1906 No. 14 IN THE PHYSICIANS' AND STUDENTS' BEADY- REFERENCE SERIES. DISEASES Lungs, Heart, and Kidneys, N. S. DAVIS, Jk., A.M., M.D., Professor of Principles and Practice of Medicine, Chicago Medical College; Physician to Mercy Hospital; Member of the American Medical Association, Illinois State Medical Society, Chicago Medical Society', Chicago Academy of Sciences, Illinois State Microscopical Society; Fellow of the American Academy of Medicine; Author of "Consumption: How to Prevent lb and How to Live with it," etc. ^^•m^. ^u^ >^gesak^ Philadelphia and London: THE F. A. DAVIS CO., PUBLISHERS. 1892. Entered according to Act of Congress, in the year 1892, by THE F. A. DAVIS CO., In the Office of the Librarian of Congress, at "Washington, D.C., U.S.A. Philadelphia, Pa., U.S.A.: The Medical Bulletin Printing Honse. 1916 Cherry Street. Library top PREFACE. This volume comprises a part of the topics lectured upon by me for several 3'ears in the Chicago Medical College. They hijve been elaborated from ni}^ lecture notes. It has been my endeavor to describe as clearly, concisely, and fully as possible the subjects of this book. I have avoided controversial topics, and may sometimes have erred by stating positively what is ratlier probably than positively true. I have tried to make the subject of treatment especially full, and have endeavored to give explicit directions as to the time when individual drugs should be used, the exact indica- tions for them, and their mode of action in each disease. In order to prevent repetitions when the mode of action of drugs was the same in several allied diseases this fact is stated, and the details of action must be learned from the description of the first of the allied maladies. That the volume might not outgrow the '• Read}' Reference Series " for which it was intended, numerous foot-notes and tables of bibliography have not been added to the text. N. S. Davis, Jr. 65 Randolph St., Chicago, October. 1892. (ui) 62418S TABLE OF CONTENTS, SECTION I. Diseases of the Bronchi, Lungs, and Pleura. DISEASES OP the BRONCHI. CHAP. PAGE I. Asthma 3 II. Trachitis and Bronchitis 22 Acnte 22 Capillary 24 Chronic 26 III. Bronchiectasis 57 DISEASES OF THE LUNGS. IV. Emphysema 61 V. Atelectasis 67 VI. Haemorrhagic infarction 70 VII. Hypostatic and passive congestion 73 VIII. Pulmonary oedema 78 IX. Catarrhal pneumonia , 82 X. Croupous pneumonia 86 XI. Cirrhosis of the lung 107 XII. Pulmonary abscess and gangrene 112 XIII. Pulmonary tuberculosis • • • 1^^ XIV. Neoplasms of the lungs 167 DISEASES OF THE PLEURA. XV. Pleurisy 169 Acute fibrinous or dry pleurisy 173 Serous pleurisy 176 Empyema 177 XVI. Pneumothorax 187 XVII. Hydrothorax 194 (V) vi Table of Contents. SECTION 11. Diseases op the Heart, diseases of the pericardium. CHAP. PAGE XVIII. Pericarditis. 199 XIX. Hydrops pericardii 207 XX. Pneumopericardium 208 DISEASES OP THE HEART-MUSCLE. XXI. Dilatation of the heart 210 XXII. Cardiac hypertrophy 215 XXIII. Fatty heart. . 220 XXIV. Indurative degeneration 22(5 XXV. Myocarditis 230 Simple 230 Purulent 230 DISEASES OF THE ENDOCARDIUM. XXVI. Endocarditis 231 XXVII. Chronic valvular disease 239 Aortic insufficiency . 243 Stenosis of the aortic orifice 245 Mitral insufficiency 24(> Stenosis of the mitral valves 249 Pulmonary insufficiency and stenosis . . 250 Tricusjiid insufficiency 251 DISEASES OF CARDIAC INNERVATION. XXVIII. Tachycardia, or nervous palpitation 256 SECTION III. Diseases of the Kidneys, functional inactivity. XXIX. Ursemia 263 diseases of renal CIRCULATION. XXX. Passive congestion of the kidneys ...... 274 Table of Contents. Vll RENAL INFLAMMATIONS. CHAP. PAGE XXXI. Acute nephritis 279 XXXII. Chronic parenchymatous nephritis 295 XXXIII. Interstitial nephritis 313 XXXIV. Suppurative nephritis 333 RENAL DEGENERATION. XXXV. Amyloid kidney 337 DISORDERS OP THE RENAL PELVIS. XXXVI. Nephrolithiasis 342 Hydronephrosis 345 XXXVII. Pyelitis 350 SECTION Diseases of the Bronchi, Lungs, and Pleura. 1 A (1) DISEASES OF THE BRONCHI, CHAPTER I. Asthma. Nature. — Asthma is an expiratory dyspnoea which occurs parox3'sraall3-, and is usually sudden in its onset. As a rule, the paroxysms are, at longest, of only a few hours' duration. The exact nature of these attacks is unknowu. Bj' most clinicians they are believed to be due to spasmodic contraction of the bronchi, which is excited through the agency of the nervous system. A smaller number believe that the narrowing of the bronchi is due to a sudden and very great congestion of their mucous membranes. Such a congestion could only be produced through the active agenc}' of the vasomotor nervons system. It may be likened to the cutaneous congestion and swelling of hives. Intense congestion of the trachea and that part of the right bronchus which can be seen in a laryngeal mirror can be observed during an attack of asthma. A still smaller number of observers explain the paroxysm upon the supposition that it is due to a spasm of the diaphrngm, which causes an enlargement of the thorax, and, therefore, sudden dilatation of the lungs and diflfi- cult and unnatural respiration. This view is based upon the fact that in many cases of asthma no movement of the diaphragm can be demonstrated. There are other cases, however, in which movements can be demon- strated. The expianntion is not, therefore, of univer- sal applicabilit}'. That muscular contx'action of the (3) 4 Diseases of the Bronchi. bronchi can be produced has been demonstrated bj' physiologists. The suddenness of the onset of these attacks, and often of their cessation, as well as the prompt relief so frequently obtained from such drugs as chloroform and chloral, demonstrates the dominant influence of the nervous S3'stem in their production. Most, if not all, cases of asthma are of reflex origin. Therefore, the physiological mechanisms wliich are in- volved consist of (1) a source of irritation or sensitive nerve-endings that are subject to irritation ; (2) the central nervous system by which the irritation ex- perienced by the sensitive nerves is reflected to the motor ones ; (3) the motor nerves and muscular fibres of the bronchi which constitute the focus of irritation. Undoubtedly the mucous membranes become reddened simultaneoush'. A temporary expansion of the lung- alveoli in this disease is the result of overfilling, because of imperfect emptying during expirntion. The calibre of the smaller bronchi is diminished ; and, as inspira- tion, which is accomplished purely by muscular action, is a much more forceful act than expiration, which is brought about, chiefl}' b}' the elasticit}' of the lung-tissue, the weight of the tlioracic and abdominal walls, and in d3'spnoea tlie exercise of voluntary muscles, which do not, however, act under the most advantageous con- ditions, more air gradually enters tlie alveoli than can be forced out. This temporary expansion of the lungs leads to an enlargement of the entire thorax during the dyspnoeic paroxj sm. Symptoms. — The asthmatic attacks usualh' occur in periods lasting from a few days to several weeks, dur- ing wliicli time they recur at regular, and usually at dail}^, intervals. The periods ma^^ be weeks or months apart. Less frequently a single paroxj^sm of dyspnoea Asthma. 5 will occur not followed by others, or followed by them only after a long intermission. In the majority of cases there are no premonitory symptoms, but in this respect, as in the causation of the disease, there is much of idiosyncrasy in each case. In a proportion of them there are premonitory symptoms that are peculiar to each individual. A person is occasion- ally found whose attacks are uniformly preceded by an unnatural drowsiness, or it may be by sneezing, or itchi- ness, or flatulence, or b}' the i)assage of large quantities of very pale urine, or bj' various other symptoms which the sufferer's experience leads him to recognize as warnings of the approach of an attack. The paroxysm of dyspnoea almost invariably occurs in the earliest morning hours, and in a majority of cases between two and four. The sufferer usuall}'' awakes from a sound sleep with a feeling of opi)ression in breathing. Almost at once tiie dyspnoea becomes intense. If the patient is not accustomed to the attacks relief is usually sought at the open window ; those who have often experienced the sufferings of asthma assume at once some favorite attitude which they have learned makes it possible for them to breathe with tlie most ease. These attitudes are various, but their object uniformly- is to fix the shoulders rigidl}^ so that the unusual muscles of respiration which find origin nbout them can act most advantageously upon the thornx. A favorite position with many is a sitting one upon the edge of the bed or upon a chair, the sides of which are grasped b^' the straightened arms, which thus hold the shoulders rigid. The body is bent a little forward, the head is thrown back to straighten the neck, and the mouth is opened to permit the freest ventilation of the lungs. The countenance expresses at first anxiety, and later 6 Diseases of the Bronchi. extreme distress, as the symptoms of suffocation inten- sify. Tlie vioieut muscular exertion that the struggle for breath involves produces at tiist a warm, moist per- spiration over the upper part of the bod}' and face. As the dyspnoea is prolonged and intensified the skin be- comes cool and chimmy ; in color it is often ashen and the lips and finger-nails become purplish. In a word, marked cyanosis is developed. The pulse is quick and frequently irregular, small, and rigid. The veins of the neck are unusually full and may stand out like whip- cords. This is due to the interference with normal venous circulation by the change in intra-thoracic press- ure caused by the dyspnoeic breathing. The bodil}' tem[)erature is rarely abnormal. A physical examination shows that, wdiile the respira- tory movements are so labored, they are no more or ver}^ little more rapid than normal. The thorax is dilated, and it retains constantly the normal inspiratory position. Tiie intercostal spaces do not change in width with the respiratory moA'ements, but are persistently stretched to their widest extent. The ribs do not move freel}^ on their axes with each respiration. As the chest is thus constantly extended to its utmost, in- spiration is only effected b}' lifting the thorax as a whole with the unusual muscles of respiration. The inspi- rator}'' act is short and jerky in character and the ex- pirator}' is ver^' much prolonged and labored. During inspiration the lower part of the chest will be observed, in children, not to be expanded, but to be retracted. This appearance is little noticed in adults, as their ribs are too rigid to be thus ])enr, but the lower intercostal spaces, as well as often the su})ra-clavicular spaces, are retracted during inspiration. This is due to the low pressure within the thorax during inspiration. The Asthma. 7 air is not able to enter and dilate the lungs when the thorax is lifted ; therefore, the atmosphere's weight presses in the yielding parts. Palpation usually reveals no change, although occnsionall}' a bronchial fremitus can be felt. Percussion reveals an increased resonance, whicli is uniform upon both sides of the chest. The area of resonance is increased. The area of dullness over the heart is diminished by the distension of the overlapping portion of the lung, and the area of liver- dullness is depressed and seen to change less in its horizon with inspiration and expiration than natural. These changes are due to the unusual distension of the lungs and imperfect respiration maintained b}' them. The apex-beat of the heart can frequently not be seen or felt, and its sounds are somewhat distant because of the overlapping lung. Auscultation is not necessary in order to hear the abnormal respirator}^ sounds, for they are so loud that they can be heard many feet from the sufterer. If the ear is placed on the chest, vesicular sounds will be found entirely absent, and only piping and crowing will be audible, and the latter can be heard as readily b}' the by-stander. The inspiratory sound is very short, the expiratory much prolonged. Usuall}' wheu the dj-spnoea is most intense, the cya- nosis most marked, and fatal suffocation appnrently imminent, relief comes and the oppression rapidly abates. With or ver}" shortly preceding this abate- ment a slight cough begins. In many cases it is so slight as to be unnoticed. Usuall}^ it is accompanied by the expectoration of a small nuuiber of sputa-chunks, of small size and glary, gra}', adhesive character. If the sputa is examined microscopicMlI}' it is found, in a large proportion of cases, to contain cliaracteristic ele- ments. The most striking are spiral coils of thread- 8 Diseases of the Bi'onchi. like fibrils. The}' ure not strictl}' peculiar to iistlima, although they occur witli it more uniformly than with any other disease. They have been noticed in the sputa of capillary bronchitis and rarely in that of croupous pneumonia and phthisis. The needle-like crystals of Charcot can also be frequently observed. The cellular elements are those usual to sputa, and are not peculiar to the disease. The paroxysm that I have described typifies those of the severest t3'pe of the disease. Ever}' grade of milder form can be observed, even to that in which there is little disturbance of respiration more than a feeling of oppression. The duration of the paroxj'sm of d3'spnoea is variable. It may last a few minutes only, — usuall}' it persists for from one to three hours. In rarer cases it will last for several da3S with little change, except an intensification during the night. These are nsuall}' cases in which bronchitis is present, and is the exciting cause of the asthma. Such cases are accompanied by more or less persistent cough and somewhat accelerated breathing. They can be dis- tinguished from capillar}- bronchitis with difficulty, except b}^ the parox3'smal character of the dyspnoea and by the absence of fever. The intervals between attacks of frankh'-spasmodic asthma are passed b}' the patient in perfect comfort. When the dyspnoea first ceases the suflferer is so ex- hausted by the preceding laborious breathing that .nlmost invariably he drops upon. the bed and falls into a quiet and sometimes protracted sleep. Ou awakening from this sleep the patient usuall}- feels perfectly com- fortable. At tliis time an examination will reveal no abnormal physical signs. In most instances the dyspnoea will recur the following night, and ma}' for several more. Asthma. 9 Diagnosis. — Diagnosis is usually not difficult ; the sudden onset, the severity of the d^^spnoea, the sudden cessation, the complete restoration dnring the intervals, and repetition of the attacks are characteristic. It is necessar}^ at times, to distinguish the dyspnoea of spas- modic asthma from that produced by laryngeal or tracheal obstruction. In the latter cases the dyspnoea is mainly inspiratory^ while in asthma it is expiratory. Upon search a cause for the dyspnoea is found in the upper air-passages. The noise of respiration is loudest about the throat. From capilhiry bronchitis we can differentiate spas- modic asthma: 1. By the mode of onset, which, in the former, is somewhat slow and gradual, not sudden. 2. By the absence of fever in asthma. It must be remem- bered, however, tliat an apyretic capillar}' bronchitis occurs at times. 3. Bv the hurried respiration of the bronchitis. 4. By the presence of cough. 5. By the sudden cessation of the d3'spnoea of asthma and more persistent character of that of the inflammator}' atfec- tion. From emphysema it is to be distinguished (1) by the chronicity of the d\'spnoea, (2) by its lack of paroxj^smal character, and (3) by the permanent dis- tension of the chest in the former. From cardiac asthma (1) b}^ the existence of a cardiac lesion that will explain its cause, (2) by its persistence, and (3) by the absence of a history of attacks prior to the development of the cardiac trouble. It must be remembered that bronchitis, emphj'sema, and cardiac disease may be complicated by true spas- modic asthma. In all cases of persistent d3'spnoea with niglitl}' exacerbations, some other cause than simply spasm of the bronchi may be quite confidentl}^ sus- pected, even if it cannot be proven. 10 Diseases of the Bronchi. Causes. — The causes of asthma are both predispos- ing and exciting. There are a few cases, the cause of which is unknown, that are often described as idio- pathic. This group is constantly growing smaller as our knowledge of the causes of the disease increases, (a) Age, to a limited extent, predis[)Oses to the disease, since it occurs most frequentl}' between the ages of 20 and 40. (b) It is said to occur oftener in males than in females, (c) Most asthmatics are nervous by tempera- ment. It is frequently noticed that the disease attacks some members of several generations of the same family, and, therefore, it is regarded as (d) inheritable, (e) Such diseases as scrofula, heart diseases, Bright's diseases, gout, and rheumatism are very frequentl}' asso- ciated with asthma, and are regarded as predisposing to it. The exciting causes are numerous, and \ixvy with the source of irritation, whence reflexly the bronchial spasm is produced. The most usual sources of irrita- tion are in the nose, bronchi, pharynx, stomach, and womb. Acute and chronic nasal catarrh, and especiall}- nasal polj'pi, are common causes. Spasmodic asthma is of very frequent occurrence in connection with the coryza of hay- and rose- fever, which is generall}' supposed to be produced by a vegetable dust peculiarly irritating to certain individuals. Bronchitis is occasionallj- accompanied b}' asthma. Whether in these cases the asthma arises from a reflex irritation of the motor bronchial nerves or from direct irritation of them b}' the surrounding inflamed tissue it is impossible now to say. As drugs which benumb the central nervous S3'stem do good in these as in other cases of asthma, it scarcely' seems probable that direct Asthma. 11 irritation of the motor nerves can be the cause of the spasm. Still more rarely enhirged tonsils and pharjm- geal and laryngeal growths are the source of irritation of tlie disease. Irritation of the stomach ver3' rarely is the exciting cause of astlima. lu a ver}- small proportion of cases we find disease of tiie womb or pregnane}^ the source of the irritation thnt produces the bronchial spasm. Compression of tiie main trunk of the pneumogastric b}' tumors, or their iuvolvement in such growth, has a few times been observed to be causative of the disease. Assertions that asthma ma}^ result from lesions of the central nervous system have not been authoritatively confirmed. It is more than probable that cardiac disease and Bright's diseases do not simply predispose to asthma, but in the course of these disorders there is produced some substance which, when carried to the nervous S3'S- tem b}' the blood, proves an exciting cause. The fre- quent occurrence in Blight's diseases of asthma, associ- ated with other symptoms of mild ursemic poisoning, has led to a general belief that it is also due to uraemia. Rarel}', examples of a peculiar form of asthma are seen in wdiich the source of irritation seems to be mental or central rather than peripheral. I refer to those cases in which the dyspnoea is caused b}' fear, and to those in which it is excited by certain, although the most varied, localities or odors. If tliese susceptible persons are not conscious of being in the locality of the noxious object, no respiratory discomfort is experienced. These are cases of mental idios3'ncras3', and usually are associated with an hysterical temperament. Treatment. — Prophylaxis can be applied to a large number and variety of cases. Exemption from the dis- 12 Diseases of the Bronchi. ease is oiil}^ obtainable by either removing the cause of the disease from the siitlerer or removing the sufierer from the cause. The latter method is especially appli- cable to the cases of liny fever in which foreign bodies in the atmosphere are the exciting cause and the nasal mucous membrane the source of irritation of the dis- ease and complicating asthma. A change of climate and, therefore, of air is curative. The localities in this countr}^ that afford most perfect exemption are the White Mountains, Mackinac, many localities along the shore of Lake Superior, and numerous places in the more elevated parts of the Rocky and other mountain- ous regions. A residence in the heart of a thickly-pop- ulated city will often grant to individual cases immunit}', although they ma}' suffer severel}- in neighboring sub- urbs. As tliese attacks are most likely to occur at cer- tain seasons, especially in August and September, and less frequentlv in June, temporary clianges of abode at these times will usually give exemption to those who are liable to the attacks. Manj- of the afflicted cannot take advantage of such prophylactic treatment. To prevent asthmas that result from the existence of chronic inflammation or tumors within the nostrils, a destruction of the irritating tissue must be effected. A temporary relief can often be obtained b}' the use of local anaesthetics. Rarel}', the source of irritation is found in the pharynx or larynx. In such cases the irritant is usually a morbid growth or a chronic inflam- mation with hypertrophy. Such lesions must be treated just as are their analogues in the nasal cavit}'. The indications for treatment are (a) to prevent the development of dyspnoea and {b) to relieve the dyspnoea when developed. In the intervals between the dyspnoeic attacks the iodides are often prescribed, with marked Asthma. 13 benefit. TJnfortunatel}' , they do not uniformly ward off or mitigate the paroxysms. The cases in which good results are most uniformly obtained from tlieir employ- ment complicate chronic bronchitis. It is probable that their good effects are largely due to the property, which they possess, of promoting re-absorption of cellular exudates in inflamed tissues. The iodide of soda is the most eligible preparation for persistent employment. It should be given for weeks, and often for months. 1 have seen several cases apparently exempted from severe attacks 1)3' senecio aureus. The drug was not given during dyspnoea, but while the parox3sms were threatening, and at a season when the patients were usually- afflicted by them. By the continued use of it for several weeks an actual outbreak was avoided. An analysis of the mode of action of the drugs that are most successful in asthma shows that in one of three ways thev relieve the spasm. We may, therefore, place them in three groups. The first includes those that affect the source of irritation, the second those that benumb the neive-centie or reflector of irritation, and the third those that act upon the focus of irritation. In the first group we must place a very promiscuous collection of drugs, since the source of irritation may be in almost any part of the body. We find, therefore, in this list, those medicines thnt alia}' irritabilit}' of nasal, phar3'ngeal, bronchial, and gastric mucous mem- branes, and also those that allay irritability of the womb and some of the parench3'matous organs. In asthma of nasal origin there is necessary for its production not ouIn' the specific irritant in the atmos- phere, but a peculiar sensitiveness of the nerve-endings which constitute the source of irritation, and possibly, also, of the nerve-centres. Advantage can be taken of 14 Diseases of the Bronchi. these facts in mitigating and preventing the disease when a change to a pnre, nnirritating air is impossible. Thus, in ha}' fever, local anesthetics api)lied to the nasal mucous membrane Avill frequentl}' hold the disease in abeyance, or at least mitigate it. Of the remedial agents that can be topically applied for anaesthetic effects, cocaine is the most important. A 5- to 10- per- cent, solution may be sprayed into the nose through the anterior nares, and, when necessary-, also applied to the posterior nares through the mouth. Or it can be employed by insufflating a powder composed of it and some bland diluent. A cocaine ointment ma}' be used, a little being placed in the nostrils and allowed to melt and trickle backward, so as to anoint the mucous sur- faces. This method is less efficacious than either of the others, since the drug is not applied so uniforml}^ to all parts of the nose. It must be remembered, in regard to cocaine, that, if used in small amounts often, or in strong solution less frequently, symptoms of intoxica- tion ma}' be produced. I have rarely found it necessary to use preparations of more" than 4-per-cent. strength. Often a few applications of cocaine will greatly aid in discovering the source of irritation, for cases occur in which we suspect the source to be in the nose or throat, and, if applications to these parts allay the dyspnoea, we may feel that our suspicions are well founded. As a topical application morphia is also useful. It acts less promptly than cocaine, but often its effects arc- more lasting. A good formula consists of 4 per cent. of cocaine and 2 per cent, of morphia, mixed with some inert powder or with water, according as one wishes to make applications by insufflating or by spraying. We must place in this miscellaneous group, also, the Asthma. 15 various expectorant and anodyne mixtures that are emplo^'ed to allay laryngitis, trachitis, or bronchitis, since these inflanmiations are frequent causes of asthma, and, therefore, their cui'e will give exem[)tion. The efficacy of such mixtures is greatly enhanced by com- bining with tiiem drugs that belong to the second group, or those that allay the excitabilit}* of the reflex centres. In the same way, asthma which accompanies un- compensated valvular disease of the heart is relieved b}^ digitalis and similar drugs. They strengthen the heart's action and give greater tone to the blood- vessels, and thus reduce venous hyperaemia of the lungs and bronchi. These remedies accomplish more for such asthmatics than those that relax muscular spasm. They do good by stopping the irritation at its source. Cases in which the source of irritation is in the organs of the alimentary tract are relieved, and often permanently' cured, by treatment of the primary lesions. Occasional!}^, a woman is found who is persist- ently troubled with asthma during pregnancy, although free from it at other times. Absolute relief is, so long as pregnane}' lasts, usually impossible. I have, how- ever, seen marked benefit obtained by the persistent use of viburnum prunifolium. This drug without doubt lessens the irritability of the uterine tissues, and thus diminishes the irritabilit}^ of the source of irritation of the asthma. The second group of drugs includes those that act on the nerve-centres, and thus inhibit reflex action. The most important of them are chloral, chloroform, ether, opiates, and bromides. When dyspnoea is intense a few whiffs of chloroform will give relief promptl3\ As the relief is often not of long duration, and as the drug cannot with safet}^ be left in the hands of the 16 Diseases of the Bronchi. sufferer, its niiige of usefulness is limited. Of this group, chloral is the safest and most universally useful. If the asthma is wholly parox3'snial, it is best adminis- tered in one or two full doses rather than in several smaller ones. Often 1.0 to 1.5 grammes (15 to 20 grains), given in sweetened water, will not only relieve present d3'spnoea, but produce an effect sufticientlj' last- ing to suppress the attack. In cases tliat complicate bronchitis, trachitis, or laryngitis, and in which the dyspnoea is not paroxysmal onh% but to some extent is persistent, since the source of irritation is constanth' excited, the best effects are obtained by the repetition of smaller doses of chloral, bromides, opiates, or of mixtures of all these with expectorants. In this wa}' the nerve-centres are constantly inhibited or restrained in their activity, so that the paroxysms of exacerbation are held in abeyance, and time is gained in which to overcome the primary inflammation. A formula that I have frequentl}' employed, with marked benefit in such cases, is the following: — R Chloral., grms. 15.00 (,^iv). Ammonii muriatis, ..." 10.00 (5iiss). Morphiae muriatis, . . . grm. 0.20 (gr. iij). Antim. et pot, tart., ..." 0.15 (gr. iiss). Ex. grindeliae robustatse fl., c.cm. 45.00 vel 60.00 (^iss). Aq. vel syr. glycyrrhlz., q. s. ad c.cm. 120.00 (^iv). Sig. : Give one teaspoonful every three to six hours, in sweetened water. Morphia and the bromides are less generally useful than chloral. The bromides, given steadilj', in rather large doses, are serviceable when the source of irritation is the larynx or phar3'nx, for they not oul}^ act favorabl}' by lessening the excitability of reflex centres, but also have the peculiar propert}^ of benumbing the nerve- Asthma. IT endings in the mucous membrane of the larynx and phar3^nx. The dose should be large; for example, 1.5 to 3.0 grammes (20 to 45 grains) of the bromide of sodium. There is another class of remedial agents which it is difficult to classify with certainty, for our knowledge of their ph3siological action is imperfect, and the results of researches are not completely harmonious. The drugs to which I refer are grindelia robusta, senecio aureus, quebracho, lobelia, and tobacco. It seems probable, however, that as remedies for asthma they can be placed in this second group. Death from tobacco poisoning is due to paralysis of respiration. The physiological action of lobelia is very similar to that of tobacco. When lobelia is used in asthma it must be given in doses of from 2 to 4 cubic centimetres (^ to 1 drachm) of the tincture, and repeated every two hours, or oftener, until vomiting and relief are produced. Mitigation of the d3'spnoea usually corresponds with intense nausea, and is greatest after vomiting. Quebracho has a peculiar effect upon respiration in healthy persons. It slows it and prevents panting when hurried movements are made. At the same time it re- tards the heart. Gutman has shown that its active principle, aspidospermine, produces death by poisoning the respiratory centre. We know less of the physiological action of grinde- lia and nothing of senecio. Grindelia produces death only in very large doses, and then by paralyzing respira- tion. In smaller doses it slows the respiration and the heart. The effects of lobelia must be carefully watched, for large doses have produced alarming s^^mptoms. For this reason I have employed it rarely, but grindelia I 18 'Diseases of the Bronchi. have administered frequently, and quebracho and sene- cio less frequenth', although enough to feel confident that to some extent the}' are useful. The}' are so much less efficacious than some other remedies at our com- mand for the relief of the dyspnoea that I rely upon them not at all for its treatment, but rather as adjuvants for warding off the recurrence of the paroxysms. Grindelia and quebracho are probabl}' mildl}' expec- torant, and, through their bitterness, tonic, to the stomach. But their bitter and otherwise unpleasant taste limits greatl}' their eligibilit}'. Their fluid ex- tracts can be administered in doses of 2 to 4 cubic centi- metres {\ to 1 drachm). The third group of drugs embraces the nitrites and nitro-glycerin. Amyl nitrite administered by inhala- tion has been used in asthma for a number of years. Nitro-glj'cerin has been used less frequently, and the nitrites of soda and potash still less. Prof. Fraser, of Edinburgh, has given us the most trustworthy^ informa- tion as to the relative value of these drugs in asthma. The}^ all relieve the spasm, and with wonderful prompt- ness. The effects of am}-! nitrite are ver}^ transitory. Nitro-gl3'cerin, when given in doses of sufficient size, is apt to provoke congestive headache. The nitrite of soda he found gave quite as prompt relief as the others, was less likel}' to provoke headache, and produced more enduring effects. The more purely spasmodic the case, the more efficacious are these drugs. Dr. Fraser found that, in two or three minutes after the administration of even half-grain doses of the nitrite of soda, marked re- lief was noticeable in the patient's breathing and a less- ening of the crowing and piping in the chest. In ten minutes or less, patients feel comfortable. It was rare that it was necessar}^ to repeat the dose in any single Asthma. 1& attack. The good effect of these drugs, when admin- istered in the usual therapeutic doses, is undoubtedh' chiefly due to their action upon the muscle-fibres of the bronchial tubes, irritability of which they lessen or temporarily destroy. In other words, they act upon the focus of irritation. In less degree they ma^^ diminish the irritabilit}^ of the motor nerves. This is a some- what doubtful effect of therapeutic doses, although it can be obtained from large doses. In using the nitrite of soda, which, from considerable personal experience, I can commend, it must be remembered that there are two preparations in the market, — a "commercial" and a chemically pure. The former can be given in doses of from 0.3 to 0.6 gramme (5 to 10 grains), and 1.3 grammes (20 grains) have been given without harm.* The therapeutic dose of the chemically-pure drug is from 0.06 to 0.3 gramme (1 to 5 grains). While the most beneficial effects are obtained in the most frankly paroxysmal cases, marked benefit may be derived from the continued use of these remedies in asthma that com- plicates bronchitis and that is to some extent persistent. In such cases I have combined the nitrite of soda with the usual expectorant and anodyne treatment of bron- chitis. It may be administered in 18- to 30-centigramme doses (3 to 5 grains) every three to six hours. Atropia, stramonium, and h3'0scyamus constitute an- other series of drugs that are analgesic to the focus of irritation. The two first are the ones most frequently used in this disease. They cause relaxation of the bron- chioles, in part by benumbing their involuntar}' muscu- lar fibres and in part by lessening the sensibilit}" of their terminal nerve-fibres. While efficient in aiding to give relief, their side-effects are so marked and often so disa- * Therapeutics : its Principles and Practice. By H. C. Wood. 20 Diseases of the Bronchi. greeable that thev cannot be used in efficient doses. The action of tlie drugs is so well known that I need hardly say that these side-eftects are : dryness of the mouth and throat, heat and redness of the skin, dil- atation of the pupil, disturbed vision, and, in ver}" sus- ceptible patients, mental perturbations. Full doses are rarely emploj^ed, but frequentl}' small doses are used to re-inforce the action of other drugs, as in the follow- ing formula, which is especially efficient for the relief of asthmatic dyspnoea: — B Chloral., .... grms. 20 (3v). Sodii nitritis, . . . grms. 3 (,^j). Tinct. stramonii, . . c.cm. 6 (3iss). Elix. simpl., . q. s. ad c.cm. 60 (5ij). Sig. : Take one teaspoonful every four hours, in water. Not onl}' do these remedies act favorably when they are taken by the stomach, but the inhalation of the smoke of the crude drugs is often of the greatest benefit. Stra- monium-leaves are used in this wa}' most frequently. The leaves are smoked either when rolled into cigarettes or from a pipe. Their efficacy is enhanced b}-^ first soaking them in a saturated solution of nitre and sub- sequentl}^ drying them for use ; or the}^ maj' be mixed with or rolled in bibulous paper that has been thus satu- rated. The nitre is decomposed by the heat, and a nitrite is formed which aids in relieving the dj-spnoea. There are numerous proprietary cigarettes and pastels for asthma, the basis of whose composition is stramonium and nitre. When uraemia is the cause of asthma, diaphoretics, diuretics, and cathartics are indicated for the elimina- tion of the poison. The first of these classes of drugs gives the most prompt relief. Of diaphoretics, pilo- carpine administered subcutaneously,is the most prompt Asthma. 21 in its action. It is necessary to prevent the re-accumu- lation of poisons thus eliminated. This is best accom- plished hy diuretics and, when the}' are not siitflcient, the coincident use of cathartics.- Cathartics and the preparations of jaborandi must be emplo3'ed with cau- tion when a patient is debilitated or has heart-weakness. CHAPTER II. Trachitis and Bronchitis. The words trachitis and bronchitis are applied to acute and chronic catarrhal inflammations of the trachea and the bronchial tubes. Besides the simple form there are specific forms of bronchitis, such as tubercular. They are best considered separateh'. Usually, both the trachea and the bronchi are simultaneously affected, but in differing degrees of severity. The inflammation may centre in the trach-ea and scarcely involve the bronchi ; the disease will then be recognized as trachitis On the other hand, if it centres in the larger bronchi, it is de- scribed as simple bronchitis, and, if in the smallest, as capillar}^ bronchitis. Anatomy of Acute Simple Bi-onchitis. — When the bronchial tubes are acutely inflamed, tlie first change that occurs is congestion of the submucosa, which is almost immediately followed b}' swelling, in part due to the congestion and in part to a serous exudate which fills the tissue. Simultaneously^, the basement mem- brane thickens and the epithelial cells resting upon it are loosened from one another. If the irritation which excites the inflammation is severe, the submucosa fills with wandering round-cells of leucoc3'tal origin. These cells, at first, are most numerous about the vessels, but soon fill the tissue diffusel}^ and in some cases pene- trate and fill the muscular coat, and even the peribron- chial connective tissue. They also mingle with the epithelial cells ui)on the surface of the bronchial tubes. Before this has occurred, however, the ciliated epithelial cells are cast oflf. The denuded surface is composed (22) Trachitis and Bronchitis. 23 of embiyonic epithelial cells, which, so long as the cause of inflammation exists and the process is active, are unable to reform ciliated columnar epithelium. So soon as active tissue destruction ceases, the epithelial surface is rapidly restored to a normal condition. The exudates, serous and cellular, are removed through the l3-mphatic channels, and perfect restoration is accom- plished. While denudation of the epithelium is the rule in acute bronchitis, true ulceration is rare. The cells of the mucous glands are usuall}^ swollen, and the calibre of their ducts is diminished in part by this swell- ing and in part b}' compression by the swollen sur- rounding tissues. The occurrence and the degree of all tiiese changes var}- with the severity and duration of the inflammation. Many of them are wanting in the mildest cases. The inflamed tissue is redder than natural, although the congestion is generall}' not evident to the naked eye when post-mortem examinations are made, and, if pres- ent, usually is seen in patches, and not uniformly dis- tributed. The mucous surface of the trachea or the large bronchi, when inflamed, appears swollen and soft and has a dull gloss. In the opening stage of conges- tion it is unusually dry ; later, it is covered with a larger amount of serum and mucus than is natural. At first the exudate is viscid and tenacious; soon, however, it becomes more dilute from the admixture of serum which partl}^ forms it. It loses its early vitreous appearance, and is made whitish b}' degenerated and cast off cells. If the inflammator}' process is severe or at all prolonged, the exudate becomes j^ellowish from the addition to it of round-cells of leucocytal origin, that resemble in all respects pus cells. The exterior of lungs in which the bronchi have been inflamed presents no abnormal ap- 24 Diseases of the Bronchi. peariiiices. When a section of them is made there flows from the cut surface, and chiefly from the ends of the divided bronchi, a frothy mucus. Muco-purulent matter, also, can usually be expressed from the latter. In simple acute bronchitis these changes are found to be symmetrical!}' distributed in both lungs. Physiological Distui^hance. — The swelling of the mucous membrane of the trachea or the larger bronchi is not sufficient to cause noticeable obstruction to res- piration. The unusually dry condition of the mucous membrane in the earliest stage of inflammation prevents the straining of the air, which is normallj' accomplished by the adherence of foreign particles to the mucus which covers its surface, and their removal b}' the cilia of the columnar epithelium. After desquamation has occurred, even though the surface is abundanth^ covered with mucus, dusts are imperfectl}' removed and maj', therefore, prove the source of additional irritation. Ayiatomical and Physiological Changes of Capillary Bronchitis. — In acute inflammation of the capillar}^ bronchi the same anatomical changes are observable ; but the difference in their normal structure leads to greater physiological perversions than are present when only the larger tubes are involved. The calibre of the smaller bronchi is proportionately very much less than of the larger, because of the deep infolding of the mucous membrane. For the same cause a trans- verse section of a bronchiole is stellate. Owing to these peculiarities the same degree of swelling which in the larger ])ronchi will cause no respiratory obstruc- tion will greatly interfere with it in the smaller ones ; and a moderate amount of mucus, cast-off epithelium, and detritus from cellular degeneration will produce complete obstruction. Dyspnoea, more or less intense, is, there- Trachitis and Bronchitis^. 25 fore, a characteristic of capillary bronchitis. There is a decided tendeiic}', also, and especially in very severe and in chronic cases, for the inflammation to extend through tlie bronchiole to the surrounding lung-tissue, and to produce peribronchitis or catarrhal pneumonia. Complete obstruction of the bronchioles leads to a circumscribed collapse of the alveoli communicating with them. (See page 67.) It is rare that such patches of collapsed lung are large, or even very numerous. Partial obstruction leads to the production of emph}'- sema. It is difficult for air to pass through the inflamed bronchioles, both in expiration and insj)! ration ; but as the former is almost wholly a passive act, being pro- duced by the elasticit}^ of the lung and by the weight of the thoracic and abdominal walls, it is not a very forcible one ; but the latter is an active one produced by muscles of considerable power, and, accordingly, is much the more forcible. Therefore, air will enter the lungs through partly obstructed bronchioles, but will be very imperfectly emptied through them. Thus, slowly an increment is constantly added to the alveolar contents, and dilatation ensues. (See page 61.) Emphysema is exceedingly common as a complica- tion of bronchiolitis ; indeed, it is to some extent a constant accompaniment of it. It may involve the lung quite diff"usely. The production of emphysema in bron- chiolitis is aided by the increased air-pressure which is produced in the tubes by severe" coughing. A frequent, severe, and dreaded complication is catarrhal pneumonia. (See page 82.) This is devel- oped in part b}' an extension of inflammation from the bronchioles to the alveoli communicating with them, and in part by an extension through their walls to the contiguous alveoli. Minute and infrequent patches of 2 B 26 Diseases of the Bronchi. consolidation tlius produced are often encountered in cases of capillary bronchitis. Occasionally the}' are very numerous, and form a severe complication. They rarely coalesce in sufficient numbers to produce extensive areas of consolidation. Anatomy of Chronic Bronchitis. — The anatomical changes wrought hy chronic bronchitis are various, and occur, in the same case, in var3'ing combinations and in different parts of the bronchial system. The mucous membrane is usuall}^ grayish or brownish red. It may be thickened. Papilliform outgrowths and excrescences are not uncommon. Unusual tiiinness of the mucous membrane is quite as characteristic as increased thick- ness. Especially in sacculated dilatations the epithelium is apt to be pavement-like and the surface to resemble more a serous than a mucous membrane. The connective tissue is uniformly hypertrophied to a greater or less ex- tent. When acute exacerbations of the chronic trouble occur, the submucosa is filled with round-cells, and all the usual changes incident to acute inflammation are observable in the other bronchial tissues. Peribronchial inflammation is usually present in severe cases, especially if the smaller bronchi are involved. As a result of it the bronchial wall seems greatly thickened and supported at points by considerable masses of firm connective tissue that extend out into the neighboring lung-struc- ture. This connective tissue develops from a thick- ening of the alveolar walls b}' inflammatory exudates. In its formation many alveoli are obliterated; others are narrowed and distorted. The muscular layers of the bronchi are often atrophied and the individual fibres separated by new connective tissue. In the larger tubes the cartilages are also at times atrophied. The bundles of elastic fibres, which are more or less numerous in the Trachitis and Bronchitis, 27 bronchi, remain unchanged or are hypertrophied. Occa- sionally the interior of a bronchus will present a fenes- trated appearance, the mucous surface being ridged both longitudinally and transversely. This appearance is due to the atropli}^ of the bronchial wall and especially of the muscular fibres, and to the unchanged condition or hyper- troph}^ of the elastic fibres which produce the ridges. The mucous glands may be quite normal in appear- ance. Often, however, they are changed. Man^^ atroph}^ They may even disap[)ear entirely. Sometimes the duct becomes funnel-shaped and opens with a wide mouth upon the surface of the bronchial tube. In otiier cases it is obstructed or compressed by the swollen surround- ing tissue, and consequently the deeper portion of the gland is converted into a small retention-cyst. Abrasions of the mucous surface in chronic bron- chitis are numerous and often extensive. Ulceration is not rare, but usuall^^ is limited to dilated portions of the bronchi. Moderate chronic emphysema is the rule. When the larger bronchi alone are involved this lesion is chiefly confined to the anterior and lower border of the lungs. It is then due to severe, frequent, and pro- longed coughing. When the smaller bronchi are in- volved the emphysema is more extensive and more gen- eralized, and is due to the same causes that produce it in acute bronchiolitis. A frequent complication is bronchiectasis. (See page 57.) The dilated bronchus is usuallj' cylindrical in shape, but may be sacculated and ver^^ large. Ulcera- tion upon the surface of the dilatation is of frequent occurrence. It may lead to an enlargement of the cavity, and rarely permits its contents to escape into the lung- tissue by penetrating the bronchial wall. This accident 28 Diseases of the Bronchi. almost invariably provokes gangrene of the lung. (See page 112.) The contents of clironically inflamed bronchi vary greatl}'. The}' may contain tenacious, adhesive, vitreous mucus in slightly larger quantities tlian is normal. More frequently tliey contain a larger amount of frothy mucus, which is not verj' adhesive, and in places some muco- purulent matter. Rarely, a bronchial dilatation will contain enormous quantities of serous fluid or pus. Either of these exudates may become fetid from the occurrence of putrefaction within the bronchi. Symptoms of Acute Trachiiis and Bronchitis. — All grades of severity of inflammation of the trachea and the larger bronchi are observed, from a cold so mild as to be almost unnoticed to one tiiat causes fever and general disturbances that necessitate confinement to the liouse and often to t4ie bed. In tlie severer cases, both of trachitis and bronchitis, the sufferer observes the same subjective S3'mptoms. The}' are distinguishable onl}' by physical signs. In moderatel}^ severe cases of these affections their onset is usuall}^ marked b}' a sensation of chilliness, or sensitiveness to draughts or changes of temperature, and more rarely b\' an actual rigor. The transitor}^ but con- stantl}' -recurring chillv sensations are felt for several hours. During this time the patient often sneezes and begins to feel a mental and physical heaviness or lan- guor. Actual headache of a dull character is frequenth' felt. Cough is an early symptom, nnd at first it is not severe, but rapidly increases in severity. Witii it, and even with deej) breathing, a feeling of rawness and sore- ness is felt beneath the sternum, which is due to the tracheal inflammation. The nose and throat may or may not be simultaneously inflamed. Trachitis and Bronchitis. 29 As the chilly sensations disappeur fever develops, and the skin becomes diy and hot. The temperature is rarely high except in children. Coincidently and dependent upon the increase of temperature, the pulse becomes quick and respiration slightly hurried. A gen- eral muscular aching over the body is felt. On the second day the soreness beneath the sternum is more constant. The cough is more severe and frequent. Often it is sufficient to cause muscular soreness about the waist, in the epigastrium and loins. As ^^et the cough is unaccompanied b}^ expectoration. On the third day, or often a little earlier, a scant, vitreous, slightly frothy sputa is expelled b}^ coughing. It rapidly becomes more abundant and more easily raised. Usually, it is more frothy and in part muco-purulent. The fever now disappears. The tracheal soreness is much lessened or gone; and as the cough, though still frequent, is less severe, the abdominal muscular sore- ness disappears. Recovery is usually completed \ty the seventh or tenth day. So long as the fever lasts, appetite is wanting or capricious. The bowels are usually inactive. The urine is somewhat diminished in quantity and dark in color. A physical examination demonstrates tlie involve- ment of the bronchi ; but in sim[)le trachitis no ab- normal physical signs are discoverable in the thorax. If the chest is examined in the latter cases the only abnormalit}' observable may be a quickening of the respirator}^ movements when the i)ntieut is feverish. When there is bronchitis, vocal fremitus is usuall}' normal. Rarely, a bronchial fremitus can be felt. Reso- nance is natural. Auscultntion reveals in the earl}' stage dry rales, which are coarse when the large tubes 30 Diseases of the Bronchi. only are inflamed, and fine when the smaller ones are. Later, when the exndate within them becomes thinner, moist rales, coarse or fine, according to their location, are audible. The moist rales are not heard continuonsl}^ in one place, but ma}^ disappear after coughing, to be discovered elsewhere ; or, they may be heard for a few moments, disappear, and not re-appear for man}^ min- utes. If the exudate is very abundant and the inflam- mation quite diffuse, the rales may be continuous. Symptoms of Acute Capillary Bronchitis. — Acute capillar}' bronchitis oftener begins with a rigor of some duration, which is followed at once by fever. Frequent, dry, and hard coughing is at once noticeable. The breathing gradually becomes quicker, more labored, and productive of the subjective sensations of d3'spnoea. In thirt3'-six hours, and often much earlier, the disease has become severe, and endangers life. The patient's coun- tenance is anxious and disturbed. The face is somewhat congested ; the lips full, and, as the d^^spnoea deepens, livid; the nares open wideh' with each inspiration. The rapidity and labor of breathing increases. It is often noisy, expiration producing a prolonged wheeze or whistle. So diflScult is breathing that a sitting posture is constantly ke})t rather than a reclining one. Young children are most comfortable when held or carried. The cough continues frequent, harsh, and wearying. It is accompanied b}' little expectorate, and in young chil- dren usually b}' none. The skin is hot and dry; the temperature ranges from 101° F. to 103° F., the higher temperature being most frequently observed in children. The temperature is highest at night, but is usually nearly or quite normal in the morning. The pulse is quick ; at first full and firm. If the disease tend to a fatal termination the dysp- Trachitis and Bronchitis. 31 noea is greater and cj-anosis is marked. The face is aslien ; the lipsand finger-nails are purplish ; the skin is cold and clanim}'. The pulse grows small, soft, and quicker. The patient is somnolent or nearl}^ uncon- scious ; is now too feeble to sit, and lies upon his back, with his head buried deeply in the pillow, and mouth open. Respiration grows shallow ; less wheezing is heard, but a constant rattle in the throat replaces it. Respiration becomes irregular for a few minutes, a few convulsive movements pass over the body, and breathing ceases. In these, the commoner cases, death is caused by suffocation. Less frequently, heart-failure is its immediate cause. Although capillary bronchitis must be regarded as one of the severe acute diseases, fortunately a large proportion of those who suffer from it recover. Im- provement nsuall}^ begins by the third or the fifth day, although at times it begins several da3'S later. The cough is easier and more satisfactory, as with it an expectorate is raised. This at first consists of small lumps of vitreous mucus, but soon consists of large quan- tities of frothy mucus, in which are imbedded small muco- purulent chunks. If this latter expectorate is thrown on water the frothy mucus floats, and from it dangle minute muco-purulent strings, which have been formed in the small bronchi. The fever gradually lessens. Respiration is less hurried and difficult. The skin is no longer hot and dry, but natural. The appetite improves. Strength is gradually regained. Somewhat slowly health is restored. In severe acute attacks the suflTerer is much weak- ened and often considerably emaciated. In less severe cases and in those that are subacute or chronic, nutri- tion is little interfered with. Relapses are especially 32 Diseat^es of the Bi'onchi, frequent in capillary bronchitis, and must be guarded against with unusual care. Ph3^sical examinations show a chest that is enlarged. In severe cases the chest is constantly in the inspira- tory position. During respiration the ribs move little ; the intercostal spaces are persistent!}' stretched, and inspiration is produced b}- a lifting of the entire chest by the unusual muscles of respiration. The degree to which these changes develop depends upon the severity of the attack and upon- the amount of coincident emph}'- sema. The frequency of respiration is increased in pro- portion to the intensity of the dyspnoea. In young children the lower ribs and the abdomen are deeply pressed inward during inspiration, the intra-thoracic pressure being low, because of the bronchial obstruc- tion. In adults, in whom the ribs are firm and little pliable, the intercostal spaces onl}- are pressed in, and the abdominal wall is crowded back toward the spine. Tenderness over the chest is often noticeable, and especially in children. No abnormal fremitus is ob- servable unless a complication has caused somewhat extensive consolidation of lung-tissue. On percussion, resonance is found to be normal or, from the emphy- sema, somewhat increased, and especiall}- increased in area as the dilated lungs crowd the liver and heart downward and overlap the latter. Auscultation reveals fine rales, either moist or dry. The vesicular sounds are obscured by them or are lacking. The inspiratory sound is short and the expiratory feeble and prolonged. These modifications of the respiratory sounds are best heard over tlie lower and posterior ])arts of the chest. The characteristic fine rales are often noticed, or are mixed with coarse ones, when the large bronchi are simultaneously aff'ected. Trackitis and Bronchitis. 33 When the common complication of catarrhal pneu- monia (see page 82.) exists the physical signs are rarely modified ; for tlie consolidation of lung-tissue does not involve areas of sufficient size to produce increased vocal fremitus, duUuess, or bronchial respiration. Sometimes, however, the affected lobules are so close to- gether tliat physical sigus of consolidation can be dis- covered. Catarrhal pneumonia causes an increase in temperature if it is at all extensive, the evening tem- perature ranging then above 103.5*^ F. ; and all the symptoms are intensified, though not changed in char- acter. Many mild cases of capillary bronchitis are seen in which the symptoms that have been described are observable, but in less severe or in a modified form. Symptoms of Chronic Bronchitis. — Inflammation of the bronchial tubes may be chronic in character from the first, or acute bronchitis may become chronic. There are also numerous subacute cases which present a mixture of the symptoms of those that are acute and chronic. The}^ last several weeks. Chronic bronchitis is of very frequent occurrence. Many S3anptoms are common to all cases and man\' more are variable. It is therefore a disease whose ph^'siognom}' is multiform. Its duration is indefinite. Often it will last for ten, twent}^, and even more years. It does not lead to fatal results except when complicated by other ailments. Its course is not one of uniform severit^^, but frequent ex- acerbations and remissions are the rule. Different varie- ties of the disease also var^^ in severit}'. In general, we ma}^ say that, the longer it lasts, the severer grow the symptoms which are constantly present. Often the exacerbations resemble in all respects acute bronchitis. The state of general nutrition of those who suffer from chronic bronchitis varies greatl}^, and is not 2* 34 Diseases of the Bronchi. dependent upon the disease. We often find chronic inflammation of both the large and small bronchi in those "who maintain, nevertheless, an unusual proportion of flesh and are in all ways robust. When, however, it occurs in aged people, it usually prevents the accumu- lation of fat, and exacerbations cause loss of both weight and strength, which is with difficult}', if at all, recovered from. Vomiting, which often occurs imme- diately after eating, be.cause of hard coughing, is seldom sufficiently severe to interfere materiall}'- with the main- tenance of strength. The putrid and purulent varieties of bronchitis are wasting diseases, and in this respect resemble phthisis. Uncomplicated chronic bronchitis is an afebrile dis- ease. Purulent and fetid bronchitis are usuall}' accom- panied b}'^ fever of a hectic type. The pulse is normal in rapidity and character unless sudden or violent exertion or fever has quickened it. Changes in the heart are not ver^' common ; rarel}' its right ventricu- lar wall hypertrophies because extensive peribronchitis interferes with the pulmonarj' circulation. Pain about the chest is not usual. In the milder cases, when acute exacerbations occur, tracheal and, therefore, substernal soreness is felt during breathing and coughing. Al- though in chronic bronchitis the cough is more apt to be very severe and prolonged than in acute, muscular soreness is seldom complained of about the waist or line of attachment of the diaphragm. This is because the muscles have become accustomed to the strain, and have hypertrophied in consequence of it. The muscles which most frequently 113'pertrophy in chronic bronchitis are the recti abdominalis and the sterno-cleido-mastoids, — the first because of the persistence and severity of the cough, and the second because of d3-spnGea, which, in Trachitis and Bronchitis. 35 some cases, is great. All who suffer from chronic bron- chitis notice an unnatural shortness of breath on ex- ertion. If the bronchioles are involved or if there is extensive peribronchitis, d3^spnoea, usually slight, though varying much in severity, is felt constantly. Ordinarily the respiratory movements are not unnaturally quick, but are hurried if sudden and rapid movements are made and also if dyspnoea is considerable. Coughing occurs more or less frequentl}^ each day. In the mild cases it is so infrequent and slight as to escape the sufferer's notice. When severe it is apt to be harsher, more prolonged, and more distressing than in acute bronchitis; but its character is very variable. The character of the expectorate of those suffering from chronic bronchitis is perhaps the best index of the nature of the changes that are taking place within the bronchi. Therefore, upon its peculiarities are based the varieties which are usually described. 1. Simple chronic bronchitis^ or, as its milder form is often called, chronic winter covgh^ is most common. When mild, there is so little coughing or respiratory dis- turbance during the summer that the existence of a bronchial affection is not suspected. But each fall the cough is aggravated, and is troublesomelj' persistent until the following summer. Such winter exacerbations and summer remissions ma}- occur for years. XJsuall}', as summer follows summer, the persistence of the cough throughout the year is more noticeable. Occasional acute exacerbations will occur in hot weather, and greater shortness of breath, when hurried movements are made, attract the sufferer's attention. In the severer cases coughing is frequent and hard at all seasons; dyspnoaa is troublesome ; sleep is usuall}^ disturbed by coughs ; prolonged or severe physical exertion is impos- 36 Diseases of the Br^onchi. sible ; and occupations that necessitate exposure dur- ino- inclement or clianoreable weather or the inhalation of irritating dusts must be abandoned. The amount of expectoration usuall}^ varies with the severity of the attack. It is muco-purulent or, in mild cases, froth3\ It is most abundant and purulent in the morn- ing. Usuall}', if purulent in the morning, it becomes froth}' and vitreous during the day. Coughing is almost invariably harshest in the morning, on first arising, and at night, on first retiring. Frequently it is provoked by going into rooms or atmospheres of diflerent tem- peratures. 2. Dry bronchitis occurs less frequently than the preceding variet}^ It is characterized by the absence of expectorate or b}' the occasional discharge of a small clump of tough, vitreous mucus, which is loosened and dislodged with difficulty. The cough is especially inclined to be harsh and parox3^smal. Asthma and chronic emphysema are frequent complications of it. 3. Bronchorrhcea constitutes a third variety. Bron- chiectasis always co-exists with it. In the dilated tube there rapidly accumulates a large amount of serous fluid, which is expelled periodical!}' by coughing. The periodicit}' of the cough is ver}" marked in most cases, and occurs just so soon as a certain quantity of fluid accumulates. The cavit}' is often emptied more fre- quently and more perfectly if the sufferer lies upon the side in which there is no cavity. In rare cases the quantit}' of expectorate is enormous. It may be several pounds dail}'. Its amount, its serous character, and the periodicit}" of its expulsion are its important pecu- liarities. 4. Purulent bronchitis also occurs when bronchi- ectasis exists and when the wall of the cavity is exten- Trachitis and Bronchitis. 3T sively ulcerated. The sputa is moderate or large in amount, and consists of thin pus. It is not raised in formed lumps, which float separately' in a sputa-cup, but as mouth fuls of liquid pus, which at once coalesce in the cup, and resemble pus from an abscess. 5. PutrHd bronchilis is characterized by putrefaction of the contents of the bronchi. This ma}' be a compli- cation of either of the other forms, but most frequently is associated with bronchorrlioea. It is most apt to de- velop when the brouclii are imperfectly emptied and tlie secretions stagnate in them. It leads, in serious cases, to sloughing of the bronchial walls and sometimes to gan- grene of the lung. When severe it is a wasting disease, accompanied by hectic fever. It may terminate in a few weeks if gangrene of the lung is produced, or it ma^' last for many months. Mild cases sometimes recover. The contents of the bronchi are so foul that the breath becomes excessively offensive. Its odor is often plainly detectable by those standing several feet from the sufferer. It usuall}- causes lessened apj^etite and some- times nausea and vomiting. The expectorate is consid- erable or very large in amount. If collected in a sputa- cup it separates, on standing, into three layers. The uppermost is frothy; the middle is a serous fluid; the lower consists of opaque, granular matter. At the bottom roundish, gra3'ish-yellow balls are also found, varying in size from a pin-head to a pea. These are extremely' offensive, especially if compressed. Under the microscope the^' are found to consist of granular matter, fat-ciystals, micro-organisms of various kinds, and filamentous growths. These bodies are called mykotic plugs, and are supposed to be the cause of the putrefaction. The spnta ceases to emit odor after it lias stood for a time, but does aaain if it is asfitated. 38 Disease fi of the Bronchi. The pli3'sical signs necessarily vaiy somewhat with the severity and form of the bronchitis. Increased rapidity of respiration is noticeable only after greater or less ph3'sical exertion, nnless emphysema is consider- able. If the bronchitis has long been chronic, thoracic expansion is always imperfect. The subjective symp- toms of dyspnoea are not felt in uncomplicated bron- chitis. Xo abnormal fremitus is felt by the pali)ating hand unless, from extensive peribronchitis, considerable consolidation of lung-tissue has occurred. Thoracic resonance is also normal if complications are absent. Auscultation reveals the most positive physical signs. In the milder cases the normal respirator}- sounds are exaggerated and roughened. In these cases occasional moist rales ma}- or may not be heard here and there. An expiratory sound is almost alwa3'S present, Its length and intensity var}' much. In the severer cases vesicular respirator}- sounds are inaudible because moist or dr}- rales obscure them. So frequentl}' are com- plications present that the sounds are often further modified by them. If the bronchioles are involved and emph)'sema is considerable, whistling and crowing sounds obscure all others. Bronchiectasis may pro- duce the physical signs of a cavit}-. Peribronchitis ma}' cause lung consolidation, which can be recognized. A peculiarity of the physical signs of uncomplicated chronic bronchitis is the uniformity of their distribu- tion over all parts of the chest, or at least their sym- metrical distribution on the two sides. Diagnosis. — It is not difficult to recognize simple acute bronchitis. It is rarely mistaken for any other disease. At times a pharyngitis, laryngitis, or trachi- tis, which produces a severe cough and some systemic disturbance, may be mistaken for acute bronchitis. Trachitis and Bronchitis. 39 The absence of ph3'sical signs of disease of the bronchi and evidence of disease of the upper portions of the respirator^' tract should rectify the diagnosis. More rarely an acute exacerbation of a mild chronic bron- chitis is mistaken for the simple acute inflammation. This only occurs when the history of the case is imper- fectly obtained. Occasionally we must differentiate between acute bronchitis and phthisis; more frequently between chronic bronchitis and phtliisis. We can, how- ever, best discuss the distinouishing characteristics of each after describing phthisis. (See page 138.) The characteristic symptoms of capillary bronchitis and asthma have been described (see page 9) and emphy- sema will be. (See page 61.) Causes. — Bronchitis in all its forms is influenced by the same causative factors, although in varying degrees. It is both a primary and a secondary disease. When a secondary disease it sometimes results from mechanical interference with the circulation of the blood through the bronchial vessels, and sometimes from poisonous and infectious matter that is inhaled and causes the bronchitis and subsequently a disturbance of the whole system. Illustrations of the latter group of cases are seen in the bronchitis of measles and whooping-cough. Many cardiac lesions cause persistent, passive engorge- ment of the lungs and bronchi, and lead to an inflam- mation of them. Cases of primary bronchitis are the result usually of both predisposing and exciting causes. It occurs at all ages. It is sometimes said to occur oftenest in childhood and old age. My own experience does not confirm this statement. I believe it occurs with about equal frequency at all ages. It is a more dangerous disease in infancy and old age ^han at other times. 40 Diseases of the Bronchi. Debilit}", which lessens the power of man to resist disease, is one of the most frequent predisposing causes. We therefore find bronchitis of common occurrence during convalescence from other troubles. Anaemia, rheumatism, Bright's diseases, and diabetes seem espe- ciall}' to make those suffering from them susceptible to bronchitis. Bronchitis itself, more than an}' other dis- ease, makes one susceptible to repeated attacks. Enervating habits are frequently the cause of in- creased susceptibility to the disease. Sedentary habits, and especially if they necessitate the constant breathing of (\\'y, warm air, predispose to all forms of simple in- flammation of the respiratory passages ; for the cliange which those subjected to such surroundings must ex- perience on passing from the dr\^, warm, and often close air of the house or office to the moist, cold air outside, such as exists in temperate climates during the fall, winter, and spring, is greater than any atmospheric change ordinarily produced by nature. Air laden with impurities is always irritating to the respirator}^ passages; therefore, a life of confinement, in poorly ventilated rooms, increases one's susceptibilit}^ to bronchial inflammation. The excessive use of alcohol, and even its steady moderate use, is a prolific source of inflammation of the respiratory passages. Continuous excess causes enervation and decidedly- lessens the power of the human organism to resist disease of all kinds. The benumbing eflTect of alcohol causes an insensibility of those using it, to cold and atmosi)heric changes, and to other exciting causes of bronchitis, so that thej' protect themselves imperfectly. There are occupations which predispose to bron- chitis. They are such as necessitate the inhalation of Trachitis and Bronchitis. 41 dust or certain gases. The coal-miner, tlie stone-cutter, and the grain-shifter are each exposed to dusts that are frequently exciting causes of the disease. Many per- sons who are eniplo3'ed in foundries, in boiler-rooms, and gas-houses are subjected to great heat at times, and through carelessness expose themselves to rnpid cool- ing. Among such pei'sons bronchitis or affections etiologically allied are of constant occurrence. The exciting causes of bronchitis are (1) most fre- quentl}^ atmospheric changes, and (2) less often irritat- ing dusts or gases. The atmospheric conditions which most frequently provoke it are sudden depressions of temperature in a moist atmosphere. Bronchitis occurs relatively much oftener in a moist than in a dry atmos- phere, for the withdrawal of heat from- the bod}' takes place much more rapidly when the air is filled with moisture and a sudden chilling of the surface ma}' be thus produced. In a moist air a sudden fall of tempera- ture of onl}' a few degrees will be felt more keenly b}^ the human S3'Stem than a fall of manj' degrees in a dry air. These atmospheric conditions occur oftenest in the spring and fall, and therefore we find cases of acute bronchitis or acute exacerbations of chronic bronchitis most frequent in these seasons. They are least frequent in the dr}' cold or hot portion of winter and summer. They are also less frequent in years in which the sum- mers are cool and .damp, and in which there are not great extremes of temperature or other atmospheric conditions. Bronchitis is more or less prevalent in all climates, but least so in tiie tropics and most so in temperate regions, if we except from the latter such localities as are characterized by great dryness. 42 Diseases of the Bronchi. Dusts and gases, which are exciting causes of bron- chitis, vary in their degrees of irritating power with their character. For example, dusts of vegetable origin are the most irritating, those of animal origin a little less irritating, and mineral dusts least so. Very few cases result from the inhalation of gases, and the most irritating gases, such as bromine, chlorine, etc., are not commonly met with. Capillar}' bronchitis is produced b}^ the causes alread}' enumerated. Often it is the result of the extension of inflammation from the large bronchi to the small ones. The exanthemata and whooping-cough among acute dis- eases, and Bright's disease and weak heart among chronic ones, especially predispose to it. Chronic bronchitis is peculiarly apt to occur in those who have rheumatic, gout}', and scrofulous diatheses or diabetes. Treatment. — The prophylactic treatment which is applicable to bronchitis is almost equally applicable to all its forms. Many attacks of acute bronchitis could be prevented by correcting enervating habits and dis- eased conditions which predispose to bronchial inflam- mations. Not only can acute attacks be often prevented, but the tendency for acute inflammation to become chronic can in the same way be counteracted. The deleterious effects of atmospheric changes that are exciting causes of the disease can be avoided by keeping the skin covered with woole^ii underwear, which maintains it at a comparativel}' equable temperature. Dwelling in rooms whose air is artificially higlil}- heated and dried should be avoided at all seasons. The best indoor winter temperature for those who are vigorous is 68° F.,and it should not be permitted to exceed 70° F. The air of offices and dwellings should be kept fresh by TracKitis .and Bronchitis. 43 careful ventilation, for stale air is both enervating and often directly irritating to the air-passages of man. Especially should these directions be kept in mind by those who are prone to bronchitis. The breathing of dust-laden and irritating air must be avoided by all who are predisposed to the disease, and especially by those who suffer from chronic bron- chitis. This often necessitates a change of occupation. Grain-shifters and others who must breathe irritating dusts can frequently avoid its effects b}' wearing a respirator. The simplest is a sponge fastened beneath the nostrils and over the mouth, through which the in- spired air is strained. Medicinal treatment must be varied with the form of the bronchitis and with the stage of the inflammation. To lessen the frequency and severity of coughing, to modify the secretions and excretions formed upon and within the inflamed tissues, are almost universal indica- tions for treatment in bronchitis. To meet the first of these, opium or its anodyne alkaloids are chiefly relied upon. The bromides are often used instead for children, but they are not as efficacious. Chloral, administered alone or coincidently with opiates, is exceedingly useful when coughing occurs in paroxysms of nervous origin. If, however, the paroxysms are caused b3^ an accumula- tion of secretions in dilated bronchi, chloral proves no more eflficacious than other anodynes. A large number of remedies ma}^ be used to modify the secretions and excretions. Ammonium chloride and carbonate are administered, in order to render mucous secretions thinner, less adhesive, and more easily dis- lodged. The carbonate is preferable when the finest bronchi or lung-tissue is involved, but there is little choice when the larger bronchi are inflamed. The nau- 44 * Diseases of the Bronchi. seating expectorants, such as tartar emetic, preparations of squills, and others, act partly' as do the ammonia compounds, but are most useful in aiding the expulsion of secretions from tlie bronchi. It is seldom necessary to resort to vomiting to empty the respirator}' passages of secretions. In chronic bronchitis it is often desirable to stop sui)purative inflammation. The purulent character of sputa can be promptly and to a most marked extent diminished b}' the internal administration of turpentine, Venice turpentine, creasote, and simihar drugs. The fetid quality of bronchial secretions is best counter- acted and its persistence prevented by the conjoint administration \)y the mouth of creasote and terebin- thines and by the inhalation of volatile antiseptics. In the chronic forms of bronchial inflammation tlie prevention of the development of ne^v tissue and the thickening of the bronchial walls b}' the round-celled exudate which occurs is a common indication for treat- ment. The iodides exert the greatest influence over these conditions. Their steady emplo3'meut apparently hinders the development of adult from embr3'onic tis- sue. The iodides of sodium, potassium, an Diseases of the Bronchi. fibres. The bronchial tubes are often narrowed just bej'ond the cavities or obliterated. The latter change will cause collapse of the lung-tissue continuous with them. Causes. — Bronchiectasis is always a secondary lesion. It usually results from chronic bronchitis, but ma}' result from chronic inflammation of the lung or pleura. The bronchi are weakened by chronic inflammation, especially by ulceration, and therefore become dilatable. Increased air-pressure, which is caused b}' coughing, helps to pro- duce their distension. Destruction of lung-tissue along- side of a bronchus also weakens its wall. Man}' saccu- lated cavities are due to ulceration and destruction of a part of a bronchial wall and the neighboring lung-tissue. The walls of such cavities are, for the most part, com- posed of granulation tissue. Tubercular ulceration of a bronchus is a common cause of cavities. Interstitial pneumonia and extensive peribronchitis are lesions in the course of whose development new fibrous tissue is formed in extensive bands. Contraction of the newly-produced tissue always occurs in these bands. This will cause traction on the bronchus which is surrounded by the new growth, and will tend to dilate it. Large cavities are not made in this way unless, at the same time, adhesions have occurred between the costal and visceral pleura, which make the thoracic wall a fixed, unyielding point, from which the contracting tissue can pull. Cavities produced in this way are usuall}' fusiform, but are sometimes angular. Chronic pleuris}^, causing adhesion and the development of masses of connective tissue in the lung, beneath the pleura, sometimes produces bronchiectasis in a similar way. Symptoms. — As bronchiectasis is always a secondary Bronchiectasis. 59 lesion, its symptoms must be expected superimposed upon those of the })rimary one. . Often cavities of small size or deeply located cannot be discovei-ed during life. The characteristic physical signs of bronchiectasis are those of a pulmonary cavity. They can be best de- scribed in connection with tubercular diseases of the lungs. (See page 133.) Bronchiectatic cavities occur both in non-tubercular and tubercular troubles. If the cavity is large, and especially if the secretions which it contains are thin, it is usually emptied periodically by coughing, and large amounts of expectorate are voided. A cavity can frequently ])e best emptied if a patient lies upon one side rather than the other, or assumes some position wliich enables the bronchus to drain it with thoroughness. To determine whether it is tubercu- lar or not, one must ascertain the precise character of the primar}^ affection. Bronchiectatic cavities, if well drained b}^ a bron- chus, may remain open and undergo little change during many years ; or they may gradually increase in size and destroy the lung extensively. A bronchus may become permanently obstructed. The cavity is thus converted into a C3^st. Its liquid 'contents may then be absorbed and its more solid contents transformed into cheesy or, finally, into calcareous matter. A contraction and dimi- nution in the size of a cavity frequentlj' occurs, espe- cially when it is converted into a C3St by obliteration of the bronchus ; but it ma^' also occur whenever unusual air-pressure is not produced within it or accumulating secretions cease to distend it. A perfect restoration of a dilated bronchus to its natural shape and size never takes place. The chronic inflammation within a cavity- can be treated by drugs, as chronic bronchitis always is. There 60 Diseases of the Bronchi. is no specific medicinal treatment for it. The objects should be to prevent increased air-pressure within the lungs, the accumulation of secretions in the cavities, and the extension of ulceration. The first of these is best accomplished b}^ lessening or preventing coughing, and the second and third by medication which will lessen the formation of secretions and of suppuration. DISEASES OF THE LUNGS. CHAPTER lY. Emphysema. Anatomy. — Emph3'Sema begins with a dilatation of infundibular passages. As this increases the alveoli enlarge, their walls are stretched and finall}' torn. Tlie infundibuliun and alveoli are tluis converted into a single small cavit}", which by gradual inflation becomes spheroidal. Pin-head-sized sacks are thus formed. If the stretching of the lung-tissue persist or increase, the elastic fibres in the infundibular walls atrophy and the walls rupture, and neighboring sacks are thus made to communicate with one another and unitedly form larger cavities. It is rare that the cavities are larger than a pea or bean, but they may in exceptional cases be much larger. These anatomical changes are neces- sarily accompanied by destruction of capillaries. At first the capillaries covering the alveoli are stretched and narrowed. Later they are torn and destro3'ed. The vascularity of the emphysematous tissue is greatly lessened, so that it is pale or slightly ros3\ The vascu- lar changes lead to less and less perfect nutrition of the tissue, which in consequence becomes weaker and more easil}^ stretches and tears. Prolonged stretching of the elastic fibres leads to a loss of elasticit}' in them. The dilated alveoli therefore have gradually less ten- dency to contract strongly, and to assume a natural form, and to fulfil their function of emptj^ing the lungs of air that has been utilized in them. (61) 62 Diseases of the Lungs. The lesion of empliysema may be unilateral or bilat- eral in distribution, circumscribed or diffuse. The anterior, median, and lower borders of the lungs are oftenest affected, and the upper lobes oftener than the lower. The deep lung-tissue is rarel}' emphysematous. The lesion is almost confined to tlie superficial portion. Emph3'sema, when it is extensive or generalized, makes the lungs unusually voluminous. Distension of the anterior and lower borders causes tiie lung to cover more or less completel}- the pericardium, to separate it from the chest-wall, and to depress the heart and liver. When the thoracic cavity is opened emphysematous lungs do not collapse. An incision in them will, how- ever, permit the air to escape. The surface is unusually dry. The lungs when compressed creak little or none. From the cut ends of bronchial tubes muco-purulent matter can be expressed, for bronchitis more or less severe and extensive accompanies emphysema. Other lung-lesions are frequentl}^ present, as emph3'sema is a secondary one. When the enlarged lungs crowd the heart downward, the diaphragm may be simultaneously depressed ; therefore, the liver and abdominal viscera may be pushed downward. Causes. — It is probable that eniph3'sema can be pro- duced in several wa3's. If a lung is not property nourished it becomes weak and emphysema is easil3'' developed. This b3' man3' observers is claimed to be the most important factor in forming the lesion. When emph3'sema is generalized, as in old age, it un- doubtedly is the most potent factor. When it is circumscribed it is chiefly the result of influences acting mechanically. For example, in capillary bron- chitis the muco-purulent plugs which mny obstruct the l)ronchioles permit air to enter the infundibula and Emphysema. 63 alveoli, but as the ex[)irjitory act is less forceful than the inspira.tory they do not permit them to be emptied. Tlie alveoli thus gradually become disteuded. When emphysema is compensatory it must also be the result of mechanical influences only. Emphysema is of very frequent occurrence in the aged. In them the lungs are not increased in volume, but the alveoli are distended. It occurs oftenest in men. It is observed occasionall}' in successive genera- tions of a family, but this is probably a coincidence, and not evidence of its heredity. Severe coughing is a common cause of it. By coughing the air within the lungs is placed under unusual pressure, which of neces- sity stretches the lung-tissue. If coughing is frequent, chronic, and severe, it is especially apt to produce emphysema. The severe cough of pertussis or of chronic bronchitis may cause it. Small areas of emphysema are not uncommon in phthisis. Bronchiolitis, particularly if it is subacute or chronic, is especially liable to cause it. If one lung or one lobe is compressed or consoli- dated and rendered useless, the opposite lung or neigh- boring lung-tissue will become distended and emph}-- sematous. Symjjtoms, — If emphysema is circumscribed., often it cannot be detected by examination of the chest before death. If, as frequently happens,, the anterior and lowef borders only are distended, no subjective symptoms may be produced, but physical examination wnll reveal a diminished area of cardiac dullness, depression of the liver, absence of apex-beat and distant cardiac sounds, If, however, the emphj^sema is generalized, the ph3'sical signs, as well as the subjective symptoms, are striking and distinctive. The thorax is abnormally em larged. Its lateral diameter is greater than is natural. 64 Diseases of the Lungs. The antero-posterior diameter is increjised less. The spine is arched backward and the sternum forAvard. The centre of the tliorax especially is distended. This gives to the entire chest a barrel-shaped appearance. The intercostal spaces are constantly' stretched, and the whole thorax maintains permanentl}' the position of deep inspiration. The acts of inspiration and expiration are performed by lifting and lowering the whole chest by the unusual muscles of respiration. The unusual work thus given to the sterno-cleido-mastoid, and other respirator}^ muscles which are rarely used, causes their hypertroph3\ Yocal fremitus is diminished, especialh^ in advanced life, when the thorax becomes rigid and the costal carti- lages ossified. On percussion, the area of pulmonary resonance is found to be permanentl}^ increased. The area of cardiac dullness is diminished or absent. The lower borders of the lungs remain distended, and the line of resonance does not move with the respiratory movements as it does in health. Vesicular murmurs are feeble or wanting. In man}- cases the crowing and piping sounds, which are caused by the coincident bronchial inflammation, obscure all others. The apex-beat of the heart is invisible and usually cannot be felt. The cardiac sounds are not as loud as normal, especially at the apex. The second sound over the jmlmonar}' orifice is accentuated in cases of chronic emphysema. This is due to obstruction to the pulmonary circulation which the destruction of capilla- ries causes. Cardiac murmurs are rarel}^ developed, but if they exist they are due to dilatation of the heart. The most prominent subjective symptom is dyspnoea. It is wanting in mild cases and when the lesion is circum- scribed but is often very great. The vital capacity of Emphysema. 65 the lungs is greatly lessened ; therefore, less oxygen is furnished to the blood. The destruction of pulmonary capillaries also interferes with the blood's aeration. These are the important causes of dyspnoea. The ex- piratory power is greatly lessened, because of the im- mobility of the ribs and loss of lung elasticity. Whenever dyspnoea is great cyanosis develops. It is rare that the causes of dyspnoea just mentioned are sufficient to produce much cyanosis; but, if bronchiolitis is extensive and the tubes much obstructed, it is com- mon ; or, if the heart-muscle become weak and passive engorgement develops, it is very evident. Death usually is caused b^^ oedema of the lungs or heart-weakness. The disease has an indefinite duration. If not severe it does not much interfere with life-work, but when severe causes chronic invalidism. In itself it rarely leads to fatal results, though it increases very greatly the danger to life when other diseases attack its victims. The prognosis, therefore, depends upon the nature and severity of accompan^^ing diseases. Ti-eatment. — The causes of emphysema should be removed whenever possible, and if it has not been of too long standing recovery then becomes probable. Many cases of bronchitis which cause it are curable. Compression of the luug from pleural effusions, which provoke emphysema of the opposite lung, is often capable of relief. Manj^ other causes of it are remov- able. The treatment of chronic cases must embrace a care- ful regulation of habits, so that as good general health can be maintained as possible. Tonics, such as strych- nia and quinine and iron, are invaluable whenever tissue enfeeblement or degenerative changes are prominent factors in the causation or maintenance of the lesion. 66 Diseases of the Lungs. They must be eniplo3'ed for long periods of time. The best results are nsuiilly obtained by occasional changes in the preparations which are used. Iodides do much good when chronic bronchiolitis is the cause of the emphysema. Chronic emphysema of long standing results iu an absolute loss of elasticity in the affected [)ortions of the lungs, and a degree of alveolar and capillary destruc- tion which is irreparable. Iu cases less in degree and duration the elasticit}^ can largely be restored by train- ing the luugs to contract and ex[)and. This can be accomplished hy pneumatic apparatuses of vnrious kinds. Exhalation into rarefied air will cause partial collapse of the alveoli b\' withdrawing from the lungs an unusually large amount of their contents. By repeated exhalations of this kind the lungs are made forcibly to contract and expand to a normal extent, and gradually a habit of approximately normal respiration can be acquired. Yery great temporary relief to dysp- noea can always be obtained in this way. As the loss of lung elasticity is largel}' the cause of the prolonged distension, considerable relief is often obtained by wearing continuouslj' a broad elastic band about the thorax. It gradually increases the force and deepens expiration, and thus enlarges the vital capacit}' of the chest. CHAPTER y. Atelectasis. Anatomy. — The part of the Imig which is collapsed is usually depressed below the surface of the rest, is angular, uueven, and brownish or l)luish red. If the atelectasis is of long duration, it ma}' be grayish in color. An entire lung may be colla[)sed, but iu most cases a part only is affected. The atelectatic portion is hard, and feels fibrous when the lesion is chronic. It is leathery or brittle. It does not crepitate. If com- pressed, no air can be squeezed from the cut surface, although mucous generally can be from the bronchi. The affected tissue sinks in water. At first, the alveoli appear smaller than normal, more anguhir, and some- times quite flattened. The capillaries are usually visible as swollen and tortuous vessels. Later on, the epithe lial cells are loosened from the alveolar walls, and degenerate. The connective tissue is thickened by h3'perplasia of its cells. The capillaries become less swollen, and the outlines of the alveoli less evident, because more and more collaiised and contracted. On account of these cirriiotic changes the capillaries are less permeable, and the increased blood-tension thereby produced in the pulmonary artery leads, in extensive and chronic cases, to h^'pertrophj^ of the right ventricle. Cause. — Atelectasis is commonly caused in four ways : 1. It is congenital. Tiie aflTected lung or por- tion is then uninflated. This condition maj- graduall}' be corrected, or remain a permanent one. It occurs oftenest in premature, prolonged, or difficult births. (67) 68 Diseases of the Lungs. 2. It is due to absorption of the air from the alveoli. This occurs oftenest when the small bronchi are ob- structed by mucous plugs, the result of bronchiolitis. Fresh air cannot enter the obstructed tube, and, there- fore, the air that is held in the un ventilated alveoli is slowly absorbed b}^ the blood. The oxygen is first taken up, and then tlie carbonic-acid gas and, later, the nitrogen. Obstruction of large bronchi b}^ swollen lymph-glands, tumors, etc., which rarel}' occurs, is also followed by absorption atelectasis. 3. Compression atelectasis is usually due to pleuritic effusion, pneumo- thorax, tumor of the pleura and lung, rarely to pericar- dial effusion, dilated heart, or aneurisms. Other causes are : mediastinal growths, deformit}^ of the thorax, abdominal tumors, and ascites. 4. The last form is known as marasmatic atelectasis. It is the result of the great debility which is produced by wasting dis- eases, such as tuberculosis and typhoid fever. Congenital atelectasis usually- occurs in the base of the lungs ; not ver}^ unfrequentl}' in the anterior lower borders, and rareh' at the apices. Absorption and marasmatic atelectasis also occurs oftenest in the lower part of the lungs. The part affected in compression atelectasis depends entirely upon the location and char- acter of the cause. Symptoms. — If congenital atelectasis is extensive, the child will breathe superficial!}', and with unusual rapidit}-. Often a soft, murmuring noise is produced by respiration. The child will refuse the breast. Its face will be gray or livid, the pulse quick and weak. Death may result from suffocation. Twitchings and even con- vulsions often precede the termination of life. .If the collapsed areas are extensive, the lung and even the thorax may be retracted, but tiiey are rarely of sufficient Atelectasis. 69 size to cause dullness on percussion, bronchial breathing, or other signs of consolidation. In acquired atelectasis the sj-mptoms are the same ill kind, but they are frequent]}- transitory, as compen- satory emphysema usually accompanies them. When collapse first occurs, fine crepitant rales can be heard. If the air has only been partly removed from the affected parts, t3'mpanitic resonance may be audible. If the air is altogether absorbed, and the area is at least one and one-half inches in surface-area and two-thirds of an inch in thickness, dullness can be detected, and broncho-vesic- ular or in larger areas bronchial breathing and increased vocal fremitus can be heard. If the conditions are present which lead to hypertrophy of the right ventricle, the second sound over the pulmonary artery will be ac- centuated. Percussion ma}- demonstrate enlargement of the heart to the right, and substernal pulsations will be evident. Ty^eatment. — If the cause of atelectasis can be re- moved, deep breathing, pulmonary gymnastics or inhala- tions of compressed air may, singly or combined, re- expand the collai)sed tissues, but if the collapse has lasted long enough to have caused cirrhotic changes and ol)literation of the alveoli, recovery is impossible. If the atelectatic areas are not too large, emphysema may fully compensate for them. CHAPTER VI. HiEMORRHAGIC INFARCTION. Causes and Anatomy. — Hemorrhagic infarcts in the lungs are possible, because the puhnonar}^ arterioles are terminal. An embolus, which will produce them, may be derived either from the veins of the bod}^ or from the right side of the heart. Fibrinous clots are not uncom- monly formed in the right ventricle when it is dilated, and in the veins when they are inflamed. The infarcts may form in an}^ part of the lung, but they are oftenest observed near the surface and in the lower part. If an embolus obstruct an arteriole, the circulation will cease beyond it. The pressure is, therefore, nothing in the artery beyond the obstruction. The blood now flows back into the arterioles from the capillaries, and even from the veins, and engorges the area supplied bv the obstructed artery. The blood extravasating into the pulmonary tissue and alveoli consolidates the lung at this point. The solid mass is conoidal, with an apex at the point of embolism and base usualh' at the pleura. Infarcts vary in size from a cherr\'-stone to a hen's egg, and rarely are larger. .They can usuall}- be seen through the pleura as dark, purplish, slightly raised masses, which feel Arm to the touch. The pleural surface is usually congested and covered ^with more or less fibrin. When cut through, tiie conical sha[)e of an Infarct be- comes evident. At first its surface is purplish red. If resolution take place it becomes i-eddish brown, a rusty color, or even grayish, with an excess of brownish-black pigment. Under the microscope there is seen at first (70) Hoemorrhagic Infarction. 71 only a, mass of blood in the alveoli and lung-tissue. If resolution occur, wlnte cells become more numerous and the red ones disintegrate, and thereby form pigment granules, which are deposited in the interstitial tissues or absorbed into it. The interstitial tissue is thickened and ^a permanent toughening and [)igmentation of the lung results. The air once more enters the air-cells, but they expand and contract im[)errecth', because of their thick walls. The arterial embolus may also disappear, but usuall}^ it leaves a thickening of the arter^^'s wall at the point of embolism. The permanent pigmentation gives the cirrhosed tissue a brown or slate color. If resolution is delayed, and especially if the infarct is large, a part of the lung-tissue maj^ be destroyed, being liquefied and converted into an odorless, brown i)ulp. This either finds its way into a bronchus and is expec- torated, or it is absorbed and the cavity' obliterated by cicatriziition. In rare cases the cells and the tissue in- volved in the infarct disintegrate slowly, dr}', and are transformed into a caseous and cretaceous mass, which is surrounded by a librous capsule. If the embolus con- tain p3'ogenic matter an abscess is the result. Pleuritic adhesions ma}^ form over infarcts. An infarct is not caused whenever there is an embo- lism of a pulmonary artery. Sometimes death occurs before it can be produced. Sometimes collateral cir- culation by the capillaries or communicating arteries may prevent it. Sym])lomii. — Infarcts may exist and produce no symp- toms. Embolism of the large arteries may cause sudden death, or when this does not happen sudden and great dyspntiea and thoracic oppression may be felt. The most characteristic symptom is haemo[)tysis. Tiie expectorate may be mixed blood and mucus, or consist almost en- 72 Diseases of the Lungs. tirely of dark blood. Tlie lisemovrliage ma}* last a few hours onlj^ or several days. Pleuritic pains ma}' also be felt. If the infarct is small or deeply seated, physical examination will afford no positive information. Pleu- ritic friction-sounds are sometimes heard. If the infarct is larger and superficial it may produce an area of relative dullness on percussion, and crepitant rales or bronchial respirator}' sounds may be audible over it. Fever ma}' be absent or present. A diagnosis will depend upon the existence of a cause for embolism of the lungs and upon the occurrence of haemoptysis. The prognosis depends upon the primary disease, the strength of the patient, and character of the embolus. If the malady complicates heart disease it is rather unfavorable, for it signifies weakness of the right ventricle. Treatment. — When the causes of embolism of the lung exist, bodily rest is essential for its prevention. Treat- ment must be symptomatic. Pleuritic pains may neces- sitate the use of anodynes. The primary disease re- quires special treatment. Resolution is best assured by removing the primary disease and maintaining a good circulation and good general nutrition. CHAPTER YII. Hypostatic and Passive Congestion. Causes of Hypostatic Congestion. — Hypostatic con- gestion is a secondary lesion of frequent occurrence. It develops when the venous circulation through the lungs is impeded by an enfeebled heart's action, and when, through the prolonged retention of one position, the blood stagnates in the veins. It is the prolonged retention of the recumbent posture that usuall}' causes it to develop in the posterior and lower part of the lungs. The enfeebled heart is oftenest the result of wasting illness, such as typhoid fever and suppuration. Fractures and paralysis may also cause the essential weakness and dorsal decubitus. Impediments to respi- ration, such as pleuritic adhesions and thoracic de- formit}', or compression of the lungs by distension of the abdomen, increase the tendency to hypostatic con- gestion. The capillaries and veins are distended, and impart to the affected tissue a purplish and often almost a black hue. The alveoli are filled with serum. A few blood- corpuscles find their way into them. The epithelial cells are cast off and become granular. If the lesion is quite persistent the alveoli contain large numbers of these cells, and closely resemble those consolidated by catarrhal pneumonia. Under such conditions the lungs become heavy and firm. They do not crepitate. Atelec- tasis and pulmonar}" oedema are often associated with hypostatic congestion. Symptoms. — This lesion may persist for days or 4 D (73) *r4 Diseases of the Lungs. weeks, or disappear in a few hours. It is readil}' over- looked if attention is concentrated too closel}' on tlie primary disease. In diseases in which it often occurs (especiallj- typhoid fever) it should be guarded against and watched for. Frequently rapid respiration is the onl}' symptom which suggests its existence. If the lesion is extensive it may cause cyanosis. Cough is not often present ; when it is it may be accompanied bj- a mucous, muco-purulent, or even purulent expectorate. Fever is not caused by hypostatic congestion unless in- flammation supervenes. Percussion over the posterior thoracic surface will usually at first give a tympanitic resonance, because of the relaxed condition of the lung. In more chronic eases various degrees of dullness exist. At first fine, moist rales are heard, and the respiratory sounds are often feeble. Later the sounds become bron- chial and consonant. Increased vocal fremitus is then demonstrable. These physical signs are those of con- solidation of the lung, and, therefore, the same as those of pneumonia. It is to be distinguished from the latter disease chiefl}- by the history of its development, its secondary character, and by its usual bilateral distribu- tion. (Edema rareh" produces consolidation, and usually causes the rales to be more widelj' diffused. A positive diagnosis is at times impossible. The prognosis is grave, though by no means hopeless. Treatment. — The most successful treatment is prophy- lactic. It consists in frequently shifting the patient from side to side, and thus preventing the gravitation of blood to an}' one part of the lungs ; and in administering a cardiac tonic, such as digitalis. In febrile cases spong- ings and baths maintain a better periplieral circulation, by creating a greater degree of arterial tone, in conse- quence of which a better balance is maintained between Hypostatic and Passive Congestion, T5 the arterial and the venous blood. When the lesion is once established the same care must be maintained to prevent its increase. But the carbonate and chloride of ammonium are now useful, both as cardiac stimulants and as expectorants, if there is an accompanying bron- chitis. Counter-irritants will temporarily relieve the congestion when it first occurs. Causes and Anatomy of Passive Congestion. — Brown induration, or chronic venous h^-peraemia, is difficult to diagnose with certaiut}'. It may be suspected whenever there is much dyspnoea accompanj'ing heart diseases. It is, however, only one of several factors causative of dyspnoea. Wlien the lungs are examined, the pleural snrface is usually, at least in places, reddish purple, and the interlobular septa are evident, because they are pig- mented by a dark-brown coloring matter. Generally slight emphysema exists here and there. The lungs feel hard and dense, especiallj' in places, and raostl}' about their bases. The cut surface permits a reddish-brown fluid, mixed with air, to exude. It is redder than nor- mal, though not bright, but a brick-red. The pleura and interlobular septa are unusually thick and contain much of the red pigment. Under the microscope the alveolar walls are seen to be unusuallj^ thick. The capillaries are enormously- distended and very tortuous. Their walls are thick. The blood-corpuscles completel}^ fill them. In the alveoli there are man}^ red corpuscles and large cells, which contain large granules of golden-brown pigment. In the alveolar walls the same pigment can be seen, but usuall3Mt is a little darker in color. Where the lungs are most dense the alveoli are most filled with such cellular contents. This lesion is developed by a venous stasis, which, slowly dilating the veins and then the capillaries, causes 76 Diseases of the Lungs. finall3' a moderatel}' copious serous exudation in the alveoli, and some haemorrhage. It is thus that the red corpuscles and serum are expressed into the alveoli. The epithelium is soon detached and almost wholly lost. The white corpuscles take up the pigment-gran- ules which are formed by the disintegration of the red cells. The}' increase in size, and thus form the large pigmented cells that have been described as a part of the contents of the alveoli. Some of the pigmented cells find their way into the lymph-channels and deposit in them their coloring matter Minute hsemorrhages from which pigment is formed occur in the pleura and interstitial tissues. The small bronchi are greatly con- gested. The walls of the distended vessels are thick- ened. The mucous membrane is somewhat swollen, and man}' epithelial cells are loosened. Symptoms. — The changes in the bronchi and conges- tion of the alveolar vessels, which dimiuishes the air- spaces in the lungs, are important factors in producing dyspnoea. The partial filling of the alveoli with serum and cells diminishes the lung-capacit}'. The slow and imperfect pulmonar}- circulation causes a lessened oxi- dation of the blood, and also contributes to produce dyspnoea. Anything that obstructs the pulmonary vein may cause this lesion. All forms of valvular disease of the heart ma}^ do it, but oftenest it is a mitral stenosis that does. It is a peculiar and not well-explained fact, that in one case brown induration will be developed to the fullest extent, and in another, with apparently the same causes and conditions present, it will not exist. Often, in these cases, exaggerated or puerile respirator}' sounds are heard during life. If the large pigmented cells can be found in the sputa, a positive diagnosis may be Hypostatic and Passive Congestion. 77 made. Red blood-cells are also sometimes seen in the sputa. The pigmented and blood -cells rarely color the expectorate. The prognosis depends upon the primary heart- lesion. Treatment must be addressed entirely to the latter. CHAPTER YIII. Pulmonary (Edema. Anatomy. — The anatomical clianges which are char- acteristic of oedema of the lungs are enlargement of them and increase in weight. The}' are often very pale in color, but the}' may be congested. The}' do not col- lapse when the thoracic cavity is opened. When pressed between the fingers pits remain, as they do in other cedematous tissue. When a lung is incised an abun- dance of serous fluid flows from it, which is usually colorless, ])ut may be either pink or red, according to the degree of congestion that exists. The fluid may or may not be frothy. When only a part of a lung is involved in oedema, it is the most dependent part. If circumscribed inflammation of the lung — as croupous pneumonia — exist, it is often found to be bordered by a zone of cedematous tissue. Symptomii. — The symptoms of oedema of the lungs which are of diagnostic value are not developed unless the oedema is considerable in degree. (Edema is often the immediate cause of death. It may develop with great rapidity and produce fatal results in a few hours, or may develg)p more gradually. When oedema is the outgrowth of other lesions of the lungs, pathognomonic symptoms are often wanting. (Edema of the lungs does not cause fever. Persistent dyspnoea is one of the most striking- symptoms which it produces. As it becomes greater, cyanosis develops. The lips and finger-nails become purplish, and the skin ashen, usually cool, and bathed (78) Pulmonary (Edema. 79 with perspiration. Coughing occurs with more or less frequenc}', and considerable or, sometimes, very large quantities of serous fluid are expectorated, which ma}'' or may not be frothy, pink or colorless. The abundant expectoration usually does not .continue long, for, as the lungs become more and more comi)letely filled and the blood cyanotic, mental dullness develops, which grad- ually passes into somnolence. This hebetude causes a cessation or diminution in the frequency and strength of the cough. Under such circumstances the fluid gathers in the throat and causes a coarse rattle there. Respiratory movements become more and more shallow, then a little irregular, and finally they cease. If a physical examination of the chest is made, the respiratory movements will be observed to be rapid and shallow. Unless the oedema is due to a localized inflam- mation which is in one lung only, the respiratory change will be found alike on both sides of the chest. This S3'mmetrical distribution of physical signs is especiall}' characteristic of the oedema which accomi)anies heart, renal, and general diseases. Palpation reveals no ab- normalit}'. Percussion reveals a normal resonance, or, frequently, a semi-tj-mpanitic resonance. Moist rales are abundant. At first, they are fine ; later, coarse. A diag- nosis is possible onl^- when we find dNspnoea, cyanosis, an abundant serous expectoiate^ and a cause for oedema. Cannes. — Rnrel}', cases of oedema of the lungs are observed which develop rapidly, and for which no ade- quate explanation can be given. They are sometimes termed idiopnthic oedema of the lungs, serous apoplexy-, or serous pneumonia. Exposure to cold is an alleged cause, but we have not positive proof that it is one. Localized inflammations are a cause of circumscribed oedema, which occasional!}' spreads and involves an en- 80 Diseases of the Lungs. tire lung, or both of them. This happens not infre- quently in cases of crupous pneumonia, and oedema then becomes the immediate cause of death. Often pul- monary oedema is a part of general oedema, such as complicates heart and renal diseases. Mitral-valve dis- ease is especially apt to lead to pulmonary oedema, but all cardiac diseases that are accompanied bj^ dilatation of the heart and weakness of it are liable to precipitate oedema of the lungs. The cardiac weakness which re- sults from prolonged fever or other wasting disease is frequently the cause of pulmonary oedema. The lesion is also caused b}^ the paralysis of the left side of the heart, which occasionally- occurs just prior to death. We find, then, upon post-mortem examination, oedema of the lungs, although no symptoms of it existed prior to death. When it accompanies renal affections, it is due in part to an enfeebled circulation and in part to an impoverishment of the blood. Treatment. — The most successful treatment is pro- phylactic, and should be used when causes of oedema exist. When the lesion is established, especiall}' if it involve the lungs extensively, it is rarelj' amenable to treatment. A prognosis in such cases must be guarded, and the immediate danger to life recognized. Prophylactic treatment must var\' with the cause which exists. In fevers oedema can be avoided b}- fre- quent changes of position which will prevent hj'postatic engorgement. Cardiac tonics, such as digitalis and str3'chnia, should be administered when the heart is feeble and the blood-vessels relaxed, to counteract these conditions. Frequent spongings of the surface of the body stimulate tlie circulation, and maintain a better tone in the peripheral vessels. It is also an important aid in maintaining a good general circulation. Pulmonary (Edema. 81 In cardiac find renal diseases, when general oedema is extensive and pulmomuy cedema must be anticipated, diaphoresis, dinresis, and catharsis are useful modes of treatment, as tliej' lessen the general oedema. Heart tonics are usuall}' necessar}-. In the so-called idiopathic cases venesection has been found to do temporary good. It should be fol- lowed b^' the administration of digitalis, strychnia, and ero;ot, — ao;ents which will maintain a vigorous action of the heart and a good degree of vascular tone. If oedema of the lungs must be treated after it has developed, reliance must be placed upon digitalis, strych- nia, and ergot. I have seen such good results obtained from the inhalation of ox3'gen in these cases that I be- lieve it should always be tried if the gas can be obtained. During the last winter I saw, in consultation, a woman just delivered of a child and simultaneously attacked b}^ pneumonia. In a few hours extensive oedema of the lungs developed and threatened immediate destruction of life. She labored severelj^ for breath, was cyanotic, covered with cold perspiration, and almost pulseless. Oxygen was administered b}^ inhalation for several minutes every half-hour. The cyanosis disappeared, the labored breathing lessened, the skin became warm, and the pulse full, firm, and stead3\ So prompt and decided was the improvement that the treatment was persevered in and life undoubted!}' prolonged for several days. Ox3-gen inhalations will undoubtedly enable us to save some cases that would otherwise prove fatal, by maintaining life for a few hours or da3^s, until a turning- point in the primary disease can be reached. 4* CHAPTER IX. Catarrhal Pneumonia. Causes. — This disease raa}^ be acute, subacute, or cbrouic iu its course. It is secondary to others; most commonlj^ to bronchiolitis. It is a frequent complica- tion of infectious fevers. Measles, diphtheria, influ- enza, and whooping-cougb are complicated by it with especial frequenc^^ It is rare exce[)t in childhood and old age. Debilit}" predisposes to it. It is one of the usual lesions iu chronic tubercular diseases of the lung. Pneumonic nodules are often built up around miliary tubercles. Anatomy. — Catarrhal pneumonia is characterized b}^ the development of solid nodules Avhich may be scat- tered through the lung. They var}' in size from a pin- head to a walnut. Large nodules are produced by the coalescence of the smaller. In number they mny be few or almost countless. They are most frequentl}' formed along the posterior part of a lung, and are more numer- ous at the base nnd gradually less toward the apex. When they exist the surface of the lung is not quite even. The superficial nodules cause depressions in it. Over the nodules there is often pleuritic inflammation. They can be readily felt as hard, compact bodies. If a section is made through one it' appears purplish in the early stages and grayish 3'ellow later on. The surface is dry and granular. The}' contain no air, but a yellow- ish or brownish fluid can be scraped from them. Around the nodules the lung is often slightl}' emph3'sematous. A bronchiole forms the centre and focus of each nodule. (82) Catarrhal Pneumonia. 83 From it a muco-purulent plug can be squeezed. Man}^ suppose that llie iiiflaiiniiation which causes the nodules originates from drawing into tlie lung detritus and pus from inflamed bronchi ; otliers believe that the inflam- mation extends by continuit}' from the bronchioles to the lung. The latter seems th.e most probable ex- planation, although the lesion may at times be produced in both waj^s. The central bronchiole in each nodule will be found to be filled with desquamated epithelium, granular mat- ter, pus-cells, and mucus. Its wall will be found thickened and infiltrated with round cells. The adjoin- in": alveolar walls are similarly aflJected. Toward the margin of the nodule the alveolar walls are less and less thickened. At first the alveoli are filled with serum and the capillaries engorged, but soon the alveolar epithelium becomes granular, is cast oflf, and helps to fill the air- cell. Leucocytes are also abundant, especiall}' in the alveoli nearest to the central bronchus. Occasionall}' red corpuscles may be seen forming part of the contents of the air-spaces. They are usually observed in the earlier stages. In the air-spaces nearest to the central bronchus, fibrin is also observable when consolidation first occurs. In the alveoli at the periphery of thfe nodule the consolidation is due almost entirely to the abundant and closel3'-packed, large, oval, epithelial cells which fill them. In these alveoli the process is purely a catarrhal one, while nearer the central bronchus the inflammation is accompanied b}' round-cell infiltration. As catarrhal pneumonia is almost uniformly a com- plication of some form of bronchitis, the anatomical changes within the bronchi, characteristic of their in- flammation, are to be expected coincidentlj'. The pneu- monic nodules may undergo resolution. The contents 84 Diseases of the Lungs. of the alveoli will be absorbed, and complete restoration may take place. Instead of resolution occasionally the contents of the alveoli become dr}", the cells degenerate ; finally, the alveolar walls degenerate, and the whole is transformed into a fine, hard, drj^, grayish, chees}^ mass, which may remain unchanged indefinitely. Symptoms. — A positive diagnosis is often impossible. Catarrhal pneumonia is so uniforml3' a complication that it is frequentl^^ obscured by the primar}^ disease. It is rare tiuit it is ushered in b\' a chill or an}- other noticeable phenomenon. When it develops, the symptoms of the pri- mary bronchitis are usually intensified. Cough is gen- erally drier, often more painful, and occasionally accom- panied by slight pleuritic stitches. Respiration is more rapid. In severe cases dvspnoea is marked, and C3'ano- sis ma}' develop. General prostration is great. The temperature is higher than in simple bronchitis. In the latter it rarel}- rises to 103^ F., while in catarrhal pneu- monia it often exceeds this. It follows no definite t3"pe, but is usuall}^ remittent, the morning temperature being nearly or quite normal. Deff'ervescence takes place slowl}'. In children, breathing is often painful, and accompanied by moaning. The thorax is tender. No characteristic ph3'sical signs are developed unless the nodules coalesce into patches of at least two inches superficial area and of two-thirds of an inch depth. Then the usual evidences of consolidated tissue can be found; increased vocal fremitus, bronchial respiration, and dullness being the most important ones. The lesions are usually discoverable in both lungs at the same time. A probable diagnosis can be made in the course of bronchitis if the temperature is abnormally high, the breathing unusually quick, and the prostration much greater than is to be expected from acute bronchitis. Catarrhal Pneumonia.- 85 If the chest is tender, and pleuritic stitches are felt during bre:i thing or coughing, the probability is still greater. A certainty- in tlie diagnosis can be felt if, in addition to these symptoms, patches of consolidation can be demonstrated. Tlie disease often runs a ver}' acute course, lasting only a few hours, or two or tliree days. Frequentl}' it pursues a subacute course, and may last for two or three weeks. When it accompanies measles, it is inclined to be acute ; when whooping-cough, subacute. Treatmei}t. — The treatment is the same as would be employed in cnpillary bronchitis. More attention must be paid to the maintenance of strength. Food in its simplest forms must be administered regularl3\ The heart's streugtli must be preserved by the administra- tion of digitalis, strophanthus, and similar tonics. The carbonate of ammonia, camphor, and other diffusible stimulants are required when tlie heart flags. The rules for their administration are practically tiiS same as in treatment of ci'oupous pneumonia. (See page 101.) To stimulate deeper breathing when it is shallow and cya- nosis is developing, aid can be derived from douches and sponging of the skin of the bod3', especitilly with alter- nating hot and cold water. Fomentations so prepared as to envelop the whole chest often relieve dyspnoea and cough, and contribute to the well being of the sufferer. The prognosis must alwaj's be guarded, and the dis- ease looked upon as dangerous. It is very fatal : from one to two-thirds of all cases die. CHAPTER X. Croupous Pneumonia. Nature and Causes. — Croupous pneumonia ma}' be defined as a fibrinous inflammation of the lungs, afTect- ing simultaneous]}' large areas and accompanied b}' fever. The exact nature and mode of causation of this disease form unsettled questions. It resembles closely an infectious disease, and without much doubt is one. As in other infectious diseases, its general symptoms are not correlated with the local inflammation. For in- stance, the fever, often the delirium, and the rapidit}' of respiration cease suddenly, and before consolidation has disappeared from the lungs. It also resembles them in that it occurs epidemicalh' and endemicall}-. It has rareh' been found to be the cause of death in infants who are born while their mothers are suffering fiH)m it. There is also much, though not conclusive, evidence thnt micro-organisms are its exciting causes. Several micro- organisms are capable of producing fibrinous inflamma- tion of the lungs. Xo one form is found to unifornily accompany pneumonia. The pneumococcus of Fried- lander was the first form carefulh' studied, but it is not observed as often as Fraenkel's coccus. Seibert believes that the latter is tlie usual cause of sthenic pneumonia, or of those cases that run the classical course, and that the former is tiie common cause of those which run a prolonged and more typiioid course. Eichhorst thinks that secondary pneumonias are not the result of super- imposed infection, but of the infectious agent of the primarv disease. For example, that in tj'phoid fever (86) Croujjous Pneumonia. 87 and mensles, the cause of these diseases is the cause of the pneumouia y\'hich may couiplicate them. It must l)e admitted, however, that as yet our knowledge of the re- lationship oT micro-organisms to crou[)ous pneumonia is not definite. It is probable that the cases now known as croupous pneumonia constitute what from an etio- logical stand-i)oint might be regarded as sx'veral dis- tinct diseases. The micro-organisms supposed to cause croupous pneumonia are frequentl}' found in the pleural, pericardial, and meningeal exudates that result from complicating inflammations. Pneumonia resembles a general disease, in that its course is cyclical, that its general symptoms are not correlated to the local ones, and that it is endemic and epidemic. The general symptoms are undoubtedly^ due to a poisoning of the system by some chemical substance or substances produced by the local inflammation of the lun2:s or the micro-oroanism that causes it. In this re- spect there is a strong analogy between the disease and typhoid fever. (See Physiolog. Act. Typhoid Poison, etc.) What may be the nature of the poison or poisons is not known. The recent researches of Roger and Gaume upon the toxicit}^ of the urine open the way to a better knowledge. The}^ found that during the period of pneumonic fcAcr the urine contained only a third or fourth as much of toxic matter as is normal, and that at the time of crisis it suddenly augmented to more than normal, or at least to the normal amount. This would suggest that the poison which produces the general symptoms is not eliminated for a time, and that, when it is, they cease. The toxic ingredients of the urine are certainh^ not anj- of its welhknown constituents. Anything that lessens vitality predisposes to the dis- ease. Bad h3'giene and debilit\' from other kinds of ill- 88 Diseases of the Lungs. ness are predisposing causes. Excessive use of alcohol not only increases the gravitA^of the disease, but greatl}^ augments an individual's susceptibility to it. Pneumonia occurs in all parts of the world. The statement has been general! \- repeated since Drake first made it. that it is most prevalent in the southern third of this coihitry, and least in the northern third. By a recent review of statistics, N. S. Davis, Sr., has found that it is most prevalent in the middle third and least in the southern. It varies much in prevalence at different seasons. In large cities it is endemic, although, at least in the northern cities, primarv croupous pneumonia is rare in summer. In Chicago, and other cities with a similar climate, it is most prevalent from December to Mai-ch, and much the most prevalent in December and Jan uaiy. Some years it is epidemic. Its severitj' also varies from 3'ear to year. It is most prevalent during or im- mediately following intense and penetrating cold weather. A moist, cold air will provoke an increase of all kinds of respiratory diseases. Individuals in everv period of life are linble to attacks of croupous pneumonia. It is, however, most prevalent during 3'outh and the first half of manhood, and is rare in infancy. It is commoner among men than women. It has been claimed to be contagious, but observations are not numerous enough as yet to prove that it is so. Although often exposure to cold is appnr- ently a cause, in very man}^ cases such exposure cannot be traced. It is a disease, like bronchitis, er3'sipelas, and rheumatism, that strongly predisposes to renewed attacks. Wounds that can be regarded as causative occur in a very small proportion of cases. I have a few times known an injury to cause pleurisy- and a slight Croupous Pneumonia. 89 pulmonary luemorrlinge, which was followed, in two or three days, 1)}^ pneumonia. The injured lung-tissue was undouhtedh' the focus of the pneumonic inflammation. Anatomy. — Either of the lungs and any part of them ma}^ be affected. Usually an entire lobe or lung is involved. Tiie lower lobe upon the right side is most frequently the seat of pneumonic inflammation. Not unfrequently one lobe or one lung after the oilier is attacked, and, therefore, upon the post-mortem table we find different parts of the lungs exhibiting simultane- ousl}' the characteristic appearance of two or more stages of pneumonic inflammation. Anatomically, four stages of the disease are recognizable : a stage of (1) congestion, (2) red hepatization, (3) gray hepatization, and (4) resolution. In the stage of congestion the portion of the lungs affected is enlarged, heavier than natural, but light enough to float on water. The pleural surface is red- dened. Upon it the congested vessels are often visible as red lines. The lung crepitates and pits somewhat, when compressed. The cut surface is red, and a pinkish and often more bloody, frothy fluid flows from it. The alveoli are partly filled with fluid and air. Under the microscope the epithelium is seen in places to be loos- ened, and some of the cells lie in the alveoli, and undoubtedly • float in their fluid contents. Red and white corpuscles are also more or less numerous. They are least numerous at the beginning. The capillaries are distended, tortuous, and crowded with corpuscles. In the stage of 7^ed hepatization the affected parts are firm and hard, still more enlarged, and two or three times heavier than normal. The solidified lung sinks when placed in watei". 'i'he pleura is usually red, though it may be uniformly pale after death. It is covered D3 90 Diseases of the Lungs. with serum, which makes it feel to the touch as if covered with soapj' water, and usually with flakes or patches of fibrin. Tlie lung is so much enhirged that it completely fills tlie thorax, and its surface is furrowed by the ribs. When removed, it looks like a cast of the cavity. If compressed, tlie lung does not crepitate. It is brittle. The cut surface is dr3', granular, and dark red. The portion of the lung immediately adjoining the solidified part is, to a greater or less extent, oedema- tous. The opposite lung or other lobe of the affected lung may appear perfectly normal, or present evidences of bronchitis. From the bronchi in the consolidated part fibrinous casts can be drawn, which, w^hen floated upon water, exhibit the outline of the bronchioles. The larger bronchi are alwavs more or less inflamed. Under the microscope the alveolar walls of the solidified lung are seen to be thickened and the capil- laries on them congested. The air-spaces are compactij' filled with small round-cells. About the margins of the alveoli desquamated, large, oval, epithelial cells can be seen, and here and there a few red corpuscles. All these cells are held together b}- a mesh-work of fibrin- fibres. The pleura also seems thickened. On its sur- face there are white cells, occasionally red ones, and some fibrin. The stage of gray hepatization is looked upon by a few pathologists as occurring only in fatal cases. Often a part of the solidified lung will be in this stage and a part in the former, which causes the whole to appear mottled-gray and red. In size, weight, and solidity it resembles the lesion of the preceding stage. It is, however, more brittle and easily torn. The pleural sur- face is covered more or less abundantly with n fibrinous exudate, and is still furrowed by the ribs. The cut Croupous Pneumonia. 91 surface is reddish 3'ellow, or, later and more character- istically, 3'ellowish gray, dry, and even more granular than in the preceding stage. Under the microscope the alveohir walls still a[)pear thickened from cellular and serous infiltration. The hmph-channels are distended with granular material and cells, which have been absorbed from the air-spaces. The capillaries are no longer distended. The cells which fill the alveoli are more granular, fattily degenerated, and some of them are disintegrated. The fibrin is in shorter threads, and rarelv attached to the alveolar wall. The contents of the alveolus appear more concentrated in the centre and detMched from the walls. In the stage o^ resolution the lung is soft and flabb}'. The pleura ma}^ still show evidences of inflammation, or present a normal appearance. A pus-like fluid exudes from the alveoli exposed upon a cut surlace. Under the microscope the air-spaces are seen to be filled with numerous cells, which resemble pus-cells, and an al)un- dance of granular matter, which is cellular debris. The alveolar walls are thickened chiefly b}- distension of the l3'mi)h-channels, which are crowded with absorbed cells and granular material. The cells which in the earlier stages of the disease fill the alveoli and solidify them during resolution disintegrate or migrate into the lymph-channels and are absorbed. A pnrt of the mass may be expectorated when it loosens. The kidneys, liver, and intestinal tract are usually congested, — at least, so long as the solidified lung- impedes the circulation. The kidneys and liver often undergo albuminoid infiltration. After death the right cardiac cavities are usualh' full of blood and post- mortem clots, and the left are empt}'. The muscles of the ])od3' are, as a rule, flabby and soft, and some of the 92 Diseases of the Lungs. fibres may undergo waxy degeneration. Yenous con- gestion of the bniin is usual. Rarel}' a case of croupous pneumonia is met with in whicli the lesion becomes chronic. Instead of resolu- tion taking place and the fibrinous clot originall}' filling the alveoli undergoing solution and absorption, it becomes organized. The round-cells which fill it are gradually transformed into connective-tissue cells. The air-spaces are thus permanentl3' obliterated. As the connective tissue is developed contraction occurs, and tlie solidified lung grows smaller and hard. Often bronchiectatic cavities are formed in tliese cases. Tuberculosis, abscess, and gangrene are other lesions that develop occasionally in pneumonically-inflamed tissues. Symptoms. — Different cases of croupous pneumonia vary in the development and duration of their symp- toms. A majority, however, follow a typical course. In the typical cases there are rarely prodromal symp- toms. Malaise may be felt for one or two days preced- ing the attack. It is usually ushered in by a severe chill of considerable duration. Almost at once the sufferer feels that he is very ill. During the da}' follow- ing the chill, and the two or three next, the patient develops characteristic symptoms. The face locdis full and flushed. Tlie skin is dr}' and hot. The pulse is (piick, full, and firm. The tem[)erature commonh' is from 103° to 104° F. Soon after the Initial chill pain is felt, in the region of the ni[)ple. upon the affected side. It is aggravated greatly by coughing or deep breathing. Alrliougii coughing occurs, it is suppressed as much as possible, because of the pain. The respira- tions are from 30 to 40 per minute. They are short or superficial. The patient lies upon his back or the Croupous Pneumonia. 93 affected side. His tongue is covered, at first, by a white coat, whicli soon becomes brownish and dry. Appetite is wanting. Thirst is considerable. The bowels are constipated. Delirium often exists. He is usually extremely ill. In favorable cases, at the end of the fifth or seventh da3^, or, exceptionally, by the ninth or thirteenth da^^, the fever suddenly disappears. Simultaneously the other distressing symptoms lessen or disappear. The breathing becomes much less rapid. The pulse becomes almost or quite normal. The mind is clear. The skin is cool. A copious sweat often accompanies the subsidence of the fever. Coughing persists. Sometimes the side is still painful, but usuall}^ it is not. The appetite improves. Digestion seems more perfect, and thirst is no longer felt. In unfavorable cases, on the fifth or sixth day the delirium becomes duller. A semi-comatose or somno- lent condition develops. The pulse grows soft, smaller, and quicker. By degrees the skin grows cool and ashen in color, and is covered with a clammy sweat. These changes are first noticed in the extremities. In- voluntary discharges from the bowels and bladder are usual. The respiratory movements become more and more shallow and labored. The nares dilate, and the larynx is lifted with each inspiration. Death oftenest occurs on the sixth, eighth, or ninth day. Its immediate cause is usually either heart-failure or suffocation from cedema of the lungs. In the course of the disease the physical signs — first of congestion, and later of consolidation, of the lungs — develop. Usually the earliest signs of a lung-lesion are detected on the second day of the illness, but their appearance may be delayed to the third or fourth day. In a considerable number of cases the fever docs 94 Diseases of the Lungs. not leave suddenly, but gradually subsides by h'sis. In secoudaiy pneumonias there is usually no chill at the inception of the attack, and all the S3'mptoms are obscured hy those of the primary disease. The exist- ence of pneumonia is suspected only from the unusual rapidity of respiration, and proved b}^ ph^'sical examination. The sideache, which is an early and in man}^ cases a bothersome sym[)tom, is not always present. In cases of secondary pneumonia it is generally wanting. The pain varies much in degree. It is usually stitch-like and dull simultaneously. It is aggravated by deep breathing and coughing. Often there is some tender- ness to the touch. The pain is usualh' felt about the nipple, or a little outside of it, on the affected side. The pain is the result, chiefl}', if not wholl3',of pleuris3^ That a neuralgia ma}' accompany the pleuritic pain is possible, for in rare cases pain is not felt upon the side on which the lung is inflamed, but upon the opposite side. Coughing is an earl}^ and almost constant symptom. In primar}' pneumonia it is usuoll}- severe. It is sup- pressed, as far as it can be, because of the pain which it excites. In secondary pneumonia, and especially wlien the primary disease causes mentnl stui)or, — such as ex- ists in typhoid fever, for instnnce, — the cough may be absent. An ex})ectorate may be wanting in children and aged persons : in the one been use tliey do not know how to expectorate, and in the other because they are too feeble. In others weakness or the failure to cough occasionally prevents expectoration ; as a rule, it is present. At first the sputa is scnnt and adhesive. It is often expelled from the mouth with difficulty. As soon as the blood and fibrinous exudate has formed in the Croupous Pneumonia. 95 lung the sputa becomes red ; it is a dull, brick red. The color is produced by red blood-corpuscles in it, but also, and chiefljs bv blood-coloring matter in solution. In a small proportion of cases tlie sputa is purplish red and likened to " prune-juice." In a considerable number of cases the sputa is not raised from the lungs, but from the larger bronchi, and is not red. In most instances in which the sputa is abundant there can be found in it small gra}^ or yellowish-gra\^ balls, which, if dropped upon water and shaken, will unfold and reveal them- selves as branching fibrinous casts of the smaller bron- chi. Rarely, these are composed of the spiral threads which so uniformly form bronchial casts in asthma. The sputa contains mucus-corpuscles, some cells that resemble those of pus, red blood-cells, and a few epi- thelial cells. Micro-organisms of various kinds can be found, especiall}' the cocci sui)posed to be peculiar to pneumonia. Graduallj^ the sputa loses its red color, becomes purulent and loose, then frothj', and finally it ceases. Respiration is always abnormally quick. It is shal- low, especiall^^ upon the affected side. The rate of respiration is abnormal, in that it does not correspond to the pulse-rate or temperature. In health and in other fevers the pulse bears about the ratio to the respiration of 4 J to 1, but in pneumonia it is nearl}^ 2 to 1. The number of respirations is commonly 45 per minute, and may be 60 or more. This peculiarit}'' of the respiration- pulse ratio is almost pathognomonic. The rapidity of breathing is, in part, due to the pleuris}^, which prevents deep respiration because of the pain. It is also quick, because of the increased temperature of the blood. Something else must also excite the respiration, for it is quick, out of proportion to the temperature, even when 96 Diseases of the Lungs. pleuritic pains are not felt. The diminution of lung- space does not account for the quickened breathing; for, after crisis, when the temperature has fallen and the pain has ceased, the respirator}' movements, though quicker than normal, are one-half or two-thirds less than earlier in the illness. It is probable that respiration is quickened, at least parti}', by a poison wiiich acts upon the nervous S3'stem, and is produced in the course of pneumonic inflammation. The pulse bears about the usual ratio to the increase of temperature. It is quick, usually from 100 to 120, and at first full and strong. In favorable cases it remains full and strong ; in unfavorable cases it grows soft and small and quicker. An intermittent pulse is an unfavorable S3'mptom, and is due to a complication or feebleness of the heart. An abnormally slow pulse usuall}' indicates disease of the brain. The temperature varies in its range and course. It is rarely more than 105 degrees or less than 102 degrees. In typical cases it pursues a continuous course until crisis occurs, on the fifth to the niuth day. At the onset of the disease the temi)erature rises rapidly, and in twelve hours is usually 103 degrees. Its highest point is generall}' reached on the third da}- ; on the fifth, seventh, or ninth the temperature falls to normal. Be- fore the crisis the dail}' range is about 1 degree. In most instances the temperature falls during the night of the fifth da}', and thereafter remains normal. Crisis is sometimes less abrupt : for instance, during the fifth night the temperature will fall from 104.5° to 102° F. ; during the sixth d:i\ it will rise to 102.5° F.,and during that night fall to normal and remain there. False crises may also occur ; most frequently they hap[)en upon the third day. The temperature may fall to normal, but Cr^oupous Pneumonia. 9*1 usual!}' only to 100° F. or thereabouts. If such a crisis occur earlier than the fifth day it is rarely permanent. The typical or classical cases of pneumonia convalesce with a crisis, but a considerable proportion of cases convalesce, after a slow subsidence of temperature, by l3'Sis. The whole temperature-curve then closely resem- bles that of t^'phoid fever, but its course is usuall}' shorter. During the height of the disease the urine is scant in quantit}^, red, and often cloudy. Its specific gravity is increased. The relative proportion of urea that it con- tains is greater than natural. Sodium chloride is almost or quite wanting. Occasionally, small amounts of albu- men can be found in it. If nephritis does not follow or complicate the pneumonia the albuminuria ceases when the fever subsides. The signs elicited by a physical examination are all important for diagnostic purposes. In the stage of congestion the respiratory movements appear to be defi- cient upon the affected side. This is partly due to the congestion and obstruction of air-cells, and partly to the pain which full expansion would cause. Vocal fremitus over the affected parts is normal or increased. Reso- nance is normal, or sometimes, just before consolidation occurs, semi-tympanitic. Auscultation reveals the most characteristic sign, — fine crepitant rales. In tiie stages of consolidation the chest over the affected area usuall}^ seems slightly distended, and is almost motionless. Yocal fremitus is alwaj^s increased. There is dullness over the consolidated parts ; it is ex- tensive, usually covering an entire lobe, or a large part of one. The area of dullness is frequently bordered b}' a narrow area that is semi-tj'mpanitic ; over the remain- der of the lung the resonance may be normal. The 5 E 98 Diseases of the Lungs. respiratory sounds are bronchial whenever there is con- solidation. An abnormal degree of resistance is often felt by the hand, when i)ressed upon tlie side, or Mhen percussion is being practiced. As resolution progresses duHness gradually lessens, or is replaced temporaril}^ by semi-t^'mpanitic percus- sion-sounds, which are due to the relaxed condition of the lung-tissue. Fremitus graduall}^ becomes normal. Coarse, moist rales are usuall}- present. If there is much bronchitis similar rales may be heard in the stage of consolidation. The distension of the side ceases and the respirator}' movements become more normal. As different portions of the lungs may be successively involved, we ma}' be able to demonstrate resolution in one part and consolidation in another. Pleurisy, with eflusion, complicates a few cases. Pericarditis and endocarditis are rarer complications. Meningitis is an occasional, and usually a fatal, complication. Often dual names, such as typho-pneumonia, are ap- plied to individual cases descriptive of complications. The following can be recognized as more distinct vari- eties : Protracted pneumonia is the form in which the fever disappears b}" 13'sis. Spreading pneumonia is the form in which the lesion graduall}' increases b}^ involv- ing neighboring tissue in successive invasions. Wan- dering pneumonia is the form in which different, but not contiguous, parts of the lungs are involved successivel}". Relapsing pneumonia is the form in which, after crisis has occurred and convalescence has apparent!}' been established, the lung again becomes consolidated, either where it first was or at some other point. Intermittent pneumonia is a name applied to rare cases which are probably complicated by malaria ; all the symptoms of the stage of congestion will suddenly develop, persist Croupous Pneumonia. 99 for three or four hours, and then disappear, leaving the patient apparently well. The next daj^, or the second day, a similar attack will occur. Several of these threat- eiiings of pneumonia ma}^ occur, each a little more intense than the preceding one, and at last a full devel- opment of the disease will take place. When established, such a case may follow the classical \>y\>Q of the disease. So-called chronic 23?i(?i^ a pi-ogressive loss of flesh and strength occurs, which finally ends in death. Diagnosis of Abscess. — A diagnosis is based upon the history and the i)resence of the characteristic sputa. It must beditferentiated from (1) abscess of neighboring organs, — a^ of the liver or spine, — which may penetrate the lungs and be drained by the bronchi. Bits of lung- tissue cannot be found in the sputa in these cases. From (2) phthisis, which is accomi)lished by the historj^ and by the presence of tnbercle bacilli in the sputa of the latter; from (3) pulmonary gangrene by a purulent, and at least not constantly fetid, sputa, by the absence of mycotic plugs, and a larger number of haematoidin- crystals. Causes of Gangrene. — As the occurrence of pulmo- nary abscess requires the presence in the lungs of pyogenic matter, so, for the i)roduction of gangrene, the bacteria of putrefaction must be present. It is probable that they frequently- enter the lungs in small numbers b}- the bronchi, but they are unable to harm healthy tissue. Conditions of disense in the lungs, especially inflamma- tions, make it possible for them to develop gangrene. Rarely, a healthy person may, by an accident, permit putrefiable matter to enter a lung, — as, for instance, particles of food ; and with these as a nidus gangrene may certninly develop. It will oftenest develop thus in persons who are insane, delirious, comatose, or whose muscles of deglntition are paralyzed. . At times bits of decomposing tissue, from cancers or ulcers about the mouth or throat, may be drawn into the bronchi and cause gangrene. Very rarely, ulcers accompanied by decomposition may penetrate the thoracic wall and attack the lung, causing putrefaction in it. Fetid bron- Pulmonary Abscess and Gangrene. 115 cbitis mn}^ also be the cause of the lesion. Pneumonia and tuberculosis are occasionally complicated by gan- grene. In these cases the i)utrefaction occurs in the inflamed tissue, but is not the cause of it. Gangrene may be caused by emboli that have been carried from other parts of the bod^' where decomposition is going on. For instance, they may be derived from extensive and foul bed-sores or abscesses. Anatomi/ of Gangrene. — Either or both lungs ma}' be attacked. The right one is oftenest. The lower lobes are more liable to invasion than the upper. The lungs may be affected diffusely and very extensivel}^ or only small parts of them may be involved. Gangrene often- est spreads from a single focus, but may originate from several. The affected tissue first becomes soft, and brownish or greenish black. It exhales an offensive, fetid odor. The tissue soon liquefies in part, and a ragged, irregular cavity is formed, which is filled with a greenish-black fluid and bits of decomposing lung. An area of catarrhal or croupous inflammation usually exists about this cavity. The cavities commonly rup- ture into the bronchi, but many open into the pleura, pericardium, peritoneum, or, very rarely, externall}^ through the thoracic wall. The gangrenous process gradually involves more and more of the contiguous tissue. In favorable cases a circumscribing inflamma- tion separates the necrosed tissue from the rest as a sequestrum, and forms a limiting wall around it. The latter may be thin or thick, and in time may become fibrous. Extensive h.nemorrhage is rare, as it is pre- vented by coagulation within the pulmonary vessels before they are destroyed. If the cavity is thoroughly emptied of its putrefying contents, the fibrous capsule usually contracts it. The granulation tissue by which 116 Diseases of the Lungs. it is lined may cause its final obliteration. Pleiirisj' is a common complication of gangrene, and is often purulent. Symjytoms of Gangrene. — Tlie symptoms which ac- company gangrene vary much. As it is often secondary, the symptoms of the primary aft'cction may obscure those that are due wholly to the gangrene. In such cases the sputa affords the most characteristic signs of the disease. It is often large in amount. It may be as much as fifteen to twenty ounces per diem. It resembles in physical attributes the sputa of fetid bronchitis. Its odor is extremely offensive. It taints the breath of the patient, and even the air about him for many feet. If allowed to stand it stratifies, as does the sputa of fetid bronchitis. In the lowermost la3'er pus-cells and granular matter predominate, but plugs and shreds of tissue can also be found in considerable amounts. The plugs contain numerous crystals of fatty acid imbedded in countless bacteria. But what distinguishes this from the sputa of fetid bronchitis is the particles of lung-tissue which can be found in it. Various chemical substances are produced by the putrefaction which are characteristic of it. In very rare cases upon the post-mortem table gangrene of the lungs is demonstrated, though never suspected before death, for the characteristic sputa and foetor oris were wanting. Tlie other symptoms are not peculiar to it. Cough and ])ain in the side are usual. Dj'spnoea is sometimes marked. Centrally- located gangrene does not mod if}' the physical signs, but when it is superficial and exten- sive, at first, the signs of pulmonary consolidation, and, later, of pulmonary excavation are demonstrable. The signs of pleurisy are frequently present, and may obscure the others, Pulmonary Abscess and Gangrene. lit Fever usually exists, but, as a rule, it is quite irregu- lar. If the gangreuous slough is freely eliminated from an encapsuled cavity and absorption is thus prevented, fever msij be absent. The foetor of the breath often destroys the patient's appetite and ma^' even cause vomiting. The absorption of putrefying matter rarely causes rheumatoid pains. Metastatic abscesses may result from gangrene. Death has often been immediatel}' caused bj' a secondary abscess of the brain. A diagnosis can only be made when the character- istic sputa is present. Prognosis of Pulmonary Abscess and Gangrene. — The prognosis of pulmonary abscess must be a guarded one. It is always a grave disease. But a large proportion of the cases that occur are curable. A small proportion recover spontaneously. They are those in which the abscess is thoroughly drained b}' the bronchi or by rupture through the thoracic walls. Diffuse gangrene of the lungs is rarely recovered from. Circumscribed gangrene may be. It must always be remembered, however, that infection of other parts of the lungs may occur so long as any gangrene remains. Death is the result either of general loss of strength or of complications, such as pulmonar}^ haemorrhage, pleurisy, and brain-abscess. Both in abscess and gangrene of the lungs the prognosis will depend, in part, also, upon the vigor of the patient or the existence of other underlying disease. Treatment of Abscess and Gangrene. — Gangrene may be prevented by removing food from the air-passages if it accidentally fall into them when the muscles of deglu- tition are partly paralyzed, or a patient is mentally dull. 118 Diseases of the Lungs. Persons who are thus liable to errors of swallowing should be closely watched while eating. In abscess, if the sputa is offensive, and always in gnngrene, much beuelit cau be derived from the inhala- tion of antiseptics. The best effects are obtained by the prolonged inhalation of them. Therefore, antise})- tics are best administered by a respirator, which should be worn for hours. Turpentine, oil of pine, eucalyptus, beech-wood creasote, and carbolic acid are among the most useful antiseptics. Inhalation through the res- pirator may at first cause a feeling of oppression, but this will pass otf as the user becomes accustomed to it. Simpler means of inhalation, though less certainly use- ful, may be employed. For instance, the vapors of tur- pentine or of creasote, or of eucalyptus, ma}' be inhaled from a pitcher in which they have been mixed with steaming water, In^ fitting a paper cover over the pitcher for a mouth-piece. Or a Florence flask with an air-inlet and iuhaling-tube may be employed. When such antiseptics are inhaled the}' not oidj- check the putrefaction, but also check suppuration. The pro- longed use of the mask or respirator insures the impregnation of all the air in the lungs by them. Sym[)tomatic treatment may be needed to relieve pleuritic pains, or to allay nausea and vomiting. The radical treatment for abscess and gangrene of the lungs is surgical. Success can usuall}* be expected from it. Abscesses should be drained as soon as the}' can be located. The drainage should be as thorough as pos- sible. It is often impossible to wash the abscess-cavity through a drainage-tube, because the lungs are very liable to be flooded by the injected fluid, since bronchi mIso usually communicate with it. A large proportion of cases, if opened by puncture or incision and well Pulmonary Abscess and Gangrene. 119 drained, will recover. Occasional!}^ a fistula will be left. In one case, under m}^ own observation, a fistula per- sisted for more than a year, but was finally obliterated. Recourse to the same surgical procedures affords almost the only hope of successfully treating gangrene of tlie lungs. Many cures have been effected by incision and drainage. To give a patient the best possible chance, resort should be had to this method of treatment. In both diseases the individual's strength should be conserved as much as possible. Rest should be main- tained, both to prevent the employment of strength un- necessaril}' and, at least in gangrene, to more perfectly prevent the spread of the gangrene to other parts of the lungs, which might be caused by constantly var3'ing the body's position. The appetite should be stimulated by bitter tonics when it is deficient, and digestion aided if it is imperfect. Food, under all circumstances, should be given with regularit}^, and in amounts suflficient to maintain general strength. The kinds of food to be employed, and their amounts, must be varied according to the condition of the patient's appetite and powers of digestion. CHAPTER XIII. Pulmonary Tuberculosis. Definition. — Pulmonary tuberculosis, or phthisis, is a specific inflammiitioii of the bronchi and lungs. It is excited by the bacillus tuberculosis. The specific inflam- mation is always associated with simple inflammation, and usuall}' with suppurative inflammation. It is a wasting disease, and commonly a chronic one. Anatomy. — The anatomical changes which are ob- served in the lungs of those affected with tubercular disease vary greatly. The}' ma}^ be extensive, or slight, catarrhal, croupous, or interstitial inflammations. The lung is at first consolidated, and hiter excavated. While the anatomical lesions are so various, there are certain ones always present and characteristic ; the}' are the tubercle-nodules. Miliary tubercles are usually present. Infiltrating tubercular tissue may also exist. The characteristics of the miliary tubercle are the formation by cells of a globular mass the size of very small shot. This body is composed of large numbers of small round- cells. Near its centre are larger, oval, epithelioid, and giant cells. To some extent within the cells, and more abundantly between them, tubercle bacilli cnn be seen. No new blood-vessels are formed in these nodules. When— and sometimes before— it attains its minute growth the cells at its centre lose their vitality, degen- erate, and become a shapeless mass of dry fat-granules. This degeneration and desiccation constitute caseation. At first the miliary tubercles are gray and gelatinous, but soon become yellowish. (120) Pulmonary Tuberculosis. 121 These minute masses may coalesce and form larger ones, which are sometimes called tubercle-nodules. Irregularly shaped or disposed lines of caseous material are also often observable. They may be made by the coalescence of miliary tubercles, but they may also be made by the degeneration of tissue that is infected by the tubercular poison. It is probable that some sub- stance formed b}^ the bacilli so affects the tissue-cells that they degenerate. The absence of capillaries, be- cause of the non-formation of them in the inflammatory tissue and the frequent obliteration of them in old tissue, leads to the drying or caseation of the degen- erated mass. The tendency to degenerate, though origi- nating usually in a miliary tubercle, spreads from them, when they are completely involved, to the surrounding structures, providing the bacilli continue growing actively. Tubercles are the foci of extensive simple inflamma- tion, or they render chronic what was at first a simple inflammation. For example, around a miliary tubercle there may arise bronchitis, catarrhal or croupous pneu- monia, and where tuberculosis infects the lungs, because of an existing bronchitis, it may make the latter chronic. Infection most frequently occurs first in the small bronchi, where a miliary tubercle is formed. It excites a catarrhal inflammation of the mucous membrane, as well as inflammation of the submucosa and deeper tissues of the bronchi. This may lead to several diff"erent results : — 1. Atelectasis mny be produced if the inflammation and catarrhal desquamation produce obstruction to the minute bronchi. A patch of consolidation, lobular in size, will thus be formed. Soon, in the wall of some of the collapsed alveoli, miliary tubercles will develop, and 6 F 122 Diseases of the Lungs. excite more extensive round-celled infiltration into the alveoli and interstitial tissue. In some of the collapsed air-cells catarrhal inflammation will be excited, and the}^ will be filled with epithelial cells. Thus a tubercle- nodule is formed. 2. Instead of this course the localized tubercular capillary bronchitis ma}- lead to peribronchitis and catarrhal pneumonia. The solidified tissue in this case, also, is lobular in size. It resembles in all ways the lesion of catarrhal pneumonia, except that it is infected by tubercle poison, and miliary tubercles ma3^ be formed in it, or it becomes extensively caseous under the influ- ence of the bacilli. 3. Croupous inflammation of the lung ma}' be ex- cited. Oftenest the fibrinous consolidation is very limited in extent, but it ma}^ be extensive enough to involve an entire lobe. 4. To some extent in all cases, but especially in the most chronic cases, do the interstitial tissues become inflamed. Such inflammation produces broad bands of fibrous tissue. Tubercle-nodules and lung-cavities are frequentl}' encapsuled b}- them. Cirrhotic inflammation is usually protective, because it tends to encnpsule, and thus to limit the spread of the tuberculous infection. It helps to contract and to obliterate cavities. It produces the contraction of the lungs which is characteristic of chronic phthisis. In the fibrous tissue tubercle bacilli are very rare. It may almost be said that they do not exist in it. Apparently it is a barrier to their dissemi- nation through the lungs. New connective tissue may encapsule a caseous nodule of any size and isolate it. All the cells containing bacilli finally degenerate; the bacilli die and disappear, and the caseous mass is thus rendered inert. It will then usually calcify, and may Pulmonary Tuberculosis. 123 remain in the lung- indefinitely and liarnilessl3\ Such protective capsules are not perfectly developed except in the chronic cases. 5. Ulceration of the bronchi may result from their primary infection. Caseation in a bronchial tubercle will spread through it until the submucosa is involved and the epithelium cast off. The cheesy matter will crumble off into the bronchus, and a loss of substance will be rapidly caused. Suppurative inflammation then sets in, and the bronchial wall is quickly eroded. A minute cavity is thus formed. A large one may be pro- duced rapidl}^ by the coincident destruction of tissue by caseation and suppuration. 6. Pleurisy is always excited when inflammation occurs immediately beneath the pleura. The latter is thickened. Adhesions between the pleural surfaces always exist when tubercular disease is widely diffused in the lungs, and often so extensively that the pleural sac is obliterated. The pleurisy which accompanies phthisis is usually dry. In a moderate proportion of cases it is serous, and rarely it is purulent. Miliary tubercles may form in the thickened pleura, but do not uniformly. Serous effusion occasionally occurs into the pleural cavity or into a part of it that has been divided off by preceding dry pleurisy. Cavities are formed in two ways in phthisis : (1) b}^ softening and excavation of tissues consolidated by catarrhal or croupous pneumonia ; (2) by the dilatation of bronchi and their erosion through suppuration. The pathology of bronchi ectatic cavities I need not repeat. (See page 5if.) The influence of tubercle bacilli, or the chemical products of their life, is to cause fatty degener- ation and caseation. This tendency is increased by the non-vascular character of tuberculous inflammation. 124 Diseases of the Lungs. Softening and snppiiration, though exceedingh' common in caseous nodules in the lungs, is not as common in simi- lar formations in other organs. It is undoubtedly true that softening and suppurative inflammation of consoli- dated and caseous portions of the lungs is often due to a superimposed infection by pyogenic agents. The latter is, then, the cause of liquefaction of the nodule. Koch's experiments with tuberculin show that chemicals the products of the growth of the bacillus tuberculosis ma}' also cause suppuration. The softening usually takes place first in the centre of the mass. This is especially true if originally a bronchiole passed through its centre. The softening sometimes begins about the margins of a caseous nodule. At first the puriform fluid is odorless, thin, and contains few pus-cells, but large amounts of granular matter. Such pus is doubtless the result of tubercular infection only. Later, and especially after the cavity has opened into a bronchus, and it has become infected by the commoner pyogenic organisms, its contents are characteristic pus which is often more or less fetid. Minute cavities thus formed soon, by their growth, open into a bronchus and empty in part or wholly. The}^ grow, as do other abscesses, by the degeneration and desquamation of the granulation cells that compose their wall. Bronchiectatic and other cavities in tuberculous lungs enlarge more rapidh' be- cause of the caseation which takes place here and there in their walls under the influence of the tubercle bacilli. For granular, cheesy nintter, when laid bare, will rapidl}^ crumble into a cavity and niaj- produce a considerable loss of substance. After communication has been estal)lished with a bronchus, the air-pressure within the cavity is an important factor in enlarging it, for its walls are not firm, as a rule, and may be stretched. Pulmonary Tuberculosis. 125 Cavities frequently rupture into one another. Small cavities are usuall}^ irregular in shape ; large ones are more frequently smooth witliin. Bat both vary greatly in these respects. Cavities almost invariably form first in the upper lobes ; the}' mfvy be numerous or there may be but one. In man}' instances numerous caseons nodules are observable between the cavities and the surface of the lung. As the excavations extend near to the pleura it is inflamed, and firm adhesions usuall}^ form between the pleural surfaces over cavities. A cavit}^ may occupy the whole of one lobe, and be nearly as large as an infant's head. Bands of tissue often pass across them. These are usuall}^ parts of the interlobular septa, and they may include arteries of considerable size. The latter are usually obstructed by clots, but may be- come aneurismal and by rupture cause violent or fatal hgemorrhage. About all old cavities a fibrous envelope forms ; if the cavity is perfectly drained this envelope may cause its contraction and even obliteration, pro- vided the inner granulating surfaces of its walls can be brought in contact long enough for adhesion to be pro- duced. Small cavities whose outlet becomes obstructed are rarely obliterated by the absorption of their fluid contents, by the contraction of their walls, and by the caseation or calcification of their solid contents. Un- fortunately, this is not the usual course of pulmonary cavities ; they must be expected to enlarge. The con- traction of a cavit}' necessitates a compensatory dilata- tion or displacement of neighboring lung-tissue. There- fore the lung is often drawn upward from this cause, and if pleuritic adhesions are extensive other organs ma}- be displaced. The contents of the cavities are pus, granular and oily matter. In all that are rapidly enlarging bits of the elastic frame-work of the luno' can be found. 126 Diseases of the Lungs. Tubercle bacilli and various micrococci, pus-forming and iion-patliognomonic, are discoverable in them. The capillaries in tubercularl}' -inflamed tissues be- come occluded, and new vessels do not form. The calibre of the larger arteries is sometimes diminished or oblit- erated b}' endarteritis. Occasionally small patches of hyaline degeneration can be observed in phthisical lungs. This change is usually limited to the fibrous tissues or the blood-vessels. The various lesions that have been described are combined in many ways. Oftenest caseous nodules of catarrhal pneumonia are seen scattered through the lungs. Usuall}' cavities are also observable at the apex. If the given case has been a chronic one, much connect- ive tissue will be found about the lesions at the apex, while in the lower lobe more recent nodules of catarrhal pneumonia will be observed. Or, if life has ended from an acute exacerbation of disease, one lobe may be found consolidated by croupous pneumonia. Caseous nodules, or more diffuse masses of caseous material, will also be seen in it. The tubercle bacillus, and, therefore, the cause of the characteristic lesions, is disseminated through the lungs by three channels : by the blood, by the lymphat- ics, and by the bronchi. In most cases dissemination occurs b}^ both the last-named channels, and often hy all tiiree. In miliarv tuberculosis the lesion's cause is always spread by the blood-vessels. In man3' chronic cases a few miliary tubercles will be found in the intes- tines. They are probably caused by infection from sputa that has been sw\allowed. More rarely other organs will contain them, which must have been in- fected through the blood. Infectious material is usually not carried far by the lymph. It may be conveyed from Pulmonary Tuber^culosis, 127 one part of a lobe to another part, and especiall}' toward the hilus. The bronchial glands thns become involved. But it is not [)robable that the bacilli are transmitted by these channels from one lobe to another, and cer- tainl}' not from one lung to the other. The bronchial tubes are most frequently' the channels of dissemination. The sputa is its carrier. Sputa is not always expelled when it is moved in the bronchi, but is often drawn back, and even carried into the lung-tissue, by the air- currents. J. K. Fowler has recently demonstrated quite conclusively the usual path of infection by the bronchi. Oftenest the primary trouble is at one apex. The difference in the susceptibility of the lungs is slight: the left is probably first affected a little the oftenest. The lesion does not develop absolutely at the apex, but an inch or thereabouts below it ; or else, opposite a point on the exterior of the chest, just below tlie outer third of the clavicle. The lesion is also usu- ally nearer the posterior surface of the lung than the anterior. Before the opposite lung is involved the top of the lower lobe on the side first infected becomes the seat of a lesion. The opposite lung is tlien attacked, and generally its different parts are involved in the same order. The middle lobe is last involved, and often escapes entirely. The primary lesions near the apices of the upper and lower lobes increase in size and extend particularly downward. New nodules also form close by, and, grow- ing, finally unite with the first ones. In this way the solid mass increases. It has often a rudely-triangular shape, the triangle's base being the primary nodule, the apex being downward and the anterior border parallel, and usually coinciding with, the anterior surface of the lung in the upper lobe and the interlobular septum 128 Diseases of the Lungs. in the lower. Beneath these Uirgest solid masses smaller discrete ones can be found. The way in which the diverse lesions of phthisis are produced is not perfectl}^ clear. Undoubtedly the bacillus tuberculosis causes, b3' its presence or b}^ the products of its vitality, miliary tubercles and diffuse tubercular tissue. The catarrhal and peribronchial pneumonias are the results. of the extension of inflam- mation which accompanies or surrounds wiiat is strictly tubercular. The interstitial inflammation is undoubt- edly chiefly conservative. The presence of tubercle bacilli, or, more probabl}', of the chemical products made by them, leads to caseation. It is not common for tubercular lesions elsewhere than in the lungs to suppurate ; when they do, other microbes than the tubercular are found in the pus and inflamed tissue. It is therefore not clear that suppuration of tubercularly- inflamed tissue is often due to the tubercular infection onl}'. The tubercular inflammation excites general symptoms as well as local ones. The former are very like those of a chronic septicaemia. This is especially true after suppuration, when usually a genuine septi- caemia exists. Miliary tuberculosis of the lungs develops when the blood is infected. The miliary tubercles will then develop simultaneous!}' in most of the organs and tissues of the bod}-. The disease is a general one, and not strictly one of the lungs. In such cases the tuber- cles are uniformly scattered through the lungs. Thej* may be so numerous as to fill a large part of the lung- tissue, or the}^ may not be at all numerous. They ma}' coalesce to form small nodules. The lesions of so-called acute i)ulmonary phthisis do not differ from those of the chronic form, except in Pulmonary Tuberculosis. 129 the rapidity with which they develop and spread. Fibrous tissue is rareh' developed, or, at least, to an3' considerable extent. Miliary tubercles may not be present. Often one entire lobe is consolidated and extensivel}' caseated or excavated. The lesions may be catarrhal or croupous, or both. They caseate with rapidity, and cavities form in them as quickly. Gan- grene not unfrequently supervenes. Symptoms. — In chronic tubercular disease of the lungs tliree stages are recognized clinically : a stage of incipient tuberculosis ; a stage of consolidation ; a stage of softening and excavation. The first is anatomically characterized by a localized bronchitis, usually in one or both apices, and by consolidation too small in amount to recognize clinically ; the second by clearly recogniz- able consolidation ; the third by the formation of cavities. In the first stage the ph3^sician maj^ be consulted either for a gradual loss of flesh and strength or for a persistent cough. Frequently, an acute bronchitis, which becomes chronic, tliough mild, is the origin of the disease. An insidious loss of strength, which causes lassitude and loss of flesh and color, are characteristic. The face grows gray or sallow, tliough the lips remain red. The patient tires quickly. His respirations are short and quick on slight exertion, and even when at rest the movements are shallower than is normal or they are unequal on the two sides. There is usuall}^ a slight, constant, hacking cough ; the coughing is now and then aggravated by a fresh cold. Often the appe- tite and digestion remain normal, but sj^mptoms of dyspepsia are not unusual. The pulse is quick, var3^ing from 90 to 100 per minute. The temperature is slightly raised : when the bronchitis is severe it may be 102° or 130 Diseases of the Lungs. 103^ F., but usuall}' it is about 100^ F. by eight o'clock in the evening, when it reaches its maximum. It is normal in the early morning hours. Xot uufrequentl}^ a sense of chilliness is experienced about the middle of the forenoon, and, rarely, an actual rigor occurs. When the bronchitis is severe considerable sputa may be ex- pectorated. It is in tiie early morning commonly muco- purulent, and later in the day frothy mucus; but the commoner, persistent, hacking cough is dry. In the sputa tubercle bacilli can be discovered if patiently sought for. Haemopt^'sis may occur. Bleeding at this stage is small or moderate in amount ; it does not occur in half the cases. The physical signs are most characteristic in those who inherit a predisposition to tubercular disease. We discover this stage, usualh', developing in bo^-s and girls between the ages of 14 and 22. The}' are slender; their muscles are small and weak; their skin is thin and white ; the chest is long, narrow, and thin ; often the head droops forward or the shoulders bow ; the anterior and upper surface of the chest is flat, and expands very moderatel}' with inspiration. In those in whom the predisposition is acquired in adult life the shape of the chest is not characteristic. Respiration becomes shal- low, and, usuall}^, especially so upon one side. There is no abnormal fremitus. The apices are less resonant than is natural, but localized dullness is not dfscover- able. The respiratory sounds are not uniform over the chest : they may be exaggerated at both apices, but more frequently the}- are not uniform upon the two sides ; for instance, in the left supra-clavicular region inspiration may be loud, in the infra-clavicular and supra-scapular regions it may be loud and often hitching. There is no expiratory sound. Over the lower part of Pulmonary Tuberculosis. 131 the left lung the sounds ma}' be clear and purely vesicular, but over the right apex the sounds ma}^ be low, and near the outer end of the clavicle the^' maj' be absent ; a prolonged expiratory sound may be heard. Over the lower part of this lung the sounds will probabl}' be low, vesicular. It must not be supposed that the respiratory sounds are alwa3's just as described in this illustration. The characteristic of them is rather a marked difference upon the two sides, and even in different parts of the same side, and especially an abnor- mality in the sounds at one or both apices. In the second stage of the disease the bronchitis is more severe. Coughing occurs often, and is alwa3'S a noticeable symptom, while in the first stage it is often so slight MS to be overlooked by the patient. The expectorate is more constantly muco purulent, and bacilli are more numerous. Often, in acute exacerba- tions, the usual symptoms of acute bronchitis will be present. Emaciation goes on more rapidh', and the patient is more languid. The appetite is often lessened and capricious. The pulse remains quick, is smaller and softer. The temperature follows the same course as in the earlier stage, but averages a degree higher by eight o'clock in the evening, and is usuall}^ a little sub- normal in the earliest morning hours. Sweating at night may occur in the first stage, but less often thjin now. Respiration is shallower, and decided!}' so upon one side of the thorax. It is more easil}' excited, and breathlessness on exertion is greater. On inspection, the difference in the freedom of ex- pansion of the two sides is evident. Often, especially in the chronic cases, the supra- and infra- clavicular regions upon one side will be more retracted than upon the other. Yocal fremitus is increased over these retracted 132 " Diseases of the Lungs. area.s. At these points there is greater relative dull- ness, but nowhere is there absolute dullness. Over these same areas the respiratory sounds are broncho-vesicular. Moist rales can occasional!}' be heard. These evidences of lung consolidation ma}' not be confined to one apex, but may be elicited over areas of either lung, or different parts of each. The}' are discoverable, usually, at the apices, or posteriorly at the top of the lower lobes. Over other parts of the lungs tlie physical signs may be normal, or those of bronchitis only. In the third stage of the disease the emaciation is often extreme. The cheeks are "hollow. If the invalid attempts to sit up, the back quickly bows and the shoul- ders sag. Speech is frequently slow. There is little endurance, and sooner or later the patient is bedridden. The pulse grows smaller and remains soft and quick. The temperature varies much from day to day, but aver- ages 102° F. at night, and is almost uniformly subnormal in the early morning. Xight-sweats are often of daily occurrence. The cough is constant, but varies greatly from time to time, and in individuals as regards severity and frequency. It is accompanied by the expectoration of a muco-purulent or purulent sputa. If the cavities are enlarging by the disintegration of lung- tissue elastic fibres can be found in the expectorate. The appetite is variable, l)ut is usually diminished or very capricious. Pain in the chest may be felt in any stage of the dis- ease. Oftenest it is of pleuritic origin ; more rarely it is neuralgic or rheumatic. Inspection of the bare chest demonstrates the great emaciation which has occurred. The lungs do not ex- pand equally, and respiration is much quickened. Pal- pation reveals increased vocal fremitus over areas of consolidation. Not unfreqnently a bronchial fremitus Pulmonary Tuhey^culosis. 133 can be felt. Resonance is lessened when there is con- solidation, but is t3'mpanitic or senii-tympanitic over superfi(nul cavities. Over areas of consolidation the respirator}' sounds are broncho-vesicular, or bronchial ; over cavities they may be cavernous or metamorphosing ; or, constant bul>bling rales may be heard at one point, rales that do not move or disappear after a cough, or with cliMuges of the patient's [)osition. Often, however, we must rely upon the discovery of elastic fibres in the sputa in order to prove th.it excavation has begun or is progressing. Toward the close of life the pulse grows more thread- like ; the skin becomes moist and gradually' cold. Res- piration is very shallow and may be labored. Cyanosis is apparent. The mind may remain clear to the last, but oftenest consciousness graduall}^ is lost as cyanosis deepens. During the last few days of life, or at least during the last few hours, coughing becomes infrequent or ceases, or if it occur is unaccompanied by expecto- ration. Mucus and oedema gradually obstruct the lu'onchi and lungs until respiration is impossible. I have described the stages of chronic tubercular phthisis ns though they followed each other rapidly, but they ma}' not do so. Periods of quiescence or of par- tial recovery are the rule. The}' may occur between the various stages, or in their midst. For exjunple, some pulmonary consolidation may be developed, nnd then apparent restoration to health may occur. After months or years an extension of consolidation may take place, or a cavity may form. It is these periods of quiescence that make the disease so eminently chronic. During them the physical signs of some consolidation or of a cavity will remain The tempeature may be normal in range, but its daily curve usually differs from a normal 134 Disease.': of fhe Lungs. one, in that the maximum point occurs late in the after- noon instead of early. It is important to know what are symptoms of im- provement. One of tiie first tiiat is noticeable is disnp- pearance of temperature or prolonged remissions. The pulse becomes slower and often fuller. Flesh is gained. It is true, that rarely flesh may be gained wiiile the fever persists. An individual's change in weight is so good n criterion of the course the disease is pursuing that it should be frequently observed. A gain in weight is sig- nificant, at least, of a diminished general tubercular in- toxication. A sign of improvement still more im- portant is an increase of respirator}' capacity. It means that the lungs are filling more perfectly, and, nsualh', that the croupous and catarrhal exudates are at least in part being absorbed. This change does not occur, as a rule, except during remissions in the disease. Changes in the respirator}' capacit}' are best measured b}' the spirometer. When very considerable increase takes place, measurements of the chest's girth at the end of deep inspiration will demonstrate it. The physical signs change if improvement occur in the con- dition of the lungs. It must be remembered that im- provement in a consumptive's general condition often occurs witlTout a diminution in the extent of diseased tissue in the lung, and is coincident onl}' with a cessa- tion in the activity of the disease. If areas of consoli- dation not only cease to increase, but also contract and become encapsuled, dullness-will diminish, and all other physical signs of consolidation will be less notice- able, or will disappear. If a cavity cease to grow or it contracts, the signs of its existence will be less diffuse or evident. Elastic fibres will disappear from the sputa. The latter will become less purulent and less abundant. Pulmonary Tuherculoais. 135 The tubercle bacilli will dimiDisli in number and ma}' disappear. Improvement may go so far that a consump- tive may be able to accomplish work e(|ual to that of a man in perfect health, and still a cure may not be effected. To accomplish tlie latter, all tubercular poison that exists in the lungs must be destroyed, not simply rendered dormant to be rekindled later. The cough is one of the last symptoms to leave a case doing well. Its severity is never a criterion of the intensity of the dis- ease. There are several important complications, of more or less frequent occurrence. Indigestion is not uncom- mon. It is freqnenth' the result of a catarrhal inflam- mation of the stomach. A disinclination for food is ver}' common, but more than half the time it does not indicate indigestion ; for if food is introduced into the stomnch it does not ferment or cause distress ; and, furthermore, experiments have demonstrated that the stomach secretes a normal gastric juice. Disorders of the stomach are suspected oftener than the}^ occur. Diarrhoea may occur at any stage of the disease. It commonly has two origins. It may be due to catarrhal inflammation of the intestine or to tubercular nlceration. The latter is a lesion of gravity, while the former rarely is, except when the individual, for other causes, is ex- tremely weak, and cannot withstand even moderate additional exhaustion. It is often diflflcult to diflfer- entiate between catarrhal and tubercular inflammation of the intestines. If the tubercle bacillus is discover- able in the faeces tubercular inflammation may be con- fidentlv diagnosed, for it is very seldom that the bacilli are swallowed and voided from the intestines unchanged. Tubercular ulceration rarel}' occurs while the bowels re- main constipated. In some cases symptoms of sudden 136 Diseases of the Lungs. peritonitis, i)eri- or para- typhlitis, intestinal perfora- tion, liaimorrliage, or signs of internal bleeding first suggest tlie presence of latent ulcers. The larynx may also be the seat of a complicating tuberculosis. In the earlier stages the laryngoscope will reveal swelling of the larynx, especially pale, nodu- lar swelling. Later, ulcers can be seen. Hoarseness and even aphonia are common. Sharp, piercing pains are usual. Swallowing is often so distressing that food is refused, and all attempts at deglutition are avoided. Haemorrhages may occur at an}^ stage of the disease. When slight, onh' streaks of blood are seen in the sputa ; when moderate, a few mouthfuls of bright-red and usualh' frothy blo(Hl well up into the throat. In severe cases large quantities will be thus voided for hours or even days at a time. When large amounts are raised vomit- ing may be provoked, or tlie blood may simultaneOusl}' flow from the mouth and nose. Haemorrhage from the lungs is accompanied by coughing. Haemoptysis is dis- tinguished from hsematemesis b}' an accompanj'ing cough with the former and vomiting with the latter, by a brighter redness of the blood from the lungs and blacker hue of that from the stomach, b}' the alkalinitv of the former and aciditj' of the latter, b}^ its absence from the stools of the former and presence in those of the latter, by tlie existence of preceding disease of the lungs in one case and of the stomach in the other. Haemorrhage from the lungs is rnre for any other cause tlian tubercular disease, and is, therefore, an important diagnostic symptom. It is seldom dangerous to life. Pleurisy is so constant in its occurrence that it must be regarded as part of the disease rather than as a com- plication. Often it is chronic, and produces so little pain and symptoms so insignificant that it escapes atten- Pulmonary Tuberculosis. 13*7 tion. In a large number of cases it causes character- istic pain and other symptoms. Not unfrequentl}' tu- berculosis is the cause of pleurisj^ with effusion. In the beginnings of phthisis the effusion may fill an entire pleural cavity ; in the later stages, after adhesions be- tween thei)leural surfaces have become extensive, eff'u- sioiis are usually circumscribed or pocketed. Pleuritic pains are often very distressing and in many cases recur frequently. They may be felt at any time diiriug the course of the disease. Renal lesions do not often form com})lications. Re- nal tuberculosis maj' develop. More frequently amyloid infiltration of the kidney occurs. The commonest he- patic complications are fatty degeneration and amyloid infiltration. What is called quick consumption or acute phthisis may vary greatly in its course and mode of develop- ment, the common feature of all cases being the rapidity- of the course. In many cases the symptoms are the same as those of chronic phthisis, but no periods of quiescence come in their course, and consolidation and excavation develop in quick succession. In many in- stances, during a few weeks preceding the actual out- break of the disease, a slight cough and noticeable loss of flesh will attract the patient's attention. Suddenly a sharp pain will be felt in the side. The temperature will rise to 104° F., or thereabouts, and for a few days perhaps })e continuous, but will soon grow irregular and approximate a hectic type. Emaciation wall progress rapidly. The cough will be hard and painful at first. The expectorate may nt first be mucous, later muco- purulent, and, when excnvation progresses, purulent or gangrenous. Tubercle bacilli can be found in it. The appetite is diminished.. The bowels may be constipated 138 Diseases of the Lungs. or irregiilur, but often, toward the close of life, the}- are loose. The pulse is soft from the first, grows small, 'and is constantly- quick. Respiration at first is painful, on one side at least, and therefore expansion of the chest is lessened, and its movements are superficial. Almost from the first large areas — lobar ones often — are con- solidated by croupous inflammation or b}' a combination of it with catarrhal inflammation. Therefore, percus- sion soon reveals dullness over these areas ; ausculta- tion, bronchial respiration; and palpation, increased fre- mitus. Usually coarse, moist rales are abuildant from an early date. The disease runs too short a course for much contraction of the lungs to develop. In a few weeks after the consolidation excavation begins and progresses with rapidity. It is revealed by the usual physical signs, and b}- the presence of bits of lung- tissue in the sputa. In several instances I have seen gangrene supervene. The duration of these cases varies from six weeks to three months. Diagnosis. — A diagnosis is made directl}^ by the his- tory of loss of flesh, by the existence of a small, soft, quick pulse, an irregular but persistent fever, the phys- ical signs of a circumscribed bronchitis or pneumonia, the existence of tubercle bacilli in the sputa, and, in the stage of active excavation, of elastic fibres in it. It can be differentiated from acute bronchitis b}^ the persistence of fever, by the greater loss of flesh, and by the limitation or concentration of the physical signs at the apex of one or both lungs. In simple bronchitis the inflammation is quite uniformly diflTused in both lungs. After consolidation and retraction have oc- curred, it cannot be confounded with bronchitis, although it might be with interstitial pneumonia and peri- bronchitis. The latter aflTections are not accompanied Pulmonary Tuberculosis. 139 by the hectic fever and progressive emaciation which are inseparable from phthisis. In the stage of excavation elastic fibres are significant, although they maybe found in the sputa that comes from simple abscess and gan- grene of the lung. In the stage of softening it can hardly be confounded with an}' other disease, because of the history of its development, its chronicit}^, the chiefly apical location of its lesions, the simultaneous existence of areas of consolidation, retraction, and excavation. The discovery of tubercle bacilli iu the sputa at any stage makes a diagnosis a positive oue. Causes. — So generally is it admitted tiiat tubercular inflammation is due to the bacillus tuberculosis that I have uot discussed the history of the growth of knowl- edo^e in reoard to it. Belief that this b.'icillus is the cause of the disease is based upon the facts that (1) it is always found associated with its lesions, and (2), when isolated and inoculated into animals, it produces characteristic tubercular lesions. A few cases of acci- dental inoculatiou of man have borne the same results. It is found that the bacillus does not produce the disease with equal readiness in all animals, and that all men are not equally susceptible to it. Therefore, there must be other predisposing causes or susceptible states of the system. A predisposition to the disease may be either inherited or acquired. It is very rare, if ever, that the bacillus is transmitted to the child while in the uterus ; but tuberculous and cancerous or otherwise very feeble parents usually give birth to children who are peculiarly susceptible to the disease. Many inf:ints are infected by the milk of tuberculous mothers or nurses, and usually become scrofulous, or develop intestinal tuberculosis. There are several factors by means of which a sus- 140 Diseases of the Lungs. ceptibility may be acquired. Usually several of these factors act together. Persons who breathe air that is confined in poorly-ventilated rooms, and especiall}' air that is simiiltaneousl}' breathed b}^ many persons, are peculiarly apt to develop a susceptibility. They are liable to the malady both because their general vigor and abilit}^ to withstand disease is lessened by breathing such air, and because the air is es[)ecially apt to contain the bacilli. Lack of exercise is a second factor that aids in developing a predisposition. If general exercise is wanting, vigorous health and powers of resistance cannot be maintained. If exercise, such as will insure frequent, deep breathing, is wanting, the lungs will be imperfectl}' expanded and air will remain in them long unchanged. If the lungs are thus imperfectlj^ venti- Inted, it is possible for the bacilli to gain lodgment and to remain long enough to grow. As the}' grow^ with l)eculiar slowness, good pulmonnr}- ventilation will greatl}'^ help to prevent infection. Foods may be a source of infection. Cows' milk and beef sometimes contain tubercle bacilli, and when eaten ma}' cause tuberculosis. This, however, rarely occurs, except in infancy, when raw, infected milk may })e taken for weeks and months consecutively. Healthy digestion often, but not always, kills the bacilli. Cook- ing always will. There need be little fear of tuberculous food if it is not taken raw. A lack of nutritious food will cause a degree of general feebleness which makes one little resistant to nn}- form of illness. Other i)uln)()nary diseases, especially chronic ones, predispose to tuberculosis of tiie lungs, by removing the natural guards of tiie respirator}' passages against infection. Bronchitis often destroys the ciliated epithe- Pulmonary Tuhei^culosis. 141 lium of the bronchi, whose function it is to keep the latter clean. Excoriations or superficial ulcerations make it comparatively eas}- for infectious germs to gain access to the deeper interstitial tissues, and to lodge in the air-passages long enough to multiply. We there- fore find pulmonary tuberculosis often following other inflammatory affections of the lungs. Diabetes is a general disease which, with peculiar frequenc}", is followed by or associated with tuberculosis. It certainl}' creates a susceptibilit}^ to the latter disease. Both sexes are aflTected with equal frequenc}^ Pul- monar}^ tuberculosis may develop at any age, but it is least likely to in the earliest and latest years of life. Most frequently the earliest symptoms can be detected in the latest 3^ears of youth and earliest years of adult life. It is a disease that is ubiquitous. It can be found in all climates. It is, however, not equnlly common in all. In general it maj' be said that in the most sparsely peopled regions of the world it is most infrequent. High altitudes and higli latitudes are most exempt from it. The coldness of such localities leads to purit}' of tlie air. The rarefaction of the atmosphere in high altitudes also contributes to its purity, especially to its freedom from dust, because the latter is not easily suspended in thin nir. The liabits of the inhabitants of such regions necessitate vigorous exercise out of doors, and the stimulating qualities of the dry. cool air incite them to it. This insures deep and freciuent bieathing of pure air and the maintenance of a good circulation. The rarefied air of high altitudes necessitates deep breathing, involuntarily trains the muscles of respiration, and develops voluminous lungs. Pulmonary tuberculosis is also somewhat less fre- 142 Diseases of the Lungs. quent upon dry, well-drained soils than upon low and poorl3'-drained ones. The disease is most abundant in temperate and warm climates, where the soil and air are damp and the temperature is changeable. Pulmonar}' tuberculosis is a constant scourge and is more deadly than the epidemic diseases. On an aver- age, 1 in 7 of all who die, the world over, succumbs to it. In certain localities the mortality is much greater, and in others less. In many, especially in old prisons, from 50 to 70 per cent, of the deaths are from this disease. Clean, fresh air is so important for its preven- tion that good ventilation of rooms and good ventila- tion of the lungs, maintained by exercise, have lowered high mortalities from it in the inhabitants of prisons, barracks, schools, and monasteries. Prophylaxis. — Prophylaxis is extremel}^ important. We can hope that, by a proper regulation of the life of the people, it ma}^ be possible to greath' diminish the frequency of the occurrence of pulmonarj' phthisis. This must be accomplished bj- preventing infection, b}^ removing an inherited predisposition, and by preventing its acquisition. Tuberculous milk, whether it comes from a mother or from cows, should not be fed to infants. Tubei-culous milk and mejit are less apt to infect adults, for they rarely take much of either in an uncooked state. As infection takes place almost exclusive^ through the respiratory- passages by means of contaminated air, it is self-evident that pure air only should be breathed. To prevent contamination the bacilli should be destroyed as far as possible, and perfect ventilation of living-rooms and shops should be maintained. The nir is contam- inated by tuberculnr matter only Mhen the latter is dried and forms a part of the atmosphere's dust. Such Pulmonary Tuberculosis. 143 dust is almost exclusively formed by the drying of sputa. Wlien it is remembered that sputa is cast upon the floor of buildings, upon the ground, and upon hand- kerchiefs or other articles of dress, and permitted to dry and be scattered by air-currents, the abundance of the contaminating material becomes evident. For the safety of others, tuberculous patients should be instructed to always expectorate into vessels filled with water, or upon handkerchiefs or other articles that can be boiled or burnt before they (\vy. Cuspidors should not be emptied upon the ground, but into sewers or upon a fire. The}^ should often be thoroughly scalded. If sleeping-rooms, living-rooms, factories, oflflces, and halls, where much of our life is spent, are well ventilated, the air will be constantly diluted and purified, so that the chances of infection will be greatl}^ lessened. The fact that those whose occupations or modes of life necessitate their breathing a close and confined air, and especially one that many are simultaneously breathing, are more subject to the disease than others, establishes the need of fresh air for healthful living. Some 3^ears ago it was found that, among certain English soldiers, the mortality from consumption exceeded very greatlj' that among the towns-people about them. The old and poorl^'-ventilated barracks -that they were then using were torn down and replaced b}" new ones, especiallj^ constructed to maintain ventilation as perfect as pos- sible. The result was, that the mortalit}- fell to as low a point as in the healthiest districts of England. A life out-of-doors — if possible, in the countrj- — should be led by those predisposed to the disease. The bad influence of a sedentarj^ life upon those pre- disposed, and its influence in developing a predispo- sition, emphasizes the need of exercise as a means of 144 Diseases of the Lungs. propli3'laxis. Exercise should be general to maintain a good degree of nutrition and a vigorous circulation. The}' must, also, often be especially adapted to develop the lungs and to increase tlie forcefulness of respiration. In those whose build predisposes them to consumption the lungs are unusuall}- small in vertical diameter, but very long, and the heart is small. General exercise will strengthen and enlarge the heart. Pulmonar}^ exercise — that is, voluntar}^ deep, full breathing — will enlarge the lungs, strengthen the respirator}' muscles, and create a habit of deep breathing. Life at high altitudes, hill-climbing, and running especially lead to involuntary deep breathing. In young people the chest is mobile, and can be shaped and enlarged bj' persevering exercise. It is often necessary to correct other muscular weak- nesses which produce deformities that hinder good respiration : such are round shoulders and stooped neck. They are due to weak shoulder- and back- muscles. For children and youth who are physicall}- deficient special physical training is needful. Dail}^ baths or douches, and thorougli rubbing after them, are useful in training the peripheral vessels to dilate promptlj^ and restore warmth to the skin when it is suddenly chilled. If this habit can be acquired by the vessels the evil etfects of sudden and violent atmos- pheric changes will be lessened. The body should be constnntly covered by woolen garments. They may be light or heavy, according to the season, but in changeable climates they should be worn throughout the year. It is best, also, that woolen night-garments should be worn. The advantage of woolen clothes is, that they maintain within themselves an atmosphere that is slowly influenced by external changes. They are porous, and do not keep upon the Pulmonary Tuberculosis. 145 skin exhalations wiiich sliould be carried off in order to maintain cleanliness. Certainly, colds are less fre- quentl}' taken or aggravated b}^ those who exercise such care in dressing. The climate best adapted to those disposed to the disease will be indicated when the climates which are most suitable tor the different stages and varieties of consumi)tion nre descrilted. For tiiose especial!}' sus- ceptible out-door em[)h)yments shoukl, b}- all means, be preferred. Close confinement to a desk or at trades, such as sewing, tailoring, and shoe-making, should espe- cially be avoided ; particularly should such individuals not work in poorly- ventilated rooms. If the tonsils of a child are chronicall}' enlarged and, by their mechanical interference with respiration, prevent the proper development of the chest, they should be removed. Respiratory affections, especially such as subacute or clironic bronciiitis, should be cared for as quickly as possible, for the}' also make the indi- vidual affected more susceptible to infection. Treatment — Hygiene. — We know of no specific for tuberculosis. Medicinal treatment is therefore symp- tomatic. Hygienic treatment is all important. Hygi- enic measures, as well as medicinal treatment, must be adapted to individual cases. Pure air is as essential to the consumptive as to those predisposed to the disease. The purest air is found in mid -ocean and upon moun- tain-tops. It is better in the country than in the city. At high altitudes — that is, at elevations of more than five thousand feet — advantage is derived not only from the purity of the air, but from its rarefaction and con- sequent influence upon the depth and frequency of respiration. High altitudes are especially indicated for young people who are predisposed to the disease, or 7 G 146 Diseases of the Lungs. have it in its incipienc}', provided tliey do not have fever. It is indicated for fibroid phtliisis, especially if it occur in young persons. It is also indicated for tliose suffering , from any A^ariety of chronic phthisis during a period of quiescence. But it is not so uni- forml}" beneficial in those who are past middle life or ver}^ feeble. The rarefaction of the air causes involun- tary, deep, and, at first, frequent respiration. Little by little the lungs expand, so that their capacity is in- creased. As this change takes place the breathing becomes slow, but remains unusually deep. The deep and strong respiratory movements that are thus con- stantly necessitated enforce a better ventilation of the lungs, a better oxygenation of the blood, and, therefore, more active tissue-change throughout the bod}', and a strengthening of tlie respirator}- muscles. The increased capacit}' of the lungs is brought about b}^ distension of the air-cells which, in lower altitudes, are only partly expanded and little used, and often by rendering other portions emphysematous. This helps to prevent infec- tion by mruntaining good ventilation of the lungs. Emphysema is usuall}^ produced about areas of consoli- dation. The stretching of the lung-tissue here and consequent stretching and narrowing of the capillaries prevent congestion. The dryness which is character- istic of liigh-altitude atmospheres causes the exhalation of unusually large quantities of water. This aids in bringing about an absorption of inflammatory exudates. The breathing of pure air lessens the tendency to infec- tion by p3^ogenic organisms, and the liabilit}^ to form abscesses. Dry, clean, cool mountain-air is peculiarly invigorating to the nervous system. It often stimulates the ambitionless and letliargic to take the all-neede(i gxercise. It gives greater buoyancy of spirits. Pulmonary Tuberculosis. 147 High altitudes are contra-indicated in acute catarrhal cases, or in other forms in which there is an acute exacer- bation. Fever is a contra-indication, since it is usually aggravated by high altitudes. Great debility is also a contra-indication. If the lungs are so extensively in- volved in consolidation or excavation that respiration cannot be well maintained in rarefied airs, the high alti- tudes are likewise contra-indicated. A very nervous temperament contra-indicates them ; for the stimulating air may cause sleeplessness, extreme nervousness, and even muscular pains. Many places in the Rocky Mountains are high-alti- tude climates par excellence. In this vast region em- ployment can be found by those who can take it; and ver3^ excellent locations for permanent residence exist there. Of health resorts Colorado Springs and Mauitou are the most famous. The Alps in Switzerland are also famous for the cure of consumption, but they are not as good as the Rockies, since permanent residence in high altitudes cannot so well be maintained there, for in the spring, when the snow melts, the air becomes damp, and exercise is limited bj' the wet and slush. l\\ the Rockies snow lies on the ground only a short time and disappears with rapidity at most of its health resorts. High-altitude residences are few in the Apalachian Mountains, and when they exist they are on mountain- peaks that are frequently cloud-capped, enveloped in mist, and exposed to harsh winds ; but residences at moderate altitudes of two thousand or three thousand feet are numerous. The3" afford climates that are stim- ulating and air that is pure, while, for those who can take exercise, the hill-climl)ing will accomplish nearly as much toward expanding the lungs and dilating the c^iest as the rarefied air of high altitudes. They are 148 Diseases of the Lungs. better suited, too, for those whose lungs are extensively- crippled and who are greatl}' enfeebled. Sea-air, which can onl^' be had to the fullest advan- tno-e at sea, on a vessel, is especiallj' suited to the same classes of cases as high altitudes, and also to persons past middle life and to those greatly weakened. It is characterized bv purit}' ; therefore, suppuration from superimposed infection is not likely to occur. It is invigorating to digestion and nutrition, and its moisture and equability make it palliative to dr}', harsh cough- ing. Involuntary expansion of the lungs, enlargement of the chest, and prompt absorption of inflammatory exudates must not be expected. Pulmonary exercises, when indicated, must be voluntarih' taken. The great- est benefit has been derived from high-altitude and sea airs; but, if the best results are expected, cases must be carefully selected for each. Sea-climates, because of their sedative influence, are indicated for the ver}' nervous, who are too greatl}' stimulated by drj', high- altitude air. Long sea-vo3'ages, as well as prolonged residence at high altitudes, is essential to produce the desired effects. At least six months, and, better still, a year or more, should be spent in these climates. A sea-vo3'age is con- tra-indicated for those who are ver}' weak or in danger of rapid failure, since they cannot turn back when started. It is contra-indicated for those subject to prolonged sea- sickness. A time of year and a direction should be chosen tlint will promise good weather. Three succes- sive summers can be had by starting from the northern temperate zone nnd sailing across the Equator to the southern })art of America or Africa or Australia, so that the winter will be pnssed in southern seas, and a return voynge made so that home is reached the follow- Pulmonary Tuberculosis. 149 ing spring or summer. Boats should be selected that are not overcrowded with passengers and that are well provisioned. Good and varied food is essential for an invalid. A voyage in a sailing-vessel is the best for an invalid, for such boats go more leisurely and are less crowded than steamers. A modified sea-air can. be had ui)on many islands and coasts, which is often very beneficial. But it is neither so pure nor so constanth" invigorating, because more changeable. Islands often resorted to are the Bermudas and the West Indies. Shore resorts are numerous. Those of California .and Florida are pecu- liarl}^ favorable to many cases of consumption. It is desirable to remove mau}^ consumptives who, although in the early stages of the disease, are feverish and ill adapted to the climates already mentioned from the changeable and inclement weather of our northern cities. Those who are suffering in the advanced stage of the disease, if it is not making rapid progress, are also benefited hy escaping winter and spring weather at the North. For persons who are naturallj- lethargic and need a stimulating climate, the dr3^, mild, and equable air of Southern California is peculiarl}^ favor- able. Its distance often makes it inaccessible. West- ern and Southern Texas afford an excellent winter and spring climate for those who need a moderatel}' dr3^ and warm air, and, therefore, one moderately stimulating and genial. Those who, because of the nature of their case, cannot make their home either at high altitudes or on or b}^ the sea, are often most benefited by transitor}' residence in southern States during the winter and earl}^ spring, and amid the pine- forests and moderate eleva- tions of Virginia, Georgia, or New York in summer and autumn. Often those who cannot safely take 150 Dif^eases of the Lungs. advantage of a high-altitude climate, because of fever and the acuteness of their trouble, though in the first stage of the disease, can spend the winter with benefit near San Antonio, Texas. There the}' can live almost constant!}' out of doors and take the needed exercise, while the change will invigorate the appetite and usu- ally cause a general improvement. Often their fever is gone before spring, and the}' can go with safety and the greatest advantage for a sojourn of a year or more to Colorado or Xew Mexico, where the mechanical effects of a rarefied air ma}' be obtained. Localities should always be chosen where there are few cloudy days, and where violent atmospheric changes are rare. Often pure air must not only be sought by changes of climate, but it must be insured in the homes or places of business of consumptives. As little time should be spent in-doors as possible by those able to be out. Sleep- ing-rooms should be most thoroughly ventilated. T'heir windows should be kept open by day, and if it is neces- sary they may be moderately warmed before bed-time. Warm clothing and bedding should be at hand, but the temperature of the air need not be high. For those who are able to be about the house and out by day, it need not in winter l)e more than 45° or 50° F. if the air is dry, but must be much warmer if it is damp. For those who are quite weak it is best that the temperature of the room be kept uniform and at about 68° or 70° F. For tliose wlio cannot leave the house, but can leave their beds, it is best that two rooms be at their disposal, one to be used by night and the other by day. The one occupied by day should be sunny and cheerful ;" its windows should be opened wide by night, as the others are by day. At all times there should be permitted an Pulmonary Tuberculosis. 151 egress of air that a constant change and freshness of the atmosphere maybe maintained. Suitably regulated exercise is quite as essential for the consumptive as for those predisposed to the disease. Exercise should be regularly taken, but should never be exhausting. B}^ those who are feeble very little should be taken at a time, but in varied forms it may be taken often through the day. Short walks and rides are all the}' can bear. By those more vigorous and without fever field sports and games may be resorted to. These general exercises help to maintain muscular tone and vigor, and therefore a more perfect Ijnnph circula- tion. The latter helps to eliminate much that might be detrimental if it accumulated in the system. This is probably the reason for the frequently-observed fact that, if accustomed exercise is not taken, night-sweats return and the appetite is lost. For those in the first half of life, and especially for those with fibroid phthisis, respiratory g3'mnastics are especially useful. These consist in enforced deep breathing. With the head erect and the shoulders back, as deep a breath should be taken as slowly- as possible every two minutes while one is walking, and once in from half an hour to an hour while sitting in-doors. By this means the lungs are kept well expanded and the air in them most perfectly changed. The respirntor}- muscles are strengthened and trained to involuntnrily maintain deep breathing. The chest can gradually be thus enlarged quite as much as by higli-altitude life, provided onl}' one will be suf- ficiently persevering. Another excellent but less-fre- quentl}^ available means of maintaining respiratory gymnastics is by the alternate inhalation of com- pressed air and exhalation into rarefied air, such as can be aff'orded by the pneumatic cabinet and similar 152 Diseases of the Lung }:. contrivances. In this way the good eti'ects of enforced deep breathing can be had, and the lungs can usually be more rapidly enlarged. Respiratory gymnastics, as well as general muscular exercises, must be gentle in the extreme when debility is great, or fever is continu- oush' liigli? or cavities are large. Hours for rest and sleep should be regularly pro- vided. Many consumptives carr3' on business and give themselves insufficient rest. The clothing of the con- sumptive should be light, but warm. Too much cloth- ing is frequentl}^ worn. It is burdensome, restricts the respiratory movements, and is not cleanl}'. Impervious garments, such as are made of leather, are not whole- some, for they make it impossible to dissipate the exha- lations from the skin. Mufflers should not be worn over the mouth or nose, unless a high wind must be faced or a cold air excites a cough. In the latter case, they ma}" be worn for a few minutes wdien the cold air is first struck, and until a tolerance of it is obtained. For consumptives occupations should not be seden- tar3' or necessitate confinement in-doors, nor should they cause mental strain or worr^'. The diet should be varied, but simple. As appetite is often poor, it should be tempted by a variety of food. If structural disease of the stomach exist, it may make necessary a still greater modification of the diet. It is usuallj^ necessary to crowd food upon consumptives, because of the lack of incli- nation for it. It is well to prescribe, in addition to such food as may be chosen at meal-times, a part or a full glass of good milk between meals and at bed-time. Milk is especially wholesome for those who like it. Butter, cream, and oils are also good, if easily digested. The fat-producers are the ingredients of diet that are espe- cially needed by consumptives. Codliver-oil is peculi- Pulmonary Tuberculosis. 163 arly good, for it is easily digested. If it is taken, cream and otlier oils should not be too much urged upon a patient, lest his fat-digesting powers be over- tasked. If indigestion exist oils cannot be taken. When they can they help rapidly to increase flesh, and with its increase otlier symptoms are ameliorated. The best preparations of codliver-oil are the clear, light- colored ones. The}' should be given to adults in as large doses as can be well digested. It is best to begin with a teaspoonful or less, and to graduall}^ increase the dose. It is also best taken after eating. The taste maj^ be made less objectionable if a little salt is taken before or after it, or if a bitter like gentian is added to it. The various emulsions are palatable, and by many readil}^ taken. It is easy to administer tiie oil in elastic cap- sules containing from fifteen drops to a teaspoonful. If the taste of codliver-oil constantly return to a patient's mouth, or if it lessen the appetite for other wholesome food, it is not beneficial, and either the quantity taken must be lessened or it must be discontinued. Malt-extracts are concentrated solutions of grape- sugar, with more or less of a diastatic ferment added. They have been recommended as a substitute for cod- liver-oil. This they are not. But they are good fat- producing foods, and as such ma}^ be used. Forced feeding b}' a stomach-tube has been tried in this disease where there was great disinclination for food. It has been found that usually there is no dis- order of digestion. Such feeding generall}^ causes an increase of flesh and strength. It, however, does not occur if the destruction of the lungs is extensive, and if weakness is consequently' very great. Treatment^ Medicinal. — Medicinal trentnient must be palliative and sj-mptomatic. The cough of tubercular 154 Diseases of the Lungs. phthisis is a chronic one. It ma}' be influenced, as are coughs from other causes, b}' expectorants and ano- dynes; but as these remedies often nauseate, and usuall}- diminish the appetite, the}' must be used with discretion. As a general rule, it may be said that the}' must not be used if tbey can be avoided. If coughing is severe and the expectorate is tight because of a fresh cold, the formula given on page 46, containing ammonium muriate, will be found serviceable. But such expectorant mix- tures cannot be long used judiciously. In most cases an anodyne can be advantageously given at night to lessen the cough and insure sleep. The best anodynes are codeia, morphia, and chloral. The first of these is usually sufficient, and is the least objectionable. When the stoniach is irritable, I have found a mixture of Acidi carbolici, . . grm. 0.5(1fTtvij); Antipyrin, . grms. 10.0 (3iiss) ; Tinct. gelsemii, . " 15.0 (5iv) ; Glycerinse, . . 15.0 (5iv) ; Tinct. opii camph., " 30.0 (Ij); Aquae, . q. s. ad '• 120.0 (5iv) ; to be serviceable. It allays the irritability of the stom- ach, and often lessens the cough in a surprising way. Teaspoon ful doses may be given from every three to six hours. When the cough constantly needs mitigating, small doses of codeia may be given every three or four hours without disturbing the stomach, and with benefit. To loosen the expectorate when it is scant and tiglit the expectorants must be employed. If expectoration is abundant it can be lessened by terebinthines. Its purulent character may also be lessened by the same remedies. Beech-wood creasote has been lauded as especially curative for tubercular lesions of the lungs. I cannot think that, in therapeutic doses, it exerts a PuJmonari/ Tuberculosis. 155 very powerful influence upon the bacilli in the Kings, for T have never seen the number of bacilli in the sputa lessened by it. It is certainl}' beneficial in rendering the sputa less purulent and less abundant. It does not, at the same time, make the sputa adhesive and difficult to raise, as does turpentine and its congeners. Creasote may be given in minim doses, and gradually increased to four or five times that amount, and the doses may be repeated every three to six hours. It is most agreeably administered in capsules, with gentian or pepsin or some other vehicle. A few times I have known it, in the larger doses, to cause some gastric burning and dis- tress. More rarel}', I have found the urine darkened, and exhaling the characteristic odor of the drug. In order to get most fully the best effects of creasote it must be given for weeks at a time. I have more fre- quently seen good results follow the persistent use of creasote than of any other drug. This good effect, I believe, is chiefly due to a diminution of the activity of suppuration. When the larynx and trachea are much inflamed an inhalation of hot-water vapor, which has been impreg- nated with carl)olic acid, or creasote, or turpentine, or pine-oil and paregoric, gives much comfort; it lessens the cough and the tracheal and lar3'ngeal soreness. An inhalation of this kind can be best obtained from a flask partl}^ filled with the medicated hot water and fitted with a cork, through which one glass tube passes to the bottom of the liquid and a second, shaped for a mouth- piece, into the vapor that fills the upper part of the flask. When inhalations are made the air is drawn in bubbles through the water, and is thus laden with moisture and is medicated. The inhaler should be used often if the inflammation i:^ sharpl}^ acute. Steam- 156 Diseases of the Lungs. atomizers may l>e employed instead of the inhaler, but in my hands have seemed less efficient. Codliver-oil and malt-extract, though more properly foods, often lessen cough, and ma}' be used, at least, as adjuvants. Troublesome coughing can often be pre- vented by careful management. Many patients are most troubled by prolonged coughing at night when the}' retire and on awaking in the morning. The night- cough is due partly to the irritability of the nervous system from weariness, but more to a sudden change of position, and often of rooms and of clothing. The physical labor of disrobing and the stooping and bend- ing which it necessitates are sufficient to provoke a spell of coughing, as can often be proven b}' having a patient assume the same posture and make the same movements at other times in the da}'. If a patient who is troubled with evening cough must climb stairs to a sleeping- room this should be done with great slowness, and a rest of fifteen to thirty minutes should be taken before clothing is removed. The room in which the patient undresses should be of the same tempei'ature as tiiat just left. One garment should be removed after another, slowly, and with frequent pauses for rest. It is best, usually, that cheerful conversation should be kept up, and the mind diverted from the expected siege of coughing. In many cases an attendant should help to remove the clothing, so that as little effort will be required of the patient as possible. The night-clothing should be warmed, so that it will not chill or shock the skin. In the process of uncovering the body, as little of it should be exposed to the air at one time as possible. The bed should be warmed. Often conohino- can also be averted by not at once reclining in bed. The patient may at first sit in bed or lean against pillows, and then Pulmonary Tuberculosis. 15t very gradually slip down into the bed and assume a recumbent posture. An hour or more should be occu- pied in leisurely getting to bed. The patient should, therefore, begin earl3^ Yery frequently, if those who retire at eight with a severe cougiiing spell will begin at five or half-past, and get finall}' settled b^- half-past six, they will avoid it. It is a mistake for consumptives to sit up late or to become too wearied. The morning cough is oftener difficult to stop, for it is usually caused by an accumulation of secretions in the air-passages or in cavities during sleep. If coughing occur occasion- ally during the night, but does not prevent the patient from falling asleep quickly again, it need not be checked, for it often prevents a wearisome and distressing spell of coughing in the morning. The morning cough can often be mitigated by taking a warm, nourishing drink on first awaking. A cup of warm cocoa is particularly^ grateful at this time. When coughing begins the patient should not sit up or get up, but should keep as quiet as possible. In this way coughing can be pre- vented from recurring with frequency. After the largest part of what is usually expectoi-ated in the morning is raised the patient may begin to dress, but it should be done slowly, in a room whose atmosphere is genial. If the patient is feeble the hot, nourishing drink that has been recommended will be found especiall}' beneficial if taken an hour or two, or even longer, before breakfast- time. Often, wdien the coughing spell begins at four or five in the morning, it will be mitigated by it, and an additional sleep will be obtained. Anorexia is a very common and ver3' troublesome S3aiiptom. A change of air nnd scene are often imme- diately beneficial. As the maintenance of strength bj' food is all-important, to counteract a disinclination for 158 Diseases of the Lungs. it becomes a necessity. By varying the diet, and by having all of its ingredients appetizingl3' prepared, the object may be accomplished. Oftener it is necessary to administer food in prescribed amounts and with the regularity of medicine. Milk, or some of its prepara- tions, like kumyss,can thus be best given. It will often be more persistently taken if it is medicated. A bitter tonic may be mixed with it. A few years ago a decoc- tion of mullein-leaves in milk was commended as one of the innumerable consumptive cures. The gain in weight and general improvement which followed its administration came from the amount of food that was thus forced upon the patient rather than from the drug. Bitter tonics, such as quinine, nux vomicM, and gentian, are often prescribed, but in my hands have been of little avail. Such exercise as the patient can take and an out- door life are especially serviceable in maintaining an appetite. Vomiting oftenest is due to severe coughing, and will cease if the cough is lessened in severit}^ b\' ano- dynes. More rarely it is due to gastritis, or other com- plicating disorders of the stomach. Generall}^, resorcin and bismuth will prevent it, or the carbolic-acid mixture described on [)nge 154, from which the antipyrin may be omitted. Diarrhoia and constipation frequently need treat- ment. The latter is amenable to the usual laxatives, such as aloes and cascara sagrada. The former maj' result from a catarrhal or tubercular inflammation of the intestines. They are both often persistent and recur- ring. If the diarrlia\a is not severe the carbolic-acid mixture just mentioned may suffice to check it. In severer cases, and especially if intestinal ulceration exist, one of the following forniuhv will be better: — Pulmonary Tuberculosis. 159 1. R 01. gaultheriae, . . . •. c.cm. 2 (3ss). 01. terebinth., . ..." 10 (Siiss). Tinct. opii, . ..." 13 (3iij). Sacchar., "30 (5J). Acacise, "25 (3vj). Aquae, . . . q. s. ad " 120 (5iv). Sig. : Make an emulsion and give in teaspoonful doses, diluted with water, every two to six hours. 2. R Argent, nitrat., . . grm. 0.015 (gr, \). Pulv. opii, ..." 0.015 (gr. \). Ext. gentian., ..." 0.12 (gr. ij). Sig. : A pill, to be taken every four to six hours. 3. R Plumb, acet., . . . grm. 0.12-0.3 (gr. ii-v). Morphiae, . . . . "0.008 (gr. ^). Sig. : A pill, to be taken every four to six hours. Numerous other astringents can be used, but none are more generall}' efficacious than those mentioned. Astringents and anodynes can sometimes be usefully given as enemata. Food must be administered with care, so that it will not irritate the bowels. It should be easily digested, and should not form bulky stools or contain irritants, such as seeds or fruit-stones. Ferruginous preparations and the phosphates are indicated to relieve the anaemia which is almost con- stantly present in phthisis. They rarely meet the indi- cation, unless the}^ are given during periods of quies- cence, Avhen there is no fever and no active inflammation. Fresh air, sunshine, and good food are much more cer- tain to stimulate the blood-creating tissues of the body. The fever of phthisis is rarely treated. Antipyretics certainly onl}- temporarily depress the temperature. The course of tlie fever is an intermitting one. In the milder and most chronic cases, when a rise of temperature is present at all, it is of short duration, and intervals of 160 Diaeaiies of the Lungs. noriiml temperature are of some hours' duration. What- ever lessens tlie tubereuhir inthunmation and sup[)ura- tion will lessen or remove the fever. Colliquative sweats are of frequent occurrence, and are often ver}^ persistent. Thej' may be so mild as to be only a little annoj'ing, or so profuse as to increase the sufferer's weakness. So long as the}' are not weak- ening, special treatment need not be resorted to. I saj- this because most drugs which are employed are not satisfactory, and those that are produce unpleasant side- effects. Slight and occasional sweating is sometimes due to a lack of air and exercise. It can often be lessened hy salt, or alcohol, or vinegar, or other weak acid bath at bed-time. In those cases in which sweating occurs only in the early morning hours it can frequently be stopped by taking a drink of milk, or a little of some other food, in the middle of the night, or an hour or two before the sweating is most apt to occur. Ergot, strychnia, and digitalis, each alone or combined, will often do good for a time. They probably contract the peripheral vessels, thus lessening the blood-supplv to the glands of the skin, and therefore their activity. A few drops of nitric acid or other strong mineral acid, given at l)ed-time or even several times daily, may be useful temporaril}'. The oxide of zinc is another remedy of value. Its mode of action is ujdvuown. It may be given, in doses of 0.18 gramme (gr. iij), once to three times daily. The various })reparations of belladonna, and especiall}' atropia, are the most uniformly useful. Six tenths of a milligramme, a one-liundredth of a grain of atropia, administered at bed-time, will generally greatly lessen and often prevent the sweating. Larger doses mav be needed, or it may h:ive to be "iven two or three times duriug the night. To be efTicient, it must Pulmonary Tuberculosis. 161 generally be given in doses that cause dryness of the mouth, and at least slight dilatation of the pupil. These are effects that to man}' are more unpleasant than sweat- ing. When atropia is efficacious in small doses it is probably due to its quieting influence upon the respi- ratory centre. When it has to be given often, and in full doses, it paralyzes the ends of the secreting nerves. Haemoptysis, if very slight, requires no treatment, but ergot may be given for a time to prevent its return. If at all copious, perfect quiet must be enjoined. Even coughing must often be suppressed by full doses of anodynes. Cold water to drink and ice to swallow help to prevent the bleeding. Frequently ice-bags ma}- be placed upon the chest with advantage. Ergot is always useful, and can be given b}' the mouth or hypodermat- icalh\ Astringents, like the acetate of lead and tannic acid, are also given. Turpentine and the subsulphate of iron may likewise be administered by the stomach advan- tageously. Bleeding is rarely so copious as to endanger life, and, when it is, all these remedies may prove un- availing. When bleeding has ceased a recumbent pos- ture should be kept for some hours, so that the obstruct- ing clot will not be loosened by exercise. For the same reason the cough should be mitigated, and ergot should be given for some daA-s. Pleurisj^ is a frequent complication, and a painful one. It must be treated just as it would be under other circumstances. (See page 178.) Blisters are often used to check pleuritic inflammation. For this purpose they may be small, — an inch square or thereabouts. They also do good when there is fresh pneumonic consolida- tion. They then frequently hinder the extension of consolidation and mitigate the cough which accom- panies it. 162 Diseases of the Lungs. Since the discover}' of the tubercle bacillus much has been hoped for from the emplo3'ment of antiseptics. The}' have been administered by inhalation, b}' injection beneath the skin and into the lungs, b}' the mouth, and even b}' the rectum ; but no positive cures have been effected b}- them. The best results have been obtained from antiseptic inhalations and intra-pulmonary injec- tions. Unless it is desirable to modif}' fetid secretions or laryngeal and tracheal inflammations the inhalations accomplish little. It is true that, if a respirator is worn for hours at a time, all the air in the lungs ma}' be more or less impregnated by the drug. The best antiseptics for use in this way are the volatile ones, like the terebinthines, oil of eucalyptus, thymol, creasote, and carbolic acid. Statistics do not show as good results for this treatment, when applied to all classes of cases, as for the constant breathing of clean, fresh air. Intra-pulmonary injec- tions have sometimes done good, but the results obtained when they are used are so various that they have not won the confidence of the profession. I need hardly speak of the numerous therapeutic fads which prove to be passing fashions and are useless as cures. To this class belong the rectal injections of sulphuretted hydrogen gas, recently tried so extensively, and the inhalations of very liot air, that have been tested still more recently. As yet no specific has been found for tubercular diseases. A year ago Koch issued to medical men what is now commonly known as tuberculin. It has been very exten- sively and thoroughly tested as a cure for consumption. It is a glycerin extract of the products of the growth of tubercle bacilli in culture media. From it the bncilli and germs are perfectly removed, and only the chemical prod- ucts of their growth remain. Tuberculin is a brownish. Pulmonary Tuberculosis. 163 S3^rup-like fluid. A lij'podeiniatic injection of 4 minims into a healtliy adult will cause, in tliiee or four hours, pains in tlie legs and arms, languor, inclination to cough, difficulty of breathing, — which is quite intense, — a pro- tracted chill, and rise of temperature to 103.2° F. One- sixth of a minim usually produces slight pains in the limbs, transient fatigue, and sometimes a rise of one or two degrees of temperature. This is the smallest dose that commonly affects a healthy person. A consumptive, however, reacts moderately to one-tenth of this amount ; therefore, treatment of this disease is usually begun with ^Q minim. Chill, fever, increased cough, and gen- eral aches are the symptoms which it commonly produces in the consumptive. After this dose has been repeated a few times, upon successive days, no symptoms are caused by it. The dose can then be doubled, and re- peated until it i)roduces no symptoms. Thus the quan- tity administered can be gradually increased until ^ minim, or sometimes a little larger dose, is given, and no reaction is produced. The mode of action of tuberculin is peculiar and extremely interesting. A year has passed since it began to be generally used. Though favorable results are still occasionally reported, its effects have generally been disappointing. My own trials of it have been uniformly discouraging. The drug is one of great virulence, and must be used with the utmost caution. My first trial of it was upon a young wouian who had plainly slight apical contraction of the lungs, no cavities, onl}- a hacking cough, no fever or night-sweats. I used about one-half the dose advised b3' Koch as a beginning one. No febrile reaction followed, but much soreness was pro- duced in her chest. The same dose was administered on four different days, at intervals of from two to four 164 Diseases of the Lungs. days. There was no febrile reaction, but the soreness of the chest increased each time, and was so un- comfortable that I delaj-ed increasing the dose or re- peating its administration. Three days after the fifth injection a rise of temperature took place, and in a few hours she was confined to her bed with pleurisy. An extension of the areas of dullness took place rapidly. In three weeks a considerable cavit}^ had formed at one apex, and at the end of ten weeks the patient died. I feel confident the tuberculin rekindled an old tubercular pleuris} , which in turn led to pneumonic infiltration of the lungs and rapid disintegration of them. I describe this case to illustrate the danger which even unusually small doses sometimes produce. Tuberculin has the peculiar propert}^ of exciting- active inflnmmation about tubercles. It does not do this — or accomplishes it xery imperfectl}" — unless the tissue about the tubercles is somewhat vascular. Often ver}' old and verj^j^oung tubercles are not much affected by it. The inflammation which it excites sometimes causes encapsulement and oftener cellular degeneration. Koch says tuberculin can cause suppuration. Chemical analysis shows that it contains albumoses, which constitute its active principles. By their separa- tion, possibly, a less dangerous, but beneficial, agent may be discovered. The recent researches of Hunter and Koch give promise of this. The utility of tuberculin must, be looked upon as still unestablished. From the statistics thus far gath- ered it is evidently not of frequent advantage. It is a drug that must be administered with the greatest cau- tion, and only to patients who can be closely watched. Each trial of it must be looked upon as an experiment. Koch recommended it to aid in making a diagnosis. Pulmonary Tuherodosif^. . 165 He believed that onl}- tuberculous patients would react to one-sixtieth of a minim. But it has been shown that tuberculous patients do not always react to it even when larger doses are given. Prognosis. — The mortaJity from pulmonar}- consump- tion is very great. While its ratio to all deaths is esti- mated tlie world over to be one in seven, it falls as low as 1 per cent, in some localities, and rises to 60 and 70 per cent, in others. The frequency' of the occurrence of the disease cnn be grently lessened b}^ improving the personal hygiene of the people, and still more b}- developing by physical exercises those children and 3^ouths who are prone to the disease because of defective growth. The prognosis for those in whom the disease has begun its course must be guarded, but, unless great feebleness has resulted from the extent of the lesions or from their destruction of the lung, it need not be hope- less. Tubercular consolidation often is made harmless })y encapsulement, degeneration, or calcification. Cavi- ties may contract, and even be obliternted. Where sta- tistics have been carefully collated in the autopsy-room, very numerous cases have been found in which tubercu- lar lesions had cicatrized and become inert. In hospital cases, which, for the most part, come from the poorest people, because the}: neglect the beginning of illnesses, and in chronic ones continue to live unhygienicallj^ the average duration of life after pulmonary consiunption sets in is about two ^^ears. This is undoubtedly far from a correct average for those who cnn have early attention and can afford to care for themselves as they should. The average with them is from five to seven years. The statistics of Williams are the most exten- sive and reliable that have come nnder my observation.* * Pulmonary Consumption. By C. J. B. Williams and C. T. Williams. 166 Diseases of the Lungs. Of bis private cases, 36 per cent, lived from one to five years; about one-balf of tbese died during tbe first tbree years. Sixty-nine per cent, lived from five to tbirty years; abont one-balf of tbese died before tlie tentb year of tbe disease. A prognosis cannot be based upon tbe number of bacilli in tbe sputa. If fever is constant, tbe chances of permanent recover}^ are not good. If tbere is a per- sistent loss of flesb tbey are not oood. On tlie otber hand, a gain of flesb is always a favorable sign. If sud- denly a large part of a lung is consolidated by pneu- monic inflammation, it is probable tbe course of tbe dis- ease in tbat case will be sbort. If consolidation extend slowly and by small increments, and especially if long- periods of quiescence occur in an individual case, a long course, and even ultimate recover}', is probable. Tbe absence of fever and tbe possession of good mus- cular and mental vigor make it possible always to bold out bope of an ultimate recovery. Healing occurs oftener tban is supposed. In nineteen tbousand and fifty -tbree autoi)sies reported b}' various observers, ten hundred and thirty -two were found to attbrd evidence of healed tuberculosis. In otber words, out of nineteen thousand persons, about one thousand, or about 4.7 per cent., liad had consumption and recovered from it. It is also a noteworthy fact that death occurred in these cases of healed tuberculosis with great frequency from cancer (estimated by different observers at from 13 to 41 per cent.), lieart disease (6 to -16 per cent.), and renal, bladder, and genital diseases (9 to 12 per cent.). CHAPTER XIY. Neoplasms OF the Lungs. Of neoplasms 011I3' carcinoma and sarcoma are of importance or recognizable clinically. A diagnosis is difficnlt and often impossible, the disease being mis- taken for some other chronic pulmonar}' affection. It may be secondary to new growths in any part of the body. Cancer of the breast is oftenest the sonrce of the metastatic cancer of the lungs. It occurs most fre- qiientl}' in those who are advanced in 3'ears. The new- formed tissue may be circumscribed or infiltrating. Occasionally cancer occurs in miliar}^ nodules. The pleura and the bronchial, cervical, and axillary glands are commonl}' affected. The cancer may be medullary, scirrhous, or epithelial. In its earliest development a diagnosis cannot be made. Gradualh' increasing shortness of breath is felt, and often oppression across the chest. Sporadic and harsh coughing is usual. Sometimes pleuritic or neu- ralgic pains are distressing. The expectorate frequently has nothing significant in it, but becomes quite charac- teristic when it is reddish or blackish brown in color jind gelatinous in consistence. Cancer-cells can some- times be found in it. Occasionall}^ the sputa is oft'en- sive. There is a gradual loss of flesh. The cancerous cachexia is developed, and, as in neoplasms elsewhere, loss of appetite, even disgust for food, and vomiting become prominent symptoms. Pressure upon the superior vena cava ma}^ cause oedema of the neck and side of the chest and, arm, or the veins may be greatly (167) 168 Diseases of the Lungs. distended. Pressure on the oesophagus ma}' obstruct or prevent deglutition. Pressure upon the bronchial plexus or the involvement of the nerves in the cancer may cause intense neuralgia or paresis. Physical signs are not pathognomonic. Irregular areas of dullness are usually' found. If the bronchi ai'e obstructed respiratory sounds and vocal fremitus will be wanting, or. if the}- are patent, the former will be bronchial and the latter exaggerated. Rales, and some- times friction sounds, may be heard. Inequalities in the surface of the chest or prominences are significant. The prognosis is unfavorable. Death generally occurs in from six months to two years, and is due oftenest to gradual loss of strength. The treatment must be supporting and sj-mptomatie. The same remedies are used as in other pulmonarv affections for similar symptoms. DISEASES OF THE PLEURA. CHAPTER XY. Pleurisy. Anatomy. — An iiiflfimmatioii of the lining membrane of the plennil cuvit}' is called pleurisy. First, a con- gestion of the pleural vessels occurs ; the superficial cells become loosened and are cast off; tiie connective- tissue cells beneath swell and, it may be, multiply ; the whole tissue is thickened by exuded lymph (which infiltrates it), b}^ leucocytes, and, in spots, even hy red blood-cells. An entire pleura may be inflamed ; usually, how^ever, only a part is affected. The inflammation generall}- varies in intensity in places. The pleura at one point may be thickly crow^ded with leucocytes and embrj^onic cells, at another only slightl}' swollen by the lymph. The serous exudate ma^^ be scant, ma}* clot readil}^ and deposit fibrin upon the pleural surface. It is then called fibrinous, and often dry^ pleurisy. When it is purulent it is called empyema; when the serous exudate is so abundant that it accumulates as a mass in the pleural cavity it is called pleurisy ivith effusion, or serous plemHsy. Pleurisy may be chronic in character from its start. The pleura is then per- sistentl}' , but moderately, congested ; its connective- tissue and its superficial cells undergo considerable hyperplasia, and little or no exudation forms upon its surface. A permanent, and often very considerable, thickening of the pleura is thus produced. An acute pleurisy may persist and become chronic. 8 H (169) 170 Diseases of the Pleura. Whenever the raw visceral and costal pleural sur- faces are held together they tend to adhere permanently, and thus to obliterate the pleural cavity or to divide it into compartments. They may unite, as it were, by first intention. Adhesions are often temporarily produced by a fibrinous exudate. A permanent band of tissue may supplant the fibrin if the latter become "organ- ized." In this i)rocess the fibrin fills with embryonic cells, which, while they cause the fibrin to disappear, develop new and permanent connective tissue. The results of fibrinous pleurisy are (1) resolution. The fibrinous exudate may be liquefied and absorbed, the swelling of the tissue may disappear, and a perfect restoration may take place. But more frequently (2) permanent thickening of the pleura or (3) adhesions are left. The lung is frequently crippled b}- these thicken- ings, since they prevent its full expansion. The super-' ficial air-cells are often diminished in size or obliterated bj' an extension of the inflammation below the pleura into the lung's interstitial tissue, which becomes swol- len, and often permanentlj^ thickened and indurated. Dry pleurisy may slighth' contract or deform the thorax. The imperfect lung expansion, whose cause has just been ex[)lained, will lead to a depression of the over- lying thoracic wall. Thickening of the costal pleura across intercostal spaces often prevents their expansion during respiration, and, therefore, the full distension of these portions of the thorax. The result of a serous pleuris}', or pleurisy with effusion, may be resolution, with or without deformity. When serum parti}' or wholly fills a pleural cavity the lung must be correspondingly compressed. If the liquid remain in the cavity long enough for the visceral pleura to become permanently thickened so as to prevent or Pleurisy. 171 limit the lung's re-expansion jind is tlien absorbed, the atmosphere's weight will cause the thorax to be pressed in to meet the collapsed or partly expanded lung. This is a common cause of permanent thoracic deformity' in young persons, but it can produce only very moderate deform- ity in older persons, whose thorax has become rigid hy more perfect ossification of its frame work. In them some liquid will remain if the lung cannot expand and the thorax cannot be compressed. Sometimes, even under these conditions, the liquid ma3' be absorbed, and the cavity which it filled may be obliterated by an emphysema of the opposite lung, Avhich will crowd the thoracic organs into the nnexpanded side of the chest. Often an abundant serous exudate will be completely absorbed, the lung will perfectly expand, and no de- formity will result. This takes place whenever the active inflammation is of short duration. A serous exudate mav remain in tlie pleural cavity for a verj' long time. It nia\' also become purulent. More frequently an enip3'ema is such from the begin- ning. Circumscribed emp3'ema will rareh^ result (1) in absorption and caseation or calcification of the solid elements of the pus. Occasionally, therefore, we find •after death, within the thorax, a plate of lime, which represents this process. The liquid of the pus was ab- sorbed ; its solids were dried and finally cnlcified. The pus ma}^ be (2) spontaneously drained by ulceration through the thoracic wall, which produces a fistulous channel. It mu}- ulcerate into the pericardium, or through the diaphragm into the abdomen. These are fatal results. It also is (3) rarely drained spontaneously through the bronchi or stomach or intestines into which it ulcerates. If neither spontaneous nor surgical drainage is estab- lished, death results as from other large abscesses. 172 Diseases of the Fleu7'a. Exudates, both serous and purulent, cause displace- ment of the thoracic organs. A considerable accumula- tion of fluid in one pleural cavity- will crowd the heart to the opposite side. Extra-pericardial adhesions may then produce its permanent displacement. The thoracic viscera are usuall}' depressed. The lung always floats above the fluid, no matter what may be the pcxsition of tlie thorax. It is also more or less compressed. If the entire cavit}' is filled with fluid, it will be completelj^ compressed, and may not occup}' a space larger than one's hand. It is then non-vesicular tiiroughout. Causes. — Pleuris}' ma^- occur at any age, but is ob- served most frequently between the twentieth and fif- tieth years. Males are somewhat of'tener affected than females. Those who are in vigorous health are less sus- ceptible to it than those who are feeble. The malad}' is sometimes primary, but oftener sec- ondary to some disease of the lungs or neighboring structures. The commonest cause of primar}^ pleuris}' is a wound of the thorax. A penetrating wound, or even a severe blow, will sometimes excite it. If the thoracic wall is deeply bruised, or for an^' cause in- flamed, the pleura may be involved because of its con- tinuity- with it. A few clinicians deny that primary pleurisy can be produced except by a wound. But a majorit}' believe that exposure simultaneously to damp air and to a sudden fall of temperature may, at least in feeble individuals, provoke it. Pleuris}' uniformly accompanies pneumonia unless the latter is entirely central, as it may ver}' rarely be. It is almost as uniformly a comi)lication of tubercular disease of the lungs. It always accompanies this dis- ease unless the tubercular trouble undergoes resolution in its incipiency. Pleurisy may be one of the earliest Pleurisy. 1T3 phenomena of pulmonary tuberculosis, but more fre- quently it complicates the later stages. All other superficial inflammations of the lungs are accompanied by pleurisj'. Peritonitis, abscess of the liver and spleen, and ulcer of the stomach or intestines may pro- duce pleuris}^ b}^ an extension of inflammation through the diaphragm. Pleurisy often complicates Bright's diseases. Pyaemia may be its cause. Miliary tubercles and cancerous nodules excite a surrounding pleurisy when they form in the pleura. Symptoms. — Pleurisy is not always accompanied by symptoms. This is especially true of chronic pleurisy. Extensive pleuritic adhesions ma}^ be found in the thorax of plithisical patients in whom, before death, pleurisy was not diagnosed. Often persistent localized soreness about the chest, and especially at the upper part of the chest, in tuberculous patients, is indicative of chronic pleuris}-, although there ma^' be no character- istic physical signs or subjective symptoms. Acute fibrinous or dry pleurisy usually begins with sharp, and often severe, pain in the side. The pain is localized, but the painful area may increase. It is aggravated by deep breathing, and sometimes even b}^ restricted respiration. A dry cough is usual, but is suppressed as much ;is possible because it aggravates the pain. Respiration is quick. The thoracic move- ments are short, and upon the affected side less ample than on the other. Tenderness is experienced in all sharply-acute cases. It is limited, generally, to the intercostal spaces. A rigor, or a succession of slight chills, announces the beginning of acute attacks, and is followed by a fever. The latter may last only a few hours, or may persist for several days. It does not follow a typical course. It is rarely high, ranging. 174 Diseases of the Pleura. ordinarily, from 101° to 103° F. In subacute attacks these same symptoms are present, but are much less intense than in the franklj'-acute ones. IMie physical signs of dr}- pleurisy are ver}' important for making a positive diagnosis of the disease. Occasionally the pal- pating hand may feel a friction fremitus. Percussion usually reveals nothing abnormal. Sometimes, if the fibrinous exudate is unusually abundant, there may be a localized relative dullness. Auscultation demon- strates the characteristic friction sounds. They may be loud, but more frequently they are low. They are characteristically heard with each respiratory move- ment; sometimes, however, they are only audible with deep inspirations. The ph3'sical signs of pleurisy with effusion are the same when the exudate is serous and when it is puru- lent. If, as is usually the case, the fluid enter a pleural cavity that has not been divided by pleural adhesions, the affected side will be observed to move much less freely than the opposite. It will appear fuller because the intercostal spaces do not show, and, therefore, the surface of the chest on that side seems smooth. It is also rounded as the normal angles are less acute. The apex-beat of the heart is often displaced. The displace- ment will be to the right if the left cavity is filled, and to the left if the opposite one is. Usually, and espe- cially if the left pleural cavity contain the fluid, the apex-beat will be depressed because the diaphragm is. Vocal fremitus will be lessened, and generally is want- ing. Percussion reveals an area of absolute dullness when the fluid has accumulated. Often it is bordered above by a semi-tympanitic space. This kind of reso- nance is due to the relaxed condition of tiie partly-com-' pressed lung-tissue. If the fluid fill less than half of Pleurisy. 175 the pleural cavity, a change in the position of the body will cause the area of dullness to shift. It will be alonor o the back if the patient is reclining, and will occup}^ the bottom of the thorax if he is sitting or standing. If much more than half the thorax is filled, it is difficult to detect the changes in the position of the surface of the liquid. The surface of tlie liquid is not perfectly horizontal. If the patient is sitting the line of demar- cation between lung and fluid will be found to be curved. It is lowest at the spine, rises gradually to the axilla, and then falls a little to the sternum. This contour cannot be made out if the thorax is ver}^ full. The line of separation is also often difficult to locate, posteriorly, because the lung above the fluid is partly solidified, as it is not well filled if the patient is con- stantl}^ in the recumbent posture. The curve which the surface of the intra-thoracic fluid produces is due to the displacement of it by the partly-expanded lung. Per- cussion better than inspection will demonstrate cardiac displacement, and, if the fluid is in the right pleural cavity, a depression of the liver. The respiratory sounds are not transmitted through pleural effusions unless the lungs are solidified. There- fore, auscultation usually reveals an absence of respira- tory sounds. Upon the unaffected side the sounds are exaggerated or i)uerile. If a pleural cavity is completely filled with fluid, bronchial respiration may be heard through it, especiall}- toward its upper part. These sounds may be transmitted from the unaffected lung, but I believe are most frequentlj' from the bronchi in a compressed and consolidated or carnified lung; for I have never heard the sounds except when the lung was in this condition, or the trachea and largest bronchi were imbedded in a mediastinal tumor, throuiih which 176 Diseases of the Pleura. vibrations could be easily transmitted to the fluid. The reason that lespirntory sounds are not ordinarily heard is not that fluid is not a good conductor of sound (for it is), but because the vesicuhir lung-tissue does not transmit the sound well to the fluid. The sounds are transmitted when the lung loses its vesicular character. It may, however, be as Garland urges, that such sounds are transmitted b^' the ribs and thoracic wall. Friction sounds are often heard at the beginning of a pleuris}^, and before the pleural surfaces are separated 1)3' the effusion. They may again be heard when the fluid is absorbed and the raw surfaces come together. The plhysical signs of encysted effusions are the same, but the area of dullness which the}' cause does not change its position. This area can be mapped out, b}' percussion and by palpation, bv noticing where the vocal fremitus disappears. If respirator}- sounds are wanting within the bounds thus established we ma}- feel confident that an eff'usion exists. When a serous pleuris}- begins often all the symp- toms of a fibrinous pleurisy develop, but the pain ceases as the fluid accumulates in quantities sufficient to sepa- rate the inflamed surfaces. Respiration grows quicker and more difficult as the lung becomes compressed. If the fluid accumulate rapidly considerable d3'spnoea may be felt. Soon the opposite lung expands, and will com- pensate for all moderate accumulations, providing the j)atient is at rest, but walking or an}' other form of exertion will quicken the respiration or cause dyspnoea. Cyanosis is not caused by pleuritic efl^usions, for the blood is well oxygenated by the healthy lung. Fever usually accompanies the outl)reak of the inflammation, as it does that of fibrinous pleurisy, but it may last a day or two only ; in other cases it persists for a week or Pleurisy. 177 longer. It does not follow an}- definite type. Tlie heart at first is quickened by the fevered blood, and later its increased motion is maintained by the obstruc- tion to respiration which the lung's compression causes, and often, in part, by its own displacement and conse- quent disadvantageous action. The pulse is usually not greatly lessened in size or firmness. If, as often hap- pens, the fever is of short duration there may not be much loss of flesh or strength, but dyspnoea prevents exertion. A serous effusion may persist for mau}^ weeks. Usually it begins to be re-absorbed after two weeks or thereabouts, if resolution occur at all. Not un frequently it becomes purulent. The subjective symptoms o^ empyema are those of a serous pleurisy, with those superadded which are due to the absorption of purulent matter; therefore, the fever is hectic in typo. Occasionally chills recur with each access of temperature, but more frequently the temper- ature follows a very irregular, intermittent course. Colliquative sweating is of nearly dailj- occurrence. There is i)rogressive, and often rapid, muscular wasting. The pulse is soft, and of medium or small size. It is as quick as it is when a serous eflfusion exists. Death will usually result from the slow exiiaustion which extensive and prolonged suppuration produces. It may result from some of the accidents which perforation may cause, as purulent pericarditis or peritonitis. The course of the disease covers a period of from one to four weeks, but, rarely, is more protracted. Diagnosis. — The diagnosis of (h-y pleuiHsy can be directl}' made whenever friction sounds can ])e heard. When they are wanting, pleuritic pains must be differ- entiated from those of intercostal neuralgia and myalgia. Neuralgic pain is often intermittent, and is likely to 178 Diseases of the Pleura. occur when the breath is held and respiratory move- ments are not made. The three characteristic points of greatest tenderness are usuall}' discoverable when the intercostal nerves are involved. Neither coughing nor fever are produced b}' it ; it is true, however, that pleuris}' ma^^ exist witliout either. Muscular pains are more shifting in character than pleuritic, and often are felt simultnneoush"about the arms or the opposite side. Palpation often makes it possible to locate them in a given muscle. A pleurisy sufficient to cause pain, and of a character not to cause friction sounds, will only occur when there is a chronic inflammatory lesion of the lung. If no such lesion is discoverable the pain can be diagnosed as not pleuritic. The ph3-sical signs of an effusion into the pleural cavit}^ are so definite that it can be diagnosed directly by the coincident (1) want of expansion of the afl^ected side, (2) prominence of the intercostal spaces, (3) per- cussion flatness, (4) absence of vocal fremitus, and (5) almost uniformly of respiratory sounds. Pneumonia enlargements of the spleen and liver, and thoracic tumors have only dullness in common with pleuritic efl'usions, but in them the dullness is not absolute. After the existence of an eflfusion has been determined, it is necessary to ascertain whether the fluid is of pleuritic origin or dropsical (seepage 194.), and whether it is serous or purulent. A hectic fever is suggestive of empyema, but is not positive proof. We can only decide positively after an experimental aspiration with a hypodermatic or aspirator needle. Treatment.— The soreness which is often felt in chronic pleurisy, and the momentary but sharp pleu- ritic stitches which accompany mild acute pleurisy, are usually relieved by counter-irritants. A mustard-plaster Pleurisy. 179 may suffice, but a small fl3^-blister is surer. The latter need not be large. One an incli square is sufficient. *In sliarply-acute eases a larger blister is more effective, and should be followed by fomentations. Instead of apply- ing counter-irritants the affected side of the chest mny be " strapped." That is, strips of adhesive plaster may be so laid on that they will prevent or limit the motion of the ribs, and thus check the rubbing of the raw pleu- ral surfaces against one another. Very great relief is often afforded by this procedure. The strips should be long, and should be applied at right angles to the ribs, so that they will bind them together and keep the inter- costal si)aces as small as possible. Oi)iates must be used whenever the pains are very severe. Often drugs are contra-indicated, as the}- tend to diminish the appetite, or even to cause nausea. Fre- quently a small blister will be found to i)roduce more permanent relief than an opiate. Morphine and codeia are the preparations oftenest employed. Just as in pneumonia calomel is frequently used (see page 101) because it seems to modify the exudate and prevent its being so fibrinous, and as it seems to promote the ab- sorption of such exudates, it is used in fibrinous pleu- risy. It may be given, at the beginning of the attack, in two or three doses of 1 grain each, or, perhaps more advantageously, in small doses of \ grain each, which can be administered for two or three, and sometimes four or five, days. Even mild salivation should be avoided. Purgation is usually not caused, as opiates must generally be simultaneously^ given. Antipyretics are of little use unless the high temper- ature causes delirium, as it often does in children. An- tipyrin or acetanilid will be found to afford relief to this symptom by depressing the temperature. 180 Diseases of the Pleura. It is desirable that the bowels should be kept regu- lar/ At the beginning- of the attack moderate depletion, by provoking a few watery movements from the bowels, does good. This can be provoked by administering two or three powders, at intervals of two hours, of calomel and bicarbonate of soda, containing 5 grains of each ingredient, or by giving the liquid citrate of magnesia, or some similar prei)aration. While there is fever the diet should be simple. If there is no fever the regimen of health may be followed. The first or painful stage of pleurisy with effusion must be treated the same as fibrinous pleurisy. As soon as fluid is found to be accumulating the patient should be placed upon a dry diet, and liquids should be withheld as much as possible. A serous efi'usion can often be checked in this wa}', and its re-absorption hastened. There are a number of drugs commonly emplo^'ed to promote re-absorption of an exudate, but with doubtful utility. These are, especialh', iodine painted upon the surface of tlie thorax ; sodium chloride and potassium or sodium iodide administered internally. Common salt is occasionailv given, — in as large amounts and as fre- quently as the patient can bear it. It is believed that if the blood can be made strongh^ saline a demand on the part of the system will be created for water, which will be satisfied by the absorption of the exudate if water is not drunk. The good effect of the iodides probably results from their increasing diuresis. They are not, however, as efficient diuretics as the acetate of potash or am- monin. Digit nlis is usuall}' combined with these in a diuretic mixtur<\ but its employment must be governed by the rapidity of the pulse. If it is slow it may pro- voke vomiting, by making the heart too slow or irreg- Flevrisij. 181 nlar. Diuretics have almost invariably disappointed me when I have relied upon them alone to promote absorp- tion of the exudate, but they are useful adjuvants to other methods of depletion. Saline cathartics may be used with them advantageousl}^, but should not be pushed to that extent that the^^ produce much weak- ness. Diaphoretics ma}^ also be used with one or the other of these methods of depletion. Sweating pro- voked by dr}' heat (see page 270.) is usuall}' the best. Pilocarpine may be used, but it causes an enfeeblement of the circulation, — wdiicli is contra-indicated in some cases, — and often very uncomfortable salivation. De- pleting agents cannot be successfully used if the patient is very feeble, and the}' often prove useless, even when employed as thoroughl}^ as is possible. Aspiration affords a means of withdrawing the fluid promptly and surely, and, if properly done, without danger. If the amount of the eftusion is large it should be preferred to any of the methods that are emplo^'ed to promote absorption. The indications for aspiration are usualh' snid to be: (1) if the effusion cause marked displace- ment of the heart; (2) if the fluid remain without change or increases in amount during three or four weeks. I have never felt justified in waiting three or four weeks before aspirating. If there is much fever, especially if it is hectic in character, I believe that one should not delay more than ten da3^s before positivel}' determining whether the fluid is serous or purulent. If aspiration is practiced, in order to establish a diagnosis some of the fluid may as well be withdrawn while the needle is in place. If there is no fever it is not expe- dient to w\ait more than ten days before aspirating if the fluid does not in that time begin to diminish in amount ; for the longer the lung is allowed to be compressed, the 182 Diseases of the Pleura. more danger is there that a thickening of its pleura or interstitial tissue will prevent its re-expansion. If tispi ration is to be practiced, the thorax can be best punctured in the lower part of the axilhuy space. The patient ma}^ sit or recline while the fluid is being withdrawn. It' he is recumbent he should lie partly upon the affected side, but with it overhanging the edge of the bed. The fluid ma}- be withdrawn until coughing is provoked, or decided distress in the side is produced from the dilatation of the compressed lung. It is not necessary to withdraw all the fluid within the pleura, for if its quantit}- is lessened an absorption of the rest will, as a rule, rapidl}^ follow. Unfortunately, it will occasionally re-accumulate. Aspiration ma}^ be repeated as often as is necessary. It is only dangerous if the needles are not aseptic, or if a piece of emphysematous lung is accidentalh' punctured, for the former mischance may produce purulent inflammation and the latter pneu- mothorax. After aspiration, a physical examination will demonstrate that the area of dullness is lessened, and that respiratory sounds can be heard over a greater portion of the chest. In the rare cases in which re- absorption cannot be eff"ected excision of the ribs may be resorted to ; but it should be avoided unless every other resource fails after patient and persevering trinl. If pus is found in the pleural cavity it should be drained therefrom at once. A cessation of suppuration within the pleural cavit}^ is efl^ected by the permanent union of the visceral and costal pleura, which results in the obliteration of the cavity. This can only be accom- plished while the luug is able to expand and fill the cavity after the pus is withdrawn. It is extremel}' im- portant that an empyema should be drained as early as possible before the lung's expansibility is lessened by Pleurisy. 183 adhesions or a thickened pleura. Drainage is best established by making an incision through an inter- costal space, — which is as low as will admit one to the pleural cavity, — and by inserting through it a large and closely fitting drainage-tube. A tube with a flange, which will prevent its slipping into the thorax, is to be preferred. If it is not at hand, this accident must other- wise be guarded against. If the operation is performed early and while the lung's expansibility is good a single drainage-tube will suffice, providing it is managed so that the lung is kept inflated. This can be accomplished b\' opening the drainage-tube only during inspiration, when the pus will be forced out by the dilating lung. During expiration the tube must be closely compressed. By thus pumping the cavity it can be thoroughly emp- tied. After it has been emptied in this way the tube ma}' be temporarily corked. The procedure must be repeated whenever an ounce or two of fluid accumulates. This may, at first, necessitate its frequent repetition, especially if the pyogenic surface is extensive. But, usu- allj', in a few days a part of the cavity will be obliterated, and it will have to be drained less and less frequently as less pus is formed. The pyogenic cavity can be washed with antiseptic solutions, and they can be aspirated out or pumped out in the same waj' that the pus is. This very simple metiiod for preventing the access of air to the pleural cavit}^ and consequent compression of the lung, was first devised by Prof. Edmund Andrews, of Cliicago. Others have contrived more elaborate appli- ances, containing a valve in tiie drainage-tube, that makes constant drainage possible. I have seen An- drews's method repeatedly emploj^ed, and with results that could not be bettered. A more usual method is to insert, at different points, into the pleural cavity several 184 Diseases of the Pleura. drainage-tubes, letting the iiir enter freelj^, and trusting to frequent washing and a depression of the thorax and distension of the opi)osite lung to obliterate the cavity. This is not so uniformly successful as the other method in the cases for which it is adapted. If, however, the lung cannot fully expand several orifices for drainage are usually needed, and should be so placed that they will make it possible to thoroughly drain and wash the cavit}'. Often it is impossible to obliterate completely a large cavit^', because the lungs cannot sufficientl}" ex- pand or the thoracic wall sufRcienth' contract. In such cases resection of a part of the ribs ma}' be resorted to, in order to bring together the pleural surfaces and make possible their adhesion. Resection is a grave operation, and at the best entails much discomfort upon those operated on. I believe it should be resorted to only after other methods have been most faithfully tried and found unsuccessful. Occa- sionall}' a fistulous opening will persist in the side for months, from which a few drachms of pus will daily flow. The patient will regain flesh and strength in spite of this, and be able to do varied and even laborious work. Twice in just such cases I have seen resection tried and fol- lowed b}' a fatal result within two weeks. The prospect of months, and perhaps of years, of comparative health was good before the operation. I have seen in other similar cases such fistulse and discharges persist for a year and more, and ultimatel}' perfect recover}' occur. If the pyogenic cavit}^ cannot be easily closed, though drainage restore the patient to a condition of moder- ate strength and entire freedom from fever, I advise trying the inhalation of compressed air, or a residence at a high altitude, or enforced deep breathing and pos- Pleurisy. 185 tural breathing, which will distend the lungs to the greatest extent possible. Perfect drainage and antiseptic washings of an empj'ema will usually promptly remove the fever, as well as the night-sweats and the other symptoms of septic poisoning. The appetite and ability to digest food return with their disappearance. As the drain upon the system is great, the maintenance of strength is all-important. Food should be given ns freel3' as the stomach's digestive power will permit. It must be easily digested and highly nutritious. In conditions of great weakness milk, eggs, custards, and beef-juice form the best diet. As strength returns it can l)e varied, and made more nearly that of a healthy person. Often, before drainage is established, the system is so fully poisoned by absorbed septic matters that great enfeeblement of the whole bodj^ exists. The pulse ma}' be very small, soft, and quick. Vomiting may be of frequent occurrence, and diarrhoea and night-sweating H!ay be exhausting. If drainage and the consequent removal of the source of intoxication do not cause these symptoms to disappear, the case must be treated symptomaticall}'. For instance, the cardiac weakness must be counteracted b}' digitalis or one of its congeners, and the vomiting and diarrhoea must be checked b^' the drugs usuallj' emploj^ed to combat such symptoms. Malformations of the chest which result from pleu- risy can frequentl}' be corrected. This is especially possible during the first third of life. They are cor- rected b}' dilating the lung and by bringing about a hj'pertroph}' of its tissue. These objects can be accom- plished b}^ persistently exercising the crippled lung. Frequent enforced deep breathing is useful. Postural breathing is still more useful. For example, as a long H» 186 Diseases of the Pleura. and deep inspinition is being taken the patient maj^ lean to the unaffected side, so that its lung cannot easily ex- pand, while every opportunit}' is given to its crippled mate. A still better postural exercise consists in grasp- ing, during complete expiration, the thigh on the un- affected side with the hand of the same side, and in the slow raising of the opposite arm from the side by swinging it outward and upward, as an inspiration is slowl}' and deepl}' made, until it is stretched as high as possible above the head. Other forms of postural res- piration can be devised that are better suited to the location of certain deformities. The inhalation of com- pressed air is exceedingl}' useful. A residence in high altitudes will also help to expand the chest. But thej- should be combined with postural respiration. Running, mountain-climbing, and other exercises that especially lead to involuntary deep breathing and lung develop- ment are useful aids. Prognosis. — The prognosis of pleurisy must depend ujDon its character and cause. For primary drj^ pleu- ris}^ the prognosis is favorable. For dry pleurisy at the apex, especially if it is subacute or chronic, it must be guarded, as tuberculosis is its usual cause. As a rule, perfect resolution will take place in serous pleurisy, especially if a large amount of fluid does not accumu- late. By aspiration most serous pleurisies in which effusions have been extensive will undergo resolution. Purulent pleurisy very rarely recovers spontaneously. By surgical treatment most cases can be cured, and if it is applied at the beginning of the disease almost every case can be saved. CHAPTER XYI. Pneumothorax. Causes. — Air mrel}- exists long in the thoracic cavities without exciting inflammation, which is accom- panied by a fibrinous, or oftener serous or purulent, effusion. Air may gain access to the pleural cavity from with- out through a wound, such as a stab or bullet wouud, but oftenest it is admitted b}^ perforation of a lung, which permits its air to escape. A broken rib ma}' tear tiie lung and cause pneumothorax, though the chest wall is not opened. More rarely, after adhesive peritonitis has glued the stomach or an intestinal loop to the diaphragm, tliey are perforated by ulceration, and per- mit air or gas to escape from them into the pleura. The lung is oftenest perforated by the rupture of a phthisical cavity. This rarely occurs, except in cases of rapidl}' developed phthisis, for, if the disease is chronic, either the pleura becomes greatly thickened over the vomica or the costal and visceral surfaces adhere and obliterate the thoracic cavity. Gangrene and abscess of the lung- may lead to perforation of the pleura. Lung-tissue which is emphysematously distended rarely gives wa}^, and produces a minute channel by which air can escape from the lung. Forced respiration, associated with violent physical exertion, ma}' produce such a rupture, and, in extremely rare cases, seems to be the sole cause of pneumothorax. An empyema may ulcerate through the pleura, and the pus ma}^ escape by a bronchus. The hole in the pleura thus formed is rarely the cause "(187) • 188 Diseases of the Pleura. of pneumothorax. It has been asserted that purulent and putrid fluids in the pleural sac may produce gas and an apparent pneumothorax. It is very doubtful if this ever occurs. A single opening may admit the air to the pleural sac, but often several do. Pneumothorax is very rare in both pleurae. Varieties. — If the channel b}- which air enters the pleural cavity remain constantl}' open, it is called "open pneumothorax''; if closed, "closed pneumothorax": and if it is open during inspiration and closed during expiration, it is called "valvular pneumothorax." A permanent closure may be effected by a fibrinous exudate, which becomes, at least in part, organized ; or it may result from compression of the lung. In closed and valvular pneumothorax the air within the pleura is under more than atmospheric pressure, and if an exit is afforded it will escape with a hiss. A valvular pneumo- thorax will be formed when the perforation through the pleura is an oblique one. The air of a closed and open pneumothorax varies in composition. Carbonic-acid gas is more abundant, and oxygen less, in the closed. Often air can gain access to only })art of the pleural cavit}', because of adhesions. Symptoms. — The onset of pneumothorax is generall}' sudden. If it is due to rupture of the lung, as it commonly is, a pain is suddenly felt in one side. The feeling is described sometimes as like the breaking or tearing of something. It ma}- be agonizing or moder- ately severe. It ma}' be transitory or may persist for some hours. When persistent it is ver}- like the pain of pleurisy, and may be due to inflammation. Rapidly after the pain begins dyspna\a of varying degrees of intensity arises. If the pleural sac quickl}' fill with air, the lung upon that side will partly or wholly col- Pneumothorax. 189 lapse, and the heart may be displaced. The heart will beat rapidly, because of the interference with the pul- monar}' circulation which tlie collapse causes. Rarely the development of pneumothorax is accompanied by the symptoms of collapse. The temperature falls ; the countenance is anxious and gray ; the skin is cold, and often clammy ; the lips are purplish ; the pulse is small, soft, 120 or more per minute. Death may occur in a few minutes, or in a few hours, from the great disturbance suddenly caused to respiration and circulation. Usualh^ death is not sudden. If it occur at all, it is after days or weeks. Recovery ma}^ take place, but does not do so commonl3\ The primarj^ disease — which is usuall}^ phthisis, or abscess, or emphj'sema — causes death, or a complicating purulent pleuris}^ iii'>y. If recovery take place, obstruction to the ingress of the air occurs, a serous exudate replaces it as absorption progresses, and finally the hydrothorax may be relieved b}^ treatment or spontaneous absorption. If the air in the pleural cavitj^ is not large or fills only a section of it, absorption may take place without being followed b}^ a serous exudate. Commonly pneumothorax provokes inflammation of the pleura and a complicating serous or purulent inflamma- tion, A diagnosis can only be made from the physical signs which pneumothorax causes. The affected side is 'distended. The intercostal spnces are wide or bulging. Respiratory movements are slight or wanting, while exaggerated on the other side. Vocal fremitus is usually absent. The resonance is great. Percussion sounds are loud and clear. They may be tympanitic, but usualh' are hj'per-resonant only, because the distension of the thorax-wall prevents the production of a tympanitic note. The area of resonance will be much greater than 190 Diseases of the Pleura. usual if the wliole of a pleural cavity is filled with air. The liver will be depressed if the right side is affected, and the heart may be crowded wholly into the right thorax while the left side is affected. If the heart is thus dis[)laced, its pulsations will be seen and felt to the right of the sternum, and its sounds will be heard there and will be lacking on the left side. Auscultation may demonstrate an entire absence of respirator}' sounds. Oftener they are audible, but have a characteristic metallic qualit}'. There may be amphoric metallic respiration. This occurs when there is an open pneumo- thorax, or the sounds ma}' be the usual bronchial or tracheal ones, which acquire a metallic qualit}' when they are transmitted through the air in the pleura. Metallic rales or tinklings are often heard. If, while auscultation is practiced, a plexi meter is struck by the handle of a percussion hammer or other solid bod}'', a metallic percussion sound will be heard. If, as is so often the case, an effusion as well as air is in the pleural sac, the usual sio;ns of a pleural effusion w'ill be found over the most dependent part of the thorax. The sur- face of the fluid will not be curved, as in ordinary pleural effusions, but will be horizontal. It will change with changes in the position of the body. Moreover, the heiglit of tlie metallic sounds produced by the pneumo- thorax will vnry with changes in the position of the body, because of the resulting change in the shape of ' the air-space. Sudden movements of the body may cause a metallic splashing. Diagnosis. — A diagnosis is usually not difficult, if the physical signs are sought for. It may be difficult to differentiate between a circumscribed pneumothorax and a large, superficial i)ulmontiry cavity. The former is oftenest in the lower part of the thorax, the latter in Pneumothorax, 191 the upper. The iiitercostiil spaces are usually wide or bulging in the former, and contracted or retracted in the latter. Vocal fremitus is slight or wanting in the former and may be strong in the latter. Cardiac dis- placement is indicative of pneumothorax. Treatment. — The indications for treatment are : (1) 'to relieve pain while it exists ; (2) to strengthen the heart, if collapse occurs; (3) to relieve dyspncea ; (4) to treat pleuritic inflammation that may complicate the pneumothorax. The pain which the pulmonary rupture causes is usually transitory. If, as rarel}' happens, it is severe, one or two doses of morphine may be needed. Per- sistent pain is usually due to pleuris}^ Morphine or codeia may be needed for its relief. Often counter- irritants and fomentations will answer as well. If the patient is in a state of collapse, cardiac and diffusible stimulants are required. Ammonia by inhala- tion and by the stomach produces prompt but transitory effects. Camphor acts in the same way, b}' stimulating the heart, and can be given hypodermaticall}^ in an oil solution. (See page 101.) Digitalis and strophanthus produce more lasting but less prompt effects. The dyspnoea which is due to a sudden compression of the lungs and interference with the circulation ma}' endanger life. Often those who have not suffered from dyspnoea before the pulmonar}' collapse occurs are at once overwhelmed and fatallj- suffocated, while those who are habituated to dyspnoea b}' other lung-lesions may not be endangered b}' a similar accident. Dj'spnoea produced in this way cannot be easil}' relieved. Aspira- tion of tiie air within the pleural sac has been resorted to. It can do no good unless the pneumothorax is a closed one. Puring the first few hours, while the 192 Diseases of the Pleura. dyspnoea is most keenly felt, it is least likely to be closed. After three or four dixys a small perforation ma}' close, and then the cavity ma}^ be aspirated of its air. Often, just as when liquid effusions are withdrawn, coughing is excited or thoracic distress produced b}- aspiration. A part onl}' of the air can then be with- drawn. Indeed, it is undesirable to remove it all, for b}' so doing there is danger of stretching the weak lung, so that it will again rupture. Emp3'ema and serous effusions must be treated as the}' would be when there is no pneumothorax. The former should be drained as soon as possible. If the pneumothorax is a closed one, drainage ma}' be followed with a partial expansion of the lung, and gradually a complete expansion. Under these circumstances, ad- hesive pleurisy may gradually obliterate the cavity, and the suppuration may cease. If the pneumothorax is open and the lung cannot re-expand, not only is drain- age needed, but usually resection of the ribs, to produce contact of the pleural surfaces. Rest should be enjoined from the first, that no bodily exertion may widen the rent or prevent its closing. As the only hope of recovery lies in the preservation of life until absorption of the air can be brought about or complicnting pleurisy cured, foods must be judiciously administered. Pneumothorax from penetrating wounds is often curable. The wound must be closed. The air may be partly aspirated, but will usually be absorbed. The danger is from pleurisy, but if the air that entered the pleura was clean, and not infectious, pleurisy will not sui)crvene. Prognosis. — If pneumothorax is due to ulceration through the diaphragm from the stomach or intestines, Pneumothorax. 193 a fatal result must be expected, and treatment must be palliative. If it is due to rupture of an emphysematous lung, serous [)leurisy often does not occur, for the air admitted to the pleura need not be infectious. In such cases recoveries have often been recorded. But rup- ture of a phthisical cavity will almost invariably admit to the pleura infectious matter and provoke empyema. Pneumothorax is always a dangerous disease. Death occurs in one-fourtli of all cases within a week ; in about one-half within a month ; and in the rest life may be prolonged for a year, and in a few recovery will take place. 9 I CHAPTER XYII. Hydrothorax. Causes. — H3'drotlioriix is alwa3's a seconclaiy lesion. It is a form of drops}- that is associated with general oedema. Commonly it is caused by Bright's disease, heart disease, or emphysema. It does not often develop until after dropsy- of the subcutaneous tissue and ascites have appeared. It is usually bilateral, but the fluid com- monly accumulates in one side to a greater extent than in the other. Diagnosis. — By compressing the lungs it causes d3'spnoea, and ma}' produce fatal suffocation. The physical signs by which it must be distinguished are those of pleuris}' with effusion. If the physical signs are carefull}- noted it cannot be confounded with any other disease. To differentiate it from pleuris}' ma}' be difficult. The latter is rarely bilateral, as the former usually is ; the latter is not commonly associated with general oedema ; there are no evidences of inflammatory fever in the former, such as are present in the latter. If the fluid is withdrawn from the pleural cavity it will be found to contain the largest percentage of albumen when it is of inflammatory origin. If its specific grav- ity is less than 1015, it is usually regarded as an effu- sion ; if it is more than 1018, an inflammatory exudate. The fluid of serous pleurisy, when examined micro- scopically, is found to contain blood-cells, especially white ones, and epithelial cells ; the fluid of hydrothorax contains few or none of them. The latter often coagu- lates spontaneously after it is drawn from the chest, and the former rarely does. (194) Hydrothorax. 195 Treatment. — Hydrothorax must be treated by re- moving its cause. If the kidneys, skin, and lungs can be made to eliminate water freely a pleural effusion ma}^ re-absorb, as other dropsies ma3'. Often it threat- ens life, and immediate relief is demanded. It can be afforded by aspiration. Pr^ognosis. — Hydrothorax usualh^ necessitates an un- favorable prognosis. Even if the fluid is temporarily removed from the thorax by aspiration, it may return, for the primar}^ disease which causes it can seldom be removed. SECTION II Diseases of the Heart. (197) DISEASES OF THE PERICARDIUM, CHAPTER XYIII. Pericarditis. Anatomy. — An inflammation of the pericardium con- stitutes pericarditis. The anatomical changes wrought by it are precisely the same as those produced by in- flammation of the pleura. Its varieties are also the same ; there may be a dry pericarditis, a serous pericar- ditis, a purulent pericarditis, and chronic pericarditis. Its results are similar ; it may undergo resolution ; it may produce adhesions and even obliteration of the pericardial sack; it ma}^, if purulent, ulcerate through the pericardium and thorax, or oftener into the pleural cavity or a bronchus, or througli the diaphragm, or into an abdominal viscus. Pericardial inflammation may extend b}^ continuity to neighboring structures and ex- cite inflammation of the heart-muscle, or pleurisy, or peritonitis. Serous and purulent efl'usions may rapidl}' compress the heart and interfere with its work. Peri- carditis in any of its forms, if not very extensive or verj' acute, may not greatl'y disturb the heart's action. Causes. — Pericarditis is rarel}' a primary disease. The causes of primary or idiopathic cases are imper- fectly understood. It is usuall}^ secondary to inflam- mation of neighboring tissues, as of tlie pleura ; to acute and subacute rheumatism ; to miliary tuberculo- sis ; to eruptive fevers, and to p3aemia. Syinptoms and Diagnosis. — The sj'mptoms of peri- carditis are often obscured b}^ those of the primar}' (199) 200 Diseases of the Pericardium. disease. In the mildest ciises and in chronic ones there ma}' be no subjective symptoms. In severe cases, and especiall}' if a pericardial effusion is considerable, patients usually appear anxious, cyanotic, and dysp- noeic ; or the mind will wander, the delirium some- times being active and other times passive. Stupor and even coma ma^^ exist. Pain is occasional!}' felt keenl}- in the cardiac region, but generally is not very notice- able. It ma}' be sharp and lancinating, or oftener con- stant, and rather a feeliug of fullnes, of tension, and oppression than pain. Tenderness is usually noticeable over the heart. Headache is often associated with peri- cardial inflammation. Occasionally a dry, hacking cough may be heard. The patients usuall}' prefer to lie with the head and shoulders raised, or to sit upright. Dj'spnoea varies in intensity. It is usually slight, except when a serous effusion is considerable. The d3'spnoea is in part due to pressure upon the lungs by an enlarged pericardium, but is chiefly due to the change in the heart's action. The A'entricles dilate and fill im- perfectly. The pressure within the right ventricle and the pulmonary vessels is low, and the current through the latter is slow. This is provocative of d3'spnoea. The same ph3'sical conditions exist in the left side of the heart and in the general circulation. There is, therefore, a small and soft pulse. The heart is rapid, and, if much weakened or irritated, may be irregular. The veins about the neck are distended. These circula- tory derangements cause the mental symptoms that. are sometimes observable. Fever is usually due to the primary disease. It ma}^ be increased b}' pericarditis, or remain unchanged. If the fever is due wholly to pericardial inflammation, it is found to follow no regular type, and is not high. Slight pericarditis and chronic Pericarditis. 201 pericarditis may exist without causing fever. Vomiting and hiccough are sometimes symptoms. They may arise from unusual pressure on the diaphragm, or from an involvement of the vagus nerve in inflammation. The general circulation may be sufRcientl}^ interfered with to cause general oedema, and even ascites or hydro- thorax. If death occur, it ma}' be due to cerebral con- gestion, oedema of the lungs, or tlie primary affection. The symptoms of recover^' are diminution of dyspnoea and disappearance of the characteristic physical signs. The heart is usually excitable long after the inflam- mation has subsided, or is quickened by mental and physical exertion. The duration of acute attacks is ten dajs or two weeks. Chronic ones maj^ last many weeks or months. A diagnosis is possible, but must be made from the ph3^sical signs. The prsecordia usuall}^ appears promi- nent. The intercostal spaces may even protrude if the effusion is great. The apex beat is generall}- invisible if there is much effusion. Under the same circum- stances it ma}' not be felt, unless the patient leans for- ward or to the left, so that the heart can gravitate against the chest-wall. A shifting of the position of the apex beat is diagnostic. If with changes in the patient's position the beat moves from right to left or disappears and re-appears as the body moves backward and forward, it is evident that the heart is swinging loosel}^ in a distended sack. In the beginning of peri- carditis, before effusion has separated the pericardial surfaces, and in the fibrinous variet}^, a pericardial fric- tion fremitus can sometimes be felt. Palpation demon- strates tenderness in the cardiac region. By percussion the area of dullness is found to be increased whenever there is an appreciable pericardial effusion. The latter 9* 202 Diseases of the Pericardium. first accumulates about the base of the heart. As it becomes greater it separates the heart from the thorax and pulmonar}' pericardium. The heart gravitates to the most dependent part of the area. The shape of the normal area of dullness is modified. It l)ecomes more quadrilateral. It is broadened above, and, when the effusion is considerable, also below. When the effusion is great the dull area ma}^ reach the axilla to the left and the nipple to the right. Sometimes along the lateral borders of the area of dullness there is a semi- t3mpanitic resonance, which is due to the compression and consequent!}^ relaxed condition of the lung. If when the patient sits upright the apex beat is not in the left lower corner of the area of dullness, but nearer the median line, it is evident the pericardium must be distended with fluid. At the beginning of acute pericar- ditis friction-sounds can be heard in almost every case. They will disappear if eflfusion take place sufficient to separate the pericardial surfaces, but may re-appear as the fluid is re-absorbed. They may be absent in chronic pericarditis. The sounds are usually not loud, and can rarely be heard bej^ond the area of cardiac dullness. The}^ are often loudest when the bod}^ is in certain positions, as when it leans forward, or when deep inha- lations are drawn, or when the stethoscope is pressed against the chest. Sometimes they are heard only under these circumstances, and are not constant. Usuallj' they are hitching in character. One sound is heard with the contraction of the auricles, and is pres\'stolic ; another with the systole, and a third with the ven- tricular expansion, or diastole. The character of the sounds varies. They may resemble a soft rub, or be creaking. They may be so loud as to obscure the car- diac sounds. Usually the latter are plainly audible. Pericarditis. 203 unless an effusion makes them low and distant. Endo- cardial murmurs may be heard simultaneously with the pericardial sounds, and maybe due to blood-states or to endocarditis. A diagnosis of fibrinous pericarditis can only be made when pericardial friction-sounds are heard. They are pathognomonic. Endocardial murmurs need not be mistaken for pericardial, for they are blowing, not rub- bing, are not increased when the stethoscope is pressed against the chest, or during deep inspiration, and are always synchronous with a given part of the heart's cycle. It is never difficult to distinguish extra-pericar- dial or pleuro-pericardial friction-sounds from them. Pleuritic and pericardial friction-sounds may be heard together, both being produced in the pleural cavit}", and they will cease when breathing is stopped. The absence of subjective symptoms, which may accompany pericar- ditis, will help to confirm a decision. Permanent pericardial adhesions, or a partial or general obliteration of the pericardial cavity, may exist for 3'ears. They ma^' result from acute or chronic in- flammation. If the adhesions are small, they are oftenest near the large cardiac vessels. The heart- muscle underlying the adhesions is usually involved in connective-tissue infiltration and degeneration and atrophy of the superficial muscle-fibres. A diagnosis of adhesive pericarditis, even when it is extensive, may be impossible. In some cases the adhesions constrict the coronary arteries and interfere with the heart's nutrition. The symptoms then are of heart-fatigue, or exhaustion. The concurrence of two symptoms may be considered positive evidence. These are a sj^stolic retraction of the apex, intercostal spaces about it and the lower end of the sternum, and diastolic collapse of 204 Diseases of the rericardium. the cervical veins. A systolic retraction of the apex alone may be produced whenever the heart cannot be pushed downward during systole. Rigidit}^ of the arch of the aorta, as in atheroma, may cause it ; aortic-valve stenosis maj^ ; and even sliglit pericardial adhesions at the base of the heart ma3\ If the apex cannot descend during systole, it cannot produce the normal beat, for the ventricles, when they contract and lengthen, push the apex backward, instead of forward, and thus cause retraction. But if the retraction is diffuse and involves several intercostal spaces and the lower part of the sternum, it is quite surely due to pericardial adhesions. When s3'stolic retraction occurs, a diastolic apex-beat may be produced. The diastolic projection of the chest- wall which is thus produced probably favors the indraw- ing of the venous blood by the heart, and therefore a diastolic collapse of the cervical veins. The diastolic projection may also cause a dull sound to follow closelj^, and seemingl}' duplicate the diastolic sound of the heart. The existence of pericardial effusion can usually- be diagnosed directly from the physical signs that have alread}^ been described. The increased area of dullness which it causes may have to be differentiated from (1) enlargement of the heart, which is accompanied b}' an a[)ex-beat, in the lower left corner of the dull area, and by greater distinctness of the heart's sounds ; from (2; mediastinal tumors, aneurisms, encysted pleuritic effu- sion, and consolidation of the borders of the lungs adjacent to the heart, which produce a greater irregu- larity of outline of the dull district and characteristic general and local symptoms. The apex-beat is lacking in pericardial effusion ; at least, it is lost when the patient lies upon his back. It is also often absent when the heart is weak, and not hypertrophied. In the Pericarditis. 205 latter case the cardiac sounds are not distant, and the outline of the dull area does not change with the position of the bod}'. It rany be absent when the borders of the lungs are emphysematous, but the area of cardiac dull- ness is then small. The character of a pericardial exudate can only be told by aspirating a part of it. If pyaemia is the cause of pericarditis, it may be purulent. If rheumatism is, it probably is serous. Tubercular pericarditis is rarely primary. It may be acute or chronic. The symptoms in the following case will illustrate those of many : A young man, aged 24, entered Mere}' Hospital, after an obscure illness of two weeks. He was slightly dysp- noeic. His pulse was feeble and quick. He often felt apprehension. At times he was nauseated. There was a trifling oedema about his ankles. His temperature was very irregular, but never high (102° F. and less). He had colliquative sweats. The physical signs of peri- cardial adhesions were plainly- present. At first no tubercular lesion could be found in the lungs, but later they were involved. Some months after the beginning of this illness he died from pulmonary phthisis and car- diac weakness. Several of his brothers and sisters are tuberculous or have died of phthisis. In more acute cases a suddenly developed cardiac fatigue produces the existing symptoms. Slight pericarditis often undergoes resolution. It is, however, always a grave disease. Purulent pericarditis is almost certainly fatal. IVeatment. — The indications for treatment are to remove the primary affection as promptly as possible, and in its earl}^ stages to combat the inflammation b}' rest, by derivatives, by depletors, and by opiates. Rest should be enjoined, at least -so long as acute pericarditis 206 Diseases of the Pericardium. or pericardial effusions exist. Blisters, cups, and leeches applied over the heart often lessen the severity of the general symptoms which may arise. A promptly acting cathartic is often prescribed as a depletor. By these agents inflammatory congestion ma}' be lessened and the extension of inflammation prevented. Opiates are useful vrhen pain and tenderness are great. Calomel, in doses of from 0.015 to 0.06 gramme (^ to 1 grain), is often prescribed to hasten resolution, and especiall}' the prompt absorption of serous and fibrinous exudates. If Iieart-fatigue or exhaustion threaten, cardiac tonics and stimulants must be relied upon to maintain the heart's vigor until rest, nourishment, and the removal of tiie cause of weakness will effect a permanent restora- tion of it. Digitalis, strophanthus, convallaria, caffeine, ammonia, and camphor may be used. (See page 222.) To remove the effusion, blistering plasters may be ap- plied over the heart. Often diuretics and diaphoretics are relied upon. Of the former, digitalis, strophanthus, potassium, and ammonium acetate are commonly used. Dry heat is chiefly employed to provoke sweating, for preparations from jaborandi weaken the heart's action. These same drugs must be used to remove dropsies which pericarditis ma}- cause. If cardiac exhaustion is threatened hy an effusion, it may be averted by aspirating the fluid. ^ Aspiration gives prompt relief, but it is often onl}' temporar\', as tlie effusion may re-form. The needle should be inserted in the fourth or fifth intercostal space, close to the sternum. If the liquid is pus, permanent drainage of the pericardial cavity should be established. Recoveries have occasionally been obtained by this treatment. After pericardial adhesions have formed they cannot be influenced by drugs. CHAPTER XIX. Hydrops Pericardii. Hydrops pericardii may be produced under the same circumstances as hydrotliorax. (See page 194.) Com- pression of the coronary veins, for instance, by pericar- dial tubercles or cancerous nodules, may cause it» It will cause the same symptoms as pericarditis with liquid effusions, except that friction-sounds will not at first be present. It can be distinguished from the latter by its causation and by the low specific gravity of the fluid (below 1015), by its usual association with other drop- sies, and absence of pericardial tenderness. Aspiration may be practiced, and even often repeated, when com- pression of the heart threatens its exhaustion. Diuret- ics and diaphoretics are used, as in other dropsies, to promote absorption of the fluid exudate. If cardiac exhaustion is imminent heart-tonics must be used, as in pericarditis. Complete absorption of the fluid and re- covery are possible ; but pericardial dropsy may re-form after such absorption if its cause is not removable. (207) CHAPTER XX. Pneumopericardium. Causes. — Pneumopericfirdium may be caused by (1) external, penetrating wounds; by (2) contusions of the thorax, which cause the fracture of a rib, that in turn lacerates both the lung and pericardium; by (3) ulcera- tion of tubercular or gangrenous pulmonarj- cavities into the pericardium ; by (4) ulceration of the oesopha- gus or stomach, either simple or cancerous, Into the pericardial sack, and by (5) ulceration of a purulent pericarditis into the oesophagus, a bronchus, or the stomach. By most of these processes p3'ogenic matter will be admitted to the pericardial cavity, and purulent inflammation, as well as pneumopericardium, will be the result. Symptoms. — Subjective sj-mptoms which accompau}' the lesion are usually as obscure and as little character- istic as in pericarditis. If much air fill the pericardial sack, heart-exhaustion will rapidly be produced. The phj'sical signs are characteristic. On inspection the praecordia usually seems prominent and the inter- costal spaces protrude. The apex-beat is invisible. Palpation will not reveal it, unless when the patient leans forward the heart gravitates against the chest. Sometimes a friction-fremitus can be felt, or a peculiar splashing. On percussion- the area of cardiac dullness is replaced by unusual resonance. A metallic qualit}' is imparted to the percussion sounds if a pleximeter is struck witli a rod or metallic bod}'. Auscultation re- veals, also, a metallic qualit}' of the cardiac sounds which they do not normally possess. If fluid is also in (208) Pneumopericardium. 209 the pericardium, the}' will only be heard when the pa- tient is recumbent. If friction-sounds are audible, the}^ too, will be metallic in character. Fluid and air both within the pericardium usuallj'^ produce, when stirred b^^ the heart's movements, splashing or gurgling sounds. These various metallic sounds, as well as areas of resonance that in part displace the heart's dull area, may be produced by large, superficial cavities in the lungs beside the heart, through which its sounds are transmitted, or the}^ may be simulated b}^ the stomach when it is greatly distended upward. Tr^eatment. — The treatment must be S3-mptomatic. Cardiac tonics are indicated if heart - exhaustion threaten. Pain must be allayed by opiates. If the gas within the pericardium is dangerously^ compressing the heart, it may be aspirated out. If purulent inflam- mation occur, drainage should be established. We may attempt to limit the inflammation by blisters, cups, and leeches, or by the ice-bag, as in simple pericarditis. Prognosis. — The prognosis must be unfavorable un- less the pneumopericardium is caused by a penetrating wound of the thorax which has not admitted pyogenic matter. I' DISEASES OF THE HEART-MUSCLE, CHAPTER XXI. Dilatation of the Heart. Causes. — Dilatation of the heart maj' be secondary to other cardiac lesions, as, for instance, valvular ones, or degeneration of the muscles; or it ma^' be secondaiy to arterial lesions and to diseases in distant organs. The latter are often called idiopathic cases. The causes of dilatation of the heart are mechanical and nutritive. Frequentl}^ both act together in a given case. Of the mechanical causes those oftenest acting are valvular lesions of the heart ; obstructions to the aorta by com- pression or b}^ contraction ; aneurisms of it ; arterial sclerosis, not alone of the aorta, but of the smaller arteries as well. Obstruction to the pulmonary circula- tion will provoke dilatation of the right side of the heart. This may be caused by chronic disease of the lungs, which destro3's man}' of the capillaries and, it ma}' be, some of the larger A'essels. Pleuritic effusions which will compress a lung will also interfere with a perfect pulmonar}' circulation. Sudden, severe physical exertion will occasionall}- cause cardiac dilatation ; but this M'ill rarely happen unless in some wa}' the heart's muscle has been previously weakened. Most of these mechanical causes produce dilatation of onl}- one of the cavities of the heart. A few affect it more extensivel}'. If nutrition has been imperfectl}' maintained in the muscle of the heart, it may be dilated by an exertion which is not abnormally great. Malnutrition oftenest (210) Dilatation of the Heart. 211 results from fevers, — especially protracted ones, — from anaemias, from indigestions which cause a general mal- nutrition, from fatty degeneration and infiltration, and from obstructions to the coronar^^ circulation. Anatomy. — Dilatation of one ventricle only ma}' occur, as when there is aortic-valvular insufficiency; or both sides may be distended, as in mitral insufficienc3\ Usuall}^ dilatation and h3'pertrophy co-exist, but the ventricular walls may be thin. Often the heart is pale from degeneration of its muscle. Venous hyperaemia mny exist in many organs if the dilatation has been chronic or great. Symptoms. — A diagnosis can onl}^ be made from the physical signs which dilatation of the heart produces. In man}' cases there are no subjective s3^mptoms that can be ascribed to the heart-lesion, although there ma}' be others that are due to a primary affection. If there is no hypertrophy of the heart accompany- ing the dilatation, the apex-beat will be invisible, or it will be feeble and diffuse. It is displaced more or less to the left. On palpation the heart's beat can usually be felt, even when it is invisible. If much hypertrophy accompany the dilatation, the apex-beat may appear strong and feel lifting and energetic; but the pulse will be small, soft, and quick. Irregularity of the heart is often due to dilatation. Percussion will demonstrate an increased area of cardiac dullness. The directions in which this increase is greatest will depend upon whether a single cavity of the heart or several are involved. Auscultation will reveal feeble cardiac sounds. Tlie first sound will lose much of its booming character and resemble closely the second. Even when valvular lesions do not exist sys- tolic murmurs may be heard. This will rarely happen 212 Diseases of the Heart- Muscle. except when dilatation is associated with anaemia. If hj'pertrophy is co-existing the sounds may be booming, and even stronger than natural. We can, then, conclude that dilatation exists only because there are evidences of heart-exhaustion, and we know that where they exist with hypertrophy dilatation does also. With valvular lesions we know that dilatation and hypertroph}^ are alwa3's associated. Subjective symptoms ma}- exist, although commonh- the}' are wanting. If the dilatation is great the usual s^-mptoms of cardinc exhaustion will be present. They result chiefly from an imperfect balance of the venous and arterial blood. The arteries grow small and the veins dilate; passive engorgement, therefore, develops. Dyspnoea, enlargement of the liver and spleen, the symp- toms of renal engorgement, or general dropsy ma\' exist alone or in combination. In mild cases, and especially if the dilatation accom- pany an excitable nervous sj'stem, the quick beating of the heart ma}^ be felt, as palpitation. A beat ma}^ drop or be delayed, and ma}' then cause anxiet}' or fright. Frequent and uncontrollable sighing so often accompanies dilatntion of the heart that I always search for the latter when I observe the former. Tlie sis^hinor is undoubtedl}' due to an unsteady enervation of the respiratory muscles ; it ma}' also be caused by mental depression or flatulent indigestion. Not un frequently one of these latter conditions accompanies cardiac dila- tation. A lack of energy and endurance characterizes all cases of cardiac dilatation, unless compensating hypertrophy co-exists. Treatment. — The object of treatment is to cause con- traction of the heart or compensating hypertropy of its muscle. Strength may be temporarily given by the Dilatation of the Heart. 213 drugs that increase the force of the systole, such as digitalis, strophanthus, and convallaria. It can be per- manentl}' mnintained only when an}' degeneration of muscle-fibres that may exist undergoes resolution, and when with suitable tonics, foods, and exercise they are invigorated. The tonics which will stimulate the cardiac tissues to a better degree of nutrition are strychnia, caffeine, quinia, and iron. They are indicated not only when anseniia exists, but also when muscular degenera- tion does. The}^ may be best given combined with digitalis or its congeners. If it is a moderate dihitation arising from a pro- tracted fever tliat must be dealt with, sponging the skin and baths with tepid or cold wat^* stimulate the circulation and aid in maintaining a vigorous action of the henrt which will prevent dilatation. If the heart is dilating, liquids must not be drunk in quantities sufficient to augment the blood. This is especially true if there is drops}' or anaemia. Then a reduction of the bulk of the blood will prove advanta- geous. (See page 224.) Food must be nutritious and not difficult to digest. Martin has shown that alcohol will cause dilatation of the heart. Such beverages cer- tainly predispose to it by leading to tissue degeneration and to loss of vascular and cardiac tone. They should be excluded from the dietary of those suffering from this disease. If moderate exercise is steadily persevered in it will lead to a better nutrition, and, it may be, to hyper- trophy of the heart's muscle. If it is violent, it may strain the muscles by unduly increasing the blood- pressure, and thus augment the dilatation. Antipyretics diminish tissue-change and interfere with nutrition. Their frequent or prolonged use is 214 Diseases of the He art- Muscle. contra-indicated whenever degeneration exists and we wish to prevent its spread. Aconite, venitrnni, nnd other drugs that cause vascular and cardiac relaxation are contra-indicated. Prognosis. — The prognosis of cardiac dilatation will depend entirel}' upon the possibilit}' of removing its cause. Mechanical causes usually cannot be removed. If the obstruction which the}^ cause to the circulation can be overcome by hypertrophy, they will not endanger life. Dilatation from a w^eakness of the muscular fibres of the heart, because of their malnutrition, can generally be perfectly overcome. If degeneration is extensive or its cause cannot be removed, a favorable result is impossible. Weak muscles, because of haemorrhage, acute or subacute anaemia, indigestion, or fever, is curable ; but if it is due to chronic Bright's disease or to obstruction to the coronary arteries, it is incurable. CHAPTER XXII. Cardiac Hypertrophy. Anatomy. — "When the heart's muscle hj^pertrophies, the number of fibres ma^^ increase or they maj^ enlarge. Usually, both these changes occur simultaneousl}^ Hy- pertroph}' may enlarge the entire heart, or a part of it. A few of the muscular papilUi^ onl}' may enlarge, or the right or left ventricle, oi'both. The auricles are capable of very limited hypertroph}'. The cavities of the heart are usually dilated when tlie walls In^pertrophy, but may remain normal, or, in extremel}^ rare cases, be contracted. The interstitial tissues sometimes increase. If, in spite of the hypertroph}', the heart is continuous!}- fatigued, it may undergo fatty degeneration. Hj'pertrophy causes the heart's wall to appear thick, and to be unusually firm and hard. It is usually normal in color, but may be a brownish red, from an excess of i)igment in it. Causes. — Hypertroph}' is the result of prolonged overexertion. This ma^- be due to obstruction to the circulation, which must be overcome, or to unusual and prolonged muscular work, and rare!}- to nervous excite- ment and strain. Obstructions ma}- exist within the heart at its valvular orifices, — for example, in chronic valvular disease, — or outside the heart, as in stenosis or compression of the aorta or small arterioles. Endar- teritis obliterans often obstructs the arterioles exten- sivel}-, as in the kidne3's in chronic interstitial nephritis. Aneurisms of the aorta or its main branches cause additional work for the left ventricle, and provoke it to hypertroph}-. Permanent pericardial adhesions fre- (215) 216 Diseases of the Heart-Muscle. quentlj- lead to hypertrophy. Acute and chronic parench^'matous nephritis are sometimes accompanied b^^ cardiac hypertrophy. It cannot always be due to vascuh^r obstruction in these cases, for the latter does not always exist. It is probablj^ sometimes due to a chemical cardiac irritant which is in the blood. Symptoms. — H3'pertroph3' of the heart is usually a secondary lesion. Subjective sj-mptoms that accompany it are due to the primar}^ affections. Occasionalh^ per- sistent hard beating of the heart is felt, and especially during left decubitus. But one must depend upon physical signs in order to make a diagnosis. The prae- cordia is unusualh' prominent. Particularh' is this true in the earlier years of life. The apex-beat will be seen to the left of the nipple, and lower than is normal. The beat moves a larger area of the chest-wall than is usual, and it is more powerful and lifting. Palpation confirms its location, its diffusion, and its strength. If the left ventricle only is lijqDertrophied, its anterior surface will press against the thoracic wall, and the right ventricle will be rolled backward. The apex-beat will then be produced b}' the left ventricle. If the right ventricle is chiefly or exclusively hypertrophied, pulsation may be seen and felt to the right of the sternum, and will, in almost ever}- case, be easily' demonstrable just beneath it. This is due to the contact of the right ventricle with the thoracic wall, for when it hypertrophies the left is displaced backward, and the right ventricle chiefly forms the anterior surface of the heart. Per- cussion demonstrates an enlargement of the area of cardiac dullness. If the left side of the heart is exclu- sively involved, it will be increased to the left; if the right side, to the right ; and if both sides, in each direc- tion. It may extend an inch or more to the left of the Cardiac Hyper tj-ophy. 217 nipple, and tlie same to the right of tlie sternum. The cardiac sounds are usually normal. The first sound at the apex ma^' be louder and more booming. If the left ventricle is hypertrophied, the second sound over the aorta is accentuated. If the right ventricle is hyper- trophied, it is the second sound over the pulmonarj^ arter}' that is accentuated. Tiiese accentuations aie due to increased tension of the respective semilunar valves. If both sides of the heart are thickened, we find a com- bination of the signs just described, and especinlly evidence of cardiac enlargement, both to the right and left. The cardiac sounds can often be plainly heard at a considerable distance from the heart. The carotids often pulsate visibly, and sometimes a systolic murmur can be heard in them which is due to the unusual ten- sion of the vessel's wall and its consequent irregular vibrations. The pulse will be large and firm. If the cause of the heart's increased work cannot be removed, or at least compensated for, the heart will become fatigued, in spite of its hypertroph}'. It will grow rapid in action, or irregular. The lungs will become congested, and d3'spno?a will develop. The liver will enlarge. The legs ma}- become oedematous. The urine will diminish in quantity and may grow cloudy and contain albumen. Dropsy of the abdominal cavit}' or other serous sacs may be produced. The pulse will be soft, of medium or small size, in spite of the strong throb of the heart against the chest. Death may be caused by oedema of the lungs or heart- exhaustion. Moderate hypertrophies which are produced by causes that are remoTable may disappear when their cause is gone. Hypertrophy is a conservative process. It is favor- 10 K 218 Diseases of the Heart-Muscle. able to life. It ma}- enable the heart to overcome, per- fectl}' and with ease, a permanent obstruction to the circulation. XJnfortunatel}', often the obstruction grad- uallj^ increases, and finalh' cannot be compensated for b}^ hypertroph}'. Then the symptoms of cardiac ex- haustion develop. Treatment. — No treatment is indicated if hypertro- phy compensates for an existing obstruction to the blood's flow ; but after compensation has been obtained the heart must not be wearied b}' additional and unnec- essary labor. Therefore, fatiguing exercise must be avoided. Constipation and slow or labored digestion will impede the circulation and involve the heart in extra labor. They must be prevented or i)romptly cured. The diet should be simple and nutritious. Stimulants and tea, coffee, and tobacco must be avoided. Milk, eggs, lean meat, simple vegetables, and wholesome fruit may be used. Greasy, fat, and very farinaceous foods must be used sparingh', or not at all. Sufficient exercise in the fresh air should be taken to maintain a good oxygenation of the blood and a fair degree of muscular vigor, but it should never be ex- hausting or violent. The nitrites are sometimes used (see page 228.) when high arterial tension is the cause of h3'pertroph3'. They will lessen it, and thereby reduce the heart's labor. Digi- talis is contra-indicated so long as the heart beats slowly and steadily. If it is often or persistenth' quick or irregular, it ma}^ be used. Strophanthus is to be pre- ferred because, in usual doses, it does not cause so much arterial contraction, and, therefore, as high arterial ten- sion. The former gives the heart more worlv to do. After the heart has In'pertrophied, and tlien grows rapid or irregular in action, we may feel sure that dila- Cardiac Hypei'trophy . 219 tation is forming or increasing, and, usuall}^, that fatty degeneration is established. The treatment must then be adapted to combat these lesions. Cardiac exhaustion is tlie cause of death when the heart is hypertrophied. Its prevention is, therefore, the indication for treatment. CHAPTER XXIII. Fatty Heart. Anatomy. — Two lesions are named fatty heart. They are technicall}' named fatt}' infiltration and fatty degen- eration. In fatty infiltration the connective tissue be- neath the pericardium, and especiall}' about the coronar}" vessels, is filled with I'at. The entire heart ma}' be thickly enveloped in it. Fnt may also accumulate be- tween the muscle-fibres in the fibrous frame-work of the organ. The muscular fibres may atropli}' and become very small. Such an accumulation of fat and concomi- tant muscular atroph}' interfere with a vigorous action of the heart. As the lesion is almost limited to obese people, the cardiac fatigue which often co-exists with it is partly due to tlie larger volume of fluid that must be moved through their more numerous capillary vessels. Fatty degeneration is due to a malnutrition of the cardiac muscle wliicli ma>' lead to its disorganization. In the muscle-fibres appear minute granules, that often obscure their striated sti'ucture. If the malnutrition is suflflcientl}' great, the outline of the fibre is lost. A crowd of granules represent it for a time, but soon they are absorbed. Thus, disintegration and disappear- ance of tissue may grow out of the degeneiation. The muscles that are aflfected are alwavs weakened. They show this b}' a lack of endunince, as Avell as by a feeble- ness of contraction. The entire heart and many other organs and tissues may l)e simultaneously aflfected in this way; but usuallj' only a patch of muscle-fibres here and there is involved. The muscular papillae and the (220) Fatty Heart. 221 fibres beneath the endocardium are especially apt to be. The inside of the A^entricle often appears mottled with 3^ellowish spots. When the entire heart is degenerated it will all look yellowish-red and greasy. It will be soft. If a knife is drawn across the cut surface of de- generated muscle-fibres, droplets of oil can be seen in the fluid that gathers on it. Cloudy swelling may precede fatty degeneration, or be associated with it. Symptoms and Causes. — A positive diagnosis of fatt}^ heart is difficult to make, and is often impossible. Fatt}^ infiltration may be suspected in persons who are obese and whose heart's action is feeble. The thick chest- wall may make it impossible to say whether the heart is enlarged or not, or to judge of its strength by the apex- beat, for the latter often cannot be felt. But if the heart is weak it will beat fast, even from moderate phys- ical exertion. Its first sound will be short, and valvu- lar in character. The pulse will be small and soft. If the heart is much enfeebled, the cervical veins may be distended. Shortness of breath is partly due to the cardiac weakness, and largely to the obesity of the chest. A feeling of oppression is often experienced, and sighs for breath, which are unsatisfying, are invol- untarily drawn. Little endurance is possessed. A disinclination for ph38ical exertion is usual. Much fatty infiltration or fatt}- degeneration may exist and be unaccompanied by symptoms. Sponta- neous rupture of the heart has been known to occur suddenly, because of the weakness of its walls. In other cases the symptoms of heart-exhaustion may develop, such as chronic venous hyper.'iemia and oedema of various organs; or angina pectoris may develop. A slow pulse, psendo-apoplectic attacks, and Cheyne-Stokes respira- tion, if they occur together in the same person, are quite 222 Diseases of the HeaiH-Mascle. characteristic of fattj' heart. Unfortunately, they rarely occur together, and either S3'mptom alone is not charac- teristic. The pulse niaj^ be ver}' slow, — even less than twenty beats to the minute. This is not, however, usual, for oftener it is quickened, at least, b}^ bodily exertion. The arcus senilis frequently develops in those in whom fatty degeneration exists extensivelj', or results from local anaemias that, in turn, are caused hy arterial stenosis. The presence of some of the causes of fatty degeneration aid one to make a diagnosis. Prolonged anaemias are especiall}^ apt to produce such degenera- tion. Chlorosis, leukaemia, and pernicious anaemia are examples of the forms oftenest leading to it. Chronic or protracted fevers will also cause it. Valvular lesions or arterial obstructions which cannot be compensated for by h3'pertroph3^ are common causes. Coronary sclerosis, by producing local cardiac anaemias, ma}^ lead to it. Phosphorus poisoning will cause intense general fatty degeneration. Chronic tobacco and alcoholic poisoning may lead to similar results. Obesit}' and fatty infiltration of the heart-muscle ma}' be an inherit- ance ; oftenest it is due to a lack of vigorous exercise and an excess of fat-producing foods. Treatment. — If the heart beats feebl}^ and is excit- able, because of fatt}' degeneration, cardiac and general tonics are indicated. Aniiemia requires iron. This drug- also seems to prevent degeneration. Such general tonics as strychnia and quinia will invigorate nutrition. Such cardiac tonics as digitalis, strophanthus, and caffeine are required to temporarily strengthen its beats and restore the equilibrium of the venous and arterial currents. Strophanthus is preferable to digitalis in these cases, for it contracts the peripheral vessels less and increases the arterial tension less. Catfeine seems Fatty Heart. 223 not only to stimulate the heart, but to increase its abil- ity to appropriate nutriment. A combination like the following will often prove promptly efficacious : — R Ferri citratis, . . grms. 12.0 (gr. ij). CafFein. citratis, . . grms. 15.0 (gr. iiss). Pulveris strophanthi, . grm. 0.015 or 0.02 (gr. \ or ^). Sig. : To be given iu a capsule every four hours. It is especially adapted to the stage in which palpi- tation is easily provoked. As the heart grows stronger, strophanthus or digitalis may graduall}^ be omitted and strychnia or quinia substituted. It must be remem- bered of powdered strophanthus that it is laxative. Such treatment must be persisted in for weeks, and often for months. Inhalations of oxj^gen have been recommended, as a lack of it is supposed to cause degen- eration. But we have no evidence that the blood will take up more oxygen if it is breathed pure than when diluted, as in common air. Respiratory gymnastics vsee page 151), which will insure frequent empt3ings of the lungs and their complete expansion with fresh air, will accomplish quite as much as ox3'gen inhalations. To maintain good nutrition of the heart good nutrition must be maintained everywhere. A perfect lymph- circulation is essential for this, and can only be assured by general exercise. Exercise should be gentle, but should be as long continued as is possible Avithout pro- ducing a feeling of excessive fatigue or exhaustion. It should not be violent. To diminish the amount of fat which may infiltrate the heart's muscle in obese persons, Oertel's treatment is the best. It aims to lessen the bulk of fluid in the vessels and the addition of fat, and to strengthen the heart by exercise. If the quantity of blood and fatty 224 Diseases of the Heart-Muscle. tissue is lessened, the amount of work which the heart has to do, in moving the fluid through the adipose tissue, is diminished. Copious sweatings will relieve the system of its excess of liquid, but to prevent its prompt resto- ration its ingestion must be limited and carefully pre- scribed. Sweating may be produced etfectively by Turkish baths, or by vigorous and prolonged exercise. To prevent the continued accumulation of fat, carbo- h^'drates must be eaten very sparingly. If an albuminous diet is adhered to, the fat already stored in the body will be utilized as carbohydrate food. This is especiall}' true if exercise is taken freely, so that tissue-changes are kept vigorous. Exercise will provoke sweating, will maintain a vigorous circulation, necessitate deep and frequent breathing, thorough blood ox3'genation, and active tissue-change; it will strengthen voluntarj^ muscles and cause them, and with them the heart, to hypertroph3\ Exercise should, if possible, be continued for several hours daih', b3' those who need this treat- ment. It should gradually be increased. Oertel recom- mends mountain-climljing more than any other form. In level countries, rapid walking, and, later, as strength and endurance increase, running may be substituted for climbing. It should be sufficientl}' active to provoke some shortness of breath and increased rapiditj' of the heart's action. If these symptoms begin to cause dis- tress, a few moments' rest should be enjoined. The amount of exercise that should be taken by an individual will depend upon its effects. Therefore, each patient must be closely watched and guided. Too violent exer- tion might permanentl}^ and dangerously injure the heart, which is already injured and fatigued. When the quantity of fluid that is to be ingested must be prescribed, it is best to ascertain about how Fatty Heart. 225 often and how much the patient habitually takes, and at first lessen the amount rather than the frequency of its use. So it is best to learn what his usual diet is, and then eliminate from it the greater part of the carbo- hydrates. Alcoholics should be excluded from the diet of those who have fatt}- heart. They make tissue-change slow by lessening the oxygen-carrying power of the blood. The}' lessen the vigor of nutritive changes partly in the same way, and by expanding the peripheral vessels and slowing the peripheral blood-current. Tlie weaker preparations, such as beer, are taken in such amounts as also to greatly augment the fluid within the bod}-. If the heart is exhausted and can be spurred onl}- temporarily, the symptoms of passive engorgement and oedema of various tissues will be little affected, and, sooner or later, in spite of these drugs, the pulse will grow smaller and quicker. As the symptoms of ex- haustion intensify, diffusible stimulants like ammonia and camphor are employed advantageousl}-. (See page 101.) To relieve the oedema which may accompany' fatty heart, such as anasarca, ascites, pleural and pericardial dropsy, the alkaline diuretics and more or less drastic cathartics (see page 292) can be used in addition to car- diac tonics. The serous cavities may have to be aspi- rated or punctured to effect immediate relief. 10* CHAPTER XXIY. Indurative Degeneration. Anatomy. — By indurative degenei'fition I mean a lesion that is primarily a degeneration, and secondarily an li3'perplasia, of connective tissue which causes indu- ration. It results from a gradually produced and per- sistent local anaemia within the heart. Sclerosis, throm- bosis, or embolism of some branches of the coronary arteries are its usual causes. In the anaemic area there is first degeneration and atroph}- of the muscle-fibres, because of diminished nutriment and a lessened vitality'.. Under conditions of nutrition, in which highh' special- ized structures, such as muscle-fibres, cannot live, the connective tissues grow. This is possibly nature's method of attempting to repair the weakened fabric. If a heart in which induration and necrosis has devel- oped is examined, there will be found imbedded in the muscle, and usually near the apex, a patch of gray, fibrous tissue. "Tlie heart's wall may or ma}' not be very thin at this point. The patch may be minute, or the size of a half-dollar. While oftenest in the ven- tricular wall, and near the apex, it ma}' be an^'where in the heart's substance. It ma}' be deeply imbedded in the muscle or near its surf^ice. It may involve only a small part of the heart's wall or its entire thickness. Under the microscope the indurated tissue shows its connective-tissue character. If the patch is still grow- ing, about its margins the cells composing it will be embryonic in type, and will infiltrate the neighboring muscle-fibres, which will be granular and atrophied. The result of these anatomical changes is always the (226) Indurative Degeneration, 22t production of a Imrcl, cicatrix-like structure. But tli(3 loss of muscle-fibres makes the wall of the heart weak and tlie connective tissue cannot compensate for the loss. Rupture of the heart through the indurated tissue may occur, or, if the latter is just beneath the endocardium, and roughens it, a cardiac thrombus may form, which, in turn, may produce emboli. Cardiac aneurism is a third occasional result of this lesion. At the point of weakness the heart's wall will bulge and form a thin- walled sac containing blood. Such aneurisms may be the causes of thrombosis, because of the slow blood- stream within them, or they may rupture. Symptoms. — Indurative degeneration may exist and produce no symptoms. In some cases the only symp- toms are those of cardiac fatigue or exhaustion. The group of symptoms named angina pectoris are common accompaniers of this lesion. Unfortunately, they may also occur with fatty degeneration of tlie heart, with coronar}' sclerosis without indurative degeneration, with aortic valvular lesions, and aortic aneurism. But though this is true, angina pectoris is always sug- gestive of coronary sclerosis, and the latter of indura- tive degeneration. If with angina pectoris we find evidence of sclerosis of radial or temporal or other arteries, we may feel quite sure of coronary sclerosis. Angina pectoris implies, when it is severe, an agonizing pain of oppression in the chest, about the sternum, accompanied by radiating pains to the left breast and shoulder, and into the left arm. The suf- ferer's face expresses pain, and even fear. The skin is pale, cold, and often clammy. The pulse is small, hard, and quick. The heart-beats are rapid, feeble, and often irregular. More rareh^ they are diffuse and vigorous, though the pulse is weak or irregular. Respiration is 228 Diseases of the Heart-Muscle. oppressed, irregular, sighing and unsatisfying, but not dyspnoeic. Death from heart-failure may occur in the midst of such an attack. Usuallj' the onset is not sudden, but, from a feeling of discomfort during two or three hours, an agonizing pain develops. It may last a few moments or for hours. When it subsides, vomiting not unfrequently occurs. When the pain is gone, as a rule, great prostration remains. The pulse gradually orows full and slow, and often is irreo^ular and excited b}' slight physical or mental exertion. The attacks may recur frequently, — at least, ever}' da}' or two, — or at long intervals of months or years, or not at all. They ma}' be of all grades of severity, from slight, almost momentary, attacks of heart anguish to those of intense severity. It is evident, however, that during life a positive diagnosis of indurative degeneration is impossible, for neither the symptoms of cardiac fatigue nor angina pectoris are pathognomonic of it. If angina pectoris and arterial sclerosis co-exist, we may conclude that the former is due to coronary sclerosis, and we know that this may lead to indurative degeneration. In rare cases angina pectoris occurs when no lesion of the circulatory apparatus is demonstrable. Treatment. — Treatment must be symptomatic. If there is cardiac fatigue or exhaustion, it must be treated as in other diseases. (See page 222.) Angina pectoris may be relieved by morphine, or chloroform, or ether; but these drugs must be used with great caution, as they are liable to produce functional derangements of the nervous system. The nitrites are equally efficacious in certain cases, especially in those in which there is an arterial spasm. Amyl nitrite may be given by inhala- tion with wonderfully prompt effects. The cold, gray Indurative Degene7'ation. 229 skin of the face soon grows flushed and warm, the head feels full, and the agonizing breast-pain lessens. Nitro- glycerin is equally beneficial in the same cases, but little less promptly so. It may be given in doses of 1 or 2 drops of a 1-per-cent. solution, and may be repeated every three or four hours. The nitrite of soda ma}' also be used, in doses of 0.06 to 0.12 gramme (1 to 2 grains) of the pure drug, or 0.3 to 0.45 gramme (5 to 8 grains) of the preparation usualh^ dispensed. While the i)atient is cold he should be made warm with hot flasks and his skin chafed. To avoid returns of the attacks, tiie patient should eschew excitement or undue bodily exertion, — should in no way produce high arterial tension by arterial contraction, as may be done by constipation or indigestion. Such hygiene as will promote good nutrition, active tissue-oxidation, and healthful muscular vigor will help to prevent these attacks when a degenerating or en- feebled heart causes them. CHAPTER XXY. Myocarditis. Anatomy. — Indurative degeneration has been by many regarded as of inflammatory origin. But inflam- mation in the lieart-muscle is due to extension from neighboring tissue or to septic infection. It commonly results from a peri- or endo- carditis which deeply in- volves the heart-wall. Inflammation may produce thick- ening of these thin tissues and destruction of the superficial muscular fibres by causing their atroph}^ or degeneration when the^' are separated by round-cells, which ultimately are transformed into fibrous tissue. In these ways an indurated area or scar may be pro- duced which will resemble indurative degeneration. Purulent myocarditis is produced by septic emboli. Ulcerative endocarditis and pyaemia are oftenest the cause of them. They alwaj's produce abscesses. This form of myocarditis is rare. The abscesses are usually small. There may be several of them, or only one. Symptoms. — There are no distinguishing s3'mptoms. Myocarditis, which grows out of peri- or endo- carditis, produces no other svmptoms than those of the primary disease. The scars which may result from it will pro- duce no symi)toms, or they may be accompanied b}' the various ones associated with indurative degeneration. Purulent myocarditis can rarely be diagnosed. Treatment. — The treatment of mj'ocarditis does not differ from endo- and peri- carditis in the first group of cases or from p^'semia in the other. (230) DISEASES OF THE ENDOCARDimL CHAPTER XXYI. Endocarditis. Anatomy. — Inflammation of the lining of the heart is a common cardiac affection. Any part of the interior of the heart may be inflamed, but commonly only the valves or their immediate neighborhood is involved. Acute endocarditia is almost invariably limited to those portions of the valves which chafe against each other. After birth it rarely affects the right side of the heart, though it commonl}^ does before. When acutely inflamed the point of attack is at first reddened. The subendothelial tissues are soon infil- trated with serum and round-cells. If the valves are aflfected, the}^ are thus thickened. The endothelial cells loosen, and are detached. The raw surface is now coated with a thin, opaque film, which ma}' grow, b}^ deposition of fibrin, into a wart-like protuberance as large as a pin-head, or even a bean. These protuber- ances are grayish, or yellowish, or reddish yellow in color. The}' are often brittle ; brej^k, and form emboli. Two forms of acute endocarditis exist : The first is known as septic^ malignant^ or ulcerative ; the second as non-malignant^ simple^ or verrucose. The former is due to septic infection. Micro-organisms abound in the lesions, and produce, when carried elsewhere in emboli, septic infection of distant organs. Septic endocarditis is so uniformly characterized by loss of substance in the (231) 282 Diseases of the Endocardium. valves that it is often iiuined ulcerative. Similar loss of substance may occur, but seldom does, in simple endo- carditis. In ulcerative endocarditis, if the valvular vegetations are detached, a loss of substance, with ragged and sharpl3^-cut edges, is laid bare. This ulcerating destruction of the tissues maj^ extend deepl}', and may even penetrate a valve. Oftener, where the valve is thus thinned the endothelium upon its opposite surface be- comes distended and protrudes. Slowly, it will be stretched out into a sac, with a narrow neck at the point of ulceration. Such a sac is known as a valvular aneurism. It may contain fluid blood or a thrombus. An aneurism may rupture, or even a thin valve that is not aneurismal ma3\ In simple endocarditis there is oftenest built up on the abraded valvular surface a vegetation, the base of which is composed of round or granulation cells and the upper part of fibrin. Under the microscope the upper- most cells in these vegetations are degenerated and granular. In the deepest layers of fibrin a few atrophied nuclei ma}' still be seen, which have been set free from cells that have disintegrated. Chronic inflammation may begin as such or grow out of acute inflammation. It is characterized b}' thick- ening of the valves, roughening of their surfaces, rigidity, contraction and contortion of them, often degeneration of their deeper tissue, and even calcification. The valves may become partly adherent to one another, or to neigh- boring parts of the endocardium. The fibrillse and mus- cular papillie ma}' be involved, both in acute and chronic changes. They may be broken, or shortened, or con- torted, and thus, also, interfere with the function of the valves. If chronic endocarditis arise by extension of endarteritis, the base of the aortic valves may be chiefly Endocarditis. 233 involved instead of the edges, or the upper instead of the lower surface. When the inflammation spreads from the mitral to the aortic valves, or vice versd^ the base is also especiall}^ apt to be atfected. Instead of lapsing into chronic inflammation or leaving a chronic valvular lesion, acute endocarditis ma^^ undergo perfect resolution. This is rare, however. These various changes in the valves modiiy their func- tion. Their swelling, causes rigidit}^ Chronic tliicken- ings and calcifications make them still more rigid. Yer- rucosities or chronic roughness will prevent perfect coaptation of the edges of the valves Contraction of them will prevent a perfect closure of the orifice, which they should guard. Their roughness, their slow move- ment, and other changes will cause unusual eddies and currents in the blood-stream, which produce the modified heart-sounds that are recognized as murmurs. The imperfect opening or closing of a cardiac orifice by tlie valves will produce other changes in the heart and circulation. We can best describe these later. (See page 240). Emboli originating in the heart may cause abscesses, if they are septic; or infarcts, or dropsy, or local anaemia, if they are aseptic. Gause.i. — It has been proven that septic endocarditis oftenest arises as a complication of puerperal fever or of some other form of sepsis. As the point of infec- tion cannot ahva^'s be discovered, some cases are described as idiopathic or primar3\ Several diff'erent forms of micro-organisms have been found in the car- diac lesions. It seems quite well established that the disease has not a single specific microbic cause. Old valvular and cardiac lesions are especiall}' the locus of septic endocarditis. After puerperal fever, septic endo- 234 Diseases of the Endocardium* carditis oftenest complicates articular rheumatism, infec- tious exanthemata, diphtheria, typhoid, periostitis, and osteomyelitis. Simple endocarditis is rarel}^, if ever, a primary affec- tion. It usually complicates articular rheumatism. It is associated both with the mildest and the severest cases and with subacute and acute. It is said to occur oftenest in those cases in which many joints are simul- taneously involved. Gonorrhoial and other rheumatoid affections are rarely accompanied by endocarditis. Chorea is ver^^ frequently' associated with it. The exanthemata, protracted fevers, nephritis, pleurisy, pneumonia, phthisis pulmonum, and many other dis- eases may be complicated by it. The tubercle bacillus has been found in endocardial vegetations which devel- oped in a consumptive. Oftenest the valves become irregularh' slightly thickened and roughened in phthisis, but not sufficientl}' modified to cause cardiac symptoms. Chronic endocarditis frequentl}' grows out of acute attacks, but in man}- cases its origin is insidious. Senile changes which produce sclerosis in the blood-vessels lead to chronic valvular and endocardial thickenings and induration. Severe and unusual muscular strain also disposes to the disease, as military surgeons have demon- strated among recruits. It often follows nephritis, diabetes, gout, S3'philis, chronic lead and alcohol poison- ing. Certain irritants in the blood undoubtedl}' produce it in these affections. Symptoms. — It is impossible to describe a group of symptoms which characterize all cases of acute septic endocarditis, for no two are precisel}^ alike. Many cases cannot be diagnosed, and many more not without weeks of observation and study. The course of the temperature and many of the sj-mptoms commonly Endocarditis, 235 resemble either t3^plioid or intermittent fever. But the cardiac disease is often unnoticed in the course of a primary affection, such as puerperal fever or some other septicaemia. Those cases which most resemble typhoid have a fever of a continuous type. The patients are apathetic. The tongue is dry and brown ; the pulse is quick, soft, and dicrotic ; the abdomen tympanitic, and sometimes roseola spots can be found on it. Other cases not only resemble intermittent fever in the course of their temperature, but, as in them, the spleen en- larges ; a chill, fever, and sweat recur with uniformity each day, or each second or third day. If the disease runs a long course the fever gradually becomes more continuous and less intermittent, or less regularly so. In both groups of cases there may be ph3'sical signs of a cardiac disease, or they may be entirely wanting. The occurrence of embolism is most suggestive of a cardiac lesion. Emboli ma}' cause hemorrhagic infjircts, or cedema, paralj'sis, or often abscesses. If they are very minute, and especiall}' if the}' are in internal organs, tliey may not manifest themselves. Embolism of the skin and retina can be observed more readily. If the physical signs of a valvular lesion gradually develop, a diagnosis may be made with some positiveness. A gradual, but progressive, loss of flesh and strength takes place. Death is almost inevitable. Acute non-malignant endocarditis can usually be diagnosed with certainty. If the lesion is not upon the valves, or if it does not interfere with their action, a diagnosis is impossible. Reliance must be placed en- tirely upon the physical signs, for subjective S3mptonis may be wanting or indefinite. In rheumatism and chorea the heart should be frequentl}^ examined, as valvular lesions may otherwise be overlooked. The 23fi Diseases of the Endocardium. temperature imxy be raised or remain unchanged when the heart is iuA^olved. Sometimes oppression is simul- taneously felt in the cardiac region ; more rarel}', pain and tenderness are there. Palpitation or irregularity of the heart first attracts attention to other cases. Sj'n- cope and d3'spnoea are rare; if they occur, they are usually due to heart-clot or embolism. Ofteuer no sub- jective symptom suggests a cardiac lesion, but it is discovered b}' the development of physical signs. Em- bolism and its effects will often make positive a diagnosis that otherwise is probable. If in the course of a disease that is likelv to be com- plicated b}' endocarditis murmurs arise, we are justified in suspecting its existence and often in affirming it. If diastolic murmurs develop under these circumstances, we are assured that endocarditis has produced the con- ditions which give rise to the murmur; but, unfortu- nately, diastolic murmurs are not the commonest. SN'stolic murmurs may develop in fevers or when there is anaemia, even though no endocarditis exists. Though, as a rule, endocarditis is the cause of systolic murmurs which accompany acute articular rheumatism, I am sure that in several cases I have heard a mitral systolic murmur which was not due to this cause. In these cases the murmurs disappeared entirely when the pa- tient regained strength and his blood its richness. If, however, such murmurs persist, and if, subsequently, changes in the size and shape of the heart develop, which are usual when the valves are permanently modi- fied, we may make a positive diagnosis. If embolism occur, a diagnosis can be made with greater certainty. While it is impossible always to make a diagnosis of acute endocarditis when it exists, and especially of the maliijnant form of the disease, a diagnosis is usuallv Endocarditis. 23T possible. The symptoms of most value are those which a physical examination demonstrate or which arise from embolism, and the co-existence of one of the diseases that are commonly regarded as causative. The physical signs which make it possible to determine which valve is chiefly affected are the same that enable us to make the same determination in chronic valvular disease. (See pages 243 to 250.) Treatment. — The treatment of ulcerative endocarditis must be directed to the conservation of strength. Gen- eral nutrition must be maintained bv administering food as it would be to those suffering from continued, intermittent, or septic fever. Milk, gruels, broths, and eggs should constitute the regimen. If the stomach is not retentive, or if its digestive powers are impaired, food is best given frequentl}^, in small amounts, but to others it may be given more generoush^ and less fre- quently. Cardiac exhaustion and failure are commonly the immediate cause of death. As the lieart grows feeble, it must be spurred to greater efforts by digitalis, stro- phanthus, convallaria, and similar drugs. When it is extremel}' feeble, diffusible stimulants, such as ammo- nium carbonate and camphor, must be relied upon. A great number of antiseptics have been administered in these cases, but unavailingly. As non-malignant endocarditis is a secondary affec- tion, treatment must be addressed to the primary disease. In the onset of the endocardial inflammation an ice- bag may be constantl}^ applied to the prnecordia, or, instead, blisters, followed by fomentations, may be used. They will act as they do when serous sacs are inflamed. The mild chloride of mercury is used as in pleurisy' and pericarditis, with the hope that it will modif}^ the exu- 238 Diseases of the Endocardium. date and prevent its organization. In subacute and non-chronic cases tlie iodide of soda or potash is used. Digitalis or analogous remedies must be employed if the heart is undul}^ weak, irregular, or fast. During conva- lescence they can be gradually omitted, and bitter tonics and iron can be adVantageousl}- used to restore the heart-muscle to a greater degree of nutritial vigor. In these cases, too, nourishment must be carefully admin- istered, so as to maintain strength. Prognosis. — In malignant endocarditis the prognosis is unfavorable ; in non-malignant cases it must be guarded, for, almost without exception, a chronic val- vular lesion is produced. If this does not interfere so greatly with the function of the valves that the heart fails by hypertrophy to compensate for it, life ma}^ not be shortened. In such cases there is a physiological, though not an anatomical, recovery. But, in many cases, either the lesion is too great to be compensated for or the general vigor of the individual is not sufficient to make hypertrophy possible. CHAPTER XXYII. Chronic Yalvular Disease. Nature and Anatomy. — Anatomical deformity of a cardiac valve may exist without disturbing its function. For example, a scar upon a valve may make it abnormal, but it may still open and close perfectly the orifice it guards. No cardiac disease is produced by such a lesion. If a valve is so displaced or deformed that it narrows the orifice it should protect, or leaves it con- stantly open, its function is not performed, and a more or less extensive change in tlie heart, and usually in other organs, will be produced. The valves may be unusuallj^ thickened and rough- ened b}' inflammation, by degeneration and calcification, or, infrequentl}', hy new growths. The}' may be con- torted by scars ; the}' may be adherent to one another, or to the adjoining wall of the heart ; they may be torn ; they may be perforated by an ulcer or ruptured aneu- rism. Their functional activity may be interfered with b}^ rupture, contraction, or degeneration of the muscular papillae or chordae tendinse. A valvular orifice may be dilated and the valves made incompetent though the}^ are not diseased. Some of these lesions ma}^ be devel- oped congenitally, — either from imperfect development of the foetus, or from inflammation or other less frequent and imperfectl}^ understood causes. When lesions are congenital thej' are usually upon the right side of the heart. In adults the}^ are commonly due to endocar- ditis ; degenerative changes, such as produce arterial atheroma, also produce some of them. A valve is rarely ruptured from strain alone. But usuallj^, as in a case (239) 240 Disease fi of the Endocardium. that recently came under m}' own observation, a severe bodily strain increases the arterial blood-pressure, and causes a rent in the edge of, for example, an aortic valve that hns been slightlj' weakened b}- degeneration — which may be extensive — in the aorta. Occasionally, when the cardiac cavities dilate, the orifices are also stretched, so that valvular incompetency results. Tumors are A'ery rare within the heart. Sometimes foreign bodies, espe- ciall}' cardiac thrombi, entangled in the chordae tendinse and protruding through a cardiac orifice, will produce S3'mptoms that precisely simulate a valvular lesion. Symptoms. — The general symptoms which accompan}* a chronic valvular lesion are due to cardiac weakness, and are the same as those accompanying cardiac weak- ness from other causes. If the heart, by hypertroph}', can compensate for the stenosis or insufficiency which a chronic valvular lesion ma}' cause, general symptoms will not arise. These symptoms are due to a disturb- ance of the balance between the arterial nnd venous circulations. The arteries are imperfectly filled ; the blood within flows slowly, under diminished pressure. The veins are overfilled, but in them, too, the Jjlood- stream is slow ; tiie pulse, therefore, feels soft, and is small or of medium size. The heart is quick when com- pensation is not perfect, and often becomes irregular and tumultuous. Physical exertjon, mental excitement, or difficult digestion will frequently hasten the heart's action to a distressing degree. Stenosis causes this imperfect vascular balance by making the arterial stream slow, b}' filling the arteries slowly- and iraperfecth', and, consequently, making pressure within them low. Be- hind the point of stenosis the pressure is increased and the veins are overfilled. Insufficiency produces the same results, because of the regurgitation, which also Chronic Valvular Disease. 241 ciiuses overfilling and increased tension in the veins, and imperfect filling and low tension in the arteries. The imperfect vascnhir balance leads to passive engorgement of various organs. The lungs and bronchi are commonlj' thus afl[*ected. The}' may undergo the changes which are chnracteristic of passive hypersemia, and that are known as brown induration. Often, when congested, the bronchi become inflamed, and remain persistently so, with varving degrees of severity. Dysp- noea is a common symptom, and may be due to the congestion, to bronchitis, to brown induration, to oedema of the lung, or to pleural drops}'. The liver may be greatly enlarged from venous hyperaemia. It can then be felt as a smooth body with rounded borders. It may be so large that the lower ribs will be pushed outward. It is usually subject to frequent and very marked variations in size. It is ten- der, and its distension often causes i)ersistent soreness. If the hyperaemia has lasted long, the. liver may gradu- ally contract and its surface ma}' grow rough ; it will then become hard. Thus, it is transformed into the condition known as the nutmeg-liver. Often an icteric hue can now be observed in the patient's skin. The kidneys are also liable to somewhat similar changes. By congestion albuminuria may be caused. The urine becomes moderately diminished in qnantit}'. Its specific gravity is from 1025 to 1035. It is usually turbid, and deeper colored than natural. The amount of albumen present is not great. Hyaline and granular casts can be found in the sediment, but are not numer- ous. Blood-cells are also often present in small num- bers. In this stage of congestion acute inflammation may occur ; if prolonged, congestion leads to contraction and cirrhosis. The urine will then increase in amount; 11 L 242 Diseases of the Endocardium. its specilic gnivit}' will fall below normal ; the albumen will be redaced to a trace, and casts will be rarely found. Passive h^'persemia of the stomach and intestines leads to slow digestion, constipation, and, finall}', often to catarrhal inflammation. These lesions produce cor- responding symptoms : indigestion, anorexia, vomiting, flatulence, and constipation ma}' characterize one case; sour stomach, p3'rosis, tenderness, or diarrhoea another. Anasarca and dropsy of au}^ of the serous cavities ma^- also result from the imperfect balance of the arterial and venous circuhition. All of these lesions and symptoms do not ordinarily occur in the same case, but the}' occur in varying com- binations. Oftenest a congestive dyspnoea and general anasarca are combined. I have seen cases in Mdiich the liver was enormousl}- enlarged by congestion while the lungs were almost unaffected, though respiration was uncomfortable, because the liver impeded the move- ments of the diaphragm. Indigestion also increased tlie patient's distress, but there was no anasarca. In other cases the kidneys may be early involved. Bodily temperature is not changed in these cases, unless inflammation causes it to rise. A slow and im- perfectl}' maintained circulation leads to slow and imper- fect tissue-change. Reparative processes are retarded. Perfect nutrition is not maintained. The disturbances of the pulmonar\', gastric, hepatic, and renal functions contribute to malnutrition. The muscles grow small and weak. The blood becomes impoverished, and, there- fore, the face is often sallow or anaemic. The patient feels languid and lacks endurance. If dyspnoea is con- siderable, voluntar}' exercise may be inhibited. If anasarca is extensive, locomotion may be impossible. Chronic Valvular Disease. 243 A diagnosis must be based upon the local or cardiac symptoms. The existence of a cardiac murmur, of en- largement of the heart, and cardiac exhaustion are not sufficient to make certain the existence of a chronic valvular disease. I have seen pericarditis and peri- cardial calcification produce these symptoms, which gradually developed and lasted for several 3ears. I have known muscular degeneration to cause similar symptoms. It is true that under these circumstances tiie murmur is always S3^stolic, and is usually best heard Mt the heart's apex. To establish a diagnosis, we must find a cause for a chronic lesion, and we must find, on physical exnmination, the comhination of changes which are the result of valvular lesions. Aortic insufficiency will cause great dilatation of the left ventricle, and, if the lesion is chronic, hypertroph}' also; for the ventricle must hold not only its norniMl quantum of blood, but also what flows back into it through the patent valves during diastole. The other cardiac cavities may not be changed. These lesions cause the prsecordia to be prominent. The ap,ex-beat is readih' seen and felt. It is diffuse. It is to the left of the nipple, and usually a little lower than is normal. In the slipra-sternal notch pulsations can often be seen. The carotid pulse is usunlly visible, and sometimes a capillary pulse can be demonstrated beneath the finger- nails by the varying breadth of the color-zone with each heart-beat. Pulsation in the retinnl arteries can also sometimes be seen. Palpation confirms the diflfusion of the apex-beat, and demonstrates its powerful lifting character. This unusual forcefulness is due to hyper- troph}'. In many cases a diastolic fremitus can be felt at the base of the heart. Percussion demonstrates the cardiac enlargement. The left border of dullness will 244 Diaeasea of the Endocardium. extend to the left of the nipple, and sometimes even to the tinterioi" Jixillary line. The area of dullness usually begins a little higher than natural. Rarel}^ it extends a little to the right of the sternum, in the second inter- costal space; this is due to dilatation of the aorta. The right border of the heart remains unchanged, except in rare cases, when it is found farther to the right than is natural, and a substernal beating and accentuation of the pulmonar^^ second sound indicate a dilatation and 113'per- tropli}' of the right ventricle. The cause of these changes is usually obscure. It maybe due to stretching the mitral orifice, and consequent insufficienc}- of the mitral valves. A diastolic murmur characterizes aortic insutlicienc}'. It is generall}' best heard about the centre of the ster- num. This Is because the murmur is produced not at the aortic valves or in the aorta, but in the upper part of the left ventricle, where the blood from the auricle and the blood flowing back from the aorta commingle and produce the eddies which cause the murmur. Often the second aortic sound is obliterated hy the murmur, but not always. If some of the aortic leaflets can un- fold naturall}' the}' may produce the second sound. In other cases a second sound ma}' be transmitted from the pulmonar}' arterj^ The murmur is usually heard oyer the pulmonary artery, but not so loud and clear as farther to the right. At the apex there usually is no murmur, and both first and second sounds are normal. Occasionally^, a diastolic murmur is faintly heard there, and more rarel}' a systolic one. The latter is not always significant of aortic stenosis. Wlien it exists a satisfac- torj^ explanation of its causation is difficult. It maybe due to irregular contraction of tiie heart-muscles. In the carotid a systolic murmur is often heard. It Chronic Valvular Disease. 245 is sometimes propagated from the valve ; sometimes it is due to irregular vibrations of the vessels, which arise from their excessive tension ; or, it is of heemic origin. At times the signs of aortic insufficiency' disappear. This may be due to the stretching of one valvular cur- tain so that the valvular leakage is stopped, or vegeta- tions ma}' grow so that the}^ can help to close the orifice. Occasionall}^, an insufficienc}' is gradually con- verted into a stenosis. - The pulse is usually fall and tense. The arter}' fills and empties quickly. This is best demonstrated b}' a sphygmographic tracing in which the ascending and de- scending lines of the pulse-wave form an acute angle. The rapid emptj'ing of the artery is due to the fact that it both empties forward into the cai)illaries and back- ward into the ventricle. On the descending line the diastolic notch is usually shallow, and approaches the respirator}'' line. In the carotid s3^stolic thrills can sometimes be felt. If there is stenosis of the aortic orifice the blood within the ventricle is under unusual pressure. This causes a slight or moderate stretching, or dilating of the ventricle. But to force the blood through the narrow opening the heart must work hard, and there- fore hypertrophies. The aorta fills slowly. The auri- cles and right ventricle ma}' remain unchanged. The enlaro-ement of the left never attains the i2*reat size that it does when there is aortic insufficiency, as it is not dilated by an unusual quantity of blood. The prjiecordia is prominent in chests that are plastic. The apex-beat is usually visible, and is generally strong and lifting when felt; but, in some cases, it is unusually M'eak, and can scarcely be perceived. This is, at least in part, due to the absence of recoil, as the aorta is slowly 246 Diseases of the Endocardium. tilled, and, therefore, straightened less than is normal. The apex is depressed and disi)kiced to the left. Palpa- tion often reveals a thrill in the second intercostal space adjacent to the sternum. B\' percussion the area of car- diac dullness is found to be moderatelj' increased to the left, and rarely to the right. Auscultation demonstrates a systolic murmur which is loudest in the second right intercostal space, adjacent to the sternum. Usually, it can be heard elsewhere, over the heart, and mn}' even obscure the other heart-sounds. It is occasionally heard extensively over the che.st and in the back. It can be traced along the aorta, and heard almost always in the carotids. Usuallj', the second heart-sound is obscured over the aorta and carotids, and often over the pul- monarv artery. Generally, it can be heard at the apex. Except over the aorta the normal cardiac sounds ma}^ be heard, but oftenest the murmur is transmitted somewhat to all parts of the heart. The pulse is often slow and, as compared with the apex-beat, is retarded. The pulse is characteristically liard and small. The artery fills and empties slowly. This latter fact is best demonstrated b}' a sphvgmogram, in which the lines are seen to ascend and descend grad- ually and to form a round-topped wave. When the mitral valves are affected, changes take place in the heart much more extensivel}' than when the aortic valves are the locus of disease. If the mitral valves are insufficient, blood will flow into the left auricle, as usual, by the pulmonary veins, and in the usual amount, but it will also flow in from the left ven- tricle. Necessarily the auricle must dilate, in order to hold this abnormal quantity of blood. Moreover, as the left auricle contains an unusual amount of blood, the ventricle also must dilate to hold it when it is expelled Chronic Valvular Disease. 247 from the auricle. The overfilling and stretching of the auricle increases the blood-pi'essure within it, and also in the pulmonar^^ veins. If the mitral leakage is con- siderable, congestion of the pulmonary capillaries results, and increased blood-pressure is transmitted through them into the pulmonarj^ arter}'. A heightened blood- pressure in the pulmonary artery leads to slight or moderate dilatation of the right ventricle, and often to ver^' consideral)le hj^^ertrophy of it. The leakage at the mitral orifice must be compensated by right ven- tricular hypertrophy, for the weak walls of the auricle are capable of very little hj^pertroph}^, and certainly not of enough to compensate for the results of the usual mitral lesions. Very moderate hj-pertrophy of the left ventricle is produced by the necessity of propelling a somewhat larger amount of blood than is normal. From these anatomical changes one can reason to most of the phj^sical signs that are characteristic of the lesion. The praecordia is usually prominent. The apex- beat may be normally located, but generally is immedi- atelj^ beneath the left nipple or to the left of it. The beat is diffuse. The end of the sternum is often raised at each systole. This is significant of hypertrophy of the right ventricle. In the epigastric region throbbing is almost uniformly visible. Occasionally, it can be seen to the right of the lower part of the sternum. This generally happens when the right ventricle is much dilated. Rarely, a systolic impulse has been seen over the pulmonar}^ arterj^ It occurs when that vessel is distended and lies against the chest-wall. Over the pulmonary vessel a sharp impulse can sometimes be felt, which is synchronous with the closure of the pulmonary semilunars. At the apex a S3'stolic thrill is of frequent occurrence. Occasionall}', it can be felt only when the 248 Diseases of the Endocardium. patient leans forward or to the left, or after hurried movements have been made. The area of cardiac dull- ness is broader than normal. It is often extended to the left, but alwa3's noticeabl}' and sometimes greatlj' to the right. It usually extends to the right of the right sternal border. Auscultation reveals a s3'stolic murmur which is loudest at the apex. It can sometimes be heard all over the heart. In the rare cases in which the appendix of the left auricle is distended and wrapped around the base of the pulmonary vessel, it ma}^ be heard loudest over that vessel ; that is, in the second left intercostal space. It can usually be traced to the left of the apex, into the axillarv region, and sometimes to the back. It is least frequentlj- plainl}^ heard over the aorta ; that is, in the right second intercostal space. A S3'stolic sound is also often audible, and is synchronous with the murmur. It m^y be transmitted from the tricuspids or produced by the ventricular contractions. Over the pulmonary vessel an accentuated or sharply clicking sound is produced b3' increased pressure in the pulmo- nar3^ vessels and b3^ hypertroph3' of the right ventricle. The radial pulse is not characteristic, but is especiall3' apt to be irregular if there is imperfect compensation. The sph3'gmogram is not peculiar, though it usually demonstrates a low arterial pressure. Mitral insufRcienc3' occurs more frequentl3' than an3' other chronic valvular lesion. It is very often com- bined with mitral stenosis, the phN'sical signs of which are wanting. Compensation may be quite perfect, but ^•arel3' is as perfect as it may be when the aortic valves are affected. Recoveries have been reported. I have m3'self observed cases in which mitral S3^stolic murmurs and dilatation of tlie right heart completel3' disappeared Chronic Valvular Disease, 249 that bad originated in an attack of acute articular rheumatism. But the patients had become anaemic during their rheumatic attack, and I did not feel confi- dent that the murmur was the result of a valvular lesion, for in anaemia and fever dilatation of the right ventricle and systolic apical murmurs ma}' exist. A diagnosis of a mitral lesion is sometimes difficult. An accentuation of the second pulmonary sound is confirma- tor}' of a valvular lesion, as is also a wide distribution of the murmur, especially to the left of the heart. If there is uncomplicated stenosis of the mitral valves^ less extensive changes are usually wrought than by insufficienc}'. Because of the obstruction to the outflowing current from the left auricle, blood-pressure within it is increased. This dilates the auricle some- what. The increased pressure is, however, transmitted througli the pulmonary vessels to the right ventricle, which also dilates, and, in order to compensate for the mitral obstruction, hypertrophies. Tlie left ventricle does not hypertroph}', and may even diminish in size, because the blood within it is under low pressure, and may even be diminished in amount, because of tlie mitral obstruction. The praecordia is usuall}- prominent in those whose ribs and cartilages are pliable. Dilatation and hyper- trophy of the right ventricle, as in mitral insufl^iciency, produce a diff'use cardiac impulse, which is visible be- neath the sternum or lifting it, and sometimes in the intercostal spaces to the right of it. The apex-beat is seen to the left of the left nipple when the right ven- tricle is much enlarged. A fremitus, or thrill, can often be felt at the apex. It is presystolic, or, rarelj^ diastolic. It is usuall}' con- fined to the apex. Often it is best, or only, felt with the 11* 250 Diseases of the Endocardium. patient reclining upon his left side or leaning forward, or when pli3sical exertion or mental excitement quickens and makes forceful the heart's movements. A diastolic impulse may be felt over the pulmonary arterj', in the second left intercostal space, as in mitral insufficiencj'. Percussion will demonstrate a right-sided enlargement of the heart. The shape of the area of dullness is sim- ilar to that in mitral insufficienc3\ Murmurs may be wanting, but usuallj^ a pres3^stolic, or, rarel}', a diastolic, one is heard at the apex. The murmur is often heard less plainlj' at the end of the sternum, and is least likel}^ to be heard over the aorta. The heart-sounds over the aorta are often feeble. The second sound over the pul- monar}' is accentuated. At the apex the first sound is clearlj' heard, the second is sometimes absent. Earel}', a re-duplicated diastolic sound is heard over the aorta and pulmonar}^ artery. This is due to the low blood- tension in the former and high tension in the latter, which causes the valves in the two vessels to close at different times. Systolic murmurs raav be heard over the carotids and subclavian. The pulse is usuall}' small and soft ; it may be irregular, and often is fast. A mitral stenosis is rare, except as it is combined with insufficienc}'. It ma}' graduall}' develop out of the latter by the growth of verrucosities or b^^ hardening of the valves. The prognosis is less favorable than in mitral insufficiency. Pulmonary insufficiency and stenosis repeat upon the right side of the heart what aortic insufficienc}- and stenosis cause on the left. As these lesions are oftenest congenital, prsecordial prominence is usually produced in the infant's pliable thoracic wall. The impulse is seen and felt to be diffuse, and especiallj^ is it demon- strable at the end of the sternum. Thrills are often Chronic Valvnlar Disease. 251 felt. If there is insufficiency, they will be diastolic, and will be felt best, or exclusivel3% in the second left inter- costal space. If there is stenosis, the}' will be systolic, and felt best in the same place, but nia}^ be diffused over the entire henrt. Percussion demonstrates a right-sided enlargement of the heart. Auscultation reveals mur- murs, which are best heard over the pulmonary artery-, but may be transmitted toward the end of the sternum. If there is insufficiency, the murmur is rarel}^ heard at the apex, but maj- be if there is stenosis. Tiie diastolic sound ma}' be absent over the pulmonary artery or feeble ; at the other valvular orifices the sounds may be normal. If there is insufficiency, a S3'stolic, as well as diastolic, murmur is sometimes heard in the second left intercostal space, which is due to irregular vascular vibrations, because of excessive tension, not necessarily to a complicating stenosis. Unfortunatel}^, accidental murmurs often simulate pulmonar}' stenosis. They do not generally produce a fremitus, and are less likel}' to be accompanied by an}' considerable change in the right ventricle. Steiiosis usually causes cyanosis. Lesions of the tricuspid valves are rare, and when they occur are usually congenital, though they may be secondary to mitral lesions. Stenosis is so rare that it is of no clinical importance. Its symptoms can be theoretically constructed with ease. Tricuspid insuffi- ciency is not uncommonly due to dilatation* of the right auriculo-ventricular orifice, though the valves remain normal. This is likely to occur when the right ventricle dilates greatly. Cardiac dullness is increased to the right in this case. A systolic murmur is heard over tlie tricuspids. I have observed a case in which this mur- mur was so loud that it obscured all other cardi:>c sounds, although it was produced by relative insuffi- 252 Diseases of the Endocardium. cienc}'. It disappeared under treatment, and the primary' mitral lesion was revealed. Systolic sounds may be heard over the jugular and cervical veins, and, if the venous valves afe insufficient, murmurs may be heard. A venous pulse is especially characteristic of tricuspid insufficienc3\ It ma}' be seen and felt. It is oftenest detected in the jugular veins and liver; less frequently, in the legs and other distant vessels. The pulsations are not evident, even though there is tricuspid insuffi- cienc}-, unless the venous valves are incompetent from dilatation of the vessels. The venous pulse is due to stasis in the vessels and the transmission of the pulse from the heart. Rarel}', both the auricular and ventric- ular contractions produce a pulse, but usually it is the latter onlv that does. When the tricuspids are insuffi- cient the right auricle is distended with blood, dilates, and li3^pertrophies ; the right ventricle dilates a little. The increased tension in the auricle is transmitted to the venae cavse and veins. The jugular pulse can often be felt, as well as seen. It can be best distinguished from a pulsation of the underlying arterj' by compress- ing the vein in the middle, when it will collapse below the point of compression if there is not a true venous pulse; if there is, it will continue to be seen and felt. A venous pulse is ver}- rarel}'' produced when there is hypertroph}^ of the right ventricle and no tricuspid insufficienG3^ Hepatic pulsation is best demonstrated by placing the hands over the liver, in front and behind, when the}' can be felt to separate with each impulse of the heart. The liver often becomes enormously dis- tended by this passive congestion. There is low press- ure in the pulmonary arter\-. 'IMiis tends to diminish or prevent pulmonary congestion and consequent dyspncea; therefore, the liver may be enormously enlarged when Chronic Valvular Disease. 253 there is relative tricuspid insufficienc)^ and a primary mitral lesion, though there is very little dyspnoea. A combination of valvular lesions occurs very often. They frequentl}' hasten cardiac failure and rarely so counteract one another as to retard it. Stenosis and in- sufficiency may co-exist at the same valve, or two valves ma}^ be simultaneously involved. Combined lesions may be said to be the rule, but are least likely to occur when the arterial orifices are involved. Thouoh combined lesions are so common, they usually cannot be diagnosed during life, for one or the other will so f;ir predominate that the clinical picture will be of a simple lesion. Sometimes the symptoms of a secondary lesion in a combination will supplant the primar3\ As, for instance, in the following cases : In the first the heart beat tumultuously. There was a loud s^^stolic murmur plain-ly audible at the end of the sternum and along its right border. It could be heard feebl}' elsew^here. No other murmur was audible. The heart w^as considerably enlarged to the right, but not to the left. A diagnosis was made of tricuspid insufficiency^ probably due to dilatation of the right ventricle, which, in turn, was caused b}^ t\ mitral lesion and probably by stenosis. Two days later, when the heart had been slowed and some- w^hat contracted by digitalis, the murmur fust heard was gone, but at the apex a low presystolic murmur was au- dible. In another case, when the first examination was made, tlie heart was beating reguhirly, but rapidly. A loud diastolic aortic murmur was heard, and a low sys- tolic one was suspected, but not plainl3' audible. Some days later, when the heart was benting slowl}-, the dias- tolic murmur was almost gone, but the systolic one was plain. In this case there was evidently a combined in- sufficiency and stenosis at the aortic orifice, and the 254 Diaeaaes of the Endocardium. murmurs were chiinged in character by the rapidity of the blood-stream. Such a combination as this last may retard tlie heart's dilatation and muscular weakness ; for the stenosis will prevent a reflux of so large a quantity of blood into the ventricle during diastole as might otherwise take place, and so retards or prevents great ventricular dilatation. During systole the effect of the insufficiency is lessened b}' the stenosis. Occasionally, the character of the murmurs at different orifices ma}' enal)le one to diagnose combined lesions, or if both a S3'stolic and diastolic murmur exist we can generall}' conclude that there is a combination of lesions. An ex- ception to this general statement must be made, since systolic murmurs may be produced b}- irregular vascular vibrations and ma}' be accidental. Prognosis. — In general, it ma}- be said that chronic valve-lesions are unlavorable to long life. If compensa- tion is good, life will not be shortened. Sudden death does not often result from them. Simple aortic lesions are least likely to precipitate the symptoms of heart fatigue or exhaustion. If, because of one's social po- sition or occupation, it is possible to avoid all exhaust- ing exertion and still to so live as to preserve generai health and vigor, the chances of a long life are good. Unfavorable symptoms are: dyspnoea, i)alpitati()n, in- creasing dilatation of the heart, weakness of the apex- beat, oedema, bronchitis, or other intercurrent disease. Even when oedema is considerable, and arythmia and feeble pulsation characterize the heart's action, it is often possil)le,by persevering treatment, to remove these symptoms, and by a careful regulation of habits of life to maintain for years sufficient cardiac strength. Treatment. — We cannot modify the valvidar lesion by medicinal treatment, but, l)y strengthening the heart Chronic Valvular Disease. 255 and b}' removing nil impediments to the circulation, com- pensation wvAy be established. Ph3'sical fatigue must be avoided, and in cases in which compensation is lack- ing any exertion must be avoided. There are many pa- tients who do not exhibit signs of weak heart except after sudden or violent exertion. Such individuals must be especially careful not to overdo. Indigestion and constipation impede the circulation and help to fatigue the heart. The}' must be corrected or prevented. Changes of climate and habits of life, which will con- tribute to one's general vigor, must be encouraged. So much exercise as can be taken without exciting the heart is useful, but in many cases all active exertion is contra-indicated. Under such circumstances, gentle, passive exercise — massage — may be resorted to with good results, as it helps to maintain a better peripheral circulation. When flagging of the heart is evidenced by persisting rapidity of the pulse, and, perhaps, aryth- mia, digitalis, strophanthus, and their congeners, must be used to strengthen and slow it. They need not ])e given so often, or in their stead caffeine, strj^chnia, and other bitters may be used, if the heart is onh' accel- erated by exercise or general movements. Iron is usually indicated, as in other cases of heart-fatigue and weakness. The treatment, in a word, must be the same as has been described for these conditions (page 222). Complications such as oedema and bronchitis must be met as in other cases of weak heart. When passive congestion causes them, heart tonics like digitalis will often relieve them perfectly. At other times the usual treatment for such complications (see page 225) is also needed, DISEASES OF CARDIAC INNERVATION. CHAPTER XXVIII. Tachycardia, or Nervous Palpitation. Symptoms. — By tachj^carcUa is meant a rapid or forceful beating of the heart, wh'ch is subjectively recognizable, and is not due to organic heart disease. The heart may beat rapidly and forcefull}' \Yithout being subjectively recognizable, but does not then constitute tachycardia. This often occurs in cases of chronic valvular disease. Tachycardia, when violent, is accom- panied b}^ other varying symptoms. Attacks of nervous palpitation ma}^ last onl}" a few minutes, a few hours, or even for several days. Between the attacks are inter- vals of varying length of normal cardiac action. Sometimes premonitoiy S3^mptoms give warning of an attack. These vary greatly in character in in- dividual cases. The^' ma}^ consist in a feeling of terror or apprehensiveness, or the heart will apparently stop. Dyspnoea, slight syncope, vertigo, cold sweat, or head- ache foretell an attack in others. Often the paroxysms occur without premonition. The attack is characterized by rapid throbbing of the heart and a diffuse and lifting apex-beat. The pulsations are felt b}^ the sufferer and ma3' increase the anxiety, fear, vertigo, or deepen the syncope. In many cases the heart is also irregular. The first sound of the heart, especially at the apex, may be metallic in quality or murmur-like. The changed rapidity of the blood's tlow or the abnormal muscular contractions are ac- (256) Tachijcardia^ or Nervous Palpitation. 257 countable tor these peculiarities. At the apex the diastolic sound is often feeble or almost inaudible. This is probably due to the imperfect filling of the aorta and pulmonar}' artery by each of the quickly-repeated cardiac contractions. Very i-arely, tlie heart-beats are audible at a little distance from the patient. Usuall}', the carotids throb Yiolentl3', and in them a systolic murmur aud thrill can frequently be heard and felt. 'V\\Q radial artery is generallj' full, hard, and quick; rarely, it is small and soft. Two hundred or more beats per minute may be made. D\'spnoea on exertion generally exists while there is i)alpitation, and sometimes it is experienced even when the sufferer is quiet. It leads him often to seek an upright position, for it is increased b}' recumbence. Speech may become jerky because of the throbbing against the lungs. Epigastric pain is sometimes complained of. The face often becomes flushed and moist, and rarely is pale or cold. Tempo- rarih', there may be a slight rise of temperature. Frequenth', dizziness and faintness are felt. Attacks commonly terminate suddenl}^, but palpita- tion ma}' lessen slowly In many of the cases in which tach3'cardia frequently recurs there is constantly a quicker beating than is natural, which occasional!}' in- creases and produces tlie subjective symptoms that have been described. Attacks often subside with eructation of gases from the stomach or with vomiting or defecation. Tachycardia can be readily distinguished from endo- cardial disease by the absence of a persistent murmur and evidence of changes in the size of the heart's cavi- ties. It is more difilcult to distinguish between it and affections of the heart-muscle. It can only be done by carefully studying the history of tlie case and the excit- ing causes of the palpitation. 258 Diseases of Cardiac Innervation. It is impossible to designate tlie part of the nervous system that is chiefly involved in each case. The ner- vous disturbance may originate in the brain from hfiem- orrhage, tumor, softening, etc., or much oftener from jo}^ fright, or violent mental emotions. I have frequently seen quite persistent attacks excited by fright. In one woman severe attacks re^curred almost dailj' for two years, which originated from excitement produced by lightning that struck near her. Another similar case was excited by witnessing a distressing and fatal railway accident. Causes. — It may be caused by compression of the pneumogastric or sympathetic nerves, by tumors, or by other lesions. Futile attempts have been made to clin- ically recognize cases due to paralj'sis of the heart's inhibiting nerves and those due to irritation of the excito-motors. Exhaustion of the nervous system, as b}^ mental overwork, excessive vener}', loss of blood, excessive lactation, will produce tach3'cardia. These same condi- tions predispose to it, as do also anaemia, convalescence from severe disease, or other conditions of general en- feeblement. It is especiall3' apt to occur in those who are hysterical and those with a gout}' diathesis. Reflex attacks are common ; indigestion, constipa- tion, uterine, renal, and hepatic colic nre frequent excitors of them. The excessive use of tea, coffee, and tobacco is one of the commonest causes. Attacks mtiy occur in childhood, as well as in adult life, and may occur in either sex. Treatment. — Treatment mnst var}- with the cause of tach3'cardia in individual cases. If predisposing condi- tions or causes exist, they must be corrected or removed. Anaemia may have to be treated, or the nervous system Tachycardia^ or Nervous Palpitation. 259 rested, £ind the whole body nourished in order to remove tlie nervous excitability, which provokes palpitation. Hysterical palpitation is often difficult to prevent. If fright or some other emotion excited it the avoidance of a repetition of the emotion and mental diversion (such as may be effected by change of scene and sur- roundings, or of work, or mode of life) will often produce the best results. A class of cases which closely resemble hysteria, though there may be in them no other hys- terical manifestations, are those in which tachycardia recurs often, and at times is quite persistent, without discoverable exciting or predisposing cause. They are often helped by the same changes that aid the hystericnl. In both relief can sometimes be promptly obtained by means peculiar to each individual. For instance, one person may be able to stop the- parox3'sms by swallow- ing bits of ice; another by hot drinks, another by strong- coffee, another by drawing a long breath and holding it, another b}' reclining upon the back, another by pressure upon the abdomen. These various and idiosyncratic modes of relief maj- change from time to time in the same case. The use of large amounts of strong tea and tobncco should be forbidden in all cases of palpitation, for the}^ may increase the disposition to the affection, and often are exciting causes of it. It may be necessary to empty the stomach by emet- ics when gastric fermentation reflexly excites palpitation. Persistent treatment of the gastric disease will remove the cardiac affection in such cases. If the origin of the reflex irritation is in the uterus or other organ it will require especial treatment. When tachycardia arises from destruction of nerve- tissue by a structural disease of the central or peripheral 260 Diseases of Cardiac Innervation. cardiac nervous meclianism, no hope of permanent relief can be expected. Frequently, an ice-bag placed over the heart will check palpitation. A sinapism, similarl}' placed, often acts with equal efflcac}'. Of drugs, morphine oftenest gives relief. It must be given in moderate, but not somniferous, doses : a sixteenth, an eighth, or a sixth of a grain is usualh' efficient. Chloral, bromides, ether, chloroform, lu'oscyamns, and belladonna are also used with good results. In the hysterical cases bromides and valerian are verj^ useful. In anaemic and weak persons strjxhnia, ergot, and iron are oftenest beneficial. Digitalis ma}' be tried, but frequently proves inefficient. It is most useful in the cases for which str3'chnia and iron are indicated, and with them should be used persistently for a long time. The constant electric current has been applied to the neck over the pneumogastric and to the S3'mpathetic with varying results, which have notj'et been so analyzed that we can deduce indications for it. SECTION 111, Diseases of the Kidneys. (261) FUNCTIONAL IN A CTIVITY OF THE KIDNEYS. CHAPTER XXIX. IJRiEMIA. Natni^e. — Uraemia is secondniy to various diseases, but cliiefl}' to renal disorders which diminish the ex- cretion of nitrogenous waste. In its most character- istic form, the onset and course of uraemia is acute, but obscure and variable symptoms may precede or presage an acute attack and characterize its chronic form. The symptoms are of nervous origin. Then- precise cause is unknown. It was early su})posed that the retention of urea provoked them ; but both experi- ment and clinical observations demonstrated that the quantity of retained urea was not proportioned to the severity of attacks of uraemia, and that even when con- siderable quantities of it were introduced into the blood the S3anptoms were not always produced. An excess of carbonate of ammonia in the blood, cerebral anaemia, and oedema are other explanations that are equallj^ un- tenable. More recentl}' kreatinin and kreatin have been thought to be the poisons which produce uraemia. There is little doubt but that some product_ot* tissue-metamor- phosis is the cause. It is not known whether the sub- stance is produced b}^ normal tissue-changes and accu- mulates in the blood when the kidneys cease to perform their function properly, or whether it results only from pathological tissue-changes. Cholemia and diabetic coma resemble uraemia, and may have a similar origin. (263) 264 Functional Inactivity of the Kidneys. Cannes. — Untmia occurs when urea-produciDg sub- stances are retained in the blood, or when the}' are tbrraed in excess. It usuall\' occurs when the urine is much diminished in amount, or, at least, when the nitrog- enous elements of the urine are diminished. Mechani- cal suppression of the urine maj' cause it. Uraemia rarely occurs when diuresis is profuse. Ammoniacal decomposition of the urine in the bladder or pelvis of the kidney, especiall}' if it is not freely voided, and is, therefore, absorbed, will cause uraemia or symptoms resembling it, that are sometimes called ammonsemia. Of kidne}' diseases, chronic interstitial nephritis is oftenest productive of uraemia. Acute nephritis is next most likelj' to cause it, and chronic parenchymatous nephritis is least likely to. It oftener complicates scar- latinal than diphtheritic nephritis. It is rarely asso- ciated with waxy kidne}' or passive congestion, but often with the renal disorders that accompan}' preg- nanc3% Symptoms. — The variable and numerous sj-mptoms which often precede acute uraemia are called prodromata, or are coUectivel}' named chronic uraemia. Headache is one of the commonest of these. It is usually most severe in the morning, and is often occipital. It ma}', however, occur at other times, and may be variously located. Gastric disturbances are also common, but are not peculiar. Anorexia onl}^ ma}' occur in one case, nausea and vomiting in another, flatulent indigestion in a third, or all these symptoms successively in others. These symptoms must be looked upo.n with suspicion when they occur in the course of a nephritis. A case under my own observation during this winter illustrated their importance. A young man suffered from chronic parenchymatous nephritis, and had repeated attacks of Uraemia, 265 anorexia and vomiting, which lasted for days. There was no apparent cause for them. They were regarded uraemic symptoms, and were promptly relieved by dia- phoretics and diuretics. Unfortunately, he at last refused to submit to sweating, and the gastric symptoms culminated in acute uraemia. Diarrhoea is also a fre- quent prodromal symptom. Occasionally, intense pru- ritus suggests a uraemic state. In other cases, or alter- nating with these symptoms, asthma may occur. The d3'spnoeic paroxysms resemble perfectly those of asthma of a different origin. (See page 3.) As in a case now under my observation, asthma often alternates with gastric symptoms. Occasionally, insomnia is a promi- nent and distressing symptom of uraemia. Blindness may develop suddenly, last for a few days, and as sud- denly disappear. Its cause is unknown. Deafness or buzzing or ringing in the ears may occur, either coinci- dently or independently^ Numbness of the skin and formication are other variable premonitor}' S3'mptoms. Delirium or an apmirent intoxication may also occur in chronic nraemia./Several times I have observed, during the few hours just preceding an acute attack, hyperses- thesia and pain in the skin resembling a cutaneous rheumatism. In one case there-JYas, for moi-e than two weeks prior to the acute and fatal attack, persistent, and at times almost unbearable, shifting pain in the extremities. The symptoms of acute uraemia are definite in char- acter and easily recognizable. The^^ consist in convul- sions and coma. Coma occurs almost invariably, and is usually accompanied b}- convulsions, but it ma}' occur without them. It generally begins as apathy, which deepens into somnolence, and finally into complete unconsciousness. These attacks may graduall}^, within 12 M 266 Functional Inactivity of the Kidneys. a few hours, pass off, or may last for days. The patient generall^^ breathes loucll}^, at times, if not continuously. Respiration, also, is often irregular, or it may be of the type known as Cheyne-Stokes. Death may occur b}^ a gradual deepening of the coma, but usually results from convulsions, in the course of which respiration ceases. In other cases convulsions occur suddenly, and unconsciousness only lasts during them. The}- then resemble epileptic seizures. Sometimes twitchings of the muscles are limited to a small group oi* to one* side of the body. The attacks may occur at intervals of days or weeks, but usually recur frequentlj'. When severe, they may repeat themselves every ten or twenty minutes, or even oftener. Usuall}', coma exists between ^the paroxysms. If the disease take a favorable course, convulsions will occur at longer intervals, or will finally' cease ; or, if a fatal course, they increase in frequency, severity, and duration. When chronic nephritis dis- poses a patient to uraemia, he will usuall}^ suffer from the chronic form of the maladj^ even if he recoveiC^rom , the acut^,-WDuring convulsions the bodily temperature is oftenelevated, but ma}- be even subnormal. The pulse is usually quick, soft, and small. It often becomes irregular. Just before an acute attack it is sometimes abnormally slow. During ursemic attacks the pupils are usuall3' normal or large. The sweat and sputa of uriemic patients often exhale a urinous odor. Urea has been ■found in them, and sometimes crj^stallizes on tlie skin or in the hair of the head or face. The urine is usually diminished just prior to and during an attacli, and in- creases when it subsides. In these rarer cases in which ^ it increases before the attacks, its solid constituents \ diminish greatly. During prolonged coma there is "^nerally incontinence of urine and faeces. Uraemia. 267 Diagnosis. — A diagnosis of acute uraemia is usually easily made directly from the assemblage of character- istic symptoms. It must sometimes be differentiated from other diseases, and especially from epilepsj', apo- plexy, and alcoholism. The convulsive attacks are ver}' like those of epilepsy. The convulsive movements are seldom unilateral, as the}^ usually are in epilepsy. In the latter disease the historj' of prior attacks, the ""occurrence of an initial cry, and the absence of albumen ""are distinctive symptoms. Epileptics become deeplj^ "Somnolent after their attacks, but not truly comatose. — H3"sterical convulsions will seldom be mistaken for ^^urpemic, because the sufferer rarely- becomes trul}^ un- — conscious ; the convulsive movements are oftener irregu- lar, affect a single extremity at a time, or, when general, usually cause opisthotonos. Commonly after an attack a large amount of non-albuminous, limpid urine is -Voided. Cerebral apoplexy is sometimes accompanied " by convulsions. They are associated with paralysis. In epileptic and h3'sterical convulsions there is rarel3' a rise in temperature, which often occurs in uraemia. The coma of uraemia is differentiated from apoplex}' by coincident parah'sis in the latter ; from opium poisoning, by its normal temperature and the contracted pupil. It is distinguished with more difficulty from alcoholism, as the two conditions are occasionally asso- ciated. A history of alcoholism, the odor of liquor in the breath, and no rise of temperature, are indicative of alcoholic coma. Treatment. — The symptoms of chronic uraemia always indicate that the elimination of nitrogenous matter b}^ the normal channels must be stimulated. In all cases in which uraemia threatens, or ma\' possibly occur, a diminution in the quantity- of urine, and especiall}- if 268 Functional Inactivity of the Kidneys. its specific gravit}' is low, must be regarded witli appre- liension. Tlie kidne3S must at once be stimulated to greater activity. Rest is essential, in order that the amount of mus- cular waste may be lessened. An abundance of fresh air is also needful, for it insures as good an oxidation of the blood as is possible, and therefore as perfect meta- bolism of the tissues as is possible. A prescribed diet is also of great importance. Albuminous or richly nitrog- enous foods are contra-indicated, for they will increase the danoer of surchargino- the blood with the class of ingredients which produce uraemia. When it is neces- sar^' to exercise the utmost caution to avoid uriemia, a patient maj", for a few days, be fed onl}' water-gruels made of barle^'-meal or arrowroot. Such a diet is not sufficiently nutritious to be maintained long. In three or four days other forinaceous articles must be emploj'ed, such as rice, potatoes, and turnips. When the uraemic symptoms disappear, milk and milk-gruels may be ad- ministered. A complete mixed diet should be resumed very gradually, and with much caution. No specific remedy is known by which the ursemic poison can be counteracted. Purdy (" Bright's Disease and Kidne}'' Affections ") recommends, as almost a specific in chronic cases, the subcnrbonate of iron. It should be given in doses of 1 to 2 grammes (20 to 30 grains) every two to four hours. It is said to rapidly relieve headache, nausea, and other s^^mptoms. My own experiments with the drug have afforded conflicting results. The mode of action of this remed3' cannot be explained. Copious draughts of pure water are also helpful, as they will dilute the blood, thus making it somewhat less toxic, and the}' will joromote more copious excretions Urcemia. 269 from the various organs of elimination. The water should be as free from mineral products in solution as possible, that its dissolving powers mny be as great as possible. The salicylates and benzoates have also been fre- quently used. They unite with uric acid, and make it more soluble and, therefore, more easily eliminated. It has not been proven, however, tliat the}' make other im- perfectly oxidized products of tissue-change more sol- uble. Their utility in uraemia is, therefore, a 2^f"io?'i, doubtful, and it has not been established by their trial. They are mildly diaphoretic, and in this way will do good. In my hands the salic^date of ammonium is most certain to produce diaphoresis, and will produce it more copiously than any other of this class of remedies. It is, therefore, to be preferred in uraemia. In chronic cases it can be best administered in a hot drink, such as hot lemonade. The patient should at the same time be well covered with clothing, that sweating may be encouraged. In both acute and chronic cases reliance must chiefly be placed upon drugs that promote elimination from the skin, the intestines, and the kidneys. Jaborandi, or, better, its active principle, pilocarpine, may be admin- istered to produce sweating. Pilocarpine will provoke copious diaphoresis ver}' quickh' if it is administered subcutaneousl}' in doses of 6 to 8 milligrammes (| to yV grain). These drugs, although so efticacious as dia- phoretics, are contra-indicated in individual cases in which the heart's action is feeble, for they enfeeble it still more. Occasionally, their administration has been known to precipitate pulmonary oedema. It is safer to rel}' upon hot-air baths to provoke sweating. Air which is heated by a lamp can be readily conducted under bed- 270 Functional Inactivity of the Kidneys. clothes by ii bent stove-pipe. The patient, reclining upon w bed, should be thickly covered with bhmkets. The desired effect will be attained most promptly and most perfectl}' if a hot drink is administered when the hot-air bath is begun. Sweating may be advantageousl}" provoked dail}', or even oftener in extreme cases. I have seen patients who were comatose, and occasionall}^ convulsed, bronght to a state of consciousness by this means. In two fatal cases life was prolonged for several da3's and periods of consciousness were established, though permanent consciousness could not be restored. If a patient is very oedematous and is suffering from chronic unemia sweating must be resorted to with care, for it has been known to provoke acute uraemia. This is due to the sudden re-absorption by the blood of oedematous fluid which held in solution ursemic poison. The re-absorption was provoked by the elimination of the blood's water through the sweat-glands. Under such circumstances only moderate sweating should be produced, or the oedematous fluid should be first with- drawn through incisions at the ankles. (See page 293.) While elimination of the uraemic poison can be most certainl}' and most rapidly and perfectly' accomplished b}^ the skin, it can be helped b\' catharsis and diuresis. The cathartics which will accom[)lish the most good produce copious liquid stools. If frequentl}" employed, they ma}^ provoke a catarrhal inflammtition of the bowels or cause great weakness. They are best employed occasional!}' as an adjuvant to diaphoresis, and in per- sons who are fairl}^ robust. Salts may be administered in a concentrated solution with excellent effect. For instance, if 30 grammes (1 ounce) of Rochelle salts or magnesia sulpliate, dissolved in 60 cubic centimetres (2 ounces') of water, is administered when a patient first Uraemia. 2T1 awakens after a night's sleep, and if no more water or fluids are drunk for some time, several ver}- copious liquid passages will be i)roduced. Elaterium is deserv- edly a favorite liydragogue cathartic. It \\\\.\y be given in doses of 1 centigramme {^ grain). The compound extract of colocjMith may be used, in doses of from 2 decigrammes to 1 gramme (3 to 15 grains). Croton-oil is also efficacious in its usual dose of 1 minim. Diuresis sliould always be attempted, but disappoint- ment often results from the attempt. In mild chronic cases sufficient elimination can generally be thus accom- plished to relieve the S3'mptoms, but in cases of greater intensit}' diuretics do not suffice. They are frequentlj' useful when, hy diaphoresis or catharsis, the symptoms have been removed, and it is desired to steadily maintain a moderate increase of elimination of the ur?emic poison, that it may not again accumulate in toxic quantities. The diuretics oftenest used are digitalis, strophanthus, acetate and citrate of potassium, ammonium, or lithium. These are often well given in combination. They must be adapted to individual cases, for they ma}- be contra- indicated in certain renal diseases, as will be explainied later. Digitalis and stroplianthus produce diuresis chiefly by suppl3'ing to the kidney more blood under higher pressure, so that filtration of the blood's water is accelerated. If the blood is cj^anotic because of the feeble action of the heart, and therefore the renal as well as all other tissues are acting imperfectly on account of insufficient nourishment, digitalis will help diuresis by strengthening the heart, and thus promoting a better general circulation. Oxygenation, tissue-nutrition, and action nre. therefore, improved. Potassium, acetate, citrate, and carbonate increase the fluid of the urine, but also, to a marked extent, the 272 Functional Inactivity of the Kidneys. elimination of nric ucid and extractives like kreatin and kreatinin. The citrate of potassinm can be administered in the most agreeable form. Two cnbic centimetres (a ^ drachm) of it and the carbonate can be mixed with a small glass of lemonade and drunk while effervescing. The acetate is eqnall}^ efficacious, but not so agreeable to take. The value of water as a diuretic must not be for- gotten. It can be administered freely in all ursemic cases. Life can sometimes be saved by subduing nrsemic convulsions by complete anaesthesia with chloroform, ether, chloral, or morphia. Many cases end fatall}- be- cause the convulsions stop respiration, or impede and weaken the circulation. By preventing the convulsions such a result may be avoided, and time ma}' be gained in which by diaphoresis and catharsis the ur?emic poison can be eliminated. It is usually best to check the con- vulsion b}' inhalations of chloroform, ether, or by hypo- dermatics of morphia. After convulsive movements cease, and before new ones are excited, a large dose of chloral, 2 grammes (30 grains), should be administered to prevent their recurrence. If this is successfully ac- complished, as the effect of the chloral subsides a smaller dose must be given, and the drug repeated in successiveh' smaller doses until the ura?mic poison is eliminated and its re-nccumulation prevented. Opiates retard the elimination of nitrogenous waste, and, there- fore, in renal diseases, cannot be steadilj' used with safet3^ But the}' can be used temporarily to subdue convulsions when diaphoretics, cathartics, and diuretics are simultaneoush' emplo3'ed. Individual cases may require the use of cardiac stimulants, such as ammonia or camphor; or tonics, such as digitalis. Other com[)lications in particular cases may also require special treatment. Ursemia. 273 Prognosis. — Ursemia is a dangerous condition. Chronic uriiemia is usually readil}" amenable to treat- ment. It is to be feared, as it indicates the possibility of an acute attack. Acute ursemia is very fatal. Braun asserts that 30 per cent, of cases of puerperal convulsions are fatal. Urj\?mia which accompanies acute nephritis is less frequently fatal than that whicli accompanies chronic renal inflammation. The immediate prognosis of uraimic coma without convulsions is more favorable than with them, for there is more opportunity of effect- ing an elimination of the ursemic poison. But such coma oftenest occurs in the most chronic form of renal disease, and, therefore, the ultimate prognosis is not good. 12* DISEASES OF RENAL CIRCULATION. CHAPTER XXX. Passive Congestion of the Kidneys. Cause. — This lesion of the kidiie}' nia}' be produced whenever the normiil balance between venous and arte- rial blood is so disturbed that the veins are overfilled. Such a disturbance results from cardiac disease. It is often est associated with chronic A^alvular disease, but may be with degeneration or other disease of the heart's wall or of the pericardium, wdiicli makes the organ weak. Passive congestion of the kidiievs ma}^ also be the re- sult of obstruction to the venous circulation in the lungs, or between the kidneys and heart. Of lung dis- eases, emph^'sema, chronic bronchitis, interstitial pneu- monia, and more rareh^ phthisis and chronic pleurnl dis- eases may produce passive renal congestion. Cirrhosis, or tumors of the liver, may cause sufficient obstruction to the venous current from other abdominal organs to the heart to produce an engorgement of the kidneys. Much more rarely abdominal tumors and the pregnant womb compress the inferior vena cava, or veins from the kidneys to it, and cause renal congestion. Throm- bosis of the renal veins or vena cava is a very rare cause of the lesion. Anatomy. — The anatomical changes in the kidney, when it is passivel}^ engorged, vary somewhat with the rapidity of their development. As usually observed, the kidne}' is enlarged, especiall3' by congestion of the cortex. If the couirestion develop very slowly the organ may (274) Passive Congestion of the Kidneys. 275 be little or not at all swollen, and, if it is rapidly devel- oped to a considerable degree, it may be greatly en- larged. The color is characteristically dark brown or purplish. The stellate veins are very plainly visible be- cause distended. Whenever the congestion is consid- erable, haemorrhages, usually minute, are observable ; but if the lesion develop very slowly the organ will not be so dark, and no h{-emorrhages will be discovera- ble. If it is very chronic the kidne}'- becomes paler, smnller, (irmer, the surface roughened, and the capsule adherent in places. Ordinarilj^ the kidnej'S are firm, elastic, smooth, and the capsule can be readilj^ stripped from the cortex. When a section is made through the organs, the cut surftice is characteristically purplish in color, but the glomeruli can be seen with unusual distinctness, as red dots which are arranged in rows. The medulla has a striated appearance, which is plainest where congestion is the deepest. The striation is due to the venous distension. In tire more chronic cases, when the kidney's surface is paler, the cut surface is also. Under the microscope the veins and capillaries are seen to be stretched b}- the blood-cells. Often small haemorrhages into the glomeruli or tubules can be found, or the site of former haemorrhages can be identified by the brownish pigment-granules that may be seen in the tubules, or epithelial or connective-tissue cells. More rarely black melanin cnsts are observable, which have been formed of the modified blood-pigment. The glomeruli are sometimes a little enlarged. In very chronic cases, when the kidneys have contracted, patches of fibrous .tissue can be found here and there, especiall}^ just beneath and usually adherent to the cnpsules. In these areas the glomeruli are often contracted, fibrous, 276 Diseases of Renal Circulation. or homogeneous and h3'tiline. The tubules are obliter- uted or com[)ressed. The epithelial cells ma}^ appear nearly normal, but the^' are often in places, and sometimes extensively, large and granular, or contain fat-droplets, or are partly disintegrated. When enlarged they will nearly fill the tubules. In the latter hyaline casts are occasionall}' observable, or a few red corpuscles, and, less frequently, epithelial cells. The walls of the blood-vessels are usuall}' thickened. Tlie fibrous patches are probabl}^ due to interstitial inflammation which arises about the blood-vessels or spreads from venous and arterial walls. It causes com- pression of the tubules and consequent atrophj' and destruction of them. Symptoms. — The symptoms of passive engorgement of the kidne^^s are superimposed upon, and associated with, those of a primary disease. For instance, the usual features of mitral-valve disease of the heart may be accompanied with the evidences of renal engorge- ment. In such cases usuall}' the pulse and heart are weak, and there is general oedema and dyspnoea. The characteristic signs of the lesion must be sought for in the urine. General I3' the heart-lesion or other primary atfection and its symptoms exist for weeks, or months, or even years, before the kidneys are serioush^ involved. The urine is usuall}' diminished in amount. It is strongly acid in reaction. Its si)ecific gravity is from 1025 to 1035. It is deeper colored than is normal. A relative and sometimes an absolute excess of urates and uric acid must be expected. Uric-acid crystals are frequently deposited in the urine when it stands. If, as is usual, a urinar}' sediment exist, it is composed of these chemical substances. Often a few blood-cor- Passive Congestion of the Kidneys. 27 T puscles can be found in it, and a few ii^aline or, rarely, granular or blood casts. Epithelial cells from the kid- ney are also rarelj^ observed. Oil droplets or granules must not be expected. The urine usually contains a small amount of albumen, — a fifth of 1 per cent, or less. Uriemic symptoms are rare, for the comparativel}' normal condition of the renal epithelium enables it to eliminiite nitro2,enous matters. Renal conoestion is frequentl}' transformed into nephritis, for it predisposes to inflammation of the organ. Death commonly- results from the primary disease, and is not produced by the renal lesion. The renal complication is significant of the gravity of the primary trouble. Renal engorgement ma}' occur repeatedly in the same case during a period of several years, or, after developing, may persist. The duration of the diseases which produce this renal lesion is uncertain and very variable. The diseases are alwaj's, sooner or later, fatal. Whenever a cause for passive engorgement of viscera exists, the urine should be examined. If there is evi- dence of a heart lesion and engorgement of the lungs or liver, and the urine presents the featnres just de- scribed, a direct and positive diagnosis can be made. It must be differentiated from acute and chronic nephritis. (See page 288.) Treatment. — Passive renal congestion requires no peculiar treatment. Its cause must be removed. If, as is oftenest the case, a feeble heart canse it, the latter must be relieved of unnecessar}' work b}- bodily rest. In some cases, after a few daj^s spent in Led, the symp- toms of renal congestion will disappear. Strophanthus, digitalis, and similar heart tonics are indicated. The treatment must be that which we have already described as essential for weak heart. (See pages 206, 222.) 278 Diseases of Renal Circulation. Nephritis must be guarded against. Cold, damp, and changeable weather should be avoided. The bod^- should be protected from sudden atmospheric changes by clothing it with woolen under-garments. If the quantit}' of albumen in the urine is for this disease considerable and the quantitv^ of urine small, foods, beverages, and drugs that irritate the kidne3S should be avoided. Under such circumstances, albu- mens should be taken sparingl}- ; alcoholics should not be used ; and cubebs, turpentine, and other drugs that are renal Irritants are contra-indicated. As a rule, the diet should be generous and highly nutritious, in order to maintain as good cardiac vigor and general health as is possible. RENAL INFLAMMATIONS. CHAPTER XXXI. Acute Nephritis. Causes. — Acute nephritis is especially apt to com- plicate the eruptive fevers, infectious and septic dis- eases. Of these maladies, scarlet fever and diphtheria are oftenest accompanied hy nephritis. It has been supposed that in such cases micro-organisms which caused the primary ailment were also the cause of the nephritis. This has not been proven. It seems quite as probable that irritating chemicals which are formed under conditions of malnutrition that accompany the primaiT disease are the cause of the renal inflammation. It must be acknowledged that mau}^ observers have found micro-organisms of different kinds in diseased kidnej'S. Their presence where the inflammation was most intense suggests their causative relation to -it. But more numerous observations are needed to confirm the scattered ones already made. The kidneys appear capable of eliminating some micro-organisms in small numbers, but if they are required to attempt the elimi- nation of many the interstitial tissues are found filled with them, or obstructing clumps of them are seen in the tubules. If such collections take place in man, as may occur in animals experimented upon, they maj'- sometimes provoke an inflammation. Such substances as cantharides, turpentine, salicylic and carbolic acids, when ingested, are eliminated hy the kidneys, and will cause nephritis when absorbed into the blood in large (279) 280 Renal Inflammationit. amounts. Cases of acute nephritis, the result of tur- })entine poisoning, are not very uncommon. I have observed them oftenest during the summer, in painters using turpentine in close and overheated rooms. Ex- tensive burns of the skin have produced acute nephritis, but in what wa}- is undecided. It ma}- be that the kidneys are overworked, as they attempt to vicariouslj- perform the eliminative functions of the skin, or that the\' are irritated b3' substances which should be elimi- nated through the skin, and which, because of injurv to the latter, accumulate in the blood. The causation of many cases cannot be satisfactorily explained. The}' often occur after sudden exposure to cold and dampness. Acute nephritis, therefore, is observed most frequenth' in seasons and in climates that ai-e character- ized by changeabilit}" of temperature, with moisture. It has been claimed tliat at times nephritis is epidemic. The cases that have been collated are, however, too few to prove its epidemicity. Acute nephritis may occur at an}^ age, but is oftenest observed in early adult life. Men are oftener subject to it than women, if we do not take into consideration puerperal nephritis. Albuminuria and other urinar}" changes indicative of renal disease are of common occurrence in the course of continued fevers like typhoid. The evidence of renal trouble is usuall}^ slight, reaches'its maximum when the fever is most severe, and subsides with it. These are cases of acute degeneration or cloud}' swelling, ratiier than of true nephritis. Occasional!}', some nephritis accompanies the degeneration. Anatomy. — The pathological chnnges characterizing acute nephritis, as might be expected from the varying etiology, are not uniform. An affected kidney may re- Acute Nephritis. ' 281 main normal in size, but usually it is more or less enlarged. In some cases it is greatl}' swollen, cliiefly because of an interstitial serous exndnte. The surface of the kidney is smooth, and the capsule will strip from the cortex with ease. The color of the surface varies from red to pearl}- yellow, or is mottled red and 3ellow. When the organs are enlarged the incrensed size is due to thickening of the cortex, for the pyrnniidal part of the organ remains unchanged in size. The red kidneys are usunlly of a dark hue. and so much congested tliat blood AY ill drip from their cut surface. The glomeruli are often prominent as red dots. The mottIe' occurs often and tends to become purulent. Pneumonia is an occasional complication and an es- pecially fatal one. Pleural and pericardial drops}^, as well as ascites, are accompaniments of general drops}^, and may be the immediate cause of death. Uraeraic asthma is another respiratory complication that is some- times observed. Appetite is usually much diminished or almost wanting*. Nausea and vomiting occur occasionally. At first they probably are of reflex origin, and due to renal congestion and irritation. Later, the}' may be uraemic symptoms. The bowels are usuall}^ constipated, but occasionall}' there is diarrhoea, which may be due to intestinal oedema or to a vicarious elimination of abnor- mal matters from the blood. Uraemia is especially- apt to occur in this disease. Transient uraemic amaurosis occurs occasionall>\ Retinal haemorrhage, nose-bleed, or other ha^morrhnges than haematuria are not common. Life is chiefly endangered b}- uraemia and various com- plications, such as pneumonia, pleuris}^, pericarditis, dropsy of the serous sacs within the thorax, or oedema of the lungs or of the glottis. Relapses may occur repeatedly after convalescence is apparently established. Li this way the course of individual cases ma}^ be much protracted. The duration of mild cases is from one to two weeks, but other cases may be protracted from four to twelve weeks. A small proportion of acute cases become chronic. Uraemia develops from failure to properlj- eliminate waste matter b}' the kidneys. It must be suspected whenever the urine is grently diminished in amount, and especially when the total nitrogenous waste for twenty- four hours is greatly lessened. These are signs of 288 Renal Injiammations. gravity. The iimount of albuinen voided is not signifi- cant of the severity' of the disease or its dangerousness. When improvement begins, the urine grows more abundant, hsematuria ceases, the albumen lessens, casts are less numerous, shorter, and more broken. If there has been much drops}', and if it is being absorbed during convalescence, the urine will become unusually copious, and its specific gravity ma}- Ije abnormall}' lowered. Diagnosis. — A diagnosis is usually not diflflcult, aiid may be made from a urinalysis. In mild cases there may be no signs of the disease, other than those that are discoverable in the urine. It ma}^ otherwise be wholly masked by a primary disease. But in some cases the general symptoms are quite as pronounced as the urinary ones. A direct diagnosis can be made positively when there is associated with the characteristic urinar}' changes general oedema, rapidly developed anaemia, and a history of sudden onset and of no previous attacks of a similar kind. Acute nephritis must sometimes be differentiated from chronic venous hyperiemia and acute exacerbations of chronic parenchymatous nephritis. From the former it can be distinguished by the larger amount of albumen and a greater number of red blood- cells in the urine, and b}' the development of cedema, which usuall}' is as quickl}' observed about the e3'elids as in the feet. When passive congestion of the kidne3's exists, there must also be one of its essential causes. When in the course of chronic parenchj-matous nephritis acute exacerbations occur, there are superimposed upon the symptoms of the chronic malad}' those of the acute. The urine ma}' be almost undistinguishable from that of acute nephritis. Usually, however, oil-drops and fatty epithelial cells or fatt}' casts are abundant. A Acute Nephritis. 289 diagnosis must, however, be chiefly based on the history of prior attacks of the same kind, or at least of oedema and other sym[)toms of ciironic nephritis. IVeatment. — Tlie indications for treatment are, first, to give the kidneys, as fiir as possible, a rest ; second, to limit congestion ; tliiid, to remove obstructions in the renal tubules; fourth, to guard against or mitigate com[)licMtions or sequela^. To meet the first indications, those who suffer from acute nephritis should remain in bed, for exercise will increase nitrogenous wMste, and therefore its elimina- tion, whicli means reunl work. They should live upon a non-nitrogenous diet. Tliis last requirement must be rigidly adhered to only in the most severe cases, or when uraemia most threatens. But in all cases the diet must be so modified that it will contain only a small amount of nitrogenous matter. Water-gruels made of arrowroot or barley-meal may^atford a modicum of nour- ishment for two or three da3'S, until the height of the attack is passed. Fine wheat-flour, rice, potatoes, and turnips are additional foods that contain very small amounts of nitrogen or vegetable albumen. Apples and grapes are also somewhnt nutritious, and may be grate- ful as condiments. These latter nrticles can be em- ployed in the less severe cases, or after improvement is established. It is best to administer nourishment in moderate amounts and often, so that it will not be too long undigested, as otherwise it may irritate the ali- mentar}^ canal b}' feeding gastric or intestinal fermentn- tion. In the periods of greatest severity, or when uraemia most threatens, even milk sIkmiUI not be used, but during convalescence it is particularl}' wholesome, for it is a diuretic, very nutritious, and easily digested. It may with advantage, at this time, constitute the chief 13 N 290 Renal Inflammations. element of diet. When a normal nitrogenous elimina- tion b3' the kidneys has been re-established, other albu- minous food can be tried with caution. The fact that gastric juice and probabl}' other digestive secretions are lessened in nephritis makes it necessar\' to guard against filling the stomach with food, but enough must be given to maintain nutrition. A patient should remain in bed until oedema has wholly disappeared and urea is voided in normal quanti- ties. Exercise should not be continued if by it the elimination of urine and nitrogenous matter is lessened. To limit or lessen renal congestion, leeching and cup- ping are often emplo3'ed. Although unnecessar3' in tlie milder cases, the}' are especiallj' indicated in those in which there is the most congestion ; those in which the urine is scant, very blood}' ; and in which there is backache. Cathartics are also em])loyed to deplete the rennl vessels. Aperients, such as Rochelle salts and magnesia sulphate, are the best. In acute nephritis, and especially at first, catharsis must not be carried so far as to in- crease a patient's weakness. It is usuall}' sufficient to maintain the stools soft, and defecation should take place oidy two or three times dail}^ A small glass of Hunyadi Janos water, a little of liquid citrate of mngnesia or Carlsbad salts, taken in the morning, will usually ac- complish this. If the urine is suddenly almost suppressed, a few liquid stools will often relieve the congestion which causes it, and should be provoked unhesitatingi}-. it goes without saying that drugs n,nd beverages, which in themselves are renal irritnnts, must not be used. Among these are all alcoholic beverages, tea and coffee, terebinthins, copaiba, and squills. The obstructions in the renal tubules are composed Acute A^ejyhritis. 291 of cells, Ihe gnimilai' detritus which results from their dissolution, niul hyaline sulisttuice. Much of this can be^ washed from the tubules b}' a more copious flow of urine. The hyaline substance has been shown by l*urdy to be soluble in alkaline solutions; therefore, to make the tubules patent, the urine must be ke[)t alkaline ;uid must be Jibunchint. Digitalis will increase the general blood-pressure, and therefore the pressure in the glomerular tufts, b}'' increasing the vigor of the heart's action and by con- tracting the arterioles. This will cause a more rapid filtration of water from the blood into the urinary chan- nels in cases of acute nephritis. The quantity of urine is decidedly increased by this drug. Its action is pref- erable to that of strophanthus, for the latter, in thera- peutic doses, does not contract the arterioles. The action of digitalis upon the arterioles is, moreover, valuable, since it lessens hiemorrhage. In order to render the urine alkaline, such drugs as the citrate and acetate of potash and liquor ammonii acetatis may be used. The first are the most ngrecMble to tnke, and may be employed in doses of from 2 to 4 grammes (^ to 1 di'achm), repeated every two to four hours, as may be needed to keep the urine alkaline. Liquor ammonii acetatis may be given in doses of from 2 to 4 cubic centimetres (i to 1 drachm). It is certiunly true that, under the influence of these drugs, casts usually become less numerous and less perfect in outline. The diuretics just mentioned are useful not only to keep the urinary tubules oi)en, but also to promote a more perfect excretion of urinary solids. Digitalis heli)S by making a more copious flow of urine; the potassium salts aid b^- increasing the oxidation wMthin the system and by stimulating the renal epithelium to 292 Renal Inflammations. greater fiiiietional activit};. Therefore, larger amounts of urea are voided, which means that man^- imperfectly oxidized products of metabolishi become perfectly oxidized, and are in a condition for eas}' elimination. This will greatl}' lessen the danger of uraemia. Although lactose and glucose are often very efficacious diuretics in cardiac affections, the}' are not so in renal diseases. Indeed, in the latter diseases they sometimes produce no appreciable diuresis. Thej' probabl}' act upon the renal' epithelium, and, if it is not intact, tliey are inefficacious. In my own experience they liave proved moderately efficient in some mild cases of chronic nephritis, but almost useless in the acute disease. Unfortunateh', the epithelium is often so extensivel}' desquamated or dis- eased that these drugs are able to promote onl}' a very moderate increase of urine, urea, etc. We must depend, therefore, u[)on other channels to eliminnte the poisonous effete materials that ma}' be accumuhiting in the system. The skin will eliminate the largest amount of such matter; therefore, diaphoresis should be i)rovoked enrh in all cases in which the amount of urinary solids voided daily is much reduced. (See page 269.) It should be repeated for a few minutes daily, or every second or third day, according as the kidneys are able to do their work more or less w^ell. Dinphoresis must be resorted to with caution whenever there is much oedema, for, by pi'ovoking a sudden re-absor[)tion of oedematous fluids which contain uniemic i)oisons,an attack of unemia may be preci[)itated. It is safer first to remove the oedema by tapping or puncture. Dnistics are im[)ortant aids in preventing uraemia. They must be used with the cau- tions described on pnge 270. General oedema, if it is not great, can be made to disappear by diuretics, drastics, diaphoretics, or all Acute Nephritis. 293 combined. If it is great, the last group of drugs are the most efficacious, but, as has just been explained, must be used with caution. Sometimes ascites and pleural and pericardial effusions can be removed by the same means, but usually less prom[)tl3^ and less perreetl}^ The serous sacs, often, must be drained. Rapid drainage of the smaller ones is best accomplished b^' an aspirator, and of the larger by a trocar. If diuretics, and occa- sionall}' drastics, or, instead, a hot-air bath is given, refilling of the sacs can be prevented. If general oedema is great, and if ureemic symptoms are present or feared, it is best to withdraw the dropsical interstitial fluid through deep ankle incisions. These are made prefer- ably over the inner malleoli. They should be deep enough to incise all the tissues down to the j^eriosteum, and should be at least three-fourths of an inch long. After the incisions are made the patient should sit erect, or be placed in a semi-reclining posture, with the feet lowered as much as possible, that the fluids ma}' gravi- tate to them and flow freeh' from the wounds. In twenty-four hours all the interstititd dropsy can usually be removed from the bod}', and, by other means, it can l)e prevented from re-accumulating. During the period of recovery the greatest care must be taken to prevent exacerbations by a regulated diet, by rest, and by careful clothing, so that the skin's tem- perature will be kept equable. During convalescence it is often advisable to send patients from our raw and changeable winter and spring climate to a warmer and more equable one, such as can be found in Florida, Georgia, and Southwestern Texas. Iron, strychnia, and other bitter tonics are now most useful. The iron will cure the annemia, which is inci- dental to the disease, and it helps to prevent and 294 Renal Inflammations. counternct the degeneration of reniil epitlieliuni. Stiych- iiia is perha[)s tlie most powerful stiniuhint of nutrition that ue possess. Quinine and, to a less extent, other bitters, like gentian, act in the same way. So soon as the kidneys i)erf()rm their function fairly diuretics can be gradually omitted. Digitalis can usually be discontinued before the alkaline diuretics are, as they ma}' be longer needed to maintain the urine alkaline, the tubules free, and the elimination of nitrogenous matter abundant. The urine should be examined daily during the acute period of the disease, and particularly with reference to the amount of nitrogenous matter that is eliminated. During convalescence it need not be examined so often, but should be occasionally for some weeks, even after albumen has disappeared from it. So long as there is albuminuria exercise should be forbidden, altiiough, in a good climate and favorable seasons, carriage-riding may be permitted during convalescence, and the pntient may be moved from room to room, so thnt the mind may be kept buoyant by variety and change. Prognosis. — The prognosis of acute nei)hritis is gen- eralh' favorable, for almost all cnses recover. It is usually' considered less severe in later life than in early manhood or childhood. The danger to life is from uraemia and various complications. If the urine is very scant the case must be regarded as grave, because of the danger of unemia. If pneumonia or em[)yema develop, death is almost certain. Extensive dropsy increases the gravit}' of a case, es})eci!vlly if the pleural or peri- cardial sacs are involved. A small proi)()rtion of cases become chronic. If the acute nephritis is secondary', the character and gravity of the primary disease must modify or shape a prognosis. CHAPTER XXXII. Chronic Parenchymatous Nephritis. Causes. — Chronic parenchymatous nephritis often follows acute, but oftener it begins as a chronic disease. Scarlatina is a frequent cause of it. Ciironic sup- puration may produce chronic nephi'itis alone or com- bined with amyhjid infiltration. Malaria and S3'philis are two diseases out of which it often develops. The uric-acid diathesis, gout, and rheumatism are also causes. The constant use of alcohol, and especially of the stronger beverages, predisposes to the disease, and sometimes undoubtedly provokes it. Man}' cases arise without assignable cause. Exposure to wet and cold and change- able atmospheres is regarded by some as provocative of mnny of these cases. I must agree with Ralfe in believing that work upon damp and cold ground, or a residence in rooms that are damp and cold, is much oftener a cause. The disease occurs most frequentl}^ in males and during the first half of adult life. It is rare in childhood and of occasional occurrence in advanced life. Anatomy. — When the disease attains its fidl maturit}^ a lesion is developed that differs greatl}^ from that of its early period. These differing states may be described as its first and second stages. In the first stage the kidneys are much enlarged. They may be two or three times larger than natui'nl. The capsule is smooth, and can be readily stripped fi-om the kidnej^'s substance. When the organ is much en- larged it will gape through an incision in the capsule. The surface of the organ is usuall}^ mottled gra}^, or (295) 296 Renal Inflammations. often almost white and red. These colors ma}' exist in varying proportion. Many times the red areas are pale red. In numerons cases the kidney's surface is uni- formly white or yellow-white. When a section is made through the kidney the enlargement will be seen to be due to a broadening of the cortex. It is often twice its usual size. The cut surface of the cortex will be mottled or uniforml}' yellowish white, as is the surHice of the organ. The pyramids are red or, rarely, pale. Usuall}', there is a strong contrast of color between the cortex and pyramids. Tiie yellow color of the kidney is due to fatty degeneration. This is the most characteristic renal change in this disease. The microscope will re- veal the degeneration most clearl}'. The epithelium of the renal tubules is the focus of the degeneration. Its cells are often swollen, very granular, and contain numerous visible droplets of fat. When swollen the}' may nearl}'^ occlude a tubule. The}' frequently disinte- grate, and fill the tubules with a granular detritus tyid oil-droplets. When the cells are cast off they are usu- all}' replaced b}' new ones that are thin, and, therefore, enlarge the calibre of the tubules. These changes are most marked in the convoluted tubules, but are ob- servable, also, in the others, AVithin the tubules h^'aline casts are abundant, and granular matter, desquamated epithelium, occasionally leucocytes, and red blood-cor- puscles exicit in varying amounts. The glomeruli are usuall}' not changed in size, but sometimes tho}- are a little enlarged. Many of them are normal in apjiear- ance ; many of the others have thickened cnpsules. Tlie capsular epithelium proliferates and en uses the thicken- ing. Sometimes this thickened tissue becomes partly or wholly homogeneous or hyaline. Fatty degeneration is most common in these cells. The epithelium coyei'ing Chronic Parenchymatous Nephritis. 297 the capillary tuft is also thickened. Haemorrhages sometimes take place into the glomeruli, and also into the intertubular tissue. In the rare cases, which are called chronic hsemorrhagic nephritis, the>' are abundant and almost constant. The tuft of capillaries sometimes contracts or atrophies, and may, in part or wholly, be- come hyaline. The stroma of the kidney always con- tains a serous exudate, but in places, especially near the glomeruli and about interlobular veins, there are cellular exudates. Sometimes, in the cells of the interstitial tissue, droplets of fnt can be seen. In the second stage the kidney is not so large or, in the most marked cases, contracted. Its surfjice is gran- ular or rough, at least in spots, and sometimes gen- erall}'. It is mottled or uniforml}^ yellowish white. The capsule is adherent where the surface is contracted. The cut surface of the cortex exhibits an irregular out- line, and shows that it is a cortical contraction that causes the general renal contraction. Under the micro- scope the points of greatest contraction will be seen to be composed chiefly of connective tissue. The tubules are contracted, atrophied, and often obliterated. The glomeruli are small ; their capillary tufts are much con- tracted. The glomerular capsule is thick. Both tuft and capsule are often homogeneous and hyaline. Be- tween these areas of contraction are others that exhibit the lesions of the earlier stage. The contracted areas are usually near the surfnce of the kidney and in the interlobular districts. A desquamation of epithelium from the tubules, which then collapse and are obliterated, precedes the proliferation of connective tissue and dis- appearance of normal renal structure. The interstitial tissues now proliferate, and the exuded leucocytes help to produce new tissue, in the process of whose develop- 13* 298 Renal Infiammations. raent adhesions form with the renal capsules. The interstitial changes lead to compression of neighboring tubules and to interference with the capillar}' circula- tion. This in turn leads to more destruction of epithe- lium and an extension of the lesion of induration. Such changes occur onl}^ in the most chronic cases. Besides these characteristic renal lesions, oedema of the subcutaneous tissue and of the serous sacs is com- mon, and less frequently oedema of the lungs or glottis occurs. Cardiac hypertrophj- is common. It may be either unilateral or bilateral. Valvular lesions of the heart occur in about 25 per cent, of cases. It is quite evident, from the nature of these patho- loo^ical changes, that diuresis must be lessened in the first stage, but in the second it may be increased, be- cause of the interference with the circulation, and con- sequent increased arterial pressure which the cirrhosis produces. On account of the destruction of epithelium or interference with its function, there is a lessening of excretion of urinarj' solids in both stages. Thus, the same functional derangements that exist in acute ne- phritis are produced, but, because of the insidious and slow development of chronic nephritis, its clinical, as well as its pathological, picture differs greath' from that of acute nephritis. Symptoms. — Chronic nephritis ma^' develop from acute, and is especially apt to when scarlet fever is the primary cause of the nephritis. But its most charac- teristic type begins as a chronic affection. When it de- velops from the acute, red corpuscles graduallv disap- pear from the urine, but the albumen in it may increase. In varying amounts there are, also, casts, cells nnd their detritus, and oil-droplets either floating in the urine or imbedded in the casts and cells. (Edema persists, or, Chronic Parenchymatous Nephritis. 299 at times, disappears partly or wholh', to re-appear occasionalh\ When its onset is insidious the disease may be dis- covered by a chance urinalysis. The patient may com- phiin only of weakness, of anorexia, of asthma, or some symptom of chronic uraemia. Quite as often attention is attracted to the condition of the kidneys b}^ the de- velopment of oedema. The latter is oftenest first no- ticed in puffed eyelids in the morning, or swollen ankles at night. When the disease is chronic from its incep- tion, drops}' may not develop until it has been estab- lished for weeks or months. At first, it may flnctuate, disappear for a few days, to re-appear, or lessen, and again increase. When once developed, it rarely disap- pears entirely or for long. As a rule, in spite of tem- porary abatement by treatment, it will increase and dis- tend the subcntaneous tissue over the whole body. The abdominal cavity is generally filled, and sometimes the pleural or pericardial cavities are also. When oedema is great the scrotum is usually' distended and the skin of the penis much swollen and deformed. The legs will become so large that the tightly-stretched skin is glass- like in smoothness. Great stretching of the skin usually causes malnutrition, and eczema breaks out upon it. Occasionally, gangrene will occur, sloughs will form, and leave deep and ver}' sluggish ulcers. Not unfre- quentl}' from an eczematous surface upon the legs, and oftener from deep cutaneous ulcers, the serum will flow so rapidly as to drain the tissues of their fluid and cause a partial or complete disappearance of dropsy. Eczema may attack other parts of the body, but the legs and scrotum are its favorite sites. Ascites is often so great that it compresses the abdominal viscera and prevents hearty eating even when there is an appetite. It crowds 300 Renal Inflammations. the diaphragm upward, often displaces the heart and prevents a free expansion of the hmgs. Ascitic pa- tients are, therefore, short-winded. Tiie}' frequent!}' avoid the reclining posture, because the fluid gravitates against the diaphragm and makes respiration painfull}- short and labored. When the second stage of the dis- ease develops, the iucreased diuresis sometimes causes the drops}' to disappear. In rare cases of chronic parenchymatous ne[)hritis, dropsy does not develop; but it occurs more uniformly and more persistently in it than in an}' other form of renal disease. Its amount varies inversely as the quantity of urine varies. As in other forms of nephritis, the urine furnishes the most pathognomonic signs of the malady. In the first stage of this disease the urine is diminished in amount. This diminution may be moderate, or it may be to from 150 to 350 cubic centimetres (6 to 12 ounces) a day. It is usually dark colored and turbid. Its spe- cific gravity varies from 1020 to 1040 nnd is usually greater than is normal. Its reaction is acid. Albumen is abundant in it. Commonly, it amounts to about 1 per cent., but may be more than 5 per cent. If the disease develop insidiously, the amount of albumen is at first small and gradually increases. There is an abundant sediment in the urine. This contains urates; often a few red corpuscles from the blood ; granular and fatty epithelial cells, which are always present, and are at times very abundant ; casts and some granular matter, intermingled wnth which oil-drops caii generally be dis- covered. The casts nt first nre long, narrow, hyjiline, or granular; later, they nre shorter, broader, nnd more granulnr and fatty. Sometimes a few granuhir or f\itty epithelial cells will adhere to them. The presence of oil- droplets, or fatty cells or casts, is particularly charac- Chronic Parenchymatous Nephritis. 301 teristic of this form of nephritis. Red corpuscles from the blood are often absent in individual specimens, but may be ver}^ abundant when so-called acute exacerba- tions occur. Then the urine diminishes still more in amount, becomes red and cloudy, of high specific gravitj', and abundantl}' albuminous. It resembles verj' closely the urine of acute nephritis, but contains more oil and fatt}' matter. The urinary solids are alwaj's diminished in amount. Especially is urea diminished ; chlorides are less so, and phosphates and sulphates least. The percentage of urea in single saniples of urine is often increased, although the total eliminated in twenty-four hours is much dimin- ished. The amount of urea voided daily will vary. It may be normal for some days, and then ma}^ be dimin- ished. In the second stage of the disease, the quantity of urine voided daily is commonlj' normal, or more than normal. It is ligliter colored and clearer than in the earlier stage. Its specific- gravity will var}^ from 1010 to 1015. The quantity of albumen lessens, and the dail}' excretion of urea is still more diminished. These urinary changes are characteristic of contracted kidne}'. The formed elements in the urine are less abundant than in the early stage, but like them. In the first stage the pulse is usually small and soft. It ma}' be quicker than normal if the patient is feeble, excited, or hurried. Tiu' iieart is usually, at first, not hypertrophied or dilated. Later, one or both changes will occur in the left ventricle, and sometimes in both ventricles. If the kidney become hardened and contracted and the blood's circulation through it impeded, an hypertrophy of the left ventricle occurs, and usually moderate dilatation. But even when the 302 Renal Injiammations. kidney does not contract, if the patient grow feeble :ind oedema is considerable, some, and at times very great, dilatation of the ventricles takes phice withont hypertrophy. Sometimes hypertro[)hy of the left ven- tricle occurs in this disease without assignable cause, unless there are irritants in the blood that may provoke it. Hypertrophy of the right ventricle is i)robably due to failure on the part of the left to maintain an equilibrium between the arterial and venous circulation. This causes passive engorgement of the lungs, which must be overcome by the right ventricle. When the heart is dilated and feeble clots are liable to form in it, and may cause the various phenomena of cardiac thrombosis. The state of the blood in this disease [)redisposes to thrombosis. It contains a larger proportion of water and fibrin-makers than is normal ; a diminished number of corpuscles and albumen ; a somewhat increas"ed amount of fats and salts. The quantity of urea in it varies inversely with the power of the kidneys and skin to eliminate it. The anaemic condition of the blood sometimes produces cardiac murmurs. Accidental mur- murs rarely occur as the result of cardiac dilatation independenth' of the anaemia, and still more rarely the}' are due to interference with the action of the valves by thrombi formed on them or their muscular ])apill8B. In the second stage of the disease the pulse becomes liard. The physical signs of cardiac hypertrophy are demonstrable. If an enlargement of the heart cannot be shown to exist, an unusually forceful apex-beat, and often one displaced downward and to the left, and an accentuation of the second sound over the aorta are proof of it. Haemorrhages may occur from the nose and other mucous membranes. The state of the blood ap^ a cardiac hypertroi)hy will dispose to them. Albu- Chronic Parenchymatous Nep/i/ritis. 303 minuric retinitis (see pnge 321), while possible, is not common, und is especiall}- rare in the first stage of the disease. Tiie tempenitiire is normal, unless some com- plicating inflammation causes it to rise. The skin is usually dry and rough. Though it is pale, it has not the clear, white color that is often seen in acute nephritis. It is yellowish or parch- ment-like. This is especially true of the most chronic cases. A gradual but marked loss of strength and flesh takes place from the first. During periods of remission in the course of the disease some gain may occur, but such gains are only temporar}'. Emaciation is often masked by drops3^ It is very evident when the latter is removed. Loss of strength will, in time, confine a patient to the house and to the bed. Respiration will not be interfered with, except by cedemas, such as excessive ascites ; pleural, pulmonary, or lar3ngeal dropsy. Chronic unemia ma}' cause asthma. Lack of appetite is an early and usually persistent s^'mptom. Nausea and vomiting are sometimes due to indigestion, but often to uraemia. When oedema is great, a serous fluid is sometimes vomited, which is dropsical in origin. In such cases there is often a serous diarrhoea, which is also due to intestinal oedema. Rarely, intestinal ulceration complicates chronic nephri- tis. In many cases, although there is little appetite for food, there is no demonstrable failure to digest what is taken. If vomiting and nausea occur, unassociated with evidences of indigestion, the}' are usually due to uraemia. Recently, Biernacki has studied gastric digestion Avith care, in cases of Bright's disease. He finds free hydro- chloric acid in tlie stomach in diminished amount, and sometimes wholly absent ; pepsin apparently diminished, 304 Renal Inflammations. and lactic acid in only small qnantities. These changes occurred both with and withont symptoms of indigestion. A lack of energy and ambition is as evident, as a lack of muscular strength, even in the beginnings of the disease. Acute uraemia occurs less frequentlj' in chronic parenchymatous nephritis than in other renal inflammations. Mild chronic uraemia is not very un- common. If severe uraemia occur, it is usuall}^ when there are acute exacerbations of the nephritis, or toward the close of life. In the second stage uraemia is rela- tively frequent, but it is not so common as in interstitial nephritis. It is probable that several factors contribute to produce lunenitj^ to uraemia. The diminished appe- tite and disinclination for albuminous foods help to pre- *vent the formation of uraemic poisons. The slow waste of the tissues and disinclination for active exertion pre- vent the rapid formation of them from the living tissues. Much urea and presumabh' other effete and toxic matter is stored in the dropsical accumulations which are usualh' so abundant. The second stage of the disease is characterized by an incrensed flow of watery urine, by a disappearance of drops}', by a pulse of high tension, cardiac hyper- trophy, and b}^ relativel}^ frequent ura?mia. In the course of chronic parenchymatous nephritis, exacerbations often occur which closely resemble attacks of acute renal inflammation. The}' occur oftenest in those cases that w'ere at first acute, or in those that are sometimes denominated chronic ha^morrhngic ne- phritis. The latter jire characterized pathologicall}' by a mottling of the surface and interior of the cortex with red and vellow areas, and by numerous minute points of Ineinorrhage. Undoubtedly, exi)osure to cold and dampness often precipitates these attacks. Chronic Parenchymatous Nephritis. 305 The disease may last for months or even years. Re- covery is very rare. The longer it lasts, the less are the chances of recovery. Few cases exceed two years in their duration, unless renal contraction occurs. They may then be more protracted. A larger proportion do not exceed one year. Death ma}^ result from uraemia suddenly, from drops}' which disables one of the organs essential to life, or from complicating inllnmmations like pleurisy or pneumonia. Diagnosis. — A direct diagnosis is usually possible. It is based (1) upon the character of the urine, (2) npon the character of tlie anaemia,, (3) upon more or less con- stant and usuall}' considerable oedema, and (4) upon the chronicity of the disease. It must, sometimes, be dif- ferentiated from acute renal inflammation, from amyloid kidne}', and the second stage from interstitial nephri- tis. It is chiefly apt to be confounded with acute nephritis when so-called acute exacerbations occur, or when acute cases tend to become chronic. Acute ex- acerbations are distinguished from acute nephritis by the history of prior oedema, or of other symptoms of nephritis, and by the existence in the urine of fatty cells and casts, and often free oil-dro[)lets. Usually, the complexion is different. It is a purer white in the acute disease. If the kidney is am3'loid only, the urine may be undiminished in amount, or even increased, and will contain abundant albumen. The most significant symp- toms of lardaceous kidne}' are, besides the existence of a cause for the lesion, the co-existence of enlargement and hardening of the spleen and liver. When, as not unfre- quenth' happens, chronic nephritis and amj^loid infiltra- tion co-exist, a diagnosis of both lesions ma3M)e impossible. It is only necessary to distinguish chronic parenchyma- tous nephritis from interstitial when the former has 306 Renal Inflammations. reached its second stage. The urine may be very simi- lar from both these lesions, though usually from the former it is less abundant, more albuminous, and of higher specific gravity. In the cases of parench3^matous nephritis tliere is a histor3' of former oedema, which is rare in interstitial nephritis, except in the last stage. The diagnosis will, therefore, depend chiefly upon the history of the development of the disease. Treatment. — Whenever it is possible, the cause of chronic nephritis should be removed. This can be done by draining abscesses, by treating S3-philis or malaria, by discontinuing the use of alcohol, or other renal irritants. If the disease begin as acute nephritis, it must be treated as the latter should be : To maintain the per- meabilit3" of the uriniferous tubules the urine should be kept alkaline ; to prevent renal congestion and cardiac h3^pertr()ph3^, or to lessen oedema, the circulation should be equalized b3^ laxatives ; to lessen oedema, and es- pecially to prevent uneniia, hot-air baths and rest should be relied upon; to maintain nutrition, and to prompt the kidneys to greater activit3', a milk diet should be maintained ; eggs and meat should be forbidden. Such a course of treatment will usually- lead to marked im[)rove- ment, and often even to recover3\ During convalescence, patients must be carefull3^ guarded against relapse. Its possibility must be remembered even for a year or more, and it should be averted by proph3hictic measures similar to those that are necessar3^ in the course of the disease to avoid acute exacerbations. If the disease is chronic from the first, the indica- tions are: (1) to guard against acute exacerbations, (2) to prevent or limit fatt3^ degeneration, (3) to lessen the excretion of albumen when it is excessive, (4) to pre- Chronic Parenchymatous Nephritis. 307 vent ui'femia, and (5) to lessen oedema. If the second stage is reached, we may attempt to lessen (1) the inter- stitial hyperphisia which characterizes it, and (2) cardiac hypertro[)hy. Acute exacerbations can be best avoided by clothing those who have chronic nephritis in woolen or other underwear that will maintain an equable surface tem- perature for the bod3', or at least pi'event sudden sur- face changes. A residence in an equable climate is extremely desirable. Patients should especially avoid damp and cold climates, and houses that are damp or upon soil imperfectly drained. All substances that, by elimination through the kidneys, irritate them should be avoided. A milk diet is, in most cases, almost a specific, so favorably does it iuHuence the disease. The most characteristic feature of the lesion is fatty degenertition. A milk diet, or, at least, one easily digested and assimilated, is essential to i)revent this, by maintaining a healthful nutrition of the renal c'ells. Thorough oxygenation of the blood is just as necessar}^ for the maintenance of i)erfect tissue-change. Therefore, the rooms of the sick should be perfectly ventilated, and, if respiration is interfered witli, or uraemia evident or threatening, oxygen inhalations ma}' possibly help both to cleanse the blood and make metabolism more perfect. Of drugs, the most important is iron. It seems particu- larly to limit or prevent degeneration. Its preparations are so numerous that there is a wide field for choice. The prei)aratious which I oftenest use are the citrate, the potassio- tartrate, the subcarbonate, the iodide, and the tincture of the chloride. Occasionalh' a change should be made from one to another of these prepara- tions. If the anaemia does not promptl}^ disappear, or the evidences of disease lessen, courage should not be 308 Renal Injiammations. lost so long as the S3'mptoms do not become more grave, for changes are slowl}' wrought, in so chronic a trouble, and tlie remedies must be perseveringly used. Iron acts best when given witli strychnia, or quinia, or both. The}'- undoubtedly stimulate cells to greater nutritive activit3\ A capsule can be given, three or four times daily, that will contain these tonics and iron in combi- nation, or a solution of them may be administered. They should be given in varied forms, but almost coii- stanth', for mojiths. In this variet}^ of nephritis the loss of albumen is considerable, and ma}' contribute materiall}^ to cause weakness. Various drugs are used to lessen it. Some of these. I am convinced, accomplish the object, but I have not seen sufficient improvement produced in the general health of a patient, while they are used and the albumi- nuria is checked, to make me confident of their utilit\'. The drugs which can be most safel}^ and efficientl}' em- pl(i(3'ed to limit the excretion of albumen are: Tannate of sodium, which can be given in doses of from ^ to H grammes (5 to 20 grains), in water; tannic or gallic acid, in their usual doses ; or nitric acid, ergot, caffeine, or fuchsin. The last is given, in doses of from ^ to 2 decigrammes fl to 3 grains), in pills. I have already described full}' the methods b}- which uraemia is to be avoided and treated. I need now onlv outline the treatment most applicable to this form of nephritis. If oedema is considerable, a patient should remain in bed, or onl}- be moved to a lounge or another bed. If there is no, or ver\' little, oedema, moderate exercise may be permitted ; but it should never be ex- hausting or ver}^ long continued, for much exercise certainly increases the danger of uraemia. A prescribed diet is most important in the treatment Chronic Par^enchymatous Nephritis. 309 of this affection, for by a Ciireful reguhitioii of it the danger of unieniia can be greatly lessened. Milk is, for chronic [)arench\ matoiis nephritis, more than a food ; it is curative. Jnst how it produces its good elfects is not known. It is readily' digested and converted into very assimilable nutriment. It contains very little of waste or useless matter. It is also diuretic. These are quali- ties which adn[)t it especially to the disease. It contains a small amount of albumen, but not enough to be dangerous, unless the dtiily volume of urine is ver}' greatly reduced. Milk, as an exclusive food, contains an excess of fats. This is undou))tedly one reason why it is so perfect a food, although it contains so little albumen, for it is proven that less albumen is needed in proportion as fats and carbohydrates are taken in increased amounts. A strictly milk diet, long continued, lias often proved curative. Disgust for milk is fre- quently caused by restricting patients too quickly to a diet of it onl3'. Therefore, the regimen should be restricted somewhat gradually'. Meats, eggs, fish, cheese, and leguminous vegetables should be first omitted, and slowly the farinaceous foods can be withdrawn. A milk diet is best tolerated when the beverage is taken in moderate amounts ever}' two or three hours. It is also important that the stomach should not be overloaded, as indigestion, which is likely to result from it, usualh^ produces substances that irritM-te the kidneys in the process of their elimination, or help to make the blood toxic. If a patient can, he should adhere to a milk diet. Often, however, patients grow wearied of it. They can occasionally be allowed a little fruit, or a soup made of milk, flavored with some vegetable, like asparagus, pease, or tomatoes. Occasionall}', thin milk-gruels, apple-sauce and milk, or some other fruit and milk, can 310 Renal luHammations. be similar!}- employed to vniy the diet. Upon a strict!}' millc diet, a patient slioiiU! ptutalie of it at about seven and ten in the morning: one. four, seven, and ten in the afternoon and evening. If it is varied Ijy some of the articles just mentioned, they may l)e substituted at ten and four, or at seven in the morning and seven in the evening, wliile milk only should be tid^en at other times. But it is best to adhere as long as possibie, and in as many cases as possible, to a purel}^ milk diet. Often, if the regimen is varied for a few days, as 1 Inive suggested, a milk diet can l)e ngain adopted hy the patient without distaste. When millv is altogether distjisteful, and cannot be taken in quantities sufficient to mnintnin nutrition, ;i farinaceous and fruit diet must be adopted, but all a!l)uminous food should be excluded from it. As pease and Ijeans contain consideraljle amounts of nitrogenous matter, the}' should not l)e used. If milk is not taken freely, water should be. It helps to produce freer diu- resis. It dilutes toxic matter that may be in the blood. Distilled water or spring water that is as free of mineral matter as possible is the best, as it is able to dissolve more waste products, especially those imperfectly pre- pared for solution, and therefore most apt to accu- mulate in the system. The use of large amounts of water at springs, and the good results which accrue, have made many famous for the treatment of renal dis- eases. At least, a glassful of water should be taken at each meal-time, and one between meals and at bed-time. If patients cannot be kept on a milk diet, but must be allowed one that is more varied, still greater care must be exercised that the stomach be not overci'owded, or indigestion produced. Only so much as can be well digested and assimilated should be taken, and it should be washed into the blood with frequent drafts of water. Chronic Parenchymatous Nej)hriiis. 311 Diuretics may be relied upon to prevent iiri^^mia if the daily quantity of urine voided and of nitrogenous matter eliminated is lessened a little only. In more urgent cases they may be aided by occasional purges or b}^ sweatings. Diaphoresis, it must be remembered, should be provoked with care, or not at all, if oedema is great. To relieve dropsy reliance must again be placed upon diuretics, cathartics, and diaphoretics. If pleural, peri- cardial, or peritoneal drops^^ endanger life b}' compress- ing the lungs or the heart, it should be relieved b}' aspi- ration, or drainage through a trocar. If subcutaneous oedema is great, and it does not seem safe to remove it b}' diaphoresis, incisions at the ankle ma}- be made, and the whole may be withdrawn. When oedema is great the amount of urine voided daily is xery small, but often when the oedematous fluid is rapidly withdrawn through incisions it will increase almost to a normal quantity. Tlie kidneys renew their activit}^, and b}' careful treat- ment free diuresis can often be mainttiined for a long- time. Perfect drainage of the subcutaneous tissues is usually accomplished b}^ ankle incisions in twenty-four to fort3-eight hours. The incisions generally- heal in three or four days after the drainage ceases. The pro- cedure may be repeated several times without ill effects. The drainage of the tissues is less likel}^ to be complete if the anasarca has been of long standing, or if the dropsy has often re-appeared. The connective tissues in which the fluid accumulates gradually proliferate, and the intercommunication of lacunar spaces and lymphatic channels becomes less perfect. If the second stage of the disease is developing, mercurials and the iodides may be used to check the connective-tissue proliferations. I doubt the efficacy 312 Benal Inflammations. of these drugs in cases that have not a syphilitic origin, and even in the latter the}^ are not alwaj-s success- ful. They are both diuretic, and may aid patients b}^ virtue of that property.. The iodides lower arterial pressure b}' dilating the arterioles, and thus ma}^ delay cardiac hypertrophy', dilatation, and final exhaustion. The nitrites i)roduce prompter and greater arterial- re- laxation, and, therefore, are often resorted to in this stage of the disease to relieve the heart of overwork. (See pages 218, 228.) When the kidne}' contracts there is greater danger of ur?emia than in the earlier stage. It must be averted b}- the same means as in other cases. The danger most peculiar to this stage of the disease is cardiac exhaustion from overwork, and this must be prevented, if possible. Complications, such as pleurisj- , pneumonia, and en- docarditis, must be treated as the}^ would be under other circumstances. While many cases of chronic parenchy- matous nephritis are incurable, life can often be pro- longed for even manj^ 3'ears b}' careful treatment, which will prevent fatal complications. CHAPTER XXXIII. I NTERSTITIAL NEPHRITIS. Causes. — Interstitial nephritis, although it may occur in infancy or childhood, is extremely rare, except in the last third of life. Deaths from it are most frequent between the fortieth and sixtieth 3'ears, and especially between the fiftieth and sixtieth years. It is, however, so eminently a chronic affection that its beginning must be dated back from five to ten years, or longer. One form of contracted kidney is associated with general arterio-sclerosis, and is one of the lesions common to old age. Renal cirrhosis is three or four times commoner in men than in women. It undoubtedly occurs oftener among high livers than among those whose diet is sim- ple. The harm is probably done by the extractives and spices which are so abundant in game, in richl3'-dressed meats and soups, such as constitute a large part of the regimen of good livers. These substances, not easily metamorphosed in the blood or tissues, are irritants to the kidneys, b}^ which they must be eliminated. More- over, those who habitually live upon such foods are usually dyspeptics, and, therefore, are only able to pre- pare them imperfectly for assimilation. In most in- stances, such eaters do not drink freely of water, which, if taken copioush', might wash these substances rapidly from the system, and not leave them long enough in it to cause prolonged irritation. The beverages oftenest used by them are the alcoholics, which are undoubted renal irritants, and most certainl}^ dispose to fatty degenera- tion of the epithelium. Writers upon this subject almost unanimous!}' declare that the excessive use of 14 o (313^ 314 Bejial Inflammations. alcoholics is the commonest cause of cirrhotic kidney. Renal cirrhosis usually occurs in those who use these beverages steadil}', but moderateh'. The excessive use of alcoholic drinks leads often to acute or oftenest to chronic parenchymatous nephritis. The pathological statistics collated by Formad prove this. My own clinical observations confirm it. Gout and the uric-acid diathesis are often primarj* to renal cirrhosis. The slow elimination by the kidneys of irritating nitrogenous substances imperfectly pre- pared for conversion into urea and eliminable matter is the probable cause of the nephritis. Chronic plumbism occasionally produces renal cir- rhosis. Scarlet fever and malaria are rarel}^ primar}' to this form of nephritis. It is sometimes said that pro- longed mental depression disposes to this renal lesion. It is true that the mental and renal trouble often co-exist. But it is not demonstrated that there is a relation of cause and effect between them. Depressed mental states are common to dyspeptics, and also to those havino- uric-acid diathesis. It is more probable that the mental and renal state have a common cause than that one is the cause of the other. In manj', though not in a large number of cases. heredity is seemingl}' an etiological factor. Renal cir- rhosis is commonest in temperate climates. It rarel}' grows out of acute nephritis. If the latter almost sub- side, but persist as a small islet of chronic inflamma- tion, interstitial nephritis may be the result. It also grows out of chronic pyelitis, and through it, indirectly, out of chronic cystitis and urethritis. Anatomy. — Tiie renal cirrhosis which results from arterio-sclerosis is a lesion quite distinct from that which results from gout^ plumbism, high living, and Intei'stitial Nephritis. 315 other cuiises. When a renal arteriole is sclerosed and finally becomes nearlj- or quite impermeable, the glonier- iile or group of glomeruli to which it furnishes afferent vessels contracts. At first the capillary loops become shrunken, hyaline, and im[)ermeable. The glomerular epithelium is shed, and partl}^ or wholl>^ disappears. The capsule contracts around the small homogeneous mass which represents the former capillary tuft. The capsule sometimes is thickened, but often remains unchanged. Such glomeruli are frequently one-fourth to one-sixth their normal size, and are functionall}- use- less. When a glomerulus ceases to pour fluid down its uriniferous tubule the latter also contracts. It at first collapses, its epithelial cells then diminish in size. They often fill the contracted tubule. Sometimes a tubule will be converted into a cyst b3^ an obstructing plug of colloidal matter. There ma^' be no interstitial change, but usually small, abnormal islets of connective tissue are discernible about the sclerosed arteries. These minute changes cause an irregular contraction of the renal cortex and make the surface rouoh or s^ranular. The kidney does not become as tongh and hard as in cases of interstitial h3'perplasia. When there is true interstitial nephritis, the kidneys are imbedded in large amounts of fat. They are con- tracted, but not equally. The surface is rough and granular, reddish brown, or rarely grayish brown. Cysts, from the size of a pin-head to a bean, are common, both on the surface and in the renal substance. They are distended with a clear fluid. The kidney is firm and leather}' in consistence. The capsule is thick and firmly adherent to the renal substance at the points of depression on its surface. A section of the organ exhibits the same color as its surface. The granulations 316 Renal Inflammations. on the surface and the tissue beneath them are dark colored. The depressed areas may be grayish. The cortex has a very irregular width, and is often in places very narrow. It may be to the pyramids as one to five or as one to six. The p3'ramids are usually deepl}^ con- gested. The pelvis is often dilated, and sometimes inflamed. In the gouty kidne}^ gray, hard streaks can be seen and felt. These consist of deposits of urates in the interstitial tissue, the epithelium, or within the tubules. Under the microscope the thickening of the capsule is seen to be due to a connective-tissue hyperplasia, which is greatest at the points of dei)ression on the kid- ney's surface. At these points the cirrhotic renal tissue and new capsular tissue are confluent, and, therefore, united. The areas of cirrhosis are irregularly disposed in the cortical substance and, usually united to a greater or less extent, encircle more normnl territories. In the centre of the cirrhotic tissue renal structures cannot be seen. Fibrous tissue only composes it. Toward the periphery of these areas their mode of extension can be studied. The glomeruli are seen to be greatl}' con- tracted or in process of contraction. They may be not more than one-eighth of their normal dimensions. Their capsules are usually enormously thickened by concentric layers of fibrous tissue. The capillnries may have atrophied and disappeared, or may be represented ])y a small homogeneous, granular, or hyaline mass. No glomerular epithelium can be seen. Occasional!}', a greatl}' dilated and cystic glomerulus may be observed. The tubules are seen to be contracted, the epithelium lining them to be atrophying, or sometimes wholl}' dis- integrated. In the latter cise the tubule is outlined only bv its basement membrane. The tubules then be- Interstitial Nephritis, 317 come obliterated. As they contract and disnppear the tissue between them increases in amount. It is fibrous and abundant. Here and there a ^qw round cells and embryonic connective tissue cells can be seen. The tubules that are least affected are often unusuall}' tor- tuous. The}' look nearly normal in places, and else- where exhibit the changes which are seen in chronic parenchymatous nephritis. Such changes develop very gradually. The atroph}- of the tubules is partly due to disturbance of nutrition, caused hy the interstitial changes, and partly by the destruction of glomeruli. When tubules become obstructed in part of their course onl}^, they may expand and form cj^sts. Many arteri- oles, especialh' in the cirihotic areas, are made useless by endarteritis obliterans. Usually, the entire arterial wall is thickened, but its intima is especially so, and the calibre of the arteriole is, therefore, almost or quite obliterated. In other cases, the tunica adventitia and muscular coat are thickened bj^ the formation in them of masses of a waxy appearance. These changes also produce more or less vascular stenosis. Hsemorrhages into the kidney are not common. It is still a question whether the interstitial hyperplasia or the tubular atro- phy' is the primary lesion ; whether the interstitial changes cause the tubules to contract and disappear, or whether, because of the disappearnnce of the latter, the former undergoes a compensatory hypertrophy. Endarteritis obliterans and arterial sclerosis also often occur in other organs. Tlie left ventricle of the heart is hypertrophied and generally dilated. Some- times both ventricles are. Occasionally, points of fatty degeneration, or indurative degeneration, can be seen in the heart-muscle. In some cases, the endocardium is thickened in spots, or there ma}' be evidence of endar- 318 Renal Inflammations. teritis. There may also be thickening or evidence of inflammation of the pericardium, pleura, or peritoneum. The dura mater and arachnoid may also be thickened. Cerebral haemorrhages are common complications of the disease. PulmonarN' consumption occurs less fre- quently, but often. Gastric and intestinal catarrh are usual concomitants of the renal trouble. Symptoms. — Clinically, three stages of the disease are recognizable ; the first maj' be described as the state in which there is high arterial tension ^Yithout recogniza- ble cardiac liypertroph}' ; the second, one in which there is cardiac h3'pertrophy ; and third, one in which there is cardiac failure. Death ma}' occur, in either of these states, from intercurrent disease, uraemia, or cerebral haemorrhage. Life is often prolonged for many years after the disease is established. The malady may last for twenty or more years, and commonly does for from five to ten. It is extremel}^ important that this disease should be recognized earl}-, as the danger to life is much greater after the heart has lijqDertrophied ; and b}' careful treat- ment in its earl}' stage the advance to the later ones can be delayed. Unfortunately, the first stage is not always readily recognizable. The onset of renal cirrhosis is alwnys insidious. The ', usuall}-, sooner or later, communicate with the uriniferous tubules, and through them empt}' pus into the urine. If tlie ureters are ob- structed, as they may be in some cases of pyelitis, pus will not be voided from the bod}*. The pelvis of the kidney will then be converted into a distended sac of pus, which will enlarge by the destruction of the renal substance. In this wa}" ver}^ large abscesses ma}' be formed. Instead of finding an exit through the urinary channels, the pus verj^ rarel}' breaks into the peritoneal cavity, or, after adhesive peritonitis has bound the kidney and intestines together, into the intestines, or externally through the abdominal wall, or b}- burrowing into the pleura or lung. Symptoms. — Abscess of the kidne}- ma}' exist with- out producing characteristic sym})toms. This is most apt to occur in septicseniia. The symptoms, which are of diagno8tic value, are pyuria, usually renal pain, hectic Suppurative Nephritis. 335 fever, and sometimes renal tumor. When there is p^Hiria, it is necessary to distinguish that which is due to renal suppuration from suppuration of the lower urinar}^ passages. When pus is formed in the kidney, the urine contains a larger proportion of albumen than when pus is formed elsewhere in the urinary tract. Re- nal tube-casts are often found in the urine, and rarely bits of renal tissue may be discovered in it. The sudden appearance of large amounts of pus in the urine usually signifies the bursting of an abscess into the urinary tract at some point in its course. Pain in the kidnej's may be wanting or may be very slight. It is caused chiefly by stretching the capsule. It is, therefore, commonly inconsiderable, except when the whole kidney is involved, and is greatly distended with pus. When pain exists, it is aching or at least constant and dull. It is usually felt quite as much in front and in the side as in tlie back. Sometimes the passage of clots, shreds of renal tissue, or calculi, when they are loosened from the kidne3^, causes renal colic. The kidney can be felt as a tumor only when it is ver^^ much distended. It can then be felt by deep pressure upon the sides of the abdomen. The shape of the kidney can usually be outlined by the palpating hand. When enormously distended it may almost fill one side of the abdomen ; when considerably distended, fluctuation may be felt. Usuall}^, the organ is too deeply located to make it possible to elicit this sign. When the kidney is suflSciently distended to be felt, it is usually' evenly so. Rarely, the surface is made uneven by projecting ab- scesses of considerable size. The symptoms of hectic fever are present unless the pus is perfectly drained,, spontaneously or artificially. Prognosis. — The prognosis of suppurating nephritis 336 Benal Inflammations. is unfavorable. RecoveiT is possible if the abscess or abscesses can be perfectly drained. This is rarely, if ever, accomplished spontaneously. When, as is usual, there are many small abscesses, and especially if the}' are in both kidneys, drainage b}^ a surgical operation is impossible. Under such circumstances death is almost inevitable. The nature of the primar}' disease, when there is one, must be considered when the chances of recover}' are computed. Treatment. — Treatment must be supporting and symptomatic. The essential of successful treatment is the removal of the pus and the prevention of its re- formation. This may necessitate aspiration, nephrot- omy, or nephrcctom3\ Food should be as generous in amount and variety as the stomach will tolerate and utilize. Renal irritants should be excluded from the dietar}', beverages, or medicines of those who suffer from suppuration of the kidueys. Anodynes ma}' be needed to relieve pain. Tonics and haematics will be useful if fever is absent and convalescence is beginning. Indi- gestion may also have to be relieved by appropriate treatment. RENAL DEGENERATION. CHAPTER XXXY. Amyloid Kidney. Nature and Causes. — This is one of the renal lesions often denominated Bright's disease. It is due to the formation of a chemical substance which, united with the reual tissue, forms a new chemical body tliat destro3's the function and structure of that tissue and replaces it with homogeneous albuminoid matter. Amyloid kidney is commonh' secondar}' to chronic suppuration, but it has been known to develop in the third week after the onset of acute suppuration. The pus may be formed in any part of the bod}'. Often amyloid kidne}' accompanies chronic suppuration of the lungs or joints. It may follow syphilis and tubercu- losis, even when these diseases do not cause suppura- tion. Rarely, it has been observed in association with chronic intermittent fever. Oftener it accompanies chronic nephritis, cancer, leucocythsemia, and other cachectic conditions. Very rarel}', it occurs without discoverable cause. Amyloid infiltrations are observed oftener in men than in women, and oftenest between the ages of 12 and 50. Anatomy. — When amyloid changes are not extensive, the kidney does not change in sizie or appearance. If they are sufficiently extensive to produce appearances that are characteristic, the kidney is large, pale, firmer, and heavier than normal. The surface is smooth, and 15 P (337) 338 Renal Degeneration. the capsule is easily removable. The cut surface of the kidney presents the same ph3'sical characters. Upon it man}' glomeruli are visible as gray, opaque dots, and here and there streaking the medulla and cortex similar gray lines are observable. If absolution of iodine is poured over the surface, the gra^' matter becomes reddish brown and is strongly contrasted with the rest of the tissue, which is yellowish. The kidney ma}- be mottled with yellow or ma}' be ditfusely 3'ellowish. Tlie color is the result of fatt}' degeneration. If a section is ex- amined microscopically, the capillar}' tufts in the affected glomerule will be found to be partly or wholly homo- geneous and semi-translucent. The vessels are swollen and impermeable to the blood. Elsewhere in the me- dulla the arteries and capillaries are seen to be similarly affected. If amyloid deposits are very numerous they will occur extensively in the vessels and may be in the basement membrane of the tubules. The glomerular capillaries and afferent vessels are first involved. Fatty degeneration of the renal epithelium is associated wMth amyloid infiltration, but the fatty degenerative and amyloid changes bear no constant ratio to one another. Often the fatt}'' cells are cast off and disintegrate. They partly fill some tubules, or granular nuitter resulting from them does. Hyaline casts and, less frequently, amyloid casts are observable in the tubules. Some- times the connective tissue is slightly infiltrated with round-cells. The evidences of fatty degeneration and inflammation may be more noticeable, both clinically and anatomically, than those of amyloid infiltration. In such cases the amyloid disease may escape notice unless it is sought for closely. Other organs, especially the spleen and liver, are apt to be similarly affected. Symptoms. — As amyloid kidney is usually a sec- Amyloid Kidney. 339 oiidary disease, its S3'mptoms are associated with those of the primary trouble. Anaemia, emaciation, and weak- ness are usiiallj'^ due both to the renal and the primary disease. Anasarca is almost invariabl}^ present, but exists to a variable degree. It is sometimes great and sometimes slight. It may develop early or late, and is not correlated in degree with the extent of amyloidosis. En the same case tiie urine often varies greatly in amount. It ma}' be much increased, but is, [)erhaps, oftener normal or a little diminished. Toward the end of life it is usually greatly diminished. It is peculiarly clear and drops ver}' little sediment when it stands. It is acid. Its specific gravity varies from 1005 to 1015. In the sedi- ment, h3'aline and, rarel}', amyloid casts are observable. Sometimes granular casts, a few oil-droplets, and grnnu- lar or fatt}^ epithelial cells are seen. The urine contains a large amount of albumen, although in the rarest cases the latter is absent. Urea is usuall}' diminished in nmount, but less so than in nei)hritis. Although the vessels of the kidneys and other organs are much ob- structed, the heart is rarely enlarged. The s[)leen and liver are commonly much enlarged. The latter can often be felt, beneath the ribs, to be unusuall}^ firm and smooth. . Uraemia is rare in simple amyloid kidney. As ex- tensive fatty degeneration, or true chronic nephritis, is frequently associated with amyloid kidney, the chnr- acteristic symptoms of the hitter may be modified and obscured by the accompanying diseases. Respiration and bodil}' temperature are not chnnged by the renal disease. The nppetite and the power to digest vary greatl}'. Usually, they are diminished, and consequently there is evidence of slow digestion Often there is diarrhoea, which is persistent and not easily 340 Renal Degeneration. controlled. It ma}' be due to intestinal catarrh, ulcer- ation, or amyloid change in the arteries of that organ, or to all these lesions combined. Death may be due to intercurrent inflammations of serous sacs or lungs, but oftenest to marasmus. The duration of the disease is variable. Its average is one or two years. It is fatal almost with unirormit3\ Re- cover}^ is supposed rarely to have occurred. Diagnosis. — A diagnosis is frequently difficult or impossible. If there is a good cause for amyloid dis- ease, and if there is an enlarged spleen and liver, abund- ant albuminuria, a normal or nearly normal quantity of clear urine of low specific gravit}', its existence is prob- able. It can be distinguished from acute nephritis by the small amount of urine which accompanies the latter, its high specific gravity', and its cloud3^ and reddish color. Blood is xQvy rarely present in the urine from am3^1oid kidney's. From chronic parenchymatous nephri- tis, amyloid kidney can be distinguished b}' the smaller amount of urine, b}^ its greater turbidit}", and b}' its higher specific gravity in the former. From renal cir- rhosis it is distinguishable b}' the larger flow from the former of limpid urine of low^ specific gravit3% contain- ing onl}' traces or small amounts of albumen. Treatment. — Treatment must be prophylactic, symp- tomatic, and supporting. Abscesses must be drained ; syphilis or intermittent fever must be cured in order to prevent the extension of the amyloid deposits. Other primary diseases must be removed if possible. (Edemas may require removal ; indigestion and diarrhoea may need treatment. If the functions of the stomach and of the bowels are much disturbed, it is impossible to properl}' nourish a patient. When these organs act well the nourishment should be abundant and highly' Amyloid Kidney. 341 nutritious. The elimination by the kidneys of nitrog- enous matter is usually so perfect that meat and eggs cnn be eaten without danger. Food should be so pre- pared and so given that digestion will not be overtaxed or impaired. There is no medicinal treatment especially adapted to amyloidosis. DISORDERS OF THE RENAL PELVIS. CHAPTER XXXVI. Nephrolithiasis. Causes and Symptoms. — When calculi form in the kidne}' or in its pelvis the condition is called nephro- lithiasis. Calculi vary in size from tine, sand-like particles to equal a hen's egg. When small the}^ nre usually verj- numerous. Their number generallj' varies inverseh' to their size. The}' are commonly rounded and smooth, but ma}' be acicular, faceted, or noduled. They are usually composed of uric acid and urates. They ni;iy be formed of oxalate or carbonate of lime, or of phos[)hates, or very rarely of cystin, xanthin, or indigo. Calculi differ in hardness and color according to their composition. Uratic stones are usually brownish or reddish brown. Calcareous calculi are often very hard. Renal stones are frequently of mixed composition. The small ones usually exhibit a crystalline fracture. The larger ones are more granular. They may be laminated. The various layers may have the same or a different composition. Calculi are supposed to form around a nucleus, which may be a crystal or a few epithelial cells, or a clot of mucus, or bacteria. Calculi often form in the kidney's pelvis. Renal sand may be deposited in the tubules or even in the intertubular connective tissue. Upon the cut surface of a kidney it may produce reddish stria* through the medulla and cortex. It will cause a knife to grate as it cuts the organ. Lnrger calculi may also (342) Nephrolithiasis. 343 be deposited in the renal substance, but oftener they are found in the pelvis or, partly imbedded in the kidnej^, protrude into tlie pelvis. The state of the blood, or the condition of metabol- ism in the kidney or generally, which causes their formation, is not understood. It has been observed that they form oftenest in childhood and old age. They have been seen in infants who died a few da^s after birth. Thej^ occur oftener in men than women. Sedentary habits and high living seem to predispose to them. Occasionally, there seems to be an inherited predispo- sition to their formation. There are geogra[)hical areas where nephrolithiasis is a common disease, and others where it is extremely rare. The use of water that is strongly calcareous predisposes to the formation of lime calculi. The3^ sometimes form in old age, when lime is re-absorbed from bones, and in osteomalacia. Pyelitis, and especially' if urinary decomposition occur with it, is often accompanied by the formation of calculi. Gout and the uric-acid diathesis are frequently complicated by nephrolithiasis. Calculi may exist in the kidney or its pelvis for a long time without causing an appreciable disturbance. Nor does the gravity of the symptoms which the}' may produce bear any relation to their number or size. They frequently cause pyelitis (see page 350), renal haemorrhage, inflammation, nnd colic. When a calculus obstructs permanently a ureter, it may cause h3dro- nephrosis. Calculous pyelitis is nsually diffuse, but may be cir- cumscribed. Ulcers niMy be caused b}^ it, and lead to perforation and perirenal inflammation, or to commu- nication with the abdominal cavit}', or the intestines. Haematuria is a common symptom. It varies much in 344 Disorders of the Renal Pelvis. severity, but usually is repeated if it happen at all. It often occurs when a patient stands or walks far, and ceases when he is quiet, or occurs only after severe or protracted labor. The blood is usually- intimatelj- mixed with the urine. Clots maj' be passed. Cylin- drical ones are casts of the ureters. Frequentl}^ attacks of nausea and even vomiting are the result of reflex irritation b}^ renal calculi. Quite as often frequent urination and vesical tenesmus are pro- duced by them. Inflammation of the kidne}^ is caused by calculi. They are common causes of suppurative, less frequentl}' of chronic, nephritis. If they produce chronic renal inflammation, it is especially apt to be of the interstitial form. Renal colic and the passage of calculi are the most characteristic symptoms produced b}^ stones in the kidney. The colic often has an abrupt onset. Intense pain develops at once. Less frequentl}' the pain grad- uall}' intensifies. If ver}' intense, the symptoms of col- lapse ma}' develop rapidh*. The patient will then be extremely prostrate, almost speechless, his pulse quick, small, and soft, and his skin usuall}' cold and clamm3\ When the pain is intense it cannot alwa3S be located, but is described as a severe abdominal cramp. Oftener it begins over one of the ureters and then becomes dif- fused over the abdomen. The colic is usuall}^ accom- panied 1)3' pains that extend into the groin and testicle, or into the thigh on the side affected. In milder cases, a stead3', teasing pain will be felt in the region of one kidney, or in the loin, which gradually shifts to the re- gion of the ureter, and is felt to move downward toward the bladder. The pains are paroxvsmal, or, if constant, become intense, paroxysmall3'. The pain is undou])tedlv due to a spasm of the ureter, and is a true colic. A suf- Nephrolithiasis. 345 ferer from it cannot rest, but walks the floor, or tosses constantly upon a bed. Yer}^ nervous persons have been thrown into convulsions by it. Nausea, and frequently vomiting, accompanies these attacks. In many eases, the vesical tenesmus is considerable. The pain may cease suddenly Avlien the stone drops into the bladder. The cause of these symptoms is demonstrated if stones are afterward passed -from the bladder, or discoverable in it. If the calculi are sand-like there may be little pain, or the attacks may be mild. Vesical tenesmus is a common symptom even in the mildest cases. Renal colic must be differentiated from other ab- dominal colics b}" the location of the pain, the extension of it to the groin, testicle, or thigh, and usually by simultaneous vesical tenesmus. It is confirmed bj- dis- covering the calculus. It is distinguished from hepatic colic by the greater tendency in the latter for the pain to radiate upward toward the heart or shoulder, and b}' its location just to the right of the epigastrium, and by subsequent jaundice, or by the discovery of bile- stones in the stools. The symptoms of hydi^onephrosis are, first, those of renal tumor. If the kidne}' is much distended, it can be felt through the abdominal walls and outlined by a palpating hand. An area of resonance usually sepa- rates it from the liver. Dullness and tumors of the latter move with deep respiration, but renal tumors do not. An enlarged kidney can be distinguished from an enlarged spleen, because the latter usually enlarges upward and outward, and may cause a lateral promi- nence of the lower ribs ; but the former enlarges down- ward and forward, and causes a prominence of the anterior abdominal wall. When the kidne}' is enlarged the spleen can, by percussion, be outlined in its normal 346 Disorders of the Renal Pelvis. place and demonstrated to be independent of the renal tumor. It can be distinguished from gastric tumor by the movability of the latter when the stomacli is more or less distended, and from faecal tumors by their removal (as is usually possible) by free purgation. From ovarian tumors it must be distinguished b}' the histor}^ of their development upward out of the pelvis. The latter are usuallj^ in direct contact with the abdom- inal wall, and produce an area of complete dullness. Renal tumors, except when ver^^ large, are separated b}- loops of intestine from the abdominal wall, and cause only relative dullness. The tumor produced bj^ hydro- nephrosis is usuall}^ not very great, although, in excep- tional cases, it ma}' fill nearlj' half of the abdomen. It is often somewhat uneven. The prominent parts cor- respond to the dilated calices. When such a small tumor is discovered, hydronephrosis must be differen- tiated from solid renal tumors b}' demonstrating fluctua- tion of it, and from other fluid tumors, such as abscess and echinococcus. In echinococcus hydatids must be sought in the urine. In abscess the symptoms of hectic fever must be expected. The discomforts which ab- dominal tumors produce are usuall}^ present, especial I3' if the renal tumor is large. The}' are : abdominal dis- tension, weight and dragging, dyspnoea from pressure upon the diaphragm, or constipation from pressure upon the intestines. Gastric symptoms, such as nausea and vomiting, may arise reflexl}'. Rarely, a distended renal capsule has been known to rupture and iiermit the retained fluid to escape into the peritoneum, which uniformly causes acute peritonitis. When 113'dronephro- sis is slight, it may not be discoverable, or may be easily overlooked, unless there is a histor\' of sudden obstruction of a ureter. The anatomical changes con- Nephrolithiasis. 347 sist in a distension of the renal pelvis, a compressing of the i)yramids, distension of the calices, a slow atrophj' of the renal substance, which is replaced or, in extreme cases, represented by a small amount of connective tissue. It must be remembered tliat hydronephrosis ma3' be caused in otlier ways than b}' lithiasis. The nreters mny be congenitally narrow, or compressed by tumors, or twisted; or there maj- be obstruction to urination at the neck of the bladder or in the nrethrn. In the latter cases both kidney's are liable to distension. If a hydronephrosis can be diagnosed, it must be treated surgical!}'. Its cause ma}- be removed, or the entire kid- nej- m;iy be taken away. Aspiration for diagnostic pur- poses is not safe, for peritonitis has resulted from it. Lithiasis rarelj' produces a renal tumor by the accu- mulation of stones in the kidney's pelvis, or by the formation of a very large one that will distend it. When thus imi)acted, stones produce a hard, nodular tumor of moderate size. Its location and sometimes obstruction of a ureter, or the histor}' of former rennl colic, or the passage of sand or gravel, make probable the difficult diagnosis of such lithiasis. Treatment. — The indications for treatment in nephro- lithiasis are the removal of stones and the prevention of their reformation. It has not been demonstrated that stones of any size can be dissolved by medicines which are administered by the mouth. They can onl}- be removed by an operation, and this is onl}- justifiable when the stones are provocative of other renal lesions, such as dangerous renal haemorrhage, or pyelitis, or hydronephrosis. When, as oftenest happens, stones are passed and the second ifidication for treatment is the essential one, we ma}' hope for a reasonable clegree of success from proper 113'giene and medicinal treatment. 348 Disorders of the Renal Pelvis. If the culculi are composed of uric acid or acid urates, a mixed diet should be prescribed that shall contain a moderate or minimum amount of nitrogenous matter, and exercise and frequent deep inspirations of fresh air shoukl be assured to make metabolism active and complete. Alcoholics should be interdicted, as their stead>^ use prevents perfect tissue-change and promotes the accumulation of waste in the system. Pure water should be taken freel}^, that the tissues ma}^ be well washed and all soluble matter removed. The water should be as free from mineral matters as pos- sible, that its dissolving power maj" be as great as possible; or it should contain lithium. Lithium and potassium salts can be given in copious draughts of water, as the}^ energize oxidation, and, therefore, make more perfect tissue-change. Therefore, urea will be formed in larger, and uric acid in smaller, amounts. Lithium also unites with uric acid and forms a very soluble compound. In these wa3's, an overproduction of uric acid will be prevented, and what is formed easilj- removed with the urine. Yichj', lithia-waters, or such salts as the acetate or citrate of potassium or carbonate or benzoate of lithium, are conimonl}^ prescribed. The benzoates are especially' useful, for they convert uric acid into soluble hippurates. The benzoate of lithium or sodium can be given in doses of from 0.5 to LO gramrrie (10 to 15 grains). The oxalates which ma}' form calculi are chiefly produced from such vegetables as rhubarb, sorrel, toma- toes, tea, spinach, cabbage, and celer}'. Their use must, therefore, be forbidden. Alkaline diuretics nre now useless. The vegetable ones, such as stigmnta maidis and uva ursa, are often apparentl}' efficacious. They can be given as fluid extracts, in doses of from 1 to 4 Nephrolithiasis. 349 cubic centimetres (^ to 1 drachm). Water should be taken freely. Phosphatic precipitates in the kidney can be pre- vented by maintaining the urine acid. A meat diet will accomplish this in many persons, or acids can be given by the stomach. Dilute nitro-muriatic is oftenest used in doses of 5 to 10 minims, or dilute lactic in doses of from 2 to 4 cubic centimetres (| to 1 drachm). Wlien calculi cause colic, the pain must be lessened by opiates, or by anaesthetics, such as chloroform or ether. It must be remembered that, as in other cases of severe pain which may suddeidy cease, the anodynes and anaesthetics, if giveii in very large doses, may pro- duce fatal or dangerous poisoning; for, so long as pain is intense the large doses may not subdue it, although they prove toxic when it ceases. The discomfort which accompanies a mild colic or the passage of sand can often be mitigated by sinapisms and b\^ heat applied externall}'. If calculi are slow in passing through the ureters, massage can be practiced over them, and atropia and strychnia can be given, as they are supposed to stimulate more vigorous contractions in muscular structures, such as the ureters. Renal haemorrhage is best checked by rest, by cold applications over the kidneys, by ergot, gallic acid, and acetate of lead. CHAPTER XXXYII. Pyelitis. Cause. — P3^elitis is an inflammation of the pelvis of the kidne}^ It may be catarrlial, or purulent, or lisemorrhagic. It is commonl}' a secondaiy disease. Occasional cases are met with for which no cause can be assigned. Some of them follow exposure to cold. Infectious diseases, such as typhoid, small-pox, and P3'8emia, are often associated with mild catarrhal i)3^e- litis, whose existence is only demonstrated upon the post-mortem table, for the symptoms of the primary disease mask those of pyelitis. It may be provoked by such drugs as cantharides, copaiba, and turi)entine. Obstructions in the urinary tract often produce the lesion. For example, compression of the ureters by a pregnant uterus or other abdominal tumor may cause it. In sucli cases, there is also more or less of hydronephro- sis. Oftenest pyelitis arises by extension of inflamma- tion from other parts of the urinary tract, or by irrita- tion from foreign bodies within the i)elvis. More or less pyelitis is commonly associated with the various forms of nei)hritis. Cystitis very often causes pyelitis, and urethritis may do so. The foreign bodies which csiuse it are usually calculi. Clots and parasites may also produce it. Anatomy. — The ]^elvis of the kidney ma}- be acutely or chronically inflamed. When acutely, it may be red- dened diffusely or only in patches. The mucous mem- branes and submucosa become swollen, and mucus, desquamated epithelium, and some round-cells adhere to (350) Pyelitis. 351 the surface or mix with the fluid contents of the pelvis. If the inflamniiition is chronic, the lining of the pelvis is often brownish or grayish in color. The contents may be the same catarrhal products as in acute pyelitis. Haemorrhage may occur in either acute or chronic pyelitis, and, when it does, often causes extravasation beneath the epithelium and subsequent pigmentation of the mucosa and submucosa. Purulent inflammation is not uncommon. It usually is the result of extension of inflammation from the bladder. In purulent pyelitis the kidneys are usually sooner or later involved. (See page 333.) The whole kidney may be destroyed or transformed into a large abscess. Usuall3%the pelvis is distended when it supi)urates. Instead of diffuse suppu- ration, ulcers may form and may penetrate the capsule and cause perinephritis or peritonitis. Symptoms. — A characteristic course cannot be de- scribed for p3'elitis, because it is usually secondary to other diseases. Acute cases are often unrecognized. Recovery may occur in some. Frequentl}', pain is complained of in the region of the kidneys. It is a feeling of tension ornehing Often it is associated with pain in the testicle or perineum, or with frequent urination and straining. The passage of calculi or clots may cause renal colic. The urine is usually acid and of normal specific gravity. It con- tains an excess of mucus and generally some pus; it may contain much of it. Under the microscope, if there is pyelitis, besides pus-cells, triangular and tailed epithe- lial cells can commonlj' be seen. The latter are often regarded as quite pathognomonic of pyelitis, but similar cells have occasionally been found in the urine as the result of cystitis. Blood in abundance is rnreh' ob- served, except when pyelitis results from cnlculi. If 352 Disorders of the Renal Pelvis. the kidney is also involved, casts of renal tubules can usually be found in the urine. If fever exist, it is commonly caused by the primary disease, but it may be due to suppurative pyelitis. Emaciation and other S3'mptoms are produced chiefly b}' the other diseases which pyelitis accompanies, but ma}' also be due to sup- purative pyelitis. Headache, delirium, and coma may be due to ammonsmia from the absorption of ammonia from decomposed urine in the bladder or renal pelvis. Diagnosis. — It is evident that a diagnosis is often impossible. If the existence of calculi or of some other renal affection can be demonstrated that may cause P3'elitis, and if, at the same time, in acid urine tailed epithelial cells can be found, a positive diagnosis can be made. It is especiall}^ diflScult to distinguish pyelitis when there is cystitis. Treatment. — Treatment must be prophylactic and symptomatic. For example, if cystitis is cured, or if calculi are removed, the p^^elitis may be recovered from. Pain must be relieved by opiates. Counter-irritants, cups, or leeches over the kidne3's will often relieve the aching. It is especiall}^ desirable, when there is slight catarrhal pyelitis, to prevent urinar\' fermentation within the kidne}^, or to lessen it, if it exist. For this purpose, such antiseptics as resorcin, acidum salicyli- cum, and salol are the most useful. They should be given b}' the mouth, in as full doses as are well borne. Of these, salol is the best tolerated and, perhaps, the most useful. After it is decomposed b}^ the alkaline juices in the duodenum into salic3iic and carbolic acids, the latter are eliminated b}' the kidneys. To limit the formation of pus, oil of sandal-wood, copaiba, and similar preparations are often recommended. The3' should be used with care, for pyelitis ma3^ be produced Pyelitis, 353 or aggravated by them. When judiciously employed, they often lessen the amount of pus formed. If sup- puration is extensive, surgical treatment may be neces- sary. The suppurating pelvis ma}^ be drained, washed, and dressed as an abscess, or the entire kidney may have to be removed. The last procedure is indicated when the renal capsule is much distended with pus and the renal tissue is mostly destroyed. In pyelitis food should be simple, nutritious, and free from renal irritants. Tlierefore, alcoholics and food that is strongly spiced should be forbidden. Milk and milk foods are especially appropriate. Prognosis. — Mild cases usually recover in one or a few weeks. Suppurative pyelitis that has not involved the kidney extensively may be recovered from. If very chronic, or if suppuration is acute and spreading, the chances of recovery are not great. pa GENERAL AND THERAPEUTIC INDEX. Acetanalid, 103, 179 Aciduin carbolicum, 154, 155, 166, 329 Aciduin gallicum, 308, 349 Acidurn muriaticum, 52, 329, 349 Afidum jiitricum, 160, 308, 349 Aciduin salic3'licuin, 352 Acidum tannicum, 161. 308 Aconite, 48, 101, 214 Alcoliol, 48, 103, 160, 213, 228, 278, 290, 295 Aloes, 158, 329 Alpes, 147 Ammonsemia, 263, 352 Ammouii aeetas, 130, 206, 271, 291 Ammonii carbonas,43, 48, 85, 101, 191, 206, 228 Ammonii citras, 271 Ammonii iodidum, 44 Ammonii murias, 16, 43 Ammonii salicylas, 269 Amyloid kidney, 263, 305, 337 anatomy, 337 causes, 337 diagnosis, 340 symptoms, 338 treatment, 340 Amylumnitritum. 263 Anaemia, 40 pernicious, 222 Aneurism, 68, 215 Angina pectoris, 221, 227, 228 Antimonii et potassii tartras, 16, 44, 50 Auti pyrin, 47, 103, 154, 179 Aortic insufficiency, 243 Aortic stenosis, 245 Apomorpliia, 50 Argenti nitras, 159 Aspiration, 181, 191, 206, 311, 331, 336 Asthma, 3, 265 causes, 10 diagnosis, 9 nature, 3 symptoms, 4 treatment, 11 I Atelectasis, 25, 67, 121 anatomy, 67 I cause, 67 symptoms, 68 treatment, 69 Atropia, 19, 102, 160, 349 Aurei et sodil chloridum, 109, 323 Belladonna, 160, 360 Bermudas, 149 Blisters, 161, 179, 206, 209, 228 Bromides, 15, 48, 261 Bronchiectasis, 27, 36, 37, 57, 92, 123 anatomy, 57 causes, 58 symptoms, 58 treatment, 59 Bronchitis, 23, 75, 88, 241, 274 acute, 22 anatomy, 22 symptoms, 28 capillary, 68, 82, 85 anatomy, 24 sj'mptoms, 30 chronic, 35, 57 anatomy, 25 symptoms, 33 bronchorrhoea, 36 dry, 36 purulent, 36 putrid, 37, 115 causes, 39 diagnosis, 38 treatment, 42 Caffeine, 206, 213, 222, 233, 308 Calculus, 350 California, 149 Calomel, 101, 179, 206, 228, 327 Camphor, 48, 85, 101, 191, 206, 228 Cantharides, 350 Cardiac dilatation, 68, 210 Cascara sagrada, 158, 329 Charcot's crystals, 8 Chloral, 15, 43; 58, 154, 260, 272 Chloroform, 15, 222, 260, 272, 349 (355) 356 General and Therapeutic Index. Chlorosis, 222 Cocaine, 14 Codeia, 48, 154, 179, 191 • Codliver-oil, 152, 186 Colchicum, 51 Colocyuth, 271 Colorado sprin2:s, 147 Convallaria, 206, 213, 237, 331 Copaiba, 54, 290, 350, 352 Coronary sclerosis, 227 Creasote, 44, 54, 118, 155, 162 Croton-oil, 271 Cubebs, 278 Cupping, 206, 209, 290, 352 Cystitis, 350 Diabetes, 42, 141 Diarrhoea, 135, 332 Digitalis, 15, 49, 74, 80,81,85,192, 160,180,191,206,213,218, 222, 237, 255, 260, 271, 277, 291,294,325,330,331 Diphtheria, 82 Dover's powder, 45, 100 Eczema, 299 Electricity, 260 Elaterium, 271 Embolism, 70, 323 Emesis, 50 Emphysema, 25, 29, 61, 82, 274 anatomy, 61 cause, 62 symptoms, 63 treatment, 67 Empyema, 169, 177, 182, 171, 192 Endarteritis obliterans, 215 Endocarditis, 98, 231, 312 causes, 233 chronic, 232 malignant, 231 prognosis, 238 simple, 231 symptoms, 234 treatment, 237 ulcerative, 231 Ergot, 81, 102, 160, 161, 260, 308, 349 Erysipelas, 88 Ether, 15, 228, 260, 272, 349 Eucalyptus, 54, 118, 162* Florida, 149 Fuchsin, 308 Gelsemium, 154 Gentian, 53, 158 Georgia, 149 Glucose, 292 Gout, 295, 313 Grindelia robusta, 16 Gymnastics, respiratory, 110, 223 Haematuria, 343 Hav fever, 10, 12 Heart dilatation, 210 anatomy, 211 cause, 210 prognosis, 214 symptoms, 211 treatment, 212 Heart, fatty, 220 anatomy, 220 symptoms, 221 treatment, 222 Heart hypertrophy, 215 anatomy, 215 cause, 215 symptoms, 216 treatment, 218 Heart, indurative degeneration, 226 anatomy, 226 symptoms, 227 treatment, 228 Hemoptysis, 71, 131, 136 Hunyadi Janos, 290, 327 Hydj-argvri chloridum corrosi- vum, 311, 323 Hydrargyri subsulphas, 50 HVdrothorax, 194, 201 cause, 194 diagnosis, 194 prognosis, 195 treatment, 195 Hydronephrosis, 345 Hydrops pericardii, 207 Hyoscyamus, 19, 260 Ice-bag, 209, 228, 260 Influenza, 82 Ipecac, 50 Iron, 65, 159, 213. 222, 230, 255, 260, 293, 307, 331 chloride, tincture, 307 Iron citrate, 307 potassio-tartrate, 307 subcarbonate, 268, 307 subsulphate, 161 General and Therapeutic Index. 35T Jaborandi, 206, 269 Kidney congestion, 241, 263, 274, 288 cause, 274 anatomy, 274 symptoms, 276 ti-eatment, 277 Kidneys, passive congestion, 274 anatomy, 274 symptoms, 276 treatment, 277 Lactose, 292 Laryngitis, 136 Leeching, 206, 209, 290, 352 Leukaemia, 222 Lead acetate, 349 Liver congestion, 241 Lithium acetate, 271 benzoate, 269, 348 citrate, 271 carbonate, 325, 348 Lithia waters, 348 Lobelia, 17 Lung, brown-induration, 75 cause, 75 symptoms, 76 Lung Hoemorrliagic infarct, 70 anatomy, 70 cause, 70 symptoms, 71 treatment, 72 Lung hypostasis, 73 causes, 73 symptoms, 73 treatment, 74 Magnesium sulphate, 290 citrate, 180, 290 Malaria, 295, 313, 363 Manitou, 147 Malt extracts, 154, 156 Measles, 82, 85 Meningitis, 98 Mitral insufficiency, 246 stenosis, 249 Morphia, 14, 16, 46, 100, 154, 159, 179, 191, 260, 272 Myocarditis, 230 Neoplasms of the lungs. Nephrectomy, 336 167 Nephritis, 40 diphtheritic, 263 interstitial, 215, 263, 305, 313, 340 anatomy, 314 causes, 313 diagnosis, 323 prognosis, 332 , symptoms, 318 treatment, 323 parenchymatous, 215 acute, 215, 279, 263, 273, 277, 305, 340 anatomy, 280 causes, 279 diagnosis, 288 prognosis, 294 symptoms, 284 treatment, 289 chronic, 215, 263, 277, 281, 295, 304, 340 anatomy, 295 causes, 295 diagnosis, 305 symptoms, 298 treatment, 306 scarlatinal, 263 suppurative, 333, 344 anatomy, 333 causes, 333 prognosis, 335 symptoms, 334 treatment, 336 Nephrolithiasis, 342 causes, 342 symptoms, 342 treatment, 347 Nephrotomy, 336 New Mexico, 150 New York, 149 Nitrites. 18, 218, 228, 312 Nitro-glycerin, 17, 229 Nux vomica, 158 Obesity, 222 (Edema, lungs, 73, 78, 241 anatomy, 78 causes, 79 symptoms, 78 treatment, 80 Oleum morrhuae, 53 Opium, 15, 45, 100, 154, 159, 179, 205, 209, 331, 352 Oxygen, 81, 103, 223, 307, 331 358 General and Therapeutic Index. Paregoric, 46, 155 Pepsin, 52 Pericarditis, 68, 98, 199 anatomy, 199 causes, 199 symptoms, 199 treatment, 205 Pilocarpine, 20, 131, 269 Pine-oil, 118, 155 Plumbism, 313 Plumbum acetas, 159, 161 Pleurisy, 58, 72, 98, 99, 123, 186, 169, 194, 274, 304, 312 anatomy, 169 causes, 172 diagnosis, 177 prognosis, 186 symptoms, 173 treatment, 178 Pneumatic differentiation, 50, 66, 69 Pneumonia, catarrhal, 25, 33, 82 anatomy, 82 causes, 82 symptoms, 84 treatment, 85 Pneumonia, croupous, 86, 73, 78, 85, 115, 304, 312 anatomy, 89 causes, 86 diagnosis, 99 symptoms, 92 treatment, 100 Pneumonia interstiatialis, 58, 107, 274 Pneumopericardium, 208 Pneumothorax, 68, 187 causes, 187 diagnosis, 190 prognosis, 193 symptoms, 188 treatment, 191 varieties, 188 Potassium acetate, 180, 206. 271, 291, 325, 348 Potassium chloride, 180 j Potassium citrate, 271, 296, 325, 348 Potassium iodide, 13, 44, 66, 100, i 180,230,311,323,330 j Potassium nitrite, 329 I Pulmonary abscess, 92, 112 j anatomy, 112 causes, 112 ' Pulmonary abscess, diagnosis, 114 symptoms, 113 Pulmonary cirrhosis, 107 anatomy, 107 causes, 109 symptoms, 108 treatment, 109 Pulmonary gangrene, 28, 92 114, 138 anatomy, 115 causes, 114 prognosis, 117 symptoms, 116 treatment, 117 Pulmonary tuberculosis, 82, 92, 114, 120, 138 anatomy, 120 , causes, 139 diagnosis, 138 prognosis, 165 prophylaxis, 142 symptoms, 129 treatment, 145 Pyaemia, 350 Pyelitis, 343, 350 anatomy, 350 causes, 350 diagnosis, 352 prognosis, 353 symptoms, 351 treatment, 352 Quebracho, 17 Quinia, 45, 47, 65, 100, 102, 103, 159, 213, 222, 293, 308, 331 Renal colic, 344 Resorcin, 329, 352 Retinitis albuminurica, 321 Rheumatism, 40, 88, 295 Rochelle salts, 270, 290 Rocky mountains, 147 Rose fever, 10 Salol, 352 San Antonio, 150 Sandalwood-oil, 352 Sanguinaria, 46 Scarlatina, 298. 313 Senecio aureus, 13, 17 Sinapisms, 178, 260 Small-pox, 350 Sodium acetate, 325 benzoate, 269 General and Therapeutic Index. 369 Sodium bicarbonate, 180 bromide, 46 chloride, 180 citrate, 325 iodide, 13, 44, 53, 66, 110, 180, 230, 323, 330 nitrite, 18, 229, 329 salicylate, 51, 269 tannate, 308 Squills, 44, 46, 50, 290 Stigmata maiadis, 348 Stramonium, 19 Strophanthus, 49, 85, 102, 191, 206, 213, 218, 222, 228, 255, 271, 291,325,330,331 Stryclinia, 45, 52, 65, 80, 81, 102, 160,213,222,255,260,293, 307, 331, 349 Sulphuretted hydrogen, 162 Syphilis, 295, 306 Tachycardia, 256 causes, 258 symptoms, 256 treatment, 258 Terpin hydrate, 46 Terrebene, 54 Texas, 149 Thoracentesis, 182 Thrombus, 70, 274, 323 Thymol, 162 Trachitis, 22 Tricuspid insuflBciency, 251 Tuberculin, 162 Turpentine, 44, 54, 118, 155, 159, 161, 278, 290, 350 Typhoid, 73, 87, 94, 99, 350 Uraemia, 263, 308, 323 causes, 264 diagnosis, 267 prognosis, 273 symptoms, 264 treatment, 267 Uraemic amaurosis, 331 Urethritis, 350 Uva ursa, 348 Valerian, 260 Valvular diseases, chronic, 239 aortic insufficiency, 243 stenosis, 245 combined lesions, 253 mitral insufficiency, 246 stenosis, 249 nature and anatomy, 239 prognosis, 254 pulmonary, 250 symptoms, 240 treatment, 254 tricuspid, 251 Venesection, 81, 100 Venice turpentine, 44, 54 Veratrum, 49, 101, 214 Viburnum prunifolium, 15 Vichy water, 348 Vinegar, 160 West Indies, 149 Whooping-cough, 42, 83, 85 Zinci oxidum, 160 NOVEMBEB, 1892. CATALOGUE OF THE PUBLICATIONS OF THE F. A. DAVIS CO., 1231 FILBERT STREET, PHILADELPHIA. BRANCH OFFICES: NEW YORK CITY.— 117 W. Forty-Second Street. CHICAGO.— 30 Lakeside Building, 214-230 S. Clark Street. liONDON, ENG.— 40 Berners Street, Oxford Street, W. ORDER FROM NEAREST OFFICE, FOR SALE BY ALL BOOKSELLERS. Prices of books, as given in our catalogue or circu- lars, include full prepayment of postage, fi-eight, or express charges. Customers in Canada and Mexico must pay the cost of duty, in addition, at point of destination. N. B.— Remittances should be made by Express Money-Order, Post-office Money-Order, Registered L,etter, or Draft on New York City, Philadelphia, Boston^ or Chicago. We do not hold ourselves responsible for books sent by mail ; to insure safe arrival of books sent to distant parts, the package should be registered. Charges for registering (at purchaser's expense), 10 cents for every four pounds or less. 2 The F. A. Davis Co., Philadelphia , Pa. ADAMS— Biography (authorized) of D. Hayes Agnew, M.D., LL.D. By J. Howe Adams, M.D. Illustrated witli Portraits and other Engravings. Koyal Octavo, about 500 pages. Handsomely printed. To be published and ready for delivery in the fall of 1892. Price, in United States, Extra Cloth, S3.50, net; Half- Morocco, Gilt Top, $4.50, net. Canada (duty paid), Extra Cloth, S3.90, net; Half-Morocco, Gilt Top, S5.00, net. Great Britain, Extra Cloth, 19s ; Half-Morocco, Gilt Top, 34s. 6d. France, Extra Cloth, 33 fr. ; Half-Morocco, Gilt Top, 37 fr. 30. BASHORE — Improved Clinical Chart. For the Separate Plotting of Temperature, Pulse, and Respiration. But one color of ink necessary. Designed for the Convenient, Accurate, and Permanent Daily Recording of Cases in Hospital and Private Practice. By Harvey B. Bashore, M.D. Fifty Charts, in Tablet Form. Size, 8 x 12 inches. Price, in United States and Canada, post-paid, 50 cents, net ; Great Britain, 3s. 6d. ; France, 3 fr. 60. BOENNING— A Text-Book on Practical Anatomy. In- cluding a Section on Surgical Anatomy. By Henry C. Boennixg, M.D., Lecturer on Anatomy and Sur- gery in the Pliiladelphia School of Anatomy ; Demonstrator of Anatomy in the Medico-Chirurgical College, etc., etc. Fully illustrated through- out with about 200 Wood-Eugravings. Royal Octavo, printed in extra- large, clear type, making it specially desirable for use in the dissecting- room. Nearly 500 pages. Substantially bound in Extra Cloth. Also in Oil-Cloth, for use in the dissecting-room without soiling. Price, in United States, post-paid, S3. 50, net; Canada (duty paid;, S3.75, net; Great Britain, 14s. ; France, 16 fr. 80. BOUCHARD— Auto-Intoxication: Self-Poisoning of the Individual. Being a series of lectures on Intestinal and Urinary Pathology. By Prof. Bouchard, Paris. Translated from the French with an Original Appendix. By Thomas Oliver, M.D., Professor of Physi- ology, University of Durham, England. lo^-one 12mo volume. In Press. Nearly Ready. BOWEN— Hand- Book of Materia Medica, Pharmacy, and Therapeutics. By Cuthbert Bowen, M.D., B.A., Editor of "Notes on Prac- tice." 12mo. 370 pages. Handsomely Bound in Dark-Blue Cloth. No. 2 in the Physicia7is' and Students^ Ready-Refei'ence Series. Price, in United States and Canada, post-paid, $1.40, net; Great Britain, 8s. 6d. ; France, 9 fr. 35. The F. A. Davis Co.^ Philadelphia^ Pa. 3 BURET — Syphilis in Ancient and Prehistoric Times. With a Chapter on the Rational Tr^eatment of Syphilis in the Nineteenth Century, By Dr. F. Buret, Paris, France. Translated from the French, with the author's permissiou, with notes, by A. H. Ohmann-Dumesnil, Professor of Dermatology and Syphilology in the St. Louis College of Physicians and Surgeons. No. 12 in the Physiciam' and Students' Ready -Reference Sefi'ies. 230 pages. 12mo. Extra Dark-Blue Cloth. Price, in United States and Canada, post-paid, $1.25, net; Great Britain, 6s. 6d. ; France, 7 fr. 75. This volume, which is one of a series of three (the other tii^o^ treating of Syphilis in the Middle Ages and in Modern Times, now in active pre]) ara- tion)^ gives the most complete history of Syphilis from prehistoric times up to the Christian Era. The subject throughout is treated in a clear, concise manner, and readers will firkd many things which are historically new. CAPP — The Daughter. Her Health, Education, and Wedlock. Homely Suggestions to Mothers and Daughters. By William M. Capp, M.D., Philadelphia. This is just such a book as a family physician would advise his lady patients to obtain and read. It answers many questions which every busy practitioner of medicine has put to him in the sick-room at a time when it is neither expedient nor wise to impart the information sought. 12mo. 150 pages. Attractively bound in Extra Cloth. Price, in United States and Canada, post-paid, Sl.OO, net ; Great Britain, 5s. 6d. ; France, 6 fr. 20, CATHELL — Book on the Physician Himself, and Things that Concern His Reputation and Success. By D. W. Cathell, M.D., Baltimore, Md. Tenth Edition. Author's last revision, enlarged and perfected. Royal Octavo, about 350 pages, Extra Cloth. Price, in United States and Canada, post-paid, S2.00, net; Great Britain, lis. 6d.; France, 12 fr. 40. CLEVENGER — Spinal Concussion. Surgically Consid- ered as a Cause of Spinal Lijury, and Neurologi- cally Restricted to a Certain Symptom Group, for which is Suggested the Designation " Hrichsen^s Disease,'''' as One Form of the Traumatic Neuroses. By S. V. Clevenger, M.D., Consulting Physician, Reese and Alexian Hospitals ; Late Pathologist, County Insane Asylum, Chicago; Member of numerous American Scientific and Medical Societies ; 4 The F. A. Davis Co., Philadelphia, Pa. Collaborator, Alienist and Neurologist, Journal of Neurology and Ps3'chiatry, Journal of Nervous and Mental Diseases ; Author of ■" Comparative Physiology and Psychology," etc. This book is the outcome of five years' special study and experience in legal circles, clinics, hospital and private practice, in addition to twenty years' labor as a scientific student, writer, and teacher. Evet-y Physician and Lavyyet^ should onm this work. Royal Octavo, nearly 400 pages, with 30 Wood-Engravings. Price, in Unitecl States and Canada, post-paid, 9^2.50, net; Great Britain, 14s.; France, 15 fr. COLTMAN — The Chinese : Their Present and Future ; Medical, Political, and Social. By Robert Coltman, Jr., M.D., Surgeon in Charge of the Presbyterian Hospital and Dispensary at Teng Chow Fu ; Consulting Physician of the American Southern Baptist Mission Society, etc. " Beautifully printed in large, clear type, illustrated with Fifteen Fine Engravings on Extra Plate Paper, from photographs of persons, places, and objects characteristic of China. Royal Octavo, 213 Pages. Extra Cloth, wuth Chinese Side-Stamp in gold. Price, in United States and Canada, post-paid, SI. 75, net; Great Britain, 10s.; France, 13 fr. 30. DAVIS— Consumption : How to Prevent it and How to Live with it. Its Nature, Causes, Pi^evention, and the Mode of Life, Climate, Exercise, Food, and Clothing Necessary for its Cure. By N. S. Davis, Jr., A.M., M.D,, Professor of Principles and Practice of Medicine, Chicago Medical College ; Physician to Mercy Hospital, Chicago; Member of the American Medical Association, etc. 12mo. 143 pages. Extra Cloth, with Back and Side Stamps in Gold. Price, in United States and Canada, post-paid, 75 cents, net ; Great Britain, 4s. ; France, 4 fr. DAVIS — Diseases of the Lungs, Heart, and Kidneys. By N. S. Davis, Jr., A.M., M.D., Professor of Principles and Practice of Medicine, Chicago Medical College ; Physician to Mercy Hospital, Chicago; Member of the American Medical Association, etc., etc. 12mo. Over 300 pages. No. I4 in the Physicians' and iStvde7its' Ready-Reference Series. Extra Dark-Blue Cloth. Price, in United States and Canada, post-paid, S1.S5, net ; Great Britain, 6s. 6d. ; France, 7 fr. 75. DEMARQUAY — On Oxygen. A Practical Investigation of the Clinical and Therapeutic Value of the Gases in Medical and Surgical Practice, with Espe- The F. A. Davis Co., Philadelphia, Pa. 5 cial Refe7'ence to the Value and Availability of Oxygen, Nitrogen, Hydrogen, and Niti^ogen Monoxide. By J. N. Demarquat, Surgeon to the Municipal Hospital, Paris, and of the Council of State ; Member of the Imperial Society of Sur- hysician, and a vx)7'k that will prove xisefvl in the hands of your patients. It is largely suggestive, and gives wise and timely advice as to when a physician should be consulted. Royal Octavo, 425 pages, Extra Cloth, Beveled Edges, with side and back gilt stamps, and Half- Morocco Gilt Top. Price, in United States, post-paid. Cloth, $3.50, net; Half- Morocco, $3.50, net. Canada (duty paid). Cloth, $3.75; Half-Morocco, $3.90, net. Great Britain, Cloth, 14s. ; Half-Morocco, 19s. 6d. France, Cloth, 15 fr. ; Half- Morocco, 33 fr. SHOEMAKER— Materia Medica and Therapeutics. With Especial Reference to the Clinical Application of Drugs. Being the second and last volume of a treatise on Materia Medica, Pharmacology, and Therapeutics, and an independent volume upon drugs. The F. A. Davis Co., Philadelphia^ Pa. 15 By John V. Shoemaker, A.M., M.D., Professor of Materia Medica, Pharmacology, Therapeutics, and Clinical Medicine, and Clinical Professor of Diseases of the Skin in the Medico-Chirurgical College of Philadelphia ; Physician to the Medico-Chirurgical Hos- pital, etc., etc. This volume is wholly taken up with the consideration of drugs, each remedy being studied from three points of view, viz. : the Prep- arations, or Materia Medica ; the Physiology and Toxicology, or Phar- macology ; and, lastly, its Therapy. It is thoroughly abreast of the progress of Therapeutic Science, and is really an indispensable book to evei-y student and practitioner of medicine. Royal Octavo, about 675 pages. Thoroughly and carefully indexed. Price, in United States, post-paid, Cloth, S3.50 ; Sheep, $4.50, net. Canada (duty paid). Cloth, $4.00; Sheep, $5.00, net. Great Britain, Cloth, 19s.; Sheep, 35s. France, Cloth, 33 fr. 40 ; Sheep, 3S fr. 60. The first volume of this work is devoted to Pharmacy, General Pharmacology, and Therapeutics, and remedial agents not properly classed with drugs. Royal Octavo, 353 pages. Price of volume I, post-paid, in United States, Cloth, $2.50, net; Sheep, $3.25, net. Canada, duty paid, Cloth, $2.75, net ; Sheep, $3.60, net. Great Britain, Cloth, 14s., Sheep, 18s. France, Cloth, 16 fr. 30; Sheep, 20 fr. 20. Tlie vohmies are sold separately. SHOEMAKER— Ointments and Oleates, Especially in Diseases of the Skin. By John V. Shoemaker, A.M., M.D. Second Edition, revised and enlarged. 298 pages. 12mo. Neatly bound in Dark-Blue Cloth. ITo. 6 in the Physicians' and Students' Ready- Reference Series. Price, in United States and Canada, post-paid, S1.50, net ; Great Britain, 8s. 6d. ; France, 9 fr. 35. The author concisely concludes his preface as follows: "The reader may thus obtain a conspectus of the whole subject of inunction as it exists to-day in the civilized world. In all cases the mode of preparation is given, and the therapeutical application described seriatim, in so far as may be done without needless repetition." SMITH — The Physiology of the Domestic Animals. A Text-Book for Veterinary and Medical Students and Practitioners. By Robert Meade Smith, A.M., M.D., Professor of Comparative Physiology in University of Pennsylvania ; Fellow of the College of Physicians and Academy of the Natural Sciences, Philadelphia ; of the American Physiological Society ; of the American Society of Natural- 16 The F. A. Davis Co., Philadelphia^ Pa. ists ; Associ6 Etranger de la Soci6t6 Francaise d'Hygi^ne, ete. Royal Octavo, over 950 pages. Profusely illustrated with more than 400 fine Wood-Engravings, some of them Colored. Price, in United States, Cloth, S5.00; Sheep, S6.00, net. Canada (duty paid). Cloth, S5.50 ; Sheep, $6.60, net. Great Britain, Cloth, 28s; Sheep, 328. France, Cloth, 30 fr. 30 ; Sheep, 36 fr. 20. This new and important work is the most thoroughly complete in the English language on the subject. Without being overburdened with details, it forms a complete text-book of physiology, adapted to the use of students and practitioners of both veterinary and human medicine. It has already been adopted as the Text-Book on Physi- ology in the Veterinary Colleges of the United States, Great Britain, and Canada. SOZINSKEY — Medical Symbolism. Historical Studies in the A7^ts of Healing and Hygiene. By Thomas S. Sozinsket, M.D., Ph.D., Author of "The Culture of Beauty," " The Care and Culture of Children," etc. 13mo. Nearly 200 pages. Neatly bound in Dark-Blue Cloth. Appro- priately illustrated with upward of thirty (30) new Wood-Engravings. JVo. 9 in t?ie Physicians' and Students' Beady-Heference Series. Price, in United States and Canada, post-paid, $1.00, net; Great Britain, 6s. ; France, 6 £r. 20. STEWART — Obstetric Synopsis. A Complete Compend. By John S. Stewart, M.D., Demonstrator of Obstetrics ami Chief Assistant in the Gynaecological Clinic of the Medico-Chirurgical College of Philadelphia ; with an introductory note by William S. Stewart, A.M., M.D., Professor of Obstetrics and Gynaecology in the Medico-Chirurgical College of Philadelphia. 42 Illustrations. 202 pages. 12mo. Handsomely bound in Dark-Blue Cloth. No. 1 in the Physicians' and Students' Beady-Refereme Series. Price, in United States and Canada, post-paid, Sl.OO, net ; Great Britain, 6s. France, 6 fr. 20. ULTZMANN — The Neuroses of the Genito- Urinary Sys- tem in the Male. With Sterility and Impotence. By Dr. Ultzmann, Professor of Genito-Urinary Diseases in the University of Vienna. Translated, with the author's permission, by Gardner W. Allen, M.D., Surgeon in the Genito-Urinary De- partment, Boston Dispensary. Illustrated. 12mo. Handsomely bound In Dark-Blue Cloth. No. 4 in the Physicians' and Students' Beady- Befereixce Series. Price, in United States and Canada, post-paid, Sl.OO, net ; Great Britain, 6s. ; France, 6 fr. 20. Synopsis of Contents. — First Part — I. Chemical Changes in the Urine in Cases of Neuroses. II. Neuroses of the Urinary and of the Sexual Organs, Classified as : (1) Sensory Neuroses ; (2) Motor Neuroses ; (3) Secretory Neuroses. Second Part — Sterility and Im- potence. The treatment in all cases is described clearly and minutely. The F. A. Davis Co., Philadelphia, Pa. IT WITHERSTINE— International Pocket Medical Formu- lary. Arranged Therapeutically. By C. Sumner WiTHERSTiNE, A.M., M.D., Associate Editor of the " Annual of the Universal Medical Sciences ;" Visiting Physician of the Home for the Aged, German town, Philadelphia ; late House Sur- geon to Charity Hospital, New York. Including more than 1800 for- mulae from several hundred well-known authorities. With an Appendix containing a Posological Table, the newer remedies included ; Im- portant Incompatibles ; Tables on Dentition and Pulse : Table of Drops in a Fluidrachm and Doses of Laudanum graduated forage; Formulae and Doses of Hypodermatic Medication, including the newer remedies ; Uses of the Hypodermatic Syringe; Formulae and Doses for Inhalations, Nasal Douches, Gargles, and Eye- Washes ; Formulae for Suppositories ; Use of the Thermometer in Disease ; Poisons, Antidotes, and Treat- ment ; Directions for Post-Mortem and Medico-Legal Examinations ; Treatment of Asphyxia, Sun-Stroke, etc. ; Anti-emetic Remedies and Disinfectants ; Obstetrical Table ; Directions for Ligation of Arteries ; Urinary Analysis ; Table of Eruptive Fevers ; Motor Points for Elec- trical Treatment, etc. This work, the best and most complete of its kind, contains about 275 printed pages, besides extra blank leaves for new formulae. Elegantly printed, with red lines, edges, and borders, with illustrations. Bound in leather, with Side-Flap. Price, in iTnited States and. Canada, post-paid, S3.00, net; Great Britain, lis. 6d. ; France, 12 fr. 40. YOUNG— Synopsis of Human Anatomy. Being a Com- plete Compend of Anatoimj, including the Anatomy of the Viscera, and Numerous Tables. By James K. Young, M.D., Instructor in Orthopaedic Surgery and Assistant Demonstrator of Surgery, University of Pennsylvania ; Attending Orthopaedic Surgeon, Out-Patient Department, University Hospital, etc. Illustrated with 76 Wood-Engravings. 320 pages. 12mo. Cloth. iVb. 5 in the Physicians^ and Student s^^Ready-Befermce Series. Price, in United States and Canada, post-paid, $1.40, net; Great Britain, 8s. 6d.; France, 9 fr. 25. While the author has prepared this work especially for students, sufficient descriptive matter has been added to render it extremely valuable to tlie busy practitioner, particularly the sections on the Viscera, Special Senses, and Surgical Anatomy. In addition to a most carefully and accurately prepared text, wherever possible, the value of the work has been enhanced by tables to facilitate and minimize the labor of students in acquiring a thorough knowledge of this important subject. The section on the teeth has also been especially prepared to meet the requirements of students of dentistry. 18 The F. A. Dams Co., Philadelphia, Fa. The following Publications sold only by Subscription, or Sent Direct on Receipt of Price, Shipping Expenses Prepaid. Annual of the Universal Medical Sciences. A Yearly Beport of the Frogresa of the General Sanitary Sciences Throughout the World. Edited by Charles E. Sajous, M.D., formerly Lecturer on Laryn- gology and Rhiuology in Jefferson Medical College, Philadelphia, etc., and Seventy Associate Editors, assisted by over Two Hundred Corre- sponding Editors and Collaborators. In Five Royal Octavo Volumes of about 500 pages each, bound in Cloth and Half-Russia, Magnificently Illustrated with Chromo-Lithographs, Engravings, Maps, Charts, and Diagrams. Being intended to enable any physician to possess, at a moderate cost, a complete Contemporary History of Universal Medi- cine, edited by many of America's ablest teachers, and superior in every detail of print, paper, binding, etc., a befitting continuation of such great works as " Pepper's System of Medicine," " Ashhurst's In- ternational Encyclopaedia of Surgery," " Buck's Reference Hand-Book of the Medical Sciences." SUBSCRIPTION PRICE Per Year (including the " SATEL- L.ITE" for one year: in United States, Cloth, 5 vols., Koyal Octavo, S15.00 ; Half-Russia, 830.00. Canada (duty paid), Cloth, $16.50; Half-Rnisia, »23.00. Great Britain, Cloth, *4 7s.; Half-Russia, «5 15s. France, Cloth, 93 fr. 95 ; Half-Russia, 134 tr. 35. The Satellite of the "Annual of the Universal Medical Sciences " is a monthly Review of the most important articles upon the practical branches of Medicine appearing in the medical press at large, edited by the Chief Editor of the Annual and an able staff. Published in coinnection with the Annual, and for its Subscribers Only. RANNEY — Lectures on Nervous Diseases. From the Stamd-point of Cerebral and Spinal Localization, and the Later Methods Employed in the Diagnosis and Treatment of these Affections. By Ambrose L. Rannet, A.M., M.D., Professor of the Anatomy and Physiology of the Nervous System in the New York Post-Graduate Medical School and Hospital ; Professor of Nervous and Mental Diseases in the Medical Department of the University of Vermont, etc. ; Author of " The Applied Anatomy of the Nervous System," " Prac- tical Medical Anatomy," etc., etc. Profusely Illustrated with Original Diagrams and Sketches in Color by the author, carefully selected Wood-Engravings, and Reproduced Photographs of Typical Cases. Royal Octavo, 780 pages. Price, in United States, Cloth, S5.50; Sheep, S6.50; Half- Russia, S7.00. Canada (duty paid), Cloth, 86.05 ; Sheep, S7.15; Half-Russia, S7.70. Great Britain, Cloth, 32s.; Sheep, 37s. 6d. ; Half-Russia, 40s. France, Cloth, 34 £r. 70 ; Sheep, 40 fr. 45 ; Half-Russia, 43 fr. 30. The F. A, Davis Co., Philadelphia, Pa. 19 SAJOUS — Lectures on the Diseases of the Nose and Throat. Delivered at the Jefferson Medical College, Philadelphia. By Charles E. Sajous, M.D., formerly Lecturer on Rhinology and Laryngology in Jefferson Medical College ; Vice-President of the American Laryngological Association ; OfBcer of the Academy of France and of Public Instruction of Venezuela ; Corresponding Mem- ber of the Royal Society of Belgium, and of the Society of Hygiene of France; Member of the American Philosophical Society, etc., etc. Illustrated with 100 Chromo-Lithographs, from Oil-Paintings by the author, and 93 Engravings on Wood. One handsome Royal Octavo volume. Price, in United States, Cloth, $4.00 ; Half-Kussia, $5,00. Canada (duty paid). Cloth, $4.40; Half-Russia, $5.50. Great Britain, Cloth, 33s. 6d. ; Sheep or Half-Kussia, 38s. France, Cloth, 34 fr. 60 ; Half-Bnssia, 30 fr. 30. Stanton's Practical and Scientific Physiognomy; op How to Read Faces. By Mart Olmsted Stanton. Copiously Illustrated. Two large Royal Octavo volumes. The author, Mrs. Mart O. Stanton, has given over twenty years to the preparation of this work. Her style is easy, and by her happy method of illustration of every point, the book reads like a novel and memorizes itself. To physicians the diagnostic information conveyed is invaluable. To the general reader each page opens a new train of ideas. (This book has no reference whatever to Phrenology.) Price, in United States, Cloth, $9.00; Sheep, $11.00; Half- Russia, $13.00. Canada (duty paid), Cloth, $10.00; Sheep, $13.10 ; Half-Bnssia, $14.30. Great Britain, Cloth, 56s. ; Sheep, 68s. ; Half-Bussia, 80s. France, Cloth, 30 fr. 30 ; Sheep, 36 fr. 40 ; Half-Bussia, 43 fr. 30. Sold only by subscription, or sent direct on receipt of price, ship- ping expenses prepaid. Journal of Laryngology, Rhinology, and Otology. A71 Analytical Record of Current Literature Relating to the Throat, Nose, and Ear. Issued on the First of Each Month. Edited by Dr. Norris Wolfenden, of London, and Dr. John Macinttre, of Glasgow, with the active aid and co-operation of Drs. Dundas Grant, Barclay J. Baron, and Hunter Mackenzie. Price, 13s. or $3.00 per annum (inclusive of Postage). For single copies, however, a charge of Is. 3d. (30 cents) will be made. Sample Copy, 35 Cents. 20 Tlie F. A. Davis Co., Philadelphia, Fa. The Medical Bulletin. Edited hy John V. Shoemaker, A.M., M.D. Bright, Original, atid Readable. Articles by the best practical -writers procurable. Every article as brief as is consistent -with the preservation of its scien- tific value. Therapeutic notes by the leaders of the medical profession throughout the world. These and many other unique features help to keep The Medical, Bulletin in its present position as the leading low-priced medical monthly of the world. Subscribe now ' TERMS, Sl.OO A TEAK IX ADVANCE. In United States, Canada, and Mexico. ENGIiAND and JAPAN, 1 Yen. AUSTKAXIA, 5 ShilUngs. GERMANY, 5 Marks. FRANCE, 6 Francs. HOL.L,AND, 3 Florins. JUST PUBLISHED. Psychopathia Sexualis. With Especial Beference to Contrary Sexual Instinct. By Db. R. von Krafft-Ebing, Professor of Psychiatry and Neurology in the University of Vienna. Authorized translation of the Seventh German Edition by Charles Gilbert Chaddock, M.D., Assistant Medical Superintendent Northern Michigan Asylum ; Fellow of the Chicago Academy of Medicine. Prof, von Krafl't-Ebing's study of the psychopathology of the sexual life was, when first published, a small monograph ; but in the seven editions through which it has passed so rapidly it has received 60 many additions and been made to cover so completely every aspect of the anomalies of the sexual sphere that the work now desei-ves the name of a treatise. It easily supersedes all previous attempts to treat this important subject scientifically, and it is sure to commend itself to members of the medical and legal professions as a scientific expla- nation of many social and criminal enigmas to which no work in English offers a solution. In one Royal Octavo volume, over 500 pages. The work will be sold only by subscription to members of the medical and legal professions at the following prices : — Price, in Fnited States, Cloth, S3.00, net ; Sheep, S4.00, net. Canada (duty paid), Cloth, S3. 30, net ; Sheep, S4.40, net. Great Britain, Cloth, ITs. 6d. ; Sheep, 32s. 6d. France, Cloth, 18 fr. 60 ; Sheep, 24 fr. 60. \ UNIVERSITY OF CALIFORNIA LIBRARY Los Angeles This book is DUE on the last date stamped below. BlOpD. LIB. AYZaREgb B\0' i^A^O oB' v^ :.'-- MAY 1 4 REC'D swWEDMAY 23 JUN2QREC'D Form L9-40m-5,'67(H2161s 1979 s8)4939