulati„„ wu iec^edlv slo"" '"T? ""'""'"'^ "'« larger, .as at least e,,ual !:; f^ o"" t '"' ™f '' '' ""' rn the arms is not so 8trilm„l„ j- ' / ' , ""^ """eular power feeble in comparison wt ^ i 'rr^'^J""'' "" >""" " of the muscles does not nnn.o u ^yper sensitiveness Bee»ee„the2;r;orCni::",:r7r- . patient took 54 3I m i« '. .V, "''^ ^^f'' of January, this e^juivalent to about 16^ ..ain. .(1 ■' P"'""''* ^rsenitis, -ent,-five da,s there we'e f rtr"'." ""'• """^'"^ '^^^ was omitted. The marked ' ""''''" ^^^« ■» ^^hich the drug pai-ent of musclar;: /"JTh:'"^'^^' ""^ «-^-' - the symptoms indicate verv clear v he '"'T'T '''''''''' '' nature of the affection • and h„ . 1 ) r^'P^""'' '"^ "^""''° in which, as in cancer ;r ub S 2" '" ^^''^^"'« -^^^-'^^ Ft it seems more rational to" Lr^^ ™''' '^"'^P' to attribute It to the somewhat J li t-i s ^' prolonged use of the arsenic, more particularly as he has had also another striking feature of arsenical poisoning, namely, pigmentation of the skin. Arsenical neuritis from accidental poisoning is not very uncommon. Less commonly it results from accidental con- tamination in certain occupations. It is claimed by Folsom. Putnam, and others in Boston, that cases may be of " domestic origin," that is, due to the absorption of extremely small quan- tities of arsenic with the dust from wall papers, carpets, or curtains. Cases such as the one reported this evening, in which the toxic symptoms have developed in consequence of the administration of arsenic as a medicine are in reality extremely rare. A few years ago Dr. J. J Putnam collected a series of cases in which serious poisonous effects had followed the lon<^ continued use of medicinal doses. A majority of them cannot be said to be very satisfactory, as the reports are imperfect as to the amount taken and as to the symptoms. Among the cases referred to are, however, some which would indicate very clearly that the prolonged use of even moderate doses may cause symptoms of a widespread neuritis. Individual idiosyncrasy plays, no doubt, an important role ; tolerance may as a rule be established, as with the Styrian arsenic eaters, but such cases as the one before you show that we must be on our guard in the protracted administration of the drug. irly as he has had •oiaoning, namely, aing is not very n accidental con- aimed by Folsom. ^ be of " domestic emely small quan- ipers, carpets, or evening, in which isequence of the reality extremely llected a series of followed the lonj^ y of them cannot are imperfect as 'ms. Among the mid indicate very ? doses may cause iual idiosyncrasy may as a rule be ■8, but such cases on our guard in UNIVERSITY |lEDIC/^L "WaqAZINE. ' 'inillU|.>TArF :-sB ^^^^ ss?^- c v: >cx r APRIL,; isfea NO.K O. . «,„._^^^^^^^^^ • - Bv W11.1.1AM OsLBR, M.D., -rores^r of Medieiue i„ th. Johns Hop.i„, cler.ity. I 1 j! '■ i is •N'OTIC ON- A ^'=';'ARK^BI.K HOUSE K.>,r,EM,C OF 1 iPHOID FEVER. BV WUJJAM OstER, M.D., ITofcsorofMecIicinei,,, he Johns Hopkins University. Grac^ Md"!'" ^'e a'c'a;e'i,rr' "7 ^^"-^'"g^-'. «bove Havre de typiioid fever: ^n'^^-kable history of a house epidemic of oce.n^;?^y!";;l:hJ^-w:?:i^Ldif " ': ^^^^^ ^" ^"^"-- ^^^ his home in Baltimore Augu t g fnd '^ ™^^^"^- "e returned to mother's home, and was ill for J; , " '^' '^'^ '^"^^ ^'^'^ to his and had. according Toth d e^ ""'^^'^ '""'^^ ^"'^ ^'^''-""^ fever. There had been no p^e^ilul ^ T"'"' '^"^^"^ "^ ^>Pb-^ house, and it is perfectly clear Ztl!^ 7'"^ '''' '^""^"^^^ '" the Cask II.-HIs wife a p f h ' ''' ''"'^ '^'^^^ ^^'^'^ ""Parted, of September with typhoid feve'; we'll n,"^' T^ '^'''" ^'^ "^^"' ^^^ ^9th At the end of four weeks she was I 'jr^';' ^^^^'^ ^^^ -^° to :o4^ rhages, and again was ill six weeks but uldt TT' """'''' '^' '^»«'- Case iri.-His sister M I . "'^'"'-^tely recovered. ^9th of September, had a v;rv bfd'-X, td"" f^f '' ^'^^"^ '^^ Cask IV.— j. b a sni^r ,„ a sradiwHy recovered. ..»% had. je.e„„;;:4e:::;vr^^^^^ a„d .... ■ " ■~'°"" "■■ '''' '• ™ °^ W„. E. rcase I), ca„.e .i.„ his (I i . ; 2 William Osier. mother from Baltimore, and was taken ill about the third week in Sej;- tember. He had a mild attack, with fever, abdominal symptoms, and well-marked rose spots. Cash VI.— John B., aged 35; fever began toward the end of Sep tember. He had headaches, diarrhea, and a tolerably sharp attack. Convalescence began about October 17th; the temperature remained about normal until October 24th, then he had a definite relapse, with fever ranging to 104° and 105^ From November 8th until the 14th there was a period of apyrexia, and then the temperature rose again, &iid I saw him on the 26th in what appears to be a second relapse The temperature has been up to 103° and 104°, and on several occa- sions 105'. On the 25th, for instance, temperature range was between 101° and 105^. He has been delirious, and has had several chills; great pain in his legs, and very great tenderness of feet, especially on the soles. This case was away from the house at Annapolis a short time, am! was the last to take the fever. Cask VII.— Nurse T., taken ill on the 17th of October, and was removed to the Homeopathic Hospital in Baltimore, where she had a well -characterized attack of typhoid fever, of which she died. She had been in the house forty-two days. Case VIII.— Colored nurse of child; was taken ill about the loth of October, went to Baltimore, and had a definite attack of typhoid fever and died. She had been in the house twenty-six days. Case IX. — Mi.ss G., nurse, had been in the ho.,.se fortv-two days, and was taken to Philadelphia, ill with typhoid fever, and died in the third week of the attack. Case X. — B. B., a sister, had also, according to the doctor's description, typhoid fever, but she kept about the house, and would not go to bed for any length of time. During the months of August, September, October and November there were ten cases and four deaths. The house, a comfortable, old-fashioned, square stone building, is situated on a ridge in the beautiful rolling district of Hartford County, only a few miles from the Susquehanna River. In front of the house the ground slopes rapidly toward the roadway, which runs ilong a narrow valley. At the back of the house the land slopes more gradually. At a distance of about seventy-eight yards in front and to the left of the stone house, and about two-thirds of the way down the hill, is a comfortable frame house, occupied by the tenant, with a family of nine, of ages from 14 to 85. About seventy yards further down the valley, close to the roadway, is a spring of clear water, close to which is erected the "spring house " for dairy purposes. )lis a short time, aiir :ober and November RemarkaSfe House HpUe.nic of Typ„oi, J^erer. Opening from the kitchen of Mr n' - i extension, there ,s a covered stonn n u ?'"' ^^'""^ ''« ^ ^-shaped i^ a cistern, square, wUhT depth o ''''.''\'''^'-''^ '^- Aoor of which bottom of which is ten fLt belowth ' "7 "f "''^^ °^ ^^" ''''' the and was last cleaned ahou X ^''t?"""- ^^^— ^^d- water from the roof and at o>ie L'^^ ^^" '^''^^'■" ^^^'^^^ts ,he spring, which was pumped up by ITJ^T'"''' T'' -- "- ago. "^ ' "^ '^ ^'^^ This was abandoned years Immediately behind the kitchen ., v feet, is a woodshed, and a orivr ,^ '• '^''^'""" °^ ^^out twenty ground behind the C,: . T e^oUom' f'lh^'"'^' "^ ^^^ ^'^^^ °^ the ground. The difference in LveTb "1 *' ^''^^'^ °" ''^^ ''^''' "^ and the top of the privy is M B hinkT K ' '""^"^ "^ *^^ -^^"" tically is the situation o'f the surfoun wl T^ T '"• " '^'^''^ P^^ comfortable ; the rooms are larje .! d i ^°"'" ''^^'^ '"^'^^ ^^ whatever in their arrangemen ttTc.] V '°"^'""'^"^- There is nothing Dr. Sappington wrlteTthVt ^f^'^^l'^^^f ^--^^-t. brother, who did not go tto the t, ^"^^'^°'^ ^°"-«ted of another drank the water, as did also a tlo ed Z'""'' "T' ''' ^^^ ^°°^ -^ (Mrs. B.), also Dr. Sappington dra.lfr 7 T? ''' '''° '^'' "^^'^er often had his dinner at the hoTse a /'? °- '^""^ ^'^^^- ^"^ ------week,:-u^^;:tr5;ir-:- one ^";^ "c^s: ni^^^^r r ;^ ^- ^^^-^ - -- fault, since living close by and usinl th . ^'?^ '""'"'' ^^^ "^^ at of the tenant, every member of h-? '"^'"' ^'''^' ^^^« '^^ ^^nnly remain, either the food suppLs or the k •".'''''• ''"° ^^^^-^^'-' way infected from the fistSsrwhi ,,"'"'"'' ^^^^ ^" ««"^e likely view, or the disease Lsp^'trr-V'' '' '^ '^^ ^^^ ^-^ which Dr. Sappington holdr^ery firmTv but "^ h f T"^^^'""' ^ ^^^ washmg the kitchen utensils CuDon wWi, '''^*^' '''^''' "^^^ for -I'll <^,-•— '»tl,orax ; euluT ,n the cavity of the lesser n. ^'"^Py^'H'a- The pus may l,e when perfora.,., c'f the o!: r or S oTr.^"'^ V'^ ^'^'""^'^"'^ '"^' -- occurs, and the abscess is then chi fl. T''^' '"■ "^ '''' duodenun,. P'>-g- ; or it „,ay he between ^h^^^T^''' ^" ''-"^' '-'^ "f the dia- phra,m, in which ens. ,he al sees ,- 'u f °^ "^'-" ^''''' '"•"^ 'he dia- thouKh usually shut off. The .lies f '' "'' ^'""""^ Peritoneum, ascending colon, or of the appendix or fr """r .^°"' '^^"'''■'"■'i""" "f il„. containing abscesses the mo t txouL,^ \'" '"'"' "''^""' '" "^e a,,- occur on either side, as ,n the c^se I th T "7,' '/ ''« ^orax u,av condition, reported by Dr. Gardner t nf M , '"^ nttention to this pneumothorax extended as hig! as^H k'T ' '" "^''^ 'he signs of which, ;.../„,,,/,,^^ the diaphrim ^ f . "^^' '"terspace, and in interspace. ^ *''" ^'^^ '^"""^ at the level of the tl.ir.: abscess, in consequence of'the'De!f!!rl-^'''''!T'"'"" "'" '''" ''''^■™ntaining -" a perinephritic abscess ' T^ " ^'-,^^"1°" ^nd communication phngm and produced a „|,. ,. ,. ,u "' '' " ''ad perforated the dia In Cask irr .u '^ -»' 'he right base. ,., ^^''' '"•• "" the other hand, there u-,s . II ■ kidney, an empyema which hid Jrf ! , ' ''^""^"'"S '" ^'ry u> i„e phrenic abscess received it at ,71 f T "' =""^"^"^ =he sub- what unusual. ' '"'^^'^ ^'•^'" 'his source, which is so.u.- and-on:i::::;::;:^-;:<^-"'c ab^^s are ofd„ubta.letio„,v, and .he^ood^results whici 'Z:::;'.^:;:^'' """'^""" ^^^'""^-•'' pne«moL;j: ::;:p;;L; i;;^:,;;^^ ■" ^';^h the diagnosis ofpyo. tollowed operation. ^"^^ '^"""« hfe, and in which recovery ^^-^^St-:^---~^^ OSLUK: CASKS Of' SUH-PH l^i;\[C AMSCESS. I ! '■ : Case I. History of dysentery ; symptoms of ahccss of liver : develop ment a>iitic resonaiiee in the n\'/it lower axillan region: diagnosis of pro - pneiiniotliorax snl - phrenieus : operation, reeovery. julin S., ;i,-;ecl thirty-six. was admitted to th- Johns Ho[)kiiis ilosp'tal on January i6tli, iSyo, coninlainini; of fc-vx-r, diarrhea, and |)ain ii: the abdomen. There was nothing of moment in his faimly history. Mr iind typhoid fever when twelve years of age. He had gonorrhea, but ni.-, sypliih's. He has l)een a very hard ch-mker for very manv years, b, September, iS88, lie had dysentery ; not a very severe atiai k, a- he ua- not laid 111) ill ''ed ; !)Ut the stools were frequent, and he passed blood and imicus. He has not been entirely free from intestinal trouble since, bm he has been able to keep at work with but few interru|)tions. Latterly he has lost flesh, and within the past six weeks has become very weak and feverish. On several occasioi^s the feet have swollen. He has had n,. ehills ; has never been jaundieed, and has never had severe pain in thf region of the liver. He stopped work two weeks ago. Condition on admission. Emaciated; weight iifi jiounds ; aneniu , muscles flabby; skin hot, dry, and salLnv ; eonjunctivie white; tongiK pale, uidentKl, and with numerous aphtlious sores on dorsum and sides. Pulse 96 ; respiration 30 ; temp.Tature IOI^ Langs are noruial, with the exception of a few dry creiiitant rales, probably pleuritic, at the right Ijase. Cardiac didlness begins at the f(;urth rib. There is a soft systolic ap^x murmur. The .second soimd is reduplicated at base. Liver. No [irominence in hepatic region. No tenderness on pressure. Dullness begins in nipi)le line at fifth interspace and extends .about 4 cm. iulow the costal margin, 15 cm. in vertical extent. The edge cannot W distinctly made (Hit, 'I'he surface beneath the costal margin is not rough, nor tender. In the median line, dullness extends 3 cm. below the tip (.i ensil'orm cartilage. Si)leen not palpable. Area of dullness not increased. The abdomen is symmetrical, a little full, t\nipanitic, nowhere tender. Lxamination of blood negative. b'rine. Specific gravity 1019 ; reaction acid. Trace of albumin. Xo tul)e casts. The stoils were frecpient, liquid, and contained much iinicus. From the history of the case and from the appearance of the man abscess of the liver vvas suspected. For the first ten days in the hosiiital the i>atient seemed better. The numlier of stools in the day reduced. He had no chills. On .several occasion^ he sweated iieavily at night. 'The temperature range was (Vcm 98" to 102°. BSCHSS. Yfss of Ih'cr : develop • rii^Jit hnver axillar\ 'ireiiieus : oper.ilioir . > tin- Johns Hopkins , diarrlica, and |)ain in s family history, i 1, d gonorrhea, but nu; ery many years, li, •ere atta( k, a- lie ua-. 1 he passed blood and lal trouble since, Iiid -iptions. Latterly he •come very weak and en. He has had no id severe pain in t!.e I 6 pounds ; aneiuit . Ctivaj white ; fon^iit )n dorsum and sides. i.u;.s are normal, wtli Jleuritic, at the ri^ht is a soft systolic apex nderness on pressure, .j-xtends about 4 cm. The edLje cannot be margin is not rougii. cm. below the tip !,| sed. itie, nowhere tender. ace of albunun. Xo uch mucus. )earancc of the man ieemed better. Tlx ) chills. On several ure range was l"r(iii) '■'Sr-'^H: CASKS oi-- ■'^t'H-PfJKICN'lC .AHSCl'S;- On the 2A iiLjIit ren.d w l-th it w •^^ noted that " i| nes X ion, i)c>t o didlnes 'duited 01 lere is ,\\. "imaniial >^tinri tend lie lateral rei ■s in tne right Hank. I, iialpatinn. \() erne ■"''^ 111 tne .itu 1 e.xte nds to th "'" : in the post iver dulln •''Pccial fnll- anuary ,Stli. '-■ '"osinl margin. '^■'■lor a.xdi.irv li •-'ss IS not in ne It be erea.s iJi'is at the eighth rib illy lie' tender 'loiiceableat th ness on the ri>d Mpuard. diere was 1' lere <: '(i'-ed he t: I'x'remity of th nght sid;. has i !<-' a d <-' tenth r isiin d' when ncreased, and fn percuss I'L sense of j "flween the ninth atu] Hevenil "•" •■' ii'nurka.blv t "nnessand tes) pressur stance. It is e' is nia.de fuincture, in ti <-' teniii ■i on tile r ^ ■"p''nitic j o (lav 'ercussio n noit am few fat In ti; iierh; f'unt of curdy, thick interspace, p,,st sine. .\ crystals. The f, pus, whicl '■'■I"|- a.\i!la;v 1 '1 (-^'piorator., ^" right flank tlie /I oilpwing note was d "-•ontained altered I"'', <>b:;iined if-tated :'ll. and >1«. sli.;lit th ■iense of ereiscertainl ngers can "leieased pnssed wi points of the te .V ;-,'roat resist; nth and ness. die rigiit sic I'Vom behind tl nice bel ^'t-'i'tli ribs ; ]; resistance. With ow costal toward the kid iK'y with ''I'linnual palpu lere is d Lie ther is no dist and inct tender i^'inct finln nitercostal spac es are 1: '"'irgm, and especial!) "so marked t ra-scapn|;u-reg ion e IS al )elow L'ss i;i theitil eiiiier iiiid-ste ness m riial hue, riglit luiiiba extends ti r s lower tiiargm of ih iree liner, L're not so we pace be)-ond. 1 1' marked. Th loll on e hfth to eis hrca CO.'- pulmo.'iary note to 1 •'^tal border. \ dth (5 iver dull ere ness in 5 cm. '" "ipp'elin.', fr breadth on the .•- I'.vieiidi <'>ver nvu-gin of seventh r sixth. 'I '1 mid a.xillary hnc tl "), and. ng Irom exactly th oe.ow, the most lere is didin ess f)r oni lere is a I linger's where it passe However, to be riorlv, th s on insen e -seventh inters alhc tvi Sll) 'y y, tne metal Ik .Vnte 'iehiiul. It extends to [ slightly dull into bowel t e.xtrenie met pace to upp,,,- margin of el npaiM, ynipanw note tyn jf( ■Pii eve dl 'tn. ere leloie bowel 'Pany extends i PiissKiii m a.xidarv 1 H'sterior axillri o within 'ympain- is >'Oes appear, reachec 4 cm line. Vlloiiet ine is ler, tympanitic ar distinctly llati \\, inc. Ill ;i line drawi ea oeciioi er, and ih len iiiriied 1 at th pl'ienic air-comaininir ;,i e level of totl le surgical depart On tl) K abscess inent. d'es p(;silioii of ensiform cirtil; ^•'is nia.Ie, and ti eie IS niova seventh to t iL'e. .\ nipple 1 'n side, prr- >'i ' dulint-s--. '•nth interspace •nagiicMs of ;i SI, le patient was traiisl, e 29th Dr. ]{. ;^'iitb 111) in the mid istei. a.xilli resected al)oa ,^'iiiiitoiis pui, which had ry li "c, and rem I'^^'l-aiient rallied well from tl 111 acid react! t an oved UK '' 'iml ■! half of rred tiic ■eiiruary 2nd. T iiperature. His le operation. on, aiul very di i''"iit a litre of a thick liinct odor of ut' iei itic note is ev le last f general eW (l; lys til .imphoric en more im conditi ^■patient has had a shght.k on, iiowev vonnt. ation en in cnaracter. h c^t, -se than before tlu er. is .J. ends ant en ir ly operation, and as fa ■e lympan- " is almost r as the nipple liii(.'. " osi.i:k: casms oi sri!-i'HKHNic abschss. where it is only lo ( ni. from the nipple line. 'The area is triangular in sha()c tile iipex beini; toward the sterninn. It is 15 cm. in transverse diameter Tile liver seems pushed far over into the left h) pochondruuii. lotli. Simx' the last note the p.itient's condition has rapidly imijroved. The temperature has been but sli;,ditly above normal, the sweats have stopped, the diarrhea checked, and his apjietite has become very gucd I'he wound is dressed every day and the cavity irrigated. Dr. HaKtti.ii is now able to [)ass his finger far down into the flank, reaching quite to th, level of the crest of the ilium. .-\ Hat tympany e.\tends in the mid axillarv line from the lower margin of the eighth to the iliac crest. 14th. (ieneral condition remains excellent. 'I'he cavity hasreduccil very < onsideialily and the discharge has lessened. The improvement continued, and the patient was disc'iarged well C,\\sii II. Tiilicrcuh'Hs pyelo-iu-phritii ; tuberculous colitis; perj\n:i tio/i at splenic flc.xu'c of colon, 7i'ith the formation of a peri nephritic air eoutainin,!^ abscess ; prominent tumor over tenth, eleventh, and (ioetf/!i ri/>s />ehinJ ; incision an J drainage ; pulmonary taberculosis ; deatit . autot^sy. In October, 1887, I saw, with Dr. R. H. Harte, of Philadelphi;i, a else which illustrates a somewhat unusual form of this condition. IT- was a young man, aged about thirty, who, as early as 1880, had pa^.scii blooil and clots with the urine, and was sent to California under the iiiip:es>ion that iie had liright's disease. He lived a [iretty hard life, and h.id been treated for stricture (jf the urethra and ii.-itable bladder. WIkt. Dr. Harte saw him in July he had lost much flesh, was very pale, but was still fairly muscular. The urine contained pus and blood ; the bladder wa.^ \''r\- irritbale, and micturition was very frecjuent. Ivarly in September he had chills, which were supposed to be malarial ; widi th.ese the fever was high, and he sweated heavily. In the middle 01 Octob; r diarrhea of an obstinate character set in. When I saw him hf w.is pale, somewhat emaciated, with an irregular fever and occasiotiai cliiils, which were evidently of a septic nature. He had profuse diarrhea, aiid the stools, at times, contained bmall quantities of pus. The urine was \eiv lujruhnt. On examination of the abdomen nothing of special note uMs observed, liehmd, on the left s'de, beneath the skin over tenth, elevemh, and twelfth ribs, there was a prominent tumor, somewhat hcnii- s[)herical in outline, an 1 nearly ecjual in extent to the palm of the hand. It was soft, not specially tender, and, on percussion, when he was in an erect pasture or on his belly, gave a most remarkable tympanitic note. On the other hand, when he was on his left side or back the note was dull. On coughing there wa^ a distinct impulse in the tumor. .Antei mrly, there wa> nothing to be fell on deep pressure, but there was evident thickenin- and pain in the left lumbar region. It was thought at first that this (irojection "^aVtAi^Mtei^aJ liSCHSS. OSLHR CASKS OK Stra.pHKKNlc ABSCKSS. ■ident thii'kenini' nm! it tliiit this [irdjeciion ™«~i^;:r;;;:LX- • fr-^ely the a',.... There was ev JJ ' '"' '''■ ^'^"'^^^ '^'^ "P- co.n^u„,cat.ci with the colon at the splenic 7"'""',""™""^'"' ■'' '-<^ « "ch would adnm a lead penril ,- ,e " T """'^^'' '^'^ "P^"'"" I--gm and produced pleurisy at the ri ht b "e''\ ,'' '"'""'"^ ""^ ^i'- P-^rcss,n, tubercular disease of tl^ ^n ' ^'" "'^ ^^'^'^^'^^ -^^ -;ecl a „un.ber of small tui r ulo^ J"'' "" ^'"'' ^''^-^ pre- ='-^ ened and contracted. ^eZed ub "T"" '""' '"'-'''- '- ■in abscess of the prosta. .^,^; '"^^^1 '"''erculous ulcers. There wis were thickened and ulceu.uct ' ^ '"'^ "'^' ^^''''''^-•- ''''k- ureter's J'^econdition has been met with foil • • • -e, which was trans/erred \o n J ^^I? '"^7' ^ '" ''- "ollow.n, Un.versuy Hospital, Philadelphia " '^"' ''^'S^'^'^ ^'^e at the Case III. Injury to am, a,>d hnrh ■ 1, . ■ asthenia: death ; autopsy. '~'^^'^"'o^'o, 0/ fetid pus; septic fever ; ^^^^^^^^^^^ to_ the surgical wards wheels of an engine. The left an„ ua cr' ',/.'' .""" '"'"^ ""^^'•- '^e -""d. The arm was amputated at ih ^^^ '^ '^^ ^ ^-P -alp '' '-""cl he complained of a n„„ ' . ■ "^^ ^'''' "" ^^^^ he had ^--■Wa, and he con^plam;;? ^ ^^ ''it ^^"^ ^ ^^^ ^^ '^^ -yMpelas developed in both arn,\n f ' /''^ "'"''■ Subsequently ■Kimrssion signs of inflammation applardrtl "' r" '""'^ ""''^'^•■^ ''^^•" mdicated by a rise of temperature IT ''^' '"fra-scapular region an. h. was transferred to^he^m ^^^ ::j ^'!;!, ^^'^'^. ^'^wing breathir; ! ■>ln|a.st healed. E.xamination of t J ^^ ^ '^ ^'"-P '^'^ this time had dullness at the left base, extendinrnea L asT ' --"--n-bed -apula and, laterally, to the mid-ax h' V " '' ^'^ ''^"^^'^- "^^ ^^e .^'™"^l-d;on auscultation, fee t il ? • ''"" ^'^^^''^ ^-'"'tus was ;;'P'"'-n, rales. Slight coug v'er ^ "^''"^'' ^"'' «" ^-P '^risy was suspected. Tbo condition r ""T"'"' '''''''■ '^ ^^P^ic f^^ several weeks, during which there w^: '" r'"'"''"^ ""^•'^'^"g^-'d -"•P'a.ned at times of pain in the ilia7 "'' " ^^'^^''^ ^^^^^ He '"' '•'^^''"" ^'^d left side, particu- 8 ()S[.i;k : c.v:es or sui-.-itiki-mc ahsckss. I larlv when he I'lew a deep lirealh. Ho soon began to -pit up f. tiM [)iis, and in iw ty-fonr hours brought up several ouncps. It was con . chided thai a locahzcd empyema had perf-irated the km;,'. C)n exann nation, tympanitic resonance, amplioric brealhinj, and me'allic ral<-. were found low down in the po-,tero-hueral region, beneath the eighdi, ninth, and tenth ribs, indicating ])neununhora.\. The autopsy s!)Owed the existence of a large abscess behind th( left kidney and descending colon, extending from the diaphragm to ilu: crest of the ilium, 'i'he chief part of the abscess lay above the kidney and beneath the diaphragm, and in this region there was a distinct cavity, partially occupied by dirty-brown pus, similar to that which ibr patient had expectorated during the last two days of iiis life. Part ot the diaphragai -as in a sloughy condition, and two orifices, through earh of which the point of the index finger could be passed, comnuiii-:- cated directly with an abs^css cavity in the lower lolie of the left lui)-. ■j'he pleural membrane of this part was greatly thickened, and there wa^ a small localized empyema betwsen the layers. There were areas of recent broncho-pneumoiiia throughout the other lolje. The left kidney was small, and presented at its upper part a distinct cicatrix, to which the capsule and adjacent tissues were strongly adherent. The sequence of events in this case was, probably, as follows : Wound of kidney with bruising of tissue in lumbar region; sub-phrenic abscess; localized empyema, probal)ly from contiguity with sub-phrenic abscess: perforation of diai)hragm and lung, with discharge of pus; developmetu of a sub-phrenic air-containing cavity which gave, in the lower and lateral aspects of the left side, the signs of pneumothorax. I regarded this case, when admitted to my wards, as one of sei>tic pleurisy, passing on to empyema and perforation of the lung. The physical signs of ]ineumothorax were of the most characteristic kind, and I must ccifess that it never once occurred to me that the air-containing cavity was below, not above, the diaphragm. C,".\sK 4. Ac/f/e ilhicss ; si[i^>/s of empyema; operation; pleura J ra . evacuation of lar^e sn/)-/>hrenic a/>ucss. John M., aged twenty-four, lirt:- man, admitted April 30th, 1892, complaining of pain in the right side cv the chest. Nothing of any note in the family history. The i)atient had measles when young; otherwise has been remarkably healthy. Denies excess in alcohol : admits gonorrhea, but has never had sy[)hilis. His bowels have been regular; he has had no abdominal pains. The present illness began about a week ago, with headache, loss of appetite, lie kept at work until two days ago, when the pain became very severe in the rmhi side of the thorax, and was much iraviited bv coughing and during a deep breath. He is positive that there wa s no chill, but he has had one B. ^^fClii^li^MiSti^iSs^^^ OS!.Uli CASKS OF Srn.PHKKMc AHSCKSS. or two heavy sivonts I' i '■- '-^ ^- fiv;.;,e„ loin'SM:;; ir"': '^^^ "^^" '--• -" ^^^ '•^'";' 7"- '■•«-',„„. the left Sid.' r"^;"'\'''^^^'^^'"'^"-'-"".-dl.no„r. -/---'- o::r;::-^^^ on the...... «' 'I- "Pf^er border of the st.th ' n '' '' '"" "^^'^' ^ '-^"- resotunce.s defective at the ri-ht '"' '»'""'-T line Behind, the -^ P'-Jbly there the hne of ^wt^ ;"" T " '""'^^^ ^^"'-■>- ^ '"^ ^-- '-he frenm.s is dn.,nishedX",e I "'''" ^'^''^'^' "•'"' ^'^ '-- Auscultation is ev - i ''"''-''''• '-ntshedin intensity, and i^ ,L ^ -eT'"^"^' ''"" '^'^'^^ ^^^'^ ' '- '^^V -les Ti,e condition of the l^a^ tn "T^" "^"" ^'^'^^'^ ^^ ^ <-. I he abdomen is full ■ the '"''''■ "0 glandular enlargemen;, and Th^' '""" '""'-^ ^^^ "" tenderness d;.^tn,ct increase in the si., of th 'l ' T' 1 ''"'''' ■""-■"t w.s thj ' t at the costal n.ar,in. Tk't^^^Z^^ 1'^ °' '"''"' ^^^"^ '^ -^i' P'-^-d'- There was marked leucor osif "'T " ''''''' '""^ -'^'-'•■" ''°"'~^^'°°° ^^hite corpuscles per The urine [)resented a trace of niK • specific gravity 1020. ^"'"'"' ^^-'^-'^ ^^^'^^ nmber-colore,!, acid • The patient had a sli.rht coujrh ■ i expectoration, in which there .ere nil ! ' "^"™-P"^"'^"t. ^li«iuly bloody '-- evident durin, the first wcSc h ^thrr "'r^^" encaps,= latec[ ^■^'^■^' .'"■ ,E-ry day the ten.penu r ^, 'iT '''' ''"' '"^'-'^ «- occ..s,onally reaching ,05^ ad o c,' 10 ' T^'"""'^ '°^° '''"<' -4°. ■- to r.o. He had at ti,„es hea y swe.ts /' ''''' ""«^^ ^^^ ^^'-n ;d two severe cl,ills, in one of i; ^2' "'^' °" "^ -^ of May he 'h;-^" nessat the right ba^e persis d ■ ''""'""^ ^'"^' ^" '°6..^ "'""' ^'''- •-•"d in front in the r.cu hi .' """"- '" ''^^^ ^^^^^ ^^''""t the -"-d very little doubt to,)r n" '"' T""'' '' ''' '^^'^^^ -^- Th re -t .here was pus i„ the p^^""^^'"'''.^'^^^^-^^ the case ca^" 'r""^-" "'^tainin, any pus " "^'^"'^"■"^' "^^le was inserted """"« I he second week th ;;-i^ted until May the 8th, ar^d then'lirr'"''' ''''''''' ' ''' '^ver between <;;» and 99=. -phe sok en ° "°'''"^''' ^1^^ ^ange beins, -t, hut he seeded aK^: 'Ur^^n '^f ^ '"^^^ ^-^'^^'^- ^^°-^adu„nuuioninthe,nn.berof ucoc^;; " ^^'' ^'- blood count ^^"~ '3,000 per c.cm. The lO 0SLF:K : CASES OF SUB-PHKIiNIC ABSCESS. temperature remained low, and patient seemed to be soinewliat better until the 151)1, when it rose to nearly 105°, and the pain in the side iiad l)ceii. worse ever since he sat up with the bed-rest two days a>;o. Yesterday it Ijccanie very intense. The physical signs have scarcely changed. There is still flatness from the fourth rib, and behind from just below the angle uf the scapula. The apex beat of the heart can now be accurately localized, and is in the fourth interspace 1.5 cm. outside the nipple. 'I'he respiratory sounds are feeble and dist.int. On the i6th the patient was agnin aspirated, and this time pus was found which was a little stained, and contained the staphylococci and micrococcus tetragenus. Shortly after the aspiration the patient was seized with a tit of coughing and began to expectorate a quantity of reddisli- brown, anchovysauolike sputa, which was examined for ameba, without finding any. It was then determined to transfer to the surgical side lor operation. Before the transfer the following careful note was made; " The patient is propped up in bed ; the right side of the chest seems a trifle fuller than the left, the upper part looking more nearly equal. Motion is defective in the lower right front. On the riglit side flatness begins in the upper sternal line in the third space, at the upper border of the fourth in the nipple line, and at the fourth space in the mid-axillary line. Posteriorly, flatness begins at the angle of the scapula. In the erect posture the upper limit of dullness in front appears to move slightly. On the right side the percussion is clear. Respirations are clear at the apex in front, but diminish greatly in intensity over the flat areas, and is of a distant tubular character. The voice sounds have a somewhat nasal quality. The vocal fremitus is only just perceiitible. In the infra-scapular regions the inspiration has a more distinctly tubular character, and there is very distinct egophony. The liver does not appear enlarged downward, and the border is not palpable." The case was thought to be probably empyema, though the possibility of an hepatic or subphrenic abscess had been considered. The following is an abstrnet of the report on the operation by Ur. Halsted : The eighth rib on the right side was exposed by an incision from the axillary line to the nipple line ; a portion of the rib, 5 cm. in length, was excised. It was found that the costal and diaphragmatic pleural surfaces were adherent. An incision made through these and the diaphragm opened at once into a large sub-phrenic abscess, which was freely evacu- ated and packed with iodoform gauze. The patient reacted well from the operation, and made practically an uneventful recovery. The discharge of pus gradually diminished, and he had fcver only on two days. He had a chill on the 30th of May, and on the 3rd of June, atler which he had no ■B», fiinher rcvcr. ijjs wci'mIii rh^U^^d August ,5th n'uh oil^y JZ.ul!" '^' ''"""'''' ''"'' ''^' ^^'^^ <1- '-' August 3,,,, ..S,a,complai„in./r,.: ' T ''*' -'^°""-y. adnm- d:phthena t.vi,:., but l.as b...;,. unt^l L't > "^ m '"^^''^'^■'^ ^"-' ''"'^' F--; -lincss began ,!„•,, „ •„,, X", ^'^''^-''-'^'^^ -' ■ ■ »•" -I' "« 'lie left, and there i, distinct l",' ''"'' ""* "^°^-'-- "^'''^'•ly so spaces under the nipple. ' ^^^'^'"^'^ '" ''^'^ fourth and fifth right Percussion on the riwht .sid ■ ■ ^he infra-clavicuiar space, g^uluX'sln "'"'"'"' '^^"^P^"'^'^ '-e^onance in '- 1'- or dullness extending ^^ t7\ '"'' ''^""^^ ^' ^'^ '"""h rib. i-Uhove the angle of the .scan -f l 'T "'''''' "S''™ '" ^ Po^n^ ■^'«'ilute flatness in front is clistinalvhi-W %"'"'' ^'"'''''' ^''^' '■"-'-'■ -flat regions. The respirato > S"' ' ^'''^ '^-i'- is absent in •!'-e parts, where the ,e.pH-ato,^ Z ''"'"''"^ ^'^''^ ^^^^P^ ^^ '^\;f the physical exan,!natio; is: ^ Xe'^ """'^ =^"^'"''^- °» ^^- , i'ere .s no expectoration. The .Z i ■ y^ ''-^- The first s.nM is louj^J , "^ ^""'^^•- ^''^ ^^'^ nb in "- --^in of the sternum was l>^a^L'7' 7' '" '''''"' ' '^'^^ - «'^^ a suggestion of a thr.ll ,u ,h.. ! , !'" "^''^ 'f ^- ^n palpation there ^" d-tole, but no definite nn^i^ ^?^^' ^f ^'^^ -^ ^ ^^.h* echo jca on inspection : the liver dullnes".^ '"'""' ^"^"^^^ ""'^'" Ijelow the costal 'lie coiuraction of inarym. •J' lie b,.rl extend jwlpable. The the altdom er !s !s three fi patient rem lined not accurate iiial muscles. The ed. '" the medical ".i(ers breadth ly palpable, owing to e of the spleen is not vards for five day.s. The ll- I ■ If ii 12 oslkk: casi:s or sub-phrenic abscicss. temperature ran^e was from yS' to lo^s'- He liad no chills, sonu sweating; tlie pulse ranged from no to 130. On the 7th, pus was drawii off with an asjjirating needle, and the patient was transferred to tlie siir gical side .villi the diagnosis of emi)yenia. 'I'he pus was creamy-looking, but no micro-organisms were found. An operation was performed by Dr. Finney on August iit' . About y cm. of the ninth rib on the right side was excised. .Xn aspirator needle was then parsed through the tiiickened iileiua, but seemed to enter a soliij mass, and nothing was obtained. On a second attempt, 250 c.c. of pus ■were withdrawn. Tlie pleura was then incised just above the diaphragm. No pus was found, but 100 c.c. of clear serum. The diaphragm presented at the wound. The pleural cavity was shut off as completely as possible with strips of gauze, and the diaphragm was incised with the Paciueiiii knife, opening into a large pus cavity with ninnerous pockets. About 100 c.c. of pus wore evacuated. .\ rubber drainage tube was inserted into the cavity. The [)atient did remarkably well, and the teuijierature fell. He was dressed daily ; the discharge was free, and he gained in weight, and left the hospital on September yth, still with a slight sinus. -V. AP.SCIISS. le had tiij chiils, sonir 1 the ytli, pus wasdrawji s transferred to tlie sur pas was crcainy-lookirij:, I Aui;ust nt'.. About 9 _d. An asjtiratnr iK-cdlr t solmikmI to fntcr a soli'i attempt, 250 c.c. of [)iis .1st above the diaphragm. rhe diaphragm presented IS completely as possible ciscd with the Faiiuuiin )iis pockets. AbcKit 100 jl)c was inserted into the le teMi])erature fell, He e gained in weight, and ;ht sinus. hjS^^i.r'^ ■ ■m ^ ""^x m ^''■'r..t.'ss,„- „r .v,..|,Vi„,, .,„|„„ „ ,,, 'V ■^'•''■' '"^"'■'"""""'■'' ■--•"-"^-'-^.-M.... ..,..,, IJ () S T O N PRESS OF DAVID CLAPP & sON. 1898. TUIJRRCrJLOlJS PLKLTUfSY. Mr. PltKS.DKNT AND FrlUWS •— '"Hi Without mnkin.r i„vi,|i,.,,, ,.,,.. "*'^"" /'"' |>le.i.i8y; >i-or„„e.pe;:.::^: 'z-:r'i:r;^^'''•'"--: r«; In the poi,t-mortem room ~\ t,,. * . "r.i,c i„oi,ie„ce of t'^>,^r.,.iZ^~;i :T;:r, rT «..;.e^e..,e,eve,,,w.a.,:i:;rj;:t;::;",,:!;-^"''"-'> Accoraino'Iv. with fl.^ i ■ i • '^^' V " -^ ^''® ''^'"'J ass stance of F).- p I i.«v„ „,„.rf„,i,. ,„„,y,5j ,1,^ „„,,..L„<„„; ':„,';. '■ ■ «.cce,„v„ ca.e, ,V„,„ ,„y „,„„,, ,, „,,.„ „,Xlfil " THE SHATTUCK LECTUUE. 1 I tlu; record is of intcro.-it as showing the incidence of tuber- culous pleurisy in u medical service varying Ironi 70 to !)U beds. OF the 101 cases, there were o2 in which the pleurisy wiis definitely tuberculous. I liave estimated as such only those in which tidx'icles were j)resent on the j)leural layers, either as fresh miliary granulations, eascous masses, or diffuse fibro-tuherculous membranes. Of these cases there were eight with piuulent exudate, all associated with pneu- mothorax, a:id two with luomorrhagic fluid. Seven were cases of acute miliary tuberculosis with fibrinous and sero- fibrinous exudate ; four were instances of acute miliary tuberculosis with a i)urcly fibrinous effusion ; and thirteen were cases of chronic sero-fibrinous exudate with more or less thickening of the i)leural layers. In four instances tiie sero-librinous exudate was encapsulated. There were thirteen cases of pulmonary tuberculosis in which pleurisy was present without our being able to say definitely that it was of a tul)e;-culous nature. In ten of these eases the exudate was fibrinous, and three sero-fibrin- ous. It will thus be scan that the incidence of tuberculous pleurisy among these lUl cases was a little less than 32 '/f , By far the most common forms of pleurisy arc tiie sero- fibrinous and fibrinous secondary to acute disease of the lungs, orocciu'ring as a terminal process in chronic aflectioiis of the heart, arteries, or kidneys. {/)) In the ivards. — Passing now from the certain and definite data of the ])ost-nu)rtem room let us turn to the wards iind in((uire into the etiology of the cases of acule pleurisy whicii iiave been unde observation. I have thought it better to review only tiiose cases in which there has been a pleurisy with efi'usion coming on acutely or sub-acuteK', and in which the pfFusion was sero-fibrinous, not simply fibrinous and not purulent. I have excluded the ibrnior from analyt' because of tiic very great frequency, as the post-mortem reports siiow, of ii simple fibrinous pleurisy in TOBK,.cl,OL:s IXKUHISY. '•' '"»'<^ definite ,.,„d nvll ' r ^''''"'''' "« "-'.v have ^'-n the n.ct U.. ahj ; " ;r;r'' "'"'"^>-' -" V-utly -•« -■'''-• .d.nine.l direc.lv ? ^^ ^"^'""' '""' """ "-^e. '>ver at once. Thi. nru- ■,; "'" .■""'^'"'■■'' ^^'"''^ '"• tmncd ^'^'-•^-nceorp:: „ :':^':^^'^^•'--l.aU..na,.k- pne.in.uthurax. Still h . ' 1',' "'''""'^ '""' ^'''-' '"^^fanee.s of '"""Wins »ualv6i,s, i|,„, ,,,,„ , 'V ''"> "»«« ill li.e "■'■"' '"■" '""'-I «- if 1 "'"*"»' "• "'^' -"* -^--■^Mvei-ea,;;, 2;;;f *»'"• Of ,l,e '•'« ; -1« ill llic „.|,it„ " • '" """ "1 llie colored ™''''»'"S:f:::;:;r':"f-'«"'-i»*.iie.ii,.,.. »iiisi,lore,l , '"" ">' ""■' '""""-ilia ,,„i„„ ,,, ,„ ,,„ l^'iist : mode of onso^ T '^f-y -n.ent, .ineeU nui i::'r' l^r^-'^ '---^^^ ^''''^''^-'-ide,o.lJ::i;^;:;;;-";'-.p%witha ->;et .« .no.e co,nn,on, h„t hv no n.e-, ."s el ■ '"^^''''""^^ It IS 8„ cases; between two and thr(>e weeks, 7 cases ; one niontli and over, 25 eases. Of tlie symptoms f(H- which they sought relief the fol- lowing were the most striking : In two cases no history could he obtained. Of the remaining r)G cases the symp- toms for which they soug'it relief were as a rule cough, dyspn(L'a and pain in the side ; more rarely fever or cliiils and t'tivcv. Tims in 4f> cases tlio patient complained of eougli ; in 41: of dyspncea ; in 11 of pain in the side ; and in 11 tliere was a history of ciiills and fevc;-. Cough and dvspncea are by far the most frequent causes for wliich the patient seeks relief in lnqiital. In two only of the cases did the patient gave any definite account of an ex[)Osure to cold or of a wetting. As stated, the onset is no etiological crite- rion, and the claim at present is that a great majority of the cases of i)lcurisy a friffore arc in reality tubercidous. In the history obtained from the patient, however, there may be very suggestive features ; lor instance, cough ar,d lo.-s of weiiiht for some months previous, or hiLMno[)tysis, or u previous attack of pleurisy. Thus, one patient, Case 1 of the series, had had a cougii at intervals for three years, and when admitted the right side of the chest was full of greeni.-ii, sero-purulcnt fluid. After many tappings he imi)roved very nuicli, and, though the cough had persisted for so long, tiiere was no sign of pulmonary disease, but subsequently bacilli were found in the expectoration. Another inter- esting;- case, No. 4, had luvmoptysis nine months bcfoi'e, and though he wa< an extremely robust, vigorous man, tin; insidious onset ot the pleurisy led us to suspect tuberculosis. Bacilli were demonstrated in the exudate. The patient subsequently developed pulmonary tuberculosis. In tuo instances only the patients had pleurisy with effusion pre- viously ; in one five months before ; in the other eight yei.rs before. lioth did well, and both were discharged at the end of three weeks. js ; between one 1 three weeks, 7 it relief the fol- eascs no history cases tlie syni[)- s a rule cough, ily fever or chills t complained of the side ; and in ):•. Coii^h and es for which the V of the cases did ex[)Osiire to cold etiological crile- it majority of the uhercnioiis. In \ever, there may , cough and loss haMno[)tyBis, or a itient, Case 1 of three years, and s full of greeni>li, he iin[)r(ived very ted for so hnig, but subsequently Another intcr- ! months before, [fforous man, tiic [)ccl tuberculosis. ;e. The patient :ulosis. In two ivith effusion prc- other eight yeiirs Jischarged at the TUl!i:i{Cl-LOUS I'l. KUIilSV. A second the f now ii( f tl point, on which acts J"^^tify. i« the tlimilv 1 """•e stress has been hU] tl o .i^f'erally acknowledged to be of le L'criii ifj.Jc T 1 ,. - >•"■'" '''S''If. Local cond lan incjc is ii ■susceptible soil,, -arclv "^^^"'■y; hut inherit ""P»''f"nce in influencing the agent so widely disfused as tl 18 interesting to note tl 'tions are probablv „f 'iisceptibility f most t of tul o !iii infectious 'ereuh.sis. Still it in tl le ascendants '0 presence or absence of tubercul '"• near relatives ; tl losis e'gl'f cases the fhther died of tJb '"■' '. "' ""«' tl'c father an 1" "lie, a broti lerculosis ; ler; in ,six. in f our, tl le lei uncle •"•J i" two the wife died of >"d sister ; i„ f, 1)111- husband. fn 'i? ^f th 'ercuiosis in the fainil tub and in tl Third tuberculos cases pos-'ive quest fi brother or ■'III aunt or "^. in one the y were answered in f| "•^■c 't could not be obtained ions ;)S to le negative, Ti lere is noti '-^'U'isms are g-wi.. cultures, aj^ '"'""""•"''"" ""^^'''"^ ^ "' """ '-'^P'^nence is in aecord with 8 Tin-, SIIATTrflC LF.CTUUK. tilis, excei)t tliat in one cas-e tlie tuhLTcle Ijacilli were (lefinitoly dotenniiicd in tlio exudate. Tliin was after repeated tappings. A sterile efliisioii is regarded as a point in favor of the tuI)erculons nature. In tlic [)urulent tuber- culous exudates tiic bacteriological results are al-^o variable. In some i>f tlie acute eases, as in one which I sliall describe shortly, the Iiaeiili of ICoch were abundant. In otiier instances only ])us organisms or the diplococci are ])resent, or there may iie no micro-organisms. A more important and more satisfactory test is the inocidation of the exudate into the peritoneal cavity of guinea pigs, experimenls whieli in the hands of some of the Frencli obser\xi>: ha\(; yielded positive results in the scr()-fil)rinous and [lurulent pleurisies of individuals apparently not tul>erculous. When i'Coch's tuberculin was in vogue it was hoped that it might at any rate give us a means of Dositive diagnosis. The rei)ort ()f the (ierman hospitals shows that in ihe subjects positively tul)erculous the great proportion of them present reaction, wliereas in susi)ectcd individuals rJ'Mit (!() per cent., and in non-tuberculous subjects only al w. 25 percent. Subscquer.tly, in speaking of diagnosis I ,ill narrate an instance in which the acute reaction to tuberculin led us into a serious error in diagnosis. And lastly, the nature of the pleurisy may not be ap- parent for months or years, when the onset of ii tubercidosis in other parts may indicate cleaily the character (jf the whole pr leess. You are all familiar with the striking statistics published of late years, none more interesting than those bv Dr. N'incent Bowditch fron) hij father's records. Such statistics from private practice are of infiniteiv more value, as a I'ule, than those from hospitals. The time li.is !)een altogether too limited at the Johns Hopkins Hospital to deter- mine, even if we coidil, the sulisequent history of the grcii proportiiin of the cases of sero-fibrinous pleurisy which ha.o been under treatment, it is interesting to note, housv," e l)iit'illi were liirt \\;\ii after rded as u point )uriilont (uher- ^ iili'o viirialile. r s: liiive yielded uleiit pleurisies lay not be ap- f a tuberculosis er or' the whole ikinir statistics ing than those TUnKKCULOUS PI.EUKISV. in strilv-inn- contrast to f5ir„,es f ii- as our I'eeoni ^^'■qii-ntly had tuhercul IS ?,"), only five of tl '•"'>i .'^nnie hospitals, that so it-v-^e patients i,ine sub '•»}• no means in favor oft! "«'■«• While our hospital )rinon.-. sero-fi! confess (hat e view that a I li'urc are pleurisies are of a t irii-eprop,„tion of all llU'l "I Itrivate praetlec I I 'i'>oiciiloiis nature, I must ■'-'.isinoly inipreesed by the i iive, year bv year, beei .]ccts of pleurisy with eff '•<'qnen<-y with whieh the -u\ culons. ,SueIi eiu A few months ai^o I 'Lvs as the toll iision siibse(jueiitlv 1 Ul)- 'ecoine tub ""■'n,^- are not t„if of fine 1)1 SfiH' Dr. Martinet "tninon. Instoi n-.q..o and general ;,ood health, and exeell •y- In t! f a man aged 40, ■nt family ", '"'."■"^'- "f ^^'■^■■^ I'e "« c-ause, pleurisy on the right si,I ■MS seen on several oecasion was aspirated twiee and mad V '(!, and in tl hoiit illHl i-esuined his work. Tl s ''.V Ih: W. s. Tl <" a very satisfactoi lis attaelv He layer ■y recovery. veloped basil "•CO months subsequently In ,U Tl cli L're was nothi "•"H>n'ng;ti.,ofuluchhediedi„tl "ir in the cond ■"•>cter of tlH, pleu, tuberculous nature, but tl if'O" of this patient .V to justify the 'le onset of a niei rec weeks. <>i' in the " '""-^ ^•""'•■^« Ji'<« tl'o tuberculous f, suggession of a lingitis which .■■.„ etc., rendered pretty clear tl '■Ml, with St ral vei •y similar ease I remember in tl H' nature of the p,.„e( il-.lS, leiigue, Dr. Ross of :\r wit I mtrcal. 'c praeti.'e of my 1 ai(! col- ' pleurisy on the left side and the I l"'eviousattacksoveralm..ntlisl young man w; ■listorv of h •liniinished, but si of tl ^ns of local d IS before. The effu admitted ivin^' had a 'e right lung. About tl 'sease developed at tl ;'"•" ent ..titis media developed on tl ii-ce montl,-^ after ad siou gradually 10 apex mission a niiiireal 'iiortly by me l'i'''l "-eck. The^auto.isy'sl '0 left side, followed ineiiibr liloiis li fines on the left sid yiiiptonis, of which he died i„ .;I '"'^v-ed greatly thickened pleural le It>, many tubercles and local tul onions liseasc at the ri-rht anov ,v;.I . , " " ,' '"""'- meningitis. ' ' ' " '''' " '"^^ereulous basih.r I '-e seen recently a young man with an advanced pul- 10 TUK SHA'rrUCK LKCTUlfK. I ! inoiiarv tiiberculosi.-, wlio cnnsulted me tirat in I'liiladelplua in October. 18dl to 'it chxvicle witli a >er<)iis exudate. There is no tultoreuh)U8 historv in his tiuuily. The dii^ease set in in.-iidiou8ly with couiili. He was tapped hut t i; 'e, and i»<: lapidly gainetl iieahli and strengtii. 1 did i.ot ,>ee liiin again prot'cssionally until tlie aiitHu\n of LSi)2, when he liad li id iuaclii "i' i^evere prostration and si\ortness of breath, but very little fever, hince tlien, sr'igns of local disease have \K'vel iped and extcnitd, am} tu!)ercle bacilli are present in the ex[)ectorati!>ii. (' ;^<•a such ks these could be paralleled I'roni the iiuu' b.^iks of any physician in large })ractice. The cases from ti;o wards which have developed puhn xiary tubercu!u.-is '.vii; be described later. II. Clinical Tyi'es. Tul)e>-cuIous pleurisy may be part of a general milian infection, but it is rare to find tiie pleuritic symptoms dom- inating, or even pronoimccd enough to attract attention. In reviewing any large number of eases, the character ot the onset and the quick or slow course offer the most valu- able features for classification, and separate two types, to wiiich may be added a third, when the pleurisy forms part of a general serous membrane tuberculosis. . i ]. Acute Tuberculous Pleurittij. It is difficult to say, in our present state of knowledge, the proportion of instances of acute sero-fibrinous pleiu'itiv due to tuberculosis. The cases are rarely fatal ; a large majority recover completely, in a few the condition becomes chronic, a variable number develop tuberculosis. ^lore than tills we cannot say, but clinical and anatomical st.' U- enable us to separate at least three groups of tubercui -■• cases in which the o:;.^^t is acute. TUBKKCULOUS ri^KUIMSV, ^ ......c,,-,,:;'!;;;:';::;;; ■ "x; '- "'° ■*• '--• »"«". 'l'0'« I.C ....,.y,l,i„„ i„ „,„ „ " •' ■ "'!>■ ^»r may cxci.o ,„,,,,:„i„,, " Tl,c off™ '"""" ■■" "'" •" ■ ^ , ^ ettiision aii"-iiipnf< .,,,,1 ♦! ■« t"PPe cral ni(intli8 in I inoiitli before ivo a very clear pital at Wa.-ili- de, and iie lay a jj;reat deal of : Patient is a ed man. lie Is the left side. r ; respirations jr high ; radial arc on adniis- rjrer and move- )ulse is seen to t front as far as the fourth and ft side theie is 'r into al)S(dnfe ; ; at the third over the whole it over the Hat tid)iilar. On V. The heart rnum, and are d. TunriKcuLous plruuisv Ex 13 i""inatIon of tlie .dxl "■'" '''c'"-, yellow, acid, f t; "Mien was negative. 'J'j lint tra patient was aspirated, and 1 ee I'' iirinc >i iilhnniin, no casts. '^iiiiin withdra For the f wri. ''"() eo. of ji ,.| '■ill', vcllow iii't inateriall ''■•"t iiioiitii in hospitjil tl mndt to 1 y improve. H,. ] le patient's eon.litio,, di,] '■)i ilwecn US.')' 'he femj)erafi iind loo ""i I" Wcinjit |,.,„„ ,-- •0 range was constantiv ""t-e, on tin; second d ' '■••'I'oly goiny to ]00 101. tiii (in The fluid gradnall i'.v after his ,,(1 •">'^, and oidy imssmn, reaehin"- )pe(l on (lie 21st the ;iOth, when 1000 I'l'-fUXMimnlafed, and I 10 was '"'ill, when 1100 .^;v'th a withdrawal of 12,S0ee.,,fH,,i,] '^vn ; and on July cc. were withdr cc. were rei wgan to improve,— til In wei made : nove( J. Karly ^■'it. On the third of A e appetite increased, and I ill .Tiilv he Tl "giist the follow ;c patient has heen aspirated in all ^t time heing „„ t|,e 2(Jth of J„l IS now very iiKirlved tlatte () le gained ing note was six limes, the '11 inspection, there expansion is greatest on the rioht Sid '"•ng of the left front. Tl le "I'fo is full and el IU)OV ear. On the left side tl e, on which jierciission ■e the second rih, below al lere 1:it areas there >inne intensity evervw ibsoliite flat i« a distant, tubular breati I ere. i^^l'cd. The breatl/so.md spiniis fossa." H August the ;',nl, witi Tl 10 vocal freinit is Hat tymj)any ness. Over the liiig. of almost the ' ^fiy nearly absent in tl lis is dimiii- •- H-as aspirated tl lie supra- I removal of 800 '""<• "11 August Kith, when ( li'l "f the last f :oo [Oil '■'ff'''' r'"f of July and the f! '''"l"'-ve ATM LKCTIUK. .«Iia(lo.s into fluiicda III the fiCtli rih, just (.iitsuJc the iiiiipl,. lino. At till' loft back tlu;iii i,s a iniirkod diilnetis, becoinin- !il)M)liilo iilx.iit nil indi below tlio aii-le of sciipuhi. Abovo tbin point (he vociil fioinitii,^ Ls Mt, boh)w it is absoiit. Kcvxpinition is board, thou-b fuel-' ,ere except at Ibe extreme base. The point ol' iiiaxiimini eanbac impujsi. is not to be made out ; the sounds are lieard distinctly over the normal area; the second pulnimiic sound is "accen- tuated." 'I lie diagnosis of pleurisy with effusion was nnide. No suspicion was entertained by Dr. Thayer, under whose care be eanie durin '-•" '-''0 fourth int.; ./ : 7""^ :--''^ '- encapsulate.! '■ lueocci. ''•'uih, and many , '1''^ '"■'■'HN 'eddish hnnvn,8p.,.,. lo->-, ,., , "f ""'"M.in, not :p,,sts. '-'' "Xylonite am.Muit I>m.mher ;i,) U ithi, ' ,he n,st 'Ml '■""^"li'lHtion have -.nn, • "'""' '''"^ ^""-"■^ "^ --ded rapidlv. , ;> "'-i.'.t .ide ,,,,, ''-'' N-ace u ;V,,n, ..''';- ;'"'"'^^^ '''-'- "^ ".0 ' '-•■""><•• -^'^e \:a.i: ;t:' : ;^:^r'" r ''*' r"-^- '''••-•"i-'-'-'-^i.H^c;; : ::,^'''';:!^^ t-"pora.ure rose throughout Deee.nher 1 '"' 1"^=-M0fio. For.he.::; oM """"I" ^'^^ ''^'-- '-nvecn 10;3o„„,, „^" '',^ "'^ '—-^ "--•'•"!..- has heen "'- i--.y,i-:;;n L ::::;• '''--'"^- ti. "'• ^-'--ingonoJ, ;;,:;:::■;:: -'-^^ "iis practised. ^ "'""c'-'te venesection ""'"""""- ■^'"^' ""'■- '— o.u.e,U„ „., ,,„,„ Hi TIIK SMA'IflJCK I.KCTUUE, side hcliind, tin (1 tlioro is now tiihiiiar lnvalhinLi: 'Vom (1 H|)in.' ^,\^ ill,, sciipul to tho 1.(180 ; pulse is o-,„„I lieratuiv (ell |i,,.( evening-- to lOl ; this niurnin'' it is hi' It' tl ic teni- ain. KM 'I'l (I I le rcppiiatioiis are ai.oni l(». Ti icrc j. marked Iciieocyto^Ks, ;j;i. ()()() wliile corpn-cKvs per ciil Dining' the day patient sank i^nadiiallv. ,iie imLse 1 lie mm. lie piiKse lieeoniiiii; f'eel.le, in spite of tlir pci sistcni adminiMration of » mm. 15oth layers were smooth g-reyish white in color, in places present \u'<: areas of con- gestion and ha'morrhaye. white irelatiiious lihriii i" Th 're was a i^ood deal of y- revisli \isceral iilcura. caseous infiltrat Tl pfaccs, close ly adi lerciit to the lere were no caseous masse s, no s [Hits of 1011 on the surface of either layer. () tion, the thickened pleura hail the appearance and d fin 11 sec- eonsislciicc as 1 fill II, new eoiiiicetive tissue, and at first siylit it seeiiicd le process were really a simple chronic pleurisy, , iiore particularly as no miliary tuhcreles were noticed surface, and no caseous masses. On close examinatiui; on the K. rt'Mtllillii the lijulit Slide, liiu Id vers of til,. 10 .■'IiTiiiii niMi'nin, nous clotiH ; iiiud- tiiiet Iiypoi'lroriliy iiiKJ OdiisidLiiililv I'd .-crouH otfiisidii piriira over the I'lu; coj-tid [ilciira l.'> cm. ; at the I'm. in tlu(diiu.'iii.s. ; not to llie .sunc ?rs were .smooth, \'^ areas of ('(im- d deal of yrcvisli adiiereiit to the IfSOf, no .xpnt,- of layer. On t;o(.'- i nnd oon!«i.-i(.iK'e (^iglit it seeiiial c iiieiirisy, more noticed on the so exanunatiiin, 'TllimvVLOVS i'Ly.VHISY. '"'*^<'VtM-. of (Ih, ,.„t ^'■•^"■'•ns, pariicularlv in pj •'■•"'^'"'••"t fibroid tuhercle. eould I places, L!ieyi.«li "le eut Niiif aces. 'J"l ""<-''««i..d dia|.|,n,;.,„„ti.. J ic>e wen were "imd siiiidl III iNcrs. 'e '^ecii |,n,i,.,.tin^ ,,1 l""'''<''darly marli<.d in d !)ove At vc »*■ liiltoreiiloiis infill ■*'"'■', from ;i ( "lie or ts\,, '|)Ot8 tl lere '•';;'"'• in extent, of .,,vi«h. I'oiisidoi'idd V CO ""'- except i,t tl 'i"|ii C-*. no easeoii,>( n iteen () tion and .so/tcni " section there lesions; no tuKercl tuherelesand small ".if the ftizo of "•»« at the apex es were 'I walnut. tlirectly with a , upper |o|,e, the Iwfv lolie, wei cr areas of caseai Ion, :oo( ^ized I Tl "•"iiclms. The I '"' area of oasea- ^"iiToiinded with "<« communicated »cre no miliary tuhercl tracheal ,i,'iands ?';eater part of the middle lol '■' I" '•• eondiiion of red I ovver l>-'iit of iht "-'. and all of the es, no here and the \vere'e small «^vollen, tumefied, and 'L' l>ronehial and caseous masses. 'M piesonteU f ^''"1 »ote in the ahdoininal 'III' I'i-ht testicle tl <'i'"ans lik structure com Tl '^-''-e was a marked tuherciil, '^■'•'Mvasafihioidandeartd ■ii'imycholeste 'L^i'e was iiothino' of '"J tul,ereles. "in ti'imly. and tin, Litter t nil. )Us 1 '.-"'uiis, cyjt- "storv in th a less upon which less have laid P"^'i""<»iiia, tubercj,. bacilli 'Pl'i'i.us \\ere hlooj patleiii' greater stre.- I'dhlistly hnilt ^'".i^cd, poini; Oi toinii time. 1 in tl as wel 'c *lei(risi/. Here rcfciviico is iidt miulo to cnsps of ocium-mI miliinv tiilKMCiilosis in whlcl, the plciirul iiioinbranes nro involvcil with otlicr parts. A miliary eruption is verv often .,{' arn-iunent. we may presiune to be (iiberculous, thecondi'- m ol'the pleiua is that of an acute miliary tuberculosis, I have no personal knowledge; but in my experience the condition lias almost invariably been, as just mentioned, a secondary or terminal process in some already existing' affection. The followin,-- arc illustrative cases : In the first ii:stance there was a chronic auivmia, induced by the liaMnorihoids, with (dd f ici of caseous ^'en '-"'on-l.oids, whieh l.ave troubTed 1!"^ '"""''' '''''^'' "'^• --. -Hi l.e I.aa J,Lt blood I "^' ''"■^' '^-" --'' ;''-e o. fo.a. evacuations eve /d ",7 ""'^^' '"-'". Lad ^"«' "« "'uoh as a pint of fl f" "' '''"^'^ '''''' ''« J'^^^ .-duailv become vcrVd ':' ''^ "" ''■'-• ^e has '"•e not bleedin.r. ^ " '^' ^''"'^-^''t f'e iueniorrlioids "•••'^ ^'ff-- Tbe pulse" V r; '", " ' '^'^ '''''''' ''"P"^- ''-'-rinecontaineda'^: ;rV^7^ -'- He .as thou-du tie/ /""''"' "^"^ "" '"'^^ from bleedin. piJes. " ''"^'^ '""derate grade of an.nua About tlie 'iiiddle of V , ^'^^'->-N »-t the ZZrZT '" ^""'^''^ '-^^- ^" l^e ^enn-solid stoui. dailv. JJe d '^"' ^'■"'» '^^'^^ ^o six '•■""'^'•■"^^ i'-eoberent way ' ""='' '"^ '-'^'^' '» '^ About November 28tli Im I >l" «e ms il,„t |,e „,„ ' , "^ O" December 3d «"'"- a. 0„,l, ,,„„,, b',„; ,'^1^;;™"";"' "■ 'Vo,,.; 2 ",t angle „f sca,iu|„ ,,„ c it 20 THK SIIATTUCK LECTUHE. fihsence of brcsUli sounds. There was no expectoration. He continued to iiave tln-ee or four loose stools daily, and died on the 5th. Autopsy. Large, well built, well nourished man, marked anioniia. Peritoneum is smooth. Over the mesen- tery, and the lower surface of the diaphragm, and in tiic pelvis, there arc numerous elevated, translucent tubercles, some of them surrounded with areas of hypera'mia. Tlic peritoneal surface of the intestine also presents numerous tubercles. The surface of the spleen and the contiguous diaphragm presents many tubercles. Acute miliary tuberculosis of both pleural sues, with about two litres of serous fluid in each. Tiie membranes were covered with a thick, fresh fibrinous exudate, after the removal of which many miliary tubercles were seen. Both lungs were compresseed ; no cavities ; but at tiie apices there were old and partially softened caseous masses, with many miliary tubercles. In the lower lobes there were only few scattered tubercles. The spleen presented u few tubercles ; no tubercles seen in the liver. Intestines. One or two small ulcers, witii irregular margins, in the ileum. The mesenteric glands iiaid and caseous. Meninges wore cedematous, but presented no tubercles. In the following instance the patient died of an acute entero-colitis, with an acute miliary tuberculosis of the pleura as a terminal event. tV- "^. ;•'" -— -ve eruption' o ' ; ^ ''! ^ f ' "" "'^ ^"^ '•-^" P-«ons ''^'^^•''-- ^'f' the heart d l' """ ^•''™"- '"aiudy, f--. or selero.es of vano:^C"'r*^'''n'''^ '"'^''^'^ ^^ ^-'-1 in .bese eases ohl f,ei o tul f' ''"'^^ ^^''^ '■"^-"« "odule at the apex or '„ /> '"^'"^"'""^ ^i^^c^rse, a '" "'^^ '"--"f-icgland..^ o Vt r •""''''' •^'^-^'«' -• -I'<-'«lly to the association of t .1 "',"" '''" '"^" -"-' "V- ^'-•; but a nun.br'"''^"""!"'"''^'' -•'■'--•« ?''"^-^''« «^' ^'-e pleura have ,1 o "'''\" '"•'"'■"'^' ^"'-•- ''-7'-ntn.a,e.i;::r^^^^^^^ ^'"'"^•1' to attract uttenti.,, r '^ ""'"'''^ ^^^"'^^0'"^^ •'^''i''"-'' Ji-Pital an eklerlv" n.a ';;.'■,;' '"f ""''^ ''' ^^'"•'- 22 THE SHATTUCK LECTUKE. it liiid come on wjtlioiit any special aggravation of the symptoms, proved to ije actile miliary tuberculosis, with eti'usion. More frequently the symptoms are pronounced, as in tlie following case : Vase IV. — Fatly and cirrhotic liver; hoemorrhage from the bowels; bilateral acute tuberculous pleurisy. Mrs. L., aged 27, admitted with hiumorrhage from the bowels and tenderness over the region of the liver, wiiich organ was slightly enhirgud. There was no jaundice. ^Sho was a hard drinker, and iiad bean in failing liealth for somo months. Signs of pleurisy were discovered on both sides, and she had a severe cough. She sank rapidly, and died witiiin a week or ten days after her admission. Autopsy. — Left lung covered with a thin fibrinous exuda- tion, thickest at base and near the edges. In places the membrane is studded witii minute granular tubercles, which are best seen where the exudation is less abundant. Tiie organ is crepitant throughout, a caseous sj)ot is seen at apex, and a narrow fibroid area in the lower lol)e. No disseminoted tubercles tiiroughout the substance. Tiie right pleura piosents a similar exudation, less abundant than on the left side. The costal pleura is thickly lined with false membrane, is congested, and presents small grey bodies scattered through tiie membrane. At tiie apex of the lung is a small caseous mass, with a cavity th( size of an almond, in direct communication with a bronciius. In the neighhorhood of this are several small groups of tubercles. The lower lobe also presents a couple of siiiiiU caseous bodies, but no scattered tubercles. Liver weinhs 2,200 grammes, is large and pale. Lobules distinct, bile- stained in centre. Organ is both fatty and cirrhotic. Other organs normal. Such instances as the following are not rare in old lios- i ! TUBERCULOUS I'LKVHISY. ot rare in oM lios- PJffil patients ujfl, n ,. ' ^^ 'Joseph A. i(,r,l 7n .^""■■is^^.c'o,;,;,...!": ,:;::'• '»•""-■• »..mi»«, ,,„,, '"S of tl,e fee, .v„ f.r,„!, ,"""='» "f l>'»ntl, „,„| ,„,„■! ;^- Sl,c novc,. |,e„,j JI'V '",«V""""''"'»" »" '"» "0 «f alcohol ,„ exce,,. ' "'^ ""'"• H" ■ "vollo,,. F,,; W („ slco,,. ="• •■""I lio lias l„„l ,„ ,j, j,|, .^ I'lescit co„i!,„-„„._j I , , . »".vco„,p,o..,,,, ;,,::/; ™™P".« i««e nitlio , „•„!,(,„ j(| ,,"""' ton|ii-i„<,„.o |oio -'a.;ll, „m.tor. ,„ |,i„,;|f, • "" " "•" '-"lional, ,„„! ,„„: '» ''x-;:,;;::::::r ■'■:,:^'™'' r. '^'^ '-« .-^ .00.,. f«« »eco,„p„„ie,l l,y „„ ,^ ,* ''""'"■"'ions every- "«= '"' «iJe, are mCi,™.; L"" ?"" ''I"-, "'"ol,, „„ 24 THE SHATTUCK LECTUKE. sides respiration is liarsli, and accompanied witii fine, moist i-iMes. Heart impulse is in fourth, fiftii and sixth spaces; maximum in sixth, 3 cm. outside tlie nii)ple line. Ivulative dulness at third rib. Sounds are feeble and hoard with difficulty. Patient was taken home August 11th; tiie dilatation of tlie heart had subsided under the use of digitalis. He had slight diarrhoea, which was checkod with alum enemata. The signs of engorgement in the lungs disappeared, and ho had no pulmonary symptoms. The case was regarded as one of hydrothorax, secondary to the dilated heart ii; chronic arterio-sclerosis. Death occurred about two weeks after he left the hospital. Autopsy (Dr. Flexner and Dr. F. R. Smith)— (J/,- slract). — The patient was found to have general artcrin- sclerosis, with hypertrophy of the heart. The pericardium was smooth. The right pleura was thickened and tlio pleural layers uniformly adherent. The costal membrane measured about 4 nun. in thickness, and was covered with tubercles, somewhat larger in size than miliary granules and, as a rule, caseous. The underlying thickened inlil- trated tissue was yellowish, and consisted of a diffusoly caseous mass. The outermost layer was more fibrous. The pleura covering the diaphragm was greatly thickened and infiltrated. The lung was somewhat compressed, doep salmon color, and contained no tubercles. The left pleura was not especially thickened ; no adhesions. There woro small miliary nodules, however, on the visceral layer. Tlio apex of the lung was somewhat retracted, 'and on the anterior edge of the upper lobe there was an area of caseous pneu- monia, with a small central cavity. There were, howevor, a few scattered tubercles throughout the posterior part ot the lunir. A coi "iited as tlie fact i siii>J)Mrat run a vei the diseas liistory, n fhe side. side, feeb Physical e; t'lo nature "s/iiratioiis (^'ear that t "as requet collection c fr"in a mar "■ere resect^ wi\s found. 'ibout five w iilceratio/is v pockets of p; '"Illation, am '"»gs- The i" the pus. Case rZ— ^ pockets I tulierculc i-izzie VV., Hurd G, April pain in the rig] i'^ather and i: liistory of Jierec '"Jl't' has alwa TLBEHCULOUS VLKVnisy. 'jr> -ted as latent and oln-onic/d t.;;;'?'"'' '''r'"''^-' ''-•.- -'i'i>-'ative disease, of a n,ol " '"' '""''' "'^--^neand ;;'" ;'. v-y rapid course. ^^7 '■''"' "'"^ '"-'• ''"^ '-d-sease attacked a youn. ] ,/,"""""= '•^'''-kable case '^^•^'.■-V-'^ set in abn,ptrv\ 7JT'''"'r^^-''^-.iiy '!•; «f • On adn,issioi tC'^.^'' j""' — I'ain i„ «Kie, /eebJe breathin. but ! ''"'"'^'^ '" ^he ri-d.t l%«ieaiexanWnatio„;:b;^r,rj-? features about:)!: ^'"-"^;- onbe case, and n , .7 '"^ ""^^'■^-■" -^ 'o 7'"-";'"'- ^V^ithin a few b ' ''''"'"^ ^ -vend ^•'-•"- ti.at suppuration n.ust b T' '''""'' '' «^^"'ed so ^^';: -^"--i to operatr lS:;;f 7;'-' J^- ilalsted collection of p..,, ,,.,,^. ^ -'^ of f,„di„,. "-•y-ected in tlu.ee differe, i ""='' ^'"'•""•-^ ^^ 'i'- ■f^^t five weeks after tbe oust :;'',?' ^^"^'' ^-^ place "'-rations were present tbro d, !, ''.'^- ^^^'''-kable I--t«of pus between tbe ? ^ / " "=''' ^"-'-' -tL '""'ation, and an extensive ac 1 '' ''""' "'^ ^'"--^ ^^'-'cu- .'""f • ^i^'- tubercle baci li .'"f ""^ '"'^--'osis of tbe '"^'^--;- -""^>etaiisoftb::r::i'--""-ers ^™'^/^'>'-''^tb,?so^::::;:;,^.'-'-vasadnd^ '"■"" '" ^'-e riobt «ide. '"'"i''"''"ng: of chills, fever, and i^"tberand,notherlivin,.,„j„,., P^'^tctly healthy .i,,. rj,,^,,^^^ ; 20 THE SHATTUCK LKCTUIiF. in service ; lias only been in this country a short time. Slic iind eryisipehis of tlic liead and hcv some months ajro, and has not ijeen quite so well since. She was seen bv Dr. Salzer, who found siums, ho thought, of efFusion at the right Ijase, with high fever, and he ordered her removal to the hospital. Present trouble began, she says, fourteen days ago with pain in the riglit side and fever. She had a chill about six o'clock, and a had a sweat at night. The pain was of a dnl! character, and much aggravated on drawing a deep breath. There was no cough. The fever, pain in tiic side, and sweating have been the chief symptoms throutihout her illness. She has been unable to work since its onset. The appetite is poor, and she has lost considerably in weight. April 8th. Present condition. — Small framed, well nourished young woman. Lips and mucous membranes of a good color; tongue slightly coated. Temperature on .idmission was 101°; this morning, at 10 A. M., it wa.s 102.5° ; pulse 88 ; respirations 28. Chest is well formed ; good costal angle; both sides expand well, the right mucii less than the left. On percussion there is flatness on the right side from the fourth interspace in parasternal line ; from the fifth rih in manuuillary line ; from the sixth in anterior axillary line. At the back there is flatness below the angle of the scapula. The breath sounds are clear in the infra-chivicular region, and as low as the nipple. Below this, behind and in front they are feeble, though clear. Behind, over the flat areas, respiration is feeble and distant. The vocal fremitus is absent over the flat areas. There seems to be a sli^dit movalde dulness at the level of the nipple in front. The cardiac impulse is in the fourth interspace in normal position. The sounds are clear, and of normal relative intensity. The abdomen is negative. The liver dulness reaches to the cos is no () acid, ] the casi tory nei axillary range d sometiin heavy ti\ On th regular, fjniet. ] side of t pntion th idarJy at of the foil at the fou nipple. ' horder of in the nfp the line ( difficult to front, is to flatness ha entrance, tliei'e are fii by cougliin- outward. An explo tlie eighth 8] ■' negative n TUnEKCULOUS I'LEUmsr. • 27 tne costal mim'in • thn i. i ""'■■''2». n„ !,,,,'.,,,,„ '\^ ;;;;;•■-' w..vdw. ••""""■7 line. I„„ „„,|,i„„ „„, V'"!"' r'""° '" "'« ".i.on,,,. "■■"« i"S .1.0 „ex. Tvee , "• • "'" ' "'"'<""' soineti.nod l„ 1040 „, „,„ """ '"'y "'■osnl^.r, ,e»clii„., heavy ,„.c,,„ „, „,V|„, • *"° ''"J oliilly fe,.|i„g, „„,, 1-f. Patient lies Jnn wl.t ^ "'"'; ''T'''''''^- nre -'^ of n.o chest nK>vc. fj "/>' " ''^^''^ ^"^ '^''^ 'oft l^'- ^'-c is „.eat ten.Ie..ne;s ZZ'T'' '''' '•"'" "'«'-Jy at t|,e third rUrUt ;„.„ ° sternnin, partic "^ ^''e fou,-th costa, c:'.;!, r^^'^ "'"" " ''^ "^••""' -^' '^: the fo.„.th space at the s^ei-nufn .'r„:' '"'T" '"•^'"'^ "■PpJe. The flatness extends nc n' 7 ' '' ""■""^^'' ^''^ '•"'•''^■- of the live.- is no " if '''""""• ^^ower f''« "ne of flatness is clear \!i ," 'fl^"''''f''>" above ''■•ffi'H.lt to hear. V..cal fi-e . i ' 7 ^'''''^' ^"^^^''"*' ""cl '■-t, is to he felt in : r " "'« P-^ticall, absent in «''t-s has not .natenall': :.,i; '^ ''^' ^''^ '•- ^f entrance. On auscultatio,; " °"' ^''''^ ""^^'^ «" f''<^''e are fine, nioist roils " 'TP'-oaches this li„e, 'I negative result. * "^ scapula, but with "«'l.y. There „,„„..;:" ; "" ">'"""' ^ t'-ngue w., ■«-"^.^..^nhe„e™i:;;:~-:;;!:n.: /. i 28 THE SHATTUCK LKCrUUK, fourth iiiteia|iaccs. Tlic Mood count <,nive over 5,000,000 red to till! cubic nun., and 1«,000 wliito corpuscles. It 8ecincsihiy diaphragmatic. The possibility also oF a sub- [)lirenic abscess was considered, tliougli this did not seem to be very likely, as the liver was not depressed. The points which made the case somewhat dubious were the extent of dulness and signs of cinision without marked dislocation of the heart apex, and without anything like a typical line of dulness and not of movable character. The absence of fluid also, on a.spiration with a good-sized exploring needle suggested that there was something unusual. The case was transferred to the surgical department, and on the 13th Dr. Ilalsted operated. Lender ether nn attempt was miido to find the abscess cavity by mea;.;- ^ ' an exploring needle, which was thru.^t into the righf ; ; wi the chest in several places, where dul- ness was i;iai'k',;iJ, Then a portion of the fourth rib over the painful spot wtts excised, and only a small pocket of pus found ; portions of the sixth and of the eighth ribs were also removed, but only small areas of suppuration within the pleura were seen. The wounds were stuffed with ifuuze, discharged for a time freely. Tubercle bacilli were extra- ordinarily al)undant in the pus. 'J'he patient died early on the morning of May 8th. Autopsy (Dr. Barker). — Body somewhat emaciated. Scars of the incisions mentioned above, and two of them had slight sinuses. On making the preliminary median incision pus oozed from beneath the skin over the sternum. On stripping back the skin, fistulous sinuses were seen close to the edge of the sternum in the second, and third, and fourth interspaces. Thorax large ; costal angle wide. Kight pleural cavity has been largely obliterated, the visceral being intimately ndlierenf color, tlii( ill J)lace8 diaphrai'ii 'ind appea face of the greenish p necrotic tis phragm, c< there is a 1; has infiltrat on the surf; abscesses e the boih'ea c '■■'ce of the tlie thickeiK from a marl •^Indded vviti i^iey and tra On the ief I»leiu-a there which are thi pleura is not somewhat cnl with tubercle miliary tuber( tubercle on or enlarged and miliary and si throughout b( iii'e reddened, •111(1 yellowish Iji-'iiie of the studded with t Jown, and the: Vixam/ixmMi: TunKiirrr.oi'H i'r,Kui{r.sv 20 "'ll'erent to tlie cnsUil ,,le.,ra • b.,Jl. I„ >" places fwilv 2 cm... in tl,i,.lo.n 7 "'^'' '*'^*'' " '« ""•' ■"'l'l"~ ".0 pent....e 1: o ' "l ■ " '"■■''''"•"""' face „f ,he ,,leu.,i t .c.v ..-o . '''"pl"-a^'.n,..io «,„- ..ec-otic tissue. I„ i\.L Zf "' '' "'" ''■"^''' "'"' ■•>''«ccvs.se8 exist alo„. ti.e 8„ino ? '' '>'t'a-,,l.u.al "- bodies or .,.e ve.^eb. :. '''He'.::. ':," ^""'" ■^''^"'">' -''^<>^<' vviu. a ,..i„,e X : ;;,^ ;; !"'>^ ^'•ey and transJucent sub-n..l,ary t„be.-cle8, H^"" 'iwt'l:;;';:'::::: r """°^'°"" -" ^-« "•« »'-'. are .l.icW, « „' ,, "I X:",:: ■"•"»■>■ ""-olc, '""."Vl,,,, o„lar-cd .Icc^^r , "■"""'''"' "''^...1. „ro ■";-'oo„„„„|„„fl„.„,.:,;•;.j;--^™.l...^^ "'"■t'Ml ands,,!!, ,vd.,lH 44-, „ ; ^'""l'l«™ « ."ii»7 »n.i .ub.„;ii,„;' :, ":,r ;,• "■" "™°'"» '"""^ ■remldoacl, and i„ »„L ,1, "e !,. ■""' '"•"''" l'»"=''=» »" .voKowM, ,vl.i,e ,„UI.:; „ 7" '"''"' "''''° m I i u ^'k. e>. 1%. v>, IMAGE EVALUATION TEST TARGET (MT-3) y A {/ 6r (/. 1.0 I.I ■^ 1^ 112.2 !if I4& 11112.0 IL25 i 1.4 1.8 1.6 riiuiOgidpiUL Sciences Corporation 23 WEST MAIN STilEET WEBSTER, N.Y. 14580 (716) 872-4503 # V^^ i\ \ :\ ^ <^/J> W1j^" ■#U*' ■■e i/.A ^ i '! n r M 30 THE SHATTUCK LECTURE. Tlie mesenteric glands are somewliat enlnrrred and hypenf- nnic. Tliere are also pale yellow areas. The glands alonn; the aorta are enlarged, anc. many of them casuous. The glands along thoracic aorta are also enlarged and caseous. The cover-slips from the pus in the pleura show large nnnihers of tubercle bacilli. Agar Esniarch's t-ibes, made from the pleural pus, spleen, liver and kidneys, remain sterile. 2. Sub-acute and chronic Ttibercnions Pleurisies, There are two groups of cases, with effusion, and the chronic adhesive form, the former being by far the most numerous. (a) ]l ith sero-fibrlnous effadon. The process may be primary, or, at any rate, most exten- sive in the pleura, or secondary, to manifiSst tuberculosis of the lungs. The primary constitute an extremely important division of the tuberculous pleurisies, and here may be reckoned a not mconsiderable number of all the cases of the insidious form. The true character of the disease is frequently overlookc(i, and indeed for a long time there may be nothing positive on which to base a diagnosis. Though we speak of the disease as primary in the pleura, in almost every ii stance there are tuberculous foci in the lungs or in the bronchial glands, oi the process has extended from the peritoneum. Freqiientlv the cases are admitted to hospital with acute manifestations, but with advanced pleural lesions, evidently of long standing, iinto-dating the pulmonary tuberculosis. The following arc illustrative cases : Case VIZ. — Bilateral luhe.rculous pleurisy ; acute tuher- culosis. Henry W., aged 43, admitted July 29th, 1891. Katlier more tli fir.d was nncl sho Ijegan al shortnesi rigors, a very JittJ does not ( on admisi i2» J resj clear, nc TJie CO! on (he Jei liglit side tlieie was "ote to Jov to the fourt Defective ; ^eliind, ant numerous i distant tubii fit the left base, with pected at b( liglit intersp etfusioji foui tlie eighth U (li;eniorrJiao-i baciiJi. The He became t fi'iger tip6 dei li>0, and Jie d Autopsy ( well-nouii'xhed line 93 cm. I'lore than a year ., . ^nd .hortucss of breath. He 7.7''"'"'"° "^ '^""«''. l^egan aboK four .eeka a^o e " " '"""' ^'"•"^'^ «!">'•'"- o: breath, h fu J 2t f'r'' '''''''' ^^^^^ '•^Sov., and had fdt ve. y weal H ^ '""'' ^''<^"''' »» ve-T iiuie expectoration' no ,ai„ 't \ ' """' ^""^^''' d«e« nut think that be ha« Jo. ' " ' ' f "" "^ ^'''- ^^^ -> adnu««ion was 102^^ ; he oi?^ •" ""'''''■ '^^^'^P^-^ture 1^^«.- .-expirations 36. T, «"'"'"= r'"*"° ^^'^' ' P"'^e «"'''^^eftt,.an:::^;;;:^^:;;rr'""«''^^-i-ie.nore ;;^^''^ -'e at the apex, and to 'he ^7'"; ".'^^"^ ^" ^''« ^''-- "as in.p,.ired resonance On ' 'I ' '^'^'"" "'"■^•'' "ote to Jower border of second "rib , '" ''^'-' '' '^J^'"- ''^ t'.e fourth, and fronuhefo"!;'''""^ ''•"'» ^'^ -^^nd ^ef-tive resonance over X 'e /";"''' ''^''^ '^ «''^"-- l-ehind, and flatness at ti.e b.se '" . T'"'' "^' '^'' ^'^"S "."'— raJes at the apex ""l " •- ' '""° ^''^'-^ "- d-atant tubular breatiun-' L ea l ^'^^'^^'i''-!"^' «n^J behind ;'' '''« J^^' base. On The H- 1 f T", "'' "'"'"«' ''*>««"' t^-e, with distant tuOuh^ bf ,r ''"'"^ '« «''^"-« "t the l-'^cl at both bases, .^d J " l'"^- • ^^-'^ -as sus- r;gl.t interspace behind, al;:;,,"^^''''^^^ "" ^'- eighth effusion found. On the ,1 ;"""""' "^^"^'•""'•^''"orrhagic) ren.oied I ! '"^ '"^ *«^^' ^'^- »f «uid -i'ii- The ten.peratur; w-l hi.T"^' '""'"'"'^ '"^^-'^^^ He became delirious had ° ' ''""^ ^^^° '" 1^*°- f ■'.- tips cieveloped 'a 'tS 'T''<^' ^'— of ;,, ^^0. and he died on Ihe n^t^'''' '"-'' -'^eebled, ;"^W (Dr. Counciinn^? i '^'■""■^^'''• ;veJI-"our[shed „,a„; circumfiri* '>'"' ^^^^^^-deveJoped, line 1)3 crn. «'rcumference of the thorax in nipplj I i 32 THE SHATTUCK LECTUUE. i ■^ ■,. ' I Left pknirnl cavity partially oblitcrateu by old adhesions, especially at tlio apex and posteriorly. The remainder ot' tlie cavity filled wi h about 300 cc. of turbid, yellow serum with flakes of fibrin. Uoth layers of tlie pleura much thickened by a new grey vascular tissue, and covered with a gelatinous fibrin. There are many opacpie white nodules beneath the membranes, and the thickening is marked. The layers can be peeled off as a continuous membrane, and beneaih thei'i can be oeen opaque yellow and grey miliary tubercles. The right pleural cavity presented old adhesions only at the base, and it contained 3;")0 cc. of sero- fibrinous fluid, the surfaces covered with fresh grey fibrin ; the {)leiu'a and the membranes slightly thickened. The pericardium was smooth ; heart ijresented nothing abnormal. Lungs. — At the apex of the left lung there is an irreguliir cavity measuring 3 by o cm., the tissue about it in a coii- diiion of gelatinous and tuberculous pneumonia. There are clusters of tubercles and miliary granulations scattered throughout the rest of liie lung. The right lung presents a few scattered miliary tubercles without any very huge areas of consolidation. A i'ew fine miliary tubercles were found in the kidneys ; mesenteric glands presented a few small tubercles. The condition of the pleura here ante-dated evidently the more acute onset of his final illness, and he was prohahlv the subject of a latent tuberculous pleurisy, followed in- a general infecfioii. Case VIII. — Chronic tuberculous pleurisy loith elja- sion. E. .S., male, aged 31, colored, admitted January l:>th, 18S)L complaining of cough, pain in the right side, iiiid dyspna'a. He has had cough at intervals for a year- no lucmorrhage. About Christmas of last year he uot vcrv nuich \ sweats, and pci-i He is finger ti respirati the secoi side. I] inovcd. bo.-der ol at the b; L'4o, Mui asj)irated The c|)ufj until the nioderate extent. ' IJreatli so present on still very i: rules. Th bronchitis, tubciT'lc'S. peratiu-e kc i3- TL-nEKCLLOUS PLKUIM8V. oo He IS well iiDurislipd • f.mn v "i"vcd. After ..8..;r.,f; ,. ' ^"^ "^O "f fluid re- '.-io.or,,,i:jiZ';;r;: ::iv:;vr »' 'lie l«.-c. TI,o ton.nn,. ''"« '""> «»l"Kd uiHi UO 1 or PniKrli ^^l as])irated n-ain on the 9q,l , T '"^ '"'^"■"^ ^v'"* riM ^ "^ ''^^ «nd one J ho <>f' « • i il.e.,>„t.„,,s exannnod renc..Uodh. •!< '■"""^•'•'• ""fi' fJ'o l«t of Fel„u.uv I ^'," ' "^^^■■'^•^'<-' ■•-.dr., n>oderaten„n,be,.T :«.;,;: :7' '"'"' ^^^^ ^-<' i" -'e"^. Ven. .narked LwJ; •"'""■''"'"^ '' ''">• B.-catl, sounds were cl ^.I 'T''"" ""''"' ''"^^ -■''^"• P-ent on the left de ^o fl I 't " "'^ '" ^■""'"^- -"* ^'"•11 verv .narked r,,/ ^'T' "''"='' "'^ ''"'"^•- -''^ Penuure kept high until the • '/ i ''"'" ' '''^' '^■"'- ^'1, when he died. ' ^'" ''-^^"•""' '''<-"" ^' ."'SO ,„ „,, Autopsv (abstrnef^ T: i^ i 0«0,„ ; ,i;„ . :,'„-"" !•'<="" -"--" "VC- o,„;,.„ lc„ „„l,a,-^ ,„ke,dc» sca.,0,.0,1 ,l,„,„j,l,„,;, I , 'n i 1 1 84 THE SHATTUCK LECTt-RK. the lung. Small nicer in the left vocal cord. No tubercles in tlie liver or spleen ; one small tuberculous ulcer in the intestines. ]More commonly the pleurisy sets in insidiously, and is the most prominent feature in the ease. There may be no suggestions of tuberculosis, but in some instances the his- tory of a previous attack, or of haunoptysis, may arouse 8usj)ieion8. After asjiiration the Huid re-accumulates, and repeated tappings may be necessary. The patient regains a certain measure of health, with greatly thickened pleural membranes, and persistence of tiie dulness on the atfected side. When these cases are carefully followed, a certain number of them develop unmistakable pulmonary tuber- culosis, or they die of a general infection. The following- illustrative cases are of interest, from tiie fact tiiat they were inider observation for loii'xr periods than is usual in hospital practice. (y((se /A'. — Uoiiyh and /icenwptysis a yea)' before ; (jrad- ital onset of the effdsion; repented attpirations: tubercle bacilli found in the exudate; tmbsequent developmoit of pulmonary luberculusis. Christian T., aged 39, German, admitted September 25th, ](S(^1). Patient is a large, well built, nuiscular man, very well nourished, with thick panniculus adiposis. Willi the exception of measles as a child, chills and fever in Ger- many, and a ciiancre with mild secondaries in 1884, he has enjoyed excellent health. Xo history of [)ulmonary trouble in his family. His wife died of consumption four years a'^o. He was very well and strong until al)Out a year ago, wlien he had cough with much expectoration, and on one occasion he spat up a mouthful of blood. In January, 1889, he lost in weight, and for the first time began to be short of breath. He had no pain, and was able to be at work, but on any exertion been hiti does not admissior "■eiglit ai The chest is no spe fuller than expands V( in the fifti "ipple lim either side, hiller thai fremitus oi itnd there i anteriorly i Jh'catli sou except in ttihularand and loud, moved. Oi tlie same, an It was more -'"i ounces, general cond and about tin t'le 11th he v Jiawn. He lent expecton successive da_) liistory of an ; ''•lised a suspi 'liere was not) "ifl it was m nearly three m established, thi 3 «^^^^^^l^^i:i^^li^^Mtli^ i^^i^^MfiiS^ TUUKKCLLOUS VLKVlilSY. exertion l.o becn.ne breathless ,„,, , ^'- not think tl...; he ,;:: I..':; '' ''^-^^ «-''^- -'.-er. He achnisMon was .%o t|„> . i- ? , '^'' ' ^'^'"l'^^'""^ '"-e on "■^'•^'''t about ICO pounds r, •'-*'" ''"''^''^'''''^'''''''; 'PI 1 . I'^inius , pulse is 7-> . t . n.e ehest i« lar^e, well forned On ' T^''' '' ^'''^■•"'• '« "o ^^Pecial difference, no, ' 'l , ? ^""' ^'"''^^'"^ ^''e'-e A.ller than the left. Whe , '. "^"^ ^ ''^'''^ -''« looks expan.I. very .li„|.„„ '^ ''" ''"'^^ '■' ^'^ep breath the ri-d.t ^'! ''i-^'> ^--^,'ce, bi:::;: i;77 ;-^^^^ "'I'P'« ''"e. The intercostal "'^ ""'«'^« ^''^ eit'-r side. F.,,... behh d t^^ •'";'" "'" "'^^ "''^'^^^ on '"''- tl.an the left ;t::^^^^^ f'e.ni'us on the ri^ht side .''''" "'"'' '^ ''^'"^^"^0 of "-' "-e i« ab.oi:te du e^ r^ 'T '"'""" ^''^ ^''--'^^ -teriorl, it extends to " IftV , '"'"'"^'^ ^'""■"' ^'^ i5.-eath sonn,Is are feeble -ukI r " ' "' ^''^ «''-'^"""'- --P' i" th. lower in L Lit " "' '" '"'"''^ «'^^' :'-'• ^"•''oH.vst"fo:;i,:.ri^t:'"''^"--- I'e ^sune, and 30 ounces were ..,; ' •" f ^''' l"-"«f'"«ally " -- "'ore turbid. On tie ifh ^ ''^'■"^'"- '^''"'^ ^i"- 2.^ ounces. Cover slips „nd c ""' "^'"'"^^^ "^-"■" >• J,-"o.al condition all th L "L '" "?''' "e^-tive. ^j; -'' «'-"t the ward, a d th tenn" "" '"" '^^ "'^ "i' f ^^^'' '- was a,ain tap eV J'aT" "" ""'•'"'^'- ^^ J'-'nvn. fie had a very s i It e ■ T''' '^' ^"'^^ "■"t'- '^^ -pectoration, w'.fch w !'^ '"'!'' '""^''' — l'"'- ;"--ive days wilhou di^::^:;:'?^^.;!?''^ ^or seventeen '"«tory of an attack a year "J f " ^■^'"'"'='' ^J- '•'"■^ed a suspicion thi til '"""'' ^'"^ '"«'"oi.tysi. "-■0 was nothingwl etr^T '''''' '' '"^^-^"-' -' it was not until t,^^'^ "\^" '''''^ ^^^^^^^ "--•ly three weeks, and h con 1 ""'"' "''^^'•^''^'"" f-' if I l'^ Elisspi^'~-*v^¥j^:ii .' I ! i i! 3(5 THE SHATTUCK LECTUlfK. Oil till! 18tli lie wa.s iispiratod and ;»2 ounces wore witli- drawii, and tlio note liocanic clear as low as tlio nijiple. On "J7lli 11) ounces were removed. On November 7tli tlie note reads: ''The right lung is fairly resonant to the fciirtii rib, and in axilla to eighth, posteriorly to middle of scapula." 'riie fluid again accumulated, and on the l(!tii 2- "'"^•'« ^\l"q)orod voice over ,!.« dul • "' ''"'''-■"'^^' '""^'■|''e. T""'"'^ «"'J- Tl.e foJJowin. c ;;""''^^'' ^••-"''"-' «-o- - t'- 1 7,1. „.e condition wa e "''"f'"," ^"« -"'•^ -e-aecun>ulated rapidly, ,„,, ,;«?, '""'''"''^«- '^'''0 rtuid ^•'"' "■'■''' a withdraw' of 32 ; '"'•"■'^^^^ •''^^-■" <>" the •^ ^^"''^'--l of 29 ounces .nd""'"''; "" "" '''^" -^<' -■^'' ^•■•'' "'■ ^^7 ounces. Ont 20tV ""'"''■'^'--''- ••O'-t pero„s.ion is now dear to W T "'!'' ""'''' ^'"'^ '» J"''H- r.-om this point dow p : 'r' '' ^'''^ "'Pi'io; - --•"a, distant breath s,n ndfo ''", ^'•■^^='^''»^' -'^'- i„ "'^ «th of ,hny he h.d il '''■ "" •'"" area. JW -'^^'"-'-^^pp'e,anj;;;;:e::,':j^;;;!-n-pace, "laiKecl h-iction sounds £: j;i [«• 38 TlIK 8IIATTUCK LKCTUllK. in the loft mniiiiiiary region and in the acnpiihir region Ijchind. 'I'iie cover slips luid cultures made hy Dr. AI)hott from the tluid were negative. When he entered the hos- pital the sputum was abundant, sero-purnlent, and was examined repeatedly with negative results. Sidiscquently his cough lessened and ex[)ectoration was more scanty, thicker, and greyish yellow in color. At no time did the temperature rise above 100^, and it was usually between 'J,S^ and l»y^. He left the hospital with a diagnosis of pleurisy witli eil'usion, and though there was a suspicion, based chiefly upon the fact that he had had a cough for so long, the diagnosis of tuberculosis could not be positively made, and he looked such a vigorous, healthy man that it did not sccni likely. lie attended in the dispensary, where I saw liiin rei)eatedly. On the 20th of July it was noted that though the apex beat was just below the nipple in normal position, there wiis everywhere defective resonance over the right side, not absolute flatness, and everywhere from the second rib down there could be heard a loud, leathery, creaking friction. lie remained in very good condition, though the cough still persisted. He had no fever. On September lOth tubercle bacilli were found in his expectoration. The leathery, creaking friction persisted, and the defective reso- nance on the left side. He had lost somewhat in weigiit, and the cough had become aggravated. On Se[)tenil»er 4th, 18'J0, I made the following note : There is marked depression of the right shoulder ; shrinkage of the right chest. Heart is a little drawn over ; impulse in left para- sternal line. The resonance is defective above, and shiidi's to dulness below the level of the fourth rib. The tactile fremitus is felt to the base. At the right apex the breath sounds are somewhat feeble ; there are numerous n\les on coughing, and on drawing a deep breath the sounds are amphoric. Marked cavernous breathing at the apex behind, The l,r l)afle. He con On the feet svve more co inspira^'i signs at nfter this r( fco. ,W,|| „, ,•„„„„, .'' ""° "'" ■ "« «lill l..„k, won ; ,1... -rc c,„.„,,.,e, •„'!:'".'"■ ™»l.- '1.0 ,i.,„ ,:,„,; '"',.."...•..,. .„o..„ i. vow, ' , ■ ,™."" ■ f ;■ ,. •'"8. A., il'rPll 90 n "<"l . »l<»ck- ,i,„il,„. ,„ ,1,0 "^„ • „j''™ "'°'"l'» a.-,. 1,0 |„„| „;, 'Vilii fevor, cliillv looli,,.,, ." \ ' "S». -him- 24,1,, '""" 'I- -»".!,, „„„ „:;::„ ,: 'f ■■ ""f.- »« ,v„,.fco„ Joe,, n,,pi,.„i„„, „|,^„ ,,,„, '' '"^'""' • '""■■" " i,lo,„ „„ «'»-'■"» in.o ".a„„„a r rM' "'" '"■' "P«. !| PMJ i I |i M |"ii fll i t 40 TIIK SIIATTUCK LKCTITHK. cxtieiiicly movable nnil iiscoihIh wlieii \w sit.-' up. Hcliind it readies to the niiddio of tlic scapula. Dij^tunt, tuliulm brcatliiiij,' over tlie dull reyion. No friction. Souiuli) on tlic iij,dit «i(lo clear. Apex boat of tlic heart not palpal)le; houikIk cleai' Didiiess in the sittinjf posture at the level of the fourtii rih ; movable dulncHs very marked. The temperature lOP; the cou,i,'li is better; sputum is muco-punilent, and doc- not contain iiacilli. On the Mth the temperature Imd fallen to UH"^. The effusion had not increased, and tiic movable dulness is now more diUicult to obtain. Tliou;;h there were a few r.'des in the left infra-clavicular space, there did not appear to be sij^ns of any cavitv. The pleural effusion j^radually diminished, and we wore inclined to regard the case as one of simple pleurisy. lie still had cough, with streaked nuicoid anii yellowish expectoration, and in it, on the 18th, well-char- acterized tubercle bacilli were found. He improved very much, and on the 22d decided to go out. On the left side the resonance was clear to the sixth ril). There were suh- crepitant rales over the third ril), and in the lower axilla slight friction sounds. There was dulness in the infra- scapular region, diminisheil tactile fremitus, and feelile breath sounds. This man was lost eight of until February, IS',}',], of ihe present year, when he applied at the dispensary, complain- ing of cough and pains in the chest, and diarrha'a. lie has kept pretty well since hfs attack in 188t>, and has been at work. He is now fairly well nourished. He has very slight ex[)cctoration, and none could be obtained lur examination. There is rather a high-pitched note over both apices and there are moist nMee, greatly increased by cou"hini'. The effusion in these cases is sero-fibrinous, often has a green isl ha'morrl Hacterln of Chrisi itself. Sero-i piilniomii The case iiosis is I plication The insid infrequent shortness oi'iginal di seemed to with recur, case. Son mine wliicli ing case ; ( that the jilFi TlMiKiMirous I-LKUIUSV. ?:'■ if-lr. "'''""'"' ^^•-'^"'■-""i in tlu.cxu.laro 'S<3r(»-/il.riM„„s DlciirHv -.„ f"' y .nl,o..o I, ,;,:":,";'■'.""; '" "•« o„n„e „f '■''" ■■■■"- «io bv „„ „ """■■■" '" '•'■'■■>■ ■""^•'•. '<" '">">•■■«> ..„„t ,„„, „,„ „,; ' ' I .'" '1"^. img ,ii,c,,.c.. ""'■""■•I I" Il,« ,|,„ cri,. inn '••'""■"I""'- I. I,«, ""' -«•"".« ex .i,::^, ':::;, - . "r "-"«■ -- «»«■ S>,„c,i,„e, i, i. ,11^',,,; """"I' "f cl,m„ici,y „, ,„„ 77-. ^^^'!:r ::,';:;::■ ""'!''''' - •''li«k"""-s ii..ll,i„„ „f |,B,. r,, .,,"•■'"'• ""'> 'vo„k-„c..8. l'CM.„„i,e, .110,1 ,„°,„;,„,,';,' '"""'>■ '""""■.>•• l".-.l,e,. ,!,.„ „,„, J'r''ur:':i:;',;,''f ;;:f;';"",f • .-y""" «-■ .i. P-.™. illnc, l,e,„„ .;",;" "' -^'l«™n *.... Ilcr '"' -»".-i.:^;.M,t ;',:;:;';' i'"*- «'■« (»ral,„,„ „v„ „;e|,, ? ' "'•' ''"=" 'l'"""g ".Lick sluN- s- de„, „r .,,„ J;,;:;! ;;!:;;;;^ -'"-- »i.e w « „ I 42 THE SHATTUCK I.KCTUUK Present condition. — She is eniiUMMtetl ; much more so than is consistent witli ii history of an ilhiess of sucli sliort dura- tion. Tlie tiiorax is Jong and narrow. Tlie clavicuhu- de- pressions are nuuked. Tiio exi>an8ion is more marked on tiie left than on the riglit side. Briefly, the pliysioal exam- ination gave — at tiie left apex, signs of an extensive cavitv. with cracked pot sounds, jind am[)horic l)reathing ; at the rigiit apex tliere were indications of a smaller cavity, be- hind, there was marked didnees in tlic supra-spinous fossa', and impaired resonance over the whole of the riglit side hehtw the spine of the scapula, with feeble breathing, and rales only on full inspiration. Tiic abdomen was swollen and tympanitic; no signs of effusion. The patient had an irregular, hectic fever ; her pulse was very rapid; she failed progressively, and died on the l.Stl.. Postmortem (by Dr. Flexner. Abstract) . — The [leri- cardium is adiir-ent to the right pleura, but is itself smooth on both of its layers. The right lung is universally adhe- rent ; the left is adherent at apes and in places behind. The left lung presented a large, irn-gular cavity at the apex, numerous groups of miliary tubercles and caseous musses, with small cavities in the middle and lower lobes. Where adherent, the pleura is not specially thickened. On the light side the pleura is everywhere adherent ; the entire lung is much reduced in volume, and measures oiiiv 12.,") cm. in lengtii. The top of the upper lobe is occupied by an irvegtdar cavity lined with slate colored granuliitioii tissue. Tiie pleura of this lung is enormously thickened, more particularly the costal layer, which measures D mm. on the side, and about 11 mm. on the diaphragm; and in other places it is at least 2. .5 cm. The tiiickened membrane is uniforndy yellowish in color, and shows cheesy masses. ^.Vliere the visceral and costal layers are not adherent tiiere is fibrinous exudate on both surfaces, which, when scraped off, shows tubercles on the membranes. The I TJiere is tonea] n] I Iiave 'ubereub I'lirident '*ii'>acuto effusion is '•imount of 'hat anion one form o mortem frc '^'"' effusi tiiberculosii there ware to an acute of tubcrcul( nrferio-scJer ■■'ide and a instances pn^ Our clinic thorax, of v course, d-> ... the \{] cases 'erred as sooi: side, there vv; iiit,ther in five ciilosis ; and i 'lie I)ancrea8, sclerosis ; f,„„. wliich were op, 'ecily wellorvc '"Stance of emj TUBKHCULOUS TLKUiUSV. Ti I 43 J''ebro„cI,ial.I,n,,,.,,^ J'"^'-o .. .narkcl intestinal tubl ' '"'•"• ""'' ^'^^^-'"«- / '"'vo alrea.Iv spoken of t) '"''^'■^'"l^n.s plenH SncI . T"'' '••"■"'^^"' ^•"•'" "f -'^— te i„ onset, cl.'oni. a ,:'"'" , '""''^ — "ly ■"'"""' "^'^''^^y-atter/ i ''"",' ""l' -"^-"« '^ 'urge "'^'';->"^ tl.e 32 cases il l 11^1' "7''"'"^ ^'^ "^^ "-' ^-••» o.' another was p.-esj i . ' ""^ '•^""■'■«>- ^^ ^'-•« "-ere but t.vo with mln.lent 1' """-^"''^'-^"'""^ eases ^^ ^" --euh-us pentoniti; '■';;" •\'^''^^' "'^^''^ enough. -;eno-seIerosis, who had . , " '" "^" "'^' '"■•"' ^-^'' -'« "-' a -..-o-fihnnous pe H : "^f"'"" «" ^'- ^eft '-;--es pncunococci vvej "nT"", " '■'"''^- ^^ ^^»''' Our clinical reno.t^ i '" '''" ^'^"'^''^e- ^••"'•^^«, d.. .,ot intere -t us sn .• ,, ^•'"'"'«"^^' ^nd which, of fcned as soon as possil.Je fi-on 1- '''"''' ^^''^'•^ ''■-"«- '"r''.^'-'"«- cases; inonfe e ;r'^f'^ '" ''^ ^^^'''- or -'!--«.• and in one an aun f, "'^^''^ ^'^'' "^ ^-'l^er- ": "'— ' and one I' j^'''^'^? ^^''"-^ -nee. of ««-os,s,. four cases folJowod ir '""" ^^'^'' --^^'io- ;''f -- oi--atcd upon 1^^:^ ";;"'":• '''"'^ ^-^ -- .'^'^''>-""o'-ver3.nnch'in,;..oved ; ! '?"f' ^ -•^'-- Pe- ij lii ! ^Ill i^ i 44 THE SIIATTUCK LICCTL'RE. Unfortunately I liave not full particulars of tlie bacterio- logical examinations made in all of the cases. The dotailj^ of the oarly ones, taken l)y aiy late assistant, Dr. Meredith Keese, have been mislaid since his untimely deatii ; so that, from our personal experience here, we can draw no conclu- sions as to tiie number of these cases in which the lesion reallv depended upon the presence of tul)ercle l)acilli. I would again refer to the somewhat interesting circumstance that, with the exception of the pyopneumothorax cases, not a single instance of tuberculous purulent pleurisy was met with in the 101 autopsies in which pleurisy of one form or another was present. (c) Chronic adhesive tuberculous pleurini/. The special feature of chronic tuberculous pleurisy is the enormous thickening of the serous layers. In all the ca.-es of chronic sero-fibrinous exudate the visceral and parietal layers were greatly thickened. Post-mortem, we see throe varieties of this form. (1) Primary proliferative tuberculous pleurisy. Aiiv one of the three great serous membranes may be primarily affected in tuberculosis, though probably in the majoritv of all these instances the affection of the lymph sacs is sec- ondary to that of the glands in connection with them, or the organs which they ensheatlie. In this form the tubercles developing in the pleural and pericardial membranes cause early union of the surfaces, and tlieio is never at any time a free exudate. With the progressive growth of the t.iber- cles the layers bee. -me greatly thickened, and united iiiiiv measure from 1 to 2 or more cm. in diameter. On sectimi the thickened membranes seem to be made up of diffu.^e tuhcr- culous tissue, sometimes caseous liiyers, and much filmml tissue. In the early stages of the process grey and grevish yellow tul)ercle nodules are seen. With the exception of involvement of the bronchial glands, this may be the only tuberciil( Ijilateral. strictly c exudate, lecently c .'It the Uni day of an layers on condition f.vphoid fe (he late Dv adhesive tu iiifrerjuent pockets of back, or on at the .lohn able case, t( wliich both were enornu clieesy mass( alone there v (-^) Muc, and ill the u|: ("•anes, there iliapltragmatic 'Hit sometime '^'''us of the ; pleurisy, there membranes an '" Connection Case I., refe,.,, 1)6 abrupt as in i'ecouie greatlj '-ipt^ulated sere f''e left pleura. H. TLBERCULOUS VLKmuSY. uberculcus process i,. ti.e bo.Iv I^ '^''"^'■'•al. r J.ave seen but • ''' ^" ""''"^^'•"J "'• «tnctly confined to tl , . ' l?'"""" '" '"''^'^ '' -- --'•■^'e. One ... a vo', :,-"*''"'^'!"-^ -.,.o-fi,.,„,,, ''■^y "fan attack of It„ ' '';''''^'''''' '''^'' ''" ^'^ ''n-rd --iiHonjn.tde':;:r?;;::7'^!'''^^--'^- Wl.oid fever, vvln-ch died und!," I " '""""'' "'"'^ '^ ^'-^^^ "^ "'0 late Dr. K'o.s, vvhe e 1 ' ''"'' "^" '">' ^'>"«a^'ue, -"-i"ent to see tin's' oo f^ ""^ "'^ '^^^"^^'""- ^^ - "ot ^- . - on ti.o diap,n.a,„.,i :2^ ^^^f ^^^f ''^ ^'^'^^ "^ - H- Johns Hopkin, kospit.1 \ : i;,/^'- ^l'— showed al'le case, to wl.ici, I si,,,!] r..f.... ""'^^' '^ '^'"a'k- "■''-'• t^oti, la,e,-s of the pi ; ; 77 "" '' ''" "'"-"^«' '" were enonnously tln-ol n,o,e cc^r , ''';"-fi^^'-'"«"« exudate. -nes, ti.e,e is separation o tI.e , ' 7 ''""'"' '"^""- '''"l''"-a.^^>natic surface by an evnJ . '^'^^ovv and on tI.e !- -"-i.nes contain; ;::::: '"'^"V"''-'^'^'-'""-' ^''"« of the 32 cases pr^serui . '"" ''"'^^ '"^'t^''"'-^'- !''-'-T, there were I.>''.ie " J'-^-^o'-^-n tuberculous '-"'.n.nes and ^ero-fibrinoi.s Z^^^^'' nft"'''' '''''''' '" connection with nJ,I 7 ''"^- <^f f'esc six were l«»n.c ,,„,„|^ tl.iokcned. r„ , , , """"''""« Sn.Jually <»l''"l»le.l aor„„, eff,„i„„ „„,. ,' ''™" ""■« "'"s an e„. i ill' ^ ' 1 40 THE SIIATTUCK LECTUUE. Imd united, and ranged in thickness from 1.5 to 2 cm. In connection \vitli this variety tlierc arc two points of vcrv great interest. In tiie first ])lace it may be extremely difti- cnlt to recognize at sight that the process is tul)ercuh)tis. In tiiis very case of John A., who liad been under onr care and tapped repeatedly two and half months prior to hi,-; entrance to tlie hospital witli an acute pnuemonia, it wna 'only the closest examination of the dense, thickened pleural membranes which revealed old fibroid tubercles. A super- ficial, maci'oscopical examination might have entirely over- looked the tuberculous character of the process, as the lung on the left side presented no tubercles or caseous areas. Of course, it would have been in any case a suggestive fact that at the apex of the right lung there was an area oi' caseation and softening the size of a walnut, but I rcpoiU again, as it is a point of importance, that without the most careful scrutiny the nature of the extensive, chronic plourisy on the left side might have been overlooked. The sccdiid point of interest is the fact, well shown in the case just mentioned, and also in the case of John P., that a chronic tuberculous [)leurisy may exist for a long time, and lead to great thickening without any extension of the fibroid process into the lung itself. (3) y\nd lastly, in some instances the fibroid processes in the pleura u)ay invade the lung tissue, and lead to exten- sive sclerosis. In only one instance out of the 32 instances of tuberculous pleurisy was there any evidence of direct in- volvement of the lung. Case XIII. — Chronic tuberculous jjl^urisy ; interstitial pneumonia, ^Ym. S., aged (JO, admitted November 1st, 1890. The patient is a large, stnmgly bui't man ; states that his faniilv history is good ; denies syphilis ; has used alcohol to excess; had typoid fever five years ago ; rheumatism six years ago. lie came which syi year. IJ Has iiad that he li Thoijrrl is auiemic of' good d sion on tli axilhe ; a breath soi prolonged friction soi lireathin'i- .Many tube was regard pliysema. and on the with small, The temperi as low as 1)( TUBKHCULOUS I'LEURISY. 47 wtr::;;;,:;:t';;::;« ■■', 'i"--- »•■ '-h. „„., „„„„ i,.l:t"''rru;o '"""--"^'^ =-' n«.o.. M,„„l i„ ,|,c l„„.o,- l,.ft „;,i,|, , , ,''■''■ " " 7 '■"""■•''-I '" »- of .„,„„„,,„„,, '^^"^; ^'- «» '«•'" V fib.™, ten, I r ' ' ' ■■ ""'""""- i»t™,.8, dense IbukI, „f fil„.„ . """'" "" ""■ .I.C nose ,„„k ,t „ ■",'° " '"■« •'"■""»-!' *«lv fro,,, ,1, , ta. , , ;','"?' ""•' ""'« •"""'» «'-''! ■=''t lung. The cuiKlition i. '''"'^^'I'-ut at the apex of the right lu,u 48 THE SFIATTUCK LECTUUE. tliiit of ail iiitci'stitiiil pncumoniu, with diluted bronclii, iiiid ill! extensive tuberculous pleurisy on ;lic right side. There is ii sinidl tuberculous ulcer in the larynx. .'5. (r'eiiey<(l neroit-'^ inembrnne tuberculosis. There is a yruup of cases of tuberculosis in which the serous inendjranes arc ciiietly involved, either simultaneously or more commonly one after another, forming a clinical type fairly distinctive and readily recognized. Tliere have i)een several interesting studies of this condition, notably the Paris Theses of ^Nloran and Boidland in 1«84 and 18ti,j, and the careful study of Vierordt.* The plcin-operitoneiil membranes may be alone involved, or the jjleuro-peritoncal and pericardial surfaces. Tliere are, as noted by BouUaiul, three groups of cases. First, an acute tuberculosis, with rajiid evolution of the disease in pleuriu and peritoneum, generally consecutive to local disease of the tubes in women, or of the mediastinal or bronchial lymph gliinds. Second ; cases in wliicii the disease is more chronic in its nature, witii exudation in both peritoneum and pleunc, the formation of cheesy masses, and the occurrence of ulcerative and suppurative processes. In this group the pleural iiivolvement is much more commonly secondary to the peritoneal, or both may be a sequence of" pulmonary tuber- culosis. And, third, there are instances in which the pleuro-pcri- toneal affection is still more chronic, the tubercles hard and fibroid, both tlie membranes showing much thickeiiiiiif often with very little exudation. My experience witii this form of general involvement is not great, and of the ?)\ instances of peritoneal tuberculosis which have been under our observation at the Johns Hopkins Hospital, in only one was there involvement of tiie pleura. I have not met with an instance in which the three serous • Zfitschiift far Klinscho Mcdeein, Bk. XI. i^ i\ TUBKl^CLLOU.S I'LKUHISV. 43 -Xri::;::;L'r ''"■■; '''7'^' -^^ ■-" ...«y 1.0 «,„.„,,!^, ':,,::;;;, x: ':"r 't'™^ -" i.'.-eat nnpruvement, ,u„l tl.ero nmv be t lo ' ! Til,. *..ii • . .^ *' iittle or no fcvpr I1.C following ca«e .. ut present under observation : J!. A B. c„l„™l, „„«, 3„, ,,,,,„^, ,_,,^^ If J, c ,„,,l,,„„„,, „,■ „,„„;, „,, ^,^_^ ^^1 J , --.W ■„„,,.„,,,„,, ,,„j „,,„ ^,,,^ J -^^^ .'■.■-.,,i.*e„. ii»» n,,;w;:i zi"'',:,:':''''^' «- i„„o., . „e .,. e„„«„;d ,„ :t;, „ ,:::,:,,r ""J was not able to lie down Jle 1,...I . "'^.'""«"f''8- I 50 Tin: SHATTUCK LIXTUIJK. exertit)ii, nnd of the swollen sibdomen. He liiis n little coiij,r|, ftnd slight, scanty cxpcctonition. Patient iy a niedium- sized, moderately well hiiilt man ; face not epeciallv emaciated. Tiie temperature on admis.xion was i)7.o- ; rose in the eveninjr to lUo'^, lie lies quietly in bed, head not elevated, no respiratory distress. The conjunctiva' are a little yellow, pupils are diluted. Mucous membranes are somewhat pale. Pulse is regular, !)0 to the minute, the vessel-wall a little sclen.sed. The brachials pulsate vi.^ihly. The chest is well formed ; costal angle good ; the lower part of the thora.x is expanded. On deep inspiration the left mh moves more than the right. Percussion gives a dull note on the right side, beginning at the sixth rib in the rccumlient posture, and in the erect posture at the fourth rib, the diii- ness being distinctly movable. Ikhind, when sitting up. the line of dulncss is above the angle of the scapula. Percussion is clear throughout the left side. Tactile fremitus is dinnnished over the dull area on the right side, and the breath sounds are feeble. There is no friction mnrniur heard. Ai)ex beat of the heart is not very distinct ; pul- sation in the fifth space, just inside the nipple line. The sounds are everywhere clear. A needle was inserted into the pleura and a serous, greenish yellow fluid was with- drawn, containing a little blood, which did not coagulate on standing. Cover slip preparations of the serum showed no organisms, and cultures on agar remained sterile. The abdomen is distended and large, but symmetrical in the flanks and a little prominent in the umbilical and epigas- tric regions. On palpation it is everywhere soft, painless, not resistant, except in the upper zone, a little above the level of the navel. In the whole of this region up to the xi|.h(ii(l cartilage and the costal margin, there is an ill-defined, dougiiy resistance, which terminates below in a tolerably well-defined border. On three separate occasions a very definite friction murmur was felt. The ed"-e of the liver TUHKHCULOUS I-LKUlJlSr. 5, ^'»;v:;:';*;;''t;;:v"'''''-'''' - » ■-•-■^ «i •!» rji::,,:'"'':;;rn',;''°,*^'»'''-- > i..v,,„: tin. ni>.„l,. r. "" *" ^''•' costal iiiiir^nn i,, t|„ nip, Die JlllC. Tl.e '■'■' '"'c Jio gl.'iiHiular e"'urgenK...u. ; ,,0 c.deii.a of the feet T. • =' i-^y >-I bluo,I coi.pu.ole. 'J , ' '""^•-yt'-vs, and '^'-ve 100^. He Is ^^ , ' '"' ^^''^'^-'nituie did „ot .^o ^:^«^'"^"-v,lie,.,::c;1s;;::t^r'''"''^^^ tive, *-*' "'"* "i»ays been nega- un";i',c";r.;; i/tvtt" '""="™'"* -- '«. wa. deeply injected, and the viscenl "iv ' J';'''^""^'"'" o.nei.tn,n wa« rolled up .nd ^h ^^^^^'de.. The ■•'^-'t tl.e «to,.,aeh and eo'lon "' '""' °'"'"' ''"■'-•'^''^"'■"^' 4 "'"■ "« J'"™ Ws illness f,o,„ m 52 TIIK SIIATTLfK I.KCTHUR, tliis timo. IIo Clin reatly emaciated, progresssively weaker, and died January i?.")th. Autopsy. — Anterior mediastinal glands caseous. \]nt\\ lungs were hound down l)y firm adhesions. 'I'he pleui:il membranes thickened ; the costal layer, easily stripped olf, was covered with fibrinous exudate, beneath which were numerous tubercles and caseous masses. On the [)ulmon;iry pleura there were numerous tid)ercles and flat caseous areas. Both lungs showed large cavities at the apices, numerous caseous areas, and miliary tubercles disseminated and in groups. There was only a small amount of clear fluid in the peritoneum ; the intestines were agglutinated, and on the peritoneal surface many groups of tubercles and flat case- ous masses. The mesenteric glands were greatly enlarj^td and caseous. There were numerous tuberculous ulcers throughout the entire intestine, beginning just beyond the pylorus and extending to the rectum. There was tuber- culous ulceration of the bladder. We have many opportunites of seeing slight extensioa of the disease through the diaphragm, cither downward from the pleura, or more often from the peritoneum into one or other [)leura. In the following case there was extension roin the right pleura to the under surface of the diaphnii^m, and to the peritoneum covering the liver. thy O'use A' I 'A /> / ^'-va.,>.le, e.n.<.ia,c,l • ^ U '-; P-.-sM ever mmco. ...(.■nai.g cavity. si,e „.■,« ;, i ^ ' "-"■* "'' '•'""- ''^'- '-f -ro„« Huid n : J t •; r" '' '^ '-'^• OH\s. '" ''"''^ ^ej.ten.ber 12th of JKunu.p- I''""'''' l'--'"-i nunu.n.us iwr''"'; '•'''' """""•' '*' ^J- ^'-- Tl.o lu„,. a.Kl V , ' °'''"""'"^ ^-''-'.^- '..l>er- --dwit,.a,n.nCjr.^;:;:'^''f'^"^ '^'f'-nghout the left h.„. th^r'""'' "" '"'''''' ^'^^'^^'^^y ' ""^•"■•'-"■•'1 dilatati„n of a bru . , '" "'"' ''' '■"I'f"''^"J The under «u,.f;.eeo!i:^'''*^''"''-"-T--te.T. "'H'orent «tro,..I,. ,, the \C^ T "" ''" '''"^^'' ''^^^' ^^as ^-y ^uberc,e«, which were aL7L:::r!;^'l' ''"'"^'-"''^ "i'P'''-8Nrface of the liver -in,! fl "''""' "" f''« •'"i,'es about the.n. ' '"''' "'"■''' ""merous lux^nua- r 1 ii 54 THE I»II.VTTIJCK LKCTtnR. Tlurc \va8 tiilurcnlnii-* ditieiisK of tlir liiiiil)iir vcrl«'l)i!i'. The mi'i-cnti'tit! ^ilatidtt were ciilar^'t'd, lnit not cutteous. TluTc were tiibereiiloiis ulceret in tlie iN'iini, Attentitiii lia.-* ol'tcii lieeii ealled to tlie t'leqiiciit nssoeititiim of tulierciilou!* perioanlitis with tiil)eieiili)iin pleurUy. 'I'liiis (.f 17 eases vvliieli 1 recently de?eril)e(l* tliere was eonil)iiic(| (ii.-ease of tliece iiieniliraiic.s in Cases I\'., \'II., and X\'. Jii tlio following,' ease the periearihtis in all prohahility followed the chroiiie tuhereiiloiis pleurisy. Cuf>e X\'ll. — Clii'iinlc luliei'culoiis jth-inisij ou th< Irfl side; ncute tubtrcaluns pericarditis and pitnritix dextrn. .Toiin 1*., aged thirty-eii;ht years, admitted Aujiust l)StIi, witii suellinji- of the legs and dyspmea. The fnnily history is ('Odd. lie has heeii, as a rule, healtiiy, though in his ehildiiond and youth he had many of the infeetions diseases. lie has heen a moderate driidier. lie denies syphilis. 'I'lic present illness began ahout two weeks ago with pain in the left shoulder and ahout the heart. Feet began to swell ten days a^o, and he has had eough and shortness of breath for about the same length of time. He has had no nausea; his appetif t has been fairly good. Within the past le^v days he has become much worse. On admission the patient had intense orthopna'a ; pulse inO, l)Ut moderately full. He hud a distres-ing eoiigli, witii elear watery expectoration. There was great (cdcma of the lower extremities and of the scrotum. The finger-tips and mucous memi)ranes were bluish in colcr. In the cx;un- inaticm of the hcrrt at the time no murmur coidd l)e detected, but the second ui;l. wa^ accentuated at the pulmonary cartilage. On the follow i .'jj ■ n'- v;^,' the patient was quiet ; respirii- • American *^:ua.ui tl.e Medical ScN aces, Jaiiuuiy, 1893. lions i in rhyi inislu'd Th(M pron.fn sides '^( ril) mill (iuineas "uineroi I'assjiifr sounds I'itch of at the ri« On fill 'ine nilej base the Heart : slight gen 'ive (hihi( tlie riglit jiist at the at this poll tivc dulnes tlio nipple. intensify ai Tlier the I ''O tOlld. I ljeco,iie assi (liastcilic in pericardial i base. The 'liiin dtu'ing '|>iiii..ne j;; ':.::;: :;;:r7'''''- -'''-^ ^'^ f>" 'M,sn.|,atio„ ,1.0,, 'o" " "'"""''"'^ toh;tl.e..ei.„ot.C,^ ii.lClloa! (llirtriiiir 'pi J: ' f 145 •''' TIIK SIIATTUCK LKCTUUE. illation of tlie alHloiiiinal organ,-* is negative. The mine is yellow-col„iT(l, acid, i. gr. 1024, distinct trace of ail)n- niln ; several iiyaiine easts were found. Tiuoiigiiont tiie 20tli and 21st the i)atient remained in nuieii tiie same con- dition. On tiie 22(1 tlicre was a slight rise in tenipcrature to lUO.o"; the i)iil8e varied greatly in rate and character; at noon was slow, regular, and full, from 70 to i)0 per minute, and again was as ra])id as 140. The jiatient, in many respects, was better. The codema of the legs had disa|)peared. 'I'lic urine had increased in rjuatititv. On the IDtli only l.S(» c.c, and on the 20th ;].")0 c.c. had heeii l)a u-itli I The diapl section it t?inous, g) masses. ' touch, and connective There are tered fibroi Therigh extent free numerous i glomerate, costal pleiii'; ■'ire, here ai] li)l>e present; The splcei of !i(tfe in t present tiibei ! !l TUBEacULOUs VLKVUISY. ,,7 cumferenoo. Ti.ickne.s of ri^l.t venf.-i I r •"■"-« '-^ -„. i„ drc.„,„fe,,„: T ' ; """• '^'•'■'•"^i"-'J '^I'l-x'- -•oal.no.t oo„' "k """ ^^"'^-'^ "- auno,,!,.,. ""'''I'T n.bcrdos. " """"' '•»!'•''iit and fixe lobules are i tides. L'Iti, glands, whici: I'iiss, nioi'o am attached to th '■■'f^' <'t'pends 1 li.'ippily f;„. ,], gi-outh. It is '" 'lie mode ( i'ortion of indi TUBKKCULOUS serous moiiib: W'KUitisr. 'bacilli,,,,.,...., '1'?.'^:'^"^<^'' '>"f «I-eII, O ;i '" >"'ifile tuber qntnl nrd •■'"■•'C'lic.I fo tlie ,1 ' ^•'■'•fainly i„|,,,|e f] «^'-^^ '■» eiti,>8 and work ust '•;«l>'"n.tor.v. system i. u'ell i>i''t.••P|.c^.rint!KM^r .'■''"'' "'^ «"'-P'"S-« of "^' ^'-I-'-'iclo. read, tie L^^^^^ Many ■•'^f''^'^«' h tl,c ;,,r<.e d, ' ''""^ "■" '"•'•« "'«o m Part '-'i;'''/'>oo.,neral8eaven.-ervo ;,;"'' "' "" •'-'^^' ^'> "';''^""^- ^^-'taeon^n': t "''""" '"^--'"^'v y^es of the hronehial tree .n T "^^"I'^ ^'^ I>'"^C^o- ;'-^i---.-n the h.tj^^^^':; ^7''' -'' P- through "'•^'V;' "'^ ''- J,n,ph nodes t ' ''"'"■" '"''■^■^ ""■-^^h •■'f "■'^■^''' ■•••"' "->y of the :.;;!" ""^ "' "■'■'-'' ^'-^y are "^ ^'- ^oliindar cord, o ^ '"T"'. «-" '"" ^''o cells ;'^-^'''' 17 >"^o the wide s.^!ij;;'' '';-""- "'•' --^^ "'0 poripherv of the ,' ""'''' '^^'"■•"-^- Ifere. '''"^' ''^ -- adult, ;nanv f '%-''^ '''•■••^' '^^ '^Ij-'c^ are aocuratelv n.anne, / P '' ^^" "'"' "^'^^ the "^'-- L^'tnnatelv,;e ^"'^ '''''" ''^■'>'-'M'ar. '•"^'^^"'o.vandmoro.lee'; ' " '" "^ "«' ''•'^ ^'-o years '' .f''-'^'^ vor, n,ueh u „ t " "'7 ••""^-- -"J their "• "'^ •"-'« of in(ec,io^ 2 ;"•"■' "■'"• "^-"- !/ I ! fiO THE SIIATTUCK LECTUJfE. nodes of tlio respiratory system niuy he called, tubercle iKicilli efFcet a lodgement. Indeed there have heen im- portant oliservations uithin the past few yeai-s to siiow that tiic Imcilli may be pre.-^ent (witliont having caused any mis- chief) in apparently healthy lymph glands. There is'direct communication i)etween the sub-pleural lymphatics and the sac of the pleura, so that it is possible to conceive of a direct entrance of the bacilli in that way. More commonly. Iiowever, the disease spreads from a sul)-plcural nodule or ii lymph node in whicli tiie bacilli have grown. The wide and free anastiimoses which have been demonstrated to exi.-t in the lymph vessels of the pulmonary pleura favor the rapid diffusion of the virus under suitable conditions. Possibly, too, in some instances, direct infection may take jdace from the bronchial and tracheid lymph glands. Under all these circumstances it is tlie visceral layer of tiie pleura which is involved. The lymphatics of the parietal pleura have wide and extensive con)munications, discharninn- as they do partly into the lymph glands along the vertebras and partly in the anterior mediastinal group, along the in- ternal mammary artery. Infection may come from tiie Iviii- phatic glands in the neck, particularly the supra-clavieiilar, which conununicate freely with those of the axilla and of the sub-maxilla. Infection of the pleura in tuberculosis of the glands in these two groups has been frequently noted, and has been made the subject of a special essay by Hernandez. In rare instances the disease may extend t( the pleura from tuberculous caries of the bones in the neigliborliood. An interesting instance of this was reported to the Jolins Iloi)kins Hospital Medical Soci(!ty by Dr. Flexner last winter. A colored man, aged 24, had a sinus in the neck which led to an erosion, involving the outer third of the right clavicle. The supra-clavicular glands in the neigiihor- hood were involved, particidarly the group between the clavicle and the upper border of the pleura, which were expectoration 'iUHKKCULOUS PLKUHISV. (jj tnlaroed and caseous. The ri.rl.f o,.,. i , i.-i tic. ...■ XZ:!::' "'•""'" """-• "'"■ "•« IV. I)lA(i.NOSIS. -->"'" » ..io..ri,v, c ;:!„:"' :;TV """? a .lia."no.i,. X i, , ,- ' , " ''"" "I""' "''i'^'' '" '»- o™*;.o ,„„,■" '; ° """■^'••."'- ""■• '"'"»"- "f .1,0 -.-...,,,,, ,,,,„^ J--, ^'3. «><^ .1, ii,v,„, ,1, :„ : , ""■ :'"''' '"' "'■ i«'« '• .1 .0 '"i«'|'-"i"us „ic,„.i.v „f : • '" "■'«•'' """- '-. '•:::i:o.:;: ':;:,:■■ :r:';''- 7' ■'-'"''■• »anl». I have .,lrp.„l„ ,. li , " '™"' """I'"'! .|.ccidlvi,, ,, ;; '•X'""'^ "'f "•■" •" "" P.."..s ,„ 1,0 "■-»-■■ .';:;::; :'ni;r!::;::;,«;::;;'"-v»-«»-'. tii^uou.s to the nlenr. tl,. " ''/" "'P'' ^^lan.le con- - •--v::r:;r:,r::s^^^^^ fljiifj i! I !l (;2 TIIK SIIATTUCK LKCTUUR. a very siiuill fixMis of .^ufteninjj tubercle in comiminiciitinii with the l)riiii('lui!S. On more tlian one occasiion it iiaa hfi])- pened that tlieir iliscovery after repeated exaniiiiatii)n Ims cleared up tlie i 'itnre of an ohscure pleurisy ; and it i,s worth nolinjj that in Case I. the only spot of fsoftenitiL; from which the tuhercle bacilli coidd have come in anv numbers did not exceed the size of a hiizeliuit, and wns in tile \uu<<; on the iside opposite to that of the elliisioii, The physical chara>'tcrs of the exudate offer in a majoritv ot instances nothini;- distinctive. A luemorrhagic exuda- tion is suiTgestive but by no means distinctive, in as mucli as it may occur in cancer, or it may occur with ordinarv simple pleurisy, as in two instances in our list. It is im- portant to note that the effusion may be hosmorrhagic in either a chronic or in an acute form. I call to mind one instance in which the presence of luvmorrhagic exudate led us to suspect a terminal tuberculous pleurisy, but there were no tubercles on the membranes. The bacteriological examination has been made now so frequently in acute pleurisies that there are facts enon<>li at our disposal to warrant a somewhat definite opinion, ami the general conclusion is tliat, except in very rare instances, the serous exudates are sterile, and tubercle bacilli have only i)cen detected in a very moderate number, in only l\2 cases, according to the recent article of Prince Liiduj^' Ferdinand of liavaria. The inoculation of the exudate into the peritoneum of rhe guinea-pig, which has been practised in many cases, also gives variable results, hut when positive is of great value. The inocidalion with tuberc(din is, as mentioned, micer- tain, and I may state here an instance in which it led u> into error. ,[ust as we were beginning to try it the late Dr. Christopher Johnston sent into the wards a vmiii:: woman aged about 28 or 29 with a bunch of enlaiged lymph glands on the left side of the neck and the axilla. She was but of ofj nurmg sei i* TUBICliCULOUS PLKUIi.SV. ,50 »..J axill.,.,. rci, ^""l'''>'i-.J. ... ,1,0 M,l,.el„vle„l„, .'.■i T .I.--..X :,,!::; "''"'■'™'''™""-'-'''« of « -.Im,. i„ ,la. Ic^ , ' ■■"■"""""" "'""" 'l.= »i» :.. |..--.i», I »„ . "•.■.™l-,cc. „.|,i,|, „,. ,,ll ...oe, ^ "111.1111011 to the cumlition of th,. |„-,... f depend upon infection with .tren.o.oeei ,''"'' ^'^''^'^''-f- "y the staphylococci Tl.,. f , ' ""V ' '^ i"'^'"'"*^^'occi, -Hi in some .c" e.. ■ ! "t^ '""" '"'^^' '' I^^-^ ""'- the efFu«ion i« .teiile. The cm.!, ' '' '""*-'- ; " -^ "*'"•' ""coiiinionJv tuhcTciil,,,,. t ■•'l-emly mentioned, the fluid may „ot he't. " ^^' li'e mo.t .u»|„c.on. usance, are tho.e i„ .vhich i, tn f ^^y I ill THE SUATTLCK I-KCTUUK. tlie fluid oontfiiiitly recurs in Kpite of repeated tiippintrs and ill wliicli, witii (liiiiiniitioii apparently in tlie anjoiint nf exudate, the flatness persists, usually with traiisini.-^sioii (.(' tiie taetile Creniitus, and sometimes, as time proceeds. n)arl^ ,„' ;ises I., IX., X., and XI. show a sequenee of events oidv too eonnnoii. Possibly some of iliese eases, with flatter at the l.ase and slight retraetion, heal, and no further trouble oeeurs. Certainly they are not alwavs tubereni iinL' Ull.- Wlli) 1 1 ess sueh a process may follow a simple sero-Hl)rin()Us pleurisy or an empvivma. Tiius in a vounij woman ji'a'd 2',] was admitted to my wards Xovendjer 17th, 18!)(), with riyht chest Hattened behind and at the sides, with did at the right base and curvature of the spine (and who died of aniemia associated with syphilis of the liver, and Ivni- phatic nodides), the right lung was firmly adherent, the l>Kiual membranes were thickened, particularly at the extreme l)ase, and between the thickened layers there was a cavity eontaiiung about 70 ec. of !in opaque, w thud. The cavity presented adherent calcareous tl liiii>h iu ko.,. ,i,c r—"^^'" «-*"::::":;;:;'"■ 't'f'^'"'- "'"'"■I"'"" ""™'" 'Uoa„„c, ,„.„ :„M*,I I, i ■ '""""" l'> raiiciiil.ei-ilm( ivlicn H,h,i . ""|"m,int 'i'"-yK"".n«,I, , , """* '" ""■ -''"' i' i- I".- Tl.e di,„«i„, „,, r° ,'™ "■" '■■'"''';"° '«""-* .■;,,,MK, = tirm,l.,„„g,l„. Iy,„,,l,„„c,„f ,l,i.c,„ia|,,|„,„,,,.. i:™;;S;':ife,;;»*2;;;;;;...;,,,,,„ ,, „ H (50 TIIK HIIATTUCK LFXTUlilO 111 tiio ciisL's of I'luoiiit: scro-flhrinous efru.sion witli tliiok- t'liiiiir of tlio iiieiiilniiiu'B tlio fluid ic-iiccuiimlates rnpidly, iinil iifpiratiuii may liave to l)u pcit'urmed very many timo.-i. In tlief wliicli of t'(M)(] ait tliu piuit lit rceliict Hint of '!j k_ X ». X I »/ FMIT W. THE DIATHETIC DISEASES. TUBERCULOSIS. By WILLIAM OHLKli, M.I)., BALTIMtlltK. I. General Etiology and Morbid Anatomy. {<}) Incidknck nKTfUKKci'i.osrs i.\ I it liiis luiiir i„>on known tliat, in the (lu.'iint I Nrwcv AM) ("im.Kirdui). — ,\ n^Ni;i;,'(' uf Sir Tli(ini!is I '(•onHuniptivc iiiid tiil)iil nx.ts spioiit early," the appreciation of tl pfead |ii'e\.ilence (tf tiihereiilosis in the early periods of iif hliitiiifli • I'liWIic, ic Willi'- observations. Kxt niontlis of life, tli (' IS due to ivvciit veai- and in fl reiiiely rai'e in the new-horn and iinconnnon in tiie tiist tl e eases increase rapidly throii^rhoiit the latter half of I IV le second vear. the year tub IS! It I In the rn''-rl„' of the llopital Tenon of I erci If IS stated that more than lA per cent, of the hahif , ilosis. Of i',")7t> autopsies on infants made at Kiel, Holt/, fmiiiiriji ilic \'m ■•in-, ;!i dlCli nf cases of tuberculosis. The followin ages ;r tabl e ;;ives the proportions ai A\\]v]w. Iiifimts l)( !• rorii (I to 4 weeks (i " 12 I " -z 10 " •') montlis (Ml per 1(10 ' ]■' (Ml " " 0.(1 " " S.ti " " i«.;{ " '• 2(i.8 " " to .! vear* 10 ■' 1.- . ;t;!.(i . •-".i.() . :{|.s . 'M.w ■ 30. 1 )cr 101) The statistics of the late Prof under three yetirs. Of these there were essor Parrot embraced '21'^ case •s III Liiilmvn From 1 day to .'{ iiioiitlis >>^ " •'{ to () niDDlhs 'jr. tl ..... ........... ll )3 givinn:_ a_ total of! 11 umh-r one year of ar;e, and from one to two vcaix lOS ()t .)00 autopsies iii children at the Munich Patholo^rjc,,] Institute, Miilj loiim 1 tiihereiilosis in 1.^0. Of .■,27 infants dead in hospiFal of various ,"| tubercles were present in :]14 140 set of combined autopsies on 2280 children .rave T",:] tul 7 non-tuberculous. Tl le ajres ul the tub iseasi's, )errillnll.s llll'l erculous cases are thus u:r'iii|ii'il Fnmi liirtli to 1 moiitli ]( Iji to 2.^ yi'iii-s . . . h'viim .S t(j ■) viio-s ....... 11 " 1.- 94 25.5 22ti 124 .\ ialoi{ous liiii lie observ y. ;iii; rate, tb; I. .Ih' lifteelili :ii till ^liiiids. - ,ic after pnl inlii'niilosiM in t I till' di'Vd to th I III' fificetitli, ."!. I •Mikiiiu' manner ri'l. Ill: in th :iii' tenth. 14; f |A| Thi.; n.A .■:i|i.iMc of ex|)r( 'iiMiiisiii diseovt ill li'ii^'tli, ami I hiviic the bacilli I SIlL'lt'. Kiir deiiionstr siii'fiictory : The !«i'li ii small sha lil'iwod to dry ii i:uiii'. .\ few di ]'"' L'l'aiiis. carbo: ■111' iilaced upon tl iiiij. The i.'lass .■nliitiiiii — naiiielv, nlgnmis — ar(>'p Iriiiiiiitc. The ^r],.| I'H' drying betW( |staiiK'(lrod, while t hi sect ions the "f the -loiiiis llopi I'lli'iliol and imbedi l'*liii slimilil b(> re [etlipr. .\fi,.i' this IfliiT). ami ihei, pla i-tlie carliul-fiKdisi I ifiiiporature of (;()° "i-i'i;'lit lii.iirs in th [tajieratiiiv). The ''''■lllelisin. .V IT,,, '■•'""•'tory (acid, hvi finnTss must ln> '(.. [funu'tcij. III,, tuber I i' IS lust to |V„|ov(. (""■"led pink tint. I'l'Wlt. llipici.lls.sol 11 ''"lor from the ti.- 'J'iiii:i{('i t.osj^ A laloifoiis >(ati.sficH ar,. ,i„f t »/i hilt iiio <>l).H('rv)itioii,s of N'ortI O III .V know I, ..I;.,., iiviiilahio i„ tl itiiti; rate, tlmt tlic i| "ipiit till. New V,,rk 1 til ill' tith I till ;iliint|H, nki t) '••ntii vrar tiilxTciiLmi i>«'asf iiiiiMt picvi.il ,,iiit, "lllilllM^r Asvlll • IN country, III >Im»w. II. ami Imiii •"^ I'oiitriliut IX alnii vtTv f 'i''«'xt(.nsiv,.iv. Kro'ii, ,|„, ,|,ini i'"''|in'iit, aii(f it iw'M 111 th(. „Mt-pati<-t,t .Icpartim.nt.M of | '■ n Vi'iT r(»ii.>i(|(.ii,M,. pel '!■ IMildn-ll M (list ast'.s. l<>"<|>it!ll.S 1111(1 "< iiiaiiifcstiitioiis ■•••'lltllL'<' ut'illl •'i"'-tality. Iii;,rl„,., i„ th,. (i III llic special iiiliii iiancs .ll>r,ltl.Tpill„.rtv. Tliiis„n(),()(.o"| ihi'iviilosis in ill,. fi,.^t ^.,,,,,, m Inl-i",:!, ■:''''':' '•'r!''^'''>-'''';:li''''f.'liiNI ivin-, tlicT.. .lii.([-. s. ( tilt' til 'I'd to til lilt I. 1'.!': t III the sccoimI, III III' Hlimilli, ;{.:!. Tli,. Ki,.| I'oni III,' 111 'iki iiml IliiC tciitli, ii.u' nianiici-: of III niio i lit ,. 'fli to the t,.|,t|,. o. j.,^^||^ j """"'lit V statistics! I |,.l|,.r) also, si IIIMIlj, yiisiis. |«7o) ,,j- I'din H' tcntli to III the tliinl. ;",.<»; | 'yiii;r, tlicrc died i,, i|„. ( low this in .|'/t'|■-'■^«^«^•.^:.|«:H,.;u,':,,;;■■;r>r'■^^:^;"•' a 14: I '■'"" '!"■ ti-ntl. to the firte,.,itli. 1 'iftli, ••54: fVniu till. fiCtI ic see- to {>•) TlIK H.ACII.M s Tt c'ljiaii Ic of i)i:n J-'rams, alcohol 10 cism— nanielv, distilled is le water iHll. IC cover-^rlass. whid, is held •"liiliiiii — II ! I'i'l I'l'aiiis — ■ I-* then washed in 'ii'icly, methylene hliie | ovcr till :i'iiiiis, fiichsin 1 ^ram— c until it he^rius t lam ■are iiiiiiiiit.. The 1) iriist's aiiufd red, while tl 'letween filter ■paper, in oij ,„• ),j, mill allowed to remain tl III "liter, and mounted citi 111 scrtions the f IC iiiiclei of the cells and iii ( sectK fi.« from the acid alcohol while tl osincr their stain. coiintcr-stain is tl 'cy still ret; wlor trniii the t ■'■^ .solution of m,.tl,ylenel,l„,>. Tl <'» used, the most desirable 1 issue-elements and stains tl lis removes all n teini iin a r a '1 'mainiiii' fucli icm a delicate blue. The tiil uher- ! If J 9() AMERICAN TEXT-ROOK OF DISEASES OF CHILD RE.. ; J I 7 I HJ c-le biicilli are stained a brii;lit red. The sections are to be dehydrated n ,,!jso. lute alcoiiol, cleared in oil of cloves or preferably in xylol, and mounted h. xkW balsam. It is best to examine with an oil-immersion lens, althoiii,'h if tli, iii,;.,]]',' are numerous they can readily be made out with a <,'ood hijrli-iiower i!\ !(.,;, (Zeiss 3, or Leitz 7). Tubercle bacilli may be demonstrated in tiss ,.< 1, means of the rapid method used for staininif them in »])utuni, but the rcsuls are very unsj.tisfactory, owing to the distortion of the tissues residtii,- tioni the action of the heat and the stronj^ acids. The bacillus is aerobic, and, altliou<:h somewhat dillicult to cultiviiic, nuiy be grown ()ii blood-serum, glycerin agar, or even on potato. The colon hsfMi',; dry, grayish-white, scale-like masses. In the growth the bacillus forms coitiiii, soluble product or toxines, which, if introduced into the body, produce Icsiuns similar to those induced by the bacilli themselves. The bacilli are tolerably tenacious, and retain their virulence after ficczirir • desiccation, and salaison. It is stated that the bacilli have been fomul alu^! after burial of the subject for two years. The combined action of drvncss iq,,] exposure to air is stated to diminish the virulence, but tuberculou's spiiiiiiii exposed to the air for from fifty to one hundred days still retains its viinlcna. The bacilli are rapidly killed in a few minutes by moist heat, as in lioijiinr' ldrk:. tlriited 1. ,,!js„. ounteil 1.1 xvld! ^'liiftlh'iiacilii [lower (l.v |,.,i. I in tissues i,y but tlic i|.si,|('< rosiiltih- iv,„„ eultiviiic, iiiiiy e colonics f;,n!, s t'oi'ins ccTtiiiii [irodiicr lesions after f: cczin;, -'II t'oiind alivc of (Irviil'SS ;.||,1 culoiis spiitiiiii ■* its viniK'iieo. as ill iioiliiii,; do iiuiiiIrts ill s. fibrous, mill *viii,^ •eneral tiiliiT- j I'M'ulatioti of ""#•1 If- - i. ';>K .^'N' •%. ^K'.yj- •ty •rtvl* \\\ ,{ • Mh. ^■^ •* '^::.'tt^ -)e5> *!i PC, if> UlM ;m '''h •I',. „■» 'Vi. r\.v ;.^^ ' •^-•ifM NV.«f ■"-..• • »•.- ^ •..«.=' .11',' «'-; '^••^'^'^ • • ».• » . ••••j i^ '^ 'r 'Ti -^. /T -< -i \, ^ xy% i-? -t V i;ii --1^ >v matei'iiil into iieiiii. The d MdchM in tl: I fiiiiiciaicd. ill • C'litiiviy loca I iijc'i'tfil into t i|fve]o|iiiient ot If a iiiruiT (|ii; Ik'liirc I lie tulii Tlic triin.siii |4' f)iu.>iiii,' anil] ill sdiiie iji.st liave tiillowt'd. |al>o lircii (leinoi |ol' tiiliciciiious ( (2) Uiinh't,, "Cil ;is follow I Mil luiivnt to ol Irtiate to tlio tra |!v|io of tissiie-.soi |iiiial infection. Coiiirt'iiital fii Jiirca.se of (.'Jirii jiiii' muiitlis old, ]tiiiM, born at ten iiiw were fonin iMidi were .showi |!iik'rciiloii,s motlic |c«ys of the jmla m^ tlio fdctii.s, be liviT, peritoneum, 1 the child bon llmr and spleen v In all of the a liraiisiiiissiion is not Ifiamita, Tiibercn Jftli'ii'teil an ins(ane( |k'«;rlifli ,))■ niiitli siirf-iLTs of the |l!"' fliaracfei'istic h( '■'' 'III' placenta of ■i!'''ltliat tlieanmii ■'I'l-iiiiiea-piir. 'Iit'rcarcsevei'al Iftoiiii). ulnVl, ind Iffircseiicc „f ,„.t„,, ft K'tiises lioni of tl, A nio(lili,.,i view ( I* tliat 111,, virus ri'l"|) until MMiie ti ""''«• of cases of fi /"■ijlmvcal.vadybc ""'wulusis in the 7 I 1 ■ ' f)7 i;iateii,il into the antnvi'n,. .1 i Wore the tube v S •''''''^' ^'"'' "'""'"' ><'av di en - \ '" *''^' ^^P'*^^'"- TI.etn.n^:-i,^-;-.;;;;^^i^ to ti.e ,..,i;';.: '^ l-'-ul infection pH"l MS tollou-.s: AVliile in ■, f,.u- ,. ""''"* op'nion on this noinf ,„.. 7 ,fr'iii !-'.it.nt to offsnnn-r i, i, '*"'" ^'^'^^''^ tuberculosis is trn . 7,''^ ^^- ,^|.of rissue-soiUavoml et du.r\''''''*' ^'"^ «f " 'lisi^ i n J '^"7"^^ ^iiitai infeetion. '" ^^'^ ''ovelopnient of the disc- so i ^•;."''^'' ^ Congenital tuberculosis h,s b. . '"'' '^ "'-■^•^- licease of ('|„Tin,i tber « ^''" o^'-^'^rve.l in some siv <,.- ■ , wiiieMvere found -it i„l "°^'"^''' •''^^«l "n the nintl , , '""" '''« '■'"ifc'i iiii instance I., .. ,. '"'•^"'f'l '« very rare T <.!,,. , '"°"«'' "le ""■|'i<'^c'iHrof ,„.t„,i f, L I "'.^ ^"'"^ 'nay be present in \ V '''''"'""^ S Sir "5&^ I u.iuiH.,, legions 10 ivliitl, ,|,„ 98 AM/'JRICAA^ TEXT- HOOK OF DfSKASKS OF ('IIILDni. biuiilli would not l)e likely to he coiivcved in iiccidcntMl ini'cftion. Tl natal development he re^jiards as analoLrous to xiipliilis lirrnlltiirin fardn Hii^jj^ests that the actively irrowiii,:,' tissues of the eliild restrain or inl development of the jj^eiMiis. There is no evidence to show tliat a tuherciilous fati Ml it the disease 'r lei' can dii'ecii recent article on '* llereilitv in Ti le experimental evidence is also ne^rative. (Jiirtii ■ l'M>t. .^nlJl,. II t!i, M'aii-- le ilierciilosis IS the most important f"iiii'ilii , 'lUll ti(tn made to the sni)Ject of late years) found that in rabbits and with artificially induced tuberculosis of the testes, and whose semen l)acilli, the emlir us were never infected. On tlie other liand, of ( f^niiie;i-piifs wliich had consorted witJi the tii1)erculoiis bucks, 5 presentcil tuberculosis, and of o!» female rabbits under similar conditions ]] infected. In su])]K)i't of the vi(>w that tuberculosis is hereditarv irrcat sti 'latiirallv on •'"iilaiiic ''CCailu; the fi ■eiiueiicy witli which a history of the disease is met the par-nts. 'i'lie estimates of various authors on this point varv frmn |ii ;■)() per cent. Of 427 cases at the Johns llo))kins l[os])itaI, there w in which 'Ir- mother was affected, ")2 in whieii the father had had ti and lO.") in which sister or brother had had the di,' children and relatives of tuberculous individual.- :ease. '{'he fact eiT(,l||y uliciviilii> are more directly c\ contaLUoii than otiier individuals I'cnder it dillicult. as Fa;;ire rema'rk> fi clear line between liereditv and lliat th./ I" ili'an- accidental infection. (•5) Jihh'ii/'ifiifu. — This is not verv common ii th 1 man. as the skm ( a very siiitabie sod for the development of the tubercle liacilli. T infecti'in is, !i iwcver, seen in persons whose occiqtations In'iii'f tl I'K'S iKit oil,.;' lis iiiful,. ,,j' icui ill co'iiai! omv aiv naitici;. Avith dead bodies and animal products. l)(>monstrators of aiiat larly su'ojcct to a local tubercle on the linger or ba(d< of the ri;niil~i| called post-mortem Avart. rmnii-a iirf/YK/ciiicn. the "• lichen " till HTc Oeiinaiis. Only in very exceptional instances is this followed by seridii-^ yi' lialicm- is harmhss, but the sputa, dried and widely diffused in the form of iliist. chu- stitiite one important medium of transmi.^sion in the disease. The invi'.«ti-| Rations of Cornet have shown the greater infectiveness of the dust dl' Incalitii- fre(iuented by patients with ,,ulinonary tul)erculosis. The f the religious communities more than three-fourths (d" the dcall le iiiaiirr n[ tiv-ii rom tiiliii'ciildsiv i- III :!!;'''; <*" fl'<\"tlior hand, M ■'pitals tnhoroiil osis IS o.vtrci irfa '"■I.V »" niotlu.,' and hVi'l'lnl'd '!T\Z^J! P'-'i't'eularly intimate, as I.etween «■ then, are fi-nires whieh ind 1.''^" "''■'" '"""^ '''''^''- '" f''<' J^'ttc" m be coiniminioated by in-esti,.„ of't ,l,e ' , '"'' '"'"' ''"'^ i'lfo.'tion ^'-nrnportaiitproIdeinsVelatest n^ot "'!' "''''"■'•'••''■ '""' ""^' <-»• the f:^!"'""""^^''l.v.' it has boon i <• I , '''' ''"' '"'"^ "'' f"'H'n.ulo„s eow .V. oven wlK. the disease I ll ;^-;'-fated that s.ieh n.i,k is ii.ft,:: n>iio(^neeossa.j that the nddor shoid V ' ' "''f "r"" ':"'"'"'• "*"1 f'"'* AelMcil. may be pivsent i„ ,!„> mik '• , ^''"'-^^ '"'^ ■^'"'^vn that Ti-l:H..orof infeelioi, (Von, this Zt^l^^ '^ "" ^"'---I"'- manunitis. .'..sinitan- inspeetion shunid be made ,.•,,!!"' " '''7 'I!-''"'' "'"' ^^^"•>"- is'i'iiexponmoiits made with the milk """'• '^ "^•(■•''•^.•n'v. im.eii- , "'•" !'<'roonta-e of tiiljoronlous animals in fl i • .v.y inaeh la,-.of than has been si ^ ^':;;, •^";:'^--^''''l^"^ of our eitios If'rlnrixo numbers aro not available It ,. i "!"""' '" ^'''« '•"""ti'v [«Tent. of the .lairv stock in the R , T^' •'^"^'''' "'"^ ^•■"•" 1<» to If, !f"W'Iv;'. low estim'ate. "■^'^■''" ^^^''^'^^ ''^ tubereulous. This is The vinilence is retained in the er i- l-b the presence of the baeilli in tin' nnil'Ir: 1- t\ l""'''''" ' *"'"" ^•"'"'itio.is '™">^"^"l- In some instances the - • str , "" '' '"" ""* ''^<^"'»^ ^on- A-. conditions of the tissue 1,.^; to , T """•>', ^'^^^''^.^ ^he bacilli; in ' tl-e .seed. Experimentallv it Is ""Vsb ''?,''^' /" ^''^' development i*<'Mns not nocessarv. and iZt mi of ^7" "' '"'"'' "^" *''« ■"t'^«- f "^ 'l''""^'l' ■•. normal m„eosa. I'os vtii '"T^''"'''*' -''•""•« '""v take ■■■^'-i^m.hildren finds hore it ex t 0,^1 '^li"^"«T of mesenteric I*. unv,.ver. is only marke.l w he tdi :;"''' ^' ^•""fi'^'^'^^-l- The viru- J •'•" ^)o«n that the flesh of tuln.r o s " m '' -'T ''''''''^''- ^^ ''"s |W4J,owevcrJnaseriesofex-,)er 11 L^^^^ nifoetive to .jruinea-pi.s. [ '".ity-oiie cases with ffoner d , e • I • """ ^'"'^ '^'' -'"''"^^ •>*" ^''^ •"-'le h-f ..inea-pi.s, ..nlAnco prX;;i ;;:!::ll;::'':..'''-'^^'^^''' -^^ the perito [til llnlii HTCUloslS I'^Pwiiilly with tl "vcnroxs lvkmikntimj [ M'KCTIoX. — I '0 environment of in.lividuals,expl (\)C >nin;tL—Thefio, deal nil 111 a irreat msr measure the ■M I I ^^ 100 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. frequency of tlie disease in certain localities. 'I'lnis one of the most iiii^ itant is residence in tlu? larj^e centres in wiiicli many j)eo|)l(! are crowded t'. ili,,|- Tlie death-rate from tiiiterculosis is very n)iicli hi^lier in towns than n t|,(. country, and a very consideratde share of tlie hij:;h infant mortality of eitn s j^ to be attributed to it. Not only is the air of the larj^e towns less pure, !;,u th,; cliaiices are very much j»;i'eater that the dust, blown in all directions, hi. hhI; it the i^ernis of the disease. The inhalation of impure air in certam uvy\\. pations, whicli in adidts is an important jiredisposing factor in pulmonar\ ml,,.!-. ctdosis, does not prevail to any special extent in children. Climate in itsdj' does not influence tlie conditions mat(M'ially, Imt, as a I'ide, the disease ,s iii(|iv common in the temperate iTgiotis, hirjfely because in these are found the hirir,^; collection of human beinjxs. Soil and locality have an important inlliuMiiT cold and dampness increasinj: the personal liability by fuvurinji; the ilcvcjoi,. ment of catarrhal affections. There are fewer caso of tnl)erculosis aiiil fewer foci of infection in rejiions such as the Alps and in elevated ])late:iii\ :i> in Mexico, but altitude itself does not confer immunity, and there aic luimv j mountainous regions in which the itdiabitants are much affected by tuliciviildvis. More im)iortant than these are the factors rebitiiii: to personal envirniuiieij, as of the dwelliiiirs. The constant i)reathinir of a vitiated air, as in tlusiDnil crowded rooms in the tenements and narrow alleys of our larj^c cities. ;uiil ihe | absence of siinliLrht, are two of the most important predis|)osinjf I'lcineiiis m tubi'rculosis in children, 'i'liese iidlueru'e infection in two ways: lir>t, l,v favorinir the distribution of the bacilli ; and. seccmd, by loweriii;:; tlie uiitininii j of the individu;d and leadinix to conditions favorini;; the entrance of tlic haeiiii j to, or their develo|)ment in. the !)ody. (2) Jndiridwtl I'rfdispnsifioii. — From the time of Hippocrates it liii< Lein | thoiijxht that there was a certain conformation of body which rendered , iinl] vidual more prone to the disease. Ills words are : '" The form of bodv peculiar | to subjects of jihthisical complaints was the smooth, the whitish, that ivsw blinj:; the lentil : the re(hlish, the blue-eyed, the leuco-phlejimatic ; and tliutw:; the scapulic havinj!; the appearance of wings." In children it may b(! siiiil that I the build and type such as here described is certainly more pnme to tiilnr. culous affections. Two types of conformation have long been recojiiiized as predisposing in some way to infection ; the tuberculous, with bright eyes, oval face, thin skin, and long thin bones, and the KcrofidoKi^, with a lieavv fiLmie, | thick lips and hands, opaijue skin, and large thick bones. JJut, as in ailiiltj, well-developed, healthy infants and children nmy become subject to the disease. In addition to the conformation of the chest, the respiratory capacity. tliereli-| tion l.'Otween the volume of the lung and of the heart, a relatively small litart Avith narrow arteries, and a })ulmonary iirtery relatively wider than ilieanitai (IJeneke), and relatively Iarge-sizegro scciiis iiiniej liable to the disease tlian the white races, and it is stated that the llebiuws| possess a relative immunity. Mori' important in children are the local conditions influeiu'ing iiifeeliim. Acute and clironic catarrhal troubles of the throat and upper air-|ia>sai:es, ami of the lung, undoubtedly favor infection, either by allowing the freer (iitiaiii'e| of the germs or by weakening the powers of resistance. The ird'cctiiniMlisoasos, particularly whooping-cough, measles, and influenza, act probably in this way, while small-pox, typhoid fever, and syphilis influence the condiiimis rallierliyj reducing the power of resistance. In institutions the frequency witlnvliidi tuberculosis follows the infectious disorders is very striking. TUHEItCULOSIS. 101 Ul k)cul iflTocf ons of tlio l,u,.s winch pro.lisposo to tuberculosis, haemoptysis riich >vas regarded as an nnpo.lant cau.o. is now thought to he u. inES r:,.lK"j of the (vx.stence <,t th,. .lisease. Such disorders as dilatati f " .".Hi,, and pleunsv also heighten the liability to infection, tho ' o The subjects of congenital or acquired contraction of the orifice of the plnHU.ary artc.T usually, as is well known, d,e of tuberculosis. W to e ,H. .im.ent ot the disease uu.ny subjects show a inarkcl a.uenda. an.l a m e ! «.hiy cl.hn-o«ts oilers ia vonn. conditions fbr the developu.cnt of this aft S Ii,.«,sc ot the st.uuach and tntesttnes, particularly chronic entero-coli is in- crease the susceptibdity to infection. i^^iius, in- B1..WS and contusions favor in some way the development of tuberculosis .rncularly m ehddren ,n ^vho.n spinal caries and hip disease may ? 1 w jH ...jury ; less otten does ti^auma play any part in pulmonary t,.b tcuI s IkTC. too may be mentioned the favo,.n. influence of 'ope,., t ion : resec of a n KMTulous joint ,s occasionally followed by an acute infection iJliv'betSiSr'"'^''''"'' "'• '^" ^""^I'^i''''^ ^vhieh inHuence it the fbllow- (.)'Jn a few cases the disease is directly transmitted from the mother and appwu's in the child at birth. uiuiuei, ,inu {/') The primary tuberculosis of the bones, joints, kidney, spleen, liver etc l.l?in;;il;;?;?'S'^" "' ^^^ '^' ^"^^^'^'^ '^ rost-f«.tal-through the (.) Heredity influences the soil. All are Uihcradizahh. to use a French expiessum ami very many of us actually become infecced. Whether or not "he md .lovelops depends finstly. upon the character of the tissue-soU and mnAh upon the exi.stence of special favoring circumstances. ' (/ ...munity, a relative condition,- enjoyed chiefly in consequence of .nl:o.-.ted fssue-resistance, IS lessened by all circumstances which depm" nutr - on, such as ba.l air, bad food, and imperfect hygienic surrounding.s^ Next to .1.0 jro,.,.. a vulnerability of tissue, however brought about, whethe congel. ta' o.:,n,,.,red, IS the mo.st important factor in the c^^iology of the disease^ (•]) Ihr Relahms of Tuhn-ruhsh and Scrofula .-'Vh^ lesions known as scrof- «lo.,s .re tuberculous and .iue to the development of the hanlluTZlrlnhs^ h-"a t,,e term scrofula IS now almost, and'may well be entirdv^ aS^^^ o,>gh the so-ca led scrof uous lesions of glands and bones and skin aJe £ h v ^ ongui, yet 1 has been shown that their virulence is not so extreme as S otu erculous products in the viscera, the latter, accordin/tcA o '...,. when .njected, both guinea-pigs and rabbits, the fbrnu^.^mi;.;,- "a! fi-'s. J his .-orresimnds with the more protracted course and the . „.,•,. f..,. ;™.nat,ou of the so-called scrofulous 'aflWtio^r It h^^^^ -. , n. abeivulous manifestations are caused by an attenuated v" n r lias been made by writers, particularly Marfan, to show that th,> scrof, lo" -;:;!:;:: ;:;rb^';h;■::z::^:;;■s^^ --^ " -'--^ - p»!-- •., uuL tilt cMutiKo Toi this i.s not yet very slronty (') AxATOjiioAT, €r^Ami^:s I'koduckd by inii TniiEKcr p Bacitw 'n,« 1 ' 111 !i II I B! lOJ AMHIUCAX TEXT- HOOK OF DISEASES OF CHILDliF. , if- tojiother. iiiiiv fdiiii liirfjo infiltratod amis, so that u distiiicti lit'twtrii tlic iioiliilar ami the dilViiscly iiifiltrati'il vari l>aiiiii;:arl('ii and dtlicrs have t'iial)lc( chaiii't's iiidiici'd Iv the bacillus. on is o fp cllcs. Ti It' Stil I IIS to follow acciirati'ly the MIIUlol IIIIIIVV iii'si- arc- HIS. (1) Tlic iiiiitiplicatioii oftlio fixcil tissiic-clcinciits liy a process of km ,,,k TI ic cells ol the vascular epitl leliiiiii. o f til onliiiiiry epitlielimi irif. tl ]ar;:e, rounded, ciilioiiial, or pol_v,iioiiai cells wiili vesicular nuclei — le connective tissue proliferate, and jfradiiallv there is produced f iiiiij the efiif/icliolil cvWs — inside some of which the bacilli are seen. This rean the fixed elements of the tissue would appear to lie the nriniarv elfect '-(•1(11 nil I (li) iieiicocvtes, chielly polvniiclear. miurrate, and focus of infection. These form the lymphoid cells which were fo to ll e so characteristic of the tuhercl Th accumiilate al rmeri\ 'Ht t. 'lei ||'iii,i:l.tl lllVlSloll. Niiiie believe that thev at cv do not, however, im liiini' denionstrai Infiltrated tu faiall sonit'tinies ;iR'lllllJ.'S, for ill; .jiriiiiiided by Z( iirmliicts of the | tlic bacilli ca, ,,iriisii>nally in ai iui;;. There is r ;i,ito(l tubercle. .*>ecoiidary inl itlac appear to bo successive invasions of I lestrov the bacilli. Th 'I'l'iro sill,. eucocytes at the focus of in , many of them undergo rapid destruction. It is stated, too, that lal little tubercle j^rows. the leucocytes wiiicli siirrouml it are of the n. form, or lymphocytes, and that these persist and do not under^'o tl deg dear f onus. eiieratioii of the polyniic (•')) A reticulum of fibres is formed in the tubercle by the fib ^•t' tiilicrde : (1 and destroy the bacilli. 'liMMv wonliM.THWtli is in reali i'i'i'ii'i"ii. ;iiiilH»Mi-'li "liiy be lim ii> tla'Hti:*' li'ii,^'' there i.^ i>ion>iiiiii'|,i;,|.H|il'.'ratiiiii (d' tlu! ( I' rM|iii|H4i<»l- and lymph (!') Tho'bacil i>rill;it!(iii ;iiii|^iiiW'rcMilosis; ex]H Iprtieiilai'ly Koch |i'i-is of the lun;:s, "y an I iicrcfl«e^B result of a mi.xeij in the jirotoplasm and in the nuclei of an individual cell, or po'ssildv hv tliel i'i) A slow, re fusion of several cells. The bacilli are usually, but not always, sccii iii tiieHiiitlio formation o; -,'ianf-cells. There seems indeed to be an antajronism between tiie iiiiiiiboi'an(lHi;ri.v.tli, and consti virulence id" the bacilli and the giant-cells: thus in joint and gland tulicrciilH^isHMt in the diseas and in lupus, in which the former are scanty, die latter are abiiiiiLiui : rarefaction of th e connective-tissue matrix, most margins oi' the irrowtli. apparent, as a rule ill tl, :ie| (4) In some, liiit not in all. tubercles iriant-cells are formed miliary tubercles, and. as a rule, in all lesioiVs in which the bacill th e giant-cells are scanty, iiilpial 1 arc aliiiinlnii', The tuberculous nodule thus formed may undergo necrosis and or may gradiiallv be converteil into a coniiectivc-ti.ssue i c;isc;Uifiii, iiass. C iscaiidii "I'lllSl Ht the central part of the growth, and appears to be owing to the dinrt aiiinnl of the bacilli. The cells undergo coagulation necrosis, lo.so tl come irrc guh leir outline, am material in which tl 1 are finally converted into a homotreneoiis. stnictii le ce are no Ioniser distinirui; diabk aiu 1 w lie- I'l'k'ss I iicli no IiiiiotI takes the stain. .Vs this process extends involving several nodular tiibcitic they are gi'adiially converted into nniform yellowish-gray masses. Nd lijunij. vess(ds are foiiiiii in the central portion, but the bacijli are iisiiallv alHiiKkiit, J>y the union of many of the nodular tubercles large ma.sses ma which may undergo either ("1) softening or liijuefaction with the f cavities; (i') fibroid limitation, leading ultimately to encapsulation: (.'1) in tliel sses iiiav lie for irniiitioii iiit'ij dd older ca seoiis ma.sses. particularly when encapsulated, lime salt lere is necrosis ol the ti s may he (k'po. ot of the ca'si'diis production of fibro-ca.seous tiiberch f)/(f)(nc lufi/fnifcil Tiihcrclc. — It was formerly thought tlia any^ simple intiammation might become casecuis. and the identity pneumonia and of scrofulous lesions with tiibende. which Morton (Kifi.)) niiiiii- tained. and which liaeiinec laid down as a fundamental proposiiimi. was For n| lung time disputed, ])articularly by Virchow. ^'ow, the researches of K"cL n. Foii.Ms of tube Iciiiiiiiion ill infants Ikiis (if local diseas rill .siijierlicial lyii I tiii'oiiiitei'cd in wlii iitlior that of ail in iiiti'iise infection a\ I nimingcs of the hn i-iKi liard-and-fast .'i':iiiiilati(iiis occur i>l'rniii three to six |w:iiiis there are c vlinieal course is of cvfii sixteen weeks. I into three groups, a '''I'Vditen typhoid f '•i'l'i'it'thel'imgs. 'I ity 111' the ciises. 'I wi^urrini; in childre: ll»' sviiiptoins of a ] I'liis furiii. whic. h TinEiivcr.osi.s. j,,^ L.!;';;i:«^:li;tt s;::? ;::;;;!;::^!f ■" ■■'■ ^^ ;■■"■" : "■"■ '-"• •»" b„:i;:::,;r "— --^^^":^::^t'!;:.s:z^z^^ o) A slow, rtju-tiyc ii,ll,„i„„„ii„„ „„,„,, „|„„|t „„„ ,„|,e„ij, rcsullin. e- n. Generalized Forms op Tuberculosis. (1) ACTTK MlIJAliV TrnKHCl'LOSIS. FoiiMs of tuhern.lous infe,.tio,. nnn.in,^. n vapi.l ,.„„rse arc .locide.llv morP wmon m infants and dnhlren than in adults. I'ra.tic.Ilv tl, ,o / ki,sono,.al disoa.. in a l.roncl.ial or niosonteic ' !• d a >h ' ' '^""T * «thor tlK. of an acute i,dbcti,,n witlu>ut definite nKuJfbikirM-^ -Monso ,nle..r,on with pronouneed svn.pton.s V^nni^^^T^lT^^ ^ Z h'lv often tvnhoid f;.vo.- m. fl t- ,i-Ciieial infeclion, siiniilatmjr 't\ ut tlic ,.;i>os. liiei-e nmv he niej.t oned. iu -tdditio n '■.. ......f > J :■ 101 AA//:/i/('AX ti:\t-iuk)Ik of dishasks or ciiiLinn 1 : vifrrt/'riisr tuhcrrnlnixc HnntH/>i<\ is not jiciicrallv recognized, but tl,, (.,;„,, (leseril.ed by Liiiidoii/.y and others pr.wt.ntcd «|iiiie niii'or tubeiridon. i,si,;,p of the Iiin;,'s or of oilier or;,'iiiis. willi rlie clinical synintonn of verv i,t,.„J infection, the severity of wliicli \vas out of all |)ro|M>rtion to the local \i-:',u tu,"] to the number of miliary jxranulatioiis found ;hrou;:hout the body. It i- i;„,i|'r)'t to be due to tho action of the tulierculous toxine-. ' '" ' 'I'he acute tulierculous nieninL'ilis will be dcMi 'led scjiaratoly. V ,. .||.||| here speak oidy of the typhoid and of the pulmoi.arv types. Tiijihiii,! 7'//yy,.,— The onset is usually insidious, ai'id coniinoidy thnv Ii^ been an indisposition or slight cou>.di, but prior to the fever tlu" c|ii|,| m.^. have been in ,L'ood health. The fever is noticed in the afternoon (U- e\,.ii|,|,; and with it there is loss of appetite, and the child loses in wei,(! health. Within a week, or oven earlier, tliecliil,| tik,'« to bi'd, and the .symptoms of an infection are well pr.iiounced. The t,,ii"iii. ,>" white iin.l furred. The abdomen is distended, sometimes painful on pir'-mv' and there may be diarrhiea. The spleen is usually eiilartred, and can It in,li|'v felt. The liver may be also distinctly swollen. "The j:astro-ii testiti.il in,iil,i',. with the continued fever may be strongly au rule, flie child has been failing in lic;ilth or is at the time convalcsciim from -,iiiie iiciite illness or is the subject of an acute naso-pharyntreal catarrh. The fcvir is Mnii, and mjiy reach from 10:5° to 10.',°: the pu'lse is rapid, from l-id to 14ii, The respiratory symptoms are marked. At first the shortness of breath is.slJL'lit and pr,;p,)rlioiiate to tiic fever, but gradually it increases, and the rcspinitiniH may l)c from 00 to 70 per minute. The cough is fre(|uent. div. and va becomes more marked thecolor of the ih.rcliaiiL'i'^, and flicreis si in diiM'c iirc rarel_ ilnra, but ti.e ' /iMr Tlie will 'ilivsn al exaniin I till' lr beset with iiPi account ; tin I ifi'ii instances of IMiii'Ii more impo fiuicnt. IiKpiiri I Jiseasos not infrof ofliiiling health c o;i>('S ai'c those in ?"im'fiincs the aci tlio iicck or the of or, in very rare in lyjic, when the fei flvi'i' may be extrc record he kept, it in tnlicrciilosis, an roiiiis.sions. As m fvensuhiiormal, in MMic in both disea.-^ |ii-ii;dly present in 'He sign. Kxpecb fliniild he looked fii miliiiry tnherculosis 'liiili tiihcrcle baci The cxaminatio fntasfroipientlv in jlmnM he carefully lavi' resiihcd fhuu i The profound ii •liat of aciifi tuben frtitni'os, would bo ftiiaiTlial or iironcho in? "f the acute tub Prognosis. — Th tMiicntioiieil ii type •"lii'i's, which tliev ( te either the first nia <"' 'lie e.\-pressioii of tuljcrciilous process. iUO iiiiii rlioro is , slight (•yanosis 'ri„.ii,rl, «i c • !• > aii.l aiiscnltatioM at first .sl,..,vs .; „ ,•':'' ""'" !'^ ''''■••,"•■ •'^■'■" l'y|...m.soM,u.t. i.Ui-..' breatln,,. n.ay lie lasml' .• , ' V ' ' '"'"'• ""'' '" l''"^'*'^ '"■^''"••t .:.y.ii."at tlK. o,.,l of a w..L " ■ ! , \^ H ,""; I -'-. -M'i-i. -.1 -i:.. cIuM f.nt,v.. c-ata,Tl.-,„oro .onnnonlv in on? i, t ' L 7"^ "' ''!' "•'"*' -''■ fm." I. |in.L:r,.ssiv,.lv advancin- asp|,v,i." '^^^''^i'"'' '"'urtm. davs. nsnallv .'n:::::^;;]; tl;:;!s;::;':,;^^ '••''■-"•- -., i.. ...... ".-.ronnt; tin- s„,-na.n.lin;,s < f ';: J " "S' '^''7 t''"'"' '- •^''-■" i.'n i-.stancos of tnlxTCMlosis in tl.jL'.'o-^' '''"'''"'' "'^•'•^' '"'v.' P'iont. In, -i.-s sl.onl.l l.f ,' ^ ^.T"' '"'""""' ;•"'""""" "'' 'I'o ili-ensosnot infrequently f<,llowe,l l.y „.;, i "'"'."I''.''^'-''""^'!' .-..,(1 measles, of fiiilin.' Iicaltl, ,!r of protraet e a .n . '"'''■"■" "•"V^- ^^'»"<-tinu.s a historJ -- -■- .1.0SO in whiel! the," 1 ^ '/£,'?, "^'fr"'" ,''''"• ■""'^' --'-^ Soniotinavs the acute urteetion f.-Ilow^'n,:;;^ .''''■ "'; '"'"" tnhereulosi.s. tLoneek or the opening, of a joint ,1 . ' ''. '"\ '" '"'''■'■'•"'""^ ^'lan.ls of «'•. i>i very rare in .tani^s ,1,/ li m f <'^<:" ,'>» 'i •'^o-calle,! ool.l al.seess -vp-. wlu^. the feature; re i. TS" 1,1 ';;""'"' r"'"'""' ^" "^ ^^1'''-' f->nnay he e.xtren.olv close. e ' f L ' ^""••'"^'"" "f "'•••inary -e/Heric rKora he kept, it uiirn:...umy bo f n. ,h h l" ' '" '"'f'''^ f^'"'l>.M-ature ■" 'Hl^reulosis, an.l ea.ly in^ho .li t h , '; *" l' " T^' T\ ^••'•"^"'- roinissmns. As noted l.efore, in a f.'W inst' m les 'l ? '""' """■'^*''' """"i"g wn suhnormal, in the niornin.' The ... i. . V . ' ^^I'^^.' -'tare may ho low^ .'»'ii'' in hoth .Iis(>ases. Th,> ahsen,.. of, ' T T' " '"*^'^'ti"n are inucl, the h-lly i---nt in ohihlren, ;::'";. ^;^::;i';:r'': ""'-^ ^^ - there, .hi..!, is tivcsiirn. Kxpeetoration is rarolv oh" •■ 1 . "' ,", ".'"'^ ""l-oi-tant ne-u- »"li^'>'y'"herenlosis takes its o /i in ^m iP ''r,''''''P"''^ ^''"^ *»" ^''-'••te "":,!: "'•-•'••^' ''-il!i "-.y reach tl.'p^t,:;;." "' •' ^^'"■"'^ '" «"^ '""g' f'-n - '''h;;^:':;:;;.';:;;;!;;;^;'''^^ y Ehrnch-s reaction is ,.,.. ^"7-''""' fVonl uro^enual tuhe'S^ ''''''''''' of general infection ;'7-vo,,hl he in.portant di^t^^;!, ^^j i;';;: "* l^-*' --1 -'''olic '"'"■'•''"' '"• '"•oncho-pnennmnie tv„<. .;! 7 I u ' '"', <''".2iosis of the •l-». .I,„.|, ,|;,'v ,. I ' ,,'" )" '■'■'•"!■""»> v Kn.I.i». I„„„l,,„v "Z / K 1 T KMi .i.i//;A'/r.i.v T/:.\r-/i()()h' or ihseases oy ciiiijhu:.^ the tciiiiK'niturt- ciirvi' would iiut ii|>|.ciir to ;.'ivf imv di'liiiitf nitcrion, ! ij,,,, ill Ihct. tlicrc is suiiic iociil iiilpiTcnlniis focus. | do iiot sec Imw tliix fonn nro^nizrd. Mini niaiiv oftiii' cases reported l.y A\ irii;,Miet in liis iiioiioirn,, not at all eoiniiiciii;,'. 'I'liat there may be," liouever, either earlv in :, oiilosis. or as a secondary event in a loe'iil process, an int'ection of the tlie toxines is exlreiiiely iikelv in adults it is not verv uiic( Wit '■|lMr;|.', liU'civiir If :ici|tr /■'■ tVoili oiir or liv,.. II arc I II her. ,'lci,, find II tuheiruloUM focus completely overlooked in a ^.'eiieral infection iMlievwl to he typhoid fever, and in wiiich the secondary development of niiliar\ .fctnu. lations soom.s scarcely sullicieiit to cccount for all the svmploiiis. ' * (2) Cmiionic Diiiisi: 'i'l iikkci i.i.sis. This, one of the most common iiirms of tuherciilosis in children, i- terized anatomically hy the ;.ri'adiiiil development of tuiiercles in niiiia > parts of the hody : they are not. however, tiie miliary ^.nanulations o|' i tuherciilosis, hut coarse, grayish-yellow tuiiereulous niasses, varviii" in - ii pen toil walnut. In the liiiiirs. for iii>iance. there are cas is tuiieri'lc .sizes, areas of (nisoous hroiicho-pneiimonia. some of which have uin' ."ofteiiini:; hiit cavities are not common except in children ahove " The hr-uichial ;,dands are often ijivjitly enhirjred and I'aseous, ami xuiiciniiis present ahscosses. The ahdomimil or^Jins show extensive tuherciilovi,. 'I'l,,. .spleen is ^'reatly eiil.irjred. and on section presents numerous ;,'ravi>l.-\(HMiv tiiliei'culoiis masses, varying' in size from 'l to Id mm. 'i'he liver is cii'lar'cil and may show miliary tiihercles on the capsule, hut in many iiistaiicis tli'ri- !ire coarser yellowish-^rray masses which have developed ahoiit the l)ilc-c'a|iil- laries. and whii'h, iuiviii;,' s(d'teno(| in the centre, present a yellowisii-L'iccn hji,,. stiiiiied pus. 'I'lie small intestines may show tuherciiloii.s ulceration to .■! ;.nv,iiir or less extent. The mesenteric jrliinds tire usually enlar^ri'd ami • ;im;.iii,. Tlie kidneys may show coiirse tuiiercles, sometimes an intense tuherciiJiMis ini.. litis. In the hrain there may he either an acute tormina I menin^ritis m i|,i , are coarse tuberculous nculides scattered throughout the siil. stance, piniicni, in the cerebellum. The chronic diHuse tuberculosis is muv h more fivi|iiiiii li, infants than in children above i\w a,u;o of two. The symptoms are lli -,• uf ii proixressive enfceldement of the nutrition, as a rule iritlioKt f,-rn: ml witb inanifestiitions in different orf.'ans varyinjj; with the de-zrec of 'tubeirilizatinii. 'i'he affection may set in iiciitely as a bronchitis or a broncho-pncimiipiiia. tlie symptoms of which usually tumefied, and both the liver Mini ^plfcn, are enlarjred. When the abdoiiunal features are marked, the cliincMl jiit'tiire is that really of some cases formerly described as tabes nicsenriiii'a. Tlie .superficial trlands may be enlar^'ed and li;ird. ( 'ou,t;h may be pre-cnt. iisimlh' dry, and very rarely there is dyspiia'a. The physical signs ilioi(,ii;,'li()iit llioj liinjrs are either dulne.ss in the interscapular rejiionsor scattered ;iiv isof ilctlc- tive re.sonaiice with bronchial ru!"s and blowin;^ breathing,'. Tl; ijijietiti' lil Jioor. the di^restioii feeble, voniitinjf is fie<|ueiit, and diarrlia'a is c iinoii. X"t| only may there be no i'rwr, but the temperature may even iljiioniia Death usually results from some compilation, either a secondu evasion o pneumococci or streptucocci, or an acute meningitis. I") I riiivitf't, •r;ii of tlie disea iii|i|)(i>r(l. howev ;"|wficial lymph-^r '"L'kin's disease. '(■iiiiiTJi of the iipp l"i!'H:irt'Miciit of the '■"inlition of the ''I'fiVycr's folli, !''''il'l'™ lii'Md of om illlll^S, '''I I'ljiivicu, Ai ""■'"■t'k (.'111 brace tl iterion. ! this fDriii < lrlU||t(J.'l;i •iiilv in , II I'f tllr V IIIU'llll.,, foctioii >t' iiiiliiii !i ;iiv .-tfiil 'Hi, t,, .'raiiti. llll'CII. i> clllll;,,.. II iiiaiivilitrciviir UllS ..!' lil,. ;|,.||J|. 'iii^'in -I/.,. (V„||| tlllifrrlr> ,it'a]| iiivc iiiMlcr^'Miie •M' liilll- III- fivi.., iiiid ."^diiictiiiics (•i'ciil(i«i>. 'I'll,. j,'riivi>|,.vi.ll„iv ivt'l' is cliliii'^H.il iiistjiiiivs tlicrt t till' lnic-ca|ii|. visii-jrrci'ii liil|..i ion to a ^'iviitir 1 Mini Ciisijniij, j iljci'fuloiis jive- inj.'iti.s (ir tlil'rei L't". |)iirti('iilai; JI'C tV('i|l|rIi| in are tii">(.'ut'a '''vrvi\ ml with I iilifi't ■liizatiiiii. iiH'iitiioiiia. tliej follows wilnnp. Vt'(|iii'iitlv it \A licahli.' Tiief u' skill i.s iiiii-ei ^iiicntfd. Tiie) 'I'lic thorax ii| ^IIS (it' CUfXist- V(T and spliriij liiiiral jiictiirtfj ■iiifi'ica. Tliol '•(•~r!it. u?iiall_ ■" '^,dioiit tliej ..ilMi.f.r- lii ippetitf M iiiiciii. Ni il»ii(inii;i ivasiuii u 'rriii:iicn,usis. MnMitution.: ami, sn-ondlv. .'..• i | ' ■"'T" '" "'"'"^. l-Vtinilai y :i::M.i. 'd til.. int..,s,i,u.,s. Tj.i.s ca ... I, . "";'"";j''s iiou „r ,i„, |„„„, ; I""-'-"; ••"-; iH-.iis.ii.,„isi...d iv:,:;\ ::''■■';!''• '''"•'- ...i....vni;;i;: : .:iianli. and of ,MV|diilis. I,, n..L..f- i '."''^"•^> "' t'lii'onic -'astrn-i,,t..stiM..I .ipunant ii..^.a.iv,. si,.,.. \ ,r,,, , . i:'/ ,"'''" I"' "' ''"' lvM,,d,-;,la„ds is , .i.cas,s "'•|.ndou,.ds,,.I,ilit':' ,^ '" :^7 "-'f in .lis.n,,Llu,.. .., ^ 1 ' r".''K-'i juid ,i.,..,d....i.'and live .::;,:,;;:, '';-"i-'i-''i ^i.n..i; ,...v ,'. in. LocLAizED Tuberculosis. (1) Ti-,i,,,„ri,os,s UK Tin; I.VMn,-.,.,^,.^ 'i'mss,n(a.rs), in.'iv present adv.n<-..dt,. ''"'. ' •^'•■'•""'- " lie lv..,,,l,.sac.s V'"' — -• otliVi' pa..ts. 'n;r^r;,^ ;:';;-;,' ; '. in volJ-ement t ' e s„,,,,ose,l. In .son.e instances of -^ener- , I , l' ''''"' ''■'' '"'^•^' ''*■'•■- ''M-l'vii there n.ay he what l.e.r,.o„v :,•'"'"'"'"'" ""^''''i"" in v,„u..r a>i'i IWal have deserihed .as,.s j,. ehihi; . i ) '■'" '"''"^'"^'^ J'^'^"^'^' r'*'^'""'"^ "^ ""' '.vn,|d,ati,- ^dands , i V « ' '', '''''''*' ^^••'•^ l"-"^"vssire "-f tl- axilla, and lastly tl.e cenS'S' n !'""" "'' '''" ^'•"'"- "'<"' ■:a oction ,„ so„,e of the Jases as I o , n :"'"' ^7""!-; They re-rard ,J";Mu.vet).ediseas,.toheeon.n.|. ; ^'y, ""-'-"•^ tuhere.dosis; i„ ..tluTs ^n.ml eMl,-.r.en,ent of the sn,.,.W .![ ;,,,''" r^''"''''''"'^ "» ^'''-^ '•'"••n of.,,,. '«"" ■'' 'i'vei-and withou! , ^ \ ^'i;;!' ^ "T i'-^'-ivoeaehexia ,.i ::•-;: i:;;;ii^;;.:d:i;;'t;:i'^-^:;;:^t '■-\ ••- ^<-'" ^h... e,.,ai,.. -e in eliildren, in wlii.-h. h . I "I ^Z- '"''■ '""'"' "'" ^'"''^'t serious effect.' jaiiiated deej) alonn ledv direct contac't \k caseous bronchi kIiit instances it t, [iui'inir rarer seipicii [in; adlicsioii ,)f ,,„ ^ k'lf the anterior Hwiiloiis adenopa NiHicd ;r|a,id into Symptoms. — J„ I'i^aicvcr. and even it H'f- Aufho,-,s di; pi J think correctly Wm^A Ihe vei„.s" iS"'iiiidha'iii„rrlia(res '•ifimctcr of M,". ),, l'"'"^'i f'.v "ie same w .*; 'iVipiendy in til l*''"'"»^'> '■vaiiosis, ar '«' piii'o.vysms may "'•Ii to iiivssiire at tli( , "' fiiis Way lar' fres^ion of one or othei common. Obsorvation 'lands biiciJl 1 may |,(. p,.^, 'f I^ooinis (J,..) ,sl, wy .trgo j)i;o;,ortion of ulj at tJif Hivst itifoetioii ow even that fiiiid'a I iir.iih'.'ii >\ to tlie ,>so.calle(l'l wJtJiont any local 1 wa.s in tlicso st aw f; I'iniiii I masses j ""P. t'lo bi'onciiial l\ ^;^IOIl in tlio 1 =';?Srrrfc«* 'Pparently normal in a "ppear ■^'" it woiibi " >'■» i'-s;;;ii' K;: !.-i!.'* ''"^'«- Of i2r> and.s lows. * (-"i.sos e\a "lily be iiiinod b """'■'^'■'^"*^'-^; i"l^.itwas in. , m;H' ll|■('S(■ll^ ,„ -I- ""IIUMI ^"T''-.i«».;*™sr^,r?.;«:£.;::;;.;i^j ;'}■ I'lvscnt ^niy ijjjjj. lorsiit'tiiiiii^r witl iiisfs thoro is niueli sd ■"•y tiiberclys, 1 t'J tlio bronciiial .r] ' ^"PPnration, ,„. old (l,, \ |'m>nt tnborel 'kIn alon- P« ill flic Inn ">'';. '"'pigiiicntcMi llflT ill irterenflv ^■'•"•^".s and j.i^rn, '"^•".Ivod; thus tl <-ififd ('Illation nia; <:ni.\ f't ".volvon,.ntoftbo'bn,nc-l 'k> di 111 W '«y glands ■^'■«».s, f„ei Tl '10 '0 ''>ii;,'-stan(l inir li'uini ■"•(' 'Mvolvod, and ^-■''-'".ay'b; ;;;r^.r"j-'-yb' ^■^•■•■ascoiis masses unifonnl B-llM'iK'trating deeply I r /!'"'^^ ,p'-p-^ M vt-ry often those d '\;">'^-'' aflected witi! y ■■^iiiTonnd i; ;:':,!" ''-'"!■- "r.wi ".'•f <'oininonly all tl lioiit 10 Jjiiivilf I lie abscosso Ifiilarircd ii. I - """"llir tlie iiimIi, I 1 •^"i- 111 "■""'■■" liif iok..,7, ,1. '"■"",':'"'» ••""1 it» ns. '.r." f^"' ^''aiid i visions, laite of JJ;,,.,] 'ii'lails the read 'lo e/1 oets of tl >* 8np. lioi'e ai Ijh!. Iii'oiicli nioi ■(• mstai Ifta'iiinogastric nerve mav I, '/■"•y artery, aiid of '(•/ •i.uJ ^ '"\'^"'<'L'i' IS referr , ,1; '"' ^^'"""*'' (tome :j). _[ 'l< OS on iv.„ 1 ,. )• A loferi'ed to tl lese 10 ''" J'f't^ord of c( it(eiie( tl "" ")• -It IS snf- >iiipression of the fill '-' biH'h. M iciii'd Ifiniicil I "'•£' iiii})ortant. ''t' involved ^'•^' i-arely serio,;;i '- -y.os vein: The t^^, '••""'-^ '"to the bi^onel I'y- partieiilarlv tl, V ( impressed. "<-' I'oeiirrent 1 lea 'ho |Vf\>t' •::^'^^^.^^^£S^^-^^-^^ siii-emuch less i"y"gcal and Ifcition oi" tli (■'•mmon, but tl Itiiist sc "iiiiatf '--opi.a:;;:;:;;';,rs'"!-..yart^;h;;,, ^'HMl bronchial .Wand l> 7 '^:'' '"^ ^^ - Piilinonarv art^.,- .:, / '''''"'-^lons of the ''"•lis effect ci'n dosei'ibed" iMiiis enecr« iu ;..»■ ^' — ■"^•-■ii 111 .sever il c, l>oen opened. 1 'er- 11,. ' -n '"e o fl)V(hrect contact, and i "•'•"^•i'i. The i '.f ^•"' ^''"'"'^ ''y tl iile cast'ii '"■^ bi-onchial ,rlan,| f '"toction m '«*?»• Ono of th !""y 'h; ditfieult to d lotern ly, as i 'f '''■'*.'«"« glands IS often clearl liuii '^'' "-'ances it takc:s j.Iaee ,1 '"'"^raivrseipience ^--i'.atos and tile n;;;;;:i".-"--ti<-\^^ soon, piiliiionar III:' adi •"^'. t'lo root of the I y tissue I iiore 'ogins. J -::^c"^^£i^-:-^^^^ "'ividuiis a( and aortic '■"**<|"ont retract 'sop, ''''g'i« follow- ""• and, in the .'I'llCll L'Imik Symptoms, I'iMifvci'. and even "'<'nopathv •in.l . • , '^' /''"O'llis, the ^\•iu,^, \ '' '" the II tlu K-irdiiim g''cat iiiajority of "'■ I'y niptiiro of iFwit. Aiifl |ii-iltliii)k 'I'lrs diff; 1" cnorinons enj •• f'.xti iFi'-Hi'ii of ill ''•"■'■<'<•'' ly. 'Iiat tl '*'"'<''y in th( i<^' iiianifestat '."■g<'iiiont press instances tl. ii" view.v ■llKvinorr "'!'''"^^'"''''>I-v,d Ions, IM-e-sio;n.s I on tl ^''■«' arc no indicati '.'■■'y"ot havob ions con as a rule. ?-^'-n.er,:fi;;;,;r;:!t ;:.s^''-''fti.e. ;; P-""t. Many hold ■>'<■ vorysli.rht. ( I'actcr of the 1 ('.V till 'Urv ih'(|iii lieai'(. ■soiim aiiie writers. Th(. I f and attacks of '<'z and Sjini <'iiis cauf Al \\\\i 'IOC, oin- lO- Irratli 'l'"""y ill the aft, itfer paro.vysnia! i|v, cyan '•'I'ations ii r"""^' <'ya"o.is, and coh I paroxysms n.,y succeed pdi to '';"""", and (hei ''"(•at.s, almost lil *'"/' "n suddenl 110 o|)j 'c I'S oxtren ft piKOa are d <'" at re.ruli '''■fr'"'^' at the bif, each 0(1 Y ■■'" attack of 'I'cssion with les- itr apid . ■•" '-^ lllO iHtlircatinr, of fl, , -'-'''-^;:^,/;:^.v^cai,..n.^1;o;;:'t:;:-«-.P-.^^ r''onofoneor^.S'? ' '11)0(1 not .so '■oiichus, '' ^'au.sing feeble b ♦""' ' ' . '.*' 'si I no com- '"" "» the side most 'i-eath i I : I 110 AMERICAN TEXT-liOOK OF DISEASES OF CHILI) HE... affoctod witl. sil)ilaiit and fine nllos. Usiiullv, liowover, wlioii the -],, ,|, very iiuidi ..nlaiigfd the lung is also involvc-d. and it niav iKMlilficult t.^ ,\ ' tar the alterations are due to the clianges in it. Still hVss reliable is tli. i„| niation obtained on perenssion. for tl.e dulness in the iipner j)art of the m. .,■„,',"' and in the interseapnlar spaces is. when present, hv no means a posiiiw.s|,'" I lie thvniiis may eaiise .sternal flatness on percu.ssion ; and behind nnl,«ri" glands are enormously enlarged and the ehild very thin, it is difheiilt t.. ,|,.| " mine any special modification of the resonance"' in the interscaDiiim s,,.!'' between the first and third dorsal vertebrte. ' '' (r/) Mks|.;\tkrio Gl.\M).s (T.ahes Mk.'^enterica).— The glaiid< mesentery and the gastro-hepatic omentiiiiraii, cheesy glands witiioiit ulcers. Of 144 childrei :> con.secutive post-moiicms „ "I tlic ^lllll ill ainl rjand were tuberculous, onlv 44 showed neither ul ■en III wliK h tl le Uh the intestines (iJarlhez and Saniiee). (•('rations nor tiibcric M'litcric n a great many instances the condition is found accident who liMve died o f oti fig ler diseases. 11 res, tl I llllV 111 ihili|ivi|| le intcctioii 111 iiiair- o of the intest 1 f tl iKjiiestioiiabiy. as is indicatcl l,v tii. iiie IS ,iot nece lese cases is primary in the ghi'id- iry. Some e.\periiiK>nts have shown -I'Slnll )acilli may gain entrance tlirough a healtliv mucosa, to the ]iossibility id' infectiiui by the baeill'i in milk we" iliar ill pecial interoi n.lm,. II k nown that in animal more partieulail tuberculosis of the intestine s e.\'perinientallv fed with infected as heen irod iiceii. s. with e.xtensive di.sei ill of t y !i- i; i< milk pniiMirv le nieseiHei primary tuberculosis of the intestin iiestioii will be referred to affiiin on ti es. The eases fall into 1 le ,L'l;il|i|., •^lilijccr nf (1) Very slight tuberculous affection of a f_ _ ,.,., ly ones), met with accidentally in children wlio"have (lieii our irrniiiis on orders. ew L'laiids (which i of liny 1)0 til,. v;irions dis- (2) In the chronic generalized tubercul osis. in both the acute pulmonary tuberculosis, and in the more chronic forms of till liny of the organs in children, th and caseous. ami cIiiMiiic •erciilo.sis nf Tl lie mesenteric glands ma-v be foiiml ciil lere arc instances, too. in which the afteetioi teric and retroperitoneal glands with those of the tlior lll'L'Cil I of the 111|K(T,. 1 esioii. ii.x constitiilcv il In both tl ese groups the disease of the glands d any symptoms pointing to abdominal disorder (■>) In a third group there are siLHi.s of clii ,oes not neces-iirii V (Vllhf ation and verv marked distiirl '11 chieliv in children irltanee in tl 'onic intestinal catarrh nr iilnr- le general nutrition. T Il CSC CIlSl'- yea !'■ •etween the ages of eighteen moiulK and |iv ibdonien is distended, tympanitic, usuallv a littl pressure, but no nodules arc felt. Tlie diarrl... toni : the stools are frei[ueiit. brownish or yellow-! lainfl Idea is the most troiiMi ll oil llci'jl I'lllC s yiii|i- mucus, not often blood, '{'he diarrl • I'own 111 color, (■(iiitiiiiini:; for del liiea is variable, and may soiiici several weeks. There is usually slight fever, but tl ility are the mo-it cbaract(>ristic' features. Tiie name liibi I UK'S ji(_'l'si>t le wneriil uii^iiii'' nml often applied to this condition. Tl e course is chronic and may cMcimI over a I'O I t'BERC liiivfilvcd ; thu.s ;a.-fro-iiilestinai luiviilvcil : in li< Jivii„irkiible, coil |w>c of the stoii joM'S. That tl [(•\|i('riiii('iitiilly 1 •iic iW'diiig of ca IH'iv many series I infected through ■liililrcii is lud |f;i>i'(iiis foci in t i-iMiiccs of prill in ;i great i yi'iici'iil infection jfiiictiy in I lie ileu I tiilici'des may bi |«iin|(' ilciiiii max [iniduliir iiiberch''; jiiiiK'oiis niciiihrau I III' very (•.\lciisiv( 'I'voiid ihcir linii -"tninsverse to It'L'cs {iml base a 11'' also iiividved [tiili(>rck's or wdl- Priniiiry tuber ['•vtciisivc iilceratii [(':is(' limy he rei.rar I !" iiiy wiii'ds with (i tliiTi' weni (iiilv a, [cvii'ii-ivo disease. jciivliii;; ulcer, the hvoi'iii-oiitcn. and c i'«astlii(d< Mild op I 111 tliwc i,'irdlii,(r I n the ^lainls aro ffifiilt to - , ii„,^; iililc is til, iiii;,,, rtof the ^vii that i|„. illtcl-l'st i.,.l;it,.< icularlv ii^ i; \, ^ milk jifiiii.'irv iciitcric irl:iii/iv tli(> sulijcrr „\ ' ij;i'(Hijis : •h iii;iy he the of variciiis ilis- TUliElUULOSIS. tiirrii 111- iilnr- Th('<(' r\ mn^f o..,f,. ■ . ;i,ffic„li tod.tc.rn,inowlio e,-^; Lu^ [;;":,.l''''''r^'''"- ^' '^ ^""'<^^i'"*>« very nnmc del.iliry and wastin.^ J | d • ; , /", ■'"•"' '"^■'' " ^'"'""^i"" <'f l™-ie'^;i »vohvd. IU.0 tlio .liaiTlHca. .OS £';,:' '" "'"^'"". *''*' l-ntonn,n, is ..0 wasting arc as in tlio provioi, ™ • ^ m ;;:.,r''''"'^r^'''''' ""'' I"■"^'•^'^- w„h disease of the peritoneum, in vTiie 'no ^vmptoins are assoeiated n.v iH' .-onsi.leral.le ascites. TJie e '. ■ ■ > ''"T' T^ ''^" '^•'^' ■'""I 'iKTe li: iniu: ,:,;,y W ..onsideral.Ie ascites, a^™;,;'; J 'V' '"";-- f'^' 'h" felt, and tliere nmler IVritoncal Tuberculosis. "' '■'^^"''■'■'* ^^ '»o''e particularly IMI-MIN,..,. A.ND OK TUK AnDO.MIXAL ORfi.v.VS. ('0 'rriiKucrLDsts UK 'I'HK liinvFi s 'n '^"l-'l: thus, of 141 children j^esen ""l, '^If "" 'r'""' ^'^"''""'^'y .:i"I^«"I: i» feedin. of n^ ■ *^ "•""entary canal is shoAvn JlV.l.ngof cahes and^ 'l?, 1^^ ;;:|V^^T'^'' -'!"-- "f' 'l^^ hacillus an.l ..V iiKiiiy series of cases U^hu n m e '"'^'''•^""V^" •""'^- '''''^■'■^' ">■« ":i-"''l through this lattersou ce.i'iri ;•.;;'' 'r''"'' "''"'i''^ "'">• ''« :;:l"-r.;:t;r;;its^ ,.,..1 ,.d.c;lo:r;^„;:\,i,r;i;'^,,:;;;- are part of a ^li.^v "Hlieileu!n,i,n-olvin,r the soli,. ^..,;-' , .'•,",." '■"''^ ^'-'' ■^'t-'ft'd '"i'-clcs may he seen as snu.H n u io^ f n''' "i *"""^^'^«""Vo.-. The «!'"1<' il<'".n n.av present a renm' ]' ' '" ."""^•"•^" = .^"n.etime.s the ""'l"Ia>' t„hcrcles,'the L , f ! ] i" /''''"^'''•''•'^•^^ *'■;"" "'^^ ^"•ayish-vellow «oi.s i,iemhrane.s. The ca it an ""''."''{'"f ^''^ ^"''•""cosa an.l the !"■ vorv ...x.cnsive, inv, in 1 ^^^w ''"' /" "''■•'••"ti"". "hich may i-oiiii ihcir limii;. 'n mh ■' h Hi T.r r '^r ';;^ ""'■"^"^''>- ^■^^^"■•'"'^ i-"tniiisversetothelnn/ xs .3v '^ It O'b's and hase are infilra'l^d; ..;;;:;': ? !"' T^-"'"'- '" -^'i'-= the »'■-''- i>'-.lv..d in the tulK^nlo s ; .'Z^^^ ' nuisculari.s ''■'"■'•^•''■^ '"■ w<.ll-marked Ivn n , i . rfe ' "'''^■\ '"'""'"^ "^^•"""S iVi.iiaiy tiiherculosis .d-'the Ce ^ " J." T'"' "" /'" ''■'•'"'^•" •■^t^sivc ulceration in the ih n d\i l; 1 ?' ' '■"'''• '"" '" ^•'''''''•<'" ^^'th -" niay he rcarde-l as r ^ ^'lu "^f^'^'r '■' ""'^■'' I""''^ ^'"- ''- """.v^vards wi 1. dropsv an l- ch '•'"l; aged nin.. who was admi.ied •1"- worn oidv a, (l. ^^n 1 f ' , e 1 7 "") '"7 "^ ^'" '"""*''«' -'•"•='ti""- ""■'-ive disease. Vho ,. , "'^- ', '''':'*" ^"^ '"t-slines showed most '•'HiiiL' ulcer. theedJsof ,1 '' '" '.'"'"''■"'"" there was a lar.re il :'l I' :■ iJ Ihil ^ih '■' I I Hi :| I 112 AMERICA X TEXT-BOOK OF DISEASES OE VIULDUEX. larn;e, deep ulcer, wliilo the inosciitcric iittiicliiiieiit about the ileum fur ;i,.ti ,,, liu-i^e tuinor-niiiss froiu tlic c\ iit of tiio involvcMieiit of the jj^laiids. !'.!,(. peritoneum presented scattered ubercles and the mesenteric glands wotr v\u iisiwllv enlarged and painful, and the .odular ma.sses may be felt. In a few iiistaiKvs there are gastric symptoms, which do not necessarily indicate ulceratidii in the stomach, but there may lie loss of ajipetite and occasional vomiting, and tlioiv are uistances on record of profuse luematemesis or mehena from ercisinn i,f an artery. The outlook is unfavorab'e. and death may be caused by the se\eiitv(if the intestinal symptoms, or more rarely by the accidents, such as perfoiatioii w litcmori'hage. Recognition is rarely difficult, except in the primary cases, wliidi ire regarded at first as simple entero-colitis. Usually, however, when wi'lUs- talilished, the diagnosis is easy, particularly when other organs bcciJiiic in- volved. In susjiected cases the stools should be carefully examined for tiibmle bacilli. {h) TfiuatcuLosis OK Livi:h. — In all cases of acute miliary tiiliemilnsis j granidation.s are found in this organ ; sometimes they are extiTuicIv miiiiito and are only detected microscopically. The liver is usually soinewhai eriiiiivtd, pale, and fatty. In more chronic cases, particularly the diU'use geiieralizi'il | tuberculosis of young children, the tubercles may attain considerable sizcinnl develop about the finer liile-ducts. They underg'> rapid softening, and ;;ivi;i| very remarkable appearance to the liver, whi(di is in extreme cax's aliinist honeycombed with tuberculous abscesses, varying in size from a pea to aiintrblo; t! .' pus is usually bilc-2 in clul- .:i-s ,r is secon.lury t^ tulj^ ^i '^^ ' ' f'?' ^"' '" ^ "'"•'"••'^^ "*" "'« .iilir genitalia. ' ^'^'""-'^ oi the intestines, mesenteric glands, or I Morbid Anatomy.— Tnliercles ii> tl„. ,„...,v »^tl' HI the iMMlios ot <-l.ildic' r, o , "'r'""' '"r'"* inft-equentl^ „,ct nn,es m 10;> pc>st-nun.,en. . " i*^.. "'H^'i^?''-'«- .J^^^^'-y ""t-1 tlui 88 I n.nes m 10. jK.t-numen.s on luf;;;;.^,. ' S r" Tl^:;' • , ilie^'iMV -raimlations witli or witlu.nt ov, ? ' "^'ciir eulier as (1) 1^ -■-^^'"-:''tire^peritone„i:tnnd^;i^^^^^^ I, III N'-- vnrieries the j.roeess nia ^ hH L . ' "'''''T^!^'' ^'^^"^ '» '"'tK blally i-ost-morteni. More f W.mu'i v r "Wv "'"'"," ''^ ""'^ "'''' "^'^•i- i:- tuherHes ai. in the fon o^ •,^' : l?"!?;^ •'--'-- !"--nt, ™in;: tiattem.l tul.ercnlous ,,la, uos T t^',,! "'•■"^''■''•^' \" *'"'"''' "*'^'" F-mlent. the coils of intestines are m-.r I , '^ >s P'.rulent or sero- .l..n ti,ere may be large <-as,.l;",.^:.;""', ;:;:;;• /"^<'' -•' - "layW Z^ Cl'!. "" ^^T'I!' ^"•^■'••■^' '" ..netinies tlie process is confined ]o h c- ^ of t ' I''" ' •""" """"'' = '■tla-r cases it is in the j...Ivis, less freouentk , V ^''f, '^'^^^''' P^'ntoneum ; in .):av l,e multi- or mono locular *"''""'*'^ '" ^''^' "'"l^"^' P«>-t'-n. The cysts ..Sr\- !;nc;;;;:Sn v^tt:^ ^^'^ "'^-^- "- —tea, f'-ficntlv hv the hands of connectiv > i ^ f'"f '?'"'"-'^ "'»''^''^^« ^ "'«••« Ai.i;i^^..;i.sf.i.ndfiveinsLr:;';^i.^rri.:eh!;dr :r^^^ ^^ ^''^ ^"--• i™i'j:::ui;;;;!r;;;i'"'^hel;!;^^ l""''i'"'"''fl'''al,dominai c.vi it.; ^'''•' '"""'""'"f"" '- in the central lit iiiay ultimately heal. '''. ' "'"'■'' P'^'''^''^t^ <'"' '"onths Symptoins. — The svinotorn« r.f t„i i ^•"^■•'■Hl it is verv lifli • t 'iv .. '•"'■'^■"'r-r i':'''"""itis are extremely h''-v..,nce.th;.ce cl,,:.l^^ l"iw„k(.n foracut. enteritis or ev '-^"h' onset that ca.ses have been '■'■'T'ontlv the onset is s, ;„ ,1 is " i " r"';""?" '' ^"■'•'""- ^I<"'« •l-^n.. indigestion, and , t oia ai^ r ^T '"^' ''l"'^'''*''" ^'^^■^•'- "*' ->"'« , ^^'- '- - n.ny instan.: ''".Cs' ^h lent ''i d '^ T ''" "'';'?""''' '^ 'I'o synipton. for which the phvs Cian is co J, 1 ^l ' M :"';"'^"^.'^' /'''^''"'"■" K">'""1 to cMsi-lorable de-r,-,.. ^vitho , f^^v 1 " , '" ''""'"""" '"•'<'^'''' ""^y '^-"i>.:Mi,aiiy4ai,ingh;;,j;t;r^::;:;:;V^:L;^^^ ■•'■'« "imns in some instances iW-,,-,-] .,, '^ r i '^""* '''fon. Intestinal di.s- r';-'"^ I'^'Hiatin. w;;i:;:;;:^'±;:i''"'^,::"':'^'^^;i--' -■ "^t- attacks of i <;liiinictcri,sti( . with constipation. Tlu- l,,cal sy-npton.sare by nomea^; t'eins Ti.ca.>i,.,.,o„i,ui,,,„;,„,:iL'*;,''^,;;n;r";;;s;-;,': ! 1 114 AMKRICAN TEXT-BOOK OF DKEASES OF ('IIILI)RF.\ «'iiliir;:;tMl. I'crcussioii gives (liilmss in the flanks, wliieli is niovabl in tl le iiniliilical i'e;,'iun. tind there is a well-marked fliict tion niav lie entireiv neL;ative: no nodular masses are felt. '1 are not otti'n enlarirei I. [t unless there are tuixTciiloiis 1 niav lie extremelv i liil le, resi nation wave, he liver and iiK'e >\i'{'\\ leiilt. or (|inte ini|>n -il,|, the nature of tli esions in other I'eLcioiis. to speak defii III' ,i:raiiiiall\--devel()|iing aseite Tl le clinieal pieture similar, indeed, to ihat of the eases of aseites from cirrhosis, and a eondition is met with in the rare eases of s V'TV le aseites may demand tapjiinir. but tlie fluid reaocuinuiate Tl exudate may he enevsteil. foriiiinir a u iiiiple eiiroiiie peritonitis in n HI' eli, s rapidl\ 'I iivii ... . „ Jironiineiit tumor in the epi^r; nii)ilieal regions (in wliieh case the etVusion is prohaldv within the lt~s toneitni). or it may ho situated in the pelvis or in the flank, and simul, closely cystic ovarian disease. This foi and very good results have followed operation; of ni IS not very uncommon in cliilil >'ric 111' ■II jicri- llc Vi'l'V ture, recovered Tl nine instance; lis ascitic form. ( (level in tl 01)1 presenting the picture of a chronic ascite far tl ng slowl I'CII, I'' lltclM- s or operation in encapsulated exiidat lie most favorable variety, and eases may recover spontaneouslv y, and uliiiiuitc c. Is li "1' ;ifk^ (2) Thr uh'n-atiiw. f orm IS much more serious. Tl le peritoneum h. i tains larger caseous masses which break down, and there is a difluse peritonitis. The coils of intestines are matted together, nodular t ma.s.ses develop on the parietal and visceral lavers, the <'land larged, and in ])rotracted eases extensive iilcerati V ciili. jILflllclit llhiivi|l,|||< are givurlv i.i,- iiis occur. Tlie onset are pronounced riii is usually gradual, but the abdominal syinptoms child complains of colicky pains, diarrlnra. 'and chr aI;(loiiicn is enlarged and painful. The eondition on examinat , flatt .skin. tluliK ened in tlie L'nh flank tl chronic indigestion. Tlio ion may be eiitiivlv letriciil, ii,i( •eiieiitli \\w s ; nodular projections may sometimes be seen 1 ess there is a very extensive purulent effusion there is no movil flat ess. Ihere is a flat tympany or there are alternating areas of ic iuid diiliiess. On jialpation there is a boggy, doughv feel, and nodiil may be felt in dilfereiit regions. The liver' and spleen niav both 1 'lll,-|l|C(. !ll- IlllhSI'.S In tl is suppurative form the effusion niav be •nuieral. or it le ciil niav be ciicv• f)ri/ TiiI'iT''}i!'.!Ux l*,>ritiiuifiit. — Iji a alile number of all cases of tuberculous peritonitis there is litt or purulent exudate, but the tubercles are surrounded with a ti :ilii| Illi'lV was ail I'Xtt'ii.sivi' n a vi'i'v consiiliM'. e iir 110 serous iiiii'iiis Ivniiiii Her is in itself miiiiy (if the case; The condition ami fniiii chronic pie, is a rare disc kt alter withdraw uiiiisiiiilly hard, an lar. 'flic general fi('i|iieiitly a slight ii"i sii marked. Hiii|ile chronic per e.\|ilorat(iry laparot I'l' siiiiill nodular hin|Hirtaiit in these 'ii'ilee to determine filiioiil. the experin iiMaiiecs of report( Iwc been instance ['I'll'' iileera live foriii [ill tlie |ioritoneuni w 'iiffii'iilty in diagnosi '"I'liis also may be li>tiila. simple or st Prognosis. — Th '■'ii'i'iiii' iidliesive va ii'i^ jrniiliially di.sap] i );ii''<-'t,v. wliei'i the al "i*'|||H'i'iitiiiii of inci .'"''- lovacply pig,„onfed fii;;„id adh ^U , o ! S'h '^'''•'' '•^"' -"•'-"-l-l dusisof the peritoneu.n is localized -th, TZ t 7 "^^^^^-^>\ ^l'^ tuher- aUc. nr i.. the regiu.i ,.f the ciecfm, 'a, , i *'" '"'I'''^ '" '' ''^•'■"'■••'' '^"c a.v iN^ta,.ces in ^^^.ich thrnn.r I ''''/' '■ "' ^ ^^^ ^'''■'•'•"'"- '''''<■-■" until :• fonns a ri,I,H>-Iike tu, 'i' " ..^ l. I.'''' '"■'"'"""•^: ""•'"' '""' '•""-' ^'"^ '"-"i«- -nK.;:ive torn, is n i S iJ Xnt'in''TT.'""""" ^'^" ^''-''"'•'•"<'"- »n:i)t''nis are very indefinite Tl„ .1 i ' ^'''il.lren as ,n adidts. Tiie ■' 'i'^' » r™- ■ri- so„..,.ai ».4, «,™ r ' ' 's;'!;;;. "'•,;"''"■'■ ■""■''?" wistin^' and cachexia, sometimes with .......l- •• ^'^"'V'*- "'<'''« niav be forn,.s are not intC -mlT e h 7 7' '''""^''' '''^'•^^^ •^^''•'""i^ "ay be subnonnal. "^^ ^!:':t3;r^r: ^j'- ^-M-ut.:re, II e.xtcii.sivr 1 Y\ (.'niisiilci'. 1 ir no scrolls 1 111 HIS lvill]lll aiilicxivc iN'l.eil. n,ay be subnormar'SvUhM!;'' v!^ t">-ou»J,ont. or'the ten.perature; «y Ik. no .;yn.pton.s direct v fro , he e it? ' f '\' '■°^'^'^>' P'''''^ there .inp.i,.ated\vi/h tubercles 1 X ^r^'^';";:;;'';;;'"^ ^'-;-- '-0 ve.y often l«n?s may be exten^ive]v diseased '[i, "'♦^^■'^^'nteric jrhuuls or the Innivcrv is not infreciuent " .ureases m which spontaneous .an. .if the ,,„o, „(■ »i,r,J . .i,., ,"'"'' "'""■';";l'»'i»- DoiiMI,.., von- il..M.on.liu«,M« ,„ I," ,i ",';,, ' '■""•■"'y '<-■ S I" tl,i,s ,|i,<,„,,,' |J.'. IS a rare disease in children. The loe-,1 sv 11 ' ■\M.''"litic or sim- Init alter withdrawal of th," fluid the ,., . •^^" Pt'""'^ "'-'y jrive us no v\nv, b. Ihe ^^eneral svmpton.s are more imn..rt ' r ^''.^^ H"l'«. 'm-n- -'- -narked." Ai one • ^d exmh^ X f •"T'"'*'^^'!'"' ^^"'''^"•- "'- ^nnplo chronic peritonitis: tho ,'h t ^i^i^ n Hi""' "^ ^;''-'-'''-i^- A "I'ioratory laparoton.v, the dia.Tnosi ,; - ' , , '''''''■^■''- ""'''/'^■^■" "ft^''" tl.o "'•^'""" '""'"'"•• «'''-i'l '-'an,Ts of r,.ported .•ecoverv i rit , , ," ■'"'" ''"'^'^'l*'" t^'^^t ^'»>"o '-'■ '-'■" ins/ances of th ^ J j^'^ /''''•"'r''^:'':'^ after laparotomy n.av ■'''"■"''-'■••"-■•-■ fonn "ith npp i „ H, !'T""r '^ ^^"'' "'"•"''> "-Inle.s. ,„,|,,,,„,i,„.„,„„ ^^.^,, fr,,,' ''.'':'■ tlio development of no.Iular n.asses '!'«i"""ty in diagnosis. It t . i J, ."f "^f '' '■'"■^■'^; "«^'''^ ^he slightest '■■™^ also n.av be en-^vsted •. d tl . /• ■"\"'''';' ^'"'^ t>'^' ■^"■M'urative I- .irmilnally disappeared have Ihv tn J ' "• "' "''''•'' t^'*"' "'^^'it^''^ ;:|™y. when the absecss In li e| •. eJ^^^ b ' ""',' '"''" '" ""^ "''''^'-"tive "'•■"l'"''"i"" "f incisi.m an ,1 i, i '"• '!"'''''• '-e'-'^-erv has followed *l,l,,.,,;,i.. ,„„ , '"^'•"""1 and diaimi,iie has certainly favored re.^ ,ve.-v in •" 'I'"' niiiiilier or ca»es ' "'-"'" "'' T'' '*"'^''"' Mitain anvair. Tlio con^olLbitio., ,„.., •. , ^ ^"'"' '""' s^^arco y ...noted -that t!.. proeel^ls i n j V I'm:"' ^"'^'^ "7'^''"' '^"^ «" «^«''"» d,e general consolidation l,as ar J " t f "^!" T '" ' '"•;'"■ I""^'""'^"'^' l>-t Ikof the lobules, groups of .j' 1, ! '» 'o ven.ent of a very largo num- lapsed tissue. Tlie^.nidilted ,1^^ "r;/;^? '^^^ ^"•""<'^<'*" '•-l col- place, have softened, fo,.n,in.. caviicf 'i- ! "''''■^;""^- <-a«'at.on. anl i fi ^ "•"^•'"""- an<« may ii ;.ve usaally are the ,reas of"ca e i.n T "' "!' ^'"^^"^ ^''« •""••^' ^"-^^^^ ofiheso oases show a ndxed inS^n an .7// P'-""'"-''V"^'^™"^«"^' """^^ LnmclM-pnoumonia le pleura ,nav show n.anv nodu s • Jb '^*:T''.^''«^"^«'' "'' pneun.ococci. l^he JLnous ;,r even purulen ex^^, ue ^'^-T,! ' ^f""'*"'^ 'j-^'-'afN -.n.etin.es a sero- .ia,,o.l. tumefied,' and stu.ld . th tu clts'or ^ f'"" V'"'""'""' ^''"'"'^ -- lliantiv having softened to form .1 .fi i e £ce,s t .' '^ "^' '"*'"'■ lD,ayl.e.reatIv,.nIar;:e.lan(lex-temlde ,L , f ,,^ ''f ,«l"n^l« at the hilus I'lancos there would anne.,- l^ZT^^'^l ''^^'}^<-^^n. »'e lobes, and in some in- cliitis an.l peribronchitis excited bv the'V,;L.V'r T^"\':'' '.^"^'on '^ a bro: lofthecontim.ous ni....ells ^vl ' w/, *" '^^^^''^cdli, with inflammation ^iti^ T ' ? ' ""^ ^'f' ^V^^\^^YvA products, the '!< i«. J he accompanying phenomena of a electasis and bt'^rLz H352? -r^^^^^^^^ l'"'ks simple in character, is iiavtuL ''"''• T] ''''"'', '^'"^^""'i'^'^lly '"")■ '"' dillicult son.etim^s to de o ,nin """ ''"' ^'^ *^'" ^"^^''"i- It Ip-nnonia is tubercuh.us >r 1 b / ' T," ',1 T ' '"''" 'T/*"''' ;'*" ''••«"^''«- I'e™ .small tnbercles or areas of caT.;' ; ' ' '.""^'•"^^■"P'call.y, there will be ^■eroadilv,len,onstrable T." 2 : "' ''l"''^ '" •'^^''""^•^ '^^«i«n« the bacilli i"d)lp 'ri,<. • 1 , ' '" • """^"' **ecnons 1 10 bac Hi al)0. lie simple hroncho-pnoumonia in some cases nre IS, particularly after measles, scarlet fever .liXheria ZT\ r^>'i''iH..,,,,,.,,o.p::r;ar::::i;^r^T'T7^"'"r?^^^ "^••'"1H"1 pnm.ing to fre 1 i ,r : ",' •'"^''^; '''"'^ ^''^^" symptoms have ' ^"^^'^''''Jus broncho-pneumonia. Somnfim.^ .i.. ; (i '.% lis AMKlilVAN TKXT-lUKiK oi' DISh'ASKS OF ('llILl)lil: infection is less inti'nse, and a subnciite or cliroiiic pulinoiinrv tulnTi cstalilislioil. Ill ciist's of tiiliiTcuiosiH conMiTiitive to ))roiiclio-|iiicm wo sorts: siiii|ilc, iiitiiinmiatorv, iion-tiiliciriiloii- liiTiliroiicliial siip|iiiiatioii. dilalalioii of the hrdiiclii', li'siuns uf rlio alv tlu'limii, and |uTibroiK'liial and pcri-iilvcolur sflciosis ; tlicn, in addit find tlic i('si(iii> of t at o tlu' trill' tiilioiTiilous procfssi's. ]K'i'il)i'oncliial iiodiilcs, tiihcrci II lllll w,. i'"i. tlicr,. tion, iinil caseous areas (.Mosnv) loll- iiihlin, In otiier instances tiie tiilierciiiosis precedes the hronelio-pni Tliis i.s met witli particularly in cliildreii tlie siiliject of latent tiilx illllllll; whom, followinj; one of the infectious diseases, a simple lii'onrhn-] develops. Accoi'diiii,' to .Mosiiy, the lesions mav In rciiiiisi>, "■ HllKllil;,! seen as an nU siiiTomiiuin.' the tiilicrculoiis perilirunciiial nodules, or foci of sininl coliii. C'liloiis liroiiclio-piicuiiioiiia ticciir scattered throujrhout the apices of piieiiiiioiiia dependent upon pneiiiiiococci orstreptoci e mill till IS a iiroiicho- It 11 lull'' alreatlv tlie seat of local tiilierciilosis ih( lllll:' ■I iiiv;i(|ii|.. Symptoms. — Clinieally. tiiherciiloiiH broncho-pneumonia scareelv i\\\l any feature from the simple form. 'I'he onset may he acute in a previous child, hut iiioi'c fre(|uently the disease sets in duriiiif coiiviilesccuce from infectious diseases. In the ti ihei-.Mi loiis fi ITS ml l.\ lll'llltllV 'UlCdl'tlH. orm the tever is sonietimes iioi mid not so persistent, showinir imue variations throii^dioiit the day. ( dyspnica are proiniiu'iit symptoms. Tl imeiinioiiia. 'I'lu liL'lil ali/atioii of the Icsioi jiliysical sijrns are tliose ol l/r(iii,.|„ |||iL'li;ni tiu' luii<'. where there mav I IS more coiiimonlv at the iiiiicc le siir ns of consolidation with Hue ercpitani atiilsiili.l crepitant riilcs. There are no physical si^^ns of any moment in ditlci( a simple from a tuherculoiis Itroiicho-piieiimonia. and indeed even il ization of the disease at the apex, upon which so much stress is laid. very much value, since we freniieiitly lind in yoiinj,' children a ml .. process hejiinninii at the hase or in the central portions of the \n\vz- I iitiiiiiii,' II' liii';i|-| is iioti.f it'r('iil"iis course of the disease, however, indications of iri 11 'lifl the end of the second week tl eat va lere are more ma liie develo]); thus towiiril rked oscillations in teiii|icratiirc often with profuse sweats. The child emaciates rapidly, and there iiiiiv suin,.. times develop signs indicating softening. In the acii'te cases the ilunitiun i. from three to five weeks. Throughout the course id" the d no single iiulication of much value in definitely determiniiu often have to depend more on the general features of tl isease tlieiv iiinv lie| tl le nature, anihve I'les slioii Id h le case. (' ma< le as to heredity ; also the personal hist liretlll ii|.|ii|. orv iiiiiiu'ijiattlv iVIll precedm^L,' the onset. .Sometimes important information may he gallieii'ii systematic examination of the child. There may be a till local bone disease, or a tuberculous test lerciiloiis iKJciiiiK IS. Simi .is a rule to recovery : in exceptional cases, however, it beco ultimately clironi''. In the more subacute and chronic ca (ronclio-pneiimoiiia may presi nt li irge areas ot caseation. pie lironclio-piiemii'iMia hw iiies siiliiiciitc. aiiij ses iiihcrciiliiii* ilie physical signs of consolidation, perhaps of an entire hdie. In su. sid'tening and the signs of cavity not infreipiently develop, an. I f the nature of the iirocess. As the little | defii lite indications o wliicli i.qvt' ilie I iiistaiirt'S L'ivc VflTj latii'iiis rarelv inH'tiincs. I expectorate, examination for bacilli can seldom be made vomiting occurs, portions id" mucus may be picked out, and iiiiiH>itiiiit cvi- •h'lice in this way obtained. niiicli may bo ( lakiiig its origii (7/) ('llKuNic Pfi.MONAHv Tfiii:i!ni,os[s. — Tn infants and w'ry Vdiiiii;! children -ve find the lungs either involved in a generalized tuben 'dosis nrtliel seat of an acute tubtn-iiloiis bronclio-]»iieuinonia. After the siv !i or dgli TVJii:ii<'rLONis. uar luwcs arc not very iiticnt lironic tiil)('iviil iiiiH.ti in wliicli tl (ISIS piiliiioiiiini oC ||„. adult. picture resembles that of Morbid Anatomy. — The 1 (■iim.«is ot alW.- i> r «:^;;.::::^^i:v ';;=:''':::;;:*■::". V'"-"- ■-'■ ■ -..w f sof'teiiiii;r n,„l „f'fil,n.i(l ii„| ||»'i'il>i'(incliiiil nu(|ii|(.; The t St liii-t 'e so CnMiiifmlv tiic inv iiralion, and cavit cs of vari liisooiiM liloelvM. liii' liase. fi'liirL'i'i soat of di.soa.sc niav I i'SK.n of till" liin.r from tl "US .sizes. w vs It Iroad y inentioiied in h H" ill the central |M.rtion of tlic 1 >L' a|)c,\ downward. tlu" j,'r()iips aloih' tlic trad pea km;: ol' liiiioivii and cascoiis. "•' "'"' ••''""e frrealli I'atiiic 111 the cliroi piiiniMi.ary tiiheiciilosis (.f ehildreii Indeed ^•„ ^- "c ciin.iiic -..IS .0 spread ilirectly from t le h.,,! • Id . 77- ''TTr ^''" ^'''''''' vl,i,.l, l.ii.v l.omw. r.l , . '"l".\l''-'» instances in avIi essor I'arrot, in 21 H cliihl 1.1 till' analysis b i tiljrous tubercles are found, and .'ee months. Ii .cli cavities existed. 1 .•en under two bidii in a great majority of sometime 'tig-standing cases hard ' •"> of these s cietaccous iiodiiji ii'in. I inking its origin in tl instances is a tiilierciiloiis bronel ;ii"l siilis»mc case, '•'litis. mode of onset is not so 1 rogressive failure in heal liistsviMpioms to attract attention. ixtrenic .iiiorexia which we find "idi viiriiitjdiis. persists. Jt iK'distril liiso-pharvngeal catarrh ever, may arouse i'e(|iient as iil adults. witl III find strength, coiiuli and f I recurring bron- lieie is 1 ever, are the OSS of appetite, but rarely tl ■rsiil'.iects. (Jough is ra!-..Iv absent in some cases of pulmonary tuberciil among the init short and dry at first, siil lie osis in lal sviiiiitonis. and, with 'iifcd eiiually throughout the o expectorate Th .'tnires uKin '•''il'l''<'n inHh.r ten. " Oertainlv'it onict lilies it is more .set ■e (Ictinitc'y purulent. Iliemoi.tv It. ..1. «^ /I . • t . . ' I SIS may be said t* iildren aljovc the sputum is mucoid at first, ■o-niiicoid, and in the later Tl 111 aiiKiiiMt. '"■I'll. i-iMilis from the i ''I'liii'li (if the pull lil'VUiil K' terminal luemoptysis. rom IS very rare at the onset, h i 'e infr<'i|uent in iiptiire of "ii'ii in the adult, but arv artery. an aneinism in a small cavity s usiially small '•are in chil- 1"^ leiiiittent, the dail cniiiif l> COllllllllll. Sill y excursions sli;.dit ever of on.set and duriiifr t tr erosion of a le eai •ly HIS t: >se(|ueiitlv, when the d ■a range between l()-_>° atid ■n jilace with the foi mation of cavities, th isease is more extensiye and ,soft- e temperature is more \k W ' A\ II ii i ■ 120 AMt:iilJSI:ASI:s of <'Ull.l)lii:.\ NT h('(!ti(; in cliunicttT. iml thr inoiniri;; oltscrviition mav be rioriiiiil or sulm iriiilil wliil(« ill tlic (.vfir _' tlif llHMinoiiictcr iii;i\ i.'i;isto'r 10;J.r)° or 104°, ,,i ,.v,.,|' lii;;lu'r. Chills aiv ii-it ■• .tv (■0111111011. lirfiidiiiij,' sweats aiv fVo(|iicri'. i,,,!. ticulail.v towanl tlic ciosi.. Dyspiid'a limy he j.roHeiit at tlic onset and mni,.- thf ciirly sta;H('s, and mav li.' .Inc in part rli ilic Ci-vtM-. soiiicliiiH's to the |,i.w,.|i," of a (lift'uso Itronclims. Markcil incivasc in the ivspirations. wilii cMumsix inilicatcs very rapi.l projiri'ss in tlitMJiscaso. In protracted cnHos, just n u, ||„'. iiiiiilt. tlicir niay Ix- very extensive (|cstnicti..n li.'iii,.st (lyspnu'a. The ehihl may eoin|ilain of pains in the ehesl. iisiially a- Mi.it,,! \viih pleurisy. In a majority of instaiiees the di.sea.se is painless' tliini|.-li„i,t Its eoiirse. Qvislinir ,|i,ti..s that an early si^rn is tenderness on peicii~.|Mi, „t the aileeled side, or on pre.ssiiro in the' inteirostal spaees, piirtieiiliiii\ n, (j,,, lii'st spaee at the apex. I'ro^'rcssive weakness and wasim^' are very pronomieed sviiipt.iiii^ ,i„,| there is usually pro;rressive pallor. Kre(|iiently*the ahdoininal viscera h.rdii;.. involved, and there is diarrlnea due to iMherniloiis ulceration, and ili,. Ij^.i and splei'ii may heeonie enlar<;eil. The urine does not often show chan-e,. I,iit as the disease proLfresses aliiiimin is common and a secondary nephruis niuv develop. A child may (!onie under oliservatioii with ^fcneral aiiasnic;!. ,|i|',, partly to the anifinia. partly to the renal condition, and the puli arv iiil,cmi. losis may he entirely overlooked. Physical Signs. — /iisiin-tioii freiiuently shows in advaneeii cusms un extremely thin chest, with marked interco.stal spaces. Deforniitics due i„ moiith-hreathiiii,' or to rick<'ts are not uncommon. On the atVecteil >ii|,. tlic respiratory mov.'ment may he decidedly less marked, or the clavicle may st;iii.| out |)r(uuinently ; .u- tliere may he subclavicular dejiression at the aflectcd li|i,.\_ a siirn usually of a chronic process. In verv lon;,'-staiidini,' cases wiih i,iii,l, lihroid ehaniie there may he llattenin^' of tJie atfected side, with d.^prcxMni, of the shoulder. By i),(tl„ti one appreciates any ditferences in e.vpansion on the luosiil and the iliflerences in the tactile fremitus, and it may he of valii.' mi (jifiiiii' painhil points. PcrriiHuioii. — In the early condition, when the tubercles ares':!t|. cdortlie areas of hroncho-piieumoiiia are limited, there may he no (dian;,v :,. the m- eussion note. Indeed, the emphysema about the aftected areas may cause .s|i4t hyper-resonance over the pari affected. Hxteihsive involvement at one un^ usually ^rives loss of resonance beneath the clavicle, which may amount to diil- iie.ss and is accompanied with marked increase in the resistance. \\)A\\w llatne,s.s is rarely met with. Skoda's resonance, the flat tvmpanv. is not fi,. • liient. The cracked-pot .sound has very little value in children. ,is it iiiiiv .sometimes b(> elicited in a thin-walhMl healthv subject. Auxrnltation may give only the si;:ns (d" bronchial catarrh, pipiiiL' nili* and moist sounds, but when there is definite diilness there is iisuallv clKUL'f in the character of the rcsiiiratory sounds, wliicdi have lost their vesidilin' ciiii- racter and are harsh, broncho-vesicular, or (hdinitely bnuudiial. ^niiu'iiinrs with defective resonance there is enfeebleiiieiit of "the respiratoiv niMniiur, with prolongation of expiration. The auscultatory phenomena arc'.dieii vm deceptive. Diffuse liroiichit.is may lead us to suppose that there is mieli trreiitcr involvement of the lun,;: than in reality exists. In very younji infaius >r^'nsnt' cavity are rar(dy present. I.iit in older" children in adviuiced ciises. uithliectic and emaciation, the nietallie .splashino; or amphori. (|UaIiiv of ihe i.iies. with the loud cavernmis breath-sounds. leave no (bmbt as to'thc exi Kiicc of ,1 vomica. In cliildren. more fre(iiiently than in atlults, we arc deceived by the or Hul.i, ,riii|,|^ l"!", (II «.v(.|| tViM|U('ti', |,ar. Ht't iuhI MIIIIIi^- t" tllO |il.>('||(> Willi cviiriosi,, jii''t a 111 tlif lit lIlC .-ll^'illist ally a>-Mi'ii||,,,| (MX tlir..||;r|,„i|, pcrcil«.|n|| ,,(■ iciiliirlv ill rlic i'iii]itiiiii>. aijij ■isci'i'ti liccoiiii. ami the livci \ cliaiip',*, I, lit lu'plirilis uiiiy aiiiilnl| tllC l\MI sillo, I'' 'M clicitiii.' '/YVy/vV.-rrAOAV.V. i)ii >.i-cailo(l I»."«'ii(l().ciiveriiiiii-< .si^ns Oi or of l-Hitiv.. .lul,K..,s insi.i'n.li,;,; an, !';!Ii'' "''I "''''''>'"l>' •'^•'••-'Hvo re,Ho,.a„ce lnar..l..ras..s,vi,|, Ih.|. H.v t on • . , ^ ''f convoyed M..,.ns..|v tu ,|„. ..C. ^'^c:u^'iT.:?fi'''-''r'r ''^ - '• ■-' "'--;;;:' '-' - "'•- ^'« •« The Jis,.as.. is ,.,„.kH, n..w I /Kv ^i; IV'' ''' ^'^ ""-■von.lm.hs. l:'™l'"Hin.nstm,t.,.nal -.n,liti,.n:>o;,i..,i„us ':„ \>' "p/'^tm,, .r ,ho '"'^■'•'"'•'■••"f ">^'..k,s sinnilat.. ..|,>.c.lv 1 ,• t, „ ' "'■","'""•.• ^ ""' "'" ''-■«« i«'inva«i„n „f ..Hut ,,o,,i,;,„ of ,|„ I,,,,!; " '■'"'' "'^'J F"'"' > ir...n.te *'''''''i^^''i'lfcs'pi;u.niiil u^^^^^^ i;!n'r'"^' i-'^'-'-^-^ '■^'•■nsiv,. (ii....,i,i ""t'i""'.'.^ then, is ,|„|n,.s.s at ,1 . 1 ^ . . ' .""•""' i'l"l"Ms. Tsnallv in s,,. I, •iv-n,oi,ssi^nsattl„.,„„.x \ V L nv ' i "."''. ' ""^■'' '«'-'an..,., i,,,,! ""■ ';!^'' interspace;. A eliil^ ml,;;'':"" ''"''^"^^"' '■"'" "'" ^^'o.-n.! ,o .""I «"• .V"«T.s live a t„|,.,..,Mv .•. n f;7 ,' W- ^■^''''' /I '""" '"^■"■^"'•'' "f I'-altl. ..?rpr';^'':;;;;-;:'-';:-^^^ , >-a;.'s tl„: e,>n,li,i.,n is nsm.llv tl.H? „ 'i;'^, tubereulosis. In the early I'll "ml repeatcl plivsiral exa'min- ti m ,*","'"'" '"•"•"•''»-pm..,n.onia. ( ■„,.- ^-'-'"•^^...s. Tl.e p. Ji, , ,,• t r 'T''''"' ^''^'""^ "'•• -.."1-tionot fc, f 1- 1-,. tho in:...ease. ^, ^^. oI e" ,?r "' '\" "'"^ ?•' ^•'■""•"' 1-^-" rr' ''•"'l'"'"">- •■""ti...mle,l i om, ■ , , r /' '' '* , '''^' ^''T' ''''"' •"•^"''•^e li'n.^'of tlu. intercostal space ' ,. tk 1, i ^''; 'l'"^ '■''''<■ •'"'"o.ss, tl.o poii,t.s. ' ''"' •'"" "'^' -'l'.-t'"ce of t.euiitus are valuable Au.sciiltiition is an evt».f.i.i<.l,. r.n • •!"■ Praditioner astray. Wlu.n in loh/Zlv liZ.'" '"■"'"•• ?5 ^''*^ ''"^« '•">< led ""■ practitioner astray. W lu. in h/,?''''"'';''-^' """■"'»•• "^ ^lie l.ase h„s led > «-l tW the purpose of ,Iia,n . T e it^;;! li '?'7 f"""^' ^'""''' ''« *'-' V 1"'"";-'"^' -metinios .ivc^ a .reat >■ o ' r ' "* ^' '•■'""*^^ .^imple l.ronel,,;. ^ ■:l^''^''-'- wlu.the,- we l.ave t , lo : ; . ' ^.^ ''•■' "/"^ ^''^' '''"^" ^'''■"'"'t alone ^'-i.eii„in.. wiu.ther;: 1.; .^' ; ,:r: ,r;';;;f •■' r' ''" "'"^ ^•'■"-'^ "'- InMlie v..|y instances in which -.nv f *''l'^f •"'"••^^ process or not. These '"^'•'t *•- an,I oxanune,l\,'' ;/;;•;:' ;;;'"^ «* ■'^P.m.n, sliouhl he carefully l"I"M, tlifi.loffood an.lwit.ll '^^ ^ cou-hm^r the chihl n.av h.-in- |i""^ -t an.i exa„.;;.;;rlw';i;i.:^:' ;;s;r"'""' ^^'"^'' «''«"'^' ^^ -••^'i^^ , ""■ ""'•■'■ ''■■""I. .hen case a : . n e 'l -" fT-'r'^'r "*' ^•»^' '""^'- On ;-77,-|v take place. Th,: la '^ Xj^^ .""f --'•^'''e comlitio." ** / ;;: :ri™;^a^^^^^^^^^^ » ■ I If t 122 AMIUtJVAN TEXT-BOOK OF DISEASES OF ClIILDRK. . of ,six and fiftocn. f..r the reason, no doubt, that tlio tubercuh)iis I,,,,,,,),. l)iKMnn.)nia is so otu-n an acuto procoss, carryin^r oft' tlie victim bofor. it 1,.,^ assumed the characters of a ciironic affection. (4) TUBEUCULOSIS OK TIIK PlkURA. This is usually secondary to existing' disease in the lun^ or in the hi„i,.],i i glands. A certain number of acute seroHbrinous jileurisies in chil(h,i, , ', be as in the adult, due to tuberculosis: but the cases, as a rule, rim , f,v"; able course, and unless the child has dehnite manifestations of tubercui„.H ^„ other parts the assumption in any given case is of course purelv "mitrtm 1 iirulent pleurisies in children are most commonlv associated with Inh'ip ',! broncho-imcuiiioina. but in a certain prop,.rti.u. of tile cases the process i. t'l,!,,',' culous. Ihe (isease is usually latent, an.l failing health, pallor, and sl,„iti„." ot hreath are the symptoms for which relief is souirht. The 1,c. im befor* it I,;,, TVIiERCVLOSLS. in tlie liiMiirlii,] in cliiidi, II 11,,^. iile, run ,i tinni'. :' tubei'oiiiiisis in ii-ely ,i:r;i!iiitiiiiv. ll with |ul|;||. ,,. process i . tulicr. r. and slmnni.^^ 'iicnil s\ iiijitiiiii- Kseoftlif siiiihli. ■on rc|i(iri|.il m ' by I>";irkl||;i||, instiiiiccs witii ed and sotU'iic.! L'r(i-fil)riii(iii> ,,!■ of all the ca,,.. ( to tills caiivc, :)ni the iiicilia,.. adinif in i.riv;it 10 hriirt. 'Tin. ] 2;j 'I ibemilosi.s of the uretpi-s ni„l M n ,|i«ea of the prostate. ^^^^ "^ "'<^ kidney, sometimes to (/■I TlMiKK('i:i,()sis 01,' T,,|.' '|',-o.,.,^ ^\■ 1-- in ;l- testicles, but 'x^Ll^s-'^Z^ f^"^' "^"^^^^ ^^ ^- "'■•!' "'/• "'•'■•en. Uresehfeld has n.po t 1 „ . "'f- "'■^""'^ '''^ "«^ "^ "" bsis .the testis. Manv <.ases liave C J 1 ' 1m "* ^""-•'"i^"' tubercu- Iw Julhen, ( wore undei- one vea • and 6 b C ''"' r"'"'^' *^^' -'^ ^'"^^^ oivaii^ may be affected. The'dis,.,', . '","' '""' *"" ^'•"■s- I5oth allm^uiea or i„ the opIdi.lvmL. , le /ir;;'""^' ''"■^''"''^ '" ^'^ ^-- ffll'<'l tumors. In othei" insfm.es ' '"' *'"'"'"t'"» «'f liard oircnm- '!"• ■' '-■ -sses are hu^e ^ cSi .Hr "'l'^' '^ T''' '""''-• ^V n fr- •"l-:^-nent of the'c.pididvmlr '\ • ^ ^' " ''"'"''■'':" '"' ''""'''^' ^'""i"^^' ™llyassonatelosi.s the infection is at th.\r,u!^]J;\"^';!^^^^^^ z'::^::^ :?:;:::::' b-n.pi.-..andsi. -r^-t::: i:^-;rtiz ^: JJ .n;rr^^^^^^^^^ s;S;:;r;;i::-^^^^^^^^ -V^ .-e. care ■"ii"''er. Every part of the ex-n<.<.t , '''''* "^,\^P'"'"g about in a careless Wc;l.am] the- Aiont-H tidk : iS' ;,,: I't' l'^ ^"'•^^""^ -"-t-' and '"'''"'"'".vof cliihlren to inf,rti..n •,, n •"'"''" '"'" '^"'''"^ ^vater. '^" "* -'"'t^^ I-ossibly on acco " 2^1^^!^ "w'^ ""•^i'' ^••^'^-- *'-' 'm^ to the members of the f.milv ., "'^'"■■'f^ relations which the child '"'I'P™ f'> '-liseased. ' .e 1 t" o I^'"-^."'!!''"lv the mother should le K',i"? -en-thing in th " mm If^ ij "f ■"'""^\- '^'^ '••'-P about, of ,,,„„„,^f„,,, " luoutlLs mhances greatly the liability to eon '.I ™»z" ''"is;::, h;,^;:::^! i^,:;:;";- ^^ ". „« ,„■ , „:„, .,.,„^. ip;ind .-alves btiMe '»'r:f",-e ..careful insj.ection of d i ^ ''" ^^'' "l. '"^^ ^-'l^^'"-' 'o the "' '""'«"' ""'l^- '-.less rhV source is / . . " , ' •'" ^"H"""-*' 'ie« in the use r;:;::;;;;;.:"'''-'''---''' ^•'■--M::.;s>i^i;''y:;isss^ ;^''fp:!"ti:;'tf!:^:;'v;:'^^^^^^ Achiidboru; "■"""' "■'fl"lH",W.atest care.- Very . cci ''''i ''fi f^^-""^^'' should bo iffi 12A AMJJIi/CAX TEXT-BOOK OF DKEASES OF ('mLDI?E.\ ;.'■ til,. ii'Mllli on the first indcat.on of rnoiUh-breatl.infr a tl.orougl, examination of tl, pharynx shoul, ho nuulo and any a.lenoi.l vegetations ren.ove.l ; an.l tonsils iire at ail enlarged, it is better to have tlieni cut out. The ehild live in the open air as much as possible, and the nurserv should be thor ventdated more partieularly at night. The meals shou'ld be at regular ,, the foo.l plain and ni.triti.ms. Every eneouragement should be gFven „, , , fats, and milk and cream should be used freelv. It is a -ood nrncri,.. t the mother to sponge tlio throat and neck of "the chihl night and , ,;;','; witli cold water. ' "'r The trilling ailments should be carefully watched. The convalesce..,. fV,„„ measles scarle iever diphtheria, ami whoopi-,,g-cough should be >,„., guarded. As the child grows o!,ler a systematic.li v n.gidated ex.-rcise .,1 ' ot pulmonary gymnastics may be taken. "^ V. Treatment. Fortunately, a yerv large proportion of all cases of tuberculosis nr,y„ Many instances of adenitis and disease of the bones heal spont,. J' Even in pun.onary tuberculosis it is remarkable how often we fi ' mortem ^- n deuces ot heale.l lesions, the percentage in some series l!, ,„': ' nigli as .iK In tact, one may say that in a very large number of dl ,:, " in which the bacilli find a, lodgment in the glands ami in the soli,| , i': he con.litions not being favorable, the growth remains local and temls , - , | spontane..usly. Ihe essentud point in the treatment of tuberculosis is ,l„. „ tenance ot nutrition at the highest possible grade. To .li.l in this tinv,. ' ures are to be practised : ' "" First : A life in the fresh air and sunshine. The importance of ,,,vi,„„ ment ,s well shown in Trudeau's experiments with inocuhlted rabbi,' confined in a damp dark place succumbed rapi.llv ; those allowci t„ „ dd recovered or showed very slight lesions. By fin- the most imp,,, ngle element in the treatmem of tuberculosis of all forms is the const.,, i ation o fresh a,r. The good effects obtained at (iobersdorf Falkensteiu S. Lake, Davos, and Colorado are due primarily to the fac, Hiat the p.,M.,„sl, hte ,n the ojren air and sunshine. Even in cities mud, can be don., by i„ 'i' t" ing upon open windows night and day, except, of course, in the vorv i,,'..!,.,,,,, jeasons. It is an easy matter to protect the patient from drauglits,-an feve 1, cough, nor night-sweats contraindi-.to in anv way fresirair. Tin reality the very essence of the climatic ...atnient of tuberculosis: ,|, , |, considerations, such as moisture, barometric pressure, temp<.r,.t,„v ,.„• , secondary ,s wel shown by the fact that cases of various tvpes of tide ,1, rea,>.er comp etely at places so diametrically opposite as Colorado S,„i„.' 1 lor quay, i he regions of high altitudes with low barometric pressu,,. m.o m- tainlymore stimulating, and, according to Jaccmul, are better for c-.^.. „f(.;,Hv pu ..mnary tu l.erc.losis. Cases of bone and gland tuberculosis do ,v,„,,,k,>l.lv ell at the Adirondacks and in Colorado. The level irgions with low l,,nvH„e„K. pressure such as Riviera, Florida, and Southern California, are re,,,,,,.,! ti k more se.lat.v,; in their action and better for tuberculosis in th,. in,. ,■ ;„lv;„„v,l grades and with high fever. The secon.l important nu-asure is feeding, and the mitlook in mmv rn,r. ,,:„- ticularly of pulmonary tuberculosis, depends very much upon the st„lnlitv,)f,lK. digestive powers. In no way does the open-air treatment ,lo luo.v .-.„;,1 ,1,;,,, in improving the appetite an.l dig(.stion. A highlv nitrogenize.l Ju i. consist- ing ot broths, eggs, milk, and meat, should be taken, la child,, . ilie imlk Ibrillai'v niedici tioii of til. um. ■'od; and ,r tj,, lie diild ,ii;,||],| \ be tlunvMi^'iilv t re^idai- iioius, e given 1., UiU >od pnici;,-,. (;„. It and iiHii'iij,,,, 'rUBKliVLLOSIS. 125 ■0!ll valesceiK Id lie siHriiiln- Lercise ni' (•diiix. Kulnsis recovor, •■^pontaiifoiivlv, we find [Mist- dories Wwvf^ n, >er of all rases f Solilj 0|V;ll|s. d tends n, li(.;,| sis is the main. 'li.s tlircf iii|.a>- :ce of enviniii- Ll)l>its. TliiK(. llowcd to mil last ini|Kimiit :'onstinit inlial- istein, SiuVHiac L' [iiiiicnfs live done l)_v iii>i.ereulons el.ildren it I s.^:: ,: 'i^^^ ."S' ^' ^^^^^^ - ^^^ ai.'i '";iny I^.tiont.s ],avo an aversio tn;i ' '''*''"'^ ^ manage tlio diet >-t ;|.lapted. (lavage can rj;:! v ,'0^.1";?.. •;;"'" ^'.^""^ ^'-'' -^ llnr.l, the use of s„el, remedies as co ive V"'^' '''^^■"/'^"''g^' i» H'on,. »r;enK winch „np,ove the general nn tio„ ft V, ' ''>l-l'l'«^pl'ites, and nl.bing, and batl.,ng, ail of wJuch sti , ItTand """T'''-"' '""■^ ^'•'''^^'""S- Liratment directed to the T,dun- .„/ /, \ ti;- «.,be..„iin of Koci^ t^id t; ;::fC:;;r'^---''''''' ^^-^^ ^-^-nt f' t»''"''t'l^' baeiili, has been nract ' K . ^^^'T'"^' •••^"■'^■t of the culcui'es ^f ;" ^'- i^-'ds of TrE ,th;:r:;/''n'^'' ''^^ "-'• -"'" n.i«; IMC hope that something yet may h ' , ' '""'''^ '"odification '^"''"••^" ""■•''••''ti'>" is as yet nnknmY 'V'7'""r'''-^'H-.rirl m r wi T' ''^ '■'■'"••"■J^^'''l<' ''flW-ts in jo n «ase. Creasote is a remedy i. d t M^^St T' " T''^"' *'"''"^ "^^"^ tlic tid-ereulous processes. h nrol,.,! l! 1 . ^T'"" ''' ''™^'«cial action on i^"n,l. it is statell to inHuenco p e ;^^^;;: "? ''^' '"^ -;ti'-.-iiian- ac".;" «so common in tuberculosis.^ 1 e ^s tl '? '^' ""^^ "^^"'^''^^^J i-''^^: ■'"" ","^- ""P>';>ving the appetite, .linun ii .' ' f' '"' "'"^ '' ^'^■"^''■"' ""tritive '-'al'ol.sn. and. according \o some/ s ' i^; ' !,/""^''' "■'•V"-<.'»'«ti"g ^'-o- ^'■-'!,"-'-*'^Videly used than any ^tC ' J^ rr^' '\ '^ P'-"''"l^ly at ^"" yul. some practitioners for n>any vL^t^ T''- ' \ '"'■' ^*^'^"" "^ *'' vo- te to the powerful advocacv of ^;.' V "'^ I'l'mtroduction bas been l^f ''^ given in h^r^^^^S l^r^Z:'!^^', ^•""••'""••'' ''-' -'-- l" ;'"'';' ""■"■" fl'^-e- tin.es a day, and u n^as^n ;« fiv""""^ '" ^"""^ ^'''••''•"' nay bo given m /;«7,'.v, or in" .ills o, i. " '' "'" ''"•■" '*'" '"i"i"'s. it -iswithtinctu4 '^ ''^ ^ve!l bornu ^r- ™.,/ consisting of crcI^H '^., ^^.^'^ " '"''i"''^'-' .'1- -cailei oiigrains, water to one ..unce- a te.sn,,,. f ^ ^■''»''j"iiate of magnesium '^" ^ -^''.this are stronglVv . m ^ ' - "j l""t of wat<.r at 140^ uC '"1-ti.^ns of n,,asote in oil have i- e n H., ' T •'•" '"' '""•''^'•-•''«'J ?":"aool. Iins been nn.ch used, both by tl uu l,. I " "T'' ^'''"'^V^' <>f it, KhiIiUiom. It may be made u,, witi ' ti ut ' J'vpo.lerniatically. (ii,,,, ■••-• lv|.oderma,i,.ally. il i . Pw h '^^^^^^^T ^'''''1^ ^'^'•"^' "'"^ '.'""'•"• ' "••-' per cent, iodoform n, .v , ^^■"'^^/''l "live oil. •, j,,r cent. '""^•''■•'; i>U.vted, gradually h c . nf ^ •> ''''''"^'"■•' "'"' '^' '""' ^ <- of the !-^ Y f "''^ ft--" n-<-as.;te : ,l"b tfi .,"; f ' u" ''"'' ^ ''•■ <"-' rareiy ;""""•• ''■'■^'' airandag.r^l e f ,":' ^^'/r "'" /'Hi-y the assodat 1 ;' v-y ,ie;u service, as Witness! 1 i,. 0, bm v T "! "''^'' "•^^^^«<'n- i^ no hmkaliiv tolerant of it ..nd <. , " V'""''.^ '">'^l"tal practice. Patients ,,.e "'-■'-. such as ^uJdvS," . 1;:^^ rd-;';, ■" -'r-- '''- '^'i-- '^'*'' ''wn i-,.„mmended.* ' " ^•'"''""t'""^. thy„,oI, and menthol I? ' 'a : Ulr;'- .■.-:;-*,v.;^:i*ES;:r:£ t'll 126 AMERICAN TEXT-JiOOK OF DISEASES OF CHILDRE, The cliiki may be wrapped up and taken into the fresli air for the jrrear > p.., of the day. We have no thoroughly satisfactory medicinal means f?)r n ,1,,;.;',, the temperature. Antipyrine, antifehrin, and acetanilide, if used at a'. ^^J, be given with groat care. Quii-ine and salicylic acid are still used h 'ni„,v imictitioners. When the temjierature is persistently high in the earlv ^ti.-,' of tuberculous broncho-pneumonia, cold in various forms will probaMv 'ul't most efficient measure, and oy careful sponging the temi)erarure may be n.,i,icJ several degrees. The most satisfactory antipyretic is found in the fresli ■iii' more particularly the change to a res M-t such as the Adirondack's or Cnl.in'l,,' In the chronic pulmonary tuberculosis of children, when the fever i,s of .' hectic type, sweating is a very troublesome and disagreeable symptom, for wlii,.!! atropine, aromatic suljjhuric acid, and tincture of nux vomica may be iisetl li young children great care should be taken to prevent the chillin" of llic !„„i'' after a profuse night-sweat. For the cough, if troublesome at night, \m^.ul or sniall doses of Dover's powder may be used. Codeine or, in extreme ns,N small doses of morphine may be given. Where there is marked tenx\vy^ probalilv iif '[\^^^ may bon.,ii,(,,,l I tlie IVoh .i||._ ks or (,'ni(,ni,ln! ho fever is of .,^ ptoiii, f(,r wiii,.], lay he u-cl. 1.,, ng of i|i(. l„„],, light, iMrc;;on,. extreinc (>asi'<, i tcn«h'riH's> (,|; (lieveil l,\- ,iiil,| ;ion of ici'oli,iii,, ^toratioii. en iw usually a 'et, and if ])ivi :*rej)arati(m.>i of | ocessi's thci'i ipi'ovc ([iiicklv be paid to tii'o it' ai'iil may !■.■ illg, lllf filHin. I I C-A^X V '( f! ! DI8EA8E8 OF THE BLOOD. By WILLIAM (\SLER. ImnvODUC TTON. The blood may bo lookod upoi .ili-r as a fliiul tissue in wliicli thp corpuscles rcpivsout the ct^lls itud ih'-. plusnia the matrix, or as an iiitenml medium bearing the same relation to the constituent tissues of the body as tlm external medium does to the individu.rl as a whole. The cor|)usdes iiiiikiMi|i a litti' less than one-halt" of the weight of the blood, the rest beinj; |)lasiii;i. The hitter contains in solution the fibrin-forming factors, various ])n)tci(l >iiii. stances, cMraetives, gases, and salts. In healthy persons the composition of the blood varies within extreniely narrow limits, so well compensated arc tin- "outgoings" bv the " incomings" in the different regions of the bodv. During the \s:\A half century, and more particularly during the last (Imitlc, much has been added to our knowledge of the blood and its functions, nM of the advances having been gained through improved methods of iii-tdlniiical and microscopical technique. In tlie healthy adtdt hunuin body there are three kinds of corpii.-clo to lie made out: (1) the red; (2) the white; and (3) the so-called blood-plaqims. The red blood-corpuscles are honH)geneous, circular, biconcave di>loii}.'li i this latter ])oint we areas yet profoundly i^,. :ant. Some of them arcGi]';' "^ of active amteboid movement, which may be watched with ease in tVreli bl(i"l|;| specimens. The leucocyte^ will be classified and further descri I xd ulitn » -■* speak of th(,' differential methods of staining them. The blood-plaques, or blood-plates, of Hizzozero are now ginnalh rcmL'' nized as normal blood-elements. They have been described imdt.'r MmW names, and the most various functions have been assigned to ilnMi. Tlw'^rf Hayem regards them as the ordinary red corpuscles in an tarlicr .stai'i.j 182 hkI ■ • calls • iii!a-!,iic (lis 'if \ii I ii.'e iiilotlli liii'V Stain w( riaii-\' inlet. ^raiiiilc-massc: '■i|iit.'i(i'>n of o' ilii'olv!'n-iip V III' '..'.r iijodll ((i injiciviiK'ed in', :HV \\\<- led or ) ii"iiriiiiig to S liii«"l-|>lates 111 liisTilied bv \( ilrir liieiiioglol) ill olivcrvatioii ( 'iic ill vest |V;,f|V,| The Orig-in ( M-icw < if the li limi- of over OIK "iir kiio\v|(>Noiiilii'yoiiic I W'^' shall briefly I>iiriii,ii; the fii '"imcd. When «liii'li ivrtaiii soli v>>cls ; the ceiiti- I*' liiciiioglobiii (•"I'piisclcs, The iiinii the \'essel w; •""' "\'iil, resenibi «"i'l<('l's lielicvc i, 'ii 'lie latter eiiil) ''""''' ''"'iiple.v, an ■"'•"■■■'I. Thewi ' 'iver inaiiii '' )>il>e(ichyina '"t<'f iiivestijrat " i''-iimrrou) also { '"'liisions nil liis ' ''ill' ill man '■ "id finally tl ■ ■ ' "I'litiplieati ■'!''■"• liS82, So. m. ' in wliich the as an internal ;Iic body as tin; iisples make up bein>; plasma. IS ])n)(ci(l sill). compositidii ui 'n.sati'd arc tiic body, tiio last (ii'cadi', fiuu'tioiis, nin.t of lii,-ti)l(ii;ical 'oi'[)iisclc,< t(i Ix' KHl-plaquos. vc dihks, avor- •iiiK'li'atpdccIl-, I iviiicli is iiiiitcil isina), the cuiii- ojrlobiii by the I t it i'roiu I'aiiltvl colls, all iiiiolc :c, (■(iiitracfililv in, altboujfh lyy H'lii arc cap:' 'M 'ill t'rcsh bill"! ' rilicd when ^^■ /^Vr/,'0/;^Y'7'/0iV. ■iiils (lipiii b.'HiiatobI if 'fl;i-!.ii«' (li> ;isf> T) '-S U'iurl, ,„ fivsl, |,|,„„| '<'y arc small, I. '■'ilMKJi,. 11. CO lorlc is; iro- [iaii-\i( I ':-';';-''i'-'-.bioo.i-e<,.p„.,;i ;;;■"•' ;■; i-^ ■■'■P-..n, p,.,,L,„ '■^'"r" ' ''-tob..ist, tbat tl.,.so b.I " , ' ""' ^'";''^ -" ••"-•iM.v anv ';'''fr '""^^ ""^ f- -..nfbnmhH! wi b ' '"^'' ;Pr<'"'- gravity. Tbo "-^ '--^''>''in. J ,,.sc.nb...l tb;:;n "',;:''"":?; '•^'' ^'"''"''■^ ''"P'-ived of :i" observation .o„Hnno(l bv P.i..o.,.ro a !•,"""'' "^' "''''^•-^ tbn.n.bi-. •l-''-<.i,.ntio„s ../• Kb,,,,-,. ancl^I ;.; I """ "'"■■"•'.-'~t..a(,.d bv The Origin of the Corpuse Ls ' "'T''' '■""' ^''"' ^'^ ^^ >■'"''• ™'""^''" ''^•-'-''-•'■nn i^ ";;f Jr' '-■•'■•"■■.t oxbansti.. -V" "7'- -' ''"n.b..l inustiX tin ■" '■'■'■'• ^•' "' "^'•"•"- >'u- k.umlclo,, „f t,,,, ,,,.;. ^ , ' f"'> b..bi ,t ,„.,st b,.a.bnilt,.,l tbat ""•™''"^-'- H'i' is <.;. now, ' ;'^'-'--|:"-l- citbo.- in .nbrvoni. '^-'-" '>■-% nu-ntion be, v .o ,2 "T^r^''"^"'^ -"> "..-ttl.;i sta,^' Tf- '"*"" ^'"^- ''^' ''PP.... tb • r.y 7" ='- "" •''<-i-pus<.b.s "'"" '•'■'■^"■" -li'I -lunn,s ar. buM dow I "r '"'" '"•-'•'"^•i" '-t'^' --ii ' : r^, :• ";'''•''"--• Man.. '"'"■'' "'"'"-^••"'"' P--i«".- ' """ : ''^'•" -•'^- of tbo oaHv ,r • ./''"■'^•■''' ''"■•-■^ ''av. boon " ' '^'"■' '"■'"'-":->''t-"-«.| ,„..st of't,,; ,,,,•; "'"^•"•^- ™ "'• tl..' opinion '"^- '"-stigators favoPod the d " t^.t V "'"•' "'^"•■'-' •"•'"'"-. "r":"''"'^^ ' "'^■' ^""'^ "" a <>i..''-" -d ' •"«l 'inallv tin. I.,.„„„„..,.: ,.. "^' ^''^ '-"vnlatH.ir |,1,„„,. f,„ iindtinl '"'if'-niarnnv, plication of (I roj 10 ro( >i'osfnt siiocossiv Iivor, tl 10 I Hi weed I II,, '<'f. /', '/'•■«, 1882, .Vo. ;j()i 'i"//((, / .s;, ' «'»'lls. Hoxvoll snl f'<'oiitrosfo,.t|„, f ■"•''.hlx7\- M,;/.Xavs, I ^stantiall ornia- .V agroos witb tl lis. SS(j, Apl. ('"itmlblatf / nwrl. U if^.ini- / 184 DISEASIJS or Till': liLOOl). M. and thinks that the iicwly-forniiiitj; vessels all over tlie Ijodvffive rise to li|fii,(|. cells by a softeiiiiiji' ot" the central cells ot" thecolniuns — a I'ael which ha- Uitu proven at least (lir the vessels ol" the posterior linih. 'Pile nneleate(l corpuscles i'ornicd in the later enihryonic period are -malld' and non-nncleated forms soon appear, so that hy the tit'th month in the Immaii tJctns the majority of red cells arc non-nncleated. At hirth there are vi i \ (;.^ nucleated red blood-corpuscles present in the l)Iuod, and they soon di-.i|i|ii;ii. ontii'ely. In the adult the red corpuscles are tbrined almost entirely l'i..|ii i],,. micleatcd reil cells which are f'oinid in the n.'d marrow of bones, di-i ,i\-,.|.,,|| independ(-ntly by Xi'umann and l>i/zozero in l.S()>i, and since tiieii e;iivt'ii||v studied by many prominent histologists. The transformation of the>e nmli. ated colls into the ordinary red jrlobules probal)ly takes place by a piMn-s ,,(■ exti'usion of the nucleus, althontih many still believe that the nucleus ui;ii|||;|||(. ,'anisiies within the cell. The lunuber of nucleated ylobides in the iiiaiTuw becomes enormously increased where there have been great losses of blodd^ im,] in all severe auiemias they may be found in the circulating blood. Thi' im,!,.. ated cells may divide at least once in the bone- marrow by a karyokinciic iiin- cess. It is fronj certain light-bordered, homogeneous, colorless ni.niciu-nll- (erytliroblasts) that these true lia3matoblasts arise, which, as I' have iHiintnl out, arc not to be confused with leucocytes. The leucocytes probahK iievir change into red globules, although that idea first advanced by Wharton Joins is still maintained by some authors. The view of Ilayem, that the red ij|,i. bules develop from the blootl-pla(|UCs, has not been confirmed hv otjitt observers. xVs to the origin of the white blood-eorpuscles still less is known, A dr- tain numlier come frona the lymph-glands, while others ap|)arentlv have tlirir birthplace in the spleen or bone-marrow. In a most interesting series of articles on blood-formation Luwii ivi;;inl. the lymph-glands, spleen, and bone-marrow as blood-forming organs, iiml claims that in each, from a common mother-cell, two kinds of cells IVw fidiii hicmoglobin are formed, erytliroblasts and leukoblasts, the latter haviiii; uinu- boid movement. The nucleus of the leukoblasts is relatively large, ami i mi- tains one or more lumps of chromatin connected by radiating lines with iln' chromatin nuclear membrane. The erytliroblasts are never anKrliuiil, amlj have no true nucleoli ; they divide through mitosis, the leiikoblasi- dividing through amitosis {'Vivmn Indlreda per (/rdmdn). His erytliroblasts ijo nvir into the blood, as a riiie, free from luomoglobin. They gradually nivnmiihiif coloring matter there, and so become nucleated red blood-corpuscles; the iiiicIhij in the main becomes disintegrated and gradually disappears by al)S(ir|)tioii. An exhaustive review of the difrei-eiit theories of blood-format inn, toi;vtliif| with the results of his own experimental work, will be found in Ihmi article in the JoHvmil of Mnr})linl(>f/i/ for June, 1890. Howell inaiiitaiiis tli;it! the red blood-cor))Uscles in extra-uterine Hie are derived iVotii lln' niiiliMltilj red cells (normoblasts) by a process of nuclear extrusion (the pioa-s in liia ' Centndblalt f. meil. ]\'in.',-i(iiiit iif;. , l^f*'! upon as a ; I'" 'Ih' cxiict origin '"■ills reached an' [smlcd, 1111(1 wo tnii ^nintever may I bvc boci struck i Wii'f?, tli(> norma »■ cirpiiscles soni( •I'l't' of thirty, fo ''''k' ii/1'tiine of a «i>i(lcnil)|y. The I '■""I'' 'ipiH'ar to J,a, '"'■''• '■'' (I'll'', wouh: '"'' ■'I-' ^vc are al: ■"'"Wl from tlic 1,1 '"""Jl' If i^ impossil !':'^ "'■ •li^int-atio. '"■'' 'I"' ivd <'ells ai', ' '"'"i-marr„,v iaig, • riso to lili,,,(|- liicli lia- iMt'ii k1 arc -im;i||i.|. I ill till' liiiiiiiiii ro arc vriy );.,( .soon (li-,i|i|H;,r tiroly I'lMiii |]„, lies, (li.-c.iVc|'|.(| tlicii (■.■iivliillv ly a ]>i'iMr^> i,t" ■1CUS0|•;|,|||;||)^. II tlic iiiiirn.u s of l)lo(i(|, iiml I. The llllcl,.. ■yokiiiciic |ii',,. ! iiiarcow-rcl!- IlilVC iHlilltlll irolialiiy iicvir Vlinrioii .luiii> It tlic rnl -In- iik.mI 1)v (iilitr /^vy'A'o/>rr7'/o. "" '" (lie mar row), Willie ill Ih: !'^""t" t''<' ..irci.la.ii.o. |,|,.,„, ittia'iiii; 1 S()I)|(, kiiii iiiid I iiivdcrivod (r lavc tlicir "II <'olorI lie ""l'fll()|,|;,..jt^ IIIC '"■'«iii in .stijj J eatei red ''•■^■•^ mature / arc allowed ( '■^ 'lividc l,v I, >n-i ""fotie divisions off I ^'■^•"^^ I'ntlM'ol.Iasts, i|„. I ■' '"•''^'\'«'s (liat iii„|, ii'' .«|ileeii may agai 111! eruditions it ^\y le \vel|-|< itlcr er cert, """'11 man '"■'"•S Wliieli i„ ,1 '"•viii^r rcsiiJi,,! / '•;• pJKi.oiooi,,,) ,,,„„, (i\v-cc. will '> pass at liird,. 'j^i Ih Illy ( ' Vcsieiilj,,. „|„.I reiiic ;i lamiitt "■""'• ^'1^'nionts of tl„. hlood view ad '«' I'cgarded that NH'iiemir retr()(rc(,, "'^' ''<'velo|.ed fn,i„ t| ""■■* with e.vt '""*•"'"". wJ.iel, ,„„| a need ei. iia'iiiia er iiur- ■■' I"''y"ior|,|,oii.s „„(,] '^'f clianw'. '"•"^■•■". l>"l most liistol, le s ''•^- 'J-'^^-'ll, tliat all oils III tl 'I' "rdiiiarv j '^^'■■^ts agree wit|, | mall IvmnI mpli "• ''■'<■' tliat the nnel ''""Jtytc iiKJi oevtes. "Ill ill (hiiil< cat( •■' a eoin- ilNirhi'd lias heeii ens „/• tj„ iitk'iits in •""•Pportcd I "I'li'i.ir definite IJiielly suniini "ly wards, |„it >y mi'iKiroiis ol 'lonnohlastf '■-\tnided rather || can at ni as to tl le lilt «'"'-va(ioi,,s „f the |,|„„, lan present \> ''"'f 't^iho adnJt the i "^^ "P onr knowh.,! aid ""ate fate ..f tl ana'iiiii "• <'\triided ,„„.| ens «'<■ of the 1 lit ill tl\> liHur iif its I ";"<-"'am,w n,„|unh,,,d| -"='^""' "f the re<| gl,,,,,.,,,. «^'"^' a dev .J 'J^li •I'l'fii lias always ha Mil we loo k i » i' "iiieh evid eiice Ml Ies, but niij; ivaehei 'lei inav Th "'"■•^t rather I mh riiat. and we must "'y iiiianiniitv of "^''>f« «'<• the bloo.I lavc be V(lill«r tJi ver may be tl "•ait for fnrti "I""'"". Onlv a f ay, therefore, that we are still fi,,. f JO as I'om ■»'» struck with th ^" mode of blood. "''• '"vestigatioi.s to c| •■" points are definitely '«. me normal <' i'<'"iarkabl '•('H'eiieratioi , everv •''I'' "P 'lie subject, must <'iimciaii pw cor 'puscles sonieti Pi'oportion of red 1,],,^^, ':/T"y ^^i^'' "hich, afh.r Hie r ■'tf of thirty, f; Tk' Iif;. ■ me; )rt\-, '' ""<'<■'• favorable end f'"i'piiscles niav I ""•' "'' a red blood >i-even fifty, tl; onsatid per ""'lis, beiiH Jirofiis «' i-estored. tl 10 111 ^"^'■'•''''y- tih> biic-coi. •«Jrpnsc|,> ,ve do „ot '"m. a (lav, :"iufaetured at roil III •'PI"'"- to have tl onng niatter.- ;i; ,w and fiiK'li, if (ni(. '^"' "^ wc are ab|. K'lr origin i <'<^i-tain of tl y varies "■""''' '•'>IJ /or thv .lailv " an altered 1 lii'inoi [PlMuVcd f,., ri|(lli(r|| I'f j o see, '". f'"' '>lood before t! possible as vet ( lowever, the •le.striiction of 'f probabi 't' "I'iiiary pigments globin—a eond Hion nianv re( 'fy 'lave under corpnseles w] OOllIc; )bl 'f'" worn out :':(''™'.«™«..n,H„:»;,;,,zri"'' -':■-'> "f a'ly marked ci are "I'll tlio r '('(I C( •s are "'lif-iuarrow brol 'ai-go ceils P"'<'ii and liv veil lip. Oc-ea.. t'l- are beli->v(,d witJi laiige,. eaii b lonall y ill tl to bo tJ i-e,!i:ard to the 10 organs ii ^ «-t'" fille,! with red "' normal sjijee,,, | «»i-pti,sele,s and it I iveiv i;is i; 'II' 18(5 /> AS'/.. I, SAW ()/' ini: HLuon. I)ci'ti thniiulii iliat (hoc ;iiv .luod-.lc.siroving vAU. The cliaiijj.vs win, , ,|„. ivil (•(.i|iii,-clcs iiiHlcr;;.) in tin maiTow, lis v, aiitl spN^-ii have Im-cii i-imhIIv .stiuliVd In- (Quincke and I'dciv, wlio hilVr iSCCIi tin; inoiiicnl stdivd ii|> ,|j,:„ tlic cells of tlid.sc ui'uaiis in ilic Ton i of an aliiinninafi' ..(' ii , ivail |,|n|,. ill)ly to !)(• n><(l liver again in the 'Irvclopniciil <(f' nt'W (•(.r|Misi'l('.,. Blood-plasma. — Tlic study ol the blnod-piasnia is dailv assuniinn grcatrr ini|nirlanci', mitwitlistamlliij; the icndcncy to attril)nlc all -en,,,,, l)l(i(>d-i'lianncs ((I 'iinscnlar altcratidii.-.. It cuiitains water, a r .■ ,iiii,,ii,it of sernni-albnniiii and set iiMi-glolinlin, willi small (jiMntities of innru,!,,,,, salts — .sodium, i-aleinm, potassium, and maiiiiesinm. Tlie in vest ij-at ions recently (•.•irried on in connection witii the (jne-iinn „f inininnity liave lid to a Uiiowled^'e of certain pi'cvionsly unsnspect,,! pn,,,. orticsof tlie .senim. (Jroluiian, .\nttall, IJelirino-, Xissen, I5nclni.r, and ,,t||,T. liave proved e.xperimeiitidly that the fresh hlood-.sernm of mammals ha^ h,,u. crfnl jierrnicidal proi>erties. This l.aeterici.jal power of the serum of .lid'dvnf iuiimal- vai'ies, and, what is still more interest iiij;', the mi.xiiijr of the >. inm ,, one animal with that of another residts in the destruction of the Mviiiijri,!;,] powers of both. What the substance is that po. Imi ly, since it i> iv,,. dered inactive l)y warminii at a temperature of ')r^° ( . for half an iniir, i,,,,] exposure to liu'ht also robs the serum of its irerm-killind out that the blood-serum of one Miiiihil had a destructive action on the red bjood-corpuscje.s of an animal of a ditf,,. out species— a fact wlii.-h explains the worse than usolo.s.s practice of \^U;\. transfusion from lower animals to man. [iuchner has shown that thi- ''ul, lieidal " action of the .serum is quite analouous to its ird-mieidal actii.ii. N ,[ only are the red blood-corpuscles destroyed by the t;)roijru scrum, l)m \W-\n\. oocytes are killed, as shown by examination (in iho war i sta<'c. Iliicliinr further refi-rs the antito.xic action of the i :> ..d-seruin of immune animal- tn;i quite analogous chemical action. He does not believe that the>c -iihstiiim-, germicidal, globulicidal, and antitoxic, ('an b" i-iple "dead" protcids in s-H tion, but regards them as highly (•om|)lex molecular conihiiuttion- wliiiji m some i)e<'uliar way are (ie|)endcnt .for their integrity on a loose . nnibiimlinii with salts of the alkalies. Hankin terms these bodies alexii ■ an individuals into others as a protective or curative meM.-iirc) i> Hl of promise. S , n'lid; |,|.,,|,. |nisc||.>. lily iisMii!iii|H )utc all .,Ti„ii. .'Hiiiiiiiir cs ol" iiiMrMiii,,,, *ll<' (|llr-l;,,|| ,,r i.siispcct,,! j,|.,,|,. Iiiii'i', iiiiil otlicr, imilills ||;|, |,„„. I'imi of .|;ti',.|viit Ol'tjlc >,T1|||| ,,t' ' tlic pTinii'iiiJ ■oiiliiir |MUciM! , since it is ivi|. It' an .•Kill!', iiml lie . I <>t" line Mlliliiil uial (if a i|i!)ri. mtico of l)|(in,l, lat tliis"g|, al action. \i; HI, 1)111 ;lii' !,.!|. tagc. r>;icliiiiT IK" animal- til ;i lesc -iilistniiiv., >r()tci(l< in sd'; liun^ uliirli 111 '.so ciiiiibiiKitiii and i)clii'-!s !i>|)liilc variiH' fy'/'iju/ff <-/•/( >.v. i.s: ^f ";•>:''••'"." '•'• tin. ,,„| l.ioo,|-cor„„.,.|c • '■'""••:""v<"lwiflMli.,iIlcd water U " "'"''■"■""' ''•""' "'<• -»n,n,a u li ■""".-'"" /"■•■vm tin. .solvent aci . I "''"""" ^^'"''•l' is in f , '" '■''^ ""• ••"llee.,tlV,(io„ „| tl,,. „,|, , ''■ '^■•''^•■'•Nilll.l oiImts " '!"• x'ni.n. Uv"sav ' * '" «''<'"t■"■ ».-ivof .1,0 u.«.i,„„k, „!,.■,,'" " '"" -'PI'.-.™.!,,,, „r„-i„-,,, j„ 'r;77^'■b•..;;;a'M^;;:;:;;;:;-;;;;■-»i..■.^.«^,:,:i::,;::;;:;-:; icoevtio form« ..,,.1 ;..., . '"'*^ '*"t SOn)otime.< r'i>'-.!i,i„„,j.., iilKf k tlic ic c.xcivis "i7"i"<'l<'.s, thev iiiav (j( ^I'et'iiiie tl wi "Of to allow ,!„> „il-(l i,and if thorn l,r a 1; ^et'ii it, f|,o f,.(..sh '!> 11 be (] otitri >ywl. 1-op to reach the ^J-gc- 'iiinihorof niicl ^pwinie,,. Soni edge of th ( cai-e e oover-gJas,s- il: Mi 1K8 i)/s/:.\st:s or riii: //aoo/>. Enumeration of the CorpuBcles. — Tn n liciiltliv miin flu'i'csliuiiM Im (Vom five to li\ (' ami ii liall' millinn- of n-d coi'ihim'Ics in .1 cuhic milliiiH'Irf ni IiI.khI tlic number in women Itcin^ iiDrrnally it lidlc iiiidcr tliis. Tlie wliiii u1mih|. CDrpiisi'Ies vnrv in niniilxT at tlill'crcnt (itn-^ ol" tlic iluy ; tluis, tiicy an m,,! numerous after a meal than (liirini; the ilii^c-tive prooess. Speaking gen, i;il|\, Fid. ;i. OJ O c ii. cs. o o l-i o o ■a <;;> c .v-,0 c ^ Ci o D C:i C -o- o i^ ^- O ::> -Ta-< -^ O o C .21. tJ o .^^ cO Ci^ o o O D A ^^ Tliuiiiii-Zciss HI I'CoiMitiim' A|>|iiiratiis tMiiilit'ck). A. MelauL'i^iir: a, Ciipilliiry tuhr in whicli the hi 1 is tiikcii: b. ('Iminhcr fur inixiii'.' Ilir lil""'! »;'| the (lilutinK solutiim ; c, (iliiss hull to aid in niixiiij,' tlic bldiiii with tlii' ililiitiiii; snlmi.m. B. Cross-stM'tioii (if the chaiiihcr in wliiih llie hliiiid is edunteil. C. Sectinii iif the field on wliieh tlir IiIckhI is ciinnted, shii« inj; thirty-six S(iuares. D. DiaKrum of llie wlmle liilil. tlionwrnjifr i fn'O'lO. 'I ivil-known ii III till' ''mixer •[lecilic fjravif iw'oniiiiendiMl vliicii tlw wJi ' The drop of tl "■'"" «ii'-biil)l)lo,s, am WefoseeAWton's "''' ''!•' «»ri.l,.s,.I,>s h; * "'^"'it. Two ^vlu |lli:i|| squares in vac] llicll'c ol iiiu,,,!^ H' Wllili li!,M„|. , tllt'V nil' IIIMI . ,killg}r<'ll,|;il|v, V — o o ^ o. D C jv ilioiH'pnijro niinilmi. of «i •* '^" "'^o (A) ..11.. Imn,|n„| ,„. ,..,, , „. , ''^- .'^•'' ' '"' l'l<».,I is ,|i|,„,,| l-'iQ. 4. '""" -—.«...•. ,-, ,„„„„_,, •". *-l...M,K, ,„„, ,vi„.„ „ ' "■"■ '"■''""-'""..•*.-« Ui I' !)1 n f.tifl 190 DISEASES OF THE BLOOD. whole fields for the wliites. Although the process of counting and calc iLitinc is not a conij)licated one, yet careful and conscientious work is required in did,,,, that the results attaimnl maybe reliable. With the Thoma-Zeiss eoi;. i.p jn, experiencetl hiematologist should not make an error of more than 2 lii:ej water; A', I.aueet for obtaining the bluuil (l.imbeeli). Ill' nil ini{i I'c gt'iieraJly If t'minierati, alpiii'/xw. Xo,. Silliiiclic. Examination %• ^,), ^fiilassez, |i.fiii()iijeter devise(i ''^W'S there* go w ■*i to very eri-oneo rtioiis with distill <"'T''i' in a s(.c(.ii "»"'«''-''^v, a w(.,lg "*' I'lc two cIk, ""'irt' liiilaire) ;, '''■''itiii, /onus of rii'Tcaiv ti„i,..s, J,„ "''■"'' 'I 'I'lfilitative "■'■''"'"■••^f 'l..neby n "^''' '"'en iiiv,., "•''"'''•' poison in, ""'•■"•"scop,. (I,,. ed the hfcmatokrit. The wheel is then turned, and, the tube revolvintriit of ilOOO revolutions ])er minute, the red I)loo(l-corpu, an exa ptaic of tlie tl ■li- I'C ditii'reii E'Vcr contains aivfliimd in hii P'tiVal (liagiKi (I) The eosi; liiaid in cells w 'rniiiid, liijrhlv n. till' acid group piiiiilcs are nuu Willi alhiiniiiKiii '("pliKin. 'i'lic tliiiity [\)Y eosin (-') l'>asophiIic '|"«i u'lidse gran NllllKill eiionirjl (•5) Tlic neiitiv li'',i;Taiiiilations, ; '"■ tiiii', and re.- ''■'iii ill the iieiit i-'ii. \ irclmu in ISi ''"''' tliaii tweiiiv ' ■' 'iiurpiiiil(,y.i,,.,| '■"'ij'-^. Ill iiorina '"'"l-i'Mrpiisrlcs : ("I Llllilji/l(iiu/tvK '"i'lir lai'ov. n.nni *;■' TIhw arc del [»!' -'«> or ;i(, ,„,,, ,,, ^'oi. II. -i:i JNTRODUVTlO?r ;it Ic'iViirc. Hcforo^f'ii'iii'.... *i ■"= PI- ''=..•) ^^;;:::;;!;:';:r;:;;;;;;;::rv^^ '''"•■'' ^^^^^ '■'ix '1.0 ln.n....|,.l,i,. of <1.., .,„, ,,;.:',':' ^"""I'-.a,nnM,-120°C., in ..nlo "-•f '-N-'i'lo gnnula,io„s," tho , J r ^ '''""'"•'' '^"'^ ^^.n.! vario- '"■'-""■ ^'-"•<' -t-M grnnps of- .t:^;":'^'^''''"!'"- ''!-■' ^''<'i-l.-ifi^^ -""""'"f"'^ at H,st >ni.k.a,li,.g, si,,..; nuT^T f "'''^' ''"'' ""<' ''-sir-a liicli liirlil is r.'l!i"l(4 ^■p-''' iiiKlir tli( c'liaiiiit'- IBiiI' .||, )(1 mill u airr : '/, i;;t|4l' ^H ^llllilli ai'c tlici (|iiickiv ii'o used tiii'iinlil- si, ape (it'tlii'ii'l- CCS ami cxaiiiiiiiij ---^i—. ^^-n,l.i,,an,: :; ;'f'''^''^^ ->' - ■'" ,.xa,..,>i. .,• th, fi.,t, rosa,,iii,/' ;""''';'';;'''''"'" '"■'•^'*" '"'^'-^ >- ''- "'■ ''i«^"'^'"t a.,i Is sc.v,.„ ilHini,!! "" '''''" "* '''■"""-^'■at." in t],. '™' '""faiLs ».o,v tl,a„ a si,,..!,, v,,,-,,,". ,''''\ J^'-a"Niatin„s ,• o„o ,.dl ,vlnu,„l ,„ h„„....,: i>|,....l. a„.l ..Mlv,w,;j,.,v; ■) ''"V ''"■ "'^'"■^'^ rariral (lia.ir„osti( value: ' "" • ^^'^'" ■"''"'^^■" to be of I 'I)TlH.onsi„o,>|,iii,,„, «-„,,,„„,,^i„„ , H '" «vlls with /i,i,.|v la,...v H„,|,.i ul.l I • '-• ' (•^)-) 'J^J"""^ >>^ pniilcs aiv ,„a.l,. „,, ..f ..(.itl,,;,- /:„ ,„„. i,' " ';''"'" ''as pn.w.l that these -"• '•''- grannies a.. .J 1- ' T^;'''''''^ -•^-" '"' ^1- cell-p,.,.- (2) Hasophilie. or ^-^r,,„,„l,,tio„. O,,],. ,„,,,.., F""'«''"- J,n-annh.s sta,„ o„|v ,,■„, „.,,;. ', • ""■^ ;"'" -" --'Is i„ the "'""""" <'"on^^h i„ the " „,ast/ellen " c ., '' ^""^"''' ''"'" ^''a'^latio,, is ri\ 'V\ . I .,. ' "' '■"' tissue*: '■^^ '"'."'•""•"l>'"lH.',..re-,,,.,.a„„la,io„. This i ,1, ,^nmnlat,ons, and is Io„m(I i„ ,h,, n,.,io,-ifv ,• i """^ "",.,„.,a„t of .,11 ^- «-■ an.I .vsolvahh ,. .^^12 7T ''^'■•■^-'•''- are " i" t' antral --.: . • 't "'""'■;"' ^''" '"■■— I-. Thev ^ '''''"'^^ '" I'^b-. |„,in(,.,|o„ttvv„f , "'"^*" '""""■" <"'f<"ofo,,„s of le„eoevte. ..1 '"■^''"" '"""ty yea,:, lat,.,- Max Sehnlt.o e.,.. f 7 """"•' " •^'"""• ' "-•Pl-l0..i<.al ,„.ity i„ the leneoevt f..,^ •' ' " '"'^ "'*" """ "'>-«'e "r ' •'-' '•'-'-' -' now .iisti....;i h irisr' """''•.•''--<>" i->to "^-'■<>vvusrhs : ''"' " ^'"' 'onow,„ir va.-ietios of white (") /,'/m/.Ao<.y,,s..-S„,all ,.ells al.o,it th,. r'f' ;•'■ '■•■•' l>loo.l-,.o,.,„:s,.|,,s, ,,. """""^ l:ir.v. ,.o„„,]isl,, .leeplv-staini,,... ,.„ , M ''•■'""•""'-"'•pnsch.s, ,.,.„. ':;-^' '•-"t.ofthewh.J •'^;7r'''^'''''-<'y-a,,dLk^ I Vol. 11.. .i;, • ""■^^^'"' a Jaiw oval orovnM r-.„i.u. ! mm ii 194 ni.Sh'ASKS OF THE HLOOD. •staining nucleus, an;ranulcs. (Plate I, Fig. 1 (c).) Khrlich iu'licvcs that tl.. v mr. gradually transformed in thecirculatinghlood intotiiesnialler polynuelcii i .rm.. ('') Jjcucoctiti'x irit/i J'n/ipnnrplioiiH Xuc/ci (the so-called " jmlynuclea! Im- cocvtes). — This is tiie most common t()rm, since they represent two-tli m|< ,,| the whole number of white blood-corpuscles. (Plate I, Fig. 1 («',').) Tin are smaller than the largo mononuclear elements, and are characteri/ed liv li,,. irregidar forms of their miclei, which take all sorts of shajies — S, V, Y, Z. (.!•[ •ThtMr protoplasm is thickly studded with tine neutrophilic grainiks, >,, tlmt ; they are often called " jxdynuclear neutrophiles." ((I) TrumitUm Formn. — These cells are similar to the large moni.iiucli;!! cor]iuscles, but differ in having indentations in their nuck'i. (Plate j, \\ 1 {d, (/).) Krhlich regards them as intermediate forms between h m\ The mononuclear cells, together with these transition forms, represeiii ;iliniitH(,it„jj and will vary l)ctween mid ill youth ,ikii(i\vn voli Imt f.'ikes up vlil.'iu, wJio p ill' tlii'/i adds ariiuiid in tJie urdinary way ■ "<•- of ("ami uioiiaiy ])htiiisi /'/" A//:a/m line, ijiit the an ' piltllo|()jiri(.r 6 per cent, of the whole number of leucocytes in normal blood (<■) Eosinnithi/is. — These are cells of about the size of the jwlynnelcar Ic cytes with variable nuclear forms, and a protoplasm containing large rdVaitiv.' eosinophilic granules. (Plate I, Fig. 1 (/).) They make up from L' to 1 |„.r cent, of the white blood-corpuscles, and have their origin probalilv in -;,, bone-marrow. Fnrms />, c, an-marrow. The proportions of the different forms above given ari' fairly (dii-iimii health, but mav vary widely under ditfereiit pathological conditioii>. Hi a "differential count" of the leucocytes may l)e of very great yahic. a> I - show later, in the clearing up of the diagnosis of a difficult case. In some diseases cells not normally ])resent in the i)lood at .■,11 iiiav found in dried -pecimens, and the presence of these, together uiili (ciiai deo'cnerative and regenerative forms of red lilood-corpuscles, to be ,-|Hik('nii later on, are signs hitherto insutticii'iitly appreciated. It would be going beyond tlH> limits of a general te.\'t-i)ook to ivtir tn n the various staining methods which may be advantageously used, flic ml ing mi.xtnre of greatest j)ractical yaltie is perha|)s that known a- tin' nipl stain " ( Khrlich-i^iondi). It contains methyl grc(>n, acid fuchsin, ami maiii (r. With thi- tluiil the miclei of the white i)lood-corpuscles arc in iiieiii< < granules a deep violet. 'Tie plasniodiii malaria' may be '^ndied in dried speciiiirii- -laiiuil 'wl I 1. Im's solution of eosin and iiKthyleiie blue, but tliese bodic- ■■■>n \«- ixm iiied much more satisfactorily in the fresh blood. The stainin oriranisms in other blood infection- ('•. [/. the tubercle i)acillus in aciitc mil; tnberciilo.-is) gives results too inconstant to be of niuch practical ^ liiii(';il val 'flic Esthnati ippmxiiuate, an The older w lf|MH(liiig eitJier or "II an increase liii,t;iiifi'ii)iiti()„ tj Tlic n>v. „f 1,1, *'ls :'- ill clioler Iptlmra, Accessory Methods of Examination The Spccltic (iriirHi/. — In health the s[)eoitic gravity ot i hliiiiil iill ■'""■'ilia riijty [ji. ■"'""■• -pendent f'J^KTIfORA. 1!)5 vary Lchvoon 1045 an■'' -'' at r ",""■',; '^ •'"<■ ™f''-'- f" ehan^esi.. t ' v. '''""'''''"'' "'" ^"""-l^^-l^i- ": '''^"•''"•'-" t'-. to aetnal i....,-.,. J h:7Tr"' P'"" ^"'^'•^'"'"- ^'"^ ' " '■"-- "f '>lood-,.o..,.en,..ati,.„ ; 11 '■"'""'' "'■ '•'"*'mia. There are individual- wIlk, persistent pallor of the face i.s due to hereditary iuHuenees or to local vmm,. motor disturbanoe.s, who may have their full complement of corpuxles ami of lijemoglobin. Patients who have any advanced degree of antpmia present a charaitciistic set of symptoms — viz. pallor, shortness of breath on exertion, palpitatiii'i- of the heart, headaches, and in women men.strual disturbances, ukki (,t't«| amenorrhcea — svmiitoms which alwavs demand a most careful bloud-i\aiiiiii;|. tion. Even with the marked improvement in the hajinatological teeliiiii|ii(. ,,1 to-day it is often difficult to pass judgment on certain obscure cases, and ali classifications given are at best only provisional. It will be found coiiNciiicni to .separate the so-called primary or essential ansemias from the secoiidai'v m symptomatic forms, it being understood that what we now call primarv mif- \ mias are so only because we are as yet unacquainted with their exact etiol(wv The Primary or Essential Anemias. Of these we have two distinct forms — Chlorosis, and Progressive IViiii- cious Aniemia, CHI.ORO.SI.S, Definition. — An affection occurring chiefly in young females, wliith pin- duccs clinically the group of symptoms common to the aiutMuias, and i- char;;. terized by a marked diminution of the amount of luemoglobin in the imliviil. ual corpuscles. Etiology. — The great majority of cases oeciir betw(!en the ages of f(iiiitnii| and twenty-four — a fact which gives some supj)ort to the view that llnri' i>;i intimate relation between the affection and the changes which the mvaiiH midergoes at ])uberty. In girls in whom the disease occurs early in their treii-l we are aj)t to find a certain precocity and an almost premature ap|i(ariiinrH|' the mcn.ses, while cases occurring later are associated with a histrnv (if a lato puberty. .\s a rule, the pallor begins a year or two after the nieii-i< arc lii'-i| seen, and scanty meiistrunlion or total amenorrhoea is a concomitanl '-vmptHiii, the mcnorrhagic chlorosis of Trousseau, as fiir as our experience uncs, hoiii^'l uni'ommon. (lirls with light hair and fair complexion ,are more liwiiicntly attacked riiau lirunctU's. 'I'he affection is rare in males, though -ijiac iM-e- occurring at puberty have lieen reported. Virchow has advanced the theory that a congenital hypoplasia uf tluMi-j cirLORosis. u,>i;i uf till' vai- *--:''t:';.:::J::;;'r:::--r:r"" ^ '- -^^^ Ilia Inm. Hilorosis .Mf tl.. s,,.,.,. fi,,,,. " Tl| , *''"''"'"""•" ■^'■^t^'''^ -"HiT- ,|„||v). ' -^ '•'""'■'■> ••'•nu.nnnah.l witl. tubcnM.lo.is , , \ l";'":"->- "••■■VMS „ngin is dai.nc..| In- so,,,. u|,m ,.,>, • , ' -'"''•'^- " p'-ti- t-n., io.. 5.i;!;i:";!j "';^ m,,.!,.,,,,,!," .,• .hai..,...,,, ,,l 'Hr«'^ ^-Hl <.r ,„ast.„-l,atio„ l.avc 'it "soon V > '" "^" ""'"'''"^'' '■'■^""' ip-y p-i... a la,,. p.-opo;t;ir:" ,. \:::.':;: ;-"7-'--.'. m i»''iiiM,u- ^«'wmo.-.i,.is or lk.t.„T-opo,-ativ,.. u- , ""' "'"""- '""■''- r«.M,s. a„.l havo s™al fli..|„s of . ;, ',";'"""''^^'^^'' '""' '-lly-]i,d.t..,| ,-^'-' ^- ='" i.y.i-.^. lat- ;;;:;: ;r7^- f-- , ^■•'^^' « eo.wa„t lr.n, ,l„. ,.ulo„-a t,.„. ,.„,„,,,„„ "' "'^ "^ *''^' "''-'•pt'"" of toxic {„.o,l„c,s Morbid Anatomy.-Tl.,.,,atl,oloi.v of ,.I,Ion,sls; • . , l>H- cMMs .lie ,iin,.tlv fro,,, tl, ■ ,ii.,.., : I , ' ""P<''-^«'f v un,l,.,.stou,l. \ h Lav. to autops l: ' ; :',::t '"■ '^"^'""'"^''•=" '-•''"^> i" .1.OS0 [^^•' i-nt..l o.,t ....,ai,.' insta,.:J "i , :;;, i::;;; '"'"r"'-- '^-''"-alies of h-ph,s,a of tl.. vas.„lar svst.,., fu,,.,! i„ •'•■■^<''-'l'". « ■"■-• >: >= .i.-i " Ilvt';:;;: -.n:!;;:;::!:: ™'^" '""■''■■- h^.inanL..iot.s...ot,,^;,:;;:::,t^^^^^ m... !"■ M-ina,. is bc,,ed to di.-..t'l.is tt^u , t:;;""^"^ ''avo ceas<..|. a„.l I'li'finii. t'L'itimnt towai-d a r.storation .,f this ^lifgciieial symptoms of .hlui'osis •„•.. ,1, r nju.usis aio those ui an ana-mia of a moderate I its DlSK.iSh'S OF TIIF. /}/.<>(>/>. orailc. Till' p'ltiont is !:;om'i'ally well iiiniri ti, . eiirions tinge of the eomph'xion which has given rise to tiie popuiaf nimy ol" " l)in-poverty may he judged I,,-; ;,y examining tlie eohir of tiie palpebral conjnnetivic and that of the matrix utili, tino-er-nails. The lips and cheeUs may be of a rosy-red color on exert inn, cv,:, wiien the valeur f/lobiilaiir is considerably diminished (chlorosis rubra). Tli. skin about the joints not infrciiuently shows areas of pigmentation. Ti, breathlcssne.-^s, palpitation, and tendency to fainting are evidences of tlic insiitli cient oxygenating power of the circulating blooil. The "symptoms referable to the digestive system arc often interc-iiiiLr. |: some cases the functional distnrbaneos are so marked that many author- -pdik of a '■ dyspejUie ty])e" of chlorosi-^. The apjiotitc is i>oor in many patients— iii„i, often it is perverted, the girl refusing to eat ordinary articles of diet, but luii:- ing for unwhttlesome dishes like pickles or other highly-flavored foods. S(h„„|. l irirls have been known to eat quantities of the mo.st indigestil)lc substiiii(v<, such as bits of chalk, slate-pencil, or (l.," is ..It,.,. -M-ients,.. n .:n.p,:i;;'r ;;:;;: ;;;;;r^ ^;' "-^'^ '■'/^"•- vm"i-'l '»'• bnicliii.l veins vvl ,.,.„ if ; \ • '^ '"".'' "••'''"• '" <1'" t "I »'"'--' .::^:!;:.:,::tn:;;;;:;™"''-' "•■ '-- .«™:;:::;™:;:;:'"'"^ "■■-« -'-'i.-,:,, ,„., I III-; JJrooi) Ev \Miv \ii,,v 'ri 111. I »i«., ai.i,„,„i, ,':.:-'";;"' «'"'""•- '":'.;■ '- 1 ™< i" ™„i Fro. 8. Ill ME4W NORMAL NO, 0^ WHITE CORPUSCteS, """''""''''■''^'•''^"■''•''-^'-^''--^^ "'. '"'^l '1- average .,ua,.t.ty of lue...oglol,i„ was 42.3 jt,. ..„„t Tl.i ! m V 1 i J • I 2(M) DJSKAsi:s or tin: lu.uon. rclativclv jircat oliu'iicliimniciina, tir-l poiiilcd (Hil hy Diiiu'iiii, is tlioili>tiii ui,||. iiif;- cliiiiactcristic ol'tlii- hloiMl in t-lilorosis, and .-crvi's t(i ditU'rcntiatc it ~ii;ii|i|v from (list'ast'.s, like pcrniciuns ana>niia, whrrc tlic .;lul)Mlar valnc in liuMnnLiluiiiii is incrca.-^cil. In ono case tiic olijfocvtlia'niia was severe, liiei'c bein- mi],' l,95;!,ll(M) icds, witii 17.") per cent, of lia'inoj:;li)liin. 'I'lie white cell- u,|, onlv sliii'litlv increased in innnher, avoraji;inji; in the alxive O". case.s 8407 lu ||,.. cnhie iniliinieti'e — /. e. 1 white to 40S red. ( )ne ease with over 85 pi i ivin. of red ulohuh's and only -'}•") per eent. oi' lia'nioij,lol)in pnsented aecnrati Iv lin. clinical aspect of a pi'ofonnd aiueniia. If a drop of fresh Mood l)e examined, the pallor of the individnal . iir|in,. ole.s is at once apparent. There may i)e niiniy poiluloeytes, by whirli ^vc mean defornieil red i;lol)n!es assnnun^j the most eiirlons flask-like, hiiiiiinii.. siiapeil, or pyriforni appearances. In the dried and stained specimens a >iiiai| mielcated r-d blood-eorpusele (the mirmoblast of l^hrlich) may now aiul tlicii be seen. (Iriuber's determinations, accord inji to Landois's proeednre. sJKjWdl a diminution in the alkalinity of the blood, l)nt investijrations by more ;i(vii. rate inetiiods have not eontirmcd this. Diagnosis and Prognosis. — When a yonug girl comes to ns wit! -iidi in arrav of symptoms and com|»laints ,( <■ lionld never assume the re>puii»ilii|itv of exeludinu- a urave aiuemia bei. ", .Miking' a careful blood exaininatini, althouuh the diaiiiiosls in the uutiociiy <;f eases is tolerably easy. TlHivap eases of secondarv aniomia, however, with considerable dinnnutioii in ihc cnr. ])usenlar luemojilobin value : this is t'specially true ot" the ana'mia i I' ihcia:- liest stages of tubercMilosis of I' (■ bniiis. One should always satiety liinhilf that the lungs are clear before giving a ])ositive diagnosis, an| list, where the red blood-cor|)uscles were below two millions and the liii'iiio- globin below '20 per cent., at the end of ibiir weeks the mnnbcr- :.f rcdswicl found to have increased to r),{)!)(),000, and the hiomoglobin to 70 pir (viit„aiiil at tho end of the eleventh week her hicmoglobin percentage was '.)'>. All lit tlio cases of the series were given iron in the form oi" Bland's pill-, iwi* piil^ {'" Iiedi.-tin. iii~||. tiato it -ii:ii|,|v ill illl'lllii-iniiili .'I'c iH'iii- iiiiiv liite cell- nvir ■iCH 84(i7 In til,. c'V H') |iii- ivnt, aooiiniirlv [III. i'n(KUN:ssi\/.: n.i isiciors AX./: I//. I. I'fi v«' ^n'aiii s ciicli iirt,.|. "iii'"i" (u<) lioiirs ill fl •■^••■'•y'"..ai. Til,. ,,,,„•,.„, Ix'lw ceil li<.|' ";"'."■" ""• •'"'■'y, ami tu ,..,k,. ,1 "a« .■||c..lir;i-(.(l (r L'Ol -|icil(| IllClils III (I '< I'^c ol" tlic t "•'■'' or I. .Ill' t;lii>s,.^ ,,(• ■.r->aiT, ,-uiis.i,.,(io„ uiis (natcil |,v sij \v<'Mty-<(.ii|. I '""' '"rill ,.f ip,,,, ,1 ""'X 111 tllC II) Kiiir. W lire iv I'o tala.n witlioiit (h.,il.|,>. If '-"■-"■"'- "csliiill nCfcii lin.l (I ilii'iii' } "f" IJlllif^y I'll ill aiiv fiin dctcclcd Ml (he /;,.,.,.s^ I ilj.l "^ " Vcrv |)l;,l|sil,| n,. " i-^ ""' it- -^iiKv an ,M|ii;i| ;i, M-'in-jrcn sniplii.i,, „, ,„|,,,,, ,^^ l'l"'^^'N"i' tluM.fli,.,. |,,„„| fl lat lll(irii;.;|,ii,. j,.,, ""iiMt fMii alu.-ivs I, ami tliiis iMTiiiits tlic a! mI' ii'uii wliici I'll'"' ••<>in|>,.iiii,|s ill (I ''•-'"•Ptioii of tli,. liiViii,. ,,„ , '••<' It iiiiit,.s witli til,, ■iiilcslinal lr;„.|, II' yastn wv^ as an i ' ''''f '" 'i'"iiniiiiat,. ,,t' iron A:, tlic ,uirl ,<,Ta,liiaII\ lai'ciiiit imcuinnion, hut tl >i'i'al an, trcMtinciit. r I i-oiiaiiis liei- ,.„] '<'>'■ arc of triflii la Fli l.-clll v»' tnniiil th,. svst t»r, acncifon ig imp,)rtaii " ''I'lipti^uis on t|„, t; ''•' =""' ri"M t,. til,, onli. icc Itrfatiiiciit iiiiti illlllO llU'lllO<>-|,)l)ii •' "'•^f'in„.,it a valnal.l,. ai.l '■"'"t- ,>xan,i,iatio,i or ,h,, b|,.,„| ^^.j,, '•'ii'cl, as tl III cn,.()iii.;|i,i 111; 't'v grow iiitcmst,.,! I'.'Hiciits t,. ,.oMt J)<'r,',.|itaij,., '" \vat,.|iii,g. the .stca,l mil,' y iiici'ca.so I' it'XiHKssrvi.: Vkus IIS (ilsca; {.NK'KII-S AX.KMIA. •' "-'s first clearly ,I,.s,Til„.,| im,! ■^•'11, \Vll,)> |ffl'nil;i" \,y .Vdil '•'""■';""■ '•lii.'^sical. Wilks, L,.|„,,t (., cr ill,. II V":"""* "'■ fl'<' ••li"i<-al liist,.rv of tl '""' "'■ " idiopati lie '"tlif literal iir, i:Hts (■lini,.al aspe,.ts, and 'it is t,j B laniiiiiir, ;,|„| (;,,, If aft CCtlOll ^'T'!- ''^'"'^ 'S"-, tlH' dis,.asc Iia,| I •''•""■all liavca,|<|,.,| "'''" -^tiiilicl cliii.Hv ";.'} "f tlic al(,..cti,)ii, tl lat \v,. ,)\ve tl *■""■" lias been stii,li,.,l l.y a liost of 'O'-mor, who in IS(J8, ,lis,.„ssed tl H' ivvival of iiit,.i.,.st in tl Etiology.— A, Id I is,.rvc|.,. II' palh,)!- "' aili'ctioii, which I.SDIl IClllll '■■'; :iiiii 111 hi.s 111 as ..arlyas 184-3 ha,l spok liv.. Illlll III!' ,'l iiill a liricf 1,, ;icc( Allograph oil tl ""It Dfthis fi.nii of pDlvcii of the ,1 "'. '^"P'-'rcnal (.aj.siil,.s pnl,Iisli,.,| IIS i-'^fasc in I ill Isr,o, lot pcridd I lia,I f ""I'M'ia, .ifwlii,.hlicsp,.al' fi'iK' to time met witl ows : rliii'li il ii'i'i' liad l),.,.|| ,1 *'""mno. without any ,li,,.overaI,l vm- rcmarkahl,. j iNl'H'iisis, no pill "liilifriiiiiit ilis,.ase P'""l'"fa, no renal, siil I)revi,)u,s loss of I,I„ofl, no ex I c cause whatev(.r— , oriii fases in Tl ;''"t'>;nnVlin85,S), while tl 10 nam,. " ..ssential '■'"<'. iMiasniati,', o-lanihil; laiistinu- diarrhrea ii'tl Ity i;i,.ri I'tiiiii. ic term '* aiiii'iiiia" hail its ,,|.i •I", .strumous no or IK '■' "■'"' thought lie was ih.a'l pronivssive p,'nii,.i fill with r.e- '"g with a pr,.vi,)iisl oii'^ aiiiemia " w IS V link I sown ililisoiis aiuemi: pll'tllllc t(| I "■^gfographieally wi.Iely ,]ist,.i|„ite,l. It to flu. fa,.t tl ;"'Par(icnlarly,.o,i,|„o„ ,-,; ,| "at It was eonliised witl If (^aiitoiis ,if S 1 ."^ome of the m "as thought at \vitz,Tlaiid, owing prol,. my grave cases of .1^„ *■'« IMAGE EVALUATION TEST TARGET (MT-3) 1.0 I.I |iO "1"^^ 11-25 PI.4 1.6 <^ %■ //, ^ 'c^l «p:^/J!^ 'V Sciences Corporation 23 WEST MAIN STREET WEBSTER, N.Y. 14580 (716) 872-4503 '% ft r O S 4^ y « I I i 202 niSEANi:s OF Tin-: hlood. f I" • ■ i ; l^^^^w Hi' li HB L % .soooiidary aiueniiii .-^('cii tlicrc. Mai>v cases have I)w'n doscribod in this cnuiitu and t\v(Miry-i'iw _ BQous increase of iron in the liver, and those of Hunter bearing on tlir ,,x,|,. | "nl noted tion in the urine of ipiantities of j)athological urobilin, are interesting in ti,i- connection. Birch-Hirschfeid holds that the tissue-destruction and the retardation nt blood-coagulation favor the idea of a'l infectious origin. Unfortmiately. diir kn()wle(lg-e of the etiology is as yet far too limited to enable us to eoiisinirtMnv theory which is wholly adequate or satisiactory. Only by the most caivHi! tm\ minute examination after death of patients whose blood during lit;, ims hn ctirefiilly studied according to modern methods can we hope to find the soliitimi of the proi)lem. Morbid Anatomy.— The pallor of the whole body surface and ..f tli>' | organs is striking, =.nd a characteristic lemon-yellow tint of the skin i^ piosciii in many cases. As a rule, the body is not emaciated, and, as in most imivmia-, the subcutaneous fat is not diminished. The muscles may be pair. l„it aiv often intensely red. Piinctiform hiemorrhages in the orgous and on ilir s ; 'i^ membranes arc (juite common. The lungs are iK.t particularly abiinrniMl. Tlio heart-muscle is very pale, light yellow in color, and shows in fiv-li tvn-A preparations the most intense fatty degeneration. The walls of t!,. sviitii.l:- are remarkiibly lax and flaccid, and the cavities ccmtain light-eoloivd IhA The intiina of many of the smaller vessels may show patches of lliDvdcuamr- alio'i. 'I'JK fiitty degeui ivsiilliiig fi iviTiii'ded as and liitty. ■I'dii ill the il('|Hisited in ■|wiiiiens a picture from tlio disease, A. ('. Scott .- aiiiPiiiia. Xatm-ally Tlir spleen si iiiorciised. T :lioy were of iias also been :iMiI is apparei Kimlflclseh th and Hiiidfleisc «iis Mil iiiabii imrniiil iion-ni (Vrtalii oth *^ii('li are the ^rilks, and Bi ■iini noted bv Symptoma li";iltliy lieu'ins :illy tlic onset if- alile to give tlu '"'lies paler, an |iitatioii of the I fill' fill's are no| :i:';:nivatc(l, and iliaractoristic lei 'iPl'i'tite is poor, ii'dcniiitoiis. and Tlic end is grapl till- patient can 'alls into a prosti to the very last, '"'^'* of the gene -trikinir contrast I'ospppt." /'/^Or/A'y.Vv/r^^ /'/^A>A'/<70.x AX.7,^fu. >(1 in tliig CMiiiiti'v. B ''""''■ II. A]tli(iii:ii i|„, 1 i- those .11' iiijil. onty, hut (Miiliti, :' age, Afiilr- aiv Tl K' stofiiiicli in til tlitty (loirc'iierativo cl it»iij,n's ill tlio I""'<'ly idiopatli '(' cases is t ""'"•f ''■'"". ''•"■^'•'■"'f' "t'-oi'I'V of the i'tl lornial e.\e( IH' seeretinjr tiihiil, iriiiiided as primary ,111(1 liittv, TJ nnicosa must of ■ptf iir 203 liiiht "; '>vor i„ most of my autop, 't' aiiji'uiia <'ours(. |,(> m, lou.r, 111 ill tlie liv " «'•'•.«'■■ cases it ^^•as enlarjr,,,]. 'j^| »sio.s was iKiniial r in si/0 iUiy instances ,,|' ■liiiically tVnin ||,, •egiiancy ami j,;,,'. LTiiicious im,-i'!iii;„ Mm tlii' < hraiic give i>is,. ,,, of tli(> iiupnivc^l oinotime< lie pus. y aiuemias i;,u.,.. toiiia (liiu(|(.|i;i|i. ■ :iicivasof| jni/e until ;iit,T t'r seems f,, I,,. ,.) laractei-istie of tl l<1"'site(l i„ tJ,o outer and niiddl ■p-xmions appeanu. to outline the [.ii;:,;,.;,, zones of tin. lol,,,], iiictiiro from that won in secondary ana-n !arie; 'o pcn.liar distribution of t| I'^'cs, the pigment I 0^ inid in two of lese ( le Tl ins i> I'scaso. The liver in fortv-ti "'i>, and may |„)ssil)lv I K'ing my quite a ditreren't A. ('. Scott sliowed tl iis.s ve consecutive :iiit liiijpiiiia. 'pccial lesion in ik opsies examined f »t' J>eculiar to wi.ses other than those or me hv •f IK X.idi'-ally, the h.-cmopoiet pernieioi; The spleen sliows no charact -istic '<• organs Jiave been tl ic o Tl ;lioy were of a rich d yniph-glands mav 1 esioiis ; the ibjects of nnount of iron in it is usu Icep-red color reseml )(' nnclianged, though in tl anxious study, aliv IS ai)I); illK ami Kiiidfleisel ipprpciablr cnn,, <<'ri|)tion. A-\rt ire aiia'iiiia< i< Im 'iiesis. Stcpli,.;, B "ii ■^ome tiinh in \h,- ■ "'"'mal iiliieraiiic. Tii- increased Iiumhm- ■ "^'"'l' are I'd to the ciinr- ng on the (\\(iv- itcresting in tiii- iiiis also lieen noted by Weigert. Tl )l;ngspleen-tissne- 'ii-co of mvc; ises iirenth Itlcisch the iiiai replaced l)v hji>mobl ''0 amount of yellow 'IStlC marrow I'ow appeared to be. fd marrow, fn ■a condition which IS diminished one h 1 case rej)orted bv !' 's inclined to think that tl 1;* an inability of tl "on-nucleated red I.K,,,,! Certain other h 10 cause of tlu <' organism to ch,,ige the nucleated ii'J^o mass of nucleated red e<.|I pernicious ana>in ■<''Ji'pi!S':les. i-od cells into tl la iO tl ■iinl noted ions Iiave been described, but '<" ;-'^=niges in the sympathetic gangl the posto none of them ar niivs, ami Rrigidi,:„„I the scl orosis in ! nitardation ni ■ ^ili^' ^^h- I'ogins gradually to develop the 's a rule it i I mentioned by (iueek nor columns oif tl ■0 constant. eft. lie .s ipinal " nuiivichial wl 10 Por' .ips has before 1 onset IS rai)id, but symptoms of an >oen jierfectiv aliletogive the exact date of the I s so insidious that the aiiiemia. Ocea,- lon- paticnt is scarceh "»'?■•< pal.'r, and notices that I l/eginning- of his illness. Ho grad ration of tl 10 licai't •otireseasily, gets out of breath, ami I l)C- tlii' ears are not niicoi oil the least exertion. *Head imon as earlv ache, vert ''irsrravated, and later o., the pall •^vniptonis. All th '^i<», and iialh las ]j ti- nuging in face and of tlii' L' skill is prcsi'iii 1 inosl aiiii'inia-. )c pair. Imt :i:v id on tlic si ; "i< abiiorniul. Tlie ill fiv-ji tciHvl I '"'""^ <><' tl 'li'i^'teristic lemon-ydlow tint. The ,1 I'""'"' '"i>y 1)0 extreme, the si, ose may be gradualh iPi"'ti(e is poor, and nan ■."•estive in assuming the "'''•'">!'t'>'is, and hiemorrl if^oa and voniiti organs become disturbed, tl Tl 'tl fill "■ ^'"«l 's graphieaily described bv Add '=>.i.^os may take place into tl "'■ patient can no Ion into a ler rise from bed, tl i«>n : " The debilitv 1 iie lecome 'o mucous membranes. "f? are fre(|ucnt. The ankles 1 1. Tlie I '" t'"' very last, and "•ostrate and half-torpid state, and at" I 10 m:nd occas afte '0 general frame and t! r a sickness of several leiiirt! iH'comes extreme, ionally wanders; he i^rn expiivs; neverthcl 'ess. (I;r v-ntnrl'.« ■ ■^ti'il^'ing contrast to the fail -colored hli«"l, pf lii!!\-(l('::c'Md'- i'c«|)r<'f, Ul >o amount of obesity oft "'••nths' duration, the bnlki- •0 and exhaustion observabl Thk I5i,,,„n EXA.MINATIOX. ■on present a m,)st !o in everv other ■Tl 10 oligocytha?mia'is al ways ,()()() red eorpii.seles to tlie eiibie iiiilliiiietre just Ix'toro deatli. T|„, oligoeliromieiiiia does not keep pace with the eell-rodiictioii, the peiv, nra-v of hienioglobin always being iiiglier i-ehitively tliaii the percentage ,,[' |,,1 gh)bnles. In one of my eases tiie hicniogiol)iii percentage was greater Irs |ii per cent. This relative increase in tlie indivifhial globular riciinrs- j, .n, iiui>ortant point in the differential diagnosis between this disease and elil,,r,,,i. as well as the se(!ondary aiiieujias. The value of this sign was first noi<.,| l,,. Laaehc, anil it has by many been considered path(jgnomonie of the di-iasr. Via. it. BLACK, RED C0RPU6CLE3 RED, HAEMOGLOBIN. liliKMl-cliiirt (if ('use (■!■ IVriiiciiiiis niciniii, BLUE, COLORLESS CORPUSCU! M!. While we acknowledge and appreciate its diagnostic importance, vrt ui' hum warn the student that even with the best clinical luenioirlohiimuc!!!' >. Fleiseld's) which we possess the ii(' tm-ns w r^- ^"^ '-.->.'.• -o:; I't^lrrr 'z ;'tr^^r ='^ ''■ '-" '-'■' «oiil.l alway-s bo loft nioro o.- L i d i t sT ^ ^.^7 '" ^■"•^' ^"^'^' -'" Til.' frosli blood-siido rovo'ils ....„., . «.,-i,np. ..„, ,,„i,„i.„ „„:,:, t;, s ':r "• "'""""•'•'" "•"■«■ '^ l»- '.v,K..» They ure a o„„„„,;, fi' . : ;;:'■'!" « °'' " ," -versio,, ,„ „ <'■ <>'■■" I.").- size wliici, „.<,,„„„ fW tl^r " " " ""W"""' '» Mi»S"'. I«..i..g hi., „,,i„i„„ „„ , ,„„|' ' ."'"'■^^ l'.™."gl..lm,-i„,.,-„Ko. K,,,.. ""■* ™"'"°' "^ '" "" -«-''^> - '-■-• ™«-he:: ::;;,:;r;;;:;,:^^^ Fro. 10. o, I fioJ rorpnsdos from a case of profound ana-mia i , k^^ , Hood-corpiiscles are maerocvtes. Besides tliP«. ii ""■ •"""I'or of lenooevtes would "ovn, lofu-ooytosis ; in.lood, "t '■- ■' ".t.::!irt\;';i::;;r '" "-'•'""'■ ^'^ "'"-- arh-,.|i. l,„„,,.or hn, ,,„i„,„| ! reiativcly am.cwhnt i„cre,»o■ '»"■> » .i-nK.- <"y la'u- ii.nn,, „i,h J^ ft"; I''"™ V'""","™""' '" ""' '■'" i ""'I (2) ;i* ■■<■ ..:,„.,i..„). ,P,.,.:;i, ■; :'-r n , ' * "■';?'""''"'» - '^'-'"■ I"", '"- ' -*■ «mb,v i,i:„«,j':j: :,,""""' "■■'^"■" <'■* y"^. ""' "">'"l"l>l!»!s are toiuKl „i,|v in VITV „„nll' 1 'J Mil MMll iiiiiiibois, and tlm, ,i,„cli '"""H- '*'■*'-. ni,r|iH(, 188D. ill 1 H f I 'I 206 DISEASES OE TIIK lilAHHt. r I if (Icp'iioratod, in tlip isccoiulary ima'inias ; in pcriiicioiis anajiiiia and in ii:c |:it,,r .stages (.f Icuka'niia tlioy arc niinicroiis. Ehriicli's description of tlio ii;ii;.n.|„ forms of defeneration of the red disks will he foiuid of great interest. .M.^v particularly we wonlil draw attention to the retrogressive changes i. mhI,,, in specimens stained (lonl)ly with hajmatoxyliii and eosin. TiiK Ciitcri-AToRV Systkm.— The important symptoms referal.h i,,,],, eardio-vascidar system have heen already mentioned, of which the di>!iossin.r palpitation may give the ])atient most concern. On physical exaniinar,,!,' besides the loud venous hum in the neck, nnirnnn-s may always 1h Ii,..,.,] over the cardiac area. There may he visible pulsation and throbi)in;. of ti„ larger arteries, and in two of my cases venous pulsation was noted. A ,.;i|,i|. lary pulse is frequently to be seen, and a sphygmographic tracing of the ..,,|. lapsing pidse may be quite suggestive of aortic insufficiency. HieiMMnl,;,,,,. into the skin and mucous memliranos are by no means rare, and there nmv 1« retinal hiemorrhages, causing blindness or partial limitation of the visual li,,],] An ophthalmoscopic examination should be made in all severe cases of aiiirmii The tendency to fatal tin il)osis spoken of in connection with chl(,i(wi> i, never seen in ))ernicions auicmia. Tmk Kksi'[I!at(>i,-v Systkm.— In the earlier stages dyspnrca is cniniiinnK present — a symptom which later may be much aggravated, even to Mich an extent that the breathing becomes stertorous (amemic dyspncwi). Toward tlie end (edema of the Iudl--^ and dropsical effusions may be looked for. Thi-: DnJKsTivi, Systkm.— The lips and tongue are pale ; the appctiic i- variable, but is generally poor. Dyspepsia, nausea, vomiting, and di;iriii..;i may be present throughout the whole coui'se. The liver, as a rule, is of wmwi size, but the spleen is often slightly eidarged and its border at times |)aliiablr, The urine gives evidence of decided changes in tissue-uietaniorplKisis. Tlie urea and uric acid are increased. A low specific gravity along with a (link- colored urine is more c less characteristic. Hunter and Mott, wlm li;m investigated the urine chemically, have proved this to be due to the piv-iii,, of pathological urobilin, a substance differing in many ways from (he iii„l,||i,i found in normal urine. The addition to the urine of a fi'w drops of an ;iir... holic solution of zinc chloride gives a marked green fluorescence, but tli(resent, a well-marked ;d)sorption-band will bo visible lying vW,- tn tli. line F and fading off toward h, With a considerable absorption of the diitir part of the blue si)ectrum. rcptomu-ia has little or no significaiKc. Fever may or may not be present. Thus, a normal tcmperatiiic iiuiy h. noted for weeks, and afterward be followed by an irregular pvivxia. Tin increased sensitiveness of certain bones (c. y. the sternum) to pivsMiir lia- probably been exaggerated. With the "aiuemic sclerosis" of the coid \\m are in some cases disturbances of .senvi.tion, and in one instance ;iii cxtcii- sive paraly • .as observed by Lepine, Diagnosis. — The essential points to be noted are— (1) the severe irradcof oligocythicmia; (2) the increased mUnr (jUAmkurv ; (,'}) the presen.r of iniiiiv "' ".relapsing ji ill which the in '"!-(■ rcpdi'ted re( fitter cure by nr.- Treatment.- "-is ill this (li,«o flint \vc iiinst nii iiiJiTiuiiially inci ''«' i'iUieiit will ''fai'twith ;! mini tliei'ml „f the (1, a and in tin |;,t,,r II of tlic i« ICCa is (•nllllMiiiiiv L'VOn to .-llcll ;||i a). Toward tlic i\ for. ; tlic a|i|)('tit(h ir, and (liai'i'liu>;i "idc, is orii(iriii;il t times |ial|Kii)lr, morpliosis. Tlic >iiff with a (l;irk- Mott, who have to the |)i'('S('iiii' roiii the iiniliilin Irops of ail iilcii- leo, l)iit the sill, oli),i;iVal urnliilii in^r clii-c t(i till ion ol" the mitiT | iiidcaiirc. |ieraliirc ninv iw ' pyrexia, Tlic to pressure h< ' the cord tlicrc tamv an I'Xtt'ii- „,aere,ytos and Ki^antuldusts ; (4) the al.senee of nnv ,..„■ r ana..nia; (5) oeeasionai fehrii,. distnrl.aneos • in *'"•''"'"; '"'' •^••'••>"«la.T 7, l,a:norrhages, ..artienlaHv retind S /.^^^ ' •"""'" "'" "'" ^''" ■^'<''" = rieney of troat.n.>nt. ' ' ^^ '' '""^^''^''^-^'v.' course and the ineth- j;:^;;;;:i:z:,r,:::;:';::/''^^^^ •^.^i^.n-the '•'-••<' Kl<.b.dar richness in h:!;; ^ Zt^' '"' 'TT. ""-^ ^"" lol.Ia-ls. .\frain,aswehaves.,i,l iL ,'." '""V'"' "•••-•^•"«" 'd Khrlieh's .,•„,,„. :aaH..d. The .ii.,;.rentia; dh^ ;• ';: ;f: • :;;:';^ ■" ^■'"••'•'f i^ "."ver ve., an- ana.nda n.ay he extren.eh- dilli..,;,: O , !.. ''7"""'" ''":'"^ "^" — '- main to a niock-ratc anionnt df e...-*..;..*, r ' *'""''"'' '" ""^"^t "'•'^'-'■^ .:nVin of th,. jrrave secon.i v e 1 ' ' •"" l'"' ^'""'•^' •''" *'''" '''"><"I- The ■ahc.astri.-'^nneosa Iv ,: :r rr''T'^\'''^''^^'-^^^ i"i^- •"■'•"'•brthe l-asitcs or thei.: <^..; Sc; ' ^'^'^ —- ' .ni-'t oven he i^C^.,, ;'■'"■"■ ^ " ^"■'•'""'^"•' ''^- =' -ell- "' '"--er at the antopsv Z:^::^^TTT "'"' ^""'•'"""^ ''" ="^'^ .v..nled dnri,,, ,i,c. as' .„. a,.,..,' • ^ ' , •" ;^;^- ~ -hieh h. has Pro.nosis.-The p...^,.,.i, ,. , „,.;;; ;^ --"; ^vpe. urv arave. Tn to a short fi.,,,. . .i i- ' "■"' "'' "".ii''f cxiu'ct, i::l^';;/i«??^;;'^::'=..:f;:;:,::;\;:;::^^ I ^'M-. Son.e cases appear to have l,cen e .ti^e . T "" """"•' '''""- of the atleetion, at least for ■, tinu I ^ ^ ^ , ' "'"' '" '''''''>' ^''" l''''^'-^^-^ ; -- of 2H eases. 2 ha^^: r^ : ij't:;;:'^^ Jl; -'"''^^ •■•"■••'^- ^ >'" ^y <-« ^ -;■•!• "'• ^'"' -i..-s rcnaincd in con :! i ^ ^ '^^Z} !' i''"" '"'"' = ='"'l'li^=>|'pcared fron. obsorvathm R,l,n.,.. ./c/ , '"' " '''"■ .^■^■"•'^' I '■^"■"""■'>' <-•">'"">. an.I snch •„, occur ''" ,'""'''''' ""I'-'-vcnu.nt are ' ^r..-.- ^. • . • • '"• '"•'•-"•'•cn,.c ,s so <.haractoristic that Stephc.,, Mackenzie in his recent lectnres n.al . i. ;. T'TT 1'"' '^•'''''^'" ;■< ".-i^'l-ng por„i,.ions nn.tnia." I n vs 1 ^l> ? "'''" '"' "'"^ ^'^'^^ '■■ "■'"••'' ;'"' i-l.-ven.ont was .naintai:- P • n ^ 'i .r ii;::''^ "\« -'^ '"!>(• reported rccentiv bv Hale Whifo I... • • , •""""'' '"'* <"'•> after enre by arsenie! '"•''•'"'' -""'' '"■"'f'' f^'^" ^'^von years Treatment.-In contradistin.'tion to the b,M>..(i,.;..l iv * e • "■^'^ ■-' tl.is disease tiio .Irn,. see.ns to 1, n ' "^ "■"" '" •■'''"'- ^•'"' ^ve n.nst n.ai.dv rolv It n v • '""."" r^'" ' "'"' '^ '"^ "" ="--'- - .-Inally i„...,,,,5,., j^,/ , " , i^;)'^". ^ ^'"" *-- <>f' Fowler's solution "'" I""-" -" P>-ol>^>ly do'.^ , r ^^'T-*-" ^^' -t well bcrno, I'll 2()S i)isK.\si':s or TiiK m.oojK f %- the patient is taiviiifj; f'nim '1\) to 2") iniiiiiiis tliiicc daily. In (tiic of iii> i;i„,« which rciiiaiiicd well iiir three yeai's I was able to push the (iriijf ii|ii,;;(i minims at a dose. Tlie |)atieiits oeea.sioiially do surprisingly well, and (, y_^,. offeet.s from the drug an; unusual. Some }!crsons, thoujih, are more sum- |,tl|,|p than others, and as soon as soineccdema of the eyelids or digestive (list m i,,,,,. are noted, t!ic administration of tlu^ drug shoidd be discontinued n ;ii! such symptctms have ilisappearcd, and then resumed at the dose ;ii .v],;,,! we left off. Rest in bed is essential at the beginning of the treatment, A li:^||| I,, . nutritions diet is highly desirable, tor the longer the digestive powers ||,,|,| ,„,, the greater the liope. As a ride, the eases are l)est treated at ln.me, reini,v;i| |,, the .seaside or mountain resorts being often iiiiil;ir comlitions, with apparently the same etiological factors at work, the iiiiii'ini;! in one case may be slight and in another profound is difficult to cxnlMin, The BhoiJ. — \o matter what the eatise, the blood in the sviiiptiiiii;iric antcmias pi-esents certain characteristics which arc more or le.ss constMiit. Tin' degree of oligoeythiemia may vary from a slight diminution in the iiniiiliiint' corpuscles in a mild case to an enormous decrease, almost as great a^ w.ikIi! !» seen in a case of |)ernicious auiemia. The amoimt of luenioglobin (Iicicmm's imri pasm with the number of red blood-eorpuscles. At times the individinil globular richness may be below ])ar, but there is never an in<'rea.-i'. siirli ;is occurs in perm'cious auiemia. The mimber of white blood-corpuscle^ isiihva\^ relatively, and generally absolutely, increased. The fresh blood-slide varies in its appearances according to the (lejriv.,MiN anaemia. Tn mild cases little or nothing abnormal may be noted, while in tiiej severer grades one will find as marked alterations in the size and >lia|K' of the) corpuscles as are ever seen in one of the essential aiiiemias. ]\ricr(ievtos. ni:i-l crocytes, and poikilocytes in such a case will be mimerous. In staiiieil >|Hvi mens nucleated red blood-corpuscjos can always be found, although thpswnli may bo a long one if the aiuemia be slight. Tt is the normobia-t that pi^j ' Vent. med. Woch., 1892, Apr. 1, 28. '' i> >urpi'isin(i "■'"!'! iiiiioimt Ik l«1ilon'lij|(re if it „ f"' iii'tci'iai pi-es,«ii; !'»'> ill tlie tissues '""""• "■iit'^iy, an( ["■'■''liiiliir clement hM«w (luring thi VuL. 11.-14 domiiiatoH here tl 'SKrONDMiv AN.I,^„,,s. tkf.vfralciicocvt 'if^ 'llpshas,ln,.sf|„.l '•y «'ftc" Ih> (liHinilt t., ,1 I ifl: 'avc Ik'cii n l<'«''t(ire of '<"! iiiav l)c til le rcMi It lai'eal varices, and in v ""»i,or in cirri l)c severe | "II anenrisn !ia'niori'|iajr(. j,, 1 or i:fi»i»iTliages we mean f| ■"■""•« "tlior cndit ion>' |rli;ij;ic diatliesi ''•■^•' "'•'•nrrinjr in individna'l; f'<'-i.s of tlic liv.T from tl I'c so-called sjM.ntan, \W tl eases of le (I'soph. Intakes place. ,pn'eklv tl !/• "1 {)iirpni '. scnrvy, and h S Sllflf.n|,,r f If; ii-oni a lueni 'Oils lor- inic (ili";einia. T\ ";"'••-' /'^ <•' lood '•""'■terial tension so lonercltl III ''oiistitii,.nts """•<■ siHlden and profuse the loss tl 'at death result, ay 1.0 .so n.u,.h diminish,.,! un,| s 111 a ti lt;il, l'«' rapid .shechling of th fie <>■ '••cater the d, <'U' moments, and '""ioea.se which f •^''" "'■ four pounds of hl,„„i i"',i;or of /lital SVIICO -aw seven and a half would prohablv I 'pe. )e V mnoimt, cs,-aped into the nleu,-. ' " '""'"'' "^" '''"'"'• "" ^..-u- ;"-''-"' -''- there are fW. ! ^ I^l^:'''^' '"' ;';' ;--"-".. On til "■ 'f "".'^ "'^""atoly roc-over. Thus ' " "'='^' ""'''I^^' '""' vot ,„„,„n,,,„d in one week fn.ii. '.■.;,''" '^"•;"" "■'"-' to lose over ..n ^""7"-^ - ".ay he nnahle .^ . , /'::';":':'"'^^ -^'-^ -.-"nl.ing. '■^ "' •■"temrrhagia fr,>ni the „., 'P' "^ '"'^'"•''■''I'age, as h, "^ or ironi cirrhosis of the ^^ U^T'"" . •^"•"'"""'••- '-H'n^chal ;- '"H- in the ..ases of female pl^ ::""'• ' '' '-">'^- - -thhehl, ^"'•'•I'agm. ''''''^"^'^ Mifienng from hhvdin^r pi|,,, ,,; -i';.-m;r'h',;: 'Sinr::!;!;;!:.:?^:^'^""-;'^-*' "-<-- ti. """•'•I'l'fTo if it oc,.„, ;,. , previous 1 " ' "•■•:'; •"• ^- ''^'vs aft,... the '"''"™' '"— I--.nit the ^W ^''Vr'"'"'"'''- '^^'- '«-orin,,; vl'ilo the h..emn....i : ' ... '•""'*''*' P<"r.va.scnlar Imcv I \V!it(.iT, and ,sal 1110 constituent lorrhage is still '7''"'- '■'^■'"onts, an.l it niav 1 ''M^ irxCtnUo ad hh ^N--'<^n. The ,.,.st s are mueh 'o ov(>ii M-eel, gonijr on. The all KS Ol' 'iioro (pii,.h}y ,.,.„e„.e<| tl )ii- oratioti of (h,. j "loiiths hefhr,. tl; lan oro is a "o eurj.u,s,.ulai. ,|ev,.| '"i'"'<>glohin ,hjes not lopn.eiit. 210 i)ish.\si:s oi' Tin: iu.ood. 2. An-kmia KiioM Inanition. — Here the plnsma, as a nilo, sudc j,, than tlic (lorpiist'lfs ; the latter may Ih> pt'osciit in aliiiust iiorinal iiiin 1. 1,, tlic riihic inilliiiu'trt'. Tlic iiiaiiition may Ix" diic citlicr tu a (IcticiciicN ,11 ||,. l'(t(Hl-sii|)|)ly (ir to (listiirl)aii('('s (»(" one or iiiDrc of llic variinis |iliy,-.iM|.ii;i|..,| processes by wliieli digestion and al)soi'ptioM are carried on. (iood cv niiili, of tliis form of ana-mia are seen ii1 <'aiicer of the (csopliajjns or pylori^ riH , and In llie cliionic dyspepsias, especially in llio>e ihw to atrophy of tli' -umi . mn<'ons ineini)rane. .'J. \ prolonjred drain on tiie all)innint)ns materials of the Mood, n<. uijiiii, what the canse, is accoiintahle for a 'arge <;ronp of cases of ana'nii.i. Tin lilood-im|toverishment of l?ri<;ht's disease, of chronic su|)pnration, uf in',,. loni;ed lactation, etc. may he i'xplained in this way. \. Toxic An.k.mia. — ITnih'r this lieadinmia. In malarial hlood one inuv wiiiiji the corpuscles jj;row pale nndcr the ai'tioii of tiu' plasmodial parasite. A |in.;. typhoid ana'inia is not nncommon,and in some cases the jrrade may 1m' mvh . In these toxanuMiiias the red hlood-corpnscles may 1h' directly deslruvcd .i^ in malaria, or the ordinary rate of their consumption may he inereaxil, The aiuemia aecompanyinfi; pyrexia is (hie partly to the direct actinn of ij, poison prodncinjr the fever on the Mood itself, partly, perhap>, to mphh iiii.|. ference with the workint;' of the hiomopoiclic origans. Treatment. — ( )l)vionsly, the first indication in the treatment will li.tnr the removal of the canse. In the secondary aniemias, as in other seciiiiilar atlections, this is nnf()rtnnately too often im[)ossil)le. .\ careful |iliv-ir;i! examination of the or|iiimiii, urine, and fieces by modern methods will often reveal the primarv rnusc, It mij>ht .seem iinneecs.sarv to speak of this were it not well knoun ilmi tin aiiiomia aceompanyinii malaria has been treated with iron before anv iiit(iii|ii was niaile to kill off the swarms of plasmodia which were the ;ictive ctiiisi .1 the blood-deirencration. In every case strict attention nuist he ^ivci) totii' dietetic and hyiiieiiio management, a part of the treatment fnlly a~ iiii|i()ii;i;ii as the administration of drugs. The blood in the antemia followiiitr .■«ii>liliii liaMnorrhage in individnals jtrevionsly healthy may be restored wiili ;i>tiiiii-li- ing rapidity, and often without any medicine. Ft is generally best to begin by confining the patient to bed. Fur tiii' aiiiLMnia, apart from the treatment of the primary canse, iron is the lust dni;. The particular fljrm chosen must depend in each case to a great cMi tit on tin idiosyncrasies of the ])atient and the condition of the alimenttn-y li:iii. In in- far the greater number of cases HIand's pills wore fonnd to be pcrllrtly ^ali- factory, thotigh some patients do better on the officinal tincture .4' the [nr- chloride. Jaiufway prefi'rs the tartrate of iron and potassiniii. lnit iktIiuii- it may be necessary to .search still further before the preparation .i|i|»r(i|iri;iie I'm •-ides tl miiiiy (iinditi Tlii'sc lion-le ;b li'iicdcyto," lcii('(H'ytosi.s ( Iciicocytosis 1 iiKiiiia. Ife lied t" the 1) litifjite, and, ; these cells, it '.'iviifcr ninnh till' lilund in t ;H'iit(' siippnra .Milch ligli t\i>t('iice of cl Ikt (pf leiicix' Iiifirc aliscess, I iiiii<'li as in id \\w ninnher o iiicyfi's at the "I'lriiDs arc ca| w'tivity. The tniiii these ca.sc iiitii'ciy (if poh ■'^pcaiviiig g( imt there will I prorKiuneed locj tiim in a certai iiimasc in the tlii> (itlicr hand, 'lit' ji'ciirral pro .It !lll. The Incaj )•(.; Tlii'i'c Mi'c, as \\ "tilers wliicji ro| I'l' rcs|)(.clivclv iiiitiire we as ycj pi'iKliicts cliisclv "f cpi'taiii tissue- ti'"iMliiit the pr '/'// /; I. /; I ('()v\ 'TOSES. •Ulo, SllfVc li,„|.,, I'lllill lllllll "IV I,, (l('tici('nr\ II il,, •IIS |iliy.-i.i|.ij;i|.j|| <><"• \\,\\ and niiil.'ii'iti mv (tllC IllaV «;|Iri, arasitc. A |in.:. Ic may In' MVrn. y (ll'stl'nycil ,i» ill iiicrca-i'd. ■cct aniciii di' li,,. ».-, t(i M.iiii' iiiiir- nicilt W ill lie till' (it her S(rii|ii|;ii' farc't'iil |i]n«ir;il ic jiiici'. sjiiitiiiN. iinary c-iiisc. It Iviiiiwii llini till' fore any alti'iiipi ' active ciiiiN .|' l)C L;i\rll tDlili illy a- iin|pori;i;it I ollltwillii >inllldl 'd willi a-tiiiii-!i- 2\\ Mil" '"ISO in liarid will |„. (;,„„,| •limiL'- will ...n.Hi.ucs ,,n,v,. cnici,.nt. Still, wl,,, iiiii-t lall hack on arsenic. riic ^waters ..(• (lu. vari.,„s cl.alyhcatc The Leucocytoses. '-^:'™-tx:::;:;;::;;r;^^^^^^^ -""■ n..- -ihii-,,., |„,,^„,,, ,i„„. „„, ,i„„ . i.' , ," " ' '''";■•' '» ""■■■■■^'-i- l.iB.-vM.«i» „Tnm.,.. „r(,.r „,™l, ,,„| i„ ■', ,'' l'l'>--.l,„,ll„. „,,v„,, „,.,,, , ' "■ "- '"I "'""■'l llicn l„ |„„. 1.1 1 „„.... V,,, li," : I "'''''r '"■"■'■" '""■'■ *"""' .i;;:ll't.,;;:„":;;!;r ';•;::; - -' t '; » ■->■ ••'■ ".^ u „f I, ,„.s wi,i,.i r,i,„ ■ ':""'.' " ""■ "■""" ' '- ::m-;x::z!;::;;;i;:: - -no,,,, j.,.„„„;r ,;;;',!;:;;;:; ^|"':ikin.r generally, wo aro al)I(> to -nuss :., .„,.. .„.„.„ i- , , "'" f''-" "ill be a IcMocvt.M-s If tlw , i ? •'^•"'^/l>«easo whether „r l"--->uvd lo..al reaction-- ;:. di 1- " T '" "''"'' ^'""•'' ''^ '^ "-' in a certain m,^ ^f tl "/i 'T''''''*' ""''' '""-"""t.'ry exuda- ^li •212 />/.%'/;, I. v/.'s oy 77/a; ni.. tivtly clit'iiKitaL'tic!, ami lliul llic |>n'-('iicc nC dead hactrriii siitlicos to ; .(,111" tor till' attnu'titui of tla- IfiKtifvli's (|{iimti). 'I'liis (loc."* not, liowoviT, 1 iihiii, the flicmntaxis nsiiltiiiij; tVoiii tlic iiijrciioii of -.nltstaii(<'< like tiir|H'iiii 1 , n,, that wliicli taki'ii |ilarr alxml n riaiii nccroiir iii'<':i-< in the li\'i'r an«l i . hiiiIi. ^Iinals which havi! Iwcii shown to hear no ciiicct rriation to niii to-oi-h rj^m. The Miibjcct, liowcvcr, in too wi*ion Ikm, \\, vonld cniphasizc the fact that lcncocv(osi> occnis, as a rule, only in 'ii-cii., which have a local reaction, and that its extent is |»io|)oi'lii:nat<' to tin hut,. so that wc arc ahic to say a jtrinfi in a e;iven infections diseax- wlietli. ,,| ,, a Icncocytosis will exist. Tims in a croii|ions pnennionia or in a sn|i|iiiiiiii\. pleiM'isy there will he a leneocyto>is |)ro|iortionatc to the extent of the liiii._' ,r pleura involved, while in typhoid H'vcr or malaria, >vliefe there is no iiiinknl local reaction, there will he little or no lencocytnsis. Indeed, in t\|ilii)i(| tin nninher of leiieocvtes would appear to lie diminished. This pecidiar clini;!,. tcr of the hlood in typhoid fever l'nrni>hcs lis with a ready method n\' di-inv. vviw^ coinplications in that disea-e. I have often in my own wards sim ^ Iciieocytosis appear precisely at the onset of a complicating pleurisy or pinn. nionia in the course of typhoid lover. The course of the leiicoeytosi;- in pMennionia is extremely iiit(iv«tiit". lucreasinj:; with the liiiijr-coiisolidation, it reaches its niaxiinum jii-l liiinr, the crisis, and then the decrease in the mi ml )er of leucocytes is as iii.irkiil ;, the fall in temperature. Thus, a lencocytosis of 20,000 to ."jOjOOd iiia\ ilinn within a few hours to (5000 or SOOO. There is some reason for hi'lieviii;!' tli;it| the jfivater the de;;ree of local reaction (of which the leueoeyto>is nmv Ik;] rcfiarded as an index) in a disease like acute lobar pneumonia, the less i. dio virulence of the ffeneral l)lood-j)oisonin<;. Thus Tsohistovitch claim- ilmt ii a pneumonia where the leiieocytosis is sliii'ht or absent the teniiiiiiiiiini i always fatal. The theory has received some support from von Jjiksi'h ; ;iiii if these results are coiilirmed, the blood-examination in pneumonia will bin grciit use tiir the prpjiiiosis. In one of my own cases, however, tliciv un- leiieocytosis of over 45,000 to the cubic millimetre just beflire dcatli, tli autopsy showinfx a croupous pneumonia of the ri<.dit upper lol)c, tiijrotlii with a fibriiio-puriilcnt pericarditis, with myriads of the lanceolate piuii mococci in the exndatc. In a recent fatal case there was a leuc(M\tii«i< „\ 114,000 to the cubic millimetre. The disappearanoe of the IcuciMytosi- i erysipelas is, as in pneumonia, also by crisis. In addition to these iutlammatory leiicocytoses, a large, sonietimc- iiioniMii^flMnnjr,.a| Ivninl increase of the leneocytes has been observed in the cachexias of nialiiriKiiiH'"""'"^ neoplasms. How far this hnicocytosis is dependent on the InenI icactinni the neighborhood of the tumor (necrosis and wandering-in of li indcvtc-) not as vet clear. ivitli alterati iiikI l)one-nii History - lo priority In nan I lie (iis( "riiiial leati \rUf\i' appear 'rai-lc had d 'iiMl llie peciil iiyly spoke 0/ 111 I'iorry .-ind |ivii'iiiic condit lili'. In I Mo I rvilia'iiiia to ill Jimilliiiri'jipj, ,j ilii'allirtion — . •'r« (if Kdiiibi \'iii|i()\v d,, III states that h lii'|ii'('seiiee (if I'Citlicr with ni Ki-iN where thr li'i'iiis that were j """ii-^ foi'iu in w '«• Ik'i'ii custom nii:i-, it is rare t( ill'' twit latter. ; M'lirdcd (f.eidx' inilt|ii'iMleiitly of liinii is, Iiii\v(>ver, ™lly,;iii(l there w '"I'l'^nwd headiiif 'iiliicr reportcc |fp.'initiis of the iilmtic eiemonl Ipvi'tlic name Ivn iis we sh; Definition. — A peculiar disease, assuming various forms, elKinu'trrizcil 1 a persistent increase in the number of the white blood-corpuscle-, associiitd \ 'listiiietion b "'"""'• is iiMiel, 1,,, Etiology. —X^t '!">^i«i! and JMctcri "'^'l'^^a.^Msalnios 1'^' l"ika-rr.ia is a II'IK.KMIA, iiU'k'OS to ; ,„||,. hoWCVtT, ( .|)|j,i,| (■ liirpciilli , III, ivcr iiml l.|ii|,!|. inicni-or i.m, ssidii li(i.. \\, only in Mix';!., ate III tli>' hilt,,. I' wlirlln I ,,)' ||,., ill a sii|ij.iira,i^ it iif tile hiji^r ,,r| iTf is nil iiii,r|„,| 1, ill lyi'liiiiij til, |M'ciiliar i|i;ii:i,. Il'tllllll III' lliiCnl, ill \V!iril> sirii ;i| )lt'iirif._v up jiiiiii. 'ntlinlh.rnh'oiis.Mviimiiir,.;,!,,.. • i "'"' ' '—I • - ' ""«'• ■■'■ '■«'"■'- "■ "..■ -|. Iv„,,,,.„| ,, History of t.h« A «.._^i_ ' i«tory of tho Am.ction 1 |>i iDi'iU' lia^ I I"' Hrsf \ n;b I "•••" """ll 'lisjM,(,,i and its Different Porm«. <> !•(■( -..Miiiil (i'ainiv ,,/• (I,,., I ii'irli' ii).|M'aivi| in \ ••V"i/.. II... inci 1' l> llnw (i( Mciallv ■'I'llnlljrl, ,|„, ,,| iscasc M va>c in tl •'^'11V(. it tl I'riii-ic liad (l<.s,.rilH.,| "VcnilMT, iHir,; ,•„(,,,,„, '•■ "liilc |,|,„„| K' name Icnl '•'■••"I tlial \'i,,.| iiiii lluw •"•"rpiiscic. icrol'tl i an liKw's ;iv>|M»ki' of it as kI KoI itiiii ' \^iis (Inc to tl 'V// ./, '_""■ vcar IScnnctt and ■'A l>iit tlioii..|it uin In rnnTv at Ipvifiiiii' t'oiiditiun. !|ilr. "■^"l'l""alionorilM, |,|,„„,. oti KXi'MsKy, u|,„ ,|,„ ,„,,.. ^.^,^1 ^j "•;;';••'-■'"■•• "•'•pMs. and a..,.,.;! "•'■ '"'^«> li.'id 1)(.(.„ „| III l«r,i, I lifiiiia to tlic (lis,..,. "«'•■' ''i' IN-I!)uas the ( •;:""*■" ^•""'■••"•"l additional lat I 'served ii'sf to diair "'.^' \V'Tc .Iralinir wit I "Kiio-^f flic di I a """";«'-'pl' on fli.. siil,j,.,.t, ,.| ill Ui(. tiill nwiiii.- vcar til "iscs, and jrjivc tl ~'"is(. diiriiiir iitli'ction I paper wliieli """"J,^ - is as mark,,] :,Bi..Ttli.-r with inarke,? i„vi,i '0,01 Ml y (lr„|iH«Ns, when, the spleen or lielieviiij.' tli;itHl"i'»is that \\ ocytosis may Inj^*'"" ''""in in which the 1 'i»niis ,,f the (lis \w to rec ■cas(.. ■"i^'"'z<' oi hiss of fn h IS ( Hluhr Pntlml :''.'"""'"•'• -niie smaller fi case; ii^* chaiaet ^■••""•"f ..*• ti.e lyniph-dand "■'lis of leiieoevt,' eri/i'd hv was inn. verejiredoininaiit. M <'i)iars i> tln'H'Ki'- I ■ll claiiii- that iij G toriiiiiiiitiiin ijj .'Oil .lakscli ; aid iioiiia will Ijc 'ver, thi'i'c u;i- lefoi'c liratli. tli( M" lot II', tni^otlii'l ianceiilati' \\\\m I I('lli'iir\tihii .. lellnirvlosi" ill ctiiiic- I'Miirninii^ lis of inaliirii liical iviirtiiiji i^ ot' iiiiroi'Vto) eharacfpi'i/f'ii hi iisi'lc-, ussociaw '«'ii oiistonijiry t it i-' rare to tind '"''^'-'"ill-row sliow(.d niarhed <■! ••"liiailll(h.seril,e(| '"'I' .series of ■II " •^P'^='l< "f lyniphatie, sol anire, ''"■'"■" '"'f<'''. .Sofiir, onl i' piii'e tiiriii ,,f •|''<'iiie. and mvel .\ll ii iiiyelojr- lioiiul, it any one of tl iMnrilcd ( Leiil .V <•"<■ ease of ,„„.,, ,„^.,,j les,., Ill ore I null l"''i''''"tly of hon,.- ''^/;"<' J^I<^i^«-I..T). and whetl •»«<'lioiis leiil^ o;fenoiis lenh..,.. pi'i'tieiilarlv of '<■'• a spl,.,,,-,. h.„k [einia has I lecn ■in IS, however, sharp! ,"'■•"•'•""■ '•''■■'iW'swoidd seen, d ii'iiiia can o,.,., |rali'y, 1111(1 tl mliT two h li lere would •'"■''"'■■'"■•'''•'"" fl'<"otli,.rsl,otli el ""'"'■"I- The Jvninl ir ^eciii to he ;, tenil "="""M'^-(I)splenic-n,veh, ";""■'■ '•*■!""■''■<' "" '■-'t<'.^»ii.al type ,i l<'"''y at present t ""i< ally and "f^''-oMpallh.|,ha.n latie iiiiatonii- 'y .ons and (2) lymphatic \,ul lias ipparatiis of the l)„w |l>'iii|tliiiti( and 1"' eharaeterized |,y ,.| •'I'liiia. •leiiieiits of tho sj. "P"'-' '■'! 188.-> recorded '"I'ges in the lymph atie i^''"iMiaiiie|ym,,ho,jj., '<"' were first involved—; a •"I'^e in which tl teii'viinr(>a| lyiiipli-element "•'■""'. ='^ we shall point ma ])oriii eiosa. Tl '" alllvtion to which h 10 s seem to h out when "' '"'ses in which th,. t pniiiarily alfectc-d iiisill ar and "•<" '^P'-ik of tl„. etiol, are )f peculiar A ilisti iicti on bot iy of the d is- priiicr is 1,1, K'h h Etiology— XotwitI woon aent(. and el,,.,,. """"•" f''an the latter, 'SS (•( '.nival ari( ''acterioloi,.|Y.a| '■^tamliim- most earefn! c| ,'';"•■ '^ "'""«t as nrofotuul m Iciik ti'iiiia IS a prof (specific iiivestijration the '^"'""■a is j.istitial.le, l,„t the '"'^"'' ■^f"<'.v and thoron.di his- new as it was half ^^•'•^■t of the eanstitivo fi.ct, ir ir; iidectioiis d '*'■•'"' "'••.^■a.uo. The idea '«oaso (KJehs, Osterwohl . >ux) lias. ! 'i I V' 214 nj.sj:Asi:s of the hlood. however, jfaiiied groniul during' the past decade. Histologically, thriv ;,|.o n;aiiy points of rcseniblanco between ieukieniia and the inf'eetions granulni,; , and this, tal'.en with the fact that the acnte cases running a fatal course in ,i il^ davs or weeks with high temperature correspond throughout to the (linii.ji j)icture seen in the acute infectious processes, goes far to make a micro-oiMaiii- mal origin ])rohal)le. An interesting case has been recordcHl recently by Obrastzow, in whirh tli. atteiidant of a ])atient suffering from acnte leuka'Uiia developed the sam<' (|ir;iM and (lied: this suggests not only infection, but also the possibility of direci iiiiii;|. gion, but inoculations with Icukicmic blood have so far been without ii-uh. Since Hi nterbcrger in Nothnagel's dinic pointed out that by far the laigiininr. ber of the acute leukiumias are accompanied by a stomatitis or by intestinal iiltcia- tion, we are tempteil to regard these not as complications, but rather as |>iiiiinr. affections affording a gateway of entrance (infection-atrium) for the Ii likn'm;, virus. A patient^ with spleuie-myelogeuous Icuka'uiia, who entered in\(liir in August, 1892, gave a history of a dysenteric attack two years previ(iii>|v— /. ('. in the snnnner of 1890 — but dated his splenic eidargcment only frui.i February, 1892 : while the splenic tumor nuist have existed loiiucr tliini this, yet the eases in which a leuka'uiia has beei preceded by intestinal loi.ni- occur far too fre(iucntly to allow us to regard the circumstances as racnlyair:- deiital. Troje has specidated further, and suggested that in the ehidiiic jm. kiemia.-. wliere enlargement of the cervical lymph-glands occurs lariy, fii virus may have entered by way of the swollen tonsils. At a recent incdicil meeting in JJcrliu, ' TroJe idvanccd the theory that the so-called |)m'||(1ii-|( i- ka'Uiia represents a leukaiuic condition, the forerunner of a true lenkitiiiii. AVhilc cases which have been delinitely diagnosed as pseiido-leuka>iiiia li;i\v, under the eyes of thoroughly eonipetent clinicians, been ol)scrved tn jia>- ii into true leukaMnia, yet the statistics are too limited to permit us to liniij that such a relation is constant. The j)eculiar disease occ^urriug in cliildMi under two years of age first described by von Jaksch (who named it "aiiaiiii:! infantilis pseudo-leukicniica "), and sid)se(picntly by Luzct, in whieh cliiii.iii. one finds the spleen somewhat enlarged, the blood oligocythien:ii' wiili an increased number of white blood-corpuscles, would seem to staiul in an iiiii:- mediate position i)etwecn the pseudo-lenkiemia of ITodgkin and Troib^iiin and till' truespleuic-myelogenous leukiemia : where tiie atfection is imt iiiniin- ated early by an associated gastro-enteritis, the blood may assume ilic rli;ii>- teristics of a true lenkjcmia, the so-called "hypertrophic" leucoiytcs luiii. present. So tar, no micro-organisui has l)een definitely ])roven to be the ean^r nt'iln disease: the monads of Klebs. the cocci-like bodies described by IJyidni llniiii- well, the iiacilli of Majocehi and l>icehini have ])rol)abty nothinu' to dd wiiii the atfeclion. Kelsch and Vaillard report a case in which they funml li;uilli, and recently Pawlowsky of Kiew" describes a bacillus which In' rlaiin- i- peeidiar to leukiemia au.„,. J, ,•.,„„ ,• ,. , o|Mi ; >ram.|y aiiv oiu- iiovv-a-.lavs lool--' , o 'T '""'' ^^'" ''"'•■'^ - '■ ti- I.atl.olo,i..al ..Iian,.s ,01 - ^ '2 !!;"'"' ^'""'^- "^ ='" "■^l"- i I-" -tos, 11 o,.,.nnv" (<• !-<■ more r:H.< uoro males, and the dis.^ase is nn.lo.ihtedlv " • "" "' "'•^■ or m ..ases eolleeted I.v BiHi-iriJ '^ , ,! "'"•'r"'" "I ^--'"^ = ^liiis AltlioMol, the maioritv of the .v.f '"'*'' '""' '^^ '''"'"Ic's. '■■:-. "0 deHnite inHneil ! . t S Ir;: '^^T ^'l" '-- =-' -'.Ho Mental worry and depression Inve ' T '""' ■^"'"^"••^- -'"'itions. Li-y of iniu.,-a Let to ^J^M. B^C:;;:^ ^^^'^Voslu, ean.es. A : -^ -f-'i.-t : 3 of my patients laid I I '""^.I'^'-r^'' ':"-^-"- •^ ""^ -f-'l.'-t : 3 of my patients la 1 ^ ^^ Z -''7^' ""^■"^'""- 'li-- to Lavin, straine,rti:„n.elve; , V t ""l^j ^ 'I 'T' ^ r"'""^ ^''^•''• -■^< '■•"■" a l.orse. It seems Mnit<.in,n;o.. ."Z'""' ' ^" !''" '■"•-t^ <"' a i^i"'< '-•"■" a l.o.;>. It ;;„ d i" "^^V;--';'^'"^' --• > to tl. em.ets of a - ",. a process of ,1;^;^;^ •""^•' -l>-'>al,Ie that t,...matisni hy it.df eonid n.l hi^tory, and over one-third of niv "i ' "''^''''^ '■'' ''''*' =' ■""'a- ..lalarial invM>ion. ■ ''■^'■' '""' i"-«'^-'o"sly Miffered from f" ''""='''■ patients the afi^etion most often develo.n .t the V . • tli'md. pnonaney would seem somexvlnt to nr,.,i; ' '•Imiaeterie, •'^"- '^ - ^f-t-a. ,.ass<.d thro:;^rt;r :::::,;:: ■;• ' '— ^• '"■•■asioi, a iion-lenkaM.iie .-hild Tint i.r...,.,l,V '^^"■"""■^' ^'«»'"'g "i. each ^'-•^-' I'v this same case si„ ' H. ' V" ' ""'■""'■' I''"-^'"^ '^•^'"^ Part is '-• '•''"<'■•"" n,::s not mfivpiently have Ieiika>mia aii.I it I... 1 1 -, , --. ''ars, swine, and mice (Bollinger, liCt,,) "" *'""'''"'' '" ''-«^«> Symptomatology.—Thc onset ^- , fl I • - '•- i-iious that the splenic Z!.\:tm JV'"''''''''''' J^"'-'-') ; liii'ii iii. 1,11V I'liiii) ill patient sntfl iic s itliat liHiii- and III idc' " that he first i"s iiiiich itiooiiv eiiieiice. foiisnlts the pi =' 'a''S'«' l>art of the ai.d, A^ a ride, it is for this l(ir ll'l' sv ''lii|ito|ii> o|(|,| '<'•' ,a"fti,i.r short of breath and has"„al "iptouis common in aiiaMiiia. I< 'vsician, or perhaps he not 1 occur early ; tl liey may even precede tl palpitation of tl pistaxis and .^ast ices If hear •t. pal- i'<»-iiitestinal le ( "'•^•'t of the disease. !:f " I in)i !'S t I 216 /)/sj:as/:.s of '/'///; liutoi). ic (icciirrciicc nf a prt'vidiis dysciittTv we liiivc already rciiiai On t 'aro iiistaiK'cs in wliii'li a sudden or kcd. I'atal liRMiiorrliatic lias been the lirst toMl. be 1m line (il the eases ot my series a buy who diei d oi' liaMiiateiiie lil'I'C ll:ii| en twii davs before apparently ([iiite wei and iiad j)layed in a i;ai: aerosse, Tl le syinptoiiis re i'erabie to the stoniacii, such as a teeliny; oi" ojjpi after eatin«r, nausea, and voinitin<>;, are rar ■Iv al )sent. he voinitint!;, in I'uri, often appears e; rlv, and is at times a troublesome featiu'e. The 1 )0\\i ;iri isuallv loose, diarrliu-a freiiiiently oeeiirnn-^ early m tl le disease : this to bo more Ire ('(iiien t in those eases in which the lymph-foUieles of || II lilt' tines are iiivo 4 Ived. The stools ar(> tiiin and watery ; in some eases then a true dysenteric ])roee; are ^ivn in the iieces. ill the colon, w ■ith te nesmib and niuciis and The 1 iver be comes enlary;e( Hut common, but mav result from o d at some stages of the disease ; jaiiiidi(v i> bstruction due to catarrhal iiiHammation nt'il,,, duet or to pressure .f tl 10 ir lands in the hiliis of the liver. Ascites m prominent symptom, a nd is probably due either to the splenic tumor or tn tllr )ressure o t' onlarircd inlands on the portal vein. Willcooks has dociilh^ leiikiomi e peritonitis due to new "; rowths in the niembrane. The lilooil. — No mattt'r what the form of the disease, it is the blood rNlllii- in [ition alone that oilers distinctive feature.- W e liave aireadv meiiiumcii ditVerent forms of lencocytes, and the relative proportion of those of form to the whole number in health. In tiie lieno-niyelonjonic forMi> ,A (Mcl k iLMiiia the mo: ;t striking;; blood-chaii_<>;o is the enormous increase in I le lllllllllif of the white cells. Instead of the normal proportion of 1 white i( KKH) red cells, tiie proportion In Icukicinia may be 1 to 10 or 1 t ,1(111 o ••), 111' till' two kinds mav occur in cipial iiuini)ers ; indeed, tliere are cases recni( which there w<'re actiiallv more colorless than colored elements. A blood from the iiiiii'er-tii) in a we 11- mar ked ease wii l)e mor<' or llrnp n| tlU'iiiil, reddish-brown in color, or in extreme cases possibly clioeolatc-coi often a sinirle tilance thronjih the microscope at the fresh blood-sl ored I'i'V Ide will -cltlr tl le tiiagiiosb M ich discussion liad taken place i)eiore we w(>re well :iri|u;iim with the aifectioii as wliite bloo'i cell to how great an increase then; must be in the iinmluini' 11(1 what relation of wiiites to retls is necessarv to nuMii'iiil leiiKa'mia. After this, when l^^lirlich had pointed out that ;i> ;l Vlllr tl;' lis c'osmoplulous cells wer(> inereasec reyrarding an increase in those i'< isease, clinicians weiu iwii'av ml in th lis as |)athogenic of leuka'iiiia. \\'\ true that they are generally both relatively and absolutely iiu no means alwavs the case, and besides, we nil' It I- reased. tills i- liv| n"ist not ibrget that tlii'ir iiiiiiiiit mav health. The lymphocytos (Plate 1, Fig. 1, h, b, h) are ivh.tiv in number ; instead of making u[) 20 or .30 per cent, of the of white cells, these small mononuclear ibrms may he reduced tn less than 1 1 (■|\ illlllllll-llril wltn'r imiiil'i-rj )er ce nt. The leiicoevtes \\ith polymorphous nuclei and neutropliilir t;' (Plato 1, Fig. 1, (', <) may ho present in normal [>roportioiis u-ii;illv raiiiiiis IlllU- |L^-j I tt -Hi :te titn -t-hr • be as i>-reat or even greater in c(>rtain other aifections, and even ;it tiiiii'- iiiH - liirUcd. . iici,, tlic lirst -. 11 i. ■matoiiK'-i liiid ill ii jH'ai; ■ ,.( ; of ()|ipiv-. i,,ii initiiii";, in I'ari, TllO l)()\\i i> ;|h so: lliis i- siiii cs of till in|..„ (' cases ilirrc i. KMis ami li|(i,i(i jaiiiidicc i> II, i| niinatiiHi ui'tlir scites may Ih-i 'iiiiuir HI' til 111,. lias (locribcij n lie hluiiil I'Xaiii- • iiiciitioiu'd till' [' those lit' I'licli (' t'onii- III' Icii- ' ill till' niiiiiliiT vliite III :>i){\ ,,r if 1 to '), 111' ih, scs reeorili'il in ts. A (lrii|i,i|' or less tiu'liiil, j ■Colored. \'irv -slide will -iuli' well aei|ll:lillliii| 1 the iiiiiiilicrni' irv to eon-tii'ili'l at a> a rule tl:i'| Weill artaiii cells wliieli may lie said not to occur at ail in normal Lidm], Tlioc cells closely resemble the larji;e inononiiclear leiieoeytes, but ditl'ci IV,,;!, tliein in -cveral important parti(!ulars. Klirlich has studied them will care, and first described them as hw^rv m til ononiu lear I onus eontainiiit. UIVJl ickly-sct e-or neiitrophilic uramilation. lielieviiif:; that they ori<>;inat(il in ih,. boue-marrow, he has named them myelocytes. (Plate I, Fig. 2,;/.) in mi,, of my eases, in which the blood was e.vainuied by Thayer according to Kliiii( h'. method, these myelocytes at one time niav a in tl lese the cell-body ^lightly thickened iayc.'r of cell-suiistanee. Mito: d ]\Iiiller has shown tliat nreciselv i> an -innlar eel and k; iryokinetic figures occur in the 1 )()ne-inarrow. Minilar (vlls also been described earlier by Coriiil and were iiained by him ci'l/ii/c' la ■iJiil. urn. .My own study has convinced me of the importance of this | leenliai' ci form for the diagnosis of a myelogenic Icnkiemia, and I have no donlii tli;it Fhrlich, Cornil, and Miiller have been deseribing under dill'erent naiiKstli same morn hoi oii'ica 1 el ement. Occasionally there are leucocytes in the blood of leiikfemic patient^ wlurh contain basophilic granules; they are by no means always to i)e foniul. A-;i rule, there is no marked oligocythiemia, the red corpuscles rarely guiii;; lnwu than two millions per cubic millimetre ; the amount of Iwemoglobiii eoircsiiiiini. to the decrease 1)1 e or is reduced in a somewhat greater proportion. ibh \ iclcalcd ivi ood-corpuselcs are present, and, as a rule, in eoiisideral)le immliers ; lliiv;ii\ latr chiefly iiormoi)lastic in type (Plate I, Fig. 2, /*), but megaloblasts I'^ig. 2, /) oct'asionally occur. ( ascs with the blood of the type of a aiiiemia have subsc(pieiitly develoj)ed a true leiikieinia. In the ])ure lymphatio leukicmia the blood-condition is quiic Here one never meets with the enormous increase in the miiiibcr of whiti' Irl'MK'liill. Icl'clit. 1 tu 10 cells deseriiu'd as characteristic of the ordinary form, a proportion n being rarely exceeded. The increase takes place solely in the siiia nuclear elements (lyinj)hocytcs), the large mononuclear and polyiiiKJcar fimii- iiiiiiiii- beiiig relativelv grcatlv diminislied in number. The eiiori nous (ll>|l|-0]Hi|'lin|l is well shown in a ease described by Uthemaini, where ',)'■> per cent, ol' all ih white cells were lymphocytes. Kosinophilous cells and nucleated red corpii- cles are rare ; mve loevt< are as a rule, not present unless there be an asMiciatiil disease of the boue-marrow. |llltr i|lll^ut'iati'(l i-I':vk\i:mia. -Iii.-it as tl 21 !» i»'i'<' aro Milxcd forms oflrHil, imiy "in.on as yot not mid Miku.mia uas first p„i„t,.d „„t bv C'alidV • tl wv.smY.ms Icnkii'mic blood will "t i.._ the nhite .dis oV tl„. blou.l MS \f I'liiiiation is easy to find ' "onnal spci.iiiK.ns on tl particularly noticeable wl cr- in ion polvmicl , smco wc know that of tlic 1 '•' warm stajrc. The iiiii iiits to be mentioned !t'ar fbrms which I are- lave active amoeboid fiicocytes in health it IS nimsnally dense fibr (Ijtl ■ill network b"t IH'anmo,. of Charcot's octahedral cn-stal i«' abiindance of blood-phitos ^"wii the oorpiisck inovenicnts. ()t| ler "1 many cases; "id (;}) the ;i'lit Cor a short time r/(c ( 'iiVHlittory S,i.sfaa.~li T'^tals in blood-slides which have I K'OIl ilif Ilea I t.altl loii"!! the i^* Hire that the e.ila.Ke.1 spleen. The pnlse, thoiitrl/l |;iiiil ol low tension. (Kd 'l>;'X-lH'at may be displaced coiisid ■«' are symptc.nis referable U 'I'abl J,^" large in vohiiiui, i .\' upward bvlh nil' toward the i-e from the nasal 011(1 (,f the (I L'uia of the aiikl isoase. Hi <'.'^, or even In two cases which i I I imic(.iis membrane boin.r tl eniorrhages are conn •s usually fmpient, soft, general anasarca, imiv lave seen fatal I K! most fre(|uont. i"»" iu all stages, »>in.ysuspie,onof ancM-sting leuk '••'hral apoplexv was tl kioiiiia. liieiiiatomosis oceiirred before tl H Oil -I'liiic retinitis" [>■ n;i! Olid, \ .vs.— aiioti i(! cause of death i lor manifestation of the I ii'uiojjtysis and h " one case of niv ser lore ii'uiatiiria are 10." Tl le The shortness of breath is d ''■';''f'<"' ^'\ving to the oligocvtluemia. Tl '-"•any symptoms until toward the end """"""" ""i.v «irry off the pat lieiiiorrhagic tondeiK uc, as a rule, t(, defi '\ , •ililc I It-' iungs are scared v ICIOllt K.'llt. of the disease over respoii- ', when U'dema or li ^vc t x«v|.t t\Hi cerebral symptoms, si.cl winch are assodated witl 1 as headache, di^/i ' ariiomia, the central iH'ss, and faint- ■""""" '•*':""'''';'"^'<-^'"'- Wohaveahiad uorvoiis system d "lililCIl ('(11 iia fbllowinu- | l'"'"'i'"' i'''iinitis, which is I K liit'inorrhage from one of tl y spoken of the oceu oes |f:l!(ilc,-. ffilinlis '"It tliore arc al,- »y no means rare le cerebral f'roiice of vessels. "I ro,iiid-ee in tl ^'» ■sometimes true leiil ', consists dii(>tlv of I licariiiM- is iV( K' retina. Kii'Miio now growths with The laMiiorrhagio lfa>c, As Ml as 10: iiiii'i'vals ,1 a riil<. ■ }0 ■quontly affected, and di,,f ', the ^'iiipcraturo is i '•'""""•^ optic noiiritis is not 'less may ( aggro- c'omiiion. or lO.T F., but periods of "ore or hss elevated ■OHIO on early in the di "oniial temporafun J>yroxia may alfernat< ranging at tii 110; as wit! ' J'l'olongod I nil .ill 'iiii'H' may be all iiiriiial iiicrea Juuiiiious, but it is bv Wim's may sfaiid in d ''<' '" (he aiiioiiut of "o ineaiis always ui'ic acid o.\( 'J^l lore IS I '-Oct relation to the spl •ivtcd, which Salkowsk It'UiV oulargenient. Tl J Ik' cause 1*1 220 DISKASIJS or THE lilJiOl). I III of llic persistent priapism wliicli ol'tcii occurs i-; iinkiiowii. In a case roc i,|,.,| l>v Kdcs it was the first symptom; it may persist for days or even .,|:. (IVal)o(lyK yV/c Sp/rtii. — Wlien a patient siilfcrint!; from lieno-mednllary leiil rini:, first consults tiie piiysician, the s|)lceii is nearly always mncli eidaro'cd. mid. tliouiili nsnally somewhat tender, may jiive rise to very little ineonveim n,.,.. Its i)urdcr will he felt in the left side of the ahdomen as a iiard, .-c il, rounded lump which rolls over the fin^^er-tips with each fnll inspiration. Tl,, oroan when much enlar<>('d may extend as far as the navel, and I haw rvin seen it fill the whole left side of the abdomen and extend into the riuln ili;i,. Kio. 12. ("use (if I,it'iiii-nu'(l\illiir>: lA'tikniniii-clKiwiiij; t'liliirKOiiRMit (if si.lccM. fossa. (See Fig. 12.) One can sometimes feel a friction freinitii- dvcr tin- tumor, and on auscultation, besides the rub, a "splenic sontlle," ^y-tnlir in rhvthm, may sometimes be heard. (Jerhardt has described a puls.itiiij,' s|(k(ii in one of his cases of leuku'inia. That the tumor is the spleen is, as a rule, easily decided from tlic i)na .l,n„nislu.,l. As nn^I.t l.o .xpctcd, prossnro-.ynn,. .„. . w.t,„.os ....„,, sue ns.lisfvssaft..,. ..tin, ..,• nl>s!,.,„,i. ..ftl. ".' iron tl... latter „t wl.,c-l. ,loatl> has l,a-.. k„..w„ ,„ ,,.,.1, ' wrtlu'ly.Mph-olaii.lst.. beinu.'li ,.„lanr,M|- att.Tt ,.l , i ' , '"■" ''"^ .1^. tlu, h „p„u. ^lan.Is may innvas.. i„ si/., |,„t .v.m tluM, it is th. s,n J I ...1 u,„. wl.u.h are ,.nu..-ally ali;..,,.l. ()..„ ,„„,,, ,,.,, ,„„,. ,,„., ,„.,.,",. .I..M, as are tmnd ,„ the pseudo-loukic.nia of ITud.rki., I,, mm,. ::|Un.ia tho ,y.,.ph.,,a...,s a. .......aHy ...a.-^i;';;;;, t!: '; ;„;:';:;;: .^ ^I..l.tly so, but the d.soase is a ve.. .-a. one i,..„....l, and', Is'tlX TiM.ro may bo sca,.-oly any tendorness over the bo,,,. d„,.i,„ li,;,, ,.hiei. at ..o,., show to „,ost adva,.eed ..,a..,.ow-ei,a„,es ; th.. patie,.,s ometim^ ;.n,.hu,, who,, the sten,,,,,, ^ ,„„,,,.„, ,. „,, ,.„.„,^,. „, .^^^ ^ - ,.on. Invgnhmty a.ul defbn-.ity of the ribs, the ste,.,,..,;.. imd ...h., H t '"'^ "••«'^'"""lly '-..suit fro,n the leul<.e.„io bone-.-han-os Morbid Anatomy.-The body is pah- a.,d „,ay be uuul nuacM ; edema h„a n,ps,ea of „s,o„s a.-o con,„.o„. Wl,e„ the hea.t or aorta is ope ,^1 he .1 .s usually fo.„,d to bo eh,tted, the elots havi,,, a pee.diar ..-ee,, Li,- 'll " hU, ren ,...1,.,. o„e of the fat of a t„.-tIo. Whe„ tl,e ine.-L i,. th,' vl i . ,n..„ts as bee,. ext,.e,,.e, the color of the ..lotted „,asses ,„av be veHowisl h nto, a„d .t has n,o..e than ouco happened (as i„ a case of Virchow's) that the |olH'rv(>r on openiiijr the r irht auricle li'i^ Iw.i;-.,. I <• , ^ '""' ^"^ IWo>olnn,.„ abM.e>.. J .. la,-j.e a.nonnt of bloo.l in the hea.t and vessels ;..,. eworthy fcatn,-o; n. one of ,ny .uses the heart-.-han.be.-s alone o .a.no.l bloo.l-clots we,,.h,n,. G20 ,,.-an„nes. All of the vessels u,,,. en... "l ". t . sune way, the po.-tal vein Just above the union of its b,-anel,es n^a:. • |iii;rn em. ,n circumference. '"<-a,sni The blou,l has been examined chemically by various observe.-s with result. wlH. do not altogether orrespond. Sci,e,.cr as ca..lv as 1852 found l.C I -ulnn, laet,e ae..l, h.rm.c aci,l, aeeti<. aei,l, Icucin, an.l Urosin p,.esent, , I .n.n„t.o,, ..f the alkalescence of the bloo,l (it is even acid at ti.nes) ha b«^ l"I KK.d ., be ,lue to organ c acids. The presence of a notable , ant tv of Tl. octahedral crystals which a.-e found i, blood which has been allowed -«ta„,l lor so„,e tune we.-e Hrst describe,! by Cha.vot a„,l Robin Tllir l..:.ny ,.as yet unpc-fbctly un.le.-stoo.l : s.une h,.. thought thenr^e t,.'^ l-« Gaingoe claims that thev re,n-cse„t •, „h„s„l,.,f,. Ai : ' -k;™i ., ...,n,.i„„ ,„■,.,:, :,•;„';::,::;:;;;;;;,;"„;:;;;; "'"* ' '""" ".. ™an,„„„s ,1,.. I„,,rl i, will W fi„„„, |„„|,„| „ „ ,,.; , 1 '(( il 1 li t / 222 DISEASES or THE liLOOD. <|ii('iitly present eeeliynioses, and lenkieinie new }j;r()\\tlis may exist tli 'v a. well iis on the peritdneuni. 'I'iie cavities of the heart are, as a nile, dilaicl and the nivocardinni soft ; if the papillary nniseie.s bo teased out, a nwii-jati' grade of iiittv elianji'e is evir the heaviest on record. On section the spleen is tn'in and tough and ilicMir- fiice a reddish or purplish brown. There may be throughout the organ \\\v\mt. rhagic intiu'ctious or areas of a rusty, reddish-brown color, the siti u|' ,,|,| extravasations. The Malpighian bodies are not prominent; indeed, i Ik \ an. as a rule, not reeogni/able. On the other hand, grayish-white, well-dctincil lymphoid tumors may occur throughout the organ, contrasting strongly with the reddish-brown ground-substance. U the spleen be seen in an einly >taL'c and before the disease has jirogressed far, it will be found softer, and ilicic will bo swelling of the pulp and proliferation of the cellular elements; ru|iluiviit the spleen, it is sai( the air, LEVK.KMrA. 223 l.oa an.l f.x..l.al>I v h-,; .l.alin. h .ll-."-lns.ons N„..loa,o.l red I,lood-<.o,,.„s..l..s al..! .osinophilons .• M. ro - an. J he fnnction of th.. hn„. ,iant-....|ls of tho n.a'rou-, uh ,.; ^ Ikilth or disi-aso, w still unknown. >'"in(i in WlK.n.s-c.r thm. an> lyn.phatic dnnonts in th. l.ody th.Mv n.av 1. lonk^ennc e n,,,.s; tiM,s th. i,ynu. ,hu.,l, tho solitary and a^ndnat-d fi.llidos i "'t.stMK tho t<.nsds,tlu. lyn.,.h-folIi,.I,.s of th,. tnn.n.., pl.arvnv and m ,ntl ' ^, ^^;;^: '" "'" i:' ;-• '-n. ti. ntti. ..oii..;.tio;. ' of iVn;;i 1 :t; I . .1.0 ddforont o.^ans, „, the lungs, live, kidnc,-s, etc., n.ay undi-^o pLlilb :: TlH. liver is frc.,,nontIy enlarged. Weh-h has deseri[,e,l a ease in whieh ,. wo„l,ed over h,rt..en pounds. lIistologi,.ally, the enlar,,.n.ent is see, ^^ N- t. a dd h.s. l.„ka.nnc ndihration; the eapillary eetasis Is extren.e, and he j.J,n.ns oJ^Wcells are wi<.ely separate()(|.eo,-pi,seles had nsen ' "A' H. I'. Muller, Dn,, Arrlnr. / ,W„. ,/,^., ,„,. ,,,;• j, ,-_ i|lllKl-('(lM III I ml I -• I'l 22i nisKASKs or Till-: iu.ood. f If r t ill iiiiiiilK'r to 3,rjOO,0()(), iiii.l the liii'iiiogl()l)iii luul iiifmiswl to 44 jut wit. Could one iiiulcr tli(sc (•irciiiiistiinccs, woiiij; tho (Uhc lor the first tiinc. Iiuw inadc till' (lia>,m(wis of IciikiiMiiia? It is liorc that tlic value of Klirlnii^ iiicdiods is wtll (k'luoiistratcd. A careful coloi-aiialysis was made In my assistant, W. S. Tliaycr, at diiU'icnt times, and the estimates given in tiir fnl- U>w\u^ talile were hased oii dillerential eouitts of ut least one thoiisaii.l ku. oocytes at eaeh examination : N"i niiil Nnv. ',1, .Inn -19, F.'l.. 7, K.I.. H, Fell. '.ll, K.-r. ■>, Illlnnl. IH'.m. IH'.ll. IWIl. IMll. IHIll. l.v.l I.VIliplKH'Vtt'S .... . 20 :m)'/o ■Z.\'/c (».1)(1% \.r>^h - 1 ,c tu»;i 10 ;; rolymii'loiir . . (i()-7'> 73.8 70 8;{.i> 84.7 83.2 T\l .Mdiiiiiiiicliiiriind \ I'liiiisilion foiins 1 . . ti.O ■t.f> ;{.o \.r, 2.1 2.r. •J.o Ivisinopliik's Myi'locytcs . . 2.4 . . ■1.8 14.7 215.5 4:2. 8.6 1.6 8.5 3.0 4.0 1.1 1.7 I Now, on Feb. 2I.st, while the enornions enlarfjement of the spleen wdiiM have made one think of leukioniia, yet the mere numerical estinintr u\- tlic examination of the fresh blood wouhl have given no hint that a l(iiki..|iiic i)rocess had e.xi.sted. As will be seen, however, by reference to the above talili, the dried and .stained specimens still showed 4 per eent. of typical inydocvKs and this would have hinted at a previous existence of, and the pcssibility ol a return of, a lenka'mia. An enormous leucoeytosis might be mistaken for a leukremie enmlitidi,, Imt niav be easily excluded by the .stuily of stained specimens; in all unliniuv leu'cocytcses "the increase affects solely th<' polynuc-lear neutrophilia The enlaro-ement of the spleen in chronic malarial cachexia or malign;uit di-cw mav also be ditfercntiated from hsukiemia by the blood-examination, li iii-i tainlv is not ju.-ititiable to make (as has been done in at least one cmm' of lui-l kfemia) an exploratory abdominal incLsion to examine the spleen licll.iv ilic blood has been carefully studied. The pure Ivmphatic form of leukremia has to be distinguished rimii trin- eral lymphadenoma or Ilodgkiu's disease; in the latter, however, the uImikU are found in much larger l)unches ; and, besides, the blood-eonditiuii i« ' lymphatic leukiemia (piite characteristic {ridv supra). Course and Prognosis.— In the splcnic-myelogcnous form the |>rnirn' slowlv progressive lor months and years. Recovery oeeasionally ou'in>. Imt I this is so rare that when the diagnosis is once established we can expect dci'li almost certainly within five years, and, as a matter of fact, the niMJeiityof cases terminate fatally in two or three years. Certain symptoms. :i> liiiMimr- rhage, high fever, severe diarrhfca, and oedema, will indicate a nipiil coiir-cj The progress of the atfection is very irregular, and there may !..• tniibldit intervals'^of comparative health, which encoin-age the patient I, ;. time, niily to be followed ^oonor or later by a return of the .symptoms. I liavn kiinwna patient (Case VIII, of my .series) with an enormous spleen to uvt iilioiit tnrj months, attending to a light business, when his blood-count showed a ratio uff 1 white to G red cells. ros ij /■A7 7,-. /;.)//. 1. J -'livt: !;;::■; T:::;-;;;!;';,:;;: ■'"""- - ^"' ■■'■ ■ ""' ""'-'«'■ K i,„.„ „:,..' :„:;■"' '■"-" '^ ""■ '-"'< ■"■ «.- '-:"l'™l ^•P"|.l..vv ,„,, „„.,„i,:„ ■ "s "'■■'">■""«'■■"■ 'I- ■! .-. , »■; ■■'/ « "'• '"' ™-^ a,:;;;:: i^;,:'"';.";""'^ ■ '■' --^ ■',.. ' Tl... »,.,„.r„l l,,„„l„„i.. ,,„„, „■„,,,',': '"":'""■ ...i..r-..-™w,i,.,w,,,/v :/:;::;:::,;;:;;:: "'■''' "■'■"'-■ i.v;-«i., ■'"^ I '"•<...-i... i.i.y,.i..i„„ „'■■''; i"'. '"""*■ '" '">■ "■■" i- atl,„li,.M ,„ ,|„. |,vgi,.„i,. s„„-,„„ I , ,■ ""'""■""" '" >'">' l"'"'-"- |...li .1- „ll ki,„l,, ' ''" '■ "'"' '""■' '"""> «""y ."..I m,.,„al ,*.S;::.::„rr:,::: :,.;:• ,::;;::i/'f- -';« • l.;H-ini|)r()viii(r, ;it i-jisf f',,,. ,, *:,„„ ,.. kmiii-, m my Jiands, most LU..I, since the o,„.i<.„s n-nus , , ' "''''''''^^••''^:-' "'' ^' --'^ l» parti...!;... . pati.-nt, u ho l.a.l hcon n.nH u ' , ■ ;'"'""' """ ^'^'^'^ f.".i".u.a .,vatM,ont aM.1 net to hi. ho ,, V ''"""" '"'"'"'''' '"^ '''- M,,ho l>lood-connt .showi... ,„a,-l „ '■'''",""' '"""'''■^ '''^"' '"•'••'- Jrc rcnrlR..!. ' " ""' '""'''' <'"« proeantion, till Jarg,. doses I .r,,,„„,„_,|,., ,„,„„,, „f „,_. ,,„7 , .7' "» l"™'"""t' i» tl„. „,„,,, I" '•.■»tv.i;..,r li,„„f„r l,,,|<.,„i,, M ' ' ■■'l'l''"«"'".v l.» !«'.■.. I VoL.ij.-,5 """' •'^•^•^ "» good, and is now srarooly k^ I y 22(J itJsnAShs o/ tut: nij)(>j). '!: t ever advised. Notwilh 'aiuliii^ tlir tact that the disease is almost alwas |.i,,. |(r>"ssivo d(.-^|)it(> tlie most .an'fidly (iii'ected treatment, vot the pructitinii. i iim du a I It d.al to relieve the distiY -mj^ symptoms. The stomaeh ti .iil,|,. uiid the .1 laiTliu-a should In" attended to. lluMuorrhaps are lre(|nent ui I n ,• rarely dangerous, and are to l)e cheeked hy the usual methods. Mttli m 1» done to relieve the «lratry;inK feeling in the lel\ side; the pain may suinnii,,,. he so severe as to call lor sedatives, but their use shouhl he delayed a- l.nm a. possihie. In the use of purgative medicines much caution should he ul,.,|v,. Hodokin's Disease. Definition.— An atl'eetion charm-terized by progressive hyporplaM:i at' i| Ivmphatie glands occurring with aiuenna, and .sometimes uoecmipanicd hy il,, (ievelopment of secondary lympliatic growths in various parts of ilic h,„|v, History. — The disease which now hears his name was lirst dcHiilicil |,i ll.idgkin of (Iny's Hospital in 18;{2, in a pa|)er entitled "On 8(.nie Mnil,;,| Appearances of the Ab.sorbent (Jlands and Spleen."' Morgagni ami (,ilii.|j observers had before this mentioned cases with enlargement of the l\ mphaiiJ glands terminating fatally, but the aooinpanying histories are too niraon J allow of any judgment as to the nature of the maladies with which tiKydcait.j A number of the cases described by llodgkin were undoid)tedly e.\;uii|)ii>nt I tid)erculous adenitis, but at least four of them were genuine instance ,,1' wluJ we now speak of as " ITodgkin's disease." The atVectioii received its iiamJ from Wilks in 18(Jo, when he .cported a series of cases in whicli, t(ip'(li,fj with aniemia, there was enlargement of the lymph-glands with gn.wtib iJ the spleen and other organs. Virehow described the histology of lyiiiplhKuj t:nma in 1845, and later Cohidieim^ discussed the pathology of the alVniiniiJ giving it the name of pseulaiirj to leirka'inia. The studies of these investigators attracte«I general iittciiticm i.| the subject, and the literature is voluminous. UidbrtUh.i'vly , miiiiy «kJ described have to i)e weeded .)Ut, a^ (he alVection has been iv;. \v<^\s m\\ founded with tuberculosis, true leuk:emia, syphilis, and iienplaMni;'a of i lymph-glands, r.illrotlr' endciivored to distinguisl- these growth-, wlii.h li| named malignant lymphomata, clinically from the local non-infectiw lyiiiiilmj sarc( -.ta, .stating "that in the former there was no invasion of the |M'ii'laiiil ulart., ■('•■. while in th<' latter the new growth did not conline ii-rlt'tn''' glatuts. •." ..les( .■;,>ion of this disease given under the name ..f wWu the great i^;.*'<'..h clinician Trousseau is so accurate that the all'erti.m i> nrnj often lei- yiv ' tr as tiie " \- ado-h'tikicmia of Modgkin-Trousseaii." HanvKJ introduced the term Ij/mph-athnih; and the number of other syii(iii\ moii.-Mnij used is very great. Thus, Wilks has termed it aiiffiinia lymphatica; WiiLMioj and R. iSchulz, "desmoid carcinoma;" Mur.sick called it lymphatie ea.licMal > Truruiaclinux Mnl.-(;hir. Soc, v.,1. xvii, 1832. ' Vi,rhwr,< An-lur, I!.l. x sxiii. |). V>1 ^ JkUriiye zur PathdoijUclwn Hixtoluyif, Berlin, 1857. JifUKiKLWs />/.,/ ,,v,. 227 liiniik ",.a,.|».xia siiis l.'iirM.ii.l,. •" » l>il., < .1 ■\y .lUus. i,s no, „„,..„,„„,.„ in An,...i.,, Etiolo«ry.^At,„vs,.neu..,„„,sM,llnw,h..'„.nn ....ml I 1 • .-i. an.i ,ii.; t .litall (, : : "'";■'' ''"'"'■•• '""^^ -■■" '«• -••-^"•i-i »itl. tlu. Jifmitrnv of no,lirkiM's,Ii .... V' • ""!""'"'" •"'"•'l-'aint hinw.lf I 'i'i'-. i-v,.i..,. H ,tt!:;;;;^;:;::;:'r-'-^;;;;''';''''-''''<-'^.'.^ ^.l.e....v s..v..n.I i„sf:.n,.„s n..M in whin ,.;"";'"' '"'* "•"••-"'^• |li;inj:.' lias taken pla.v. '"'''' "'^^''''vatioii mid, a .vi,n„.,r M, persons „„.),..■ /;„,v v,,„-s of a.; T L ; '•"'"'.'■:'"■"' n.ia an.] lound tul.c- Jlit't;;:;:::;:;::;:;'; -r ^ ••- -n-o^o eases i. ..,.. ,.... H-i'.. septic inf;:;;;;* ^ :;;;:' •; 7"? -'^ '^^ t"-'-'-'--- -Jt^. a ^'". my uanls, ha« n.a.l,. ont .... t in 1 V "^ "'' ""' "'^^'""^ ••^' =' '"^'^'^ l-nntos wl.iel. possiblv stan.l'in a r,ns..| ' J ' ''"/'"""^^ •"«y '^^' ani.nal l-.vd .naterial fn>n, Another .; "^''"iV? ^'"" '•^^•^••^-"- f-ter l.e ""l"-,lnl,.s in tluM„testi,la ; iV ; r^t' '" """"^ ^''^ ^=""" '>'"''- J"'l'"-"=n I nn-aute partielc. wi I "l. ^'""'^ '!"^''^^''""«'"^*'"' "f-p.-ot-plasn,, I "'"■•' «itl, ha.n,atoxv]in a„taii(r nf variable eonsistence ; sometimes it is soi't and juicy, while in other caso it mav be firm and drv. The tumor is nsually grayish-white in color, and tlio-i caM- in which caseation has been reported were probably not eases of psc^ucL-li iika- mia at all, but rather a tuberculosis of the lymph-glands. Pyogenic pinci-M. sometimes occur, especially if the growths invade the skin, the sui)|imatiiiii here being of course due to a eoinplicatiug infection with eoeci. I'u~ ruinia- tions in the deeper sets of glands arc rare. The glands of the body most frequently affected in this disease luv tin superficial chains, particularly those of the neck. Not infrecpiently, at ilif post-mcrtem examination one is able to trace the cervical glands as cnntiiiiicii- ehains running down along the trachea and large vessels to join the axillan and mediastinal glands. \ext to the cervical groups the axillary glamU an most frequently attacked, and then the tnnior-niasses may extend in nnilcitln pcctoralis major and minor nniseles and backward beneath the M'apu'a. hi-, ot'ten such masses are formed from the glands in the groin. Those rax- an ])articularly interesting in which the glands in the thorax are inudi ciilaiirnl and press on the vessels, or even occasionally perforate the sterntun ami apiicu externally as a tmnor-like projection. The retroperitoneal and mesenteric — in short, any of the lyni|ih-i:liiniL- dt the bodv — mav be involved. The diagnosis when the abdominal gland- nlmn are implicated is of coin'.-e extremely ditfieidt. I remember when in (Idinaiiy some vcars ago seeing a leading gyna'cologist perform a lapamtdiuy lln' in abdominal tumor, presinnably a myoma of the uterus: the inci>ion rcvdilid masses of enlargcil lym|)h-glands adherent to tlu' uterus and adncxa, tliciiiM proving to l)e one of Hixlgkin's disease. The histological changes in the glands seem to consist chiclly iA' a liypw- plastie proliferati*)!! of tlie cells, t!t(> rcticnbnn, as a rule, imt brinu- thiikim-J. The normal relation of the lymph-paths are in the early stages inaintaincii, and it is oidv when the growths have become large thiit these aiv (listiii'lnil. The bands of reticular tissue vary in thickness and density in dill^ > at places f the st;i';iiii;r le sM])|Mir;iti(iii HODdKI.Ws I) IS I : ASK. oo.) ,n k spleen. : ,„ .5 por cvnt. of tlw «... tahula.-,! l.v (iow... the .- . o, o Hilar-cmci.t of ths ()r..-aii and in -,(! .>„.. . .\' i'» it \\a> ,>oni(; iii^' '-«A, (1.0 iv,„p I ,1,, „, ,|„, ' ""; "" i""«-"'"iT»«-, 'V.™ - ->ita'.v ..iiiou. in ."ilr: ,';:';:;;:;; j::j" -'' Ite lung. ,„-o ,x.-oasi„„»llv :„v„lv,,l, ,.i,lK,. I,v ,liaH..( i„g,,,„.,|, ,■,,„„ ,|,e i.»-..»i k.in,v. Ti,o .ki„ i. »,„„„,„ „,.. „,, .,nv„,pi,™,„ ,;;',' ■ns: . ,. lal.o,. o«„^,l „„„ of „„, „„„„,, „„,| ,„^,,^, ,,__, _ ' A ,,,,,,,,1 c.v„„„„M,,„,, A ,,«. i„ ,v|,i„|, ,1,0 l,o„,.,.,„„„,„ „.„:„. ,„| , i.,.|H™ ,l™b„l by WK.g,„„|,. TI,o ™,„,,1 „o,-v„„s sv»,o,„ ,1,0 1, r aiiJ !i.lrviials iiiT i-jroly iiiviidod. ■ "-'"' ""^ B'mtJl", TI,o ,IUHl„„io„ of ,l,e ,„ota„a«, „m.*i,a,o, ,l,o a»«,mpei„„ „f eho oo„. v«a.uv ol tho oxo,t,„g age,,, i|„.o„gl, „,„ |,l„„,i.„„„,,,„ ' - "'" SsmptomatoloCT._S,„« at p,.osc.„, wo a,-o (m-cwl to i„o|„,Io ,„«lo,- ,l,e .r ,•.„,„„.„,, appi,o„,io ,„ all „,„,. ,,.. ,|,„,| „; .i,,,,i ,'";.;; 1-r :::: «:,:::::,!:;: ft : - "" ■ '"^^ "'™ ^'^^ ■■"l»«li;„.,ixvoa,^ 1,0 ;, I f' ''■",'" ""■ "''ill", "-biol, i,a,l l,„„, ,,, ,,, ,; 8,; „.","• "'"■""' «'""'i« '•" ti'- «"- -lo. \vi,o„ i ■! I ■ ^f iff- 280 DISEASES OF THE BLOOD. by physical examination. Fn a case observed by Ross of Montreal, (oi. \lij,,|| 1 made an antopsy) in which redema of the feet and lancinating pain- ,i; [j,,. distribution of the nerves, occurrinfj; early, were followed by complcti paia- pleijia, we (bund a jrland-mass pressing on the spinal cord. If the luillmv glands be much enlarged, there will be (vilema of the hand and arm (iMm venous obstruction. The inguinal glands sometimes form large tiuuoi uhi,.], occasionally become pedunculated. Extraordinary symptoms from the pressure of intrathoracic gland- mv n; times met with. In a man who still frequents my clinic the superinr vi.na cava is completely obliterated. Tiicre is considerable congestion of tii!' hcul and upper extremities, but a fairly good compensatory circulation Im.. I,,,,,, established through the superficial veins. The chest-walls have been ciiiivcmd into a huge felt-like mass of dilated veins, tlie latter emptying into two laivf trunks, the dilated epigastric veins. Occasionally he has an aii;i(k of phlebitis in one of the smaller veins, and here and there small plilcijoliths have been formed. One day, while doing heavy lifting, he had an attack i.i' hiemoptysis, losing about a ijuart of blood — an accident which relitvwl tli congestive symptonis for some little time. The retroperitoneal glands are more fre([uently enlarged than the nuMn- teric, and in thin individuals the nodules in the abdomen can be tiukIc (.m, Along with tlie afl'ection of the abdominal glands there may be wtll-iuiirktil bron/ing of the skin, as in Case IV. of my series; Fereol described a simiiar case, and Crocq suggests, by way of explanation, pressure of enlarged ol;,ii,l, on the suprarenal capsules. The variation in the rate of growth and in the size of the glands at (liHl.r- ent times is astonishing. Where they have been large they may tliniinish in volume or even entirely disappear ; a rapid diminution in the size oft iKMrlan,]. shortly before death has been frequently observed. The spleen is often sufficiently eidarged to be easily palpable in the kti hypochondriinn. The thryroid is occasionally affected, and in rare iiistanco" the thymus as well. The patient may go on for a long time complaining of little else tliaii liie inconvenience resulting from the presence of tumors. Sooner or later, tli(in;.'|i, the auicmia and the cachexia gradually appear. He begins to feel iaiionid ainl disinclined for exertion, whether mental or physical ; oedema of tiie leirs, luatk ache, palpitation, and dyspncea succeed. The blood-count is, as a nik', iifi strikingly low ; in oidy one instance have I seen the red blood-('ur|iii-.(le,< >iiik lower than 2,000,000 per cubic millimetre and often there is no ihrmiH' ;it all in the nundx'r of red blood-corpusdes. There is no extreiiie pdikilnov- tosis and the lencocytosis is inconsiderable. In tlu," diiferciitial eeiint ilie lymjihocytes aj)pear to be relatively increased. Where there i- a inarkcil lencocytosis with a i)r('))ouderance of lymphocytes, we have tn tliiiik, 4 course, of a lyujphatic leiikiemia. An occasional nucleated red ■clj (umiiid- l)last) may be fiiund. The jialpitatiou of the heart may or may not be severe. ( >ii exaiiiimitinii j HC)DaKIN\S DISEASE. 231 nninnurs mav usually ho hoTi-d r.,.nr fi i- only functional in chLct T "^^ "'''"" T' ^"' ^^^^ «- P-bably or !>'- clue t<, pressure o who T , ' ■^'*""' '""-^' ^^' ^'"-^ "^''^ "^ ^ho ana-mii .ea.nu.of thoLS ^, ", 2^^^^^^^ oocas-onall,^ there is hvdrothorax or ^■- will he ..uu^ eve/iute:: r;;; r '■=';:^:^tr'r^ '-^'^ ^''- ^^^^ -■•-■I' more often has a recurrent tvne In 'c-.s • """'""•-•■^' '^"' ''t -"-•l-Me a,ue-likeparoxysn.s at' Lvi-^^ ini^v^ xir"':: '"" r'^'"'^ .iiav persist ibr weeks or even n.onth. h-u-o J \ ,• , ' ""'""'''' '''''«'' i.l^'l,tho «>nner ohserver b;;^ h J : :.^:.:;t::f ,k T l' ^'^^^'^ ^'"' "--"*«-tions disease, since durin<. a period of n " 'l'««>vero,l a :.rtarks of fever lastin-. fron, t.-n fn / T ' '""""'■^ ^''" P'^^'^"* ''a ^^'^"'-'^'"^ ^vith apyrexia Usually the digestive symptoms ar.> not nnrl-od .Ifl i • , «l.ic^i. there is extensive atrophv of tl ' [ ' L 7' '" *'"'' ''''' '" .'-•.ect to find serio..s disturb.neos Tl ^'■'^'^-"' '''^^'""' ""•<'"'^a one woul.l ii- is slightly onlar J ^" ": ^''T '"^ '"^ « ^'"'^ »«-tos, and the ^li iiie naso-pharvnx which Inve oiihui''^.'" ""r'^"'"* '^^ «^'^""id S'-owtl. •"ilatoral ituH.u J ^m " ^ '1'" "'''"■^ 1" ^'"^ ^-^-''"-^ tubes. • '^y 'ii'atatiou of one Zl:::^::.^^^ .^"^^^^^^ ^'-ving Oi! cxainimitKin I 1'" -„. In addition " ^ i" • fi ' "ll^r^f"" ^' ^'"^ ^''^^'^' '^^ --^'■^ -^1 the bronzing hd 1 :"",^*'"' ^'^'" ^>; 'y-P'-mato.. ■ionallyan intense anle^me^J^„ 'h'' ''""'r'"'^'' ^''^'"^ '' «^^«- So„H.tin,os there is albunnnuria ' I . '^ '"' ""'"'"* *'' ^''''J'"''"'- '■^^^''• .•l.:.<.s into the skin and Z::::\:ZT ^ ''''] "'T '' ''=^'"'"- '""• '••■"'arks on Leukaemia of the .! ^ '""'" '*''"™'^y '^P'^'^^" i» 1- 1«- .I-oribed byt j:L^ "t"- f -'"-'-'<-"ic an.mia which lii^tory uf ehancro can be obt-iine,! ;i ^M>'"lis. hven when no .v.ard to ulceration of L r t k " P^'^-ont nn.st be ,uestione■■'■ ^>^ouid ascor;;;:, ;' i "it 1 1 r 1="^ -''' ' ' '- ^^ 'iifentiation from tuberculous .uloni ^ ■ '".soarriagos. The •I'ief points of distinction a i'^ "llf ''T' ""^ '''^-It. The '-i'"l-vonng,ar.,l involve the ^f'''''^"'""'^ '"^^'-iti.^ i-^ more com- ""- nunnng altl.g the ^ : tT''- 7^7'' '''^'""'^ "^^^^^ *'- «l'c'.v,.s those latto^- are ,no f.f ' >"■ '"'*^"'' "^ ^''^ '^to'-KMnastoid, ,|.,„^,^^^ more frequently the first attacked in Hod,d '•"'^''"' "" -'™o„s size. ' ^Ve n C ; 1':r' T'"'''^ ""''^^^ ^''^^' '•^'- "'"t-i>"'<' of su.h a nossiblo . t ' "'P''--''""'-^ "^ the nook. As an '"'•>-«-"■ «.■■»'';:* ";,:™r:;:,;;::;'v'- •^;"';»™^.<-: a „„.„ „f '-"'-'■ • '^ ----;-Xtsi;;;L;si^ ■^i Hi I , 232 DISEASES OF THE liLOOI). f witli irregular fcvor ami cliarrha>a : a diagnosis of Ilodgkiii's disoasc first made, but was ai'torward given up. The oeourrc^nce of ague-lik. i,;,.. oxysnis and of recurrent attacks of fever is in favor of psendo-leuku'iin ,, but there certainly are cases in which it may be impossible for a time to i, :i[<,. , certain diagnosis. Where the glandular enlargement is localized, it oidy justifiable, but also advisable, to remove them, when the diao-iic be cleared up by microscopical examination. at lint The disease is to be distinguished from genuine leuka;mia bv the aiiiiii- ation of the blood, which should be nuule carefully in tdl cases. Prognosis. — ITodgkin's disease is in the long riui almost invariablv a i;ii;|| affection. There may be marked variaticjus in the course, distinct cx.Kri'ha- tions and remissions being characteristic, but the cases of complete and iicnna- nent (lU'c are rare. Where the gland-involvement remains localized fur a luii" time and docs not extend to other groups, we may expect a loiin- pciioi] ,,f comparative health, but when the ghnid-tnniors are multi])lc and aiv tii be found in different regions of the body, and especially in those eases in wliidi the cachexia develops early, a fatal termination may be soon expected. Drati, comes in different ways, but most frequently it is the result of tin ■j:n\m] asthenia: the patient grows weaker, and perhaps becomes emac , kI ; tli. dysphiea and palpitation increase, the legs become sw(jllen, and at iliu (inl perhaps there may be hydrothorax or eedema of the liuigs, with heart t'ailinv, Of course death may occur from pressure upon important parts, as in tli(w> cases where the trachoo-bronchial groups of glands are much eidai'uvil. Tin' occurrence of high fever or of hajmorrhage is of grave import, 'flic .iciito cases may die in a few days or weeks, the chronic lasting sometimes maiiv years. Two of my cases (l'm\ from general infection with the stl•(■)lt(l(0(^l^ pyogenes. Treatment. — Besides hygienic measures, the internal admini>tiatioii n|' arsenic is certaiidy of value in some instances. As soon as the (li;inii(isi> Ii;h been established, the patient shoidd be given Fowler's .solution after uw.iU. well diluted, the dose being gra liim time, returning to it later when they have passed off The injiction „i' arsenic into the affected glands by means of a hypodermic needle li;i< lim.i recommended, but \\v shoidd be inclined to regard it as a wholly imiMivssirv procedure. When the case is seen early and only a few glands arc eidargtd, witlmiit any evidence of increase in the size of the spleen, the question of exeisinn ,,t the nodules may arise, and, if there be also no cachexia, I coiisiiler it goml practice. Xot oidy does the diagnosis become entirely cleared up, hut tlicp' may perhaps be a chance of limiting the progress of the disetise in tin's \v;iv, and at any rate, with the improvements in technique possessed U\ nuideni mi:- geons, the operation is trifling and attendelHiKIN\S DISEASE. intcnnl admi„i,stration of iodine an.l of l.o .-7 ^'f''""""^"' ^''^^'''t- The -n to be of ..,,,eater .m^^^ :^ ^^ Vot...uun wo.dcl not Imo .een good results following the use If ''"'"'"* '^''''^ *''«* ^'"^v -on the arsenic is not well h.^ Zlt^'"" T' '"'' '''''''''' '-' -v U^f roconunends inunctions o '" ^":^^^ 7'^' "^^ ^-- ^ ^rial. y,", Everytlu-ng possible should be dfne ^^ ""^V'""""^' galvanis.u. -'' -•'•' -tntious food, an nvi ^^ r?^T ''';' ^^'•"'^'^'' '^^'^l-- Patient: hnlof tonics such as cjuinine T Z do T'l ?' m"'"^"'' "'""' -'■^'' ^''« -Ha'v to the in,lividual affect'l Chal f " '^ '' *'" ^""^^^''^ "-1 l»ell-c->.Klucted establishment where hZfnth '"' ««^"«. « course in a / C x- X y v'i |i \i ; i On Sporadic Cretinism in A merica. BY WILLIAM OSLER, M D PKOKESSOR OF MEDICINE IN THE JOHNS HOPKINS UNIVERSITY CHIEF TO THE JOHNS HOPKINS HOSPIT AND PHYSICIAN-IN- AL. .'Si PROM THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES. November, 1893. M r lil I H Hi J''.Mnirl|.,| (Voiii 'I'll,. \ 'iicricMM Jen iriiii/ 'I'llif Afwii,,, •^••i'-'iKvs, NovcNil,,.,', |>;i;i. "■-•"-"t"^n group „n.H,,,,,,. , I'T' '\ —al.K- ho,.. i„ u.e Ardation I.e. „Wn „.;T'?'"' "'"'"''''' •"^'"■•'^'•'^• ™,,„A.iult Life i„ \\'. uj- a :\,'V' ''"'"'"•' ^'"''' ^^''pe.- 1^". ". a fuller .le^cTipUo,. of „k. 2 . ^'""•'>- ;^l'i"-'-^'""l Ly Onl, i„ '''•■;-•'-' «^"f- ..(• ti.e ,hv.-oi,i , n w"; '" "'•" "^ '•'""""•"- -th -'■''-'" io.,n,l hy ,lK. s.!.. ol,:; ■ . T "'T'"'^- ^^-' -nKu.kal.le ;■'■'"'"! ^-^^'^ "n„tal ..x,irp,,i„„ „ ,' "■^■^"':"" '""' K'H.luT, ,o foil,.,, -:1--, ,luvw a lloo-lof ]i.|„ ' If ?."^ -' -/-W-nental „n.x- ^'---'•iHion. i. t,„ ooounvn, ; , :'"^'"" ''"'^ --no,, to all '"-'^•'"J^ t'H3 annihilation of ,he u t ^ /"'"^^ "'' "'" "l-'''ttions , "--^ ''-i at n.v dini. ni , ?"" " ''!^' ^''>'''-' '-'1-"^ ';^- P>-e^e.ne.l at this .....tin. I , ", j" '' ^"'^'^^f "^--yxoden. w. '•^l--' '-- nnule i. i J,, „„„„ ;, . '' •''-«- >" this ..ount.^.. Th ne as r- ' "™''l«^'l'"rtMheAss„oi,i '"'" " '•"■^•'•"1 search of tht 1 iferatureso far '»-.'"" ••! ,i f uinini|i,.L. ,,i th,. i-ii, ■ , ■'■•^" i-i'i---. Mav, Imu ''■ '.'i'' l.oii.l,,,!, isss. ; I I ns it rclntc.* 1.. the United States aiid Caiuulii, and upon in(iiiiries ninde (if tlie siipeiinlciidcnt.s of the Asyhinia for the Insane and of fnstitu- tions for Feel)Ie-niin sent me from different institutions did not belong to this type of idio.'v. it may lie well to define somewhat earefiilly the precise eonditions t,. wiiich this term should be ajiplied. In the first place, there is no essen- tial ditlerenee between the eases occurring in large niimiiers in goiln.u-. districts and the sporadic cases, The term should be limited accurate!, to a form of idiocy associated with changes in or ab.sence of the thvn id gland. Tile following .statements are i)ased upon the recent articL' (,;' Horsley.' Tlie important factor is the loss of the function of t!ie thyroi.l gland, wliether this results from congenital detect, progressive Jitrophy, or coarse changes which gradually annul its function. 1. Cuni/enltal crefinimn is rare, and is usually associated with absemc of the thyroid gland. The chiM rarely lives, but the changes presents! are sufficiently distinctive for diagnosis. The supra-clavicular iiitty tumors are well marked and the skin generally is ih-k and in folds. The lind)s are short, the epiphyses swollen, while the s-iafts are mu,li cssified. The skull is b>-oad and short, the sutures ojien, and the liasi- 8j)hen()id junction is prematurely o.^sified, a i)oint uixin which Virclmw laid great stress. This congenital variety may be difficult to distinguish from rickets. Degenerative changes, slow over-growth of the fibrous tissue, and a myxcedematous condition have also been met with. 2. A)ile-tHital and mbHiquatl n/oir tlrrf/njiiiient of crcl!ni»m. Ihie the changes ajipear to have been initiated during fretal life, l)ut iiie slight and scarcely noticeable at birth. " The infant shows no, or very slight, signs of intelligence, but the physical signs arc less obvioii.^. According to some, the majority at birth have a goitre, usually of about an inch in diameter; the i)ody is large, with disprop,,.-tionate head and hands, and, what is more important still in connection with the similaritv to myxa'dema, in many eases the subcutaneous ti.-^sues appear ledciiia- tous ; occasionally, according to the severity (jf the case, there is also non-development (»f the facial bones, a flattened nose, giving a stii|iid appearance, and a large thick tongue. The neck is short and thick. It is obvious that under these circumstances we have the same condiliuii as that described ai)ove, only much less severe; the further history of these cases shows that the destruction of the thyroid glann.UT8 of .ponuli,. ,.n,ini.H„, I,,.].,,,, to I. r ■ ""''"'■"•■ "'' "''' '■"■ ^''- -"-.nark., lordosis, .. „,.., ^L ^ :""' ""''• ""••" '-"^ '■"""H-r the neck is .shorlen..,! .1,,. 1 'M'>'on„n..nt. I„ like li|.« thick, an.l the teeth ve../ n .f^ "'"T'' "^^ ""«« '■"' -'. "- '"-« clear hecon.e. thiek. |,e vX^ ' /'^^ "''1' ''''^ ^i'-'''- '' ' "■"•"'^•-'^""'-'v isph.ei., tost., ;;; V ti:t:;: "^ ^'""r"-''""""^' '•""'e« scanty an.l thin. There is u l T "'""'■"'' ""' '""''■ ''«- ..eoim tissues have a pecniiar kin.l of ,'"" "'""""'"= ""^ ''"'"^"'«- --. - .0 speak, soiil, o..,en t ,; :X '"' "''"^'•'"•'' "^ "' "'-'^ tisMies. .t -."Hy .. the ...1 ..r i-as attained -UM-lete .leveh, 1 ',^1 ""''!• '"' '^""^>-^''^^' -"'^ '^ ■^tationary un.ii death. Hence ., """r, ''"'"''' '"^^"'"'■"■^ l'--'-'"y -- |.resente,l i« that of a ,;; tlT " .'"-^ ^'" ''''^•^'^■"' "I''-"- --'-•'y .i..<. not advance C^, tl7^ ^u ";'^""*"""' '••>"'"'-» '•" '!"•« paper belong. i„ ,i,i« division "' "' "'"'"'' '"''^ ''""sfated Tlio adult condition of cretinisn. ■, • ■ • "I-i si-vly,and have reac 'irTV'""" "''"'' ''"^^' ■'--'■ "-. i^ very ciu.racteri.tic. Th '• ' L ^7" '"""'^ "'• "''^^>- -'<' r^'"^'"-^ " '-». degenerate 1, p n' 'T'''':' /'^ '^ "^ '-» "' •^'"""■^^ '""' ••'•"•'i.sh in appearand t;,! "'^^"^■^■^"ally ; .hort excml that of a chihl fn.n, IJZT " ''"'^''" "'""""y d"es not ■•-.'1^ -n,etin.es brown d "f. .7?" r""."'- '^'" ^^^"' '"« <>^'^^n ■""ii.s tissues are much infilt,a,ed si. »l, . ','" '"■■"^"^•^■■* the subcuta- ''-'• ■^.'Pm clavicular folli; l, .'.^ ; ^ ^ ''"' '"'^ ' ""•'""■^'>' -->' ""■ ^•""■""•n. The hair n.av W tud "'" ."'■'•''^"'*'"""<'"s characteV '"■'"'• "•- i" adults; but . ne u'/" " T''^' """""^'^ ^" ^''^ "-"'•■and on the pubes T f' , '"'" ""'" "'^^ ^'•"-'^ '» *'- Hi'v. though -metin,esi„tlLs2. ;:;'" "^/"^^^''^ ''"'"e- and stu- J'"' 'il- are broad and thick ad " '' ''''''^'''^ '•""' ^■"■■li"','- •-- ^'--^trilswide;t^; 1.^^'!'"^ l''^ "^ "^ '"-1 at t^ ''^^-- -^" the .u.o.iabiait<; 'V :: :'i ^''^^^.T'!''''"^""^- ^"«"^' ■-'■'"^""""« present strabisnu.s. The e veild ' ^-'^''y «"Parated and *- *'•>'''"''' '"■'-^ "ften .edenmtou.s. fn '■'I , > 1 1, 1.': advaiur.l .asos tli(iii;;li tlicy hc,. thingH, y.'t they mcc willimil tiny iiitclli. Kt'iice, uikI the t'xpnwioii of tlie vyv^ atlils v.iy nmcli to th,. iiiipa-^ivf, iiiimohilt' asptrt. T\w Um^w \h often thick, larp', and may constaiillv pnitnidi' from the mouth. Tlie j tliyn.id glariil may lie .iilarged or may he completely ahwent. The thorax i.n iimimIK detormed in association with lateral or antcro-posterior curvature .!| the spine. The ahdonicii i.s prominent and full. The limlis are ex tiemely sihort, .sometimes enujciated, ocea.sionally deformed liy rickets. The muscles are fee!)le, the hands and feel are large, the lingers thirk and liroad, and the nails olteii coar.se and large, and may he rudi- mentary. There are varying grade.s of cretinism, and ju«t as we recogni/c complete idiocy, imhecility, and feehle-mindcdness, so there have heen descrihed three degrees of this alleetion : cretins, which present in a iM..st advanced degree the jdiysieal characteristics ahove mentioned, ami .ir, in addition deaf-mutes with tlie vegetative functions alone active; semi- cretins, with mental dulne.ss, harsh guttural voice, expressionless ( i|. tenance, and the physical condition similar to hut less pronounced than that of the true cretin; and lastly, the cretinoid condition in wlii.h there is .some degree of enteeblemeiit of the intelligence, speech >oiii,- what impaired, and the physiognomy and physical i formation i- that of the cretin. The recognition of the condition of cretinism, though ea.sy in advanced and typical ea.-es, is often, I !ind, not clearly made: I judge this from the numlier of descriptive cases sent to me as instances oif this eomiitioii, hut which in reality have heen cases of various forms of idiocy, Tlie imjiortant criteria are the |)hysiognomy, the slia|)e of the head, ilic stunted growth, and the condition of the connective li.ssues. The menial deticieiicy is less characteristic, presenting nothing not seen in instances of ordinary idiocy. The condition of the thyroid is uncertain. Tlure are cretins with and cretins without goitre, while in others ih,. u-lamj seems entirely alwent. The most .satisfactory diagnostic leature i- ihe condition of the skin and connective tissues, whidi, as Ilorslev .-iii;- gests in the following words, shiaild form really the basis of the chi^-ili- eation. " Hy excluding all cases in which the appearance of idimv i.^ not accomimnied by any noteworthy changes in the skin or conncciivc ti.ssues we obtain a considerable delimitation of the condition wliirh ue ought to call cretinism, for by adopting such a plan of diticreniiniinii we necessarily leave out all eases due to direct injurv or .iisease ,.r ihe i:;t;i;;;::;:::;:;;::'i!;;:;;;';;^ .<....... ,i.„...„_, i.li.K.v (ollowi... .nr.. I . '"■•"'"'«^-..-l. a, ,.on...ni,al i,|i....v. -■'-p-'-' '.y wan, ,,r .2:1: ' ;, i:"''''''"^ ^ ;:.'n..ral Him,,... i,, |,„ ;,„„.' ,' ' ' """ '" "" ''"'"•f '>'' -•'•lainlv „,. l->w., ,.|a>.i,i;.a,i„n ' "'"-""' "^•'' "'^ '■'"•"'■^•-■^ "- Imsi,:,,,' „,.. -.te relationof th ... I .; ' ' .''"'"•^- """"""'-. an.l ,1... in.j. 'ikely ,o ,nn. .etinou. HUI,, J. :i? 1^:^^^^^^^ 'e '■■■"•'■"'■^"1 "l-n •■..n.liiions of ,1„. ,,,,.,,;. , ""^'"'"l"'""'"'"''' "f "'y-'i'l i« >'s,nillv absent, an.l in mII . ',■ I i r . ' ''""'*""'' ''"■''■■^ "'« ^v.nMw..u.,ea..en...,.n.a.S;;;;rj:;::;;j - ='I..-. ,o I. at all .in.' n ;^ep ::V'"" ""'^ "^'^''"■-'" ''<- "' -'y Hite it i,s Htat.l l.v IJart ,n t i J '"" ' '" "" "'''' •■'-'"" ' "- l'"i'e.l Stat... JJnnvn ,e ;" " '^ '"" '•"'•^■'>- -' -•"' i» ^^l'"l. state r have l.e.-n al.le to levr n.'. "' '^ "«*^"^''"««t'« («>r P'it.v..it in .state.I that th.re a u'r " "'" ""•'"''•^"'■^^ "^ -'-""' I-I-Ia.i rahont L:^inriV:i T'l''''^^""'' somewhat fVe.,u..nt ca.seH of oretini n „ 7 '"" "'•"^" ''^''^''^'^ -..•Cape M^nUoeino. in C.^ ':::;;; '\;''"''' "' ^";"'- '-"« ;^<' -aonntainons parts of Souther '. J I "''':;:r'^'^ ^' -''-•' '^ '" Hn.h pass current i„ varions works tZn «t"^^'"H'"t. of -i.... on the su.>jeet. in the ^ V ' v//' 7^ 7' '"" "' 'T '"^"^ «ays: "In North An.erica cretinit o/ '''•^■'■"•^•- 'l' ^•/''W../,' veunont, m Jiassachuaetts, and in »=:""""■""" ' '"""- "■ H, .,.,..,,..„ ,, , ■•4". "(•r..tinlsme,"byliniliftngi.r, Vi.l. " .nn."(Tt;t( IIISIII.' vri'i.vliiiljtT. r 6 Calitoniia.-' AVhen wo turn to the ..ri-inal somres f„r these state- ments, nearly all „f which antedate l.SK), we fin.I, tor example, the authority for tlie occurrence of the affection in A[as.sachiisetts the.reneral statement of Kneelan.I,' that there are twelve hundred idiots an.reretins m a i)o).u]ati,.n,,l'„i,e million. I can find no detailed observation in this article, and the term "cretin " was probahly used in a loose wav t„ indi- cate some variety of imbecility. Ho far as I can ascertain, thestatemenN as to the existence of the disease in Vermont and New Hampshire re-i on a paragraph in Buckminster i'.rown's article on cretins i„ Switzer- land :- "Simpletons or idiots are to he met with in the valleys of Ver- mont, Xew Hampshire, or Sctland." There is no reference to cretinisn, in Dorr's' account of the prevalence of goitre in the vallcvsof the ( ircen Mountains. Trask, of Windsor, Vermont, speaking of [he pix-valence of goitre among the early settlers in the valley, says:' " In most countries goitre IS connected with a species of mental imhecilitv called cretinis,,, ■ but^in the United States, thanks to God, it is a mere corp(,real affecti(,n.-' Traslow's account of the occurrence of cretins in California I have not seen, but I have letters from several correspondents in thnt s'nt,. who know nothing „f its existence at present, while in the Stat'; Insii,,, Asylum, at Stockton, Dr. Hoisholt tells me, there are only two cases.' Barton,* whose essay on goitre, pui)lished in the year l.SOO, is one oC the few systematic attempts to study the distribution of this di.sease in America, states: " I have heard of some cases of cretinism among (1,,. Indians inhabiting the neighborhood of San.lusky. But such cases are undoui)tedly very rare in North America. This circumstance, as I have remarked, is well calculated to show that goitre and iodiotism are not necessarily connected with each other." Here and there one meets with the assertion that cretinism occurs in Lower Canada among the French, but I have not been able to trace thr allusion to its source or to verity the fact of its existence. Some vears ago I looked through two of the large institutions fbr children in .Mont real, and the Limgue Pointe Asylum, without finding any, and luo cases supposed to be cretins, at Cacouna, proved to be remarkuhle rhachitic dwarfs. The more recent literature descriptive of cases is ms. very sciuitv Jacobi, in the Jlu.jjilal (lazdtt; x\. V., 187!», vol. v., ics..' died" hriHlya case, the first on record in this country— a child of e.^nt years. .I„li!i- son's paper, in the Detroit Review of Medicine, January, \i, .\|inl, K)\ ■ Iliiil., is|-, ix. ]i. ill. ■' Now Yiirk .Mo(|ioMl Ik'iwsiUiry, x. ■• HfM.i. Sn.itI, H„rloM, ITofosoruf Matoria .\K.,li,.,i „• l-iiivL-rsllv oC IViin^vlvaiir. ■■ \ "''"'""■ '■ '■"'"•« I'l^' "oil"' ii> il ITovails i„ DiiUTiMit I'Mits of .\„hIi Amoiioi " !■■, •.■| Plilliiilflpliiii, ]S(i(i, ■ ' ""common among the ohUdron " in fl.. . '""'" "'"« ""^ ^•'^''v owing to the inH.tx of inn . ' /"- /'"'"f "* ''''^'"^^•^ "^^'^^^eu- York ■'- to the foets of its preSr "" ''*"'""•' '''•^^' =- --ilablJ I'ave led in Knrope to .taten „ 1 a V h "' ''''''^-'^"-^^ -hieh -ien.-e fonn, have heon has i ... ^ '''' 'I'-^'^'^'^- "^ ir iu.e in -"' ^^t'"'i- upon, goitre, n,a.le f .' f 7"' "."•■•'""'«' -''--e'-e- to, -"^-T- ^o far ,; I cm lea n l.e i ^ T" '" "" "^'•'^' '""'^ "^■^'- <-1-'i-lly in this eonntrv. U mlJ t '"V"' ""' ''"" ""^ -^'^ ^••-t goitre whieh I have'gl.meZ nv f' '"'/" ""'^ ^•"■^'*'" ^'''^^ refer to this n^ahuiy only s.rfh,. • , i ' ^ ^, T'T' """ "'''^''' ''-^■^'^■e'', orotini.n. in a locaiitv. Hirs . i ' ' ''^''''^ ^" '^'' '^'^^^euve o P--'enee; and, as' he re^lu^J^'^^ l''^^''''^^ -''"-^7 a. to its opcurrenee of goitre in North Am'eriea . ,1 "'*'"'':'"^';'" «" ^'e endemic '-■'y yeans of this centurv a„d1 v t ''^" '"'' '"^^ '"^^ 1"-^ to the "'-"'y -ferred to. and the a t I s ^f ^^Jl^'^'^^^;" '^--f-'^ -uen.oir """ the n.ost authentic inf.rnvuion , V "" ""^' ''' '^'^""«^ ' ^<'»- suhse.juent writers have .Irawn' fl,,,!.. • " ' '."■''^'*'^"<^e. tVom which ■■"'" 'J^^^ails which are avaih.b e „ i'.'l ''""?""' ^^^'"^'"'"^ ^^''^^^'-'''g goitre has been described s p v in " ""■^' .'' ""^^- '" '^'^'^"^ ^ha! along the Detroit Kive, Z'I^ZT'T^'' ""''''''' ^-'-'■'-'^ John and Montreal; in he v a ', V '" ''''''' '''^'"■^-» ^^■ •■" fl''' "-fal parts of New V r ' , ^ T""' '"' ^"^^ """'I-hire; 'I'e Caroiinas; anave no recent observations ' J h " •""•'"'■''■' "*' *''^'^^' '•"■«'ities in which it could be said to be endemic, attacking a very large number of persons. In the neighboring Province of Ontario, in the limestone re-ions at the end of Lake Ontario, the disease is very prevalent. In response to my iixpiiry about cretins. Dr. V. K. Clark, of the Kingston Asylum mentions the extraordinary prevalence of the disease. Thus in an asylum poi)uIation of about 600 there are 288 eases of goitre. He writes : "The goitres are generally developed when the patients are admitted to the asylum, and it is rarely indeed that we see recent cases unle.-s among the employes. After studying the subject carefully I have come to the conclusion that Eastern Ontario is a distinctly g(,itn,u.s district, and I do not believe that outside j)ractitioners have"given the matter any attention. It is difficult to get accurate statistics even from asylums, and for this reason I have never published the returns smt in from nearly every hospital fur the insane in America. A .superintendent would answer my circular and state that his institution was withmit goitrous i)atieiits. I would go to his institution myself and probably find twenty or thirty goitres. The inference was plain, an.l when in.ti- tutiuus side by side gave returns showing marked differences the infir- ence was plainer still. " Outside practitioners about Kingston have written nothing of interest in connection with the subject, but I find goitre prevalent even anion.' the lower animals ; most of the curs about the asylum have goitres, s.mi'e of them so large that anyone can notice them. The tendency ti. ihis disease seems to run in certain strains, and the youiitr of some fan.ili,- uf dogs and horses are invariably goitrous. In two cases of human beiii-s 9 troitres l.ave pn.ved fatal throu-h pressure \t .„ r r - believe that mental •• .»..lai„, .here l,„ve l^te 1 I ''"' "'' '" ''""• '" '" »» ' ««" "f .m™ cases at the ,l„l„„ ,1 1^™ ft,! "" t™"," "! ''"I"'' •'""-■'-'*«' i«le.«l to the ,„e„,bers ,f , ! A ' "'"""''" " "-""I'l ''« "' ,c„ssi,. : .™,e™" ■:,""' ';""""'"'■"■ ■■" """""- <";.ll .!» a3yl,„„ s„,,eri,„e„.le„.s i, tlfe U t j L.^ Tr. "T .!« »;a.re prevaiW en.len.ic.lly. A,„„„g ,, ,, ' „'.'""' ""'« were ( escr nt ons of i»nni. ,.,.. i' • i- • ^ 'i-|)iics wliicli 1 received '» "«ias ^1 iV ? " , ,"'° °''''''"" "'""'' «™ "-'feMlv the.™ ei ■ 1 : '^^ '""'■'';" -- ' "a™ «(erre,l t,' •ill !■'■ 8iv.a I ,1 it " f '"■'"'*"■ "" ''"""'I"'"" "f "hid. ««..™«.a. ,„ te :, r;'""""" '"l»-i«o.„len,s there were 10 or four years of life. I have at present two cases uikUt treatment, Inn, botli for such a short time that it is impossisK' lo say as to the chanf,'i's ill the noiulition. r t ■n ill it w Cask [.— ^[., aged (now) two years aiid three months, was l)roufi;ht to luc first i'r )ni the Eastern Sliore of Maryhmd, .laiuiiiry '0, 1S02. Tlu' piircMii- (tirst cousins) are healthy and stronir. No hereditary aihnents on cither side ; no members of the family Inive had jroitre. The patient was the wecond chili] : the labor was easy, and she throve well. Xotliing special was noticed aboni the child until tlie end of the first year, when it was susjiected sonietiiiii>; miglit be wronjr. as she iiad not cut lier teeth, and did not attempt to walk di to talk, 'fhrongiiout her second year she };rew fairly well, but had several attacks of sliirht fever, and did not develop as other children, making no attempts to crawl or to walk, and seemed unnaturally (piiet and dull. Shr did not cut the incisor teetli until she was nenrly two years old. Within the past si.K months she has changed remarkably in color, has become very pale and '.vasy, and the face and limbs seem iiully and swollen. She lias lakcn milk well, and has developed a little mentally; smiles, and attempts ii, repeat her own name when it is said, and has learned to say '' mamma" .iml "papa." /'resent condition . Under-sized child for her age. Aspect is very strikiiiir; color jiale ; face, very broad across; the mouth is open; tongue jirotrudes, and is evidently enlarged ; the lips arc full and heavy ; the cheeks very larire, almost pendulous; the hair is long and straight; the eyes are blue; tlie sclerotics very pale; the eyelids glossy and infiltrated. The forc'hci'.d is large, not l)adly shaped; the head well formed, rather prominent behiml; the anterior fontanelle is not cpiite closed. She looks good-tempered, hut takes very little notice, and smiles in a feeble way. The facial aspect is that of a cretinoid idiot. The muscles of the arms are feebly developed ; the siiln'utnneniis tissues are much infiltrated ; the hands are swollen and glossy — not teiiso, and look oedematous, but the infiltration is firm, and only yields nn |iiii- longed ]M'essure. The legs look large ; the thighs present several folds; the skin looks glossy, and the subcutaneous ti.ssues are much infiltrated, 'i'lie skin over the dorsal portion of the feet is very glossy and tense, and e was -I/^"W, 1, l.sii;;. Patient hro,if:ht a-ain to d.,v l„,i which have clapped since I sa^the cl 1 h ; i " T "'"' '"" '"""'1'^ is now three-and-a-hair vears ,1 • ''l""'^' ren.arkably. She intelligent, takes n.o,v no, ! .^^ u.et.i f" '' '' ''"■ "" '""^^ """•" She tries „. sav a (cu- won Is C 1 ^-^l"-''^*""" '^^ !"^" ">'--' P-tmding sli.htlv. ifead is .-,1,.-. ,.„.. i„ circl ; e u. M "'" '""' '"''"' "'■^' ^^"' -"'■^'""id : and sh,„.,, and prese, " •" ll' "'"'"'"r; "' ' "'"■ '^'''" "^^^^ is thick '^ "- palpable.' and Z^JZ Zld" ' '"' '^ ''" '"^^"'^ *^'-'' will, .he greatest disti,,ctness 1 / , '""" ^'"^ ^''"^■''^■'^ *^''" ^^ ^t sternun,. '""' ^'^"^'""' '^'•'"■*^^" "'« ""gers down to the- ..j:;:i'=:i^e;::;;;::.:;:;;;;- ';:--^'« eretm.. treated with the taking the glycerin extract oHir^e^-'u^r''''''' '" ^""'' "'^^ •'^^" - ''•"•••' =' 'l"arter of a gland in the n ' ^ t ^^ 17' ''Tr'''' as ye, notiml after nearly a month's trealnle.u '^ '''""^'' ^'^ i.os;i;aM:yh:;^:;;^;;;':;^::;;7;:;:;;^!;-.^^^^^^^^^^^ are not blood relation ; , i^'en '''•'''"''"'" ^'''"^' '■ '"^''-'^^ troMhles. Patient is the second hi dl''''"''''^^ "" '''''"'' '"' '"^"'<'»1 I'-lthy when born ; fat and I l;,' '""•^' T "'" '-'—"al ; she was thee„dofthisti„,etha,i V ;,S'h^';''" ■ r^T"""'''^^''^""''"^ She did not seem to grow a„ Zt^^V^Z '""''T"" I" ''«-'""-"*■ food well, and was in other respect.s o i .u ''T' ^'"""'^ ^''^ ^-l^' '-^ thought that she was eoinpletelv idiot! ,!. ' , '"" "'""'"^ ■""'"'•'^ '' ^^^^ '0 1-..W what was said to her si i,',' u''' "''"' '""'^' ""^'''^^ '""1 •^^^™«1 the lap. and the tonguw :„:.;':' 7\ '"i '^"' '"' '"■''' ^" '^^ '-'^ '" -. h.gin to cut her Teeth „ i t frd r 1 '''""' '''' '""""'• '^''^ '''-' twelfth year, The anterior Con ta e d , "" ""!' ^'" "" '^"""''• year. She did not begin to walktnt ' .it! '"^ T'' '^'^'"" leanicd to read or to write. i«eirtii 3 ear. .She has never l're»'iit coitditioii. Her heiiMit iu n,..„„ *• . • the feet are turned out t Iti: a t . r ' """ '''"''"'■ '''"' '"''''''' ^-^i'v ^ pit. wi,h ,he hands spr a ' T 1 ' ^•""'' ' "^^ The expression is pleas nt she s il 1 7 ^'' characteristics of a cretin, has a cluldish.soL^h :i ; : '"'''■'«''^''^' '•""' ''-'^■■'' ^-«^1 "atured. but V*., ly e.Kpressioii. "e sits quietly, as a rule, with II ^ i 12 her iiioiith slmt, but soiiictiiiips the toiiiiiic protriKlcs between tbe li|is. Tlir f'liee is liroad, luid all the leatures thick iiiid eoarse. The nose is nimny^i. the nasal (irifiees very apparent, and the ahe thick, and measure across the margins fully 5 mm. in thickness. The lijis arc thick and lull; the clicek- ])niminent, larjie, and broad. In tjie ujiper jaw the lateral incisors are absent : the central inci.sors are of fair size, the enamel much eroded ; the canines arc small, also witii defective enamel. The premolars and molars are small and much decayed. In the lower jaw the teeth are all present, but they arc irrcjinlar and show the same character of defect. The root id' the mouth is much vaulted, the palate is not defective. The forehead is full, a little proM) inent in front; the head is long; the occijiut jirojects, and it is broiid immediately behind the parietal eminences. The occipital iirchcs are iihk h developed, and there are thick ridt'c-like p.ojections at llie line of the s(|uaiii.i- parictal sutures. The circumfen nee of the head is 51.^ cm. ; from the tip .if one ear to the tip of the other, 27 cm.; from the occipital protiiberamc to the glabella, 88 em. The ears are well formed. The neck is Hii cm. in eircumference. The thyroid gland is diatinetly en- larged ; the left lobe more than the right. The hands and arms are well Ibrmed ; there is no enlargement of the epiphyses, ^he uses her fingers will. and can feed herself and jdck up small objects, but the movements are some- what clumsy, ami she is unable to dress or undress herself The legs are linn and strong; not bowed. The gait i.s as above mentioned; she falls easily, and, as her mother e.xjjressed it, has no elasticity. 8he is flat-footed. The kiu-e-jerk seems slightly increased. The body looks squat and full; the thorax is capacious; the back shows a moderate antero-posterior curvati:rc. The abdomen is large. Examination of the thoracic and abdominal organs negative. She is well nourished, and the subcutaneous ti.saut^ are firm but do not pit, and there is no appearance like that of myxedema; it is only in the thickness of the features that the condition is suggested. >She talks a great deal; the voice is high-pitched, very difficult to under stand. Some words she speaks clearly, and she talks and behaves very much as a child of two or three years. She is easily amused ; showed with gnat pleasure and childish joy a little new ring, and is very fond of |>retty things. She has a very good musical ear; can sing several little songs. She is vcrv good-hearted ami generous, and always very anxious, if she has anything nice, that the servants, who are devoted to her, should share it. She is, how- ever, self-willed, and does not like to be thwarted. She began to menstriiMte eighteen niontlis ago. Case III. (Dr. Hooker.)— Minnie K., white, aged three and one-half yc:ir-. came to Johns Hopkins Hospital Dispensary November 2.5, 18i)L'. She w.is born In Lebanon, Pa , and lived there until one year ago, when she was moved to Steelton, Jld. Horn in natural labor; mother had only three hard pains; was a fat, healthy child up to second summer; when one year nid, had sumner diarrlujca, about sixteen stools daily tor a month; after tliiii the bowels became regular, and the child improved for a short while, then Ncgaa to waste again without anything to account for it. She had no cough, no fever. There ap[iears to have been no growth aiul no improvement -i'.tce the attack of diarrhcea at one year of age, excepting the slight improvdneiit 13 - brought t.. t..: di: ::^Lt;:;;::r.'t;:'^''"-^'"«''- '^"^ ^ • -arse; lo-.gue Im d • i t'l ,.1 - ' '"" '"-'"'' '''^'''^''^'^''^ ' "l^ '''ick h.uI nearly black. (The two lower incisor, w^e ' u i, ' . " ,' '"''"' ""' a.'e, and Just before the diarrhea con.me ".hI Th S ' ' n"'" ^""' "'" the time of slight improvement in tl " , ' ^ ''' '"Howmg October was tins tin,e the Uvo u,., c^r nc I we^T" ""':"'"" '" '"'' '^''"'^' -"' »»* t-tl'.) The nose is lat and 3 ■ ' 7T '''^" ^''« ''«« ^ad no other .In.k, coarse, chestnut- .wtd^r ' si^uir '"' I'"'! ^'" ''""' ^■"'--'' "-V -es very sn.all. There is s ,„ ' e l',, .'"'" .'" ^""' '^''' ' ''■^^"^^ •>'' "'« tio'-id gland, btttitr;: : J j::;';: ;: t''^t "\f '^«'"" '"'"^ Mnnd thesterno-cleido.mas.oid o^^ h , -j^':;!;'- ,:''?'"' ""''"""« lively short; thev are thin ■m.l fh/ '-'•i^'" e. Ihe limbs appear rela- >lH' limbs. Hands a^ t ' rit" " nl' '?"' ""' '" ^'"'"^^ '''''^^ -- tlu' hands. Kigh, wris K'been s I h"" ■''"' ■■"""'' ''"'' '" '"'''-^ <^^-- do-ninal organs'do no; p u tl b 1 t^r""?" ''' ''''''''' ''''''■ ''• .dands of body enlarged UWht Ijf ' '^ '" ""' ^^'"- ^^y'"P'i'"ic Ten.perature, .;s.4" in '; ;um n L/"'"'^'r^ ''"""''''; '«"gth, .;„ en>. -'il'l ^ay ■' mamma " a d >;„.'' t t : .7 ,""" ''' = "'"^^^^ -'^^ '^ --.gh for that, lllood e.xi nuio 1 'l " "" ''"' ''"^'"'■''-"' >ome of which contain pigmene'ln^^ 'I';",""' "* ^"''"^ ^'''-'""^•"«. The .did was under 'ot^i^i.^rir;:;:,''';;::'^^'-:;"""^^- , with .niinine and arsenic, and lor a while .,nn« .' ^ '''"' ^'■'^'^'^'^ '" >i' "|.. which was mor than 1 ^ .;,,':, '" " "7""'' ' ^''^ ^^"^ '''''« ^Vhe. h.st seen at the dispetKsa;y iV " , t ^^^TT^ 1 '!" "'■■^''""^'''•-- 1.'^ hecn gained, and was prett/mucJr:,; ;^: ^^^l^ rt^'' "'^' ^^'^ ihe mo her sab the " ^'- ''-t year, up to ai'sulutely no growth. '"" ""''■*^ "''f"^'"-"' t" I'ave been ('As-nV. (J>r. Kotchand Dr. J{ullard.)-G.K female- ...... ■ American, i,arents n<.t blood relations nn^ ,1, ,"."^'"'".^' '^a'^'fl **'x years, '^''^'^ "'-'''^' --lition is n.u 1 3ebld ("•''■"■;"' ^"'""- '^'"^'^ "-^ 4.i.^c,a.; measure«,ent Iron, oci.m^tf ,""''":?'" "^' ''''' '''^'^"' '^ '-| 'nan external n.ea.ns to ext:! ^ ^ :: "r' ^;^^":' ^ -''- '- ^"""1"'"" <"■ inliltration like mvxceden.a of h'e" k, t> ' " "' ^'''""'^ '>'^' '" be felt. Oircun.fere,.ce of ,h r x i 4 ; , V'" ■''"" ^'""' ''' I i ! • I I ! I ■ « ill -ii.-,4 14 She is S(). 5 cm. ill lipif:;lit ; \veii:;lit, 41 poiinds. Tlie coinplexioii is sjilldw voice (lisconliiiit, liiirsli. She Micei)s well; is good-iiiitured, and is sel(liii:i uiliiig; is ;i great (iivorite in the household. J^iirgest girtii of head, ^)2 cm. Croni iiosc to occiput, :i").."> cm. : I'rom ear to ear over vertex, "_'(!. 7 cm. ; girtli of iieci<, :ili.3cm.; girth of cliest, ')4.") cm. ; girtii of abdomen at uml)iiicii>. Vw.. I. Fii, l^x^. 1 1 4 1 ^^^^^m*^" ■' 1 ; JP « M\ Ca?e V. ■^unili Mi<;., iii^cil iiiiK'toiMi. (i2 5cm. Tlie abdomen is protuberant and tiie cliest is narrow; tiic Ii'l:< are perfect, but the knees incline inward. The flesh of the Inuuls and feet imiks old and wrinl^ied ; the teeth are a good deal decayed and notched. There seems to be complete atrophy of the thyroid gland ; there is fulness in ijie supra-clavicular fos.-ite ; there is marked curvature of the spine, both hiieial and anteroposterior. Ca.se VI. (Indian School for Feeble-minded Children: Dr. Van Swcr- ingen). — f.ouisa S., aged fourteen years, horn in America, jiarents not rehileil, no goitre in the family; nationality Cierman. Height. llo,.'i cm.; cir.iiiii- ference of head, •')<) cm. ; from occiput to root of nose, 83 em ; from ixu-nial meatus to external meatus, 2(1.7 cm.; circumference of neck, 2S cm. flip skin is loose and flabby, elastic ami soft, very abundant. She is a deaf-male, bill ap|iears ijuite intelligent. There is no curvature. The tliroa.x. i- ■•!:■': cm., abdomen, li'^.ii em. The limbs seem a little enlarged about the iVlt (.(• the 15 .iei..::\o^rri;e:.;;S:!:M;:r^-':;r''^ -^'"^^'^""^ ^ '■^'-^^• put to root of nose ;{•' r.c.n • ,!■ V< ' '"«"«"'-e"'ent /n.m oeci- app-T infiltrate.1 a„,l n,vxc«d,.,„.Uo h .'n^M, ' ^"'^"'"'''"^""'^ tissues ,1,. nan,™ „f „i,j„„, „„j „.„ ,„„;;; j;;;;;^ »"■ i- '>'-""y .bi,». k„„„., ...-rib;™," :::;■: ,;7i',: '";;:,t,r"™",''"""r "" •■'""■■"«""'« '«"- ij.weiii,,B,iJLL:H ;,'''■''■' "t"'" °'"" '"-""I" si«"'i. .«.■." ...';ye, e4;;s::, '„'r,„t'''T;;"r^^ MuihM- is wrinkled. He is imbeeile tL u , • ^'''' ^"^^ '» -e n„ definite tun.or n.Mss s I -e he I "c e' 'the "'"' ""•■"^^'- ^"^^^« ;^ -1 to have been nu.ch brighter si ';"::a.r Th";;:: U "'""' '^^ lias had ..ccasional epileptic fits " ' ''"■^^^ •^'^'"''^ '»« ""tat all bright except tba 1 ,1 ,' ''»7^''.^^''''-^'^"'y '"telligible; he is -«. ,.n,c.,i, 4,s.4c,„. : ,•,,„„ ,„,,„„. „, „,:';, «■■;;; ■:";:• -™;"""; niraiiis t(i external meatus ii •',.,„ ^n i- • ' ■ ■ ^"'- > '">»i t-xtenial i ; .( Hi; ,/' 1 u CcTfiirc III' (lie llioriix, .54,7 cm.; of iilMloim'ii, ")1 iiii. ; it is diHlinclly |)i'iiilii loUH. Siic ciiii (iiily stiiiid witli ttHsistuiice. Tlie epipiiywes of tiie liiiibn hpiih, sdiiu'whiit I'lilarjiicil, Intcllifrcnce in extremely .slijjlit, imd she never talk-. but eaii <'all the uariie of the mir.xe. She is ullectionate in disiioHition, an. I on recogiiiziiiff the Doctor utters i peculiar slirill cry. The Doctor writes tlmt the child looks about tlie age of three years; ,s uiuible to walk ortostaud erect without sui'iiorl. 'I'he photo>;ra|di illustrat.'s a typical cretin. C"A.SE XI, (Inmate of the l.'al.iorniu llonie tor Feeble-uiiuded (,'hildreii; Dr. A. E. Oshorue.)— I. N., female, aged probably thirty-live years; natin!. ulity nnknown, supposed to be Irisii; no data al)out the jiarenls. lleiirln, JdS cm.; circumference of the head ."x) cm.; measurement from occiput to root of nose, 35cm,; circumference of neck, ;{S.,'J cm.; circumfereiiie of thorax, .Sl.;{ cm.; of alidomen, St cm. The face is broad and llatleiicd; the skin rough, and hangs in fold< over the body • the complexion is sallnw; the hair very scanty and coarse; the teeth are defective, t)nly half aduzcn in the ujiper and lower Jaws ; ..o thyroid gland is palpable ; the spine is slightly curved. The intelligence is of a low order, but her memory is gcMnl. The disposition is docile. .>^he is tractal)le iuid allectionale, and forms strong attachments. She is quick to ajipreciate .. favor, and has a fair sense cif humor. The speech is slow and measured ; the voice ra^'er low and i;i.p- ing. llesi>iration is slow, and the body temperature is below normal. !|i OPKRATIVi: MYXCKDE.MA. In coiiucction with the subject of myxiBdei. i, I am indebted tn I)r. McGniw, of Detroit, for photographs iliiistiating the followii:i,' ca>e, which, so far as I know, is as yet liappily uiii(|iie in American siii'<.'crv — niiraely, one of operative myxfvdeina : Cask X II.— The patient, George M., is now about thirty years old. ami was operated on .Mar '■ 7, IS.Sl. Complete extirpation of the thyroid. The pliotD- graph [exhibited] was taken March liO, IS'j.'i A full descrijition of the case will be published by Dr. .McGraw. Suffice it to say here that there has been a gradual but jirogressive change in this young man since the ihitc of the operation. The hair is scanty and coarse; the skin thick and roiijrh ; the subcutaneous tissues very thick ; the integument and underlying tissues nnike great ridges on the back and on the hands and feet. I'he intclligenv.e is good, but the action of the intellect is slow, and he is unable to dn any continuous work or to sfdy. He complains of fulness in the liead and ring- ing in the ears when he stoops. Even in standing he is not steady on liis feel, and has a tendency to fall. Temperature is normal ; pulse, 70; respira- tions, I'o. lle.irt's action is normal. Voice is harsh and sipieaky. H ii. OF THE MEDICAL SCIENCES. •Illy. ■ ' It haj ' . , and . 'iiin'ls \iticles; ' lii'S of "1 the ; apcrs II' 1 such I U that I yej.il medical MONTHLY, $4.00 VKB ANNUM. WITH i«93 Tub Amkkican Journal ok thk Medical Scikncks enters uiiun 11 ; fourth year, still the leader of American meilical manazinea. In it» lont; cat* developed to jierfection the features of usefulness in its department of literal presents them in unrivalled attractiveness. It is the medium chosen by the leadi 1 of the profession on both sides of the Atlantic for the presentatl.-u of elalii.iate Original its Reviews are noted for discernment and absolute candor, and its Classified Sump I'rogres* each month present an epitome of medical advances gleaned by specialist various departments. According to unquestionable authority, " It contains many origin . of the highest value; nearly all the real criticisms and reviews which we possess, carefully prepared summaries of the progress of medical science and notices of foreign « from this file alone, were all other publications of the jatientspe month; Perpetual, undated, for 30 patients weekly per year; Perpetual, for 60 , a kdIs weekly per year. The first three styles contain 32 pages of important data and 176 paj;. - of assorted blanks; the 6o.patie!.t perpetual consists of 256 pages f blanks. Price, each, $1.25. In com- bination with ei'her both above periodicals, 75 cents. Or, Journal, News, Visiting List and VEAR-li<. Thumb-letter iniicA iof VISITiT"'; .-isx, 25 cents extra. LEA BROTHi PUBLISHED WLAOELPHiA, 706 A 708 SAMSOM rREET. r, Thk NKWshas ,e its ii'.liiciionin heapc^t ns well as 11 the ii.'Cin;ni2e(l 3pon countr\' k ine i"*vn, a startlin H< xMortl 'spital urns and cliil- ii'Lips studies it nou-c\-er, cluneal and '^ prevalence of the d ^how, as is well published d ^ietailed statistics, ^matomical obs the isease. result of W e miss, Gc uring the i)ast fe servations. systematic cnn.in colleges. Tl w such as have b een >'ears by oiu" French and are tl lose fest, obta le most reliable fi itions are so I'led in the post post-morte gures, of course clinical bt ^UI)J)1 protean that m room. Th emeu very many tuberculous 1 ted b>' "ilc'ss in fatal '111 anatomical e Tile stud y Would iu)t iic'ctly beneficial Kra.l by title befi esions are overlooked >'ily be interest e mani- <^"ases the xamination, III im proving tl N. v., Ma •%. ore the A "ig in itself, but ^iiitary surround- "HT.can Pediatric So"ck■^^\;;;nw: le i/i m >/ / 2 OSLER: Tuberculosis in Childn'H, iiigs of the institutions, promoting;- tliat scrupulous clean- liness, that aseptic environment, quite as important (though we are apt to forget it) to the physician as to the surgeon. Whatever stand we ma)- take on the quc-- tion of heredit}', tlie fact is indisputable that in the tuber- culosis of children the enemy in a large proportion ^f cases enters through the ever open portals of the re- piratory and alimentary systems. As the surgeon with ,i case of streptococcus infection in his ward knows that there has been some frtcus of infection, so in these in- stances, when we lind the bronchial nodes or the mesen- teric glands the seat of advanced disease, we shouid recognize definitely air or food contamination. Attaciied to every foundling asjdum or children's hos- pital there shoukl be a paid pathologist, who should i, - port yearl}- to the Board of Managers and to the Medi. al Board on the prc\'alence of tuberculosis in the Institu- tion. He, better than an}-one, would be in a position to furnish data upon which important sanitar\- changes might be based. In ever>- institution so ecjuipped four nr five years' work would not only throw important ligiu ..n the prevalence of this scourge, but woukl also give indi- cations as to the best means for its prevention. II. rnr, fkvkr of tubkrculosls. The second point requiting study relates to tlu> fcwr of tuberculosis. Usuall\-, w hetlier more or less continu- ous or definitely remittent, the fever is associated u itli active development of tubercles, their caseation, soften- ing and suppuration, or with a peri-tuberculous pneu- monia. The more definite hectic or intermittent t\ pe of fever in tuberculosis, w ith intermissions sometimes List- ing for man\- hoiu's of the twenty-four, is seen in elul- dren as in .adults only in advanced cases of tuberculosis, In all these instances some definite relationship exists between t'le severity of the fever and the extent of the disease. Our French colleagues have recentl\- called attention to two other types of fever in tubercidosis which reipiire ilous clean- important ician as to ;i the ques- 1 tlie tuber- jportioii nf if the re^- fenn w ith a :no\vs that tliese in- ;he mescn- we sliouid ti.e'n.berc^dolt! ""^Z^ ^^1!^"'' ''''^'''''''' ^' '^^-'- '" --rityas to kill bet^r a v "";''*""" "'^^ "^ --'J' profound infection, but nf ,,"^'^'' ''" ^he features of a t'-'vial changes were found eith '•"'?'^' "^^-^P^'-atively .^'ands. This/.y.,w;::X;'-;^'-^'-.-or in the t-'se tuberculeuse surai.uJ Is U " ^^''''' ^"^'^- ^" - t'.c monograph of Aviragnet Th '■"""'''^' "^'"^■'■'•^-^ scnted are those of a -ener-.I 7 • '^y^Ptoms pre- '"-■'' ^''-rder. and in ?hcl,d ,•[""?" '"'''^^ '''''' ^^y "" '-iciiously. sometime! '. " '^^'^'■''^-' - comin ' "" '"sidiously, sometimes u-ith v v '^ '•^•'i. sometimes dry th, V '"'"'t'".^; the tongue is^ "-■ntal syn,pto,./;,e ^^t"' ""f '''^ ^'-'■'^^^y ^"^^5^; the '-"•"^^p- ^'-bdo;:^nt';us:ri°""^i- nd snU ..,, '"■''tended, sometimes finind depre p.iinful; th. i, .,•■--; nnri 1 "" '■ ' •-• and sn foil n.-.^ . ■■.■^-o ^--"Ptoms are. in fact those r"''^"'"' ■'^^^'°"'^"- '^"''e "■'thout definite local s'io-ns ' „ , '' P'''*^"^'"^^ infection ^^•'"■^■I> the disease has run r "'^' ''^''^ ^-^^^nbed in ^-^ ^^y- The autopsy ;,^::'"' '" ^^^''''-" '" a verv lous lesion, perhaps on y^ t e" b ^"f. '^''^''^ tubercu'- ^r^all area of tuberculous K. ,°"''"^'^' ^^''''"''^ "'• a '^'^^'^ -ay be con;;;:;:, 'r'^^'^-P"---"-. or the .-lands in the mesentery or the „e'ck''''°Ti; °^ '"'''■^^^' Ha- beheved to be caused bv the tnl , ' -^y^Ptoms "sua! amounts under certain f-,, ,T ^'""''^'"P"' '" un- -te of the local disease ,f;'' '^°"''^'°"-^ ^'^ the stance of the kind in clu'lcl re , l"?T "'"' ^^■'■''' ^'" i"- -tted to my wards on ]^ ^ ^ t'' ""^ ^^ ^-^ ^d- elieve to belong to this t''%;;/''';^'^^' '-t. which I '^-•ty-^c^-en. had a swellin:. on the I TT' " *""" ''^-''^d f"^]> '--or and delirium. He h, H^ad %"' ^'" "-'^•■ o'- hvc u-eeks' duration.and vd.en '" '"""'^■'^ "^ '°"r ;■- ^'x-e of a mos „ "/ ''^'--al disease to be disc """" "■'^'o^'t any ..lands of the neck. tZuui:'"'' "'"' ^^'-'^ «^ ^he ^"?gesti^-e of typhoid fever"],' "^''T"""" '''^'' ^'^ShW ■ '"ti-eck sel-med to be defir '" V" ^''^ ^lU '"-^'1 "" the fifth day 'ft.:'"'^"'^^'>' tuberculous, H iliei admfssion. Th e au topsy ttl 4 Osli:r: Tuberculosis in Children. showed numerous punctiform h.xmorrhagcs. There was s ,;hain of tuberculous glands, yellow and caseous, on th,' left side of the neck, evidently of some age. The kin" ; were crepitant, and there was an area of commcncii?- pneumonia with fresh pleurisy over it in the right low^- lobe. There were scattered miliary tubercles through- out the liver and the spleen. To another form of fever attention has also been called b)' our French colleagues, the typho-tubenulosc. .„■ continuous tuberculous fever, acute fever developing i,, connection with a tuberculous infection, but which,"!!,,- like the acute miliary tuberculosis, runs a favoral)lc co..rse. Apparently it may be one of the first manifesta- tions of the invasion of the organism by the bacilli, but it may be the expression of what may be called an aborted acute tuberculosis, consecutive to some local disease, and Landouzy refers to it as a bacilliary tox- -mia. The general symptoms are those really of tvph.,i,| fever, from which the diagnosis may be extremely diffi- cult. It runs a course of from four to five weeks,and from the description and the temperature chart given by A.viragnet there must be extreme difficulty in its reco..'- nition from typhoid fever. In fact, as he remarks, when- ever we find a child with a cortt\i^rc of symptoms' suffic- ciently marked to make one think of typhoid fever but not sufficiently characteristic to make a clear diagnosis, the question should always be raised as to the existence of tuberculosis. Shall we then recognize an acutely ercufosis in Children Case I. — (ieitei-y/ ^ ::ra,u,iar casts „,!'''''"'■'■'"'' '''^""""' ^^vW kvnlin • ^ moderate fc: L^ f, '"''"'' ^"^'K^h; diff /^^^ '' , ^'"^ "" Jt-^r, death 01/ fl,^ f J, ".//"•*' t'ronchiti^: • adenitis of t'le /,,■„„ ■/ / f -f^'O'tfi day Ti,/, •. J, ' i he nature of thf ■ >^cck: ;;;•''-■'- -ithpnen;oni:-:;t!:'^'i^'^^''; --^ «aid to be tl'cr.a o, ,^^ fever At t;r',^"'^^'''^"°therdfph! ^cc-Mi. tlie child v.as wasted • . f'^^P^'^^^O'. uhc„ fi^4 ai'c '. broncliial : limy prc- thc entiif us consoli- :avity con- upper ami ^^acli, Ini- ) it was a °'"''-- "-"""■"""Sis l„ C,.i,.M:. 'edematous, and tl,p -.u i Iiiorax. — The '"ertasccl. luse til H.icla.„ecl a„. tensive ami circling ulcer, the edj^^es of wliicli were un dcrmined, the base irregular, worm-eaten, and containrd necrotic j,n-e>- and yellow material. It extended to the muscular coat, and the peritoneum o\-er it was thick .m,! opaque. At the mesenteric detachment there was en siderable thickening and infiltration of the tissues. Tlu~e girdle ulcers occurreu at vr )-ing intervals througlu.;it the small intestine, separated from each other by a {^w cm. There were in addition circular or oval smallrr ulcers. On the peritoneal coat, corresponding to the ulcers, were numerous nodules of an o))aque white and yellow ish color. In the cacum corresponding with the mesenteric detachment was a closely adherent tuiii'.r mass composed of caseous glands united by infiltrated fibrous tissues. The omentum was adherent over this mass, and when torn away the underlying tissue crm- tained large and small tubercles. The cecum itself pre- sented an extensive deep ulcer, occupying almost the entire mucous membrane. The rest of the large intes- tine was healthy except the rectum, which presents a small ulcer." Peritoneum. — In addition to the nodules corresponding to the ulcers the peritoneum generally was sprinkled with tubercles varjing in size from a pin's head to a hemp seed. Between the liver and the diaphragm were masses of caseous tubercles and tubcrcidous granulation tissue, and tubercles were seen on corresponding points of the pleural surface of the diajihragm. The mesenteric glands were enormously enlargcil and converted into caseous masses. The retro-peritoneal glands are al.>;o swollen and caseous. r \t y li. I ■' ! .yx V v';(L ^ T()X/i:mia rx Tij'.KRrrLosis, IIV Wll.LIA.M nsl.KK, M.I)., I'rtifisMW tif M.tliriiic, Jnlui'i f/ii/,/. his {'iiiiyfui/ii, l:,ili:,„i,n, TliK syinptoiu.s of a profuiuul iiiloxicntidii in tuberculosis aic met with under ilnx'v eoiulitidns : tiv.st, in tlio.xe rare cnsi'.s (lescribeil nm.st eoininonly in ehilclrcn, in wiiicii iKnt'i iii:i\ occur witli syinptonis of a profound toxieniia betoif tlier^ are any extensive localised loci of di.sease. " The ciiildren Iiiivc presented in thi- cour.se of tlie disease all tlie .sion.sof aprofoiind intoxication, and as tlie tuberculous lesions of tlie lung,-* .nul all other oi-o-aus are altogether insufHcient to prnihice deatli, it is quite reasonabh' to attribute the fatal results to the bacillary intoxication.'' ' The.se are the instances of they/tV/r Ui/ntinm inhariiicusc mruhjut. Second, acute miliary tuberculdsis is often accompanied with toxic features, giving to many of the cases clinical pictures of severe typhoid fever. Pu&t uiorlnn. miliary tubercles are found cxtens -i; throughout tlu' viscera and on the serous surfaces. Thirc in hronic pulinnnarv tuber- culosis there may develop, with oi witlumt fever, a profonml toxiBUiia, with dry tongue, delirium, rapid pulse, and siyns of intense intoxication. The patient may be admitteil to hospital unconscious, with a normal or .subnormal temperature, ami, as in a case which was under my care at the Philadelphia Hospital, the autopsy alone reveals the true nature oi' the disease. The following case- may perhaps be regarded as an instiiuci' of the fchri^ Uthvrmlosa iieracuta. The striking features wort- ' Aviragiiet : Do la Tubercnilo.su cliez le.s Eiilant.s. I'aiis, ISl'-J. I - Repovteil in the I'hih'ideliilii.i Maiicul Ncks, December 2, 1S92 '""'^■''"'" '■"^""■^'■^v i" tlu. live, t ^ '■•^ercuiosis of verv '^■'t «'do of the neck, euu-l. ,„ . ' '•''V:'^'' •'' -^•'"ing in ti.. •^<'f'"-"g very .l.-finite i, 1 7''"^'^^' "'"1 -'^'Imuu,. for about two weeks, .n. , ^ ":'^'' ^^ "'"'"-• previously H^' '-Ioe,usio„.|lvl',.u,,i,,';^ ' ,;' •^••"•; '" tlK. ab.Iom.„. f'-'''i'':'-iin.s:.u,'r ^^^^^^^^ >t^vas„ot,ee.ltl,attl.o..l.uuk Ti r '"'^ " "-^'^'l^ '''te.' «-e>ks before presontin, iZ^^u ,7^ ' ""'-'• -til tlnee ^"""fing, but tbere was loss of '.,' V '' '.'"^''"' "'"'^^^'^ "«'• ness and fever. For fully two wj iT i "I , '"''^^''-^^i^^ ^^oak- f "i^'-t qnite .ielirious: TWd '^ T " '*"' ''■"'''^"^'' -"' -'"'.^of profoun.l weakues. ... ' ""' ''•'^^' '''^^'» t^'^' ''^;_^--«..eun.be,;:oS:^ Oil admission the Dationf K i . -''-^•r^androse^^^V t' (;?'":"= ^''^^-1-^ '^•'-e the ten.peratnro h.i .! , / ^^'™"Sliout the day ''-'-' '-db.Ldelirio:''^^^^:-^^^^ """"^^'''-^•l "^an, and di.l not look Y '" ''''" '' ^''''•'.^- ^^ell ^-t length of time. The c^,! ' ''"' '^^" ^" ^'^ -'7 -'' --us nien.branes w4 Xr 7''^ T'^' '"* ^''^' ''l- "■^'f ofniediuiu sixe and rot V , "^^."^"^^ ^^''""••. The pupils ^-'- Thetongu; irS" f^^ there was n^ :;;;!: - -Pid. 124. regular but s^r , ^ II "l^*?" ^''« P"'- Tlie respirations were a little Inirri '^'^'^^'.'^''^ compressible. "^ ^''^^ -■•'» di notliiii^f lit ;'us. Peyec's )raue of the r !l I > I ,1 I ED KROM UNIV -RSITY 'OICAL Magazine. KIM V. tnr :. STAFF J IjANUAIn' . , 1884 FAROTITIS IN PNEUMONIA "SE O. Pi^HICAHBITlS TREATED BV INCISION AND DRAlNAGli. By Wiluam Osler, M.D., /'^m^r 0/ the Theory and Pra. Johns Hopkins Medical Scho. ctice of Medicine in the 'ol. I WUm II II i '». ■« ^ i i ii , 1 I" ».■«' ;l THr. .. '^^''''''''^ ^N PNEUMONIA This complication iq of ^ • the Montreal General HspLTwhrh T'^" ' ^^'"^^^ - case at ^n th,s disease, nor was there ,nfn. '" "°"«"^-»»y large service the disease Which I performed ."^^Ln'^^ "^ ^°^^--^^^^^^^^^ ess frequent than endocarditis or ,... '"'*'^"^'°"- It is very much has in one or two instances Itn 1 ."''"'°^'^'«' ^^'th which, howevTt in which in the course :;rabr::loll ^""'^ --^ions Tc^;;; parom. developed on theforty./ftrd ! t^r"? P"^"--"a, double The following is the nni ^ ' ^^ P^^»^»t recovered personal observation The c 'diac ^ "'^^^ ''^^ come under mv great interest, inasmuch aVthee J "' ''^"^ ^^^^^ ^'^° « ve^v pericardial friction. '^''' ^^« ^ very well marked pleuro P.VHrMOm.OK.HRUPPHKTHZKr>OKXHHln ;--• "tL mie:^:^tlZ^'-f^^ Hospital, October elmous no history could be obtaTn d The t "''' ^"' '^ ^^ -«« at 4.30 I'.M., was 10," . r,„l«« ^ temperature onadmisMnt, «'«-"nirt.a„dif„srared,^tai ?""°"- ^^ He 1:^; iiivolunlarily. medicne, feces and urine „e„ J October 30 i p jj ,.1^ delirious; tongue dry i 'h a nd^ tremulous aT " '°"°"« "^ ^^^ient is ^edcothes; pulse r.o, feeble re ^LTo^"'"'"''^ ^ Expansion on the left side is defecuir . ^t' ^^'"P^^^ture 103° tyn^panmc note from clavicle to sixlh rib '''''' '' ^ "•^'' marked «te„d>ngfrom near the spine of tt ' ^f'^^^^^y ^here is dulness -to the posterior half of th'e xiHa or'f ''""'^^ ^° *^^ base and -ds are tubular, with rales ^thee„d of '""• "^'°" ^^^ ^-^^h breathing :smtense at the angle of scapula r, '"'P''^^'°»- blowing The heart sounds at the apex are clear ^'''' '^ "° expectoration -Pe^r ^:m ^^:;:-^ -;;; - -:- ;^P.ation ,. to , ' Gtsa: '""lelte Beitr.ige, l)d. "■ Article 20 "-US and has had very littl^ I r ^ 2 Parotitis in Pneumonia. sleep. Takes medicine and nonrishmeut well. Has been taking carbonate of ammonia, aromatic spirits of ammonia, whisky and strychnia. The patient is decidedly worse. The pulse is more feeble and the skin looks now a little bile-tinged. He is still delirious; it was noticed this evening that the left parotid gland was swollen. The bowels have been freely moved. The physical examination gave the following; Left lung clear to lower border of fourth rib, below which there is duliiess. There is a loud friction murmur and many rales in left axilla. Below the third rib and to the left of the sternum there is a well-marked pericardial, to-and-fro, friction murmur. It is not heard at the base and is loudest in the fifth interspace below the nipple. It was concluded that it was pleuro-pericardial friction. The condition at the back of the chest remains the same. November 2. Temperature through the day has ranged from 102^ to 103° ; pulse from 126 to 130, regular and small ; respiration 44 to 52. Examination showed blowing breathing outside the nipple line and in the scapular regions rales were numerous. At the apex both sounds were heard, a soft systolic murmur with the first. Sounds are clear at the aortic cartilage. The to and fro friction in the fourth and fifth spaces is scarcely audible. November 3. The patient passed a fair night, slept better. The parotid gland not much swollen. Temperature 102.9°. 1'he apex systolic murmur, which is much more distinct, is not heard in the axilla, but is much intensified towards the sternum. The sounds are clear at the aortic cartilage. The murmur is loud in the third and fourth left interspaces. The pleuro-pericardial friction sound has entirely disappeared. The percussion note is clear to the uppe^- border of the fifth rib ; it is dull from this into the axilla. November 4. The patient is weaker; pulse 130 to 140; tremor is constant ; respiration 44 to 56. Passes urine and feces involuntarily. The apex systolic murmur is distinctly louder and rougher than two days ago. Sounds at the aortic cartilage are clear. There are 11c cutaneous ecchymoses ; no sputum has been obtained. Respiration 65; pulse 160; temperature 103.6°. Death took place at 12.15 p.m. Autopsy, twenty-four hours after death. Body that of a small, moderately muscular man : skin slightly icteric ; left parotid swolleii. Thorax : A pint and a half of seropurulent fluid in the left pleura. The upper lobe of the left lung is glued to the pericardium by thick fibrinous exudation. The entire pleura, visceral and parietal, is covered with a very thick creamy material. The right pleura is smooth. Heart : The pericardium i.^ smooth ; no exudation. The right Death took Pfficardiiis Treatrd /,,. a. • ■ eatcd by Incision and Drainage chambers are dilated and full of rlnri, r drawn from the vessels. No endocardiii«""A?°''' ^^'^^' ''" '^" ^''J'- what relaxed and turbid. The .X ' -.'^"^^"^'^^ ^"bstance .some- the „„ddle of the second joint "^ '^""'^ "-^'^^ ^"ffers to airlei^a.:;i: Jl:: ^ '^[r^e:'^ J^^" ^°^^ -e collapsed, nently, is verj. firna and in a conditio , f ''"'' °"' ^"^ ?">»"■- bronchi of this part are filled vv,T ''^"'' '"' ^^^P^^^^ation The lobe is crepitant throughout trd^r?" ''"'^'■°"- '^^^ "PP- "ot contain much blood or se urn T. ^^f'' '' '^^ '^^«^' ^"tiid tbe ba.se. The bronchial gla d are el"' .' '""^ '^ ^^"^'^'^^^'^ «t ^spIeen .s enlarged and soff and cont f ""^ '"'"^^^^'- '^^^^ ■nrarcts with yellow brown loTL^^Tix^^, '"^^^ ^^^-^^aped turbid; no infarcts. The liver n ^^'"^ ^'^"^^'S are swollen and swelling. The stomach s sm\, -The . ^'^ '"°''^'^" °^ <^'-'^y bowel presents patches of deep „g ', .r^^If^ ^-^^ ; the large eeply congested; the interlobular en, '• «^^ '^^^ P^^-^^'d gland is here and there are distinct focfof PUS %\'"f'.^^^^ with blood and changes. °' P"^- The brain presents no special CASE OF PERICARDITIS TRFATi-^r. .. AND DRA^^OE '"^ '^'^'^"^^' J'!!^.''"-^nracut' (0 Aseptic pericar- ehnum occasionally seen with pedca dia eff "°'' ^ ^^^ ^^^ P^^"^'- two weeks after operation, when C mH . I ?°° ' ^^'^ '^^ ^"•'^et, excessive cardiac debility/problirdurtom '.'"'^ '°^°^ -"' ^^ January ic, rgon t c/ , ° myocardit s. few days before the New Year he ''''"' '^^"'''^^'"^-^ ^^ ^'^ ^-^e 'a ;tich became acutely infl!m dt/f^^l!' '^^V""'^^ ^^^^ ^- -.e fetor m the secretion Dr. Donaldson T u '°^ ''^""^^ ^^ere was no was present. A week or so befJre l^'^u- ''"' ""''''''' ^^ ^he bones ;ortofbreath. the fever, wLHt/b:::'''^ '^ began to get a litt e 'l^ere were signs of con.,.>ion at the b 7^'"' ^'''"^^ ^'^SK and pulse became much mor^^ P^d a^,H r m ''' °^ '^" "^^t lung The ^'"^t. When I saw him the condition ' '"' *^^ ^^^^^ «°""d« indis! ;P;nbed. Respiration is noisr^rtt-?'-'^"'""- «« sits propped i i 4 Pericarditis Treated by Incision and Pminage. breathing r-omes from *' i ' both nostrils are obstructed. The pulse is no, irrorn'.P' in vo!mie and in force. Heart; inspection, nothing noticeable, .is a lieavy layer of panniculus covers the mammary regions, no impil-ie. No thrill. Dulness extends to upper border of the third rib in parasternal line and to .1 level of the second rib on the sternum ; to the right it reaches two fingers' breadth beyond the sternum ; to the left at least two inches beyond the nipple line. On au.scultation no heart .sounds audi' ■ \ .. ^.iv of heart or towards apex. At the base feeble, distant, only just distinguishable sounds can be heard. Pes(- hypodermically. There was ap'are ,, itv T' "^"'"^ ""^^P^^ du. --ss to the left, but Dr Hals^eH ,^ '^^^ extension of the the p ricardium and there see™ d' b! no '"' '" '°^^^ ^^^ -'^hin fon 'te heart sounds were clear but , ?''°° '° ''" ^ reaccumula- February 7. Patient has fllVran h", ""Z '''°"^ ' "^ ^"^'""r- ular and f. .A.. Great restleTsne 1 Cnf ''• "^"^'^ ^^^^^'^'^^y ^^reg- more hurried. P.-bruary 8. Tsan^a;;:!-^^ T'' ^^P-tions autopsy. ■"* '^""^ and died this morning. No William Osler, M.D t^ Z''" ^'" Mns Hopkins Medical School. /.] '1 t Fro ^1 ;, I < L-GETOAL mrSIS AND SUMMARY OF 239 CASES OF TfPHOID FEVER. II.-THE TREATMEST OF TFPHOID FEVER. m.-A STUDY OF THE FATAL CASES. IV.-SPECIAL SYMPTOMS, COMPLZOATIONS AND SEQUELAE. By WILLIAM OSLEE, M.D. I| ' ! '■ i; 'I' I ^ tU John, MopUM Eo^ua S^^, Vol. IV, m. 1, ■Baltimore, M4, TTf i ij 1 1 I. ^ t •^t- 7 ;> \ k- ^v J^ r \ ft n >r ^ r>^ f i r^ .*-i& < rt^ "^ t ^ ■V LA ^ f ^\ F :h rs f - ^ i ^ TN % ^. 1^ 'K N" .^> -<' >, >v J.— GENERAL ANArv«JT« a x^t^ ^ Bv WILLIAM OSLER, M. D. To May 15th. ISQS ooq n.edieal warcf. ' '" ^'' ^''"^ "^ ^-^•P^-'l '"-.r .ere treated i„ the Tlie patients are isolated in Wnvd T i ^ or for some special reason ' ^^ ^' ''^'° violently delirious Th vcrylarse pr„|,„rti„„ offt,,.,™, "?? ' *■■■'"" '- *^'™ 1- !.«,c„la,.|.v„fQe,,„„„,,. „„j J,; ;';''"■ " 1»'-S» foreign,,,, „„„„, "■« it will l,e sec, ,|„,t „;,,;|,. ,„ , «»"„! in the third ,|„,,je. '" • •'" P" «™' "f all (!„• eases Mortality Of the '''>q - -erage rate of n.o,;:,.t3n; '' h!:^ I' '''' -"^' -'-L is "7 the .nortality has ,..: ^^ ::! i'^^ "'' ^!'^^ -,d-hath treat- '"d conditions inflnencin. the no.; ^''.Vr''""' -•'•-mstances 'nsuleration of the fatal clses ^ "''^ ''^ ^'^'^''^ ^^^th i„ the "Annual Report of the ileiilM, n " iietutli Department. 1892 'I i. I S; i William Osier. [2 Season. — Typhoid is essentially an autumnal fever, and more than one-half of the admissions were in August, September and October. The admissions in each month were as follows : January 9, February 6, March 3, April 5, May 8, June 9, July 22, August 40, September 38, October 40, November 34, December 1(5. The average duration of stay in hospital for the 229 eases was 28.1 days. I'he majority of the j)atients are persons without regular homes, and their stay is sometimes unusually protracted; i convalescent from typhoid fever is allowed to remain until he feels well enough to go out and work. The distribution of the eases in the city will bo dealt with in a special section (VIII). Only one case originated in the lio.spiial. A nurse, Miss R. (Hos. No. 3729), had been on night duty from August 1st in ward F, in which was a large number of cases ol' typhoid fever, and she superintended the giving of from seven to eight baths every night. Prior to August 23rd, when she went off duty, she had been for two weeks " out of sorts " with oot;asioiial headache and felt very tired and weak. There was nothing whatever in the history to indicate that she had taken the disease outside, and so far as we knew she had not been exposed except in her daty. Another nurse had typhoid fever, but just previous to the attack she had been outside nursing a brother with the disease. A doubtful case was that of Sallie R. (Hos. No. 4716), who \-i^ admitted F'^bruary 16th, 1892, with a choreic affection and spasms. From February 16th to March 1st, 13 days, she had a normal tem- perature ; then from March 1st to 7th there was a gradual rii-e each day (with the exception of the 5th), the temperature registering a little higher than the last. She gradiuilly developed a typical attack oi typhoid fever. She was a resident of Hojjkins, Accomack County, Va., but a week before her admission had been staying at Barro Street, in a house, however, in whicli there was no typhoid fever, hi the next bed to her was u patient with ty])hoid fever, but it is quite possible, and indeed probable, that she received the infection outside. as the fever developed within the limits of the period of incuhation. r f*= m CLk JI— TREATMENT OF tvdw^ JF TYPHOID FEVER BvW.LUAMoSLER.M.a. {a) Nursinq and Dht o- ™«J and fod, and Zi 1, ™ L "r.''" ""= '""'»' - « ...«l>a ed by appropriate renfedTe" TT"'."' '''™W "'"y »"se are '-* .f best expressed in the te™ ,." '™f ""= """«■•-=' '" "a" - ■»«li».ne snnply because the „aZt I . ""P^^oy." givin. "o rfa^td^^™'-^- ''''^ X'^atrj '■"'" ^"'-«"*° tares, as Sydenham said of FT;. ^ decisiou. Hp orJ.r^ ™;;*-oeroi„., <.fontrt;ed!t :?-• " "^ '"PPon of en^^:' A Jarge proportion Of all cases 7^ any and all for„,s of treatnae, t ;: , ""'' ''°* ^* ^^ast-recover under -d regulated diet upon vvhTrCh ''° ^''"^^"* ^^'^ g«od nursznj care, by careful feedL .nTi '^^V^^''^ ""'«^' ^t^'^ss. Bv ;„d; ^ a'Hl.fanyrel,anceean be placed '!," , '"'^ ^""^^^^ ^^e saved P- oent are saved by hydxJ^trera.n'v''""' ^" ^-^^^"^ three or four Good nursing not only „,eaL ^ / ^""'^''''^ ^-^'^■J.u. «,h.st. '"^ P--"Se of „„ses to pa«el" "st^dlt !* w '^rf 1 c IS p . '^ *! 7i Cli a .2 'S tug -3 S liZ — < 5 c £ 1 1 J.' 0/ 4^ ~o •^3 «0 3 .1 ^ OS . 08 02 1^ CO _et CO WW) ■33 5 »J o 5 5 o t> o c M a -Si is o o E-g.S -2 a o > Si ■J 'a j5 ._^ c o 1 wo t«<7 no IK) NO ro B "B ;S a> s s c a £ 8 .2 5 tK) a 5 *-• S s » ;3 3 ^ s «M 3 •M 3 rl ^ r i> ^ ■s X! ^S s S5 s g <; P^ -»5 (S < <3 ^ ii c > S t> 3 r-T r-n ^ t IT lO i-r, ro l^ rn r-l lO r'> K) y t-. r3 >. 6^ tlT ?rb' t-£- >* T3 £• fc- b CO b b 0) 0^ OJ a. e8 « « o 9 ^ 2 n ASA J= J3X! j: Si J3. ja A a3 03 CO pa CZ3CQ xnmuim Wc« M Ol M a » J3 J c 03 -•-) ^ .58 o o 'A c8 8) s X b '*-> M 8, c a X! SJ 11 -4^ 03 ■a pa 1 ^ t ►* M ^i^^i o u CJ o ?< o * !i< OJ « W CJ N CJ CJ M o o^ o o o o CO O MO ooooooooo O O 1'*^ O O 'C iff CJ50 eo'S" O— OCOOOCOw'O r^ OOS — «'^'?|'«| ^] Treatmmf. of Typhoid Frrer. — ij 0/ 2 2 J" 2i « "3 ^_0J ^. «a . * =•11 :• ^ I"? ll^i a 'J'a 5|F = O 4) O C IL '/. " !> Kt> >.,t<^. .^^ ^^ > ^ r-^ >-. 2 s.s ^ IT, — s I'i 03 ■y; <- o 5= z in o o ift o o '<: Iff >5 — ?I >-i CI ^ x' 06 aj o o c MiJk is the Staple article of diof of,.! • i r- g'ven in the twentv-fb„r hou^ ' J! ';: ^"' ^''^^ ^« ^o- pints are "i<"t8 Of an ideal fever fo.d Jf2, .' "''*'*" **^'^ ^^'e req„ire- "-^«1 with e,,-.n,,,„,„ or • t t^'ttLl " :'^ ''' ■■■^ «"PP'e- f "V"«P-tion of the .stools sJnvHCt ^ '''n ''' "" ^''^^ «'^«» -jested. Water is .iven free v - n t " """' '' '^"* thoronghlv •''•'"'! - --f' of it as he ca^ ' ^t^ ^'''^''' '^ — .ed to -1 .n fnll doses when the fbve^^ s m ^''\^"" ^^^^ -d. bath, An Klea of the dietetic and r^i^Jf' ''"^' '''« P"'«' feeble ■^tr<:ngth in ^ serious ease nnv i '"^««"'-t'« used to s„p,,ort ^^'!f^ of the diet and ZrZ^ :; t^4 f""^ ^^^ ^ ^' ^- rauldle of a relapse. ""^ -^ '"""•« 'n a case in the (6) TA. mUath Treatmcnt.~-For vears 1 J ■ vogue as a means of com ba tin,, the more ' " " ''"'P^' ^""^ ''^''» "' ever. Advocated toward the^ endTt " ri'-'^''^^'^-^'^^^^ has come into general use bv the .tron. 1 '""*"''•" '••^' C''''^''^ 't many and of the l>hvsicians"of 1 r^ T''' ""^ ^^'•='»'J "' «er- i". l.ere the adn.lL.ble re^J Lt ^1^ I "t '^ ^^ ^^'^^^'' 'i^^" "' ale, who practised hvdrothera, , t , -1T"' ^''^'''' ^'"'^''^ "'^b-ns 1798*: " B.,t the most Sa m P" 'T' "'^ -"-'yappar- Pe-at.u-e of the body is l,v the „s .^^ J' '!"' "?'"^'"'''"^' *^'« 'em- ■"^^rnally or applied ext^-nally Wh , ' "'''''' "'^>^ ^^ ^-'<«n dem-e cold water to drink i sho l''''""'"'*'^''^' "^'^'""^ disease abstracted from the body by the w.ter h" 1 ^' ''"""'''^^' ''^" ''^^^ -•-, - but small, and except in" ;rwle ', --' "'' ^''■'"'^■' ^«- --ch, ,t produces ,>erspiratio„,l :^, r''*-^- ''' '"""-- - the ihe only of>ectual method of J • '"^ ''''>' ^"^'^f?- k. fc«t ,0 any *g,ee we ,,]„,«. D ,' ^ t" ""."'"« "'•• «>" l«e„ **«. modes of making thiK a„„ 1 I 't™'°""" """^ »'i°PW ""BMn; while others ,,rrfo,.,l™ ""•"'""■ »" J-;-' case with feeble he.rt i Patientistuckedcareft y ;;; ,^7^^^ ^" «^'- instances the anath the t L" ' T f'^"' ""'' ""^^^- H'^'f -' .-I of three hours the tem " ; "" "/' "^"^"'"^- ^^'"* ^^'' is repeated. During thoZth ttV iv"' "'' ^"^-'^^ *^^^ b'"^*'' '■""y watched. Tho^g ,ttst 1 •" "' '^' ''''''"' '« --'- :.blc, within five or siv .i „t " t T " ""'"' ^' '^'^'^ "^'^ee- in.' cold and beconK^'ler Tn '"^"."^"'^-^''>'--I>Iainsof feel- I'eginsand the patient's teeth" chatter"''" the'' T'^' ''''^'^^'-^ l)econ.e a little blue. Systematic f! f I ^''^''•^'"'t.es and fiice shivering and the tencle.i^ -"o c . "";^': "^'"'^ '"^ -""^eract ^■iinvatched,andthe;;;::t;;^; 'r\,th '^ r'^"^^ ^'^ -- ^'resigns of increasing weakness. '' ' ""' '^'''" *f'^'"^' file pi'ocediire noon vilnV-i, n ^ , .».nel,: ,ho carrying™:, I 1"h>7; ''"''»'«• ''''Srea...,^ I«?in..ins of the diiase bv vl ich *?"■"■"' '''■™' "- -">' ««tox„.|„i„„.le...e,, «, L ' T'"'"' '""^''^- On'vi" >• *e ™<1 of; the first woeic ■■"'""»<««■« "ere i„, „„,, „3„„,|, ''"P«.* was ctabiis ,".';»">■ ''<«"» 'he baths before the 8 Williniii Osier. [>^ The frequency of the baths dependfi upon the severity of the cis, Four is an average iiiunl.er for the 24 hours, but the maximum UMinh,r possible, eight, iiave often to be giveu. The arrangenjents arc s,,,!, that they are given in iii(. night as well as in the dav. The Innrp.t Dumber of baths given an individual case was 147 ; live eases r.c. iv(,,i more than 100 baths. Though followed as a matter of ronti-,, there have i)een siuec we began the treatment (Ive cases in wliirh the patient was admitted in such a state that it was not tli.ni.hi advisable to bathe him ; while in eight eases the extr<>me debiliir,,, the patient madr us abandon, sometimes for a time onlv, the tiiat- llHIlt. Brand urges that all cases should Iw bathed, that every ease „t' typhoid fever, whether grave or moderate, should be treated by tlic eold bath. This we have not considered n(!ees.sary, and of the' Htii eases admitKd since the beginning of the treatment there wen. '•' winch did not receive any baths,-nearly all, except those above men- tioned, mild cases in which they did not seem indicat(-(l. In bin .,„e instance! in the entire series did a patient who entered with i..w tem- perature su! -.(.lently develop serious symptoms with high fever nnd great prosi, ■.!-.,>, The case is of no little interest, and an abstriu i „f It will be f-?!!o,i itmong the fata! eases, Xo. 22. Wo did not roallv appreciate th.-n he had typhoid fever during the first week in i,o.'- j)ital. The i: .aperature chart was very deceptive, and we tiMm-lu that It might be an anomalous form of malaria, but rep(>ate(l exami- nations of the blood were negative. After the enlargement of the sj)leen and the appearance of a few rose-spots rendered certain tiic diagnosis of tyi)hoid fever, the temperature did not ri.se above 102^ until th.. thirteenth day in hospital. The baths were then begun, hm the case proved to be one of unusual severity. lie took iii'lij] 11} baths. Death occurred from perforation on the fiftv-lii>t dav. One could not but regret that the baths had not been started at tlie outset. 2. Genrraf resu/f,^ of the tmdment.— Without enteriuij upon a dis- cussion of the theory of the action of the eold bath, th,rn,ost hupon- ant effects may be said to be in the reduction of the teDiperatiiro and in the general .stimulating eifeet upon the patient, particularly iipo,, the nervous sy.'^tem. Brand's statement that by the cold bath it is possible to keej) tlio patient in an afebrile condition is not borne out by our experience, In a majority of cases the action of the bath is prompt, and within 'ity of the caKc. xiiinuiniiinilHT iients arc such i'he Inri^cvt e cuscs rcccivcil iter of roiitiMc, casoH in wlnVI, !is not tlioii-lit cine (lcl)iliiy ,)| )iily, tlio trciit- (ivcrv case of treated l)_v rln 11(1 of the |!ii; tliore were :'•_' ISO above iiii'ii- (1. fn lull (iiio witli low tfiii- liitrli fev( r md an abstnu! nf lid not reallv week in ims- d we tlioiiglii peated e.xanii- reinent ol' the 'd eertain the V above 102 en beijiin, but )!< in all 111 rst (lav. Oui at the outset. ; upon a (li>- niost iiiipdi't- tperatiire and iculai'ly npnn to keej) tlic p e.\])erieii(c. t, and uitliiii m ^ IMAGE EVALUATION TEST TARGET (MT-S) k /, "HV//y/ Chart II showing marked action of the baths. j { ■ dniiUed ^'f^ '/''■ /''> ^\\m^ JJ- : • IV V e baths. I ' lilO l«n ;j 17(1 1«>(I 150 HO i;iO 120 no mo 90 811 70 60 i 50 I ! 40 I 30 '/f> Tlwv/ ts .; i. ;., .; ^, Mill 180 ;.:..,, : .. i7li lull ■•■•:•? 150 ....... ; ...f , HOJ : .'■ i;iO ■••■■ \-\ -; ■• 120 nil „,.;...;. 100 ::::i::.:. 90 ;--i--; • ^ 811 . .^...: . 70 ■■:-■' : ■■■■■■ ■; • 60 \ :■■■•■• : ■ .iO •ill •■■;■■•. --■ ! 1 1 1 , 30 i 1 US It ts le 1- le It le )t le No. ''•("r. J{iA^.J{u, *^. >^t.'?-.S5*«*<' Admitted /«<^ ><. '^ /^/ > Ward t .>. 98 »7 96 Temp Pulse Resp Stools Urine Dhv of n iseaue . ^ .;.. \.. ♦■■ ■'■■ ■ « ■ ■ » ■,■ ■■ ■ i. •' ■ ■ ^...,i... • ' -..;.. • ...;.. . » ■ V *■ ■•■ #....;. .. • ♦ ■;. ;.. ;... ?••■■-■ «■■:■■•? ■ ■•••r--'--f--f-^- ?■■■|•■^■ ■;■••■•• ^■••j••■:•■■^■•^•■ 1 •■|| 1...^....;... j.. .|. ..,...: .»....; .|. J . |., i... [...;. .j. j ,;.,:..; T ■■■ -f-p-: ■ ■••■■; ■v--;...i.. .J. . ....... ^....i....f.^..i.. .;. .;....;.. .J.. .|.. -j .,:... .i.. ..;....,........,■...:.., .| .,|., ;,, .j .,;. ; . | .; | ; | ,..: /:,.■, ,/ ,..:,,vi,», ,,>;^*;,^;.,, ,i^,,i:,,r,,,t,».'^^^ „j;»;„/,^,,;„, .^r;,^.^;!^; ,•;,i.;,w^.^:,«;,^:,,,;,«U " ' ^ — ' ■*-"-^ — i.:i_i-.:.ii4:_^;--'"i---;-- ■•-...:.. -i.. i .. : .. 1 -..,;. ...i.. • ...i... . ■ : ; —1 1 1 1 1 1 1 1 1 1 ! 1 \ 1 1 1 ^ — I.:-!- ! 1 "l ! 1 ! i 1 — t— H 1 1 1 J_ 1 1 1 t 1 1 1 1 1 1 1 i i 1 1 1 /■? 1 10 ,'. / 80 70 60 50 40 30 Chart I showing very slight action of baths. :*'it m i I /t^ > ^ /f.^ Wa/r^ j± ■If ■■:■ ■*1 r ^f;- ■;■■■;■•• if:-! ■*.•*■_•■ ■■■ • *-■ ;»■•■ ■■ • t ■ •■ : .'.W lit: im'ilr. l*:'iijH:l*>^fU.l>/;iif lu ' 'i UiijfiifU/:^'';^*:.?*.,'':,?*'^*!-^: "■ '■ • ;• r ;" "ri Tui»r IHI) 180 170 16U 1.10 140 1»0 1?0 no 100 90 80 70 on 50 40 30 hs. i'J Ward C 'f II tit;; \ y '■ ' 1H» IHll 170 ..;....j. 160 150 140 KIO r.'o llll :■ ■ 101) n ■ 90 .. . 80 '■ 70 v:;-'.; on "■U":".. 50 '»r'»:"^'f ■«•" 40 >f.^>Ui(. y "■ ■' <• ■•'■ -r — s- - - 30 1 ^ i _4 (- ," ' Trcatmmt 0/ T,,p/ioul Ferer. I'^'"'^'" '"»"• "fter the patient comes out of the Intl. flw. r, . 1 . IHn.nre i.s lowered from one to three ch^r e T . "' show as a rule a crradn-il ri«, '",/ *^ ^ ^"'" *"""* •^'''"'^^ tcnperatnre is .In" . W T ' •' '"' ^'"^ ''"■ ^--h-"-iy it.L.riu.i,ht.^rtheriX :;;:'rr - s.... ti.e fever Kept do.„ r.Lor. tl-an'a^: . ": ^^rt otlier liaiid there are nof -i fi.,,, „,. • ■ • . "oiii.s. vjn tho in -vl,id, a. ,1,. e„d „f,h, „,„*•„, ,„„ ,;„„:, J'' '""■^ »7 », .V,,, lau.,-, ,i,.,,,„i„ ,,i,, „„, „,„,„ia';i t , i::i": ;;:'; IS 10 siy, ■ "f"".v,an,l „n overv ^^i : ^ ''^ '»' ">° '■"' imni.al ,)r even to il.i" „r <)(!» ' T„ 1 1 ? tei„|,erali.ro to »■.,-. a, »ee„ fron „ Z^ o, e' u" 'T'''"""'-,'--' "'« «'-™ in .1.. later period,, a. i,,,: tir';,..! "-,:".';:""•'• '' '" .""■' » '"' i"- .1.0 Lath bii ' : ,,: r, i";"» . ""■. .-- °f - It ".»> in.le«l bee„„,e extreme vain, ," ""■'"""■''■ i. |»r,ie„larl, „„,i„,ble in as I,' " '"' ", ''T'^' "'''''' of writiiii: (October 20th) there are tweuty-eitiht eases of tjphoid fever in the medical wards, not one of which has or has had delirium or trcmm'. On the respiratory system the baths exercise no special intludiic, They certainly do not aggravate the preliminary bronchitis, aiul ilc idea that they are liable to induce pneumonia or pleurisy is entirely groundless. Patients treated with the cold batii appear less often to have iln dry, brown tongue. Gastric irritation is not sofreciuent. niarrlmn and tympanites are so variable symptoms in different epidemics tiiat it is diilieult to say whether they are specially intlueneed iiy tin baths, but comparing the series treated with and without the Imtli,-, they certainly appear to have a good effect. There were seven cases of hemorrhage in the bathed cases ; only one in the thirty-three ca-ts treated symptomatically. The proportionately large number of ruses of perforation among the fatal cases was probably accidental and had nothing to do witli the treatment. The number of relapses in our bath scries, 9.2 per cent, contriists strikingly with the entire absence in the small number (rented symptomatically. The incidence of rclai)Se ranges in ditferent places from 2 or 3 per cent to 9 or 10 per cent, and it does not stem right to attribute any prejudicial influence to the baths. Coniplicu- tions with the bath treatment are rare, and the only unpleasant eiit was the skin-boils, which certainly occurred in a greater ntitnliei' o; cases than in any series treated l)y me in other hospitals. The cold-bath method carried out in all its details is exceediiiiily onerous, j)articularly if thert; is a large number of cases in the hospital at the same time. It is, moreover, to a very consiileraide majority of all the patients excessively disagreeable, and at least nine out of ten of our patients have comjjlained bitterly of it. So liarsli does it often seem that I would not sutler it in my wards tor u day did I not feel sure that under its systematic employment the deatli-rntf in the disease was definitely lowered. Results such as pul)lishe(l by Brand, in cases treated in garrisons and in private practice, cainidt be expected and are not obtained in ordinary hospital work. The mortality in the Red Cross Iiosj)ital at Lyons, as given l)y Tiipiir llj Trenlmeiit of Typhni,! Fmv. n :i?i(l Boiivorot, irivps n .w... p.fo,l „f „,n, ;^e.ar,s, an,l prior t„ tl.^f .?;,," ^ ' ''"'' "'"^ '" «'"e Tl- 3.3 oa«e.s treated sv n,,t,. „ „' T \ "' '' '•'"• '^•"^■ '"•^I'ital work ha<] a ...orialilv .^^^ .; t:' '^ '''' ^"^'^ "'" ^'- H -•-^e l.e„,orrha,i i-lciouble pnounK,nia;t';!.::'S''7 "'■;''■ ^'"^'^ "••'^ ^''^ hmerrliajr,. fron, the i,owe)s Th *, '"''"'•"■''t''*". »"a th 'M on the twenty-third dav h-Lv! ''"' n '"""""' '"^"^«'^'^' ''>"J «'n.itted in the third week t I^' 'Z' !'' f ' '"^^''■^- ''^'-ee were "" tl.o seventh, one on th. JZhTu "" ^''^' ^'■^^'' ^'•■'-^•' ^"o ''^^•-;u. on the twel.h. o:;:?;';l;;:;:;--'!-'--he tenth possible to say how Ion-, he h-.d bo., 11 ,' " '""' '* "'«« "»- condition was thought tVl e 'u! " ' ""^■•'''^'-^"^'^1 -ses t],e '^e,.ost-.orten. shewed H\r::';Za'^l-''-^^^ «'^' ^^n, but \r C^ X t-/'_ in._A STUDY ov rriK fatat. casks. Bv WILLIAM OSLER, M . D. * i. ! Manv <'irciimHtaiu!eH iuHiicnco the deiith-riitc in t\ plioid li'\( r. (,| wliioli the most iinporttint are the inherited dis])()siti()ii, tlic miikiiihi ami ehariU'ter of" tlie poison, the time at wideh tlie patient kjimo under Hkilled eare, and the mode ol'treatnii nt. Tiie variation in wymptoms, so strikinu; in the infections disc.i-.(., no one case resemblin- indivi(lii;il disposition is the varyinfj; ineidenee of typhoid i'ever witli ai:e. 'flii' conditions favoring infection increase with eiich (luiniiiienniiil pcridil from the third to the sixth. Not the tender blade, not the bud. lim tile full flower of early womanhood and manhood falls vietiin to tlii- seonrjje. The eases are not only more fre(pient between the llth and 25th years, but the death-rate at this period is the highest. Oi th<' 22 fatal cases in our series, 11 were under twenty-live yens of iige. Ex])erimental evidence has abundantly demonstriited that tin symptoms vary with the dose of a poison, and while anaiooy woiiM lead us to infer the same in the spontaneous infeetions, we know nothint!; of the circum.stances influencing the dosage in typhoid icver; not even if the variations dejiend on the amount of infective iinitLiiil or on differences, at diflercnt times and in different jilaces, in the intensity of the virus. The severity and duration of the symptoiib, and the termination, whether in deatli or recovery, are iiiiliionad jirimarily, in a larsic majority of all oases, by these two factors, vi/„ disposition, constitution, soil, or whatever we may term it; and the virus, possibly by its relative virulen<'e, possibly by its dosage. Fortunately, spontaneous recovery follows in a majority of tlic eiists in the .self-limited infections, .such as typhoid, typhus, smallpox, otc. The term mlj-lhiut,'(l implies that the duration is fixed— fixed, we I'M ^1 S'fHflif nf fhr Fatnl < •„.,,«. (l.rn.crly tho.ml.t, l,y an exhaustion ..f the .„il „„ „, •H'nisniorc likolv, I,v tl„. „,,„Im..I ' , ".'" "'*' K'Tnis; now, as it inhil.it,contn,lan:i,iJ,^! :;;:'';;■••" 'f 7'--- .i«s.H.-Htute unalo,aM.s t<, that en?, .";.?;'''' ""'"'•"■"" "'" '' Tiic niortalitv is inlliiciic;.,! „r„..ti,. i .1 -.under tn:atnn.n,'^';:r'rr^^^ t" m.;.n so n.nch in f;.v.r .a.,., th. I. tt, tl I ^ '""'' ^■•""« ii,i,...f ,ho ./. ..//.,,./.,. .. . :; , i "" *'""''""■•• '" •»'« 1-1-K-i latorv oases, which ftke o ; i '•"T"'^'^' t"^"""""''- A,„l,„- L'> in the thinl, S i„ the f„„rth '> in 'i . • '" ''" '•'*'••"•'' ■•Hruasin,.o;sihie ^. ";..;' '';'!;''''' ' 'v'" ^"^'''"'"' '» ill-ss hefij entering t/^ u Xr TUU " " ^^^ ''""'"" "'" *''« aeaths in patients i„ The fir d 'fi o ' "'"" '' '''"""••" ^"-•' "'' ^•••^> ^'^'--i-'-iHinitei;::t ti: :!:^;:•:;" ^^•'''^'' •-- ^'"1- l"-il'n., the .h.ath-r-.t '' ";' '""■'^'" "''""''» '"'• '•«'«•- '7^;^-e-,::l^:;rtot;::i':^:;;:^ Nidiral ward tile avei-i»r,..f.,(r.>r ' ^M'"<>i(l. Jn the men's '--." with tMo onleriies. In e .t e^n " '' ^'" ^'^'^ fetion,rej,n.laritv.nKl svst.. / V ''"■'•"'^' '"'* ^'^'"'v --i.;....fi.«;i::ii-^;i:;;;j':::i;;:::!::«.;;;';' "".. I I I I 14 Willidiii Osier. [1 (2) To intercurrent affections, usuiilly caused by an invasion oftii • weakened organism by other parasites, pneumococci, strepttK'ncci, etc.; and, (3) To accidents of the lesion — erosion of a large bl'>od-vessol, or perforation of an ulcer. Analyzing the 22 deaths according to this division, there cai'ic in tiie first 8 cases, in the second 4 cases, and in the third 10 case^. I. — Death bv Pkooressive Asthenia. No case in the list died, so far as one can judge, directly from tlic effects of the fever, that is, from hyperpyrexia. The highest tenipir- ature recorded among the fatal cases was 107°. Nor was there an instance of death from early toxieraia, by which is meant the rapid overpowering of the system, and a fatal result within the lirsr week. Such cases are extremely rare. More commonly the toxaniia is slow and i)rogressive, catising a gradual failure and exhaustion dl the strength of the i)atient, usually but not always with coma and delirium. Of the 8 instances here given 6 died of the progressivt toxicmia due to the disease itself. One of these was a case of re lapse. and of the others, 1 was admitted on the sixth day, 3 in the second week, and 1 after three and a-half weeks' illness. As a rule there ii; marked involvement of the nervous system with delirium, coma and tremor. In only one instance. Case III, did the patient retain con- seiousness to the end. The temperature is usually high, tlie rani:*' from 103°- 105°. Sometimes, uc in Case III, which was vcrv pm- tracted, the temperature may towards the end sink and be luinnal dr even subnormal. The pulse is always rapid and feeble; thus tlie range in the six cases was usually above 120, and in every instancr rose above 140. The average duration in hospital of these case- was a little more than 12 days. Four of these six patients were bathed. Iluxham's* description of this mode of death is particu- larly graphic: " Now Nature sinks apace, the extremities grow co!d, the nails pale or livid, the pulse may be said to tremble and flutter rather than to beat, the vibrations being so exceeding weak and quick that they can scarce be distinguished, though sometimes tlioy creep on surprisingly slow, and very frequently intermit. Tiie sick become quite insensible and stupid, scarce aflf'ected with the loudest *Aii Essaj oil Fevers, Second edition, 1750, page 78. ]ol A Study nf the Fatal Oa^es. 15 noise or the strontroff Mcrhi i^i i I"'"'"'>'"h1 coma, and thnt delirium now ends i„ ,i blnod-vcssd.or ■ ='"'1 tears run off involuntariiv'.lnr'™''^ '''''*• '^^''' «t"<'l^ "rine as the vast tremblings and t iL'm 'T";'"'' " '^''^^^-^' ^'i««"I"ti"", "'■ H'e. In one or other of thj ^ ;'; ,re t'h" -"l'" ''' ^'^ ''''"''' havinf. languished on for fi>urte,.r t *^^ «'^'^^ ^'''''•'^l "ff, after --■times for mud. lon'er '' "'^^'"' "'^ *"^"^^- <'-•-' "'O'. The eases with progressive asthenia are as follows: Case III. Admistiion at end of third wfel- n * ba™ and .he had at Li ,1 " "*' •""■ '""<»' '"""-l""" :«l".i"«l ,ho >vas i„ a ver . ZZ^T ";"•""'""" " ''"> ■ "'"«" - »o,dio,.„,ic.a„,;:;:,:tM,r .'n'' *"""?*"" '»=°' .'"■ ««I. and ,.„,„, ,he .o,.,„f;: " ^/r "^ ^JH- a„„„. ttilarijod, there were no spots ^een Tl u' ^^'^ ^P't'eii was i"'^ifai the temperature^l: d pr^^lt"? f ^^^^ ^^'^ "' "luch sometimes as /i° or 4° l.on. ? • '"'•' ^''"•'at><>"s, as 1-ture. On August h anr;h"tl rt'"""''"^ •"'"' ^^'^'"'"^^ ^-'- i-^"-'"^' onee dropped to ^ll^ /^^^r J^ ---^^i'. I".t conscious. On the 10th, Hth and 19.,, ,h t 7 "I'^^l'^tie, 103° and 104°, and on the l^th and Lh 'T '^'"^•^ ^'^^"■^■^" 'h-o" the morning of the 13th I e """"'' ^'" ^^ *'«'"•«' ^" « - "'■ -as norntu "rem i f ?"^^*"^« g'--'"='llv fell, and I'-s, then p-aduallvros a rr,;;T T T' ''■'' ''' '' rose to 103.5°. " ^'"'^ ^^"'' ^'"" <'•'>• of her death, The irregular and low temner-iturn ;, ,\ ■ ^'as associated with the mo Cf , '" '"'' '"^^'"''^^ ^''« «'««" and diarrhu-a. ' '"^"^'^""'^ ^'•^^'^«'"''^' '•'•^Pid, feeble pulse, There was no autopsv. -ASK VIII. Admission 771 second , re,'/ n- i "■7-- l>ro,res.i.e asthenia, deatC^^Jl!;,^^ ' ''""''"'"' '''''■'"'" -'' v 108. Throujrhout the first and second weclvS in liospital the case w.is regarded as one of ordinary severity ; the ])ulse was never ver) hijih, not above 98, the temperature between 102° and 104°. On sevdH occasions he had very profuse perspirations. 'Die nnnd was eliur. The diarrhh necrotic sloughs. Tlie mucous membrane of the large intestine was extensively congested. The spleen was much enlarged. The heart muscle was pale and soft, but on microscopical examination did not show fatty degeneration. Tn this case the patient had been doing well, had had only niodir- ate fever, the pulse was not high, and of fair volume, and it \v:is not until within four or Hve days of the fatal issue that the symptdiiis became in any way alarming. There was nothing in the anatomical condition to account for the sudden development of these more serious symptoms. Cask X. Adnmxion late, prolxibty in third ireek. Hif/h ferer,iii(ti- oi'ism, diarrha'ii, r/r(idual e.vhauniion , death, (tutopsy. Joseph J)., aged 43, admitted August 21st, 1890 (IIos. No. lGS7i. He is a German, has been in this country eight years, and states that with the exception of "abdonunal typhus" (which expression he used himself) six years ago, when he was ill ibr live weeks, lias always enjoyed good health. In .luly he had what he called a sun- 17] -' f^My of the Fatal Case.,. in etrry >ttiiijc nf . rol-e ^ ^"^ --■-al cough. He was s.'i ,:,':' '"""'"' '""'' '"" ''^''^ ''='^ '"•s tomperuhu-o was 101.4°, and ,.'"""'•' ^''-'"^^ ^^''' -''''» l-I'i;^.I- On adnn-.s,sion n/in " i l.""" •■'••'^"' ^" -"- -to H,e 120, dicrotic; first sound of the I e-n- /•/T"''''""''"''' ^^^'^^ P"l^e f ,-Pox; abdon.n f„„ «„„ a llttl" .d ^•^f■'■''''^ -"" -^"-' "t dclined rose spot.s ; spleen not r.-iln-hlo ' '"''''"" ""»^' "'^'l --'-'-•^t drv. Patient was , d ,' ,; "•'^";" ^"^'^^"^^ " '--T ^t, «-t two days he seen.ed prett o . .^m^ "'Z '^^"""^-^- For the --tnntly to ri.sc to 105° but he^,^ ''''' '"' temperature tended he had a good deal of tremj t^' • "'^'' "■^"- ^^" ^'•^" 26,h a^.ionu.n was distended; rt;nn:r?'''" ""^'"^' ^•'^'^^- T'^ ='^ the .seventh rib in nippi; ?• "" ^r"'''"" "'^^"''-^ "^^'-^h -1 h.vpochondriac regions^ T t ^ ' f .' ""'""'" "' '^^* '^'- •l'« "ipplo line. The . splenic Z ' m'"' "' ''^'"' ^"'"^«« i" «1- was not palpable, 'ffe ^^s XX ^""^ ^^ "-'« ""*; the n..e, and given turj)entine intennllv O . o"'"'"'" ^^■'■^'' ^"''Pen. ^"^^-' -•* ^i;f^ended, not tend^ ^^pres^^f ^ f^' theabdon.enlas general condition altogether better Vu , , ^^^ """^ ''^o marked, ti'e pulse was still 120? a^he"8?h , '''^' ''' ^"'^^"^ "^ ^'- -'^ 132, and he has had for the past two ] ' "'"' ''"'■'' '^'"^^ "•^^''^^^ P»l«e -^ thcevening ho failed Srbt'"' "-- ^.'arrhcea. Through- "- 2f.th and died in the evenin. " ' "' ""'^' '^^'''^ ^"'^ ^veak on The urine, on admission, was dear anr] . • , "'^r^' "ere hyaline and gra.dar caTts S 7 ""'^' "" "'^'•■'"'■"' but ; "«i ••-"x.min in a small anu nT nd '""^^""'T''^ '^^ -ine con- ^''««"'--" -- "over of sue :li ^'- S-nuIar casts persisted. Of uneasiness. '"""""* «« to excite special attention This i)atient had in all twenK- « i , ^'-d very well and did not 2^^;^:!^^:' "■^"'^'^ '^ — ^ to ^«'o/«y rOr. Councilman) !" :'''"V^""''''""'^- /'««""o»m. ^ ""P"^ ""'/* «^A-//w, i«c^>/e„^ broiicho- Peritoneum smooth. At thp I,. • • *'«« I : 18 WiUinm Ot^ler. [18 which it was situated was raised above the surrounding parts, and the ulcer was irregular with eroded edges. In only three of the ulccn, had the process reached the muscular coat. Tiierewere threci sii|i( i- ficial erosions in the sigmoid ilcxnre. There were marked (cdenui and congestion of" the lungs at tin bases, and throughout the substance were several patches of Ixkui- ning bronclio-pneumonin. The spleen weighed 137 gramiiics; iIh kidneys were enlarged; the cortices swollen. In both there wuc suuUl nodides about 2 mm. in diameter, not raised above the surfaci', of a yellowish color, and surrounded by a zone of hypertemia. The heart muscle was of a brownish-red <'olor ; the striiu wer(> well marked ; no wide-spread fatty change. The valves were normal. (Jask Xir. Admission in relapse. Dflirium, Irif/h fnrr, sliijlil hcnwrrhdffcs, dyspncra, prof/ressire cardiae ircakiiess, (Jentli, aiiiojjsji. John S., aged 34 (IIos. No. 2983), admitted A])ril 2Gtli, 1891, Patient was a bartender, liad always enjoyed good health since child- hood. No acute illne.ss until last autumn, when he was ill i\n- three weeks with fcvvr, cough, and jiains in the right side and the l)aek, He got better and remained well until eight weeks ago, when lie was taken ill suddenly with a chill and fever. He felt very badly and was in bed for six weeks and a half. Was delirious at times. He had no ])ain, not even headache. About five weeks after the onset he began to sit up. lie had been at work for some time (lie says three weeks, but that is inccmsistent with the former statement), when on the 24th, that is two days ago, he began to feel badly again mid had chilly feelings. On the 2r)th and 2(5th he had vomiting, with fever and a little nose-bleeding. The patient is a stout, j)lethoric, healthy-looking man, and it is diflicult to credit the stateme.it which he makes that within the iia>t three months he has spent at least six and a half weeks in bed with a prolonged fever in which he was delirious. He looks now a very ill man. His pulse is 120, tension low, but not dicrotic. Tiie tem- perature rose in the evening to 104°. Abdomen was large, pannie- uliis thick, skin covered with u very co]»ious and typical rose-red rash. Kdge of the spleen distinctly ])alpable. The heart sounds wen' eleiir, the first appro'iches the second in character. The patient was rational, but at night was delirious. For the first week in Inispital the tcmjjcrature was remarkably continuous, even the two-liourlv ,^^*!Blfcta- 10] ^ Kliidy oflhe Fatal (hse.'<. 19 temperature sliowiiiir very littl,. ,..,,.;..• . rt was not until he had a ^iT ?"""" ''^° "»'> '^^''^ "'<- -- "H,d, variation Tn Z e 7 """ "'" '•'"• ''''>« ^'-t '1'^- -<1 "f tl.e first ue.,;; ;,;',. ••-'■-• -^'-e F>..Ise towanls f>'-- '-«-r states that the , ' ""' '""'T'^^- ''^''^" -«■ '.v case previous! V treated i' ''''■"' ''"^ '""""H''" tl'"" in an"v reotsean.eoutin ThennteofAray4thisasfoii;nv uir ' "''^ ^'"■-^' '"^^ ^^"•^>""- tren.or of the hands ; t„,„.,,, is 'L- • . 'Tr''" ' ^'''''^ ''^ '' '''»'« I"-'-- '>.Wed,48; th; i ^ ri..:: 7' '^'T I^''"''^' ^-•' ^ -- TlH.dvspn.a was n.arked; th 7^ ^ Vf ' '"' " ^"'•^- '^'•'•'"-•'' l"".aH in front, and there vas llJT.l ;''"^^'"^'^^"'»''^ «ver the -n.el.le,l breathing and nun.:. ^ J ^^ ^J '^'' '--«' -^h ovtosis. The red oorpuseles u-er. ..I '"' "'" "'» ''^"^■"- ^^'"•t'- '-tween five and si tl u" n :"' '^" "'"''""^ J""" -'- '^e about 80 p, . a.nt. On ih,. ml T '■'"•';'"'^ ^''^ l>.^".ogioI,in at ■ bowels, not followed bv anv fl I ! T ' ''^^"^^'rhage from the -«te.l ; heart sounds vn-v f" eb^ " -"I-rature. The deliriun. p,.- -^ '•<»"• or five davs 1 e b t" '' ^"""- ^''"'■■"g *!>« rlu.a.'s, none of large an.ount '" ""'",^'-^- -^<' ■^-'-' flight he.nor- rai.i.l, HO to 1(50. He^yn. M 't ^ '•? ^^i^'^^neh feeble and theHth,whichwasab:^^ '?8^^;r''''^"^^^''^^- >H>t«i— ''Rashisfadin<..al 1 • • ^"^^^'^^•"> Ix'spital, the '™p-y extends ab .2 '^nZZ " -"-l-.blvdistende,!; b^.e] -- 1^^; respi- --i.<" head eon.:^ : f;::i ■;:: :;^-rt;''- t- He amldu.d on the 15th. ' '^' «"»'^ gradually During the nineteen d-iv th* ■ '"■•0 is noted as below 102°" in theT'"'.""'/'' ''"''*'"' ^^'" ^""MHTa- ""^ i" «Pite of the n.ot' r ;^^^^ ^I'""^i"^- He had in all 7 1'^ 'n '^'*"'''" '""""^ -"^ 10-t^ in the great n.ajorifv of" ' ' i '^''"''^'•'"^"'•^ ^^as above nearly 107°. ^ ' "^ *'"' ''^"^"'"'''^^ and it onee reached The special interest in this ease was fb,> i « •. '"■»"'''-'« to a previous -.tf c • . , f /^'^"'^^ ■'Statement whieh '"^ ^'''^'^ives, there appa. u " n b I T ''''"' ''' "— ^^ '>^ ! -.1 .1^1 •i '^, ■i^ 20 WUtidin 0.ile): [vO Aiihpaij. Anatomical diagnosis : Ti/ jilio id fever ; ufcrrs irHhcli'im bases, ami t/taiulu in a starje of vmlulldry infiltration ; fi'.sio)i.i nf relapse; catarrlial pneumonia of loicer hheti of hath lunijs ; artii,' mhirgement of the spleen; swellinc/ of the mesenteric f/landt ; old tuhrr- cAilosis of the lunc/s, T1k> body was tiiat of a larjj;<', stronuly built, wcll-noiirisbcd inmi ; occbyniosos on the arms. Pcritoneiini sniootii. Small intestini! presented in tbc upper jjart oi'tlic jojununi, 100 cm. from thcstoniMcli, many jjoints of extreme congestion in tlio valvuliv ('onniventes. 'I'Im' upper Peyer's patches in the jejunum were liyperaMiiic and swolKn, without any ulceration. Lower down the solitary follicles wire affected as well ; some of the Foyer's patches were greatly elevntcd above the surface and had very sharp edges. The first distimt ulcer was 20 cm. from the valve. Tt had clean edges, and a bnse on the muscular coat. Close to the valve was a series of ulcers with perfectly clean bases. In the upper portion of the ileum every stiiuc of change in the glands up to necrosis was present. There were iid distinct sloughs in any portion of the intestine ; the (mly lesions were medullary infiltration and the clean-cut ulcers. The mucous mem- brane of the vermiform ai)pendix was swollen, but not ulcerated. The mucous membrane of the descending colon i)resented patches of old pigmentation. The sjdeen was much enlarged, weighing 7o(l grammes. Mesenteric glands were all greatly enlarged and soft. The liver was enlarged and substance soft. The heart muscle was p.ik', isoft, flabby, no mottling visible; but there was extensive fatty degen- eration in the form of very fine molecules. The lung presented at both bases scattered areas of bronctho-pneumonia :ind a few nld caseous and tuberculous nodules. A ])oint of very great interest in this case was, whether we could judge from the anatomical lesions the truth of the statements of the friends, and of the man liimself, that he had only been a short time convalescent from a protracKd fever fiefore the onset of the attack in which he died. At the nieetini: of the Hospital Medical Society at which the s])ecimens were shown, Dr. Councilman, who ])erformed the autopsy, regarded the condition of the lymphatic elements of the intestine as rather bearing out this view. Extensive clean-cut ulceration in the lower part represented, he thought, the old unhealed ulcers, whereas above they were in :i condition of unusually marked fresh hyperplasia. T took the view- that the lesions present might have been produced during tliis attack, which had lasted for exactly three weeks. 21] A fUndij of the Fatal Cases. 21 ('ASK XIV. Ad,ms,>on !n thinl ,neek Great ,hl 77 ikUnnm, death, (nifop.v/ 'Mnhty, meteorisvi, giv.. » «,y .«a,M,o.,„, „o,,„„ , ■ , ■ '"'7 " •'■;"•■ «'"' ™" hail been ill |b,ir ivrcli, ah. ,. ', . ■""'' """'I 'I'"' »li<> f..r tlim. ,vock, al,e l,a» liecn i„ «I ""'7';"";"S.C.r .,.,e „oek, and n.i' patiuit uns «cll lV,r„„,l , ,■"""'.•'•'"' """' ™n..tiii!:. .■<|..-.»io.., .cnpera,,,;" l^Jjot ,:;i,lZ'"''"'' '""' " '»>>.'- ing rose to nearly 10o° Thr. „.;, i em,,eratt.re in the even- 1-i retention), contained .1^, ^'i^dT" ;f ''• '' ^''^''^^^ (^ ^he first week in hospital the tenn.ervt" i^ -'' '"'"''• ^'"'"'f? '^' SlK. refused nourishn.en t "o, tl T/ ''"';'' ""^^'"'"'^ ''^■ restless and even atten.pted '^ 1 . '^ T" ^''^ "'''■^ --.^■ -•"'"'f • The abdo„.en wns erv t n ' "'^ ""^ '"^^ *'"»^'« '!•"*« tl.c' 0th she was so feebh- h t \, ^7""'^'" ''" ^''^' ^^"^^'-o" of 1-1 in ail thirty-three. O^t^l: f '^ T^/T'"' ^''^^ ^'^ '-<' (•(instantly between 102° and 104° the middle and u,,r ;, r n l^'es "" ■ ''' ^'■" ''''''' ''"'"-« ''n -cd more rational and ut ut J tn "i"^'- ^" ^''^' "'^^'' ^^- t" '..ulerstand what was 1 id T W ^"' '"; ^"'"'''""'' ^^^"^^^ ^li^ht pressure o„ the abdomen ^^ J" "'''^r^ ^""'^"'^'^^ <- ^i''l- On the 9th the note i s "P, " ';'" '''''' '^'^y ^-Pres- :h / •'' "'' ^^^^'^^^^ ^^is -•^-Irawn; .he pulse is feebl "' "."■^'''^^' ^''^ ^«^« i« "'0".^h not so diSended ■ s t v'. T""' '' "^^^'^ ^^"'Panitio, '^^lor. On the right 't"„ale^ '''"'•'' ''"^ '' '''^ '''^'■" v^-' -- 2 c,u. in diame ; th !" "^ "'^ , '' "'' ''''-''< '^'-ated -^^•" ^-^ent.nkandl;ri;a;;rr^^^-"^^'^^"- M! -'.-w^!*** \ 22 Willi mil fhler. [■>•! Autojm/. Anatomical diajinosis : Typhoid fever, HwelUnr/ itu* .11. (liar, out leeDle. 1 |,e patient took liis Iviflw u,.ll • fl., f tiiir wuH very l.iirl, ,l„,.i„./ H„. ,:, , , '*•' ' V " ' "" '"'"I'l'ni- ;™*- -^V'- .■™:- n;';^ r;L: ■:!,;;;.;::;:-'- '^^ ?'■';"■• '"■;-, '•"'-" -'" .0 «A:;::,;;:l^:Trir::;:,s fnrly and strvcin ,'1. Flo wis v,..-v ,]i,li i i "* J^'^^^" '"t-oliol Mcondweek .„ hospital, about the ICth of J.,|v the / Ixrame lower, and from tho 10th to tl o • I ' i '"".''^"'•'^^'"•^ I()-'° Tl.« ..l.-i -iOtli It did not r so al)ove lU- . llie alxloinon was not < istended TI.,. .>„!. i verv feehlo TI,,,.. "■ le'HUU. 1 lie pulse, however, was ■.'",; ,''"'*■ ^^■^'■•' ••'PI'nrently no coniplieations On the evening,, of the 'JOth the temperature rose t< 10; 5° ' the J~ extremely .ehle,a^ ..ive ofthese ohlong ulcers, 1..:^ of Uiem ;r^r-bad ^^tl^ enlaced. ^^^^J^^SJ^^^C:^^:^'^- T -only slightly enlarged. The kidiu^^^l^^l :^,/ 1^^ l^^ riie heart muscle was pale and flabby. ■ ■''Wtlbng. .|-;.»i on„e .0.,,,., „-„e, i,:;^;;™! t. r;":i;v-: v;;;^' i-^- I J :J. 24 William Osier. 24 Case II. Ailviimon on 1th dtii/. Delirium, kic/k fever, irretjulni lemperaUwe in tJiinl uwek, j)rrs!ntnil roniilinf/, dinrrlititt, pandUis, tlattji (lUtojMlf, Barhtiru L., aj^t-d 15 (Hos. No. 150), admitted July '2()tli, iHsii, iibout the Heventli ilay of lier illiies.s, witli u temperature ol" 105..'1 She was ii well nourished, healthy-lookiiiii ji;irl. Tiie ilhiess l)(;:;iii with hea(hioheH and eough, and on the 2'Jnd siie liad a ehill. On admission the temperature was 105.3". Siie was delirious from the outset, very restless, and liad marked nervous symptoms. Tiie ti m- perature was hij^h, and diirinj^ the first week the daily variaticms were never more than 2 or 2\ degrees. Towards the end of tjio second week of the illness the morning and evening temperature uus about 102°, and the daily range of the two-hourly temjjeraturc not more than 2.5°. Throughout the third week she was delirious; tlie pulse between 110 aiid 129, the tongue dry, and on August (ith jinni- titis began on the left side. She also began to have frequent attacks of vomiting. The fever during the third week was extremely irreir- ular; thus on the 16th day there was a drop in the afternoon to 96.5° without any eiiill and not following the sponging. It rose in the evening to 103.4°, the highest temperature which she had hud for more than a week. Throughout the 17th, 18th and 19th days of the ill- ness the tem|)orature on several oeeasions was normal, and on tin; 20th day it was subnormal for the greater part of the twcntv-inur hours. She had had for several days a good deal of vomiting mid was extremely feeble and weak ; pulse 142. Throughout the LM<;iicr part of the fourth week this renuirkable condition in the tempcratiirp persisted, and throughout the 21st, 22nd and 23rd days the t(iii])(r- ature was subnormal for a large part of the time. Thus on August 10th the temperature at 8 p. m. was 99°, at 4 a. m. was !)lt,(i\ at 8 a. m. it had fallen to 95°, at 10 a. m. to 94°; it gradually rose throughout the day, and between 2 p. ni. and 8 a. m. the next luoru- ing was constantly between 98° and 99". The next day tlu'ie was a drop agaiu to 95°. The pulse was during this period not so rapid, but extremely feeble. The vomiting was persistent and i'olluucd immediately the taking of food. She was given stimulants constantly, and hypodermics of ether and brandy. On August loth, the 2(]th day of the disease, the temi)erature began to rise, and on the 27tli and 28th was between 103° and 104°. Then throughout Aiijiiist 18th, 19th and 20th it remained between 100° and 102°, and on the 20] A Study 0/ the Fatal CWw. 25 latter dite nlie dit-d in ■• «.rm.i;*- /• ■ ."'.••-'.-".....: :;:;;C::::;i;;::;,,"7'''-v.™.n,^^ t«o to four dailv. It was mor« ,.,.... I . "'" '■""^""- ''•"'" "-. Ti.o rash .:• ,n:W '""'' ''^""^'"" "'"' "--• ^"-'- I'lio special f«'atiirt'H of tlie case u<.,v. fi «'' .l-n-i.., tl.o second ^^t tl'u'' r'""'""^^' "^" ^''" udy .,.4 :^;!t;:;yr""' ^^-' ^ ^— ^-/^^ im^ r,M ileo-ca^cal valve, and co„s , ,7 ' '''*'^'' ^'^^ ^'"- <••""' t''^' l«'<^'"-'-l f,.n Is ere sw I T ';'""' ^^ ""' ^'^^'^'^" ^''^' ^'--''^ U ulcers with v i„ i-"^'l --^r : t^;;,™'-;- ''Pl"-^- -as swollen and -"'>'■" 'ullicles were le. .!?''• ! "" "'''^'^'^ "^- ■^^-'■'^^''•^- The f 36 WUtinw Oahr. [2i) rapid 1)ii1ho. Tin orgiin ut-ijilicd ISO griunmcH; tlio vuIvom wipt noriiKil, and tlie note I)y Dr. H'elcli on tlic licart muHcle is, "niicrn- urnpioally entirely iiorniiil ; .striic distinct, no triit'O of i^rannlar op fut (Hos. No. A.oof]), iidniittcd .Fnly l-Jth^ 18!(2. Tliia patient was in lios])ital just a year bei'ore and wms treated Cor entero-eolitis and recovered. He states, however, that lie has since had several attacks, for which he has had repeatcdlv tn *alioii. The ton^ruc was covered with thick white fur. Tem- perature airs or in series of tiirce, lour, or five. Many of tiie beats did not reach the radial. The senmd aortic sound was clear. So feeble, intermittent and irregular was the heart's action that he was given several times hypodermics of ether, and was at (mc(! ordered digitalis and whiskey. The lirst days in hospital the patient was very restless and delirious. The iieart for the first twenty-four hour.-s, as stated, was extremely irrcnular and the action rapid. The rasii became very abundant, the petechia' gradually faded, the spleen was enlarged; he had troublesonic V \V hoBmof/loh initrid , Marked fdrdini 29] diarrhma, fi A Study of the Fatal Cases. 29 liigl), ra ; hve or six stools njiinsr i" fi flay. The t( was s 'fOJ)J)(.cl, patient soomed to be d was delirious only from 101° to 103°. Aft iJs the piilse he ■niporature was not ^r the fit], the dij-ital . ^^^^^ regidar l,ut more rani ;"^;vel,tho.„hhehadhaddian.l: IS and pneumonia develops I'litil the 7th of A' and after that did extended rapidly, pneiinioeocci. The jjulse he Tl: oveniber, when e tenij.eratn 'oi-(' rapid. The id'a and si.uns of plonrisv not ri.se above 10'^° <^i i rn, , ''""^*' "J'i , tlioiiuh tl ire rose to 104° on the 7th The reddish-l 'I'own sj.uta contained ■("une extremely feebh and ii and pneumonia nunierou.s ■•'ip'd, the respirations were between F,n .,,,,7 m Auto]] 'wy. Anatomical diapiosis .- 7 krfje intestines, loh Tl v(('' pneumonia, pi morning oi" the 9tli )ipI)oid uhm/tion HTo was extensive ulcerat 'eunsi/. in .viiaM ant/ fvon to the rectum. The ul ion of the 1 ;i rii liowcl tilt' V, If, clean bases; tl cers were round and !ii-ffo intestine, extend iiiir ii-regular, with. -—'.-«-; thoy- involved the entire Wth of '• ine deum j)resen(P,l .,vf„..,.: , _ ^".-t" ot nive, Th presented extensive ul left liinu iileiira was et.pper and posterior portion of the' con,sol,dated,andinastateof th( ■oration, particidarl large y near ower lob(> oftln over it was covered with a tl nor part of the lower lobe of the nVht pleura 0.10 presented a similar lil red hepatization. The The posfe- ■ing was also solid, and the iin pellicle of fibr in. grammes. The heart muscle was da )nnous exudate. The sol ITOented no fatty degenerati on. pleen weighed and flaccid. The fibres Case XI. Admission in sfat,' nf ,.,./-. j , ... r^^.-..iai;;-;;^t;!i;::.^,^;:^'^:;: •7-' l-althy man, but cannot .;,,^^':"^ ''''"' *''^'^ '"> ''- ^'It- States that he has not had'^ 1 '"^'f t"*-^- ='^^«""^ "f him- '--gular; no chilhs n v^o i^'';;'''"V':^^ ^''^^ '--'« ''-- -^'-^'>"l^i". in aoondi^'o^scSle'dS:" ^""^^ "'"•^'' ""re was 97.5° at 8 p. n, ■xm\ d,M „., f'^»''t}- Hie temper- ='-'f^i^.i-72,r!,uia;/:;L ti^;::,^^^^^ "■''•^- ''-'vily coated, dry an pneumonia in an old man. Auto(mi (Dr. Welch). Anatomical diagnosis: Typho'ul fm,: Remit croupous pneumonia of the left lon-er lobe, enldrc/cd xiileen, (/(ill stones. Peritoneum smooth ; the peritoneal surface of the ileum near the valve was covered with streaks of dark-red hemorrhagic infiltration. Tiie small intestine ))resented a number of ulcers, the largest were in the lower part of the ileum. They were irregular, nearly always as dec)) as the transverse muscular coat, and with little or no thickening, and without adherent sloughs. Many had dark-red liciiiorrliiii'ic floors. One occcu])ied the margin of the ileo-ctecal valve. Tlicy extcTided upwards for a distance of 50 em. There were also many small follicular ulcers. The edges of the ulcers were but little wwlvr- mined. In the ciccum and beginning of the colon were several small ulcers ; glands moderately swtdlen, soft. There was no tviicc of tubercles over the ulcers, which were undoubtedly tyjiluml iii character. 31] A Stnrh, of the Fatal 0„e,. ypleen was soft and we,V|,i„. .(JO "- " "- '^"^ lower Iobo\':' iS'V"?^:''-^'— soH a- oa-.._oan,e, thought very natu,. ..:/*■• '""':"•' "-'- -hose 'levHojm,. p„,„^,,„j .; J tl'.'tit was an insfance of slowly -" -"-'-l, n-as seoondar t^it' • ' • ' " ^^"'"'"■'^ ^^^^^'^ ;- < .V.S befbre death, .on-c„rre I ,:;:"':"; '' -''"^^ '""". two l-e ol.ta.ned as to the length of ti „e U^Tlf'r ''^^"■''^ -"'>;" the ten.peratnre was '■^'n only once did the ten>,,erature r 1 T ' ' " ""' ""•'^'' '•'>«^rva- -'--"s hemorrhages werl «u h as 1 "' /''°- '^^'"'' ^-^ensive tracted cachexia of elderly people. ^'"^""'^'>- '" ^he pro- Case XVJ. Jf/,„/,,,/^,, -^^ Annie M., aged '^3 (JJ ,■ v P"'i™t was transfe;ed to'th^ nielne.!?' -'f";!'"' ^"»"«ry 1, 1892. -Uo which she had been'X ^i'^ "'? '''' gy.-colo.ica ; 'p- and nuUaise. She had ' .h^"' '"''"•^' -'"Plaining M.ad had one child, iwl , 1' " •' "■'""^'" ' "'«med at ^P-ionsly felt well. H .'^d iT" ''^'^ ^'^^-'^<>- «he :' ?•''''-;' ^ 'ver, with relapse. Sell T 'T''' '"' "» ^^tack ''^- Healthy lookin. ^vell nour ''" ^'""■'■'^'' ^«^- "«"arlv . ^"""' 1-Htitis, and thcT e.^.nu V";"'"- ^'^-<><'oM inte,' r'Vf"""- ^^0. T,;:; e^^n.7f --'^'tched. Ten,:;. ;n^yJ t t ^i * 32 William Osier. [.■5:i The urine contninerl no albumin. For the first week in liospital she had no special features except the jKTsistont liitrh fever, w hi el i was not nuioh controlled by tlie batiis. She was rational. 'I'hc pul-c ransred from 104 to 112; slie had no diarrhwa. Ai'ter tlie l!)lli sh, did not take the baths well, and considering her condition, it \v,i> thou^-- contact. The mesenteric ^AJaTZ" ' "'""=''''*» ■" ^''"«e <'"l--g«l, weighed 250 .ram^ur The l- 1'"'' •' ''''''''^'''- «P'^-" numerous small areas on the surface ' '"^/'"'^'^/^^^ Palo ; there were -•rounded by areas of hvpen .•.;•" "'"""" '""'^^''^'^ ''-^'•- containing the typhoid bacilli Th.""'" '"""'' ^^ '^^' "^-^^'««- Afarked cedema and con,r,.«f;. ' ^ ^'^"y degeneration. rose again, and on the 8lh a„,l ,„," T * ' '"''"""I"™"J- •''« fever CEdenia of the L'iotHa ;a ., „ .!'« -ha,..ive Xu b L,'™:™? :t'::^'rP'-.<>« fever. I„ «ere senous laryngeal co„,plieaH„„. i « ■"''"P""'* '" "Wdi there "ly 8 cases the condition ™ t:,!™ j.lill:*™ ™ ""™'- '" III- -ACCIDENTS OF THE Lesiox. Hemorrhage.— Of the '>9(t tl;e bowels, three of which pfo'ventar^';' 'f.' '"'""^'^Se fron. eWery man, admitted on the h ^l! o/h • ''^ '"* '"«^--' - attack, with severe diarrhcea nndM "^ ^'^ '""^««' ^^d a sharp aeath followed shortlv af^.; ver. ^^ J'^''^. '" *''^^ ^^-^'^ ^veek ; ^o«-ol«. In the seeon'd ca e \ vo^ ^ '" i'emorrhage from the '-t two or three weeks befo'e aT^ "'" '"^'" ^"^ ^'"' '" ^^' -' 'Hmorrhage the day after ,sadm""" ''\ ''"^'"^='^' ^"-^ ^ large "--. In the third case ^llrUmJ''' ''''''' ^-"- ^'"fl 't '« given in that section. ^' ''^ ''^" l^^rforation, Cask VIII. Admimon on JO//, / ^■o>niti»ff,per,i,tence of fever in 4, f , ^H^orhosa, occasional '^'-^■^' ^'>out 48 hours after admission . "? '^' '''''"'"•'^' "^"^''^ ^th, disease. «^l'»>-^^>on. and on or about the 28th day of the Autoimj. Anatomical diaraosis- T„^i •> , acute broncho-pnamonia. ''^""' ''^"^''^'t^on of the ileum, Peritoneum smooth. There u-.,« „^ • , ,. ^ines. rn the ileum there v";; ,1"^ l"'^'"""" "^'^''" -^- ^'"'I ""morous swollen soliti • Vn,! ">««r« ^vith sharp edges latter had greatly ole^M ^e iH^n? ff' ■ '"'"^ ""^ ^« anoe. The solitary glands .^ T^^^:;^^' 'T'^' T''- showed superficial necrosis at the apices Tl, "^'' '""'^ ^''''^^ tt'f' '"ost extensive ulceration T ^''« '^""g^ '"destine showed "leors .ith clean bases T:,cr";; "7 "^"""^'^^ ^■^•''■-' (a<-withareasofnecrosisriL. ''•''''''''""■' ""'''' ^*'« «"'- "''• -Kl there was soTe Itv ^ il" ;• "^'" ''^ '"-^^ '*""-• '««'<«d =''-'t them. The soTrce of .t', " ^'" '"■"'"'•^ "'^"»'--- ^ands of the mesentery:::^ ^ a ^tl^::? not discovered. The the valves normal. The musd. ll '''""'•, ^^''^^ ''^art was pale, The lungs showed at L b"e . "" ^''^ '^/^'^^y degeneralion. ■'V brain and cord sho!!:,':::,:^:^"^'^^ '^^ broncho-pneumonia. 'l».l« from .his ca,,,;,.,.- „ :„-*of'r' T" """""■"" '" «m. Or.lK.d^.hto . ,. r '™'"'''''' ™"»^-'3.4 ,,or *ra,. colleclcl oas™ ivas, however, as l,i„h as 11 •^'■■5^-^^ 11 I 36 Willi(i)i) Onlev. [36 The time of the occurrence of the perforation in tiiese eigiit eases was as foHows : in tlie 8th week, 1 • in the 7th week, 2; in tiic Tjih Aveek, 1 ; in the 4th week, 2; at end of seeond week, "_'. In every one of the eases, as may he gathered from the notes, tlie attack was severe, and in more than one-half of tiiem protracted. In six cases the symjitoms of perforation were j)resent — pain, inereasinj; abdominal distension, and collapse. Tn one case (\XI) tiie abdomen was retracted. In two cases the conditicm was unsuspecited, tiioiiuli in one (case IX), in which the appendix was perforated, there was great pain in the right iliac Ibssa. Perforation of the appendix in typhoid fever is not very (iommoii, 3 per cent in the 167 eases of perforated bowel collected by Fit/, who remarks:* "Clinical evidence, on the contrary, though perluips misunderstood, is abundant as to the probable frequency of perfora- tive appendicitis in typiioid fever. The ])robability of its occurrence furnishes the best solution as to the i)rognosis of intestinal perfora- tion in the latter disease. Most of the cases of recovery from .symptoms of perforation of the bowel in ty))hoid fever are those in which an attack of appendicitis is closely simulated, while the fatal cases of perforation of the bowel in typhoid fever are, in a great majority of instancies, those in which other parts of the bowel than the appendix are the seat of the perforation ; hence the prognosis of apparent perforation of the bowel in typhoid fever is to be regarded as the more favorable the more closely the sym])toms and course resemble those of an a])pendieitis." Case IV. Admismon in. third urch. Hemorrhage from lioirrk, prof/rcmvc adiienia, /}erforatio)i, death, aidopxy. Zachariah L., aged 40 (Hosp. No. 319), admitted Se])teinl)er '21, 1889. Tiie patient applied at the surgical dispensary, and while wait- ing became very weak, and had a large bloody stool. When taken to the ward he was extremelv feeble, and stated that h(! was a sailor bv occupation, and had not worked for three weeks on account of fever and diarrhiea. No further history coidd be obtained. Temperature on admission was 101°; pulse 92, dicrotic; tongue was furred, not dry; the abdomen soft, with a few sus])icious-looking spots. Tlic heart sounds were very feeble, the first particularly weak, and tliciT was a systolic murmur at left border of sternum. lie had no further •Transactions of tlie Association of American Piiysicians, vol. vi,, p. 209. V,_ ;!7] ^'1 ^tudy of the Fatal Ca,e^, .37 blmlinj,' throujrl, the day ami «„ • ently drowsy. On tho 80th \u\ ^ ' ^"^ *"" "'«« I'^^sist- -^ the first'two week Oo ."/'''"''''"' '" ^" ''°- '^^''-"Sh- «l-''■:• i"-,i„e. ass,„.i,:;,;:r ' ^ :, :rf ""- '"■- «°"^ -I'-miK tl,c ,,mto,K.M„,. r„ lower oart f | ' Z '^" "'"'I'"' "" «»o. si,e;:i:'„ v;o!z. .^r;„^,»; '^'''' "'""i"'" ■^'»-i. 5. . ctnth „me to ll.,s country ; had been ill for .il S8 William Oder. [38 k: ^ a week with pain in the head and back, coiijjh and fever. It is dilli- cult to say exactly how \im\i she has l)een ill, but she says for not more than a week. .She had coniplained of a ^jood deal of'alxloininal pain, and as there was distiirbanee ol' menstruation she was adniittdl to the fiynecolotjical ward. When transferred to us, the tempera tun was 103.5°; the abdomen was liill, tense, and tender on pressure: pulse 120. The abdominal distension was so }j;reat, with a tympany extendiujito tlie fifth si)aee on the right side and obliterating' the llvi r dulness, that Dr. fiatleur thought that possibly j)erforation had occurred. On the (Uh at 10.30 a. m. she had a chill lasting"; a hwW hoiir; complained of very severe abdominal ])ain. The tem])rratiirc was 101.5°, and only rose by 1 o'clock to 103.5°. The note i)y Dr. Lafleiir on the (ith was as follows : " Complains of seven; abdom- inal pain; respirations 48, shallow ; expiration f>;roanint,s pidselfiH, compressible ; skin hot and dry ; face slifjhtly flushed, not anxious- looking; tongue moist, with a brownish fur; pupils equal. Lun^^s present a few moist rales at the base. Tli(> heart sounds arf fffital in character, very rapid, possibly a soft s -s.olic murmur m the apex. The abdomen is uniformly distended, ri;!;id, very ensi- tive in right iliac and lumbar regions; l)owel tymi)any extends to fifth interspace, and in the nip|)lc line the liver dulness occupies only three-fourths of an inch. The spleen is not palpable. K*opc spots present on back." The evening temperature on the titli rose to 103.5°. Throughout the morning of the 7th the teiii|)(r- ature fell and was 98° at 12.30 a. m., then gradually rose throiij:h the morning. At the visit the patient was sweating profusely, looked collapsed; face j)ale, hands blui.sh; pulse 170, thready aiul very compressible ; respiration shallow, rapid • mind perfectly clear. The liver dulness was practically obliterated, 'i'he temperature between 10 a. m. and 7..30 j). m. ranged from 104° to 105°. Tiiroughout the early morning of the 8th it fell and at 2.45 a. in. was 96.5°. It rose at 5 a. m. to 103° and fell again at ») a. m. to 96°. At 8 a. m. it rose to 104°. The patient on tiie 8th was some- what cyanotic, with cold extremities. The temperature, however, kept up and was between 104° and 105°. The heart sounds were fbt'tal in character and extremely rapid. On the morning of the Htli the temperature rose to 106° and she died at 12.45. Auiopay. Anatomical diagnosis: Typhoid ulcers in the ileum and coBOum, perforation of ileum in three of the ulcers. General puruleM peritonitis. Sacculated peritonitis between the liver and diaphraqm. ILI^. .'59 1 A Slludy of Uic Fatal (hses. 39 Tlu; coils of intestines .ere .natt J ^ ^ j^.'" t^ '"";'■ ' "y'^^' ().rlorn(i()i,.s were seen Tlw ,li.„ ^^"'"- ,^" st'paratn.jr tlioni ponclod to the loner LMt''rT'.:'" ^''" ^'^'''* "•''^' -"- lower bonier of tl.e fllllrtl. ril, '' '"''• = "" *''^' '"'' «>^^ ^« ^he tions; thefirHt,GOcm.alove he it. \ T ^"'"'"'"' P*'^'''™" ""ovo ..is an. another a^iuLl'irSI ^i rj, jr^ ''^'"• teno f^^lands were verv large an.I soft T 7^ Jhen.esen- .run.mes. The heart was no " t; / " 7'^"^'" -"■"'''-1 156 muscle fibres. ' "" ^''^^>' J^'K«'>"'ration of the acW, p„, in the „b,l„„,«„ „„d ,|i,,|,t Z,l Tl, """" Iwve pirsiste.! until the present „,„.,„ .1 •. »Jnipt„n,. th'oe Javs ago. Slie 1,.,1 frl ■ f ' ■ ™""""K. "I'^l" stopped »i.l.ont any lln On ad!.T""\ " '*'" "'""'^ » <•">•■ "a.erv Ld ;"..n..i.,..nt. Tongue t,Lu:::LrT:s;:;„;'L:;t''''\""' liad systmiatieallv everv tl,™„ 1 , """ !""'«"' al»ve 102.5-, wee tZ t', m V'™ "" '™'l..ralure rose «- a few doubtful ose 1 ,rT'", "" "'" ''"' "'"' m \ i 10 Willinw Osier. [4(1 iiiul feet Klifjhtlv cold, toilful! dry iind luird. SciiHorimn very kIiVIiIIv clouded. At tlic l)!is<' of the rij^lit liiii^' tliore is niodified diiliicss; hreiithiiin is Hlijilitly tiibidiir. Abdoincii (lislcndcd, not paiiil'iil. Heart souikIh arc clear and rapid. Patient passed stools inv(»ltmi:i- rily in tlie ni^ht. To-day she was so feeble that the baths were imt given. Thev were resumed on the 4tli. On tlu^ /ith she wms extremely restless ; pulse small and rapid; mind clear. Respiration 30; tongue dry and brown; abdomen soft, not distended, but is tender on pressure in the right iliac fossa; the spleen is not pal- pable. Temperature in the evening rose ra])idly to 10(5°, and she died at midnight. The patient had 29 baths. AiUnjtsy, Anatomical diiignosis : Tjiphnid ulceration of ileum ; perfordtion of rei-mijorm uppendix ; ati.si„ tir;4i;:ur S;rV" '"'''•''''''"'>• '^^^^ <■>.<■«; thus a hath of 20 mhuitos at 70° "I 4 '"'•■ '"•"''"""••«'• ""l"' tl^e !»th mined tho (..aneratn^o , <)f-o ,"• "'•,"" *'"-' """'"'"^ "*' onlv ri-sen to 07^ an.l al S ' <, J ""."' 7" ? " '"• '' ''^'^ rapid. It was noti<.cd H,;. . " ''"''''' '''''^"•"« '"ore ^ ml h tended, rather tirn, tyn.panith, hut not '•--'.■ «^H the' le: !:::;; r':r:>;;-'<;;;;^^^^^^^^ Karlyon the mornin r of the 1( th % ''■""'"^' "'"'* '^^■^"• '"I-', the ten,K.ratnr: c^'o '"^ ''" f^'"'V^"^ '" '"■'"'••"'^l -'- p' -estieLni^ht a:, L,j:.t:;i:i'^ '•:;'', "^'-' 'I'^^-l. , tense, tyn,,aniti,, an.l tende/ ,> :: ,, ^tT"" ^^"^ Fctcd that perihration had taken pl.c,. Th ""' tliroimh the (hiv 'ind hv 8 ,> 1 ' "- temperature rose . "'Y •'"" ''} « !>■ ni. had reached neirlv 104° rr r i on the night of the 10th. The urine io tl.;« • ,' '''"' tl'o onset contained alhunun wihr""-> "-• di:;;:etK-t.r;;:!.d"' '^''-^ ^-^ '"^-'>- Peritoneum contained "-m- fl.„ „,„ i 42 Willidvi Oftlcr. [4: in diameter, ill tlie centre of which was ii round perforation 2 mm. No ulcers in the large intestine. The spleen was enlarged jmd weighed 510 grammes. Intense congestion of lower lobes of both lungs. The entire upper edge of the epiglottis was ulcerated and covered with a dark hr(i\vu, eas^ily separated fibrinous mass. There was slight necrosis in aI•ea^ on the posterior wall of the pharynx. The heart was pale and soft, the muscle not fatty. Cask XIX. Admmio/i in nccond wed: In fifth week of ilhw^^ great abdominal pain, vomiling, no pain or mcteorium, emaciation ; awl in seventh week pain in abdomen, no .•^wcliinr/, vomilinff, dian-haa, death, antopi^y. Benthinc L., aged 21, domestic (Hos. No. 5597), admitted Julv 22nd, 1892. Patient had been a healthy girl. Present illness h(.i:aii about a week ago with loss of appetite and chilly feeli.igs and fcv.r. On admission the temperature was 104.5°; pulse 118. Abdoinen was not distended, but tense. There was a sliglit erythematous l)hisli over the lower thoracic and upper abdominal regions. Thcs splem could not be felt. Examination of the heart and lungs negutivt'. Urine contained a trace of albumin, and there was distinct diazo reac- tion. During the first week the temperature range was between WV (after a bath) and 105.8". The baths reduced the temperature an average of three degrees. There had been a characteristic rose rash and the spleen could be distinctly felt. During the second week in hospital the fever kept high ; the baths had a very marked inHueiice, often reducing the temperature five and on one occasion six dcirrco,-, The pulse was feeble and rapid, from IIG to 120. The tongue wa> dry and coated. There iiad been no abdominal distension or tender- ness, and onlv lately a little tendency to diarrhiea. In the third week the temperature was on the whole soru.o.-hat lower, though it often rose to 104° and once to 105°. She t ok f ,e baths well and they still had a very marked infiuence on the ft/er. The rose spots dis- appeared. The pulse had been somewhat better. She had iiiid troublesome boils on the back. There was no delirium. During the fourth week in hospital the temperature was not so high, and between August 13th and 17th it was usually between 101° and ll)2^aIl(l she seemed to be doing well. On August 18th, after a bath the toni- perature fell from 105.8° to 99.2°. The pulse rose above 140, und 4;5J rforation 2 mm. A Study of (he Fatal Cam. 43 "«■ Patient complained of ...-eat -ihrln • , exeremely weak condition, st hi; "? .^"'"' "''^ -«« "' - g'v™. Tl.e temporatnre;notvil''T ''"'.'" "'^^^'^^ ''«^l to 1,. "nt.i -' a. „j. u fell and ..eached lOl' p', '/ ',""' ''"'" ^''^'^ ^'"-' se vomited j^reenish fluid. Since ih. . u '' '"""'"" ^'^^ ^^th of t,m,.,s and complains of ah.lon n ' '"'"•■^^^' ^ ""'»'>er tl'e n)tl. the patient was bettor thnn ' " "" "^•' '""^'^""-'t. On ^y^ The ahdomen .as ^l^t t " ^ "'"^' /^^' ^^^^ "^^ better h th the vomitin. .as u tro«b,c,.so„ i,,;^;''"'^' ^''^ "«^^ "'«*, the what nervous and excited Thet ^ ' '"' '''''^ ^^'^ ^^as some- H'f ^ but after spon.ing salk^ T'^"" "" ^'"^'"^^ ^^«^ -sc to abdomen had been retracted ton 1 ' T""*""'^ ^^'^'''^ '*^°- The l^'tient was now n.^^ ^J^ ^'P' tender to the touch '"""'-l'-'^^-^- l^>on. this in ;^^^^^^ ^/^=^^-- ^J-wn, the -..■erne V irregular, each dav r ^n ';:''^^' ''' '-"P"-ture was 'I'cn ^allmg, sometimes to norm , . ''"' ^^^° '-"'^ ^04°, and f '• ^^Oth the special tend^; ' Ir;^^'^'" ^--'"^ -.^normal On ""5 f - -- no distensiot S ' "^ "; ^''^' *'^^''«-" -- noticed, ^'"-l ^'- vonu-ting had been severe On '^h'Tw'"' "'■'^''"^'>' «^^W^' ^;nc.al condition had not iml.^d '^^ "''^'^ ^^^^-^ that the Tliere was less vomiting; the nu se u ""'""'=»*'«» ^ad increased '"f^.^- "'oven.ents during the ni^ht O .,""'"* ^''''^' tive invol- ''"' ""t rise above l()O.V/sl l' ^^V''^^ '^^'^t the temperature I •«"'«"• l.st. ' "'" ^'^^'^""^ ^^«bler and died on Sep , /^"^« Anatomical diagnosis- /... , (F//..v,k ^ '^'•^«'«''".^/ «^«- ^" «.yy«o/./ /,,„,,, /^J^j I'eritoneum covered witi, « i '":-«: . On .he s,>,„„i;" ,;'';: ;■-»"•' ^ ''"'e or „„ «„M -I- Tl,„ „„g,, „,„„ ^,„„;™' " '■ 71-d ..o dc,,,.. „,„!, ,1,, " "* ""^"- '" '^» 8-, and'- .„:,;r x r::;""","- -- I *^™ "«« "ndermincd » t ■ I i 1 1 44 William Osier. [H edges with clean bases, exposing the transverse muscle fibres, hi the large intestine there were no ulcers, nor were the follicles at all swollen until the descending colon was reached. Here the solitar, tbllicles were prominent and showed superficial losses of subHtaiici. At one of these points perforation had occurred. The ulcer had clean-cut edges and the perforation was 2 mm. in diameter. Anotlur ulcer occurred in the sigmoid flexure. In the rectum there was ;i large irregular ulceration just above the anus, 3x3.5 cm. in size. The mesenteric glands were swollen and enlarged ; the spleen was not much enlarged. Cask XX. Admission about end oj first locek. Moderate J'i'm. rapid and feeble pulse. End of second week, abdominal distension and pain; de(dh, autopsy. Henry A., aged 35 (Hos. No. 6231), admitted November 1st, 1892. Present illness began about a week ago with pain in the back n^i the neck, general stiffness and soreness. Worked until five days airo. Four days ago felt very dizzy and had pains all over, and has tilt hot. Has been in bed for five days. When admitted the temper- ature was 104°, the pulse 120, respirations 32. The tongue wasdrv and coated; there was a well-marked rash on the skin of theabdoiiuii, and the s{)leen was palpable. The fever persisted, not nmeh influenced by the baths, only occasionally there was a drop of iiidie than two degrees. The patient seemed to do well, took his food satisfactorily ; the pulse was sometimes ra])id and feeble, 120 to 12i). He was perfectly rational. The abdomen was tender and not specially distended. On the 8th the note was, " temperature from 4tii to 8th has ranged from 100.«° to 104.2°. The temperature of the baths was reduced to 05°. The drops in fever after bathing have not been at all marked. The pulse has been feeble and rapid, a'ld the patient has been given stimulants freely and strychnia." It wa,' noted to-day that there is some tenderness over the al)d()inon. in the evening the abdomen was found considerably distended, i)artiou- hirly in the epigastric region just below the ensiform cartilage. The bowel-tympany reached liigh and completely obliterated the liver dulness. The patient sank and died at 11 p. m. on the 8tli. I noted as follows: "When I saw this man at 12 noon there were no marked collapse sym])toms; the pulse was rapid, hut not small; face not pinched or anxious-looking, and he answered ques- ^V- A l^tudy of the. Fatal CW.^. 45] "^ "J "'K ratal Ua.Wi tions readily. TJipro woe .,„• • . . .l«'»J»J- Anatomical fi^nno.. e.ud.to i"-t. At a distance ol" 8 e„ • bo^ 'l. ''T ' '"*"''" ""^'^^ '— ■^ >'>• ^2 mm., which passed "r^'rha^.h" ""'^ "' "'^'•■•^*'- serous layer. The n „rn^.. " , ^"^ '^''"*'' perforating,^ the ^o.nUtheso;;ta;^;s;^,:nr :x^ ^r ^^^^ ^^'- presented small nlcerations In flu l throughout, and son.e not MvoIIen. The spleen vei.]. "l L ''" '"'"'"'' ^''^ '"'"^•■- "-^ little ,.ale, butof go d con is tn '^'f ""'"^'•^- '^^e kidneys were a -1 i" color and'looked C ; ^^;;^^-^* -"-•« was brownish- changes. "'>• ^^^ ^""gs showed no special Case XXI. Admission in fourth w,rl- nr ■ ■ , !imt miity si,ns of perforatioi, ^ Z^,, f ^ '" ''''' ''^''^''''' FerdniandW.,agedlS(Hos io (hA i . Patient had been a healtl/v nvu, Prf '''.m"'"'^ ^^'«^'- ^^*''' ^^92. ago with headache, which hafLn '"'' ^'^^"" ^'^ '''^^ been in bed three weeks tit, a'r^^fr""^ ' ""'^^""■- «^ ^- l«.'t few days he has had diarrhea 1^ "^"J'''^'*'^«- ^^''tJ'in the l.ad opistaxis five or six t „ e On -H •"' V''^' ^"^ ^^--''^'^ '"" 105°, rose in the evening to 106° .p:^^""''^«'«» /''« temperature was not emaciated; temperature at the i^*'' '!'^''^"* ^""'<-^ ^vell and was P'.l.^c. 1.0, small in volul ; o irtr"V"'"'"^'"' ^^"^'^ ''''• '""•«'• There was no delirium Tf >^"' '^''^"^"' =^ ^'^l^ ""'i the anterior superior Inine ,1 ' """^""^ '^'*^^^^" ^^^ "^'vel »bo'" ti.e si^e of a V ;ur : ft InT T"/ '^"';"^ ''"'"^"^ -- |-;- There was resonaneoer it t:;!",' '"^ ^^'"■^'^'^'^ <'" We; heart sounds were clear n, . ! ^''''" "'"■'' ""^ palpa- l-^'«^™tlyhigh,bu wa h^l„,f ;"^'\?^^^ "•«"'^- ^^^ ftvirwas 'ion bein^/from ^ to V W " ?: /"'r'^; ' •^' ^'"' ^''^''^' ^'^ -'- "' i-«Pital he became vefy m\,el f' M ". "'^ ^'" ^^'« ^'"'^^ ^^•-'^' ^''"'« -nuMn,t. He ha 'bv , r^^"' '' ^™'' "^ well-defined ^'-ges in the mass in t' ^ ' ""'"I"''^ ' '^""^ "^^^" - >^''='t dry and fissured. O. ht L '• ""' '"'^'"" ^^^ -'— ^" the 24th the notes as follows: "Patient i .1,, i M 46 Wiltutm Osier. [tfi is lying on his left side with his hand on the abdoracu, groaning, eini- tinually. The al)doinen is retracted and very tense, and is pa in In] on pressure, but after examination considerable i)ressiire is borm without much increase in the pain. Fulse is 120, full, but ot )i,\v tension ; tongue is dry, brown, glazed. Yesterday he had six sfool.s fluid, yellowish, and contained no blood. There is no leucocytot-is. On the evening of the 24th the tenij)erature rose to nearly 107 ' On the 26th the note is, " temperature remains elevated ; the diar- rhoea, which was better, has recurred. The abdomen is retracted :uh1 tender; the pulse is small and soft; face is ])inched. The teni|)(rii- ture rose to 106° at noon." He gradually sank and died in rlic afternoon of the 26th. Autopsy. Anatomical diagnosis : Typhoid fever, perforadou of appendix vcrmijornm, jihrino-puraleiil peritonitis, ehronia diffuse )iepj,r\. lis, gas hacillus in the hlood. In the lower half of the peritoneum there was an extensive fibrind- purulent exudate. In tlie right iliac fossa there was some; browniMi- yellow fluid with distinctly foecal odor. The vermiform ap|)eii(lix was 6 cm. long and buried in a mass of lymph. On examiiiatidii u pin-hole perforation was found near its attachment to the wocuiii, from which gas and fluid escaped on pressure. Small intestine was apparently normal until the middle of th" ileum is reached, at which point there was a single enlarged follicle. Peyer's patches were not swollen until 35 cm. above the valve. The swelling was slight in amount, the edges a little elevated. The lir.-t ulcer was 20 cm. above the valve, in a patch. Other uk'crs with sloughing contents occurred just above the valve. Tiie ca'cimi jire- sented many ulcers varying in size, some with sloughs atrach<(i, others with clean bases. Many ulcers existed throughout the asctiid- ing and transverse colon. In the rectum there was an ulcer ;] niiii.iii extent. The appendix vermiformis presented two ulcers corn'si)oii(l- ' ig to the jHU'forations menticmed. The mesenteric glands were enlarged; the spleen weighed 210 grammes. The kidneys weighed 260 grammes together; the capsules adhe- rent, and microscopically the organ showed a chronic diffuse ucpliritiN The heart muscle was pale. The lungs were congested and (I'deina- tous at the bases. Gasp: XXIl. Admission in end of first week Mild atbid- atjir-i in third week liigh fevtr and delirium, in sixth week much deliriim '»''' 47] ^■' ^"^tndy of the Fatal Cases. "go «l, eo„gl, and ,,„i„ ,■„ .H.- ,, j,"^ ' '"<» l^^.-a,, „•, „.„^, ™" «>"r day, ago, ,vi,e„ ,„ ,/ ;, ' I"'!" »' «„rk, h„„,„ "t igh, usually ..euehing e - dt to"\^^"^^^ '" ^-P^tal "^99°; thus on the 14th, lotirund 4t% n '" """'"■"" '« '^^o '-0 ran.e was between 990 ,;,^"f;/.^'^ <>f Deeember the tempera- - r'des disappeared. The p„,,se ta's no." T"^^ ""^ ^^'"^^ -"I •'""•'•''^«='- About the ninth davZ ''^ ^^^' '"^ ''=^1 no -'' it was regarded as a 1 of ''V'''''""'"-"^''^'-^--^ ^-e spot --' --'c in hospital t:;:';::;^^^ '"^^"^•^^•- ^^--"^ - ■^-- -i 103°, and the baths r:!!" '"^^ ^""^' -' ^'-^^th wk the teniperat.ire kent nn o, ^ -^'H-<»'g-hout the third '- f ^0^°. He tooriir.;:;;; ;:r"^' ^? ^^'^ -^^•''- anoe of a patient severelv ill. He 'a I ' """ "^' '^'^' "''I'^•■"- -K 116, and of low ionsiou ^'1^^'::;!^: "?'' ^''« 1-'- -as that the baths were omitted H. I 1 '' ^' '^'-^«^"'^' -^o feeble f; 0'- ^-or. He hadt, ^tr:T\ 'f '""^ ""^^ =^ ^"^ :^l^'''>'"«' was not speeiallv ten e V J^^'' ''^'"^-n-hage. The !;;i'roved sonaewhat, so tha't the Mh; ' "' ^''''''''"^ '"'^J ^e rhe te„,perature throughout the fi „• h 'T""^'^^ "" '^'' 28th. ro. 010 to 103.50. tie ren nS h^ ""' "'" ^^^'■^•-' ^•""^^-g '- throughout the fifti, week H 1 d "V' the san.e eondi^ -H^cnerall, eontr,>lle,l with a pill oV """'''•' '^''"•''"'^'' ^^'''-h '"'■^ "« ten.perature heoan.e nol ' ^ "'""'"• ^" ^''^'^'-^th ;7/'-l- -ari, to normal ^ Iff' i;-^ ^-I'-^b' there f ■'' !| - IS William Oskr. [48 k'litly ;\;Ji pigmented edges. ^ ^^^ "^^''i-' were two ulcers There was an irrpfmln.. i t-'e. The spleen weighed 21otatiesr^^^^^ '"'' '""^ ^"b^"-- -;e swollen, the substance coarsf aTd ?h 1 "" '"'' '^*'« ''^^^^y^ . The heart substance was moderateh fi ^ "'''' "'''^''^' •nt.">a of the aorta was fattv tZP ' '''°'''' '" ««^"'-- The and a-dematous at the bases " ^°^' '""■' voluminous, congested iitf! r i W (Ly^L. ii\ IV.— NOTES ON SPECIAT. FEATURES, SYMPTOxMS AND COMPLICATIONS. by william osler, m. d. 1.— Analysis of tuk General Symptoms. (/. Tke Ra.-th. — Rose spots were noted in 199 cases, 8G.9 per cent. In nine cases they were very abundant, occurring not only on tlir trunk, but on the arms and thighs. In one instance, a lad of 14, they were present on the face. In two instances there were small petechial spots. In one of the cases (IIos. No. 469) the attack was very severe, and the patient died. In one of the fatal cases there were extensive ecchymoses. A diffuse erythema, usually punctiforni, and in m.ost instancts about the thorax and abdomen, was noted in seven cases. Iv was present usually at the time or shortly after admission, and disappeared in all instances within two or three days. In one case it was also on the arms and about the joints (168). In one case, a boy of eight, there was an urticarial rash on the face. Peliomata— tachcs bleuatres or maculse ceruleie — were noted in several instances, always in association with pediculi. h. The Fever. — The temperature was taken every two hours in tlie rectum, unless there was special reason against it. In hospital practice there are but few opportunities of studvini; the fever of onset. There were two instances in which, contrary to the general rule, the temperature reached the fastigium on the seoond day. One is the interesting case, to be given under the section of "typhoid fever and malaria," in which within 24 hours, from 4 p. m, on the 22nd of October to 4 p. m. on the 23rd, the tempcratiu-e rose eight degrees, and then remained high. The other instance illustrate? how abrujjtly the temperature may rise at the starting-point of ;i relapse. In No. 3684, after seven days' apyrexia, the toniperature rose more than seven degrees in 36 hours. This was the starting- point of a relapse, and the temperature did not reach normal again for fifteen days. An instance in which a gradual step-like ascent 51] SYMPTOMS ■"""'"' *"""'■ 'Wc™, una a.,.p,u„uo„.. - 51 of the tempornture occurred ,1.,.^ i 7 4710), a case .ulmitted for Z.f Z "r '? t"" ''• <«-• ^o. '-- after thirteen days' sta,!: 1.;: ^^'"^'' ''"'^'"P^d typhoid I here were 152 cases G(i 'i the pcrature above 106o f '"' '"'''' '-^"^ «^ ^''e 8 -^- There was only one fata cas^Mvith Tt ""' ' '"^''^'' ^^^ P- '' n-n a^-ed 70, who was admittc . T^l 7'7^^"- '-'o- 104", iiowing is the ::t;:^ :?inl: r'" r^^ ^^ ''' --^ -- 10oases,of whichTdied; 150-160 5 '\"''' ''^'^ = ^''ove 160, ;:^^; J5 cases, of which 5 died 130 iT', "'"'' ' '^'"^^ l^O-' '':; ; 120-130, 52 cases, of wh d. fdi ^ '^ "^^«' ^' -'>-^ none «'th the pulse rate belo^v 1 '^0 T>. ''"^ '''''■' ''"^ f'^t-'l case |-nce very slow pulse, on: at 4 calem!""?''' k""'"^'^ ^«'^-- 1 12j per minute. ^ ^ ^ ^^^' '""' another at 56 (case ''• I >i(irrh(m. —The l)oweIs -t. Of these, in 28 the disclZ, ";;:. '" "''>' ''.''^^^> 33.2 per ''^■^'-^'•f- In 153 cases there wis 1 , u'^'""'' "' ^^' "^«^l«rate '^^ ''"-'« ■•" the fatal cases wa t folio """ '''' ^«"^'^-n «f --^'•Vht, in 10 it was proC and T!- '" ' """'^ '''' ^^'-^^-a ''• ^/^/m,._The organ was enh" 1= '"' ^^'"'^ "'^ ^^^"'hcea. '^-ostal margin in 147 Jates '^'^ "'^^'-^^^^ *« be felt beneath - — Relapse. In the 229 cases there were TS '*> fever «„„ed a„d |,orsistaI J !,„/;, ° '"'''""' "f •■'l'."e.via, "'»»' more |.ro.n„e„, „3.„,,,„;; ' 7" '"'" » "™'--, a,>d i„ ,,,,,„,,' "*■ '»'-.'«; ^piee„, „. u:„T.::.i;;.:,t:;:„r "-«. - the in \ I Hi • ! '. ^ \.^. 62 Willitiiii Onler. •■).' The iiatiiri- of the relapse in tyjihoid fever remains obscure. W, spealv of a fresh invasion of the bacilli, u iresh formation of tli, toxins, but whv the disease should start afresh after a wkK- convalescence, aiid perhni's pursue a more severe course than in tli. original attack, or why in some cases there should l)e a second ,„ even a third repetition, nvc remain completely ignorant. We d(, imi even know whether the incidence depends on endemic intluencfs i;,. would appear from the great variation in the freciuency of rclnpse in different places), on influences which affecahc fie^-r/ ; or on peculiariti.- in the individual organism, influences which affect theso/7,exha.iM. I quickly by the first crop, but renewed r..=^ quickl.v, and again reiidcr/M susceptible. The first attack gives, as a rule, that intiiiii.tc nii.i remarkable modification of the tissues, fluid and solid, which wee;,!! immunity; but, failing this, however produced (weakness of the arni.v of phagoctves? f\vilure of the development of the antitoxins/i th, organism is again liable to infection. On any . lew it is diflicilt f understand why indiscretions in diet should sometimes precipitiito ;i relapse. There were no relapses in the first 33 cases treated on the symp- tomatic plan. In the 196 cases treated ^ince the introduction of i\v cold-bath treatment there were 18 definite relapses, 9.2 per cent. Tl.c dfts of apvrexia were as follows : 12, 3, 5, 10, 4, 7, 6. All of tiie cases of relapse were bathed. Four cases died. We cannot follow accurately the rule of calling nothing a relaiiM without a definite period of a])yrexia. In rectal temperatures tlie normal limit must be placed at about 99° ; and after the declin.. n. the original attack, a period of some days with a teniporatuiv between" 98° and 99.5° should be regarded, i)articularly in a voiiii-- person, as an interval sufficiently definite. Thus Ada P.. (IIos. Xn 5430) was admitted about the 10th day with a severe attack. I.y the 20th day th^ temperature had fallen to 99°, then on tl.c 21st. 22nd 23rd and 24th davs the temperature was between 99' and 100 . occasionally falling to 98°, and twice in these four days nsn.- above 100°. Then on the 24th, 25th, 26th, 27th and 28th days tliere was a gradual ascent and the temperature reached 102 5°. On the 28th it reached 104.5°. The spleen enlarged and ^hcre «:,- a crop of rose spots, and it was not until the 35th day that the te.- perature reached normal. .^3] •V/a/ FmUur., S,„njAon,, and Coo.pfications. .Iw.' i. a n„rte,. „,,,„.,,„e» „r .„ .Ik S, , , ^ i' "'i; "' T iHiH„„,. A,,.::;:^;:;:;;/;'':7^■:t;:r;::^t;'''■T" »»r.v 2n,l, tl,,: te,„,„.rature f„r ,l„. r.J ""-,""" '". ■<""■ -'.> -ird she ,„„l „ ol,i„, i„ „,.w, .,,„ ,e,,!„I . »„„. .„' ™::",;'""- -s between lokn^l lo/o" tT"' r' ^''^ '''' ^''" ^-M-ature I,™. , Tl,e„ „„ ,^ "",■'"'' "" """"gl" cmv-alcsceiice w„s •b""""^- men, on the aiternoon »if tl». ii.i. ^ rose to 104°, and by ,nidnid.t to iX ll ! temperature » -. .ash, „„„ .he 'de \^:;:t;tt: ir''"''';''V'"'' -lirt.i..g ..r.hedisease, I ,„. fr.„, 'la , ,"y td 1 , Z 7 > ', " I. .e„„o,l a eontal J , "t, ;e^ rallT'™"' "'"• T"''' ""' Ui V. ill; It Ih > I 51 Wi/liiiin Oxhr. [fH 101^. All tlie sytnptoniH improved and Im lookod sih if howns ciifcr iiig upon iiip convalescence. Then on tlio Kltli, 17th and IHth tin temperature was between 9fl" and 100", and on the 19th day rose t.. 103°. The spleen enlarf^ed and there were roHO s|»ot8. Tlie seediiij attack lasted lor only ei;j,ht days, the fever p-adually suhsidini;'. It is iiii|)ossil)le to draw a hard-and-fast line between tiieseeasi.. and the }j;enuine relapse. This is well illustrated by the follo\\iim oases : Annie M., ajred 28 i Hos. Xo. looG), admitted aimut the eij:lit[i day of a very severe primary attack. On the morniui;' of the Utlli day the temperature touched 98", then on the 25th, 2(Jth and 27tli ii ranged from 100" to 104°, on the 28th day it attain reached ncurl'. 9,S°, but on the 29th, 30th and 31st there were no marked (b(>|is and the teni])erature was between 101" and 103". About the .'Jlst day the temperature began to rise, and she entered ii])on ii period in which the evening rise was up to and above 104°. There wen rose spots which came out in crops, and this recurrence foriiiwl a very severe attack. Kven with the sponging, Ixstween the 31st ;mil 43rd day, the temperature did not sink below 101°. Trom the 4otli day the temperature was lower. She gradually sank and dieil on the 49th day. Here was a case in which it was impossible tosaytli(rc had been any interru])tion in the pyrexia for more tjian an hour or so at a time, but taking the symptoms as a whoU , there can Ix' no question that she had a very definite and positive rela|)se. Mary :\IeG., aged 13 (Hos. No. 6405), admitted with fever which began two weeks ago with severe headaches. For the first hi days in hospital there \\:i- scarcely a day in whi ii the temj)eratureilid not rise to 105*^, and once rose to nearly 10G°. The baths and spoiigings had very little influence. On Decend)er ItJth and 17th the tempcratniv became a little more irregular, and from the 17th to the.'iOtli, nearly two weeks, there was a remittent type of fever, the temperature fall- ing each day to the neighborhood of 100° and then rising in the evening to 103° or 104°. These remissions were very marked on Dt- cember 24th, 25th, 2()th and 27th, when the evening teiiijM'ratiirosank on each day to 99°. Then on the 28th, 29th, 30tli and 31st the niornins; remissions were not so market d u|)oii a pcrioil 4°. Tlion,. wciv irrcnro fornicd a ct'ii th(! .'51st ;iii(l From the -lotli ink and died on ^sible to saytlicrc than an lioiir nr there can lie im 'lapse. with fever which the first I'Ulavf iperatiire,d. the snleen J , T''"" "" l"'«t-tvphoid :- ...od. and it .;.s, r^u!- ; "v ; ::^j:; "7-- -...ii.i<>n instance of relapse. From r. \ ' "-^ ' ""' '"'Wrch-d as .i,, » iicic were i|i, . , ,,fg_ During convalescence there ,..«,- i intervals. There were ei' h. , ^r "^."^".^.r^'^ ^-- ^or short normal temperature, the CL C:m;" v' ' '^'^ '^ ^'^"'^^ «^ """"'alH-.s Of convale.,..„,e m„sf , V ,, ""^"^ temperature "•-<' so-called ree, ...^ee" 1 !?':' :\ ^''"^'-^-'^'-'d '.•om ■"'Portant to recogui/e the fio. ./ /l^'^-^^'I'^^'d elevations. It is -vous subjects,' the aL^^^^T '" •"'"'' ''"''''"»' ^'^^ '» -- n'-^locted, and when strong ""^^.1^ ^""'-"^ ''"^""*''^'' '^'^ '--}' '-e "I'- Though really of n n Z'\ '' '^^ d V ""'' '^ ^''"" ^'^ ^°^-* no little anxiety to the phvsthn ', uT'' '"">' ^'' '^' «"»«« of '''ready been referred to L count I 'u' '" ««»^-^^'^'«-™ee has ='->• 1<-'P up a slight fever 11; f '\' "'"""" ^-'•'^' *««> «'■ complications and se.,ul th ' , "'' ""^ independent -'1 -derstood elevations of l^rZ^T "" "'^ -''''''''''^' 56 William Osier. [56 relapse. The following are brief notes of the eighteen cases in which, after the establishment of normal evening temperature, irregular elevations occurred : Case I. — Henry H. (Hos. No. 392) ; mild case, afebrile on the 23r(j day. Ten days subsequently the temperature rose to 101°, and remained between 99° and nearly 101° for 36 hours. He had had solid food on the 7th. He had been constipated for five days. With the return of the fever there were no special symptoms. Case //.—Charles S., admitted June 7, 1891 (Hos. No. 3244). A very protracted and severe attack. The decline in the fever was very slow, and it really was not until the 50th day that the teminr- ature was normal ; then, every day or two he had an evening ri.-o to 100° or 101°. From the 61st to the 67th day the temperature was normal ; then from the 67th to the 75th day thp temperature rose every afternoon, and on the 71st, 72nd and 73rd reached nearly 103. There was nothing apparently in his condition to account for this rise in temperature. He was at times constipated, but it was never very clear upon what fever depended. He ultimately made a satis- factory convalescence and was discharged from the hospital on the 79th day. Case III— A. G. (Hos. No. 3260), admitted on the 12th day of a mild attack. The temperature was normal on the 21st day. Then from the 23rd to the 29th day the temperature range was from 97' to 99.5°. On the 30th, 31st and 32nd the temperature rose to between 101° and 102.5°. On the 37th day the temperature rose to 102° and remained elevated for 12 hours, then became normal and remained so. There was nothing in the condition to account for this subse- quent rise. Case IV.— Vim. S., aged 24 (Hos. No. 3552), admitted on the 7th day of a moderately severe attack ; temperature range from 103" to 104.5.° On the 21st day the temperature was normal and did not rise above 98.5° until the evening of the 26th day, when it Ijonan to rise and on the 27th day was 103.3°. The edge of the .'^pleen could be felt, and as there were a couple of doubtful rose spots, we began the baths again. A relapse seemed ])robable, but on the 'iSth day the temperature fell and was 99.5° in the morning. From the 28th to the 43rd day he seemed perfectly well and lie gained in weight. Then on the 43rd day, 18 days from the ])revious elevation, the temperature rose rapidly in the morning to 105.5°. There were 57] 'V«^«^ Fe.U.e, Sy..,to.. an,. c:o.,n.aUons. % between 101° and 102o. O "ZT. 7'. '"'"'''"^^ ^" ^^^^ ^-i"' Has normal from the 46th to his i oh-.t V " '''^' ^''"'^^"^"-V, and ^00, It was impossible to attritt h ?' T '''"' '''' ^''^>'- ^ere, ■'special constipation. ^'''^ "'^ ^" '-^"r error in diet or to normal on the 27th and 28th\hv. n ^^^ . ^^''"P^rature was the -^Oth it rose to 105°, an on L .?' ''"' '''^ '* >•"«« ^o 103°, on to i'or discharge it rem'airir 1^" Th'''"' -• ''''"^ ''^ ^^^^ "»<' nervous, and very oonstinnllj rr ^'^*''"* "«« e^^eitable to 105° after the temp rat 'Ht '''" "'"'" ''^"'^^''" than a week and had 'been norm' '"V""!'""^' '^"'"^ ^^ "-- -- complication, but nothing :^^ fo undt "' ""'^' "^ ''^^J-^ 21st, on the 8th da, of a ^^t^r!^;^''- 'J!''^' -'-^^^d October nornml on the 24th day and rem-n'; d ' ^^'^''"''^^•'^^"r^' beached -- to 103° and ren.ain.l betw Jooo ::;," It''''' '''^' ^^•'-» '^ ■ng morning. Looking for the n „b r. ^^ ""^'' ^^^ tbllow- absccsses were fo„„d on'the b el 'if' "'!"' '"' ^^"■^' ^-' -'="' ;-eted ,; he did not gain streng ;,,,": "'"r^'^''^^^ "«« very p,,,- -'' the 81st to 83rd days fronf 1 e ' ' '/ "^^ ''' •^— >' l«t, 2nd and "a ''"'7; !!' ° "'^'""^ -'^ --" ' '""'''""' "" '^'"'"'•'^- '-^th,^th^:h t'lf :^nd ? ?""• ''"• ''''^' ^''-tted Octo- '•" to normal on the •25[h d ^ On'';;'"''' '^"'"'^ ^ ^^'"^--ture '^"'I'orature rose to 102°, and ker^nn 7'''"'"^^ '^ *^'^ -^^th the obvious cause. He had n^t hid so ,7 ?' "'-'' '^""y ^^''thout any ;'o«', and on the 47th, 48 h a^;^ 49' "'; "^'^ -"-'J-cence wa '"-' the teniperature'rea „• : 103° -If ''! 'r' '^ "^^"^' ''^^^-'^- <>^ "•as established. ^ ""^ ^ •''^^'' "''.ch the convalescence ^^^^^^2™;;;?;:^::.^-;:^^ Xo. 4452, admitted De- ^t-e not tailing to norn.a/.^ n r" 5;r?"'"' T"^' '^' ^^I- : ""•'-^- "»J ''ad hysterical attacks V f l?' . ^^' '^'^'^^'^'-^d ^ery !ye,nporature ranged from osf^rino""^''' ''''' ^^' the 15th '■f-ated and he complain d "L a ' '. ''^ ^«"^- -- - ''^'^^•^'^'-^•onthebaAandabllr:^.^^^ «re a tew suggestive ■4 f I IN,-. 58 William O.'^kr. [OS spots. On tlic iii-iht of the 14tli he was ulso delirious. We thouglit that it was possibly a very late relapse, but the temperature fell and on the 18th day was normal. He had not been constipated, and at the time of the fever he had been having solid food for between two and three weeks. CWe 7A'.— Louis M., aged 17 (Hos. No. 4458), admitted on tli( 10th day of an attack of moderate severity. The temperature on the 20th day was normal. From the 20tli to the 30th day the temper- ature range was from 97° to 99°. From the 17th of January, tlie 30th day, to the 2nd of February there was mild fever, the temper- ature rising every day to 100°-101°, without complications or un- favorable symi)toms, and it seemed an instance of protracted i)ost- typhoid fever rather than a definite relajise. He was not constii)!Ued ; he sat uj) February 7th and made a good convalescence. Cv,sc A'.— George P., aged 21 (Hos. No. 5737), adhiitted on the 8th day of a severe attack. Tlie temperature fell gradually, and was normal from the 31st to the 50th day, when without any ol)vi(.us cause it rose on the 51st, 52nd and 53rd days to 100° and 102°. The tongue was slightly furred ; the spleen not enlarged. There was no consti])ation. Case A'/.— David Martin (Hos. No. 5900), a very protraek-d (•a^^e, in which the temperature did not fell to normal until the 33rd day. The patient was febrile from the 45th to the 52nd day, due apparently to a phlebitis of the left femoral. Case A/J.— Wm. W., aged 23 (Hos. No. 5937); case of modenite severity. Temperature normal on the loth day. From the 2oth to tlie 28th day tlie temperature rr>nged from 99° to 101°. This occurred when he was up and about the ward, and did not disturb the con- V'licSCCllCC ' Case A7//.— Minnie — , aged 22 (Hos. No. 5995), admitted September 29, 1892, a))parently late in the disease. The teiiipw- ature Wi>s irregular and fell to normal October 9th. From October 19th to 27tti the temperature rose once to 104° and every day to nearly 103°. She had one or two sweats; the abdomen was Hat, not sensitive, no spots, tongue perfectly clean ; bowels regular. Conva- lescence undisturbed. In very protracted cases the convalescence h often slowly cstuli- lished, and the temi)erature may be normal lor a day or two and then slight elevations will occur for four or live days without any special significance, thus : 59] %o.W Features, ,y>n,to.. and Co.pl,.aUons. Case ATF— Cliri attack of great severitv, and fro temperature had been' fall ^eyer, aged 52 (Hos. N -o. 6095), had '» the 43rd day to the 53.^ d 59 an 101°. Then from the 53rd the 58th to the 70th there "g gradually and to the 59th dav ra !iy the "giiif^- from 98° to without any slight fev vr w aggr dissociated witl was every day a rise of fr It was normal. ]i roni 'ation of the gen '"ni 2° to 2.5° :^::5!^^'"-«-ged28rS general symptoms. Possibly thi crop of boils. I- 30th, 1892, with an'att k of mod ""^ '"''^' ^^^™'^^^^ Octo- perature was normal bv ^"venLt ""•"'' '"' '" ^^^'"- parotitis. On November' 25th 2«th n.] 97/." T^"" "^" ^ "'•^•^^^^te •■ally rose reaching 103°, and 'fell iCu^Vlll^"''Tl'''' ^"^^■ iibdommal symptoms. '^ '^ "^^'' ^"<1 29th. No Case XrZ— Charlr.s H no-eri ir /tr . November lOtl. ^^'-2, on d,; Stl, d. rf ^^ """ ''''^' ^"^"''"^^ •'>• ^''« ^Oth d ,; the 21st tJ.!i ; ^"^P-'-^^ture was normal ^eil to norma.. .,,„ „„ t ' 7 "tr 30?.^^ '''"' '^"^ ^"^" '* "MS between 99° and 101° witho t I '^' temperature range the 28th temperature rose o 1 0?° tZl Zl '" ''"' '''''' ^"^ «" 2!)th kept above 101°. It ml '^ '^f ' '"^"^ ^i»-o»gl>o«t the 'H'tween 99° and 100° for sev ru "d^ •' T '^'' ^^'^'' ^»* remained ;- a relapse, but no spots were leen ,L tf ''T "' ^'''' '^""^''^* *" Ti. pati.t had a 4 .narked S;:^;!^-^^^-" was not palpable. <'.M 'V I 777.— John F., asred 90 /Tt xt October 10, 1892, on the 15th r f ^ ^"^ ^^^^^' ^'^mitted -«'>• '■'.'. ;-er. On tlle^U^ ?, ^ 38^ d^tf^' ^^-^^^ '""^'- "'IS nornml; then on the 39th 40fh or n , '' *''" ^^'"Perature «-" 10^^^ to 103°, and it w^i.ot '.t I'^I ,f , ''^^' -".^e .vas ""■re was again norn.al. There we ' f '' '''"' ^'^^ ^^^'"P^'^- •^P'-" was not palpable, and Ire w. "'' ■'•''"''^""^'^ ' ^^e constipated. "'"^ ^"^^« ^^^''^Mio rose spots. He was not -ogi^;i:nS^Sr ir?— --'-^ o-'e.nite ■•I I \f I m i \%, 60 Wifliam Osier. [60 returns f r the city of Baltimore for 1892 there were 33 cases imdor the head ng typho-malarial fever. We have had very good oppor- tunity of studying the relations of the two diseases, as there have been under treatment in the medical department about 500 cases of malarial fever during the time in which the 229 cases of typhoid fever were admitted. _ We do not profess always to be able to distinguish in their early stages cases of malarial fever from cases of typhoid fever. So much alike are they that frequently patients have been sent to the wards from the dispensarj and have had their heads shaved and the bath treatment ordered. The routine order in all fever cases is to have careful ai.d repeated examinations of the blood during the first tw.. days. If Laveran's organisms are absent, malaria is definitely excluded. To mistake typhoid fever for malaria is much less rare than to regard a case of remittent as one of typhoid. There was no case with the characters of the two diseases so blended that it seemed a com ound or hybrid malady, nor was there an instance m wliidi the manifestations of the two diseases were concurrent. Very nuiny patients with typhoid and malarial fever were admitted from the same low-lying sections of the city and the suburbs, districts in which both diseases prevail extensively in the autumn, so that it would have been strange not to have met with some cases of tho combined infection. in three cases there was a definite history of malaria within a tew months of the onset of the typhoid fever. Martin M. (Hon. No. 4027), admitted October 12th, 1891, had had, three weeks before h.sl admission, chills every other day for a week ; then the next week or every day, followed in each instance by fever and sweating. Subse- quently the bowels became loose, and on admission he had a con-l tinuous pyrexia between 104^ and 106°. The blood was negative.! It was noted tho second day after admission : " This case is oil interest, coming from Sparrow's Point. He had been exposed to malaria, and probably had three weeks ago genuine internutten fever ; he has had no sweats and no chills since admission." j The disease ran an ordinary course, the fever presented nothnij uncommon, the temperature gradually declined, and he made a sati^ factory convalescence. , ^ , A second case, Richard B. (Hos. No. 4083), admitted Octobe 1st, 1891. A month before admission had had for a week teitiaj so.asBai 28.S4.i4\ t H LJ 33 cases under ry good oppor- as there have lit 500 cases of ses of typhoi( in their early ver. So mucl t to the wards jd and the batli eases is to have ng the first two a is definitely much less rare There was no i that it seemed stance in which it. Very nuuiy iiitted from the rbs, districts in umn, so that it me cases of the ria within a few 1 M. (Hos. No. weeks before iiis ;he next week oii k-eating. SubM- 1 he had a con- id was negative This case is o been exposed ti line intermitten lission." resented nothin ho made a s^ati .dmitted Oetobi >r a week tertia Xo 40^1. ±rim^.__ .^t::u-^^y Admitted. (£J/ /6'^9l r Tpin[) Ri^si Stools Urine Dav .)! !6 iS: 7f) 70 S2 64- 16 20. ■60 16 84 20 ■80 6e ■16 ■ :/6 ■72 64 ■.7.4 20: ^-4^- V .■ -T ■ ; - T %■ ■• 48 ■e6\ ►•■■■• •■■••••■'• . ..».-■ -; •/(5 - .,i..-.i 52 -.56 : : .88 .22 .12 '6- '6 ■72: ■.56 ■24: I ' ! J \ ' ■ •■• •■ — j Chart 111 Case of combined Malarial and Typhoid infection. :■■■•■■ •■:■■••■ ■t •- ; o- -.88 • ■■7Z: -.56 .^4. -eo '80: IS- ■56 SS : TZ '.SO JOS- 84 ■ .88. -96 '.92: :9! 16- 18 ■24: :2 US ■■ '-.20: IZ : .n :Z0. ■ 20 ■ ■.20: ■.24- id: :?e; ■ ■20: :pg- ■.2Z: ':/3 \ I ' I : i I ; : --1 1 -- I"" T I I — 4- ■ - "t- ''/. '3; T , I 22 13 23 2^ 25 26 • • ■•■■': • • ' -». . «. • ' t ■3 u * . «■•■ • ; , f • ; •»•■•: •i: ;-i ■■!•■; :i^ . i.- * • 5 Q. »N S. .? ..T * • ■<> IS : ■a; : s — I % . \ \ ' \r \ • • • ■■ . • f J *.. .....g .... ...9.;....,. : <0 .$.; s., ...:.?r, : \ . <^ ■ . ■» ■ 'o > <\ ? t-N-, .... ,, . .... .,....,....,....;■... 72 .60 ■20 24 •»••••:■• •••■ ./OS- a*- ■20: Vf*. 88 -96 20 28' .92 ■ .99 .??•• 13 ■ -.92 ■ -.28 \84': ■96 ■2 8: ■.24- (I J (2) S ■ ■ N ..i.;.t, .i....:....;....i....,....,...».--v-»--V---f' •■■•■<•■•■'■•■■»■ "i""^' 80 . .83 24: 4.:,...:...... *:? .^.r.-H., tf .....,., :.|,;....:..,„ 88: -94 ': 20\ :3e, +-- rs^ 26 27 28 mi ..<....:..;..,.:... ;. M : Iv- ■'Si ^ : 13; ») !•■ 1st ■4-^ ■tt-f 29 'I CO "> ;5! < ■ « ; V • ij- * u : Id OD 50 ; la; •1^ 3^ '■ t « • i i : • *■ ■• •• • ••< ■ dS: 84-. — • •■• B0.88QB.B8. •,e4:79'\ 1^.24.24.24: \ '20:32' rsj — + ,. ,,,..,..,,,.,,.,.....,,. • .1 . •.*.! ... .. . .«. . .>.,...,..,, . ., ... ..... . . . .^ ... ••«•.•• . •( • • •••• .-■ • *■ ■ • • • ,.....,....--.... ..#...---■... .■....»....,...,, g ,...._. ..t • « 7»: .as'. \84'. '86'96 80Ba\B4.80\96.7Z 88.88:/04': .92: -.SS-Se ]96'/(fO\S2g4 88 SB ./SO 88 32' '■.23* :38* 2a'.i0:24'-2e:2a'.Z4.24 24 28 24\2B: '.sa' ■ZB\20\3i'^32.3e'2B\38*2i..24'l8\ f6) J L i i (1) (9) ill] iiiterniittcn 'iirtlier chil (ntioii. J] actively do] 'i'vor ran a 11" chills; t liis case to c !"■ 'lad had i A third ( November 4i year he had i cine. He hii month hefure irregular fev« rose spots, no in any way si The /bllowi with malaria, ''lood, subseqi ''fred 20, had, t'oiigh, occasi( October 16th, ( "Ifhe 17th to '■" the blood. day. On the a. 111., and at 3 rose to nearly "wmal at 8 a' i and the quinine 22nd the tempei pcratiire had be( grains of quiniii liad disaj)peared ature was 97.5°. the evening, and it was 102.2°, ro ^05°:sothatwi( on the 23rd the this was a recurr (;i] ^-"/ Feot,..., S,,.,,,,,,, , ro.,Ur.aion. n.onth l,oforo ad, .Lssion • „o dZf ''.^,^";--"-- H. wa.s ill fo.. , irr^ular fev.r. This pw" .'"''''' '".*/r^f'>- ^"-"*-"« and -e spots, no special onh^^ 1 1;X:" V ?"''^' ^^'^"-"'-•k^' '" -y way suggested a n.:Uaria;L •;:'"'• ^" '"^"'''^'^ "' ^''" "^ J'K' 'ollowinsr fnsf. ic *iw i '''"od, subsequently develoned tv, l -'r.- " ^'•^■a""nation of his a^ed 20, had during rxri'V:; 7""^ ■'''' '•^^■^"^' " "-" eough, occasional noseJl . dfnt a Th ' r'.f ""' ''"■''>-''^' -"' Oc'tober 16th, the ten,.erature 's Z^T^rtK ^" ^'^'"'^^-"' "'■ the 17th to 9r,o. i^,„ „ 2,ri ' r" ^''^ '" ^^'^ ^''•"b' "-rning : the blood. He was o U^^^ ™t ^"" '•""' '" '^ ^"'^-^ ''=^y- On the 17th the Ivn ZJ ' " ^'''"'' ""-*=« tin.es a rose to noarlv lO.^', t h., fe i . ro ' 'Z "'"'' *'" ^-^l-'atur,. "ormal at 8 a! n.. T 7 1^^..^:"'^';:'"* *''^' "-* ^^^K and was -<• the ,„i„i„e was cont;" d On l'"', «T"' ^"^'''"' '"'-'""-t, ^'2nd the tcnperature J ZLl or ^" \ ''^'' ''^''' ^^'^^ and I'--a■« -as a recurrence of the n.n Ma " L'it- f th" ^ "' ^''"'^^'^^ uaria, ,n spite of the administration 62 miWim OhI,',: [62 of the y spon-,nnu;. The quinine was continued until noon on the 26th. The whole appearance of the man was Hu^'gestive of typhoid lever, and subsequently spots appeared, the spleen enlart;ed, mid the disease ran a perfectly normal course, tyi)ieal, but of great sevcritv, the temperature not fallinfjf to normal until between the fifth aiid sixth weeks. The tempcirature chart annexed t^ives a fac-.siinilc ol' the ward temperature chart, and shows the ingle nudarial paroxvsni and file abrupt onset of the typhoid lever uid its pi :sistence. Th,. patient had in all 68 baths, and made a good recovery. 0. — (^omi'licationh. Digestive Sv8tem. [a) Parotitic. — This occurred in five cases, of which one died. It occurred in the left jjarotid in two ; in the right, in two ; on both sides, in one. [n three cases it was opened ; in two the swelling subsided. (6) Mekna occurred in eight cases, of which three proved fatal. Notes of the fatal cases have been given. Hos. No. 6086, Patrick S., aged 27, had a very protracted attack of typhoid fever ; was in hospital 67 days, had 87 baths, a long-continued high fever verv little influenced by baths or sponging. He had at intervals ten hemorrhages, none of them very large. Hos. No. 6198, Wm. P., aged 32, also a protracted case, had repeated hemorrhages, but m \ n'y severe. Hos. No. 6235, Jos. R., agd J, had one hemorrhage, not more than two ounces. Hos. No. 6320, Wm. Mc^I., aged 32, had a single small lieiiK.r- rhage from the bowels following prolonged constipation. Hos. No. 7318, Wm. p]., aged 38, had moderately severe attiick with relapse; small hemorrhage during relapse. With the onset of the hemorrhage the baths were omitted. Tiie pill of acetate of lead and opium was given, and cold applications applied to the abdomen. (c) Hemutemems.—:io\m M., aged 40 (Hos. No. 1683), admitted August 21st, 1890, with a history of illness of some weeks' duration, flic chief syi negative, an feinperatiire li;nl vomitinj i-h-l)rown /) disintegratioi the 29th, ;{0 evidently con "laterlal, /[ .Vkhvoiis Sv ^«) Tifphold pcarance of tl, '"'fi), admittc ("itcliing, whi l«'<'<>nies uiicon; imve irregular [lersisted, Th( "''iinsoiind min ^^'1 admission » 'th scars, a hir and one on the i p\'(' an intellig( file examination ""'1 of the musci the legs. The "fi.vthmical. Th '''ere was no hem dark-colored spot ''".trer of the right ^"'•'iig the first w "■"'•«e; thus on ti " Patient is worse to feed herself, 'f 'iHi.selesoftheface " ''ttle distance off "w.v ehorea except "^'•" From Marc] f);{j ^'^prcifif Features <.. , "'• -"f '. -WU. and ;jist thv .uJ ""• '" •'"'""'f'T. ()„ ""'■^""- ''«'"-'-• -;\.;.j'::::; '-••'7''. iv.,.,da^ "f "i.Kic ;, ^,,,,,1 recovery. N'KRVOtJS SVSTEM. '«) Ti/ithoiil Jhrr in a ra^ ' On adiiiissioii she wa^ u„ll ^""' -'« o" tl.o right sideof, he :'•;"' "" ^''" '"•'''^- '>'-tf.e nose ;;-■'■ - ".telllgent aceo„„t of h^ ",„^ " ""^ '-'-•fv rational anc ''";-:";""arature was normal within a week after his admission. He entered upon a very satisfiictory convalescence. On October Kith after he had been up for three days, it was noted that he iiad a peculiar mental condition, having an idea that he was going to die. Within a week this became much more manifest. He thought that he was going to be executed and was very much frightened about it. He saw and heard, as he insists, the headsman icad his coi-.dt nina- tion to death. After a few days of this delusion he said that he was ashamed of himself; then he became again very apprehensive, and about the second week of his convalescence sank into a state; of pro- found melancholia. He did not speak to anybody, would scarcolv answer a question, ate little, slept badly, and looked very much depresc d. His physical condition improved after the middle of October, and on October 26th he was taken to his home by iiis i'i lends, still very melancholic. Pauline L., aged 28 (Hos. No. 5685), admitted August 4, 18'J2. This patient had a very severe attack with a well-marked reinpsc. She, however, took the baths well and had no special delirium, l)iit once or t\v fo "ornial i (lays of apyr and could' s iH'urly three distress aboi going to get upon convale more cheerfu Henry N., 1892. He^v moderate but He was ahvay upon the con "onld not tal 'January he h; rapidly in \veij very much in liis mental con( {<') Hysteria.- Ill one (Hos. I tlie baths. The deal about them tenderness and c of the l)ody. T The second ci iioimced hysteri, tliroughout the g ber, at 5 ]>. ,,1., h restless, the eyes to his throat and •'t fi time. He h( "Ponit- The ex, »'''^''' he did not ''ody to ami fro. "'"""■"g he had til behaved queerly a "«i'"ced hysterica! leased. b',5J ^'^'^ ;^ o^ apyrexia she was profo;„ d1 1' T 1 'T"^ ^'^^ ^^«^'«» or eigh and ^Id searoeh- bo .ncSueodt ;;^^^''^;: ?'^-f -'"^l not s,^ "^ '•'> three weeks, she vvas vctv ne-T; ' ''^''i'''' "''i^f' Jested 'i-'^tress about the heurt -in 1 I u"' ''"'"PJained a ,n-eat de-d nf , He"0' N, aged 32 (Ho; xlU,. '"'*'''>' "^'omv. ''f Ho was ud„„-„od ■ -.W, :r' r'f'W N„ve;„W ,,,„, "' '""^h in spirits, and when he u! ^- . """'>' =""' improved tenderness and coniphiineci of .t , u ' ^'"'^ '^'^" '"'''rJ^'ed genera ^^:^ -b-. The con Jll^e 'ir'^t:"'^"" ^"'^' ''""^^^ rhe second ease (Hos. No 372lT ''' ^^^'>«fi^«torv. ;;-"eed hvsteria. H. had a .teU, 's? ' "^'' ''' '^^'^ "-«^ !>->- l-ughout the greater part of S„ "' A""^'^ «^" ^--, Jas in, ;"•' «^ 5 p. n.., he eomplained tf^n^!; .^" ^''^" ^^^h of Septen.t - less the e^-es were closed, and he J f/" "?"«"-^'"^^ --very fo i^'s throat and nodded his J„ , "' ""* '1'^^'- He „,ade si.-ns '' '^ '-- He held his otn b 7^1f '^' ^'^^ '^ -'"»^e or w^^' "P?" 't. The expression ^l^^"^"" ^' ^^^'^'' -^ «h.,t the teet ;'^--'' he did not do. He ro Ld " o "'"f ^ '''"' ^^ "'- ^^^^ ''ody to and fro. He w.s it f I l^ ? "^' **^ ^''^^ ""d swaved hk' ;'P'»f 1^0 had the sar 1ZZ^'''V'^^^- '''^ ^^^^ helmed ,ueerl. all through hi t^!?"'^ ""'^. "'- ^^^y noisv. JlJ -'"-d hvsterieal attaeks! V^th '^e TV''^ '''''''' ^-7 Pro- ^■«a«^'d. 'th the subsidence of the fever hev 66 William Osier. [()« GuHtave G., aged 22, admitted December 27th, 1891, with a severe attack, the temperature not reaching normal until January 23rd. At times, when tiie lever was high, he was delirious. On the eveiiii)u of the 27th of February he had a pronounced hysterical attack" throwing himself on the bed, breathing in a hurried manner, and presenting very ])eculiar twitchings of the eyelids. He was sjwkcn to sharply and tlie gas turned down, and he went to slee[) quietly. On the 6th of March he had a second attack, while sitting in a chair, when he suddenly comjjlained of a pain in the head, fell on the tloor and behaved '"n a distinctly hysterical manner. Perhaps the most interesting case was that of a young girl aged 13 (Hos. No. G497), who was admitted December 24th, 1892. She had been ill for at least two weeks with very odd nervous symptoms, and which, though she had fever at the time, were regarded as hysterical. She behaved in a very odd and peculiar manner, had crying spells, was very restless, and sometimes quite delirious at night. So definitely hysterical were these initial symptoms that until a day or two before admission the case was regarded as one of pure hysteria. During her stay in hospital she had an unusually severe attack with a definite relapse and had delirium, but no subse- quent hysterical symptoms, {(l) iVe(m'- '^^^^ \erv rapidlv • f I,. • '^'^""' the novf fw^ '""'Sue'l; no ne nad been nlv«„ j ""acK. (j„ ^j. «- , ^' t, ioyi «.-..") Lack of .he {T',!"' 7'l"»inod *« posterior lib! :'':»'"'«' "■•"'•"Venos,!!?,,'-'' "'""'' ««""' persisted and it ««^. , ^^''^'if,^ loiit thn w.u , ^ ^^"-^^ ^"■«re ,.ost-tvr T^'^^ '"'""''•'^^^ ^he Ltient u *'"'' ^«"^^'^>«« Mary MefJ o , "''f*I>eared. "'^'^^ '" the anterior ••'l>0"t the end of the ^ ?'• '^*'- ^'^^Sj, admitted J). ■ i'"-^ of t„,.;;:,tr'T:f "^'^^•''- ^-'^ ^r:t '' ^'''' '«"g time, and ,h, ''" t«"M^crature Jcent nn f- ''' '"''""« »-disco;tin:ed t::;v"/'"''^ ^'-^^ =•«- et,- ---an. «"t the Gth week thnAl " ' ""*'"' ^''« ^'"cl of the ^.I , '*'' ^''^-^ l^th, while theV '^""^"''■^^"'•<' fell to\l , ^""^' ^^'^«"gl'- ■'or seve al d ''!"''^^'^^^"'-« ^vas still hil h '"''• ^" December sponged thf '" ''' "^"■'"■^>' «^' 10 ° a ;TT '^^"^ --tantlv ^^^ ied out ''''"'" ""^' '■» ^h r h ff !^ -'"Plain of very attacks contin Tf""'"'^' "'"> "^''e had to '' '"''' '''''''''- that f" ^'-e r a";„f ^ «^-e„ the 14th an he 2 r -T"''"''- ^hese "fthe ioint -To ^''f ^- " -on -subsided h!rr'' ''"^'^^ — -tv- • - - "0 paxn ai,„g ,^^ „^^^,^ trunks si" "" '"^o'-«'«ent '• ®^« screamed out if 68 Wi! mill Osier. [f)8 any attempt was made to move the right leg. There was no ttiider- ness abont the hip, no swelling of the knees, and repfeated exanihui- tions seemed definitely to exclude any articular trouble, Graspincr the leg at any place seemed to cause extreme pain. On the 18tli, three patches, like erythema nodosum, appeared on the right foot, one at the metatarsal joint of the small toe, one midway between the lied anvl toes, and ore on the outer and back part of the heel. Tlux looked like largo chilblains, and around one there was a distinct bluish discoloration. The two smaller ones disappeared within a day or two. The larger one on the heel remained red for some days. There was no superficial necrosis. She never seemed able to localize the pain accurately. It was never definitely in the situation of the sciatic nerve. It was quite uncontrollable by anythin-; Imt morphia. After causing great anxiety to us, and distress to tlie patient, for nearly ten days, the pain subsided and had disapprared by the 25th or 26th, two weeks at least before the temperature became normal. Wm. McM., aged 32 (Hoj. No. 6329), admitted Nov. 19th, 189:^, at about the .'^econd week. The attack was of moderate severity, the temperature ranging between 103° and 104.5°, and not fallilijr to normal until the fifth week. Just about t.^ a time the temperature became normal, that is on the 12th of D< -jiber, the patient com- plained of general soreness and pains iii the limbs, particularly in the arms, and he winced on pressure upon the forearms and anus. He had been in very good condition and convalescence seemed well established. The grasp of both hands seemed weak, but particularly the loft, and he complained of a sensation of pins and needles in the left foot. There was no tenderness along the nerve trunks ; no pain on pressure on the muscles of the calves; he winced a little when the muscles on the right thigh were pressed. On the 17th of Doeember the note reads, "Lett arm looks somewhat swollen and feels tense. It is not red; the temperature is not elevated. He moves the mus- cles with difficulty and says the arm is very sore. On the inner part of the upper arm there is very great tenderness r'or " the course of the brachial artery and of the nerve trunks. 0' . • ' -ar nerve is iLso somewhat tender at the elbow. There is teLde-—. of the? muscles, particularly of the biceps and of the extent as of the upper arm. There is no anesthesia ; no sensation of pins and needles. All move- ments in the limb cause him pain. There are flying pains in the legs, but no swelling: no tenderness; knee jerks were incre.ised; no ankle cloni "ally di.siip muscles. (c) Local ^946), admi very peculia of the heel. the region ( extends aloii red; there ii affected." "W the region of si)otsofredn( right ankle a flii'h, raised ai in the rig'^t \i attack, and bj during con val( out any rednes (/) Tender 2 imrajsthesia—ai have been terra I'athed cases, vi tlie soles and d{ t'hiiblains has i special coniiectii The condition d been given, and bedclothes on th "iiy change in tii ^vhich is not unc feet in typhoid ai 'oii^'li on the toes tbe ward, J have through the l)edc salutation which 1 sideration by a bu: be due to a drying macerated by the r 'a.vers beneath, bu( 69] *"'" """"'" '^"""^ -" a.,,,„,,„,. ankle clonus." The «vv,,ii- jy peculiar condition of tlJl^"^^ f 7!')- f - -InWs.ion, a J^- J'eel. The note reads, " t" si f? "" ^'" "«gl.borho;d ^'' -^-on of the heel, are swol on V '"' I>'"-^'«"'"'-ly in extends along the lateral aspect of th"; "'' *'^^' ^''^ «^^ -dne -di there is n^arked swelli ^ ,;Vn , 7 /^'^^ ^^^ - a bluish effected." Within a week the f ij n'r; ' 'T '' ^'^ ^«^« ^^^ -^ the region of the heel, but on tZT^ "'"^"'^ ^i'^appeared from ^17; of redness and idel, a 'd r"" f ''' '^^^ *''-« -- 2^t ankle and one on the'o e' de oTtf T "'^ ''"^^ ''''^ '^^ ^^e di^h raised and swollen. On the 2t?/. '^^ '^''^^« ^^'^-'^e red- - ^;e rig;-t wrist without^; ten ;'''t/*''''"^ ''' ^^^' r>l attack, and by March 30th the tlm "f . ' ''"''^"^ '''''d ^^ ' "-Id d'Ting convalescence some n- « il r^' !"' "''"^■'^ "«^"'al- He ha out any redness. P'"" '" '^' ^'^'^t forearm and wrist will, {f)TmderToe.s-~A, v para^sthesia^as these cliZ, f ,"7'"'' ,''"' ''^'^"''^'- ^"^^ of aero - been termed by Fr.^h If 1^'"^^'^ "'^"'^^"^^^ «^ --^^- lathed cases, vi.., exquisite ser s.V" ^ '"^ '" "" """'l^er of the ; esoles and dorsal Ln.1 7^^'' f "^ *^-' --^^--^ 'uWams has frec,ue„tlv been not d .".f/ V'^^^^'"'"""'^^ •'^'■""''^•- to Pecal connection has b;en obso vll, '' ''''' ^'"'^ »^"fl'' '"'t no ri.e condition develops abou a Jed' orT'T " "'' ^''^' ^"'^^ ^oes b'en given, and the first complai^ ? '\t"'' ""'''' *'"« baths have bedclothes on the feet v" r J '"""^' "^ ^^e pressure of h! 2^-^^ ^» ^''e ap; .^:r ?r:,r '"^ ^'^'^ ^- --^ - vhich ,s not uncommon in the nail / ' ?"'^'^ *^'^ ^^How tin<.e ^«et in typhoid and, I think nth '*" ^'""^''^ «°J ^oles of L ;;-'" on the toes caused si:'^:fr'f-^«'.«^vers. The sHght ; f'>e ward, I have long h-ul ! ! . I''''^-^'nf? ^on. !.rd tc bed i, ^''^ough the bedclot t a .,V :'>"'-^^"""S ^^^^eetof .p " ^^'"^^^ion which has ^J^^^^^^: '' 1' "'^"^"'^ ^^^ ^a "«leration by a burst of tears T I '"' "^ ^''« ^'='«es under co„ '' ^'- ^o a drying and Li, .t"f "^' '"^ *^"* ^''^" l-'" "% GU ^•er.« beneath, but the skin has always looke, pressure of it on tl 'e sensitive I " natural, and though 70 WiUidin Osier. [70 thoro lias mvor hern any inipairmont of li.nsrular j>o\v.t, wt havo gradually been Uul to regard the condition i(« a local nenritis. All the ca.sos recovered without leavinp any i. "ilec^.. Tiiu irejutrjlnt was not very Butisfactory ; strong cocaine solutions on cotton-wo.,1 proved i)erhaps the most efllr;aeiou8 remedy. RkSPIUATORV 8 V'STEAf. OetJcmuoftJH'GloVh.-Thii ■•■,.^o ,:as been -iven among vh. fVial cases an was the pneumonia exten- sive, and fl.., diagnosis rested upon defir.ite dulness, with distinct tubular breathing. P/««r%.— There were only two cases of : his complication Wm. E., aged 38 (Hos. No. 7218), admitted with a well-marked friction and crepitant rales in right axilla. There was no effusim, Frederick S., aged 20 (Hos. No. 192), admitted August 10, 1889 with perfectly well-marked signs of eifusion at the left base, with' dulness, absence of tactile fremitus and of breath sounds. Tlie effusion gradually disappeared during convalescence. CiRcuj-ATouY System. Ajiart from the gradual failure of the heart power with the bodily strength, generally indicated by a shortening of the \oiyj: ])ause (the foetal rhythm), there were few cases presenting cardiac complications. A heart murmur was present in many instances. This, of course, was not regarded as in any way indicative of endocarditis, but d.iesimplv sometimes to weakness of the cardiac muscles, sometimes to the con- dition of the blood. Among the fatal cases there has already been referrc.l to one in which there was pronounced arrhythmia orlis. There was no instance of endocarditis, and among the fata^ .- s, as will have been noted, there were few even of those with si. - ; of prooTcssive heart failure v: Ail 71J 1" '^ "('tons. 7] mi*:":,:;;,,"™'""" r-'''™« «'<'»«r.ii,i«, but „,■ protruotw one ami fi ", "'® '^'^•'"'l weok. T1,p ^„. ^"'^^'^1' Cutaneous System. Profuse (Iroiiciii,,,, «„„, „ "■■■1 • »■"■« i» Li.fr '" '"'■''" "«-' «- i-e oiassi«er f:i:,::-- """'- ^^-'.■«e«i;, .i: Osseous System. ^'■nW^/s occurred in the rio-hf ,;, • • 72 William Osier. [72 of typhoid fever when the condition was in reality malaria. On nior*' than one oecasion a i)atient has had his head shaved and has IkkI baths for twenty-four hours before the error was corrected. Such mistakes have not been so common since a thorough examinatiim nf the blood in every case of fever has been made a matter of routine, but we have been occasionally caught nai)i)ing, as when a patient has had malaria for some time and has been taking quinine, so that the organisms are scanty or absent for a time from the blood. In two very interesting instances the mental condition at the onset of the disease led to a mistake. In Hos. No. 6497 the error was not on our part. The patient, a young girl of thirteen, had been treated outside for a week or ten days for hysteria, and certainly, according to the mother's account, the symptoms which she presented were (luite typical of that disease (the performance of odd and anomalous acts, with laughing and crying spells), yet the fever, which was high when she was admitted, should possibly have given a clue to the condition, about which there was no question when she ciuue under our observation. The second case was a young woman, aj^ed 28, whom I saw on a Sunday afternoon in the admitting room. She was completely " off her head," and the account given by the friends was so unsatisfactory as to the duration and mode of onset of the trouble that I told Dr. Hoch that I did not think the case a suital>le one for admission, regarding it as an instance really of mental dis- ease. The temperature was very slightly elevp.ted, the tongue was clean, and the whole behavior was so much suggestive of mental aberration that I was comi)letely led astray. Fortunately Dr. Ilurd saw her subsequently, and it was decided to admit her. She had a mild attack ; the delirium disappeared and she had no serious .symp- toms. In only two cases did the anatomical correct the clinical diagnosis. Both of these are given fully in the history of the fiital cases; one (Case 11) was the old man, aged 70 (Hos. No. 1814) who was admitted in a condition of cachexia, with pneumonia of the right lower lobe. In the other. Case 18 (Hos. No. 5556), the patient had been in the hospital a year before with severe entero-colitis, and when admitted had diarrhoea and an irregular temperature, and not ■ unnaturally he was thought to have a recurrence of his former severe trouble. The only suggestive feature in his case was the presence of the diazo reaction in the urine. He died on the seventh day after admission, and the autopsy showed the lesions of typhoid fever. V._ON THE iVRlTROsiS FOr.LOUTNG ENTERIC PEVEIl KNOWN AS "THE TYPHOID SPINE." Bv WILLIAM OSLER, M.D. In IHHH Dr. (Jibmy, of New York, ,losoril.ecl at th. AnuTicun Or hojuodic Association a 8.q„el of enteric fever whiel, hr ..alled n,e typhoHl spme," ., whieh he rej^arded as u perispomMitis me.an,n. an ae.ite .nthunmaticn of the periosteum and the fd,ro,.s tn.etures ul„d, iiold the .spinal eol.nnn to^^ether." He .stated that h.s reason for the use of the tern, "was the production of acute pain on the sl.KW,test movement, whether lateral or forward, and the al' .nee of any marked f, l.ril,. disturl.anee or neuralfjia." He de.scr.l,ed four cu.ses ; in the first, a lad of 15, towards the (.ul of <.on- valescence, complained of severe pain in the hack, partieularlv in the lumbar reg.on, and especially after any movement. There was n.> d.,s.ase of the hone, no pain in the distribution of the sciatic or aiiterior ejural nerve. He wa. .seen in the autumn of 1882, with Dr. Beverly Robinson. A spinal brace affbrded relief, and in the ' ^e of two or three weeks he was practically well, but the brace wa. A orn for more than a year. The .second case, a younj; nutn aged 24, had an attack of tvphoid fever which ran a normal course. After convalescence was w.-ll established he cMuplained of pain in the back, but he was able to be ui. and about, and play,.! tennis. After a fall tennis the p-iin became very severe, and he sufK^ed so excruciatinglv ,hat h. could only rest ,n a recumbent posture. Deep pressure' , ;er the iliac region on the left side, and lateral or antero-posterior motion of the I'-sisted from the latter part of iNovember until the beginnin.. of January hut it was not until March that he was ab.c to get aboi^;. ihe third case^ a lad of 18, had typhoid fever in November, was iva escent by December 27th, and went to Ne,, York. On January 10 h ho fell win e skating and struck his left hip. A week after thi^ hehadpainin the repou of the lumbar spine. The .stifFness became more marked and the pains increased in severity. On the lOtb of 74 WiUiam Onler. [74 ** February he went to bed and was ..en b>- a «urgeon in Albany, who regurd«.d tlie case as one of psoas abscess. There wis no fever n„ evident idisease of the spine, h„t the patient could not move wit!,- out ex(iui8ite pain. He did not recover until Xfay. The fourth case seems to me to belong to an entirely differem category as it was an instance in which, during typhoid fever, the boy had kept both limbs tle^ 1 on the alulon.en, and .luring conva- lescence was unable to straighten tlum, an event met with in manv protractecl illnesses i„ which the patient lies curled up in bed witi, the l€!gH flexed. In 1890 in a discussion at the Association of American Physicians tollowing the reading of a paper on some points in the natural' historv of enteric or typhoid fever, by Dr. James E Reeves,* Dr. Loomis, Sr" referred to Dr. Gibncy's observations, and to one of the cases he had asked Dr. Gibney to see. Dr. Loo.uis knew of no reference in literi- ture to a similar condition. Dr. Jacobi, at the same meeting, besides protesting against the introduction of a new name, such as " tvohoid sp.ne, suggested that, in the absence of temperature, it might he one of two things, either a neurosis or a spondylitis, re.uarking that mi d forms of spondylitis are not so un(;ommon as they are l)eliev(Mi to be. In the American Text-book of Medicine (page 90) Dr Pepper remarks in his article on typhoid fever that he has observed in h series of cases "obstinate peri-osteitis of the sternum or of the crests of the il.a, or in two instances, judging from the location of the pain and from the effect of movement of the trunk, of the front of the spinal column." Eskridge also described a case last year I have not been able to find any other references in text-books or monographs on tyj.hoid fever, either in English, French or Gernmn My attention hnJ not been called to the condition until recently' unless perhaps a case which I saw several years ago with Dr Gr-i- sett, of Toronto, was an illustration ; a young officer, invalided Iron, India after a prolonged fever, had for many months, on the slightest movement, attacks of the most severe pain in the back, which incapacitated him completely, though when seen by me he looked strong and robust and had a good appetite. He subsequently got quite well. ^ ■' ^ •Transactions of the Association of Aii.^rican PhysiciaES, vol. v., 1890. 75] The Typhoid Spine, 7a Patient was Htronj? and well uiitiljiilv ISQo » i . , never., atta.k of typhoid fever w hW^'R '''"''' ^"""'^ nearly three months- verv slow! T^ ^"^ """ '" ''"' ^«'' for three weeks, whe'n t^ role 7^ rT'" "• ."""^■""^'^ ^^«" Lack an,i hi,,s, usually of tsho in , '^""' ""''" f^"'"" '» *»'^' pain in the ahdomen of Ijoh he 'n '"'''''' ""^^ ''"•''"-^•"•"« "^ the day. He had o t.ke 1 .^-^^'^ «» «ometin.es have several in weeksfhavin, t ueh' ^ :^z t^: ^::fr:'T "\ '-- the front of the legs H.. nov.V ' . ^^ ^'"'^ '^"^ ^"^^n -y paralysis. Ifout T^.ne o 7h-"" ^ ' f"" '"■" "^^'"""*' ''"^ to .0 out 'and do 1 ^ "k l^JT '"^ T ^'^ ^'"""^^ '•f .^-ne he had another a Hd of 1 "'"". ^" '^'^ ^'^*^^'- P"''* abdomen. He had n t to ^ t be/ tT' '"" '" *'" '""^ ""^ and shootin,. in the righ Te. from the h" T ""'' '"•''"^^' ''^"» the latter n-^rt nf T 'j^ trom the hip down to the knee. In in. and has c t^^^ ^T rsi::;:^ 1;^:^^^ r 7r pains at time.s in the back and J,, ih i 7 present he has slight aohi,,. „ai„ W .l,eS;t ' ' , 1r''C''''''•?-»™"" HB never vomits, tl,ou,{h h» „fjn i°7 '"'"'""' " «°°''- -ve. He .,„e'«„,e, L/,- *: ^ rr™- ''°"^'= "' Present Condito^i.—Healthv Inol.;,. ,. lairly well-doveloped n,.^.:^'^^^^^'' ""'"'. "'"■ a neurasthenic natienf T ;,.. i ^ "'^ *^*^ "npre-ssion of tender. The .hheZllJt o^'T ""? "" ""'' """'"'"^ hurt, hi,,, to t.,rn in bed H . 1 °^"""'''™« '» ">-> l>«clr, and it year a, beginning i" , he ;„,a^„fT,!' f''" ''"''" "'''"'' '» ''»-' '-' kone»„nd^he„ !Xi:i tZ^tfT' "'•"""."'" "'" trouble was thought to he in ih ^ scarring, the chief Btill a little ten^tL: :]^^^ T\ "' ''^ ^P'"'^' ^^'^^ ^ - - -n pressure just above the left sacro-iliac 76 William Osier. [76 Kvnchondrosis. There is no tenderness over the sacrum itself, or along the iliac crests. Patient gets out of bed readily and stands well; walks with a natural gait; does not sway with the eyes shut. After prolonged standing or walking lie complains of great' iucreas^e of pains in the back. The knee-jerks are present, a little exagger- ated ; there is no ankle clonus. The most careful examination of the spine fails to reveal any signs of organic disease. The urine is normal. The patient remained in hospital for a little more than a week ; took large doses of nux vomica, and was encouraged to believe that he had no serious organic disease. Subsequent examinations gave no additional information, but the patient evidcmtly was highly neurasthenic. in Caiic 77.— A. A., aged 21, architect's assistant, seen with Dr. King, May 10th, 1893. Patient has always been a healthy man and has never had any very serious illness. He is not of a robust constitu- tion, and though bright, not of a very strong mental fibre. There are no special nervous troubles in the family. In November and December last, i)atient had typhoid fever, an attack of moderate severity. On New Year's day lie sat up for the first time, and convalescence was gradually established. There wcro no sequelse, no complications, and early in February he went to his work. He gained in weight ind looked very well. He remained at work about three weeks, complaining only at times of pain in the back and of being very tired after sitting for a long time. One day he was very much jarred in the back during a sudden jerking oi'ii cable car in which he was riding. Early in March, after complain- ing very much of his back and of the pain on moving, and of tired feelings, he took to his i)ed, where he has remained ever since. Dr. King tells me that the chief symptom has been i)ain on move- ment. His general health has been excellent. The appetite has been good, he has gained in weight, and he has slept well. He has been nervous and at times almost hysterical, ^yhen (piiet and at rest and not attempting any movement he does not complain of pain, but on turning or on attempting to get out of bed, cv even the thought of the attempt to move the legs, is enough to cause him to cry out. The pains have been in the lower part of the back, extend- ing sometimes up the .spine and down the back and sides, more 77] The. Typhoid Spine. 77 rarely the front .f the le^ as far as the knee. He has had no fever 1.0 cmlls, but has sweated a good deal. He has had no swellinro; the Joints. »tiuug ui Present M/on.-Patient is a well-grown young man, well nour- ished, inuseulature of moderate developn^ent. The pahus of the hands are mo.st and sweating; he was somewhat excited and at our entrance flushed over the cheeks and neck and upper t o th eiKjst. Pace does not indicate any speei.! strength of ^character nuher th. reverse. Pupils of medium si.e, equal, active; tong "e d-n. Patumt „, the dorsal decubitus, his usual attitude. On pull.ng down the bedelotnes he in.plored us not to touch him, as he w.. sure .twouhl hurt him very much. The abdomen wa full natural ookmg. On palpation he con^plained of a good d^al of P-" m tlK. leit iliac region, but on withdrawing his attention and pressing fombly with the left hand in the region of the heart and asking whether he had pain here, the right hand at the same tim CM. <1 be pressed deeply into the iliac fossa without causing any di - .u-bance. The .leepest pressure in the lun.bar and ili.' regions faded to reveal any glandular enlargements or thickening. The .nguinal glands not enlarged; no special sensitiveness along the ante- rH>r crural nerves. On asking him to lift the leg he said t was imposs. le, as it hurt him so na.eh, but in a few moments, ac.„g e hand beneath it, he lifted it apparently without pain \hen hfted m a semi-flexed position he said it was impossibi for him to straighten it, but in a few moments it could be readi v extended and he straightened it easily on the bed. There wal Lk";i :"^":? •'" "'^^ ''''■ ^^ «"'"•' "-- ^^" ^he musses ' <1) and uas able to get up and stand on his legs if he took time I he sensation was perfect; the knee-jerks present, perhaps a little ^l^gera^d; no ankle clonns. The feetand ankleJ^ere ,!erspir!^ ed) . No swelling of the articulations, and no pain on pressure of 01 ns left SKle he demurred very much, but gradually, and apparentlv . a great deal o difficulty, he got himself over.' The llgs could hen be momi easily and freely; no pain about the hip joint, and eel be flexed and extended readily. The' spine' was straight, the lower dorsal vertebrae a little prominent. xNo tender- lower lumbar and sacral regions he was sensitive at a distance of an I I: I 1 1 78 WiUiavi Oder. [78 inch and a half or two inches from the middle line and mrf,". i i There were „„ ,en.,ory d,a„ge., „„ l,e,„i„„,esthe.ia, „„ l,e,„i a .ops,.. The ,,a,ie„t ,„,d that hi, chief trouble was „,o e Z e d "I i>mv,„K, lest ,t .ho„|d ea„se ,,ai„, than any pain it„|, t 'lavs ngo he sat „p iV,r „ «„„,*, ofhours, ..„> "I o^be, h „ "T sat on the Cai, b,.t fe.t ver,' tired, and .ireae^^asl'^^ "'::;' to H,! r, "^ '•"■'"' """"'"'''° "'"' "'<=««"•«">•. ""-I the I'aqnelin eanterv ^:«nr.e ut^ri'dtr'""" "'™""-^- -" "-" '- »^' '"• = -«- .^:afe,,rps,^ii-i-,t;-b d.t.on No pain ,„ the back : feels a little stiff; knee Irks ' normal ; condition good. > '-nee jeiks an> Cases II and III in J)r. Gihney's paper arc very nn.ch lil-n H one he.e mentioned, particularly i„ thl fLt that t^^^ , ^ , ^ ^-d after convalescence, and in both instances the^e w ^ sMu ^nr;."7rr-'"rf^^''^^-^"^ *«'"-' -d - -other m en . ' "'"'' ^^^•'^'"'^^- ^° ^''« -«« '-ported here Z pat ent also lays a great deal of stress on the jar which he re civ e, b the sudden jerking of the cable car. In b^th of those c ,s' Tt ^:;':;i%;;;;i:^-^^^^ An explanation of the symptoms in these cases is bv no means e..v As^^ ready ment.oned Dr. Gibney regarded the i;sion T ^ : mX^^! :r ^^'''""''' ^^-^*^^''' '-d -'th this view, ro! t T 1"^*'^*'0" g'^'^"' I^r. Pepper seen,s to agree typhoid fever, but the symptoms do not usually develop (as in throe or four of i oence has 1 the stern u I to suppural disappear v protracted | suppural' on as are descj in the s'jcon simple perif puration. ] patients was be very illoj same cau8c, 3 simply of the and anaJogoii spine" and ti have pains 01 the second ca was that of a a leg— even t yet in a few n the slightest ij I') scream out, sure could be in a few days iucoii.sistent w; I have recen but which I th neurosis. Case III.—^ Nov. 2nd, 1895 Family history insane. He was ner\ excited, and hac times; never h iilcohol, but is n September 23i 79] The Typhoid Spine. 79 or four of the cases hero described 1 .f . . cence h.s been well established Th '^.'' '""' "^^'^^ ^«"vales- ^J'e ster„u.n .nd the ribs, proceeds .r""?''^; '''" "'^^'"'^^ '^^«"* to suppuration. I have in s ver ] il; '"''' '^"' ""^ "ocessarily, ;>t.r«''«' «»d -»P)o perispondvlitis u lucr „!';"'' " '"-^'-' ^»-> f, . Purat.on. In both of „,v ,,ises ZL ,"'""'' P"'"'^^ ^^" ^o sup- patients was that they wer^ n sthef "" Z'";""""" ^'^'^^ »'>' the ^^- very illogical to Lsun.e thT of ,1 " ' ''"""■^^' ^^ ^-"'^ -- -use, yet I cannot hel^n:^.: '"^^^"f- -« ^ue to the -jply of the painful neuros s ^„ Si v plr""" '^ /'"" areexan.ples and analogous to the painful condiT ' "" '^''"^^ n-ritation," ;P"-" and the "railiy^L^^t'^^™^. ''t .'" ^'^ " ^'^'^'--' J'ave pains on the slighLt\noJl''.r u ',''' ^''^' '^^^'^^ "^av tl.e second case reported, th: , ^ h v ^ ^' "^ ^ "^ '^^^^ ^" was that of a hysterical patient- thu , ."''"^ '*'"' «™inatio„ aJog^eventheidea wal o,"!gh " r^; "' ^''"'^ ^^ ^'^"^^ yet ,„ a few minutes he lifted it hims.l " "^'"'"^■"S Pain, and t'-' .slightest pressure in the u d , -r"^ ^"^ '"* ''' ''^*'- ^o also to scream out, but while his atten / '''"^^5>«»« would cause him «- couhl be nude with d.,:; r^,'''''^^'^^'' elsewhere, pres- '» =' ^- <'^^ys, with disapp a^ r tn tf '''' ''''' ''^^^^y --..s^stentwithacl.ronii H>risp: dvi,-' ''" '''^^^''^^> '« ^-^e 1 have recently seen . I ^'^'lus. insane. » "" ' ''"'""•- '■"%'; »no sistor, however, is lit! was nervous as a bov l e.«i>cd,„,Kii,„,i ..,„.„„„,„;,'" 511°,"'"'"'''° "■■■•" """='' "I'™ 'i™»; "ever l,ad |,„,. :,„ku,n.,,A ''"'"''^""' ""■«« «' f"" •"» '-"' is no. a hard dH„;;;: '""'' "■'"■'"" '•'• '"■'-'■ Take, S...e„..er .3rd, >S9:,,e had a„a„aek„n,p..d,ver of „„„.„, 80 William Oshr. [80 severity, with prolonged dcsliriiim, extensive bed-sores, and very .^r, ,u prostnition. Convalescence was not cstabli.shed until January lOtI, 1892. During and after convalescence he was very nervous, !ui.! had uneasy i)ainH in the le-s, his feet were tender, and he tired 'v(,v easily. He had no pain in the [)aclv, no soreness, b„t the tendernc-'. in the feet and nervous feelin-s persisted for six or ei-ht months ait. r convalescence, and he does not think that thev have ever entirely disappeared. He attended, iiowever, to his business, gained i„ weight, and felt pretty well, though never entirelv free from nne-.M- sensations in tlie feet and legs. In the spring of this vear th. ... symptoms increased, particularly after some sprees. He had neur- algic pains in the legs, and he felt weak and unstrung, and evi« dnn,„ished some^vhat within fiv. ! ""^ \'^'' '^^'^ «>■»»}> ';:- diminished so.;vi:;r r t r^ ^"" ^^^- -''- « -p- <''«;]>P-re,I, and reeurred with inten i T ' """'''•^' ""'"' ^"^'-'.^ -> b)'l.ronounoed neurotic n,a Si '''^^^-f 'T' ^'--^- i-> ^>'Pro,K,unced ;: :,:^:!;^-;>- '^'^^.^ i'-d chara.;. ^i'-ibed there were no pai J ' t td- or f "' ''^ ^^^^^^ ^^^-^• ^''t.on of weakness. The sv,„„t«I '''^""'"' '*"'.^' '^ ««n- i-ion; (2) neuritis; or (3) a^ el^s "S'"' i •' ' ^ "'"^^"' ^«'--l) -Klent that the doctor n att« Ze f 7 '" ''^'^^^^^ it was it ^vould seen, that the pati S tnd f " ' ''"^''^^ "^^^'^^-"' ^ut -- ^-m the ■•'»• does tl,e case conform i„ its l^^fX "'''"■^' '''°>' «"^h view; -an insists that the same fee its w" 1^' *" " """'■^'^- ^^^'e I>resent during the convalescence fi^/r f ,""" '" ^''^ ^'^^^ -- -'-q-ntly. There did no. a >pt o .l l ""' '""'' "'^"^'^'^ '""scular weakness such as sometimps , """ ^'"O' «Peeial ='ttaek of typJ.oid fever witho t , ™ 1 ' T' "'^" '' ^''^''^^^^^ J" the paper by Dr. Georgv 1 s ' vT- '' ''"■'''''"•''' "^'"-tis. He refers to these cases in the fb lowilr ''',' "''" ^^•^''''•"'^ ^^^^r* '"■t- typhoid fever of conscW bit ' " "'' ''^ "^* ""•--' enfeebled condition of tl,eh>we^^^.^^^J^^^^^^ *°.«»^ " deflnitelv aml sometimes a person never eUr ^ ^'"'"'"'^^ ^"^ ''^"'"^ ti'^'^. - n ;',"•' " ""'' ''^^ "-'- '»- ""rvous centres." InthecnsenT !'''^«"g^^d ^^xhaustion of the ^-al appearance of the p^io^ ""i;';:^:^;:' ^'^ ''''^'' '''' ^^- pLoHl fever. The para^sthesias'st": I r'-r!,'^''"^''"^ ""common sympton.s of neurastheni i , ^'"''^'^"'''^d are not -fle-xes are not at all infrequem ' '" "'"'^^ '^'^ --"ggcrated ' Transactions of the .Association of 4meri.^„ P, • ■ -imericn Physicians, Vol. lil, i888. i i i x 82 WiUiarn Osier. [82 i ' It is not unlikely that under the designation of "typhoid spine" Dr. Gibneyhas described several distinct affections, and T would not be understood as holding that there may not be a perispondylitis. Nor indeed are all the i)ainf\il backs in typhoid fever neurotic; thus, a patient recently under my care (Hos. No. 80-19) n-as admitted in an attack of moderate severity about the end of the third week, the tem- perature falling to normal by the 26th day; then after a period of apyrexia of seven or eight days he luid a wfll-markcd relapse of about two weeks' duration. During convalescence he began to comjilaiu of severe pain in the back of the neck, and at the attachment of the muscles of the occipital bone. There was no actual tenderness in the vertebrae, and movements to and fro and lateruUy were not associated with any very great pain. An application of the Paquelin cautery relieved it for a few days, and then it recurred. The examination from the pharynx was negative. The condition persisted for at least two weeks, and while at first coniincd to the neck, subsequently he had soreness and stillness of the back ; he walked stiffly and lield himself very erect. He says that it is better when moving about than when lying down. No special tenderness in the spine, and no sharp i)ain; no increase in the reflexes; no indication of neuritis. He gradually improved, and when discharged he was very much better, having gained 11| pounds in weight. TYPH( From the Joh C^ X u. \/^ TYPHOID FEVER IN BALTIMORE. By WILLIAM OSLER, M. D. From the Johns HopJcim Hospital Reports, Vol. IV, No. 1, Baltimore, Md. Vlil.-TVI'lIoii) FK\ i;i{ IN I'.M/n .MoiM-: BY WILLIAM OSLER, M. D. AiiH.iin. We nu.y speak for this latitude with so onfidence npon tins point, after a study of son,e 300 cases of typhoid 1,1893, there had applied for treatment at the Johns Hnnlnn« n . /"/"^'""i'' cases of malarial fever. Thesn-calM fvp! o, naiad f' ' '' "'*'" """^ fever in the Boston, New York, und Ph^lI^Il^S::' " '^ '""''^' "''' ''''^^' urns. IMAGE EVALUATION TEST TARGET (MT-S) 7 // {/ :<° c^ .- tl niorbiditv as above, an annual average of 7941. (!, 1 t lie o aliout cvei'v 125.09 of the inhabitants Th e ward map published in the City Health iJeport for LSI gives the greatest number of fatal eases, and one may suppose the greatest ])revalence oltlie disease, in the outlying wards of tl moi 'c particularly in ward 1, which has the highest ti "lire le citv, \vai'< '" Ileport of Uealtli I)e|mrtmeiit, page 8, 1892. IFroiii lii,'iiv(>s Uiruily fiirnislied liy Eiiirnoiis Clarke, Secretary of the lioiinl of Health. i Report of Health Oepartmeiit,189'J. ironi which thcv amc" From tl„> v ,"•""""' to tfic wards Baltimore Countv n, i " \ " •. ^^7 ^^^^ ^"^ -- = ^-n. caoe. Of the ca... in the c v w i J u ."T ' '""^ ^^"''™-^' ^ »">li' ■n.ich remains to learn ■ilmnt th„ r. ^•'^"'■■^vand f^rowti, o<'thetv„h i ■ """^''^'""•- ''^^orin.^- the .'-'-l = vi., its Tith defeetive dr«;„ " ... ., . " '\' ^'"^ :.itimate eonnection — ection --ln,tally eontaminated l.v .l,;';:;:::;"" '^' '"^''^' ^l""'' - """<- 'ii- these factors are at uorl-" in . ■' "' '"■•'•^" ""T'i^v I'ow i"*u.eoroneort;:::: : ;;;:;;::;^;\'^^^^ (0) The I(Wn-,s',W,_ „ '.''""'•''" '^' "'" '"<«'t.ons .liseases. ...alitv. In the ant. ^ 1 J h^'""" T "' --l'^'<-'ib- .ood during the present ve-.r hot r "'"' ••^■^"•^'^"rs are low, as onsl,tonta!ninat:,\:;;h :.;•;: ;;:r"-^-'-f^ ^^! '>^" <^an,er- -alysi. can he made, as th^ F , ;. ^ ' '''''T''' '"•'"«'-' skilled haeteriolo.eist. '"^ '' '"'^ '"'•"'^h"^! ^vith a The distribution of the disease indiffi.rentlv in ..11 . . I'^'vailing n,orc in the area supolied t ! v' '''.'"'''' ^ ^"^'' l-v-"ving <'^"ot in large eonte;;;lr:;l;;;~rr'"^^^^ vo freedom of the hi.dier Ips« L. i a ' comj.ara- 1 . "'h"^"i less crowilcd. n-.rts nf fiw> ^^ *" ""■" '^"■'-" "■•™ " ' .". '..■ .:i:::;i,;:';;r;;;.'"sc' ti 102 W'illiaw Os/,r. 1(1 thewntcr alono responsible, tlim; woiiid liave boon, in areas supi.bV,! by OIK or other of the streams, e])i.lomics of wide extent, siul: as hav.. been described in otlier cities with a double water-supply. Xeitl„r streaui is tree from suspicion while so many possible sources of pollu- tion exist. Typhoid ft;\er has prevailed extensively in areas drained by Jones Falls, particularly in Towson, in LuthJrville, and about Pikesville. In the sanitary history of cities it has been amplv denKmstrattd that an abundant and good water-supi)ly, though „f tiie iirst imp.,rt- ance, is not enoufrb u> reduce tin' death-rate from typhoid fever to ;. ininimuni. In j.altimore the deaths from typhoid "fever per 1(),(KI0, prior to 1875, ranged from 7.4 to 8, and sinJe the introduction of th' water-supply the rate has been only from o to (3 per 10,000.* It is to be remembered that this rate is not correct, since deaths from typlio- malarial fever have been, in all the late returns at anv rate, exclialcl. There are several remarkable instances which illiisinite the persist- ence of high rate with good water-supplv, but it will be sullicient t.i quote the city of Dantzic, in which the new water-works were com- • pleted in 1869. The high death-rate from typhoid fever persisted until the introduction of the sewage system, after wliicli it fell thm an average of <).<> per 10,000 to l.r, f„r the six years eu " v JS.S-l. The same is shown in Stockholm (to be referred'to hm wliich the dciith-rate froia typhoid fever fMl pari pa.s,'^u with the i.Ntension of the sewage system. An important liictor in certain wards, particularly in the annexed districts, is the continued use of well-water. It is possible that the virus may be spread widelv throng!, the water, not in liosage potent enough to cause ihe disease, excvpt in very susceptible persons, but in the preseiu'e of favoring comlitions capable of rapid development. Thus one or two tvphoid bacilli in a glass of water may be, probably often ar<., taken with, impunitv bv an individual not specially sus.'eptible, but a tinv in water used to rinse a milk can or Jug would find in the milk such a suitable medium for growtii that in twenty-four hours the food would be highly infective. (/>) DefeHive JJrninar/e.~Thv influence of defective drainage on the incidence of typhoid fever could not be more clearly shown than in •Ei'wiM F. Stnith: T?ie Influence of Sewerage and Water Supply on the Ikalh Kate in C'ltie.i, [iii^je 140. Lansing, Mich., 1886. llil! 163] tlie annexe trastinj^ se' ;i filtli (li.soi .'inv local it; the inhabit trreater tiie tics that th- produce an the deaths 1 in the very nearly doul Admirabl only siirliict are collectei most part ii from 70,000 (iC the city, v tinht are noi occurs in a ' vicinity. Fi sewage and grooves, j)a.s houses, cons: polluted to rliflcrent loci out than the typhoid fevei ulone sufficie the soil, pari rcruarkahle i\ strikingly sh( (I'll step l)y St fiilling from ] 8937 metres ( 40,435 metres 65,709 metre? been almost a Prof, von Zie the hospital 1 163] Typltohl Fern- in naUimorr. 163 he annexed chart fron. Dr. S.nith's article, aln.adv referred to, eon- rastn.,. sewered and unsewered t.nvns. Typh,>id fever is essentially .. filth d seascand ...the words of Liebenneister, ' hited to a very considerable depth, varying very greativ with rh k.ent ocahties. No single fact has been more ck.^lv bi-ought out than the intimate association between sewage-polluted soil and tvi.ho.d fever. As already stated, wholesome, healthv water is not '.one sufficient to abolish the disease; but healing of ihe sickness in the so.l, puntying it by proper drainage, is at once followed bv a .vn.arkable fall in the death-rate fron. typhoid fever. This has been strikingly shown in many cities ; thus i„ St<,ckholm the mortalitv • step by step with the increase in the number of metres of sewers a Inig fi^m 1877, with a mortality of 5.1 per 10,000 inhabitants and 8 .J. metres of sewers, to 3.7 per 10,000 inhabitants in 1883, with 40,43o metres of sewers, and to 1.7 deaths per 10,000 in 1887, with o,.09 metres o sewers. I„ Munich and Vienna typhoid fever has been almost abolished, and three years ago, when in the former city. Pro . von Ziemssen stated to me that the reduction in the cases in the hospital had almost changed the character of the service and \\\\ '•r I«U \Vi/liiim Os/c.r [Ifil tlioy had soiirccly piiticnt cliiiiciil courses. The i s ciioiio;!! to illii.stnilc the disease in tii I'll res lor .Mmiicli and \' l)een (|iioted that it is not necessarv to ref ienna liave so oft( er to ti leiii nil ■ther tl '71 'v,m Id to State that the deatiis per 10,000 living have fallen from 12 between 1 and 2. Tiic loeal conditions perniittinj.' tlie disease to l)e endemic throimh out the year relate Mncniestionahly to the persistent pollution of U,, soil \Vh le cases of ty])hoid lever occur in tially an autumnal disease, and th ihieh at this season renders tl every month, it is essen- ere is a factor as yet unknown iikelv, favors i le ])oison more potent, or, what is n factory explanation has vet b n some way its urowth and distribut ion. N( Hire ■iitis- een uiven of tliis autumnal prevalence certainly one of the most striking' fiicts in the natural historv ol lisease. After the heat of th su when the streai lauier, partieularlv a hot, drv and with it a proportionateb us and ponds are low, the drainaue sea s( 11 1, area is exteiuhd, Th le amount of organic matter is also tl increased liahilitv to cont aminatim: ten much increased, renderinn the water a more suitable medium for the growth of all kinds „i bacteria. The heated soil, too, after tl their development; but the fact le summer weather mav favor particularly by v. Pettenkoft durino- the autumn months. Unfortunatelv no data 1 or on which the greatest stress is laid r, is the low erinji- of tl (iollectcd in Haltimoi 'e on which t< t)oint. hei>!;lit oft! Ao systematic observations I ) Dase an opinion on this important le .uround-watf lave ever hcci th le li-round-water at diilereiit seasons. ave ever been made on thi tion nor IS iinv inloi th ivailable as to the nature of the soil in tiie ditlerent iiiii- e citv It portions of IS to be hoped thai the new topographical survev wil prepare maps, such as those iiuuh; for Jierlin and other cities, !■ lug the distribution in the wards of clay, gravel and sandv soil: (r) Conveyawe thruiu/li Food N/lft/^'.— Mere the chief d \\(<\\- contammation of milk, which has 1 mger is tl source of the disease in )een shown to have been many epidemic conveyed in the water with which tl tlic The infection is iisnallv possibility of direct infection tl le |)ans are scoured, but the must also lie borne in miiul. as when lose engaged in milking the cows have also to do with. ami landl the care inti of persons sick with the d isease inspection of neither milk nor dairie,- ialtimoi 'e liiis th We need information regarding tl ei r condition, and also the i)rop()rtionate le number of citv cow-sheds and amount of milk supplied to the cit dairies tin had. Ev( exposed to ceptible t( licst kind, altering th lilown in a contain ge reach the ( disgusting Mianure in i whole grou ing the i)ai and horribl in many in readily und( There does Health OfK members of of the faniil lived in a sm stable in the about in a m place a few- condition as localitv. Th I65J r,,i>hohl Fnrr h, Baltimore. 165 'i^^>tz^::zJ:::^7 --t- '• - -^ '^- l>«'l- Eve, «I,,,,C "■■'"' '■'""■''''■'' '» •'■"'■'■""■I-- '••■I'til'lc t(. infection .m,l V """'' ^''^" '""^t sus- i-t kind, p.. ^ :^^^ -Itnre „.,.loun in all .li- ,tions fn„ . 1 ,' V , ' ''"'' """^ ■^"'-I'i"^-- -"ta,n ,c.rn.s wl.i c. v i ""?"' '''''''' '""^^ -"^ "'•^"' -acl. tl.: open pan W, "•' ^""-'->^^-'^-^ "^v '■^•i-; 111 iimnv nstances fi;«t;ilr„... /• '"'t.S the onlv foo, ■■ ■•»•■. 'r z '::;:! :''T,;::i,r;, '''^ "'"■"■'™" Hoal.l, Office c.a,'Xe . |:;hv T'"'""' ',""™"""' '•' "'""'' ""■ "f tl,o fan,ilv l,a,| |„,,i, i| ', "" '" "?' "•"•''»■ '"" '"eiiilHr, «".i i..us,„aii .»,.;. ,,.';::,; ;;:; ""'',■""'• ■'■'- i>»pi« rtaM,. i„ ,he bade var.l ivi,,,. i , "i''' "'"' " """"' >■•"»- 1.1.C0 a fe-v bi„c.,<, ,„»,„„■,,„„., :; ,„ ;' '■„,:":,':;;""™".'"" '■on,l,t„„i a« clisKMsti,,}-!,- ,|irn as i, I,, I ' , "'" '" " 'V|.lmi.l KM-iii, will „,■!. """■ -*'." ''"S 1»™ »lio«„ ,|,„, ,!„, -'™ ". an i"M.:'.l.!i:::,,::f ;,.;::;; ■ii^ri:';;:'-?'?' ;■' :'°- -' excreta, lif^hting on milk meut an,l ., '"^ "' ^''<' ^''"'^d ^^''ie for tl.eir .levolop,!;'„t '"'' "^-^'^^^^•^' ''^^ ->"^litio„.s suit- Kj 166 Williiiin Onle.r. [16fi Cold, lili'IcsH tliiiif^s, figures makd no iiioro iiiipreHHiou on tlu! ordi- nary mind tliiin would tlic cnmncration of the davH of the y<'!ir; noi more also docH the Htutenicnt that at an estimate of an averajrc of hn weeks' illness to each case, there have been from 18H8 to 1H92 (iiiclii- sivc) ,S2,")1'J weeks of lin^'erinliould be a Nnte.—'ri tli(^ Vitdi SI •I S. Billing, have stated, included. ( tinctures the years coveret Mkahkues Xecessauv r)h the FreveiVtion of the Diseask. 1. Scrupulous care on the part of physicians in charge of cases, that (./) the stools are thoroughly disinfecto.'d, and (i>) that all sources of contamination are prevented from the soiled clothing, etc.; (c) active co-operation in notifying the health authorities of the existence of cases. 2. The presence of ty|)h()id fever in a city means bad drainage, oi' |)olluted water-supply, or both, and since the morbidity and nior- tality may be reduced to a minimum by a i)roper sewage system and an ample supply of pure water, it behooves civilized communities to insist upon these elementary Ineasures of public health. Baltimore 167] Typhoi,! Fcnr /„ lialliniore. 167 ;:;:;:r:r ■;;;;;:!::;;;:■, ;;":;;:■■';' -i.:-™...- '•"'!<" i'""i...iofwi,i„i,Li, 1 ""■ ^•";:"" 'i"» .».iM,„,.,„, ,i„. -"<»i "11 r „r i„,,, ,;,«;::':. ;;,""■ '"-' ';'i'"" -'■ "■« '"■"« '" i.ivci, ,i„„.,.,.„ , ■• " : „ ■ ";."»7- ' - »B0 .1,,. ,l,,„|,-,,,(e fr ,, 'l f''"'""'-''' "■"' '""I" Iruin- l.re..M,r.,,.„n ,''"■'-;' ™ -'■'■I '«• -I,,..,, ,„„„ i,, Tl,« .»UT H„„-,.c, ,„,,;'"'-' '" '"*™' »■'« "■'' l-vail ^listriots, and th-it , h .i ' ■'"" ''"'""^ ='"'' ''" '■"'"f^'i" THI PHOrgss <^K U N/ll I I THE ARMY SURGEON. BY WILLIAM OSLER, M.D. r«Or,SSOR OK V«,„C,NB. ,o„NS „«,.„.«, „N,VKRS,TV. „*tT.MOR,. i). i'l I FROM THE MKDICAL NKWS, March 34, 1894. fl •I I I t< TUi ndoul le n ' Sll « manage ^^"^ of the more salient f^'. ^ '°"°''' ^^^ever. apon „ gating that about Ms[lTZ °' ''^ ''"''^^^^ Mtel ^y too particular knowled J , ^ '*^° '» uuhamnor',,! '"edical surroundings it ^^1.^,'^.'' '-^""ding to his J , 'v ^"-«m. index cat^alog e *\7'",''?'--to the Hbr^^ t'onary, and the median it'- / '"^ ^^^ow Jikg . , J' , best fo. -e place is never log enotlT\ ^'^^^P^' ^^ --c'e t deeply as to make the process of tr 'f '^^ '•""^^ strike o I "bout local ties. inde^Lnt f"tf '^*^"°" '"<> P^^'^f^' •I'-'oy surgeon escapes many o7 the .nl.-^"'"°' '^« y°""^- •-i^il P"ctitioner-tho n '*'*' ^^'"^^ f«t t!.e ^-owleije , fP"'"'^*^"^'^ comfort ZyU "T'^'T '"' '" 'Growth i„ thp n. ■ '^"'fi' '"uch, but in » • ■^''^'alue ^.i.,* 1 " acquis t on fif fo » . '" seeing wispiv ^ ''ted With .levelopmentMl '' "°' ''^'^^'^^JilyZ/o ■'if^. Which adl ; '^'r''""' ^han that de.^'tS* • " '^^^ ■^'"i'ersin thei inv . '^ ^° '^^ studies of 1 '° "'" . ' T>^turbi„g than those whih;:kituh''°°' '"^'"^ '-« °r m the routine of a gene tlhn v ^' '° ^^"nily Practice d.3orders may be tracke!^ rom i ceZn , '''"^ '=""'-- alluding to the pursuit of th^ ".''^P''°'^ "^ "''Jse. Dr. O.sl^r. «uch as botany, zoology geolo^v ?1 ""T^^^ *° medicine. t.e/irstduty of the m?dca officer T '''"°'°^y' «<^'^'^ '"^a; ciiie as the best way to serve th^f " "^^'^''tl'eless to medi- ^nd the p„blic. Setting aide T"'- '^' P^°f«««i°n Pomts to the experiments an^obf "":"""'"• ^°'"'''' ^e .';aiceandthephysiologytf TiLTn; T-l'"' '''' ^'^^^"c M.a, surgeon in the UnS sLV'^ '"'^ ^'""'^°"'- 1833, as an illustration of what ha^r!"™^- P""'«''ed in '\We circumstances by one !„ °"' *°'*'^ ""^■"'°"- ^k^rts of h.p .■ y.°°e who w,s quick to •■ grasp the PHOPR;So|) o TH£ ARMY SURGEON.^ I" MEDICINB lOHNS HcirKlN ^f.D.. '■^ I'NlViUMlv I Al.TlMOKK h^lf of the profession, to o fe 'n m"'"" '""' °" ''«- I eparfnent hearty co .ratJ t o s ' '}''''' '''^^''-^ of he arran,.ements whic h ' " "'V'" ^'-'P'^tion gathennj;. Wjt,, ,anar t^!l J '"'''^^ P^'^^ible this 'he schools at large canLthl '' '"'*"^' '^'^^^-^'on l^Seons with the^ fu, Tt .iK o;'"'"' /° ^''^P -"v g''ince at the curriculum J^ '''^"'' ''^^i'^R. A ^harp reh-ef the disabili e u '°!"'''«'"< '^rin,' into n;-st have proceede' t^ f; T /'^'^ P'-ious dasse of wh,ch have had to nVk "''' "^^ '"embers knowled.^e traversed n tJe lect,; '""'.^-"'^ ^'^'"--ible cises of the session Mnt .. ' '""'^ 'aboratorv exer- " - -my medical sZj'^'^l °^ •■''' 'he advant!"es °f the younj, officers „ Th ,h i '" ''""''" "'e cont^c under whose directions tey ,/'"'"?' "'^'^ '^e men '" comparison with their nre''^ """'>" ^^^e to work -'fedin.s and ideas w 11 ' t'" ^ j^''^/ ^'^ what differ-' he.r duties in the various po't , " 1 T "' *^"'«'- "Po" ass>;.ned. Instea.i of ha v no '''^ "'^>' '>ave been ^-'» 'he J:xami„in. Do ^ "° '°"^-P^'haps to one fresh -;'hority at U ashrn^torlr ';T'"^°''"--°^^''^entrll retary of War. and of an exnnr '" ^"'hroned as Sec youn. officer who ha ^n , "" •'^"'"eon.r.enerxl tt: |-offour..ont^'';;;^S ;^;el,,htfu,opSu;:;! 'ngs. which teem with ;em nl V"'P'^'"» ^"'•'ound- corps and of the .reatn^ '/ p^r f""- ^"'"^'^ °^ '^l officer, I _say, must be iiuleetl a nuKldy-mettied fellow who does not cany away, not alone rich stores of infor- mation, but, most precious of all educational {;ifts,atrue ideal of what his life-work should be. Miiiil'crs of tlh- (.]i(u/ii(itiiii; C/ass : Though to you it may not, to me it seems peculiarly ap[)ropriate that the Surgeon-Cieneral should have asked a civilian to make an address on this occasion. With the strictly military aspects of your future life you have made yourselves familiar ; of the merits and demerits of the army as a career for a physician you have in the past four months heard very much ; but about all subjects there are some questions which are more freely handled by one who is unhampered by too particular knowledge, and this is my position, I may say my advantage, to-day. For me the Army Medical Department, so far as particulars are concerned, means a library with unsurpassed facilities, the worth of which is doubled by the liberality of its management; a museum in which 1 have spent some delightful hours ; an inde.x-catalogue, which is at my elbow like a dictionary ; and the medical history of the late war, particularly the volumes by Woodward and Smart. Further, I ha\ e here and there gleaned in my general reading in the history of the profession of this country facts about the corps and its members. I have read the spirited vindication of John Morgan, who may be called the first Surgeon-General, and I am familiar with the names and- works of many of your distinguished predecessors who have left their mark in our literature. Hut as I write an aspiration of the past occurs, bring- ing me, it seems, closer to you than any of the points just mentioned, a recollection of the days when the de- sire of my life was to enter the India Medical Service, a dream of youth, dim now nnd almost forgotten — a dream of " \'ishnu land, what i\vatar ! " Speaking, then, from the vantage ground of my ignor- ance, let me tell you brietly of the opportunities of the life you have chosen. First among your privileges 1 shall place a feature often spoken of as a h'lrdship, \iz., the freepient change from station to station. Permanence of residence, good undoubtedly for the pocket, is not always best for wide mental vision in the physician. Vou are modern representatives of a professional age long past, of a day when physicians of distinction had no settle.1 homes. Vou are Cyprid larva>. unattached, "^^"''y'"^'"'"'^'' ^^e'"^' '""ch in manv places ; not fixed as we barnacles of civil life, head downward, degenerate descendants of the old professional Cirripeds. who laic! under contribution not one, but a score of cities Without local ties, independent of the public, in, while not exactly of, our ranks, vou will escape many of the anx.et.es which fret the young physician-the pangs of d,spn.ed worth, the years of weary waiting, t„e uncer- tain y of the effort ; and perhaps those sorer trials inev itable in an art engaging equally heart an"" "" -^^iapt y^,", °"^er, yo„ u,,i ,, j^^ 1 ttle bv , r,'""'"'' "^ «°'>'e Po^vers without which no man if "' "^°'*'^ ^^'''yins ''-•nks. Vour opportunitL 7n ",^ "'"'^'^ ^'''''"e in the •■^ -de field in medic .' and L?'-^' "'" ^^^^ '"^^ '•- -oth.ng slip by j.„, . the or !" '"■■'">■ -"-S'lns. I et ■"-n.n,. routine maf l"' h"' '""''^"™ ^'--^^ of S -d Picuued, but stud'y ad ot'" """'■'Y^'^' ^'--"^^d were new_so it is so f „ w 1 ^^P'^-'ately as thouj,d, it '^ncl if the spirit of the tuienr'' ■''"^' experience ^^^es be there. Look at i^ c^ 's It'V" '''! "^^ '^^^ - ^ ext-books and n,onographs Z ^?" "' ^''"^"^f^^'"' °f stones ,n the progress of „,';. ? ■ , '° "^'''"y steppin.,. '"e -t. This w^I sa^eC T'''''T' "--'°P'nent ,''n •;«''>'de of the men w^trCl iT "!f ^''^'^^'^ "'ental ^^^'n to Heersheba, and a eve , ^ °' P'--'"^'"^e f.o.n desolat,on, ,ts d,ea,ines Z?]^ "' """ "P"" ''s Uuience Sterne, we can -, v. T "'onotonv. With '■ ^"' '^' -"« thev -th-n themselves, a res to" "'rV''^>' ^°'"P'-n ^--'y -.^— ";;:'h;;c^s^- ^•^^^■^"^^^- -" be f'-lness m the day of sma fh"'""^^ '" <^'vil life. Faith- >-"• powers, cor;ect,::;';;:^E-;;^;-ns.blywid^ • '^"•^' 'n moments of despondenry comfort may be derived from a knowledge that some of tlie best work of the profession lias come from men wiiose chnical Held was limited but well-tilled. The important thing is to make the lesson of each case tell on your education. The value of experience is not in seeing much, hut in seeing wisely. I^xjierience in the true sense of the term does not come to all with vears, or with incieasing op|)Oitunities. Crowth in the ac(|ui- sition of facts is not necessarily associated with develop- ment. .Many grow through life mentally as the crystal, by simple accretion, and at fifty jiossess, to vary the figure, the uni( ellular mental blastoderm with which they started. The growth which is organic and endur- ing, is tot.illy diiferent, marked by changes of an un- mistakable character. The observations are made with accuracy and care, no pains are spared, nothing is thought a trouble in the investigation of a problem. The facts are looked at in connection with similar ones, their rel.i- tion to others is stuilied, and the experience of the recorder is compareil with that of others who have worked upon the question. Insensibly, year by year, a man finds that there has been in his mental proto- plasm not only growth by assimilation but an actual de- velopment, bringing fuller powers of observation, addi- tion.U capabilities of nutrition, and that increaseil breadth of view which is ol tne very essence of wisdom. As clinical observers, we study the experiments which Nature makes upon our fellow-creatures. These experi- meiits, however, in striking contrast to those of the labor.-itory, lack exactness, ])ossessing .is they do a vari- ability at once a despair and a delight — the desp.iir of those who look for nothing but fixed laws in an art which is still deep in the sloughs of Empiricism ; the delight of those who find in it an expression of a universal law transcending, even scorning, the petty accuracy of test- tube and balance, the l.iw thai in man " the measure of all things," mutability, variability, mobility, are the very marrow of his being. The clunteh' in which you work has, however, more stability, a less extended range of variation than that with which we de.il in civil life. In a botly of c.'irelully selected active young men, you have a material for study in which the oscillations are less striking, and in which the results of the experiments, /./•., the diseases, have a greater uniformity than in infmcy '•« •■'«.;. stand,,,-.! of . o ;, , 1"\°"'''«'' ">•" tl.ey serve "f ^Inve to reach the low " ? " ' '" '-'^'1 practi.-e P;''"^ "' the treat.,,;; ',;;^.;'::-'^"i'y of ar.:,. his! •"rf ^yn,,non,at„lo.v haJecoJ^f '' "'"^' '° ^''°'"^'y 'I'-xea-se under the most ^avo,. "'""'•'' '""'"'V ^^f a ('e-'n,ents are n,o,e idea U ' '^ '■'■'""stances ; the ex- Jan those whi. h prevail eL""^?""-^ '-^^-^ '''-^''-''in" the routine of the J, : , ' ' '"■ "'">' '"■■"^'"'^ ">■ m" "-" disorders c.,:^^^'^;^; .^'-»- of the ,:o„ " ']' '^^^"i be done in no othe , r ""-'^P'i"" to close '•-'-""- for the Tnt tu:,^!t:dr;''"'^^•'•^■■^-''''e :'«'•e;.nec,ualled. This, whi h ,?, • '"■'"'" ='""^'^"""s '" the .ntrinsic edncat o , f \ ..tt"!"' '?^ appreciated deeded adv,ant,,;,re ove,- vo r I '''"'''■'• ^''^'-^^ >0'> a Vour extrao-cimarv a r . ^""■"' '^'■'^""•^'" •I'-JdaKeysto'lUfC'T"'""'^-- ^aLfornu,, affords unequa Id f '"li, "!-"' '" ■'"""'<^'-n •"•;»>• of the vexe.l p,o e!,L 'n ', '■ "'" ^""'>- "^ indeed, which in the live !i '"^^"^'"e-facilities be studied a,e ec,ualle ' '^ "* •'"°''^'^ conditions to - .be.e ,nentio'„"f L: "fT"" 'i" '-■'^■'' "-• ^ t P'oluahly en,a,e your attention v/"'j^^.'^ that ,nav '"Portance at present than he se«l ''"'■^"°" '^ °' '"'^'^ the vanetiesof feverin the V 't .nd'^""''' ''''"''''•' °' of liaun,j;a,ten in St I ol u i ?^"'"''- '^"'''^ studies '" the Southern Sf es ' "/ ^'"''^'''^-'^ ^^"'' "'hers ^dduion to typho-i' e.'er'Sr .:'! '"'''''''' '"- '" ' affecfons-there are other ever ""-"^'^ ™'"'"on and morbid anaton,y of u' ichs, 1 ^>"^Ptomatolo,.y dation. In this you will ^ , !n '" "''.''""■^ ^'areful eluci- notable p,-edeceiors i the ^n, '"" ." "" '""''^''^'^^ '^^ "'"■•ks of \\•ood^vard and Sma^ ' , ' '".''^ '" '^"^ '"'''haustive a'b.de,l, and which are aS,' " " f','^ ' "''^'^ ^^'"-'^"'y a basis f,on, which vou ..a v' art." ''' ' °" ^^'" ""^ - ma> start your peisonal observa- lions. More particulaiiy in this direction do we need careful an.itoniical investiK.Uion, since the symptomatol- ogy "f leiiain of tlic alledions in (|ucstioi. has much in common with that of the ordinary continued fevers of the North. I may call your attention to the satisfactory settlement of the nature of moantain fever l)y army sur^jeons, and neetl hardly add that the specimens con- tributed by iloff and by Oirard to this museum tlemon- strate condusively that it is in reality typhoid tever. In the Southern posts malaria with its protean mani- festations presents still many interesting problems tor solution, and you will leave this school better equipped than any of your predecessors for the study and differ- entiation of its less known varieties. With jmsitive knowledge as to the etiuloj^'y, anil a practical familiarity with methods ot blood-examination, you can do much in many localities to vjive to malaria a more definite position than it at prebciu occupies in the |)rofession, and can offer in doubtful cases the positive and satis- factory test of the microscope. The hematuria of the .Soutii requires to be studied anew— the lilarial cases separ.Ued from the inalari.il, and, most important of all, the relation of quinine to hematuria positively settled. In the more distant posts, where, so far as the soldier is concerned, your opportunities for study may be lim- ited, you may add greatly to our knowled^je ot the dis- orders prevaUnt among the Indians. .More particularly do we need additional information as to the frequency of tuberculosis among them, and its clinical history. One of your number, Dr. Edwards, has already fur- nished ailmirable statistics upon this point, hut the . '1.1 is still open and much wi lains to be done. In this connection, too, you may be able to carry saving ivi'.,\i edge upon the etiology of the disease, and enforce regu- lations for its prevention. You have only to turn to the Inde.x-catalogue 'o see how scanty in reality are the facts in the nosology o! the North American Indian. At many posts there will be presented to you the in- teresting eflects of altitude, with problems of the greatest hvfu.k ','ical importance. An excellent piece of work icav hi-, done upon its inlluence upon the red blood- ••.i;;'-..i3cles, in •<(■ ;rmining whether, as has been main- tiii:ied, there ib . ., increase numerically per cubic miili- •aetre, so long as the individual remains in the more rarefied ..imos,,he,e. |„ ch '"'"'» remain to ■' "leasiireinent 'f "/'»n the chest "e sfitled also 's still |.„.|. '"'.' "le heart, ami '■^'parity, the h'A'h altiliule: '">f "11 'inestions lel, '" "ne of ■^ "l'"n many of the or.l ■"'"),' to the inll "iir knoivledjre ■e''se-milk-si,:k di. know ireased si vo '". perhaps, anoth '"■"■>■ 'liseases iiente of ness er |)er„lia,|y ^me ^rican '7'^e of its etiology hi „!:'^' "^ '^'"^ret. Our «l sinrf tl,- „...., ^' "''^ ""' been malerinlK. :„ well described "'■e the earl Th its V papers on the sub, ese arc but .i few of th symptomatoloj; :y. terially in- lett, which so 'es to selv could direct si-'tvicf, trav and •">■ "lind. to which your attention. e"'">; with seein le -n;:irn;;:;::j:i;:„jjf-;;^';aved.eitchienyon Vour activities mi^^ht be en;,' ,"';'-' '7^"°" '" ^^^ich '•lymK the foundation of -.n ? "''"'^ >°" =ire thus '° the technical si.t of M; "IT""" '" •^" '""'^ -'"^t ^^""^^ which call for a wo d ^^ °",' '^"'^ "« ""'er "" to which you ma; "e sen^l ""• '" '^' ^°'"">t.ni. anny officers, you ow'e a le^" r.^ ''"f '"•^'' "'°"^'' fession, to the memhei- of wwl •'" *^""oral,le pro- ° a most bindin,, <:har.,cter n sit^;"' ""'^'"' *'>• '^^^ advanta.^es of a more criticli trnin 1 '""' '" ''^'''^' the of superiority over your 'J^' ''■^'"'"^^«'ve you a measure be apparent in you de„ eTnor'h .'" ""' "'^- '^t it not favors. There are re.Mon ^ . '^''^'^^' ""t to .rrant ;vhich you will Ko H mi si.'" ^"""'"' '•''^"''•/'■-V to '°>;"'>' to truth tn the s :nce "d "\T^'"" "^^ «-Pe' of f"d your lives of devo, on ^ '^ '"'''« art of medicine Jatin^^ example. Vol.ZZ'rT '° "'•-*">■ ^ ^timu lO everywhere showing that you are at all times faithful students, as willing; to teach as to be taught. Shun as most pernicious that frame of mind, too often, I fear, seen in physicians, which assumes an air of superiority, and limits as worthy of your communion only those with satisfactory collegiate or sartorial credentials. The passports to your fellowship should be honesty of pur- pose and a devotion to the highest interests of our pro- fession, and these you will tind widely diffused, some- tmies apparent only when you get beneath the crust of a rough e.Nterior. If I have laid stress upon the more strictly professional aspects of your career it has been with a |)urpose. I believe the arrangements in the department are such that, with habits of ordinary diligence, each one of you may attain not only a high grade of personal development, but may become an important contributor m the advancement of our art. I have said nothing of the pursuit of the sciences cognate to medicine, of botuiy, /oology, geology, ethnology, and archeology. In every one of these, so fascinating in themselves, it is true that army medical officers have risen to distinction, but I claim that your first duty is to medicine, which should have your best services and your loyal devotion. \ot, too, in the jjerfunctory discharge of the dailv routine,' but in zealous endeavor to keep pace with, and to aid in ' the progress of knoivledge. In this way you will best serve the department, the profession, and the |)ublic. Generalities, of the kind in which [ have been indult;. ing, though appropriate to the occasion, are close kin.'^l fear, to the fancies fond, that vanish like the gay motes which lloat for a moment in the sunbeams of our mind. Hut I would fain leave with you, in closing, something of a more enduring kind— a picture that for me has always had a singular attraction, the picture of a man who, amid circumstances the most unfavorable, saw his opportunity and was ([uick to " grasp the skirts of happv chance." Far away in the northern wilds, where the waters of Lake Michigan and Lake Huron unite, stands the fort of Michilimackinac, rich in the nu-moiies of Indian and Tvy,?;--,//;-, one of the four important posts in the upper lakes in the days when the Rose and the I-leur-de-lys strove for the mastery o( the Western world. Here was the scene of Marquette's mission, and here Siirjjeon II beneath the chanel of S. r ;-t. Here the i^n ^d' j ',« ".'^^ ' ->' '-d I>is bones to the resolute Du L^h had h4id '*■"'" ''"°"'>' '-^"rf '"gs, Its palisades and t, r '" /'''"■ "•''^' "''"'der- whoopsofOjibwas'n d(L "V^'"^ *='^'>°«' 'he war- -Kl had beei U^ c' ne o bS "' """"^ '^"'' '-I"-. fo"Kl.t n.dus. At the conl> •' "^'-'^^''^'^'•'^^ ^^"cl of hard- 'iftertwo^enturiesof.f ^ '°" °^ '^^ ''^'^ ''^ '8n most famous of her minor Jin,^ celebrated one of the the high-soundin, Z^^o ^uw\"''\''''''''' '^^'^^^ -Kle, and into cildefwhere ,'"-'^"""'-»'^'<'"-c far and -■Salle were unknown "efhl'Ts:' ''" '-"'^'' ■'^-' to duty at the fort, which hnlh' ' "•'' ^^^'^^^^^ keep the Indians n c ck Sur f" u^lV'""^'' '" "^^ '° then a young man in the ,^^^'"" "<^^'">""nt, i""e, ,S2., the accidenfl 'r'",'" ""^ ''^"- ^^" the .2d o ■St. -Martm a I;!' .?;"''' ^^''l^'l^'-^''^ "^ - "n-sket „,ade stomach, and he o 0' eVed ' i ^ ""^'"' '''''^ "P^' '^^^ fistula of an exceptionall ,? f^^''"^"ent gastric was not slow to e' "thf extZ'd '"'^ '"'• ^^<=— "' were before him. Farlvln 7. "''^P"''''^"'''^« that 'century the process of si. '''°"'' '^^""''^^ "^ the '7 d-etodiJect m:^sj;:;s;s7'^^. '';!'^^'^^ '° "fa v.tal principle, and tlCh Jl i , " r '^' "'^''°" J.nce had long been entertained th ? °^ '^ '"'^'^"t ■""'^ ./W/.v. The serie of ! ■■ ''''°'' '^"^^tion was on St. Martin se tied fore er the" "'"^' '>' ^'^^^'^-t in ...e rni,.,^,,„rAr,;:^. ^!S;,^':^;;^:""'' ''•"■• [2 of its kirnl, aiul on every paj^e is revealed the character of the man. Ironi the first experiment, dated AuL'ust I, I.S25, to the last, dated November i, 1833, the obser- vations are made with accuracy and care, and noted in plain, terse ian-ua-e. A remarkable feature was the |)ersistence with which forci-ht years ISeaiimont pursued the subject, except during two intervals when St. Martin escaped to his relatives in l/)wer Canada. ( )n one oc- casion I'-eaumontbron-ht him a distance of two thousand miles to Fort Crawford, on the upper .Mississippi, where, in rS2(>, the second series of cxpeiiments was made. The third series was conducted in Washinj^ton, in i.S:;^' and the fourth at i'lattsburjr, in 1833, The determina- tion to sift the .[uestion thorouj,ddy, to keep at it per- sistentlv until the truth was reached, is shown in every one ot the 238 experiments which he has recorded. The opportunity i)resented itself, the observer liatl the necessary mentil eipiipment and the needed store of endurance to carry to a successful termination a Ion" and laborious research, William iSeaumont is indeed a bright example in the annals of the .Army .Medical Department, and there is no n.ime on its roll more deservinj; to live in the memory of the profession of this countrv. And in closinj,^ let me express the wish that each one of you, in all your works be.Ljun, continued, and ended, may be able to say with him : " '['ruth, like beautv! ' when unadorned is adorned the most,' and in prosecut- ing; experiments and incpiiries I believe I have been guided by its light, " LE AN ADDRESS AND WIL Pr ^-->c uvin THE LEAVEN OF SCIENCE AN ADDRESS DEUVERED.TTHKOPHN.NG AND BIOLOGY OP THE UNIVERSITY OF THE WISTAR INSTITUTE OF PENNSYLVANIA, MAY =,, , OF ANATOMY 894. BY WILLIAM OSLER, MD FRro r '"' '*'i-u., F.R.C.P. (LoND.), - P-^essor 0. Me.c,ne i. .. .oHns HopKins University. Reprinted from University Medical Magazine, June, i8q4. H> 1 ! //„ a ^) // .\UyQ- ?^i 7// ^f.)// /t ^^. /y^-t^ . 6=i2i^W-c r/ ////n/ // // / // -V/////^/V/ t / /////. / "/' /, ^/ // f/'^ /////// ^^ / '/ /// ////// r / // //. / /S y' ^ A/,y(yC t £ f C- /- L/- V. f/^. / // , / ,/ .!/. ,///// // ./// //V/ /i / ,//..,/„/ ;' ,y. ^<^c/C c^ Cflx /' r^y^'^cC >' Ct^* ^ ^r, ■c- /^4 7' /A^y /Jl — »«.«>«iie»»- •>. ^/ ; // r/ //i /■/„ 1/ y (/ / Wi Ai:/. /./ ' ^/i' '-'t y. /:^/^/x/j w ^/ ^-■/^^ /T. /, / /. t f/^^/ V// /^ . r -/ -v '^Ai: t-^C -^Y > ''V' ^^^ /■ /'A,- 'r<^ Ci'i^ / /. y-'^ ■/ / ^'L . ^ I v r />- >'-' ''■^r -'^ />//- ^''^ t/ /^r/', ^ /: ^ /^^^r^ /: // ''^^- y '^xfxT ^'^ '^ 1^ ^ ^ ^ // r v^. /'/' ^ ^ // /// ,''/' ^ >'/, X' x/ «/* •^ '^ /'-^r ,;; X X /. ^ A Y '^^^ Xy ^ /^ /f / ^ ^f^ M^^/ /^^ 7 //•^^^ ^4^_ /'^ /Vt^ t-4r yy y^Y. 'i^r^. '^c /'y ^7 / I/' / ■r^^^r. >i X . A- Y-^-f^c t^ y ^ r*' /. ^^K/i^^Zv../f/:' 7t ^«^ 'y. / /Z A ^ ^z r ^'>>'., / W. /z.^ /^^/^ y^^ ^^. (T *^ ^'^^'^/Z-. Y^i^i-^ •■f^f'.t/^ ? //.•J, // /. 1/ V. '■/ //*' /. I//// 4^t '///<' A r»«V -9.V / V//i ^/'/s'. /7 f /f.il ]/ , 'A ... //. y"/>,y./,, ; ,y,,y,,, ^ f, I /-^ / ' .'I //i /■/(■'/■ ^yf r / r^li /A ,, ^ ^ >^ ,, ;^ ^/ "^ / r / / / ' V r.'.'t ^z-^' /^^/v, .//'. /. .u I f\ mm LEAVI I •i'\H AM) l!|()|.i),,v I WILLIAM ( Prof fssdr (if Um THE I-EAVEN OF SCIENCE. '""'^:^'""^"-"^'nn <,„,„,,,,,, "" WIM\K. INS I, I, '^ "'-■■-'->,;;.;„:;;::,:::;:::;::-"'- i:v l^t'PriiucJ lr.,m l"mersitv MeJic-il M.i.u,,/,,,,. ■'"lie. iSgj Mr. Pi, ieiiienibratic( iioMest insp: own sake, s because in tl; a deinocrac}' Roman Iiisloi of the scrupu Ambarvalia, ihoiigli feebli lives of their < whicli the col the touch di equivalent to :iii ever-presen religion of Xi.i tiiose who wc importance of ire of everythi Its possibilities this institution oblivion falls d perhaps a natne lorgotten seem.' we reco^niize th teachers is passt "len ; and in tin ^vise, ' as they ca tiiey play no p invoked nor bles the need is ever liays of trial and colonial colleges. To-day, thrc lilting monument 'nil; i.i:.\\|.:,\ of scii.;\ci.:. Mr. Provost, r.Ai.ij.s \x,, p, ...,,, reincnibrance (,f a L-lorioiis 'tv,«f • ' ' '•'•^"•■'•' ^ '" Hie continual ..oldest inspiration, a,:Mr;X;h;-"'^ ""' "^'^'""^ '^■"' ^"-r own sake, so important in its a o'i H ^''''' •'""' ''' ''^^''^^'^' ''<"■ its '-cause in the strong donu-n.ce TfT^ ''■'''^^^^^-'' i« it not .' ^■->ocracy, we hate lo t V J '!;""7."-'' ^^ characteristic of Roman history of the ceren.n ^"ntnunty ? As we read in of ti.e scrupulous ^i^tm! : :rrrr"f ^ -^ "-^ "^^-^-•' -^^ Ambarvalin, the dead were invoked V, "^"'"'''" ''^•^^■^•''''•'^ '''« tbe tl>o"8h feebly, the part ud ic thi! ''-'■-"'•ered, we appreciate, lives of their successors,- .."r'^^ "^ -"^'"-ty played in the -i"ch the cold rotUine of t^e p ^s^ t!"^"'^""^^ ■"'^-"-. through ■the touch divine of „ohIe natu^s ^ "t ' """ "' "'"^^' '^°"' equivalent to this feeling exists and the °"'' '"°'''"' ''^'^-^ "" an ever-present immortalitv, recognized soT , ""^ P""^'""" '""^'^^ °f religio.: of Nunua. has lost all vafue o u. w " ' "" •'' ''°^^'-^- '" ^'- those who would recall the n.st nn.i , ^^ ^ ''''^^ e^^'" impatient of importance of its recognition .^'a'fa .-l :„":;'' '"■^'•^V"P- ^he are of everything save the present witl i n ' ""^'''""^ ^' ^^ ns possibilities. Year by vear tU P''°«P^cts, the future with t'=is institution fades fron^ otU the c nTe'7n°' ,''' '""' ^'^-^ '"«^'^ ■'''-■••"" falls deeper and dee r oL ii / '' '"' ^''^ ^"'^ "^ perhaps a name alone, remains to ,,u , I""' ""''' ^ P«^^^«'^- «>- -gotten seems i.ievi able "at no • 1'' '"'^ ^^'^'^ ^^'^" ^"'^k. To be - -'.."i.e the fact that th da - , ^ ^l" 7" °' '""'^"^''°^>' ^« teachers is passed heedless of the f „ e ° ^ '' '^"''^^"^^ ^^"^ents and ^"en : and in the second state subli',, 1\ ''" ^''^ ''^""^'" "^ these --. ' as they cast their e be W to 0^'^' "'""' '''' ' ^''-^'^ "^ ^^- "•ey play ,.o part, on g;th eil ' look down on festivals in which ■■"voked nor blessed, Btft o r ^ l" "'"' ^^"'"^ "-"- -^ neither "-.eed is ever present to c j s r'''" '" "■'^' ''"^""'^ ■'" ^'"'"-'^^ W istar. The tribute of deeds lias already been paid, to him in Mr. splendid structure, to all in the stately group „f academic bnihli . '. which you now see adorning the campus -the tribute of words rem i--s to he able to olTcr which I regard a very special honor. Ihil as this is an Institute of Anatomy, our tribute to day m-u 1, justly restricted, in its .Ictails at least, to a eulogy upon the men nb have taught the subject in this r.iiversity. About the professors],,,, '■ anatomy cluster memories which give to it precedence of all others vr HI the septemviri of the old school the chairs were arranged, with i'".' of anatomy in the centre, with those of physiology, chemist, v a,,','^' materia medica on the left, while those of practice, surgery ,,„■' obstetrics were placed on the right. With the revival of iJiini,,,,' anatomy brought life and liberty to the healing art, and thn.uohoH the sixteenth, .seventeenth, and eighteenth centuries the great nan.es of the profession, with but one or two exceptions, are those of the ccv anatomists. The University of Pen ii.sy Ivan ia has had an extraonlnn,'; experience in the occupancy of this important chair. In the anti'.t.' and a quarter wliich en.Ied with the death of I.eidy, six names a„nc,r on the faculty roll as professors of this l,ranch. Dorsey, howeu r o„iv delivered the introductory lecture to the course, and was sei/»l th same evening with his fatal illness ; an.l in the next year Phvsi, k wi. transferred from the chair of surgery, with Horner as his adjuiu t ir reality, therefore, only four men have taught anatomy in tins nhoo! since Its foundation. Physick's name must ever be associate.l w,ih th- chair of surgery We do not know the faculty exigencies winch Id .o the transfer, but we can readily .surmise that the youthfuha-.s w Horner, who was only twenty-six, and the opportunity of filchinLM^ surgery .so strong a man as Gibson from the r'aculty of the Universii,* of Maryland, then a stout rival, must have been among the ,m:i weighty consid^'rations. If in the average length of the period of each incumlu ncv th. chair of anatomy in the University is remarkable, much more so is it for the quality of the men who followed each other at such loii.^ intervals. It is easy to praise the Athenians among the Athenin.is hm wher IS the school in this country which can show such a siuressici of names 111 this branch: Shippen, the f.rst teacher of anatomv \\istar, the author of the fir.st text-book of anatomy ; Horner tk hrst contributor to human anatomy in this country ; and Iei.lv .me.i the greatest comparative anatomists of his gencratior ^ ( )f iM.nmean schools, Kdinburgh alone presents a parallel picture, as ,h.,i„.r ,1,, same period only four men have held the chair. The lonsrvity and tenacity of the three Monros have become proverbial ; in Mirccssion they held the chair of anatomy for 126 years. .Shorllv before the I'oiiiulatioii of this sclio.il \t t-..ht uninterruptecliv .' r/:::f ^!"' ^"^^^^^'^^ '^ '^'^'-r. and tlK' d.air fornearly the same I'uliinf r '°"' ^^""''^ ^'■'^'^'^' ^"-^''1 I.e.iocl has hee„ covered I,^• the ol "^' '"'' '''^' '■^"'ai.ider of the --essor, Sir X^'inia,,, T u e the n''"?' °' •^"'" ' '^"^■^-- -><' '-^ To one feature in t,, , ', '" P'^'-'''''^ '"'^"'"I'ent. afer in ])assing. shipnen J!. "^ ^"'^'^^"'>' '" t'-is school I must •'Hohn Hun^.. ir:::^:^:;:' Cu^' ''"^' ^"'•' ^''"-■''">^' I'^can.e in addition his house- s.um-on Ti r '""' '-^^'^''-^''tagcs, hut iKul enjoyed the intin.ate con n,w V r''^'" ' ^^"'^I^'^^'- ^^^t'' observer of nature since Aris2"'""" " ''" "'"^^ -"-^''"^■e tillc conceptions and syn.pathies U 'i /'IT ''"''', ^'!'^'*^'' '^'"^ "■"■'^ ■'^<^'"en- ■nemher of o,„- profess on and v o ' f T" "'" '""" ""■'-' ■'" «- are uniy now becoming pr;v din ? '^"•"'";"^'>ta] notions of disease uas derived the powerful inspiratio,, V'l" V'""''^ ^'"'"^ ^'''*'" t'"'^ -"source One of them, o„ his retu^;;: ' ;^^;;:r:t '"^^ ^■;ese young men. anatomical classes which were held i,' m , •""'' ''"«"" '^"^ ''"'•'^t upon that career so notable and so h ^'\V^'*'<'"'^-'^ • the other entered 0'- the Rather of American W^^^^ from Join. Hunter can.e the i.Lnce w HdMnT,'"' '" ''"" ''''' ''''''' "'-^^•1>-'. -"<1 that .eal in the aau it ,) '""■•'""' ^ ...atclyled to the splendid collectio s of WM^'Tr'"""''^ "'"■^" "'^'- W.u.iAM Siu,.,.K.v shares withT , a '•'*''»''■ ^^"'""^^ -Mi'seum. i"LM>.edical instruction in this ciuu^''^'^ iiad discussed plans, but it was mI T '^' '" ^''"^'''''^^ they 0' the trustees, and who roache f d" 7. 'T' '' '''''' '''-' ^■^ -- ■Discourse,- delivered in Z -6- ll ' ''''"'" '" '''' ^'^'^^''"^ed the year that Shippen signifij^ [o Ih^ bo .rhis"!,;'"" ''' "•^"'"" "^ professorship of anatomy and surgery To , '''"'"^"^^^•^ '« '''^-'-'^Pt a mentioned, the friendship of John Hnnf T, ""J"^""'- ^'^ ^ have 1..S celebrated brother, U'illhm \ ' ' T^ ''' ■'^^"^^■^'^' ''^'-'^^ ^'ith -s Wniiam Hewso,, who uhst'^M "'''' ''"' "'^ fellow-pupil a-tonnstandphysiologi t a."" n^^^ "^"'^"^ '^^ ^^"""- -^ an n.e blood, and whose descend Irhc ""'" "'' ^'^^ '^'"^^^'^^'^ "f" 'ession of this city. No wonder H, •'" ^"°'"''"-^"^ ^" th^' pro- .-"ger Shippen' on h^ tun i:';:'' '^'V' "'"^'^^'""- "-^'^- ^l;onMluuxM.egunacour.seofle tues;^ an"; " ^r"^3-->^th year, winch was delivered in the State H.^ ^ "'"' '^'" '"^'•"^^"ctory to ;^^-Ks the great merit of ' "^L": ^°^:^""'- '^''>'- 'l'^> 1-" brought from the Hunters methl , ''^'^^'"'ung, and of having ^^™>' ■" this school. ^vZTtt 7 ■ "'''""^ "■"•'^'' '-'^^ i^^w "■^^^i" as a lecturer and 1 dl ^^f^;"" "^^^ -™ ^^i^nUe to -"--^ i^e taught the sui,ect ^:^^rr:n^^''f;::: from his comaclion with this institution he served as DirectorCen. r,! of the Military Hospitals from 1777 to 17S1, and was the second pi.s,. dent of the College of Physicians. In the history of the profession of this country Casi'AK Wisi \i holds an unique position. He is its Avicenna, its Mend, its Kothci^iH the very eml)odimeiit of the physician who, to paraphrase the words oi Armstrong, used l)y W'istar in liis J'dinburgh (^.raduation TliL-.sJs "Sought the cheerful haunts of men, and mingled with the hustlii,, crowd." He taught anatomy in tliis school as adjunct and proksso'r for t\/entysix years. I'rom the records of his contemporaries we Iian; that he was a brilliant teacher, "the idol of his class," as one ol his eulogi.sts says. As an anatomist he will be remembered as the author of the first American Text- Book on Anatomy, a work which was exacj. ingly popular, and ran through several editions. His interest in the subject was not, however, of the ' knife and fork' kind, lor he was an early student of mammalian palaeontology, in the develup- ment of which one of his succes.sors was to be a chief promotor, Dm Wistar's claim to remembrance rests less upon his writings than upon the impress which remains to this day of his methods of teacliii- anatomy. vSpeaking of these, Horner, who was his adjunct rind Jnti^ mate associate, in a letter dated I'ebruary ist, i8iS,says, " In reviewing the .several particulars of his course of instruction, it is difTicult to s-ay in what part liis chief merit consisted ; he undertook everything; with so much zeal, and such a conscientious desire to benefit those whn came to be instructed by him, that he .seldom failed of giving the most complete satisfaction. There were, however, .some parts of his course peculiar to himself These were the addition of models on a very Ian;. scale to illustrate small parts of the human structure ; and the divisioii of the general class into a number of subclas.ses, each of which lie sup- plied with a box of bones, in order that they might become th()r<)iit;h!y acquainted with the human skeleton, a subject which is acknou Idged by all to be at the very foundation of anatomical knowledge. The idea of the former mode of instn:ction was acted on for the7irst tinit- about fifteen years ago." We have no knowledge of a colieelion u: .specimens by Shippen, though it is hard to believe that he coidd liau- dwelt in John Hunter's house and remained free from the insatiable hunger for specimens which characterized his master. But tliee.stab lishmenl of a mu.seum as an important adjunct to the medical school was due to Wistar, whose collections formed the nucleus of tlie S|)len- did array which you will inspect to-day. The trustees, in accepting the gift on the death of Dr. Wistar, agreed that it should bo .styled the Wi.star Museum, and now, after the lapse of seventy si. \ \oars, the collection has found an appropriate home in an Institute of A.natim'v which bears his honored name. J5nt\Vistar has established .^.M , • ^"•'J l.ospitaI,Ie, he reig„o.l sun '„?"'' ■'"" ''' ■'^"'^"•'•^-ince. (ienia ...aiitie. of heart .J u..:::^:^:;:'^ li! 'r- -^ "-^"'"-> CaMwell, "the ,svvAv,v/,,,;,,<,;,,,,,,,,^^, ''':""' "' ^hc- language of Charles "'^"'I'^'r name in our ranks cluster such".f ^""■^'.''^ "'" '"■-•^"^l^-" About a.u Rood cheer, and it stands to^v '•""'' "' ^""'^ '"'^""^•^''iP and social intercourse. Year by ii, ' , ' "^^ ''' ■'^>"""3''» <"or .•./.;// ;.■:- to the " Wis.ar Parties" (st 1 ' !,' '' ^'"'''''^ "" ^''^ '"^•'ta- 1"^- ■" I'Jnladelphia) perpetuates th' ,nl ^^"'-''"^ '"""^^'■«" °^ winter cheerful haunts of men." ' '""'^'"S^ «' I>''« Hfe, "Go seek the Iltnv different was Hip „ •-f -^ t'- sui>ject I iu.j:'Zs z::!::: "" "'^"-^^ -^^ -xt and throughout his life those obii, ' ! "^ ''''''''''^ '-"'^ ^iifinlent, -i su«;.ring have so often wru.^^ : r,:^':;^'--'"^^ -'->' i" doubi f',. .tn.gs wuhin and fears withc^.t , "aTs , V '" ''''''''' i'^^^^^^^- -ul, on ulnch mort.dity weighed leav h . '^ ^^^nUe and sensitive things were ,nore real than the nnt , ' ' ■", '" ''^''''^' ^''^ <■""•• 'ast le^ "s a ...-../ ..,,,,, .„ ,,,1 • ^^;;' -^^;ci; he worked. He has was a sort of n.e.lioal prototype < ! Z \ ^ ^'^ '^"'■^''' ^^'" ^^''O'" l>e i"gsof fate and the fulure, ir^iceoVrf". "'""'" '"^ 'i-^-^^ion- conf.ss,on. the so.d's cry f„r inu rd L^ ' "' ■^^"'-'-'^^'i-ation and '-ely heard.- Listen to hin, jl"^"'''' "''«'>^ '"'''ke the.u.selves yet the watchman had cried the hi, '''"/'''■'^' '"''''"' "^""■"'g. ere turbed .sohtude giving my ^ o J '.T "" ''' -«■'■ --' i" -> dis! prayed fervently that I might be ,1 .b ''f^'^'^^-^-^S to my Maker. f '' '';^'^ ^ '"'-g-t be freed^on: t ^1:1. '" "''^ """""^"-^ -"> irom the alluren,ents of personal fr ndshi 7 ''"''' '"'"agination, educat,on,and that I ,nig iu under n'' '"'''" ""^ Prejudices of pennitted to .settle this q^es'tio i i i '"""""^^ "^ ^'-"^ grace, he "-■ry, the great and eLee H ' '"" ""''''^•^•" ^^-v ^atniliar i! "'■'^ -'• ^'»'">t">l of the victr . f r^"" "T "^ ^'"^ ^'''°"« •'^""^ '" the "■nvhom both blessings rested ' , '"'."'^^''^^^ever, was one of those f ■•'' them, and reachecl the d 'irel h^^ ^'^ T'"'''' °^ ^'-" '--i. 1 e =>ealtl. and fits of depression he cTr j 1 ""i • '" '''''' "^ ^^'^'^ ^^o.Uly ;eal and as an original work „" amho"', "•^ T""''"''' ■^^"^"■- -'^'^ '=■; V,— -ty- I'articularly dicT h^e " ^T ' """' "^"^'''-" '^ ^auaMe preparations, and lis nane w .' '""''"'" ^^''^'' '"^>"y »' ^ -^- in the anatomical coll ct ^wL'hT ''^T"""'^^^" ^^"■^" ^^^'-^^ Ii''l ^vhat shall I say of f fm.W , ' ^'''■' "'^"' »au>es. science wrought with labor and travail r '"'" '"""''"'" "^^ '^^ve„ of r I the pat.ent spirit, the kindly disposition, the sustained zeal -^we .l,.!' not see aga.n incarnate. The n>enu,ry of them alone remains. As ,1,, echoes of the eulogies upon his life have scarcely died away. I need „ reconn to tins au.lience his ways and work, but upon one a;pect o, characer I nK.y dwell for a moment, as illustrating an inlluencLfsnV udnch ha.s attractcHl n.uch attention and aroused discussion. So f,r ,. he facts of sense were concerned, tliere was not a trace of I>y rrhonis,,, i,, h.s co.nposu.on, I,nt in all that relates to the idtra-rational no nune . , hat del.ghnl ..,,..., that imperturbability which is thedistingui.sl,,,,.: feature of the Pyrrhonist, in the truest sen.se of the word. A st.ik, ^ parallel exists between Leidy and Darwin in this respect, and it ,. ^ luterest.ng fact that the two men of this century who have livul closest n>tercour.se with nature should have found full satisfact,..,, ,„ the.r stud.es and ,„ their domestic affections. In the autobiographin- sect.on of the hfe of Charles Darwin, edited by his son Franlis .' wh.ch are la,d bare with such charming frankness the inner tho„:.h,: of the great naturalist, we find that he, too, had reached in s,,;,, sensuou.s affairs that state of mental imperturbability in win. h ,' borrow the quaint expression of Sir Thomas 15rowne, they .stuiclKd not us />ur nm/rr. Hat while acknowledging that in .science .scenfcisn, IS advisable, Darwin says that he was not him.self very sceptic' 1 d the.se two men, alike in this point, and with minds distinctK ,:r tl. Anstotehan type, Darwin yet retained amid an overwhehnin, ace,,. nudat.on of facts-and here was his great superiority-an extraouin.arv povver of generalizing principles from them. Deficient as was tl.i'. quality .n I e,dy. it was not associated in him with " the curious a,„i lamentabe lo.ss of the higher aesthetic ta.ste" which Darwin nxnirn. and which may have been due in part to protracted ill health, and to an alxsolute necessity of devoting all his capabilities to collecting facts in support of his great theory. When I think of I.eidy's simple life, of his devotion to the suuh of nature, of the clo.seness of his communion with her for so „,a„; years, there recur to my mind time and again the lines,— " He is made one with iiatmc ; there is hcanl fj His voice ill all her music, fVom mnaii i*U-^ Of thunder to tlie son- of nighf^fswect bird ; He is a presence to he felt and known In darkness and in light, from herb and stone, SpreaH,»,„. fan i„ „,,„ ,, »„„„„„„„,„,, ,„„J, ' r „„\"',S; Iw.K <.f a n«vx..-ll,ai will be all. Ji,„ l,e„.ari. • !•, I, i« , ! , i<- t,icaner.s, who gather up ears ciioti.rh from tlie l.nr^. rulges to make a few loaves of breid ^,„^i, , T, list centiirv \'.} , ,\ " ^^'•''''-' ^''*-' 'Tiatomists of last ccnturj,— \alsalva, Cotuiiniu.s, Haller Wiiislmv \-i - i- ^ Ca.nper. Hunter, aud the two Mouros f as 'ofl u ^ '•''• .U.O., u.e.ti^/r-r'o^^- Nc. gee.se they were, gleauin,. an.i.l the stubble of a rest "ed field wlK.n the broa.l acres of biology were open before then, T ^se ^^ e the days when anato.ny meant a knowledge of the hum.n fr- neV ....... a„a.o.-.a,M.e::s-r;r,!^r,:^^:- The determination of structure u-itli o ,.; ^ .1 function has been the foundati f , ^ 1 '%l\'' /"--•->• °^ always have been for " him who ru is to re.d ■ nf 7 T' "°' ;;e.. at the time ^r .on. clear : and'yelV;:;;!;.^ ^ i;.";:^ t;:^':; ^ onn and relations uutst precede a correct physiology. Tie tt or d.nary development ot all the physical sciences, a,ul the corrls Z " 2 - "ement of means of research, have contribute t^T^r 1^ the enl,ghten„,ent of the < geese' of Barclay's witticism Tate tl progress „, any one departn.ent which has a practical Ipect such I ." the anatomy and physiology of the nerv..us sx'stT TV , ^ exuniple. in the third edition of Wistar's ■' Anaton, V^ ite ^ ^^nf;^ ro >H^r in ,s,s, tlu- .Icscripti,,,, „f tl,. .-..nvolutinns U tl>e l„ai„, o„ wlin :, U.-C ay a wl,.,lo ar„,y of special stu.lcM.t. a,o at work, n.e.l.eal, .,„«!. ... anlhropol„,,ca , and tl.e lu.utions uf wind, arc ,!,. ol.j.c-tivc po,.„ •">-"';'K',^;'l a".l psycI.oloKical rcM.arcl,, -th. wlu.I. suhject is tin, ■sposc. of: n,e surface.,, ,l,e h,ai„ rcsc-„,I,..s that of tie n.ass tlie sn.a 1 nUest.ne, or of a con . olute.l, cyli.ulrioal tt.l.e ; it is. the ' aul to he convoh.te- uUeresting to note the widespread d.nen.lence of departments ,.n accurate anatonucal knowledge. The new ce r^ anatcnn3 parfcularly the study of the surface of the brain, so njanly d.snnssed in a lew I.nes by Wistar. n.ade plain the p: H.t-gand I-ntsch, the careful di.s.section of ca.ses of di.seas „, , .ra.n prepared the way for llughlings Jackso. ; and gra.luallv a , phrenology on a scienti.lc basis has replaced the crudt notions o nd .Spurzhenn; .so that with the present generation, little bv „ there ha.- been established, on a .solid structure of anatomy, the! ' at>on of n:any of the functions of the brain. Plxcite w h a to.ch, from wtl:... or fron. witho,:t, a sn.all region of that n:yst u |u:rf^.ce and my lips n:ay move, but not in the articulate exp^!^ bought and nnay see, but I cannot read the page before me ere and s.ght ,s gone, and there again and hearing fails (J„e 1 U,e centres may be touched which preside over the^ muscles . without the loss oi consoousness. Touch with the slow linger m Tn e he nutruun, of that th:n layer, and backward bv .slow det^c r siinness, f .ick to the oblivicm of the womb To this new cerebral physiology, which has thus graduallv .level- oped wth .ncreasing knowledge of structtne, the study o ca ? f d^ease has contributed enormously, and today the diagnosis of ..ffc r..c>. Ihe uterdepen.lence and sequence of knowledge in v.uious b anches of science is nowhere better shown than „, thi.tverv M.h c Ihe facts obtained bypreci.se anatomical investigation, from c ^ ments on animals lu the laboratory, from the study of uature's ex peri- ir =;;'';::ri;r,--r:z:r;;;t-r::;^- > > '" a practical age this vast rl.anK. Ins wn„ 1 • ^■''"''' "«"• ""•'"1 in our ideas „f vvh.t ,,,.1 ^^n.u.^ht a crrespo.ulinK altor- whattodoJ-ntalsounattJlt :;r ?' y'' '''"^ ''"''' ". the surface of the brain has rJmi „ ^i '"'^■'''""^^'''" "'" ^"'^"tres .siMerahle .le^ree of cert'iin v t 1 ,^ 't possible to ,„ake. with a com- p:.tho.ogy „ a'i.:te:; ';;:!■: ;:;.";ru';"^ ^"■^'^'^""«>' -•■ arc scarcely credible ^ ' ' ' "'-^'"^•^•'•'■'^'••t> of which "-^"-.tr:*,::::;':;;;:.':-;--- ;.-... incrcawl convolmi,,,, of ilic- |,r„i„ „ "f" t „ "'="'-->l.'"'l""-..K-„l ami .':»'.•'. of „a.e,„,-s ..„.,; .:;: \ ;; :,r;r;^' -•^•" '■>■ 'i- numite anatomy of the orp-,,, l,n. i V twcntyhvc years the methods of cver-incr .s fd ''^■^•".^"'^J--'-' ^" --tensive stndv by mechanism. IM.e n^r 3u n" nl '^^ I'"" '"*' ''^^^'^ '^^ -'"•I">- theanatomicalb^^^^;;; ;^^^::--^7'«-y-^ and complex connection oF th;:::^'^ t^;:^^";"' ='r '•;""• tenned, the psychical functions are Lrre led ' r 7 """ ''"" :Va! conceptions have been c-uld , [^^^"^^^ i'^^ th,,^ n^^cluu- Croonian Ucture before the Z.' S " ''''''""' fn.u. the recent ■-e.l the action and the g;; :,':;': d' 'V ''^" '"""'"' ' ^'''J^" upunthecompIexitvoftheceH mt ^''-'^7''>P'»-"t of intelligence the physical Lsis o no c^ n^^!!:';:" '"f ''' r""^^'^"^" '^-" Researches upon the fine;^.::^;^^ ^r l!;^^^^,;'^"?"?---- conclusion that inibecilitv ,n^„ini i '^ereltral cortex lead to the of insanity are but sy n ; ' '""'f """^ "''^ '''' --»->- '-..s cells, and not sep r^' He ioL oT"''" • Tf'"'''' "'" '^'^ '^^•--"•'»> Still further; there i\' ;scw;r "^^ ^'""^>-- the mind. associate mor 1 derlntmen "th n, " 7f ^ "^'"'" ^'^'^-^'^ ^- of the brain, and ur^ f 1 L^ P'-.y-cal abnormalities, particularlv arevillainsbynecestit /fool I V """,""' ^"'"'"•^■^' '" "''''^'' ""'-■> andtreacberAy:^;^,^:^,^ -:^'r-;;^^^ i'l our knowledge of brin f,^, i" ^'"''^ '■^■■"•'^•''^•^''le revolution careful and accurate .s^^; l^''Chv ^'^^ "'^""f" r ''''''' ^^°"' ^'- the nervous system Trnk , ^7"^'^>' "'' ^eese.' of the anatomy of '-..better ti::;^:;;e j;:;:^^ is:;^^ °^ ^'^ ''''-' °^ ^^p^-^- ^- Ihe study of structure, however qc the h^«;. f •* i , •^« «-« ,.ov.ce Of „,..o„„, }„.„;; ,r r;::,-; ;:; ^„^»-:;;»; ill 13 I , r?'V "'■"' ''""^^''"' ^'" """^"-"" manifestations .1 ■ "■^•^': ;\'^""^^' ^''^- '^'^^'^ K'nvc„,i„K tl,. growth, .Icvclopna.,,. -t.ons o, u-.n, tlnn«s. Join, Ilnntcr, the nK..lcr of Sl.ipp n . ,, h ok. was tl,e fust great Mologist ... tl.c n-ock-rns, not alon '• l.ca ,' <.f lus c.xtraonl,n:.ry i-oucrs of uh.servation and tl.c conn.reh.Ms,. sweep onus uuelleet. hut cl.ieily l.ecause h. fnst l<,.,ke.l at ,1. who e. „„ studied all of its n,auifes:at,ons, iu onler and diso ; , '-'"■ •■^'•^1 >•■ .hsease. He first, iu tlu. words of lU.ekle, 'Metcrnun t" -uten.piate nature as a vast an.l united whole, exhil.itiuK, i , ! a d.ff^rent tunes, dillereut appearances, hut preserving anm s change, a pru.c.ple of uuitorn, and uninterrupted order, admitting lant> hut tn the cou.mon eye .rrcKularities ahound on every sid. ■ \\eo the n.ed.cal profession n.y take no little pride in the h, ,a here have never heen wantin, n.en in our ranks who have tro,,, " i I.e . ly, hnt n, a ,nore luunhle way n.auy of the n.ost .lili.ent sL dents oi hu,loKy have heen physieiaus. fVon, John Hunter to Char " mvn, enorn,ous progress was n.ade in every .lepartn.ent of 1 ' aud hot u>y, an.l not only in the accunndation of facts relating to stn^:. .re, hut u, the knowledge of function, so that the conceptto . ^ Phemuuena ... hving matter was pr.,,ressively wi.len.-l. ^Then v he ()r,gu. of Species" cau.e the awakening, an.l the theorv o . on has not only change.l the entir.- ,spect of hiolo.v, hut has r „, . tioni/.ed every .lei.artnient of human thought Kven the theory itself has con.e within the law : aud to those . ■ ,. whose hu ogy ,s ten years old. the new cone ptions are, perl, ht tie hewd. ern.g. The recent literature shows, however, a r n.ark .ble fcrtduy au.l strength. Aroun.l the nature ..f cellorgauhation , k tie w.ges n>..st fiercely, and here again the knowledge of structmv sough eagerly as the hasis of explanation of the vital'phenomc S r heal have heen the changes i„ tins direction that a new an,-.,,,,,. ca ted ternnuology has sprung up, aud the sin>ple, undiirere,:..a.l t of protoplasm has now its cytosome, cytolymph, caryosouK. , hro- ™ie wuh the:r somacules and hiophores. These accurate suul^ n the v,ta un.ts have led to material modifications in theth.wv„f descent W e.smann s views, particularly ou the immortalitN oi the n.ucelhUar organ.s.us, an.l of the reproductive cells of the higher f,„ .ns ando,. the transnussiou or non-transmissiou of acquired 'han:! luve been hase.l .hrectly upon stu.hes of cell structure an.l celLf...,,, iu uo ^ . has biological science so widened the though.s of men as mn application to .social probleu.s. That throughout tl,e ages, m the gradn.al evolution ..f life, ov...- ..nceasing purpcse runs; 13 :^::nrs::: jrr /!:';;:! !■";:-'- ™"v'^' - « - I'lifiUMiiciKi must in iMliiir l,c hand „„ Hk- l,i„lM>,i • i :;:i:"ru;::'::;::,;:;;:;;7;;:;:::;;::'-*-''";'-'---"* r.i I • '"''"•■"'■'" <'»11' I'ClSdIls flic nxiiU '■' ""■■ '■''"""'"" ^""' "" "'^'1 '■ ral ™u,„v „f pas,U.« .1 , H ,c w. ...a,. v.,„„rc. ,„ aH.i..i,,a,. a fau.r. .sonCv „„id. „,l? n , . „ ,' l.ut which may i.„„ii,„R- u. make ,.r....„.. , ,,„ ,,,„„., ,"""'' , MispuKitd, the I .uilion rtnu alt( t-xacllv tn il.p iMcncc, ami the- inlaKoinsin hft«nn iho iiKlivichial ai„l ihc s.Ki,,l u,„aii,M,i cxli„K„i5h„l. llul ir the views .,f il„ ,."vare in the iiian, ..,„<«: if there catiheL ;;!':;; ™^^ accntttla ,.,„ „f c„„«e„i,al variations ahove the av'ra„e "til, .ea of „ her, l,el„w : if. „ ah„ut the e,„is,a„t stres, ol'el t „ „"ieh ;:;sit t= :?— :^ ;;;f -- p-'-. --::r; '-^^,;';-"'.-.v-'--^--'v:re;i::,™.Th:i;:;r,;;Se^ 1... ogy toache, the ,,rol,le,„» of life a, every poittt. a„.l ,„v " °„, o.:':L:r'^:.::::r-;:r,?:e::;;,,r:rxr- ».-. „. this l,„ti,„te a ,„„„„,i,e„,al t„„wle!lge of the law 'of lil '4 ► To tlie physician particularly a scientific discipline is an incalculal .:, gift, which leavens his whole life, ^nving exactness to liahits of thouj^ht and tempering the mind witli that judicious faculty of distrust whirl, can alone, amid the uncertainties of practice, make him wise unto sal- vation. hor perdition inevitably awaits the mind of tlie practitioiui who has never had tlie full inoculation with the leaven, who has nev.r grasped clearly the relations of science to his art, and wh.. knows n„tli nig, and perhaps cares less, for the limitations of either. And, Mr. Provost, I may he permitted on higher grounds to mi,, gratulate the Tniversity of Pennsylvania on the acquisition of Hiis Institute. Tliere is j;reat need in the colleges of this country of „,ai who are thinkers as well as workers,— men with ideas, men who h ,vr drunk r divine, has worked any perm, .nt change in him. Listen to the words ol a student of the heart of man, a depictor of his emotions • ■ I., all ages the reason of the w.nld has been at the mercy of hrnte Mice. I he reign of law has never had more than a passing realitv and never can have more than that so long as man is human. The' In.li- y.dual intellect, and the aggregate intelligence of nations and races have alike pen.shed in the struggle of mankin.l, to revive again indeed' hilt as surely to he again put to the edge of tlie sword, l.ook where you will throughout the length and breadth of all that was the world 5u,,o or 500 years ago; everywhere passion has swept thought before It, and belief, reason. Passion rules the world, and rules alone And passion is neither of the head nor of the hand, Init of the hear' I ove hale, ambition, anger, avarice, either make a slave of intelligence to serve their impubscs, or break down its impotent opposition with the unanswerable argument of brute force, and tear it to pieces with iron hands. (Marion Crawford. ) Who runs may read the scroll which reason has placed as a warn- nig over the human menageries ; "chained, not tamed." And yet who can doubt that the leaven of science, working in the individual, leavens n. some .slight degree the whole social fabric. Re.son is at least free ...nearly so ; the shackles of dogma have been removed, and faith her^ self, ireed from a morganatic alliance, finds in the release great gain. < 'ne of the many fertile fancies of the "laughing philosopher," a happ.v anticipation again of an idea peculiarly modern, was that of the nil ne.ice upon ns for weal or woe of Ivxternals, „f the idola, images ami ellliiences wiiich encompass us, m,[ b;Kternals upon which so much "I onr happiness, yes. so much of our every character depends The tren.l ol scientific thought in this, as in the atomic theory, has reverted 10 the .sage of Al.dera ; and if enviroiiment really means so much, how all-tn.portant a feature in education must be the nature of these eneompa.ssing eriluences. Ths magnificent structure, so admirably ■Hlapud t.) the prosecution of tl) t science from which modern thought I'as drawn its most fruitful inspirations, gives completeness to 'the :ihva,lv exhilarating ;;^,y,W/ of this University. Here, at last Mr 11 I6 I rovost. and largely owing to your iiidonntable energy, are gathered all the externals which make up a .SV/../« /.a./.^ worthy of this gnu Commonwealth. What, after all. is education but a subtle, slowK nfTected change, due to the action upon us of the ICxternals • of the written record of the great minds ..fall ages, of the beautiful -,„,] harmonious surroundings of nature and of art, and of the lives <.„„i or .11 of our fellows.-these alone educate us, these alone mouUrth, deyelop.ng numh. Within the bounds of this campus these innuen..s will lead successive generations of youth from matriculation i„ Uic college to graduation in the special school, tlie complex, varied i„ .Muencesof Art, of Science, ami of Charity ; of Art, the highest devel,,,, ment of which can only come with that sustaining love for ideals which, 'burns bright or dim as each are mirrors of the fire for whidi all thirst ;• of Science, the cold logic of which keeps the mind i„de pendent and free from the toils of self deception and half-knowled..e ■ of Charity, in which we of the medical profession, to walk worthilv „u,st live and move and have our being. CL l_ Oliver Wendell Holmes n ItEMARKi^ MADE AT TllF thttju.^ ,. lllh JOHNS HOPKINS MEDICAL SO, IET7, OCTOBER 15, I8<. 894 By WILLIAM GSLER, M D limiliancy of his mind had no^ for a moment faded Like his own wonderful "one-hoss sha " the end was a sudden breakdown; and though lie would Ime confessed, no doubt, to " a general tlavor of '^leeav " le reusing of al hunum spectacles, those cold gradations of decay, u. which a n.an takes nearly as long to die as lie do to growup uud hvesasort of death in iffe, 'Ufa sinelZ mare, lin sine mortemori." ,-- V Enough has been said, and doubtless well said, by those A7ho'' niake criticism their vocation, upon the literal-; position :d affinities of Oliver Wendell Holmes, and I sh/ll^pareyo perhaps already surcharged ears.' He has been sandwiched iu Chats r", ^'^^^ ""'{ ''-''' '^^^^^'^" ^1-- Goldsmith d Charles Lamb More than once he has been called, I think he American (.0 dsmith. Certainly the great distinct 1 of both men lies m that robust humanity which has a smile fo Ihe English 01, ver, with a better schooling for a poet fhad he not learned in suffering what he taught in son^) hid, l^ner fancy and at his best a clearer note^ With boH wdt / z ;: L: '° c '^ '"" ^^''^' '^ '^'^ '"^^ ^^"-' «- ?'- merirwh^^\ """ ""'"' ''"' ''^''' I»-««^-writers of equal ment.who have so successfully courted the "dra<.<.le-f, led Muses," as Goldsmith calls them v Like CharrefLamb Holmes^ain^e affections of his readers at the first siSg,' ^.•Remarks made at the Johns Hopkh. Medical Society, Oetobe.. I !\ and the genial humor, the refined wit, the pathos, the tendor seusitiveness to the lights and shadows of life, give to the Breakfast Table Series much of tiie charm of the Essays of Rlia. y. •' While it is true that since Rabelais an ' Linac-re no -cneni- tion has lacked a physician to stand unal)ashed in the temi)le at Delos, a worshipper of worth and merit amid the votaries of Apollo, I can recall no name in the past three centuries eminent in lUurature— eminent, I mean, in the sense in which we .-egard (Goldsmith— which is associated in any cndurin- way with work done in the science and art of medicine. Manl physicians, active practitioners— Sir Thomas Browne foV example— have been and arc known for the richness and ^•a'riet^ of their hterary work; but, as a rule, those who have remained in professional life have courted the "draggle-tailed Muses" Hs a gentle pastime, "to interpose a little ease" amid the worries of practice. Few such have risen above mediocrity • fewer still have reached it. We know the names of Garth of Arbnthnot and of Akenside, but we neither know them 'nor their works. The list is a long one, for the rites of A],ollo have always had a keen attraction for the men of our rank^ but the names fill at the best a place in the story of the litera- ture of tlie country, not a place in the hearts and lives of the people. Far otherwise is it with a select group of men Gold- smith, Crabbe and Keats, vA the outset members of ,.,',r pro- fession, but who early broke awav from its drudgerv. In pride we claim them, though in reality no inlluence of their si»trial studies IS to be found in their writings. Two of these, at least, reached the pure empyrean, and to use Shellevs words, robed' in dazzling immortality, sit on thrones "built l)eyond mortal thought, Ivr in the Uniipparent." Oliver Wendell Holmes may not reach the same exalted ejihere, but he will always occupy a unifiue position in the ali^ections of medical men. Not a practitioner, yet he retained for the greater part of his active life the most intimate con- nection with the profession, and as Professor of Anatomy at Harvard University, kept in touch with it for nearly forty years. The festivals, at Hpidaurus v '.'e never neglected by ^nnn, tl.e ninetoentl. cen ury tl oe scho , ''"" • liiive luouldeiUhe tJio.Kdif. .,,,,1 , . '" "^"^'cession fession in fins con. y" / T'""^ "^ ^''^ •"^'^'•■«'^' m'o- American st„den"w:^:,,t'"';f"'r- ^f^-'^ ^o .h.u school. .Since. KSflo the , h " \ eadungof tlie French been ull-powcrf ] L of ;" "' ''"'""" '"^'J'^--' J'- a'xl that, when .....sibie fh "''^ ''o trnly s„el,, in France and Kngland ' ' ''"""^ •"" '^^^''^- ■^^-''^■^ st.^^h^'^;?eSj^,;Xn:?'^ 'f ?■ ^^ ^"""^ ^"-•'-- Hohnes, Jana^s .,a kso r T '"'"', \f "^^-^liver Wendell Hnd Stille, from Phil- de r,.^ ' f T" ^''' ^ "'■'^•' ^'^^''^-'ini They broukt back ott^^' ;''''^ ^ '^^'''■' ^''""^ J^'^ltinu.re. and habits .. 'rate l. ^^ '" "^'"''''^ ''''"''''' '' --!< -.'.t also, w;::;'^:^ t :t:>;fT:r';';"'^"'^^ ^"^^"-^ inspiring enthusiam. 80 T s H o " ; '""^' '^ '''^ American pupils reni-uii/ fnl V ' •""' ^^""' «^ J^«"i«"« Ht^,oftLkive:-;;'s;::::.:^.s-^^-— ^ro. ^ienisridrd^^iifk:^^^^^^ to his class in 18Sa is Hr< .K ' ™l*'dictory lecture old Paris teachers ^ ^' ""^^' "*> of ren.iniscences of his evid^t^'hJ^/^r^/-^--^^l e,u:p.ent is verv 1830 and 1837 eCl in "'^ to medicine. In the year^ Boylston priJs, it't!; --^""y competing fo/ the ^El^^a, on ^e;„.algia:X ;f^^;:;;;^^;^^^ver in New of Direct Exploration ;„ Ar r 1 .. ^ ' Jmprovemeut ™«yoni„te™i,"r ,',';':','"=''"; "' "-e H,o '■I i ! ; purpose he infide ii careful and thorough examination of the records of the first century of the aettleinents. Here and there throughout the essay there is evidence of his irrepressibh; humor. Referring to the old w iters, he says, that because indexes are sometimes imjierfect, he has lool^^ ' ' '^"'''" "^ ' "'^^''^'^' productions. ■ A few vt. tl ", '' '''' "l'«" ^'^^^^ ^^rlier article which will nfk J "■' ^^''"'■' '^*' ^""^"^^"ted an ^ Child-hedfever\^^^un In^ "''""'■^^''"■" '" ""• '■''''^'• Wendell Hohnes sh dief ^ ind' .'ir" v "'" ^^^ «^-er who had proclaimed rd 2 ^^J^V'T ";"""= •""' highly contagious nature. Indeed so ff IT' ''"'^ ''' of Aberdeen, not only ca led t • "' ' "' ^^'^' ^'"'•^*^"' he could predict rth''';' ' «P^«"^^ ^«"t.gion, but said m.rses in who e pr "ti ' , '^^ ^'^^"^'^5^ ^^e very doctors and ^-nent the^snriJir s:^^^t^:^:, li^^^^'-^ fhut doctors ;rZ:e?couhfco;'^^^^^^^ ""^'^^^ ^^^ ^^- weis had not the^ e'un to ll T^ 1 ''''"^"- ^"'^'"'"^l- «ive observations f or w 1 e ,\ ' "^^^'''^^^'^g '''"J conclu- greatly honored ''' ^'^ '"""'^'•y ^''^'^ ^--"y been so In 1843, before the Boston Society for Medfp.i r '"ent, Dr. Holmes read a paper entitled -Pblp P'"°'" of Puerperal Fever" in wiS f Contagiousness -ayofLtsinir^po; oT evit ra^f^^^ T'"'' ' ^^"^ ^Hgious, conveyed usually by the Lcto r H l ''' '''?'"■ to a specific infection Af th! 7^*^^^ "'^ "^^ ^"^se, and due ="' article in which Z'sutlf '' ^^''' ""''^'"'^ ^^^ "«t - convincing nnn ft^lT'T "' " ^"^"^'^^^ '^"^ -Who.;? .,.,4--^--;^,;^.^ ( 6 loudly mu\ 8.) clearly timt he compeiH i„.„ u, hear him- it, \, to hiin thill the credit beloi.crs; uud ho far as this country is .•..neerned the cre.lit of insi^iing upon the great practical ruth of the contagiousness of puerperal fever belongs to Dr. Ilon.es. J he essay is characteriml in phices by intenseness =ind great strength of feeling. He savs he could not for a moment^ consent to make a cjue><(ton of the momentous fa.'t which should not be considered a subject for trivial diseus.iun iH.t whicli should be acted upon with silent promptitude. •' No uegative facts, no passing opinions, bo thev what thcv may or whose they may, can form any answer to" the series' of cases "ow within the reach of all who choose to explore the records of medical science." .lust l.efor.. the conclusions the following •■loc,ueut j.aragraphs are found, portions of which are often quoted:-" It is as a lesson rather than as a reproach that J call up the memory of these irreparable errors and wron-^s No tongue can tell the heart-breaking calamities the- hau' caused; they have closed the eyes just opened upon li new world of life and happiness; they have bowed the stronc^th of inanhood into the dust; they have cast the helplessiR.ss of lutancy into the stranger's arms, or be.,ueathed it with less cruelty the death of its dying parent. There is no tone deep enough for record, and no voice loud enough for warnii,.' I he woman about to become a mother, or with her new-boni infant upon her bosom, should be the object of tremblii.o- care and sympathy wherever she bears her tender burdeii, or stretches her aching limbs. The very outcast of the street has pity ui.on her sister in degradation when the seal of i.roniised .naternity is impressed upon her. IMie remorseless vengc-anee oi the law brought down upon its victims by a machirn'ry a^ sure as destiny, is arrested in its fall at a word which reveals her transient claims for mercy. The .solemn jirayer of tli,. iturgy singles out her sorrows from the nuiltii.lied trials of Utc, to i)lead for her in the hour of peril, (iod forbid that any member of the profession to which she trusts her lif. doiibly precious at that eventful period, should regard it! negligently, unadvisedly, or selfishly." The results of his studies are summed up in a series of eiiilit conclusions, and the strong ground which he took may l,o gathered from this sentence in the last one : " The time' Ins r'ori.f wli.'.i Mr. existence of a private i.t'sfil..., • . . Medicine, ...L.e:;:!ea^::;S;ir;::^ nients were too bold a„d the wiiole tone too . i '" arouse the antugonisn. of those wh s 1- li. ; 'I';' '"" /" years diametficallv onnoKo.! tnii, '''-''^"'"Ss li.ul been inv fever. ■•hiladelpLil/n^.^;^:';?'^"? "' ''''''"''' in obstetrics in L .oun.^ l:;!^]; ^ ^I^;:V:u 7"' American school of oUstetricans it i. dn o tl ! .o < T professors of tliis branch in that citv Z f I P "^ '''" nu-tnory of the n,en we .-on d I t't "' " '''-7' ^'"^ which I will now allude. ^M>»>'>i^ed the uieident to In J 852 the elder Tr.i,l,r,> i>. c ,. ^^ University of PeXlI^fp S^..:^ ^'^^^^^'^ '^^ ^''« contagious character of PuJr n ■ I f / /'' " T' ""^ """" a Meigs, I'rofessor of Vbt^t .:;,'' '" '''''■^ ^"""''-^ (•ollege, published a work on h nt're 'T ''"'"'"' of child-bed fevers in. ". V ! ' ^"'' ™'^ *^"^'''t'''^'''t of his class, no ^o the: em : tt r'";' r'' -^^ ''' '^""'""^^ fessors of ol>stetric,s in , H ', ,^f. 'T' '''^^'-'S-i^l'^l 1-ru- Hoin^^uui Meigs hani;:';-i;:;;L:f:r;;r'^^''^^"'"^^ D 1-1 T, •■' '^''■'""o 't ruvrnmtl Fever nv „ /v;„„> t.o„ which pmhicrf thi, e»*.y.-'n,V ,?,"■'""■" ,. . ^ V I'^jBiLuuis am nurses /^iqj-u rm llKV »„ld ever carr, .ho horril*. ,i,,r-„fj\ ;:';'"'"' 8 The iulrochution to li.e .snay. wliid, wu« renrinted us il Weaml .„ lH-l-> is o,.o of tlw- uhlo.t and mo t trencll IHeces o wntu.g witl. which I am m.^uHintol. There r «en,raUtnk.ng paragraph.; thus, in alludi,,, to the .tro ^ ad pornonal hm-M.age .used l.y Afeigs, Ilohnos Hay« : " I take no oirence and atU-n.pt no retor( ; no n.an n.akes a\,uarre with n.e over the counterpane that covu. a mother wi L her m'w not to Ik. deceived by (I,,, statements of the two dlHtin^Miished Fofessors which seen, to h„n to enconrage professioLn;:!;:;! -lUt. One paragraph has become clasaical: " Thev n'ltnr.llv have faith in their instrnctor, turning to then /t U J tHk.ngwintt they may choose to give then.; babies in k ow -Ige, not yet able to tell the breast fron. the bottle, pumni I uway fo, the ndlk of truth at all that oifers, were it rloSl bettei than a professor's shriveled fot-eflnrrer " The high estimate in which this work" of llohnes' is held has frequently been referred to by writers on obstetrics. , .Some year^^ ago in an editorial note I comn.ented upon a qi.OHt.on winch Dr Jlolmes had asked in his " Hundred 1) J i, Europe. Somewhere at dinner he had sat next to a suc- cessful gynaecologist who ha.l saved some hundreds of lives by his operations, and he asked, " Which would give the mo afsfactmu to a thoroughly humane and unsellsh beinj" c .1 .vated ,nte bgence and livelysens- iv es: to have wrU en a he p ays winch .Shakespeare has 1 -> an inheritance for K ui a hundred fellow-creatures, and restored them to sound and coiufortable existence:-"' I remarked that there was Woer.T T ! Tr' '^''' ^^"^'^"^'^ ^« satisfactorily as the An ocra and asked from which he derived the greater satis- uction, the essaf,onpucrpcmlfcver,which had probably saved r^^7^^"'^, """ "'^ "'^^'^'^'^^^^ ^T"^'cologist, or the Ua>M M!us, which had given pleasure 1o lo many housands. The journal reached Dr. Holmes, and 1 read you his reply to me, under date of January 21st, 1889- " I have rarely been more pleased than by your allusion to an old paper of mine. There was a time certainly in which I wonld have said that the best page of my record was that in which 1 had fought my battle for the poor poisoned women. p:s'.st:'l."or,':x:^;:,':-' "■ ' ■ »» therefor, cca, c,l tl,„ wi , """ >'"''" '•''• ""J ".y.olt which „„.i;:;, ^'^,'', "7; "' • l.h™,e« .i,„„t I f"rg,-t which. ■ '- ' '"" " ■ ''»'')• »!■ '-'lity. !-"> »f .nine, H,o„«h , w J '";;„"" I,,;;' » '»•"'•'"■ coines up „t long !„(„.„ ,, ,.,, "'Jstlt. r !,„ „s„j. „„| ».«n.ory, ,.,„, i/v„, , ' ' ,",71,:?""' "«" '" ">>■ h; torn,, „, „,„„1„„,. „r ; '^, ■■■;-™-,"..,.io„t,, pli'as u re, i confess it. l..,., ii- -/ ' *^' ^ '"''' u siivaw to me,i„ their ;,,c!o '"'■'■' '"' '"'^'^■^' '^'^ ■* ^^'^mecl writing the ocm 4s fl :T'''';f ""^^'^''-S- Hut in highest state^of ,,ent,U V • "'^\\.''^""'' feoling-the clairvoyance, as i "« tf ^^^^^^^^^ -^«^''"'- to n,e-I mean tlmt lucid vi2n nf . . ''" -''"•^"^ forms of expression wJclwil , '"' ' '''""^^'^^ '^"^^ "•' whiel. is the pXnei "i :l"'"'^'r "mount or value. There n ' Tu'' '''■^'-' '''• «""'" •« out of the noem-perh^^ n ''"'^ P^^''^'"'^' ^^ ^'^' ^'"'1 saving labor." ^ ^^^ " ""'^'^"' ^'^^'^'''^'tion from the life- referring to the subjeet in very uu cHli ' " " "' ''"-"-^ nm in his letter to L. oIIm two o Tb ' ^'"'^'T '' ^'' quote. " Still I was att-irkll ' P'^'-agraphs f may '-„. p.re.„.r;is:;:: i:'s otir'" '^ '"" "™ not !v?tt' :t^st;v:"aV'T r-'r''''^''«""-'"">' -t,.a„.o'rt,tr:t.;:?:\-r:^^^^^ II tOi-^v-. A^.. ''1 ^3^^H 10 might a-ainst the terrible evil, before I did, and I sravo then, full credit for it. "But I think I shrieked my warning louder and longer than any of them, and I am pleased to remember that I took mv ground on the existing evidence before tJie little army of microbes was marched up to supjjort my position " Fortunately, Dr. ilolmes's medical essays are reprinted with his works. Several of them are enduring contributions to the questions with which they deal : all should be read carefullv by every student of medicine. The essay on Homeopathv remains one of the most complete exposures of that therapeutic fad There is no healthier or more stimulating writer to students and to young medical men. AVith an entire absence of nonseiise, with rare humor and unfailing kindness, and with that delicacy of feeling characteristic of a member of the Jirahnun class, he has permanently enriched the literature of the race. Search the ranks of authors since Elia, whom in so manv ways Holmes resembled, and to no one else could the beautifn'l tribute of Landor be transferred with the same sense of propriety : " He leaves behind him, freed from grief and fears Far nobler things than tears, The love of friends without a single foe, Unequalled lot below." OLrV'':U WENDELL HOLMES AS PHYSICRX Thk greater glory of Wendell Holmes, the writer of classical prose and poetry, has for the most part eclipsed his record as a physician. Yet his purely pro- fessional wo.k had in its time no mean share in guiding current medical opinion to sound conclusions on various points of importance. This aspect of the like-work of the distinguished American has been ably (li^cuescd by Dr. William Osier, of Baltimore W^ learn that m 18.30 and 1837-shortly after his return Ironi thel'arisian schools-young Holmes distinguished hmiself by wmning several of the Boylston prizes in .succession. The subjects which he chose for his theme ~" -~- ~— ^ we^e Intermittent Fever in New England, Neuralgia, "f"^^™' '^^^ they .should observe and intermittentfever contained a tb:rr;urry:fff-P-ise^^^ the views and observation of earlier New England ' "^ '°"'^ --espects one of /hi writers, and are of value to-day because they show th« ^ ''"'' °^ ^^°ylston essavs '- t ''"^ localities in which malaria was then prevalent -^£' «°J.-- embarked uZanotT'^r ' essay on neuralgia contain, an exhaustive review of I ''^''^ ^^« ^^Weved solid aS, ? all that was known of that malauy in the vea 1 H3f- '"* *'"'e. strange as if^ ^'*'"^ lTi,afi.,VH^,o<,».f„*:„_ .,.-. ,. ' - ^ ^'''- ichera of hi ^ '* "^^ now seem, The third dissertation^ tha. ondirecfe^^^:: ^^f ers ^'' ^^^"^^^yi:Z;7:T us back to an interesting epoch in practical medicine '''"' '""''^ be conveyed bvl. f ! It may be briefly described as a plea for the mo Hx .^''"'"'■^- J" ^'^^'Tr Hnl Tf°'^ tended use of auscultation and percussion as metodsr'?;''^^ -^^«'^-' l4 ov^^ TVefr of exact diagnosis As Dr. Osier aptly remarks, the^' ^°"*«gi°"«ness of I^ZSl , f » slowness with which these two great advances were''^"''^'' *^<^ theory that the c. p. ' adopted by our fathers contrasts in a striking LZ> ^'^^^^ ^^« of a powerful td In '''? with the readiness with which at the pre.sent day we^?.^""'^"^ lay i„ the manLrt uK take up new improvements and appliances. Aven '°''°" °^ ^^'^ ^"""trymen to an inr brugger's work on percussion dates from i~ri k ? *^^ "'most practie;,! ; " ^° ^" ""ecog- ... ... a.ti, fc be«i..i., of'.'hi,'r.„ ; l'." t "» "tuud/r ' i7r.r ■ "'; art of percuss on was revived hv n • ! -fi "gs had for ,,«„ u ^^°'''^'" of Laennec ; while Piorry, asTf^t l.'ri^ .!" -ta^iouttt^^r. !!lf ^ I Laennec ; while Piorry, as Holm, s^ys;™ ^d" -^^^--- oT^ , r "^ ., creating for himself an European reputa ion by as • .it'^''^ "'^ t^diously.'an^t en t ^^' Imt u.seful modification in the art, referring to li"^ ^^'^ "^^'^f opp'inel t^o m 1 eximeter, of which he says in another place tha^ ''''' ''^^ of the Tatter n J lorry" makes a graven image.' The great iiscoverie '"'' "to divest their mind . . a tact which Holmes explains in the fnllLin^ °'^^''' ^^r. Hod.'e sair? ^f li ' passage: " It is perfectly natural that they "spaS^ '° ^"""^"te t^^^^^^^^^^^^ '^'^^^ of older practitioners " shn<,]H l^.t I^ '^ °^ Ii -h I can fnr,., accident or upon tUi, i„„oduoti„„'„r it, mi:.farr r'»° »' ""■^l I caLr;:''''™' ""«' 'e literature of the q^e tion" ^.^ contributions to l^r forty years Dr. Ho m" fi, d'the "'/^^ ^'^^^ '''^■ of Anatomy at Harvard TTn.-vil /^' ^?^ "^ ^'^fessor of Anatomy at Harvard I nivr.t ""T '^ ^'™f«««or he was able, to contribute " If f' '"' ■'' '''' «'^t and art of medicine in the m dst j?r' °^. '^' ''^'^^' >« no small testimony to th et^n". '''. '''"''^^^ ''^« ;vbich has placed him amongX f'' °' '^' ^'^°'"« tlie century. "^ '^^ foremost writers of "■■^ praolieal amJica'lo. » T,"" "?''''' '"''l"""" i" undoubtedly of frrpnf ,.., " • '^^''^^ ^^^^ys were been described as ''n' '"'''' '"'^ '^'^^ ^" n^alariahas best of the longs riesorv/r^^*'^ °"^ °^ '^^ ^^^ cal .subject, in which .??''' "P°° ^"^tJ^^-- '"^di- renown ^ thartJn.p T/'^''"''^ '°'^^ ^"'^ '^^'ing t'.e leading teacl L f' Sl'T^ '' ^^^ -- seen' that puerperal fever coulrl I ^^ ''°"*'^ *^^ ^^ea nurses to their vZT'^ ;::rf:' ^ l^^^^^r. and the Iloston Society for Medical ' ^^'^'™^«> before paper upon ^' The Oonf«^ Jtuprovement, read a - ;vhich\e 3uptortTdix:;th:;"trr' ''''-'" contagious. His essay was of 1 n . , '''''"'" ^^« nature, and its great meHM. • .f "'"'^''^ ^"'^ '"g'^al he drew the attenttn^f ^ ^ '° *^' "^^'^'^^r ^^ which nised point of he -Los?'' '^°""*?™«" *° an unrecog- bold and resolute attitu.f "'"!;' '"^'^^^t^nee. HLs those whose tea hing fj""'^ '^' -^^^onisn. of opposed to the contaiulss of ' ^''° diametrically controversy dragged on tl? , ^"""P"""' ^^^^'•- The -e still find\n.o'4his chtS;"'. ''' ^^"^ '^'- of obstetrics. In uS on. FTT' ^""^ Professors begged his students ""toditftJ:""'-^;- '''^''' dread that they could ever carry theT ""-u' °^ *^^ while in 18,54 the other Dr r ^ "'"'''^ ^"'us " ; of deaths. .'I prefer to atfrKirtr'f ^' ^'^^^ ^^^^ Providence, of which lean fnl ^° ^"^"^ent or than to a contagion of winchr ' ^"""^^Ption, rather idea.' The issue oJthedtl. '^°°°t^°rni any clear position of Ho..„e.s, ^ho tirstit^i^f '^ by American writers on obste ri L ''^u'^ '''^^''^d essays have been reprinted and «!' ? .'"^"'^ °^ ^''^ a« that or, homo^opItV at enl ''" °^ '''^"'' '^^^ the literature of the o/.e.H ? contributions to i'or forty years Dr IIoTme filTedT/' "'"' ^^^^ ^^-'• of Anatomy at Harvard Tnitl. ^°'* "^ ^'™^'«««or he was able to cont Se to hT^J' '"'^ ^l''" ^^^"^ ^hat and art of medicine in the md3?of IT ° ■'''^ "'«"- 18 no small testimony to th« v« !-f- "'^ '''^''^'•y life which has placed him amon JX f ' °' '^^ «^"'»« the century. ^ *^'^ foremost writers of I j I 10^-. * CLIN \fl I i >, \ Tvi'iirs li liipsiii;;- fever lever lias not many years ; iiig yearly 1 only of" the ()1( in lull posses leges, still rei capacity, to ii r.irelessness, ; kssional sup the autumnal the latter j)a be^'inniug- of nervous fe\-er < scores (jf vict villages; and t of the century, the year. No disease and thorougli s tionsare so va experience tiie ')e at the con «i'>(-'li it jjresen Pi'eliniinar\- with, your o'bs the wards I woi important liter; ^^■hicli v(Hi wil the library. I. typhoid, both th '^t;"!i, by H. J Wicles in the . I-NTRODrCToKV IiI-'\r\|.u-< T . CLINICAL DKMONSTRATIONS OX TYP HOID FEVER. I J""ST-(;KA,n-.rKCorKSK,Jo„xsHo.K,NS HosP.TAr,, OCTOHKR ;„ ,sg.. />> //'//// «;w I!,.|,l '■'"■'"'■"^'■""'^'-^' — ,.M..:,„.u..,„..,:vu..X,.. '''iilii'f 17, |s(i|. l.^Ni s lever has almost ^^one ; re- lapsing lever we never see now : vellow tever has not reached these latitudes for many years ; niahuial fevers are heco.n- ii.S yearly ess frequent ; one member o,.yottheohlgroupofthefeversre„,ains I" tulIpossessKmofits rights and privi- leges, still remanis a witness to civic in capacity, to municipal folly, to domestic carelessness, and shall I not add, to pro l^ssional supineness ? Typhoid "fbver" ;-;'"t'nnnal fever of the Vhysicia,"; .clatter part of the last ami of thl lii-MinuiK of this centurv. the slow nervous leverofHuxham. still numbers scores of victims in cities, towns and ^ lages; and t.Klay. as at the beginnin ;jti.ecentury, it is the serious ^ve,;;]- Xo disease demands a m,n-e careful and thorough study, since its manirs! nuns are so varied and the larger vour pen^ice the more impressed wiirv.;;^ '.icJ it presS'^"^^" "^ "*^'-^-- Preliminary to, or rather concurrent Wli, your observation of the cases theu^mls r would urge vou to read the •■pc^tant literature on the sul^e'^ ;Mi.x;i:.steifw;k^''" KM, 1 3 II. J i>,j^vditch ; (Gerhard's ^^"c!es 1.1 the .h.rnan, /J.-.^/^;/,' between tnl' ^''^^'^■^^■'>tial difference. dea hud' '"'•"" '•^■'^'"•'^^ '"^^■^^>-« ^vere eU-s w i ''r''^'-' '-^"""""ced ; Bart^ lie tu wH™ ^"''"'■■'^ (r«42). in whici ere an thoT'fl-^'"'" separately con inrk of Murclnsoii oi, the coiitimierl vors ; ,1,0 „,,icle by Lic-berme ""I* 'tiousuuderwhich it develops. I C 'n,,.,- 1,1 • '^V \^itli food or water n-e^ ,ettle m the lymph follicles of tlu estine, ,n the mesenteric ghSds stage :^LZtL:Ti^,£^'^ '"'^' .-ving and extendi,^. ;":,rS:^^' ! f ent toxic material to cause symptoms. It IS important to hear in niiiul tliat they (1„ „„t settle on the mucosa of the I'owe l,ut tliat they grow /// its tissue, an(l tliey are not iomid in tlie feces ii'itil the middle or toward the end of the second week. It is an infecti.m of the chyh>poictic lymphatic system, not of the intestine alone, and there are tutal cases in which thelnnvel lesion, be- lieved to he cliaracteristic, has been ex- tremely slight or even absent. There may he the most inlen.se toxic and ner- vous manitestations with very .slinht i-i- te.stinal affection. ^ The dangers of the di.sease in order of severity are : i. The general toxemia. 2. Ihe intestinal lesion. 3. The. second- ary infections. The typho-toxines niav he produced in such quantity as rai)idlv to overwhelm the system, and i,atient's may succumi) within a week or ten days witli inten.se nervous .symiitonis before the ulcers form in the intestines. In other instances the system fails gradu- ally in a less profound hut more i.ro- loiiged toxemia. The dangers from the intestinal lesion are very great. As the necrotic tissue separates,blood-ves.seIsmavbeenK!edaiid cause a iatal hemorrhage or the sloughs may he so deep as to extend through the entire wall, or in separating leave so thin a base that perforation subse- quently occurs. These two accidents together account for fifty per cent, of the fatal cases. Primarily causing an afTection of the chylopoietic lymph glands the typhoid bacilli may themselves pass to distant or gans and excite inflammations— nephri- tis, meningitis, pneumonia, etc but more otteii the organs, weakened by the prolonged fever, fall a prey to the colon bacilli, the staphylococci, the strepto- cocci and the micrococcus laiiceolatus which cause the secondary complications and winch constitute the third great danger in the disease. Upon the question of the treatment of typhoid fever the profession has not reached any unanimity. I must say that the cases are still, as a rule, over- dosed. I am sometimes appal U-d at the number and variety of drugs which are P Hired into an unfortunate victim u,i|. tins disease. Vou wili here luv, opportunity of .seeing what a nonn J c.nal planot treatment can do, si,,', very larg. majority of our cases ,,.,viv "o drug.s from the beginning i„ ' close. VVe employ a systeinaii;. v, , the apy, believing that on this ,,l, eer am percentage of the cases are aul ''»l'ty in large series orcsst liosp.ta, practice is reduced below six seven per cent. ' Not much progress has been ,„-l ;mh the so-called specific tic^u ,. i'S line r'"'- '?7'"^'-'''tn'l.<.idc„l,„,, have been used, hut the number of CKs ■s as yet .scarcely sufticient uponwhid, o base any positive opinion i , durinrbHr'"':^^"*'^^'''---"-i;3 culfurts. Both were cases ,,| crrc-.t seventy, and one patient after s.v.a i, ections seemed so ill tliat we tl,o,J, 't better to abandon the injeciio„s t returii to the baths. I„ thi ^llC^ also the injections did not seem to hJ any special influence. Following,, e^ l.einjectionsinha!fanhonrt],enatim liada very heavy chill ' ' agcd, a.s the outlook for serum theranv seems at present unusuallv bright. S, J- cific medication in the fever, has il.t kept pace with the enoinions devflup. ment in our knowledge of their etiohxn JaKc, for example, the cases adinitu;! during the past two daxs which v. saw in Ward F this morning. I„ hds .S and 10 we could say positixelv that hv specific medication the fever would dis appearand the patients would he afebrile at the time of the next ward visit on i-riday ; whereas in the i)atieiits in beds 23 and 24 by no method of j.n.mhire witJi which we are acquainted an-'d ue arrest the progress of the fever. It i< however, quite possible that some dav we may have typhoid fever under uiir control just as we have malarial fever. I should like to call vour attention to the fact that we do not give a prelin.i- nary calomel purge, nor do we iiiiiui if constipation exists. In looking over .1 .my Innjr st-ries of oases von ,i.in r . arnk. turn tims. with diarrhea. [, extrcmdy nUc-resti,,^. to note how from t.m.to tune the profession return ol'H.as on praet.ee which it had aba '!'">"l years ap,. At present v,n, wi 1 sjva,ooddeai,n the journals about he ehnnnat.ye and purgative treatn.e t of 'yi'lH.Kl fever. To pn,„„.tc. i„ ^,,^ way the exeret.on of the toxines , i - m.!nMKM].esk,„aetiveandbvstimuat- inRtheflowot urine) is a mast ration 1 '"'^•''^'"■^'^esnnetbytl.euseofwat; eNtenial and internal. If the b- -ii ; "-"'-tured their prisons .il^he face <. ilie mucosa, calomel laxatives ■ind n.tesm,al antiseptics of vario "o s ;vouiabeu.d,cated. butasf menti ncd "ymi, the universal opinion of I J cnolo-nsts is that the bacilli are ct '"•mcl m the feces or on tlie muc4S •mt. about the middle of the seeo »x-ck, by which time in .severe cTsis • i;'-«*'^"'Kl toxemia may have devek^e'l ami ".anv even have proved fatal. S or in the disease, when the slout • .1, t^tal mortality during the fc ^V^';,! : ^iiiee tne introduction of the Brand's nicthod has been in the 276 casJi 6 S I-rcent. Of the fata! cas^s Sst ''eai^^ two were admitted at the end ot' the ecoiKl week : one was a man wi e^ tensive uberculosis of the 1 ^ rr. h Hands- one .bed of perforation, n. "'asx' 'no' Posedtohave meningitis, ,s of ?Jceli' oiiahnterest, as it ilhistrates one of 't " commonest mistaken i,. h, i- • typhoid feve Tl ', ', ' "> ^''''^-?"°-^>-^ of J,- , ^"*- case has verv ev ; |.l»nal pthoIoKicil fea.nrcs am win « q.ort„l ,„ full b, ,„, i,|^.^„ . I '> I S.VC y„„ „ brie, ab..,-ace of ?,. K inouii. J he ab(l(,men was a littl' i s en ,,,, , ,,„ ,j,^.^.„ ^,^^^j^j at, he urine s^" ''"•'"'.' •''•''^''-'■^'•'•^■tio^^ I'aths and SrecPc^ '/!''" "I'°"^*' •11,, I . 'i'<-ieo a cieasote mixture ;:-' .morplua hypodermically iu^'Th, with a -, L'v . • ^^>^^'3es open an TM arm Were actiT» to be livclv ;,,f,>''^^-Jei'-^ appeare iuci\. 1 he uterus and it« nri uexa were normal. There was a smnlg amount of albumen in the due wit a /ew red blood cells * of^tl/'"" '?^'' ^'''-^ '■isidity ofthe muscle was noticed thnt tliere wal o ' !i , swelliu"- in tl ua- ? ^ '^''ff'i This fel f-^ ^f* P'^^tid region 11ns led to a suspicion ^,,1 the pan o 1 wiuAi l^r. TliaycT that tli ii'igiit really lu' I vplioj,] fever " I to this \vv had w^a of iiioningitis. The 1 oil bk lis u-f ha• was between 98° and autopsv showed characterist ic The l^^onsof t>,.hoid lever, witli" ^;;^ mo;; [I extensive dr„ribut' aresonietinus exirenielv dinknil JH.gni/e, but it is well f,')r you ahv;, I1-' C'iiS t ll le ><-'ar in mind Stok es s c ver 'there is ik lict uin, ^inol re- ^ ysto t'iat ill bacill 1 111 lii ion sjib't'ii, of the typhoid indepciid in wlucii may not and IllIU ntl gie nervous does not v ol :i(lnev: ol the inaii 1, nerves ors any appreciabj,. imial •'^ nip. Ivsiiiii lEOIC t33=B.f. JANUARY P CANr li Uv 1) fmi Magazine. ■ ■■■■ ^skx: mmF fm- ■'frtmn, Ci uit ■ts'a fe-^^^ -- J^^^Hiss:::; JANUARY, 1885 CANr ^ OF THt STOMACH WliH VERY RAPID COURSE. Bv WILLIAM OSLER, M.D., Pr.ronsor of Med.cin. Joh„, „„p„„. Unive„ity. ' ) I ■Hi' CAN-CiiR o,.- THrc STOMAC, W,T„ VUKV ,' '"^"> duration cf the disease Thl u ' '" ''"'" ^''"•i*'' "">••'* i" the ti>ree years; a dur:: ^n ■^J'72^'''''^'^ "'"- ^'>- ^wo or while a rapid course-three n li JTst' V""' ^''"''''"""' evun in younir persons in wJu.,,. .T ''tiU tnore uncommon, 0,.., ..e „„„4L or;:.;'!'::;::",:,,:;-:;- «.-"' '"■ ^^■^■'="' "•""•» weeks. With theexcentonnf ^^" T'' '^'^ ^""^ ^^« ""^er six enjoyed good hLX'^r hLT-^:;;: /''""'^ ^^!'^^^'-^ '■^' ^-' •"'->•« At the post-morten, there was found a S^' 7"' """""'^ ^■°'"'^'"^- prese,,. .ve J reau^' ^? spedlire;/,"™'"' ' ''■'"^^- ^■"' -- rJl'tZ":""' ""■=' °' '^"■■'^'"^ ™'*" "^ "■= oorrecion of s.o.«hLrof r l::;''''^"''^ °*-""-^ (»-»' f-^O °0or, d„e .„ m,b,- Diffuse /„T'r,LT ■^''"t""" «"■' «'»« ■■^■UM„ T-.,, trouble. "•"" "^P"' "• ~°'P'a">'"S of vertigo and of stomach ' Johns Hopkius Hospital Bulleti.i, Vol. „. ! 1 IVilliavi Osier. good"'" He' W V ' ''"■'^^■'r '^^'- '^y o-upatiou. His habits have bee,, good^^ He has been a steady smoker in,til about a month ago The patient was well and strong as a young man, and has throu,!, out hfe enjoyed tolerably good health, though for many years let ' months. Iwo years ago he had an attack of biliary colic sev. enough to require hypodermic injections of morphi Vou mo tl ! A terThf^th r' ' "'°"' ^''""'^^ ^^-'^^ S-^^ P^« - the Tgir r After his he skin was a little yellow. He has had no attacks s„cf a s.milar character. For about eighteen months he has had attack severe vertigo associated with flatulency. The first one occurr u .v, i he was sitt,ng at the table in a restaurant drinking claret pui oh jumped up and said to his wife. "Catch me catch me " n ,H J '. hold of ,, table to steady himself. He hfd alt^n ^ f tt 2r attctts eTib" T T'' ^°' ^' '' ^^'^^^"""^ -- '" motion a tack la ted about an hour. He did not vomit, but looked pale -ut^ broke out into a profuse perspiration. He has had only two attack- similar severity, one while in his carriage. He said Limed ;: horse was^down and everything was turning over. This at ack 1 ' about an hour. He had to go to bed and felt very badly "nd a , he was all confused in his head. ^' ^^^''' '' The milder attacks have occurred with great frequency Scircelv a day passes without one or two ; thus, yesterday after breakfa ' whatever in the chest or elsewhere. The attacks do not come' during sleep, but he has had several of them while in bed ^roni his statement the vertigo apparently is both subjective -.nd objective. Objects go to the right, but he feels that he u , V "^ In the attacks it is impossible for him to walk. It appears to 1 ' i one foot goes about ten feet higher than th. othe K h lea M tight the attacks do not appear to be so severe. He ha never o 1 IS t^rweek.r ' '"'"^"' '^ '" '''' '''''' ^'^'-"^ -» ^^ 'ck He lays the greatest stress upon the condition of the stoniach i,,,! says that everything comes from it. and that the belching t:. and most distressing. ^ nK-t.vsaiu Though he did not complain of difficult hearing, it was evident Canrcr of ,ke S,o,..„,, „,„, ,.„-,, ^,^,y Co,..se. 3 in which ...ere I, i'^i Ho e n^lT'' """■"'""*■ "" ""^ "«'>' "'• -cl. louder, a„d so^Se" t ere h r";""""'; '" '"' •■"'^"■' " - special scleroMfof , farteri , '1' 7"' ■ ■"" """-^ ''' '''•■ ^o N-o increase i„ area ..fX,,! Thrs^ ™ ■;lT"'"--' ""' '^'■■'=^'=- .acce„tuated at the base. TI.ere is a sT.!l r '" ""^ """'"^ ""^ area. Nodiastollc m„r„,„r a ul We '°!J,-J!°"= ">""■""■ >t the aortic icnderne,,., on palpatio,, at c„ a arBil T '" I' "'" J-'^S'"- No .h-nded. T.n,pa„,. extends o.f, ril 1^,1 " '"t'T' al)Ove the navel. Soleen not n.i„ , 1 "' "" '° 'hre^ finger-breadths ri.ht side. He sa,f ^ Li £ I, ^^l^ ^^^ ^^P^i-d on years He can hear the watch i„ do ontac ^^tlTTr ' ''"'' hear It at a distance of six inches. ^^^^ ^^^ ^*" Dr. Theobald, to whom I referred the mti^nf r ■he ears, wrote .bat tb.re was deafne^ ,'r,„''e° ! ^ :;X";""T°" °' ni the and torv nerve or it« «„,.. • • , ^ ' ""^ *° changed was a.so slight ^z • tiT e^rriv" ?,:jf -■■■'^'^- .-^ "- ^^- showed a rather high grade of 1 ! n . examination of the eyes of ascigniatism, whi hTe tilt t w""rr' "''' '^ '^^^~''^^' ^^^^ ^ Rlas.ses, as the error of rcfr't ' materially benefited by -' i"g the atti:;::^ t^^^'^,::r^' ^" ^^^-^-^ ^-- ^» was reasonable to suppose t at th. , ' '^'' "'''^^ ^"^'^ '^'^' it with it. The chanee^n tl ! '' '. " '"'^'^' ''^^^ something to do i-d ..as«es:::rstr::rr: r u::^.^:^^- ^^■'-''-^^- the end of May, and said tl,«f J.. "e came to see me again towards ■•ad l.e had no seve e at tcl ^,7^ T7 ^ •"" '"'^ = ''''' ""^ °"'y peared completely His Ton' If ''" """^'" ^"^'^^^ ^^^ disap- not nearly as bad'as it iLte;:: ' ^""'^^' '^''"- ^"^ "^ -''^ -s His «"::"irt::;^t:^^/""^ ^^^t'^ "^- ^-^'--^• kept abont and h,ul been tran^"c1in V'' ^"'^'' ''^""^'^ '^^ ''=^^ ". On that day he beln to" v t ^-?^.''"-"ess as usual until June thing on the stomach s.eetheVr";"^' "f '""'' "°^ ^^^'^*" '''">'- tl.i"R into his stomach wi o .t ag ravath' "h' "" '"^ ^° ^'^'^ '''">^- tervals between the attackrl . f ^^ ^'"""ting. In the in- distress is just pri:rr:i : ng t^tta^^.^'^rr^"' '^' ''' ^"'^ or four hours. The material '"f "'7"^^'^^' ' ^^'^l"-ec»t every three cole, and not bloody. "''"' ^'^ ^^ «^^^ ^^t-r>'. grayish i„ To-day when I saw him his condition was as follows : He looked H ^ Wa/iam Osier. slifih. fur. H. bdche., a „ er T Tl 1,," '"", "' '"°''"' "■"■ '■'" " Of... s.o„.ac„ ; .he,tTare'r„.,;::';;;;^,:r '= '-'' '■■ "- -™ I tl,„ugl„ fr„„, ,|,e ac,„e on«t a„d severity that it might nossihi. er;rx--;i:;i:--r-:;-:5 On Monday and Tuesday the miting continued and h. .hi,, ,e*„,,h-bro„.„ fl„i;,, witf :x; , : eXe,;' '° T^' T- ' s,.ch Iha. we suspected perft.ratic, i,,.o ,l,e bowe t wn! ,' Tf l,ow ,„„oh I,e brought up fr„,„ the s.,„„ . in tt tw rfr"," '' ,:L':;::u:eh."""'^' '■" "" — "- = --^ "^ -- .-"n^..'.,:,,':: The examination of the fluid slmw^d f),nf ;,■ feebly ^r free „ydroe„,„,ie aeid. ^Iti:: re " ^."^^p::;.^^'' ular ./,V;/v>, hut no formed elements On 1' T ''°'^"''^''-'' -'^■'"- e.a„.i„ed the „.ateria, w..,d. Z ' bee.f J, :?:: s™' ','.'^, "',r"" eJit-eraely foul, wi.l, a dis.ir.ctly fecal odor LI V ""' was fouud i„ ,he f.ag,„e,..s of blo'o^clLt u ,^^Z:r'7'::^ mouas was seen. The pipette wltieh I used ,„ re„,„v . stuZ been standing n a iarof witer h„f t i a ^ ""vt me nuui Had draw,, alcohol into hbifJe '"iug " " --"-'"ary ,„.„„ne, n ucn the sa,ue. hut he beca.ne weaker after each vomiting spell i„ tl.e even.ng ,t was evident that he was failing very r„p,>, ,y ,!!„, I ifi'';ii[innif f ~ fr i iiiiirn- ': -i Cancer of ike Slo.nacl, e.M :.,,, f,,^;, Course. He sank and died en the morning of had not the strengtii to vomit the 5th. nnterior „.„ were .lo^e 'u^L't;'™;": ■,""'' ^ "","" """' " "^ "^ tlie left lobe of tlic liver n„ 1 f,^ ., '''^ S»" '«"■« co%ered by .he .ra„,ver»e „,'„„ „.! a,y Jn of £ '''°'','- V"«'^"ecl. Neither c.vity,„,tbesa,n,l„«„e„:ltl e ri/n""" "'°°^ ""'" '" "" tl.e organ was tbe .eat of a dim" m ated ™""'"'- '''"= """^ "f curvature and tbe posterior wa I 7 •-•.■"rcnonta. In tbe lesser of .be band slongbinj "d .Ik'n "l " ""t,'''"'-' "" "'' "' '"" '"'" ated snrface to whicb shre s of ' oroticTitrw " '",f ' ""•• "'"^■ index Bnger conld be oassed i„f„ I "" »""'"™.. Tie was free." Tbere was "oTerf" "i n' '■^'°",^. -■«« ■ '"^ "«"- orifice were no cbanges in .be ot'b^bdo.nit.aTXr "'°' ^'"°°"'' '"' '""^ .r„w°:r.r;s;o,r:rb'ad'trof r' t ;; ^-^^^'^ "'»'" '-»' '^^ no. -io,,siy„„dernH,.'di,iT,,r„r; ;■■:,', 'Tz "" " ■■^■' to have seen such a remarknhl. .^ ■'^'^^"Sth. I rarely remember ...e .orrection of bis ::::::^£;::^';^- ^:;r '^t ""- "'- 1., he was " living a new life " ,nH L r "™''f' ''■ ^' '^' expressed of May he looked\erv!n„ Ibelter Tbed "" "■'" '""""^ "" "" bn. be no longer had ,be i„C„. mI^^'^Z:"^ "-™" '"-• ser.ons a.,d fata, illness was wi.hin a .nt,. o'f ,h s d « "This" "^ of n.fil.ra.mg neoplasm disturbs in tbe le„t d.„ L ,i , ™ .he stomach, and tbere are n,,, . * "^ ""^ functions of had dim,se carei„o„,rwl e tirrni;:/"-"' "■"" ""■= good almost to the end. '"lP«>'le and digestion have remained c.se,?m;;tbe';7t'h«"V'"K"''','"'' '"' '■°"-'"' ^'-^■' ■■" t>- a fe^al odor oftl vo,^ tns S/'le 1 """""'' """ """ "- ^1- howe, as well. Very" rs'ibW 1. 'L "i ^-^^^l.rr-"'™ "'"- ™-.g ...ere was ntore or less regnrg'i tat' Ir^'f t iZel'^r -eiief'tfThrrrf;;:,^: i:;"S. '™"'- '■■ -^^ -- -- «.^ =....« ^ T '^ L-l'li TEACHING AND THINKING The Two Functions of a Medical School. BY «'M. Osmu. M.1,., KB,,,,, more. i ...■.^ ^-xi '.-,,_.„■„.,. -■ ^^■1 1 1 1 H V 1 Rrpnnt.l fn,.„ ikr M,nU,;.a M„lir„/ Journal, F.'hrnnr, 180.5. TKA(MII\(; AM) TIlfXKIX Till-: T\\(i l'"i\(T(o.\ "^ OF A Mkdku, S Many tliiiins hu\-,, i I'lllMII M'i'll illi;'( '•'■iitury civilization^tliiit political ..r.frand.i 1,1^-aiiist our iiiiictrcut nils III {luarcliv, that tin SClllCllt (>n!v I Iv wiilcsia'cad unrest i I'iiituul Irakis ,mly to UMl„.|i,.r, mi,| that thr hrst taiy on our Itoastcd culii'lit aiiMsand the nat fnnicnt is tl Ofth ionsc\ciy\vii,.i'c "iiai'i'i n iiiattci-s coinnicn- •' l>i<'tuiC of Imij',,|„. tilrf I>i'a('tical })L-(jMiv.ss in on,' diivct u xiety : l.nt the .|; so sacri win '11 tl "Hit has lieeii of such valu lasheen so much the i livinn- oru-anisni lia '.V <\ when ueasui'e as a s seemed II' olihu'atioiis t scfliied so nil pcr«tivc. |!ut tl c< )iHparisoii M-ith ti H'Se Cham Dei "K- Thehitt ic renicrkahle inc " ivirard his rights hav( ;i's are as nautjlit in rease ni his physic; Ciition of the nat or cry of Isaiah that with themultii>l ions their joys had not 1 lioiiiiirks iiiiidn lit th pll- >oen incieased, still f "pening '"""- llopkius University, Bolti th ^e. by William oX"y:i, ,"F.f ^ i F k^P p""!^'"''. "'„"'« Medical F«c.ri more. toiij., Protossor of MeU auulty icinc ► I i I i ' I • ■f'lioi'.s ill oiu- fiirs. Th ti'Uf, iiKiv not liiivc li |Wllll IIIKl suf] • ■niiL''. tl 1' sorrows jiiid troul.Irs of ■'■" iimt.M-iully th loin liirth to death :' T our race tlirou<,di centui pnin which has fallen and will fall u| II in the other ics past and to eoi ta aiiti' view of it— think of the N liut t like ken pain .lurin- the past fifty year einesiswliich I las o\i'i' •ejitic siiie-ery have almost ■s! Ana-sthet les a I 1(1 since their introduction th manacled the d eliioii. iuii •n prevented far (aitweiVhs in civilized ignTojrate of pain wliici I liii^ ^vhicll has lieen suffered. K ■n lifted from the soul of v«'n the cui communities tluit se of travail ha-- Tl w n. e <,'reatest art is in th say that we of the me.lical Vou of the puhlic who h aiiaii concealment of art, and I n'ofi iiiii\- 'ssion excel in tl lis respecl ar me oo ahout the duties of ay profoundly indifferent to the facts 1 I tioned. Y,,n ,] for t not know, many of you do not le crossdeei,^..! .luiio who presided lave just iiii'ii- care, that your ,i,n'andparent,s, tl lei leife'ec over the arri ■e now sits a lienio-n and str .i,^o.Ides,s. Yon take it for ..ranted that if a si iiiilit IS dislocated thei in.stead of the is chloroform and a del mnl'ler fifty if ^ years aifo. \ aji'ony of the jiulleys and icious Xepeli parapln riiali I et accept with a selfish complaeeinv a« jou were yourselves to he thanked tor it, that tl le aiiuw.' ,'r:icy, ii>s [■ aiTuws )t' ilcstnietioii ll\- i„,t, •I tliiekl n..\v raivly walkctJi in the ,|u|.|, nalizc that yon with )i I't.'iisoiialil y, and Mint tl K I less may \u,w pray llic pr I't'ospcc't of its i'lilHliincnt II' |M'>til(.nc(' 'y'i',,r iirzckiiii, .science has made to almost evecvol a few years. I .say you i| t know tj ■since III le o! voli tl oilei'li pi'eselil 1,1' ami the more intelligent ill yoiir lieai'ts, Imt tlie\- take foi'irnvnted, like tlie thill ^'oi, I :iiiioiiy yon pi'ihaj) ai'i' aiiioiiu- th,. thim em, le.ir (if th |i"llilel' til,. II which Di'ioiLs lioavcns. suiishiiic, mikI the II on "\\l'l'S, illld th, tl "I'is no idle cliallcnu'e which we le world when we claim that (ai I'li.Wsieiaiis tl 'W out tl am 1 of th noblest kind, not n\ r mission is ,,1' tin I liicatiiie' til people in tl "He in ciiriiiL!' d i.si'a.'- IllL !'■ I'lws of health, and IlLI'llest l.llt III the spivad of plaeiu'.s and la.stil 111 pre\(.|| i^aiii.said that of late v leilces : iinr c-m it I, ears (air record a- a mure encoura;,nn-' in its practical results tl Dtlier learned prof iMKJy mil t leen lim- hcst ideals, tar from it ssions. Not that lose ol we a I liicli Ideals, w ueans more. we are laily men. Hut live up to the We means much, an.l the\- lia\-e Of .■r»'e for .shekels, wl course there are ( I'c realizahle, wliieh i.veii and tlie jinolinir of t| lose ears hear oulv th 'I'liazis aiiionn' u ■s Wllo tioi IS, am, th le j^'uiueas, i.ut tl lowini;' of th le.sc ami e rank and fil,. |; are e\ci sclt-.sacriHcini-- devotion t il'our earnestly for voi II' Lfood. hcst Work ' your interests animat I's our le e.xerci.ses in which wi are '"cident in this heneticent work cvervwl icre: an nicident whiel <>-day enya^vd f vvliich is in 1 wil II pun certain as])eets of tl enalije 111,. preinotion of tile physical well- ic university as a fact( orm an proLfros l:i dwell r in the great university has a dual functii •me- of the r ice tliiiik. The educational I'lii'i'ijies, and in th iiiKi in I'll Hi I >ii, to te, ich and t( aspects at tirst ahsorl rii a! c eijuipnient of the va providing salaries, it finds itself I Its c\en the first of these d uti nous li'partmeiits pressi'd to iai .| OS. The ])e,-i has told us I i 6 " tl"' Inst .•■■mk as a Iraclii,,- l,n,|v | I,,,,,,,, .1,. , ^:?':;M:S-;;:7'-,i;:;:t-{:i5-?^^ ncr, l,.,tl, .. whu-h ,nst,t,Uio„s lonn .nosfc ...ssnu^ I Hlml, . natter, an.l.t is for tins that HV ask th. ,1,1 n,. ""-• (''•■•"■^t'y,anat.Mnyan,l,.|.vsiolo,v ,nv,. th.t n ;;i-tn..,,ie,,..na.,,..s,,n,t..p,ao..n.;;a;;,n!l tl...p,.op...p iUo,.intlH.solu.n...oriitV,an,lafi;,nh,, tnrstuo.tl.y ,.x|H.m.ncv ..ay 1... la.ilt, Ka,-!, ,.n,. „r ,1 i. -■nc.. ,n ,ts. r, ..,,,,,,,, „.,, ,„„.,„ ,,,. ,,,; ate tlupnnc.pl,.san,le..rtain..n , „,,, • .... ,>„n.l..,,. Only s,. fa., as tln.v l„.ar ,p„n ,., ,h„. t .,nv.partoitln.u,c.,la.alcun-icu!„n,a„,lf,.,.„stl,,..,n. c. not .ec..>n.e a cun,pet..nt surgeon without a full k,..wl- ..- o hmnan anat.any an.i physi,,l..,y, a,,,, ti,,. phvsi..,.,, -t Out pl^.s,olo^y an.l ch..nusto- Houn,h.rs alol., i. .. a"nles« lasluou, uc-ver able to gain any accurate cone,,,.,,,,, I' 'lisfiisc. pnictisiii"' II sort ,,!' [„,i nnw till' iiialii.ly mid nyain tJic kim\\'iiii;' wliicli. Tlic iii'iiiiary fiiiictioii ,,{' (his ,\, ';,'•" I plmnimry, I,it,HiiM I»ifi«'Mt, lie Iiiins..|r not >tty IS to tfiu'li iitcii (|j •|>'irtiiic'iit ..!' tl ^'•'is.', what it is, its iMT' ow it limy l.(. pivvciitc.l, ,ui.i how it ■ liii these thiiiHs the four hull. In, I iiiaiiit'esuitioiis, '"■cnivd; and Ut i.'iesi' lieiiclies lia\ Is nil 11 eht <• collie IViilii IIKIV ,V""II^' men Wlin sit on iiin ill till tter. tliciilties, s( ivsponsiiiility which a facult |'"its of the land, liiitit task IS not eas\- I leuiii' >nie inherent in tl ,v fissuiiies in this ■•■^ct with countless Mien thelliselv "' snl.|ect, others inf iiiltiti Kle T ■'•^ "nd nut a few hniind """'",1; which we do(.t. dent in lip with th le processes of disease ai M\ely ditKcult t( ami aithouiiii we 1 searcl ors Work ■'' ^0 complex that it I o'lt the laws wliii-h is e\ "^^■*' ■^'''■" 'I t' plet.' revolul control tl Ces- lem. ideas, what has iH-ei, accoiiipjished 1 1011 III our iiii'i iicinc is oidv an ea ic three OTcat adv nicst of what the fntu 'V the new school of i'<' lilts in stoi kimw lei L''e )f tl "I'c^'s .)f the centurv haw I the iiitrodiictioii of ic mode of controll leeii a htic method iiavsthetics, and the ad 1"^^ epidemic diseases ■s 111 surirery. Heside tli nisipiilicauce, as these tlin l»Tsn|ial causes o the discovery of the methods for tl Mich a sfoiirj-'e as typhoid fever contril.utc so 01101 option of anti- cm all others sink into comloit of th,. individual. The study t so-called infecti.ais disordiTs has led ■monslv to the of tl le directly to ill presence of perfect draiiiaire and nater supply. The taitlook, too f icirccaitrol; for example, lecoiiies almost unknown' 111! uiicontaminated tieatiiient in tl lese a tfect I!' specific methods of lulls 't not lie disc( ■•'IIS IS most mraired laillll'es. are mi tlu tl In' few, I'opeful. The puhlie or even by many linkers who ai'e d(.i„fr tlio work for ri.i^ht path, and it voii IS HO vain fancy that l.ef IIh' twentieth century is very old the t many of the conta 4 .^^ Jr>^ . -m^ i< m 7i 1.0 I.I ■- IIIIM ■ 5 ""'== L25 III 1.4 IM [ 2.2 IIM 1.6 if i e c V] ^» ^ Photographic Sciences Corporation 23 WEST MAIN STREET WEBSTER, NY. 14580 (716) 872-4503 -^•V iV ■O' \ '€^ %^ ..*. ^ ( : I ^ pi'«ro(l, unt iK'w ones arc always cr ays cr<)ppinf:f up, and I iiotic, that witli it all tliciv is not only no decicasf yivat increase in the lumilicr of (joctoi-: Tlic total aholitioii of the infect hut a V expect, and for nianv vears t« iou,s o;r(Mip we eaiiiidt <> eoiuc there will iriuain is, even aiiioni-' preventaiile nialadit t( hosts of liodi'v il occupy our lahours ; hut thei'e are t jiiain thi" relative nuuiorical increase in the profession in wo reasons whici 1 e.\- )it( )f tl n.'at decrease in th number )f certiiin Il I'lii- • iiseases. The development of specialties has oi\-,. Dloyment to many extra men who now do much of th ioner, and anain pe()|)lc cni- fj^ive occupation to work of the old family practit ploy doctors more fVcquently and iiany moic than ff)riiierlv It cainiot l)e dein'ed that we have l<'arned how to ja-event than 1 definite outline of moi'e rapidl\ low to cure diseases, hiit wit J ;i our lyiiorance we no lonj^er live i a fool's i'aradise, and fondly ima^i-ine that in all control the issues of life and death potions. It took the pi'ofessii low in 1 with our cases \\( pills am that fevers ran their cou hy druos, ,u,d the tOO which old ]> spent in medici'ie in >i. many generations to lejim rse influenced verv little, if at ill 'over complaine wen a case Of" ordinary fever alioMt th ry is now hetter expend ('(I iiu middle of tlH> last centu trained nurse, with infinitely less risk, and with intiiiitel .-•■reater c mifoi't to tli<' patient. Of the difficulties inhennt in the art not one is ,so serious as this which rehif,.^ i,, th,. iiiif\ cur<- of disea.se hy dru,o\s. There is so much uncert and (liscoi'il even amon-f the Iiest autlusrities (u) Dssentials it is ti-ui-) that I al ways feel the force of could not (|Uote in the tender ears )f student!' ton iimi- n wrll- own stanza in " IJahlii B,.,i Ezra," which I lOA'CNTI-, One of the chief roa.sons for tl lis uncertaintv is ^easinj;- variahility in the manifestations of I /II' ijii- li an\- line .!!■,- ease Ls no two faces, .so no t wo cases ai-( respects, and unfoi-tunately it is not only the .1 which is so varied, hut the suhject^ tfiemsel liaritics M-hich modify its action. isea> III nil ■ it- II' \('S have pn.u- With tl It' 'limiiiislicil ivl i.-iiice u .1 ivtiii'n witli pioHt to the old poll .Iniirs, tl,,.,.,. has 1 liatli.s, and tVictioiis, th- iv:n..li...s witl Asclcpiadi's doctored the J t'l" iiicjisiircs of diet. )i'(ii |'X('i'cis( , \vliieli tli(. I!vth(i lirst L,ciitury. 'I'hoiinl, used Ics.s f loiiuuis so sncccsst'ii! ijii w yivcii with iiiHiiitcIy VciiiU'iitiv, II man y III th( iTrilti i''dieiii(.s ari tlioir indiuitioiis and fontmd--ctions, and i.y (ivvcrsino. the proportion ,jf iiftv vcai '•'I' slsijl : M-,. k\u,\v l„.tt vv one diiiiiancd iiv dosji >,U. one Iiuiidi Wf may salVly >> »M' mist;l Ke on III' commonest I' s prof(.ssion \no\\ini4- it. Tl icrc nvc mei ^'" ''"""nh.son f „s without jii'i'liininary education the f who ha ve iii'Ver imdamental truths of t winch would ,.iiai th lal.le (1h.||i t> I Lirasn IS hased OtI "■ ■'^L"l'''l< 11 which Illed that heiit of mind wl "■i-s h.'ive poor teachers, ai ICIlie I'lhuatioii ; jthei iicli is the all id never receive ill::- th at tl s ayaiii fall <.ai iinportant fact or III el' know it ly into the error of tl nils I'NlH takes or tl liellefitillM- ||,,i( ' 1 1 1 k - leir suc(i>s.ses, mis her l,v tl rii'iice, and di<. I nss the vei\- tliiy started. 'I' "ho practice with their I in-n-,.!. f, essence ( if leir .f all possil 'li', cuaii w »■'•'' ;>i'i' only two sorts of doctors • tl leli tl.'i'ir tolliriK wishes t ii'ains, and tl 'I'lie studi(Mis, hard lose who practice \vith workiiiM- n.aii who '> know his profes,sion thonaiohlv, who | I'^l'it.ils and dispcni.sari ives 111 tl I's, and who st aiH pl'ilosophieal concepti(,ii ,,f d ri ves to olitain a wiih ISl ";" ''"^'»l'Hr[)(>rf('iN ni' all tli fitii iiostruins mid Imiiiliiinnviy with wliicj. the i;- j^raduailv, and We liiuc consolation of knowiiiff tlint \-ear liv vear the tot, II aiiMHiiit )f un inecessary sutieriii!;- is decreasiiiii: at a rapid rate In teachino: men what iliseasc is, how it may h vented, and how it mav he cured, a Ti iiversit\- is fultil one o f it S Ver\' IIOMlc -t functioi is. I as and the splendid e\aiii|ile of such niei land, ( an'iphell, Howard, Hoss, Macdonnel 1", 'I'he wise instruct iiiii Holmes. SllliiiT- , ami otllelS ||,i\r ca rried comfort int(j thousands of homes thnaielioiit liii- and The h 'uetit: s derived tr< an tl le increasi'd faciliti the teaching- of m edicine winch have come with tl ■ivat chan,i(es made here and at the liuspitals during th. uast }• 11 t'CflMv (illr (if •"^' ^'7"- "•'" ,7^ •' "'^'"•"'f"tlH.,.|tix,.ns„rtInstuwn I'ntvv.lMM.w.l.ly ,lifl„s..u ,,,,,1 iVlt In .vnv lu..alitv to wind. til.. -,a,luatrs ,,f this s.Ihm.I ...uv ■.>. ; an,| rv,., v u-Ut ^^l'"'l' I'>''M„.,t..s hio.h,,, ,„,,,;,„, ,„,-„,,j-,„ .,,^^1 ■^,-^^^^ '•nal.les tlir nu.li.al faculties tl.r.mol.out tl,. ,„uuiyv tn tnn. ..ut Lrttrr ,|„ctnrs, moans IVuvr niistak.s in .lia..n'„sis .uivatiT sk.II -n .l..aliMo- witl, ..n...rnvM,.i..s, a,.,| tl,,. vuin'n' '■: 1'^"'. au.l >,usu'ty U, .•nuMtl-ss s.^l.,, ;. a.ui tl,.!,- tn,.n,ir Tilt! physician i wiii-k is arduous and coniiilcx, i "vdsaclcar h..ad and a kin.! heart ; hi> \-i'i y hijfhcst I'acultics ol' ti i'(|Uinni;- the rXiTcisr ., fth II' mind, will! •onstaiitly anj ci-niii .\t 1 iiii^' to the emotions and tiiier f iiiHiiene.. Imvii nioiv potent, at no time has 1 I'i'WHful a factor r,„- good, and as it is one of tl |ii)ssihle duties of a e-j'cat I I'aNin^', so it will 1, )eal <' time has hi- le heeii ni\el'sitv to fit liyhest lllell 1(11- thi> cuie. to carry on the i V-nrhii-hest mission, student,- ot llledi- lid death, hett H'Nei'-eiidine- warf •■!• <'i|mpped, ahlci- men tl sers, liut animated wit!, tli ii'c against di lan ynnr pivdi sease 'pes, '■ for llope of ''If spirit and sustained l,v tl leiv \Vf heal-. cxcry creature is tli I' hjinner that Miversitv is totl iinl The other function of a U ■uirent knowledu-e in ail -lepartnients, teacl 'y which the .slaf cacliiiio' Uii the steps nvj; In •■"ilcnv facuiti "s jnursm.s lias heen reache.l, and teacl 'W to teach, form the lout iiie work of tl es, winch mav iiiaiiiier \>y men who I tliiir suhjects to know that ic vai'ious '"' '•'>"<■ i" n pri'functory liiv.' nevei' "■one .!c..p|y ..uouoh into 111 any way ii I'liiiftion of nportant. What J ivally thinking- ahout tl lem Is I I I nean l.v the tliinl corps owes to enl Work of th "v.'rsity, is that duty which the prof irj.e the IxHindaries of hunian'knowled Kill';' cssioiial fiiiil itt IS sort makes a, ( niversity oivat, and \\\ aciiltv. Tl " exorcise . I wi.l.> inriuencc on the mimls of t.ind to-day at a critical point in the 1 alone moil. list ikrli "^ oquipinont for toacliinir, t Ol yofir.s of hard stni>M Cote street school were hetter than those with which t\\v faculty started ; we and our ways at the new huildin- ,.ii University stiwt wore hetter than those of Cote stn.i ; and now you of the present faculty teach and work iiiuih hetter than we did ten years a,i,'o. Everywhere the old order chann-eth, and happy those whc can chanov with ii Too many, like the defeated gods in Keats' Hyperion, un- ahle to receive the halm of the truth, resent thi' wise wnuU of Oceanus (which I ipioted here with very ditfeirnt IV,. |. ings sojue eiirhteen years ay,) in an introductoiy lectiiivi "Still 1)11 our Iu'cIn ,1 lifsh iicrlcclidii (icjuls, * * * * l)01'll of lis, Kati'd to cxi'i'l u.-<." Now the fresh perfection which will tread on ,)ur li., I, will come with the opp,)rtunities i'oi' hjoher uni\, isitv work. Let me indicate in a few words its .sco[)e and iiims. Teachers who teach ctu'i'ent knowledoe aiv not nec,'s>,ii ilv investioators; many have not had the ne,>,|ful trainiiin': others have not the needful time. The very h,.st iiistin,t,,r for students may have no C()nce])tion of the hiolu'r liii,> of work in his h.-anch, and contrariwise, how man\- luillijini investigators have lujen wretched ti^achers ;• lii ,i s,!,,,,,] which has reached ihis stage ami wi.shes to do thinkinu as well as teacliing, men mu.st he selected who are nni ,,nlv thoroughly nwvuuniiil with the hest work in tluird.pait- 18 nil inir Ih'ils ' Ulli\(i'-.ity [>(■ aiiil iii;ns. ' iii'(.T>Mirily 111 trniiiin^-; st iiistnictiir ;'li('i' liiirs III' my iirilliaiit III a scIkhiI tliinkiiio- us I'c imi ,,nly lii'ir'|i'|iiirt- niriit tlic World ()\ <•!•, Iiiit wl II) fllsi .Miiil..t.(m mill ...irruy t„ ,,„t tl„,n intof .•will, I'lU-ll olir III I M MS spin. IV, tn tllr stniv nf '<"-'"l.'.l-.. Mm of tills stmiip nloni. coiif ' l"i\<' ulcus, witli ••I't'i'. iiini who can tl ic Worlds "I"'" " -"Vc■■s,t^•. Tlicy .should l,c so„'V "ivati less '•■ fur and raho's cloak lie o f Mic chief difliciilties in tl ,i;ates in ut rarelv -ood tl selectin^r 1 i 11 k e rs is the stress of I'ontiiie cl, w liich often saps tl tllllle'S. "■ ''liernirs of niei "■ "'ly of advanced iss and lal.oratorv duties lici'e are twi I capalil the profes.sors plenty of assist sseiitial |)r( e ol lilirhej- 'Visions, fii'st, t o invc Wiil'll o "t witli teachings and, .second "lice, .so that th.y will not I, iiiiiil to n-radimtes and others t llieir direction. Witl to !>i \'c elK-oiir; II system of " <'ni'iy on researches mid er ''"'■•ii'ships 11 iinivcrsitv niav 1 illowships and ivsearch liive a liod\ ""■'I. who on til., outpo.sts of knowledi "I alile \-o|]ii Mll\e\||ii. \M\fil ami \isi 'diii isili !!<;• and correct ini!' Til si^ii that a ,'' 'ire explorilio- I'll' Work istheont- uiiiversitv is thi ""ii"l'''l I'V fi i^Tonp of lirin-ht ill ••iilvanced methods, m-t onlv stiiimlatod to .lo his he.st work, lait 1 •ikiiiy-. Sill .vniiii- minds, well trained IS the profe.s.sor him.self iiiclil and to know what is st 'w II iloiiiaiii. ic has t o kei ■p fi iiTin-' III every part of hi,. With tl IC wi.se co-opei-atioii of tl .\ il'il anthorities Montn^al sh.aild I '" •\""''";'. a orcat medical centre to which ii,y, who.s.. lahoratories will 11' university and tl 'cconie the |< le 'I' Miiuiii leanii st stiidcnt.s, and whose teacl line- wil ■mils, universally recounize.l as of the hiid iirsi type. Now I clllllMiri;li men will flock attract the 'ri'^ out into all lest and of the "'•''' is the outlook MelJill. What past more eiicourai (luy; than at ;1TSS lit tl ,yuai-antee for the future does tii ' cade afford .' No cit le nro- (le '"'^ - lilierally endowed lii,i.|icr education ""^v to io.ster that undeHiial-le .somethin.- wliiel 1 y on this eontiui'iit lere remains 1, for want ► i 'i' il lii'ttil- tiTI II. \M' I'llll tile Ulli\C|>ity S|,i|it, il s cti.i winch ;i iicli iiistitulidii may 11.. ( have, and witli wliicl pnnr i.iir iiiav lie satiiratcil. a siaii.tliin-- w I '',V I .'I Willi men and not witi iicli IS aNsiiciat. ill Ml ihl 1 iiKiiicy, wliicli caiiiint lie piirclia iii;irl<('t 111' yi'dwii ti> urilcr, lait \vl IK'll colllt's 111 .SM)I\- with |(i\-, \Mtil"llt Whicli .\,'l,,ishh sol si'll- ili'\<>tiiai to duty and I.. hin|| ideal s, ainl " is w ritti'ii (ill its |Mirtal> H siiiiicti.i,!^ vitli wliicli ,, I is il>s()ci;lti.| III' [iiircliast .i follies iliscii- II i'lriils, iill'l .l-t;ils. > I CLui\J Case of Sporadic Cretinism (Infantile Myx- oedema) Treated Successfully with Thyroid Extract. BV WILLIAM OSLER, M.D. Professor of Medicine, Johns Hopkins University FROM ABi""Mi\rirc! r»i? February, 1895. ►l ^ i :'■ CASE OF SPORADIC CRETINISM (INFANTII K MYXfEDKMA) tri.:ati;d SUCCESSFUI fv WITH THYROID I'XTRACT. BV WILLIAM OSLKk. MD, l'r,.fuss„r„l .MHicine, John. Hnpkins liiiv.rsiiy. In my paper upon sporadic cretinism in America read before the Association of American I'liysicians. in May 189;,, I reported three cases of this ilisorder. One of these which had been under Dr. Hooker's observation subse qucntly passed out of sight. The other cases haVe been treated with the thyroid extract. In the girl aged nine- teen the treatment has not been ve.-y .systematically carried out by the patients, and the condition has not materially improved. In the third case the results have been truly remarkable I give the notes in full from the American Journal of Medical Sciences, Nov., 1893. M.. aged two years and three months, was brought to me first from the Eastern Shore of Maryland, Jan- uary 10, 1892 The parents (fir.st cousins) are healthy and strong. No hereditary ailments on^ eithe side^ no members of the family have had goitre The patient \vas the second child ; the labor was easy, and she hrove well. Nothing special was noticed abou[ he chilS until the end of the first year, when it was suspected something might be '. /ong, as she had not cut her teeth and did not attempt to walk or to talk. Throughout he; second year she grew fairly well, but had several attacks of slight lever, and did not develop as other children mak.ng no attempts to crawl or to walk, and seemed un-' na urally quiet and dull. She did not cut the incisor tee?h until she was nearly two years old. Within the oast six months she has chnno-f^H r^m-,.-!-->i-i • • V V ^ v^r.. r, 1 J ' "'^ngf^aremaikablyin color, has become ver> pale and waxy, and the face and limbs seem puffy i !■ I I ^ I ( 2 OSLER : Cretinism. and swollen. She has taken milk well, and has developed a little mentally ; smiles, and attempts to repeat her own name when it is said, and has learned to say '< mamma " and "papa." Present Condition.— Under -?.[7.ed child for her age As- pect is very striking ; color pale ; face, very broad across- the mouth is open ; tongue protrudes, and is evidently enlarged ; the lips are full and heavy ; the cheeks ver'v large, almost pendulous ; the hair is almost straight • the eyes are blue ; the sclerotics very pale ; the eyelids glossy and infiltrated The forehead is large, not badly shai)ed the head well formed, rather prominent behind • the an- terior fontanelle is not qjite closed. She looks "ood- tenipered. but takes very little notice, and smiles'' in a feeble way. The facial aspect is that of a cretinoid iihot Ihe muscles of the arms are feebly developed • the sub- cutaneous tissues are much infiltrated ; the hands are swollen and glossy— not tense, and look (edematous hut the infiltration is firm, and only yields on prolonged pres- sure. The legs look large ; the thighs present several folds ; theskin looks glossy, and the subcutaneous tissues are much infiltrated. The skin over the dorsal portion of the feet is very glossy and tense, and on firm pressure nits with distinctness. 1 he abdomen is distended and the sup- erficial veins prominent. Palpation is negative ; the cd^e of the hver is palpable about six cm. below the cosul margin. The edge of the spleen is not palpable, nor does the organ appear to be enlarged. The thora.x is well formed ; no trace of rickety enlargement of the ends of the ribs ; no evidences of rickets in the long bones. The apex-beat of the heart is just within the nipple line There IS a systolic murmur with the first sound, which is loud and intense at the pulmonary cartilage ; the breath sounds are clear. There is no enlargement of the super- ficial lymphatic glands ; the thyroid gland is not en- larged ; the cricoid cartilage can be well felt, as tan also the entire trachea as low as the sternum, and it can he taken between the two fingers quite plainlv. Dr Ilalsted thought he could feel the thyroid beneath the sterno- mastoid muscle. The percussion note on the first bone of the sternum is clear. The examination of the blood showed a moderate increase of leucocytes and some irre... ularity in the .size of the red blood-corpuscles. The condition was diagnosed sporadic cretinism \s it was evident that the blood condition of the child was very much below par, she was or^lered the syrup of the iodide of iron. OSLER : Cretinism. , March I, i893.-Patient brought again to-day In tho year and two months which have elapsed sincfl saw t e child she has improved remarkably^ She ?s now three and-a-half years old. Her height is 7rcm ^ 1 1 i i "?°->;<^".if-t, takes moreno?icland\hefociaUxpres' sion IS decidedly brighter. She tries to say a ewvords" :;: kinl' ^^Zl^:Ztl:'f ^ ""'^ --tanVe.^Thrmtt fnSSSdTe eni^gof'll''"^ u- 1 ^'iiiig ui in m subcutaneous n»Hfma which was so marked a feature. She still has a liSle ?J filtration about the eyelids and cheeks. The imbs a so look full, and they are firm. The skin is / k/hT , over the hands and feet The "on^nL H-^ . ^ °' -^ so often from the mouth. S;lgh^?l:n'S: ?a°c?i;rre^ pose It IS frequently seen protrtding slightly The face' 11 rednoid head '"' ''" expretsio.r an'd aspect ar: still cretinoid , head is 51.5 cm. in circumference the -ih domen 54-5 cm. The neck is thick and S^kid ore' sents a large tranverse fold nf f^t tk ^""'l, ana pre- not palpable, and below the thy^^^ f ^"f '^ can be felt with the greatest dis^h/clne" ' .X'^s;:;:,'^^^:^ tween the fingers down to the sternum ^'^""P^^ ^c- ^^Ir'A.T rS' ^'^' ''^^'■°'^ ^•^'^'•^'^t was begun in March The child was brought to me on Anril "S rQr.. ti change has been of an extraordinary cln"r,'ce?'^\nl' manifest : first in entire loss of the c?et noi Us^ colons good, the nutrition evidentlv verv rnV, -I, i?^ ' f ' q'lui),, anu in the totirteen months whiVli i,>,.„ 1 j ti i"ugh she is, of c lere was an)'thi ourse. still ng peculiar about her undersized, undeveloped M ► "^ OSLER ; Cretinism. The case adds another to those in which benefici-,1 effects have followed the administration of the Xrofj extract in infantile myxoedema. tnyroid Oct. 1894 —The improvement in this case continues r saw the patient again in July. She is a very brig? active- child, in whom no one would notice that tLr^ w k anything wrong, and in whom no"ne would nodce 'm" thing amiss except, perhaps, that she does not talk as plainly as a child should at her age. i ur years and ch beneficial the thyroid continues. I bright active :re had been 1 notice an\-- not talk as ■5 I ^ Archives of Pediatrics A^ n DILLON BROWN, M. D.. Adjunct Professor of Pediatrics »^e New York Polyclinic, etc. This is the only English publication devoted exclusive! v to diseases of infants and children caliusi\ t ly practitioner '^" "''' '^"''' °' '^"^ ""''' ""'"' ^°^ ^^e general It is practical. It makes an annual cyclopaedia of Pediatrics, carefullv indexed, of inestimable value for constant reference ' «3.oo a yeir in a'dfrce*'"^'*"""^- SubscripUons may begin a, any time. isend lor sample copy and catalosu,- BAILEY & FAIRCHILD, Piibllshcrs, ^.^,__,^^_____ 2* Park Place, New Yi.!.. CL /_ • TYPHOID FEVER IN COUNTRY DISTRICTS. BEING THE Subject for GKNFHit iw .^ 'h' William Oshr, J/ /J) RepH.ue..fro.n u. M.Kv:...n M.nxc.. JO.K..., M., „ '•'^95. iHK dwellers in cities have a verv deep concern i„ the prevalence of typhoid iever in country towns and dis tncts. In the first place vve treat in the CUV many cases which originate in the country, cases which too often ^o to sue! our mortality Inlls. During the past SIX years I have h.ui under niy care n the public 01- private wards of he ohns Hopkins Hospital 89 patients wo have come from outside the city li„ s The figures are as follows, from a t tal ^01 lit), ^8; from Maryland outside jM,„ County, ., ; ^,,„,,J^ I Secondly, we take our holidays in the country at the latter half of the sun mer «iien t>plioid tever is most prevalent Suice we have no means of knowing the munber of cases which occur an miai v '"the city, we have of course i" wiv 01 ascertauiing how manv have been liie untortnnates who, in seeking heaUhi country resorts and seaside places In e foJsei^usillnessandnotLr«;;e„th ca:i':r;hrkindiir''^'""'^-"'^'o- come under mv nl . "' ""' "^^^^"eiiti. past five or sixVlarr VI ITt'"'-'"^/^^" •stances in which ,?,' ^"°^'^ ^^ '" family have hi 'iNSd"7'''''^ -^fence in count ";:;;:il;'"""^ ^'^^' Popiilousdislesn u 1 °"^'^^^"'l' typhoid fe^^rprevaii:'''''^^'^^-^-''^"^"'"' for1>u'r Si'nnlf '"""'^^ ^--^^ ^I'-'il taw;"i!:S\?^;^:;^""-->'^eprofi tl.e prevalence o-typioidfS"'^^-^ ""'''' try districts. We inu ',,"?' "I-"""" statistics to the Ki^n !'-'''■" ^°^ th ■ Beard of llZ. \Tfar Z ?'' ^''' ^ typhoid^w^S^-?i'^^:^-"-f statements are to be fJ.,,,^^ r" ''"'^ "' ^»e mav glean an V tf ^''°"' "'^>^- the incidence of tKd'^'^" ^^°" ■ ties and towns o^th'S^'trr ' like very much to ask tl,.. pi ' ■ " °"'' ' tl.e Secretarv of tl?^ I i' J^T''"'" ^"' ■ -thisomission/w?;;^t:?y:r::; ; ¥ > treme importance and directly concerns the health of the citizens. I suppose the absence of all facts relatin ji'h,.,' The water sni)])ly in this instanu' i,",. certainly not contaminated, since- it » ! used in common with another hi ri^ciir ily consisting of manv i)er.soiK';,i '(]!' susceptible age. Here the luo.l sii|,„vi might have become in scjiiie wav iiilVcu'j though Dr. Sappington, who had ^.i,,,'. of the cases, .seemed to think that it «i most probably transmitted 1)\- ,ii,',.\ contagion. ^ A State lioard of health of am rf ciency would receive earlv lu.tilint.n of every house outbreak, and uithji proper corps of inspectors, snitihv means could be taken to l)reveiit, at iin rate, difTusion of the i)oisoii. How mi teresting it would I)e to know just Im I many ca.-^es of the di.sease occurrd 1k| antunni along the watershed .,f the (;,'„' powder and Jones' Kails, both rf u'^nii .streams are liable to pojintidii \1V can never be free from daii>;cT on liij .score until the city has conipkte con. 1 trol of the streams. The third point for discnssion, aiulin reality the most important (iiic, ruLitcJ to the possible contamination Ot' il, milk supply of this citv. Hnw niaiiv | cases of typhoid fever occur in the tiinii'. lies of those who in this St;itf siipplv milk to^ the citizens of this town. 0;; Dr. McShaiie answer, or can any iik'-:- ber of the .State Hoard of Health auMvc or it they cannot, can tliev tell us \m to obtain the facts at oui next tvpli.ci season so that an answer could 1* given? The dairy indnstiv, asive.il know, is enormous, and oiieoftlk-s;™; est import in the health of the' ciu The readiness with which tvphoid !mr is transmitted by milk has been iiiiiplv demonstrated : nor does it iv(iuin' tli;ii:i man ill himself with typhoid tcur should milk cows or jje in contact wiiii the milk. A man whose hnv is ill wiiii ■ klie disease, or tlie woman wlio lias been iiiirsiii,^: her dauK-Iiter, may readily, Ui |si'iViMl ways, carry the itit'ectiou. (I Asa iiieilium ("or the development of f*^ the typhoid hacilli milk is well known 5j;to he most favorable. It is probably not iilone from the water of a eontami- vii.iU'il veil used lor washing the milk JiMiis that infection arises, but in many piiMaiices from the direct contact ofdirtv [.; !i,iii(lswith the milk or with thy vesselsin r uliicli it is placed. The onlv possible ^Mlci^iiard is in a rigiil .system of inspee- hioii of every dairy which supplies milk Jiii the city, an inspection whicli should |1)- fre.juent, systematic and thorough. I liiive no desire to take up tbe ti'ine (if the l''acidty with figures from other >:: liK-alities. There are those which show, ' ;is ill New V.:)rk .State, that while ty- ]iiioi.| is progressively decreasing in oiir l,i!Xo cities, it is jirogressivelv increas- ing; in the country districts. Baltimore, widi a mortality from this preveiital)le olhi'tu'ceti 5 ami 6 per 10,000 of popu- ation, ranks with the unsewered towns t le sanitary conditions of which are still antuine. We shall probal.lv never reduce the death rate from this disease to tfie ratio of modern cities until the cesspool system is completely abolished. Hut bel^^.re that great work is under- taken, the citizens should demand that at any rate the sources of contamination ''■'.>"! outside should be reduced to a ■'innmuni ; that our sources of water supply should be scrui.ulouslv guarded ■ and that our citizens should be guarded apnist all possibility of infection through the milk. The points, I think, which could be dis- cussed with advar.iage this evening are 1. 1 he actual prevalence of tvphoid fever in the country districts and smal' towns Uiroughout this .State. 2. The measures which should bt adopted to prevent contamination ofoui water su])ply. .1- The (piestion of the inspection o uairv farms. . i i I ► C Z-l// VISIBLE CONTIUCTfLK TUMOlfR OF THK PYLORUS FOLLOWING! I LCER OF THE STOMACH. BY WILLIAM OSLHR. M.D,, LL.D, FRCP Professor of Medicine. John.s Hopkins Univor.sity." lllt'i...„,,. Reprinted from the Montreal Medical Journal, Augwt, 18'J5. H I f I f)( VISIBLE CONTRACTILE TUMOUR OK TIIK I'VLORUS FOL- LOVVIN(J ULCER OF THE STOMACH. Hy WiMiAM Osi.KR, M.I)., LL.I)., F.R.f".l>. Professor or Me.licine, Johns Hoi.kins University. Baltimore. In Stricture t.f tl... ..nHc.- o,„. can n.,t inFn..,n..ntIy IVoI the con tnu.f-.ns ,n tit. ,.n,„.n,o„sly l,yi,..,.tr.,phi...| pylnrie n.^ion of tho stonmch In such cas.-s a wave .,f p.-ristalsis may hf' felt, ,hn-in.r which the antffo,- wall „f the .,r.-an hanlens, an.l then, as the wave nppr..ache.s the pyl.„.„s, a Hrn., har.l ntass n.av h- oTasne,!, which |rra,lnally relaxes s.,n,etin,es with a ...r^lin. .,f ^a. In ve.y thin patiet.ts w.th n.uch .hiatat.on t.f the stt.n.ach the peristtdsis is mulily -Ik. seen a,.,l th.> pyloric tun.t.ur ,nay also hecu.e visible. L, the f.'l own... case the tuntour at the pyh.n.s was ren.arkal.lv .listinet, -M as ,t hanlened n, contraction lift..l the skin i,. the\.pi.v«stric rm so that a pronn-nent mass coul.l he seen even at a 'listance ...t the Instory, and tho evt.lont .nuscular character of the n.as.s. nmde - eel sure that . was chieHy .hze to the hypertrophied nnuscdaris I.- suhse.)ucnt h.story of the case, too, is of interest. Successful .i^astre-enterostomy was performed hy Dr. Bres.sler, and three weeks --•1-'^ y the Murphy h„tton which ha.l heen us d perf 1" he colon, causinu' fatal peritonitis. * "- •l""'i's of rm^tral;na~nc,materu..i.--Pronunent tunumr at /'///^•.s.. n,/ut./. relaxe, ami mntracts and appear, and dimppears i>"n.a,kthe .shn-Ddatation of the ^tomackLGastro.enieJ^Z Verjoration of the colo>i h,j the Ma rph y hution '^^^^««««'«2/ > Is Vsiif '"* ^^'''''"'"^^ *° ^''' Johns Hopkins Hospital I)ecend,er ^^t, 1,S,).J, con.plaunng of pains in the stomach. His family history is (II II "'■ '"'" ' " ' in.y. witl. thr ..xc.«|.ti..n uF ,itt.u-kH ..IM I' IISI'S (llcnlldl ill IIKdIcrutidll y.s|M'|),siii III Muv, |.S!H>, iit'ti ill Mh' l.'l't si. I., ul' til,. hImI ran iiiiliscifti(.ii in diot, he liml cniiiin lik Imt tl H' pIllMs IVCiniVij ill ,1 f,.\v || 'iiii'ii. Thr iittiick dill nut last iitvaryiii^r intrrviils. TIh'Y IukI no ivl ays atxl cdntinni'd for nlMnit <• pam- ■y '"111; a MKHltli ,i'i was often nauseatoti, h,. onl lation to iiiciils, and altli..n.di to k'd in this illness and lost ''sc-nption it was evident that tl y Kfcasionally vomited, lie w as conhine.l Al't, ^''•ttinn' up li,, ivit fairlv wdl fonsidemhly in \vei;,dit I'Vom j, le pain was of \ery ^M'cat seveiif' exei ac pt for ini^r pain in the ai..lonieii. He kept at work and an occasional dull throiicrj, the snnniK r mikI autiniin III Deeeiiiher, |,S!)2, he a,L,^ain Lena,, t<, 1 was verv we ill like in character and of nreit foin- honi's after meals and lasti for an I lave attacks of pain, ei severity, eomin^r on as a I'lde th 'ami •ee 111- le wiis WMltei' of |,'S!»2 !>;{ 1 time, iidt .ilije t lar--e (|uantities of food, afpiart ata t iiaii' or two. 'riironidioiit lli in the house and in iied a ;,M-eat part of tl "wnrk. Towanls H,e sprin- he v.anited at interv„| ar(,'e amounts. Hesai.l it looked like tine! ime. In Mav he vomited hi • lays afterwards the stool y minced liver ; f I III or several s were dark an.l tarry. After this he n,,t fjuite well, the appetite n'turned, he frained in weinj to work. Towards the latter part of tl it, anil Went Imck anen, which has increa.sed m in the leftside of the ahd a--o the patient bad a return of tl has since vomited hlood four ti amount;- On admission the patient looked a littl. mucous memhranes were of fairly ^rood colour summer he noticed a liiiiii III Sl/( A Wee 10 severe crampdike spasms, and I's, not, however, in verv lai I'inaci.Ued, hui the h'l pounds. K.\aniinati(ai of the (I o iev"i Is Welnlit \-2S men looks natural ; the left than tl le ri.<;ht. The stomaci Co\-elvd \,y the rilis. It di loracic „.• HM.l with u mnn.j.MlMnr, w-.v ,v v..,i ' This ,v- M..t...| syith i.l.I.,nwl,uMM-vm.illin f.-r ||C|, .u,l with I'tHmuiM's tost '''■.''"'^"';"""'; ''"l'^; ^ ^^•'■'•" l"'-"t: lO.r. U-..-V „..ntmli.,.l hy M..-. CO. ., .i.-n-Mnn.m! sn,|imn hy.lrat,. s-.h.ti,,,,, ami 10 cr. ,f th.. iuic; ^liakcn tlM.nai.rhly with ..thrr w..,v nrMtraiix,.,! I,v |().-.' , ,.f ''l..,.!- iin.inal .snijiuni liydmtc. The pati..„t was ..nlcn.,) (ivc ymiiis of hirarhnnnt,. of s, ■!.. ,.v..l•v '"", """" j" '"'";: ."" '■ •"-'' ''"l-i'lly, ;,'.i I in w.-in,,, took small .,,,a,.t.tH..s of t.H„| at s -t iutn-vals, an.l s... | to , ,• .|oi„o W.I . lia. t,.st ,n..al,s always jrav a ,na,k...i ifcvas.- i„ tl,. total nciijity. S|...cial attrntioM was .liivct,-! t.. tin- ....nWitiu,, of tl„. tuMin.r It was ..xtn.,n..ly variahl.. i„ ...sitinn, .i..,a.n,li,„. .nti.vlv ..po,/ tho .l..^n.,.,. ,|.st....s,on ot tl... sto.nach. Shortly ,.lt.... a,h„issiou i, was nut,n..l that tl... tmnoM,. .nass was visil.l.. Unn-atU th. skin. app,.,. -i,,.. an.l . ,sapp,.anM,. (... wafhi,,.- th. ..pi^astnc- .v.noM an ..i-sati, n o'l" tl... _skn. to,.k plac-e, ns.mlly .ni.lway l„.tw..,.n tl... nav..l au.I ^he ms,t..n,. mrtilaj..., an.l a .l..|init.. t,„„..n,. pn.j..ct..,l, whid. coul.l ho s...... plan.ly at so,.,., -lista..... away. Aft..,- ,...,nai„in;: fo,. tVo.u half a niM...t.. to a „.,n„t.. it f^m-lually .lisapp,.a....,l, (,n palpati..,,, wh.-n vis.hl.. th.,.e ,s t._, he telt an ..xt,...„„.|y ti,.,„, l,„,i, s.„n..wl.at sau.s,ur. - shap... ,„a.S8, which, as it .lisapp..a,.s, ,...lax..s an.l j,r..ts .soft Tl,..,.." no yisihl.. pon.stalsis, t-xc-pt wh..,, tl... st..„mol. is inHat.-.l ""■pat,,..nt,...,„ain...l in tl... h.,spital th,..,,,.),,,,,,, j).,,,,,.!,..,- .aim-.l ......what .,. w..i.ht, an.l took his f I uvll. II.. .as .Iisi.ha,-....l .hum iiy 7t,l,, ISIU. " '"; •'H...m.-y !5tl, 1... was ,...-a.l„,itt...l, ...anplaini,,.. ,.r a ..y.y. ;•; - •"'" '", ^''" •■I'Wtstnu,.., y .,.|i,.v,.,| l,v ..ati,.,-. Wl.il,. '>!-..... 1... t.,.,k iV.a.. (ivo t., t..n .grains ..f hi,..,.h,.,.,a, of s.„la '■--y U., hou,.s. .Sho..tly aft..,- a,ln.issi.a, I ,na,l.. tl,.. following, 't.. : n... t,.„.,a„. n.ass in tl,.. ah.l.,,,...,, ..pp..a,.s an.l .lis.tp- -■s .IS tonnorly ,.ot...I It occupi..s a positi..,. to the |,.ft of '''V'"'"'"^" "■•"•■ 'J'lK- variations in it a,... v..rv strikin<- As it -nt,.acts an.l l..eo,nos ha.-,! it lifts th. skin \u..l ca.^I. then H-'ly sen. As the contraction ,...|axes it .lisapp,.ars, oft.n with •tU to 1... touch. But even in this state tlie tubular in.lumtion can s.... ' o ,\ T,TV7' '''"'•"' '""'^''""' -^^'"''^ ^^■'^^■- '•*' P«"-^talsis ^-1. t.. the left oi the tumour mass below the costal margin " Janmii'v 2Gtl.. After 1 iiiviii^^ had IK) f 1 siiico 10 p.m., the tiili was|,ass.Mlat,S,u..,a,„l2(J(i cc. ..f a y,.||„ui,sh l,r<,\vn MmM ..f tl '•onsi.sU.ucy oi- thi.i ,n,.„,.l wvr," withdnuv.i : o,l.,r randd. It mictrd .str()n<,dy to litmus paper, ami the i.iilonx-l roactioa I'oi- tli .1 K' lactii- acid test. Tlic total acid iicin-vaiiiilin for acid ) ••c. dcci-iioi'iiial .sodium liydi'at(! .solut ity was iifutrali.scd K of JanuaiT tlic patioiit did not d dilatation of the stomach, aMy the distended | 111 thr U'liiric ion Oh the 2(itli of Fel increases the peristalsi;- the .st The peristalsis was ver iruary the patient vomited 200 cc. of I V active ;a zuv cc. ot hrii^lit iTcater curvatuiv of till oinacli extends two fingers l.rcadth l)el.)w the hncl of tl iiour mass to-dav is far over in th le na\i right liypogastrium. T patient was ordered eiiemata of peptonized milk and eg only tw allMuiieii water l.v the mouti ■g, and iii\('ii 1, with hicariionate of sod o 1 1 ours. 2.Sth tomach is much reduced : the pyloric tii meiliau line : there is no peristalsis. •March 2iid. The patient has ha.l no ni< lietter. Th,. alidomeii look.s natural ; there i a e\i'|'\' nionr is ni || )re vomiting, and is iniicli p3'loric tumour is todav iust ah Th Th contraction and relaxation patient during this attack liaslo.st s no peristalsis. T )ve and to the right of the uiiiliili,i ire apparent to-day. I'M pounds on till' l.Sth : I ill weight. Thus he wei-lir,| le no M tl arch r)th. Patient insists on goin<>- 1 w only w(>ighs 128 pounds. )ine ; he has hecn lietter i'i^v le past f.'w day.s. The dilat.ition of the stomach has verv nmcli lessoned. The pyloric tumour is situated just helow the en>irn,iii cartilage. Xo peristalsis i.s'.seen. Th.' .stomach hulgres just lir,i,,itli the I.'ft costal margin. The tum.air mass is not nearly .so van.Mc and almost constantly hard and h'rm. Remarks —This case presented many points of interest, and was shown ropeatc'dly in tlic wmd flass.'s history of .lyspcpsia, tlu- u-astrajoic- attacks, t'l (luantities of l.loo,!, and the persistent 1 juice, pointed unniistakal.jy t tVatine of special conniieiit. T lie aii'e o >f th patient, til le vomititii lyperaciditN of tl " ulcei'. The t if laro-e le yastric phantom character. Jt K' most ri'Miaikalih' p| iiiiiour mass was tho lennnion was its the ;iavel ami tiie ensiform cart w.Hihl lift the skin in themipcfirini;- as d Wfls then to the t( ■linitr tnm our a ndnnte ti oiieh Jirm nnd hard. Afti MiU', with .sometimes an ' ii nnntite it would ;r;iiln;ul\- uisai)- ndilile sizxlinii' sound tuiiionr mass liecanie wry mud was evident as o(ly, which 'Xl)laiiatioii idcei' there was mucli 111' onlv rational )ric orifice, and P3'lonc zone the tumonr ccadd be alon.' explained on th. iiate contraction and relaxation of the hvpertropl uhout the pyloru.s ; and with this the evid..nce ol con- ''"' pliMiit character of su|)positioii (,f an alter- pined muscular tissia was accord, since when the tu cessivelv firm ami Hard fully ii skin, it was e the hand, and with a marked cl tions in position and .size of the tu dilatation, is often noticed iiKHU' was visibh 'tained ,m palpat ion daxat ion took lann'e in tl beneath the place undei- le consistei icy. lie \aria- iiiour, with the incn patient was nri-ed to hav III pyloric mas.ses of this el -ianuary 20th, bSHf,. Since tl e an operation, but laracte: Would not consent. in th . Tl le ascertained that this patient, durin- tl the cai-e of J)r. Bressler, wl stoii diovi' remarks wer. le summer of |,S!)4. o perfol'iiied successf ' written, I came under ly, usinj,. Murphy's button. At th.. ..,i.l of th.. tl ••.mvale.scence was eHtablishe.l, neneral p..rit..nitis d lie I lie. I. ully .yastro-.'nter- lir.l w..(.k. after .'X.'loll. ol wliieii Dr. Bressler aii.l .lescription. vei ■y kindly sent th.' .siiecinien to nie I or examinati .)!! The specimen consists .)f st.imacl intestine removed en iii(i.sKe. Attached to tl 1, except cardia, with th e.)ii )f stomach, alwut 6 cm. from pyl..ru le o ri.at.'r enrvatiire .)f th (jojiimmi) nil. I with.ait adl he line of attaclnm.nt is si s, is a portion of th small inti.stim i.»\v st.Muach a.lmits th.. in.l..x fi '"•liiiid the attachment of tl il ii'sions. The artificial .irifie.. bet II 111 frcait ; iiarr.iw. cl can. • Li'er. . tra ween intestine and iisverse colon e.xil 11' st.iniach and inte.sti '•ntuni adherent, and tlicre is considerable thickoninj.- (,r peritoneal tissues al.out it. When the duodenum is opened, 'l.h, thickened lips of the i)ylorus ean he seen, and a circular oriHcc; ahoui 5 mm. in diameter. From the stomach, the little tinj^er cannot ]>,■ niserted into the rinn- There is a narrow channel throus^h which a Icn I pencil could !..• pas.s..,l. When laid open, the thicken.'d walls seem tu I le made up of a oreyish connective ti.ssue, and enormous thickenin.. of the mu.scularis. The wall measures in , place 14 nun. 'I'li' mucous membrane correspond intr to the thickened portion is in placs pucker.'d, looks thin, and at one jKant, correspoudin.t;- to the anteri.^r wall, and about :i cm. from the duodenal orifice, tliere is an area i:, by 10 nnn., which looks lik(; the door of a healino- ulcer. The wli,.|c nm.'^culai- coat of stomach is <,n-eatly hypei-tro})hied. A portion of the pylorus was cut out from the peritoneum to tlir flooi- of the ulcer, and I am imlebted to Dr. Blunur for sections. There was nowhere any trace of carcinoma. Almost the entire niiiss was made up of enormously hypertrophied nuiscularis. Neai' the fln,,r of the ulcer a large artery was cut acro.ss, which showed a thickeii,.,] muscularis and great proliferation of the sub-eiulotlielial layer. c^uvii CHAPTER VI. DISEASES THE DIRErT OR rXDIllECT lUNn T OF IXFErTIOX. Hv WILLIAM! OSLKR, ,M.D. CERBBRO-SPINAL MENINGITIS. Definition. A specific infections d '■]' isciisc, dcciirriii" cliiiractcnzcd auatomiciillv hv ini iraiiiciiilv and III s|iiiial conl, and ciiuicaiiv hv an e.xcec'diii'd " ■ fcv ' ■ ~ aiiiinatioii of tiic I. rain and syiiiiitoiiis licina- fever, pain in tlie lieail and had severe tonus, delirium and eoiiia. Etiology. Tile iiistorv of tlie disea.se (hiriim- tl liale of tlie first i'eeo;:nizeiI epid: the worlds of Hii-seh, of St ilk', y iiTe-nlar course, tlie ciiief imisciihir spasms, and. in •iiiic in Cieneva, in Ist le present centiirv, from ll ("iiil(h and of Joseiili ,J IS fnl ly ,i:iven in one:' ■en anrontreal. 'od much more )ftawa Ivivor, severe Iv tl Kill did The affection has 1 eiich otlu Tl rokeii out neniiioiiia, and it iiaiiy epidemics. I; is als wn Inis also heen d enionstrateil in t spinal le nieniiioitis deve heen found now iiieiiinoitis. The same organ- 'piiiu- ill the course of ► (r- 204 XERVor.s i>i.si:asI':s .l\7> thi.vr tiieatmkxt. flisciisfs otlicr tliaii |mfiinn)iiiii and in llmt follDwiiiif iiijiirv. Altd^ri'tlii r, scrvatiuiis of tlic |)asi ten years point to' the associalinn tile hactcriolooicai of the niicrococcus lanccolatiis witli hotl'i t lie sporadic and tlic cpidcniic f ot the disuasi'. Otlirr ornanisnis liavc liccn met with in purulent nieninL.. tiu'stapiiylocfHTUs jn-ojivncs aureus, tlu' typhoid haeilhis, the cohju hacfll and other li'ss detiniti' forms. Olllli ■ili«, tl There are insnperahh diftienhies in the wav of a rational exiila le conditions favoriii:^- t le Lii'ow iiieiiiiiiie? a Tl til and development of tl nalmii ,,| u' ori;anism in ih,. le micrococcus lanceolatus is a normal occu|)ant of the lioij very considerable proportion of all individuals, at least 20 percent inir to some authors. The possibility of the disea>e heini;- due to an aiito-infeclion has 1 V II! ai'ciii'i Lrested through the nasal leeii -ii- Flexner and iJark lossa li\- strumpe T and throuiih the intestine li lere are serious ditHcuIti es, llowever in tl acceptinir such views which otlia' no explanation whatever of tl prevalence, or of the remarkable facts ipioted bv llirsch in I transmission from one localitv to another bv a third person Morbid Anatomy. The patient inav die'before aiiv " le \Miy (i|' le cjiiili mi,. ivor (.r i|. nccnrs in the meiiinu'es, and then the condition if 1 lypera'inia and o f a slioht s( in iiinatory exiuhitr is one ot an extreme rolls efliision. In well-devel i'i'ililc i>l)eil cases 111! external inspection the petechia/, sometimes herpes, may be noticed on th,. skin. On removiii,:,' the skull-cap the dura is tense, aiid its inner sinrnc, liyiK'iU'inic; the sinuses full of tirin clots. On exijosin^ the cert in .severe ca.ses the eonvolut ions mav be eovereii comijietelv witi exudate. Often t i ciiriix cri'iiiiiv IS patcuy, most marked, perhaps, on either side of i| iiLrittidinal tissiire and in the chief sulci. Tl le cortical veins inav lie ill tended and prominent, and the smaller ves.-cls of the pia are (iee]>ly eiiLiiiri;v, Occasionally siiperticial hemorrhau'es are seen; the exudate is upon tlic pi Iter ; the arachnoid itself may be opatpie. The etfiisiou is usual at the ba.se of the brain about the chiasi na ami in the Svlvian tissii le plU V auiiiiiliint res, iiikI ni; ly cov(>r completely the pons and medulla. The lesions are not conlimil to the meninges, but the cerebral substance is also iiivob, ed, and t ilit V a meiiinuo-eiiceji halitis. Theuray matter is hypera'in foci of intiltralion and of hemorrhage may be seen. Absces.ses of' .(u are occasionally tiiund. The intlaiumatio'n may involve ti ba.'^e, which are surrounded with the tibrinoiis exudate. Tl contain oiilv an increased amount of serum, 1 lie pi'iirr" ic. Juicy, 1111.1 Mr >i/c It till' le nerve- le veil triclr- eriim, hut in some instances the ii Illation IS most inteiis the velum and choroidal nlexiis r le epciiihina is softened, ecchymosed, inliltrated with and <'overed bv pus, and tl triciilar contents may be of the same nature. In ea.H's which have l:i>i(d Inr a long time there may be no longer any tibrinoiis exudates, but ilmv mv areas of meningeal thickening, adJicsions, and most constant of all -ivat in- crease in the serous I'lfusion, which may cause great dilatation of the viiiiriclr- (hydroc<'plialiisi. Mveii in cases in which (leej)ly enL:nii;i.,|, te is iijioii I he |)ia ' usually ahumlaiii Ivian fissure>, mihI are not eimliiu.il I, and the prnrr" I'ra'inie, '\iury. mid [•esses of sonic >i/(. the ner\r> at ilic 'lie ventrirlr- inav •taiiees the iutlain- The i'|M'iiilviiia |)us, ami ilir vni- eh have la>ie(l tnr tes, hut llierr aiv It of' all -nal in- 111 of the \rlllric|r> 1 place ,~n -non a- three piiiN. Tile es are im'I iiiioihi- iirliid M'i'uni, Imt isterior pari of the ■eu'ioiis, pl'oiliiciii:; exudation en tliu In sonic iii>laiiiv> pllo-|H|l illrlll r.VH- •lianu'i's as in the es, soiiicliiiH's tiii'i •opieally the cxii- % % isri:'' -nHatmnati.a. ..f th.. ph.nra an.l ..f tl... peri.S h:,> .ISO he. , t..n...l: en,lo,.ar,lms is ra.-e; ..olitis n,av 1... ,.nL..nt 1 .. >pl....n nsna Iv varu.s ,n s,/.. a.r.a.lin,. t., th.. p,.,.!.,,! 'a, wh,.|, ,|. nh s ocrm"....l. It naiv s.)in(.tini..:; h(. H|.,..,t|y ..nl.M'..-eil ".niina> Symptomatology. A s.a....of in,.uhation with |.ro,!,„M,ai svn.pton.s i< rare Le^sol a|>,...t,t.., .nalais.., h,.a.la..h.., ,,a.n in th.. Ihnhs o,.,.nr in a tew .•' ■ " lh.;oMs..t,as a rule, as ,n pnentnonia, is ahrnpt. an.l the i.ati..nt. witlani m.,nn nary sympt.mis .,t any tn.unent, is sei....l with a ..hi! .,r with v ..■a.lM..h... v..nn tnjr, an.l tever. F..w .lisor.iers ,,r..s..nt so vari..,l sv t, - „Mlolo;,y an. the .■as..s ar.. perhaps iu.st .l..s..rilH..l in .ronps ..j.ara.ie' 1 Itv sin'CKH iciiturcr- . Ialun,.n,l Juni, N., acute .l,sease-ch.,lera s..ar....|v .■x..ept,..l-n>av 1< 11 with sn.'h rapnhty as ,.er<.hr.,.spinal «,enin,.itis. Cas..;. are ., 1 r.'cn n wu..h.l..a.h occnrre. after an illn..s> of t..n hours, or ev,.u ..f i v . , las type .s seen w.th yar.ahle fre,|Uen..y in .lirt;.r..nt ,.pi.l..n,i..s. I ho >•.;....>. .a.e stu.he. i.y !• leNn..r an.l I'.arker ten patients '.li,..l witlm. tat ' ,.,,■!, h.n.rs after lu- app..aran,... ..fth,. sy„,pt.ans.' Th.. .,ns..t is ahrupt if], ;• vinl'M. ..Inll, an.l without tin- s „iu.st pretnoniti.m the pati,.nt n,av 1 . ...i , Mh a^.au/,n;, lu.u ache, vonnfn;,, hij^h fbver. a.-tive .I'lirinni, sue....e.l. h , .,, ,l..pr..ss,.a, ..f the y.tal funetu.ns, jrra.lnal sonn,.,l..n..... >on;..,in,..s 111 .1 n,,. ,ty..f the nHis,.les or even o,.u..ral ..onvnlsions. I),.ath niav .'e r l"'t"'r 1... .K.v..lopnient .,f p..t....i,ia. .,n the skin, hut in ..as..s !,• •, , ""Mv than tw,.nty-f.,ur hours lu.rp..s an.l ..,...hvu,.,s..s a.v ahu., i v ri .1 Iv .-s..nl. la. fever i„ this s.M.all...l ap.,pi....tic tvp.. is no . L ^hI h 'Muaayot the .'a.es , has luru .,uite naMlerat...' 102= an.l lo;^ ; ,le ule 'nav h,. rapi.l a.j. feehle, hnt instan..es are ,a. re..or.l in whi..], i \l 1 ' ,n >lnw, iMlhnirt.DOor (iO in th.. mini ... *^^" •J. Onlnmnj form. ( oinin.mly witlmut anv pr.).lonml sv Um< the .li< .,>..ses,nwm.s.w..n...hill,hea.la..h...an.lv..nn'ti,.;r. Thelu.i.la ... „i ..\.r. an.l a..,.o,npau...,l with -irat sensitiven,.ss t.. lid.t an.l t., n.ii e< ■ • l-i:tlHs.. over the entire hea.l, or !o..alix...,l chi..tly to the ,.c,.i,,,it .a- ti? tul' lH't "'-•■ .T^ i--;'^ the ,n..st istaut .i.atu;:of' iia^Ms;;:;. ''''Vl e t^ a,. ally even in severe cases the pyr..xia is n.>t at the „uts,.t .n- .h r ll"''-u,s..ot a h.i:h ora.ie. The pulse is full ami >trou..- • lat..r irr... 1 ," ai: u ..n >yn,p,.,ins of .lepressi.m .urnr fLehle an.l ra,:i, . u , -re ' " '''li l:as „.. hx,.,ltype,. .K.sn..t really lu.ar anv relation t. th,. s..v,.ri n , f tS ;r symptonis. \ ,an.tin,^ whi..h o,.cnrs ..aViv. mav .-..as., with n we„ ■ hours..,,, in ex.;cpt. .1 ..as..s r,.,.nrs thnai^hout- the ...airs.. of 1 "£. ^. of tho hack a..c.aupanH..l with aehin,-, whidi often ..xt..n.ls in -s A. tie .hsease i.r..^ivss..s, usually fr..in the s..,.on.l t.. the 'i 'l.i.v. ilu St ttm.ss he,...nu.s ima'c mark..,!, ami ther.. mav 1... rio-i.litv .i■ ,;; -- - m jhe Im.-k an,l u....k, th.. la^ '. ' |i>Ih.).ai.,s is i,.,t .■..mmon. hut .a-thot,a,.,s, in which the trunk i< .-"i..,.l n,„htN ami stiHiicss was su,.h that the l.o.ly ,.,u.|.| h, ,„„v..,l like a if a I i h •201] i\/:iiyoi's dis]':asi-:s am> tiieiu teeatmi-:xt. statue, rniliitfral spasm (if tlic liack niiisclcs, Icadiii^r I" |ilciir(.stliut rare. Kxcciil in early cliilillKiipd ami a slmrt t' ' Ollll- viilsions are nut coimiikiii. T liie heliife death general i mi ■emiiror elunie >))asms may lie present. S| i)t tlu' muscles 111' tlie face may also eeenr. Lesions (if the nerves ut the li:!-, may cause paralysis of the muscles supplied hy the third, ineijuality of ih, pujiils, nysta^.-'ums, deafness, and disturliances of the sense of smell, i^joliii,.. respirations, and ( 'heyne-Stokes lireathiiii,'- are met with in some insian, ,"' Intra-ocular ehanui's are com i, partiddarly passive couLicstion of ili, retinal veins and optic neuritis. I )i.-iurlianee' (.,' sensation is common, |,;||-. ticiilarlv hypera'sthesia of the skin, and the patient mav crv out wImi, attemiitin^n- to move the trunk or limlis. In part this mav he due to li\|„|. a'sthesia, and sometimes to the tension spasm in the nuiscles. It mavlic\,n marked in the leas, and the sliiihlest movement may lie sufilcient, even in':, patient in a profound stupor, to cause reflex spasms. Thecutaiieous features of the disease are important. The petechial r.i.ji which hasi-iven the name "spotted fever" to the atlectiou, is very varinli],' Stille states that they were pre.-*ont in only .'!7 of !t«ea.viii. metrical. _ In the epidenuc at r.oiiaconinj:, studied hy I'^lexner anil IJaiku, the jietechial eruption was comparatively rare, hut an indistinct pnr|,li>|i mottlim;- over the surface of the liody was" more common. Herpes is piiliMi,, iiiore freijiK'nt in this than in any" other disease. J t is seen first upon Ih,. face, either on the nose or li|is, iuit" often extends, and is svunaetricid in ii- (li.strilnition. Urticarial forms of erytheuui, pemphiuiis, and in a few in- stances oanirrene of the skin have lieen descrihed. As alreadv nuMitioned, vomitinii' is an early and a prominent s\ iiipimii. The tonpie in protracted ca. not ;i eommon feature. Of respiratory .symptoms disturhed rhvthm in lirealliiiii' is comnuin, particularly toward the elo.-^e, and the respirations may he of tin" Cheyue-Stokes type. Mpistaxis is a very fre(|ueiit feature in som(' e|ii(|riiii(s, Bronchitis, lironcho-pncumonia, and pneumonia occasionallv occur, ;uhI in the protracted cases there is much hypostatic coue-estion at tlie lia.-^es. In the severer cases the urine is alhuminoiis and mav show the prc'^ciicc nf hyaline ami have >iili- sided may lie inti'irupted hy the complications and .^ecpiehe to he iiieiitidiiiil shortlv. .S. .1/ I /nil--' /'(; (<0 Ahortii'i- fi///i: TIr. attack mav set in aciitfly with hiji-h fevei', severe headache, ]ihotoplioliia, hut in a few da\ - all tin- symptoms suhside and rapid eonvale.n is ciiinniiii iiiiy ciy (lilt \\\ : !)(' (hie t(i I |iai'- i\ iii'i- III! It may lie icieiit, e\ci I III ;i The |)eteeliial rash. II, is verv varialilc, in the I'l'iiiad I'l ervll l|ilil;i leliia, ii|' ecliia' may hr m m. exiier and IJaikn. imlistiiict |iiii|ili>|i Herpes is |icilia|is lli'lll tlio seen first i symiiielricai iii m and in a iiw in- (iminent syiii|iiiiiii. sonles. l,ariiiiiir ly 1)0 (hie eillicr to I'ation. Diarrliua Iv ref'erri'd in ihciv raeted llllllllCO nies enlarucil, Imt, evidently i< imt a ■thiu in lircatliiiiL' (ins may he nf tlii' in sdiuc e|ii(|iiiiics. liiv (icciir, ami in tl i\v tl le Dase.' le iirc^riicc lit ss, and 111 I iiiav 1 noted, and il iuh The liliiiiil cull- (Uiiid marked icii- r the ha'iiiii;;iiiliiii laii oiie-ha ndicatid iii|it e to I If of the IV a full ( 'iillVll- (■ni> nave .-iin le iiifiitiiiiii'i liV set !:i iinitcly few (la\ - all llii.-r Striiii ■11 distill- » isiF.iriVK I) IS/: ASKS. 2(17 ^'iiislifi* iM'tWci'ii the iiliiirli\(' forrii, set I, aiiilmliint cn.-c.-, wliidi Imvc liccii (Icsciilicd liiiir in with lh'i'ih inicii-iiN , mul I'liiiiiilaiii III III! Ill Wllicll III!' IIMliclll- illHl si ill! IflKlilClIC, IlilllM.ll, llll|>ll'ilMIIII SCllSillidllS ill till' llllck illlll li's« III tllc lice Tl llllli> ll'Vi'i'. >ii('li I'li.^cs iMiiih I mil iciv iiiav lie III) initial v itiiiL;- ami vcrv sliyht y, III I'fiilitv, III' ic(M);:iii/,c(l if I he (lisca.-c (jiirin;;- the iirfvalciicc (if an cpidci iliii' \i> till' |iii|snli //) liilrniiilti iif hi/ir. In this form the fever is of iis-iiniiiij.' sometimi's a (|miti(lian, sometimes a tert an inlei'inittenl type, laii chafacter, ami in tin liTvals of the fever there may lie almost eomphte freedom fru'iii the ot her plonis of the disease. This is a form upon whiel >\iii tdriiiation. ue reipiire further in- in H'ninlr hi/i,. 'I'he attack may he pioiraeled for two orthree i tlis '.(•ii extend to SIX months, ami may lead lo the most intense iiiara>iiiiis There are reeiirreiiees of the fever; thus lleiii )ner ui\es an ni>taiieenf a iai iL'cil seven years, who had repeated reeiirreiiees from the end of I'eiirii nil the end of dmie, and, tiioiiiih \\(irii to a .-keielnn, he mail i'eciiver\'. naile a enlllpl.-le lerieardiiis are rare. CiiMi'i.lcATloNs AM) S|.:(;tKi,.K. Kiiiioeardilis ami I'lieiiinonia, Inhar or lolailar, is a fre(|iient eomplieatioi'i in some eiiiih.nill'- Tlie pereeiitap of ca.ses is, however, very variaide in dilli'ivnl epiileiiiii>; in - I'll niaiority of the eases iaive jncseiited this ei.mplieation. It mav he pivseiit only toward the close of an epidemic. Parotitis has lieen descri'lied, mill occuired in a nnmlier of ca.ses in the Lona coiiino' epKJeiiiK V ivniarkalile eomidication is the arthritis first descrihed hy .James Jack- n^iderahly in ditll'rent epidemics. In .■^oii, Sr., the miinlier of ea.ses varv ma: •'•> lie Ijiinaconin LT e])i(lemic twenty per cent, of the .severe itH'ctiiiiis, the knees, elbows, wrists, and aiikl case; had nine cases ill which, had it not iiiciiliiiiitis, the disease would iiav ipciii;; involved. Ther lieeii I'or the initial svmptonis indi joint e were catiiii'- a e heeii iliaa'iiosed acute rlieiimatisi K ei'- meiiinaitis has described a symptom which he thinks is iiatlionnomonic of . ill tliirt(rn eases he oli.seryed a iieciiliar fiexion-coiitractiire ( i)eii::vdide with the thiiilis d .symptom wa,s .still present. It liiis been claimed that tl lis contracture was eom- ra may he ,era- tis may he followed by atrophy and bliiidi IC; 'erioiis auditorv le- oiilih' optic iieiiri- loiis are Mill more common. Deafness may follow inflanimatioii of the labvriiith, ami III rliililreii this not iufreiinently h^ads to the condition of deaf-mu'tism. It is mtcivsiniu' to note that in the (ieaf-nmte institution at lianiberg, of forty-two I'liliils 111 |,S74, all had lieeome deaf luntes from epidemic meiiiii"itis"{ von /iciiissen). Mcntiil feebleness and aphasia have occasionallv followed the disorder lltailache may persist for mouths or years after an attack. \ n( ciiuseioiisiies.s, eouvulsions, and involuntarv dischariies of feces and iiiiiH'. Paralysis of .some of the cranial iierve.s liiav jiersist. (Occasionallv ) I I m 208 .\ /■:/!]■<> IS />/.s7.;,i.s7vW .i.\/) v///;//- Tiii:.\nn:.\r. .(in-Js,-.m.lv.is..mlwa.,m. ur, sin.uUU. ,\u. ,„ n,ul„,,|.. „..„,„; Diagnosis, Duiinir ..„ ,.|,i,|,.„M.. tl,.. ,v..u;,„i,i f ,1... ,lis,,w. i- ...mv ,„ " '■'''■^'•"1" "I 111'' MiinniMloii- iv.Ms is riuw -,, ,.|,,,r tl.i.i il, v I " ■ ' "" rase iinist |„. ivc.-iii/.,..! fn)ni ixninuKui. 1 1,, ,|,. 1. rnhlh, ntth, Arnh, I nfrrlj,,,,.- IH.,„.,.. Tll('l '-',''•-'•• l-^i-'-'i-^ wi.l, .aark.-l -rn.l.n In .',,:: :' known at \,m tl.m- instan.vs i„ uhirl, ,|.. .lia.nosi,Juas n , . .f ,.. i ' ^p.nal f..vn-. I.nt |.us,.,M„rl..,M tl... I..sio„s wnv thus.. „f tv,.h .y , j " iMn„Mp.s ,,ns,.„t,.,| „„ly ...Ntr,.,,,.. ......uvslin,,. Th. n.v... , r ' , . , " M V. I ""■'""^■'■"1 ^vnipt...... may l,.a.l to a .vvisi f .liM.., .Mai.N . ( tl,,..,. ,.a>..s. iml..s,s an autopsy is s,.,.nr,.,l, ;,„ j,,,., ,|„. ,n„rt.,| u I as ,.,.r..|.r„-sp,nal t .v,.r. S, als,. in iypluis »i.v,.r:,l„. I„.a L' 1 • .' •!".-• l'VjM'ra.stl„.sia, an.l tl... ,.n.s,.n,.,. of n,s,.„la an.l , ,',. !| .,'. ' """i '""^••:,'''" I"''''."!!'!''"...' in .|!,ui„. In ,...,.,ain . f 1, slv ..,•,' smallp-.x t ... a,on,.n.,. |„.a,|a,.|.,. an.l ,1... ,,..„„.|.ial .-asl. n a '.„ ^ ' m^nos.s .,t ,...n.|,n.-spinai n,..ninjritis. A tou,-v,.a.-ol,l .' I „ . >.;IW..ny with t,.v(..-, pains in tl... I.a.'k an.l I,,:,,,! ..,,1 „. i.. ''", 1 K'k an, I ilea. I, an.l .mi tl.,. >,•,.,, ■Ill', ..l>. I . Il.>uai..l, wla.sawit ni (•onsultati..n. au-m..| that tli..«va "■■.■m-,v,l, a...l ll„. ,.hi ,,| , „ ,|„: Ki ' . ' , , "• ''»■''""""'■'■ ,.i .l;;f :lt'i^: ..' 'i;;:';;^;;:::i;::,i!s;:-,;^„-;;";r^ - '-''- Ot/,rr /■orws „, ]fnnn;,>tU. I, i.s t.. I„. r(.nu.n.lK..v.| "tliat ....ILunv, liii- unv -.■ur ... ..p,.l..n.n. i.a-n.. In tl... n;,..a..kal.l,. ..n,l,..,.ak wl.i..|.'.,.';., .'n ^M alH.iit lu.tan.l, \ m...,nt, an.l w|„..h is .l..s..ril.,.,| l.v Cav.rlv .,(' tl.ii ,1„ n-any ot ,1... ,.as,.s w,.v .h.,.,.),, „ ,i,,, „ 1,, ..,.r..|.,-;,-spinai t- ! -. "' . {'n h>/>rrn,/„Hs. I,,,-,, il... i„si.li.,ns „„sot an.l , • ,' pr„t,.a,.t,.,| ,n„i-, uv ;.n|-,an,j.,,,,,,s^an,l.as_tl...,,,,.nin^..s of tin nl a.' ■.!!, .Ilh n i:;!';,;:;. Tllr -kill l-.«k.[<'li,. an.l .•|o„j|,y an.l r..t.-a..ti..n ,.f tl.,. h,.a.l aiv s,.|.I.„m s,,,, miptionsaiv also la.v in tnlK..r,.l..ns n...nin.i,is. an.l tl„. pr,.s..n, c-l.a;an, l...,.p,.s,sa,,a,n.t .1,,. t,il,..n.„|„„s fl,,.,,,. On tli,. oil,,.,. V,,,,! i,„.,i li::^: t o?'.dr r' rr'"^ '--pi^^-.'! =.pi.asia an.;..,;;':.;.,;;;:;;, :: in po tant of all. t .. .l,.|....nnnati..n of lo.'al tnl„.m.lons,lis,.asi. in oil,,,.,,,,,.!- I> ) Pu. ,nn,uiir Mn,nHj,lis. As tl.c n„.inl.,.an,.s „f tl.,. la^ain •„•,. 'hi ( i-' ;t;:;i;;;';;:rT''""'''^v^*""'''?'''^-^' :'•''■'■'••'''• ''-^^ sp.iM„ l.nt not ,.ft,.n -,.,,,t n.t,.a..t,.,n ..f tl... n,us..l..s„f il... .....'k .„■ I,i, k In Ii: ;;,::,.;'''';;;;;.;!',:; .;;,;;'"'';'f''- '"' ;'" "r""^''^" ^' '"'• ■■•■ wlii,.|i a lar;:,. n.aioritv .,f tl '). ( 'crtiilii til 10 ,'as('s vuisi.ins, riai.litvan ii.nc conihliuiiy, i)arti..nla|.|v iifa.. AVLTc (•,)nipli,.at,..l l.v pi 'o->p..,al iiii'iiiniiiii- ill i.'Uiiinnin. m.a, an.l : iia, n.av li,. ass.if.iMi.d with .■mi- initiial,. m son. ,. .I,.;;r(.t. c(_.rc.l)nK-])iiial i.ifi r'.i//;.v/'. I" iiiiilli|ilc riciini;, ' iliscasf in cusv. Mini at llicy, tint, aiv uni ly arise ill tlu. s|m,|;|. iK'i'c (it'lcii (liayih.v'l t rii"pi<,.||. 'I'll, ,|i,. cry iiivcly Id |,i'i ,,,||, true (•('rcl)i'(i-.|,iii;,| iMiiiCotatidiis (I, |i|.. i'lit.\ "f tile liili-rl,. '•' pi<'liin'. I |,;n, s made (.(' cci, III-,,. 'Inpiii tile seciiiiij I.I retnietidii nf ill, nieiiiiiLMlis isi-ini io.se care thr i|iil,| ^(■('(1 tliat liii' -Miij,. it'niis lieiiiiirr|ii|M,„ 't'liic, laeiiialriiicM, |"ist.||i,,i'|(.i|| iliciv a.iiic skill |i;i|iii|i, lll|"iX \v:l« iiiili;i|i- : (if it. |iniiniiiyelili> iikiv 1 (icciirrcd ill l^'.l) rlv, ut' tliai iiiuii, I fever. itl'aete(| cnlii-.r ;liv Hit ufteil allirlid. II seen. Tlir -kill liresellcr nf jirt,.. tilller iiaiiil. Iiii-il Kirecdiiiliiiiii, ;ilii|, 'il-seili (illiiTiiiiil-, nil! are cliirtlv in- ti'eiiiiir ••iimI iiintiir leck (i|nriiiT III' iiai iii('iiiii;;iii- ill elinmni:!. -iieialcd w illi cnil- lini->niiial lijcllill- ( 1 iXFiyrivK nisi:As/:s. 209 .ins I hcabsnuv ul frv,.,- ainl tl,.. coiHliii,,,,- ,n„l,.r whiH. ihr >v,„|,l,u„< =n'-.j>''-l ... ura.ima. tlu. |„v.,.,„v „f alhnmin an,l ,uh,.-.,,M,< in ,1,.. nrin.. ^liiiuM make tiic (liatiitosis dear. Prognosis Th.. .nmlality has nm-oW in various ..|,i,l,.,„irs tV ■'(. „, T.", |„.r ,vnt ll.ix.h statestluu ot l.-,,.;;;2 ,.as..s ;!7 pcT ......1. Uir.l. In ..InMrn, th.. .Irath-rao ,s n.^hcr than n, a.lults. Cases ni,h .hvp ,.„n,a, rei-eate,! eon- vul-mns. a. .1 lugh tever rarely re...ver. In tl,e ..hronie turn., ev. n aft,.r the .vNipmnis have persisted for months an,l tl,..,v i, ,,x, ,,,„„. ,,,,„i„„. ^j,, , , li:b-lur''s, |ierleet I'ecuvery mav oeenr. Treatment. Consi.h.rin- tlie liv,,nent assoeiati f ih,. ,lisea<.. w-ii, lihhv sinro.Mahn-s an important prophyhuMJe measure is the thor.,.i..|. .h.uKi Z,!' lowii- and vilhi,u-es Ml localities liahl,. to the disorder ~ ' A. in other sp...iti,.t;.ver< eaivtul ,n.rsi„. and n.edi,,^ are the n.w, inmor- l:ni elements m the reatnieiit. 11,,. i,,,,,,, should he kept dark and tmr- eudily vntilated I he diet should eon.isi of milk and slroie.- hroih- Manx- eases are very .lilheult to t^ed, and it may he i„.,.e>sarv to use the ^tonnef, tuhf. or to resort to rectal injections. In th, -hmild he treeh' iiiveii. ' iiiiire ehi-onie cases stiiniilaiits 1 I stiotiu.tol list patients with hiuh tever and much mental ex.ate nt letiii- may l.e emploved. I he appl^ati ,f cold m the iiead and <|,ine which was .•ecominende.l so stron-lv hy the New I'li^hind phvsicians i, the hrst epulem.cs ,u this .-ountrv, is of ..reat >ervicc. The ic'e-eap to the hea.I and the spinal ice-l.a- may l.e kept eontinnallv applied. With hi.di fever and iH^tivc .leliruim or coma th.. c.dd hall, mav 1... used, or cold HM,n~in..' or It .UMH^iry the cohl pack. CounteMrritatio,, i. of doul.tt\.l hem.lit. imd if applied at all the good eliects are prohaldy ol.tai I l,v the li.ht applicati.a. (it ilie I aipielin caiiterv. i i " " •H'tl.edrun- treatment of the disease we have no s.tisfactorv knowledge imm has iHvn mud. used hy A luencan physicians. It is panicilarlv lecm.: nu Hied h Siillc. Ilvpodcrn.i..s ot morphine mav he n.ed in ivdueiiio. the ;."l.'.i-of the imisenar spasms. It .hould he freelv used until the sniip- toMis are controHed. Mercury lodid.. of potassium, .p.iuiue, the s.lh.vlales ei-o, helladon,.a. au, calal.ar Lean are a few anio.io. the I,om of dn... ■.'which have heell .■ccomineniled. " TETANUS (Trismus— Lockjaw). Definition. \n a.'ute ii,f;.etious .lisease charac.eri/ed l.v tonic .pa Wei an War and ii'i the Civil W paiuns has varied liin. V oiiserverv a])! to (Icve op siiiiiiiianeon>l Al'ter the first inontli of lite the disca^ c and slieep arc also alii'ctc e IS rare m ( iiihh It most f'rc(|ncntly in tlie tliird and fourth ik'cailes. >rales arc somewhat f're(|iicntiy atli'cted tliaii females. prevail. IIHilv n a vci-v laiyc proportion of all cases there i.s a trauma. nized spocitic character of the malady, manv now donht if tiie d VIK'C the n ocelli's withont a h the snrtiice, tlii'ouuii wliici ISl'ase i\rr 1 the poison may lie iii'r. diiccd. It may tldlow wounds of any kind, hut is more common aft tnse rei \\' "iiiiil^ lecoiiii' ill- tooth, and even the most tritlinji- injuries, as the stini;' of an inse u> rcnioNiil ;i ilinter of wood. It is rare after sui'uical opi'ratioiis ( 'uses I i-'t, tir a Hiiiiij lave orriin'ci durini;' the proures.- ol' vaccination. A special form of it is met with in .on- nection with the open siirllice of the uterus after parturition — the |inerpir;il tetamis — of which mention will be made later. It is inti-restiiiy to luite that in a larire ju'oportion of all the cases t ileiv i i;b Nllce atlcll- in a considcraliji. le woiind witli been in the injury a possibility of contamination bv the si tion has iieen uiven to the point, it has been observed that ]iro[)ortion of the cases the injury involvt'd contamination of tl •il, as ill falls on the aroinnl, a puncture by a broken stick or stak( uImVIi I a spliiiiiT il : roiii a fall in had been in the earth, or iiy a s|ilinter from a dirty flo(n-. Sucl from the floor of a skittle alley, penetrating- beneath" the nail, has in'oihilrd one fatal case was due to a compound fracture of both femora, t which the ends of the bones were covered with earth; liardeners liav; >i., fered from punctures by sticks. In most of tlie.se cases the telanii> limilli were fiiiind in the source of the contaminatiiia' material; their prescmi. r\- Uriiv dains the iiitlueuce of tlie.se injuries. They have been found in spid and tetanus has followed the api)lication of such webs a; lar custom in some ])laces), and also the aijplication of earth t 1 styptic I a in|ll|. (I a wmiiikI owcrs. ) 'n le c.xjicrieii )f the Civil Wa r IS intcrcstinj:- in connection with iIk' in- stances of the (lisea.se in militarv suruH'rv. Of ■'»((•") ca.ses of tet; iwiuiT was the distribiiti on : np|)er linih, \'.\t ; i distributed as fi mil- ihr I'lil- lows : dmiil- >( ; lowiT liiiili, der, .">1 ; arm, .">7 ; coiide, 7; forearm, 24; thumb, 4; hand 2!t2 ca.ses : hauche, 2 ; tlii^h, !l!l ; knee, 1 7 ; lea', !».") ; coudepied, 22 ; mihI . 57. It is intercstinii' to note that tlie.s(. figures t,ili- nieiit that tetanus more usually follows wounds of the hand than of ijn t'n"l. The relative fre(|uency of the disea.se after operations and wound- i- ,i- IM- lows: in 2!),9''S0 amputations tliore were IKi ca.ses of tetanus; in jd.ii; n-d- tions there wi'i'e 1.") CISC; and in 212,07(1 wounds there w ere -x 4 ca-i- 'riir Trfuiiii.i lliiri //!(■■<. The disca.si' is caiisi'd bv a specili( discovered by N icolaier, and siib.se(|Ueiitly studii'il elaboratclv li\ 1 The oriianisin may be procured by iuoculatiui:' an aj.;ar till wound of a human beinj;- sutterinj^- from tetanus, which in the iiuiiliaii.ini .'i")" to ;{7° < '. shows the characteristic drum-stick bacilli. "The hn.illi i;T"» oil I'l:;iiii>iii, \illl,SII". IC w itli |iii- liMiii a t into loiio- threails at ortlinary ro(Uii tcmperalnrc ; but form ili fcristic .spores at '■'>'}- to ;'.7° ( '. in the iiiciibalor in about l\\eiil\-rniir I They then appear as short, Hue rods, with a lara-c round kiiol 1 (III line ciiil, the knob coiistilutin^ the resistant, friisteuinu- spore. The bacilli liavc imli pendent, but slow inotioii." (Holton.) MKXT. •V at tlir caslcrii • n lis liaVC lolln- I'lTuM i|> siiiiiiliaiu'ini>l> ,, aHi'ctcd. lildri'ii. It |)rcv;ii^ arc soiiu'wlial immi, a. Since tlic re r.,-. if tlic disease (Ni-r IKtisnii may l)c inii'ij. ciiminnii at'liT cm. \V iinii ICCdIlli' III- iiividvci ai)lc to I IS, the fcinoval nf a 111 insect, (ir a -iiuill 'ascs liavc occiinvd is met witli ill niii- tifin — till IC llUcr|i(T;|l tl 10 cases the! ui V iia- ■"ince alien. It Ml a ('(III- I of t nil i':il ic woiiml Willi or staise w liicli Slid UI, lias 1 a prod 11 |iliiiii-i eed il : iiora, from a Ihil in ■ardcners liav;> -iit- tlie telaiiii- li.iiilli leir |ire : -linlll- id, 'Vt : jowii- iiiiili, 'pied, '_'•_> : ami IImii. irni tile ii-iial .-iiUr- 1(1 lliail of llir tniit. il wound- i- a- t'"l- mis; ill lii.'ii; rcxr- verc •"174 ca-e-. specilie iii-uaiiisiii. rately li\ Kiiiisii". lie w itii |in- li'diii II ill the iiiiiiliiiinr Ml "Tlie liurilli ;;l'ii\v It tiirm llir cliiinii'- t\veiil\-riMir ji(iin>. knoll ell ciiic ciiil, ' liacilli li;i\(' iiiiii'- isriy -rr 1 1-: nfsi:. i .S7.;,s'. 211 ot u,.„ty-tl,m. si„.r,nu.ns „f s.„l tak.,, iV VMrious parts of Cn,,,,!;,,,,,,, Hxl.rn prove.! vinilnil when in.M.i.latr.l it.i,, animals. Th<- n. the sp.,.iH. poison of ,.,uu, from uinrh I?n.-vr has separatcl two hasi,. ho,li,.s. whi,.!, aro raih.,l t.' ' „' ami t,.tano-toxuu. Hru...... and Kra,.nk,.| havo also separated 1 e "! MlhuM.en. hut tlu. true eiu.inu.al nature of the poison hai not lurn acrur, .-Iv (Iciei'innieii. man i\ With the pro,lnets of the orowth .,f th.. tetanus l,a..illus the disease is very ivad, Iv produced ;;^'T<;''"n-uta Iv and eoniparativly small .h.ses are ronuired „. kdl a n.ouse-(..()(.l eem. ot the filtrate. Oou-s, whieh are in.mune , at ' al iv, re,|U,re a proportionately lar-er dose. The poi.son is not ef!;.etiv.. w u a,hnnnst..red thron_.-h the .sfon.aeh. Th.. .li.sease prodneed ..xmh r men ' I - present, a pieturestnular to that seen in tuan. It is interestin. ',,! ., , ,' .;; • ;■ '•'■=' ^ '''7''"i; '^''^f '" ''": "...sel,.. near,.,st ,|,.. .seat of inoenlation. The etleets a.e produeed l.y the poison, not l.y the ha.alli at the site of the inoeu- atiou. I Ins ,.s shown l.y the aet that the id.M.tieal sv.npton.s are pro, n e 1 hy the .enn- ree hltrate ot the pure ....Iture, and al.so'hv the in'tere' „!■ .xpernnents ot kttasato, who u.jeeted the tetanus baeilli i„to a .uouse, at he oo, of the ta.l, and oxc.sod and burnt the seat of inoenlation at a i ,< iM,es atterwani, a.s halt an hour, an hour, an hour and a half d,.str.,vin '■ n lias way all the haeill, at the seat of in.,eulation. Onlv those anima s "'";•'' ""Vr""^ •!♦ '''"*'"1'" «as treated loeally l.y ineision and hurniu.^ ha f ^"! ':'nr after u.jeefon reo.vere.l ; the othe.s die.l of the .lisease, showin-': witnn an hour enough ot the pot.on is absorbed to produ.v the svn.pto and eause h, al results. There arc .several very inter.Uiu,- points A\SuZ worked out about the production of the poison ; th.is it has be,.,, shown tint -lu.M the eiiltures aiv orowii at 20° to 22° C. thev do not tbr s..vo a .■ n I'l'-diuv any p,.is..n. and are m. longer virulent. Jt is interostin.r to,, to n. e that tlu.se n,ai-p,,,som,us baeilli may bec.ine toxi,. when J'^wl 1 "X 'nns not ..apable ot pro. hieing the .lia.a.s,.. In a..ei.leutal infe,.t ,n h e l.-al suppuration pr<..luc... by ..th..r .u-anisn.s iuo,.ulat..,l at the same ti e navfurinsh the very e._.u,liti,.n fava'abl.. f.,r the l.ro,lu,.tiou of ,h t t i is I"-']!., llH'r.Ms..xp..r.mental evi.l..u,.e to sh..w that th.. poison w,., ! ko strvi'hiim,.. an, has its M,.tt,,M ,..w.„ fi, ,,,..:.. ..1 i ' '^ '"^"^ lis its aetiou up,.n tlie srinal eonl. tl] Morbid Anatomy. Tlie eon.lition ..f tl nerv.'s in the loealitv I liave l.ei.u ti.un.l re.l.l(.n<.d K' W(.un.l is variable. \' laajority of the ea.se.s they have be<.n norma HI till, brain ..r e.)rd. (_' porivas,.|ilar exudation, ii I'i'i'a d,'s,. ril...,l, but these .•! .'rcliyiiiii-es are eoininor on thesei LTSti I. >■ ami swiilK'n, but ii. ift(.ii o charaeteristi.. l..si..us. cs.-:('ls, small h i>nge.sti.iii of th.. blo,),lv i..rease,l pi.oinentati,.n in the (.annlion cells I a is,.ecur cm.)rrliai;e( liangesare neither iinifbrni nor.li.stii 111 i.f the lungs are tVe.piently j.re.sent. 1 I'csiilt fn ini tl Sympcoms. Foil ic int(.nsitv ..f the spas '..us surfaces. (Kilenia and h\ tii].tur.. ..f mus.'l lavc ictiv... Minute postati.. .',.11- i*. fil.r(.s niav iisualb flLsi'S, Mliil lu owing an injurv th.. first laaiiifest within ti'ii davs. "in Vaudel .h.b s stati.sties in ibiir-fiftiis of ti indicati.dis of ih(. disea.se are tatistics in tw<.-tift]is of the legan l.,.f,.re the fifteenth .lay. Slight stifiiiess of tl le cas..; tlie symptoms clcsef il iaw is the earliest featii iicek and of th." ji 111,- 'II iiiastH'atioii, or that tl laikiii"-. r... or th,. pati..nt complains ,.f ,liHicultv 10 m,.veinents of tl tongue are not .so t ree in I 21-2 xfuvoi'.^ diseases axd their ritEATMEsr. Ill a few cases cliilly i'coliiigs or cvfii rijidrs may iircccdo tlii'sc syiiiiilm ;-. ami till' a day or so there may lie sensitiveness or even pain in tlie Wdiin,! (iradiiailv tlie tonic sjiasni of the muscles increases until the condition ,,| trismus or lockjaw liecomes so marked that the jaws are separated willi ih, ureatest ditticiiltv. With the muscles of mastication those of 'he face mi, also involved, so' that the aiiiiles of the mouth arc drawn outward ami uj ward, prodiicini:' the sardonic ,i;riii, »•/.<((■•< surdiiiilcii.-'. With increasing: in volvemeiit of the muscles of the neck the head is drawn backward and ih, ninscles of the back heconie ri,i:id, and the contraction may lie vWhi,, cnonu'll to cause marked archiiiu'of the verteliral column. The liody may iji ( , remain |ii'rfei>tlv straiiiht. the comlilioii known as orlhotonos ; or de|ieihliii_ upon tlicstrcii,i;'tliof llii' spasm of the dilltTcnt ,i;i'on|)s, opisthotonos, in wIilI, the back is arched like a bow ; emprosthotonos, in which the body i> In m forward; or plenrosthotonos, in which it is turned to one side, 'i'hc hh'- spasm iiiav involve the mnsclcs of the Iciis and arms, but as a rule the ;i!!;,- aml hands are not much affected. While the riiiidity is tonic in cliai.h i, r there are fi*e(|Uent clonic exacerbations, which arc a|)t to be excind li\ peripheral irritation, such as a dranuht of air, or a touch, nv a noise. Tli,-, exacerbations vary very much in fre(|ueiicy and severity, and they beai- -iik proportion to the intensity of the disea.se. At tirst the riu'iiiily is ikiI \(|\ painful, but subsei|Uently the suHerin.i;- is extreme I'rom the violent cniiii;i,. ti iniuhr ,!1 is not increased. There may be retention from spa.siii. 1'Ik' mind ii-n;iin remains clear, except toward the close in protracted ca.ses. Death may nrcm dnrini:' a paroxvsm either from asphyxia or cardiac dilatation. Tin it i- ; instance on reeiM'd ir. which rupture of the walls of the heart occunvd III iir- iiiii' the violence of the sjiasm. In other cases the fatal result is brdiiulii .m by exhaustion. There arc certain varieties which are of interest. In the //--(r/-/, /.»,/"- ni Hose, which has followed in a majority of instances wounds of (he I'act , iii- mus, (Ivsphauia, respiratory distress, and facial paralysis are tln' iinniiiiinii features. Oil account, too, of the spasm in the dei;iutition niu-cl.-, iiii'l conseipiciit dilKenlty in deji-lutitioi', this form has been called alsu iriaiii- hvdrophobieiis. Tlie caur^e of the facial paralysis is not kiiown. Th. iv niav be al.so paralvsis of the eye innseles on the same side. This iiiodiricaiion i- uot verv common. .laiiin' has collected all the cases, thirty-one in niiiiiln r. 11)) to i.S!l2, and he regards it as a form in which the toxic niatnial- ;ui chiefly in the medulla. The attacks recur at varyinu;- intervals. Imi iin v may lie id'iiost continuous. In other cases they are extremely sli'.:lit ; iIh most serious attacks are those caused by atteinpliiiL' to take food, wlnii llun may Iks si)ii.sin of the museles of deirlutition and j;reat interfcreiicr wiili ili' res] I i rat ion. 7V/,f//(),w ii'-Dii'il'iriiiii, a rare form in temjieratnre reii-ioiis, ami I'diiiiiiMlrlv now rare in the trojihie.s, was formerly very common in certain inuiinn-, jiarticularly in the West Indies, where in some islands one-half ol iliciiiri" I I'nris Tlic'sis. I)n Totiuios lUilbiiire, 1892. [i:sT. .■ ilu'sc syinptiiiii". );iiii ill tlu' wciiiinl. I lIlC ('lllldilioll n| s('|iiiral('o lel;iiri> now 11. Tli.'i'r nun riiis modilicjii'iii i- irty-oiie ill iiiiiiiliiT. toNic mali'i'iiiU ;iii illtel•val^, liiit dirv livniely >li'jlil : iln' cil,-f. Ililliliy, ill lii- Dis,, ,..,.. I>,r„/;,ir h, III, ll'oV liulilt hlilllils, uivcS the tilllowilln' nn,|,|,i,. ,„.,,, , ,,|' III,, ,li„,|.,|,.|.. ■• |.',,|. wliiii till' child isns i|i tliis iniscnililc, riiii.!, iiiiiiK.viiliir cnnditioii, ii|m,ii mov- ;ir. its Imiiils or fi'ct in the must identic iiiiiniicr, or xifilv Iniichinu jiiiy j>;itl nt il^ IkhIv, oi' ,-iviii.i;' it the Icnst tioii, even fcciiii- its |.iilsc iii lii.'' iiin.-t -clltlc, tender niiUlller, or liie least IK.ise. ur even Inwellini: its eldtlies, will 'ii'i'M^ "I' 'Ik' ' vnisive s|iiisiiis, and eiinse it to lie -truii-iv eonvnised hack- •Aiinl, nr drawn intoa ri;;id sirai-lit line, slnainlv extended iiml iimiinvahle like a statue, and will so remain iiiiniovahle out of either of iho-e |iostures, i''i' i' I sideralile time, a minute or two." (Kditioii l.v I'.eniamiii \{\\Ai l.slh. Ill the Southern States .il' Aineriea the disease was tormerly Very eomnioii. I'lierperal tetanus is now fortunately rare, hut i'ornierlv in" some countries ii |, roved the inost fatal of all tornis oi' the disease. The'disease he^ins, a-^ a rule, within live or ten days after parturition. In a immlier of cum's it has fiijliiwed ahortion. Whetiier tetanus ever occurs idio|.alhically has iieen dnnl.i,.d, Imt liiere niv cases on rei'ord. particiihirly in army jiractice, in which, without anv :i|i|iMrciit externa! injni'y, the disease has developed after expo>ure to cold. Mirhilihj. ^ 'fhe prognosis is always extreinelv urave. and two of the aplinrisiiis of Hippocrates may he ipioted at the present dav. namely, "the spasm siiperveninu' <>n a wound is fatal," and "such peisoli.- as aiv'sei/ed with tetanus die within four days, or if they pass these they recover." In llic iraiimatie eases the dcalh-rat<' is not less'than -SI) per cent. In the eases which develop without any wound the moi'talitv is not nearly so hi-h. From tile puerperal form recovery is .■xces-ively rare, and the lorni iiT infants i> also very fiital. J)eatli occurs from asjihyxia. or from heart strain, which in one rA. The serum of animal -n treated has the power of eonferrin;.' immunity. For more suseeptilile .1111 nials Hehrinj;' employe(l the houillon cultures, diluteil with the aihliti f iodine trichloride, lie'i^inninL' with a culture eonlainin;.' d.".'.') per cent., tlicn :i |iercentat;c of lt.2, tlie 1 a pereentaue of 0. l.'s, and ultimately the undiluiid culture. The serum of aninuds imnuiui/.ed in this way may he prcMivnl with (•.() per cent, of carliolie acid, and may he used for imnuini/iuL;' oilm animals not previously treated. The material used hy 'I'i/zoni ami Catani in their observations upon nam is t!ie serum of the imnmni/.ed dojr treate(l wiili alc(diol, hy which they ohlained -i naiterial known as the tetanus antitoxin. Animals inoculatei'l with I'alal doses of tetanus poison treated with iIk serum of imnmidzci! animals have recovered. I'p to the early pari iif l-ult has been obtained in any on. of the cases, as the healed cast's wer. not so acute that the projiuiis's w;i- 1 n- tirelv thaibtful. On the other hand, Ivemesotf and i'"edorolf,' in a r( n ni report of a ea.sc supposed to bo cured by the serum of an immuni/eij aiiimiil, claim in a review of tlie rec(a'ded cases that the duration of the di:-oii|ri' i- decidedly diminished by the treatment, that the temperature is reduced. ,lic attack. ,.f spasms are le.ss severe, sleep is promoteures are usually employed at the site of the lesi(jn, ^urji ;is burning; or excision of the sear. I'nless done very promjitly experiiiic iii;ii evidence, as mentioned above, would indicate that they are not of inucli iiii- portaiiee, and this is borne out by experience. Kxeision of the nerve- :ii \\\v part and stretchin;,' have also beea employeil. Thoroujrij cleansing;- ami di- infectin.iz' of tlie wound, po.ssibly excision, arc the nio.st ju.stifiable reiiuilic The ^■eiieral management of the ca.se is most imjiortant. The patieni -ImiiM be in a darkened ro attended by only one person at a time, and nil inii- side ( ununieation should be forbi(lden. \'eteriiiarians_ haVe Ion.-' apjinri- ated the importance of complete seculsion, and in many of their well-ei|iii|)|itil intirniaries there is .seen a brick, padileil chamber, in which the.se ca-i- ;nv treated. Tlie M I' iiiiH'uliitiiiii. (|iu'sti(iii willi I. I vcr\ sliiilitlv I- (■ liy tlic iiijcri i ... iMiiii lit' iiniiiial -I. re ■'iisci'|)tilili' Mil h tlic ii1I4 (I by the 'ri//nni- ly cx]ierls in \hv t'avoralih' ; thus lacteriohiLiy, I'^'.M, itaiiie(l in any mn' iu'duiios's wa- 111- di'dtr,' ill a i( iiiit iiiiiiiini/.cd aniiii;!!. (if the disiijihi' i- lire is reditciil, ,iir a very lircnt im- i iilniaii 'rhiiiii|i-i.ii in slionhl ln' ii-nl tlie lesidll, -llrli ;is |itiy cxiicriiiKiitiii e not of iiinrii itii- f the nerve- at llic (■lean.--iiiLr ami ili- isiitiahle riiiinhi-. riie patieiu -liniiM , time, and all mil- iaV(^ lonu' aiiprici- licir \vell-ei|iii|i|"il icll these en-c- ;iiv I |)ortant, nwlu-j; tn noni'isiiiiiLi lii'ntli" I'veii when llu'i'c i> ito the stoiiiaeli liy onietinio hii'ii I'X- to the nutritive in- rst jilaee. !'!' remo- II is the nil 1-1 satis- etlcets pa- away. ll f. \ isii.rrivi: hisi:.\si:s. 2 IT) Nilrili' lit' aiii\ I iiiiiy lir irinl lin' tlir sun.' |iiirj.H.r in liU'L'f ilci-r-, uimI in llin -iM II' |>iinix\>in-. the ^mlilm iiiliiiliitinn -onicinni'- cini.-cs rcluxiitinh. .Mm- |,|iiiir niMV Immim'iI I'di- the siiinc |inr|iusc, nrnl in xirnc iustaiiccs has scfnuMl to li, iiciiially cniativc. ('Iilural liyilratc lia- liicn lai'L^flv iiscil, Tu lie cUt'c- li\, il must lie iiivcn in cluscs nl' tVnm a ili'arlnn in Iwn'ilraclnn^ in the ilav, aihl iiici'iusinj:. In llic tetanus ni'iinalunun it ^Imiilil lie mxmI in |)in)H,rliuii- Mhlv snialli'r(lnscs. It may lie «nniflimc> •umiminl with tlir iin.miilc nf |ioiassinm. Thf ( 'alaliar lican has liccn nscil .-nccc-liillv in >cimc ca-cs ; also I lUMiy, which nui.^l Ih miiihiynl in laruc (hiscs, a- di as a i|narlir nr half !i iiniiii I'Vi'iT hiair or twn. It i- nut. Iiowcvir, uilln.nl ilam:iT. AnKini; iilliir iiu-ans which have iiifn iccdninaiiiliii ni'c llic cnntinniMis warm liatlis] iniii the a|)|)licatiiin u[' ice tn the >|iine, ami electiieity tnid lijiedin--. In the vvcivr >|ia>Mis, leaiJiiiL:' to -to|i|,ii,i;e of re-ja ration ami eyano-is, ai'iilicial res- hiiation -iioulil he ac|ivel\ empinxed. HYDROPHOBIA (Lyssa— Rabies). Definition. An acute infectiou- di-ease of unimals, dependent n|iies. is niel with chietiv in iIk r- iiivdia, |iarticularl\- d(i-< ■■ ' w.,, ^. Jt is c(anmuiiicated from animal to iiiiiiiial hy inoculation : ,., the exti'eiiie rarity of the diM'a.-e iu countries Mich as N(a'tli (ierm;in\, wliere the inu//iiim of do;rs i> rii;i(llv enfcu'ced. It i« net infrei|iieiitly ■onimiiiiieated hy iiiocnlatiiai to cattle, and oceasionallv In horses and pi-- It 1> said tiiat iu the Western States the skunk is par- liiiiiarly liahle, ai,d anunilier of instances have heeti reported ot' the disease fniliiwiiiL;- tile l>ite of this aiiiiiail. In ihe doir the earlv sym])l(uii- area cimiiire in the dispo.sitioii : it Ik mes ipiiet, dulj and heavv, and vei\ irritii- hic toward -trauuers. The hark may have a jiecuiiar riu;.dnu (duiracter. 'lie nil' > iu)t take its (U'dinary food, hut eats all -orts of ;irticles, such :i- -"■•; '•• ^^ 1. I'lul clirt. In soini' instances, the Mi-called furious rabies, llicni- \eiy much excitement, hut in a majority of ea,ses the symptoms are lailnr iImm^ of the duud), or so-ealle, from •hiiic I, l.sx.s, to .January 1, 1S!)4, collected seveiitv-eiirhl cases, an aveiai:e -t t.Miiiirii prr iinnnui. Sixty-two per cent, of the'cases were in the Atlantic ^iMli's. Ihe disease Ts nuieli more eoinnion in Kurojie, p.irlienlarlv in Itussia and ill l"i-;nic('. Incubation. There is an extraordinary variahility in the time which i'hi|i-.|.. !-.etwe«i tlie iutniiluciion of the vini.- ami ll'ie appearance oi' the iia|iloias. Horslev .states that tl tiwtiirs: "if. Ai Fur 111 Th le variation depends u|)on the following !■ nliviims reasons the f e nil nhataai is shorter in children than in adults. r.rlrd. Th,, or ner are more fre.(uently attaidvcd. h. Part iu- •apidity of onset of tiie svmptoms is i;reatlv determii led l)v the 216 Xh'nVOUS DISEASES AM> TJll, in 'mEATMEXT. i 7\ part of tlic l)(»|y wli tlic fiicc iiiiil head ill i<''i may liappcii i,, liavc U-vn hittvi talil I' I'siicciallydiinwioi W Tl y •■•line hitcs nil th,. Iiiill(ls,"tl ii.-^; next in order of d lis rcliitivc ord face, I Tl "•ad, iiiKl hiiiids Ml ci' IS, no (loiilit, HTcatIv (l( ' .Iiirics on tlic otji, otiiids idi rurccs of III ■!■ liarts of tlu' 1)( (' II ic extent iiiid severitv of t sually inikcd, whil,. t|,e ,,t| l-yi'lfiit n\ he fact t Illy. lat ill,. daiiueroiis ; the la fi ICC ccratioiis arc fatal wound. I'liiict iiT parts arc ejoil lire wounds are tl itlordi'il for ahsorption of t m proportion to tlie extent of i iiiteetion. In onU^r of le virus. d. Tl le animal IC li:..«| IC Mir- eat: tliird, the doo-; f;,„,.ti decreasing .seventy cniiip : first, the wo|( ro 111 SIX weeks to t 1. other animals." Tl eonvcyiiii;- || second, il iiioiiths, and tl Wo months. It niav 1 icavera .ue period is prolijilil icre are <'a,scs m which the •e proloiin-cd to iiioi-e tl I year or eiuhte.Mi months. Of persons hittcn'l iViH>ationlias apparentlv la.- laii thiv'i. percciitauc heeome infected cent. Th acco Hit neatli-ratc of t rdiiiu- to FI II liv raiiid d o,i!-s onlv a led i; orsh>\- n I' cer|;iii| KISC IllttCIl l)V ot more than 1 es upon tlie face are iiarticnhirlv di wolvo IS not l(..s than M) Symptoms. In the premonit lllU'ero||> per (VIII, the hitcs. Slid lieadach and si fc\- 1 as pai iiiiil)nes< , d .1 |>ry sta-c there isiisiiall ir paricstlicsia. T y sonic irritation ;ii„ e, and deprosioii ot spirits. The pat ■re i> loss of ee])lcss, and there is a er has lieen noted at this .sfi lent ma\' a|ipi III,.. con.-taiit sense of ii lecoinc very irriinl,!,. seiisihility IS nreativ iiici la'f, npcinlinn. ,|ano(. IIIL ^titl IIC^ 'eased ; a hrin-ht liuht ilid the piiU' is accelerated. Tl ii-hi iiav 1 alioiit the throat iiiiir or a I, Mill le i;,.|i,-i- IC expressed, and the v eli's, and shuht ditfici noise IS verv ,h«i Jieriod of excitcnieiii— tl oi ee is a little liiiskv. In i| ilty III >wall IV"- iiwill" afil rent stiniiilant- lere is oreat restlessness and I )f a verl )al siiuo-cstion — will cans a .sound or a draiiiiht of le secoml stau' iy|ieraslhe.Ma.' -.V ■c III,. I\ iiir, or the mere as .viiiptoiiicnnstitiitcs the most distrcssinn' t e a violent retlcx ociniioii P"-^"!- Ill man ilij. which affect parti iii,trly painful and a eiihirly the miiscles of the la catiire of themaladv. 'j'l when the iilottis lev). Ai lecompanied liv an ryiix and nioiiih, an iesh:i>iii s IS widely opened or traelicotoinv has I intense .M'lisc of ,] .v.-piiica, ,v,p iiiiisclos o ly attempt to ta i lie idea of the |)re>ciicc ,i|' a ,1,,^ le all, 11, lam, iny attempt to injure t occasional fits of fu lo avoid hiirlinu' aii\-on,.. lie saliva IS iisiiallv le larynx and phUrynx odd .sound I'l'iiis iiiania. and in the cm ll,'lV 'iwiiiir to the difficiiltv th aliundant and tenacii itraiii.iii ,if are occasiomillv mnivil, fins stai. IS iisiiallv el patient has in swall IS, and flows from tl • wiiiii il. T may lie afclirile llirouiihoiii. evatcl, and may reach from lUll-^ to !(»;!'. 'j le I nil, le temjieraiiirc in lie (vIlr.M' tl In add Itloli to tl icre ma\- Ik le local spa.-nis of th,. rcspiraii a day ami a half to tl convulsive seizure- of "111 and dcLiliitiiidi: wliicfi the iree (lavs this is a tetanoid character. Afi sciousiie,. pasiiis no foiiu'cr oci ur. ■^ilccecdcd liv ^s ,i;radiiallv supervenes. le patient I .rlr-. er la>liiin' f;,r lie paralytic M.ii;,., in iechlc, and death occurs 1 stau'cs arc aliscnt as a riih le heart s action u'cts leconies (|uict, and iii »\' svncoiK nm- more and imiiv pe. In aiiimals the ]>roliininar\ ami ruri,iii. he so-called duiiili raliii" ami the paralytic may he marked f III n laii the paralytic f.rni is exlreinel roiii ill,. tiiM, \ lill(.|llM- I TMKXT. (yii. Wounds iiliMiii T (if (l(>iiTC('S of liii.v. ■I' piirts of the li.nn "1 'lie fiict thiit ii„ '■ I'.'irts aiv clnil ,| Ollllds lllV tllC ll: ,-1 i' extent of the Mir. inial coiivi'viiiM ii,,, III' wolf; siH'ond, lii,. ;•(■ period is prohaMv to nio;v tliiiii ilir,;,. i))|)iiiviitiy liisti'd i;,|' loss of a|i|i(iii,. ■coiiic very irriialil.- ii.ii' dani^cV. Siinh, iited. Till' iivi:(.i:|| oisc is very di>iiv„. "I't.v ill >\'vall(iniiiM second sta.;:c ill,. lerasllu'sia. "Aiiv lie mere associaiid'n ^iii- In man ihi- lady. 'l'lu's|,MMiiv Houtli, arc c\(v,..|- of dyspiiicii, i.\i |i performed." , i|,,i. if'iil s|iasni> (if ill,, iif llic liyoid Imiii,.. of water, and h.^ itory and di-jmi. iieialcd with iniin- e palicnt ni;iv In ||elusinn> iiin\ iir presence III' 11 i|,,^ I'e tiic allriiiliiiii. X anyone. Thin' tile contraciiiiji u^ "i.-ioiially iiiirivil, t'i'om (he liiniiil]. he lempeialiiiv in '*■')'. The cilii',,. i!'liitition niiiM'lc-. •Vflcr ia.Miii:;' t^r ira lytic ~hiM,., i,, uiet, and iiiirnii- more and inmv inary aiei iiii-inii- 'il from I he lir-i, xlrenu'lv inicnin- :i IXFECTIVi: h'SEAsi:. iii'Hi. tli(ni,^li ciws oi' ii ||;iv,, ] 21' ii'l'iiii liiiraplci^iji, ;ui(l wit "••■11 iv|M,rt,.(|, ami Morbid Anatomy. Tlic v\nv\ 1 Miiiptdiiis rc,-ciiili| " Illil.V .Icvclolicd will will. IlIlS {■Xilllllllcil I) •iitmiis lit' vascular distiir il.-CS, ('(11111(1 li'sKins arc in [| iii.ii' acute ascend I it rt,c-lik lailcc; I iiiorlnd chaiiucs in II' iicrvdiis s\>i( iiil;' nnclitis, ill. ( ■ lilatat e <;oi'))iisclcs iifoiiiid tliciii and in tl 'I'll (if small vessels ■vKJeiitly fornied diirinu' lifl le tissue *>1CIII. (i()\\,.ly_ I lic>e were indi- acciinnilalidns df iiv nicl witli 111 vari till' iiiediilla (il)l(iimat "ii> I'arts, especiallv ii and niinnte licniorri '•lilts in small lauc: 'J'l Ves- lese cliaiiu'es ill llie iiiediilla, liet I, and the spinal (Mird. 'j 1 tlie cortex of the liemisnl ween tile emiiientia teres al nev are alw jiynniiids M.iu, and especially in the nei^hhorlK,:,,! al, and spinal ihdiit the vos.sels (1 aecessdrv nuclei. T didve and the d if tl plleres, i.v> iiiii>l inlense ■eii.-salidii (if ih,. le piieuiiKiiiasiiic IS a verv cull iHcUdus change. '| It' aecuiniilatidiis of |,.|| ciievte.- Y'li ;iH(l may he s.M.nmenins as t(i fill up the wh,',le sp -C( \\<. arc ihc llllrralld: (lie voxels with I mailer; in this the cliai :iitlHiiit;h thev involve tciisc a,- t since the cdrpii.-cl • ■•(, ' iniliarv ii>uallv miK'h si ay may he a-.-reoaled and es liia\- lie i I lai'M-er niinil fir aliscesses. e^arded as idemi i.uliter, ai eiicocytes and to an in i.tii's are usiiall are confined t •■I'fase III the niiml ley involve these ii " eoiistitute a I severe fir y .UTcater th; in tl ler 111 eal Willi pinal cdrd " eneriistatidii df nher within the univ III till ins If Uillle eoliimi a ca-c has run so r ''"'"ilitioM praeticallv of aci ie\- nia\'. 111 'I":' :• '•oui'.se as to he final in || 'te myelitis. ]■; "eiij, lie .vo ni- riiaii-c^ may he ediispiciioiis. The ' niiliarv al III the ciii itllcr ;i Itcrati On the other hand, tl an animal iiioeiil; Ills than are com ic eenlral iierv nve days siicl ' are verv sel len ited with ral mill, 'itter death f 'ins svstein 1 Veil wl 1 myelitic ddin seen .-v.-lciii Iciicdcytnl intiltratidii has I dues, as well i''"ii iisphxia, and' this Tl Klilne\- III the iiiaifir which the IS lieeii le miicdiis meiiihrane (if i'-' in man. ( )iit-id d nay iJi'i'seiit 111 even in t' the iierv (lUs tlu! stdiiiat'h iidt iiif ;;•■■','" tl'<'^=il|varydandsaii(l in th pharynx is ciumt'.'^ted. tile larvi IX and animal has eat reipienilv cdntai '"l"iiinial iir thiiracic viscera. Diagnosis. 'I'l en. Tl ns straw, In ii'i'e are no IV, and f orei^i'ii tnnii "ihcr or: ami (T.iiiip. In tetai i.fi'<' 1^ rarely any diftic„ltv in .liiiiiiilalc the true disea.se. A Mi|i|i(i-r(| to he so, mav di: "her, ^vmptomsresemhiin iii""dv. (•(iiistaiitl 1 IS a neurotic or hvsterical ic .so-called Clear. pseiidiidivdrdiihdhi nianifestatidii, and 1' nia\- c 'H;rvi.iis person hiiieii hy a dou. either'ral.id a, or (iselv play within a W 'li.vdrojihohia. He In u nioiitl or even several v •■'■'''■'III '" .iiii mad. Tl Jieaks of his al; irmiiii •laiiesirritahle, di ear.- pressed, and '•■re may he hy.sterieal paroxv conditidii, and insists that I ::;''';,:-';-i'ietodri,ii._and'shu.id;.:;;x!:s ■ins, 111 which 1 MVcIv at '!•■* tliniat, and I U'eiinies enidt It ( le sav.- i"'"l;M|iei'swere full of the details of 1 idiial A f II Iliinl "."'■'I NIC, who jiad heeii I asteiirs treatiiiei ew vears a"' rrasps eoiivul '", when the slill :d lie had ntten a year nr more previiaislv I It. a yiiiiiiii- man o on- >i''e of hi., felldw clerks had joked I y a dd(i- whieli was ii'aihiallv 1 '•■'•o'I'e very much alarmed. When [ s iim upon thesuhjeet, and ^'J'''tly excite.1, had pains in 'the th. '"^•"'I'tiiiu' to take a o.|ass of water I ii'iial, didieiiltv iw him he w; le would I 111 >walliiwinu', and H'i'iinie -reatlv excited an I U I I ] hi I ^18 alai'iii'. sis-c(l ), xrnvors nrsiusi-js and their mEiTMENT. 1 Wdiild have a |tsl'^l(l()-(■(lllVlll^iv(■ attack. Tlicsc syni| I coiiplo of weeks, and iiltiiiiatelv vieideil to treat timi- eleetricity. There have l)eeii instances piiltlisl nienl with si nil' led as lvss((i)holiia in wliiih M'conii' mure f're(|nent, and the jiatien't lias died exliaiisinl. iiese seizures have 1 Gowers hdhis tiiat llie niajurilv oi' these c remarks (in this pdint are wort'ii ((Udtiny: " Tliere has more ot'teii 1 deney to regard tlie jreniiine disease as ima-:inarv tliaii to mistake t uses are in rea litv jreminie, and genuine. This tendency is es|icciaily in for tlio not seen tlie case, w ho d case: rked )een a Uw- ies|)iii'j,,||. It is not certain that deati o not scniple to east (haiiits on tlie nat iiiioni;- critics w ho I, lire of even liHal Xowadavs tlie test of the nature of a fata! inoculation experiments are (iiiite coiiehisivc li has ever occurred fnnn mere Ivssoidiol 'I'll' ease can he readilv ma('.« er mav be tried in ,\ lere I- liiii> I'i;i:vi:\Tivi; Inocii.ation. Tasteur found that tl cords of inoculated rabbits, wl le virus 111 till leii preserved with careful anti.seiili tions, gradually diminished in intensity, so that the fourteeii-dav-old igt'r poisonous. Dogs inoculated with portions of cords di no I pile jH'crail- hvi con I wii ■led ill tlii.< way and (it increasing intensity ac(|uire immunily, and are in realiu vairj- nated against ihe strongest virus, which would otherwise I .... lave priivnl fatal. le long incubation |iii'ii IJelyiiig oil tlie.se observations .(nd on the fact of t ^ ,.,,„ ['asteiir began the inoculation in luinian beings bitten bv rabid aiiiiiial what is known as the .simple method the individual receives an in the (irst day of a portion of the spinal cord of a rabbit which has serve(| in the drv air for foiirt thirt receives an injcriinii mi cell (la\s ; on the sec( ecu days old, and so on until the cord of the fifth d ind (lav a bit of tin is called the more intensive metliod, on tl IV IS used. •I I nf vJKlt lie inornin:!' of the first dav n i.iiriiini f the cord (rubbed up in sterili;;od bouillon ) of the fourteenth and lliiilcciiil dav is used, and in the eveninir the cord of the twel i'c and eleven Oil the .second day in the inoriiing the cord of the tenth and ninth d; ill li :iy, Ibcil, MENT. iu'sc synii)tunis |i,.|'. ■(■atiiu'iit with st;iii,. <.«(>l>Iinl)ia ill wliiili llilS (lifd t'xlliHl>Iri|. ty genuine, and \\U re often heen a it n- nistake the s|iiirinii« ml:' critics wIki have iiatnre (if even liual mere lyssopholiia." •adiiy made, as ih,. )f diseases in w liicli itiy nrged a iiiuiv ,L;i'cater eautidn in (lus jieople, arc a|i| ant. If on a limli, tlioronghly caiihi- if nothing heiii rjv used. The viiimi pen for some lim... •ea.-ie lias develii|i|.|| room, in charge nf •aiiit, and tlic \A\\- leir duties. Tliciv - licen transiiiiiicil jntridied, and dues :s should he ni.aiir 11 swallow reailil\. •ensitiveiios .if ih,. , nutrient eiieiiia;;i miuith, large injir- violent spasm tlic , hnnuide nt' pn(ii>- y he tried in doso until there i< iiins- I'irus in the -pinal antiseptic precnii- i-day-ujd cipril \\;\< ■ords drie(l in this 'e ill reality viicci- lave pro\-eil fatal. inculiatiiiii jierinil. ahid aiiiiiia!-. In ■es an iiijeeiiiiii nn licll has heell |il'i'- a hit oi' tlii'euni iif is used. In \vli:it first day a hni'tiini itli and limieciiih lid eleveiilli ii;iy. iiiiith da\ i^ iiM'il, INFECTIVi: DISEASES. 219 s.nr< IS l„.i.nii.. usi.allv with tl,,. ,.,.nl „f t ,. ' " "'"'•, • ' '"'" " "'"■ All fiiornioiis ininilxT ((hm, ]-SN(i to" .iMnii-M-v i is.,. ,. ,, """ '^VM.M■nlulsn,l,i,|,orsul,,H.s,.,lt.>lc- ; -I ' I *' V'^'"' '"■'■^""^> isiii.itc. Of tlu'so o, Iv 72 . m , i, \ '"■'■;.' ''■'■^'"■■' '" '!"• l'".-^t..ur 7:!;. j"'''^i"-''i--aHvnor'.,::':;j;;;;t':i::." Ii III lilt ••^ nics(.aircai'enillys..])i,nii.d. u Mil,. III,. ,,r,.v,.ntiv,. iii,„.,ih,li„„ is M,„ invui. ,N •• 7'l*"''.'";"- 'IV iialural.sin..,. manv |.,.rs..i,s ani.lv .,. ■ ' r"''<7'^<"'- =i^ ni,|..,.,|, i, v :niii.ial,s u.Hlu„l.t...llv mCI^^^I^'^':! ''^V'^V '" '"''^""^ ''""■" ■VMtIv l,.s,s,.n,..l, an.l in^onu. v,..;. • ^"■.' ""<;>" ''v tl.- .im,.,ilati,Mi, v,.rv ■'-"■;' i" "I-..: ,1... na,.,",^' ; ;:.::•;;:;• ! ;:r- -v >^"i: -f' ^>'»-* 1-.-... '.-' Hi,., is ,.._ i.;2..i/-;;;;;-^. ;::;;. ^^ I t;'l',.i ilVi ;i mil llin Definition lllrlilli;' el Etiology A TETANY. /"!';:^:r"'.l'.''"^'''''''"''''''''-'^<'t<''-!^<''l''vl>ilat..ral t'llv the oxtroiiiit Til,, disease, dcnrs cliieflv tiiiiic siiasni-: III vmiiii '■;!l.'''i''''''i'''fi'<.MiHMitiy tliaii n.|iiai,.s. ( )f lOi 'lilli'i'iiil s,iiiiv<.s, 7() were in maii.s ^' ;'"l";i;'Miil con.iiiions xuu\vv whirli'tiio'llis I'ci-soiis, and attacks males i-iscs a.iii.ctcd l)v ( iiiid (Ki ill females. Tlie i\ '(»\v,.rs fV( nu '/. Ill I'lii -iirii as iliarrhiica. Idrt.n associated with tl 'i'l ic c "illi ncl<(.|s, is rcNiirded I -i'||iiciicc of the fi'ver.- irpopedal >v soiiic a.- le (Ichiiitvof cj :eas(' (lev. "Howum arc the inmic cxhaiisti -|)asiii, so • cases have ,levelo,,edaih.r,v,d.oidti:; ' eel ion with hr,.n'na '■P"l''>Mics A feu- typical instances | pregnancy ami lactation, 'l I' lave occurred in A. A lliyi'iiji rliiiic. iiitilie coniractioii of nui ii'iiiiirkahle a,ssociat It lam Thirt ion exists hetw iiiiiv recur in sm ronsseaii called the dis ease the <'en easLs f.ilowed 7.S tl ecu tetanv and tl cessive preunanei. ^i'; of which prov,'d fatal. It 'III- 1- ili(. mo :iiii'iiiil> is also toll serious f( fill "■'II of the (lis. IMS total, J lyroidi.ctonii le r(.moval of tli es 1 n Billrotl 1 .s iit>t partial extirjiation. 'Mil a cas,. reported hv .J '"W«,"ll>vtc.tany. Tetanv and nivxied '''ease. Kemoval of the thvroid i !■ Tl le (iiseast iimes Stewart. ema mav lie as in sociateil M>,.as,. o,.,.nrs ni ep„|,.n.ic f;,rm. part iiirni'i- t If unit., 1. ......,ti. I-. '. "i'"l"' diiriiiir the wintei III j.s, I'' yiMlllo' III,. II (if ( mid I,s7(i, and a months. Kx '•'".'"'•ly "11 the continent of •■'I'e I'ai'e in th le work I'eceni (.pidenii teiisiv,. ( |ildeni les oc( A >liiii IS feen practised. w ea.ses to l,s<)2 „ill piis'ii he included the di 111 epidemic tonn. If .America true tetiuiv iii\\ev(.r, ea.ses of ■"■■^c IS not iiifr(.(jii,.|ir, and (;riflith 1 is Very earpo- las lie,.]] TmiisiutioiiH ,jf tlio As ^ssofiutioii of AiiKTiouii I'll .vsiciuiis, vol. iv. It i % I :i; 22(1 XJ:i!Vnr.-i D/sK.lsh'S AMI Til III i; TliEATMHST. llilf u II I •I tViim I lie iitcriilmv 72 c ascs, 1 1 111 tiir iirtc'cliiii If cindiiiiil -.yiniitonis, is rarclv seen. 1 IM iliilllts, Willi Symptoms. Tlic t'ollowiim' WwV statcinciii dl' waids in 1.S1I4 will illustrate soiiu' of tl 111' tetany wliicli recurs witli i)re;;iiaiicv a ease w liici 1 was III le reiiiarkalile cliaraelers dI the i; Mis. I cij ihii'tv-tl iree years; iiia-i'ied at eiirliteeii ; first eh iiiiieieen iiioiitli^ aflerwanl, and a second child two v While three liioiiths |)l'ei;liant uiti eafs after the II I' , ■lied and felt tired, and tw -yniptonis continned until a short time hefore h i-i. e 1' tlire the second child she noticed tliat her h;iii,|. e times a day would uct i|iiite stiff. Tl much hetter. he remained free fi er eoidiiiemeiit, when sin fell labor, when thev returned iind the cramiis until the ninth da were more violent. Not olilv were til •loseil in eram|., liiit the feel would aNo di'aw toucther. The'attaei acc(mipaiiiei| hy niiieh pain. In the intervals the hands and feet I usual. The attacks recurred for five months and then disappeared f months. In Novemher, 1.SS2, after e.\|)osure appeared with greater intensitv, and earlv in D y nil, e liiiiiij were ||u| ■ell ;i- er exiiosure in the snow, the si or iwi lasiii- iv- severe attach in which the hands were closed, the ell held close to the body. The spasms in the hamls did not relax t ecemlier she had an iimi- lows Hexed, and the fiv \n her third e months she pi'eL;nanc\-, wine had 1 lo cram ps, hut h followed in a short time, di or a \\i iriiiu' tlh lii laily. They apiin disajipeared just hefore I in the last four months she had iln IV, and the fourth iirciii ibor. She did not niir-c ih IS lielo .iiiiancy followed m tour month cramps t;)r the first four or five months, but thev recurred ; the last four months. While in labor she had a very severe attack four or five hours. She afterward remained free until the ninth (!;■ she had a very severe attack. In her fifth iirepianey, which tiillowed in f ne iiiKi ||M re d iinii:: a-iiii" i\-, ^^ III I at intervals throui^hoiit the entirt |>eri( ive months, the spasms oimmiv, In her sixth preuiiaiiev, whicj beiian eighteen months after the bii-th of the fifth child, she was fre the first five i iths, then the cramps returned wor.se than ever. e illinii:; ami leu's W( luld net stiff and iiainful, and she had for the first t The I le liaiiil' the larynx. Diirini;' the last i ith of tli ime 'I hey recurred a^ain on the ninth dav afi^ r J IS preirnancv there were no all ii'i h ler .seventh preiiiiancy, nearly thr( iiior. I'^'om this t line liiilil irs, ,-lie \\,is well, except at abiiiil iIh' time of the menstrual periods, when she alwavs had the spasms II her seventh pre^iiiaucy the atlacl for a lonu'cr period before lai ks occurred as usual but si le wa~ iii'titi' )or. Since ,Iuue, l.S!t2, the date of her last i-t ( Iinemcnt, she lias had the ,•111 at intervals, usually about the time of the menstrual period. The patient is a youn-i-lookiuu' woman, well nourished, a little pale. Tl or nerves wa.s verv yreat, ih e >llL;lili-t mechanical excitability of the mot taj)|)in,u- ill the course of the facial nerve was sutfieieiit to pniduce W meiitioned hereafter, were present in a tvpical manner. Tl le onset of the intermittent spasms mav as a rule there are slight feel if iiunil le siiilileii and iinexpr mess or pain in the extreiiii il. lull ii-. Ill' ■e usiiallv alteclnl lir.-l. a feeliny of lassitude and heailaclie. The hands a_ and the spasms may be confined to them. The eontraetion beuiiis in ilic in- terossei and the smaller muscles of the hands, which feel stifi" and nai d. and L'^radiiallv assume what has been known IS the writiuii' post fin-ers are cjiKriy pressed toi:(>tlier, the thumbs adducted and mv. lie airainst the index fi neath the finder-. The hand itself is wnerallv flexed, and t ii^-ers, or, in children, not infre(|Uently flexed liL^hi pres.i ,| iiriiiiv V lit.- held in flexion. In children the arms are not' iufreiiiientlv fold le eliidW iil^ii ivcr liu' ".i//;.v7'. •tiiin ill iiiliills, Willi wliicli wiis ill iMV iraclcis III ilic Inijii II ; iii'st cliilil liniii cars after the lir,| ticcd that Iicr li,iii,|. ft qllitl' Stitr. 'Iliisii iiiriit, when >lic ti'lt the ninth ihiy ■aWvy Illy Were the IkiihU he attacks wciv nui (Is and t'cct fell ;i> lisa|i|icarcil i'< IV- c liail an iinii-iiallv Icxed, and the aim- )t rehix i\>v a wnk. le, diiriiiL;- thi IIim iitiis she had lli.iii did not iinisc ilii> tlis. She had ii., I as hejiire dili'iii;j I'cre attack Li-iiiL le ninth day, \Uh i lie s])asiiis iicciiirivl |)re,i;naney. w liirh die was I'ree ihii'in- I ever. Tlie haml- first time spa-m ni fe were no allack-, 111! this time iiiiiii 'xee|)t at ahniii iL lasiiis. lint slie w;i> lii'iii, las had tlir aiiaiL- )(h a little pale. Tli. i'reat, the >li;;llli-l riidnci niraciinii id reaetioii,-. in \\ id llllexpeetcd. Inil the extreiiiilic-. nr iially alH'cii il liiM. n heii'ins in ilir in- stiH' and riaiiipi'ii, inj: piisinrc. The and ])rcs,-id iiniiiy • Hexed ti'jiitly ln- iid tile cIImw al-o ■|v folded over till' ! i iM/:f T/vi-: itisi:.isi:s. 221 I'lir.l. Ill lllc I '•«'■!• •■XllVillilic, ill,. (|,,x Ijnll i-i.i; III.. tn,.sMn,iiu.|y ||,.x,,,h„„| ,!„. ,;,,,, III ,, ">•' of I III. i;,,| ,111,1 , riif tlii,L;li iiiii- coiiiiiioiily illltickcd. ' I •'•■' IMV niivly ilivnlvcil. 'ri IC tillllK',' "<•> iH'c III tiiiiic "■||iiini>-v:inis |)n^i. !>' Illll>c|c, of till' I H'l' tllllj tlir :ilii;'lcs of tl iiivdivcij, hilt llicr ''• '""."ilMiiv.lniwiioiii. Til., tniiij, 'iH.v..n. ,,,>,., Ill,,,,, may I,,., |.iM,MK,ni,| IML iMVcivspa.Miitlif Ihoiiix iiiiiv III' I ;i::;r";:;',"S' "■■-;" "'■'^i'->." -.;::'.v:i III nicilthlliu-. lllllliMIS. ri K' -Kill of the liiiii(i> ainl t IK' >|.iisiiis III',' |iiiroxv.iiial. coiiti li'Mir or more, occiisioiiiillv la>tiiin' tl,. I't't I- Miini'liiii iiiiiiio- fi-oi i< iiiiiscli's arc \i'i'\ rarch ir- CllltV 'x«' ,aii(l lii.'i'.. may h, .-li^linlitti •■■^ ii'iiM' and O'llC- niir, |iaiMl('-s rlillli|)-lik('. mill ill cases Itiit several ila\-. Tl 'I :i i''U iiiiiiiiies to ai 'I'l Mlieii the sjiasins are iiilense'il I'' i''iiitnietiii'e 1.-, j|« 11 If lilillil is el siieiatcd with dilalcil I'ar, c.\ee|it in || 1'' |iaiii niav "• '■xirciiii' d.l.iliu of i|iiriil areoiiipaiiiinciit. 'I'hc hnii ■I'llliaell, ill uhicii coi sevci'e and cliiiijrcii (Ml hill It lliav he sill het\ •-lioriiiii Tl K'lallircissoiiieliiiics el cell the |>arux\-.iiis|hei'( i«'|'"'-'''> ilsiiallvaeei I iiensatioii nf siil lerale. IntI le inter- l|;iv |i.v several tmportant symptoms on th.. part of the m „.,. I n-usseaw h.iind thatj.ressnre o,i th,. nerve , VnnU o, ' IK'ss in the liilisele; III allaeiv of .-.pasin in ll ••I've triinlss oi tl I's and ner\('.' I- iH'l over, the paroxysms mav I uiseles of the linili le \ c-se iiroiiLiht iiiMiiit has heen free from th H' ri'prodiieed at will " i"iii: MS the alta<'k l;^" I •- "!• Ill'ire. 'I'his isalll'ete.l I • '111 lor twenty-hair, thirl v-i • ■Veil tlioiiuli ihi '"I'l.^-fiiiht, seveiitv- '.y-^imply e,,mpiv>sino. tl,,. allheteil ;;"'";'" "-•'"••■•■'i';" yni-irpHn-'ipalnerve-irunks v.'.M'k so as t.. impede I he venous or arterial e ••liiii'ii.'lei'i.slK'cii.sesti-lit pivs>iirei nd ll •■lamp of the milseles of th,. ||,.,||,|_ parts ii'i'iiialioii. "•• "Vcr their hlood- (T iii.sseaii. ) h llervcs. !•' wri>i may hesiilHeienl to pr,„| Mr,' A a I'emarkaMe iiien veiysli-ht tai ill ll !•■ iiii'^'liaiiieal exeitahil iliii^'^ iiriive e i~ |. .yiiiptom. [t i.iiiilly he iiidiieed in liihereiilosi.s. .\ ell It Known ri~tii' of (■"iitnictioii of the tilee inn.- • '■••■ase in the eleetriciil •rent from a sinol • 'Xeltal)llll\ Very important le eii ACIC, K()(" I'l^'S. " [listead of tl f ffii ma\ he >iifi I'l I he motor iierv, A( iC. KCIC. AOTe." (( iistly, tile meeliaiiieal \<><', we have I, .\( ml 'owei's. ) If normal AOC; .-!, KCIC, ,a.'l ii'ient to cans '••lion I, KCIC A()( ;il-" -really increased ( floff "■ -iipni-oriiital, tiie aiirieni mid electrical exeitahiliiv of tl iiiannV symptom), and tiie slight le .seiisia'v nerve ins ina.i^niis, or the ulnar il|li.v iH'i'vewoiihl only p,-,„l,„.,, ;,' sli-ht local ' ' ' l"""'^ 1" which the lilament: lU'i've.' fst pressure ,)ii which in a ;"'N-r para'sthe.sia in the part ii'liiiil symptoms are prof "-■.'•l'»^ iii-ticaria, nutritive eliaiiM-e.. ^kiii, aiKl III rare instances h>eal •••'ticxes are iisnallv iiorimil, '"''■ '•^■•■. lint epileptic att use sweatiii!.:-, n'demat 'iisilioni IS sntKcient t( are i,!.;nientation of the sometimes ex; .irffateil. I'svchi e 111 llsi^les. Th. '''"'' •"■'■ iiitermitteni, tl icks have heen di-eril.c,|. '1 'IIS. lift,.]! in th -"iiii'tiiiies diiriii "■"'.V •■xist wiihoul tl ify are .sometimes remittent, or tl • •al distnrhan tl ees I'lii.uli tlie.spa,sms as a f simc ea.se. ft is .^tated, too, tl Tl If re are ea.ses in which I) jvoiiicii 111 techi,, in.,dtl,, ^vho 1 niiml; tliiit i(> spa.sms ( Jowers speaks of a variet ify may he eontimi- ■•^pasins mav persist par,-estiiesi:e and'siitiiu..>> lat the tlii'i 11 iiwakeiiiiiir, wliii lave a teeliiin- of stitli .vniet with in adult f are mstai ll may la.st for a ) and tiiiLilii i;:' ill th 1'^ III which this "si fw miiintfs or loiiaer. He s; •■fp tetany" recurs throuoh the .hi av." M 1< 222 yi:i!\'))i.s i)isi:.[si:s .wd 1111:111 THhwr.unxr. The cniirsc uf ih< lisciisc is viTv viirialplc, 'I'lic |iiili(iif iimv Imvc un, ,,i l\vosli;.'lit iiltack,-' mill no rfciirrcncc. or it iiuiv la.-'t fur many iiioiilli- | then airain, as in tlic casi' aluiVf nicntioiii'd, it uiay rcciir tliriHiirli'int a |" ii.„| i>t' vcMiv. 'riicrc .in instmircs in wliicli it has rcriirrrd year liy vcar ihiiin- the winlfi' niiijiilis. In a few instances tiie disease proves tiital. 'I'ron-viii" nieiilioiis siicli a ease in whieh \vi(h very violent coniraelioiis, |iMrtienlaiK of the nmsehs of I lie face ami iieeL, asphyxia developed and caused d.inli, .More -erioiis are the ea.-es whieli follow exiirpation of the thyroid and ilm,, which devel )p in inection with dilatation of the stomach.' Children imi infrei|nenilv die of the disease causinj: the exhaustion, nirelv of tiie teiain itself 'l"he aiialomicai condition is unknown, nor is its j itlKdo^rv as vet ihir The oecnrrence in epi.lemic form has lieeii held to .-Ik,,, the in'fei 'ive I'iiii.i, terof the di.sea.-e. The oeeiirrence alter lh\ roid extirpation and in ilil,iii|. tion of the stomach snji'^resl its dependence upon some toxic material. !■. ih, nature of wlii(di, however, we have no clew. IJoiiveret ami Devic in ci-i. of tetany in dilated stomaeh have extracted from the stomach eonieiu. :, material which they stme produces a tetany-iike irroiip of symptoms in imi. nials. Iieeentiy ( )ddo and Sarles have reported a ease of tetanv in n mM au-ed eiLditeen montlis, a.ssociated witli retention of urine and anasarca. I in i wa.s however, no aiimmiii in the urine, lint indieaii and an excessive <|ii;ni!ii\ of earthy phosphates. Diagnosis. Typi<'al forms of the disea.se are very readily reeonni/.ed. ||\,. teria may sinmlale it vi>ry clo.sely, hut neither Trousseau's iiheiiomeieiii i|,,r the increased excitaliility of the nniseles and nerves is present. In i ;i, in. stances the disease nii.uht lie mistaken for idiopathic tetanus when the -|i;i-in- are widespread, and in .such a ca.se the etiolojrical factor would he iiki-i ini- jiortant. Some writers include with tetany all ca.ses of carpopedal -pii-m. in children. This has lieeii done liy (Jriffith in his recent paper. It i- im,., as he says, that there arc numlierlcss L'-rai hit ions lietwcen the condiiii.n .4 Well-marked, widespread, intermittent c()pedal -|i;mii> t iiaper. Ii i- nii,., ■n the cDiidiiinii (,| le eontiiuKiiis III' in- tliere are instance- ir than thiw nf iln ny (sdnietiiiics uiih ci tlldse eases wliiil and electrical cxrii- iiihalatiiins m.iy in c of antis|)asiiinilic. | stryehniiie, aisiiiir. valerianate of /inc • a AoM' of diiiitali- (nrins may he iimI ?. undoriyiiiu' inmli- iften t'dlldw diivciiv as pussihle. Willi: xtracr of the ;;l;ui i lanted. tlio innculaiinii 4 diphtheria luii'illi hat which nrciifsiii ill I rxF/yrnf:' d/skas/:. niii M. Tlio oltscr 223 lie (•licniic ill viitioiis „r Sidncv .M;ir .let l>ri)(Iiicts of tlic (lijijitl tin 1)11 ill,, clianici iIImi <> cxtnict fniiii ih an ainiiinosc and un ori: iiijcricil siihriitancoiislv liiiiiica I' spleen an itnic acid, pyrexia, 1( Tl 'I'la liacili li liiiiod lit' ii> lire must ''!■ iind actmn^ 'iiipnrtant. Ih ic alliiiiMiisi |1(IS(I|1> d,.i„| of (lipliil ly was shown to he (hie to d ilfi' I iiiiinial it the nerves. Th 'ss in weit-ht^ o,!,^enei'atioii an •' pi'iKhieed i lena and il all litr:;rr doses wei I'l'y siiniiar results f 01 weiirht w "llowed the i asa verv slrikinu. | II aiiiniais, when paralysis, which aiia- "Pliy "f the ax is V necessary. .Martin's ",)''''ti"ii of the cylin- caf v ill ihe That the hacillns f products, viz. : all orn IS 111 the dipl cdiichisioiis ar 'iruan;. acid, iiut Iniiiid 111 the tissues of )iinioses and ai iflit'i'ia nieinhr; '<■ as tollow.- I oro-.,iii(. ;„,,■, I Hf and in cnltiii\ That Ihe pliysiolcoicj,] ""'■sons dead from diphij |in"hicts, vi;;. : fev actions of s (l,.n-,.|ier ,-|iiiii(liiii;- siiDstaiices ohtaiued cr, emaciation, and proj,- icria. mule or i Kiiiitical with tlio>e itioii of the peripheral ressive mu peated doses of |1 nerves, are ti ■ciilar itself ii'oin the tis le same as tli( ■lies, and tl lese due to U' corre- llie pheiionieiia of tl riiat the hacillns is therefore tl 4. "That it lil •erates m the iiieml le ])riiiiarv infect i:ist> the [iroteids of the hodv, f That these are tl .«is, ciiiaciatioii, and deal I '!. ■•That the relati\;'l )lit le iininediat inlirane a ti i'lmiiii;' allium ivc aucnt il rii le 1 di|)htlieria. '"'I'f "hich when al.M.riied' e agents m the I'ses and an oruaiiic acid. !>i'|iductioiiof fever, paraly- ly enorinoiis (luantitv of tl s|ii('iii Mil (liplitlieria as in anthrax) is ex I'li'icids normally present— staanatii than ill the uH'iieral circiilationr ])Iical)le l)v the 1 lese product fou lid in till '-' -^o to say— in the hhiod of iri;<'r proportion of the Anatomical Changes. Tl ■ph'eii 'i'l icre niav I le central nervous s liifi. and the smal •il "■ 'I sli-ht iiililtration of tl ystem is not, as a ler vesst Is I 'l'l"li''ii:i.iiacilli are not found in tl lave heen tluind hloeked will le iiieiiiiiH-es, hemorri e, 111- lauic lavcdescrihed chaiin-es in the mot le nervous svsti 1 micrococci. 'I'j linal cord, hut they are not i(^ nerves show iinporfaiil T eonstant. i)f nerve cells of {] M le le anterior hor inv ohserver- lis of ih \'iil| in in those of tl • '''■'•'''''''•'I'. '''■-'"'•'■ *'•">" . Local and livncral forms of (li|)litlu'ritic paralysis arc recognized. r^ocAl. I*Al!Al,Vsis. {!() J'ii/(iti\ jii'iiirjiii.r, niid /uri/ii.r. By far the iim.,| (■onirnon form is the aradnal loss of power in the nniscles of the palate, inili- eate(l hy a nasal tone of the voice and difHciilly in swallowinLi'. The ciiiiii^ in the voice is due to the fact that in the pronnnciation of certain woi'd- ili,- cavity of the nose is not shnt oif. In conseipienc" also of this iindiiliu !|m patient cannot distend the cheeks or Mow ont a candle nnless the iim., j, held. The difficulty in swallowinu', manifest hy rcLiiiru'ltation of liniiiii- throULi'h the nost', i-- variable, heintr nnu'h more marked in some in^i.inr, , than in others. The i)alate is seen to he relaxed, haniis more verlicalh. ;iii cannot he raised. When touched the sensation is also nuich impaiiMl, Atrophy of the muscles follows the paralysis, and the reacti(ai of dcLivii, i;|. tion has been obtained, thoniih with difficulty. This, the slin-htest ;md i i transient form of dipiitheritic paralysis, may disap])ear spontaiu'onsly widiin two or three weeks. Occasionally uiulateral facial paralysis occurs wiili ii, When tlu' muscles of the pharynx are involved, which is fbi'iunalcK n.i! :.o conimou, the act of swallowing' is accomplished with diiHculty, or in i\- treme cases may be impossible, so that the patient has to be fc(| with a iiiln'. Involvement of tlu' lai'yngeal nerves: " I'ai'alysis of the upper p;ir! fsujierior larynueal nerve) is more frecpu'nt than that of the voial im|,|- f inferior laryuLi'cal nerve). In tbt' formei' case the eiiiu'lottis stand- iik; against the base of tiic tonu'U(!, and does not descend over the o|)eniiii: dnriii. the act of dcLihitition, in conse(pience of the wcaknes.'. of the de|Mv--iir., The upper piii't of the larynx is insensitive, althou;.;h when a fiu'ciiiii IimiK- reaches the vocal cords pain is felt, llenco, fooil is apt to jret into the l;it\ii\ ami to cause couuhiuL;'. The voici^ is hoarse, pi'ohably in consei|Ui nci' .ii paralysis of the crico-thyroid nuiscle, but the vocal cords move as usual, li; otlitir cases there is paraly.-is in the rcLnon of the inferior laryngeal iinvr. anil phonation may be impossible. The laryniiiisco])!' then shows iuminlijlitv of the cords and sometimes a pi'cpoudcrant weakness of abd\ictiou, -^ tlmi the corils are not separated dcriiii:- inspiraticai. In one fat.al case, al ilnin,! of the first week, swallowing- was impossible, and there was complete niii|,ii;iii, I sensory paralysis of the larynx. ' ((iowcrs. ) {/>.) SjiicIk/ .ini''i-'<. I'araly- is of the eye muscles, intrinsic and e\ii-iii-ii'. is not uncomiiiiiu. Lossof the jiower of accouunodatiou, due to atlictinii hi' the ciliary nai-cle, and loss of the liulit reflex may be present. I'ln-i- ami external and internal strabisnuis ai'c occasionally seen, and in rare iii-tnnci- complete o|)hthalinople;.Na. There may be ('(infraction of flu- fields olxiMnii It is UHU'li rarer to have the other special senses involved, hut cax- an m: record of loss of the sense of taste, of smell, and of hearint:'. (r) CiiriliiK' iirrris, N'arious forms of arrhythmia are i it \inconniinii. I'lii heart's action may be slowed to twenty or thirty beats per minute. In nilm cases there may be tachycardia, or the two conditions may alteruaic in tin same patient. In othei' cases the j)ulse is irreaidar in volume and in iliyllmi, hiatal svncope mav occur, either at the lieiLiht of the disease or dininu rnii- valescence. < )ccurrin;i' durini:- the fever the child may, after an exai:;;i'ialii'ii of the symptoms, present niuisual palloi'; the ))ulse may cithei' be \M;ik ainl rapid or may be not more than forty or titty ; the extremities arc ■ njil. iln temperatui'c sinks, and dcjlth takes place within a lew hours wiili nil tin' features of collajise. .More ofti'U the fatal event (*iccurs(lurin!.;('on\nli'Mi'iiiv, even as late as the sixth or seventh week alter apparent reco\( ly. lin' attack mav occur abi'ujitlv while the child is in bed, or may follow a sinliicii exirtion ; more commonly lln'ie iiavi' been .symptoms [lointinu' to ilisturhul Mi:XT. i-tliir(ls (if iill cn-t., I liv pariily.-ir, ('(•(ii;iii/i'(l. By fill' tlif iii(,-( III' lIlC pilllltC. illili- Willii'. 'rilC cll;!!!",' if (•(■rtiiiii WdrcU ih,. if tliis iiiiiliilii\ ilir (! unless tlic iin-i i- rji'itiition (if lii|;iiii. 1 ill sdiiic in-iaiicc- iKirc vci'ticalK'. ani] c, al ilir iihi coni|)lcti' iiiiilniaiid I Ii ■msic ami i\niii-ic. , due to atliTiidii "i' ■(■sent. I*lu-i- aiiil 111(1 in rare in-iaiirc- the lieids (irvi-inii. ed, but cax- inviiii 111:'. it llllCOIIIIIln:i, Till' r iiiiniite. in iiii'liei I i* L\rE(T[VK DISEASES ciiiiliiic rliytlini, or tlioiv liavc iKrii faint iirrccdci 1 tl ic attaci AWm increase in tlic Tl iii^' s])ells. I n sonic H'lv arc not often i.iiysical area of dninoss and t I'sc senons syinptonis arc ascriiu'd t H' jircscncc of 225 cases voinitnitr nan -'fills other t ii ii liloj) rliytliii tniisK' heart nerve? I liy ^fosler and liv f^cvd ossihlv 111 SOI ";! ■"■Mntis of tlie va-i or of the i Me ol the ,.., ,. . ™','::,,k";»,-!,,:™'"'*' '">""'■-■''•■ i'"-'--.-:- ,.,,,1;:::;,, !,;' ,',',k c.,^^ Tl,,. .I,,"....:- .. J- .1 cdiu't onlv (i (lied. .• - "■ '>^ ^ we vtiussi- .™';.;I;;;;:';';;;;;' Tzzsc :z?zzt "'j^'";'' •■ -"■™' ■ "- -' ' •■-■•■■ ■ .li.i "."r;;;;;,, I ,,.r ;: ,,:i ;!:::"■;;' -""'™>i" «i 'i.« I" "' wnnii 'i'"' "f tlu' heart. The most .lam ei us • H ' ' ','• V"' '""^^■^ "'f'' •''<"'^- I1...I paUy supervenes shortly ancM^' 1 t;: lli:: lH''' '' -'-' -' -«'- Diagnosis. I he diatmosis is n ■• -Iv doni.tfnl .1 \'i 1 ■ "''''ipl"l'"na is clear! In nia iv i wt ' . ''"' 'V/^'"'^^^^ "•-I'l" l.as iieen nia.le maniflJ ^. 'Z^, ", ";'"7 "' =1 ^'I'-ai or nose ai'teis of that which so oft,,, t\ wl li, I I ,; 'VJ'""'-''^''^ '"'^'"'t^ tin' ehiir- l<-"H.;ierks and the slid.t i n - ^ i ' ^ ^, /'"••*"'>: ^""•I" the nhsenee of ^itaxia. uor is the ^ait,' when tl e "l s ' ^ f ' f ?'"^""i^ "^ I'^'moUn- "■'■'■; nplicatin^ the -lipl.the £ pj l^si? l''' '"' T"'"' 'V^'''"'' ''>-^- intal .,r lieiniplc.W,. paiahsis, ha> .•anscl aiuesthesia, either -'::rS!„c;';;';.et:r':md^r''''''' ■'■''■ r"'^-' ^'-- '^ -^-ik- a i''"i-'-^ ^t,...n,th and ';;:,/':;: '^;;''' '•;•'■-;--/'- to suppo,., \ut '"">'l-'> I'.v.'lectncitvand n a s. v Tw '"r''''"' f''<' ""fiti.m of the 7'liHMryformsof peripheanm, ?is ' t ,^;«''"' I'-^'^'-'ient is that of the • -N'eurologischfsCcntralblati, Bd. ix. 1.5 I •■* I f 1^^ II I iLi ^^ 13 226 NERVOUS DISEASES ASl) THEIR TREATMENT. tliaii li(|uiils. NVIicn tin- pharynx is seriously uivol;! ' ;liO paii-nt nn^i he fi'd per ri'ctuiii or with i; soft stoiiiacii-tiihi', thi' -roatest liiiv hciiiy; oMTciMil tliat particles of food do not got into the larynx. It is too rfoon to say how far the new antitoxin iri-atiiient (the residr- nf whieh soom so favorahle) 'a'U diinii^irii ;'ie liaiiility to these most seiiuiis se(|nehe of the disease. Disorders other than neuriiis may follow diphtheria ; thus nuiltiple sri, n,. SIS may develoj) in children, as noted part'' darl;. hy Slavic. Ilcmiplegi.'i following diphtheria is not usiudly .hu> t) neuritis, Iviit lo nciit' •encephalitis or to cerebral end)olisni from heart-dise:;.-''. Of Kidca-c; ol' iii- fantii" '^ niiplegia in Wollenhcrg's statistics, threi' followed diphtiieria. Ndi one ..^ iiiy series of 120 casesfolliiwed this disease. Seifert' lias reported iwd interestiii'X ea-'S Iioili in hildrcn ahont the age of ten, who had hail ilu- ordinary palsy ni' the ihrr/ai following diphtheria. In inw. hemi[)legia ilcvc]. oped sud>'. id ;• ; in the other more gradually. lie has collected only six <;is(s from the. litcuture of complete hemiplegia after tlijihtheria, two of wliiih wore fat.il, botli from lieinorrhage. As in other inshmces, the conditinn i> jirol)a^ily dm to an acute encephalitis, setting in witi convulsions and Icm r, (Jaspar Sjinrples ha.s re|)ort(>d the ca.iii. 1 Neurologisclies Ccntralblalt, No. 12. 2 Medical News, August 4, l.S'Jl. Studies in Typhoid Fever.— Five Years' Experience with the Cold Bath Treatment. BY WILLIAM OSLER, M. D. I \ I JOHN MUBI'IIY A CO., I'BINTKKS, BALTIMOKK. Ife irr.-FIVE YEARS' EXPERIENX'E WITH THE roi n BATfl TREATMENT OF TYPHOID FEVER By WILLIAM jLER M. D. During the first year of tlu- Flospital sorvioc, tvphoul fever was n-<..«l .symp(,.mat,..ally. Tl.o nun.ber of severe .a.L admitte'l was unusually large, and there were eight deaths anu.n, (hirtv-throo patientH— a percentage <.f 24.2. For tlu. iv.ct fl,.„ •-> mru, -,.l, 180% ' , ,. , , '^"' ^'"^1'''^* nve years, ending Mav loll. 189. .ystemafc hydrotherapy has been u,se.l_the method of Bnu,d w,t eerta.n m.nor n.odiHeations. J,, the first Ji.,or, (Vol rV) the plan was g.ven ; but I n.ay repeat here that ea h patent' .ce,ve,s a tub-bath of twenty nnnutes at 70° every third hour wl th. .0 tal ten,>eratu.e is at or above 102.oO. FHetions are a'p it ..c bath, and a warm drink or a stiu.ulant is given after vLd 1 the p.n s eeble wh.skey ,s given, and strychnia. The diet is - K.r -I'olly .n, k or in part b-oths, and egg albumen. It mt be .ot«l tha all the cases come under my i.nnu.diate care or Tn m y absence, that of Dr. Thayer, the Associate in Me.liein. ^ In estunating the value of any plan of treatment, it is imnort.nt that all cu-ct.mstan<...s should be taken into account. I„ the nre ™ report I dealt with the statistics as so many patients admu " om ,so many d.ed ; and this, I think, should be done in ali r t.tut,ons-g.vo the total number of cases of each disease treated aconcus>on, and the number of deaths, irrespective altogether o He length o stay ,n the hospital, or the .onditiou ou ad. ission n..,-al hosp,t.ds are everywhere liable to be repositories of the n o : vere or troublesome eases, and in typhoid feier more partieu ly f n racted cases .n which serious symptoms ha^. dellop^l 1 ^ ma h r ""'' rate of .mortality in any given acute disease may be an md.cat.on of a s,>ecial usefulness of the institution A eady g.ven, the general statistics of the Hospital in typho d fevt I' 321 I ;122 Willium fMir. Cases iidiiiilti'd "luring the six yours eiulinj{ May lotli, 1895, \miil)('r of (It'iitlis, - - - - - IVrcontiitrc of niDrtallty, - - - - Cases luliiiittcd lu'l'on- tlic iiitrodiii'tiou of iiydro- tiicrapv, _.-.-- NiimlxT of (Icatlis, I'crcerJn '(' of mortality, . - - - Cases admitted since tlic iiitrodiietion of liydro- tlierapy, Number of deatiis, Pereentaffe of iiinrtality, . - - - Xumlier of cases hallied, . . . - Nunii)or of deaths in tlie bathed cases, l'ercentay;e of mortality in the bathed eases, - 38U 34 M.7 ;53 s 24.2 3oG 2(i 7.3 2it!i 20 G.6 The percentaj^e 7.3 represents the total mortality durino- the |ki-i five years; but as it does not represent the mortality of the i;i-'s treated by hydrotliera|)y, the figures must undergo a further analysi-. Many circumstances interfere with the systematic earryinj; out nl' ili, plan, among which the following are the most important. In the first phur, a number of cases are admitted in the sccdiHJ week, and even in the third week, with u falling thermometer, ami the fever constantly below 102.0°. Cases, too, are admitted early, which have low temi>eratures and mild symptoms throughout, liraiul and others urge that tlie>e should also be bathed; but in a large pro- portion of all such cases, this appears superfluous. There are exci ji- tions, however, — cases in whicii the fever is low on admi-sion. and even remains low for a week or ten days, to be followed by active and threatening symptoms. Nos. XXII and A'A'/A'of the fatal cases were of tiiis kind, and in both one could not but regret that the l)atli> had not been used from the outset. In the very mild cases, mi ii more frequently in private than in hospital practice, the baths are unnecessary. Last year we admitted an unusually large number ot such mild eases. In the se(!ond place patients are adnr^ted late in the disease, ami are too ill to l)athc. A patient broughi m at the end of tiic third week, with high fever, rapid, feeble pulse, meteorism, and diarrineii, lay - 38i» . :U - H.7 ro- . ;53 - 8 - 24.2 ro- m :}5»j - 2(1 • 7.:} - 295) - 2t» . (5. (5 diiriliif tile |i;iM lity of the i;i-ee, the batiis mv hirgc uuniiiri' ot II the disease, luul end of tile tliiiil , Fhu Ymrn' Krperkncr iritl, (he < hf,l Hull, 'JW<>f,n,nf. ;;2:'. ^ta..d.s I helieve a nn.eh he.ler .hunee, with earefnl sp.uvinu. ,o '"'•"■;" »'"• *^'v<;>-, than he .ioes with fihl,iM,r everv fourth ,„■ mU hour an.i (he dmtnrimnee nnuvidahl.. i„ the hfting'out of h.d The,., were hve patients u.hnitted in too feel.h. a .ondition to hu.he", no, one i<\ wliom liied. Tl,irdly, there is a ;:ron|, of .,,ses whi,.h on adn.ission present serious 'ympI.mt.onH-huMuorrhag,, signs of p, rfora.ion, very intense hron- . IntiH, pnenmonni, plenri,sy or intenso meteorism with severe .liarrh... , On aeeom.t of ha.uorrhage the baths were postpone,! on -everal o..,..', - sK.ns There was no insta.we in whieh .,n ..chnission ,he puin.unarv symptoms seemed to eontraindieate tlie treatment Fonrlhly, there a r." cu-es whi.^h wer.^ not bathed' at tirst b,ranse the ely resend,liug typiu.id fever-s„ nn.eh so that baths 'u-e been g.yen. These are instances of the so-eal!e,l astivo-autnunud tevor, m which the organisms may at lirst be ditfieuit to lin„,orrhage, 1;} ..a.ses; perfora- ta"., in wlu..h condition even th. sponging is ra.elv allowable, but in winch the extremities may be bathed without disturbing the patient • on ..count of great weakness and prostration, 11 eases; ,.,. account of' 'f Y" mental symptoms, f.,r one day in one case, for two d.us in ai'otl.er; for extreme tenderness of th,,. ab.lomen, for one .lav" one case; for severe bronchitis, fbr intense laryngitis, after operatio'n . al..scess of par.>t,d, fbr severe phlebitis, for plenri.sy, eae one -as 324 Williwa Osier. In many of the fatal cases tlio baths were suspended for twenty-four, sometimes forty-eiglit hours before death. There were several instances in which the symptoms of relapse weiv so slight that the treatment was not rigidly enforced. Of the 356 cases treated during the five years, 299 were bathed, (jf these 20 died, a mortality of 6.6 per ceiit. Of the 57 cases which were not bathed for various reasons, usu- ally because of the mildness of the disease, six died, a percentage of 10.3. This high ratio of mortality in the unbathed cases is, of courw, due entirely to the circumstance that conditions, mentioned below, interfered with the use of the baths in a group of cases of unusu;i! severity. In the six fatal cases, the histories of which are given in full in another place, in two, Canes A7 and XVIII, the diagnosis \va> wrong; in the one an old man of 70, with consolidation of the lower lobe, the disease was thought to be lobar pneumonia; and in the other, the patient had been in hospital tiie year before with entero-coliti.-, and on re-admission with severe diarrhcx'a, typhoid fever was mi suspected. In Case XXVIl the disease was at first thought to be tuberculous cerebro-spinal meningitis — the temperature was low, the nervmi- symptoms marked, and it was not rntil parotitis developed that torionsIv ,mcer- tan, unless all the circumstances are taken into acco.n>f. In our own f:.n.rcs for the past five years, fur example, illustrate this-G.2 percent in the bathed ease.s^ 10 in the unbathed cases-as the latter group i.' nuule up enttrely of cases too n.ild to bathe and six patients i,> whotn either the disease was not recognized or who were too ill on admission to treat. Statistics have a value in this connection only when the figures on which they are based are numerous enough to neutralise in some measure their notorious mobility. Small groups of cases are useless • -t per cent, o mortality in our first year in thirty-three eases, and a .eries of nearly fifty bathed cases without a death, illustrate the abihty to error ,n discussing a few cases. Unfortunately, typhoid fever ,s a disease in which the cases may be re'""'■«' e"t''ng May 15th, Siox.— 124 were males, 36 females For the xl.v years.^SU were males and 78 females. iiA(i.:._147 were white, 13 were colored. /'«;■ /Ac ««; /;mrs.— 355 white, 34 colored Tl.o mf ^ , , wlMte in the admissions to the wards is allnit 17 ''"'""' '' Nationality.— Americans (exclusive of col..r«l^ 77 n »^; ''<'I<'H, 8; Irish, 7: En ^'ennans, "oiH-nian„ 3; Welsh, 1. " ' ^' S-«cl,navmn, 4; Russian, 3; /w//,e.s;.ri;mr.s'.— Americans, 154 -Germans 114 J ■ u ^^ ^ ;M5;8cotch,2;Welsh,l;Se;Klin ~^^^^^^ 12: Russia.,3; Italian,!; Syrian, 1 ; Fi„; i'. '^"^''''^' Bol'em.ans, amity, 2. •^' ' ^ ^^ ^^^^y' '^ > sixty to I'or Ike m- (/ra/-,9. — Five to Mtoon 'io . «a ':- • >. 203,' tl,i,.., ,0 ;„,*;"52 fo, „X .6^^ ,"^"""'^ «lyt..«.venty,6. More tl,M „, p l! f f ., ^' ' "fj" <" »'«?, 8; l>m!iijbor, 3. ' ^^aoDer, 25; JNovember, 18; 281 I 1 I I ' * i ; 1 ; 1 1 . iji -mam 282 William Osier. For the six yeors.— January, 16 ; February, 9 ; March, 5 ; April, 1 1 ; May, 9 ; June, 14 ; July, 42 ; August, 74 ; September, 69 ; OctolaT, 65; November, 52; December, 19. Locality. — Far the six years. — From the City, 303 cases; from Baltimore county, 50 cases; from Maryland, outside Baltimore county, 14 ; from outside Maryland, 18 ; from steamers and doubtful, 4. Mortality. — In the 5th year eighty-one cases were treated, with five deaths— a rate of 6.1. In the 6th year seventy-nine cases wviv treated, with seven deaths — a rate of 8.8. Of the one hundred :iiul sixty cases considered in this report, twelve died — a rate of 7.5. For the six years. — Of three liundred and eighty-nine cases treated to May 15th, 1895, thirty-four died— a mortality of 8.7 per cent. For the five years since the introduction of the Brand method, tiirw hundred and fifty-six cases have been admitted, of which twenty-j^ix have died— a mortality of 7.03 per cent. Of 299 bathed cases, 20 died— a mortality of 6.6 per cent. cl),5; April, 11; er, 69 ; Octolicr, 30!) cases; from Jaltimore county, doubtful, 4. ere treated, witli '-nine cases wcic )ne hundred ami rate of 7.5. nine cases treated 8.7 per cent. nd method, throe vliich twenty-j-ix per cent. ...^SPEOIA. ^-i^ATORKS. mrPTOMS ANB COMPLI. By WILLIAM OSLER, M. D. '.-ANALYSIS OF THE GENERAL SYMPTOMS l~J^\f^^^-~^'''^-n^ot, were noted in 119 cases Total for the s,.v year^.^Zn, 81.7 per cent. PEcnLiARmES or the IU,SH.-(a). Hannorrha.le .lames M., aged 22 (Hosn. No 779aN n i ••" i>n.rnse on the ahdonien -u d In,'.! r l '''^'»>'««'»» tJie rash wa.s The eruption was ahnni: thl: C' 1^:^ '^ ^ ^ "^^ severity. Recovery. ^ '""^'^ack was of moderate b»n a,-ca ,he«ize of a IvTI, aHr"',"^''^"'"'''" 'P*- ""J '^ere b. .a.™ ..lace. I„ iilrj^^ ^ :^';t X""",' "'™"*"«^ spots are seen." ^^" '''^''^' ecchymotie rose- ti. ''3:^f •;:'^ irarr:r ^" r r -' - ^'^^^ - a'-ndanton the arms. Tie sits ^".7. 1'"' *'*^^ ''' ^^^ more ha^morrhagic, and a si In "^'""''^'^"^ ^^e 4th have become left costal border=in\hem d^x ar^;fn:TH^^" ''''''''' '''^'" ^'^^ a'so upon the posterior axillary fold!" " "' ''"""^'^ P^^^^^"* Michaels., aged 22 (Hosp. No. 11392^ Tha.,. . 283 284 William Osier, ill numerous on the upper part of the chest. They were present also un the arras and a few were seen on the thighs. On the 10th spots dt' simple purpura apjieared on the skin of the right shoulder and ot' upper arm. On the 11th many of the rose-spots on the abdomen wire htemorrhaglc and did not disappear on pressure. Jesse T., aged 28 (IIosp. No. 1 1861), admitted January 19th, IS!'."). The attack was severe and the fever was high. Tlie eruption was profuse, and on the abdomen the spots became luemorrhagic. (6). Riish Persistent while Patient Afebrile, John G., aged 21 (Hosp. No. 84G1), admitted on 10th day. The temperature was 105°, with unusually abundant rash, of a deep lowe- red color. The temperature i)ecame normal on the 21st day. < >ii Noveuil- . xd, the 23rd day, v lion the temperature had been iKirmuJ for 36 ;,-•>:, fresh spots appeared on the abdomen. On No\iinl)t'r Qth, tiiv /{*>i!! day of illness, there were fresh rose-spots. The rectal temperaiurc' had, in a two-hourly record, only registered 99.5° oiKr, and once 1(0° since 12 midnight on November 1st. On XovcinlMr 9th the spots of the 6th had faded. Charles S., aged 25 (Mosp. No. 8930). Mild primary attack ; scvore relapse. Hash abundant. During the 3rd week of the relapse, ■while the temperature gradually fell from 100' to normal, fresh spots appeared on the abdomen, and on the 23rd day of the relapse, when the morning temperature had been normal for five days, the spots were still visible. (c). Anomalous Distribution of Rash, Augusta A., aged 48 (Hosp. No. 3168), had a very mild Mttack. The spleen was easily palpable. There were no typical rose-spots on the abdomen, but on the arms and hands there were many slightly raised, red spots looking like those of typhoid fever. id). Exceptionally Profuse Rash. August G., aged 26 (Hosp. No. 11119), admitted OctolxT lltli, 1894, about the end of the 3rd week of the fever. The tenipt'ratiire was high and all the features of the disease well developed. On admission the rash was exceptionally profuse over the entire trunk and on the shoulders and arms, and very thickly set. On the loth Special Features, Syntpioms ami rom,Mcafiom. 286 the spots had extendecj down the nn.w ..„,! <• 0" .1.0 neck, a .unnbc- could be" ./hm"'' V' '"^' ""^ •^'"" none appeare,! on the face. ''"^''''' " ^"" "" ^''« '«g«; (r). Pc/mnata. Tlie only cases were as follows :— .lames E., aged 32 (flosi) \„ •n(io\ i •.. . , ^v.■.■k. There were wcl -nn -..I ^ -^l^'^), n.hn, ted the end of the first flank two steel-granlClur^ '''''■'''''' ""^' ™ ''^^ «'-> o^' tLe loft Carl JV., aged 25 (IIosi) No 9fi'■>'-,^ I. i . . of demonstrating two cases •— v oi. v ; ,,„ t|,e occasion ia.j »"..o ,.„s „po„ «.„•,. iJenccC'u" ;;":,',;;;■;' ;'":= o»as«,nal ..cciirreiuK uiti, ,K.,liciili 0,l„,, i ^ ' ""'"' l'>".l., .■lain, ,|,„ „„, ,,„', ,7 ' ;, 2™ •*'""7. 7«i-lly li.e .inilarl, tl,c Hiouli pubi,; "U'^.r l"' ,';"'' '"°''° '""- tl- l-li.»li or ti„ir „L ™, lib ,,1 f I ;."" "'" "I""" '^'''"' .« of (v,,l,„iJ fove,. in wl.J .1,1 r " "'°''"°'' "■' '" "'« * ; ea.: !„,.„« .o'l:':::;:::,i: ::::;-::•;'— ^^^ -■- There are at present hi c' T '''"'^'"*^*' ^^■'■^'' '"^^^'^'''U- dice and a, ot"! «lT I" '" T'''^; "" "'^'^ -^-rhal Jaun- "oither case i he^ a^^^^^^^ '"'"^''"^'■^ ='"'' -'Pl'-Vsen.. In are numerous st e Ir ! s ! "tf ^7'"''-^^"-' '"'^ '" ^^o^'' there inner sides of tldgls..Kl "fr' '"" *^" ''"^''«'»^"' ^''-«^. both the nedie, J " '''''''' •^" *^« '"''"« «°d J^gH- In ent J„ both e. M "^'' '''''''' ^^'' ^'"■^"' ^^^^"^'''•^••s- are pres- 1.- ! tri: d^:^r' -^'^f ?' ;- ^"^^^'^'^^' ^-^ •- "^^- appear to hav" c s d n u I'!- "" '""' "' ^''^^^- ^'-7 do not caused much ,rr>tat.on ; neither patient complained of \\U\ IMAGE EVALUATION TEST TARGET (MT-3) /. ,v c^. Us 1.0 I.I •i^lllllM ill I4£ = •- I— 12.2 - lis llilio IL25 II 1.4 18 1.6 Phoiograpliic Sciences Corporation 23 WEST MAIN STREET WEBSTER, N.Y. 14580 (716) 872-4503 # iV iV % V ^L^ \ •^-l^" ^^'^^ J I I 286 William Osier. itching nor are there marks v/f much scratching. Indeed, I find tlint one patient, formerly an Austrian soldier, is quite indignant at tlie removal of both hair and i>ediculi. He tells me that they are m- sidered as bringing luck to the bearer, and each sells for from 5 to 10 kreuzers among the soldiers. They had been carefully carried by liim for ten years. Crocker states that "Moursou in 18G8 wrote concerning the fingor- nail-si^ed, steel-gray spots of pigmentation (maculae cerulcae, taclies ombrecs) which are frequently seen deep in the epidermis of the affected areas. Duguet in 1880-82 showed that this pigment was contained in the thorax of the a.iimal, opposite the anterior pair of legs, where there are known to be taro pairs of salivary glands, and it is probaWe that the secretion is conveyed into the tissues through the haustellum. Jamieson thinks that the stains have some antestlietic eifect as far as the itching is concerned." In this patient the lnrhc'i bleudtres stand out plainly against the somewiiat jaundiced skin, and, as can be seen, are most numerous in those positions in which the podi- culi were most abundant. The pigmentation seems to disappetir after the skin containing it has been pinched for a few seconds. n. — The Fever. — In 119 cases the thermometer registered 104° and over (rectal temperatures), Six cases only had a temperaluni of 106°. Forty-nine cases had a temperature between 105° and 1(16°, and sixty-four cases a temperature between 104° and 106°. In no case did the fever reach 107°. Of the eleven fatal cases during the 5th and 6th years, the liigliest temperature recorded was 106.3°. Nine had fever above 105°. Case Susie B., given fully on page 345, had a low temperature during the greater part of her stay of 9 days in the Hospital. The highest record was 103.4°, and there were only a few hours in "liieli the temperature was above 103°. In the case of A. B. (p. 468), tlie tera- peratare was 104° on admission tc the v ard, but at no time subse- quently did it reach the bathing point, 102.5°, except just before death, when it registered 104°. For the six years. — Of the 389 cases, there were 271 in which the thermometer registered 104° and over. In only one case was tlic tem- perature 107°. In 14 cases the temj^erature was 106°. In 118 cases the register was between 105° and 106°, and in 147 cases tlie fever was betwee' 04° and 105°. Special Features, Smwioms ,nu1 o r ■ III, — The Pulse .Tl ■ °"'y 2 ™ i' "ore than 160 ,^r lllj^.^ '"''*■ '"'""'='' '«■ IV.— Diarrhoea Ii, 41 pa.p„ ...„ i ^'-•e -e at son. ti.„e or Xdllw^^ ::;:;"-^ ^ ^^ -- movements in the day-n.oderate diarrlue. J,; «' ^' '1^"^' '' ^«"^ "'• more mov^enients in the ihy~exc,..;.n r > ''' *''^'^ '^^''^^ '^^^ The condition of the bowel in t k 7m ''"• -von the diarrhea was ,"^ , ^ ^1 "" "" " '^""^^--■» bowels were regular. ' ' *'"'''' excessive, in two the For the six year^-.— The hnwol^ ,. 1 ^30 per cent. L, 36 of ^tj^;;;: ''"''' ^^ ''' ^-^^^ of ^eS89- "HKlerate or slight. '"ovements were frec,uent ; in 81 .>i^:;Itn.f^r;;;^;:;;:;:;^^^^ relaxation of the abdo.nfna t I .f ■, P'^''^"'^^'«"- ^^^'^1' ordinary organ can be felt ^X^t^:^'' of a nuxlerately enlarged the splenic re,,ion, the Ingers we 1 1 I 1 "' 7''^' '^' ^'''' ^'«-' «» pain, pressing towards the'r ^ \, f ll' :"!' T^'^^ ^^-rds, the 'leep breath, and the fingers of Ih 1 /''? ''^ '''''^ **> ''-"v a border, will feel the edge of the s n l f T' '"'' ^"^'"^ ^''^" ^^^^^ over the.n. When the f bdon a t" J ""''"""' '""' "'^'^^^ to palpate Just as the mnscl Lr d ITr '''''f''''' '' '' ''''''^ yet the border of the'organ c 'd lottfV"' ""' "'""""'' '^"^ ti.e abdominal walls. * ^' ^''*' «^^'"g *« the tension of For the six years.—Jn 244 of fJ,« oon was palpable. '^ '^' '^^^ ^««^« ^^e border of the spl^„ 2— RELAPSE. Tliere were five oases of relaose in a. ^.1 "' the 6th_fourt^n cases i7tr ?''/'"'' ""^' »'»« ^«es per cent. The total Tu, ^ t T ,""'"' ^'"^ '^'■^'^' '• ^"^ ^.7 nine,.ases was thirty-twolsV pe It "t, '" '^ ."'' ^'^'•*^- "ot included. ^ ^^"^- T'^e d 02.5° to 101.:!°, ble. The tongue ons. September 29tii, s severe, and the 1st. It renuiincil Jtion of 10 hours abdomijial |)!iins, i furred, and the ;ver ranged from ; no definite rose- \ the 15th to the nd after the 19th :ed August 28th, intermittent, and od was negative, pots. The (cm- four days ranged it was normal— noon of the l-'Stli tl until the 2oth. ibtful rose-spot,s might liavf iieen (in the Hospital) An interesting dor, whirii, with spleen (together seemed to settle ;i2 baths before the temperature ^oM 1 ,l'\^' ''''^'^^> «"d he had and 10th tl,e ten,perature to he 1 T ""Y'^' ^» ^^'^^^^^ ^^h 14th there was a;yrexial^r;'tr;;1;"^ ^-m the 11th to the iIh' 15th reached 103.5° Tifo V , '"' '"^'^'"''•e^', and on ^ ■ i iiL lever •"■•■ ■ •-■ > -. « . - i-e had 41 baths in the rdapse" Tlirf '"' '"'''''.'' ^^^^-lOo", and hve baths; ,e,u,,er„„„,, ,,„«o ,V„„, loso! JV »' tP'"™' *™"'^- became normal on the 41st dnv v . * ^''^ temperatui-e .i.« 4is, ,„ .,,e 64,1, day T^~:^::-:;;;'''^7»'''- ''"^'■'■* •■»"■ 20.1. n slight rise in tompe™, J , ' ,7,2 , '''''';'*; "" "'"'^''^^ fever ta lOOo. P,,.i„ ,vi.|, J/, „1 ' l^ ' »"'' ^^"l chilis, with const,t„(,.,„al ,.v,„p,„,„s fVo,,, Decen.tl 2 , ?' ''* '""' *«"> #%.. Pain in al,'™"-"' »"'" .i.ai .... April 23„,, jnst si;,!:„nl'X iiX,'"" "' '"" "«- TI,e.o„,p„,.at„.„ ™ge .v:^,it:n X'o! 04o'"'iT''>- <■';-»,"«>■""• ...».k;»l ...fl..e„ce, and eaeh tin.o rednced the 'te "' ""' " ""^ 01- siilHiormal. On the cvrni„„ „r . , - , '"""" '° "»"nal »«.., .he feve,.disapp e , "Sf, : ""•' '>'\'"' '^X afte,- aseenee give a nictn,.p „ V ""•^■' =^'"' "'^' fe've p.ctuie unhke anything but a rela,,se EvaM.,aged25(Hos„ No lOBOfn , . , «l.e was a Lithuanian, a nd eoi iS'l' f' '^''^""'"-^'- ''^^^>''^^- -'"> lert her at the H^spitaH t vT 7T""' ^ '"'^ ^'^ •— weeks. From the 10th L the 22n ,: ""' ''' '"" ''^'' '-' ^-> times above the bathing point (1095;; ""p/''"^''' "'''>• t''''- -" tour reaction; doubtftd spots were seen • tZ i "'"' '' '^"'"t 'I'azo- were no abdominal syn,ptonsTh .:!'"" "" ""^ ''"'i'^'''^'" tl'e.e ^7' -d the tongue at'fi.t was cJ t: '^ f^ "'^ '"" ^'' T'"'^'*' at the base of the left lung, with rile. nnT ■' "''' '''^''^ ^'"'"^^«« "ogative. Fron. the 22ndVo t 4 1 ," ""? ''"'*'^'"^^'- '^P"^^ tl'en a rise gradually to 104° ;',\ 'T" ''^'"■--^^•^•- ^'^'^s; Tl-ere were no spots / the s,^een ", if" " ^ ''''-'' *'"-^'-- diazo-reaction. Fever, in rZ I t's'! ! ' ^^" ""^ =' ^-'"^ were the only symptoms. '''^'"" "'"' ^'"•^l tongue Charles \V„ ai^ed '>I /'W \- , 1804, about the ^nd ll ^Zr^l^''^' ^^""'•""^ October 2nd, ranged between 103° and 104° th, "'"■ '^''^' ^-"P-'ature '"arked ; the spleen was palnablen'n t"''' '^'"' *''^ ^'-^^''^ ^vere "-->'• O" the 11th, 12^^ :i"3 ;:;;'^^^''' ^'-^ ^-^P-atnre was 97° and 99°. On the Hth it, ^ temperature was between to 10.3°, and then f^ l^ ^f ^U f ?"^ '''' ^ ^'-'-»' "- 102.5° and 103.5°. The f ver d T""'^^ temperature between were no fresh rose-spots th! " ' ""''' ^''^ ^^^''^ There was coated. ^ ''' ^'^^ '^^'"^ ^^^« Pa'pable, and the tong e r. j 292 Witlidm Osier. John S., aged 20 (colored) (Hosp. No. 11102), admitted Octolxr 9tli, 1894. He had been ill for four weeks, hut he was so dull ml stupid that it wasdiifieult to f^et any accurate information. Until the morning of the 12th it was not thought that he had a specific fever, as the temperature did not rise al)ove 99.5°. Fo" the next week it ranged from 99° to 103°-104°. The tongue wjis furred; then; was no diarrlKca, but a diazo-reaction was oresent. Tlie spleen was not palpable. Tiie fever fell slowly, and by the ;5Ist the teniperatinc was normal. For five days the morning and evening records wcw below 99° ; then, on the evening of November 4th, tlie tomp'M'atuic began to rise, for a day or two not reaching beyond 102°, antl ou the 8th and 9th touching 103° and 104°. The tongue was furred, but the spleen was not palpable. On the Tith the temperature was normal; on the 13th and 14tii there were slight rises, and snl)S('- quently the temperature remained normal. This patient may have been admitted in an interval between two febrile periods, lie looked as though he had had an illness, and the muscles were weak ; but his tongue was quite clean, and tlier.' were no abdominal symptoms. Subsequently an interval of five days sepa- rated two periods of fever — one of nineteen, the other of seven davs. William H., aged 28 (Hosp. No. 11212), admitted October •J.iid, on the 18th day of fever. The tongue was furred, the spleen was enlarged, but there were no spots and no diazo-reaction. The attack was mild, and by November 4th the temperature was normal. On the oth it rose slightly, and then remained normal until the l.'llli— eight days. From mid-day on the 13th to the 24th there was t'l vor of slight range, not rising above 102.5°. The tongue was furrctl, the spleen was enlarged, but there were no spots. There was no diazo- reaction, and the patient had no abdominal symptoms. Albert G., aged 31 (Hosp. No. ), admitted February 5tli, 1895, about the 10th day of the fever. The attack was severe and typical; he had thirty-tive baths, and by February 21sl. the temperature was normal. He sat up in bed on March 2nd ; out of bed on the 4tli. The temperature remained normal and sub-normal from Fchruary 21st to March 13th — twenty-one days. On March 13th, 1 Ith ami 15th the temperature rose a fraction of a degree each day, reaching 102.1° at 10 p. m. on theloth. On the 16th and 17th it once or ''^P^cial Feature., Syn^plo,,, „„,^ twice tiiicJied 102 5° onrl ♦, • . " -^ '"rrcd; there were no alZ^ J "''''' ''''''^^^^^' ''^'"e t„n,M, was felt in the o-i^ina, attae^ : Wd i^X'^'' ' ^''^ ^'"-'^ wl'.^ '-V «...spu,.ous spots. The eon^les 1 t " I '""'' ' ^''"'^ ^^-^ a -"'l'''""-J -f a general te.ulen.e.ss of , '''; ''" -^'"■'' -^^'^ ''« The days of apyroxi. w.. r „ ""' ''''"'' ^^'''^ """"^f- 7. -3, 5 8, 21. One case ha.l two well „, i ', ' "'' -•^' ^ ^ -^. ^7, -nterval separated the ori.in-d ■ u " '■'"'"•'^^"d relapses; 23 days' .lays the first and second ^^T '"' "'"' '•^■'"''-' -<' 4^ KkLAI'SE.— DOUHTFUL Cases. Charles S., aged 25 (irosp. No 89'lnN ) • For ten .lays the feverwas Lyth^t tf r^ •'"""'•^' ''^'' '804. po.nt. The spleen was ^alpahlT; d t ""' '•"■'' "'<' '-''""g There was no diarrhea. () tl 'i5t| r7,r;''' =' ''^'^^ — P"^' l--t"re tonched nonnal and ro n l ' ^"' ""' '«^'' ^''« 'en,. iOl °. Then, from the 19th to tie ' h"""'"'^ '^ '''° =""' '""•<" ^o 1^°, and the patient heean. In d ^ ^^^ ^^ V^^^^' --'^ to not present nntil after the lOth Tl. . ^^'"^ *''^^'>-'-«l,o.e were „„„|,'|„, , 7 '^""''"'S^'i Le <-on,plai„«, „f 204 Will id III (hlcr. Kniilo (J., a>?wl It (Hosp. No. 10;W5), admitted July 9tli, 18!»l. iSeVfiv attack ; scvonty-thrtr baths to Jtdy 28tli. Kidarpcd spleen; no definite spots ; no diarrlujoa. From July 28th to Au^;ust 1st the temperature was between 100° and 101°, falling once below normal. From August Ist aecession of fever — 104°-104.5° — baths causing drops to !>8° and 97°. High and persistent fever of nine days' dilu- tion; spleen enlarged; distinct rose-spots /'oy the jird liiiw. From tlii' 9th to 15th of August gradual I'all of fever to normal, followed hv uninterrupted convalescence. Walter J., aged 26 (ITosp. No. 10426), admitted Jidy 19th, 18!M. 'riic patient was a soldier, and had been in bed, in hospital at Fortress Moiu'oe, for thirty-two days with headache, fever and weakness, hut he had not had diarrho'a. When admitted his temperature was !»!)°, but in the evening it rose to nearly 103°. The edge of the splci n was palj)able, but there were no spots. From the 19th to the 2")tli the fever only twice rose above 102°. On the 21st there were snnic suspicious rose-spots. From the 25th to August 11th the fever wiis higher, 103°-104° — and ho had baths steadily. The spleen was enlarged, but there were no fresh rose-spots. The diazo-rcaetiim. which was not })resent on admission, became well marked. ( )n AiiLnist 1 1th, r2th and part of the 13th the temperatm'e was below 100" most of the time, and the tongue became clean and he felt better. I'lorii the 13th to 15th the fever again rose, and until vVugust 2ii(l kept between 103° and 104'^, requiring constant baths, of which ho had to tiie latter date ninety-four. On August 17th typical rose-spots wiiv seen, and they recurred. The tongue became furred, but the general condition kept good. The diazo-reaction was present, and the spleen remained large. From August 2nd to 12th the lever fell slowly to normal. From August 13th to October 3rd the temperature ranged fi'om 99° to 100° and 101°, and twice rose for a few hours to between 103° and 104°, the last time on October 4th, the day on which he sat out of bed. Counting the time in which the patient was in bed at Fortress Monroe, the fever lasted one hundred and ten days. It is very probable that on admission he was in an interval between two attacks, though we do not know that the fever had been down for any length of time. The three days from August llth-13th separate dearly two febrile periods in the Hospital, and in the interval the tongue clearal IjL July lOtli, 18!M. ■^pital at Fdrti'css 1(1 weakness, luit )oratun> was !M)°, \iTO. of the spleen lOtli to the I'otli tliere were sdinc til the fever \v!is The spleen wus le diazo-reaetion, ked. On Auirnst below 100" most It better. l''rom Uigiist 2nd kept which he had to il rose-spots wvw , but the geiioral it, and the spleen ver fell slowly to iiperature ranged hours to hetweeii y on which he sal ween two attacks, i^u for any length )arate clearly two lie tongue cleared •Vem/ Fmfure., s,,nj,(o,n uiid he looked '" "'I'l (hmn/, III srze. "iiioh better. 'i'|, 'iiij/ic(ifin)is. iM ri()(is I'o c«He belon^H („ a group „/ '^I'l'^-M, however, did 29/5 not reduce of hijrh ( f»!)° to 100° an.l loi IJohert R, «ver ai'c separated I P"U'';"at interest, hMvhici )V '"tervals of mihi ' two or till 'ee Vyvoxm of ;'^-'2''(irosp.Xo.n%-.3,,ad 'f'"layofhisfi.ver. Tl... -.' fS!»o,on the 14th day of | • ,.week-]04o_io/i./i°. He'hi.d I 'J'i "' '<''iip'^''ii(ui niittwl Feh, nary 3rd. aiiitc pleurisy, with eff, )ath « and then ■0 ranjr,, w^s U\^\^ '<■•' SIX CllllScd IK) SVIll I" March ilih th. ,, tlic isth the i'ever fell (late fell below 99° i :''^---'<'«m.hiaiiv(LL!!^^ 'I' ••••-' llfTf A An fro was coiitim,„„,s f "'sappciin.,!. I nun KTadiiall 'ever. I{,,t 'iiission, but •Vbruary;in| y> and ,,„ t|„, , fcnipcriitiire at some «!• 100.5^ ill the aft to March flth, OIK ''••^"' the 1 8th t(»tl iv w J>art oftho (1; "•""• Then followed ''<* niornii en IS below 99°, but \v '■("'. the loth and '""■"'■"J,' "f (he latter ' 'K '>f (he 24th the '■<»>'<' to 100° n which there spilt ■'• 'caching 102.5°. Thosnl \V'as a mild fever— ior)° '» period, from the 24th no f/iazo-roaction in tl '}>ieendi,l„„t,.„j3,,^,^..jj to 102°. -only ^.snoleucocytosis. The pleural dad no diarrli ell or ^'a. He had lie urin(> efr.i 7;'^7'-''t-''ernessofthe r\^ (lid tieno.-m-' "'I '"*".«. The fever fZ "; r !" oT ' "' T. ""'' "" '^^femlH.r 27tl, o .7 ^"^ tempera- *vo.„ 98,5° „„,! ,00.50, rf" "■ f " ','»™g '■■■>ng«I f„r ,„.„ „J° 10.,5 ;j„,| re,„ai„«l belivm. lon'o j , ""■ '™|Kralnre 298 William Oslo'. fluctuations botwcen normal and 100°. The tongutMvas clean, the bowols i-egnlai', anil nothing was found to account for the three davs of Ibvor. Ca,sr A'A' 1 7i.— Harvey S., aged 25 (Ho.sp. No. 10975), adniiii,,! iSepteniher 26th, 1894, at the end of the ilrst week of fever. \un- a week the temperature ranged high, once nearly to 100°, hut tlniv were no s|K'(!ial features, and on October otii, (Jth, 7th and 8th ih,. temperature touched normal each day. On the morning of the ,si|| the iever rose u) 102.5=, and on the !)th to 104°. There were exadlv forty-eigiit hours of iever, after which it disappeafed completely. The case is interesting since a period of four days in which tli,. fever was not contiiuiously normal was (idlowed by what aijpcaivd to l)e a very characteristic post-typhoid recrudescencic. Case A'A'17i/.— Ciiristopher T., aged 19 (Hosp. No. llOO!)), ad- niitted October l.st, 1894, in the third week of the fever. The lever fell on the 10th, and he entered upon a satisfactory convalescence. On the 2Sth the fever rose, and on the 29th reached 103.5°. On th,, evening of the ;30th it fell to normal. The rise Wi.s due to a foin.iihu' tonsillitis. Streptococci were obtained in pure culture. Case A'A'/A'.— >.richael S., aged 22 (Hosp. No. 11392), n.lmitled November 14th, 18!)4. Tlie attack was .severe, with high ievei'. Tlir lysis was protracted for about fourteen days — from Novembei- 2Stli to December llth ; the temperature remained between 99° and 102 . On the mornings of the llth and 12th it was normal. .Vt 8 p, ni, on the 12th the temperature was 100.5°. During the morning di'tlu 13th it rose to 103°, and throughout the day ke|)t high. On the 14tli it remained about 101°, and fell to normal in the evening. It did not rise subsecpientl)- above the normal. There was nothing' (oiind to account lor the elevation. It is interesting as .separated hv a vorv brief interval of apyrexia (scarcely, indeed, for an entire dav) f'idiii a very prolonged lysis after a severe attack. 4.— TYPHOID FEVER AND MALARIA. A careful examination is made of the blood in everv patient with fever admitted to the wards, without which some of the cases of autumnal malarial fever could not be differentiated. A full aiialvsi> of our malaria cases for five years has been given by Drs. Thayer and J'i ''"'"' ^"'-'- ^.,^^.. .„„ a.^,,,,,_„ ,,^ jr^'-f --,^-" tlK. sa.no :, ^^^'7^ ^''•«. vieinit, a^ ^ '''■'""■f <>" fypl'oi.l fovc- thoro was "»'ntione.l i„ our first ;: «'-Y";>..,i. ,,.., ,. ,.,,,^ . ; , ^ ';;V"i''---. '•• one ,..o in '"'•-"•/'•-I occnrrcl before the Ja ) ""' "■'^■^^'"" -'"fi' tl.o '" f". followinfT n.n.arkal.Ie ''''^aj.peare,!. '■'""■■""ons malarial fever .-1 ''''"' '"''*"'' ^•>'''''"''' ^''-'vor fbllowed a Kate f.j ao-ed 'i] (]\ . v ."'^ Pat.ont was admitted Sentend U """ '•' "'^ ^'How.s - '•'""^ ;" /'- '-1^ and .ides,: ":.''';' T' """"l"--.. of -;-'y >.. Fobrnan-, i8.4. ' She |^ ^ ''", 'T^ '-'arial f^er =""^'^«|'-<>';g- "''■' '''^ ■■' '••'1'^^ been very healthy ^r^p^^^'l^l^^ ''^'. -^'. i'oadaehe and S e as had nansea, h„t has onl v ^S 7' ""' '"'" '^"^' ---^- ;'«-'^' -me on snddenly when sh "1 /'"VT ^-"- *''"-• The '-'...•nation of the blood i„ he j'" '""'''^ ^•"- -'"^' tin.e' T " ^•- o.. adnn-ssion was nearJv IO40 ' ""'" ''"'' "^'«"^'>«- Ten.pera- •^'.^Mvas a large framed/stont woman T ;7';" '""•!>-; pnlse soft, not d eZ ..f "^'- -'--^ ^lean ; there O'l the 30tli and Oct.,bp,. . . f . ^'"'- H' 300 William Osier. V ^ ! , marked intra-cellular amcjeboid hyaline body. On October Ist tlie temperoture reached 103°. On the 2nd tliere were perfectly characteristic hyaline malarial parasites seen, each containing small fine pigment. Quinine was administered on October 2ud. She felt very well ; temperature gradu- ally fell, became normal on the 4tli, and on the 7th she felt w.ll enough to leave the Hospital. On the 7th it was noted tliat the blood has been negative since the 2nd, and that no crescents luul developed. The organisms present were those associated with the irrci;ulai' autumnal malarial fever. On admission, November 6th, the temperature was 104°, and idsc in the evening to 106°. She was a well nourished woman, a trifle pale ; rational ; pulse, 120 ; respirations, 30. There were well inaikcd rose-spots on the abdomen, and the spleen was enlarged and palpable. The blood examination was negative. On the 6th, 7th and 8tli the fever was high, rarely falling below 104°. From the liistorv we were in doubt as to the nature of the disease, and baths were nut begun until the 7th ; they had very little influence. On the 9tli she had grs. xv of Quinine, hypodermically. At 4.30 p. m. on the 7th, when the temperature was 105°, she had a chill, not severe, tiio only one during her stay in hospital. Until November 14th the lever kept continuously high, rarely going below 103°, even after the hatlis, She was drowsy, the tongue was furred, the rose-spots charactoristie, and the spleen enlarged. The blood examination showed no changes, On the 12th and 13th she had slight diarrhoea. From the 14th the fever was less intense, and on the 19th, after the forty-sixth hath, it touched normal for the first time. On the 22d it rose again to 104°. From the 24th to the 27th the temperature was normal ; at S a. iii. on the morning of the 28tl', the temperature was 99.4, and during the day rose to 103°. She then had a continuous fever for .six day.s the maximum temperature, 104.7°. She had no chills, no sweats The general condition was good. The tongue was clean ; the niiiul clear; there were uo abdominal symptoms; the spleen coidd not he felt and there were no rose-spots. The diazo-reaction was not present, From December 4th to the 7th the temperature was normal ; then, until the 27th, there were daily irregular elevations to 101°, 102°, and 103°, usually in the afternoon between 4 and 8 p. ra. ; the morn- J 3n October Ist tlie witli the irretriila: 'W ...w, ,„,„, „„„ ^ mg record being l^i;,,,. ,„„„ """ ""■» te general e„„dm„„ ,1' ^'^ f ^ 'l;e 20,1, l„|„„ 990. „ Most careful examimtio,,, „„. „"a f !""^ "'"'<"■ '^a,, tl,e fever ™ «.„„„. After ,l,e 27, , ett /'" '"^ ' '» -ga In J Digestire System. («). I'akotitis. The only instance among the IfiO . ■ It was really the development of tlHs V- ^"''"' '"^'-^ ^^ P- '345 d-agnos. The clinieal 'lia^nosL i t . u"'''"" "'"■'^'' -^^gesL, tie ^urat.on before admission ; rnodlrato f "' ^^^'^"^'^'^ ^^ ^'vo weeks or muscles of neck and of Zt Z ' '"'''''' '^l^'^" ' -^ Jl'^aneons hyperesthesia and In LroVr^t'''''^^ ^^ ^i^'-^'" 1^'ood ,n the nnne; no dia.o-reaeHon f .f"'^-^ ' «"'all amount of nonna temperature; parotitis. ' '"' '^'"'^ ^'«>- "^ofore death -'« f/ie .vx years Fivp <»*. "Mel, ,vi,l, •„„, ,■; 27]°Ty '■" "'■= P''^'°'" »ne, „f 229 "^f :t;;rr:,r'-» -■--■ ™.e ,r„.d ..^^ I'l most of the cases .V , -n i -^ '•" "0 -e did th; f : t:i:i';;''^';.^ lumorrhage. ^^""^^ ^""ow directly upo„ .^^..Jl^^' 111 the previous series H.o..„ - the ,..entage ^l^ 1^::^^: ^T' ' ^ ^'^ ^" ^'^e 389 OlafJ., aged 24 (Hosp_\o. 7992) and lug] fever W^ i j i •'•^''•';- A severe case w.M, "-■ r '-a, ™":i't :: ,r;rr- °" ''-^'!' err P'«bl„„J, „„d ,„ , ,!,„„,," *',,''='• "« Pa'ien. passed 250 co „I ■ " "" <'"'rrhM after it. X|,e„ I' ^ll iiii ji I I 302 William Osier. was no reduction in the temperature, and the general condition \va« not aggravated. Alice C, aged 18 (Hosp. No. 7602), on the 16th day of an attark of moderate severity, after the 32nd bath, passed a stool contaiiiiiiLc clots, not very abundant and not large. Slie had not had diarrlma. Charles H., aged 31 (Hosp. No. 7955), on the 23d day of a so\oiv attack, after the eighty-second bath, passed a stool in which wtiv about 1 iv of clotted blood. The bowels had been a little Ioi.mj. The hajmorrhage did not recur. George S., aged 34 (Hosp. No. 8287), on the 17th day of a wiv severe attack, had a soft movement containing clots of blood. He had had diarrhcea and much abdominal distension. He had a vtiy prolong! (1 attack with relapse, but there was no further liajmorrhagL'. Florence M., aged 22 (Hosp. No. 8448), had on the 13th day a small hicmorrhage, which was found in the draw-sheet. She had had nodiarrhtca, but the abdomen had been distended. As the next stuul contained no blood, the baths were resumed after a single spongin;;, John W., aged 24 (Hosp. No. 9566), admitted April 3rd, on the 8th day of illness. On April 12th he had a soft stool, intimately mixed with blood, with one or two small clots. Shortly after lie passed a second stool containing still more blood. The fever did not drop after either stool. He had been having one or two soft move- ments each day. He v,as ordered lead and o[)iuin pills. No further bleeding occurred. The baths had already been omitted on aivonin of the intense bronchitis. Charles S., aged 18 (Hosp. No. 10517). The case is given fiillv among the relapses. The attack began severely; temperature rose to 106°. There was no diarrhoea, and the abdomen was nut ten* At 3.30 a. m. on August 2nd he passed an involuntary stoitl cuii- taining biood, with very little ffecal matter. On August 'M\\ lie passed another stool containing small clots and dark rcddisli- brown material On August 4th he had another small luemoi- rhage. The hfemorrhages occurred without diarrhoea and had ii« injurious influence. After August 4th the temperature fell, and he improved rapidly. eral oondition Homer H., aged 2' H v J-n04o. There .a. « ^pio f orrr""^'''"^^'' ''^''-- 103° '-temperature had been below the b^t, ''• .^" *''^ ^1^'' ^ncl J2th '-•;l'gl.t diarrh,.a ; then, o,. th U "f '^r' ''" ^'^'"''-- ^^ A ^ a. m. o„ the 13th he had astoo Z" •^'''' ""' ■'^^'-' «-'' ^'ny. r ere was „o ,>ain ; the temperat Xr'n "'^'""^^ ""- '^^-'• ''''' ^'"^ *^'»P^™t„re fell to „Ual l^Tli T '^"''''- ^" ^^e Joseph M., aged 20 (H . v " '^ ^' "'^'' "^«-'->'- ^^H on the «t,fda;:iI^;lLf-^^fU admitted October 25th -g and .harrh^a. The temp^^tu^ r"^ T '''''' ^^^'^^ --i^" ''^"•een 104° and 105°; often 1 1, . '" '^''""^ ^^'^' ^''^t week ^0 '-e g.ven in the twent;-fon;,I' , T"", """^"^ '^^' '^'^^''■^ ^'a ro.e-,spots were abundant. A T' „ ^^''^ ^'''^^'" "'-^^ 'a-'go and th •■'gl'teenth bath, the patient h.da , ' "\ "" ^'^« 29th, after the ^";;f bright blood,\,ot IS \ d:;"'Tf ^^^'^^'"^ '^'-'t i^al ^ ' ''"^ "«t affect the temperatu e ! ^u^!'' '^'^^''^y "'"t'' Pieces --103° and 104.2° .^.ti^t X^t''' '''''' ^^'^^^^^^ g hieechng. The abdon.en was not IW r,"" ''^ '''-*'' '"">tl^er o.>.htion was good, though the toZT .'"'''''' ''"^^ ^''^ general ^'- .^Oth, the stool passed at u?? T ^'■"^^■" «"^' ^^^^-'ol On '-.V l>lood. The stool at 3 ' 'n rtf"."^*^ ^'^"* ''' ^ "^^ ^'ark "'a"er, but no blood. B, /, "j;,?" '^\'f'^ -obtained dark fav l' '«"' -^' "e made an u:;ii;::::;;::;::^;^;;;-i-.ature tour; (c)- I'erforation. Ill tile ])revious series tliP,v> ■ , i» •(■»;-. „.,„,,„,;;;;;\;-Y«i.' -lea.Ls r,,„., „.r,Wa„-.,„, ^<»' f he SIX yearn "^sq " .••^- '!» 6.al cases. """* ""o S-'.,, a, „. 473 i„ ,|„ i,'/"';'- ;«*»io.. of tl,e b.,„.i a, d tT' r;r '^""' ">■"■"•"'"' -Ws. « S™.«.ally ,1,0 serio,, fea„ ™ , ,! '"'"'"" ''' *'»l«UeIj1l ■ '«"'»ii».leHyi„g„„,„|i,i„„;"""'' 'l-^W-ear, a„d we are i„ d,,,,^, "j •^«"; t'trs'.?: £r:efi°„;r^' if"' -""^ ^^o. '«»^. "• T''" 'eniperafure ranged 304 Wiliiam Oslei: from 102.5° to 104.5° ; the spleen was palpable, the rose-spots wen distinctive and the general condition very good. There was n diarrhoea, an 2d, the teinperutnre was ing 1st d the abdomen was not distended. At 8 p. m., Augi s 103°, and he had a bath ; and for the folioM- forty-eight hours he was distinctly better. At 7 p. m. on th nil- ;}d he complained of a sudden pain in the right ^ido, at the lower The abdomen was held tense, and there was tendernoss on pressure in the right hypochondriac and lumbar regions. Duruig tiif ---lit the patient complained but little of pain, after a hypodermic injectiim of morphia, but the pulse became very weak and rapid, and the ex- pression of the face was noted by the nurse to have changed, ami lu seemed dazed. On the morning of the 5th, Dr. Thayer made the following ikiIc: " Patient is lying on his back with the eyes sunken and rolled up- wards ; the face is pinched and drawn, and the expression vciy suggestive of peritonitis. The hands are cold and the fingers l)lur, The abdomen, which was previously relaxed and sunken, is nuw distended, and the nniscles are tense and contracted. The liver flat- ness is obtained upon the 6th and 7th ribs. The note is the same over the entire abdomen on direct percussion, and on auscultatorv percussion the ' tap ' is everywhere conveyed directly to the ear. The pulse is 128 and small. The second sound at the base of the heart is redupli<'ated." The temperature was 104° at 10 a. m., and through the day did not rise above 102°. There was no diarrhoea. He had profuse sweat-. On the 6th the fever was higher, 10a°-105°, and the pain was still severe. At 6 a. m. he had a large soft yellow stool. He was given strychnia hypodermically, and spirits of turpentine by mouth. The facial expression was better, and the pulse stronger. On Augu-^t 7th the fever was lower and the abdominal i)ain and distension imicli less. The perspiration was profuse. August 8th. He had a comfortable night and was in all respects better. The temperature did not rise above 102° and the abdoiniiiiil pain had disappeared. On the 9th the serious symptoms had had all disappeared, and he made an uninterrupted recovery. Ambrose B., aged 31 (Hosp. No. 11310), admitted November 4th, at the end of the 2nd week of an attack of fever. The temperature '-"18th there were only one or twc^n!"'; ' ^'^ ''■°'» ^''^ ^«' '' ^«' i- «"^'an to con,,,lai„ of pain i„ Z T '""'"''' '^'^h'- On the 14th -.'if out beyond sli^htsi-ene^tt^^^^^^^^ T'''^ '-'^' ''o '--derabJe distention, the soreness "j ''" J''^ ^ "'^''^ ^'-'- was le^Mvas drawn np. r„ ehe eveni.t , '""'^'"'' *'""' "^ '-'^''t =""' "'« l>"l«e to 126. He had ': • ^""''^'''"^'"•c ''ose to ]05?5° 'n-.nely sensitive and tense ivu^hV,,, '''"''" ^^'^'^ ^l'"'^'' ''"led ex- '-pa^,ation was ve.y di^^U TS;:,.t/'^''^ '"^'^ ^^^ - at-l .n the n.pple ]i„e. There were nl H " ^"''^ ""^ "'>''^er- '""'-• , The patient was extre e v „ t '" '""^'""'"^'^ '"" ^'^ 24 l-'so though rapid was of fai. v ,1," "'' ^'"'^^ '^tional, and the -".ata. The von.iting had eoasc J. "h""'^ ••'•''-'"' ^'"■IK'ntine =''f-; ."aJ '^^""^v in ^lood. The tongue was furre but n T , '"' ■"' ^''■'''^•'"" "^^ '>'-igl>t -<' -'-H.SS prevented anv I Vatt ' ■^■- ''^'"' ^--' '''-^tensfn T':- was no inereased nwS ^^t^T"-?'"'' "^' ^''-Wo-n" 1-.A.I, and could be extend d T,: Vt ''^ ^^^'^ "-v not so ""P'ovement. The fever 1 tt.ed 7 i" T' '""'^ "'^'■^ <'«-'-' a o„„„a pain and distension werre^^^^^^^^^^ che,,,,^, ,„, ,,^ of the abdomen had been above the nvel . 1 ^'^'^'^''-'^-n^ent 1'en.s als.s, were seen in this part Pa 'r ' ."" '^'' 22no right iliac W H.e pat.ent was discharged Janua^Stl "'''''"'"' -"valescenee r'le intense abdominal mi,, / v -PKi Pnlse suggested p^f^ h;' " ^^^"'""' ^''^ --t''% and the "'^' ^aeial expression (.Ihich Cf „e. e^^|•'""^ ^•""•''■^■■-' '--ever ,"^;;-"« state or' the patient, the abs 1 ;''""'' '^^' ^''« ^-^ren.ei; ; : 'yr^^^-^> -acie us doubt t:xi:eL; ;"^""'^-^ '^'--^- J m 306 Wil/iam Osier Vascular System. Phlebitis. Thomas T., aged 36 (Hosp. No. 8667), on the 35tl) day of a wrv severe attack, while the temperature was still ran^inti; as high as 103.5", began to conii)lain of pain in the left groin. The note on Decemlii r 22nd reads as follows: — "There is tenderness in the left groin, ami slight snperfioial redness. It does not appear to be a glandnlar in- largoment, l)nt there is a fnlness in Scarpa's spaee. The vein is imt to be feit. There is redema and pitting on the left tibia. Hecaniidi Hex the left tln'gli npon the abdomen." Snbseqnently, a cord devcldpcd along the inner aspect of the thigh in the position of the long sapluii- OHS vein. On the 24th the superficial redness in Scarpa's space piT- sisted ; bnt the redema of the leg had disappeared. He had no further trouble from it. Tiiis patient had diills at intervals from the 3i(l to the 8th weeks. He had none in the 5th week when the symptoms of thrombosis were present, John E., aged 26 (Hosp. No. 8509), towards the end of a rcliipM', in the sixth week, had swelling and tenderness in the left groin and an induration just below the saphenous opening. Scarpa's space looked fuller on the left side, but there was no swelling of I he let;. Movement of the leg caused pain. A thrombus developed in the long saj)henous vein, but did not extend to the femoral. lie had a slow, tedious convalescence. There was no aggravation of the IIvit while the leg was painful. Theodore B., aged 24 (Hosp. No. 10298), admitted July otli, KS!I4, at the end of the second week of fever. From the 12th to the 15tli the temperature ranged between 99° and 100°. On the evening of the 15th it rose to 104°. On the I6th he began to complain oi' \y,\u] in the inner part of the left thigh. Tliere was no redness, mi swell- ing, but a well-marked cord could be felt in the course of the iiiteinal saphenous vein. On the 16th and 17th the temperature kejit iip. From the 18th to 22nd it was almost normal. On the morniug ot the 22nd he had a chill, and on the 26th the temperature rose again to 104°. There was no sign of redness in the course of the sai)lienoii- vein, the thrombus in which could be well felt. The general condi- tion was excellent, and he made a good recovery. '" the end of the first sn.k oV fll ; of ( "'"""^"' '"^y ^'"^-'^ ' «» ». "a.s l.el,nv 102° and J.o was in,: " '^."^"•^^ "f'', wlu., th. fevn' --•<. '- had a sudden ;;• : ' ^i:;^,;" -;7 -.y am.,, a J::; ;'"«1 1^-,C were swollen and tender L J tl ^" ,/" "'" ^•^"' t''^' t'">'' HUornal saphenous vein eonl.l l' 'fe . l' ""^ '"'-^ '''"■^'- 'r'- "" '"^'rease in the fever, which ren ■ .' r""" '"'^'^''- '^^''«<' was ' ""^^ the ,„ner aspeet of the thi.d Wi "'" ■''"'' *"'<'"'•'-« ''-I'Fared, and he recovered eon^petelv' " '"^ ^''-^^^ ''"'^ ''"d Respiratory System. I'l-EURiSY. O'iset of Typhoid Fever with Acute Pi.. ■ '^'-'•■«y '•« not a fre,ueltc ?"'■"■"■""''■' ^'^-^^'o-U^Mi., ^y^^^^^^.^^Z.'^T^^^^^- The."w..: General Hospital, acute pleurisy was .•''''''■^'■*' *''^' -^^<'ntreal :;-e. The oon,pli<,atio„ l 3l ttj "?", '"■"^' ""^' -"Pven.a '"•■■^trates the forn, of typhoid t' •" ^'"^ ^''^^ ^•'■'- ^^^^'given -Imonts, n^easles, typhoid feve'7) snt.^ ^''"^'' •^^-' '''•"' -any ^"■- puberty she has l,een verv well "'';'' ^""' ^"'^"n'onia. attaek of ague. "• '^'"' ^^'"' the exception of an i'resent illness Viw i -V"f t ^'^^" ''^^^ -S^-dt.^:;^ "" ''^^" ^^^''"^ ^•^- "g".^i'elmdashakinLrchill which T ,7' ' ^^'^ "^''^'a- Xine davs ; '^'-1 „. t,,er a^l 2lS::f^ ^ ^ "'^ ^^ "'' "^es, and ..: '•; "P and about, but she had .u^.sen 2 ^ t\ "^' ^''" ^"""fe''' ^o ^'- ''as had a slight cough. Yeste ' " " " '^''"^ ^''^' ^''-^ ■^e^-e'e pain in the left side (n.T \ """"^^ ■^''^' ''^^l a ve.-v '''■-tlO,andfeverand ogh Ir l','"'" "^'--^^ '^>' taking a J , «" ^''--ion the tel^it ;:t r'^f"'^ f^^ ^°"^^ -''^' '•"^"^-' 32. The blood exan. ation ' '" ^"'^^' ' ''^°' -«!>- l'^-- ^- »>• ^""' ••'-^ "^-«''ve ; leucocytes, 1500 Hi i i 1 ( i t J 308 Williavi (Mei\ Present condilioii. Tho patient is a licaltliy looking, well nourished jrirl. At. the time of the examination she was Hwcating, and eried out a ^rood deal with pain on i)ein<''<''- r.i;. !^"liy H.ar it .as thought .;,lvlsaU: :'h " ''^'t ""' ''''''''' ^ "'•t°. ">Hl .... the 7th he,an to , TT't '"'"•■'■" ^03° an.! ti.e fever fell rapidly, a.ul „„ tho I '\^\ ' '■'"" ""'^ "■"'^' <'" The condition of the left pleurrJ.u'ur. ''"'''"' T"' '■--'"^■'' «"• On October 5th the bre.t N, ^ ""P.oved. On theGth it was noted tl.nf fi ' "- angle of the seapnia. F v . n't'"""'' "'"' '"" ^'^^^''^^ '-'-v "' tl.e axilla the iHetion sonnr^^ r^:;:;;''^ ^^ ''i^^''-^ - "■as not so tronldesonie. ^ '" '""•'• J '"c eongh On the ]3th it was noted th-if tl„ I i aln.ost disappeare,!; the fi tt on t ' "" "' ''" '"'^ '«- '-' n.a.le a very satisfactory -o 1 ^ ''''''''^';, ^^'^^^ ^LLs .she --and gained hetLn^;:;^..:'^;;;/-^^^^^ Hi.™ she went out, nearly ninetee,. ,. 7 ' ^^"venil)er l«th, i--ted nntil the Hrst of N^Z^Z Z "^'^''^- '''^" «-'^'-' '-- "as practically norn.al I k '"'; ']' ^•""'''■'-" at the left rea--l freely, si.; ,,,, ,i J', f ,"' ! " "'"■^'"">'' ^^'"■^■'' ■^l- 'ec^le ..-ychniu in doses of a t i^yl^, Jl^'^ ^^^^ -^- -Pi^^ and It ,s interesting to note in this cJ ^•■'""• l'aHn'ng-56 baths between 10 n o. H ZT' "^ *'" ^•'^^l-'-t •2 noon on the oth of October ' st'?, '''' ^'^ ^^i"-"'-, and -'^>-the pleurisy progressive J iL;, '^'^^ :," ^--^^ "^ ^ve a "g^^'avated. The condition when el , '" '"'^'' ^^'^^ ""^ -■'i'^al; thusonthe3rdit va „ Jlf^^^^^^^ I"^ '^"^'''^ ^^- verv f"'«^' -as 160, respirations I T " , ' "" '^ ''" '"^'^'^ ^'-^ the '•"tshe took the food and stimulal T -T ''""'""'""'^ ""^^ ^'n-; great tenderness of the t Lt e 1 ' '"'' ^"^'' *''^' «'^^« ^^-I'fo.. 'of '-•..tcTupted recovery ^""-^J"-- of the baths she made an •lc«fe Pleurisi/ at Onset. •lacob G., aged 35 (Hosp. No 101 ^QN . • , ! I I : li 310 Wiilidtn (hlfr. no particular pain in tlu" cliost. Tlu'rc is a ditt'iiH' l)ri>iicliitis. II, li;ul a mild attack ; the pleurisy (lisappoarcd in a lew dayn. Avnfe I'/inrix;/ with IC(f'un!i>n in the Thiid \V*-ek\—S'o SiimjitoiiiH. RobtTt U., aged 'JO (IIosp. No. 11!)6:{). admitted FeWniary ;{|(i, 18!»5, o» the 14tli day of the fever. The attack hud l)egnii with a chill and nausea, but he had neither cough nor pain in the bide On Fchrnary 5th a friction ruh was noted in the right lower axiliiuv region. He had no pain, no cough. In a few days there were wdl- inarked signs of einisioii. On the 12th the lino of dulness heliind had reached the angle of the, scapula; an exploratory liineturc hroimhi away a clear, brownish fluid, which was sterile. He had protii-c sweating. For the fn-st wL'ck thi; fever was liigii — 10;J°-10.')-. The cifnsion cleared gradually, and by the time he left the Hospital- March .'Ust — the resonatK'e was only u little defective. Tlicrc wi iv no symptoms pointing to the pleurisy. InTEN.SE BltONCH ITIS. In Caxe XXVI of the fatal cases the bronchitis was so intcn-i and the cvanosis 'occame so extreme that bleeding was cinplnvcil, Renal. Urink. In Volamv IV, a very thorough consideration of this secretidii in tyi)lioid fever was given by Dr. Hewetson. The cxaminatimH uiv made daily in the sevcri and at short intervals- ii: li e mild cii-i .. An interesting study of Pyuria and its as:MV-i:iL' d mi ■lo-orgaiiisnii, by Dr. Blumer, will be found in another part of this ftiseiculii-. Albumin was present in 1.39 cases. In only five of these was it abundant; in a majority there was only a distinct trace with the "sual tests, such as is almost invariable in the fevers. T-.'r.'P ('(tsts were present in Gl cases, usually oidy a few and soiiie- limes found )-.Iy after the use of the centrifuge. There were no eases of serious nephritis in the series, such a.^ were jiresent in the first. Dictzo-readion. — This was present in 118 cases — about 74 percent. Its importance, &c., are fully consideral by Dr. Hewetson in \'ol. IV IS was so iiiti'ii!.c i; was cnipluyed. ' this secret inn in oxamiiiatinii- iw I lie mild cnsi ., mi'TO-orj^Miiisiii", is fasc'ic'iilii-. \,'e of tlicso was it ct trace with tin- 's. ' a few and some- sries, such a.-* \\i'i'i' ■about 7 t percent. •etson ill Vol. IV. '"Special Fenfinra v .// "iiiplainiiij,' o/ week' witli '''•'"■ili.ea ami /;. !»J()), I'l' liad 11(1 I 'eiiiperatiirc oii tli I't'a.laclu., ,|i,„.,.| ';''"."■'""' •V'-;,„s,l,t,., ^■';''- ".- Iiad l»,.|, ill ueiiiorrli ""••'. 'i'V.'r, 1,11,1 H\y.. '«^'S an.l „„ ,,,„„,j(,^^^ ^. '' ' wealviic; "' f'Veililljr „f jiil '••111 til,, „ "•■ "early tin III (lie ln.|K ■cc «iis dicrotic l().s. 'pj,,. ^.^^j satis/iictory. Tli ••""I coiitaiiit'd nil I . . '^ ■ "le llusc "'"*'^'"" r-.se to 104^ Tli '"•• "■"•'' K«od, and hi Ik' f'lilse '*; "••'"<• «.-Ht |.assod"vas',.o ■ , ^"""'■"' ••'""'-'<"' I'f the Hpleei '"It not tuiidi ''"""" and ,,,..,1, to I0;j «'er Oi " ^^''M palpal.l,.. '|'j_ Tile /evi-r for tl 'loi'fjd, , ^''•"""lar till,,, ,.„st,s iIkI '« alKloiiici, ''(' /ir.st t,,„ ,1 \vas 'I*' i-'i'. Ii.'-i2, 'i'lie c'd-(. a li ••' oiiiittwl (on ac l-iiii to tlie 17tli. ''lie anioniit of '"'"»ii in color ' ff'e 'listend: "' '^'"' ^■lil.■^;::;'':'•::''r'.''■' -"i led. 'i^'oiint of (I "' <''>iidition of tl !:''■•"" ''=i"'N iMit a iiriiic peci/i }^"'"'-- .leliris and ,„anv t„I llie iirinogavoall lan^rcd from 80() K''avity alH.iit 1 020 "■ '"•'•H') fro,,, ,1; liev 10 t<» 1200 cc, It and was reddi.sli » "ii' miiiierotis exam "' "«iial react '' ::''^^'^' '"'t "o re,l |,|o,„, 't>"-^ 'or l)Iood.,,,l '•""t"'"<'d i,„„.|, ^'oi'l'll^clc- 110 I'cd-hlood ••'Jnxi.sclos wcr "'"t'<'>'8 i.iado between tl •''"'g matter, l,„t I , "fi.-iuius wore SPPH u .1 ;'!'''f ' 7' -s vellow W. ri..'^^ ^''^ ^'^^''- t' 'ainod only a trace of alb '^' "'''■•'iid tliel7tl, "••»vn in color, no | 'H' urine bad iiiiiiii t'H' c,.|„r H'as normal '<>",i?er turbid, and ' , "' "" '^'"'"^ «"^' no tub ='"•""""• Tl,c hatbs 'Henty-.si.xbei;Metlie I'apidly, with tl and til were resumed at "•'•« Nvas only a fi.int t teniperatiire fell below 102. 't; exception of a rei "" '•"'"' examination, mad, >lioued no malarial le re OIVi 'ganisms. On 'peatedly '>'"iiin bnt ther. noon low Icseiiee y dun ''^ejiteml '^"^''t^ l"(b,and I U con- •e cast.s. ()„ race of 'le took <' convalesced •^^' «ve days o first few davs ^K'r .9tl, the ■« Here no tube cast." urine still I'l'osi'iited a trace of all Cutaneous System. Hieresa H., asred 'M /w« *t t I li 312 William Osier, (6). General Erythema. Heinrich VV., aged 12 (Hosp. No. 8369), before taking baths had a diffuse erythema on chest and abdomen, which persisted t'nr two days. Charles S., aged 18 (Hos}). No. 10617), had, on admission, a general erythematous blush upon the trunk ; no rose spots. (c). Boils. During the 4th year, throughout the autumn of 1892, there ww many examples of boils during convalescence. At one time there were seven or eight cases in Ward F. During the 5th year there were very few cases. One pationt, Evans (Hosp. No. 8029), with a very mild attack, had, late in con- valescence, a large boil in each axilla. Chas. B., aged 17 (Hosp. No. 10563). The attack was severe, with high fever and delirium ; twenty-six baths. Crops of boils began to appear before the fever had fiillen ; there were many small ones on back. I^ater, a large boil developed on outer aspect of ritflit thigh ; cultures showed a pure growth of staphylococcus aureus. ((i). Urticaria. Theodore B. (Hosj). No. 10298), during convalescence had an ex- tensive outbreak of urticaria on both forearms, unassociated with any error in diet. (e). Post-Typhoid Abscfjss. William P., aged 22 (Hosp. No. 8145), admitted September lltli, 1893, on ihe 8th day of the fever. The temi)erature ranged from 102° to 104°, and fell to normal on the 25th. On the 'ioth an abscess was opened between the buttocks and a considerable anioiinl of pus escaped. Cover slips showed a coccus as the preddiiiiiiatiii!: organism, but in culture both the colon bacillus and the staphylo- coccus albus were isolat'^d. Olaf J., aged 24 (Hosp. No. 7992), admitted on the 4th day of the fever. The attack was very severe, and the baths had very little influence on the fever. On the 15th day he had a slight lueiuorrhage *"''^'"'""->'''-»''""''-..v.:^^^^^^ 18 IK IK /i'om the bowels The t ' f" ^'- «fxth week a hr^^Z!^"'" r"""^ "" ^''^ ^^'^^ ^'ay. '-I'-atnre did „ot ..i.se ,l„nng t f, , V/' ' '"'"'«'•"> ^-^- TJ,e ^''l''^ "-' tl,e p„s showed onlv ' ;^""^^ f'^'— Cove, eoccus all.M.s and s. aureus, an.l iuso ' '" '"^""■^' ^''^' ^^aphylo- «!'^V'n the 7th day oniL fcX; •:p,':f ^' -''-«-' 0.,ol„„. 9,,,, - -;i -veiling was notieed in ^: I ^:;: ^^^ " --" --ea of ..,- ' =' well-n,a,-ked .-ose-spot ; hv tl^ ; ^ ^ "^'""' -i-^ ='* the site "'■'"''!'""• '^ -all ai.e.. . •.. .,, J ^ ■;;' 1-7-1 and there was ^'"'"•''''=''--^--'' -'the staph vio;:::^:::;f^'-«^''- ^'"'t-vs ''■"■'■■"'^I^ao.edoWiro.p.Xo r,j.,,, , '. ^• "" ^''*' ^^1' (•) 'lay of the fever "n /^' " ""'' ^^^''^'■<''' -^'"'- '.S!.4 ^'- 22nd day. The note on "mJ. ! :rr^';- '-''- nonna, ..; -vera] days the toes in th. ri.ht to, ; , 1 ' " '''"^"^ = " ^o'" ■io..nm there is a well-n.arked l.lnsh ■ i /• ? '?""'"'' ^'^^ -' the -^■•" <>''*'-HHwhehlnshpe^;t ';?;■'■"'' ''^'^^'-^ i>e toes were very ten.Ier. There w ' '''""'="• ■^'"•'a'-os of Tl.e Ml foot was not affeetec w; j;);^' '^f "- - the dorsnn, -the nsnal 'tender toes' whieh < o e^ n ''V'"'^ ^''-ondition 0th d,e swelling had extended, and t , " ''" '"^'"^ ^->" the ^'-f t.> the ankle Joint, h„t Z,, ^ '": "':^ '^"'^'^^ '•cached -'; : .-f the dorsnn.. The toes a J '• i! I"^""' --• "- -tire ^»<' '"^ -as greater and fh.etnatll ! ' ":'''^'^'- '^>- tlu" KUh the ^uelliMg was greater and fh.ctnaHin, » " "'";""''• '^>' *'' '■«'^'''-l -H.rmal on this ,U T \ ""' ^'^"'^'"t- The te -acl..l normal on this day. T , '"''"'^- ''''^ ten.peratnre ;^^- — '• The cnlLres 1; '::;r^ '''--' -"' ahont ; ij iomrus aureus. About the 13th ' •';''"'^'''' "^' ^''^•' -^taplu- nght car an., tenderness over tlfeLX" '' '''''' ''^''' ■" ^''« -s a waten- diseha.^e f^.o,„ „e " u d ZH '"' '" ^ ' ^'' ^'-- ' '- 'over did not rise again after ul; ^u '" '"''^''' '-»^J- rilOlrina T" 1 r.^ Tliomns T, age,i 30 (H,„p. ^ ' ' I ;;»""■;""' "»J'. «■"- than',,™ /el 'a'i ' , ' ''T"' ""■"-l-eenee. I William Osier. ^.^ 1 ^ n« thoueh it was an acute periostitis, goinc and he had no further trouble. Nervous System. r. nP T EFT Middle Cerebral Arteries. (a) Thrombosis of LiEir ivn^i See Case XXXIII of the series of fatal cases. (6). Insanity. ^^^^^^.^^^^ q^^^^,,, i,,„, Florence M., aged 22 (H osp. ^ ,^^. ^^,„, ,,,,, 1893 ; she had no initial dehruun. The f'^^'^'^ ' ^^^^^, haths'did not n^tU^once ^^^^ fever^-, .^^^^^ |^^,^ ^^ of abdominal d.stensmn. The ^'-^^^ '^'^ ^ ^ have vavi..u. November 14th.-'' Three days ago the pa "be^ ^^^^^^ ^^^^^^ delusions; as that she had l-j -^,^\^^ ^j, ,,, throat. 8h. visitors; and that another pat ent v.sh d '^ ,q^^^__. ^\,, ,i„gs and talks to herself w en d ^ ^-- ^ ^,^^^^^^^, ,,^,,,, is not in Ihe least melancholic, but '« ^ ^^^[^ Subsequentlv s!,o She thinks now that she .s ^^^^^^J^^ ,,,, lu.- h.K, became somewhat melanchohc. bhe e e /,^^^^ „,,„,,„ which seemed to improve her mental -o"^. on ^_^ . ;Ltter and left the Hospital well, January 7th, 1894. (c). Catelepsy. ^j^^ 2^^^ ,, f Betty G., aged 27 (Hosp. No. ^^ « ' ^dm e ^^ ^^_^ ^^^^ ,,e illness. The fever h. a week r.ged^^^^^^^^ ,,,,^^ ^,^^^. ,,,. tremulous, no.y and w^ ^^^ f^;;^^^,!,,,, ,,t lay withtl. .,fter her adnuss.on, she won d not ^"^^^J' ^ ,,^„,,,^i,,„i ;„ :;:^r;::ru:d:'>uiL-^ Special Features, .Symptoms and Compl{catiom. 31 - 30th, she had no fit. Ou this d-,v ..fv .1 ('•). PlySTERFA. (./■). The Pai.vful Back of Typhoid Fever fTvp„„,„ « ••I'aracteristic cases. ' ^"'' ''"'l'"'''^'' several ^el!:^ and'^ri,;: ;;^'!::;,— -- ^^^ '---' !-'-<«., the ^ _^ l^__ . ^^^ n> wh.d. the .sym,,to.„.s were n.ilder and less ^f;"^-' aged al)«nt 3.5, admitted Febniarv 19fh ixo^ rr . , boon in War "I toiiipiainec of soreness in fl.« i i i stooping and in walking,, and Lv this the P ^ I "'''" plied. He snvs H.nf fl • ''"1"''''" ^'^"^^0' \vas an- >an jiani or a null aohintr character Tl>n „„ ■ ^- «e uas given the tincture of nux vomica in large dose.s, 316 William Oder. and the Paquclin was applied lightly on the lower dorsal region m, several oeeasions with much benefit. Me improved very slowly, an.i left the Hospital nearly well. The following oases are of interest as illustrating milder forms of this trouble, and in one the pain began and was for some time local- ized in the neck. Florence M. (Hosp. No. 8448), whose case is given under the sec- tions of insanity and post-typhoid elevations, on Decend)er 16th, after she had been sitting up for nearly a week, began to complain of severe pain in the back, which was much increased l)y any sudden jar or after walking about. The examination was negative, and there was no iKiiii on prciSure. On the 17th and 18th the pain was too severe to allow her to sit up. It continued to trouble her for more man a week. There was no disturbance of sensation or of motion in the legs. ( )i) the 27th she sat up, and after this she improved rapidly ; and when she went out— January 7th— the tenderness in the back had almost disap})eared. Christopher T., aged 32 (Med. No. 3228), had sat up on Octol.er 4th, when convalescent from a relapse. On October 6th he began te complain of pain in the back of the neck, particularly in the tipper part. There was no swelling. The soreness persisted and was very troublesome ; the patidit could not turn his head from side to >i.ie. The Paquelin cautery gave him nuich relief. Nothing could l)e felt on examining the cerVical vertebrte from the pharynx. Subsecpteiitly the soreness extended to the back and down the hips. He hel« ™*.s .1,0 cndi'ti.,,, „ r„ "»i- ".e oaptio,, „,,„,, g; j"«« " ''^ i-t ,„ .speak „f ,i,/„„„:,i;;;; »*1 for .e„ day, „,- ,„„ ,,,^f;'« , ^''= »»;«.»« and «,iffi,e,; p","' »«»„„( for it. '^o"". b-t no local fea,„,.,^ devolopafL 0(Ar //. — Emma E ncrn,i i p /tr '" tlie calf of the nVhf l„„ V ' ^o^plained a m-eat '"- ""■ '•■•^-al eharaeters. ^ *'""" "' ^»"'- cases, all presenting Special Senses. Otitis. iiarris G.. ao-ed 91 nr ^^ ""« »■"= -^vori.. On \„ve,„ W ,4,, ,1 "'■""' ""= S<»>"al sv„,,,. "■"• M ear; the ,ua,„<,id p,.„c Jt 1' :?;™r ''''"'"^^ ''■"'■»4 l»'.v gland on this side wa» , ,. t ""','™''"- Tl,c ,„b„,a,M. *"'«"«« »"''«'■*''- and gave n„ fl,rll„.,;;,X'" '"'"«'"""• Tlie Theresa H., a^ed 94 'w -vt ''^^^- On .^;ve.befli?l:^^;r^^^^^;1-«-' ^^^«-"'- ^'^1' - a discharge f..,.. the 'i;ft", ^n"' "' '"^ ''''••^' ^-'^^ the.: l^l'0''ewas not much pain; the dis ehn. '"' '•"' '^''^^''^ tenderness. -''^■- The note as to^ndt re J :t ,"1,""?""'^ ^•"- '^^ ^han a GauliusF f '"^^ "^'■'''^'^J «'Kl not a.Ided. Gaul us F.-(,.,en under post-typhoid abseess. ^liariesa,agedl7(Hosp.Xo lOofi-^^ ; evere attack ; high fever, deliriun; e'! 'o ,"' ^"^"■^* ''''' ^^94. f^^'t the patient had an offensive it ?" "'^^ ^^'' '^ ^^'''^ "oticed ''«*1 I'acI from infancy but Ttl '"^'' ^'"'" ^'"^'^ ^''>'-''- This he -■b-laysof his fever.' '"""^ '""^^ ^^^^'^^vated during the *SeeVoLIV,p.69,ofthe^^<,.,, i I i U 320 William Osier. Ambrose B., aged 31 (IIosp. No. 11310), admitted November 5tli, 1894. Severe otitis media, with purulent discharge during the heis,'iit of the fever. Dr. Bhuner isolated the bacillus pyocyaneus and tw.. other undetermined organisms. Locomotor System. Arthritis. Frank H., aged 16 (Hosp. No. 11108), admitted October lOtli, about the end of the first week. He had in all twenty baths, and by October 24th the temperature was normal. It was a very typical ati.u;a f s " ^'ci "^ """^'■"' '>■ ^^''-i -^'y "I tl.e clisea.0 by a dose o .s 7'?'' ^^'"■'•'' ^^'^-^ -Started -a" ."tense «eptio.e,nia with ^L^::'' '" ^J^ ^^'^^ the,. •ally thKs case is of oxoeptional i UereTf « ,, ' ■' ■^'^''"•'^^''- ^^'^-^- -ggosfve of oe,-ebro-.spi,,l nu. " if" , ''.Vr*'^^^^"''-^'«.v-Pton.s ^''-'"..sclcs of the ne<,k, Wgiciity , ' wT 'f"''^^ ^^'^'' '"'^'••''•ction of 7' '■;"--"« hvper...sthe:ia. 1 e f 'r''"' '"~-' -Aex.s, ;- '^'.-befbre death was no,™a T j J 1" "" '""' ^"^ ^-• -Jl-f our attention to the nossibi'itv o^ ? ^'""'"^ "^"^ P«''«titis ^■'i^e 's Mly considered by D, F ^ ^ '^^'""'^ '"^^^tioi. The fa.scicuh.s. 'y ^'- F^^-^"-- ,n another portion of the ^ ASF VV'vrr •C.n,i.„.,,r„„Vol.,V,f,|,eK,p.„,. ■Io9 460 Wiltiaiii Oder. TIh' patient luul Imh'u at (Jarriscn, Baltimore county, all the slim- mer in a nlare where two l.oy« and three girls were ill with typho,,! fever Five days ago his illness began suddenly, with pain iii tli(> back He has boon in bed ever since, feeling very weak and liroii. He lias had no chills, no nose bleeding. He took castor-o.l, and han jmd six or seven watery stools each day. On admission the temperature was 101°. The blood cximinatio,, was negative. The p'ltient was a well formed, well nourished man ; tlie tnnxl was clear; the tongue was coated in the centre, clean at the ed^cs The pulse was soft, regular, and dicrotic. The abdomen louk,.l natural, was nowhere tender; there were several suspicious look,,,. spots on the skin. The heart and lungs were normal, ihe tem,„ ,,,- turo range in the first week was from K-," to 104.5°. The l,a,l,< acted very ,)romptlv. He had three or fom loose stools each day. On the 24th he was a little husky Irom the baths, and they w.rr omitted. . On the 26th and 27th he had some delirium. I he pulse wa^ II., dicrotic ; the tongue was swollen and dry. From the 29th to November 2nd he seemed somewhat better. I lir spleen was readily palpable; there were no fresh rose-spots, a.ui tl,. abdomen was a little distended, and he still had three or four i.u>v.- ments each day. From November Jk'd to 6th he l- ^ame worse ; the terapenituiv rose ; the diarrha>a still continued, and he was weaker. On the 6th the temperature rose to 105.3°. He took his nounsl,- inent well, and there was no vomiting. He had the lead and opnm, pill for the diarrh.ea, and hypodermics of a twentieth ..f stry.hn,,,. Throughout the 7th he was extremely feeble, th..ugl. latimuil, There was marked fcrtal heart rhythm. He sank gradually ihiuugli the day and died at 5 p. m. No autopsy. Case XXVII.— i''^"eA'« of two weeks duration before a(lvus,voii ; mod- ' erate fever; enlarged >^pleen; rigidity of muscles of neckaiul of right arm ■ mental dulncss and delirium; cutaneous hypera'sthem aivl increase of the reflexes; s^nall amount of albumin, with red hloo/ o/f/,. /,„f^,f ^,^^^,^_ lood vxaminaliim he pulso wa> 1 1 j. H—Dkath from lNTEm,ruRE^.T, Vp.p^ '''e P"l.se, and death o..cnn-e,l'i„ Tver .t • ' ^"'' ''"■ '"■"'-•'•••P^'-- antopsy. "^v^O feu' niMHites. Thon- was „„ Cask XXIII V i^'^zie G, aged 2], (Ros. No 784n / , '••""^'■•"■""■"^' of weakness. " '"^^^^-'^"""^l Augnst 1st, 189,3, Family history g„od. I'ee.. „,a..si„g. ^''"^'' ''^ seven months old, she has On ailmissiou tl,e ml™, r t m '®>'<"'«1- '*«"•■•'■ ■'& It;:,::!,;!" "■- ^™«" •^.- ■•-i* .„o „ip. 462 Wll/lam Onh: Hocoiul Houiuls were well licanl at tlie hano, the Hwontl aeociitiiat»'(|. The temperature "?»' ^^j^„,i^<, ^e^vale.! «!«-! to them. Jnst ahovc the valve ''"^^ «""=;= ^ ^ „,„, ,„„„, .trating the ^^ ^^Z i^ in length, .l,na,«l HO ri:.iW n^.*e n L cLm and eoloo the solitary folHeles ..» "Tal^edand ulcerated. The mesenteric glands were la„e, .-*, ^1 study of the Fatal Qms. IS substituted. The 05° and 106°. lie 465 soft, and ha^morrhagic. TJie spleen woi.^ho,] '^m was extensive parencl.ynaatous cle.ene iion "'^,^'™'"'^^^«- 'J^''^-'^" In the former there were nnJ "^ '"'"'" '"^^^^ "<'"<^"ey,s. l.noaththecapsuIe4 ;L:r"ir'"f ^^'.''^^ "^''■"^ visible ucre caseous. ^ ^P'^^^ata. 1 |,e enlarged gla,,,!,. of the i.eok (c). Endocanlitk in typhoid fevn ™i -nda.^ inLtio.::: : r: it;^^ T'rf ^'^' ^ ^^'>'- tl'o twenty-eight post-,..orten.s w ih , ! '" '"'^f ''''''■ ^" or iiis assistants in the thirty-fort , /""'"' '•^' ^'•- ^^'^l^'' n>y wards i„ the Johns H,>nl „ Ho! f .''"7 "^ '-'•''"■'' '■^'^•^■'- «•«'" Xo instance was present d «t^ t ' "^'^' "'^ '-^ ''"'^ '-n-ed. i" ;.pi.oid oases 'at the m!^:^ ;^:::::t:;!:r f-' ' --"^ u'Hler my care in tlie Philadelplua Hosnit .T " • ' '"""' ''"'' H-tm..t to place on record here. '^"■^l'"'*'-^'"! '« of sutfident Tlie extrejne raritv nf tU^ i, • '"r "- only eiJve,, ii:; :;!"'h ::"t '""'"'-^"t'' '"=''-« infaH.«,, (hvoml by .1,0 i ',t,,,;,;,l ,1 ''■"" " '"■™..uhoo„,i„.a,:f.;,:t:::n-;-.:a^ '.= taJ .«,! • bee,, i, j for H r'"'?'"" "'■" f"""!-^ -i'' 'l'»t for .evo,-al week". '■'■° ''''^'' '"" """ ''= h^d bee,, ailing 466 William Osier, II Condition on admission. — Tiic patient was a well built, muscular man, was unconscious, could not bo roused, muttered frcquontlv, and liad nnicli tremor. The tongue was dry and cracked. The abdomen was distended, and the skin presented a copious rash of rose colored spots. The sj)leen could iiot bo palpated, owing t,, the abdominal tympany. The patient had diarrhea. A UvUv apex beat could bo felt in fifth interspace in the nipple line; the area of transverse dulness was increased. There was a loud systoiir nnirmur in apex region, transniittcd to the mid-axilla. The seooml })ulmonic sound was accentuated. The pulso was 117, dicroiic; temperature 103°. December 14th. — The patient is in much the same condition ; marked subsultus tcndinum ; pulse 112; temperature 102°. December 10th. — For the past two days the condition has Ixni very serious, though the temperature is not high, ranging Iron: 100.5°, to 102°. There are no changes in the cardiac couditinn. During the afternoon the temperature rose rapidly and he became vcrv feeble. The thermometer before midnight registered 109.6°. lie died early on the morning of the 17th, on the fourth day after ad- mission. Autoi)sy. — The ileum showed the characteristic lesions oi" typlioid lover. The Pcyor's glands were greatly swollen, infiltrated, and a few near the valve presented small ulcers. In a great majority the sloughs wore still adherent. In the cioeum and ascending c(ih)n the solitary follicles were much involved. The mesenteric glands were greatly swollen and the spleen was enlarged and soft. Heart. — The jioiicardiuu) was slightly adherent over the riojit ventricle. The organ was considerably hypertropliied, particuhu'lv the left ventricle. The mitral orifice admitted only two fiiiirers. Both valve segments were sclerotic; the chordic tendinea? wore short and thick, particularly those of the posterior valve. At the base of the auricular surface of this segment, and extending to the adjaccm wall of the auricle, there was a Hat, superficial ulcer, circular in out- line, nearly 2 cm. in diameter. It was somewhat raised, had a grav- ish-yellow appearance, and was roughened by the presence of a few vegetations. The aortic segments were healthy; there were no in- farcts in spleen or kidneys. A Study of the Fatal Cases. 467 Cask XX VIJJ.-^,/„,^,,;,,, .^ ^^^^^ Tl.o patient was seen at her ho.ne bv Dm . • «'y.^ l>.-0VK,u.sly. SI.e luKl then been ill fj ' , T '"""" '^'^""^ t^'" acl.o, loss of appetite, and o,„e,al c n! n ' '"■''^' ^^''*'' ''««'- 103.5°, and tbo patient lool^d .m l^'^^ ' !? ^-'i-'ature was and brown. Tbe patient was jriven •„ . ■■ ■ ' *'"'^'"'^' "'''^ '^''y -•'^1 -te.. tbe Hospital tba ;^ "'i;^^^'- ^^'l>' -1 said si. gettn^s gradually worse, and this S ^''' ''"V^"'" '" '•^^' ^'^ J'"'"^". i-norrhage froL the b ..^.^ . ,, f^'"^"", f '" '^^^ to bavo . ':' ^'"^ '-■ to the Hospital. 'sU^t^r^ ''' 'r'^' -"' 'bey s'o... "'^'^ '''^'«l"'fe^ J>rofnsoly on a.bnis- Tlie temperatn.-e was 102° at 6 „ n, . l . i^ationt bad five la.^e stools of al h.",;, "'l"" Vl' ' '*• "'• ^''^' was dull an.l beavy, and did ., , ,' "''' '"'"' ^''»ts. 8be ^^'"^''>;''--i^M^.rL:;;o wi^^^ -' If Pa'>lo, tbe sounds wer elear b t 't i " T' ^''' ''"'^ was shortened, and there was f.tal I ,; V'*''" "'" '""^^ I''^"^^' '""'"' "''^'"•^^'- ''"t there ua. s il^ tt •',"'• '''"' ^""'-"^■n i'ofelt. "'^''* ^^'"I'^-'-V J tl.o spleen eouhl not The following mornin-ture had n.>t been tb oo° , T, rT"'"'" '''''^'' '' ''- 98.(i° in the axilla. She had h .d ^ ' ''"'^ """'"'"fe^ '"t was -"ta---d bile, and there was a ,h ub ful d '''"""■" '•'^'->'^'J'-v ^-Jor, June 16th— Tbo f-.. / """"' ^''^^o-i'caetion. ■"-"..• Thep;;L;:r;t'-^xtrr'"T^^^-«'''^«^°^''i« f-J -ly a blood-stained n'ucus Att"' '"^ 'r''''' ""^^ •^'•^■' ''o'"K -ell; the pulse was of lood . '' '"; •'''' ■^^'^'""^ *" '«" spoken to. ^ '■' '^"" •""•' '^tupid, she answered when -^t 8 p. m. the patient was delirious -ind I., i i'.V|.onostl,esia of the skin so that '' '"-''^"''="' <''«'"'^e I . I 468 William Oslei: and feet were cold. The heart's action was rapid, feeble and tuniul- tuous. The temperature had risen to 102°. The abdomen was not distended and the liver dnlness was not obliterated. At 8.15 p. ni. the patient vomited 100 cc. of dark brown fluid, which reacted ior blood-coloring matter. She gradually sank and died at 8.40 p. ni. Anatomical Diagnosis. — Typhoid fever ; lesiom in the small and large bowel; ver/etative endocarditis; acute splenic tumor; extenaive necrosis in liver. Body was well nourished ; rigor mortis marked. The lungs were dark in color, hyperremic; there were no distinct areas of broncho-pneumonia. The bronchi contained much Ihitliy mucus. The pericardium v/as smooth, and there was no excess of peri- cardial fluid. Heart. — The left ventricle was contracted ; the right disteiKlid with dark clots ; the organ was not enlarged. All the valves wvw normal except the mitral, along the edges of which there were a iimu- ber of recent vegetations varying in size from the head of a pin to fnui' or five times that bulk. Tiie heart muscle was dark brownish-nd in color, slightly mottled. The coronary arteries were normal. Tlie intima of tlie aorta was smooth. The spleen weighed 1020 grammes, was soft, of a deep ochre yel- low-brown in coloi', opaque and very cloudy. Scattered throuiilioui the substance were reddish-brown specks the size of a pin's head iiiul smaller, with liypei'ajmic margins. The kidneys together weighed 400 grammes, soft and swollen, tlie cortices pale and grayish-yellow, in color; the stritc were almost absent. Intestines. — Beginning in the lower part of the ileum there wore the usual typhoid lesions. Tiie solitary follicles were enoniioiisly swollen, elevated above the surface as much us 4 mm. The swoiloii Peyer's patches had firm edges which slightly overlapped the lw«e; some of these had undergone necrosis, beginning on the surface; aiul near the valve were a number of patches in which sloughing had oc- curred. In the ileum about a foot and a half above the valve there was a small hsemorrhage beneath the mucous membrane, projecting as a little blood cyst. ^ study of the Fatal Ca,es. ) excess (it Throughout the cntir,.c,„o„,„,, I , ' '"^^ -l« were „„if„r„,|y „ffe„,«l, .„„ I'f '"'f'"" ""■solitary ,i,,. hr„e ™»,.r„w-lk, ,«„ ,,„„^„, »'Hv o„l,,rge,|, „,„, ,. ,/ , ;ver,a„d fro,,, the |,M„e,„. ft^ nt Mr "'" ^"'""■' «■"" <1. h reg,.e.al.,„c„l„,,i,,,,,/,, ;"^. « later ,„^„„,, ,„ „„,,,. "'"" "°"'°' "''-''■''■-' -'';s';'rt;;r,;;:,j,r'--'- Convulsions in tvnlmiM f MiMclnson (TI.e Continued Fevers of P n ':«". !>• 04i) states that in 2960 cZ , T ^'''''''"' '^^^'''-'l Kdi- -• Inoneof thesetheoonv ,^'::::"'-- ''''''''' '" -' - the sixteenth day, and the padent , '''" '""^■'' ^^^''''Mnn afterwards. The kidneys were fin J • '"'"''''"'^^ ^'^^^ «" i'onr a 'oy of thirteen, died 'uddeny:',.'^: :/''--'• ^ --'"' - r -^-'^ m> post-n.orten. examin r H " :'" ^'"■'•''^'^'' "-• "V"lsu>n.s oeenrred on the eieve t ,av *'""' ^•«'^^' ^-'--1 t|'e fourth .nstance, the patient reeov e i "''' '"''°^'^''- I" 'ons, Jastn^g a quarter of an hour II ' ''''''' ^' ^'^ -onvuJ- f^- The fifth ease, a n,an ^d 't ^ ' T'^'f "" »'- fourteen t. •lay two severe epiJeptiforn. cofv d on^C^^^^^^^ "" '^-' twelfth -, a „.n omty, during conval ^^e dT"'"'i '^^''^ '^^^^^ acLs He had also thrombosis of the left f ?' ^^''^^'Pf'^o'-'" at- a good recovery. "'^ '^'t femoral vein. He made Jii Volume XI of tl.« T„ - ".,„l,er 20th i„ „„ ill„e,,!f I ',, . " ,''^"""« "■"" »<''-'« l«...o .as al«v.e ,05-. O,, ,,e 2 f.rf " '"""""■ ™« .»». Rl < I'l 470 William Oslei: the third attack at 9 p. m. he suddenly expired. No clot or Jiny lesion was found in the brain. Case XXXIV. — Very mild Ujphoid fever ; development nf sccov convulsiom on the ninth day; death in a convnhion. Tlirmn- hotiis of branches of the left middle cerebral artery, A. B., ii,.n, (/" '>'''^f ^-•"'■'O^ and i„ .spit; ,/ , "• Akatomtcal Duo^osis -r, , • . - "' ' "■^'^• ^'»rer ileum; thronbo.,s of L,:,,Jz7 i^'''''- ' -^"perficlal ulcers in the 'i'lie iJeiiin was tlie seat of '■"^ f '« iej.nu.n, to a Jess J J"';^f ''«^7«''''l.agic enteritis, affe,,- ;7"'-- -s ,,vpor.nH-c, a d „ ,'"' !'" ''-'- ^i.e ,„,.,: . ; - place into the subst^n^ "^ -^--tions of blood h at( ,es. 1 Ley were.. nperfioial partlv.x. t ""'' '" *''« ^'oyer's f'- largest „.,t n.ore tba„ i.5 J^^T J '"'""'*'' ^'^ '-">- '"ejnbmno wa.s h.on.orrhagio. 'ri, . ' '' • "' ''"^^^ ''' ^'- '""oo, s' =!'"' -f'ened. The heart valves w ""■^''''^"•'^' g'«" '-'..-S and is a H..p,tal. Thepereenta,.'.f p,, , ,:, '-^ '-- ^'^ the Ji..ishane Case XX J V a,i • • • >. 'm. CO.,,,,.,-,,,,,?. .„■-:■,,':„:'";,:; "^,' """■"«' ■^'■'"™"- -^.h, "" na.„l ,,ev„„, „„,„ „J^^ 2 ' "," '■^■'"'""1 '•■™- ". i»-"-»i:i-"t'; t.» 1,0;:, !: z;::f r^'-;''''' ''-i-'- -a T^l'e l.atient Nvas a health v Inn ' . ''''' ^^^heteri^ed. ^ ••^'^' ^'-^''ed; the io:^e\^:'^jf^^r''^^^rU thefaeea "^•eryulK-re soft; there were no m ' ^''" '''Women was f^- '^''---ination \ :Ir,T^i '" •^^'^'^" -« -^t ! ^'"Perature range was not idgl "f i" "? "" "^^^^^^^^ The . «o«i;'tal she had only si^ Ss '°t, /? *''^ ^''' '^^'^ clays in ^^'«^- ;;>- on the eiglh she h^ ftl !Zt' ''''''' ''-' --^- I ; HI U' 474 ]Vi//i(im Oa/n: On .Septt'inlHT 9tii and lOtli tliD tomixTatiiic was liiijlicr iiiul iiini;' porsistcnt. T\w |)iiiw was ri'ifuliir, of t^ood vdIiiiiiu, and not (licmiic. Tilt' alidoniiMi was not distended ; tlie spleen was not palpalile, Mini tlit'ic were no rose-s|)ots to 1k! seen. She had two or three soft move- ments each day. On the 1 nil iind i2tli the teniperatii"e Uopt between 10"5° and 104°. The alnlonien was soft, not distended, not painful ; the ton^riK wms fnrred, not dry. (^n the null she was not so well ; pnL-e was more rapid, and remind 130; the temperature was nearly 10.")°. She eonipiained of i>;iiii in the abdomen, liiit there was no special swelling-. She had three move- ments on the l;5tli. On the llth the temperature was almosi 'onstantly al)ove Kit , and at 2 a. m. reached 105.2°. The abdomen was slifiluly disieiiilcd ; the (liarrlKca had increased very miieh ; the respirations were >lioit and costal. The hands and feet were cold and clammy. The trniv- itv of the general condition coiitrasle«. with the comparatively slio;lit local features. The abdomen was not much distended, and pai ilui only on deep pressure. There was f(Etal heart rhythm. Throiiiihont the iiitrht of tiie 14tli she liecanie much worse; the moveiiK'nts were frequent, and the condition of collapse was marked. She was given sulxiutaneous injections ol salt solution. The pulse was verv rapid, almost unconntabie. The patient took her iiniiii-.h. ment well. The abdomen became more distended, tyiniiaiiitic ami tendt'r. There was 3 em. of liver dulness in the right nipple line. The patient became much worse throughout the l„,,|i „ ^j.^'; '^^ ^'' ''■ "l> work .six dav.s ago ::::;;:.'-'- ----"-:; t':::;i -.l,,ro ,e„,le,, Tl.ore „ V l' ' ■'■'"""'■•""'I. -«, tv,„,,„„i,i 'f '^ l>- "1. to 104 0° Ti • a''-'>iissioij was 101° .,n,i ,. *■"— wt'^.-k';;: "'""" '■'""^"■■«' ° '-- %»i".e «:;:',';;:: Diiniiir the first week in H v i . ^tamly between 103° and moZt'^T'^'^'T' '""^-^ -- ''''-■" ^^«-^ readily palpable • tl e ton ''''^' f'''''"''^^'^- The "•as no diarrhcea. Thi „,t':.t r T^''" '""' ^''"-^^ '""'^ '"'^^vn • there ^^ ;• '■■•/'« '-^' a pX i:,:i.::;: ^^^ji/'-f ^e 21st, ;,.:!;:: """' ^'""^'•'- Ti.e h.nu.rrhage did^ T , J :, ^^ -« "right red uuencettie temperature. He i i 476 Wif/!nrn Osffr, was ordoml the lend mid (»|)iiiiu pill, iiiid on tlu! 22nd lio had tliivc irivolimtarv niovcruciits, noiu' of uliicli coiitaiiu'd l)l()(»d. On the 22n(l and 2;}i'd he sccnipd lurtcr ; tlw tcnipfraturt' wns nnf so liifjli, l)ut he still had slijj;lit dii'.irhd'a. On the cvf'ninj:; of tiic 2ltli tlu' patient eoinplainetl of scvric ahdoniinal pain ; he became nineh oxeiteil, attenijitcd to ^rot out of bed, and reliis(«h iie nas always been a )i,..,|f|,„ '"■•■" •''•'< <""• four ,Iavs bof; ,■ • ' '""' ''''^" f''"t lu" ind ' Oil iidinissioii (|j(. ,,,,,,, J . "" • " was not palpable Tl "''''^' "atiiral • '»■ »«".e,l ,l„i„,. „i„.,,. ; """'Ri' »1 t.nie, ,.«,|«, , , ,^|. ™ • ^"'■piiIsiMvas 119 ; ■ ' ^ "'1^ Qiiietor l,.,f "' ,""; i»>'™' wi,, j„ ,s ':::'; ™ <■"" "■"' '"•'■' - ™ "«« "S-me,! i„,cl, ';„r8e T , , j """«'' '""l-ood of I04» Tl,. "■' •"""■"« -0.,. „a. J;„ t;;^;- -a.,,, ,,, „,„ .-^^f]' K "*■ "« face was pi„<.,,ed I , 478 William Osier. and he looked collapsed ; the pulse was rapid and feeble. He had two loose movements in the day. He sank and died at 4.30 ]). m. Anatomical Diagnosis. — Perforation ofti/phoid ulcer of Unun ; general Jibri no-purulent peritonltiK ; acute nephritis; chronic tulnr- culosis of luncarri;ii;es. She has been nursing her husband, who has had a serious altaek ot -1 ^fudy of the Fatal Ca,e,. a serious attack ot gall-.stoncs, and is i„ tj,,. rr . , ' "^^^ "'^ present i||,„,,s i„,„ , ; ' -"■ ''-'-^--i '-aek; noeo.!:,,,. „:',''-. '"-'ache an.l pai./in ""■■""-^'ve. To-day,, he <;,h at o, il'^' '^''^' ''-^^''^ 'mve '^- -oating. She has not «^ ^ I ■ ''" ''"' '* "'"'"' ^'''Jow < -t know of any eases of iey^l^Z ' """T '"^''""' -"' ■^'- ^ •"K .n Tennessee. '" "'^" i»'^''« "l.ere she has been st y , '^''^' '''ood exann-nation was negative Tl Pa^ahle, an.l the. ..,, „, , J ^;""' -^'- The sp,o.„ ,,,, ,,, Dnnng ,he h'rst ten days in FT v, ■"" '^'"^^ ''ad typhoid feve, ^^J / '"'"' '"' '''^^' '■" ^onbt whether or -^^'^° i" the morni,^-a, : ;:';;f "---he.th,Otha:^ ^ even.,g. ^ '^"'> Wwee„ J00° and loio ;„ ^j' , ^'^'••"» thellthtothelothif f 1 > ;«^^ and I7th it was ..twee;/ o^;;--^ ^-T "ay, and on the ""•■ ^ ' '' ^» l^'-5°. The i,lood w. et ,? ' •^'"'^ "" ^'"^ ^'^'^'"'"g of 7 'nalanal o,^anisnu. The," wa 'o "' '■''*^^^*^'">'' ^'-- N^re --t,on, .,Hch was p^-esent ,„ ,1^ ,S "" ^^^^ '^^^'^ The diazo- "0 Laths; her tongue was elea • ""'' ^'«='l'l«'a''«I. «lie had "---'^,I>r. Thayer, .l^^^Z:: "" ''='"'•''-' ^^''^ - - '■' ;'onl.t as to the existenee of v, h d " """ ^'^"' '^"'>' ^^^'^ ^'" t'"' l<^th the temneratnn •'*''""' ^''^^•^''•• '7^'^''< ''----action^a„dani.^,,l^j:,^'' ^.^^^ there was a ^;^^-' to have diarrhoea. From 6 n"'''" "f ''"^"•^'«'' -"' «''« '''-■f^"'«e only i„ the twen persi , " ^^ '^^ -^k- «''owing a ";' ''"'"■' '^"' "'<'.V had no infl e 7.) " "' '^" ^''""^^^ ^^'-T I'll ! M i 480 William Oder. stools in the twenty-four hours. A characteristic rose rash develoi).. I ; the tongue became dry and brown, and there was sliglit delirimu. On the 25th the abdomen became .slightly distended. On the 2yth Dr. Thayer's note reads as follows: "The patient has been extremely weak for the past two days. I'he pulse has Um rapid and feeble, the abdomen much distended and hard. There has been constant diarrhea. She lies with her eyes half closed and nnit- ters at times to herself. There is snbsultns; also tremor of th.. tongue. To-day the patient seems better; the pulse is slower; tl.c tenrperature, which has been persistently high, is flilling.and at n.mn was 100°. The abdomen is, however, much distended." On the ;50tli the patient looked extremely pinched; the pulse was feeble ; the abdomen greatly distended. At 2 p. m. the patient siid- dqnly 'collai)sed ; the titce was pinched and the eyes sunken ; siie sweated profusely; the hands and feet were cold and blue; the pulsc was extremely feeble and rapid. She could not be roused ; the al)- domen was distended and tense, an I the liver dulness was almost obliterated. She sank and died at 7 p. m. Case 'yiHY .—Protmdi'd hif/hftver; on.sd of (Uarrlma at the cud of the fifth week; syviptoiiiH of perforatioti ; no autopsy. George H. W., aged 27 (Hos. No. 8295), admitted October l>t, 1893, complaining of headache and chilly feelings. Patient had been night orderly in Ward F for twenty-three days, and had charge of the bed-pans. He thinks that he has can-lit the disease in this way, as he confesses to have been very careless with the pans and frequently got his hands soiled. He had been ailinj; for about a week before he went to bed in the ward ; had coiiiili. headache and })ain in the back. The bowels were constipated, and three days ago he took a dose of salts. Last evening he had a slink- ing chill. He was seen three days before admission and was then not thought to have much fevei . On admission the blood examination was negative. The tempera- ture was 104°, and at midnight reached 105°. The tongue was red, glazed and dry; the pulse was 104, soft and dicrotic; the edge of the spleen was just palpable, and there were a few rose-spots on the skin of the abdomen. A Study of the Fatal Cases. 181 ror the first week the p-itient VI lHVh-104°, occasionally ]Oo°-l„!f TT T,'"' ^''^ ^'^"'I'f^'-atnre was gos that the baths a>'.l opiutn enenmta ordered " '"''''' '^"''''''' ""d .starch On the 29th the patient did not seem .o well TT pan, in the abdomen, chiefly i,. ^U, ]„,,,,. , "'"• f^^/^""^plamed of appearance had altered a good d^a n / "" ''" '^^^ ''''^'- ^is The pulse was between 150 and 160 • ,, '' ' ^^^-"ty-four hours. - ^-ting. The ten.pera..;l^^.^: C T^^"1"' ^1 "^ at 2 p. m. on the 28th -ind I,;, f * ^ ^^w hini however, was quite flat. On the mn... • "^"'g''^ ' the abdomen, ^-1-at.ne did not rise a bote "040 Tl" "T ''! "^"' ^'""^^^ ^h^ rapid and he was bathed in perspi;ation W '' r'' ^'T' ^'^''^ p. ni. the face was pinched the hX "^ " ^ '^'^ "'"'" «* 3 very feeble; the 1 ver 1] J ""t " tT"""'' I^"'- ^^O, solution was infused suboutreour T^l -'' "'''^"'''*^^'- ^alt action very much. The o" ^Z^^^,^^^ ^ '"'^''"'"' ^'^^ "mart's ..egatived. He died at lO^t " No ^^^ ''''' ^^''^'-'^ ^"t ^" Positive thecontinned ^vers generally an 1^ ,1 ""'" .•''''"'' ^^^'^ -^ ent exist, and that the dootrh, ' „ « ;'' "T"*";'^ '"" ""^ ^'^ P'^- by new and carefully recorded I W.''^.^!,''^^^^^' ^ ^^ — basis .readf2:^S;;S^:- ;- of 10 Jnenritis and of wide- Local jVeuritis. ^^^%^^:^Z:'^^ ^^'- f- heen .>nr with well- -'"•cl. was not treated for the Z; in . u'' ' ' "^''^'^'^'y -«« Before describing these T J n , ^°''^'^'"^'- 'feasting and diftre'^ ^ ' ^1, t '^ "' ^"^"^'^" ^« ^ -^ classed as a neuritis-nanfeirt,?";^";'^ '""^^ *^'««' I think, be When in the Report on Tvn . ?^ "'' "^ '^'^''"'''^ ^^^er. I -lied attention H.^s^n t^, "T^'rf '" ^^^^ ^^^'^^ '^ '0 ..bject in the literatu,'e 'bu -.f R "''/"" "^^^ '"-^-» of *Read before thfiN».„„,„„:..... . *Read before the Neurological Societ, of P,,,«,elphia. i-, 397 398 Willimn (Mer. in which this feature i.s accurately described. His words are : " For some weeks past there has been tenderness of the toes vi' both fctt, so that the toe-nails could not l.e cut on account of the pain it eau.-ed in the nail-bed and in the pulp at the end of the toes. In three other cases recently," he says, " 1 have met with this condition of pain in the toes, and in one of them in the arms also. In one instance \\h' tenderness of the feet was so threat that they hud to be protected IVo,,, the pressure of the bed-clothes by a cradle. But in none of tli. ,„ was it followed by muscular wasting or detinite loss of sensation s(, far as I could detect." Not having met with the condition before using the baths, I wa.s inclined to regard it as an effect of the cold water; but in a pcrsomil communication from Dr. Ilandford T gather that his cases were imt treated by the Brand method, so that it is evidently one of these coin- cidences winch arc so ai)t to be mi: leading in medicine. Before .Inly, 1890, when the Brand method was introduced into my wards, I liiul never seen an instance. Since then we have had twenty or niu,v cases, all of which have been bathed. Though not serious, the condition is very distressing, and a cause of much sutlering. It usually develops in the latter half of the dis- ease ; sometimes, indeed, after the temperature has reached nininal; thusi in a patient at present in ward C, the teiuler toes wciv not noticed until early last week, the fourth of the fever, and wlun the temperature had already begun to fall. The patients usually com- plain first of the pressure of the bed-clothes, and as Dr. Hiuuirord mentions the sensitiveness is so great that the toes have to be pro- tected by the use of a cradle. The area involved has been in nil of my cases the toes, with occasionally the pad of the sole of the loot; never the dorsum, and rarely extending as far back as the heel. The tenderness has always seemed greatest at the tips and on the i)lantar surface of the toes. Even the slightest pressure on the nail causes pain. I have never seen any redness or swelling, though of course in the reaction following the cold baths it is not uncommon to see the feet extremely red. In a few instances there has been sweating con- fined to the feet and toes. At first 1 thought that the pain might be cause,„.a,e.i to bo v 1 ' T'"' •''■^^'"•'-"-. '"'.1 in <'"vcn>,l, an.l we have I,,.,,,, Io,I .rul„ , .'"''' ''"^''' "" '■^"- <- '•'•ac.-0-panestl...ia i.os.il.,v'.,„„ ' , ;;.;;f "•^' ^•'" --'itio.. us '''etreatnKM.tis„ot-^ory.sa;is(iu.forv r, "J'l'''r'"">""^; thcuo win-eh s,.o„H to .J., '"•" "•'^''•' "" ■^'"■•^ '>^' soh,t,on o„ cotton wool. ^ '" '""'^^ '■'■"^•' i"^ ^ hut .ooaine ijocal neiii'iti,^ jjj (y.,], : i /• tI.ecIisea«e«rafbrcon-aios,.' l»««'^ away 'Hh,' two tol|„wi„^r eases' Mro f|„ , Case I. — /,t ,vrco;jr/ 7eerk sfi-r,;- 0, „ ; • •*■-« «/ ■-. '-v™*; t : X^^^^^^^^^^^ "" '":""■'■"« .• .,» .«- ^- n., aged 25, admitted Oetober 8 is^O i. .• " , -•"f'-ly severe attael.-, and the tenme -Un J Im" "' ''^'^ '' '""'J" ""' ^''"' 'lay. On Oetohe.. 1, ' 1 '■' ^''l '"/.'T'' "--"'al until a.Kl while the te.pe.atnn. .an, d ^r t^i'"'' f^"^^'- '-- gantoeom,,lainof,,ain.si„thcr.,nn S I f "?' ^^'■^°' '^''^ ''^- r ^'- tenth da!, Oetobe'ur ^n!' ='•'""""'' '^ ^^"'<"-^'> clKuacter. 0„ the Ifith the note 'read ' ^'^ ■ ""'' ".'"'■'^'-''-' '" very mneh worse, ,she ean scarcely lift the' .r„,s ■;r"""'"'' ''''" '"^ '"S "^ the joints or any tender,,. . , ^'"''''- ''' "^^ «^^'t'll- "-. The soreness i L^ e Hv^^ ?! ''"'" "' ^'" «'''»-^ l"''- once when they are ,'", ^^ " .^'" '""■^^■'^- ^^'-" ^inL at TlH-reisnoswollin.of the ln.n n . ''''' " ^'^''^''^''^''-Jy tender, plexuses in the axilhe o.'aL ^ JT"'. "" "n?"" '" ^'"^ '^^-'^^I «'-otin, in character, but it ext 7' " '"'" '"-^'^'^ '"^ "«* JOO WiH'inm Osier. \\ be moved. The paiii is continiiouH. Tliere is no disturbuiu-c r.l' Bc-nsufK.n, no pins and necdlos, no HWoHi.iK "f tlu' joints; tiu" le^^s aiv not iminfiil." On tlu> 22nd tlic noto mids : " Tlio iiot ai>plic-ati..ii« have relieved the pain somewhat. Yesterday the hands were (iiiite numl). 8ht' says the haiuls aelie like tootiia.'he. Joints not swoll. n ; arms and forearms still very sore to toneh." From tlu" 18th to tiie 30th this condition persisted with very little chan^' She ha.l h;ul and opium applieations and antipyrin internally. Hie temp niliiiv meanwhile K>-adually ieii and her general condition improved. On November 2nd the note is : " Arms very much better ; pains still ii, the left arm and she can move the arms wH ; no wasting of the muscles." Within the next two weeks she improved very rapidl , the pains in the arms graduaily .lisappeared, and she recovered coni- pletelv without any wasting of the muscles. The pain in this r:,se was of a most aggravated character, sometimes causing the patimt to cry out. Ca8E 11.-/1 third week onset of severe pahs in rir/ht arm ami In/ : rapid improvement in arm; agonizing pain in h;/ ; (jreat MnxiUrf ness of muscles; erythema nodosum; recoveri/ after ten (/a//«. Mary McG., aged 13 (Hos. No. 0405), admitted December 4, l,S!i2, about the end of the seciond week of what proved to Uv a very severe attack of tvphoid fever. The tempc-^nre kept up for at. unu-nally long time," and she became so feeb>. n *, after the 44th bath they were discontinued. It was not until S ond of the otli an.l throMuJi- out the 6th week that the temperature fell to normal. On DceeinlxT 14th, while the temperature was still high, having been <'..iistiiiitly for several days in the vicinity of 105°, and after she ha.l lieun sponged with ice-water for two days, she began to complain ol very great pain in the right arm and in the right leg, of such severity tiiat she cried out constantly and she had to have morphia. These attacks continued between the 14th and the 20th with great severity. In the right arm the pain soon subsided ; there was no involvement ol the joints; no pain along the nerve trunks. She screamed out if any attempt was made to move the right leg. There was no tenderness about the hip, no swelling of .the knees, and repeated exaniinatiuns seemed definitely to exclude any articular trouble. Grasping the leg at any place seemed to cause extreme pain. The leg was not swollen. ^ruri,,: Dun,,, and AfUr T,ipl„M F.,er. 40, On tlio 18tli tliivc imtcli<.« i;i,-. .1 ^"■' ' -« «e .1 ";I::;. ■S'^in';:'-:";; '-■«' - «■« >-!. TiH. loou i : L" ,;;;;: ;•■: ^'-^ •>•;'- -a 1...^ .... ..• ., ' .listinct biuiHh .ii.....o.;;ir 1 ; ':;^.r'' """:' -« ^'--^ -- « a .lay or two. Tlu- larger one c> , tlu h ■ ' •.""■V''^"!'!'""'-^"' ^vitl.in tlio pain accu-atolv. It w,s ..o, ... I • '' "''''' ^" '•"'''''^^^ «"^ "-Pl-i.. •"•arly ten , lays, the pain ,snl)side,u; ' """ •"'^'■••"^' ''"• or 2ml, two weeks a least .ntV '''-''l--^! ''y tlu- 2.0,1. /-'-«- pain was l,:;:!;:;:.::::-^^^^^^^ trenie sensitivenesH on pressure , <; i ^ '"*""' '""' t'"'''f' "as ex- »- r"'- -"-i» "..r:,:;:;,:;:;:;: : :; f ir;.,; r ; '«• •'■'- niiiiil)ncs.s and tinirlinLM'n fin. «..,.«.. . ii ' "'' ""-"'■*' ^^as ™» panned ,l,e peculiar l«i," ^ , '' ™^"""r- ™o.c.o„„d on suddenly. Vi.ere w scl.W n.^ V ''" '^'^ ^'^' ''^''''^' ^'-'"^ t'- i-teri^. tibial, i:! '^^^^^^ir^^r 7^^ 'r " -r^ ^^"-^^^ ens muscle. The toes wero -I •' ''''""^' '''"^ ^'^'•^''■« anti- — in then: i;.::^;^ r^:,: h:' '^^r^^^ ^ ^^"'"-^ ^^ it .^eemed probable the natient ^v • "'"'''*"'" J"''''-''^'^^' ^^''^^ i i U 1 11' 402 William Onler. tenderness, and the sensitiveness in the anterior tibial muscles iiad disappeared. Case IV. — With nmet of convdIc.Hccme soreness and pains in limhs, jjarticularli/ the arms; 'pins and needles' in left foot ; sivcllimj a ud tenderness of left arm; gradual improvement and reroverij icitluml atrophy. Wm. McM., aged 32 (Hos. No. 6329), admitted Novcmhor liltli, 1 892, at about tlie second week. The attack was of modeiate severity, the temperature ranging between 103° and 104.5°, and not falling t^i normal until the fifth week. Just about tlie time the temperaimv became normal, that is on the 12th of December, the patient coin- plained of general soreness and pains in the liml)s, i)articuiarly in the arms, and he winced on pressure upon the forearms and anus. He had been in very good condition and (H)nvaleseence seemed well established. The grasp of both hands seemed weak, but particularly the left, and he complained of a sensation of pins and needles in the left foot. There was no tenderness along the nerve trunks; no pain on pressure on the muscles of the calves; he winced a little when the muscles on the right thigh were pressed. On the 17th of DcccnilKr the note reads : " J.eft arm looks somewhat swollen and feds tcnsv. It is not red ; the temperature is not elevated. He moves the nui>- cles with ditliculty and says the arm is very sore. On the inner i)art of the upper arm tlun-e is very great tenderness along tlie comv-c of the brachial artery and of the nerve trunks. The idnar nerve is also somewhat tender at the c'bow. There is tenderness of the nuisclrs. particularly of the biceps and of the extensors of the ui)p(r arm. There is no anesthesia, no sensation of pins and needles. All move- ments in the lin\b cause him pain. There arc flying pains in the legs, but no swelling; no tenderness; knee jerks were increased; no airkle (•'■ nus." The swelling and tenderness in the left arm grad- ually disappeared within ten days and there was no wasting of the muscles. In bjth of these cases there was great sensitiveness of the nerve truidvs, and in Ckse IV it seemed for a time as though the patient were about to i ave an attack of multiple neuritis, but the symptoijs became localized in the left arm, whicii became swollen an^l exqui- sitely tender. Ill rauscles liiiil ^^euritU Durinq and ifu. 7- , -, ./ "m After Jyphoid Fever. ^qS oonvalesZl; Z^^rriiro/' M ''V'' ''" ''''^' ■^'"'' '^'"^'"^ OradunJ veeorern. ' ^'''' '''"''^'•'- /"o(-drop; ficu ty ,n wall V"""'; "■"«' ^-•>' "HK'h of the ri-d t folt : .""'f * ^"•'^'■^ "IN -'-n evidently ^•e,,. sonsitiio. Ho vo \, / '. ''"' '^''^ <'"''' -><' u-s ''^ -'^' "ot wallc npon it Ti J /, '"•■'""'^- '""'■'' ''^ -d al'le to got aiK>nt on it with a l!;;;f "'"'"^ ""'•'-■"'' -<' ''"s heo„ IVsont Condition.— The pI,;i T •" Ti.e intoiJigonce is good. The ^ n^He n '^ ^''"'^ -'i-nonnshed. scorn por/oetly normal. I„ wal ' H '? '''"'^-•"'' ^'^"^''^ My "-• The f;,ot is held li„ ,, '" f, ''^ ^'^''^ '^^ '« Aexed at tlie P'^'"- On examination the n^l V '' ""' •^^^""' ^" ^■"vo any •^"■='"-' ^''- tl.e left. H L I t ? : ''"' '^■"^^' ''^ <'--'Jedly -'>-"''^'- '"-'OS hoiow th . r ;r" nr r'""^^'^'--- '" «^-'">""ation, as he cried out .nd se.,I T ,','"" ^" "'"'^''^ '' P'-<>Per ^^-•''-^ l^ut this is apparently :eX^;^;"' ^""^^ ^''^' '^^' ^'> be B"'T'.s article. ' "^ '■o^^'reiices are to be seen in I I i i 404 William Osier. Tin's localized atrophic paralysis after typhoid may be due to polio- myelitis, and the distinction between the central and peripheral nature of some of tiie cases is often very obscure. Sudden onset, sensory disturbance, and permanent disability in certain of the muscles of tiic affected limb, speak for a central lesion. The case reported by Shore (St. Bartholomew's Hospital Reports, Vol. XXIII), is perhaps the most satisfactory on record, as showing conclusively the existence (jf acute polio-myelitis in connection with the atrophic paralysis follow- ing typhoid fever. In Case V, while the general appearance of tli.' limb, as the boy stan.ls, is highly suggestive of spinal paralysis, yet the gradual onset and the extreme sensitiveness are in favor of neu- ritis. The reaction of degeneration and the absence of the reflcxt's are symptoms common to both central and peripheral lesions, l-'or the tiiird and most important diagnostic criterion ; viz. : the complete recovery or permanent disability in certain muscles, the time which has elapsed has not been sufficient. Multiple Neuritis. The most serious forms of paralysis following typhoid fever lU'C those in which there is a rapid or gradual development of paralysis of the legs or of both arms and legs. Cases of the parai)legic tyjie are not infrc(iueut in the li^'raturo. In my own practice I liavp, however, never met with an instance, ^yidespread loss of i)owor in all four extremities is, if one may judge from the recorded cases, vuiy much less common; but within the past two years the following caso.-^ have been un r my observation. CaseY I. —Severe fever of three weeks' duration ; during cnnealescence weakness of arms and legs, nnth finally complete paralysis; foot- drop and wrist-drop; great soreness of the muscles; progressive improvement; complete recovery, after persisting Jor more than a year, D. S., male, aged 9, applied at the Neurological Department of the Disi)ensary November 1st, 181)3, Nsith paralysis of arms and legs. There is nothing of any moment in his family history. He was always healthy as a child. He went to school 1-t winter and developed well in every way. I^ast July he was in b. 1 three ^'euritis During and After T,j,,,;,i j,^^^^ weeks with a fever <<.. I,? f i . ^"^'' ^^'^ J/.0 mother think, that Ihis ,.Z '"' »'"" I k,m f,,pl He ha, „„t „,„,„, ,,.„^^ , ;; ' - ■■»™ .1.0 ,., ,„, Zi power i„ then, alloMhoV H, f ' "'"' '"" »™lioa ^ I'?""" ^'-'^ '« -aroelv Je extended in the least. He'i 1 ^ ''' ^''''''''' ^"'' ''^nno't fip on the right .^ide and tl C „d t H^ ^''^' ^^ -■^'^' i ere are no n.oveme„ts of the s,, d ^n 1 ' ^"^'^^'^ "" ^'- '^ft. w .ole arn, and fore-arn. are v^"; T i! " "' ''^ ''^""'- The ri.e sku, over the last phalanges is "iittl T' '' 'i'""^^ "«'•«'«!. '! <- of the table the back^ is ci J d ;? ' '''^"" •^'""'■"^^ «« ^V^l'en on the back the mtwnf J . ' ''"^ "'"""»* .sit straiTrht ;..ie of about 450 ; :i.rtft ,;:;;,^:,.^r" '^^-" ^'-^ bod,::t^ I'as 3o.„e power in extensors an f I ^"" "'''"' *''« '•''^''t. He ;; -'i -'t. The extensor rusdes :f t^ ' ^^^ ^'^" ^^^^^ the ,e^ t ^ fl-ors are the weaker. Be Inv te l'" '" T ' "" ^^^'^'d-; P'eto paralysis. He can slight,; fl" ;""! ^'^^ '« «'-ost com-' '"'^■•k^'Uy atrophied. I„ .vaJn.n V ^''''- ^''^h legs are :^;« f pain, also wineer ^ : ^7''"^ ''' ^^^'-'^^ "- 0^ the orearn, also are slightly "22Z •'""'*^- ^^''^ "'"^^'^^s cannot be obtained. The mnsdi! ^"'''''"■'^- ^l.e knee jerks ->• ^"•S'^^ to the galva^ t .:;" Vr ?• '^'•'''"■■^'"' ^"'^^ ^^ '^nt. The pat.ent was ordered the 406 William Oder. syriip of the iodide of iron, m. xv three times a day, and massaj^e with electi'ieitv. On Januaiy 12th, 1894, the note reads : " He lias heen given elec- tricity three times a weelv, and has improved. He can now \.alk a little alone. He has a very typical 'steppage' gait. There is still complete foot-drop. The muscle groups are still sensitive on iinn pressure. There is still the reaction of degeneration in the nuisdcs below the knees. The muscular strength in tiie arms has improved very much. Ho can Hex the wrists with a fair amount of i»o\vei." Throughout the early part of the year the hoy did very well, and there was a progressive improvement. H" came to the Dispensary on the 24ih of August, when it was noted that, though he still drags the toes somewhat, the gait has Inst its typical character. He can move al the muscles of l)oth arms and Ic's and has considerable power. All the muscles respond (piickly to the electrical tests. On December 1st Dr. Thomas made the follow .g note: "Legs are well-nourished, and he moves them in every -(ction; he can flex the legs and thighs fiat to the body, and resi .s extensi(.ii very well. The' flexors of the knee are strong, but not so strong as the extensors. When the foot is extended it cannot be dorsa'Iy flexed ; when raised, however, it can be easily extended. In the arms all the muscles act normally, but the flexors are stronger than the exten- sors. This is especially true of the wrist. The mu.scles of the legs respond to the faradic current; the flexors respond to a third higlior current than the extensors. They also respond to the galvanic. The extensor and flexor muscles of the arm respond promptly. Sitting the boy still has a tendency to bowing of the back and to toe-diop." I showed this boy at one of my clinics in January, 1895, wlieii he seemed well in every respect, and the only abnormality to be detected was an inability to raise himself readily on his heel . his toes. Case YU.— Severe attack of I i/phoid fever ; durinrj "onvu :mncepro- yreii,sive loss of power in «m.s and legs; recovery in < inns ; atrophy of leg wiuscfes toith foot-drop ; great improvement. Wm. E. K., aged 24, admitted October 16th, 1893, complaining of inability to walk. The family history is good. The father and mother, and one brother and three sisters are living and well. \ massage with Neuritis Durinr, and After Tunk^id P "'•'^"'a' ^^'- "•e luuKls a„,l in tl.o 1,.^,.. Tlu- ,1,11 '" '-'•"'^•^'^•^" '"'^^ "f power i„ ;"'^^7' •'""' '-^ --S net until, faylfth !•"':, t '"' ^""^' ^■■"'^' '><"i- •■'^i '-I .nneh pai„ .,-,1. th. attack 1„ ""^ '•^■'"-"'-- that he ^ - ^-t Dnrin,. the present ye^rt , "'"' T''^ ^""-" ''^"-'Jin^ of «'"-'y ■" the logs, bnt it has l^l^lr^,^:^, '"? ''^^" -'"-^"^ -vere pan.nychia in hoth big toes 'h? "' '^ ^'''' ''-•"'"PnK.t cff powor con.pletely. '' -" ''*" ''*'"<'■'* ^'kI arms recovered Condition on admission — Tl . -l^s uith crntches.' h; has'^H^r ^n ''""'^' ^""'-'^ "-' ; He looks a httle pale; the pnpi,, .,. e' nl . \" '"^'"'^' "^ '""« ^'a-. accommodation. ' ' "^ "^1"'^' ^nd react to light and on The exan)ination of tl,„ >i 1 • , appeared to be weaker than ^X^J^' "^^^ ''''^ '^''^'^^ he arms were weaker than the ^ .1 r ' '"'' ^'"^ --tensors in "•f ™ "«^ q">-te as strong as i o e of 1^ "' •".''"'"'^ ''^ *'"^ ^^^ marked wasting in the muscles of tiT '" '■'-''^- ^'* <«^ was -• '-^-wer, but both feet could be flexed somewhat. The patient had a tvpical steppage gait of foot-drop. Throughout the early part of the year he did re- markably well, gained in strength and could get about readily with- out crutches. He left the hospital May 9th very greatly improved in every way. I heard of the patient through Dr. Scott, on January 16th, 1895, who said that the progress continued satisfactorily. Case VIII.— i^ew of four u-ceh' duration; numbness in legs ; swhkn onset of paralysis in arms and legs; gradual improvement in arms; slight in legs, in which the paralysis recurred; marked improvemait under treatment. Stephen T. McK., aged 25, admitted November 4th, 1894, com- plaining of loss of power in both legs, weakness in the hands, and pain in the lower part of the back. His parents are dead; the father of bilious colic; the motliorof pneumonia. He has two brothers and one sister living and well; there have been no nervous troubles in his family. The patient had measles and whooping cough as f monia when thirteen. In June, 1892, he had typhr confined to the 'a>use for seven weeks. F hart years ago. , Present illness.— In February, 1894, the ^x ^^nt had a protracted fever, which lasted four weeks. He had vomu,;;.?; no diarrhoea; uo convulsions. He had some sweating; no chiii . [le had pain ' kl. and pneii- er, and was .;norrhvement inaiias; •ked hnprovemfut 4th, 1894, com- the hands, and ; ; the mother of iving and well; .•b'ld, and pneu- id fc-'er, and wiis ..norrhcea three had a protracted g; no diarrhoea; i. lie had pain -'™'';«. "eiow U.0 elbo^tllC "nf 1,.,",'""^ ''"'"-" pm« anil needles. There wn, „n „o t .'•,'""'» ^'Kation of IWal „,„«,,e,, „,„, „„ ™,™„ I '""'>••;" <" "'0 «""B..c, o,- „f tl.e ;ive t,« .„e <^,,„ o/::i;r ::t^^^^^^^^^^^ »» -<•"•= p«'- l.e .nsists ca„,e on in the con« of I Z °* ''""'"' >"'''"'' W l.«n han,i,$ Uown^ T'le ^ 'l; tr^l "™" ""? '""^ ays, loss of sensation. '' ' '^''""■' ™ also, lie .1, '':™t- T^ersirirrr '"■'""^^™"' '» "- """.-'ion of The sensalion in the fot ' "!, r "" "'''' '° ''''«' ''''"»lf- :"rsS.'"^:t:;;t';:"''7v^'-°-^^ again the power of isH; e e^' ^^ ht':' '^^"i'' T'^ '"'^^ '"»' lion. Sinee then he has lielnf, '^ "I'slucbanee of sensa- ^Ngl.%,b„t is still n„aWe';?;:a,r "'°'""' '" "" '"-« "" <•«' *aH. and well. Lr. isr-in^Kr -^'rE^'r:"' Ihe |.n|„ls are equal an.l the iris reflexes are ,„e,e °''' ' Jlic examination of tlie aMomiml »nd.i. ■ Tkere is no enlargement of re,ee„ ^^T T" ''' "''«"'™' «ell-nourished ■ the snine V. 7 T , ' "'""'' """"'^ '"ok III. hands looi oTnt t li ,.! * ' "'"', "'™ '■' "° '»<■""«• xiusi^its. All tlie movements are nerfeet .,nrl fi.„ "- -.gers and the grasp of the hands are S Tl ^"""/" seeni to have recovered Pnm..l.f i .u . , ^ ^'^^^^ muscles ^0 strong as he w^. ''"^^'^'^^>'' *^«"g^ ^^ says he is not nearly 9 410 William Osier. The logs are very thin, particularly below the knees. All of l\w muscles are here very much wasted. The legs can be moved freely at the hips and at the knees. There is complete foot-drop, 'llio patient can neither move the feet nor the toes. The knee jerks a... absent; there is no ankle clonus; m. ledema ; the feet feel cul.l. There are no fibrillary twitchings. The sensation is everywhere iwrfect to heat and cold. The electrical tests show the reaction ol' degeneration in the peroneal nerves ; the extensors cannot be m;ul. to act at all. The gastrocnemius and soleus show marked reactidu of degeneration. The arm muscles react well to weak currents. Patient was ordered strychnia and massage to the legs twice duily. Throughout November and December the i)atient improved rapidly. He was soon able to walk with a stick. The feet have perspiivd a great deal, and they get very red after he has walked about on t\mu. The gait had the typical steppage character of extensor paralysis. By the first of January he could walk without a cane. On Nd- veraber 18th he weighed 102 pounds; he gained rapidly, and m December 10th he weighed 118 pounds, and on his discharge, .Imii- uary 28th, 1:35 pounds. His improvement was satisfactory and i.ro- gressive. On December 4th the electrical reactions were as toilows (Dr. Oppenheimer.) Arms.— All muscles and nerves react well to moderate currents. Legs.— The peroneal nerve of right leg reacts well to modci atoly high faradic current; contraction slow, but does not give the typical reaction of degeneration which it did on previous oc'casions. Muscles of the right leg do not react. In the left leg the contraetiou ol the peroneal is slower and lazier than that of the right. The muscles do not react. To the galvanic current the peroneal nerve and the muscles react, and there is a sharp contraction, not particularly slow. At the time of discharge he had gained 33 pounds ; lie still had the characteristic gait of extensor paralysis. He had not rc-imed much power over the muscles of the toes. He could fiex and cxleiu! the veii,„r„w„ S"l ™lor; the ,„,,i,, arc' of ^ ;'".'°""- '"™>l'ra..« L " " '^"""™'-''"'-'--:2sr;ii';,^.- 412 William Osier. The examination of the abdomir' ,. ' - mc or,n.ns .s neguln .. The .ph-en is not enlarged. B..lh arms and legs 1.k.k atroplued Thire is no wrist-drop. All n.ove.nonts ot the hngers hands and arm, are perfect. The grasp, however, is extremely teehle. ihe.v is n- sensitiveness alon, the oonrse of the nerve trnnks, bnt th. Inscles themselves are very tender. He eries out .f the arn> >s "asped above the wrist. The museles of the legs look wa... . Tl.> e is complete foot-drop. He cannot move the toes or the k . He can flex and exteml the legs ; W can ^et ont ot bed, but slan s withalittl.-dimcnlty,und walks with the aid of a cane, drags th. oes, and has a typical steppage gait. The sensatu.n seen,s perieH, and he no longer complains o'" pin. and needles ; there .s no tender- ness along the ec.rse of the sciatic ; the sensitiveness o the .n.. ,. s s very marked. He winces if th. thighs .r calf muscles are pn^s..!. There has been no trouble with the ^Phi"f ^ '""^'•'^;- . , ,„„. . . The patient was under observation nntd tebruary 4th, l89o , the general condition improved rapidly. On adm.ss.on he weighed . pounds, and at the time of hi. .v- neuritis were not under ,.s<., - vaUondnSig the primary il! . a-., the diagnosis o typho. evor rest, upon the statement eitl of physician or ot he en,.. The only doubt really is Co.. .'HI, a. this patient is state.1 to hu. had typhoid fever in June of 1892. I have not been .u e t. get any imat^on from the physician who attended him, but his illness. as e^dently very severe, as he had fever of four weeks' duration, w.tlu dbrrha^a and without chills, and the paralysis did not come on m, 1 coalescence was established. In Case IX, in the third week oi the illness the lather noticed the soreness in the legs. The mode of the onset is of some importance in the diagno.s.s, sine. there are cases of multiple neuritis which set in with fever ukI id azv contraction Nmritk During „„, ,, . ,. . H ».„„,,„, , ,,,, J,^- '.;;"«!. 1,0™,,,,, „,„ „,,„, '•'"<' •'•■'inimi. He |,p„„,„„ ,. . '^ '""""' sflnrat on. -- never at an, time svn.pt, „, ^ ' "r^'^^'^' ''<''l>'' -■ »>"t U.r V re not ,„volved. TIh-,.' n^ 1 ' '" • '^^•'"•- T'- splunctors -"g'-ut Xovo„.be..and Do,J ,""''"^ "^" '^e extre,„i,os. =^">- able to get about. "''" ''^' ""Proved, and was gradu- ^Vlunadmittod on January 2nd 180^ ., -;- Ho is a pa)., dolieato- 0:1 :, S ' *''«„-"*' ■■^'"n was :. fol. r'T"^ gai^ flopp.,.. ,, ,,,, ,,^ ^^ '-J walks .itb a ve,y distinct t'-iae«aet ..onnally. Then- is o i,.!'""'''''^'^ "^ *'"-'«>•«« and of "'"^^'^«- ■ muscles of the h .d an \'""""' "' ^''^' P''"'-v..geal -eeasdysh, ,,.,, ,„, resist fl^^^ The sho-ulders 0' tl>e shonl,le..s also act wel oPf '"''''"'• '^'^^' *''^i'— strong on both sides. Flexi,;,, „ h [ ''"''"' "'^ P^^^^''^' muscles are 0" both sides. The .nu X f 1.! "■'"" '' ''"-' ^''^-- -e go d are feebly developed. In L L "T"' "™ ^"^' ^'">"'<'- -nil -ak; paIn,a..rteiion is a^o t r'lt T' f^'"" ''^ "^ ^^^^ He 's entirely unable to extend h.: fi "' *''"" ^''^ ^'«'--' A^^^'on. ^- i-'i"ts. [/• these Jointr . t^T '"' ''l ""■^'-n-phaian- ; '^^''tly extend th. .....nin..., phd :">;''"''"'' ^''" '^^^^-^ -" J" -nst is held and «oxed < ors K^tno r^'"'^*'''' ''^'"'' ^^en The small .nus.-les of both ban k n ' ^ ' ''^^^^--on the righr side ; '•' to oppose the thun.b'lnd 1 ^ r;:;^ X' , '"^ ''''^' ^« "^ ';" >■ W»H' the kuees. He ean Hev n f'"^^" ^" thin, partieu- "''"-"'«"'' the legs on th h. .l "ti:"'^"' '" ''"'^'''^ "" ^'- '■ '■^"."'«t flex or extend the feet a "tb n " '^^''''"^ ^"^^-''''^P- ;'felitis the sensory symptoms are .puK" mi1,- sidiary, whereas in polyne.n-itis there is more or less pan,, or sensa- tions of numbness and tingling. It will have been not.ced ,n to report that the muscles themselves were in several rases extr..nu.ly sensitive to pressure, a point to which Wilks and others have .mII.! attention as specially characteristic of neuritis. ThinL The atrophy is certainly more rapid in the central l.sio. but it may reach quite as high a grade in neuritis. In ('».. \ 11 the wasting of the leg muscles when he first came under observation was very pronounced. Fourth. According to most authors the lectrical tests alloni very little assistance in the diagnosis, since the reaction of .leg,.n,.iation is present in both, but there is this important d.fierenee; a.nu^l which has lost its faradie contractility in consequence of des rue ion of the motor cells is permanently damaged, wherea the lo^s oi laiadic ^''urUiH Dnrinn and l/>. t . ./ "»'( After Typhnul I>'ever a^m contractilitv ii, the m ^* "•every of t . r '" " ''^''•"'""*"'t .'Mo, .o tl 1 ' T^ '""''"*' 77 Hoasat.on, cliHt„,i.anc,vs <,f h '*'"''^'"^' ^''•'P'"'" <'»'aM.aN '^pp:'-"' * - •- -r;::",:;,.;;ri -f-i!::tr;zrr"^ h,.„. ^^■'"^•''^«n,eumh,. observation V ' '""''''''•■ ""■"•'"t'- • In (Zv f'-7! "> an inability ,. ,«,-,, ,; 7;^' ^''^ tho only n.nn.ant ufus '" ^^•'"^•'' tl.o paralysi. ancl a r ' " '"' ^'''^' «'' t"''^- ^ ^.v. 1 7/ "-at ti.e naralvsis ll. """"'•>' '^"f'' '>'' tliis veir ■,» > ' j'<'i.n>.siH Jias almost comi.h.f^j i- • ' ''"'' '<^ '« stated -- Imvo recover.! po.-.r in tl 'a^ ^'''r''^!?'-^- '^'-^ oti.or to "'" '•«'')ver coniplotdv V, ,'"''''' "'"•'•ants fi.e belief tb. tU -.-ivo ,.o,io-4,,Ht ^,::;; -'if ^" ••' ^^^y..:!^; :z l"''"an.ntly dan,a,.od. "" '""^^'« g-"l>.s are .sure to r.uZ "-'"^^ to paraplegia. SoZul^^' "'!':'' "-- '" "4^^ ^ ^ "■^"^"y '•« a transient atf i 1 T " '"''' '^ ■^''S''^ ^'a ^vitli the full esf-il.i; I ' ^^''•^''' passes ofl' i,, ., f '" ^■^tahJisliiijoiit of ll,..,!,), ! . '" =* lew weeks a ase of typhoid fbver wi(J, J ) '^ ^''^' "'""'''« ago I saw « "" give lo ,l,e mZ^T::V7 '""■'•'"■'■ "'^ "■•""■on "l.iel, I ii .1 416 William Osier. other forms of multiple neuritis, so in this, the outlook for complete recovery is good ; tiie histories I have given show how favorable is the course, even in very severe cases. In trcatmcnf jiersistcnt massage is very important; electricity is ol less value ; medicines are of d()ul)tful utility ; from twelve to eigh- teen months time is the essential factor. )k for coniplotc ()\v fiivorabk; is electricity i~ "f twelve to eigli- "^""'«'*"°'»'*"'»*"«^ff^/. ^ieporu, V<,i, V.7 ^as^^^^m CH/LLS m TYPHOID FEVER HY WILLIAM OSLEii, M. I). WSRSaSKfiaMR JOHN MUKPHY 4 CO., I'KINTEKS, DALTIMORE. JX.— CHILLS Ii\ TVPrxr^r ryPHOlD FEVER BVW,UUAM OSLER. M. D In the systematic writers n., f . • ft»nd to chills, except I ; ^^ '"' ^^^'^^^ «<^«rce]y a rer f -V and again 'i„ the In .aJsT'^"" ^' ^'^ -* ^ ' t eir " fnii 1 \^>'amactom Vol ty^ ' -American Phv in- severe chilis n.. '" af^coiiipa„iod bv nill («)• -'1/ the Onset of the n.:. ^f /-' cases treafprJ <.> , . '.'■'>" M^dioai, 1892. "'''^ "'^an with 445 446 William Osier. shaking diills. In two cases thore were several severe rigors, in three cases there were two, while in eight the rigor was single. {b). At the Omet of the Relapse. (Chart f.) Case I. —Severe prima rij ailack; )io chill at onset; normal fcinjHr- ature on the forty-first day ; apyrexia for twenty-three day.^ ,• severe chills at onset of relapse ; fever for forty-two dayt- ; apy- rexia for forty-two days; second relapse, without chilli, offowrlcn, days duration. (Chart I.) Tertia C. W., aged 22 (?) (Hos. No. 8488) admitted October :• Ith, 1893, on the seventh day of the fever. There were no chills at iur. onset. The fever was high 103°-105.5°, and she had seventy-five baths. The temperature fell to normal on the forty-first day. For twenty-three days there was no fever. On December -JOth the fever of the first relapse began, and rose to 103.5° by 10 a. m. of the 'ilst, when she had the first chill, not a severe one. At 2 p. m. there \v;is a second chill, in which the temi)erature rose to 106°. A third one occurred on the morning of the 2:5d, and at 11 a. m. the temperatme was 106°. By sponging it was reduced to normal. On the '24tli :it :!.30 a. m. she" had a fourth chill, in which the temperature roro u> 104°. The three last chills were severe and she sweated pml'usely after them. On the 2oth there was no chill ; on the 26th there wns a slight chill at 2 p. m. These five chills initiated a relap.-e et great severity, which persisted for forty-two days. There was then a period of apyrexia of six weeks, which was followed by a second relapse of two weeks duration. There was nothing in the nioilo of onset of the first relapse to account for the development of tlie rliilK. Case U.— Severe primary attack; severe sincjle chill at onsrl oj relapse. Edith T., aged 13, (Hos. No. 6487), admitted December 24111, about the end of the second week of a very severe attack. On Jan- uary 2nd the tetuperature for the first lime reached normal, ami re- mained throughout the day between 98° and 99°. On Janiiuiy :!r(l she had a severe chill in which tlie fever rose to 105° and fell in the evening to 99°. Throughout the 4th the '^Gx^iv rang<' ills '"'* Ti/phohl p, I'VCt vei'L' I'lgoi's, 111 ,s single. normal femjjer- di/-fh)'et (l(ij/K ; ""U S nr"3";::rao !--« „. .,,, -i,;:;,;;:;Ti':;»„^"«- -eat. "e' r 'f M- Po. .1,0 fi,f. „, „t' f r,,^"; "■'"• »"">i«e.l F„|,„,„,. .,„, •J" «.e «iain,«, „„ ,L-,;;:;. ,;';«"- - ,03.5- 3 1 J; Z- «■« 7.5» ami ,l,e ,,a,l „ ,~o o i„-,r!,;""'"'f''"l- '»m™„„,. "■I'Klly, a,„l by 2 a. „,. ,.„„.,,„, ',;;^'i'' "'"■ »1"<1, ,1,0 f„.c,. .„« (fl') Chills with the OnM of r. r ■ .i)"nng the height of the fever or -.fto '■;^or n,ay precede the cleve Wt If ^""^''''^■^-"»«' ''as begun, a "^"s, su,.puratio„ i„ t,,, ,„esX ; , J"'^"">»-a, pleuris/acute '-<'"eys, perforation of ile,„„ ^ ' T"' ''^'^'"'^' -'>^«^«ses of the f" rare eases it n.nv ,,recede the J , "'^' "'" ■^^''^'^■»«"« veins Vl-Kyrexia. On nJ.^^Z.^r''^ «^' -■^^' ->•! fa"/ - .on,s of typhoid fever, a w J ("'.f" ":^' ''^^ '" ^'- eon. ^^l'.ehIhavegivenofour;»«es ""''*' '" ^'^^ ^"" a'mly.is In thrombosis a chill may oecur .f n '»ay be associate,! later n.-tlfsn,,,. •'"'''' or r^onrring .i-^or. •''■^■"'•^l-«-.t of py.e„.ia. ^"''''"'•''•^■on >n the clot and .vithlL ^""^^"^^-Severe chill mth onset of thr , • ^ ^ -««■ (Chart II.) '^ ''" ^'''^^-^^^'^ ^/ internal saphenous Theodore B., aeed •>4 (U at M°-I04». a,„l fe^ „„ ,3;,; ■ «'" o,npen„„„ ,.a„^,, „.^ J^' »"" '".«l"eti., ,7, » oi ine ^2iK(, when, at 6.45 ^i 'H H 450 WUIinm OMler. a. in., lie liad a severe fliill, and by 8 a. in. the temperature was lOo.ri . The paroxysm histed fur 24 hours, and was followed l)y heavy sweat-, l-'rom 8 a. m. on the 2;?rd the tiMnperatiire remained normal until thi' evening of the 2(Jth, when tiiere was a r\sv. to 104.2" without a chill. Varolii this time there was no further fever. There was a marked leucocytosis at the time of development of the thrombus in the left saphenous 21,200 per em. l"\)ur days later the leucocytes had fallen to 0,750 per cm. Subseiiueutly the leucocytes rose ' ;V \ - -' - *: 1" ■': \ ■% A v... ... — t ■ ^ .V v:. ^^'^\ T- - ■- I- - £Ar £S £t 21 £6 Z3 JO Jl JZ JJ JV JS Ji J7 (JiiAur II.— Cliill (It Onset oj ThromhoB't. , CA.sr<: VII. — Severe attach of fever; thrnmhoKiH of the femoral trin; eight days later a severe r'ajor. September 23rd, 1895. — While makini!; rounds in Ward I', my attention was called to the patient in Bed 18, whom we fouiul in ii severe rigor. He had been very ill for ten days. On the 1-Jili ()i September a thrombus had developed in the left femoral vein, and the loot and leg were swollen. He had a very dry tongue ami wa.s delirious. This morning at 8 a. m. the temperature was 102 . At ten o'clock the eliill began, and he shook for twenty-five iniiiiito^. The temperature rose during the" paroxysm to 105°. He wa- vm- cold and blue during the ehill, but half an hour later, when 1 lit the ward, he was feeling very eomfortable. No further chills (ncmi'ed, rt> was 1()5.."> . licavy Mwrats, •inal until the itiioiit a chill. van a maikr,| us in tiu> left 'tcs had (iiiliii ^'-'"■/^•v/. T;,i,hni,, /,',,,^. ('A.SJ.; vjir. -.Ir//, P.i/re.i'i, WUil f'li'l daith. < U NCI •ire I 'Hl'»- JnUnwrd I, I'foiirliiiin Kllfj I'-S/flll ''// <:i/'nto.v's, /, •illlU! Ml to(( "1 a state of j '\ '-^^-i^i-.^ tins pa,,,,, s< ""'"'at a, .rival 'ptcml), ''• ^'«t, JS05. J)i Tl; 'ypoi'pyrcxii,. aft '''"""'""" ^^'anlCl.a.l.i;,.,, 'Ujirr- aisuii). • Vboiit A ''^' paticiil, \\\ \v <'i' a .s(j\-( TO I i^'or. ■^iiddoiil, ".f^t]5,),, a, (,,,,„„ ( '-"•' I". Has adM.im.l '"'" '"ise,-al.lo. Tl.inI, >"y: tliat tli( '"y, lie first I ■■^•■pl'inlxT J |(j, iiiuci !i \V()rs(. vuiiiitcd Til ig<' '^iiiiiniit. sea did ''t- ,irastri(r ,sv Alioiit .Sept, almost cvorvd iiipton na were vci-v "'^"" '" '<^"l wivtcluHl ■"iIxT I,st|„,| ; •■■- "n„„r;,::n 1, ::.,:::"^- ".:^».i. 'Ji'.ii'i'avatci "■(•aiiic vcrv iiiiil lia.s tal, '^«'" very larjre do.se.s of '(■adaclic and »''■" trcai,,! / """'''••ate, not i^ad Mi'i'iinc. Tlio t ' ^:'' ''«•"' of p,,,s,,at nr '"u, an( V( '••V' Jivid and l)hu- aft '"'•f^lO^^- HcMoolcIuir '■'•'■ '!^«- iniicl) I in ,1 ■rtl tlif l)atl \vas 'IS vci-v I "'■'>n,.|,itis tl.at it was tl, pnJ.se ";'"' ••'";! "n8c.ptend,e,-]Dtl, -adly, w IS ="if'y a .sntfused, \va.s good and t\n> \ "'ii,i,dit l)(.tt( onien w I) woinewliat ""ift sonnds el '■' f'> sidjstitute tl , tlicie wa.s so ll.sliv !oai- l)Mt pOMirc; ■'^ distended and sort. " Tl "PP«ii-ance of (|,(, | li.id ''"'*;' =' ''^^^^^I>iginenk.,l "t'i'e were no ,.|, iU'c, araetei'ist con- 'Ih' ab- I,, .li- , "^iwi \ . I J,, 1...... „, If !• )>e- hiiiise On S, ''^.andonSepfeinl 'pten)ber 20tl Vy?r ''^''"^^'^■'^'y ^'•igl'tened' 's ni.iitai '^''' '7(b ami I8tl, tried ahont li and 21st I; ' g't ont of Ih.,i. ;:7'-;»""ie, and a fe 'i^J and I <'!■<' was a "■:'-™--' *.in„:,.'-~r„'r' The evening reeord foi^ slight traee of lai at half ijcttcr, ■I)a,st el iind I ordered t\ ",■^•7 <"' S<-pten,ber 21st Tl poratnre was 102.5'= 'le bati visi it lie was at 10 's to be re- 'le 'le I ine easts ''''<'iichitis u-as 't' morning teni- le seemed better and At th was rational. IMAGE EVALUATION TEST TARGET (MT-3) 1.0 I.I 1.25 ■ 50 '""== 2.5 22 ^ 1^ liP-0 U lllll 1.6 Photographic Sciences Corporation 23 WEST MAIN STREET WEBSTER, N.Y. 14580 (716) 872-4503 iV ^^ ..<*. '^^ ■\ 452 William Osier, He had ta.veii his nourishment very well. At one o'clock he had a very severe chill, shaking violently. The respirations were hurried with loud expiratory blowing. The expression of the face was tluu of fright, and he constantly talked of someone trying to kill him, and called out for help. The pupils were widely dilated and equal ; Ik; sweated profusely. At noon the temperature was 104.2° ; at 1.45 p. n:. it had risen to 106.2°. At this time the chill had almost disappeared. He had become, however, quite cyanosed, the hands purple, the lips blue and the face very dusky; the pulse could scarcely be felt. There was from this time slight twitching of the left side of the face, but no regular convulsion. The cyanosis be(;ame more marked, and he became progressively weaker. The temperature rose to 107.5° at 2 p. m., the highi.st recorded temperature in any case in typhoid fever treated in the Hospital. He died at 2.45 p. m. (e). Chills {septic /) during convalescence in severe and protracted cases. In a few instances rigors occur throughout the course of the fever, without any local symptoms to account for them. Tiie followin^r cases are of great interest in as much as the chills were not associated, so far as could be ascertained, with any complication, and, thoiiL'li very aiurming, they gradually subsided with complete recovery of both patients. Case IX. — Severe and protracted fever ,• in the seventh and eii/lith week of illness recarrinr/ chills with hie/her fever; no local si(/ns ,- recover I/. (Chart HI.) Thomas W. T., aged 36, (Hos. No. 8667), admitted Novoiiiher 21st, 1893, on about the eighth day of the fever. The teniper;itiire range was high and the constitutional symptoms severe. Fie was given during the first week injections of sterile cultures of ty[)lioid bacilli in thymus gland bouillon, without any influence. ! )n \o- veniber 2.Stli an injection was given at 2 p. m. The temperaMn-e did not rise more than a degree. At 12 midnight he had a shaking eliill of twenty minutes duration, followed by profuse sweating. The in- jections were omitted and he was ordered baths. He had audthci' chill on the 30th at 6 a. m. The temperature rose to 105°. The j)atient did well with the baths and sponges, though he had delin'iiii) \\ 'clock he had i s were hurried le face was tin t to kill him, and and equal ; lie 1°; at 1.45 p.n). 3st disappeared, purple, the lips be felt. There, if the face, Liit narked, and lie to 107.5° at 2 1 typhoid fever irotracted cusck. 'ie of the fc\(^r, The following.' not associated, II, and, thoiiL'li 9te recovery nf nth and ejijhih 110 local ,si(/n.i ; ted Novenil)er le teinpe'ratiin' vere. Fie wa^ res of ty{)li()i(l ncc. On No- >nipera*i;re diil 11 shakiiiti: ''''ill ting. The iii- e had anDthcr io 105°. Tlio e had delirium Chil/s in ^>/p/ioid Fev, ev. 463 :1m 454 Wit/ium (Mcr. irenior, II dry tongue and a slightly distended abdomen. On W- ceinher lltli tlie temperature rose to 103.5° and he had a spon-v bath after whi.'li he had a chill. 1'hen, about the Ibrty-Jourtli dnv of the illness tlie temperature reaehed normal. He had been verv ill and had a sligiit phlebitis of the long saphenous vein. From the J3th to the 2:,.) ' '"^^^'"-'"^ tOtKtT, no ^tmf. •'•. , ''"'''"'It'll \V;,s i, fi".^ors breaclU. beJow the amWe f L '' "'"^ '^'^^"^'^ ^o thro" -p.. ar region tl.ere u-as foel.Jo , " , '' "''"^r""- ^^^•-- the inf,, ^«"- ^"e, craoklin. rales -u. \'^' '"''"" ^'^<^P i'>.^pir,tio Tiw. 1 . '^ I'litS), and tile t'i#.til,> ^ • ^ '"■'firation a .p " '"■"'■' »"»* wee dear. T|,l , "'"""""' ™» ''".■.•msl.e.l ""■""■■"•.'olW^ media. "" "■"■' "" l'"» .-.. the „,.iro .»-Ue,,,;ea,,„fc ,„,,„,,,, '°f '';«'op.-otol,le , hat the c»,se wL "f eo»e isasf„,i.„v,.. Rotter ',?■'■, ''"'" •™''« temperature range was ot o , "^03. Fronuhe 20th to the 2itht,:: ;::;;::,:: f. ) m ; ' I :V 456 William Osier. . J. . N T- .... -r- -^ •r- bU ■f- - ., . ■\- ?- .;. ■r- ..;. "i" " < •i- .J. ■T- -■;- ■ ■•;^ > ■■i ■ • ' ■ < -■1- - *■- . L. < >.... .1. --h -i- ..;.. ■i- it^ ■"- ■-i-- ... -:■ .■. ..'.. ,^ ^\- ■ ;- -^ ^ T- ■■:• ..■.. 1 -r- -\- S j;'" -V ■ ■i" -t ■ < T- ■■■■ ... .... "^k >- -■:-- ■-r- -:- . J - '•^" ..l. ;■■ ... .... "T' ,.,.. ^ ..L. ,.;.. ■*v -1- -r _ -z »>• - nm) ■ ■ ■y '\ ^ --;•- ■-:- -,. ■;• ..;.. ;- -• • (■■ 'S ..;.. -• -'-- ■:- --• V - T- "i" ■•■■ ..? si. ..;.. ■;• • -- -r -;- jS it- ..'. ••• — • ■1- .<: Y -;- .;.. . i . .li* ^-f' i. -*■ -\- niu3HJ9 -■;- . « n- ~r- -4^ ^ -:-■ ■ivm ■ 01 Tc — ' -i^ ' ''" uy9 >. ■ ; ■ J t/dit .-\. \ "1" — .■ ..... ..j. •-•- ..J. 1VH3 ■ 31 ,.j.. j.l r:^ -s — *^ -f- • 1 § § 5 1 '^ § 1 'S \ ■>j ■8 KJ a - s. s Q^ a Ohills in Typhoid Fever. was lower, only roachini„ati;n w. 1 ti '' 'VT''''' "^" '-^P'-id '•• '"•> -I'en the temperature had b eV ^ r P" *''^ ~^''' =>^ ^"^O "•0° /or twenty-four hour c ,nd "I" l"";"^'^ '-'-en 104° and 1*1 (IL. X n Ctx.H'^ ■^' 0^ THK PKACTICAL VALUE OF LAVHRAN'S DISCOVERIHS. BY WILLIAM OSLER, M.D., OF IIALIIMOUR. Ml).: PHOFKSSOR OP MBI.IC1NE, J,„1NS HOPKINS UNUHKSITV. FROM » THE MEDICAL NEWS, November 33, 1895 ill IKn'rintedfmmTll..; MK..I.AI. \f.\vs, N„v„n,,„, f 2.<. 1895.1 THE PRACTICAL VALUE OFLAVERAN S DISCOVERIES.' Bv VVIM.IAM OSLER, M.n., Ill* IIAI.riMrinr!. Mil , PBOFESSOH Ol' .M ■"">M:. In.lNS II.M'KINS IMVKHM | V. Even m well-known affections advances are made from t.me to fme that render necessary a revi on old°nlv"""""''^ ^""^'^'^'^- ^ ^-djustHK-nt of old posu.ons, a removal even of the old landmarks Perhaps the most ren,arkable illustration of this offered by the discovery of the tubercle-bacilu before i88r ! Happy those who had agility and wit sumc.ent for the somersault! Scarcely 'ess im portant has been the revolution in our knowledge of malar.a s.nce the researches of Laverar., in iSS ', on he paras.te o the disease. His discoverv attracted for a tmie little ^Uention, chiefly because the workers m patholo . ^he world over, had not op- portunuies for studying the disease. The verifica- tion of his work came slowly, while the conception fr .rrr "^ consequences has not yet filtered trom the laboratories and clinics into the wide field of every-day practical medicine. .Z^^'^ ^--e several aspects in which Laveran's studies may be considered as of immense value ; THE RELATION OF THE PROTOZOA TO THE ACLriE INIECTIONS. A Stimulus has been given to research that has already borne fruit in observations upon amebic dysentery Texas cattle-fever, and certain skin-affec- tions. The question of the protozoal origin of car- cinoma has been revived, and prosecuted with an ' Read before the Medical Society oTthe Distn^oTcolu^ energy that must result in a valuable addition to our knowledge of the structure, and ])ossil)ly, too, of the etiology of malignant growths. Althougii the life history of the ])arasite is as yet imperfectly known, sufficient details arc ivailable to furnish one of the most interesting chapters in pathology, and at last we have revealed the meaning of that peri- odicity, SI) mysterious a feature in the malarial fevers, which has puz/.led generations of physicians since Hijjpocrates. As a direct outcome of the study of the protozoal jiarasites of |)aludism may be men- tioned the really brilliant discovery by Theobald Smith of the i)arasite of Texas fever, also a hema- tozoon, connected in its life-history with the cattle- tick (Boui)hilus bovis). Xo more interesting prob- lem in com])arative i)athology has been solved of late years, and the life-history of the parasite is better known than that of any other path(;genir protozoon. IIIK liIACNOSlS Ol' MAI.AUIA! IKVKK. The best guarantee of a truth, xi some one has said, is the wisest men's acceptance of it. There has been an extraordinary unanimity in the verifica- tion of Leveran's main facts by every competent worker who has had suitable opportunities for the study. The extensive and complete bibliography-- the most complete yet published — in the mono- graph by my assistants, Drs.Thayer and Hewetson,' gives some idea of the widespread interest which the question has aroused. It is not too much to say that Laveraii's work has revolutionized the study of fevers, as now a trained observer can deter- mine whether any given case of fever depends upon a malarial infection. The parasites are present in all forms of the disease, and constitute a diagnostic criterion of unfailing accuracy in uncinchonized subjects. A certain technic and training are re- quired, which a season in any malarial center can ' " The Miliaria! P'evers of Baltimore." Johns Hopkins Hos- pital Reports, 1895. Vol. V. ties I shall refershortly to theexiraordinarv ahi.se of the term n.alaria, whi.:h is used as a cloak to cover our ignora.u eof the nature of ob.cure fever A more extended knowledge of the fart that the ma arjal fevers are readily and qui, kly recr.Kni.ahle w.ll Kive the physician pattse in a hasty ditgno and wll ,n fme obviate one of the most «lar . maj:^^urac,e. in the mortuary returns of cer.ain Hut it is in the study of the fevers in the tropics thatLaverans discovery will prove of the ..rcaiest serv.ce, and as shown by the work of N^,„dyk Carter, .n India, and Dock, in Galveston, the dilL enfation of malarial from other fevers is n„ickiy made. It ,s nu.st important that men who desire to study this problem should be equinoed with the necessary technic. Several recent reports on ma- laria ,n the tropics have been sadly defective, and show that valuable opportunities h.ve been wasted from lack of proper training on the part of the ob- server Accurate information on the subject, in iMiglish, has not been until recently available Mv article in the Brithh Mciical Journal (,887 "l) remained for several years the only one which had a wide circulation, and the letters which I have received from i.ractitioners in distant parts of the world indicate that, with the imperfect literature there coexisted as a rule imperfect training and faulty apparatus. Now. however, the publication by the New Sydenham Society of Laveran's mono- graph, and of the works of Marchiafava and Big- nami of iMannaberg, and the monograph of Thayer and Hewetson. already referred to, gives access to all the ava.'a'ie literature, and should prove a great stimulus to the study of tropical fevers from the new standpoint. For so many generations the paroxysm of inter- mittent fever has stood for the type and representa- tive o the class of fevers associated with chill that It has been, and still is, very difficult, particularly in ;i. ' this latitude, to avoid the suspicion of paludism ''n any disease associated with recurring rigors ; and yet one may safely say that, in the" cities of the Atlantic seaboard, the instances of chills and fever due to the malarial parasite are greatly exceeded by those of various other affections. The idea seems firmly ingrained in the mind, and I scarcely pass a week without seeing some instances in which the diagnosis of malaria has been made, simply because the patient has had recurrent chills. The error would not be so unfortunate were it not for the fact that it often causes delay in the adoption of suitable treatment, and may completely blind the physician to the true nature of the case. Perhaps the most frequent mistake is in the chills and fever of tuber- culosis. As is well known, these occur at the two extremes of the disease. It is more particularly in the < arly stages that the mistake is serious, and I have on many occasions known a patient treated per- sistently for malarial fever without a suspicion hav- ing arisen Lhat the trouble depended upon tubercu- losis. In all vaiicties of septicemia the mistake is most frequent. Malaria postpartum, of which one hears not a little, is very often septicemia, and I rarely see a case of abscess of the liver that has not been drenched with quinin, in some instances for months, in the belief that it was a chronic malaria. Frequently pyelitis, pyelonephritis, gall-stones, and empyema are in the same way overlooked, and, even when the diagnosis has been demonstrated, I have often heard from physicians expressions which indicated a lingering idea that after all the septic trouble was only a consequence or a complication. The profession at large has not yet laid to heart the following rules : 1. That the diagnosis of the malarial fevers can be made with certainty by the llood-examinatton. 2. That an intermittent fever which resists quinin is not of malarial origin. A rich experience during the past nine years warrants the expression of these positive statements. In the differentiation of the fevers of the South about wh>ch so niuch discussion has taken p a e dunng the past ten years, the study of the chan s n he blood must ,n the future play a n.ost impor " role. 1 he question of the existence of a thi d type of continued fever, which has been advo ated v Guireras, Baumgarten, and others, cannot te de- term.ned without a mo omplete study than has yet been given to the cases, When one reads the report of the Proceedings of the Orleans Parish Medical Society, in whi ff°r many years the nature of the long-continued L of Louisiana has been discussed, the condition eally seems to be similar to that in which the pro- fession labored before the differentiation of ty,S us and typhoid fever. It is interesting to notet£t i New Orleans at least physicians seem to be comin " gradually to the conviction that the long-continued fever which resists quinin is in reality typhoid a view strongly advocated by Dr. Matas in a hi.t paper, n r.n.: Mei.k;.m. Nkws of December ,5, X894 M.M.AKIA AND VITAL STATISTICS. • '^'!f ^:'- f" '^^^"'"' '^^•'°''' f""- 1890, recently issued, which covers the six years ending May ^ 1890, gives the following number of deaths from malaria, to which I add for comparison those of typhoid fever .- n^!^Tr''^f^'^T- 5-= Typhoid fever, 850. New York- •■ <■ 3;';,^; „ l' 9°4 Brooklyn- •' ",,,.. ., „ -°^^ '-t'j' 1002 That in Baltimore, New \'ork, and Brooklyn the dea hs from malarial fever exceeded those from typhoid will no doubt, be read with astonishment, particularly by those familiar with the conditions of practice in those cities. Any reasonable physician m ] hiladelphia or Baltimore will at once acknowl- edge that a death from malarial fever is a great rarity, while deaths from typhoid fever are only too common. Taking the reports of the large New York hospitals as a basis, one can estimate the degree of reliability of the figures on which the mortuary sta- tistics are prepared. In the last-issued report of the Department of Public Charities and Correction of New York (1894) for the year 1891, the compara- tive rarity of malarial fever is well indicated by the fact that, of above 15,000 patients admitted to Bellevue Hospital during the year, there were only 15 instances of intermittent malarial fever. It is true that there were 76 cases of typhomalarial fever and only 16 of typhoid in the figures, which is sur- prising, considering the little stress that has been laid of late years upon typhomalarial fever ; but when one turns to the list of deaths and finds that all the cases of typhoid fever died, 16 in number, it looks as if the diagnosis rested a good deal upon whether the patient recovered or not. In the total number of deaths, 1547, malaria does not appear as accounting for a single one. So also at the Charity Hospital, of 619 deaths not one was caused by malaria. At the Roosevelt Hospital in the year 1893 there '.vere treated in the medical division 1436 cases, and, so far as one can gather from the report, there does not appear to have been a single case of malaria treated in the wards. Br. Roosevelt, to whom I wrote on the subject, kindly informs me that from January i, 1883, to December 31, 1893. inclusive, there have been but two deaths from malaria, both cases of the pernicious form. The total number of deaths in medical !:,ases during this period was 2024, so that the proportion of deaths from malaria to all deaths from disease in the medical division of that hospital during the 11 years was about i to 1000. In the New York Hospital, for 1893, of 1482 medical cases, there were in all 38 cases of malaria, with one death from pernicious fever. Through the kindness of Dr. Browning I am able to give more extended figures for Brooklyn, a city 7 in which the prevalence of mahrin h. attention of the profession ?n ""'^^^'^ '^^ figures and tables s n to 1 ^ """' '''''■ ''''' direction of the Col itt o He'.^r"?^ ''" supervision of the secretar D "^^^:':sf^f havedin:inii::d\;tt7:::;;;;'U'^'"^'r'"^^'-- one-half, the tvLhoiH ll I " ^° '"^ ^'^^n During the same nerioH U ' ^r '""^ ^""l^'^d. fully oL-harin y a i^ri" '^tnM '"-^ '"^^^^^^^ the city's area Fv^n '\'"'^'' ^^'^''" l^y nicrease in inc, Jed r„..^-:tv :^x;»,,x .'■.'- figures and tl, '^'l^^^^iscrepancy between these lows, Typhoid frvef.V,,'^'""? "' "= f"'" TT^. J T ' ^^' typ'ioma arial fevpr "04 ; and malarial diseases, 2006 In the Tr. ' .ha. il™i„7„ r::;„,T ed iJ' "" -^»°«'>'^«i rif;iri:f""^--=^:^'is • N. Y. .Nf.,|, journ., 18 I II I < iiii il 8 do I see one mentioned in the discussion following the reading of the reports. In September, 1893, the members of the Society of the County of Kings again discussed at length the ([uestion of malaria in Brooklyn.' I have looked carefully through all of the papers there read, and it is certainly a very significant fact that not one of the authors of the papers, and not a physician who discussed the ques- tion raised, mentioned the occurrence of fatal forms of malarial fever. In the article by Dr. Hall on types of malaria seen in Brooklyn, in which he quotas the observations of a number of physicians, no mention is made by any of them of fatal forms, and this is a city credited in the bills of mortality with as many deaths from malaria as from typhoid fever ! Certain of the writers of the papers seem to have themselves been a little suspicious; thus Dr. Hall re- marks that " Carelessness of diagnosis probably affects our ideas of the prevalence of malaria to a considerable extent;" and Dr. Law, in the methods of treatment of malaria in Brooklyn, states that it seems to him a good practice in cases of the remit- tent type of the disease to give quiniri in large doses for two or three days, and then, if the fever is not broken up, to stop and take bearings and search for some inflammatory lesions, or reconsider the possibility of typhoid. The report from the Brooklyn Hospital gives the following : In 1S90, of 608 medical cases admitted there were 18 cases of ma'aria and no deaths. In 1S92, of 742 medical cases admitted there were 27 cases of malaria and one death. In 1893, of 6S3 medical cases admitted there were 20 cases of ma- laria and no deaths. In the report from the Kings County Hospital for tiie year 1892 there were no deaths from malarial fever in a total of nearly 3000 patients treated with 310 deaths. In the rejiort for the year ending July ' Brooklyn Med. Journ., Jan. 1893. 31, 1893. there was one death from pernicious ma- larial fever in a total of 3258 patients treated, with 425 deaths. In dealing with the statistics of malaria, Brooklyn may be taken as a model, and I have dealt with it part y because of the reputed large death-rate, and part^iy because the activity of the members of the Medical Society of the County of Kings has fur- nished most su^rgestive material, which has been supplemented by the kindness and energy of Dr Browning. In localities frequented by the disease, malarial fever kills in such a way that the diagnosis is rarely m doubt. In the acute cases death follows within a few days. In other cases the hemorrhagic features prevail, while the malarial cachexia or the acute exacerbations in the malarial cachexia less frequently prove fatal. The simple intermittents rarely kill even when protracted. Taking into consideration the statements of physicians in Brooklyn and Long Island, as given in the reports referred to, together with the striking absence of all reference to fatal forms, also the distinctive and readily recognized character of the fatal forms of malaria, one cannot help feeling that in these localities and elsewhere the diagnosis is put down carelessly, and does not repre- sent in any way the incidence of malarial fevers. In the oft-quoted and oft-printed chart of the Michigan State Board of Health, showing the comparative mortality from typhoid fever in sewered and un- sewered toi"ns, Brooklyn figures almost at the bot- tom of the list, having a mortality of 1.5 per 10,000 mhabitants, a mortality which is much more than doubled if we add, as it seems should be done, the deaths due to typhomalarial fever and those due to malarial diseases. The conclusion of the whole matter may be thus briefly expressed— the mortuary bills dealing with malaria are false, due either to ignorance or to wil- ful deception on the part of those who make the re- turns. Malaria is a disease that now rarely kills in ! V if 10 the large towns on the Atlantic seaboard, and it be- hooves the profession to abandon the practice of making a careless diagnosis of the disease in every case of obscure fever which proves fatal, and the Medical Boards should refuse to receive a death- certificate signed malarial fever without more spe- cific details than have heretofore been demanded. ' ' <^^yin On the Visceral Compiicalions of Erythema Exudativum Multiforme. BY WILLIAM OSLER, M.D., F.R.C.P. Lond., PROFESSOR OF MEDICINE, JOHNS HOPKINS UNIVERSITY, BALTIMORE, MD. KROM THE AMERICAN JOURNAL OF THE MEDICAI, December, 1895. i 259 MARLBOROUGH STREET. B0S1 X ro /^A"'/^.^^' / /^?. ' /'/ .-^^ 'r z^ u^ ) -V f • \ ^^^^^^^^^^Kf 259 MARLBOROUGH STRtlT, BOSTOh li^c^<-^^ /' ^L (V^^ij '/ ^^/ / / <' //<2/ LI, l> /'l> i< Yi, /^ (J r^* / /. /' i 7, •/('■/ u // fc / ( /^>/ '/ / // / ^ I / L '■C{*df if // .) /< ft /^ /lo r. U^u/ /. /'f A/ /^ ( / ji^ < ■t 'i) /^/ ini^^ / > ni^/n f^?^^^^ ^'^ //,')! /' /t'A~ /!<■ I ^ A J /'I' //7. / ?; rt^i' - itL^ .^r? u <'> y/. /?t/^ ///f/ //^^^ U «i a ^. 7- Jt_^ fi/UJ ti:'^ / ^< /Z A, 7/^l^^^r( /? ^ /j /fT^-i^ /l^^ ,/ ^ / /i^/? /2 y ^^?^ j/u-l/ /jC ' /y ^ 'y /U^< /f- L 'id " /y. u'^^ rL /^4l^ /: y?'?-/' // /^, '^^Vt^;? ^/^ ^<. ^> .^, -^fu ^a^ . ;%f L />//^. v^^ ^^y' ^j 2> inU42^i) '/"' / ^^^d^ J I' ^' , •> ^ * ^ ..»'">#■'■ Jfi)'>.! •,. f"-£ // 'J;o //. V-'/^' ^f /^ r cV// ' //{c<'f f TY ; 'Ju'( //^ ^tttt ^*/-/- /, ^ict U A'-// / ^/ -7// /. /t 7 //^/ /V//' y/ //.?///• 7/^ / /> /< cV //'K A':<*\ /! A u /i^i<:/l //'/ ^ cV/-*-' .^^ /y// //- /<■ ^< rcf /A . A^ r ^> r 7^. / (H / Yr< ^la /. 7 J //•/ / j/t) ^/^Z ^i'i^~-> > : f VrA. //, fu *itA iC c?^I /fC uu ^yJi C/Jt c'^f}/ l(< /Z- .:'/^<<.<->'' //<; /, X- CmuJ.^ ^-^ ^ c<<<- ■n y / ? '^ A; ^ ( Ji. <^i /•.Ui" A ^ //tc /^/7t^ T'ni ,^r//^ vM^-^' /^'" ' ^ 4-^ /fir.^^/ /A/--'' Z'^'^' / ^Xr^/-' A^ -- . ^' /^ uU^ 4. /. ^7^ A y? 7^^'fe ^ ^' Kri O oZ ^dm^ «B» MARLBOROUOH tTRHT. BOSTON. Jamkb C. White. M.D. / OfriCt MOURi I2T03, ^^^^^ CO^.'t^, 4><-V- Charles J. White, M.D. OFFICE HOURS IIT0I2. / / ^ f BvV^ ^ *->^ /^ ri^^ S/^^v^-^wl^ ^-^-e, .jt^ ^ £^ A^ / ^ JiC^wu ^ >^X-^ :? >V;7/Vr£^^ ^ ,^ .. ; •^ «^-i. >7^ ^>>-<^ £H^<^ <;^- V. ^ J ^J^ ^' ^-ys ^^^.^i-^* ^il^U-xu-Vo^ Ui^ , ^A^i ^C uo /7/C^--^^^^ ^'V^' /o ^■ F-c\ / ^-i-i^^t s.^- :? / t- C-uL^ ,pI<1^^<-^ il^-ri d-.^X^/ ^-TN- ^, <^. u ^i^-t ?7 ^^Wt- «U^ a^^Cc 'U 'tCL ^ CL^ .«^-C^>^-i i->-> ^i^' C_* «^- 6- [Extracted from The American Journal of the Medical Sc! leiK'es, Dcwmlicr, IN1I5,] ON THE VISCERAL CO.MPLfOATlONs OF EIIYTIIFMA EXUDATIVU.M MULTIFORME. By Wilijam Osi.kr, M.I)., F.R.c.P. Loxo PIIOKKSSOU OF MKUtrlNE, J„IINS HOlMvIN.'- UNlVKlf^ITY, BAI.TI) '' moi;k, md. By exudative erythema ,s understood a disease of „„k„own etiology with polynorpluc sk.u lesio„s-l,y,,enen.ia, u-deu.a, and hemorrha.e- arthrius occas.onu ly, and a variable nund.er of visceral „>a„ifestatt,ns ol which the most important are gastro-intestinai crises, endocardi ' pericarditis, acute nephritis, and hemorrhage from the mucous surfaces' l^ecurreiice is a special feature of tiie disease, and attacks may come n nmuth after month, or even throughout a hmg period of vear. V. ability in the skin lesions is the rule, and a case may piusenl in o e" attack the features of an angio-neurotic a>dema, in a second of a nu.l ! l.)rm or nodose erythema, and in a third those of peliosis rheumatic The attacks may not be characterized by skin manifestations; the vit ceral symptoms alone may be present, and to the outward view the putieiit may have no indications whatever of erythema exudativum Of he eleven cases here reported the visceral manifestations were as'fol- nvs: In all gastro-intestinal crises-colic, usually with vomiting and duu-rh-ea-hve ha.l acute nephritis, whi<.h in two cases was followed by general anasarca an,l death; iKematuria was present in three cases hemorrhage occurred from the bowels in three cases, from the stomach in two cases from the lungs in two cases, fmm the nose in three cases- .me patient ha< spongy and bleeding gums ; two cases presented enlarge-' ment of the spleen ; in one case there were recurring attacks of couth a-ul bronchitis without fever; in one case there was a heart murnurr. iMve of the cases had swelling about and pain in the joints rheskin lesions were J.olymorphic, ranging from simple purpura to xtensive local .e.iema, and from urticaria in all graded an/l forms to large luhltrating hemorrhages of the skin and sui,n>taueous tissues In "I'l'v.dual cases the cutaneous eruptions were often of the uiost varied ciiaracter. The reu.arkable tendency to recur is a feature of all forms of exuda- tive erythema, [t will be noted that of the cases here re,,orted in only one was the attack single. In the others there were multiple outbreaks (listrihuted over iir>rin,lc •...«„;..„ e.. i. ,i . . . years. A majority of the cases would be described under tli^h puia or peliosis, since liemorrhi ge was the most constant 1 leading of pur pi; esioii, but the is OSLER: EXUDATIVE ERYTHEMA. viirial)!e character of the eruption, and its interchanj^eahle nature in individual cases, make a wider delinition of" exudative erytlienia thi more accei)tal3le. A renuirkai)le circumstance, whicii I have not seiii mentioned in tlie literature (tlioii<,fh it is not likely to have been over- looked), is the recurrence of severe attacks without cutaneous inanif'e,- tations. In the first two cases — which are at present under observatimi — one would not for a niouient suspect the true nature of the disc.isi^ from the existing' manifestations, which are entirely visceral. I will first give a detailed report of the cases which have come umkr my observation. Cask I. For six ijairs ncun-iiii/ f/utitrd-tiilr.-ititKif erisrs — rn/li;, vnnii/- !)![/, (did diarrha(L — willi fever, delirium (tnil eri/tlti'ma inulllfoniir ; far lim years no slin lesions irifh the uttne/.-s ; enlnrt/eineiit of the spleen.. — Ben jamin L., aged twenty-seven years, Norfolk, Va., consulted me October ] Ith, complaining of attacks of gripes and cold feet, whicdi have recurreil wry frequently during the past eight years. For a time the attacks were thought to be severe indigestion with colic. They recurred at first everv two or three months; he once passed six months without an attack, Imt for nearly three years he does not think that he has ever been free for so long as two months. He gives an account (corroborated bv that which his wife has written) of a very remarkable series of events, lie is always, for a day or two, warned of the attack by the occurrence oi' Cold feet, an unerring jjremonitory feature. They are also cold to the touch, sometimes for as long as forty-eight hours. Frei|uetitly, i.m, he has had at this period uneasiness in the stomach. Independent of food or of the time of the day, he then begins to feel pain in the alido- nien, and has severe Oripes, as he calls them; sharp recurring attacks of colicky pains in the central portion of the abdomen. Formerly the pain was sivcre enough U) double him up, but of late years it has not been so inlen.-c, and lie gets more relief by straightening himself out to the full extent. He often vomits, and in the early attacks always did so. Of late yciirs he has had more belching, which seems to relieve the pain. In some attacks he has had diarrhcea, but of late he has been constipated diiriii^r and after them. With the abdominal ."symptoms, sometimes preicilinir them, there is Fever. He gets burning hot everywhere but in his feet. Wiiliin a few hours he becomes delirious; as his wife ex])resses it, he talks "out of his head." He himself says that he talks much nonsense, just as in a fever, and imagines all sorts of things. One of his favorite fancies is that in an attack, during the colic, he has twentv-six throats and tw'cnty-six stomachs, which are all in a row, and he cannot pick unt the one which belongs to him, and whicli'is causing the jiain. I had obtained this much of the history from him, and was beginning to be very interested, as it seemed an vinnsual .sort of affection, when he voluntarily expres.sed the iufornnition that in the attacks " greiii !)ig liver spots came out all over him.". In several of the first attiiriv- he thought he had been poisoned by eating something that had disagreeil with him. The spots came out on the trunk and arms, not so ofiiii ou the legs, and they were sometimes so large that they took days to dis- igeal)le nature in ve erythema tlie I have not .seen ) luive lieeii ovcr- utaiieourt nuinit'e," under observatimi ire of tlic (liseiisf sceral. liave come iimler ri^fx — rofic, I'diiiit- ullijorinr ; fur In-,) p/rcii. — Beiijaiiiin me Oetol)er 1 Jtli, ave recurred very the attacks were rreil at first everv )ut an attaeli, init 3ver heeii tree for •ohorated l)y liuit es of events. He he occurrence (if are also cuM tn Fre(|uentiy, Inn, Inde()en(leiit of pain in the alwln- f colicky jiaius in pain was severe t been so inleiise, to the full extent. 0. Of hite yeurs e pain. In some onstipated diiriii"; letimos precedinir s feet. Within a it, he talks '• out ch nonsense, just e of his fiivoiite wenty-fsix tlii'oats le (Muinot pick out e pain. lid was heuinning itll'ction, wlicn he ttacks " jrreal big le iirst attarii; he uit had disaiiTeed IS, not so ollin oU took days lo dis- oslek: kxudative krythkma. 3 aj.pear. Rome have l.een as large as the palm of his Jnnd T a ways re.l,somet.n.esrai.sed, hut never itch. Durin . u ir,/,. ""' almost every attack was characterized hv then,, fer.e. •■''"'' he has not iiad any of the i)]ocches on tl,",. 1,;, ti • •, "" >'^''*''** the attack is froin" six to ten 1 , s Vtu , u-,.,' '' TT' ''"'•"""" "^" the abdomen, particularlv the ri It'si,!. Ii • ' ?'' '■''''>' '"'^ '» IS sometimes hiudi coiorenc,>t of ike ../....-The f^^H wi!: . ' J^^^!!!! ';i;"''"^'^^':'" ' -^ and (jueMui auach:i wir/i arl/intis and, A-.s/o/(.< ,,/■ pnithr, hu;e,ncnt of the .pken.-The followiCLe i^ fct "ulZ^U '' "" ot the persistence of the abdominar svmp oms^S h! , ^'"1 antenna fbr such a long perio.l before the a, ™ o u ^ erythema exudativum. aitniiti,-, and W.E.B aged eleven years, was seen linst. March 10 1.S')4 r.,,.,;i i • About a vear ago he began t,. have attacks of severe pain in t he abd ' men, ..nnnig on very abruptly, not associated with an ' , s , ' J ' and often ot such .scveritv that he would roll unon ,1,,. I ' ' ' His appetite kept good and he has never liad any v mit^^"l "n, i !: the latter part of the summer he had a verv ' \lr T" : i , F ;v^si^,ected to be pertussis. Once du.-il.^ IL 'nXr h^K i ^^ ll ! tack of hives below the knee. He has never ha.l anv rlieun • s ■ "^^irSierlh;^:;^;.,!;" """'^ ^"^ •--• '>"• "^■•-^ ^^^^^ lheappet,tefo,- the past year has not been verv good and he has been very par^icidar about bis food. The bowels' lK;ve b.vn re. u ^ and the attacks ot colic have never been f.llowcl bv ,liarrl„ea During the winter he remained pale and had occasional attacks of ohc, and the cough reeur.vd at intervals. 1 le has been able weve to go to .school, but has i„)t been at all .m.n.r "onever, I'mt condition. A fairly well-nourishe.l bov, a little ,)ale in the a e but the lips am tongue are of goo.l color. The ,.u>rles e feebly developed ; the skin is clear ; there is no purpura, no staii n./ e.ssuit I he edge o the iver can be rea.lily felt at the costal mar- Snu Ihe spleen is enlarged and extends in the parasternal line nearly OSLKK: KXUDATIVK EHYTirEMA, ic iiriiic to l\w levfl of tlio navel ; tlie edjfe and its notch are to be felt very plainly, 'riie npper limit of dulness ia at the lower margin of tlie seventh rib. The lu'iiit-soiinds are clear, and there is no enlargement ot thi^ or^an. The lungs are everywhere clear on peren-ssion, but at the right apex and right u|)per axillary region there are a few medium-sized moist nXles, The bloud presented no special changes ; the leucocytes were not in- creased. There was a moderate grade of ansemia, about .SO per cent, red bloo(l-c(ir|)uscles, and about the same of h;emoglobin. The was clear, and contained neithi'r all)umin nor tui)e casts. I confess to have been (piite puzzled by the. case. The hi.story of protracted colic with cough and the moderate auiemia with enlarge- ment of the spleen formed a symptom-group which did not seem "to come into the category of any recognized affection. There had been no articular troubles, and the occuri'ence of the urticarial rash last summer seemed to be an accident. On April Dth his mother said that he had complained several times of pain in the left shoulder, but there was nothing to be seen inspec- tion. Under the free administration of arsenic and iron he improved a >jr,vvM deal, and the spleen reduced considerably in size. In the middle of Ajtril he had an attack in which the cough was much aggravated, and he had slight fever, the temperature reaching nearly to 102°. There was no dulne.ss, but at the ajjcx of the left lung there" were many moist rales before and behind. It was with great difficulty that any expecto- ration could be obtained ; it was bronchial and contained large num- bers of alveolar cells. He improved very much toward the end of the iDonth. Fridiiij, Mail IS. He has been doing very well. The spleen is only just palpable beneath the edge of the ribs. He has complained since last Sunday of jjains about the legs and knees. I noticed to-d;iv one or two bluish stains as if there had been purpura. '12(J. The patient came again to-day. Last Friday evening when he went home the ankles were swollen and red, and bl()tches of urticaria and |)urpura came out over the instep and first phalanges of the toes. They extended along the outer surface of the left leg and there W( ri' a few on the right, but there was not so much swelling in the feet. This is the first occasion on whichhe has had an outbreak of pur|)ura; with it he had an attack of .severe colic, the first I'or several weeks, 'fhe legs and feet today present the fading stains of the purpura. There is no swelling and no sorene.'^s, and he feels (piite well. The ti'oulilc in the lung seems to have almost disappeared, and he ha.< very little cnugh. Jtiiie (!. Since the last note the boy has been verv well, with the exception of an attack of (edematous swelling on the back of the left hand. Today he has had a good deal of itching and an acute attack- in both ankles. The condition is as follows: On the back of the left hand there are three or four scattered patches of ervtheuui wMh exuda- tion. Over the knuckle of the little finger there is considerable swell- ing, but no ecchyniosis. The right ankle is swollen, and the swelliuir extends over the dorsum of the footand about half-way up the ankle. There is .=onie heat, and extending for about two inches at)ove the mal- leoli on either side there are mottled ecchvmoscs. The same extend half to bo fi'lt very inarjfin nf tlic (1 several times seen inspcc- .'oninj^ wlieii lil- ies of iirticaiia ;!;es of the toes. 1(1 tliere were u the feet. Thi.-i jiiirpura ; wiili 111 weeks. Tile )i)i'a. There i.s The trouble in •rv little eciiiirli. well, with tlif laek of tlie Kit iin aeiite attark ick of the left ma w'tli e.Kiida- siderahle swell- id the swelliiiL' ' lip the ankle, above the nial- inie extend half o s I, K K K.Xr DATIVE KRVTHK.M.-V. way down the dor.sinn of the d le entire Icir j loiudi the a nkh IIOl. .s eovered with tin The 1 eft ankle is a littl es are swollen and look v einnant.s of purpuric urii' piillV, and walk to the house, and eould take (,tr leniperatnre, i)!).li°. '-~>h. Patient has been at .Vtl •erv his sh f^ore, vel he w H's and stoel earia. iis ahie to beneliti lit iks t iiitie City and ed<;e ean be felt two t iin and kinL,'s alone. is not been inaterialh I"";;; t'";«l'l«^n is still palpable, an.l th hath of A soluiion ULTUst, ■"iiirh the winter and has nif'ht he had tervals tlin very severe attacks o( H;r allowed hi,,, lo play hockey. Last ter. Tl lUgh this morn colic. I Te has had t h lere \vas no arthritis: i 111,1,^ I saw hi,,, iu ') o'clock • I point on his ri-ht siKaildcr. Jle had had s numerous piping rales, chiefly at th lo skin eruption. He had had em also at iii- le seenieil j)et- (ine tender abdomen was nef,'ative; the s'^nl e nubt at 'line coujrh, and there were !• previous occasion. The liver pleen was smaller than it had 1 xamination of the wl lere on pali)at was not enlarir ion. June '). He has been niiicl, bett( ! bepn to cough about three weeks atr,,, and iit night. Ihe spleen is a full hand-breadth bel He 1 :ed ; no tend ir; no attacks of coli( >een erness on any am is a remarkabl e condition of right ajie.x a^-ain ; tl !) spots. now coughs " terribly" )elow costal niiirgin. There liitch than normal as low as the" fou'rtl scapula. There ar I ri note is higher in •e many large moist n iiiainmarv and upper axillary i but is a little harsi 'eirions. h and behind to the spine of les over whole infraclavicular, breathing is not tubular, Tin last 1!>. The cough has been b examina ion, only just two (in"-ers' I -etter. Tl le spleen is not so la lie resona L'kli ireadth below the costal nee is still a little high' pitched at the righ. . eiaekling n.les from the clavicle, extending throu-d, tl I'ge as at niaririu iion into the axilla October 21. He has had palpable; no colic tl It apex ; numerous le mammary re- a irood spots. ^lere are now crackling ra, right lower axilla; a lew, t R summer. ■ecently the es at the loft, lowei The sjileen is only just ootigh has returned', and Cask HI. (10, at the a lex. mammary region and •iti))^. -Ab fonit ;v((/h.s' ; co/lc with diarrh appearing in crops; me/mna u'.a; urti varin purpura nr- >y, aged six years, seen witli Drs. I) aeute nephritis; death. (Abstract.') 'untonand Agnew. There was ' Rciwt...l in n,ll in Now Voric M,.,ii,,,l Joiunnl, ll,.,.o,nI,.r ISS-f. ! fc 6 osi,kk: exudativk erythema „ vluM.mutir lii.torv in tl.e iiuuily. an.l tlu- .lnl,l -.1 m. aunt on tl.e fa he 8 "id ' r of l.ur,H."ni bemorrluiKin.. 'Hie onnot waB_ xvuh ,.an,s u tlu a kl nlovoai.vc.olieana an urticaria-liko orui.t....n. llenw.njnvo ? tiu' .wds f,;ii..wo.l in ahnnt t.n .lays The recurnnj, at acks ot ^lic were n>o.t .listres.in.. Ahnu, the ( fVh week atter tl>e o e t ^ urine heeanie scanty an.l alhnn.inous, an.l sliowe.! a tew hlo.Ml-empust es an n .mM-..UH tnbe casts. Alter the .level.,,.nu.nt .,1 the 'I'-l-X attaeksof pnrpnra oease.l, an.l he .lie.l ..f the aeute ne,.hnt,s u.thm three numths of the onset of the illness. Cask IV. .Wm/ «//.»•/. ; «r//Mv7..s,- mluneou. /''''"''' t'^r'-Te mtient a man aged tortv-six years, was a.l.nitte.l to the 1 lula.lel|.l. Coital "■"'- "Jy eare, with diarrluea an.1 -.o.- y' puHume raslwu d nolvuthriti< About eiL'htcen months before he ha.l ha.l a siiniiai verv V .; v t a k w bieh ha.flasted three weeks. In the present one he bad icn ri K i... swelling, an.l ten.lerness of b..tb elbows, of_ the r.«b W, an^ ot the ri.bt ankle. There were nn merons p,u-pur c spo^s m •u-nw and le.rs. The v.m.itinjr whs a very .listressn j: leatuie. ll.ne vs ; r adndssion a fre^h ^npti..n_.,ee,n.e.l ot-nrtu.aruunu pu.Tur^ ThV .nuns were not sp..nfrv. The unne eonta.ned nu.eb alb.u mi a minv valine an.l ep tbelial casts. The patient impn.ve.l rapi.ll v, an I "Sn a nulnih IVom the time .-f adinissi,.n seeme.l quite well, th..ugh nn his di^ehar.'e there was still albumin in the urine. CX'^VY (imorrha'a; acute arthritis and .„n,nt., nuth purpura; severe rolh and vomilinr,, wdh mccr.^ive ontt>reak.< oj purpura, ^'rtwarm an laracr extravasations; hamaturla. Reeovert, ajtcr .." '^nd Bwe in." the wrist- ..ints and fever. The patient kn.,ws verv httle ot hi 1 dl list...-v, ..ther than that his lather .be. ., pneumonia He hai alwavs been healthy, an.l can only recall having measles when seven v.>ars ..1.1. He has never ha.l rheumatism. He c.ntracted g..n.u- rba'a a m.u.tli ago and still has a slight .lisehargc. . iiii t illiiessM,egan March 9th with fever, pain, an.l swelling m be knt;: ami in the calves .,f the legs. He .lid not g.. to 1-' >;^; ^'J^ a .li«i.ensarv in the citv and was ..nlere.l an ointment. On Maicli J- bewnsls became sw.dlen and the lever increase.l, an. he had much pain in the back. Two ..r three red sp.)ts came out on the skin. ' JWsrnI ronddhn. The patient is a we 1-n.uirished y..ung "■'"'• \"; temnerature is !>9.5°. The face is flush...l ; lips re.l ; tongue cated on the . n re.l at thee.La>s. There is now m. swelling ..I the knees. Kth wr^ls'and the backs ..f the bands an.l ..f the l;'n.«- -;i -'l^;; and ten.ler. an.l are re.l.lener six -f "-^^es^ Imy jU. also nresent on the inner surface of the thighs, and a lew ai." sc, tt( rt.l o t ba k an.l buttocks. About the ankles th.re are some large . c ilueiU .mes. which are ca,,pe.l wHh y^icles. The heart s ac ion « . ,,,.„„!.,-, ,,„d there wre no murmurs. The urine was yelloVMsh in col..i, a lini;: ;;m4.y, aci.i. sp. gr. 1025, an.l microscpically it presente.i many 1 Ibiil. OSI, Kl{ KXriiATl VK KK VTII K M A orrlnif/e-f mid /'*■/(- (Abi^fract.'t— The 1, the riiiliidelpliiu inir|>iiric riisli and liiul a similar very present "lie he Imd bows, of the ri^'lit [Uiriniric spots on iir feature. Three icaria and luiipnra. iiiich allunnin and roved rapidly, and quite well, though iV/.-i, with purpura; pnr{>urii, urficurla. er an U/nc^x of two vas admitted to the linin.ir of piiin 'i"'\ knows very little of ' pi'eunionia. lavinji; measles when le contracted gonor- hlood coipiiscjcs, with some 1 meatus of tiic out. .\ iiaetei lyaiiiie and a few cpitji, li;,l ca-is. Tii Jienis IS red and tnoisi, hui no disci iolo;;ieal exainmati.in was made of tl liU'liC can lie S(|Ucc/rd vesicles on the le-is. Esnuirch's tubes were mad At lirst we regarded th le material tVoni tli hut nothing ijreu. pura. but the Hub.'eiiuent history of tl e ca.se as one of gonori'iio'al synovitis grouped as erythema exM.latiyum. le case ln)w.> thai It , with piir- nii.-t lie M'irr/i 17. A large, swollen, inner malleolus of tlie rio-lil Ic.r )f m 1 deep-seated pain in the abd iemorrliagic_ wheal d.-yoloprd on the eningthe patient complained In th le ey 18^A. The temperature i )nien, and vomited again this morning and conmlai las ranged from 99' to I(»I°. Iff v '2i)t/i. The urine cont easts are still present aiiis nuieh less blood, I For the lirst t I good deal of pain in the l.acl. omiled m tiio i)ulmonary area. 2"_'»/. The hands are its middle is swollen and tend )ut hyaline and e]Mthelial line a murmur was noticed today very much better. The left biceps lo-dav ah„ut ler, and it nain 2Sd. The ])atient complains of a great deal ot |)ains him to nioye it. below the navel. He I spot las had no furti pain 111 the abdomen s are present to-day oyer t ler yomiiinL le clavicK nceps has increased ; extension of the ar T l-'resl li purpuric lie swell I lu )f tl le It 'ft Tl lere is no discharge to-day from the urethra III is particularly painful. 24lh. A group of eccl bice men, and for thi ps to-day is very tender. He com] iynio.ses has extended about the neck. Th nior)ihiiie hlood-cor color. Tl ■puscl n the. evening he had to I ilaius much ol jiain in the ab le urine s es, till and numerous hvali iintams a moderate amount given a hypodermic of ne casts. It h alhun nil, red iis a distinct cIk rry sma II, ins ->t/r tep, capped with a distinct bleb. ( rai.sed erythematous area has appeared oyer the right vhicl subse(|uently sliowe( 2()//(. Albumin am i t le presence o ulture le ftl '.7t/i. Urine is lisrht casts persist. s troiu tins were made, ordinary pus orgaiii-^ms. roved somewhat; the biceps is be er in color, no blood noted to-day. raiiem 1 tter. las 2m. Within the ^ s|)ots has developed i>n the outer side ot past t wen I ^ inir hours a large patch of purpuric right buttocks there ha somewhat injected margins the left torearm, ami on tla; come out a crop of ordinary urticaria with \--:m^ k to-dav CdiittMl ; the iiniic! i.s tiirhid, .srnoUy, iiml .k'li.sci, an iimiHiiallv large iiiini"- luT (if tiil)i' casts, some of which are pale, others made up of leiicocvtes and a i'ew l)lood-('or|)Uscles. H)//(. The blood persists in llic tiriiic; the casts are not so niimuroiis From the 20tli to tiie I'lM he was lietler, no fever. On the L'lJd a fresh crop of pnrpiira came out on tiie ri^^lit instep. He lias no fever and has been Letter; appetite ■rood. He has gained in weight. He iin|)roved .|nite rajjidiy early in May and left (he ho-oital on The 12th. At the time of discharge the urine had a sjiecific gravity of 101;;, con- tamed a trace of aihtimin and a few hyaline casts. Cvsi.; Vr. 'f/iini (itlad: I'i(r/iiirii. co/ir, dud me/iriKi ; nniilh'iir/; vt- curn'ii'/ iilfiic/c-f ; ;o other illne.«s. Sixteen months ago he had the first attack of the alU'ction with which he suffers at i)resent, namely, spots on the skin, which recurred freipiently with l)ain in the bowels and blood in the stools. The present illness "bean about two months ago; the spots first appeared. He lost his and got pale. Five weeks ago he had the first attack abdomen, with nausea and vomiting. It la>ted all dav and he had several bloody movements, and there was a little blood i"n the vomitus. In a week or ten days he improved and remained better until two weeks afro, when an attack began in the same way, with little pain in the ab- domen, iKULsea and vomiting, and bloody stools. On seven is appetue pain in the nees have been a little stiff in the evening, but there has b his k swelling and no pain. In one of the attacks his moti coughed up a little blood, and one day een no a fresh crop of spots appeared on the skin ler states that ho s nose bled. With each attack Present coniliti 0)1.. lie is a healtbv-lookin!. hoy tl le lips and mueons membrane are ])erhaps a little pale ;"the pulse isof good volume 104 the temperature is 100=. When asked what is the matter with him I- places his hand on the abdom Over the arms and leirs tl en and says he has pain and soreness. the legs are fading; those on the arms are f lere is a copious purjiuric rash. The spot s oil evening of the lOth he vomited a esh. Oil the afternoon and great deal, and was unable t anything, and had a good deal of pain in the shoulders peared in the vomitus or in the stools. On tl Xo blood o retain an- te morning of the 20th a fresh cro]) of spots was noticed, jiarticularly over the shoulders and back. 1 he joints were neither enlarged nor tender. The ape.v beat was inside the nipple line; the sounds were loud and clear. The abdomen looked natural ; the spleen could not be i)alpated ; the area of dulness was not increased; the liver was not enlarged. The urine was turbid, vellon, sp. gr 1020 and presented a tr.'ce of albumin. On the 22d attacks "f vomiting and pain and the fresh crop, the specific gravit ifter tl 1020, the amount of albumin had ii tube casts were found and a few red blood icreased, and a few finely V WM-' irraiiulai' Th corpuscle e patient improved very much on tiic 21st and 22d, the vi.mil ceased, and on October 2od his mother i emoved him (I ; roiiiitiin/ ; ?>- — Will. L.', iiL'cd ctolitT 18, 1,S1)2, V history is ff^ni ; iuo liviii;; and iirti'cii yt'iU'M a^'o. ' had piKMniioiiia iiliK'!*s. SixtoL'u whicii lie suffffH t'rcMjiieiitly with lit ilhiess hei;aii htst hirf appetilL' k of pain in the ay iiiKJ lie had in the voiuitus. •until two \veelv8 pain in the aii- everal occasions ire lias hceii uu r states that Im rVitheach attaci< 1, tiie voiiiiiiii Dr. I I'lney saw her thai ev were swollen and swollen appearance d eniperature al.out 'lOP, an.i the hand en I Hi:, wl y. and in cov- en she iietosuhcntane.Mis h.cali/ed inlil JliviUi; a curious patchv hlneness. Tl well as the ilor.sal surfaces. The f liesc were seen .m tl sive pur|>une urlicari; liirly scattered over the lindi^. '| lie 's ol any d'llu II aiioiit the ell '1 lollowinir die, presinted a "■"lions with hlocd, le palmar as On the'sth slu' i joints fiow.- lere was IK '(■re was a verv e.xten- ankles and kiiee.s, and irrcgu- pecnil swellin.r or sore- eliaracter, coiniiiir ,,i, .,(, j„f(, •egaii to have uaiiis i and i ree f'l rvals with voniiti II the ahiloineii ..f I -.11. u-l '"""""I""": tlH'>)owcls were not '•'llj. "hen I saw her, she had in hricfthef, eessive crops of „,„.st e.\teiisiv(! ciita loose, fi I'rampdike lie urine was clear 'fiiii the 8lh to the owiiii,' .symptoms: ;"■"' "' "I'ticaria, hut „,,^ , ""•"I'.illi tlic skin only a hhiish .liJI iieoiLs liem.irrha;,'es, chiell 'i'>»'i.v_ were deep, suhculaneous.'and small Icet wer( •'i- purpuric spots not rai.sed al use color. Tl swoll en and the anki love the surface of |lu; sk tiere were alsi in. y in the pic-cnted ' niaiiv lints (lid not seem to he allected'. t'-joints eiilaived aii.l tender. 1 Tl ^'rentlya'denial..u completely, were seveial Tl and the swell *)ii the iL'th the lorehead 1 'he otl lis swelliiH' was not iijrextended to the eyelid associated with I :s. closin:,' th IK pots on the face and ears. 4. 1 leiiLirrhat'c, ■■■^-^--olhat the slightest tone! rXireme ic 'ler iiccanie leni There :eiieral .sensitive luin.s, ciinsistinj' of i.-eemed painful. .'). .Ah.lominal ihslinati paroxysmal attacks of colic of ;,q'Jat she had heen t lo.iked hriirjit. mucous suiface with fadiiii: eccl voniitin.!:. At the tin "r tour d, Tl IV." le ot my Visit the child was hetter il - le was sitting up in hed. and the I le left cheek was .swollen, tender, and liatchy, whiti.sh appearaiiee. Tl lyniose; sy 111 p- cverity and of lan ice presented on the Th le arms were '"'i'lmtion oftheskin.andon the suhcutaneoiis iiililtrati..ns Tl hut o.-^e ahoiii the elhow were stil coverei hand on hoth si.lcs tl raise( fi lere were hluisi were tolerably ahiindant pots were not nunierous on the tl •lUll I he hill locks, where tl upon the ahdomen and verv llieiialches almost covered the sk iiey presented the appearance of lorax, numerous over surf sni iices of the ki licutaneoiis infillrat knees. Thv ankles looke.l selves. 1 iiui than from invol in of the face, and ah.iiit the arge, rather it seemed f'n ordinary urticaria. exteiis(U' vement of the joints tl icii, the skill' t with hlood icy were, however, painful on pressure. The i use due largely to a dillu.se sul rhe ahd lomen wa.s not tender, ther lem- eet were swol- liciitaiieoiis infiltration •e was n.i enlargement of 10 OST, KR: KXl'DATIVK KRVTHKMA. the liver or wpli'cn, the licarl-.soiiiKU wfrc iidiimiiI. Tlic l>lii(i(l uus cxani iiii'd hy Dr. TImyi'r, and sliowcd iiotliiiijr s|>ccial cxccpl u ftli;,'lil in (■reuse in tlie miiiiiier of leucocytes. T!ie l)ou(>l< were c..i).sli|.ate(r. 'i'lie urine .xeeiiieii mnMnal in i|iiantily ami c(pntain(ii a trace (if allinniiii, Itiii no i)l(i(iii. ^ Dr. Finnc. had ^'iven various rnncdics witiioiil s|)ecial iiitluenee. Er;;ot was employed witiiout .snece.s.s. Tiie solution of morphine seemed to be nioHl eflectual, allaying the pain and jrivini,' the child sleep. The child recovered completely. (.'Asr: \'III. SHijIit IniiDiiii : cm/ts <>/ /turjuini : mt iirlhri!l.-<: .vrer-' cnlir irit/i iliiirrlidd ; aniti nrp/irili-- ; i/nin-'d iiiKtsiircn : unniiia ; iIkuIi Olive L, ai,'ed live years, rctcrrcil to tne l>y Dr. (ioldsltorough, ri (Jam- l)ri(lj,'e, iMd.,.luly II, I8'.ll, with general anasarca. Tile (iitlier has sn tiered much at times with rheumatism; the inothir and three other children are well. This was the first child : she had always heen strong and roliu.''"lelies came out on the -.'Oil, and •'Ist Jio ahdomiiial pain at this attack ;::i:'::;' Xz ;;i:;;;:;;;""'i.;riV; -^i., -i^ ;.;;;;;,.„l'::i''„ ;;,,;;:: ™ .1. TI..- |»,n,„ri.. n„l, ™,..„;'i; , ,1 :";,„k'".,;',""' ^•'•<'-<-«M Ihe heart-.soiim sare clear Tin. ,!.,, ... ," fi.'lin. ()„ thesanu. di' 'an " „ ,"ri' :" 7'^''i';' "-■ n.sl. .a '"i"<'l<, which lH.^a.i with-v ;;.,"" ".'"""^''."" 'V"' " very s.ven ,,,, I ,, I "' it" the clicsi. " '"> .^^''^'l' ^^■" '-"^v him the rash was Piii-Mura came out «•!.!, il,;. „...,. ■ " '". '"■''■ -^ ''■<'>l< eroi, of He has heeii 'a'tlin-r |„ f Her, liut small, il-;ta- Hwollen. ile hud no colic. There was m, all ' ' "'""' """^"'"'^ te,„l,,„.v i„ |,|„„|' •- '"'"I'l-"'""!-' "1 •«-.'llii.K ..I'll,,. ;,„„,, ,„„| „ »n,^";::''"'i.'S,I;'',,';;'i';;r,,:;r "r' ■'' '"r"""^- '■■ - -- "«...a-... uk.„ .,?^L:i',,» .. ;; I r'r; i,"""i, '■" » ,"'• al liiis lime i;,r !«■.. weeka -r'" "n ml.-. II,. »,u in 1„..| £r''^.;ri-?f;'i'""'.'«""'^i»Si,i;:';s,,l:^ le lie 'iMt 12 OSLKH: KXlliATIVK K It V I' II K M A , li'jfM iitnl iiriiiM (mill cpmcc nt'llif liicc) lic.'ciiiic cnvcivil Willi rai.-'i'il hlui-h j>p(tt!<. Tlif cliill (■iiiiiis tiixi, its M rule, mill is imi alwiivs Vfiv fU'vcic Liitt'ly lie has liiul no cjiisiaxis, (inly llic hici'iliiij; riniii ilic i,'iiiiis, 'I'lu; jiaiiLs ill ihc aliilonu'ii arc (if ;,'rcat iiilcii.xity ami arc liko onliiiarv colic, riicy lairiy last iimrf lliaii ImlC an lunir to mi lidiir. The V(iiiiitiii;j I1118 ^-oiiu'tiincH Ih'cii Hcvciv; he never In ujlit ii|) m.v lilnod ; neve" pasHcil Iddiiil in the stools or with the urine. He has' never hail aiiv piiins in the joints. The |iatieni lonks |iale, hill he is iint |iroroiiii(lly aiia'iiiie ; the inilse i« ,L,'"o"l, a little jerky ; the i;iiniH are swnljen, s|ion;.'v, hut are not hieeiliiii;. 'l"he skin of the iirnis mill le;.'s is covered with reiiiniint.>4 ot' the attack of fmr weeks airo ; some of the stains are liiri'e, as if the rash had hcen |)nr|iiira nrtieans. 'i'lie heart-soiiiiils were clear. The sjileen was not enlarj,'ed. I'alitnl soiij^iii direction with reference to the possihle prevention of the attacks. He was onlered P'owler's sohilion and the juice of half a ienioii twiee daily. I heard ol' tlii.s patient on the l.lth ,,f iM'hrnary, 18i)ri. Dr. O'Hrien tellrt nie that, with the exception nf mie sliyhl attack slmrtlv aller he saw me, he has had 110 oiitiireak. Me took the Fowler's .solution at intervals for a Ion;; time, and atlrilnites his recoverv to it. (".\si.;XI. Fur j'liiir ijidr^ ricnrrlii;/ ii till "III seen iij;aiii Oeioher 7, I.si»,-,. si solution, and has liei n in i iiier s ihe I las had f •uv attack iiaiiy wavs riinch heti IMS lieen takiic Fouler's voinitiii;; lieiran in liie even "lie with vondliiii;' and lllnlluji .||,, ^1,,,,. Tl tl ic siiots canic 111,1,' ahoiit >i,\ (I'eloek "I" \Mlh j.'reiit raiiidiiv and unii lie ariiH and je^rs. hi one of || Were swollen and lender. In le attacks the ki lasted very e,\le||.ivc over A.,M. snial I '■ the attacks Dr. (iild lecs and ank les were |i<'t. of the iMirpiira and loini,! „,, | that the heniorrl At t 'I'll ia<.'e Wi lie time of the liellv aiiiiui till ll'ist rellloVld II i"w lieantifnljv, present visit ijie ski lis sectiiiiis -1 hair follieles, I i> almost eniirelv cle;ir. visceral lesionH of the various t fully studied l)v nianv ol y pes of erythema have I )servcrs. anil II erythema ikmIosii in pericarditis have hceii freipieiiilv disscrihed. ] teen care- Ill, endocardiii- et with heart complicalion .ewiir III o.s e :iscs leu iiistaiiees of heart alll'cti, the t ype ervthciua eh .-i.v time,., and Stephen .Mackenzie' lound '11 III llW ca.seM of erythema no |iains in ij,,, j,,i„t,_ the all iiraeteri/.ed by lieniorrh sum niatica the visceral coiiiplicati f'rei|Ueiit than in erythema nod nephrit ection ktiown as purj In ii;rcs and ledema with "lira, or peliosi,^, rlieu- "iis are, as Kaposi remark., much more OSUIII. Tl IS ail. acute eiidocar diti icy arechietly albuminiii ia with Ever since Willaii i ISO.S) de.scrilied violent vomitiiiir, excrii ill},' of the letrs, tl rkal a case (if ••iatiiiLT pains in the |)„u-,. purpura asMiciaied uiih li'dis, and iiniiil h rcmarkahle symptom complex-. () !s. and aiia.sa icons swell- iive licen reported with this of C; pecial interest inasmuch lie of Ihe earliest ca.ses hv (, as with the e iivier IS .simple (edema of the eyelids and of the hand eeliviiio.ses there was also If enoch' in l,s74 a,„i j,| il>rr h'iiKlrrl-nnikht'lIni, called CoutyMcseril.ed the ( liij,,,, .,.v .^ »i> in the various editions ,if jiis I',,,/, atleiitiiiu lothi,- voiis oriirin. comlimationofsympt special form of purpura of '' the works on skin diseases by American authors the special symptom-group to which I refer is scarcely menti.me.l. In addition to those collecte(l by v. Dusch and Iloche there are cases re- ported by Ku.ssell,-' McKay," Dutt,' Collie," .Monillot,'' I'renti.ss,'" and two cases by Musser." Other cases are reported by Silbermann." When one considers iiow benign, as a rule, in all its types, is the course of exudative erythema, the mortality of the cases with severe vis- ceral complications is remarkable. Of sixty-one cases (including th(^se in V. Dusch and Hoche's table, the additional ones which I have collected, the 11 cases here reporte.l), there were thirteen deaths, a percentage of Of the visceral manifestations by far the most common are the Ga.-'tro-inteMimUc.rUcx, which are claimed as the distinguishing charac- teristic of Henoch's purpura. The features are very varied. There may be simi)le colic of all grades of intensity, from a transient, readily borne belly-ache to an attack of such agony and duration that repeated hypo- dermics of .nor])hine have to be given. Vomiting and diarrhoea are fre- quent, hut not necessary, accompaniments of the attack. In some cases the vomiting occurs without the colic, or a »r,,.,-o attack of vomitin- and diarrlnca may accompany the outbreak o th- ,.urpura. The attack bears no relation whatever to food, and may . w.e'on abruptly in a i)er- son iu excellent health, an.l in Cn.e II. (in which the colic occurred alone so frequently) the boy's mother could never notice any circum- stances which increased the liability to the trouble. An identical form of cohc IS de.scril)ed iu the so-called angioneurotic .edema, many cases - liisi'nscsol tlio Skill, Jd (.'diihiii. |i, ii . ' IiiswisosiiC Uio Skill. ^ Diswiscs (if llio Skin, IS'.il. < I'athnhmie iiiKl Tliumpio ,Wr IfiiulknuiklKMlcii, VieiU' .\.illaKO, ISM " liritish Mudiciil .loiiniul, i,s,sa, ii, ., i|,j,i ,,,^|., jj' ' "'i'"-. l-^ss.ii. . ,.a,„;',i, ls:H,i ' IninsiU'tKiii.-iuf the .Vrink-iiiy (if Mi-diriin.', Iiciiui.l, vol. v. I" Trioisiii'tioii,sof tliu A,ssooiiiti(iii ol .ViiiiTiciiii l'livsiiMiiii« vol v " "'*'••• ^■"'- ^'' '''^ lIoiioJii's VoslM.lirin. MA. use, this syinptoin- lisli and American Duscli and lloclie ?s. Of tile recent I" as I can see, no ro-intestinai symp- the exception of a iiniatica. Kapo.>i' ong wlii.'li, under and gangrene of 's, severe arthritis, nodosum, besides heumatica, hiema- ises hy American ;arcely mentioned. I there are civses re- I'rentiss,'" and two mann.'^ 1 its types, is tiie eswith severe vis- including those in I have collected, S a percentage of ion are tlie iiguishing charac- •ied. There may Jnt, readily home It repeated hypo- diarrhoja are fre- :. In some cases tack of vomiting; ira. The attack hrujitly in a jier- le colic occurrc'i itice any circiim- n identical form ema, many cases 1. Jil filitiull, |i. II,"., ises OUL' 0,SLKR: EXL-l.ATIVK KKVTHKMA. I5 of which should doubtless be reckoned uitl. (1,1 fv, <■ ^-ivun. In .u.t,in one of U.e att.lllr ' /^ :,: L:^:^:;-''- om,rred w.thout purpura. In the ren.arkable .audi , :! :^; a few years ago,' in which acute circun,..cribed o.den.a . hve generations, the gastro-intes.inal crises fb n, ,;';"' r"' '". the attacks. Of great interest in this couuectio ,, ;:"";:'^ tory ,s g.ven un.ier fusr /., i.. ,vhon, for n.ore than two , H T have been characterised l>y iever, deliriun. ' • ^ I'l^''^^^ of great u.tensity, but without ..kin le-ion. "' '"''' U IS imssible that among the cases of recurrin.r ..Htro-inte,!,..,! • .n^r::::r;:::;;:;«:3:::;;'::«;:;;'™ '"'-"• '■-"-■"■^™"- .vMoi. fou, .,ie„. „; ,„: „j,t : r : :::,;;t ;:"'T "»■»■,"'■ markec trace a>i ni ('•!.:»> X'^rr » 1 . '^ ^^'^^"" ■ind Vrrr Tl . ' ^'""^'^ 'tities, as in Cases HI IV '" <1 \ III. 1 he tube casts were hvaline and epithcli,! .,„,! f tamed bhKHl-corpuscles. Dropsy was present i,! : ''u ; .;:^'" Z majority of the cases the recoverv is comnletP i.nf • '.•'■"''• ^'"^ nephritis becomes chronic. T e" . nl S^o "."rk"""-" ^ literature has been reported by Dr. I'renH ;, ^ Wa hi .';r";; T Association of American Pl.vsicians in M.,v J,s. the bowels and bladder. In this attack he was delirious „' yspiuea lunl swelling of the tiu-ehead. On December 1 s^:. iH l.ad recurring attacks at intervals of a month or si.v week The' the fact that he had large hemorrhages into the skin, which became .■ j^-|. and sloughed. At our meeting this y.^^yi!:^^'^!^ 'Hpl'utis. with drop.sy, albuminuric retinitis, increase.l tension, anuost extraonlinary and distressing feature of the di.e.se IS the tendency to recur, which is so „oti<.eal,le in all types of exud'.tive erythema. In C^e XI., in which the disease has pirsisti; f li f yj.u-s_dur.ng tl. hr^ two years the girl no sooner recovered fi ,.„e attack than another l.egan. In Case [., the patient's life is, as he ..vs a burden, owing to the recurrence every month or two of the .c^v;re colic. ivcie he collected cases. The periarticular more often than the intra-ar.icu ar tissues are affected, and the chief part of the swelling is often due to effusion m the ten.lon sheaths about the joints, and as in (Ve II the patient may be able to walk quite well with the ankles' much swollen. The anatomical conditions associated with the visceral symptoms are not well understood, but the changes in the gastro-intcstinal canal at least, are probably the counterpart of those which occur in the ski„ namely, exudation of serum, swelling, hemorrhages, and in rare in- stances necrosis. At autopsy hemorrhages have been found in the internal org.ns A remarkable case is given by Silbernumu in Henoch s le.sen-.Jt for 1890. A chihl, aged ten years, was attacked on December 15, 188/, with fever and pains in the knees. ()» ,he 16th there was an outbreak of purpura, with colic, Inematemesis, and inekena After persisting lor three days the symptoms disa,,peared. I he attack recurred in January with great severity, ami on the 20th ^Ist, and 22(1 there were signs of an acute peritonitis. The autopsy showed an acute purulent ].eritoi.itis, which had resulted from a perL- ation at the fundus of the stomach. There was no ul..eration in the bowels, but the mucosa was swollen and congested. There were necrotic foei 11. the stomach and intestines, and throud.i were foun.l in son.e of the bloodvessels. I„ a few instances necrosis and gang,-e„e have occurred on the skin, as mentioned in connection with Dr. Prentiss's case. Thc> outbreak of this type of erythema n.ultifo.-me during gonorrhaui as in Case V. of my series, is interesting in con.iection with the etiolo.ry' mwe th.s ..s one of the infections with which a seve.'e type of true pur- pura hemorrhagica occurs, an*S(!, i. ■^.11 v|! II If : !:. '' ! 18 OSLER : EXLTDATIVK EKYTHKMA of erytlieina exudativiim. 1 linvo nothing to say which would iielp to clear the existing confusion or uliicli is not already better said in jour- nals and monographs easy of access. My purpose in this paper has "been to call attention to the importance of the visceral manifestations of the disease. In Cases J I. and X., arsenic appears to have been beneficial ; in other instances it did not seem to do good. would help to ' said in jour- >ii|)cr has been stations of tlie cial ; in other ib, October "i isur. JOHN KEATS THE APOTHECAKY POET BY WILLIAM OSLER iiAl.TIMUlU-: THE PRTKDKNWALI) COMPANY 1890 - j--l-MafeA--' ^^. ' IF,.. T,, ,.,„ ,„„„ ,,„,„ ^„„^,,,^ ^^ ^ ^^^^^^ ^^^ JOHN KEATS-TIIE Al'OTHEaRY I'OET. We have the verv hio-heaf- nnfh,,..;,. t discerumeut, Phito reonirni7..= ,. """"^'o". with a keener granted to men. Of this divinp ,.,.. i ^'I'^test blessings of the fourfokl partitio . t^^7T' ^^^"^^'^ «'- kind is the madness of t lose w ' ^'^f""^'«"= "The third winch^ taking hold ^:'rHr:a^:^s:i:{td^r' i-trnction of^'posteiS; u t who h"""' '""" '^^^ ^'^^ Muses' madness in his sou^ o.il'l' "e" V" '°"^' "^^ ^'" tl^^'t he will get into the tern >1 ^h le,p ,f Tt "l' \''"'^'^^ and his poetry are not admitted; [he sane mn, .' ~ ' ^ ''^' marrow of the na:re;f;etr.XT the very pith and is drawn bv many modern wH I '^"^.'^/''^^'"•<^'' 'I'^tmction than the spirit, ^f th^fZn \ir ::Jm ^s';r' f ,"^^^ ^'^ '^ without the Muses' nT„ln. '''•'"^''t. By the help of art, poet is a " lii:: d^^^'^t;;;? "^ ''' 'r^^- ^^^ tion, genius, facultv, wlfat vj ,^'^^'7' "^^^ '"^P""- allied to mudness-he i. i ^ ''^'°^'' ^° ^^" ^t, is dell Holmes ,; et e S": • T ""r"^''- ""''''' '''^■ modern terms, speakiuioi^i ^ery charmingly in more ' 'P^'^^^"S of his own condition when composing 1 , i* • i i ■ ■ i: i: 1 /■ 1 r * ! 1 C j 4 f. 1 < 1 J * il f n ! f, 1 . ^ ! 1 ; K j ! i s n i jl i, ii 1 -^ ^; ^ i 1 ' 1 i ■ i ; 1 ^ i i;1 ,(. 1 ! 1 f jj ■1 ^ ■if 1^^ ]'f tl'e collec- these reviews are believ .1 (.1? 1 (''; 'tvroo,/. im,,,,,,,, a belief fostered b, the ju.uitXrtli^l!;:"; ^^^'''^ ^•^'''^•^- " -Tis «tran«,. th„ „,i„,i. tl^u very Aery particle ^''-''''etusclf be snuffed out hyanVr?S:."' -i-l thai. h^'IuS^i ^: i^ ^j^';;i--«'-tne.of his the Hrst place, he had . c l , ' "'''^ '^''""■^'- ^'^ and the value of his work. The , f oe h. 1 " ^'°"""' the most remarkable ever J h , 1 / ^""""' ^"' ^^ judgment. He felt h-li I ' ."*""' '"' "^^" '"^''^1 ihS i\ ^ f'>iindations were "too s.nulv" .luuu ur a ,\oung man in trans tion "■' «Th^ imagination of a boy is healthv nn,l fi,. . '""'"O" • J he * ,.„ '"' ^'^""^•''it, the character undeoideil Hio way of life uncertain, the ambition thick-sightec 1 c^^^ oeeds .nwkHhness and all the thousand bitters'.!- tC^ as t e (^«.r ,r/^ /;,,,„„ j,„t, -.^ .^j^^ ^^^^^ incongruous ieTs n the most uncouth language," but the poem\ n « iK'tlir;::i;ir ^"" ^"^^^'^ ^-^ ^^^-^^ ^-« ^^- ^ rankled deeply lu his over-sensitive heart, but after the first ' I 10 pangs he appears to have accepted tlie .castigation in a truly philosophic way. In a letter to his friend Hersey, dated Oct. 9th, 1818, he writes, " Praise or blame has but a momentary effect on the man whose love of beauty in the abstract makes him a severe critic in his own works. My own domestic criticism has given me pain without comparison beyond what Blackwood ov the Quarterly could possibly inflict,— and also when I feel I am right, no external praise can give me such a glow as my own solitary reperception and ratitication of what is fine. J. S. is perfectly right in regard to the slip- shod Endymion. That it is so is no fault of mine. No!— though it may sound a little paradoxical, it is as good as I had power to make it— by myself." And he adds, " I will write independently,-! have written independently tvithout judgment. I may write independently, and with judgment hereafter. The Genius of Poetry must work out its own salvation in a man." A young man of twenty-three who could write this, whatever else he possessed, had the mens suna, and could not be killed by a dozen reviews. In June 1820 appeared Keats' third work, "Lamia, IsabcUa, The Eve of St. Agnes, and other poems;' which placed him in the first rank of English writers. I will quote briefly the criticisms of two masters. "No one else in English poetry save Shakespeare," says Matthew Arnold, "has in expression quite the fascinating facility of Keats, his perfection of loveliness. 'Ithink,' he said humbly, ' I shall be among the English poets after my death.' He is; he is with Shakespeare." Lowell, speaking of his wonderful power in the choice of words, says, "i[en's thoughts and opinions are in a great degree the vassals of him who invents a new phrase or reapplies an old one. The thought or feeling a thousand times repeated becomes his at last who utters it best. ... As soon as we have discovered the word for our joy or our sorrow we are no longer its serfs, but its lords. We reward the discoverer of an anesthetic for the body and make him a member of all the 11 Houghton's Life and Leffpf, °'^^^ *^ ''^'^ ^^^rd almost unfathoniably deep irtbf.lw,' P°''^'^ (^'^^"gh sense and humoi etc of tl !!' t"^ "f • '^^°"- "^''^^'-'"Ji"^ I an. tempted to' Zn^L p l^f ci;:if ^f" '' fl^'^'^'^' than any poet since." ^'"'''' '^"'^^^ ^^ Poetic faculties, IV. Very few indications of his r)rofp=! ' I '''^ take fees-and vet I should ilL V V "'^ ^ ^""'^^ "°<^ writing poems ind ttg '. tl m\,t L' \e' If "? ^^^'^^ "^- Review shambles " In 1S1% 11 ? . , ^'^-'^'«^'» on the " Were T fn / i , ^ """^^^ *'' ^^^ friend Reynolds \\ eie I to study physic, or rather medicine -iff-iin T f ^ would not make the least difference in m nl'f^ ' I V^ mind is in its infancy a bias is ^ZZy^C^^t it ''^ acquire more strength, a bias becomes n b '" 1]!': thlt he IS glad he had not given away his medical ios'i;^^^^^^^ attack of tr^^^^ ^^^ ^-J^Tf ^^ *'^ '"' of three things-oV a lealt two s .^ a '' ""'^ '^'^^'^ i 1 t 1 V i : '} I ' 1 1 1 ! ^ i ;■ ,' i !j I : :i i ■| ' ,' 1 u, ;)' 1 Hi i: : : li ', I. *^ 12 in a letter to Miss Jeffreys, he spoke of voyaging to and from India for a few years, but in June, 1819, he tells his sister that he has given up the idea of an Indiaman, and that he " was preparing to enquire for a situation with an apothecary." Allusions to or analogies drawn from medical subjects are rare in his letters. In one place, in writing from Devonshire, he says, " When I think of AVordsworth's sonnet, ' Vanguard of Liberty ! Ye men of KeH^ ! ' the degraded I'ace about me are puh'is ipecac sitnplex — a strong dose." He played a medical prank on his friend Brown, who had let his house to a man named Xathan Benjamin. The water which furnished the house was in a tank lined with lime, which impregnated the water unpleasantly. Keats wrote the following short note to Brown : Sir .—By drinking your damn'd tank water I have got the gravel, What reparation can you make to me and my family? Nathan Benjamin, Brown accordingly surprised his tenant with the following answer: Sir :—l cannot ofifer you any ren^uneration until your gravel shall have formed itself into a stone, when I will cut you with pleasure. C. Brown. In a letter to James Rice he tells one of the best maternal impression stories extant : " Would you like a true story ? There was a man and his wife who, being to go a long jour- ney on foot, in the course of their travels came to a river which rolled knee-deep over the pebbles. In these cases the man generally pulls off his shoes and stockings and carries the woman over on his back. This man did so. And his wife being pregnant, and troubled, as in such cases is very common, with strange longings, took the strangest that ever was heard of. Seeing her husband's foot, a handsome one enough, looked very clean and tempting in the clear water, on their arrival at the other bank she earnestly demanded a bit of it. He being an affectionate fellow, and fearing for 13 the comeliness of his child, gave her a bit M-hich he cut off with h,3 clasp-knife Not satisfied, she asked fo a^ he' morsel Supposing there might be t.vins, he gave her a si ce moi^. Not yet contented, she craved another pie e' You Take t'haT'" ^'^ ^^^\' --nU yon .isl. me to kill mys^r? Take that, upon which he stabbed her with the knife cu her open, and found three children in her belly: two of then very comfortable with their mouths shut, tl/th nl 1 " eyes and mouth stark staring wide open 'Whn wli tho^jght it r cried the widowe^ and JC iied Dis oZ ''''' The estate of Keats' mother was greatly involved, and it Abbey. H,s books were not successful, and having no love for th: .,anmry hack work in literature, he was lar^el ^'' ^- r lett ^ 'T' '' '' ''''''''' ^-- ^^^^^ win" f *^^'f*^^f the receipt of money is acknowledged Who could resist a charming borrower who could thus wifte "I am your debtor; I must ever remain .0; nor do I .ih be clear of my i-ational debt; there is a comfort in throwin' oneself on the charity of one's frienda-'tis like tbe albaS eeping on its wings. I will be to you wine in the ce lai- nd the more modestly, or rather, indolently I retire into the ^.ckward bin, the mor. Falerne will I be at the drinking" We must remember, however, that Keats had reasonable expectations. He says to Haydon, December 23d 181 nfh I,. '^^ ' , ,^''''''^ '" g°°'l lest the weather IZ^aJ^ mVC 1 '?'" "'^^'^'"'"^ or cold continually threatois Le.'' ' ' "'' '" "'^■"•^'^" On February 3d the smoulderink nd lis ^h i(> d go to th<' BurRcrifS of the mcdiciil otlicfrs. I'rintiiiK, 8ta- tioncry, and salary of clerk an- alone taken out if tlie doctor's Sueli a scheme as this will Rive tlie poor all the advantiiRPS of an ordinary private patient. The scheme is HUtlieienlly coinpreliensive to provide for the medical relief of all the working elasses between those who nn- in receipt of parochial relief and those who are able to pay the lowest i)rivate fees in any district. , , ,, ^ ,. Tliere are undoubtedly a large number of tlio strugRling working classes in which the weekly payment of sulmcrip- tions to a medical t)ene(it is the f,iily method by which thtJ doctor gets paid at all. A certiun .lass of these peotWc; are not to b<' trusted for a i)rivate account of even a few shillings. The provident scheme is, therefore, favourable to the profes- sion. , , , i • 1 It is tlie well-to-do working man I'lio li ts been trained up in the custom of getting the doctor's aid for next to nothing, and who has yet to be taught that he will be expected to con- tribute according to liis means. . . A comparatively simple organisation of easy Bupervision— with an attractive scheme -should enable the medical profes- sion in each town and district to remedy the present abuses of the club system. It is necessary, however, for each section of the profession— be it in town or country— to sliow a united front, and make a determined stand, otherwise a few weak- kneed individuals might cause the w I lole profession to lose the advantages of combined action. ARCH^OLOtilCA MEDICA. XXVII.—" DOVER'S ANCIENT PHYSICIANS' LEGACY." In the Bulletin of the Johns Hopldiu Hospital, vol. vii, p. i. Dr. Osier has given an interesting account of " Ihoma.. Dover (of Dover's Powder), Physician and Buccaneer. In this paper Dr. Osier speaks of the confusion that exists as regards the various editions of Dover's Ancient Vhmicians Leaacu. The Dictionary of National Bioyraphy states that the first edition of this book was published in 1733. Dr. Osier points out that this is an error, and states " that it is due to the fact that in this year appeared an edition of the 7>eyacy not stated on the title-page to be a second edition 1 his is the earliest copy in the library of the Royal iMedical and Chirurgical Society and in the Radclifle Library." Dr. ()sler probably was unable to examine both these copies and so clear up tlie diilicuUy. The 1 733 edition in the Royal Medical and Chmirgical Society's Library bears internal evidence that it is not tlie first edition, as on p. 181 there is a heading " Addenda : The substance of several letters sent to the Author since the publication of the last edition ; with further remarks." There is a copy of this book also in the library of the Royal College of Surgeons. The Radclifl'e 1733 book is difFerent from that of the Royal Medical and Chirurgical Society, and is evidently the second edition, as it does not contain the addenda referred to above, but leaves oil at the end of the " Hospital Surgeon." This clears up the chiej difficulty as regards the early editions. The second and third have nothing on their title pages to show the edition ; the fourth and fifth, also published in 1733. aif' so called on their titles. , . ^ ,,■,.•, i. j +, Dover took his M.B. at Cambridge, but did not proceed to the degree of M.D. Dr. Osier states that " on the title page of the first edition, however, the letters M.D. occur after his name." This is a mistake; the 1732 edition has M.B., the second and third have Thomas Dovar, M.D. ^h« two last- named editions are both " printed for the relict of the late K. Bradly F.R.S.," and the 1) is in all probability a misprint. From the fourth to the eighth editions the author s name is spelt Dover. '. ^ j • iv 1 *„„ Although additional matter was incorporated m the later editions, Dover does not seem to have remodelled his book. In the first edition there is a postscript headed. Having — it*"d the following letter from Anthonu Balam Esq. in Great Russell Street, winch I designed to have inserted wheni was speaking of Quicksilver, I shall give it my Readers in this place " This matter appears in the same form in all the sub- aeqnent editions, and was never incorporated in its proper place. LOGICA MEDICA. r THt ««iTi»ii Aff 1 f t II- 1. t ff e 8- 18 ck nd tis d go to till' surgcrit's ..{ tlif n»i' advantageH of an ordinary private piiticiit. Tin- scheme in rtudiciently coinprehenBive to provide for the medical relief of all the working classcH between thoKe who an- in receipt of parochial relief and those who are able to jiay the lowetit private fees in any district. There are undoubtedly a large number of tlni struggling working claHses in which the weekly piiyment of Hubscrip- tions to a medical henelit is the only nu-thod by which the doctor g<'tH paid at all. A certain class of these peo^tlo ar« not to be trusted for a private account of even a few shillinKs. Tlie provident scheme is, therefore, favourable to the pn i s- sion. It is tlie well-to-do working man who has been trained up in the custom of getting the doctor's aid tor next to nothing, and who has yet to be taught that he will be expected to con- tribute according to his means. _ , A comparatively simple organisation of easy supervision— with an attractive scheme- should enable the mediial profes- sion in each town and district to remedy the present abuses of the club system. It is necessary, liowever, for each section of the profession— be it in town or country— to show a united front, and make a determined stand, otherwise a few weak- kneed individuals might cause the whole profession to lose the advantages of combined action. ARCHiEOLOGICA MEDICA. \ XVII.— "DOVER'S ANCIKNT PHYSICIANS' LEGACY." In the Bulletin of the Johns Jlopkins Honpital, vol. vii, p. I, Dr. Osier has given an interesting account of "Thomas Dover (of Dover's Powder), Physician and iUiccaneer." In this paper Dr. Osier speaks of tlie confusion that exists as J ... • ^j:t;„„„ „f /)„„«,.'« Anr.iimt I'hunicians' 'BBU^V JO -I'SPJO J'H JO (SSU[0 !)S1) I'lSjuM I' i'q o') 'ipiAiuoaJO 'imidHoii sjioiuuds '"n Jo ^^n -uody '!ii-Ji[.3i[M -tl •Jj\[ pa^ujoddu sBq «,)p,)A\s }o iJuixf ;inx •pjMH puB puooas ain .loi ui in ■jsnf srionip,) .i.Hj SB '^pjui ^[p.tBt[ si siq'j ;nq 1 3{0oq oqj pajuiid pHif ^(piMji -ji rf;i)iai[) JO iO![ajaiii}t su s>(oo[ mqSiH'jB.iinV ■'lo^fll I'liH i(j.io.vis,j;vi!T 's.ioijsnqnd luuiSi.io'oin'oj }[OBq -HfoS ,)Ai;i( p(uoiis j.)AO(j Srjuo .i.);b( eq^ .loj g.'uq') ptiB 'uorjips 13.i!( oq'Huo.ij.t.tqsnqnd'pw.WHip v Aq ponssi uaoq .)ABq p[u6iis suonipj p'JJdqumuun oAq aq'j ^iii(; snojino .u)q^B.i si ^ •oruBs .)!{') siuBaw.i uocjBoipap oi[} JO Sinp.ioAi .»in inq ..'^wqoa,, o% paaj^pi si .".unor,, auiBU •)i[% suoiiip.) 'jso'pq aq? uj; -suoqip.! p.mn p'uB puooas aq; o] uonB.upap on sBq AfpBag -Ji a^Bi ai[; jo !),iqaa aqT ■A«'^««1H JO hi[.i 'XiB.iX Ui{Of 0^ pOJBjipjp ai :[U(.iq z£li aq^, •uoi-jipa auiBs aq'j o'+ s./aBcl ojiii jo sias om .to ^^> / i % ^ I '"''" "''""^' 'f"'Pi'''l l'i^U,n..al VI.,, •I'tnuiiry, /,s,'*,;_ THOMAS DUVKR (OP |)ovK,'s f„vvi,. M PHYSICIAN AND 3UCCA NEER ftY ^ILLJAM OSLER BAI TIMORK THE FUIEDK.VWAI.I. ...MI-ANV ISOd h^yt^ A i^-«^«. fi7'9<^^^€^ C^^*^^ ^ ^U^^ ^ /W'7V.*«^*^<'A-. ^'^^^♦.^^-•'^v /y^z/^ '/■^ fiU-ff'W*** • -p*^^*^ ^«*.^-^- y^ ■^. CFrom ne Johns napkin. Ho.pUal nuUetin. N' O' 5s, .lanuary, ifSM.j THOMAS DOVER Ar r ,. ^ i-HlSJClAA AND BUCCAXEER .^'^ ''^"'Thomas Browne remark^? in f), t/ , • iniquity of oblivion blind! v oil h^^'^^'''''^'^'^^^''"-- "The with the inen,o.-v of men tho^ Hi '7 ^'^^^^ -'^ '^^I« ftuitj." Thus it happen h t) '^ '' ''''''' '' P^^- has drifted into our mode 1 "'' ^''''^ ^^''^ ^o^tor, -y of entering the ^^^l 'S^Sf ^ '^^'^^ ^^o which bj Mithridutes, many would^refe ol "'' '^"'' '^^"^^''^^'^ ous immortality on a nowdP,- ^ ''*" °'^^^"0"' even to continu- Buccaneer, third in command onrnf .1 ' "°''''' ^'^e and president of the Cou ^T tl e A.V'""?;^^ ""^"•^' privateers of the ancient .md 1. *^f, ^"'^^ '"'d Duchess,- eoverer of Alexande S Jd^ ^ ' '''' '' ^^•-^"J'-dis- iB spite of more end i" Him '"^"'"'^ '^"''"^°" ^''■"^°<^)' forgotten. '^ ''''""* «" o'"' g^'atitude, has been was born in Waruickshire aCo t ^^^Jn^^J- "^ '''''' '^'^ ^^ of medicine of Cambridge on tl;,'* ^' ''"'' '' ^''^^^^'^^ov the Aaenae Can,,H^; Z^^.:^'''^ ^\ "- -thor of on the roll of the grad nte A V V?"'' ^^"'^ "^* '''^' settled in Bristol, and la-t^^^ ''^"'^ his degree he -ei-chants in a p/'ivateelS ;e%e^ft Ln "^n'^'n"' '"!''' ^^"^^ to England he resumed m-acSc at Bn' . ' T' ^"^'"^'^ -ber of patients he salsr^^ti^^'d^^dS^^ •' m ft i i aaijittMiKiaLtia wWB epideinic of the fever, he must have obtained the coulidence of the inhabitants of that city." In 17^1 he settled in Lon- don and was admitted a Licentiate of the IJoyal College of Physicians. He resided in Cecil Street, .Strand, but in the latter part of 1728 he removed to Gloucestershire, where he lived for four or five years, when he tinallv settled in T lOnd at flrst in Lombard Street, and afterward on. s in Arundel Street. Strand, where he died probably in the latter juirt of 1741 or tht of 17-12. ::^ssentially the same details are given bv beginning Dr. ]Vorman ^Nfoore i,i the Dictionary of Xational Biograpliy. In his work "The Ancient I'hysician's Legacy" he oftL'u speaks with veneration of Sydenham as his IMaster; and in his description of the snuill-pox he says, "whilst I lived with Dr. Sydenham," so that he was probably a house pupil of the great physician, who was at the height of his fame at the very time we may suppose Dover to have been a student of medi- cine. On the title-page of the first edition of the "Legacy," 1732, he speaks of forty-nine years of practice, so that he probably took his degree in 1GS3. Apparently he never pro- ceeded to a doctor's degree, since he speaks of himself as a "poor Bachelor of physic." On the title-page of the first edition, however, the letters M. D. occur after his name. We know really nothing of Dover's life until he appears as one of the promoters of a privateering expedition to the South Seas in 1708. In this he was associated with a group of Bristol merchants, among whom were Alderman Bachelor and Sir John Hawkins. Two ships, the Dnke and the Duvhafts, were fitted out with great care. Dover went as third in com- mand, being styled Captaii\ Dover, and as owner of a very considerable share of both vessels, he was president of the Council, and had a double voice in the deliberations. The days of the buccaneers were almost numbered, but there was in Bristol at this time one- of the last and one of the most famous of ,.■ old South Sea captains, William Dampier, a man who knew more of the Spanish Main and of the Pacific than any one living. He had returned recently from a disas- he confidence ?ttled iu Ldii- al Collegi' of 1, but in the ire, where he edin London, •iindel fStrcL't, of 1741ortlie i ;ire given Ijy il Biogniplij. cy " he often ister; and in b I lived with I pupil of the lie lit the very ent of medi- he " Legiicy," e, so tluit he le never pro- himself as a ; of the first 3 name, lie appeai-s as tothe^outh a group of Bachelor and the DuvhfS!<, ihird iu corn- ier of a very ident of the ations. The )ut there was of the most Danipier, a f the I'acilic from a disas- i» »-l.ich words OI.„,os Ki„„3,., .," "' '* »' *' "~ ot Hit- voyaj-e is toM (,,. f',,,,!-,,,, ,,. , °"- iHeiwrralive The expedition u-.,. i ' -^' ^'""don, i;io Captain Kog^,,. """ '» ""« tolil i„ (h, „„,j^ ^^ off to go on shore, t^: g ' 71"^;?'^ '"^^^- ^^^^^ -^ the ship. Asitgrewdark%veoter; d! • ^7' '''^'''' '''"^ some were of the opinion was from n ° '' °" ^'^"'•«' ^^J^i'^h cleutlytoolargeforthat nut 7 " '""*' ^"^ ^t was evi- boat, firing o.u- c.uart t ; ^ .::; T''' ?• ''^"^^' ^« ^^-ect o^r -d fore shrouds', that our ^.i^^Lv^fl '''' '' ""' "-- to leeward of the island. Our Cf ,"'' "' ^^'^ ''^^^^ ^'^''^n two in the morning, l,avi,.ttnt r;'"V'''°'"''^ ^'°^"" ^^bout ashore wheti withini I a^ ^ ! jT "" '" ^'^^'"^^ ^^^^ ^i.^ht of so well, as it now beg^; to 1 on T ^'"' '"''^ ^^^^ ^°t that the light which w hid 1^ J%"'^^'^' '^" ^-"»-d therefore prepared our ship for ' ^''"^ '^'' ^^ore, and -.£ht proceed from so^!^^ ^^^^^^ -'PPosing it must either fight or want water Till''- '"'''''' ''^'''^' "'^ sion, as we afterwards found • I'ose f -n " '"'^ ^PP^'ehen- Passed in our imacrination fn !• ' ''"' P"*^'' »'^^»' who Frenchmen, or a ^^Tj :^^:r'': '""^^^"' ^' '^^^ '>f strange notions some of o , ' '' '' "'''"^^^^' ^^^^t light; yet it served o sho th S t ™'"'"""^ ^^^'^"^ ^^is enabled us to guess how I n^^^^^^^^^^^ -"' ^P^^'ts, and really were enemies on the ishnd '' ' "^ '"^° ^^'^'"'^ 6 ! i i "While uiuler these apprehensions we stood to the back of the isLuid in order to fall in witli the southerly Avii.d till we were past the island; then we stood bacii for it again, and ran cl.we aboard the land that begins to form its N. 1']. side. 'J'iie ilaws came heavily off the land, and we were forced to i-eef our to])-sails when we oi)ened the middle bay, where we ex])ecteil to find oui enemy, but aU was clear and no sliips either there or in the other bay near the N. E. end. These are the only bays in which ships can ride that come here for refreshnu'iits, the middle one being the best. We now conjectured that there had been shij)S here, but that they had gone away on seeing us." "About noon of the 2nd of February we sent our yawl on shore, in which was Captain Dover, Mr. Fry, and six men, all armed; and in the meantime we and the Duchess kept turn- ing in, and such heavy squalls came off the laud that we Jiad to Itt fly our top-sail sheets, keeping all hands to stand by our sails, lest the winds should blow them away. These flaws proceed from the land, which is very high in the middle of the island; but when they passed by we had little or no wind. As our yawl did not return, we sent the pinnace well armed to see what had occasioned the yawl to stay, being ;.. :• u'd there might be a Spanish garrison on the island, who ij'ht have seized her and our men. Even the pinnace delayc'. returning, on which Me put u}) the signal for her to come back, when she soon came off with abundance of cray-iish, bringing als ) a man clothed in goat skins, who seemed wilder than the orig- inal owners of his apparel. His name was Alexander SeK-i7'k, a Scotsman, who had been left here by Captain JStradliug of the Cinque-Ports, and had lived alone on the island for four years and four months. Cupt. Dampier* told me he had ♦Selkirk had been eailinfr master under Captain Dampier in liis expedition which left in May, 1703, and luid l.ieen put ashore on the island at his own request. Dampier's expedition was unsnccessfiil. and "the merchants were so sensil)le of his want of conduct, that they resolved never to trust him any more v.ith a comman ' " J;- y, but o„l, two eunu^o , ho, :. H '-T' '''''^ «'"'P« f«"'>'l to he fS]>ani.sh, unci th v f ''" ''''""'' ^^'"^-l^ he which they (ireclu( hi n m '^'"" '""^''^'^ f'-o'u tlien, on ^jeyheenVenehi:::; t::r''rt^^-''^ "^2 chose rather to r„n the ri«k ovh,!;,'''' to thon.; hut f''^>l '"to the hand, of tJ,e sl i'""\°" ^^^^' '^'-hI thau ^vould ether put him to .iea or m'l'', ' '"^^"^^"''^'' "'*-T """es. The Spaniards had 'e / h ""J ' ^^'"'^^ '" ^'-"> ;ere and can.e so near hin, . u , ^'^' "'^"^ ^'"^^ for ti.ey not only shot at hiz^ h pu 'u n"'' ^^'^ '' ^^^^I-' where he climbed upa tree . U . f t ^ '""' "'^" ^^'^ ^^oods -ulo water and kl./ed s:::'. ' .tf et ^^''7' ""'^ '' ^^-'- (liscoverinir ],i„,." ^oat., ^et went away without "ile told us he was l)orn in T Scotland, and was bred a sailor f,"^"", '•" ^^'" "^"""^^ ^^ Fife, of his being left there wlTii";" " '■''''''• ''^^^ --ou 1'"^, which, together wit teSh^ ','''! ^^^^'^=''" ^^''-i" ^■•^t rather willing to stav e 1^'"'^" ?-'^' "'"^^' '»"" ^^ '^"'^ ^^''^^'^ut last he was'in i„ , '? '^''"^■""^ "^ the ship; would not receive him. He 5 ^" '^"'^ ««"^' th« eapta u wood and water, when two oL'r/' "'^ ^'^'^^^^ '-^ore t jx n^onths, the ship bein' cha el T ' '''' "P«" ^^ ^^^ «- ships; but the Oin.iu^PoiStj r^^' 'f ^^^ '--eh South at which time he was le t. [fe I d -H /• "'^ '"°'^' ^'^^'" ««• l>e^l'ling, with a firelock and so , ] ^""^ ^"^ ^'°''^«« ""d *«'-"■<>. =^ ^nife, a kettle, i";,;?;'"' '^'''' ^•■"^^^^' «'»- h'^ mathematical instrument ir "" "^^''''" '^«°'^«' "ud viJed for his sustena e n '^V^'^^'-^^d hin.self and pro- -'o to bear up against m":^;;^: -'J^V''^^"^^ "'"^^ ami was sore distressed at bein^ii , '' '""''^ ''»'^t months, Pl-- lie built lun,s 1 two i /^""'^ "^ "'^'^^ '^ ^^-^'ate -ith long grass and lii.ed w :"'/•"""; ^?, '''''' «^-tched needed then, with his gun o on t l"'"'' ''"° ''''' '' '^^ » *o long as lii« powder lasted, which I ; I- v;ts only about, ii iiouii 1 iit llrst. WIhmi all tiuH was sjht'I lie procured tire '.)v riililiip j; two stick.s of piiiiciito woe ■ 'ii-x'tiur. Ill' slept, ill lii.s larger liiit. ami cooked lii,- vidua., iii li.e siiialler, wliicii was at. soine distaiu'i'. and eiiiployed Ip Ji.seit" ill readiiii;, ])rayiIll,^ and . iiii;iiijj; jit-aljiis, so tiiat (le said lie was a lieller ('liristiaii diiriiiij; In > solitiKir fU.tu lie (^ver had been before, and tiiaii, as he uas afraid, iu' .voiiid ever Ik; a^^•lin." '"At tirst. he never ate but. when rest.rair.ed \-\ liiiiif^ei-, ]>iirt,ly from jj^rief, and partly for want, of bread aiu salt. Neither did In- (lien go to bed till lie could walcii no longer, flu- }>iiiu;i((.' wood serving him both for lire and candle, a.'^ it. buriu! vers I'lear and ri-freshed him by its fragrant, smell. lie migli! iia-.i bad lisK uioiigb, but wtuild not. eat. them for want of N.:'.. as t.iioy (>ccasione(l a looseness; except, eraytish, wliieh are :>,' iarge H:^ lolisters and are very good. These he aoiiK'times lioiled, and at. other times broiled, as he did his goaf's llesh. of which he made good broth, for they arc not so rank as 01! r goats. Having kept an account, he w.ud he had killed r>()() goals while on the island, besides having caught as many more, which he marked on the ear and let tl em go. AVIion his powder failed he ran down the goafs by s|H'ed of fool ; for his inotle of living with continual exercise of walk- ing and riinning cleared him of all gross humours, so that lie could run with wonderful swiftness throngh the woods and up the hills and rocks, as we experienced in catching goats for us. We had a bull-dog, wliitdi we sent along with several of our nimblest runners to lielj) in catching the goats, but he outstripped our dog and men, caught the goats, and brought them to us on his back. On one occasion his agility in pur- suing a goat lu'arly cost him his life; as while jiursiiing it ■with great eagerness he caught hold of it on the brink of a jirecipice, of which he was not aware, being concealed by bushes, so that he fell with the goat down the precipii'e to a great depth, and was so bruised and stunned by the fall that he lay senseless, as he supposed, for twenty-four hours, and •when he recovered liis senses found the goat dead uiuh r him. lis >|u'ti( lie II' * 'ii;^'L'ttUT. iiu..' Ill iiic yoil Itifisc'lf • siiid lie Wiis T lliul l)lM'll iigin-, jiarMy II." NfitluT Joiiger, tlx; audio, us it, ,n'.inl, siiu'll. it. tlicm for |)t. criivlisli, 'I'lu'so lie ho (lid his y lire not so jiiul ho hiul ? Oiiiii^ht an si. tl:('in go, by wpi'od of so of walk- 1, so Miaf. ho woods and diiiig goats ivith sovoriil mis, hut, he 111! l)rought lity ill piir- jmrsiiiiig it brink of a )nc'eaied ])y ■oipico to a 10 fall that hours, and undi r him. II >• was M <'''^''""l, an, I ,,,,,1,1 "■" ■^'•iir.vly aid,. ( ■II hr,.a,i n,i| " I'l-aul I (ur '' •■'''""' 111 l,.l,ir(), , In (h mil '>;-;:un r " 'lis i,|,f NlioiM an, I sal ' ivhsii i or ii nicn, liad al '"l'«- "hiVli |,a,| I )iriiji,.|. "■^ inral uril '" davf 'I niiie 'I'i'ii '|>roa,| -I'asDii "■"•I liud n,,„. '■^•"i'>iin,ian,.oof ,.",'i «^'HSO,U.dhisf,„„|,,i,|, J, '»f(| li over diaLM' saiiic wiMi ,; n- r KTl. f^<-'V,Tal fniiii I nl aiiiai I'll if by ( aiti'cs lie cal """"«•'' "'iUioiit l'l''n(y „J' irn„,i iiplaiii I) of -bai "iijtior's ^'I'oiin, fo ■'^" ii.^|)i'oi,-s of h|. ra. 11 l"'l'l"'i-, an, I I las ;i r ox II polling »iii,| and l"'l'|"T<'all, I'i'nrnii), u i (illc (1, -pal Ik :tvor. "Js, and '"■'•'' i.s the I! S,)()|| w,, '■nrinL'' "ri Jn ho \v,),)i|f an, I I'o ,)|1( |,i,^ ^1 '^ ,^ rijHv ' '""/''/M/, „lii,.| "'■ /oiiiul good 1 U'a,-: wcaiu, iH'Mll '""'s an, I ()(j «o hard IJiiti. i iiiri'i "■'• 'dotlics ) voni,.M,.t., and it 'f ran a '" •''"''■' "idioul, (I 'y ''"unin'r could Wt woar thoiii. !ir si) was soiii,. I »)ii( '"t'«, as his I '"if af(,.r h ''Vorywl),..n U'ln, uitJ L' OailK' ^■^''' Hwollod when i (o 'lis feet 1011 1 incoii- •After he h:ul lie lirsi "■I bof,ji-o h( anil '«wl himself will ^■'"i 'lio.lafoof I /fol' l»ottor of ! ''ogan I 1 <.'iir villi;- I '1I.-5 Illol, res id OlU'o. I'cnig ill,,, 'ii-< nan ■o, and '"loliolv Ik had ^^t first I lie oil (1,^. '"-' l-inie ,jf ] ''i-od ther i« H-its mil,. I ""iiii'tinio.- S, Ir.ged lis sol it le; arv 'I di,- wliich had '^ "1 groat I iiiinli ■d with watered at the isl «•'"■ <>" .slior,. fn„i, ,s| ■rs f, '•"'« 'I'Hl nils, which ■"'II .some of ,_.a,.i when ho w foeil "Iff Hiom witi uid. 'I' Wiisloej), uliiol lio ral,- S'» (anio that (I ' ;-^'>iifs II, ..si 1 oldii;-(.|i I "V flial ha,| "•''"•(■d his fV,., Ii Sjieeios »'<)o'^ms '. i :i: 10 Subsequently the expedition sacked the two cities of Guaiii- quil, in tlie ussiuilt on which Dover led the van. They took several i)rizes and cruised about the coast from Peru to Cali- fornia waiting for treasure ships. Of one of the largest prizes, which they named the Barhehr, after the Bristol aldernuui doubtless, Dover took command as chief captain. Tliey then sailed across the Pacific to Batavia, where they refitted, and in October, 1710, sailed for England, which was reached in 1711. Captain Thomas Dover returned from the South Seas a wealthy man; the expedition had been unusually successful, having realized the enormous sum of £170,000. To Dover, who is stated to have been the owner of a very considerable part of both ships, fell a considerable share of the spoils. Alexander Selkirk as mate received £.'^00 prize money. Harris ( Voi/affcs, etc.) makes the following comments on the voyage: "It has been universally allowed by such as are proper judges of such expeditions that there never was any voyage of this nature so happily adjusted, so well provided in all respects, or in which the accidents that usually happen iu Privateers were so effectually guarded against." This he attributes to the aliilities of the gentlemen of Bristol, ami remarks that it was owing to this expedition that the spirit of privateering in the South Seas was not totally lost in Kng- land. The large sums realized had evidently made an endur- ing impression, and Harris adds, " I might, perhaps, ^,o too far should I assert that this voyage gave rise to the South Sea Company, but this much I can safely say, that the success of this voyage was what the jiatrons of that Company chietly insisted upon in their defence, when the plan of it was attacked as insufficient and chimerical."' In 171:! Dover must have been fifty years of age, and quite ready to enjoy a period of leisure. Where he settled or what he did we do not know, but it is certain that three years such as he had spent at sea were no preparation for practice. I'os- siblv he travelled, and in the introduction to the Anrient ies of fiuuiii- , They took I'eni to Cali- argest prizes, tol iilderiiKiu Tliey thuu retitted, and s readied in 5outh Seas a ly successful, . To Dover, considerable if the spoils, loney. inientsou the such as are 3ver was any 1 provided in lly happen in t.'' This he ' Bristol, and uit the spirit lost in Kng- ide an endur- rhaps, ^;o too :he South Sea he success of iipany chielly ; was attacked ge, and (piite ttled or what •ee years such ractice. I'os- ) the Ancient 4\ 11 Phi/nkinn's Legani he scoff. .,f fi . "'"'-<■ -^I'^'aking. and des ribt! t '' '^:"'^'''"">' '^"^ ^'^^ the f'HT. hi.nseif. If, ,,.f . ' r^f ''' "' ^^'''''^^' ''*•' '^'^J I'fen -'^-•f the g,o..,:.a^'i;: '';:;;-"% t-^ in. wide kno^wl '""cessary to nnike an acconin M V'^''.' '^ travelling bo t'"^^ \ '"- travelled n^ S n '^^Z' r'^T"'-^ "" ^^'•>-- lintainpnt together." '''" Physicians of (;,.eut ^» 17:31, as nienfioucd bv ^\^u^v i, «f the Uo,,i College o pIvS" '""" "^^^'^'^ ^^'^-tiate •j'"^''!-! a nnm at that time o ,';'•' ''"'^li'i^'^tio.i which ;^-'!--ter. rtisdou;fuCt."r"''^'"'^^'--""i .'"'"^ '" '-mion ; at any rate heVt t s7. I 7'""""^ ''' ^'"« '" ''■--tershire in the yea " ^ . ^^^ f^o "^ '^' ^^''-^ '■'^■■^^•^ ^vhud, he mentions in his bool- '. "^""'^ "^ ^^'^ '"■'•'"""^'"t «ottlen,ent dates frorn ^/^^'^ l''^'''^^'' "'^ t'HM.seuf .,nicksHve;,ho ir^f'Jn' '"''"" ^^''''^tures ou \ i-e lost three paU^^ti ; t e p^T ^"^ '^ ^''^-^'-- "••.^' calle,! either in acute or c Z " ' ' "^■'''^'•^' "•^"-'" I was -ttled in town about eig e . :."?; fr "'^"'^ ' ''^'^ ^^■- ;vell on in years, .d.out o ab^^ ,^;^V " ?'"' ""'''' •■v'-l. ;o begin practice in Londo,; ''''''' " '''' =^^^''' ^^ ^'•-i-« <>" n,edic.a S^ts ^ co;;/""-'"'."' -"'■-P"i-'- ^^■•■■•" '-y very able men ( o ''"''!' ''^"•^'' ^'='^^"^^-' ^'^^^ '""^ '■<">!, /^()^forn,s.me..!:2 ,Vr^"'^^ f''^"" "« ^f'",T-^V'r'''''^' t'! ^^•'•'to a treatise, on some minenl w , ' f r""^^' ^''"" ^^''^ of n particular spa. Sn.o t ,? ' ""^'"^ ^''" ^-'''^"^^ v^'-^'tliuns an.l dis u.poin 'e' / , "' '"" '''^^ ^''^ trials, "'^' P-fcssion in i\^. i^^ ^t^^ '''''' '^'' ^^"'liti-' of ""^M.cce,sful attempt to introduce hini- |v ■■ : 12 self ill 1(1 K a say on the External Use of Cohl HW/f?", etc. Dr. Jj II with iiis "hotch-potch of criulitioii ami cxtnivagaiico," ami the pedantic ihjctor in Perc(jrine I'tckle, in wlioni he satirized (he learned Dr. Akenside, were well-known types; while in Dr. Fathom the "ivystery ' Oi the sons of I'aean, as ho terms thorn, is mercilessly exposed, Amonj,' the "means nsed to force a trade"* Smollett mentions "the insertion of cures hy way of news in the daily papers," the erection of u "hospital, lock or inlirmary, l)y the voluntary snl)Scrij)tion of his friends; a scheme whicli had succeeded to a miracle with many of the profession, who had raised themselves into notiee on the carcasses of thi poor." To understand Dover's rela- tions with the apothecaries (to which subsequent reference will be made) the reader must know that they were the gener;il practitioners of that day, and dispensed their own medicines, but in serious cases always called in a physician or a surgeon. Smollett's a' 'ouni of the practice "parcelled ut into small enclosures, occupied by different groups of per- sonages," who tossed the ball (the patient) from one to another, would almost lit modern usage, in which a jnitient is sometimes tossed in a circle from si)ecialist to specialist, until ho returns with an inventory of his local woes to the consult- ant from whom he started. In Smollett's days the patient had to be content witb three, except in the cases requiring a midwife. "The apothecary being summoned, finds her lady- siiip in sue', a delicate situati' i that he (.b.'clines prescribing, and advises ..^r to scud for a physician without delay. Tiie nomination of course falls to him, and the doctor being called, declares the necessity of immediate venesection, which is accordingly pv;iioriued by the surgeon of the issociation." While meriting the general criticism of Latham, the wo'-k with which Dover trusted to reach Dvactice had many import- ant (jualilications for succss. .1 appealed directly to the •This seems to have bee ..t(i Engliah Malady, in an autob. ■raphutil note. irase ; Cheyne uses it in his le uses it in his 13 ins Ihat 11,0 ,li«,,,.. i„ i,| , „ ; , ' """■'•, '•'" '" "■'.■»rl- i»„.n f..m„i, :!z ^ "•:':'.::"" r """ ^"■■■ t.o other booksHlens^ TtiA ' ""^ :/f' 7'f,.^'"^ """'^'^ -'f of which is in the British Museun J,, l ' " '"''' r-', ■' to be a sofond edit on. This is th,. pn..ii. of Lica^ry of the Uoyul Medioui a (" h t, ^U? ,3 '" /^" t.eH.,:.it^,,brar,^,,,,,^.,.,,^^,^,^^^^^^^ p.,^;. . different. Korty-nine years of practice •ire 1 Sryr ^*^^'-'^^^^^-^-^that..;hrx:;; ^ eftetts of n , y ^re more particularlv on.idered." After the author's name, Thomas Dovar, M Jj .,,/, , , r.ithr.nar,cs only," and the spirit of the buccaneer was not dead in the old man, as no occasion is nnssed either to blow his own trumpet, or to tilt a lance at his colleagues. '• Let me but come to I'eople as early in this Distemper (dro))sy) as they generally apply for relief from other Physicians, ami it shall be cured," etc. On page IS, in the section on gcuil is given the formula of his famous powder. " Take Opium one ounce, Salt-l'etre and Tartar vitri(jlated each four ounces, Ipdcacuana one oimee. i'ut the Salt,-l\'tre and Tartar into a red hot mortar, stirring them with a spoon until tiiey have done ilaming. Then powder them very tine; after that slice in your opium, griud them to a powder, and then nu\ the other jjowders with these. Dose from forty to sixty or seventy grains in a glass of white wine Posset going to bed; covering up warm and drinking a cpuirt or tliree pints of the Posset — i)rink while sweating."' The same formula is repeated in all the editions. lie mvs that some apothecaries have tlesired their patients to make their wills ami settle their affairs before they venture upon so large a dose as froui forty to seventy grains. ''As monstrous as they may represent this, I can produce uiuleniable proofs where a j)atient of mine has taken no less a (juantity than an hundred grains, and yet has ap])eared abroad the next day." In the treatment of fevers he follows the practice of the "good Dr. Sydenham," for whose menau'v he i)rofesses "the greatest veneration." "In this Distemper as in all other (' (if aliolll fdl'ty- rity of whi( h an- ^^kill. 'J"lu' Inter atientd, extolling sciireuly such a.s Sydi'Uiiaiu. Till' Hpells it, is Very ujHsibly u frifinl, re are eviik'iuicfj revuiiiie purjio.M'.s t deatl in the old Ills own trumpet, 1110 but come to iH they general] V shall he cured." 1 the I'orniula of ;e, Salt-I'etri' and nana one ounce. mortar, stirrin ; , ' -ng and poisonous Po.ders."- in anoth'::" .''':; rwl'T'-''' ''"''''^^"^^"^ '''''--'-'- H^^^ ■■sinallpox. in thi ounces of blood and liad ''^ginning he lost tweni WHS blind, and then took to my room, my windows were c( It vomit. II,. went abroad wet •0 ordered to be laid no hi.rlior tl '"■''• "I had no lire all )nstantly ojien, my bed-dotl y-two until he owed in me take twelve buttles of small 1 'i"i my waist. Jle made vitriol every twenty-four hours." Tl.. . , „-, ,^.„ V referred to fre.,uently, and he meiitVons' A ^V'est I "dies, and Hungary, in connect 'eor acidulated with spirit of ieexj)eriences of his travels siii, the East and in i)racticc. There i ion with special luiints sailors of the Duke and Duck ^ an account of the plague am two cities of ( The Ancient I'h 'iuiia(|uil, under tli •''■S "when I took bv I'Ks in the .South Se ong the slorin the ysician's chief legacy to hi lis. quicksilver, which was Jiis specific i.rahnost th e use of wlii(di i letters from jiatients. II s vaunted in a most forcibl s country was every disease, and e ordered an ounce a.juarter of crude mercurv dailv 1 Jiatii'iit from all manner iu or an ounce and iifving tliat it freed the and in •ormicular diseases, opened all obstructions, who hat itUea])ure])alsamof theblood. A( lived by the doctor's d of Snails and such stutl'," took for 1 irection "on As aptain Ilarrv Coit, iiiiilk, Svr hreatli twenty ])ound derii an ounce a day, and took altoo-eth s cough and shoi ■up tness of r an hundred and s weight, n.nvr says that he was called ion, T/ie Quicksilver D 'OilvV. 'J'hi in m active jiainphlet war, and for trt-ent merits of crude me •cury were mucii disuissed Legacy" stirred up y years or more the 16 If Dover's object in writing the work was to iraia jniblicity he could not have taken a better way than in his sharp com- ments on the ))hysicians and apotliecaries. The hitter he assaults in terms wliich must have tickled the frequenters of the coffee-houses, among whom we are told tlie book made such a noise. "I never affronted any Apothecary, unless in ordering too little Physic; and curing a patient too soon IS, ni their Way of ^I'hinking, an unpardonable Crime. I must confess, I never could bring an Apothecary's 15111 to three pounds in a fever; whereas I have known some of their bills 111 this disease amount to forty, fifty, and sixty Pounds. ^ If they can't cure with less charges, I can't forbear saying, That I have t!ie same opinion of their Integrity as [ have of their Understanding." The doctrine of the apollie- cary was that, "Tis your WrituHj-FJnjsician only lolw has a litle to n Fee." Dover takes strong and most reasonable ground against the constant varviuir of prescriptions wlim there is no occasion for it. The hostility of the apothecaries to him, according to his own account, arose from his bein- "always inviolably attached to the Interest and Welfare of my Patient and entirely regardless of these Gentlemen's um^ar- rantable Gains." These attacks did not pass unnoticed, and in 1733 II. Bradley, Surgeon, criticises the Ancient Physi- cian's Legacy, and makes some "animadversions on his <('ur rillous Treatment of the Professors of Physic in general; uith a word or two on the uselessness of his Legacy to all Private Families." Daniel Turner, -of the College of Physicians," who in (he same year, "impartially surveys the Ancient Physician's Legacy," refers to the Guaiaquil incident in the followi.io- terms: "I think the Doctor had much better have left out his Bravado of having taken two cities by storm, unless he thinks It an honour to a Physician to kill and slay, and after to plunder the Innocent, those who never wronged him, and to carry off the spoil; a good i)relude, this, to the blood 'shed after among his own men." (Dover had had them bled i to gain publicity, 111 his sharp com- 3. The latter he ;he frequenter.s of :1 the book made hecary, unless in patient too soon, enable Crime. I .pothecary's liilj ! known some of fifty, and sixty s, I can't forbear eir Integrity as I le of the apotlie- i only tvho has a most reasonable escriptions wlien the apothecaries from his beiii'r d Welfare of my tlemen's nnwar- 5 unnoticed, and Ancient Physi- ions on his scur- iu general; with cy to all Private us," who in (he snt Physician's 1 the following ■r have left out torm, unless lie slay, and after Juged him, ami the blood slied bad them bled 17 copiouslv for the platrnn ^ t quicksilver did not a mtle to h7"';""' ''''' ^''- ^^— ^'^ tragedian, Earton Boot ovh' r; Z' ?'''■'' '''' '^'^'^^''^ted 3d and 8th, within two on ces o , T'' '''''''''' ^'^J Like his master, Dover'^,^ L i /'"^"^^'' "^ ""^'•^•"•3'- lege of Physician; w.^.;S t "'^'^ ^'^^ '^'^^'^^ ^o'- ti- license. Sydenham irfM^r";;;!'"' 'i-^'i,ieation of guished English cluneal phvsioVnw'. "" "'"'' '''^fi"" regarded as innovators. "":;:^/i^ ' '^'^ -"tury, .,,« College, who, as Svdenhani reni r ■ , - J '' ^"-"''^' '^ ^'^« to reduce practic^ to gr at« e In. ° ' T '' ^"^ =^"^'"l'ts coolness and moderatio.rof u e t "" .^'"'"'"^- '^ '^<^ "Ancient Physician," whoin 1^ ' Tv"°'^""'^'^^'^ ^^^^he tlemen of the faculty, and^rt n 1 f "" f^'"'^-^ "'^S- every Graduate for a Physic :;;"'" ^''T' "^'"^ ^' ''^^^^ tlemen forOracles." II^^Z r "^ I'^-^Jmliced (ien- aha, or as he terms it on the t Ue ^^'" T'' '"''''''^"^'^^-Mor- of the College of Physic n T , ^ ^^ % 'J ^^''' "'"'''' conversation dix, togethj; .iti:T^^^£:^'^'^^-)j>y-^^^^ tl^e whole purport of th^ " C n-ersatioi^ '' ^-^r"^ '""'''^ ^'^^ Ignorance and to deceive their mis n I .•' " '"'''''^^ '^''^^^ ins desire is " more to do u i " T Ar f ^'""'' '^"' ''^ '^^ers and provoke a Set of ct^ ^ wh.^ t ""' /''"^ '^ '''^^'^ g'onnd, lest their Practices sho 1 '''"' '''''^' ""'l"' ;-e." He again refers loU.:^^!^^^''''.^ ''' ^'"^'"- the physicians in the following^;: '^r^™--^h r;nerally speaking, have it in their Tower m ^^l^«^'^»-'^«''i^^«, Plivsician, which is the wron-^es ^ '^^^ to recommend the take: The Physician, to grTf^it^Y ■'''"'* ^'^'^ ^^^^ self obliged to-order [^ f^,;^ ' „ ^ tj'f ^^'T' thinks bin. really wants, by which me. V T "'" ^''"" ^'^^ ^'^tient and too of ten li lA^^^^^^f''} T' '" ^'^^titution, cary's Bill in a Fev Z- " ,ld " ' '' ^'''''''^' '"^ ^^l'^^'^^^ more Pounds:^ C 'l '/""°""\^" '"'^-'y "'• i'^^ ft v. or several of those Apo Le a 1 n^'a!^' wf '''''''''' ^^^^ ----.sicia;i,but.v;:t'z;;dr^;rr^:::;; ( ii 18 Shilling ii Day into their Pockets: What must the Conscience of such Physicians be, tluit would forfeit their Eeputation and every thing that is dear to them, by cheating for others ? I would venture to say, Neither Sydenham's nor Eadcliff's Bills did ever amount to Forty Shillings in a Fever, and yet they recover'd their Patients without the Kule, at present pre- scribed, of Vomiting, Bleeding, and multiplying Blisters in all Cases whatsoever; so since this is to be their Rule of Prac- tice, they are very indifferent in their Enquiries what the Patient's Disease is." Dover continued to practice in London, and in the seventh edition of the A. P. L. there is a letter to him from Catherine Hood, dated November 6, 1738, in which she speaks of havincr consulted him in 1737. ° In 1742 appeared the sixth edition of the Legacy, which must have been issued by the author, as he speaks on the title- page of fifty-eight years of practice. He is stated by Munk to have died in 1741 or 1743, probably the latter, but his name does not appear in the register of deaths in the Gentleman » Magazine in either of thoKe years. Doubtless the old buccaneer, described "as a man of rouoh temper, who could not easily a- ' e with those about him," ^uis a striking figure as he passed along the Strand to the Jerusa- lem Coffee House, Avhere he saw his i)atients. A good fighter, a good liater, as alas! so many physicians have been, his weak- nesses and evil behavior we may forget, but Captain Thomas Dover, who on the 2nd of February, 1710, fouiid "Robinson Crusoe," the world should not forget; and we also of his craft have cause daily to remember with gratitude the student and friend of the great Sydenham, who had the wit, in devising a powder, to remember his master's m]\mci\o\\: Sine papa- veribus, si?ie opiatis et medicament i,«, ex iis confcdix, manca et clauda, esset medicina. .1 the Couscience Reputation and for otliers y I Eadeliff's Bills , and yet tliey \,t present pre- ng Blisters in • llule of Prac- iries what the in the seventh rom Catherine eaks of having: Legacy, which ks on the title- ,ted by ]\Iunk bnt his name 16 Gentlema7is man of rough iQut liim," was to the Jerusa- . good fighter, eeu, liis weak- ptain Thomas id " Robinson e also of liis le the student it, in devising 1 : Sine pupa- 'ctis, manca d lili^ i. h\ :H «S»BB«08^ CLk\/< January, is;).;, ' ^^N ALABAMA STUDENT n\- WILLIAM OSLER H A I.TIM OH K ■r"R fRrKnENn'Ai.D company I son I!' I i I ~ym ! "WaB'to:*^,, 11 fi b ai '"°"'"'""'^^-'-— ~.Xo...,., "ary. IS!*.] AN ALABAMA STUDE.V T. t'hief iinionc- the lvii-,i ^ ■ iin me is not wortliv of i tecepfaiiee, and wiijch th its is- i-'i' 01- niothei- Yet tJit 11 le. is r lara- :(?r more ■or rather, perhaps, as it wu li'i'= compelled men to follow near and the dear on -IS th «'• son or dauo-ht jin^th,,tniaaei,os;ihi; "lity as it •esponsible for Christ] iileals, even at th "»e which in all ao-es tinieor another, the call ^s at home. In varied ot a stndeut; to the i(? sacrifice of the tones, to all, at scorn delio-hts and ] S innvasi. :\r, third to 1 i^c the labor one and follow ous davs as the old Greek h ^'"3; are the wand-hearers, f^ ■^^"ounce all in the life of M any are called, but fe as It, or. in tlr ;e \\ are th e mystics tied, but th Th e same spirit are chosen. 'J'] o''ds»-h,eh„.eknowbette iiiimated the " fi le gifts were d iversi- . -f'V- the patient so„l of P." """" '''''' '' ^^' ™g|ity intellect of John Plunter.' ^'""''' '"^"^^ the We honor th the story of their 1 could not have be lose who i\ i^'es; an pond to the call; we 1 d ^vhile feel ill''- recognize in the power of -".;vitlithem.faithfuI°„;tode ove to tell Perhajis, that we ath, yet we o"'"i= in Liie nowei- nf lu ■ --' "v.iLii, vet we ' chose men. They see of tir are oft en not h H'py men. often not th: my lied and, in the bi trei 'C travail of th better than their fatli •lie ■ss of the thougl leir souls and and die ers, ai 'it that thev ■sties ■' iccessful i'"e not satis- •^ ready, with Elijah, to 'lie dow are not u 4 To-iiiglit T wisli to toll you the story of a man of whom yon have never heiinl, whose name is not written on the scroll of fame, but of one who heard the call and forsook all and fol- lowed his ideal. AVhen looking over the literature of malarial fevers in the South, chance threw in my way Fenner's SiMthern Mndital Reports, ^'ols. I and II, which were issued in 1849-50 anil 1850-51. Among many articles of interest I was particularly impressed with two by Or. John Y. I^assett, of Ilutitsville, Ala., in whom I seemed to recognize a "liken.-ss to the wise below," u "kindred with the great of old." I wrote to Ilunt.sville to ascertain what had become of Dr. Bassett, and my correspondent referreil me to his tlaughter, from whom I received a packet of letters written from Paris in 183(;. I have her permission to make the extracts which are here given. By temperament or conviction there are a few men in every community who cannot bow to the Baals of the society about them, and who stand aloof, in thought at least, from the com- mon herd. Such men in small circles tread a steep and thorny road, and of such in all ages has the race delighted to nuike its martyrs. The letters indicate in Dr. Bassett a restless, non- conforming si)irit, which turned aside from the hollowness and deceit of much of the life about him. As a student he had doubtless felt a glow of enthusiasm at the rapid development of tiie science of medicine, and amid the worries and vexations of a country practice his heart burned with the hope of some time visiting the great centres of learning. As the years passed, the impulse grew more and more urgent to go forth and see the great minds which had controlled his hours of study. All students Hocked to Paris in the fourth decade. Nowhere else was the pool so deeply stirred, and Laennec, Broussais, Louis, Andral, Velpeau, and others dominated the thoughts of the ])rofession. One can imagine how carefully the plan was laid, antl how for years the little surplus earnings were hoarded for the purpose. But the trial which demanded the greatest coura-o was the k-uvin- of wif, , ■ •, , r'r' '" ^''^ '^'^--^ -1-1. i^ii ;i t ";■' "" ^'"'••^ "- l«ur.l.n.,t nnl,v,l without biUc.n,.TT ' '*''""'•-' ^"^ for a.> apparent crueltv in i.,vi, .'h T S'''^' f-VMU-ndy profession ; and ti.e nd.hho ^ f, "" ''■. ''"'■ '^''^- "^' l"' poor wife, whose desertion t' ev ''^■" '' ^'"■^'■^■'' <■'"• "''^ of H.e letters ho savs;Hes losophers torture dogs • Ii'.tt ' f " ^^'1'^"'"^'"^ -^ I'ln"- «'<■•" .suints. and asl , ; , " !'™"^ ^"^'^^'1"^^^^^^ 1-ims anoUier he savs, <^\rv "^^^^^^^^^^^ "^'" ""^ ""^t''"'"-" And in man's repent,u,ce. kno^uZ'"' "" " ""'"^ ^'^ =^ ^^^ for and fro.n me. and wi ,:;:';;'' r""' ''-■^' ''-''- "-eh you may do it pleasanth -n^'" -"S;-''and I hope to know, you have a h.i^la ' , ^ ""•^'.^'''^t.tication to you The lelters begin f^mP," ''^'^'''^''''^ .vour conduct." l>ocen>ber, ]S3o. ^ e 1 ai o t ■ !iL mine save on the backs of females ! ! ! ! It is a fact that tit •;•■> are women whom tliey call bearers, whose business it is to uarry coal out of the pit." He was very enthusiastic about the museum of the College of Surgeons, and tlie Infirmary, where he witnessed in tlio presence of Mr. Syme, an operation by '• Mr. Ferguson, a young surgeon." PVom Edinburgh he proceeded to Glasgow, then to Belfast and Dublin, and then on to London, where hespeut two weeks, aj)parently of great misery, as the weather was atrocious. lie shook the mud of England from his feet at Dover, and departed, hoping never to be soiled with it again. He took a through passage from London to Paris for XI 18s., and he gives an amusing description of the additional payments. He asked the master of the hotel to give him some information regarding P'rench traveling, and got, he says, a regular English account, Johnsonian without his wit. " They ;'guson, a young will ohcuf you at every ston- fi, i~3ouwit,,,,iH;:, ^,;i^^];- -'-you^ "'"tton or beef, and notlnn- , ! ''' ' >'°" ^^''" S^t no "'''l.ou,.h I paid everytZ^i ''";'■ "r""- ''''•^•" ^^ ««V8. of ti.e little extra cha^l ?, , ""'^r' ';."' ^'"^ >'^" '^ ''«* e-espuicl." IIegiv,.;aui( :ri'i;;;y';'-'f' ften charges in the two ikvs and n,, ''■''"*^'- '•'•^tra diligence. One of Ui^ Z 7'' ''u'''' ''' •^l^" ' i" ^''o -filing. notoIdS:/":tT'"""^'''"^'''-' over his ladder. "To the ,,„ . ^ '' '^"'^ J^mp^''! for seeing that nobody cleZ '''',"':'; '' """ ''' ^'^ ^o^els, "The conunissioner o^f 1 a-n "' 1^" l"n.self, si. ^billings.'' damned ra.cals, for l^cLe ,1' f ;"::;,/ ^,rV""'^^^ «^ '"^ and sixpence." '^ ^ " '""^ ''^■l"'g lies, 1 shilling seau ; and tlie Pantheon in w i ° •"'^"""'^ ^"^ ^ous- tl-i'- bodies, fron. v ; : ut T: f' 1,"°"'^ '^"l-^'^^d its classic front before n v u W n T """ '"""' '^^'^^ not so much of an iniide U '^ °" '^ '^'"^ ^^-^^l ^ '^m ^He attached hi.:;S::^r n-Uc^fvP"-"^''"^^-'' Charite. On his (Ir.st day he ..v. b! . . ''^''^" =^^ ^.a than half he said but 1 cm nd^f Vl "°^ ""^erstand more there was a gentlJm:! t 1S:^^^ TT"":- . ''' "^^^ there for three years. Americ u s ' ! ' '''^'' ^'''"^ ''"''' four or f,ye from \ew Yo 1 f / ^^ '"'''^^^^ "'^■'•^' ^^ere from Boston a^^P i.',: 'h 7 ^7^"'"^ ^'"^ — » nume.sbutitispleasa toU n^^^ '^T "°^ '"^"^i«" «>eir ut La Pitie with Wd tch V "^^^ '"""'^^ "'''''' Stille. He luJn ci c • :/^ "''' '"""'' ^'''^''"^ '"^^ six francs an eS and .°"''' '"'^^^^^^ ^^■^'''^ ^I'-'l- forty sous. ^ ^^ ^'" '""""-^ '' '^'''^' «" ^1- 'i^'st day for -iS-^™tr^ a to pay but toi the private courses, and the fee IMAGE EVALUATION TEST TARGET (MT-3) // {■/ I (/. 4 fA 1.0 ^iM la I.I 1 !^ IS f •- m U I. Uuu 1.4 1.6 1.25 ^ 6" <^ ^^ % /: . piece of news to communicate that 1 know will gratify you ; at least I feel very much gratified myself. This morning 1 received the appointment of externe in La Charite under Velpeau. The duties of an externe require him to be ac the liospital at six o'clock, answer to his name, follow the surgeon round a certain number of leds, attend to his prescriptions, a-^.l to dre^s tlu- , r -e receive nothing, and tl^^^^''^' ^-- ''- -.'vice yououghttobegrutitieduttln V °' ''' ^'">' "«fl'i"^S- I huve not been wasting n 't r"""' '' ''''' -'-ince vo'u' starting for Switzerland and L '," ""' ''" ^'"-' ^^'^ of celebrations on the -th ^St^^aZ^'f'^ *« "i^'^.s the was nude me I did what I h vo ' ''"' ^^■''^" ^'"« «ff^^v another sacrifice for n.y pr f i^" 'T? '" "'-^- ''^^^— ^^' and take the servic. I have 1 ' ""'^ ^^'-''^''^i^ed to remain W been in Europe ; it is a re Ue^i; Z' ^'^^''^^^ ^^'-e I He was very much impressed ,1" f'"'^'*^'""'^ ""solicited." the French physicians. lie ...v. - V"''''""^ industry of the medical men by w'^om t'.,V '" '""'^' "^ -^onie of blnsh for shame; Jid men hn" '""T'"'^'''' '' ''^'^^'^ '"« white locks with bovs and , ' ' ^' ''''^" "^'-^i'-S their -nlor of youth. S^^el',^ '!:""^ ^''^^^- P™^--n .^th that is idle, for if he ^^.^V.^ '' ^''^'' "'-^ "' France stripped; it is a race, and he '.i • """""' j^' ^^'^"'^^ '"^ «"t- are not pressed by others ZnTT ^' ^'' '^''''^ ^'>='t they there are none allowed to ' 1 f^'"'' ^' " '''''• ''"'^ I^onssais, lecturing and h^'^S^t "":"• "'"^^^ after having elevated liimself to h ' ? ""^"'" ^''"'■^'-''f. bachelor with thousands d, ,f ^ ^'T'^'' ' ^^'^^^'•-'^- an old h-on for ten months bV ]);";' '"''"^''f ^"^^ '^-'yvi^it and iJionths he from choice oiv , '^''''''^ J^'' vacation of two Bollier may be seen daih^ ,' Vo,..-';''' "^ ^Tf "''•^"'^ ' ''"^^ ^'^^ bed-post as jolly as .f 1 e'T'f ;.'';"'' '!'°'" '-H-o.t to f-ni a poor boy without mo e tim e"' T'' '■^''^"■''"' ^j;._^>aust,madehimsei;^:;"s:;;rs:rs::g:rt "The pupils of '30 Cs :!rit:"T "' ^'''•^■"^'•^^^•^ a little less than our old \ ' shi. . 1 '' '' "' '^'■«"=^^' Broussaisisagenius,^!: ''°tt:;:^"r^''"'^^•- -eth.ngwastobedone,orrath:r^rttJr^r:^r f jt '4 10 tiling, and he seized the science of niedicine as a good old jootur would a bottle of lotion, and shook it n.tn/, Hy l^f^^^rnauy, all Europe, parts of Asia, and A ne^Ja have fel the agitation. Jiut younger n,en also feel the n ces- V ,. don.g son.thing and they are now endeavoW g ^ •luiet the comniotiuii he has raised, and in France thev Lve nujasurably succeeded When the giant dies I doubt" i i -^^ ^f^^'^^^ov-lus conquests, like Alexander's, will he uuled and then fall into insignificance. He fights well while u the rn,g against awful odds, for the truth is against htm , '• .,, 'f -' '''*'" '^''^"^ to «"ter the field, and I have no I oubt will p ace a splendid monument over him, to- ven liim from being forgotten." P'e^enc " r am glad I know what great men are. I am c^iad I know o what they are made, and how they made themsel^s g a Kuigh this knowledge has broken the last of my ho ise- H> -1 gods ; yet it has taken away the flaming swords t la Xod H'ture he gates of this Paradise, where may still L IX ck of the serpent and of the .levil himself, so I will keep out of bad company." i^ Scattered through his long, often closeh-crossed letters there are here and there some choice bits which indicate he Huracterof the man. For months he did not he • Jd f.om home; then letters came at long intervals. 1 4 enty had been re-i^ading some of his wife's letters, in "^ o which she had been reproaching him for using strom language. He says : " Isaphaena, you tell me to break m ,f ion. of rehg.on ; that it will make enemies, etc. Xow listen to ine while I speak the truth, for on this subject y k lo w th^ always do speak what I think is .rue. I ncvei'did s." it'j nl 'r' '* ''"'"'^ entirely, for nobodv wou d 1 1 e„tand me, and it would be useless to waste breath when ;"ow can put it to a better use. As ,to religion, ther il "ot much here of any kind, and I assure you I have not ^aid u ■■ . ■ J^ere, where VoltaireJJo ,^ ' ^ ^f "°'' ^'" ^ -P-t to; ...d mighty-minded n.en eU id f r ^^^'^'^ -'-fellatio,, of Isaphuena-notsomuchuuh; /'"^r and died, 1 fel- by ciuTch-going people. W ';;•'''" "^''""'^^"■■'■«""decl f^omeut doubted the sincor v of ■'' ^ ^'''^ '''^ver for a l^«n'e I looked into the e v 1 7 Tf''' ^^•'^'"'«' ^"tat --there I saw ignorance 1::;::^'"" ^'" ^''^"'' ^^^'-^^ they were the nio.t pron-i ,e .r ,1 .T'' '''' ^^''^"'o^t; seen. Here I still look on Jv j °'' 'jf T^ '''^'^''>' ^^ ^ ^^Ur„ , Jltll '"^ ^'"'^ '^ ^^''•""^''-^- ^'W -^^ /^-r know you will ^1 ^'^^^-^^//--.^mv..., -and return nie safe to a count" ih r "'' "^"^^ ^^"^^'"'^e n^ent without it. I an, con td hi h '^""" ""^ '' ^-^•-- are worse-ay, nu.ch u-orse-^Z ' ''''^ °^ ^"''^^'Hty "Had I the talents of M. > '"' ''^'°'"" whatevu-." ^ ^«t spend it as they did or fn^n"?"'^'"^'^ "'*^" ^ «-o"ld effect produced. Thei ^ . J " '^ ^^'f^^' -"'^^ they see the of a corrupt priesthood- ut htif'^T^" ''''''' ^'^^ evils tools given to children J 'L ^"'"'^'^ ''''' 'i^e edged theii rehned and perf 'tec " '"T' '' ""^ ^-'f^^^' -'<1 and if we were perfec w 1 ' "^ '"°'"^'''^ '''^^ "«t apply --Is of truth \nt:^:::)l' -^ "-^ then. I speaJ^lS ■ne evidently was of Sf r> v subjection of the wife! li"! ' '^•^'"°" ''"''^' ''^^'^'^^^^^ to the b'^ve spoken cross to you scolIdV"' ^''''•' "^"^^* '^ ^ duty it was at least n rm- viW /r"' ^^ '' '''' ""^ "'7 pleasure of doing it ao In^ . >'' '"^? \'^-^P^^t to have the offends to cut it^off, et^ ,en s elv i '''\' '' """ ''^^"'^^ '^^^ we ought to have the li- ert v of u / °"' '^^""-'^'^1^ offends His last letter is fronp. ';'??;' ^^"'^•" ;-entS:;;::t::r,:-^^^^^ by the first of the yoar 1 f h , I T- ''"'''' *° ^' back -snmed practice at nu;>::,ne " ''" ''''' ^^ ^-^-^'^ M ! J ■uw'.aim m The two papers in Fenner's Southern Medical Reports are the only ones I see credited to him. They are cluiriningly written and display in every page the wise physician ; wise not only with the wisdom of the schools, but with that deeper knowledge of the even-balanced soul " who saw life steadily and saw it whole." The Report in Vol. I deals with tlie to]50graphy, climate, and diseases of Madison County. Dr. Fenner states that it was accompanied by a beautiful map drawn by the author, and a large number of valuable statistics. In an historical sketch of the settlement he thus depicts the early border life: "'J'he most of those who did not pro- cure homes at that time, belonged to a class who, from taste or compulsion, had separated themselves from the whites, to live on the trail of the Indians; and who, like tigers, and Judases, were not without their use in the mysterious economy of nature. They suri)assed the natives in physical force and in genius, and equalled them in ferocity. ^ They had the piratical appetite fi»r gain natural to the English race, which they had culd\aled among the whites, and they readily acquired the Indian taste for blood." " Thus, without any i)articular standard of morals of their own, and having fallen out with that which restrained tlieir Christian brethren, they found their interest in adopting the ancient one of Moses and of the savages among whomthev resided— 'An eye for an eye,' and 'blood for blood '." "These men, like the fabulous Behemoth that lay in the reedy fens of the early world, drinking up the abundant waters and eating down the luxuriant forests, to make way for civilization, have left little more than a vague tradition of their existence and exploits, the latter of which has been so embellished that the former already begins to be doubted." "yuch a race leave but short records of their diseases. Where bloodshed is always epidemic and every man his own surgeon, the few that recover feel grateful to none, and hang no 'votive tablets' on the natural columns of their forests"; Kej^orts are cliiinningly siciun ; wise that deeper life steadily ihy, climate, tates that it the author, bhus depicts :lid not pro- , from taste e whites, to tigers, and us economy .1 force and ey had the race, which ley readily •als of their aiued their -lopting the whom they lay in tlie i abundant make way ;radition of las been so oubted." r diseases, an liis own and hang 3ir forests ; W and when a missInuM,.,. -,d pu.ie H ;:::i:- -^^^^^^^ a« ."ost things, as well as '?"'? ^'"^ '^^'^'^ l^ut, "tanner as they pass over t ' 1 "'"i^' "'° '''''^' '» ««'»e niude their mark." ' ^^''"^ ''''^y «4uatter.s have also The good example of I),. 'I'l, days of the regulL sett erne vTth "I"', "'" '" ''' --'v S'on, is well drawn. "Tl f ni '''^"" '^^ ^'"-Mx'ofes- reputation upon the profession !!'?'' "f, ^'"'^ -^^'""^^"'un's of thoroughbred ph-sicia ;;,'"'"•' '^ '^ '^^^ ^^-^^^ce -hon, he had been directh' s U i;.;;''"^'"?'^'^-^' "'-'v of consequence followed: mr eke v '" "^''^''^ting; another Although quackery is inli^eno, •"'". "'"l"''''^'''^'" abated, thieving and lying! and alv':-.' " ^"""^'" ''*^'^'-^' ^^'^e the indirect ratio^^f the S^ " ' T''' ''' '' "°'"''^^'-^ ''" of the regular part of the" r 1,^ ' ''T' ^'-'"'"-tions exteiisively patronized pln-sci-mtn , '" ''-"'''"' ""^ <^iplom,.,. and the expeHe o V "'''^ ^'^ '''' ''^^I'-^ite g'-owso dull in diu.io Attol/r' '"'^^''" t'>^'"'-^^']ves to an hour before deat^l ' 1 ' " ''^^''''^ P''^'^»t half stimulating through the d.uorr'l^""''/'"' ^^''^' ^"^ '^<^"^ the dignity of theh- hig^, e Hin^ ,f ' '''■' "" -'"P-'^-^e or ]M-escribe 'Mother's kuero"l^,'''''T ' "'^ ^^'"-'^^"V smaller pretensions .nd nn- T "'"^ ^'°'"'"'' "'"^ of information, should " " T fT""" r'''' ^'^ '-"- springing up around sul k m . I ""'■'"' ''' ^'"^'^'^-7 ^ .ol^sc^-j::-;;:^:;;-^^^^^^ five or six cases of nio-hf- ki;, i " t^"ssett mentions Very full account S:^^;^^?":.^-^ ^^^^^^ l-'ge doses. of the former disease. ]),• B.,,,2 1 , ''''''' treatment equipped librarv and }Jlf "* '"'^^ '^"^' '^ ^-^11- Hew-ie not >; ■'' , rtrf .' """"" ''''' ''' -^ .y ^"} tun, but most appropriate. <>In the 1 1: i. 'ii I ' t! 14 sprin- of 1833 we Avero visitetl by the scarlet fever in its most iiiiiliynaiitforni; during tlie ])reviilence uf this epidemic more than fifty infants perislied in Huntsvilie, iit the only age they are not an annoyance here. I treated nine bad cases, and four terminated fatally; I lost nearlv half in almost everv instance An older i)ractitioner was called in, but I am not certain that 111 their own proper practice they were more fortunate. In more than one instance there lay more than one dead child in the same house at the same time. I feel certain that this was a most malignant disease; but I do not feel certain that in every case our best physicians remembered the united counsel of Hippocrates and Ovid, that -nothing does good but what may also hurt,' and which should never be lost sight of by the man of medicine." The following is an extract from the account of the 'small- pox epidemic of 1835 ; - My treatment was prettv much that laid down by Dr. Meade: bleeding, gentle aperients, cool air, sub-aoid drinks, mild anodynes and vitriolic infusion of barks. Although the purgative j)art of this treatment embroiled the faculty of the early part of the 18th century to such a degree that the like has not been heard since the days of Guy Patiu and Antimony— shaking the authoritv even of the celebrated triumvirate, Mead, Friend and liadc'litfe, and who, on their part, embalmed one Dr. Woodward in their gall and handed him down to posterity, like a 'dried preparation,' as a speci- men of the folly of small men who attempt to run against 'the throned opinions of the world '—and a proof that -polite literature does not always polish its possessors '—yet we of Huntsvilie were too willing that our brethren should have our cases, to question each other's practice." Dr. Eassett states that among the 30,000 inhabitants of the county, thirty physicians practiced who were paid about ^50,000 a year, <■ which," he says, -is but bread, and scarce at that -; and when we contemplate the 50 lbs. calomel and 1000 ozs. (piinine which they swallow, it reminds one of Falstaff's bill uf fare: "But one half-penny worth of bread to this intoleraole deal of sack." r in its moat lidomic more Illy age they ses, and four ery instance, certain that rtiinate. In ead cliild in hat this was •tain that in ited counsel •d but wliut sight of by f the sniall- r much tliat ts, cool air, on of barlvs. ibroiled the ell a degree Guy Putin ; celebrated 0, on their ud handed as a speci- iin against hat 'polite -yet we of Id have our mts of tlie )aid about d scarce at 1 and 1000 ' Falstaif's id to this There IS a very clever d debated question of th following is a good evtr science to have to st 18 '■^cussior on th '^ "^(-' of anae; 0- :it that t 'act : " li; ithet I 'ill', muc.'i 'i-'s in lal dull 11 ess of the cl op and IS truly hu lor, truth— to see sucl ^'■i.7 can fra '■•-'■^f upon her cou sto])ping in th. ' " "laii us i) nie an excuse f, The niiliating to I'Sf until tlie or an obvious side. "-^ '"idst of jiis h,l ■ko a monk of the fif !iO)\ Nmi.sou, of Kdinbur-h prove a truth at mid hy practice in th (lav. I'v ai risi^ of losing l,y nio-i Let I Ilebr e nioriiii It u- loj) logic bv tl teenth centurv. to end. """■"t. which he had iuid th "■ 'le had earn *-'''L'by riinni "g at lea le Way- avor to pi'oven St a "s examine in plain Kndish h ••e«' authority for the ,^, fd thr.M.gh the d 'f '"■'"■ translation of IV. getting one dent' out of i another in." At the head of tl I'f chlorof tht I's turtle S {.nri '"■'" and see if i. he d 'oes not put volume of 1- en lie r's "' article l,y D,.. j \{ tliought it better, in doubtful ■ports stands t: >"-^^i--tt in the th quotation, "C'eh second iin none at all "; w|,ieh 1 foil ence and ^''^^-^.totrya.loubtfulremed owing vigorous style: -J ' opinions, 1 desire to 't' quotes only to cond :i villi my individual us "in in the ciiee ana opinions. 1 desire in / - '"^"^'I'l'al ex «.e lest i„.™„, ,,;;; ;» ™-.;-.o,,. ,, ,,,^ lis charitable. I ujl 'late, in my own ],|.actic fortu the head of tli iu the eyes of and it is not heref Host, and exjierience peri- ') cases ore oiilv hut rend say that I have 1 ers •een I'^iii'ticle. That rule of ^y'/yersing the aphorism at that have opposed it I every generation of both ,1 ^^■«'Hlerful that the feu- abj Pi-actice has found f iivor French expect !i"ve warre.l in vain,— that octors and patients le men of everv ao-e lave ahk-e failed; d "cy,andthequackervof ( the science of 'When phvsici ; tiyingiiieii uill 1 ■ ei 'man honia follow the dictates of H Ills were re.piired. 1 nive pills and | ojia •thy, sors, us closelv 'IS Cliristi OSes and tl ippocrates. and h mandments of 3[ _ to act boldly their faith opinion sustained them; and h ;iarson5 ic opinion, to s immediate succes- '.V luibl ans lunv ])rofess to follow th prophets, thev cl 111 these autl iiimed e com- !i right 'S» and public >«'ever uitlicuit the task, thev loritie 1 found it much eiisier to unilorstiinil the written liiiigiiiiye of llippocratf-s tiiiiii the yet iiiuru obscure toiu;liiiii,'s of Nature, Itetwei'U wiiic'ii iuitl iiis followers lie stood au iufallilile inter- preter, inalxiiig lier mysteries so jdaiu tliiit wayfaring men, tliougli fools, ciiuid not err tiierein. llii)poenites was but our fellow-servant, and we are but ministers of >;ature; our wliolo art consists in understanding her language and laws ; our whole i)ractice, in obeying her nnuuhites : if we do not under- stand them, it is either our fault or misfortune; to act as though wo did is quackery. Celsus says, this bold practice of old, fere tjuos ratio non restiluit temeriUts adjurat; but shrewdly remarks, that 'Physicians of this sort diet other men's patients more liapi)ily than their own.' 1 doubt, how- ever, if, in the present state of medicine, u thorough physician is ever, in any stage of any disease, so completely without rational education as to be thus non])lussed, iuid driven to the necessity of dealing a blow in the dark ; where there are no intelligible indications, it is clear there should be no action." "Then, if 1 have not followed the advice of this master, it has not been liglitly laid aside; nor, as 1 have stated, without precedent; anil if [ have, in a measure, adopted another of his rules, to nuike food physic (optimum vero medicanientum est, cibus datns), it has not been upon his mere authority. I revere authority, believing with the royal preacher, that 'whoso breaketh a hedge, a serpent shall bite'; yet I rejoice that its fetters are broken in iiiedicine — that we no longer are hedged with the eternal cry of ' Ilipjiocrates and reason.' Hut if, in getting rid of the authority of the Ancients, we have discarded the example of their labor and learning, and turned a deaf ear to their opinions, it is easier to be lamented than corrected. If the unthinking part of the profession of old, that followed authority, and 'on the first day of a fever loosened the belly, on the next opened a vein, on the third gave a bolus,' etc., are now represented by those who follow fashion, and give calomel, quinine and cod-liver oil every day, we have but changed authority for fashion, and are yet h\ liin^fiiii,!,'o of ,'s of Nature, 'iillihie iiitor- yfiiriiiy luc'ii, 1 WHS hut our e; our wliolo il liiWfj ; our o not uiidor- c ; to net ii8 bold j)racticu idjuntt ; hut t diet other doubt, how- ^h physiciaa tely without Iriven to the there are no ? no action." is nuister, it ted, without . another of Llieanieiitnni uthority. I lacher, that et I rejoice longer are bond 17 V- hutfuHhiou. ihond. wind, and if fo ilfsi/s'iiintr in its .. Jiiark.-i, at whidi w 'I- a till,,.. i( indoiiiifiil '■'llTlu.S th. '■i'- '•luinoe.s xiti, ,] '-■'"•'••■nt. it .soon 1 ^^niajl eraft. tl ^'' \veak or fes 'Sional nuirtvrduni I' can at least Ik'arelv has ti tifuli II- '•redd of y exjiressed tin a Xr;il( til at tile study of relates to medicin ■" III ihe foil f oreinn Ijij i.i,''!!!^^', and wj natun <■'> is an casv t K:::;'"":'r^''-"'-'.a.]and ''".^'''' ^vithout f.ar of pro- 'II' I'i'vsieian been n,ore 1 ""•"Iff words: -rd )eau- '"""inandeonii o not iisl. let ai ""'"live, as f my ill' as it '"" ff" into its n.it '^■" I"-' thinks he 1 "y ""K' iindertak e a th. t-' polite and well-iiif '^'t' eoiujtry and "i-i niastered it, j^t tile illiterate and rud ornu'd ; if "^'■'"i'f louse it am lunatic sentences tin "'^y'li'n, where th U'llen '"-' •'iiLTeed, Ift 1 lonjr sla "'I i iini '^o amoui "i''' tlie mouth of ^ vornaeuhir is babbled •^ t'urrent; i„to tl le '"Hierstand this; should m that he k calculate the cost7in""l '"' ''liot. and atte "' "gain succeed 1 broken nipt to ""^vs that lan.ua^e fe 7 "\'"^ "'"^- ^"^^'^ ^"y this amount and ii''t>i', time and tal *•'" set do wii i-'Ut; tht »n and len S^Mdlvintothestudv'f V ' "'"'"''-' »•-' lias exhausted his pr SlUlorry; ^^^^^^ '^"'"'' y '<"«cking at the doln- o . '"^ "'" "'»' '''"'^^If opened; for dil nnikc lye'H'e, like t _*'""'; of the tempk, and 11 way throutjh fi our profession. \Vl,en h portions of the iute 'ozeu le 18 All le vjuegar of \l '■"*'• It is tht open It will be iiunihal, will satisfied with the b intricate and astound '■101-, its vast and varied di !i"-s of a singular stahTl "Iff action of its mach 'S(nnc iful niension of ]>ro. I the larmony under th. be anything second ity, whose e government of sec. such are not satish .w^ i,uL sarisueU unt ultimate object, to take hi '7 in luiture l-when 1 suffer " >t'l informed), he will be led Laz thes "inc th 'iit^i'y, obeying 'es re •■* satisfied (and to ills '.' coiilliet produt 'mlary laws-if th, aruses,— into th '. lo taKe ilk .w(- 1, -.. p ^"-^ ••" "18 fevered ,.r 1 t;°'" ''■"»■•'- 1«.- 1 "ii'l phreiizied, fr di lo io magazines of mi sease and sin, h «'iiig the e.> e pest-houses and •sery and cont 'O'li tile Jobs prisons, and her and •e, in I. ne must not only take uji h 'igion, these JJabels of ample of his Divide M iJi abode, but fol- dwell there ;-this is Kathir'"' "''"' '^^' "'"^^ ^-^^ to !| ! 1 i U * 18 " When such an one rc."ntei-H tlio world, he is a pliysioian ; his viiat liiimrs hiive not only tiui^rjit him how little he knows,' but that he knows this little well, ('onscions of this viiluoi he feels no necessity of trumpeting his professioiwil ucfiuire^ ments iibroiul, i)nt with becoming modesty undtrue dignity, which constitute genuine professional pride, lie leaves this to the good sense of his fellow-citizens to discover." Dr. Hassett developed tuberculosis, and the last letter in the budget gent to me was dated April ICtii, IH.'.l, from Florida, whither he had gone in search of health. He died Novemlier I'd of the same year, aged K;. To a friend he writes on the date of April r)th: "This world has never occupied a very large share of my attention or love. T have asked but little of it, ami got but little of what 1 asked. It has for nuiiiy years been growing less and less in my view, like a rec^'ding object in space ; but no iietter land has appeared to my longing vision; what lies behind me has become iiisig- niticant, l)efore me is a vast interminable void, but not^a cheerless one, as it is full of pleasant dreams and visions and glorious hopes. I have covered it with the landscapes of C'huKle, aiul peojded it with the martvrs of science, the pioneers of truth, the hound-hunted ami crucified of this world, that have earned and then asked for bread and received a serpent— all who have suffered for the truth. IIow glorious it is to contemplate in the future these time-bufTeted at rest, with their lacerated feelings soothed as mine have been this day by the tender regard your wife has manifested for mv future wcll-beiiiff." The saddest lament in Oliver Wendell Holmes' poems is for the voiceless, " for those who never sing, But die with all their mnsiu in them." The extracts which I have read show Dr. Bassett to have been a man of more than ordiiuiry gifts, but he was among the voiceless of the profession. Nowadays environment, the i pliysiciaii ; Ic 111' knows, ■ this virtue, mill ac(|uirc- rue (ligiiity, L-'iives this to ist. letter in ISAl, from 1. He (lietl 'This world tiou or love. Iiat I usked. ill my view, iis iijiiieureil come iiisig- but not a visions and idscupes of cicnce, the ied of this II (I received ow glorious ted lit rest, e been this ted for my W '•I'lx'rtiiiiiiv fnv work theslirf r I tl'f siimmil. To (iios'e ivslioss .'! !"'''? '''"""'" ''"'''> '"^•" '" with.MK ..|.poriMni,i,.< ..Md ;, ' ^^'"'I'uvehadaml.Kiun I'fgan by Sluing ,hut I w,inld te I vl'r" ""'' '"' " •^"''"•"- ' •n,lH:j« h, left ,.if,,^„,, ,,,i,,,:j 1'" '^;' '•^•v^''v.l. -Hi lor whom "H-^ To-diiy soiircely one ,.f , Z. ,,;^''^' ^•>- '•^■"^■'' '^"-vn to ."«^vith anydrmness from (h' . '''A '" "'^•""'""■^ ^"'"'''-^ >t nmy be said, thov are us l . ''^ " "wjority of ( |,,,„ Allowed, are shadow; I;" J"'" /-"'"- -''O". i^a.sett P<4'il),clragg.du,,t(u^i,,,,,.; ,: 7' '"' "'-''■^"'H.t us the ncii who would learn phiiosoph; i Sstn' T ''l""' '""'^"'■" to have made an edort. to h.ivo 1 V '' ' « '"'^•'' «'nvon, u--uono are worth ti:'x':rr^"''T'' '■'''- generation, one or two sii'it,.!, . '""^ "" '""^ """i" '" u •n.t for tlH. rest of .: ; \:::'^';;''«/-- and his tciichers-ami ^'"'"'-^ve, too, are with Uassett "no one asks Who or what we have l.een, More than he asks what waves, in le moonlit solitudes mild Of the nudmost ocean, have Hwdie.l Foam'dforamoment,,an,i,-one' • I ;, poems IS 'tt to have ivas among iment, the i: 1 1 i ^^xy/7 ON SfX CASKS OF ADDISON'S DISEASE, urn I II IK DV I HI', I'SK orniE SUI'HA- liflNAI. K.VriUCT. BY "'"-';|AM „sM.:,t, M.D., i,,«,P, (r..,,) lMf»»,„,,|,,„,l„,,,,„,„„..„, '■ ll'ipkiiisCnivcrsiiv. $ ' ^^^Pri'^eajro. .. .._,,,„, ^^^^^^^^ ^^^^^^^_^ ^^^_^^^^^^^ ^^^^^ I I; '' mS? w!!''^^^^'^ ^^^^^^'^' ^^™ THE ^'^ IHL U8E OF THE SLTIU- J'RNAE EXTHACT. r.i N'iNK cases of tin's nr,. off »• two of tl,ose I .na^rr :^r nr '''" ""''^■- "•^--va.io.. tie Transactions of the PhUadcluhia Pm'l i '*" '" '''*'""'« ■^••■''■- of six oases, which 1 here give, h v t , : ;''''^' "t''' '''' ^'''''''--l Recent studies renv ^- and is caused directly bv the itsf t '"l'' '" I'" -P-ts to „,yxa,den,a, The comparison between thes to d e T T""""' '' ^''^ ^^'«-l« As far backasl88o,i„a„a icle n nr ^'V^''^^"-^'>' '-en drawn, te.. c^Medicine,"^ I nsed the llllt:;^' i:!!::^ '"^-^ '" ^'^i'^-^ " %«- 'The relation of affections of the thvr, i l" . , cret.n.sm, and the experin.ental pro 1 , el,- .1 "" '" '"•^•^^''^'"'v and -val of the thyroid,' have JlZ^T^ ^H ^"""""" '' ''' ''- ductless glands. It is interestin.r to n! .. "uportance of the and Addison's disease. H f the t. V"-''T ""''''''' "'-^-'--^ the tissues-in one an increas:;!; 'II tZ;'''''^:^ ^'^^^ '» p.gment-and in both marked nervous ,1 ' "" '"''"^^-^^ '"" tl'e gressive dementia in nn-xa.dem.rrZr';'''"?'-" '"'"'»' •'"'"-^' ^ l-O" We regarded the thyroi/^ ^ ,;::^';: .r''^" f J" '^•'^''-"'^ «"-se. geons and extirpation in monk b H J" ''''''''"^•*^ "^ ^"•- of its function was followed by seHo's'T: 7 'T''"^''^' ^''='^ =''"'iition tl.e experimental removal ofr^:„dr;:r''"'"^^ "^ closely allie''^-«" ■""^'1' more demonstrate that these little bod et .^fPenmented upon-nuay health. " ' '^'''''*' '"' "'-^^ ""t ^^-''''""t their influence upon __^Althoughjhe viewof disturb.nnnervatio.^.e,uent upon involve- 'British Medical Jourr.al, 1895 vol '' ^"'"'^'P'"'^- Series iii., vol. viii. ^ British Medical Journal; 1895; lot U, \ t^l^; '^^^- "" iv <4 ^^^l ^ 91 WILLIAM OSLEU, M.D. niont of tilt' abdominal sympathetic meets the case, theoretically, better than any other, ant! is at present widely held, yet there are signs of a return to tlie old view of A(hlison." The analojiy will be complete if it be found that in suitable cases the use of the suprarenal extract cures Addison's disease in the same remark- able way that tlie thyroid extract relieves myxoedema. Clinical workers may now <'ontril)nto their share by carefully studying the efTects of the extract in selected oases. Addison's disease is so rare that every opportunity should be seized. At the same time the greatest caution should be exercised, on the one hand, to .select only well-characterized cases, and, on the other hand, to exclude cases in which the conilition is a concomitant of wide- spread tuberculosis. Cask I. — Fi'.i ling health for a year; attacks of faintness; bronzing of face and iiands ; sudden death. (Abstract.) A. J,, agoil about forty, lawyer, consulteil me in the spring of 1885, complaining of weakness uiid attacks of faintness. He was a healthy-looking, well-nourished nnin, of (jood family history. For about a year he had been overworked and worried, and hiul had at times dyspepsia. On one occasion, in court, he felt very faint and almost fell. On two or three other occasions he felt very weak and jiros- trated without any obvious cause. I'or nearly a year he had noticed a gradual dark- ening of the »kin of the face and of the hands. At the suggestion of his physician he sought an opinion as to the existence of Addison's disease. The patient's gen- eral condition was so good, without ansemia, loss of flesh, or any signs of tubercu- losis, and tlie pigmentation was so sligiit and limited, that doubt seemed reason- able. Dr. I'oppcr saw the case with me, and we agreed that the pigmentation and causeless faiiUing spells were, to say the least, suggestive, and we advised him to give up business for a year and live quietly abroiid. He went home prepared to follow our advice, arranged his affiiirs, and made preparations for his trip, when one morn- ing he dropped dead in a railway station. There was no autopsy. Casio II. — Gradual asthenia ; progressive bronzing of the skin ; attack of syncope ; nausea and vomiting. Autopsy : chee-sy foci at apex of left lung and in bronchial glands; tuberculosis of the adrenals; very slight matting ol' the .semilunar ganglia and nerves. Xellio U., aged forty-one; admitted to the Philadelphia Hospital July 2, 1886, with great weakness and bronzing of the skin. Her father and mother both died of lieart-disease, one sister of dropsy, and one of heart-disease. She had small-pox when a child ; otherwise she has been a very healthy woman until a year ago, when she was attacked suddenly with great pain in the region of the heart and with dysp- noea. The distress lasted for at least three days. Until April of this year she has been in fairly good bealtli, excejit that she seemed more languid than formerly and felt indisposed to work. Lust November her friends noticed that she was changing in color, and througb- out the winter her normally fair com|)lexion has been replaced gradually by a dark bronze. Three weeks before admission she hsd a sudden attack of syncope, pre- ceded by di/./.iiiess in the head. Shortly afterwards she, began to vomit after meals, and has done so almost every day since. She has had no pain anywhere. J'lfKnil Comittioii. — Small, somewhat emaciated woman. Face, neck, and hands deeply, general surface of the trunk slightly, pigmented. The bronzing of the face is extreme J it is interesting to note that on the forehead the deep small-pox scars SIX CASKS OP A odiso.n's DISKASK. are unpigmented. The skin of tl,,. .,iwi the finger, are not clubheu " U^ '"''"'^'"■'^'" '''""''''""'•''- '''"-x thready; the heart-sound. ar; el .:,;';?'""'■ '.''? ''"'- ^ »"- -"all and chivKdes at botl. apices, and the percu s , 1 '' r'V l*"'" """*'"'"^' '"'"'^""' 'he a fcw rales on deep .nspiration. Tl , " ^r" ^ ' '''"'' '""■'"''' '''"' ''""•-'- theep.gastriun^- no tenderness on e,£r::r' "?'""" ^"' '''^"lM"-e.ssure in mentation of the n.ueons nienihru ?, " ■"""'' "■'«'""'• ''"'"''•e i^ >'o pig- good; noana.niia; temperature 98=' F '"""'' '■^''" ^"'"'' "•' 'he lips is (airly Tlie patient had most profound ■n,nr„v • • ■ twice vomited small quantities of hlood s.J" "''! H""'"'" f^'""^'^^'""""- ''-1 once or ^«fe;«y.-liody not emaciated ■ skin olf ' ' ^""'^' '"'^' '''•-''' '^" '''^ 13th. bronze eolor; marked pi.mentatio;, of ij J; ;' ^^f , '-.'''^ -"' arms of a light a dark patch on either side. V.„.i„, , " """^'" ■'^"'•'a^'es of cheeks abdomen three-fourths of an inch ilrthic'kneT'' "'" '''*-""''"''^''; Pa"niculu.s over Periloneum. — Adhesions betw tl The omentum is adherent to the wall of'thenT-"'" 't' "'''' ''""' ^'"^ diaphragm, at the right apex and general adhe l' ^^, e "a sil" "'Ti" .''"^ ''"" •■^'"'-'"- blood and clots. The valves are normal- M\r I"' ^''' '"''"■' '"■""""■"^ fl"id Zu«y..-The left is crepitant ex i'.' '"''^'''"'■' " '' ""'*- P"'-- areas of anterior margin, which si,;, v i ^sv f kr*:, '"^ '' "^ ';"!'', '"" '"" "^ ^'^^ -''-^ll tion. The right lung is evervwhere c e . t Tl ■""T""'"'^^ ^y S^'"''"""-^ i"filtra- at the apex. The bronchiafglands are caseous '"■"' " "''^•'''^"'^''. Particularly Stomach. — Everywhere tliron I t\ two millimetres in diameter. The.^is", i.mlT r""' *"■' """" "'''^^ ^^"""^-^ about and no other special changes. l"g'"<^"tat.on towards the pylorus ; no erosions The spleen is of average s!7p n^r^.„^ n looka „o„„al. • "• ''"""'> •■«""■"■'" ■» tl'e ' -"'d lege o?pSS::i";hn:;5:ir' ^'^^""^ '^ '- ^"^ '''''- ''--- °^ ^^^^ ^°'- I i ■ -l ll 4 WILLIAM OSLRR, M.D. Case III. — Dyspepsia and occasional attacks of vomiting for two or three years ; '"or some months gradual pigmentation of the skin and mucous membrane of the mouth; attacks of dizziness; extreme prostration and antemia ; profuse diarrhcca; urgent vomiting; death; no autopsy. William S.,age(l fifty-nine, longnhoreinan ; admitted June 30, 1887, to the Phila- delphia Hospital, complaining of vomiting and great ])rostrati()ii. With the excep- tion of yellow fever, in 18()4, iie had enjoyed very good health until three years ago, when he began to have dyspepsia and occasional attacks of vomiting. He has, how- ever, kei>t at work". For many months past (he does not know the exact time) he has himself noticed, and his friends have remarked, that he was becoming very dark in color. Eight days before admission he had an attack of dizziness, in which he fell but did not lose consciousness. Since then he has been extremely ])rostratcd and the attacks of vertigo have become more frequent. Condition on Admission. — Large, well-nourished man; slight oedema of the feet. Skin of the face, neck, and hands of deep mahogany brown. General surface of the body very much darker than ordinary; sclerctics are pearly. The lips are pale, and there is evidently marked ana'mia. Mucous membrane of the lips and inner side of the cheeks deeply pigmented, and a large patch can also be seen on the soft palate. The lungs are entirely negative: no rales at the apices; no dulness; no sign of old tuberculous disease. The apex-beat is in the fifth interspace. Pulse 90, small. There is a venous hum in the vessels of the neck ; no luemic murmur at the base of the heart. There is marked pain on pressure over the tenth and twelfth ribs on the left side; none on the right. The blood showed the characteristic features of an extreme ancemia, and the blood drop looked very watery. The count gave one million red corpuscles per cubic millimetre. Proportion of white to red one to four hundred. The patient sank rapidly after admission ; had profuse diarrhoea and urgent vomiting, and died July 6. The temperature ranged from 98.2° to 101.4° F. So far as could be ascertained from the patient himself and his friends, there had been no tuberculous disease in. his family. This is the only case of Addison's disease which I have seen witli pro- found anasmia, a symptom on which Addi.son laid a good deal of stress. In a majority of the ca.ses the blood count does not fall below fifty or sixty per cent. A difficulty sometimes arises in the diagnosis of the disease in cases of severe anaemia of the progressive pernicious type which have irreg- ularly mottled pigmentation. I have recently .seen a case in which, with the progressive ansetnia, there was a degree of asthenia and gradual pig- mentation highly suggestive of Addison's disease. Cask IV. — Gradually developing languor and asthenia; frequent attacks of causeless vomiting; progressive pigmentation of the skin; con- vulsions; toxjemia ; death. Autopsy: sclerosis and atrophy of the adre- nals ; no tuberculosis. David A., aged fifteen and a half, a patient of Dr. Mullin's, of Hamilton, Ontarii), who consulted me by letter about him, and who very kindly sent me the suprarenal capsules for examination. The patient's father died at forty-five from pulmonary tuberculosis of four years' duration. The mother is a healthy woman ; the brothers and sisters are healthy. SIX CASKS OK ADDISON'S DISIUSE. The boy lind siifTured until tiie onset of tl I'roni no serious ij >e present illnc whieh he was confined to bed 1„. he iippearcd to be sunburned, luid too long in the spring. JJ to apply himself "f'ss ineurly life, and bad good or two d I" .Mareh lie had" a s!i.r| iiy«. Karl\ It fol liealth to study, Ka e seemed ai »be tliougjit it was du in April bis mot! fbriic attai'k-, in reqi'ently ,„, account of the scold Ills of three or f fretted and cried t March he lias had at interv...., brought up greenish and yell , the mother noticed that the skin "be lent and took b ■riv in tl so languid and listl >• to wearinjr licr noticed that '(' summer he was m ess, and did not Ills Scotch car ■en Iron sch f^cem able !is he ow matter, aft "iir weeks attacks of v "{,'«. Ever since the attack lit little exercise and did fame much more '■ "liich he felt better. In tl ■oiniting, in which he was fair and his hair of a light color ami ,1 ened through the sum not en iin liseolored. lie w and sometimes acted nicr, was very niark( His final il statement in full. stranwl y, iis if silh 'Siige in any sp.jrts. Hi «" tiiat his discolorat He bail at t ic summer iis very indo- s complexion ion, which iiiics very severe lieadad ache. ness is so graphicallv d escribed by Dr. M 'On Jlonday of tl ills week be complained of ■iickness "llin that I give his id beadii Wednesday he did not rise from bed- th.it ni,ri,t 1 > ;■'••■■■• ■iuaoacne. un Thursday he was langui.l and st -e'd i b d •'"? "'"' '"'' ""' '^""''''^'i"' ^>" he had no headache, but had a 1 a^ te 1 ' '"l"'/,"' " ""'•-' ^'^'^^" ""^"^^ ■ ^-'^'i strange, and he acted as if he did „,!' vi'l , 7' ' ''T*^ '"•'"'-'■ = '''"^ 'y^'' ''l'l"--="-e.l little oyster-soup ; this was . k h '''' '!'''''''''■ -^'^-" ^ v.m. he 'took a later he vomited slightly, Abo:t ,"'•', :;:':;;:"'-''' " """-^- '"' ^'-"-1 ; the wall as if he wished to sleep \ 11, i^ ^v<.uld not answer .,uest,ons; turned to violent; the limbs were fixed ■ he wis , l,o 'v"" " """^"'^i"" occurred, not slight frothing; thehandsjerk^irii! I ' IfrrT''rf"' ' ""''^ ''^""'' '""' 'yes,' 'yes'; he would put out his ton' e'an.^r '^"\ ""' 'i^'^^^^'^'^^V^ to say and moved to the back of the bed w! ' '""""'' "'"^ "'«" ''"•"'■•! "^vay by a physician, who said h tl Los- n ents w "" '""^.^ '"' '''''''''''' '^ ^'^ --» cal patient, I saw him at n o'Zk t n ' '"'' ""'""" '° ^'"'^^ °'' '^" ''>'-^'"'- but did not seen able to fu t. d r ta 1 H ' ""T ,"' "'" ""' "~-'-. request, but soo.i turned and m ed tt le w 1 'T "\ '"' '™"' '" ""' ^^'^ "' "'^ be counted at the wrist ; the hands wltl It ' ''"'''"'"' ^''^^' '"''' ^'""'^ "°t fallen one degree since'taken f e ,e c , mds Z'^Tr'" '" ''-^""'' '''' ^' ' ' ''^ '-^ yellow ; the breath seemed foul, Dt^ n e i I 1 ""'"' "'" ' ""'^ ''""'^''' side to side and pulling the bedelod.e II . ' "''~ '''''^'''' ""^'"^ ''^•"^ for the vessel. 'L nett n.or igvtued i .:';;:' "'1^'? ' '1 '''' "*"' '" ''''''' nails blue ; pulse so feeble that it eonb ,1 , ' ''""^' '""'' '^"'''' '^''"«''. i32p.minL. oc.sion:;;;^:r ::l^;^:;:^^ and anl^c^:;': ■ :i:t;:^:";,;^' t^^'" 7T "-•^^^ - t'- '^ee, the shoulders, deeply; the itUegumentsX^ areola around each nipple wL dL^r "7 T^Z^' IZ^'^'"'-' '"'" "^ cesses from the level of the scapular spines to the s u r m 1' ^ ''""""' '"■°" the size of a quarter of -i dollar mor. 1 1 " '"'^ "* ""' ^''"'^ "'^""^ il 6 wii.i.iAM osi.Kn, M.n. (lel|)liiii. Unfortunately, tlie s|ii'cin)ens and sectioni of both this and tlie following Citst> iitive been nii.slaid. Both capsules were extremely small, not half the normal size, anil surrounded by muuli Cat. They were firm, and on section showed no dis- tinction between tlie medullary and cortical portions. .Microsco|)icnlly, there was a condition of dill'use sclerosis, with here and there areas of fatty dcKencratiou. There was n(» tuberculosis of the or};ans. Cask V. — Attacks of voinitinji; and indii^'ostioii for eijrlit months; gradual |iiginentati()ii of tlio skin; intcnst' prostfation ; deatl). Autopsy: tuberculosis of l)otli adrenals; no involvement of other organs, William I?., aged nine, a patient of Dr. William E. Parke, of riiiladelphia. Pa. The boy was at (iirard Collefre, and according to the doctor's statement he had seen him, on and off, for about eight months, during which time he had been re- peatedly admitted to the infirmary with attacks of vomiting and indigestion, occa- sionally with a mild tonsillitis. His color had changed and lie had become very much bronzed, but this was suggested to have been due to a dark ancestor. His last illness was characterized by most intense prostration and weakness, a!id obstiiuite vomiting. There was no elevation of temperature; the ])ulse had been rapid, but on the morning of his death it can. ■ down to forty. I made the autoi)sy on the 28th of March, 1888. Unfortunately, the notes which I dictated to Dr. Parke at the time were mislaid. The skin was uniformly pigmented and about the color of a mulatto's. There was no enlargement of the lymph-glands; the heart and lungs were normal; no tuberci.losis; no involvement of the lymph-glands in the abdomen ; no changes in the stom.ach or intestine. The suprarenal glands alone were diseased. Both looked small; the right was larger than the left, and presented a flattened tuberculous mass a'oout the size of an almond, the left a smaller mass in the ui)per part of the gland. There was no thickening or adhesion about the semilunar ganglion in the nerves passing to the glands. Case VI. — Pulmonary ttiberoulosis; injury two years ago; dyspepsia; gradual asthenia; pigmentation, deepening for nearly two years; treatment for eight months with suprarenal extract; rapid disappearance of the serious symptoms ; marked and persistent improvement in general condition ; no cliange in the pigmentation. William H., aged forty-six, sail-maker, admitted to the Johns Hopkins Hospital May 3, 189.'), complaining of cough, shortness of breath, great weakness, and a change in the color of his skin. Fatnihj History.— Hi* father died of cholera morbus and his mother from the effects of a stone in the bladder. He had three brothers and two sisters, all of whom are dead. He does not know of what the brothers died. One sister died in confine- ment; the other from poisoning by mercury. He knows of no tuberculosis in his family, and none of his relatives have had discoloration of the skin. Personal HMori/. -~\Vheu a child he had measles, diphtheria, chicken-p.ox, and mumps, and when al)out seventeen years of age, varioloid. In his sixteenth year he served on board a man, f-war at Panama, where he had a protracted fever of nearly four months' duration, fei'ortly after this he had jaundice for a month, since when he has never had a very healthy or natural-looking color of the skin. Ten years ago he had two attacks of severe i»ain in the hypochondriac and epigastric regions, lasting about five hours. He was doubled up with the pain and had to have morphine. The attack was not followed by either jaundice or chills. In vluly, 1893, the pati-^nt was run over by a wagon, the wheels passing over his abdomen just below the navel. He was laid up for two months, and suffered a great deal of pain in the abdomen. There was no paralysis afterwards, but he has not been very strong since. For two years the srx CASKS OF :lie following f the tionniil owed no diH- , tliere wiw a itiuii. There It nioiitlis; Autopsy : idclphiii, Pa. iiciit lie Imd iiid been re- :estiori, occa- beconie very or. His hint nd obstinate n rapid, but Y, the notes IS uniformly ment of the involvement estine. The it was larger fan almond, lickening or d». (lyspep.sia ; ; treatment iioe of tlie I condition ; ins Hospital ness, and a er from the all of whom i in confine- ilosis in his en-p.ox, and 2nih year he er of nearly , since when en years ago ions, lasting piiiiie. The jiiiti'^nt Wii8 navel. He Tien. There wo years the wkin has 1 ■\l'IHS().\\s orsKA.SK 'fen growing darker I-^t five or six n^ontl.:,),. pig.. , i. ;' '"* '^'^"'^ "-- no.ieed tl.at ni.l.i,, „.e "t nuervals tl,n.ug|.,..u his life I T] I".'' ';«^''""^' ""H'h n.ore inCns... 11. .. , ,J -"..ting. Twelve years ago ^ U / .t'lt'T >• "' T'"' "' '""^^ ''<"^''i'.k o During the past two years I.,. ,,„ l^"";^' ^ "M.arrhuM. which lasted for , w ek a..• "Pl-et.te is p„or, but he has l.a.l „ ,", " , "^'f'' '""' ''^ '^^'co,„e verv weal T ' t=on of the heart. ■'■"'^'-'' ••""! "" vomiting. He has had no pa,,,!'; about five leet, eight inches ^^ t:^ ■'^""'"'' -"-ly.onris i „,„ ^ ,,i^,,, a .nission wasloPK.; pulse i;: ,2 TV''"'' '""""'^' '^'■'"l-U..:;^ very apa hefc. One's attention is i„ .. ] ''i , ^ '" T^ "''^ •^""'<"". a-.-l he looks '"" '>' "'<■ sl^ -"' '"-"^ .".on, r le on the velum there is slight pig,. ^1 '"■" "^ '-' f'^bes of pig,...,,,,.,; The sk.n of the hands and wrist: is ot ! .V V "" "" ''''■^' ^'''^•'■'^^ - K"".^ .« .nore marked in the axiihe and he be ,7'' ' ir'^n"""'"- ''''"-' "'^""-tatio. n.pples and the genitals ,..re dark brow .11..".; ' , "' ''''"' "^^'"'^ "'' 'be be body shows a marked bro,„.i„. T le r "'''"■• '"''^' «'^""al surface of be shins, and there is uccentuati,:;; o ZCaT "' T ''"' "'^-"'"i-n c^ 1 e superficial glands are not enlarge T ,." tddi'l "" '^'t" '"' ""-' ^^"^ ^o-- rhe pulse ,s regular, of niediu,,, vohune . ,V'"'^"'-^"'f-' a.,d testes are normal, tb.ekened. ^""""^' '^''"''on normal, the vessel wall slightly '-'^^r^^^^^S'^^^^^ clavicles prominent. The Hpace there is a well-nnirked friction r ^^JT' "T' '"•"•« ''-'" 'be second axillary regions and around to the back tl, ""-""Sbout the mammary and both apices behind there are a few fine n/i '^?,""'""" "'« i"frascapular area -V "e.ative. The sputum the ^^Ir^'JX^:^:,. ?" '"^ ''"\ '"' '^^^'^^-^o,^ a.n.ng a considerable quantity of -^recn ,'"•' '''"'"''"'^ """' ''^'"b.v, con- fou'Hl. • "'""''' "'"«'i'"s, but tubercle bacilli were not The apex-beat of the heart is in fwvi • . The .sounds are everywhere clear. ■ ""^'.•■^pace, just outside the nipple line. The abdomen is somewhat r.>)n,.t„,i i not easily palpable; no i^^H 'ZTilr^T ^'^ ^-''^ "'• 'he liver is palpable; neither kidney can be felt. ^'"'"''''- '^''^' ^P'^^^n is not There is no enlargement of the thyroid or of tl,„ i i .- , lesions of the bones. ^ ^ ""' 'ymphatic glands ; no nodes or to 35 He expectorated a^^S^: r;;^?::'^^' -piratio„;.om^ which was examined every other day for tube 1 b Si , , ^ '"! ""'^"■" '"' ^''"•"'"' elastic tissue was foun-". The nilienf I, J i , ' ^'"^ ''""'out result ; and no and the rapidity of the helltS i 'S. V:^' T "^ '•"""' ^™^'^'"'- of local disc:i«c of the lung. ^ "' *'" P.-oport.on to the amount On May 16 the treatment with suprarenal extric f . suprarenals were obtained it fl,P t\,L T , '^^^""- Tliirty-si.„ pigs' i< ij 8 HIX CASKS or ADDISON 8 DIHKASE. I i; I if. !)^ ^{'! wore aiMi'il, iiiul the whole nllo\ve; leiieoeytes, fi(!0atient in charge during the summer, wliile he was in ifie ward, does not think that there is any material change in the face, but thinks the discoloration is less intense on the trunk. It is still of a very advanced grade, such as is seen only in the most typical cases of the disease. The small patches of pigmentation on the pal 3 have disappeared. The local comlition in the lung has cleared, and there are now only a few rales to be heard occasionally on coughing. The friction is still audible just outside the right nipple. The change in the patient's general vigor is remark- able. He walks briskly, is active, energetic, in very good spirits, and siiys that he is as well as he ever was in his life. I reCriKeriitor. , The liltriite Alter fUter- correspotided ! times a iliiy. il eorpuMcles, he flr.Ht time, to tile treiil- Tiio note by L't, wiis : The riin^^eil i'roiii Ic tlie e(|iiivii- iind a diifer- lere were no (»0 per cubic t" pouiidx, — a Tlie patient r. Tiiayer on )an a month, ?ginninf? the twecn 84 and metres in the ,d he h)oks a tion murmur led tlirough- mgressively. one iiundred •ing tiie very ;)n liiid been md was pro- iVonderfully ; iscliarge was )igmentation ospital occa- and Decem- ee pounds in ows : Dr, Thayer, ard, does not ration is less n only in the n the pal 3 lere are now still audible r is reniark- ys that he is t ?' International Medical Magazine. AN ILLUSTRATED MONTHLY OCVOTCO TO MEDICAL AND aUROICAL SCIENCE. EDITED. UNDER THE SUPERVISION OF ' i ;f ■\ i I JOHN A8HHURST, JR.. M.D., AND JA8. T. WHITTAKEK, M.D.. LL.D., BY HENRY W. CATTELL, A.M., M.D. THE development of medical science i.s proceeding at such a rapid rate that a medical journal is an absolute necessity to every practising physician. The Intkrnationai. Mkdicai Magazinb supplies this need by giving, as it does, authorit, tive expression to the results of the experience and investiga- tions of the foremost physicians, surgeons, and lecturers of the leading medical .schools of the United Stateo and Canada, together with those oi the great medical centres abroad, such as London, Paris, Berlin, and Vienna. Th6 contents of each number embrace Original Contributions and Clinical Lectures by leading practitioners, whose labors are exercising a directive, stimulating, and con.servative influence on tlie healing art. In addition to these departments and with a view to securing ex- haustiveness, thoroughness, and reliability, .specialists, tried in the school of experience and tested by their success in their specialty, have beta placed in charge of separate departments embracing the following subjects Medicine. Therapeutics, Neurology, Pediatrics, vSurgery, Genito-Urinary Surgery, Orthopaedics, Obstetrics and Gynaecology, Ophthalmology and Otology Laryngology and Rhinology, Dermatology, Hygiene and Bac- tenologi , Pathology, and Climatology. To this must be added translations of what is best from the medical literature of Italy, Spain, and Portugal. The department of Forensic Medicine, dealing with mer*' '> !c 1 questions, and the legal duties and respo bilities arising out rtt, -. < incidental to, the relation of physician and patient, as ascertr - 1 n ' defined by courts of last resort, has proved an interesting and ^^aiuable feature of the Magazine, and called forth many expressions of apprecia- tion and approval from its readers. The department of Book Reviews furnishes a brief critical anal\ sis of all the n. -t: important medical books and periodicals as soon as they are publisnec« The K'gi< icci'-'.':, therefore, the medium by which all tint is settled as as> , i o'- rj department of medical and surgical science throughout nt. • v 'l-ai world, ''• placed within the means of every practitioner. INTERNATIONAL MEDICAL. MAGAZINE COMPANY, PUBLISHERS. 716 Filbert Street, Philadelphia, U. S. A. SAMPLE COPY atsm un APPLICATION. :0 MONTHLY TCO TO HO aUROICAL CNCE. M.D., LL.D., ig at such a ; necessity to Ah Medicai. €s, authorit.i- tid investiga- f the leadiiii.; with those (il , Berlin, antl ibutions and : exercising a ling art. securing ex- in the school Y, have bei.n 'ing subjects : inito-Urinarv ilmology and ;ne and Bac- i translations nd Portugal, mec^v. 'c ; out r-t, ertr n ' and »/Uiuable i of apprecia- tical analjsis soon as tluy lich all that gical science ns of every lOMPANY, ADDISON-S DISEASE BV WILLIAM OSLER, M.D iversity 0/ Baliimore An a.J,ln>s« ,!eliverej bofor,. the c!as„w of il„. \I„ i, . r> 'in laiiiKiiy L'l, 1890, go 01 I'liila.lril ^"■'^"""'^ ™m lHH.\l,„„,M. „„.,,,,„- phia, U. S. A. i\ 1 1 f^ The glan are divided tliein, as the elaborate n are poured serve some meiititious. cretion, one and the othe directly or t phatics, and Icretion. Tc livliich forms ,ncrens, wl ItivetJiiid anc: markable gl} ; tliird groi pleen, thyrc Jprarenal hoc tritices of dis Jess glands." lemal secreti pe blood anc ; glands, a ive most in; |(5S of our ki pse glands Let n le functions ( pnncrin whi 1 In the first ' in region liany of the c lairmcnt in f The HI |r3iigely malf : or feebli • An addri ADDISON'S I'V WILLIAM t'rofesso,- of A;=cii,:i„e ,„ ,he j„|,„, „ The .g^lands of the body, you are auar. are divided into different classes; cer • n oi t)em, as the sahvary glands and tlie kidneys elaborate materials from the blood, wiiich are poured out externally and which either serve some useful purpose or are exc e- .entitious. Other glands have a doulle e- cre.on, one of which is discharged bv a duct ar.d t e other is passed into the%lo I eit t rectly or throughthe medium of the • m phat.cs, and hence is termed an mternal e- >t.on To this group belong the 1 ver be cT which' ''^ r' ^'^•'^°^-"' '-'the ' ancreas, which secretes a powerful diges- ive flind and an internal secretion with ."i-e- : babble glycolytic function. Then there is i tlnrd group o glands, comprising Ue .leen, thyroid, thymus, pituitaiv, and ! -rarenai bodies, which have no ducts or e.-s glands. _ These bodies elaborate an in- IM^ Jr'"?" ;-''V''? '^'^ P^'"-^^! '^^ck into I I e blood and which, in the case of some of lieglands.at any rate, has been shown to tave most important functions. The nro"- r ?"'\'^"°^^I«'ge of the phvsiologv of lese glands has been very rapid of late b !■'' '"? f''\ '^^" yo"r attention to le functions of the thyroid gland and to the te fi'" '",'' "''•^' ':"^'^ '^^"^ determined. In the first place, It has long been known Ian} of the children present a peculiar im- pairment in physical and mental dei ■'^y^'i^'^t-';' '^'"own as cretin • com |ti iir i o> :' n n n il ptic or feeble-minded. The iplctcl y are fouTid pat • An .ddres, delivered before the classes of the Medico-i Scluff had demo, series of change,, tion of the thn-o scrvations were c many observers whose experime, iiiunkeys. it u;i- "ivariably f,,]io^,. ^■'■'"d, and in nu,, ticed very simila "'^■"- if. on the . an- thyroid gku,; not occur, or evei gland were left . tile thyroid were nial operated un,j| '"^■"tal studies ( the prune functio, roid lor the norm il'.en came tiie' duction which ha striking therapon eni times. I„asn oi symptoms folk aiinnal did not oc animal were tran,' ural suggestion w ray— a pupil of I- procedure in cas. plantation was a found that feedinr advantageous or"" nsed subcutaneou Alurray's shrewd one of the most i "Story of therap. »een before the p long enough in w nicnt, and it may t'lyroid feeding in early cretinism ai tical medicine. J tration. A lady c months ago, wht changing gradual! J^.v- ^ She had bee Habby, and the ^ face puffy, and tit. were great cushi, cous tissue about •"'rv. ami there wa^ Pccia. She had - bright, active, inte taking charge of a listless apathetic i was to be let alo, advanced case of to walk, and pres( li ADDISON'S DISEASE. By WILLIAM OSLKR, M.J)., Professor of Medicine i„ ,he Johns Hupk.ns Universi.y of a.l.i.norc. [The ^.ands of he body, you are aware, |e divided into different classes; certain of pn, as tile salivary glands and the kidneys bborate materials from the blood, which le poured out externally and which either Irve some useful purpose or are excre- lentitious. Other glands have a double se- ttion, one of which is discharged by a duct Id the other is passed into the blood either Irectiy or through the medium of the lym- latics, and hence is termed an internal se- pon To this group belong the liver, lich forms both bile and glycogen, and the ticreas, which secretes a powerful diges- le fluid and an internal secretion with a re- Irkable glycolytic function. Then there is ■third group of glands, comprising the ■een, thyroid, thymus, pituitary, and su- Irenal bodies, which have no ducts or 'Hces of discharge; hence, the term "duct- s glands.' These bodies elaborate an in- to secretion which is poured back into blood and which, in the case of some of glands,_ at any rate, has been shown to le most important functions. The prog- j Is of our knowledge of the phvsiology of |se glands has been verv rapid of late I rs. Let me f^rst call vour attention to j » functions of the thyroid gland and to the inner m which they have been determined in the first place, it has long been known I 'n regions in which goitre is endemic fly of the children present a peculiar im- fnient in phvsiral and mental dcvclop- ft. The subjects, known as cretins, are ,'igdy malformed, and either completelv pc or feeble-minded. Thev are fouTid par- ticularly in certain European countries, and m some ot tiie Cantons (,t Switzerland thev occur by hundreds. It lias long been recog- nized that the condition is in some way con- nected with disease or atrophy of the thy- roid gland. While the allectfon is endemic n certain regions, it also occurs sporadical- y, and cretins are occasionally met with in tins country. Si/\v!n^ second place, tl,e observations of Sir Wlliam Gull and Dr. Ord showed that m adults a remarkable physical and mental change was liable to supervene in certain forms of disease of the thyroid gland The subjects of the affection presented a grea? : thickening ot the subcutaneous tissues marked change in the nutrition of the skin' I and a gradual impairment of the brain-func- tion leading ultimately to dementia So similar was this conditin,, to that of the ere- » An addresi itin that Sir William G„1I called it the "cre- : tinoid state," and Dr. Ord .gave it the name , of myxedema, owing t,. the large amount I of mucoid material in the subcutaneous tis- sues. A further step was the discovery bv sur- geons, particularly by Kocher and bv Rev- crdin. that total extirpation of the thvroid as IS so often practiced in goitre, was follow- I ed in a certain number nf cases by a condi- tion identical with that of mvxedema The patients grew listless and apathetic and the cutaneous tissues underwent the same re- markable change alroadv referred to These were the clinical contributions to the question. Then the experimental physi- ologists added their all-important studies delivered before ,he classes of ,he Medico-Chirurgical College of Philadelphia on hnu:.ry^s^,~ Ml^l^lOUlN S IJlSJtAbi'. i Scliiff IkuI (li'inoulratrd that a remarkable scries ul I'liau.Ljes tollnwotl complete extirpa- ticm ul the tiivroid in animals, and his ob- servations were conlirnied and extended by many oi)scrvers, particularly by liorsley, whose experiments were condncted npon HKjnkeys. It was shown that these changes invariably followed total extirpation of the gland, and in monkeys a contlitimi was no- ticeil very similai indeed to myxedema in men. if, on the other hand, a snpernnnier- ary thyroid gland existed, the cliange did not occnr, or even if a small fragment of the gland were left, or if, indeed, a portion of tile thyroid were transiilanted into the ani- mal oi)eratcd npon. The clinical and experi- mental slnilies demonstrated conclnsively the prime fnnctional importance of the thy- roid for the normal metabolism of the body. Then c.une the all-important practical de- dnction which has proved one of the most striking therapentical discoveries of mod- ern times. Inasinnch as the peculiar train of svmjiionis following thyroiilcctomy in an animal (hd m^t occnr if a gland from another animal were transplanted, it was a very. nat- ural suggestion which occurred to Dr. Mur- ray — a pupil of llorsley'.s — to try the same jirocedin-e in cases of myxedema. Trans- plaiuation was at first used; then it was found that feeding by the mouth was equally advantageous or the extract of the gland used sulicntaneoiisly. The consequences of Murray's shrewd suggestion have opened one of the most interesting chapters in the history of ther.ipentics. The treatment has been before the profession now for a period long enough in which to form a clear judg- ment, and it may be said that the results of thyrt)id feetling in myxedema and in cases of early cretinism are without parallel in prac- tical medicine. Let ine give you an illus- tration. A lady came under my care some months ago, who for six years had been changing gradually, both mentally and bod- ilv. She had l-,ecoinc heavy, bloated, and flabby, and tlu- skin exceedingly dry, the face jMiffy, and the eyelids baggy, and there were great cushions of swollen, subcutan- eous tissue about the neck. The hair >• dry, and there w;is a condition r.t patchy alo- pecia. She bad changed mentallv from a bright, active, intelligent woman, capable of taking charge of a large household, to a dull, listless aiiathetic creature whose only wish was to be let ;il<.iie. Tn short, she was an advanced case of myxedema, scarcely able to walk, ;in(l presenting in many respects a pitiful caricature of t'.ie human fonn al face. Within three months under the iiuj the thyroid extract she had lost all tid- ed a])pearancc; phy5,ically she had !).iiji| active and energe'^^'c, and mentally :-:.f loj an interest in everyt '."ng. She rerunic her Imiic, resumed her domestic r-.w <:^ y. has been practically rescued from a c iij tion of hopeless fatuity, and she is apiiii happy and intelligent member of ^.r] This ,s not an isolated instancy iu: cases are now numbered by scores; l.i. ihj the infantile and adult myxedema '.his markable change has been effecte 1. TJ is a brilliant triumph, too, for experiiiuMi] medicine. The facts which I have nientiom;! :ii| cate clearly that the thyroid gland seep, some important substance whicli, 'lo-ii back into the circulation, is of vital impi in maintaining the metabolism of the br[ and of the subcutaneous tissues. How stands the case now of .\dfli?i)l disease? Eleven years ago in Pepper's "Si tern of jMedicine" I wrote as folke ■ relation of affections of the thyroid .^land myxedema and cretinism and the expl mental production of these conditions bvf removal of the thyroid have widened view of the importance of the diictll glands. In both there are distinct histoll ical changes in the tissues — in one, anj crease in the mucin ; in the other, an incre| in the jiigment — and in both marked nd ous phenomena; mental dullness, a pro^; sive dementia in myxedema, a profound I thenia in Addison's disease. We re.^jarj the thyroid as unimportant to life until I experience of surgeons and extiipationj monkeys by Horsley demonstrated thatal lition of its function was followed by a si ous traif of symptoms; and perhaps the I perimental removal of the suprarcnalsj monkey.s — so much more closely allieif man than the animals hitherto expcrinieij upon — may demonstrate that these bodies are also not without their infliiej upon health." We may divide the steps in our Rnq c(\s:e. as we did in the thyroid, into the( ical. experimental, and therapeutic. .\\ son in 7854 described the disease very f| oughly and recognized the three iniporl svmptoms — namely, gradual det pcninft the pigmentation of the skin; protMini'l th en I a both nmscular and mental, and tro-intestinal disturbances. Anatnniicj Addison found that these clinrcal syniptl i: i\uuisyjis s uiSJLASfc. ntrated that a remarkable followed complete extirpa- id in animals, and his ob- onfinned and exteiuled by particularly by llorsley, ats were conducted upon i shown that these changes ed total extirpation of the nkeys a condition was no- r indeed to myxedema in other hand, a supernumer- d existed, the change ilid 1 if a sn'all fragment of the or if, indeed, a portion of transplanted into the ani- 1. The clinical and experi- lenionstratcd conclusively nal importance of the thy- al metabolism of the body. all-important practical de- s proved one of the most tical discoveries of mod- luch as the peculiar train iwing thyroidectomy in an :ur if a gland from another -.planted, it was a very.nat- hich occurred to Dr. Mur- lorsley's— to try the same ;s of mvxedema. Trans- t first used; then it was • by the mouth was equally the extract of the gland sly. The consequences of suggestion have opened nteresting chapters in the 'Utics. The treatment has rofession now for a period hich to form a clear judg- be said that the results of myxedema and in cases of •e without parallel in prac- .et me give you an illus- ame under my care some ) for six years had been y, both mentally and bod- ■omc heavy, bloated, and kin exceedingly dry, the I eyelids baggy, and there )ns' of swollen, subcutan- the neck. The hair ^' a condition r.f i\'itchy alo- Mianged mentallv from a lligent woman, capable of large household, to a dull, •reatnre whose only wish le. In short, she was an myxedema, scarcely able ■nting in many respects a pitiful caricature of tlie human fonn rind face. Within three moi>;hs under tlu u>^: the thyroid extract slie had lost all lur l);.,:,t| ed appearance; phys.ically she had luoiir,. active ami energetic, and mentally ,>;.e ioqiJ an interest in everyt I'ng. She rerunie: her Iniiic, resumed her domestic r.n' (_ has been practically rei-cued from a cjirj tion of hopeless fatuity, and she is ;ii^ain happy and intelligetit member of s.v. This .s not an isol.^ttd instancy i. i*. cases are now numbered by scores; !■ i.i the infantile and adult myxedema 'lib markable change has been effecte I. T is a brilliant triumpli, too, for experiMn.u medicine. The facts which 1 have mention' i ;:, cate clearly that the thyroid gland sucr, some important substance which, iiou-el back into the circulation, is of vital impo in maintaining the metabolism of t!,i> brai and of the subcutaneous tissues. How stands the case now of Addison disease? Eleven years ago in Pepper's "Sy tern of Medicine" I wrote as follows: "T! relation of affections of the thyroid glanr mvxedema and cretinism and the exper mental production of these conditions byti removal of the thyroid have widened o view of the importance of the ductle glands. In both there are distmct liistnk, ical changes in the tissues — in one, an i crease in the mucin ; in the other, an increa in the pigment — and in both marked ne ous phenomena; mental dullness, a pM;;ri sive dementia in myxedema, a profound; thcnia in Addison's disease. We re.ijard the thyroid as unimportant to life until i experience of surgeons and extirpatinn monkevs by Horsley demonstrated tliatal lition of its function was followed by a >t| ous train of sv:nptoms; and perhaps tlie perimental removal of the suprarcnab monkevs — so much more closely allie'' man than the animals hitherto experiniei i,pnn — may demonstrate that th-^sc i bodies arc" also not without their influe upon health." We may divide the steps in our \m\ edge, as we did in the thyroid, into tliecii ical, experimental, and therapeutic. .V| son in 1S54 described the disease vervts oughlv and recognized the three iniivnii svmptoms — namely, gradual deepenin?; the pigmontation of the sl-rin: pm' \i-\m' thcnia, 'both iiniscular and mental, av tro-intestinal disturbances. .\naff Addison found that these clinrcal ;vini tlic human foim niid J lUli ni:!ii. an livi Ij.'l^fj cally she had liccoir, ...^ .„^_ were associati-d uitli rhn ~ ^~~ ot'lhs uikIlt th. u>,M '•'■"aJ Ijoch'cs, usuallv n r//^'""" '" *'"^ ^"P^a-, ■ had lost aU luT b:r,a« tmn, which was subscni mN"'''f""' ^''^■'"a^ ■ tuberculous. Wliil t ' 'I'L"'"^^" ^" I^- tc.-ation, in other nmi n "- ^""""(^n al- f;la^dshash.;^n..,;:^':!"^^^^trophyof tlK. V CllI^ .-ill^ ..«V4 I'Vk^.J] Mud nientaily s'.i,' I'j.j '."r.y. She rerunie;! '. ^r doimstic c.n' '11 j| un ■i'.'t\ rescued from a c ity, and she is ag; It member of s., V.i.d instancy l):i. , ;red Ijy scores; 1' n'n ,| .lit myxedema '.bis ri s been effecte 1. Tl; , too, for cxperinKMir have mention'' 1 thyroid gland -.. )stance which, n. ition, is of vital im[>jr letabolism of tliu bra ous tissues. :asc now of A(l(li?i:i| rs ago in Pepper's "S,i vrote as follow?: "tii of the thyroid rjKiii :inism and the expd these conditions byt'i •oid have widened n •tance of the diictu re are distmct histnk tissues — in one, an in the other, an iiiireal 1 in both marked ner ntal dullness, a pr^X'' xodcma, a profouii' disease. We regarcl portant to life until 'ons and extiri'.atii^:; ' demonstrated tliatal) was followed by a jfj ns; and perhaps tliei of the suprarena!? more closely alliei Is hitherto expcrime".j strate that th-^^e lit without their infld :he steps in our kiij he thvroid, into theal and therapeutic. .\'t ^d the disease verv;:j izcd the three inqv. , gradual dcepcninjl f the skin: profuitnil lar and mental, aiifl! rbances. Anatniiiicf : these clinrcal sviii] -■''•'^ again cancer, and in a h-w cV"' "■' ' >. -■ n-t been .nuC a ded to o'"' , '"''^■'■^' ''■''■^ anatonn-cai know " 'of A, r'"":'' '''"'' ea.se. You will ihuuCc urw'"" ' '''■^- R.Mleston's Goulsto i'm r ..V'"^"'^''--' '■> Ruval College of P -; ^^'"^"'•^'s at the tl.c Lancet In^ ll^ZT'v'^f'r'''''^ ^" Vol. I. of last year '''^""' -'^ii>-nal, Iv by A ldiso,^'s n° : .' ^^"^'''-^^^^'1 direct- Slands were necefsan 'to'^"-'^'"''^;^' '^''' ^''^^ the pigment. I must ^Kr iuo?'f"" °' Lectures for full detailsof ?1 o , ^"""^^-^to" « pcriments. Recenlv S l f ' ''"''"'^"^ '-'-^- Lve found tl;a^an^x''f^rM'"^''''^^^^ tiie mcdullaiy portion of . ''""' ""'^'" gland contains a^i or°" n^ n ' •^"P"'"^"'''! traordinarv power ?h ^^T^'^' °^>'^- "pon the muscular fiir s of tie h ''''.''""^' tl>e peripheral arteries anflnl '''" ''""' vokintarv muscles Tho '" "P°" ^he the balance of evidence ;« 1 , " ". ^'^''^ oftbe view that the adrenn"^"^'--' '" ^*■^^'"'• Liands which ve and vigoroiTs. whatever in the pirr, . \ showed this pat e'ff'it montbs after treatment. He co,i He has no longer a ji's busuiess, and sa- there i,s no essentia tation. .^'nie alone will 1 tarn by this method results such as we 1 the use of the thvrc all probable that the 'y^^ood. In the firs adrenals associated IS often only a part c tn advanced cases 1 extract i.s not likel'v associated with mal pal, May 3, 1895 stiff e ring from cougb ;::-™Si'ii St--"- anatomical kno^^U^^yZlt'''"^ 'T^ riie cxi)crinicntal steps in our knou-k. a. in the case of tlie thvroid lirown ?rAdSo:V'°'^"^^^^'"'^''^'^-'^i-"- ^anLl;;;^^:;LSi;rtoi;ie'^;!?,;i;?-'-^ influenced in some vvav t . T i *'"--^' the pigment. I mt^t o?i o , to Rolll"." ^' Lectures for full details of l>e s Lccu ntTx' pernnents. Recently Schaefer and O iver" lave found that an extract nreinrerl fr^f.^ he medullary portion of t'he'Crarc " gland contams an organic princi e o "k traordmary pouer which 'acts esnccialh^ upon the nmscular fibres of tie heart a I C P^'^'"'^^"' ""'''''''' ^'"I '-ilso noon t e Ivoluntary muscles. Thev were ,ir .iVi . p>t^ct^^;;j^;sSco!i^,e??-;i I present the most that we can s is' 1 1 a I e balance of evidence is strongly in favor * nds which contribute an important inter- tl secretion the nature of which is as yet determined, but which probably has ^an KfXsl""'"'? °" the normal metabo- m ot the skin and muscles (The third step, which in the case of the |yroid has so brilliantiv clinched and Inr- rbet^H,'^""'^'''^' '"'^ experimental'd' , Is been taken m connection with Addi- Ic niT" '7 ''r ''^^'■"'"i^tration of the ex- ict of the gland to patients. The disease |en treated, and the results arc not as 'yet I ny means assured. I liave had, for he |n Mh.ch has improved in a very ren.nrka- I nu.nner. 1 he followincr is an ai,stract hs his orv: Wm. H.. a^xl 46, sril-iS I was adn^.tted to the Johns Hopkins ITot- !"'• '^lay 3, 1895, suffering from cough, f th s i' '" v'"! "'■'■^'^^'"S: pigmentation •vug had tubercul, MS. At the age of 16, V nonboanla,nan-.,f.vvaratl'anan.a.he S ' ''"''^"'^ ;^' jann,licc, and he says his or si. CO r.'r ''''" '" •' P^''-f^^^-tly good col- run over '''''• '"l"'.vofi8g3lK'was across fl, /-■,' ^"^""' tl'<-' ^vhcel passing ..s had ind.ge.siK,,, ,„r several years. Iv.r m>m.;V J'l' "'■'■'"' •"' i'K-reasing pij.-- ;''y"ofthesk,n. Within the past' sLx "lOlUllS e ll.'l-, ri. 1 I I f 1 . .111,,- . ' '' ^"'5'' ''^'•''' of coucfh and i; u'^ ^-1-^. .ration. On !dmis- ranlhr'''-''^"''''--'"^^'>'^^«^^-^'-^^^"'''<- tion o 1, /■■'" ''•''''"''^•''^■- '^^''^" Pigmcnta- on H,^,^ '" T'^ '''-y '"^'•■"^^^'' particular- ,;" ' '''"•• .f'^'-.^'"'-'^!' '•^"l- roof of""' ^^•'''^■^'^^•l" pi.g">cntation on the Id the?' u ■ ';"'-• ^vas of fair tension : 'Hi the wall o( the artery not thickened The e .^' V""","'''"">- '-'"^l ^-^i'lary regions, o tl e yer ^"'''""^•.''"^"t of the splJt.,, or ot the Iner. no special tenderness over the region of the suiirarenals. The sputi m w is 8,^1-^^ yellow, but did not coiS"^ Uastic tis.sue or tubercle bacilli. I'rom the date of a^hnission to May 'i6tli ue lecs 1 . On :\Iay 16th he becran to take he gained five pmuvN— an mrvn-;. c ■ and a lialf poulids sii.ce'i^^S;;; -- ^Sm. I he pulse .gradually fell from 04 S 84. the sputum decreased to ^o r, Kil "^ ! metres daily, the anneti^e inVrme . TJ" patie,.,ookedveryn,uc;rC?'K;;l^ ^nnecf'^lid'ir;^^ nt^SS":n^^r°;f audinweiVht He losrl"; i'e ;\ "^1 apathetic appearance, and his bodil? ' improved greatly. °''''> ^''^or "S Ul^jl There was no change emphasized the fact that the qncstion is On September loth he left the hospital, the change in his -r ulition being in every way remarkal)lc. He had gained nineteen pounds, was bright mentally, and vej-y ac tive and vigorous, whatever in tlie pigmentation. I showed this patient at my clinic exactly eight months after the beginning of tlie treatment. He continues well and strong. He has no longer any cough, he attends to his business, and says he feels perfectly well. There is no essential change in the pigmen- tation. Time alone will tell whether we can ob- tain by this metliod of treatment the brilliant results such as we have in myxedema with the use of the thyroid extract. It is not at all probable that tlie results will be uniform- ly good. In the first place, tlie lesion of the adrenals associated with Addison's disease is often only a part of a general tuberculosis In advanced cases, therefore, the suprarenal extract is not likely to be of use. In cases ment will, of course, be fruitless. In a ;. w instances, however, it is cpiite possil)le that the progress may be checked or tliat tlie dis- ease may be i)ermanently cured. I liavcl in the tentative stage. The experiiiicntall evidence has not that strong ancl powniulj unaiiimily such as we have noted in the i a^J of the tliyroid gland; still, it is extI•eliil•I\^ suggestive of the view that the adrenals ar. important functional glands, furnisliini' internal secretion. If the symptoms ni tht disease are directly dependent upon du ab| sence of this internal secretion, then in -int^ able cases the extract of tlie gland may sup ply this defect, and, as in the case of niyx dema, arrest the progress or even cure tb.; disease. The cases treated so far nuinV^' only eight or ten, and I think it may be . r that in a majority of these the condition h. been iniprove^-^^**'^ t*'//' t c .t< [at^^ ^'^ ^ ' . i Hi" riiitloss. Ill a !■ ,v |iiitt' possililt.' I'l It ictl (ir tliat the ^1:- y curc(|. 1 li.ivi' lie question is ^u\\ Tlic t'Xl)criiii(tiial oiif^ ami powuiul e noted in tin: r;is, II, it is extreiiiiK It the aiireiKils ;in' ids, furnisliin- ci • syinptonis >i\ ^\\^ ident upon the rib- etifin, then in suit- he f^land may sup- the case of iiivxe- i or even cure the :ed so far nunihi r link it may lie said .' the eonditinii ha. case I have nu'ii- nv of any instance ms of the disoase pearcd. v (s^'fU*, L uv./- ■\ |:^ i? ^%l O} Pr< %/%'^ L- X-|; TIVE ;^^'^|TONITIS. AND RHCURRING ASCITHS, WITH OIUM. ADHHRHNT PHRICAR- '^V Wll.MA.M (Jsil.K. M.I)., Professor ol .Vledirinf i i i, •wt^'licine, J ,h„s Hopkins Univcrsitv I'h • ■ • [I ' ':¥ 'iV WII.I.IA.M OM,(,K, M.„. f'-ressor of M..„i.,ne,J,.hns „,,,,,„,„.; ... '"'"itn.l valve lesion with consecutiv - ' ''"' "'°'' ^'^'^^"-^"^'^ cMtlHM-totheatropln-,consec,e , H '■"^^'' '" ^'^'^ ''^'^'•' due ■n adults to an ai.oc;at:;Z ' ^H ^^^'^'^^'^ '"'^'^"^'°"' - also in children, in which the ,.• / "^'-^'''•^ '"'''' '"stances "'"^^^'y, a chronic pro . -, V n ? " '"' '' ^'""^'^^^ ^^'^•^'^: hepatitis and peri-splenit,s "'^"""^ ^'"'^ extensive peri- univX'f;;;.;;;;;r;-,^:;:;:,;;,;-'d^^ f-t-vorrecurrin^attacJo , 1^^ la'Sed heart, and a loud apev . ■ l '''^^ ' ^e.^v j?reatlv en- observation tor a lonu t,n "n t /""'T'' "' ^'^" "'^^' dropsy was limited to the er tone n ^'^7^"' ^'^P'^^^'^^'^- ^he a-s one of old nmral dise se w t " T ""' ''^''"^'^ ^'^^' '^'^^ The autopsy show i :;nlu , "n'"'' ""'^^'^ °''^'^^' '--• Perieardiun., an onornnn s v h 'e h ""I '"V' ^'" ''^'^'^''^ a chronic proliferative per o ui ' wi ^0 without valve lesion. splenitis. The case was „nu n ^ l^:-':''''\ ^'"^' ^'-'- •-'-n,onths.urn,:;!;:'L.:::;7;::;::r;;r^^^^ Ma (fiul Ik f,, (■ I lie A lilt; i;aii Pediatric S. (irictv. ii-.tpnia Hot Spi "■W^!t»'^Aft'«BK*-fi«'i H 1 1 ui ?! ill f g t! 3 Osi.ER : Enormous Heart Hypertrophy. Ward G of the Johns Hopkins Hospital from May 14. i^g'' to Doa-inluT «, 1894, a period of more than three and a half years, her a^e on tirst admission being eleven years; at the time of her death, fourteen. Pm'ious History.— There was no history of acute rheumatism or of St. Vitus's dance. She had had measles, scarlet fever, and whooping-cough. On questioning the mother closely about rheumatism, she says that Louisa had at one time growing pains in the legs, and the muscles of the right .irm were once so stiff that she could scarcely use it. The joints, however, were never swollen or tender. Onset of Illness.— About May i, i8qi, she began to have short niss of breath, with swelling of the feet and of the abdomen. Nothing abnormal had been noted before this time. On her fust admission there was orthopnoea, general anasarca, cyanosis, and extreme ascites, so that she was tapped at once, and over three litres of clear fluid were withdrawn. There was enormous hy- pertrophy of the heart, with great bulging of the praecordia. Theie was no thrill, but there was a very loud blowing systolic murmur at the apex, rough in quality, and transmitted to tlie spine. The murmur was heard also at the lower sternum and at its left margin. The pulmonary second sound was accentuated. The child improved a good deal, and the d-dema of the feet disappeared, but the swelling of the abdomen persisted. The spleen could be felt below the costal margin; the liver was en- larged, the edge only one inch from the transverse navel line. The case was regarded as one of mitral valve disease with secondary enlargement of the liver. On the I'lrst admission she remained until August 29th, and improved very much. A few days before leaving the note reads that "the ascites has disap- peared, the heart's action is regular, the pulse 72, and of medium volume. The apex beat is in the sixth space in anterior axillarv line; there is a wide area of heaving impulse as high as the third rib. Tnere is a systolic thrill at the apex, and a loud, musical. systolic murmur which is transmitted to the back, and the pul- monary second sound is intensely accentuated." We had no other idea about the case than that it was one ol mitral insufficiency, though the question came up on several oc- casions whether or not she had in a.ddition adherent pericardium. She was readmitted October 8, 1891, with great shortness of breath and ascites. She was tapped, and nearly three litres Osi.kk: E„o,-n,o„s Heart Hv^, / ., ;'K;iin removed. She wis \- f'^^ l^^'nds .nd leet. Th;c:„.ni nIv" ?'""''^' P^'^^'-^^^'^'rlv in ~^' 'Olid, roLiiih, apex svsf i ' '""' "-"-^ ^'^-'•'-' the same 7-- 'nd..,.,;,^,:;:;:;;-;-Mn,ns„.ttedwe.,to;h: ^'^■"nite murnn.,-. There v .,s ■." ' ''''' '■^'""^''-^ '^'t no ■^'^■mnl rei,non, but no specTildiir. " '""'■'"^"' ''" ^'^^^ 'ower 'H'al.ne casts. Verv 11,1! no e ^ "' ' T f ^""'^^ granular and P^-'-t'cularly with reference to th ':''-: °' *'^^' '^^'■^^ ^'t intervals. ^'Pex beat seemed to have lowenH '°'\ "" "' ^'^^ '^'^^'«- The -^tb space 7 c. n. outsideX :^ppi:' ''''' '^ '^'^ '" tbe sev- Throuirhout the summer of ■No; .h occasions, and the condition e ",in d T '''''"^ '" ''''''' -X';h:r::::;:;^:--:^'--nune.,s..itw^^ loud, musical, systolic murmur whH.' u'^P' '^''^^^^^ ^^y ^• ^'x-lla and back, having at t sc^ ^''■^''''^ throu,.hout the j'cter. Passing upwards an , ^^ Vo" T"'' "^^'"^ ^h^'^" !ost its musical character Tl " s "'' 'P^'"' ^^' '^'-'nm>. feebly at the apex, was inten e v ' °" Z'"'";^' '''^''^' ^^'^ ^eard t--^^Pace. The sounds in « ' '"" ''"^ '" '''' ^'^''''^ '^'^ *'- ;i-t time, just before her\ h ^olT'^ """ ^'^"^- ^^^ ^^^ l^^'t of the sternum, a doubi m ' J,, , ""'"^ '^"'^'''^^'^ ^° ^he behind, as it were, the ac n ul ""f '^' ' ''^' '^''''''^^'' •'-^'^ sternal border th^mr::;::::::;^;-:;" '^^'^^'"^'^^- -r;;^Et^t^;- ^^^^^^^^^ P-l. The She was readnmted o.kS^ : , "fso/ "'?'• continuously in the hnspif,! until h,/, ,^ ' '""^ ''emained During this'entire period si e'^Kth" .""'"'^'^^ ^' '«'^4. fe'ture. Prior to th,s ^llnS^ ^ V^ ;::'f ^'1 ^^^"^'"-^ or four times, fo December 7 hh ' '"\^^'PP'-^d o"'y three was tapped n, fmes m . ' ' '^ ^''*^''' '^^'' ^eath, she on each occasi n We :;!;; T'^' ^^ '"'''^''^ ''^'^^' ^'^fi^erent pericardiu^as 2. .!':!!J" *'' P''°^^'^^"'»y ^^ere was Th of tht lere was systolic retract icfion in the a praecordia, and the upper li well as extreme mitral insuflicien cy. seemed very fixed pex region, marked bulging PPer limit of pulmonary reson ance 4 Osi.er: Enormous Heart Hypcrlropby. Diirin.r these hist two vcars. the condition of the liver in- terested us very greatly. When the abdomen was emptv the organ lornied a visible and actively pulsating tumor niidway between the navel and the costal border; and it is well figured in my lectures on the diagnosis of abdominal tumors. It was smooth, descended with inspiration, and expanded visibly, ts edge was rounded and the whole mass could be grasped in the hand, teeling like a large spleen. The edge passed beneath the ri-rht costal margin about the nipple line, and tar over on the lett costal margin the enlarged spleen could be felt. Grasped in the hand, the pulsation was expansile and forcible, a little later than the cardiac impulse. Early after her admission on this occasion, there was telt toi the first time also a distinct peritoneal friction rub just below the edge of the liver. The condition of the heart did not materially change, except that the area of dullness increased. The loud, intense, apex systolic murmur persisted, and was heard all over the right side of the chest, in the sixth space a little above the nipple, there was a rumbling, echoing sound occupying the entire diastole, and in a limited area this had almost the charac- ters of a presystolic murmur. The first sound was always well heard Along the left sternal margin the soft diastolic murmur already mentioned was well heard. It was not aidibie at the aortic cartilage, but in the third, fourth, and fifth interspaces on the left side. She never had general anasarca after her hrst admission. , ^ . • u There were two additional features of great interest in her case It was noticed on her first admission that the cyanosis of the hands and feet was extreme. This persisted with but little change, no matter what her general condition might be, whether she was suffering with great dyspnoea or whether she was wheeling herself about the ward in a chair, the hands and feet were permanently cyanotic. She became very thin, but the ex- treme lividity without any oedema was a remarkable feature in her case. .• j *u . Then shortly after her last admission, it was noticed that subcutaneous fibroid nodules were developing, and a series ot these appeared about the knuckles, the wrists, and the elbows. As 1 have already mentioned, the primary lesion in this case ^D. Appleton & Co., New York, 1894. he liver in- empty the lor midway well figured IS.* it was visibly. Its asped in the beneath the er on the left •asped in the tie later than t was felt lor ist below the ot materially The loud, leard all over tie above the :cupying the ;t the charac- ; always well tolic murmur tudibie at the ;iterspaces on liter her first nterest in her le cyanosis ot vith but little it be, whether ther she was lands and feet n, but the ex- ible feature in s noticed that nd a series ot 1 the elbows. 3n in this case \V''-^ thought t(, he niiini .c\ ^^y^''-, :ind enon.ou ; X^ '" t'l^' nght eh:,n,hers. Th ' ''yP^''"ophy and dilatation P-'c-dium. and as the p , t ;;r^t^'^^''"'-^ ''• --'^f>-^Unm, diaphragm, t'l^lc-dilatation of ,-..7.. ; Vf^--''''^'''-;'-''^^'-'' of left ven- '-'^'onn- proliferative pcrifoniii ft 1' ,™" ''"^"^'^ ^<^fi^nents~ ^:s~~eirr,os,s of tke /i.v;i!t;; '' f"'"^'^"^'^" a>ui peri^.p,,,,,. "'^^stines. sto,uarl,, .>ut tuJnTjT^''''^''^''" of t1,e spteen . ^^nd hands. >''^^"0~/iho„s nodules about tlw elbozes The body was much e,iiaciated- the l.. ^'tous; the veins we.-e p,-o,nin h, , " "^''^ ' ''»'^' '^"^^'-'•"- '"•'f ='nd legs had d.s.lpp '• ' '/'^' ''^'''^' ''^'^^''^y of the •'"^' there was a p,-o,.i,l^,,; t.ul ^ ^ f "? ^"'^ ^^'^^ended '^upe.-f,c,al, abdominal and tho,-,cL"n '' '"'''"'^^- T^e were subcutaneous fib.oid nodi , . V ' '''^''■'•:P''°'"ine"t. There -ion. rheparietX' l: :^ r: .r^''';'"' ^° ^'^^ ^— - 'n many places cove ed w itl 1^^^^^^^ 'ts^'" ""^'extent was opaque, "'"■ous tissue. The i^ r "■ ^ '^'^^^"'"g^ ^'"^^ threads of opaque and thickened. ^Un2"^7''^''''''''^ ''' ^^^'^°^^' ^"nl^'-ged. The spleen w, ,Wl7 ? '"^' "'' ^'^''^^^'-^'l were not "■■■e.u,a,ly thickeiec^ a,::;^'^^: J^';^ ''''''''^' "^^'^ m consistence, and dark in color liu ^ T ^''"'^ ^'^ ^'^"^^ 6 Osif.r: Enormous Heart Hypertrophy. It w;is much deformed; without clear separation between the ri,i,'ht and left lobes, but the whole organ was enveloped in a thickened, pearly white membrane of from two to five mm. in thickness. The gastro-hepatic omentum was also thickened. From the hilus of the liver thickened bands of fibrous tissue passed with the portal vessels, and in some places the Glissonian sheath was greatly thickened. The liver tissue itself was greatly altered in appearance; the cut surface was dark, almost black, with here and there light areas apparently of fat tissue. The central veins of the lobules were dilated. The length of the liver was 1 5 c. m. ; thickness 6 c. m. ; width lo c. m. The consistence was greatly increased. The hepatic veins were enormously en- larged, and even in the middle of the organ they easily admitted the little finger. The kidneys presented a markedly cyanotic appearance; on section there was much congestion, the consistence was much increased, almost of stony hardness. The mucous membrane of the stomach and intestines was greatly congested. Otherwise it showed no special changes. Thonix.—The heart occupied an enormous space in the front of the chest. The intercostal spaces were dissected out so as to get accurately the limits of the heart m situ. From the mid- sternal line the following w .re the measurements: In the second interspace to the right, 6 c. m.. ; to the left, 8 cm. ; third inter- space to the right, 8 c. m. ; to the left, 1 1 cm.; fourth inter- space to the right, 1 1 c m. ; to the left 15 c. m., so that the total transverse measurement of the heart in the fourth interspace was 26 c. m. (10^ in.). In the sixth interspace the right border of the right auricle is 11 c m. from the median line, and the apex was 14 c. m. (6 in.). The right auricle was enormously large, and (before removal of the heart) measured, in an oblique direc- tion from the tip of the appendix to the orifice of the cava, just above the diaphragm, 14 c. m. (6 in.). The front of the heart was formed almost entirely by the right chambers. The peri- cardial sac was partly obliterated by old adhesions, which were situated particularly over the right ventricle, involving the left ventricle only a short distance beyond the septum. The greater part of the right auricle itself was free and the whole of the posterior surface of the heart. The adhe- sions were composed of strong fibrous bands. The right auricle was enormously distended and filled with partially decol- / ' Os'kr: Euonnoits Heart n . . til art Hypertrophy orized dots. The will- ' endocarciiuM, vv.s opaque ''■!-?'' ' •""'^''^^" "^'^■'<^ "-'' '"id the c^'va trom the auricle o,t s .w r '" ^""^''^■'•' '^^«^'"K intoThe greatly dilated hepatic ve s Ithn' ^ ''"'^^ op^i^n.s ^ ;^ Passed The coronary is w'' l'^" '"^^'^ ''"Ker could the foramuia Thehesu' Were u , V"'" ^"■^'^'^'>' ^l''"<-' "nd ventncle was much dilated ndhr' '^'''^''''- '''''^' ''Kht «••''-" was lar^e; ndmitt^i ^ ^r"'"'^""'- ''""^ '^^^^^ miisxles were thickened and ttTV""''^'- '^'^^ f'^'P'"'v thickened and tlattened. The t ' " ' "'' f^'l^^'^ulae likewise ,^-e a little opaque but no s unT"'^ ""l ''" ^^'^'H^id valv 'omm was closed. The (I In '"• ^'^'-' ■'^^'Pt^'m ventric . -- 8 mm.; the len, ,' :^";" "'^'^ -'" of ri.ht vJ^ ^^ ^l^e. The valve se^..;,; ^^^'J^^^ ^-'"--"7 '.-tery wa^ 'eft ventncle was not nearly 'i '"^' ^'^'^ ^^'t^r. The c- '". ; thickness of the nn ul , w f ''' "^^' '•'^''^^; '"-'-^^-red 8 ments were not shrunken h 1 ' '?'"'"• ''''^^ '"'tral se,.- "-■"-'• The nmral orilic "a l^^'fj'^'^"^- throughout th.t. the point of insertion of the do \ V'"'^ ' h^'"" "ngers. At ments there were a few c Ic ,le ' '"^'""^' ^^ ^'^e n.tral seg- ;;;-cle and the trabecU^ w ^\ ^l^ ^^ , ^"'^ Posterior papi„a^ the left auricle was opaque Z i I '. V'' endocardium of W'.s not specially dilatej. T ! ' ^ f"'^^ ' '''' the cavity itself segments were not specially thicken 'l '^"^ '^''''- ^he which was thickened, and thi 1 '""''^^ ^^e middle one. '--' clilatation as lar^; ' ^"u^^r' rT''' ^' ""'" ^'"'^"^- ;"tery. The aorta i.:;t aboyf /he ".r ^^^' '°°'^ ^^""^^'^ ^^e t^^i-ence; at the end of the arch , - ^"' '' '■ '"• "^ ^"''-•^'ni- ''"g'oma, In other places the iv,'" "^''^ almost like an •he increase of conne t ssu w "": T" '''''^' P^^-'-ed. scribed thick bundles. Tl e Is ? "" ■ '^""^'^' '^"^ "i circum- tncle showed a moderate d^rcT V I ""' ^' ''' ^'^'^^ -""- much more marked than on fh,; "'-/''"f '^^^'^'^^nerat.on, which was Remarli: tion with th -Th on the left side ere are many points of 's case, but / only can refer h great interest in conn r lere to the recurr lec- 8 Oslf.r: Enormous Heart Hypertrophy. iiscites with proliferative peritonitis. The c;.se is ahnost the ex- act counterpart of the one uiuier niv care in i'hiladelphia. Chronic proliferative peritonitis is met with chietly in adults under conditions similar to those which produce cirrhosis of the liver. It has been in my experience a rare disease in childhood; and in the adult the svmptoms are in reality those of atrophic cirrhosis of the liver, and the diagnosis is very rarely made before death. Rosenbach is the only author I can find who suggests the possible connection between adherent pericardium and a chronic peritonitis; and he thinks that the chronic proli'erative process extends along the veins, through the diaphragm, and involves the peritoneum. It is not unlikelv that in the case here reported this sequence may have occurred. Some of the cases of indurative mediastino-pericarditis present a very similar clinical picture (see Harris. Meiiicat C/jroiiute. 189s). Other points of great interest in the cases were : The enormous hypertrophy and dilatation of the heart with only partial pericar- dial adhesions; the clinical picture of mitral valve disease, which most of these cases of adherent pericardium preser ' so soon as the cardiac dilatation becomes excessive; the diastolic murmur along the left sternal margin which was probably associated with in- sufficiency of the valves of the pulmonary artery— Graham Steell's murmur of increased pulmonary tension; the subcutaneous fibroid nodules in a .i.ild who had never had acute arthritis and who had no mitral valve disease; and lastly the remarkable tumor formed by the pulsating liver. I WksT FkaNKI.IN STKHI/r. (Ll. yy ost the ex- hia. ly in adults hosis ot the childhood; ot" atrophic nade before .up;pests the id a chronic ive process involves the L'porled this f indurative picture (see le enormous ■tial pericar- ease, which I soon as the .irmur alon<{ ed with in- ham Steell's jbcutaneous arthritis and kable tumor """""" "" '-i'r^i:!^- M.» ...„, .„„ , ■ly. 1896, Hemi|)le,!ria j,, Tv,,|,„i,| |.-,vcr. HV \VILLrAM OSLER, M.D., Professor or M..lic.i,K., John Ilopk.ns diversity, rw. iiiioro. ^\ i^'f '"''^"''M:<;I.A IX TM. Moil) l'|;\-i.;K. "^- Wir.MA.Mosi MK . M.n I'riilcssoi , '"■ ' "■"■^ -,.,.,,.,„ „ orn.sof paralysis n>o ',^0;;:" "" '''ackhoanl f '!;!: a ter the specific fevers " -^ " ' ^^•''"^ 'luring- a„d varied ,n their svmnf, r' < ■ "" ''•^■> ^''^'V are Ver "afm-e of the local S ' " ->-'"^' varicl/t-u, .^ ,^i SVMJ'Tom.s, I Ileiiiipletjifi. Paralyses during ^S: , after fev- J ^^''aplegia. ers. 1 Diplegia. Monoplegia. [ Local paraly? ses. r.KsroN. !^5is'"'--='rs. I inL-nioirhago ; j;:s^;-"p'-Htis. ( ^'eiiritis. ' \- • . , -Neuritis, .' ''o'io-myelitis ' ^'euritis. ' Neuritis. .' Toxij. ' Myositis, ' ''"essure. We can divide the Phc ai esions, affcctino- ^^ena, sniall-pox, ,S 'A clinical lecture ..irtlu.joh as Hopkins Hospital, Dec. '«95. A uv/j./.u/ os/.r.k. fever, the palienl may become hemiplegic at the height of the disease, a condition which may be preceded by convulsions. In reviewing a large number of cases c)f hemiplegia, particularly in children, one meets with manv instances in which the paralysis has developed during the course of one or other of the infectious dis- eases T thus, of the one hundred and twenty cases which I analyzed from the Infirmary for Nervous Diseases, Philadelphia, and the Institution for Feeble-Mmded Children, IClwvn, there were sixteen with this history. The anatomical lesion in these cases is not known in all instances. In a certain number, ha^miorrhage has been found ; in others, thrombosis of the 'cerebral arteries, or of the meningeal veins; while an acute encephalitis mav exist. _ You will find an exhaustive consideration of the whole question in the address by Dr. J. J. Putnam before the Third Congress of American Physicians and Sur- .reons, Dublished in Vol. III. of the Tran.sactions. "^ 1 have recently given in full detail our experience during the past six years of paralysis during and after typhoid fever." Of the nine instances under observation hve were monoplegias, or local paralysis, and in four all the extremitTes were involved— diplegia. In every one of these cases the lesion seems to have been a neuritis. You will notice that I have placed among the lesions causing local paralysis, myositis. I have done so because we have had several instances in which the disabilitv was associated with great pain in the muscles, with positive swelling, and great tenderness on pressure as though the trouble was within the muscle itself. The two cases which I shall first show you illustrate one of the most serious of the accidents of typhoid fever. C\^V.l. -Protacti'ddiiack of typlioid fever ; in the tent It week, zv/iile t lie fever still /persisted, sudden convulsions ; Jtemi- f^lcoiiUi^'ith aphasia. 'Annie F., aged ;, admitted to the medical wards October 3. 1S95, complaining of inability to use the right There is nothing of note in the family history. With the exception of measles at four, she has been unusually strong and well ; and has always been a very bright, intelligent child. 'i:i ll ■Studies in Typhoid I-ever, Johns Hopkins Hospital Reports, Vol. V. f'f'-yri 'I. /■:(,•/ tin ]) / rx "'.'"^- thu first yy/'//o//) F/aEA'. ity and patient 1 WL-e, "g of jj-iin (ipistax 'ad imich •1 A nia! had feve to be d '"• *'" the 6th sh P'-il of the ■so with head; '" the a!.<] aiu a slow 1" ^'ontiiuiino- f, "men, fe '"■"^'■^'^•t^'d attaek ',"" "'"•■c^- than ten w ^'went to bed ver and diaiTh j""'-se/ii \(_' L'lie and del bil- the d •<^inp]ain- '»-'a. Sh( seized with V ole' ""''' '^""day, J thehe,-w1 n,, .^"^'-""vulsiop u ■eeks. SI iarr]](x>a and H> seemed the head, th '^'he attaek noon the m ^ riyht L-aine UISK '"in and 1( /\"V .^- when she whieh were Was "venient on in tJie SI ^'xion and ext •"^ cease iiKjrnin ^^ was nn ^'cnfined t( ■<1 in tile ^--days/^rrS7;"::'\^'-^'--nnt; R. and in the aft lead ' <-'"nscioiij er- "ompletely j arm or I hem eg. ;^aralvze( " "''ticed that th 'Hit movement' "■' arm for nearh- and she iplegia th T lie f; and tl le child e riu-ht side w; ^'-'c was also '■tiinained ^l^ was total loss of wasnnable t.; mov :is involved. W proved, bt.t verx- tirst noticed in th 4'hasie for th th tht P^^wer of speeeh slowlv Vol sion. She has has gradually b t-' right leg six «even weeks. SI untarv mov never i l^^ weeks after th ements w le im- ere ained L' C(;nvul -•-' "^-.^aineu power in fi, -■-->^iivi '^'«"" to talk aL..!in 'm"^^?.^™'^tu si '::ii:^^^'.^-^^tn,:]z^f^\''^-^^^h 'le plegia, whi(-h li she walked into th be--- ind ^'•'^ partially ffait charaeteristic of'h reeovere ing dragged, witl that she h.,. the sole of tl >^ room that she 1 ^'ou IS now, emi- notie ■ed as IS worn ' ^l-wl„;;?;ff^''^-nghtleg ^'^vay entirelv h!,*^'^.:..,^"" ^<^^, too. g'ots al Y, ong vet iL' right shoe. Cr t'l'ely the onte ou notiee as' I y well and Ppled as "" -see, too r portion of en wh tended fr left th «i?e attempts to j« able to ni ^^ i«. yet sh( V'^\' this eoin int " quite bri; ^n the sid pick it up, th arm and side fo ^^^ and semi-ile.xed e 1 th ight but kly. 'irena, that arm is ex. l^">-^rwi;^,';r;;;!;;";;!,.-si!-^; •'^iie })uts the to th Sh '■^ side, the wrist Hexed pose the right e coin with th( e e can voluntarily i\ can lift the'h; I bo w ex and th e fin extension in th '"d extend" th ,,'irm is held elo.se Rcrs also Hexed '^^\^'M\iG head, b finders, and of^'^S"":'.^"?-, power Of 'U( th e arm at the pJetely lost. Wh foi Jjrasping with the hand an object, th( y exertif extension in tl are almost eo power of le side, but thei condition of the f-.^ hrst .saw her early i en niakintr an 'e are no irreuid ice ha Id 'r movement m- of t! I bett le muscle! 11 one other n Oct •■^ unproved out from the •'^ in it. The her, but th ^■er}' much sin ere IS still par ce we 'esis er. <>n notii ;;^PecJ too, she has ,ot ■e now : hat si le can u; ve'-'- m„(,], iiie olijects cor- 1 I 6 \V 11. 1. 1 AM OSLER. rcctly, recognizes a knife, a watch, and a cent, but is con- fused somewhat between a cent-piece and a live-cent niece. Her sister tells us that in the inalter of sneaking the improvement has been quite rapid of late, and, indeed, she savs a great many more words now than she did when she came under observation early in the session. She looks also bright and intelligent, and evidently understands what is said to her. Hrieily, then, tins child is suffering with hemiplegia which followed a convulsion in the latter part of an attack of tvphoid fever. vShe is recovering the power ot sneech and the paralysis of the face and of the leg is better, but the arm remains (|uite helpless and is becom- ing spastic. , , As not infrequently happens, when one unusual case appears, another is certain to follow, and I am able to show you here a second instance of hemiplegia deve op- ing during typhoid fever in a man who has just applied for admission to the hospital. . ,r , p C.\sK U.—Scvcrc attack of typhoid fever in March, 16(^5 ; at the end of the second wck, without convnhwn, slii^ht hcmi- hlcvia, which /persists. ■.. a . m W. H. B., aged 25, clergyman, was admitted to the hospital November 30, complaining of paralysis of the left arm and leg. ,-,,.•. ^ , ,,11 His family historv is good. Patient was not at al strong as a child ; but was very well as a young man and whileVi""'^^ii"g l^i'^ theological studies. On March 10, 1895, he went to bed with headache, fever, and diarrhea. Gradually all the features of a very severe attack of typhoid fever developed, with much delirium. 111 On I^Iarch 24th the paralysis developed suddenly without convulsions. There was also, Dr R. k. Kneass informs me. no aggravati.m of the delirium follow- ing the attack. . . , He had no difficulty in speaking, there was no trou- ble with either rectum or bladder. He had a very pro- tracted convalescence. Throughout the summer there wasaoradual improvement, so that about July ist he was able to stand and began to walk. Ihe power over the Ic"- muscles has returned more rapidly than m those ofthe'"arm. He has never regained any power in the fniP-ers. There has been a steady gam m weight since his illness. This is the history of the^ ca.se as^obamed i)v Dr. Thomas who first saw him, and from Dr. R. K. '"■'K'nal ^e«Pect. Tlie left arn 1 '", '>'^^-^ '-»'•« "ormal n e .e,; aim are very thi„. ,.,,„i t],,> >,^';- ^J^^' niusc'es r,f the left lejr ean br Trv..,! f. , '"^^'"■'^■^ei are wasted 'n extended at ^^ ''"''^'y ''^ ^''^ tliio-h an n i "" tended sli;^- . '^ '^^^e feet ean ^>e S vc^f and T'' AI;n.n.entsofeversionaJ-.t"rsf;:;; An interestinrr featnn- n < • oceurrenee c.f Nvide'^''^^''^ ^^ er fifteen vears of aoe hL / 'V^-''' '" ^''^''^^ren un- the data were -iven u'e ti m f "'■^^^" ^''''■^^^'^ '" ^vhich week in one cr^se, du ^V' V\hi"ri"'i '" ^'^^ «^^°"S during the fourth week in t J -L ^^'^^^^'k m six cases, cenee in fi,.. ^ases TI " - o^..""- f ' '^"""- '-^""vales- twelve oft !(■ SlXt een cases i .I'iftht side w whieh th as paralv^ed e sid m e was niei n t ,.ii i 1 8 WILLIAM OSIER. lioiu'.l. Aphusi . accompanied the hemiplegia in twelve inslatu'cs, Of the seventeen collected cases only two died, and in both of these a thrombus was present in the middle cerebral artery. Probably this is the usual lesion in ivplioid fever, and, as you know, in this perhaps more than in any other disease, there is a tendency to Ihe formation of' thrombi in the arteries, lindocarditis is so rare that hemiplegia from embolism must be very uncommon." We had tliis year a sad illustration of the occurrence of lhrond)ous formation in the cerebral arteries in ty- phoid fever. The case is given in full in our recently issued "Studies .n Typhoid Fever," but I give here a brief abstract since it' bears directly upon the question. The patient was a young man, aged 22, of good fam- ily hislorv, who was admitted April 24. 1S95, on the fourth day of an illness, in which he had headache, pam, and fever. On admission the temperature was 104", but sank on the ■■ dlowing morning to 100.7 . l''"i" ^^^^ f<^^- lowing three or four days the temperature range did not reacli the bathing point. 102.5°. On the 27th rose- spots were seen, and the spleen was palpable. On the morning of the 28th the temperature was 99.3 and m evening 100°, and he seemed to be doing well in every respect. At noon on the 29th, as we were making the visit in the wards, Dr. Thayer was hurriedly called, and he found llie patient in .some distress, complaining of un easv feelings in the head. The pupils were dilated, and in a few minutes he had a short, sharp, general, clonic convulsion, beginning almost simultaneously in both arms. The eyes showed marked conjugate deviation to tlu left and upwards, the head also being drawn some- what to the left. For about an hour the convulsions were re[)eated at short intervals. Morphia was given liypodcrmicallv, and chloroform administered. They tlien became less intense, and finally cea.sed altogether for several hours. During the convulsions there was profound unconsciousness, and in the severer ones great embarrassment of the respiration, .so that he became (|uite livid. In the interval the patient appeared to be conscious, and spoke to those about him, and seemed to unc'.crstand questions, though he had a confused, fright- ened look. At 5 P. M., the convulsions recurred with great severity, and in spite of inhalations of chloroform. '"'John Hopkins Hospital Reports," Vol. V., page 465. liey ivciirrcl a, ,„,,,,,„, . . "^"'.. „ mmsmmB »f.->nce corrotoK ,. •'■'to'";,:'"'-'""'' ■•>"" "'^' br hM^' hate neighborhood of tlKhr •'\''''^^^^"^'^> i" the im,^i areas extend sometime for d""'"'"' ^'^■«''^^^'«- l^iese ■'^'.s,. as likewise the Svlvy'^'T '"''' ^'^^ ^'-^m thrombn traceable i„t,ahc bran? "'r,';"' ''■■"* "■■''""W rae fenor external frond'rfi '^'"V S^-nerallv. Thel " anterior perforated i;^^^;^^^ f^ arteries '^^, . "On seetion of thi bAin ti , , '^'^ *'"'" thrombi, mieal lesions. The ven rVl/ '"^^'^^ "^' '^^oss anato ''ct:ituresofty;,;;::y\;:;::^----tdiiau.d^ -^- Kiew Horn different or- ?ans. There two',;!;i^;^"7;-iS;ty "f ,.0^00. ,ecov gain eompletelv th 1^''"' ;^''"- in all proba])iI en- in these power uf speeeh. 1 n both nty. re- eases TO U/f./.lAM OS/./'.h'. I H!l l! I 1 there will be some additional improvement in walking. In the matter of prognosis in recent cases, it is worth noting that of fourteen of the cases collected by Haw- kins, in which the result is given, nine recovered com- ])lctelv. , • ^1 i- ^„ These upper motor segment paralyses m the fevers are fortunately exceptional and rare. In a much larger series of cases the lower motor segment is involved and the picture is of a spinal or neuntic paral> iS. 1 he lesion may be either central, involving the grey matter of the cord to a greater or less extent, or peripheral, involving the nerves oi the extremities, more rarely those of Uie eve and of the palate. _ Gowers states that anterior \w\\o myelitis is more frequently secondarv to typhoid fever than to any other acute specific disease, adding, however, that when the onset is subacute the symptoms are no doubt due in many cases to a multiple neuritis. I he very full report .riven by Bury of cases of paralysis following typhoid fever U" the monograph by Ross and Bury on peri- pheral neuritis), does not, however, bear out this state- ment In a great majority of all the cases there noted the condition had been evidently a peripheral neuritis. It is stated that some cases have presented the picture of an acute a,sccnding paralysis, and death has followed in a few days ; but it may be that even in these instances with the type of Landry's paralysis the lesion is a peri- pheral neuritis. The two cases of ascending myelitis described by Raymond (Revue de Medicine, 1S85), both of which showed marked changes in sensation, as well as progressive muscular debility, and which recov- ered rapidly, would nowadays certainly be regarded as neuriti.s There is less doubt about certain cases of monoplegia and of local paralysis; as m the case re- ported bv Shore (St. Bartholomews Hospital Re- ports Vol.'xxiii), in which there was acute myelitis of the antei-ior cornua from the third to the eighth cervical nerves. . ^ , 4.1 ■„ i For the purpose of comparison I show you a tuiia case illustrating the neuritic form of paralysis m typhoid fever. From his general appearance you can easily see that this patient has been through a severe ordeal He has been in the private ward for exactly two months, and is now, as he would express it, as long and lank and brown as the Ancient Manner. He is, however, convalescent, and has consented to come II Wore ,o„ .„.,„, „^;;-'"™'- --"«■. „ I Will first reid .- ,• "^'^-^"^ed us great abdomen. "= -"■^ "-' ••■ «o„l ^eafof Sn^V,'iU;; ',;";,:I^ .'-'n admission fh^ f . '" uit quite well marked ^n,/^^^"'-es of typhoid fever elbow or shoulder, o? of f^f '"'"'• ^"^v^.,,v,.. ,,, ,^,^ ^^^._^^^^^ 001 M'ifli .losos of fVon, ] ,„ ., , ::;^ V"'"v''"" '•■-'•■-' .t:'?'''r'r''''' '''^^■•'-'^- ' " '• if .■or.a.nly |„s ,,0 ..,11., ,„„ ' ' '^ ^'""■*;"^^l'Iy ^"ti.-^fa.torv ,,„. |„. ;• 7' '"' '■'"•••^ "I .1... .In..|. .i . " '■-^•'••'•ilitv of tlH. I.^„.,,. ;;: ^:' ;;■ " ;''- «--. . ,.",";,::' ;;', '"- -" :. .1....: ™"-."»™h, :;:;,.;;■'■'■ "; '"'■-^■""'.:r",;;t"":": ::'■■""' '^^- ^"'; '":;:" r,,;;!:;'^- '"7; -«-'""^.. i :;:;;:; ^-'<-. of: 8o,no patio,,,. :.,.„. ,/t^.3^^' ^'l':'"^ '""- " ^lay, J,.s b.,„„ , -, o„s a,.t,..ities. Tl.,.,,, oM:; ,::':;;;;; '■- '--> .•ooon„„on,K,.M,' ''^^N'b ao:a„,st ,t. A, :tl,„ sa,„o,i„, , '"' ""' ''<■ w-Vhod vo,-v' pa ie.u ,s a chu,.o,- that .houl.l t Zl l' '""''"'" •^^' "" "l'-"'-ont..,. '^ r;'': --• "-v..v,.,vas I haCe ,';:v""^'^':"'''^'-- ^■^P«-Hy h. i. i^ ^^«•l-8a„ a„tho,-ity tha., r.a,,.e„ll^^ 1 ^ " "' ^'" ""•*' »^" a»ou,-i.s,„ -•!■ treatjne,.,. The sy,..pto, a , :' ^" '''\ '— ' '--ofit ii. m "'f J?ene,-al co„ditio„ of the natie,, '""■^' ''^' "^"'^''-l "speeiallv to '•'""^^vhioh oan be .x^hY-Ved h .^""''''"^''^'"'''^ (''••^''''1^ tuber ,,] ; -^- Who,, the he,;,o.^.a,e ^ : : t" ' "" • "f ' "^^"'^' -"' ^ '-"- ^^ «ac „,to a bro,.ehial tube, tl,e 4 ^ ' " '" ''" '""J"""'" "^ -' ""eu- '-ires, dcpe„diu, upou lesious of b o ^ ^ ' T '?r""" '"''^"^ '-»-- -«;"i>ns fo tl,e rules ostablisl,ed i\,Z T '^ ' ""' '""•^^' '""'^^ ^o Seated T" '■IosI„.-r t],is el,aVter I •. ' ,f' """^ "^ J.<.,„orrha,.e. •'"• present ti,i,e |">iitaiieoi,,« cure have I cases „f euro have Ik «''•" a ease of tl '<'(•» ob,scrvcd, I am t ■ei. a very ■^'poi'tol, and eases of :iii< '"i-aeie aueurisu, vuivd. I \t; I'w to confess that I | ave „ever ;'-' \ ff-.k, i^eon able to prolo.ig mlTi^::'''''':^''''' ""'•''^^■-'' ^ ' ^"^ ^ '"^^^' "«t obseiTod auything approximating a cur# n C /-- X X ■.I :! ^ fj I DISEASES OF THE BLOOD AND THE DUCTLESS (;lands. liY WILLI a:m oslkr. The Anemias. THKORF.TICAM-Y tlic iuifiuias (lopt'iid upon oitlicr iiuTOJiscd ronsiiinptinn or .liminislicd prodiicticm of the l)loo(U'lcinents, {■onned or imformcl ; l.ut it is pra(!ti<'iUlv impossible to niako a division of the eases into those with increased henioivsis and those with defeetive heinoKcnosis. Not infrequently thi> two conditions coexist. Of the patholofiv of certain ..f the more important forms of anemia we are still iKii<»nint. For the purposes of this section I shall consider— (1) Anemia ironi hemorrhage; (2) The secondary or symptomatic anemias; and (.3) The primary or essential anemias. 1. AnKMIA IMtOM TlKMOIUUIArrE. Small hemorrhages, such as an occasional bleeding from the nose, make n.. impression whatever on the general conditicm. Frecpiently repeated, howevci-. they may lead to very prononneed anemia, as, for example, in eases of nterinr niyomata, or of hemorrhoids, or of aidisi:asi:s oi 'Hi: Jii.iKi /> .\.\f> '/•///,; '""' ''l''l f'..r (vv.mIj, IXrTl.Lss (ti..x V vs and on udn /'.v. !)()({ "^^'"" I" 111.' lln-,,i,,.,I ""• ""iK'ali.ms ill ;uK,,,|.MV 1 '"' •■••^"""i"n. "'""""'"■' ••■''■•'^-■•"v.fi.s,, „...,.„„,, „,,.,. , ____^ ' '"IK NIC li|(.,.(||,|,r . "!<►? 0,(KKl,l»Kl Mf oml, to replace, it ivor m cvtTv way l.l,„„l-f , It nece.«sa,y, tlio voliuiic of It IK'IIIOIT, i« iinpo,ssibIe t„ . likely to come into gen<>ral use. Two or three well-made glass syringes, of a capacity of 20 or 25 c.cm. each, are provided with sharp hypodermic needles, united by a short piece of rubber tubing. The instruments must all be carcfnllv sterilized, and tlie skin of the arm of both the giver and the receiver of the blood properly disinfected. A couple of assistants arc neces- sary, and a snj)ply of hot sterilized water and hot sterilized salt-solution. The .svrino-cs and needles are kept in the liot sterilized salt-solution. The blood is drawn with a syringe directly from the median vein of the givor, without anv preliminary incision. It is usually ncfcessary to apply a bandage on the upper arm in order to get the vein sufficiently distended. AVhen the syringe is nearly full an assistant inserts a needle into the median vein of the receiver, and the blood withdrawn from the giver is injected directly through thr needle. With instruments in proper order am' everything prepared systemat- ically there is very little risk of the blood clotting; and Von Ziemsscn s;iy- that from 200 to 300 c.cm. of blood can 1 . injected in tiiis way in the cour.-i' of fifteen minutes. If for any reason it should be thought advisable not tn transfuse into the vein directly, lo or 20 c.cm. of blood, withdrawn in the way described, may be injected subcutaneously. A means that has supplanted in great measure the transfusion of blood is the use of sterilized saline solutions. The tcehn>(' is very simple : Th" warm .solution is poured cipher into a funnel or into the bag of a foiintaiii- svringc, i)rovided M'ith rubber tubing of jnoper length, to which is atta-e the fluid can be rcadilv dill'tised Ijencath the ,-kiii. if m!ccssar\' the salt-solution mav I)c dircctlv infused into a vein. The nm-t common solution is the common sterilized salt-solution of 0.75 jier cent. foil owing; .solution has been iiukIi used i'or the subcutaneous infusion in rics. postiuv, with ion lA' opium )t' pulmoiiarv ) of vos.st'ls — ies omj)loy('(l jlly discussed H't the second 10 circuliUinii e sequeuce of be practised, blood for tlie t sutliee, urti- rinated blood c.cm. may be a chill, wliii'li transfusion i.- lass syring(!s, ) hypodennir cuts nuist all ^ivcr and the its arc ueccs- olution. The 1. The blo.Ml fiver, without ndage on the n the syringe f the receiver, through till' ired systemat- /^iemsscn say- in the course i>-isablc not fn .drawn iu the ision of bloiiil simple : The jf a fonntain- :'h is attached the tlaids, I'.iid rim in slowly. icalh the .-kill. n. The iiii-t K'r cent. Tlie IS infusion in i'l AVI I Slip, and stai'v J>arti Stollli iiiaiii red IK iiiiiiil 'Irani clironi ('■) prof; bers ( (•f tl m 111 a ^v< t if "lis, ,■; fev eis liiit, as 1 ■"^ypliili.. '•"th the fi'atii ro. Of tl iiiul in c liowover, i'<'si.st.s trc iiii iiishiiii aiii'iiiia as IS Mot Ilea 111 all ;'i'<'iiiia tJi; J>ISh\USE^ or yy^/. nuM>D Ay„ Tin,' l^ViTLKss a •■'7'"'- '"■-.".■.I » ,,„»,„. , '"^« ^''..I.VAV. WS "■'■" "■'■•». ™^[ -• -''- ,;;;:';;";;;: ;'■'.■■■''; '«■ i.>-.i .. ,; , , : ;;,, ";■ "•ill I.,. „„,i,„| i„ ,i„, ,, . '"' l"-l'a.v,ii.„„ „)■ i,,,„ „/-'"'• " li'« "" a •> v.. -• 0|-.( ( )\ 1, 1 I,,. 4 (") Anemia fro.« inanitio '""•"^- .'■ 'V ; ■■;■'■""■'"•'"' "■'"' »"-i.i" ::"' '" •■'"■"""■■I.-I..1.A..S boi-s of tl,,o„,,,„,,,|,, . "' ""=. '>'»< <'Itl..T ,l<.s,„,W„„ ,.,„;:■ """""" :■'■ ""» '>•■- <» ..-o.:;.; ":."■;::,"■;■"■ i-i"--.. ■ ii. ?. ;;;?;;;:'»- "' " ""k <»■ ove„ lo,, „„„;„ „';'■''" •" "« *,. .!.<. .*■„„ of,"-'""' -^:r::tt*;;,;:;--:;n::r;;f,::tr~ "f*"'"'" °f l«ul-,,„c™« in „,,„,, ""'7 ""'' ""■"• ' ''»" .."■.' ; ' II all vii>iv '""■'1 tJiat aro of "'o t'oiiiinoii. 'S of sown y'n.otoinatic aiienila t\ '"■' "»''•«•>">•, or i.]>o..,,I,oras ""''*'''^''"<^^N ^"••ii as b,eathl, '•'■'•' •"•^' feit'MVs oth,,, tl le«"^^N jmlpitation of the j laii t] le loart i^ M 11 i I til I ;i im AX AMERICAN TEXT-BOOK OF TIIERAPEUTJCS. on .■xorti.m, tet'lin-.s of vorlig.. ..r faintnehs nmisoa, somotimos vomiting, -r prulunH and tr„nl,leson... .iyspepsia. Small traces of albumin m tho urun, and a tew tube-easts, arc almost •■oi.Mant aoonipanimente of anemia ot ■•^■•n niclimn grade, and slight fever is n..t at all uncommon. _ Treatment of the Secondary Anemias.— In every cas. it is most import- •uit to ^ I'ving in tlte open air, with good foo.l, will ranidlv brin- about a norn.al h]M,<^conditi<.n. The same good residts are seen in the'anemkt fbllowiug prohmged lactation. Even in cities very nntch can be done. Instead of remaining in a close room all day, the window shoul be .pen and the patient suitably covered, or when possible the patient shou.l be xvl-.eelcl ui.on a balc(»ny. In eases of chronic illness there is still too mne than one in which the o. oohjor.t.s and fats predominate. Tea and coffee should be used in moderation. ncimc 11. a- a ru le. without stimulants of any kind. Whei j)atients do we thlimi, !:■ ft "I gWJH P jmuM.ii i 1 4 I n>r.,f,. I '' ■^"'' ''!<■ iiiiJdc.r 1...,, . '^ " '" '"f" }.">0(1 form. It ,«""•"■■■' p"Tn.l,;r ';;,;'■,';:: "'■'" '•» pi"- (-'" , ^o ',;'"'t';:i - ""' iiatiinil iron-water ;;7-t part to „.e n.!;,o .,' ' j"' ."r "^'-^ '-«'! cm." ^ '-■•'-'•e aoici, and tlu- vain, o/ .n ., "" '■ " ''"''''- ••'""^-' -ith f !^ -.ne of tins carbonic an-d is noJ n I /^^";"/''-" "-^'to.'s arc o.vportoc "<■ l-ottld waters to a .leposi „ ^ ■ ^,^^^' ""' ^'"^ - a ,reat tende cv „ :'"^'-ac'ts greatly in.,, the valne o in ,!"'"" '" ^''^ ^-•"' '^^^ oxid, mIuV "•"" :^ -ally present a. C^,!^';^'^' ^^"^^^ ^'^ ^''-' -uree.'' The ""- ""1-ant iron-spas are 8ei. .Jd t, ^ ^l,;;;;^' ^^^ P-l-tions. Th: ,. . r, ,. ' ^' ''^'^"^^-""' I^'nonl, i., Europe. '*• iHi-: Prim \i{v ^t. i^ '""•', 'ZZou will*:;':;;:;;:!' «;7;''* - -...^ fe,„„„ ,„„ ,, . # <»l'«lcs. , '"""i"ll«-'l«Lioglol,i„oftl,- imlivi.iuai « I I {»()8 A A- ami:ri(.\.\ Ti:xr-in >u njt' TUMUAI'ErTK 'S. hi: Wliile tlie twsciitial ' \iial functions is shown by its onset in joun^r fbnialos Ixtwccn tlic aj^rs of fomtmi and twenty. Tlio atUction is rare ia males. Hereditary intlnenees are met with in a few cases, and it is stated tiiat (he ehihh-en of llnnilies in wliieii tnbereulosis is preval-vl • , ve likely to lurome elilorotie. The disease is most common in cit\-l)red girLs, particularly in those wh.> live sedentary lives, and whose work or position doew not enable them to have |>lenty of out-of-door exercise. In dispensary practice the eases are most numerous in se^nn^'-girls and factory-operatives, who work in cl()>e, ill-ventilated, hadlv litrl led rooms, who hav.' long hours, and wIk.sc diet is in- suilicient and imperlecily prepared. The disease, however, is common enough in well-to-do families. " There is a dost; relationship between tiie disease and menstrual disturbance. It often occurs early in girls in whom the menses have a|)peared prematurely. Other cases are associated with a late development of pubertv. Scanty menstruation or total amenorrhea is the most constant eon- comiUuit. Cases with menorrhagia are nmch le.s.s freque it. Blonds are more commonly the subject of the disease than brunets. From the frequeni associa- tion of dyspepsia" and constipation with the disease, an inti -tinai origin has been sought, and >n- Andrew v lark particularly has advocated the view that it results from the absori)tion of toxic products from the bowel---a copremia. Ill this country Forchheimer has strongly advocated the same view. On the other hand, a primary nervous ori>:in is claimed by some writers, \s ho base their opinion upon the development of the di-'iise after a sudden shock or a violent emotion, such as disappointment in love ; and (li nervous factor is one that has often to be tJiken into acc( > 'it. In (crtain i -tances the entire vas- cular system has been found abiiorm,.!ly small (a condition that N'irchow ha> described as liypoi)lasia), with imperfect development of the generative organs. The symptoms of the disease are th-.'s^' ;)f anemia, with one or two addi- tional features, of which the retention of the panniculus an/v^...vAw nr rn, n,on„ ,,-„ , /V/A/>rr/y.AXsw,7....V/.s' ;„,., T'"'' ''■"'''•'' ''-■••''^- wn.^.^.^l^.^^^^^^7^ '•' '■•■IK. ../■ t\\v i"T .■••Ml. ri,,-,^ >i:i"ii \iiii:i; ''''=HS^^^^^ '"•'•""•"•"■'^ ""<'->ia, in wl,i,.|, tl„, ,.i„, ""<■ ''asc f|„> oli,r,„.vt) 'lj|'l-'r Villi.,. i„ ]„.„m.rlo| "■'• ;'""t. oi- homoglobi,. The,.,,! <;"".•! was pn.foiHul— 1 or)3 ,000 red minibi lorl. "'' "'"^^'"g '" ^h« 63 ca.es studied b^ -,.'-'<^,wu red corpus, ■.«s cells w,.re only sliojitj i>iii is increased. Ii >n"i«t'los, wit], ]7.,r] TJi y increased in fiyr .S4G7 to the cnhi, niiJIi I 910 .l.V AMKRIVAN TEXT-BOOK OF Til HliA PFATICS. .11 i| ■\h. h ' 11 „n-tcr— /. r. 1 (•<)l(>rl»->s to 408 ml corpiL-c'lc.-. One nisc with over Xo per ('I'lit. of reil globules imcl only ;35 per eeiil. (jf iiemoglohin presented the clinical aspect of a profound anemia. The treatment of chlorosis is simple, and in the large majority of cases exceedin.dv satisfactoiA. In protracted and >evere cases, particularly when MAU II. ATI Ul,. __-„ M.W. — , zr io z s i" // /¥ /? 20 Z3 lb 29 Z 5 8 // /* '7 IQ 23 =- . ~~~" ■"■ — — —^ 1 ' ' 11(W .... lOCV't 5,000,000 /i 90r. / — = — — «— 1-^ *K 4,000,000 / / IW, / — r- / eO'S 3,000,0(K1 **" ,-^ .•- p*'- 50< — .^ f 6,00<) 4,000 .:'. — — ^ rrr ^ -r. — ... — ... — .... — ■-- — — .... ,_. ,/ 2,0iKi ~ 1 4- - Fig ■!! -CiM. ul- .•l.l.n'uM. «ith nuirk.,1 „li-oohrnmoinia: tlu- rurvo « ro,,r.-s,-nts the m.mb..r of rort .-r- punch's ; Mho ,K.r,..nt«go of l.o.uoglobiu ; o, the nun,!,.,- of .olorU.HS corpuscles ; ,^ ,/, the mean >,o,- mill number of colorless corpuscles. there has been swelling of the feet and much breathlessncss, it is best to con- fine the patient to bed lor a couple of weeks. As a rule, this is not nece.s.sary ; and the patient should bo in the fresh air as mudi as possible, but not takmu much exercise. Among the poorer classes, however, we often have to tivai ca,ses in faetorv-girls who are unable to give up work, but even in these the results of treatment are usually quite brilliant. The three important points m the treatment are correction of errors in diet aixl digestion, regulation of tlir bowels, and tiie administration (jf iron. The in|)(> idp; to ll le ^-IK'Cl -•t f, orl I. T, in ell Jon "lMfi|lll.« It MOMS, il t'(.([ ly-es .^ J>J-si:asi:s ^'•' yv/A- nr^ •St nil (.(I t OOD Axn nu-UCCTL ord " '"y -tialrnis til ESS (!L ■ ■■ •' ^ '••*liMi l-^7),s■ f»!i "miT (SISOS. •'""'I'lt'C' iniifilitv of Ji onie oases ,milp| J>in'.iiiitivi' 1 '''llC(llc> I,, f_. II IL- ■salts wiJI ii.snall ""• is ai III ( Tl •*iilli(,'( ■'^iit tliC . Jaiid's ,,iIK, J aiiioiii.' tlifsc / ."•'■iicral oj.iiii on ^ h ' .U'lvcn bv X las "I' years ;| OlTi Sll Pot; 1 At first Ipl issii i.arl Ti-afracaiitli., oiiati,- >*'-\- j)i a^i .'is'i O'i.) lis. 1- s- lit It. pil. iiiav I luereascd uuti >^' given three t ondorso the foil J tlii-eo pill IIIH >* a dav are tal pills o.xcol all other i ""•"ig .stateiiirnt ,,,• x^- en t\ '"'d then the d ^^^iy satisfic wjiial j-esiilt <'''rii,'"le n.e of oti lave ]•( py ran he ad minister "'"y "' lilaiidV pill "y gave d KT rei'i peat- oses (,i I"'s obtained ^•fi'y rarely hapj,ens tl " 111 verv |j ■aiiiiot he '••I'"" size; |„„ J .^, irii'e dose,. -'irpassed, so and tlK" reduced tl iron le new onrai 'ill any oth,.,- f ^^■"hout disti sinij)|y he,.., Use sonietiine,' orin of aoTee 'Jpniion, however, of game preparations of iiearh- so efi men who 1,;,^ wJio have I leaeioiis as tl iron e llM'i •y'ter with del have no e.\ iron is needed. Tl essin^r the patient. leate st tl either the dia^r >eeii uitihv th le iiioi-j aiiie eon staiK ^oi 1 point. j:iio.si> or tlie treat previous care of leiii pound perien(.(.. '/" M.eiiis to he ti^.^^ ,j le earhoiiate oiiiaeh>, l,„t with 'e .ireiieral "■y are not "'eeiiio- ! OO o npoiiiids as h,.,.f f'en the pj, '<> t le negleet of the okh \viiie, and ir nieiit of old -i''i.'in ha> | praetitioiiers, J atients -ay that "11, or some of tl ><'<'n playii l'"ip/er, and f '" "nsettleet fbrth hh mlt^k ge ' th "■en niiieh di.: '■"•y- whieh. I eiissi »0WI1 L,li,i,m-h^ he J, ■-'ee, in tl •I, and IS le recently P 1. Tl revious r)hservations | 'as not modified, is t| III.S le inor. Tl <'omains onlv 10 salts of "'"n promote the f eonelnsion., p,.,,!,.,!,!, "rinafion of I, orL'aiiie f It ij>}>''ars /( ^i""s, and i.s „o, foriii-^ of j ' nie that the ( r'ili "■ ! now eeoneih's all lhr w ■ee eoiielii- e 111 {•reparations of some way pro.oeted f,,,,,, ,] e 11111-1 as^iini.. that th iron. ilphid of eeonipositi,,|| i„ aniiuoniiiiu ■Il li il !)12 .I.V .l,l//;A-/r.|.V TEXT-nOUK OF THERAPEUTICS. uraduallv sonaralr> tl.c iron tV.mi tho or^nmic .■...npniUKl of iron. Now, .lUalin,.". .biuations nf sulphur a.r also found in ti.e intestine, ospmully n, ,li...s,iv.. .li>tnrl.an.v, ul.icli is invarial.ly on. ..f tho >ymptoms ot ehloros.s. II inoroani. .-on.ponn.ls of iron a.v pn ^ ..t, they will at ov..v fix thr sulplu.r „f thr imsalinc Milphids, before it .'an art upou the organic eonipomuls „t inai. The laiter are ihus preserved from decomposition, and are absorbed. - I, appear, that in chlorosis the amount of gastric juice secreted is msut- ,i,u,H, (.I'i.aps bv r..a.on of the poorness of the blood), and that, in c<^isc> ,„,„,,, ,l,,,n..niali've organisms are introduced into the intestine. The chief i' „.,„,„.„ of th,. gastric jui.v probably lies in the antiseptic action ot the free hydrochloric aci.l. Should the amount of hydrochloric acid be msut- ,l,.i,,,t'lun..i an.l bacteria get into the intestine, particularly those winch pro- ,,,„,,, lii.ivric f.T,n,.ntatiou. In butyric fermentation, however, hydrogen is set ,V,„, :„„l'. bv ihe reducing action of the nascent hydr.-gen, alkaline sulphids arc funned iVum ih .mpoiinds of sulphur in ilie food. These decompose the oi-rani. mpo.m.is of iron. In this respect a recent snggestK^i, that l.y- ro- ..hLrir acid is a re effectual remedy fbr chlorosis than iron, sliould be taken in... cui,si,lenvtion. Again, the experience of physicians, that iron is only o „.c. in cases of lv,>i..al chlorosis, an' l.-inallv, the doctrine . . . that iron is only effectual in large doses is in l.armonv with mv hvpothe.is. Considerable (piantitics of iron are necessary to nndrr ihc alkaline sulphi.ls formed in the intestine inert, whereas a very small amount wonhl suffice for the formation of hemogh.bm." ' On the other hand, there is some experimental evidence to show that iiior- tranic iron is absorbe.l. " Knukel fed two dogs on a similar diet, but to one ^ave iron in a.ldition. After >ome time he killed them, and on determining „,.. „.,„„„ „,• i,„„ i„ the various organs he found that the liver and ..ther oivaus oi' Ihe .io.v which had taken iron along with its food contained coi.sider- aldv lunre than those of the other dog. Experiments on mice gave similar reM.li-. lie himself, however, points out ihat this experiment i> not con- clusive, a,- the iron administered might only improve digestion and allow the i,.,n of til., (bod, whi.'h is in organic combinaticm, to be more freely absorbed. \nother view, the so-called stimulation-theory, is that " the iron ..i the i;„„l ,vhieh <'.|uals about G to 9 centigrams .laily in an ordinary diet, is more than M,tlici..nt to make up any deliciency of iron in the 'olood, and that nnuse. iron i^ alwav. b.^ing excreted f^'om tne bowel even in cldoroMs. 1 he intestinal .nncou. m...nbrane, however, is supposed to be so bhunlless that it cannot pmp- erlv iicrfoi'Mi il- absi >rpt!v< fiinetions, hence tlic iron o if the food is not taki dvaiilage (.f. iJiit when inorganic iron is g ivcn, I t stimulates and tone; the gasli'o-m )ei-iinal inucoiH mcmbraiK so t hat digestion and absorption ol ' l'liii»iiih(iie(il ' Stockiiiiiii VhemiMr,!, Weeiih'idfjes triinsliUion, j). lOS. Brid ,h M.,l!nilJnuni(il, l«'j;i, 1. ws. roil. Now, L«pc't'ially in of chlorosi.-i. the sulpliiir iiuls of iron. J. !to(l i.-- in>iif- at, in c'(jnse- ■?\w (;liief lotion of the ■id be insuf- V which pro- (Irojicn is set line .-nlphids L'f'onipose the , tiiat liydi'o- lulcl lie taken >n is only of X, agree.s well listnrbanee in " iron which ve doses is in are necessary hereas a very low that inor- iet, bnt to one n deterniiniug ver and other lined eonsiiltjr- ! gave similar it i> not CI 111- aiul allow th( ■Iv absorbeil."' le iron of tin v diet, is more lid that nnns'-il The intestinal it cannot prop- d is not tak( n ; and tones up absorption of 58 ilwiiiioala- will ,,„,, ,n '■ '""»i"i.- |.ivi«„.„i„„ "I'""", as i.i|»iny, and on ( „, ,„i , , ' """ m.ii siili, h , „|„, ,,,„ " "re Jiist a., ,,,,,„|,|,. , . ""«■'■ lani'l llial l,i,„„„,|, ,„ , '"■"" "'= "i-fs A- n. jra.„ii;,;;; I,',"''"'" "",'•' ■■" ■''i--">k ' ■■ ■■' »'■'"'« »» 1"« l«a .Ionic !'"" ""S""" "«.-."al. ,. 'T''?'""' """■^ •■>'■= •■nt«,i„„l „*;"'■"•": """'"--■ In „ I ,r™ "."" '"■ ""• "".. , ;™.«.-vi,m:;: :;;;:--■■ '■« ".rrxr *:,' /'■= ''oucomitant of tl,oi,- .,l "-^' •'^"""Jant a.tion flun- . 'i"t'"'''al progressive Pernicious Anemia n'' '" '''""''-P'^'^'na." ' ;;;'7 ;*i.™t a„, „i,e„vo,;;;„ t x; ;:^^ '-- "f g^neii a'::t I ;,: ' ' "'*"'• mn,n.utio, slan.lnlar ,er„„ ! ' "",''' '"'■""». "» l>'"l".i-a, „„ :" ■I--*.'™'.-! .,• .1,0 'o™;; ;,*:;"': ''" ^avo ,hooi,a™„„,-„,„.,, „ Ab.ract fro,„ /..,,, ,,.,,„, .,^„,,,^^,^^ ^^^^"'^^'^^^ •^^,11 appropriate. \U it ! 914 .LV AMERICAX TEXT-BOOK OF THEItAPErTTCS. There Ikis of late heeii ii toiulcney to overlix.k llii> pniiit, and while lh(Te an? vai-ioiis causes that inav pruilii.e aiien.ia al once pro) the form of chrome gastrUis associated with -reat atrophv of the mucous membranes; (c) the parasitic ane- mias due to the ankvlostoma or to the bothriocephalus ; and {,!) lastly, in a few rare instances of carcinoma the anemia is i-arly and progressive, and the patient mav die profoundlv anemic without any suspicion that a neoplasm is pre>Hnt "Now, apart froiii these conditions, whi<'h are more or less readily recognize^!iit. recognized, a males, oc- aiii obscure. : ; ill others ced that the )tion of poi- supposed to This is fol- ,11 d accounts iTnients, par- has boon so ivor, though '. An indi- Inally to de- )iit as a rule t date of the tires easily, ast exertion. early syni])- pallor may The dige^- nd vomitiui: ly take phiri' by Addison : rora bed, tiic 3id state, anl 3SS of several int of oIm's'hv ^l^ observa .pj)osed to 1)^ 1 as examples hk m ( II /; II p< til p" ihi ill Ml cliii iio i iisod Jiyr, treat speci less. An of hrp; resciiil tlic sul the lip, not Ion sub-ictc of inorli elii'itwl i'l ii ma eould n< wcro oiil ahoiit 2(1 nu'ilicine •1 'Ifiy, f,) takin^^, 1) fontimio,] For u\ colored CO to lo dr„p the drug „ '0.8 1 aslig "Iv (0.31) J i'liprove m< supervened (0.00065) 01 % June 13 improved, a s'-en on Sej lousiness, an ""'lit witi ' ;"'"""'•• '"'^"s i„,„ , ""••"''i" iiiiiv,,! 'IcfiuM |,\. j{ V'"-' n,.i,„„,<„i ,:;■"'■" ••"•^"'.-m.im., inuinvc •r ' •'' r- "'••'f N,„,,|,„„ ;y, I"'i/iici(,| ■"H'llllJI. M'h ipsc.s ii/(,.,. •ii/ic ^M'dllps )j,(, :i|'|>aivirt fijr« "•".u:r(w „r ,|n, .,„, iirc vci" '"' frcaf. if'tioii Jijis sc ,. ■'^l''^ into ;i / •'•'lllliluli. f'"' ''|-ticill;iilv (ll '<-'Oll(|;||-v .\ ll'lllill in fl ''■""« «li«'t, \h\\ "•' '"''"f I'l bod MitI 'H'lllll •';'"'■'• ••'I'd iVwU'tu- '"■'" <•'■ n'l;i,,sin^r inc'i.' IM'Oi "' 'iitestiiios. / K.'Vllllr 1),.,( I'll till J>iitioiit 1 "''■.^lill;il ' "'•''^N.uo. ff,„„ "P<"i tlii.s tl "III ill I ''"''"' of ,„„| '"f'^'I'lirs l.nvo I 'K'l'i' Jiro /; <'!• l'<'<'nni„i,.,„|. wcr lor •i^c, iiioro ■I" exeJiisivciv "■''II 11.-0(1 (, Ji'ifn'/liofivo o/i "ii'xit tin iigos :5^rS=;5;£r~s «P-i/io, and ov 1 :r "'"""-• '" .mai, If :'''-^"'" -'— in the , -^"-^-:'Zir;r"i ^'"--'v:!:!:: """"-"' -.--t „o^.: ;'- Hps a„„ ,o„„;;,:; : ;; : ; --'"p^;i. ^n.o„ fi...e ; ^^'i ;; '^ --' *" t.u.e ..„::; ^"'HoteroiVItintoftliei T,, '" '•""^^"t''"lark clraiJl^'T'' ■'""■'--''•'' o . inocJorato vol.uno. \V u J ••■">I'--ati.ro ,vas a little 0";'?'''?' •^■'"f-"-.vollo«., '""''I not 1,0 ,„ado at tlio ,i , , '''"'"^''■^ "'' advanced ■>!, ^ "''""'' ■^'"'"•''•l "^•-'^ 20. „o was , ; ' :: '"^ •" ^'"^ "•"-• '-111^ , ' , J ;• '^^"/-■•■'^^ 'aU'.-. there ""j-'i-nes bismuth ,md s H, ;!;7" « '-"^-'-t, ordo, ;;',!;"'"'-'--" 'a.e was »''".v,to be increased ,„ ' " '"^'"""f''- «'itl. I'Vnvler's s |, ■-'' ""™ '-i ''«>% an.l as ''^■'-^> by the ad i T' , "'7' i':'>'>^> «'aily at tl, ^ " ';' "^^^ ''»''^' >• "-roe tin.e: continued. '"'^ '-''.-,0,,., a„ eli.vi,. of i ' J J'^^' . "^' '"ad been ,F^"r fwo n,ontJ.s there w.. , . ''^'"'"' "■'"■^■'' "-^ "l^- (0.31) aeain tlJ ^"'•'■"^''' 'i"d the ars-nie u-, \ , ^- **" '•''adiinff m v,-;,- -p^m^ied, .ith'S,r ^;::t,?^"' '^!r ^- wee.':;;:::,;::!!:^- ^- -med to fO.OOOfi.5) Fiv j; or ar,enous acid ordered n. t "e 13th he riiiMvas then .stopjx.d f gastric irritation :ri!^':!'«r"'«^v;rs ™-^;;^:;;";ri:r:--^^^ ;'""">^^«l^t the patient "*'■ '"•' 'iays, and j.ills of was allowed tr gr. incT :'• '^'"^ ''lood-condition 7 ''■''.'■'' "•''^'■ly -»,ooo,ooo get uj), rapidlv ""^»-. ''- «w:;;:;f'^ '™-»^'^ '■>»-. i.rzr;:s "■■■» IMAGE EVALUATION TEST TARGET (MT-3) 7 A {/ / f/> ^^ 1.0 I.I 1.25 1^ ilM \k t 1^ III12 IM 2.2 40 1.4 12.0 1= 1.6 3 V <^ -^ /: '^.>y 1 . moiogrdpmc Sciences Corporation 33 WEST MAIN STREEf WEBSTER, NY. 14580 (716) 872-4503 \ iV fv ^ •^ <> k. k v^^ b i'. ^. fi t*' 4 ^ -m W.r z WJa ^ p I- \ \ k \ k ■ b -b' n v 916 AN AMERICA X TEXTBOOK OF THERAPEUTICS. The subsequent history of this ease illustrates an only too common feature in the disease. ..,.,. j „<. The man remained well for nearly two years, was very active in his business, and sat for a session in Congress. Anemia then developed again, and when I saw lum about four months after its'onset he had mucli edema, and an extreme grade ot anemia, from which he never rallied. Fowler's .solution is the most satisluctoiy form in which to give arsenic. Beginning with doses of from 3 to 5 minims (0.18-0.31) thrice daily, it may be gnrdualU^incrcased until the patient takes 15 or 20 minims (1.-1.23) at a dose. The better tlx' patient bi'ars the arsenic the greater are his chances of recovery. The drug .'^honld be interrupted only when toxic manifestations develop, and then aftcT a week it should be started again at ihe dose the patient was takiuo- when the toxic symptoms ai)peared. Sometimes a patient will take ansenous acid more readilv than Fowler's solution, or it may be necessary to employ the drug hvpodermicallv. It is well to be frank with tin; patient, and explain the liability of relapse, and to urge the importance of very careful attention to hygienic and r arsenic lias ed, and there Hcial. Fraser V, but in the ut improved, per e.mni. to Danforth, in The marrow cl opping up ;e for three or Hiltiufj; liquid itly employed days without (d, and rapid 3 blood-count ous of boue- it increase ui [jani^es, either •row. Icidiotiiias, we nlonc is niu( li eukemia is on well niarkcil. 1 ii I J^ISEASJJS OF rrrr nr^ '•'*/y J//F DLCTT P^VV r . .• ■'•I'lenie tunior «.^ w*^:: 'X T '"■' ■■ ' '■' '"^ *'• H:"t. ;-:" ""-'- and I.n, , • .' '^■'' "^' "f'tieynij)toin. f,, o,„. „<• .1 -ntiy „„•,,. „,,„, „„,, ; , ' «,.,e,„«i» ,„„, ,^., ,„,„ ; ; • ; >•"' m. i,n,,i™i. n,. ,„„„;: ,'',""■ ■>"M.i.-fi.Micios „f „,„ ,;,: ' - «„ i„ „„ ,L. "" "■'""■ « "' -nu,„ a,„, ,„:,;,:: •;,;'■;;;;;,; I he J:ver beoonies enlaro-od .,t ■ « a pro,,,,,,™, ,,,,,„ r ■ , ' '"I'lY" "'- '■-■»■■ As<,V, „ ' ti »-"-"a.«™«wm-^„:,r:Ltz' c !)18 Ay AMERICAN TEXT-HOOK OF TJIERAPEVTICS. s ^f i! %\ '» iU ml(lisli-l)n)\vii ill cdlor, or in cxtrciiic cases possilily cliocolate-colurwl. Very often a sinjile glaiiee tiirougli the niicroscopo at tlie fresh bh)0(l-sli(le will settle the diagnosis. Lvnipliatie leukemia is not so frequent. The cervical glands are usually first involved, and then the axillary and inguinal groups, and suhsequeutly the deep-seated ghiiids in the thorax and abdomen, rsually these eases run an acute counse. and may terminate within three months. I have recently had under observation a case that has persisted for eight years. An enormous leukocytosis might be mistaken for a leukemic condition, but may be easily excluded by the .study of stained speeimons ; in all ordinary leukoeytoscs the increase affects solely the polynuclear ueutrojihiles. The enlargement of the spleen in chronic malarial cachexia or malignant disease mav also be differentiated from leukemia by the blood-examination. It cer- tainly is ni)t justifiable to make (as has been done in at least one ca.se of leu- kemia) an exploratory abdominal incision to examine the spleen before the blood has been carefully studied. The pure lymphatic form of leukemia has to bo distinguished from gen- eral lymiihadenonia, or Hodgkin's disease ; in the latter, however, the glands are found in much larger bunches; and, besides, the blood-condition is in lymphatic leukemia quite characteristic. (/;) Pseudo-leukemia, or Hodgkin's disease, is characterized by progres- sive hyperplasia of the 1 •mph-glands with anemia, and sometimes with the development of secondary lyiiii)liatic growths in various organs. Etiologii. — At jireseut we must allow the term p.seudo-leukemia to cover certain groups of pathologic conditions that before long will be recognizeil as definite and distinct diseases. One has only to attempt to accpiaint himself with the literature of Hodgkin's disease to appreciate the hopelessly confused condition in which the matter at present stands. There is a growing convic- tion, especially among the (Jerman clinicians, that in at least one class of cases, if the patients live long enough, there develops a true leukt'inia; and certainly there are several instances recorded in which under direct observation sucli a change has taken place. Hodgkin's di-sease is more common in the young, over GO per cent, of the cases occurring in persons under forty years of age. That it is an intectiou- process there would now seem little reason to doubt. What the infectious agent is we do not know. Those cases in which pyogenic cocci have been found niv to be looked upon as pseudo-leukemias with a complicating septic infection. Sif)iipfomatohgi/. — As we are at present forced to include under the name of pseudo-leukemia conditions varying so widely in a jiathologic sense, it will of course be impossible to lay down a ty ':'•'. and definite series of .symptoms applicable to all cases. The variation in the rate of growth and in the size of the glands at dliln- ent times is astonishing. When they have been large they may dimiiii>li in volume or even entirely disiippear ; a rapid diminution in the size of tlie glands shortly before death has been frequently observed. orod. Very lie will settle s arc nsually iwiuoiitly the •ases niii an recently had ondition, but all ordinary |)hilf'8. The niaiit disease ion. It ccr- ! ease of leu- n hofore the (1 from gcn- I", the frlaiids ndition is in I by progres- iies with the uia to cover le recognized aint himscll" ssly confused wing couvic- ■lass of oases, uid certainly rvation such ' cent. ()<" till' an infection- ectious agent !en found an infection. iei- the name sense, it will of symptom-^ uds at dillir- • dimini.-h in ; size of the J> IS BASICS '>!' Till: /if. T\ ^>f>n Axn rin: "• •'^!>l''«'n is „rt, f>rrTLKSS (ij^A xns. 'yp'H'lioii.lniMi.. Til,, ti " ■-"ni<'k'nth- ,.„|„. ,1 Siiy .sfaii t|,v, Tl Mll> i.vn.iil y|j,,„| tl pJidVrit iii.iv ;is u,. IK'CJISK '"■ •'•■'^"y l'.''l|'.'.l.l.' in tl,, left '"'••'•' iltiiiMf M" nil i;,,. ., I, 'liitllll "' *'""'""■" :"i(l t|,„ ,,„,j '■mil ill '■|"''^t'll if (lie t •■;;"Hi.iai,iiM^onittio,.is„ti„„t) " ■^'" j;ni(|ii;ill Mlllois. IC 111- y .ipjKar. Flo I ')"f S(ri|,()(ifi( 100 """■ MiMaiic,. I ia\-,' IS in. Il'l-C "'"I" niniil),.|-. 'I'j ""■^i«l■ -'" i> ■■»«. >f je ■so ', "' .mivery lias nn,l„„|,t,dlv ,k.,.i,i.,.„ I 7 ' """'''■'■ l'"''"senee of --.on, the patients may feel v ,",;"!; ["'^^'^ '^^ ^ "<^ 1- cent., as i^ Arsenif !« tlw> i . • '^oiniortabje. ^Iionld be given syste rem,.dy that anemia. I Jiav oi' this di systemutieally and ■(' several very interes «'oni.s (o hav(. a "1 niereasitijr d "y positive influence, and •»i? in leukemia. The el ting charts si 't^ "o,ses,jnst as i It n l)erniei,mg '""•ing the benefieial effects Tr.Uook of Medicine, of a Z k" . """r"' '" '">• -'^-le in the A »ie)-icnn "■^^ - "'-™«on ,™r8;;::,z' i'i ! t i 920 ^i.V AMKIUCAN TEXT-liOOK OF THKnArKmcS. 1890, to XovciuImt, 1H!»2, is imrticiilarly iiitoivsfiiij^. Tlic It'iikcmia was of hii'li irnulc. On admission there were 500,000 U'likocvtcs and 2,000,000 red * 1 • 1 corpuscle's per c.nini. From Jaiuiary 2!> to Ftl)rnary 21 tin- patient took arsenie in increasinjz; dos((s, and the eolorh'ss hloud-cor|»nseK's iell IVoni 71 1,000 to 7500 per c.inni., and tlie red i)Iood-c<)rpnseles increased to ;},500,000 per e.nini. Tlirougii the months of March and April tiie leukemia entirely dis- appeared, and the colorless hlood-corpuscles were ollen helow 4000 per e.mm. The lar<^er the doses the patient can take, the more heneficial the drun; would appear to he. It is best given in the form of Fowler's solution. I have used it hypodermically, ami in several cases have followed Mosler's j)lan of direct injections into the spleen, which has not, however, any special advantat-es. In Ilodidxin's disease arsenic also is the most trust wort hv tlrutr, iuid under its use the glandular enlargements may diminish remarkably. Caution has to be exercised in these cases, as arsenical neuritis may occur. I have reported an instance of Ilodgkin's disease in which severe peripheral neuritis tleveloped after the nse of f.^iv ."j V\\\\\} (125.) of Fowler's s()luti.)n. Of other drugs, iron is sometimes us(,'ful when there is pronounced anemia. Phosphorus in doses of gr. ^^ (0.0022) three times a day has sometimes seemed beneticiid. Inhalations of oxygen may also be tried. The residts are, how- ever, very variable, and as in most of the cases arsenic has been used at the same time, it is ditlicult tu say how much of the beuelit was due to the oxygen alone. Cold douches in the region of the si)leen may be tried ; and electricity i)er- haps may give the ])atieiit a feeling of comfort and satisfaction that something is being done for him. Notwithstanding tl.e fact that the disease is almost invariably progressive, the practitioner can do much to relieve distressing symptoms. Care should be exercised in the use of purgatives, as an acute colitis is a not infreipient and sometimes fatal complication. Hemorrhages, which are always dangerous, are to be treated according to the usual methods. Very litth; can be done to relieve the dragging sensations in the side, but warm applications often give relief. The surgical treatment of leukemia and of pseudo-leid.()()(),()00 ir»l patient toiik IVom 71 J, 000 5,r)()0,(KM» per , entirely dis- i)0 pel' ('.mill. 1' (iriiu woiilil I have us(' reported itis developed uice.s back i accord Th called Addist firoven In a c£ lias los] Villains DISEASES OF rnn nr '"•^"f "f the ,ra„.||, .,„ , ^^^^ f'f^A.YDs, 921 ^•-<' the syn^pto,!;;:,. t "m "^ '" '^'''^^^^^^^ --ton, ()„ . , a'H' to ,list,n-l,..n,. V . ^^" ^lie other "i»22 AN AMERICAN TEXT-BOOK OE THERAPEUTICS. no change in tin; pigmentation. The ghmd is given in the ibnn of a glycerin- extract, and tiie patient may receive at first the amount ecjuivalent to one, ami subsequently to two or three, suprarenal bodies. ExoPTHALMic Goiter (Graves- Disease ; Basedow's Disease ). Although this disease has a very complex syniptoiuatology, in its fully developed forms it is readily recogni/cd by the triple features t)f eidargement of the thyroid, exophthalmos, and rapid heart-action. Ft occurs much more frequently in women than in men, in the proportion of al)out 12 to 1. It is sometimes seen in several members of a fiimily. There is a remarkable in- stance on record of an hysterical woman who had ten children, eight of whom had ext)phtlialmic goiter, and one of these children had four daughters with the disease. It is not very uncommon to see two members of a family afTected. \Vorry, fright, and depressing emotions precede the development of the disease in many cases. In a large number diarrhea has preceded the onset. The symptoms come on gradually, although there is an acute form, with vomiting, diarrhea, and even maniacal outbreaks. To the well-recognized triple combination of exophthalmos, goiter, and tachycardia there has been added a fourth cardinal symptom, namely, tremor, which is present in a very large proportion of cases, and which is of value in the diagnosis of the early and masked cases. For the more special features and symptomatology of the disease the reader must be referred to the manuals of Practice. Three principal views have been advanced to account for the pathology of the disease : first, that it is a neurosis ; second, that it is an afPcctiou of the medulla oblongiita ; and third, that it is really a disease of the thyroid, and that the symptoms are ilue to perversion of the functions of this gland. Tiiis latter view has been particularly advocated by ^r()bius, Greenfield, Joff'roy, and others. The following are the arguments in its favor, which I take from a recent paper by one of my assistants, Dr. Oppenheimer : (1) ralholofjic aiudomi/. All autopsies Jiave disclosed some changes in the thyroid gland, and frequently these have been in th(,' direction of functional hyi)erplasia. In some cases, however, the gland wiis almost completely fibrous. (2) The adion of flii/roid extract. Soon after the discovery of thyroid therapy fi)r myxedema, Murray, and later others, warned against the effects of overdosage. These were notably tachycardia, tremor, headache, sweating, prostration and anorexia, diarrhea and jjolyuria. At a meeting of the Societe des Hopitaux held Octoljer 12, 1894, Bederc ri'ported a case in which exoph- thalmos developed after an overdose of thyroid, and at a later meeting of the same body, J?allet and Enriguez reported some experiments on a dog in which they injected thyroid extract. The dog had two courses, and in each developed goiter, which diminished and disa])peared when the injections were; omitted. (2) The usual effect of thyroid administration in exophthalmic goiter is to increase the symptoms. There are exceptions to this. (4) The most .successful line of treatment, so far, is that tending to diminish the bulk of the goiter. Out of sixty-eight operations on record, completr TICS. oC ii ^lyceri li- nt to one, and Disease). y, in its f'nlly A' cnlargeniont rs much more 12 to 1. It is •emarkal>le in- ?i"* -I'H'.i. 1;J p,,- cent "...^«io„.. T,,.i .,:,■':;„:;:,,:■ '7;::;v:'"- -;i""! ■•.• :'«.•..,. „„„ ""■'■■' '■'-"■iilly m,,|,r „„■<,,„■ K\iii.i,ii,..i....- '■•'"''''"'"'Ii"i''i.'<.itur,.\lrs V Pulse ,,„ "K^''l ' '"'Provement and ,,,„,. («) Finally, the course of tin' V ' ■ ''''^'—m-. probable that the ehlef hnu.t of tiT ' '• ?,? '"^'' '"' '"t'>^--atio„. It is ton, a„.l this ..o„l,l ,ivo rise , , ir""" '''^ "" ^''^ •-^'•^l nen-ouss- Treat.,.,^Tl. disease ,';'•' ^^''"l*^"'- -^'-"t .narked lesiti ;'f treat,..e„t. Change. <.fd,.ntt, p„, " , /" /'" ,"' ""^ ^'""'"' «-•-« '-y-' '" -'K> eases In- ,„,,,,„, , "'*' f "-^'-■ato elevation, has been fol- -t'7 -^' the heart, ttn.l perhaps hv^ j-o,!" "'ri" ''''"' ""'^'' ^•^"^- '-I'i'l "'-.pprchension exists as to the etfe 'I^!^ '^ T '™'"*"'^'' ^"^''^ ^''^'^ "■»■-'' '•"•■O "" the cire, latorv or,an . • ? 'T'^'''«^^ ^I-^vations as this(;i2oO -■vous states whieh st.h rC^ ^1 r' ''='"^ ''' -'^•^■- '■"'■•■t d. the '■"•""'^>t"'T organs, an.l the pun.v" ! ' 'l'^^''-^^'^^^^^ '"ost tavon.blv o„ the strengthening „.d .vstonttiveXt:'' "" ^'"''^^ "' '^'^ ^''- '"'- ^' ^-entl Systematic hvdroihefiov „;fi TI.0 »ot pack caVofnllv .piilk nrtr;;,"'","'*™ '" *"""' "'■'■ '■""<««"■ '"««"■. ,„ allay ,l,„ ,;,,. i,v „,,; ™" '';' ','""■'- "'"" -'y "-!.«: sin.'k '-".V case* ™„„ivo. ,i„ ,,; L^, , " '" ■ ;"■•'■'" ■■"'"«■■■'"■' "' '- '" i\ m ' :1<\I 924 AN A.^fERJCAN TEXT-BOOK OF THERAPEUTICS. TIio dnig-treatinont of tlio disease is most iinsatisfiujtorv. Helladoiina is perliiips the most trustwoi'thy inodicanient, and should be given until it pro- duces ])liysiologic etteets. I have never seen any good results from the use of ergot. The vaseular depressants, such as aconite and veratrum viride, are rarely indicated. Digitalis will sometimes do good, particularly in the anemic cases, when combined with iron. In the advanced stages of the disease, when the heart begins to fail and edema appears, T have seen it prove very beneficial. Stropiuuithus has also been employed. The combination of potassium bromid with valerian is often usefid in allaying the excitable condition so pronounced in many cases. In the paroxysms of urgent dyspnea, with ])alpitation of the heart, liy])o(lermie injections of morphin may bo tried ; Trousseau recommends copious venesection. In some cases in which these paroxysms are most pro- nounced, a whole scries of remedies may be tried without avail. The diarrhea is sometimes obstinate and difficult to treat. Thyroid extract has been used of late in many cases, nearly always with injurious results, aggravating th(> jialpita- tion and increasing the nervous condition ; although in some cases great benefit has iieen reported. In a few instances attended with hypertrophy of the mucous membrane of the nose, or ])olypi, treatment of the local conditions has been followed by etn-e. The surgical ti'catment of cxo[,iithaliiiic goiter has of late proved luore hopeful. Excision of ])ortions of the gland has been practised, and in a few cases ligation of the arteries passing to the thyroid has been bencficial. Myxedema. A disorder that follows loss of function of the thyroid gland, characterized clinically by an infiltration of the subcutaneous tissues, in children by an arrest of develo})ment, and in adults by the gradual production of a cachexia in some respects reseiubling cretinism. There are three groups of ca.ses : 1. Cretinism, Sporadic and Endemic. — When there is congenital absence or atrophy of the thyroid gland, tht; infant is born a cretin and does not, as a rule, survivi! birth very long. The body is stunted and broad, and the subcuta- neous tissues over-developed. Sometiiues the child shows only slight traces of the disease at birth, but as development proceeds the condition becomes very manifest. There is a subcutaneous myxedematous swelling; the head is large; the neck short and thick ; the li])s full ; and the tongue large and oflen pro- truding. Mental development is extremely slow. In some cases the thyroid gland cannot be felt ; in others there is slight enlargement ; sometimes there is a definite goiter. In other cases, the condition does not develoj) until between the third and fifth years. Cirowth is retarded ; the head becomes dispro])or- tionately large and broad, the nose retrousxe, the lips thick ; the limbs are short, the subcutaneous tissues infiltrated ; the sk'in has a .glossy a|)])earanc(!, and there is a thick, solid edema above the clavicles. The voice has either a rough or a stridulous character, and the hair often i)econies thin and scanty. These changes are usually progressive, and reach their maximum between the twelfth and fifteenth years. The child never properly matures, and, the condition remain- KUTICS. . Rclladonna is iven until it pro- < from tlic uso of" itriiin viridc, aro rly in the anoinic! the disease, wiien ve very IxMieficial. [)ota,ssiiini hroniid jn so pronouneed |>a]pitation of the IS1;asi"s ( »r 'I'll I- . '■'''■:^^^«;i.AXi.s. |.,,,.,,v) md, characterized dren by an arrest cachexia in some es : 'ongenital absence md does not, as a , and the subeuta- )idy slight traces ion becomes very the head is large ; e and often ])ro- cases the thyroid ometimes there is loj> until between conies dispropor- e limbs are short, \'irance, and there ther a rough or a f. These changes the twelfth and condition remain- i 111- li: 111 i>r -"I i, i. ,,..,. i,.,,.,,„„ „.„ r^"""''7-,-. ^ ■; -.i... -,...., o^.m. ,;„, J t;"':^;'- "- ^.,.,.0,.. .,os,...i.....i .. oIow„,g n.ay I,. ,.„„..u.,.a,..,l : Tin .."l. ,'"'"' "'^' '"''"' "'" 0-|..-i....s " /'- 'xxly : .In. linn swdli... of Hi.?' '":''"""' '" "'<' ^<'"-"l "'"He """T" " "'"' '"''^^ '-"-'tl.,;,.| ;; ' 7 '"^^'"- "" •"•'-">v, inelastic, '•"•'^'"'- ••'• 'iH. skin, ,..n.|| . , i ' ^:' ^'^- ^'-"'"-" ; tl... .Iryn..ss anj Ijy fVionds and ob.sorvors " ^ "" '"^"-'"pts at inteiTuption ''"•■f-" on. n>nit..avo,,n.nan..;l: ,: ^^^^^^^ ^'^ ^^'^l'^'^' ^-"i-^ Uo "•'1 others have sl.oun that if ., sm,.,II ' ; . ^^'^^ '-'■^■P"•"»ent.sof•Hol•sk.v <•- ao not oceui-, and in H,',:::': ::;Z;;^^ '- -'-'" ':e 1^'ft these syn.,; ccos,sory j^lands have been nn.. n. ',' 1"'.""" '" """"'''^ tl'at H.rvivc ni tlie l)a.se of the t( 'en present. The...-,. | tlie hvoid 1 >"giio to th,. aorta ; thvroid t liave been fonnd in all situation)- in the Clinical Society ;o"e and in the trachea. Of 4(),s\.onm| « i-oport, my.xedcma developed in'tjli 1 tissue has even been found in picte thyroidectomies analyzed iiii 926 AS AMKllICAM 'ft:XT-nnnu( of TIli:iiM>rj'TTf'S 'I'licM' three (Additions, (||rn — cietinism, tiiyx<'A in el••• no (h'fference in what way the gland is achninistered, so long as proper car ^ i. !n to -?lect healthy glands. The glycerin-extract can readily K- ^,a,h hy any practitioner. Several dozens of thyroids of young slieej) ,-.• a;.'!.': ire carefiiW .-iparated from the connective tissue, cut into small piccei-t aboi;' the size of a bean, and then put in a jar and covered with glycerin of the best quality, allowing 2 c.cm. of glycerin for each lobe of the thvroid used. The mixture pen I stand Tlie fullest is liy Iloiiisheiiiier : Knlwickrliiiifj und jdziger Stand der Schilddrusenbehandluny. Miinchcn, 189.J 'I', uiid oiwrativp il arc ill iciiliiv (' fliyrniil jj;laiiil, tailTflteiiaiicc of (IK'S of the body, ii'osciits liny diC- tn he inistaki.'ii iriiic is sli;;litly to of till' thyroid ', \\\\\ points tliat \\ niori' yellow ; iijr ill niyxt'dciiia lliii}^ of du'oiiic incnd siiiiciitaii- Ih' rough, liarsh l)r('S('iit. Tiieii, particularly the k'omoii that may ■ the face, often myxedema, and 1(1, they should Mjual)le cliiiiatc. bs, shampooing, and pilocar))iu. a by I )r. G. R. cuts of J lorslcy sly, and several the administra- spaco of time, lie >A sporadic ipriva. !• cooked, or in Id only be par- , as a rule, are way the gland glands. ioiicr. Several rated from the I, and then put iiig 2 c.cm. of mitted to stand il 'm: DUCTLESS GLANDS. 9»7 '"'• <\vonty-four or tl.irty-.ix I about liali' a .r|.,„,l „ , "\''MH'>Mblo. Of f),,-, .. •"' 'Hi, .so ;'-^- r'^-ti- of ..a,.boii. .^i^ n : 7'; '^ ''^'^'«' J-if a .1,.;.! (,, .., , ^ ; />o,s.«^,,_()ft,,^^ J • t'",.. or four tnn.s a week-. Jt ... Mell to hogin with 7n,i or mii , ) Xi.'"" .„ ''■''' "' '■"''"'"''" ■'•vxo.lc.na "---0 until nix or mLiJ Srt ; t''"^'"'--'"'''^'-'-'^'^ Murray d.vulos the troatu.em o? ' .— ^"^ ^'"'^'^^ ^''""^^ « dav. "^ t he ,„,,„„^ ,,. ^,^^ ;t o, , ^^.^^ .tagos-tirst, the" removal ^"'f'^'-- ^''ti..firststa«.Vi .rr^-^''''"''''"^-'--'-'''^ and gradually inerease then^ The vLto ""1 ''"'"'''''^y ^^•'*'' -"='" -^'1 ^-0 ever, not to suggest to the panln t '. "^ T '^r '"^^^''- ^^ ''^ "•^■", Ih.w- "";^ward syn,pton.s are in .a i ^ e" T^ '^^^ "'" ^'" ••^•-^'^■' '- 'hi r'\^" t^^- or three weeks, an.n" s;,,,/^"' ^"'"^'^'^-^----'-allv notiej ''as been remarkable. TIk.; eff e • ""' T'"''" " '""'"'' "- ^'''an^! f^volhng and the loss in wei.h, 1" "rT I!' *^^ ^'^"'"'^l ''-l.-tion of tte sl-gbtly, reaching normal, and the C-^ .C!^' ^'^ ^-"I-'^'t.- i.Leases In «tsesof infantile -nyxodema-eon.^ h ,r •'' ^''*^'"^' "'"''^ ^'^^'ve. ^•en.arkable, and son,,, .f the ill„ i r '''"'■''"-^'^^'^'''anu^'sarensnajlv In a .use under n.y ...re there oeenrre ,,'""'' T" ''"^^ «'^tonishing. ' entu-e loss of the ere.inoid aspeet • the I , " '""^^ f ^^•"'•^-" '""nths .u. i ■'"proved, and the flesh l,eea Lo f r„ „ T7 ^""''' *'''' """'■"■"" ^-^atly ^ and tnc.eased fbur inehes in he ! ;":;;'' Z''^' ''''^'r'^ <'--l.>pod n,.idly ;- and M-alked about evervwl,;: 1^:1""^ '•'''; '" -"^. ^Le now -^•■aordman-. At the Ix^inning, ,ho . , ! ''^■, T'"^"' ^'--lop.nent vas ^'.0^ ke likely to be followed by nephritis than severe ones. Why it is that the ne])hritis after scarlet fever is excited bv exposure during convalescence rather than at the time the; j)oison is most active is not clear, but the fact remains. It laav bu that the chilling of the skin thus already overwroutrht in induced throws enough more work on the kidneys, their efforts to eliminate the jioisrm, to produce not, however, limited in its occu 928 an inflammation. Nephritis is rrence to this stage of the disease, as it not rs. •x'xn isition of the urine ions, the diagnosis r)ends for the most the indioatioiiH for ase of the diseases ough study of the Is the accuracy of The Cerei^ai CoMplications of Raynaud'. Disease. cidney may, in a 1. So far as the lephritis are con- beyond our con- , however, some- of such causes? of scarlet fever. ;1 of scarlet fever greater care no\v len children were when des(jnama- 'h more common, vitli scarlet fever latiou should he -room, while the ini are less than he insisted upon it is remembei-ed ritis than severe itcd hy exposure ; most active is of the skin thus overwrought in n. Nephritis is lisease, as it not BY WILLIAM OSLER, M D rxuM THE AMERICAN JOUKNAI. OR THE MEDICAL SOENCES November, 1896. ' *l ■ t i 1 I ■j 1 Kxtracte.l fnini The A,,,,.,.; i I'l!liri>S(i|; (,], , "'•' iiAVXAi-rrs nrsKAsK. »AV\.VII)\ ,1 norvolis systt lsc;|v|. , "iiy cniniilicat tl "' '"<'>t iviiiarkiilil "'• I'lTliajis il 'VstcTia. ('as,. \- 1 1 1. (• niaiiv aiTccti II' iiKist f'r( 'Oils of tllr riMit III liavnai 'I'"'"' 'lfs.,.7i,.r with whi,.) 1(1 s orii^iiia! t piiriixvsiiis iif |,j, " <'\-aiiiiil(. "u iv,.„r,I. \Vi,|, ■;", ifsis IS ral 1 it is iH'i'lia)! •'oiitractiii ■('■■', and ai '" ■■""' ''"'-il a>|'liv.xia, si ial-cs|;,. 'I' It: liiid livst(.ri,.;i| l"">t !l-:,J.;,Vi.(,M! a^vatod ,.xa.npl,.s. I,,,.,,/, K' lilcratii re ('(intaii '•"iiviii>i(iii- wlio rccontlv t( L.ai f dix'usscd tl ''"'"'■ Xi'uriili 1^ a iiiiMiiirr ,,f |,.,<^ "rill, iiiiliiicd I COIl.|.i,.t,.ly hv Iiy|,l,„si 'layiiaiid's d "' '|ii''>ri(ai, Ii„|ds i|,,,t tj '1 cati.scvs, and \v| r/'''/'"'. •lamiarv ;!() \ N'.»; 'J, 'y ciiKitioii, it'i'c i> a piiivly 11 lii'ii may ii,. n'licvVd Hcasc is not In- S)iul,ey.^ Tin. dis (W ILMl ■'wortli/ i-^(>asc "111 in aciii at all 1,1 lias I),,,., K'oiniiioii in asvli 'iii-i'ascs, as iKitrd ' ""'f ^^'tl' ill .■i.il..|iti,. d twoiity-throc years, | at'iito mania 111. stood on | lad hai ;■ 'iiania. |!laiid 'i'^ fVoni his tliiri,. (.11(1 '■nii'iiiia 111 tiio feet, an,i at tl 11-' fi't't forciM-ht patient, a iiial 1 -.car. r e a; Kitti^ 1 HI: I't'ported t "' -^aiii,. time |)ar,.xvsniai I 'ii.^-lits. Thed II an attack of isi.as(. d level, II peri,)d ,.f ,U.,,|.(„, ^^■" <'ases ill w!ii,.|, |,„.al as la'inatiii la oeeurreil. Tl le disease has | ere are i «ii«' spinal eor,|. '1 with liydro,.e,,halns, tuo o7tl T. K. :\r '•'(•II noted ill manv el i-lpliyxia devehipe,! in tl ./'" ii'onie affections of the 1 '1 ■•('<' instances at I,.ast of tl le irain '« <'as,.s in adult. a-' asso,.iat 1011 ':":'"'" " ••''"'' -'f nineteen nioiul and on,., i pateho8 of |„eal asol • levoloped syniiiietri,.ul phyxia in ,liff,.,-oi,t 'nxl Iia.l from hirti I'cjiioiis, and at tl •''porteil by lll0ttl(.(l 111 t'oiiiieetioii wit faii,<,nvn,. of the toes. Tl H' aj,re men t ion, .d Visceral i^iniilar to tli are exeeedint;! 1 syrinjroinyelia and with I lore are instance: iianifestatioiis, t "•■^e "111,. I, |,r,,dii,.,, th H' ex-pressi,)!, ,)f vasciil; oconiotor ataxii also \' I attacks of eol ai-c. In a few inst f jH'ripheral pi 'I' I'lianjres of a kind fK'iioinena ,)f the dis •edema ; lint I |, '' "•■•■'"• not unlike those which ,1 mces ,«astro-iiit(.stinaI case, ci'ises and know of no jiost- iiorteni rep,)rt of eveloj) ill an<,nonenrotic Keari bt'liirt. tlie ■lease ill wlii(.|i ,.| la n lie: '■ Oiiotofi in Hii Ampriaun Ncnrolosicnl -"ins. I'ati Aiiimlcs Mi.(iieii-P lloWsAppoudix, Sy.leilli xxxviii. 1SS7.( igicnl Society, iSflfi. !l. ■'^1)0. I,oii(I. mm Society Seluetetl M, « (ilui 'Kou- Moiliciil J louriml, WM, iio^niphs, ISSM, p. iiiij, ' Liuict'l, issii ;i ■! 1 2 (»SI,KI{: (^OM IT.IC ATFON'S OF RAYXAUD's DISEASK. ill tlio organs have beon foiiiid at all suggestive of prolonged local dis- tiii'haiH'c of tlie circiilatioii. Occasionally there are symptoms })ointing to serious disturhnnces in the functions of the liraiii. A numherof the ])atients have been epilep- tic ; but with the exception of the first case, to which I shall refer, I know of no instance in which the attacks a])peared to be directly asso- ciated with the development of Raynaud's disease. In Case XIX. of Raynaud's original thesis, usually (pioted as an illustration, the woman had e|)ilcptiform attacks which preceded and were jiot sp(>cially related to the gangrene of the feet of which she died. (^ur attention was directed to cerebral symptoms in the disease by a patient at tlu' Johns Hopkins Hospital, whose case is reported in full by Dr. II. .M. 'riiomas in Volume II. of the /.V/w;tf (18'J0). I give here a brief abstract and a note of his condition subsequently to Dr. Thomas's report : ('ask I. For xi.r ((>//( /c/N attach nf Rai/naud's disecme ; attric/c--i of epi- l>'p. During this winter he had repeated attacks of discoloration of tlie ears, iiose, and fingers, with the ])assage of i)loody urine. On this admission he had no convulsions. He had, however, two additional symptoms of great interest, namely, attacks of severe abdominal pain, resembling colic, which recurred at intervals, and enlargement of the spleen, which could be felt 4 cm. below the costal margin. The patient has not been under observation for the past three years, and I have not been able to find his address. I can find no parallel case in which the epilei)sy occurred only during the manifestations of Raynaud's disease. So far as I can gather from the literature, the only instance in which a[)hasia dcvelopeil in connection with the iittacks is reported by M. Weiss.' A woman of very nervous tein})erainent was subject to most aggra- 1 Wiener Klinik, 1S82. nrsRASR. inj;;e(I local clis- disturbances iu ave been ejHlep- I sliall refer, I be directly asso- n C^ase XIX. of ;ion, the woman specially related lie diseaf-e by a ■eported in full ^1890). I give ecjuently to Dr. ; attack-'^ of ep'i- hd'innrffohiiinrla. inters in succes- d ears and nose far as tlie local e in the ear-ti])s, al)le peculiarity 1 tlie association binuria, a symp- The epilejitie ciation with tlie by Dr. Thomas Is on two subse- , 189.']. Jn the y much, and he dinission be had ody urine. We is winter he had fini^ers, with the no convulsions, iiterest, namely, ich recurred at felt 4 cm. below ervation for the dress. red only during stance in which id by ^l. Weiss.' to most aggra- osi.i:!} f'f>MlM,|(.,\ p vated attacks „f ] '<..VS OF ,{.\v \.\ri ' '^ l>l-^KAsi; superfi oc;d 11- eial gai half of the f gangrene of d. l'''r-^i'i in til,, (i Hirer." Icll cheek, f, buttock- I)aiior, IW(>Ut\- I On Octol and sli.rl,, "'-" 'I'ld patches ' '"'l(.u,.,| hv .,, "■itii ai-tlin,j lillllic '<'i''^lh sli,. I .f cN-aiiDsi,. 'iiinuic i>ttril)uted rl On X lad "f the •'upei'lici i''ciil\- distiirl '■"I'liy «( llic l,.f| gangiHMiM (Ml tlic lips T laiicc of the third left III the foil 'c cerei)ri "^■'■"''"■'' "'tl. siie iia.l '"■ i'ltack ia-ied l"'ccli, will. lift ani frontai lowinir ■^ynipioiiK I 1''"'^'" "iih transient I '■"iivolniinn i'''inarkai)|i ' a spast '•^ -iniiiar attack. \\ cell or ic iscii ei.> :<'inni in tiii. i '"ise til iciini 'Icyia, '11 ere ^\■^,y^, ,.,.,. ^ rriiii ( off/, AS nioff /,,>;/ nf.th,. fi '' ''linieal sn ■cgloii of attack^ of miiiarv is as ollow,- "/■ -"/.r h "/'•-•. ii'iii,.'<;,.„f ' I, IIIJl r: ■'''''!!'■'' '"'''iixi'tnni ott„rL l>'ttii iiiul l„,,„l ' III ( III II. •ItllxOUlllsiu AprH^ IS!)] "" 'llf'irl.- of ,/;■. I'l mini In """•m,, m.j, „ tl;,,, 'i'y:"''>'>tiii;ff/r 0,1,1 " iiioiifh lilt, mid. ■-"iperfirifi/ ), 'icon, I ott,,,./- '•''ro.yi.u,ff/„.f. iittor ii'Ifh wHI, •/•;'://;xr:^i:r';-^'-f^--'>/^'w:r. rifjhf lionil. .1 ,;;,;,,^/^ I'm ! nil I ,1 In,/, '"'"■h- on tl, iiiii ■yipiini,;/ „.;//; „,,.,/^ ''■l';''.!''"-''"l''->-(th,-n,,hf„„t "■'","•.'/. ','■'■/// ,ipho::;o. I, . ■ ■" '•nil I, nil "'III ,i,'/„nr, n, til,. ,, 1^, f h,' SI, "J i-oinplilr n„l. ll(T,-Osi't of / 4f/i f'V, ■rnilni,/ ,ii,„i, V mill fi, 'iiiin,'! 'pliii'/ f'^:'j^"''""^iii'ini:i:i ^rm-e „ff„,.l.^ ,,;,i^ 1^ 'in.r .WVV'/V /on 1 1 lliiipfoni.s y>li,,sii,^ irlll IliinI of fuck „f ,^. ''» riiijif 1,11 i,;i niHl'nn',;,, '"'/'lil/il ,l,-i;'/„p- ■ ■' ■I'lhlrh ■ III fli 'II 1 1 '"' mil In h'ri fillip llllr 'I ■•'/I'jhf 'irinii "/ i-'ulif lion, I. I'i'I'liI l-ri-i,ri'v, '/"/■■"'I !'[_ fill' ,;'f//if I'll III 'pfiil.riii. ''jlit ■II. /,S'/y,7, I,,,.,,/ , , III' rii H aire( 1 fort '••^i'itai. Fell', '"'.7 ,'/'""/ y-cigiit v' ///./, ','//'/ 'l. Ifllf ''l'.l"t poivhlsi. of fl„. i„t /lonil oiii h- ■ ,, ■'. On A,,,-! I ol fi 'iniiip/.,,;,,. /,;,.„/ nipr: "iii'inp /,S!)i!j„t •^ijni-op '■'''"' i.i-finilln,) to fh On .liilij lutl, il ii^iihit.i ,1 'II' I'l ho II of peeni uarv !l. of 1 liad Tlie f nir sensati ■-;,ud,nittedto\va,;, 7. ;/;;;;;' .''V-. eompiaininL^ of ,1;.+;,.,,., • '"'"ly liistorv ons Ml iier W nijer.. 'f diftieiilt, '•>'■■«■ 1""" In rlijhf hun.l : iliiifli,^-\{y^ ■biinis IIopl^ I'oino K'f relative; Si IS good. .-^Iie |, m speal. Kill!. kin,- and one iniscarriaire 'lealtli. In 1,S7.-, sj,,. | le IS ma rnei in l,s7,s aiK A- ':''""'^.'»fllnsi,nil as ha a rnli 'I a mini "' '•i>inp!aint icr of III anv iins and i "six week joint; Tl 'le attack "■'•' '"•lite rlienmati.. lie .\t . , ""ix Week.. Ill tlie big toe. O, colic, and intervals wa-: vi 'I'y intense t ■in.affeet has eni ctiilijren. S| le '•' 'lad had slio| '>ra week ing and the hand e.\cell,.i,f, W'^iiHiad what her~d It I'etiiriis of tl. "x'tor called r| '•■*ted ill all al ws. llHMlt le pains in tl she doe; fill' oii'tl )r fi roi'l li\ her |>hysieians tl ■'"f fl'iiik that she has lenniatie If attacks of :ors. \'(' or six year.- at !is (>vei least passed a stone 'lal slu lias : le .ii'ont I'eiial rravel. t sense of thigiin. and nnml 'i>, in (he i,.,|| I, chie '<'oiiie mottled. Tl I .1 tew hours, thondi slu- | W<'eks. The tingiing feel "I the t l-iecnliar feelii ■y at the (i iiger-tii It' condition lunil). At I 111 the and had attac .["''•■jisted iisnallv f put her hand (111 ice. ecani(> that of chilblains, tlu.u"l ':{-;-.itheback..;heri:ht. en .-several le would ocea- aiK ver, that iter ri;;]it arm ached veiy much, iind at eleven o'clock she looked at her riu-ht hand and saw that the little and I'iiiii' iinu'crs were ol' a purplish-liinc color. They remained lilack and painful for nearly live (lays, and were nundi for a loiijicr time. There was no loss of suhstam'c. She had no furtlutr attacks imtil just five weeks aht di.sability of the liaial, which ill the second iittaek was much more marked, so that she could not dress herself or use the hand to feed herself. Shi' thinks, too, that the hand was somewhat swollen. A week ago she had a tliird attack, which came on witii much riiifxing in the head, particularly in the rij^ht ear. She felt very dizzy, hut did not lose consciousness. Her teeth, however, chattered, and there were involuntary inoveineiits in her riirht hand. She had headache and saw double. She found that her riudit hand was almost useless. She could imn'e it from the elbow and shoulder, but slu; could not hold a ,:ilass of water. On atiemptiuL;' to jret iq) she scarcely could stand, and the right foot and leg were weak. For the first time the speech was affectiid. She could only mumble words, and could not be understood. She had no nausea and no vomiting. The diftienlty in speaking and the slight hemiplcLiia have persisted, and it is for this condition that she seeks relief. S. P. — T'lie patient is a well-nourished, somewhat corpulent woman ; the color of the face is good ; the venules (m cheeks and nose arc a little dilated. The pu|)ils are eipial, react to light iind on accommodation. There is no diplojiia ; the ocular movements are perfect. There is no facial paralysis, and th(>re are no disturljanees of the seiis(> of taste or smell. The temperature is normal ; pulse regular, tension a little in- creased ; the vessel-wall of the radiid arteries is a little sclerotic. The iiKjvements in the right hand are good, but the hand is weak and the grasp feelile. She can pick up a pin, can use a fork, and can write, though slowly and with dithculty. She says that the power in the hand has been returning rapidly within the jiast few days. The skin )f the left hand ami fingers looks (piitc^ mitural. The terminal phalanx of the right index finger is of a deep bluish-red color, iind the nail is deeply discolored. On the pad of the finger the skin is very dry, and there is I ISEASK. if tln' condi- s were iK'vcr IC lll'Cllkfilst- licr, anil for Till' attacks, inoiitli later lintr slu> tVlt f the idanx of the ail is deeply and there is "'"■^^ '"■• nAv.v.vrn's ,.,s,,vs,.. 5 ';'"^K:;f''^rmdshn' ;;,"''■'•''"''•'••■ ulnar side of, IH. Ph., ;<"' Thenu-ddieand vL n^l ^" T' l'^ "'- l'''=''""-v there I .'w "'", 'f"" 'i"..vr i> covered'; -^i''' '"''"• ''"''^' '*■'■'"'""' pl I n, , f ^r'' '■"• "-"' i' looks as ,|,,„ i^'"'i:"^.":'"- 'l-nnis. Tl„. Lut^', ' articuhitioi :V^'-s«i..:;;r;l:,t.t:;r'-K "'""'■""' ' po-astnc and "''t; 'i'-'-.n,y.Hna,a. ' '""" ''' """"i.i.'d i.v iar.;.'n,;s:;.:';;.;;;; "'<■ urine was Ij-lit v,.ll„„. ■ , ■ - 1 " .. !'!"" =' faint rin.o, !,,{:„'':?:.:".;;"'"'••. ^vith a spcc_ ast 'oniyoniata. ...•'.lih':'";;:;' :,;ri;:;;;:;;:[ ';;;;'';; "'--y". ■.< ,<.. .,„i,. s,. „"'" '■;.' I'"itmi„„. T -„ : '!" "I -I'o «|."l;c will, ,.|,,,,„„ , ' ri, ■■''""•' "v„,vf,,„„ !;/,■„ '""■', I'"l.^ii"l tl n-slci.; Throu,!,rh the kindiK-s. ,,f [),. i- , , ,, , , 4, l.S!»-Mu.says: ' " l"".^'* >> -Ulus ease. In u letter dated .\p a..a.?:r;;:d'nn;'s:m!r':.::;;;:;;\f'''^^^ '-^i-i^^i she i,ad .„.„„er "'• with loss of sp,;.i (' Vr I ''1'' ";'^' ''■""'•'•' "' tiie i ; she was ta k n^ wi.l, son.e frie s w ,e H, ■', /'I'' , •^' ""'<■'• "'^•'"H l''"-<'- Tlu.re was no iriddt: '^,:^'':."'' ';'':"'>■ '''■-''"'■ '■'•nmlete]; at •d .\j)ril >H'.-.^. She was laid' messcnn-,,. „,,,s sent to fetd, ,„, f ,.; i T, '"',' "" '• '""'nire and a was perfeetiv .sensible . n , • V, ■ ""'"''' ^''*' '"^"^'' ^t 4 .m, 4e -pb- ^1.0 -could ;;t;S"r;;^.rsnr^' ,'''■• "-^'^ "''''■''-» H.o seemed to know what sh.. w ZC , ■ i""' "1'^'" f'"" '"""th. f- Hu.re was no donble visln 'n';' Ti''. /''''"''' ""' ^•^'•"•"•^•^ times convulsed. The •itto, , • ■> "-'" '"""' "as stiff and .u ^^ wc 1 as before the attack. T c l uC' '^"' ^'"^ '"'^^ ''"^ ^''^ tallied any thrcatenino' of e on lio 'li hands, not lere woiv one or t :an,!j'i'ene as was f associateil will wo snndl discolored "rinerlv tla ' any paui, or with •ase in the fini'-ers. H 1! I? 6 ()SI,KK: com IM,l("A'l't(>NS OK KA Y N A I" d's DISKASK. Dr. lioiitclU; int'oniis iiic tliiit fniiii this ihilc until the siniinicr of IM'.M slic iviimi!i(>(l well, Imviiij,' no syniptdiiis of the trDiiitlc. Al this tiiiic sill- liiid a sudden iittiiek of pain and aehintr in the rijjht lejj and toes, imt no discoloriition. The pains would last for from a few niinnten to a few hours and then disiip[)ear. I'nder ilatt' of March 2."), j.S!)."), he writes : " Hix weeks aj;o the middle finj^er of the ri,i;iit hand lieeame very dark over the termimd phalanx, just as in the old attacks, i)ut there Were no ccrehral symptoms. Tlie discoloration has hccn disappearini,', and is now almost ^one. Tlie nail is slightly raised, hut I do not tliiidv it will come off. She con^nitiMl nie lately for a return of the interndt- tent pains in the riuht ley'. (Thesi' are prol)al)ly presut any l»(>netit," On .\i)ril «, iMil.-), Dr. Moutelle writes: " Just now Mrs. — 's case is presenting; some very peculiar features. On .\pril 4th, ahout !) I'.M., she had an alta<'k ot t'aintness and jiiddi- ness, witii pain in the index, rinjr, and little linger- of the ri^ht hand. I saw iier the next evenin;^- ahout idx o'clock. She had had a severe headaciie, partirularly in the riji'ht temple. She said that her left arm and ley felt weak and heavy, hut she couhl move them very well. There was, howevi'r, nnirked clumsiness of movement in the left hand. The tinu'crs were sendllexe(|, and she had dithcnlty in straiu'hteninii' them. There was m) , lie I'caiiii' very s, hilt tliiTo isll|)|)(■n^iIl^^ lo not tliiiik ic iiitci'iiiit- -paiiis from )ils arc nor- iitrlvc'crin in iar features. ami i_i'i«Li:i{; « OMlM,/( A,., < t \ s "I' i;av lihle, \vi( .V.\ 11) I a feu •^ l>ls|.; "".i.1;f^;,:>t;- •'":,::-,. ^eatlen II'. tl A s I.; '■-pOl.v oil (I ".''."•"I- Tl„. tipuf ,1 Ti.: :::::::'"":"'.»'-•'-'- iud pn )(■(■; il spot of ,.,.,.] ""'"••I'/VomtJM.stvloid <'n the L'-'d sli(.\vi ■■'-■■• ' i'andvvasstil|,.o|,| ,';■;;;;''>•','''''■''!''•'''•'•. and 'f tl "' •U-'lit radiii iiyiiiosis iiii i <"iy sviiipiiiii le nose lie On ti <'xaiMiiied hci I and atropii On April eves. In Ihi and 'lile (•()!,, 'r of (lie (i ';:;;."i!rr'-i'i'"y. At^H "a-i ;il)||. (,, ^.,.| '".vers was fad nil. i.v half The in. iltlaek (I '!'■ '-' ••'-.•oi;Htis: ui ril";!!' "." •"•-''■^^ I'' nriiic u .^r rs. lied ,1 '■^"". l>r. l!o,„..|| ii> iienativi I oiuiiini 111: optic <• uritcs: '".V 'ast report. | wvere thoiiol Hillary :.'!) l.s; last ,si I as (h,. f .""""■'• -lie had ":• She did oriiic a rati vcrv Well f '•'■ a time at s.i'!;::;;;;.,';"""' i. .;;;i™r-;r'."' -- aral ' f II rued livid" i ."' attack of ui.i.i "■ 'yl'l hand. M in tl l"iiii, which si I II ess y at sii pretty well, si not so iraiii- lilt l'l'™.- a htt'e l,cwildere,| •^actly, ivf'erri 'liie, and tl "^' H to the cll K'Ve the 10 most ill! eiise .-peccli. \ and eoiifi,.,,,,! lore was i '" ■■'oiisatioi low or }i"til Ihv hand and pain, (iradii '•.V">"vei,iciitofi|,c|,an;i mentally, |„|( t| I 111 lore allv tl lie eold into a ei 'Ilia, an ir 7;li;;;'L'!;-,:':';-^r;-:;'i:; and livid "■'' '" a eoiiplc of ,1 '■•••^o'l writes ahont the final IM'S ir as the cll '"' arm pive ".V iiK'i'oased low. .'si le said 'On \ 'land and finy ii"' I'otuni I attack """•• at his mot I to the shoulder, and '•'■•■■* eoiiiplctcl ■an,ureii()iis 'ci'V final ill lie: pino'roiions. as (ar as the cll Tl 'le found low It *v.MV and persistent hoadach '' (tod po.is;/,nf /,!/.sU.riral.~K T neurotic fiimily. She is a"l fiu/f ''"!/ of the A isoase //'■'"•■-• ,■ f'llli y.i hdtm-n the k 'Hi'i;.' '»J t" \vhat appears to have 1 ii'^^c, hoalthv-lool, vears, ( ■''•'man, of a -ioventy when shew "'•ef. ^'i-oups of sv...,,,, swelling hchind tliV left as ten ptoni 'foil an attack of'vl '".^,^■"•1. Ilcr illness I loifan years old. Tl VIZ. lainful V^ was followed '<"'oa of coiisiderahle tiiiuc welling of the I iinniediatoly hy 'If until 1. About now. a V '-'''"'' <*'^«-^'-Miuys,^i:>::::'" ear after the onset the cond lave con- ' ITaiisactiotis of the Collegi 'tion of the Jeg.s is de.. "f I'liysicians, Pliiiadelphia, 1S92. interval the skin had a reddish, mottled, (e.lematoiis look. Some coiisiunt |)tiiii aiul oxccssivc hypura'slliesia. As well as t'oiild 1)1' made out the sense of temperature was liiiinted, if not lost. Knee-jerk jircseiit, lhoii;.di sliirhi. 'rh,. nffected area extended from the insertion of the patellar li;i;aiiieiit to ankle, and was sharplv delined at each limit, and extended coiimletely around the le;:s. I)rrniihr,\ 1H,H.'). On the whole better. The affected area lui« lieeotuo limited, liy the approach of the upiier and lower hoiindari. s some two or tlireo iiiehe.s nearer each other, lias better and worse days, hut for last year or more has lieeii active in playin;: about, except duriiin- attacks of jiaiii, and lately these have not been severe or distinct eiioii;:h to iiiake her lay up, but all day the condition is as described in July, IMS.'), cominj,' the subjective sense of [)aiii \io\\\-, which comes and e(„;s, but never suppiir intensity of the pain and swelliiit;- coineid iiiii' over tile ate: Tl 10 1 Fallini,' attacks. At lirst, and for a year, she would fail forward, two or three times a dav, on her hands and head, and mil would roll over on the 1! ess eauuht 0(M'. Tl lere was no aura, no ei probably no loss of conseioiisiiess, but of this she is llivul: piick. I'\)r the last two vears has not sure. 'ion, and {ecover\' was ( or ioiiii<''e, never 1 alwavs had tune to "ct to a chair OSes consciousness, and it never lasts more than (ive niiiiutes, and often only a few seconds. I .saw one which consisted merely in puttinjr lier head on iier mother's shoulder, who was sittinjif near her, 1 almost iiumediately pickiiiir it up again. It had the apjuarance of am being done Un- my lu'uelit. During these attacks she feels faint and jiowerless. Iloart-sounds normal. nrHKAHK, |)l li> Ix'il ; the i;;li llif nielli ; xti't'riit'lv imiii- uikI I'liii ilowii ca. I'llinc (III ill the hI ly (Itliiii'd at t'U has I •ec'diuo irit s some two ■ (lays, lull for liiriii;^- atta