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<l ammonium 
 are also mild expectorants, acting as do the chloride 
 nud carbonate of ammonium. Of the iodides the ammo- 
 nium compound is the best ex[)ectoraut, but is most 
 irritating to the stomach. Therefore, as tliey must in 
 many cases of chronic bronchitis be emplo3'ed continu- 
 ousl}^ for long periods, the iodide of soda is usually to 
 be i)referred. 
 
 Undoubtedly, many threatened attacks of bronchitis 
 can be checked or rendered abortive. But this is only 
 possible in the stage of congestion, before inflammation 
 is established, and providing the exciting cause is re-
 
 Trachitis and Bronchitis. 45 
 
 moved. If, just as the chill is passing off and tracheal 
 soreness and coughing begin, diaphoresis is promptly 
 produced and simultaneously a full dose of opiate is 
 administered, a cessation of the development of the 
 disease can be obtained. Dover's powder is the opiate 
 that is best adapted to this stage, and should be given 
 in a single large dose. Diaplioresis should be estab- 
 lished at the same time by hot baths and drinks. The 
 opiate undoubted!}^ lessens the irritability of the con- 
 gested tissue, and the diaphoretics deplete the congested 
 vessels and prevent the formation of exudates and other 
 phenomena of inflammation. Tliis mode of treatment 
 is well adapted to sthenic cases onl}-. If the patient 
 is debilitated from an}- cause, if his tissue-changes are 
 taking place slowh', a different abortive treatment 
 proves more effectual. This consists in the adminis- 
 tration of one or two large doses of quinine and an 
 opiate. In these cases there is a lack of vascular tone, 
 and, therefore, depletion of the congested vessels does 
 not lead to their contraction and restoration. Quinine, 
 however, and strj'chnine also, seem to stimulate the 
 vasomotors, so that the lost vascular tone is reg-ained. 
 The opiate is still needed to lessen the irritabilit}- of 
 the bronchial tissues. A capsule of quinia sulphate 
 and morphia sulphate, in doses of 0.3 gramme and 0.008 
 gramme (5 and ^ of a grain), respectivel}^, is the most 
 convenient form of administration. Two of these 
 should be given at first, and one every three or four 
 hours afterward, until four or five doses have been 
 taken. 
 
 Unfortunately, abortive treatment can rarely be 
 applied, as patients do not often seek a physician until 
 the inflammation is fairly established and until it is too 
 late to employ it successfully.
 
 46 Diseases of the Bronchi. 
 
 In the dry stage of simple acute bronchitis the indi- 
 cations are (1) to lessen cough and soreness, (2) to pro- 
 mote the formation of a thin expectorate, and in the 
 moist stage (3) to aid the elimination of secretions. 
 As the course of the disease is usually short, a formula 
 is generally advised which will meet all of these indica- 
 tions at once ; such as the following : — 
 
 1. R Ammon. muriat., . . grms. 10.0 (3iiss). 
 
 Morph. muriat., . . grm. 2 (gr. iv). 
 Antim. et pot. tart., . grm. 0.15 (gr. iiss). 
 
 Syr. glycyrrhiz., q. s. ad c.cm. 120.0 (5iv), 
 
 Sig. : Give of the mixture one teaspoonful to adults every 
 three to six hours. 
 
 2. R Sod. bromid., . 
 
 Tinct. sanguinariae, . 
 
 Tinct. opii camph., . 
 
 Syr. scillse comp., 
 
 Syr. tolut., . q. s. ad c.cm. 120.0 (^iv). 
 
 This can be given in the same doses as the last, but 
 more frequently, if needed. All expectorant mixtures 
 are more or less nauseating, and diminish the appetite 
 and make digestion slow. The second formula, while 
 less efficient as a cough-mixture, causes verj' little dis- 
 turbance of the stomach. I have found frequentl}' that 
 when the stomach is peculiarl^^ sensitive the following 
 capsule proves efficient : — 
 
 R Ammonii chloridi, . . grm. 0.06 (gr. j). 
 Codeise, .... grm. 0.012 (gr. \). 
 
 One should be administered each hour. When the 
 larynx and trachea are cliiefl}' involved, a compressed 
 tablet of the following ingredients is exceedingly 
 useful : — 
 
 R Terpin. Iiydrat., . . grm. 0.12 (gr. ij). 
 Extract, cannabis Indica?, grin. 0.003 (gr. ^). 
 ■ Codeiae, . . . . grm. 0,008 (gr. |). 
 
 grms. 
 
 20 (3v). 
 
 c.cm. 
 
 10.0 (Siiss). 
 
 c.cm. 
 
 45.0 (|iss). 
 
 c. cm. 
 
 45.0 (5iss).
 
 Trachitis and Bronchitis. 4Y 
 
 They may be given alone, one every half-hour or 
 hour, with less frequent doses of expectorant mixtures. 
 They should be allowed to melt gradually in the mouth. 
 
 The fever of bronchitis rarely requires especial 
 treatment. In ad3^namic cases, or when debility is a 
 prominent feature, moderate doses of quinine are useful 
 (from grm. 0.15 to 0.25). In sthenic cases aconite may 
 be used, and may contribute materiall}^ to lessen fever 
 and to produce a feeling of greater well-being. To 
 children who sometimes have high temperature and 
 consequent delirium, a few doses of antipyrin can be 
 given most advantageously. 
 
 Many mild cases of acute bronchitis require no 
 treatment, and numerous complications necessitate a 
 modification of the course just sketched. It is desira- 
 ble that the bowels be kept regular. As the opiates 
 which are usually required cause constipation, a laxative 
 must be administered. 
 
 The indications for treatment in acute capillary 
 bronchitis are (1) to maintain strength, both (a) gen- 
 eral and (b) cardiac ; (2) to relieve dyspnoea hy (a) 
 loosening and (b) expelling the secretions from the 
 bronchioles. 
 
 The course of simple acute bronchitis is so short, 
 and ordinaril3^ the general strength of a patient is so 
 little affected, that special dietary directions are unnec- 
 essary. In capillary bronchitis, however, very great 
 and rapid physical prostration is produced. Often, 
 cardiac weakness is developed, which greatly increases 
 the danger to life. For these reasons the sufferer's 
 strength must be preserved. A diminished appetite, 
 and even a disinclination for food, is the rule in this 
 disease. Therefore, feeding should take place with as 
 much regularity as the administration of medicine, and
 
 48 Diseases of the Bronchi. 
 
 should not be governed by appetite. The food should 
 be concentrated, and in such a form that it is most 
 easily digested. Milk and milk-gruels are probably the 
 best foods. Occasionally-, to var^^ the diet, meat-broths 
 can be advantageously given, or soft cooked eggs or 
 raw eggs beaten up in the milk. The food is best 
 administered in small quantities during the severest 
 part of the attack, and frequently' repeated, so that the 
 stomach, which is doing its work slowl}', may not be 
 overloaded. And even when disinclined for food a 
 patient will take two or three teaspoon fuls without dis- 
 gust. Especial attention must, in severe cases, be paid 
 to the maintenance of strength. 
 
 Cardiac strength must be preserved, whenever acute 
 failure is threatening, by the combined use of diffusible 
 stimulants and cardiac tonics. The carbonate of am- 
 monia is one of the best diffusible stimulants. Its 
 effects are the most promptl}- obtained when it is given 
 in solution, and they may be somewhat augmented by 
 dissolving it in camphor-water. The doses should be 
 such that the}' can be repeated as often as every hour, 
 for the stimulant effect of the drugs is transitor}^ Ex- 
 cellent results can be gotten from a solution of camphor 
 in oil administered h3'podermaticall3'. The effects of 
 alcoholics under these circumstances can be best con- 
 sidered in connection with the treatment of croupous 
 pneumonia. (See pjv<:e 103.) If used, alcohol should be 
 given diluted, so that its exact strength is known. Its 
 stimulant effects on the circulation are transitory- and 
 are obtained only from small doses. So soon as its 
 anesthetic effects are developed, either from the admin- 
 istration of large doses or small ones, frequently re- 
 peated for some time, cardiac stimulation is no longer 
 obtained, and the patient is less likely to keep the air-
 
 Trachitis and Bronchitis. 49 
 
 passages clear hy coiigliing and voluntary efforts to 
 breathe deeply ; congestion is prolonged and tendencies 
 to congestion confirmed because of the lessened vascu- 
 lar tonicity- which is produced. Furthermore, alcohol 
 in the blood lessens its al)ility to take up oxygen from 
 the air inspired. In a word, it increases the difficulty 
 already existing of furnishing to tlie tissues the oxygen 
 that they need. Digitalis, or strophanthus, which is 
 often better in these cases, must be used simultaneously 
 with the diffusible stimulants. As a rule, before the 
 latter drugs are indicated, when the pulse is rapid and 
 begins to grow soft or small, digitalis, or one of its con- 
 geners, should be employed to stimulate the heart's 
 contractions and prevent the development of marked 
 cardiac weakness. Yeratrum and aconite should never 
 be used unless at the xery onset of an attack, and then 
 the3^ may act as depletors might, — to relieve congestion 
 and prevent inflammation. If used while the heart is 
 laboring and growing weary, the}' increase the tendency 
 to cardiac dilatation. They are hardl}' ever required in 
 bronchiolitis. 
 
 To relieve dyspnoea, the air-tubes must be emptied 
 of the obstructing secretion and the swelling of the walls 
 of the finer ones lessened. The first of these indications 
 for treatment can be met b}' rendering the secretions 
 more liquid, and therefore" more easil}^ dislodged. The 
 carbonate and muriate of ammonia will help to accomp- 
 lish this. The inhalation of moist air is exceedingly 
 beneficial, as all the moisture inhaled at once aids by 
 diluting the secretions. Those suffering from severe 
 attacks of bronchiolitis should be kept in rooms whose 
 air is at a constant temperature and made moist by 
 evaporating water. The inhalation of the warm spray 
 
 of a steam-atomizer is also useful. The patient can 
 
 3 c
 
 50 Diseases of the Bronchi. 
 
 render the secretions less tenacious, but also more 
 copious, b}' free libations of water and fluid foods. 
 
 Emesis is seldom advantageous. By it the bronchial 
 tubes are most perfectl}^ emptied, but the depression 
 which most emetics produce is deleterious, and often is 
 followed by an irritable condition of tiie stomach which 
 interferes with the maintenance of nutrition. The sub- 
 sulphate of mercury' causes prompt emesis with ver}- 
 little depression.- It can be used. when there is much 
 dyspnoea in strong and vigorous patients, but it should 
 not be frequently repeated. Oftener emetics are given 
 in small doses as nauseating expectorants. Apomorphia 
 is a favorite with man}', and is given in doses of 0.003 
 gramme, or one-twentieth of a grain, everj^ two to four 
 hours. Similarl}' tartar emetic (dose, grm. 0.005, or 
 gr. y^^) and syrup of squiljs and ipecac (dose, c.cm. 2 to 
 4, or 5ss to j) can be emplo^^ed. 
 
 Forceful respiration is one of the principal means 
 by which mucus is dislodged from the bronchi. In 
 dyspnoea, when voluntary exertion flags and when cya- 
 nosis develops, deep and forceful breathing is stimulated 
 by sudden immersion in a bath or b}' a douche upon the 
 back of the neck of alternating hot and cold water. 
 
 In subaeute and chronic cases much aid can be ob- 
 tained from inhaling compressed and exhaling into rare- 
 fied air, for then the respirator}' movements are aug- 
 mented and surprisingly large amounts of mucus emptied 
 from the bronchi. Anodynes and ansestheties are contra- 
 indicated except in the mildest and in chronic cases. In 
 all severe acute cases the}' lessen cough and diminish 
 the force of the respiratory acts. This increases the 
 obstruction of the bronchioles, and cyanosis and pul- 
 monary oedema are not unfrequently precipitated, when 
 they should be avoided or guarded against.
 
 Trachitis and Bronchitis. 51 
 
 Antipyretics are generally of no use. By lowering 
 the temperature they do not remove the cause of its 
 elevation. They contribute little to a feeling of well- 
 being. They lessen the power of haemoglobin to take 
 up oxygen, and thus increase the desire already felt for 
 it. Baths are useful, especiallj^ sponge-baths and douches, 
 because of their stimulating effects upon the circulation 
 and respiration, as well as for their antipyretic influence. 
 They are not, however, needed unless the temperature 
 is very high or the dj-spnoea ver^^ great. They may 
 then be resorted to frequently with advantage. 
 
 Some cases, mostl}^ of the subacute t3'pe, are appa- 
 rently- the result of rheumatic conditions. The addition 
 of salicylate of soda and of wine of colchicum to the 
 usual treatment for bronchiolitis often effects conva- 
 lescence with wonderful promptness. 
 
 In chronic cases the iodide of soda, continuously 
 employed, proves useful in man}- instances, but gener- 
 ally does not effect a complete cure. In the acute 
 cases nothing relieves the swelling of the mucous mem- 
 brane so much as getting the bronchioles free from 
 obstruction, so that the varyiug air-pressure which is 
 caused by respiration ma^' promote a more perfect lym- 
 phatic circulation, and thereby absorption of inflamma- 
 tory exudates. 
 
 The frequent complications — emphysema and catar- 
 rhal pneumonia — will be treated of separatel}'. (See 
 pages 61 and 82.) 
 
 During convalescence the utmost care must be taken 
 to avoid exposure to causes that might excite a new 
 attack. Atmospheric changes must be guarded against 
 by woolen clothing. A ver}^ careful and gradual expo- 
 sure to air otlier than that of the sick-room must be 
 contrived. Relapses can frequently be avoided^ wheij
 
 52 Diseases of the Broncln. 
 
 recoveiy is fairiy obtained, b^'' a change of climate for 
 a winter from the inclement and changeable air of north- 
 ern temperate regions to localities warmer and more 
 equable. During convalescence food can be varied and 
 often can soon be made that of 'health, as the appetite 
 returns and the digestive function is restored. When 
 there is an atonic or depressed physical condition prior 
 to the attack of bronchitis, and occasionall}^ in other 
 cases, the appetite does not return as the bronchitis les- 
 sens. Under these circumstances, bitter tonics, such as 
 gentian or weak solutions of strychnia, especially when 
 combined with active preparations of pepsin and with 
 h3-drochloric acid, are useful. 
 
 The general indications for the treatment of chronic 
 bronchitis are the same as those for acute simple bron- 
 chitis ; but each variet}^ affords additional important 
 indications. 1. For example, it is frequenth' necessar^^ 
 to forcibh' maintain permeability of the air-passages, 
 in order to overcome the dyspnoea M'hich develops from 
 the accumulation of secretions within the bronchi and 
 from the thickening of their walls. 2. Less frequentl}^ 
 true asthma is present, and must be treated. 3. To 
 modify purulent and fetid secretions is another frequent 
 indication for treatment. 
 
 What I have termed chronic winter cough, usually 
 the mildest and least harmful form of chronic bronchitis, 
 must be treated in the main as is acute bronchitis. This 
 form of the disease can often, in the first year or two of 
 its course, be cured by prophjdactic measures. A 
 change of climate to a warm and equable region is 
 usuall}'- necessary. The general health should be main- 
 tained at the highest degree of vigor. Exposing occu- 
 pations and unwliolesome places of residence should be 
 avoided, Whenever acute exacerbations occur they
 
 Trachitis and Bronchitis. 53 
 
 should be promptly alhiyed by the usual medicinal 
 treatment for acute broncliitis. 
 
 In some of the more chronic cases, especially when 
 there is moderate but persistent dyspnoea on exertion, 
 the iodides can be given with advantage. Their use 
 should be continued for months ; therefore, the iodide 
 of soda is the preparation to be preferred. In children 
 we obtain good results by the persistent use of cod- 
 liver-oil. This is true especialh' of those who are 
 slender and not well nourished. In adults the oil ap- 
 pears rareh' to accomplish the same results, because it 
 is taken in comparatively smaller quantities, and is more 
 apt to cause disgust or digestive disturbances. 
 
 In dry broncliitis, with its usual paroxj^smal cough, 
 much relief is obtained from prolonged or permanent 
 residence in a moist, warm climate, or In^ the frequent 
 inhalation of steam vapor or atomized vapors. These 
 lessen the frequency and severity of the cough, and, by 
 adding moisture to the mucus within the bronchi, 
 render it thin and more easily dislodged. Chloral is an 
 efficient adjuvant to opiates to modifj^ the spasmodic 
 qualit}' of the cough. It may be combined with ordi- 
 nary anodyne and expectorant mixtures, and thus admin- 
 istered frequently in small doses (grm. 0.2 to 0.3); or, if 
 the cough occur with much regularity it may best be 
 administered in larger doses once or twice daily, a little 
 before the paroxysm is expected to occur. 
 
 The persistent use of ammonium muriate or the 
 iodide of ammonia or soda also increases the liquidity 
 and usually the amount of secretions. I have often 
 thought the most prompt effects were to be obtained 
 from small doses often repeated, as, for instance, from 
 12 centigrammes (2 grains) of the muriate of ammonia 
 every hour or two. After the secretions have thus
 
 54 Diseases of the Bronchi. 
 
 been loosened, the}' can iisuall}' be maintained so by 
 using larger doses two or three times daily. These 
 remedies interfere somewhat witli digestion and with 
 the appetite, therefore the}' cannot always be. efficiently 
 emplo3'ed in clironic cases. It is often more important 
 to maintain good nutrition than to ease a cough. 
 
 Spasmodic dyspnoea, or true asthma, is to be relieved 
 by the remedies whose use has been described (See 
 page 12). Our efforts should be especiall}' directed to 
 tlie removal of the cause during the intervals of normal 
 breathing. 
 
 Turpentine and similar drugs are especially adapted 
 to those cases in which it is desirable to diminish the 
 secretions of the bronchi or to render them less puru- 
 lent. To this class of remedies belongs turpentine-oil, 
 terebene, Venice turpentine, copaiba, eucal^'ptus, crea- 
 sote (beech-wood), etc. It is often surprising how 
 quickl V a marlied diminution in the amount of expecto- 
 rate can be effected by these remedies. The secretions 
 are lessened and made more tenacious. Therefore, when 
 the expectorate is alread}' tenacious and difficult to dis- 
 lodge, the employment of these drugs makes expec- 
 toration more difficult and coughing harder and more 
 prolonged. Tliey shoukl not be used under such con- 
 ditions. They are especiall}^ indicated when the exi)ec- 
 torate is tliin and abundant. 
 
 The same drugs (especially turpentine and creasote) 
 will convert, often with great rapidity, a thin, purulent 
 secretion into one less abundant and muco-purulent. 
 They certainl^^ modify suppuration in the air-passages. 
 Turpentine is best administered as an emulsion. Venice 
 turpentine can conveniently be given in capsules, in 
 doses of from 0.05 to 0.20 gramme (1 to 3 grains). 
 Creasote is also convenientlv administered in capsules,
 
 Trachitis and Bronchitis. 65 
 
 in doses gradually increased from 0.2 to 0.3 gramme 
 (3 to 5 minims). Usually, these drugs must be com- 
 bined with anodynes to allay cough. 
 
 The fermentation which characterizes putrid bron- 
 chitis is modified somewhat by the internal administra- 
 tion of remedies belonging to the group that has just 
 been described, mid most by creasote, eucalyptus, and 
 terebene ; but much more benefit is gotten from the 
 employment of antiseptic inhalations. To cause anti- 
 septics to penetrate to the deepest part of the air- 
 passages they must be inhaled for hours at a time, and 
 all the air that is breathed impregnated with them. 
 This is best accomplished by using a respirator which 
 covers the mouth and nostrils and can be worn for hours 
 consecutively. The cotton or other absorbent which it 
 holds and through which the inspired air is drawn must 
 be saturated with carbolic acid, eucalyptus-oil, thymol, 
 or similar volatile antiseptic. Steam inhalers and atom- 
 izers are sometimes employed, but are of comparatively 
 little use. A Florence flask partly filled with hot water 
 to which there has been added a volatile antiseptic, and 
 so arranged that air can be drawn tlirough the hot 
 medicated water for inhalation, will prove moderately 
 efficient ; but as it cannot be used as continuously as the 
 respirator, it is not to be preferred. By this treatment 
 putrefactive changes can lie greatl}' lessened and often 
 entirely prevented. The best results are, of course, 
 obtained in cases that come early under treatment. 
 
 Purulent and putrid bronchitis is usually accom- 
 panied by hectic fever and gradual but persistent loss 
 of flesh and strength. Therefore we have, as prominent 
 indications for treatment, the- maintenance of strength. 
 This is best accomplished by the systematic administra- 
 tion of the most nutritious food. Usually, the appetite
 
 56 Diseases of the Bronchi. 
 
 is poor or capricious; therefore, food must often be 
 varied. Exercise whicli is exhausting must be avoided. 
 The fever, if it require any treatment, needs that which 
 will be described (see page 159.) where tuberculous 
 disease of the lunas is considered.
 
 CHAPTER III. 
 
 Bronchiectasis. 
 
 Anatomy. — Diliitation occurs most frequently in the 
 medium-sized bronchi, rarel}^ in the smaller ones, and 
 still less frequently in the large ones. It occurs with 
 equal frequency in both lungs, but oftener in the lower 
 and middle lobes than in the upper. Usually a single 
 bronchiectatic cavity is formed on one bronchus, but a 
 number of them may be. They are then commonl}' sep- 
 arated from one another by unusually narrow tubes. 
 The cavities vary much in shape. They may be fusi- 
 form or sacculated, round or angular. As a rule, they 
 are not large ; but they may occupy almost an entire 
 lobe of the lung. They differ from other pulmonary 
 cavities in that a single bronchus enters them, in that 
 their walls show some of the anatomical elements of 
 bronchial tubes, and in that usuall}^ the}^ are not angular 
 and are not intersected b}- bands of fibrous tissue and 
 blood-vessels. The walls of the cavity are so modified 
 b}^ chronic inflammation that the anatomical elements 
 characteristic of a bronchial wall are often obscured or, 
 in places, obliterated. The mucous membrane varies in 
 appearance, as it does in chronic bronchitis, when no 
 dilatation exists. It may be unusuall}^ smooth and re- 
 semble a serous membrane, the cylindrical epithelium 
 having been shed and replaced b}- flattened, pavement- 
 like cells. Or it ma}^ be loose and thrown up into folds ; 
 or from it excrescences may protrude. Or the surface 
 may be fenestrated by the atroph}^ of the muscular ele- 
 ments and persistence or h3q)ertroph3^ of the elastic 
 
 3* (57)
 
 58> 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<mo?im follows the acute 
 attacks. Sometimes fever persists for weeks, and even 
 months, but it is hectic in t^pe. Often, in such cases, 
 an abscess forms, or tubercular complications develop. 
 In other cases the fever ceases, and a part of the 
 patient's sti'ength slowly returns ; but he remains short- 
 winded, often coughs slightl}'', and fills the affected side 
 less than the opposite. The affected side is a little dull, 
 and increased fremitus persists there. The respiratory 
 sounds may be consonant, but more frequently they are 
 low and broncho-vesicular. The thorax on that side 
 slowly contracts. The opposite lung becomes emphy- 
 sematous, is h3'perresonant, and the respiratory sounds 
 in it are exaggerated. Resolution may finally take 
 place, but often the lung is permanently crippled. 
 
 Diagnosis. — In most cases a direct diagnosis can be 
 made from the sudden onset of the characteristic symp- 
 toms ; from the course of the fever ; from the occur- 
 rence of rusty sputa; from the characteristic pulse- 
 respiration ratio ; and from ph3'sical signs. 
 
 It can be distinguished from drj' pleurisy by the 
 greater severity of the disease, by the pulse-respiration 
 ratio, b}" the rusty sputa, and the physical signs of 
 lung congestion or consolidation. It can be distin- 
 guished from typhoid fever by the absence of abdom- 
 inal S3'mptoms and of the t3^phoid rash ; b3' the presence 
 of the usual pulse-respiration ratio ; often of a bloody
 
 100 Diseases of the Lungs. 
 
 sputa, find the ph3'sicfil signs of lung consolidation. It 
 is more difficult to distinguish between h^^postatic con- 
 gestion and the catarrhal consolidation which frequently 
 accompanies it, and a complicating croupous pneumonia. 
 If fibrinous casts are found in the sputa they are quite 
 characteristic of croupous pneumonia. The congestion 
 is usually bilateral, and involves the dependent parts of 
 both lobes of the lungs, while croupous pneumonia is 
 usually unilateral, and involves only one lobe, — gener- 
 ally- the lower. Hj^postatic congestion does not cause 
 as great ph3-sical prostration as does a complicating 
 pneumonia. 
 
 Treatment. — There is no sj^ecific treatment for 
 croupous pneumonia. It must be treated sj-mptomati- 
 cally. The mildest cases require good nursing, and 
 almost no medication. The severe cases require a sup- 
 porting and stimulating treatment. The disease is espe- 
 cially characterized b}- great prostration, which, in some 
 cases, might almost be called shock. For its relief, as 
 well as to allay the pleuritic pains which are usually at 
 first felt, opiates must be employed. When pneumonia 
 is of moderate severit}-, and occurs in one who is robust, 
 Dover's powder is a useful preparation. If, however, 
 the patient is debilitated at the start, the opiate should 
 be combined with quinine. A pill of morphia and sul- 
 phate of quinine is then the "most conveniently admin- 
 istered. The opiates should be used in such doses and 
 repeated with such frequenc\' as to insure at least 
 moderate relief from pain, but. if possible, constant 
 drowsiness should not be caused. When quinine is 
 used, from 10 to 12 grains dailj'' is sufficient. 
 
 In the stage of congestion depleting agents rarely 
 will shorten the course of the disease, or even prevent 
 consolidation. Venesection has most frequently accom-
 
 Cr^oiipous Pneumonia. 101 
 
 plished this. It can be safely practiced upon sthenic 
 cases, but is almost invariablj^ useless for those who are 
 not vigorous and robust when attacked by the disease. 
 Instead of venesection, especially in asthenic cases, 
 blisters, diy^ cups, and fomentations on the affected side 
 are indicated. Aconite and veratrum have been com- 
 mended in this stage, because, b}' relaxing the peripheral 
 vessels, a depletion is produced. They must be used 
 with caution, however, and onl}' in the stage of conges- 
 tion, for they tend to weaken the heart's action. There 
 is so much danger to life in this disease, because of car- 
 diac w^enkness, that its strength must always be pre- 
 served. After consolidation has taken place, the 
 ammonium carbonate (grm. 0.18 to 0.3 — gr. iij to v) 
 or mild chloride of mercury (grm. 0.015 to 0.06 — gr. ^ 
 to j) may be given to hasten the solution of the exudate. 
 The severest cases must be treated like the milder 
 ones, but there are two great dangers to life which must 
 be guarded against. The first is heart-failure, and the 
 second is suffocation. In order to maintain the heart's 
 vigor, resort must be had to cardiac tonics and diffusible 
 stimulants. The best of the latter group of remedies is 
 ammonium carbonate. In order to get its full effects as 
 a cardiac stimulant, it must be taken in solution, for its 
 irritation of the gustatory nerves reflexl}- excites the 
 heart to more vehement action. After absorption it 
 also stimulates it. The effect of ammonia is very 
 transitory. It must, therefore, be often repeated. The 
 doses may be from grm. 0.18 to 0.3 (gr. iij to v) everj' 
 hour. A solution 1 part of camphor in 10 of olive-oil 
 has been used, with excellent eflect, hy hypodermatic 
 administration. Diffusible stimulants are chiefl}^ indi- 
 cated when failure is imminent. When the impulse of 
 the heart first loses its force fulness and the pulse begins
 
 102 Diseases of the Lungs. 
 
 to soften or to grow small, cardiac tonics, such as digi- 
 talis and strophantlius, are indicated. The latter is to 
 be preferred, for it provokes qnite as forceful contrac- 
 tion of the heart as digitalis, and does not contract the 
 peripheral vessels to the same extent. The latter effect 
 should be avoided, because it increases the work of the 
 heart. The tinctures of strophantlius and digitalis are 
 the most certain preparations for administration. I have 
 found 10 minims of each, repeated ever\' four or three 
 hours, the best dose for steady use, although, at times, 
 a little larger or a little smaller dose ma}' be preferable. 
 In many severe cases it is necessary to give those reme- 
 dies almost from the beginning of the disease. 
 
 Spongings of the bod}', showers, and douches, espe- 
 cially when a[)plied about the chest and the back of the 
 neck, are strong cardiac and respiratory stimulants. 
 They also are chiefly indicated when heart-failure is 
 imminent. 
 
 While these especial cardiac stimulants and tonics 
 are useful as prods or goads to the flagging organ, it 
 must not be forgotten that the strength which they 
 excite is a temporary one. They call forth, as it were, 
 the organ's reserve strength. To give true strength to 
 the heart reliance must be placed upon food. Strj'chnia 
 and quinine are often serviceable, because the}" prompt a 
 more rapid and better degree of general nutrition. They 
 can be advantageously administered in combination with 
 the cardiac tonics. 
 
 Suffocation generally results from pulmonar\' oedema. 
 I need not repeat the treatment which is indicated when 
 it occurs. (See page 81.) If pulmonary oedema exist 
 digitalis is to be preferred to strophantlius, because it 
 does contract the vessels, and ma}^ possibly hinder 
 exudation through their walls. Atropia, ergot, and
 
 Croupous Pneumonia. 103 
 
 str3"chnia are the other drugs upon Avhich reliance must 
 be placed. The inlialation of oxygen will save a number 
 of otherwise fatal cases. 
 
 When bronchitis is severe or precedes pneumonia it 
 greatly increases the danger to life, as it increases the 
 tendenc}^ to pulmonary oedema. Opiates must be used 
 with caution in these cases, for, by suppressing cough, 
 they prevent the clearing of the air-tubes, and they also 
 tend to dilate the peripheral vessels, which may hasten 
 oedema. 
 
 Antipyretics, especially antipyrin and its congeners, 
 have been extensivel}^ used in pneumonia, but with 
 doubtful efflcac3\ The temperature is rarel}^ so high 
 that, in itself, it is a source of danger; therefore, it is 
 not necessary to lower it in order to save life. Anti- 
 pja'in, acetanilid, and similar drugs depress the nervous 
 sj'stem, frequently increase the depression or condition 
 of shock which the disease produces, and may even pro- 
 duce a state of collapse. The}^ lessen the oxygen- 
 carrying power of the blood. In many cases it is \e\'y 
 important to preserve this power. To depress the 
 temperature does not shorten the course of the fever or 
 modify the important local lesions. The statistics of 
 cases treated with antipyretics show often an increased 
 mortality, and certainly not a greater ratio of lives 
 saved. I have discontinued their use in these cases. 
 
 Quinine is especially indicated in atonic cases, and 
 then is best given in daily doses of 10 or 12 grains. 
 When malarial trouV)les complicate the pneumonia larger 
 doses may be required. 
 
 Alcoholics have been used in pneumonia with great 
 freedom. The}^ have been prescribed for two purposes, 
 neither of which, I believe, is attained by them. They 
 have been used as foods and as diffusible stimulants.
 
 104 Diseases of the Lungs. 
 
 Whether thej' are foods or not is a question still debated. 
 It is proven, however, that those who take them cannot 
 accomplish as much work or endure as much hardship 
 as those wlio do not. They are not, therefore, strength- 
 giving. As diffusible stimulants, therapeutists state 
 that they provoke stronger pulsations of the heart when 
 given in small amounts. If their anaesthetic effects are 
 produced they weaken the heart's action. Even in small 
 doses no stimulation is produced in persons who are 
 accustomed to them. Such effects are very transitorj' ; 
 and, if the drug is frequently repeated in order to main- 
 tain them, its ansesthetic properties are manifest. In 
 large amounts, — several ounces daily, — as it is often 
 prescribed, it lessens the oxj^gen-carr^-ing powers of tlie 
 blood, and thus delays tissue change. The drug is not 
 necessary for the treatment of this disease, as abundant 
 clinical evidence has demonstrated to me. In Mercy 
 Hospital, during the last ten years the death-rate from 
 pneumonia has been a little less than 12 per cent., though 
 no alcohol was employed in the treatment of the cases. 
 During the same time the death-rate in other Chicago 
 hosi)itals. where alcohol was used with greater or less 
 freedom, was 28 to 38 per cent. I have no hesitation in 
 discarding alcohol in the treatment of pneumonia. I 
 believe that often it has done harm. 
 
 Pneumonia commonh^ runs a short but severe 
 course. Ver}- great prostration ma}' be felt when con- 
 valescence is first established, but usually strength is 
 rapidh' recovered. However, those who were feeble 
 when attacked by the malady may recover slowl3\ It is 
 important in all cases, but especially in the latter group, 
 to maintain strength during the illness. As an inclina- 
 tion for food is usually wanting, it must be taken as a 
 necessity. It should be given in a form as concentrated
 
 Croupous Pneumonia. 105 
 
 and as easily digested as possible. Milk is most uni- 
 forml}^ the best diet. A little should be administered 
 every hour or two during the severest portion of the 
 illness. It will be least liable to disturb the stomach or 
 cause repugnance if it is thus administered. If the 
 heart is weak, beef-tea, or chicken-broth, or strong 
 coffee should also be given. They are stimulants rather 
 than foods. During convalescence food should be 
 simple in character, but should be gradual 13- varied' as 
 the appetite returns. 
 
 In chronic pneumonia we must combat a tendenc}' 
 to abscess formation, or treat abscesses, if the}'' exist. 
 To check the iuflammatiou, blisters or sometimes 
 milder counter-irritants, occasionally applied, are useful. 
 Anodynes are needed to allay cough, when it persists. 
 Strength must be conserved and, if possible, improved 
 by careful feeding. If the fever disappear, the ten- 
 denc}' of the affected side to contract and to prevent the 
 full inflation of the lung must be counteracted by 
 respirator}^ gymnastics. At first, gentle, enforced, deep 
 breathing, and, later, the pneumatic cabinet, or, better 
 still, a residence for a few months in high altitudes, 
 should be tried. The respiratory g^-mnastics expand 
 the lungs, help to lessen tlieir congestion, and prevent 
 permanent contraction of the affected side. The dry 
 air of high altitudes also promotes a more rapid absorp- 
 tion of inflammatory exudates. If an irregular remit- 
 ting fever persist, which, although not enough to keep 
 the patient bedridden, is enough to make high altitudes 
 dangerous, a residence at low altitudes, in dry climates, 
 — such as can be found in Western Texas, Arizona, and 
 Southern California, — is exceedingly beneficial. XJsuall}' 
 such a change improves the appetite, tempts to more 
 active exercise, to the rapid absorption of the exudate, 
 
 5*
 
 106 Diseases of the Lungs. 
 
 and, with these changes, to the disappearance of tem- 
 perature. If abscesses or tubercular disease super- 
 vene, they must be treated as they would be under 
 other circumstances. The medical treatment of the 
 chronic cases must be symptomatic and tonic. Iron 
 and bitter tonics must usually be given. 
 
 Pneumonia is ver}^ frequently' a fatal disease. The 
 proportion of fatal cases has been variously estimated 
 in different hospitals and by different observers. It 
 varies also from year to 3'ear. The mortality is esti- 
 mated as high as 25 per cent., in some hospitals. In 
 my own hospital and private practice during the last 
 five years, it has varied from 4 to 12 per cent. It is 
 especially fatal in persons more than 40 3-ears of age. 
 In children and in the earlier years of manhood recovery 
 occurs in a very large proportion of cases. In those 
 who are addicted to the free use of alcoholics the mor- 
 talit}' is mucli greater than in total abstainers. Croup- 
 ous pneumonia of the lung's apex is especialh' dangerous, 
 for it is usual!}' accompanied and followed by tubercu- 
 losis, if it does not at once cause deatli. Complications 
 alwaj's greatl\' increase the danger to life. A tempera- 
 ture of more than 105 degrees must usually be regarded 
 as significant of danger. A temperature of 104 degrees 
 accompanies tlie disease in its moderateh' severe form. 
 It is found, also, that an increase of temperature after 
 the fourth day is usually significant of an unfavorable 
 result.
 
 CHAPTER XL 
 Cirrhosis of the Lung. 
 
 Anatomy. — Cirrhosis of the lung is often called in- 
 terstitial pneumonia. It results from the formation of 
 large amounts of new connective tissue, which begins 
 with infiltration of the interstitial tissue of the lungs 
 by embryonic connective-tissue cells. The change may 
 involve the whole of the lungs, and is then verj' mod- 
 erate in degree. It may be very circumscribed, or 
 limited to a single lobe, or more frequently to a part of 
 a lobe. When the lesion is extensive it causes contrac- 
 tion of the lung, so that, for instance, an upper lobe 
 may be transformed into a small mass of firm, tough, 
 unaerated tissue not one-quarter its normal bulk. More 
 frequentl}^ smaller areas are involved, which produce de- 
 formities of the lungs and render portions of them use- 
 less for respirator}' purposes. If the cirrhotic tissue is 
 cut into, it often creaks like cartilage. Usuall}' the 
 pleural cavity over cirrhotic masses is obliterated by 
 adhesions. If a section is made into a lung containing 
 a cirrliotic area, the diseased portion appears as a band, 
 or more or less extensive area of gra}', compact, hard, 
 and fibrous tissue. About it the air-spaces nre irregu- 
 larlj' shaped and have thick walls, which deform them. 
 As the cirrhotic mass enlarges the interstitial tissue 
 becomes thicker and thicker, and the air-space is dimin- 
 ished proportionately and finally is obliterated. Pig- 
 ment is often deposited, in considerable amounts, in the 
 cirrhotic tissue, and produces a mottling of the cut sur- 
 face. Bronchial tubes in this tissue are often dilated 
 (see page 57). Less frequently" they are obstructed or 
 
 (107)
 
 108 Diseases of the Lungs. 
 
 obliterated hy the contmcting scar-tissne. Adhesive 
 pleuritis and contracting cirrhotic lung-tissue often pro- 
 duce a deformity of the thorax, and impede breathing 
 by drawing togotlier the ribs, narrowing and making im- 
 mobile the intercostal spaces. Adhesions, the results of 
 cirrhotic changes in the lungs, often occur between the 
 lungs and pericardium, and result in displacement of 
 tiie heart. Whenever the cirrhotic change is exten- 
 sive, hypertrophy of the right ventricle occurs in order 
 to compensate for the obstruction to tiie pulmonary cir- 
 culation offered by the obliteration of many capillaries 
 and small arteries 
 
 Symptoms. — The lesion is always secondary-, and 
 the onh' appreciable signs- of diagnostic value tiiat it 
 produces are physical ones. Small or deeply-seated 
 jireas of cirrhosis mav exist and may not be de- 
 monstrable before death. Larger areas, and especially 
 superficial cirrhosis, cause retraction of a portion of 
 the thoracic wall, which is visible to even a carelessly- 
 observing eye. This retraction occurs most frequently 
 about the apices, as it causes the flattening of the chest 
 in consumption. It less frequently produces deformi- 
 ties about the lower part of the thorax. The chest is 
 alwaj's diminished in size by these changes, as well as 
 rendered irregular in shape. The ribs are drawn to- 
 gether and comparatively immovable, so that respiration 
 is not equal upon both sides of the thorax, and is 
 especially limited at the points of retraction. The other 
 physical signs are those of consolidation of lung-tissue. 
 Yocal fremitus over the area of consolidation is in- 
 creased, and often bronchial fremitus can be detected. 
 Dullness is noticeable at the same point. It is usually- 
 relative. Its com])leteness depends upon the size and 
 superficial position of the solid, cirrhotic tissue.
 
 Cirrhosis of the Lung. 109 
 
 Broncho-vesicular or bronchial respiratory sounds are 
 usually heard over the same area. Vesicular sounds 
 are alwaj^s. obscure, or wanting. If dilatation of a 
 bronchus has occurred, tubular or cavernous sounds 
 may be audible. 
 
 The demonstration of displacements of the heart, 
 liver, or viscera adjoining the lungs or thorax is ex- 
 cellent corroborative evidence of the existence of cir- 
 rhosis. If the vascular obstruction is considerable in 
 the lungs, the second cardiac sound at the pulmonary 
 orifice will be accentuated. When the right ventricle 
 is enlarged and hypertrophied, its increased size can be 
 demonstrated by percussion, and infra-sternal pulsations 
 can be felt. 
 
 Causes. — Cirrhosis often occurs primarily in old age. 
 It is then moderate in degree and generalized. Few of 
 the air-cells are completely obliterated, bnt most are 
 misshapen, contracted, and surrounded by thick, un- 
 3'ielding walls. 
 
 In all other cases it is secondary and usually to 
 chronic inflammations of the pleura, lung, or bronchi. 
 It is present, to a greater or less extent, in all cases of 
 chronic phthisis. 
 
 Treatunent. — The treatment consists, first, in obtain- 
 ing a cure of the primnr}^ affection, or removal of the 
 cause; second, in correcting the deformit}^ that the 
 lesion produces, or in compensating for it. Good hygi- 
 ene, and especially the breatliing of pnre air, is essential 
 to prevent fi-esh irritation of the lungs and exacerba- 
 tions of the trouble. Pleurisies, bronchitis, and similar 
 affections, which may be the cause of cirrhosis, are to 
 be treated by customar}' methods. To prevent the for- 
 mation of cirrhotic tissue, and even to cause its disap- 
 pearance, the double chloride of gold and sodium, chlo-
 
 110 Diseases of the Lungs. 
 
 ride of potassium, and iodide of potassium and sodium 
 are commonly recommended. I have not been able to 
 convince m3'self of their utility, except in one case, 
 where sj'philitic inflammation was the cause of pulmo- 
 nary cirrhosis. In tliis case the iodides were beneficial. 
 
 To correct the deformities and displacements which 
 cirrhotic tissue in the lungs causes, pulmonary gym- 
 nastics are of great utility. Deep breathing, frequently 
 resorted to, will often suffice to cause again an expansion 
 of a retracted area of the chest. It accomplishes this 
 not by removing the cirrhosis, but by bringing into full 
 use man}' neighboring air-cells that were before imper- 
 fectl}^ inflated, because of the weakness of the respira- 
 tor}' act, and, to some extent, by producing a compen- 
 sating emphysema adjoining the cirrhotic area. Often 
 good results are quickest obtained b}' directing the 
 deep inhalation to be taken while other parts of the 
 lungs than the cirrhotic ones are compressed or kept 
 unexpanded, so that as much air as possible can be 
 forced into the affected areas. This mode of expanding 
 the lungs is especiall}' applicable when the lower part 
 of one lung is affected. By bending the body to the 
 unaffected side, and retaining the position while as deep 
 an inhalation as possible is taken, the retracted part of 
 the chest often can be more rapidh' and perfecth' re- 
 expanded. When the upper part of the lungs is con- 
 tracted and the thorax flattened, exercise of the pectoral 
 muscles and others attached to tlie chest, shoulders, 
 and arms aid deep breathing in expanding the crippled 
 parts. Pneumatic differentiation nnd residence at high 
 altitudes are especiall}^ useful to distend a contracted 
 thorax. 
 
 Prognosis. — The prognosis of cirrhosis of the lung 
 depends entirely upon its cause. If resulting from tu-
 
 Cirrhosis of the Lung. Ill 
 
 bercular trouble, the prognosis is necessarily governed 
 by the nature and progress of the disease. If the cause 
 can be removed, the lesion ceases to extend, and me- 
 chanical treatment ma}' prevent permanent deformity. 
 It is impossible to remove the cirrhosis ; but it may be 
 compensated for by hypertrophy' or dilatation of the 
 lungs.
 
 CHAPTER XII. 
 Pulmonary Abscess and Gangrene. 
 
 Causes of Abscess. — Abscess of the lung is not com- 
 mon. Pj'ogenic matter deposited in tlie lung is essential 
 to its formation. Such matter may gain access to the 
 pulmonary tissue with foreign bodies which lodge in the 
 bronchi. It frequently produces an abscess when 
 croupous or catarrhal pneumonia consolidates the paren- 
 chyma. Oftener it gains access to the lungs in septic 
 emboli. The}' are produced in pysemic conditions. 
 Multiple pulmonary abscesses may then be formed. 
 Penetrating wounds of the thorax also rarel}' admit it, 
 and are causes of suppuration. 
 
 Anatomy of Abscesses. — Abscesses ma}^ be formed in 
 either lung, and in any part of them, but they occur 
 oftenest in the upper lobes. The}' vary greatl}' in size, 
 — from almost microscopic dimensions to cavities which 
 occup}' an entire lobe. The cavit}' is usually globular, 
 but ma}' be anguhir. It contains pus. Its walls vary 
 in thickness. Within they are composed of numerous 
 layers of green ish-3'ellow or brownish pus, and outside 
 of this of granulation and fibrous tissue. B}- suppura- 
 tion the lung-tissue is destroyed and dissolved. Sup- 
 puration may occur in a lung consolidated by pneumonic 
 inflammation or by Intmorihage. Recovery may be 
 produced b}' a spontaneous drainage and contraction of 
 the cavity, and ultimate obliteration b}' granulation upon 
 its inner surface. A-'ery rarely, small abscesses ma}' 
 desiccate, contract, and be transformed into cheesy or 
 calcareous nodules. More or less complete spontaneous 
 (112)
 
 . Pulmonary Abscess and Gangrene. 113 
 
 drainage is the rule. It general!}^ occurs into a bron- 
 chus, but may occur into a pleural or into tlie peritoneal 
 cavity, where it excites purulent inflammation. Yer}' 
 rarely, an abscess ruptures through the thoracic wall. 
 
 Symptoms of Abscess. — The clinical histor3^ of pul- 
 monary abscess varies with its origin. If it complicate 
 pneumonia crisis is usually delayed, or is imperfect, and 
 the fever soon rises again. Pains are felt in the chest, 
 and often local bulging is recognizable. Finally, the 
 lesion manifests itself by a copious expectoration of pus. 
 Abscess is to be suspected if the patient has been 
 addicted to alcoholics, or if the pueumonia has been a 
 hsemorrhagic one, and a verj^ purulent sputa is expelled. 
 
 The sputa constitutes the most characteristic symp- 
 tom. It is usually abundant, and resembles laudable 
 pus. It appears suddenlj-. If it is not expectorated 
 freely it may become offensive in odor, but loses this 
 characteristic when it is freely evacuated. In chronic 
 cases it is rarely lumpy, like the expectorate of phthisis. 
 If allowed to stand it separates into two la3-ers, — a lower 
 granular and an upper serous one. In the pus particles 
 of lung-tissue, large enough to be recognized by the eye, 
 are almost invariably present. Under the microscope 
 the bits of lung are seen to consist of elastic fibres, 
 which often display the outline of the alveoli. Besides 
 the pus-cells, fat-crystals and reddish pigment-granules 
 are frequently seen. Hsematoidin-crj'stals are unusually 
 abundant. Micro-organisms are numerous ; they are 
 chiefly round, and occur in groups. 
 
 Often, at first, the physical signs of pulmonary con- 
 solidation can be discovered, especially when the abscess 
 is superficially located. Later, when it is drained, the 
 signs of a cavit}" supersede these. 
 
 Fever, of a hectic type, is almost invariably present.
 
 114 Diseases of the Lungs. 
 
 If perfect drainage is not established spontaneous!}' or 
 artificial! >^ 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<l form contains 
 less blood. The cortex in the pale form is in places — and 
 sometimes diffusely — whiter than is normal, although 
 the pyramids are dark-red, and often appear striated. 
 The lighter color of the cortex is due to fatt}' degen- 
 eration. 
 
 The microscope demonstrates that the focus of the 
 lesion varies in individual cases. Sometimes the glom- 
 eruli and their neighborhood onh^ seem inflamed ; some- 
 times an interstitial serous exudation, with some degen- 
 eration of the connective-tissue cells, is the important 
 change; in other cases the e[)ithelium of the tubules is 
 chiefly aflfected. In the cases of acute albuminuria in 
 which there is the least renal change the lesion is a 
 degeneration of the epithelium of the tubules. To the 
 unaided eye the kidneys appear unchanged, or onlj' a 
 trifle large and i)ale. Under the microscope the epithe- 
 lial cells are seen to be swollen, so that thev nearl}- close 
 the tubules ; they are more granular than natural, and 
 may have no nucleus, or in them it is obscured. The 
 interstitial tissues, glomeruli, and blood-vessels may 
 remain unchanged. Such lesions are oftenest observed 
 in cases of typhoid fever, diphtheria, or other fevers of 
 
 M2
 
 282 ^enal tnfiammations. 
 
 an asthenic ty[)e. They are rather due to acute degen- 
 eration than to inflanmiMtion. The condition is denom- 
 inated cloudy swelling. Fatt}' degeneration ma}' grow 
 out of it, or it may be associated with true inflammation. 
 Fatty degeneration ma}' occur acuteh', for it need not 
 develop from cloudy swelling. It is oftenest the result 
 of infectious diseases, or anaemia, or phosphorus poison- 
 ing. When fatt}' degeneration exists the epithelium of 
 the tubules and glomeruli are not only granular, but oil- 
 droplets are demonstrable in them. Cells that are fat- 
 tily degenerated oftener disintegrate than those cloudily 
 swollen. If inflammation as well as degeneration exist, 
 inflammatory exudates will also be observed. Degen- 
 erative changes ma}' precede inflammatory ones, but 
 quite as often follow them. When inflammation exists 
 some degeneration can also be demonstrated. In certain 
 cases the kidneys are greatly enlarged and softened. In 
 them the interstitial lymph-spaces are usually distended 
 with a serous exudate. A few migrated round-cells 
 may be found about the vessels, but the inflammatory 
 exudate is chiefly serous. In specimens preserved in 
 alcohol small clots of albumen can be seen within the 
 glomeruli or in the lymph-spaces. The renal epithelium 
 is usually granular and degenerated. 
 
 In other cases a cellular exudate can be found about 
 the interlobular vessels. The tubular epithelium is 
 usually partly degenerated, and often extensively cast 
 oflf. The swollen cells or their detritus fill some 
 tubules ; the calibre of others is increased by the loss 
 of epithelium. 
 
 In other cases, oftenest in those which follow scar- 
 latina and poisoning by terebinthines, the glomeruli are 
 chiefly involved. The capsule of Bowman is usually 
 thickened, the nuclei in the capillary tuft nre increased,
 
 Acute Nephritis. 283 
 
 and the tuft is enlarged. Round-cell infiltration can 
 be seen about tlie glomeruli. The tuft of capillaries, 
 instead of being clianged, as just described, ma}^ become 
 liomogeneous and vitreous from h3aline degeneration. 
 Small hsemorrliages are frequent in and about the glom- 
 eruli. In all forms of acute nephritis minute haemor- 
 rhages are common, and they may occur anywhere in 
 the cortex. 
 
 We often find glomeruli, tubules, and interstitial 
 tissues all affected, but in varying degrees. In some 
 cases epithelial desquamation from the tubules is very 
 moderate, in others very extensive. So the amount of 
 haemorrhage varies, but it is present to some extent in 
 almost every case of acute nephritis. Some of the 
 blood-corpuscles find their way into the tubules and are 
 eliminated with the urine. It must not be supposed 
 that all the glomeruli are equally, or even at all, 
 affected. Usuall}^, some remain perfectlj' normal, and 
 continue to imperfectl}' perform the functions of the 
 whole organ. When the kidne}' is congested the vessels, 
 especially the interlobular ones, are distended with 
 blood. The medulla of the kidney is usuall}' little mod- 
 ified. Sometimes, when degeneration is extensive or 
 congestion very great, it may be affected slightly, as the 
 cortex is extensively. 
 
 Acute degeneration and acute inflammation prevent 
 the physiological action of the kidne3\ Tiiese lesions 
 cause, almost without exception, albuminuri.-i. What is 
 much more important, the separation of waste nitrog- 
 enous matter from the blood, and its elimination 
 through the urinary channels, is lessened or prevented. 
 Therefore, the liability to surcharge the blood with these 
 products of waste, and the danger of uraemia because of 
 them, is considerable.
 
 284 Jienal Itr/iammations. 
 
 Diuresis is interfered -with by tlie vurious changes 
 which may occur in the glomeruli, and also by obstruc- 
 tions in the tubules, which may be formed of desqua- 
 mated cells or thiir detritus or of hj'aline casts. 
 
 Symjjtoms. — The disease may devehjp insidiousl}-, 
 and not be suspected until it produces striking symp- 
 toms, such as oedema. The milder cases, especially 
 tliose that complicate fevers, ma}' not Ite suspected 
 unless the urine is frequently' examined. A di.'ignosis 
 can be made from the changes observed in the urine, 
 but in all moderately severe cases there are other symp- 
 toms that are characteristic. In the cases which de- 
 velop insidiously-, oedema is usually the first s^'mptom 
 to attract attention, though some })atients notice changes 
 in the frequency of urination or in the a[)pearance of the 
 urine. In a smaller proportion of cases a chill announces 
 the onset of the attack. This is followed by a rise of 
 temperature which will last a few days. Headache 
 usuall}' accompanies the onset. Sometimes, a dull 
 achino- is felt in the small of the back, but oftener back- 
 ache is absent. Tiie urine is observed to be scant, tur- 
 bid, and deeply colored. The skin rapidly grows pale, 
 and, as a rule, general oedema is noticeable after the 
 first two or three days. These constitute the most 
 striking symptoms of the sharplj^-acute cases. Very 
 man}', however, run an apyretic course. General oedema 
 exists, as a rule, but in mild cases it may be absent, and 
 is usually in those cases that are acute degenerations 
 rather than inflammations. The oedema is generally 
 first observed about the ankles, or simultaneously about 
 the feet and in the eyelid^. At times patients become 
 ra))idly and excessively oedematous, so that feet, hands, 
 face, and body are greatly swollen. The eyelids rarely 
 are so filled with oedematous fluid that they cannot be
 
 Acute Nephritis. 285 
 
 opened, and are distended beyond the forehead. Usually 
 dependent parts only are much oedematous. Tlie feet, 
 the penis, scrotum, and, less extensively, the hands, are 
 oftenest affected. 
 
 We must search for the pathognomonic symptoms in 
 the urine. It is diminished in amount, and in extreme 
 cases is almost suppressed. It will measure from 125 
 to 500 cubic centimetres (4 to 16 ounces) in twenty -four 
 hours. It is reddish or brownisli red nnd turbid. Some- 
 times it is blood3\ As a rule, blood-corpuscles can be 
 found in it in varjing numbers, and often are very 
 abundant. Its specific gravity is increased to from 
 1030 to 1040. It is acid in reaction. Albumen is mod- 
 erately, and, may be, ver}' abundant in it. There is 
 usuall}' from 0.5 to 1 per cent, of it, and there may be 
 as much as 3 per cent. In individual samples of urine 
 there ma}^ be an excess of urea, but during twenty-four 
 hours its amount is from 25 to 50 per cent, less than 
 normal. The other solids are also diminished. If 
 allowed to stand, a sediment is deposited in the urine. 
 In some cases it is composed chiefly of red blood-cells, 
 in others of epithelium, but in most cases of both these 
 elements, together with casts and urates. The blood- 
 cells often are attached to casts, and sometimes cover 
 them, but are most abundant as free cells. Clots do 
 not form in the urine even when haemorrhage is copious, 
 providing it is from the kidney. Epithelial cells are 
 usually observed in large numbers, and are recognized 
 because the}' are small, cuboidnl, or rudely rounded, and 
 contain large nuclei. If the disease has lasted long, fat- 
 drops can often be seen in them. Earlier, they are granu- 
 lar. While they are most abundant as free cells, they fre- 
 quently are adherent to hyaline casts, and more rarel}' are 
 adherent to one another, forming hollow tubes. Casts
 
 280 Renal Inflammations. 
 
 of all kinds are observable in acute nephritis. Usuall}', 
 particular kinds predominate in individual cases. Blood 
 and epithelial casts, such as have just been described, 
 are often seen. Grauular and hyaline ones are also 
 common. Long, narrow casts are usually formed in the 
 early stage of the disease, and short, broad ones later. 
 Besides these formed elements, granular matter, which 
 is the detritus of disintegrated cells, is usually abun- 
 dant. Crystals of uric acid, urates, and oxalate of lime 
 often compose part of the sediment. Oil-drops are 
 rarely seen in the urine of acute cases. Micturition is 
 frequent and accompanied b}' painful straining. 
 
 The anatomical changes in the kiduey readily account 
 for the abnormal character of the urine. Hsematuria is 
 due parti}' to haemorrhages in the kidney, and partly to 
 the abnormal permeability of the renal vessels, es[)ecially 
 in the glomeruli. The changes in the glomerular epithe- 
 lium and capillaries permit the escape of albumen and 
 lessen diuresis. The obstruction to the tubules by 
 casts, epithelium, and its detritus still more interfere 
 with a copious flow of urine. The degeneration aud 
 desquamation of the renal epithelium account for the 
 diminished exci'etion of urea and other urinary- solids. 
 
 The loss of blood by the kidne3's leads to auiemia, 
 which in turn produces the waxy whiteness of the skin 
 characteristic of these cases. Not only does the blood 
 lose many of its cells, but it is poor in albumen, and 
 its specific gravity is lowered. Urea, uric acid, and 
 other excrementitious matters ac(;umulate in it. The 
 heart is rarely liypertropliied in acute nephritis, but it 
 is sometimes acutely dilated. Pericarditis is an occa- 
 sional complication. The blood tension in the arteries 
 is usually increased. The pulsc-inte vnries with bodily 
 temperature, or it may be quickened if the heart 'is di-
 
 Acute Nephritis. 281 
 
 lated and weak. Bronchitis is a frequent complication. 
 Pleuris>' 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 
 <iarly symptoms do not direct attention to the kidneys. 
 In the first stage most of the syni})toms are variable. 
 They will exist in one case :ind not in juiother, or at dif- 
 ferent times in the same case. One of the most constant 
 of these variable symptoms is indigestion. It is usually 
 very persistent when it exists. It is characterized by 
 flatulence, and rarely by pain and nausea. Another of 
 these early symptoms is headache. It may affect any 
 part of the head, but oftenest it is occipital and felt
 
 Interstitial Nephritis. 319 
 
 chiefl}' or onl}^ in the morning. In many cases there is 
 heniicrania. These are undoubtedly often S3'mptoms 
 of mild uraemia. Yertigo is a common s3'niptom. It is 
 usuall}' momentar}^ but is especially liable to recur. 
 The character of the pulse is quite constant. It is fairly 
 full and regular, but unusuall}^ tense. It feels cord-like 
 under the finger, and is not readily compressible. In 
 the sphygmogram the dicrotic notch is elevated from 
 the respiratory line, and the line descending from the 
 apex of the wave to the dicrotic notch is noticeably 
 bowed upward. The urine is still more characteristic. 
 Usuall}', it is made once or twice during the night, and 
 in quantities abnormally large. This ma}' be the first 
 S3'mptom that attracts the ph3sician's attention to the 
 condition of the kidneys. It does not alarm the patient, 
 for frequent nocturnal micturition develops so slowl}* 
 that he regards it as a habit, and not as a pathological 
 condition. More urine is made in twentj^-four hours 
 than normal, but it is especially increased at night. It 
 is usuall}' limpid and clear, acid in reaction, and from 
 1014 to 1020 in specific gravit3\ It may be faintl}- 
 albuminous at all times, or only after a heart3' meal or 
 violent exercise, and not in the earl3Mnorning. But fre- 
 quently it is altogether absent. On standing a precipi- 
 tate ma3" form, which is usuall3' composed of crystals of 
 calcium oxalate and uric acid, with sometimes a few h3^a- 
 line casts. The quantity^ of urea voided in twent3-four 
 hours is often less than normal. 
 
 With these symptoms we get the histor3' of high 
 living, or of some of the usual causes of the disease. 
 If there is persistent high arterial tension and none of 
 the other common causes of its existence, renal cirrhosis 
 should be sought for. If high arterial tension co-exist, 
 with the voiding of an unusuall3^ large amount of urine
 
 320 Benal Lijlammations. 
 
 of low specific gravit}-, which contains a diminished 
 proportion of urea, the existence of beginning renal 
 cirrhosis ma}' be looked upon as probable. If albumen 
 is present in small amounts, constantly or occasional!}-, 
 and if hyaline casts are found in the urine, the diagnosis 
 ma}' be made positiveh*. 
 
 In the second stage the symptoms of the first are 
 ascaravated or intensified. Headache and vertigo are 
 more common than in the first. If there is indigestion, 
 it is more severe. Not only is there flatulence, but often 
 nausea and vomiting. The gastritis is usually persist- 
 ent if it exist, but varies greatly in intensit}' from time 
 to time. The pulse is even more tense than in the ear- 
 lier stage. The heart causes a strong apex-beat which 
 can be seen and felt, but is somewhat lower and farther 
 to the left than is normal. The cardiac sounds are nor- 
 mal. At the apex the first sound is strong. Over the 
 aorta the second is accentuated. B3- percussion the 
 area of dullness is demonstrably increased to the left. 
 Occasionalh', haemorrhages from the nose, or into tlie 
 retina, or within the brain, will occur. The uriiiQ is even 
 more abundant, and more uniformly abundant, and 
 made oftener at night than in the earlier stnge. It is 
 more constantly limpid and clear. Its si)ecific gravity 
 is lower, — from 1004 to 1014. It is, witli rare excep- 
 tions, slightly albuminous. However, cases are observed 
 in which albumen is never discoverable. Usuall}-, it is, 
 occasionalh', if it is not constantly, present. It will be 
 found most certainly' in urine that is made in the even- 
 ins;, after a dav's work, and after a meal. The dailv 
 elimination of urea is oftener less than in the first stage. 
 As in the latter, the nrine may contain no sediment, or, 
 if any, a very small one. A few casts can occasional! v 
 !)e found in it. Tiie}' are hyaiine or gr.Mnuljn-, and mn.y
 
 Interstitial Nephritis. 321 
 
 sometimes contain a few oil-droplets. Uric acid com- 
 poses a part of the scant sediment. Cells are rarely 
 found in it. 
 
 Respiration is usually normal. It is rarelj' dyspnoeic 
 from asthma which is caused b}^ uraemia, or from pul- 
 monary oedema. The bronchi and lungs are especial!}^ 
 liable to various inflammations. In the first stage there 
 may be no oliservable loss of strength, but in this endur- 
 ance and, usually, streugth are somewhat lessened. The 
 skin is dr}^, rough, and parchment-like or gra}^, but not 
 white or clearly antemic, as in acute nephritis. 
 
 Nervous sjniptoms, usually of uraemic origin, are 
 common. The dangerous ones are convulsions and coma. 
 The less dangerous ones are disturbances of hearing, 
 such as roaring, singing, or temporary deafness and 
 insomnia, mental depression, various shifting neuralgias, 
 and numbness. Uraemia is especially frequent in this 
 stage of the disease. The eyesight is often impaired. 
 It may be extensively affected bj' uraemic amaurosis, or 
 what is called albuminuric retinitis. The first affection is 
 usually temporary, although blindness may be complete. 
 The blindness is generally sudden in onset. The pupils 
 continue to react to light, and no changes are discoverable 
 in the retina that are necessarily associated with the 
 blindness. " Albuminuric retinitis " may be due (1) to 
 oedema of the retina; (2) to degeneration in patches, 
 which appear white, and are fatt}' or sclerotic ; (3) to 
 haemorrhages; (4) to inflammation of the ocular end of 
 the optic nerve ; and (5) to atroph}^ of the retina and 
 nerve, produced b}^ some of these lesions. Often more 
 than one of these lesions co-exist. They can onl}^ be 
 diagnosed by an ophthalmoscopic examination. The 
 subjective symptoms vary. Blindness may be gradually 
 or suddenly developed as a result of them, or eyesight 
 
 14*
 
 322 Renal Inflammations. 
 
 ma}' be imperfect. All objects may be blurred, or only 
 near ones or distant ones. Objects may appear distorted. 
 Bright or dark spots ma}^ come before the eyes. Many 
 of the symptoms are mitigated b}^ time, especially those 
 that arise suddenl}' ; but the}^ rarely disappear entirel}'. 
 In the third stage the prominent symptoms are those 
 of cardiac exhaustion and failure. The hypertrophied 
 heart is dilated, and is usuall}' degenerated. The pulse 
 grows soft, small, and quick. It often becomes irregu- 
 lar. The area of cardiac dullness is increased. The 
 apex-beat is displaced to the left. It ma}- be visible 
 and somewhat forceful because of hypertroph}' of the 
 heart-muscle, although the latter is too weak to do its 
 work. In other cases it can be faintly seen or felt. The 
 cardiac sounds are not so strong as in the earlier stage, 
 and especially does the first sound at the apex grow 
 short and valve-like. But more significant than these 
 cardiac chanoes are the diminishinor excretion of urine 
 and the developing oedema. The urine maj^ be much re- 
 duced even below the normal amount. The total dailj' 
 excretion of urea remains diminished. The specific 
 gravit}' may increase, but almost uniforml}' remains 
 below the normal. Albumen is usually a little more 
 abundant. Casts oftener contain fat or oil. (Edema 
 begins first about the legs, but sooil increases and ma}'^ 
 be considerable. Ascites is often present. The liver 
 frequently is congested and some connective-tissue 
 hyperplasia may develop and produce a subicteric stain- 
 ing of the skin. Diarrhoea is a common complication, 
 and one that often proves intractable. It may be due to 
 enteritis, but is oftener due to oedema. The discharges 
 are usually copious and are sometimes streaked or mixed 
 with blood. In this stage patients are usually' too weak 
 to be about the house, and, for safet}', rest is essential.
 
 Interstitial Nephritis. 323 
 
 Uraemia is especifilly apt to develop. It manifests itself 
 almost constantly in a chronic form, and often ends life 
 b}' developing acutely. Cardiac thrombosis and con- 
 sequent embolism may be the immediate cause of death, 
 but it is oftener uraemia or some complicating inflamma- 
 tion. When cardiac weakness develops, the disease 
 completes its course nipidl}^ 
 
 It is most important to prolong each stage of the 
 disease, as danger to life is greater and the course shorter 
 in each successive one. Therefore, as the disease pro- 
 gresses, life is hurried more rapidly to a close. 
 
 Diagnosis.-— W\\QYi albuminuria exists, a diagnosis is 
 not ditlicult. The abundant diuresis, high arterial ten- 
 sion, and cardiac hypertrophy are characteristic of the 
 earl}' stages of the disease. In the last stage the 
 symptoms of cardiac exhaustion and scanty urine, of 
 low specific gravity, are equally distinctive. From sec- 
 ondarily contracted kidne}^ true cirrhosis must be dis- 
 tinguished by its history, and usually by its less abun- 
 dant albumen and less abundant evidence of fatt}' change 
 within the kidnej'. 
 
 Treatment. — Important indications for treatment are 
 to avert uraemia and cerebral haemorrhage, or other 
 common complication. These indications exist in ever}' 
 stage of the disease. There are others that are peculiar 
 to each stage. There is no specific which successfull}^ 
 counteracts the characteristic renal lesion (connective- 
 tissue hyperplasia), although, to limit or cause resolu- 
 tion of it, such drugs as the iodides of sodium or potas- 
 sium, mercurials, and the double chloride of gold and 
 sodium have been used. I have been disapi)ointed by 
 not obtaining positive good eflfects from them. Un- 
 doubtedly, the first two may prove useful in the rare 
 cases of syphilitic origin. I believe the iodides are
 
 324 Renal Inflammations. 
 
 useful in renal cirrhosis chiefly b}^ lessening arterial 
 tension and b}^ promoting diuresis, but are of little or 
 no use to prevent the cirrhosis. The chloride of gold 
 and sodium may be tried, for it is thought to be decid- 
 edly efficacious by Bartholow, Tyson, and Purdie. Q\iick 
 results must not be expected of drugs used to meet this 
 indication. 
 
 The first step toward successful treatment is to re- 
 move the cause of the disease. High living and the 
 use of alcoholics should be forbidden. Exposure to 
 cold, dampness, and sudden thermpmetric changes may 
 aggravate the renal trouble. The}' must, therefore, 
 be avoided by change of climate and hy careful clothing. 
 In the first and second stages of the maladv life ma}' be 
 much prolonged by a permanent residence in equable 
 and balm}' climes. Southern California is nearly an 
 ideal climate. Many islands, like the Bermudas and the 
 Sandwich, have similarly equable and balmy air. Florida 
 and many places in the Southern States and on the 
 Mediterranean coasts are also suitable winter climates 
 for those who can make only temporary changes of loca- 
 tion. The skin should be protected by wool, so that 
 sudden thermometric changes will not be felt. Food 
 should not be highly spiced, or rich, or contain large 
 amounts of albumen. It must, howevei-, be nutritious 
 and varied. No treatment for this disease is so curative, 
 or, at least, so protecting to life, as a suitable diet. By 
 it the great danger to life — uroemia — may often be 
 averted, and an increase of cirrhosis may be prevented 
 or delayed by limiting the amount of material irritating 
 to the kidneys which is admitted to the blood. 
 
 Whenever the daily excretion of urea falls below a 
 normal standard it must be increased by stimulating- 
 diuresis, and an accumulation of noxious waste matter
 
 Interstitial Nephritis. 325 
 
 must be averted by diminisliiiig the metamorphosis of 
 iiitrogeiious mttterial in the system. Tliis hist may be ac- 
 complished by regidatiiig the diet. If unemia threaten, 
 a nou-albuminoiis diet must temporarily be used, but at 
 other times it need onl}' be simple and free from an ex- 
 cess of meat extractives, such as exist in rich gravies, 
 soups, and game. A modicum of albuminous food ma}' 
 be used if it is simply cooked, and so long as nitrogenous 
 matter is eliminated in normal amounts. Milk is nearl}" 
 as useful as in chronic parenchymatous nei)hritis. To 
 stimulate the kidneys when tlieir secreting })o\ver is 
 lessened, such salts as tlie citrate or acetate of potas- 
 sium or sodium, or carbonate of lithium should be em- 
 ployed. Digitalis and strophanthus may be used, but 
 in the first and second stage very temporarily, for it is 
 not desirable to increase arterial tension -when it can be 
 avoided, as it in turn increases the heart's lal)or and may 
 hasten exhaustion. Strophanthus, in therapeutic doses, 
 contracts the arterioles throughout the bod}- least, and 
 is to be preferred. It is, therefore, evident that close 
 watch must be kept of the quantity of urine and of 
 nitrogenous matter that is being voided. Patients 
 should measiu'e the urine made b}^ them in twenty-four 
 hours, at least twice each week. If it fall below an 
 average, which each patient must determine for himself, 
 a physician's counsel should be sought. However, so 
 great confidence c.-innot be placed in measurements 
 of the dail}' quantit}' of urine voided as in coincident 
 tests of the amount of urea voided; for the nitrogen- 
 ous elimination does not alwa3's fluctuate directl3'as tiie 
 quantity of urine does. The former may diminish much 
 more than the latter. Intelligent patients can be easily 
 taught to take the urine's specific gravity, as well as to 
 measure its amounts. The table on page 326, which I
 
 Renal Infiammations. 
 
 % I 
 
 + 
 
 1 1 
 
 ■c ^ 
 
 ^ % % S 
 
 -* gl 3 2 
 
 + 
 
 o « 
 
 „I5, o «o o 
 "^ § o o 
 
 s g 
 
 2 I 
 
 O " 
 
 O 
 
 
 linve computed, will enable them to 
 determine when tliey are excreting 
 normal quantities of urinary solids. 
 
 This table is calculated in cubic 
 centimetres, and the pints named 
 are approximate equivalents, but 
 sufficientl}' near for clinical pur- 
 poses. 
 
 In the table the si)ecific gravi- 
 ties represent for the different 
 amounts of urine a normal average 
 of 35 grammes of urea, and a mini- 
 mum normal of 15. 
 
 The diet should be restricted, 
 and the kidneys should be stimu- 
 lated as soon as the specific gravity' 
 falls below the "minimum normal " 
 for the amount of urine made ; and 
 the patient should endeavor to 
 keep it at or above the " normal 
 average." It must be remembered 
 that the amount of nitrogenous 
 matter voided varies with the diet. 
 For instance, according to Frank, 
 on a pure animal diet, 51 to 92 
 grammes of urea will be excreted 
 daily ; upon a mixed diet, 36 to 
 38; upon a vegetable diet, 24 to 
 28; and upon a non-nitrogenous 
 diet, 16. The amount eliminated 
 daily is greater in men than in 
 women, and in different individuals 
 it varies much. Different observ- 
 ers do not aoree as to the normal
 
 Interstitial Nephritis. 327 
 
 daily variation, and most of them affirm that about 34 
 grammes daily is excreted by men, and 25 by women ; 
 but 15 to 18 may be said to be the minimum normal. 
 And this is a dangerously small amount, if a patient is 
 on a rich meat diet. 
 
 Hot-air baths, which will produce sweating, can be 
 used with advantage to relieve uraemia. Nothing else 
 is more promptl}' efficacious in chronic uraemia. Laxa- 
 tives are beneficial b}^ aiding to eliminate vicariously 
 ursemic poisons, and they help to prevent high arterial 
 tension. Drastics may be required for this purpose, but 
 their use cannot be long continued, because the)' are ex- 
 hausting. The stools should, however, be kept soft, for 
 if the rectum or intestines are distended with compact 
 faecal matter the pulse becomes more tense and the 
 labor of the heart is increased. 
 
 In the first stage of the disease all unnecessary car- 
 diac labor must be avoided, so that its hypertroph}- will 
 not be hastened. To maintain soft stools, moderate 
 doses of Hun3'^adi Janos water or Rochelle salts are 
 among the best remedies. Sometimes the persistent use 
 of calomel, in small doses (J to ^ grnin), will keep the 
 bowels moving easily and promote better diuresis, if it 
 is lessened. 
 
 In the second stage uraemia and common complica- 
 tions must be avoided, as in the earlier stage. Cerebral 
 apoplexy and other haemorrhages are most apt to occur 
 in this period of the disease's course. The natural ter- 
 mination of this stage is cardiac weakness. Its post- 
 ponement is the special indication for treatment. The 
 sclerotic changes which often occur in the arteries of 
 various organs are an important cause of haemorrhage, 
 but they cannot be much modified by medicine. Brittle 
 arteries will not often break unless they are unusually
 
 328 Renal Inflammations. 
 
 stretched by blood that is under abnormalh^ high press- 
 ure. The cardiac h3'pertrophy, the renal sclerosis and 
 consequent vascular obstruction, and often the more 
 generalized obstruction which thickening of the arterial 
 walls causes, constantl}' keep the blood under an ab- 
 normally high pressure. There are many other tem- 
 porar}' and removable causes of high pressure, — such as 
 undue physical or mental exertion, indigestion, and 
 constipation. Excitement, anxiet} , or mental strain 
 of any kind must be avoided. It is not best to require 
 patients to give up business or all mental occupation, 
 for tiieir stimulus is needed if the}' do not necessitate 
 overexertion, and if the individuals are not too weak. 
 Absolute phj'sical rest is not necessary or desirable, but 
 overexertion, which is exhausting, should not be per- 
 mitted. Hurried and violent movements, such as run- 
 ning, stair-climbing, rowing, or gymnasium exercises, 
 must be avoided. Occupations should be sought that 
 do not require hurried movements, or heav}^ lifting or 
 other violent exertion. Gentle exercise, S3'stematically 
 taken, is essential to maintain good muscular strength. 
 Indigestion, both in this and the first stnge, must be 
 promptl}'^ treated. It is due to slow digestion, which 
 makes it possible for abnormal fermentation to take 
 place in the undigested food. Digestion may be hast- 
 ened by administering only such foods as are easily di- 
 gested, and \)\ avoiding an overloading of the stomach. 
 Food should be taken if necessaiy four or five times 
 daily instead of three, and in amounts so small that the 
 stomach will not at one time contain more tlian it can 
 quickl}' digest. Pepsin is useful in such cases. Slow 
 peristalsis is oftener the cause of indigestion than dimin- 
 ished gastric ferments, for a little of tlie latter can 
 accomplish much. Peristalsis is best increased b\'
 
 hiterstitial Nephritis. S29 
 
 gentle general exercise, or by massage over the bowels, 
 and by frequent deep inhalations of fresh air, which, 
 by better oxygenating and purifying the blood, invigor- 
 ates the function of every tissue, and also by tonic 
 laxatives like cascara and aloes. Abnormal fermenta- 
 tion can be best prevented b}^ avoiding such foods as 
 are most readily attacked and decomposed into noxious 
 substances, — for example, fats and starchy foods, wliich 
 are not semi-liquid, granular, or easily made so, — and b^^ 
 administering anti-ferments, such as carbolic acid, resor- 
 ciii, muriatic acid, etc. • These drugs must be used with 
 caution and in small doses, as most of tliem are elimi- 
 nated by the kidneys and are irritating to them. A 
 dietetic treatment is to be preferred to a medicinal one, 
 in such cases. Constipation must be preve;ited, as in 
 the early stage of the disease; or, if it is associated 
 with atonic indigestion, by cascara, or aloes in combi- 
 nation with blue pill or calomel. Drastics may some- 
 times be needed to relieve uraemia. An occasional 
 gentle purge with salts is useful to lower arterial ten- 
 sion when it increases. Arterial tension must be as 
 closely watched in this stage as must signs of renal 
 incompetence. If arterial tension is perceptibly increas- 
 ing, as can be most easily demonstrated b}^ the sph^-g- 
 mogrnph, it should be lessened. This cannot always 
 be permanentl}' accomplished. A temporary lowering 
 of the pressure can be effected with promptness and 
 certainty b}^ the nitrites. A rapid lowering of pressure 
 is usuall}' not so desirable as a prolonged one; there- 
 fore, the nitrite of sodium or potassium is the best to 
 use. It can be given in doses of from 1 to 3 deci- 
 grammes (2 to 5 grains) three or four times daily. It 
 should not be given oftener than is necessar}^ in order 
 to accomplish the desired reduction in pressure. Its
 
 330 Renal Inflammations. 
 
 persistent use is often commended, but I do not believe 
 that it is safe to employ it for man\' days or weeks. It 
 lowers the arterial pressure by lessening the irritabilit}^ 
 of the vascular muscles and intrinsic nerves. In full 
 doses it simultaneously quickens the heart's action. It 
 lessens the oxjgen carrying power of the blood, and 
 diminishes the quantity of urine. The last two modes 
 of action make it contra-indicated for continuous use if 
 there are S3^mptoms of chronic uraemia. It may be 
 temporarily employed to relieve uraemia, for it lessens 
 the excitability of reflex centres. From its action upon 
 the heart and tlie blood-vessels it is evident that it 
 lessens the heart's strength, and, b}' diminishing the 
 oxygen carrying power of the blood, would, if continu- 
 ously emplo3'ed, hasten fatty degeneration both of the 
 heart and the kidne3S. While it is an extremely valu- 
 able remedy- in renal cirrhosis, it must not be used as a 
 part of routine treatment, but judicioush'. Because of 
 the analogous action of the iodides they can be usefully 
 emplo3'ed in this disease. The3^ do not produce so pro- 
 nounced an arterial dilatation, but it is more prolonged. 
 The3' must be given in full doses (0.5 to 1.5 grammes — 
 8 to 20 grains) if possible, and ma3' be used with safet3' 
 for a long time. 
 
 The urine must be watched as closel3' in this stage 
 as in the earlier. The same remedies ma3' be emplo3'ed 
 to stimulate the kidneys to functional activit3'. Digi- 
 talis and other vaso-constrictors are contra-indicated. 
 If some allied drug is demanded for a short time, 
 strophanthus is the best. Hot-air baths temporaril3' 
 increase blood-pressure, but if uraemia is imminent they 
 must be used, and even repeated often. The3' should, 
 however, be used in this stage of the disease only when 
 it is necessar3', and onl3' so long as it is necessary. An
 
 Interstitial Nephritis. 331 
 
 abundance of pure, clean air, and frequent deep inhala- 
 tions of it, are certainly useful to prevent uraemia and 
 fatty degeneration by maintaining good metabolism. 
 Inlialation of oxygen may be tried, for it is believed bj' 
 many to be of value. It has always disappointed me in 
 such cases. 
 
 In the third stage, when cardiac weakness exists, a 
 different class of agents must be used. Tlie chief indi- 
 cation for treatment is to maintain the heart's strength, 
 Tiiere is greater danger of uraemia than in the earlier 
 stages. It must be averted by the same regimen and 
 treatment. Arterial pressure is low, and digitalis, con- 
 vallaria, or strophanthus may be used with impunity, 
 and often are absolutely essential. By them the heart 
 can be, at least temporarily, strengthened. Usually, 
 degeneration as well as muscular exhaustion causes the 
 heart's feeble action. Iron, str3-chnia, quinia, and other 
 bitters are best calculated to stimulate and maintain 
 healthful tissue-change, and, therefore, to avert danger- 
 ous degeneration. They must be used persistently, and 
 nsuall}' combined with digitalis. An abundance of fresh 
 air, deep inspirations of it, and very gentle active or 
 passive exercise are also needful. The chances of suc- 
 icessfully removing the cardiac weakness are not good, 
 jfor when it develops the blood is impoverished, the 
 i muscular and nervous systems lack vigor and tone, and 
 I often the stomach digests food imperfectly'. These con- 
 ditions make it almost impossible to do more than to 
 jtemporaril}' strengthen the heart. The diet must usu- 
 ; ally be poor, both because digestion is not good and in 
 order to avert uraemia. It should, however, be as 
 : strengthening and as liberal as is possible under the cir- 
 I cumstances. (Edema is a symptom in this stage that 
 requires treatment. Sometimes aspiration of the pleural
 
 332 Renal Inflammations. 
 
 or pericardial sacs, or incisions at the ankles, are neces- 
 sar3\ Usualh', reliance is placed upon diuretics, dia- 
 phoretics, and cathartics. 
 
 In renal cirrhosis opiates are generall}' contra-indi- 
 cated, since the}' lessen the urine and especially the 
 elimination of nitrogenous waste. Their use, therefore, 
 increases the danger of uraemia. It is especial I3' neces- 
 sary to bear this in mind in treating inflammator}' com- 
 plications of the disease. If opiates are employed the 
 urine must be examined daily, and they must be discon- 
 tinued if they materially' interfere with the renal func- 
 tions. The persistent and very intractable diarrhoea 
 which sometimes occurs in this disease must be treated 
 chie% b}^ astringents, such as tannic acid, lead acetate, 
 or nitrate of silver. Oedema or inflammation of tlie 
 lungs must be treated as under other circumstances. 
 
 Prognosis. — It is scarcely necessary to recapitulate 
 the prognosis of this disease. If the malad}- is recog- 
 nized in the first stage, and if urpemia or intra-craniai 
 haemorrhages are escaped, the chance of living from five 
 to ten 3-ears is good. It may be possible to prolong life 
 even more than this. If uriemia threaten often, the 
 chances are not good for a long life. Tiie second stage 
 commonl}' lasts from one to five years, though it may 
 be more prolonged. The third stage rarely extends 
 over a 3'ear. To treat the disease successful!}' the pa- 
 tient must be instructed as to its chronicit}', its dangers, 
 how their approach is to be recognized, and regarding 
 the necessity for continuous guidance b}' a physician.
 
 CHAPTER XXXIY. 
 
 Suppurative Nephritis. 
 
 Suppurative nephritis is more properly a surgical 
 than a medical disease ; but, as a diagnosis is generally 
 demanded of the physician first, it is appropriate to 
 describe it briefly here. 
 
 Causes. — P3^ogenic matter may gain access to the 
 kidneys through the blood or the urinary channels. 
 When by the former, p3'8emia or purulent endocarditis 
 is oftenest the primary disease. Rareh', it complicates 
 other diseases that are accompanied b}' suppuration, 
 such as d3'senter^^ 
 
 Suppurative diseases of the urinary channels, such 
 as urethritis, prostatic suppuration, C3'stitis, and pyeli- 
 tis, are oftener its cause. Much less frequently renal 
 suppuration originates by extension of inflammation 
 from the perirenal tissue, or results from penetrating 
 wounds. 
 
 Anatomy. — The kidne}^ ma}' be enormousl}' distended 
 and its tissue almost wholl}^ destroyed and replaced by 
 pus. This is rare, except as the result of suppurative 
 pyelitis. Usuall}', the substance of the kidney is 
 studded with minute abscesses and the organ is verj^ 
 little enlarged. It may retain its normal color, or be 
 mottled. Abscesses are frequently visible through the 
 capsule as yellow spots. Over them the capsule is usu- 
 ally adherent to the cortex. On a cut surface the ab- 
 scesses, if they are of p3'Bemic origin, are generall}' 
 most abundant in the cortex; if they originate from 
 diseases of the urinary channels the pj^ramids are as 
 
 (333)
 
 334 Renal Injiammations. 
 
 apt to be extensivel}' involved as the cortex. The ab- 
 scesses are often miliary- and verj' numerous. Wlien 
 small they appear as minute 3'ellow spots, usually sur- 
 rounded In' a zone of hyperaemia. Often, when the sup- 
 puration arises by extension from the lower urinar}' 
 channels, the kidney seems striated by lines of pus ex- 
 tending through the pyramids and into the cortex. In 
 these cases the inflammation originates in the renal 
 tubules. When the pyogeuic matter reaches the kid- 
 ney' b}' the arteries, it usually lodges in a small vessel 
 or o-lomerule. At first a collection of leucocvtes and 
 pus-cells marks the site of the abscess. As the}' accu- 
 mulate they compress and destroy the neighboring tis- 
 sue. The}^ may grow large, or coalesce and make cav- 
 ities the size of a cherr}' or greater. Both kidnevs are 
 frequently" affected simultaneously. 
 
 Abscesses in the kidne>', 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. 
 
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 Being the second and last volume of a treatise on Materia Medica, 
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 SHOEMAKER— Ointments and Oleates, Especially in 
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